LICENSE,DRIVER LICENSE AMA CLASS D DOB EXP WONDERFUL ENDORSEMENTS RESTRICTIONS A ISS SEXM HT 505 EYES BLU WT 120 HAIR BLN Colonal a Director of Public Safety onnonSample LICENSE, DRIVERS LICENSE 4a ISS 4d NUMBER 4b EXP 3 DOB CS83 9 CLASS 12 REST END D NONE NONE 1 SAMPLE 2 Sample 18 EYES BLU VETERAN 15 SEX M 16 HGT 604 DONOR 5 DD Rev LICENSE,L North to the Future DL DRIVER LICENSE poe 4a INS 46 Exp Last Name 2 First middle name TEST a Cardholder address 15 Sex F 18 Eyes GRN 16 Hgt 707 17 Wg 440 lb Teat alada 9 Class D 9a End ne 5 DD 1116373 0 12 Rest LICENSE,Arizonal DRIVER LICENSE USA 9 CLASS D 9a END NONE 4d DLN 12 REST B 3 DOB 1 SAMPLE 2 8 4b EXP 4a ISS 15 SEX M 18 EYES BRO VETERAN 16 HGT 509 19 HAIR BRO 17 WGT 185 lb sample DONOR 5 DD LICENSE, DRIVERS LICENSE 9 CLASS 4d DLN 3 DOB 1 SAMPLE 2 3 8 4alSS 4b EXP NS60 o o 15 SEX 16 HGT 18 EYES M 510 BRO 9a END NONE Sample 12 NONE 5 DD 1234 LICENSE, DL DRIVERS LICENSE DRIVERS LICENSE Governor Bifh 4d DL NO 3 DOB o 9 CLASS C 4b EXP 2 IMA 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TEST ONE 8 RR 2 9 CLASS AM 9a END NONE 12 REST WBJ 15 SEX M 16 HGT 510 17 WGT 180 lb fanice Sample 18 EYES BLU 5 DD 629414352 ST17165M1923DB DONOR PASSPORT, PASSPORT CARD Passport Card No Nationality Surname A Given Names HAPPY Date of Birth M Place of Birth NEW YORK Issued On Expires On DEPAATMENT OF STATE PASSPORT,weite Toople Oftbe United States in to form a the etaction propide for the the and the sizona of Liberty to and our andain and this the c of OF BEARER IGNATURE TITULAR SIGNATURE ALIENS PASSPORT PASSEPORT pour EXTRATERRESTRE UNITMED OF PASAPORTE para EXJRATERRESTRE AP Surmame Nom OF AMERICA Alliana Date e birthy Date 06 Fecha de moin fato Flax of F of de Fitre de expecición a caducidad Department of State SEE PAGE 4 PCLINTON REDESIGNEDBY PASSPORT,Of the in Onder to form a more perfect Union establish insuge domestic provide for the commont defemer promote the gemerial Wedjare and secure the Blewing of Liberty to and om Pastenity do ordain and establish this Constibation for the L billedstate of América 3 SIGNATURE OF BEARER SIGNATURE du TITULAIRE FIRMA DEL TITULAR PASSPORT PASSEPORT UNITEL STATES OF AVICRICA PASAPORTE TypeTypeTipol CodeCade Codigo No as Passeport No de Pasaport P Surname Nom Apellidos Given NamesPrénonsNombres Nationality Nationalité Nacionalidad Date of birth Date de naissance Fecha de nacimiento Place of birth Lieu de ruissance Lugar de nacimiento SexSexeSexo Date of issue Date de délivrance Fecha de expedición AuthorityAutorite Autoridad Date of expiration Date d expiration Fecha de caducidad Department of State Endorcements Mentions Spéciales Anotaciones SEE PAGE 27 WAYNE 85208188M171014650115576290672 PASSPORT,Wete Tiople Of the in Order to form a more perfect Union establish Justice insure domestic Tranquality provide for the common defence promote the general Welfare and secure the Blessings of Liberty to ourselbes and om Pastenity do ordain and establish this Constitution forthe TritedStater of 3 SIGNATURE OF BEARERSIGNATURE DU TITULAIRE FIRMA DEL TITULAR PASSEPORI UNIME state PASARORTE TypeTypeTipg Passport No P SurnameNomApellidos Given NamesPrénomsNombres sample Nationality Nationalité i Nacionalidad Date of birth Date de haissanceFecha de nacimiento Place of birth Lieu de naissance Lugar de nacimiento Sex SexeSexo COMILLA M Date of issue Date de délivrance t Fecha de expedición AuthorityAutorité Autondad Date of expiration Date d expiration Fecha de caducidad Department of States indorsementsMentions Spéciales Anotaciones SEE PAGE 27 4317072328407066M225569 PASSPORT,3 SOGNATURE OF 5 ou FIRMA DEL TITULAR PASSPORT are AVOMRICA PASSEPORT PASAPORTE Date of de de rucimierto PIRA of de de nacimiento ILLINOIS M Date of a Date de de espedición Date of de confucidad Department of State Endorsements Mentions SEE PAGE 27 PADAM PASSPORT,Of the States in Order to form a more perfect Union establish ustice insure domestic Tranquility provide for the common defence promote the general Welfare and secure the Blessings of Liberty to ourselves and ont Pastenty do ordain and establish this Constitution for the States of America 3 SIGNATURE OF BEARER SIGNATURE DU TITULAIRE FIRMA DEL TITULAR PASSPORT PASSEPORT OF PASAPORTE TypeTypeTipo Code CodeCodigo Passport No No du Passeport No de Pasaporte P SurnameNomApellidos Given Names PrénomsNombres Nationality Nationalité Nacionalidad OF AMERICA Date of birthDate de naissance Fecha de nacimiento Place of birth Lieu de naissance Lugar de nacimiento Sext SexeSexo F Date of issue Date de délivrance Fecha de expedición Authority AutoritéAutoridad States Date of expiration Date d expiration Fecha de Caducidad Department of State Endorsements Mentions Spéciales Anotaciones SEE PAGE 27 7US F 309610 PASSPORT,PASSPORT STATES OFR AMDERICA PASSEPORT TypeTypeTipo Code CodeCodigo Passport No de Pasaporte PASAPORTE P USA SurnameNomApalidos Given NamesPrénoms Nombres Nationality Nationalité Nacionalidad Date of birth Date de naissance Fecl ha de nacimiento 10 A Place of birthLieu de naissancel Ltigár de nacimiento Sex SexeSexo Date of issue Date de délivrance de expedición AuthorityAutoritéi Autoridad Date of expiration Date d expiration Fecha de caducidad Department of State Endorsements Mentions SpéciatesAnotaciones SEE PAGE 27 USA 9 601510 PASSPORT,weire Teopic Ofthe Orda to a perfect Union Justice Trampazility procide for the comment defence promaire the and are offiber to and andair and establish we 1 of 3 SIGNATURE OF will Dy FIRMA DEL TITULAR PASSPORT OR PASSEPORT PASAPORTE 435106S560 Nationality e Dutal de de SexeSee Plase of to de QUEENS M Date DATE de Date of axpiration Date d de Department of Staté t Mections SEE PAGE 27 PPARKER PASSPORT, Oft the Order the form perfect Union inter domestic procide for the promote the Welfare and secure the Blessings of Liferty to amd and establish this Constitation the Li States oft Th2 3 SIGNATURE OF BEARERY SIGNATURE ou TITULAIREFIRMADEL TITULAR PASSPORT PASSEPORT OF PASAPORTE TypeTypeTipo Code Code Obdigo NO de Pasapoite P USA SurnaneNomApeliting Given Names Prénoms Il Nombres Nationality Nationalité Nacionalidad OF AMERICA Date of birthDate de naissance Fecha de nacimiento Plaor of birthLieu de Luger de nacimento F Date of issueDate de delivrance de expedicide Date of Fesha de saducidad Department of State EndorsementsMentions Spéciales Anotaciones SEE PAGE 27 USA INSURANCE_ID,IN NETWORK COVERAGE ONLY ambetter superior FROM healthplan TDI TM Subscriber Member ID UXXXXXXXXX Effective Date of Plan Ambetter Balanced Care 1 Vision Coverage Adult Dental Rx BIN 008019 Copays PCP Coinsurance MedRX Specialist Deductible MedRx ER Rx GenericBrand INSURANCE_ID,Anthem Anthem Core DirectAccoss eacg EPO BlueCross Sample Identification Number J000 Effective Date Deductible 5000510000 Contract Code 00000 OOP 6350512700 Rx Bin 000000 CoInsurance Tier 130 Tier 250 PCN A4 Office Visit 3 OV 60 then Rx Group WLHA Ded and 30 Coins Plan 040 Rx Tier1Rx Tier2 Ded then 19550 Rx Tier3Rx Tier4 Ded then 7530 Select Rx List Pediatric Dental Prime Pathway Tiered EPO INSURANCE_ID,UnitedHealthcare R Health Plan Member ID Group Number Member PCP Payer ID PCP Phone OPTUMRx Rx Bin Copays Rx PCN Office ER Tier 1 OV RX Grp UrgCare Spec Tier 1 SpecOV Referrals Required UnitedHealthcare NexusACO R DOI0508 Underwritten by Appropriate Legal Entity INSURANCE_ID,1 INSURANCE COMPANY NAME COVERAGE TYPE 2 MEMBER NAME 4 EFFECTIVE DATE XXXXXXXX MEMBER NUMBER XXXXXXXXX 3 GROUP XXXXXXXXXXXX PRESCRIPTION GROUP xxxxx PCP COPAY 1500 PRESCRIPTION COPAY SPECIALIST COPAY 2500 1500 GENERIC EMERGENCY ROOM COPAY 7500 2000 NAME BRAND 5 MEMBER SERVICES 1800XXXXXXX CLAIMSINQUIRIES 1800XXXXXXX INSURANCE_ID,Blue Cross Blue Shield R R Enrollee Name FIRST M LASTNAME Enrollee ID RxBIN 004336 DZW920000000 RxGrp RX4655 Issuer Blue Dental Blue Vision R R INSURANCE_ID,Molina Marketplace TDI MOLINA ID HEALTHCARE Member DOB Plan Subscriber Name Subscriber ID Provider Provider Phone Provider Group Medical Cost Share Prescription Drugs Primary Care Generic Drugs Specialist Visits Preferred Brand Drugs Urgent Care NonPreferred Brand Drugs ER Visit Specialty Drugs Molina Healthcare Rx Bin Rx PCN Rx Group INSURANCE_ID,North Garolina Subscriber BERNICE D SAMPLE 01 State Health Plan FOR TEACHERS AND STATE EMPLOYEES A Division of the Department of State Treasurer Subscriber ID Treasurer CPA XXXXXXXXXXX InNetwork Member Copay Northampton County Sch Date Issued Group No Selected PCP 10 S27130 PCPMental HlthSubst Abuse 25 RXBIN RXPCN RXGRP Specialist 80 004336 ADV RX0274 PhyOccuSpch TherapyChiro 52 Primary Care Provider PCP Urgent Care 70 None Selected ER 300 Ded 20 same for outofnetwork BlueOptions 8020 Plan Deductible BlueE PPO Paid for by YOU and other Taxpayers INSURANCE_ID,Statewide Network Hometown The preferred provider network for members residing in Renown Health medical facilities for emergency Member Number Healths and hospital care Open Access HMO Visit Member Name Plan Nurse Advice Line or Subscriber Name Submit claims to ID 88023 Mail claims to Hometown Health Member services BenefitsID card Member Login at Contract ID XXX 799981703 OR download mobile app ERUrgent care facilities only outside NV Multiplan Eligibility benefit or precertification information Visit HometownR RxBIN 019059 or or RxPCN 07570000 RxGrp HTH Pharmacy services Possession of this card does not guarantee eligibility INSURANCE_ID,Health Insurance Generic Inc Health Plan 123456 123456789 Member ID 123456789 Group number 123456 Member individual de Generic Inc Employee Plan Employee 56A8 Anytown Payer ID 123456AB Dependents Employee spouse 56CD Rx BIN 123456 Employee child A 56EF RX GRP GENERIC Employee child B Copays Office visit 20 ER50 Specialist 560 Health Insurance Co PPO Underwritten by Health Insurance Co INSURANCE_ID,TEXAS LIABILITY INSURANCE CARD COMPANY PHONE NUMBER COMPANY OLD REPUBLIC INSURANCE CO COMPANY NUMBER 24147 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE MWTB 313468 YEAR MAKEMODEL VEHICLE IDENTIFICATION NUMBER ALL OWNED AND OR LEASED VEHICLES AGENCYCOMPANY ISSUING CARD ARI FLEET LT INSURED BNSF RAILWAY COMPANY L This policy provides at least the minirnurn amounts of liability insurance required by the Texas Motor Vehicle Safety Responsibility Act for the Specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy SEE IMPORTANT NOTICE ON REVERSE SIDE CMS1500,1500 HEALTH INSURANCE CLAIM FORM APPROVED BYNATIONAL UNIFORM CLAIM COMMITTEE PICA PICA 1 MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 10 INSUREDS ID NUMBER For Program n 1 CHAMPUS HEALTH PLAN BUKLLING Medeare Medead Sponsors SSN SSN or ID SSN ID 2 PATIENTS NAME Last Namo Frit Name Middlo Inittal 3 PATIENTS BIRTH DATE SEX 4 INSUREDS NAME First Name Middle Initial MM DD YY M F 5 PATIENTS ADDRESS No Street 6 PATIENT RELATIONSHIP TO INSURED 7 INSUREDS ADDRESS No Street Self Spouse Child Other CITY STATE 9 PATIENT STATUS CITY STATE Single Married Other ZIP CODE TELEPHONE include Aree Code ZIP CODE TELEPHONE include Area Code FullTime PartTime Employed Student Student 9 OTHER INSUREDSNAME Lest Name Est Name Middle 10 IS PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FECA NUMBER a OTHER INSUREDS POLICY OR GROUPNUMBER a EMPLOYMENT Current or Previous a INSUREDS DATE OF BIRTH SEX MM DD YY YES NO M F b OTHER INSUREDS DATE OF BIRTH MM YY SEX b AUTO ACCIDENT DE PLACE State b EMPLOYERS NAME OR SCHOOL NAME M F YES NO c EMPLOYERS NAME OR NAME c OTHER ACCIDENT c INSURANCE PLANNAME OR PROGRAM NAME YES NO d INSURANCE PLANNAME OR PROGRAM NAME 10d RESERVED FORLOCAL USE d is THERE ANOTHER HEALTH BENEFIT PLAN YES NO yee return to and complete itern 9 sd READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM 13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize 12 PATIENTS OR AUTHORIZED PEASONS SIGNATURE authortze the release of any medicator other Information necessary paymentot medical benefits to theundersigned physidian or supplier for oprocess this also request payment of government benefis other to mysell or tothe party who accepts assignment doscribed below below SIGNED DATE SIGNED 14 DATE OF CURRENT ILLNE ss First symptom OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILINESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJUAY Accident OR GIVE RAST DATE MM DD YY MM DD YY MM 00 YY 4 PREGNANCYLMP FROM TO 17 NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 10 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY 17b NPI FROM TO 19 RESERVED FCR LOCAL USE 20 OUTSIDE LAB CHARGES YES NO 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 1 2 or to Item24E by Line 22 MEDICAID RESUEMISSION CODE ORIGINAL REF NO 1 3 L 23 PRIOR AUTHORIZATION NUMBER 2 4 24 A DATES OF SERVICE B c D PROCEDURES SERVICES OR SUPPLIES E F G H I J From To PLACEOR Explain Unusual Circurnstances DIAGNOSIS DAYS Fority ID RENDERING MM DD YY MM DD YY SERVICE EMG CPTHCPCS MODIFIER POINTER CHARGES UNITS Ron QUAL PROVIDER ID 1 NPI 2 NPI 3 NPI 4 NPI OR 5 NPI 6 NPI 25 FEDERAL TAXID NUMBER SSN EIN 26 PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE gwl 000 badki YES NO 31 SIGNATURE OF HYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATION 33 BILUNG PROVIDER INFO INCLUDING DEGREESOR CREDENTIALS I certity that the statemente on the reverse apply part thereot SIGNED DATE a a NUCC Instruction Manual available at OMB APPROVAL PENDING CMS1500,HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE NUCC PICA PICA 1 MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1n INSUREDS ID NUMBER For Program In item 1 HEALTH PLAN BLKLUNG Medicare MedBald IDADODA Member IDI ID ID ID 2 PATIENTS NAME Laxt Name Firat Name Middle Initial 3 PATIENTS BIRTH DATE SEX 4 INSUREDS NAME Last Name First Name Middle Initial MM DO YY M F 5 PATIENTS ADDRESS No Streat 6 PATIENT RELATIONSHIP TO INSURED 7 INSUREDS ADDRESS No Street Self Spouse Child Other CITY STATE 8 RESERVED FOR NUCC USE CITY STATE ZIP CODE TELEPHONE Include Area Gode ZIP CODE TELEPHONE Include Area Code 9 OTHER INSUREDS NAME Last Namo First Name Middle Initial 10 IS PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FECA NUMBER a OTHER INSUREDS POLICY OR GROUP NUMBER IL EMPLOYMENT Current or Previoua a INSUREDS DATE OF BIRTH SEX MM DD YY YES NO M F b RESERVED FOR NUCC USE b AUTO ACCIDENT PLACE State b OTHER CLAIM ID Designated by NUCC YES NO AND c RESERVED FOR NUCC USE c OTHER ACCIDENT c INSURANCE PLAN NAME OR PROGRAM NAME YES NO d INSURANCE PLAN NAME OR PROGRAM NAME 10d CLAIM CODES Designated by NUCC d IS THERE ANOTHER HEALTH BENEFIT PLAN YES NO II yes complete Items 9 9a and 9d READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM 13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE I authorize 12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any modical or other Information necessary payment of medical benefits to the underalgned phyalcian or supplior for to process this claim I also request payment of government benefits either to myself or to the party who accepts assignment services described below below SIGNED DATE SIGNED 14 DATE OF CURRENT ILLNESS INJURY or PREGNANCY LMP 16 OTHER DATE 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY MM DD YY MM DD YY QUAL QUAL FROM TO 17 NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY 17b NPI FROM TO 19 ADDITIONAL CLAIM INFORMATION Designated by NUCC 20 OUTSIDE LAB CHARGES YES NO 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate AL to service line below 24E ICD Ind 22 RESUBMISSION CODE ORIGINAL REF NO A B c D 23 PRIOR AUTHORIZATION NUMBER E F G H I J K L 24 A DATES OF SERVICE B c D PROCEDURES SERVICES OR SUPPLIES E F G H I J From To PLACEOF Explain Unusual Circumstances DIAGNOSIS DAYS EPEDT OR Femily ID RENDERING MM DD YY MM DD YY SERVICE EMG CPTMCPCS MODIFIER POINTER CHARGES UNITS Plan QUAL PROVIDER ID 1 NPI 2 NPI 3 NPI 4 NPI 5 NPI 6 NPI 25 FEDERAL TAX ID NUMBER SSN EIN 26 PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMOUNT PAID 30 Rsvd for NUCC Use For govt olaims see YES NO 31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATION 33 BILLING PROVIDER INFO PH INCLUDING DEGREES OR CREDENTIALS I certify that the statements on the reverse apply to this bIll and are made a part thereof n b a b SIGNED DATE NUCC Instruction Manual available at PLEASE PRINT OR TYPE OMB APPROVAL PENDING CMS1500,AETNA HEALTH INC HEALTH INSURANCE CLAI FOR BLUE APPROVED BY NATIONAL UNIFOR CLAN COTTISE caos nca PICA Y L EDICARE EDICAID TRICARE CHAPHIA GROUP FECA OTHER sa INBUREDS LD NUBR LAN KUNG For Program as disonsors Altenter DE a a AET45454 2 PATIENTS NAE Last Name some intus 3 PATIENTS BRITH DATE SEX 4 INSUREDS NAE Last Name Post Name PORTER ONICA F PORTER S PATIONTS ACDRESS street 6 PATIENT RELATIONSHEP TO INSURED 7 INSUREDS ACDRESS N Sull Spouse Chide Other CITY STATE PATIENT STATUS CITY STATE HI high arried Other HI ZIP CODE TELEPHONE Include Area Code ZP CODE TELEPHONE Include Aven Code Tamo Past Time Emproyed Student Student a OTHER INSUREDS NAE Last Name Name ode to PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FICA NUBRA PORTER NATALIE 142 OTHE POLICY OR GROUP EPLOENT Currert INSUREDS DATI OF BATH BEX AF1244543 DO Y YES NO b OTHER INBUREOS DATE OF BRTH SEX b AUTO DO VY PLACE State EPLOYERS NAE OR SCHOOL NAE VES NO EPLOYERS NAE OR SCHOOL NAE OTHER ACCIDENTI INBUPANCE PLAN NAE OR PROGPA NAE ves NO FAILY PLAN INSURANCE PLAN NAE OR AA RESERVED FOR LOCAL USE 6 THEPE ANDTHER E PLANT FAILY PLAN YES NO y return 10 and complete 9 READ BACK OF FOR SEFORE COPLITING SICAING THIS FOR 13 INSUREDS OR UTHORIZED PERBONS SIGNATURE 12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE the al any medion or other information become of medical the undersigned or super for lo process request payment government benefits to be poft we accept assignvent services described below below SIGNED SIGNATURE ON FILE DATE SIGNATURE ON FILE SIGNED Y 14 DATE OF CUPPENT LLINESS Pes OR is PATIENT HAS HAD SAE OR SL AR LINESS 15 DATES PATIENT LIVABLE TO WORK N CUREENT QCOUPATION DO Y NAURY ave FRBT DATE und do W DO A FRO 17 NAE OF REPERPING PROVIDER OR OTHER SOURCE 12a 18 HOSPT SEATICE DATES PELATED TO CUBRENT sgrvices DO Y usa DO 15th NOT PRO 10 RESERVED FORLOCAL USE 30 OUTSICE LABT CHWRSS VES NO 21 OR NATURE OF LLINESS OR PLURY 12 300 24E by yLine 22 EDICAID PE SUBISSION ORIGINAL REF NO 002 9 23 PRICH AUTHORIZATION NUBER 2 2D46782344 24 A DATECE OF RERVICE c D PROCEDURES services OR e à 1 a To United DIAGADS o RENDERNO DO YV DE TY EO PONTER CHARGES 1867 OUN 1 12 15 11 12 15 11 11 0010 1 124 00 1 NPI 1111111111 2 NA 3 1991 4 N 5 NPI 6 NOT 25 PEDERAL TAXLD NUBR EN 20 PATIENTS ACCOUNT NO 27 accept 28 TOTAL 29 AOUNT PAID 30 BALANCE DUE back 216 YES NO 124 00 0 00 00 31 SIGNATURE OF OR SUPPLER 32 SERVICE FACUTY LOCATION TON BLLING PROVIDER DEORBES OR CREDENTIALE ARK DAVID DEO LOCATION Be on the apple bell and spite part ADDRESS2 ADDRESSID ADDRESS2 SIGNATURE ON FILE ARK DAVID SIGNED DATE FG2FC763T6767 11111111111 Y NUCC instruction anual available at APPROVED OB09380999 FOR CS1500 0805 CMS1500,1500 HEALTH INSURANCE CLAIM FORM of MATIOPAL 0098 III CED DE PLAM INA then o ne pey a 18 We DEX 4 HIME C Patient Name PATENT APATENT ary o ze 0006 200000 E FO NC ones on A to W M NO e X AITO PLACE NO 6 6 VES a a them PAAM P VES A arrow TOPAL PORSONG pory undenter ryad re paty the oare L 14 40 the 10 MATC 16 M mow 10 en on osen as Y 35 n mow to SORLOCAL 90 E P W AID 786 53 250 61 414 01 465 3 A of 6 c A T Yo YY MI 00 YY EMA L 1 99213 21 1 93 po 1 2 99213 21 1 33 po 1 MPL E 3 E 12 05 oal sal 06 los 33213 21 4 18400 2 4 5 D 6 PAR X123400 4 372 op 372 30 on 98 Bring Providar to ve PO Anytown OR DATE NUCC instruction at APPROVED FORM 1500 CMS1500,Access Medicare Cuatro LLC HEALTH INSURANCE CLAIM FORM pin orn mem ID112345 that My is M the fresh thread states x NATIONAL Datas and thes 75202 the wan 15 river can on mini CareCore National LLC Aetna Radiology GP167890 POLIONT NAMER concept or w W 0212345 are 01 INTEREST NCD times Numb one on the novel numb GP247890 and to can no on on instruct whom MAM SIGNATURE ON FILE SIGNATURE ON FILE 14 10 a and mean am am 10 ar meal the with 1 g a a mow to 14 can 2900 th 77000 m mm and ED 9 am prospect 80291XA U 6 L or e PROCEDUPEL 1 K a n on none mm 1 18 et 1500 2 17840 3 16 220 4 s 750 x AD3F2 2430 60 500 os sumper on Our on on Rest V x are a 1234567893 mean PLEASE CMS1500, 1500 HEALTH INSURANCE CLAIM FORM s 0 a 2000 Norm an e 1 2 3 4 6 d 2 N cow SAMPLE CMS1500,HEALTH INSURANCE CLAIM FORM mas are na IT are The over name nan as the a pos a an MOR where more to are and one SAME on MOCK of or 0000 Cater at CODK the NAME marks NAME two your NONE the more am and on NO SCHOOL NO ones of company e we e press HOUPWICE us MORE all ME new NONE cones Companies we the and DE PERSONS something de resion come work SONATURE came BOND SONATURE ON FILE uses men som 3 one am MAI 29 NONE no am now MARK or movees a and 100 n 5 ADOTIONS NS on convention m scrames to on was MA cowe 6008 L L w n name e a activities SA unda E to e 20 me 1 m more 10 A 1234567890 10 11 A 1234867890 B 10 11 A E 10 11 A w 1234967890 10 11 A 222912345 11 A not KNOW a 2 more Online me hurt acc DO 00 on works and WORTH 5551212 10mg ROHARO KIDARE wo 10 succ instruction nee TO BORCER LL can TBK AMOND FORM 1900 a 12 CMS1500,HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNFORM CLAIM COMMITTEE NUCC PICA PICA 1 MEDICARE MEDICAID TRICAPE CHAMPVA OTHER ta INSUREDSID NUMBER For Progr am in item 1 PLAN Medicare Medicaida DI IDW ID 2 PATIENTS NAME Last Name First Name Mode Inital 3 PATIENTS BRTH DATE SEK 4 NSUREDS NAME Last Name First Name MM YY 16 66 M F x 5 PATIENTS ADDRESS No Street 6 PATIENT RELATIONSHP TOINSURED 7 INSUREDS ADDRESS No Street Self Spouse Child Other CITY STATE 8 RESERVED FOR NUCC USE CITY STATE OPCODE TELEPHONE Indude Area Code field 8 reserved for NUCC use ZIP CODE TELEPHONE Include Area Code 9 OTHERINBUREDS NAME Last Name First Name IS PATIENTS CONDITION RELATED TO INSUREDS POLICY GROUP ORFECA NUMBER Policy123456678 a OTHER INSUREDS POLICY OR GROUP NUMBER a EMPLOYMENT Current or Prewious a INSUREDSDATE OF BIRTH SEX MM DD YY OtherPolicy12345678 YES NO 16 66 M F b RESERVED FOR NUCC USE b AUTO DACCIDENT PLACE State b OTHER CLAIM ID Designated by NUCC 9b reserved for NUCC Use YES NO TN xx b Other claim ID c RESERVED FOR NUCCUSE c OTHERACOIDENTI c INSURANCE PLAN NAME OR PROGRA AM NAME 9c reserved for NUCC Use YES NO c Insurance Plan Name d INSURANCE PLAN NAME OR PROGRAM NAME d CLAIM CODES Designated by NUCC d is THERE ANOTHER HEALTH BENERT PLAN 9d Ins Plan Name or Program Name d Claim codes YES NO yes complete items 9 9a and 9d READ BACK OF FORU BEI FORE COMPLETING A SIGNING THIS FORM 13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize 12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE lauthorize the release of anymedical or other information recessary payment of medical benefits to the undersigned physidan or suppler tor to process this claim alsorequest pa yment of government benefts ether tomyselfor to the party shoaccepts assignment services described below below SIGNED 12 signiture here DATE 13 signiture here SIGNED 14 DATE OF CURRENT ILLINESS INJURY or PREGNANCY LMP 15 OTHER DATE MM DO YY MM DO YY 16 DATES IENT UNABLE TOWORK IN CURBENT OCCUPATION QUAL 123456 QUAL QL FROM TO NAME OF REFERRING PROMDER OR OTHER SOURCE a a 21215464 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DO YY MM DD YY Smith b NPI 251987531 FROM TO 19 ADDITIONAL INFORMATION Designated by NJCC 20 OUTSIDELAB CHARGES additional claim information YES NO 0000 21 DIAGNOSIS OR NATURE OF LLNESS OR INJURY Pelate AL bse woelne below 24E ICD Ind E 22 RESU JEMISSION CODE ORIGINAL REF NO A a525 B b52500 C c525 D d54554 ABC123 origrefno123456 E e52220 F f52422 a g45420 H h54556 23 PRIOR AUTHORIZA TION NUMBER I i54122 J 54221 K k654 L 158556 priorauth123465 24 A DATES OF SERVICE B c D PROCEDURES SERVICES OR SUPPLIES E H L J From To PLACEOF Explain Unusual Craunstances DIAGNOSIS DAYS ID RENDERING MM DD YY MM DD YY SERVICE EMG OPTHCPCS MODIFIER PONTER SCHARGES UNTS Ple QUAL PROVIDER 1 21 1C 99201 1 12500 1 H NPI 51987555 c 2 A33 2C 400 2 000 2 H NPI 251234567 3 si 44 3C 640 31 32 33 34 3 50 1 3 NPI 252121212 4 44 4C 99444 41 42 43 44 4 4040 4 H NPI 254141414 5 12 55 5C 451 51 52 53 54 5 5500 5 H NPI 255454542 6 12 13 66 6C 478 61 62 63 64 6 6600 6 H NPI 256565656 25 FEDERAL TAX LD NUMBER SGN BN 26 PATIENTS ACCOUNT NO 27 29 TOTAL CHARGE 29 AMOUNT PAID 30 Revd to 471234567 AC549879 YES NO 396 90 20000 31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATION 33 BILLING PROMIDER INFO PH INCLUDING DEGREES OR CREDENTIALS 800 12222 that the statements on thereverse Facility name Facility name Billing Provider Info apply this bil and are made part thereof 2 Facility Road 33 Billing Provider Street 31 signture of physician 2820 SIGNED DATE a 32216649a 32245165b a 33216649a 33245165b NUCC instruction Manual available at PLEASE PRINT OR TYPE APPROVED CMB0938 97 FORM 1500 12 CMS1500,ABC Insurance 123 Main Street HETH INSURANCE CLAIM FORM City ST 12345 BY NATION UNIFORM CLAM PCA III MEDICARE THOCARE CHAMPVA THPLAN use is INSURADSID allen 1 L Number CA on spay NAME 3 80 SEX 4 NAME Last Name Name Mode inda 5 PATIENTS ADDRESS Served PATIENT UPEO INSUREDS ADCRESS ons Street Other CITY STATE RESERVED FOR NUCC USE CITY STATE Mycity Mycity noude become TELEPHONE Ave Code 12345 OTHER ASURIUS NAME Name Name Mode waul 10 SPATIENTS CONON TO 11 GAOW ORIGA NUMBER ABCDE123 OTHER on NUMDER a EMPLOYVENTI Current or INSURE DATE or SEX YES NO M F a RESERVED FOR NUCCUSE b AUTO ACCADENT PLACE Sure o Designated by MUCC VES NO c RESERVEDOR NUCC USC DENT o INSURANCE PLANNAME on YES NO d INSURANCE PEAN NAME on NAME 106 NUCC THERE PLAN YES NO Pyrs compane term 9 a was READ BACK or FORM BEFORE COMPLE TING SIGNING THIS FORM 13 INSURLOS OR AUTHORIZED PERSONS seas FUE 12 PATIENTS on AUTHORIZED PERSON Pe release of any other interration necessary payment of medical No the andersy ned physician or supgler for as am required pryment of givenes benefits other as cells to spenty accepts servicesdesoribedbere beine SIGNED Signature on file DATE SINED Signature on file r 14 or or am 15 OTHERDATE MM YY DATES xt male J9 WORK our OU FROM 17 NAME or nor PROVIDER OR OTHER sounce 176 18 HOSAT DATE LATED TO 175 NP FROM 10 ADD TON CLAN FON NICC 20 OUTSOD LABS SCHWROCS Yrs NO 21 OR NATURE or Polate toserves and below 248 com 22 DIVISION A a c D c a 23 PRICA AUTHORIZZATION NUMBER KL 24 A SURVICE a c 0 PROCEDURES services e From To o RENDERING um DO YY MM DO YY M 1 MODIFIER PONTER or am o NM 1 12345678 12345 UI 12 1 4 NPI OWETYUI 2 NM 12345678 12345 UI 3 50 4 MP OWETYUI 3 MP 4 NF 5 NPY 6 N 25 FEDER TAXIC SIN EN 26 PATIENTS ACCOUNT NO 27 25 TOT CHARGA 29 AMOUNT PAO MAKE Use 234678219 ABC12345 NO 150 0 0 31 SCHATURE OF PHYSO on 32 SERVICE FACIUTY LOCATION TION 33 BUING ACCURANCE DEGREES 555 5789012 that the statements on ABC Clinic apply to this bil MD are made pert City DATE a 12345678 123456778 AKEUFLKJDSLFI NUCC Instruction Manual available at LEASE PRINT OR TYPE APPROVED OMB OICE 1197 FORM 15 0212 CMS1500,Insurance Company Name Address HEALTH INSURANCE CLAIM FORM Payer ID COMMITTER CHOS 022 PICA MIDICAME MEDICHE PRICATE or onen 18 D for 1 PLAN MG address Studentle 00 on ABC4444333 2 PARES Name First Name 10 4 Test Name x Shom any STATE a any STATE Anycity Anycity 9 Name 10 to CM 12345 MPLOIMENTS Demate America require OF CHICH 189 NO M Fl PESERMED TORMACCUS a AUTOACCEINT PLACE devele onem CLAMIO NO C RESEMVER NACCUSE c E INSURANCE PLAN OR AND NO di INDURANCE PLAN NISE on NAME 100 THERE ANOTHER HEALTH PLAY ves NO Eyes a was THAD BACK or FORN one comme The warom o CA AUTHORECO 12 PATIENTO OR SOBATURE ce fes or persons of the I for Ancien die not present the using storage and ted BONED Signature on file DATE GONED Signature on file 14 DUARENT a LMP 15 CHERBATE as DO TY MM am 00 YY 19 WORK IN M 00 no are than to 17 OF PROME OR OTHER SOURCE 17 18 MOSP gation DECEMBER services 06 lew or 110 PROM TO 19 CLAM 10 try 20 sownes ves NO 21 di Alume OF OR AL CAN 0 22 12F NO F4320 c c 28 a 2 A a servica e c D services E 9 4 Foom To PAT 1 Epic have MM DO w DD YY trives MORE PONTER SCHARGED are ne 201 1 90637 A 125 00 N 7 2 NA 3 wh 4 which 5 NA 6 at 25 GBN CN PARENTS ACCOUNT NO 27 29 TOTAL ONCIGE 20 SMICUNT PAD 11 ex NUCCUME 99999999 65 NO 12500 9 2500 21 OF on SUPPUER DEFINE MOURY LOCATION PROVIDER 04 the of CREDING that de Your Practice Name Here Therapes Name Asdress Address Therapist Name City State State Zip some NUCC instruction Manual avalable a nece ag PLEASE PRINT OR TYPE CMB 2 Clear Forme CMS1500,1500 HEALTH INSURANCE CLAIM FORM AMPROVED BY ncA 1 MIDICAD good on NUMBLA For a nx in ay sand DE SSNar ARD NAME Name time Make SEX NAME Name Name Mode ints Same as Patient ADCPESS one 6 PATENT TO INSURED 1 ACCPESS Na than the Other same cmy STATE PATENT STATUG GITY STATE sage Other 20 Ful Taxe Student Student OTHER NAME and TEAR Name PATHINTY CONDITION RELATED TO POUCY on FECA 999999 OTHER POLION OR GROUP NUMBER EMPLOYMENTY or Previous of mith SEX in Y88 NO u DATE or AUTO ACCIDENTY use DO YY PLACE claim a EMPLOYERS OR SCHOCL NAME M YEA NO Doe Incorporated 6 EMPLOYERS TEAMEL OR NAME 0 OTHER ACCIDENT PLAN NAME om ves NO Big Insurance Co OR 100 nom LOCAL use di THERE WEAL PLANT VES NO a you man to axe and od TIEAD BACK or form SEFORE COMPLETING THES rom cn PERSONS 12 PATENTS on PERSONS the any the persons the markgand et measure no can as come DE The cony were aconces describos Signature on File Signature on File DATE SONIO Y 14 GATE or GLNESS on 15 if PATENT MAS MAQ SAVE on SIMILAR 65 DATES TANT PADLE WORK om GIVE PRST DATE uns DO 7 THANK or movision on sounce 17 18 gan st DARESPELATED 10 Y see 00 on NM FROM to 10 FOR ICCAL USE 20 SCHARCES YES NO 21 CHONCES CRINATURE OF OR NURY itens 12 24E 22 VERICAID coce CRICIAN FER NO 90210 x 23 PRICH ITHORIZATION 24A OF SERVICE e C D PROCEDUPES OR APRLES e a From Te mate o MM DO YV DO YY am and 1 07 18 99990 1 12500 1 un 2 07 10 99990 1 12500 1 MA 3 99999 1 9999 1 in 4 MM 5 M 6 M is FEDEPAL TAX LD NAMSEN EN 25 PATIENT ACCOUNT NO 29 28 TOTAL 29 PAD 30 BALANCE DUE 999999999 x NO 34999 2500 32499 21 or on sumum 12 service FACALTY LOCATIONI INCLUDINO on CHEDENTIALE John Doe Therapy a carry the the the apply 10 the 01 make part SERVICE DATE 999999 999999 NUCC Instruction Manual available at APPROVED OMB 09380999 FORM CMS1500 INVOICE_RECEIPT,IF PAYING BY CREDIT CARD FILL OUT BELOW CHECK CARD USING MonerCant DISCLYER FOR PAYMENT VISA VERICAD ESPRES MedCredit CARD NUMBER EXP DATE SIGNATURE AMOUNT PAID Billing Questions Please call us at or STATEMENT DATE ACCOUNT NUMBER PLEASE PAY THIS AMOUNT Monday Thursday 0000000 41907 Please check box if address below is incorrect 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payment please call Payment requests older than one 1 year from the service provision date will not be accepted INVOICE_RECEIPT,HOSPITALNAME Street Address Phone CHEST Address 2 Pax City Email SERVICE CHARGES invoice 090987 Barto Name Date Company Name Customer ID Enter customent Street Address led Number Bed Number Address 2 Admission Date Date Discharge Date Date City sr 2P Code Se Medche Equipment Amount Payment Bolance Panado 13500 o 13500 2 Ceradip 2300 o 2300 3 Equipment 25000 25000 Total 40800 Paid Amount 40800 REMITTANCE Reminder Plosse indude the receipt number on Potient Nome Enter customername Terms Bilance dee in 30 days Customer ID Intercustomer o Invoicel 090987 Signature Date Amount Due 000 Amount Enclased INVOICE_RECEIPT,Page 1 of 2 TM Statement Date Thank you for choosing for Account Number 11000000 your health care needs Responsible Party Sample Patient REQUEST FOR PAYMENT Account Summary Details on next page Important Message Total Charges 1198381 Previous balances are due immediately Current charges Insurance Payments Adjustments 831714 are due within 30 days of this statement Patient Payments Adjustments 000 This statement reflects charges and balances due for hospital services You will receive a separate AMOUNT YOU OWE 366667 statement for physician services Delinquent balances assigned to a collection agency are not included on this statement Insurance Information Payment and Other Information Primary UHC United Health To manage or pay your account online visit Enter Account Number 1 1000000 Enter Activation Code ZZZZZZZZZ If you need to contact us please call MTh Fri Sat or email us at To learn about s Financial Assistance Program please call or go to If you would prefer to visit us please do so at to review our financial assistance program in detail Office Hours Pay By Mail Mailing Ref XXXXXXX Amount Due Amount Paid 366667 If mailing payment please include the Mailing Ref located to the right We Please enter credit card information on the do not refund overpayments less than 100 VISA back of this payment coupon Make Checks Payable to DISCOVER MEDICAL_TRANSCRIPTION,Description A 23 year old white female presents with complaint of allergies Medical Specialty Allergy Immunology Sample Name Allergic Rhinitis Transcription SUBJECTIVE This 23 year old white female presents with complaint of allergies She used to have allergies when she lived in Seattle but she thinks they are worse here In the past she has tried Claritin and Zyrtec Both worked for short time but then seemed to lose effectiveness She has used Allegra also She used that last summer and she began using it again two weeks ago It does not appear to be working very well She has used over the counter sprays but no prescription nasal sprays She does have asthma but doest not require daily medication for this and does not think it is flaring up MEDICATIONS Her only medication currently is Ortho Tri Cyclen and the Allegra ALLERGIES She has no known medicine allergies OBJECTIVE Vitals Weight was 130 pounds and blood pressure 124 78 HEENT Her throat was mildly erythematous without exudate Nasal mucosa was erythematous and swollen Only clear drainage was seen TMs were clear Neck Supple without adenopathy Lungs Clear ASSESSMENT Allergic rhinitis PLAN 1 She will try Zyrtec instead of Allegra again Another option will be to use loratadine She does not think she has prescription coverage so that might be cheaper 2 Samples of Nasonex two sprays in each nostril given for three weeks A prescription was written as well Keywords allergy immunology allergic rhinitis allergies asthma nasal sprays rhinitis nasal erythematous allegra sprays allergic MEDICAL_TRANSCRIPTION,Description Consult for laparoscopic gastric bypass Medical Specialty Bariatrics Sample Name Laparoscopic Gastric Bypass Consult 2 Transcription PAST MEDICAL HISTORY He has difficulty climbing stairs difficulty with airline seats tying shoes used to public seating and lifting objects off the floor He exercises three times a week at home and does cardio He has difficulty walking two blocks or five flights of stairs Difficulty with snoring He has muscle and joint pains including knee pain back pain foot and ankle pain and swelling He has gastroesophageal reflux disease PAST SURGICAL HISTORY Includes reconstructive surgery on his right hand 13 years ago SOCIAL HISTORY He is currently single He has about ten drinks a year He had smoked significantly up until several months ago He now smokes less than three cigarettes a day FAMILY HISTORY Heart disease in both grandfathers grandmother with stroke and a grandmother with diabetes Denies obesity and hypertension in other family members CURRENT MEDICATIONS None ALLERGIES He is allergic to Penicillin MISCELLANEOUS EATING HISTORY He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester New York and he feels that we are the appropriate program He had a poor experience with the Greenwich program Eating history he is not an emotional eater Does not like sweets He likes big portions and carbohydrates He likes chicken and not steak He currently weighs 312 pounds Ideal body weight would be 170 pounds He is 142 pounds overweight If he lost 60 of his excess body weight that would be 84 pounds and he should weigh about 228 REVIEW OF SYSTEMS Negative for head neck heart lungs GI GU orthopedic and skin Specifically denies chest pain heart attack coronary artery disease congestive heart failure arrhythmia atrial fibrillation pacemaker high cholesterol pulmonary embolism high blood pressure CVA venous insufficiency thrombophlebitis asthma shortness of breath COPD emphysema sleep apnea diabetes leg and foot swelling osteoarthritis rheumatoid arthritis hiatal hernia peptic ulcer disease gallstones infected gallbladder pancreatitis fatty liver hepatitis hemorrhoids rectal bleeding polyps incontinence of stool urinary stress incontinence or cancer Denies cellulitis pseudotumor cerebri meningitis or encephalitis PHYSICAL EXAMINATION He is alert and oriented x 3 Cranial nerves II XII are intact Afebrile Vital Signs are stable Keywords bariatrics laparoscopic gastric bypass weight loss programs gastric bypass atkin s diet weight watcher s body weight laparoscopic gastric weight loss pounds months weight laparoscopic band loss diets overweight lost MEDICAL_TRANSCRIPTION,Description Consult for laparoscopic gastric bypass Medical Specialty Bariatrics Sample Name Laparoscopic Gastric Bypass Consult 1 Transcription HISTORY OF PRESENT ILLNESS I have seen ABC today He is a very pleasant gentleman who is 42 years old 344 pounds He is 5 9 He has a BMI of 51 He has been overweight for ten years since the age of 33 at his highest he was 358 pounds at his lowest 260 He is pursuing surgical attempts of weight loss to feel good get healthy and begin to exercise again He wants to be able to exercise and play volleyball Physically he is sluggish He gets tired quickly He does not go out often When he loses weight he always regains it and he gains back more than he lost His biggest weight loss is 25 pounds and it was three months before he gained it back He did six months of not drinking alcohol and not taking in many calories He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin s Diet for one month two years ago PAST MEDICAL HISTORY He has difficulty climbing stairs difficulty with airline seats tying shoes used to public seating difficulty walking high cholesterol and high blood pressure He has asthma and difficulty walking two blocks or going eight to ten steps He has sleep apnea and snoring He is a diabetic on medication He has joint pain knee pain back pain foot and ankle pain leg and foot swelling He has hemorrhoids PAST SURGICAL HISTORY Includes orthopedic or knee surgery SOCIAL HISTORY He is currently single He drinks alcohol ten to twelve drinks a week but does not drink five days a week and then will binge drink He smokes one and a half pack a day for 15 years but he has recently stopped smoking for the past two weeks FAMILY HISTORY Obesity heart disease and diabetes Family history is negative for hypertension and stroke CURRENT MEDICATIONS Include Diovan Crestor and Tricor MISCELLANEOUS EATING HISTORY He says a couple of friends of his have had heart attacks and have had died He used to drink everyday but stopped two years ago He now only drinks on weekends He is on his second week of Chantix which is a medication to come off smoking completely Eating he eats bad food He is single He eats things like bacon eggs and cheese cheeseburgers fast food eats four times a day seven in the morning at noon 9 p m and 2 a m He currently weighs 344 pounds and 5 9 His ideal body weight is 160 pounds He is 184 pounds overweight If he lost 70 of his excess body weight that would be 129 pounds and that would get him down to 215 REVIEW OF SYSTEMS Negative for head neck heart lungs GI GU orthopedic or skin He also is positive for gout He denies chest pain heart attack coronary artery disease congestive heart failure arrhythmia atrial fibrillation pacemaker pulmonary embolism or CVA He denies venous insufficiency or thrombophlebitis Denies shortness of breath COPD or emphysema Denies thyroid problems hip pain osteoarthritis rheumatoid arthritis GERD hiatal hernia peptic ulcer disease gallstones infected gallbladder pancreatitis fatty liver hepatitis rectal bleeding polyps incontinence of stool urinary stress incontinence or cancer He denies cellulitis pseudotumor cerebri meningitis or encephalitis PHYSICAL EXAMINATION He is alert and oriented x 3 Cranial nerves II XII are intact Neck is soft and supple Lungs He has positive wheezing bilaterally Heart is regular rhythm and rate His abdomen is soft Extremities He has 1 pitting edema IMPRESSION PLAN I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding infection deep venous thrombosis pulmonary embolism leakage from the gastrojejuno anastomosis jejunojejuno anastomosis and possible bowel obstruction among other potential complications He understands He wants to proceed with workup and evaluation for laparoscopic Roux en Y gastric bypass He will need to get a letter of approval from Dr XYZ He will need to see a nutritionist and mental health worker He will need an upper endoscopy by either Dr XYZ He will need to go to Dr XYZ as he previously had a sleep study We will need another sleep study He will need H pylori testing thyroid function tests LFTs glycosylated hemoglobin and fasting blood sugar After this is performed we will submit him for insurance approval Keywords bariatrics laparoscopic gastric bypass heart attacks body weight pulmonary embolism potential complications sleep study weight loss gastric bypass anastomosis loss sleep laparoscopic gastric bypass heart pounds weight MEDICAL_TRANSCRIPTION,Description 2 D M Mode Doppler Medical Specialty Cardiovascular Pulmonary Sample Name 2 D Echocardiogram 1 Transcription 2 D M MODE 1 Left atrial enlargement with left atrial diameter of 4 7 cm 2 Normal size right and left ventricle 3 Normal LV systolic function with left ventricular ejection fraction of 51 4 Normal LV diastolic function 5 No pericardial effusion 6 Normal morphology of aortic valve mitral valve tricuspid valve and pulmonary valve 7 PA systolic pressure is 36 mmHg DOPPLER 1 Mild mitral and tricuspid regurgitation 2 Trace aortic and pulmonary regurgitation Keywords cardiovascular pulmonary 2 d m mode doppler aortic valve atrial enlargement diastolic function ejection fraction mitral mitral valve pericardial effusion pulmonary valve regurgitation systolic function tricuspid tricuspid valve normal lv MEDICAL_TRANSCRIPTION,Description 2 D Echocardiogram Medical Specialty Cardiovascular Pulmonary Sample Name 2 D Echocardiogram 2 Transcription 1 The left ventricular cavity size and wall thickness appear normal The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70 to 75 There is near cavity obliteration seen There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination 2 The left atrium appears mildly dilated 3 The right atrium and right ventricle appear normal 4 The aortic root appears normal 5 The aortic valve appears calcified with mild aortic valve stenosis calculated aortic valve area is 1 3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm 6 There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation 7 The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension Estimated pulmonary artery systolic pressure is 49 mmHg Estimated right atrial pressure of 10 mmHg 8 The pulmonary valve appears normal with trace pulmonary insufficiency 9 There is no pericardial effusion or intracardiac mass seen 10 There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum 11 The study was somewhat technically limited and hence subtle abnormalities could be missed from the study Keywords cardiovascular pulmonary 2 d doppler echocardiogram annular aortic root aortic valve atrial atrium calcification cavity ejection fraction mitral obliteration outflow regurgitation relaxation pattern stenosis systolic function tricuspid valve ventricular ventricular cavity wall motion pulmonary artery MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful Medical Specialty Bariatrics Sample Name Laparoscopic Gastric Bypass Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis ANESTHESIA General with endotracheal intubation INDICATION FOR PROCEDURE This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful She has been to our Bariatric Surgery Seminar received some handouts and signed the consent The risks and benefits of the procedure have been explained to the patient PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table All pressure points were carefully padded She was given general anesthesia with endotracheal intubation SCD stockings were placed on both legs Foley catheter was placed for bladder decompression The abdomen was then prepped and draped in standard sterile surgical fashion Marcaine was then injected through umbilicus A small incision was made A Veress needle was introduced into the abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg A 12 mm VersaStep port was placed through the umbilicus I then placed a 5 mm port just anterior to the midaxillary line and just subcostal on the right side I placed another 5 mm port in the midclavicular line just subcostal on the right side a few centimeters below and medial to that I placed a 12 mm VersaStep port On the left side just anterior to the midaxillary line and just subcostal I placed a 5 mm port A few centimeters below and medial to that I placed a 15 mm port I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device I then ran the distal bowel down approximately 100 cm and at 100 cm I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb and I passed a 45 white load stapler and fired a stapler creating a side to side anastomosis I reapproximated the edges of the defect I lifted it up and stapled across it with another white load stapler I then closed the mesenteric defect with interrupted Surgidac sutures I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic I then put the patient in reverse Trendelenburg I placed a liver retractor identified and dissected the angle of His I then dissected on the lesser curve approximately 2 5 cm below the gastroesophageal junction and got into a lesser space I fired transversely across the stomach with a 45 blue load stapler I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His thereby creating my gastric pouch I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil I pulled the anvil into place and I then opened up my 15 mm port site and passed my EEA stapler I passed that in the end of my Roux limb and had the spike come out antimesenteric I joined the spike with the anvil and fired a stapler creating an end to side anastomosis then divided across the redundant portion of my Roux limb with a white load GI stapler and removed it with an Endocatch bag I put some additional 2 0 Vicryl sutures in the anastomosis for further security I then placed a bowel clamp across the bowel I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch I distended gastric pouch with air There was no air leak seen I could pass the scope easily through the anastomosis There was no bleeding seen through the scope We closed the 15 mm port site with interrupted 0 Vicryl suture utilizing Carter Thomason I copiously irrigated out that incision with about 2 L of saline I then closed the skin of all incisions with running Monocryl Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well without any complications Keywords bariatrics gastric bypass eea anastomosis roux en y antegastric antecolic morbid obesity roux limb gastric pouch intubation laparoscopic bypass roux endotracheal anastomosis gastric MEDICAL_TRANSCRIPTION,Description Liposuction of the supraumbilical abdomen revision of right breast reconstruction excision of soft tissue fullness of the lateral abdomen and flank MEDICAL_TRANSCRIPTION,Description 2 D Echocardiogram Medical Specialty Cardiovascular Pulmonary Sample Name 2 D Echocardiogram 3 Transcription 2 D ECHOCARDIOGRAM Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships Cardiac function is normal There is no significant chamber enlargement or hypertrophy There is no pericardial effusion or vegetations seen Doppler interrogation including color flow imaging reveals systemic venous return to the right atrium with normal tricuspid inflow Pulmonary outflow is normal at the valve Pulmonary venous return is to the left atrium The interatrial septum is intact Mitral inflow and ascending aorta flow are normal The aortic valve is trileaflet The coronary arteries appear to be normal in their origins The aortic arch is left sided and patent with normal descending aorta pulsatility Keywords cardiovascular pulmonary 2 d echocardiogram cardiac function doppler echocardiogram multiple views aortic valve coronary arteries descending aorta great vessels heart hypertrophy interatrial septum intracardiac pericardial effusion tricuspid vegetation venous pulmonaryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Suction assisted lipectomy lipodystrophy of the abdomen and thighs Medical Specialty Bariatrics Sample Name Lipectomy Abdomen Thighs Transcription PREOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs POSTOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs OPERATION Suction assisted lipectomy ANESTHESIA General FINDINGS AND PROCEDURE With the patient under satisfactory general endotracheal anesthesia the entire abdomen flanks perineum and thighs to the knees were prepped and draped circumferentially in sterile fashion After this had been completed a 15 blade was used to make small stab wounds in the lateral hips the pubic area and upper edge of the umbilicus Through these small incisions a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen A 3 and 4 mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate which was mostly fat little fluid and blood Attention was then directed to the thighs both inner and outer A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs After this had been completed 3 and 4 mm cannulas were used to suction 650 cc from each side approximately 50 cc in the inner thigh and 600 on each lateral thigh The patient tolerated the procedure very well All of this aspirate was mostly fat with little fluid and very little blood Wounds were cleaned and steri stripped and dressing of ABD pads and was then applied The patient tolerated the procedure very well and was sent to the recovery room in good condition Keywords bariatrics lipodystrophy abd pads suction assisted lipectomy abdomen aspirate lipectomy perineum steri stripped thighs umbilicus abdomen and thighs abdomen thighs MEDICAL_TRANSCRIPTION,Description Echocardiogram and Doppler Medical Specialty Cardiovascular Pulmonary Sample Name 2 D Echocardiogram 4 Transcription DESCRIPTION 1 Normal cardiac chambers size 2 Normal left ventricular size 3 Normal LV systolic function Ejection fraction estimated around 60 4 Aortic valve seen with good motion 5 Mitral valve seen with good motion 6 Tricuspid valve seen with good motion 7 No pericardial effusion or intracardiac masses DOPPLER 1 Trace mitral regurgitation 2 Trace tricuspid regurgitation IMPRESSION 1 Normal LV systolic function 2 Ejection fraction estimated around 60 Keywords cardiovascular pulmonary ejection fraction lv systolic function cardiac chambers regurgitation tricuspid normal lv systolic function normal lv systolic ejection fraction estimated normal lv lv systolic systolic function function ejection echocardiogram doppler lv systolic ejection mitral valve MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy Medical Specialty Bariatrics Sample Name Laparoscopic Gastric Bypass 1 Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy ANESTHESIA General with endotracheal intubation INDICATIONS FOR PROCEDURE This is a 50 year old male who has been overweight for many years and has tried multiple different weight loss diets and programs The patient has now begun to have comorbidities related to the obesity The patient has attended our bariatric seminar and met with our dietician and psychologist The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form PROCEDURE IN DETAIL The risks and benefits were explained to the patient Consent was obtained The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation A Foley catheter was placed for bladder decompression All pressure points were carefully padded and sequential compression devices were placed on the legs The abdomen was prepped and draped in standard sterile surgical fashion Marcaine was injected into the umbilicus Keywords bariatrics morbid obesity roux en y gastric bypass antecolic antegastric anastamosis esophagogastroduodenoscopy eea surgidac sutures roux limb port stapler laparoscopic intubation MEDICAL_TRANSCRIPTION,Description Normal left ventricle moderate biatrial enlargement and mild tricuspid regurgitation but only mild increase in right heart pressures Medical Specialty Cardiovascular Pulmonary Sample Name 2 D Doppler Transcription 2 D STUDY 1 Mild aortic stenosis widely calcified minimally restricted 2 Mild left ventricular hypertrophy but normal systolic function 3 Moderate biatrial enlargement 4 Normal right ventricle 5 Normal appearance of the tricuspid and mitral valves 6 Normal left ventricle and left ventricular systolic function DOPPLER 1 There is 1 to 2 aortic regurgitation easily seen but no aortic stenosis 2 Mild tricuspid regurgitation with only mild increase in right heart pressures 30 35 mmHg maximum SUMMARY 1 Normal left ventricle 2 Moderate biatrial enlargement 3 Mild tricuspid regurgitation but only mild increase in right heart pressures Keywords cardiovascular pulmonary 2 d study doppler tricuspid regurgitation heart pressures stenosis ventricular heart ventricle tricuspid regurgitation MEDICAL_TRANSCRIPTION,Description Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery Medical Specialty Bariatrics Sample Name Gastric Bypass Discussion 3 Transcription PAST MEDICAL HISTORY Significant for hypertension The patient takes hydrochlorothiazide for this She also suffers from high cholesterol and takes Crestor She also has dry eyes and uses Restasis for this She denies liver disease kidney disease cirrhosis hepatitis diabetes mellitus thyroid disease bleeding disorders prior DVT HIV and gout She also denies cardiac disease and prior history of cancer PAST SURGICAL HISTORY Significant for tubal ligation in 1993 She had a hysterectomy done in 2000 and a gallbladder resection done in 2002 MEDICATIONS Crestor 20 mg p o daily hydrochlorothiazide 20 mg p o daily Veramist spray 27 5 mcg daily Restasis twice a day and ibuprofen two to three times a day ALLERGIES TO MEDICATIONS Bactrim which causes a rash The patient denies latex allergy SOCIAL HISTORY The patient is a life long nonsmoker She only drinks socially one to two drinks a month She is employed as a manager at the New York department of taxation She is married with four children FAMILY HISTORY Significant for type II diabetes on her mother s side as well as liver and heart failure She has one sibling that suffers from high cholesterol and high triglycerides REVIEW OF SYSTEMS Positive for hot flashes She also complains about snoring and occasional slight asthma She does complain about peripheral ankle swelling and heartburn She also gives a history of hemorrhoids and bladder infections in the past She has weight bearing joint pain as well as low back degenerating discs She denies obstructive sleep apnea kidney stones bloody bowel movements ulcerative colitis Crohn s disease dark tarry stools and melena PHYSICAL EXAMINATION On examination temperature is 97 7 pulse 84 blood pressure 126 80 respiratory rate was 20 Well nourished well developed in no distress Eye exam pupils equal round and reactive to light Extraocular motions intact Neuro exam deep tendon reflexes 1 in the lower extremities No focal neuro deficits noted Neck exam nonpalpable thyroid midline trachea no cervical lymphadenopathy no carotid bruit Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished Cardiac exam regular rate and rhythm without murmur or bruit Abdominal exam positive bowel sounds soft nontender obese nondistended abdomen No palpable tenderness No right upper quadrant tenderness No organomegaly appreciated No obvious hernias noted Lower extremity exam 1 edema noted Positive dorsalis pedis pulses ASSESSMENT The patient is a 56 year old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities The patient is interested in gastric bypass surgery The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities PLAN In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively I have recommended six weeks of Medifast for the patient to obtain a 10 preoperative weight loss Keywords bariatrics weight watchers roux en y atkins medifast meridia south beach cabbage diets laparoscopic roux en y gastric bypass surgery rice weight loss six weeks of medifast weight loss modalities body mass index gastric bypass surgery bariatric surgery gastric bypass MEDICAL_TRANSCRIPTION,Description Surgical removal of completely bony impacted teeth 1 16 17 and 32 Completely bony impacted teeth 1 16 17 and 32 Medical Specialty Dentistry Sample Name Bony Impacted Teeth Removal Transcription PREOPERATIVE DIAGNOSIS Completely bony impacted teeth 1 16 17 and 32 POSTOPERATIVE DIAGNOSIS Completely bony impacted teeth 1 16 17 and 32 PROCEDURE Surgical removal of completely bony impacted teeth 1 16 17 and 32 ANESTHESIA General nasotracheal COMPLICATIONS None CONDITION Stable to PACU DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure A gauze throat pack was placed and local anesthetic was administered in all four quadrants a total of 7 2 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of bupivacaine 0 5 with 1 200 000 epinephrine Beginning on the upper right tooth 1 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal aspect with straight elevator Potts elevator was then used to luxate the tooth from the socket Remnants of the follicle were then removed with hemostat The area was irrigated and then closed with 3 0 gut suture On the lower right tooth 32 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal and distal aspect with a high speed drill with a round bur Tooth was then sectioned with the bur and removed in several pieces Remnants of the follicle were removed with a curved hemostat The area was irrigated with normal saline solution and closed with 3 0 gut sutures Moving to 16 on the upper left incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal aspect with straight elevator Potts elevator was then used to luxate the tooth from the socket Remnants of the follicle were removed with a curved hemostat The area was irrigated with normal saline solution and closed with 3 0 gut sutures Moving to the lower left 17 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal and distal aspect with high speed drill with a round bur Then the bur was used to section the tooth vertically Tooth was removed in several pieces followed by the removal of the remnants of the follicle The area was irrigated with normal saline solution and closed with 3 0 gut sutures Upon completion of the procedure the throat pack was removed and the pharynx was suctioned An NG tube was then inserted and small amount of gastric contents were suctioned Patient was then awakened extubated and taken to the PACU in stable condition Keywords dentistry intraoral bony impacted teeth throat pack buccal aspect saline solution gut sutures envelope flap periosteal elevator MEDICAL_TRANSCRIPTION,Description Preoperative visit for weight management with laparoscopic gastric banding Medical Specialty Bariatrics Sample Name Laparoscopic Gastric Banding Preop Visit Transcription HISTORY OF PRESENT ILLNESS I have seen ABC today for her preoperative visit for weight management I have explained to her the need for Optifast for weight loss prior to these procedures to make it safer because of the large size of her liver She understands this IMPRESSION PLAN We are going to put her on two weeks of Optifast at around 900 calories I have also explained the risks and potential complications of laparoscopic cholecystectomy to her in detail including bleeding infection deep venous thrombosis pulmonary embolism injury to the small intestine stomach liver leak from the cystic duct common bile duct and possible need for ERCP and further surgery This surgery is going to be planned for October 6 This is for cholelithiasis prior to her Lap Banding procedure I have also reviewed with her the risks and potential complications of laparoscopic gastric banding including bleeding infection deep venous thrombosis pulmonary embolism slippage of the band erosion of the band injury to the esophagus stomach small intestine large intestine spleen liver injury to the band port or tubing necessitating replacement of the band port or tubing among other potential complications and she understands We are going to proceed for laparoscopic gastric banding I have reviewed her entire chart in detail I have also gone over with her the Fairfield County Bariatrics consent form for banding and all the risks She has also signed the St Vincent s Hospital consent form for Lap Banding She has taken the preoperative quiz for banding She has signed the preop and postop instructions and understands them and we reviewed them She has taken the quiz and done fairly well We have reviewed with her any potential other issues and I have answered her questions She is planned for surgical intervention Keywords bariatrics laparoscopic gastric banding pulmonary embolism lap banding potential complications gastric banding banding stomach gastric laparoscopic weightNOTE MEDICAL_TRANSCRIPTION,Description Neck exploration tracheostomy urgent flexible bronchoscopy via tracheostomy site removal of foreign body tracheal metallic stent material dilation distal trachea placement of 8 Shiley single cannula tracheostomy tube Medical Specialty Cardiovascular Pulmonary Sample Name Tracheostomy Transcription PREOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea POSTOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea OPERATION PERFORMED Neck exploration tracheostomy urgent flexible bronchoscopy via tracheostomy site removal of foreign body tracheal metallic stent material dilation distal trachea placement of 8 Shiley single cannula tracheostomy tube INDICATIONS FOR SURGERY The patient is a 50 year old white male with history of progressive tracheomalacia treated in the National Tennessee and several years ago he had a tracheal metallic stent placed with some temporary improvement However developed progressive problems and he had two additional stents placed with some initial improvement Subsequently he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD YYYY He underwent bronchoscopy by Dr W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management Exploration of trachea removal of foreign body stents constricting his airway dilation and stabilization of his trachea were offered to the patient Nature of the proposed procedure including risks and complications of bleeding infection alteration of voice speech swallowing voice changes permanently possibility of tracheotomy temporarily or permanently to maintain his airway loss of voice cardiac risk factors anesthetic risks recurrence of problems upon surgical intervention were all discussed at length The patient stated that he understood and wished to proceed DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in the supine position Following adequate monitoring by Anesthesia Service to maintain sedation the patient s neck was prepped and draped in the sterile fashion The neck was then infiltrated with 1 Xylocaine and 1000 epinephrine A collar incision approximately 1 fingerbreadth above the clavicle this was an outline incision was carried out The skin subcutaneous tissue platysma subplatysmal flaps elevated superiorly and inferiorly Strap muscles were separated in the midline dissection carried down to visceral fascia Beneath the strap muscles there was dense inflammation scarring obscuring palpable landmarks There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable There was a markedly enlarged thyroid isthmus Thyroid isthmus was divided and dense inflammation attachment of the thyroid isthmus fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection Trachea was exposed from the cricoid to the fourth ring which entered down into the chest The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation The tracheal cartilage externally had marked thickening and significant stiffness calcification and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness The trachea was entered and visualized with thickening of the mucosa and submucosa was noted The patient however was able to ventilate at this point a 6 Endo Tube was inserted and general anesthesia administered Once the airway was secured we then proceeded working around the 6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis After removal of the stents and granulation tissue the upper trachea was widely patent The mid trachea had some marked narrowing secondary to granulation Stent material was removed from this area as well In the distal third of the trachea a third stent was embedded within the mucosa not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time All visible stent material in the upper and mid trachea were removed Initial attempt to place a 16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third Also this was removed and a 8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa The distal trachea and mainstem bronchi were widely patent This secured his airway and no further manipulation felt to be needed at this time Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3 0 Vicryl The skin laterally to the trach site was closed with running 2 0 Prolene Tracheostomy tube was secured with interrupted 2 0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition The patient tolerated the procedure well without complication Keywords cardiovascular pulmonary airway laryngology shiley alteration of voice bronchi bronchoscopy cannula cartilage cricoid flexible foreign body mainstem obstruction perichondrium stenosis stent subglottic swallowing trachea tracheal tracheal stenosis tracheostomy shiley single cannula tracheostomy shiley single cannula single cannula tracheostomy thyroid isthmus stent material tracheostomy tube tube thyroid MEDICAL_TRANSCRIPTION,Description Patient status post lap band placement Medical Specialty Bariatrics Sample Name Lap Band Adjustment Transcription REASON FOR VISIT Lap band adjustment HISTORY OF PRESENT ILLNESS Ms A is status post lap band placement back in 01 09 and she is here on a band adjustment Apparently she had some problems previously with her adjustments and apparently she has been under a lot of stress She was in a car accident a couple of weeks ago and she has problems she does not feel full She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better PHYSICAL EXAMINATION On exam her temperature is 98 pulse 76 weight 197 7 pounds blood pressure 102 72 BMI is 38 5 she has lost 3 8 pounds since her last visit She was alert and oriented in no apparent distress PROCEDURE I was able to access her port She does have an AP standard low profile I aspirated 6 mL I did add 1 mL so she has got approximately 7 mL in her band she did tolerate water postprocedure ASSESSMENT The patient is status post lap band adjustments doing well has a total of 7 mL within her band tolerated water postprocedure She will come back in two weeks for another adjustment as needed Keywords bariatrics lap band adjustment lap band placement lap band MEDICAL_TRANSCRIPTION,Description Fertile male with completed family Elective male sterilization via bilateral vasectomy Medical Specialty Urology Sample Name Vasectomy 4 Transcription PROCEDURE Elective male sterilization via bilateral vasectomy PREOPERATIVE DIAGNOSIS Fertile male with completed family POSTOPERATIVE DIAGNOSIS Fertile male with completed family MEDICATIONS Anesthesia is local with conscious sedation COMPLICATIONS None BLOOD LOSS Minimal INDICATIONS This 34 year old gentleman has come to the office requesting sterilization via bilateral vasectomy I discussed the indications and the need for procedure with the patient in detail and he has given consent to proceed He has been given prophylactic antibiotics PROCEDURE NOTE Once satisfactory sedation have been obtained the patient was placed in the supine position on the operating table Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely The procedure itself was started by grasping the right vas deferens in the scrotum and bringing it up to the level of the skin The skin was infiltrated with 2 Xylocaine and punctured with a sharp hemostat to identify the vas beneath The vas was brought out of the incision carefully A 2 inch segment was isolated and 1 inch segment was removed The free ends were cauterized and were tied with 2 0 silk sutures in such a fashion that the ends double back on themselves After securing hemostasis with a cautery the ends were allowed to drop back into the incision which was also cauterized Attention was now turned to the left side The vas was grasped and brought up to the level of the skin The skin was infiltrated with 2 Xylocaine and punctured with a sharp hemostat to identify the vas beneath The vas was brought out of the incision carefully A 2 inch segment was isolated and 1 inch segment was removed The free ends were cauterized and tied with 2 0 silk sutures in such a fashion that the ends double back on themselves After securing hemostasis with the cautery the ends were allowed to drop back into the incision which was also cauterized Bacitracin ointment was applied as well as dry sterile dressing The patient was awakened and was returned to Recovery in satisfactory condition Keywords urology sterilization vas fertile male bilateral vasectomy vasectomy cauterized MEDICAL_TRANSCRIPTION,Description The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone Medical Specialty General Medicine Sample Name Airway Compromise Foreign Body ER Visit Transcription HISTORY OF PRESENT ILLNESS The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone PAST MEDICAL HISTORY Significant for diabetes hypertension asthma cholecystectomy and total hysterectomy and cataract ALLERGIES No known drug allergies CURRENT MEDICATIONS Prevacid Humulin Diprivan Proventil Unasyn and Solu Medrol FAMILY HISTORY Noncontributory SOCIAL HISTORY Negative for illicit drugs alcohol and tobacco PHYSICAL EXAMINATION Please see the hospital chart LABORATORY DATA Please see the hospital chart HOSPITAL COURSE The patient was taken to the operating room by Dr X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated If not she would require tracheostomy The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated She was doing well with good p o s good airway good voice and desiring to be discharged home So the patient is being prepared for discharge at this point We will have Dr X evaluate her before she leaves to make sure I do not have any problem with her going home Dr Y feels she could be discharged today and will have her return to see him in a week Keywords general medicine diabetes hypertension asthma cholecystectomy fishbone foreign body airway compromise airway MEDICAL_TRANSCRIPTION,Description Whole body radionuclide bone scan due to prostate cancer Medical Specialty Urology Sample Name Whole Body Radionuclide Bone Scan Transcription INDICATION Prostate Cancer TECHNIQUE 3 5 hours following the intravenous administration of 26 5 mCi of Technetium 99m MDP the skeleton was imaged in the anterior and posterior projections FINDINGS There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull The uptake in the remainder of the skeleton is within normal limits The kidneys image normally There is increased activity in the urinary bladder suggesting possible urinary retention CONCLUSION 1 Focus of abnormal increased tracer activity overlying the right parietal region of the skull CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated 2 There is probably some degree of urinary retention Keywords urology prostate cancer technetium whole body urinary retention bone scan radionuclide MEDICAL_TRANSCRIPTION,Description Patient discharged after laparoscopic Roux en Y gastric bypass Medical Specialty Bariatrics Sample Name Gastric Bypass Summary Transcription FINAL DIAGNOSES 1 Morbid obesity status post laparoscopic Roux en Y gastric bypass 2 Hypertension 3 Obstructive sleep apnea on CPAP OPERATION AND PROCEDURE Laparoscopic Roux en Y gastric bypass BRIEF HOSPITAL COURSE SUMMARY This is a 30 year old male who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities Underwent standard bariatric evaluation consults diagnostics and preop Medifast induced weight loss in anticipation of elective bariatric surgery Taken to the OR via same day surgery process for elective gastric bypass tolerated well recovered in the PACU and sent to the floor for routine postoperative care There DVT prophylaxis was continued with subcu heparin early and frequent mobilization and SCDs PCA was utilized for pain control efficaciously he utilized the CPAP was monitored and had no new cardiopulmonary complaints Postop day 1 labs within normal limits able to clinically start bariatric clear liquids at 2 ounces per hour this was tolerated well He was ambulatory had no cardiopulmonary complaints no unusual fever or concerning symptoms By the second postoperative day was able to advance to four ounces per hour tolerated this well and is able to discharge in stable and improved condition today He had his drains removed today as well DISCHARGE INSTRUCTIONS Include re appointment in the office in the next week call in the interim if any significant concerning complaints Scripts left in the chart for omeprazole and Lortab Med rec sheet completed on no meds He will maintain bariatric clear liquids at home goal 64 ounces per day maintain activity at home but no heavy lifting or straining Can shower starting tomorrow drain site care and wound care reviewed He will re appoint in the office in the next week certainly call in the interim if any significant concerning complaints Keywords bariatrics medifast laparoscopic roux en y gastric bypass roux en y bariatric clear liquids gastric bypass laparoscopic gastric bariatric bypass MEDICAL_TRANSCRIPTION,Description Normal vasectomy Medical Specialty Urology Sample Name Vasectomy 1 Transcription DESCRIPTION The patient was placed in the supine position and was prepped and draped in the usual manner The left vas was grasped in between the fingers The skin and vas were anesthetized with local anesthesia The vas was grasped with an Allis clamp Skin was incised and the vas deferens was regrasped with another Allis clamp The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips two in the testicular side and one on the proximal side The incision was then inspected for hemostasis and closed with 3 0 chromic catgut interrupted fashion A similar procedure was carried out on the right side Dry sterile dressings were applied and the patient put on a scrotal supporter The procedure was then terminated Keywords urology vasectomy allis clamp catgut hemoclips iris scissors scrotal scrotal supporter testicular vas vas deferens vas was grasped deferens clampsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Voluntary sterility Bilateral vasectomy The vas deferens was grasped with a vas clamp Next the vas deferens was skeletonized It was clipped proximally and distally twice Medical Specialty Urology Sample Name Vasectomy Transcription PREOPERATIVE DIAGNOSIS Voluntary sterility POSTOPERATIVE DIAGNOSIS Voluntary sterility OPERATIVE PROCEDURE Bilateral vasectomy ANESTHESIA Local INDICATIONS FOR PROCEDURE A gentleman who is here today requesting voluntary sterility Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy DESCRIPTION OF PROCEDURE The patient was brought to the operating room and after appropriately identifying the patient the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table Then 0 25 Marcaine without epinephrine was used to anesthetize the scrotal skin A small incision was made in the right hemiscrotum The vas deferens was grasped with a vas clamp Next the vas deferens was skeletonized It was clipped proximally and distally twice The cut edges were fulgurated Meticulous hemostasis was maintained Then 4 0 chromic was used to close the scrotal skin on the right hemiscrotum Next the attention was turned to the left hemiscrotum and after the left hemiscrotum was anesthetized appropriately a small incision was made in the left hemiscrotum The vas deferens was isolated It was skeletonized It was clipped proximally and distally twice The cut edges were fulgurated Meticulous hemostasis was maintained Then 4 0 chromic was used to close the scrotal skin A jockstrap and sterile dressing were applied at the end of the case Sponge needle and instruments counts were correct Keywords urology hemiscrotum bilateral vasectomy voluntary sterility vas deferens vasectomy skeletonized scrotal sterility deferens MEDICAL_TRANSCRIPTION,Description Normal vasectomy Medical Specialty Urology Sample Name Vasectomy 2 Transcription DIAGNOSIS Desires vasectomy NAME OF OPERATION Vasectomy ANESTHESIA General HISTORY Patient 37 desires a vasectomy PROCEDURE Through a midline scrotal incision the right vas was identified and separated from the surrounding tissues clamped transected and tied off with a 4 0 chromic No bleeding was identified Through the same incision the left side was identified transected tied off and dropped back into the wound Again no bleeding was noted The wound was closed with 4 0 Vicryl times two He tolerated the procedure well A sterile dressing was applied He was awakened and transferred to the recovery room in stable condition Keywords urology scrotal incision right vas bleeding anesthesia vasectomy MEDICAL_TRANSCRIPTION,Description Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction Medical Specialty Urology Sample Name Urology Discharge Summary Transcription PROCEDURES Cystourethroscopy and transurethral resection of prostate COMPLICATIONS None ADMITTING DIAGNOSIS Difficulty voiding HISTORY This 67 year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction Physical examination revealed normal heart and lungs Abdomen was negative for abnormal findings LABORATORY DATA BUN 19 and creatinine 1 1 Blood group was A Rh positive Hemoglobin 13 Hematocrit 32 1 Prothrombin time 12 6 seconds PTT 37 1 Discharge hemoglobin 11 4 and hematocrit 33 3 Chest x ray calcified old granulomatous disease otherwise normal EKG was normal COURSE IN THE HOSPITAL The patient had a cysto and TUR of the prostate Postoperative course was uncomplicated The pathology report is pending at the time of dictation He is being discharged in satisfactory condition with a good urinary stream minimal hematuria and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet DISCHARGE DIAGNOSIS Enlarged prostate with benign bladder neck obstruction To be followed in my office in one week and by Dr ABC next available as an outpatient Keywords urology tur bun cystourethroscopy difficulty voiding bladder neck obstruction creatinine cysto enlarged prostate transurethral resection of prostate urinary stream bladder neck neck obstruction prostate MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair template The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia Medical Specialty Urology Sample Name Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Umbilical hernia POSTOPERATIVE DIAGNOSIS Umbilical hernia PROCEDURE PERFORMED Repair of umbilical hernia ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was prepped and draped in the sterile fashion An infraumbilical incision was formed and taken down to the fascia The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia and then the wounds were infiltrated with 0 25 Marcaine The skin was reattached to the fascia with 2 0 Vicryls The skin was approximated with 2 0 Vicryl subcutaneous and then 4 0 Monocryl subcuticular stitches dressed with Steri Strips and 4 x 4 s Patient was extubated and taken to the recovery area in stable condition Keywords urology marcaine steri strips mattress sutures umbilical hernia repair umbilical hernia MEDICAL_TRANSCRIPTION,Description Vasectomy 10 years ago failed Azoospermic Reversal two years ago Interested in sperm harvesting and cryopreservation Medical Specialty Urology Sample Name Urology Letter Transcription Sample Address RE Sample Patient Wife s name Sample Name Dear Sample Doctor Mr Sample Patient was seen on Month DD YYYY describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan He has remained azoospermic postoperatively The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife Apparently several attempts at induction have been tried and due to some anatomic abnormality they have been unsuccessful At the time that he left the office he was asking for cryopreservation At the time of sperm harvesting I recently received a phone call suggesting that he does not want to do this at all unless his wife s ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately At his initial request Month DD YYYY was picked as the date for scheduled harvesting although this may change if you require fresh specimen Thank you very much for the opportunity to have seen him Sample Doctor M D Keywords urology letter urology letter azoospermic cryopreservation specimen harvest sperm harvesting vasectomy vasectomy reversal fresh specimen reversal sperm MEDICAL_TRANSCRIPTION,Description Desire for sterility Vasectomy The vas was identified skin was incised and no scalpel instruments were used to dissect out the vas Medical Specialty Urology Sample Name Vasectomy 3 Transcription PREOPERATIVE DIAGNOSIS Desire for sterility POSTOPERATIVE DIAGNOSIS Desire for sterility OPERATIVE PROCEDURES Vasectomy DESCRIPTION OF PROCEDURE The patient was brought to the suite where after oral sedation the scrotum was prepped and draped Then 1 lidocaine was used for anesthesia The vas was identified skin was incised and no scalpel instruments were used to dissect out the vas A segment about 3 cm in length was dissected out It was clipped proximally and distally and then the ends were cauterized after excising the segment Minimal bleeding was encountered and the scrotal skin was closed with 3 0 chromic The identical procedure was performed on the contralateral side He tolerated it well He was discharged from the surgical center in good condition with Tylenol with Codeine for pain He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead Call if there are questions or problems prior to that time Keywords urology vas contralateral desire for sterility scalpel sterility vasectomy MEDICAL_TRANSCRIPTION,Description The patient noted for improving retention of urine postop vaginal reconstruction very concerned of possible vaginal prolapse Medical Specialty Urology Sample Name Urinary Retention Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup No dysuria gross hematuria fever chills She continues to have urinary incontinence especially while changing from sitting to standing position as well as urge incontinence She is voiding daytime every 1 hour in the morning especially after taking Lasix which tapers off in the afternoon nocturia time 0 No incontinence No straining to urinate Good stream emptying well No bowel issues however she also indicates that while using her vaginal cream she has difficulty doing this as she feels protrusion in the vagina and very concerned if she has a prolapse IMPRESSION 1 The patient noted for improving retention of urine postop vaginal reconstruction very concerned of possible vaginal prolapse especially while using the cream 2 Rule out ascites with no GI issues other than lower extremity edema PLAN Following a detailed discussion with the patient she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily She will follow up next week request Dr X to do a pelvic exam and in the meantime she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention All questions answered Keywords urology urinary retention dysuria gross hematuria postop vaginal reconstruction vaginal reconstruction vaginal prolapse urinary retention prolapse vaginal incontinence MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Urology Sample Name Umbilical Hernia Repair 1 Transcription PROCEDURE PERFORMED Umbilical hernia repair PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table The patient was sedated and an adequate local anesthetic was administered using 1 lidocaine without epinephrine The patient was prepped and draped in the usual sterile manner A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery The sac was cleared of overlying adherent tissue and the fascial defect was delineated The fascia was cleared of any adherent tissue for a distance of 1 5 cm from the defect The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures The umbilicus was then re formed using 4 0 Vicryl to tack the umbilical skin to the fascia The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The skin was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords urology fascial defect umbilical hernia repair curvilinear umbilical hernia sac metzenbaum scissors umbilical hernia bovie electrocautery electrocautery hernia incision umbilical MEDICAL_TRANSCRIPTION,Description Persistent frequency and urgency in a patient with a history of neurogenic bladder and history of stroke Medical Specialty Urology Sample Name Urinary Frequency Urgency Followup Transcription HISTORY OF PRESENT ILLNESS This is a 55 year old female with a history of stroke who presents today for followup of frequency and urgency with urge incontinence This has been progressively worsening and previously on VESIcare with no improvement She continues to take Enablex 50 mg and has not noted any improvement of her symptoms The nursing home did not do a voiding diary She is accompanied by her power of attorney No dysuria gross hematuria fever or chills No bowel issues and does use several Depends a day Recent urodynamics in April 2008 here in the office revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes and cystoscopy was unremarkable IMPRESSION Persistent frequency and urgency in a patient with a history of neurogenic bladder and history of stroke This has not improved on VESIcare as well as Enablex Options are discussed We discussed other options of pelvic floor rehabilitation InterStim by Dr X as well as more invasive procedure The patient and the power of attorney would like him to proceed with meeting Dr X to discuss InterStim which was briefly reviewed here today and brochure for this is provided today Prior to discussion the nursing home will do an extensive voiding diary for one week while she is on Enablex and if this reveals no improvement the patient will be started on Ventura twice daily and prescription is provided They will see Dr X with a prior voiding diary which is again discussed All questions answered PLAN As above the patient will be scheduled to meet with Dr X to discuss option of InterStim and will be accompanied by her power of attorney In the meantime Sanctura prescription is provided and voiding diaries are provided All questions answered Keywords urology neurogenic bladder urge incontinence urgency frequency vesicare enablex persistent frequency and urgency frequency and urgency persistent frequency voiding diary voiding MEDICAL_TRANSCRIPTION,Description Ultrasound examination of the scrotum due to scrotal pain Duplex and color flow imaging as well as real time gray scale imaging of the scrotum and testicles was performed Medical Specialty Urology Sample Name Ultrasound Scrotum Transcription EXAM Ultrasound examination of the scrotum REASON FOR EXAM Scrotal pain FINDINGS Duplex and color flow imaging as well as real time gray scale imaging of the scrotum and testicles was performed The left testicle measures 5 1 x 2 8 x 3 0 cm There is no evidence of intratesticular masses There is normal Doppler blood flow The left epididymis has an unremarkable appearance There is a trace hydrocele The right testicle measures 5 3 x 2 4 x 3 2 cm The epididymis has normal appearance There is a trace hydrocele No intratesticular masses or torsion is identified There is no significant scrotal wall thickening IMPRESSION Trace bilateral hydroceles which are nonspecific otherwise unremarkable examination Keywords urology scrotal pain epididymis torsion ultrasound examination intratesticular masses ultrasound scrotal testicles scrotum MEDICAL_TRANSCRIPTION,Description Transurethral resection of a medium bladder tumor TURBT left lateral wall Medical Specialty Urology Sample Name Transurethral Resection Of Bladder Tumor Transcription PREOPERATIVE DIAGNOSIS Bladder tumor POSTOPERATIVE DIAGNOSIS Bladder tumor PROCEDURE PERFORMED Transurethral resection of a medium bladder tumor TURBT left lateral wall ANESTHESIA Spinal SPECIMEN TO PATHOLOGY Bladder tumor and specimen from base of bladder tumor DRAINS A 22 French 3 way Foley catheter 30 mL balloon ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE This is a 74 year old male who presented with microscopic and an episode of gross hematuria He underwent an IVP which demonstrated enlarged prostate and normal upper tracts Cystoscopy in the office demonstrated a 2 5 to 3 cm left lateral wall bladder tumor He is brought to the operating room for transurethral resection of that bladder tumor DESCRIPTION OF OPERATION After preoperative counseling of the patient and his wife the patient was taken to the operating room and administered a spinal anesthetic He was placed in lithotomy position and prepped and draped in the usual fashion Using the visual obturator the resectoscope was then inserted per urethra into the bladder The bladder was inspected confirming previous cystoscopic findings of a 2 5 to 3 cm left lateral wall bladder tumor away from the ureteral orifice Using the resectoscope loop the tumor was then resected down to its base in a stepwise fashion Following completion of resection down to the base the bladder was _______ free of tumor specimen The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen this was sent as a separate pathological specimen Hemostasis was assured with electrocautery The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor Following completion of the fulguration there was good hemostasis The remainder of the bladder was without evidence of significant abnormality Both ureteral orifices were visualized and noted to drain freely of clear urine The bladder was filled and the resectoscope was removed A 22 French 3 way Foley catheter was inserted per urethra into the bladder The balloon was inflated to 30 mL The catheter with sterile continuous irrigation and was noted to drain clear irrigant The patient was then removed from lithotomy position He was in stable condition Keywords urology turbt bladder tumor cystoscopic resectoscope hemostasis foley catheter tumor bladder lithotomy transurethral resection hematuria MEDICAL_TRANSCRIPTION,Description Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia Medical Specialty Urology Sample Name TURP Transcription PREOPERATIVE DIAGNOSIS Benign prostatic hyperplasia POSTOPERATIVE DIAGNOSIS Benign prostatic hyperplasia OPERATION PERFORMED Transurethral electrosurgical resection of the prostate ANESTHESIA General COMPLICATIONS None INDICATIONS FOR THE SURGERY This is a 77 year old man with severe benign prostatic hyperplasia He has had problem with urinary retention and bladder stones in the past He will need to have transurethral resection of prostate to alleviate the above mentioned problems Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Formation of urethral strictures PROCEDURE IN DETAIL The patient was identified after which he was taken into the operating room General LMA anesthesia was then administered The patient was given prophylactic antibiotic in the preoperative holding area The patient was then positioned prepped and draped Cystoscopy was then performed by using a 26 French continuous flow resectoscopic sheath and a visual obturator The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe The anterior urethra was normal without strictures or lesions The bladder was severely trabeculated with multiple bladder diverticula There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone Using the resection apparatus and a right angle resection loop the prostate was resected initially at the area of the median lobe Once the median lobe has completely resected the left lateral lobe and then the right lateral lobes were taken down Once an adequate channel had been achieved the prostatic specimen was retrieved from the bladder by using an Ellik evacuator A 3 mm bar electrode was then introduced into the prostate to achieve perfect hemostasis The sheath was then removed under direct vision and a 24 French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained The patient tolerated the operation well Keywords urology benign prostatic hyperplasia cystoscopy foley catheter turp transurethral bladder bladder diverticula electrosurgical obturator prostate resectoscopic transurethral resection urinary retention resection of the prostate transurethral electrosurgical resection anesthesia hyperplasia resection prostatic MEDICAL_TRANSCRIPTION,Description Transurethral resection of the bladder tumor TURBT large Medical Specialty Urology Sample Name TURBT 1 Transcription PREOPERATIVE DIAGNOSIS Bladder cancer POSTOPERATIVE DIAGNOSIS Bladder cancer OPERATION Transurethral resection of the bladder tumor TURBT large ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is an 82 year old male who presented to the hospital with renal insufficiency syncopal episodes The patient was stabilized from cardiac standpoint on a renal ultrasound The patient was found to have a bladder mass The patient does have a history of bladder cancer Options were watchful waiting resection of the bladder tumor were discussed Risk of anesthesia bleeding infection pain MI DVT PE were discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure DETAILS OF THE OR The patient was brought to the OR anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in the usual sterile fashion A 23 French scope was inserted inside the urethra into the bladder The entire bladder was visualized which appeared to have a large tumor lateral to the right ureteral opening There was a significant papillary superficial fluffiness around the left ________ There was a periureteral diverticulum lateral to the left ureteral opening There were moderate trabeculations throughout the bladder There were no stones Using a French cone tip catheter bilateral pyelograms were obtained which appeared normal Subsequently using 24 French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base Deep biopsies were sent separately Coagulation was performed around the periphery and at the base of the tumor All the tumors were removed and sent for path analysis There was an excellent hemostasis The rest of the bladder appeared normal There was no further evidence of tumor At the end of the procedure a 22 three way catheter was placed and the patient was brought to the recovery in a stable condition Keywords urology transurethral resection of the bladder tumor transurethral resection bladder cancer bladder tumor bladder turbt insufficiency tumor MEDICAL_TRANSCRIPTION,Description Cystoscopy transurethral resection of medium bladder tumor 4 0 cm in diameter and direct bladder biopsy Medical Specialty Urology Sample Name TURBT Transcription PREOPERATIVE DIAGNOSIS Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder POSTOPERATIVE DIAGNOSIS Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder TITLE OF OPERATION Cystoscopy transurethral resection of medium bladder tumor 4 0 cm in diameter and direct bladder biopsy ANESTHESIA General laryngeal mask INDICATIONS This patient is a 59 year old white male who had an initial occurrence of a transitional cell carcinoma 5 years back He was found to have a new tumor last fall and cystoscopy in November showed Ta papillary appearing lesion inside the bladder neck anteriorly The patient had coronary artery disease and required revascularization which occurred at the end of December prior to the tumor resection He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT FINDINGS Cystoscopy of the anterior and posterior urethra was within normal limits From 12 o clock to 4 o clock inside the bladder neck there was a papillary tumor with some associated blood clot This was completely resected There was an abnormal dysplastic area in the left lateral wall that was biopsied and the remainder of the bladder mucosa appeared normal The ureteral orifices were in the orthotopic location Prostate was 15 g and benign on rectal examination and there was no induration of the bladder PROCEDURE IN DETAIL The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion He had been given oral ciprofloxacin for prophylaxis Rectal bimanual examination was performed with the findings described Cystourethroscopy was performed with a 23 French ACMI panendoscope and 70 degree lens with the findings described A barbotage urine was obtained for cytology The cystoscope was removed and a 24 French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced Several biopsies were taken from the tumor and sent to the tumor bank I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria Because of the Ta appearance I did not intentionally dissect deeper into the muscle Complete hemostasis was obtained All the chips were removed with an Ellik evacuator Using the cold cup biopsy forceps biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved The irrigant was clear At the conclusion of the procedure the resectoscope was removed and a 24 French Foley catheter was placed for efflux of clear irrigant The patient was then returned to the supine position awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords urology transitional cell carcinoma urinary bladder bladder tumor cystoscopy transurethral resection acmi panendoscope foley catheter cold cup biopsy forceps ta nx mx cold cup biopsy laryngeal mask bladder neck bladder biopsy tumor MEDICAL_TRANSCRIPTION,Description Left spermatocelectomy epididymectomy and bilateral partial vasectomy Left spermatocele and family planning Medical Specialty Urology Sample Name Spermatocelectomy Epididymectomy Vasectomy Transcription PREOPERATIVE DIAGNOSES 1 Left spermatocele 2 Family planning POSTOPERATIVE DIAGNOSES 1 Left spermatocele 2 Family planning PROCEDURE PERFORMED 1 Left spermatocelectomy epididymectomy 2 Bilateral partial vasectomy ANESTHESIA General ESTIMATED BLOOD LOSS Minimal SPECIMEN Left sided spermatocele epididymis and bilateral partial vasectomy DISPOSITION To PACU in stable condition INDICATIONS AND FINDINGS This is a 48 year old male with a history of a large left sided spermatocele with significant discomfort The patient also has family status complete and desired infertility The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy FINDINGS At this time of the surgery significant left sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to the operating room A general anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in the normal sterile fashion for a scrotal approach A 15 blade was used to make a transverse incision on the left hemiscrotum Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field The left testicle was examined A large spermatocele was noted Metzenbaum scissors were used to dissect the tissue around the left spermatocele Once the spermatocele was identified as stated above significant size was noted encompassing the entire left epididymis Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery Electrocautery was used to confirm excellent hemostasis Attention was then turned to the more proximal aspect of the cord The vas deferens was palpated and dissected free with Metzenbaum scissors Hemostats were placed on the two aspects of the cord approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends Testicle was placed back in the scrotum in appropriate anatomic position The dartos tissue was closed with running 3 0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with 4 0 chromic Attention was then turned to the right side The vas was palpated in the scrotum A small skin incision was made with a 15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat Two ends were hemostated with hemostats and divided with Metzenbaum scissors Lumen was coagulated with electrocautery Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum A 4 0 chromic suture was used in simple fashion to reapproximate the skin incision Scrotum was cleaned and bacitracin ointment sterile dressing fluffs and supportive briefs applied The patient was sent to Recovery in stable condition He was given prescriptions for doxycycline 100 mg b i d for five days and Vicodin ES 1 p o q 4h p r n pain 30 for pain The patient is to followup with Dr X in seven days Keywords urology partial vasectomy spermatocele epididymis family planning vas deferens metzenbaum scissors vasectomy spermatocelectomy epididymectomy testicle deferens hemostats electrocautery MEDICAL_TRANSCRIPTION,Description Left testicular swelling for one day Testicular Ultrasound Hypervascularity of the left epididymis compatible with left epididymitis Bilateral hydroceles Medical Specialty Urology Sample Name Testicular Ultrasound Transcription TESTICULAR ULTRASOUND REASON FOR EXAM Left testicular swelling for one day FINDINGS The left testicle is normal in size and attenuation it measures 3 2 x 1 7 x 2 3 cm The right epididymis measures up to 9 mm There is a hydrocele on the right side Normal flow is seen within the testicle and epididymis on the right The left testicle is normal in size and attenuation it measures 3 9 x 2 1 x 2 6 cm The left testicle shows normal blood flow The left epididymis measures up to 9 mm and shows a markedly increased vascular flow There is mild scrotal wall thickening A hydrocele is seen on the left side IMPRESSION 1 Hypervascularity of the left epididymis compatible with left epididymitis 2 Bilateral hydroceles Keywords urology hypervascularity bilateral hydroceles epididymis epididymitis testicular ultrasound ultrasound flow hydroceles testicle testicular MEDICAL_TRANSCRIPTION,Description Salvage cystectomy very difficult due to postradical prostatectomy and postradiation therapy to the pelvis Indiana pouch continent cutaneous diversion and omental pedicle flap to the pelvis Medical Specialty Urology Sample Name Salvage Cystectomy Transcription PREOPERATIVE DIAGNOSES 1 Radiation cystitis 2 Refractory voiding dysfunction 3 Status post radical retropubic prostatectomy and subsequent salvage radiation therapy POSTOPERATIVE DIAGNOSES 1 Radiation cystitis 2 Refractory voiding dysfunction 3 Status post radical retropubic prostatectomy and subsequent salvage radiation therapy TITLE OF OPERATION Salvage cystectomy very difficult due to postradical prostatectomy and postradiation therapy to the pelvis Indiana pouch continent cutaneous diversion and omental pedicle flap to the pelvis ANESTHESIA General endotracheal with epidural INDICATIONS This patient is a 65 year old white male who in 1998 had a radical prostatectomy He was initially dry without pads and then underwent salvage radiation therapy for rising PSA After that he began with episodes of incontinence as well as urinary retention requiring catheterization One year ago he was unable to catheterize and was taken to the operative room and had cystoscopy He had retained staple removed and a diverticulum identified There were also bladder stones that were lasered and removed and he had been incontinent ever since that time He wears 8 to 10 pads per day and this has affected his quality of life significantly I took him to the operating room on January 16 2008 and found diffuse radiation changes with a small capacity bladder and wide open bladder neck We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him I felt like if we could remove the bladder safely then this would also provide a benefit FINDINGS At exploration there were no gross lesions of the smaller or large bowel The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally The opened bladder which we were able to remove completely had a wide open capacious diverticulum in its very distal segment Because of the previous radiation therapy and a dissection down to the pelvis I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment PROCEDURE IN DETAIL The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained placed in the supine position flexed over the anterosuperior iliac spine and his abdomen and genitalia were sterilely prepped and draped in the usual fashion A nasogastric tube was placed as well as radial arterial line He was given intravenous antibiotics for prophylaxis A generous midline skin incision was made from the midepigastrium down to the symphysis pubis deep into the rectus fascia the rectus muscle separated in the midline and exploration carried out with the findings described Moist wound towels and a Bookwalter retractor were placed for exposure We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries This was quite challenging because of the previous radiation therapy and radical prostatectomy We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles and these were taken between double clips approximately and clipped distally We then approached things posteriorly and carefully dissected between the __________ and posterior bladder There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum We then peeled it off the remaining rectum and passed the specimen off the operative field Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis We then completely mobilized the omentum off of the proximal transverse colon This allowed a generous flap to be able to be laid into the pelvis without tension We then turned our attention to forming the Indiana pouch I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon The colon was divided proximal to the middle colic using a GIA 80 stapler I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum The mesentery was then sealed with a LigaSure device and divided and the bowel was divided with a GIA 60 stapler We then performed a side to side ileo transverse colostomy using a GIA 80 stapler closing the open end with a TA 60 The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures We then removed the staple line along the terminal ileum passed a 12 French Robinson catheter into the cecal segment and plicated the ileum with 3 firings of the GIA 60 stapler The ileocecal valve was then reinforced with interrupted 3 0 silk sutures as described by Rowland et al and following this passage of an 18 French Robinson catheter was associated with the characteristic pop indicating that we had adequately plicated the ileocecal valve As the patient had had a previous appendectomy we made an opening in the cecum in the area of the previous appendectomy We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3 0 Vicryl sutures The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb 75 Between the staple lines Vicryl sutures were placed and the defects closed with 3 0 Vicryl suture ligatures We then turned our attention to forming the ileocolonic anastomosis The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end to side anastomosis performed with an open technique using interrupted 4 0 Vicryl sutures and this was stented with a Cook 8 4 French ureteral stent and this was secured to the bowel lumen with a 5 0 chromic suture The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2 0 chromic suture A 24 French Malecot catheter was placed through the cecum and secured with a chromic suture The staple lines were then buried with a running 3 0 Vicryl two layer suture and the open end of the pouch closed with a TA 60 Polysorb suture The pouch was filled to 240 cc and noted to be watertight and the ureteral anastomoses were intact We then made a final inspection for hemostasis The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures We then matured our stoma through the umbilicus We removed the plug of skin through the umbilicus and delivered the ileal segment through this A portion of the ileum was removed and healthy well vascularized tissue was matured with interrupted 3 0 chromic sutures We left an 18 French Robinson through the stomag and secured this to the skin with silk sutures The Malecot and stents were also secured in a similar fashion We matured the stoma to the umbilicus with interrupted chromic stitches The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch The rectus fascia was closed with a buried 2 Prolene running stitch tying a new figure of eight proximally and distally and meeting in the middle and tying it underneath the fascia Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips The estimated blood loss was 450 mL and the patient received no packed red blood cells The final sponge and needle count were reported to be correct The patient was awakened and extubated and taken on stretcher to the recovery room in satisfactory condition Keywords urology radiation cystitis voiding dysfunction retropubic prostatectomy salvage radiation therapy salvage cystectomy indiana pouch continent cutaneous diversion omental pedicle flap ligasure gia stapler gia stapler vicryl sutures radiation therapy silk sutures bladder therapy sutures endotracheal MEDICAL_TRANSCRIPTION,Description Spermatocelectomy and orchidopexy Medical Specialty Urology Sample Name Spermatocelectomy Transcription PREOPERATIVE DIAGNOSIS Right spermatocele POSTOPERATIVE DIAGNOSIS Right spermatocele OPERATIONS PERFORMED 1 Right spermatocelectomy 2 Right orchidopexy ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY OF THE PATIENT The patient is a 77 year old male who comes to the office with a large right spermatocele The patient says it does bother him on and off has occasional pain and discomfort with it has difficulty with putting clothes on etc and wanted to remove Options such as watchful waiting removal of the spermatocele or needle drainage were discussed Risk of anesthesia bleeding infection pain MI DVT PE risk of infection scrotal pain and testicular pain were discussed The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down The patient was told about the risk of recurrence of spermatocele The patient understood all the risks benefits and options and wanted to proceed with removal DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient s scrotal area was shaved prepped and draped in the usual sterile fashion A midline scrotal incision was made measuring about 2 cm in size The incision was carried through the dartos through the scrotal sac and the spermatocele was identified All the layers of the spermatocele were removed Clear layer was visualized was taken all the way up to the base the base was tied Entire spermatocele sac was removed After removing the entire spermatocele sac hemostasis was obtained The testicle was not in normal orientation The testis and epididymis was removed which is a small appendage on the superior aspect of the testicle The testicle was placed in a normal orientation Careful attention was drawn not to twist the cord Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4 0 Vicryl and was tied at 3 different locations Absorbable sutures were used so that the patient does not feel the sutures in the postoperative period The dartos was closed using 2 0 Vicryl in running locking fashion There was excellent hemostasis The skin was closed using 4 0 Monocryl Dermabond was applied The patient tolerated the procedure well The patient was brought to the recovery room in stable condition Keywords urology orchidopexy spermatocele spermatocelectomy scrotal MEDICAL_TRANSCRIPTION,Description SPARC suburethral sling due to stress urinary incontinence Medical Specialty Urology Sample Name Sling SPARC Suburethral Transcription PREOPERATIVE DX Stress urinary incontinence POSTOPERATIVE DX Stress urinary incontinence OPERATIVE PROCEDURE SPARC suburethral sling ANESTHESIA General FINDINGS INDICATIONS Outpatient evaluation was consistent with urethral hypermobility stress urinary incontinence Intraoperatively the bladder appeared normal with the exception of some minor trabeculations The ureteral orifices were normal bilaterally DESCRIPTION OF OPERATIVE PROCEDURE This patient was brought to the operating room a general anesthetic was administered She was placed in dorsal lithotomy position Her vulva vagina and perineum were prepped with Betadine scrubbed in solution She was draped in usual sterile fashion A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder Two Allis clamps were placed over the mid urethra This area was injected with 0 50 lidocaine containing 1 200 000 epinephrine solution Two areas suprapubically on either side of midline were injected with the same anesthetic solution The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally The Foley catheter was removed A cystoscopy was performed using a 70 degree cystoscope There was noted to be no violation of the bladder The SPARC mesh was then snapped onto the needles which were withdrawn through the stab wound incisions The mesh was snugged up against a Mayo scissor held under the mid urethra The overlying plastic sheaths were removed The mesh was cut below the surface of the skin The skin was closed with 4 0 Plain suture The vaginal vault was closed with a running 2 0 Vicryl stitch The blood loss was minimal The patient was awoken and she was brought to recovery in stable condition Keywords urology stress urinary incontinence foley catheter metzenbaum scissor sparc sparc mesh bladder orifice perineum sling suburethral ureteral urethral hypermobility vagina vaginal vault vulva cystoscopy suburethral sling stress urinary urinary incontinence incontinence MEDICAL_TRANSCRIPTION,Description Left scrotal exploration with detorsion Already de torsed bilateral testes fixation and bilateral appendix testes cautery Medical Specialty Urology Sample Name Scrotal Exploration Transcription PREOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion POSTOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion PROCEDURE Left scrotal exploration with detorsion Already de torsed bilateral testes fixation and bilateral appendix testes cautery ANESTHETIC A 0 25 Marcaine local wound insufflation per surgeon 15 mL of Toradol FINDINGS Congestion in the left testis and cord with a bell clapper deformity on the right small appendix testes bilaterally No testis necrosis ESTIMATED BLOOD LOSS 5 mL FLUIDS RECEIVED 300 mL of crystalloid TUBES AND DRAINS None SPECIMENS No tissues sent to pathology COUNTS Sponges and needle counts were correct x2 INDICATIONS OF OPERATION The patient is a 4 year old boy with abrupt onset of left testicular pain He has had a history of similar onset Apparently he had no full on one ultrasound and full on a second ultrasound but because of possible torsion detorsion or incomplete detorsion I recommended an exploration DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification was verified Once he was anesthetized he was placed in supine position and sterilely prepped and draped Superior scrotal incisions were then made with 15 blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery Electrocautery was used for hemostasis The subdartos pouch was created with curved tenotomy scissors The tunica vaginalis was then delivered incised and testis was delivered The testis itself with a bell clapper deformity There was no actual torsion at the present time there was some modest congestion and however the vasculature was markedly congested down the cord The penis fascia was cauterized and subdartos pouch was created The upper aspect of fascia was then closed with pursestring suture of 4 0 chromic The testis was then placed into the scrotum in a proper orientation No tacking sutures within the testis itself were used The tunica vaginalis however was wrapped perfectly behind the back of the testis A similar procedure was performed on the right side Again an appendix testis was cauterized No torsion was seen He also had a bell clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with 4 0 chromic suture The local anesthetic was then used for both as cord block as well as a local wound insufflation bilaterally with 0 25 Marcaine The scrotal wall was then closed with subcuticular closure of 4 0 chromic Dermabond tissue adhesive was then used The patient tolerated the procedure well He was given IV Toradol and was taken to the recovery room in stable condition Keywords urology de torsed bilateral testes testes fixation bell clapper deformity testicular torsion subdartos pouch tunica vaginalis scrotal exploration appendix testes scrotal testes torsion detorsion insufflation testis MEDICAL_TRANSCRIPTION,Description Cystoscopy under anesthesia retrograde and antegrade pyeloureteroscopy left ureteropelvic junction obstruction difficult and open renal biopsy Medical Specialty Urology Sample Name Pyeloureteroscopy Transcription PREOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty percutaneous procedure and pyeloureteroscopy x2 and status post Pseudomonas pyelonephritis x6 renal insufficiency and solitary kidney POSTOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty percutaneous procedure and pyeloureteroscopy x2 and status post Pseudomonas pyelonephritis x6 renal insufficiency and solitary kidney PROCEDURE Cystoscopy under anesthesia retrograde and antegrade pyeloureteroscopy left ureteropelvic junction obstruction difficult and open renal biopsy ANESTHESIA General endotracheal anesthetic with a caudal block x2 FLUIDS RECEIVED 1000 mL crystalloid ESTIMATED BLOOD LOSS Less than 10 mL SPECIMENS Tissue sent to pathology is a renal biopsy ABNORMAL FINDINGS A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis TUBES AND DRAINS A 10 French silicone Foley catheter with 3 mL in balloon and a 4 7 French ureteral double J stent multilength INDICATIONS FOR OPERATION The patient is a 3 1 2 year old boy who has a solitary left kidney with renal insufficiency with creatinine of 1 2 who has had a ureteropelvic junction repair performed by Dr Chang It was subsequently obstructed with multiple episodes of pyelonephritis two percutaneous tube placements ureteroscopy with balloon dilation of the system and continued obstruction Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction DESCRIPTION OF OPERATION The patient was taken to the operative room Surgical consent operative site and patient identification were verified Dr X and Dr Y both agreed upon the procedures in advance Dr Y then once the patient was anesthetized requested IV antibiotics with Fortaz the patient had a caudal block placed and he was then placed in lithotomy position Dr Y then calibrated the urethra with the bougie a boule to 8 10 and up to 12 French The 9 5 French cystoscope sheath was then placed within the patient s bladder with the offset scope and his bladder had no evidence of cystitis I was able to locate the ureteral orifice bilaterally although no urine coming from the right We then placed a 4 French ureteral catheter into the ureter as far as we could go An antegrade nephrostogram was then performed which shows that the contrast filled the dilated pelvis but did not go into the ureter A retrograde was performed and it was found that there was a narrowed band across the two Upon draining the ureter allowing to drain to gravity the pelvis which had been clamped and its nephrostomy tube did not drain at all Dr Y then placed a 0 035 guidewire into the ureter after removing the 4 French catheter and then placed a 4 7 French double J catheter into the ureter as far as it would go allowing it to coil in the bladder Once this was completed we then removed the cystoscope and sheath placed a 10 French Foley catheter and the patient was positioned by Dr X and Dr Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll He was then sterilely prepped and draped Dr Y then incised the skin with a 15 blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr X performed cautery of the areas advanced to be excised Once this was then dissected Dr Y and Dr X divided the lumbosacral fascia at the latissimus dorsi fascia posterior dorsal lumbotomy maneuver using the electrocautery and then using curved mosquito clamps __________ At this point Dr X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia Dr Y then used the curved right angle clamp and dissected around towards the ureter which was markedly adherent to the base of the retroperitoneum Dr X and Dr Y also needed dissection on the medial and lateral aspects with Dr Y being on the lateral aspect of the area and Dr X on the medial to get an adequate length of this The tissue was markedly inflamed and had significant adhesions noted The patient s spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction Ultimately Dr Y and Dr X both with alternating dissection were able to dissect the renal pelvis to a position where Dr Y put stay sutures and a 4 0 chromic to isolate the four quadrant area where we replaced the ureter Dr X then divided the ureter and suture ligated the base which was obstructed with a 3 0 chromic suture Dr Y then spatulated the ureter for about 1 5 cm and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder Dr Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed Dr Y then placed interrupted sutures of 5 0 Monocryl at the apex to repair the most dependent portion of the renal pelvis entered the lateral aspect interrupted sutures of the repair Dr X then was able to without much difficulty do interrupted sutures on the medial aspect The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr Y and Dr X closed the ureteropelvic junction without any evidence of leakage Once this was complete we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position This opening was at least 1 5 cm wide Dr Y then placed 2 stay sutures of 2 0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15 blade knife and curved iris scissors for renal biopsy for determination of renal tissue health Electrocautery was used on the base There was no bleeding however and the tissue was quite soft Dermabond and Gelfoam were placed and then Dr Y closed the biopsy site over with thrombin Gelfoam using the 2 0 chromic stay sutures Dr X then closed the fascial layers with running suture of 3 0 Vicryl in 3 layers Dr Y closed the Scarpa fascia and the skin with 4 0 Vicryl and 4 0 Rapide respectively A 4 0 nylon suture was then placed by Dr Y around the previous nephrostomy tube which was again left clamped Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr Y over the nephrostomy tube site which was left clamped and the patient then had a Foley catheter placed in the bladder The Foley catheter was then taped to his leg A second caudal block was placed for anesthesia and he is in stable condition upon transfer to recovery room Keywords urology cystoscopy pyeloureteroscopy ureteropelvic junction obstruction pseudomonas pyelonephritis renal insufficiency fortaz ureteropelvic junction repair nephrostomy tube renal biopsy renal pelvis foley catheter ureteropelvic junction renal ureteropelvic MEDICAL_TRANSCRIPTION,Description Radical retropubic prostatectomy robotic assisted and bladder suspension Adenocarcinoma of the prostate Medical Specialty Urology Sample Name Prostatectomy Robotic Radical Retropubic Transcription PREOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate POSTOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate PROCEDURE 1 Radical retropubic prostatectomy robotic assisted 2 Bladder suspension ANESTHESIA General by intubation The patient understands his diagnosis grade stage and prognosis He understands this procedure options to it and potential benefits from it He strongly wishes to proceed He accepts all treatment associated risks to include but not be limited to bleeding requiring transfusion infection sepsis heart attack stroke bladder neck contractures need to convert to an open procedure urinary fistulae impotence incontinence injury to bowel rectum bladder ureters etc small bowel obstruction abdominal hernia osteitis pubis chronic pelvic pain etc DESCRIPTION OF THE CASE The patient was taken to the operating room given a successful general anesthetic placed in the lithotomy position prepped with Betadine solutions and draped in the usual sterile fashion My camera ports were then placed in the standard fan array A camera port was placed in the midline above the umbilicus using the Hasson technique The balloon port was placed the abdomen insufflated and all other ports were placed under direct vision My assistant was on the right The patient was then placed in the steep Trendelenburg position and the robot brought forward and appropriately docked I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis This nicely exposed the space of Retzius I then defatted the anterior surface of the prostate and endopelvic fascia The endopelvic fascia was then opened bilaterally The levator ani muscles were carefully dissected free from the prostate and pushed laterally Dissection was continued posteriorly toward the bundles and caudally to the apex The puboprostatic ligaments were then transected A secure ligature of 0 Vicryl was placed around the dorsal venous complex I then approached the bladder neck The anterior bladder neck was transected down to the level of the Foley catheter which was lifted anteriorly in the wound I then transected the posterior bladder neck down to the level of the ampullae of the vas The ampullae were mobilized and transected These were lifted anteriorly in the field exposing the seminal vesicles which were similarly mobilized Hemostasis was obtained using the bipolar Bovie I then identified the Denonvilliers fascia and this was incised sharply Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles I was able to then identify the pedicles over the seminal vesicles which were hemoclipped and transected The field was then copiously irrigated with sterile water Hemostasis was found to be complete I then carried out a urethrovesical anastomosis This was accomplished with 3 0 Monocryl ligatures Two of these were tied together in the midline They were placed at the 6 o clock position and one was run in a clockwise and the other in a counterclockwise direction to the 12 o clock position where they were securely tied A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation The patient was given indigo carmine and there was prompt blue urine in the Foley I then carried out a bladder suspension This was done in hopes of obtaining early urinary control This was accomplished with 0 Vicryl ligatures One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis This nicely re retroperitonealized the bladder The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision A JP drain was brought in through the 4th arm port and sutured to the skin with 2 0 silk The camera port fascia was closed with running 0 Vicryl The skin incisions were closed with a running subcuticular 4 0 Monocryl The patient tolerated the procedure very well There were no complications Sponge and instrument counts were reported correct at the end of the case Keywords urology adenocarcinoma prostate radical retropubic prostatectomy robotic assisted bladder uspension bladder neck intubation robotic retropubic prostatectomy MEDICAL_TRANSCRIPTION,Description Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer Medical Specialty Urology Sample Name Prostatectomy Radical Retropubic Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATIVE PROCEDURE Radical retropubic prostatectomy with pelvic lymph node dissection ANESTHESIA General epidural ESTIMATED BLOOD LOSS 800 cc COMPLICATIONS None INDICATIONS FOR SURGERY This is a 64 year old man with adenocarcinoma of the prostate confirmed by needle biopsies He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Deep venous thrombosis 6 Recurrence of the cancer PROCEDURE IN DETAIL Epidural anesthesia was administered by the anesthesiologist in the holding area Preoperative antibiotic was also given in the preoperative holding area The patient was then taken into the operating room after which general LMA anesthesia was administered The patient was shaved and then prepped using Betadine solution A sterile 16 French Foley catheter was inserted into the bladder with clear urine drain A midline infraumbilical incision was performed The rectus fascia was opened sharply The perivesical space and the retropubic space were developed bluntly Bookwalter retractor was then placed Bilateral obturator pelvic lymphadenectomy was performed The obturator nerve was identified and was untouched The margin for the resection of the lymph node bilaterally were the Cooper s ligament the medial edge of the external iliac artery the bifurcation of the common iliac vein the obturator nerve and the bladder Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips The lymph nodes were palpably normal and were set for permanent section The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors The puboprostatic ligament was taken down sharply The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2 0 silk sutures The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area The dorsal vein complex was ligated by using 0 Vicryl suture on a CT 1 needle The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors The urethra was then identified and was dissected out The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors This was extended circumferentially until the Foley catheter could be seen clearly 2 0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides The plane between Denonvilliers fascia and the perirectal fat was developed sharply No tension was placed on the neurovascular bundle at any point in time The prostate dissected off the rectal wall easily Once the seminal vesicles were identified the fascia covering over them were opened transversely The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected The bladder neck was then dissected out carefully to spare most of the bladder neck muscles Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen The specimen was inspected and appeared to be completely intact It was sent for permanent section The bladder neck mucosa was then everted by using 4 0 chromic sutures Inspection at the prostatic bed revealed no bleeding vessels The sutures which were placed previously onto the urethral stump were then placed onto the bladder neck Once the posterior sutures had been placed the Foley was placed into the urethra and into the bladder neck A 20 French Foley Catheter was used The anterior sutures were then placed The Foley was then inflated The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly Mild traction of the Foley catheter was placed to assure the anastomosis was tight Two 19 French Blake drains were placed in the perivesical spaces These were anchored to the skin by using 2 0 silk sutures The instrument counts lab counts and sponge counts were verified to be correct the patient was closed The fascia was closed in running fashion using 1 PDS Subcutaneous tissue was closed by using 2 0 Vicryl suture Skin was approximated by using metallic clips The patient tolerated the operation well Keywords urology prostate cancer foley catheter metzenbaum scissors prostate adenocarcinoma bladder lymphadenectomy pelvic lymph node dissection perivesical prostatectomy retropubic urethra radical retropubic prostatectomy lymph node dissection dorsal vein complex radical retropubic lymph node dorsal vein vein complex bladder neck sutures foley urethral MEDICAL_TRANSCRIPTION,Description Radical retropubic nerve sparing prostatectomy without lymph node dissection Medical Specialty Urology Sample Name Prostatectomy Nerve Sparing Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATION PERFORMED Radical retropubic nerve sparing prostatectomy without lymph node dissection ESTIMATED BLOOD LOSS 450 mL REPLACEMENT 250 mL of Cell Saver and crystalloid COMPLICATIONS None INDICATIONS OF SURGERY This is a 67 year old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate Due to him being healthy with no comorbid conditions he has elected to undergo surgical treatment with radical retropubic prostatectomy Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Injury to the adjacent viscera 6 Deep venous thrombosis PROCEDURE IN DETAIL Prophylactic antibiotic was given in the preoperative holding area after which the patient was transferred to the operating room Epidural anesthesia and general endotracheal anesthesia were administered by Dr A without any difficulty The patient was shaved prepped and draped using the usual sterile technique A sterile 16 French Foley catheter was then placed with clear urine drained A midline infraumbilical incision was performed by using a 10 scalpel blade The rectus fascia and the subcutaneous space were opened by using the Bovie Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly A Bookwalter retractor was then placed The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected Given this patient s low Gleason score and low PSA with a solitary core biopsy positive the decision was made to not perform bilateral lymphadenectomy The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors Opening was enlarged by using sharp dissection Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device The dorsal aspect of the prostate was bunched up by using 2 0 silk sutures The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure of eight fashion With the prostate retracted cephalad the deep dorsal vein complex was transected superficially using the Bovie Deeper near the urethra the dorsal vein complex was transected by using Metzenbaum scissors The urethra could then be easily identified Nearly two third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors This exposed the blue Foley catheter Anastomotic sutures were then placed on to the urethral stump using 2 0 Monocryl suture Six of these were placed evenly spaced out anteriorly to posteriorly The Foley catheter was then removed This allowed for better traction of the prostate laterally Lateral pelvic fascia was opened bilaterally This effectively released the neurovascular bundle from the apex to the base of the prostate Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat The prostate was then dissected from laterally to medially from this opening in the perirectal fat The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate Maximal length of ureteral stump was preserved The prostate was carefully lifted cephalad by using gentle traction with fine forceps The prostate was easily dissected off the perirectal fat using sharp dissection only Absolutely no traction to the neurovascular bundle was evident at any point in time The dissection was carried out easily until the seminal vesicles could be visualized The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side The bladder neck was then dissected out by using a bladder neck dissection method Unfortunately most of the bladder neck fiber could not be preserved due to the patient s anatomy Once the prostate had been separated from the bladder in the area with the bladder neck dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles This was developed without any difficulty Both vas deferens were identified hemoclipped and transected The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off as it extended quite deeply into the pelvis About two thirds of the seminal vesicles were able to be removed The tip was left behind Using the bipolar Gyrus coagulation device the seminal vesicles were clamped at the tip sealed by cautery and then transected This was performed on the left side and then the right side This completely freed the prostate The prostate was sent for permanent section The opening in the bladder neck was reduced by using two separate 2 0 Vicryl sutures The mucosa of the bladder neck was everted by using 4 0 chromic sutures Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck This was performed by using a French needle A 20 French Foley catheter was then inserted and the sutures were sequentially tied down A 15 mL of sterile water was inflated to balloon The bladder anastomosis to the urethra was performed without any difficulty A 19 French Blake Drain was placed in the left pelvis exiting the right inguinal region All instrument counts lap counts and latex were verified twice prior to the closure The rectus fascia was closed in running fashion using 1 PDS Subcutaneous space was closed by using 2 0 Vicryl sutures The skin was reapproximated by using metallic clips The patient tolerated the procedure well and was transferred to the recovery room in stable condition Keywords urology prostate cancer foley catheter gleason psa prostate adenocarcinoma bladder neck core biopsy figure of eight lymph node dissection nerve sparing prostatectomy rectus fascia retropubic bladder neck dissection dorsal vein complex nerve sparing perirectal fat seminal vesicles sutures bladder urethra posteriorly seminal vesicles fascia neck dissection MEDICAL_TRANSCRIPTION,Description Adenocarcinoma of the prostate Erectile dysfunction History Physical Medical Specialty Urology Sample Name Prostate Adenocarcinoma H P Transcription HISTORY OF PRESENT ILLNESS The patient is a 62 year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes He has a PSA of 3 1 with a prostate gland size of 41 grams This was initially found on rectal examination with a nodule on the right side of the prostate showing enlargement relative to the left He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr XXX and ultimately underwent an open biopsy that was not malignant Prior to this he has also had a ProstaScint scan that was negative for any metastatic disease Again he is being admitted to undergo a radical prostatectomy the risks benefits and alternatives of which have been discussed including that of bleeding and a blood transfusion PAST MEDICAL HISTORY Coronary stenting History of high blood pressure as well He has erectile dysfunction and has been treated with Viagra MEDICATIONS Lisinopril Aspirin Zocor and Prilosec ALLERGIES Penicillin SOCIAL HISTORY He is not a smoker He does drink six beers a day REVIEW OF SYSTEMS Remarkable for his high blood pressure and drug allergies but otherwise unremarkable except for some obstructive urinary symptoms with an AUA score of 19 PHYSICAL EXAMINATION HEENT Examination unremarkable Breasts Examination deferred Chest Clear to auscultation Cardiac Regular rate and rhythm Abdomen Soft and nontender He has no hernias Genitourinary There is a normal appearing phallus prominence of the right side of prostate Extremities Examination unremarkable Neurologic Examination nonfocal IMPRESSION 1 Adenocarcinoma of the prostate 2 Erectile dysfunction PLAN The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy The risks benefits and alternatives of this have been discussed He understands and asks that I proceed ahead We also discussed bleeding and blood transfusions and the risks benefits and alternatives thereof Keywords urology gleason score gleason prostate gland prostascint retropubic prostatectomy adenocarcinoma of the prostate erectile dysfunction adenocarcinoma radical prostatectomy erectile dysfunction prostate MEDICAL_TRANSCRIPTION,Description Prostate Brachytherapy Prostate I 125 Implantation Medical Specialty Urology Sample Name Prostate Brachytherapy Transcription PROSTATE BRACHYTHERAPY PROSTATE I 125 IMPLANTATION This patient will be treated to the prostate with ultrasound guided I 125 seed implantation The original consultation and treatment planning will be separately performed At the time of the implantation special coordination will be required Stepping ultrasound will be performed and utilized in the pre planning process Some discrepancies are frequently identified based on the positioning edema and or change in the tumor since the pre planning process Re assessment is required at the time of surgery evaluating the pre plan and comparing to the stepping ultrasound Modifications will be made in real time to add or subtract needles and seeds as required This may be integrated with the loading of the seeds performed by the brachytherapist as well as coordinated with the urologist dosimetrist or physicist The brachytherapy must be customized to fit the individual s tumor and prostate Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder Keywords urology i 125 implantation tumor prostate prostate brachytherapy implantationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right ureteropelvic junction obstruction Robotic assisted pyeloplasty anterograde right ureteral stent placement transposition of anterior crossing vessels on the right and nephrolithotomy Medical Specialty Urology Sample Name Pyeloplasty Robotic Transcription PROCEDURES 1 Robotic assisted pyeloplasty 2 Anterograde right ureteral stent placement 3 Transposition of anterior crossing vessels on the right 4 Nephrolithotomy DIAGNOSIS Right ureteropelvic junction obstruction DRAINS 1 Jackson Pratt drain times one from the right flank 2 Foley catheter times one ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None SPECIMENS 1 Renal pelvis 2 Kidney stones INDICATIONS The patient is a 30 year old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries Up on consideration of various modalities and therapy the patient decided to undergo surgical therapy PROCEDURE IN DETAIL The patient was verified by armband and the procedure being robotic assisted right pyeloplasty with nephrolithotomy was verified and the procedure was carried out After institution of general endotracheal anesthesia and intravenous preoperative antibiotics the patient was positioned into the right flank position with his right flank elevated Great care was taken to pad all pressure points and a right arm hanger was used The patient was flexed slightly and a kidney rest was used Sequential compression devices were also placed Next the patient was prepped and draped in normal sterile fashion with povidone iodine Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test A low pressure high flow pneumoperitoneum was adequately obtained using CO2 gas Next a 12 mm camera port was placed near the umbilicus The camera was inserted and no bowel injury was seen Next under direct vision flanking 8 mm camera ports a 12 mm assist port a 5 mm liver retraction port and 5 mm assist port were placed The robot was docked and the instruments passed through respective checks Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially Next the right lateral duodenum was cauterized for further access to the right retroperitoneum At this point the right kidney was in clear view and the fascia was entered Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole These arteries were dissected carefully and vessel loops were applied Next a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out The pyelotomy was extended so that the renal collecting system could be directly inspected Sequentially each major calyx was inspected under direct vision and irrigated A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient At this point we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis The proximal ureter was spatulated using cold scissors Next redundant renal pelvis was excised using cold scissors and sent for permanent section We then identified the most inferior dependent portion of the renal pelvis and placed a heel stitch at this for ureteral renal pelvis anastomosis in a semi running fashion 3 0 Monocryl sutures were used to re anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis Next remainder of the pyelotomy was closed to itself also using 2 0 Monocryl sutures Before final stitches were placed a 6x28 ureteral stent was placed anterograde This was accomplished by placing the stents over a guidewire placing the guidewire under direct vision anterograde through the ureter This was done until the proximal end was in the renal pelvis the guidewire was removed and good proximal curl was verified by direct vision Then the pyelotomy was completely closed again with 2 0 Monocryl sutures Next attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis Good pulsation was verified by direct vision proximal and distal to these pexy sutures Next Gerota s fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum Hemostasis appeared excellent at this point There was no obvious urine extravasation At this time the procedure was terminated The robot was undocked Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion Then all skin port sites were closed with 4 0 Monocryl in a subcuticular fashion and Dermabond and band aids were applied over this Also notably a Jackson Pratt drain was placed in the area of the right kidney and additional right flank stab incision The patient tolerated the procedure well and no immediate perioperative complication was noted DISPOSITION The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery Keywords urology pyeloplasty ureteral stent placement nephrolithotomy ureteropelvic junction obstruction jackson pratt drain foley catheter renal pelvis kidney stones monocryl sutures pelvis renal ureteropelvic sutures MEDICAL_TRANSCRIPTION,Description Cystourethroscopy right retrograde pyelogram and right double J stent placement 22 x 4 5 mm Right ureteropelvic junction calculus Medical Specialty Urology Sample Name Retrograde Pyelogram Cystourethroscopy Transcription PREOPERATIVE DIAGNOSIS Right ureteral calculus POSTOPERATIVE DIAGNOSIS Right ureteropelvic junction calculus PROCEDURE PERFORMED 1 Cystourethroscopy 2 Right retrograde pyelogram 3 Right double J stent placement 22 x 4 5 mm FIRST SECOND ANESTHESIA General SPECIMEN Urine for culture and sensitivity DRAINS 22 x 4 5 mm right double J ureteral stent PROCEDURE After consent was obtained the patient was brought to operating room and placed in the supine position She was given general anesthesia and then placed in the dorsal lithotomy position A 21 French cystoscope was then passed through the urethra into the bladder There was noted to be some tightness of the urethra on passage On visualization of the bladder there were no stones or any other debris within the bladder There were no abnormalities seen No masses diverticuli or other abnormal findings Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter however the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis An open end ureteral catheter was then passed ________ into the distal right ureter Retrograde pyelogram was then performed There was noted to be an UPJ calculus with no noted hydronephrosis The wire was then passed back through the ureteral catheter The catheter was removed and a 22 x 4 5 mm double J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance The stent was clear within the kidney as well as within the bladder The bladder was drained and the cystoscope was removed The patient tolerated the procedure well She will be discharged home She is to follow up with Dr X for ESWL procedure She will be given prescription for Darvocet and will be asked to have a KUB x ray done prior to her followup and to bring them with her to her appointment Keywords urology ureteropelvic junction calculus cystourethroscopy retrograde pyelogram double j stent placement double j stent cone tip catheter ureteral stent ureteral orifice ureteral catheter retrograde pyelogram catheter ureteral MEDICAL_TRANSCRIPTION,Description Open radical retropubic prostatectomy with bilateral lymph node dissection Medical Specialty Urology Sample Name Prostatectomy Transcription PREOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4 3 with 85 burden and 8 12 cores positive POSTOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4 3 with 85 burden and 8 12 cores positive PROCEDURE DONE Open radical retropubic prostatectomy with bilateral lymph node dissection INDICATIONS This is a 66 year old gentleman who had an elevated PSA of 5 His previous PSAs were in the 1 range TRUS biopsy revealed 4 3 Gleason score prostate cancer with a large tumor burden After extensive counseling the patient elected for retropubic radical prostatectomy Given his disease burden it was advised that an open prostatectomy is probably the standard of care to ensure entire excision The patient consented and agreed to proceed forward DESCRIPTION OF PROCEDURE The patient was brought to the operating room here Time out was taken to properly identify the patient and procedure going to be done General anesthesia was induced The patient was placed in the supine position The bed was flexed distant to the pubic area The patient s lower abdominal area pubic area and penile and scrotal area were clipped and then scrubbed with Hibiclens soap for three minutes The patient was then prepped and draped in normal sterile fashion Foley catheter was inserted sterilely in the field Preoperative antibiotics were given within 30 minutes of skin incision A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus Dissection was taken down through Scarpa s fascia to the level of the anterior rectus sheath The rectus sheath was then incised and the muscle was split in the middle Space of rectus sheath was then entered The Bookwalter ring was then applied to the belly and the bladder was then retracted to the right side thus exposing the left obturator area The lymph node packet on the left side was then dissected This was done in a split and roll fashion with the flimsy tissue and the left external iliac vein was incised and the tissues were then rolled over the left external iliac vein Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally Care was taken to avoid injury to the nerves An accessory obturator vein was noted and was ligated The same procedure was done on the right side with dissection of the right obturator lymph node packet which was sent for pathologic evaluation The bladder subsequently was retracted cephalad The prostate was then defatted up to the level of the endopelvic fascia The endopelvic fascia was then incised bilaterally and the incision was then taken to the level of the puboprostatic ligaments Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders A Babcock was then applied around the dorsal venous complex over the urethra and the K wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle A 0 Vicryl stitch was then applied over the dorsal venous complex which was then tied down and cinched to the symphysis pubis Using a knife on a long handle the dorsal venous complex was then incised using the K wire as a guide Following the incision of the dorsal venous complex the anterior urethra was then incised thus exposing the Foley catheter The 3 0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra The lateral edges of the urethra were also then incised and two lateral stitches were also applied going outside end The catheter was then drawn back at the level of membranous urethra and a final posterior stitch was applied going outside end The urethra was subsequently divided in its entirety A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex The prostate was then entered cephalad and the prostatic pedicles were then systematically taken down with the right angle clips and cut Please note that throughout the case the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex pelvic veins and extensive vascularity that was noted in the patient s pelvic fatty tissue Throughout the case the bleeding was controlled with the aid of a clips Vicryl sutures silk sutures and ties direct pressure packing and FloSeal Following the excision of the prostatic pedicles the posterior dissection at this point was almost complete Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers fascia The seminal vesicle on the left side was dissected in its entirety however the seminal vesicle on the right side was adherently stuck to the Denonvilliers fascia which prompted the excision of most of the right seminal vesicle with the exception of the tip Care was taken throughout the posterior dissection to preserve the integrity of the ureters The anterior bladder neck was then cut anteriorly and the bladder neck was separated from the prostate Following the dissection the 5 French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity Following the dissection of the bladder from the prostate the prostate at this point was mobile and was sent for pathological evaluation The bladder neck was then repaired using Vicryl in a tennis racquet fashion The rest of the mucosa was then everted The ureteral orifices and ureters were protected throughout the procedure At this point the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position Hemostasis was then adequately obtained FloSeal was applied to the pelvis The bladder was then irrigated It was draining pink urine The wound was copiously irrigated The fascia was then closed using a 1 looped PDS The skin wound was then irrigated and the skin was closed with a 4 0 Monocryl in subcuticular fashion At this point the procedure was terminated with no complications The patient was then extubated in the operating room and taken in stable condition to the PACU Please note that during the case about 3600 mL of blood was noted This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation Keywords urology bilateral lymph node dissection retropubic prostatectomy radical retropubic prostatectomy gleason score prostate cancer trus biopsy bilateral lymph node lymph node dissection catheter was inserted bilateral lymph node dissection vicryl stitch prostatic pedicles pelvic veins external iliac iliac vein seminal vesicle lymph node foley catheter dorsal venous venous complex bladder neck dissection prostatectomy bladder endopelvic vicryl catheter vein venous fascia dorsal urethra MEDICAL_TRANSCRIPTION,Description Prostate gland showing moderately differentiated infiltrating adenocarcinoma Excised prostate including capsule pelvic lymph nodes seminal vesicles and small portion of bladder neck Medical Specialty Urology Sample Name Prostate Adenocarcinoma 4 Transcription PHYSICAL EXAMINATION Patient is a 46 year old white male seen for annual physical exam and had an incidental PSA elevation of 4 0 All other systems were normal PROCEDURES Sextant biopsy of the prostate Radical prostatectomy Excised prostate including capsule pelvic lymph nodes seminal vesicles and small portion of bladder neck PATHOLOGY Prostate biopsy Right lobe negative Left lobe small focus of adenocarcinoma Gleason s 3 3 in approximately 5 of the tissue Radical prostatectomy Negative lymph nodes Prostate gland showing moderately differentiated infiltrating adenocarcinoma Gleason 3 2 extending to the apex involving both lobes of the prostate mainly right Tumor overall involved less than 5 of the tissue Surgical margin was reported and involved at the apex The capsule and seminal vesicles were free DISCHARGE NOTE Patient has made good post op recovery other than mild urgency incontinence His post op PSA is 0 1 mg ml Keywords urology capsule bladder neck surgical margin moderately differentiated infiltrating adenocarcinoma pelvic lymph nodes prostate gland infiltrating adenocarcinoma radical prostatectomy seminal vesicles gleason s seminal vesicles adenocarcinoma prostate MEDICAL_TRANSCRIPTION,Description Moderately differentiated adenocarcinoma 1 enlarged prostate with normal seminal vesicles Medical Specialty Urology Sample Name Prostate Adenocarcinoma 3 Transcription PHYSICAL EXAMINATION The patient is a 63 year old executive who was seen by his physician for a company physical He stated that he was in excellent health and led an active life His physical examination was normal for a man of his age Chest x ray and chemical screening blood work were within normal limits His PSA was elevated IMAGING Chest x ray Normal CT scan of abdomen and pelvis No abnormalities LABORATORY PSA 14 6 PROCEDURES Ultrasound guided sextant biopsy of prostate Digital rectal exam performed at the time of the biopsy showed a 1 enlarged prostate with normal seminal vesicles PATHOLOGY Prostate biopsy Left apex adenocarcinoma moderately differentiated Gleason s score 3 4 7 10 Maximum linear extent in apex of tumor was 6 mm Left mid region prostate moderately differentiated adenocarcinoma Gleason s 3 2 5 10 Left base right apex and right mid region and right base negative for carcinoma TREATMENT The patient opted for low dose rate interstitial prostatic implants of I 125 It was performed as an outpatient on 8 10 Keywords urology sextant biopsy vesicles seminal apex interstitial prostatic implants moderately differentiated adenocarcinoma normal seminal vesicles enlarged prostate gleason s moderately differentiated prostate adenocarcinoma MEDICAL_TRANSCRIPTION,Description Patient presents to the Emergency Department with complaint of a bleeding bump on his penis Medical Specialty Urology Sample Name Penile Mass Emergency Visit Transcription CHIEF COMPLAINT Bloody bump on penis HISTORY OF PRESENT ILLNESS This is a 29 year old African American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis The patient states that he has had a large bump on the end of his penis for approximately a year and a half He states that it has never bled before It has never caused him any pain or has never been itchy The patient states that he is sexually active but has been monogamous with the same person for the past 13 years He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice The patient does state that last night he was trying to get some meaning that he was engaging in sexual intercourse at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis The patient said that there is a large amount of blood from this injury This happened last night but he was embarrassed to come to the Emergency Department yesterday when it was bleeding The patient has been able to get the bleeding to stop but the large bump is still located on the end of his penis and he is concerned that it will rip off and does want it removed The patient denies any drainage or discharge from his penis He denies fevers or chills recently He also denies nausea or vomiting The patient has not had any discharge from his penis He has not had any other skin lesions on his penis that are new to him He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years The patient has never had these checked out He denies fevers chills or night sweats He denies unintentional weight gain or loss He denies any other bumps rashes or lesions throughout the skin on his body PAST MEDICAL HISTORY No significant medical problems PAST SURGICAL HISTORY Surgery for excision of a bullet after being shot in the back SOCIAL HABITS The patient denies illicit drug usage He occasionally smokes tobacco and drinks alcohol MEDICATIONS None ALLERGIES No known medical allergies PHYSICAL EXAMINATION GENERAL This is an African American male who appears his stated age of 29 years He is well nourished well developed in no acute distress The patient is pleasant He is sitting on a Emergency Department gurney VITAL SIGNS Temperature 98 4 degrees Fahrenheit blood pressure of 139 78 pulse of 83 respiratory rate of 18 and pulse oximetry of 98 on room air HEART Regular rate and rhythm Clear S1 S2 No murmur rub or gallop is appreciated LUNGS Clear to auscultation bilaterally No wheezes rales or rhonchi ABDOMEN Soft nontender nondistended and positive bowel sounds throughout GENITOURINARY The patient s external genitalia is markedly abnormal There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus This pedunculated mass is approximately 1 5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well There are no open lesions at this point There is a small tear of the skin where the mass attaches to the glans near the urethral meatus Bleeding is currently stanch and there is no sign of secondary infection at this time Bilateral testicles are descended and normal without pain or mass bilaterally There is no inguinal adenopathy EXTREMITIES No edema SKIN Warm dry and intact No rash or lesion DIAGNOSTIC STUDIES Non emergency department courses It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass ASSESSMENT AND PLAN Penile mass The patient does have a large pedunculated penile mass He will be referred to the urologist who is on call today The patient will need this mass excised and biopsied The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER Keywords urology bump on penis bleeding bump glans urethral meatus penile mass emergency department penis penile pedunculated bump mass MEDICAL_TRANSCRIPTION,Description Ex plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700 Nonfunctioning inflatable penile prosthesis and Peyronie s disease Medical Specialty Urology Sample Name Penile Prosthesis Replacement Transcription PREOPERATIVE DIAGNOSES 1 Nonfunctioning inflatable penile prosthesis 2 Peyronie s disease POSTOPERATIVE DIAGNOSES 1 Nonfunctioning inflatable penile prosthesis 2 Peyronie s disease PROCEDURE PERFORMED Ex plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700 ANESTHESIA General LMA SPECIMEN Old triple component inflatable penile prosthesis PROCEDURE This is a 64 year old male with prior history of Peyronie s disease and prior placement of a triple component inflatable penile prosthesis which had worked for years for him but has stopped working and subsequently has opted for ex plantation and replacement of inflatable penile prosthesis OPERATIVE PROCEDURE After informed consent the patient was brought to the operative suite and placed in the supine position General endotracheal intubation was performed by the Anesthesia Department and the perineum scrotum penis and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15 minute prep including iodine solution in the urethra The bladder was subsequently drained with a red Robinson catheter At that point the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient s pacemaker and monopolar was only source of hemostasis besides suture At that point we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies Attention was taken then to the tubing going up to the reservoir in the right lower quadrant This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis At this point as we tracked this proximally to the area of the rectus muscle we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis As we tried to remove the tubing and get to the reservoir the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery At that point this tubing was then tracked down to the pump which was fairly easily removed from the dartos pouch in the right scrotum This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked first starting on the right side where a corporotomy incision was made at the placement of two 3 0 Prolene stay ties staying lateral and anterior on the corporal body The corporal body was opened up and the cylinder was removed from the right side without difficulty However we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery this was very difficult and was very time consuming but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding which was controlled with monopolar and cautery was used on three different occasions but just simple small burst under the guidance of anesthesia and there was no ectopy noted After removal of half of the pump all the tubing and both cylinders these were passed off the table as specimen Both corporal bodies were then dilated with the Pratt dilators These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces At this point using the Farlow device corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally He had an 18 cm with rear tips in place which were removed We decided to go ahead to and use another 18 cm inflatable penile prosthesis Confident with our size we then placed rear tips originally 3 cm rear tips however we had difficulty placing the rear tips into the left crest We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm At this point we went ahead and placed the right cylinder using the Farlow device and the Keith needle which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally entered the crest without difficulty Attention was then taken to the left side with the same thing was carried out however we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders This then forced us to down size to the 1 cm rear tips which slipping very easily with the Farlow device through the glans penis There was no crossover and no violation of the tunica albuginea The rear tips were then placed without difficulty and our corporotomies were closed with 2 0 PDS in a running fashion ________ starting on the patient s right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants At that point the wound was copiously irrigated and the device was inflated multiple times There was a very good fit and we had a very good result At that point the pump was subsequently placed in the dartos pouch which already has been created and was copiously irrigated with antibiotic solution This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump Please also note that before placement of our pump attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device which was subsequently placed without difficulty and three simple interrupted sutures of 2 0 Vicryl used to close the defect in the rectus and at that point after placement of our pump the connection was made between the pump and the reservoir without difficulty The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated After completion of the connection using a straight connector the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left but this was able to be ________ with good cosmetic result At that point after irrigation again of the space the area was simply dry and hemostatic The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers The soft tissue and the skin was then reapproximated with staples Please also note that prior to the skin closure a Jackson Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings would be left in place for approximately 12 to 20 hours This was also sutured in place with nylon Sterile dressing was applied Light gauze was wrapped around the penis and or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally Coban was used then to wrap the penis and at the end of the case the patient was straight catheted approximately 400 cc of amber yellow urine No Foley catheter was used or placed The patient was awoken in the operative suite extubated and transferred to recovery room in stable condition He will be admitted overnight to the service of Dr McDevitt Cardiology will be asked to consult with Dr Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics Keywords urology inflatable penile prosthesis peyronie s disease perineum scrotum penis penile prosthesis bovie cautery corporal body glans penis pump cylinders penile prosthesis inflatable corporal MEDICAL_TRANSCRIPTION,Description Excision of penile skin bridges about 2 cm in size Medical Specialty Urology Sample Name Penile Skin Bridges Excision Transcription PREOPERATIVE DIAGNOSIS Penile skin bridges after circumcision POSTOPERATIVE DIAGNOSIS Penile skin bridges after circumcision PROCEDURE Excision of penile skin bridges about 2 cm in size ABNORMAL FINDINGS Same as above ANESTHESIA General inhalation anesthetic with caudal block FLUIDS RECEIVED 300 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS No tissue sent to Pathology TUBES AND DRAINS No tubes or drains were used COUNT Sponge and needle counts were correct x2 INDICATIONS FOR OPERATION The patient is a 2 1 2 year old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection Plan is for repair DESCRIPTION OF PROCEDURE The patient is taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized the caudal block was placed and IV antibiotics were given He was then placed in a supine position and sterilely prepped and draped Once he was prepped and draped we used a straight mosquito clamp and went under the bridges and crushed them and then excised them with a curved iris and curved tenotomy scissors We removed the excessive skin on the shaft skin and on the glans itself We then on the ventrum excised the bridge and did a Heinecke Mikulicz closure with interrupted figure of eight and interrupted suture of 5 0 chromic Electrocautery was used for hemostasis Once this was done we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again IV Toradol was given at the end of procedure The patient tolerated the procedure well was in stable condition upon transfer to the recovery room Keywords urology heinecke mikulicz penile skin bridges caudal block penile skin skin bridges excision circumcision penile MEDICAL_TRANSCRIPTION,Description Complete urinary obstruction underwent a transurethral resection of the prostate adenocarcinoma of the prostate Medical Specialty Urology Sample Name Prostate Adenocarcinoma 1 Transcription HISTORY This 75 year old man was transferred from the nursing home where he lived to the hospital late at night on 4 11 through the Emergency Department in complete urinary obstruction After catheterization the patient underwent cystoscopy on 4 13 On 4 14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved Final diagnosis was adenocarcinoma of the prostate Because of his mental status and general debility the patient s family declined additional treatment LABORATORY None PROCEDURES Cystoscopy Blockage of the urethra by a markedly enlarged prostate Transurethral resection of prostate 45 grams of tissue were sent to the Pathology Department for analysis PATHOLOGY Well differentiated adenocarcinoma microacinar type in 1 of 25 chips of prostatic tissue Keywords urology urinary obstruction voiding resection of the prostate adenocarcinoma of the prostate complete urinary obstruction prostate adenocarcinoma transurethral resection cystoscopy transurethral resection prostate adenocarcinoma MEDICAL_TRANSCRIPTION,Description Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate Medical Specialty Urology Sample Name Prostate Adenocarcinoma 2 Transcription PHYSICAL EXAMINATION This 71 year old man went to his primary care physician for a routine physical His only complaints were nocturia times two and a gradual slowing down feeling The physical examination on 1 29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity R L PSA was elevated The differential diagnosis for the visit was abnormal prostate suggestive of CA IMAGING CT pelvis Irregular indentation of bladder Seminal vesicles enlarged Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus Impression prostatic malignancy with extracapsular extension and probable regional node metastasis Bone scan Negative for distant metastasis LABORATORY PSA 32 1 PROCEDURES Transrectal needle biopsy of prostate Pelvic lymphadenectomy and radical prostatectomy PATHOLOGY Prostate biopsy Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate Lymphadenectomy and prostatectomy Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa Therefore the radical prostatectomy was canceled Final pathology diagnosis Pelvic lymphadenectomy left obturator fossa single negative lymph node Right obturator fossa metastatic adenocarcinoma in 1 5 lymph nodes Largest involved node 1 5 cm TREATMENT Patient began external beam radiation therapy to the pelvis Keywords urology nocturia asymmetric prostate gland periprostatic metastasis poorly differentiated adenocarcinoma differentiated adenocarcinoma radical prostatectomy metastatic adenocarcinoma lymph nodes prostatectomy prostate lymphadenectomy adenocarcinoma MEDICAL_TRANSCRIPTION,Description The patient is a 16 month old boy who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge Medical Specialty Urology Sample Name Penile Cellulitis Transcription CHIEF COMPLAINT Penile cellulitis status post circumcision HISTORY OF PRESENT ILLNESS The patient is a 16 month old boy who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago The mother states that on Thursday he developed fairly significant swelling scrotum was also swollen the suprapubic region was swollen and he was having a purulent discharge and a fairly significant fever to 102 to 103 He was seen at Hospital transferred to Children s Hospital for further care Since being hospitalized his cultures apparently have grown Staph but is unknown yet whether it is methicillin resistant He has been placed on clindamycin and he is now currently afebrile and with marked improvement according to the mother I was requested a consultation by Dr X because of the appearance of penis The patient has been voiding without difficulty throughout PAST MEDICAL HISTORY The patient has no known allergies He was a term delivery via vaginal delivery Surgeries he has had 2 circumcisions No other hospitalizations He has had no heart murmurs seizures asthma or bronchitis REVIEW OF SYSTEMS A 14 point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned He also had an ear infection about 1 to 2 weeks before his circumcision SOCIAL HISTORY The patient lives with both parents and no siblings There are smokers at home MEDICATIONS Clindamycin and bacitracin ointment Also Bactrim PHYSICAL EXAMINATION VITAL SIGNS Weight is 14 9 kg GENERAL The patient was sleepy but easily arousable HEAD AND NECK Grossly normal His neck and chest are without masses NARES He had some crusted nares otherwise no other discharge LUNGS Clear CARDIAC Without murmurs or gallops ABDOMEN Soft without masses or tenderness GU He has a fairly prominent suprapubic fat pad and he is quite a large child in any event however there were no signs of erythema There was some induration around the penis however there were no signs of active infection He has a buried appearance of the penis after recent circumcision with a normal appearing glans The tissue itself however was quite dull and is soft or readily retractable at this time The scrotum was normal and there was no erythema there was no tenderness Both testes were descended without hydroceles EXTREMITIES He has full range of motion of all 4 extremities SKIN Warm pink and dry NEUROLOGIC Grossly intact BACK Normal IMPRESSION PLAN The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis This is being treated but it is most likely Staph and pending sensitivities I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad I recommended that he be treated most likely with Bactrim for a 10 day course at home bacitracin or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad which makes it more likely Otherwise it is a fairly healthy appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so He has a scheduled followup appointment with his urologist and he should keep that appointment or followup sooner if there is any other problem arising Keywords urology newborn circumcision suprapubic fat pad penile cellulitis penile swelling cellulitis penis penile suprapubic circumcision MEDICAL_TRANSCRIPTION,Description He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally Medical Specialty Urology Sample Name Pediatric Urology Letter Transcription XYZ M D Suite 123 ABC Avenue City STATE 12345 RE XXXX XXXX MR 0000000 Dear Dr XYZ XXXX was seen in followup in the Pediatric Urology Clinic I appreciate you speaking with me while he was in clinic He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally When I examined him he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region however on actual physical examination he seems to complain of pain through his entire right side His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration They also feel that since he has been on Detrol his pain levels have been somewhat worse and so I have given them the option of stopping the Detrol initially I think he should stay on MiraLax for management of his bowels I would also suggest that he be referred to Pediatric Gastroenterology for evaluation If they do not find any abnormalities from a gastrointestinal perspective then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain Thank you for following XXXX along with us in Pediatric Urology Clinic If you have any questions please feel free to contact me Sincerely yours Keywords urology differential function diuretic renal scan abdominal pain renal scan pediatric urology MEDICAL_TRANSCRIPTION,Description Prostate adenocarcinoma and erectile dysfunction Pathology report Medical Specialty Urology Sample Name Pathology Prostate Transcription SPECIMENS 1 Pelvis right pelvic obturator node 2 Pelvis left pelvic obturator node 3 Prostate POST OPERATIVE DIAGNOSIS Adenocarcinoma of prostate erectile dysfunction DIAGNOSTIC OPINION 1 Adenocarcinoma Gleason score 9 with tumor extension to periprostatic tissue margin involvement and tumor invasion to seminal vesicle prostate 2 No evidence of metastatic carcinoma right pelvic obturator lymph node 3 Metastatic adenocarcinoma left obturator lymph node see description CLINICAL HISTORY None listed GROSS DESCRIPTION Specimen 1 labeled right pelvic obturator lymph nodes consists of two portions of adipose tissue measuring 2 5 x 1x 0 8 cm and 2 5 x 1x 0 5 cm There are two lymph nodes measuring 1 x 0 7 cm and 0 5 x 0 5 cm The entire specimen is cut into several portions and totally embedded Specimen 2 labeled left pelvic obturation lymph nodes consists of an adipose tissue measuring 4 x 2 x 1 cm There are two lymph nodes measuring 1 3 x 0 8 cm and 1 x 0 6 cm The entire specimen is cut into 1 cm The entire specimen is cut into several portions and totally embedded Specimen 3 labeled prostate consists of a prostate It measures 5 x 4 5 x 4 cm The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration External surface also shows tumor induration especially in right side External surface is stained with green ink The cut surface shows diffuse tumor induration especially in right side The tumor appears to extend to excision margin Multiple representative sections are made MICROSCOPIC DESCRIPTION Section 1 reveals lymph node There is no evidence of metastatic carcinoma Section 2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node Section 3 reveals adenocarcinoma of prostate Gleason s score 9 5 4 The tumor shows extension to periprostatic tissue as well as margin involvement Seminal vesicle attached to prostate tissue shows tumor invasion Dr XXX reviewed the above case His opinion agrees with the above diagnosis SUMMARY A Adenocarcinoma of prostate Gleason s score 9 with both lobe involvement and seminal vesicle involvement T3b B There is lymph node metastasis N1 C Distant metastasis cannot be assessed MX D Excision margin is positive and there is tumor extension to periprostatic tissue Keywords urology pelvic obturator node erectile dysfunction seminal vesicle prostate lymph node specimen section adenocarcinoma of prostate pelvic obturator tumor lymph node specimens adenocarcinoma MEDICAL_TRANSCRIPTION,Description Right undescended testicle Orchiopexy Herniorrhaphy Medical Specialty Urology Sample Name Orchiopexy Herniorrhaphy 1 Transcription PREOPERATIVE DIAGNOSIS Right undescended testicle POSTOPERATIVE DIAGNOSIS Right undescended testicle OPERATIONS 1 Right orchiopexy 2 Right herniorrhaphy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal SPECIMEN Sac BRIEF HISTORY This is a 10 year old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis The patient and mother had seen the testicle in the right hemiscrotum in the past but the testicle seemed to be sliding The testis was identified right at the external inguinal ring The testis was unable to be brought down into the scrotal sac The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle HCG stimulation orchiopexy were discussed Risk of anesthesia bleeding infection pain hernia etc were discussed The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy PROCEDURE IN DETAIL The patient was brought to the OR anesthesia was applied The patient was placed in supine position The patient was prepped and draped in the inguinal and scrotal area After the patient was prepped and draped an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal The incision came through the subcutaneous tissue and external oblique fascia was identified The external oblique fascia was opened sharply and was taken all the way down towards the external ring The ilioinguinal nerve was identified right underneath the external oblique fascia which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture After dissecting proximally the testis was identified in the distal end of the inguinal canal The testis was pulled up The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring There was very small hernia which was removed and was tied at the base PDS suture was used to tie this hernia sac all the way up to the base There was a Y right at the vas and cord indicating there was enough length into the scrotal sac The testis was easily brought down into the scrotal sac One centimeter superior scrotal incision was made and a Dartos pouch was created The testicle was brought down into the pouch and was placed into the pouch Careful attention was done to ensure that there was no torsion of the cord The vas was medial all the way throughout and the cord was lateral all the way throughout The epididymis was in the posterolateral location The testicle was pexed using 4 0 Vicryl into the scrotal sac Skin was closed using 5 0 Monocryl The external oblique fascia was closed using 2 0 PDS Attention was drawn to re create the external inguinal ring A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord Marcaine 0 25 was applied about 15 mL worth of this was applied for local anesthesia After closing the external oblique fascia the Scarpa was brought together using 4 0 Vicryl and the skin was closed using 5 0 Monocryl in subcuticular fashion Dermabond and Steri Strips were applied The patient was brought to recovery room in stable condition at the end of the procedure Please note that the testicle was viable It was smaller than the other side probably by 50 There were no palpable testicular masses Plan was for the patient to follow up with us in about 1 month The patient was told not to do any heavy lifting for at least 3 months okay to shower in 48 hours No tub bath for 2 months The patient and family understood all the instructions Keywords urology undescended testicle orchiopexy herniorrhaphy external oblique fascia inguinal ring scrotal sac oblique fascia testicle herniorrhaphy orchiopexy inguinal MEDICAL_TRANSCRIPTION,Description Overactive bladder with microscopic hematuria Medical Specialty Urology Sample Name Overactive Bladder Transcription REASON FOR VISIT Overactive bladder with microscopic hematuria HISTORY OF PRESENT ILLNESS The patient is a 56 year old noted to have microscopic hematuria with overactive bladder Her cystoscopy performed was unremarkable She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night No gross hematuria dysuria pyuria no other outlet obstructive and or irritative voiding symptoms The patient had been previously on Ditropan and did not do nearly as well At this point what we will try is a different medication Renal ultrasound is otherwise unremarkable notes no evidence of any other disease IMPRESSION Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted She has no other significant findings other than her overactive bladder which had continued At this juncture what I would like to do is try a different anticholinergic medication She has never had any side effects from her medication PLAN The patient will discontinue Ditropan We will start Sanctura XR and we will follow up as scheduled Otherwise we will continue to follow her urinalysis over the next year or so Keywords urology overactive bladder with microscopic hematuria irritative voiding symptoms anticholinergic microscopic hematuria overactive bladder ditropan microscopic hematuria bladder overactive MEDICAL_TRANSCRIPTION,Description Reduction of paraphimosis Medical Specialty Urology Sample Name Paraphimosis Transcription PREOPERATIVE DIAGNOSIS Phimosis POSTOPERATIVE DIAGNOSIS Phimosis PROCEDURE Reduction of paraphimosis ANESTHESIA General inhalation anesthetic with 0 25 Marcaine penile block and ring block about 20 mL given FLUIDS RECEIVED 100 mL SPECIMENS No tissues sent to pathology COUNTS Sponge and needle counts were not necessary TUBES DRAINS No tubes or drains were used FINDINGS Paraphimosis with moderate swelling INDICATIONS FOR OPERATION The patient is a 15 year old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis The plan is for reduction DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis Using Betadine and alcohol cleanse we then did a dorsal penile block and a ring block by surgeon with 0 25 Marcaine 20 mL were given He did quite well after the procedure and was transferred to the recovery room in stable condition Keywords urology dorsal penile block reduction of paraphimosis penile block phimosis paraphimosis MEDICAL_TRANSCRIPTION,Description Left inguinal hernia repair left orchiopexy with 0 25 Marcaine ilioinguinal nerve block and wound block at 0 5 Marcaine plain Medical Specialty Urology Sample Name Orchiopexy Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Left undescended testis POSTOPERATIVE DIAGNOSIS Left undescended testis plus left inguinal hernia PROCEDURES Left inguinal hernia repair left orchiopexy with 0 25 Marcaine ilioinguinal nerve block and wound block at 0 5 Marcaine plain ABNORMAL FINDINGS A high left undescended testis with a type III epididymal attachment along with vas ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 1100 mL of crystalloid TUBES DRAINS No tubes or drains were used COUNTS Sponge and needle counts were correct x2 SPECIMENS No tissues sent to Pathology ANESTHESIA General inhalational anesthetic INDICATIONS FOR OPERATION The patient is an 11 1 2 year old boy with an undescended testis on the left The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then placed in a supine position and sterilely prepped and draped A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15 blade knife and further extended with electrocautery into the subcutaneous tissue We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring We were able to dissect all the way up to the ring but were unable to get the testis delivered We then made a left inguinal incision with a 15 blade knife further extending with electrocautery through Scarpa fascia down to the external oblique fascia The testis again was not visualized in the external ring so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15 blade knife further extending with Metzenbaum scissors The testis itself was quite high up in the upper canal We then dissected the gubernacular structures off of the testis and also then opened the sac and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors Once this was dissected off and up towards the internal ring it was twisted upon itself and suture ligated with an 0 Vicryl suture We then dissected the lateral spermatic fascia and then using blunt dissection dissected in the retroperitoneal space to get more cord length We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off We then found that we had an adequate amount of cord length to get the testis in the mid to low scrotum The patient was found to have a type III epididymal attachment with a long looping vas and we brought the testis into the scrotum in the proper orientation and tacked it to mid to low scrotum with a 4 0 chromic stay stitch The upper aspect of the subdartos pouch was closed with a 4 0 chromic pursestring suture The testis was then placed into the scrotum in the proper orientation We then placed the local anesthetic and the ilioinguinal nerve block and placed a small amount in both incisional areas as well We then closed the external oblique fascia with a running suture of 0 Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure The Scarpa fascia was closed with a 4 0 chromic suture and the skin was closed with a 4 0 Rapide subcuticular closure Dermabond tissue adhesive was placed on the both incisions and IV Toradol was given at the end of the procedure The patient tolerated the procedure well was in a stable condition upon transfer to the recovery room Keywords urology inguinal hernia repair ilioinguinal nerve block external oblique fascia hernia repair epididymal attachment external ring inguinal incision scarpa fascia cord length inguinal hernia nerve block ilioinguinal nerve undescended testis testis inguinal fascia hernia dissected MEDICAL_TRANSCRIPTION,Description Right orchiopexy and right inguinal hernia repair Medical Specialty Urology Sample Name Orchiopexy Hernia Repair 1 Transcription PREOPERATIVE DIAGNOSIS Right undescended testis ectopic position POSTOPERATIVE DIAGNOSES Right undescended testis ectopic position right inguinal hernia PROCEDURES Right orchiopexy and right inguinal hernia repair ANESTHESIA General inhalational anesthetic with caudal block FLUIDS RECEIVED 100 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS No tissues sent to pathology TUBES AND DRAINS No tubes or drains were used INDICATIONS FOR OPERATION The patient is an almost 4 year old boy with an undescended testis on the right plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed He was then placed in the supine position and sterilely prepped and draped Since the testis was in the ectopic position we did an upper curvilinear scrotal incision with a 15 blade knife and further extended it with electrocautery Electrocautery was also used for hemostasis A subdartos pouch was then created with a curved tenotomy scissors The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments As we were dissecting it we then found the testis itself into the sac and we opened the sac and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment not being attached to the top We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps Once this was dissected off we then twisted it upon itself and then dissected it down towards the external ring but on traction We then twisted it upon itself suture ligated it with 3 0 Vicryl and released it allowing it to spring back into the canal Once this was done we then had adequate length of the testis into the scrotal sac Using a curved mosquito clamp we grasped the base of the scrotum internally and using the subcutaneous tissue we tacked it to the base of the testis using a 4 0 chromic suture The testis was then placed into the scrotum in the proper orientation The upper aspect of the pouch was closed with a pursestring suture of 4 0 chromic The scrotal skin and dartos were then closed with subcutaneous closure of 4 0 chromic and Dermabond tissue adhesive was used on the incision IV Toradol was given Both testes were well descended in the scrotum at the end of the procedure Keywords urology ectopic position inguinal hernia inguinal hernia repair hernia sac tunica vaginalis gubernacular attachments testis ectopic position curved mosquito clamp caudal block hernia repair undescended testis orchiopexy dissected hernia inguinal testis MEDICAL_TRANSCRIPTION,Description Bilateral orchiopexy This 8 year old boy has been found to have a left inguinally situated undescended testes Ultrasound showed metastasis to be high in the left inguinal canal The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum Medical Specialty Urology Sample Name Orchiopexy Bilateral Transcription PREOPERATIVE DIAGNOSIS Bilateral undescended testes POSTOPERATIVE DIAGNOSIS Bilateral undescended testes OPERATION PERFORMED Bilateral orchiopexy ANESTHESIA General HISTORY This 8 year old boy has been found to have a left inguinally situated undescended testes Ultrasound showed metastasis to be high in the left inguinal canal The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum Both testes appeared to be normal in size for the boy s age OPERATIVE FINDINGS As above both testes appeared viable and normal in size no masses There is a hernia on the left side The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement OPERATIVE PROCEDURE The boy was taken to the operating room where he was placed on the operating table General anesthesia was administered by Dr X after which the boy s lower abdomen and genitalia were prepared with Betadine and draped aseptically A 0 25 Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision An inguinal incision was then made through this area carried through the subcutaneous tissues to the anterior fascia External ring was exposed with dissection as well The fascia was opened in direction of its fibers exposing the testes which lay high in the canal The testes were freed with dissection by removing cremasteric and spermatic fascia The hernia sac was separated from the cord twisted and suture ligated at the internal ring Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring However this would only allow placement of the testes in the upper scrotum with some tension Therefore the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with 4 0 Vicryl and divided This maneuver allowed for placement of the testes in the upper scrotum without tension A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel The testes were then brought into the pouch and anchored with interrupted 4 0 Vicryl sutures The skin was approximated with interrupted 5 0 chromic catgut sutures Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted 4 0 Vicryl over the spermatic cord and the external oblique fascia was closed with running 4 0 Vicryl suture Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running 5 0 subcuticular after placing several 4 0 Vicryl approximating sutures in the subcutaneous tissues Attention was then turned to the opposite side where an orchiopexy was performed in a similar fashion However on this side there was no inguinal hernia The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord so that the Prentiss maneuver was not required on this side The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well The inguinal and scrotal incisions were cleansed after completion of the procedure Steri Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision The child was then awakened and transported to post anesthetic recovery area apparently in satisfactory condition Instrument and sponge counts were correct There were no apparent complications Estimated blood loss was less than 20 to 30 mL Keywords urology bilateral orchiopexy bilateral undescended testes prentiss maneuver subcutaneous tissues internal ring dartos pouch scrotal incisions undescended testes spermatic cord inguinal canal testes inguinally orchiopexy undescended cord vicryl ultrasound spermatic canal MEDICAL_TRANSCRIPTION,Description Examination under anesthesia diagnostic laparoscopy right orchiectomy and left testis fixation Medical Specialty Urology Sample Name Orchiectomy Testis Fixation Transcription PREOPERATIVE DIAGNOSIS Nonpalpable right undescended testis POSTOPERATIVE DIAGNOSIS Nonpalpable right undescended testis with atrophic right testis PROCEDURES Examination under anesthesia diagnostic laparoscopy right orchiectomy and left testis fixation ANESTHESIA General inhalation anesthetic with caudal block FLUID RECEIVED 250 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMEN The tissue sent to Pathology was right testicular remnant ABNORMAL FINDINGS Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring INDICATIONS FOR OPERATION The patient is a 2 year old boy with a right nonpalpable undescended testis The plan is for evaluation and repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed The patient was placed in supine position and examined The left testis well within scrotum The right was again not palpable despite the patient being asleep with multiple attempts to check The patient was then sterilely prepped and draped An 8 French feeding tube was then placed within his bladder through the urethra and attached to the drainage We then incised the infraumbilical area once he was sterilely prepped and draped with 15 blade knife then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3 0 Monocryl We entered the peritoneum with the 5 mm one step system We then used the short 0 degree lens for laparoscopy We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found Because there was no testis found in the abdomen we then evacuated the gas and closed the fascial sheath with the 3 0 Monocryl tacking sutures Then skin was closed with subcutaneous closure of 4 0 Rapide A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery Electrocautery was used for hemostasis A curved tenotomy scissor was used to open the sac The tunica vaginalis was visualized and grasped and then dissected up towards external ring There was no apparent testicular tissue We did remove it however tying off the cord structure with a 4 0 Vicryl suture and putting a tagging suture at the base of the tissue sent We then closed the subdartos area with the subcutaneous closure of 4 0 chromic We then did a similar curvilinear incision on the left side for testicular fixation Delivered the testis into the field which had a type III epididymal attachment and was indeed about 3 to 4 mL in size which was larger than expected for the patient s age We then closed the upper aspect of the subdartos pouch with the 4 0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos skin and subcutaneous closure with 4 0 chromic on left hemiscrotum At the end of the procedure the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure The patient tolerated procedure well and was in stable condition upon transfer to the recovery room Keywords urology diagnostic laparoscopy caudal block testis fixation undescended testis subcutaneous closure testis orchiectomy laparoscopy testicular scrotum MEDICAL_TRANSCRIPTION,Description Orchiopexy inguinal herniorrhaphy Medical Specialty Urology Sample Name Orchiopexy Herniorrhaphy Transcription OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating room table The patient was prepped and draped in usual sterile fashion An incision was made in the groin crease overlying the internal ring This incision was about 1 5 cm in length The incision was carried down through the Scarpa s layer to the level of the external oblique This was opened along the direction of its fibers and carried down along the external spermatic fascia The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free A hernia sac was identified and the testicle was located Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring This was performed by incising the transversalis fascia circumferentially The hernia sac was ligated with a 3 0 silk suture high and divided and was noted to retract into the abdominal cavity Care was taken not to injure the testicular vessels Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum The testicle was viable This was wrapped in a moist sponge Next a hemostat was passed down through the inguinal canal down into the scrotum A small 1 cm incision was made in the anterior superior scrotal wall Dissection was carried down through the dartos layer A subdartos pouch was formed with blunt dissection The hemostat was then pushed against the tissues and this tissue was divided The hemostat was then passed through the incision A Crile hemostat was passed back up into the inguinal canal The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision The neck was then closed with a 4 0 Vicryl suture that was not too tight but tight enough to prevent retraction of the testicle The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4 0 chromic and the skin was closed with a running 6 0 subcuticular chromic suture Benzoin and a Steri Strip were placed Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly This was done with 2 to 3 interrupted 3 0 silk sutures The external oblique was then closed with interrupted 3 0 silk suture The Scarpa s layer was closed with a running 4 0 chromic and the skin was then closed with a running 4 0 Vicryl intracuticular stitch Benzoin and Steri Strip were applied The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block was awakened and was returned to the recovery room in stable condition Keywords urology orchiopexy benzoin crile hemostat scarpa s layer caudal block cremasteric fascia groin crease hemiscrotum iliopubic tract inguinal canal inguinal herniorrhaphy intracuticular stitch retroperitoneum spermatic fascia testicle hernia sac inguinal incisionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral scrotal orchiectomy Medical Specialty Urology Sample Name Orchiectomy Transcription BILATERAL SCROTAL ORCHECTOMY PROCEDURE The patient is placed in the supine position prepped and draped in the usual manner Under satisfactory general anesthesia the scrotum was approached and through a transverse mid scrotal incision the right testicle was delivered through the incision Hemostasis was obtained with the Bovie and the spermatic cord was identified It was clamped suture ligated with 0 chromic catgut and the cord above was infiltrated with 0 25 Marcaine for postoperative pain relief The left testicle was delivered through the same incision The spermatic cord was identified clamped suture ligated and that cord was also injected with 0 25 percent Marcaine The incision was injected with the same material and then closed in two layers using 4 0 chromic catgut continuous for the dartos and interrupted for the skin A dry sterile dressing fluff and scrotal support applied over that The patient was sent to the Recovery Room in stable condition Keywords urology scrotum hemostasis marcaine catgut incision scrotal orchiectomy spermatic cord sterile dressing testicle transverse suture ligated chromic catgut orchiectomy scrotal cordNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 6 mm left intrarenal stone nonobstructing by ultrasound and IVP Medical Specialty Urology Sample Name Microhematuria Consult Transcription HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr ABC s office regarding the above He was seen a few weeks ago for routine followup and he was noted for microhematuria Due to his history of kidney stone renal ultrasound as well as IVP was done He presents today for followup He denies any dysuria gross hematuria or flank pain issues Last stone episode was over a year ago No history of smoking Daytime frequency 3 to 4 and nocturia 1 to 2 good stream empties well with no incontinence Creatinine 1 0 on June 25 2008 UA at that time was noted for 5 9 RBCs renal ultrasound of 07 24 2008 revealed 6 mm left intrarenal stone with no hydronephrosis IVP same day revealed a calcification over the left kidney but without bilateral hydronephrosis The calcification previously noted on the ureter appears to be outside the course of the ureter Otherwise unremarkable This is discussed IMPRESSION 1 A 6 mm left intrarenal stone nonobstructing by ultrasound and IVP The patient is asymptomatic We have discussed surgical intervention versus observation He indicates that this stone is not bothersome prefers observation need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed 2 Microhematuria we discussed possible etiologies of this and the patient is agreeable to cystoscopy in the near future Urine sent for culture and sensitivity PLAN As above The patient will follow up for cystoscopy urine sent for cytology continue hydration Call if any concern The patient is seen and evaluated by myself Keywords urology intrarenal stone ivp ultrasound microhematuria hydration kidney stone renal ultrasound MEDICAL_TRANSCRIPTION,Description Stage I and II neuromodulator Medical Specialty Urology Sample Name Neuromodulator Transcription PREOPERATIVE DIAGNOSIS Refractory urgency and frequency POSTOPERATIVE DIAGNOSIS Refractory urgency and frequency OPERATION Stage I and II neuromodulator ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid The patient was given Ancef preop antibiotic Ancef irrigation was used throughout the procedure BRIEF HISTORY The patient is a 63 year old female who presented to us with urgency and frequency on physical exam There was no evidence of cystocele or rectocele On urodyanamcis the patient has significant overactivity of the bladder The patient was tried on over three to four different anticholinergic agents such as Detrol Ditropan Sanctura and VESIcare for at least one month each The patient had pretty much failure from each of the procedure The patient had less than 20 improvement with anticholinergics Options such as continuously trying anticholinergics continuation of the Kegel exercises and trial of InterStim were discussed The patient was interested in the trial The patient had percutaneous InterStim trial in the office with over 70 to 80 improvement in her urgency frequency and urge incontinence The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator Risks of anesthesia bleeding infection pain MI DVT and PE were discussed Risk of failure of the procedure in the future was discussed Risk of lead migration that the treatment may or may not work in the long term basis and data on the long term were not clear were discussed with the patient The patient understood and wanted to proceed with stage I and II neuromodulator Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR The patient was placed in prone position A pillow was placed underneath her pelvis area to slightly lift the pelvis up The patient was awake was given some MAC anesthesia through the IV but the patient was talking and understanding and was able to verbalize issues The patient s back was prepped and draped in the usual sterile fashion Lidocaine 1 was applied on the right side near the S3 foramen Under fluoroscopy the needle placement was confirmed The patient felt stimulation in the vaginal area which was tapping in nature The patient also had a pressure feeling in the vaginal area The patient had no back sensation or superficial sensation There was no sensation down the leg The patient did have __________ which turned in slide bellows response indicating the proper positioning of the needle A wire was placed The tract was dilated and lead was placed The patient felt tapping in the vaginal area which is an indication that the lead is in its proper position Most of the leads had very low amplitude and stimulation Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks Please note that the lidocaine was injected prior to the tunneling A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead Screws were turned and they were dropped Attention was made to ensure that the lead was all the way in into the InterStim Irrigation was performed after placing the main unit in the pouch Impedance was checked Irrigation was again performed with antibiotic irrigation solution The needle site was closed using 4 0 Monocryl The pouch was closed using 4 0 Vicryl and the subcutaneous tissue with 4 0 Monocryl Dermabond was applied The patient was brought to recovery in a stable condition Keywords urology refractory urgency urgency frequency neuromodulator subcutaneous tissue interstim MEDICAL_TRANSCRIPTION,Description Mini laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap Adenocarcinoma of the prostate Medical Specialty Urology Sample Name Mini Laparotomy Radical Retropubic Prostatectomy Transcription PREOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate POSTOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate TITLE OF OPERATION Mini laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap ANESTHESIA General by intubation Informed consent was obtained for the procedure The patient understands the treatment options and wishes to proceed He accepts the risks to include bleeding requiring transfusion infection sepsis incontinence impotence bladder neck constricture heart attack stroke pulmonary emboli phlebitis injury to the bladder rectum or ureter etcetera OPERATIVE PROCEDURE IN DETAIL The patient was taken to the Operating Room and placed in the supine position prepped with Betadine solution and draped in the usual sterile fashion A 20 French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage The table was then placed in minimal flexed position A midline skin incision was then made from the umbilicus to the symphysis pubis It was carried down to the anterior rectus fascia into the pelvis proper Both obturator fossae were exposed Standard bilateral pelvic lymph node dissections were carried out The left side was approached first by myself The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially and from the bifurcation of the common iliac vein proximally to Cooper s ligament distally Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2 0 silk ligatures The obturator nerve was visualized throughout and was not injured The right side was carried out by my assistant under my direct and constant supervision Again the obturator nerve was visualized throughout and it was not injured Both packets were sent to Pathology where no evidence of carcinoma was found My attention was then directed to the prostate itself The endopelvic fascia was opened bilaterally Using gentle dissection with a Kitner I swept the levator muscles off the prostate and exposed the apical portion of the prostate A back bleeding control suture of 0 Vicryl was placed at the mid prostate level A sternal wire was then placed behind the dorsal vein complex which was sharply transected The proximal and distal portions of this complex were then oversewn with 2 0 Vicryl in a running fashion When I was satisfied that hemostasis was complete my attention was then turned to the neurovascular bundles The urethra was then sharply transected and six sutures of 2 0 Monocryl placed at the 1 3 5 7 9 and 11 o clock positions The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers fascia was incised distally swept off the rectum and incorporated with the prostate specimen The lateral pedicles over the seminal vesicles were then mobilized hemoclipped and transected The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips Ampullae of the vas were mobilized hemoclipped and transected The bladder neck was then developed using careful blunt and sharp dissection The prostate was then transected at the level of the bladder neck and sent for permanent specimen The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge The bladder neck was reconstructed in standard fashion It was closed using a running 2 0 Vicryl The mucosa was everted over the edge of the bladder neck using interrupted 3 0 Vicryl suture At the end of this portion of the case the new bladder neck had a stoma like appearance and would accommodate easily my small finger The field was then re evaluated for hemostasis which was further obtained using hemoclips Bovie apparatus and 3 0 chromic ligatures When I was satisfied that hemostasis was complete the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck A new 20 French Foley catheter was brought in through the urethra into the bladder A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight The pelvis was also copiously irrigated with 2 liters of sterile water A 10 French Jackson Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2 0 silk ligature The wound was then closed in layers The muscle was closed with a running 0 chromic the fascia with a running 1 0 Vicryl the subcutaneous tissue with 3 0 plain and the skin with a running 4 0 Vicryl subcuticular Steri Strips were applied and a sterile dressing The patient was taken to the Recovery Room in good condition There were no complications Sponge and instrument counts were reported correct at the end of the case Keywords urology mini laparotomy radical retropubic prostatectomy pelvic lymph pelvic lymph node dissection cavermap mini laparotomy prostatectomy bladder intubation adenocarcinoma endopelvic hemostasis neck MEDICAL_TRANSCRIPTION,Description An example template for meatotomy Medical Specialty Urology Sample Name Meatotomy Template Transcription OPERATIVE NOTE The patient was taken to the operating room and was placed in the supine position on the operating room table A general inhalation anesthetic was administered The patient was prepped and draped in the usual sterile fashion The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated Next a midline ventral type incision was made opening the meatus This was done after clamping the tissue to control bleeding The meatus was opened for about 3 mm Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6 0 Vicryl sutures The meatus still calibrated between 10 and 12 French Antibiotic ointment was applied The procedure was terminated The patient was awakened and returned to the recovery room in stable condition Keywords urology urethral meatus mosquito hemostat meatus mucosal edges glans meatotomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Neurogenic bladder in a patient catheterizing himself 3 times a day changing his catheter 3 times a week Medical Specialty Urology Sample Name Neurogenic Bladder Consult Transcription HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr ABC s office regarding the above He has history of neurogenic bladder and on intermittent self catheterization 3 times a day However June 24 2008 he was seen in the ER and with fever weakness possible urosepsis He had a blood culture which was positive for Staphylococcus epidermidis as well as urine culture noted for same bacteria He was treated on IV antibiotics Dr XYZ also saw the patient Discharged home Not taking any antibiotics Today in the office the patient denies any dysuria gross hematuria fever chills He is catheterizing 3 times a day changing his catheter weekly Does have history of renal transplant which has been followed by Dr X and is on chronic steroids Renal ultrasound June 23 2008 was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space Creatinine July 7 2008 was 2 0 BUN 36 and patient tells me this is being followed by Dr X No interval complaints today no issues with catheterization or any gross hematuria IMPRESSION 1 Neurogenic bladder in a patient catheterizing himself 3 times a day changing his catheter 3 times a week we again reviewed the technique of catheterization and he has no issues with this 2 Recurrent urinary tract infection in a patient who has been hospitalized twice within the last few months he is on steroids for renal transplant which has most likely been overall reducing his immune system He is asymptomatic today No complaints today PLAN Following a detailed discussion with the patient we elected to proceed with intermittent self catheterization changing catheter weekly and technique has been discussed as above Based on the recent culture we will place him on Keflex nighttime prophylaxis for the next three months or so He will call if any concerns Follow up as previously scheduled in September for re assessment All questions answered The patient is seen and evaluated by myself Keywords urology neurogenic bladder catheterizing catheter urinary tract infection self catheterization intermittent self catheterization renal transplant catheterization MEDICAL_TRANSCRIPTION,Description Left orchiectomy scrotal exploration right orchidopexy Medical Specialty Urology Sample Name Left Orchiectomy Right Orchidopexy Transcription PREOPERATIVE DIAGNOSIS Left testicular torsion POSTOPERATIVE DIAGNOSES 1 Left testicular torsion 2 Left testicular abscess 3 Necrotic testes SURGERY Left orchiectomy scrotal exploration right orchidopexy DRAINS Penrose drain on the left hemiscrotum The patient was given vancomycin Zosyn and Levaquin preop BRIEF HISTORY The patient is a 49 year old male who came into the emergency room with 2 week history of left testicular pain scrotal swelling elevated white count of 39 000 The patient had significant scrotal swelling and pain Ultrasound revealed necrotic testicle Options such as watchful waiting and removal of the testicle were discussed Due to elevated white count the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis The risks of anesthesia bleeding infection pain MI DVT PE scrotal issues other complications were discussed The patient was told about the morbidity and mortality of the procedure and wanted to proceed PROCEDURE IN DETAIL The patient was brought to the OR Anesthesia was applied The patient was prepped and draped in usual sterile fashion A midline scrotal incision was made There was very very thick scrotal skin There was no necrotic skin As soon as the left hemiscrotum was entered significant amount of pus poured out of the left hemiscrotum The testicle was completely filled with pus and had completely disintegrated with pus The pus just poured out of the left testicle The left testicle was completely removed Debridement was done of the scrotal wall to remove any necrotic tissue Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum There was good tissue left after all the irrigation and debridement A Penrose drain was placed in the bottom of the left hemiscrotum I worried about the patient may have torsed and then the testicle became necrotic so the plan was to pex the right testicle plus the right side also appeared very abnormal So the right hemiscrotum was opened The testicle had significant amount of swelling and scrotal wall was very thick The testicle appeared normal There was no pus coming out of the right hemiscrotum At this time a decision was made to place 4 0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion The hemiscrotum was closed using 2 0 Vicryl in interrupted stitches and the skin was closed using 2 0 PDS in horizontal mattress There was very minimal pus left behind and the skin was very healthy Decision was made to close it to help the patient heal better in the long run The patient was brought to the recovery in stable condition Keywords urology testicular abscess necrotic testes orchiectomy scrotal exploration orchidopexy hemiscrotum testicular torsion penrose drain scrotal swelling scrotal wall testicle torsion MEDICAL_TRANSCRIPTION,Description Left orchiopexy Ectopic left testis The patient did have an MRI which confirmed ectopic testis located near the pubic tubercle Medical Specialty Urology Sample Name Orchiopexy Transcription PREOPERATIVE DIAGNOSIS Ectopic left testis POSTOPERATIVE DIAGNOSIS Ectopic left testis PROCEDURE PERFORMED Left orchiopexy ANESTHESIA General The patient did receive Ancef INDICATIONS AND CONSENT This is a 16 year old African American male who had an ectopic left testis that severed approximately one and a half years ago The patient did have an MRI which confirmed ectopic testis located near the pubic tubercle The risks benefits and alternatives of the proposed procedure were discussed with the patient Informed consent was on the chart at the time of procedure PROCEDURE DETAILS The patient did receive Ancef antibiotics prior to the procedure He was then wheeled to the operative suite where a general anesthetic was administered He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure Next with a 15 blade scalpel an oblique skin incision was made over the spermatic cord region The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery The fascia of the external oblique creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors This was then continued to open the external ring and was then carried cephalad to further open the external ring exposing the spermatic cord With this accomplished the testis was then identified It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord Once again meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens Weitlaner retractor was placed to provide further exposure There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with 3 0 Vicryl Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis Next bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment This was taken down to approximately the two thirds length of the left scrotal compartment Once this tunnel has been created a 15 blade scalpel was then used to make transverse incision A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment Once this was achieved the apices of the dartos were then grasped with hemostats and supra dartos pouch was then created using the Iris scissors A dartos pouch was created between the skin and the supra dartos both cephalad and caudad to the level of the scrotal incision A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra dartos pouch ensuring that anatomic position was in place maintaining the epididymis posterolateral without any rotation of the cord With this accomplished 3 0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis The sutures were then tied creating the orchiopexy The remaining body of the testicle was then tucked into the supra dartos pouch and the skin was then approximated with 4 0 undyed Monocryl in a horizontal mattress fashion interrupted sutures Once again hemostasis was maintained with Bovie electrocautery Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures External ring was then recreated and grasped on each side with hemostats and approximated with 3 0 Vicryl in a running fashion cephalad to caudad Once this was created the created ring was inspected and there was adequate room for the cord There appeared to be no evidence of compression Finally subcutaneous layer with sutures of 4 0 interrupted chromic was placed and then the skin was then closed with 4 0 undyed Vicryl in a running subcuticular fashion The patient had been injected with bupivacaine prior to closing the skin Finally the patient was cleansed The scrotal support was placed and plan will the for the patient to take Keflex one tablet q i d x7 days as well as Tylenol 3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum He will follow up with Dr X in 10 to 14 days Appointment will be made Keywords urology pubic tubercle ectopic testis ectopic left testis metzenbaum scissors dartos pouch bovie electrocautery testis orchiopexy ectopic scrotal cord dartos MEDICAL_TRANSCRIPTION,Description Examination under anesthesia and laparoscopic right orchiopexy Medical Specialty Urology Sample Name Laparoscopic Orchiopexy Transcription PREOPERATIVE DIAGNOSIS Bilateral undescended testes POSTOPERATIVE DIAGNOSIS Bilateral undescended testes bilateral intraabdominal testes PROCEDURE Examination under anesthesia and laparoscopic right orchiopexy ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 110 mL of crystalloid INTRAOPERATIVE FINDINGS Atrophic bilateral testes right is larger than left The left had atrophic or dysplastic vas and epididymis TUBES AND DRAINS No tubes or drains were used INDICATIONS FOR OPERATION The patient is a 7 1 2 month old boy with bilateral nonpalpable testes Plan is for exploration possible orchiopexy DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then palpated and again both testes were nonpalpable Because of this a laparoscopic approach was then elected We then sterilely prepped and draped the patient put an 8 French feeding tube in the urethra attached to bulb grenade for drainage We then made an infraumbilical incision with a 15 blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3 0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors Once we got into the peritoneum we placed a 5 mm port with 0 degree short lens Insufflation was then done with carbon dioxide up to 10 to 12 mmHg We then evaluated There was no bleeding noted He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas which was barely visualized The right side was also intraabdominal but slightly larger had better vessels had much more recognizable vas and it was closer to the internal ring So we elected to do an orchiopexy on the right side Using the laparoscopic 3 and 5 mm dissecting scissors we then opened up the window at the internal ring through the peritoneal tissue then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney mid way up the abdomen and across towards the bladder for the vas We then used the Maryland dissector to gently tease this tissue once it was incised The gubernaculum was then divided with electrocautery and the laparoscopic scissors We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side left side of the ring We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15 blade knife and extended down the subcutaneous tissue with electrocautery We used the curved tenotomy scissors to make a subdartos pouch Using a mosquito clamp we were able to go in through the previous internal ring opening grasped the testis and then pulled it through in a proper orientation Using the hook electrode we were able to dissect some more of the internal ring tissue to relax the vessels and the vas so there was no much traction Using 2 stay sutures of 4 0 chromic we tacked the testis to the base of scrotum into the middle portion of the testis We then closed the upper aspect of the subdartos pouch with a 4 0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4 0 chromic We again evaluated the left side and found again that the vessels were quite short The testis was more atrophic and the vas was virtually nonexistent We will go back at a later date to try to bring this down but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present We then removed the ports closed the fascial defects with figure of eight suture of 3 0 Monocryl closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath and then used 4 0 Rapide to close the skin defects and then using Dermabond tissue adhesives we covered all incisions At the end of the procedure the right testis was well descended within the scrotum and the feeding tube was removed The patient had IV Toradol and was in stable condition upon transfer to recovery room Keywords urology laparoscopic right orchiopexy undescended testes orchiopexy bilateral undescended testes mosquito clamps subdartos pouch internal ring laparoscopic MEDICAL_TRANSCRIPTION,Description An example template for meatoplasty Medical Specialty Urology Sample Name Meatoplasty Template Transcription OPERATIVE NOTE The patient was placed in the supine position under general anesthesia and prepped and draped in the usual manner The penis was inspected The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove This was incised longitudinally and closed transversely with 5 0 chromic catgut sutures The meatus was calibrated and accepted the calibrating instrument without difficulty and there was no stenosis An incision was made transversely below the meatus in a circumferential way around the shaft of the penis bringing up the skin of the penis from the corpora The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie Using a skin hook the meatus was elevated ventrally and the glans flaps were reapproximated using 5 0 chromic catgut creating a new ventral portion of the glans using the flaps of skin There was good viability of the skin The incision around the base of the penis was performed separating the foreskin that was going to be removed from the coronal skin This was removed and hemostasis was obtained with a Bovie 0 25 Marcaine was infiltrated at the base of the penis for post op pain relief and the coronal and penile skin was reanastomosed using 4 0 chromic catgut At the conclusion of the procedure Vaseline gauze was wrapped around the penis There was good hemostasis and the patient was sent to the recovery room in stable condition Keywords urology penis meatus urethral groove corpora glans meatoplasty bovie chromic catgut hemostasisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Laparoscopic lysis of adhesions attempted laparoscopic pyeloplasty and open laparoscopic pyeloplasty Right ureteropelvic junction obstruction severe intraabdominal adhesions and retroperitoneal fibrosis Medical Specialty Urology Sample Name Laparoscopic Pyeloplasty Transcription PREOPERATIVE DIAGNOSIS Right ureteropelvic junction obstruction POSTOPERATIVE DIAGNOSES 1 Right ureteropelvic junction obstruction 2 Severe intraabdominal adhesions 3 Retroperitoneal fibrosis PROCEDURES PERFORMED 1 Laparoscopic lysis of adhesions 2 Attempted laparoscopic pyeloplasty 3 Open laparoscopic pyeloplasty ANESTHESIA General INDICATION FOR PROCEDURE This is a 62 year old female with a history of right ureteropelvic junction obstruction with chronic indwelling double J ureteral stent The patient presents for laparoscopic pyeloplasty PROCEDURE After informed consent was obtained the patient was taken to the operative suite and administered general anesthetic The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient s positioning for bowel retraction Hassan technique was performed for the initial trocar placement in the periumbilical region Abdominal insufflation was performed There were significant adhesions noted A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two and half hours also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus an additional 5 mm port in the right upper quadrant subcostal and midclavicular After adhesions were taken down the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially The kidney was able to be palpated within Gerota s fascia The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction The renal pelvis was also identified and dissected free There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open An incision was made from the right upper quadrant port extending towards the midline This was carried down through the subcutaneous tissue anterior fascia muscle layers posterior fascia and peritoneum A Bookwalter retractor was placed The renal pelvis and the ureter were again identified Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery The tissue was sent down to Pathology for analysis Please note that upon entering the abdomen all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue At this point the indwelling double J ureteral stent was removed At this time the ureter was spatulated laterally and at the apex of this spatulation a 4 0 Vicryl suture was placed This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated The back wall of the ureteropelvic anastomosis was then approximated with running 4 0 Vicryl suture At this point a double J stent was placed with a guidewire down into the bladder The anterior wall of the uteropelvic anastomosis was then closed again with a 4 0 running Vicryl suture Renal sinus fat was then placed around the anastomosis and sutured in place Please note in the inferior pole of the kidney there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue This was repaired with horizontal mattress sutures 2 0 Vicryl FloSeal was placed over this and the renal capsule was placed over this A good hemostasis was noted A 10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis The initial trocar incision was closed with 0 Vicryl suture The abdominal incision was also then closed with running 0 Vicryl suture incorporating all layers of muscle and fascia The Scarpa s fascia was then closed with interrupted 3 0 Vicryl suture The skin edges were then closed with staples Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator We placed the patient on IV antibiotics and pain medications We will obtain KUB and x rays for stent placement Further recommendations to follow Keywords urology retroperitoneal fibrosis pyeloplasty laparoscopic lysis of adhesions ureteropelvic junction obstruction laparoscopic pyeloplasty ureteropelvic junction junction ureteropelvic intraabdominal adhesions MEDICAL_TRANSCRIPTION,Description Bassini inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Urology Sample Name Inguinal Herniorrhaphy 2 Transcription PROCEDURE PERFORMED Bassini inguinal herniorrhaphy ANESTHESIA Local with MAC anesthesia PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table The patient was sedated and an adequate local anesthetic was administered using 1 lidocaine without epinephrine The patient was prepped and draped in the usual sterile manner A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Care was taken not to injure the ilioinguinal nerve Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and the sac was found anteromedially to the cord structures The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery Once preperitoneal fat was encountered the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2 0 silk suture ligature The sac was excised and sent to Pathology The stump was examined and no bleeding was noted The ends of the suture were then cut and the stump retracted back into the abdomen The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart s ligament to the conjoined tendon using a 2 0 Prolene starting at the pubic tubercle and running towards the internal ring In this manner an internal ring was created that admitted just the tip of my smallest finger The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 2 0 Vicryl in a running fashion thus reforming the external ring Marcaine 0 5 was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control The skin incision was approximated with skin staples A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords urology ilioinguinal nerve adherent cremasteric muscle bassini inguinal herniorrhaphy external oblique aponeurosis inguinal herniorrhaphy metzenbaum scissors external ring blunt dissection cord structures bovie electrocautery inguinal electrocautery MEDICAL_TRANSCRIPTION,Description Laparoscopic right inguinal herniorrhaphy with mesh as well as a circumcision Recurrent right inguinal hernia as well as phimosis Medical Specialty Urology Sample Name Inguinal Herniorrhaphy Circumcision Transcription PREOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis POSTOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis PROCEDURE PERFORMED Laparoscopic right inguinal herniorrhaphy with mesh as well as a circumcision ANESTHESIA General endotracheal COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery room in stable condition SPECIMEN Foreskin BRIEF HISTORY This patient is a 66 year old African American male who presented to Dr Y s office with recurrent right inguinal hernia for the second time requesting hernia repair The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right The patient also is requesting circumcision with phimosis at the same operating time setting INTRAOPERATIVE FINDINGS The patient was found to have a right inguinal hernia with omentum and bowel within the hernia which was easily reduced The patient was also found to have a phimosis which was easily removed PROCEDURE After informed consent the risks and benefits of the procedure were explained to the patient The patient was brought to operating suite after general endotracheal intubation prepped and draped in the normal sterile fashion An infraumbilical incision was made with a 15 Bard Parker scalpel The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg Next the Veress was removed and 10 bladed trocar was inserted without difficulty The 30 degree camera laparoscope was then inserted and the abdomen was explored There was evidence of a large right inguinal hernia which had omentum as well as bowel within it easily reducible Attention was next made to placing a 12 port in the right upper quadrant four fingerbreadths from the umbilicus Again a skin was made with a 15 blade scalpel and the 12 port was inserted under direct visualization A 5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization Next a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral The peritoneum was then spread using the blunt dissector opening up and identifying the iliopubic tract which was identified without difficulty Dissection was carried out freeing up the hernia sac from the peritoneum This was done without difficulty reducing the hernia in its entirety Attention was next made to placing a piece of Prolene mesh it was placed through the 12 port and placed into the desired position stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract The 4 8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re peritonealized re approximating edge of the perineum with the 4 8 mm staples This was done without difficulty All three ports were removed under direct visualization No evidence of bleeding and the 10 and 12 mm ports were closed with 0 Vicryl and UR6 needle Skin was closed with running subcuticular 4 0 undyed Vicryl Steri Strips and sterile dressings were applied Attention was next made to carrying out the circumcision The foreskin was retracted back over the penis head The desired amount of removing foreskin was marked out with a skin marker The foreskin was then put on tension using a clamp to protect the penis head A 15 blade scalpel was used to remove the foreskin and sending off as specimen This was done without difficulty Next the remaining edges were retracted hemostasis was obtained with Bovie electrocautery and the skin edges were re approximated with 2 0 plain gut in simple interrupted fashion and circumferentially This was done without difficulty maintaining hemostasis A petroleum jelly was applied with a Coban dressing The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition Keywords urology herniorrhaphy with mesh laparoscopic blunt dissector inguinal herniorrhaphy inguinal hernia hernia inguinal peritoneum circumcision phimosis foreskin MEDICAL_TRANSCRIPTION,Description Left inguinal herniorrhaphy modified Bassini Left inguinal hernia direct Medical Specialty Urology Sample Name Inguinal Herniorrhaphy 3 Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left inguinal hernia direct PROCEDURE Left inguinal herniorrhaphy modified Bassini DESCRIPTION OF PROCEDURE The patient was electively taken to the operating room In same day surgery Dr X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery Informed consent was obtained and the patient was transferred to the operating room where a time out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis which was opened The cord was isolated and protected It was dissected out The lipoma of the cord was removed and the sac was high ligated The main hernia was a direct hernia due to weakness of the floor A Bassini repair was performed We used a number of interrupted sutures of 2 0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl The dressing was applied and the patient tolerated the procedure well estimated blood loss was minimal was transferred to recovery room in satisfactory condition Keywords urology inguinal herniorrhaphy modified bassini herniorrhaphy modified bassini hernia direct inguinal hernia inguinal bassini MEDICAL_TRANSCRIPTION,Description Cystopyelogram and laser vaporization of the prostate Medical Specialty Urology Sample Name Laser Vaporization of Prostate Transcription PREOPERATIVE DIAGNOSIS Benign prostatic hypertrophy POSTOPERATIVE DIAGNOSIS Benign prostatic hypertrophy SURGERY Cystopyelogram and laser vaporization of the prostate ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 67 year old male with a history of TURP presented to us with urgency frequency and dribbling The patient was started on alpha blockers with some help but had nocturia q 1h The patient was given anticholinergics with minimal to no help The patient had a cystoscopy done which showed enlargement of the left lateral lobes of the prostate At this point options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream Continuation of alpha blockers and adding another anti cholinergic at night to prevent bladder overactivity were discussed The patient was told that his symptoms may be related to the mild to moderate trabeculation in the bladder which can cause poor compliance The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream which in turn might help improve emptying of the bladder and might help his overactivity of the bladder The patient was told that he may need anticholinergics There could be increased risk of incontinence stricture erectile dysfunction other complications and the consent was obtained PROCEDURE IN DETAIL The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient was given preoperative antibiotics The patient was prepped and draped in the usual sterile fashion A 23 French scope was inserted inside the urethra into the bladder under direct vision Bilateral pyelograms were normal The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder There was enlargement of the lateral lobes of the prostate The old TUR scar was visualized right at the bladder neck Using diode side firing fiber the lateral lobes were taken down The verumontanum the external sphincter and the ureteral openings were all intact at the end of the procedure Pictures were taken and were shown to the family At the end of the procedure there was good hemostasis A total of about 15 to 20 minutes of lasering time was used A 22 3 way catheter was placed At the end of the procedure the patient was brought to recovery in stable condition Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night Keywords urology laser vaporization of the prostate cystopyelogram benign prostatic hypertroph benign prostatic hypertrophy alpha blockers laser vaporization anticholinergics laser vaporization prostate bladder MEDICAL_TRANSCRIPTION,Description Direct inguinal hernia Rutkow direct inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Urology Sample Name Inguinal Herniorrhaphy 1 Transcription PREOPERATIVE DIAGNOSIS Inguinal hernia POSTOPERATIVE DIAGNOSIS Direct inguinal hernia PROCEDURE PERFORMED Rutkow direct inguinal herniorrhaphy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident Preoperative antibiotics were given for prophylaxis against surgical infection The patient was prepped and draped in the usual sterile fashion A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was placed around the cord structures at the level of the pubic tubercle This Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and no sac was found The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels This was dissected back to the hernia opening The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring The plug was secured to the ring by interrupted 2 0 Prolene sutures The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2 0 Prolene sutures By reinforcing the floor with the onlay patch a new internal ring was thus formed The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 2 0 Vicryl in a running fashion thus reforming the external ring The skin incision was approximated with 4 0 Monocryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords urology cremasteric muscle pubic tubercle external oblique aponeurosis inguinal herniorrhaphy inguinal hernia cord structures penrose drain bovie electrocautery inguinal herniorrhaphy metzenbaum bovie electrocautery cord hernia MEDICAL_TRANSCRIPTION,Description Inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Urology Sample Name Inguinal Herniorrhaphy Transcription PROCEDURE PERFORMED Inguinal herniorrhaphy PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was placed around the cord structures at the level of the pubic tubercle This Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and the sac was found anteromedially to the cord structures The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery Once preperitoneal fat was encountered the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2 0 silk suture ligature The sac was excised and went to Pathology The ends of the suture were then cut and the stump retracted back into the abdomen The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 3 0 Vicryl in a running fashion thus reforming the external ring The skin incision was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped and draped with benzoin and Steri Strips were applied A dressing consisting of a 2 x 2 and OpSite was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords urology inguinal canal cremasteric muscle pubic tubercl inguinal herniorrhaphy blunt dissection penrose drain bovie electrocautery cord structures inguinal electrocautery cord MEDICAL_TRANSCRIPTION,Description Bilateral inguinal hernia Bilateral direct inguinal hernia repair utilizing PHS system and placement of On Q pain pump Medical Specialty Urology Sample Name Inguinal Hernia Repair 3 Transcription PREOPERATIVE DIAGNOSIS Bilateral inguinal hernia POSTOPERATIVE DIAGNOSIS Bilateral inguinal hernia PROCEDURE Bilateral direct inguinal hernia repair utilizing PHS system and placement of On Q pain pump ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard sterile surgical fashion I did an ilioinguinal nerve block on both sides injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides Keywords urology phs system on q pump on q pain pump inguinal hernia repair bilateral inguinal hernia anterior superior iliac direct inguinal hernia subcutaneous tissue scarpa s fascia cord structures phs mesh ilioinguinal nerve external oblique inguinal hernia hernia oblique inguinal mesh MEDICAL_TRANSCRIPTION,Description Direct right inguinal hernia Marlex repair of right inguinal hernia Medical Specialty Urology Sample Name Inguinal Hernia Repair 5 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Direct right inguinal hernia TITLE OF PROCEDURE Marlex repair of right inguinal hernia ANESTHESIA Spinal PROCEDURE IN DETAIL The patient was taken to the operative suite placed on the table in the supine position and given a spinal anesthetic The right inguinal region was shaved and prepped and draped in a routine sterile fashion The patient received 1 gm of Ancef IV push Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue The external oblique fascia was exposed and incised down to and through the external inguinal ring The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal The cord was surrounded with a Penrose drain The hernia sac was separated from the cord structures The floor of the inguinal canal which consisted of attenuated transversalis fascia was imbricated upon itself with a running locked suture of 2 0 Prolene Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord It was placed around the cord and sutured to itself with 2 0 Prolene The patch was then sutured medially to the pubic tubercle inferiorly to Cooper s ligament and inguinal ligaments and superiorly to conjoined tendon using 2 0 Prolene The area was irrigated with saline solution and 0 5 Marcaine with epinephrine was injected to provide prolonged postoperative pain relief The cord was returned to its position External oblique fascia was closed with a running 2 0 PDS subcu with 2 0 Vicryl and skin with running subdermal 4 0 Vicryl and Steri Strips Sponge and needle counts were correct Sterile dressing was applied Keywords urology marlex repair inguinal region external oblique fascia inguinal ring direct right inguinal hernia inguinal hernia inguinal repair marlex oblique fascia hernia MEDICAL_TRANSCRIPTION,Description Right inguinal hernia Right direct inguinal hernia repair with PHS mesh system The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease Medical Specialty Urology Sample Name Inguinal Hernia Repair 4 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right direct inguinal hernia PROCEDURE Right direct inguinal hernia repair with PHS mesh system ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was administered with endotracheal intubation The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease Dissection was taken down through the skin and subcutaneous tissue Scarpa s fascia was divided and the external ring was located The external oblique was divided from the external ring up towards the anterior superior iliac spine The cord structures were then encircled Careful inspection of the cord structures did not reveal any indirect sac along the cord structures I did however feel a direct sac with a direct defect I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac Once I cleared out the preperitoneal space I placed a PHS mesh system with a posterior mesh into the preperitoneal space and I made sure that it laid flat along Cooper s ligament and covered the myopectineal orifice I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring making sure that it was not too tight so that it did not strangulate the cord structures I then closed the external oblique with a running 3 0 Vicryl I closed the Scarpa s with interrupted 3 0 Vicryl and I closed the skin with a running Monocril Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well and without any complications Keywords urology groin phs mesh inguinal hernia repair direct inguinal hernia preperitoneal space external oblique cord structures inguinal hernia inguinal hernia external oblique mesh MEDICAL_TRANSCRIPTION,Description A 9 year old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia taken to the operating room for inguinal hernia repair Medical Specialty Urology Sample Name Inguinal Hernia Repair 1 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right inguinal hernia PROCEDURE Right inguinal hernia repair INDICATIONS FOR PROCEDURE This patient is a 9 year old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia The patient is being taken to the operating room for inguinal hernia repair DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s inguinal and scrotal area were prepped and draped in the usual sterile fashion An incision was made in the right inguinal skin crease The incision was taken down to the level of the aponeurosis of the external oblique which was incised up to the level of the external ring The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed The distal remnant was taken to its end and excised The testicle and cord structures were placed back in their native positions The aponeurosis of the external oblique was reapproximated with 3 0 Vicryl as well as the Scarpa s the skin closed with 5 0 Monocryl and dressed with Steri Strips The patient was extubated in the operating room and taken back to the recovery room The patient tolerated the procedure well Keywords urology inguinal skin crease inguinal hernia repair external oblique hernia repair inguinal hernia inguinal hernia MEDICAL_TRANSCRIPTION,Description Repair of left inguinal hernia indirect The patient states that she noticed there this bulge and pain for approximately six days prior to arrival Upon examination in the office the patient was found to have a left inguinal hernia consistent with tear which was scheduled as an outpatient surgery Medical Specialty Urology Sample Name Inguinal Hernia Repair Indirect Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left indirect inguinal hernia PROCEDURE PERFORMED Repair of left inguinal hernia indirect ANESTHESIA Spinal with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well was transferred to recovery in stable condition SPECIMEN Hernia sac BRIEF HISTORY The patient is a 60 year old female that presented to Dr X s office with complaints of a bulge in the left groin The patient states that she noticed there this bulge and pain for approximately six days prior to arrival Upon examination in the office the patient was found to have a left inguinal hernia consistent with tear which was scheduled as an outpatient surgery INTRAOPERATIVE FINDINGS The patient was found to have a left indirect inguinal hernia PROCEDURE After informed consent was obtained risks and benefits of the procedure were explained to the patient The patient was brought to the operating suite After spinal anesthesia and sedation given the patient was prepped and draped in normal sterile fashion In the area of the left inguinal region just superior to the left inguinal ligament tract the skin was anesthetized with 0 25 Marcaine Next a skin incision was made with a 10 blade scalpel Using Bovie electrocautery dissection was carried down to Scarpa s fascia until the external oblique was noted Along the side of the external oblique in the direction of the external ring incision was made on both sides of the external oblique and then grasped with a hemostat Next the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament Attention was next made to ligating the hernia sac at its base for removal The hernia sac was opened prior grasping with hemostats It was a sliding indirect hernia The bowel contents were returned to abdomen using a 0 Vicryl stick tie pursestring suture at its base The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen This was then sutured at the apex of the repair down to the conjoint tendon Next attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an 0 Vicryl suture and removed as specimen Attention was next made to reapproximate it at floor with a modified ______ repair Using a 2 0 Ethibond suture in simple interrupted fashion the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia Once this was done the external oblique was closed over reapproximated again with a 2 0 Ethibond suture catching each hump in between each repair from the prior floor repair This was done in simple interrupted fashion as well Next Scarpa s fascia was reapproximated with 3 0 Vicryl suture The skin was closed with running subcuticular 4 0 undyed Vicryl suture Steri Strips and sterile dressings were applied The patient tolerated the procedure very well and he was transferred to Recovery in stable condition The patient had an abnormal chest x ray in preop and is going for a CT of the chest in Recovery Keywords urology bulge groin ethibond suture vicryl suture external oblique inguinal hernia hernia inguinal ligament oblique vicryl indirect sac suture repair MEDICAL_TRANSCRIPTION,Description Right inguinal hernia Right inguinal hernia repair The patient is a 4 year old boy with a right inguinal bulge which comes and goes with Valsalva standing and some increased physical activity Medical Specialty Urology Sample Name Inguinal Hernia Repair 6 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right inguinal hernia ANESTHESIA General PROCEDURE Right inguinal hernia repair INDICATIONS The patient is a 4 year old boy with a right inguinal bulge which comes and goes with Valsalva standing and some increased physical activity He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair We met with his parents and explained the surgical technique risks and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia All their questions have been answered and they agreed with the plan OPERATIVE FINDINGS The patient had a well developed but rather thin walled hernia sac on the right The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy Therefore high ligation was performed and we aborted the plan for laparoscopic view of the left side DESCRIPTION OF PROCEDURE The patient came to operating room and had an uneventful induction of general anesthesia Surgical time out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution During our time out we reiterated the patient s name medical record number weight allergies status and planned operative procedure I then infiltrated 0 25 Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique After the oblique layers were opened the cord structure were identified and elevated The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed I attempted to gently pass a 3 mm trocar through the hernia sac but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3 0 Vicryl The excess sac was trimmed and the spermatic cord structures were replaced The external oblique fascia and Scarpa layers were closed with interrupted 3 0 Vicryl and skin was closed with subcuticular 5 0 Monocryl and Steri Strips The patient tolerated the operation well Blood loss was less than 5 mL The hernia sac was submitted for specimen and he was then taken to the recovery room in good condition Keywords urology laparoscopic external oblique fascia oblique fascia spermatic cord cord structures external oblique hernia sac inguinal hernia sac hernia inguinal fascia repair oblique MEDICAL_TRANSCRIPTION,Description Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally Medical Specialty Urology Sample Name Inguinal Hernia Repair Transcription PREOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles POSTOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles PROCEDURES Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given ANESTHESIA General inhalational anesthetic ABNORMAL FINDINGS Same as above ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 400 mL of Crystalloid DRAINS No tubes or drains were used COUNT Sponge and needle counts were correct x2 INDICATIONS FOR PROCEDURE The patient is a 7 year old boy with the history of fairly sizeable right inguinal hernia and hydrocele was found to have a second smaller one on evaluation with ultrasound and physical exam Plan is for repair of both DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized he was then placed in a supine position and sterilely prepped and draped A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors Using a curved mosquito clamp we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal The cord structures were then dissected off the sac and then the sac itself was divided in the midline twisted upon itself and suture ligated up at the peritoneal reflection with 3 0 Vicryl suture This was done twice The distal end where a large hydrocele noted was gently milked into the lower aspect of the incision The hydrocele sac was then opened and drained and then the testis was delivered into the field The sac was then opened completely around the testis The appendix testis was cauterized We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4 0 Vicryl as a figure of eight suture Once this was done the testis was then placed back into the scrotum in the proper orientation Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0 25 Marcaine A similar procedure was done on the left side also finding a small hernia which was divided and ligated with the 3 0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3 0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure Scarpa fascia was closed with 4 0 chromic suture on each side and the skin was closed with 4 0 Rapide subcuticular closure Dermabond tissue adhesive was placed on both incisions IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure The patient tolerated the procedure and was in stable condition upon transfer to the recovery room Keywords urology bilateral hydrocele repair bilateral inguinal hernia external oblique fascia ilioinguinal nerve block bilateral hydroceles external oblique oblique fascia cord structures hydrocele sac lord maneuver nerve block bilateral inguinal ilioinguinal nerve inguinal hernia hernia inguinal hydrocele bilateral sac MEDICAL_TRANSCRIPTION,Description Left direct and indirect inguinal hernia Repair of left inguinal hernia with Prolene mesh The patient was found to have a left inguinal hernia increasing over the past several months The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh Medical Specialty Urology Sample Name Inguinal Hernia Repair 2 Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left direct and indirect inguinal hernia PROCEDURE PERFORMED Repair of left inguinal hernia with Prolene mesh ANESTHESIA IV sedation with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to Recovery in stable condition SPECIMEN Hernia sac as well as turbid fluid with gram stain which came back with no organisms from the hernia sac BRIEF HISTORY This is a 53 year old male who presented to Dr Y s office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh INTRAOPERATIVE FINDINGS The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac The patient was also found to have some turbid fluid within the hernia sac which was sent down for gram stain and turned out to be negative with no organisms PROCEDURE After informed consent risks and benefits of the procedure were explained to the patient the patient was brought to the operative suite prepped and draped in the normal sterile fashion The left inguinal ligament was identified from the pubic tubercle to the ASIS Two fingerbreadths above the pubic tubercle a transverse incision was made First the skin was anesthetized with 1 lidocaine and then an incision was made with a 15 blade scalpel approximately 6 cm in length Dissection was then carried down with electro Bovie cautery through Scarpa s fascia maintaining hemostasis Once the external oblique was identified external oblique was incised in the length of its fibers with a 15 blade scalpel Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring Next the external oblique was grasped with Ochsner on both sides The cord cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it Next the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down grasped with two hemostats A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored There was some turbid fluid within the hernia sac which was sent down for cultures Gram stain was negative for organisms Next the hernia sac was to be ligated at its base and transected A peon was used at the base Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen An 0 Vicryl stick suture was used with 0 Vicryl loop suture to suture ligate the hernia sac at its base Next attention was made to placing a Prolene mesh to cover the floor The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures Attention was made to salvaging the ilioinguinal nerve which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact Attention was next made after suturing the mesh with the 2 0 Polydek suture The external oblique was then closed over the roof with a running 0 Vicryl suture taking care not to strangulate the cord and to recreate the external ring After injecting the external oblique and cord structures with Marcaine for anesthetic the Scarpa s fascia was approximated with interrupted 3 0 Vicryl sutures The skin was closed with a running subcuticular 4 0 undyed Vicryl suture Steri Strip with sterile dressings were applied The patient tolerated the procedure well and was transferred to Recovery in stable condition Keywords urology left inguinal hernia prolene mesh hernia sac gram stain inguinal hernia repair inguinal hernial repair metzenbaum scissors cord structures inguinal hernia sac inguinal hernia metzenbaum prolene vicryl cord suture oblique mesh MEDICAL_TRANSCRIPTION,Description Right inguinal exploration left inguinal hernia repair bilateral hydrocele repair and excision of right appendix testis Medical Specialty Urology Sample Name Inguinal Exploration Transcription PREOPERATIVE DIAGNOSES Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair cerebral palsy asthma seizure disorder developmental delay and gastroesophageal reflux disease POSTOPERATIVE DIAGNOSES Left inguinal hernia bilateral hydroceles and right torsed appendix testis PROCEDURE Right inguinal exploration left inguinal hernia repair bilateral hydrocele repair and excision of right appendix testis FLUIDS RECEIVED 700 mL of crystalloid ESTIMATED BLOOD LOSS 10 mL SPECIMENS Tissue sent to pathology is calcified right appendix testis TUBES DRAINS No tubes or drains were used COUNTS Sponge and needle counts were correct x2 ANESTHESIA General inhalational anesthetic and 0 25 Marcaine ilioinguinal nerve block 30 mL given per surgeon INDICATIONS FOR OPERATION The patient is a 14 1 2 year old boy with multiple medical problems primarily due to cerebral palsy asthma seizures gastroesophageal reflux disease and developmental delay He had a hernia repair done on the right in the past but developed a new hernia on the right and a smaller on the left The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then placed in the supine position IV antibiotics were given He was then sterilely prepped and draped A right inguinal incision was made in the previous incisional site with a 15 blade knife extended down through the subcutaneous tissue and Scarpa fascia with electrocautery Electrocautery was used for hemostasis The external oblique fascia was then visualized and incised There was a moderate amount of scar tissue noted but we were able to incise that and go down into the right inguinal canal Upon dissection there we did not find any hernias however he did have a fairly sizable hydrocele We went down towards the external ring and found that this was indeed tight without any hernias We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15 blade knife We then extended down to the subcutaneous tissue Electrocautery was used for hemostasis The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis which was then excised and sent to pathology We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection was up above so we then wrapped the sac around the back of the testis and closed it with a 4 0 chromic suture in a Lord maneuver We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4 0 chromic and placed the testis into the scrotum in the proper orientation We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0 25 Marcaine without epinephrine 15 mL was given We performed a similar procedure on the left incising it at the scrotal area first rather than below and found this tunica vaginalis and dissected it in a similar fashion and cauterized the appendix testis which was not torsed This was a smaller hydrocele but because of the __________ shunt we went up above and found that there was a very small connection which was then dissected off the cord structures gently twisted upon itself suture ligated with a 2 0 Vicryl suture The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0 25 Marcaine were then done by the surgeon as well The external oblique fascia was closed on both sides with a running suture of 2 0 Vicryl 4 0 chromic was then used to close the Scarpa fascia The skin was closed with a 4 0 Rapide subcuticular closure The scrotal incisions were closed with a subcutaneous and dartos closure using 4 0 chromic IV Toradol was given at the end of the procedure Dermabond tissue adhesive was placed on all 4 incisions The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room Keywords urology inguinal exploration inguinal hernia repair hydrocele repair appendix testis ilioinguinal nerve block external oblique fascia tunica vaginalis ilioinguinal nerve inguinal hernia hernia repair hernia torsed inguinal hydrocele appendix testis MEDICAL_TRANSCRIPTION,Description Left communicating hydrocele Left inguinal hernia and hydrocele repair The patient is a 5 year old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele MEDICAL_TRANSCRIPTION,Description Incision and drainage of the penoscrotal abscess packing penile biopsy cystoscopy and urethral dilation Medical Specialty Urology Sample Name I D Penoscrotal Abscess Transcription PREOPERATIVE DIAGNOSIS Penoscrotal abscess POSTOPERATIVE DIAGNOSIS Penoscrotal abscess OPERATION Incision and drainage of the penoscrotal abscess packing penile biopsy cystoscopy and urethral dilation BRIEF HISTORY The patient is a 75 year old male presented with penoscrotal abscess Options such as watchful waiting drainage and antibiotics were discussed Risks of anesthesia bleeding infection pain MI DVT PE completely the infection turning into necrotizing fascitis Fournier s gangrene were discussed The patient already had significant phimotic changes and disfigurement of the penis For further debridement the patient was told that his penis is not going to be viable he may need a total or partial penectomy now or in the future Risks of decreased penile sensation pain Foley other unexpected issues were discussed The patient understood all the complications and wanted to proceed with the procedure DETAIL OF THE OPERATION The patient was brought to the OR The patient was placed in dorsal lithotomy position The patient was prepped and draped in the usual fashion Pictures were taken prior to starting the procedure for documentation The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection The penile area was opened up distally to allow the pus to come out The dissection around the proximal scrotum was done to make sure there are no other pus pockets The corporal body was intact but the distal part of the corpora was completely eroded and had a fungating mass which was biopsied and sent for permanent pathology analysis Urethra was identified at the distal tip which was dilated and using 23 French cystoscope cystoscopy was done which showed some urethral narrowing in the distal part of the urethra The rest of the bladder appeared normal The prostatic urethra was slightly enlarged There are no stones or tumors inside the bladder There were moderate trabeculations inside the bladder Otherwise the bladder and the urethra appeared normal There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma Again biopsies were sent for pathology analysis Prior to urine irrigation anaerobic aerobic cultures were sent irrigation with over 2 L of fluid was performed After irrigation packing was done with Kerlix The patient was brought to recovery in a stable condition Please note that 18 French Foley was kept in place Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied The patient was brought to Recovery in a stable condition after applying 0 5 Marcaine about 20 mL were injected around for local anesthesia Keywords urology i d penoscrotal penile biopsy cystoscopy urethral dilation incision and drainage fungating mass penoscrotal abscess abscess urethral MEDICAL_TRANSCRIPTION,Description Hypospadias repair TIP with tissue flap relocation and chordee release Nesbit tuck Medical Specialty Urology Sample Name Hypospadias Repair Chordee Release 1 Transcription PREOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma POSTOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma PROCEDURE Hypospadias repair TIP with tissue flap relocation and chordee release Nesbit tuck ANESTHETIC General inhalational anesthetic with a caudal block FLUIDS RECEIVED 300 mL of crystalloid ESTIMATED BLOOD LOSS 20 mL TUBES DRAINS An 8 French Zaontz catheter INDICATIONS FOR OPERATION The patient is a 17 month old boy with hypospadias abnormality The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed IV antibiotics were given He was then placed in the supine position The foreskin was retracted and cleansed He was then sterilely prepped and draped A stay stitch of 4 0 Prolene was then placed on the glans The urethra was calibrated with the lacrimal duct probes to an 8 French We then marked out the coronal cuff the penile shaft skin as well as the glanular plate for future surgery with a marking pen We then used a 15 blade knife to circumscribe the penis around the coronal cuff We then degloved the penis using the curved tenotomy scissors and electrocautery was used for hemostasis The patient had some splaying of the spongiosum tissue which was also incised laterally and rotated to make a secondary flap Once the penis was degloved and the excessive chordee tissue was released we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection He was still noted to have chordee so a midline incision through the Buck fascia was made with a 15 blade knife and Heineke Mikulicz closure using 5 0 Prolene was then used for the chordee Nesbit tuck We repeated the artificial erection and the penis was straight We then incised the urethral plate with an ophthalmic blade in the midline and then elevated the glanular wings using a 15 blade knife to elevate and then incise them Using the curved iris scissors we then also further mobilized the glanular wings The 8 French Zaontz was then placed while the tourniquet was still in place into the urethral plate The upper aspect of the distal meatus was then closed with an interrupted suture of 7 0 Vicryl and then using a running subcuticular closure we closed the urethral plates over the Zaontz catheter We then mobilized subcutaneous tissue from the penile shaft skin and the inner perpetual skin on the dorsum and then buttonholed the flap placed it over the head of the penis and then used it to cover of the hypospadias repair with tacking sutures of 7 0 Vicryl We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic 7 0 Vicryl was used for that as well 5 0 Vicryl was used to roll the glans with 2 deep sutures and then horizontal mattress sutures of 7 0 Vicryl were used to reconstitute the glans Interrupted sutures of 7 0 Vicryl were used to approximate the urethral meatus to the glans Once this was done we then excised the excessive penile shaft skin and used the interrupted sutures of 6 0 chromic to attach the penile shaft skin to the coronal cuff On the ventrum itself we used horizontal mattress sutures to close the defect At the end of the procedure the Zaontz catheter was sutured into place with a 4 0 Prolene suture Dermabond tissue adhesive and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place IV Toradol was given at the procedure The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room Keywords urology coronal hypospadias with chordee coronal hypospadias tissue flap relocation nesbit tuck hypospadias with chordee horizontal mattress sutures chordee release zaontz catheter coronal cuff hypospadias repair penile shaft zaontz glans urethral repair coronal hypospadias penis chordee MEDICAL_TRANSCRIPTION,Description Pelvic tumor cystocele rectocele and uterine fibroid Total abdominal hysterectomy bilateral salpingooophorectomy repair of bladder laceration appendectomy Marshall Marchetti Krantz cystourethropexy and posterior colpoperineoplasty She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Medical Specialty Urology Sample Name Hysterectomy BSO Appendectomy Transcription 1 Pelvic tumor 2 Cystocele 3 Rectocele POSTOPERATIVE DIAGNOSES 1 Degenerated joint 2 Uterine fibroid 3 Cystocele 4 Rectocele PROCEDURE PERFORMED 1 Total abdominal hysterectomy 2 Bilateral salpingooophorectomy 3 Repair of bladder laceration 4 Appendectomy 5 Marshall Marchetti Krantz cystourethropexy 6 Posterior colpoperineoplasty GROSS FINDINGS The patient had a history of a rapidly growing mass on the abdomen extending from the pelvis over the past two to three months She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Curettings were negative for malignancy The patient did have a large cystocele and rectocele and a collapsed anterior and posterior vaginal wall Upon laparotomy there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five month pregnancy The ovaries appeared to be within normal limits There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation and during dissection a laceration inadvertently occurred and it was immediately recognized No other pathology noted from the abdominal cavity or adhesions The upper right quadrant of the abdomen compatible with a previous gallbladder surgery The appendix is in its normal anatomic position The ileum was within normal limits with no Meckel s diverticulum seen and no other gross pathology evident There was no evidence of metastasis or tumors in the left lobe of the liver Upon frozen section diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy OPERATIVE PROCEDURE The patient was taken to the Operating Room prepped and draped in the low lithotomy position under general anesthesia A midline incision was made around the umbilicus down to the lower abdomen With a 10 Bard Parker blade knife the incision was carried down through the fascia The fascia was incised in the midline muscle fibers were splint in the midline the peritoneum was grasped with hemostats and with a 10 Bard Parker blade after incision was made with Mayo scissors A Balfour retractor was placed into the wound This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care The infundibular ligament on the right side was isolated and ligated with 0 Vicryl suture brought to an avascular area doubly clamped and divided from the ovary and the ligament again re ligated with 0 Vicryl suture The right round ligament was ligated with 0 Vicryl suture brought to an avascular space within the broad ligament and divided from the uterus The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do and during dissection the bladder was inadvertently entered After this was immediately recognized the bladder flap was wiped away from the anterior surface of the uterus The bladder was then repaired with a running locking stitch 0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two layer closure of 0 Vicryl suture After removing the uterus the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors and the straight Ochsner was placed by 0 Vicryl suture thus controlling the uterine blood supply The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps divided from the uterus with 10 Bard Parker blade knife and a curved Ochsner was placed by 0 Vicryl suture The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using 10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors A single toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors The vaginal cuff was then closed using a running 0 Vicryl suture in locking stitch incorporating all layers of the vagina the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect The round ligaments were approximated to the vaginal cuff with 0 Vicryl suture and the bladder flap approximated to the round ligaments with 000 Vicryl suture The ______ was re peritonealized with 000 Vicryl suture and then the cecum brought into the incision The pelvis was irrigated with approximately 500 cc of water The appendix was grasped with Babcock forceps The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors The curved hemostats were placed with 00 Vicryl suture The base of the appendix was ligated with 0 plain gut suture doubly clamped and divided from the distal appendix with 10 Bard Parker blade knife and the base inverted with a pursestring suture with 00 Vicryl No bleeding was noted Sponge instrument and needle counts were found to be correct All packs and retractors were removed The peritoneum muscle fascia was closed in single layer closure using running looped 1 PDS but prior to closure a Marshall Marchetti Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted 0 Vicryl suture Following this the abdominal wall was closed as previously described and the skin was closed using skin staples Attention was then turned to the vagina where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa and flaps were created bilaterally In this fashion the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted 0 Vicryl suture Excess vaginal mucosa was excised and the vaginal mucosa closed with running 00 Vicryl suture The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted 00 Vicryl suture The skin was closed with a running 000 plain gut subcuticular stitch The vaginal vault was packed with a Betadine soaked Kling gauze sponge Sterile dressing was applied The patient was sent to recovery room in stable condition Keywords urology marshall marchetti krantz cystourethropexy pelvic tumor cystocele rectocele uterine fibroid hysterectomy salpingooophorectomy bladder laceration appendectomy colpoperineoplasty marshall marchetti krantz cystourethropexy bard parker blade knife vicryl suture vaginal mucosa uterus vaginal uterine mucosa scissors ligament bladder MEDICAL_TRANSCRIPTION,Description Hypospadias repair TIT and tissue flap relocation and Nesbit tuck chordee release Medical Specialty Urology Sample Name Hypospadias Repair Chordee Release Transcription PREOPERATIVE DIAGNOSIS Penoscrotal hypospadias with chordee POSTOPERATIVE DIAGNOSIS Penoscrotal hypospadias with chordee PROCEDURE Hypospadias repair TIT and tissue flap relocation and Nesbit tuck chordee release ANESTHESIA General inhalation anesthetic with a caudal block FLUIDS RECEIVED 300 mL of crystalloids ESTIMATED BLOOD LOSS 15 mL SPECIMENS No tissue sent to Pathology TUBES AND DRAINS An 8 French Zaontz catheter INDICATIONS FOR OPERATION The patient is a 1 1 2 year old boy with penoscrotal hypospadias plan is for repair DESCRIPTION OF PROCEDURE The patient was taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized a caudal block was placed IV antibiotic was given The dorsal hood was retracted and the patient was then sterilely prepped and draped A stay stitch of 4 0 Prolene was then placed in the glans for traction His urethra was calibrated it was quite thin to a 10 French with the straight sounds We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors Electrocautery was used for hemostasis The ventral chordee tissue was removed We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test which showed that he had a persistent chordee In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen We then used a Heinecke Mikulicz Nesbit tuck with 5 0 Prolene to straighten the penis Artificial erection again performed showed the penis was straight The knot was buried with figure of eight suture of 7 0 Vicryl in Buck fascia above it We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade We then elevated the glanular wings as well in the similar fashion An 8 French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7 0 Vicryl and then a running subcuticular closure of 7 0 Vicryl to close the defect We then put the stay sutures in the inter preputial skin with 7 0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors We buttonholed the flap and then placed it through the penis as a sleeve Interrupted sutures of 7 0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty Once this was done a two 5 0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis Interrupted sutures of 7 0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7 0 Vicryl used to reconstitute the glans We then removed the excessive preputial skin and using tacking sutures of 6 0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures We then closed the ventral defect Once this was done the stay suture in the glans was used to keep the Zaontz catheter to tack it into place We then used Surgicel Dermabond and Telfa dressing with Mastisol and an eye tape to keep the dressing in place IV Toradol was given at the end of the procedure The patient was in stable condition upon transfer to the recovery room Keywords urology tissue flap relocation penoscrotal hypospadias urethra nesbit tuck chordee release horizontal mattress sutures hypospadias repair chordee release zaontz catheter urethral plate glans hypospadias penis chordee MEDICAL_TRANSCRIPTION,Description Hypospadias repair Urethroplasty plate incision with tissue flap relocation and chordee release Medical Specialty Urology Sample Name Hypospadias Repair Transcription PREOPERATIVE DIAGNOSIS Coronal hypospadias with chordee POSTOPERATIVE DIAGNOSIS Coronal hypospadias with chordee PROCEDURE Hypospadias repair urethroplasty plate incision with tissue flap relocation and chordee release ANESTHESIA General inhalation anesthetic with a 0 25 Marcaine dorsal block and ring block per surgeon 7 mL given TUBES AND DRAINS An 8 French Zaontz catheter ESTIMATED BLOOD LOSS 10 mL FLUIDS RECEIVED 300 mL INDICATIONS FOR OPERATION The patient is a 6 month old boy with the history of coronal hypospadias with chordee Plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room with surgical consent operative site and the patient identification were verified Once he was anesthetized IV antibiotics were given The dorsal hood was retracted and cleansed He was then sterilely prepped and draped Stay suture of 4 0 Prolene was then placed in the glans His urethra was calibrated to 10 French bougie a boule We then marked the coronal cuff and the penile shaft skin as well as the periurethral meatal area on the ventrum Byers flaps were also marked Once this was done the skin was then incised around the coronal cuff with 15 blade knife and further extended with the curved tenotomy scissors to deglove the penis On the ventrum the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage Once this was done an electrocautery was used for hemostasis were then used A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee We then incised Buck fascia at the area of chordee in the ventrum and then used the 5 0 Prolene as a Heinecke Mikulicz advancement suture Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight We then left the tourniquet in place although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings Using the curved iris scissors we then elevated the wings even further Again electrocautery was used for hemostasis An 8 French Zaontz catheter was then placed into the urethral plate and then interrupted suture of 7 0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the 7 0 Vicryl suture There were two areas of coverage with the tissue flap relocation from the glanular wings The tissue flap that was rolled with the Byers flap was used to cover this as well as the chordee tissue with interrupted sutures of 7 0 Vicryl Once this was completed the glans itself had been rolled using two deep sutures of 5 0 Vicryl Interrupted sutures of 7 0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of 7 0 Vicryl used to roll the glans in the midline The extra dorsal hood tissue of preputial skin was then excised An interrupted sutures of 6 0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline The patient s scrotum was slightly asymmetric however this was due to the tissue configuration of the scrotum itself At the end of the procedure stay suture of 4 0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing Telfa and the surgical eye tape was then used for the final dressing IV Toradol was given The patient tolerated the procedure well and was in stable condition upon transfer to recovery room Keywords urology tissue flap relocation urethroplasty plate incision penile shaft skin chordee release zaontz catheter penile shaft hypospadias repair flap relocation coronal cuff urethral plate tissue flap hypospadias flap chordee MEDICAL_TRANSCRIPTION,Description Left hydrocelectomy This is a 67 year old male with pain left scrotum He has had an elevated PSA and also has erectile dysfunction He comes in now for a left hydrocelectomy Physical exam confirmed obvious hydrocele left scrotum Medical Specialty Urology Sample Name Hydrocelectomy Transcription PREOPERATIVE DIAGNOSIS Left hydrocele OPERATION Left hydrocelectomy POSTOPERATIVE DIAGNOSIS Left hydrocele ANESTHESIA General INDICATIONS AND STUDIES This is a 67 year old male with pain left scrotum He has had an elevated PSA and also has erectile dysfunction He comes in now for a left hydrocelectomy Physical exam confirmed obvious hydrocele left scrotum approximately 8 cm Laboratory data included a hematocrit of 43 5 hemoglobin of 15 0 and white count 4700 Creatinine 1 3 sodium 141 and potassium 4 0 Calcium 8 6 Chest x ray was unremarkable EKG was normal PROCEDURE The patient was satisfactorily given general anesthesia prepped and draped in supine position and left scrotal incision was made carried down to the tunica vaginalis forming the hydrocele This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord In the fashion the hydrocele was excised and fluid drained Cord was infiltrated with 5 mL of 0 25 Marcaine The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3 0 Vicryl sutures for hemostasis The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3 0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia The left scrotal incision was closed first closing the Dartos fascia with interrupted 3 0 Vicryl sutures Skin was closed with an interrupted running 4 0 chromic suture A sterile dressing was applied The patient was sent to the recovery room in good condition upon awakening from general anesthesia Plan is to discharge the patient and see him back in the office in a week or 2 in followup Further plans will depend upon how he does Keywords urology hydrocele erectile dysfunction spermatic cord tunica vaginalis vicryl sutures dartos fascia hydrocelectomy psa testicle scrotum scrotal MEDICAL_TRANSCRIPTION,Description Left hydrocelectomy cystopyelogram bladder biopsy and fulguration for hemostasis Medical Specialty Urology Sample Name Hydrocelectomy 1 Transcription PREOPERATIVE DIAGNOSES Bladder cancer and left hydrocele POSTOPERATIVE DIAGNOSES Bladder cancer and left hydrocele OPERATION Left hydrocelectomy cystopyelogram bladder biopsy and fulguration for hemostasis ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 66 year old male with history of smoking and hematuria had bladder tumor which was dissected He has received BCG The patient is doing well The patient was supposed to come to the OR for surveillance biopsy and pyelograms The patient had a large left hydrocele which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on etc Options such as watchful waiting drainage in the office and hydrocelectomy were discussed Risks of anesthesia bleeding infection pain MI DVT PE infection in the scrotum enlargement of the scrotum recurrence and pain were discussed The patient understood all the options and wanted to proceed with the procedure PROCEDURE IN DETAIL The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn The sac was turned upside down and sutures were placed Careful attention was made to ensure that the cord was open The testicle was in normal orientation throughout the entire procedure The testicle was placed back into the scrotal sac and was pexed with 4 0 Vicryl to the outside dartos to ensure that there was no risk of torsion Orchiopexy was done at 3 different locations Hemostasis was obtained using electrocautery The sac was closed using 4 0 Vicryl The sac was turned upside down so that when it heals the fluid would not recollect The dartos was closed using 2 0 Vicryl and the skin was closed using 4 0 Monocryl and Dermabond was applied Incision measured about 2 cm in size Subsequently using ACMI cystoscope a cystoscopy was performed The urethra appeared normal There was some scarring at the bulbar urethra but the scope went in through that area very easily into the bladder There was a short prostatic fossa The bladder appeared normal There was some moderate trabeculation throughout the bladder some inflammatory changes in the bag part but nothing of much significance There were no papillary tumors or stones inside the bladder Bilateral pyelograms were obtained using 8 French cone tip catheter which appeared normal A cold cup biopsy of the bladder was done and was fulgurated for hemostasis The patient tolerated the procedure well The patient was brought to recovery at the end of the procedure after emptying the bladder The patient was given antibiotics and was told to take it easy No heavy lifting pushing or pulling Plan was to follow up in about 2 months Keywords urology hydrocele fulguration bladder biopsy hydrocelectomy cystopyelogram cystopyelogram bladder bladder cancer bladder MEDICAL_TRANSCRIPTION,Description Bilateral scrotal hydrocelectomies large for both and 0 5 Marcaine wound instillation 30 mL given Medical Specialty Urology Sample Name Hydrocelectomy Transcription PREOPERATIVE DIAGNOSIS Bilateral hydroceles POSTOPERATIVE DIAGNOSIS Bilateral hydroceles PROCEDURE Bilateral scrotal hydrocelectomies large for both and 0 5 Marcaine wound instillation 30 mL given ESTIMATED BLOOD LOSS Less than 10 mL FLUIDS RECEIVED 800 mL TUBES AND DRAINS A 0 25 inch Penrose drains x4 INDICATIONS FOR OPERATION The patient is a 17 year old boy who has had fairly large hydroceles noted for some time Finally he has decided to have them get repaired Plan is for surgical repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then shaved prepped and then sterilely prepped and draped IV antibiotics were given Ancef 1 g given A scrotal incision was then made in the right hemiscrotum with a 15 blade knife and further extended with electrocautery Electrocautery was used for hemostasis Once we got to the hydrocele sac itself we then opened and delivered the testis drained clear fluid There was moderate amount of scarring on the testis itself from the tunica vaginalis It was then wrapped around the back and sutured in place with a running suture of 4 0 chromic in a Lord maneuver Once this was done a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation A similar procedure was performed on the left which has also had a hydrocele of the cord which were both addressed and closed with Lord maneuver similarly This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this A similar drain was placed The testes were then placed back into the scrotum in a proper orientation and the local wound instillation and wound block was then placed using 30 mL of 0 5 Marcaine without epinephrine IV Toradol was given at the end of the procedure The skin was then sutured with a running interlocking suture of 3 0 Vicryl and the drains were sutured to place with 3 0 Vicryl Bacitracin dressing ABD dressing and jock strap were placed The patient was in stable condition upon transfer to the recovery room Keywords urology bilateral scrotal hydrocelectomies bilateral hydroceles lord maneuver hydrocelectomy hydroceles MEDICAL_TRANSCRIPTION,Description Patient presents with gross hematuria that started this morning Medical Specialty Urology Sample Name Hematuria Consult Transcription HISTORY OF PRESENT ILLNESS This is a 77 year old male who presents with gross hematuria that started this morning The patient is a difficult historian does have a speech impediment slow to answer questions but daughter was able to answer lot of questions too He is complaining of no other pain He denies any abdominal pain Denies any bleeding anywhere else Denies any bruising He had an episode similar to this a year ago where it began the same with hematuria He was discharged after a workup in the hospital in the emergency room with Levaquin Three days later he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding His H and H was down in the 6 level He received blood transfusions He was diagnosed with a malignancy coagulopathy and sounds like was in critical condition Family actually states that they were told that he was unlikely to live through that event but he did Since then he has had no bleeding The patient has had no fever No cough No chest pain or shortness of breath No bleeding gums No blurred vision No headache No recent falls or trauma He has had no nausea or vomiting No diarrhea No blood in the stool or melena No leg or calf pain No joint pain No rashes No swollen glands He has no numbness weakness or tingling to his extremities No acute anxiety or depression PAST MEDICAL HISTORY Has prostate cancer MEDICATION He is receiving Lupron injection by Dr Y The only other medication that he takes is Tramadol SOCIAL HISTORY He does not smoke or drink PHYSICAL EXAMINATION Vital Signs Are all reviewed on triage General He is alert Answers slowly with a speech impediment but answers appropriately HEENT Pupils equal round and reactive to light Normal extraocular muscles Nonicteric sclerae Conjunctivae are not pale His oropharynx is clear His mucous membranes are moist Heart Regular rate and rhythm with no murmurs Lungs Clear Abdomen Soft nontender nondistended Normal bowel sounds No organomegaly or mass Extremities No calf tenderness erythema or warmth He has no bruises noted Neurological Cranial nerves II through XII are intact He has 5 5 strength throughout GU Normal LABORATORY DATA The patient did on urinalysis have few red blood cells His urine was also grossly red although no blood clots or gross blood was noted It was more of a red fluid He had a mild decrease in H and H at 12 1 and 34 6 His white count was normal at 7 2 His PT was elevated at 15 9 PTT elevated at 36 4 INR is 1 4 His comprehensive metabolic profile is normal except for BUN of 19 CONDITION The patient is stable at this time although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy the patient is discussed with Dr X and he is admitted for orders Also we will consult Dr Y see orders for further Keywords urology prostate cancer bleeding gross hematuria speech impediment hematuria coagulopathy blood MEDICAL_TRANSCRIPTION,Description Likely molluscum contagiosum genital warts caused by HPV It is not clear where this came from but it is most likely sexually transmitted Medical Specialty Urology Sample Name HPV Consult Transcription He has no voiding complaints and no history of sexually transmitted diseases PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Back surgery with a fusion of L5 S1 MEDICATIONS He does take occasional Percocet for his back discomfort ALLERGIES HE HAS NO ALLERGIES SOCIAL HISTORY He is a smoker He takes rare alcohol His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid He travels to anywhere for his work He is married with one son FAMILY HISTORY Negative for prostate cancer kidney cancer bladder cancer enlarged prostate or kidney disease REVIEW OF SYSTEMS Negative for tremors headaches dizzy spells numbness tingling feeling hot or cold tired or sluggishness abdominal pain nausea or vomiting indigestion heartburn fevers chills weight loss wheezing frequent cough shortness of breath chest pain varicose veins high blood pressure skin rash joint pain ear infections sore throat sinus problems hay fever blood clotting problems depressive affect or eye problems PHYSICAL EXAMINATION GENERAL The patient is afebrile His vital signs are stable He is 177 pounds 5 feet 8 inches Blood pressure 144 66 He is healthy appearing He is alert and oriented x 3 HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Soft and nontender His penis is circumcised He has a pedunculated cauliflower like lesion on the dorsum of the penis at approximately 12 o clock It is very obvious and apparent He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber His testicles are descended bilaterally There are no masses ASSESSMENT AND PLAN This is likely molluscum contagiosum genital warts caused by HPV I did state to the patient that this is likely a viral infection that could have had a long incubation period It is not clear where this came from but it is most likely sexually transmitted He is instructed that he should use protected sex from this point on in order to try and limit the transmission Regarding the actual lesion itself I did mention that we could apply a cream of Condylox which could take up to a month to work I also offered him C02 laser therapy for the genital warts which is an outpatient procedure The patient is very interested in something quick and effective such as a CO2 laser procedure I did state that the recurrence rate is significant and somewhere as high as 20 despite enucleating these lesions The patient understood this and still wished to proceed There is minimal risk otherwise except for those inherent in laser injury and accidental injury The patient understood and wished to proceed Keywords urology sexually transmitted molluscum contagiosum genital warts hpv MEDICAL_TRANSCRIPTION,Description Follow up consultation second opinion foreskin Medical Specialty Urology Sample Name Foreskin Followup Transcription REASON FOR VISIT Follow up consultation second opinion foreskin HISTORY OF PRESENT ILLNESS A 2 week old who at this point has otherwise been doing well He has a relatively unremarkable foreskin At this point in time he otherwise seems to be doing reasonably well The question is about the foreskin He otherwise has no other significant issues Severity low ongoing since birth two weeks Thank you for allowing me to see this patient in consultation PHYSICAL EXAMINATION Male exam Normal and under the penis report normal uncircumcised 2 week old He has a slightly insertion on the penile shaft from the median raphe of the scrotum IMPRESSION Slightly high insertion of the median raphe I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision This kid should otherwise do reasonably well PLAN Follow up as needed But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age but may do well with a person who is very accomplished doing a Gomco circumcision Keywords urology formal circumcision median raphe penis gomco circumcision gomco circumcision foreskin MEDICAL_TRANSCRIPTION,Description Cystoscopy and removal of foreign objects from the urethra Medical Specialty Urology Sample Name Foreign Object Removal Urethra Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATION Cystoscopy and removal of foreign objects from the urethra BRACHYTHERAPY Iodine 125 ANESTHESIA General endotracheal The patient was given Levaquin 500 mg IV preoperatively Total seeds were 59 Activity of 0 439 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold 4 needles Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back BRIEF HISTORY This is a 72 year old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex Options such as watchful waiting brachytherapy radical prostatectomy cryotherapy and external beam radiation were discussed Risk of anesthesia bleeding infection pain MI DVT PE incontinence erectile dysfunction urethral stricture dysuria burning pain hematuria future procedures and failure of the procedure were all discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure The patient wanted to wait until he came back from his summer vacations so a one dose of Zoladex was given Prostate size measured about 15 g in the OR and about 22 g about two months ago Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient had a Foley catheter placed sterilely The scrotum was taped up using Ioban Transrectal ultrasound was done The prostate was measured 15 g Multiple images were taken A volume study was done This was given to the physicist Dr X was present who is radiation oncologist who helped with implanting of the seeds Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside They were done directly under transrectal ultrasound vision The seeds were placed directly under ultrasound guidance There was a nice distribution of the seeds A couple of more seeds were placed on the right side due to the location of the prostate cancer Subsequently at the end of the procedure fluoroscopy was done Couple of images were obtained Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra which was grasped and pulled out using grasper which was difficult to get the seed off of the spacers which was actually pulled out There were no further seeds visualized in the bladder The bladder appeared normal At the end of the procedure a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition Keywords urology foreign objects foley catheter transrectal ultrasound prostate cancer cystoscopy ultrasound urethra endotracheal prostate MEDICAL_TRANSCRIPTION,Description Recurring bladder infections with frequency and urge incontinence not helped with Detrol LA Normal cystoscopy with atrophic vaginitis Medical Specialty Urology Sample Name Flexible Cystoscopy Atrophic Vaginitis Transcription PREOPERATIVE DIAGNOSIS Recurring bladder infections with frequency and urge incontinence not helped with Detrol LA POSTOPERATIVE DIAGNOSIS Normal cystoscopy with atrophic vaginitis PROCEDURE PERFORMED Flexible cystoscopy FINDINGS Atrophic vaginitis PROCEDURE The patient was brought in to the procedure suite prepped and draped in the dorsal lithotomy position The patient then had flexible scope placed through the urethral meatus and into the bladder Bladder was systematically scanned noting no suspicious areas of erythema tumor or foreign body Significant atrophic vaginitis is noted IMPRESSION Atrophic vaginitis with overactive bladder with urge incontinence PLAN The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks Keywords urology urge incontinence frequency overactive bladder vesicare flexible cystoscopy bladder infections atrophic vaginitis incontinence cystoscopy vaginitis MEDICAL_TRANSCRIPTION,Description Microscopic hematuria with lateral lobe obstruction mild Medical Specialty Urology Sample Name Flexible Cystoscopy BPH Transcription PREOPERATIVE DIAGNOSIS Microscopic hematuria POSTOPERATIVE DIAGNOSIS Microscopic hematuria with lateral lobe obstruction mild PROCEDURE PERFORMED Flexible cystoscopy COMPLICATIONS None CONDITION Stable PROCEDURE The patient was placed in the supine position and sterilely prepped and draped in the usual fashion After 2 lidocaine was instilled the anterior urethra is normal The prostatic urethra reveals mild lateral lobe obstruction There are no bladder tumors noted IMPRESSION The patient has some mild benign prostatic hyperplasia At this point in time we will continue with conservative observation PLAN The patient will follow up as needed Keywords urology benign prostatic hyperplasia urethra lateral lobe obstruction flexible cystoscopy microscopic hematuria cystoscopy hematuria obstruction MEDICAL_TRANSCRIPTION,Description Epididymectomy Medical Specialty Urology Sample Name Epididymectomy Transcription EPIDIDYMECTOMY OPERATIVE NOTE The patient was placed in the supine position and prepped and draped in the usual manner A transverse scrotal incision was made and carried down to the tunica vaginalis which was opened A small amount of clear fluid was expressed The tunica vaginalis was opened and the testicle was brought out through this incision The epididymis was separated off the surface of the testicle using a scalpel With blunt and sharp dissection the epididymis was dissected off the testicle Bovie was used for hemostasis The vessels going to the testicle were preserved without any obvious injury and a nice viable testicle was present after the epididymis was removed from this The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also There was no obvious bleeding The cord was infiltrated with 0 25 Marcaine as was the dartos tissue in the scrotum The testicle was replaced in the scrotum Skin was closed in two layers using 3 0 chromic catgut for the dartos and a subcuticular closure with the same material A dry sterile dressing and compression were applied and he was sent to the recovery room in stable condition Keywords urology scrotal incision 0 25 marcaine bovie epididymectomy chromic catgut epididymis fluid scalpel scrotum sterile dressing testicle tunica vaginalisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Common Excretory Urogram IVP template Medical Specialty Urology Sample Name Excretory Urogram IVP Transcription There is normal and symmetrical filling of the caliceal system Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects The postvoid films demonstrate normal emptying of the collecting system including the urinary bladder IMPRESSION Negative intravenous urogram Keywords urology intravenous urogram caliceal system urinary bladder excretory urogram collecting systems ivp urogram intravenousNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Left flank pain and unable to urinate Medical Specialty Urology Sample Name Flank Pain Consult Transcription CHIEF COMPLAINT Left flank pain and unable to urinate HISTORY The patient is a 46 year old female who presented to the emergency room with left flank pain and difficulty urinating Details are in the history and physical She does have a vague history of a bruised left kidney in a motor vehicle accident She feels much better today I was consulted by Dr X MEDICATIONS Ritalin 50 a day ALLERGIES To penicillin PAST MEDICAL HISTORY ADHD SOCIAL HISTORY No smoking alcohol or drug abuse PHYSICAL EXAMINATION She is awake alert and quite comfortable Abdomen is benign She points to her left flank where she was feeling the pain DIAGNOSTIC DATA Her CAT scan showed a focal ileus in left upper quadrant but no thickening no obstruction no free air normal appendix and no kidney stones LABORATORY WORK Showed white count 6200 hematocrit 44 7 Liver function tests and amylase were normal Urinalysis 3 bacteria IMPRESSION 1 Left flank pain question etiology 2 No evidence of surgical pathology 3 Rule out urinary tract infection PLAN 1 No further intervention from my point of view 2 Agree with discharge and followup as an outpatient Further intervention will depend on how she does clinically She fully understood and agreed Keywords urology flank pain unable to urinate urinary tract infection flank MEDICAL_TRANSCRIPTION,Description Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection Medical Specialty Urology Sample Name E Coli UTI Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup recently noted for E coli urinary tract infection She was treated with Macrobid for 7 days and only took one nighttime prophylaxis She discontinued this medication to due to skin rash as well as hives Since then this had resolved Does not have any dysuria gross hematuria fever chills Daytime frequency every two to three hours nocturia times one no incontinence improving stress urinary incontinence after Prometheus pelvic rehabilitation Renal ultrasound August 5 2008 reviewed no evidence of hydronephrosis bladder mass or stone Discussed Previous urine cultures have shown E coli November 2007 May 7 2008 and July 7 2008 CATHETERIZED URINE Discussed agreeable done using standard procedure A total of 30 mL obtained IMPRESSION Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection completed the therapeutic dose but stopped the prophylactic Macrodantin due to hives This has resolved PLAN We will send the urine for culture and sensitivity if no infection patient will call results on Monday and she will be placed on Keflex nighttime prophylaxis otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr X All questions answered Keywords urology urinary tract infection escherichia coli prophylactic macrodantin e coli infection MEDICAL_TRANSCRIPTION,Description Left flank pain ureteral stone Medical Specialty Urology Sample Name Flank Pain Consult 1 Transcription REASON FOR CONSULTATION Left flank pain ureteral stone BRIEF HISTORY The patient is a 76 year old female who was referred to us from Dr X for left flank pain The patient was found to have a left ureteral stone measuring about 1 3 cm in size per the patient s history The patient has had pain in the abdomen and across the back for the last four to five days The patient has some nausea and vomiting The patient wants something done for the stone The patient denies any hematuria dysuria burning or pain The patient denies any fevers PAST MEDICAL HISTORY Negative PAST SURGICAL HISTORY Years ago she had surgery that she does not recall MEDICATIONS None ALLERGIES None REVIEW OF SYSTEMS Denies any seizure disorder chest pain denies any shortness of breath denies any dysuria burning or pain denies any nausea or vomiting at this time The patient does have a history of nausea and vomiting but is doing better PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile Vitals are stable HEART Regular rate and rhythm ABDOMEN Soft left sided flank pain and left lower abdominal pain The rest of the exam is benign LABORATORY DATA White count of 7 8 hemoglobin 13 8 and platelets 234 000 The patient s creatinine is 0 92 ASSESSMENT 1 Left flank pain 2 Left ureteral stone 3 Nausea and vomiting PLAN Plan for laser lithotripsy tomorrow Options such as watchful waiting laser lithotripsy and shockwave lithotripsy were discussed The patient has a pretty enlarged stone Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed The patient understood that the success of the surgery may be or may not be 100 that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting The patient understood all the risk benefits of the procedure and wanted to proceed Need for stent was also discussed with the patient The patient will be scheduled for surgery tomorrow Plan for continuation of the antibiotics obtain urinalysis and culture and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow Keywords urology flank pain ureteral stone shockwave lithotripsy shockwave nausea vomiting lithotripsy ureteral stone MEDICAL_TRANSCRIPTION,Description Elevated PSA with nocturia and occasional daytime frequency Medical Specialty Urology Sample Name Elevated PSA Chart Note Transcription REASON FOR VISIT Elevated PSA with nocturia and occasional daytime frequency HISTORY A 68 year old male with a history of frequency and some outlet obstructive issues along with irritative issues The patient has had history of an elevated PSA and PSA in 2004 was 5 5 In 2003 he had undergone a biopsy by Dr X which was negative for adenocarcinoma of the prostate The patient has had PSAs as high as noted above His PSAs have been as low as 1 6 but those were on Proscar He otherwise appears to be doing reasonably well off the Proscar otherwise does have some irritative symptoms This has been ongoing for greater than five years No other associated symptoms or modifying factors Severity is moderate PSA relatively stable over time IMPRESSION Stable PSA over time although he does have some irritative symptoms After our discussion it does appear that if he is not drinking close to going to bed he notes that his nocturia has significantly decreased At this juncture what I would like to do is to start with behavior modification There were no other associated symptoms or modifying factors PLAN The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed He already knows that this does decrease his nocturia He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha blocker to something of more efficacious Keywords urology daytime frequency psa irritative symptoms elevated psa frequency nocturia MEDICAL_TRANSCRIPTION,Description Cystoscopy TUR and electrofulguration of recurrent bladder tumors Medical Specialty Urology Sample Name Electrofulguration Bladder Tumor Transcription PREOPERATIVE DIAGNOSIS Recurrent bladder tumors POSTOPERATIVE DIAGNOSIS Recurrent bladder tumors OPERATION Cystoscopy TUR and electrofulguration of recurrent bladder tumors ANESTHESIA General INDICATIONS A 79 year old woman with recurrent bladder tumors of the bladder neck DESCRIPTION OF PROCEDURE The patient was brought to the operating room prepped and draped in lithotomy position under satisfactory general anesthesia A 21 French cystourethroscope was inserted into the bladder Examination of the bladder showed approximately a 3 cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice No other lesions were noted Using a cold punch biopsy forceps a random biopsy was obtained The entire area was electrofulgurated using the Bugbee electrode The patient tolerated the procedure well and left the operating room in satisfactory condition Keywords urology bladder neck bladder tumors cystoscopy tur electrofulguration bladder MEDICAL_TRANSCRIPTION,Description Cystourethroscopy urethral dilation and bladder biopsy and fulguration Urinary hesitancy and weak stream urethral narrowing mild posterior wall erythema Medical Specialty Urology Sample Name Cystourethroscopy Urethral Dilation Transcription PREOPERATIVE DIAGNOSIS Urinary hesitancy and weak stream POSTOPERATIVE DIAGNOSES 1 Urinary hesitancy and weak stream 2 Urethral narrowing 3 Mild posterior wall erythema PROCEDURE PERFORMED 1 Cystourethroscopy 2 Urethral dilation 3 Bladder biopsy and fulguration ANESTHESIA General SPECIMEN Urine culture sensitivity and cytology and bladder biopsy x1 DISPOSITION To PACU in stable condition INDICATIONS AND FINDINGS This is a 76 year old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past last cystoscopy approximately two years ago FINDINGS AT TIME OF SURGERY Cystourethroscopy revealed some mild narrowing of the urethra which was easily dilated to 23 French A midureteral polyp was noted Cystoscopy revealed multiple cellules and mild trabeculation of the bladder Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa No obvious raised bladder tumor was noted No foreign bodies were noted The ureteral orifices were noted on the trigone just proximal to the bladder neck DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to the operating room general anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate 23 French cystoscope Cystoscopy was performed in its entirety with the above findings The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area The bladder was drained cystoscope was removed scope was reinserted and bladder was again reexamined No evidence of active bleeding noted The bladder was drained cystoscope was removed and the patient was cleaned and sent to recovery room in stable condition to followup with Dr X in two weeks She is given prescription for Levaquin and Pyridium and given discharge instructions Keywords urology bladder biopsy fulguration urethral dilation weak stream bladder cystoscopy cystoscope cystourethroscopy biopsy urethral MEDICAL_TRANSCRIPTION,Description Cystourethroscopy and tTransurethral resection of prostate TURP Urinary retention and benign prostate hypertrophy This is a 62 year old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound office cystoscopy confirmed this Medical Specialty Urology Sample Name Cystourethroscopy TURP 1 Transcription PREOPERATIVE DIAGNOSES 1 Urinary retention 2 Benign prostate hypertrophy POSTOPERATIVE DIAGNOSES 1 Urinary retention 2 Benign prostate hypertrophy PROCEDURES PERFORMED 1 Cystourethroscopy 2 Transurethral resection of prostate TURP ANESTHESIA Spinal RESECTION TIME Less than one hour INDICATION FOR PROCEDURE This is a 62 year old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound office cystoscopy confirmed this PROCEDURE PROCEDURE Informed written consent was obtained The patient was taken to the operative suite administered spinal anesthetic and placed in dorsal lithotomy position She was sterilely prepped and draped in normal fashion A 27 French resectoscope was inserted utilizing the visual obturator blanching the bladder The bladder was visualized in all quadrants no bladder tumors or stones were noted Ureteral orifices were visualized and did appear to be near the enlarged median lobe Prostate showed trilobar prostatic enlargement There were some cellules and tuberculations noted The visual obturator was removed The resectoscope was then inserted utilizing the 26 French resectoscope loop Resection was performed initiating at the bladder neck and at the median lobe This was taken down to the circular capsular fibers Attention was then turned to the left lateral lobe and this was resected from 12 o clock to 3 o clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum Ureteral orifices were kept out of harm s way throughout the case Resection was then performed from the 3 o clock position to the 6 o clock position in similar fashion Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed Open prostatic fossa was noted All chips were evacuated via Ellik evacuator and 24 French three way Foley catheter was inserted and irrigated Clear return was noted The patient was then hooked up to better irrigation The patient was cleaned reversed for anesthetic and transferred to recovery room in stable condition PLAN We will admit with antibiotics pain control and bladder irrigation possible void trial in the morning Keywords urology urinary retention transurethral resection of prostate prostate enlarged obstructive voiding symptoms benign prostate hypertrophy ureteral orifices prostate hypertrophy cystourethroscopy turp hypertrophy resectoscope urinary bladder resection MEDICAL_TRANSCRIPTION,Description Some improvement of erectile dysfunction on low dose of Cialis with no side effects Medical Specialty Urology Sample Name Erectile Dysfunction Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup history of erectile dysfunction last visit started on Cialis 10 mg He indicates that he has noticed some mild improvement of his symptoms with no side effect On this dose he is having firm erection able to penetrate lasting for about 10 or so minutes No chest pain no nitroglycerin usage no fever no chills No dysuria gross hematuria fever chills Daytime frequency every three hours nocturia times 0 good stream He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN mid left biopsy with two specimens being too small to evaluate PSA 11 6 Dr X s notes are reviewed IMPRESSION 1 Some improvement of erectile dysfunction on low dose of Cialis with no side effects The patient has multiple risk factors but denies using any nitroglycerin or any cardiac issues at this time We reviewed options of increasing the medication versus trying other medications options of penile prosthesis Caverject injection use as well as working pump is reviewed 2 Elevated PSA in a patient with a recent biopsy showing high grade PIN as well as two specimens not being large enough to evaluate The patient tells me he has met with his primary care physician and after discussion he is in consideration of repeating a prostate ultrasound and biopsy However he would like to meet with Dr X to discuss these prior to biopsy PLAN Following detailed discussion the patient wishes to proceed with Cialis 20 mg samples are provided as well as Levitra 10 mg may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed The patient not to use them at the same time Will call if any other concern In the meantime he is scheduled to meet with Dr X with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy He declined scheduling this at this time All questions answered Keywords urology improvement of erectile dysfunction erectile dysfunction erectile dysfunction cialis psa biopsy MEDICAL_TRANSCRIPTION,Description Right hydronephrosis right flank pain atypical dysplastic urine cytology extrarenal pelvis on the right no evidence of obstruction or ureteral bladder lesions Cystoscopy bilateral retrograde ureteropyelograms right ureteral barbotage for urine cytology and right ureterorenoscopy Medical Specialty Urology Sample Name Cystoscopy Ureteropyelogram Ureteral Barbotage Transcription PREOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology POSTOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology 4 Extrarenal pelvis on the right 5 No evidence of obstruction or ureteral bladder lesions PROCEDURE PERFORMED 1 Cystoscopy 2 Bilateral retrograde ureteropyelograms 3 Right ureteral barbotage for urine cytology 4 Right ureterorenoscopy diagnostic ANESTHESIA Spinal SPECIMEN TO PATHOLOGY Urine and saline wash barbotage from right ureter through the ureteral catheter ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE This is a 70 year old female who reports progressive intermittent right flank pain associated with significant discomfort and disability She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone She has some ureteral thickening in her distal right ureter She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia associated karyotypic profile She was brought to the operating room for further evaluation and treatment DESCRIPTION OF OPERATION After preoperative counseling the patient was taken to the operating room and administered a spinal anesthesia She was placed in the lithotomy position prepped and draped in the usual sterile fashion The 21 French cystoscope was inserted per urethra into the bladder The bladder was inspected and found to be without evidence of intravesical tumors stones or mucosal abnormalities The right ureteral orifice was visualized and cannulated with an open ended ureteral catheter This was gently advanced to the mid ureter Urine was collected for cytology Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter An 0 038 guidewire was then passed up through the open ended ureteral catheter The open ended ureteral catheter and cystoscope were removed and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis Using direct vision and fluoroscopy to confirm location the entire renal pelvis and calyces were inspected The renal pelvis demonstrated an extrarenal pelvis but no evidence of obstruction at the renal UPJ level There were no intrapelvic or calyceal stones The ureter demonstrated no significant mucosal abnormalities no visible tumors and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate The ureteroscope was then removed The cystoscope was reinserted Once again retrograde injection of contrast through an open ended ureteral catheter was undertaken in the right ureter and collecting system No evidence of extravasation or significant change in anatomy was visualized The left ureteral orifice was then visualized and cannulated with an open ended ureteral catheter and retrograde injection of contrast demonstrated a normal left ureter and collecting system The cystoscope was removed Foley catheter was inserted The patient was placed in the supine position and transferred to the recovery room in satisfactory condition Keywords urology hydronephrosis ureteropyelogram ureterorenoscopy flank pain renal pelvis urine cytology ureteral cystoscopy barbotage cystoscope retrograde urine MEDICAL_TRANSCRIPTION,Description Discharge Summary of a patient with hematuria benign prostatic hyperplasia complex renal cyst versus renal cell carcinoma and osteoarthritis Medical Specialty Urology Sample Name Discharge Summary Urology Transcription ADMITTING DIAGNOSES 1 Hematuria 2 Benign prostatic hyperplasia 3 Osteoarthritis DISCHARGE DIAGNOSES 1 Hematuria resolved 2 Benign prostatic hyperplasia 3 Complex renal cyst versus renal cell carcinoma or other tumor 4 Osteoarthritis HOSPITAL COURSE This is a 77 year old African American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission He stated that he never had blood in his urine before however he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago He was admitted to a regular bed Dr G of Urology was consulted for evaluation of his hematuria During the workup for this he had a CT of the abdomen and pelvis with and without contrast with early and late phase imaging for evaluation of the kidneys and collecting system At that time he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended He had an ultrasound done of the cyst which showed a 2 1 x 2 7 cm mass arising from the right kidney which again did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor so an MRI was scheduled on the day of discharge for further evaluation of this The report was not back at discharge The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular and he was diagnosed with nonprostatic hyperplasia His urine slowly cleared He tolerated a regular diet with no difficulties in his activities of daily living and his Foley was removed on the day of discharge He was started on ciprofloxacin Colace and Lasix after the transurethral resection and continued these for a short course He is asked to continue the Colace as an outpatient for stool softening for comfort DISCHARGE MEDICATIONS Colace 100 mg 1 b i d DISCHARGE FOLLOWUP PLANNING The patient is to follow up with his primary care physician at ABCD Dr B or Dr J the patient is unsure of which in the next couple weeks He is to follow up with Dr G of Urology in the next week by phone in regards to the patient s MRI and plans for a laparoscopic partial renal resection biopsy This is scheduled for the week after discharge potentially by Dr G and the patient will discuss the exact time later this week The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output Keywords urology discharge summary bph benign prostatic hyperplasia hematuria osteoarthritis clots cystoscopy gross hematuria kidney renal cell carcinoma renal cyst simple cyst prostatic hyperplasia transurethral resection discharge summary transurethral prostate prostatic hyperplasia gross benign renal cyst MEDICAL_TRANSCRIPTION,Description Cystourethroscopy right retrograde pyelogram right ureteral pyeloscopy right renal biopsy and right double J 4 5 x 26 mm ureteral stent placement Right renal mass and ureteropelvic junction obstruction and hematuria Medical Specialty Urology Sample Name Cystourethroscopy Retrograde Pyelogram 1 Transcription PREOPERATIVE DIAGNOSES 1 Right renal mass 2 Hematuria POSTOPERATIVE DIAGNOSES 1 Right renal mass 2 Right ureteropelvic junction obstruction PROCEDURES PERFORMED 1 Cystourethroscopy 2 Right retrograde pyelogram 3 Right ureteral pyeloscopy 4 Right renal biopsy 5 Right double J 4 5 x 26 mm ureteral stent placement ANESTHESIA Sedation SPECIMEN Urine for cytology and culture sensitivity right renal pelvis urine for cytology and right upper pole biopsies INDICATION The patient is a 74 year old male who was initially seen in the office with hematuria He was then brought to the hospital for other medical problems and found to still have hematuria He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation PROCEDURE After consent was obtained the patient was brought to the operating room and placed in the supine position He was given IV sedation and placed in dorsal lithotomy position He was then prepped and draped in the standard fashion A 21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder The patient was noted to have mildly enlarged prostate however it was non obstructing Upon visualization of the bladder the patient was noted to have some tuberculation to the bladder There were no masses or any other abnormalities noted other than the tuberculation Attention was then turned to the right ureteral orifice and an open end of the catheter was then passed into the right ureteral orifice A retrograde pyelogram was performed Upon visualization there was no visualization of the upper collecting system on the right side At this point a guidewire was then passed through the open end of the ureteral catheter and the catheter was removed The bladder was drained and the cystoscope was removed The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction The wire was then again passed through the flexible scope and the flexible scope was removed A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system Upon visualization of the collecting system of the upper portion there was noted to be papillary mass within the collecting system The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass Once this was done the wire was left in place and the ureteroscope was removed The cystoscope was then placed back into the bladder and a 26 x 4 5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis The stent was noted to be clear within the right renal pelvis as well as in the bladder The bladder was drained and the cystoscope was removed The patient tolerated the procedure well He will be transferred to the recovery room and back to his room It has been discussed with his primary physician that the patient will likely need a nephrectomy He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday Keywords urology renal mass hematuria ureteropelvic junction obstruction cystourethroscopy retrograde pyelogram ureteral pyeloscopy renal biopsy double j ureteral stent placement ureteropelvic junction flexible scope papillary mass ureteral stent renal pelvis ureteral orifice amplatz wire retrograde pyelogram ureteral cystoscope ureteroscope renal bladder MEDICAL_TRANSCRIPTION,Description Cystoscopy Transurethral resection of the prostate Medical Specialty Urology Sample Name Cystoscopy TURP Transcription PREOPERATIVE DIAGNOSES 1 Ta grade III TIS transitional cell carcinoma of the urinary bladder 2 Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy 3 Inability to pass a Foley catheter x3 POSTOPERATIVE DIAGNOSES 1 Ta grade III TIS transitional cell carcinoma of the urinary bladder 2 Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy 3 Inability to pass a Foley catheter x3 PROCEDURES 1 Cystoscopy 2 Transurethral resection of the prostate TURP ANESTHESIA General laryngeal mask INDICATIONS This patient is a 61 year old white male who has been treated at the VA in Houston for a bladder cancer His history dates back to 2003 when he had a non muscle invasive bladder cancer He had multiple cystoscopies and followups since that time with no evidence of recurrence However on recent cystoscopy he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically there were no abnormalities I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms and there were still healing biopsy sites We elected to allow his bladder to recover before starting the BCG We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter I repeated a cystoscopy in the office with findings of a high bladder neck and BPH After a lengthy discussion with the patient and his wife we elected to proceed with TURP after a full informed consent FINDINGS At cystoscopy there was bilobular prostatic hyperplasia and a very high riding bladder neck which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ PROCEDURE IN DETAIL The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position his perineum and genitalia were sterilely prepped and draped in the usual fashion A cystourethroscopy was performed with a 23 French ACMI panendoscope and 70 degree lens with the findings as described We removed the cystoscope and passed a 28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to 32 French with van Buren sounds Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck The groove was cut at 6 o clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o clock to 5 o clock Hemostasis was achieved and then a similar procedure performed in the right side We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis Chips were removed with Ellik evacuator There was no bleeding at the conclusion of the procedure and the resectoscope was removed A 24 French three way Foley catheter was placed with efflux of clear irrigant The patient was returned to the supine position awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords urology urinary bladder benign prostatic hypertrophy transurethral resection of the prostate turp acmi panendoscope van buren sounds transitional cell carcinoma foley catheter bladder neck bladder carcinoma cystoscopy MEDICAL_TRANSCRIPTION,Description Cystourethroscopy bilateral retrograde pyelogram and transurethral resection of bladder tumor of 1 5 cm in size Recurrent bladder tumor and history of bladder carcinoma Medical Specialty Urology Sample Name Cystourethroscopy Retrograde Pyelogram Transcription PREOPERATIVE DIAGNOSES 1 Recurrent bladder tumor 2 History of bladder carcinoma POSTOPERATIVE DIAGNOSIS Keywords urology recurrent bladder tumor bladder carcinoma bilateral retrograde pyelogram transurethral resection of bladder tumor lateral wall bladder tumor transurethral resection retrograde pyelogram tumor bladder cystourethroscopy pyelogram MEDICAL_TRANSCRIPTION,Description Cystoscopy under anesthesia bilateral HIT STING with Deflux under general anesthetic Medical Specialty Urology Sample Name Cystoscopy Transcription PREOPERATIVE DIAGNOSIS Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection POSTOPERATIVE DIAGNOSIS Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection PROCEDURE Cystoscopy under anesthesia bilateral HIT STING with Deflux under general anesthetic ANESTHESIA General inhalational anesthetic FLUIDS RECEIVED 250 mL crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS Urine sent for culture ABNORMAL FINDINGS Gaping ureteral orifices right greater than left with Deflux not in or near the ureteral orifices Right ureteral orifice was HIT with 1 5 mL of Deflux and left with 1 2 mL of Deflux HISTORY OF PRESENT ILLNESS The patient is a 4 1 2 year old boy with history of reflux nephropathy and voiding and bowel dysfunction He has had a STING procedure performed but continues to have reflux bilaterally Plan is for another injection DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized IV antibiotics were given He was then placed in a lithotomy position with adequate padding of his arms and legs His urethra was calibrated to 12 French with a bougie a boule A 9 5 French cystoscope was used and the offset system was then used His urethra was normal without valves or strictures His bladder was fairly normal with minimal trabeculations but no cystitis noted Upon evaluation the patient s right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone This was similarly found on the left side where the Deflux was not close to the orifice as well It was slightly more difficult because of the amount impacted upon our angle for injection We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1 5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect Once we injected this we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding Similar procedure was done on the left This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection At the end of the procedure the irrigant was drained and 2 lidocaine jelly was instilled in the urethra The patient tolerated the procedure well and was in stable condition upon transfer to Recovery A low dose of IV Toradol was given at the end of the procedure as well Keywords urology bilateral vesicoureteral reflux deflux sting procedure hit technique cystoscopy under anesthesia hit sting with deflux vesicoureteral reflux ureteral orifices vesicoureteral cystoscopy urethra hit sting ureteral MEDICAL_TRANSCRIPTION,Description Benign prostatic hypertrophy and urinary retention Cystourethroscopy and transurethral resection of prostate TURP Medical Specialty Urology Sample Name Cystourethroscopy TURP Transcription PREOPERATIVE DIAGNOSES 1 Benign prostatic hypertrophy 2 Urinary retention POSTOPERATIVE DIAGNOSES 1 Benign prostatic hypertrophy 2 Urinary retention PROCEDURE PERFORMED 1 Cystourethroscopy 2 Transurethral resection of prostate TURP ANESTHESIA Spinal DRAIN A 24 French three way Foley catheter SPECIMENS Prostatic resection chips ESTIMATED BLOOD LOSS 150 cc DISPOSITION The patient was transferred to the PACU in stable condition INDICATIONS AND FINDINGS This is an 84 year old male with history of BPH and subsequent urinary retention with failure of trial of void scheduled for elective TURP procedure FINDINGS At the time of surgery cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in the normal sterile fashion and a 21 French cystoscope inserted into urethra and into the bladder Cystoscopy performed with the above findings Cystoscope was removed A 27 French resectoscope with a 26 cutting loop was inserted into the bladder Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed ________ irrigator was used to evacuate the bladder of prostatic chips Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop Any obvious bleeding from the prostatic fossa was controlled with electrocautery Resectoscope was removed A 24 French three way Foley catheter inserted into the urethra and into the bladder Bladder was irrigated and connected to three way irrigation The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring Keywords urology urinary retention cystourethroscopy transurethral resection of prostate foley catheter bph cystoscopy bladder benign prostatic hypertrophy turp MEDICAL_TRANSCRIPTION,Description Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder Medical Specialty Urology Sample Name Cystopyelogram 1 Transcription PREOPERATIVE DIAGNOSIS Gross hematuria POSTOPERATIVE DIAGNOSIS Gross hematuria OPERATIONS Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder ANESTHESIA Spinal FINDINGS Significant amount of bladder clots measuring about 150 to 200 mL two cupful of clots were removed There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side The right ureteral opening was difficult to visualize the left one was normal BRIEF HISTORY The patient is a 78 year old male with history of gross hematuria and recurrent UTIs The patient had hematuria Cystoscopy revealed atypical biopsy The patient came in again with gross hematuria The first biopsy was done about a month ago The patient was to come back and have repeat biopsies done but before that came into the hospital with gross hematuria The options of watchful waiting removal of the clots and biopsies were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed Morbidity and mortality of the procedure were discussed Consent was obtained from the daughter in law who has the power of attorney in Florida DESCRIPTION OF PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in the dorsal lithotomy position The patient was prepped and draped in the usual sterile fashion The patient had been off of the Coumadin for about 4 days and INR had been reversed The patient has significant amount of clot upon entering the bladder There was a tight bladder neck contracture The prostate was not enlarged Using ACMI 24 French sheath using Ellick irrigation about 2 cupful of clots were removed It took about half an hour to just remove the clots After removing the clots using 24 French cutting loop resectoscope tumor on the left upper wall near the dome or near the 2 o clock position was resected This was lateral to the left ureteral opening The base was coagulated for hemostasis Same thing was done at 10 o clock on the right side where there was some tumor that was visualized The back wall and the rest of the bladder appeared normal Using 8 French cone tip catheter left sided pyelogram was normal The right sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots The contrast did go up to what appeared to be the right ureteral opening but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening A little bit of contrast went out but the force was not made just to avoid any secondary stricture formation The patient did have CT with contrast which showed that the kidneys were normal At this time a 24 three way irrigation was started The patient was brought to Recovery room in stable condition Keywords urology clot evacuation transurethral resection bladder tumor bladder neck gross hematuria bladder cystopyelogram hematuria clots MEDICAL_TRANSCRIPTION,Description Cystoscopy and Bladder biopsy with fulguration History of bladder tumor with abnormal cytology and areas of erythema Medical Specialty Urology Sample Name Cystoscopy Bladder Biopsy Transcription PREOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema POSTOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema PROCEDURE PERFORMED 1 Cystoscopy 2 Bladder biopsy with fulguration ANESTHESIA IV sedation with local SPECIMEN Urine cytology and right lateral wall biopsies PROCEDURE After the consent was obtained the patient was brought to the operating room and given IV sedation He was then placed in dorsal lithotomy position and prepped and draped in standard fashion A 21 French cystoscope was then used to visualized the entire urethra and bladder There was noted to be a narrowing of the proximal urethra however the scope was able to pass through The patient was noted to have a previously resected prostate On visualization of the bladder the patient did have areas of erythema on the right as well as the left lateral walls more significant on the right side The patient did have increased vascularity throughout the bladder The ________ two biopsies of the right lateral wall and those were sent for pathology The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema Bovie was also utilized to cauterize the areas of erythema on the left lateral wall No further bleeding was identified The bladder was drained and the cystoscope was removed The patient tolerated the procedure well and was transferred to the recovery room He will have his defibrillator restarted and will followup with Dr X in approximately two weeks for the result He will be discharged home with antibiotics as well as pain medications He is to restart his Coumadin not before Sunday Keywords urology bladder biopsy with fulguration iv sedation bladder biopsy bladder tumor abnormal cytology bladder cystoscopy tumor cytology erythema MEDICAL_TRANSCRIPTION,Description Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached Medical Specialty Urology Sample Name Cystopyelogram Transcription PREOPERATIVE DIAGNOSIS Left distal ureteral stone POSTOPERATIVE DIAGNOSIS Left distal ureteral stone PROCEDURE PERFORMED Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached ANESTHESIA LMA EBL Minimal FLUIDS Crystalloid The patient was given antibiotics 1 g of Ancef and the patient was on oral antibiotics at home BRIEF HISTORY The patient is a 61 year old female with history of recurrent uroseptic stones The patient had stones x2 1 was already removed second one came down had recurrent episode of sepsis stent was placed Options were given such as watchful waiting laser lithotripsy shockwave lithotripsy etc Risks of anesthesia bleeding infection pain need for stent and removal of the stent were discussed The patient understood and wanted to proceed with the procedure DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A 0 035 glidewire was placed in the left system Using graspers left sided stent was removed A semirigid ureteroscopy was done A stone was visualized in the mid to upper ureter Using laser the stone was broken into 5 to 6 small pieces Using basket extraction all the pieces were removed Ureteroscopy all the way up to the UPJ was done which was negative There were no further stones Using pyelograms the rest of the system appeared normal The entire ureter on the left side was open and patent There were no further stones Due to the edema and the surgery plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours Over the 0 035 glidewire a 26 double J stent was placed There was a nice curl in the kidney and one in the bladder The patient tolerated the procedure well Please note that the string was kept in place and the patient was to remove the stent the next day The patient s family was instructed how to do so The patient had antibiotics and pain medications at home The patient was brought to recovery room in a stable condition Keywords urology laser lithotripsy shockwave lithotripsy double j stent distal ureteral stone ureteral stone basket extraction cystopyelogram laser lithotripsy stones string ureteroscopy stone stent MEDICAL_TRANSCRIPTION,Description Holmium laser cystolithalopaxy A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self catheterization recent urinary tract infections The cystoscopy showed a large bladder calculus short but obstructing prostate Medical Specialty Urology Sample Name Cystolithalopaxy Transcription PREOPERATIVE DIAGNOSES 1 Prostatism 2 Bladder calculus OPERATION Holmium laser cystolithalopaxy POSTOPERATIVE DIAGNOSES 1 Prostatism 2 Bladder calculus ANESTHESIA General INDICATIONS This is a 62 year old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self catheterization recent urinary tract infections The cystoscopy showed a large bladder calculus short but obstructing prostate He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy He is a diabetic with obesity LABORATORY DATA Includes urinalysis showing white cells too much to count 3 5 red cells occasional bacteria He had a serum creatinine of 1 2 sodium 138 potassium 4 6 glucose 190 calcium 9 1 Hematocrit 40 5 hemoglobin 13 8 white count 7 900 PROCEDURE The patient was satisfactorily given general anesthesia Prepped and draped in the dorsal lithotomy position A 27 French Olympus rectoscope was passed via the urethra into the bladder The bladder prostate and urethra were inspected He had an obstructing prostate He had marked catheter reaction in his bladder He had a lot of villous changes impossible to tell from frank tumor He had a huge bladder calculus It was white and round I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath and broke up the stone breaking up approximately 40 grams of stone There was still stone left at the end of the procedure Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik Then the scope was removed and a 24 French 3 way Foley catheter was passed via the urethra into the bladder The plan is to probably discharge the patient in the morning and then we will get a KUB We will probably bring him back for a second stage cystolithotripsy and ultimately do a TURP We broke up the stone for over an hour and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient Keywords urology prostatism holmium laser cystolithalopaxy urinary tract infections holmium laser bladder calculus bladder cystolithalopaxy diabetic urethra urinary catheterization stone calculus prostate MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy resection of small bowel lesion biopsy of small bowel mesentery bilateral extended pelvic and iliac lymphadenectomy including preaortic and precaval bilateral common iliac presacral bilateral external iliac lymph nodes salvage radical cystoprostatectomy very difficult due to previous chemotherapy and radiation therapy and continent urinary diversion with an Indiana pouch Medical Specialty Urology Sample Name Cystoprostatectomy Transcription PREOPERATIVE DIAGNOSES 1 Clinical stage T2 NX MX transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy 2 New right hydronephrosis POSTOPERATIVE DIAGNOSES 1 Clinical stage T4a N3 M1 transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy 2 New right hydronephrosis 3 Carcinoid tumor of the small bowel TITLE OF OPERATION Exploratory laparotomy resection of small bowel lesion biopsy of small bowel mesentery bilateral extended pelvic and iliac lymphadenectomy including preaortic and precaval bilateral common iliac presacral bilateral external iliac lymph nodes salvage radical cystoprostatectomy very difficult due to previous chemotherapy and radiation therapy and continent urinary diversion with an Indiana pouch ANESTHESIA General endotracheal and epidural INDICATIONS This patient is a 65 year old white male who was diagnosed with a high grade invasive bladder cancer in June 2005 During the course of his workup of transurethral resection he had a heart attack when he was taken off Plavix after having had a drug eluting stent placed in He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event The patient has been followed regularly by myself and Dr X and has been continuously free of diseases since that time In that interval he had a coronary artery bypass graft and was taken off of Plavix Most recently he had a PET CT which showed new right hydronephrosis and a followup cystoscopy which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated I took him to the operating room and extensively resected this area with findings of a high grade muscle invasive bladder cancer We could not identify the right ureteral orifice and he had a right ureteral stent placed Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy He was interested in orthotopic neobladder and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier Therefore we planned on an Indiana pouch continent cutaneous diversion OPERATIVE FINDINGS On exploration there were multiple abnormalities outside the bladder as follows There were at least three small lesions within the distal small bowel the predominant one measured about 1 5 cm in diameter with a white scar on the surface There were two much smaller lesions also with a small white scar with very little palpable mass The larger of the two was resected and found to be a carcinoid tumor There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes The small bowel mesentry was fairly thickened at the base but no discrete abnormality noted Both common iliac and lymph node samples were very thickened and indurated and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect viability was unable to be determined There was a frozen section of the distal right external iliac lymph node that was negative The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures The external iliac lymph nodes were resected on both sides of the obturator the lymph packet however was very stuck and adherent to the pelvic sidewall and I elected not to remove that The rest of the large bowel appeared normal There were no masses in the liver and the gallbladder was surgically absent There was nasogastric tube in the stomach OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained having placed in the supine position and flexed over the anterior superior iliac spine his abdomen and genitalia were sterilely prepped and draped in usual fashion The radiologist placed a radial arterial line and an intravenous catheter Intravenous antibiotics were given for prophylaxis We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis deepened through the rectus fascia and the rectus muscles separated in the midline Exploration was carried out with the findings described The bladder was adherent and did appear immobile Moist wound towels and a Bookwalter retractor was placed for exposure We began by assessing the small and large bowel with the findings in the small bowel as described We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two layer running 4 0 Prolene suture We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum The ureters were carefully dissected out and down deep in the true pelvis The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber I kept the ureters intact until we were moving the bladder off as described above At that point we then ligated the ureters with the RP 45 vascular load and divided it We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes The common iliac lymph nodes remained stuck to the ureter Frozen section with the findings described on the left I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally I was however able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels Clips were used to control the lymphatics distally These lymph nodes were sent for frozen section which was negative We made no attempt to circumferentially mobilize the vessels but essentially swept the tissue off of the anterior surface and towards the bladder and then removed it The obturator nerve on the right side was sucked into the pelvic sidewall and I elected not to remove those On the left side things were a little bit more mobile in terms of the lymph nodes but still the obturator lymph nodes were left intact We then worked on the lateral pedicles on both sides and essentially determined that I can take these down I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate At this point I scrubbed out of the operation talked to the family and indicated that I felt the cystectomy was more palliative than therapeutic and I reiterated his desire to be free of any external appliance I then proceeded to take down the lateral pedicles with an RP 45 stapler on the right and clips distally The endopelvic fascia was incised I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically I was able to pass a 0 Vicryl suture along the dorsal venous complex tied this and then sealed and divided the complex with a LigaSure and oversewed it distally with 2 0 Vicryl figure of eight stitch I then divided the urethra distal to the apex of the prostate divided the Foley catheter between the clamps and then the posterior urethra I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum and the specimen was then free of all attachments and handed off the operative field The bivalved prostate appeared normal We then carefully inspected the rectal wall and noted to be intact The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis We then turned our attention to forming the Indiana pouch I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon The colon was divided proximal to the middle colic using a GIA 80 stapler I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum The mesentery was then sealed with a LigaSure device and divided and the bowel was divided with a GIA 60 stapler We then performed a side to side ileo transverse colostomy using a GIA 80 stapler closing the open end with a TA 60 The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures We then removed the staple line along the terminal ileum passed a 12 French Robinson catheter into the cecal segment and plicated the ileum with 3 firings of the GIA 60 stapler The ileocecal valve was then reinforced with interrupted 3 0 silk sutures as described by Rowland et al and following this passage of an 18 French Robinson catheter was associated with the characteristic pop indicating that we had adequately plicated the ileocecal valve As the patient had had a previous appendectomy we made an opening in the cecum in the area of the previous appendectomy We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3 0 Vicryl sutures The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb 75 Between the staple lines Vicryl sutures were placed and the defects closed with 3 0 Vicryl suture ligatures We then turned our attention to forming the ileocolonic anastomosis The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end to side anastomosis performed with an open technique using interrupted 4 0 Vicryl sutures and this was stented with a Cook 8 4 French ureteral stent and this was secured to the bowel lumen with a 5 0 chromic suture The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2 0 chromic suture A 24 French Malecot catheter was placed through the cecum and secured with a chromic suture The staple lines were then buried with a running 3 0 Vicryl two layer suture and the open end of the pouch closed with a TA 60 Polysorb suture The pouch was filled to 240 cc and noted to be watertight and the ureteral anastomoses were intact We then made a final inspection for hemostasis The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures We then matured our stoma through the umbilicus We removed the plug of skin through the umbilicus and delivered the ileal segment through this A portion of the ileum was removed and healthy well vascularized tissue was matured with interrupted 3 0 chromic sutures We left an 18 French Robinson through the stoma and secured this to the skin with silk sutures The Malecot and stents were also secured in a similar fashion The stoma was returned to the umbilicus after resecting the terminal ileum We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant Rectus fascia was closed with buried 2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia Interrupted stitches were placed as well The subcutaneous tissue was irrigated and skin closed with surgical clips The estimated blood loss was 2500 mL The patient received 5 units of packed red blood cells and 4 units of FFP The patient was then awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords MEDICAL_TRANSCRIPTION,Description Cystoscopy Visual urethrotomy procedure Medical Specialty Urology Sample Name Cystoscopy Visual Urethrotomy Transcription CYSTOSCOPY VISUAL URETHROTOMY OPERATIVE NOTE The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia A Storz urethrotome sheath was inserted into the urethra under direct vision Visualization revealed a stricture in the bulbous urethra This was intubated with a 0 038 Teflon coated guidewire and using the straight cold urethrotomy knife it was incised to 12 00 to allow free passage of the scope into the bladder Visualization revealed no other lesions in the bulbous or membranous urethra Prostatic urethra was normal for age No foreign bodies tumors or stones were seen within the bladder Over the guidewire a 16 French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water He was sent to the recovery room in stable condition Keywords urology cystoscopy foley catheter storz urethrotome sheath teflon coated guidewire urethrotomy bladder bulbous urethra dorsal lithotomy position knife membranous urethra cystoscopy visual urethrotomy visual urethrotomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Newborn circumcision The penile foreskin was removed using Gomco Medical Specialty Urology Sample Name Circumcision Newborn Transcription PROCEDURE Newborn circumcision INDICATIONS Parental preference ANESTHESIA Dorsal penile nerve block DESCRIPTION OF PROCEDURE The baby was prepared and draped in a sterile manner Lidocaine 1 4 mL without epinephrine was instilled into the base of the penis at 2 o clock and 10 o clock The penile foreskin was removed using a XXX Gomco Hemostasis was achieved with minimal blood loss There was no sign of infection The baby tolerated the procedure well Vaseline was applied to the penis and the baby was diapered by nursing staff Keywords urology nerve block newborn circumcision foreskin gomco penis circumcision newborn penile MEDICAL_TRANSCRIPTION,Description Circumcision Normal male phallus The infant is without evidence of hypospadias or chordee prior to the procedure Medical Specialty Urology Sample Name Circumcision Infant Transcription PROCEDURE Circumcision PRE PROCEDURE DIAGNOSIS Normal male phallus POST PROCEDURE DIAGNOSIS Normal male phallus ANESTHESIA 1 lidocaine without epinephrine INDICATIONS The risks and benefits of the procedure were discussed with the parents The risks are infection hemorrhage and meatal stenosis The benefits are ease of care and cleanliness and fewer urinary tract infections The parents understand this and have signed a permit FINDINGS The infant is without evidence of hypospadias or chordee prior to the procedure TECHNIQUE The infant was given a dorsal penile block with 1 lidocaine without epinephrine using a tuberculin syringe and 0 5 cc of lidocaine was delivered subcutaneously at 10 30 and at 1 30 o clock at the dorsal base of the penis The infant was prepped then with Betadine and draped with a sterile towel in the usual manner Clamps were placed at 10 o clock and 2 o clock and the adhesions between the glans and mucosa were instrumentally lysed Dorsal hemostasis was established and a dorsal slit was made The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed The infant was fitted with a XX cm Plastibell The foreskin was retracted around the Plastibell and circumferential hemostasis was established The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis Keywords urology dorsal slit hypospadias chordee epinephrine hemorrhage penis adhesions circumcision phallus lidocaine foreskin infant MEDICAL_TRANSCRIPTION,Description Circumcision The child appeared to tolerate the procedure well Care instructions were given to the parents Medical Specialty Urology Sample Name Circumcision Child Transcription PROCEDURE Circumcision Signed informed consent was obtained and the procedure explained The child was placed in a Circumstraint board and restrained in the usual fashion The area of the penis and scrotum were prepared with povidone iodine solution The area was draped with sterile drapes and the remainder of the procedure was done with sterile procedure A dorsal penile block was done using 2 injections of 0 3 cc each 1 plain lidocaine A dorsal slit was made and the prepuce was dissected away from the glans penis A Gomco clamp was properly placed for 5 minutes During this time the foreskin was sharply excised using a 10 blade With removal of the clamp there was a good cosmetic outcome and no bleeding The child appeared to tolerate the procedure well Care instructions were given to the parents Keywords urology circumstraint dorsal slit gomco clamp circumcision childNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Consult for prostate cancer Medical Specialty Urology Sample Name Consult Prostate Cancer Transcription CONSULT FOR PROSTATE CANCER The patient returned for consultation for his newly diagnosed prostate cancer The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding infection rectal injury impotence and incontinence These were discussed at length Alternative therapies including radiation therapy either radioactive seed placement conformal radiation therapy or the HDR radiation treatments were discussed with the risks of bladder bowel and rectal injury and possible impotence were discussed also There is a risk of rectal fistula Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis gynecomastia hot flashes and impotency Potency may not recover after the hormone therapy has been completed Cryosurgery was discussed with the risks of urinary retention stricture formation incontinence and impotency There is a risk of rectal fistula He would need to have a suprapubic catheter for about two weeks and may need to learn self intermittent catheterization if he cannot void adequately Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence Observation therapy was discussed with him in addition I answered all questions that were put to me and I think he understands the options that are available I spoke with the patient for over 60 minutes concerning these options Keywords urology prostate cancer cryosurgery hdr radiation prostate surgery bladder bleeding bowel consultation impotence incontinence infection prostatectomy radiation therapy radical rectal rectal fistula rectal injury prostate cancer consult cancer radiation prostateNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cystoscopy cryosurgical ablation of the prostate Medical Specialty Urology Sample Name Cryosurgical Ablation of Prostate Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the prostate clinical stage T1C POSTOPERATIVE DIAGNOSIS Carcinoma of the prostate clinical stage T1C TITLE OF OPERATION Cystoscopy cryosurgical ablation of the prostate FINDINGS After measurement of the prostate we decided to place 5 rows of needles row 1 had 3 needles row 2 at the level of the mid prostate had 4 needles row 3 had 2 needles in the right lateral peripheral zone row 4 was a single needle directly the urethra and in row 5 were 2 needles placed in the left lateral peripheral zone Because of the length of the prostate a pull back was performed pulling row 2 approximately 3 mm and rows 3 4 and 5 approximately 1 cm back before refreezing OPERATION IN DETAIL The patient was brought to the operating room and placed in the supine position After adequate general endotracheal anesthesia was obtained the patient was positioned in the dorsal lithotomy position Full bowel prep had been obtained prior to the procedure After performing flexible cystoscopy a Foley catheter was placed per urethra into the bladder Next the ultrasound probe was placed into the stabilizer and advanced into the rectum An excellent ultrasound image was visualized of the entire prostate which was re measured Next the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement Then 17 gauge needles were serially placed into the prostate from an anterior to posterior direction into the prostate Ultrasound guidance demonstrated that these needles numbering approximately 14 to 15 needles were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra Repeat cystoscopy demonstrated a single needle passing through the urethra and due to the high anterior location of this needle it was removed The CMS urethral warmer was then passed per urethra into the bladder and flow instituted After placing these 17 gauge needles the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature The urethral warmer was left on after the needles were removed and the patient brought to the recovery room The patient tolerated the procedure well and left the operating room in stable condition Keywords urology carcinoma of the prostate ablation cystoscopy cryosurgical ablation prostate ultrasound cryosurgical urethra MEDICAL_TRANSCRIPTION,Description Followup circumcision The patient had a pretty significant phimosis and his operative course was smooth Satisfactory course after circumcision for severe phimosis with no perioperative complications Medical Specialty Urology Sample Name Circumcision Followup Transcription REASON FOR VISIT Followup circumcision HISTORY OF PRESENT ILLNESS The patient had his circumcision performed on 09 16 2007 here at Children s Hospital The patient had a pretty significant phimosis and his operative course was smooth He did have a little bit of bleeding when he woke in recovery room which required placement of some additional sutures but after that his recovery has been complete His mom did note that she had to him a couple of days of oral analgesics but he seems to be back to normal and pain free now He is having no difficulty urinating and his bowel function remains normal PHYSICAL EXAMINATION Today The patient looks healthy and happy We examined his circumcision site His Monocryl sutures are still in place The healing is excellent and there is only a mild amount of residual postoperative swelling There was one area where he had some recurrent adhesions at the coronal sulcus and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed IMPRESSION Satisfactory course after circumcision for severe phimosis with no perioperative complications PLAN The patient came in followup for his routine care with Dr X but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound If that does occur we will be happy to see him back at any time Keywords urology circumcision adhesions followup circumcision sutures phimosis MEDICAL_TRANSCRIPTION,Description Right lower pole renal stone and possibly infected stent Cysto stent removal Medical Specialty Urology Sample Name Cysto Stent Removal Transcription PREOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent POSTOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent OPERATION Cysto stent removal ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid MEDICATIONS The patient was on vancomycin and Levaquin was given x1 dose The patient was on vancomycin for the last 5 days BRIEF HISTORY The patient is a 53 year old female who presented with Enterococcus urosepsis CT scan showed a lower pole stone with a stent in place The stent was placed about 2 months ago but when patient came in with a possibly UPJ stone with fevers of unknown etiology The patient had a stent placed at that time due to the fevers thinking that this was an urospetic stone There was some pus that came out The patient was cultured actually it was negative at that time The patient subsequently was found to have lower extremity DVT and then was started on Coumadin The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE The repeat films were taken which showed the stone had migrated into the pole The stent was intact The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin Cipro and Levaquin where treatment was little bit more complicated Due to drug interaction the patient was admitted for IV antibiotic treatment The thinking was that either the stone or the stent is infected since the stone is pretty small in size the stent is very likely possibility that it could have been infected and now it needs to be removed Since the stone is not obstructing there is no reason to replace the stent at this time We are unable to do the ureteroscopy or the shock wave lithotripsy when the patient is fully anticoagulated So the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin which would be probably about 4 months down the road Plan is to get rid of the stent and improve patient s urinary symptoms and to get rid of the infection and we will worry about the stone at later point DETAILS OF THE OR Consent had been obtained from the patient Risks benefits and options were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed The patient understood all the risks and benefits of removing the stent and wanted to proceed The patient was brought to the OR The patient was placed in dorsal lithotomy position The patient was given some IV pain meds The patient had received vancomycin and Levaquin preop Cystoscopy was performed using graspers The stent was removed without difficulty Plan was for repeat cultures and continuation of the IV antibiotics Keywords urology infected stent cysto stent removal cysto stent renal stone lower pole infected stone stent cysto MEDICAL_TRANSCRIPTION,Description Circumcision and release of ventral chordee Medical Specialty Urology Sample Name Circumcision Chordee Release Transcription PREOPERATIVE DIAGNOSES Phimosis and adhesions POSTOPERATIVE DIAGNOSES Phimosis and adhesions PROCEDURES PERFORMED Circumcision and release of ventral chordee ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid The patient was given antibiotics preop BRIEF HISTORY This is a 43 year old male who presented to us with significant phimosis difficulty retracting the foreskin The patient had buried penis with significant obesity issues in the suprapubic area Options such as watchful waiting continuation of slowly retracting the skin applying betamethasone cream and circumcision were discussed Risk of anesthesia bleeding infection pain MI DVT PE and CVA risks were discussed The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix Consent had been obtained Risk of scarring decrease in penile sensation and unexpected complications were discussed The patient was told about removing the dressing tomorrow morning okay to shower after 48 hours etc Consent was obtained DESCRIPTION OF PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in supine position The patient was prepped and draped in usual sterile fashion Local MAC anesthesia was applied After draping 17 mL of mixture of 0 25 Marcaine and 1 lidocaine plain were applied around the dorsal aspect of the penis for dorsal block The patient had significant phimosis and slight ventral chordee Using marking pen the excess foreskin was marked off Using a knife the ventral chordee was released The urethra was intact The excess foreskin was removed Hemostasis was obtained using electrocautery A 5 0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done The patient tolerated the procedure well There was excellent hemostasis The penis was straight Vaseline gauze and Kerlix were applied The patient was brought to the recovery in stable condition Plan was for removal of the dressing tomorrow Okay to shower after 48 hours Keywords urology phimosis adhesions release of ventral chordee ventral chordee circumcision penis chordee foreskin MEDICAL_TRANSCRIPTION,Description Normal penis The foreskin was normal in appearance and measured 1 6 cm There was no bleeding at the circumcision site Medical Specialty Urology Sample Name Circumcision 7 Transcription PROCEDURE Circumcision ANESTHESIA EMLA FINDINGS Normal penis The foreskin was normal in appearance and measured 1 6 cm There was no bleeding at the circumcision site PROCEDURE Patient was placed on the circumcision restraint board EMLA had been applied approximately 90 minutes before A time out was completed satisfactorily per protocol The area was prepped with Betadine The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection A Mogen clamp was applied to the cervix The excess foreskin was excised with the scalpel The clamp was removed At this point the procedure was terminated Sterile Vaseline and gauze was applied to the glans penis There were no complications There was minimal blood loss Keywords urology mogen clamp glans penis emla penis foreskin circumcision MEDICAL_TRANSCRIPTION,Description Circumcision procedure neotal Medical Specialty Urology Sample Name Circumcision 2 Transcription CIRCUMCISION NEONATAL PROCEDURE The procedure risks and benefits were explained to the patient s mom and a consent form was signed She is aware of the risk of bleeding infection meatal stenosis excess or too little foreskin removed and the possible need for revision in the future The infant was placed on the papoose board The external genitalia were prepped with Betadine A penile block was performed with a 30 gauge needle and 1 5 mL of Nesacaine without epinephrine Next the foreskin was clamped at the 12 o clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis The incision was made Next all the adhesions of the inner preputial skin were broken down The appropriate size bell was obtained and placed over the glans penis The Gomco clamp was then configured and the foreskin was pulled through the opening of the Gomco The bell was then placed and tightened down Prior to do this the penis was viewed circumferentially and there was no excess of skin gathered particularly in the area of the ventrum A blade was used to incise circumferentially around the bell The bell was removed There was no significant bleeding and a good cosmetic result was evident with the appropriate amount of skin removed Vaseline gauze was then placed The little boy was given back to his mom PLAN They have a new baby checkup in the near future with their primary care physician I will see them back on a p r n basis if there are any problems with the circumcision Keywords urology neonatal circumcision gomco gomco clamp external genitalia foreskin glans glans penis infant meatal stenosis penile block penis preputial skin circumferentially infection bell MEDICAL_TRANSCRIPTION,Description Circumcision procedure in a baby Medical Specialty Urology Sample Name Circumcision 3 Transcription CIRCUMCISION After informed consent was obtained the baby was placed on the circumcision tray He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion Then 0 2 mL of 1 lidocaine was injected at 10 and 2 o clock A ring block was also done using another 0 3 mL of lidocaine Glucose water is also used for anesthesia After several minutes the curved clamp was attached at 9 o clock with care being taken to avoid the meatus The blunt probe was then introduced again with care taken to avoid the meatus After initial adhesions were taken down the straight clamp was introduced to break down further adhesions Care was taken to avoid the frenulum The clamps where then repositioned at 12 and 6 o clock The Mogen clamp was then applied with a dorsal tilt After the clamp was applied for 1 minute the foreskin was trimmed After an additional minute the clamp was removed and the final adhesions were taken down Patient tolerated the procedure well with minimal bleeding noted Patient to remain for 20 minutes after procedure to insure no further bleeding is noted Routine care discussed with the family Need to clean the area with just water initially and later with soap and water or diaper wipes once healed Keywords urology circumcision 1 lidocaine betadine glucose water adhesions circumcision tray diaper wipes foreskin frenulum meatus straight clamp sterile fashion clampNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Circumcision in an older person Medical Specialty Urology Sample Name Circumcision 1 Transcription CIRCUMCISION OLDER PERSON OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating table General endotracheal anesthesia was administered The patient was prepped and draped in the usual sterile fashion A 4 0 silk suture is used as a stay stitch of the glans penis Next incision line was marked circumferentially on the outer skin 3 mm below the corona The incision was then carried through the skin and subcutaneous tissues down to within a layer of fascia Next the foreskin was retracted Another circumferential incision was made 3 mm proximal to the corona The intervening foreskin was excised Meticulous hemostasis was obtained with electrocautery Next the skin was reapproximated at the frenulum with a U stitch of 5 0 chromic followed by stitches at 12 3 and 9 o clock The stitches were placed equal distance among these to reapproximate all the skin edges Next good cosmetic result was noted with no bleeding at the end of the procedure Vaseline gauze Telfa and Elastoplast dressing was applied The stay stitch was removed and pressure held until bleeding stopped The patient tolerated the procedure well and was returned to the recovery room in stable condition Keywords urology circumcision elastoplast meticulous hemostasis telfa vaseline gauze circumferential incision corona cosmetic result endotracheal anesthesia foreskin glans penis hemostasis stay stitch circumferentially stitchNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Refractory priapism Cavernosaphenous shunt The patient presented with priapism x48 hours on this visit The patient underwent corporal aspiration and Winter s shunt both of which failed Medical Specialty Urology Sample Name Cavernosaphenous Shunt Priapism Transcription PREOPERATIVE DIAGNOSIS Refractory priapism POSTOPERATIVE DIAGNOSIS Refractory priapism PROCEDURE PERFORMED Cavernosaphenous shunt ANESTHESIA General ESTIMATED BLOOD LOSS 400 cc FLUIDS IV fluids 1600 crystalloids one liter packed red blood cells INDICATIONS FOR PROCEDURE This is a 34 year old African American male who is known to our service with a history of recurrent priapism The patient presented with priapism x48 hours on this visit The patient underwent corporal aspiration and Winter s shunt both of which failed and then subsequently underwent _______ procedure The patient s priapism did return following this and he was scheduled for cavernosaphenous shunt PROCEDURE Informed written consent was obtained The patient was taken to the operative suite and administered anesthetic The patient was sterilely prepped and draped in the supine fashion A 15 French Foley catheter was inserted under sterile conditions Incision was made in the left base of the penile shaft on the lateral aspect approximately 3 cm in length Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum The fascia was incised in elliptical fashion for approximately 2 cm A 14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted Attention was then turned to the left groin and the superficial saphenous vein was harvested Due to incisions brought up into the initial incision after gauging enough length this was then spatulated with Potts scissors for approximately 2 cm Vein was irrigated One branching vessel was noted to be leaking this was tied off and repeat injection with heparinized saline showed no additional leaks Tunnel was then created from the superior most groin region to the incision in the penile shaft Saphenous vein was then passed through this tunnel with the aid of a hemostat Anastomosis was performed using 5 0 Prolene suture in a running fashion from proximal to distal There were no leaks noted There was good flow noted within the saphenous vein graft Penis was noted to be in a flaccid state All incisions were irrigated copiously and closed in several layers Sterile dressings were applied The patient was cleaned transferred to recovery room in stable condition PLAN We will continue with antibiotics for pain control maintain Foley catheter Further recommendations to follow Keywords urology corporal aspiration winter s shunt foley catheter corpora cavernosum refractory priapism saphenous vein cavernosaphenous shunt corporal priapism aspiration MEDICAL_TRANSCRIPTION,Description The patient had spraying of urine and ballooning of the foreskin with voiding Medical Specialty Urology Sample Name Circumcision Transcription PREOPERATIVE DIAGNOSIS Phimosis POSTOPERATIVE DIAGNOSES Phimosis OPERATIONS Circumcision ANESTHESIA LMA EBL Minimal FLUIDS Crystalloid BRIEF HISTORY This is a 3 year old male who was referred to us from Dr X s office with phimosis The patient had spraying of urine and ballooning of the foreskin with voiding The urine seemed to have collected underneath the foreskin and then would slowly drip out Options such as dorsal slit circumcision watchful waiting by gently pulling the foreskin back were discussed Risk of anesthesia bleeding infection pain scarring and expected complications were discussed The patient s family understood all the complications and wanted to proceed with the procedure Consent was obtained using interpreter DESCRIPTION OF PROCEDURE The patient was brought to the OR and anesthesia was applied The patient was placed in supine position The patient was prepped and draped in usual sterile fashion All the penile adhesions were released prior to the prepping The extra foreskin was marked off 1 x 3 Gamco clamp was used Hemostasis was obtained after removing the extra foreskin using the Gamco clamp Using 5 0 Monocryl 4 quadrant stitches were placed and horizontal mattress suturing was done There was excellent hemostasis Dermabond was applied The patient was brought to recovery at the end of the procedure in stable condition Keywords urology ballooning of the foreskin spraying of urine gamco clamp spraying ballooning circumcision urine phimosis foreskin MEDICAL_TRANSCRIPTION,Description Brachytherapy iodine 125 seed implantation and cystoscopy Medical Specialty Urology Sample Name Brachytherapy Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATIONS Brachytherapy iodine 125 seed implantation and cystoscopy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal Total number of seeds placed 63 Needles 24 BRIEF HISTORY OF THE PATIENT This is a 57 year old male who was seen by us for elevated PSA The patient had a prostate biopsy with T2b disease Gleason 6 Options such as watchful waiting robotic prostatectomy seed implantation with and without radiation were discussed Risks of anesthesia bleeding infection pain MI DVT PE incontinence rectal dysfunction voiding issues burning pain unexpected complications such as fistula rectal injury urgency frequency bladder issues need for chronic Foley for six months etc were discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure The patient was told that there could be other unexpected complications The patient has history of urethral stricture The patient was told about the risk of worsening of the stricture with radiation Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR Anesthesia was applied The patient was placed in the dorsal lithotomy position The patient had SCDs on The patient was given preop antibiotics The patient had done bowel prep the day before Transrectal ultrasound was performed The prostate was measured at about 32 gm The images were transmitted to the computer system for radiation oncologist to determine the dosing etc Based on the computer analysis the grid was placed Careful attention was drawn to keep the grid away from the patient There was a centimeter distance between the skin and the grid Under ultrasound guidance the needles were placed first in the periphery of the prostate a total of 63 seeds were placed throughout the prostate A total of 24 needles was used Careful attention was drawn to stay away from the urethra Under longitudinal ultrasound guidance all the seeds were placed There were no seeds visualized in the bladder under ultrasound There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position Other than that all the seeds were very well distributed throughout the prostate under fluoroscopy Please note that the Foley catheter was in place throughout the procedure Prior to the seed placement the Foley was attempted to be placed but we had to do it using a Glidewire to get the Foley in and we used a Councill tip catheter The patient has had history of bulbar urethral stricture Pictures were taken of the strictures in the pre seed placement cysto time frame We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in At the end of the procedure again cystoscopy was done the entire bladder was visualized The stricture was wide open The prostate was slightly enlarged The bladder appeared normal There was no sheath inside the urethra or in the bladder The cysto was done using 30 degree and 70 degree lens At the end of the procedure a Glidewire was placed and 18 Councill tip catheter was placed The plan was for Foley to be left in place overnight since the patient has history of urethral strictures The patient is to follow up tomorrow to have the Foley removed The patient could also be shown to have it removed at home The patient was brought to Recovery in stable condition at the end of the procedure The patient tolerated the procedure well Keywords urology iodine 125 seed implantation seed implantation prostate cancer cystoscopy brachytherapy councill tip catheter brachytherapy iodine ultrasound catheter urethral prostate MEDICAL_TRANSCRIPTION,Description Normal Circumcision Medical Specialty Urology Sample Name Circumcision 4 Transcription The patient tolerated the procedure well and was sent to the Recovery Room in stable condition Keywords urology circumcision circumferential proximal incisions hemostasis vaseline soaked gauze catgut foreskin needlepoint bovie pain block shaft of the penis supine position penisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Release of ventral chordee circumcision and repair of partial duplication of urethral meatus Medical Specialty Urology Sample Name Circumcision 5 Transcription PROCEDURES 1 Release of ventral chordee 2 Circumcision 3 Repair of partial duplication of urethral meatus INDICATIONS The patient is an 11 month old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding He is here electively for surgical correction DESCRIPTION OF PROCEDURE The patient was brought back into operating room 35 After successful induction of general endotracheal anesthetic giving the patient preoperative antibiotics and after completing a preoperative time out the patient was prepped and draped in the usual sterile fashion A holding stitch was placed in the glans penis At this point we probed both urethral meatus Using the Crede maneuver we could see urine clearly coming out of the lower the more ventral meatus At this point we cannulated this with a 6 French hypospadias catheter We attempted to cannulate the dorsal opening however we were unsuccessful We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication At this point we identified the band connecting both the urethral meatus and incised it with tenotomy scissors We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans At this point we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee Once all the chordee had been adequately released we turned our attention to the circumcision Excessive dorsal foreskin was removed from the skin and glans Mucosal cuts were reapproximated with interrupted 5 0 chromic suture Dermabond was placed over this and bacitracin was placed on this once dry This ended the procedure DRAINS None ESTIMATED BLOOD LOSS Minimal URINE OUTPUT Unrecorded COMPLICATIONS None apparent DISPOSITION The patient will now go under the care of Dr XYZ Plastic Surgery for excision of scalp hemangioma Keywords urology release of ventral chordee repair of partial duplication partial duplication ventral chordee urethral meatus glans penis circumcision ventral chordee urethral meatus MEDICAL_TRANSCRIPTION,Description Circumcision A dorsal slit was made and the prepuce was dissected away from the glans penis Medical Specialty Urology Sample Name Circumcision 6 Transcription PROCEDURE Circumcision Signed informed consent was obtained and the procedure explained DETAILS OF PROCEDURE The child was placed in a Circumstraint board and restrained in the usual fashion The area of the penis and scrotum were prepared with povidone iodine solution The area was draped with sterile drapes and the remainder of the procedure was done with sterile procedure A dorsal penile block was done using 2 injections of 0 3 cc each 1 plain lidocaine A dorsal slit was made and the prepuce was dissected away from the glans penis A Gomco clamp was properly placed for 5 minutes During this time the foreskin was sharply excised using a 10 blade With removal of the clamp there was a good cosmetic outcome and no bleeding The child appeared to tolerate the procedure well Care instructions were given to the parents Keywords urology gomco clamp dorsal slit glans penis slit circumcision penisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Closure of bladder laceration during cesarean section Medical Specialty Urology Sample Name Bladder Laceration Closure Transcription PREOPERATIVE DIAGNOSES Bladder laceration POSTOPERATIVE DIAGNOSES Bladder laceration NAME OF OPERATION Closure of bladder laceration FINDINGS The patient was undergoing a cesarean section for twins During the course of the procedure a bladder laceration was notices and urology was consulted Findings were a laceration on the dome of the bladder PROCEDURE Initially there as a mucosal layer of suture already placed This was done with 3 0 chromic catgut The bladder was distended and while the bladder was distended with physiologic saline a second layer of 3 0 chromic catgut created a watertight closure The second layer included the mucosa an dinner layer of the detrusor muscle A third layer of 2 0 Dexon was used Each of these were placed in a continuous running locked suture technique There was complete watertight closure of the bladder Hemostasis was assured and a Jackson Pratt drain was brought out through a separate stab wound The remaining portion of the operation both the cesarean section and the wound closure will be dictated by Dr Redmond Keywords urology mucosal layer closure of bladder laceration watertight closure cesarean section bladder laceration bladder cesarean closure laceration MEDICAL_TRANSCRIPTION,Description Recurrent bladder tumor The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5 cm area of papillomatosis just above the left ureteric orifice Medical Specialty Urology Sample Name Bladder Tumor Transcription CHIEF COMPLAINT Recurrent bladder tumor HISTORY OF PRESENT ILLNESS The patient is a 79 year old woman the patient of Dr X who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5 cm area of papillomatosis just above the left ureteric orifice The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006 This was followed by bladder instillation of BCG At this time the patient denies any voiding symptoms or hematuria The patient opting for TUR and electrofulguration of the recurrent tumors ALLERGIES None known MEDICATIONS Atenolol 5 mg daily OPERATIONS Status post bilateral knee replacements and status post TUR of bladder tumors REVIEW OF SYSTEMS Other than some mild hypertension the patient is in very very good health No history of diabetes shortness of breath or chest pain PHYSICAL EXAMINATION Well developed and well nourished woman alert and oriented Her lungs are clear Heart regular sinus rhythm Back no CVA tenderness Abdomen soft and nontender No palpable masses IMPRESSION Recurrent bladder tumors PLAN The patient to have CBC chem 6 PT PTT EKG and chest x ray beforehand Keywords urology bladder neck voiding symptoms hematuria transitional cell carcinomas ureteric orifice bladder tumor bladder cystoscopy papillomatosis transitional carcinomas orifice MEDICAL_TRANSCRIPTION,Description Bladder instillation for chronic interstitial cystitis Medical Specialty Urology Sample Name Bladder Instillation Transcription CHIEF COMPLAINT The patient comes for bladder instillation for chronic interstitial cystitis SUBJECTIVE The patient is crying today when she arrives in the office saying that she has a lot of discomfort These bladder instillations do not seem to be helping her She feels anxious and worried She does not think she can take any more pain She is debating whether or not to go back to Dr XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this and she fears these bladder instillations because they do not seem to help They seem to be intensifying her pain She has the extra burden of each time she comes needing to have pain medication one way or another thus then we would not allow her to drive under the influence of the pain medicine So she has to have somebody come with her and that is kind of troublesome to her We discussed this at length I did suggest that it was completely appropriate for her to decide She will terminate these if they are that uncomfortable and do not seem to be giving her any relief although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality She had Hysterectomy in the past MEDICATIONS Premarin 1 25 mg daily Elmiron 100 mg t i d Elavil 50 mg at bedtime OxyContin 10 mg three tablets three times a day Toprol XL 25 mg daily ALLERGIES Compazine and Allegra OBJECTIVE Vital Signs Weight 140 pounds Blood pressure 132 90 Pulse 102 Respirations 18 Age 27 PLAN We discussed going for another evaluation by Dr XYZ and seeking his opinion She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete The instillations give that a full trial and then he would be willing to see her back As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today s instillation which she did choose to take then she would choose to cancel Friday s appointment also that she would not feel too badly over the holiday weekend I thought that was reasonable and agreed that that would work out PROCEDURE She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine We waited about 20 minutes The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10 minute wait the bladder was instilled with DMSO Kenalog heparin and sodium bicarbonate and the catheter was removed The patient retained the solution for one hour changing position every 15 minutes and then voided to empty the bladder She seemed to tolerate it moderately well She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it If not she will cancel and will start over next week or she will see Dr Friesen Keywords urology urethra dmso bladder chronic interstitial cystitis interstitial cystitis bladder instillation instillation instillations MEDICAL_TRANSCRIPTION,Description Cystoscopy bladder biopsies and fulguration Bladder lesions with history of previous transitional cell bladder carcinoma pathology pending Medical Specialty Urology Sample Name Bladder Biopsies Fulguration Transcription PREOPERATIVE DIAGNOSIS Bladder lesions with history of previous transitional cell bladder carcinoma POSTOPERATIVE DIAGNOSIS Bladder lesions with history of previous transitional cell bladder carcinoma pathology pending OPERATION PERFORMED Cystoscopy bladder biopsies and fulguration ANESTHESIA General INDICATION FOR OPERATION This is a 73 year old gentleman who was recently noted to have some erythematous somewhat raised bladder lesions in the bladder mucosa at cystoscopy He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months Recent cystoscopy raises suspicion of another recurrence OPERATIVE FINDINGS The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder Scarring was noted along the base of the bladder from the patient s previous cysto TURBT Ureteral orifice on the right side was not able to be identified The left side was unremarkable DESCRIPTION OF OPERATION The patient was taken to the operating room He was placed on the operating table General anesthesia was administered after which the patient was placed in the dorsal lithotomy position The genitalia and lower abdomen were prepared with Betadine and draped subsequently The urethra and bladder were inspected under video urology equipment 25 French panendoscope with the findings as noted above Cup biopsies were taken in two areas from the right lateral wall of the bladder the posterior wall of bladder and the bladder neck area Each of these biopsy sites were fulgurated with Bugbee electrodes Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear The patient s bladder was then emptied Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area There were no apparent complications and the patient appeared to tolerate the procedure well Estimated blood loss was less than 15 mL Keywords urology cystoscope carcinoma transitional cell bladder carcinoma bladder lesions bladder fulguration biopsies cystoscopy MEDICAL_TRANSCRIPTION,Description Austin Youngswick bunionectomy with Biopro implant Screw fixation left foot Medical Specialty Surgery Sample Name Youngswick Bunionectomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux rigidus left foot 2 Elevated first metatarsal left foot POSTOPERATIVE DIAGNOSES 1 Hallux rigidus left foot 2 Elevated first metatarsal left foot PROCEDURE PERFORMED 1 Austin Youngswick bunionectomy with Biopro implant 2 Screw fixation left foot HISTORY This 51 year old male presents to ABCD General Hospital with the above chief complaint The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time The patient desires surgical treatment PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 7 cc of 0 5 Marcaine plain was injected in a Mayo type block The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was then inflated to 250 mmHg The foot was lowered to the operating table the stockinet was reflected and the foot was cleansed with wet and dry sponge Attention was then directed to the left first metatarsophalangeal joint Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint just medial to the extensor hallucis longus tendon The incision was then deepened with a 15 blade All vessels encountered were ligated for hemostasis The skin and subcutaneous tissue was undermined medially off of the joint capsule A dorsal linear capsular incision was then made Care was taken to identify and preserve the extensor hallucis longus tendon The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx There was noted to be a significant degenerative joint disease There was little to no remaining healthy articular cartilage left on the head of the first metatarsal There was significant osteophytic formation medially dorsally and laterally in the first metatarsal head as well as at the base of the proximal phalanx A sagittal saw was then used to resect the base of the proximal phalanx Care was taken to ensure that the resection was parallel to the nail After the bone was removed in toto the area was inspected and the flexor tendon was noted to be intact The sagittal saw was then used to resect the osteophytic formation medially dorsally and laterally on the first metatarsal The first metatarsal was then re modelled and smoothed in a more rounded position with a reciprocating rasp The sizers were then inserted for the Biopro implant A large was noted to be of the best size There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx Following inspection the sagittal saw was used to clean both the medial and lateral sides of the base A small bar drill was then used to pre drill for the Biopro sizer The bone was noted to be significantly hardened The sizer was placed and a large Biopro was deemed to be the correct size implant The sizer was removed and bar drill was then again used to ream the medullary canal The hand reamer with a Biopro set was then used to complete the process The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit There was noted to be distally increased range of motion after insertion of the implant Attention was then directed to the first metatarsal A long dorsal arm Austin osteotomy was then created A second osteotomy was then created just plantar and parallel to the first osteotomy site The wedge was then removed in toto The area was feathered to ensure high compression of the osteotomy site The head was noted to be in a more plantar flexed position The capital fragment was then temporarily fixated with two 0 45 K wires A 2 7 x 16 mm screw was then inserted in the standard AO fashion A second more proximal 2 7 x 60 mm screw was also inserted in a standard AO fashion With both screws there was noted to be tight compression at the osteotomy sites The K wires were removed and the areas were then smoothed with reciprocating rash A screw driver was then used to check and ensure screw tightness The area was then flushed with copious amounts of sterile saline Subchondral drilling was performed with a 1 5 drill bit The area was then flushed with copious amounts of sterile saline Closure consisted of capsular closure with 3 0 Vicryl followed by subcutaneous closure with 4 0 Vicryl followed by running subcuticular stitch of 5 0 Vicryl Dressings consisted of Steri Strips Owen silk 4x4s Kling Kerlix and Coban A total of 10 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain was injected intraoperatively for further anesthesia The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well The patient was transported to PACU with vital signs stable and vascular status intact to the right foot The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q 4 6h p o p r n pain The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema The patient is to follow up with Dr X in his office as directed Keywords surgery hallux rigidus metatarsal youngswick bunionectomy screw fixation ankle tourniquet metatarsophalangeal joint biopro implant proximal phalanx foot austin anesthesia osteotomy screw MEDICAL_TRANSCRIPTION,Description Patient with a history of gross hematuria CT scan was performed which demonstrated no hydronephrosis or upper tract process however there was significant thickening of the left and posterior bladder wall Medical Specialty Urology Sample Name Bladder Cancer Transcription CHIEF COMPLAINT Bladder cancer HISTORY OF PRESENT ILLNESS The patient is a 68 year old Caucasian male with a history of gross hematuria The patient presented to the emergency room near his hometown on 12 24 2007 for evaluation of this gross hematuria CT scan was performed which demonstrated no hydronephrosis or upper tract process however there was significant thickening of the left and posterior bladder wall Urology referral was initiated and the patient was sent to be evaluated by Dr X He eventually underwent a bladder biopsy on 01 18 08 which demonstrated high grade transitional cell carcinoma without any muscularis propria in the specimen Additionally the patient underwent workup for a right adrenal lesion which was noted on the initial CT scan This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement All of this workup was found to be grossly negative Secondary to the absence of muscle in the specimen the patient was taken back to the operating room on 02 27 08 by Dr X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck At that time the referring urologist determined the tumor to be too large and risky for local resection and the patient was referred to ABCD Urology for management and diagnosis The patient presents today for evaluation by Dr Y PAST MEDICAL HISTORY Includes condyloma hypertension diabetes mellitus hyperlipidemia undiagnosed COPD peripheral vascular disease and claudication The patient denies coronary artery disease PAST SURGICAL HISTORY Includes bladder biopsy on 01 18 08 without muscularis propria in the high grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2 The patient denies any bowel resection or GU injury at that time however he is unsure CURRENT MEDICATIONS 1 Metoprolol 100 mg b i d 2 Diltiazem 120 mg daily 3 Hydrocodone 10 500 mg p r n 4 Pravastatin 40 mg daily 5 Lisinopril 20 mg daily 6 Hydrochlorothiazide 25 mg daily FAMILY HISTORY Negative for any GU cancer stones or other complaints The patient states he has one uncle who died of lung cancer He denies any other family history SOCIAL HISTORY The patient smokes approximately 2 packs per day times greater than 40 years He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month He denies any drug use He is a retired liquor store owner PHYSICAL EXAMINATION GENERAL He is a well developed well nourished Caucasian male who appears slightly older than stated age VITAL SIGNS Temperature is 96 7 blood pressure is 108 57 pulse is 75 and weight of 193 8 pounds HEAD AND NECK Normocephalic atraumatic LUNGS Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung which is clear somewhat with cough HEART Regular rate and rhythm ABDOMEN Soft and nontender The liver and spleen are not palpably enlarged There is a large midline defect covered by skin of which the fascia has numerous holes poking through These small hernias are of approximately 2 cm in diameter at the largest and are nontender GU The penis is circumcised and there are no lesions plaques masses or deformities There is some tenderness to palpation near the meatus where 20 French Foley catheter is in place Testes are bilaterally descended and there are no masses or tenderness There is bilateral mild atrophy Epididymidis are grossly within normal limits bilaterally Spermatic cords are grossly within normal limits There are no palpable inguinal hernias RECTAL The prostate is mildly enlarged with a small focal firm area in the midline near the apex There is however no other focal nodules The prostate is grossly approximately 35 to 40 g and is globally firm Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault EXTREMITIES Demonstrate no cyanosis clubbing or edema There is dark red urine in the Foley bag collection LABORATORY EXAM Review of laboratory from outside facility demonstrates creatinine of 2 38 with BUN of 42 Additionally laboratory exam demonstrates a grossly normal serum cortisol ACTH potassium aldosterone level during lesion workup CT scan was reviewed from outside facility report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam There is a 3 1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted IMPRESSION Bladder cancer PLAN The patient will undergo a completion TURBT on 03 20 08 with bilateral retrograde pyelograms at the time of surgery Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr Y The patient will be scheduled for anesthesia preop The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging The patient understands these instructions and also agrees to quit smoking prior to his next visit This patient was seen in evaluation with Dr Y who agrees with the impression and plan Keywords urology retrograde pyelogram bladder biopsy muscularis propria bladder cancer gross hematuria bladder wall ct scan bladder hematuria MEDICAL_TRANSCRIPTION,Description Bilateral vasovasostomy surgery sample Medical Specialty Urology Sample Name Bilateral Vasovasostomy Transcription Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens This incision was carried down to the area of the previous vasectomy A towel clip was placed around this Next the scarred area was dissected free back to normal vas proximally and distally Approximately 4 cm of vas was freed up Next the vas was amputated above and below the scar tissue Fine hemostats were used to grasp the adventitial tissue on each side of the vas both the proximal and distal ends Both ends were then dilated very carefully with lacrimal duct probes up to a 2 successfully After accomplishing this fluid could be milked from the proximal vas which was encouraging Next the reanastomosis was performed Three 7 0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen This was all done with 3 5 loupe magnification Next the vas ends were pulled together by tying the sutures A good reapproximation was noted Next in between each of these sutures two to three of the 7 0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid tight There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum The subcuticular layers were closed with a running 3 0 chromic and the skin was closed with three interrupted 3 0 chromic sutures Next an identical procedure was done on the left side The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition Antibiotic ointment fluffs and a scrotal support were placed Keywords urology vasovasostomy adventitial tissue anastomosis fluffs hemiscrotum loupe magnification lumen muscle layer scrotal support subcuticular vas deferens vas ends bilateral vasovasostomy chromic suturesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description This patient has undergone cataract surgery and vision is reduced in the operated eye due to presence of a secondary capsular membrane The patient is being brought in for YAG capsular discission Medical Specialty Surgery Sample Name YAG Laser Capsulotomy 1 Transcription PREOPERATIVE DIAGNOSIS Secondary capsular membrane right eye POSTOPERATIVE DIAGNOSIS Secondary capsular membrane right eye PROCEDURE PERFORMED YAG laser capsulotomy right eye INDICATIONS This patient has undergone cataract surgery and vision is reduced in the operated eye due to presence of a secondary capsular membrane The patient is being brought in for YAG capsular discission PROCEDURE The patient was seated at the YAG laser the pupil having been dilated with 1 Mydriacyl and Iopidine was instilled The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied A total of Keywords surgery abraham capsulotomy yag yag laser capsulotomy capsulotomy laser membrane eye capsular MEDICAL_TRANSCRIPTION,Description Cystoscopy cystocele repair BioArc midurethral sling Medical Specialty Urology Sample Name BioArc Midurethral Sling Transcription PREOPERATIVE DIAGNOSIS Stress urinary incontinence intrinsic sphincter deficiency POSTOPERATIVE DIAGNOSES Stress urinary incontinence intrinsic sphincter deficiency OPERATIONS Cystoscopy cystocele repair BioArc midurethral sling ANESTHESIA Spinal EBL Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 69 year old female with a history of hysterectomy complained of urgency frequency and stress urinary incontinence The patient had urodynamics done and a cystoscopy which revealed intrinsic sphincter deficiency Options such as watchful waiting Kegel exercises broad based sling to help with ISD versus Coaptite bulking agents were discussed Risks and benefits of all the procedures were discussed The patient understood and wanted to proceed with BioArc Risk of failure of the procedure recurrence of incontinence due to urgency mesh erosion exposure etc were discussed Risk of MI DVT PE and bleeding etc were discussed The patient understood the risk of infection and wanted to proceed with the procedure The patient was told that due to the intrinsic sphincter deficiency we will try to make the sling little bit tighter to allow better urethral closure which may put her a high risk of retention versus if we make it too loose then she may leak afterwards The patient understood and wanted to proceed with the procedure DETAILS OF THE OPERATION The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A Foley catheter was placed Bladder was emptied Two Allis clamps were placed on the anterior vaginal mucosa Lidocaine 1 with epinephrine was applied and hydrodissection was done Incision was made A bladder was lifted off of the vaginal mucosa The bladder cystocele was reduced Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal Using BioArc needle the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed The mesh was right at the bladder neck to the mid urethra completely covering over the entire urethra The sling was kept little tight even though the right angle was easily placed between the urethra and the BioArc material The urethra was coapted very nicely At the end of the procedure cystoscopy was done and there was no injury to the bladder There was good efflux of urine with indigo carmine coming through from both the ureteral openings The urethra was normal seemed to have closed up very nicely with the repair The vaginal mucosa was closed using 0 Vicryl in interrupted fashion The lateral thigh incisions were closed using Dermabond Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement The mesh was placed in antibiotic solution prior to the placement in the body The patient tolerated the procedure well After closure Premarin cream was applied The patient was told to use Premarin cream postop The patient was brought to Recovery in stable condition The patient was told not to do any heavy lifting pushing pulling and no tub bath etc for at least 2 months The patient understood The patient was to follow up as an outpatient Keywords urology cystoscopy cystocele repair bioarc midurethral sling sphincter urinary incontinence stress urinary incontinence intrinsic sphincter deficiency intrinsic sphincter sphincter deficiency incontinence mesh urethral bioarc MEDICAL_TRANSCRIPTION,Description Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot Medical Specialty Surgery Sample Name Youngswick Osteotomy Transcription TITLE OF OPERATION Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot PREOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot POSTOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot ANESTHESIA Monitored anesthesia care with 15 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain ESTIMATED BLOOD LOSS Less than 10 mL HEMOSTASIS Right ankle tourniquet set at 250 mmHg for 35 minutes MATERIALS USED 3 0 Vicryl 4 0 Vicryl and two partially threaded cannulated screws from 3 0 OsteoMed System for internal fixation INJECTABLES Ancef 1 g IV 30 minutes preoperatively DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s right foot to anesthetize the future surgical site The right ankle was then covered with cast padding and an 18 inch ankle tourniquet was placed around the right ankle and set at 250 mmHg The right ankle tourniquet was then inflated The right foot was prepped scrubbed and draped in normal sterile technique Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6 cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe The incision was deepened through the subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed multiple osteophytes were encountered Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint which were consistent with a medical history that is positive for gout for this patient Using sharp and dull dissection all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions Using the sagittal saw all the osteophytes were removed from the dorsal medial and lateral aspect of the first right metatarsal head as well as the dorsal medial and lateral aspect of the base of the proximal phalanx of the right great toe Although some improvement of the range of motion was encountered after the removal of the osteophytes some tightness and restriction was still present The decision was thus made to perform a Youngswick type osteotomy on the head of the first right metatarsal The osteotomy consistent of two dorsal cuts and a plantar cut in a V pattern with the apex of the osteotomy distal and the base of the osteotomy proximal The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy The wires were also used as guidewires for the insertion of two 16 mm proximally threaded cannulated screws from the OsteoMed System The 2 screws were inserted using AO technique Upon insertion of the screws the two wires were removed Fixation of the osteotomy on the table was found to be excellent The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation The capsule and periosteal tissues were then reapproximated with 3 0 Vicryl suture material 4 0 Vicryl was used to approximate the subcutaneous tissues Steri Strips were used to approximate and reinforce the skin edges At this time the right ankle tourniquet was deflated Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff The patient s surgical site was then covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels The patient was given instructions and education on how to continue caring for her right foot surgery at home The patient was also given pain medication instructions on how to control her postoperative pain The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for her first postoperative appointment Keywords surgery hallux limitus deformity metatarsophalangeal joint plantar cut youngswick osteotomy dorsal cuts ankle tourniquet proximal phalanx anesthesia tourniquet youngswick phalanx metatarsophalangeal proximal metatarsal dorsal osteotomy MEDICAL_TRANSCRIPTION,Description Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair Patient with a 5 5 cm diameter nonfunctioning mass in his right adrenal Medical Specialty Urology Sample Name Adrenalectomy Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia POSTOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia OPERATION PERFORMED Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair ANESTHESIA General CLINICAL NOTE This is a 52 year old inmate with a 5 5 cm diameter nonfunctioning mass in his right adrenal Procedure was explained including risks of infection bleeding possibility of transfusion possibility of further treatments being required Alternative of fully laparoscopic are open surgery or watching the lesion DESCRIPTION OF OPERATION In the right flank up position table was flexed He had a Foley catheter in place Incision was made from just above the umbilicus about 5 5 cm in diameter The umbilical hernia was taken down An 11 mm trocar was placed in the midline superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin A liver retractor was placed to this The colon was reflected medially by incising the white line of Toldt The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly The vena cava was identified The main renal vein was identified Coming superior to the main renal vein staying right on the vena cava all small vessels were clipped and then divided Coming along the superior pole of the kidney the tumor was dissected free from top of the kidney with clips and Bovie The harmonic scalpel was utilized superiorly and laterally Posterior attachments were divided between clips and once the whole adrenal was mobilized the adrenal vein and one large adrenal artery were noted doubly clipped and divided Specimen was placed in a collection bag removed intact Hemostasis was excellent The umbilical hernia had been completely taken down The edges were freshened up Vicryl 1 was utilized to close the incision and 2 0 Vicryl was used to close the fascia of the trocar Skin closed with clips He tolerated the procedure well All sponge and instrument counts were correct Estimated blood loss less than 100 mL The patient was awakened extubated and returned to recovery room in satisfactory condition Keywords urology adrenalectomy laparoscopic hand assisted umbilical hernia repair vena cava renal vein hernia repair laparoscopic umbilical hernia MEDICAL_TRANSCRIPTION,Description Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue secondary closure of wound and VAC insertion Medical Specialty Surgery Sample Name Wound Debridement Transcription PREOPERATIVE DIAGNOSES 1 Open wound from right axilla to abdomen with a prosthetic vascular graft possibly infected 2 Diabetes 3 Peripheral vascular disease POSTOPERATIVE DIAGNOSES 1 Open wound from right axilla to abdomen with a prosthetic vascular graft possibly infected 2 Diabetes 3 Peripheral vascular disease OPERATIONS 1 Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue 2 Secondary closure of wound complicated 3 VAC insertion DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was brought to the operating room where a general anesthetic was given A time out process was followed All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion The xenograft was not adhered at all and was easily removed There was some what appeared to be a seropurulent exudate at the bottom of the incision This was towards the abdominal end under the xenograft The graft was fully exposed and it was pulsatile We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft A few areas of necrotic skin and subcutaneous tissue were debrided Prior to this samples were taken for aerobic and anaerobic cultures Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it There was a separate incision which was bridged __________ to the incision of the abdomen which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound Prior to that I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge Multiple layers were applied to seal the system which was suctioned and appeared to be working satisfactorily The patient tolerated the procedure well and was sent to the ICU for recovery Keywords surgery open wound prosthetic vascular graft closure of wound surgisis peripheral vascular disease wound debridement subcutaneous tissue vac insertion wound betadine debridement xenograft insertion MEDICAL_TRANSCRIPTION,Description Visually significant posterior capsule opacity right eye YAG laser posterior capsulotomy right eye Medical Specialty Surgery Sample Name YAG Laser Capsulotomy Transcription PREOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye POSTOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye OPERATIVE PROCEDURES YAG laser posterior capsulotomy right eye ANESTHESIA Topical anesthesia using tetracaine ophthalmic drops INDICATIONS FOR SURGERY This patient was found to have a visually significant posterior capsule opacity in the right eye The patient has had a mild decrease in visual acuity which has been a gradual change The posterior capsule opacity was felt to be related to the decline in vision The risks benefits and alternatives including observation were discussed I feel the patient had a good understanding of the proposed procedure and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified Pupil was dilated per protocol Patient was positioned at the YAG laser Then of energy were used to perform a circular posterior laser capsulotomy through the visual axis A total of shots were used Total energy was The patient tolerated the procedure well and there were no complications The lens remained well centered and stable Postoperative instructions were provided Alphagan P ophthalmic drops times two were instilled prior to his dismissal Post laser intraocular pressure measured mmHg Postoperative instructions were provided and the patient had no further questions Keywords surgery capsule opacity yag ophthalmic yag laser posterior capsulotomy capsulotomy opacity laser visually eye anesthesia MEDICAL_TRANSCRIPTION,Description A complex closure and debridement of wound The patient is a 26 year old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant just below the costal margin that was lanced by General Surgery and resolved however it continued to drain Medical Specialty Surgery Sample Name Wound Closure Debridement Hydrocephalus Transcription TITLE OF OPERATION A complex closure and debridement of wound INDICATION FOR SURGERY The patient is a 26 year old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant just below the costal margin that was lanced by General Surgery and resolved however it continued to drain There is no evidence of fevers CRP was normal Shunt CT were all normal The thought was he has insidious fistula versus tract where recommendation was for excision of this tract PREOP DIAGNOSIS Possible cerebrospinal fluid versus wound fistula POSTOP DIAGNOSIS Possible cerebrospinal fluid versus wound fistula PROCEDURE DETAIL The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway positioned supine and the right side was prepped and draped in the usual sterile fashion Next working on the fistula this was elliptically excised Once this was excised this was followed down to the fistulous tract which was completely removed There was no CSF drainage The catheter was visualized although not adequately properly Once this was excised it was irrigated and then closed in multiple layers using 3 0 Vicryl for the deep layers and 4 0 Caprosyn and Indermil with a dry sterile dressing applied The patient was reversed extubated and transferred to the recovery room in stable condition Multiple cultures were sent as well as the tracts sent to Pathology All sponge and needle counts were correct Keywords surgery debridement of wound shunt costal margin cerebrospinal fluid cerebrospinal closure debridement hydrocephalus draining fistula wound MEDICAL_TRANSCRIPTION,Description Excision of dorsal wrist ganglion Made a transverse incision directly over the ganglion Dissection was carried down through the extensor retinaculum identifying the 3rd and the 4th compartments and retracting them Medical Specialty Surgery Sample Name Wrist Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Wrist ganglion POSTOPERATIVE DIAGNOSIS Wrist ganglion TITLE OF PROCEDURE Excision of dorsal wrist ganglion PROCEDURE After administering appropriate antibiotics and general anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg I made a transverse incision directly over the ganglion Dissection was carried down through the extensor retinaculum identifying the 3rd and the 4th compartments and retracting them I then excised the ganglion and its stalk In addition approximately a square centimeter of the dorsal capsule was removed at the origin of stalk leaving enough of a defect to prevent formation of a one way valve We then identified the scapholunate ligament which was uninjured I irrigated and closed in layers and injected Marcaine with epinephrine I dressed and splinted the wound The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery origin of stalk extensor retinaculum wrist ganglion incision excision dorsal tourniquet wrist ganglion MEDICAL_TRANSCRIPTION,Description Placement of right new ventriculoperitoneal VP shunts Strata valve and to removal of right frontal Ommaya reservoir Medical Specialty Surgery Sample Name VP Shunt Placement Transcription TITLE OF OPERATION Placement of right new ventriculoperitoneal VP shunts Strata valve and to removal of right frontal Ommaya reservoir INDICATION FOR SURGERY The patient is a 2 month old infant born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt PREOP DIAGNOSIS Hydrocephalus POSTOP DIAGNOSIS Hydrocephalus PROCEDURE DETAIL The patient was brought to the operating room underwent induction of general endotracheal airway positioned supine head turned towards left The right side prepped and draped in the usual sterile fashion Next using a 15 blade scalpel two incisions were made one in the parietooccipital region and The second just lateral to the umbilicus Once this was clear the Bactiseal catheter was then tunneled This was connected to a Strata valve The Strata valve was programmed to a setting of 1 01 and this was ensured The small burr hole was then created The area was then coagulated Once this was completed new Bactiseal catheter was then inserted It was connected to the Strata valve There was good distal flow The distal end was then inserted into the peritoneal region via trocar Once this was insured all the wounds were irrigated copiously and closed with 3 0 Vicryl and 4 0 Caprosyn as well as Indermil glue The right frontal incision was then opened The Ommaya reservoir identified and removed The wound was then also closed with an inverted 3 0 Vicryl and 4 0 Caprosyn Once all the wounds were completed dry sterile dressings were applied The patient was then transported back to the ICU in stable condition intubated Blood loss minimal All sponge and needle counts were correct Keywords surgery ommaya reservoir frontal strata valve intraventricular hemorrhage vp shunt ventriculoperitoneal hydrocephalus MEDICAL_TRANSCRIPTION,Description Vitrectomy under local anesthesia Medical Specialty Surgery Sample Name Vitrectomy Local Anesthesia Transcription DESCRIPTION OF PROCEDURE After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table After intravenous sedation was administered a retrobulbar block consisting of 2 Xylocaine with 0 75 Marcaine and Wydase was administered to the right eye without difficulty The patient s right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants A lens ring was secured to the eye using 7 0 Vicryl suture Keywords surgery lid speculum conjunctival peritomy vitrectomy operating superonasally anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Vitrectomy under general anesthesia Medical Specialty Surgery Sample Name Vitrectomy General Anesthesia Transcription DESCRIPTION OF PROCEDURE After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty The patient s right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants A lens ring was secured to the eye using 7 0 Vicryl suture Keywords surgery ophthalmic fashion vitrectomy operating superonasally anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Vitrectomy opening A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Medical Specialty Surgery Sample Name Vitrectomy Opening Transcription VITRECTOMY OPENING The patient was brought to the operating room and appropriately identified General anesthesia was induced by the anesthesiologist The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Hemostasis was maintained with wet field cautery Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant A 5 0 nylon suture was passed through partial thickness sclera on either side of this mark The MVR blade was used to make a sclerotomy between the preplaced sutures An 8 0 nylon suture was then preplaced for a later sclerotomy closure The infusion cannula was inspected and found to be in good working order The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants Keywords surgery westcott scissors inferotemporal quadrants conjunctival peritomy sclerotomy vitrectomy supranasal supratemporal cannula inferotemporalNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Pars plana vitrectomy membrane peel 23 gauge right eye Medical Specialty Surgery Sample Name Vitrectomy 2 Transcription PREOPERATIVE DIAGNOSES Epiretinal membrane right eye CME right eye POSTOPERATIVE DIAGNOSES Epiretinal membrane right eye CME right eye PROCEDURES Pars plana vitrectomy membrane peel 23 gauge right eye PREOPERATIVE FINDINGS The patient had epiretinal membrane causing cystoid macular edema Options were discussed with the patient stressing that the visual outcome was guarded Especially since this membrane was of chronic duration there is no guarantee of visual outcome DESCRIPTION OF PROCEDURE The patient was wheeled to the OR table Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified Preparation was made for 23 gauge vitrectomy using the trocar inferotemporal cannula was placed 3 5 mm from the limbus and verified The fluid was run Then superior sclerotomies were created using the trocars and 3 5 mm from the limbus at 10 o clock and 2 o clock Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps ILM forceps the membrane was peeled off in its entirety There were no complications DVT precautions were in place I as attending was present in the entire case Keywords surgery epiretinal membrane pars plana vitrectomy membrane peel macular edema cystoid eye retrobulbar epiretinal vitrectomy membrane MEDICAL_TRANSCRIPTION,Description Unilateral transpedicular T11 vertebroplasty Medical Specialty Surgery Sample Name Vertebroplasty Transcription PREOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain POSTOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain OPERATION PERFORMED Unilateral transpedicular T11 vertebroplasty ANESTHESIA Local with IV sedation COMPLICATIONS None SUMMARY The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion The patient was given sedation and monitored Using AP and lateral fluoroscopic projections the T11 compression fracture was identified Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o clock position of the lateral aspect of the T11 pedicle on the left The 13 gauge needle and trocar were then taken and placed to 10 o clock position on the pedicle At this point using AP and lateral fluoroscopic views the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times Once the vertebral body was entered then using lateral fluoroscopic views the needle was advanced to the junction of the anterior one third and posterior two thirds of the body At this point polymethylmethacrylate was mixed for 60 seconds Once the consistency had hardened and the __________ was gone incremental dose of the cement were injected into the vertebral body It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra A total 1 2 cc of cement was injected On lateral view the cement crushed to the right side as well There was some dye infiltration into the disk space There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal At this point as the needle was slowly withdrawn under lateral fluoroscopic images visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space Once the needle was withdrawn safely pressure was held over the site for three minutes There were no complications The patient was taken back to the recovery area in stable condition and kept flat for one hour Should be followed up the next morning Keywords surgery transpedicular vertebroplasty fluoroscopic views fluoroscopic images epidural space compression fracture vertebral body compression pedicle fluoroscopic vertebral needle MEDICAL_TRANSCRIPTION,Description Insertion of a VVIR permanent pacemaker This is an 87 year old Caucasian female with critical aortic stenosis with an aortic valve area of 0 5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias Medical Specialty Surgery Sample Name VVIR Permanent Pacemaker Insertion Transcription PROCEDURE PERFORMED Insertion of a VVIR permanent pacemaker COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal SITE Left subclavian vein access INDICATION This is an 87 year old Caucasian female with critical aortic stenosis with an aortic valve area of 0 5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore this is indicated so that we can give better control of heart rate and to maintain beta blocker therapy in the order of treatment It is overall a Class II indication for permanent pacemaker insertion PROCEDURE The risks benefits and alternative of the procedure were all discussed with the patient and the patient s family in detail at great length Overall options and precautions of the pacemaker and indications were all discussed They agreed to the pacemaker The consent was signed and placed in the chart The patient was taken to the Cardiac Catheterization Lab where she was monitored throughout the whole procedure The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion Myself and Dr Wildes spoke for approximately 8 minutes before insertion for the procedure Using a lidocaine with epinephrine the area of the left subclavian vein and left pectodeltoid region was anesthetized locally IV sedation increments and analgesics were given Using a 18 gauge needle the left subclavian vein access was cannulated without difficulty A guidewire was then passed through the Cook needle and the Cook needle was then removed The wire was secured in place with the hemostat Using a 10 and 15 scalpel blade a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia The skin was then undermined used to make a pocket for the pacemaker The guidewire was then tunneled through the pacer pocket Cordis sheath was then inserted through the guidewire The guidewire and dilator were removed ___ cordis sheath was in placed within This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy It was placed into the apex Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained the lead was then sutured in place with 1 0 silk suture to the pectoris major muscle The lead was then connected on pulse generator The pocket was then irrigated and cleansed Pulse generator and the wire was then inserted into the ____ pocket The skin was then closed with gut suture The skin was then closed with 4 0 Poly___ sutures using a subcuticular uninterrupted technique The area was then cleansed and dried Steri Strips and pressure dressing was then applied The patient tolerated the procedure well there was no complications These are the settings on the pacemaker IMPLANT DEVICE Pulse Generator Model Name Sigma model 12345 serial 123456 VENTRICLE LEAD Model 12345 the ventricular lead serial 123456 Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex BRADY PARAMETER SETTINGS ARE AS FOLLOWS Amplitude was set at 3 5 volts with a pulse of 0 4 sensitivity of 2 8 The pacing mode was set at VVIR lower rate of 60 and upper rate of 120 STIMULATION THRESHOLDS The right ventricular lead and bipolar threshold voltage is 0 6 volts 1 milliapms current 600 Ohms resistance R wave sensing 11 millivolts The patient tolerated the procedure well There was no complications The patient went to recovery in stable condition Chest x ray will be ordered She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia Thank you for allowing me to participate in her care If you have any questions or concerns please feel free to contact Keywords surgery aortic stenosis vvir permanent pacemaker permanent pacemaker insertion congestive heart failure tachybrady arrhythmias subclavian vein cordis sheath ventricular lead pulse generator permanent pacemaker insertion ventricle vvir ventricular permanent pacemaker leads MEDICAL_TRANSCRIPTION,Description Vitrectomy A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Medical Specialty Surgery Sample Name Vitrectomy 3 Transcription DESCRIPTION OF OPERATION The patient was brought to the operating room and appropriately identified Local anesthesia was obtained with a 50 50 mixture of 2 lidocaine and 0 75 bupivacaine given as a peribulbar block The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Calipers were set at 3 5 mm and a mark was made 3 5 mm posterior to the limbus in the inferotemporal quadrant A 5 0 nylon suture was passed through partial thickness sclera on either side of this mark The MVR blade was used to make a sclerotomy between the pre placed sutures An 8 0 nylon suture was then pre placed for later sclerotomy closure The infusion cannula was inspected and found to be in good working order The infusion cannula was placed in the vitreous cavity and secured with the pre placed sutures The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on Additional sclerotomies were made 3 5 mm posterior to the limbus in the supranasal and supratemporal quadrants The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed There was moderately severe vitreous hemorrhage which was removed Once a view of the posterior pole could be obtained there were some diabetic membranes emanating along the arcades These were dissected with curved scissors and judicious use of the vitrectomy cutter There was some bleeding from the inferotemporal frond This was managed by raising the intraocular pressure and using intraocular cautery The surgical view became cloudy and the corneal epithelium was removed with a beaver blade This improved the view There is an area suspicious for retinal break near where the severe traction was inferotemporally The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears holes or dialyses were seen There was some residual hemorrhagic vitreous skirt seen The soft tip cannula was then used to perform an air fluid exchange Additional laser was placed around the suspicious area inferotemporally The sclerotomies were then closed with 8 0 nylon suture in an X fashion the infusion cannula was removed and it sclerotomy closed with the pre existing 8 0 nylon suture The conjunctiva was closed with 6 0 plain gut A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye The lid speculum was removed Maxitrol ointment was instilled over the eye and the eye was patched The patient was brought to the recovery room in stable condition Keywords surgery conjunctival peritomy westcott scissors lid speculum inferotemporal quadrants inferotemporal conjunctival scissors supranasal supratemporal sclerotomy eye vitreous vitrectomy infusion cannulaNOTE MEDICAL_TRANSCRIPTION,Description Combined closed vitrectomy with membrane peeling fluid air exchange and endolaser right eye Medical Specialty Surgery Sample Name Vitrectomy 1 Transcription PREOPERATIVE DIAGNOSIS Vitreous hemorrhage and retinal detachment right eye POSTOPERATIVE DIAGNOSIS Vitreous hemorrhage and retinal detachment right eye NAME OF PROCEDURE Combined closed vitrectomy with membrane peeling fluid air exchange and endolaser right eye ANESTHESIA Local with standby PROCEDURE The patient was brought to the operating room and an equal mixture of Marcaine 0 5 and lidocaine 2 was injected in a retrobulbar fashion As soon as satisfactory anesthesia and akinesia had been achieved the patient was prepped and draped in the usual manner for sterile ophthalmic surgery A wire lid speculum was inserted Three modified sclerotomies were selected at 9 10 and 1 o clock At the 9 o clock position the Accurus infusion line was put in place and tied with a preplaced 7 0 Vicryl suture The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position and closed vitrectomy was begun Initially formed core vitrectomy was performed and formed anterior vitreous was removed After this was completed attention was placed in the posterior segment Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata After all the vitreous had been removed and the membranes released the retina was completely mobilized Total fluid air exchange was carried out with complete settling of the retina Endolaser was applied around the margins of the retinal tears and altogether several 100 applications were placed in the periphery Good reaction was achieved The eye was inspected with an indirect ophthalmoscope The retina was noted to be completely attached The instruments were removed from the eye The sclerotomy sites were closed with 7 0 Vicryl suture The infusion line was removed from the eye and tied with a 7 0 Vicryl suture The conjunctivae and Tenon s were closed with 6 0 plain gut suture A collagen shield soaked with Tobrex placed over the surface of the globe and a pressure bandage was put in place The patient left the operating room in a good condition Keywords surgery vitreous hemorrhage retinal detachment combined closed vitrectomy vitrectomy membrane peeling fluid air exchange endolaser vitrectomy with membrane peeling membrane peeling hemorrhage detachment vicryl eye retinal MEDICAL_TRANSCRIPTION,Description Placement of left ventriculostomy via twist drill Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure Medical Specialty Surgery Sample Name Ventriculostomy Placement Transcription PROCEDURE Placement of left ventriculostomy via twist drill PREOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure POSTOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure INDICATIONS FOR PROCEDURE The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage His condition is felt to be critical In a desperate attempt to relieve increased intracranial pressure we have proposed placing a ventriculostomy I have discussed this with patient s wife who agrees and asked that we proceed emergently After a sterile prep drape and shaving of the hair over the left frontal area this area is infiltrated with local anesthetic Subsequently a 1 cm incision was made over Kocher s point Hemostasis was obtained Then a twist drill was made over this area Bones strips were irrigated away The dura was perforated with a spinal needle A Camino monitor was connected and zeroed This was then passed into the left lateral ventricle on the first pass Excellent aggressive very bloody CSF under pressure was noted This stopped slowed and some clots were noted This was irrigated and then CSF continued Initial opening pressures were 30 but soon arose to 80 or a 100 The patient tolerated the procedure well The wound was stitched shut and the ventricular drain was then connected to a drainage bag Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding Keywords surgery intraventricular hemorrhage hydrocephalus intracranial pressure camino monitor twist drill ventriculostomy hemorrhage intracranial pressure intraventricular MEDICAL_TRANSCRIPTION,Description Chronic venous hypertension with painful varicosities lower extremities bilaterally Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions bilaterally Medical Specialty Surgery Sample Name Vein Stripping Transcription PREOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally POSTOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally PROCEDURES 1 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions right leg 2 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions left leg PROCEDURE DETAIL After obtaining the informed consent the patient was taken to the operating room where she underwent a general endotracheal anesthesia A time out process was followed and antibiotics were given Then both legs were prepped and draped in the usual fashion with the patient was in the supine position An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided Then an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities Then a vein stripper was passed from the right calf up to the groin and the greater saphenous vein which was divided was stripped without any difficultly Several minutes of compression was used for hemostasis Then the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do Then in the left thigh a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side Also an incision was made in the level of the knee and the saphenous vein was isolated there The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis Then a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient s position would allow us Then all incisions were closed in layers with Vicryl and staples Then the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg The stab phlebectomies were performed with a hook and they were very satisfactory Hemostasis achieved with compression and then staples were applied to the skin Then the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix fluffs and Ace bandages Estimated blood loss probably was about 150 mL The patient tolerated the procedure well and was sent to recovery room in satisfactory condition The patient is to be observed so a decision will be made whether she needs to stay overnight or be able to go home Keywords surgery chronic venous hypertension varicosities stab phlebectomies greater saphenous vein stripping lower extremities vein stripping saphenous vein vein incisions hemostasis stripping branches phlebectomies thigh calf saphenous MEDICAL_TRANSCRIPTION,Description Fertile male with completed family Elective male sterilization via bilateral vasectomy Medical Specialty Surgery Sample Name Vasectomy 4 Transcription PROCEDURE Elective male sterilization via bilateral vasectomy PREOPERATIVE DIAGNOSIS Fertile male with completed family POSTOPERATIVE DIAGNOSIS Fertile male with completed family MEDICATIONS Anesthesia is local with conscious sedation COMPLICATIONS None BLOOD LOSS Minimal INDICATIONS This 34 year old gentleman has come to the office requesting sterilization via bilateral vasectomy I discussed the indications and the need for procedure with the patient in detail and he has given consent to proceed He has been given prophylactic antibiotics PROCEDURE NOTE Once satisfactory sedation have been obtained the patient was placed in the supine position on the operating table Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely The procedure itself was started by grasping the right vas deferens in the scrotum and bringing it up to the level of the skin The skin was infiltrated with 2 Xylocaine and punctured with a sharp hemostat to identify the vas beneath The vas was brought out of the incision carefully A 2 inch segment was isolated and 1 inch segment was removed The free ends were cauterized and were tied with 2 0 silk sutures in such a fashion that the ends double back on themselves After securing hemostasis with a cautery the ends were allowed to drop back into the incision which was also cauterized Attention was now turned to the left side The vas was grasped and brought up to the level of the skin The skin was infiltrated with 2 Xylocaine and punctured with a sharp hemostat to identify the vas beneath The vas was brought out of the incision carefully A 2 inch segment was isolated and 1 inch segment was removed The free ends were cauterized and tied with 2 0 silk sutures in such a fashion that the ends double back on themselves After securing hemostasis with the cautery the ends were allowed to drop back into the incision which was also cauterized Bacitracin ointment was applied as well as dry sterile dressing The patient was awakened and was returned to Recovery in satisfactory condition Keywords surgery sterilization vas fertile male bilateral vasectomy vasectomy cauterized MEDICAL_TRANSCRIPTION,Description Desire for sterility Vasectomy The vas was identified skin was incised and no scalpel instruments were used to dissect out the vas Medical Specialty Surgery Sample Name Vasectomy 3 Transcription PREOPERATIVE DIAGNOSIS Desire for sterility POSTOPERATIVE DIAGNOSIS Desire for sterility OPERATIVE PROCEDURES Vasectomy DESCRIPTION OF PROCEDURE The patient was brought to the suite where after oral sedation the scrotum was prepped and draped Then 1 lidocaine was used for anesthesia The vas was identified skin was incised and no scalpel instruments were used to dissect out the vas A segment about 3 cm in length was dissected out It was clipped proximally and distally and then the ends were cauterized after excising the segment Minimal bleeding was encountered and the scrotal skin was closed with 3 0 chromic The identical procedure was performed on the contralateral side He tolerated it well He was discharged from the surgical center in good condition with Tylenol with Codeine for pain He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead Call if there are questions or problems prior to that time Keywords surgery vas contralateral desire for sterility scalpel sterility vasectomy MEDICAL_TRANSCRIPTION,Description Endoscopic third ventriculostomy Medical Specialty Surgery Sample Name Ventriculostomy Transcription PREOPERATIVE DIAGNOSIS Aqueductal stenosis POSTOPERATIVE DIAGNOSIS Aqueductal stenosis TITLE OF PROCEDURE Endoscopic third ventriculostomy ANESTHESIA General endotracheal tube anesthesia DEVICES Bactiseal ventricular catheter with an Aesculap burr hole port SKIN PREPARATION ChloraPrep COMPLICATIONS None SPECIMENS CSF for routine studies INDICATIONS FOR OPERATION Triventricular hydrocephalus most consistent with aqueductal stenosis The patient having a long history of some intermittent headaches macrocephaly OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in supine position with the head neutral The right frontal area was shaven and then the head was prepped and draped in a standard routine manner The area of the proposed scalp incision was infiltrated with 0 25 Marcaine with 1 200 000 epinephrine A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture Two Weitlaner were used to hold the scalp open A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated Neuropen was introduced directly through the parenchyma into the ventricular system which was quite large and dilated CSF was collected for routine studies We saw the total absence of __________ consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle I could bend the ventricular catheter and look back and see the aqueduct which was quite stenotic with a little bit of chorioplexus near its opening The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________ various motions We went through the membrane of Liliequist We could see the basilar artery and the clivus and there was no significant bleeding from the edges The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2 0 Ethibond suture The wound was irrigated out with bacitracin and closed using 3 0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri Strips The patient tolerated the procedure well Keywords surgery aqueductal stenosis ventriculostomy triventricular hydrocephalus neuropen endoscopic third ventriculostomy endotracheal tube anesthesia burr hole port aqueductal MEDICAL_TRANSCRIPTION,Description Burr hole and insertion of external ventricular drain catheter Medical Specialty Surgery Sample Name Ventricular Drain Catheter Insertion Transcription PREOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury POSTOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury PROCEDURE Burr hole and insertion of external ventricular drain catheter ANESTHESIA Just bedside sedation PROCEDURE Scalp was clipped He was prepped with ChloraPrep and Betadine Incisions are infiltrated with 1 Xylocaine with epinephrine 1 200000 He did receive antibiotics post procedure He was draped in a sterile manner Incision made just to the right of the right mid pupillary line 10 cm behind the nasion A self retaining retractor was placed Burr hole was drilled with the cranial twist drill The dura was punctured with a twist drill A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle The pressure was initially high The CSF was clear and colorless The CSF drainage rapidly tapered off because of the brain swelling With two tries the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound the depth of catheter is 7 cm from the outer table of the skull There was intermittent drainage of CSF after that The catheter was secured to the scalp with 2 0 silk suture and the incision was closed with Ethilon suture The patient tolerated the procedure well No complications Sponge and needle counts were correct Blood loss is minimal None replaced Keywords surgery intracranial pressure cerebral edema external ventricular drain catheter ventricular drain catheter brain injury burr hole ventricular brain catheter MEDICAL_TRANSCRIPTION,Description Vitreous hemorrhage right eye Vitrectomy right eye A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus Medical Specialty Surgery Sample Name Vitrectomy Transcription PREOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye POSTOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye PROCEDURE Vitrectomy right eye PROCEDURE IN DETAIL The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia Initially a 5 cc retrobulbar injection was performed with 2 Xylocaine during monitored anesthesia control A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus MVR incisions were made 4 mm posterior to the limbus in the and o clock meridians following which the infusion apparatus was positioned in the o clock site and secured with a 5 0 Vicryl suture Then under indirect ophthalmoscopic control the vitrector was introduced through the o clock site and a complete vitrectomy was performed All strands of significance were removed Tractional detachment foci were apparent posteriorly along the temporal arcades Next endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control Finally an air exchange procedure was performed also under indirect ophthalmoscopic control The intraocular pressure was within the normal range The globe was irrigated with a topical antibiotic The MVR incisions were closed with 7 0 Vicryl No further manipulations were necessary The conjunctiva was closed with 6 0 plain catgut An eye patch was applied and the patient was sent to the recovery area in good condition Keywords surgery ophthalmoscopic vitrectomy endolaser lancaster lid speculum vitreous hemorrhage vitreous hemorrhage conjunctiva MEDICAL_TRANSCRIPTION,Description Normal vasectomy Medical Specialty Surgery Sample Name Vasectomy 2 Transcription DIAGNOSIS Desires vasectomy NAME OF OPERATION Vasectomy ANESTHESIA General HISTORY Patient 37 desires a vasectomy PROCEDURE Through a midline scrotal incision the right vas was identified and separated from the surrounding tissues clamped transected and tied off with a 4 0 chromic No bleeding was identified Through the same incision the left side was identified transected tied off and dropped back into the wound Again no bleeding was noted The wound was closed with 4 0 Vicryl times two He tolerated the procedure well A sterile dressing was applied He was awakened and transferred to the recovery room in stable condition Keywords surgery scrotal incision right vas bleeding anesthesia vasectomy MEDICAL_TRANSCRIPTION,Description Normal vasectomy Medical Specialty Surgery Sample Name Vasectomy 1 Transcription DESCRIPTION The patient was placed in the supine position and was prepped and draped in the usual manner The left vas was grasped in between the fingers The skin and vas were anesthetized with local anesthesia The vas was grasped with an Allis clamp Skin was incised and the vas deferens was regrasped with another Allis clamp The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips two in the testicular side and one on the proximal side The incision was then inspected for hemostasis and closed with 3 0 chromic catgut interrupted fashion A similar procedure was carried out on the right side Dry sterile dressings were applied and the patient put on a scrotal supporter The procedure was then terminated Keywords surgery vasectomy allis clamp catgut hemoclips iris scissors scrotal scrotal supporter testicular vas vas deferens vas was grasped deferens clampsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Voluntary sterility Bilateral vasectomy The vas deferens was grasped with a vas clamp Next the vas deferens was skeletonized It was clipped proximally and distally twice Medical Specialty Surgery Sample Name Vasectomy Transcription PREOPERATIVE DIAGNOSIS Voluntary sterility POSTOPERATIVE DIAGNOSIS Voluntary sterility OPERATIVE PROCEDURE Bilateral vasectomy ANESTHESIA Local INDICATIONS FOR PROCEDURE A gentleman who is here today requesting voluntary sterility Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy DESCRIPTION OF PROCEDURE The patient was brought to the operating room and after appropriately identifying the patient the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table Then 0 25 Marcaine without epinephrine was used to anesthetize the scrotal skin A small incision was made in the right hemiscrotum The vas deferens was grasped with a vas clamp Next the vas deferens was skeletonized It was clipped proximally and distally twice The cut edges were fulgurated Meticulous hemostasis was maintained Then 4 0 chromic was used to close the scrotal skin on the right hemiscrotum Next the attention was turned to the left hemiscrotum and after the left hemiscrotum was anesthetized appropriately a small incision was made in the left hemiscrotum The vas deferens was isolated It was skeletonized It was clipped proximally and distally twice The cut edges were fulgurated Meticulous hemostasis was maintained Then 4 0 chromic was used to close the scrotal skin A jockstrap and sterile dressing were applied at the end of the case Sponge needle and instruments counts were correct Keywords surgery hemiscrotum bilateral vasectomy voluntary sterility vas deferens vasectomy skeletonized scrotal sterility deferens MEDICAL_TRANSCRIPTION,Description Laparoscopic assisted vaginal hysterectomy Abnormal uterine bleeding Uterine fibroids Medical Specialty Surgery Sample Name Vaginal Hysterectomy Laparoscopic Assisted Transcription PREOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Uterine fibroids POSTOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Uterine fibroids OPERATION PERFORMED Laparoscopic assisted vaginal hysterectomy ANESTHESIA General endotracheal anesthesia DESCRIPTION OF PROCEDURE After adequate general endotracheal anesthesia the patient was placed in dorsal lithotomy position prepped and draped in the usual manner for a laparoscopic procedure A speculum was placed into the vagina A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix The uterus was sounded to 10 5 cm A 10 RUMI cannula was utilized and attached for uterine manipulation The single tooth tenaculum and speculum were removed from the vagina At this time the infraumbilical area was injected with 0 25 Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity Aspiration was negative therefore the abdomen was insufflated with carbon dioxide After adequate insufflation Veress needle was removed and an 11 mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity Through the trocar sheath the laparoscope was inserted and adequate visualization of the pelvic structures was noted At this time the suprapubic area was injected with 0 25 Marcaine with epinephrine A 5 mm skin incision was made and a 5 mm trocar was introduced into the abdominal cavity for instrumentation Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular The fallopian tubes have been previously interrupted surgically The ovaries appeared normal bilaterally The cul de sac was clean without evidence of endometriosis scarring or adhesions The ureters were noted to be deep in the pelvis At this time the right cornu was grasped and the right fallopian tube uteroovarian ligament and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery The uterine artery was identified It was doubly coagulated with bipolar electrocautery and transected A similar procedure was carried out on the left with the left uterine cornu identified The left fallopian tube uteroovarian ligament and round ligaments were doubly coagulated with bipolar electrocautery and transected The remainder of the cardinal ligament uterine vessels anterior and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery The uterine artery was identified It was doubly coagulated with bipolar electrocautery and transected The anterior leaf of the broad ligament was then dissected to the midline bilaterally establishing a bladder flap with a combination of blunt and sharp dissection At this time attention was made to the vaginal hysterectomy The laparoscope was removed and attention was made to the vaginal hysterectomy The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum A circumferential injection with 0 25 Marcaine with epinephrine was made at the cervicovaginal portio A circumferential incision was then made at the cervicovaginal portio The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty The right uterosacral ligament was clamped transected and ligated with 0 Vicryl sutures The left uterosacral ligament was clamped transected and ligated with 0 Vicryl suture The parametrial tissue was then clamped bilaterally transected and ligated with 0 Vicryl suture bilaterally The uterus was then removed and passed off the operative field Laparotomy pack was placed into the pelvis The pedicles were evaluated There was no bleeding noted therefore the laparotomy pack was removed The uterosacral ligaments were suture fixated into the vaginal cuff angles with 0 Vicryl sutures The vaginal cuff was then closed in a running fashion with 0 Vicryl suture Hemostasis was noted throughout At this time the laparoscope was reinserted into the abdomen The abdomen was reinsufflated Evaluation revealed no further bleeding Irrigation with sterile water was performed and again no bleeding was noted The suprapubic trocar sheath was then removed under laparoscopic visualization The laparoscope was removed The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed The skin incisions were closed with 4 0 Vicryl in subcuticular fashion Neosporin and Band Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition Estimated blood loss was approximately 100 mL There were no complications The instrument sponge and needle counts were correct Keywords surgery abnormal uterine bleeding laparoscopic assisted vaginal hysterectomy uterine fibroids bipolar electrocautery vaginal hysterectomy vicryl sutures tooth uterine uterosacral laparoscope electrocautery hysterectomy laparoscopic coagulated vaginal ligament transected MEDICAL_TRANSCRIPTION,Description Vacuum assisted vaginal delivery of a third degree midline laceration and right vaginal side wall laceration and repair of the third degree midline laceration lasting for 25 minutes Medical Specialty Surgery Sample Name Vaginal Delivery Vacuum Assisted Transcription PREOPERATIVE DIAGNOSES 1 A 40 weeks 6 days intrauterine pregnancy 2 History of positive serology for HSV with no evidence of active lesions 3 Non reassuring fetal heart tones POST OPERATIVE DIAGNOSES 1 A 40 weeks 6 days intrauterine pregnancy 2 History of positive serology for HSV with no evidence of active lesions 3 Non reassuring fetal heart tones PROCEDURES 1 Vacuum assisted vaginal delivery of a third degree midline laceration and right vaginal side wall laceration 2 Repair of the third degree midline laceration lasting for 25 minutes ANESTHESIA Local ESTIMATED BLOOD LOSS 300 mL COMPLICATIONS None FINDINGS 1 Live male infant with Apgars of 9 and 9 2 Placenta delivered spontaneously intact with a three vessel cord DISPOSITION The patient and baby remain in the LDR in stable condition SUMMARY This is a 36 year old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix When she was admitted her cervix was 2 5 cm dilated with 80 effacement The baby had a 2 station She had no regular contractions Fetal heart tones were 120s and reactive She was started on Pitocin for labor induction and labored quite rapidly She had spontaneous rupture of membranes with a clear fluid She had planned on an epidural however she had sudden rapid cervical change and was unable to get the epidural With the rapid cervical change and descent of fetal head there were some variable decelerations The baby was at a 1 station when the patient began pushing I had her push to get the baby to a 2 station During pushing the fetal heart tones were in the 80s and did not recover in between contractions Because of this I recommended a vacuum delivery for the baby The patient agreed The baby s head was confirmed to be in the right occiput anterior presentation The perineum was injected with 1 lidocaine The bladder was drained The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally With the patient s next contraction the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby s head to a 3 station The contraction ended The vacuum was released and the fetal heart tones remained in the at this time 90s to 100s With the patient s next contraction the vacuum was reapplied and the baby s head was delivered to a 4 station A modified Ritgen maneuver was used to stabilize the fetal head The vacuum was deflated and removed The baby s head then delivered atraumatically There was no nuchal cord The baby s anterior shoulder delivered after a less than 30 second delay No additional maneuvers were required to deliver the anterior shoulder The posterior shoulder and remainder of the body delivered easily The baby s mouth and nose were bulb suctioned The cord was clamped x2 and cut The infant was handed to the respiratory therapist Pitocin was added to the patient s IV fluids The placenta delivered spontaneously was intact and had a three vessel cord A vaginal inspection revealed a third degree midline laceration as well as a right vaginal side wall laceration The right side wall laceration was repaired with 3 0 Vicryl suture in a running fashion with local anesthesia The third degree laceration was also repaired with 3 0 Vicryl sutures Local anesthesia was used The capsule was visible but did not appear to be injured at all It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with 3 0 Vicryl in the typical fashion The patient tolerated the procedure very well She remains in the LDR with the baby The baby is vigorous crying and moving all extremities He will go to the new born nursery when ready The total time for repair of the laceration was 25 minutes Keywords surgery intrauterine pregnancy non reassuring fetal heart tones vacuum assisted vaginal delivery vaginal side wall laceration fetal heart tones vaginal delivery vacuum assisted laceration intrauterine tones contractions MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair template The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia Medical Specialty Surgery Sample Name Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Umbilical hernia POSTOPERATIVE DIAGNOSIS Umbilical hernia PROCEDURE PERFORMED Repair of umbilical hernia ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was prepped and draped in the sterile fashion An infraumbilical incision was formed and taken down to the fascia The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia and then the wounds were infiltrated with 0 25 Marcaine The skin was reattached to the fascia with 2 0 Vicryls The skin was approximated with 2 0 Vicryl subcutaneous and then 4 0 Monocryl subcuticular stitches dressed with Steri Strips and 4 x 4 s Patient was extubated and taken to the recovery area in stable condition Keywords surgery marcaine steri strips mattress sutures umbilical hernia repair umbilical hernia MEDICAL_TRANSCRIPTION,Description Upper endoscopy with removal of food impaction Medical Specialty Surgery Sample Name Upper Endoscopy Transcription PROCEDURE Upper endoscopy with removal of food impaction HISTORY OF PRESENT ILLNESS A 92 year old lady with history of dysphagia on and off for two years She comes in this morning with complaints of inability to swallow anything including her saliva This started almost a day earlier She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything She is on Coumadin and her INR is 2 5 OPERATIVE NOTE Informed consent was obtained from patient The risks of aspiration bleeding perforation infection and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed Daughter was also informed about the procedure and risks Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus There was a meat bolus in the distal esophagus This was visualized after clearing the liquid material and small particles of what appeared to be carrots The patient however was not tolerating the conscious sedation Hence Dr X was consulted and we continued the procedure with propofol sedation The scope was reintroduced into the esophagus after propofol sedation Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net Then a snare was used to cut the meat bolus into pieces as it was very soft Small pieces were grabbed with the snare and pulled out Thereafter the residual soft meat bolus was passed into the stomach along with the scope which was passed between the bolus and the esophageal wall carefully The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy No active bleeding was seen There was a distal esophageal stricture which caused slight resistance to the passage of the scope into the stomach As this area was extremely inflamed a dilatation was not attempted IMPRESSION Distal esophageal stricture with food impaction Treated as described above RECOMMENDATIONS IV Protonix 40 mg q 12h Clear liquid diet for 24 hours If the patient is stable thereafter she may take soft pureed diet only until next endoscopy which will be scheduled in three to four weeks She should take Prevacid SoluTab 30 mg b i d on discharge Keywords surgery dysphagia removal of food impaction distal esophagus stomach distal esophageal esophageal stricture upper endoscopy food impaction endoscopy aspiration sedation bolus impaction esophagus MEDICAL_TRANSCRIPTION,Description Exam under anesthesia with uterine suction curettage A 10 1 2 week pregnancy spontaneous incomplete abortion Medical Specialty Surgery Sample Name Uterine Suction Curettage Transcription PREOPERATIVE DIAGNOSIS A 10 1 2 week pregnancy spontaneous incomplete abortion POSTOPERATIVE DIAGNOSIS A 10 1 2 week pregnancy spontaneous incomplete abortion PROCEDURE Exam under anesthesia with uterine suction curettage ANESTHESIA Spinal ESTIMATED BLOOD LOSS Less than 10 cc COMPLICATIONS None DRAINS None CONDITION Stable INDICATIONS The patient is a 29 year old gravida 5 para 1 0 3 1 with an LMP at 12 18 05 The patient was estimated to be approximately 10 1 2 weeks so long in her pregnancy She began to have heavy vaginal bleeding and intense lower pelvic cramping She was seen in the emergency room where she was found to be hemodynamically stable On pelvic exam her cervix was noted to be 1 to 2 cm dilated and approximately 90 effaced There were bulging membranes protruding through the dilated cervix These symptoms were consistent with the patient s prior experience of spontaneous miscarriages These findings were reviewed with her and options for treatment discussed She elected to proceed with an exam under anesthesia with uterine suction curettage The risks and benefits of the surgery were discussed with her and knowing these she gave informed consent PROCEDURE The patient was taken to the operating room where she was placed in the seated position A spinal anesthetic was successfully administered She was then moved to a dorsal lithotomy position She was prepped and draped in the usual fashion for the procedure After adequate spinal level was confirmed a bimanual exam was again performed This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size The previously noted cervical exam was confirmed The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution This solution was then removed approximately 10 minutes later with dry sterile gauze sponge The anterior cervical lip was then attached with a ring clamp The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied The tissue dislodged revealing fluid mixed with blood as well as an apparent 10 week fetus The placental tissue was then gently tractioned out as well A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity With the vacuum tubing applied in rotary motion a moderate amount of tissue consistent with products of conception was evacuated The sharp curette was then utilized to probe the endometrial surface A small amount of additional tissue was then felt in the posterior uterine wall This was curetted free A second pass was then made with a vacuum curette Again the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered A final pass was then made with a suction curette The ring clamp was then removed from the anterior cervical lip There was only a small amount of bleeding following the curettage The weighted speculum was then removed as well The bimanual exam was repeated and good involution was noted The patient was taken down from the dorsal lithotomy position She was transferred to the recovery room in stable condition The sponge and instrument count was performed and found to be correct The specimen of products of conception and 10 week fetus were submitted to Pathology for further evaluation The estimated blood loss for the procedure is less than 10 mL Keywords surgery spontaneous incomplete abortion uterine suction curettage fetus anterior cervical lip spontaneous incomplete abortion bimanual exam ring clamp suction curettage uterine curettage suction MEDICAL_TRANSCRIPTION,Description Urgent cardiac catheterization with coronary angiogram Medical Specialty Surgery Sample Name Urgent Cardiac Cath Transcription PROCEDURE Urgent cardiac catheterization with coronary angiogram PROCEDURE IN DETAIL The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest The right groin was prepped and draped in usual manner Under 2 lidocaine anesthesia the right femoral artery was entered A 6 French sheath was placed The patient was already on anticoagulation Selective coronary angiograms were then performed using a left and a 3DRC catheter The catheters were reviewed The catheters were then removed and an Angio Seal was placed There was some hematoma at the cath site RESULTS 1 The left main was free of disease 2 The left anterior descending and its branches were free of disease 3 The circumflex was free of disease 4 The right coronary artery was free of disease There was no gradient across the aortic valve IMPRESSION Normal coronary angiogram Keywords surgery cardiac catheterization coronary angiogram angiogram MEDICAL_TRANSCRIPTION,Description Uvulopalatopharyngoplasty and tonsillectomy The patient with a history of obstructive sleep apnea who has been using CPAP however he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea Medical Specialty Surgery Sample Name Uvulopalatopharyngoplasty Tonsillectomy Transcription PREOPERATIVE DIAGNOSIS Obstructive sleep apnea POSTOPERATIVE DIAGNOSIS Obstructive sleep apnea PROCEDURE PERFORMED 1 Tonsillectomy 2 Uvulopalatopharyngoplasty ANESTHESIA General endotracheal tube BLOOD LOSS Approximately 50 cc INDICATIONS The patient is a 41 year old gentleman with a history of obstructive sleep apnea who has been using CPAP however he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea PROCEDURE After all risks benefits and alternatives have been discussed with the patient informed consent was obtained The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole The needle tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar Once the tonsillar pillar was identified and the superior pole was released the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly dissecting the tonsil free from all fascial attachments Once the tonsil was delivered from the oral cavity hemostasis was obtained within the tonsillar fossa utilizing suction cautery Attention was then directed over to the left tonsil in which a similar procedure was performed Once all bleeding was controlled the mucosa of both the hard and soft palate was anesthetized with a mixture of 1 lidocaine and 1 50000 epinephrine solution Now attention was directed to the posterior pillars A hemostat was used to clamp the posterior pillar which was then taken down with Metzenbaum scissors The posterior pillar was then approximated to the anterior pillar with the use of 3 0 PDS suture so as to create a box shaped soft palate Now the uvula was reflected onto the soft palate and 12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula The mucosa was dissected off with the use of Potts scissors Now the uvula was reflected onto the soft palate and sutured down in place with use of 3 0 PDS suture approximated with deep muscle layers Now the mucosa of the soft palate and the uvula were approximated with interrupted 3 0 PDS sutures Finally 4 0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula which had been reflected onto the soft palate A final 3 0 PDS suture was used to further approximate the anterior and posterior tonsil pillars Final inspection did not reveal any further bleeding The mouth was then irrigated with saline and suctioned At this point the procedure was complete He was awakened and taken to recovery room in stable condition He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management Of note IV Decadron was administered during the procedure Keywords surgery endotracheal metzenbaum soft palate obstructive sleep apnea tonsillectomy uvulopalatopharyngoplasty obstructive mucosa uvula palate MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Surgery Sample Name Umbilical Hernia Repair 1 Transcription PROCEDURE PERFORMED Umbilical hernia repair PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table The patient was sedated and an adequate local anesthetic was administered using 1 lidocaine without epinephrine The patient was prepped and draped in the usual sterile manner A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery The sac was cleared of overlying adherent tissue and the fascial defect was delineated The fascia was cleared of any adherent tissue for a distance of 1 5 cm from the defect The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures The umbilicus was then re formed using 4 0 Vicryl to tack the umbilical skin to the fascia The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The skin was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords surgery fascial defect umbilical hernia repair curvilinear umbilical hernia sac metzenbaum scissors umbilical hernia bovie electrocautery electrocautery hernia incision umbilical MEDICAL_TRANSCRIPTION,Description A 21 year old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office Medical Specialty Surgery Sample Name Vacuum D C Transcription PREOPERATIVE DIAGNOSIS Blighted ovum severe cramping POSTOPERATIVE DIAGNOSIS Blighted ovum severe cramping OPERATION PERFORMED Vacuum D C DRAINS None ANESTHESIA General HISTORY This 21 year old white female gravida 1 para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office Due to the severe cramping a decision to undergo vacuum D C was made At the time of the procedure moderate amount of tissue was obtained PROCEDURE The patient was taken to the operating room and placed in a supine position at which time a general form of anesthesia was administered by the anesthesia department The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion A weighted vaginal speculum was placed in the posterior vaginal vault Anterior lip of the cervix was grasped with single tooth tenaculum and the cervix was dilated to approximately 8 mm straight Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction Methargen 0 2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure Once the procedure was completed the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed The patient was repositioned to supine position and taken to recovery room in stable condition Keywords surgery pitocin single tooth tenaculum vaginal vault vacuum d c blighted ovum speculum tenaculum curetting blighted cramping MEDICAL_TRANSCRIPTION,Description Subcutaneous ulnar nerve transposition A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Medical Specialty Surgery Sample Name Ulnar Nerve Transposition Transcription PROCEDURE Subcutaneous ulnar nerve transposition PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected Osborne s fascia was released an ulnar neurolysis performed and the ulnar nerve was mobilized Six cm of the medial intermuscular septum was excised and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly The subcutaneous plane just superficial to the flexor pronator mass was developed Meticulous hemostasis was maintained with bipolar electrocautery The nerve was transposed anteriorly superficial to the flexor pronator mass Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve A semicircular medially based flap of flexor pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating The subcutaneous tissue and skin were closed with simple interrupted sutures Marcaine with epinephrine was injected into the wound The elbow was dressed and splinted The patient was awakened and sent to the recovery room in good condition having tolerated the procedure well Keywords surgery neurolysis ulnar periosteal flexor pronator mass ulnar nerve transposition medial intermuscular septum nerve transposition intermuscular septum flexor pronator ulnar nerve nerve MEDICAL_TRANSCRIPTION,Description Upper endoscopy with foreign body removal Penny in proximal esophagus Medical Specialty Surgery Sample Name Upper Endoscopy Foreign Body Removal Transcription PROCEDURE Upper endoscopy with foreign body removal PREOPERATIVE DIAGNOSIS ES Esophageal foreign body POSTOPERATIVE DIAGNOSIS ES Penny in proximal esophagus ESTIMATED BLOOD LOSS None COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the pediatric endoscopy suite After appropriate sedation by the anesthesia staff and intubation an upper endoscope was inserted into the mouth over the tongue into the esophagus at which time the foreign body was encountered It was grasped with a coin removal forcep and removed with an endoscope At that time the endoscope was reinserted advanced to the level of the stomach and stomach was evaluated and was normal The esophagus was normal with the exception of some mild erythema where the coin had been sitting There were no erosions The stomach was decompressed of air and fluid The scope was removed without difficulty SUMMARY The patient underwent endoscopic removal of esophageal foreign body PLAN To discharge home follow up as needed Keywords surgery upper endoscopy endoscopy endoscopy suite esophagus foreign body foreign body removal esophageal foreign body stomach MEDICAL_TRANSCRIPTION,Description Bilateral tympanostomy with myringotomy tube placement The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy Medical Specialty Surgery Sample Name Tympanostomy Myringotomy Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss POSTOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss PROCEDURE PERFORMED Bilateral tympanostomy with myringotomy tube placement _______ split tube 1 0 mm ANESTHESIA Total IV general mask airway ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy After risks complications consequences and questions were addressed with the family a written consent was obtained for the procedure PROCEDURE The patient was brought to the operative suite by Anesthesia The patient was placed on the operating table in supine position After this the patient was then placed under general mask airway and the patient s head was then turned to the left The Zeiss operative microscope and medium sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to 5 suction After this the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a 5 suction demonstrating dry contents A _____ split tube 1 0 mm was then placed in the myringotomy incision utilizing a alligator forcep Cortisporin Otic drops were placed followed by cotton balls Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed The external auditory canal was removed off of its cerumen with a 5 suction which led to the direct visualization of the tympanic membrane The tympanic membrane appeared with no signs of retraction pockets cholesteatoma or air fluid levels A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1 0 mm was then placed with an alligator forcep After this the patient had Cortisporin Otic drops followed by cotton balls placed The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears Keywords surgery chronic otitis media with effusion conductive hearing loss bilateral tympanostomy myringotomy tube placement cortisporin otic drops otitis media tympanostomy tympanic membrane otitis media effusion conductive hearing ear tube myringotomy MEDICAL_TRANSCRIPTION,Description Adenotonsillar hypertrophy and chronic otitis media Tympanostomy and tube placement and adenoidectomy Medical Specialty Surgery Sample Name Tympanostomy Transcription PREOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media POSTOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media PROCEDURE PERFORMED 1 Tympanostomy and tube placement 2 Adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room prepped and draped in the usual fashion After induction of general endotracheal anesthesia the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction Attention was directed to the nasopharynx With the Bovie set at 50 coag and the suction Bovie tip on the suction hose the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior The McIvor was relaxed and attention was then directed to the ears The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris An anteroinferior quadrant tympanostomy incision was made Fluid was suctioned from the middle ear space and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle Cortisporin ear drops were instilled into the canal and a cotton ball was placed in the external meatus By a similar procedure the opposite tympanostomy and tube placement were accomplished The patient tolerated the procedure well and left the operating room in good condition Keywords surgery robinson catheters palate tongue tympanostomy adenoidectomy chronic otitis media oral cavity adenotonsillar hypertrophy tube placement hypertrophy nasopharynx adenotonsillar MEDICAL_TRANSCRIPTION,Description Transurethral resection of the bladder tumor TURBT large Medical Specialty Surgery Sample Name TURBT 1 Transcription PREOPERATIVE DIAGNOSIS Bladder cancer POSTOPERATIVE DIAGNOSIS Bladder cancer OPERATION Transurethral resection of the bladder tumor TURBT large ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is an 82 year old male who presented to the hospital with renal insufficiency syncopal episodes The patient was stabilized from cardiac standpoint on a renal ultrasound The patient was found to have a bladder mass The patient does have a history of bladder cancer Options were watchful waiting resection of the bladder tumor were discussed Risk of anesthesia bleeding infection pain MI DVT PE were discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure DETAILS OF THE OR The patient was brought to the OR anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in the usual sterile fashion A 23 French scope was inserted inside the urethra into the bladder The entire bladder was visualized which appeared to have a large tumor lateral to the right ureteral opening There was a significant papillary superficial fluffiness around the left ________ There was a periureteral diverticulum lateral to the left ureteral opening There were moderate trabeculations throughout the bladder There were no stones Using a French cone tip catheter bilateral pyelograms were obtained which appeared normal Subsequently using 24 French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base Deep biopsies were sent separately Coagulation was performed around the periphery and at the base of the tumor All the tumors were removed and sent for path analysis There was an excellent hemostasis The rest of the bladder appeared normal There was no further evidence of tumor At the end of the procedure a 22 three way catheter was placed and the patient was brought to the recovery in a stable condition Keywords surgery transurethral resection of the bladder tumor transurethral resection bladder cancer bladder tumor bladder turbt insufficiency tumor MEDICAL_TRANSCRIPTION,Description Decompression of the ulnar nerve left elbow Left cubital tunnel syndrome and ulnar nerve entrapment Medical Specialty Surgery Sample Name Ulnar Nerve Decompression Transcription PREOPERATIVE DIAGNOSES Left cubital tunnel syndrome and ulnar nerve entrapment POSTOPERATIVE DIAGNOSES Left cubital tunnel syndrome and ulnar nerve entrapment PROCEDURE PERFORMED Decompression of the ulnar nerve left elbow ANESTHESIA General FINDINGS OF THE OPERATION The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel There was presence of hourglass constriction of the ulnar nerve PROCEDURE The patient was brought to the operating room and once an adequate general anesthesia was achieved his left upper extremity was prepped and draped in standard sterile fashion A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg Perioperative antibiotics were infused Time out procedure was called The medial epicondyle and the olecranon tip were well palpated The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3 4 cm proximally and 6 8 cm distally The ulnar nerve was identified proximally It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers which was released sharply The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches The ulnar nerve was well isolated before it entered the cubital tunnel The arch of the FCU was well defined The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization Distally the dissection was carried between the 2 heads of the FCU Decompression of the nerve was performed between the heads of the FCU The muscular branches were well protected Similarly the cutaneous branches in the arm and forearm were well protected The venous plexus proximally and distally were well protected The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it Proximally multiple vascular leashes were defined near the incision of the septum into the medial epicondyle which were also protected Once the in situ decompression of the ulnar nerve was performed proximally and distally the elbow was flexed and extended There was no evidence of any subluxation Satisfactory decompression was performed Tourniquet was released Hemostasis was achieved Subcutaneous layer was closed with 2 0 Vicryl and skin was approximated with staples A well padded dressing was applied The patient was then extubated and transferred to the recovery room in stable condition There were no intraoperative complications noted The patient tolerated the procedure very well Keywords surgery ulnar nerve entrapment ulnar nerve ulnar nerve decompression cubital tunnel syndrome ulnar nerve fascia decompression cubital tunnel MEDICAL_TRANSCRIPTION,Description Transurethral electrosurgical resection of the prostate for benign prostatic hyperplasia Medical Specialty Surgery Sample Name TURP Transcription PREOPERATIVE DIAGNOSIS Benign prostatic hyperplasia POSTOPERATIVE DIAGNOSIS Benign prostatic hyperplasia OPERATION PERFORMED Transurethral electrosurgical resection of the prostate ANESTHESIA General COMPLICATIONS None INDICATIONS FOR THE SURGERY This is a 77 year old man with severe benign prostatic hyperplasia He has had problem with urinary retention and bladder stones in the past He will need to have transurethral resection of prostate to alleviate the above mentioned problems Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Formation of urethral strictures PROCEDURE IN DETAIL The patient was identified after which he was taken into the operating room General LMA anesthesia was then administered The patient was given prophylactic antibiotic in the preoperative holding area The patient was then positioned prepped and draped Cystoscopy was then performed by using a 26 French continuous flow resectoscopic sheath and a visual obturator The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe The anterior urethra was normal without strictures or lesions The bladder was severely trabeculated with multiple bladder diverticula There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone Using the resection apparatus and a right angle resection loop the prostate was resected initially at the area of the median lobe Once the median lobe has completely resected the left lateral lobe and then the right lateral lobes were taken down Once an adequate channel had been achieved the prostatic specimen was retrieved from the bladder by using an Ellik evacuator A 3 mm bar electrode was then introduced into the prostate to achieve perfect hemostasis The sheath was then removed under direct vision and a 24 French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained The patient tolerated the operation well Keywords surgery benign prostatic hyperplasia cystoscopy foley catheter turp transurethral bladder bladder diverticula electrosurgical obturator prostate resectoscopic transurethral resection urinary retention resection of the prostate transurethral electrosurgical resection anesthesia hyperplasia resection prostatic MEDICAL_TRANSCRIPTION,Description Tube Shunt Ahmed valve model S2 implant with pericardial reinforcement Sample Template Medical Specialty Surgery Sample Name Tube Shunt Ahmed Valve Implant Transcription PREOPERATIVE DIAGNOSIS Open angle glaucoma OX POSTOPERATIVE DIAGNOSIS Open angle glaucoma OX PROCEDURE Ahmed valve model S2 implant with pericardial reinforcement XXX eye INDICATIONS This is a XX year old wo man with glaucoma in the OX eye uncontrolled by maximum tolerated medical therapy PROCEDURE The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding infection reoperation retinal detachment diplopia ptosis loss of vision and loss of the eye corneal hemorrhage hypotony elevated pressure worsening of glaucoma and corneal edema Informed consent was obtained Patient received several sets of drops in his her XXX eye including Ocuflox and Ocular S He was taken to the operating room where monitored anesthetic care was initiated Retrobulbar anesthesia was then administered to the XXX eye using a 50 50 mixture of 2 plain lidocaine and 0 05 Marcaine The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion A speculum was placed on the eyelids and microscope was brought into position A 7 0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva At this point smooth forceps and Westcott scissors were used to create a 100 degree superotemporal conjunctival peritomy approximately 2 mm posterior to the superotemporal limbus This was then dissected anteriorly to the limbus edge and then posteriorly Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure At this point we primed the Ahmed valve with a 27 gauge cannula using BSS and it was noted to be patent We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly We then measured with calipers so that it was positioned 9 mm posterior to the limbus The Ahmed valve was then tacked down with 8 0 nylon suture through both fenestrations We then applied light cautery to the superotemporal episcleral bed We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon We then used a 23 gauge needle and entered the superotemporal sclera approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea We then trimmed the tube beveled up in a 30 degree fashion with Vannas scissors and introduced the tube through the 23 gauge tract into the anterior chamber so that approximately 2 3 mm of tube was extending into the anterior chamber We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens away from the cornea and away from the iris We then tacked down the tubes to the sclera with 8 0 Vicryl suture in a figure of eight fashion The pericardium was soaked in gentamicin We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with 8 0 nylon suture At this point we then re approximated the conjunctiva to its original position and we closed it with an 8 0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites We then removed the traction suture At the end of the case the pupil was round the chamber was deep the tube appeared to be well positioned The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate The speculum was removed Ocuflox and Maxitrol ointment were placed over the eye Then an eye patch and shield were placed over the eye The patient was awakened and taken to the recovery room in stable condition Keywords surgery tube shunt ahmed valve healon maxitrol ointment ocuflox open angle anterior chamber bleeding conjunctival peritomy cornea corneal edema corneal hemorrhage diplopia elevated pressure glaucoma hypotony infection loss of the eye loss of vision ophthalmic fashion ptosis reoperation retinal detachment sclera superotemporal worsening of glaucoma ahmed valve model superotemporal limbus eye ahmed implant bss valve limbus MEDICAL_TRANSCRIPTION,Description Laparoscopic tubal sterilization tubal coagulation Medical Specialty Surgery Sample Name Tubal Sterilization Coagulation Transcription PROCEDURE Laparoscopic tubal sterilization tubal coagulation PREOPERATIVE DIAGNOSIS Request tubal coagulation POSTOPERATIVE DIAGNOSIS Request tubal coagulation PROCEDURE Under general anesthesia the patient was prepped and draped in the usual manner Manipulating probe placed on the cervix changed gloves Small cervical stab incision was made Veress needle was inserted without problem A 3 L of carbon dioxide was insufflated The incision was enlarged A 5 mm trocar placed through the incision without problem Laparoscope placed through the trocar Pelvic contents visualized A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline Under direct vision the trocar was placed in the abdominal cavity Uterus tubes and ovaries were all normal There were no pelvic adhesions no evidence of endometriosis Uterus was anteverted and the right adnexa was placed on a stretch The tube was grasped 1 cm from the cornual region care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation The tube was grasped again and the procedure was repeated for a separate coagulation so that 1 5 cm of the tube was coagulated The structure was confirmed to be tube by looking at fimbriated end The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it Under traction the amp meter was grasped 3 more times so that a total of 1 5 cm of tube was coagulated again Tube was confirmed by fimbriated end Gas was lend out of the abdomen Both punctures repaired with 4 0 Vicryl and punctures were injected with 0 5 Marcaine 10 mL The patient went to the recovery room in good condition Keywords surgery cervix cervical stab incision laparoscopic tubal sterilization tubal sterilization tubal coagulation sterilization laparoscopic endometriosis MEDICAL_TRANSCRIPTION,Description Right ulnar nerve transposition right carpal tunnel release and right excision of olecranon bursa Right cubital tunnel syndrom carpal tunnel syndrome and olecranon bursitis Medical Specialty Surgery Sample Name Ulnar Nerve Transposition Olecranon Bursa Excision Transcription PREOPERATIVE DIAGNOSIS 1 Right cubital tunnel syndrome 2 Right carpal tunnel syndrome 3 Right olecranon bursitis POSTOPERATIVE DIAGNOSIS 1 Right cubital tunnel syndrome 2 Right carpal tunnel syndrome 3 Right olecranon bursitis PROCEDURES 1 Right ulnar nerve transposition 2 Right carpal tunnel release 3 Right excision of olecranon bursa ANESTHESIA General BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Thickened transverse carpal ligament and partially subluxed ulnar nerve SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained his right arm was sterilely prepped and draped in normal fashion After elevation and exsanguination with an Esmarch the tourniquet was inflated The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues The palmar fascia was divided exposing the transverse carpal ligament which was incised longitudinally A Freer was then inserted beneath the ligament and dissection was carried out proximally and distally After adequate release has been formed the wound was irrigated and closed with nylon The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected A medial antebrachial cutaneous nerve was identified and protected throughout the case The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed The ulnar nerve was freed proximally and distally The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided The intraarticular branch and the first branch to the SCU were transected and then the nerve was transposed it did not appear to have any significant tension or sharp turns The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight The wound was irrigated The tourniquet was deflated and the wound had excellent hemostasis The subcutaneous tissues were closed with 2 0 Vicryl and the skin was closed with staples Prior to the tourniquet being deflated the subcutaneous dissection was carried out over to the olecranon bursa where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa A posterior splint was applied Marcaine was injected into the incisions and the splint was reinforced with tape He was awakened from the anesthesia and taken to recovery room in a stable condition Final needle instrument and sponge counts were correct Keywords surgery cubital tunnel syndrome carpal tunnel syndrome olecranon bursitis ulnar nerve transposition carpal tunnel release excision of olecranon bursa transposition ligament tourniquet excision bursa syndrome subcutaneous ulnar olecranon carpal nerve tunnel MEDICAL_TRANSCRIPTION,Description Left canal wall down tympanomastoidectomy with ossicular chain reconstruction microdissection NIM facial nerve monitoring for three hours Medical Specialty Surgery Sample Name Tympanomastoidectomy Transcription PREOPERATIVE DIAGNOSIS Left canal cholesteatoma POSTOPERATIVE DIAGNOSIS Left canal cholesteatoma OPERATIVE PROCEDURE 1 Left canal wall down tympanomastoidectomy with ossicular chain reconstruction 2 Microdissection 3 NIM facial nerve monitoring for three hours COMPLICATIONS None FINDINGS There is an extremely large canal cholesteatoma which eroded most of the posterior and superior canal wall There was a significant amount of myringosclerosis and tympanosclerosis There is some mild erosion of the lenticular process of the incus The facial nerve was normal We removed the incus removed the head of the malleus and placed a titanium PORP from the stapes capitulum to a cartilage graft PROCEDURE The patient was taken to the operating room placed under general anesthetic and intubated without difficulty The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure There was no abnormal activity during this case We inspected the ear canal identified the huge defect which was completely filled with cerumen Through the ear canal we removed as much as we could and then infiltrated the canal and postauricular area with 1 100 000 of epinephrine We prepped and draped the ear in a sterile fashion We reopened the previously used postauricular incision and dissected down the mastoid cortex We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone A 6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out We went all the way to the mastoid antrum We finished a complete mastoidectomy with identification of the tegmen sigmoid sinus We removed the lateral aspect of the mastoid tip We lowered the facial ridge The incudostapedial joint was already membranous in nature we went ahead and used the joint knife and removed the incus We separated the incus from the stapes and then removed it We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity There was no cholesteatoma within the middle ear space but there was roughly 40 surface area perforation The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic this was removed There was also a large focus of tympanosclerosis between the stapes crura which was impinging the ability of the stapes to move We carefully dissected this out This did seem to improve the mobility of the stapes somewhat At this point there was a near total perforation There was only a minimal amount of anterior remnant of the drum left We tried to go ahead and harvest the temporalis fascia but there was really only wisps of this fascia in place He had already had a previous tympanoplasty but even outside the areas where the graft was taken the temporalis muscle was quite atrophied and lumpy and I suspect this was due to his chronic disease and long history of corticosteroid usage We harvested a few pieces as best as we could We went ahead and did a meatoplasty by making a canal incision in the 6 o clock and 12 o clock positions We excised cartilage posteriorly and inferiorly to enlarge the meatus This cartilage was thin and used for cartilage tympanoplasty We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it We did cut a titanium PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants We placed a layer of Gelfoam lateral to the graft closed the postauricular incision in layers and put 2 Merocel packs in the ear Glasscock dressing was applied The patient was awakened from anesthesia and taken to the recovery room in stable condition He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week Keywords surgery cholesteatoma gelfoam glasscock dressing microdissection nim canal canal wall cerumen facial nerve incus myringosclerosis ossicular chain reconstruction titanium porp tympanomastoidectomy tympanosclerosis facial nerve monitoring ear canal cartilage ear MEDICAL_TRANSCRIPTION,Description Desires permanent sterilization Laparoscopic tubal ligation Falope ring method Normal appearing uterus and adnexa bilaterally Medical Specialty Surgery Sample Name Tubal Ligation Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Desires permanent sterilization POSTOPERATIVE DIAGNOSIS Desires permanent sterilization PROCEDURE Laparoscopic tubal ligation Falope ring method ANESTHESIA General ESTIMATED BLOOD LOSS 10 mL COMPLICATIONS None INDICATIONS FOR SURGERY A 35 year old female P4 0 0 4 who desires permanent sterilization The risks of bleeding infection damage to other organs and subsequent ectopic pregnancy was explained Informed consent was obtained OPERATIVE FINDINGS Normal appearing uterus and adnexa bilaterally DESCRIPTION OF PROCEDURE After administration of general anesthesia the patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion The speculum was placed in the vagina the cervix was grasped with the tenaculum and a uterine manipulator inserted This area was then draped off the remainder of the operative field A 5 mm incision was made umbilically after injecting 0 25 Marcaine 2 mL A Veress needle was inserted to confirm an opening pressure of 2 mmHg Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity The Veress needle was removed and a 5 mm port placed Position was confirmed using a laparoscope A second port was placed under direct visualization 3 fingerbreadths suprapubically 7 mm in diameter after 2 mL of 0 25 Marcaine was injected This was done under direct visualization The pelvic cavity was examined with the findings as noted above The Falope rings were then applied to each tube bilaterally Good segments were noted to be ligated The accessory port was removed The abdomen was deflated The laparoscope and sheath was removed The skin edges were approximated with 5 0 Monocryl suture in subcuticular fashion The instruments were removed from the vagina The patient was returned to the supine position recalled from anesthesia and transferred to the recovery room in satisfactory condition Sponge and needle counts correct at the conclusion of the case Estimated blood loss was minimal Keywords surgery tenaculum uterine manipulator veress needle tubal ligation permanent sterilization uterus adnexa cavity laparoscope laparoscopic needle sterilization MEDICAL_TRANSCRIPTION,Description Cystoscopy transurethral resection of medium bladder tumor 4 0 cm in diameter and direct bladder biopsy Medical Specialty Surgery Sample Name TURBT Transcription PREOPERATIVE DIAGNOSIS Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder POSTOPERATIVE DIAGNOSIS Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder TITLE OF OPERATION Cystoscopy transurethral resection of medium bladder tumor 4 0 cm in diameter and direct bladder biopsy ANESTHESIA General laryngeal mask INDICATIONS This patient is a 59 year old white male who had an initial occurrence of a transitional cell carcinoma 5 years back He was found to have a new tumor last fall and cystoscopy in November showed Ta papillary appearing lesion inside the bladder neck anteriorly The patient had coronary artery disease and required revascularization which occurred at the end of December prior to the tumor resection He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT FINDINGS Cystoscopy of the anterior and posterior urethra was within normal limits From 12 o clock to 4 o clock inside the bladder neck there was a papillary tumor with some associated blood clot This was completely resected There was an abnormal dysplastic area in the left lateral wall that was biopsied and the remainder of the bladder mucosa appeared normal The ureteral orifices were in the orthotopic location Prostate was 15 g and benign on rectal examination and there was no induration of the bladder PROCEDURE IN DETAIL The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion He had been given oral ciprofloxacin for prophylaxis Rectal bimanual examination was performed with the findings described Cystourethroscopy was performed with a 23 French ACMI panendoscope and 70 degree lens with the findings described A barbotage urine was obtained for cytology The cystoscope was removed and a 24 French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced Several biopsies were taken from the tumor and sent to the tumor bank I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria Because of the Ta appearance I did not intentionally dissect deeper into the muscle Complete hemostasis was obtained All the chips were removed with an Ellik evacuator Using the cold cup biopsy forceps biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved The irrigant was clear At the conclusion of the procedure the resectoscope was removed and a 24 French Foley catheter was placed for efflux of clear irrigant The patient was then returned to the supine position awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords surgery transitional cell carcinoma urinary bladder bladder tumor cystoscopy transurethral resection acmi panendoscope foley catheter cold cup biopsy forceps ta nx mx cold cup biopsy laryngeal mask bladder neck bladder biopsy tumor MEDICAL_TRANSCRIPTION,Description True cut needle biopsy of the breast This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin Medical Specialty Surgery Sample Name True Cut Needle Biopsy Breast Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the left breast POSTOPERATIVE DIAGNOSIS Carcinoma of the left breast PROCEDURE PERFORMED True cut needle biopsy of the breast GROSS FINDINGS This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin At this time a true cut needle biopsy was performed PROCEDURE The patient was taken to operating room is laid in the supine position sterilely prepped and draped in the usual fashion The area over the left breast was infiltrated with 1 1 mixture of 0 25 Marcaine and 1 Xylocaine Using a 18 gauge automatic true cut needle core biopsy five biopsies were taken of the left breast in core fashion Hemostasis was controlled with pressure The patient tolerated the procedure well pending the results of biopsy Keywords surgery carcinoma true cut needle biopsy nipple discharge dimpling puckering breast MEDICAL_TRANSCRIPTION,Description Nerve root decompression at L45 on the left side Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left Interpretation of radiograph Medical Specialty Surgery Sample Name Tun L Catheter Placement Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low back pain with left greater than right lower extremity radiculopathy POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Nerve root decompression at L45 on the left side 2 Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION FOR PROCEDURE Severe and excruciating pain in the lumbar spine and lower extremity MRI shows disc pathology as well as facet arthrosis SUMMARY OF PROCEDURE The patient was admitted to the operating room consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels After the towels were places then sterile drapes were placed on top of that After which time the Epimed catheter was then placed this was done by first repositioning the C Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5 verifying the sacral hiatus The skin over the sacral hiatus was then injected with 1 Lidocaine and an 18 gauge needle was used for skin puncture The 18 gauge needle was inserted off of midline A 16 gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss of resistance technique the needle was placed Negative aspiration was carefully performed Omnipaque 240 dye was then injected through the 16 gauge RK needle The classical run off was noted A filling defect was noted L45 nerve root on the left side After which time 10 cc of 0 25 Marcaine Triamcinolone 9 1 mixture was then infused through the 16 R K Needle Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique An Epimed Tun L catheter was then inserted through the 16 gauage R K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized The tip of the catheter was noted to be L45 level on the left side After this the 16 gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side After this was successfully done the catheter was then secured in place this was done with Neosporin ointment a Split 2x2 Op site and Hypofix tape The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected The classical run off was noted in the lumbar region Some lyses of adhesions were also visualized at this time with barbotage technique Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect After which time negative aspiration was again performed through the Epimed Tun L catheter and then 10 cc of solution was then infused through the catheter this was done over a 10 minute period with initial 3 cc test dose Approximately 3 minutes elapsed and then the remaining 7 cc were infused Solution consisting of 8 cc of 0 25 Marcaine 2 cc of Triamcinolone and 1 cc of Wydase The catheter was then capped with a bacterial filter The patient was noted to have tolerated the procedure well without any complications Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure This verified positive nerve root decompression The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side Positive myelogram without dural puncture was noted during this procedure no sub dural spread of Omnipaque 240 dye was noted This patient did not report any problems and reported pain reduction Keywords surgery low back syndrome low back pain nerve root decompression steroid solution c arm epimed tun l catheter nerve root negative aspiration omnipaque dye filling defect nerve root catheter adhesions injection needle MEDICAL_TRANSCRIPTION,Description Postpartum tubal ligation and removal of upper abdominal skin wall mass Medical Specialty Surgery Sample Name Tubal Ligation Postpartum Transcription PREOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass POSTOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass OPERATION PERFORMED Postpartum tubal ligation and removal of upper abdominal skin wall mass ESTIMATED BLOOD LOSS Less than 5 mL DRAINS None ANESTHESIA Spinal INDICATION This is a 35 year old white female gravida 6 para 3 0 3 3 who is status post delivery on 09 18 2007 The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level PROCEDURE IN DETAIL The patient was taken to the operating room placed in a seated position with spinal form of anesthesia administered by anesthesia department The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed The fascia grasped with two Kocher s and then sharply incised and then peritoneum was entered with use of blunt dissection Two Army Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock s and followed to the fimbriated end A modified Pomeroy technique was completed with double tying of with 0 chromic then upper portion was sharply incised and the cut fallopian tube edges were then cauterized Adequate hemostasis was noted This tube was placed back in its anatomic position The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side and upper portion was then sharply incised and the cut edges re cauterized with adequate hemostasis and this was placed back in its anatomic position The peritoneum as well as fascia was reapproximated with 0 Vicryl The subcutaneous tissues reapproximated with 3 0 Vicryl and skin edges reapproximated with 4 0 Vicryl as well in a subcuticular stitch Pressure dressings were applied Marcaine 10 mL was used prior to making an incision Sterile dressing was applied The large mole like lesion was grasped with Allis It was approximately 1 cm x 0 5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4 0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied Instrument count needle count and sponge counts were all correct and the patient was taken to recovery room in stable condition Keywords surgery sterilization fallopian tube tubal ligation postpartum MEDICAL_TRANSCRIPTION,Description Laparoscopic tubal fulguration Medical Specialty Surgery Sample Name Tubal Fulguration Laparoscopic Transcription A 1 cm infraumbilical skin incision was made Through this a Veress needle was inserted into the abdominal cavity The abdomen was filled with approximately 2 liters of CO2 gas The Veress needle was withdrawn A trocar sleeve was placed through the incision into the abdominal cavity The trocar was withdrawn and replaced with the laparoscope A 1 cm suprapubic skin incision was made Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope The trocar was withdrawn and replaced with a probe The patient was placed in Trendelenburg position and the bowel was pushed out of the pelvis Upon visualization of the pelvis organs the uterus fallopian tubes and ovaries were all normal The probe was withdrawn and replaced with the bipolar cautery instrument The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus Electrical current was applied to the tube at this point and fulgurated The tube was then regrasped just distal to this and refulgurated It was then regrasped just distal to the lateral point and refulgurated again The same procedure was then carried out on the opposite tube The bipolar cautery instrument was withdrawn and replaced with the probe The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes The upper abdomen was visualized and the liver surface was normal The gas was allowed to escape from the abdomen and the instruments were removed The skin incisions were repaired The instruments were removed from the vagina There were no complications to the procedure Blood loss was minimal The patient went to the postanesthesia recovery room in stable condition Keywords surgery tubal fulguration cohen cannula laparoscopic trendelenburg position veress needle abdominal cavity bipolar cautery dorsal lithotomy fallopian tubes fimbriated ends fulgurated laparoscope uterus distal trocar tubesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Laparoscopic bilateral tubal ligation with Falope rings Medical Specialty Surgery Sample Name Tubal Ligation Transcription DIAGNOSIS Multiparous female desires permanent sterilization NAME OF OPERATION Laparoscopic bilateral tubal ligation with Falope rings ANESTHESIA General ET tube COMPLICATIONS None FINDINGS Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid PROCEDURE The patient was taken to the operating room and placed on the table in the supine position After adequate general anesthesia was obtained she was placed in the lithotomy position and examined She was found to have an anteverted uterus and no adnexal mass She was prepped and draped in the usual fashion The Foley catheter was placed A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix An infraumbilical incision was made with the knife A Veress needle was inserted into the abdomen Intraperitoneal location was verified with approximately 10 cc of sterile solution A pneumoperitoneum was created The Veress needle was then removed and a trocar was inserted directly without difficulty Intraperitoneal location was verified visually with the laparoscope There was no evidence of any intra abdominal trauma Each fallopian tube was elevated with a Falope ring applicator and a Falope ring was placed on each tube with a 1 cm to 1 5 cm portion of the tube above the Falope ring The pneumoperitoneum was evacuated and the trocar was removed under direct visualization An attempt was made to close the fascia with a figure of eight suture However this was felt to be more subcutaneous The skin was closed in a subcuticular fashion and the patient was taken to the recovery room awake with vital signs stable Keywords surgery sterilization laparoscopic bilateral tubal ligation with falope rings falope ring applicator laparoscopic bilateral tubal ligation bilateral tubal ligation veress needle tubal ligation falope rings anesthesia tubal ligation falope MEDICAL_TRANSCRIPTION,Description Insertion of a triple lumen central line through the right subclavian vein by the percutaneous technique This lady has a bowel obstruction She was being fed through a central line which as per the patient was just put yesterday and this slipped out Medical Specialty Surgery Sample Name Ttriple Lumen Central Line Transcription PREOPERATIVE DIAGNOSES 1 Bowel obstruction 2 Central line fell off POSTOPERATIVE DIAGNOSES 1 Bowel obstruction 2 Central line fell off PROCEDURE Insertion of a triple lumen central line through the right subclavian vein by the percutaneous technique PROCEDURE DETAIL This lady has a bowel obstruction She was being fed through a central line which as per the patient was just put yesterday and this slipped out At the patient s bedside after obtaining an informed consent the patient s right deltopectoral area was prepped and draped in the usual fashion Xylocaine 1 was infiltrated and with the patient in Trendelenburg position she had her right subclavian vein percutaneously cannulated without any difficulty A Seldinger technique was used and a triple lumen catheter was inserted There was a good flow through all three ports which were irrigated with saline prior to connection to the IV solutions The catheter was affixed to the skin with sutures and then a dressing was applied The postprocedure chest x ray revealed that there were no complications to the procedure and that the catheter was in good place Keywords surgery central line triple lumen central line subclavian vein bowel obstruction lumen percutaneous bowel obstruction MEDICAL_TRANSCRIPTION,Description Trigger thumb release Right trigger thumb The A 1 pulley was divided along its radial border completely freeing the stenosing tenosynovitis trigger release Medical Specialty Surgery Sample Name Trigger Thumb Release 1 Transcription PREOPERATIVE DIAGNOSIS Right trigger thumb POSTOPERATIVE DIAGNOSIS Right trigger thumb OPERATIONS PERFORMED Trigger thumb release ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon with local COMPLICATIONS Keywords surgery trigger thumb trigger thumb release tenosynovitis trigger tenosynovitis release thumb tourniquet trigger MEDICAL_TRANSCRIPTION,Description Foraminal disc herniation of left L3 L4 Enlarged dorsal root ganglia of the left L3 nerve root Transpedicular decompression of the left L3 L4 with discectomy Medical Specialty Surgery Sample Name Transpedicular Decompression Transcription PREOPERATIVE DIAGNOSIS Foraminal disc herniation of left L3 L4 POSTOPERATIVE DIAGNOSES 1 Foraminal disc herniation of left L3 L4 2 Enlarged dorsal root ganglia of the left L3 nerve root PROCEDURE PERFORMED Transpedicular decompression of the left L3 L4 with discectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal SPECIMEN None HISTORY This is a 55 year old female with a four month history of left thigh pain An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root which appears to be a foraminal disc herniation effacing the L3 nerve root Upon exploration of the nerve root it appears that there was a small disc herniation in the foramen but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body so otherwise the surrounding anatomy is normal I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer at this point I was not able to perform this biopsy without prior consent from the patient So surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations OPERATIVE PROCEDURE The patient was taken to OR 5 at ABCD General Hospital in a gurney Department of Anesthesia administered general anesthetic Endotracheal intubation followed The patient received the Foley catheter She was then placed in a prone position on a Jackson table Bony prominences were well padded Localizing x rays were obtained at this time and the back was prepped and draped in the usual sterile fashion A midline incision was made over the L3 L4 disc space taking through subcutaneous tissues sharply dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3 Retractors were placed into the wound to retract the musculature At this point the pars interarticularis was identified and the facet joint of L2 L3 was identified A marker was placed over the pedicle of L3 and confirmed radiographically Next a microscope was brought onto the field The remainder of the procedure was noted with microscopic visualization A high speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis At this point soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen As the disc space of L3 L4 is identified there is a small prominence of the disc but not as impressive as I would expect on the MRI A discectomy was performed at this time removing only small portions of the lateral aspect of the disc Next the nerve root was clearly dissected out and visualized the lateral aspect of the nerve root appears to be normal in structural appearance The medial aspect with the axilla of the nerve root appears to be enlarged The color of the tissue was consistent with a nerve root tissue There was no identifiable plane and this is a gentle enlargement of the nerve root There are no circumscribed lesions or masses that can easily be separated from the nerve root As I described in the initial paragraph since I was not prepared to perform a biopsy on the nerve and the patient had not been consented I do not think it is reasonable to take the patient to this procedure because she will have persistent weakness and pain in the leg following this procedure So at this point there is no further decompression A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral The pedicle was palpated inferiorly and medially and there was no compression as the nerve root can be easily moved medially The wound was then irrigated copiously and suctioned dry A concoction of Duramorph and ______ was then placed over the nerve root for pain control The retractors were removed at this point The fascia was reapproximated with 1 Vicryl sutures subcutaneous tissues with 2 Vicryl sutures and Steri Strips covering the incision The patient transferred to the hospital gurney extubated by Anesthesia and subsequently transferred to Postanesthesia Care Unit in stable condition Keywords surgery dorsal root ganglia nerve root discectomy foraminal disc herniation transpedicular decompression lateral aspects disc herniation nerve anesthesia foraminal MEDICAL_TRANSCRIPTION,Description Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter Hyperpyrexia leukocytosis ventilator dependent respiratory failure and acute pancreatitis Medical Specialty Surgery Sample Name Triple Lumen Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Hyperpyrexia leukocytosis 2 Ventilator dependent respiratory failure 3 Acute pancreatitis POSTOPERATIVE DIAGNOSES 1 Hyperpyrexia leukocytosis 2 Ventilator dependent respiratory failure 3 Acute pancreatitis PROCEDURE PERFORMED 1 Insertion of a right brachial artery arterial catheter 2 Insertion of a right subclavian vein triple lumen catheter ANESTHESIA Local 1 lidocaine BLOOD LOSS Less than 5 cc COMPLICATIONS None INDICATIONS The patient is a 46 year old Caucasian female admitted with severe pancreatitis She was severely dehydrated and necessitated some fluid boluses The patient became hypotensive required many fluid boluses became very anasarcic and had difficulty with breathing and became hypoxic She required intubation and has been ventilator dependent in the Intensive Care since that time The patient developed very high temperatures as well as leukocytosis Her lines required being changed PROCEDURE 1 RIGHT BRACHIAL ARTERIAL LINE The patient s right arm was prepped and draped in the usual sterile fashion There was a good brachial pulse palpated The artery was cannulated with the provided needle and the kit There was good arterial blood return noted immediately On the first stick the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery The femoral catheter was used in this case secondary to the patient s severe edema and anasarca We did not feel that the shorter catheter would provide enough length The catheter was connected to the system and flushed without difficulty A good waveform was noted The catheter was sutured into place with 3 0 silk suture and OpSite dressing was placed over this 2 RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER The patient was prepped and draped in the usual sterile fashion 1 Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle Using the anesthetic needle we checked down to the soft tissues anesthetizing as we proceeded to the angle of the clavicle this was also anesthetized Next a 18 gauge thin walled needle was used following the same track to the angle of clavicle We roughed the needle down off the clavicle and directed it towards the sternal notch There was good venous return noted immediately The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein The needle was then removed A small skin nick was made with a 11 blade scalpel and the provided dilator was used to dilate the skin soft tissue and vein Next the triple lumen catheter was inserted over the guidewire without difficulty The guidewire was removed All the ports aspirated and flushed without difficulty The catheter was sutured into place with 3 0 silk suture and a sterile OpSite dressing was also applied The patient tolerated the above procedures well A chest x ray has been ordered however it has not been completed at this time this will be checked and documented in the progress notes Keywords surgery hyperpyrexia leukocytosis ventilator dependen respiratory failure pancreatitis brachial artery arterial catheter subclavian vein triple lumen catheter catheter brachial needle MEDICAL_TRANSCRIPTION,Description Need for intravenous access Insertion of a right femoral triple lumen catheter he patient is also ventilator dependent respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access Medical Specialty Surgery Sample Name Triple Lumen Catheter Insertion 1 Transcription PREOPERATIVE DIAGNOSIS Need for intravenous access POSTOPERATIVE DIAGNOSIS Need for intravenous access PROCEDURE PERFORMED Insertion of a right femoral triple lumen catheter ANESTHESIA Includes 4 cc of 1 lidocaine locally ESTIMATED BLOOD LOSS Minimum INDICATIONS The patient is an 86 year old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site The patient is also ventilator dependent respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access PROCEDURE The patient s legal guardian was talked to All questions were answered and consent was obtained The patient was sterilely prepped and draped Approximately 4 cc of 1 lidocaine was injected into the inguinal site A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30 degree angle cephalad and aspirated until a dark venous blood was aspirated A guidewire was then placed through the needle The needle was then removed The skin was ________ at the base of the wire and a dilator was placed over the wire The triple lumen catheters were then flushed with bacteriostatic saline The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times The wire was then carefully removed Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports Each port was closed off and also kept off Straight needle suture was then used to suture the triple lumen catheter down to the skin Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site The surgical site was then sterilely cleaned The patient tolerated the full procedure well There were no complications The nurse was then contacted to allow for access of the triple lumen catheter Keywords surgery intravenous access catheter femoral triple lumen catheter triple lumen catheter lumen ventilator respiratory guidewire MEDICAL_TRANSCRIPTION,Description Trigger finger release A longitudinal incision was made over the digit s A1 pulley Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The sheath was opened under direct vision with a scalpel and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease Medical Specialty Surgery Sample Name Trigger Finger Release Transcription PROCEDURE Trigger finger release PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made over the digit s A1 pulley Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The sheath was opened under direct vision with a scalpel and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease Meticulous hemostasis was maintained with bipolar electrocautery The tendons were identified and atraumatically pulled to ensure that no triggering remained The patient then actively moved the digit and no triggering was noted After irrigating out the wound with copious amounts of sterile saline the skin was closed with 5 0 nylon simple interrupted sutures The wound was dressed and the patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery a1 pulley neurovascular bundles trigger finger release proximal digital digital crease trigger finger trigger finger sheath incision MEDICAL_TRANSCRIPTION,Description Trigger thumb release A transverse incision was made over the MPJ crease of the thumb Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles Medical Specialty Surgery Sample Name Trigger Thumb Release Transcription PROCEDURE Trigger thumb release PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual sterile fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A transverse incision was made over the MPJ crease of the thumb Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The flexor sheath was opened under direct vision with a scalpel and then a scissor was used to release the A1 pulley under direct vision on the radial side from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx Meticulous hemostasis was maintained with bipolar electrocautery The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained The patient then actively moved the thumb and no triggering was noted After irrigating out the wound with copious amounts of sterile saline the skin was closed with 5 0 nylon simple interrupted sutures The wound was dressed and the patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery neurovascular a1 pulley trigger thumb release mpj crease trigger thumb flexor sheath triggering sheath proximal incision MEDICAL_TRANSCRIPTION,Description Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines Medical Specialty Surgery Sample Name Transesophageal Echocardiography Probe Transcription INDICATIONS FOR PROCEDURE Impending open heart surgery for closure of ventricular septal defect in a 4 month old girl Procedures were done under general anesthesia The patient was already in the operating room under general anesthesia Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures PROCEDURE 1 Insertion of transesophageal echocardiography probe DESCRIPTION OF PROCEDURE 1 The probe was well lubricated and with digital manipulation was passed into the esophagus without resistance The probe was placed so that the larger diameter was in the anterior posterior position during insertion The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography At the end it was removed without trauma and there was no blood tingeing It is to be noted that approximately 30 minutes after removing the cannula I inserted a 14 French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned There was no overt bleeding PROCEDURE 2 Attempted and unsuccessful insertion of arterial venous lines DESCRIPTION OF PROCEDURE 2 Both groins were prepped and draped The patient was placed at 10 degrees head up position A Cook 4 French double lumen 8 cm catheter kit was opened Using the 21 gauge needle that comes with the kit several attempts were made to insert central venous and then an arterial line in the left groin There were several successful punctures of these vessels but I was unable to advance Seldinger wire After removal of the needles the area was compressed digitally for approximately 5 minutes There was a small hematoma that was not growing Initially the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds Using 1 lidocaine I infiltrated the vessels of the groin both medial and lateral to the vascular sheath Further observation the capillary refill and circulation of the left leg became more than adequate The O2 saturation monitor that was on the left toe functioned well throughout the procedures from the beginning to the end At the end of the procedure the circulation of the leg was intact Keywords surgery impending open heart surgery ventricular septal defect antibiotic prophylaxis cefazolin transesophageal echocardiography probe arterial venous lines groin transesophageal echocardiography echocardiography probe insertion transesophageal arterial venous groins echocardiography probe MEDICAL_TRANSCRIPTION,Description Transurethral resection of a medium bladder tumor TURBT left lateral wall Medical Specialty Surgery Sample Name Transurethral Resection Of Bladder Tumor Transcription PREOPERATIVE DIAGNOSIS Bladder tumor POSTOPERATIVE DIAGNOSIS Bladder tumor PROCEDURE PERFORMED Transurethral resection of a medium bladder tumor TURBT left lateral wall ANESTHESIA Spinal SPECIMEN TO PATHOLOGY Bladder tumor and specimen from base of bladder tumor DRAINS A 22 French 3 way Foley catheter 30 mL balloon ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE This is a 74 year old male who presented with microscopic and an episode of gross hematuria He underwent an IVP which demonstrated enlarged prostate and normal upper tracts Cystoscopy in the office demonstrated a 2 5 to 3 cm left lateral wall bladder tumor He is brought to the operating room for transurethral resection of that bladder tumor DESCRIPTION OF OPERATION After preoperative counseling of the patient and his wife the patient was taken to the operating room and administered a spinal anesthetic He was placed in lithotomy position and prepped and draped in the usual fashion Using the visual obturator the resectoscope was then inserted per urethra into the bladder The bladder was inspected confirming previous cystoscopic findings of a 2 5 to 3 cm left lateral wall bladder tumor away from the ureteral orifice Using the resectoscope loop the tumor was then resected down to its base in a stepwise fashion Following completion of resection down to the base the bladder was _______ free of tumor specimen The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen this was sent as a separate pathological specimen Hemostasis was assured with electrocautery The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor Following completion of the fulguration there was good hemostasis The remainder of the bladder was without evidence of significant abnormality Both ureteral orifices were visualized and noted to drain freely of clear urine The bladder was filled and the resectoscope was removed A 22 French 3 way Foley catheter was inserted per urethra into the bladder The balloon was inflated to 30 mL The catheter with sterile continuous irrigation and was noted to drain clear irrigant The patient was then removed from lithotomy position He was in stable condition Keywords surgery turbt bladder tumor cystoscopic resectoscope hemostasis foley catheter tumor bladder lithotomy transurethral resection hematuria MEDICAL_TRANSCRIPTION,Description Tracheotomy for patient with respiratory failure Medical Specialty Surgery Sample Name Tracheotomy 1 Transcription PREOPERATIVE DIAGNOSIS Respiratory failure POSTOPERATIVE DIAGNOSIS Respiratory failure OPERATIVE PROCEDURE Tracheotomy ANESTHESIA General inhalational DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine on the operating table General inhalational anesthesia was administered through the patient s existing 4 0 endotracheal tube The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring The incision area was infiltrated with 1 Xylocaine with epinephrine 1 100 000 A 67 blade was used to perform the incision Electrocautery was used to remove excess fat tissue to expose the strap muscles The strap muscles were grasped and divided in the midline with a cutting electrocautery Sharp dissection was used to expose the anterior trachea and cricoid cartilage The thyroid isthmus was identified crossing just below the cricoid cartilage This was divided in the midline with electrocautery Blunt dissection was used to expose adequate cartilaginous rings A 4 0 silk was used for stay sutures to the midline of the cricoid Additional stay sutures were placed on each side of the third tracheal ring Thin DuoDerm was placed around the stoma The tracheal incision was performed with a 11 blade through the second third and fourth tracheal rings The cartilaginous edges were secured to the skin edges with interrupted 4 0 Monocryl A 4 5 PED tight to shaft cuffed Bivona tube was placed and secured with Velcro ties A flexible scope was passed through the tracheotomy tube The carina was visualized approximately 1 5 cm distal to the distal end of the tracheotomy tube Ventilation was confirmed There was good chest rise and no appreciable leak The procedure was terminated The patient was in stable condition Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition Keywords surgery bivona tube duoderm tracheotomy tube respiratory failure cricoid cartilage tracheotomy tracheal MEDICAL_TRANSCRIPTION,Description Trabeculectomy with mitomycin C Sample Template Medical Specialty Surgery Sample Name Trabeculectomy Transcription PREOPERATIVE DIAGNOSIS Open angle glaucoma OX POSTOPERATIVE DIAGNOSIS Open angle glaucoma OX PROCEDURE Trabeculectomy with mitomycin C XXX eye 0 3 c per mg times three minutes INDICATIONS This is a XX year old wo man with glaucoma in the OX eye uncontrolled by maximum tolerated medical therapy PROCEDURE The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding infection reoperation retinal detachment diplopia ptosis loss of vision and loss of the eye corneal hemorrhage hypotony elevated pressure worsening of glaucoma and corneal edema Informed consent was obtained Patient received several sets of drops in his her XXX eye including Ocuflox Ocular and pilocarpine S He was taken to the operating room where monitored anesthetic care was initiated Retrobulbar anesthesia was then administered to the XXX eye using a 50 50 mixture of 2 plain lidocaine and 0 05 Marcaine The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position A Lieberman lid speculum was used to provide exposure Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap Residual episcleral vessels were cauterized with Eraser tip cautery Sponges soaked in mitomycin C 0 3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock Sponges were removed and area was copiously irrigated with balanced salt solution A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap This was dissected anteriorly with a crescent blade to clear cornea A temporal paracentesis was then made Scleral flap was lifted and a Super blade was used to enter the anterior chamber A Kelly Descemet punch was used to remove a block of limbal tissue DeWecker scissors were used to perform a surgical iridectomy The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea A scleral flap was then re approximated back on the bed One end of the scleral flap was closed with a 10 0 nylon suture in interrupted fashion and the knot was buried The other end of the scleral flap was closed with 10 0 nylon suture in interrupted fashion and the knot was buried The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber Therefore it was felt that another 10 0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber Conjunctiva was then re approximated to the limbus and closed with 9 0 Vicryl suture on a TG needle at each of the peritomy ends Then a horizontal mattress style 9 0 Vicryl suture was placed at the center of the conjunctival peritomy The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck cel sponge The anterior chamber was inflated and there was noted that the superior bleb was well formed At the end of the case the pupil was round the chamber was formed and the pressure was felt to be adequate Speculum and drapes were carefully removed Ocuflox and Maxitrol ointment were placed over the eye Atropine was also placed over the eye Then an eye patch and eye shield were placed over the eye The patient was taken to the recovery room in good condition There were no complications Keywords surgery trabeculectomy kelly descemet punch maxitrol ointment open angle glaucoma tg needle bleeding corneal edema corneal hemorrhage hypotony diplopia elevated pressure glaucoma infection iridectomy loss of the eye loss of vision mitomycin c ptosis reoperation retinal detachment temporal paracentesis worsening of glaucoma balanced salt solution anterior chamber scleral flap eye angle mitomycin conjunctival chamber flap MEDICAL_TRANSCRIPTION,Description Tracheostomy and thyroid isthmusectomy Ventilator dependent respiratory failure and multiple strokes Medical Specialty Surgery Sample Name Tracheostomy Thyroid Isthmusectomy Transcription PREOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes POSTOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes PROCEDURES PERFORMED 1 Tracheostomy 2 Thyroid isthmusectomy ANESTHESIA General endotracheal tube BLOOD LOSS Minimal less than 25 cc INDICATIONS The patient is a 50 year old gentleman who presented to the Emergency Department who had had multiple massive strokes He had required ventilator assistance and was transported to the ICU setting Because of the numerous deficits from the stroke he is expected to have a prolonged ventilatory course and he will be requiring long term care PROCEDURE After all risks benefits and alternatives were discussed with multiple family members in detail informed consent was obtained The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt tip marker The skin was then anesthetized with a mixture of 1 lidocaine and 1 100 000 epinephrine solution The patient was prepped and draped in usual fashion The surgeons were gowned and gloved A vertical skin incision was then made with a 15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage Blunt dissection was then carried down until the fascia overlying the strap muscles were identified At this point the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery Once the strap muscles have been identified palpation was performed to identify any arterial aberration A high riding innominate was not identified At this point it was recognized that the thyroid gland was overlying the trachea could not be mobilized Therefore dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland which was then doubly clamped and ligated with Bovie cautery Suture ligation with 3 0 Vicryl was then performed on the thyroid gland in a double interlocking fashion This cleared a significant portion of the trachea The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery Now a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea The second tracheal ring was identified The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based At this point the anesthetist was appropriately alerted to deflate the endotracheal tube cuff The airway was entered and inferior to the base window was created The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified At this point a 8 Shiley tracheostomy tube was inserted freely into the tracheal lumen The balloon was inflated and the ventilator was attached He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist Now all surgical retractors were removed The baseplate of the tracheostomy tube was sutured to the patient s skin with 2 0 nylon suture The tube was further secured around the patient s neck with IV tubing Finally a drain sponge was placed At this point procedure was felt to be complete The patient was returned to the ICU setting in stable condition where a chest x ray is pending Keywords surgery ventilator dependent respiratory failure multiple strokes thyroid thyroid isthmusectomy ventilator dependent respiratory failure strap muscles thyroid gland endotracheal tube cricoid cartilage bovie cautery tracheostomy ventilator strokes cartilage tracheal isthmusectomy MEDICAL_TRANSCRIPTION,Description Tracheostomy change A 6 Shiley with proximal extension was changed to a 6 Shiley with proximal extension Ventilator dependent respiratory failure and laryngeal edema Medical Specialty Surgery Sample Name Tracheostomy Change Transcription PREOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Laryngeal edema POSTOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Laryngeal edema PROCEDURE PERFORMED Tracheostomy change A 6 Shiley with proximal extension was changed to a 6 Shiley with proximal extension INDICATIONS The patient is a 60 year old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed The patient was noted at that time to have transglottic edema Biopsies were taken At the time of surgery it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection The patient is currently postop day 6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support A decision was made to perform tracheostomy change DESCRIPTION OF PROCEDURE The patient was seen in the Intensive Care Unit The patient was placed in a supine position The neck was then extended The sutures that were previously in place in the 6 Shiley with proximal extension were removed The patient was preoxygenated to 100 After several minutes the patient was noted to have a pulse oximetry of 100 The IV tubing that was supporting the patient s trache was then cut The tracheostomy tube was then suctioned The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned With the guidewire in place and with adequate visualization a new 6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea The guidewire was then removed and the inner cannula was then placed into the tracheostomy The patient was then reconnected to the ventilator and was noted to have normal tidal volumes The patient had a tidal volume of 500 and was returning 500 cc to 510 cc The patient continued to saturate well with saturations 99 The patient appeared comfortable and her vital signs were stable A soft trache collar was then connected to the trachesotomy A drain sponge was then inserted underneath the new trache site The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes COMPLICATIONS None DISPOSITION The patient tolerated the procedure well 0 25 acetic acid soaks were ordered to the drain sponge every shift Keywords surgery shiley proximal extension ventilator dependent respiratory failure laryngeal edema tracheostomy cannula respiratory laryngeal nasogastric edema ventilator MEDICAL_TRANSCRIPTION,Description Neck exploration tracheostomy urgent flexible bronchoscopy via tracheostomy site removal of foreign body tracheal metallic stent material dilation distal trachea placement of 8 Shiley single cannula tracheostomy tube Medical Specialty Surgery Sample Name Tracheostomy Transcription PREOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea POSTOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea OPERATION PERFORMED Neck exploration tracheostomy urgent flexible bronchoscopy via tracheostomy site removal of foreign body tracheal metallic stent material dilation distal trachea placement of 8 Shiley single cannula tracheostomy tube INDICATIONS FOR SURGERY The patient is a 50 year old white male with history of progressive tracheomalacia treated in the National Tennessee and several years ago he had a tracheal metallic stent placed with some temporary improvement However developed progressive problems and he had two additional stents placed with some initial improvement Subsequently he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD YYYY He underwent bronchoscopy by Dr W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management Exploration of trachea removal of foreign body stents constricting his airway dilation and stabilization of his trachea were offered to the patient Nature of the proposed procedure including risks and complications of bleeding infection alteration of voice speech swallowing voice changes permanently possibility of tracheotomy temporarily or permanently to maintain his airway loss of voice cardiac risk factors anesthetic risks recurrence of problems upon surgical intervention were all discussed at length The patient stated that he understood and wished to proceed DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in the supine position Following adequate monitoring by Anesthesia Service to maintain sedation the patient s neck was prepped and draped in the sterile fashion The neck was then infiltrated with 1 Xylocaine and 1000 epinephrine A collar incision approximately 1 fingerbreadth above the clavicle this was an outline incision was carried out The skin subcutaneous tissue platysma subplatysmal flaps elevated superiorly and inferiorly Strap muscles were separated in the midline dissection carried down to visceral fascia Beneath the strap muscles there was dense inflammation scarring obscuring palpable landmarks There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable There was a markedly enlarged thyroid isthmus Thyroid isthmus was divided and dense inflammation attachment of the thyroid isthmus fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection Trachea was exposed from the cricoid to the fourth ring which entered down into the chest The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation The tracheal cartilage externally had marked thickening and significant stiffness calcification and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness The trachea was entered and visualized with thickening of the mucosa and submucosa was noted The patient however was able to ventilate at this point a 6 Endo Tube was inserted and general anesthesia administered Once the airway was secured we then proceeded working around the 6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis After removal of the stents and granulation tissue the upper trachea was widely patent The mid trachea had some marked narrowing secondary to granulation Stent material was removed from this area as well In the distal third of the trachea a third stent was embedded within the mucosa not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time All visible stent material in the upper and mid trachea were removed Initial attempt to place a 16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third Also this was removed and a 8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa The distal trachea and mainstem bronchi were widely patent This secured his airway and no further manipulation felt to be needed at this time Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3 0 Vicryl The skin laterally to the trach site was closed with running 2 0 Prolene Tracheostomy tube was secured with interrupted 2 0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition The patient tolerated the procedure well without complication Keywords surgery airway laryngology shiley alteration of voice bronchi bronchoscopy cannula cartilage cricoid flexible foreign body mainstem obstruction perichondrium stenosis stent subglottic swallowing trachea tracheal tracheal stenosis tracheostomy shiley single cannula tracheostomy shiley single cannula single cannula tracheostomy thyroid isthmus stent material tracheostomy tube tube thyroid MEDICAL_TRANSCRIPTION,Description Total thyroidectomy with removal of substernal extension on the left Thyroid goiter with substernal extension on the left Medical Specialty Surgery Sample Name Total Thyroidectomy Transcription PREOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left POSTOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left PROCEDURE PERFORMED Total thyroidectomy with removal of substernal extension on the left THIRD ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 200 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 54 year old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine The patient subsequently then had a CT scan which demonstrated a very large thyroid gland especially on the left side with substernal extension down to the level of the aortic arch The patient was then immediately set up for surgery After risks complications consequences and questions were addressed with the patient a written consent was obtained PROCEDURE The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed After this the patient then had the area marked initially The preoperative setting was then localized with 1 lidocaine and epinephrine 1 100 000 approximately 10 cc total After this the patient was then prepped and draped in the usual sterile fashion A 15 Bard Parker was then utilized to make a skin incision horizontally approximately 5 cm on either side from midline After this a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle There appeared to be a natural dehiscence of the platysma in the midline A sub platysmal dissection was then performed in the superior inferior and lateral directions with the help of a bear claw Metzenbaum scissors and DeBakey forceps Any bleeding was controlled with monopolar cauterization After this the two anterior large jugular veins were noted and resected laterally The patient s trachea appeared to be slightly deviated to the right with identification finally of the midline raphe off midline to the right This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors After this was dissected the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland After this attention was then drawn to the left gland where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly After this the superior and inferior parathyroid glands were noted The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly After this the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors After this the thyroid gland was further freed down to the level of the Berry s ligament inferiorly and the dissection was carried once again more superiorly The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry s ligament tissue from the gland with the bipolar cauterization and the fine stat Finally attention was then drawn back to the patient s right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry s ligament The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with 2 0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally The Berry s ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization After this Surgicel was then placed in the bilateral neck regions and a 10 Jackson Pratt drain was then placed within the left neck region with some extension over to the right neck region This was brought out through the inferior skin incision and secured to the skin with a 2 0 nylon suture The strap muscles were then reapproximated with a running 3 0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a 4 0 undyed Vicryl The skin was then reapproximated with a 5 0 Prolene subcuticular along with a 6 0 fast over the top After this Mastisol Steri Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain The patient was then turned back to Anesthesia extubated in the operating room and transferred to Recovery in stable condition The patient tolerated the procedure well and remained stable throughout Keywords surgery thyroid goiter goiter thyroid total thyroidectomy berry s ligament dissection gland thyroidectomy anesthesia berry s ligament cauterization extension substernal MEDICAL_TRANSCRIPTION,Description Left thyroid mass Left total thyroid lumpectomy The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan which demonstrated a hot nodule on the left anterior pole Medical Specialty Surgery Sample Name Total Thyroid Lumpectomy Transcription PREOPERATIVE DIAGNOSIS Left thyroid mass POSTOPERATIVE DIAGNOSIS Left thyroid mass PROCEDURE PERFORMED Left total thyroid lumpectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 50 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 76 year old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan which demonstrated a hot nodule on the left anterior pole The patient was then discussed the risks complications and consequences of a surgical procedure and a written consent was obtained PROCEDURE The patient is brought to the operative suite by Anesthesia The patient was placed on the operative table in supine position After this the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll After this the skin incision was marked approximately two fingerbreadths above the sternal notch It was then localized with 1 lidocaine with epinephrine 1 1000 approximately 7 cc total After this the patient was then prepped and draped in the usual sterile fashion and a 10 blade was then utilized to make a skin incision The subcutaneous tissue was then bluntly dissected utilizing a Ray Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions After this the midline was then identified and grasped on either side with a DeBakey forceps The raphe was noted and Bovie cauterization was utilized to cut down into this region The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle It was separated on the left side from the patient s sternothyroid muscle After this the sternothyroid muscle was identified grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners After this the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself It was freed from the thyroid gland and reflected laterally and posteriorly The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally After this the patient s thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter As the gland was rotated more anteriorly the recurrent laryngeal nerve on the left side was identified and further dissection along Berry s ligament on the medial aspect was performed The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected After this the gland was easily rotated anteriorly with further dissection carried up to the superior pole The superior pole was exposed with the help of a Richardson and Army Navy retractors with cross clamping and tying of the superior laryngeal artery and vein Further the small bleeding vessels were identified and bipolared and cut with the Metzenbaum scissors The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea Berry s ligament was finally freed and the gland was cross clamped on the opposing thyroid isthmus with a mosquito After this the gland was cut with a Metzenbaum scissors and tied with a 3 0 undyed Vicryl tie The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization Surgicel was then cut in small strips and three replaced in the lateral part of the neck The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses The strap muscles were then reapproximated with 3 0 Vicryl on a SH followed by reapproximation of the subcutaneous tissue with 4 0 Vicryl followed by reapproximation of the skin by running subcuticular 5 0 Prolene and a 6 0 fast absorbing gut Mastisol Steri Strips and bacitracin were placed followed by a sterile 4 x 4 dressing The patient was then turned back to Anesthesia extubated in the operating room and transferred to Recovery in stable condition The patient tolerated the procedure well and will be admitted to hospital for 23 hour observation and will be followed up in one week afterwards Keywords surgery thyroid lumpectomy thyroid uptake scan thyroid mass nodule total thyroid lumpectomy parathyroid glands berry s ligament metzenbaum scissors thyroid gland thyroid mass gland thyroid total MEDICAL_TRANSCRIPTION,Description Total knee replacement A midline incision was made centered over the patella Dissection was sharply carried down through the subcutaneous tissues A median parapatellar arthrotomy was performed Medical Specialty Surgery Sample Name Total Knee Replacement 1 Transcription PROCEDURES Total knee replacement PROCEDURE DESCRIPTION The patient was bought to the operating room and placed in the supine position After induction of anesthesia a tourniquet was placed on the upper thigh Sterile prepping and draping proceeded The tourniquet was inflated to 300 mmHg A midline incision was made centered over the patella Dissection was sharply carried down through the subcutaneous tissues A median parapatellar arthrotomy was performed The lateral patellar retinacular ligaments were released and the patella was retracted laterally Proximal medial tibia was denuded with mild release of medial soft tissues The ACL and PCL were released The medial and lateral menisci and suprapatellar fat pad were removed These releases allowed for anterior subluxation of tibia An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau perpendicular to the axis of the tibia Its alignment was checked with the rod and found to be adequate The tibia was then allowed to relocate under the femur An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted and the block was pinned in appropriate position judging correct rotation using a variety of techniques An anterior rough cut was made The distal cutting jig was placed atop this cut surface and pinned to the distal femur and the rod was removed The distal cut was performed A spacer block was placed and adequate balance in extension was adjusted and confirmed as was knee alignment Femoral sizing was performed with the sizer and the appropriate size femoral 4 in 1 chamfer cutting block was pinned in place and the cuts were made The notch cutting block was pinned to the cut surface slightly laterally and the notch cut was then made The trial femoral component was impacted onto the distal femur and found to have an excellent fit A trial tibial plate and polyethylene were inserted and stability was judged and found to be adequate in all planes Appropriate rotation of the tibial component was identified and marked The trials were removed and the tibia was brought forward again The tibial plate size was checked and the plate was pinned to plateau A keel guide was placed and the keel was then made The femoral intramedullary hole was plugged with bone from the tibia The trial tibial component and poly placed and after placement of the femoral component range of motion and stability were checked and found to be adequate in various ranges of flexion and extension The patella was held in a slightly everted position with knee in extension Patellar width was checked with calipers A free hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers Sizing was then performed and 3 lug holes were drilled with the jig in place taking care to medialize and superiorize the component as much as possible given bony anatomy Any excess lateral patellar bone was recessed The trial patellar component was placed and found to have adequate tracking The trials were removed and as the cement was mixed all cut surfaces were thoroughly washed and dried The cement was applied to the components and the cut surfaces with digital pressurization and then the components were impacted The excess cement was removed from the gutters and anterior and posterior parts of the knee The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened Once the cement had hardened the tourniquet was deflated The knee was dislocated again and any excess cement was removed with an osteotome Thorough irrigation and hemostasis were performed The real polyethylene component was placed and pinned Further vigorous power irrigation was performed and adequate hemostasis was obtained and confirmed The arthrotomy was closed using 0 Ethibond and Vicryl sutures The subcutaneous tissues were closed after further irrigation with 2 0 Vicryl and Monocryl sutures The skin was sealed with staples Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap The patient was transferred to the recovery room in stable condition having tolerated the procedure well Keywords surgery proximal medial tibia total knee replacement parapatellar arthrotomy subcutaneous tissues tibial plateau incision cutting patella femur femoral component knee MEDICAL_TRANSCRIPTION,Description Short flap trabeculectomy with lysis of conjunctival scarring tenonectomy peripheral iridectomy paracentesis watertight conjunctival closure and 0 5 mg mL mitomycin x2 minutes left eye Uncontrolled open angle glaucoma and conjunctival scarring left eye Medical Specialty Surgery Sample Name Trabeculectomy Tenonectomy Transcription PREOPERATIVE DIAGNOSES 1 Uncontrolled open angle glaucoma left eye 2 Conjunctival scarring left eye POSTOPERATIVE DIAGNOSES 1 Uncontrolled open angle glaucoma left eye 2 Conjunctival scarring left eye PROCEDURES Short flap trabeculectomy with lysis of conjunctival scarring tenonectomy peripheral iridectomy paracentesis watertight conjunctival closure and 0 5 mg mL mitomycin x2 minutes left eye ANESTHESIA Retrobulbar block with monitored anesthesia care COMPLICATIONS None ESTIMATED BLOOD LOSS Negligible DESCRIPTION OF PROCEDURE The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines In the preoperative area the patient received pilocarpine drops The patient received IV propofol and once somnolent from this a retrobulbar block was administered consisting of 2 Xylocaine plain Approximately 3 mL were given The operative eye then underwent a Betadine prep with respect to the face lids lashes and eye During the draping process care was taken to isolate the lashes A screw type speculum was inserted to maintain patency of lids A 6 0 Vicryl suture was placed through the superior cornea and the eye was reflected downward to expose the superior conjunctiva A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea All Tenons were removed from the overlying sclera and the area was treated with wet field cautery to achieve hemostasis A 2 mm x 3 mm scleral flap was then outlined with a Micro Sharp blade This was approximately one half scleral depth in thickness A crescent blade was then used to dissect forward the clear cornea Hemostasis was again achieved with wet field cautery A Weck Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes The site was then profusely irrigated with balanced salt solution A paracentesis wound was made temporarily and then the Micro Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed A Kelly Descemet punch was then inserted and a trabeculectomy was performed Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0 12 forceps The iris was then repositioned into the eye and the anterior chamber was inflated with BSS The scleral flap was sutured in place with two 10 0 nylon sutures with knots trimmed rotated and buried The overlying conjunctiva was then closed with a running 8 0 Vicryl suture on a BV needle BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage Antibiotic and steroid drops were placed in the eye as was homatropine 5 The antibiotic consisted of Vigamox and the steroid was Econopred Plus A patch and shield were placed over the eye after the drape was removed The patient was taken to the recovery room in good condition She will be seen in followup in the office tomorrow Keywords surgery uncontrolled open angle glaucoma open angle conjunctival scarring trabeculectomy tenonectomy iridectomy paracentesis watertight conjunctival closure conjunctival scarring eye glaucoma cornea scleral MEDICAL_TRANSCRIPTION,Description Tracheostomy with skin flaps and SCOOP procedure FastTract Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease Medical Specialty Surgery Sample Name Tracheostomy SCOOP Procedure Transcription PREOPERATIVE DIAGNOSES 1 Oxygen dependency 2 Chronic obstructive pulmonary disease POSTOPERATIVE DIAGNOSES 1 Oxygen dependency 2 Chronic obstructive pulmonary disease PROCEDURES PERFORMED 1 Tracheostomy with skin flaps 2 SCOOP procedure FastTract ANESTHESIA Total IV anesthesia ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 55 year old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home The patient with extensive smoking history who presents after risks complications and consequences of the SCOOP FastTract procedure were explained PROCEDURE The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position After this the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg The patient s sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch The midline was also marked and 1 lidocaine with epinephrine 1 100 000 at approximately 4 cc total was then utilized to localize the neck After this the patient was then prepped and draped with Hibiclens A skin incision was then made in the midline with a 15 Bard Parker in a vertical fashion After this the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with 2 0 undyed Vicryl ties Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles The patient s sternohyoid muscle was identified and grasped on either side and the midline raphe was identified Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization After this the patient s anterior trachea was then identified and cleaned with pusher After this the cricoid cartilage along the first and second tracheal rings was identified The cricoid hook was placed and the trachea was brought more anteriorly and superiorly After this the patient s head incision was placed below the second tracheal ring with a 15 Bard Parker After this the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage After this the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap After this the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100 The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours The patient will have the stent guidewire removed with a scoop catheter 11 cm placed Keywords surgery oxygen dependency chronic obstructive pulmonary disease tracheostomy scoop procedure nasal cannula scoop procedure fasttract thyroid isthmus cricoid cartilage isthmus oxygen dependency scoop cartilages MEDICAL_TRANSCRIPTION,Description Right total knee arthroplasty Osteoarthritis right knee Medical Specialty Surgery Sample Name Total Knee Arthroplasty Right Transcription PREOPERATIVE DIAGNOSIS ES Osteoarthritis right knee POSTOPERATIVE DIAGNOSIS ES Osteoarthritis right knee PROCEDURE Right total knee arthroplasty DESCRIPTION OF THE OPERATION The patient was brought to the Operating Room and after the successful placement of an epidural as well as general anesthesia administration 1 gm of Ancef preoperatively the patient s right thigh knee and leg were scrubbed prepped and draped in the usual sterile fashion The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg A straight anterior incision was carried down through the skin and subcutaneous tissue Unilateral flaps were developed and a median retinacular parapatellar incision was made The extensor mechanism was partially divided and the patella was everted Some of the femoral bone spurs were resected using an osteotome and a rongeur Ascending drill hole was made in the distal femur and the distal femoral cut anterior and posterior and chamfer cuts were accomplished for a 67 5 femoral component At this point the ACL was resected Some of the fat pad and synovium were resected as well as both medial and lateral menisci A posterior cruciate retractor was utilized the tibia brought forward and a centering drill hole made in the tibia The intramedullary guide was used for cutting the tibia It was set at 8 mm An additional 2 mm was resected because of a moderate defect medially A trial reduction was done with a 71 tibial baseplate This was pinned and drilled and then trial reduction done with a 10 mm insert This gave good stability and a full range of motion The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw A 34 mm component was drilled for A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces A packet of cement was hand mixed pressurized with a spatula into the proximal tibia Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic The tibia baseplate was secured and the patella was inserted held with a clamp The extraneous cement was removed At this point the tibial baseplate was locked into place and the femoral component also seated solidly The knee was extended held in this position for another 5 6 minutes until the cement was cured Further extraneous cement was removed The pneumatic tourniquet was released hemostasis was obtained with electrocoagulation Retinaculum quadriceps and extensor were repaired with multiple figure of eight 1 Vicryl sutures the subcutaneous tissue with 2 0 and the skin with skin staples A sterile bulky compression dressing was placed The patient was stable on operative release Keywords surgery osteoarthritis arthroplasty knee patella retinacular parapatellar total knee arthroplasty total knee knee arthroplasty baseplate femoral tibia MEDICAL_TRANSCRIPTION,Description Total left knee replacement Degenerative arthritis of the left knee Degenerative ware of three compartments of the trochlea the medial as well as the lateral femoral condyles as well was the plateau Medical Specialty Surgery Sample Name Total Knee Replacement Transcription PREOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee POSTOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee PROCEDURE PERFORMED Total left knee replacement on 08 19 03 The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr X TOURNIQUET TIME 76 minutes BLOOD LOSS 150 cc ANESTHESIA General IMPLANT USED FOR PROCEDURE NexGen size F femur on the left with 8 size peg tibial tray a 12 mm polyethylene insert and this a cruciate retaining component The patella on the left was not resurfaced GROSS INTRAOPERATIVE FINDINGS Degenerative ware of three compartments of the trochlea the medial as well as the lateral femoral condyles as well was the plateau The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component HISTORY This is a 69 year old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living He attempted conservative treatment which includes anti inflammatory medications as well as cortisone and Synvisc This has only provided him with temporary relief It is for that reason he is elected to undergo the above named procedure All risks as well as complications were discussed with the patient which include but are not limited to infection deep vein thrombosis pulmonary embolism need for further surgery and further pain He has agreed to undergo this procedure and a consent was obtained preoperatively PROCEDURE The patient was wheeled back to operating room 2 at ABCD General Hospital on 08 19 03 and was placed supine on the operating room table At this time a nonsterile tourniquet was placed on the left upper thigh but not inflated An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure The tourniquet was then inflated to 325 mmHg At this time a standard midline incision was made towards the total knee We did discuss preoperatively for a possible unicompartmental knee replacement for this patient but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus We did start off with a small midline skin incision in case we were going to do a unicompartmental Once we exposed the medial parapatellar mini arthrotomy and visualized the lateral femoral condyle we decided that this patient would not be an optimal candidate for unicompartmental knee replacement It is for this reason that we extended the incision and underwent with the total knee replacement Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella Once the patella was everted we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee At this time a femoral sizer was then placed with reference to the posterior condyles and we measured a size F Once this was performed three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur At this time the intramedullary guide was then inserted and placed in three degrees of external rotation Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues Next this was removed and the distal femoral cutting guide was then placed in five degrees of valgus This was pinned to the distal femur and with careful protection of the collateral ligaments a distal femoral cut was performed At this time the intramedullary guide was removed and a final cutting block was placed This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking At this time the block was pinned and screwed in place with spring pins with careful protection of the soft tissues An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut Peg holes were then drilled The block was then removed and an osteotome was then used to remove all the bony cut pieces At this time with a better exposure of the proximal tibia we placed external tibial guide This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia At this time with careful soft tissue retraction and protection an oscillating saw was used to make a proximal tibial osteotomy Prior to the osteotomy the cut was checked with a depth gauge in order to assure appropriate bony resection At this time a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut which had soft tissue attachments Once this was removed we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface The knee was taken through range of motion and revealed excellent femorotibial articulation The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason we performed a minimal small incision lateral retinacular release Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis At this time an intraoperative x ray was performed which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut At this time the prosthesis was removed A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia Once the drill holes were performed we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components At this time polymethyl methacrylate cement was then mixed The cement was placed on the tibial surface as well as the underneath surface of the component The component was then placed and impacted with excess cement removed In a similar fashion the femoral component was also placed A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content Once the cement was fully hardened the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone Once this was performed copious irrigation was used to irrigate the wound and the wound was then suctioned dry The knee was again taken through range of motion with a 12 mm plastic as well as 14 The 14 appeared to be a bit too tight especially in extremes of flexion We decided to go with a 12 mm polyethylene tray At this time this was placed to the tibial articulation and then left in place This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact A drain was placed and cut to length At this time the knee was irrigated and copiously suction dried 1 0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure of eight fashion A tight capsular closure was performed This was reinforced with a 1 0 running Vicryl suture At this time the knee was again taken through range of motion to assure tight capsular closure At this time copious irrigation was used to irrigate the superficial wound 2 0 Vicryl was used to approximate the wound with figure of eight inverted suture The skin was then approximated with staples The leg was then cleansed Sterile dressing consisting of Adaptic 4x4 ABDs and Kerlix roll were then applied At this time the patient was extubated and transferred to recovery in stable condition Prognosis is good for this patient Keywords surgery degenerative arthritis nexgen polyethylene cruciate total knee replacement proximal tibia knee replacement femoral cutting tibial knee arthritis femur cementation MEDICAL_TRANSCRIPTION,Description NexGen left total knee replacement Degenerative arthritis of left knee The patient is a 72 year old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs Medical Specialty Surgery Sample Name Total Knee Replacement NexGen Transcription PREOPERATIVE DIAGNOSIS Degenerative arthritis of left knee POSTOPERATIVE DIAGNOSIS Degenerative arthritis of left knee PROCEDURE PERFORMED NexGen left total knee replacement ANESTHESIA Spinal TOURNIQUET TIME Approximately 66 minutes COMPLICATIONS None ESTIMATED BLOOD LOSS Approximately 50 cc COMPONENTS A NexGen stemmed tibial component size 5 was used 10 mm cruciate retaining polyethylene surface a NexGen cruciate retaining size E femoral component and a size 38 9 5 mm thickness All Poly Patella BRIEF HISTORY The patient is a 72 year old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs She wishes to proceed with arthroplasty at this time PROCEDURE The patient was taken to the Operative Suite at ABCD General Hospital on 09 11 03 She was placed on the operating table Department of Anesthesia administered a spinal anesthetic Once adequately anesthetized the left lower extremity was prepped and draped in the usual sterile fashion An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle Care was then ensured that the patellar tendon was not violated The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed Rongeur was used to take out any osteophytes and the size of approximately size E At this point the epicondyle axis guide was then inserted and aligned in a proper orientation The anterior cutting guide was then placed Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur After this was performed this was removed and the distal femoral cutting guide was then placed The left knee placed in 5 degrees of valgus guide was then placed and a standard distal cut was then taken After the cuts were ensured further to be leveled and they were and we proceeded to place the finishing guide size E and distal femur This was placed slightly in lateral position and secured in position with spring tense and head lift tense Once adequately secured and placed in the appropriate orientation the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws After this was performed the guide was removed and all bony fragments were then removed Attention was then directed to the tibia The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position Care was ensured if it is was a varus or valgus and the appropriate The femur gauge was then used to provide us appropriate amount of bony resection This was then pinned and secured into place Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability The trial components were then removed The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment After it was stemmed and broached these were removed and the patella was then incised a size 41 patella reamer blade was then used and was taken down a size 38 patella button was then placed intact Again the trial components were placed back into position Patella button was placed and the tracking was evaluated They tracked centrally with no touch technique Again all components were now removed and the knee was then copiously irrigated and suctioned dry Once adequately suctioned dry the tibial portion was cemented and packed into place Also excess cement was removed The femoral component was then cemented into position All excess cement was removed A size 12 poly was then inserted in trial to provide compression at cement adhered The patella was then cemented and held into place All components were held under compression until cement had adequately adhered all excess cement was then removed The knee was then taken through range of motion and size 12 felt to be slightly too big this was removed and the size 10 trial was replaced and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice The knee was again copiously irrigated and suctioned dry One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed there were none found and a final articulating surface was impacted and locked into place After this the knee was taken again for final range of motion and found to have excellent position stability and good alignment of the components The knee was once again copiously irrigated and the tourniquet was deflated Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained A drain was then placed deep to the retinaculum and the retinaculum repair was performed using 2 0 Ethibond and oversewn with a 1 Vicryl This was flexed and the repair was found held securely At this point the knee was again copiously irrigated and suctioned dry The subcutaneous tissue was closed with 2 0 Vicryl and the skin was approximated with skin staples Sterile dressing with Adaptic 4x4s ABDs and Kerlix rolls was then applied The patient was then transferred back to the gurney in a supine position DISPOSITION The patient tolerated well with no complications to PACU in satisfactory condition Keywords surgery degenerative arthritis nexgen stemmed tibial component all poly patella nexgen cruciate total knee replacement patellar tendon proximal tibia epicondyle axis bony fragments patella button tibial knee arthritis nexgen patella MEDICAL_TRANSCRIPTION,Description Right total knee arthroplasty using a Biomet cemented components 62 5 mm right cruciate retaining femoral component 71 mm Maxim tibial component and 12 mm polyethylene insert with 31 mm patella All components were cemented with Cobalt G Medical Specialty Surgery Sample Name Total Knee Arthoplasty Right 1 Transcription PREOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee POSTOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee PROCEDURE Right total knee arthroplasty using a Biomet cemented components 62 5 mm right cruciate retaining femoral component 71 mm Maxim tibial component and 12 mm polyethylene insert with 31 mm patella All components were cemented with Cobalt G ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME Less than 60 minutes The patient was taken to the Postanesthesia Care Unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 51 year old female complaining of worsening right knee pain The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling The patient requested surgical intervention and need for total knee replacement All risks benefits expectations and complications of surgery were explained to her in great detail and she signed informed consent All risks including nerve and vessel damage infection and revision of surgery as well as component failure were explained to the patient and she did sign informed consent The patient was given antibiotics preoperatively PROCEDURE DETAIL The patient was taken to the operating suite and placed in supine position on the operating table She was placed in the seated position and a spinal anesthetic was placed which the patient tolerated well The patient was then moved to supine position again and a well padded tourniquet was placed on the right thigh Right lower extremity was prepped and draped in sterile fashion All extremities were padded prior to this The right lower extremity after being prepped and draped in the sterile fashion the tourniquet was elevated and maintained for less than 60 minutes in this case A midline incision was made over the right knee and medial parapatellar arthrotomy was performed Patella was everted The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed The posterior cruciate ligament was intact There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild to moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case At the extramedullary tibial guide an extended cut was made adjusting for her alignment Once this was performed excess bone was removed The reamer was placed along on the femoral canal after which a 6 degree valgus distal cut was made along the distal femur Once this was performed the distal femoral size in 3 degrees external rotation 62 5 mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion Excess bone was removed Next the tibia was brought anterior and excised to 71 mm It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia Once this was performed a 71 mm tibial trial was placed as well as a 62 5 mm femoral trial was placed with a 12 mm polyethylene insert Next the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed The knee was taken for range of motion had excellent flexion and extension as well as adequate varus and valgus stability There was no loosening appreciated There is no laxity appreciated along the posterior cruciate ligament Once this was performed the trial components were removed The knee was irrigated with fluid and antibiotics after which the cement was put on the back table this being Cobalt G it was placed on the tibia The tibial components were tagged in position and placed on the femur The femoral components were tagged into position All excess cement was removed ___ placement of patella It was tagged in position A 12 mm polyethylene insert was placed knee was held in extension and all excess cement was removed The cement hardened with the knee in full extension after which any extra cement was removed The wounds were copiously irrigated with saline and antibiotics and medial parapatellar arthrotomy was closed with 2 Vicryl Subcutaneous tissue was approximated with 2 0 Vicryl and the skin was closed with staples The patient was awakened from general anesthetic transferred to the gurney and taken into postanesthesia care unit in stable condition The patient tolerated the procedure well Keywords surgery degenerative joint disease knee total knee arthroplasty biomet cemented cobalt g arthoplasty osteoarthritis polyethylene cruciate ligament patella femoral tibial MEDICAL_TRANSCRIPTION,Description Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer Removal of antibiotic spacer and revision total hip arthroplasty Medical Specialty Surgery Sample Name Total Hip Arthroplasty Revision Transcription PREOPERATIVE DIAGNOSIS Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer POSTOPERATIVE DIAGNOSIS Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer PROCEDURES 1 Removal of antibiotic spacer 2 Revision total hip arthroplasty IMPLANTS 1 Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6 5 x 30 mm screws 2 Zimmer femoral component 13 5 x 220 mm with a size AA femoral body 3 A 32 mm femoral head with a 0 neck length ANESTHESIA Regional ESTIMATED BLOOD LOSS 500 cc COMPLICATIONS None DRAINS Hemovac times one and incisional VAC times one INDICATIONS The patient is a 66 year old female with a history of previous right bipolar hemiarthroplasty for trauma This subsequently became infected She has undergone removal of this prosthesis and placement of antibiotic spacer She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip DESCRIPTION OF PROCEDURE The patient was brought to the operating room by anesthesia personnel She was placed supine on the operating table A Foley catheter was inserted A formal time out was obtained in identifying the correct patient operative site Preoperative antibiotics were held for intraoperative cultures The patient was placed into the lateral decubitus position with the right side up The previous surgical incision was identified The right lower extremity was prepped and draped in standard fashion The old surgical incision was reopened along its proximal extent Immediately encountered was a large amount of fibrous scar tissue Dissection was carried sharply down through this scar tissue Soft tissue plains were extremely difficult to visualize due to all the scarring There was no native tissue to orient oneself with We carried our dissection down through the scar tissue to what seemed to be a fascial layer We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed This was used as a landmark to orient remainder of the dissection The antibiotic spacer was exposed and followed distally to expose the proximal femur Dissection was continued posteriorly and proximally to expose the acetabulum A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure Once improved visualization was obtained the antibiotic spacer was removed from the femur This allowed further improved visualization of the acetabulum The acetabulum was filled with soft tissue debris and scar tissue This was removed with sharp excision with a knife as well as with a rongeur and a Bovie Once soft tissue was removed the acetabulum was reamed Reaming was started with a 46 mm reamer and carried up sequentially to prepare for 50 mm shell The 50 mm shell was trialed and had good stability and fit Attention was then turned to continue preparation of the femur The canal was then debrided with femoral canal curettes Some fibrous tissue was removed from the canal The length of the femoral stem was then checked with this canal curette in place Following x rays we prepared to begin reaming the femur This femur was reamed over a guide rod using flexible reaming rods The canal was reamed up to 13 5 mm distally in preparation for 14 mm stem The stem was selected and initially size A body was placed in trial The body was too tight proximally to fit The proximal canal was then reamed for a size AA body A longer stem with an anterior bow was selected and a size AA trial was assembled This fit nicely in the canal and had good fit and fill Intraoperative radiographs were obtained to determine component position Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur The remainder of the trial was then assembled and the hip was relocated and trialed Initially it was found to be unstable posteriorly We changed from a 10 degree lip liner to 20 degree lip liner Again the hip was trialed and found to be unstable posteriorly This was due to reversion of the femoral component As we attempted to seat the prosthesis the stent continued to attempt to turn in retroversion The stem was extracted and retrialed Improved stability was obtained and we decided to proceed with the real components A 20 degree liner was inserted into the acetabular shell The real femoral components were assembled and inserted into the femoral canal Again the hip was trialed The components were found to be in relative retroversion The real components were then backed down and the neck was placed in the more anteversion and reinserted Again the stem attempted to follow in the relative retroversion Along with this time however it was improved from previous attempts The femoral head trial was placed back on the components and the hip relocated It was taken to a range of motion and found to have improved stability compared to previous trialing Decision was made to accept the component position The real femoral head was selected and implanted The hip was then taken again to a range of motion It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation The patient reached full extension and had no instability anteriorly The wound was then irrigated again with pulsatile lavage Six liters of pulsatile lavage was used during the procedure The wound was then closed in a layered fashion A Hemovac drain was placed deep to the fascial layer The subcutaneous tissues were closed with 1 PDS 2 0 PDS and staples in the skin An incisional VAC was then placed over the wound as well Sponge and needle counts were correct at the close of the case DISPOSITION The patient will be weightbearing as tolerated with posterior hip precautions Keywords surgery infected bipolar arthroplasty antibiotic spacer revision placement of antibiotic spacer total hip arthroplasty scar tissue soft tissue antibiotic spacer femoral hip arthroplasty total acetabulum femur MEDICAL_TRANSCRIPTION,Description Right knee total arthroplasty Degenerative osteoarthritis right knee Medical Specialty Surgery Sample Name Total Knee Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee POSTOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee PROCEDURE PERFORMED Right knee total arthroplasty ANESTHESIA The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized TOTAL TOURNIQUET TIME Approximately 90 minutes SPECIFICATIONS The entire procedure is done in the inpatient operating suite in the Room 1 at ABCD General Hospital The following sizes of NexGen system were utilized E on right femur cemented 5 tibial stem tray with a 10 mm polyethylene insert and a 32 mm patellar button HISTORY AND GROSS FINDINGS This is a 58 year old white female suffering increasing right knee pain for number of years prior to surgical intervention She was completely refractory to conservative outpatient therapy She had undergone two knee arthroscopies in the years preceding this They were performed by myself She ultimately failed this treatment and developed a collapsing type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live Medial compartment had minor changes present There was no contracture of the lateral collateral ligament but instead mild laxity on both sides There was no significant flexion contracture preoperatively OPERATIVE PROCEDURE The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department Thigh tourniquet was placed upon the patient s right leg She was prepped and draped in the usual sterile manner The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time A straight incision was carried down through the skin and subcutaneous tissue Hemostasis was controlled with electrocoagulation Medial parapatellar arthrotomy was created and the knee cap was everted The ligaments were balanced A portion of the fat pad was removed and the ACL was completely removed Drill hole was made in the distal femur The size to an E right Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side This was checked with the epicondylar abscess and with three degrees of external rotation drill holes were made Intramedullary guide was then placed pegged and anterior cut carried out There was excellent resection It was flat Distal cutting guide was then placed in five degrees of valgus Appropriate cuts were carried out The standard cut was utilized The finishing guide for E was held with pins as well as screws Cutting was carried out posterior to anterior then posterior chamfer and anterior chamfer femoral sulcus cut was carried out and drill holes for pegs were made The cutting guide was then removed The bone was removed Excess bone was taken out posteriorly The posterior capsule was loosened up There were two different fabellas in the posterolateral compartment and they were loosened Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner An extramedullary tibial cutting guide was then placed pinned and held A cut was carried out parallel to the foot Hard copy ________ was obtained deemed to be satisfactory after evening up the edges Trial range of motion was satisfactory It was necessary to perform a lateral retinacular release to the patella The patella was isolated Approximately 10 mm to 11 mm were reamed off The size to 32 mm button and drill hole guide was placed impacted and drilled Trial range of motion was satisfactory The tibial guide was then pinned Drill hole was placed broached and utilized Copious irrigation was carried out Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella The implants were sequentially placed in tibia to femur to patella Once excess methylmethacrylate was removed and cured 10 mm Poly was placed There was excellent ligament balancing A separate portal was utilized for subcutaneous drain Tourniquet was deflated and hemostasis was controlled with electrocoagulation Interrupted 1 Ethibond suture was utilized for parapatellar closure running 1 Vicryl suture was utilized for overstitch Trial range of motion was satisfactory Interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin Adaptic 4x4s ABDs and Webril were placed for compression dressing Digits were pink and warm with brawny pulses distally at the end of the case The patient was then transferred to PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords surgery arthroplasty knee degenerative osteoarthritis subcutaneous osteoarthritis degenerative tourniquet drill MEDICAL_TRANSCRIPTION,Description Total hip arthroplasty on the left Left hip degenerative arthritis Severe degenerative changes within the femoral head as well as the acetabulum anterior as well as posterior osteophytes Medical Specialty Surgery Sample Name Total Hip Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Left hip degenerative arthritis POSTOPERATIVE DIAGNOSIS Left hip degenerative arthritis PROCEDURE PERFORMED Total hip arthroplasty on the left ANESTHESIA General BLOOD LOSS 800 cc The patient was positioned with the left hip exposed on the beanbag IMPLANT SPECIFICATION A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner a 28 mm cobalt chrome head with a zero neck length head and a 12 mm porous proximal collared femoral component GROSS INTRAOPERATIVE FINDINGS Severe degenerative changes within the femoral head as well as the acetabulum anterior as well as posterior osteophytes The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis This was revealed once we removed the trochanteric bursa HISTORY This is a 56 year old obese female with a history of bilateral degenerative hip arthritis She underwent a right total hip arthroplasty by Dr X in the year of 2000 and over the past three years the symptoms in her left hip had increased tremendously especially in the past few months Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication the patient has elected to undergo the above named procedure All risks as well complications were discussed with the patient including but not limited to infection scar dislocation need for further surgery risk of anesthesia deep vein thrombosis and implant failure The patient understood all these risks and was willing to continue further on with the procedure PROCEDURE The patient was wheeled back to the Operating Room 2 at ABCD General Hospital on 08 27 03 The general anesthetic was first performed by the Department of Anesthesia The patient was then positioned with the left hip exposed on the beanbag in the lateral position Kidney rests were also used because of the patient s size An axillary roll was also inserted for comfort in addition to a Foley catheter which was inserted by the OR nurse All her bony prominences were well padded At this time the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure At this time an anterolateral approach was then performed first incising through the skin in approximately 5 to 6 inches of subcutaneous fat The tensor fascia lata was then identified A self retainer was then inserted to expose the operative field Bovie cautery was used for hemostasis At this time a fresh blade was then used to incise the tensor fascia lata over the posterior one third of the greater trochanter At this time a blunt dissection was taken proximally The tensor fascia lata was occluded with a hip retractor At this time after hemostasis was obtained Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor the gluteus medius At this time a periosteal elevator was used to expose anterior hip capsule A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle Once this was performed Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck At this time a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum At this point a large bone hook was then inserted over the neck and with gentle traction and external rotation the femoral head was dislocated out of the acetabulum At this time we had an exposure of the femoral head which did reveal degenerative changes of the femoral head and once the acetabulum was visualized we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum At this time a femoral stem guide was then used to measure proximal femoral neck cut We made a cut approximately a fingerbreadth above the lesser trochanter At this time with protection of the soft tissues an oscillating saw was used to make femoral neck cut The femoral head was then removed At this time we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum A long handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum With better exposure of the acetabulum we started reaming the acetabulum We started with a size 44 and progressively reamed to a size 50 At the size 50 mm reamer we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum We then reamed up to size 52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in Once the cup was impacted in place we did visualize that the cup was well seated on to the internal portion of the acetabulum At this time two screws were the placed within the superior table for better approaches securing the acetabular cup At this time a plastic liner was then inserted for protection The leg was then placed back in the bag A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time we began working on the femur A rongeur was used to lateralize over the greater trochanter A Box osteotome was used to remove the cancellous portion of the femoral neck A Charnley awl was then used to cannulate through the proximal femoral canal A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem At this time we began broaching We started with a size 10 and progressively worked up to a size 12 mm broach Once the 12 mm broach was inserted in place it was seated approximately 1 mm below the calcar A calcar reamer was then placed and the calcar was reamed smoothly A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed Once this was performed the hip was taken to range of motion with external rotation longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation At this time we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum This was impacted and placed and checked to assure that it was well seated with no loosening Once this was performed we then exposed the proximal femur one more time We copiously irrigated within the canal and then suctioned it dry At this time a 12 mm porous proximal collared stem a femoral component was then impacted in place Once it was well seated on the calcar we double checked to assure that there was no evidence of calcar fractures which there were none The 28 mm zero neck length cobalt chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________ Next the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction external rotation as well as hip flexion We were satisfied with components as well as the alignment of the components Copious irrigation was then used to irrigate the wound 1 Ethibond was then used to approximate the anterior hip capsule 1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter Next a 1 Ethibond was then used to approximate the tensor fascia lata with figure of eight closure A tight closure was performed Since the patient did have a lot of subcutaneous fat multiple 2 0 Vicryl sutures were then used to approximate the bed space and then 2 0 Vicryl for the subcutaneous skin Staples were then used for skin closure The patient s hip was then cleansed Sterile dressings consisting of Adaptic 4 x 4 ABDs and foam tape were then placed A drain was placed prior to wound closure for postoperative drainage After the dressing was applied the patient was extubated safely and transferred to recovery in stable condition Prognosis is good Keywords surgery degenerative arthritis total hip arthroplasty tensor fascia lata vastus lateralis gluteus medius femoral neck femoral head head femoral acetabulum hip attachment arthroplasty MEDICAL_TRANSCRIPTION,Description Total hip replacement An incision was made centered over the greater trochanter Dissection was sharply carried down through the subcutaneous tissues Medical Specialty Surgery Sample Name Total Hip Replacement 1 Transcription PROCEDURE Total hip replacement PROCEDURE DESCRIPTION The patient was bought to the operating room and placed in the supine position After induction of anesthesia the patient was turned on the side and secured in the hip table An incision was made centered over the greater trochanter Dissection was sharply carried down through the subcutaneous tissues The gluteus maximus was incised and split proximally The piriformis and external rotators were identified These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule The hip was dislocated A femoral neck cut was made using the guidance of preoperative templating The femoral head was removed Extensive degenerative disease was found on the femoral head as well as in the acetabulum Baseline leg length measurements were taken The femur was retracted anteriorly and a complete labrectomy was performed Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas The trial shell was placed and found to have an excellent fit The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction Screws were placed by drilling into the pelvis measuring and placing the appropriate length screw Excellent purchase was obtained The trial liner was placed The femur was then flexed and internally rotated The extra trochanteric bone was removed as was any leftover lateral soft tissue at the piriformis insertion An intramedullary hole was drilled into the femur to define the canal Reaming was performed until the appropriate size was reached The broaches were then used to prepare the femur with the appropriate amount of version Once the appropriate size broach was reached it was used as a trial with head and neck placement Hip range of motion was checked in all planes including flexion internal rotation the position of sleep and extension external rotation The hip was found to have excellent stability with the final chosen head neck combination Leg length measurements were taken and found to be within acceptable range given the necessity for stability The real stem was opened and impacted into position The real head was impacted atop the stem If cement was used the canal was thoroughly washed and dried and plugged with a restrictor and then the cement was injected and pressurized and the stem was implanted in the appropriate version Excess cement was removed from the edges of the component Range of motion and stability were once again checked and found to be excellent Adequate hemostasis was obtained Vigorous power irrigation was used to remove all debris from the joint prior to final reduction The arthrotomy and rotators were closed using 1 Ethibond through drill holes in the bone recreating the posterior hip structural anatomy The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl The subcutaneous tissues were closed after further irrigation with 2 0 Vicryl and Monocryl sutures The skin was closed with nylon Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap The patient was transferred to the recovery room in stable condition having tolerated the procedure well Keywords surgery range of motion hip total hip replacement gluteus maximus femoral head subcutaneous tissues incision ethibond trochanter subcutaneous acetabulum femur MEDICAL_TRANSCRIPTION,Description Right hip osteoarthritis Total hip replacement on the right side Medical Specialty Surgery Sample Name Total Hip Replacement Transcription PREOPERATIVE DIAGNOSIS Right hip osteoarthritis POSTOPERATIVE DIAGNOSIS Right hip osteoarthritis PROCEDURES PERFORMED Total hip replacement on the right side using the following components 1 Zimmer trilogy acetabular system 10 degree elevated rim located at the 12 o clock position 2 Trabecular metal modular acetabular system 48 mm in diameter 3 Femoral head 32 mm diameter 0 mm neck length 4 Alloclassic SL offset stem uncemented for taper ANESTHESIA Spinal DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up After review of allergies antibiotics were administered and time out was performed The right lower extremity was prepped and draped in a sterile fashion A 15 cm to 25 cm in length an incision was made over the greater trochanter This was angled posteriorly Access to the tensor fascia lata was performed This was incised with the use of scissors Gluteus maximus was separated The bursa around the hip was identified and the bleeders were coagulated with the use of Bovie Hemostasis was achieved The piriformis fossa was identified and the piriformis fossa tendon was elevated with the use of a Cobb It was detached from the piriformis fossa and tagged with 2 0 Vicryl Access to the capsule was performed The capsule was excised from the posterior and superior aspects It was released also in the front with the use of a Mayo scissors The hip was then dislocated With the use of an oscillating saw the femoral neck cut was performed The acetabulum was then visualized and debrided from soft tissues and osteophytes Reaming was initiated and completed for a 48 mm diameter cap without complications The trial component was put in place and was found to be stable in an anatomic position The actual component was then impacted in the acetabulum A 10 degree lip polyethylene was also placed in the acetabular cap Our attention was then focused to the femur With the use of a cookie cutter the femoral canal was accessed The broaching process was initiated for No 4 trial component Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation In addition in full extension and external rotation there was no dislocation The actual component was inserted in place and hemostasis was achieved again The wound was irrigated with normal saline The wound was then closed in layers Before performing that the medium sized Hemovac drain was placed in the wound The tensor fascia lata was closed with 0 PDS and the wound was closed with 2 0 Monocryl Staples were used for the skin The patient recovered from anesthesia without complications EBL 50 mL IV FLUIDS 2 liters DRAINS One medium sized Hemovac COMPLICATIONS None DISPOSITION The patient was transferred to the PACU in stable condition She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions We will start the DVT prophylaxis after the removal of the epidural catheter Keywords surgery total hip replacement epidural catheter tensor fascia lata hemostasis was achieved medium sized hemovac tensor fascia fascia lata trial component medium sized sized hemovac total hip hip replacement hip osteoarthritis piriformis fossa total hip acetabular extremity tensor fascia hemostasis acetabulum dislocation hemovac replacement osteoarthritis femoral piriformis fossa components anesthesia MEDICAL_TRANSCRIPTION,Description Aortic stenosis Insertion of a Toronto stentless porcine valve cardiopulmonary bypass and cold cardioplegia arrest of the heart Medical Specialty Surgery Sample Name Toronto Porcine Valve Insertion Transcription PREOPERATIVE DIAGNOSIS Aortic stenosis POSTOPERATIVE DIAGNOSIS Aortic stenosis PROCEDURES PERFORMED 1 Insertion of a mm Toronto stentless porcine valve 2 Cardiopulmonary bypass 3 Cold cardioplegia arrest of the heart ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS 300 cc INTRAVENOUS FLUIDS 1200 cc of crystalloid URINE OUTPUT 250 cc AORTIC CROSS CLAMP TIME CARDIOPULMONARY BYPASS TIME TOTAL PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the neck chest and legs were prepped and draped in the standard surgical fashion We used a 10 blade scalpel to make a midline median sternotomy incision Dissection was carried down to the left of the sternum using Bovie electrocautery The sternum was opened with a sternal saw The chest retractor was positioned Next full dose heparin was given The pericardium was opened Pericardial stay sutures were positioned After obtaining adequate ACT we prepared to place the patient on cardiopulmonary bypass A 2 0 double pursestring of Ethibond suture was placed in the ascending aorta Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine Next a 3 0 Prolene pursestring was placed in the right atrial appendage Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine A 4 0 U stitch was placed in the right atrium A retrograde cardioplegia catheter was positioned at this site Next scissors were used to dissect out the right upper pulmonary vein A 4 0 Prolene pursestring was placed in the right upper pulmonary vein Next a right angle sump was placed at this position We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery The aorta was completely encircled Next an antegrade cardioplegia needle and associated sump were placed in the ascending aorta We then prepared to cross clamp the aorta We went down on our flows and cross clamped the aorta We backed up our flows We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart The patient had some aortic insufficiency so we elected after initially arresting the heart to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit Next after obtaining complete diastolic arrest of the heart we turned our attention to exposing the aortic valve and 4 0 Tycron sutures were placed in the commissures In addition a 2 0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view Next scissors were used to excise the diseased aortic valve leaflets Care was taken to remove all the calcium from the aortic annulus We then sized up the aortic annulus which came out to be a mm stentless porcine Toronto valve We prepared the valve Next we placed our proximal suture line of interrupted 4 0 Tycron sutures for the annulus We started with our individual commissural stitches They were connected to our valve sewing ring Next we placed 5 interrupted 4 0 Tycron sutures in a subannular fashion at each commissural position After doing so we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve The valve was lowered into place and all of the sutures were tied Next we gave another round of cold blood antegrade and retrograde cardioplegia Next we sewed our distal suture line We began with the left coronary cusp of the valve We ran a 5 0 RB needle up both sides of the valve Care was taken to avoid the left coronary ostia This procedure was repeated on the right cusp of the stentless porcine valve Again care was taken to avoid any injury to the coronary ostia Lastly we sewed our non coronary cusp This was done without difficulty At this point we inspected our aortic valve There was good coaptation of the leaflets and it was noted that both the left and the right coronary ostia were open We gave another round of cold blood antegrade and retrograde cardioplegia The antegrade portion was given in a direct ostial fashion once again We now turned our attention to closing the aorta A 4 0 Prolene double row of suture was used to close the aorta in a running fashion Just prior to closing we de aired the heart and gave a warm shot of antegrade and retrograde cardioplegia At this point we removed our aortic cross clamp The heart gradually regained its electromechanical activity We placed 2 atrial and 2 ventricular pacing wires We removed our aortic vent and oversewed that site with another 4 0 Prolene on an SH needle We removed our retrograde cardioplegia catheter We oversewed that site with a 5 0 Prolene By now the heart was de aired and resumed normal electromechanical activity We began to wean the patient from cardiopulmonary bypass We then removed our venous cannula and suture ligated that site with a 2 silk We then gave full dose protamine After knowing that there was no evidence of a protamine reaction we removed the aortic cannula We buttressed that site with a 4 0 Prolene on an SH needle We placed a mediastinal chest tube and brought it out through the skin We also placed 2 Blake drains 1 in the left chest and 1 in the right chest as the patient had some bilateral pleural effusions They were brought out through the skin The sternum was closed with 7 wires in an interrupted figure of eight fashion The fascia was closed with 1 Vicryl We closed the subcu tissue with 2 0 Vicryl and the skin with 4 0 PDS Keywords surgery cardioplegia toronto stentless porcine valve tycron sutures coronary ostia porcine valve retrograde cardioplegia cardiopulmonary bypass sutures valve insertion toronto aortic stentless chest coronary porcine cardiopulmonary prolene atrial bypass heart aorta MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy Severe menometrorrhagia unresponsive to medical therapy anemia and symptomatic fibroid uterus Medical Specialty Surgery Sample Name Total Abdominal Hysterectomy 1 Transcription PREOPERATIVE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Anemia 3 Symptomatic fibroid uterus POSTOPERATIVE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Anemia 3 Symptomatic fibroid uterus PROCEDURE Total abdominal hysterectomy ANESTHESIA General ESTIMATED BLOOD LOSS 150 mL COMPLICATIONS None FINDING Large fibroid uterus PROCEDURE IN DETAIL The patient was prepped and draped in the usual sterile fashion for an abdominal procedure A scalpel was used to make a Pfannenstiel skin incision which was carried down sharply through the subcutaneous tissue to the fascia The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel The O Connor O Sullivan instrument was then placed without difficulty The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty Hemostasis was noted at this point of the procedure The bladder flap was then developed free from the uterus without difficulty Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using 1 chromic suture ligature in an interrupted fashion on the left and right side This was done without difficulty The uterine fundus was then separated from the uterine cervix without difficulty This specimen was sent to pathology for identification The cervix was then developed with careful dissection Jorgenson scissors were then used to remove the cervix from the vaginal cuff This was sent to pathology for identification Hemostasis was noted at this point of the procedure A 1 chromic suture ligature was then used in running fashion at the angles and along the cuff Hemostasis was again noted Figure of eight sutures were then used in an interrupted fashion to close the cuff Hemostasis was again noted The entire pelvis was washed Hemostasis was noted The peritoneum was then closed using 2 0 chromic suture ligature in running pursestring fashion The rectus abdominis muscles were approximated using 1 chromic suture ligature in an interrupted fashion The fascia was closed using 0 Vicryl in interlocking running fashion Foundation sutures were then placed in an interrupted fashion for further closing the fascia The skin was closed with staple gun Sponge and needle counts were noted to be correct x2 at the end of the procedure Instrument count was noted to be correct x2 at the end of the procedure Hemostasis was noted at each level of closure The patient tolerated the procedure well and went to recovery room in good condition Keywords surgery menometrorrhagia fibroid uterus total abdominal hysterectomy rectus abdominis muscles fibroid uterus suture ligature therapy hemostasis anemia abdominal MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy Enlarged fibroid uterus pelvic pain and pelvic endometriosis On laparotomy the uterus did have multiple pedunculated fibroids Medical Specialty Surgery Sample Name Total Abdominal Hysterectomy 2 Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Pelvic pain POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Pelvic pain 3 Pelvic endometriosis PROCEDURE PERFORMED Total abdominal hysterectomy ANESTHESIA General endotracheal and spinal with Astramorph COMPLICATIONS None ESTIMATED BLOOD LOSS 200 cc FLUIDS 2400 cc of crystalloids URINE OUTPUT 100 cc of clear urine INDICATIONS This is a 40 year old female gravida 0 with a history of longstanding enlarged fibroid uterus On ultrasound the uterus measured 14 cm x 6 5 cm x 7 8 cm She had received two dosage of Lupron to help shrink the fibroid Her most recent Pap smear was normal FINDINGS On a manual exam the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated On laparotomy the uterus did have multiple pedunculated fibroids the largest being approximately 7 cm The bilateral tubes and ovaries appeared normal There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament PROCEDURE After consent was obtained the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife The fascia was incised in midline and the incision extended laterally using Mayo scissors The superior aspect of the fascial incision was grasped with Kocher clamps tented up and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors Attention was then turned to the inferior aspect of the incision which in a similar fashion was grasped with Kocher clamps tented up and dissected off the underlying rectus muscles The rectus muscles were separated in the midline and the peritoneum was identified grasped with hemostat and entered sharply with Metzenbaum scissors This incision was extended superiorly and inferiorly with good visualization of the bladder The uterus was then brought up out of the incision The bowel adhesions were carefully taken down using Metzenbaum scissors Good hemostasis was noted at this point The self retaining retractor was then placed The bladder blade was placed The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension The uterus was then grasped with a Lahey clamp and brought up out of the incision The left round ligament was identified and grasped with Allis clamp and tented up A hemostat was passed in the avascular area beneath the round ligament A suture 0 Vicryl was used to suture ligate the round ligament Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament An avascular area of the broad ligament was then identified and entered bluntly The suture of 0 Vicryl was then used to suture ligate the left uterovarian ligament Two straight Ochsner s were placed across the uterovarian ligament proximal to the previous suture The ligament was then transected and suture ligated with 0 Vicryl Attention was then turned to the right round ligament which in a similar fashion was tented up with an Allis clamp An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with 0 Vicryl Two straight Ochsner s were placed across the ligament proximal to previous suture This was then transected and suture ligated again with 0 Vicryl The left uterine peritoneum was then identified and grasped with Allis clamps The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors This incision was extended across the anterior portion of the uterus and the bladder flap was taken down It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray Tec The Ray Tec was left in place at this point to ensure that the bladder was below the level of the cervix The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner s Each were then transected and suture ligated with 0 Vicryl A curved Ochsner was then placed on either side of the cervix The tissue was transected using a long knife and suture ligated with 0 Vicryl Incidentally prior to taking down the round ligaments a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie The cervix was then grasped with a Lahey clamp The cervicovaginal fascia was then taken down first using the long handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix A double pointed scissors were used to enter the vaginal vault below the level of the cervix A straight Ochsner was placed on the vaginal vault The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue The vaginal cuff was then reapproximated with 0 Vicryl in a running locked fashion and the pelvis was copiously irrigated There was a small area of bleeding noted on the underside of the bladder The bladder was tented up using an Allis clamp and a figure of eight suture of 3 0 Vicryl was placed with excellent hemostasis noted at this point The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down A figure of eight suture of 0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament The round ligament was too short It would be a maximal amount of stretch to incorporate therefore only the left round ligament was incorporated into the vaginal cuff The bilateral adnexal areas were then re peritonealized with 3 0 Vicryl in a running fashion The bladder flap was reapproximated to the vaginal cuff using one interrupted suture The pelvis was again irrigated at this point with excellent hemostasis noted Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder There was no spillage of blue fluid into the abdomen The fluid again was allowed to drain All sponges were then removed and the bowel was allowed to return to its anatomical position The peritoneum was then reapproximated with 0 Vicryl in a running fashion The fascia was reapproximated also with 0 Vicryl in a running fashion The skin was then closed with staples A previously placed Betadine soaked Ray Tec was removed from the patient s vagina and sponge stick was used to assess any bleeding in the vaginal vault There was no appreciable bleeding The patient tolerated the procedure well Sponge lap and needle counts were correct x2 The patient was taken to the recovery room in satisfactory condition She will be followed immediately postoperatively within the hospital Keywords surgery pelvic pain pelvic endometriosis astramorph total abdominal hysterectomy enlarged fibroid metzenbaum scissors vaginal cuff scissors vaginal uterus ligament hysterectomy endometriosis pedunculated fibroids infundibulopelvic uterovarian abdominal laparotomy peritoneum MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy Chronic adenotonsillitis The patient is a 9 year old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy 5 Transcription POSTOPERATIVE DIAGNOSIS Chronic adenotonsillitis PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal tube ESTIMATED BLOOD LOSS Minimum less than 5 cc SPECIMENS Right and left tonsils 2 adenoid pad 1 There was no adenoid specimen COMPLICATIONS None HISTORY The patient is a 9 year old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years PROCEDURE Informed consent was properly obtained from the patient s parents and the patient was taken to the operating room 3 and was placed in a supine position He was placed under general endotracheal tube anesthesia by the Department of Anesthesia The bed was then rolled away from Department of Anesthesia A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap The McIvor mouth gag was carefully positioned into the patient s mouth with attention to avoid the teeth The retractor was then opened and the oropharynx was visualized The adenoid pad was then visualized with a laryngeal mirror The adenoids appeared to be 1 and non obstructing There was no evidence of submucosal cleft palate palpable There was no evidence of bifid uvula A curved Allis clamp was then used to grasp the superior pole of the right tonsil The tonsil was then retracted inferiorly and medially Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection The tonsil was then dissected out within this plane using a Bovie Tonsillar sponge was re applied to the tonsillar fossa Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa Attention was then directed to the left tonsil The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection The tonsil was then dissected out within this plane using the Bovie Next complete hemostasis was achieved within the tonsillar fossae using suction cautery After adequate hemostasis was obtained attention was directed towards the adenoid pad The adenoid pad was again visualized and appeared 1 and was non obstructing Decision was made to use suction cautery to cauterize the adenoids Using a laryngeal mirror under direct visualization the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates After cauterization was complete the nasopharynx was again visualized and tonsillar sponge was applied Adequate hemostasis was achieved The tonsillar fossae were again visualized and no evidence of bleeding was evident The throat pack was removed from the oropharynx and the oropharynx was suctioned There was no evidence of any further bleeding A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx The suction catheter was also used to suction up the stomach Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively DISPOSITION The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition Keywords surgery chronic adenotonsillitis tonsillectomy adenoidectomy adenoid tonsils tonsillar fossa tonsillar fossae suction cautery adenotonsillitis oropharynx hemostasis cautery suction tonsillar MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy and Left superficial nasal cauterization Recurrent tonsillitis Deeply cryptic hypertrophic tonsils with numerous tonsillolith Residual adenoid hypertrophy and recurrent epistaxis Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy 4 Transcription PREOPERATIVE DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis POSTOPERATIVE DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis FINAL DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis OPERATION PERFORMED 1 Tonsillectomy and adenoidectomy 2 Left superficial nasal cauterization DESCRIPTION OF OPERATION The patient was brought to the operating room Endotracheal intubation carried out by Dr X The McIvor mouth gag was inserted and gently suspended Afrin was instilled in both sides of the nose and allowed to take effect for a period of time The hypertrophic tonsils were then removed by the suction and snare Deeply cryptic changes as expected were evident Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive They were shaved back flushed with prevertebral fascia with curette Hemostasis established with packing followed by electrocautery In light of his history of recurring nosebleeds both sides of the nose were carefully inspected A nasal endoscope was used to identify the plexus of bleeding which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device The bleeding was admittedly a bit of a annoyance An additional control was established by infiltrating slowly with a 1 Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself No additional bleeding was then evident The oropharynx was reinspected clots removed the patient was extubated taken to the recovery room in stable condition Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops Office recheck anticipated if stable and doing well in three to four weeks Keywords surgery tonsillitis cryptic hypertrophic tonsils tonsillolith nasal cauterization adenoid hypertrophy hypertrophic tonsils adenoidectomy nasal cauterization hypertrophy epistaxis tonsils hypertrophic intubation tonsillectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy 3 Transcription PREOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis POSTOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis SURGICAL PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal technique SURGICAL FINDINGS A 4 4 cryptic and hypertrophic tonsils with 2 3 hypertrophic adenoid pads INDICATIONS We were requested to evaluate the patient for complaints of enlarged tonsils which cause difficulty swallowing recurrent pharyngitis and sleep induced respiratory disturbance She was evaluated and scheduled for an elective procedure DESCRIPTION OF SURGERY The patient was brought to the operative suite and placed supine on the operating room table General anesthetic was administered Once appropriate anesthetic findings were achieved the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy He was placed in semi Rose ___ position and a Crowe Davis type mouth gag was introduced into the oropharynx Under an operating headlight the oropharynx was clearly visualized The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique was removed from its fossa This followed placing the patient in a suspension position using a McIvor type mouth gag and a red rubber Robinson catheter via the right naris Once the right tonsil was removed the left tonsil was removed in a similar manner once again using a needle point Bovie dissection at 20 watts With the tonsils removed it was possible to visualize the adenoid pads The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique The adenoid pad was greater than 2 4 and hypertrophic It was removed with successive passes of electrocautery suction The tonsillar fossa was then once again hemostased with suction cautery injected with 0 5 ropivacaine with 1 100 000 adrenal solution and then closed with 2 0 Monocryl on an SH needle The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period The patient s oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine and she was recovered from her general endotracheal anesthetic She was extubated and left the operating room in good condition to the postoperative recovery room area Estimated blood loss was minimal There were no complications Specimens produced were right and left tonsils The adenoid pad was ablated with electrocautery Keywords surgery obstructive adenotonsillar hypertrophy pharyngitis tonsillectomy adenoidectomy uvula obstructive adenotonsillar hypertrophy hypertrophic fossa tonsils oropharynx electrocautery pads MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy 1 Transcription PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia The McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction The nasopharynx was inspected with a laryngeal mirror The adenoid tissue was fulgurated with the suction Bovie set at 35 The catheters and the dental gauze roll were then removed The anterior tonsillar pillars were infiltrated with 0 5 Marcaine and epinephrine Using the radiofrequency wand the tonsils were ablated bilaterally If bleeding occurred it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9 The tonsillectomy was completed The nasopharynx and nasal passages were suctioned free of debris and the procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords surgery tongue nasal passage palate mcivor mouth gag gauze roll nasopharynx tonsillectomy adenoidectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy uvulopalatopharyngoplasty and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum Medical Specialty Surgery Sample Name Tonsillectomy and Septoplasty Transcription PREOPERATIVE DIAGNOSIS Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate POSTOPERATIVE DIAGNOSIS Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum OPERATION Tonsillectomy uvulopalatopharyngoplasty and septoplasty ANESTHESIA General anesthetics HISTORY This is a 51 year old gentleman here with his wife She confirms the history of loud snoring at night with witnessed apnea The result of the sleep study was reviewed This showed moderate sleep apnea with significant desaturation The patient was unable to tolerate treatment with CPAP At the office we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate A tortuous appearance of the septum also was observed This morning I talked to the patient and his wife about the findings I reviewed the CT images He has no history of sinus infections and does not recall a history of nasal trauma We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway Depending on the findings of surgery I explained that I might remove that bone spur that we are seeing within the nasal passage I will get the best look at it when he is asleep We discussed recovery as well He visited with Dr XYZ about the anesthetic produce PROCEDURE General tracheal anesthetic was administered by Dr XYZ and Mr Radke Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose A Crowe Davis mouth gag was placed The tonsils were very large and touched the uvula The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars Also there was a cryptic appearance of the tonsils but there was no acute redness or exudate Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present A very crowded pharynx was appreciated The tonsils were first removed using electrodissection technique Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut The tonsil fossae were injected with 0 25 Marcaine with 1 200 000 epinephrine There already was more room in the pharynx but the posterior pharyngeal wall was still obscured by the soft palate and uvula The uvula was grasped with the Alice clamp I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate We switched over from the Bayonet cautery to the blunt needle tip electrocautery The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar This incision was then deepened with the electrocautery on a cutting current The uvular artery just to the right of the midline was controlled with the suction electrocautery The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology The tonsil fossae were injected with 0 25 Marcaine with 1 200 000 epinephrine The soft palate was also injected with 0 25 Marcaine with 1 200 000 epinephrine The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3 0 chromic catgut sutures A much improved appearance of the oropharynx with a greatly improved airway was appreciated A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed I removed the cottonoids from both nostrils Speculum exam showed the inferior turbinates were large the septum was tortuous and it angulated to the right and then sharply bent back to the left The septum was injected with 0 25 Marcaine with 1 200 000 epinephrine using a separate syringe and needle A 15 blade was used to make a left cheilion incision Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator When we reached the deflected portion of the vomer this was separated from the septal cartilage with a Freer elevator The right sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome the deflected portion of the septal bone from the vomer was resected This tissue also was sent as a separate specimen to pathology The intraseptal space was irrigated with saline and suctioned The nasal septal mucosal flaps were then sutured together with a quilting suture of 4 0 plain catgut I observed no evidence of purulent secretion or polyp formation within the nostrils The inferior turbinates were then both outfractured using a knife handle and now there was a much more patent nasal airway on both sides There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose No packing was used in the nostrils Polysporin ointment was introduced into both nostrils The mouth gag was reintroduced and the pack removed from the nasopharynx The nose and throat were irrigated with saline and suctioned An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed Sponge and needle count were reported correct The mouth gag having been withdrawn the patient was then awakened and returned to recovery room in a satisfactory condition He tolerated the operation excellently Estimated blood loss was about 15 20 cc In the recovery room I observed that he was moving air well and I spoke with his wife about the findings of surgery Keywords surgery obstructive sleep apnea syndrome afrin drops bayonet cautery cpap cottle elevator crowe davis freer elevator obstructive sleep apnea tonsillectomy hypertrophy mouth gag nasal nasal passage nasal septum nasopharynx nostrils palate pharynx septal cartilage septoplasty sleep apnea soft palate tonsils uvula uvulopalatopharyngoplasty hypertrophy of tonsils anterior tonsillar pillars soft palate incision palate incision tonsillar pillars incision MEDICAL_TRANSCRIPTION,Description Tonsillectomy Chronic tonsillitis Medical Specialty Surgery Sample Name Tonsillectomy 1 Transcription PREOPERATIVE DIAGNOSIS Chronic tonsillitis POSTOPERATIVE DIAGNOSIS Chronic tonsillitis PROCEDURE Tonsillectomy DESCRIPTION OF PROCEDURE Under general orotracheal anesthesia a Crowe Davis mouth gag was inserted and suspended Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0 25 plain A catheter was inserted in the nose and brought out from mouth The throat was irrigated with saline There was no further bleeding The patient was awakened and extubated and moved to the recovery room in satisfactory condition Keywords surgery crowe davis mouth gag chronic tonsillitis tonsillitis anesthesia tonsillectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy Tonsillitis McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Medical Specialty Surgery Sample Name Tonsillectomy Transcription PREOPERATIVE DIAGNOSIS Tonsillitis POSTOPERATIVE DIAGNOSIS Tonsillitis PROCEDURE PERFORMED Tonsillectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion After induction of general endotracheal anesthesia the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction The nasopharynx was inspected with the laryngeal mirror Attention was then directed to the right tonsil The anterior tonsillar pillar was infiltrated with 1 5 cc of 1 Xylocaine with 1 100 000 epinephrine as was the left tonsillar pillar The right tonsil was grasped with the tenaculum and retracted out of its fossa The anterior tonsillar pillar was incised with the 12 knife blade The plica semilunaris was incised with the Metzenbaum scissors Using the Metzenbaum scissors and the Fisher knife the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described By a similar procedure the opposite tonsillectomy was performed and the fossa was packed Attention was re directed to the right tonsil The pack was removed and bleeding was controlled with the suction Bovie unit Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs The catheters were then removed The nasal passages and oropharynx were suctioned free of debris The procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords surgery tongue palate mcivor mouth gag anterior tonsillar metzenbaum scissors oral cavity tonsillar pillar tonsillectomy metzenbaum tonsillitis pillar tonsillar fossa MEDICAL_TRANSCRIPTION,Description Tonsillectomy adenoidectomy and removal of foreign body rock from right ear Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy Transcription PREOPERATIVE DIAGNOSES Hypertrophy of tonsils and adenoids and also foreign body of right ear POSTOPERATIVE DIAGNOSES Hypertrophy of tonsils and adenoids and also foreign body of right ear OPERATIONS Tonsillectomy adenoidectomy and removal of foreign body rock from right ear ANESTHESIA General HISTORY The patient is 5 1 2 years old She is here this morning with her Mom She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well At the office we saw the tonsils were very big There was a rock in the right ear and it was very deep in the canal near the drum We will remove the foreign body under the same anesthetic PROCEDURE Natalie was placed under general anesthetic by the orotracheal route of administration under Dr XYZ and Ms B I looked into the left ear under the microscope took out a little wax and observed a normal eardrum On the right side I took out some impacted wax and removed the rock with a large suction It was actually resting on the surface of the drum but had not scarred or damaged the drum The drum was intact with no evidence of middle ear fluid The microscope was set aside Afrin drops were placed in both nostrils The neck was gently extended and the Crowe Davis mouth gag inserted The tonsils and adenoids were very large The uvula was intact Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx Tonsillectomy accomplished by sharp and blunt dissection Hemostasis achieved with electrocautery and the tonsils beds injected with 0 25 Marcaine with 1 200 000 epinephrine Sutures of zero plain catgut next were used to re approximate the posterior to the anterior tonsillar pillars suturing these down to the tonsillar beds Sponge is removed from the nasopharynx The suction electrocautery was used for pinpoint hemostasis on the adenoid bed We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices The nose and throat were then irrigated with saline and suctioned Excellent hemostasis was observed An orogastric tube was placed The stomach found to be empty The tube was removed as was the mouth gag Sponge and needle count were reported correct The child was then awakened and prepared for her to return to the recovery room She tolerated the operation excellently Keywords surgery tonsillectomy afrin drops crowe davis hypertrophy adenoid bed adenoidectomy adenoids canal catgut dissection drum ear foreign body middle ear mouth gag nasopharynx orotracheal suction electrocautery throat tonsils uvula wax tonsils and adenoids MEDICAL_TRANSCRIPTION,Description Tonsillectomy adenoidectomy Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy Medical Specialty Surgery Sample Name Tonsillectomy Adenoidectomy 2 Transcription PREOPERATIVE DIAGNOSIS Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy POSTOPERATIVE DIAGNOSIS Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy OPERATION PERFORMED Tonsillectomy adenoidectomy ANESTHESIA General endotracheal FINDINGS The tonsils were 3 enlarged and cryptic DESCRIPTION OF OPERATION Under general anesthesia with an endotracheal tube the patient was placed in supine position A mouth gag was inserted and suspended from Mayo stand Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate The adenoid area was inspected The adenoids were small The left tonsil was grasped with a tonsil tenaculum The tonsil was removed with the Gold laser The apposite tonsil was removed in a similar manner Hemostasis was secured with electrocautery Both tonsillar fossae were injected with 0 25 Marcaine with adrenaline The patient tolerated the procedure well and left the operating room in good condition Keywords surgery tonsil gold laser adenoids chronic tonsillitis adenoid hypertrophy tonsillectomy adenoidectomy endotracheal tonsillitis symptomatic hypertrophy MEDICAL_TRANSCRIPTION,Description Total thyroidectomy The patient is a female with a history of Graves disease Suppression was attempted however unsuccessful She presents today with her thyroid goiter Medical Specialty Surgery Sample Name Thyroidectomy 1 Transcription PREOPERATIVE DIAGNOSIS Thyroid goiter POSTOPERATIVE DIAGNOSIS Thyroid goiter PROCEDURE PERFORMED Total thyroidectomy ANESTHESIA 1 General endotracheal anesthesia 2 9 cc of 1 lidocaine with 1 100 000 epinephrine COMPLICATIONS None PATHOLOGY Thyroid INDICATIONS The patient is a female with a history of Graves disease Suppression was attempted however unsuccessful She presents today with her thyroid goiter A thyroidectomy was indicated at this time secondary to the patient s chronic condition Indications alternatives risks consequences benefits and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail She agreed to proceed A full informed consent was obtained PROCEDURE The patient presented to ABCD General Hospital on 09 04 2003 with the history was reviewed and physical examinations was evaluated The patient was brought by the Department of Anesthesiology brought back to surgical suite and given IV access and general endotracheal anesthesia A 9 cc of 1 lidocaine with 1 100 000 of epinephrine was infiltrated into the area of pre demarcated above the suprasternal notch Time is allowed for full hemostasis to be achieved The patient was then prepped and draped in the normal sterile fashion A 10 blade was then utilized to make an incision in the pre demarcated and anesthetized area Unipolar electrocautery was utilized for hemostasis Finger dissection was carried out in the superior and inferior planes Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior medial and lateral directions using hemostat Metzenbaum and blunt dissection The strap muscles were identified The midline raphe was not easily identifiable at this time An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid Sternohyoid and sternothyroid muscles were identified and separated on the patient s right side and then subsequently on the left side It was noted at this time that the thyroid lobule on the right side is a bi lobule Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid force in the lateral direction This was carried down to the inferior and superior areas The superior pole of the right lobule was then identified A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature This was carried out until the superior pole was identified Careful attention was made to avoid nerve injury in this area Dissection was then carried down again bluntly separating the inferior and superior lobes The bilobed right thyroid was then retracted medially The recurrent laryngeal nerve was then identified and tracked to its insertion The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid When it was completed this lobule was then removed from Berry s ligament There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation Attention was then diverted to the patient s left side In a similar fashion the sternohyoid and sternothyroid muscles were already separated Army Navy as well as femoral retractors were utilized to lateralize the appropriate musculature The middle thyroid vein was identified Blunt dissection was carried out laterally to superiorly once again A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly Once again a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis Once again a careful attention was made not to injure the nerve in this area The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects The inferior aspect was then identified The inferior thyroid artery and vein were then identified and ligated The left thyroid was then medialized and the recurrent laryngeal nerve has been identified A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible The thyroid was then removed from the Berry s ligament and it was then sent to Pathology for further evaluation Evaluation of the visceral space did not reveal any bleeding at this time This was irrigated and pinpoint areas were bipolored as necessary Surgicel was then placed bilaterally The strap muscles as well as the appropriate fascial attachments were then approximated with a 3 0 Vicryl suture in the midline The platysma was identified and approximated with a 4 0 Vicryl suture and the subdermal plane was approximated with a 4 0 Vicryl suture A running suture consisting of 5 0 Prolene suture was then placed and fast absorbing 6 0 was then placed in a running fashion Steri Strips Tincoban bacitracin and a pressure gauze was then placed The patient was then admitted for further evaluation and supportive care The patient tolerated the procedure well The patient was transferred to Postanesthesia Care Unit in stable condition Keywords surgery thyroid goiter graves disease thyroidectomy total thyroidectomy dissection superior kitner MEDICAL_TRANSCRIPTION,Description Thromboendarterectomy of right common external and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending and reverse autogenous saphenous vein graft to the obtuse marginal posterior descending branch of the right coronary artery Medical Specialty Surgery Sample Name Thromboendarterectomy Transcription OPERATIVE PROCEDURE 1 Thromboendarterectomy of right common external and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure 2 Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending and reverse autogenous saphenous vein graft to the obtuse marginal posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection placement of temporary pacing wires DESCRIPTION The patient was brought to the operating room placed in supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring lines were placed The chest abdomen and legs were prepped and draped in a sterile fashion The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4 0 silk and flushing with vein solution The leg was closed with running 3 0 Dexon subcu and running 4 0 Dexon subcuticular on the skin and later wrapped A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The sternum was closed A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma The deep fascia was divided The facial vein was divided between clamps and tied with 2 0 silk The common carotid artery takeoff of the external and internal carotid arteries were dissected free with care taken to identify and preserve the hypoglossal and vagus nerves The common carotid artery was double looped with umbilical tape takeoff of the external was looped with a heavy silk distal internal was double looped with a heavy silk Shunts were prepared A patch was prepared Heparin 50 mg was given IV Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery Distal internal was held with a forceps Internal carotid artery was opened with 11 blade Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond The shunt was placed and proximal and distal snares were tightened Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine feathery distal edge using eversion on the external All loose debris was removed and Dacron patch was then sutured in place with running 6 0 Prolene suture removing the shunt just prior to completing the suture line Suture line was completed and the neck was packed The pericardium was opened A pericardial cradle was created The patient was heparinized for cardiopulmonary bypass cannulated with a single aortic and single venous cannula A retrograde cardioplegia cannula was placed with a pursestring of 4 0 Prolene into the coronary sinus and secured to a Rumel tourniquet An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted The ascending aorta was cross clamped and cold blood potassium cardioplegia was given antegrade a total of 5 cc per kg This was followed sumping of the ascending aorta and retrograde cardioplegia a total of 5 cc per kg to the coronary sinus The obtuse marginal 1 coronary was identified and opened and an end to side anastomosis was then performed with running 7 0 Prolene suture The vein was cut to length Antegrade and retrograde cold blood potassium cardioplegia was given The obtuse marginal 2 was not felt to be suitable for bypass therefore the posterior descending of the right coronary was identified and opened and an end to side anastomosis was then performed with running 7 0 Prolene suture to reverse autogenous saphenous vein The vein was cut to length The mammary was clipped distally divided and spatulated for anastomosis Antegrade and retrograde cold blood potassium cardioplegia was given The anterior descending was identified and opened the mammary was then sutured to this with running 8 0 Prolene suture Warm blood potassium cardioplegia was given and the cross clamp was removed A partial occlusion clamp was placed Two aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture The partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Atrial and ventricular pacing wires were placed Ventilation was commenced The patient was fully warmed The patient was weaned from cardiopulmonary bypass and de cannulated in a routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire the linea alba with figure of eight 1 Vicryl the sternal fascia with running 1 Vicryl the subcu with running 2 0 Dexon and the skin with a running 4 0 Dexon subcuticular stitch Keywords surgery cabg thromboendarterectomy carotid artery coronary artery bypass mammary obtuse papaverine soaked running prolene suture cardiopulmonary bypass internal carotid running prolene prolene suture carotid sutured artery prolene coronary bypass veinNOTE MEDICAL_TRANSCRIPTION,Description Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion Right lateral base of tongue lesion probable cancer Medical Specialty Surgery Sample Name Tongue Lesion Biopsy Transcription PREOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer POSTOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer PROCEDURE PERFORMED Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion ANESTHESIA General FINDINGS An ulceration in the right lateral base of tongue region This was completely excised ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS Crystalloid only COMPLICATIONS None DRAINS None CONDITION Stable PROCEDURE The patient placed supine in position under general anesthesia First a Sweetheart gag was placed in the patient s mouth and the mouth was elevated The lesion in the tongue could be seen Then it was injected with 1 lidocaine and 1 100 00 epinephrine After 5 minutes of waiting then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total Suction cautery was used for hemostasis Then 3 simple interrupted 4 0 Vicryl sutures were used to close the wound and procedure was then terminated at that time Keywords surgery excisional biopsy tongue lesion mouth biopsy MEDICAL_TRANSCRIPTION,Description Transforaminal lumbar interbody fusion placement of intervertebral prosthetic device Medical Specialty Surgery Sample Name TLIF Transcription PREOPERATIVE DIAGNOSIS ES L4 L5 and L5 S1 degenerative disk disease disk protrusions spondylosis with radiculopathy POSTOPERATIVE DIAGNOSIS ES L4 L5 and L5 S1 degenerative disk disease disk protrusions spondylosis with radiculopathy PROCEDURE 1 Left L4 L5 and L5 S1 Transforaminal Lumbar Interbody Fusion TLIF 2 L4 to S1 fixation Danek M8 system 3 Right posterolateral L4 to S1 fusion 4 Placement of intervertebral prosthetic device Danek Capstone spacers L4 L5 and L5 S1 5 Vertebral autograft plus bone morphogenetic protein BMP COMPLICATIONS None ANESTHESIA General endotracheal SPECIMENS Portions of excised L4 L5 and L5 S1 disks ESTIMATED BLOOD LOSS 300 mL FLUIDS GIVEN IV crystalloid OPERATIVE INDICATIONS The patient is a 37 year old male presenting with a history of chronic persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management Preoperative imaging studies revealed the above noted abnormalities After a detailed review of management considerations with the patient and his wife he was elected to proceed as noted above Operative indications methods potential benefits risks and alternatives were reviewed The patient and his wife expressed understanding and consented to proceed as above OPERATIVE FINDINGS L4 L5 and L5 S1 disk protrusion with configuration as anticipated from preoperative imaging studies Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site In addition all pedicle screws were stimulated with findings of above threshold noted at all sites Spacer snugness and positioning appeared satisfactory Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported DESCRIPTION OF THE OPERATION After obtaining proper patient identification and appropriate preoperative informed consent the patient was taken to the operating room on a hospital stretcher in the supine position After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed The patient s posterior lumbosacral region was thoroughly cleansed and shaved The patient was then scrubbed prepped and draped in the usual manner After local infiltration with 1 lidocaine with 1 200 000 epinephrine solution a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum Dissection was continued in the midline to the level of the posterior fascia Self retaining retractors were placed and subsequently readjusted as needed The fascia was opened in the midline and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3 L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally _____ by completing the exposure pedicle screw fixation was carried out in the following manner Screws were placed in systematic caudal in a cranial fashion The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed Cortical openings were created at these sites using a small burr The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder They were then probed and subsequently tapped employing fluoroscopic guidance as needed Each site was under tapped and reprobed with satisfactory findings noted as above Screws in the following dimensions were placed 6 5 mm diameter screws were placed at all sites At S1 40 mm length screws were placed bilaterally At L5 40 mm length screws were placed bilaterally and at L4 40 mm length screws were placed bilaterally with findings as noted above The rod was then contoured to span from the L4 to the S1 screws on the right The distraction was placed across the L4 L5 interspace and the connections were temporarily secured Using a matchstick burr a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level This was longitudinally oriented A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression working from caudally to cranially and medially to laterally again using curettes and Kerrison rongeurs under direct visualization In this manner the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed Local epidural veins were coagulated with bipolar and divided Gelfoam was then placed in this area This process was then repeated in similar fashion thereby exposing the posterolateral aspect of the left L5 S1 disk space As noted distraction had previously been placed at L4 L5 this was released Distraction was placed across the L5 S1 interspace After completing satisfactory exposure as noted a annulotomy was made in the posterolateral left aspect of the L5 S1 disk space Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure The disk space was entered and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate Herniated portions of the disk were also removed in routine fashion The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion After completing this disk space preparation Gelfoam was again placed The decompression was assessed and appeared to be satisfactory The distraction was released and attention was redirected at L4 L5 where again distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion After completing the disk space preparation attention was redirected to L5 S1 Distraction was released at L4 L5 and again reapplied at L5 S1 incrementally increasing size Trial spaces were used and a 10 mm height by 26 mm length spacer was chosen A medium BMP kit was appropriately reconstituted A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space The spacer was then carefully impacted into position The distraction was released The spacer was checked with satisfactory snugness and positioning noted This process was then repeated in similar fashion at L4 L5 again with placement of a 10 mm height by 26 mm length Capstone spacer again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace This spacer was also checked again with satisfactory snugness and positioning noted The prior placement of the spacers and BMP the wound was thoroughly irrigated and dried with satisfactory hemostasis noted Surgicel was placed over the exposed dura and disk space The distraction was released on the right and compression plates across the L5 S1 and L4 L5 interspaces and the connections fully tightened in routine fashion The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4 L5 and L5 S1 facets on the right in a routine fashion A left sided rod was appropriated contoured and placed to span between the L4 to S1 screws Again compression was placed across the L4 L5 and L5 S1 segments and these connections were fully secured Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically The wound was closed using multiple simple interrupted 0 Vicryl sutures to reapproximate the deep paraspinal musculature in the midline The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0 Vicryl sutures The suprafascial subcutaneous layers were closed using multiple simple interrupted 0 and 2 0 Vicryl sutures The skin was then closed using staples Sterile dressings were then applied and secured in place The patient tolerated the procedure well and was to the recovery room in satisfactory condition Keywords surgery degenerative disk disease disk protrusions spondylosis radiculopathy tlif transforaminal lumbar interbody fusio danek m8 intervertebral prosthetic device danek capstone matchstick burr capstone bmp vertebral autograft screws were placed bilaterally pedicle screw kerrison rongeurs disk space disk spacers kerrison interbody rongeurs pedicle lumbar screws MEDICAL_TRANSCRIPTION,Description Total thyroidectomy for goiter Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration Medical Specialty Surgery Sample Name Thyroidectomy Transcription TITLE OF OPERATION Total thyroidectomy for goiter INDICATION FOR SURGERY This is a 41 year old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery Risks benefits alternatives of the procedures were discussed in great detail with the patient Risks include but were not limited to anesthesia bleeding infection injury to nerve vocal fold paralysis hoarseness low calcium need for calcium supplementation tumor recurrence need for additional treatment need for thyroid medication cosmetic deformity and other The patient understood all these issues and they wished to proceed PREOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration POSTOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration ANESTHESIA General endotracheal PROCEDURE DETAIL After identifying the patient the patient was placed supine in a operating room table After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube The eyes were then tacked with Tegaderm The Nerve Integrity monitoring system endotracheal tube was confirmed to be working adequately Essentially a 7 cm incision was employed in the lower skin crease of the neck A 1 lidocaine with 1 100 000 epinephrine were given Shoulder roll was applied The patient prepped and draped in a sterile fashion A 15 blade was used to make the incision Subplatysmal flaps were raised to the thyroid notch and sternal respectively The strap muscles were separated in the midline As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side The sternothyroid muscle was transected horizontally Similar procedure was performed on the right side Attention was then turned to identify the trachea in the midline Veins in this area and the pretracheal region were ligated with a harmonic scalpel Subsequently attention was turned to dissecting the capsule off of the left thyroid lobe Again this was very firm in nature The superior thyroid pole was dissected in the superior third artery vein and the individual vessels were ligated with a harmonic scalpel The inferior and superior parathyroid glands were protected Recurrent laryngeal nerve was identified in the tracheoesophageal groove This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch This was followed superiorly The level of cricothyroid membrane upon complete visualization of the entire nerve Berry s ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea A prominent pyramidal level was also appreciated and dissected as well Attention was then turned to the right side There was significant amount of thyroid tissue that was very firm Multiple nodules were appreciated In a similar fashion the capsule was dissected The superior and inferior parathyroid glands protected and preserved The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule Once the recurrent laryngeal nerve was identified again on this side the nerve had arborized early prior to the coursing underneath the inferior thyroid artery The anterior motor branch was then very fine almost filamentous and stimulated at 0 5 milliamps completely dissected toward the cricothyroid membrane with complete visualization A small amount of tissue was left at the Berry s ligament as the remainder of thyroid level was dissected over the trachea The entire thyroid specimen was then removed marked with a stitch upon the superior pole The wound was copiously irrigated Valsalva maneuver was given bleeding points controlled The parathyroid glands appeared to be viable Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system Attention was then turned to burying the Surgicel on the wound bed on both sides The strap muscles were reapproximated in the midline using a 3 0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated The 1 8th inch Hemovac drain was placed and secured with a 3 0 nylon The incision was then closed with interrupted 3 0 Vicryl and Indermil for the skin The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25 gauge needle The patient tolerated the procedure well was extubated in the operating room table and sent to postanesthesia care unit in a good condition Upon completion of the case fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility Keywords surgery total thyroidectomy goiter multinodular thyroid goiter multinodular thyroid nodules parathyroid glands thyroid goiter thyroid artery thyroidectomy MEDICAL_TRANSCRIPTION,Description History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy Wound debridement x2 including skin subcutaneous and muscle Insertion of tissue expander to the medial and lateral wound Medical Specialty Surgery Sample Name Tissue Expander Insertion Transcription PREOPERATIVE DIAGNOSES History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy POSTOPERATIVE DIAGNOSES History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy OPERATIONS 1 Wound debridement x2 including skin subcutaneous and muscle 2 Insertion of tissue expander to the medial wound 3 Insertion of tissue expander to the lateral wound COMPLICATIONS None TOURNIQUET None ANESTHESIA General INDICATIONS This patient developed a compartment syndrome She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg She was doing very well and was obviously improving The swelling was reduced A compartment pressure had obviously improved based on examination She was therefore indicated for placement of tissue expander for ventral wound closure The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well Risks and benefits were all discussed risk of bleeding infection damage to blood vessels damage to nerve roots need for further surgery chronic pain with range of motion risk of continued discomfort risk of need for further reconstructive procedures risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed She understood them well All questions were answered and she signed the consent for the procedure as described DESCRIPTION OF THE PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The medial wound was noted to be approximately 10 5 cm in length x 4 cm The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width Both wounds were then thoroughly debrided The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides At this point adequate debridement was performed and healthy tissue did appear to be present Initially on the medial wound I did place the DermaClose RC continuous external tissue expander On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor I then did place adequate tension on the sutures Continued tension will be noted after engaging the tension controller At this point I performed the similar procedure to the lateral wound The skin anchors were placed separately and appropriately on either side of the skin margin The line loop from the tension controller was placed in lace like manner through the skin anchors The tension controller was then attached to the mid anchor and appropriate tension was applied It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained Adequate tension was placed in this region A non thick dressing was then applied to the open wound region and sterile dressing was then applied No complications were encountered throughout the procedure and the patient tolerated the procedure well The patient was taken to recovery room in stable condition Keywords surgery fasciotomy subcutaneous muscle wound debridement insertion of tissue expander compartment syndrome compartment fasciotomy lateral wound medial wound tension controller tissue expander wound tissue compartment MEDICAL_TRANSCRIPTION,Description Thrombectomy AV shunt left forearm and patch angioplasty of the venous anastomosis Thrombosed arteriovenous shunt left forearm with venous anastomotic stenosis Medical Specialty Surgery Sample Name Thrombectomy AV Shunt Transcription PREOPERATIVE DIAGNOSIS Thrombosed arteriovenous shunt left forearm POSTOPERATIVE DIAGNOSIS Thrombosed arteriovenous shunt left forearm with venous anastomotic stenosis PROCEDURE Thrombectomy AV shunt left forearm and patch angioplasty of the venous anastomosis ANESTHESIA Local SKIN PREP Betadine DRAINS None PROCEDURE TECHNIQUE The left arm was prepped and draped Xylocaine 1 was administered and a transverse antecubital incision was made over the venous limb of the graft which was dissected out and encircled with a vessel loop The runoff vein was dissected out and encircled with the vessel loop as well A longitudinal incision was made over the venous anastomosis There was a narrowing in the area and slightly the incision was extended more proximally There was good back bleeding from the vein as well as bleeding from the more distal vein These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously A 4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established There was a narrowing in the mid portion of the venous limb of the graft which was dilated with a 5 coronary dilator The Fogarty catheter was then passed up the vein but no clot was obtained A patch PTFE material was fashioned and was sutured over the graftotomy with running 6 0 Gore Tex suture Clamps were removed and flow established A thrill was easily palpable Hemostasis was achieved and the wound was irrigated and closed with 3 0 Vicryl subcutaneous suture followed by 4 0 nylon on the skin A sterile dressing was applied The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well Sponge instrument and needle counts were reported as correct Keywords surgery angioplasty venous anastomosis patch angioplasty av shunt venous anastomosis av thrombectomy thrombosed arteriovenous vein forearm shunt MEDICAL_TRANSCRIPTION,Description Left thoracotomy with drainage of pleural fluid collection esophageal exploration and repair of esophageal perforation diagnostic laparoscopy and gastrostomy and radiographic gastrostomy tube study with gastric contrast interpretation Medical Specialty Surgery Sample Name Thoracotomy Esophageal Exploration Transcription PREOPERATIVE DIAGNOSIS Esophageal rupture POSTOPERATIVE DIAGNOSIS Esophageal rupture OPERATION PERFORMED 1 Left thoracotomy with drainage of pleural fluid collection 2 Esophageal exploration and repair of esophageal perforation 3 Diagnostic laparoscopy and gastrostomy 4 Radiographic gastrostomy tube study with gastric contrast interpretation ANESTHESIA General anesthesia INDICATIONS OF THE PROCEDURE The patient is a 47 year old male with a history of chronic esophageal stricture who is admitted with food sticking and retching He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy DETAILS OF THE PROCEDURE After an extensive informed consent discussion process the patient was brought to the operating room He was placed in a supine position on the operating table After induction of general anesthesia and placement of a double lumen endotracheal tube he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll Left chest was prepped and draped in a usual sterile fashion After administration of intravenous antibiotics a left thoracotomy incision was made dissection was carried down to the subcutaneous tissues muscle layers down to the fifth interspace The left lung was deflated and the pleural cavity entered The Finochietto retractor was used to help provide exposure The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed Immediately encountered was left pleural fluid including some purulent fluid Cultures of this were sampled and sent for microbiology analysis The left pleural space was then copiously irrigated A careful expiration demonstrated that the rupture appeared to be sealed There was crepitus within the mediastinal cavity The mediastinum was opened and explored and the esophagus was explored The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area The area was copiously irrigated this provided nice coverage and repair After final irrigation and inspection two chest tubes were placed including a 36 French right angled tube at the diaphragm and a posterior straight 36 French These were secured at the left axillary line region at the skin level with 0 silk The intercostal sutures were used to close the chest wall with a 2 Vicryl sutures Muscle layers were closed with running 1 Vicryl sutures The wound was irrigated and the skin was closed with skin staples The patient was then turned and placed in a supine position A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed A Veress needle was carefully inserted into the abdomen pneumoperitoneum was established in the usual fashion a bladeless 5 mm separator trocar was introduced The laparoscope was introduced A single additional left sided separator trocar was introduced It was not possible to safely pass a nasogastric or orogastric tube pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance The stomach however did have some air insufflation and we were able to place our T fasteners through the anterior abdominal wall and through the anterior gastric wall safely The skin incision was made and the gastric lumen was then accessed with the Seldinger technique Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire 18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated We confirmed that we were in the gastric lumen and the balloon was pulled up creating apposition of the gastric wall and the anterior abdominal wall The T fasteners were all crimped and secured into position As was in the plan the gastrostomy was secured to the skin and into the tube Sterile dressing was applied Aspiration demonstrated gastric content Gastrostomy tube study with interpretation Radiographic gastrostomy tube study with gastric contrast with Keywords surgery esophageal rupture thoracotomy drainage of pleural fluid esophageal perforation esophageal exploration laparoscopy gastrostomy pleural fluid diagnostic laparoscopy radiographic gastrostomy gastric lumen gastrostomy tube gastric contrast gastric interpretation abdominal pleural lumen esophageal tube MEDICAL_TRANSCRIPTION,Description Empyema Right thoracotomy total decortication and intraoperative bronchoscopy A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion On CT scan evaluation there is evidence of an entrapped right lower lobe with loculations Medical Specialty Surgery Sample Name Thoracotomy Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Empyema POSTOPERATIVE DIAGNOSIS Empyema PROCEDURE PERFORMED 1 Right thoracotomy total decortication 2 Intraoperative bronchoscopy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 300 cc FLUIDS 2600 cc IV crystalloid URINE 300 cc intraoperatively INDICATIONS FOR PROCEDURE The patient is a 46 year old Caucasian male who was admitted to ABCD Hospital since 08 14 03 with acute diagnosis of right pleural effusion A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion On CT scan evaluation there is evidence of an entrapped right lower lobe with loculations Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent OPERATIVE PROCEDURE The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department Intraoperative bronchoscopy was performed by Dr Y and evaluation of carina left upper and lower lobes with segmental evidence of diffuse mucous thick secretions which were thoroughly lavaged with sterile saline lavage Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation The right bronchus lower middle and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses lesions or suspicious extrinsic compressions on the bronchi At this point all mucous secretions were thoroughly irrigated and aspirated until the airways were clear Bronchoscope was then removed Vital signs remained stable throughout this portion of the procedure The patient was re intubated by Anesthesia with a double lumen endotracheal tube At this point the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion At this point the right chest was prepped and draped in the usual sterile fashion The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine The first port was placed through this incision intrathoracically A bronchoscope was placed for inspection of the intrathoracic cavity Pictures were taken There is extensive fibrinous exudate noted under parietal and visceral pleura encompassing the lung surface diaphragm and the posterolateral aspect of the right thorax At this point a second port site anteriorly was placed under direct visualization With the aid of the thoracoscopic view a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid Due to the gelatinous nature of the fibrinous exudate there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped Due to the extensive nature of the disease decision was made to open the chest in a formal right thoracotomy fashion Incision was made The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi which was separated with electrocautery down to the anterior 6th rib space The chest cavity was entered with the right lung deflated per Anesthesia at our request Once the intrathoracic cavity was accessed a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe middle and the right lower lobe With the expansion of the lung and reduction of the pleural surface fibrinous extubate warm irrigation was used and the lungs allowed to re expand There was no evidence of gross leakage or bleeding at the conclusion of surgery Full lung re expansion was noted upon re inflation of the lung Two 32 French thoracostomy tubes were placed one anteriorly straight and one posteriorly on the diaphragmatic sulcus The chest tubes were secured in place with 0 silk sutures and placed on Pneumovac suction Next the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running 2 0 Vicryl suture Next subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure Steri Strips were applied along with sterile occlusive dressings The patient was awakened from anesthesia without difficulty and extubated in the operating room The chest tubes were maintained on Pleur Evac suction for full re expansion of the lung The patient was transported to the recovery with vital signs stable Stat portable chest x ray is pending The patient will be admitted to the Intensive Care Unit for close monitoring overnight Keywords surgery empyema total decortication intraoperative bronchoscopy intrathoracic cavity fibrinous exudate latissimus dorsi chest tubes pleural effusion bronchoscopy thoracostomy thoracotomy decortication anesthesia pleural MEDICAL_TRANSCRIPTION,Description A 26 mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta re implanting the celiac superior mesenteric artery and right renal as an island and the left renal as a 8 mm interposition Dacron graft utilizing left heart bypass and cerebrospinal fluid drainage Medical Specialty Surgery Sample Name Thoracoabdominal Aneurysm Transcription POSTOPERATIVE DIAGNOSIS Type 4 thoracoabdominal aneurysm OPERATION PROCEDURE A 26 mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta re implanting the celiac superior mesenteric artery and right renal as an island and the left renal as a 8 mm interposition Dacron graft utilizing left heart bypass and cerebrospinal fluid drainage DESCRIPTION OF PROCEDURE IN DETAIL Patient was brought to the operating room and put in supine position and general endotracheal anesthesia was induced through a double lumen endotracheal tube Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30 degree angle The left groin abdominal and chest were prepped and draped in a sterile fashion A thoracoabdominal incision was made The 8th interspace was entered The costal margin was divided The retroperitoneal space was entered and bluntly dissected free to the psoas bringing all the peritoneal contents to the midline exposing the aorta The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm It was dissected free circumferentially The aortic bifurcation was dissected free dissecting free both iliac arteries The left inferior pulmonary vein was then dissected free and a pursestring of 4 0 Prolene was placed on this The patient was heparinized Through a stab wound in the center of this a right angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet This was hooked to a venous inflow of left heart bypass machine A pursestring of 4 0 Prolene was placed on the aneurysm and through a stab wound in the center of this an arterial cannula was placed and hooked to outflow Bypass was instituted The aneurysm was cross clamped just above T10 and also cross clamped just below the diaphragm The area was divided at this point A 26 mm graft was then sutured in place with running 3 0 Prolene suture The graft was brought into the diaphragm Clamps were then placed on the iliacs and the pump was shut off The aorta was opened longitudinally going posterior between the left and right renal arteries and it was completely transected at its bifurcation The SMA celiac and right renal artery were then dissected free as a complete island and the left renal was dissected free as a complete Carrell patch The island was laid in the graft for the visceral liner and it was sutured in place with running 4 0 Prolene suture with pledgetted 4 0 Prolene sutures around the circumference The clamp was then moved below the visceral vessels and the clamp on the chest was removed re establishing flow to the visceral vessels The graft was cut to fit the bifurcation and sutured in place with running 3 0 Prolene suture All clamps were removed and flow was re established An 8 mm graft was sutured end to end to the Carrell patch and to the left renal A partial occlusion clamp was placed An area of graft was removed The end of the graft was cut to fit this and sutured in place with running Prolene suture The partial occlusion clamp was removed Protamine was given Good hemostasis was noted The arterial cannula of course had been removed when that part of the aneurysm was removed The venous cannula was removed and oversewn with a 4 0 Prolene suture Good hemostasis was noted A 36 French posterior and a 32 French anterior chest tube were placed The ribs were closed with figure of eight 2 Vicryl The fascial layer was closed with running 1 Prolene subcu with running 2 0 Dexon and the skin with running 4 0 Dexon subcuticular stitch Patient tolerated the procedure well Keywords surgery dacron graft thoracoabdominal cerebrospinal thoracoabdominal aneurysm running prolene prolene suture dissected free graft interposition aneurysm dacron cannula bifurcation aorta endotracheal proleneNOTE MEDICAL_TRANSCRIPTION,Description Left thoracotomy with total pulmonary decortication and parietal pleurectomy Empyema of the chest left Medical Specialty Surgery Sample Name Thoracotomy Pleurectomy Transcription PREOPERATIVE DIAGNOSIS Empyema of the chest left POSTOPERATIVE DIAGNOSIS Empyema of the chest left PROCEDURE Left thoracotomy with total pulmonary decortication and parietal pleurectomy PROCEDURE DETAIL After obtaining the informed consent the patient was brought to the operating room where he underwent a general endotracheal anesthetic using a double lumen endotracheal tube A time out process had been followed and preoperative antibiotics were given The patient was positioned with the left side up for a left thoracotomy The patient was prepped and draped in the usual fashion A posterolateral thoracotomy was performed It included the previous incision The chest was entered through the fifth intercostal space Actually there was a very strong and hard parietal pleura which initially did not allow us to obtain a good exposure and actually the layer was so tough that the pin of the chest retractor broke Thanks to Dr X s ingenuity we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura We aspirated an abundant amount of pus from this cavity The sample was taken for culture and sensitivity Then at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm Once we accomplished that we proceeded to remove the solid exudate that was adhered to the lung Further samples for culture and sensitivity were sent Then we were left with the trapped lung It was trapped by thickened visceral pleura This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively Finally we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened we were able to inflate both the left upper and lower lobes of the lung satisfactorily There was only one area towards the mediastinum that apparently I was not able to fill This area of course was very rigid but any surgery in the direction __________ would have caused __________ injury so I restrained from doing that Two large chest tubes were placed The cavity had been abundantly irrigated with warm saline Then the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure of eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin The chest tubes were affixed to the skin with heavy sutures of silk Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation he was able to be extubated in the operating room Estimated blood loss was about 500 mL The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition Keywords surgery total pulmonary decortication pulmonary decortication parietal pleurectomy endotracheal tube chest retractor chest tubes parietal pleura pleurectomy empyema endotracheal thoracotomy pleura chest MEDICAL_TRANSCRIPTION,Description Left mesothelioma focal Left anterior pleural based nodule which was on a thin pleural pedicle with no invasion into the chest wall Medical Specialty Surgery Sample Name Thoracoscopy Thoracotomy Mesothelioma Transcription PREOPERATIVE DIAGNOSIS Left mesothelioma focal POSTOPERATIVE DIAGNOSIS Left pleural based nodule PROCEDURES PERFORMED 1 Left thoracoscopy 2 Left mini thoracotomy with resection of left pleural based mass FINDINGS Left anterior pleural based nodule which was on a thin pleural pedicle with no invasion into the chest wall FLUIDS 800 mL of crystalloid ESTIMATED BLOOD LOSS Minimal DRAINS TUBES CATHETERS 24 French chest tube in the left thorax plus Foley catheter SPECIMENS Left pleural based nodule INDICATION FOR OPERATION The patient is a 59 year old female with previous history of follicular thyroid cancer approximately 40 years ago status post resection with recurrence in the 1980s who had a left pleural based mass identified on chest x ray Preoperative evaluation included a CT scan which showed focal mass CT and PET confirmed anterior lesion Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction In the outpatient setting the patient was willing to proceed PROCEDURE PERFORMED IN DETAIL After informed consent was obtained the patient identified correctly She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty She was sedated and intubated with double lumen endotracheal tube without difficulty She was positioned with left side up Appropriate pressure points were padded The left chest was prepped and draped in the standard surgical fashion The skin incision was made in the posterior axillary line approximately 7th intercostal space with 10 blade taken down through tissues and Bovie electrocautery Pleura was entered There was good deflation of the left lung __________ port was placed followed by the 0 degree 10 mm scope with appropriate patient positioning Posteriorly a pedunculated 2 5 x 3 cm pleural based mass was identified on the anterior chest wall There were thin adhesions to the pleura but no invasion of the chest wall that could be identified The tumor was very mobile and was on a pedunculated stalk approximately 1 5 cm It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion Camera was placed through this port Laparoscopic scissors were placed through the posterior port but it was necessary to have another instrument to provide more tension than just gravity Therefore because of the need to bring the specimen through the chest wall a small 3 cm thoracotomy was made which incorporated the posterior port site This was taken down to the subcutaneous tissue with Bovie electrocautery Periosteal elevator was used to lift the intercostal muscle off The ribs were not spread Through this 3 cm incision both the laparoscopic scissors as well as Prestige graspers could be placed Prestige graspers were used to pull the specimen from the chest wall Care was taken not to injure the capsule The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall Care was taken not to transect the stalk Specimen came off the chest wall very easily There was good hemostasis At this point the EndoCatch bag was placed through the incision Specimen was placed in the bag and then removed from the field There was good hemostasis Camera was removed A 24 French chest tube was placed through the anterior port and secured with 2 0 silk suture The posterior port site was closed 1st with 2 0 Vicryl in a running fashion for the intercostal muscle layer followed by 2 0 closure of the latissimus fascia as well as subdermal suture 4 0 Monocryl was used for the skin followed by Steri Strips and sterile drapes The patient tolerated the procedure well was extubated in the operating room and returned to the recovery room in stable condition Keywords surgery mini thoracotomy pleural based mass pleural based nodule chest wall mesothelioma focal pleural chest thoracotomy mesothelioma laparoscopic thoracoscopy MEDICAL_TRANSCRIPTION,Description Thrombosed left forearm loop fistula graft chronic renal failure and hyperkalemia Thrombectomy of the left forearm loop graft The venous outflow was good There was stenosis in the mid venous limb of the graft Medical Specialty Surgery Sample Name Thrombectomy Transcription PREOPERATIVE DIAGNOSES 1 Thrombosed left forearm loop fistula graft 2 Chronic renal failure 3 Hyperkalemia POSTOPERATIVE DIAGNOSES 1 Thrombosed left forearm loop fistula graft 2 Chronic renal failure 3 Hyperkalemia PROCEDURE PERFORMED Thrombectomy of the left forearm loop graft ANESTHESIA Local with sedation ESTIMATED BLOOD LOSS Less than 5 cc COMPLICATIONS None OPERATIVE FINDINGS The venous outflow was good There was stenosis in the mid venous limb of the graft INDICATIONS The patient is an 81 year old African American female who presents with an occluded left forearm loop graft She was not able to have her dialysis as routine Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery Both Surgery and Anesthesia thought this would be too risky to do Thus she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning This morning her predialysis potassium was 6 and thus she was scheduled for surgery after her dialysis PROCEDURE The patient was taken to the operative suite and prepped and draped in the usual sterile fashion A transverse incision was made at the region of the venous anastomosis of the graft Further dissection was carried down to the catheter The vein appeared to be soft and without thrombus This outflow did not appear to be significantly impaired A transverse incision was made with a 11 blade on the venous limb of the graft near the anastomosis Next a thrombectomy was done using a 4 Fogarty catheter Some of the clot and thrombus was removed from the venous limb The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis Once removing most of the clots from the venous limb prior to removing the plug dilators were passed down the venous limb also indicating the area of stenosis At this point we felt the patient would benefit from a curettage of the venous limb of the graft This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage The Fogarty balloon was then passed beyond the clot and the plug The plug was visualized and inspected This also gave a good brisk bleeding from the graft The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb Attention was directed up to its anastomosis and the vein Fogarty balloon and thrombectomy was also performed well enough into this way There was good venous back bleeding following this The area was checked for any stenosis with the dilators and none was present Next a 6 0 Prolene suture was used in a running fashion to close the graft Just prior to tying the suture the graft was allowed to flush to move any debris or air The suture was also checked at that point for augmentation which was good The suture was tied down and the wound was irrigated with antibiotic solution Next a 3 0 Vicryl was used to approximate the subcutaneous tissues and a 4 0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges Steri Strips were applied and the patient was taken to recovery in stable condition She tolerated the procedure well She will be discharged from recovery when stable She is to resume her regular dialysis schedule and present for dialysis tomorrow Keywords surgery thrombosed hyperkalemia thrombectomy forearm loop graft venous outflow chronic renal failure venous limb loop graft forearm loop limb forearm graft venous anastomosis stenosis MEDICAL_TRANSCRIPTION,Description Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung Medical Specialty Surgery Sample Name Thoracoscopy Thoracotomy Transcription PREOPERATIVE DIAGNOSES Empyema of the left chest and consolidation of the left lung POSTOPERATIVE DIAGNOSES Empyema of the left chest consolidation of the left lung lung abscesses of the left upper lobe and left lower lobe OPERATIVE PROCEDURE Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung ANESTHESIA General FINDINGS The patient has a complex history which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax There was also noted to be some mild infiltrates of the right lung The patient had a 30 year history of cigarette smoking A chest tube was placed at the other hospital which produced some brownish fluid that had foul odor actually what was thought to be a fecal like odor Then an abdominal CT scan was done which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT The patient was started on antibiotics and was then taken to the operating room where there was to be a thoracoscopy performed The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions but there was bloody mucous in the left main stem bronchus and this was suctioned out This was suctioned out with the addition of the use of saline in the bronchus Following the bronchoscopy a double lumen tube was placed but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day The patient was transferred for continued evaluation and treatment Today the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted These were suctioned but it was enough to produce a temporary obstruction of the left mainstem bronchus Eventually the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that The chest tube tract which was about in the sixth or seventh intercostal space but it was not possible to dissect enough down to get a acceptable visualization through this tract A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout Remarkably the surface of the lower lobe laterally was not completely covered with a fibrotic line but it was more the line anterior and posterior and more of it over the left upper lobe There were many pockets of purulent material which had a gray white appearance to it There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time There seemed to be an abscess that was about 3 cm in dimension all the lateral basilar segment of the lower lobe near the area where the chest tube was placed Many cultures were taken from several areas The most remarkable finding was a large cavity which was probably about 11 cm in dimension containing grayish pus and also caseous like material it was thought to be perhaps necrotic lung tissue perhaps a deposit related to tuberculosis in the cavity The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm PROCEDURE AND TECHNIQUE With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this Therefore the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved but it was clear that we would be unable to complete the procedure by thoracoscopy Therefore posterolateral thoracotomy incision was made entering the pleural space and what is probably the sixth intercostal space Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense Suture ligatures of Prolene were required When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity which appeared to be from pulmonary veins and these were sutured with a tissue pledget of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14 French Foley catheter was passed into the area of the tear and the balloon was inflated which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed The patch was sutured onto the pulmonary artery tear A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity Also on the pulmonary artery repair some material was used and also thrombin Gelfoam and Surgicel After reasonably good hemostasis was established pleural cavity was irrigated with saline As mentioned biopsies were taken from multiple sites on the pleura and on the edge and on the lung Then two 24 Blake chest tubes were placed one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex These were later connected to water seal suction at 40 cm of water with negative pressure Good hemostasis was observed Sponge count was reported as being correct Intercostal nerve blocks at probably the fifth sixth and seventh intercostal nerves was carried out Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib Metallic clip was passed through the rib to facilitate passage of an intracostal suture but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table so that pericostal sutures were used with 1 Vicryl The chest wall was closed with running 1 Vicryl and then 2 0 Vicryl subcutaneous and staples on the skin The chest tubes were connected to water seal drainage with 40 cm of water negative pressure Sterile dressings were applied The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition Keywords surgery empyema biopsies bronchus declaudication endothoracic hydropneumothorax left lower lobe left lung left upper lobe mainstem pleura thoracoscopy thoracotomy thoracotomy with declaudication declaudication and drainage double lumen tube sixth intercostal space lung abscesses pleural cavity intercostal space upper lobe double lumen chest tube cavity tube chest lung pulmonary pleural intercostal MEDICAL_TRANSCRIPTION,Description Thoracic right sided discectomy at T8 T9 The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 Medical Specialty Surgery Sample Name Thoracic Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 OPERATION PERFORMED Thoracic right sided discectomy at T8 T9 BRIEF HISTORY AND INDICATION FOR OPERATION The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 She has failed conservative measures and sought operative intervention for relief of her symptoms For details of workup please see the dictated operative report DESCRIPTION OF OPERATION Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected Second check was made prior to prepping and draping Following this we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8 T9 level We then made an approach through a midline incision and came out over the pars We dissected down carefully to identify the pars We then went on the outside of the pars and identified the foramen and then we took another series of x rays to confirm the T8 T9 level We did this under live fluoroscopy We confirmed T8 T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars The pars was then drilled out We identified the disc even further and found the disc herniation material that was under the spinal cord We then took a combination of small pituitaries and removed the disc material without difficulty Once we had disc material out we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further Once we had done that we inspected up by the nerve root found some more disc material there and removed that as well We could trace the nerve root out freely and easily We made sure there was no evidence of further disc material We used an Epstein curette and placed a nerve hook under the nerve root The Epstein curette removed some more disc material Once we had done this we were satisfied with the decompression We irrigated the wound copiously to make sure there is no further disc material and then ready for closure We did place some steroid over the nerve root and readied for closure Hemostasis was meticulous The wound was closed with 1 Vicryl suture for the fascial layer 2 Vicryl suture for the skin and Monocryl and Steri Strips applied Dressing was applied The patient was awoken from anesthesia and taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 150 mL COMPLICATIONS None DISPOSITION To PACU in stable condition having tolerated the procedure well to mobilize routinely when she is comfortable to go to her home Keywords surgery thoracic right sided discectomy herniated nucleus pulposus discectomy thoracic herniated MEDICAL_TRANSCRIPTION,Description Bilateral temporal artery biopsy Rule out temporal arteritis Medical Specialty Surgery Sample Name Temporal Artery Biopsy Transcription PREOPERATIVE DIAGNOSIS Rule out temporal arteritis POSTOPERATIVE DIAGNOSIS Rule out temporal arteritis PROCEDURE Bilateral temporal artery biopsy ANESTHESIA Local anesthesia 1 Xylocaine with epinephrine INDICATIONS I was consulted by Dr X for this patient with bilateral temporal headaches to rule out temporal arteritis I explained fully the procedure to the patient PROCEDURE Both sides were done exactly the same way After 1 Xylocaine infiltration a 2 to 3 cm incision was made over the temporal artery The temporal artery was identified and was grossly normal on both sides Proximal and distal were ligated with both of 3 0 silk suture and Hemoccult The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm They were sent as separate specimens right and left labeled The wound was then closed with interrupted 3 0 Monocryl subcuticular sutures and Dermabond She tolerated the procedure well Keywords surgery headaches bilateral temporal artery temporal artery biopsy temporal arteritis temporal artery temporal biopsy arteritis MEDICAL_TRANSCRIPTION,Description Thoracentesis left Malignant pleural effusion left with dyspnea Medical Specialty Surgery Sample Name Thoracentesis 1 Transcription PREOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea POSTOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea PROCEDURE Thoracentesis left DESCRIPTION OF PROCEDURE The patient was brought to the recovery area of the operating room After obtaining the informed consent the patient s posterior left chest wall was prepped and draped in usual fashion Xylocaine 1 was infiltrated above the seventh intercostal space in the midscapular line Initially I tried to use the thoracentesis set after 1 Xylocaine had been infiltrated but the needle of the system was just too short to reach the pleural cavity due to the patient s very thick chest wall Therefore I had to use a 18 spinal needle which I had to use almost in its entire length to reach the fluid From then on I proceeded manually to withdraw 2000 mL of a light milky fluid The patient tolerated the procedure fairly well but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle At that time it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine At any rate we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation We then thought that if she was doing fine then we will send her home A chest x ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure Keywords surgery malignant pleural effusion chest wall pleural effusion dyspnea thoracentesis fluid pleural MEDICAL_TRANSCRIPTION,Description Insertion of a left subclavian Tesio hemodialysis catheter and surgeon interpreted fluoroscopy Medical Specialty Surgery Sample Name Tesio Hemodialysis Catheter Insertion Transcription OPERATION 1 Insertion of a left subclavian Tesio hemodialysis catheter 2 Surgeon interpreted fluoroscopy OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and MAC anesthesia was administered Next the patient s chest and neck were prepped and draped in the standard surgical fashion Lidocaine 1 was used to infiltrate the skin in the region of the procedure Next a 18 gauge finder needle was used to locate the left subclavian vein After aspiration of venous blood Seldinger technique was used to thread a J wire through the needle This process was repeated The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon interpreted fluoroscopy Next the subcutaneous tunnel was created The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff A dilator and sheath were passed over the individual J wires The dilator and wire were removed and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath which was simultaneously withdrawn The process was repeated Both distal tips were noted to be in good position The Tesio hemodialysis catheters were flushed and aspirated without difficulty The catheters were secured at the cuff level with a 2 0 nylon The skin was closed with 4 0 Monocryl Sterile dressing was applied The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords surgery needle tesio hemodialysis catheter hemodialysis catheter fluoroscopy catheters catheter tesio hemodialysisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Headaches question of temporal arteritis Bilateral temporal artery biopsies Medical Specialty Surgery Sample Name Temporal Artery Biopsy 1 Transcription PREOPERATIVE DIAGNOSIS Headaches question of temporal arteritis POSTOPERATIVE DIAGNOSIS Headaches question of temporal arteritis PROCEDURE Bilateral temporal artery biopsies DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion Xylocaine 1 was utilized and then an incision was made in front of the right ear and deepened anteriorly The temporal artery was found and exposed in an extension of about 2 cm The artery was proximally and distally ligated with 6 0 Prolene and also a side branch and a sample was sent for pathology Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl Then the patient was turned and her left temporal area was prepped and draped in the usual fashion A similar procedure was performed with 1 Xylocaine and exposed her temporal artery which was excised in an extent to about 2 cm This was also proximally and distally ligated with 6 0 Prolene and also side branch Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl Dressings were applied to both areas The patient tolerated the procedure well Estimated blood loss was negligible and the patient went back to Same Day Surgery for recovery Keywords surgery temporal arteritis temporal artery temporal artery biopsies hemostasis subcuticular headaches arteritis MEDICAL_TRANSCRIPTION,Description Extraction of tooth T and incision and drainage I D of right buccal space infection Right buccal space infection and abscess tooth T Medical Specialty Surgery Sample Name Teeth Extraction I D 2 Transcription PREOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth T POSTOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth T PROCEDURE Extraction of tooth T and incision and drainage I D of right buccal space infection ANESTHESIA General oral endotracheal tube COMPLICATIONS None SPECIMENS Aerobic and anaerobic cultures were sent IV FLUID 150 mL ESTIMATED BLOOD LOSS 10 mL PROCEDURE The patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route the patient was prepped and draped in the usual fashion for an intraoral procedure Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located The abscess cavity was aspirated using a 5 mL syringe with an 18 gauge needle Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing The area in the buccal vestibule was then opened with approximately 1 cm incision Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity A small amount of additional purulence was drained from it approximately 1 mL and at this point tooth T was extracted by forceps extraction Periosteal elevator was used to explore the area near the extraction site This was continuous with abscess cavity so the abscess cavity was allowed to drain into the extraction site No drain was placed Upon completion of the procedure the throat pack was removed The pharynx was suctioned The stomach was also suctioned and the patient was then awakened extubated and taken to the recovery room in stable condition Keywords surgery buccal space incision and drainage throat pack extraction site tooth i d drainage infection cavity extraction incision buccal abscess MEDICAL_TRANSCRIPTION,Description Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula Medical Specialty Surgery Sample Name Tessio Catheter Insertion Transcription OPERATIONS PROCEDURES 1 Insertion of right internal jugular Tessio catheter 2 Placement of left wrist primary submental arteriovenous fistula PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring lines were placed The right neck chest and left arm were prepped and draped in a sterile fashion A small incision was made at the top of the anterior jugular triangle in the right neck Through this small incision the right internal jugular vein was punctured and a guidewire was placed It was punctured a 2nd time and a 2nd guidewire was placed The Tessio catheters were assembled They were measured for length Counter incisions were made on the right chest They were then tunneled through these lateral chest wall incisions to the neck incision burying the Dacron cuffs They were flushed with saline A suture was placed through the guidewire and the guidewire and dilator were removed The arterial catheter was then placed through this and the tear away introducer was removed The catheter aspirated and bled easily It was flushed with saline and capped This was repeated with the venous line It also aspirated easily and was flushed with saline and capped The neck incision was closed with a 4 0 Tycron and the catheters were sutured at the exit sites with 4 0 nylon Dressings were applied An incision was then made at the left wrist The basilic vein was dissected free as was the radial artery Heparin was given 50 mg The radial artery was clamped proximally and distally with a bulldog It was opened with a 11 blade and Potts scissors and stay sutures of 5 0 Prolene were placed The vein was clipped distally divided and spatulated for anastomosis It was sutured to the radial artery with a running 7 0 Prolene suture The clamps were removed Good flow was noted through the artery Protamine was given and the wound was closed with interrupted 3 0 Dexon subcutaneous and a running 4 0 Dexon subcuticular on the skin The patient tolerated the procedure well Keywords surgery internal jugular tessio catheter arteriovenous fistula submental tunneled tessio catheter internal jugular radial artery tessio jugular artery catheterNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Thoracentesis Left pleural effusion Left hemothorax Medical Specialty Surgery Sample Name Thoracentesis Transcription PREOPERATIVE DIAGNOSIS Left pleural effusion POSTOPERATIVE DIAGNOSIS Left hemothorax PROCEDURE Thoracentesis PROCEDURE IN DETAIL After obtaining informed consent and having explained the procedure to the patient he was sat at the side of a stretcher in the emergency department His left back was prepped and draped in the usual fashion Xylocaine 1 was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed and then we proceed to draw by hand about 1200 mL blood This blood was nonclotting and it was tested twice Halfway during the procedure the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s Therefore we laid him off his right side while keeping the chest catheter in place At that time I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure Overall besides the described episode the patient tolerated the procedure well and afterwards we took another chest x ray that showed much improvement in the pleural effusion and at that particular time with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not Keywords surgery pleural effusion hemothorax thoracentesis chest MEDICAL_TRANSCRIPTION,Description Extraction of teeth 2 and 19 and incision and drainage I D of intraoral and extraoral of left mandibular dental abscess Medical Specialty Surgery Sample Name Teeth Extraction I D 1 Transcription PREOPERATIVE DIAGNOSES Carious teeth 2 and 19 and left mandibular dental abscess POSTOPERATIVE DIAGNOSES Carious teeth 2 and 19 and left mandibular dental abscess PROCEDURES Extraction of teeth 2 and 19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess ANESTHESIA General oral endotracheal COMPLICATIONS None DRAINS Penrose 0 25 inch intraoral and vestibule and extraoral CONDITION Stable to PACU DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure In addition the extraoral area on the left neck was prepped with Betadine and draped accordingly Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant total of 3 4 mL of lidocaine 2 with 1 100 000 epinephrine and Marcaine 1 7 mL of 0 5 with 1 200 000 epinephrine An incision was made with 15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible No purulent drainage was obtained The 0 25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3 0 silk suture Moving to the intraoral area periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth 19 The area did not drain any purulent material The carious tooth 19 was then extracted by elevator and forceps extraction After the tooth was removed the 0 25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3 0 silk suture The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth 2 was then extracted by routine elevator and forceps extraction After the extraction the throat pack was removed An orogastric tube was then placed by Dr X and stomach contents were suctioned The pharynx was then suctioned with the Yankauer suction The patient was awakened extubated and taken to the PACU in stable condition Keywords surgery yankauer suction orogastric tube carious teeth penrose drain forceps extraction dental abscess incision elevator mandibular dental abscess teeth intraoral extraction drainage MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm Medical Specialty Surgery Sample Name Tenosynovectomy Cortisone Injection Transcription PREOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm POSTOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm PROCEDURE Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm ANESTHESIA Local plus IV sedation MAC ESTIMATED BLOOD LOSS Zero SPECIMENS None DRAINS None PROCEDURE DETAIL Patient brought to the operating room After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release 10 cc of a mixture of 1 Xylocaine and 0 5 Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery Routine prep and drape was employed Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure Hand was positioned palm up in the lead hand holder A short curvilinear incision about the base of the thenar eminence was made Skin was sharply incised Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm Proximally the antebrachial fascia was released for a distance of 2 3 cm proximal to the wrist crease to insure complete decompression of the median nerve Retinacular flap was retracted radially to expose the contents of the carpal canal Median nerve was identified seen to be locally compressed with moderate erythema and mild narrowing Locally adherent tenosynovium was present and this was carefully dissected free Additional tenosynovium was dissected from the flexor tendons individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5 0 nylon horizontal mattress sutures A syringe with 3 cc of Kenalog 10 and 3 cc of 1 Xylocaine using a 25 gauge short needle was then selected 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique 1 cc was injected into the fourth finger A1 A2 pulley tendon sheath using standard tendon sheath injection technique 1 cc was injected into the Dupuytren s nodule in the midpalm to relieve local discomfort Routine postoperative hand dressing with well padded well molded volar plaster splint and lightly compressive Ace wrap was applied Tourniquet was deflated Good vascular color and capillary refill were seen to return to the tips of all digits Patient discharged to the ambulatory recovery area and from there discharged home Discharge medication is Darvocet N 100 30 tablets one to two PO q 4h p r n Patient asked to begin gentle active flexion extension and passive nerve glide exercises beginning 24 48 hours after surgery She was asked to keep the dressings clean dry and intact and follow up in my office Keywords surgery carpal tunnel syndrome pulley dupuytren s tenosynovitis tenosynovectomy carpal tunnel release flexor tenosynovectomy cortisone injection dupuytren s nodule injection cortisone MEDICAL_TRANSCRIPTION,Description Painful enlarged navicula right foot Osteochondroma of right fifth metatarsal Partial tarsectomy navicula and partial metatarsectomy right foot Medical Specialty Surgery Sample Name Tarsectomy Transcription PREOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal POSTOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal PROCEDURE PERFORMED 1 Partial tarsectomy navicula right foot 2 Partial metatarsectomy right foot HISTORY This 41 year old Caucasian female who presents to ABCD General Hospital with the above chief complaint The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin She states that she has been diagnosed with hereditary osteochondromas She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back The patient desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 5 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal Foot was then prepped and draped in the usual sterile orthopedic fashion Foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was then inflated to 250 mmHg The foot was lowered as well as the operating table The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge Attention was then directed to the navicular region on the right foot The area was palpated until the bony prominence was noted A curvilinear incision was made over the area of bony prominence At that time a total of 10 cc with addition of 1 additional lidocaine plain was injected into the surgical site The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis The dissection was carried down to the level of the capsule and periosteum A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone The periosteum and the capsule were then reflected from the navicular bone at this time A bony prominence was noted both medially and plantarly to the navicular bone An osteotome and mallet were then used to resect the enlarged portion of the navicular bone After resection with an osteotome there was noted to be a large plantar shelf The surrounding soft tissues were then freed from this plantar area Care was taken to protect the attachments of the posterior tibial tendon as much as possible Only minimal resection of its attachment to the fiber was performed in order to expose the bone Sagittal saw was then used to resect the remaining plantar medial prominent bone The area was then smoothed with reciprocating rasp until no sharp edges were noted The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with 3 0 Vicryl The subcutaneous tissues were then reapproximated with 4 0 Vicryl to reduce tension from the incision and running 5 0 Vicryl subcuticular stitch was performed Attention was then directed to the fifth metatarsal There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal The incision was then deepened with 15 blade Care was taken to preserve the extensor tendon The incision was then created over the capsule and periosteum of the fifth metatarsal head Capsule and periosteum were reflected both dorsally laterally and plantarly At that time there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal A sagittal saw was used to resect both of these osteal prominences All remaining sharp edges were then smoothed with reciprocating rasp The area was inspected for the remaining bony prominences and none was noted The area was flushed with copious amounts of sterile saline The capsule and periosteum were then reapproximated with 3 0 Vicryl Subcutaneous closure was then performed with 4 0 Vicryl in order to reduce tension around the incision line Running 5 0 subcutaneous stitch was then performed Steri Strips were applied to both surgical sites Dressings consisted of Adaptic soaked in Betadine 4x4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot The patient tolerated the above procedure and anesthesia well without complications The patient was transferred to the PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated The patient is to follow up with Dr X in his office as directed or sooner if any problems or questions arise Keywords surgery navicula metatarsal osteochondroma tarsectomy metatarsectomy painful enlarged navicula navicular bone foot bony capsule periosteum navicular incision bone MEDICAL_TRANSCRIPTION,Description Extraction of teeth Incision and drainage I D of left mandibular vestibular abscess adjacent to teeth 18 and 19 Medical Specialty Surgery Sample Name Teeth Extraction I D Transcription PREOPERATIVE DIAGNOSES 1 Carious teeth 2 5 12 15 18 19 and 31 2 Left mandibular vestibular abscess POSTOPERATIVE DIAGNOSES 1 Carious teeth 2 5 12 15 18 19 and 31 2 Left mandibular vestibular abscess PROCEDURE 1 Extraction of teeth 2 5 12 15 18 19 31 2 Incision and drainage I D of left mandibular vestibular abscess adjacent to teeth 18 and 19 ANESTHESIA General nasotracheal COMPLICATIONS None DRAIN Quarter inch Penrose drain place in left mandibular vestibule adjacent to teeth 18 and 19 secured with 3 0 silk suture CONDITION The patient was taken to the PACU in stable condition INDICATION Patient is a 32 year old female who was admitted yesterday 03 04 10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure A gauze throat pack was placed and local anesthetic was administered in all four quadrants a total of 6 8 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of Marcaine 0 5 with 1 200 000 epinephrine The area in the left vestibular area adjacent to the teeth 18 and 19 was aspirated with 5 cc syringe with an 18 guage needle and approximately 1 mL of purulent material was aspirated This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab An incision was then made in the left mandibular vestibule adjacent to teeth 18 and 19 The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained Penrose drain was then placed using a curved hemostat The drain was secured with 3 0 silk suture The extraction of the teeth was then begun on the left side removing teeth 12 15 18 and 19 with forceps extraction then moving to the right side teeth 2 5 and 31 were removed with forceps extraction uneventfully After completion of the procedure the throat pack was removed the pharynx was suctioned The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube The nasogastric tube was then removed Patient was then extubated and taken to the PACU in stable condition Keywords surgery mandibular vestibular abscess throat pack purulent material forceps extraction nasogastric tube carious teeth incision teeth nasogastric carious extraction MEDICAL_TRANSCRIPTION,Description Removal of cystic lesion removal of teeth modified Le Fort I osteotomy MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH with a right salpingo oophorectomy Medical Specialty Surgery Sample Name TAH Salpingo oophorectomy 1 Transcription PREOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation POSTOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation PROCEDURE PERFORMED Total abdominal hysterectomy TAH with a right salpingo oophorectomy COMPLICATIONS None ESTIMATED BLOOD LOSS 250 cc FLUIDS 1500 cc of crystalloids URINE 125 cc of clear urine at the end of the procedure FINDINGS On exam under anesthesia an obese female with an enlarged fibroid uterus freely movable on the pelvis Operative findings demonstrated the same with normal appearing tubes bilaterally The right ovary contained a right ovarian cyst The left ovary appeared to be within normal limits The peritoneal surfaces were noted to be within normal limits The bowel was also noted to be within normal limits INDICATIONS FOR THIS PROCEDURE The patient is a 44 year old female who had an endometrial ablation done in May which showed submucosal fibroids She had history of anemia and has been on iron therapy She started having bleeding three weeks ago with intermittent bouts of flooding She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy The uterus cervix and right tube and ovary was sent to pathology for review PROCEDURE After informed consent was obtained all questions were answered to the patient s satisfaction in layman s term She was taken to the operating room where a general anesthesia was obtained without any difficulty She was examined under anesthesia with noted findings above She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia With the second knife the fascia was excised in the midline and extended laterally with the Mayo scissors The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly Attention was then turned to the inferior aspect of the fascial incision which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly The rectus muscle was then separated in the midline the peritoneum was identified entered bluntly and digitally Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder The GYN Balfour was then placed A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges Attention was then turned to the round ligaments bilaterally which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the O tie was passed through and then tied down Then the round ligament was transected and suture ligated and noted to be hemostatic The round ligaments were then skeletonized to create a window in the broad ligament The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a 0 Vicryl in a Heaney stitch fashion It was noted to be hemostatic Attention was then turned to the left side in which the uterovarian vessel was isolated and then tied with an O tie and then doubly clamped with straight Ochsner clamps transected and suture ligated with a 0 Vicryl in a Heaney stitch fashion and noted to be hemostatic The vesicouterine peritoneum was then identified tented up with Allis clamps and then the bladder flap was created sharply with a Russian and Metzenbaum scissors Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray Tec sponge down to the level of the cervix The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic In the similar fashion the broad ligament down to the level of the caudal ligament the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated and noted to be hemostatic The second Lahey clamp was then placed on the cervix The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable The cuff was then outlined The vaginal cuff was grasped with a Ochsner clamp and then the cervix uterus and the right tube and ovary were transected using the Jorgenson scissors The cuff outlined with Ochsner clamps The cuff was then painted with a Betadine soaked Ray Tec sponge and the sponge was placed over the vagina The vaginal cuff was then closed with a 0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles A long Allis was then used to grasp the mid portion of the cuff and a 0 Vicryl figure of eight stitch was placed in the mid portion of the cuff and tied down At this time the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff and then tied down to bring the cuff close and together Then the right round ligament was pulled into the cuff and tied down with the 0 Vicryl that was used as a figure of eight stitch in the middle of the cuff The left round ligament was too small to reach the cuff The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic The peritoneum was then re peritonealized with a 3 0 Vicryl in a running fashion The GYN Balfour and all packing sponges were removed from the abdomen Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic The ______ was placed back into the hollow of the sacrum The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a 3 0 Vicryl in a running fashion and then the fascia was closed with 0 Vicryl in a running fashion The skin was closed with staples and dressing applied The patient was then examined at the end of the procedure The Betadine soaked sponge was removed from the vagina The cuff was noted to be intact without bleeding and the patient tolerated the procedure well Sponge lap and needle counts were correct x2 and she was taken to the recovery in stable condition The patient will be followed throughout her hospital stay Keywords surgery tah salpingo oophorectomy total abdominal hysterectomy abnormal uterine bleeding endometrial ablatio ochsner clamps round ligaments clamps ligaments cuff salpingo oophorectomy hysterectomy uterine ablation tubes abdominal anesthesia MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH with bilateral salpingooophorectomy and uterosacral ligament vault suspension Cervical intraepithelial neoplasia grade III postconization Recurrent dysplasia Uterine procidentia grade II III Mild vaginal vault prolapse Medical Specialty Surgery Sample Name TAH Salpingooophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Cervical intraepithelial neoplasia grade III status post conization with poor margins 2 Recurrent dysplasia 3 Unable to follow in office 4 Uterine procidentia grade II III POSTOPERATIVE DIAGNOSES 1 Cervical intraepithelial neoplasia grade III postconization 2 Poor margins 3 Recurrent dysplasia 4 Uterine procidentia grade II III 5 Mild vaginal vault prolapse PROCEDURES PERFORMED 1 Total abdominal hysterectomy TAH with bilateral salpingooophorectomy 2 Uterosacral ligament vault suspension ANESTHESIA General and spinal with Astramorph for postoperative pain ESTIMATED BLOOD LOSS Less than 100 cc FLUIDS 2400 cc URINE 200 cc of clear urine output INDICATIONS This patient is a 57 year old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins FINDINGS On bimanual examination the uterus was found to be small There were no adnexal masses appreciated Intraabdominal findings revealed a small uterus approximately 2 cm in size The ovaries were atrophic consistent with menopause The liver margins and stomach were palpated and found to be normal PROCEDURE IN DETAIL After informed consent was obtained the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control She was then placed in the dorsal lithotomy position and administered general anesthesia She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder At this point the patient was evaluated for a possible vaginal hysterectomy She was nulliparous and the pelvis was narrow After the anesthesia was administered the patient was repeatedly stooling and therefore because of these two reasons the decision was made to do an abdominal hysterectomy After the patient was prepped and draped a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis The second scalpel was used to dissect out to the underlying layer of fascia The fascia was incised in the midline and extended laterally using the Mayo scissors The superior aspect of the rectus fascia was grasped with Ochsners tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors In a similar fashion the inferior portion of the rectus fascia was tented up dissected off bluntly as well as with Mayo scissors The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder At this point the above findings were noted and the GYN Balfour retractor was placed Moist laparotomy sponges were used to pack the bowel out of the operative field The bladder blade and the extension for the retractor were then placed An Allis was used on the uterus for retraction The round ligaments were then identified clamped with two hemostats and transected and then suture ligated The anterior portion of the broad ligament was dissected along vesicouterine resection The bladder was then dissected off the anterior cervix and vagina without difficulty The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats transected and suture ligated with 0 Vicryl suture The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with 0 Vicryl Good hemostasis was assured The cardinal ligaments on both sides were clamped using a curved hemostat transected and suture ligated with 0 Vicryl Good hemostasis was obtained Two hemostats were then placed just under the cervix meeting in the midline The uterus and cervix were then _______ off using a scalpel This was handed and sent to Pathology for evaluation Using 0 Vicryl suture the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament A baseball stitch was then used to close the cuff to the midline The same was done to the left vaginal cuff angle which was affixed to the ipsilateral and cardinal ligaments The baseball stitch was used to close the cuff to the midline The hemostats were removed and the cuff was closed and good hemostasis was noted The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a 0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff The pelvis was then copiously irrigated with warm normal saline Good support and hemostasis was noted The bowel packing was then removed and the GYN Balfour retractor was moved The peritoneum was then repaired with 0 Vicryl in a running fashion The fascia was then closed using 0 Vicryl in a running fashion marking the first stitch and first last stitch in a lateral to medial fashion The skin was then closed with 4 0 undyed Vicryl in a subcuticular closure and an Op Site was placed over this The patient was then brought out of general anesthesia and extubated The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She will follow up postoperatively as an inpatient Keywords surgery cervical intraepithelial neoplasia vaginal vault prolapse uterosacral ligament vault suspension total abdominal hysterectomy bilateral salpingooophorectomy abdominal hysterectomy uterosacral ligament recurrent dysplasia uterine procidentia suture ligated abdominal intraepithelial tah salpingooophorectomy hysterectomy ligament hemostats vaginal MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH left salpingo oophorectomy lysis of interloop bowel adhesions Chronic pelvic pain endometriosis prior right salpingo oophorectomy history of intrauterine device perforation and exploratory surgery Medical Specialty Surgery Sample Name TAH Salpingo oophorectomy Lysis of Adhesions Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Endometriosis 3 Prior right salpingo oophorectomy 4 History of intrauterine device perforation and exploratory surgery POSTOPERATIVE DIAGNOSES 1 Endometriosis 2 Interloop bowel adhesions PROCEDURE PERFORMED 1 Total abdominal hysterectomy TAH 2 Left salpingo oophorectomy 3 Lysis of interloop bowel adhesions ANESTHESIA General ESTIMATED BLOOD LOSS 400 cc FLUIDS 2300 cc of lactated Ringers as well as lactated Ringers for intraoperative irrigation URINE 500 cc of clear urine output INTRAOPERATIVE FINDINGS The vulva and perineum are without lesions On bimanual exam the uterus was enlarged movable and anteverted The intraabdominal findings revealed normal liver margin kidneys and stomach upon palpation The uterus was found to be normal in size with evidence of endometriosis on the uterus The right ovary and fallopian tube were absent The left fallopian tube and ovary appeared normal with evidence of a small functional cyst There was evidence of left adnexal adhesion to the pelvic side wall which was filmy unable to be bluntly dissected There were multiple interloop bowel adhesions that were filmy in nature noted The appendix was absent There did appear to be old suture in a portion of the bowel most likely from a prior procedure INDICATIONS This patient is a 45 year old African American gravida7 para3 0 0 3 who is here for definitive treatment of chronic pelvic pain with a history of endometriosis She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo oophorectomy She has tried Lupron and did stop secondary to the side effects PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the Operating Suite and placed under general anesthesia She was then prepped and draped in the sterile fashion and placed in the dorsal supine position An indwelling Foley catheter was placed With the skin knife an incision was made removing the old cicatrix A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder At this point the intraabdominal cavity was manually explored and the above findings were noted A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field The bowel was then packed with moist laparotomy sponges Prior to this the filmy adhesions leftover were taken down At this point the left round ligament was identified grasped with two hemostats transected and suture ligated with 0 Vicryl At this point the broad ligament was dissected down and the lost portion of the bladder flap was created The posterior aspect of the peritoneum was also dissected At this point the infundibulopelvic ligament was isolated and three tie of 0 Vicryl was used to isolate the pedicle Two hemostats were then placed across the pedicle and this was transected with the scalpel This was then suture ligated in Heaney fashion The right round ligament was then identified and in the similar fashion two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament This was then ligated with three tie of 0 Vicryl Also incorporated in this was the remnant from the previous right salpingo oophorectomy At this point the bladder flap was further created with sharp dissection as well as the moist Ray Tech to push the bladder down off the anterior portion of the cervix The left uterine artery was then skeletonized and a straight Heaney was placed In a similar fashion the contralateral uterine artery was skeletonized and straight Heaney clamp was placed These ligaments bilaterally were transected and suture ligated in a left Heaney stitch At this point curved Masterson was used to incorporate the cardinal ligament complex thus was transected and suture ligated Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated Prior to ligating the uterine arteries the uterosacral arteries were tagged bilaterally with 0 Vicryl At this point the roticulator was placed across the vaginal cuff and snug underneath the entire cervix The roticulator was then clamped and removed and the staple line was in place This was found to be hemostatic A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally At this point McCall culdoplasty was performed with an 0 Vicryl incorporating each uterosacral as well as the posterior peritoneum There did appear to be good support on palpation Prior to this the specimen was handed off and sent to pathology At this point there did appear to be small amount of oozing at the right peritoneum Hemostasis was obtained using a 0 Vicryl in two single stitches Good hemostasis was then obtained on the cuff as well as the pedicles Copious irrigation was performed at this point with lactate Ringers The round ligaments were then incorporated into the cuff bilaterally Again copious amount of irrigation was performed and good hemostasis was obtained At this point the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally At this point the bowel packing as well as moist Ray Tech was removed and while re approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel Good hemostasis was obtained of these sites as well The sigmoid colon was then returned to its anatomic position and the omentum as well The rectus muscle was then reapproximated with two interrupted sutures of 2 0 Vicryl The fascia was then reapproximated with 0 Vicryl in a running fashion from lateral to medial meeting in the midline The Scarpa s fascia was then closed with 3 0 plain in a running suture The skin was then re approximated with 4 0 undyed Vicryl in a subcuticular closure This was dressed with an Op Site The patient tolerated the procedure well The sponge lap and needle were correct x2 After the procedure the patient was extubated and brought out of general anesthesia She will go to the floor where she will be followed postoperatively in the hospital Keywords surgery chronic pelvic pain endometriosis intrauterine device exploratory abdominal hysterectomy tah total abdominal hysterectomy lysis of interloop bowel adhesions salpingo oophorectomy bowel ligament adhesions interloop hemostasis uterus salpingo oophorectomy MEDICAL_TRANSCRIPTION,Description Arthroscopic irrigation and debridement of same with partial synovectomy Septic left total knee arthroplasty Medical Specialty Surgery Sample Name Synovectomy Partial Transcription PREOPERATIVE DIAGNOSIS Septic left total knee arthroplasty POSTOPERATIVE DIAGNOSIS Septic left total knee arthroplasty OPERATION PERFORMED Arthroscopic irrigation and debridement of same with partial synovectomy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None DRAINS None INDICATIONS The patient is an 81 year old female who is approximately 10 years status post total knee replacement performed in another state who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection The patient knee was aspirated in the office and cultures were positive for Escherichia coli She presents for operative therapy DESCRIPTION OF OPERATION After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position The left upper extremity was prepped and draped without a tourniquet The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created The arthroscopy was inserted and a complete diagnostic was performed Arthroscopic pictures were taken throughout the procedure The knee was copiously irrigated with 9 L of irrigant A partial synovectomy was performed in all compartments Minimal amount of polyethylene wear was noted The total knee components were identified arthroscopically for future revision surgery The knee was then drained and the arthroscopic instruments were removed The portals were closed with 4 0 nylon and local anesthetic was injected A sterile dressing was applied and the patient was placed in a knee immobilizer awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well Keywords surgery total knee arthroplasty arthroscopic irrigation debridement partial synovectomy knee arthroscopic irrigation arthroscopy synovectomy MEDICAL_TRANSCRIPTION,Description Tailor bunionectomy right foot Weil type with screw fixation Hallux abductovalgus deformity and tailor bunion deformity right foot Medical Specialty Surgery Sample Name Tailor Bunionectomy with Screw Fixation Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot PROCEDURES PERFORMED Tailor bunionectomy right foot Weil type with screw fixation ANESTHESIA Local with MAC local consisting of 20 mL of 0 5 Marcaine plain HEMOSTASIS Pneumatic ankle tourniquet at 200 mmHg INJECTABLES A 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate MATERIAL A 2 4 x 14 mm 2 4 x 16 mm and 2 0 x 10 mm OsteoMed noncannulated screw A 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl and 5 0 nylon COMPLICATIONS None SPECIMENS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was brought to the operating room and placed on the operating table in the usual supine position At this time a pneumatic ankle tourniquet was placed on the patient s right ankle for the purpose of maintaining hemostasis Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site The right foot was then scrubbed prepped and draped in the usual aseptic manner An Esmarch bandage was then used to exsanguinate the patient s right foot and the pneumatic ankle tourniquet inflated to 200 mmHg Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3 5 cm in length was made The incision was carried deep utilizing both sharp and blunt dissections All major neurovascular structures were avoided At this time through the original skin incision attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified This was then incised fully exposing the tendon and the abductor hallucis muscle This was then resected from his osseous attachments and a small tenotomy was performed At this time a small lateral capsulotomy was also performed Lateral contractures were once again reevaluated and noted to be grossly reduced Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw the head of the first metatarsal and medial eminence was resected and passed from the operative field A 0 045 inch K wire was then driven across the first metatarsal head in order to act as an access dye The patient was then placed in the frog leg position and two osteotomy cuts were made one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position The dorsal arm was made longer than the plantar arm to accommodate for fixation At this time the capital fragment was resected and shifted laterally into a more corrected position At this time three portions of the 0 045 inch K wire were placed across the osteotomy site in order to access temporary forms of fixation Two of the three of these K wires were removed in sequence and following the standard AO technique two 3 4 x 15 mm and one 2 4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site Compression was noted to be excellent All guide wires and 0 045 inch K wires were then removed Utilizing an oscillating bone saw the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field The wound was then once again flushed with copious amounts of sterile normal saline At this time utilizing both 2 0 and 3 0 Vicryl the periosteal and capsular layers were then reapproximated At this time the skin was then closed in layers utilizing 4 0 Vicryl and 4 0 nylon At this time attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal Utilizing an oscillating bone saw the lateral eminence was resected and passed from the operative field Utilizing the sagittal saw a Weil type osteotomy was made at the fifth metatarsal head The head was then shifted medially into a more corrected position A 0 045 inch K wire was then used as a temporary fixation and a 2 0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site This was noted to be in correct position and compression was noted to be excellent Utilizing a small bone rongeur the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field The wound was once again flushed with copious amounts of sterile normal saline The periosteal and capsular layers were reapproximated utilizing 3 0 Vicryl and the skin was then closed utilizing 4 0 Vicryl and 4 0 nylon At this time 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site The right foot was then dressed with Xeroform gauze fluffs Kling and Ace wrap all applied in mild compressive fashion The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot After a brief period of postoperative monitoring the patient was discharged to home with proper written and verbal discharge instructions which included to keep dressing clean dry and intact and to follow up with Dr A The patient is to be nonweightbearing to the right foot The patient was given a prescription for pain medications on nonsteroidal anti inflammatory drugs and was educated on these The patient tolerated the procedure and anesthesia well Dr A was present throughout the entire case Keywords surgery tailor bunionectomy weil type screw fixation hallux abductovalgus bunion tailor deformity metatarsal phalangeal capsulotomy abductor hallucis MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH and left salpingo oophorectomy Hypermenorrhea uterine fibroids pelvic pain left adnexal mass and pelvic adhesions Medical Specialty Surgery Sample Name TAH Salpingo oophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Uterine fibroids 3 Pelvic pain 4 Left adnexal mass 5 Pelvic adhesions POSTOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Uterine fibroids 3 Pelvic pain 4 Left adnexal mass 5 Pelvic adhesions PROCEDURE PERFORMED 1 Total abdominal hysterectomy TAH 2 Left salpingo oophorectomy ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 cc INDICATIONS The patient is a 47 year old Caucasian female with complaints of hypermenorrhea and pelvic pain noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003 The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment FINDINGS AT THE TIME OF SURGERY Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass On laparotomy the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass The bowel omentum and appendix had a normal appearance PROCEDURE The patient was taken to the operative suite where anesthesia was found to be adequate She was then prepared and draped in normal sterile fashion A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel The fascia was then incised in the midline The fascial incision was then extended laterally with Mayo scissors The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors Attention was then turned to the inferior aspect of this incision which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors The rectus muscle was then separated in the midline The peritoneum was identified tented up with hemostats and entered sharply with Metzenbaum scissors The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder The uterus and left adnexa were then palpated and brought out into the surgical field The fundus of the uterus was grasped with a Lahey clamp The GYN Balfour retractor was placed The bladder blade was placed The bowel was packed away with moist laparotomy sponges and the extension through GYN Balfour retractor was placed At this time the patient s anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass Attention was first turned to the right round ligament which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat It was then suture ligated with 0 Vicryl suture transected with the broad ligament being skeletonized on both sides Next the right ________ was isolated bluntly as the patient had a previous RSO This was then suture ligated with 0 Vicryl suture doubly clamped with Kocher clamps transected and suture ligated with 0 Vicryl suture with a Heaney stitch Attention was then turned to the left round ligament which was tented up with the Babcock Small window was made beneath it and the broad ligament with hemostat was then suture ligated with 0 Vicryl suture transected and skeletonized with the aid of Metzenbaums The left infundibulopelvic ligament was then bluntly isolated It was then suture ligated with 0 Vicryl suture doubly clamped with Kocher clamps and transected and suture ligated with 0 Vicryl suture with a Heaney stitch The bladder flap was then placed on tension with Allis clamps It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians It was then gently pushed off of lower uterine segment with the aid of a moist Ray Tec The uterine arteries were then skeletonized bilaterally They were then clamped with straight Kocher clamps transected and suture ligated with 0 Vicryl suture The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps These were then transected and suture ligated with 0 Vicryl suture The lower uterine segment was then grasped with Lahey clamps at which time the cervix was already visible It was then entered with the last transection The cervix was grasped with a single toothed tenaculum and the uterus cervix and left adnexa were amputated off the vagina with the aid of Jorgenson scissors The angles of the vaginal cuff were then grasped with Kocher clamps A Betadine soaked Ray Tec was then pushed into the vagina and the vaginal cuff was closed with 0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament at which time the suction tip was changed and copious suction irrigation was performed Good hemostasis was appreciated A figure of eight suture in the center of the vaginal cuff was placed with 0 Vicryl This was tagged for later use The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of 0 Vicryl suture The round ligaments were then pulled into the vaginal cuff using the figure of eight suture placed in the center of the vaginal cuff and these were tied in place The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated The peritoneal surfaces were then reapproximated with the aid of 3 0 Vicryl suture in a running fashion The GYN Balfour retractor and bladder blade were then removed The bowel was then packed Again copious suction irrigation was performed with hemostasis appreciated The peritoneum was then reapproximated with 2 0 Vicryl suture in a running fashion The fascia was then reapproximated with 0 Vicryl suture in a running fashion The Scarpa s fascia was then reapproximated with 3 0 plain gut in a running fashion and the skin was closed with 4 0 undyed Vicryl in a subcuticular fashion Steri Strips were placed At the end of the procedure the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally The patient tolerated the procedure well and was taken to Recovery in stable condition Sponge lap and needle counts were correct x2 Specimens include uterus cervix left fallopian tube and ovary Keywords MEDICAL_TRANSCRIPTION,Description Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter Medical Specialty Surgery Sample Name SynchroMed Pump Placement Transcription PROCEDURES 1 Placement of SynchroMed infusion pump 2 Tunneling of SynchroMed infusion pump catheter 3 Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter DESCRIPTION OF PROCEDURE Under general endotracheal anesthesia the patient was placed in a lateral decubitus position The patient was prepped and draped in a sterile manner The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle A pursestring suture of 3 0 Prolene was placed around the needle in the paraspinous muscle The needle was withdrawn The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak The catheter demonstrated free flow of cerebrospinal fluid throughout the RV procedure The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3 0 Prolene Antibiotic irrigation and antibiotic soak sponge were placed into the wound and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed pump pocket was created Then I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery A pocket was created that would encompass the SynchroMed fusion pump A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision and a SynchroMed pump catheter was placed to the tunneling device The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision The intrathecal catheter was trimmed A clear plastic boot was placed over the intrathecal catheter and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together The clear plastic boot was then placed over the connection and it was anchored in place with 0 silk ties Good CSF was then demonstrated flowing through the SynchroMed pump catheter The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0 silk tie Excess catheter was coiled and placed behind the pump The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2 0 Prolene 4 of the sutures were placed The subcutaneous tissues were irrigated with normal saline The subcutaneous tissue of both wounds was closed with running suture of 3 0 Vicryl The skin of both wounds was closed with staples Antibiotic ointment and a sterile dressing were applied The patient was awake and taken to the recovery room The patient tolerated the procedure well and was stable at the completion of the procedure All sponge and lap needle and instrument counts were correct at the completion of the procedure Keywords surgery intrathecal catheter paraspinous cerebrospinal synchromed infusion pump synchromed pump catheter synchromed pump paraspinous muscle cerebrospinal fluid tunneling device infusion pump subcutaneous tissue infusion synchromed pump incision MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy and bilateral salpingo oophorectomy Medical Specialty Surgery Sample Name TAH BSO Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Dysmenorrhea 3 Dyspareunia 4 Endometriosis 5 Enlarged uterus 6 Menorrhagia POSTOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Dysmenorrhea 3 Dyspareunia 4 Endometriosis 5 Enlarged uterus 6 Menorrhagia PROCEDURE Total abdominal hysterectomy and bilateral salpingo oophorectomy ESTIMATED BLOOD LOSS Less than 100 mL DRAINS Foley ANESTHESIA General This 28 year old white female who presented to undergo TAH BSO secondary to chronic pelvic pain and a diagnosis of endometriosis At the time of the procedure once entering into the abdominal cavity there was no gross evidence of abnormalities of the uterus ovaries or fallopian tube All endometriosis had been identified laparoscopically from a previous surgery At the time of the surgery all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed in supine position at which time general form of anesthesia was administered by the anesthesia department The patient was then prepped and draped in the usual fashion for a low transverse incision Approximately two fingerbreadths above the pubic symphysis a first knife was used to make a low transverse incision This was extended down to the level of the fascia The fascia was nicked in the center and extended in a transverse fashion The edges of the fascia were grasped with Kocher Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique The abdominal rectus muscle was divided in the midline and extended in a vertical fashion Perineum was entered at the high point and extended in a vertical fashion as well An O Connor O Sullivan retractor was put in place on either side A bladder blade was put in place as well Uterus was grasped with a double tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade The bladder flap was released with Metzenbaum scissors and then dissected away caudally EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip Two Heaney were placed on either side of the uterus at the level of cardinal ligaments These were sharply incised and both pedicles were tied off with 1 Vicryl suture Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact From there the corners of the vaginal cuff were reinforced with figure of eight stitches Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re approximate the edges with a second layer used to reinforce the first Bladder flap was created with the use of 3 0 Vicryl and Gelfoam was placed underneath The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips The entire area was then re peritonized and copious amounts of saline were used to irrigate the pelvic cavity Once this was completed Gelfoam was placed into the cul de sac and the O Connor O Sullivan retractor was removed as well as all the wet lap pack Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2 0 Vicryl was used to re approximate the peritoneum as well as abdominal rectus muscle The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re approximate the fascia with overlapping in the center The subcutaneous tissue was irrigated Cautery was used to create adequate hemostasis and 3 0 Vicryl was used to re approximate the tissue and the skin edges were re approximated with sterile staples Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood The patient was taken to recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords surgery tah bso total abdominal hysterectomy bilateral salpingo oophorectomy hysterectomy pelvic pai dysmenorrhea dyspareunia endometriosis uterus menorrhagia betadine soaked sponge bladder flap vaginal vault abdominal fascia rectus MEDICAL_TRANSCRIPTION,Description Missed abortion Suction dilation and curettage Medical Specialty Surgery Sample Name Suction Dilation Curettage Transcription PREOPERATIVE DIAGNOSIS Missed abortion POSTOPERATIVE DIAGNOSIS Missed abortion PROCEDURE PERFORMED Suction dilation and curettage ANESTHESIA Spinal ESTIMATED BLOOD LOSS 50 mL COMPLICATIONS None FINDINGS Products of conception consistent with a 6 week intrauterine pregnancy INDICATIONS The patient is a 28 year old gravida 4 para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today A workup done in the emergency room revealed a beta quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown rump length consistent with a 6 week and 2 day pregnancy No heart tones were visible On examination in the emergency room a moderate amount of bleeding was noted Additionally the cervix was noted to be 1 cm dilated These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient After discussion of these options the patient opted for a suction dilation and curettage The patient was described to the patient in detail including risks of infection bleeding injury to surrounding organs including risk of perforation Informed consent was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where spinal anesthesia was administered without difficulty The patient was prepped and draped in usual sterile fashion in lithotomy position A weighted speculum was placed The anterior lip of the cervix was grasped with a single tooth tenaculum At this time a 7 mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus Following removal of the products of conception a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted At this time the suction curette was advanced one additional time to suction any remaining products All instruments were removed Hemostasis was visualized The patient was stable at the completion of the procedure Sponge lap and instrument counts were correct Keywords surgery missed abortion intrauterine pregnancy dilation curettage suction intrauterine MEDICAL_TRANSCRIPTION,Description Excision of mass left second toe and distal Symes amputation left hallux with excisional biopsy Mass left second toe Tumor Left hallux bone invasion of the distal phalanx Medical Specialty Surgery Sample Name Symes Amputation Hallux Transcription PREOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux bone invasion of the distal phalanx POSTOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux with bone invasion of the distal phalanx PROCEDURE PERFORMED 1 Excision of mass left second toe 2 Distal Syme s amputation left hallux with excisional biopsy HISTORY This 47 year old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size The patient also has history of shave biopsy in the past The patient does state that he desires surgical excision at this time PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 6 cc mixed with 1 lidocaine plain with 0 5 Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses The foot was lowered to the operating table The stockinet was reflected and the foot was cleansed with wet and dry sponge A distal Syme s incision was planned over the distal aspect of the left hallux The incision was performed with a 10 blade and deepened with 15 down to the level of bone The dorsal skin flap was removed and dissected in toto off of the distal phalanx There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx The tissue was sent to Pathology where Dr Green stated that a frozen sample would be of less use for examining for cancer Dr Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen At this time a sagittal saw was then used to resect all ends of bone of the distal phalanx The area was inspected for any remaining suspicious tissues Any suspicious tissue was removed The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon with a combination of simple and vertical mattress sutures Attention was then directed to the left second toe There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe A linear incision was made just medial to the tissue mass The mass was then dissected from the overlying skin and off of the underlying capsule This tissue mass was hard round and pearly gray in appearance It does not invade into any other surrounding tissues The area was then flushed with copious amounts of sterile saline and the skin was closed with 4 0 nylon Dressings consisted of Owen silk soaked in Betadine 4x4s Kling Kerlix and an Ace wrap The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr Bonnani in his office as directed The patient will be contacted immediately pending the results of pathology Cultures obtained in the case were aerobic and anaerobic gram stain Silver stain and a CBC Keywords surgery distal phalanx mass tumor hallux bone phalanx symes amputation excisional biopsy distal amputation invasion toe symes incision flushed excision tissue hallux MEDICAL_TRANSCRIPTION,Description Closure of gastrostomy placed due to feeding difficulties Medical Specialty Surgery Sample Name Surgical Closure of Gastrostomy Transcription PREOPERATIVE DIAGNOSIS Gastrostomy gastrocutaneous fistula POSTOPERATIVE DIAGNOSIS Gastrostomy gastrocutaneous fistula OPERATION PERFORMED Surgical closure of gastrostomy ANESTHESIA General INDICATIONS This 1 year old child had a gastrostomy placed due to feeding difficulties Since then he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy The tube was therefore removed but the tract has not shown signs of spontaneous closure He therefore comes to the operating room today for surgical closure of his gastrostomy OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in the usual manner An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection The tract and the stomach were freed Stay sutures were then placed on either side of the tract The tract was amputated The intervening stomach was then closed with interrupted 4 0 Lembert Nurolon sutures The fascia was then closed over the stomach using 3 0 Vicryl sutures The skin was closed with 5 0 subcuticular Monocryl A dressing was applied and the child was awakened and taken to the recovery room in satisfactory condition Keywords surgery gastrocutaneous fistula nurolon closure of gastrostomy feeding difficulties surgical closure gastrostomy MEDICAL_TRANSCRIPTION,Description Subxiphoid pericardial window A 10 blade scalpel was used to make an incision in the area of the xiphoid process Dissection was carried down to the level of the fascia using Bovie electrocautery Medical Specialty Surgery Sample Name Subxiphoid Pericardial Window 1 Transcription OPERATION Subxiphoid pericardial window ANESTHESIA General endotracheal anesthesia OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient s family including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the neck and chest were prepped and draped in the standard surgical fashion A 10 blade scalpel was used to make an incision in the area of the xiphoid process Dissection was carried down to the level of the fascia using Bovie electrocautery The xiphoid process was elevated and the diaphragmatic attachments to it were dissected free Next the pericardium was identified The pericardium was opened with Bovie electrocautery Upon entering the pericardium serous fluid was expressed In total cc of fluid was drained A pericardial biopsy was obtained The fluid was sent off for cytologic examination as well as for culture A 24 Blake chest drain was brought out through the skin and placed in the posterior pericardium The fascia was closed with 1 Vicryl followed by 2 0 Vicryl followed by 4 0 PDS in a running subcuticular fashion Sterile dressing was applied Keywords surgery xiphoid process pericardium subxiphoid pericardial window endotracheal anesthesia bovie electrocautery subxiphoid pericardial bovie electrocautery subxiphoid window pericardial MEDICAL_TRANSCRIPTION,Description Right buccal and canine s base infection from necrotic teeth ICD9 CODE 528 3 Incision and drainage of multiple facial spaces CPT Code 40801 Surgical removal of the following teeth The teeth numbers 1 2 3 4 and 5 CPT code 41899 and dental code 7210 Medical Specialty Surgery Sample Name Surgical Removal of Teeth Transcription PREOPERATIVE DIAGNOSIS Right buccal and canine s base infection from necrotic teeth ICD9 CODE 528 3 POSTOPERATIVE DIAGNOSIS Right buccal and canine s base infection from necrotic teeth ICD9 Code 528 3 PROCEDURE Incision and drainage of multiple facial spaces CPT Code 40801 Surgical removal of the following teeth The teeth numbers 1 2 3 4 and 5 CPT code 41899 and dental code 7210 SPECIMENS Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab DRAINS A 1 5 inch Penrose drain placed in the right buccal and canine space ESTIMATED BLOOD LOSS 40 Ml FLUID 700 mL of crystalloid COMPLICATIONS None CONDITION The patient was extubated breathing spontaneously to the PACU in good condition INDICATION FOR PROCEDURE The patient is a 41 year old that has a recent history of toothache and tooth pain She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse The patient was admitted to the hospital on Monday for IV antibiotics Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia Risks benefits and alternatives of treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was taken to the operating room and laid on the operating room table on supine fashion ASA monitors were attached as stated General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics The patient was prepped and draped in usual oromaxillary facial surgery fashion An 18 gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space This pus was then cultured and sent to micro lab for cultures and sensitivities Approximately 7 mL of 1 lidocaine with 1 1000 epinephrine was injected in the maxillary vestibule and palate After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case Mouth rinse was then poured into the oral cavity The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction Using a 15 blade a clavicular incision from tooth 5 back to 1 with tuberosity release was performed A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space It was noted on exam that the tooth 1 was fractured off to the gum line with gross decay Tooth 2 3 4 and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth 2 and 3 and some mobility on teeth 4 and 5 It was decided that teeth 1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed Using a rongeur both buccal bone and the tooth 1 2 3 4 and 5 were surgically removed The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed This site was then irrigated with copious amounts of sterile water There was still noted to be induration in the buccal mucosa so 15 blade was used anterior to Stensen duct A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed A little to no pus was received Using a half inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2 0 Ethilon suture Remainder of the flap was left open to drain Further examination of the floor of mouth was soft The lateral pharynx was nonindurated or swollen At this point the throat pack was removed and OG tube was placed and the stomach contents were evacuated The procedure was then determined to be over The patient was extubated breathing spontaneously and transferred to the PACU in excellent condition Keywords surgery cultures buccal teeth canine pacu teeth extractions oromaxillary facial facial surgery buccal space throat pack buccal mucosa surgical removal canine s base necrotic teeth cpt code infection oral mucosa anesthesia facial pus toothache MEDICAL_TRANSCRIPTION,Description Subxiphoid pericardiotomy Symptomatic pericardial effusion The patient had the appropriate inflammatory workup for pericardial effusion however it was nondiagnostic Medical Specialty Surgery Sample Name Subxiphoid Pericardiotomy Transcription PREOPERATIVE DIAGNOSIS Symptomatic pericardial effusion POSTOPERATIVE DIAGNOSIS Symptomatic pericardial effusion PROCEDURE PERFORMED Subxiphoid pericardiotomy ANESTHESIA General via ET tube ESTIMATED BLOOD LOSS 50 cc FINDINGS This is a 70 year old black female who underwent a transhiatal esophagectomy in November of 2003 She subsequently had repeat chest x rays and CT scans and was found to have a moderate pericardial effusion She had the appropriate inflammatory workup for pericardial effusion however it was nondiagnostic Also during that time she had become significantly more short of breath A dobutamine stress echocardiogram was performed which was negative with the exception of the pericardial effusions She had no tamponade physiology INDICATION FOR THE PROCEDURE For therapeutic and diagnostic management of this symptomatic pericardial effusion Risks benefits and alternative measures were discussed with the patient Consent was obtained for the above procedure PROCEDURE The patient was prepped and draped in the usual sterile fashion A 4 cm incision was created in the midline above the xiphoid Dissection was carried down through the fascia and the xiphoid was resected The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium An 0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart This suture was used to retract the pericardium and the pericardium was nicked with 15 blade under direct visualization Serous fluid exited through the pericardium and was sent for culture cytology and cell count etc A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed The heart was visualized and appeared to be contracting well with no evidence of injury to the heart The pericardium was then palpated There was no evidence of studding A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium It was sewn into place with 0 silk suture There was some air leak of the left pleural cavity so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium It was sewn in the similar way to the other chest tube Once again the area was inspected and found to be hemostatic and then closed with 0 Vicryl suture for fascial stitch then 3 0 Vicryl suture in the subcutaneous fat and then 4 0 undyed Vicryl in a running subcuticular fashion The patient tolerated the procedure well Chest tubes were placed on 20 cm of water suction The patient was taken to PACU in stable condition Keywords surgery subxiphoid pericardiotomy symptomatic pericardial effusion chest x rays echocardiogram dobutamine pleural cavity chest tube pericardial effusion pericardium inflammatory subxiphoid pericardiotomy heart chest effusion pericardial MEDICAL_TRANSCRIPTION,Description Superior labrum anterior and posterior lesion repair Medical Specialty Surgery Sample Name Superior Labrum Lesions Repair Transcription PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed on the operating room table in supine position and given anesthetic Once adequate anesthesia had been achieved a careful examination of the shoulder was performed It revealed no patholigamentous laxity We then placed the patient into a beach chair position maintaining a neutral alignment of the head neck and thorax The shoulder was then prepped and draped in the usual sterile fashion We then injected the glenohumeral joint with 60 cc of sterile saline solution A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion Through this incision a blunt trocar was placed We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint We found that the articular surface was in good condition The biceps was found to be intact There was a SLAP tear noted just posterior to the biceps Pictures were taken No Bankart or Hill Sachs lesions were noted The rotator cuff was examined and there were no undersurface tears Pictures were again taken We then made a lateral portal going through the muscle belly of the rotator cuff A drill hole was made and then knotless suture anchor was placed to repair this Pictures were taken We then washed out the joint with copious amounts of sterile saline solution It was drained Our 3 incisions were closed using 3 0 nylon suture A pain pump catheter was introduced into the shoulder joint Xeroform 4 x 4s ABDs tape and sling were placed The patient was successfully taken out of the beach chair position extubated and brought to the recovery room in stable condition I then went out and spoke with the patient s family going over the case postoperative instructions and followup care Keywords surgery laxity patholigamentous superior labrum saline solution anterior superior lesions repair sterile joint shoulder MEDICAL_TRANSCRIPTION,Description Suction dilation and curettage for incomplete abortion On bimanual exam the patient has approximately 15 week anteverted mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina There was a large amount of tissue obtained on the procedure Medical Specialty Surgery Sample Name Suction Dilation Curettage 1 Transcription PREOPERATIVE DIAGNOSIS Incomplete abortion POSTOPERATIVE DIAGNOSIS Incomplete abortion PROCEDURE PERFORMED Suction dilation and curettage ANESTHESIA General and nonendotracheal by Dr X ESTIMATED BLOOD LOSS Less than 200 cc SPECIMENS Endometrial curettings DRAINS None FINDINGS On bimanual exam the patient has approximately 15 week anteverted mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina There was a large amount of tissue obtained on the procedure PROCEDURE The patient was taken to the operating room where a general anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion Once the anesthetic was found to be adequate a bimanual exam was performed under anesthetic Next a weighted speculum was placed in the vagina The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm no cervical dilation was needed A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed Two passes were made with the suction curettage Next a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed which revealed a good uterine cry on all sides of the uterus After the procedure the vulsellum tenaculum was removed The cervix was seemed to be hemostatic The weighted speculum was removed The patient was given 0 25 mg of Methergine IM approximately half way through the procedure After the procedure a second bimanual exam was performed and the patient s uterus had significantly decreased in size It is now approximately eight to ten week size The patient was taken from the operating room in stable condition after she was cleaned She will be discharged on today She was given Methergine Motrin and doxycycline for her postoperative care She will follow up in one week in the office Keywords surgery uterus anteverted dorsal lithotomy position weighted speculum mobile uterus vulsellum tenaculum bimanual exam vagina tenaculum dilation bimanual cervix suction curettage MEDICAL_TRANSCRIPTION,Description Subcutaneous transposition of the right ulnar nerve Right carpal tunnel syndrome and right cubital tunnel syndrome Medical Specialty Surgery Sample Name Subcutaneous Transposition of Ulnar Nerve Transcription PREOPERATIVE DIAGNOSIS 1 Right carpal tunnel syndrome 2 Keywords surgery subcutaneous transposition ulnar nerve carpal tunnel syndrome cubital tunnel syndrome tourniquet subcutaneous epicondyle antebrachial syndrome cubital ulnar nerve tunnel MEDICAL_TRANSCRIPTION,Description Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty Medical Specialty Surgery Sample Name Suboccipital Craniectomy Transcription TITLE OF OPERATION Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty INDICATION FOR SURGERY The patient with a large 3 5 cm acoustic neuroma The patient is having surgery for resection There was significant cerebellar peduncle compression The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex The case took 12 hours This was more difficult and took longer than the usual acoustic neuroma PREOP DIAGNOSIS Right acoustic neuroma POSTOP DIAGNOSIS Right acoustic neuroma PROCEDURE The patient was brought to the operating room General anesthesia was induced in the usual fashion After appropriate lines were placed the patient was placed in Mayfield 3 point head fixation hold into a right park bench position to expose the right suboccipital area A time out was settled with nursing and anesthesia and the head was shaved prescrubbed with chlorhexidine prepped and draped in the usual fashion The incision was made and cautery was used to expose the suboccipital bone Once the suboccipital bone was exposed under the foramen magnum the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus The dura was then opened in a cruciate fashion the cisterna magna was drained which nicely relaxed the cerebellum The dura leaves were held back with the 4 0 Nurolon The microscope was then brought into the field and under the microscope the cerebellar hemisphere was elevated Laterally the arachnoid was very thick This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa Initially two retractors were used one on the tentorium and one inferiorly The arachnoid was taken down off the tumor There were multiple blood vessels on the surface which were bipolared The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum however as the tumor was able to be debulked the edge began to be mobilized The redundant capsule was bipolared and cut out to get further access to the center of the tumor Working inferiorly and then superiorly the tumor was taken down off the tentorium as well as out the 9th 10th or 11th nerve complex It was very difficult to identify the 7th nerve complex The brainstem was identified above the complex Similarly inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain Attention was then taken to try identify the 7th nerve complex There were multitude of veins including the lateral pontine vein which were coming right into this area The lateral pontine vein was maintained Microscissors and bipolar were used to develop the plain and then working inferiorly the 7th nerve was identified coming off the brainstem A number 1 and number 2 microinstruments were then used to began to develop the plane This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve Cavitron was used to debulk the lesion and then further dissection was carried out The nerve stimulated beautifully at the brainstem level throughout this The tumor continued to be mobilized off the lateral pontine vein until it was completely off The Cavitron was used to debulk the lesion out back laterally towards the area of the porus The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus At this point the capsule was so redundant it was felt to isolate the nerve in the porus There was minimal bulk remaining intracranially All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem Dr X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus I then scrubbed back into case once Dr X had completed removing this portion of the tumor There was no tumor remaining at this point I placed some Norian in the porus to seal any air cells although there were no palpated An intradural space was then irrigated thoroughly There was no bleeding The nerve was attempted to be stimulated at the brainstem level but it did not stimulate at this time The dura was then closed with 4 0 Nurolons in interrupted fashion A muscle plug was used over one area Duragen was laid and strips over the suture line followed by Hemaseel Gelfoam was set over this and then a titanium cranioplasty was carried out The wound was then irrigated thoroughly O Vicryls were used to close the deep muscle and fascia 3 0 Vicryl for subcutaneous tissue and 3 0 nylon on the skin The patient was extubated and taken to the ICU in stable condition Keywords surgery suboccipital craniectomy microscope cranioplasty acoustic neuroma cerebellar peduncle nerve complex brainstem nurolon cavitron kerrison leksell lateral pontine vein suboccipital craniectomy nerve tumor MEDICAL_TRANSCRIPTION,Description Emergent subxiphoid pericardial window transesophageal echocardiogram Medical Specialty Surgery Sample Name Subxiphoid Pericardial Window Transcription PREOPERATIVE DIAGNOSIS ES 1 Endocarditis 2 Status post aortic valve replacement with St Jude mechanical valve 3 Pericardial tamponade POSTOPERATIVE DIAGNOSIS ES 1 Endocarditis 2 Status post aortic valve replacement with St Jude mechanical valve 3 Pericardial tamponade PROCEDURE 1 Emergent subxiphoid pericardial window 2 Transesophageal echocardiogram ANESTHESIA General endotracheal FINDINGS The patient was noted to have 600 mL of dark bloody fluid around the pericardium We could see the effusion resolve on echocardiogram The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks There was no evidence of endocarditis The mitral valve leaflets moved normally with some mild mitral insufficiency DESCRIPTION OF THE OPERATION The patient was brought to the operating room emergently After adequate general endotracheal anesthesia his chest was prepped and draped in the routine sterile fashion A small incision was made at the bottom of the previous sternotomy incision The subcutaneous sutures were removed The dissection was carried down into the pericardial space Blood was evacuated without any difficulty Pericardial Blake drain was then placed The fascia was then reclosed with interrupted Vicryl sutures The subcutaneous tissues were closed with a running Monocryl suture A subdermal PDS followed by a subcuticular Monocryl suture were all performed The wound was closed with Dermabond dressing The procedure was terminated at this point The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition Keywords surgery endocarditis valve replacement st jude echocardiogram transesophageal pericardium blake drain st jude mechanical valve subxiphoid pericardial window pericardial window aortic valve tamponade subxiphoid valve pericardial aortic MEDICAL_TRANSCRIPTION,Description Repeat irrigation and debridement of Right distal femoral subperiosteal abscess Medical Specialty Surgery Sample Name Subperiosteal Abscess Debridement Transcription PREOPERATIVE DIAGNOSIS Right distal femoral subperiosteal abscess POSTOPERATIVE DIAGNOSIS Right distal femoral subperiosteal abscess OPERATION Repeat irrigation and debridement of above ANESTHESIA General BLOOD LOSS Minimal FLUID Per anesthesia DRAINS Hemovac times two COMPLICATIONS None apparent SPECIMENS To microbiology INDICATIONS She is a 10 year old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur I am bringing her back to the operating room for another exploration of this area and washout This will be the third procedure for this At the last time there was gross purulence that was encountered Since that time the patient has defervesced Her white count is slowly coming down Her C reactive protein is slowly coming down PROCEDURE IN DETAIL After informed consent was obtained operative site marked and after preoperative antibiotics were given the patient was brought back to the operating room and placed supine on the operating table where Anesthesia induced general anesthesia The patient s right lower extremity was prepped and draped in normal sterile fashion Surgical timeout occurred verifying the patient s identification surgical site surgical procedure and administration of antibiotics The patient s previous incision sites had the sutures removed We bluntly dissected down through to the IT band These deep stitches were then removed We exposed the area of the subperiosteal abscess The tissue looked much better than at the last surgery We irrigated this area with three liters of saline containing bacitracin Next we made our small medial window to assist with washout of the joint itself We put another three liters of saline containing bacitracin through the knee joint Lastly we did another three liters into the area of the distal femur with three liters of plain saline We then placed two Hemovac drains one in the metaphysis and one superficially We closed the deep fascia with 1 PDS Subcutaneous layers with 2 0 Monocryl and closed the skin with 2 0 nylon We placed a sterile dressing We then turned the case over to Dr Petty for dressing change and skin graft PLAN Our plan will be to pull the drains in 48 hours We will then continue to watch the patient s fever curve and follow her white count to see how she is responding to the operative and medical therapies Keywords surgery repeat irrigation and debridement repeat irrigation distal femur distal femoral femoral subperiosteal subperiosteal abscess hemovac femur debridement irrigation saline anesthesia distal subperiosteal abscess MEDICAL_TRANSCRIPTION,Description Insertion of right subclavian central venous catheter Need for intravenous access status post fall and status post incision and drainage of left lower extremity Medical Specialty Surgery Sample Name Subclavian Central Venous Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Need for intravenous access 2 Status post fall 3 Status post incision and drainage of left lower extremity POSTOPERATIVE DIAGNOSES 1 Need for intravenous access 2 Status post fall 3 Status post incision and drainage of left lower extremity PROCEDURE PERFORMED Insertion of right subclavian central venous catheter SECOND ANESTHESIA Approximately 10 cc of 1 lidocaine ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE The patient is a 74 year old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries The patient went to OR today for an I D of left lower extremity degloving injury Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested PROCEDURE Informed consent was obtained by the patient and her daughter All risks and benefits of the procedure were explained and all questions were answered The patient was prepped and draped in the normal sterile fashion After landmarks were identified approximately 5 cc of 1 lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid Locator needle was used to correctly cannulate the right internal jugular vein Multiple attempts were made and the right internal jugular vein was unable to be cannulized Therefore we prepared for a right subclavian approach The angle of the clavicle was found and a 22 gauge needle was used to anesthetize approximately 5 cc of 1 lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch The right subclavian vein was then accessed A guidewire was placed with a Cook needle and then the needle was subsequently removed and a 11 blade scalpel was used to nick the skin A dilator sheath was placed over the guidewire and subsequently removed The triple lumen catheter was then placed over the guidewire and advanced to 14 cm All ports aspirated and flushed Good blood return was noted and all ports were flushed well The triple lumen catheter was then secured at 14 cm using 0 silk suture A sterile dressing was then applied A stat portable chest x ray was ordered to check line placement The patient tolerated the procedure well and there were no complications Keywords surgery intravenous access incision and drainage subclavian central venous catheter central venous catheter lower extremity venous intravenous lidocaine subclavian needle catheter insertion MEDICAL_TRANSCRIPTION,Description Open Stamm gastrotomy tube lysis of adhesions and closure of incidental colotomy Medical Specialty Surgery Sample Name Stamm Gastrostomy Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 Squamous cell carcinoma of the head and neck 2 Ethanol and alcohol abuse POSTOPERATIVE DIAGNOSES 1 Squamous cell carcinoma of the head and neck 2 Ethanol and alcohol abuse PROCEDURE 1 Failed percutaneous endoscopic gastrostomy tube placement 2 Open Stamm gastrotomy tube 3 Lysis of adhesions 4 Closure of incidental colotomy ANESTHESIA General endotracheal anesthesia IV FLUIDS Crystalloid 1400 ml ESTIMATED BLOOD LOSS Thirty ml DRAINS Gastrostomy tube was placed to Foley SPECIMENS None FINDINGS Stomach located high in the peritoneal cavity Multiple adhesions around the stomach to the diaphragm and liver HISTORY The patient is a 59 year old black male who is indigent an ethanol and tobacco abuse He presented initially to the emergency room with throat and bleeding Following evaluation by ENT and biopsy it was determined to be squamous cell carcinoma of the right tonsil and soft palate The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth The malignancy was not obstructing Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy DESCRIPTION OF PROCEDURE The patient was placed in the supine position and general endotracheal anesthesia was induced Preoperatively 1 gram of Ancef was given The abdomen was prepped and draped in the usual sterile fashion After anesthesia was achieved an endoscope was placed down into the stomach and no abnormalities were noted The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall With the room darkened and intensity turned up on the endoscope a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy A 21 gauge 1 1 2 inch needle was initially placed at the margin of the light reflex and this was done twice Both times it was not visualized on the endoscopy At this point repositioning was made and again what was felt to be adequate light reflex was obtained and the 14 gauge angio catheter was placed Again after two attempts we were unable to visualize the needle in the stomach endoscopically At this point decision was made to convert the procedure to an open Stamm gastrostomy OPEN STAMM GASTROSTOMY A short upper midline incision was made and deepened through the subcutaneous tissues Hemostasis was achieved with electrocautery The linea alba was identified and incised and the peritoneal cavity was entered The abdomen was explored Adhesions were lysed with electrocautery under direct vision The stomach was identified and a location on the anterior wall near the greater curvature was selected After lysis of adhesions was confirmed we sufficiently moved the original chosen site without tension A pursestring suture of 3 0 silk was placed on the interior surface of the stomach and a second 3 0 pursestring silk stitch was placed exterior to that pursestring suture An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four 2 0 silk sutures in such a manner as to prevent leakage or torsion The catheter was then secured to the skin with two 2 0 silk sutures Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field Prior to the initiation of the gastrotomy the bowel was run and at that time there was noted to be one incidental colotomy This was oversewn with three 4 0 silk Lembert sutures At the completion of the operation the fascia was closed with 1 interrupted Vicryl suture and the skin was closed with staples The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition Keywords MEDICAL_TRANSCRIPTION,Description Spontaneous vaginal delivery Male infant cephalic presentation ROA Apgars 2 and 7 Weight 8 pounds and 1 ounce Intact placenta Three vessel cord Third degree midline tear Medical Specialty Surgery Sample Name Spontaneous Vaginal Delivery 1 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 plus weeks gestation 2 Gestational hypertension 3 Thick meconium 4 Failed vacuum attempted delivery POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 plus weeks gestation 2 Gestational hypertension 3 Thick meconium 4 Failed vacuum attempted delivery OPERATION PERFORMED Spontaneous vaginal delivery ANESTHESIA Epidural was placed x2 ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS Thick meconium Severe variables Apgars were 2 and 7 Respiratory therapy and ICN nurse at delivery Baby went to Newborn Nursery FINDINGS Male infant cephalic presentation ROA Apgars 2 and 7 Weight 8 pounds and 1 ounce Intact placenta Three vessel cord Third degree midline tear DESCRIPTION OF OPERATION The patient was admitted this morning for induction of labor secondary to elevated blood pressure especially for the last three weeks She was already 3 cm dilated She had artificial rupture of membranes Pitocin was started and she actually went to complete dilation While pushing there was sudden onset of thick meconium and she was having some severe variables and several late decelerations When she was complete 2 vacuum attempted delivery three pop offs were done The vacuum was then no longer used after the three pop offs The patient pushed for a little bit longer and had a delivery ROA of a male infant cephalic over a third degree midline tear Secondary to the thick meconium DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery Baby was delivered floppy Cord was clamped x2 and cut and the baby was handed off to awaiting ICN nurse and respiratory therapist Delivery of intact placenta and three vessel cord Third degree midline tear was repaired with Vicryl without any complications Baby initially did well and went to Newborn Nursery where they are observing him a little bit longer there Again mother and baby are both doing well Mother will go to Postpartum and baby is already in Newborn Nursery Keywords surgery thick meconium cephalic presentation intrauterine pregnancy gestational hypertension spontaneous vaginal delivery delivery vaginal placenta newborn meconium apgars MEDICAL_TRANSCRIPTION,Description Spontaneous vaginal delivery Term pregnancy at 40 and 3 7th weeks On evaluation of triage she was noted to be contracting approximately every five minutes and did have discomfort with her contractions Medical Specialty Surgery Sample Name Spontaneous Vaginal Delivery Transcription PREOPERATIVE DIAGNOSIS Term pregnancy at 40 and 3 7th weeks PROCEDURE PERFORMED Spontaneous vaginal delivery HISTORY OF PRESENT ILLNESS The patient is a 36 year old African American female who is a G 2 P 2 0 0 2 with an EDC of 08 30 2003 She is blood type AB ve with antibody screen negative and is also rubella immune VDRL nonreactive hepatitis B surface antigen negative and HIV nonreactive She does have a history of sickle cell trait She presented to Labor and Delivery Triage at 40 and 3 7th weeks gestation with complaint of contractions every ten minutes She also stated that she has lost her mucous plug She did have fetal movement noted no leak of fluid did have some spotting On evaluation of triage she was noted to be contracting approximately every five minutes and did have discomfort with her contractions She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated 70 effaced and 3 station This was a change from her last office exam at which she was 1 cm to 2 cm dilated PROCEDURE DETAILS The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained After her membranes were ruptured contractions did increase to every two to three minutes as well as the intensity increased She was given Nubain for discomfort with good result She had a spontaneous vaginal delivery of a live born female at 11 37 with meconium stained fluid as noted from ROA position After controlled delivery of the head tight nuchal cord was noted which was quickly double clamped and cut and the shoulders and body were delivered without difficulty The infant was taken to the awaiting pediatrician Weight was 2870 gm length was 51 cm The Apgars were 6 at 1 minute and 9 at 5 minutes There was initial neonatal depression which was treated by positive pressure ventilation and the administration of Narcan Spontaneous delivery of an intact placenta with a three vessel cord was noted at 11 45 On examination there were no noted perineal abrasions or lacerations On vaginal exam there were no noted cervical or vaginal sidewall lacerations Estimated blood loss was less than 250 cc Mother and infant are in recovery doing well at this time Keywords surgery roa position arom labor and delivery spontaneous vaginal delivery term pregnancy contracting meconium lacerations pregnancy contractions vaginal MEDICAL_TRANSCRIPTION,Description Stab wound left posterolateral chest Closure of stab wound Medical Specialty Surgery Sample Name Stab Wound Closure Transcription PREPROCEDURE DIAGNOSIS Stab wound left posterolateral chest POST PROCEDURE DIAGNOSIS Stab wound left posterolateral chest PROCEDURE PERFORMED Closure of stab wound ANESTHESIA 1 lidocaine with epinephrine by local infiltration NARRATIVE The wound was irrigated copiously with 500 mL of irrigation and closed in 1 layer with staples after locally anesthetizing with 1 lidocaine with epinephrine The patient tolerated the procedure well without apparent complications Keywords surgery posterolateral chest stab wound lidocaine epinephrine infiltration closure MEDICAL_TRANSCRIPTION,Description Right argon laser assisted stapedectomy Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis Medical Specialty Surgery Sample Name Stapedectomy Argon Lasor Assisted Transcription PREOPERATIVE DIAGNOSIS Bilateral progressive conductive hearing losses with probable otosclerosis POSTOPERATIVE DIAGNOSIS Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis OPERATION PERFORMED Right argon laser assisted stapedectomy DESCRIPTION OF OPERATION The patient was brought to the operating room Endotracheal intubation carried out by Dr X The patient s right ear was carefully prepped and then draped in the usual sterile fashion Slow infiltration of the external canal accomplished with 1 Xylocaine with epinephrine The earlobe was also infiltrated with the same solution A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5 0 nylon This could later be removed in bishop A reinspection of the ear canal was accomplished A 65 Beaver blade was used to make incision both at 12 o clock and at 6 o clock Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation Elevation was carried down to the fibrous annulus An annulus elevator was used to complete the elevation beneath the annular ligament The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain Palpation of the malleus revealed good mobility of both it and incus but no movement of the stapes was identified Palpation with a fine curved needle on the stapes itself revealed no movement A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well The self retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation A small bit of additional footplate was removed with a right angle hook to accommodate the 0 6 mm piston The measuring device was used and a 4 25 mm slim shaft wire Teflon piston chosen It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate The hook was placed over the incus and measurement appeared to be appropriate A downbiting crimper was then used to complete the attachment of the prosthesis to the incus Prosthesis is once again checked for location and centering and appeared to be in ideal position Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph A small pledget of fat was also placed on the top of the incudo prosthesis junction The mobility appeared excellent The flap was placed back in its normal anatomic position The external canal packed with small pledgets of Gelfoam and antibiotic ointment She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop Sutures will be out in a week and a recheck in Reno in four to five weeks from now Keywords surgery bilateral progressive conductive hearing loss argon laser assisted conductive hearing losses intubation argon stapedectomy otosclerosis canal earlobe prosthesis pledgets laser MEDICAL_TRANSCRIPTION,Description Spinal Manipulation under Anesthesia Sacro iliitis lumbo sacral segmental dysfunction thoraco lumbar segmental dysfunction associated with myalgia fibromyositis Medical Specialty Surgery Sample Name Spinal Manipulation Transcription PREOPERATIVE DIAGNOSIS Sacro iliitis 720 2 lumbo sacral segmental dysfunction 739 3 thoraco lumbar segmental dysfunction 739 2 associated with myalgia fibromyositis 729 1 POSTOPERATIVE DIAGNOSIS Sacro iliitis 720 2 lumbo sacral segmental dysfunction 739 3 thoraco lumbar segmental dysfunction 739 2 associated with myalgia fibromyositis 729 1 ANESTHESIA Conscious Sedation INFORMED CONSENT After adequate explanation of the medical surgical and procedural options this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia MUA The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results INDICATION This patient has failed extended conservative care of condition dysfunction by means of aggressive physical medical and pharmacological intervention COMMENTS This patient understands the essence of the diagnosis and the reasons for the MUA The associated risks of the procedure including anesthesia complications fracture vascular accidents disc herniation and post procedure discomfort were thoroughly discussed with the patient Alternatives to the procedure including the course of the condition without MUA were discussed The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome The patient has given both verbal and written informed consent for the listed procedure PROCEDURE IN DETAIL The patient was draped in the appropriate gowning and accompanied to the operative area Following their sacral block injection they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure When the patient and I were ready the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching mobilization and adjustments necessary for the completion of the outcome I desired THORACIC SPINE With the patient in the supine position on the operative table the upper extremities were flexed at the elbow and crossed over the patient s chest to achieve maximum traction to the patient s thoracic spine The first assistant held the patient s arms in the proper position and assisted in rolling the patient for the adjusting procedure With the help of the first assist the patient was rolled to their right side selection was made for the contact point and the patient was rolled back over the doctor s hand The elastic barrier of resistance was found and a low velocity thrust was achieved using a specific closed reduction anterior to posterior superior manipulative procedure The procedure was completed at the level of TI TI2 Cavitation was achieved LUMBAR SPINE SACRO ILIAC JOINTS With the patient supine on the procedure table the primary physician addressed the patient s lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal Linear force was used to increase the hip flexion gradually during this maneuver Simultaneously the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane lateral oblique cephalad traction and medial oblique cephalad traction maneuver The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance a piriformis myofascial release was accomplished at this time This was repeated with the opposite lower extremity Following this a Patrick Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance With the assisting physician stabling the pelvis and femoral head as necessary the primary physician extended the right lower extremity in the sagittal plane and while applying controlled traction gradually stretched the para articular holding elements of the right hip by means gradually describing an approximately 30 35 degree horizontal arc The lower extremity was then tractioned and straight caudal and internal rotation was accomplished Using traction the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees This procedure was then repeated using external rotation to stretch the para articular holding elements of the hips bilaterally These procedures were then repeated on the opposite lower extremity By approximating the patient s knees to the abdomen in a knee chest fashion ankles crossed the lumbo pelvic musculature was stretched in the sagittal plane by both the primary and first assist contacting the base of the sacrum and raising the lower torso cephalad resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance Keywords surgery fibromyositis myalgia segmental dysfunction sacro iliitis spinal manipulation under anesthesia lumbar segmental dysfunction informed consent iliac joints spinal manipulation sacro iliitis lower extremity spinal mua cephalad dysfunction segmental lumbar MEDICAL_TRANSCRIPTION,Description Excision of volar radial wrist mass inflammatory synovitis and radial styloidectomy right wrist Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion Medical Specialty Surgery Sample Name Styloidectomy Transcription PREOPERATIVE DIAGNOSIS Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion POSTOPERATIVE DIAGNOSIS Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst synovitis was debrided and removed PROCEDURE Excision of volar radial wrist mass inflammatory synovitis and radial styloidectomy right wrist ANESTHESIA Axillary block plus IV sedation ESTIMATED BLOOD LOSS Zero SPECIMENS 1 Inflammatory synovitis from the volar radial wrist area 2 Inflammatory synovitis from the dorsal wrist area DRAINS None PROCEDURE DETAIL Patient brought to the operating room After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff Routine prep and drape was employed Patient received 1 gm of IV Ancef preoperatively Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet Tourniquet inflated to 250 mmHg pressure Hand positioned palm up in a lead hand holder A longitudinal zigzag incision over the volar radial wrist mass was made Skin was sharply incised Careful blunt dissection was used in the subcutaneous tissue Antebrachial fascia was bluntly dissected and incised to reveal the radial artery Radial artery was mobilized preserving its dorsal and palmar branches Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery Wrist mass was exposed by blunt dissection This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule This was debrided down to the wrist capsule with visualization of the joint through a small capsular window After complete volar synovectomy the capsular window was closed with 4 0 Mersilene figure of eight suture Subcutaneous tissue was closed with 4 0 PDS and the skin was closed with a running subcuticular 4 0 Prolene Forearm was pronated and C arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision An oblique incision overlying the radial styloid centered on the second extensor compartment was made Skin was sharply incised Blunt dissection was used in the subcutaneous tissue Care was taken to identify and protect the superficial radial nerve Blunt dissection was carried out in the extensor retinaculum This was incised longitudinally over the second extensor compartment EPL tendon was identified mobilized and released to facilitate retraction and prevent injury The interval between the ECRL and the ECRB was developed down to bone Dorsal capsulotomy was made and local synovitis was identified This was debrided and sent as second pathologic specimen Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard eburnated subchondral bone consistent with a SLAC pattern arthritis Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer Dorsally the styloidectomy was beveled smooth and contoured with a rongeur Final x rays documenting the styloidectomy were obtained Local synovitis beneath the joint capsule was debrided Remnants of the scapholunate interosseous which was completely deteriorated were debrided The joint capsule was closed anatomically with 4 0 PDS and extensor retinaculum was closed with 4 0 PDS Subcutaneous tissues closed with 4 0 Vicryl Skin was closed with running subcuticular 4 0 Prolene Steri Strips were applied to wound edge closure 10 cc of 0 5 plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied Tourniquet was deflated Good vascular color and capillary refill were seen to return to the tips of all digits Patient discharged to the ambulatory recovery area and from there discharged home DISCHARGE PRESCRIPTIONS 1 Keflex 500 mg tablets 20 one PO q 6h x 5 days 2 Vicodin 40 tablets one to two PO q 4h p r n 3 Percocet 20 tablets one to two PO q 3 4h p r n severe pain Keywords surgery osteophytic spurring ganglion synovitis volar radial wrist mass excision inflammatory synovitis radial styloidectomy inflammatory styloidectomy volar wrist radial mass MEDICAL_TRANSCRIPTION,Description Posterior spinal fusion and spinal instrumentation Posterior osteotomy posterior elements to include laminotomy foraminotomy and decompression of the nerve roots Medical Specialty Surgery Sample Name Spinal Fusion Instrumentation Transcription PREOPERATIVE DIAGNOSIS Severe scoliosis ANESTHESIA General Lines were placed by Anesthesia to include an A line PROCEDURES 1 Posterior spinal fusion from T2 L2 2 Posterior spinal instrumentation from T2 L2 3 A posterior osteotomy through T7 T8 and T8 T9 Posterior elements to include laminotomy foraminotomy and decompression of the nerve roots IMPLANT Sofamor Danek Medtronic Legacy 5 5 Titanium system MONITORING SSEPs and the EPs were available INDICATIONS The patient is a 12 year old female who has had a very dysmorphic scoliosis She had undergone a workup with an MRI which showed no evidence of cord abnormalities Therefore the risks benefits and alternatives were discussed with Surgery with the mother to include infections bleeding nerve injuries vascular injuries spinal cord injury with catastrophic loss of motor function and bowel and bladder control I also discussed ___________ and need for revision surgery The mom understood all this and wished to proceed PROCEDURE The patient was taken to the operating room and underwent general anesthetic She then had lines placed and was then placed in a prone position Monitoring was then set up and it was then noted that we could not obtain motor evoked potentials The SSEPs were clear and were compatible with the preoperative but no preoperative motors had been done and there was a concern that possibly this could be from the result of the positioning It was then determined at that time that we would go ahead and proceed to wake her up and make sure she could move her feet She was then lightened under anesthesia and she could indeed dorsiflex and plantarflex her feet so therefore it was determined to go ahead and proceed with only monitoring with the SSEPs The patient after being prepped and draped sterilely a midline incision was made and dissection was carried down The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes This occurred from T2 L2 Fluoroscopy was brought in to verify positions and levels Once this was done and all bleeding was controlled retractors were then placed Attention was then turned towards placing screws first on the left side Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance The area was opened with a high speed burr and then the track was defined with a blunt probe and a ball tipped feeler was then utilized to verify all walls were intact They were then tapped and then screws were then placed This technique was used at L1 and L2 both the right and left At T12 a direct straight ahead technique was utilized where the facet was removed and then the position was chosen under the fluoroscopy and then it was spurred the track was defined and then probed and tapped and it was felt to be in good position Two screws in the right and left were placed at T12 as well reduction screws on the left The same technique was used for T11 where right and left screws were placed as well as T10 on the left At T9 a screw was placed on the left and this was a reduction screw On the left at T8 a screw could not be placed due to the dysmorphic nature of the pedicle It was not felt to be intact therefore a screw was left out of this On the right a thoracic screw was placed as well as at 7 and 6 This was the dysmorphic portion of this Screws were attempted to be placed up they could not be placed so attention was then turned towards placing pedicle hooks Pedicle hooks were done by first making a box out of the pedicle removing the complete pedicle feeling the undersurface of the pedicle with a probe and then seating the hook Upgoing pedicle hooks were placed at T3 T4 and T5 A downgoing laminar hook was placed at the T7 level Screws had been placed at T6 and T7 on the right An upgoing pedicle hook was also placed at T3 on the right and then downgoing laminar hooks were placed at T2 This was done by first using a transverse process lamina finders to go around the transverse process and then ___________ laminar hooks Once all hooks were in place spinal osteotomies were performed at T7 T8 and T8 T9 This was the level of the kyphosis to bring her back out of her kyphoscoliosis First the ligamentum flavum was resected using a large Kerrisons Next the laminotomy was performed and then a Kerrison was used to remove the ligamentum flavum at the level of the facet Once this was accomplished a laminotomy was performed by removing more of the lamina and to create a small wedge that could be closed down later to correct the kyphosis This was then brought out with resection of bone out to the foramen doing a foraminotomy to free up the foramen on both sides This was done also between the T8 T9 Once this was completed Gelfoam was then placed Next we observed and measured and contoured The rods were then seated on the left and then a derotation maneuver was performed Hooks had come loose so the rod was removed on the left The hooks were then replaced and the rod was reseated Again it was derotated to give excellent correction Hooks were then well seated underneath and therefore they were then locked A second rod was then chosen on the right and was measured contoured and then seated Next once this was done the rods were locked in the midsubstance and then the downgoing pedicle hook which had been placed at T7 was then helped to compress T8 as was the pedicle screw and then this compressed the osteotomy sites quite nicely Next distraction was then utilized to further correct at the spine and to correct on the left the left concave curve which gave excellent correction On the right compression was used to bring it down and then in the lower lumbar areas distraction and compression were used to level out L2 Once this was done all screws were tightened Fluoroscopy was then brought in to verify L1 was level and the first ribs were also level and it gave a nice balanced spine Everything was copiously irrigated ___________ Next a wake up test was performed and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet The patient was then again sedated and brought back under general anesthesia Next a high speed burr was used for decortication After final tightening had been accomplished and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound The open canal areas had been protected with Gelfoam Once this was accomplished the deep fascia was closed with multiple figure of eight 1 s oversewn with a running 1 _________ were then placed in the subcutaneous spaces which were then closed with 3 0 Vicryl and then the skin was closed with 3 0 Monocryl and Dermabond Sterile dressing was applied Drains had been placed in the subcutaneous layer x2 The patient during the case had no changes in the SSEPs had a normal wake up test and had received Ancef and clindamycin during the case She was taken from the operating room in good condition Keywords surgery osteotomy laminotomy foraminotomy sofamor danek sseps spinal fusion transverse processes pedicle hooks pedicle laminotomy hooks screws instrumentation decompression scoliosis sofamor foraminotomy spinal MEDICAL_TRANSCRIPTION,Description Anterior spine fusion from T11 L3 Posterior spine fusion from T3 L5 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft Medical Specialty Surgery Sample Name Spine Fusion Transcription PREOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis POSTOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis PROCEDURES 1 Anterior spine fusion from T11 L3 2 Posterior spine fusion from T3 L5 3 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft ESTIMATED BLOOD LOSS 500 mL FINDINGS The patient was found to have a severe scoliosis This was found to be moderately corrected Hardware was found to be in good positions on AP and lateral projections using fluoroscopy INDICATIONS The patient has a history of severe neurogenic scoliosis He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression Risks and benefits were discussed at length with the family over many visits They wished to proceed PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position General anesthesia was induced without incident He was given a weight adjusted dose of antibiotics Appropriate lines were then placed He had a neuromonitoring performed as well He was then initially placed in the lateral decubitus position with his left side down and right side up An oblique incision was then made over the flank overlying the 10th rib Underlying soft tissues were incised down at the skin incision The rib was then identified and subperiosteal dissection was performed The rib was then removed and used for autograft placement later The underlying pleura was then split longitudinally This allowed for entry into the pleural space The lung was then packed superiorly with wet lap The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine Once the spine was achieved subperiosteal dissection was performed over the visualized vertebral bodies This required cauterization of the segmental vessels Once the subperiosteal dissection was performed to the posterior and anterior extents possible the diskectomies were performed These were performed from T11 L3 This was over 5 levels Disks and endplates were then removed Once this was performed morcellized rib autograft was placed into the spaces The table had been previously bent to allow for easier access of the spine This was then straightened to allow for compression and some correction of the curvature The diaphragm was then repaired as was the pleura overlying the thoracic cavity The ribs were held together with 1 Vicryl sutures Muscle layers were then repaired using a running 2 0 PDS sutures and the skin was closed using running inverted 2 0 PDS suture as well Skin was closed as needed with running 4 0 Monocryl This was dressed with Xeroform dry sterile dressings and tape The patient was then rotated into a prone position The spine was prepped and draped in a standard fashion Longitudinal incision was made from T2 L5 The underlying soft tissues were incised down at the skin incision Electrocautery was then used to maintain hemostasis The spinous processes were then identified and the overlying apophyses were split This allowed for subperiosteal dissection over the spinous processes lamina facet joints and transverse processes Once this was completed the C arm was brought in which allowed for easy placement of screws in the lumbar spine These were placed at L4 and L5 The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum This was done using a rongeur as well as a Kerrison rongeur Spinous processes were then harvested for morcellized autograft Once all the interspaces were prepared Songer wires were then passed These were placed from L3 T3 Once the wires were placed a unit rod was then positioned This was secured initially at the screws distally on both the left and right side The wires were then tightened in sequence from the superior extent to the inferior extent first on the left sided spine where I was operating and then on the right side spine This allowed for excellent correction of the scoliotic curvature Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin This was done using pulsed lavage The wound was then closed in layers The deep fascia was closed using running 1 PDS suture subcutaneous tissue was closed using running inverted 2 0 PDS suture the skin was closed using 4 0 Monocryl as needed The wound was then dressed with Steri Strips Xeroform dry sterile dressings and tape The patient was awakened from anesthesia and taken to the intensive care unit in stable condition All instrument sponge and needle counts were correct at the end of the case The patient will be managed in the ICU and then on the floor as indicated Keywords surgery anterior spine fusion posterior spine fusion spine segmental instrumentation dry sterile dressings autograft and allograft pds sutures spinous processes spine fusion spine instrumentation morcellized allograft fusion autograft MEDICAL_TRANSCRIPTION,Description Spermatocelectomy and orchidopexy Medical Specialty Surgery Sample Name Spermatocelectomy Transcription PREOPERATIVE DIAGNOSIS Right spermatocele POSTOPERATIVE DIAGNOSIS Right spermatocele OPERATIONS PERFORMED 1 Right spermatocelectomy 2 Right orchidopexy ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY OF THE PATIENT The patient is a 77 year old male who comes to the office with a large right spermatocele The patient says it does bother him on and off has occasional pain and discomfort with it has difficulty with putting clothes on etc and wanted to remove Options such as watchful waiting removal of the spermatocele or needle drainage were discussed Risk of anesthesia bleeding infection pain MI DVT PE risk of infection scrotal pain and testicular pain were discussed The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down The patient was told about the risk of recurrence of spermatocele The patient understood all the risks benefits and options and wanted to proceed with removal DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient s scrotal area was shaved prepped and draped in the usual sterile fashion A midline scrotal incision was made measuring about 2 cm in size The incision was carried through the dartos through the scrotal sac and the spermatocele was identified All the layers of the spermatocele were removed Clear layer was visualized was taken all the way up to the base the base was tied Entire spermatocele sac was removed After removing the entire spermatocele sac hemostasis was obtained The testicle was not in normal orientation The testis and epididymis was removed which is a small appendage on the superior aspect of the testicle The testicle was placed in a normal orientation Careful attention was drawn not to twist the cord Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4 0 Vicryl and was tied at 3 different locations Absorbable sutures were used so that the patient does not feel the sutures in the postoperative period The dartos was closed using 2 0 Vicryl in running locking fashion There was excellent hemostasis The skin was closed using 4 0 Monocryl Dermabond was applied The patient tolerated the procedure well The patient was brought to the recovery room in stable condition Keywords surgery orchidopexy spermatocele spermatocelectomy scrotal MEDICAL_TRANSCRIPTION,Description Split thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg Medical Specialty Surgery Sample Name Skin Graft Transcription DIAGNOSIS Stasis ulcers of the lower extremities OPERATION Split thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg INDICATIONS This 84 year old female presented recently with large ulcers of the lower extremities These were representing on the order of 50 or more of the circumference of her lower leg They were in a distribution to be consistent with stasis ulcers They were granulating nicely and she was scheduled for surgery FINDINGS Large ulcers of lower extremities with size as described above These are irregular in shape and posterior and laterally on the lower legs There was no evidence of infection The ultimate skin grafting was quite satisfactory PROCEDURE Having obtained adequate general endotracheal anesthesia the patient was prepped from the pubis to the toes The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed Once this was accomplished the skin was harvested from the right thigh at approximately 0 013 inch This was meshed 1 1 5 and then stapled into position on the wounds The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution She was then dressed in additional Kerlix followed by Webril and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them and at the same time did not put pressure across the heels The donor site was dressed with Op Site The patient tolerated the procedure well and returned to the recovery room in satisfactory condition Keywords surgery skin graft lower extremities split thickness skin grafting skin grafting kerlix grafting extremities ulcers leg MEDICAL_TRANSCRIPTION,Description SPARC suburethral sling due to stress urinary incontinence Medical Specialty Surgery Sample Name Sling SPARC Suburethral Transcription PREOPERATIVE DX Stress urinary incontinence POSTOPERATIVE DX Stress urinary incontinence OPERATIVE PROCEDURE SPARC suburethral sling ANESTHESIA General FINDINGS INDICATIONS Outpatient evaluation was consistent with urethral hypermobility stress urinary incontinence Intraoperatively the bladder appeared normal with the exception of some minor trabeculations The ureteral orifices were normal bilaterally DESCRIPTION OF OPERATIVE PROCEDURE This patient was brought to the operating room a general anesthetic was administered She was placed in dorsal lithotomy position Her vulva vagina and perineum were prepped with Betadine scrubbed in solution She was draped in usual sterile fashion A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder Two Allis clamps were placed over the mid urethra This area was injected with 0 50 lidocaine containing 1 200 000 epinephrine solution Two areas suprapubically on either side of midline were injected with the same anesthetic solution The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally The Foley catheter was removed A cystoscopy was performed using a 70 degree cystoscope There was noted to be no violation of the bladder The SPARC mesh was then snapped onto the needles which were withdrawn through the stab wound incisions The mesh was snugged up against a Mayo scissor held under the mid urethra The overlying plastic sheaths were removed The mesh was cut below the surface of the skin The skin was closed with 4 0 Plain suture The vaginal vault was closed with a running 2 0 Vicryl stitch The blood loss was minimal The patient was awoken and she was brought to recovery in stable condition Keywords surgery stress urinary incontinence foley catheter metzenbaum scissor sparc sparc mesh bladder orifice perineum sling suburethral ureteral urethral hypermobility vagina vaginal vault vulva cystoscopy suburethral sling stress urinary urinary incontinence incontinence MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of right temporal bone middle ear space Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 Medical Specialty Surgery Sample Name Skull Base Reconstruction Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space PROCEDURE Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was brought into the operating room placed on the table in supine position General endotracheal anesthesia was obtained in the usual fashion The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen The neck was prepped as well After this was performed I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle After this was performed I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible The condyle was skeletonized so that it could be easily seen The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared The neck contents to the hyoid were dissected out The hypoglossal nerve vagus nerve and spinal accessory nerve were dissected towards the jugular foramen The neck contents were removed as a separate specimen The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis A large posterior facial vein was identified and likewise clipped for later use I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus dissecting or exposing the dura to the level of the jugular bulb It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion Once this was dissected out Dr X entered the procedure for completion of the resection with the craniotomy For details please see his operative note After Dr X had completed the resection I then harvested the rectus free flap A skin paddle was drawn out next to the umbilicus about 4 x 4 cm The skin paddle was incised with the Bovie and down to the anterior rectus sheath Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin The skin paddle was then sutured to the fascia and muscle with interrupted 3 0 Vicryl The anterior rectus sheath was then reflected off the rectus muscle which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction The vascular pedicle could be seen entering the muscle in usual fashion The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel The wound was then packed with saline impregnated sponges The rectus muscle with attached skin paddle was then transferred into the neck The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9 0 Ethilon with standard microvascular technique Ischemia time was less than 10 minutes Likewise the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9 0 Ethilon as well There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case The wound was irrigated with copious amounts of saline The eustachian tube was obstructed with bone wax The muscle was then laid into position with the skin paddle underneath the conchal bowl I removed most the skin of the conchal bowl de epithelializing and leaving the fat in place The wound was closed in layers overlying the muscle which was secured superiorly to the muscle overlying the temporal skull The subcutaneous tissues were closed with interrupted 3 0 Vicryl The skin was closed with skin staples There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself The skin paddle was closed with interrupted 4 0 Prolene to the edges of the conchal bowl The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with 1 Prolene with the more running suture taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors The subcutaneous tissues were closed with interrupted 2 0 Vicryl and skin was closed with skin staples The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened The patient was then transferred to the PACU in stable condition with spontaneous respirations having tolerated the procedure well Keywords surgery rectus abdominis myocutaneous skull base defect squamous cell carcinoma skull base squamous cell rectus sheath abdominis muscle rectus sheath MEDICAL_TRANSCRIPTION,Description The skin biopsy was performed on the right ankle and right thigh The patient was consented for skin biopsy The complications instructions as to how the procedure will be performed and postoperative instructions were given to the patient Medical Specialty Surgery Sample Name Skin Biopsy Transcription PROCEDURE The site was cleaned with antiseptic A local anesthetic 2 lidocaine was given at each site A 3 mm punch biopsy was performed in the left calf and left thigh above the knee The site was then checked for bleeding Once hemostasis was achieved a local antibiotic was placed and the site was bandaged The patient was not on any anticoagulant medications There were also no other medications which would affect the ability to conduct the skin biopsy The patient was further instructed to keep the site completely dry for the next 24 hours after which a new Band Aid and antibiotic ointment should be applied to the area They were further instructed to avoid getting the site dirty or infected The patient completed the procedure without any complications and was discharged home The biopsy will be sent for analysis The patient will follow up with Dr X within the next two weeks to review her results Keywords surgery antiseptic local anesthetic hemostasis punch biopsy band aid skin biopsyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Functional endoscopic sinus surgery excision of nasopharyngeal mass via endoscopic technique and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure Medical Specialty Surgery Sample Name Sinus Surgery Endoscopic Transcription PREOPERATIVE DIAGNOSES 1 Nasopharyngeal mass 2 Right upper lid skin lesion POSTOPERATIVE DIAGNOSES 1 Nasopharyngeal tube mass 2 Right upper lid skin lesion PROCEDURES PERFORMED 1 Functional endoscopic sinus surgery 2 Excision of nasopharyngeal mass via endoscopic technique 3 Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 51 year old Caucasian female with a history of a nasopharyngeal mass discovered with patient s chief complaint of nasal congestion and chronic ear disease The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months It appears to be growing in size and is irregularly bordered After risks complications consequences and questions were addressed to the patient a written consent was obtained for the procedure PROCEDURE The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position After this the patient was turned to 90 degrees by the Department of Anesthesia The right upper eyelid skin lesion was injected with 1 lidocaine with epinephrine 1 100 000 approximately 1 cc total After this the patient s bilateral nasal passages were then packed with cocaine soaked cottonoids of 10 solution of 4 cc total The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade After this the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors After this the ________ was then hemostatically controlled with monopolar cauterization The patient s skin was then reapproximated with a running 6 0 Prolene suture A Mastisol along with a single Steri Strip was in place followed Maxitrol ointment Attention then was drawn to the nasopharynx The cocaine soaked cottonoids were removed from the nasal passages bilaterally and zero degree otoscope was placed all the way to the patient s nasopharynx The patient had a severely deviated nasal septum more so to the right than the left There appeared to be a spur on the left inferior aspect and also on the right posterior aspect The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking It was then localized with 1 lidocaine with epinephrine 1 100 000 of approximately 3 cc total After this the lesion was then removed on the right side with the XPS blade The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely This area was taken down with the XPS blade Prior to taking down this lesion with the XPS multiple biopsies were taken with a straight biter After this a cocaine soaked cottonoid was placed back in the patient s left nasal passage region and the nasopharynx and the attention was then drawn to the right side The zero degree otoscope was placed in the patient s right nasal passage and all the way to the nasopharynx Again the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius After this the patient was then hemostatically controlled with suctioned Bovie cauterization A FloSeal was then placed followed by bilateral Merocels and bacitracin coated ointment The patient s Meroceles were then tied together to the patient s forehead and the patient was then turned back to the Anesthesia The patient was extubated in the operating room and was transferred to the recovery room in stable condition The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week The patient will be sent home with a prescription for Keflex 500 mg one p o b i d and Tylenol 3 one to two p o q 4 6h pain 30 Keywords surgery nasopharyngeal tube mass lymphoid tissue torus tubarius sinus surgery nasal passages nasopharyngeal mass skin lesion lesion nasopharynx endoscopic nasopharyngeal MEDICAL_TRANSCRIPTION,Description Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus transconjunctival exploration of orbital floor open reduction of nasal septum and nasal pyramid fracture with osteotomy Medical Specialty Surgery Sample Name Sinus Fractures Repairs Transcription PREOPERATIVE DIAGNOSES 1 Depressed anterior table frontal sinus fracture on the right side 2 Right nasoorbital ethmoid fracture 3 Right orbital blowout fracture with entrapped periorbita 4 Nasal septal and nasal pyramid fracture with nasal airway obstruction POSTOPERATIVE DIAGNOSES 1 Depressed anterior table frontal sinus fracture on the right side 2 Right nasoorbital ethmoid fracture 3 Right orbital blowout fracture with entrapped periorbita 4 Nasal septal and nasal pyramid fracture with nasal airway obstruction OPERATION 1 Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus 2 Transconjunctival exploration of right orbital floor with release of entrapped periorbita 3 Open reduction of nasal septum and nasal pyramid fracture with osteotomy ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in the supine position Under affects of general endotracheal anesthesia head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion A gull wing incision was drawn over the forehead scalp Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to but not including the pericranium An inferiorly based forehead flap was then elevated to the superior orbital rim The depression of the anterior table of the frontal sinus was noted An incision was made more posterior creating an inferiorly based pericranial flap The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap These allowed exposure of the medial orbital wall on the right side The displaced fractures of the right medial orbital wall were repositioned through coronal approach Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall The anterior table fracture was satisfactorily reduced Multiple 1 3 mm screws and plate fixation were utilized to recontour the anterior forehead A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall A sinus seeker was utilized and passed into the nasofrontal duct without difficulty It was felt that the frontal sinus obliteration would not be necessary At this point the pericranial flap was folded in a fan folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead At this point the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies which were made medially laterally and percutaneous transverse osteotomy of the nasal bone on the right side There is significant depression of the nasal bone on the left side A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily There is a high septal deviation which would not allow complete correction of the deviation It was felt that this would best be left for a later date Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally Local infiltration anesthesia 1 Xylocaine with 1 100 000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor Hemostasis was achieved with electrocautery There was entrapped periorbita which was released to the fractures which were repositioned but not fixed in position The forced ductions were performed which demonstrated release of the periorbit satisfactorily The conjunctival incision was closed with an interrupted simple 6 0 plain gut suture The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum The coronal incision was closed with interrupted 3 0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples Nose was dressed with Steri Strips Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3 0 Prolene suture and the nose packed with two Kennedy Merocel sponges A supportive mildly compressive dressing with fluffs Kerlix and 4 inch Ace were applied The patient tolerated the procedure well and was returned to recovery room in satisfactory condition Keywords surgery frontal sinus nasal septal transconjunctival anterior table ethmoid ethmoid fracture gull wing incision nasal airway obstruction nasal pyramid nasoorbital osteotomy phisohex periorbita depressed anterior table nasal pyramid fracture sinus fractures inferior orbital pyramid fracture entrapped periorbita orbital fractures nasal frontal forehead sinus MEDICAL_TRANSCRIPTION,Description Left spermatocelectomy epididymectomy and bilateral partial vasectomy Left spermatocele and family planning Medical Specialty Surgery Sample Name Spermatocelectomy Epididymectomy Vasectomy Transcription PREOPERATIVE DIAGNOSES 1 Left spermatocele 2 Family planning POSTOPERATIVE DIAGNOSES 1 Left spermatocele 2 Family planning PROCEDURE PERFORMED 1 Left spermatocelectomy epididymectomy 2 Bilateral partial vasectomy ANESTHESIA General ESTIMATED BLOOD LOSS Minimal SPECIMEN Left sided spermatocele epididymis and bilateral partial vasectomy DISPOSITION To PACU in stable condition INDICATIONS AND FINDINGS This is a 48 year old male with a history of a large left sided spermatocele with significant discomfort The patient also has family status complete and desired infertility The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy FINDINGS At this time of the surgery significant left sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to the operating room A general anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in the normal sterile fashion for a scrotal approach A 15 blade was used to make a transverse incision on the left hemiscrotum Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field The left testicle was examined A large spermatocele was noted Metzenbaum scissors were used to dissect the tissue around the left spermatocele Once the spermatocele was identified as stated above significant size was noted encompassing the entire left epididymis Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery Electrocautery was used to confirm excellent hemostasis Attention was then turned to the more proximal aspect of the cord The vas deferens was palpated and dissected free with Metzenbaum scissors Hemostats were placed on the two aspects of the cord approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends Testicle was placed back in the scrotum in appropriate anatomic position The dartos tissue was closed with running 3 0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with 4 0 chromic Attention was then turned to the right side The vas was palpated in the scrotum A small skin incision was made with a 15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat Two ends were hemostated with hemostats and divided with Metzenbaum scissors Lumen was coagulated with electrocautery Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum A 4 0 chromic suture was used in simple fashion to reapproximate the skin incision Scrotum was cleaned and bacitracin ointment sterile dressing fluffs and supportive briefs applied The patient was sent to Recovery in stable condition He was given prescriptions for doxycycline 100 mg b i d for five days and Vicodin ES 1 p o q 4h p r n pain 30 for pain The patient is to followup with Dr X in seven days Keywords surgery partial vasectomy spermatocele epididymis family planning vas deferens metzenbaum scissors vasectomy spermatocelectomy epididymectomy testicle deferens hemostats electrocautery MEDICAL_TRANSCRIPTION,Description Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end Medical Specialty Surgery Sample Name Shunt Revision 3 Transcription PREOPERATIVE DIAGNOSIS Blocked ventriculoperitoneal shunt POSTOPERATIVE DIAGNOSIS Blocked ventriculoperitoneal shunt PROCEDURE Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end ANESTHESIA General HISTORY The patient is nonverbal He is almost 3 years old He presented with 2 months of irritability vomiting and increasing seizures CT scan was not conclusive but shuntogram shows no flow through the shunt DESCRIPTION OF PROCEDURE After induction of general anesthesia the patient was placed supine on the operating room table with his head turned to the left Scalp was clipped He was prepped on the head neck chest and abdomen with ChloraPrep Incisions were infiltrated with 0 5 Xylocaine with epinephrine 1 200 000 He received oxacillin He was then reprepped and draped in a sterile manner The frontal incision was reopened and extended along the valve Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts I separated the ventricular catheter from the valve and this was a medium pressure small contour Medtronic valve There was some flow from the ventricular catheter but not as much as I would expect I removed the right angled clip with a curette and then pulled out the ventricular catheter and there was gushing of CSF under high pressure So I do believe that the catheter was obstructed although inspection of the old catheter holes did not show any specific obstructions A new Codman BACTISEAL catheter was placed through the same hole I replaced it several times because I wanted to be sure it was in the cavity It entered easily and there was still just intermittent flow of CSF The catheter irrigated very well and seemed to be patent I tested the distal system with an irrigation filled feeding tube and there was excellent flow through the distal valve and catheter So I did not think it was necessary to replace those at this time The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve The valve connection was secured to the pericranium with a 2 0 Ethibond suture The wound was irrigated with bacitracin irrigation The shunt pumped and refilled well The wound was then closed with 4 0 Vicryl interrupted galeal suture and Steri Strips on the skin It was uncertain whether this will correct the problem or not but we will continue to evaluate If his abdominal pressure is too high then he may need a different valve This will be determined over time but at this time the shunt seemed to empty and refill easily The patient tolerated the procedure well No complications Sponge and needle counts were correct Blood loss was minimal None replaced Keywords surgery bactiseal bactiseal catheter codman bactiseal blocked ventriculoperitoneal shunt ventriculoperitoneal shunt revision ventricular catheter shunt revision ventriculoperitoneal shunt catheter ventriculoperitoneal ventricular shunt MEDICAL_TRANSCRIPTION,Description Right shockwave lithotripsy cystoscopy and stent removal x2 Medical Specialty Surgery Sample Name Shockwave Lithotripsy Transcription PREOPERATIVE DIAGNOSIS Right renal stone POSTOPERATIVE DIAGNOSIS Right renal stone PROCEDURE Right shockwave lithotripsy cystoscopy and stent removal x2 ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal The patient was given antibiotics preoperatively HISTORY This is a 47 year old male who presented with right renal stone and right UPJ stone The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney The plan was for shockwave lithotripsy The patient had duplicated system on the right side Risk of anesthesia bleeding infection pain MI DVT PE was discussed Options such as watchful waiting passing the stone on its own and shockwave lithotripsy were discussed The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR Anesthesia was applied The patient was placed in the supine position Using Dornier lithotriptor total of 2500 shocks were applied Energy levels were slowly started at O2 increased up to 7 gradually the stone seem to have broken into smaller pieces as the number of shocks went up The shocks were started at 60 per minute and slowly increased up to 90 per minute The patient s heart rate and blood pressure were stable throughout the entire procedure After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion and cystoscopy was done Using graspers the stent was grasped x2 and pulled out both stents were removed The patient tolerated the procedure well The patient was brought to recovery in stable condition The plan was for the patient to follow up with us and plan for KUB in about two to three months Keywords surgery renal stone stent removal upj stone shockwave lithotripsy cystoscopy stent renal shocks upj shockwave lithotripsy stone MEDICAL_TRANSCRIPTION,Description Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new Medical Specialty Surgery Sample Name Shunt Revision 2 Transcription PREOPERATIVE DIAGNOSIS Shunt malfunction POSTOPERATIVE DIAGNOSIS Partial proximal obstruction patent distal system TITLE OF OPERATION Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new SPECIMENS None COMPLICATIONS None ANESTHESIA General SKIN PREPARATION Chloraprep INDICATIONS FOR OPERATION Headaches irritability slight increase in ventricle size Preoperatively patient improved with Diamox BRIEF NARRATIVE OF OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in the supine position with the head rotated towards the left The right frontal area and right retroauricular area was shaved and then the head neck chest and abdomen were prepped and draped out in the routine manner The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter right over the sleeve on top of it and when that was entered the CSF poured out around the ventricular catheter The ventricular catheter was then disconnected from the reservoir and endoscopically explored We saw it was blocked up proximally The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter I was able to free up the ventricular catheter and endoscopically inserted a new Bactiseal ventricular catheter The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle It irrigated out well There was minimal amount of bleeding but not significant The distal catheter system was tested There was good distal run off Therefore a linear skin incision was made in the retroauricular area Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1 5 shunt assist was brought through the subgaleal tissue connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve All connections were secured with 2 0 Ethibond sutures Careful attention was made to make sure that the ProGAV was in the right orientation The wounds were irrigated out with Bacitracin closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin followed by Mastisol and Steri Strips The patient tolerated the procedure well He was awakened extubated and taken to recovery room in satisfactory condition Keywords surgery chloraprep distal shunt revision colorado needle tip colorado needle progav valve shunt revision ventricular catheter catheter shunt ventricular MEDICAL_TRANSCRIPTION,Description Right shoulder hemi resurfacing using a size 5 Biomet Copeland humeral head component noncemented Severe degenerative joint disease of the right shoulder Medical Specialty Surgery Sample Name Shoulder Hemi resurfacing Transcription PREOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right shoulder POSTOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right shoulder PROCEDURE Right shoulder hemi resurfacing using a size 5 Biomet Copeland humeral head component noncemented ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL COMPLICATIONS None The patient was taken to Postanesthesia Care Unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 55 year old female who has had increased pain in to her right shoulder X rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi resurfacing was appropriate for her right shoulder focusing in the humeral head All risks benefits expectations and complications of surgery were explained to her in detail including nerve and vessel damage infection potential for hardware failure the need for revision surgery with potential of some problems even with surgical intervention The patient still wanted to proceed forward with surgical intervention The patient did receive 1 g of Ancef preoperatively PROCEDURE The patient was taken to the operating suite placed in supine position on the operating table The Department of anesthesia administered a general endotracheal anesthetic which the patient tolerated well The patient was moved to a beach chair position All extremities were well padded Her head was well padded to the table Her right upper extremity was draped in sterile fashion A saber incision was made from the coracoid down to the axilla Skin was incised down to the subcutaneous tissue the cephalic vein was retracted as well as all neurovascular structures were retracted in the case Dissecting through the deltopectoral groove the subscapularis tendon was found as well as the bicipital tendon 1 finger breadth medial to the bicipital tendon an incision was made Subscapularis tendon was released The humeral head was brought in to there were large osteophytes that were removed with an osteotome The glenoid then was evaluated and noted to just have mild arthrosis but there was no need for surgical intervention in this region A sizer was placed It was felt that size 5 was appropriate for this patient after which the guide was used to place the stem and pin This was placed after which a reamer was placed along the humeral head and reamed to a size 5 All extra osteophytes were excised The supraspinatus and infraspinatus tendons were intact Next the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation The arm had excellent range of motion There are no signs of gross dislocation Drill holes were made into the humeral head after which a size 5 Copeland hemi resurfacing component was placed into the humeral head kept down in appropriate position had excellent fixation into the humeral head Excess bone that had been reamed was placed into the Copeland metal component after which this was tapped into position After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion had adequate range of motion full internal and external rotation as well as forward flexion and abduction There was no gross sign of dislocation Wound site once again it was copiously irrigated with saline antibiotics The subscapularis tendon was approximated back into position with 2 Ethibond after which the bicipital tendon did have significant tear to it therefore it was tenodesed in to the pectoralis major tendon After which the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2 0 Vicryl The skin was closed with staples A sterile dressing was placed The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition Keywords surgery degenerative joint disease hemi resurfacing biomet copeland shoulder hemi resurfacing humeral head degenerative glenoid subscapularis antibiotics resurfacing tendon shoulder MEDICAL_TRANSCRIPTION,Description Endoscopic proximal shunt revision Medical Specialty Surgery Sample Name Shunt Revision 1 Transcription PREOPERATIVE DIAGNOSIS Shunt malfunction The patient with a ventriculoatrial shunt POSTOPERATIVE DIAGNOSIS Shunt malfunction The patient with a ventriculoatrial shunt ANESTHESIA General endotracheal tube anesthesia INDICATIONS FOR OPERATION Headaches fluid accumulating along shunt tract FINDINGS Partial proximal shunt obstruction TITLE OF OPERATION Endoscopic proximal shunt revision SPECIMENS None COMPLICATIONS None DEVICES Portnoy ventricular catheter OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner The old right frontal scalp incision was reopened in a curvilinear manner and the Bactiseal ventricular catheter was identified as it went into the right frontal horn The distal end of the VA shunt was flushed and tested with heparinized saline found to be patent and it was then clamped Endoscopically the proximal end was explored and we found debris within the lumen and then we were able to freely move the catheter around We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract which were going into the catheter consistent with partial proximal obstruction A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before but would take a gentle curve going into the right lateral ventricle It flushed in quite well was left at about 6 5 cm to 7 cm and connected to the existing straight connector and secured with 2 0 Ethibond sutures The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3 0 Vicryl for the galea and a 4 0 running Monocryl for the scalp followed by Mastisol and Steri Strips The patient was awakened and extubated having tolerated the procedure well without complications It should be noted that the when we were irrigating through the ventricular catheter fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest Keywords surgery ventriculoatrial shunt endoscopic proximal shunt revision endoscopic proximal shunt portnoy ventricular catheter shunt malfunction shunt revision ventricular catheter shunt endoscopic ventricular proximal catheter MEDICAL_TRANSCRIPTION,Description Bilateral endoscopic proximal shunt revision and a distal shunt revision Medical Specialty Surgery Sample Name Shunt Revision Transcription TITLE OF OPERATION Bilateral endoscopic proximal shunt revision and a distal shunt revision INDICATIONS FOR OPERATION Headaches full subtemporal site PREOPERATIVE DIAGNOSIS Slit ventricle syndrome POSTOPERATIVE DIAGNOSIS Slit ventricle syndrome FINDINGS Coaptation of ventricles against proximal end of ventricular catheter ANESTHESIA General endotracheal tube anesthesia DEVICES A Codman Hakim programmable valve with Portnoy ventricular catheter a 0 20 proGAV valve with a shunt assist of 20 cm dual right angled connector and a flushing reservoir BRIEF NARRATIVE OF OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in the prone position with the head held on a soft foam padding The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0 25 Marcaine with 1 200 000 epinephrine after routine prepping and draping Both U shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir which might have been leading to the coaptation of the ventricles The patient also had a right subtemporal depression which was full preoperatively The entire old apparatus was dissected out We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted They were both inspected No definite debris were seen After removing the ventricular catheters the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter On the right side we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location The old valve was dissected out and the proGAV valve with a 2 0 shunt assist was inserted and secured with a 2 0 Ethibond suture The proGAV valve was then connected to a Bactiseal distal tubing which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir All connections secured with 2 0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve which was set to an opening pressure of 8 and the other one being the Bactiseal tubing which was going towards the flushing reservoir All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin followed by Mastisol and Steri Strips The patient tolerated the procedure well without complications CSF was not sent off Keywords surgery codman hakim portnoy slit ventricle syndrome shunt revision bilateral endoscopic proximal shunt coaptation of the ventricles portnoy ventricular catheter ventricular catheter progav valve flushing reservoir bactiseal tubing shunt ventricular bactiseal MEDICAL_TRANSCRIPTION,Description Sigmoidoscopy performed for evaluation of anemia gastrointestinal Bleeding Medical Specialty Surgery Sample Name Sigmoidoscopy 1 Transcription PROCEDURE Sigmoidoscopy INDICATIONS Performed for evaluation of anemia gastrointestinal Bleeding MEDICATIONS Fentanyl Sublazine 0 1 mg IV Versed midazolam 1 mg IV BIOPSIES No BRUSHINGS PROCEDURE A history and physical examination were performed The procedure indications potential complications bleeding perforation infection adverse medication reaction and alternative available were explained to the patient who appeared to understand and indicated this Opportunity for questions was provided and informed consent obtained After placing the patient in the left lateral decubitus position the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm Careful inspection was made as the sigmoidoscope was withdrawn The quality of the prep was good The procedure was stopped due to patient discomfort The patient otherwise tolerated the procedure well There were no complications FINDINGS Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries Retroflexed examination of the rectum revealed small hemorrhoids External hemorrhoids were found Other than the findings noted above the visualized colonic segments were normal IMPRESSION Internal hemorrhoids External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries Unsuccessful Sigmoidoscopy Otherwise Normal Sigmoidoscopy to 25 cm External hemorrhoids were found Keywords surgery gastrointestinal bleeding gastrointestinal sigmoidoscope rectum anemia bleeding sigmoidoscopy hemorrhoids MEDICAL_TRANSCRIPTION,Description Insertion of a 8 Shiley tracheostomy tube A 10 blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch Dissection was carried down using Bovie electrocautery to the level of the trachea Medical Specialty Surgery Sample Name Shiley Tracheostomy Tube Insertion Transcription OPERATION Insertion of a 8 Shiley tracheostomy tube ANESTHESIA General endotracheal anesthesia OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient s family including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next a 10 blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch Dissection was carried down using Bovie electrocautery to the level of the trachea The 2nd tracheal ring was identified Next a 11 blade scalpel was used to make a trap door in the trachea The endotracheal tube was backed out A 8 Shiley tracheostomy tube was inserted and tidal CO2 was confirmed when it was connected to the circuit We then secured it in place using 0 silk suture A sterile dressing was applied The patient tolerated the procedure well Keywords surgery tracheostomy shiley tracheostomy tube sternal notch bovie electrocautery tracheostomy tube electrocautery endotracheal shiley tube MEDICAL_TRANSCRIPTION,Description Excision of sebaceous cyst right lateral eyebrow Medical Specialty Surgery Sample Name Sebaceous Cyst Excision Transcription PREOPERATIVE DIAGNOSIS Sebaceous cyst right lateral eyebrow POSTOPERATIVE DIAGNOSIS Sebaceous cyst right lateral eyebrow PROCEDURE PERFORMED Excision of sebaceous cyst right lateral eyebrow ASSISTANT None ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None ANESTHESIA General endotracheal anesthesia CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE Stable Transferred to the recovery room INDICATIONS FOR PROCEDURE The patient is a 4 year old with a history of sebaceous cyst The patient is undergoing PE tubes by Dr X and I was asked to remove the cyst on the right lateral eyebrow I saw the patient in my clinic I explained to the mother in Spanish the risk and benefits Risk included but not limited to risk of bleeding infection dehiscence scarring need for future revision surgery We will proceed with the surgery PROCEDURE IN DETAIL The patient was taken into the operating room placed in the supine position General anesthetic was administered A prophylactic dose of antibiotic was given The patient was prepped and draped in a usual manner The procedure began by infiltrating lidocaine with epinephrine around the cyst area Then I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst The cyst was detached of the surrounding structure with the help of blunt dissection Hemostasis was achieved with electrocautery The wound was closed with 5 0 Vicryl deep dermal interrupted stitches and Dermabond The patient tolerated the procedure well without complications and transferred to recovery room in stable condition I was present and participated in all aspects of the procedure Sponge needle and instrument counts were completed at the end of the procedure Keywords surgery lateral eyebrow excision of sebaceous cyst sebaceous cyst cyst eyebrow sebaceous MEDICAL_TRANSCRIPTION,Description Left scrotal exploration with detorsion Already de torsed bilateral testes fixation and bilateral appendix testes cautery Medical Specialty Surgery Sample Name Scrotal Exploration Transcription PREOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion POSTOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion PROCEDURE Left scrotal exploration with detorsion Already de torsed bilateral testes fixation and bilateral appendix testes cautery ANESTHETIC A 0 25 Marcaine local wound insufflation per surgeon 15 mL of Toradol FINDINGS Congestion in the left testis and cord with a bell clapper deformity on the right small appendix testes bilaterally No testis necrosis ESTIMATED BLOOD LOSS 5 mL FLUIDS RECEIVED 300 mL of crystalloid TUBES AND DRAINS None SPECIMENS No tissues sent to pathology COUNTS Sponges and needle counts were correct x2 INDICATIONS OF OPERATION The patient is a 4 year old boy with abrupt onset of left testicular pain He has had a history of similar onset Apparently he had no full on one ultrasound and full on a second ultrasound but because of possible torsion detorsion or incomplete detorsion I recommended an exploration DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification was verified Once he was anesthetized he was placed in supine position and sterilely prepped and draped Superior scrotal incisions were then made with 15 blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery Electrocautery was used for hemostasis The subdartos pouch was created with curved tenotomy scissors The tunica vaginalis was then delivered incised and testis was delivered The testis itself with a bell clapper deformity There was no actual torsion at the present time there was some modest congestion and however the vasculature was markedly congested down the cord The penis fascia was cauterized and subdartos pouch was created The upper aspect of fascia was then closed with pursestring suture of 4 0 chromic The testis was then placed into the scrotum in a proper orientation No tacking sutures within the testis itself were used The tunica vaginalis however was wrapped perfectly behind the back of the testis A similar procedure was performed on the right side Again an appendix testis was cauterized No torsion was seen He also had a bell clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with 4 0 chromic suture The local anesthetic was then used for both as cord block as well as a local wound insufflation bilaterally with 0 25 Marcaine The scrotal wall was then closed with subcuticular closure of 4 0 chromic Dermabond tissue adhesive was then used The patient tolerated the procedure well He was given IV Toradol and was taken to the recovery room in stable condition Keywords surgery de torsed bilateral testes testes fixation bell clapper deformity testicular torsion subdartos pouch tunica vaginalis scrotal exploration appendix testes scrotal testes torsion detorsion insufflation testis MEDICAL_TRANSCRIPTION,Description Scleral buckle opening under local anesthesia Medical Specialty Surgery Sample Name Scleral Buckle Opening Local Anesthesia Transcription PROCEDURE IN DETAIL After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table After intravenous sedation was administered a retrobulbar block consisting of 2 Xylocaine with 0 75 Marcaine and Wydase was administered to the right eye without difficulty The patient s right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a 360 degree conjunctival peritomy was performed at the limbus The 4 rectus muscles were looped and isolated using 2 0 silk suture The retinal periphery was then inspected via indirect ophthalmoscopy Keywords surgery retinal periphery ophthalmoscopy scleral buckle operating anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Selective coronary angiography coronary angioplasty Acute non ST elevation MI Medical Specialty Surgery Sample Name Selective Coronary Angiography Angioplasty Transcription PREOPERATIVE DIAGNOSIS AND INDICATIONS Acute non ST elevation MI POSTOPERATIVE DIAGNOSIS AND SUMMARY The patient presented with an acute non ST elevation MI Despite medical therapy she continued to have intermittent angina Angiography demonstrated the severe LAD as the culprit lesion This was treated as noted above with angioplasty alone as the stent could not be safely advanced She has residual lesions of 75 in the proximal right coronary and 60 proximal circumflex and the other residual LAD lesions as noted above She will be continued on her medical therapy At age 90 she is not a good candidate for aortic valve replacement and coronary bypass grafting PROCEDURE PERFORMED Selective coronary angiography coronary angioplasty PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the cath lab placed on the table in the supine position The area of the right femoral artery was prepped and draped in a sterile fashion Using the percutaneous technique a 6 French sheath was placed in the right femoral artery under fluoroscopic guidance With the guidewire in place a 5 French JL 4 catheter was used to selectively angiogram the left coronary system The catheter was removed The sheath flushed The 5 French 3DRC catheter was then used to selectively angiogram the right coronary artery The cath removed the sheath flushed It was decided that intervention was needed in the severe lesions in the LAD which appeared to be the culprit lesions for the non ST elevation MI The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained we rebolused and the ACT was slightly lower We repeated the level and it was slightly higher We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV Additionally the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started A 6 French CLS 3 5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal An Apex 2 5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated Angiography was then performed demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium The balloon was inflated and removed repeat angiography performed We attempted to advance a Driver 2 5 x 24 mm bare metal stent but I could not advance it beyond the proximal LAD where there was significant calcification The stent was removed Attempts to advance the same 2 5 x 15 mm Apex balloon that was previously used were unsuccessful It was removed a new Apex 2 5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed Repeat angiography demonstrated no evidence of dissection One more attempt was made to advance the Driver 2 5 x 24 mm bare metal stent but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal I felt that further attempts in this calcified vessel in a 90 year old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection so the stent was removed The guidewires and guide cath were removed The sheath flushed and sutured into position The patient moved to ICU in stable condition with no chest discomfort at all CONTRAST Isovue 370 120 mL FLUORO TIME 9 4 minutes ESTIMATED BLOOD LOSS 30 mL HEMODYNAMICS Aorta 185 54 Left ventriculography was not performed I did not make an attempt to cross this severely stenotic aortic valve The left main is a large vessel giving rise to LAD and circumflex vessels The left main has no significant disease other than calcification in the walls The LAD is a moderate to large vessel giving rise to small diagonals and then a moderate to large third diagonal and then a small fourth diagonal The LAD has significant calcification proximally There is a 50 stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent This resulted in a 30 residual mostly eccentric calcified plaque Following this there was a 50 stenosis in the LAD just after the takeoff of the third diagonal This was not ballooned Beyond this is an 80 stenosis prior to the fourth diagonal and then a 99 stenosis after the fourth diagonal These 2 lesions were dilated with 10 residual prior to the fourth diagonal and 25 residual distal to the fourth diagonal As noted above this area was not stented because I could not safely advance the stent Note there was also a 50 stenosis at the origin of the moderate to large third diagonal that did not change with angioplasty The circumflex is a large nondominant vessel consisting of a large obtuse marginal with multiple branches The proximal circumflex has an eccentric 60 stenosis prior to the takeoff of the obtuse marginal The remainder of the vessel was without significant disease The right coronary was a large dominant vessel giving rise to a large posterior descending artery and small to moderate first posterolateral small second posterolateral and a small to moderate third posterolateral branch The right coronary has an eccentric smooth 75 stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch The remainder of the right coronary and its branches were without significant disease Keywords surgery non st elevation mi selective coronary angiography coronary angioplasty calcified plaque coronary angiography st elevation stenosis lad coronary selective angiography angioplasty balloon vessel stent MEDICAL_TRANSCRIPTION,Description Revision septoplasty repair of internal nasal valve collapse using auricular cartilage repair of bilateral external nasal valve collapse using auricular cartilage harvest of right auricular cartilage Medical Specialty Surgery Sample Name Septoplasty Transcription PREOPERATIVE DIAGNOSES 1 Nasal septal deviation 2 Bilateral internal nasal valve collapse 3 Bilateral external nasal valve collapse POSTOPERATIVE DIAGNOSES 1 Nasal septal deviation 2 Bilateral internal nasal valve collapse 3 Bilateral external nasal valve collapse PROCEDURES 1 Revision septoplasty 2 Repair of internal nasal valve collapse using auricular cartilage 3 Repair of bilateral external nasal valve collapse using auricular cartilage 4 Harvest of right auricular cartilage ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS Approximately 20 mL IV FLUIDS Include a liter of crystalloid fluid URINE OUTPUT None FINDINGS Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor There is also evidence of bilateral internal as well as external nasal valve collapse INDICATIONS The patient is a pleasant 49 year old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine Therefore for repair of the above mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum the risks and benefits of the procedure were discussed with him included but not limited to bleeding infection septal perforation need for further surgeries external deformity and he desired to proceed with surgery DESCRIPTION OF THE PROCEDURE IN DETAIL The patient was taken to the operating room and laid supine upon the OR table After the induction of general endotracheal anesthesia the nose was decongested using Afrin soaked pledgets followed by the injection of lidocaine with 1 100 000 epinephrine in the submucoperichondrial planes bilaterally Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor The caudal septum appeared to be now in adequate position There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place Following the evaluation of the nose a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side Very carefully the mucoperichondrial flaps were elevated over this and it was excised using an osteotome taking care to preserve the 1 5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine Very carefully the bony cartilaginous junction was identified and a small piece of the bone where the spur was was carefully removed Following this it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures Therefore attention was turned to harvesting the right sided auricular cartilage which was done after the region had adequately been prepped and draped in a sterile fashion Postauricular incision using a 15 blade the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times This was very carefully harvested This area had been injected previously with 1 lidocaine and 1 100 000 epinephrine Following this the cartilage was removed It was placed in saline noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity The spreader grafts were sutured in place using submucoperichondrial pockets After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery These were secured in place in the pockets using a 5 0 PDS suture in a mattress fashion in two places Following this attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin Subsequently the alar rim grafts were placed and extended all the way to the piriform aperture This was sutured in place using a 5 0 self absorbing gut suture The lower lateral cartilage has had some inherent asymmetry This may have been related to his previous surgery with some asymmetry of the dome however this was left in place as he did not desire any changes in the tip region and there was adequate support An endodermal suture was placed just to reenforce the region using a 5 0 PDS suture Following all this the area was closed using a mattress 4 0 plain gut on a Keith needle followed by the application of 5 0 fast absorbing gut to close the hemitransfixion incision Very carefully the skin and subcutaneous tissue envelopes were reflected The curvilinear incision was closed using a Vicryl followed by interrupted 6 0 Prolene sutures The marginal incisions were then closed using 5 0 fast absorbing gut Doyle splints were placed and secured down using a nylon suture They had ointment also placed on them Following this nasopharynx was suctioned There were no further abnormalities noted and everything appeared to be in nice position Therefore an external splint was placed after the application of Steri Strips The patient tolerated the procedure well He was awakened in the operating room He was extubated and taken to the recovery room in stable condition Keywords surgery nasal septal deviation nasal septal auricular cartilage nasal nasal obstruction nasal valve septoplasty submucoperichondrial upper airway internal nasal valve external nasal valve hemitransfixion incision revision septoplasty septal spur valve collapse auricular cartilage collapse septum valve MEDICAL_TRANSCRIPTION,Description Placement of Scott cannula right lateral ventricle Medical Specialty Surgery Sample Name Scott Cannula Transcription PROCEDURE Placement of Scott cannula right lateral ventricle DESCRIPTION OF THE OPERATION The right side of the head was shaved and the area was then prepped using Betadine prep Following an injection with Xylocaine with epinephrine a small 1 5 cm linear incision was made paralleling the midline lateral to the midline at the region of the coronal suture A twist drill was made with the hand drill through the dura A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF The Scott cannula was secured to the skin using 3 0 silk sutures This will be connected to external drainage set at 10 cm of water Keywords surgery coronal suture twist drill lateral ventricle csf placement of scott cannula scott cannula scott cannulaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Septoplasty with partial inferior middle turbinectomy with KTP laser sinus endoscopy with maxillary antrostomies removal of tissue with septoplasty and partial ethmoidectomy bilaterally Medical Specialty Surgery Sample Name Septoplasty Turbinectomy Transcription OPERATIVE DIAGNOSES Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates OPERATIONS PERFORMED Septoplasty with partial inferior middle turbinectomy with KTP laser sinus endoscopy with maxillary antrostomies removal of tissue with septoplasty and partial ethmoidectomy bilaterally OPERATION The patient was taken to the operating room After adequate anesthesia via endotracheal intubation the nose was prepped with Afrin nasal spray After this was done 1 Xylocaine with 100 000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium After this the sinus endoscope at 25 degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate A 45 degree forceps then used to open up the maxillary sinus There was some prominent tissue and just superior to this the anterior ethmoid was opened The 45 degree forceps was then used to open the maxillary sinus ostium This was enlarged with backbiting rongeur After this was done the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa After this was done attention was then turned to the right nasal cavity staying laterally to the middle turbinate There was noted to have prominence in the anterior ethmoidal area This was then opened with 45 degree forceps This mucosa was then removed from the anterior area The maxillary sinus ostium was then opened with 45 degree forceps Tissue was removed from this area This was sent as right maxillary mucosa After this the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus Protecting the eyes with wet gauze and using KTP laser at 10 watts the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction After this was completed a septoplasty was performed The incision was made with a 15 blade Bard Parker knife The flap was then elevated overlying the spur that was protruding into the right nasal cavity This was excised with a 15 blade Bard Parker knife The tissue was then laid back in position After this was laid back in position the nasal cavity was irrigated with saline solution suctioned well as well as the oropharynx Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3 0 nylon The patient was then awakened and taken to recovery room in good condition Keywords surgery sinusitis ktp laser septoplasty deviated endoscopy ethmoidectomy hypertrophied maxillary nasal obstruction nasal septum sinus turbinates turbinectomy partial ethmoidectomy parker knife sinus ostium nasal cavity maxillary sinus ktp mucosa cavity forceps antrostomies ostium nasal MEDICAL_TRANSCRIPTION,Description Repair of total anomalous pulmonary venous connection ligation of patent ductus arteriosus repair secundum type atrial septal defect autologous pericardial patch subtotal thymectomy and insertion of peritoneal dialysis catheter Medical Specialty Surgery Sample Name Septal Defect Repair Transcription TITLE OF OPERATION 1 Repair of total anomalous pulmonary venous connection 2 Ligation of patent ductus arteriosus 3 Repair secundum type atrial septal defect autologous pericardial patch 4 Subtotal thymectomy 5 Insertion of peritoneal dialysis catheter INDICATION FOR SURGERY This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection Following initial stabilization she was transferred to the Hospital for complete correction PREOP DIAGNOSIS 1 Total anomalous pulmonary venous connection 2 Atrial septal defect 3 Patent ductus arteriosus 4 Operative weight less than 4 kilograms 3 2 kilograms COMPLICATIONS None CROSS CLAMP TIME 63 minutes CARDIOPULMONARY BYPASS TIME MONITOR 35 minutes profound hypothermic circulatory arrest time 4 plus 19 equals 23 minutes Low flow perfusion 32 minutes FINDINGS Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left sided veins Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence Nonobstructed ascending vein ligated Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin At completion of the procedure right ventricular pressure approximating one half of systemic normal sinus rhythm good biventricular function by visual inspection PROCEDURE After the informed consent the patient was brought to the operating room and placed on the operating room table in supine position Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines The patient was prepped and draped in the usual sterile fashion from chin to groins A median sternotomy incision was performed Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw A subtotal thymectomy was performed Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure Pursestrings were deployed on the ascending aorta on the right Atrial appendage The aorta was then cannulated with an 8 French aorta cannula and the right atrium with an 18 French Polystan right angle cannula With an ACT greater than 400 greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2 0 silk tie Systemic cooling was started and the head was packed and iced and systemic steroids were administered During cooling traction suture was placed in the apex of the left ventricle After 25 minutes of cooling the aorta was cross clamped and the heart arrested by administration of 30 cubic centimeter kilogram of cold blood cardioplegia delivered directly within the aortic root following the aorta cross clamping Following successful cardioplegic arrest a period of low flow perfusion was started and a 10 French catheter was inserted into the right atrial appendage substituting the 18 French Polystan venous cannula The heart was then rotated to the right side and the venous confluence was exposed It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed The two openings were then anastomosed in an end to side fashion with several interlocking sutures to avoid pursestring effect with a running 7 0 PDS suture Following completion of the anastomosis the heart was returned into the chest and the patient s blood volume was drained into the reservoir A right atriotomy was then performed during the period of circulatory arrest The atrial septal defect was very difficult to expose but it was sealed with an autologous pericardial patch was secured in place with a running 6 0 Prolene suture The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6 0 Prolene sutures The venous cannula was reinserted Cardiopulmonary bypass restarted and the aorta cross clamp was released The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which following a prolonged period of rewarming allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15 French Blake drains Venous decannulation was followed by aortic decannulation and administration of protamine sulfate All cannulation sites were oversewn with 6 0 Prolene sutures and the anastomotic sites noticed to be hemostatic With good hemodynamics and hemostasis the sternum was then smeared with vancomycin placing closure with stainless steel wires The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred in very stable condition to the pediatric intensive care unit I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Given the magnitude of the operation the unavailability of an appropriate level cardiac surgical resident Mrs X attending pediatric cardiac surgery at the Hospital participated during the cross clamp time of the procedure in quality of first assistant Keywords surgery total anomalous pulmonary venous connection patent ductus arteriosus ligation secundum type atrial septal defect atrial septal defect subtotal thymectomy peritoneal dialysis catheter cross clamp cardiopulmonary bypass pulmonary venous atrial septal septal defect anomalous venous atrial arteriosus patent ductus septal aorta pulmonary MEDICAL_TRANSCRIPTION,Description Removal of infected sebaceous cyst right neck Medical Specialty Surgery Sample Name Sebaceous Cyst Removal Transcription PREOPERATIVE DIAGNOSIS Infected sebaceous cyst right neck POSTOPERATIVE DIAGNOSIS Infected sebaceous cyst right neck PROCEDURE The patient was electively taken to the operating room after obtaining an informed consent With a combination of intravenous sedation and local infiltration anesthesia a time out process was followed and then the patient was prepped and draped in the usual fashion The elliptical incision was performed around the draining tract Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue All the necrotic tissue was excised together with an ellipse of skin Hemostasis was achieved with a cautery The cavity was irrigated with normal saline At the end of procedure there was a good size around cavity that was packed with iodoform gauze One skin suture was grazed for approximation A bulky dressing was applied The patient tolerated the procedure well Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery Keywords surgery infected sebaceous cyst necrotic tissue sebaceous cyst infected MEDICAL_TRANSCRIPTION,Description Skin biopsy scalp mole Darkened mole status post punch biopsy scalp lesion Rule out malignant melanoma with pulmonary metastasis Medical Specialty Surgery Sample Name Scalp Mole Skin Biopsy Transcription PROCEDURE Skin biopsy scalp mole INDICATION A 66 year old female with pulmonary pneumonia effusion rule out metastatic melanoma to lung PROCEDURE NOTE The patient s scalp hair was removed with 1 K Y jelly 2 Betadine prep locally 3 A 1 lidocaine with epinephrine local instilled 4 A 3 mm punch biopsy used to obtain biopsy specimen which was sent to the lab To control bleeding two 4 0 P3 nylon sutures were applied antibiotic ointment on the wound Hemostasis was controlled The patient tolerated the procedure IMPRESSION Darkened mole status post punch biopsy scalp lesion rule out malignant melanoma with pulmonary metastasis PLAN The patient will have sutures removed in 10 days Keywords surgery k y jelly darkened mole scalp mole skin biopsy punch biopsy melanoma MEDICAL_TRANSCRIPTION,Description Scleral buckle opening The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma Medical Specialty Surgery Sample Name Scleral Buckle Opening Transcription SCLERAL BUCKLE OPENING The patient was brought to the operating room and appropriately identified General anesthesia was induced by the anesthesiologist The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A 360 degree limbal conjunctival peritomy was created with Westcott scissors Curved tenotomy scissors were used to enter each of the intermuscular quadrants The inferior rectus muscle was isolated with a muscle hook freed of its Tenon s attachment and tied with a 2 0 silk suture The 3 other rectus muscles were isolated in a similar fashion The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma Keywords surgery tenotomy scleral quadrants scleral thinning scleral buckle staphylomaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Ligation and stripping of left greater saphenous vein to the level of the knee Stripping of multiple left lower extremity varicose veins Varicose veins Medical Specialty Surgery Sample Name Saphenous Vein Ligation Stripping Transcription PREOPERATIVE DIAGNOSIS Varicose veins POSTOPERATIVE DIAGNOSIS Varicose veins PROCEDURE PERFORMED 1 Ligation and stripping of left greater saphenous vein to the level of the knee 2 Stripping of multiple left lower extremity varicose veins ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 150 mL SPECIMENS Multiple veins COMPLICATIONS None BRIEF HISTORY This is a 30 year old Caucasian male who presented for elective evaluation from Dr X s office for evaluation of intractable pain from the left lower extremity The patient has had painful varicose veins for number of years He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins It was recommended that the patient undergo a saphenous vein ligation and stripping He was explained the risks benefits and complications of the procedure including intractable pain He gave informed consent to proceed OPERATIVE FINDINGS The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region The vein was stripped from the saphenofemoral junction to the level of the knee Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly Additionally there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult OPERATIVE PROCEDURE The patient was marked preoperatively in the Preanesthesia Care Unit The patient was brought to the operating suite placed in the supine position The patient underwent general endotracheal intubation After adequate anesthesia was obtained the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline A diagonal incision was created in the direction of the inguinal crease on the left A self retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified The vein was isolated with a right angle The vein was followed proximally until a multiple tributary branches were identified These were ligated with 3 0 silk suture The dissection was then carried to the femorosaphenous vein junction This was identified and 0 silk suture was placed proximally and distally and ligated in between The proximal suture was tied down Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein An incision was created at the level of the knee The distal segment of the greater saphenous vein was identified and the left foot was encircled with 0 silk suture and tied proximally and then ligated The distal end of the vein stripping device was then passed through at its most proximal location The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity Next attention was made towards the multiple tributaries of the varicose vein within the left lower leg Multiple incisions were created with a 15 blade scalpel The incisions were carried down with electrocautery Next utilizing sharp dissection with a hemostat the tissue was spread until the vein was identified The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed Additionally some segments were removed The stripping approach would be vein stripping device Multiple branches of the saphenous vein were then ligated and or removed Occasionally dissection was unable to be performed as the vein was too friable and would tear from the hemostat Bleeding was controlled with direct pressure All incisions were then closed with interrupted 3 0 Vicryl sutures and or 4 0 Vicryl sutures The femoral incision was closed with interrupted multiple 3 0 Vicryl sutures and closed with a running 4 0 subcuticular suture The leg was then cleaned dried and then Steri Strips were placed over the incisions The leg was then wrapped with a sterile Kerlix Once the Kerlix was achieved an Ace wrap was placed over the left lower extremity for compression The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit Keywords surgery varicose veins saphenous vein stripping ligation vein stripping lower extremity saphenous varicose vein ligated MEDICAL_TRANSCRIPTION,Description Scarf bunionectomy procedure of the first metatarsal of the left foot Hallux abductovalgus deformity with bunion of the left foot Medical Specialty Surgery Sample Name Scarf Bunionectomy Transcription PREOPERATIVE DIAGNOSIS Hallux abductovalgus deformity with bunion of the left foot POSTOPERATIVE DIAGNOSIS Hallux abductovalgus deformity with bunion of the left foot PROCEDURE PERFORMED Scarf bunionectomy procedure of the first metatarsal of the left foot ANESTHESIA IV sedation with local HISTORY This patient is a 55 year old female who presents to ABCD preoperative holding area after keeping herself n p o since mid night for surgery for her painful left bunion The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes The patient has failed to conservative treatment and desires surgical correction at this time Risks versus benefits of the procedure have been explained in detail by Dr X and consent is available on the chart for review PROCEDURE IN DETAIL After an IV established by the Department of Anesthesia the patient was given preoperatively 600 mg of clindamycin intravenously The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection Next a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient s protection After adequate IV sedation was applied the patient was given a local injection consisting of 17 cc of 4 5 cc 1 lidocaine plain 4 5 cc of 0 5 Marcaine plain and 1 0 cc of Solu Medrol mixture in the standard Mayo block to the left foot The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was then elevated the Esmarch was applied and the tourniquet was inflated to 250 mmHg The foot was then lowered to the operating field A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot After sufficient anesthesia using a 10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally just near to the extensor hallucis longus tendon Then using a fresh 15 blade this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery A neurovascular bundle was identified and reflected medially Laterally the extensor hallucis longus tendon was identified and protected with retraction as well Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully The first metatarsophalangeal joint capsule was then identified and using a 15 blade a linear incision made down to the bone through the joint capsule The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint The bone cortex was noted to be intact and in good condition Following this using a sagittal saw with a 138 blade the attention was directed to the medial hypertrophic bone of the first metatarsal head In the sagittal plane with the blade angulated from dorsolateral to proximal medial the medial eminence of bone was resected Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well Following this bone cut 0 45 K wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head Then using the Reese osteotomy guide the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal A second 0 45 K wire was inserted proximally as well Following this using the sagittal saw with the 138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made This began with the dorsal distal cut which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal Following this attention was directed proximally and an incision osteotomy cut through the bone was made directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone Following this the distal portion of the osteotomy cut was freely movable and was able to be translocated medially The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone Following this the bone was stabilized using a 0 45 K wire distally as well as proximally directed from dorsal to planar direction Next using the normal AO manner the distal cortex was drilled from dorsal to plantar with a 2 0 mm drill bit and then over drilled proximally with the cortex using a 2 7 mm drill bit The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex Then using 2 7 mm tap the thread holes were placed and using an 18 x 2 7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved Intramedullary sludge was noted to exit from the osteotomy cut Following this attention was directed proximally and the 0 45 K wire was removed and the holes were predrilled using a 2 0 mm screw then over drilled using 2 7 mm screw and counter sucked Following this the holes were measured found to 20 mm in length and the drill hole was tapped using a 2 7 mm tap Following this a 20 mm full threaded screw was inserted and tightened Good intramedullary sludge was noted and compression was achieved Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite Following this range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted Based on this a lateral release was performed The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a 15 blade into the first interspace The incision was then deepened with sharp and blunt dissection and using a curved hemostat the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament Upon completion of this the hallux was noted to be in a rectus position with good alignment The area was then flushed and irrigated with copious amounts of sterile saline After this attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using 3 0 Vicryl suture Subcutaneous tissues were closed using 3 0 and 4 0 Vicryl sutures to close in layers The skin was then reapproximated and closed using 5 0 Monocryl suture Following this the incisions were dressed and bandaged in the normal manner using Owen silk 4x4s Kling and Kerlix as well as Coban dressing The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit Following this the patient was given prescription for Vicoprofen total 20 to be taken one every six hours as necessary for moderate to severe pain The patient was also given prescription for clindamycin to be taken 300 mg four times a day The patient was given surgical shoe and was placed in a posterior sling The patient was given crutches and instructed to use them for ambulation The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend The patient will follow up with Dr X on Tuesday morning at 11 o clock in his Livonia office The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that The patient has Dr X s pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise X rays were taken and the patient was discharged home upon completion of this Keywords surgery hallux abductovalgus deformity scarf bunionectomy metatarsal bunion hallux abductovalgus metatarsophalangeal joint dorsally foot bone abductovalgus MEDICAL_TRANSCRIPTION,Description Scleral Buckle opening under general anesthesia Medical Specialty Surgery Sample Name Scleral Buckle Opening General Anesthesia Transcription PROCEDURE IN DETAIL After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty The patient s right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a 360 degree conjunctival peritomy was performed at the limbus The 4 rectus muscles were looped and isolated using 2 0 silk suture The retinal periphery was then inspected via indirect ophthalmoscopy Keywords surgery retinal periphery conjunctival peritomy ophthalmoscopy scleral buckle operating anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Sterilization candidate Cervical dilatation and laparoscopic bilateral partial salpingectomy A 30 year old female gravida 4 para 3 0 1 3 who desires permanent sterilization Medical Specialty Surgery Sample Name Salpingectomy Cervical Dilatation Transcription PREOPERATIVE DIAGNOSIS Sterilization candidate POSTOPERATIVE DIAGNOSIS Sterilization candidate PROCEDURE PERFORMED 1 Cervical dilatation 2 Laparoscopic bilateral partial salpingectomy ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc SPECIMEN Portions of bilateral fallopian tubes INDICATIONS This is a 30 year old female gravida 4 para 3 0 1 3 who desires permanent sterilization FINDINGS On bimanual exam the uterus is small anteverted and freely mobile There are no adnexal masses appreciated On laparoscopic exam the uterus bilateral tubes and ovaries appeared normal The liver margin and bowel appeared normal PROCEDURE After consent was obtained the patient was taken to the operating room where general anesthetic was administered The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion A sterile speculum was placed in the patient s vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterus was then sounded to 7 cm The cervix was serially dilated with Hank dilators A 20 Hank dilator was left in place The sterile speculum was then removed Gloves were changed Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient s previous scar The Veress needle was placed and gas was turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted Two 5 mm step trocars were placed one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus The Endoloop was placed through the left sided port A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper A knuckle of tube was brought up with the grasper and a 0 Vicryl Endoloop synched down across this knuckle of tube The suture was then cut using the endoscopic shears The portion of tube that was tied off was removed using a Harmonic scalpel This was then removed from the abdomen and sent to Pathology The right tube was then identified and in a similar fashion the grasper was placed through the loop of the 0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop The loop was then synched down The Endoshears were used to cut the suture The Harmonic scalpel was then used to remove that portion of tube The portion of the tube that was removed from the abdomen was sent to Pathology Both tubes were examined and found to have excellent hemostasis All instruments were then removed The 5 mm ports were removed with good hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar was removed The fascia of the infraumbilical incision was reapproximated with an interrupted suture of 3 0 Vicryl The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of Marcaine was injected at the incision site The vulsellum tenaculum and cervical dilator were then removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of the procedure The patient was taken to the recovery room in satisfactory condition She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks Keywords surgery cervical dilatation partial salpingectomy permanent sterilization vulsellum tenaculum hank dilators infraumbilical incision vicryl endoloop salpingectomy dilatation hemostasis cervical laparoscopic endoloop sterilization MEDICAL_TRANSCRIPTION,Description Stage IV necrotic sacral decubitus Debridement of stage IV necrotic sacral decubitus Medical Specialty Surgery Sample Name Sacral Decubitus Debridement Transcription PREOPERATIVE DIAGNOSIS Stage IV necrotic sacral decubitus POSTOPERATIVE DIAGNOSIS Stage IV necrotic sacral decubitus PROCEDURE PERFORMED Debridement of stage IV necrotic sacral decubitus GROSS FINDINGS This is a 92 year old African American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy OPERATIVE PROCEDURE The patient was properly prepped and draped under local sedation A 0 25 Marcaine was injected circumferentially around the necrotic decubitus A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied The patient was sent to recovery in satisfactory condition Keywords surgery diverting colostomy sacral decubitus debridement necrotic sacral decubitus wound tissue debridement sacral decubitus necrotic MEDICAL_TRANSCRIPTION,Description Repair of ruptured globe with repositing of uveal tissue Sample Template Medical Specialty Surgery Sample Name Ruptured Globe Repair Sclera and Limbus Transcription PREOPERATIVE DIAGNOSIS Ruptured globe with uveal prolapse OX POSTOPERATIVE DIAGNOSIS Ruptured globe with uveal prolapse OX PROCEDURE Repair of ruptured globe with repositing of uveal tissue OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was carefully placed to provide exposure A two armed 7 mm scleral laceration was seen in the supranasal quadrant The laceration involved the sclera and the limbus in this area There was a small amount of iris tissue prolapsed in the wound The Westcott scissors and 0 12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber The anterior chamber remained formed and the iris tissue easily resumed its normal position The pupil appeared round An 8 0 nylon suture was used to close the scleral portion of the laceration Three sutures were placed using the 8 0 nylon suture Then 9 0 nylon suture was used to close the limbal portion of the wound After the wound appeared closed a Superblade was used to create a paracentesis at approximately 2 o clock BSS was injected through the paracentesis to fill the anterior chamber The wound was checked and found to be watertight No leaks were observed An 8 0 Vicryl suture was used to reposition the conjunctiva and close the wound Three 8 0 Vicryl sutures were placed in the conjunctiva All scleral sutures were completely covered The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment The lid speculum was carefully removed The drapes were carefully removed Sterile saline was used to clean around the XXX eye as well as the rest of the face The area was carefully dried and an eye patch and shield were taped over the XXX eye The patient was awakened from general anesthesia without difficulty S he was taken to the recovery area in good condition There were no complications Keywords surgery ruptured globe bss subconjunctival bleeding conjunctiva eye patch infection limbus loss of the eye loss of vision re operation scleral laceration supranasal quadrant uveal prolapse wire lid speculum iris tissue anterior chamber laceration iris chamber ruptured globe eye MEDICAL_TRANSCRIPTION,Description Laparoscopic right salpingooophorectomy Right pelvic pain and ovarian mass Right ovarian cyst with ovarian torsion Medical Specialty Surgery Sample Name Salpingooophorectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSES 1 Right pelvic pain 2 Right ovarian mass POSTOPERATIVE DIAGNOSES 1 Right pelvic pain 2 Right ovarian mass 3 8 cm x 10 cm right ovarian cyst with ovarian torsion PROCEDURE PERFORMED Laparoscopic right salpingooophorectomy ANESTHESIA General with endotracheal tube COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc TUBES None DRAINS None PATHOLOGY The right tube and ovary sent to pathology for review FINDINGS On exam under anesthesia a normal appearing vulva and vagina and normally palpated cervix a uterus that was normal size and a large right adnexal mass Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice Otherwise the uterus left tube and ovary bowel liver margins appendix and gallbladder were noted all to be within normal limits There was no noted blood in the pelvis INDICATIONS FOR THIS PROCEDURE The patient is a 26 year old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night which has been increasing in intensity The pain persisted despite multiple pain medications given in the Emergency Room The patient reports positive nausea and vomiting There was no vaginal bleeding or discharge There was no fevers or chills Her cultures done in the Emergency Room were pending The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst questionable hemorrhagic The uterus and left ovary were within normal limits There was a positive flow noted to bilateral ovaries on ultrasound Therefore it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy PROCEDURE After informed consent was obtained and all questions were answered to the patient s satisfaction in layman s terms she was taken to the operating room where general anesthesia was obtained without any difficulty She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above She was prepped and draped in the usual sterile fashion A weighted speculum was placed in the patient s vagina with excellent visualization of the cervix The cervix was grasped at 12 o clock position with a single toothed tenaculum and pulled into the operative field The uterus was then sounded to approximately 3 5 inches and then a uterine elevator was placed The vulsellum tenaculum was removed The weighted speculum was removed Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp The CO2 was then turned on with unoccluded flow and excellent pressures This was continued till a normal symmetrical pneumoperitoneum was obtained Then a 11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope Laparoscopic findings are as noted above A suprapubic incision was made with the knife and then a 12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization Then a grasper was used to untorse the ovary Then a 12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system The right tube and ovary were amputated and noted to be hemostatic The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag The ovary was too large to fit completely into the bag Therefore a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag There was approximately 200 cc of fluid aspirated from the cyst This was a clear yellow fluid Then the bag was closed and the ovary was removed from the suprapubic port The suprapubic port did have to be extended somewhat to allow for the removal of the ovary The trocar and sleeve were then placed back into the port The abdomen was copiously irrigated with warm normal saline using the Nezhat Dorsey suction irrigator and the incision site was noted to be hemostatic The pelvis was clear and clean Pictures were obtained The suprapubic port was then removed under direct visualization and then using a 0 vicyrl and UR6 Two figure of eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed Therefore the peritoneal surface was noted to be hemostatic Therefore the camera was removed All instruments were removed The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank 12 port and the infraumbilical port and these were removed The infraumbilical port was examined and noted to have a small fascial defect which was repaired with 0 Vicryl and UR6 The right flank area was palpated and there was no facial defect noted The skin was then closed with 4 0 undyed Vicryl in subcuticular fashion Dressings were changed The weighted speculum was removed from the patient s cervix The cervix noted to be hemostatic The patient tolerated the procedure well Sponge lap and needle counts were correct x2 and the patient was taken to the Recovery in stable condition Keywords MEDICAL_TRANSCRIPTION,Description Salvage cystectomy very difficult due to postradical prostatectomy and postradiation therapy to the pelvis Indiana pouch continent cutaneous diversion and omental pedicle flap to the pelvis Medical Specialty Surgery Sample Name Salvage Cystectomy Transcription PREOPERATIVE DIAGNOSES 1 Radiation cystitis 2 Refractory voiding dysfunction 3 Status post radical retropubic prostatectomy and subsequent salvage radiation therapy POSTOPERATIVE DIAGNOSES 1 Radiation cystitis 2 Refractory voiding dysfunction 3 Status post radical retropubic prostatectomy and subsequent salvage radiation therapy TITLE OF OPERATION Salvage cystectomy very difficult due to postradical prostatectomy and postradiation therapy to the pelvis Indiana pouch continent cutaneous diversion and omental pedicle flap to the pelvis ANESTHESIA General endotracheal with epidural INDICATIONS This patient is a 65 year old white male who in 1998 had a radical prostatectomy He was initially dry without pads and then underwent salvage radiation therapy for rising PSA After that he began with episodes of incontinence as well as urinary retention requiring catheterization One year ago he was unable to catheterize and was taken to the operative room and had cystoscopy He had retained staple removed and a diverticulum identified There were also bladder stones that were lasered and removed and he had been incontinent ever since that time He wears 8 to 10 pads per day and this has affected his quality of life significantly I took him to the operating room on January 16 2008 and found diffuse radiation changes with a small capacity bladder and wide open bladder neck We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him I felt like if we could remove the bladder safely then this would also provide a benefit FINDINGS At exploration there were no gross lesions of the smaller or large bowel The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally The opened bladder which we were able to remove completely had a wide open capacious diverticulum in its very distal segment Because of the previous radiation therapy and a dissection down to the pelvis I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment PROCEDURE IN DETAIL The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained placed in the supine position flexed over the anterosuperior iliac spine and his abdomen and genitalia were sterilely prepped and draped in the usual fashion A nasogastric tube was placed as well as radial arterial line He was given intravenous antibiotics for prophylaxis A generous midline skin incision was made from the midepigastrium down to the symphysis pubis deep into the rectus fascia the rectus muscle separated in the midline and exploration carried out with the findings described Moist wound towels and a Bookwalter retractor were placed for exposure We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries This was quite challenging because of the previous radiation therapy and radical prostatectomy We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles and these were taken between double clips approximately and clipped distally We then approached things posteriorly and carefully dissected between the __________ and posterior bladder There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum We then peeled it off the remaining rectum and passed the specimen off the operative field Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis We then completely mobilized the omentum off of the proximal transverse colon This allowed a generous flap to be able to be laid into the pelvis without tension We then turned our attention to forming the Indiana pouch I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon The colon was divided proximal to the middle colic using a GIA 80 stapler I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum The mesentery was then sealed with a LigaSure device and divided and the bowel was divided with a GIA 60 stapler We then performed a side to side ileo transverse colostomy using a GIA 80 stapler closing the open end with a TA 60 The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures We then removed the staple line along the terminal ileum passed a 12 French Robinson catheter into the cecal segment and plicated the ileum with 3 firings of the GIA 60 stapler The ileocecal valve was then reinforced with interrupted 3 0 silk sutures as described by Rowland et al and following this passage of an 18 French Robinson catheter was associated with the characteristic pop indicating that we had adequately plicated the ileocecal valve As the patient had had a previous appendectomy we made an opening in the cecum in the area of the previous appendectomy We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3 0 Vicryl sutures The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb 75 Between the staple lines Vicryl sutures were placed and the defects closed with 3 0 Vicryl suture ligatures We then turned our attention to forming the ileocolonic anastomosis The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end to side anastomosis performed with an open technique using interrupted 4 0 Vicryl sutures and this was stented with a Cook 8 4 French ureteral stent and this was secured to the bowel lumen with a 5 0 chromic suture The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2 0 chromic suture A 24 French Malecot catheter was placed through the cecum and secured with a chromic suture The staple lines were then buried with a running 3 0 Vicryl two layer suture and the open end of the pouch closed with a TA 60 Polysorb suture The pouch was filled to 240 cc and noted to be watertight and the ureteral anastomoses were intact We then made a final inspection for hemostasis The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures We then matured our stoma through the umbilicus We removed the plug of skin through the umbilicus and delivered the ileal segment through this A portion of the ileum was removed and healthy well vascularized tissue was matured with interrupted 3 0 chromic sutures We left an 18 French Robinson through the stomag and secured this to the skin with silk sutures The Malecot and stents were also secured in a similar fashion We matured the stoma to the umbilicus with interrupted chromic stitches The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch The rectus fascia was closed with a buried 2 Prolene running stitch tying a new figure of eight proximally and distally and meeting in the middle and tying it underneath the fascia Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips The estimated blood loss was 450 mL and the patient received no packed red blood cells The final sponge and needle count were reported to be correct The patient was awakened and extubated and taken on stretcher to the recovery room in satisfactory condition Keywords surgery radiation cystitis voiding dysfunction retropubic prostatectomy salvage radiation therapy salvage cystectomy indiana pouch continent cutaneous diversion omental pedicle flap ligasure gia stapler gia stapler vicryl sutures radiation therapy silk sutures bladder therapy sutures endotracheal MEDICAL_TRANSCRIPTION,Description Repair of ruptured globe involving posterior sclera Sample Template Medical Specialty Surgery Sample Name Ruptured Globe Repair Posterior Sclera Transcription PREOPERATIVE DIAGNOSIS Ruptured globe OX POSTOPERATIVE DIAGNOSIS Ruptured globe OX PROCEDURE Repair of ruptured globe OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was placed to provide exposure Upon examination and dissection of the conjunctiva superiorly a scleral rupture was found The rupture extended approximately 15 mm in length superior to the cornea approximately 2 mm from the limbus in a horizontal fashion There was also a rupture at the limbus near the middle of this laceration causing the anterior chamber to be flat There was a large blood clot filling the anterior chamber An attempt was made to wash out the anterior chamber with BSS on a cannula The BSS was injected through the limbal rupture which communicated with the anterior chamber The blood clot did not move It was extremely adherent to the iris At that time the rupture that involved the limbus from approximately 10 30 until 12 o clock was closed using 1 suture of 10 0 nylon The scleral laceration was then closed using 10 interrupted sutures with 9 0 Vicryl At that time the anterior chamber was formed and appeared to be fairly deep The wounds were checked and found to be watertight The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7 0 Vicryl sutures 2 nasally and 2 temporally All suture knots were buried Gentamicin 0 5 cc was injected subconjunctivally Then the speculum was removed The drapes were removed Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye An eye patch and shield were placed over the eye The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition Keywords surgery ruptured globe ancef bss maxitrol ointment ocuflox anterior chamber bleeding conjunctiva infection limbus loss of the eye loss of vision re operation scleral laceration scleral rupture wire lid speculum repair of ruptured globe ruptured anterior chamber globe MEDICAL_TRANSCRIPTION,Description Cervical facial rhytidectomy Quadrilateral blepharoplasty Autologous fat injection to the upper lip donor site abdomen Medical Specialty Surgery Sample Name Rhytidectomy Blepharoplasty Transcription PREOPERATIVE DIAGNOSIS Ageing face POSTOPERATIVE DIAGNOSIS Ageing face OPERATIVE PROCEDURE 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip OPERATIONS PERFORMED 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip donor site abdomen INDICATION This is a 62 year old female for the above planned procedure She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative PROCEDURE The patient was brought to the operative room under satisfaction and she was placed supine on the OR table Administered general endotracheal anesthesia followed by sterile prep and drape at the patient s face and abdomen This included the neck accordingly Two platysmal sling application and operating headlight were utilized Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery The first procedure was performed was that of a quadrilateral blepharoplasty Markers were applied to both upper lids in symmetrical fashion The skin was excised from the right upper lid first followed by appropriate muscle resection Minimal fat removed from the medial upper portion of the eyelid Hemostasis was controlled with the quadrilateral tip needle closure with a running 7 0 nylon suture Attention was then turned to the lower lid A classic skin muscle flap was created accordingly Fat was resected from the middle medial and lateral quadrant The fat was allowed to open drain the arcus marginalis for appropriate contour Hemostasis was controlled with the pinpoint cautery accordingly Skin was redraped with a conservative amount resected Running closure with 7 0 nylon was accomplished without difficulty The exact same procedure was repeated on the left upper and lower lid After completion of this portion of the procedure the lag lid was again placed in the eyes Eye mass was likewise clamped Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure The right face was first operated It was injected with a 0 25 Marcaine 1 200 000 adrenaline A submental incision was created followed by suction lipectomy and very minimal amounts of in 3 mm and 2 mm suction cannula She had minimal subcutaneous extra fat as noted Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post occipital hairline The flap was elevated without difficulty with various facelift scissors Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4 cm incision Rectus plication in the midline with a running 4 0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation cutting and cautery The submental incision was closed with a running 7 0 nylon over 5 0 Monocryl Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication The left side of face was first closed followed by interrupted SMAS plication utilizing 4 0 wide Mersilene The skin was draped appropriately and appropriate tissue was resected A 7 mm 9 0 French drain was utilized accordingly prior to closure of the skin with interrupted 4 0 Monocryl in the post occipital region followed by running 5 0 nylon in the postauricular surface Preauricular interrupted 5 0 Monocryl was followed by running 7 0 nylon The hairline temporal incision was closed with running 5 0 nylon The exact same closure was accomplished on the right side of the face with a same size 7 mm French drain The patient s dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3 inch Ace The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly Approximately 2 5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure The incision site was closed with 7 0 nylon The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position The patient will be admitted for overnight short stay through the cosmetic package procedure She will be discharged in the morning Estimated blood loss was less than 75 cc No complications noted and the patient tolerated the procedure well Keywords surgery ageing face adaptic polysporin ointment autologous fat injection bovie cautery kerlix wrap smas plication arcus marginalis blepharoplasty facelift platysmal sling quadrilateral rhytidectomy right upper lid cervical facial rhytidectomy pinpoint cautery facial rhytidectomy quadrilateral blepharoplasty running nylon autologous MEDICAL_TRANSCRIPTION,Description Right shoulder hemiarthroplasty Right shoulder rotator cuff tear Glenohumeral rotator cuff arthroscopy Degenerative joint disease Medical Specialty Surgery Sample Name Right Shoulder Hemiarthroplasty Transcription PREOPERATIVE DIAGNOSES 1 Right shoulder rotator cuff tear 2 Glenohumeral rotator cuff arthroscopy 3 Degenerative joint disease POSTOPERATIVE DIAGNOSES 1 Right shoulder rotator cuff tear 2 Glenohumeral rotator cuff arthroscopy 3 Degenerative joint disease PROCEDURE PERFORMED Right shoulder hemiarthroplasty ANESTHESIA General ESTIMATED BLOOD LOSS Approximately 125 cc COMPLICATIONS None COMPONENTS A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used BRIEF HISTORY The patient is an 82 year old right hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment PROCEDURE The patient was taken to the operative suite placed on the operative field Department of Anesthesia administered general anesthetic Once adequately sedated the patient was placed in the beach chair position Care was ensured that she was well positioned adequately secured and padded At this point the right upper extremity was then prepped and draped in the usual sterile fashion A deltopectoral approach was used and taken down to the skin with a 15 blade scalpel At this point blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue Any perforating bleeders were cauterized with Bovie to obtain hemostasis Once the bursa was seen it was removed with a Rongeur and subscapular tendon could be easily visualized At this point the rotator cuff in the subacromial region was evaluated There was noted to be a large rotator cuff which was irreparable There was eburnated bone on the greater tuberosity noted The articular surface could be visualized The biceps tendon was intact There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface The under surface of the acromion it was felt there was mild ware on this as well At this point the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture It was separated from the capsule to have a two layered repair at closure The capsule was also reflected posterior At this point the glenoid surface could be easily visualized It was evaluated and had good cartilage contact and appeared to be intact The humeral head was evaluated There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head At this point decision was made to proceed with the arthroplasty since the rotator cuff tear was irreparable and there was significant ware of the humoral head The arm was adequately positioned An oscillating saw was used to make the head articular cut This was done at the margin of the articular surface with the anatomic neck This was taken down to appropriate level until this articular surface was adequately removed At this point the intramedullary canal and cancellous bone could be easily visualized The opening hand reamers were then used and this was advanced to a size 10 Under direct visualization this was performed easily At this point the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins This was then removed A trial component was then impacted into place which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured It did not appear overstuffed with evidence of excellent range of motion and no impingement At this point the trial component was removed Wound was copiously irrigated and suctioned dry Cement was then placed with a cement gun into the canal and taken up to the level of the cut The prosthesis was then inserted into place and held under direct visualization All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself This _______ cement was adequately hard at this point The final component of the head was impacted into place secured on the Morris taper and checked and this was reduced The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position The wound was again copiously irrigated and suctioned dry At this point the capsule was then reattached to its insertion site in the anterior portion Once adequately sutured with 1 Vicryl attention was directed to the subscapular The subscapular was advanced superiorly and anchored not only to the biceps tendon region but also to the top anterior portion of the greater tuberosity This was opened to allow some type of coverage points of the massive rotator cuff tear This was secured to the tissue and interosseous sutures with size 2 fiber wire After this was adequately secured the wound was again copiously irrigated and suctioned dry The deltoid fascial split was then repaired using interrupted 2 0 Vicryl subcutaneous tissue was then approximated using interrupted 24 0 Vicryl skin was approximated using a running 4 0 Vicryl Steri Strips and Adaptic 4 x 4s and ABDs were then applied The patient was then placed in a sling and transferred back to the gurney reversed by Department of Anesthesia DISPOSITION The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition Keywords surgery glenohumeral rotator cuff arthroscopy degenerative joint disease shoulder hemiarthroplasty rotator cuff subscapular shoulder MEDICAL_TRANSCRIPTION,Description Arthroscopic subacromial decompression and repair of rotator cuff through mini arthrotomy Medical Specialty Surgery Sample Name Rotator Cuff Repair Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear left POSTOPERATIVE DIAGNOSES 1 Sixty percent rotator cuff tear joint side 2 Impingement syndrome ANESTHESIA General NAME OF OPERATION 1 Arthroscopic subacromial decompression 2 Repair of rotator cuff through mini arthrotomy FINDINGS AT OPERATION The patient s glenohumeral joint was completely clear other than obvious tear of the rotator cuff The midportion of this appeared to be complete but for the most part this was about a 60 rupture of the tendon This was confirmed later when the bursal side was opened up Note the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted PROCEDURE He was given an anesthetic examined prepped and draped in a sterile fashion in a beach chair position The shoulder was instilled with fluid from posteriorly followed by the arthroscope The shoulder was instilled with fluid from posteriorly followed by the arthroscope Arthroscopy was then carried out in standard fashion using a 30 degree Dionic scope With the scope in the posterior portal the above findings were noted and an anterior portal was established A curved shaver was placed for debridement of the tear I established this was about a 60 70 tear with a probable complete area of tear which was very small There were no problems at the biceps or the rest of the joint The subacromial space showed findings as noted above and a thorough subacromial decompression was carried out with a Bovie rotary shaver and bur I did not debride the acromioclavicular joint The lateral portal was then extended to a mini arthrotomy and subacromial space was entered by blunt dissection through the deltoid The area of weakness of the tendon was found and was transversely cut and findings were confirmed The diseased tissue was removed and the greater tuberosity was abraded with a rongeur Tendon to tendon repair was then carried out with buried sutures of 2 0 Ethibond giving a very nice repair The shoulder was carried through a range of motion I could see no evidence of impingement Copious irrigation was carried out The deltoid deep fascia was anatomically closed as was the superficial fascia The subcutaneous tissue and skin were closed in layers A sterile dressing was applied The patient appeared to tolerate the procedure well Keywords surgery rotator cuff tear mini arthrotomy repair of rotator cuff arthroscopic subacromial decompression arthroscopic subacromial cuff tear subacromial space subacromial decompression mini arthrotomy acromioclavicular joint rotator cuff arthroscopic decompression acromioclavicular impingement rotator cuff MEDICAL_TRANSCRIPTION,Description Ruptured globe with full thickness corneal laceration repair Sample Template Medical Specialty Surgery Sample Name Ruptured Globe Repair Cornea Transcription PREOPERATIVE DIAGNOSIS Ruptured globe with full thickness corneal laceration OX POSTOPERATIVE DIAGNOSIS Ruptured globe with full thickness corneal laceration OX PROCEDURE Ruptured globe with full thickness corneal laceration repair OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe with full thickness corneal laceration of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection astigmatism cataract re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was placed to provide exposure and 0 12 forceps and a Superblade were used to create a paracentesis at approximately 11 o clock Viscoat was injected through the paracentesis to fill the anterior chamber The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound More Viscoat was injected to deepen the anterior chamber A 10 0 nylon suture was used to place four sutures to close the corneal laceration BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound A fifth 10 0 nylon suture was then placed The wound was packed and found to be watertight The sutures were rotated the wound was again checked and found to be watertight A small amount of Viscoat was again injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue Several drops were placed in the XXX eye including Ocuflox Pred Forte Timolol 0 5 Alphagan and Trusopt An eye patch and shield were taped over the XXX eye The patient was awakened from general anesthesia S he was taken to the recovery area in good condition There were no complications Keywords surgery ruptured globe alphagan bss ocuflox pred forte superblade timolol viscoat cannula anterior chamber astigmatism bleeding cataract corneal laceration full thickness corneal laceration infection laceration repair loss of the eye loss of vision paracentesis re operation wire lid speculum viscoat corneal laceration MEDICAL_TRANSCRIPTION,Description Cystourethroscopy right retrograde pyelogram and right double J stent placement 22 x 4 5 mm Right ureteropelvic junction calculus Medical Specialty Surgery Sample Name Retrograde Pyelogram Cystourethroscopy Transcription PREOPERATIVE DIAGNOSIS Right ureteral calculus POSTOPERATIVE DIAGNOSIS Right ureteropelvic junction calculus PROCEDURE PERFORMED 1 Cystourethroscopy 2 Right retrograde pyelogram 3 Right double J stent placement 22 x 4 5 mm FIRST SECOND ANESTHESIA General SPECIMEN Urine for culture and sensitivity DRAINS 22 x 4 5 mm right double J ureteral stent PROCEDURE After consent was obtained the patient was brought to operating room and placed in the supine position She was given general anesthesia and then placed in the dorsal lithotomy position A 21 French cystoscope was then passed through the urethra into the bladder There was noted to be some tightness of the urethra on passage On visualization of the bladder there were no stones or any other debris within the bladder There were no abnormalities seen No masses diverticuli or other abnormal findings Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter however the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis An open end ureteral catheter was then passed ________ into the distal right ureter Retrograde pyelogram was then performed There was noted to be an UPJ calculus with no noted hydronephrosis The wire was then passed back through the ureteral catheter The catheter was removed and a 22 x 4 5 mm double J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance The stent was clear within the kidney as well as within the bladder The bladder was drained and the cystoscope was removed The patient tolerated the procedure well She will be discharged home She is to follow up with Dr X for ESWL procedure She will be given prescription for Darvocet and will be asked to have a KUB x ray done prior to her followup and to bring them with her to her appointment Keywords surgery ureteropelvic junction calculus cystourethroscopy retrograde pyelogram double j stent placement double j stent cone tip catheter ureteral stent ureteral orifice ureteral catheter retrograde pyelogram catheter ureteral MEDICAL_TRANSCRIPTION,Description Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity Medical Specialty Surgery Sample Name Revision Rhinoplasty Transcription PREOPERATIVE DIAGNOSIS Nasal deformity status post rhinoplasty POSTOPERATIVE DIAGNOSIS Same PROCEDURE Revision rhinoplasty CPT 30450 Left conchal cartilage harvest CPT 21235 ANESTHESIA General INDICATIONS FOR THE PROCEDURE This patient is an otherwise healthy male who had a previous nasal fracture During his healing perioperatively he did sustain a hockey puck to the nose resulting in a saddle nose deformity with septal hematoma The patient healed status post rhinoplasty as a result but was left with a persistent saddle nose dorsal defect The patient was consented for the above stated procedure The risks benefits and alternatives were discussed DESCRIPTION OF PROCEDURE The patient was prepped and draped in the usual sterile fashion The patient did have approximately 12 mL of Lidocaine with epinephrine 1 with 1 100 000 infiltrated into the nasal soft tissues In addition to this cocaine pledgets were placed to assist with hemostasis At this point attention was turned to the left ear Approximately 3 mL of 1 Lidocaine with 1 100 000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb Betadine was utilized for preparation A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane I then completed this along the posterior aspect of the conchal cartilage was transected in the concha cavum and concha cymba both were harvested These were placed aside in saline Hemostasis was obtained with bipolar electrocauterization Bovie electrocauterization was also employed as needed The entire length of the wound was then closed with 5 0 plain running locking suture The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2 0 Prolene suture Antibiotic ointment was applied generously Next attention was turned to opening and lifting the soft tissues of the nose A typical external columella inverted V gull wing incision was placed on the columella and trailed into a marginal incision The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums Soft tissues were elevated over the lower lateral cartilages upper lateral cartilages onto the nasal dorsum At this point attention was turned to osteotomies and examination of the external cartilages The patient did have very broad lower lateral cartilages leading to a bulbous tip The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect Having completed this the patient had medial and lateral osteotomies performed with a 2 mm osteotome These were done transmucosally after elevating the tract using a Cottle elevator Direct hemostasis pressure was applied to assist with bruising Next attention was turned to tip mechanisms The patient had a series of double dome sutures placed into the nasal tip Then 5 0 Dexon was employed for intradomal suturing 5 0 clear Prolene was used for interdomal suturing Having completed this a 5 0 clear Prolene alar spanning suture was employed to narrow the superior tip area Next attention was turned to dorsal augmentation A Gore Tex small implant had been selected previously incised This was taken to the back table and carved under sterile conditions The patient then had the implant placed into the super tip area to assist with support of the nasal dorsum It was placed into a precise pocket and remained in the midline Next attention was turned to performing a columella strut The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage This was fixed into position utilizing a 5 0 Dexon suture Having completed placement of all augmentation grafts the patient was examined for hemostasis The external columella inverted gull wing incision along the nasal tip was closed with a series of interrupted everting 6 0 black nylon sutures The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5 0 plain interrupted sutures At the termination of the case the ear was inspected and the position of the conchal cartilage harvest was hemostatic There was no evidence of hematoma and the patient had a series of brown Steri Strips and Aquaplast cast placed over the nasal dorsum The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well The patient was transferred to the PACU in stable condition He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore Tex implant area He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest Keywords surgery nasal deformity rhinoplasty conchal cartilage harvest conchal bulb conchal submucoperichondrial gull wing incision gore tex gull wing incision lower lateral cartilages revision rhinoplasty nasal dorsum cartilage harvest conchal cartilage cartilage nasal deformity hemostasis columella harvest cartilages MEDICAL_TRANSCRIPTION,Description Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma left nasal cavity Medical Specialty Surgery Sample Name Rhinectomy Nasal Endoscopy Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity OPERATIONS PERFORMED 1 Nasal endoscopy 2 Partial rhinectomy ANESTHESIA General endotracheal INDICATIONS This is an 81 year old gentleman who underwent septorhinoplasty many years ago He also has a history of a skin lesion which was removed from the nasal ala many years ago the details of which he does not recall He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip He was evaluated by Dr A who performed the septorhinoplasty and underwent an intranasal biopsy which showed histologic evidence of invasive squamous cell carcinoma The preoperative examination shows induration of the nasal tip without significant erythema There is focal tenderness just cephalad to the alar crease There is no lesion either externally or intranasally PROCEDURE AND FINDINGS The patient was taken to the operating room and placed in supine position Following induction of adequate general endotracheal anesthesia the left nose was decongested with Afrin He was prepped and draped in standard fashion The left nasal cavity was examined by anterior rhinoscopy The septum was midline There was slight asymmetry of the nares No lesion was seen within the nasal cavity either in the area of the intercartilaginous area which was biopsied by Dr A the septum the lateral nasal wall and the floor The 0 degree nasal endoscope was then used to examine the nasal cavity more completely No lesion was detectable A left intercartilaginous incision was made with a 15 blade since this was the area of previous biopsy by Dr A The submucosal tissue was thickened diffusely but there was no identifiable distinct or circumscribed lesion present Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section A diagnosis of diffuse invasive squamous cell carcinoma was rendered An alar incision was made with a 15 blade and the full thickness incision was completed with the electrocautery The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins Additional soft tissue was then taken from all margins tagging them for the pathologist The inferior margins were noted to be clear on the next frozen section report but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone Additional soft tissue was taken in these regions along the superior margin The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology Once all margins had been cleared histologically additional soft tissue was taken from the entire wound A 5 mm chisel was used to take down the inferior aspect of the nasal bone and the medial most aspect of the maxilla This was all submitted to pathology for routine permanent examination Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6 0 nylon suture to provide a barrier and moisture The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well Sponge and needle counts were correct Keywords surgery nasal cavity joseph elevator squamous cell carcinoma endoscopy intranasally maxilla nasal ala nasal tip rhinectomy septorhinoplasty nasal endoscopy lateral cartilage frozen section additional soft squamous cell cell carcinoma nasal cartilage squamous carcinoma cavity tissue MEDICAL_TRANSCRIPTION,Description Repair of one half full thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant Medical Specialty Surgery Sample Name Repair of Canthal Lid Defect Transcription PREOPERATIVE DIAGNOSIS Status post Mohs resection epithelial skin malignancy left lower lid left lateral canthus and left upper lid POSTOPERATIVE DIAGNOSIS Status post Mohs resection epithelial skin malignancy left lower lid left lateral canthus and left upper lid PROCEDURES 1 Repair of one half full thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid 2 Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant ASSISTANT None ANESTHESIA Attended local by Strickland and Associates COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in supine position Dressing was removed from the left eye which revealed the defect as noted above After systemic administration of alfentanil local anesthetic was infiltrated into the left upper lid left lateral canthus and left lower eyelid The patient was prepped and draped in the usual ophthalmic fashion Protective scleral shell was placed in the left eye A 4 0 silk traction sutures placed through the upper eyelid margin The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3 1 2 4 mm from the lid margin the full width of the eyelid Relaxing incisions were made both medially and laterally and Mueller s muscle was subsequently dissected free from the superior tarsal border The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6 0 Vicryl sutures and one 4 0 Vicryl suture The protective scleral shell was removed from the eye The medial aspect of the eyelid was advanced temporally The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6 0 Vicryl sutures The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7 0 Vicryl suture The upper eyelid wound was present It was advanced to the advanced tarsoconjunctival pedicle temporally The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6 0 Vicryl suture it was then secured to the lateral orbital rim with two interrupted 6 0 Vicryl sutures Skin muscle flap was then elevated was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7 0 Vicryl sutures Burrows triangle was removed as was necessary to create smooth wound closure which was closed with interrupted 7 0 Vicryl suture Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6 0 Vicryl suture to the periosteum overlying the lateral orbital rim The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7 0 Vicryl followed by wound closure temporally with interrupted 7 0 Vicryl suture with removal of a burrow s triangle as was necessary to create smooth wound closure Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure The patient tolerated the procedure well and left the operating room in excellent condition There were no apparent complications Keywords surgery mohs resection epithelial skin lid left lateral canthus lateral canthal defect tarsoconjunctival pedicle flap lateral canthal tendon skin muscle flap interrupted vicryl sutures canthal defect mohs resection lid defect pedicle flap canthal tendon lateral canthus upper eyelid lateral orbital eyelid vicryl sutures repair eye canthal defect tarsoconjunctival pedicle MEDICAL_TRANSCRIPTION,Description Repeat cesarean section and bilateral tubal ligation Medical Specialty Surgery Sample Name Repeat C section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 weeks 2 History of previous cesarean section x2 The patient desires a repeat section 3 Chronic hypertension 4 Undesired future fertility The patient desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 weeks 2 History of previous cesarean section x2 The patient desires a repeat section 3 Chronic hypertension 4 Undesired future fertility The patient desires permanent sterilization PROCEDURE PERFORMED Repeat cesarean section and bilateral tubal ligation ANESTHESIA Spinal ESTIMATED BLOOD LOSS 800 mL COMPLICATIONS None FINDINGS Male infant in cephalic presentation with anteflexed head Apgars were 2 at 1 minute and 9 at 5 minutes 9 at 10 minutes and weight 7 pounds 8 ounces Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 31 year old gravida 5 para 4 female who presented to repeat cesarean section at term The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section additionally she desires permanent fertilization The procedure was described to the patient in detail including possible risks of bleeding infection injury to surrounding organs and the possible need for further surgery and informed consent was obtained PROCEDURE NOTE The patient was taken to the operating room where spinal anesthesia was administered without difficulty The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to elevate the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors Attention was then turned to the inferior aspect of the fascial incision which in similar fashion was grasped with Kocher clamps elevated and the underlying rectus muscles were dissected off bluntly and using the Bovie The rectus muscles were dissected in the midline The peritoneum was identified and entered using Metzenbaum scissors this incision was extended superiorly and inferiorly with good visualization of the bladder The bladder blade was inserted The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors This incision was extended laterally and the bladder flap was created digitally The bladder blade was reinserted The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction Clear fluid was noted The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant s head without the Kelly The nose and mouth were bulb suctioned The cord was clamped and cut The infant was subsequently handed to the awaiting nursery nurse The placenta was delivered spontaneously intact with a three vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic sutures Hemostasis was visualized Attention was turned to the right fallopian tube which was grasped with Babcock clamp using a modified Pomeroy method a 2 cm of segment of tube ligated x2 transected and specimen was sent to pathology Attention was then turned to the left fallopian tube which was grasped with Babcock clamp again using a modified Pomeroy method a 2 cm segment of tube was ligated x2 and transected Hemostasis was visualized bilaterally The uterus was returned to the abdomen both fallopian tubes were visualized and were noted to be hemostatic The uterine incision was reexamined and it was noted to be hemostatic The pelvis was copiously irrigated The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was closed with 0 Vicryl suture the subcutaneous layer was closed with 3 0 plain gut and the skin was closed with staples Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords surgery bilateral tubal ligation permanent sterilization undesired future fertility repeat cesarean section intrauterine pregnancy mayo scissors kocher clamps metzenbaum scissors fallopian tube babcock clamp pomeroy method rectus muscles cesarean section intrauterine cesarean MEDICAL_TRANSCRIPTION,Description Cadaveric renal transplant to right pelvis endstage renal disease Medical Specialty Surgery Sample Name Renal Transplant Cadaveric Transcription HISTORY OF PRESENT ILLNESS The patient is a 50 year old African American female with past medical history significant for hypertension and endstage renal disease on hemodialysis secondary to endstage renal disease last hemodialysis was on June 22 2007 The patient presents with no complaints for cadaveric renal transplant After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys the patient was deemed appropriate for operative intervention and transplantation of kidney PREOPERATIVE DIAGNOSIS Endstage renal disease POSTOPERATIVE DIAGNOSIS Endstage renal disease PROCEDURE Cadaveric renal transplant to right pelvis ESTIMATED BLOOD LOSS 400 mL FLUIDS One liter of normal saline and one liter of 5 of albumin ANESTHESIA General endotracheal SPECIMEN None DRAIN None COMPLICATIONS None The patient tolerated the procedure without any complication PROCEDURE IN DETAIL The patient was brought to the operating room prepped and draped in sterile fashion After adequate anesthesia was achieved a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1 5 cm medial of the ASIS down to the suprapubic space After this was taken down with a 10 blade electrocautery was used to take down tissue down to the layer of the subcutaneous fat Camper s and Scarpa s were dissected with electrocautery Hemostasis was achieved throughout the tissue plains with electrocautery The external oblique aponeurosis was identified with musculature and was entered with electrocautery Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia Additionally the rectus sheath was entered in a linear fashion After these planes were entered using electrocautery the retroperitoneum was dissected free from the transversalis fascia using blunt dissection After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery Upon entering through the transversalis fascia the epigastric vessels were identified and doubly ligated and tied with 0 silk ties After the ligation of the epigastric vessels the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane This was done without any complication and without entering the peritoneum grossly The round ligament was identified and doubly ligated at this time with 0 silk ties as well The dissection continued down now to layer of the alveolar tissue covering the right iliac artery This alveolar tissue was cleared using blunt dissection as well as electrocautery After the external iliac artery was identified it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture The right iliac vein was then identified and this was cleared again using electrocautery and blunt dissection After the right iliac vein was identified and cleared off all the alveolar tissue it was circumferentially cleared as well An additional perforating branch was noted at the inferior pole of the right iliac vein This was tied with a 0 silk tie and secured Hemostasis was achieved at this time and the tie had adequate control The dissection continued down and identified all other vital structures in this area Careful preservation of all vital structures was carried out throughout the dissection At this time Satinsky clamp was placed over the right iliac vein This was then opened using a 11 blade approximately 1 cm in length The heparinized saline was placed and irrigated throughout the inside of the vein and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked The renal vein was then elevated and identified in this area A 5 0 double ended Prolene stitch was used to secure the renal vein both superiorly and inferiorly and after appropriately being secured with 5 0 Prolene these were tied down and secured The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5 0 Prolene securing both superior and inferior poles After such time the 5 0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again After this was done and the artery was secured the Satinsky clamp was removed and a bulldog placed over The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow At this time all Satinsky clamps were removed and all bulldog clamps were removed The dissection then continued down to the layer of the bladder at which time the bladder was identified Appropriate area on the dome the bladder was identified for entry This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion Before this was done 0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length At this time a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well Subsequently the superior and inferior pole stitches with 5 0 Prolene were used to secure the ureter to the bladder This was then run mucosa to mucosa in a circumferential manner until secured in both superior and inferior poles once again Good flow was noted from the ureter at the time of operation Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself At this time an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again This was inspected and noted for proper control Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects At this time the anastomoses were all inspected hemostasis was achieved and good closure of the anastomosis was noted at this time The kidney was then placed back into its new position in the right pelvic fossa and the area was once again inspected for hemostasis which was achieved A 1 0 Prolene stitch was then used for mass closure of the external internal and transversalis fascias and musculature in a running fashion from superior to inferior This was secured and knots were dumped Subsequently the area was then checked and inspected for hemostasis which was achieved with electrocautery and the skin was closed with 4 0 running Monocryl The patient tolerated procedure well without evidence of complication transferred to the Dunn ICU where he was noted to be stable Dr A was present and scrubbed through the entire procedure Keywords surgery endstage renal disease ethibond satinsky clamp aponeurosis cadaveric cross match curvilinear incision hemodialysis iliac vein pelvic fossa peritoneum recipient renal transplant transplant transversalis fascia superior and inferior poles endstage renal renal disease vein electrocautery bladder renal intervention MEDICAL_TRANSCRIPTION,Description Acute lymphocytic leukemia in remission removal of venous port Medical Specialty Surgery Sample Name Removal of Venous Port Transcription PREOPERATIVE DIAGNOSIS Acute lymphocytic leukemia in remission POSTOPERATIVE DIAGNOSIS Acute lymphocytic leukemia in remission OPERATION PERFORMED Removal of venous port ANESTHESIA General INDICATIONS This 9 year old young lady presented with ALL in Orange County and had a port placed at that time She subsequently has now undergone chemotherapy here and is now off therapy She no longer needs her venous port so comes to the operating room today for its removal OPERATIVE PROCEDURE After the induction of general anesthetic the exit site was prepped and draped in usual manner The previous incision was opened by excising the old scar The port pocket was then opened and the port was removed from the pocket There was a resistance to the catheter being removed and so therefore we began following the catheter along its path opening the tract until finally the catheter seemed to come free and could be pulled out without difficulty The port pocket was then closed using a 3 0 Vicryl in subcutaneous tissue 5 0 subcuticular Monocryl in the skin Sterile dressing was applied Young lady was awakened and taken to the recovery room in satisfactory condition Keywords surgery removal of venous port acute lymphocytic leukemia venous port lymphocytic leukemia venous MEDICAL_TRANSCRIPTION,Description Radical resection of tumor of the scalp excision of tumor from the skull with debridement of the superficial cortex with diamond bur and advancement flap closure Medical Specialty Surgery Sample Name Resection of Tumor of Scalp Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma of the scalp POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Radical resection of tumor of the scalp CPT 11643 Excision of tumor from the skull with debridement of the superficial cortex with diamond bur Advancement flap closure with total undermined area 18 centimeters by 16 centimeters CPT 14300 ANESTHESIA General endotracheal anesthesia INDICATIONS This is an 81 year old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy positive for skin malignancy specifically squamous call carcinoma This appears to be affixed to the underlying scalp PLAN Radical resection with frozen sections to clear margins thereafter with planned reconstruction CONSENT I have discussed with the patient the possible risks of bleeding infection renal problems scar formation injury to muscle nerves and possible need for additional surgery with possible recurrence of the patient s carcinoma with review of detailed informed consent with the patient who understood and wished to proceed FINDINGS The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull The final periosteal margin which centrally appeared was positive for carcinoma The final margins peripherally were all negative DESCRIPTION OF PROCEDURE IN DETAIL The patient was taken to the operating room and there was placed supine on the operating room table General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint Thereafter the local anesthesia was injected into the area around the tumor A type excision was planned down to the periosteum A supraperiosteal radical resection was performed It was obvious that there was tumor at the deep margin involving the periosteum The edges were marked along the four quadrants at the 12 o clock 3 o clock 6 o clock and the 9 o clock positions and these were sent for frozen section evaluation Frozen section revealed positive margins at one end of the resection Therefore an additional circumferential resection was performed and the final margins were all negative Following completion the deep periosteal margin was resected The circumferential periosteal margins were noted to be negative however centrally there was a small area which showed tumor eroding into the superficial cortex of the skull Therefore the Midas Rex drill was utilized to resect approximately 1 2 mm of the superficial cortex of the bone at the area where the positive margin was located Healthy bone was obtained however it did not enter the diploic or marrow containing bone in the area Therefore no bong margin was taken However at the end of the procedure it did not appear that the residual bone had any residual changes consistent with carcinoma Following completion of the bony resection the area was irrigated with copious amounts of saline Thereafter advancement flaps were created both on the left and the right side of the scalp with the total undermined area being approximately 18cm by 16cm The galea was incised in multiple areas to provide for additional mobilization of the tissue The tissue was closed under tension with 3 0 Vicryl suture deep in the galea and surgical staples superficially The patient was awakened from anesthetic was extubated and was taken to the recovery room in stable condition DISPOSITION The patient was discharged to home with antibiotics and analgesics to follow up in approximately one week NOTE The final margins of both periosteal as well as skin were negative circumferentially around the tumor The only positive margin was deep which was a periosteal margin and bone underlying it was partially resected as was indicated above Keywords surgery squamous cell carcinoma of the scalp squamous cell carcinoma radical resection margin midas rex drill radical resection of tumor resection of tumor endotracheal anesthesia superficial cortex margins periosteum skull cortex periosteal scalp resection tumor MEDICAL_TRANSCRIPTION,Description Complex Regional Pain Syndrome Type I Stellate ganglion RFTC radiofrequency thermocoagulation left side and interpretation of Radiograph Medical Specialty Surgery Sample Name Radiofrequency Thermocoagulation 2 Transcription PREOPERATIVE DIAGNOSIS Complex Regional Pain Syndrome Type I POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Stellate ganglion RFTC radiofrequency thermocoagulation left side 2 Interpretation of Radiograph ANESTHESIA IV Sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS Patient with reflex sympathetic dystrophy left side Positive for allodynia pain mottled appearance skin changes upper extremities as well as swelling SUMMARY OF PROCEDURE Patient is admitted to the Operating Room Monitors placed including EKG Pulse oximeter and BP cuff Patient had a pillow placed under the shoulder blades The head and neck was allowed to fall back into hyperextension The neck region was prepped and draped in sterile fashion with Betadine and alcohol Four sterile towels were placed The cricothyroid membrane was palpated then going one finger s breadth lateral from the cricothyroid membrane and one finger s breadth inferior the carotid pulse was palpated and the sheath was retracted laterally A 22 gauge SMK 5 mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially The needle is advanced prudently through the tissues avoiding the carotid artery laterally The tip of the needle is perceived to intersect with the vertebral body of Cervical 7 and this was visualized by fluoroscopy Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand No venous or arterial blood return is noted No cerebral spinal fluid is noted Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0 0 1 volts and negative motor stimulation was elicited from 1 10 volts at 2 Hz After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed 5 cc of solution solution consisting of 5 cc of 0 5 Marcaine 1 cc of triamcinolone was then injected into the stellate ganglion region This was done with intermittent aspiration vigilantly verifying negative aspiration The stylet was then promptly replaced and neurolysis nerve decompression was then carried out for 60 seconds at 80 degrees centigrade This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band Aid was placed over the puncture site Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion Interpretation of radiograph reveals placement of the 22 gauge SMK 5 mm bare tipped needle in the region of the stellate ganglion on the affected side Four lesions were carried out Keywords surgery sheath vertebral body regional pain syndrome radiofrequency thermocoagulation stellate ganglion rftc radiofrequency radiograph cricothyroid thermocoagulation ganglion MEDICAL_TRANSCRIPTION,Description Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose Medical Specialty Surgery Sample Name Rhinoplasty Transcription PREOPERATIVE DIAGNOSES 1 Nasal obstruction secondary to deviated nasal septum 2 Bilateral turbinate hypertrophy PROCEDURE Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 26 year old white female with longstanding nasal obstruction She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose From her functional standpoint she has severe left sided nasal septal deviation with compensatory inferior turbinate hypertrophy From the aesthetic standpoint the nose is over projected lacks rotation and has a large dorsal hump First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump rotate the tip of the nose and de project the nasal tip I explained to her the risks benefits alternatives and complications for postsurgical procedure She had her questions asked and answered and requested that we proceed with surgery as outlined above PROCEDURE DETAILS The patient was taken to the operating room and placed in supine position The appropriate level of general endotracheal anesthesia was induced The face head and neck were sterilely prepped and draped The nose was anesthetized and vasoconstricted in the usual fashion Procedure began with a left hemitransfixion incision which was brought down into the left intercartilaginous incision Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane Intact bilateral septomucoperichondrial flaps were elevated and a severe left sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed Anterior and inferior one third of each inferior turbinate was clamped cut and resected The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm The bony hump of the nose was lowered with a straight osteotome by 4 mm Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip The caudal septum was shortened by 2 mm in an angle in order to enhance rotation Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of 3 0 chromic The upper lateral cartilages were rejoined to the dorsal septum with a 4 0 plain gut suture No middle valves or bone grafts were necessary Intact mucoperichondrial flaps were closed with 4 0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room taken to the recovery room in good condition Keywords surgery nasal obstruction cosmetic dorsal hump endotracheal tube hemitransfixion incision hypertrophy intercartilaginous intercartilaginous incision nasal septum nasal tip septomucoperichondrial submucoperichondrial subperiosteal turbinate vomerine spur nasal septal nasal rhinoplasty septum MEDICAL_TRANSCRIPTION,Description Release of A1 pulley right thumb Stenosing tendinosis right thumb trigger finger There was noted to be thickening of the A1 pulley There was a fibrous nodule noted within the flexor tendon of the thumb which caused triggering sensation to the thumb Medical Specialty Surgery Sample Name Release of A1 Pulley 1 Transcription PREOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger POSTOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger PROCEDURE PERFORMED Release of A1 pulley right thumb ANESTHESIA IV regional with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME Approximately 20 minutes at 250 mmHg INTRAOPERATIVE FINDINGS There was noted to be thickening of the A1 pulley There was a fibrous nodule noted within the flexor tendon of the thumb which caused triggering sensation to the thumb HISTORY This is a 51 year old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb She was actually able to spontaneously trigger the thumb She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley All risks and benefits of the surgery was discussed with her at length She was in agreement with the above treatment plan PROCEDURE On 08 21 03 she was taken to operating room at ABCD General Hospital and placed supine on the operating table A regional anesthetic was applied by the Anesthesia Department Tourniquet was placed on her proximal arm The upper extremity was sterilely prepped and draped in the usual fashion An incision was made over the proximal crease of the thumb Subcuticular tissues were carefully dissected Hemostasis was controlled with electrocautery The nerves were identified and retracted throughout the entire procedure The fibers of the A1 pulley were identified They were sharply dissected to release the tendon The tendon was then pulled up into the wound and inspected There was no evidence of gross tear noted Fibrous nodule was noted within the tendon itself There was no evidence of continuous locking Once release of the pulley had been performed the wound was copiously irrigated It was then reapproximated using 5 0 nylon simple interrupted and horizontal mattress sutures Sterile dressing was applied to the upper extremity Tourniquet was deflated It was noted that the thumb was warm and pink with good capillary refill The patient was transferred to Recovery in apparent stable and satisfactory condition Prognosis is fair Keywords surgery release of a1 pulley tendinosis thumb flexor tendon trigger finger fibrous nodule stenosing tendinosis tourniquet stenosing tendon release pulley MEDICAL_TRANSCRIPTION,Description Bilateral rectus recession with the microscopic control 8 mm both eyes Medical Specialty Surgery Sample Name Rectus Recession Transcription PREOPERATIVE DIAGNOSIS Congenital bilateral esotropia 42 prism diopters PROCEDURE Bilateral rectus recession with the microscopic control 8 mm both eyes POSTOPERATIVE DIAGNOSIS Congenital bilateral esotropia 42 prism diopters COMPLICATIONS None PROCEDURE IN DETAIL The patient was taken to the Surgery Room and placed in the supine position The general anesthesia was achieved with intubation with no problems Both eyes were prepped and draped in usual manner The attention was turned the right eye and a hole was made in the drape and a self retaining eye speculum was placed ensuring eyelash in the eye drape The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem The eyeball rotated medially and upwards by holding the limbus at 7 o clock position Inferior fornix conjunctival incision was made and Tenons capsule buttonholed The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook The Tenons capsule was buttonholed The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle __________ extension of the muscle was excised The 7 0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders The muscle was disinserted from original insertion The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion The suture was pulled tied and cut The muscle was in good position The conjunctiva was closed with 7 0 Vicryl suture in running fashion The suture was pulled tied and cut The eye speculum was taken out Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion The suture was pulled tied and cut The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition To be seen in the office in 1 week Keywords surgery congenital bilateral esotropia esotropia tenons capsule rectus muscle bilateral rectus recession rectus recession eye speculum muscle hook eyes muscle rectus MEDICAL_TRANSCRIPTION,Description The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley Medical Specialty Surgery Sample Name Release of A1 Pulley Transcription PREOPERATIVE DIAGNOSIS Right trigger thumb POSTOPERATIVE DIAGNOSIS Right trigger thumb SURGERY Release of A1 pulley CPT code 26055 ANESTHESIA General LMA TOURNIQUET TIME 9 minutes at 200 torr FINDINGS The patient was found to have limitations to extension at the IP joint to the right thumb He was found to have full extension after release of A1 pulley INDICATIONS The patient is 2 1 2 year old He has a history of a trigger thumb This was evaluated in the office He was indicated for release of A1 pulley to allow for full excursion Risks and benefits including recurrence infection and problems with anesthesia were discussed at length with the family They wanted to proceed PROCEDURE The patient was brought into the operating room and placed on the operating table in supine position General anesthesia was induced without incident He was given a weight adjusted dose of antibiotics The right upper extremity was then prepped and draped in a standard fashion Limb was exsanguinated with an Esmarch bandage Tourniquet was raised to 200 torr Transverse incision was then made at the base of thumb The underlying soft tissues were carefully spread in line longitudinally The underlying tendon was then identified The accompanied A1 pulley was also identified This was incised longitudinally using 11 blade Inspection of the entire tendon then demonstrated good motion both in flexion and extension The leaflets of the pulley were easily identified The wound was then irrigated and closed The skin was closed using interrupted 4 0 Monocryl simple sutures The area was injected with 5 mL of 0 25 Marcaine The wound was dressed with Xeroform dry sterile dressings hand dressing Kerlix and Coban The patient was awakened from anesthesia and taken to the recovery room in good condition There were no complications All instrument sponge needle counts were correct at the end of case PLAN The patient will be discharged home He will return in 1 1 2 weeks for wound inspection Keywords surgery a1 pulley release of a1 pulley trigger thumb limitations to extension ip joint MEDICAL_TRANSCRIPTION,Description Radioactive plaque macular edema Removal of radioactive plaque right eye with lateral canthotomy A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus A 2 0 traction suture was passed around the insertion of the lateral rectus and the temporal one half of the globe was exposed Medical Specialty Surgery Sample Name Radioactive Plaque Removal Transcription PREOPERATIVE DIAGNOSIS Radioactive plaque macular edema POSTOPERATIVE DIAGNOSIS Radioactive plaque macular edema TITLE OF OPERATION Removal of radioactive plaque right eye with lateral canthotomy OPERATIVE PROCEDURE IN DETAIL The patient was prepped and draped in the usual manner for a local eye procedure Then a retrobulbar injection of 2 Xylocaine was performed A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus A 2 0 traction suture was passed around the insertion of the lateral rectus and the temporal one half of the globe was exposed Next the plaque was identified and the two scleral sutures were removed The plaque was gently extracted and the conjunctiva was re sutured with 6 0 catgut following removal of the traction suture The fundus was inspected with direct ophthalmoscopy An eye patch was applied following Neosporin solution irrigation The patient was sent to the recovery room in good condition A lateral canthotomy had been done Keywords surgery conjunctiva eye patch ophthalmoscopy radioactive plaque traction suture eye radioactive plaque MEDICAL_TRANSCRIPTION,Description Closure of rectovaginal fistula transperineal approach Medical Specialty Surgery Sample Name Rectovaginal Fistula Closure Transcription PREOPERATIVE DIAGNOSIS ES Rectovaginal fistula POSTOPERATIVE DIAGNOSIS ES Rectovaginal fistula PROCEDURE CPT code 57307 Closure of rectovaginal fistula transperineal approach MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION Includes fistula tract ESTIMATED BLOOD LOSS 25 mL INDICATIONS The patient is a 27 year old morbidly obese gravida three para one who was seen in consultation from Dr M s office in the office of Chattanooga GYN Oncology on 01 12 06 regarding an obstetrically related rectovaginal fistula dating from 1998 She had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool She had her fistula repaired by Dr R in 2000 and did well for approximately one year without complaint when she again noted the spontaneous loss of stool and gas from her vagina She has partial control if her stools are formed but she has no control of her gas She is a type 2 diabetic with poorly controlled blood sugars at times however her diabetes has been fairly well controlled of late FINDINGS AT THE TIME OF SURGERY She had a 1 cm fistulous tract approximately 4 cm proximal to the vaginal introitus This communicated directly with the low rectal vault She had good rectal sphincter tone and a very thin perineal body The fistulous tract was excised completely and intact The underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed At the completion of the procedure the repair is watertight there were no other defects DESCRIPTION OF THE OPERATION The patient was taken to the operating room where she underwent general endotracheal anesthesia She was then placed in the lithotomy position using candy cane stirrups The vulva and vagina were prepped and the patient was draped A lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made The rectovaginal septum was developed and with an index finger in the rectum the rectovaginal septum was easily defined The fistulous tract was isolated and using the lacrimal duct probe it was completely isolated Using electrocautery dissection on the pure cut mode the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa This allowed for removal of the fistulous tract intact with both epithelial layers preserved The perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4 0 chromic The rectal vault was distended with saline and the repair was watertight The defect was irrigated suctioned inspected and found to be free of clot blood or debris The perineal body was reconstructed with reapproximation of the levator muscles using a series of interrupted horizontal mattress stitches of number 2 0 Vicryl This allowed for excellent restoration of the perineal body After this was accomplished the defect was once again irrigated suctioned inspected and found to be free of clot blood or debris The vaginal defect was closed with a running locking stitch of number 2 0 Vicryl and the perineal incision was closed with a subcuticular stitch of number 2 0 Vicryl The patient was awakened and taken to the recovery room in stable condition after having tolerated the procedure well Keywords surgery transperineal approach fistula tract fistula rectovaginal septum lacrimal duct probe candy cane perineal closure of rectovaginal fistula rectal mucosa perineal body fistulous tract rectovaginal fistula transperineal fistulous rectal MEDICAL_TRANSCRIPTION,Description Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation Medical Specialty Surgery Sample Name Radiofrequency Thermocoagulation Transcription PROCEDURE Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position The back prepped with Betadine The patient was given sedation and monitored Under fluoroscopy the right sacral alar notch was identified After placement of a 20 gauge 10 cm SMK needle into the notch a positive sensory negative motor stimulation was obtained Following negative aspiration 5 cc of 0 5 of Marcaine and 20 mg of Depo Medrol were injected Coagulation was then carried out at 90oC for 90 seconds The SMK needle was then moved to the mid inferior third of the right sacroiliac joint Again the steps dictated above were repeated The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen then followed by steroid injected and coagulation as above There were no complications The patient was returned to outpatient recovery in stable condition Keywords surgery posterior rami sacroiliac joint sacral alar notch radiofrequency thermocoagulation thermocoagulation radiofrequency sacroiliac sacral alar notch MEDICAL_TRANSCRIPTION,Description Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain Medical Specialty Surgery Sample Name Radiofrequency Thermocoagulation 1 Transcription PROCEDURE Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion The patient was given sedation and monitored Lidocaine 1 5 for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body A 20 gauge 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body At this time a negative motor stimulation was obtained Injection of 10 cc of 0 5 Marcaine plus 10 mg of Depo Medrol was performed Coagulation was then carried out for 90oC for 90 seconds At the conclusion of this the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated This was repeated one more time with a 5 mm withdrawal and coagulation At that time attention was directed to the L3 body where the needle was placed to the upper one third distal two thirds junction and the sequence of injection coagulation and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated There were no compilations from this The patient was discharged to operating room recovery in stable condition Keywords surgery lumbar sympathetic chain vertebral body radiofrequency thermocoagulation motor stimulation thermocoagulation radiofrequency coagulation needle MEDICAL_TRANSCRIPTION,Description Bilateral L5 S1 S2 and S3 radiofrequency ablation for sacroiliac joint pain Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Surgery Sample Name Radiofrequency Ablation Transcription PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 20 gauge 10 mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen for the lateral branches of S1 S2 and S3 Also fluoroscopic views were used to ensure proper needle placement The following technique was used to confirm correct placement Motor stimulation was applied at 2 Hz with 1 millisecond duration No extremity movement was noted at less than 2 volts Following this the needle trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 0 5 mL of 1 lidocaine was injected to anesthetize the lateral branch and the surrounding tissue After completion a lesion was created at that level with a temperature of 80 degrees for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS None COMPLICATIONS None DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at PM R Spine Clinic in approximately one to two weeks Keywords surgery sacroiliac joint pain sacroiliac teflon coated needle fluoroscopy needle placement radiofrequency ablation ablation tissue lidocaine needle MEDICAL_TRANSCRIPTION,Description Modified radical mastectomy An elliptical incision was made to incorporate the nipple areolar complex and the previous biopsy site The skin incision was carried down to the subcutaneous fat but no further Medical Specialty Surgery Sample Name Radical Mastectomy 1 Transcription PROCEDURE PERFORMED Modified radical mastectomy ANESTHESIA General endotracheal tube PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury An elliptical incision was made to incorporate the nipple areolar complex and the previous biopsy site The skin incision was carried down to the subcutaneous fat but no further Using traction and counter traction the upper flap was dissected from the chest wall medially to the sternal border superiorly to the clavicle laterally to the anterior border of the latissimus dorsi muscle and superolaterally to the insertion of the pectoralis major muscle The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2 0 Vicryl The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely Once the lateral border of the pectoralis major muscle was identified the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist The axilla was then cleared of its contents by sharp dissection Small vessels entering the axillary vein were clipped and divided The axilla was cleared down to the chest wall and dissection was continued laterally to the subscapular vein The long thoracic nerve was cleared identified lying against the chest and was carefully preserved The long thoracic nerve represented the posterior most aspect of the dissection As the axillary contents were dissected in the posterolateral axilla the thoracodorsal nerve was identified and carefully preserved The dissection continued caudally until the entire specimen was freed and delivered from the operative field Copious water lavage was used to remove any debris and hemostasis was obtained with Bovie electrocautery Two Jackson Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major These were secured to the skin using 2 0 silk which was Roman sandaled around the drain The skin incision was approximated with skin staples A dressing was applied The drains were placed on grenade suction All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords surgery latissimus dorsi muscle pectoralis major muscle pectoralis fascia axillary vein thoracic nerve radical mastectomy pectoralis major axillary incision mastectomy fascia muscle pectoralis MEDICAL_TRANSCRIPTION,Description Invasive carcinoma of left breast Left modified radical mastectomy Medical Specialty Surgery Sample Name Radical Mastectomy Transcription PREOPERATIVE DIAGNOSIS Invasive carcinoma of left breast POSTOPERATIVE DIAGNOSIS Invasive carcinoma of left breast OPERATION PERFORMED Left modified radical mastectomy ANESTHESIA General endotracheal INDICATION FOR THE PROCEDURE The patient is a 52 year old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast The patient was elected to have a left modified radical mastectomy she was not interested in a partial mastectomy She is aware of the risks and complications of surgery and wished to proceed DESCRIPTION OF PROCEDURE The patient was taken to the operating room She underwent general endotracheal anesthetic The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well The patient s left anterior chest wall neck axilla and left arm were prepped and draped in the usual sterile manner The recent biopsy site was located in the upper and outer quadrant of left breast The plain incision was marked along the skin Tissues and the flaps were injected with 0 25 Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site The flaps were raised superiorly and just below the clavicle medially to the sternum laterally towards the latissimus dorsi rectus abdominus fascia Following this the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle The dissection was started medially and extended laterally towards the left axilla The breast was removed and then the axillary contents were dissected out Left axillary vein and artery were identified and preserved as well as the lung _____ The patient had several clinically palpable lymph nodes they were removed with the axillary dissection Care was taken to avoid injury to any of the above mentioned neurovascular structures After the tissues were irrigated we made sure there were no signs of bleeding Hemostasis had been achieved with Hemoclips Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps The subcu was then approximated with interrupted 4 0 Vicryl sutures and skin with clips The drains were sutured to the chest wall with 3 0 nylon sutures Dressing was applied and the procedure was completed The patient went to the recovery room in stable condition Keywords surgery invasive carcinoma chest wall neck axilla modified radical mastectomy radical mastectomy invasive carcinoma mastectomy MEDICAL_TRANSCRIPTION,Description Cystoscopy under anesthesia retrograde and antegrade pyeloureteroscopy left ureteropelvic junction obstruction difficult and open renal biopsy Medical Specialty Surgery Sample Name Pyeloureteroscopy Transcription PREOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty percutaneous procedure and pyeloureteroscopy x2 and status post Pseudomonas pyelonephritis x6 renal insufficiency and solitary kidney POSTOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty percutaneous procedure and pyeloureteroscopy x2 and status post Pseudomonas pyelonephritis x6 renal insufficiency and solitary kidney PROCEDURE Cystoscopy under anesthesia retrograde and antegrade pyeloureteroscopy left ureteropelvic junction obstruction difficult and open renal biopsy ANESTHESIA General endotracheal anesthetic with a caudal block x2 FLUIDS RECEIVED 1000 mL crystalloid ESTIMATED BLOOD LOSS Less than 10 mL SPECIMENS Tissue sent to pathology is a renal biopsy ABNORMAL FINDINGS A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis TUBES AND DRAINS A 10 French silicone Foley catheter with 3 mL in balloon and a 4 7 French ureteral double J stent multilength INDICATIONS FOR OPERATION The patient is a 3 1 2 year old boy who has a solitary left kidney with renal insufficiency with creatinine of 1 2 who has had a ureteropelvic junction repair performed by Dr Chang It was subsequently obstructed with multiple episodes of pyelonephritis two percutaneous tube placements ureteroscopy with balloon dilation of the system and continued obstruction Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction DESCRIPTION OF OPERATION The patient was taken to the operative room Surgical consent operative site and patient identification were verified Dr X and Dr Y both agreed upon the procedures in advance Dr Y then once the patient was anesthetized requested IV antibiotics with Fortaz the patient had a caudal block placed and he was then placed in lithotomy position Dr Y then calibrated the urethra with the bougie a boule to 8 10 and up to 12 French The 9 5 French cystoscope sheath was then placed within the patient s bladder with the offset scope and his bladder had no evidence of cystitis I was able to locate the ureteral orifice bilaterally although no urine coming from the right We then placed a 4 French ureteral catheter into the ureter as far as we could go An antegrade nephrostogram was then performed which shows that the contrast filled the dilated pelvis but did not go into the ureter A retrograde was performed and it was found that there was a narrowed band across the two Upon draining the ureter allowing to drain to gravity the pelvis which had been clamped and its nephrostomy tube did not drain at all Dr Y then placed a 0 035 guidewire into the ureter after removing the 4 French catheter and then placed a 4 7 French double J catheter into the ureter as far as it would go allowing it to coil in the bladder Once this was completed we then removed the cystoscope and sheath placed a 10 French Foley catheter and the patient was positioned by Dr X and Dr Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll He was then sterilely prepped and draped Dr Y then incised the skin with a 15 blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr X performed cautery of the areas advanced to be excised Once this was then dissected Dr Y and Dr X divided the lumbosacral fascia at the latissimus dorsi fascia posterior dorsal lumbotomy maneuver using the electrocautery and then using curved mosquito clamps __________ At this point Dr X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia Dr Y then used the curved right angle clamp and dissected around towards the ureter which was markedly adherent to the base of the retroperitoneum Dr X and Dr Y also needed dissection on the medial and lateral aspects with Dr Y being on the lateral aspect of the area and Dr X on the medial to get an adequate length of this The tissue was markedly inflamed and had significant adhesions noted The patient s spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction Ultimately Dr Y and Dr X both with alternating dissection were able to dissect the renal pelvis to a position where Dr Y put stay sutures and a 4 0 chromic to isolate the four quadrant area where we replaced the ureter Dr X then divided the ureter and suture ligated the base which was obstructed with a 3 0 chromic suture Dr Y then spatulated the ureter for about 1 5 cm and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder Dr Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed Dr Y then placed interrupted sutures of 5 0 Monocryl at the apex to repair the most dependent portion of the renal pelvis entered the lateral aspect interrupted sutures of the repair Dr X then was able to without much difficulty do interrupted sutures on the medial aspect The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr Y and Dr X closed the ureteropelvic junction without any evidence of leakage Once this was complete we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position This opening was at least 1 5 cm wide Dr Y then placed 2 stay sutures of 2 0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15 blade knife and curved iris scissors for renal biopsy for determination of renal tissue health Electrocautery was used on the base There was no bleeding however and the tissue was quite soft Dermabond and Gelfoam were placed and then Dr Y closed the biopsy site over with thrombin Gelfoam using the 2 0 chromic stay sutures Dr X then closed the fascial layers with running suture of 3 0 Vicryl in 3 layers Dr Y closed the Scarpa fascia and the skin with 4 0 Vicryl and 4 0 Rapide respectively A 4 0 nylon suture was then placed by Dr Y around the previous nephrostomy tube which was again left clamped Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr Y over the nephrostomy tube site which was left clamped and the patient then had a Foley catheter placed in the bladder The Foley catheter was then taped to his leg A second caudal block was placed for anesthesia and he is in stable condition upon transfer to recovery room Keywords surgery cystoscopy pyeloureteroscopy ureteropelvic junction obstruction pseudomonas pyelonephritis renal insufficiency fortaz ureteropelvic junction repair nephrostomy tube renal biopsy renal pelvis foley catheter ureteropelvic junction renal ureteropelvic MEDICAL_TRANSCRIPTION,Description Radical vulvectomy complete bilateral inguinal lymphadenectomy superficial and deep Medical Specialty Surgery Sample Name Radical Vulvectomy Transcription PREOPERATIVE DIAGNOSIS Clinical stage III squamous cell carcinoma of the vulva POSTOPERATIVE DIAGNOSIS Clinical stage III squamous cell carcinoma of the vulva OPERATION PERFORMED Radical vulvectomy complete bilateral inguinal lymphadenectomy superficial and deep ANESTHESIA General endotracheal tube SPECIMENS Radical vulvectomy right and left superficial and deep inguinal lymph nodes INDICATIONS FOR PROCEDURE The patient recently presented with a new vaginal nodule Biopsy was obtained and revealed squamous carcinoma The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3 Nx Mx on clinical examination Of note past history is significant for pelvic radiation for cervical cancer many years previously FINDINGS The examination under anesthesia revealed a 1 5 cm nodule of disease extending slightly above the hymeneal ring There was no palpable lymphadenopathy in either inguinal node region There were no other nodules ulcerations or other lesions At the completion of the procedure there was no clinical evidence of residual disease PROCEDURE The patient was brought to the Operating Room with an IV in place She was placed in the low anterior lithotomy position after adequate anesthesia had been induced Examination under anesthesia was performed with findings as noted after which she was prepped and draped The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament Camper s fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial The cribriform fascia was isolated and dissected with preservation of the femoral nerve The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments The medial lymph node bundle was isolated and Cloquet s node was clamped divided and ligated bilaterally The saphenous vessels were identified and preserved bilaterally The inferior margin of the specimen was ligated divided and removed Inguinal node sites were irrigated and excellent hemostasis was noted Jackson Pratt drains were placed and Camper s fascia was approximated with simple interrupted stitches The skin was closed with running subcuticular stitches using 4 0 Monocryl suture Attention was turned to the radical vulvectomy specimen A marking pen was used to outline the margins of resection allowing 15 20 mm of margin on the inferior lateral and anterior margins The medial margin extended into the vagina and was approximately 5 8 mm The skin was incised and underlying adipose tissue was divided with electrocautery Vascular bundles were isolated divided and ligated After removal of the specimen additional margin was obtained from the right vaginal side wall adjacent to the tumor site Margins were submitted on the right posterior middle and anterior vaginal side walls After removal of the vaginal margins the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2 0 Vicryl suture The skin was closed with interrupted horizontal mattress stitches using 3 0 Vicryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords surgery squamous cell carcinoma vulvectomy radical vulvectomy bilateral inguinal lymphadenectomy hymeneal ring camper s fascia carcinoma of the vulva inguinal lymphadenectomy lymph nodes inguinal vulva squamous carcinoma radical lymphadenectomy fascia vaginal nodes MEDICAL_TRANSCRIPTION,Description Worrisome skin lesion A punch biopsy of the worrisome skin lesion was obtained Lesion was removed Medical Specialty Surgery Sample Name Punch Biopsy 2 Transcription PREOPERATIVE DIAGNOSIS Worrisome skin lesion left hand POSTPROCEDURE DIAGNOSIS Worrisome skin lesion left hand PROCEDURE The patient gave informed consent for his procedure After informed consent was obtained attention was turned toward the area of interest which was prepped and draped in the usual sterile fashion Local anesthetic medication was infiltrated around and into the area of interest There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included The predominant portion of the biopsy was of the lesion itself Lesion was removed Attention was turned toward the area Pressure was held and the area was hemostatic The skin and the area were closed with 5 0 nylon suture All counts were correct The procedure was closed A sterile dressing was applied There were no complications The patient had no neurovascular deficits etc after this minor punch biopsy procedure Keywords surgery skin lesion squamous cell carcinoma punch biopsy MEDICAL_TRANSCRIPTION,Description Pulmonary valve stenosis supple pulmonic narrowing and static encephalopathy Medical Specialty Surgery Sample Name Pulmonary Valve Stenosis Transcription HISTORY The patient is a 19 year old boy with a membranous pulmonary atresia underwent initial repair 12 04 1987 consisting of pulmonary valvotomy and placement of 4 mm Gore Tex shunt between the ascending aorta and pulmonary artery with a snare This was complicated by shunt thrombosis __________ utilizing a 10 mm balloon Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy On 04 07 1988 he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10 mm balloon He has been followed conservatively since that time A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg Right coronary artery to pulmonary artery fistula was also appreciated The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair PROCEDURE The patient was placed under general endotracheal anesthesia breathing on 30 oxygen throughout the case Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a 7 French sheath a 6 French wedge catheter was inserted The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries This catheter was then exchanged over wire for a 5 French marker pigtail catheter which was directed into the main pulmonary artery Using a 5 French sheath a 5 French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta ascending aorta and left ventricle This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the recovery room in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was normal with no evidence of intracardiac shunt Left sided heart was fully saturated Phasic right atrial pressures were normal with an A wave similar to the normal right ventricular end diastolic pressure Right ventricular systolic pressure was mildly elevated at 45 systemic level There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries Phasic branch pulmonary artery pressures were normal Right to left pulmonary artery capillary wedge pressures were normal with an A wave similar to the normal left ventricular end diastolic pressure of 12 mmHg Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta Phasic ascending and descending pressures were similar and normal The calculated systemic and pulmonary flows were equal and normal Vascular resistances were normal Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus The pulmonary valve appeared to be thin and moved well The median branch pulmonary arteries were of good size with normal distal arborization Angiogram with contrast injection in the right coronary artery showed a non dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery INITIAL DIAGNOSES 1 Membranous pulmonary atresia 2 Atrial septal defect 3 Right coronary artery to pulmonary artery fistula SURGERIES INTERVENTIONS 1 Pulmonary valvotomy surgical 2 Aortopulmonary artery central shunt 3 Balloon pulmonary valvuloplasty CURRENT DIAGNOSES 1 Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus 2 Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing 3 Small right coronary artery to main pulmonary fistula 4 Static encephalopathy 5 Cerebral palsy MANAGEMENT The case to be discussed with combined Cardiology Cardiothoracic Surgery case conference Given the mild degree of outflow tract obstruction in this sedentary patient aggressive intervention is not indicated Conservative outpatient management is to be recommended Further patient care will be directed by Dr X Keywords surgery membranous pulmonary atresia atrial septal defect pulmonary artery fistula pulmonary valvotomy central shunt pulmonary valvuloplasty static encephalopathy cerebral palsy hypoplastic pulmonary annulus pulmonary valve stenosis outflow tract obstruction ventricular systolic pressure branch pulmonary arteries systolic pressure pulmonary arteries pulmonary valve branch pulmonary coronary artery catheterization artery pulmonary pressures coronary MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy radical hysterectomy bilateral ovarian transposition pelvic and obturator lymphadenectomy Medical Specialty Surgery Sample Name Radical Hysterectomy Transcription PREOPERATIVE DIAGNOSIS Cervical adenocarcinoma stage I POSTOPERATIVE DIAGNOSIS Cervical adenocarcinoma stage I OPERATION PERFORMED Exploratory laparotomy radical hysterectomy bilateral ovarian transposition pelvic and obturator lymphadenectomy ANESTHESIA General endotracheal tube SPECIMENS Uterus with attached parametrium and upper vagina right and left pelvic and obturator lymph nodes INDICATIONS FOR PROCEDURE The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended FINDINGS During the examination under anesthesia the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments During the exploratory laparotomy there was no evidence of disease extension into the broad ligament or bladder flap There was no evidence of intraperitoneal spread or lymphadenopathy OPERATIVE PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthetic was administered after which she was examined under anesthesia The vagina was then prepped and a Foley catheter was placed She was prepped and draped A Pfannenstiel incision was made three centimeters above the symphysis pubis The peritoneum was entered and the abdomen was explored with findings as noted The Bookwalter retractor was placed and bowel was packed Clamps were placed on the broad ligament for traction The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments The round ligaments were isolated divided and ligated The peritoneum overlying the vesicouterine fold was incised and the bladder was mobilized using sharp dissection The pararectal and paravesical spaces were opened and the broad ligament was palpated with no evidence of suspicious findings or disease extension The utero ovarian ligaments were then isolated divided and doubly ligated Tubes and ovaries were mobilized The ureters were dissected free from the medial leaf of the peritoneum When the crossover of the uterine artery was reached and the artery was isolated at its origin divided and ligated The uterine artery pedicle was dissected anteriorly over the ureter The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated This was continued until the insertion point of the ureter into the bladder trigone The peritoneum across the cul de sac was divided and the rectovaginal space was opened Clamps were placed on the uterosacral ligaments at their point of origin Tissues were divided and suture ligated Clamps were placed on the paravaginal tissues which were then divided and suture ligated The vagina was then clamped and divided at the junction between the middle and upper third The vaginal vault was closed with interrupted figure of eight stitches Excellent hemostasis was noted Retractors were repositioned in the retroperitoneum for the lymphadenectomy The borders of dissection included the bifurcation of the common iliac artery superiorly the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly the psoas muscle laterally and the anterior division of the hypogastric artery medially The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection Ligaclips were applied where necessary After removal of the lymph node specimens the pelvis was irrigated The ovaries were transposed above the pelvic brim using running stitches Packs and retractors were removed and peritoneum was closed with a running stitch Subcutaneous tissues were irrigated and fascia was closed with a running mass stitch using delayed absorbable suture Subcutaneous adipose was irrigated and Scarpa s fascia was closed with a running stitch Skin was closed with a running subcuticular stitch Final sponge needle and instrument counts were correct at the completion of the procedure The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords surgery cervical adenocarcinoma radical hysterectomy exploratory laparotomy bilateral ovarian transposition lymphadenectomy parametrium cervix pelvic and obturator lymphadenectomy pelvic and obturator obturator lymphadenectomy laparotomy ovarian adenocarcinoma radical hysterectomy pelvic obturator peritoneum nodes ligaments MEDICAL_TRANSCRIPTION,Description Right ureteropelvic junction obstruction Robotic assisted pyeloplasty anterograde right ureteral stent placement transposition of anterior crossing vessels on the right and nephrolithotomy Medical Specialty Surgery Sample Name Pyeloplasty Robotic Transcription PROCEDURES 1 Robotic assisted pyeloplasty 2 Anterograde right ureteral stent placement 3 Transposition of anterior crossing vessels on the right 4 Nephrolithotomy DIAGNOSIS Right ureteropelvic junction obstruction DRAINS 1 Jackson Pratt drain times one from the right flank 2 Foley catheter times one ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None SPECIMENS 1 Renal pelvis 2 Kidney stones INDICATIONS The patient is a 30 year old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries Up on consideration of various modalities and therapy the patient decided to undergo surgical therapy PROCEDURE IN DETAIL The patient was verified by armband and the procedure being robotic assisted right pyeloplasty with nephrolithotomy was verified and the procedure was carried out After institution of general endotracheal anesthesia and intravenous preoperative antibiotics the patient was positioned into the right flank position with his right flank elevated Great care was taken to pad all pressure points and a right arm hanger was used The patient was flexed slightly and a kidney rest was used Sequential compression devices were also placed Next the patient was prepped and draped in normal sterile fashion with povidone iodine Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test A low pressure high flow pneumoperitoneum was adequately obtained using CO2 gas Next a 12 mm camera port was placed near the umbilicus The camera was inserted and no bowel injury was seen Next under direct vision flanking 8 mm camera ports a 12 mm assist port a 5 mm liver retraction port and 5 mm assist port were placed The robot was docked and the instruments passed through respective checks Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially Next the right lateral duodenum was cauterized for further access to the right retroperitoneum At this point the right kidney was in clear view and the fascia was entered Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole These arteries were dissected carefully and vessel loops were applied Next a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out The pyelotomy was extended so that the renal collecting system could be directly inspected Sequentially each major calyx was inspected under direct vision and irrigated A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient At this point we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis The proximal ureter was spatulated using cold scissors Next redundant renal pelvis was excised using cold scissors and sent for permanent section We then identified the most inferior dependent portion of the renal pelvis and placed a heel stitch at this for ureteral renal pelvis anastomosis in a semi running fashion 3 0 Monocryl sutures were used to re anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis Next remainder of the pyelotomy was closed to itself also using 2 0 Monocryl sutures Before final stitches were placed a 6x28 ureteral stent was placed anterograde This was accomplished by placing the stents over a guidewire placing the guidewire under direct vision anterograde through the ureter This was done until the proximal end was in the renal pelvis the guidewire was removed and good proximal curl was verified by direct vision Then the pyelotomy was completely closed again with 2 0 Monocryl sutures Next attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis Good pulsation was verified by direct vision proximal and distal to these pexy sutures Next Gerota s fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum Hemostasis appeared excellent at this point There was no obvious urine extravasation At this time the procedure was terminated The robot was undocked Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion Then all skin port sites were closed with 4 0 Monocryl in a subcuticular fashion and Dermabond and band aids were applied over this Also notably a Jackson Pratt drain was placed in the area of the right kidney and additional right flank stab incision The patient tolerated the procedure well and no immediate perioperative complication was noted DISPOSITION The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery Keywords surgery pyeloplasty ureteral stent placement nephrolithotomy ureteropelvic junction obstruction jackson pratt drain foley catheter renal pelvis kidney stones monocryl sutures pelvis renal ureteropelvic sutures MEDICAL_TRANSCRIPTION,Description Punch biopsy of right upper chest skin lesion Medical Specialty Surgery Sample Name Punch Biopsy 1 Transcription PROCEDURE Punch biopsy of right upper chest skin lesion ESTIMATED BLOOD LOSS Minimal FLUIDS Minimal COMPLICATIONS None PROCEDURE The area around the lesion was anesthetized after she gave consent for her procedure Punch biopsy including some portion of lesion and normal tissue was performed Hemostasis was completed with pressure holding The biopsy site was approximated with non dissolvable suture The area was hemostatic All counts were correct and there were no complications The patient tolerated the procedure well She will see us back in approximately five days Keywords surgery punch biopsy skin lesion MEDICAL_TRANSCRIPTION,Description Macular edema right eye Insertion of radioactive plaque right eye with lateral canthotomy The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5 0 Dacron The placement was confirmed with indirect ophthalmoscopy Medical Specialty Surgery Sample Name Radioactive Plaque Insertion Transcription PREOPERATIVE DIAGNOSIS Macular edema right eye POSTOPERATIVE DIAGNOSIS Macular edema right eye TITLE OF OPERATION Insertion of radioactive plaque right eye with lateral canthotomy OPERATIVE PROCEDURE IN DETAIL The patient was prepped and draped in the usual manner for a local eye procedure Initially a 5 cc retrobulbar injection of 2 Xylocaine was done Then a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus A 2 0 silk traction suture was placed around the insertion of the lateral rectus muscle and with gentle traction the temporal one half of the globe was exposed The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5 0 Dacron The placement was confirmed with indirect ophthalmoscopy Next the eye was irrigated with Neosporin and the conjunctiva was closed with 6 0 plain catgut The intraocular pressure was found to be within normal limits An eye patch was applied and the patient was sent to the Recovery Room in good condition A lateral canthotomy had been done Keywords surgery canthotomy ophthalmoscopy radioactive plaque scleral surface macular edema lateral canthotomy macular MEDICAL_TRANSCRIPTION,Description Radical retropubic prostatectomy robotic assisted and bladder suspension Adenocarcinoma of the prostate Medical Specialty Surgery Sample Name Prostatectomy Robotic Radical Retropubic Transcription PREOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate POSTOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate PROCEDURE 1 Radical retropubic prostatectomy robotic assisted 2 Bladder suspension ANESTHESIA General by intubation The patient understands his diagnosis grade stage and prognosis He understands this procedure options to it and potential benefits from it He strongly wishes to proceed He accepts all treatment associated risks to include but not be limited to bleeding requiring transfusion infection sepsis heart attack stroke bladder neck contractures need to convert to an open procedure urinary fistulae impotence incontinence injury to bowel rectum bladder ureters etc small bowel obstruction abdominal hernia osteitis pubis chronic pelvic pain etc DESCRIPTION OF THE CASE The patient was taken to the operating room given a successful general anesthetic placed in the lithotomy position prepped with Betadine solutions and draped in the usual sterile fashion My camera ports were then placed in the standard fan array A camera port was placed in the midline above the umbilicus using the Hasson technique The balloon port was placed the abdomen insufflated and all other ports were placed under direct vision My assistant was on the right The patient was then placed in the steep Trendelenburg position and the robot brought forward and appropriately docked I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis This nicely exposed the space of Retzius I then defatted the anterior surface of the prostate and endopelvic fascia The endopelvic fascia was then opened bilaterally The levator ani muscles were carefully dissected free from the prostate and pushed laterally Dissection was continued posteriorly toward the bundles and caudally to the apex The puboprostatic ligaments were then transected A secure ligature of 0 Vicryl was placed around the dorsal venous complex I then approached the bladder neck The anterior bladder neck was transected down to the level of the Foley catheter which was lifted anteriorly in the wound I then transected the posterior bladder neck down to the level of the ampullae of the vas The ampullae were mobilized and transected These were lifted anteriorly in the field exposing the seminal vesicles which were similarly mobilized Hemostasis was obtained using the bipolar Bovie I then identified the Denonvilliers fascia and this was incised sharply Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles I was able to then identify the pedicles over the seminal vesicles which were hemoclipped and transected The field was then copiously irrigated with sterile water Hemostasis was found to be complete I then carried out a urethrovesical anastomosis This was accomplished with 3 0 Monocryl ligatures Two of these were tied together in the midline They were placed at the 6 o clock position and one was run in a clockwise and the other in a counterclockwise direction to the 12 o clock position where they were securely tied A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation The patient was given indigo carmine and there was prompt blue urine in the Foley I then carried out a bladder suspension This was done in hopes of obtaining early urinary control This was accomplished with 0 Vicryl ligatures One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis This nicely re retroperitonealized the bladder The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision A JP drain was brought in through the 4th arm port and sutured to the skin with 2 0 silk The camera port fascia was closed with running 0 Vicryl The skin incisions were closed with a running subcuticular 4 0 Monocryl The patient tolerated the procedure very well There were no complications Sponge and instrument counts were reported correct at the end of the case Keywords surgery adenocarcinoma prostate radical retropubic prostatectomy robotic assisted bladder uspension bladder neck intubation robotic retropubic prostatectomy MEDICAL_TRANSCRIPTION,Description Open radical retropubic prostatectomy with bilateral lymph node dissection Medical Specialty Surgery Sample Name Prostatectomy Transcription PREOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4 3 with 85 burden and 8 12 cores positive POSTOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4 3 with 85 burden and 8 12 cores positive PROCEDURE DONE Open radical retropubic prostatectomy with bilateral lymph node dissection INDICATIONS This is a 66 year old gentleman who had an elevated PSA of 5 His previous PSAs were in the 1 range TRUS biopsy revealed 4 3 Gleason score prostate cancer with a large tumor burden After extensive counseling the patient elected for retropubic radical prostatectomy Given his disease burden it was advised that an open prostatectomy is probably the standard of care to ensure entire excision The patient consented and agreed to proceed forward DESCRIPTION OF PROCEDURE The patient was brought to the operating room here Time out was taken to properly identify the patient and procedure going to be done General anesthesia was induced The patient was placed in the supine position The bed was flexed distant to the pubic area The patient s lower abdominal area pubic area and penile and scrotal area were clipped and then scrubbed with Hibiclens soap for three minutes The patient was then prepped and draped in normal sterile fashion Foley catheter was inserted sterilely in the field Preoperative antibiotics were given within 30 minutes of skin incision A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus Dissection was taken down through Scarpa s fascia to the level of the anterior rectus sheath The rectus sheath was then incised and the muscle was split in the middle Space of rectus sheath was then entered The Bookwalter ring was then applied to the belly and the bladder was then retracted to the right side thus exposing the left obturator area The lymph node packet on the left side was then dissected This was done in a split and roll fashion with the flimsy tissue and the left external iliac vein was incised and the tissues were then rolled over the left external iliac vein Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally Care was taken to avoid injury to the nerves An accessory obturator vein was noted and was ligated The same procedure was done on the right side with dissection of the right obturator lymph node packet which was sent for pathologic evaluation The bladder subsequently was retracted cephalad The prostate was then defatted up to the level of the endopelvic fascia The endopelvic fascia was then incised bilaterally and the incision was then taken to the level of the puboprostatic ligaments Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders A Babcock was then applied around the dorsal venous complex over the urethra and the K wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle A 0 Vicryl stitch was then applied over the dorsal venous complex which was then tied down and cinched to the symphysis pubis Using a knife on a long handle the dorsal venous complex was then incised using the K wire as a guide Following the incision of the dorsal venous complex the anterior urethra was then incised thus exposing the Foley catheter The 3 0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra The lateral edges of the urethra were also then incised and two lateral stitches were also applied going outside end The catheter was then drawn back at the level of membranous urethra and a final posterior stitch was applied going outside end The urethra was subsequently divided in its entirety A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex The prostate was then entered cephalad and the prostatic pedicles were then systematically taken down with the right angle clips and cut Please note that throughout the case the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex pelvic veins and extensive vascularity that was noted in the patient s pelvic fatty tissue Throughout the case the bleeding was controlled with the aid of a clips Vicryl sutures silk sutures and ties direct pressure packing and FloSeal Following the excision of the prostatic pedicles the posterior dissection at this point was almost complete Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers fascia The seminal vesicle on the left side was dissected in its entirety however the seminal vesicle on the right side was adherently stuck to the Denonvilliers fascia which prompted the excision of most of the right seminal vesicle with the exception of the tip Care was taken throughout the posterior dissection to preserve the integrity of the ureters The anterior bladder neck was then cut anteriorly and the bladder neck was separated from the prostate Following the dissection the 5 French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity Following the dissection of the bladder from the prostate the prostate at this point was mobile and was sent for pathological evaluation The bladder neck was then repaired using Vicryl in a tennis racquet fashion The rest of the mucosa was then everted The ureteral orifices and ureters were protected throughout the procedure At this point the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position Hemostasis was then adequately obtained FloSeal was applied to the pelvis The bladder was then irrigated It was draining pink urine The wound was copiously irrigated The fascia was then closed using a 1 looped PDS The skin wound was then irrigated and the skin was closed with a 4 0 Monocryl in subcuticular fashion At this point the procedure was terminated with no complications The patient was then extubated in the operating room and taken in stable condition to the PACU Please note that during the case about 3600 mL of blood was noted This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation Keywords surgery bilateral lymph node dissection retropubic prostatectomy radical retropubic prostatectomy gleason score prostate cancer trus biopsy bilateral lymph node lymph node dissection catheter was inserted bilateral lymph node dissection vicryl stitch prostatic pedicles pelvic veins external iliac iliac vein seminal vesicle lymph node foley catheter dorsal venous venous complex bladder neck dissection prostatectomy bladder endopelvic vicryl catheter vein venous fascia dorsal urethra MEDICAL_TRANSCRIPTION,Description Radical retropubic nerve sparing prostatectomy without lymph node dissection Medical Specialty Surgery Sample Name Prostatectomy Nerve Sparing Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATION PERFORMED Radical retropubic nerve sparing prostatectomy without lymph node dissection ESTIMATED BLOOD LOSS 450 mL REPLACEMENT 250 mL of Cell Saver and crystalloid COMPLICATIONS None INDICATIONS OF SURGERY This is a 67 year old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate Due to him being healthy with no comorbid conditions he has elected to undergo surgical treatment with radical retropubic prostatectomy Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Injury to the adjacent viscera 6 Deep venous thrombosis PROCEDURE IN DETAIL Prophylactic antibiotic was given in the preoperative holding area after which the patient was transferred to the operating room Epidural anesthesia and general endotracheal anesthesia were administered by Dr A without any difficulty The patient was shaved prepped and draped using the usual sterile technique A sterile 16 French Foley catheter was then placed with clear urine drained A midline infraumbilical incision was performed by using a 10 scalpel blade The rectus fascia and the subcutaneous space were opened by using the Bovie Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly A Bookwalter retractor was then placed The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected Given this patient s low Gleason score and low PSA with a solitary core biopsy positive the decision was made to not perform bilateral lymphadenectomy The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors Opening was enlarged by using sharp dissection Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device The dorsal aspect of the prostate was bunched up by using 2 0 silk sutures The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure of eight fashion With the prostate retracted cephalad the deep dorsal vein complex was transected superficially using the Bovie Deeper near the urethra the dorsal vein complex was transected by using Metzenbaum scissors The urethra could then be easily identified Nearly two third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors This exposed the blue Foley catheter Anastomotic sutures were then placed on to the urethral stump using 2 0 Monocryl suture Six of these were placed evenly spaced out anteriorly to posteriorly The Foley catheter was then removed This allowed for better traction of the prostate laterally Lateral pelvic fascia was opened bilaterally This effectively released the neurovascular bundle from the apex to the base of the prostate Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat The prostate was then dissected from laterally to medially from this opening in the perirectal fat The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate Maximal length of ureteral stump was preserved The prostate was carefully lifted cephalad by using gentle traction with fine forceps The prostate was easily dissected off the perirectal fat using sharp dissection only Absolutely no traction to the neurovascular bundle was evident at any point in time The dissection was carried out easily until the seminal vesicles could be visualized The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side The bladder neck was then dissected out by using a bladder neck dissection method Unfortunately most of the bladder neck fiber could not be preserved due to the patient s anatomy Once the prostate had been separated from the bladder in the area with the bladder neck dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles This was developed without any difficulty Both vas deferens were identified hemoclipped and transected The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off as it extended quite deeply into the pelvis About two thirds of the seminal vesicles were able to be removed The tip was left behind Using the bipolar Gyrus coagulation device the seminal vesicles were clamped at the tip sealed by cautery and then transected This was performed on the left side and then the right side This completely freed the prostate The prostate was sent for permanent section The opening in the bladder neck was reduced by using two separate 2 0 Vicryl sutures The mucosa of the bladder neck was everted by using 4 0 chromic sutures Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck This was performed by using a French needle A 20 French Foley catheter was then inserted and the sutures were sequentially tied down A 15 mL of sterile water was inflated to balloon The bladder anastomosis to the urethra was performed without any difficulty A 19 French Blake Drain was placed in the left pelvis exiting the right inguinal region All instrument counts lap counts and latex were verified twice prior to the closure The rectus fascia was closed in running fashion using 1 PDS Subcutaneous space was closed by using 2 0 Vicryl sutures The skin was reapproximated by using metallic clips The patient tolerated the procedure well and was transferred to the recovery room in stable condition Keywords surgery prostate cancer foley catheter gleason psa prostate adenocarcinoma bladder neck core biopsy figure of eight lymph node dissection nerve sparing prostatectomy rectus fascia retropubic bladder neck dissection dorsal vein complex nerve sparing perirectal fat seminal vesicles sutures bladder urethra posteriorly seminal vesicles fascia neck dissection MEDICAL_TRANSCRIPTION,Description Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer Medical Specialty Surgery Sample Name Prostatectomy Radical Retropubic Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATIVE PROCEDURE Radical retropubic prostatectomy with pelvic lymph node dissection ANESTHESIA General epidural ESTIMATED BLOOD LOSS 800 cc COMPLICATIONS None INDICATIONS FOR SURGERY This is a 64 year old man with adenocarcinoma of the prostate confirmed by needle biopsies He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Incontinence 4 Impotence 5 Deep venous thrombosis 6 Recurrence of the cancer PROCEDURE IN DETAIL Epidural anesthesia was administered by the anesthesiologist in the holding area Preoperative antibiotic was also given in the preoperative holding area The patient was then taken into the operating room after which general LMA anesthesia was administered The patient was shaved and then prepped using Betadine solution A sterile 16 French Foley catheter was inserted into the bladder with clear urine drain A midline infraumbilical incision was performed The rectus fascia was opened sharply The perivesical space and the retropubic space were developed bluntly Bookwalter retractor was then placed Bilateral obturator pelvic lymphadenectomy was performed The obturator nerve was identified and was untouched The margin for the resection of the lymph node bilaterally were the Cooper s ligament the medial edge of the external iliac artery the bifurcation of the common iliac vein the obturator nerve and the bladder Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips The lymph nodes were palpably normal and were set for permanent section The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors The puboprostatic ligament was taken down sharply The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2 0 silk sutures The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area The dorsal vein complex was ligated by using 0 Vicryl suture on a CT 1 needle The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors The urethra was then identified and was dissected out The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors This was extended circumferentially until the Foley catheter could be seen clearly 2 0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides The plane between Denonvilliers fascia and the perirectal fat was developed sharply No tension was placed on the neurovascular bundle at any point in time The prostate dissected off the rectal wall easily Once the seminal vesicles were identified the fascia covering over them were opened transversely The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected The bladder neck was then dissected out carefully to spare most of the bladder neck muscles Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen The specimen was inspected and appeared to be completely intact It was sent for permanent section The bladder neck mucosa was then everted by using 4 0 chromic sutures Inspection at the prostatic bed revealed no bleeding vessels The sutures which were placed previously onto the urethral stump were then placed onto the bladder neck Once the posterior sutures had been placed the Foley was placed into the urethra and into the bladder neck A 20 French Foley Catheter was used The anterior sutures were then placed The Foley was then inflated The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly Mild traction of the Foley catheter was placed to assure the anastomosis was tight Two 19 French Blake drains were placed in the perivesical spaces These were anchored to the skin by using 2 0 silk sutures The instrument counts lab counts and sponge counts were verified to be correct the patient was closed The fascia was closed in running fashion using 1 PDS Subcutaneous tissue was closed by using 2 0 Vicryl suture Skin was approximated by using metallic clips The patient tolerated the operation well Keywords surgery prostate cancer foley catheter metzenbaum scissors prostate adenocarcinoma bladder lymphadenectomy pelvic lymph node dissection perivesical prostatectomy retropubic urethra radical retropubic prostatectomy lymph node dissection dorsal vein complex radical retropubic lymph node dorsal vein vein complex bladder neck sutures foley urethral MEDICAL_TRANSCRIPTION,Description Insertion of a Port A Catheter via the left subclavian vein approach under fluoroscopic guidance in a patient with ovarian cancer Medical Specialty Surgery Sample Name Port A Cath Insertion 4 Transcription PREOPERATIVE DIAGNOSIS Ovarian cancer POSTOPERATIVE DIAGNOSIS Ovarian cancer OPERATION PERFORMED Insertion of a Port A Catheter via the left subclavian vein approach under fluoroscopic guidance DETAILED OPERATIVE NOTE The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port A Catheter The chest was prepped and draped in the routine fashion for insertion of a Port A Catheter The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance The needle was removed An incision was made over the guidewire for entrance of the dilator with sheath A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a 15 blade Hemostasis was effective to electrocautery and a pocket was fashioned subcutaneously for positioning of the reservoir The Port A Catheter reservoir tubing was attached to the reservoir in the routine fashion The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4 0 Prolene sutures for stability Next a catheter passer was passed from the pocket exiting through the skin at the puncture site previously placed for the guidewire and the Port A Catheter was pulled from the reservoir exiting on the skin It was placed on the chest measured and cut to the appropriate length This having been done the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance The guidewire and dilator were removed and the Port A Catheter was threaded through the sheath into the superior vena cava and the sheath removed under fluoroscopic guidance Fluoroscopy revealed the Port A Catheter to be in excellent position The Port A Catheter was accessed with a butterfly 90 degree needle percutaneously that drew blood well and flushed easily It was flushed with heparinized saline connected in cath This having been done the puncture site was closed with a circumferential subcutaneous 3 0 Vicryl suture and the skin was closed with a percutaneous circumferential subcuticular suture This having been done attention was applied to the reservoir incision It was closed with two layers of continuous 3 0 Vicryl suture and the skin was closed with a continuous 3 0 Monocryl subcuticular stitch A dry sterile dressing was applied and the patient having tolerated the procedure was transferred to the recovery room for postoperative care Keywords surgery ovarian cancer insertion port a catheter circumferential counter incision fluoroscopic fluoroscopic guidance guidewire subclavian superior vena cava port a catheter port catheter subcutaneously vein MEDICAL_TRANSCRIPTION,Description Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma Medical Specialty Surgery Sample Name Pterional Craniotomy Transcription PREOPERATIVE DIAGNOSIS Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm POSTOPERATIVE DIAGNOSIS Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm OPERATION Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma ANESTHESIA Endotracheal ESTIMATED BLOOD LOSS 250 mL REPLACEMENTS 3 units of packed cells DRAINS None COMPLICATIONS None PROCEDURE With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest turned 45 degrees to the patient s left and a small roll placed under her right shoulder and hip the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient s zygoma Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture attached with rubber bands and Allis clamps The bone flap which had not been fixed in place was removed An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool B1 attached to the Midas Rex instrumentation Further bone removal was accomplished with Leksell rongeur and hemostasis controlled with the use of bone wax At this point a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex The sylvian fissure was then dissected with the dissection description being dictated by Dr X Following successful splitting of the sylvian fissure to its apparent midplate attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of what appeared to be an aneurysm could be visualized Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm this was felt to be able to be handled with bipolar coagulation which was done and the vessel then cut with microscissors and the aneurysm removed in toto Attention was next turned to the apparent nidus of the arteriovenous malformation which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr X With removal of the arteriovenous malformation attention was then turned to the previous frontal cortical incision which was the site of partial decompression of the patient s intracerebral hematoma on the day of her admission Self retaining retractors were placed within this cortical incision and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation Following removal of additional hematoma the bed of the hematoma site was lined with Surgicel Irrigation revealed no further active bleeding and it was felt that at this time both the arteriovenous malformation associated aneurysm and intracerebral hematoma had been sequentially dealt with The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges the freeze dried fascia which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2 holed plate and 3 mm screws and the portable minidriver With this return of the inferior plate accomplished it was possible to reposition the bone flaps into their initial configuration and attachments were secured anterior and posterior with somewhat longer 2 holed plates and 3 mm screws to the frontal and posterior temporal parietal region The wound was then closed It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap The wound was then closed by approximating the temporalis muscle with 2 0 Vicryl suture the fascia was closed with 2 0 Vicryl suture and the galea was closed with 2 0 interrupted suture and the skin approximated with staples The patient appeared to tolerate the procedure well without complications Keywords surgery hemorrhage arteriovenous malformation aneurysm pterional craniotomy bone flap bipolar coagulation arteriovenous pterional malformation hematoma intracerebral MEDICAL_TRANSCRIPTION,Description Insertion of Port A Cath via left subclavian vein using fluoroscopy in a patient with renal cell carcinoma Medical Specialty Surgery Sample Name Port A Cath Insertion 3 Transcription TITLE OF PROCEDURE Insertion of Port A Cath via left subclavian vein using fluoroscopy PREOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma POSTOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma PROCEDURE IN DETAIL This is a 49 year old gentleman was referred by Dr A The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia He has developed recurrence with metastases to the lung and to bone The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere In the operating room under monitored anesthesia care with intravenous sedation the patient was prepped and draped suitably Lidocaine 1 with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty A J wire was guided into place under fluoroscopic control A 7 2 French vortex titanium Port A Cath was now anchored in the subcutaneous pocket made just below using 3 0 Prolene The attached catheter tunneled cut to the appropriate length and placed through the sheath that was then peeled away Fluoroscopy showed good catheter disposition in the superior vena cava The catheter was accessed with a butterfly Huber needle blood was aspirated easily and the system was then flushed using heparinized saline The pocket was irrigated using antibiotic saline and closed with absorbable suture The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr A s office later today for the commencement of chemotherapy There were no complications Keywords surgery port a cath french vortex huber metastatic permcath butterfly needle catheter fluoroscopy jugular nephrectomy renal cell carcinoma subclavian vein vena cava port a cath cell carcinoma insertion subclavian carcinoma port MEDICAL_TRANSCRIPTION,Description Insertion of subclavian dual port Port A Cath and surgeon interpreted fluoroscopy Medical Specialty Surgery Sample Name Port A Cath Insertion 5 Transcription PROCEDURES PERFORMED 1 Insertion of subclavian dual port Port A Cath 2 Surgeon interpreted fluoroscopy OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the chest was prepped and draped in a standard surgical fashion A 18 gauge spinal needle was used to aspirate blood from the subclavian vein After aspiration of venous blood Seldinger technique was used to thread a J wire The distal tip of the J wire was confirmed to be in adequate position with surgeon interpreted fluoroscopy Next a 15 blade scalpel was used to make an incision in the skin Dissection was carried down to the level of the pectoralis muscle A pocket was created A dual port Port A Cath was lowered into the pocket and secured with 2 0 Prolene Both ports were flushed The distal tip was pulled through to the wire exit site with a Kelly clamp It was cut to the appropriate length Next a dilator and sheath were threaded over the J wire The J wire and dilator were removed and the distal tip of the dual port Port A Cath was threaded over the sheath which was simultaneously withdrawn Both ports of the dual port Port A Cath were flushed and aspirated without difficulty The distal tip was confirmed to be in adequate position with surgeon interpreted fluoroscopy The wire access site was closed with a 4 0 Monocryl The port pocket was closed in 2 layers with 2 0 Vicryl followed by 4 0 Monocryl in a running subcuticular fashion Sterile dressing was applied The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords surgery surgeon interpreted fluoroscopy j wire dual port port a cath port a cath subclavian fluoroscopy cathNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right subclavian Port a Cath insertion in a patient with bilateral breast carcinoma Medical Specialty Surgery Sample Name Port A Cath Insertion 1 Transcription PREOPERATIVE DIAGNOSES 1 Bilateral breast carcinoma 2 Chemotherapy required POSTOPERATIVE DIAGNOSES 1 Bilateral breast carcinoma 2 Chemotherapy required OPERATION Right subclavian Port a Cath insertion FINDINGS AND PROCEDURE With the patient under satisfactory general orotracheal anesthesia and in the supine position the right upper anterior chest neck and arm were prepared with Betadine in the usual fashion The skin subcutaneous tissue and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0 5 Marcaine with epinephrine An incision transverse parallel and inferior to the middle third of the right clavicle was performed A subcutaneous pocket on the surface of the pectoralis major muscle was created The muscular fascia was also infiltrated with 0 5 Marcaine with epinephrine With the patient in the Trendelenburg position utilizing the provided introducer needle the right subclavian vein was cannulated A guidewire was passed without difficulty and the needle was removed Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium A dilator and sheath was passed over the guidewire The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava The catheter had been preflushed with dilute heparin solution 100 units mL The port which had been preflushed with saline was attached to the catheter at approximately 13 cm level The locking cap had been placed on the catheter The port was connected to the catheter and the locking cap was secured The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket Fluoroscopy again confirmed satisfactory position A hard copy of the fluoroscopy was obtained The catheter and port were secured to the pectoralis fascia in four locations with 2 0 Prolene suture Site was irrigated with saline Hemostasis was verified The subcutaneous tissue was approximated with interrupted 2 0 Vicryl suture The subcutaneous and dermis were closed with a running subcuticular 3 0 Vicryl suture A 0 25 inch Steri Strips were applied The provided needle and butterfly attachment was flushed with saline passed through the skin into the port and then flushed again with dilute heparin solution thus confirmed satisfactory The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4 s and paper tape Estimated blood loss was less than 15 mL The patient tolerated the procedure well and left the operating room in good condition Keywords surgery carcinoma bilateral breast carcinoma chemotherapy fluoroscopy port a cath catheter insertion pectoralis fascia subclavian subclavian port a cath port a cath insertion port a cath cath insertion heparin MEDICAL_TRANSCRIPTION,Description Bleeding after transanal excision five days ago Exam under anesthesia with control of bleeding via cautery The patient is a 42 year old gentleman who is five days out from transanal excision of a benign anterior base lesion He presents today with diarrhea and bleeding Medical Specialty Surgery Sample Name Postop Transanal Excision Transcription PREOPERATIVE DIAGNOSIS Bleeding after transanal excision five days ago POSTOPERATIVE DIAGNOSIS Bleeding after transanal excision five days ago PROCEDURE Exam under anesthesia with control of bleeding via cautery ANESTHESIA General endotracheal INDICATION The patient is a 42 year old gentleman who is five days out from transanal excision of a benign anterior base lesion He presents today with diarrhea and bleeding Digital exam reveals bright red blood on the finger He is for exam under anesthesia and control of hemorrhage at this time FINDINGS There was an ulcer where most of the polypoid lesion had been excised before In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa There were a few discrete sites of mild oozing which were treated with cautery and 1 suture No other obvious bleeding was seen TECHNIQUE The patient was taken to the operating room and placed on the operative table in supine position After adequate general anesthesia was induced the patient was then placed in modified prone position His buttocks were taped prepped and draped in a sterile fashion The anterior rectal wall was exposed using a Parks anal retractor The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well This was controlled with a 3 0 Monocryl figure of eight suture At the completion there was no bleeding no oozing it was completely dry and we removed our retractor and the patient was then turned and extubated and taken to the recovery room in stable condition Keywords surgery diarrhea anterior base lesion polypoid lesion transanal excision transanal anesthesia bleeding MEDICAL_TRANSCRIPTION,Description The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1 3rd region Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy Medical Specialty Surgery Sample Name Post Hemithyroidectomy Transcription PREOPERATIVE DIAGNOSES Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy POSTOPERATIVE DIAGNOSES Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy PROCEDURE The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1 3rd region FINDINGS Normal appearing thyroid gland with a possible lump in the inferior aspect there was a parathyroid gland that by frozen section _________ was not thyroid it was reimplanted to the left lower sternocleidomastoid region ESTIMATED BLOOD LOSS Approximately 10 mL FLUIDS Crystalloid only COMPLICATIONS None DRAINS Rubber band drain in the neck CONDITION Stable PROCEDURE The patient placed supine under general anesthesia First a shoulder roll was placed 1 lidocaine and 1 100 000 epinephrine was injected into the old scar natural skin fold and Betadine prep Sterile dressing was placed The laryngeal monitoring was noted to be working fine Then an incision was made in this area in a curvilinear fashion through the old scar taken through the fat and the platysma level The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid the thyroid gland was then found Then using bipolar cautery and a Coblation dissector the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally the thyroid gland was released then came into the Berry ligaments The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels which were crossed with the Harmonic scalpel and removed No bleeding was seen There was a small nick in the external jugular vein that was tied with a 4 0 Vicryl suture ligature After this was completed on examining the specimen there appeared to be a lobule on it and it was sent off as possibly parathyroid therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature After this was completed no bleeding was seen The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4 0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5 0 nylon was used to close the skin and Mastisol and Steri Strips were placed along the skin edges and then on awakening both laryngeal nerves were working normally Procedure was then terminated at that time Keywords surgery thyroid rubber band drain berry ligaments papillary carcinoma follicular variant strap muscles thyroid gland sternocleidomastoid parathyroid hemithyroidectomy MEDICAL_TRANSCRIPTION,Description Placement of a Port A Cath under fluoroscopic guidancein a patient with anal cancer Medical Specialty Surgery Sample Name Port A Cath Insertion 2 Transcription PREOPERATIVE DIAGNOSIS 1 Anal cancer 2 Need for IV access POSTOPERATIVE DIAGNOSIS 1 Anal cancer 2 Need for IV access OPERATIVE PROCEDURE 1 Placement of a Port A Cath 2 Fluoroscopic guidance ANESTHESIA General LMA ESTIMATED BLOOD LOSS Minimum IV FLUIDS Per anesthesia RECURRENT COMPLICATIONS None FINDINGS Good port placement on C arm INDICATIONS AND PROCEDURE IN DETAIL This is a 55 year old female who presents with anal cancer who is beginning chemoradiation and needs IV access for chemotherapy Risks and benefits of the procedure explained the patient appeared to understand and agreed to proceed The patient was taken to the operating room placed in supine position General LMA anesthesia was administered She is prepped and draped in the usual sterile fashion She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava The incision was then made around the guide wire taken to the subcutaneous tissues with electric Bovie cautery A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements The 2 0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3 0 Vicryl followed by running 4 0 Vicryl subcuticular stitch Heparin flush was used to flush the port Steri Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition All counts were reported as correct and I was present for the entire procedure Keywords surgery anal cancer fluoroscopic fluoroscopy iv access port a cath trendelenburg position chemotherapy subclavian vein port a cath subcutaneous tissues insertion subclavian MEDICAL_TRANSCRIPTION,Description Port insertion through the right subclavian vein percutaneously under radiological guidance Metastatic carcinoma of the bladder and bowel obstruction Medical Specialty Surgery Sample Name Port Insertion Transcription PREOPERATIVE DIAGNOSES 1 Metastatic carcinoma of the bladder 2 Bowel obstruction POSTOPERATIVE DIAGNOSES 1 Metastatic carcinoma of the bladder 2 Bowel obstruction PROCEDURE Port insertion through the right subclavian vein percutaneously under radiological guidance PROCEDURE DETAIL The patient was electively taken to the operating room after obtaining an informed consent A time out process was followed Antibiotics were given Then the patient s right deltopectoral area was prepped and draped in the usual fashion Xylocaine 1 was infiltrated The right subclavian vein was percutaneously cannulated without any difficulty Then using the Seldinger technique the catheter part of the port which was a single lumen port was passed through the introducer under x ray guidance and placed in the junction of the superior vena cava and the right atrium A pocket had been fashioned and a single lumen drum of the port was connected to the catheter which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl Then the fascia was closed using subcuticular suture of Monocryl The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away The patient tolerated the procedure well and was sent to recovery room in satisfactory condition A chest x ray was performed that showed that there were no complications of procedure and that the catheter was in right place Keywords surgery metastatic carcinoma of the bladder percutaneously subclavian vein port insertion metastatic carcinoma bowel obstruction catheter MEDICAL_TRANSCRIPTION,Description Port A Cath insertion template Catheter was inserted after subcutaneous pocket was created the sheath dilators were advanced and the wire and dilator were removed Medical Specialty Surgery Sample Name Port A Cath Insertion Transcription PROCEDURE PERFORMED Port A Cath insertion ANESTHESIA MAC COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL Patient was prepped and draped in sterile fashion The left subclavian vein was cannulated with a wire Fluoroscopic confirmation of the wire in appropriate position was performed Then catheter was inserted after subcutaneous pocket was created the sheath dilators were advanced and the wire and dilator were removed Once the catheter was advanced through the sheath the sheath was peeled away Catheter was left in place which was attached to hub placed in the subcutaneous pocket sewn in place with 2 0 silk sutures and then all hemostasis was further reconfirmed No hemorrhage was identified The port was in appropriate position with fluoroscopic confirmation The wound was closed in 2 layers the 1st layer being 3 0 Vicryl the 2nd layer being 4 0 Monocryl subcuticular stitch Dressed with Steri Strips and 4 x 4 s Port was checked Had good blood return flushed readily with heparinized saline Keywords surgery hemostasis port a cath insertion fluoroscopic confirmation cath insertion insertion fluoroscopic subcutaneous catheter sheath dilators wire MEDICAL_TRANSCRIPTION,Description Transnasal transsphenoidal approach in resection of pituitary tumor The patient is a 17 year old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor Medical Specialty Surgery Sample Name Pituitary Tumor Resection Transcription TITLE OF OPERATION Transnasal transsphenoidal approach in resection of pituitary tumor INDICATION FOR SURGERY The patient is a 17 year old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor She was started on Dostinex with increasing dosages The most recent MRI demonstrated an increased growth with hemorrhage This was then discontinued Most recent prolactin was at 70 although normalized the recommendation was surgical resection given the size of the sellar lesion All the risks benefits and alternatives were explained in great detail via translator PREOP DIAGNOSIS Pituitary tumor POSTOP DIAGNOSIS Pituitary tumor PROCEDURE DETAIL The patient brought to the operating room positioned on the horseshoe headrest in a neutral position supine The fluoroscope was then positioned The approach will be dictated by Dr X Once the operating microscope and the endoscope were then used to approach it through transnasal this was complicated and complex secondary to the drilling within the sinus Once this was ensured the tumor was identified separated from the pituitary gland it was isolated and then removed It appeared to be hemorrhagic and a necrotic pituitary several sections were sent Once this was ensured and completed and hemostasis obtained the wound was irrigated There might have been a small CSF leak with Valsalva so the recommendation was for a reconstruction Dr X will dictate The fat graft was harvested from the left lower quadrant and closed primarily this was soaked in fat and used to close the closure All sponge and needle counts were correct The patient was extubated and transported to the recovery room in stable condition Blood loss was minimal Keywords surgery transnasal transsphenoidal approach resection pituitary tumor transsphenoidal transnasal prolactin tumor pituitary MEDICAL_TRANSCRIPTION,Description Application of PMT large halo crown and vest Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion Medical Specialty Surgery Sample Name PMT Halo Crown Vest Transcription PREOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion POSTOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion and potentially unstable cervical spine OPERATIVE PROCEDURE Application of PMT large halo crown and vest ESTIMATED BLOOD LOSS None ANESTHESIA Local conscious sedation with Morphine and Versed COMPLICATIONS None Post fixation x rays nonalignment no new changes Post fixation neurologic examination normal CLINICAL HISTORY The patient is a 41 year old female who presented to me with severe cervical spondylosis and myelopathy She was referred to me by Dr X The patient underwent a complicated anterior cervical discectomy 2 level corpectomy spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate Surgery had gone well and the patient has done well in the last 2 days She is neurologically improved and is moving all four extremities No airway issues It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller She was consented for the procedure and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest The patient had this procedure done at the bedside in the SICU room 1 I used a combination of some morphine 1 mg and Versed 2 mg for this procedure I also used local anesthetic with 1 Xylocaine and epinephrine a total of 15 to 20 cc PROCEDURE DETAILS The patient s head was positioned on some towels the retroauricular region was shaved and the forehead and the posterolateral periauricular regions were prepped with Betadine A large PMT crown was brought in and fixed to the skull with pins under local anesthetic Excellent fixation achieved It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae I then put the vest on by sitting the patient up stabilizing her neck The vest was brought in from the front as well and connected Head was tilted appropriately slightly extended and in the midline All connections were secured and pins were torqued and tightened During the procedure the patient did fine with no significant pain Post procedure she is neurologically intact and she remained intact throughout X rays of the cervical spine AP lateral and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes The patient will be subjected to a CT scan to further define the alignment and barring any problems she will be ambulating with the halo on The patient will undergo pin site care as per protocol and likely she will go in the next 2 to 3 days Her prognosis indeed is excellent and she is already about 90 or so better from her surgery She is also on a short course of Decadron which we will wean off in due course The matter was discussed with the patient and the patient s family Keywords surgery cervical spondylosis anterior cervical discectomy corpectomy decompression fusion pmt crown vest pmt halo cervical MEDICAL_TRANSCRIPTION,Description Ultrasound guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea Medical Specialty Surgery Sample Name Pleurocentesis Transcription PREOPERATIVE DIAGNOSIS Right pleural effusion with respiratory failure and dyspnea POSTOPERATIVE DIAGNOSIS Right pleural effusion with respiratory failure and dyspnea PROCEDURE Ultrasound guided right pleurocentesis ANESTHESIA Local with lidocaine TECHNIQUE IN DETAIL After informed consent was obtained from the patient and his mother the chest was scanned with portable ultrasound Findings revealed a normal right hemidiaphragm a moderate right pleural effusion without septation or debris and no gliding sign of the lung on the right Using sterile technique and with ultrasound as a guide a pleural catheter was inserted and serosanguinous fluid was withdrawn a total of 1 L The patient tolerated the procedure well Portable x ray is pending Keywords surgery pleural effusion dyspnea gliding sign hemidiaphragm pleural catheter pleurocentesis respiratory serosanguinous fluid ultrasound pleural MEDICAL_TRANSCRIPTION,Description Closed reduction and pinning of the right ulna with placement of a long arm cast Medical Specialty Surgery Sample Name Pinning Ulna Transcription PREOPERATIVE DIAGNOSIS Right both bone forearm refracture POSTOPERATIVE DIAGNOSIS Right both bone forearm refracture PROCEDURE Closed reduction and pinning of the right ulna with placement of a long arm cast ANESTHESIA Surgery performed under general anesthesia Local anesthetic was 10 mL of 0 25 Marcaine plain COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HARDWARE Hardware was 0 79 K wire HISTORY AND PHYSICAL The patient is a 5 year old male who sustained refracture of his right forearm on 12 05 2007 The patient was seen in the emergency room The patient had a complete fracture of both bones with shortening bayonet apposition Treatment options were offered to the family including casting versus closed reduction and pinning The parents opted for the latter Risks and benefits of surgery were discussed Risks of surgery included risk of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure and need for later hardware removal cast tightness All questions were answered and the parents agreed to the above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was then administered The patient received Ancef preoperatively The right upper extremity was then prepped and draped in standard surgical fashion A small incision was made at the tip of the olecranon Initially a 1 11 guidewire was placed but this was noted to be too wide for this canal This was changed for a 0 79 K wire This was driven up to the fracture site The fracture was manually reduced and then the K wire passed through the distal segment This demonstrated adequate fixation and reduction of both bones The pin was then cut short The fracture site and pin site was infiltrated with 0 25 Marcaine The incision was closed using 4 0 Monocryl The wounds were cleaned and dried Dressed with Xeroform 4 x 4 The patient was then placed in a well moulded long arm cast He tolerated the procedure well He was subsequently taken to Recovery in stable condition POSTOPERATIVE PLAN The patient will be maintain current pin and long arm cast for 4 weeks at which time he will return for cast removal X rays of the right forearm will be taken The patient may need additional mobilization time Once the fracture has healed we will take the pin out usually at the earliest 3 to 4 months Intraoperative findings were relayed to the parents All questions were answered Keywords surgery closed reduction pinning forearm refracture fracture site arm cast MEDICAL_TRANSCRIPTION,Description Plantar fascitis left foot Partial plantar fasciotomy Medical Specialty Surgery Sample Name Plantar Fasciotomy Transcription PREOPERATIVE DIAGNOSIS Plantar fascitis left foot POSTOPERATIVE DIAGNOSIS Plantar fascitis left foot PROCEDURE PERFORMED Partial plantar fasciotomy left foot ANESTHESIA 10 cc of 0 5 Marcaine plain with TIVA HISTORY This 35 year old Caucasian female presents to ABCD General Hospital with above chief complaint The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long term relief of symptoms and desires surgical treatment The patient has been NPO since mid night Consent is signed and in the chart No known drug allergies Details Of Procedure An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 10 cc of 0 5 Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia The foot was then prepped and draped in the usual sterile orthopedic fashion An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg The foot was then reflected on the operating stockinet reflected and the foot cleansed with a wet and dry sponge Attention was then directed to the plantar medial aspect of the left heel An approximately 0 75 cm incision was then created in the plantar fat pad over the area of maximal tenderness The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated A 15 blade was then used to transect the medial and central bands of the plantar fascia Care was taken to preserve the lateral fibroids The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted The air was then flushed with copious amounts of sterile saline The skin incision was then closed with 3 0 nylon in simple interrupted fashion Dressings consisted of 0 1 silk 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot Intraoperatively an additional 80 cc of 1 lidocaine was injected for additional anesthesia in the case The patient is to be nonweightbearing on the left lower extremity with crutches The patient is given postoperative pain prescriptions for Vicodin ES one q3 4h p o p r n for pain as well as Celebrex 200 mg one p o b i d The patient is to follow up with Dr X as directed Keywords surgery foot plantar fasciotomy plantar fascitis plantar fascia plantar fasciotomy ankle medially fascitis fascia MEDICAL_TRANSCRIPTION,Description Chest tube talc pleurodesis of the right chest Medical Specialty Surgery Sample Name Pleurodesis Transcription PREOPERATIVE DIAGNOSIS Large recurrent right pleural effusion POSTOPERATIVE DIAGNOSIS Large recurrent right pleural effusion PROCEDURE 1 Conscious sedation 2 Chest tube talc pleurodesis of the right chest INDICATIONS The patient is a 65 year old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion Chest catheter had been placed previously and she had been draining up to 1 5 liters of serous fluid a day Eventually this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur SPECIMENS None ESTIMATED BLOOD LOSS Zero NARRATIVE After obtaining informed consent from the patient and her daughter the patient was assessed and found to be in good condition and a good candidate for conscious sedation Vital signs were taken These were stable so the patient was then given initially 0 5 mg of Versed and 2 mg of morphine IV After a couple of minutes she was assessed and found to be awake but calm so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped The patient was given additional 0 5 mg of Versed and 0 5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive The patient tolerated the procedure well She did complain of up to a 7 10 pain but quickly this was brought under control The chest tube was unclamped Now the patient will be left to rest and she will get a chest x ray in the morning Keywords surgery chest tube talc pleurodesis lateral decubitus position decubitus position talc pleurodesis pleural effusion chest tube chest pleurodesis talc recurrent pleural effusion tube MEDICAL_TRANSCRIPTION,Description Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus Medical Specialty Surgery Sample Name Pituitary Adenomectomy Transcription PREOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma POSTOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma OPERATION PERFORMED Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus harvesting of dermal fascia abdominal fat graft placement of abdominal fat graft into sella turcica reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm repair of nasal septal deviation using the operating microscope and microdissection technique and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion INDICATIONS FOR PROCEDURE This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor which is known to be an invasive pituitary adenoma He did not return for followup or radiotherapy as instructed and the tumor has regrown For this reason he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible The high risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him Many risks including CSF leak and blindness were discussed in detail After clear understanding of all the same he elected to proceed ahead with surgery PROCEDURE The patient was placed on the operating table and after adequate induction of general anesthesia he was placed in the left lateral decubitus position Care was taken to pad all pressure points appropriately The back was prepped and draped in usual sterile manner A 14 gauge Tuohy needle was introduced into the lumbar subarachnoid space Clear and colorless CSF issued forth A catheter was inserted to a distance of 40 cm and the needle was removed The catheter was then connected to a closed drainage system for aspiration and infusion This no touch technique is now a standard of care for treatment of patients with large invasive adenomas Via injections through the lumbar drain one increases intracranial pressure and produces gentle migration of the tumor This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus The patient was then placed supine and the 3 point headrest was affixed He was placed in the semi sitting position with the head turned to the right and a roll placed under the left shoulder Care was taken to pad all pressure points appropriately The fluoroscope C arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection The metallic arm was then connected to the table for the use of the endoscope The oropharynx nasopharynx and abdominal areas were then prepped and draped in the usual sterile manner A transverse incision was made in the abdominal region and several large pieces of fat were harvested for later use Hemostasis was obtained The wound was carefully closed in layers I then advanced a 0 degree endoscope up the left nostril The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium Needle Bovie electrocautery was used to clear mucosa away from the ostium The perpendicular plate of the ethmoid had already been separated from the sphenoid I entered into the sphenoid There was a tremendous amount of dense fibrous scar tissue present and I slowly and carefully worked through all this I identified a previous sellar opening and widely opened the bone which had largely regrown out to the cavernous sinus laterally on the left which was very well exposed and the cavernous sinus on the right which I exposed the very medial portion of The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present The operating microscope was then utilized Working under magnification I used hypophysectomy placed in the nostril The dura was then carefully opened in the midline and I immediately encountered tissue consistent with pituitary adenoma A frozen section was obtained which confirmed this diagnosis without malignant features Slowly and meticulously I worked to remove the tumor I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free The tumor was moderately vascular and very fibrotic Slowly and carefully I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right There appeared to be cavernous sinus invasion on the left It was consistent with what we saw on the MRI imaging The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter A large amount of this was removed There was a CSF leak as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free Under high magnification I actually worked up into this cavity and performed a very radical excision of tumor While there may be a small amount of tumor remaining it appeared that a radical excision had been created with decompression of the optic apparatus In fact I reinserted the endoscope and could see the optic chiasm well I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression Attention was therefore turned to closure The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained I asked Anesthesiology to perform a Valsalva maneuver and there was no evidence of bleeding Attention was turned to closure and reconstruction I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air Using a polypropylene insert I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm DuraSeal was placed over this and the sphenoid sinus was carefully packed with fat and DuraSeal I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation The middle turbinates were then restored to their anatomic position There was no significant intranasal bleeding and for this reason an open nasal packing was required Sterile dressings were applied and the operation was terminated The patient tolerated the procedure well and left to the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisting of tumor Keywords MEDICAL_TRANSCRIPTION,Description A 44 year old 250 pound male presents with extreme pain in his left heel Medical Specialty Surgery Sample Name Plantar Fasciitis Transcription S A 44 year old 250 pound male presents with extreme pain in his left heel This is his chief complaint He says that he has had this pain for about two weeks He works on concrete floors He says that in the mornings when he gets up or after sitting he has extreme pain and great difficulty in walking He also has a macular blotching of skin on his arms face legs feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old He also has redness and infection of the right toes O The patient apparently has a pigmentation disorder which may or may not change with time on his arms legs and other parts of his body including his face He has an erythematous moccasin pattern tinea pedis of the plantar aspects of both feet He has redness of the right toes 2 3 and 4 Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel A 1 Plantar fasciitis Keywords surgery plantar fasciitis tinea pedis tinea purpura heel fasciitis plantar MEDICAL_TRANSCRIPTION,Description External fixation of left pilon fracture and closed reduction of left great toe T1 fracture Due to the comminuted nature of her tibia fracture as well as soft tissue swelling the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation Medical Specialty Surgery Sample Name Pilon Fracture External Fixation Transcription PREOP DIAGNOSES 1 Left pilon fracture 2 Left great toe proximal phalanx fracture POSTOP DIAGNOSES 1 Left pilon fracture 2 Left great toe proximal phalanx fracture OPERATION PERFORMED 1 External fixation of left pilon fracture 2 Closed reduction of left great toe T1 fracture ANESTHESIA General BLOOD LOSS Less than 10 mL Needle instrument and sponge counts were done and correct DRAINS AND TUBES None SPECIMENS None INDICATION FOR OPERATION The patient is a 58 year old female who was involved in an auto versus a tree accident on 6 15 2009 The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention Due to the comminuted nature of her tibia fracture as well as soft tissue swelling the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation The patient had swollen lower extremities however compartments were soft and she had no sign of compartment syndrome Risks and benefits of procedure were discussed in detail with the patient and her husband All questions were answered and consent was obtained The risks including damage to blood vessels and nerves with painful neuroma or numbness limb altered function loss of range of motion need for further surgery infection complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery FINDINGS 1 There was a comminuted distal tibia fracture with a fibular shaft fracture Following traction there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula the fracture fragments were out to length 2 The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step off and approximately 1 mm displacement As the reduction was stable with buddy taping no pinning was performed 3 Her compartments were full but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed OPERATIVE REPORT IN DETAIL The patient was identified in the preoperative holding area The left leg was identified and marked at the surgical site of the patient She was then taken to the operating room where she was transferred to the operating room in the supine position placed under general anesthesia by the anesthesiology team She received Ancef for antibiotic prophylaxis A time out was then undertaken verifying the correct patient extremity visibility of preoperative markings availability of equipment and administration of preoperative antibiotics When all was verified by the surgeon anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion At this point intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length but not overly distract the fracture and restore coronal and sagittal alignment as much as able When this was adequate the fixator apparatus was locked in place and x ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture Attention was then turned to the left great toe where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive X rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture At this point the pins were cut short and capped to protect the sharp ends The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition Please note there was no break in sterile technique throughout the case PLAN The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication She will maintain her buddy taping in regards to her great toe fracture Keywords surgery phalanx fracture schantz pins toe fracture tibia fracture pilon fracture external fixation proximal phalanx fracture toe pilon phalanx reduction tibia proximal fixation MEDICAL_TRANSCRIPTION,Description Pilonidal cyst with abscess formation Excision of infected pilonidal cyst Medical Specialty Surgery Sample Name Pilonidal Cyst Excision Transcription PREOPERATIVE DIAGNOSIS Pilonidal cyst with abscess formation POSTOPERATIVE DIAGNOSIS Pilonidal cyst with abscess formation OPERATION Excision of infected pilonidal cyst PROCEDURE After obtaining informed consent the patient underwent a spinal anesthetic and was placed in the prone position in the operating room A time out process was followed Antibiotics were given and then the patient was prepped and draped in the usual fashion It appeared to me that the abscess had drained somewhat during the night as it was much smaller than I was anticipating An elliptical excision of all infected tissues down to the coccyx was performed Hemostasis was achieved with a cautery The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing The patient was sent to recovery room in satisfactory condition Estimated blood loss was minimal The patient tolerated the procedure well Keywords surgery hemostasis excision pilonidal cyst cyst abscess infected MEDICAL_TRANSCRIPTION,Description Revision and in situ pinning of the right hip Medical Specialty Surgery Sample Name Pinning Hip Transcription PREOPERATIVE DIAGNOSIS Right acute on chronic slipped capital femoral epiphysis POSTOPERATIVE DIAGNOSIS Right acute on chronic slipped capital femoral epiphysis PROCEDURE Revision and in situ pinning of the right hip ANESTHESIA Surgery performed under general anesthesia COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None LOCAL 10 mL of 0 50 Marcaine local anesthetic HISTORY AND PHYSICAL The patient is a 13 year old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis She underwent in situ pinning The patient on followup however noted to have intraarticular protrusion of her screw This was not noted intraoperatively on previous fluoroscopic views Given this finding I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one Risks and benefits of surgery were discussed Risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion of the extremity failure to remove the screw possible continued joint stiffness or damage All questions were answered and parents agreed to above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A small bump was placed underneath her right buttock The right upper thigh was then prepped and draped in standard surgical fashion The upper aspect of the incision was reincised The dissection was carried down to the crew which was easily found A guidewire was placed inside the screw with subsequent removal of the previous screw The previous screw measured 65 mm A 60 mm screw was then placed under direct visualization with fluoroscopy The hip was taken through full range of motion to check on the length of the screw which demonstrated no intraarticular protrusion The guidewire was removed The wound was then irrigated and closed using 2 0 Vicryl in the fascial layer as well as the subcutaneous fat The skin was closed with 4 0 Monocryl The wound was cleaned and dried dressed with Steri Strips Xeroform 4 x 4s and tape The area was infiltrated with total 10 mL of 0 5 Marcaine local anesthetic POSTOPERATIVE PLAN The patient will be discharged on the day of surgery She should continue toe touch weightbearing on her leg The wound may be wet in approximately 5 days The patient should follow up in clinic in about 10 days The patient is given Vicodin for pain Intraoperative findings were relayed to the mother Keywords surgery guidewire capital femoral epiphysis intraarticular protrusion femoral epiphysis pinning screw MEDICAL_TRANSCRIPTION,Description Left hemothorax rule out empyema Insertion of a 12 French pigtail catheter in the left pleural space Medical Specialty Surgery Sample Name Pigtail Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Left hemothorax rule out empyema POSTOPERATIVE DIAGNOSIS Left hemothorax rule out empyema PROCEDURE Insertion of a 12 French pigtail catheter in the left pleural space PROCEDURE DETAIL After obtaining informed consent the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion Xylocaine 1 was injected and then a 12 French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space It was difficult to draw fluid by syringe but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR Samples were sent for culture and sensitivity aerobic and anaerobic The patient and I decided to admit him for a period of observation at least overnight He tolerated the procedure well and the postprocedure chest x ray showed no complications Keywords surgery chest pleural space pigtail catheter insertion empyema hemothorax MEDICAL_TRANSCRIPTION,Description Botulinum toxin injection bilateral rectus femoris medial hamstrings and gastrocnemius soleus muscles phenol neurolysis of bilateral obturator nerves application of bilateral short leg fiberglass casts Medical Specialty Surgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 3 Transcription PROCEDURE CODES 64640 times two 64614 time two 95873 times two 29405 times two PREOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 POSTOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s mom The patient was brought to minor procedures and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation Approximately 4 mL of 5 phenol was injected in this location bilaterally Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 50 units was injected in the rectus femoris bilaterally 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL After injections were performed bilateral short leg fiberglass casts were applied The patient tolerated the procedure well and no complications were encountered Keywords surgery botulinum toxin injection bilateral toxin injection bilateral rectus neurolysis of bilateral obturator short leg fiberglass casts muscles phenol neurolysis botulinum toxin injection gastrocnemius soleus muscles short leg fiberglass femoris medial cerebral palsy active emg emg stimulation phenol neurolysis toxin injection rectus femoris gastrocnemius soleus soleus muscles obturator nerves leg fiberglass fiberglass casts botulinum toxin hamstrings gastrocnemius obturator nerves fiberglass casts muscles botulinum phenol bilateral injection toxin MEDICAL_TRANSCRIPTION,Description Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors Medical Specialty Surgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 1 Transcription PROCEDURES PERFORMED Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors PROCEDURE CODES 64640 times three 64614 times four 95873 times four PREOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 POSTOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s brother The patient was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation Approximately 7 mL was injected on the right side and 5 mL on the left side At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation Approximately 5 mL of 5 phenol was injected in this location Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified using active EMG stimulation Approximately 150 units was injected in the knee extensors bilaterally 100 units in the left pectoralis major and 50 units in the left wrist flexors Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords surgery spastic quadriparesis emg stimulation emg botulinum toxin injection traumatic brain brain injury phenol neurolysis toxin injection musculocutaneous nerve obturator nerves pectoralis major wrist flexors knee extensors active emg botulinum toxin toxin injection stimulus neurolysis musculocutaneous extensors botulinum phenol MEDICAL_TRANSCRIPTION,Description Right phacoemulsification of cataract with intraocular lens implantation Cataract right eye Medical Specialty Surgery Sample Name Phacoemulsification of Cataract Transcription PREOPERATIVE DIAGNOSIS ES Cataract right eye POSTOPERATIVE DIAGNOSIS ES Cataract right eye PROCEDURE Right phacoemulsification of cataract with intraocular lens implantation DESCRIPTION OF THE OPERATION Under topical anesthesia with monitored anesthesia care the patient was prepped draped and positioned under the operating microscope A lid speculum was applied to the right eye and a stab incision into the anterior chamber was done close to the limbus at about the 1 o clock position with a Superblade and Xylocaine 1 preservative free 0 25 mL was injected into the anterior chamber which was then followed by Healon to deepen the anterior chamber Using a keratome another stab incision was done close to the limbus at about the 9 o clock position and with the Utrata forceps anterior capsulorrhexis was performed and the torn anterior capsule was totally removed Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS The tip of the phaco unit was introduced into the anterior chamber and anterior sculpting of the nucleus was performed until about more than two thirds of the nucleus was removed Using the phaco tip and the Drysdale hook the nucleus was broken up into 4 pieces and then phacoemulsified The phaco tip was then exchanged for the aspiration irrigation tip and cortical materials were aspirated Posterior capsule was polished with a curette polisher and Healon was injected into the capsular bag Using the Monarch intraocular lens inserter the posterior chamber intraocular lens model SN60WF power 19 50 was placed into the inserter after applying some Healon and the tip of the inserter was gently introduced through the cornea tunnel wound into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument Intraocular lens was then rotated about half a turn with a collar button hook Healon was removed with the aspiration irrigation tip and balanced salt solution was injected through the side port to deepen the anterior chamber It was found that there was no leakage of fluid through the cornea tunnel wound For this reason no suture was applied Vigamox Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield The patient tolerated the procedure well There were no complications Keywords surgery cataract implantation intraocular intraocular lens lens implantation phacoemulsification capsular bag capsule intraocular lens implantation cornea tunnel wound phacoemulsification of cataract cornea tunnel anterior chamber anesthesia cornea lens chamber MEDICAL_TRANSCRIPTION,Description Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles Medical Specialty Surgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 2 Transcription PROCEDURES PERFORMED Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles PROCEDURE CODES 64640 times one 64614 times two 95873 times two PREOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 POSTOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient She was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse Approximately 6 mL of 5 phenol was injected in this location At all sites of phenol injections injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords surgery femoris and vastus medialis intermedius and right pectoralis rectus femoris and vastus vastus medialis intermedius botulinum toxin injection medialis intermedius major muscles cerebral palsy active emg emg stimulation phenol neurolysis toxin injection obturator nerve rectus femoris pectoralis major botulinum toxin pectoralis botulinum phenol injection toxin MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification of cataract with posterior chamber intraocular lens right eye Medical Specialty Surgery Sample Name Phacoemulsification Of Cataract 2 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Phacoemulsification of cataract with posterior chamber intraocular lens right eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE IN DETAIL The patient was identified The operative eye was treated with tetracaine 1 topically in the preoperative holding area The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery Attention was turned to the left right eye The lashes were tapped using Steri Strips to prevent blinking A lid speculum was placed to prevent lid closure Anesthesia was verified Then a 3 5 mm groove was created with a diamond blade temporarily This was beveled with a crescent blade and the anterior chamber was entered with a 3 2 mm keratome in the iris plane A 1 nonpreserved lidocaine was injected intracamerally and followed with Viscoat A paracentesis was made A round capsulorrhexis was performed The anterior capsular flap was removed Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique The irrigating aspirating machine was used to clear residual cortex The Provisc was instilled An SN60WS diopter intraocular lens was inserted into the capsular bag and the position was verified The viscoelastic was removed Intraocular lens remained well centered The incision was hydrated and the anterior chamber pressure was checked with tactile pressure and found to be normal The anterior chamber remained deep and there was no wound leak The patient tolerated the procedure well The eye was dressed with Maxitrol ointment A tight patch and Fox shield were placed The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain Keywords surgery cataract posterior chamber intraocular lens hydrodelineation phacoemulsification of cataract phacoemulsification lens anterior chamber eye intraocular MEDICAL_TRANSCRIPTION,Description PICC line insertion Medical Specialty Surgery Sample Name PICC line insertion Transcription PROCEDURE PERFORMED PICC line insertion DESCRIPTION OF PROCEDURE The patient was identified by myself on presentation to the angiography suite His right arm was prepped and draped in sterile fashion from the antecubital fossa up Under ultrasound guidance a 21 gauge needle was placed into his right cephalic vein A guidewire was then threaded through the vein and advanced without difficulty An introducer was then placed over the guidewire We attempted to manipulate the guidewire to the superior vena cava however we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein It was very tortuous area We made several more attempts using the mapping system to pass the glide over that area but we were unable to do that Decision was made at that point then to just do a midline catheter The catheter was cut to 20 cm then we inserted back to the introducer The introducer was removed The catheter was secured by two 3 0 silk sutures Appropriate imaging was then taken Sterile dressing was applied The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor We may make another attempt in the near future using a different approach Keywords surgery picc picc line angiography guidewire superior vena cava subclavian vein venogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens implant in the right eye Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 7 Transcription TITLE OF OPERATION Phacoemulsification with posterior chamber intraocular lens implant in the right eye INDICATION FOR SURGERY The patient is a 27 year old male who sustained an open globe injury as a child He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye PREOP DIAGNOSIS 1 History of open globe to the right eye 2 History of retinal detachment status post repair in the right eye 3 Silicone oil in anterior chamber 4 Dense silicone oil cataract in the right eye obscuring the view of the posterior pole POSTOP DIAGNOSIS 1 History of open globe to the right eye 2 History of retinal detachment status post repair in the right eye 3 Silicone oil in anterior chamber 4 Dense silicone oil cataract in the right eye obscuring the view of the posterior pole ANESTHESIA General PROS DEV IMPLANT ABC Laboratories posterior chamber intraocular lens 21 0 diopters serial number 123456 NARRATIVE Informed consent was obtained All questions were answered The patient was brought to preoperative holding area where the operative right eye was marked He was brought to the operating room and placed in the supine position EKG leads were placed General anesthesia was induced by the anesthesia service A time out was called to confirm the procedure and operative eye The right operative eye was disinfected and draped in a standard fashion for eye surgery A lid speculum was placed The vitreoretinal team placed the infusion cannula after performing a peritomy At this point in the case the patient was turned over to the cornea service with Mrs Jun A paracentesis was made at the approximately 3 o clock position Healon was placed into the anterior chamber The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108 degree axis This incision was then shelved anteriorly and used to enter the anterior chamber The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome Hydrodissection was performed The lens nucleus was removed using phacoemulsification and irrigation and aspiration Lens cortex also was removed using irrigation and aspiration Viscoelastic was placed to inflate the capsular remnant The diamond knife was used to enlarge the phaco incision Intraocular lens was selected from preoperative calculations placed in the injector system and inserted into the capsule without difficulty The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber This was done without difficulty The anterior chamber was secured and watertight at the end of the procedure Intraocular pressure was satisfactory The patient tolerated the procedure well and then was turned over to the retina service in good condition They will dictate a separate note Keywords surgery phacoemulsification intraocular lens implant posterior chamber chamber eye intraocular lens MEDICAL_TRANSCRIPTION,Description Phacoemulsification of cataract extraocular lens implant in left eye Medical Specialty Surgery Sample Name Phacoemulsification of Cataract 1 Transcription PREOPERATIVE DIAGNOSES 1 Senile nuclear cataract left eye 2 Senile cortical cataract left eye POSTOPERATIVE DIAGNOSES 1 Senile nuclear cataract left eye 2 Senile cortical cataract left eye PROCEDURES Phacoemulsification of cataract extraocular lens implant in left eye LENS IMPLANT USED Alcon model SN60WF power of 22 5 diopters PHACOEMULSIFICATION TIME 1 minute 41 seconds at 44 4 power INDICATIONS FOR PROCEDURE This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20 40 The patient complains of difficulties with glare in performing activities of daily living INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery All questions from the patient were answered after the surgical procedure was explained in detail The risks of the procedure as explained to the patient include but are not limited to pain infection bleeding loss of vision retinal detachment need for further surgery loss of lens nucleus double vision etc Alternative of the procedure is to do nothing or seek a second opinion Informed consent for this procedure was obtained from the patient OPERATIVE TECHNIQUE The patient was brought to the holding area Previously an intravenous infusion was begun at a keep vein open rate After adequate sedation by the anesthesia department under monitored anesthesia care conditions a peribulbar and retrobulbar block was given around the operative eye A total of 10 mL mixture with a 70 30 mixture of 2 Xylocaine without epinephrine and 0 75 bupivacaine without epinephrine An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted Vital sign monitors were detached from the patient The patient was moved to the operative suite and the same monitors were reattached The periocular area was cleansed dried prepped and draped in the usual sterile manner for ocular surgery The speculum was set into place and the operative microscope was brought over the eye The eye was examined Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea Then a pocket incision was created without entering the anterior chamber of the eye Two peripheral paracentesis ports were created on each side of the initial incision site Viscoelastic was used to deepen the anterior chamber of the eye A 2 65 mm keratome was then used to complete the corneal valve incision A cystitome was bent and created using a tuberculin syringe needle It was placed in the anterior chamber of the eye A continuous curvilinear capsulorrhexis was begun It was completed using O Gawa Utrata forceps A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus The lens nucleus was noted to be freely mobile in the bag The phacoemulsification tip was placed into the anterior chamber of the eye The lens nucleus was phacoemulsified and aspirated in a divide and conquer technique All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports The posterior capsule remained intact throughout the entire procedure Provisc was used to deepen the anterior chamber of the eye A crescent blade was used to expand the internal aspect of the wound The lens was taken from its container and inspected No defects were found The lens power selected was compared with the surgery worksheet from Dr X s office The lens was placed in an inserter under Provisc It was placed through the wound into the capsular bag and extruded gently from the inserter It was noted to be adequately centered in the capsular bag using a Sinskey hook The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique The eye was noted to be inflated without overinflation The wounds were tested for leaks none were found Five drops dilute Betadine solution was placed over the eye The eye was irrigated The speculum was removed The drapes were removed The periocular area was cleaned and dried Maxitrol ophthalmic ointment was placed into the interpalpebral space A semi pressure patch and shield was placed over the eye The patient was taken to the floor in stable and satisfactory condition was given detailed written instructions and asked to follow up with Dr X tomorrow morning in the office Keywords surgery senile nuclear cataract senile phacoemulsification phacoemulsification of cataract lens implant lens nucleus anterior chamber lens alcon eye cataract MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens insertion Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 6 Transcription PROCEDURE Phacoemulsification with posterior chamber intraocular lens insertion INTRAOCULAR LENS Allergan Medical Optics model S140MB XXX diopter chamber lens PHACO TIME Not known ANESTHESIA Retrobulbar block with local minimal anesthesia care COMPLICATIONS None ESTIMATED BLOOD LOSS None DESCRIPTION OF PROCEDURE While the patient was in the holding area the operative eye was dilated with four sets of drops The drops consisted of Cyclogyl 1 Acular and Neo Synephrine 2 5 Additionally a peripheral IV was established by the anesthesia team Once the eye was dilated the patient was wheeled to the operating suite Inside the operating suite central monitoring lines were established Through the peripheral IV the patient received intravenous sedation consisting of Propofol and once somnolent from this retrobulbar block was administered consisting of 2 cc s of 2 Xylocaine plain with 150 units of Wydase The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained Digital pressure was applied for approximately five minutes The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery A Betadine prep was carried out of the face lids and eye During the draping process care was taken to isolate the lashes A wire lid speculum was inserted to maintain patency of the lids With benefit of the operating microscope a diamond blade was used to place a groove temporally A paracentesis wound was also placed temporally using the same blade Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2 8 mm diamond keratome was used to enter the anterior chamber through the previously placed groove The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty The capsular remnant was withdrawn from the eye using long angled McPherson forceps Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed The lens was noted to rotate freely within the capsular bag The phaco instrument was then inserted into the eye using the Kelman tip The lens nucleus was grooved and broken into two halves One of the halves was in turn broken into quarters Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification Attention was then turned toward the remaining half of the nucleus and this in turn was removed as well with the splitting maneuver Once the nucleus had been removed from the eye the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections Once the cortical material had been completely removed a diamond dusted cannula was inserted into the eye and the posterior capsule was polished Viscoelastic was again instilled into the capsular bag as well as the anterior chamber The wound was enlarged slightly using the diamond keratome The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps Once inside the eye the lens was unfolded into the capsular bag in a single maneuver It was noted to be centered nicely The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine Next Miostat was instilled into the operative eye and the wound was checked for water tightness It was found to be such After removing the drapes and speculum TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye The patient tolerated the procedure extremely well and was taken to the recovery area in good condition The patient is scheduled to be seen in follow up in the office tomorrow but should any complications arise this evening the patient is to contact me immediately Keywords surgery diopter intraocular lens insertio phacoemulsification posterior chamber diamond keratome anterior chamber capsular bag intraocular lens intraocular allergan eye capsular chamber lens MEDICAL_TRANSCRIPTION,Description Amputation distal phalanx and partial proximal phalanx right hallux Osteomyelitis right hallux Medical Specialty Surgery Sample Name Phalanx Amputation Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis right hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis right hallux PROCEDURE PERFORMED Amputation distal phalanx and partial proximal phalanx right hallux ANESTHESIA TIVA local HISTORY This 44 year old male patient was admitted to ABCD General Hospital on 09 02 2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics which he failed The patient after a multiple conservative treatments such as wound care antibiotics the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis The patient desires to attempt a surgical correction The risks versus benefits of the procedure were discussed with the patient in detail by Dr X The consent was available on the chart for review PROCEDURE IN DETAIL After patient was taken to the operating room via cart and placed on the operating table in the supine position a safety strap was placed across his waist Adequate IV sedation was administered by the Department of Anesthesia and a total of 3 5 cc of 1 1 mixture 1 lidocaine and 0 5 Marcaine plain were injected into the right hallux as a digital block The foot was prepped and draped in the usual aseptic fashion lowering the operative field Attention was directed to the hallux where there was a full thickness ulceration to the distal tip of the hallux measuring 0 5 cm x 0 5 cm There was a ________ tract which probed through the distal phalanx and along the sides of the proximal phalanx laterally The toe was 2 5 times to the normal size There were superficial ulcerations in the medial arch of both feet secondary to history of a burn which were not infected The patient had dorsalis pedis and posterior tibial pulses that were found to be 2 4 bilaterally preoperatively X ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx A 10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact Next the distal phalanx was disarticulated at the interphalangeal joint and removed The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology Next the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected Therefore a sagittal saw was used to resect approximately 0 75 cm of the distal aspect of head of the proximal phalanx This bone was also sent off for culture and was labeled proximal margin Next the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected The flexor tendon distally was gray discolored and was not viable A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally None was found No purulent drainage or abscess was found The proximal margin of the surgical site tissue was viable and healthy There was no malodor Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology Next copious amounts of gentamicin and impregnated saline were instilled into the wound A 3 0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension The plantar flap was viable and was debulked with Metzenbaum scissors The flap was folded dorsally and reapproximated carefully with 3 0 nylon with a combination of simple interrupted and vertical mattress sutures Iris scissors were used to modify and remodel the plantar flap An excellent cosmetic result was achieved No tourniquet was used in this case The patient tolerated the above anesthesia and surgery without apparent complications A standard postoperative dressing was applied consisting of saline soaked Owen silk 4x4s Kerlix and Coban The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot He will be readmitted to Dr Katzman where we will continue to monitor his blood pressure and regulate his medications Plan is to continue the antibiotics until further IV recommendations He will be nonweightbearing to the right foot and use crutches He will elevate his right foot and rest the foot keep it clean and dry He is to follow up with Dr X on Monday or Tuesday of next week Keywords surgery osteomyelitis phalanx phalanx amputation proximal margin plantar flap distal phalanx proximal phalanx proximal hallux amputation foot plantarly distal MEDICAL_TRANSCRIPTION,Description Phacoemulsification with IOL right eye Cataract right eye A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o clock position through which 2 preservative free Xylocaine was injected followed by Viscoat Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 5 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye OPERATION PERFORMED Phacoemulsification with IOL right eye ANESTHESIA Topical with MAC COMPLICATIONS None ESTIMATED BLOOD LOSS None PROCEDURE IN DETAIL After appropriate consent was obtained the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o clock position through which 2 preservative free Xylocaine was injected followed by Viscoat A 2 75 mm keratome then made a stab incision at the 2 o clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata BSS on blunt cannula hydrodissector and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I A Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I A which then removed all remaining cortex as well as viscoelastic material BSS on blunt cannula hydrated all wounds which were noted to be free of leak and lid speculum was removed Under microscope the anterior chamber being soft and well formed Pred Forte Vigamox and Iopidine were placed in the eye A shield was placed over the eye The patient was followed to recovery where he was noted to be in good condition Keywords surgery lid speculum lens iol viscoat posterior capsule cataract speculum incision phacoemulsification MEDICAL_TRANSCRIPTION,Description Phacoemulsification of cataract and posterior chamber lens implant right eye Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 4 Transcription OPERATION PERFORMED Phacoemulsification of cataract and posterior chamber lens implant right eye ANESTHESIA Retrobulbar nerve block right eye DESCRIPTION OF OPERATION The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon Once anesthesia was achieved the right eye was prepped with Betadine rinsed with saline and draped in a sterile fashion A lid speculum was placed and 4 0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe A fornix based conjunctival flap was prepared superiorly from 10 to 12 o clock and episcleral vessels were cauterized using a wet field A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o clock position A lamellar dissection was carried anteriorly to clear cornea using a crescent knife A stab incision was applied with a Superblade at the 2 o clock position at the limbus The chamber was also entered through the lamellar groove using a 3 mm keratome in a beveled fashion Viscoat was injected into the chamber and an anterior capsulorrhexis performed Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side port incision A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants Each quadrant was emulsified under burst power within the capsular bag The epinuclear bowl was manipulated with vacuum flipped into the iris plane and emulsified under pulse power I A was used to aspirate cortex from the capsular bag A scratcher was used to polish the capsule and Viscoat was injected inflating the capsular bag and chamber The wound was enlarged with a shortcut blade to 5 5 mm The intraocular lens was examined found to be adequate irrigated with balanced salt and inserted into the capsular bag The lens centralized nicely and Viscoat was removed using the I A Balanced salt was injected through the side port incision The wound was tested found to be secure and a single 10 0 nylon suture was applied to the wound with the knot buried within the sclera The conjunctiva was pulled over the suture and Ancef 50 mg and Decadron 4 mg were injected sub Tenon in the inferonasal and inferotemporal quadrants Maxitrol ointment was applied topically followed by an eye pad and shield The patient tolerated the procedure and was taken from the operating room in good condition Keywords surgery retrobulbar nerve block posterior chamber lens implant phacoemulsification of cataract lens implantation capsular bag cataract phacoemulsification nucleus capsular lens eye MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens placement right eye Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 3 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Phacoemulsification with intraocular lens placement right eye ANESTHESIA Monitored anesthesia care ESTIMATED BLOOD LOSS None COMPLICATIONS None SPECIMENS None PROCEDURE IN DETAIL The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye The patient had the risks and benefits of surgery discussed After discussion the patient decided to proceed and the consent was signed On the day of surgery the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed Following this the patient was sterilely prepped and draped in the usual fashion After this a lid speculum was placed preservative free lidocaine drops were placed and the SuperSharp blade was used to make an anterior chamber paracentesis Preservative free lidocaine was instilled into the anterior chamber and then Viscoat was instilled into the eye The 3 0 diamond keratome was then used to make a clear corneal temporal incision Following this the cystotome was used to make a continuous tear type capsulotomy After this BSS was used to hydrodissect and hydrodelineate the lens The phacoemulsification unit was used to remove the cataract The I A unit was used to remove the residual cortical material Following this Provisc was used to inflate the bag The lens a model SA60AT of ABCD diopters serial 1234 was inserted into the bag and rotated into position using the Lester pusher After this the residual Provisc was removed Michol was instilled and then the corneal wound was hydrated with BSS and the wound was found to be watertight The lid speculum was removed Acular and Vigamox drops were placed The patient tolerated the procedure well without complications and will be followed up in the office tomorrow Keywords surgery capsulotomy diopters intraocular lens placement lid speculum anterior chamber phacoemulsification lens cataract intraocular MEDICAL_TRANSCRIPTION,Description Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation Cataract right eye Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction 4 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation ME 30 AC 25 0 diopter lens was used COMPLICATIONS None ANESTHESIA Local 2 peribulbar lidocaine PROCEDURE NOTE Right eye was prepped and draped in the normal sterile fashion Lid speculum placed in his right eye Paracentesis made supratemporally Viscoat injected into the anterior chamber A 2 8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed Nuclear material removed via phacoemulsification Residual cortex removed via irrigation and aspiration The posterior capsule was clear and intact Capsular bag was then filled with Provisc solution The wound was enlarged to 3 5 mm with the keratoma The lens was folded in place into the capsular bag Residual Provisc was irrigated from the eye The wound was secured with one 10 0 nylon suture The lid speculum was removed One drop of 5 povidone iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment He had a patch placed on it The patient was transported to the recovery room in stable condition Keywords surgery provisc intraocular lens implantation intraocular lens lens implantation lid speculum capsular bag cataract extraction phacoemulsification cataract intraocular MEDICAL_TRANSCRIPTION,Description Phacoemulsification with intraocular lens placement A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 2 Transcription PROCEDURE PERFORMED Phacoemulsification with intraocular lens placement ANESTHESIA TYPE Topical COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo Synephrine eye drops Topical anesthetic drops were applied to the eye just prior to entering the operating room The eye was then prepped with a 5 Betadine solution injected in the usual sterile fashion A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade Lidocaine 1 preservative free 0 1 cc was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber A 2 8 mm keratome was used to create a self sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap The Utrata forceps were used to complete a continuous tear capsulorrhexis and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula Phacoemulsification in a quartering and cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit The capsular bag was re expanded with viscoelastic and then the wound was opened to a 3 4 mm size to accommodate the intraocular lens insertion using an additional keratome blade The lens was folded inserted into the capsular bag and then unfolded The trailing haptic was tucked underneath the anterior capsular rim The lens was shown to center very well The viscoelastic was removed with the irrigation and aspiration unit and one 10 0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction The wound was shown to be watertight Therefore TobraDex ointment was applied to the eye an eye pad loosely applied and a Fox shield taped firmly in place over the eye The patient tolerated the procedure well and left the operating room in good condition Keywords surgery keratome phacoemulsification cortex tobradex intraocular lens aspiration unit topical chamber viscoelastic corneal capsular lens intraocular eye MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens insertion right eye A wire lid speculum was inserted to keep the eye open and the eye rotated downward Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction 3 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye ANESTHESIA Retrobulbar block COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the operating room where retrobulbar anesthesia was induced The patient was then prepped and draped using standard procedure A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0 12 The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome The chamber was then filled with viscoelastic and a continuous tear capsulorrhexis performed The phacoemulsification was then instilled in the eye and a linear incision made in the lens The lens was then cracked with a McPherson forceps and the remaining lens material removed with the phacoemulsification tip The remaining cortex was removed with an I A The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome The folding posterior chamber lens was then inserted in the capsular bag and rotated into position The remaining viscoelastic was removed from the eye with the I A The wound was checked for watertightness and found to be watertight Tobramycin drops were instilled in the eye and a shield placed over it The patient tolerated the procedure well Keywords surgery tobramycin limbal lid speculum intraocular lens capsular bag eye phacoemulsification lens intraocular MEDICAL_TRANSCRIPTION,Description Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation An Alcon MA30BA lens was used A lid speculum was placed into the right eye Paracentesis was made at the infratemporal quadrant Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction 5 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE PERFORMED Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation An Alcon MA30BA lens was used diopters ANESTHESIA Topical 4 lidocaine with 1 nonpreserved intracameral lidocaine COMPLICATIONS None PROCEDURE Prior to surgery the patient was counseled as to the risks benefits and alternatives of the procedure with risks including but not limited to bleeding infection loss of vision loss of the eye need for a second surgery retinal detachment and retinal swelling The patient understood the risks clearly and wished to proceed The patient was brought into the operating suite after being given dilating drops Topical 4 lidocaine drops were used The patient was prepped and draped in the normal sterile fashion A lid speculum was placed into the right eye Paracentesis was made at the infratemporal quadrant This was followed by 1 nonpreservative lidocaine into the anterior chamber roughly 250 microliters This was exchanged for Viscoat solution Next a crescent blade was used to create a partial thickness linear groove at the temporal limbus This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps Balanced salt solution was used to hydrodissect the nucleus Nuclear material was removed via phacoemulsification with divide and conquer technique The residual cortex was removed via irrigation and aspiration The capsular bag was then filled with Provisc solution The wound was slightly enlarged The lens was folded and inserted into the capsular bag Residual Provisc solution was irrigated out of the eye The wound was stromally hydrated and noted to be completely self sealing At the end of the case the posterior capsule was intact The lens was well centered in the capsular bag The anterior chamber was deep The wound was self sealed and subconjunctival injections of Ancef dexamethasone and lidocaine were given inferiorly Maxitrol ointment was placed into the eye The eye was patched with a shield The patient was transported to the recovery room in stable condition to follow up the following morning Keywords surgery alcon phacoemulsification cataract extraction cataract intraocular lens implantation anterior chamber provisc solution capsular bag topical intraocular MEDICAL_TRANSCRIPTION,Description Visually significant nuclear sclerotic cataract right eye Phacoemulsification with posterior chamber intraocular lens implantation right eye Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation 1 Transcription PREOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye POSTOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye OPERATIVE PROCEDURES Phacoemulsification with posterior chamber intraocular lens implantation right eye ANESTHESIA Monitored anesthesia care with retrobulbar block consisting of 2 lidocaine in an equal mixture with 0 75 Marcaine and Amphadase INDICATIONS FOR SURGERY This patient has been experiencing difficulty with eyesight regarding activities of daily living There has been a progressive and gradual decline in the visual acuity The cataract was believed related to her decline in vision The risks benefits and alternatives including with observation or spectacles were discussed in detail The risks as explained included but are not limited to pain bleeding infection decreased or loss of vision loss of eye retinal detachment requiring further surgery and possible consultation out of town swelling of the back part of the eye retina need for prolonged eye drop use or injections instability of the lens and loss of corneal clarity necessitating long term drop use or further surgery The possibility of needing intraocular lens exchange or incorrect lens power was discussed Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed It was explained that some or all of these complications might arise at the time of or months to years after surgery The patient had a good understanding of the risks with the proposed elective eye surgery The patient accepted these risks and elected to proceed with cataract surgery All questions were answered and informed consent was signed and placed in the chart DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified The pupil was dilated per protocol The patient was taken to the operating room and placed in the supine position After intravenous sedation the retrobulbar block was injected followed by several minutes of digital massage No signs of orbital tenseness or retrobulbar hemorrhage were present The patient was prepped and draped in the usual ophthalmic sterile fashion An eyelid speculum was used to separate the eyelids A crescent blade was used to make a clear corneal temporally located incision A 1 mm Dual Bevel blade was used to make a paracentesis site The anterior chamber was filled with viscoelastic Viscoat The crescent blade was then used to make an approximate 2 mm long clear corneal tunnel through the temporal incision A 2 85 mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision A 25 gauge pre bent cystotome used to begin a capsulorrhexis The capsulorrhexis was completed with the Utrata forceps A 27 guage needle was used for hydrodissection and three full and complete fluid waves were noted The lens was able to be freely rotated within the capsular bag Divide and conquer ultrasound was used for phacoemulsification After four sculpted grooves were made a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment Each of the four nuclear quadrants was phacoemulsified Aspiration was used to remove all remaining cortex Viscoelastic was used to re inflate the capsular bag An AMO model SI40NB posterior chamber intraocular lens with power diopters and serial number was injected into the capsular bag The trailing haptic was placed with the Sinskey hook The lens was made well centered and stable Viscoelastic was aspirated BSS was used to re inflate the anterior chamber to an adequate estimated intraocular pressure A Weck Cel sponge was used to check both incision sites for leaks and none were identified The incision sites remained well approximated and dry with a well formed anterior chamber and eccentric posterior chamber intraocular lens The eyelid speculum was removed and the patient was cleaned free of Betadine Vigamox and Econopred drops were applied A soft eye patch followed by a firm eye shield was taped over the operative eye The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well Discharge instructions regarding activity restrictions eye drop use eye shield patch wearing and driving restrictions were discussed All questions were answered The discharge instructions were also reviewed with the patient by the discharging nurse The patient was comfortable and was discharged with followup in 24 hours Complications none Keywords surgery retrobulbar block posterior chamber intraocular lens nuclear sclerotic cataract cataract lens implantation posterior chamber anterior chamber intraocular lens lens eye intraocular anesthesia phacoemulsification retrobulbar MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens insertion right eye The patient was then prepped and draped using standard procedure An additional drop of tetracaine was instilled in the eye and then a lid speculum was inserted Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction 2 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the operating room where tetracaine drops were instilled in the eye The patient was then prepped and draped using standard procedure An additional drop of tetracaine was instilled in the eye and then a lid speculum was inserted The eye was rotated downward and a crescent blade used to make an incision at the limbus This was then dissected forward approximately 1 mm and then a keratome was used to enter the anterior chamber The anterior chamber was filled with 1 preservative free lidocaine and the lidocaine was then replaced with Provisc A cystotome was used to make a continuous tear capsulorrhexis and then the capsular flap was removed with the Utrata forceps The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco This was aided by cracking the lens nucleus with McPherson forceps The remaining cortex was removed from the eye with the I A The capsular bag was then polished with the I A on capsular bag The bag was inflated using viscoelastic and then the wound extended slightly with a keratome A folding posterior chamber lens was inserted and rotated into position using McPherson forceps The I A was then placed in the eye again and the remaining viscoelastic removed The wound was checked for watertightness and found to be watertight TobraDex drops were instilled in the eye and a shield was placed over it The patient tolerated the procedure well and was brought to recovery in good condition Keywords surgery tetracaine intraocular lens lid speculum mcpherson forceps capsular bag eye phacoemulsification cataract lens intraocular MEDICAL_TRANSCRIPTION,Description Visually significant cataract left eye Phacoemulsification cataract extraction with intraocular lens implantation left eye The patient was found to have a visually significant cataract and after discussion of the risks benefits and alternatives to surgery she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction 1 Transcription PREOPERATIVE DIAGNOSIS Visually significant cataract left eye POSTOPERATIVE DIAGNOSIS Visually significant cataract left eye ANESTHESIA Topical MAC PROCEDURE Phacoemulsification cataract extraction with intraocular lens implantation left eye Alcon AcrySof SN60AT 23 0 D serial COMPLICATIONS None INDICATIONS FOR SURGERY The patient is a 74 year old woman with complaints of painless progressive loss of vision in her left eye She was found to have a visually significant cataract and after discussion of the risks benefits and alternatives to surgery she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision PROCEDURE IN DETAIL The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart They were transported to the operative suite accompanied by the anesthesia service where appropriate cardiopulmonary monitoring was established MAC anesthesia was achieved which was followed by topical anesthesia using 1 preservative free tetracaine eye drops The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed Two stab incision paracenteses were made in the cornea using the MVR blade and the anterior chamber was irrigated with 1 preservative free lidocaine for intracameral anesthesia The anterior chamber was filled with viscoelastic and a shelved temporal clear corneal incision was made using the diamond groove knife and steel keratome A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent needle cystotome The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution BSS on a Chang cannula until it rotated freely The phacoemulsification handpiece was introduced into the anterior chamber and the lens nucleus was sculpted into 2 halves Each half was further subdivided with chopping and removed with phacoemulsification The remaining cortical material was removed with the irrigation and aspiration I A handpiece The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty The remaining viscoelastic was removed with the I A handpiece and the anterior chamber was filled to an appropriate intraocular pressure with BSS The corneal wounds were hydrated and verified to be water tight Antibiotic ointment was placed followed by a patch and shield The patient was transported to the PACU in good stable condition There were no complications Followup is scheduled for tomorrow morning in the eye clinic A single interrupted 10 0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case Keywords surgery intraocular lens implantation eye intraocular lens lens implantation cataract extraction cataract intraocular viscoelastic handpiece implantation chamber phacoemulsification extraction visually anterior lens MEDICAL_TRANSCRIPTION,Description Cataract nuclear sclerotic right eye Phacoemulsification with intraocular lens implantation right eye Medical Specialty Surgery Sample Name Phacoemulsification Lens Implantation Transcription PREOPERATIVE DIAGNOSIS Cataract nuclear sclerotic right eye POSTOPERATIVE DIAGNOSIS Cataract nuclear sclerotic right eye OPERATIVE PROCEDURES Phacoemulsification with intraocular lens implantation right eye ANESTHESIA Topical tetracaine intracameral lidocaine monitored anesthesia care IOL AMO Model SI40 NB power diopters INDICATIONS FOR SURGERY This patient has been experiencing difficulty with eyesight regarding activities in their daily life There has been a progressive and gradual decline in the visual acuity By examination this was found to be related to cataracts The risks benefits and alternatives including observation or spectacles were discussed in detail The patient accepted these risks and elected to proceed with cataract surgery All questions were answered and informed consent was obtained Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals risks and alternatives involved as well as the postoperative instructions A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery To minimize and decrease the chance of bacterial infection the patient was started on a course of antibiotic drops for two days prior to surgery DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified The pupil was dilated per protocol The patient was taken to the operating room and placed in a comfortable supine position The operative table was placed in Trendelenburg head up tilt to decrease orbital congestion and posterior vitreous pressure The patient was prepped and draped in the usual ophthalmic sterile fashion The lids and periorbita were prepped with full strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins The conjunctival cul de sac was also prepped in dilute Betadine solution The fornices were also prepped The drape was done meticulously to ensure complete eyelash inclusion An eyelid speculum was placed to separate the eyelids A paracentesis site was made Intracameral preservative free lidocaine was injected Amvisc Plus was then used to stabilize the anterior chamber A 3 mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location A 25 gauge pre bent cystotome was used to begin a capsulorrhexis The capsular flap was removed A 27 gauge blunt cannula was used for hydrodissection The lens was able to be freely rotated within the capsular bag Divide and conquer technique was used for phacoemulsification After four sculpted grooves were made a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment Each of the four nuclear quadrants was phacoemulsified Aspiration was used to remove remaining cortex with the I A handpiece Viscoelastic was used to re inflate the capsular bag The intraocular lens was injected into the capsular bag The lens was then dialed into position The lens was well centered and stable Viscoelastic was aspirated BSS was used to re inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration A Weck Cel sponge was used to check both incision sites for leaks and none were identified The incision sites remained well approximated and dry with a well formed anterior chamber and well centered intraocular lens The eyelid speculum was removed and the patient was cleaned free of Betadine Zymar and Pred Forte drops were applied A firm eye shield was taped over the operative eye The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well Discharge instructions regarding activity restrictions eye drop use eye shield patch wearing and driving restrictions were discussed All questions were answered The discharge instructions were also reviewed with the patient by the discharging nurse The patient was comfortable and was discharged with followup in 24 hours Keywords surgery nuclear sclerotic diopters viscoelastic capsulorrhexis amvisc plus lens implantation intraocular lens intraocular topical cataract phacoemulsification lens MEDICAL_TRANSCRIPTION,Description Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation right eye Medical Specialty Surgery Sample Name Phacoemulsification Cataract Extraction Transcription DIAGNOSIS Nuclear sclerotic and cortical cataract right eye OPERATION Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation right eye PROCEDURE The patient was taken to the operating room and placed on the table in the supine position Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff Local anesthesia was obtained using 2 lidocaine 0 75 Marcaine 0 5 cc Wydase with 6 cc of this solution used in a paribulbar injection followed by ten minutes of digital massage The patient was then prepped and draped in the usual sterile fashion for eye surgery With the Zeiss operating microscopy in position a lid speculum was inserted and a 4 0 black silk bridal suture placed in the superior rectus muscle With Westcott scissors a fornix based conjunctival flap was made The surgical limbus was identified and hemostasis obtained with wet field cautery With a 57 Beaver blade a corneoscleral groove was made and shelved into clear cornea A stab incision was made at 2 o clock with a 15 degree blade With a 3 0 mm keratome the shelved groove was attended into the anterior chamber Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous tear technique Hydrodissection was performed with Balanced Salt Solution Phacoemulsification was performed in a two headed nuclear fracture technique The remaining cortical material was removed with irrigation and aspiration handpiece The posterior capsule remained intact and vacuumed with minimal suction The posterior chamber intraocular lens was obtained It was inspected irrigated inserted into the posterior chamber without difficulty Inspection revealed the intraocular lens to be in good position with intact capsule and well approximated wound There was no aqueous leak even with digital pressure The conjunctiva was pulled back into position with wet field cautery A subconjunctival injection with 20 mg Gatamycine and 0 5 cc Celestone was given Tobradex ointment was instilled into the eye which was patched and shielded appropriately after removing the lid speculum and bridle suture The patient tolerated the procedure well and was sent to the recovery room in good condition to be followed in attending physician office the next day Keywords surgery extracapsular cataract extraction phacoemulsification nuclear sclerotic cortical cataract extraction with intraocular lens cataract extraction intraocular lens intraocular extracapsular implantation conjunctival cataract chamberNOTE MEDICAL_TRANSCRIPTION,Description Perlane injection for the nasolabial fold Restylane injection for the glabellar fold Medical Specialty Surgery Sample Name Perlane Restylane Injection Transcription PREOPERATIVE DIAGNOSES 1 Nasolabial mesiolabial fold 2 Mid glabellar fold POSTOPERATIVE DIAGNOSES 1 Nasolabial mesiolabial fold 2 Mid glabellar fold TITLE OF PROCEDURES 1 Perlane injection for the nasolabial fold 2 Restylane injection for the glabellar fold ANESTHESIA Topical with Lasercaine COMPLICATIONS None PROCEDURE The patient was evaluated preop and noted to be in stable condition Chart and informed consent were all reviewed preop All risks benefits and alternatives regarding the procedure have been reviewed in detail with the patient This includes risk of bleeding infection scarring need for further procedure etc The patient did sign the informed consent form regarding the Perlane and Restylane She is aware of the potential risk of bruising The patient has had Cosmederm in the past and had had a minimal response with this Please note Lasercaine had to be applied 30 minutes prior to the procedure The excess Lasercaine was removed with a sterile alcohol swab Using the linear threading technique I injected the deep nasolabial fold We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold They were carefully massaged into good position at the end of the procedure She did have some mild erythema noted I then used approximately 0 4 mL of the Restylane for injection of the mid glabellar site She has a resting line of the mid glabella that did not respond with previous Botox injection Once this was filled the Restylane was massaged into the proper tissue plane Cold compressors were applied afterwards She is scheduled for a recheck in the next one to two weeks and we will make further recommendations at that time Post Restylane and Perlane precautions have been reviewed with the patient as well Keywords surgery lasercaine nasolabial mesiolabial fold mid glabellar fold perlane injection restylane injection nasolabial fold mesiolabial fold glabellar fold injection perlane nasolabial glabellar restylane MEDICAL_TRANSCRIPTION,Description Ex plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700 Nonfunctioning inflatable penile prosthesis and Peyronie s disease Medical Specialty Surgery Sample Name Penile Prosthesis Replacement Transcription PREOPERATIVE DIAGNOSES 1 Nonfunctioning inflatable penile prosthesis 2 Peyronie s disease POSTOPERATIVE DIAGNOSES 1 Nonfunctioning inflatable penile prosthesis 2 Peyronie s disease PROCEDURE PERFORMED Ex plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700 ANESTHESIA General LMA SPECIMEN Old triple component inflatable penile prosthesis PROCEDURE This is a 64 year old male with prior history of Peyronie s disease and prior placement of a triple component inflatable penile prosthesis which had worked for years for him but has stopped working and subsequently has opted for ex plantation and replacement of inflatable penile prosthesis OPERATIVE PROCEDURE After informed consent the patient was brought to the operative suite and placed in the supine position General endotracheal intubation was performed by the Anesthesia Department and the perineum scrotum penis and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15 minute prep including iodine solution in the urethra The bladder was subsequently drained with a red Robinson catheter At that point the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient s pacemaker and monopolar was only source of hemostasis besides suture At that point we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies Attention was taken then to the tubing going up to the reservoir in the right lower quadrant This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis At this point as we tracked this proximally to the area of the rectus muscle we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis As we tried to remove the tubing and get to the reservoir the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery At that point this tubing was then tracked down to the pump which was fairly easily removed from the dartos pouch in the right scrotum This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked first starting on the right side where a corporotomy incision was made at the placement of two 3 0 Prolene stay ties staying lateral and anterior on the corporal body The corporal body was opened up and the cylinder was removed from the right side without difficulty However we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery this was very difficult and was very time consuming but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding which was controlled with monopolar and cautery was used on three different occasions but just simple small burst under the guidance of anesthesia and there was no ectopy noted After removal of half of the pump all the tubing and both cylinders these were passed off the table as specimen Both corporal bodies were then dilated with the Pratt dilators These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces At this point using the Farlow device corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally He had an 18 cm with rear tips in place which were removed We decided to go ahead to and use another 18 cm inflatable penile prosthesis Confident with our size we then placed rear tips originally 3 cm rear tips however we had difficulty placing the rear tips into the left crest We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm At this point we went ahead and placed the right cylinder using the Farlow device and the Keith needle which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally entered the crest without difficulty Attention was then taken to the left side with the same thing was carried out however we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders This then forced us to down size to the 1 cm rear tips which slipping very easily with the Farlow device through the glans penis There was no crossover and no violation of the tunica albuginea The rear tips were then placed without difficulty and our corporotomies were closed with 2 0 PDS in a running fashion ________ starting on the patient s right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants At that point the wound was copiously irrigated and the device was inflated multiple times There was a very good fit and we had a very good result At that point the pump was subsequently placed in the dartos pouch which already has been created and was copiously irrigated with antibiotic solution This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump Please also note that before placement of our pump attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device which was subsequently placed without difficulty and three simple interrupted sutures of 2 0 Vicryl used to close the defect in the rectus and at that point after placement of our pump the connection was made between the pump and the reservoir without difficulty The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated After completion of the connection using a straight connector the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left but this was able to be ________ with good cosmetic result At that point after irrigation again of the space the area was simply dry and hemostatic The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers The soft tissue and the skin was then reapproximated with staples Please also note that prior to the skin closure a Jackson Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings would be left in place for approximately 12 to 20 hours This was also sutured in place with nylon Sterile dressing was applied Light gauze was wrapped around the penis and or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally Coban was used then to wrap the penis and at the end of the case the patient was straight catheted approximately 400 cc of amber yellow urine No Foley catheter was used or placed The patient was awoken in the operative suite extubated and transferred to recovery room in stable condition He will be admitted overnight to the service of Dr McDevitt Cardiology will be asked to consult with Dr Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics Keywords surgery inflatable penile prosthesis peyronie s disease perineum scrotum penis penile prosthesis bovie cautery corporal body glans penis pump cylinders penile prosthesis inflatable corporal MEDICAL_TRANSCRIPTION,Description A 14 year old young lady is in the renal failure and in need of dialysis Medical Specialty Surgery Sample Name Peritoneal Dialysis Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Renal failure POSTOPERATIVE DIAGNOSIS Renal failure OPERATION PERFORMED Insertion of peritoneal dialysis catheter ANESTHESIA General INDICATIONS This 14 year old young lady is in the renal failure and in need of dialysis She had had a previous PD catheter placed but it became infected and had to be removed She therefore comes back to the operating room for a new PD catheter OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in the usual manner A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection The fascia was divided and the posterior fascia and peritoneum were identified A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed which could easily be brought up through the incision A PD catheter was then placed into the pelvis over a guidewire At this point the peritoneum and posterior fascia was closed around the catheter The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return The skin was closed with 5 0 subcuticular Monocryl Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition Keywords surgery pd catheter catheter omentum peritoneal dialysis catheter peritoneal dialysis renal failure peritoneal dialysis renal MEDICAL_TRANSCRIPTION,Description Permacath placement renal failure Medical Specialty Surgery Sample Name Permacath Placement Transcription PROCEDURE Permacath placement INDICATION Renal failure IMPRESSION Status post successful placement of a 4 French Permacath dialysis catheter DISCUSSION After informed consent was obtained at the request of Dr Xyz Permacath placement was performed The right neck and anterior chest were sterilely cleansed and draped Lidocaine 1 buffered with sodium bicarbonate was used as a local anesthetic Using ultrasound guidance a micropuncture needle was advanced into the internal jugular vein The wire was then advanced with fluoroscopic guidance A dilator was placed An incision was then made at the puncture site for approximately 1 cm in the neck A 1 cm incision was also made in the anterior chest The catheter was tunneled subcutaneously from the incision on the anterior chest out the incision of the neck Following this over the wire the tract into the internal jugular vein was dilated and a peel away sheath was placed The catheter was then advanced through the peel away sheath The peel away sheath was removed The catheter was examined under fluoroscopic imaging and was in satisfactory position Both ports were aspirated and flushed easily Following this the incision on the neck was closed with 2 3 0 silk sutures The incision on the anterior chest was also closed 2 3 0 silk sutures The patient tolerated the procedure well No complications occurred during or immediately after the procedure The patient was returned to her room in satisfactory condition Keywords surgery permacath placement permacath renal failure anterior chest catheter dialysis fluoroscopic fluoroscopic guidance internal jugular vein micropuncture needle sheath sutures ultrasound guidance internal jugular jugular vein placement MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens Sample Template Medical Specialty Surgery Sample Name Phacoemulsification Transcription PREOPERATIVE DIAGNOSIS Senile cataract OX POSTOPERATIVE DIAGNOSIS Senile cataract OX PROCEDURE Phacoemulsification with posterior chamber intraocular lens OX model SN60AT for Acrysof natural lens XXX diopters INDICATIONS This is a XX year old wo man with decreased vision OX PROCEDURE The risks and benefits of cataract surgery were discussed at length with the patient including bleeding infection retinal detachment re operation diplopia ptosis loss of vision and loss of the eye Informed consent was obtained On the day of surgery s he received several sets of drops in the XXX eye including 2 5 phenylephrine 1 Mydriacyl 1 Cyclogyl Ocuflox and Acular S he was taken to the operating room and sedated via IV sedation 2 lidocaine jelly was placed in the XXX eye or retrobulbar anesthesia was performed using a 50 50 mixture of 2 lidocaine and 0 75 marcaine The XXX eye was prepped using a 10 Betadine solution S he was covered in sterile drapes leaving only the XXX eye exposed A Lieberman lid speculum was placed to provide exposure The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 or 11 depending upon side and handedness and assuming superior incision o clock Then 1 lidocaine was injected through the paracentesis After the nonpreserved lidocaine was injected Viscoat was injected through the paracentesis to fill the anterior chamber The Thornton fixation ring and a 2 75 mm keratome blade were used to create a two step full thickness clear corneal incision superiorly The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule BSS on a hydrodissection cannula was used to perform gentle hydrodissection Phacoemulsification was then performed to remove the nucleus I A was performed to remove the remaining cortical material Provisc was injected to fill the capsular bag and anterior chamber A XXX diopter SN60AT for Acrysof natural lens intraocular lens was injected into the capsular bag The Kuglen hook was used to rotate it into proper position in the capsular bag I A was performed to remove the remaining Viscoelastic material from the eye BSS on the 30 gauge cannula was used to hydrate the wound The wounds were checked and found to be watertight The lid speculum and drapes were carefully removed Several drops of Ocuflox were placed in the XXX eye The eye was covered with an eye shield The patient was taken to the recovery area in a good condition There were no complications Keywords surgery phacoemulsification acrysof acrysof natural lens acular kuglen hook ocuflox provisc sn60at senile cataract thornton fixation ring bleeding capsular bag decreased vision diopters diplopia infection loss of the eye loss of vision ptosis retinal detachment lid speculum thornton fixation anterior chamber intraocular lens intraocular chamber lidocaine MEDICAL_TRANSCRIPTION,Description Nuclear sclerotic cataract right eye Kelman phacoemulsification with posterior chamber intraocular lens right eye Medical Specialty Surgery Sample Name Phacoemulsification Kelman Transcription PREOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye POSTOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye OPERATIVE PROCEDURES Kelman phacoemulsification with posterior chamber intraocular lens right eye ANESTHESIA Topical COMPLICATIONS None INDICATION This is a 40 year old male who has been noticing problems with blurry vision They were found to have a visually significant cataract The risks benefits and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the operating room A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion A paracentesis was created at o clock The anterior chamber was filled with Viscoat A clear corneal incision was made at o clock with the 3 mm diamond blade A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps The lens was hydrodissected with a syringe filled with 2 Xylocaine and found to rotate freely within the capsular bag The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion The residual cortex was removed with the irrigation aspiration handpiece The capsular bag was filled with Provisc and a model SI40 15 0 diopter posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well The residual Provisc was removed with the irrigation aspiration handpiece The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution The wounds were found to be free from leak Zymar and Pred Forte were instilled postoperatively The eye was covered with the shield The patient tolerated the procedure well and there were no complications He will follow up with us in one day Keywords surgery nuclear sclerotic cataract intraocular lens cataract kelman phacoemulsification sclerotic cataract posterior chamber capsular bag eye anesthesia phacoemulsification MEDICAL_TRANSCRIPTION,Description Excision of penile skin bridges about 2 cm in size Medical Specialty Surgery Sample Name Penile Skin Bridges Excision Transcription PREOPERATIVE DIAGNOSIS Penile skin bridges after circumcision POSTOPERATIVE DIAGNOSIS Penile skin bridges after circumcision PROCEDURE Excision of penile skin bridges about 2 cm in size ABNORMAL FINDINGS Same as above ANESTHESIA General inhalation anesthetic with caudal block FLUIDS RECEIVED 300 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS No tissue sent to Pathology TUBES AND DRAINS No tubes or drains were used COUNT Sponge and needle counts were correct x2 INDICATIONS FOR OPERATION The patient is a 2 1 2 year old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection Plan is for repair DESCRIPTION OF PROCEDURE The patient is taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized the caudal block was placed and IV antibiotics were given He was then placed in a supine position and sterilely prepped and draped Once he was prepped and draped we used a straight mosquito clamp and went under the bridges and crushed them and then excised them with a curved iris and curved tenotomy scissors We removed the excessive skin on the shaft skin and on the glans itself We then on the ventrum excised the bridge and did a Heinecke Mikulicz closure with interrupted figure of eight and interrupted suture of 5 0 chromic Electrocautery was used for hemostasis Once this was done we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again IV Toradol was given at the end of procedure The patient tolerated the procedure well was in stable condition upon transfer to the recovery room Keywords surgery heinecke mikulicz penile skin bridges caudal block penile skin skin bridges excision circumcision penile MEDICAL_TRANSCRIPTION,Description Pelvic laparotomy lysis of pelvic adhesions and left salpingooophorectomy with insertion of Pain Buster Pain Management System Medical Specialty Surgery Sample Name Pelvic Laparotomy Transcription PREOPERATIVE DIAGNOSIS Large left adnexal mass 8 cm in diameter POSTOPERATIVE DIAGNOSIS Pelvic adhesions 6 cm ovarian cyst PROCEDURES PERFORMED 1 Pelvic laparotomy 2 Lysis of pelvic adhesions 3 Left salpingooophorectomy with insertion of Pain Buster Pain Management System by Dr X GROSS FINDINGS There was a transabdominal mass palpable in the lower left quadrant An ultrasound suggestive with a mass of 8 cm did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment the ovarian neoplasm persisted and did not decreased in size PROCEDURE Under general anesthesia the patient was placed in lithotomy position prepped and draped A low transverse incision was made down to and through to the rectus sheath The rectus sheath was put laterally The inferior epigastric arteries were identified bilaterally doubly clamped and tied with 0 Vicryl sutures The rectus muscle was then split transversally and the peritoneum was split transversally as well The left adnexal mass was identified and large bowel was attached to the mass and Dr Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament The infundibulopelvic ligament was isolated entered via blunt dissection A 0 Vicryl suture was put into place doubly clamped with curved Heaney clamps cut with curved Mayo scissors and 0 Vicryl fixation suture put into place Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then 0 Vicryl suture was put into place Pathology was called to evaluate the mass for potential malignancy and the pathology s verbal report at the time of surgery was that this was a benign lesion Irrigation was used Minimal blood loss at the time of surgery was noted Sigmoid colon was inspected in place in physiologic position of the cul de sac as well as small bowel omentum Instrument needle and sponge counts were called for and found to be correct The peritoneum was closed with 0 Vicryl continuous running locking suture The rectus sheath was closed with 0 Vicryl continuous running locking suture A DonJoy Pain Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples Final instrument needle counts were called for and found to be correct The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition Keywords surgery lysis of pelvic adhesions salpingooophorectomy pain buster pain management system adnexal mass pelvic laparotomy pelvic adhesions rectus sheath vicryl sutures adhesions pelvic MEDICAL_TRANSCRIPTION,Description Percutaneous endoscopic gastrostomy tube Protein calorie malnutrition The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores After discussion with the patient and the son they agreed to place a PEG tube for nutritional supplementation Medical Specialty Surgery Sample Name PEG Tube Transcription PREOPERATIVE DIAGNOSIS Protein calorie malnutrition POSTOPERATIVE DIAGNOSIS Protein calorie malnutrition PROCEDURE PERFORMED Percutaneous endoscopic gastrostomy PEG tube ANESTHESIA Conscious sedation per Anesthesia SPECIMEN None COMPLICATIONS None HISTORY The patient is a 73 year old male who was admitted to the hospital with some mentation changes He was unable to sustain enough caloric intake and had markedly decreased albumin stores After discussion with the patient and the son they agreed to place a PEG tube for nutritional supplementation PROCEDURE After informed consent was obtained the patient was brought to the endoscopy suite He was placed in the supine position and was given IV sedation by the Anesthesia Department An EGD was performed from above by Dr X The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization The needle was removed and a guidewire was inserted through the sheath The guidewire was grasped from above with a snare by the endoscopist It was removed completely and the Ponsky PEG tube was secured to the guidewire The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall There was no evidence of bleeding Photos were taken The Bolster was placed on the PEG site A complete dictation for the EGD will be done separately by Dr X The patient tolerated the procedure well and was transferred to recovery room in stable condition He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal Keywords surgery percutaneous endoscopic gastrostomy tube protein calorie malnutrition peg tube malnutrition nutritional MEDICAL_TRANSCRIPTION,Description Open repair of right pectoralis major tendon Right pectoralis major tendon rupture On MRI evaluation a complete rupture of a portion of the pectoralis major tendon was noted Medical Specialty Surgery Sample Name Pectoralis Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Right pectoralis major tendon rupture POSTOPERATIVE DIAGNOSIS Right pectoralis major tendon rupture OPERATION PERFORMED Open repair of right pectoralis major tendon ANESTHESIA General with an interscalene block COMPLICATIONS None Needle and sponge counts were done and correct INDICATION FOR OPERATION The patient is a 26 year old right hand dominant male who works in sales who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder The patient presented with mild bruising over the proximal arm of the right side with x ray showing no fracture Over concerns for pectoralis tendon tear he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted Due to the patient s young age and active lifestyle surgical treatment was recommended in order to obtain best result The risks and benefits of the procedure were discussed in detail with the patient including but not limited to scarring infection damage to blood vessels and nerves re rupture need further surgery loss of range of motion inability to return to heavy activity such as weight lifting complex usual pain syndrome and deep vein thrombosis as well as anesthetic risks Understanding all risks and benefits the patient desires to proceed with surgery as planned FINDINGS 1 Following deltopectoral approach to the right shoulder the pectoralis major tendon was encountered The clavicular head was noted to be intact There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion 2 Following freeing of adhesions using tracks and sutures the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps 3 A soft tissue repair was performed with 5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site Following repair of soft tissue and using the bone anchor there was noted to be good apposition of the tendon with edges and a solid repair OPERATIVE REPORT IN DETAIL The patient was identified in the preop holding area His right shoulder was identified marked his appropriate surgical site after verification with the patient He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team He then received prophylactic antibiotics A time out was then undertaken verifying the correct patient extremity surgery performed administration of antibiotics and the availability of equipment At this point the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes The right upper extremity was then prepped and draped in the usual sterile fashion Preoperative markings were still visible at this point A deltopectoral incision was made utilizing the inferior portion Dissection was carried down The deltoid was retracted laterally The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion There was a small cuff of tissue left on the proximal humerus associated with the clavicular head Gentle probing medially revealed the end of the sternal retracted portion traction sutures of 5 Ethibond were used in this to allow for retraction and freeing from light adhesion This allowed reapproximation of the retracted tendon to the tendon stump At this point a repair using 5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site At this point a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site however the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone For this reason the starting hole was tapped and a 5x5 bioabsorbable anchor was placed doubly loaded The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair At this point there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation Aggressive external rotation was not performed The wound was then copiously irrigated The cephalic vein was not injured during the case The skin was then closed using a 2 0 Vicryl followed by a 3 0 subcuticular Prolene suture with Steri Strips Sterile dressing was then placed Anesthesia was then performed interscalene block The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated Plan for this patient the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days We will then start a gentle Codman type exercises and having limited motion until the 4 6 week point based on the patient s progression Keywords surgery tendon rupture interscalene block pectoralis major tendon rupture pectoralis major tendon repair pectoralis interscalene tendon rupture sutures MEDICAL_TRANSCRIPTION,Description Ligation clip interruption of patent ductus arteriosus This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch Medical Specialty Surgery Sample Name Patent Ductus Arteriosus Ligation Transcription TITLE OF OPERATION Ligation clip interruption of patent ductus arteriosus INDICATION FOR SURGERY This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch She has now been put forward for operative intervention PREOP DIAGNOSIS 1 Patent ductus arteriosus 2 Severe prematurity 3 Operative weight less than 4 kg 600 grams COMPLICATIONS None FINDINGS Large patent ductus arteriosus with evidence of pulmonary over circulation After completion of the procedure left recurrent laryngeal nerve visualized and preserved Substantial rise in diastolic blood pressure DETAILS OF THE PROCEDURE After obtaining information consent the patient was positioned in the neonatal intensive care unit cribbed in the right lateral decubitus and general endotracheal anesthesia was induced The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion It was then test occluded and then interrupted with a medium titanium clip There was preserved pulsatile flow in the descending aorta The left recurrent laryngeal nerve was identified and preserved With excellent hemostasis the intercostal space was closed with 4 0 Vicryl sutures and the muscular planes were reapproximated with 5 0 Caprosyn running suture in two layers The skin was closed with a running 6 0 Caprosyn suture A sterile dressing was placed Sponge and needle counts were correct times 2 at the end of the procedure The patient was returned to the supine position in which palpable bilateral femoral pulses were noted I was the surgical attending present in the neonatal intensive care unit and in charge of the surgical procedure throughout the entire length of the case Keywords surgery clip interruption ligation patent ductus arteriosus premature baby intercostal space arteriosus interruption pulmonary circulation MEDICAL_TRANSCRIPTION,Description Sinus bradycardia sick sinus syndrome poor threshold on the ventricular lead and chronic lead Right ventricular pacemaker lead placement and lead revision Medical Specialty Surgery Sample Name Pacemaker Lead Placement Rrevision Transcription PROCEDURE Right ventricular pacemaker lead placement and lead revision INDICATIONS Sinus bradycardia sick sinus syndrome poor threshold on the ventricular lead and chronic lead EQUIPMENT A new lead is a Medtronic model 12345 threshold sensing at 5 7 impedance of 1032 threshold of 0 3 atrial threshold is 0 3 531 and sensing at 4 1 The original chronic ventricular lead had a threshold of 3 5 and 6 on the can ESTIMATED BLOOD LOSS 5 mL PROCEDURE DESCRIPTION Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine The patient received a venogram documenting patency of the subclavian vein Skin incision with blunt and sharp dissection Electrocautery for hemostasis The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads The leads were sequentially checked Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava Ultimately a ventricular lead was placed in apex of the right ventricle secured to base pocket with 2 0 silk suture Pocket was irrigated with antibiotic solution The pocket was packed with bacitracin soaked gauze This was removed during the case and then irrigated once again The generator was attached to the leads placed in the pocket secured with 2 0 silk suture and the pocket was closed with a three layer of 4 0 Monocryl CONCLUSION Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model 12345 Keywords surgery medtronic atrial subclavian sick sinus syndrome pacemaker lead placement ventricular pacemaker ventricular lead lead bradycardia pacemaker threshold ventricular MEDICAL_TRANSCRIPTION,Description Coil embolization of patent ductus arteriosus Medical Specialty Surgery Sample Name Patent Ductus Arteriosus Transcription HISTORY The patient is a 5 1 2 year old who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus An echocardiogram from 09 13 2007 demonstrated a 3 8 mm patent ductus arteriosus with restrictive left to right shunt There is mild left atrial chamber enlargement with an LA AO ratio of 1 821 An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy The patient underwent cardiac catheterization for device closure of a ductus arteriosus PROCEDURE After sedation and local Xylocaine anesthesia the patient was prepped and draped Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a 5 French sheath a 5 French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries The atrial septum was not probe patent Using a 4 French sheath a 4 French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta ascending aorta and left ventricle A descending aortogram demonstrated a small type A patent ductus arteriosus with a small left to right angiographic shunt Minimal diameter was approximately 1 6 mm with ampulla diameter of 5 8 mm and length of 6 2 mm The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta This catheter exchanged over wire for a 5 French nit occlude delivery catheter through which a nit occlude 6 5 flex coil that was advanced and allowed to reconfigure the descending aorta Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery Once the stable device configuration was confirmed by fluoroscopy device was released from the delivery catheter Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity Cineangiograms were obtained with injection in the descending aorta After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the recovery room in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left to right shunt through the ductus arteriosus The left sided heart was fully saturated The phasic right sided and left sided pressures were normal The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP QS ratio of 1 1 Vascular resistances were normal A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left to right angiographic shunt The branch pulmonary arteries appeared normal There is otherwise a normal left aortic arch Following coil embolization of the ductus arteriosus there is no change in mixed venous saturation No evidence of residual left to right shunt There is no change in right sided pressures There is a slight increase in the left sided phasic pressures Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP QS ratio of 1 1 Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery There is a trace residual shunt through the center of coil mass INITIAL DIAGNOSES Patent ductus arteriosus SURGERIES INTERVENTIONS Coil embolization of patent ductus arteriosus MANAGEMENT The case to be discussed at Combined Cardiology Cardiothoracic Surgery case conference The patient will require a cardiologic followup in 6 months and 1 year s time including clinical evaluation and echocardiogram Further patient care be directed by Dr X Keywords surgery cardiac murmur coil embolization cineangiograms patent ductus arteriosus pulmonary artery patent ductus descending aorta ductus arteriosus catheterization MEDICAL_TRANSCRIPTION,Description Patellar tendon and medial and lateral retinaculum repair right knee Patellar tendon retinaculum ruptures right knee Medical Specialty Surgery Sample Name Patellar Tendon Retinaculum Repair Transcription PREOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee POSTOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee PROCEDURE PERFORMED Patellar tendon and medial and lateral retinaculum repair right knee SPECIFICATIONS Intraoperative procedure done at Inpatient Operative Suite room 2 of ABCD Hospital This was done under subarachnoid block anesthetic in supine position HISTORY AND GROSS FINDINGS The patient is a 45 year old African American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x ray the evening before surgical intervention He did this while playing basketball He had a massive deficit at the inferior pole of his patella on exam Once opened he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum Minimal cartilaginous pieces were at the patellar tendon He had grade II changes to his femoral sulcus as well as grade I II changes to the undersurface of the patella OPERATIVE PROCEDURE The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department A thigh high tourniquet was placed He is prepped and draped in the usual sterile manner Limb was elevated exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes Straight incision is carried down through skin and subcutaneous tissue anteriorly Hemostasis was controlled via electrocoagulation Patellar tendon was isolated along with the patella itself A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape The inferior pole was freshened up Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer This was tied over the bony bridge superiorly There was excellent reduction of the tendon to the patella Interrupted running 1 Vicryl suture was utilized for over silk A running 2 0 Vicryl for synovial closure medial and laterally as well as 1 Vicryl medial and lateral retinaculum There was excellent repair Copious irrigation was carried out Tourniquet was dropped and hemostasis controlled via electrocoagulation Interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin Adaptic 4 x 4s ABDs and sterile Webril were placed for compression dressing Digits were warm and no brawny pulses present at the end of the case The patient s leg was placed in a Don Joy brace 0 to 20 degrees of flexion He will leave this until seen in the office Expected surgical prognosis on this patient is fair Keywords surgery subarachnoid patellar tendon retinaculum tendon patellar tourniquet knee ruptures retinaculum MEDICAL_TRANSCRIPTION,Description Excision of right superior parathyroid adenoma seen on sestamibi parathyroid scan and an ultrasound Medical Specialty Surgery Sample Name Parathyroid Adenoma Excision Transcription PREOPERATIVE DIAGNOSIS Right superior parathyroid adenoma POSTOPERATIVE DIAGNOSIS Right superior parathyroid adenoma PROCEDURE Excision of right superior parathyroid adenoma ANESTHESIA Local with 1 Xylocaine and anesthesia standby with sedation CLINICAL HISTORY This 80 year old woman has had some mild dementia She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations She was found to be hypercalcemic Intact PTH was mildly elevated A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma FINDINGS AND PROCEDURE The patient was placed on the operating table in the supine position A time out was taken so that the anesthesia personnel nursing personnel surgical team and patient could confirm the patient s identity operative site and operative plan The electronic medical record was reviewed as was the ultrasound The patient was sedated A small roll was placed behind the shoulders to moderately hyperextend the neck The head was supported in a foam head cradle The neck and chest were prepped with chlorhexidine and isolated with sterile drapes After infiltration with 1 Xylocaine with epinephrine along the planned incision a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin subcutaneous tissue and platysma The larger anterior neck veins were divided between 4 0 silk ligatures Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection The sternohyoid muscles were separated in the midline and the right sternohyoid muscle was retracted laterally The right sternothyroid muscle was divided transversely with the cautery The right middle thyroid vein was divided between 4 0 silk ligatures The right thyroid lobe was rotated leftward Posterior to the mid portion of the left thyroid lobe a right superior parathyroid adenoma of moderate size was identified This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed It was sent for weight and frozen section It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma Prior to the procedure a peripheral blood sample had been obtained and placed in a purple top tube labeled pre excision It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma However we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts and therefore we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH The neck was irrigated with saline and hemostasis found to be satisfactory The sternohyoid muscles were reapproximated with interrupted 4 0 Vicryl The platysma was closed with interrupted 4 0 Vicryl and the skin was closed with subcuticular 5 0 Monocryl and Dermabond The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well Keywords surgery parathyroid adenoma superior parathyroid adenoma excision sestamibi parathyroid scan sestamibi parathyroid parathyroid scan sternohyoid muscles superior parathyroid parathyroid sestamibi platysma adenoma ultrasound sternohyoid thyroid muscles MEDICAL_TRANSCRIPTION,Description Paracentesis A large abdominal mass which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room Medical Specialty Surgery Sample Name Paracentesis Transcription PREOPERATIVE DIAGNOSIS Abdominal mass POSTOPERATIVE DIAGNOSIS Abdominal mass PROCEDURE Paracentesis DESCRIPTION OF PROCEDURE This 64 year old female has stage II endometrial carcinoma which had been resected before and treated with chemotherapy and radiation At the present time the patient is under radiation treatment Two weeks ago or so she developed a large abdominal mass which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days The cytology of the fluid was negative and the culture was also negative Eventually the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis The CAT scan showed accumulation of the fluid and the mass almost achieving 80 of the previous size Therefore I called the patient home and she came to the emergency department where the service was provided At that time I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion Unfortunately the catheter was open I did not have a drainage system at that time So I withdrew directly with a syringe 700 mL of clear fluid The system was connected to the draining bag and the patient was instructed to keep a log and how to use equipment She was given an appointment to see me in the office next Monday which is three days from now Keywords surgery abdominal mass clear fluid cat scan pigtail catheter paracentesis MEDICAL_TRANSCRIPTION,Description Ultrasound Guided Paracentesis for Ascites Medical Specialty Surgery Sample Name Paracentesis Ultrasound Guided Transcription EXAM Ultrasound guided paracentesis HISTORY Ascites TECHNIQUE AND FINDINGS Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained Ultrasound demonstrates free fluid in the abdomen The area of interest was localized with ultrasonography The region was sterilely prepped and draped in the usual manner Local anesthetic was administered A 5 French Yueh catheter needle combination was taken Upon crossing into the peritoneal space and aspiration of fluid the catheter was advanced out over the needle A total of approximately 5500 mL of serous fluid was obtained The catheter was then removed The patient tolerated the procedure well with no immediate postprocedure complications IMPRESSION Ultrasound guided paracentesis as above Keywords surgery yueh catheter aspiration of fluid ultrasound guided paracentesis ultrasound guided needle catheter paracentesis ultrasound ascites MEDICAL_TRANSCRIPTION,Description Reduction of paraphimosis Medical Specialty Surgery Sample Name Paraphimosis Transcription PREOPERATIVE DIAGNOSIS Phimosis POSTOPERATIVE DIAGNOSIS Phimosis PROCEDURE Reduction of paraphimosis ANESTHESIA General inhalation anesthetic with 0 25 Marcaine penile block and ring block about 20 mL given FLUIDS RECEIVED 100 mL SPECIMENS No tissues sent to pathology COUNTS Sponge and needle counts were not necessary TUBES DRAINS No tubes or drains were used FINDINGS Paraphimosis with moderate swelling INDICATIONS FOR OPERATION The patient is a 15 year old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis The plan is for reduction DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis Using Betadine and alcohol cleanse we then did a dorsal penile block and a ring block by surgeon with 0 25 Marcaine 20 mL were given He did quite well after the procedure and was transferred to the recovery room in stable condition Keywords surgery dorsal penile block reduction of paraphimosis penile block phimosis paraphimosis MEDICAL_TRANSCRIPTION,Description Insertion of transvenous pacemaker for tachybrady syndrome Medical Specialty Surgery Sample Name Pacemaker Insertion Transcription PREOPERATIVE DIAGNOSIS Tachybrady syndrome POSTOPERATIVE DIAGNOSIS Tachybrady syndrome OPERATIVE PROCEDURE Insertion of transvenous pacemaker ANESTHESIA Local PROCEDURE AND GROSS FINDINGS The patient s chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated In the left subclavian region a subclavian stick was performed without difficulty and a wire was inserted Fluoroscopy confirmed the presence of the wire in the superior vena cava An introducer was then placed over the wire The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy Following calibration the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area The subcutaneous tissues were irrigated and closed with Interrupted 4 O Vicryl and the skin was closed with staples Sterile dressings were placed and the patient was returned to the ICU in good condition Keywords surgery insertion of transvenous pacemaker fluoroscopy tachybrady tachybrady syndrome chest pacemaker subclavian subcutaneous superior vena cava syndrome transvenous pacemaker wire insertion MEDICAL_TRANSCRIPTION,Description Pacemaker ICD interrogation Severe nonischemic cardiomyopathy with prior ventricular tachycardia Medical Specialty Surgery Sample Name Pacemaker Interrogation Transcription PROCEDURE NOTE Pacemaker ICD interrogation HISTORY OF PRESENT ILLNESS The patient is a 67 year old gentleman who was admitted to the hospital He has had ICD pacemaker implantation This is a St Jude Medical model current DRRS 12345 pacemaker DIAGNOSIS Severe nonischemic cardiomyopathy with prior ventricular tachycardia FINDINGS The patient is a DDD mode base rate of 60 max tracking rate of 110 beats per minute atrial lead is set at 2 5 volts with a pulse width of 0 5 msec ventricular lead set at 2 5 volts with a pulse width of 0 5 msec Interrogation of the pacemaker shows that atrial capture is at 0 75 volts at 0 5 msec ventricular capture 0 5 volts at 0 5 msec sensing in the atrium is 5 34 to 5 8 millivolts R sensing is 12 12 0 millivolts atrial lead impendence 590 ohms ventricular lead impendence 750 ohms The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules followed by 36 joules followed by 36 joules times 2 VF detection criteria set at 187 beats per minute with therapy of 25 joules followed by 36 joules times 5 The patient is in normal sinus rhythm IMPRESSION Normally functioning pacemaker ICD post implant day number 1 Keywords surgery cardiomyopathy ventricular tachycardia pacemaker icd interrogation millivolts impendence interrogation pacemaker MEDICAL_TRANSCRIPTION,Description Single chamber pacemaker implantation Successful single chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure Medical Specialty Surgery Sample Name Pacemaker Single Chamber Transcription SINGLE CHAMBER PACEMAKER IMPLANTATION PREOPERATIVE DIAGNOSIS Mobitz type II block with AV dissociation and syncope POSTOPERATIVE DIAGNOSIS Mobitz type II block status post single chamber pacemaker implantation Boston Scientific Altrua 60 serial number 123456 PROCEDURES 1 Left subclavian access under fluoroscopic guidance 2 Left subclavian venogram under fluoroscopic evaluation 3 Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345 serial number 123456 4 Insertion of single chamber pacemaker implantation Altrua serial number 123456 5 Closure of the pocket after formation of pocket for pacemaker PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient was brought to the cath lab draped and prepped in the usual sterile fashion received 1 5 mg of versed and 25 mg of Benadryl for conscious sedation Access to the right subclavian was successful after the second attempt The first attempt accessed the left subclavian artery The needle was removed and manual compression applied for five minutes followed by re accessing the subclavian vein successfully The J wire was introduced into the left subclavian vein The anterior wall chest was anesthetized with lidocaine 2 2 inch incision using a 10 blade was used The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis The patient went asystole during the procedure The transcutaneous pacer was used The patient was oxygenating well The patient had several compression applied by the nurse However her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby After that the J wire was tunneled into the pocket and then used to put the 7 French sheath into the left subclavian vein The lead from the Boston Scientific Dextrose model 12345 serial number 12345 was inserted through the left subclavian to the right atrium however it was difficult to really enter the right ventricle and while the lead was in place the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium The findings were showing different anatomy may be consistent with persistent left superior vena cava and the angle to the right ventricle was different At that point the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place At that point the lead was actively fixated The stylet was removed The R wave measured at 40 millivolts The impedance was 580 and the threshold was 1 3 volt The numbers were accepted and because of the patient s fragility and the different anatomy noticed in the right atrium concern about putting a second lead with re access of the subclavian was high I decided to proceed with a single chamber pacemaker as a backup system After that the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion The lead was attached to the pacemaker in the header The pacemaker was single chamber pacemaker Altura 60 serial number 123456 After that the pacemaker was put in the pocket Pocket was irrigated with normal saline and was closed into two layers deep interrupted 3 0 Vicryl and surface as continuous 4 0 Vicryl continuous The pacemaker was programmed as VVI 60 and with history is 10 to 50 beats per minute The lead position will be evaluated with chest x ray No significant bleeding noticed CONCLUSION Successful single chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure No significant bleed Keywords surgery mobitz av dissociation syncope mobitz type ii block boston scientific altrua subclavian venogram ventricular single chamber pacemaker implantation single chamber pacemaker pacemaker implantation pacemaker vein chest atrium ventricle atrial implantation chamber MEDICAL_TRANSCRIPTION,Description Implantation of a dual chamber permanent pacemaker Medical Specialty Surgery Sample Name Pacemaker Dual Chamber Transcription CLINICAL HISTORY This 78 year old black woman has a history of hypertension but no other cardiac problems She noted complaints of fatigue lightheadedness and severe dyspnea on exertion She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm consistent with sinoatrial exit block and she is on no medications known to cause bradycardia An echocardiogram showed an ejection fraction of 70 without significant valvular heart disease PROCEDURE Implantation of a dual chamber permanent pacemaker APPROACH Left cephalic vein LEADS IMPLANTED Medtronic model 12345 in the right atrium serial number 12345 Medtronic 12345 in the right ventricle serial number 12345 DEVICE IMPLANTED Medtronic EnRhythm model 12345 serial number 12345 LEAD PERFORMANCE Atrial threshold less than 1 3 volts at 0 5 milliseconds P wave 3 3 millivolts Impedance 572 ohms Right ventricle threshold 0 9 volts at 0 5 milliseconds R wave 10 3 Impedance 855 ESTIMATED BLOOD LOSS 20 mL COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1 lidocaine for local anesthesia A 2 1 2 inch incision was made below the left clavicle and electrocautery was used for hemostasis Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator The deltopectoral groove was explored and a medium sized cephalic vein was identified The distal end of the vein was ligated and a venotomy was performed Two guide wires were advanced to the superior vena cava and peel away introducer sheaths were used to insert the two pacing leads The venous pressures were elevated and there was a fair amount of back bleeding from the vein so a 3 0 Monocryl figure of eight stitch was placed around the tissue surrounding the vein for hemostasis The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage The leads were tested with a pacing systems analyzer and the results are noted above The leads were then anchored in place with 0 silk around their suture sleeve and connected to the pulse generator The pacemaker was noted to function appropriately The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket The incision was closed with two layers of 3 0 Monocryl and a subcuticular closure of 4 0 Monocryl The incision was dressed with Steri Strips and a sterile bandage and the patient was returned to her room in good condition IMPRESSION Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein The patient will be observed overnight and will go home in the morning Keywords surgery medtronic enrhythm cephalic vein dual chamber dual chamber permanent pacemaker dyspnea on exertion echocardiogram fatigue hypertension lightheadedness normal sinus rhythm pacemaker permanent pacemaker sinoatrial exit block sinus bradycardia valvular heart disease bradycardia medtronic atrial MEDICAL_TRANSCRIPTION,Description Plantar flex third metatarsal and talus bunion right foot Third metatarsal osteotomy talus bunionectomy and application of short leg cast right foot Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding all of which provided inadequate relief At this time she desires to attempt a surgical correction Medical Specialty Surgery Sample Name Osteotomy Bunionectomy 1 Transcription PREOPERATIVE DIAGNOSES 1 Plantar flex third metatarsal right foot 2 Talus bunion right foot POSTOPERATIVE DIAGNOSES 1 Plantar flex third metatarsal right foot 2 Talus bunion right foot PROCEDURE PERFORMED 1 Third metatarsal osteotomy right foot 2 Talus bunionectomy right foot 3 Application of short leg cast right foot ANESTHESIA TIVA local HISTORY This 31 year old female presents to ABCD Preoperative Holding Area after keeping herself n p o since mid night for surgery on her painful right third plantar flex metatarsal In addition she complains of a painful right talus bunion to the right foot She has tried conservative methods such as wide shoes and serial debridement and accommodative padding all of which provided inadequate relief At this time she desires to attempt a surgical correction The risks versus benefits of the procedure have been explained to the patient by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department Of Anesthesia the patient was taken to the operating room via cart She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction Next copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied Next after adequate IV sedation was administered by the Department Of Anesthesia a total of 10 cc mixture of 4 5 cc of 1 lidocaine 4 5 cc of 0 5 Marcaine 1 cc of Kenalog was injected into the right foot in an infiltrative type block Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg Next the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head A previous cicatrix was noted with slight hypertrophic scarring Using a 10 blade a lazy S type incision was created over the dorsal aspect of the third metatarsal approximately 3 5 cm in length Two semi elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen Next the 15 blade was used to deepen the incision down to the subcutaneous tissue Any small traversing veins were ligated with electrocautery Next a combination of blunt and sharp dissection were used to undermine the long extensor tendon which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue Next the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified A linear incision down to bone was made with a 15 blade to the capsuloperiosteal tissues Next the capsuloperiosteal tissues were elevated using a sharp dissection with a 15 blade off of the third metatarsal McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed A moderate amount of plantar adhesions were encountered The third toe was plantar flex and the third metatarsal was delivered into the wound Next a V shaped osteotomy with an apex distally was created using a sagittal saw The metatarsal head was allowed to float The wound was flushed with copious amounts of sterile saline 3 0 Vicryl was used to close the capsuloperiosteal tissues which kept the metatarsal head contained Next 4 0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique Next 4 0 nylon was used to close the skin in a simple interrupted technique Attention was directed to the right fifth metatarsal There was a large palpable hypertrophic prominence which is the area of maximal pain which the patient complained of preoperatively A 10 blade was used to make a 3 cm incision through the skin Next a 15 blade was used to deepen the incision through the subcutaneous tissue Next the medial and lateral aspects were undermined The abductor tendon was identified and retracted A capsuloperiosteal incision was made with a 15 blade in a linear fashion down to the bone The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a 15 blade Next the sagittal saw was used to resect the large hypertrophic dorsal exostosis A reciprocating rasp was used to smooth all bony prominences The wound was flushed with copious amount of sterile saline 3 0 Vicryl was used to close the capsuloperiosteal tissues 4 0 Vicryl was used to close subcutaneous layer with a simple interrupted suture Next 4 0 nylon was used to close the skin in a simple interrupted technique Next attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head A 15 blade was used to make a small linear incision under the third metatarsal head The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa The wound was flushed and two simple interrupted sutures with 4 0 nylon were applied Standard postoperative dressing was applied consisting of Xeroform 4x4s Kerlix Kling and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits A sterile stockinet was placed on the toes just below the knee Copious amounts of Webril were placed on all bony prominences 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well padded well moulded cast One was able to insert two fingers to the distal and proximal aspects of the _cast The capillary refill time to the digits was less than three seconds after cast application The patient tolerated the above anesthesia and procedures without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She was given standard postoperative instructions to rest ice and elevate her right foot She was counseled on smoking cessation She was given Vicoprofen 30 1 p o q 4 6h p r n pain She was given Keflex 30 1 p o t i d She is to follow up with Dr X on Monday She is to be full weightbearing with a cast boot She was given emergency contact numbers to call us if problem arises Keywords surgery plantar flex talus bunion talus bunionectomy metatarsal osteotomy osteotomy short leg cast hypertrophic scarring subcutaneous tissue sharp dissection linear incision foot talus pneumatic ankle capsuloperiosteal tissues plantar foot metatarsal capsuloperiosteal bunionectomy MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left distal radius Medical Specialty Surgery Sample Name ORIF of Left Distal Radius Transcription PREOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular POSTOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular PROCEDURE Open reduction and internal fixation of left distal radius IMPLANTS Wright Medical Micronail size 2 ANESTHESIA LMA TOURNIQUET TIME 49 minutes BLOOD LOSS Minimal COMPLICATIONS None PATHOLOGY None TIME OUT Time out was performed before the procedure started INDICATIONS The patient was a 42 year old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis The patient was in early stage of gestation Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor DESCRIPTION OF PROCEDURE Supine position LMA anesthesia well padded arm tourniquet Hibiclens alcohol prep and sterile drape Exsanguination achieved tourniquet inflated to 250 mmHg First under fluoroscopy the fracture was reduced A 0 045 K wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction A 2 cm radial incision superficial radial nerve was exposed and protected Dissecting between the first and second dorsal extensor retinaculum the second dorsal extensor compartment was elevated off from the distal radius The guidewire was inserted under fluoroscopy A cannulated drill was used to drill antral hole Antral awl was inserted Then we reamed the canal to size 2 Size 2 Micronail was inserted to the medullary canal Using distal locking guide three locking screws were inserted distally The second dorsal incision was made The deep radial dorsal surface was exposed Using locking guide two proximal shaft screws were inserted and locked the nail to the radius Fluoroscopic imaging was taken and showing restoration of the height tilt and inclination of the radius At this point tourniquet was deflated hemostasis achieved wounds irrigated and closed in layers Sterile dressing applied The patient then was extubated and transferred to the recovery room under stable condition Postoperatively the patient will see a therapist within five days We will immobilize wrist for two weeks and then starting flexion extension and prosupination exercises Keywords surgery distal radius fracture dorsal extensor locking guide radius fracture extraarticular metaphyseal guidewire fracture dorsal distal MEDICAL_TRANSCRIPTION,Description OssaTron extracorporeal shockwave therapy to right lateral epicondyle Right lateral epicondylitis Medical Specialty Surgery Sample Name OssaTron Extracorporeal Shockwave Therapy Transcription PREOPERATIVE DIAGNOSIS Right lateral epicondylitis POSTOPERATIVE DIAGNOSIS Right lateral epicondylitis OPERATION PERFORMED OssaTron extracorporeal shockwave therapy to right lateral epicondyle ANESTHESIA Bier block DESCRIPTION OF PROCEDURE With the patient under adequate Bier block anesthesia the patient was positioned for extracorporeal shockwave therapy The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient s input of maximum pain Then using standard extracorporeal shockwave protocol the OssaTron treatment was applied to the lateral epicondyle of the elbow After completion of the treatment the tourniquet was deflated and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well Keywords surgery epicondylitis ossatron extracorporeal shockwave therapy bier block epicondyle ossatron extracorporeal shockwave MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of the right wrist using an Acumed locking plate Closed displaced angulated fracture of the right distal radius Medical Specialty Surgery Sample Name ORIF Wrist Acumed Locking Plate Transcription PREOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius POSTOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius PROCEDURE Open reduction and internal fixation ORIF of the right wrist using an Acumed locking plate ANESTHESIA General laryngeal mask airway ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME 40 minutes COMPLICATIONS None The patient was taken to the postanesthesia care unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 23 year old gentleman who was involved in a crush injury to his right wrist He was placed into a well molded splint after reduction was performed in the emergency department Further x rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted All risks benefits expectations and complications of the surgery were explained to the patient in detail and he signed the informed consent for ORIF of the right wrist PROCEDURE The patient was taken to the operating suite placed in supine position on the operative table The Department of anesthesia administered a general endotracheal anesthetic which the patient tolerated well The right upper extremity had a well padded tourniquet placed on the right arm which was insufflated and maintained for 40 minutes at 250 mmHg pressure The right upper extremity was prepped and draped in a sterile fashion A 5 cm incision was made over the flexor carpi radialis of the right wrist The skin was incised down to the subcutaneous tissue the deep tissue was retracted blunt dissection was performed down to the pronator quadratus Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue Next a reduction was performed placing the distal fragment into appropriate alignment This was checked under fluoroscopy and was noted to be adequately reduced and in appropriate position An Acumed Accu lock plate was placed along the volar aspect of the distal radius This was checked under AP and lateral views with C arm noted to be in appropriate alignment A 3 5 mm cortical screw was placed through the proximal aspect of the plate positioned it into position Two distal locking screws were placed along the plate itself The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture AP and lateral views were taken of these screw placements again None of these screws were into the joint and all had appropriate length into the dorsal cortex Two more 3 5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws Bicortical purchase was appreciated and no screws were placed into the joint The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2 0 Vicryl and the skin was closed with running 4 0 nylon stitch 10 mL of 0 5 Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint The patient was awakened from general anesthetic transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition The patient tolerated the procedure well Keywords surgery open reduction angulated fracture distal radius acumed locking plate internal fixation tourniquet acumed orif reduction fracture wrist MEDICAL_TRANSCRIPTION,Description Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip Osteosynthesis of acetabular fracture on the left complex variety and total hip replacement Medical Specialty Surgery Sample Name Osteosynthesis Transcription PREOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip POSTOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip PROCEDURES 1 Osteosynthesis of acetabular fracture on the left complex variety 2 Total hip replacement ANESTHESIA General COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient in the left side up lateral position under adequate general endotracheal anesthesia the patient s left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion draped with sterile towels and drapes so as to create a sterile field Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion tagged and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column The major transverse fracture was freed of infolded soft tissue clotted blood and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7 hole 3 5 mm reconstruction plate with the montage including two interfragmentary screws It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface Once a stable fixation of the reduced fracture of the acetabulum was accomplished it should be mentioned that in the process of doing this the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall Once this was accomplished the procedure was turned over to Dr X and his team who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same This will be dictated in separate note The patient tolerated the procedure well The sciatic nerve was well protected and directly visualized to the level of the notch Keywords surgery hip replacement osteosynthesis intertrochanteric variety femoral insertion acetabular fracture fracture acetabular intertrochanteric femoral MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long arm posterior well molded splint and closed reduction casting of the right forearm Medical Specialty Surgery Sample Name ORIF Closed Reduction Transcription PREOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction attempts 2 right radial shaft fracture with volar apex angulation POSTOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction attempts 2 right radial shaft fracture with volar apex angulation PROCEDURES 1 Open reduction internal fixation of the left medial epicondyle fracture with placement in a long arm posterior well molded splint 2 Closed reduction casting of the right forearm ANESTHESIA Surgery performed under general anesthesia Local anesthetic was 10 mL of 0 5 Marcaine TOURNIQUET TIME On the left was 29 minutes COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 13 year old right hand dominant girl who fell off a swing at school around 1 30 today The patient was initially seen at an outside facility and brought here by her father given findings on x ray a closed reduction was attempted on the left elbow After the attempted reduction the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure Given this finding the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve At that same time the patient s mildly angulated radial shaft fracture will be reduced This was explained to the father The risks of surgery included the risk of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure need for later hardware removal and possible continuous nerve symptoms All questions were answered The father agreed to the above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was then administered The patient received Ancef preoperatively The left upper extremity was then prepped and draped in the standard surgical fashion Attempts to remove the incarcerated medial epicondyle with supination valgus stress and with extension were unsuccessful It was decided at this time that she would need open reduction The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg The Esmarch was then removed An incision was then made Care was taken to avoid any injury to the ulnar nerve The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint This was easily removed The ulnar nerve was also identified and appeared to be intact The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3 2 drill bit and subsequently a 44 mm 4 5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place After fixation of the fragment the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement The wound was then irrigated with normal saline and closed using 2 0 Vicryl and 4 0 Monocryl The wound was clean and dry dressed with Steri Strips and Xeroform The area was infiltrated with 0 5 Marcaine The patient was then placed in a long arm posterior well molded splint with 90 degrees of flexion and neutral rotation The tourniquet was released at 30 minutes prior to placement of the dressing showed no significant bleeding Attention was then turned to right side the arm was then manipulated and a well molded long arm cast placed The final position in the cast revealed a very small residual volar apex angulation which is quite acceptable in this age The patient tolerated the procedure well was subsequently extubated and taken to recovery in a stable condition POSTOPERATIVE PLAN The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days The father was made aware of the intraoperative findings All questions answered Keywords surgery orif elbow fracture dislocation open reduction internal fixation closed reduction left medial epicondyle fracture long arm posterior well molded splint splint radial shaft fracture volar apex angulation medial epicondyle fracture medial epicondyle internal fixation epicondyle fracture ulnar nerve epicondyle fracture reduction tourniquet ulnar nerve MEDICAL_TRANSCRIPTION,Description Distal metaphyseal osteotomy and bunionectomy with internal screw fixation right foot Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx right foot Medical Specialty Surgery Sample Name Osteotomy Bunionectomy Transcription PREOPERATIVE DIAGNOSES 1 Metatarsus primus varus with bunion deformity right foot 2 Hallux abductovalgus with angulation deformity right foot POSTOPERATIVE DIAGNOSES 1 Metatarsus primus varus with bunion deformity right foot 2 Hallux abductovalgus with angulation deformity right foot PROCEDURES 1 Distal metaphyseal osteotomy and bunionectomy with internal screw fixation right foot 2 Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx right foot ANESTHESIA Local infiltrate with IV sedation INDICATION FOR SURGERY The patient has had a longstanding history of foot problems The foot problem has been progressive in nature and has not been responsive to conservative treatment The preoperative discussion with the patient included the alternative treatment options The procedure was explained in detail and risk factors such as infection swelling scarred tissue numbness continued pain recurrence and postoperative management were explained in detail The patient has been advised although no guaranty for success could be given most patients have improved function and less pain All questions were thoroughly answered The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities The purpose of the surgery is to alleviate the pain and discomfort DETAILS OF PROCEDURE The patient was brought to the operating room and placed in a supine position No tourniquet was utilized IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1 1 mixture of 0 25 Marcaine and 1 lidocaine with epinephrine was locally infiltrated proximal to the operative site The lower extremity was prepped and draped in the usual sterile manner Balanced anesthesia was obtained PROCEDURE 1 Distal metaphyseal osteotomy with internal screw fixation with bunionectomy right foot A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx Care was taken to identify and retract the vital structures and when necessary vessels were ligated via electrocautery Sharp and blunt dissection was carried down through the subcutaneous tissue superficial fascia and then down to the capsular and periosteal layer which was visualized A linear periosteal capsular incision was made in line with the skin incision The capsular tissue and periosteal layer were underscored free from its underlying osseous attachments and they refracted to expose the osseous surface Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head The head of the first metatarsal was dissected free from its attachment medially and dorsally delivered dorsally and may be into the wound Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition The sesamoid was in satisfactory condition An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration Care was taken to preserve the sagittal groove The rough edges were then smoothed with a rasp Attention was then focused on the medial mid portion of the first metatarsal head where a K wire access guide was positioned to define the apex and direction of displacement for the capital fragment The access guide was noted to be in good position A horizontally placed through and through osteotomy with the apex distal and the base proximal was completed The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal The capital fragment was distracted off the first metatarsal moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head The capital fragment was impacted upon the metatarsal Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment It was then fixated with 1 screw A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction The length was measured __________ mm cannulated cortical screw was placed over the guide pin and secured in position Compression and fixation were noted to be satisfactory Inspection revealed good fixation and alignment at the operative site Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally All rough edges were rasped smooth Examination revealed there was still lateral deviation of the hallux A second procedure the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated PROCEDURE 2 Reposition osteotomy with internal screw fixation to correct angulation deformity proximal phalanx right hallux The original skin incision was extended from the point just distal to the interphalangeal joint All vital structures were identified and retracted Sharp and blunt dissection was carried down through the subcutaneous tissue superficial fascia and down to the periosteal layer which was underscored free from its underlying osseous attachments and reflected to expose the osseous surface The focus of the deformity was noted to be more distal on the hallux Utilizing an oscillating saw a more distal wedge shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin which was then measured __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position Inspection revealed good fixation and alignment at the osteotomy site The alignment and contour of the first way was now satisfactorily improved The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation The periosteal and capsular layer was closed with running sutures of 3 0 Vicryl The subcutaneous tissue was closed with 4 0 Vicryl and the skin edges coapted well with 4 0 nylon with running simples reinforced with Steri Strips Approximately 6 mL total in a 1 1 mixture of 0 25 Marcaine and 1 lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted followed by confirming bandages and an ACE wrap to provide mild compression The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time A walker boot was dispensed and applied The patient should wear it when walking or standing The next office visit will be in 4 days The patient was given prescriptions for Percocet 5 mg 40 one p o q 4 6h p r n pain along with written and oral home instructions The patient was discharged home with vital signs stable in no acute distress Keywords MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left atrophic mandibular fracture removal of failed dental implant from the left mandible The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture Medical Specialty Surgery Sample Name ORIF Mandibular Fracture Dental Implant Removal Transcription PREOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant POSTOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant PROCEDURE PERFORMED Open reduction and internal fixation ORIF of left atrophic mandibular fracture removal of failed dental implant from the left mandible ANESTHESIA General nasotracheal ESTIMATED BLOOD LOSS 125 mL FLUIDS GIVEN 1 L of crystalloids SPECIMEN Soft tissue from the fracture site sent for histologic diagnosis CULTURES Also sent for Gram stain aerobic and anaerobic culture and sensitivity INDICATIONS FOR THE PROCEDURE The patient is a 79 year old male who fell in his hometown following an episode of syncope He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above mentioned fracture He was admitted to hospital in Harleton Texas where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass His mandible fracture was not noted initially The patient also has a history of prostate cancer and a renal cell carcinoma The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending The patient later saw a local oral surgeon He diagnosed his mandible fracture and advised him to seek treatment in Houston He presented to my office for evaluation on January 18 2010 and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant which had been placed approximately 15 years ago The patient had significant discomfort and could eat foods and drink fluids with difficulty Due to the nature of his fracture and the complex medical history he was sent to the hospital for admission and following cardiac clearance he was scheduled for surgery today PROCEDURE IN DETAIL The patient was taken to the operating room and placed in a supine position Following a nasal intubation and induction of general anesthesia the surgeon then scrubbed gowned and gloved in the normal sterile fashion The patient was then prepped and draped in a manner consistent with sterile procedures A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region approximately 1 5 cm medial to the inferior border of the mandible A 1 mL of lidocaine 1 with 1 100 000 epinephrine was then infiltrated along the incision and then a 15 blade was used to incise through the skin and subcutaneous tissue A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible Electrocautery as well as 4 0 silk ties were used for hemostasis A 15 blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11 hole Synthes reconstruction plate was then used to stand on the fracture site Since there was an area of weakness in the right parasymphysis region in the location of another dental implant the bone plate was extended posterior to that site When the plate was adapted to the mandible it was then secured to the bone with 9 screws each being 2 mm in diameter and each screw was placed bicortically All the screws were also locking screws Following placement of the screws there was felt to be excellent stability of the fracture so the wound was irrigated with a copious amount of normal saline The incision was closed in multiple layers with 4 0 Vicryl in the muscular and subcutaneous layers and 5 0 nylon in the skin A sterile dressing was then placed over the incision The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs Estimated blood loss is 125 mL Keywords surgery atrophic mandibular fracture dental implant open reduction and internal fixation orif mandibular fracture mandible atrophic mandibular dental implant MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of comminuted C2 fracture Posterior spinal instrumentation C1 C3 using Synthes system Posterior cervical fusion C1 C3 Insertion of morselized allograft at C1to C3 Medical Specialty Surgery Sample Name ORIF Cervical Fusion Transcription PREOPERATIVE DIAGNOSIS Fracture dislocation C2 POSTOPERATIVE DIAGNOSIS Fracture dislocation C2 OPERATION PERFORMED 1 Open reduction and internal fixation ORIF of comminuted C2 fracture 2 Posterior spinal instrumentation C1 C3 using Synthes system 3 Posterior cervical fusion C1 C3 4 Insertion of morselized allograft at C1to C3 ANESTHESIA GETA ESTIMATED BLOOD LOSS 100 mL COMPLICATIONS None DRAINS Hemovac x1 Spinal cord monitoring is stable throughout the entire case DISPOSITION Vital signs are stable extubated and taken back to the ICU in a satisfactory and stable condition INDICATIONS FOR OPERATION The patient is a middle aged female who has had a significantly displaced C2 comminuted fracture This is secondary to a motor vehicle accident and it was translated appropriately 1 cm Risks and benefits have been conferred with the patient as well as the family they wish to proceed The patient was taken to the operating room for a C1 C3 posterior cervical fusion instrumentation open reduction and internal fixation OPERATION IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled back to the operating theater room 5 The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties Spinal cord monitoring was induced No changes were seen from the beginning to the end of the case Mayfield tongues were placed appropriately This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls The patient s Mayfield tongue was fixated in the usual standard fashion The patient was subsequently prepped and draped in the usual sterile fashion Midline incision was extended from the base of the skull down to the C4 spinous process Full thickness skin fascia developed The fascia was incised at midline and the posterior elements at C1 C2 C3 as well as the inferior aspect of the occiput was exposed Intraoperative x ray confirmed the level to be C2 Translaminar screws were placed at C2 bilaterally Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done two 3 5 mm translaminar screws were placed bilaterally at C2 Good placement was seen both in the AP and lateral planes using fluoroscopy Facet screws were then placed at C3 Using standard technique of Magerl starting in the inferomedial quadrant 14 mm trajectories in the 25 degree caudad cephalad direction as well as 25 degrees in the medial lateral direction was made This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory A 14 x 3 5 mm screws were then placed appropriately Lateral masteries at C1 endplate were placed appropriately The medial and lateral borders were demarcated with a Penfield The great occipital nerve was retracted out the way Starting point was made with a high speed power bur and midline and lateral mass bilaterally Using a 20 degree caudad cephalad trajectory as well as 10 degree lateral to medial direction the trajectory was completed in 8 mm increments this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory Once this was done 24 x 3 5 mm smooth Schanz screws were placed appropriately Precontoured titanium rods were then placed between the screws at the C1 C2 C3 and casts were placed appropriately Once this was done all end caps were appropriately torqued This completed the open reduction and internal fixation of the C2 fracture which showed perfect alignment It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access Once the screws were torqued bilaterally good alignment was seen both in the AP and lateral planes using fluoroscopy this completed instrumentation as well as open reduction and internal fixation of C2 The cervical fusion was completed by decorticating the posterior elements of C1 C2 and C3 Once this was done the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements The fascia was closed using interrupted 1 Vicryl suture figure of 8 Superficial drain was placed appropriately Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes The subcutaneous tissues were closed using a 2 0 Vicryl suture The dermal edges were approximated using staples The wound was then dressed sterilely using Bacitracin ointment Xeroform 4x4s and tape and the drain was connected appropriately The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position Mayfield tongues were subsequently released No significant bleeding was appreciated The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition No complications arose Keywords surgery fracture dislocation spinal instrumentatio comminuted fracture morselized allograft vicryl suture mayfield tongues cervical fusion internal fixation orif cervical fusion fixation spinal reduction instrumentation MEDICAL_TRANSCRIPTION,Description Fractured right fifth metatarsal Open reduction and internal screw fixation right fifth metatarsal Application of short leg splint Medical Specialty Surgery Sample Name ORIF Fifth Metatarsal Transcription PREOPERATIVE DIAGNOSIS Fractured right fifth metatarsal POSTOPERATIVE DIAGNOSIS Fractured right fifth metatarsal PROCEDURE PERFORMED 1 Open reduction and internal screw fixation right fifth metatarsal 2 Application of short leg splint ANESTHESIA TIVA local HISTORY This 32 year old female presents to Preoperative Holding Area after keeping herself n p o since mid night for open reduction and internal fixation of a fractured right fifth metatarsal The patient relates that approximately in mid June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot She continued to walk on the foot and found nothing was wrong despite the pain She was recently seen by Dr X and was referred to Dr Y for surgery The risks versus benefits of the procedure had been explained to the patient in detail by Dr Y The consent is available on the chart for review The urine beta was taken in the preoperative area and was negative PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operating table in the supine position A safety strap was placed across her waist for her protection Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied After adequate IV sedation was administered by the Department of Anesthesia a total of 10 cc of 0 5 Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operative field and a sterile stocking was reflected Attention was directed to the right fifth metatarsal base The Xi scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal An avulsion fracture of the right fifth metatarsal base was visualized The fracture was linear in nature from distal lateral to proximal medial There appeared to be a pseudoarthrosis on the lateral view A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve A linear incision was created with a 10 blade A 15 blade was used to deepen the incision through the subcutaneous tissue All small veins traversing the subcutaneous tissue were ligated with electrocautery Next using combination of sharp and blunt dissection the deep fascia was reached Next a linear capsuloperiosteal incision was made down to the bone using a 15 blade Next using a periosteal elevator and a 15 blade the capsuloperiosteal tissues were stripped from the bone The fracture site was not clearly visualized due to bony callus A 25 gauge needle was introduced into the fracture site under fluoroscopy The fracture site was easily found An osteotome was used to separate the pseudoarthrosis A curette was used to remove the hypertrophic excessive pseudoarthrotic bone Next a small ball burr was used to resect the remaining hypertrophic bone Next a 1 0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone Next a bone clamp was applied and the fracture was reduced Next a threaded K wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally A 4 0 mm Synthes partially threaded cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly All this was done under fluoroscopy Next the wound was flushed with copious amounts of sterile saline The fracture site was found to have rigid compression The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed Next the capsuloperiosteal tissues were closed with 3 0 Vicryl in a simple interrupted fashion A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl Next the subcutaneous layer was closed with 4 0 Vicryl in a simple interrupted suture technique Next the skin was closed with 5 0 Prolene in a horizontal mattress technique A postoperative fluoroscopic x ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance A dressing consisting of Owen silk 4x4s fluff and Kerlix were applied A sterile stockinet was applied over the foot Next copious amounts of Webril were applied to pad all bony prominences The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits Next 4 inch pre moulded well padded posterior splint was applied The capillary refill time of the digits was less than three seconds The patient tolerated the above anesthesia and procedure without complications After anesthesia was reversed she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She was given Vicodin 5 500 mg 30 1 2 p o q 4 6h p r n pain Naprosyn 500 mg p o b i d p c Keflex 500 mg 30 one p o t i d till gone She was given standard postoperative instructions to be non weightbearing and was dispensed with crutches She will rest ice and elevate her right leg She is to follow up in the clinic on 08 26 03 at 10 30 a m She was given emergency contact numbers and will call or return if problems arise earlier Keywords surgery metatarsal internal screw fixation leg splint fractured right fifth metatarsal pneumatic ankle tourniquet ankle tourniquet metatarsal base fracture site fractured hypertrophic bernstein orif MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left lateral malleolus Left lateral malleolus fracture Medical Specialty Surgery Sample Name ORIF Malleolus Transcription PREOPERATIVE DIAGNOSIS Left lateral malleolus fracture POSTOPERATIVE DIAGNOSIS Left lateral malleolus fracture PROCEDURE PERFORMED Open reduction and internal fixation of left lateral malleolus ANESTHESIA General TOURNIQUET TIME 59 minutes COMPLICATIONS None BLOOD LOSS Negligible CLOSURE 2 0 Vicryl and staples INDICATIONS FOR SURGERY This is a young gentleman with soccer injury to his left ankle and an x ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently OPERATIVE PROCEDURE The patient was taken to the operative room where general anesthesia was successfully introduced The right ankle was prepped and draped in standard fashion The tourniquet was applied about the right upper thigh An Esmarch tourniquet was used to exsanguinate the ankle The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes An approximately 6 inch longitudinal incision was made just over the lateral malleolus Care was taken to spare overlying nerves and vessels An elevator was used to expose the fracture The fracture was freed of old hematoma and reduced with a reducing clamp An interfragmentary cortical screw was placed of 28 mm with excellent purchase The intraoperative image showed excellent reduction A 5 hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally Excellent stability of fracture was achieved Final fluoroscopy showed a reduction to be anatomic in 2 planes The wound was irrigated with copious amounts of normal saline Deep tissue was closed with 2 0 Vicryl The skin was approximated with 2 0 Vicryl and closed with staples Dry sterile dressing was applied The patient tolerated the procedure was awakened and taken to the recovery room in stable condition Keywords surgery open reduction and internal fixation esmarch internal fixation malleolus fracture lateral malleolus tourniquet orif fixation ankle reduction fracture malleolus MEDICAL_TRANSCRIPTION,Description Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 Open reduction internal fixation ORIF of bilateral mandible fractures with multiple approaches CPT code 21470 and surgical extraction of teeth 17 CPT code 41899 Medical Specialty Surgery Sample Name ORIF Mandible Fracture Transcription PREOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 POSTOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 PROCEDURE Open reduction internal fixation ORIF of bilateral mandible fractures with multiple approaches CPT code 21470 and surgical extraction of teeth 17 CPT code 41899 ANESTHESIA General anesthesia via nasal endotracheal intubation FLUIDS 1800 mL of LR ESTIMATED BLOOD LOSS 150 mL HARDWARE A 2 3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2 0 reconstruction plate on the left angle SPECIMEN None COMPLICATIONS None CONDITION The patient was extubated to the PACU breathing spontaneously in excellent good condition INDICATIONS FOR THE PROCEDURE The patient is a 55 year old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder He was worked up by the emergency department His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage Oral maxillary facial surgery was consulted to manage the mandible fracture After review of the CT and examination it was determined that the patient would benefit from open reduction internal fixation of bilateral mandible fractures Risks benefits and alternative to treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was brought to the operating room 2 at Hospital He was laid in supine position on the operating room table ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics The patient was prepped and draped in the usual oral maxillofacial surgery fashion The surgeon approached the operating room table in a sterile fashion Approximately 10 mL of 1 lidocaine with 1 100 000 epinephrine was injected into oral vestibule in a nerve block fashion Erich arch bars were adapted to the maxilla and mandible secured in the posterior teeth with 24 gauge surgical steel wire and 26 gauge surgical steel wire in the anterior This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth The patient was manipulated up into maximum intercuspation He has a malocclusion with severe bruxism and so wear facets were lined up This was secured with 26 gauge surgical steel wire Attention was then directed to the symphysis extraorally Approximately 5 mL of 1 lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible After waiting appropriate time for local anesthesia using a 15 blade a skin and platysma incision was made Then using a series of blunt and sharp dissections the dissection was carried to the inferior border of the mandible The periosteum was incised and reflected with the periosteal elevator The fracture was noted and it was displaced Manipulation of the segments and checking with the occlusion intraorally the fracture was aligned This was secured with 7 hole 2 3 titanium locking reconstruction plate with bicortical screws The wound was then packed with moist Ray Tec and attention was directed intraorally to the left angle fracture Approximately 5 mL of 1 lidocaine with 1 100 000 epinephrine was injected into the left vestibule After waiting appropriate time for local anesthesia to take effect using Bovie electrocautery a sagittal split incision was made and the fracture was identified It was noted that the fracture went through tooth 17 and this needed to be extracted Taking a round bur a buckle trough was made and the tooth was elevated and removed both distal and mesial roots The fracture was then reduced and lateral superior border plate 2 0 4 whole with monocortical screws was placed The fracture was noted to be well reduced The wound was then irrigated with copious amount of sterile water The patient was released for excellent intercuspation He was then manipulated up into the occlusion easily Wound was then closed with running 3 0 chromic gut suture Attention was then directed extraorally This was irrigated with copious amount of sterile water and closed in a layer fashion with 3 0 Vicryl 4 0 Vicryl and 5 0 Prolene on skin Attention was then again directed into the mouth The throat pack was removed and orogastric tube was placed and stomach content was evacuated The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions At this point the procedure was then determined to be over The patient was extubated and breathing spontaneously transported to the PACU in excellent condition Keywords surgery mandible endotracheal leibinger pacu oral maxillary facial surgery maxillofacial buckle round bur lidocaine with epinephrine surgical steel wire bilateral mandible fractures mandible fracture orif symphysis fracture MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left tibia Medical Specialty Surgery Sample Name ORIF Left Tibia Transcription PREOPERATIVE DIAGNOSIS Left tibial tubercle avulsion fracture POSTOPERATIVE DIAGNOSIS Comminuted left tibial tubercle avulsion fracture with intraarticular extension PROCEDURE Open reduction and internal fixation of left tibia ANESTHESIA General The patient received 10 ml of 0 5 Marcaine local anesthetic TOURNIQUET TIME 80 minutes ESTIMATED BLOOD LOSS Minimal DRAINS One JP drain was placed COMPLICATIONS No intraoperative complications or specimens Hardware consisted of two 4 5 K wires One 6 5 60 mm partially threaded cancellous screw and one 45 60 mm partially threaded cortical screw and 2 washers HISTORY AND PHYSICAL The patient is a 14 year old male who reported having knee pain for 1 month Apparently while he was playing basketball on 12 22 2007 when he had gone up for a jump he felt a pop in his knee The patient was seen at an outside facility where he was splinted and subsequently referred to Children s for definitive care Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta Surgery is recommended to the grandmother and subsequently to the father by phone Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal Risks of surgery include the risks of anesthesia infection bleeding changes on sensation in most of the extremity hardware failure need for later hardware removal failure to restore extensor mechanism tension and need for postoperative rehab All questions were answered and father and grandmother agreed to the above plan PROCEDURE The patient was taken to the operating and placed supine on the operating table General anesthesia was then administered The patient was given Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The patient s extremity was then prepped and draped in the standard surgical fashion Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch Finally the patient had tourniquet that turned in 75 mmHg Esmarch was then removed The incision was then made The patient had significant tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement We were able to see the underside of the anterior horn of both medial and lateral meniscus The intraarticular cartilage was restored using two 45 K wires Final position was checked via fluoroscopy and the corners were buried in the cartilage There was a large free floating metaphyseal piece that included parts of proximal tibial physis This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6 5 60 mm cancellous screw with a washer The cortical screw did not provide good compression and fixation at this distal fragment Retinaculum was repaired using 0 Vicryl suture as best as possible The hematoma was evacuated at the beginning of the case as well as the end The knee was copiously irrigated with normal saline The subcutaneous tissue was re approximated using 2 0 Vicryl and the skin with 4 0 Monocryl The wound was cleaned dried and dressed with Steri Strips Xeroform and 4 x4s Tourniquet was released at 80 minutes JP drain was placed on the medium gutter The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes The patient was then placed in a knee mobilizer The patient tolerated the procedure well Subsequently extubated and taken to the recovery in stable condition POSTOP PLAN The patient hospitalized overnight to decrease swelling and as well as manage his pain He may weightbear as tolerated using knee mobilizer Postoperative findings relayed to the grandmother The patient will need subsequent hardware removal The patient also was given local anesthetic at the end of the case Keywords surgery intraarticular extension tibial tubercle avulsion fracture tubercle avulsion fracture jp drain cortical screw hardware removal tibial tubercle tourniquet orif tubercle tibial MEDICAL_TRANSCRIPTION,Description Hawkins IV talus fracture Open reduction internal fixation of the talus medial malleolus osteotomy and repair of deltoid ligament Medical Specialty Surgery Sample Name ORIF Talus Transcription PREOPERATIVE DIAGNOSIS Hawkins IV talus fracture POSTOPERATIVE DIAGNOSIS Hawkins IV talus fracture PROCEDURE PERFORMED 1 Open reduction internal fixation of the talus 2 Medial malleolus osteotomy 3 Repair of deltoid ligament ANESTHESIA Spinal TOURNIQUET TIME 90 min BLOOD LOSS 50 cc The patient is in the semilateral position on the beanbag INTRAOPERATIVE FINDINGS A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament There was no evidence of osteochondral defects of the talar dome HISTORY This is a 50 year old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement There was no open injury The patient fell approximately 10 feet off his liner landing on his left foot There was evidence of gross deformity of the ankle An x ray was performed in the Emergency Room which revealed a grade IV Hawkins classification talus fracture He was distal neurovascularly intact The patient denied any other complaints besides pain in the ankle It was for this reason we elected to undergo the above named procedure in order to reduce and restore the blood supply to the talus body Because of its tenuous blood supply the patient is at risk for avascular necrosis The patient has agreed to undergo the above named procedure and consent was obtained All risks as well as complications were discussed PROCEDURE The patient was brought back to operative room 4 of ABCD General Hospital on 08 20 03 A spinal anesthetic was administered A nonsterile tourniquet was placed on the left upper thigh but not inflated He was then positioned on the beanbag The extremity was then prepped and draped in the usual sterile fashion for this procedure An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg At this time an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site At this time a 15 blade was used to make approximately 10 cm incision over the medial malleolus This was curved anteromedial along the root of the saphenous vein The saphenous vein was located Its tributaries going plantar were cauterized and the vein was retracted anterolaterally At this time we identified the medial malleolus There was evidence of approximately 80 avulsion rupture of the deltoid ligament off of the medial malleolus This was a major blood feeder to the medial malleolus and we were concerned once we were going to do the osteotomy that this would later create healing problem It is for this reason that the pedicle which was attached to the medial malleolus was left intact This pedicle was the anterior portion of the deltoid ligament At this time a MicroChoice saw was then used to make a box osteotomy of the medial malleolus Once this was performed the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply This provided us with excellent exposure to the fracture site of the medial side At this time any loose comminuted pieces were removed The dome of the talus was also checked and did not reveal any osteochondral defects There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw this would tend to extend the fracture site It is for this reason we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site At this time a reduction was performed The 7 0 partially threaded cannulated screws were used in order to fix the fracture At this time a 3 2 mm guidewire was placed going from posterolateral to anteromedial This was placed slightly lateral to the Achilles tendon percutaneously inserted and then drilled in the according fashion across the fracture site Once this was performed a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in A depth gauze was then used to measure screw length A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw A 55 mm partially threaded 7 0 cannulated screw was then placed with excellent compression at the fracture site Once this was obtained we checked the reduction again using intraoperative Xi Scan in the AP and lateral direction This projection gave us excellent view of our screw placement and excellent compression across the fracture site At this time we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft This was placed using a freer elevator into the fracture site where the comminution was At this time we copiously irrigated the wound The osteotomy site was then repaired first clamped using two large tenaculum reduction clamps Two partially threaded 4 0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws Next a 1 0 Vicryl was then used to repair the deltoid ligament which was ruptured via the injury A tight repair was performed of the deltoid ligament At this time again copious irrigation was used to irrigate the wound A 2 0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision At this time the leg was cleansed Adaptic 4 x 4 and Kerlix roll were then applied The patient was then placed in a plaster splint for mobilization The tourniquet was then released The patient was then transferred off the operating table to recovery in stable condition The prognosis for this fracture is guarded There is a high rate of avascular necrosis of the talar body approximately anywhere from 40 60 risk The patient is aware of this and he will be followed as an outpatient for this problem Keywords surgery deltoid ligament medial malleolus osteotomy open reduction internal fixation of the talus hawkins iv talus fracture medial malleolus fracture site malleolus talus medial fracture tourniquet ligament osteotomy MEDICAL_TRANSCRIPTION,Description Orchiopexy inguinal herniorrhaphy Medical Specialty Surgery Sample Name Orchiopexy Herniorrhaphy Transcription OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating room table The patient was prepped and draped in usual sterile fashion An incision was made in the groin crease overlying the internal ring This incision was about 1 5 cm in length The incision was carried down through the Scarpa s layer to the level of the external oblique This was opened along the direction of its fibers and carried down along the external spermatic fascia The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free A hernia sac was identified and the testicle was located Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring This was performed by incising the transversalis fascia circumferentially The hernia sac was ligated with a 3 0 silk suture high and divided and was noted to retract into the abdominal cavity Care was taken not to injure the testicular vessels Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum The testicle was viable This was wrapped in a moist sponge Next a hemostat was passed down through the inguinal canal down into the scrotum A small 1 cm incision was made in the anterior superior scrotal wall Dissection was carried down through the dartos layer A subdartos pouch was formed with blunt dissection The hemostat was then pushed against the tissues and this tissue was divided The hemostat was then passed through the incision A Crile hemostat was passed back up into the inguinal canal The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision The neck was then closed with a 4 0 Vicryl suture that was not too tight but tight enough to prevent retraction of the testicle The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4 0 chromic and the skin was closed with a running 6 0 subcuticular chromic suture Benzoin and a Steri Strip were placed Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly This was done with 2 to 3 interrupted 3 0 silk sutures The external oblique was then closed with interrupted 3 0 silk suture The Scarpa s layer was closed with a running 4 0 chromic and the skin was then closed with a running 4 0 Vicryl intracuticular stitch Benzoin and Steri Strip were applied The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block was awakened and was returned to the recovery room in stable condition Keywords surgery orchiopexy benzoin crile hemostat scarpa s layer caudal block cremasteric fascia groin crease hemiscrotum iliopubic tract inguinal canal inguinal herniorrhaphy intracuticular stitch retroperitoneum spermatic fascia testicle hernia sac inguinal incisionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of right distal radius fracture intraarticular four piece fracture and right carpal tunnel release Medical Specialty Surgery Sample Name ORIF 1 Transcription PREOPERATIVE DIAGNOSES 1 Displaced intraarticular fracture right distal radius 2 Right carpal tunnel syndrome PREOPERATIVE DIAGNOSES 1 Displaced intraarticular fracture right distal radius 2 Right carpal tunnel syndrome OPERATIONS PERFORMED 1 Open reduction and internal fixation of right distal radius fracture intraarticular four piece fracture 2 Right carpal tunnel release ANESTHESIA General CLINICAL SUMMARY The patient is a 37 year old right hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago This was an intraarticular four part fracture that was displaced dorsally In addition the patient previously undergone a carpal tunnel release but had symptoms of carpal tunnel preop She is admitted for reconstructive operation The symptoms of carpal tunnel were present preop and worsened after the injury OPERATION The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia Once adequate anesthesia had been obtained the right upper extremity was prepped and draped in the usual sterile manner Tourniquet was placed around the right upper extremity The upper extremity was then elevated and exsanguinated using an Esmarch dressing The tourniquet was elevated to 250 mmHg The entire operation was performed with 4 5 loop magnification At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally This was carried down to the flexor carpi radialis which was then retracted ulnarly The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin It was then elevated off of the fracture site exposing the fracture site which was dorsally displaced This was an intraarticular four part fracture Under image control the two volar pieces and dorsal pieces were then carefully manipulated and reduced Then 2 06 two inch K wires were drilled radial into the volar ulnar fragment and then a second K wire was then drilled from the dorsal radial to the dorsal ulnar piece A third K wire was then drilled from the volar radial to the dorsal ulnar piece The fracture was then manipulated The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it Further K wires were then placed through the radial styloid into the proximal fragment A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K wires At this time the distal screws were then placed The distal screws were the small screws These were non locking screws all eight screws were placed They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth Again these were 18 20 mm screws After placing three of the screws it was necessary to remove the K wires There was excellent reduction of the fragments and the fracture excellent reduction of the intraarticular component and the fracture After the distal screws were placed the fracture was reduced and held in place with K wires which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit The screws were then placed These were 12 mm screws They were placed 4 in number The K wires were then removed Finally a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist This was carried down to the transverse carpal ligament which was divided throughout the length of the incision upon entering the carpal canal the median nerve was found to be adherent to the undersurface of the structure It was dissected free from the structure out to its trifurcation The motor branches seen entering the thenar fascia and obstructed The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm In this area careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon Incisions were then copiously irrigated with normal saline Homeostasis was maintained with electrocautery The pronator quadratus was closed with 3 0 Vicryl and the above skin incisions were closed proximally with 4 0 nylon and palmar incision with 5 0 nylon in the horizontal mattress fashion A large bulky dressing was then applied with a volar short arm splint maintaining the wrist in neutral position The tourniquet was let down The fingers were immediately pink The patient was awakened and taken to the recovery room in good condition There were no operative complications The patient tolerated the procedure well Keywords surgery intraarticular fracture esmarch k wires open reduction and internal fixation tourniquet carpal tunnel release carpal tunnel syndrome flexor carpi radialis flexor pronator muscles intraarticular right distal radius transverse carpal ligament volar flexion crease pronator quadratus flexor carpi carpi radialis flexion crease carpal ligament carpal tunnel carpal volar MEDICAL_TRANSCRIPTION,Description Bilateral orchiopexy This 8 year old boy has been found to have a left inguinally situated undescended testes Ultrasound showed metastasis to be high in the left inguinal canal The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum Medical Specialty Surgery Sample Name Orchiopexy Bilateral Transcription PREOPERATIVE DIAGNOSIS Bilateral undescended testes POSTOPERATIVE DIAGNOSIS Bilateral undescended testes OPERATION PERFORMED Bilateral orchiopexy ANESTHESIA General HISTORY This 8 year old boy has been found to have a left inguinally situated undescended testes Ultrasound showed metastasis to be high in the left inguinal canal The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum Both testes appeared to be normal in size for the boy s age OPERATIVE FINDINGS As above both testes appeared viable and normal in size no masses There is a hernia on the left side The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement OPERATIVE PROCEDURE The boy was taken to the operating room where he was placed on the operating table General anesthesia was administered by Dr X after which the boy s lower abdomen and genitalia were prepared with Betadine and draped aseptically A 0 25 Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision An inguinal incision was then made through this area carried through the subcutaneous tissues to the anterior fascia External ring was exposed with dissection as well The fascia was opened in direction of its fibers exposing the testes which lay high in the canal The testes were freed with dissection by removing cremasteric and spermatic fascia The hernia sac was separated from the cord twisted and suture ligated at the internal ring Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring However this would only allow placement of the testes in the upper scrotum with some tension Therefore the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with 4 0 Vicryl and divided This maneuver allowed for placement of the testes in the upper scrotum without tension A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel The testes were then brought into the pouch and anchored with interrupted 4 0 Vicryl sutures The skin was approximated with interrupted 5 0 chromic catgut sutures Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted 4 0 Vicryl over the spermatic cord and the external oblique fascia was closed with running 4 0 Vicryl suture Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running 5 0 subcuticular after placing several 4 0 Vicryl approximating sutures in the subcutaneous tissues Attention was then turned to the opposite side where an orchiopexy was performed in a similar fashion However on this side there was no inguinal hernia The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord so that the Prentiss maneuver was not required on this side The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well The inguinal and scrotal incisions were cleansed after completion of the procedure Steri Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision The child was then awakened and transported to post anesthetic recovery area apparently in satisfactory condition Instrument and sponge counts were correct There were no apparent complications Estimated blood loss was less than 20 to 30 mL Keywords surgery bilateral orchiopexy bilateral undescended testes prentiss maneuver subcutaneous tissues internal ring dartos pouch scrotal incisions undescended testes spermatic cord inguinal canal testes inguinally orchiopexy undescended cord vicryl ultrasound spermatic canal MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation high grade Frykman VIII distal radius fracture Medical Specialty Surgery Sample Name ORIF 2 Transcription PREOPERATIVE DIAGNOSIS Severely comminuted fracture of the distal radius left POSTOPERATIVE DIAGNOSIS Severely comminuted fracture of the distal radius left OPERATIVE PROCEDURE Open reduction and internal fixation high grade Frykman VIII distal radius fracture ANESTHESIA General endotracheal PREOPERATIVE INDICATIONS This is a 52 year old patient of mine who I have repaired both shoulder rotator cuffs the most recent one in the calendar year 2007 While he was climbing a ladder recently in the immediate postop stage he fell suffering the aforementioned heavily comminuted Frykman fracture This fracture had a fragment that extended in the distal radial ulnar joint a die punch fragment in the center of the radius The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions He presented to my office the morning of April 3 2007 having had a left reduction done elsewhere a day ago The reduction although adequate had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1 8 this was essentially an 8 The best results have been either with external fixation or internal fixation most recently volar plating of a locking variety has been popular and I felt that this would be appropriate in his case Risks and benefits otherwise described were bleeding infection need to do operative revise or removal of hardware He is taking a job out of state in the next couple of months Hence I felt that even with close followup this is a particularly difficult fracture as far as the morbidity of the injury proceeds OPERATIVE NOTE After adequate general endotracheal anesthesia was obtained one gram of Ancef was given intravenously The left upper extremity was prepped and draped in supine position with the left hand in the arm table magnification was used throughout The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient A small C arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them specifically the distal radial ulnar joint and die punch fragment At this point a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws The ulnar styloid was not affixed in any portion of this repair The plate was viewed under the image intensification device i e x ray and the screws were placed in this order The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach a locking 12 mm screw through 16 mm screws were placed in the following order Most proximal on the radial shaft of the plate then the radial styloid i e the most distal and lateral screw the next most proximal shaft screw followed by the distal radial ulnar joint screw Three screws were locking across the die punch fragment The remaining two screws were placed into the radial shaft All of these were locking screws of 2 mm in diameter and as the construct was created the relative motion of the intra articular fragment in dorsal comminution all diminished greatly although the exposure as well as the amount of reduction force used was substantial The tourniquet time was 1 5 hours At this point the tourniquet was let down The entire construct was irrigated with copious amounts of bacitracin and normal saline Closure was affected with 0 Vicryl underneath the skin surface followed by 3 0 Prolene in interrupted sutures in the volar wound Several image intensification x rays were taken at the conclusion of the case to check screw length Screw lengths were changed out during the case as needed based on the x ray findings The wound was injected with Marcaine lidocaine Depo Medrol and Kantrex A very heavily padded fluffy cotton Jones type dressing was applied with a volar splint Estimated blood loss was 10 mL There were no specimens Tourniquet time was 1 5 hours Keywords surgery distal radius c arm depo medrol frykman jones type dressing kantrex marcaine open reduction and internal fixation die punch intra articular lidocaine pronator quadratus radial styloid ulnar styloid distal radial ulnar joint radial ulnar joint distal screws orif fracture radial MEDICAL_TRANSCRIPTION,Description Right orchiopexy and right inguinal hernia repair Medical Specialty Surgery Sample Name Orchiopexy Hernia Repair 1 Transcription PREOPERATIVE DIAGNOSIS Right undescended testis ectopic position POSTOPERATIVE DIAGNOSES Right undescended testis ectopic position right inguinal hernia PROCEDURES Right orchiopexy and right inguinal hernia repair ANESTHESIA General inhalational anesthetic with caudal block FLUIDS RECEIVED 100 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS No tissues sent to pathology TUBES AND DRAINS No tubes or drains were used INDICATIONS FOR OPERATION The patient is an almost 4 year old boy with an undescended testis on the right plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed He was then placed in the supine position and sterilely prepped and draped Since the testis was in the ectopic position we did an upper curvilinear scrotal incision with a 15 blade knife and further extended it with electrocautery Electrocautery was also used for hemostasis A subdartos pouch was then created with a curved tenotomy scissors The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments As we were dissecting it we then found the testis itself into the sac and we opened the sac and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment not being attached to the top We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps Once this was dissected off we then twisted it upon itself and then dissected it down towards the external ring but on traction We then twisted it upon itself suture ligated it with 3 0 Vicryl and released it allowing it to spring back into the canal Once this was done we then had adequate length of the testis into the scrotal sac Using a curved mosquito clamp we grasped the base of the scrotum internally and using the subcutaneous tissue we tacked it to the base of the testis using a 4 0 chromic suture The testis was then placed into the scrotum in the proper orientation The upper aspect of the pouch was closed with a pursestring suture of 4 0 chromic The scrotal skin and dartos were then closed with subcutaneous closure of 4 0 chromic and Dermabond tissue adhesive was used on the incision IV Toradol was given Both testes were well descended in the scrotum at the end of the procedure Keywords surgery ectopic position inguinal hernia inguinal hernia repair hernia sac tunica vaginalis gubernacular attachments testis ectopic position curved mosquito clamp caudal block hernia repair undescended testis orchiopexy dissected hernia inguinal testis MEDICAL_TRANSCRIPTION,Description Left inguinal hernia repair left orchiopexy with 0 25 Marcaine ilioinguinal nerve block and wound block at 0 5 Marcaine plain Medical Specialty Surgery Sample Name Orchiopexy Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Left undescended testis POSTOPERATIVE DIAGNOSIS Left undescended testis plus left inguinal hernia PROCEDURES Left inguinal hernia repair left orchiopexy with 0 25 Marcaine ilioinguinal nerve block and wound block at 0 5 Marcaine plain ABNORMAL FINDINGS A high left undescended testis with a type III epididymal attachment along with vas ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 1100 mL of crystalloid TUBES DRAINS No tubes or drains were used COUNTS Sponge and needle counts were correct x2 SPECIMENS No tissues sent to Pathology ANESTHESIA General inhalational anesthetic INDICATIONS FOR OPERATION The patient is an 11 1 2 year old boy with an undescended testis on the left The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then placed in a supine position and sterilely prepped and draped A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15 blade knife and further extended with electrocautery into the subcutaneous tissue We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring We were able to dissect all the way up to the ring but were unable to get the testis delivered We then made a left inguinal incision with a 15 blade knife further extending with electrocautery through Scarpa fascia down to the external oblique fascia The testis again was not visualized in the external ring so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15 blade knife further extending with Metzenbaum scissors The testis itself was quite high up in the upper canal We then dissected the gubernacular structures off of the testis and also then opened the sac and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors Once this was dissected off and up towards the internal ring it was twisted upon itself and suture ligated with an 0 Vicryl suture We then dissected the lateral spermatic fascia and then using blunt dissection dissected in the retroperitoneal space to get more cord length We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off We then found that we had an adequate amount of cord length to get the testis in the mid to low scrotum The patient was found to have a type III epididymal attachment with a long looping vas and we brought the testis into the scrotum in the proper orientation and tacked it to mid to low scrotum with a 4 0 chromic stay stitch The upper aspect of the subdartos pouch was closed with a 4 0 chromic pursestring suture The testis was then placed into the scrotum in the proper orientation We then placed the local anesthetic and the ilioinguinal nerve block and placed a small amount in both incisional areas as well We then closed the external oblique fascia with a running suture of 0 Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure The Scarpa fascia was closed with a 4 0 chromic suture and the skin was closed with a 4 0 Rapide subcuticular closure Dermabond tissue adhesive was placed on the both incisions and IV Toradol was given at the end of the procedure The patient tolerated the procedure well was in a stable condition upon transfer to the recovery room Keywords surgery inguinal hernia repair ilioinguinal nerve block external oblique fascia hernia repair epididymal attachment external ring inguinal incision scarpa fascia cord length inguinal hernia nerve block ilioinguinal nerve undescended testis testis inguinal fascia hernia dissected MEDICAL_TRANSCRIPTION,Description Right undescended testicle Orchiopexy Herniorrhaphy Medical Specialty Surgery Sample Name Orchiopexy Herniorrhaphy 1 Transcription PREOPERATIVE DIAGNOSIS Right undescended testicle POSTOPERATIVE DIAGNOSIS Right undescended testicle OPERATIONS 1 Right orchiopexy 2 Right herniorrhaphy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal SPECIMEN Sac BRIEF HISTORY This is a 10 year old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis The patient and mother had seen the testicle in the right hemiscrotum in the past but the testicle seemed to be sliding The testis was identified right at the external inguinal ring The testis was unable to be brought down into the scrotal sac The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle HCG stimulation orchiopexy were discussed Risk of anesthesia bleeding infection pain hernia etc were discussed The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy PROCEDURE IN DETAIL The patient was brought to the OR anesthesia was applied The patient was placed in supine position The patient was prepped and draped in the inguinal and scrotal area After the patient was prepped and draped an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal The incision came through the subcutaneous tissue and external oblique fascia was identified The external oblique fascia was opened sharply and was taken all the way down towards the external ring The ilioinguinal nerve was identified right underneath the external oblique fascia which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture After dissecting proximally the testis was identified in the distal end of the inguinal canal The testis was pulled up The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring There was very small hernia which was removed and was tied at the base PDS suture was used to tie this hernia sac all the way up to the base There was a Y right at the vas and cord indicating there was enough length into the scrotal sac The testis was easily brought down into the scrotal sac One centimeter superior scrotal incision was made and a Dartos pouch was created The testicle was brought down into the pouch and was placed into the pouch Careful attention was done to ensure that there was no torsion of the cord The vas was medial all the way throughout and the cord was lateral all the way throughout The epididymis was in the posterolateral location The testicle was pexed using 4 0 Vicryl into the scrotal sac Skin was closed using 5 0 Monocryl The external oblique fascia was closed using 2 0 PDS Attention was drawn to re create the external inguinal ring A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord Marcaine 0 25 was applied about 15 mL worth of this was applied for local anesthesia After closing the external oblique fascia the Scarpa was brought together using 4 0 Vicryl and the skin was closed using 5 0 Monocryl in subcuticular fashion Dermabond and Steri Strips were applied The patient was brought to recovery room in stable condition at the end of the procedure Please note that the testicle was viable It was smaller than the other side probably by 50 There were no palpable testicular masses Plan was for the patient to follow up with us in about 1 month The patient was told not to do any heavy lifting for at least 3 months okay to shower in 48 hours No tub bath for 2 months The patient and family understood all the instructions Keywords surgery undescended testicle orchiopexy herniorrhaphy external oblique fascia inguinal ring scrotal sac oblique fascia testicle herniorrhaphy orchiopexy inguinal MEDICAL_TRANSCRIPTION,Description Left facial cellulitis and possible odontogenic abscess Attempted incision and drainage I D of odontogenic abscess Medical Specialty Surgery Sample Name Odontogenic Abscess I D Transcription PREOPERATIVE DIAGNOSES 1 Left facial cellulitis 2 Possible odontogenic abscess of the 18 19 and 20 POSTOPERATIVE DIAGNOSES 1 Left facial cellulitis 2 Possible odontogenic abscess of the 18 19 and 20 PROCEDURE PERFORMED Attempted incision and drainage I D of odontogenic abscess ANESTHESIA 1 lidocaine plain approximately 5 cc total COMPLICATIONS The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA The attempted FNA was without any purulent aspirate although limited in the area of attempted examination INDICATIONS FOR THE PROCEDURE The patient is a 39 year old Caucasian female who was admitted to ABCD General Hospital on 08 21 03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology The patient states that this was started approximately 24 hours ago The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain The patient admits to poor dental hygiene Denies any recent or dental abscesses in the past The patient is a substance abuser does admit to smoking cocaine approximately three days ago The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted After risks complications consequences and questions were discussed with the patient a written consent was obtained for an I D of a possible odontogenic abscess ________ on the CT scan PROCEDURE The patient was brought in upright and supine position Approximately 5 cc of 1 lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side This was done at the base of 18 19 and 20 teeth After this the patient did have approximately 2 more mg of morphine given through the IV for pain control After this the 18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of 18 tooth and 19 with one stick placed There were no signs of any purulent drainage although at this time the patient became very irate and noncompliant and refusing further examination The patient understood consequences of her actions Does state that she does not care at this time and just wants to be left alone At this time the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q 6h along with pain control utilizing Toradol morphine and Vicodin The patient will also be started on Peridex oral rinse of 10 cc p o swish and spit t i d and a K pad to the left face Keywords surgery odontogenic facial cellulitis incision and drainage fna buccogingival odontogenic abscess abscess drainage i d cellulitis MEDICAL_TRANSCRIPTION,Description Examination under anesthesia diagnostic laparoscopy right orchiectomy and left testis fixation Medical Specialty Surgery Sample Name Orchiectomy Testis Fixation Transcription PREOPERATIVE DIAGNOSIS Nonpalpable right undescended testis POSTOPERATIVE DIAGNOSIS Nonpalpable right undescended testis with atrophic right testis PROCEDURES Examination under anesthesia diagnostic laparoscopy right orchiectomy and left testis fixation ANESTHESIA General inhalation anesthetic with caudal block FLUID RECEIVED 250 mL of crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMEN The tissue sent to Pathology was right testicular remnant ABNORMAL FINDINGS Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring INDICATIONS FOR OPERATION The patient is a 2 year old boy with a right nonpalpable undescended testis The plan is for evaluation and repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed The patient was placed in supine position and examined The left testis well within scrotum The right was again not palpable despite the patient being asleep with multiple attempts to check The patient was then sterilely prepped and draped An 8 French feeding tube was then placed within his bladder through the urethra and attached to the drainage We then incised the infraumbilical area once he was sterilely prepped and draped with 15 blade knife then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3 0 Monocryl We entered the peritoneum with the 5 mm one step system We then used the short 0 degree lens for laparoscopy We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found Because there was no testis found in the abdomen we then evacuated the gas and closed the fascial sheath with the 3 0 Monocryl tacking sutures Then skin was closed with subcutaneous closure of 4 0 Rapide A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery Electrocautery was used for hemostasis A curved tenotomy scissor was used to open the sac The tunica vaginalis was visualized and grasped and then dissected up towards external ring There was no apparent testicular tissue We did remove it however tying off the cord structure with a 4 0 Vicryl suture and putting a tagging suture at the base of the tissue sent We then closed the subdartos area with the subcutaneous closure of 4 0 chromic We then did a similar curvilinear incision on the left side for testicular fixation Delivered the testis into the field which had a type III epididymal attachment and was indeed about 3 to 4 mL in size which was larger than expected for the patient s age We then closed the upper aspect of the subdartos pouch with the 4 0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos skin and subcutaneous closure with 4 0 chromic on left hemiscrotum At the end of the procedure the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure The patient tolerated procedure well and was in stable condition upon transfer to the recovery room Keywords surgery diagnostic laparoscopy caudal block testis fixation undescended testis subcutaneous closure testis orchiectomy laparoscopy testicular scrotum MEDICAL_TRANSCRIPTION,Description Leukemic meningitis Right frontal side inlet Ommaya reservoir The patient is a 49 year old gentleman with leukemia and meningeal involvement who was undergoing intrathecal chemotherapy Medical Specialty Surgery Sample Name Ommaya reservoir Transcription TITLE OF OPERATION Right frontal side inlet Ommaya reservoir INDICATION FOR SURGERY The patient is a 49 year old gentleman with leukemia and meningeal involvement who was undergoing intrathecal chemotherapy Recommendation was for an Ommaya reservoir Risks and benefits have been explained They agreed to proceed PREOP DIAGNOSIS Leukemic meningitis POSTOP DIAGNOSIS Leukemic meningitis PROCEDURE DETAIL The patient was brought to the operating room underwent induction of laryngeal mask airway positioned supine on a horseshoe headrest The right frontal region was prepped and draped in the usual sterile fashion Next a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line Once this was completed a burr hole was then created with a high speed burr The dura was then coagulated and opened The Ommaya reservoir catheter was inserted up to 6 5 cm There was good flow This was connected to the side inlet flat bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision This was then cut and __________ It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies Wound was then irrigated copiously with __________ irrigation closed using 3 0 Vicryl for the deep layers and 4 0 Caprosyn for the skin The connection was made with a 3 0 silk suture and was a right angle intermediate to hold the catheter in place Keywords surgery caprosyn leukemic meningitis ommaya reservoir leukemia meningeal intrathecal chemotherapy leukemic meningitis ommaya MEDICAL_TRANSCRIPTION,Description Left orchiopexy Ectopic left testis The patient did have an MRI which confirmed ectopic testis located near the pubic tubercle Medical Specialty Surgery Sample Name Orchiopexy Transcription PREOPERATIVE DIAGNOSIS Ectopic left testis POSTOPERATIVE DIAGNOSIS Ectopic left testis PROCEDURE PERFORMED Left orchiopexy ANESTHESIA General The patient did receive Ancef INDICATIONS AND CONSENT This is a 16 year old African American male who had an ectopic left testis that severed approximately one and a half years ago The patient did have an MRI which confirmed ectopic testis located near the pubic tubercle The risks benefits and alternatives of the proposed procedure were discussed with the patient Informed consent was on the chart at the time of procedure PROCEDURE DETAILS The patient did receive Ancef antibiotics prior to the procedure He was then wheeled to the operative suite where a general anesthetic was administered He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure Next with a 15 blade scalpel an oblique skin incision was made over the spermatic cord region The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery The fascia of the external oblique creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors This was then continued to open the external ring and was then carried cephalad to further open the external ring exposing the spermatic cord With this accomplished the testis was then identified It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord Once again meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens Weitlaner retractor was placed to provide further exposure There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with 3 0 Vicryl Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis Next bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment This was taken down to approximately the two thirds length of the left scrotal compartment Once this tunnel has been created a 15 blade scalpel was then used to make transverse incision A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment Once this was achieved the apices of the dartos were then grasped with hemostats and supra dartos pouch was then created using the Iris scissors A dartos pouch was created between the skin and the supra dartos both cephalad and caudad to the level of the scrotal incision A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra dartos pouch ensuring that anatomic position was in place maintaining the epididymis posterolateral without any rotation of the cord With this accomplished 3 0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis The sutures were then tied creating the orchiopexy The remaining body of the testicle was then tucked into the supra dartos pouch and the skin was then approximated with 4 0 undyed Monocryl in a horizontal mattress fashion interrupted sutures Once again hemostasis was maintained with Bovie electrocautery Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures External ring was then recreated and grasped on each side with hemostats and approximated with 3 0 Vicryl in a running fashion cephalad to caudad Once this was created the created ring was inspected and there was adequate room for the cord There appeared to be no evidence of compression Finally subcutaneous layer with sutures of 4 0 interrupted chromic was placed and then the skin was then closed with 4 0 undyed Vicryl in a running subcuticular fashion The patient had been injected with bupivacaine prior to closing the skin Finally the patient was cleansed The scrotal support was placed and plan will the for the patient to take Keflex one tablet q i d x7 days as well as Tylenol 3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum He will follow up with Dr X in 10 to 14 days Appointment will be made Keywords surgery pubic tubercle ectopic testis ectopic left testis metzenbaum scissors dartos pouch bovie electrocautery testis orchiopexy ectopic scrotal cord dartos MEDICAL_TRANSCRIPTION,Description Bilateral scrotal orchiectomy Medical Specialty Surgery Sample Name Orchiectomy Transcription BILATERAL SCROTAL ORCHECTOMY PROCEDURE The patient is placed in the supine position prepped and draped in the usual manner Under satisfactory general anesthesia the scrotum was approached and through a transverse mid scrotal incision the right testicle was delivered through the incision Hemostasis was obtained with the Bovie and the spermatic cord was identified It was clamped suture ligated with 0 chromic catgut and the cord above was infiltrated with 0 25 Marcaine for postoperative pain relief The left testicle was delivered through the same incision The spermatic cord was identified clamped suture ligated and that cord was also injected with 0 25 percent Marcaine The incision was injected with the same material and then closed in two layers using 4 0 chromic catgut continuous for the dartos and interrupted for the skin A dry sterile dressing fluff and scrotal support applied over that The patient was sent to the Recovery Room in stable condition Keywords surgery scrotum hemostasis marcaine catgut incision scrotal orchiectomy spermatic cord sterile dressing testicle transverse suture ligated chromic catgut orchiectomy scrotal cordNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Incision and drainage and excision of the olecranon bursa left elbow Acute infected olecranon bursitis left elbow Medical Specialty Surgery Sample Name Olecranon Bursa Excision Transcription PREOPERATIVE DIAGNOSIS Acute infected olecranon bursitis left elbow POSTOPERATIVE DIAGNOSIS Infection left olecranon bursitis PROCEDURE PERFORMED 1 Incision and drainage left elbow 2 Excision of the olecranon bursa left elbow ANESTHESIA Local with sedation COMPLICATIONS None NEEDLE AND SPONGE COUNT Correct SPECIMENS Excised bursa and culture specimens sent to the microbiology INDICATION The patient is a 77 year old male who presented with 10 day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage He was then scheduled for I D and excision of the bursa Risks and benefits were discussed No guarantees were made or implied PROCEDURE The patient was brought to the operating room and once an adequate sedation was achieved the left elbow was injected with 0 25 plain Marcaine The left upper extremity was prepped and draped in standard sterile fashion On examination of the left elbow there was presence of thickening of the bursal sac There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted An incision was made midline of the olecranon bursa with an elliptical incision around the open wound which was excised with skin The incision was carried proximally and distally The olecranon bursa was significantly thickened and scarred Excision of the olecranon bursa was performed There was significant evidence of thickening of the bursa with some evidence of adhesions Satisfactory olecranon bursectomy was performed The wound margins were debrided The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution There was no evidence of a loose body There was no bleeding or drainage After completion of the bursectomy and I D the skin margins which were excised were approximated with 2 0 nylon in horizontal mattress fashion The open area of the skin which was excised was left _________ and was dressed with 0 25 inch iodoform packing Sterile dressings were placed including Xeroform 4x4 ABD and Bias The patient tolerated the procedure very well He was then extubated and transferred to the recovery room in a stable condition There were no intraoperative complications noticed Keywords surgery incision and drainage infected olecranon olecranon bursitis olecranon bursa olecranon wound excision drainage elbow bursa MEDICAL_TRANSCRIPTION,Description Chronic plantar fasciitis right foot Open plantar fasciotomy right foot Medical Specialty Surgery Sample Name Open Plantar Fasciotomy Transcription PREOPERATIVE DIAGNOSIS Chronic plantar fasciitis right foot POSTOPERATIVE DIAGNOSIS Chronic plantar fasciitis right foot PROCEDURE Open plantar fasciotomy right foot ANESTHESIA Local infiltrate with IV sedation INDICATIONS FOR SURGERY The patient has had a longstanding history of foot problems The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care The preoperative discussion with the patient including alternative treatment options the procedure itself was explained and risk factors such as infection swelling scar tissue numbness continued pain recurrence falling arch digital contracture and the postoperative management were discussed The patient has been advised although no guarantee for success could be given most of the patients have improved function and less pain All questions were thoroughly answered The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities The purpose of the surgery is to alleviate the pain and discomfort DETAILS OF THE PROCEDURE The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure The patient was brought to the operating room and placed in the supine position Following a light IV sedation a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL and a 1 1 mixture of 1 lidocaine with epinephrine and 0 25 Marcaine was affected The lower extremity was prepped and draped in the usual sterile manner Balance anesthesia was obtained PROCEDURE Plantar fasciotomy right foot The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands creating a small and narrow soft tissue tunnel Utilizing a Metzenbaum scissor transection of the medial two third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band extending to the lateral two thirds of the band The lateral plantar fascial band was left intact Visualization and finger probe confirmed adequate transection The surgical site was flushed with normal saline irrigation The deep layer was closed with 3 0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples The dressing consisted of Adaptic 4 x 4 conforming bandages and an ACE wrap to provide mild compression The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact A walker boot was dispensed and applied The patient will be allowed to be full weightbearing to tolerance in the boot to encourage physiological lengthening of the release of plantar fascial band The next office visit will be in 4 days The patient was given prescriptions for Keflex 500 mg 1 p o three times a day x10 days and Lortab 5 mg 40 1 to 2 p o q 4 6 h p r n pain 2 refills along with written and oral home instructions After a short recuperative period the patient was discharged home with vital signs stable and in no acute distress Keywords surgery plantar fascial band plantar fasciitis plantar fasciotomy plantar fascial anesthesia plantar fascia fasciotomy fascial band foot MEDICAL_TRANSCRIPTION,Description Acute acalculous cholecystitis Open cholecystectomy The patient s gallbladder had some patchy and necrosis areas There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder Medical Specialty Surgery Sample Name Open Cholecystectomy Transcription PREOPERATIVE DIAGNOSIS Acute acalculous cholecystitis POSTOPERATIVE DIAGNOSIS Acute hemorrhagic cholecystitis PROCEDURE PERFORMED Open cholecystectomy ANESTHESIA Epidural with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition SPECIMEN Gallbladder BRIEF HISTORY The patient is a 73 year old female who presented to ABCD General Hospital on 07 23 2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture The patient subsequently went to the operating room on 07 25 2003 for a right hip hemiarthroplasty per the Orthopedics Department Subsequently the patient was doing well postoperatively however the patient does have severe O2 and steroid dependent COPD and at an extreme risk for any procedure The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08 07 2003 for surgical evaluation for upper abdominal pain During the evaluation the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08 08 03 the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder The patient did well postdrainage The patient s laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp However once the tube was removed the patient re obstructed with recurrent symptoms and a second tube was needed to be placed this was done on 08 16 2003 A HIDA scan had been performed which showed no cystic duct obstruction A tube cholecystogram was performed which showed no cystic or common duct obstruction There was abnormal appearance of the gallbladder however the pathway was patent Thus after failure of two nonoperative management therapies extensive discussions were made with the family and the patient s only option was to undergo a cholecystectomy Initial thoughts were to do a laparoscopic cholecystectomy however with the patient s severe COPD and risk for ventilator management the options were an epidural and an open cholecystectomy under local was made and to be performed INTRAOPERATIVE FINDINGS The patient s gallbladder had some patchy and necrosis areas There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder The patient also had no plane between the gallbladder and the liver bed OPERATIVE PROCEDURE After informed written consent risks and benefits of the procedure were explained to the patient and discussed with the patient s family The patient was brought to the operating room after an epidural was performed per anesthesia Local anesthesia was given with 1 lidocaine A paramedian incision was made approximately 5 cm in length with a 15 blade scalpel Next hemostasis was obtained using electro Bovie cautery Dissection was carried down transrectus in the midline to the posterior rectus fascia which was grasped with hemostats and entered with a 10 blade scalpel Next Metzenbaum scissors were used to extend the incision and the abdomen was entered The gallbladder was immediately visualized and brought up into view grasped with two ring clamps elevating the biliary tree into view Dissection with a ______ was made to identify the cystic artery and cystic duct which were both easily identified The cystic artery was clipped two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors The cystic duct was identified A silk tie 3 0 silk was placed one distal and one proximal with 3 0 silk and then cutting in between with a Metzenbaum scissors The gallbladder was then removed from the liver bed using electro Bovie cautery A plane was created The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel The gallbladder was then removed as specimen sent to pathology for frozen sections for diagnosis of which the hemorrhagic cholecystitis was diagnosed on frozen sections Permanent sections are still pending The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen The peritoneum as well as posterior rectus fascia was approximated with a running 0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure of eight 0 Vicryl sutures Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition Keywords surgery open cholecystectomy hemorrhagic gallbladder serosal liver bed acute acalculous acalculous cholecystitis cystic duct bovie cautery rectus fascia metzenbaum scissors fascia cholecystitis cholecystectomy cystic MEDICAL_TRANSCRIPTION,Description Nissen fundoplication A 2 cm midline incision was made at the junction of the upper two thirds and lower one third between the umbilicus and the xiphoid process Medical Specialty Surgery Sample Name Nissen Fundoplication Transcription PROCEDURE PERFORMED Nissen fundoplication DESCRIPTION OF PROCEDURE After informed consent was obtained detailing the risks of infection bleeding esophageal perforation and death the patient was brought to the operative suite and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was then placed in a modified lithotomy position taking great care to pad all extremities TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis Antibiotics were given for prophylaxis against surgical infection A 52 French bougie was placed in the proximal esophagus by Anesthesia above the cardioesophageal junction A 2 cm midline incision was made at the junction of the upper two thirds and lower one third between the umbilicus and the xiphoid process The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adaptor in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg A 30 degree laparoscope was inserted through this port and used to guide the remaining trocars The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer s line spreading the subcutaneous tissue with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 4 other 10 11 mm trocars were placed Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line at a right supraumbilical position another at the left upper quadrant at the midclavicular line at a left supraumbilical position 1 under the right costal margin in the anterior axillary line and another laterally under the left costal margin on the anterior axillary line All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position The triangular ligament was taken down sharply and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula The gastrohepatic ligament was then identified and incised in an avascular plane The dissection was carried anteromedially onto the phrenoesophageal membrane The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice This incision was extended to the right to allow identification of the right crus Then along the inner side of the crus the right esophageal wall was freed by dissecting the cleavage plane The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus The pars flaccida of the lesser omentum was opened preserving the hepatic branches of the vagus nerve This allowed free access to the crura left and right and the right posterior aspect of the esophagus and the posterior vagus nerve Attention was next turned to the left anterolateral aspect of the esophagus At its left border the left crus was identified The dissection plane between it and the left aspect of the esophagus was freed The gastrophrenic ligament was incised beginning the mobilization of the gastric pouch By dissecting the intramediastinal portion of the esophagus we elongated the intra abdominal segment of the esophagus and reduced the hiatal hernia The next step consisted of mobilization of the gastric pouch This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen away from the gastroepiploic arcade The esophagus was lifted by a Babcock inserted through the left upper quadrant port Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus A one half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus The retroesophageal channel was enlarged to allow easy passage of the antireflux valve The 52 French bougie was then carefully lowered into the proximal stomach and the hiatal orifice was repaired Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice The last part of the operation consisted of the passage and fixation of the antireflux valve With anterior retraction on the esophagus using the Penrose drain a Babcock was passed behind the esophagus from right to left It was used to grab the gastric pouch to the left of the esophagus and to pull it behind forming the wrap The 52 French bougie was used to calibrate the external ring Marcaine 0 5 was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control The skin incision was approximated with skin staples A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords surgery umbilicus insufflation phrenoesophageal membrane nissen fundoplication gastric pouch esophagus penrose antireflux nissen fundoplication trocars ligament MEDICAL_TRANSCRIPTION,Description Nipple areolar reconstruction utilizing a full thickness skin graft and mastopexy Medical Specialty Surgery Sample Name Nipple Reconstruction Transcription PREOPERATIVE DIAGNOSES 1 Surgical absence of left nipple areola with personal history of breast cancer 2 Breast asymmetry POSTOPERATIVE DIAGNOSES 1 Surgical absence of left nipple areola with personal history of breast cancer 2 Breast asymmetry PROCEDURE 1 Left nipple areolar reconstruction utilizing a full thickness skin graft from the left groin 2 Redo right mastopexy ANESTHESIA General endotracheal COMPLICATIONS None DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia the patient was placed in a frog leg position and prepped and draped in usual fashion for the above noted procedure The initial portion of the procedure was harvesting a full thickness skin graft from the left groin region This was accomplished by ellipsing out a 42 mm diameter circle of skin just below the thigh peroneal crease The defect was then closed with 3 0 Vicryl followed by 3 0 chromic suture in a running locked fashion The area was dressed with antibiotic ointment and then a Peri Pad The patient s legs were brought out frog leg back to the midline and sterile towels were placed over the opening in the drapes Surgical team s gloves were changed and then attention was turned to the planning of the left nipple flap A maltese cross pattern was employed with a 1 cm diameter nipple and a 42 mm diameter nipple areolar complex Once the maltese cross had been designed on the breast at the point where the nipple was to be placed the areas of the portion of flap were de epithelialized Then when this had been completed the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple At this point a Bovie electrocautery was used to control bleeding points and then 4 0 chromic suture was used to suture the arms of the flap together creating the nipple When this had been completed the skin graft which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft At this point the graft was sutured into position in the defect using 3 0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola At this point 4 0 chromic was used to run around the perimeter of the full thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4 0 chromic The areolar skin graft was pie crusted Then at this point the area of areola was dressed with silicone gel sheeting A silo was placed over the neonipple with 3 0 nylon through the apex of the neonipple to support the nipple in an erect position Mastisol and Steri Strips were then applied At this point attention was turned to the right breast where a 2 cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made The skin was removed from the area and then a layered closure of 3 0 Vicryl followed by 3 0 PDS in a running subcuticular fashion was carried out When this had been completed the Mastisol and Steri Strips were applied to the transverse right breast incision Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola The patient was then placed in Surgi Bra and then was taken from the operating room to the recovery room in good condition Keywords surgery nipple areola breast asymmetry general endotracheal peri pad surgi bra breast cancer frog leg position full thickness skin graft general endotracheal anesthesia mastopexy nipple areolar complex nipple areolar reconstruction nipple flap prepped and draped transverse mastopexy areolar reconstruction skin graft graft nipple areolar breast MEDICAL_TRANSCRIPTION,Description Right radical nephrectomy and assisted laparoscopic approach Medical Specialty Surgery Sample Name Nephrectomy Radical Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOPERATIVE DIAGNOSIS Right renal mass PROCEDURE Right radical nephrectomy and assisted laparoscopic approach ANESTHESIA General PROCEDURE IN DETAIL The patient underwent general anesthesia with endotracheal intubation An orogastric was placed and a Foley catheter placed He was placed in a modified flank position with the hips rotated to 45 degrees Pillow was used to prevent any pressure points He was widely shaved prepped and draped A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus The incision was made through the premarked site through the skin and subcutaneous tissue The aponeurosis of the external oblique was incised in the direction of its fibers Muscle splitting incision was made in the internal oblique and transversus abdominis The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring Then abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions Once this had been completed the scope was placed in the usual port and dissection begun by taking down the white line of Toldt so that the colon could be retracted medially This exposed the duodenum which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava Next attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down so that the psoas muscle was exposed The attachments lateral to the kidney was taken down so that the kidney could be flipped anteriorly and medially and this helped in exposing the renal artery The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device After the arteries had been divided the renal vein was divided again using a stapling device The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler and the specimen was removed Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland which was controlled with Surgicel Next the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion The estimated blood loss was negligible There were no complications The patient tolerated the procedure well and left the operating room in satisfactory condition Keywords surgery renal mass foley catheter gerota fascia muscle splitting incision pneumo sleeve endotracheal laparoscopic nephrectomy orogastric renal fossa right lower quadrant trocar umbilicus vena cava renal pneumo radical MEDICAL_TRANSCRIPTION,Description Transplant nephrectomy after rejection of renal transplant Medical Specialty Surgery Sample Name Nephrectomy Transplant Transcription PREOPERATIVE DIAGNOSIS Rejection of renal transplant POSTOPERATIVE DIAGNOSIS Rejection of renal transplant OPERATIVE PROCEDURE Transplant nephrectomy DESCRIPTION OF PROCEDURE The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously but the ureter was wide open and there was no evidence of obstruction Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested With the patient in the supine position the previously placed nephrostomy tube was removed The patient then after adequate prepping and draping and placing of a small roll under the right hip underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space During the course of dissection the iliac artery and vein were identified as was the native ureter and the patient s ilioinguinal nerve all these were preserved The individual vessels in the kidney were identified ligated and incised and the kidney was removed The ureter was encountered during the course of resection but was not ligated The patient s retroperitoneal space was irrigated with antibiotic solution and 19 Blake drain was placed into the retroperitoneal space and the patient returned to the recovery room in good condition ESTIMATED BLOOD LOSS 900 mL Keywords surgery renal transplant blake drain rejection iliac artery ilioinguinal immunosuppression kidney function nephrectomy nephrostomy tube retroperitoneal space toxic ureter vein transplant renal retroperitoneal kidney MEDICAL_TRANSCRIPTION,Description Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection Medical Specialty Surgery Sample Name Neuroplasty Transcription PREOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room status post transforaminal epidurogram see operative note for further details Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen 375 units of Wydase was injected through each needle After two minutes 3 5 cc of 0 5 Marcaine and 80 mg of Depo Medrol was injected through each needle These needles were removed and the patient was discharged in stable condition Keywords surgery nerve root decompression discectomy epidural fibrosis nerve root entrapment transforaminal neuroplasty neural foramen nerve root foramen neuroplasty transforaminal needle epidural MEDICAL_TRANSCRIPTION,Description Repair of nerve and tendon right ring finger and exploration of digital laceration Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger Medical Specialty Surgery Sample Name Nerve Tendon Repair Finger Transcription PREOPERATIVE DIAGNOSIS Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury POSTOPERATIVE DIAGNOSES 1 Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis 2 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger PROCEDURE PERFORMED 1 Repair of nerve and tendon right ring finger 2 Exploration of digital laceration ANESTHESIA General ESTIMATED BLOOD LOSS Less than 10 cc TOTAL TOURNIQUET TIME 57 minutes COMPLICATIONS None DISPOSITION To PACU in stable condition BRIEF HISTORY OF PRESENT ILLNESS This is a 13 year old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger GROSS OPERATIVE FINDINGS After wound exploration it was found there was a 100 laceration to the ulnar digital neurovascular bundle The FDS had a partial ulnar slip laceration and the FDP had a 25 transverse laceration as well The radial neurovascular bundle was found to be completely intact OPERATIVE PROCEDURE The patient was taken to the operating room and placed in the supine position All bony prominences were adequately padded Tourniquet was placed on the right upper extremity after being packed with Webril but not inflated at this time The right upper extremity was prepped and draped in the usual sterile fashion The hand was inspected Palmar surface revealed approximally 0 5 cm laceration at the base of the right ring finger at the base of proximal phalanx which was approximated with nylon suture The sutures were removed and the wound was explored It was found that the ulnar digital neurovascular bundle was 100 transected The radial neurovascular bundle on the right ring finger was found to be completely intact We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25 laceration in a transverse fashion to the FDP We copiously irrigated the wound Repair was undertaken of the FDS with 3 0 undyed Ethibond suture The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact Attention during our repair at the flexor tendon the A1 pulley was incised for better visualization as well as better tendon excursion after repair Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury The digital nerve was dissected proximally and distally to likely visualize the nerve The nerve was then approximated using microvascular technique with 8 0 nylon suture The hands were well approximated The nerve was not under undue tension The wound was then copiously irrigated and the skin was closed with 4 0 nylon interrupted horizontal mattress alternating with simple suture Sterile dressing was placed and a dorsal extension Box splint was placed The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition Overall prognosis is good Keywords surgery laceration flexor tendon volar laceration digital laceration ulnar slip flexor digitorum neurovascular bundle nerve injury ring finger neurovascular fds bundle tendon repair flexor digital ulnar MEDICAL_TRANSCRIPTION,Description Laparoscopic right partial nephrectomy due to right renal mass Medical Specialty Surgery Sample Name Nephrectomy Partial Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOPERATIVE DIAGNOSIS Right renal mass PROCEDURE PERFORMED Laparoscopic right partial nephrectomy ESTIMATED BLOOD LOSS 250 mL X RAYS None SPECIMENS Included right renal mass as well as biopsies from the base of the resection ANESTHESIA General endotracheal COMPLICATIONS None DRAINS Included a JP drain in the right flank as well as a 16 French Foley catheter per urethra BRIEF HISTORY The patient is a 60 year old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter I had a long discussion with him concerning variety of options We talked in particular about extirpated versus ablative surgery Based on his young age and excellent state of health decision was made at this point to proceed to a right partial nephrectomy laparoscopically All questions were answered and he wished to proceed with surgery as planned Note that the patient does have a positive family history of renal cell carcinoma PROCEDURE IN DETAIL After acquisition of proper informed consent and administration of perioperative antibiotics the patient was taken to the operating room and placed supine on the operating table After institution of adequate general anesthetic via endotracheal rod he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest All pressure points were carefully padded and he was securely taped to the table Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia His abdomen was then prepped and draped in a standard surgical fashion Note that a 16 French Foley catheter was in place per urethra as well as an orogastric tube The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident We then placed a Visiport 10 x 12 trocar in the right lateral abdomen With the trocar in place we were able to place the remaining trocars under direct laparoscopic visualization We placed three additional trocars An 11 mm screw type trocar at the umbilicus a 6 screw type trocar 7 cm in the midline above the umbilicus and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline The procedure was begun by reflecting the right colon by incising the white line of Toldt The colon was reflected medially and the retroperitoneum was exposed on that side This was a fairly superficial lesion so decision was made in advance to potentially not perform vascular clamping however I did feel it important to get high level control prior to proceeding to the partial With the colon reflected the duodenum was identified and it was reflected medially under Kocher maneuver The ureter and gonadal vein were identified on the right side and elevated The space between the ureter and the gonadal vein was then developed and the gonadal vein was dropped elevating only the ureter and carrying this plane dissection up towards the renal hilum Once we got up to the renal hilum we were able to skeletonize the renal hilar vessels partially and in particular we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device With the kidney free and the hilum prepared the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma and using this approach we were able to identify the 2 cm right renal mass located in the lower pole laterally A cap of fat was left overlying this mass Based on the position of the mass we performed intraoperative laparoscopic ultrasound which showed the mass to be somewhat deeper than initially anticipated Based on this finding I decided to go ahead and clamp the renal hilum during resection A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure and he also received Lasix prior to clamping the renal hilum With the renal hilum clamped we did resect the tumor using cold scissors There was somewhat more bleeding than would be expected based on the hilar clamping however we were able to successfully resect this lesion We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section With the tumor resected the base of the resection was then cauterized using the Argon beam coagulator and several bleeding vessels were oversewn using figure of eight 3 0 Vicryl sutures with lap ties for tensioning We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure We then released the vascular clamp Total clamp time was 11 minutes There was minimal bleeding and occlusion of this maneuver and after unclamping the kidney the kidney pinked up appropriately and appeared well perfused after removal of the clamp We then replaced the kidney within its Gerota envelope and closed that with 3 0 Vicryl using lap ties for tensioning A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2 0 nylon The specimen was placed into a 10 mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm It was evaluated on the table and passed off the table for Pathology to evaluate They stated that the tumor was close to the margin but there appeared to be 1 2 mm normal parenchyma around the tumor In addition the frozen section biopsies from the base of the resection were negative for renal cell carcinoma Based on these findings the lower most trocar site was closed using a running 0 Vicryl suture in the fascia We then re insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis Any bleeding points were controlled primarily using bipolar cautery or hemoclips The area was copiously irrigated with normal saline The colon was then replaced into its normal anatomic position The mesentry was evaluated There were no defects noted We closed the 10 x 12 lateral most trocar site using a Carter Thompson closure device with 0 Vicryl All trocars were removed under direct visualization and the abdomen was desufflated prior to removal of the last trocar The skin incisions were irrigated with normal saline and infiltrated with 0 25 Marcaine and the skin was closed using a running 4 0 Monocryl in subcuticular fashion Benzoin and Steri Strips were placed The patient was returned in supine position and awoken from general anesthetic without incident He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring At the end of the case sponge instrument and needle counts were correct I was scrubbed and present throughout the entire case Keywords surgery renal mass foley catheter gerota fascia jp drain kocher maneuver laparoscopic ligasure device satinsky clamp toldt bulldogs nephrectomy renal parenchyma resection urethra vicryl sutures partial nephrectomy gonadal vein renal hilum satinsky renal kidney hilum foley endotracheal MEDICAL_TRANSCRIPTION,Description Laparoscopic right radical nephrectomy due to right renal mass Medical Specialty Surgery Sample Name Nephrectomy Radical Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOP DIAGNOSIS Right renal mass PROCEDURE PERFORMED Laparoscopic right radical nephrectomy ESTIMATED BLOOD LOSS 100 mL X RAYS None SPECIMENS Right radical nephrectomy specimen COMPLICATIONS None ANESTHESIA General endotracheal DRAINS 16 French Foley catheter per urethra BRIEF HISTORY The patient is a 71 year old woman recently diagnosed with 6 5 cm right upper pole renal mass This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma I discussed a variety of options with her and she opted to proceed with a laparoscopic right radical nephrectomy All questions were answered and she wished to proceed with surgery as planned PROCEDURE IN DETAIL After acquisition of appropriate written and informed consent and administration of perioperative antibiotics the patient was taken to the operating room and placed supine on the operating table Note that sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia After institution of adequate general anesthetic via the endotracheal route she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest All pressure points were carefully padded and she was securely taped to the table to prevent shifting during the procedure Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16 French Foley catheter per urethra to gravity drainage The abdomen was insufflated in the right outer quadrant Note that the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident We then placed a 10 12 Visiport trocar approximately 7 cm lateral to the umbilicus Once this had entered into the peritoneal cavity without incident the remaining trocars were all placed Under direct laparoscopic visualization we placed three additional trocars an 11 mm screw type trocar in the umbilicus a 6 mm screw type trocar in the upper midline approximately 7 cm above the umbilicus and 10 12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar There were some adhesions of omentum to the underside of that scar and these were taken down sharply using laparoscopic scissors We began nephrectomy procedure by reflecting the right colon by incising the white line of Toldt This exposed the retroperitoneum on the right side The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only We then identified the ureter and gonadal vein in the retroperitoneum The gonadal vein was left down along the vena cava and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum Sequential packets of tissue were taken using primarily the LigaSure Atlas device Once we got to the renal hilum it became apparent that this patient had two sets of renal arteries and veins We proceeded then and skeletonized the structures into four individual packets We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland The adrenal was spared during this procedure There was no contiguous connection between the renal mass and a right adrenal gland This plane of dissection was taken down primarily using the LigaSure device We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring Once this was completed the kidney was free except for its attachment to the ureter and lateral attachments The lateral attachments of the kidney were taken down using the LigaSure Atlas device and then the ureter was doubly clipped and transected The kidney was then freed within the retroperitoneum A 50 mm EndoCatch bag was introduced through the lower most trocar site and the kidney was placed into this bag for subsequent extraction We extended the lower most trocar site approximately 6 cm to facilitate extraction The kidney was removed and passed off the table as a specimen for pathology This was bivalved by pathology and we reviewed the specimen Keywords surgery renal mass carter thomason endocatch bag foley catheter gi stapler laparoscopic ligasure toldt laparoscopic scissors nephrectomy radical nephrectomy screw type trocar umbilicus upper pole urethra carter thomason closure device laparoscopic right radical nephrectomy carter thomason closure carter thomason renal hilum kidney abdomen endotracheal radical oncocytoma renal MEDICAL_TRANSCRIPTION,Description Excision of neuroma third interspace left foot Morton s neuroma third interspace left foot Medical Specialty Surgery Sample Name Neuroma Excision Transcription PREOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot POSTOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot OPERATION PERFORMED Excision of neuroma third interspace left foot ANESTHESIA General local was confirmed by surgeon HEMOSTASIS Ankle pneumatic tourniquet 225 mmHg TOURNIQUET TIME 18 minutes Electrocautery was necessary INJECTABLES 50 50 mixture of 0 5 Marcaine and 1 Xylocaine both plain Also 0 5 mL dexamethasone phosphate 4 mg mL INDICATIONS Please see dictated H P for specifics PROCEDURE After proper identification was made the patient was brought to the operating room and placed on the table in supine position The patient was then placed under general anesthesia A local block was then injected into the third ray of the left foot The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures Identification of the neuroma was made following plantar flexion of the digits It was grasped with a hemostat and it was dissected in toto and removed It was then sent to pathology The area was then flushed with copious amounts of sterile saline Closure was with 4 0 Vicryl in the subcutaneous tissue and then running subcuticular 4 0 nylon suture in the skin Steri Strips were then placed over that area A sterile compressive dressing consisting of saline soaked gauze ABD Kling Coban was placed over the foot The tourniquet was then released Good flow was noted to return to all digits The patient did tolerate the procedure well He left the operating room with all vital signs stable and neurovascular status intact The patient went to the recovery The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain The patient will follow up with me in approximately 4 days for dressing change Keywords surgery interspace ankle pneumatic pneumatic tourniquet morton s neuroma tourniquet neuroma foot anesthesia MEDICAL_TRANSCRIPTION,Description Needle localized excisional biopsy left breast The patient is a 71 year old black female who had a routine mammogram which demonstrated suspicious microcalcifications in the left breast She had no palpable mass on physical exam She does have significant family history with two daughters having breast cancer Medical Specialty Surgery Sample Name Needle Localized Excisional Biopsy Breast Transcription PREOPERATIVE DIAGNOSIS Suspicious microcalcifications left breast POSTOPERATIVE DIAGNOSIS Suspicious microcalcifications left breast PROCEDURE PERFORMED Needle localized excisional biopsy left breast ANESTHESIA Local with sedation SPECIMEN Left breast with specimen mammogram COMPLICATIONS None HISTORY The patient is a 71 year old black female who had a routine mammogram which demonstrated suspicious microcalcifications in the left breast She had no palpable mass on physical exam She does have significant family history with two daughters having breast cancer The patient also has a history of colon cancer A surgical biopsy was recommended and she was scheduled electively PROCEDURE After proper informed consent was obtained she was placed in the operative suite This occurred after undergoing preoperative needle localization She was placed in the operating room in the supine position She was given sedation by the Anesthesia Department The left breast was prepped and draped in the usual sterile fashion The skin was infiltrated with local and a curvilinear incision was made in the left lower outer quadrant The breast tissue was grasped with Allis clamps and a core of tissue was removed around the localization wire There were some fibrocystic changes noted The specimen was then completely removed and was sent to Radiology for mammogram The calcifications were seen in specimen per Dr X Meticulous hemostasis was achieved with electrocautery The area was irrigated and suctioned The aspirant was clear The skin was then reapproximated using 4 0 undyed Vicryl in a running subcuticular fashion Steri Strips and sterile dressing on the patient s bra were applied The patient tolerated the procedure well and was transferred to recovery room in stable condition Keywords surgery suspicious microcalcifications needle localized excisional biopsy needle localized excisional biopsy routine mammogram breast cancer excisional biopsy breast needle biopsy mammogram microcalcifications MEDICAL_TRANSCRIPTION,Description Stage I and II neuromodulator Medical Specialty Surgery Sample Name Neuromodulator Transcription PREOPERATIVE DIAGNOSIS Refractory urgency and frequency POSTOPERATIVE DIAGNOSIS Refractory urgency and frequency OPERATION Stage I and II neuromodulator ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid The patient was given Ancef preop antibiotic Ancef irrigation was used throughout the procedure BRIEF HISTORY The patient is a 63 year old female who presented to us with urgency and frequency on physical exam There was no evidence of cystocele or rectocele On urodyanamcis the patient has significant overactivity of the bladder The patient was tried on over three to four different anticholinergic agents such as Detrol Ditropan Sanctura and VESIcare for at least one month each The patient had pretty much failure from each of the procedure The patient had less than 20 improvement with anticholinergics Options such as continuously trying anticholinergics continuation of the Kegel exercises and trial of InterStim were discussed The patient was interested in the trial The patient had percutaneous InterStim trial in the office with over 70 to 80 improvement in her urgency frequency and urge incontinence The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator Risks of anesthesia bleeding infection pain MI DVT and PE were discussed Risk of failure of the procedure in the future was discussed Risk of lead migration that the treatment may or may not work in the long term basis and data on the long term were not clear were discussed with the patient The patient understood and wanted to proceed with stage I and II neuromodulator Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR The patient was placed in prone position A pillow was placed underneath her pelvis area to slightly lift the pelvis up The patient was awake was given some MAC anesthesia through the IV but the patient was talking and understanding and was able to verbalize issues The patient s back was prepped and draped in the usual sterile fashion Lidocaine 1 was applied on the right side near the S3 foramen Under fluoroscopy the needle placement was confirmed The patient felt stimulation in the vaginal area which was tapping in nature The patient also had a pressure feeling in the vaginal area The patient had no back sensation or superficial sensation There was no sensation down the leg The patient did have __________ which turned in slide bellows response indicating the proper positioning of the needle A wire was placed The tract was dilated and lead was placed The patient felt tapping in the vaginal area which is an indication that the lead is in its proper position Most of the leads had very low amplitude and stimulation Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks Please note that the lidocaine was injected prior to the tunneling A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead Screws were turned and they were dropped Attention was made to ensure that the lead was all the way in into the InterStim Irrigation was performed after placing the main unit in the pouch Impedance was checked Irrigation was again performed with antibiotic irrigation solution The needle site was closed using 4 0 Monocryl The pouch was closed using 4 0 Vicryl and the subcutaneous tissue with 4 0 Monocryl Dermabond was applied The patient was brought to recovery in a stable condition Keywords surgery refractory urgency urgency frequency neuromodulator subcutaneous tissue interstim MEDICAL_TRANSCRIPTION,Description Needle localized excisional biopsy of the left breast Left breast mass with abnormal mammogram The patient had a nonpalpable left breast mass which was excised and sent to Radiology with confirmation that the mass is in the specimen Medical Specialty Surgery Sample Name Needle Localized Excisional Biopsy Breast 1 Transcription PREOPERATIVE DIAGNOSIS Left breast mass with abnormal mammogram POSTOPERATIVE DIAGNOSIS Left breast mass with abnormal mammogram PROCEDURE PERFORMED Needle localized excisional biopsy of the left breast ANESTHESIA Local with sedation COMPLICATIONS None SPECIMEN Breast mass DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition INTRAOPERATIVE FINDINGS The patient had a nonpalpable left breast mass which was excised and sent to Radiology with confirmation that the mass is in the specimen BRIEF HISTORY The patient is a 62 year old female who presented to Dr X s office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass So the patient was scheduled for a needle localized left breast biopsy PROCEDURE After informed consent the risks and benefits of the procedure were explained to the patient The patient was brought to the operating suite After IV sedation was given the patient was prepped and draped in normal sterile fashion Next a curvilinear incision was made After anesthetizing the skin with 0 25 Marcaine and 1 lidocaine mixture an incision was made with a 10 blade scalpel The lesion with needle was then grasped with an Allis clamp Using 10 blade scalpel the specimen was colonized out and sent to Radiology for confirmation Next hemostasis was obtained using electrobovie cautery The skin was then closed with 4 0 Monocryl suture in running subcuticular fashion Steri Strips and sterile dressings were applied The patient tolerated the procedure well and was sent to Recovery in stable condition Keywords surgery needle localized excisional biopsy excisional biopsy abnormal mammogram breast mass breast radiology biopsy mammogram needle MEDICAL_TRANSCRIPTION,Description Left partial nephrectomy due to left renal mass Medical Specialty Surgery Sample Name Nephrectomy Partial Transcription PREOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter POSTOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter OPERATION PERFORMED Left partial nephrectomy ANESTHESIA General with epidural COMPLICATIONS None ESTIMATED BLOOD LOSS About 350 mL REPLACEMENT Crystalloid and Cell Savers from the case INDICATIONS FOR SURGERY This is a 64 year old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy Due to the peripheral nature of the tumor located in the mid to lower pole laterally he has elected to undergo a partial nephrectomy Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Postoperative pain 4 Herniation from the incision PROCEDURE IN DETAIL Epidural anesthesia was administered in the holding area after which the patient was transferred into the operating room General endotracheal anesthesia was administered after which the patient was positioned in the flank standard position A left flank incision was made over the area of the twelfth rib The subcutaneous space was opened by using the Bovie The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered Once the retroperitoneum had been entered the incision was extended until the peritoneal envelope could be identified The peritoneum was swept medially The Finochietto retractor was then placed for exposure The kidney was readily identified and was mobilized from outside Gerota s fascia The ureter was dissected out easily and was separated with a vessel loop The superior aspect of the kidney was mobilized from the superior attachment The pedicle of the left kidney was completely dissected revealing the vein and the artery The artery was a single artery and was dissected easily by using a right angle clamp A vessel loop was placed around the renal artery The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney The Gerota s fascia overlying that portion of the kidney was opened in the area circumferential to the tumor Once the renal capsule had been identified the capsule was scored using a Bovie about 0 5 cm lateral to the border of the tumor Bulldog clamp was then placed on the renal artery The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex This was performed by using the blunted end of the scalpel The tumor was removed easily The argon beam coagulation device was then utilized to coagulate the base of the resection The visible larger bleeding vessels were oversewn by using 4 0 Vicryl suture The edges of the kidney were then reapproximated by using 2 0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through Two horizontal mattress sutures were placed and were tied down The Gerota s fascia was then also closed by using 2 0 Vicryl suture The area of the kidney at the base was covered with Surgicel prior to tying the sutures The bulldog clamp was removed and perfect hemostasis was evident There was no evidence of violation into the calyceal system A 19 French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision The drain was anchored by using silk sutures The flank fascial layers were closed in three separate layers in the more medial aspect The lateral posterior aspect was closed in two separate layers using Vicryl sutures The skin was finally reapproximated by using metallic clips The patient tolerated the procedure well Keywords surgery renal mass bovie finochietto retractor gerota s fascia herniation bulldog clamp needle biopsy nephrectomy partial nephrectomy renal cell carcinoma retroperitoneum vicryl suture gerota s kidney partial renal sutures vicryl MEDICAL_TRANSCRIPTION,Description Left laparoscopic hand assisted nephrectomy Medical Specialty Surgery Sample Name Nephrectomy Transcription PREOPERATIVE DIAGNOSIS Left renal mass left renal bleed POSTOPERATIVE DIAGNOSIS Left renal mass left renal bleed PROCEDURE PERFORMED Left laparoscopic hand assisted nephrectomy ANESTHESIA General endotracheal EBL 100 mL The patient had a triple lumen catheter A line placed BRIEF HISTORY The patient is a 54 year old female with history of diabetic nephropathy diabetes hypertension left BKA who presented with abdominal pain with left renal bleed The patient was found to have a complex mass in the upper pole and the lower pole of the kidney MRI and CAT scan showed questionable renal mass which could be malignant Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy At this point the patient was unable to go home The patient continually complained of pain The patient required about 3 to 4 units of blood transfusions prior The patient initially came in with hemoglobin less than 5 The hemoglobin prior to surgery was 10 Risks of anesthesia bleeding infection pain MI DVT PE respiratory failure morbidity and mortality of the procedure due to her low ejection fraction were discussed Cardiac clearance was obtained The patient was high risk family and the patient knew about the risk The recommendation from the pulmonologist cardiologist and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention The patient and family understood all the risks and benefits in order to proceed with the surgery DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient had A line triple lumen catheter The patient was placed in left side up right side down oblique position All the pressure points were well padded The right fistula was carefully padded completely around it Axilla was protected The fistula was checked throughout the procedure to ensure that it was stable The arms ankles knees and joints were all padded with foam The patient was taped to the table using 2 inch wide tape OG and a Foley catheter were in place A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply There were some adhesions where the omentum was into the umbilical hernia which was completely stuck The omentum was released out of that just so we could obtain pneumoperitoneum Pneumoperitoneum was obtained after using GelPort Two 12 mm ports were placed in the left anterior axillary line and mid clavicular line The colon was reflected medially Kidney was dissected laterally behind and inferiorly There was large hematoma visualized with significant amount of old blood which was irrigated out Dissection was carried superiorly and the spleen was reflected medially The spleen and colon were all intact at the end of the procedure They were stable all throughout Using endovascular GIA stapler all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve Hemostasis was obtained The renal vein and the renal artery were stapled and there was excellent hemostasis The dissection was carried lateral to the adrenal and medial to the right kidney The adrenal was preserved The entire kidney was removed through the hand port Irrigation was performed There was excellent hemostasis at the end of the nephrectomy Fibrin glue and Surgicel were applied just in case the patient had delayed DIC The colon was placed back and 12 mm ports were closed under direct palpation using 0 Vicryl The fascia was closed using loop 1 PDS in a running fashion and was tied in the middle Please note that prior to the fascial closure the peritoneum was closed using 0 Vicryl in running fashion The subcuticular tissue was brought together using 4 0 Vicryl The skin was closed using 4 0 Monocryl Dermabond was applied The patient was brought to the recovery in a stable condition Keywords surgery laparoscopic nephrectomy laparoscopic hand assisted nephrectomy triple lumen catheter lumen catheter running fashion renal mass renal bleed dissection hemostasis kidney renal MEDICAL_TRANSCRIPTION,Description Malignant mass of the left neck squamous cell carcinoma Left neck mass biopsy and selective surgical neck dissection left Medical Specialty Surgery Sample Name Neck Mass Biopsy Transcription PREOPERATIVE DIAGNOSIS Malignant mass of the left neck POSTOPERATIVE DIAGNOSIS Malignant mass of the left neck squamous cell carcinoma PROCEDURES 1 Left neck mass biopsy 2 Selective surgical neck dissection left DESCRIPTION OF PROCEDURE After obtaining an informed the patient was taken to the operating room where a time out process was followed Preoperative antibiotic was given and Dr X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room Finally a 5 5 French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation Then the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation The neck was prepped and draped in the usual fashion I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap Then I performed an extensive anesthetic block of the area Then an incision was made along the area marked for development of the flap but in a very limited extent just to expose the cervical mass The cervical mass which was about 4 cm in diameter and very firm and rubbery was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck A wedge sample was sent to Pathology for frozen section At the same time we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen Therefore a larger sample was sent to Pathology and at that particular time the fresh frozen was reported as having squamous elements This was not totally clear in my mind and therefore I proceeded to excise the full mass which luckily was not attached to any structures except in the very deep surface There there were some attachments to branches of the external carotid artery which had to be suture ligated At any rate the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma With that information in hand we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap which basically involved a reverse U shape on the left neck This worked out quite nicely The external jugular vein was out of the way so initially we did not deal with it We proceeded to tackle the area III and extended into II A When we excised the mass the upper end was in intimate relationship with the parotid gland which was relatively large in this patient but it looked normal otherwise Also I felt that the submaxillary gland was enlarged At any rate we decided to clean up the areas III and IV and a few nodes from II A that were removed and then we went into the posterior triangle where we identified the spinal accessory nerve which we protected actually did not even dissect close to it The same nerve had been already identified anterior to the internal jugular vein very proximally behind the digastric and the sternocleidomastoid muscle At any rate there were large nodes in the posterior triangle in areas V A and V B which were excised and sent to Pathology for examination Also there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen Hemostasis was revised and found to be adequate The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap The flap was replaced in its position A soft Jackson Pratt catheter was left in the area and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin I would like to mention that also the facial vein was excised and the external jugular vein was ligated It was in very lateral location and it was on the site of the drain so we ligated that but did not excise it A pressure dressing was applied The patient tolerated the procedure well Estimated blood loss was no more than 100 mL The patient was extubated in the operating room and sent for recovery Keywords surgery neck mass biopsy surgical neck dissection internal jugular vein external jugular vein squamous cell carcinoma neck mass malignant mass neck dissection mass neck wedge vein MEDICAL_TRANSCRIPTION,Description Nasal septoplasty bilateral submucous resection of the inferior turbinates and tonsillectomy and resection of soft palate Nasal septal deviation with bilateral inferior turbinate hypertrophy Tonsillitis with hypertrophy Edema to the uvula and soft palate Medical Specialty Surgery Sample Name Nasal Septoplasty Tonsillectomy Transcription PREOPERATIVE DIAGNOSES 1 Nasal septal deviation with bilateral inferior turbinate hypertrophy 2 Tonsillitis with hypertrophy 3 Edema to the uvula and soft palate POSTOPERATIVE DIAGNOSES 1 Nasal septal deviation with bilateral inferior turbinate hypertrophy 2 Tonsillitis with hypertrophy 3 Edema to the uvula and soft palate OPERATION PERFORMED 1 Nasal septoplasty 2 Bilateral submucous resection of the inferior turbinates 3 Tonsillectomy and resection of soft palate ANESTHESIA General endotracheal INDICATIONS Chris is a very nice 38 year old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis He also has developed tremendous edema to his posterior palate and uvula which is causing choking Correction of these mechanical abnormalities is indicated DESCRIPTION OF OPERATION The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1 lidocaine with 1 100 000 epinephrine using approximately 10 mL Afrin soaked pledgets were placed in the nasal cavity bilaterally The face was prepped with pHisoHex and draped in a sterile fashion A hemitransfixion incision was performed on the left with a 15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator Anterior to the septal deflection the septal cartilage was incised and an opposite sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps and a large inferior septal spur was removed with a V chisel Once the septum was reduced in the midline the hemitransfixion incision was closed with a 4 0 Vicryl in an interrupted fashion The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope Hemostasis was acquired by using suction electrocautery The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3 0 nylon suture The table was then turned A shoulder roll placed under the shoulders and the face was draped in a clean fashion A McIvor mouth gag was applied The tongue was retracted and the McIvor was gently suspended from the Mayo stand The left tonsil was grasped with a curved Allis forceps retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion The right tonsil was grasped in a similar fashion retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion The inferior middle and superior pole vessels were further cauterized with suction electrocautery The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3 0 Vicryl in a figure of eight interrupted fashion Copious saline irrigation of the oral cavity was then performed There was no further identifiable bleeding at the termination of the procedure The estimated blood loss was less than 10 mL The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords surgery nasal septal deviation turbinate hypertrophy nasal septoplasty submucous resection resection of soft palate tonsillectomy bilateral inferior turbinate bovie electrocautery nasal septal inferior turbinates turbinates nasal tonsillitis electrocautery hypertrophy MEDICAL_TRANSCRIPTION,Description Left neck dissection Metastatic papillary cancer left neck The patient had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection Medical Specialty Surgery Sample Name Neck Dissection Transcription PREOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck POSTOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck OPERATION PERFORMED Left neck dissection ANESTHESIA General endotracheal INDICATIONS The patient is a very nice gentleman who has had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound which are suspicious for recurrent cancer Left neck dissection is indicated DESCRIPTION OF OPERATION The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered the table was then turned A shoulder roll placed under the shoulders and the face was placed in an extended fashion The left neck chest and face were prepped with Betadine and draped in a sterile fashion A hockey stick skin incision was performed extending a previous incision line superiorly towards the mastoid cortex through skin subcutaneous tissue and platysma with Bovie electrocautery on cut mode Subplatysmal superior and inferior flaps were raised The dissection was left lateral neck dissection encompassing zones 1 2A 2B 3 and the superior portion of 4 The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles stripped from the carotid artery the X cranial nerve the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr X in the paratracheal region The submandibular gland was removed as well The X XI and XII cranial nerves were preserved The internal jugular vein and carotid artery were preserved as well Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure There were two obviously positive nodes in this neck dissection One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2 A 10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2 0 silk ligature The wound was closed in layers using a 3 0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples A fluff and Kling pressure dressing was then applied The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords surgery metastatic papillary cancer thyroidectomy thyroid cancer papillary cell type dissection neck metastatic paratracheal papillary cancer MEDICAL_TRANSCRIPTION,Description Nonpalpable neoplasm right breast Needle localized wide excision of nonpalpable neoplasm right breast Medical Specialty Surgery Sample Name Needle Localized Excision Breast Neoplasm Transcription PREOPERATIVE DIAGNOSIS Nonpalpable neoplasm right breast POSTOPERATIVE DIAGNOSIS Deferred for Pathology PROCEDURE PERFORMED Needle localized wide excision of nonpalpable neoplasm right breast SPECIMEN Mammography GROSS FINDINGS This 53 year old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast After excision of neoplasm there was a separate 1 x 2 cm nodule palpated within the cavity This too was excised OPERATIVE PROCEDURE The patient was taken to the operating room placed in supine position in the operating table Intravenous sedation was administered by the Anesthesia Department The Kopans wire was trimmed to an appropriate length The patient was sterilely prepped and draped in the usual manner Local anesthetic consisting of 1 lidocaine and 0 5 Marcaine was injected into the proposed line of incision A curvilinear circumareolar incision was then made with a 15 scalpel blade close to the wire The wire was stabilized and brought to protrude through the incision Skin flaps were then generated with electrocautery A generous core tissue was grasped with Allis forceps and excised with electrocautery Prior to complete excision the superior margin was marked with a 2 0 Vicryl suture which was tied and cut short The lateral margin was marked with a 2 0 Vicryl suture which was tied and cut along The posterior margin was marked with a 2 0 Polydek suture which was tied and cut The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm On palpation of the cavity there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen Hemostasis was obtained with electrocautery Good hemostasis was obtained The incision was closed in two layers The first layer consisting of a subcuticular inverted interrupted sutures of 4 0 undyed Vicryl The second layer consisted of Steri Strips on the epidermis A pressure dressing of fluff 4x4s ABDs and Elastic bandage was applied The patient tolerated the surgery well Keywords surgery neoplasm needle localized wide excision needle localized nonpalpable neoplasm needle incision electrocautery excision breast MEDICAL_TRANSCRIPTION,Description Nasal septal reconstruction bilateral submucous resection of the inferior turbinates and bilateral outfracture of the inferior turbinates Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy Medical Specialty Surgery Sample Name Nasal Septal Reconstruction Transcription PREOPERATIVE DIAGNOSES 1 Chronic nasal obstruction secondary to deviated nasal septum 2 Inferior turbinate hypertrophy POSTOPERATIVE DIAGNOSES 1 Chronic nasal obstruction secondary to deviated nasal septum 2 Inferior turbinate hypertrophy PROCEDURE PERFORMED 1 Nasal septal reconstruction 2 Bilateral submucous resection of the inferior turbinates 3 Bilateral outfracture of the inferior turbinates ANESTHESIA General endotracheal tube BLOOD LOSS Minimal less than 25 cc INDICATIONS The patient is a 51 year old female with a history of chronic nasal obstruction On physical examination she was derived to have a severely deviated septum with an S shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction PROCEDURE After all risks benefits and alternatives have been discussed with the patient in detail informed consent was obtained The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away Nasal pledgets saturated with 4 cc of 10 cocaine solution were inserted into the nasal cavities These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1 lidocaine with 1 100000 epinephrine solution The nasal pledgets were then reinserted as the patient was prepped in the usual fashion The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0 25 Marcaine solution The nasal vestibules were then cleansed with a pHisoHex solution A 15 blade scalpel was then used to make an incision along the length of the caudal septum The mucoperichondrial junction was then identified with the aid of cotton tipped applicator as well as the stitch scissor Once the plane was identified the mucosal flap on the left side of the septum was elevated with the aid of a Cottle At this point it should be mentioned that the patient s septum was significantly deviated with a large S shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity Again the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur At this point the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur Again the mucosal flap was elevated in the right nasal septum Now Knight scissors were used to remove the ascending portion of the nasal cartilage which was then removed with a Takahashi forceps A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel Once all ascending cartilage has been removed inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient s symptoms Therefore the turbinates were again localized and a 15 blade scalpel was used to make a vertical incision dissected down to the chondral bone The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone Once the submucosal tissue had been resected an outfracture procedure was performed so as to fully open the nasal passages Inspection revealed very patent and nonobstructive nasal passages Now the caudal incision was reapproximated with 4 0 chromic suture Finally a 4 0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion Finally Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident Keywords surgery chronic nasal obstruction nasal septum inferior turbinate hypertrophy nasal septal reconstruction submucous resection inferior turbinates outfracture nasal septal nasal pledgets nasal cavity nasal obstruction turbinate hypertrophy mucosal flap septal septum turbinates nasal cavity chronic hypertrophy obstruction mucosal MEDICAL_TRANSCRIPTION,Description Bilateral nasolacrimal probing Tearing eyelash encrustation with probable tear duct obstruction bilateral Distal nasolacrimal duct stenosis with obstruction left and right eye Medical Specialty Surgery Sample Name Nasolacrimal Probing Transcription PREOPERATIVE DIAGNOSES Tearing eyelash encrustation with probable tear duct obstruction bilateral POSTOPERATIVE DIAGNOSES 1 Distal nasolacrimal duct stenosis with obstruction left eye 2 Distal nasolacrimal duct stenosis with obstruction right eye OPERATIVE PROCEDURE Bilateral nasolacrimal probing ANESTHESIA Monitored anesthesia care along with mask sedation INDICATIONS FOR SURGERY This young infant is a 19 month old who has had persistent tearing and mild eyelash encrustation of each eye for many months Conservative measures at home have failed to completely resolve the symptoms He has been placed on previous antibiotics treatment for presumed conjunctivitis Please refer to clinic note for more details Conservative measures at home have failed to resolve the symptoms A nasolacrimal probing was offered as an elective procedure Procedure as well as inherent risks expected outcomes benefits and alternatives including continued observation were discussed with his mother prior to scheduling surgery Again a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure The risks as explained included but were not limited to temporary bleeding persistent symptoms recurrence need for further procedure possible need for future stent placement or repeat probing and anesthesia risk were all discussed Also a rare possibility of errant passage of the nasolacrimal probe was discussed Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome result from surgery No guarantees were offered Informed consent was signed and placed on the chart DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified Procedure as well as inherent risks were again discussed with parents prior to the procedure After anesthesia was induced in the operating room tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono Pen The pressure on the right was 17 mmHg and on the left was 16 mmHg A punctal dilator was then used to dilate the left superior puncta A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally The probe was advanced until a firm stop of the lacrimal bone was felt The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve There was also some mild stenosis distally but not felt significant The probe was used to navigate through this mild resistance A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency Both probes were removed The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system Patency was confirmed The left upper lid was everted and inspected and was found to be normal Attention was then turned to the right side where the similar procedure through the right superior puncta was performed A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe Again on this side a size 0 Bowman probe was unable to be placed initially to the superior puncta The probe was used to navigate the superior puncta canaliculus and then the probe was rotated superomedially and the probe was advanced Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt The mild resistance was over come at the approximate location of the valve Metal on metal feel confirmed patency through the right naris with a second metal probe At the completion of the procedure all probes were removed Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well Postoperative instructions were provided to the parents by me and the discharging nurse I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily Technique explained and demonstrated Erythromycin ointment to both eyes twice daily for three days Follow up was arranged and he may call with any further questions or concerns Keywords surgery tearing eyelash encrustation tear duct obstruction nasolacrimal duct stenosis nasolacrimal bowman probe distal nasolacrimal duct nasolacrimal probing nasolacrimal duct superior puncta probe obstruction eyelash duct punctal MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies with insertion of Santa Barbara T tube Medical Specialty Surgery Sample Name Myringotomy Tube Insertion 2 Transcription PREOPERATIVE DIAGNOSES Tympanic membrane atelectasis and chronic eustachian tube dysfunction POSTOPERATIVE DIAGNOSES Tympanic membrane atelectasis and chronic eustachian tube dysfunction OPERATIVE PROCEDURE Bilateral myringotomies with insertion of Santa Barbara T tube ANESTHESIA General mask FINDINGS The patient is an 8 year old white female with chronic eustachian tube dysfunction and TM atelectasis was taken to the operating room for tubes At the time of surgery she has had an extruding right Santa Barbara T tube and severe left TM atelectasis with retraction There was a scant amount of fluid in both middle ear clefts DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in supine position and general mask anesthesia was established The right ear was draped in normal sterile fashion Cerumen was removed from the external canal The extruding Santa Barbara T tube was identified and atraumatically removed A fresh Santa Barbara T tube was atraumatically inserted and Ciloxan drops applied The attention was then directed to the left side where severe TM atelectasis was identified With a mask anesthetic the eardrum elevated A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated A Santa Barbara T tube was then inserted without difficulty and 5 drops Ciloxan solution applied Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition Keywords surgery tympanic membrane cerumen ciloxan santa barbara t tube tm atelectasis atelectasis eardrum eustachian tube eustachian tube dysfunction middle ear middle ear fluid myringotomies atelectasis and chronic eustachian santa barbara t tube myringotomies with insertion chronic eustachian tube barbara t tube santa barbara insertion tube tympanic MEDICAL_TRANSCRIPTION,Description Open reduction nasal fracture with nasal septoplasty Medical Specialty Surgery Sample Name Nasal Septoplasty Transcription PREOPERATIVE DIAGNOSES Nasal fracture and deviated nasal septum with obstruction POSTOPERATIVE DIAGNOSES Nasal fracture and deviated nasal septum with obstruction OPERATION Open reduction nasal fracture with nasal septoplasty ANESTHESIA General HISTORY This 16 year old male fractured his nose playing basketball He has a left nasal obstruction and depressed left nasal bone DESCRIPTION OF PROCEDURE The patient was given general endotracheal anesthesia and monitored with pulse oximetry EKG and CO2 monitors The face was prepped with Betadine soap and solution and draped in a sterile fashion Nasal mucosa was decongested using Afrin pledgets as well as 1 Xylocaine 1 100 000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum lateral osteotomy sites Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve Further up the cartilaginous septum was displaced to the left of the maxillary crest There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate There was a large deep groove horizontally on the right side corresponding to the left maxillary crest A left hemitransfixion incision was made Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels which was rather difficult at the area of the vomerine spur which was very sharp and touching the inferior turbinate The caudal cartilaginous septum which was lying crosswise was separated from the main cartilage leaving approximately 1 cm strut The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area The caudal cartilaginous strut was sutured to the columella with interrupted 4 0 chromic catgut suture to bring it into the midline Further back the cartilaginous septum anterior to the ethmoid plate was deviated to the left side so it was freed from the maxillary crest nasal dorsum from the ethmoid plate and was sutured in the midline with a transfixion 4 0 plain catgut sutures Further posteriorly the ethmoid plate was deviated to the left side and portion of it was removed with Jansen Middleton punch forceps The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage This area was freed from the perichondrium on both sides The maxillary crest was removed with a gouge Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline Thus the deviated septum was corrected Left hemitransfixion incisions were closed with interrupted 4 0 chromic catgut sutures The septum was also filtered with 4 0 plain catgut sutures By valve septal splints were tied to the septum bilaterally with a transfixion 5 0 nylon suture Next the nasal bone suture deviated to the left side were corrected The right nasal bone was depressed and left nasal bone was wide Therefore the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline Steri Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment Approximate blood loss was 10 to 20 mL Keywords surgery nasal fracture deviated nasal septum nasal septoplasty nasal bones ethmoid plate cartilaginous septum nasal bone maxillary crest septum nasal fracture maxillary cartilaginous crest MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies and insertion of Shepard grommet draining tubes Medical Specialty Surgery Sample Name Myringotomy Tube Insertion 1 Transcription PREOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media POSTOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media OPERATION PERFORMED 1 Bilateral myringotomies 2 Insertion of Shepard grommet draining tubes ANESTHESIA General by mask ESTIMATED BLOOD LOSS Less than 1 mL COMPLICATIONS None FINDINGS The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same At this point in time he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed but no active acute infection at this point in time PROCEDURE With the patient under adequate general anesthesia with the mask delivery of anesthesia he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides Bilateral inferior radial myringotomies were performed first on the right and then on the left Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side Floxin drops were then instilled bilaterally to decrease any clotting within the tubes and then cotton ball was placed in the external meatus bilaterally At this point the patient was awakened and returned to the recovery room satisfactory with no difficulty encountered Keywords surgery serous otitis media floxin drops shepard grommet cerumen cotton ball middle ear mucoid myringotomies tubes shepard grommet draining tubes serous otitis shepard grommet insertion MEDICAL_TRANSCRIPTION,Description Multiple stent placements with Impella circulatory assist device Medical Specialty Surgery Sample Name Multiple Stent Placements Transcription PROCEDURE PERFORMED 1 Left heart catheterization left ventriculogram aortogram coronary angiogram 2 PCI of the LAD and left main coronary artery with Impella assist device INDICATIONS FOR PROCEDURE Unstable angina and congestive heart failure with impaired LV function TECHNIQUE OF PROCEDURE After obtaining informed consent the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state The right groin was prepped and draped in the usual sterile manner Lidocaine 2 was used for infiltration anesthesia Using modified Seldinger technique a 7 French sheath was introduced into the right common femoral artery and a 6 French sheath was introduced into the right common femoral vein Through the arterial sheath angiography of the right common femoral artery was obtained Thereafter 6 French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained Thereafter a 4 French sheath was introduced into the left common femoral artery using modified Seldinger technique Thereafter the pigtail catheter was advanced over an 0 035 inch J wire into the left ventricle and LV gram was performed in RAO view and after pullback an aortogram was performed in the LAO view Therefore a 6 French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained ANGIOGRAPHIC FINDINGS 1 LV gram LVEDP was 15 mmHg LV ejection fraction 10 to 15 with global hypokinesis Only anterior wall is contracting There was no mitral regurgitation There was no gradient across the aortic valve upon pullback and on aortography there was no evidence of aortic dissection or aortic regurgitation 2 The right coronary artery is a dominant vessels with a mid 50 to 70 stenosis which was not treated The left main coronary artery calcified vessel with disease 2 The left anterior descending artery had an 80 to 90 mid stenosis First diagonal branch had a more than 90 stenosis 3 The circumflex coronary artery had a patent stent INTERVENTION After reviewing the angiographic images we elected to proceed with intervention of the left anterior descending artery The 4 French sheath in the left common femoral artery was upsized to a 12 French Impella sheath through which an Amplatz wire and a 6 French multipurpose catheter were advanced into the left ventricle The Amplatz wire was exchanged for an Impella 0 018 inch stiff wire The multipurpose catheter was removed and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2 5 l min Thereafter a 7 French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0 014 inch wire was advanced into the left anterior descending artery and a second 0 014 inch Asahi soft wire was advanced into the diagonal branch The diagonal branch was predilated with a 2 5 x 30 mm Sprinter balloon at nominal atmospheres and thereafter a 2 5 x 24 Endeavor stent was successfully deployed in the mid LAD and a 3 0 x 15 mm Endeavor stent was deployed in the proximal LAD The stent delivery balloon was used to post dilate the overlapping segment The LAD the diagonal was rewires with an 0 014 inch Asahi soft wire and a 3 0 x 20 mm Maverick balloon was advanced into the LAD for post dilatation and a 2 0 x 30 mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres At this point it was noted that the left main had a retrograde dissection A 3 5 x 18 mm Endeavor stent was successfully deployed in the left main coronary artery The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery Kissing inflations of the LAD and the circumflex coronary artery were performed using 3 0 x 20 Maverick balloons x2 balloons inflated at high atmospheres of 14 RESULTS Lesion reduction in the LAD FROM 90 to 0 and TIMI 3 flow obtained Lesion reduction in the diagonal from 90 to less than 60 and TIMI 3 flow obtained Lesion reduction in the left maintained coronary artery from 50 to 0 and TIMI 3 flow obtained The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened From the right common femoral artery a 6 French IMA catheter was advanced and an 0 035 inch wire down into the left common femoral and superficial femoral artery over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes The right common femoral artery and vein sheaths were both sutured in place for further observation Of note the patient received Angiomax during the procedure and an ACT above 300 was maintained IMPRESSION 1 Left ventricular dysfunction with ejection fraction of 10 to 15 2 High complex percutaneous coronary intervention of the left main coronary artery left anterior descending artery and diagonal with Impella circulatory support COMPLICATIONS None The patient tolerated the procedure well with no complications The estimated blood loss was 200 ml Estimated dye used was 200 ml of Visipaque The patient remained hemodynamically stable with no hypotension and no hematomas in the groins PLAN 1 Aspirin Plavix statins beta blockers ACE inhibitors as tolerated 2 Hydration 3 The patient will be observed over night for any hemodynamic instability or ischemia If she remains stable the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis Keywords surgery impella circulatory assist device impella assist device unstable angina congestive heart failure heart catheterization ventriculogram aortogram angiogram ventricular dysfunction pigtail catheter was advanced femoral artery and vein artery and vein asahi soft wire circumflex coronary artery common femoral artery modified seldinger technique multiple stent placements timi flow multiple stent impella circulatory french sheath femoral artery endeavor stent descending artery coronary artery common femoral asahi soft anterior descending femoral coronary artery impella catheterization MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies insertion of PE tubes and pharyngeal anesthesia Medical Specialty Surgery Sample Name Myringotomy Tube Insertion Transcription PREOPERATIVE DIAGNOSES Chronic otitis media with effusion conductive hearing loss and recurrent acute otitis media POSTOPERATIVE DIAGNOSES Chronic otitis media with effusion conductive hearing loss and recurrent acute otitis media OPERATION Bilateral myringotomies insertion of PE tubes and pharyngeal anesthesia ANESTHESIA General via facemask ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS The patient is a one year old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy PROCEDURE The patient was brought to the operating room was placed in supine position General anesthesia was begun via face mask technique Once an adequate level of anesthesia was obtained the operating microscope was brought positioned and visualized the right ear canal A small amount of wax was removed with a loop A 4 mm operating speculum was then introduced An anteroinferior quadrant radial myringotomy was then performed A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft Reuter bobbin PE tube was then inserted followed by Floxin otic drops and a cotton ball in the external meatus Head was then turned to the opposite side where similar procedure was performed Once again the middle ear cleft had a mucoid effusion A tube was inserted to an anteroinferior quadrant radial myringotomy Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs Keywords surgery bilateral myringotomies insertion of pe tubes chronic otitis media conductive hearing loss recurrent acute otitis media reuter bobbin radial myringotomy ear cleft pe tubes middle ear otitis media effusion otitis media ear anesthesia MEDICAL_TRANSCRIPTION,Description Mohs Micrographic Surgery for basal cell CA at mid parietal scalp Medical Specialty Surgery Sample Name Mohs Micrographic Surgery 1 Transcription PREOP DIAGNOSIS Basal Cell CA POSTOP DIAGNOSIS Basal Cell CA LOCATION Mid parietal scalp PREOP SIZE 1 5 x 2 9 cm POSTOP SIZE 2 7 x 2 9 cm INDICATION Poorly defined borders COMPLICATIONS None HEMOSTASIS Electrodessication PLANNED RECONSTRUCTION Simple Linear Closure DESCRIPTION OF PROCEDURE Prior to each surgical stage the surgical site was tested for anesthesia and reanesthetized as needed after which it was prepped and draped in a sterile fashion The clinically apparent tumor was carefully defined and debulked prior to the first stage determining the extent of the surgical excision With each stage a thin layer of tumor laden tissue was excised with a narrow margin of normal appearing skin using the Mohs fresh tissue technique A map was prepared to correspond to the area of skin from which it was excised The tissue was prepared for the cryostat and sectioned Each section was coded cut and stained for microscopic examination The entire base and margins of the excised piece of tissue were examined by the surgeon Areas noted to be positive on the previous stage if applicable were removed with the Mohs technique and processed for analysis No tumor was identified after the final stage of microscopically controlled surgery The patient tolerated the procedure well without any complication After discussion with the patient regarding the various options the best closure option for each defect was selected for optimal functional and cosmetic results Keywords surgery basal cell ca basal cell mohs technique mohs tumor laden tissue mohs fresh tissue technique mohs micrographic surgery micrographic surgery parietal scalp micrographic basal cell ca surgical tumor tissue stage MEDICAL_TRANSCRIPTION,Description Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band Posterior leaflet abscess resection Medical Specialty Surgery Sample Name Mitral Valve Repair Annuloplasty Transcription OPERATIONS 1 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet 2 Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band 3 Posterior leaflet abscess resection ANESTHESIA General endotracheal anesthesia TIMES Aortic cross clamp time was minutes Cardiopulmonary bypass time total was minutes PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next the patient s chest and legs were prepped and draped in standard surgical fashion A 10 blade scalpel was used to make a midline median sternotomy incision Dissection was carried down to the level of the sternum using Bovie electrocautery The sternum was opened with a sternal saw and full dose heparinization was given Next the chest retractor was positioned The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned We then prepared to place the patient on cardiopulmonary bypass A 2 0 Ethibond double pursestring was placed in the ascending aorta Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine Next double cannulation with venous cannulas was instituted A 3 0 Prolene pursestring was placed in the right atrial appendage Through this was passed our SEC cannula This was connected to the venous portion of the cardiopulmonary bypass machine in a Y shaped circuit Next a 3 0 Prolene pursestring was placed in the lower border of the right atrium Through this was passed our inferior vena cava cannula This was likewise connected to the Y connection of our venous cannula portion We then used a 4 0 U stitch in the right atrium for our retrograde cardioplegia catheter which was inserted Cardiopulmonary bypass was instituted Metzenbaum scissors were used to dissect out the SVC and IVC which were subsequently encircled with umbilical tape Sondergaard s groove was taken down Next an antegrade cardioplegia needle and associated sump were placed in the ascending aorta This was connected appropriately as was the retrograde cardioplegia catheter Next the aorta was cross clamped and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole Next a 15 blade scalpel was used to open the left atrium The left atrium was decompressed with pump sucker Next our self retaining retractor was positioned so as to bring the mitral valve up into view Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4 0 silk After doing so the P2 segment of the posterior leaflet was excised with a 11 blade scalpel Given the laxity of the posterior leaflet it was decided to reconstruct it with a 2 0 Ethibond pledgeted suture This was done so as to reconstruct the posterior annular portion Prior to doing so care was taken to remove any debris and abscess type material The pledgeted stitch was lowered into place and tied Next the more anterior portion of the P2 segment was reconstructed by running a 4 0 Prolene stitch so as to reconstruct it This was done without difficulty The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle There was noted to be a small amount of central regurgitation It was felt that this would be corrected with our annuloplasty portion of the procedure Next 2 0 non pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion Care was taken to go from trigone to trigone Prior to placing these sutures the annulus was sized and noted to be a size for the Cosgrove Galloway suture band ring from Medtronic After as mentioned we placed our interrupted sutures in the annulus and they were passed through the CG suture band The suture band was lowered into position and tied in place We then tested our repair and noted that there was very mild regurgitation We subsequently removed our self retaining retractor We closed our left atriotomy using 4 0 Prolene in a running fashion This was done without difficulty We de aired the heart We then gave another round of antegrade and retrograde cardioplegia in warm fashion The aortic cross clamp was removed and the heart gradually resumed electromechanical activity We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5 0 Prolene We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed We then gave full dose protamine and after noting that there was no evidence of a protamine reaction we removed our aortic cannula This site was buttressed with a 4 0 Prolene on an SH needle The patient tolerated the procedure well We placed a mediastinal 32 French chest tube as well as a right chest Blake drain The mediastinum was inspected for any signs of bleeding There were none We closed the sternum with 7 sternal wires in interrupted figure of eight fashion The fascia was closed with a 1 Vicryl followed by a 2 0 Vicryl followed by 3 0 Vicryl in a running subcuticular fashion The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the intensive care unit in good condition Keywords surgery mitral valve repair mitral valve abscess resection leaflet abscess cosgrove galloway medtronic bovie electrocautery cannulation bypass annuloplasty cardioplegia mitral MEDICAL_TRANSCRIPTION,Description Mohs Micrographic Surgery for basal cell CA at medial right inferior helix Medical Specialty Surgery Sample Name Mohs Micrographic Surgery 2 Transcription PREOP DIAGNOSIS Basal Cell CA POSTOP DIAGNOSIS Basal Cell CA LOCATION Medial right inferior helix PREOP SIZE 1 4 x 1 cm POSTOP SIZE 2 7 x 2 cm INDICATION Poorly defined borders COMPLICATIONS None HEMOSTASIS Electrodessication PLANNED RECONSTRUCTION Wedge resection advancement flap DESCRIPTION OF PROCEDURE Prior to each surgical stage the surgical site was tested for anesthesia and reanesthetized as needed after which it was prepped and draped in a sterile fashion The clinically apparent tumor was carefully defined and debulked prior to the first stage determining the extent of the surgical excision With each stage a thin layer of tumor laden tissue was excised with a narrow margin of normal appearing skin using the Mohs fresh tissue technique A map was prepared to correspond to the area of skin from which it was excised The tissue was prepared for the cryostat and sectioned Each section was coded cut and stained for microscopic examination The entire base and margins of the excised piece of tissue were examined by the surgeon Areas noted to be positive on the previous stage if applicable were removed with the Mohs technique and processed for analysis No tumor was identified after the final stage of microscopically controlled surgery The patient tolerated the procedure well without any complication After discussion with the patient regarding the various options the best closure option for each defect was selected for optimal functional and cosmetic results Keywords surgery medial right inferior helix wedge resection advancement flap tumor laden tissue mohs fresh tissue technique mohs technique mohs micrographic surgery basal cell ca micrographic surgery basal cell micrographic helix basal cell ca mohs tissue stage MEDICAL_TRANSCRIPTION,Description Arthroscopy with arthroscopic rotator cuff debridement anterior acromioplasty and Mumford procedure left shoulder Partial rotator cuff tear with impingement syndrome Degenerative osteoarthritis of acromioclavicular joint left shoulder rule out slap lesion Medical Specialty Surgery Sample Name Mumford Procedure Acromioplasty Transcription PREOPERATIVE DIAGNOSES 1 Partial rotator cuff tear with impingement syndrome 2 Degenerative osteoarthritis of acromioclavicular joint left shoulder rule out slap lesion POSTOPERATIVE DIAGNOSES 1 Partial rotator cuff tear with impingement syndrome 2 Degenerative osteoarthritis of acromioclavicular joint left shoulder PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic rotator cuff debridement 2 Anterior acromioplasty 3 Mumford procedure left shoulder SPECIFICATIONS The entire operative procedure was done in Inpatient Operative Suite Room 1 at ABCD General Hospital This was done in a modified beach chair position with interscalene and subsequent general anesthetic HISTORY AND GROSS FINDINGS This is a 38 year old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention He was refractory to conservative outpatient therapy He had injection of his AC joint which removed symptoms but was not long lasting After discussing the alternatives of the care as well as advantages and disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side All else was noted to be intact including the glenohumeral joint the long head of the biceps and the labrum The remainder of the rotator cuff observed was noted to be intact Subacromially the patient was noted to have increased synovitis Degenerative changes were noted upon observation of the distal clavicle OPERATIVE PROCEDURE The patient was laid supine upon the operative table After receiving interscalene block anesthetic by Anesthesia Department the patient was placed in modified beach chair position He was prepped and draped in the usual sterile manner Portals were created posteriorly and anteriorly from outside to in A full and complete diagnostic intraarticular arthroscopy was carried out Debridement was carried out through a 3 5 meniscal shaver to the 4 2 meniscal shaver to the undersurface of the partial tear of the rotator cuff Retrospectively it was approximately 25 of the generalized thickness Attention was then turned to the subacromial region The scope was directed subacromially A portal was created laterally Ultimately the patient needed a general anesthetic once we were closer to the distal clavicle Gross bursectomy was carried out with a 4 2 meniscal shaver 18 gauge spinal needles have been placed to outline the anterior acromion prior to this It was difficult to control the patient s blood pressure with systolics ranging anywhere from 165 or 170 up to 200 Because of this and difficulties with his anesthetic it was elected to change to an open procedure Thus the patient was anesthetized safely and secured An oblique incision was carried at the cross Langer s line across the outlet of the shoulder through the skin and subcutaneous tissue Hemostasis was controlled via electrocoagulation Flaps were created Anterior deltoid was reflected inferiorly Anterior acromioplasty was carried out with a saw then a Micro Aire and then a beaver tail rasp An excellent decompression was present CA ligament had been previously resected We then took the incision over the distal clavicle The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro Aire saw The beaver tail rasp was utilized to smooth off the edges Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted 1 Vicryl Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same A superficial running 2 0 Vicryl suture was utilized for deltoid closure distally Interrupted 2 0 Vicryl was utilized to subcutaneous fat closure running 4 0 subcuticular stitch for skin closure and Adaptic 4x4s ABDs and Elastoplast tape placed for compression dressing 0 25 Marcaine was flooded into the joint prior to the skin closure Pain buster catheter was hooked up The patient s arm was placed in arm sling He was safely transferred to the PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords surgery slap lesion acromioclavicular joint impingement syndrome mumford procedure acromioplasty arthroscopy arthroscopic arthroscopic rotator cuff debridement anterior acromioplasty rotator cuff tear arthroscopic rotator meniscal shaver cuff tear rotator cuff debridement osteoarthritis acromioclavicular clavicle deltoid rotator cuff shoulder joint MEDICAL_TRANSCRIPTION,Description Endoscopic subperiosteal midface lift using the endotine midface suspension device Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad Medical Specialty Surgery Sample Name Midface Lift Blepharoplasty Transcription PREOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident POSTOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident PROCEDURES 1 Endoscopic subperiosteal midface lift using the endotine midface suspension device 2 Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 28 year old country and western performer who was involved in a motor vehicle accident over a year ago Since that time she is felt to have facial asymmetry which is apparent in publicity photographs for her record promotions She had requested a procedure to bring about further facial asymmetry She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient s requesting cosmetic surgery and was felt to be a psychiatrically good candidate She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left Preoperative workup including CT scan failed to show any skeletal trauma The patient was counseled with regard to the risks benefits alternatives and complications of the postsurgical procedure including but not limited to bleeding infection unacceptable cosmetic appearance numbness of the face change in sensation of the face facial nerve paralysis need for further surgery need for revision hair loss etc and informed consent was obtained PROCEDURE The patient was taken to the operating room placed in supine position after having been marked in the upright position while awake General endotracheal anesthesia was induced with a 6 endotracheal tube All appropriate measures were taken to preserve the vocal cords in a professional singer Local anesthesia consisting of 5 6th 1 lidocaine with 1 100 000 units of epinephrine in 1 6th 0 25 Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia The upper eyelids were injected with 1 cc of 1 Xylocaine with 1 100 000 units of epinephrine Adequate time for vasoconstriction and anesthesia was allowed to be obtained The patient was prepped and draped in the usual sterile fashion A 4 0 silk suture was placed in the right lower lid For traction it was brought anteriorly The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe A Q Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation which was present The inferior oblique muscle was identified preserved and protected throughout the procedure The transconjunctival incision was then closed with buried knots of 6 0 fast absorbing gut Contralateral side was treated in similar fashion with like results and throughout the procedure Lacri Lube was in the eyes in order to maintain hydration Attention was next turned to the midface where a temporal incision was made parallel to the nasojugal folds Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia A 30 degree endoscope was used to visualize the fat pads so that we knew we are in the proper plane Subperiosteal dissection was carried out over the zygomatic arch and Whitnall s tubercle and the temporal dissection was completed Next bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall s tubercle The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle It was bipolar electrocauteried and the tunnel was further dissected free and opened The endotine 4 5 soft tissue suspension device was then inserted through the temporal incision brought down into the subperiosteal midface plane of dissection The guard was removed and the suspension spikes were engaged into the soft tissues The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally The endotine device was then secured to the true temporal fascia with three sutures of 3 0 PDS suture Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained The gingivobuccal sulcus incisions were closed with interrupted 4 0 chromic and the scalp incision was closed with staples The sterile dressing was applied The patient was awakened in the operating room and taken to the recovery room in good condition Keywords surgery cosmetic surgery jaeger lid plate lacri lube q tip blepharoplasty conjunctiva facial asymmetry fat pad lower lid midface lift regional field block temporal fascia temporal fossa vasoconstriction true temporal fascia gingivobuccal sulcus gingivobuccal MEDICAL_TRANSCRIPTION,Description Right middle ear exploration with a Goldenberg TORP reconstruction Medical Specialty Surgery Sample Name Middle Ear Exploration Transcription PREOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss POSTOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss PROCEDURE PERFORMED Right middle ear exploration with a Goldenberg TORP reconstruction ANESTHESIA General ESTIMATED BLOOD LOSS Less than 5 cc COMPLICATIONS None DESCRIPTION OF FINDINGS The patient consented to revision surgery because of the profound hearing loss in her right ear It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate She had reports of stapes fixation as well as otosclerosis on her CT scan At surgery she was found to have a mobile malleus handle but her stapes was fixed by otosclerosis There was no incus There was no specific round window niche There was a very minute crevice however exploration of this area did not reveal a niche to a round window membrane The patient had a type of TORP prosthesis which had tilted off the footplate anteriorly underneath the malleus handle DESCRIPTION OF THE PROCEDURE The patient was brought to the operative room and placed in supine position The right face ear and neck prepped with alcohol solution The right ear was draped in the sterile field External auditory canal was injected with 1 Xylocaine with 1 50 000 epinephrine A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o clock to the 7 o clock position Meatal skin was elevated middle ear was entered This exposure included the oval window round window areas There was a good cartilage graft in place and incorporated into the posterior superior of the drum The previous prosthesis was found out of position as it had tilted out of position anteriorly and there was no contact with the footplate The prosthesis was removed without difficulty The patient s stapes had an arch but the was atrophied Malleus handle was mobile The footplate was fixed Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion however upon inspection of the round window area there was found to be no definable round window niche no round window membrane The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation She is not considered to be a reconstruction candidate under the current circumstances No attempt was made to remove bone from the round window area A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate The fit was secure and supported with Gelfoam in the middle ear The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex The incision was closed with 4 0 Vicryl and individual 5 0 nylon to the skin and a sterile dressing was applied Keywords surgery conductive hearing loss goldenberg meatal skin torp torp reconstruction ear ear exploration handle malleus otosclerosis sensorineural stapedectomy tympanomeatal middle ear exploration hearing loss malleus handle middle ear middle MEDICAL_TRANSCRIPTION,Description Mini laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap Adenocarcinoma of the prostate Medical Specialty Surgery Sample Name Mini Laparotomy Radical Retropubic Prostatectomy Transcription PREOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate POSTOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate TITLE OF OPERATION Mini laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap ANESTHESIA General by intubation Informed consent was obtained for the procedure The patient understands the treatment options and wishes to proceed He accepts the risks to include bleeding requiring transfusion infection sepsis incontinence impotence bladder neck constricture heart attack stroke pulmonary emboli phlebitis injury to the bladder rectum or ureter etcetera OPERATIVE PROCEDURE IN DETAIL The patient was taken to the Operating Room and placed in the supine position prepped with Betadine solution and draped in the usual sterile fashion A 20 French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage The table was then placed in minimal flexed position A midline skin incision was then made from the umbilicus to the symphysis pubis It was carried down to the anterior rectus fascia into the pelvis proper Both obturator fossae were exposed Standard bilateral pelvic lymph node dissections were carried out The left side was approached first by myself The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially and from the bifurcation of the common iliac vein proximally to Cooper s ligament distally Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2 0 silk ligatures The obturator nerve was visualized throughout and was not injured The right side was carried out by my assistant under my direct and constant supervision Again the obturator nerve was visualized throughout and it was not injured Both packets were sent to Pathology where no evidence of carcinoma was found My attention was then directed to the prostate itself The endopelvic fascia was opened bilaterally Using gentle dissection with a Kitner I swept the levator muscles off the prostate and exposed the apical portion of the prostate A back bleeding control suture of 0 Vicryl was placed at the mid prostate level A sternal wire was then placed behind the dorsal vein complex which was sharply transected The proximal and distal portions of this complex were then oversewn with 2 0 Vicryl in a running fashion When I was satisfied that hemostasis was complete my attention was then turned to the neurovascular bundles The urethra was then sharply transected and six sutures of 2 0 Monocryl placed at the 1 3 5 7 9 and 11 o clock positions The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers fascia was incised distally swept off the rectum and incorporated with the prostate specimen The lateral pedicles over the seminal vesicles were then mobilized hemoclipped and transected The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips Ampullae of the vas were mobilized hemoclipped and transected The bladder neck was then developed using careful blunt and sharp dissection The prostate was then transected at the level of the bladder neck and sent for permanent specimen The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge The bladder neck was reconstructed in standard fashion It was closed using a running 2 0 Vicryl The mucosa was everted over the edge of the bladder neck using interrupted 3 0 Vicryl suture At the end of this portion of the case the new bladder neck had a stoma like appearance and would accommodate easily my small finger The field was then re evaluated for hemostasis which was further obtained using hemoclips Bovie apparatus and 3 0 chromic ligatures When I was satisfied that hemostasis was complete the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck A new 20 French Foley catheter was brought in through the urethra into the bladder A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight The pelvis was also copiously irrigated with 2 liters of sterile water A 10 French Jackson Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2 0 silk ligature The wound was then closed in layers The muscle was closed with a running 0 chromic the fascia with a running 1 0 Vicryl the subcutaneous tissue with 3 0 plain and the skin with a running 4 0 Vicryl subcuticular Steri Strips were applied and a sterile dressing The patient was taken to the Recovery Room in good condition There were no complications Sponge and instrument counts were reported correct at the end of the case Keywords surgery mini laparotomy radical retropubic prostatectomy pelvic lymph pelvic lymph node dissection cavermap mini laparotomy prostatectomy bladder intubation adenocarcinoma endopelvic hemostasis neck MEDICAL_TRANSCRIPTION,Description Biopsy proven mesothelioma Placement of Port A Cath left subclavian vein with fluoroscopy Medical Specialty Surgery Sample Name Mesothelioma Port A Cath Insertion Transcription PREOPERATIVE DIAGNOSIS Mesothelioma POSTOPERATIVE DIAGNOSIS Mesothelioma OPERATIVE PROCEDURE Placement of Port A Cath left subclavian vein with fluoroscopy ASSISTANT None ANESTHESIA General endotracheal COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient is a 74 year old gentleman who underwent right thoracoscopy and was found to have biopsy proven mesothelioma He was brought to the operating room now for Port A Cath placement for chemotherapy After informed consent was obtained with the patient the patient was taken to the operating room placed in supine position After induction of general endotracheal anesthesia routine prep and drape of the left chest left subclavian vein was cannulated with 18 gauze needle and guidewire was inserted Needle was removed Small incision was made large enough to harbor the port Dilator and introducers were then placed over the guidewire Guidewire and dilator were removed and a Port A Cath was introduced in the subclavian vein through the introducers Introducers were peeled away without difficulty He measured with fluoroscopy and cut to the appropriate length The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium It was then connected to the hub of the port Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall Wounds were then closed Needle count sponge count and instrument counts were all correct Keywords surgery biopsy proven mesothelioma placement of port a cath port a cath subclavian vein fluoroscopy mesothelioma MEDICAL_TRANSCRIPTION,Description Rhabdomyosarcoma of the left orbit Left subclavian vein MediPort placement Needs chemotherapy Medical Specialty Surgery Sample Name MediPort Placement Transcription PREOPERATIVE DIAGNOSIS Rhabdomyosarcoma of the left orbit POSTOPERATIVE DIAGNOSIS Rhabdomyosarcoma of the left orbit PROCEDURE Left subclavian vein MediPort placement 7 5 French single lumen INDICATIONS FOR PROCEDURE This patient is a 16 year old girl with newly diagnosed rhabdomyosarcoma of the left orbit The patient is being taken to the operating room for MediPort placement She needs chemotherapy DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s neck chest and shoulders were prepped and draped in usual sterile fashion An incision was made on the left shoulder area The left subclavian vein was cannulated The wire was passed which was in good position under fluoro using Seldinger Technique Near wire incision site made a pocket above the fascia and sutured in a size 7 5 French single lumen MediPort into the pocket in 4 places using 3 0 Nurolon I then sized the catheter under fluoro and placed introducer and dilator over the wire removed the wire and dilator placed the catheter through the introducer and removed the introducer The line tip was in good position under fluoro It withdrew and flushed well I then closed the incision using 4 0 Vicryl 5 0 Monocryl for the skin and dressed with Steri Strips Accessed the ports with a 1 inch 20 gauge Huber needle and it withdrew and flushed well with final heparin flush We secured this with Tegaderm The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology Keywords surgery rhabdomyosarcoma of the left orbit single lumen subclavian vein mediport placement chemotherapy rhabdomyosarcoma mediport MEDICAL_TRANSCRIPTION,Description Right nodular malignant mesothelioma Medical Specialty Surgery Sample Name Mesothelioma Thoracotomy Lobectomy Transcription PREOPERATIVE DIAGNOSIS Right mesothelioma POSTOPERATIVE DIAGNOSIS Right lung mass invading diaphragm and liver FINDINGS Right lower lobe lung mass invading diaphragm and liver PROCEDURES 1 Right thoracotomy 2 Right lower lobectomy with en bloc resection of diaphragm and portion of liver SPECIMENS Right lower lobectomy with en bloc resection of diaphragm and portion of liver BLOOD LOSS 600 mL FLUIDS Crystalloid 2 7 L and 1 unit packed red blood cells ANESTHESIA Double lumen endotracheal tube CONDITION Stable extubated to PACU PROCEDURE IN DETAIL Briefly this is a gentleman who was diagnosed with a B cell lymphoma and then subsequently on workup noted to have a right sided mass seeming to arise from the right diaphragm He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma Thus he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm He was explained the risks benefits and alternatives to this procedure He wished to proceed so he was brought to the operating room An epidural catheter was placed He was put in a supine position where SCDs and Foley catheter were placed He was put under general endotracheal anesthesia with a double lumen endotracheal tube He was given preoperative antibiotics then he was placed in the left decubitus position and the area was prepped and draped in the usual fashion A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument the chest was entered Upon entering the chest the chest wall retractor was inserted and the cavity inspected It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm He also had some marked lymphadenopathy With these findings which were thought at that time to be more consistent with a bronchogenic carcinoma we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection Thus we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2 0 ties Once we had clearly delineated the arterial anatomy we were able to pass a right angle around the artery going to the superior segment This was ligated in continuity with an additional stick tie in the proximal portion of 3 0 silk This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe This was also ligated in continuity and actually doubly ligated Care was taken to preserve the artery to the right and middle lobe We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein The superior pulmonary vein was visualized as well The right angle was passed around the inferior pulmonary vein and this was ligated in continuity with 2 0 silk and a 3 0 stick tie Upon division of this portion the specimen site had some bleeding which was eventually controlled using several 3 0 silk sutures The bronchial anatomy was defined Next we identified the bronchus going to the right lower lobe as well as the right middle lobe A TA 30 4 8 stapler was then closed The lung insufflated The right middle lobe and right upper lobe were noted to inflate well The stapler was fired and the bronchus was cut with a 10 blade We then turned our attention to the diaphragm There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor and we bovied around this with at least 1 cm margin Upon going through the diaphragm it became clear that the tumor was also involving the dome of the liver so after going around the diaphragm in its entirety we proceeded to wedge out the portion of liver that was involved It seemed that it would be a mucoid shallow portion The Bovie was set to high cautery The capsule was entered and then using Bovie cautery we wedged out the remaining portion of the tumor with a margin of normal liver It did leave quite a shallow defect in the liver Hemostasis was achieved with Bovie cautery and gentle pressure The specimen was then taken off the table and sent to Pathology for permanent The area was inspected for hemostasis A 10 flat JP was placed in the abdomen at the portion of the wedge resection and 0 Prolene was used to close the diaphragmatic defect which was under very little tension A single 32 straight chest tube was also placed The lung was seen to expand We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe Hemostasis was observed at the end of the case The chest tube was irrigated with sterile water and there was no air leak observed from the bronchial stump The chest was then closed with Vicryl at the level of the intercostal muscles staying above the ribs The 2 0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer and 4 0 Monocryl was used to close the skin The patient was then brought to supine position extubated and brought to the recovery room in stable condition Dr X was present for the entirety of the procedure which was a right thoracotomy right lower lobectomy with en bloc resection of diaphragm and a portion of liver Keywords surgery double lumen endotracheal en bloc resection malignant mesothelioma lung mass endotracheal tube chest tube bovie cautery en bloc diaphragm lobectomy mesothelioma thoracotomy MEDICAL_TRANSCRIPTION,Description Microsuspension direct laryngoscopy with biopsy Fullness in right base of the tongue and chronic right ear otalgia Medical Specialty Surgery Sample Name Microsuspension Direct Laryngoscopy Biopsy Transcription PREOPERATIVE DIAGNOSES 1 Fullness in right base of the tongue 2 Chronic right ear otalgia POSTOPERATIVE DIAGNOSIS Pending pathology PROCEDURE PERFORMED Microsuspension direct laryngoscopy with biopsy ANESTHESIA General INDICATION This is a 50 year old female who presents to the office with a chief complaint of ear pain on the right side Exact etiology of her ear pain had not been identified A fiberoptic examination had been performed in the office Upon examination she was noted to have fullness in the right base of her tongue She was counseled on the risks benefits and alternatives to surgery and consented to such PROCEDURE After informed consent was obtained the patient was brought to the Operative Suite where she was placed in supine position General endotracheal tube intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away where a shoulder roll was placed A tooth guard was then placed to protect the upper dentition The Dedo laryngoscope was then inserted into the oral cavity It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view At this point it was advanced underneath the epiglottis until the vocal cords were seen At this point it was suspended via the Lewy suspension arm from the Mayo stand At this point the Zeiss microscope with a 400 mm lens was brought into the surgical field Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities It should be mentioned that the right vocal cord did appear to be slightly more hyperemic however there were no mucosal abnormalities identified This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle At this point the scope was desuspended and the microscope was removed The scope was withdrawn through the vallecular region Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable Biopsies were obtained with straight biting cup forceps Once hemostasis was achieved the scope was advanced into the piriform sinuses Again in the right piriform sinus there was noted to be studding along the right lateral wall of the piriform sinus Again biopsies were performed and once hemostasis was achieved the scope was further withdrawn down the lateral pharyngeal wall There were no mucosal abnormalities identified within the oropharynx The scope was then completely removed and a bimanual examination was performed No neck masses were identified At this point the procedure was complete The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident Keywords surgery microsuspension laryngoscopy otalgia ear pain fiberoptic dedo laryngoscope epiglottis direct laryngoscopy piriform sinuses tongue microscope mucosal abnormalities fullness ear scope MEDICAL_TRANSCRIPTION,Description Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field Medical Specialty Surgery Sample Name Metastatic Lymphadenopathy Thyroid Tissue Removal Transcription TITLE OF OPERATION Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field INDICATION FOR SURGERY The patient is a 37 year old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04 07 with final pathology revealing extrafocal extrathyroidal extension and extranodal extension in the soft tissues of his medullary thyroid cancer The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease Fine needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer Risks benefits and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed The risks included but not limited to anesthesia bleeding infection injury to nerve lip tongue shoulder weakness tongue numbness droopy eyelid tumor comes back need for additional treatment diaphragm weakness pneumothorax need for chest tube others The patient understood all these issues and did wish to proceed PROCEDURE DETAIL After identifying the patient the patient was placed supine on the operating room table The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube The eyes were protected with Tegaderm The patient was rotated to 180 degrees towards the operating surgeon The Foley catheter was placed into the bladder with good return of urine Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip The incision then was planned around the old scar to be excised A 1 lidocaine with 1 to 100 000 epinephrine was injected A shoulder roll was applied The incision was made the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly Attention was then turned to performing the level 1 dissection on the left Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric The submandibular gland was appreciated and retracted laterally The mylohyoid muscle appreciated The lingual nerve was appreciated and the submandibular ganglion was ligated The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis The marginal mandibular nerve stimulated at the completion of this portion of the procedure Attention was then turned to incising the fascia along the clavicle on the left side Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified The brachial plexus and phrenic nerve were identified The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels Attention was then turned to the central neck The strap muscles were appreciated in the midline There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed Attention was then turned to identify the carotid artery and the internal jugular vein on the left side This was traced inferiorly internal jugular vein to the brachiocephalic vein Palpation deep to this area into the mediastinum and up against the trachea revealed a 1 5 cm lymph node mass Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis Attention was then turned to the right neck dissection A posterior flap on the right was raised to the anterior border of the trapezius The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly Attention was then turned to identifying the submandibular gland A digastric tunnel was performed back to the sternocleidomastoid muscle The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated The omohyoid muscle was retracted inferiorly Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle Subsequently the internal jugular vein was identified The external jugular vein ligated about 1 cm above the clavicle Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex Dissection along the floor of the neck then was performed to allow for mobilization The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly The cervical rootlets were transected after the contribution so the phrenic nerve all the way superiorly to the skull base The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein The wound was copiously irrigated Valsalva maneuver was given No bleeding points identified The wound was then prepared for closure Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3 0 nylon The wound was closed with interrupted 3 0 Vicryl for platysma subsequently a 4 0 running Biosyn for the skin and Indermil The patient tolerated the procedure well was extubated on the operating room table and sent to the postanesthesia care unit in good condition Keywords surgery lymphadenopathy thyroid infraclavicular fossa lymph nodes dissection pretracheal internal jugular vein infraclavicular lymphadenopathy metastatic lymphadenopathy mandibular nerve vein nodes neck nerve muscle jugularNOTE MEDICAL_TRANSCRIPTION,Description Arthroscopy medial meniscoplasty lateral meniscoplasty medial femoral chondroplasty and medical femoral microfracture right knee Patellar chondroplasty Lateral femoral chondroplasty Meniscal tear osteochondral lesion degenerative joint disease and chondromalacia Medical Specialty Surgery Sample Name Meniscoplasty Chondroplasty Transcription PREOPERATIVE DIAGNOSIS Medial meniscal tear of the right knee POSTOPERATIVE DIAGNOSES 1 Medial meniscal tear right knee 2 Lateral meniscal tear right knee 3 Osteochondral lesion medial femoral condyle right knee 4 Degenerative joint disease right knee 5 Patella grade II chondromalacia 6 Lateral femoral condyle grade II III chondromalacia PROCEDURE PERFORMED 1 Arthroscopy right knee 2 Medial meniscoplasty right knee 3 Lateral meniscoplasty right knee 4 Medial femoral chondroplasty right knee 5 Medical femoral microfracture right knee 6 Patellar chondroplasty 7 Lateral femoral chondroplasty ANESTHESIA General ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None BRIEF HISTORY AND INDICATION FOR PROCEDURE The patient is a 47 year old female who has knee pain since 03 10 03 after falling on ice The patient states she has had inability to bear significant weight and had swelling popping and giving away failing conservative treatment and underwent an operative procedure PROCEDURE The patient was taken to the Operative Suite at ABCD General Hospital on 09 08 03 placed on the operative table in supine position Department of Anesthesia administered general anesthetic Once adequately anesthetized the right lower extremity was placed in a Johnson knee holder Care was ensured that all bony prominences were well padded and she was positioned and secured After adequately positioned the right lower extremity was prepped and draped in the usual sterile fashion Attention was then directed to creation of the arthroscopic portals both medial and lateral portal were made for arthroscope and instrumentation respectively The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch All compartments were then examined in sequential order with photodocumentation of each compartment The patella was noted to have grade II changes of the inferior surface otherwise appeared to track within the trochlear groove There was mild grooving of the trochlear cartilage The medial gutter was visualized There was no evidence of loose body The medial compartment was then entered There was noted to be a large defect on the medial femoral condyle grade III IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken At this point a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed This gave a smooth shoulder to the chondral lesion After this the meniscus was debrided until it had been smooth over the frayed edges At this point the shaver was removed The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge The probe was then reintroduced and the shaver removed the meniscus was probed ___________ and now found to be stable At this point attention was directed to the rest of the knee The ACL was examined It was intact and stable The lateral compartment was then entered There was noted to be a grade II III changes of the lateral femoral condyle Again with the edge of some friability at the shoulder of this cartilage lesion There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus The probe was introduced and the remaining meniscus appeared stable This was then removed and the stapler was introduced A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over The lateral gutter was then visualized There was no evidence of loose bodies Attention was then redirected back to the medial and femoral condyles At this point a 0 62 K wire was then placed in through the initial portal medial portal as well as an additional poke hole so we can gain access and proper orientation to the medial femoral lesion Microfacial technique was then used to introduce the K wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion After this was performed the shaver was then reintroduced and the loose bodies and loose fragments were further debrided At this point the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided Again all compartments were then re visualized and there was no further evidence of other pathology or loose bodies The knee was then copiously irrigated and suctioned dry All instrumentation was removed Approximately 20 cc of 0 25 plain Marcaine was injected into the portal site and the remaining portion intraarticular Sterile dressings of Adaptic 4x4s ABDs and Webril were then applied The patient was then transferred back to the gurney in supine position DISPOSITION The patient tolerated the procedure well with no complications The patient was transferred to PACU in satisfactory condition Keywords MEDICAL_TRANSCRIPTION,Description Right pleural effusion and suspected malignant mesothelioma Medical Specialty Surgery Sample Name Mesothelioma Pleural Biopsy Transcription PREOPERATIVE DIAGNOSIS Right pleural effusion and suspected malignant mesothelioma POSTOPERATIVE DIAGNOSIS Right pleural effusion suspected malignant mesothelioma PROCEDURE Right VATS pleurodesis and pleural biopsy ANESTHESIA General double lumen endotracheal DESCRIPTION OF FINDINGS Right pleural effusion firm nodules diffuse scattered throughout the right pleura and diaphragmatic surface SPECIMEN Pleural biopsies for pathology and microbiology ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid 1 2 L and 1 9 L of pleural effusion drained INDICATIONS Briefly this is a 66 year old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma Upon transfer he had a right pleural effusion demonstrated on x ray as well as some shortness of breath and dyspnea on exertion The risks benefits and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed PROCEDURE IN DETAIL After informed consent was obtained the patient was brought to the operating room and placed in supine position A double lumen endotracheal tube was placed SCDs were also placed and he was given preoperative Kefzol The patient was then brought into the right side up left decubitus position and the area was prepped and draped in the usual fashion A needle was inserted in the axillary line to determine position of the effusion At this time a 10 mm port was placed using the knife and Bovie cautery The effusion was drained by placing a sucker into this port site Upon feeling the surface of the pleura there were multiple firm nodules An additional anterior port was then placed in similar fashion The effusion was then drained with a sucker Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura Of note feeling the diaphragmatic surface it appeared that it was quite nodular but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease This will be worked up with further imaging study later in his hospitalization After the effusion had been drained 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc The lungs were then inflated and noted to inflate well A 32 curved chest tube chest tube was placed and secured with nylon The other port site was closed at the level of the fascia with 2 0 Vicryl and then 4 0 Monocryl for the skin The patient was then brought in the supine position and extubated and brought to recovery room in stable condition Dr X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies The counts were correct x2 at the end of the case Keywords surgery double lumen endotracheal pleural surface chest tube pleural biopsy malignant mesothelioma vats pleurodesis pleural biopsies pleural effusion pleural vats pleurodesis mesothelioma MEDICAL_TRANSCRIPTION,Description Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy Medical Specialty Surgery Sample Name Metastasectomy Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma POSTOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma PROCEDURE PERFORMED Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double lumen endotracheal tube with a tube thoracostomy which was used to drain the left chest after the procedure ANESTHESIA General endotracheal anesthesia with double lumen endotracheal tube FINDINGS Multiple pleural surface seeding many sub millimeter suspicious looking lesions DISPOSITION OF SPECIMENS To Pathology for permanent analysis as well as tissue banking The lesions sent for pathologic analysis were the following 1 Level 8 lymph node 2 Level 9 lymph node 3 Wedge left upper lobe apex which was also sent to the tissue bank and possible multiple lesions within this wedge 4 Wedge left upper lobe posterior 5 Wedge left upper lobe anterior 6 Wedge left lower lobe superior segment 7 Wedge left lower lobe diaphragmatic surface anterolateral 8 Wedge left lower lobe anterolateral 9 Wedge left lower lobe lateral adjacent to fissure 10 Wedge left upper lobe apex anterior 11 Lymph node package additional level 8 lymph node ESTIMATED BLOOD LOSS Less than 100 mL CONDITION OF THE PATIENT AFTER SURGERY Stable HISTORY OF PROCEDURE The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into The patient agreed based on the risks and the benefits of the procedure which were presented to him and was taken to the operating room A correct time out procedure was performed The patient was placed into the supine position He was given general anesthesia was endotracheally intubated without incident with a double lumen endotracheal tube Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double lumen tube Following this the decision was made to proceed with the surgery The patient was rolled into the right lateral decubitus position with the left side up All pressure points were padded The patient had a sterile DuraPrep preparation to the left chest A sterile drape around that was applied Also the patient had Marcaine infused into the incision area Following this the patient had a posterolateral thoracotomy incision which was a muscle sparing incision with a posterior approach just over the ausculatory triangle The incision was approximately 10 cm in size This was created with a 10 blade scalpel Bovie electrocautery was used to dissect the subcutaneous tissues The auscultatory triangle was opened The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly The muscle was not divided After the latissimus muscle was retracted anteriorly the ribs were counted and the sixth rib was identified The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears Following this the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges The patient tolerated the procedure well without any complications The largest lesion was the left upper lobe apex lesion which was possibly multiple lesions which was taken in one large wedge segment and this was also adjacent to another area of the wedges The patient had multiple pleural abnormalities which were identified on the surface of the lung These were small white spotty looking lesions and were not confirmed to be tumor implants but were suspicious to be multiple areas of tumor Based on this the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions Following this the patient had a 32 French chest tube placed in the anteroapical position A 19 French Blake was placed in the posterior apical position The patient had the intercostal space reapproximated with 2 0 Vicryl suture and the lung was allowed to be re expanded under direct visualization Following this the chest tubes were placed to Pleur evac suction and the auscultatory triangle was closed with 2 0 Vicryl sutures The deeper tissue was closed with 3 0 Vicryl suture and the skin was closed with running 4 0 Monocryl suture in a subcuticular fashion The patient tolerated the procedure well and had no complications Keywords MEDICAL_TRANSCRIPTION,Description Posterior mediastinal mass with possible neural foraminal involvement benign nerve sheath tumor by frozen section Left thoracotomy with resection of posterior mediastinal mass Medical Specialty Surgery Sample Name Mediastinal Mass Resection Transcription PREOPERATIVE DIAGNOSIS Posterior mediastinal mass with possible neural foraminal involvement POSTOPERATIVE DIAGNOSIS Posterior mediastinal mass with possible neural foraminal involvement benign nerve sheath tumor by frozen section OPERATION PERFORMED Left thoracotomy with resection of posterior mediastinal mass INDICATIONS FOR PROCEDURE The patient is a 23 year old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina For this reason Dr X and I agreed to operate on this patient together Please note that two surgeons were required for this case due to the complexity of it The indications and risks of the procedure were explained and the patient gave her informed consent DESCRIPTION OF PROCEDURE The patient was brought to the operating suite and placed in the supine position General endotracheal anesthesia was given with a double lumen tube The patient was positioned for a left thoracotomy All pressure points were carefully padded The patient was prepped and draped in usual sterile fashion A muscle sparing incision was created several centimeters anterior to the tip of the scapula The serratus and latissimus muscles were retracted The intercostal space was opened We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization Through our small anterior thoracotomy and with the video assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta The lung was deflated and allowed to retract anteriorly With a combination of blunt and sharp dissection and with attention paid to hemostasis we were able to completely resect the posterior mediastinal mass We began by opening the tumor and taking a very wide large biopsy This was sent for frozen section which revealed a benign nerve sheath tumor Then using the occluder device Dr X was able to _____ the inferior portions of the mass This left the external surface of the mass much more malleable and easier to retract Using a bipolar cautery and endoscopic scissors we were then able to completely resect it Once the tumor was resected it was then sent for permanent sections The entire hemithorax was copiously irrigated and hemostasis was complete In order to prevent any lymph leak we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace The wounds were then closed in multiple layers A 2 Vicryl was used to approximate the ribs The muscles of the chest wall were allowed to return to their normal anatomic position A 19 Blake was placed in the subcutaneous tissues Subcutaneous tissues and skin were closed with running absorbable sutures The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition Keywords surgery posterior mediastinal mass neural foraminal nerve sheath tumor frozen section thoracotomy mediastinal mass foraminal neural sheath mediastinal MEDICAL_TRANSCRIPTION,Description The patient had undergone mitral valve repair about seven days ago Medical Specialty Surgery Sample Name Mediastinal Exploration Right Atrium Repair Transcription PREOPERATIVE DIAGNOSES 1 Cardiac tamponade 2 Status post mitral valve repair POSTOPERATIVE DIAGNOSES 1 Cardiac tamponade 2 Status post mitral valve repair PROCEDURE PERFORMED Mediastinal exploration with repair of right atrium ANESTHESIA General endotracheal INDICATIONS The patient had undergone mitral valve repair about seven days ago He had epicardial pacing wires removed at the bedside Shortly afterwards he began to feel lightheaded and became pale and diaphoretic He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s 70s DETAILS OF PROCEDURE The patient was taken emergently to the operating room and placed supine on the operating room table His chest was prepped and draped prior to induction under general anesthesia Incision was made through the previous median sternotomy chest incision Wires were removed in the usual manner and the sternum was retracted There were large amounts of dark blood filling the mediastinal chest cavity Large amounts of clot were also removed from the pericardial well and chest Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation This was repaired with two horizontal mattress pledgeted 5 0 Prolene sutures An additional 0 silk tie was also placed around the base of the atrial appendage for further hemostasis No other sites of bleeding were identified The mediastinum was then irrigated with copious amounts of antibiotic saline solution Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart as well as straight mediastinal chest tube The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures The skin was then closed with a running subcuticular stitch The patient was then taken to the Intensive Care Unit in a critical but stable condition Keywords surgery mitral valve repair exploration median sternotomy chest incision pericardial mediastinal exploration pacing wires cardiac tamponade chest tubes mitral valve valve repair mediastinal mitral wires atrium repair MEDICAL_TRANSCRIPTION,Description Mediastinal exploration and delayed primary chest closure The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification Medical Specialty Surgery Sample Name Mediastinal Exploration Transcription TITLE OF OPERATION Mediastinal exploration and delayed primary chest closure INDICATION FOR SURGERY The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification The patient experienced an unexplained cardiac arrest at the completion of the procedure which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago She did not meet the criteria for delayed primary chest closure PREOP DIAGNOSIS Open chest status post modified stage I Norwood procedure POSTOP DIAGNOSIS Open chest status post modified stage I Norwood procedure ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma At completion of the procedure no major changes in hemodynamic performance DETAILS OF THE PROCEDURE After obtaining informed consent the patient was brought to the room placed on the operating room table in supine position Following the administration of general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned Through a separate incision and another 15 French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV PA connection as well as inferior most aspect of the ventriculotomy The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires The subcutaneous tissue and skin were closed in layers There was no evidence of significant increase in central venous pressure or desaturation The patient tolerated the procedure well Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case Keywords surgery mediastinal exploration delayed primary chest closure extracorporeal membrane oxygenation stage i norwood procedure sano modification chest closure infant mediastinal exploration closure endotracheal chest MEDICAL_TRANSCRIPTION,Description Medial branch rhizotomy lumbosacral Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Surgery Sample Name Medial Branch Rhizotomy Transcription PROCEDURE Medial branch rhizotomy lumbosacral INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed SEDATION The patient was given conscious sedation and monitored throughout the procedure Oxygenation was given The patient s oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs PROCEDURE The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a Teflon coated needle was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of Specifically each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra or for sacral vertebrae at the lateral superior border of the posterior sacral foramen Needle localization was confirmed with AP and lateral radiographs The following technique was used to confirm placement at the Medial Branch nerves Sensory stimulation was applied to each level at 50 Hz paresthesias were noted at volts Motor stimulation was applied at 2 Hz with 1 millisecond duration corresponding paraspinal muscle twitching without extremity movement was noted at volts Following this the needle Trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 1cc 1 lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure COMPLICATIONS None No complications The patient tolerated the procedure well and was sent to the recovery room in good condition DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made in approximately 1 week Keywords surgery lumbosacral medial branch rhizotomy medial branch nerves rhizotomy fluoroscopy MEDICAL_TRANSCRIPTION,Description Excision of soft tissue mass right foot The patient is a 51 year old female with complaints of soft tissue mass over the dorsum of the right foot Medical Specialty Surgery Sample Name Mass Excision Foot Transcription PREOPERATIVE DIAGNOSIS Soft tissue mass right foot POSTOPERATIVE DIAGNOSIS Soft tissue mass right foot PROCEDURE PERFORMED Excision of soft tissue mass right foot HISTORY The patient is a 51 year old female with complaints of soft tissue mass over the dorsum of the right foot The patient has had previous injections to the site which have caused the mass to decrease in size however the mass continues to be present and is irritated and painful with shoes The patient has requested surgical intervention at this time PROCEDURE After an IV was instituted by the Department of Anesthesia the patient was escorted from the preoperative holding area to the operating room The patient was then placed on the operating room table in the supine position and a towel was placed around the patient s abdomen and secured her to the table Using copious amounts of Webril a pneumatic ankle tourniquet was applied to her right ankle Using a Skin Skribe the area of the soft tissue mass was outlined over the dorsum of her foot After adequate amount of anesthesia was provided by the Department of Anesthesia a local ankle block was given using 10 cc of 4 5 mL of 1 lidocaine plain 4 5 mL of 0 5 Marcaine plain and 1 0 mL of Solu Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner Following this the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg The foot was then brought back down to the table using bandage scissors The stockinette was reflected and the right foot was exposed Using a fresh 10 blade a curvilinear incision was performed over the dorsum of the right foot Then using a 15 blade the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted Following this the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified Further dissection was then performed in the medial direction in the area of the soft tissue mass The intermediate dorsal cutaneous nerve was identified and gently retracted laterally Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle Using careful dissection adipose tissue in this area was removed and saved for pathology Following removal of adipose tissue in this area and identification of no more adipose tissue attention was directed lateral to the belly of the extensor digitorum brevis muscle which was also noted to have large amounts of adipose tissue in this area as well Using careful dissection from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology There was noted to be no other fluid filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well Following this feeling adequately that no other mass remained in the area the incision was flushed using copious amounts of sterile saline The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue The tendon and muscle belly of the extensor digitorum brevis muscle the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially all appeared intact No deficits were noted No abnormal appearing tissue was present within the surgical site Following this the skin edges were reapproximated using 4 0 Vicryl deep closure of the subcutaneous layer was performed Then using 4 0 nylon and simple interrupted suture the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders The patient was also given 7 cc of 1 lidocaine plain throughout the procedure to augment local anesthesia Following this the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads dorsal and plantar for compression and using Kling Kerlix and Coban The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe The patient was then given postoperative instructions to include ice and elevation to her right foot The patient was cleared for ambulation as tolerated but was instructed that with increased ambulation will come increased swelling and pain The patient will follow up with Dr X in his office on Tuesday 08 26 03 for further follow up The patient was given prescription for Vicoprofen 25 taken one tablet q 4h p r n moderate to severe pain and also prescription for Keflex 20 500 mg tablets to be taken b i d x10 days The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit Keywords surgery excision digitorum brevis muscle soft tissue mass adipose tissue soft tissue mass injections foot tissue xeroform dorsum belly extensor digitorum brevis ankle adipose muscle MEDICAL_TRANSCRIPTION,Description An example template for meatotomy Medical Specialty Surgery Sample Name Meatotomy Template Transcription OPERATIVE NOTE The patient was taken to the operating room and was placed in the supine position on the operating room table A general inhalation anesthetic was administered The patient was prepped and draped in the usual sterile fashion The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated Next a midline ventral type incision was made opening the meatus This was done after clamping the tissue to control bleeding The meatus was opened for about 3 mm Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6 0 Vicryl sutures The meatus still calibrated between 10 and 12 French Antibiotic ointment was applied The procedure was terminated The patient was awakened and returned to the recovery room in stable condition Keywords surgery urethral meatus mosquito hemostat meatus mucosal edges glans meatotomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Closed reduction of mandible fractures with Erich arch bars and elastic fixation Left angle and right body mandible fractures Medical Specialty Surgery Sample Name Mandible Fractures Closed Reduction Transcription HISTORY OF PRESENT ILLNESS The patient is a 22 year old male who sustained a mandible fracture and was seen in the emergency department at Hospital He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures PREOPERATIVE DIAGNOSES Left angle and right body mandible fractures POSTOPERATIVE DIAGNOSES Left angle and right body mandible fractures PROCEDURE Closed reduction of mandible fractures with Erich arch bars and elastic fixation ANESTHESIA General nasotracheal COMPLICATIONS None CONDITION Stable to PACU DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route the patient was prepped and draped in the usual fashion for placement of arch bars Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25 gauge circumdental wires After the placement of the arch bars the occlusion was checked and found to be satisfactory and stable The throat pack was then removed An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point the procedure was terminated and the patient was then awakened extubated and taken to the PACU in stable condition Keywords surgery closed reduction of mandible fractures erich arch bars elastic fixation throat pack arch bars arch erich mandible fractures MEDICAL_TRANSCRIPTION,Description Bilateral reduction mammoplasty for bilateral macromastia Medical Specialty Surgery Sample Name Mammoplasty 1 Transcription PREOPERATIVE DIAGNOSIS Bilateral macromastia POSTOPERATIVE DIAGNOSIS Bilateral macromastia OPERATION Bilateral reduction mammoplasty ANESTHESIA General FINDINGS The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle PROCEDURE With the patient under satisfactory general endotracheal anesthesia the entire chest was prepped and draped in usual sterile fashion A previously placed mark to identify the neo nipple site was re identified and carefully measured for asymmetry and appeared to be satisfactory A keyhole wire ring was then used to outline the basic wise pattern with 6 cm lamps inferiorly This was then carefully checked for symmetry and appeared to be satisfactory All marks were then completed and lightly incised on both breasts The right breast was approached first The neo nipple site was de epithelialized superiorly and then the inferior pedicle was de epithelialized using cutting cautery After this had been completed cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately This was taken down to the prepectoral fashion dissected for short distance superiorly and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle There was very little bleeding with this procedure After this had been completed attention was directed to the lateral side and the inferior incision was made and taken down to the serratus Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket After this had been completed cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast Hemostasis was obtained with electrocautery After this had been completed cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps On the right side there was a small palpable lobule which had shown up on mammogram but nothing except some fat density was identified This site had been previously marked carefully and there were no unusual findings and the superior tissue was then sent out separately for pathology After this had been completed final hemostasis obtained and the wound was irrigated and a tagging suture placed to approximate the tissues The breast cleared and the nipple appeared good Attention was then directed to the left breast which was completed in the similar manner After this had been completed the patient was placed in a near upright position and symmetry appeared good but it was a bit poor on the lateral aspect of the right side which was little larger and some suction lipectomy was carried out in this area After completion of this 1860 grams had been removed from the right and 1505 grams was removed from the left Through separate stab wounds on the lateral aspect 10 mm flat Blake drains were brought out and sutures were then placed and irrigated The wounds were then closed with interrupted 4 0 Monocryl on the deep dermis and running intradermal 4 0 Monocryl on the skin packing sutures and staples were removed as they were approached The nipple was sutured with running intradermal 4 0 Monocryl Vascularity appeared good throughout After this had been completed all wounds were cleaned and Steri Stripped The patient tolerated the procedure well All counts were correct Estimated blood loss was less than 150 mL and she was sent to recovery room in good condition Keywords surgery macromastia estimated blood loss monocryl steri stripped dermis inferior breast mammoplasty neo nipple prepped and draped ptotic breasts recovery room in good condition reduction mammoplasty superior breast upright position bilateral macromastia incision superiorly breasts MEDICAL_TRANSCRIPTION,Description An example template for meatoplasty Medical Specialty Surgery Sample Name Meatoplasty Template Transcription OPERATIVE NOTE The patient was placed in the supine position under general anesthesia and prepped and draped in the usual manner The penis was inspected The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove This was incised longitudinally and closed transversely with 5 0 chromic catgut sutures The meatus was calibrated and accepted the calibrating instrument without difficulty and there was no stenosis An incision was made transversely below the meatus in a circumferential way around the shaft of the penis bringing up the skin of the penis from the corpora The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie Using a skin hook the meatus was elevated ventrally and the glans flaps were reapproximated using 5 0 chromic catgut creating a new ventral portion of the glans using the flaps of skin There was good viability of the skin The incision around the base of the penis was performed separating the foreskin that was going to be removed from the coronal skin This was removed and hemostasis was obtained with a Bovie 0 25 Marcaine was infiltrated at the base of the penis for post op pain relief and the coronal and penile skin was reanastomosed using 4 0 chromic catgut At the conclusion of the procedure Vaseline gauze was wrapped around the penis There was good hemostasis and the patient was sent to the recovery room in stable condition Keywords surgery penis meatus urethral groove corpora glans meatoplasty bovie chromic catgut hemostasisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right hallux abductovalgus deformity Right McBride bunionectomy Right basilar wedge osteotomy with OrthoPro screw fixation Medical Specialty Surgery Sample Name McBride Bunionectomy Wedge Osteotomy Transcription PREOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity POSTOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity PROCEDURES PERFORMED 1 Right McBride bunionectomy 2 Right basilar wedge osteotomy with OrthoPro screw fixation ANESTHESIA Local with IV sedation HEMOSTASIS With pneumatic ankle cuff DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in a supine position The right foot was prepared and draped in usual sterile manner Anesthesia was achieved utilizing a 50 50 mixture of 2 lidocaine plain with 0 5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg At this time attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection Using a microsagittal saw the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp At this time attention was directed to the first inner space using sharp and blunt dissection Dissection was carried down to the underling level of the adductor hallucis tendon which was isolated and freed from its phalangeal sesamoidal and metatarsal attachments The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0 5 cm to help prevent any re fibrous attachment At this time the lateral release was stressed and was found to be complete The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0 5 cm resection The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw The area was again copiously flushed and inspected for any abnormalities and or prominences and none were noted At this time attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption At this time there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint At this time 0 5 cm was measured distal to that lateral measurement and using microsagittal saw a wedge osteotomy was taken from the base with the apex of the osteotomy being medial taking care to keep the medial cortex intact as a hinge The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3 0 x 22 mm The screw was placed following proper technique The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy The packing of the cancellous bone was held in place with bone wax The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed At this time a deep closure was achieved utilizing 2 0 Vicryl suture subcuticular closure was achieved using 4 0 Vicryl suture and skin repair was achieved at both surgical sites with 5 0 nylon suture in a running interlocking fashion The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site At this time the surgical site was postoperatively injected with 0 5 Marcaine plain as well as dexamethasone 4 mg primarily The surgical sites were then dressed with sterile Xeroform sterile 4x4s cascading and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion The tourniquet was dropped and color and temperature of all digits returned to normal The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions problems or concerns at any time with the numbers provided The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot Keywords surgery hallux abductovalgus bunionectomy mcbride basilar wedge osteotomy orthopro screw fixation wedge osteotomy MEDICAL_TRANSCRIPTION,Description Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple areolar complex Medical Specialty Surgery Sample Name Mammoplasty 3 Transcription PREOPERATIVE DIAGNOSES Bilateral mammary hypertrophy with breast asymmetry right breast larger than left POSTOPERATIVE DIAGNOSES Bilateral mammary hypertrophy with breast asymmetry right breast larger than left OPERATION Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast ANESTHESIA General endotracheal anesthesia PROCEDURE IN DETAIL The patient was placed in the supine position under the effects of general endotracheal anesthesia The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion Markings were then made in the standing position preoperatively The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast A McKissock ring was utilized as a pattern It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40 degree angle Medial and lateral flaps were drawn 8 cm in length At the most medial and lateral extremity inframammary folds a line was drawn to the lower level at the medial and lateral flaps On the left side the epithelialization was performed about the 45 mm nipple areolar complex within the confines of the superior medially based dermal parenchymal pedicle Resection of the skin subcutaneous tissue and glandular tissue was performed along the inframammary fold and then cut was made medially and laterally The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle and laterally the resection was performed tangential to the chest wall skin subcutaneous tissue and glandular tissue towards the axillary tail The pedicle was thinned as well so it was 2 cm thick beneath the nipple areolar complex and they were medially 4 cm thick at its base On the right side 947 g of breast tissue was removed Hemostasis was achieved with electrocautery Identical procedure was performed on the opposite left side again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45 mm diameter nipple areolar complex Resection of the skin subcutaneous tissue and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex Hemostasis was achieved with electrocautery With pedicle on the left the breast issue on the left side was weighed at 758 g Hemostasis was achieved with cautery The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides The nipple areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple areolar complex Closure was performed with interrupted 3 0 PDS suture for deep subcutaneous tissue and dermis Skin was closed with running subcuticular 4 0 Monocryl suture A Jackson Pratt drain had been placed prior to final closure and secured with a 4 0 silk suture The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization Closure was performed with an anchor shaped closure around the nipple areolar complex vertically of inframammary folds and across the inframammary folds Dressing was applied The suture line was treated with Dermabond The patient returned to the recovery room with 2 Jackson Pratt drains 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days The patient tolerated the procedure well and returned to the recovery room in satisfactory condition Keywords surgery bilateral mammary hypertrophy duraprep general endotracheal anesthesia jackson pratt drains breast asymmetry hypertrophy inframammary folds mammary mammoplasty nipple areolar complex nipple areolar complex parenchymal pedicle prepped and draped reduction mammoplasty transposition medial and lateral based dermal dermal parenchymal parenchymal pedicle subcutaneous tissue nipple areolar inferiorly subcutaneous inframammary breast tissue MEDICAL_TRANSCRIPTION,Description Bilateral augmentation mammoplasty breast implant TCA peel to lesions vein stripping Medical Specialty Surgery Sample Name Mammoplasty 2 Transcription PREOPERATIVE DIAGNOSES Breast hypoplasia melasma to the face and varicose veins to the posterior aspect of the right distal thigh popliteal fossa area PROCEDURES 1 Bilateral augmentation mammoplasty subglandular with a mammary gel silicone breast implant 435 cc each 2 TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area ANESTHESIA General endotracheal EBL 100 cc IV FLUIDS 2L URINE OUTPUT Per Anesthesia INDICATION FOR SURGERY The patient is a 48 year old female who was seen in clinic by Dr W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity She requested that surgical procedures to be performed for correction of these abnormalities As such complications were explained to the patient including infection bleeding poor wound healing and need for additional surgery The patient subsequently signed the consent and requested that Dr W and associates to perform the procedure TECHNIQUE The patient was brought to the operating room in supine position General anesthesia was induced and then the patient was placed on the operating table in a prone position The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion First multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed Once these varicose veins had been completely stripped and avulsed then next the wounds were then irrigated and were cleaned with wet and dry and all the incisions were closed with the use of 5 0 Monocryl buried interrupted sutures The incisions were then dressed with Mastisol Steri Strips ABDs and a TED hose Next the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position The anterior chest was then prepped and draped in a sterile fashion Next a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts Once the pectoralis muscle and fascia were identified then a surgical plane was created in a subglandular layer The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well A sizer was used to identify the appropriate size of the silicone implant to be used This was determined to be approximately 435 cc bilaterally As such two mammary gel silicone breast implants were placed in a subglandular muscle Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant the circumareolar incisions were closed in approximately 4 layered fashion closing the fascia subcutaneous tissue deep dermis and a running dermal subcuticular for final skin closure This was performed with 3 0 Monocryl and then 4 0 Monocryl for running subcuticular The incisions were then dressed with Mastisol Steri Strips and Xeroform and dressed with sample Kerlix Next our attention was paid to the face where 25 TCA solution was applied to two locations one on the left cheek and the other one on the right cheek where a hyperpigmentation melasma Several applications of the TCA peel was performed and at the end of this the frosting was noted to both spots At the end of the case needle and instrument counts were correct Dr W was present and scrubbed for the entire procedure The patient was extubated in the operating room and taken to the PACU in stable condition Keywords surgery breast hypoplasia monocryl pacu tca tca peel ted hose augmentation mammoplasty breast implant melasma poor wound healing popliteal fossa area prepped and draped silicone varicose vein vein stripping mastisol steri strips steri strips circumareolar incisions mammary gel varicose veins augmentation breast circumareolar incisions mammoplasty mastisol strips MEDICAL_TRANSCRIPTION,Description Bilateral transaxillary subpectoral mammoplasty with saline filled implants Medical Specialty Surgery Sample Name Mammoplasty 4 Transcription DIAGNOSIS Bilateral hypomastia NAME OF OPERATION Bilateral transaxillary subpectoral mammoplasty with saline filled implants ANESTHESIA General PROCEDURE After first obtaining a suitable level of general anesthesia with the patient in the supine position the breasts were prepped with Betadine scrub and solution Sterile towels sheets and drapes were placed in the usual fashion for surgery of the breasts Following prepping and draping the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0 5 Xylocaine with 1 200 000 units of epinephrine After a suitable hemostatic waiting period transaxillary incisions were made and dissection was carried down to the edge of the pectoralis fascia Blunt dissection was then used to form a bilateral subpectoral pocket Through the subpectoral pocket a sterile suction tip was introduced and copious irrigation with sterile saline solution was used until the irrigant was clear Following completion of irrigation 350 cc saline filled implants were introduced They were first filled with 60 cc of saline and checked for gross leakage none was evident They were over filled to 400 cc of saline each The patient was then placed in the seated position and the left breast needed 10 cc of additional fluid for symmetry Following completion of the filling of the implants and checking the breasts for symmetry the patient s wounds were closed with interrupted vertical mattress sutures of 4 0 Prolene Flexan dressings were applied followed by the patient s bra She seemed to tolerate the procedure well Keywords surgery bilateral transaxillary subpectoral mammoplasty saline filled implants subpectoral mammoplasty mammoplasty transaxillary subpectoral implants breasts saline anesthesia MEDICAL_TRANSCRIPTION,Description Lysis of pelvic adhesions The patient had an 8 cm left ovarian mass The mass was palpable on physical examination and was tender She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy Medical Specialty Surgery Sample Name Lysis of Pelvic Adhesions Transcription PREOPERATIVE DIAGNOSIS Multiple pelvic adhesions POSTOPERATIVE DIAGNOSIS Multiple pelvic adhesions PROCEDURE PERFORMED Lysis of pelvic adhesions ANESTHESIA General with local SPECIMEN None COMPLICATIONS None HISTORY The patient is a 32 year old female who had an 8 cm left ovarian mass which was evaluated by Dr X She had a ultrasound which demonstrated the same The mass was palpable on physical examination and was tender She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy During the surgery there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon These adhesions were taken down sharply with Metzenbaum scissors PROCEDURE A pelvic laparotomy had been performed by Dr X Upon exploration of the abdomen multiple pelvic adhesions were noted as previously stated A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst The ureter had been identified and isolated prior to the adhesiolysis There was no evidence of bleeding The remainder of the case was performed by Dr X and this will be found in a separate operative report Keywords surgery lysis of pelvic adhesions pelvic adhesions pelvic adhesions salpingooophorectomy lysis laparotomy sigmoid colon mass ovarian MEDICAL_TRANSCRIPTION,Description Sentinel lymph node biopsy Ultrasound guided lumpectomy with intraoperative ultrasound Medical Specialty Surgery Sample Name Lumpectomy Lymph Node Biopsy Transcription PREOPERATIVE DIAGNOSIS Left breast ductal carcinoma in situ POSTOPERATIVE DIAGNOSIS Left breast ductal carcinoma in situ PROCEDURES PERFORMED 1 Sentinel lymph node biopsy 2 Ultrasound guided lumpectomy with intraoperative ultrasound ANESTHESIA General LMA anesthesia ESTIMATED BLOOD LOSS Minimum IV FLUIDS Per anesthesia record COMPLICATIONS None FINDINGS Clip well localized within the specimen INDICATION This is a 65 year old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility which showed atypical ductal hyperplasia with central necrosis On reviewing this pathology it is mostly likely DCIS The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed The patient desired MammoSite Radiation Therapy therefore the sentinel lymph node biopsy was incorporated into the procedure PROCEDURE IN DETAIL The patient was taken to the operating room placed in supine position and general LMA anesthesia was administered She was prepped and draped in the usual sterile fashion Prior to the procedure she underwent nuclear medicine injection with technetium 99 and methylene blue Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery Two sentinel lymph nodes were identified one was blue and hot and the other was just hot These were sent to Pathology for touch prep Adequate hemostasis was obtained The wound was packed and attention was turned to the left breast Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap An elliptical incision was made roughly at approximately the 3 o clock position secondary to subcutaneous tissues with electric Bovie cautery The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia which was incorporated within the specimen The specimen was completely removed and marked double deep and a mini C arm was used to confirm this The marker was well localized within the center of the specimen The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2 0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter The wound was then closed with a deep layer of interrupted 3 0 Vicryl followed by 3 0 Vicryl subcuticular stitch and 4 0 running Monocryl The axillary wound was closed with interrupted 3 0 Vicryl and a running 4 0 Monocryl Steri Strips were applied The patient was awakened and extubated in the OR and taken to PACU in stable condition All counts were reported as correct I was present for the entire procedure Keywords surgery carcinoma in situ dcis lma mammosite radiation therapy monocryl pacu sentinel steri strips central necrosis ductal carcinoma ductal hyperplasia lumpectomy lymph node biopsy node biopsy stereotactic biopsy sentinel lymph node biopsy electric bovie lymph node sentinel lymph intraoperative anesthesia lymph biopsy ultrasound MEDICAL_TRANSCRIPTION,Description Left axillary lymph node excisional biopsy Left axillary adenopathy Medical Specialty Surgery Sample Name Lymph Node Excisional Biopsy Transcription PREOPERATIVE DIAGNOSIS Left axillary adenopathy POSTOPERATIVE DIAGNOSIS Left axillary adenopathy PROCEDURE Left axillary lymph node excisional biopsy ANESTHESIA LMA INDICATIONS Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only Note she refused her CMF adjuvant therapy and this was for a triple negative infiltrating ductal carcinoma of the breast Patient has been following with Dr Diener and Dr Wilmot I believe that genetic counseling had been recommended to her and obviously the CMF was recommended but she declined both She presented to the office with left axillary adenopathy in view of the high risk nature of her lesion I recommended that she have this lymph node removed The procedure purpose risk expected benefits potential complications alternative forms of therapy were discussed with her and she was agreeable to surgery TECHNIQUE Patient was identified then taken into the operating room where after induction of appropriate anesthesia her left chest neck axilla and arm were prepped with Betadine solution draped in a sterile fashion An incision was made at the hairline carried down by sharp dissection through the clavipectoral fascia I was able to easily palpate the lymph node and grasp it with a figure of eight 2 0 silk suture and by sharp dissection was carried to hemoclip all attached structures The lymph node was excised in its entirety The wound was irrigated The lymph node sent to pathology The wound was then closed Hemostasis was assured and the patient was taken to recovery room in stable condition Keywords surgery axillary lymph node excisional biopsy sharp dissection excisional biopsy lymph node axillary excisional biopsy MEDICAL_TRANSCRIPTION,Description Lumbar discogram L2 3 L3 4 L4 5 and L5 S1 Low back pain Medical Specialty Surgery Sample Name Lumbar Discogram Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE PERFORMED 1 Lumbar discogram L2 3 2 Lumbar discogram L3 4 3 Lumbar discogram L4 5 4 Lumbar discogram L5 S1 ANESTHESIA IV sedation PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed prone onto a radiolucent table The C arm was brought into the operative field and AP left right oblique and lateral fluoroscopic images of the L1 2 through L5 S1 levels were obtained We then proceeded to prepare the low back with a Betadine solution and draped sterile Using an oblique approach to the spine the L5 S1 level was addressed using an oblique projection angled C arm in order to allow for perpendicular penetration of the disc space A metallic marker was then placed laterally and a needle entrance point was determined A skin wheal was raised with 1 Xylocaine and an 18 gauge needle was advanced up to the level of the disc space using AP oblique and lateral fluoroscopic projections A second needle 22 gauge 6 inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections was placed into the center of the nucleus We then proceeded to perform a similar placement of needles at the L4 5 L3 4 and L2 3 levels A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting we then proceeded to inject the disc spaces sequentially Keywords surgery back pain c arm fluoroscopic projections disc space lumbar discogram fluoroscopic needle MEDICAL_TRANSCRIPTION,Description Microscopic assisted lumbar laminotomy with discectomy at L5 S1 on the left Herniated nucleus pulposus of L5 S1 on the left MEDICAL_TRANSCRIPTION,Description Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation Medical Specialty Surgery Sample Name Lumbar Re exploration Transcription PREOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation POSTOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation PROCEDURE Lumbar re exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4 5 and L5 S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4 5 and L5 S1 followed by placement of the pedicle screw fixation devices at L3 L4 L5 and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1 2 and then at L3 L4 L4 L5 and L5 S1 bilaterally DESCRIPTION OF PROCEDURE This is a 68 year old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2 She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area There was no evidence of infection on the imaging or with her laboratory studies In addition she developed a pretty profound stenosis at L4 L5 and L5 S1 that appeared to be recurrent as well She now presents for revision of her hardware extension of fusion and decompression The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia She was placed on the operative table in the prone position Back was prepared with Betadine iodine and alcohol We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it After these were removed it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase We then dressed the L4 L5 and L5 S1 levels which were profoundly stenotic This was a combination of scar and overgrown bone She had previously undergone bilateral hemilaminectomies at L4 5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels After completing this we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels We used 10 x 32 mm spacers at both L4 L5 and L5 S1 This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4 L5 and S1 tightened the pedicle screws in L3 This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level Once we placed the plate onto the screws and locked them in position we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4 L5 and L5 S1 and L3 L4 again the goal being to create a dorsal fusion and enhance the interbody fusion as well The wound was then irrigated copiously with bacitracin solution and then we closed in layers using 1 Vicryl in muscle and fascia 3 0 in subcutaneous tissue and approximated staples in the skin Prior to closing the skin we confirmed correct sponge and needle count We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies The Cell Saver blood was recycled and she was given two units of packed red blood cells as well I was present for and performed the entire procedure myself or supervised Keywords surgery degenerative spondylolisthesis spondylolisthesis stenosis lumbar re exploration internal fixation plate hemilaminectomy diskectomy synthetic spacers pedicle screws fusion lumbar pedicle fixation hardware MEDICAL_TRANSCRIPTION,Description Lumbar puncture A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained Medical Specialty Surgery Sample Name Lumbar Puncture 2 Transcription PROCEDURE PERFORMED Lumbar puncture The procedure benefits risks including possible risks of infection were explained to the patient and his father who is signing the consent form Alternatives were explained They agreed to proceed with the lumbar puncture Permit was signed and is on the chart The indication was to rule out toxoplasmosis or any other CNS infection DESCRIPTION The area was prepped and draped in a sterile fashion Lidocaine 1 of 5 mL was applied to the L3 L4 spinal space after the area had been prepped with Betadine three times A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained The spinal needle was then withdrawn and the area cleaned and dried and a Band Aid applied to the clean dry area COMPLICATIONS None The patient was resting comfortably and tolerated the procedure well ESTIMATED BLOOD LOSS None DISPOSITION The patient was resting comfortably with nonlabored breathing and the incision was clean dry and intact Labs and cultures were sent for the usual in addition to some extra tests that had been ordered The opening pressure was 292 the closing pressure was 190 Keywords surgery spinal needle lumbar puncture lumbar gauge csf MEDICAL_TRANSCRIPTION,Description Injection for myelogram and microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain Medical Specialty Surgery Sample Name Lumbar Laminectomy Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain PROCEDURE PERFORMED 1 Injection for myelogram 2 Microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left on 08 28 03 BLOOD LOSS Approximately 25 cc ANESTHESIA General POSITION Prone on the Jackson table INTRAOPERATIVE FINDINGS Extruded nucleus pulposus at the level of L5 S1 HISTORY This is a 34 year old male with history of back pain with radiation into the left leg in the S1 nerve root distribution The patient was lifting at work on 08 27 03 and felt immediate sharp pain from his back down to the left lower extremity He denied any previous history of back pain or back surgeries Because of his intractable pain as well as severe weakness in the S1 nerve root distribution the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on After an informed consent was obtained all risks as well as complications were discussed with the patient PROCEDURE DETAIL He was wheeled back to Operating Room 5 at ABCD General Hospital on 08 28 03 After a general anesthetic was administered a Foley catheter was inserted The patient was then turned prone on the Jackson table All of his bony prominences were well padded At this time a myelogram was then performed After the lumbar spine was prepped a 20 gauge needle was then used to perform a myelogram The needle was localized to the level of L3 L4 region Once inserted into the thecal sac we immediately got cerebrospinal fluid through the spinal needle At this time approximately 10 cc of Conray injected into the thecal sac The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast The myelogram did reveal that there was some space occupying lesion most likely disc at the level of L5 S1 on the left There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C arm fluoroscopy At this point the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy A long spinal needle was then inserted into region of surgery on the right The surgery was going to be on the left Once the spinal needle was inserted a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5 S1 nerve root region At this time an approximately 2 cm skin incision was made over the lumbar region dissected down to the deep lumbar fascia At this time a Weitlaner was inserted Bovie cautery was used to obtain hemostasis We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left hand side At this time a Taylor retractor was then inserted and held there for retraction Suction as well as Bovie cautery was used to obtain hemostasis At this time a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression Once the laminotomy was performed a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots Once the ligamentum flavum was removed we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root which was compressive We removed the extruded disc with further freeing up of the S1 nerve root A nerve root retractor was then placed Identification of disc space was then performed A 15 blade was then inserted and small a key hole into the disc space was then performed with a 15 blade A small pituitary was then inserted within the disc space and more disc material was freed and removed The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc Once this was performed we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free At this time copious irrigation was used to irrigate the wound We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur At this time a small piece of Gelfoam was then used to cover the exposed nerve root We did not have any dural leaks during this case 1 0 Vicryl was then used to approximate the deep lumbar fascia 2 0 Vicryl was used to approximate the superficial lumbar fascia and 4 0 running Vicryl for the subcutaneous skin Sterile dressings were then applied The patient was then carefully slipped over into the supine position extubated and transferred to Recovery in stable condition At this time we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level Keywords surgery microscopic assisted lumbar laminectomy discectomy nerve root lumbar laminectomy herniated nucleus thecal sac spinal needle nucleus pulposus disc space root nerve weakness lumbar laminectomy nucleus pulposus myelogram MEDICAL_TRANSCRIPTION,Description Lumbar puncture with moderate sedation Medical Specialty Surgery Sample Name Lumbar Puncture 1 Transcription PROCEDURE Lumbar puncture with moderate sedation INDICATION The patient is a 2 year 2 month old little girl who presented to the hospital with severe anemia hemoglobin 5 8 elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test She was transfused with packed red blood cells Her hemolysis seemed to slow down She also on presentation had indications of urinary tract infection with urinalysis significant for 2 leukocytes positive nitrites 3 protein 3 blood 25 to 100 white cells 10 to 25 bacteria 10 to 25 epithelial cells on clean catch specimen Culture subsequently grew out no organisms however the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital She had a blood culture which was also negative She was empirically started on presentation with the cefotaxime intravenously Her white count on presentation was significantly elevated at 20 800 subsequently increased to 24 7 and then decreased to 16 6 while on antibiotics After antibiotics were discontinued she increased over the next 2 days to an elevated white count of 31 000 with significant bandemia metamyelocytes and myelocytes present She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI I discussed with The patient s parents prior to the procedure the lumbar puncture and moderate sedation procedures The risks benefits alternatives complications including but not limited to bleeding infection respiratory depression Questions were answered to their satisfaction They would like to proceed PROCEDURE IN DETAIL After time out procedure was obtained the child was given appropriate monitoring equipment including appropriate vital signs were obtained She was then given Versed 1 mg intravenously by myself She subsequently became sleepy the respiratory monitors end tidal cardiopulmonary and pulse oximetry were applied She was then given 20 mcg of fentanyl intravenously by myself She was placed in the left lateral decubitus position Dr X cleansed the patient s back in a normal sterile fashion with Betadine solution She inserted a 22 gauge x 1 5 inch spinal needle in the patient s L3 L4 interspace that was carefully identified under my direct supervision Clear fluid was not obtained initially needle was withdrawn intact The patient was slightly repositioned by the nurse and Dr X reinserted the needle in the L3 L4 interspace position the needle was able to obtain clear fluid approximately 3 mL was obtained The stylette was replaced and the needle was withdrawn intact and bandage was applied Betadine solution was cleansed from the patient s back During the procedure there were no untoward complications the end tidal CO2 pulse oximetry and other vitals remained stable Of note EMLA cream had also been applied prior procedure this was removed prior to cleansing of the back Fluid will be sent for a routine cell count Gram stain culture protein and glucose DISPOSITION The child returned to room on the medical floor in satisfactory condition Keywords surgery moderate sedation lumbar puncture needle lumbar MEDICAL_TRANSCRIPTION,Description Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques and repair of CSF fistula microtechniques L5 S1 application of DuraSeal Lumbar stenosis and cerebrospinal fluid fistula Medical Specialty Surgery Sample Name Lumbar Laminectomy Transcription PREOPERATIVE DIAGNOSIS Lumbar stenosis POSTOPERATIVE DIAGNOSES Lumbar stenosis and cerebrospinal fluid fistula TITLE OF THE OPERATION 1 Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques 2 Repair of CSF fistula microtechniques L5 S1 application of DuraSeal INDICATIONS The patient is an 82 year old woman who has about a four month history now of urinary incontinence and numbness in her legs and hands and difficulty ambulating She was evaluated with an MRI scan which showed a very high grade stenosis in her lumbar spine and subsequent evaluation included a myelogram which demonstrated cervical stenosis at C4 C5 C5 C6 and C6 C7 as well as a complete block of the contrast at L4 L5 and no contrast at L5 S1 either and stenosis at L3 L4 and all the way up but worse at L3 L4 L4 L5 and L5 S1 Yesterday she underwent an anterior cervical discectomy and fusions C4 C5 C5 C6 C6 C7 and had some improvement of her symptoms and increased strength even in the recovery room She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation though she has been cardioverted She and her son understand the nature indications and risks of the surgery and agreed to go ahead PROCEDURE The patient was brought from the Neuro ICU to the operating room where general endotracheal anesthesia was obtained She was rolled in a prone position on the Wilson frame The back was prepared in the usual manner with Betadine soak followed by Betadine paint Markings were applied Sterile drapes were applied Using the usual anatomical landmarks linear midline incision was made presumed over L4 L5 and L5 S1 Sharp dissection was carried down into subcutaneous tissue then Bovie electrocautery was used to isolate the spinous processes A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5 S1 The incision was extended rostrally and deep Gelpi s were inserted to expose the spinous processes and lamina of L3 L4 L5 and S1 Using the Leksell rongeur the spinous processes of L4 and L5 were removed completely and the caudal part of L3 A high speed drill was then used to thin the caudal lamina of L3 all of the lamina of L4 and of L5 Then using various Kerrison punches I proceeded to perform a laminectomy Removing the L5 lamina there was a dural band attached to the ligamentum flavum and this caused about a 3 mm tear in the dura There was CSF leak The lamina removal was continued ligamentum flavum was removed to expose all the dura Then using 4 0 Nurolon suture a running locking suture was used to close the approximate 3 mm long dural fistula There was no CSF leak with Valsalva I then continued the laminectomy removing all of the lamina of L5 and of L4 removing the ligamentum flavum between L3 L4 L4 L5 and L5 S1 Foraminotomies were accomplished bilaterally The caudal aspect of the lamina of L3 also was removed The dura came up quite nicely I explored out along the L4 L5 and S1 nerve roots after completing the foraminotomies the roots were quite free Further more the thecal sac came up quite nicely In order to ensure no CSF leak we would follow the patient out of the operating room The dural closure was covered with a small piece of fat This was all then covered with DuraSeal glue Gelfoam was placed on top of this then the muscle was closed with interrupted 0 Ethibond The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion Scarpa s fascia was closed with a running 0 Vicryl and finally the skin was closed with a running locking 3 0 nylon The wound was blocked with 0 5 plain Marcaine ESTIMATED BLOOD LOSS Estimated blood loss for the case was about 100 mL SPONGE AND NEEDLE COUNTS Correct FINDINGS A very tight high grade stenosis at L3 L4 L4 L5 and L5 S1 There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis The patient tolerated the procedure well with stable vitals throughout Keywords surgery microtechniques fistula duraseal foraminotomies lumbar stenosis cerebrospinal lumbar laminectomy ligamentum flavum csf laminectomy lamina MEDICAL_TRANSCRIPTION,Description Microscopic lumbar discectomy left L5 S1 Extruded herniated disc left L5 S1 Left S1 radiculopathy acute Morbid obesity Medical Specialty Surgery Sample Name Lumbar Discectomy Microscopic Transcription PREOPERATIVE DIAGNOSES 1 Extruded herniated disc left L5 S1 2 Left S1 radiculopathy acute 3 Morbid obesity POSTOPERATIVE DIAGNOSES 1 Extruded herniated disc left L5 S1 2 Left S1 radiculopathy acute 3 Morbid obesity PROCEDURE PERFORMED Microscopic lumbar discectomy left L5 S1 ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 50 cc HISTORY This is a 40 year old female with severe intractable left leg pain from a large extruded herniated disc at L5 S1 She has been dealing with these symptoms for greater than three months She comes to my office with severe pain left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery I have discussed the MRI findings with the patient and the potential risks and complications She was scheduled to go to surgery through my office but because of her severe symptoms she was unable to keep that appointment and reported right to the Emergency Room We discussed the diagnosis and the operative procedure in detail I have reviewed the potential risks and complications and she had agreed to proceed with the surgery Due to the patient s weight which exceeds 340 lb there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient s back and abdomen and I have discussed this with her She is aware that she will have a much larger incision than what is standard and has agreed to accept this OPERATIVE PROCEDURE The patient was taken to OR 5 at ABCD General Hospital While in the hospital gurney Department of Anesthesia administered general anesthetic endotracheal intubation was followed A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing The table reportedly does have a limit of 500 lb but the table has never been stressed above 275 lb Once the table was reinforced the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded A marker was placed in from the back at this time and an x ray was obtained for incision localization The back is now prepped and draped in the usual sterile fashion A midline incision was made over the L5 S1 disc space taking through subcutaneous tissue sharply with a 10 Bard Parker scalpel The lumbar dorsal fascia was then encountered and incised to the left of midline In the subperiosteal fashion the musculature was elevated off the lamina at L5 and S1 after facet joint but not disturbing the capsule A second marker was now placed and an intraoperative x ray confirms our location at the L5 S1 disc space The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina Ligaments and fragments were encountered and removed at this time The epidural space was now encountered The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening This disc fragment was removed and the nerve root was much more supple it was carefully retracted The nerve root was now retracted and using a series of downgoing curettes additional disc material was removed from around the disc space and from behind the body of S1 and L5 At this point all disc fragments were removed from the epidural space Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify The disc space was now encountered and loose disc fragments were removed from within the disc space The disc space was then irrigated The nerve root was then reassessed and found to be quite supple At this point the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device At this point the wound was irrigated copiously and suctioned dry Gelfoam was used to cover the epidural space The retractors were removed at this point The fascia was reapproximated with 1 Vicryl suture subcutaneous tissue with 2 0 Vicryl suture and Steri Strips for curved incision The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia subsequently transferred to Postanesthesia Care Unit in stable condition Keywords surgery extruded herniated disc radiculopathy microscopic lumbar discectomy lumbar discectomy morbid obesity herniated disc epidural space nerve root disc space space intractable lamina epidural incision nerve herniated MEDICAL_TRANSCRIPTION,Description Primary low transverse cervical cesarean section Intrauterine pregnancy at 38 weeks and malpresentation A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively weighing 3030 g No nuchal cord No meconium Normal uterus fallopian tubes and ovaries Medical Specialty Surgery Sample Name Low Transverse C Section 5 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 38 weeks 2 Malpresentation POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 38 weeks 2 Malpresentation 3 Delivery of a viable male neonate PROCEDURE PERFORMED Primary low transverse cervical cesarean section ANESTHESIA Spinal with Astramorph ESTIMATED BLOOD LOSS 300 cc URINE OUTPUT 80 cc of clear urine FLUIDS 2000 cc of crystalloids COMPLICATIONS None FINDINGS A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively weighing 3030 g No nuchal cord No meconium Normal uterus fallopian tubes and ovaries INDICATIONS This patient is a 21 year old gravida 3 para 1 0 1 1 Caucasian female who presented to Labor and Delivery in labor Her cervix did make some cervical chains She did progress to 75 and 2 however there was a raised lobular area palpated on the fetal head However on exam unable to delineate the facial structures but definite fetal malpresentation The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring The contraction pattern was inadequate It was discussed with the patient s family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended All the questions were answered PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt Prior to this the spinal anesthesia was administered The patient was then prepped and draped A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel The fascia was then incised in the midline and extended laterally using Mayo scissors The superior aspect of the rectus fascia was then grasped with Ochsners tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors The superior portion and inferior portion of the rectus fascia was identified tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors The rectus muscle was then separated in the midline The peritoneum was then identified tented up with hemostats and entered sharply with Metzenbaum scissors The peritoneum was then gently stretched The vesicouterine peritoneum was then identified tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors The uterus was entered with the second scalpel and large transverse incision This was then extended in upward and lateral fashion bluntly The infant was then delivered atraumatically The nose and mouth were suctioned The cord was then clamped and cut The infant was handed off to the awaiting pediatrician The placenta was then manually extracted The uterus was exteriorized and cleared of all clots and debris The uterine incision was then repaired using 0 chromic in a running fashion marking a U stitch A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis The uterus was then returned to the anatomical position The abdomen and the gutters were cleared of all clots Again the incision was found to be hemostatic The rectus muscle was then reapproximated with 2 0 Vicryl in a single interrupted stitch The rectus fascia was then repaired with 0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion This was palpated and the patient was found to be without defect and intact The skin was then closed with staples The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She will be followed up as an inpatient with Dr X Keywords surgery low transverse cervical cesarean section cesarean section pregnancy neonate metzenbaum scissors intrauterine pregnancy rectus fascia rectus muscle intrauterine peritoneum malpresentation transverse astramorph MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization Intrauterine pregnancy at 35 1 7 Rh isoimmunization Suspected fetal anemia Desires permanent sterilization Medical Specialty Surgery Sample Name Low Transverse C Section 8 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 35 1 7 2 Rh isoimmunization 3 Suspected fetal anemia 4 Desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 35 1 7 2 Rh isoimmunization 3 Suspected fetal anemia 4 Desires permanent sterilization OPERATION PERFORMED Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization ANESTHESIA Spinal anesthesia COMPLICATIONS None ESTIMATED BLOOD LOSS 500 mL INTRAOPERATIVE FLUIDS 1000 mL crystalloids URINE OUTPUT 300 mL clear urine at the end of procedure SPECIMENS Cord gases hematocrit on cord blood placenta and bilateral tubal segments INTRAOPERATIVE FINDINGS Male infant vertex position very bright yellow amniotic fluid Apgars 7 and 8 at 1 and 5 minutes respectively Weight pending at this time His name is Kasson as well as umbilical cord and placenta stained yellow Otherwise normal appearing uterus and bilateral tubes and ovaries DESCRIPTION OF OPERATION After informed consent was obtained the patient was taken to the operating room where spinal anesthesia was obtained by Dr X without difficulties The patient was placed in supine position with leftward tilt Fetal heart tones were checked and were 140s and she was prepped and draped in a normal sterile fashion At this time a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery The fascia was nicked sharply in the midline The fascial incision was extended laterally with Mayo scissors The inferior aspect of the fascial incision was grasped with Kocher x2 elevated and rectus muscles dissected sharply with the use of Mayo scissors Attention was then turned to the superior aspect of the fascial incision Fascia was grasped elevated and rectus muscles dissected off sharply The rectus muscles were separated in the midline bluntly The peritoneum was identified grasped and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder Bladder blade was inserted Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U shaped fashion with the scalpel Uterine incision was extended laterally and manually Membranes were ruptured and bright yellow clear amniotic fluid was noted Infant s head was in a floating position able to flex the head push against the incision and then easily brought it to the field vertex Nares and mouth were suctioned with bulb suction Remainder of the infant was delivered atraumatically The infant was very pale upon delivery Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team An 8 cm segment of the tube was doubly clamped and transected Cord gases were obtained Cord was then cleansed laid on a clean laparotomy sponge and cord blood was drawn for hematocrit measurements At this time it was noted that the cord was significantly yellow stained as well as the placenta At this time the placenta was delivered via gentle traction on the cord and exterior uterine massage Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1 0 chromic in a running locked fashion Two areas of oozing were noted and separate figure of eight sutures were placed to obtain hemostasis At this time the uterine incision was hemostatic The bladder was examined and found to be well below the level of the incision repair Tubes and ovaries were examined and found to be normal The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp Mesosalpinx was divided with electrocautery and a 4 cm segment of tube was doubly tied and transected with a 3 cm segment of tube removed Hemostasis was noted Then attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp Mesosalpinx was incised and 3 4 cm tube doubly tied transected and excised and excellent hemostasis was noted Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen Gutters were cleared off all clots and debris Lower uterine segments were again re inspected and found to be hemostatic Sites of tubal sterilization were also visualized and were hemostatic At this time the peritoneum was grasped with Kelly clamps x3 and closed with running 3 0 Vicryl suture Copious irrigation was used Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline At this time the fascia was closed using 0 Vicryl in a running fashion Manual palpation confirms thorough and adequate closure of the fascial layer Copious irrigation was again used Hemostasis noted and skin was closed with staples The patient tolerated the procedure well Sponge lap needle and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia The patient will be followed for her severe right upper quadrant pain post delivery If she continues to have pain may need a surgical consult for gallbladder and or angiogram for evaluation of right kidney and questionable venous plexus This all will be relayed to Dr Y her primary obstetrician who was on call starting this morning at 7 a m through the weekend Keywords surgery intrauterine pregnancy rh isoimmunization primary low transverse cesarean section bilateral tubal sterilization pfannenstiel skin incision fascial incision uterine incision fetal anemia permanent sterilization rectus muscles incision tubes cord MEDICAL_TRANSCRIPTION,Description Primary low transverse C section Postdates pregnancy failure to progress meconium stained amniotic fluid Medical Specialty Surgery Sample Name Low Transverse C Section 4 Transcription PREOPERATIVE DIAGNOSES 1 Postdates pregnancy 2 Failure to progress 3 Meconium stained amniotic fluid POSTOPERATIVE DIAGNOSES 1 Postdates pregnancy 2 Failure to progress 3 Meconium stained amniotic fluid OPERATION Primary low transverse C section ANESTHESIA Epidural DESCRIPTION OF OPERATION The patient was taken to the operating room and under epidural anesthesia she was prepped and draped in the usual manner Anesthesia was tested and found to be adequate Incision was made Pfannenstiel approximately 1 5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty the fascia being incised laterally Bleeders were bovied Rectus muscles were separated from the overlying fascia with blunt and sharp dissection Muscles were separated in the midline Peritoneum was entered sharply and incision was carried out laterally in each direction Bladder blade was placed and bladder flap developed with blunt and sharp dissection A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction Allis was placed in the incision and an uncomplicated extraction of a 7 pound 4 ounce Apgar 9 female was accomplished and given to the pediatric service in attendance Infant was carefully suctioned after delivery of the head and body Cord blood was collected _______ and endometrial cavity was wiped free of membranes and clots Lower segment incision was inspected There were some extensive adhesions on the left side and a figure of eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present Cul de sac was suctioned free of blood and clots and irrigated Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated Lower segment incision was again inspected and found to be hemostatic The abdominal wall was then closed in layers 2 0 chromic on the peritoneum 0 Maxon on the fascia 3 0 plain on the subcutaneous and staples on the skin Hemostasis was present between all layers The area was gently irrigated across the peritoneum and fascial layers There were no intraoperative complications except blood loss The patient was taken to the recovery room in satisfactory condition Keywords surgery pregnancy meconium stained amniotic fluid low transverse c section amniotic fluid meconium peritoneum blood chromic fascial amniotic incision MEDICAL_TRANSCRIPTION,Description Repeat low transverse C section lysis of omental adhesions lysis of uterine adhesions with repair of uterine defect and bilateral tubal ligation Medical Specialty Surgery Sample Name Low Transverse C Section 3 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 33 weeks twin gestation 2 Active preterm labor 3 Advanced dilation 4 Multiparity 5 Requested sterilization POSTOPERATIVE DIAGNOSIS 1 Intrauterine pregnancy at 33 weeks twin gestation 2 Active preterm labor 3 Advanced dilation 4 Multiparity 5 Requested sterilization 6 Delivery of a viable female A weighing 4 pounds 7 ounces Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces Apgars 6 and 7 at 1 and 5 minutes respectively 7 Uterine adhesions and omentum adhesions OPERATION PERFORMED Repeat low transverse C section lysis of omental adhesions lysis of uterine adhesions with repair of uterine defect and bilateral tubal ligation ANESTHESIA General ESTIMATED BLOOD LOSS 500 mL DRAINS Foley This is a 25 year old white female gravida 3 para 2 0 0 2 with twin gestation at 33 weeks and previous C section The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm The decision for C section was made PROCEDURE The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision The patient was then given general anesthesia and once this was completed first knife was used to make a low transverse incision extending down to the level of the fascia The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically The abdominal rectus muscle was divided in the center and extended in a vertical fashion Peritoneum was entered at a high point and extended in a vertical fashion as well The bladder blade was put in place The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus The first fetus was vertex The fluid was clear The head was delivered followed by the remaining portion of the body The cord was doubly clamped and cut The newborn handed off to waiting pediatrician and nursery personnel The second fluid was ruptured It was the clear fluid as well The presenting part was brought down to be vertex The head was delivered followed by the rest of the body and the cord was doubly clamped and cut and newborn handed off to waiting pediatrician in addition of the nursery personnel Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B Once this was completed the placenta was delivered and handed off for further inspection by Pathology At this time it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection Then there were multiple omental adhesions on the surface of the uterus itself This needed to be released as well as on the abdominal wall and then the uterus could be externalized The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re approximate the uterine incision with the second layer used to imbricate the first The bladder flap was re approximated with 3 0 Vicryl and Gelfoam underneath The right fallopian tube was grasped with a Babcock it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized The same technique was completed on the left side with the knuckle portion cut off and cauterized as well The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis Interceed was placed over this area as well The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position The gutters were wiped clean of any remaining blood The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re approximate abdominal rectus muscles as well as the peritoneal edges The abdominal rectus muscle was irrigated The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center The subcutaneous tissue was irrigated Cautery was used to create adequate hemostasis and 3 0 Vicryl was used to re approximate the subcutaneous tissue Skin edges were re approximated with sterile staples Sterile dressing was applied Uterus was evacuated of any remaining blood vaginally The patient was taken to the recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords surgery intrauterine pregnancy gestation preterm labor omentum adhesions low transverse c section uterine adhesions intrauterine adhesions abdominal uterus uterine MEDICAL_TRANSCRIPTION,Description Repeat low transverse cesarean section and bilateral tubal ligation BTL Intrauterine pregnancy at term with previous cesarean section Desires permanent sterilization Macrosomia Medical Specialty Surgery Sample Name Low Transverse C Section BTL Transcription PREOPERATIVE DIAGNOSIS Intrauterine pregnancy at term with previous cesarean section SECONDARY DIAGNOSES 1 Desires permanent sterilization 2 Macrosomia POSTOPERATIVE DIAGNOSES 1 Desires permanent sterilization 2 Macrosomia 3 Status post repeat low transverse cesarean and bilateral tubal ligation PROCEDURES 1 Repeat low transverse cesarean section 2 Bilateral tubal ligation BTL ANESTHESIA Spinal FINDINGS A viable female infant weighing 7 pounds 10 ounces assigned Apgars of 9 and 9 There was normal pelvic anatomy normal tubes The placenta was normal in appearance with a three vessel cord DESCRIPTION OF PROCEDURE Patient was brought to the operating room with an IV running and a Foley catheter in place satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip The abdomen was prepped and draped in a sterile fashion A Pfannenstiel incision was made and carried sharply down to the level of fascia The fascia was incised transversely The fascia was dissected away from the underlying rectus muscles With sharp and blunt dissection rectus muscles were divided in midline The perineum was entered bluntly The incision was carried vertically with scissors Transverse incision was made across the bladder peritoneum The bladder was dissected away from the underlying lower uterine segment Bladder retractor was placed to protect the bladder The lower uterine segment was entered sharply with a scalpel Incision was carried transversely with bandage scissors Clear amniotic fluids were encountered The infant was out of the pelvis and was in oblique vertex presentation The head was brought down into the incision and delivered easily as were the shoulders and body The mouth and oropharynx were suctioned vigorously The cord was clamped and cut The infant was passed off to the waiting pediatrician in satisfactory condition Cord bloods were taken Placenta was delivered spontaneously and found to be intact Uterus was explored and found to be empty Uterus was delivered through the abdominal incision and massaged vigorously Intravenous Pitocin was administered T clamps were placed about the margins of the uterine incision which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis Secondary running locking stitch was placed for extra strength to the wound At this point attention was diverted to the patient s tubes a Babcock clamp grasped the isthmic portion of each tube and approximately 1 cm knuckle on either side was tied off with two lengths of 0 plain catgut Intervening knuckle was excised and passed off the field The proximal end of the tubal mucosa was cauterized Cul de sac and gutters were suctioned vigorously The uterus was returned to its proper anatomic position in the abdomen The fascia was closed with a simple running stitch of 0 PDS The skin was closed with running subcuticular of 4 0 Monocryl Uterus was expressed of its contents Patient was brought to the recovery room in satisfactory condition There were no complications There was 600 cc of blood loss All sponge needle and instrument counts were reported to be correct SPECIMEN Tubal segments DRAIN Foley catheter draining clear yellow urine Keywords surgery placenta low transverse cesarean section bilateral tubal ligation permanent sterilization cesarean section intrauterine btl sterilization macrosomia uterine MEDICAL_TRANSCRIPTION,Description Primary low transverse cervical cesarean section Intrauterine pregnancy of 39 weeks Herpes simplex virus positive by history hepatitis C positive by history with low elevation of transaminases cephalopelvic disproportion asynclitism postpartum macrosomia and delivery of viable 9 lb female neonate Medical Specialty Surgery Sample Name Low Transverse C Section 9 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy of 39 weeks 2 Herpes simplex virus positive by history 3 Hepatitis C positive by history with low elevation of transaminases 4 Cephalopelvic disproportion 5 Asynclitism 6 Postpartum macrosomia POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy of 39 weeks 2 Herpes simplex virus positive by history 3 Hepatitis C positive by history with low elevation of transaminases 4 Cephalopelvic disproportion 5 Asynclitism 6 Postpartum macrosomia 7 Delivery of viable 9 lb female neonate PROCEDURE PERFORMED Primary low transverse cervical cesarean section COMPLICATIONS None ESTIMATED BLOOD LOSS About 600 cc Baby is doing well The patient s uterus is intact bladder is intact HISTORY The patient is an approximately 25 year old Caucasian female with gravida 4 para 1 0 2 1 The patient s last menstrual period was in December of 2002 with a foreseeable due date on 09 16 03 confirmed by ultrasound The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases The patient had been seen through our office for prenatal care The patient is on Valtrex The patient was found to be 3 cm about 40 0 to 9 engaged Bag of waters was ruptured She was on Pitocin She was contracting appropriately for a couple of hours or so with appropriate ________ There was no cervical change noted Most probably because there was a sink vertex and that the head was too large to descend into the pelvis The patient was advised of this and we recommended cesarean section She agreed We discussed the surgery foreseeable risks and complications alternative treatment the procedure itself and recovery in layman s terms The patient s questions were answered I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire PROCEDURE The patient was then taken back to operative suite She was given anesthetic and sterilely prepped and draped Pfannenstiel incision was used A second knife was used to carry the incision down to the anterior rectus fascia Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature The rectus muscles were separated The patient s peritoneum tented up towards the umbilicus and we entered the abdominal cavity There was a very thin lower uterine segment There seemed to be quite a large baby The patient had a small nick in the uterus Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity clear amniotic fluid was obtained A blunt low transverse cervical incision was made Following this we placed a ________ on the very large fetal head The head was delivered following which we were able to deliver a large baby girl 9 lb good at tone and cry The patient then underwent removal of the placenta after the cord blood and ABG were taken The patient s uterus was examined There appeared to be no retained products The patient s uterine incision was reapproximated and sutured with 0 Vicryl in a running non interlocking fashion the second imbricating over the first The patient s uterus was hemostatic Bladder flap was reapproximated with 0 Vicryl The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures The patient had three interrupted sutures of this The fascia was reapproximated with two stitches of 0 Vicryl going from each apex towards the midline The Scarpa s fascia was reapproximated with 0 gut There was noted no fascial defects and the skin was closed with 0 Vicryl Prior to closing the abdominal cavity the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact The patient was hemostatic All counts were correct and the patient tolerated the procedure well We will see her back in recovery Keywords surgery intrauterine pregnancy herpes simplex virus hepatitis c cephalopelvic disproportion asynclitism postpartum macrosomia low transverse cervical cesarean section rectus fascia cesarean section intrauterine transaminases herpes uterus fascia MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section via Pfannenstiel incision Pregnancy at 40 weeks failure to progress premature prolonged rupture of membranes group B strep colonization and delivery of viable male neonate Medical Specialty Surgery Sample Name Low Transverse C Section 6 Transcription PREOPERATIVE DIAGNOSES 1 Pregnancy at 40 weeks 2 Failure to progress 3 Premature prolonged rupture of membranes 4 Group B strep colonization POSTOPERATIVE DIAGNOSIS 1 Pregnancy at 40 weeks 2 Failure to progress 3 Premature prolonged rupture of membranes 4 Group B strep colonization 5 Delivery of viable male neonate PROCEDURE PERFORMED Primary low transverse cesarean section via Pfannenstiel incision ANESTHESIA Spinal ESTIMATED BLOOD LOSS 1000 cc FLUID REPLACEMENT 2700 cc crystalloid URINE 500 cc clear yellow urine in the Foley catheter INTRAOPERATIVE FINDINGS Normal appearing uterus tubes and ovaries A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively Infant weight equaled to 4140 gm with clear amniotic fluid The umbilical cord was wrapped around the leg tightly x1 Infant was in a vertex right occiput anterior position INDICATIONS FOR PROCEDURE The patient is a 19 year old G1 P0 at 41 and 1 7th weeks intrauterine pregnancy She presented at mid night on 08 22 03 complaining of spontaneous rupture of membranes which was confirmed in Labor and Delivery The patient had a positive group beta strep colonization culture and was started on penicillin The patient was also started on Pitocin protocol at that time The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor IUPC was placed without difficulty and contractions appeared to be regular however they were inadequate amount of the daily units The patient was given a rest from the Pitocin She walked and had a short shower The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions Maximum cervical dilation was 5 cm 80 effaced negative 2 station and cephalic position At the time of C section the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation as there was suspected macrosomia on ultrasound Options were discussed with the patient and family and it was determined that we will take her for C section today Consent was signed All questions were answered with Dr X present PROCEDURE The patient was taken to the operative suite where a spinal anesthetic was placed She was placed in the dorsal supine position with left upward tilt She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel The fascia was incised in the midline and extended laterally using curved Mayo scissors The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle The rectus muscle was separated in the midline bluntly The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors The peritoneum was then bluntly stretched The bladder blade was placed The vesicouterine peritoneum was identified tented up with Allis and entered sharply with Metzenbaum scissors The incision was extended laterally and the bladder flap created digitally The bladder blade was then reinserted in the lower uterine segment A low transverse uterine incision was made with a second scalpel The uterine incision was extended laterally bluntly The bladder blade was removed and the infant s head was delivered with the assistance of a vacuum Infant s nose and mouth were bulb suctioned and the body was delivered atraumatically There was of note an umbilical cord around the leg tightly x1 Cord was clamped and cut Infant was handed to the waiting pediatrician Cord gas was sent for pH as well as blood typing The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris The uterine incision was grasped circumferentially with Alfred clamps and closed with 0 Chromic in a running locked fashion A second layer of imbricating stitch was performed using 0 Chromic suture to obtain excellent hemostasis The uterus was returned to the abdomen The gutters were cleared of all clots and debris The rectus muscle was loosely approximated with 0 Vicryl suture in a single interrupted fashion The fascia was reapproximated with 0 Vicryl suture in a running fashion The subcutaneous Scarpa s fascia was then closed with 2 0 plain gut The skin was then closed with staples The incision was dressed with sterile dressing and bandage Blood clots were evacuated from the vagina The patient tolerated the procedure well The sponge lap and needle counts were correct x2 The mother was taken to the recovery room in stable and satisfactory condition Keywords surgery c section cesarean section low transverse pregnancy rupture of membranes cervical dilation kocher clamps metzenbaum scissors vicryl suture pfannenstiel incision uterine incision rectus muscles incision transverse colonization rectus muscles bladder uterine section fascia MEDICAL_TRANSCRIPTION,Description Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate Medical Specialty Surgery Sample Name Low Transverse C Section 2 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate 2 Protein S low 3 Oligohydramnios POSTOPERATIVE 1 Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate 2 Protein S low 3 Oligohydramnios 4 Delivery of a viable female weight 5 pound 14 ounces Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7 314 OPERATION PERFORMED Low transverse C section ESTIMATED BLOOD LOSS 500 mL DRAINS Foley ANESTHESIA Spinal with Duramorph HISTORY OF PRESENT ILLNESS This is a 21 year old white female gravida 1 para 0 who had presented to the hospital at 37 3 7 weeks for induction The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration Due to the IUGR as well a decision for a C section was made PROCEDURE The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department The patient was then repositioned prepped and draped in a slight left lateral tilt Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis This was extended down to the level of the fascia The fascia was nicked in the center and extended in transverse fashion Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique The abdominal rectus muscle was divided in the center extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus Presenting part was vertex the head was delivered followed by the remaining portion of the body The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel Cord pH blood and cord blood was obtained The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0 chromic and a continuous locking stitch with a second layer used to imbricate the first The bladder flap was re peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2 0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum This area was then irrigated Cautery was used for adequate hemostasis corners of the fascia grasped with hemostats and continuous locking stitch of 1 Vicryl was started at both corners and overlapped in the center Subcutaneous tissue was irrigated with saline and reapproximated with 3 0 Vicryl Skin edges reapproximated with sterile staples Sterile dressing was applied The uterus was evacuated of any remaining clots vaginally The patient was taken to recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords surgery apgars low transverse c section fetal heart rate bladder blade intrauterine pregnancy intrauterine MEDICAL_TRANSCRIPTION,Description Primary cesarean section by low transverse incision Term pregnancy nonreassuring fetal heart tracing Medical Specialty Surgery Sample Name Low Transverse C Section 1 Transcription PREOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing POSTOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing OPERATION Primary cesarean section by low transverse incision ANESTHESIA Epidural ESTIMATED BLOOD LOSS 450 mL COMPLICATIONS None CONDITION Stable DRAINS Foley catheter INDICATIONS The patient is a 39 year old G4 para 0 0 3 0 with an EDC of 03 08 2009 The patient began having prodromal symptoms 2 to 3 days prior to presentation She was seen on 03 09 2007 and a nonstress test was performed This revealed some spontaneous variable appearing decelerations She was given IV hydration A biophysical profile was obtained which provided a score of 0 8 with only a 1 cm fluid pocket found Therefore she was admitted for further fetal monitoring and evaluation She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated She was having somewhat irregular contractions but with stronger contractions continued to have decelerations to 50 to 60 beats per minute Due to these findings a scalp electrode was placed as well as an IUPC for an amnioinfusion This relieved the decelerations somewhat However over a period of time with strong contractions she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations Due to this finding it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery These findings were reviewed with the patient and recommendation was made for cesarean section delivery The risks and benefits of this surgery were reviewed and knowing these facts the patient gave informed consent PROCEDURE The patient was taken to the operating room where her epidural anesthesia was reinforced She was prepped and draped in the usual fashion for the procedure After adequate epidural level was confirmed the scalp was utilized to make a transverse incision in the patient s lower abdominal wall This incision was carried down to the level of the fascia which was also transversely incised After adequate hemostasis the fascia was bluntly and sharply separated up from the underlying rectus muscle The rectus muscle was separated in midline exposing the peritoneum The peritoneum was carefully grasped and elevated with hemostats It was entered in an up and down fashion with Metzenbaum scissors The bladder blade was placed in the lower pole of the incision to protect the bladder The uterus was palpated and inspected A thin lower uterine segment was noted The vertex presentation was confirmed The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall Clear fluid was noted upon entering into the amniotic space At 05 27 a term viable female infant was delivered up through the incision She had spontaneous respirations She was given bulb suctioning for clear fluid Her cord was clamped and cut and she was delivered off the field to Dr X who was attending The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes Her birth weight was found to be 5 pounds and 5 ounces The placenta was manually extracted from the endometrial cavity A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis The uterus was delivered up into the operative field The endometrial cavity was swiped clean with a moist laparotomy pad The uterine incision was then closed in a two layered fashion with 0 Vicryl suture the first layer interlocking and the second layer imbricating Two additional stitches of 3 0 Vicryl suture were utilized for hemostasis The uterine incision was noted to be hemostatic upon closure The uterus was rotated forward normal tubes and ovaries were noted on both sides The uterus was then returned to its normal position of the abdominal cavity The sponge and instrument count was performed for the first time at this point and found to be correct The pelvis and anterior uterine space was then irrigated with saline solution It was suctioned dry A final check of the uterine incision confirmed hemostasis The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture The subcutaneous tissue was then exposed and the fascia closed with two running lengths of 0 Vicryl suture beginning in lateral margins and overlapping the midline The subcutaneous tissue was then irrigated and inspected No active bleeding was noted It was closed with a running length of 3 0 plain catgut suture The skin was then approximated with surgical steel staples The incision was infiltrated with a 0 5 solution of Marcaine local anesthetic The incision was cleansed and sterilely dressed The patient was transferred to the recovery room in stable condition The estimated blood loss through the procedure was 450 mL The sponge and instrument counts were performed two more times during closure and found to be correct each time Keywords surgery low transverse incision edc para amnioinfusion nonreassuring fetal heart tracing primary cesarean section fetal heart tracing low transverse term pregnancy fetal heart heart tracing rectus muscle uterine incision vicryl suture incision transverse fetal suture uterine MEDICAL_TRANSCRIPTION,Description A repeat low transverse cervical cesarean section Lysis of adhesions Dissection of the bladder of the anterior abdominal wall and away from the fascia and the patient also underwent a bilateral tubal occlusion via Hulka clips Medical Specialty Surgery Sample Name Low Transverse C Section 10 Transcription PREOPERATIVE DIAGNOSES 1 36th and 4 7th week intrauterine growth rate 2 Charcot Marie Tooth disease 3 Previous amniocentesis showing positive fetal lung maturity family planning complete 4 Previous spinal fusion 5 Two previous C sections The patient refuses trial labor The patient is with regular contractions dilated to 3 possibly an early labor contractions are getting more and more painful POSTOPERATIVE DIAGNOSES 1 36th and 4 7th week intrauterine growth rate 2 Charcot Marie Tooth disease 3 Previous amniocentesis showing positive fetal lung maturity family planning complete 4 Previous spinal effusion 5 Two previous C section The patient refuses trial labor The patient is with regular contractions dilated to 3 possibly an early labor contractions are getting more and more painful 6 Adhesions of bladder 7 Poor fascia quality 8 Delivery of a viable female neonate PROCEDURE PERFORMED 1 A repeat low transverse cervical cesarean section 2 Lysis of adhesions 3 Dissection of the bladder of the anterior abdominal wall and away from the fascia 4 The patient also underwent a bilateral tubal occlusion via Hulka clips COMPLICATIONS None BLOOD LOSS 600 cc HISTORY AND INDICATIONS Indigo Carmine dye bladder test in which the bladder was filled showed that there was no defects in the bladder of the uterus The uterus appeared to be intact This patient is a 26 year old Caucasian female The patient is well known to the OB GYN clinic The patient had two previous C sections She appears to be in probably early labor She had an amniocentesis early today She is contracting regularly about every three minutes The contractions are painful and getting much more so since the amniocentesis The patient had fetal lung maturity noted The patient also has probable IUGR as none of her babies have been over 4 lb The patient s baby appears to be somewhat small The patient suffers from Charcot Marie Tooth disease which has left her wheelchair bound The patient has had a spinal fusion however family planning is definitely complete per the patient The patient refuses trial labor The patient and I discussed the consent She understands the foreseeable risks and complications alternative treatment of the procedure itself and recovery Her questions were answered The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure which would result in either an intrauterine or ectopic pregnancy The patient understands this and would like to try our best PROCEDURE The patient was taken back to the operative suite She was given general anesthetic by Department of Anesthesiology Once again in layman s terms the patient understands the risks The patient had the informed consent reviewed and understood The patient has had a Pfannenstiel incision which was slightly bent towards the right side favoring the right side The patient had the first knife went through this incision The second knife was used to go to the level of fascia The fascia was very thin ruddy in appearance and with abundant scar tissue The fascia was incised Following this we were able to see the peritoneum There was really no obvious rectus abdominal muscles noted They were very weak atrophic and thin The patient has the peritoneum tented up We entered the abdominal cavity The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia The bladder flap was then entered into the uterus as well There are some bladder adhesions We removed these adhesions and we removed the bladder of the fascia We dissected the bladder of the lower segment We made a small nick on the lower segment We were able to utilize the blunt end of the knife to enter into the uterine cavity The baby was in occiput transverse position with the ear being cocked at such a position as well The patient s baby was delivered without difficulty It was a 4 lb and 10 oz baby girl who vigorously cried well There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection The patient s placenta was delivered There was no retained placenta The uterine incision was closed with two layers of 0 Vicryl the second layer imbricating over the first The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized Then we ligated this as there was bleeding and oozing The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc The 400 cc was instilled The bladder appears to be intact The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment There was some oozing around the area of the bladder We placed an Avitene there The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx The patient has two clips on each side There was excellent tubal occlusion and placement The uterus was placed back into the abdominal cavity We rechecked again The tubal placement was excellent It did not involve the round ligaments uterosacral ligaments the uteroovarian ligaments and the tube into the mesosalpinx The patient then underwent further examination Hemostasis appeared to be good The fascia was reapproximated with short running intervals of 0 Vicryl across the fascia We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible The Scarpa s fascia was reapproximated with 0 gut The skin was reapproximated then as well via subcutaneous closure The patient s sponge and needle counts found to be correct Uterus appeared to be normal prior to closure Bladder appeared to be normal The patient s blood loss is 600 cc Keywords surgery intrauterine growth rate charcot marie tooth disease amniocentesis c sections trial labor low transverse cervical cesarean section lysis of adhesions dissection bladder abdominal wall fascia hulka clips bilateral tubal occlusion intrauterine transverse uterus abdominal MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section Medical Specialty Surgery Sample Name Low Transverse C Section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Arrest of dilation POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Arrest of dilation PROCEDURE PERFORMED Primary low transverse cesarean section ANESTHESIA Epidural ESTIMATED BLOOD LOSS 1000 mL COMPLICATIONS None FINDINGS Female infant in cephalic presentation OP position weight 9 pounds 8 ounces Apgars were 9 at 1 minute and 9 at 5 minutes Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 20 year old gravida 1 para 0 female who presented to labor and delivery in early active labor at 40 and 6 7 weeks gestation The patient progressed to 8 cm at which time Pitocin was started She subsequently progressed to 9 cm but despite adequate contractions arrested dilation at 9 cm A decision was made to proceed with a primary low transverse cesarean section The procedure was described to the patient in detail including possible risks of bleeding infection injury to surrounding organs and possible need for further surgery Informed consent was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where epidural anesthesia was found to be adequate The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left ward tilt A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to elevate the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors Attention was then turned to the inferior aspect of the fascial incision which in similar fashion was grasped with Kocher clamps elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors The rectus muscles were dissected in the midline The peritoneum was bluntly dissected entered and extended superiorly and inferiorly with good visualization of the bladder The bladder blade was inserted The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors This incision was extended laterally and the bladder flap was created digitally The bladder blade was reinserted The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction Clear fluid was noted The infant was subsequently delivered atraumatically The nose and mouth were bulb suctioned The cord was clamped and cut The infant was subsequently handed to the awaiting nursery nurse Next cord blood was obtained per the patient s request for cord blood donation which took several minutes to perform Subsequent to the collection of this blood the placenta was removed spontaneously intact with a 3 vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic suture Hemostasis was visualized The uterus was returned to the abdomen The pelvis was copiously irrigated The uterine incision was reexamined and was noted to be hemostatic The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was closed with 0 Vicryl the subcutaneous layer was closed with 3 0 plain gut and the skin was closed with staples Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords surgery intrauterine pregnancy at term arrest of dilation cephalic presentation low transverse cesarean section cesarean section rectus muscles intrauterine MEDICAL_TRANSCRIPTION,Description VATS right middle lobectomy fiberoptic bronchoscopy mediastinal lymph node sampling tube thoracostomy x2 multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor Medical Specialty Surgery Sample Name Lobectomy VATS Transcription PREOPERATIVE DIAGNOSIS Right middle lobe lung cancer POSTOPERATIVE DIAGNOSIS Right middle lobe lung cancer PROCEDURES PERFORMED 1 VATS right middle lobectomy 2 Fiberoptic bronchoscopy thus before and after the procedure 3 Mediastinal lymph node sampling including levels 4R and 7 4 Tube thoracostomy x2 including a 19 French Blake and a 32 French chest tube 5 Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor ANESTHESIA General endotracheal anesthesia with double lumen endotracheal tube DISPOSITION OF SPECIMENS To pathology both for frozen and permanent analysis FINDINGS The right middle lobe tumor was adherent to the anterior chest wall The adhesion was taken down and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis The final frozen pathology on this entire area returned as negative for tumor Additional chest wall abnormalities were biopsied and sent for pathologic analysis and these all returned separately as negative for tumor and only fibrotic tissue Several other biopsies were taken and sent for permanent analysis of the chest wall All of the biopsy sites were additionally marked with Hemoclips The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe ESTIMATED BLOOD LOSS Less than 100 mL CONDITION OF THE PATIENT AFTER SURGERY Stable HISTORY OF PROCEDURE This patient is well known to our service He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control The patient was subsequently taken to the operating room on April 4 2007 was given general anesthesia and was endotracheally intubated without incident Although he had markedly difficult airway the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi No abnormalities were noted in the entire tracheobronchial tree and based on this the decision was made to proceed with the surgery The patient was kept in the supine position and the single lumen endotracheal tube was removed and a double lumen tube was placed Following this the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded Sterile DuraPrep preparation on the right chest was placed A sterile drape around that was also placed The table was flexed to open up the intercostal spaces A second bronchoscopy was performed to confirm placement of the double lumen endotracheal tube Marcaine was infused into all incision areas prior to making an incision The incisions for the VATS right middle lobectomy included a small 1 cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula The camera port was in the posterior axillary line in the eighth intercostal space through which a 5 mm 30 degree scope was used Third incision was an anterior port which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space and the third incision was a utility port which was a 4 cm long incision which was approximately one rib space below the superior pulmonary vein All of these incisions were eventually created during the procedure The initial incision was the camera port through which under direct visualization an additional small 5 mm port was created just inferior to the anterior port These two ports were used to identify the chest wall lesions which were initially thought to be metastatic lesions Multiple biopsies of the chest wall lesions were taken and the decision was made to also insert the auscultatory incision port Through these three incisions the initial working of the diagnostic portion of the chest wall lesion was performed Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative The right middle lobe was noted to be adherent to the anterior chest wall This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue but no tumor cells Based on this the decision was made to not proceed with chest wall resection and continue with right middle lobectomy Following this the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45 mm EndoGIA stapler Following division of the right superior pulmonary vein the right middle lobe bronchus was easily identified Initially this was thought to be the main right middle lobe bronchus but in fact it was the medial branch of the right middle lobe bronchus This was encircled and divided with a blue load stapler with a 45 mm EndoGIA Following division of this the pulmonary artery was easily identified Two branches of the pulmonary artery were noted to be going into the right middle lobe These were individually divided with a vascular load after encircling with a right angle clamp The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk and following this an additional branch of the bronchus was noted to be going to the right middle lobe A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus This was divided with a blue load stapler 45 mm EndoGIA Following division of this the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe Following complete division of the fissure the lobe was put into an EndoGIA bag and taken out through the utility port Following removal of the right middle lobe a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package Node station 8 or 9 nodes were easily identified therefore none were taken The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted A 19 French Blake was placed into the posterior apical position and a 32 French chest tube was placed in the anteroapical position Following this the patient s lung was allowed to reexpand fully and the patient was checked for air leaking once again Following this all the ports were closed with 2 0 Vicryl suture used for the deeper tissue and 3 0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4 0 Monocryl suture was used to close the skin in a running subcuticular fashion The patient tolerated the procedure well was extubated in the operating room and taken to the recovery room in stable condition Keywords surgery middle lobe endogia fiberoptic mediastinal lymph node vats bronchoscopy chest tube chest wall endotracheal tube endotracheally lobectomy lung cancer pneumonitis sampling thoracostomy utility port lumen endotracheal tube superior pulmonary vein chest wall lesions anterior chest wall middle lobectomy fiberoptic bronchoscopy anterior chest lymph node node port chest bronchus tumor pulmonary incision MEDICAL_TRANSCRIPTION,Description Right lower lobectomy right thoracotomy extensive lysis of adhesions mediastinal lymphadenectomy Medical Specialty Surgery Sample Name Lobectomy Lymphadenectomy Transcription PREOPERATIVE DIAGNOSIS Right lower lobe mass possible cancer POSTOPERATIVE DIAGNOSIS Non small cell carcinoma of the right lower lobe PROCEDURES 1 Right thoracotomy 2 Extensive lysis of adhesions 3 Right lower lobectomy 4 Mediastinal lymphadenectomy ANESTHESIA General DESCRIPTION OF THE PROCEDURE The patient was taken to the operating room and placed on the operating table in the supine position After an adequate general anesthesia was given she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion Lateral thoracotomy was performed on the right side anterior to the tip of the scapula and this was carried down through the subcutaneous tissue The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly The chest was entered through the fifth intercostal space A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection The right lower lobe was identified There was a large mass in the superior segment of the lobe which was very close to the right upper lobe and because of the adhesions it could not be told if the tumor was extending into the right upper lobe but it appeared that it did not Dissection was then performed at the lower lobe of the fissure and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe Then dissection of the hilum was performed and the branches of the pulmonary artery to the lower lobe were ligated with 2 0 silk freehand ties proximally and distally and 3 0 silk transfixion stitches and then transected The inferior pulmonary vein was dissected after dividing the ligament and it was stapled proximally and distally with a TA30 stapler and then transected Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected The bronchus was stapled with a TA30 bronchial stapler and then transected and the specimen was removed and sent to the Pathology Department for frozen section diagnosis The frozen section diagnosis was that of non small cell carcinoma bronchial margins free and pleural margins free The mediastinum was then explored No nodes were identified around the pulmonary ligament or around the esophagus Subcarinal nodes were dissected and hemostasis was obtained with clips The space below and above the osseous was opened and the station R4 nodes were dissected Hemostasis was obtained with clips and with electrocautery All nodal tissue were sent to Pathology as permanent specimen Following this the chest was thoroughly irrigated and aspirated Careful hemostasis was obtained and a couple of air leaks were controlled with 6 0 Prolene sutures Then two 28 French chest tubes were placed in the chest one posteriorly and one anteriorly and secured to the skin with 2 0 nylon stitches The incision was then closed with interrupted 2 0 Vicryl pericostal stitches A running 1 PDS on the muscle layer a running 2 0 PDS in the subcutaneous tissue and staples on the skin A sterile dressing was applied and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition ESTIMATED BLOOD LOSS 100 mL TRANSFUSIONS None COMPLICATIONS None CONDITION Condition of the patient on arrival to the intensive care unit was satisfactory Keywords surgery right lower lobe gia stapler mediastinal non small cell carcinoma cancer frozen section hilum lobectomy lymphadenectomy lysis of adhesions pleura thoracotomy upper lobe lower lobectomy adhesions chest MEDICAL_TRANSCRIPTION,Description Primary low segment cesarean section Medical Specialty Surgery Sample Name Low Segment C Section Transcription PREOPERATIVE DIAGNOSIS Pregnancy at 42 weeks nonreassuring fetal testing and failed induction POSTOPERATIVE DIAGNOSIS Pregnancy at 42 weeks nonreassuring fetal testing and failed induction PROCEDURE Primary low segment cesarean section The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia Bleeding points were snapped and coagulated along the way The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles These were divided in the midline revealing the peritoneum which was opened vertically The uterus was in mid position The bladder flap was incised elliptically and reflected caudad A low transverse hysterotomy incision was then constructed and extended bluntly Amniotomy revealed clear amniotic fluid A live born vigorous male infant was then delivered from the right occiput transverse position The infant breathed and cried spontaneously The nares and pharynx were suctioned The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team Cord blood samples were obtained The placenta was manually removed and the uterus was eventrated for closure The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two layer technique using 0 Vicryl suture with the second layer imbricating the first Hemostasis was completed with an additional figure of eight suture of 0 Vicryl The cornual sac and gutters were irrigated The uterus was returned to the abdominal cavity The adnexa were inspected and were normal The abdomen was then closed in layers Fascia was closed with running 0 Vicryl sutures subcutaneous tissue with running 3 0 plain Catgut and skin with 3 0 Monocryl subcuticular suture and Steri Strips Blood loss was estimated at 700 mL All counts were correct The patient tolerated the procedure well and left the operating room in excellent condition Keywords surgery nonreassuring fetal testing anterior rectus fascia pennington clamps fetal testing low segment induction suture MEDICAL_TRANSCRIPTION,Description Right upper lung lobectomy Mediastinal lymph node dissection Medical Specialty Surgery Sample Name Lobectomy Lymph Node Dissection Transcription OPERATION 1 Right upper lung lobectomy 2 Mediastinal lymph node dissection ANESTHESIA 1 General endotracheal anesthesia with dual lumen tube 2 Thoracic epidural OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered with a dual lumen tube Next the patient was placed in the left lateral decubitus position and his right chest was prepped and draped in the standard surgical fashion We used a 10 blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula Dissection was carried down in a muscle sparing fashion using Bovie electrocautery The 5th rib was counted and the 6th interspace was entered The lung was deflated We identified the major fissure We then began by freeing up the inferior pulmonary ligament which was done with Bovie electrocautery Next we used Bovie electrocautery to dissect the pleura off the lung The pulmonary artery branches to the right upper lobe of the lung were identified Of note was the fact that there was a visible approximately 4 x 4 cm mass in the right upper lobe of the lung without any other metastatic disease palpable As mentioned a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung Next we began by ligating the pulmonary artery branches of the right upper lobe of the lung This was done with suture ligature in combination with clips After taking the pulmonary artery branches of the right upper lobe of the lung we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung This likewise was ligated with a 0 silk It was stick tied with a 2 0 silk It was then divided Next we dissected out the bronchial branch to the right upper lobe of the lung A curved Glover was placed around the bronchus Next a TA 30 stapler was fired across the bronchus The bronchus was divided with a 10 blade scalpel The specimen was handed off We next performed a mediastinal lymph node dissection Clips were applied to the base of the feeding vessels to the lymph nodes We inspected for any signs of bleeding There was minimal bleeding We placed a 32 French anterior chest tube and a 32 French posterior chest tube The rib space was closed with 2 Vicryl in an interrupted figure of eight fashion A flat Jackson Pratt drain 10 in size was placed in the subcutaneous flap The muscle layer was closed with a combination of 2 0 Vicryl followed by 2 0 Vicryl followed by 4 0 Monocryl in a running subcuticular fashion Sterile dressing was applied The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords surgery mediastinal thoracic epidural lymph node dissection lymph node artery branches lobectomy lung anesthesia bovie electrocautery lymph pulmonary branches MEDICAL_TRANSCRIPTION,Description Left lower lobectomy Medical Specialty Surgery Sample Name Lobectomy Left Lower Transcription OPERATION Left lower lobectomy OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position After general endotracheal anesthesia was induced the appropriate monitoring devices were placed The patient was placed in the right lateral decubitus position The left chest and back were prepped and draped in a sterile fashion A right lateral thoracotomy incision was made Subcutaneous flaps were raised The anterior border of the latissimus dorsi was freed up and the muscle was retracted posteriorly The posterior border of the pectoralis was freed up and it was retracted anteriorly The 5th intercostal space was entered The inferior pulmonary ligament was then taken down with electrocautery The major fissure was then taken down and arteries identified The artery was dissected free and it was divided with an Endo GIA stapler The vein was then dissected free and divided with an Endo GIA stapler The bronchus was then cleaned of all nodal tissue A TA 30 green loaded stapler was then placed across this fired and main bronchus divided distal to the stapler Then the lobe was removed and sent to pathology where margins were found to be free of tumor Level 9 level 13 level 11 and level 6 nodes were taken for permanent cell specimen Hemostasis noted Posterior 28 French and anterior 24 French chest tubes were placed The wounds were closed with 2 Vicryl A subcutaneous drain was placed Subcutaneous tissue was closed with running 3 0 Dexon skin with running 4 0 Dexon subcuticular stitch Keywords surgery lower lobectomy electrocautery endo gia stapler subcutaneous drain endotracheal subcutaneous lobectomy MEDICAL_TRANSCRIPTION,Description Liposuction of the supraumbilical abdomen revision of right breast reconstruction excision of soft tissue fullness of the lateral abdomen and flank MEDICAL_TRANSCRIPTION,Description Closed reduction and placement of long arm cast Medical Specialty Surgery Sample Name Long Arm Cast Transcription PREOPERATIVE DIAGNOSIS Left distal radius fracture displaced POSTOPERATIVE DIAGNOSIS Left distal radius fracture displaced SURGERY Closed reduction and placement of long arm cast CPT code 25605 ANESTHESIA General LMA FINDINGS The patient was found to have a displaced fracture She was found to be in perfect alignment after closed reduction and placement of cast The radial deviation was well corrected INDICATIONS The patient is 5 years old She was seen in our office today 1 week after being placed into a cast for a displaced fracture She was noted to have significant loss of alignment especially on the lateral view She was indicated for closed reduction and placed of the long arm cast Risks and benefits were discussed at length with the family They wished to proceed PROCEDURE The patient was brought to the operating room and placed on the operating table in supine position General anesthesia was induced without incident Previous cast was previously removed An arm was approached and a closed reduction was performed This was checked under AP and lateral projection and was found to be in adequate alignment There was very mild residual dorsiflexion deformity noted A long arm cast was then placed with plaster and molding Repeat x rays demonstrated adequate alignment on both views The cast was then reinforced with fiberglass The patient was awakened from anesthesia and taken to recovery room in good condition There were no complications All instruments sponge and needle counts were correct at the end of case PLAN The patient will be discharged home She will return in 3 weeks for cast removal and clinical examination She would likely be placed into a wrist guard at that time She has a prescription for Tylenol with codeine elixir Keywords surgery long arm cast closed reduction displaced fracture radial deviation distal radius fracture arm cast MEDICAL_TRANSCRIPTION,Description Excision of lipoma left knee A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient s anteromedial left knee Medical Specialty Surgery Sample Name Lipoma Excision 1 Transcription PREOPERATIVE DIAGNOSIS Mass left knee POSTOPERATIVE DIAGNOSIS Lipoma left knee PROCEDURE PERFORMED Excision of lipoma left knee ANESTHESIA Local with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal GROSS FINDINGS A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient s anteromedial left knee HISTORY The patient is a 35 year old female with history of lump on her right knee for the past what she reports to be six years She states it had grow in size over the last six months rarely causes her any discomfort or pain denies any neurovascular complaints of her right lower extremity She denies any other lumps or bumps on her body She wishes to have this removed for cosmetic reasons PROCEDURE After all potential risks benefits and complications of the procedure were discussed with the patient informed consent was obtained She was transferred from the Preoperative Care Unit to Operating Suite 1 She was transferred from the gurney to the operating table All bony prominences were well padded A well padded tourniquet was applied to her right thigh Anesthesia then administered some sedation which she tolerated well Her right lower extremity was then sterilely prepped and draped in normal fashion Next a rubber Esmarch was used to exsanguinate her right lower extremity Next approximately 20 cc of 0 25 Marcaine with 1 lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass Next a 15 blade Bard Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass This was easily excised with blunt dissection Examination of the wound then revealed a second piece of fatty tissue which resembled a lipoma measuring approximately 1 5 cm x 2 cm This was then also excised utilizing Littler scissors Hemostasis was obtained The wound was then copiously irrigated after this all the underlying bone tissue was removed 2 0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing 4 0 horizontal mattress nylon sutures Sterile dressings was applied of Adaptic 4x4s and Kerlix as well as an Ace wrap Sedation was reversed Tourniquet was deflated The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition Her prognosis for this is good Keywords surgery excision of lipoma adipose tissue fatty tissue lipoma tissue knee MEDICAL_TRANSCRIPTION,Description Suction assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies Medical Specialty Surgery Sample Name Lipectomy Breast Transcription PREOPERATIVE DIAGNOSIS Mammary hypertrophy with breast ptosis POSTOPERATIVE DIAGNOSIS Mammary hypertrophy with breast ptosis OPERATION Suction assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in the supine position Under effects of general endotracheal anesthesia markings were made preoperatively for the mastopexy An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold A stab incision was made bilaterally and tumescent infiltration of anesthesia lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle 200 cc was infiltrated on each side This was followed by power assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4 mm cannula This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o clock position This would result in an elevation of the nipple areolar complex with transposition The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle Hemostasis was achieved with electrocautery After the epithelialization was performed on both sides nipple areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple areolar complex beneath the transposed nipple Closure was performed with interrupted 3 0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4 0 Monocryl suture Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing The patient tolerated the procedure well The patient was returned to recovery room in satisfactory condition Keywords surgery breast ptosis dermabond mammary hypertrophy monocryl anesthesia breast tissue endotracheal anesthesia lipectomy mastopexies mastopexy nipple nipple areolar complex suction assisted lipectomy nipple areolar complex lactated ringers nipple areolar areolar complex epithelialization areolar breast MEDICAL_TRANSCRIPTION,Description Intramuscular lipoma right upper extremity Excision of intramuscular lipoma with flap closure Medical Specialty Surgery Sample Name Lipoma Excision Transcription PREOPERATIVE DIAGNOSIS Mass lesion right upper extremity POSTOPERATIVE DIAGNOSIS Intramuscular lipoma right arm approximately 4 cm PROCEDURE PERFORMED Excision of intramuscular lipoma with flap closure by Dr Y INDICATIONS FOR PROCEDURE This is a 77 year old African American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid biceps region of the right upper extremity The mass has been increasing in size and symptoms according to the patient The risks and benefits of the surgical excision were discussed The patient gave informed consent for surgical removal GROSS FINDINGS At the time of surgery the patient was found to have intramuscular lipoma within the head of the biceps It was removed in its entirety and submitted to Pathology for appropriate analysis PROCEDURE The patient was taken to the operating room She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity The skin and subcutaneous tissue were incised as well as the muscular fascia The fibers of the biceps were divided bluntly and retracted The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures The mass was submitted to Pathology Good hemostasis was seen The wound was irrigated and closed in layers The deep muscular fascia was reapproximated with 2 0 Vicryl suture The subcutaneous tissues were reapproximated with 3 0 Vicryl suture and the deep dermis was reapproximated with 3 0 Vicryl suture Re approximated wound flaps without tension and the skin was closed with 4 0 undyed Vicryl in running subcuticular fashion The patient was given wound care instructions and will follow up again in my office in one week Overall prognosis is good Keywords surgery excision mass lesion intramuscular muscular fascia vicryl suture intramuscular lipoma suture mass lipoma MEDICAL_TRANSCRIPTION,Description Percutaneous liver biopsy With the patient lying in the supine position and the right hand underneath the head an area of maximal dullness was identified in the mid axillary location by percussion Medical Specialty Surgery Sample Name Liver Biopsy Transcription TITLE OF PROCEDURE Percutaneous liver biopsy ANALGESIA 2 Lidocaine ALLERGIES The patient denied any allergy to iodine lidocaine or codeine PROCEDURE IN DETAIL The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today The patient was told of complications which might occur consisting of bleeding bile peritonitis bowel perforation pneumothorax or death The risks and benefits of the procedure were understood and the patient signed the consent form freely With the patient lying in the supine position and the right hand underneath the head an area of maximal dullness was identified in the mid axillary location by percussion The area was prepped and cleaned with povidone iodine following which the skin subcutaneous tissue and serosal surfaces were infiltrated with 2 lidocaine down to the capsule of the liver Next a small incision was made with a Bard Parker 11 scalpel A 16 gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration Liver cores measuring cm were obtained and will be sent to Pathology for routine histologic study POST PROCEDURE COURSE AND DISPOSITION The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication Normal activities can be resumed tomorrow The patient is to contact me if severe abdominal or chest pain fever melena light headedness or any unusual symptoms develop An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made COMPLICATIONS None RECOMMENDATIONS Prior to discharge hepatitis A and B vaccines will be recommended Risks and benefits for vaccination have been addressed and the patient will consider this option Keywords surgery bile peritonitis bowel perforation pneumothorax klatskin needle mid axillary liver biopsy percutaneous lidocaine biopsy liver MEDICAL_TRANSCRIPTION,Description Suction assisted lipectomy lipodystrophy of the abdomen and thighs Medical Specialty Surgery Sample Name Lipectomy Abdomen Thighs Transcription PREOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs POSTOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs OPERATION Suction assisted lipectomy ANESTHESIA General FINDINGS AND PROCEDURE With the patient under satisfactory general endotracheal anesthesia the entire abdomen flanks perineum and thighs to the knees were prepped and draped circumferentially in sterile fashion After this had been completed a 15 blade was used to make small stab wounds in the lateral hips the pubic area and upper edge of the umbilicus Through these small incisions a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen A 3 and 4 mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate which was mostly fat little fluid and blood Attention was then directed to the thighs both inner and outer A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs After this had been completed 3 and 4 mm cannulas were used to suction 650 cc from each side approximately 50 cc in the inner thigh and 600 on each lateral thigh The patient tolerated the procedure very well All of this aspirate was mostly fat with little fluid and very little blood Wounds were cleaned and steri stripped and dressing of ABD pads and was then applied The patient tolerated the procedure very well and was sent to the recovery room in good condition Keywords surgery lipodystrophy abd pads suction assisted lipectomy abdomen aspirate lipectomy perineum steri stripped thighs umbilicus abdomen and thighs abdomen thighs MEDICAL_TRANSCRIPTION,Description Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon a 40 mm bioabsorbable femoral pin and a 9 mm bioabsorbable tibial pin Repair of lateral meniscus using two fast fixed meniscal repair sutures Partial medial meniscectomy Partial chondroplasty of patella Lateral retinacular release Open medial plication as well of the right knee Medical Specialty Surgery Sample Name Ligament Reconstruction Meniscus Repair Transcription PREOPERATIVE DIAGNOSES 1 Torn anterior cruciate ligament right knee 2 Patellofemoral instability right knee 3 Possible torn medial meniscus POSTOPERATIVE DIAGNOSES 1 Complete tear anterior cruciate ligament right knee 2 Complex tear of the posterior horn lateral meniscus 3 Tear of posterior horn medial meniscus 4 Patellofemoral instability 5 Chondromalacia patella PROCEDURES PERFORMED 1 Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon a 40 mm bioabsorbable femoral pin and a 9 mm bioabsorbable tibial pin 2 Repair of lateral meniscus using two fast fixed meniscal repair sutures 3 Partial medial meniscectomy 4 Partial chondroplasty of patella 5 Lateral retinacular release 6 Open medial plication as well of the right knee ANESTHESIA General COMPLICATIONS None TOURNIQUET TIME 130 minutes at 325 mmHg INTRAOPERATIVE FINDINGS There was noted to be a grade II chondromalacia patellofemoral joint The patella was noted to be situated laterally past the lateral femoral condyle There was a tear to the posterior horn of the medial meniscus within the white zone There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus There was a complete tear of the anterior cruciate ligament The posterior cruciate ligament appeared intact Preoperatively she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability HISTORY This is a 39 year old female who has sustained a twisting injury to her knee while on trampoline in late August She was diagnosed per MRI An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint All risks and benefits of surgery were discussed with her at length She was in agreement with the treatment plan PROCEDURE On 09 11 03 she was taken to the operating room at ABCD General Hospital She was placed supine on the operating table General anesthetic was applied by the Anesthesiology Department Tourniquet was placed on the proximal thigh and it was then placed in a knee holder She was sterilely prepped and draped in the usual fashion An Esmarch was used to exsanguinate the lower extremity Tourniquet was inflated to 325 mmHg Longitudinal incision was made just medial to the tibial tubercle The subcutaneous tissue was carefully dissected Hemostasis was controlled with electrocautery The tendons of gracilis and semitendinosus were identified and isolated and then stripped off the musculotendinous junction They were taken on the back table The soft tissue debris was removed from the tendons The ends of the tendons were sewn together using 5 Tycron whip type sutures The tendons were measured on back table and found to be 8 mm as the most adequate size they were then placed under tension on the back table Stab incision was made in the inferolateral parapatellar region through this camera was placed in the knee The knee was inflated with saline solution and operative pictures were obtained The above findings were noted A second port site was initiated in the inferomedial parapatellar region Through this a probe was placed Tear in the posterior horn medial meniscus was identified It was resected using a meniscal resector It was then further contoured using arthroscopic shaver Attention was then taken to the lateral compartment A partial meniscectomy was performed using the resector and the shaver The posterior periphery of the lateral meniscus was also noticed to be unstable A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon There was noted to be excellent fixation The shaver was then taken into the intrachondral notch First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint Next the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle Next a tibial guide was placed through the anterior medial portal A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament This tibial tunnel was then drilled using 8 mm cannulated drill Next an over the top guide was then placed at approximately the 11 30 position A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm Next the U shape guide was placed through tibial tunnel into the femur A pin was then placed through the distal femur from lateral to medial through the U shaped guide a puller wire was then passed through the distal femur It was then pulled out through the tibial tunnel using the You shaped guide The tendon was then placed around the wire The wire was pulled back up through the tibial into the femoral tunnel A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons Attention was then pulled through the tibial tunnel The knee was cycled approximately 20 times A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft There was noted definite fixation of the graft There was no evidence of impingement either in full flexion or full extension The knee was copiously irrigated and it was then suctioned dry A longitudinal incision was made just medial to the patellofemoral joint Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision Following this a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication The medial retinaculum was then plicated using 1 Ethibond sutures and then oversewn with 0 Vicryl suture The subcuticular tissues were reapproximated with 2 0 Vicryl simple interrupted sutures followed by a 4 0 PDS running subcuticular stitch She was placed in a DonJoy knee immobilizer The tourniquet was deflated It was noted the lower extremity was warm and pink with good capillary refill She was transferred to the recovery room in apparent stable and satisfactory condition Prognosis for this patient is guarded She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension She may remove her dressing two to three days however follow back in the office in 10 to 14 days for suture removal She will require one to two more physical therapy to help regain motion and strength to the lower extremity Keywords MEDICAL_TRANSCRIPTION,Description Ligament reconstruction and tendon interposition arthroplasty of right wrist Medical Specialty Surgery Sample Name Ligament Reconstruction Tendon Interposition Arthroplasty Transcription OPERATION PERFORMED Ligament reconstruction and tendon interposition arthroplasty of right wrist DESCRIPTION OF PROCEDURE With the patient under adequate anesthesia the right upper extremity was prepped and draped in a sterile manner Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field Further blunt dissection exposed the radial artery which was dissected and retracted off the trapezium An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint Sharp dissection exposed the trapezium which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon The radial beak of the trapezoid was then osteotomized off the head of the scaphoid The proximal metacarpal was then fenestrated with a 4 5 mm drill bit Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision The FCR tendon was divided and this incision was closed with 4 0 nylon sutures Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound The FCR tendon was then threaded through the fenestration in the metacarpal A bone anchor was then placed distal to the metacarpal fenestration The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect The MP joint was brought into extension and the capsule closed using interrupted 3 0 Tycron sutures Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0 035 Kirschner wire The pin was cut at the level of the skin All incisions were closed with running 3 0 Prolene subcuticular stitch Sterile dressings were then applied The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords surgery arthroplasty ligament tendon fcr tendon interposition arthroplasty ligament reconstruction reconstruction trapezium metacarpal joint interposition MEDICAL_TRANSCRIPTION,Description Repair of upper lid canalicular laceration Sample Template Medical Specialty Surgery Sample Name Lid Laceration Repair Transcription PREOPERATIVE DIAGNOSES 1 XXX upper lid laceration 2 XXX upper lid canalicular laceration POSTOPERATIVE DIAGNOSES 1 XXX upper lid laceration 2 XXX upper lid canalicular laceration PROCEDURES 1 Repair of XXX upper lid laceration 2 Repair of XXX upper lid canalicular laceration ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with XXX eye upper eyelid laceration involving the canaliculus PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient was brought to the operating room and placed in the supine position where s he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery once the appropriate cardiac and respiratory monitoring was placed on him her and once general endotracheal anesthetic had been administered The patient then had the wound freshened up with Westcott scissors and cotton tip applications Hemostasis was achieved with a high temp disposable cautery Once this had been done the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene The proximal end was then found and this was intubated with the same tubing system Then two 6 0 Vicryl sutures were used to reapproximate the medial canthal tendon Once this had been done the skin was reapproximated with interrupted 6 0 Vicryl sutures and interrupted 6 0 plain gut sutures To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater and the tube was cut short The patient s nose was suctioned of blood and s he was awakened from general endotracheal anesthesia and did well S he left the operating room in good condition Keywords surgery laceration monoka tube westcott scissors bleeding canalicular laceration canthal tendon cotton tip infection lid lid canalicular system lid laceration loss of the eye loss of vision ophthalmic plastic reconstructive surgery re operation upper lid lid laceration repair laceration repair lid canalicular canalicular MEDICAL_TRANSCRIPTION,Description Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping Hoarseness bilateral true vocal cord lesions and leukoplakia Medical Specialty Surgery Sample Name Laryngoscopy Vocal Cord Biopsy Transcription PREOPERATIVE DIAGNOSES 1 Hoarseness 2 Bilateral true vocal cord lesions 3 Leukoplakia POSTOPERATIVE DIAGNOSES 1 Hoarseness 2 Bilateral true vocal cord lesions 3 Leukoplakia PROCEDURE PERFORMED Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 33 year old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office Discussed risks complications and consequences of a surgical biopsy of the left true vocal cord and consent was obtained PROCEDURE The patient was brought to operative suite by anesthesia placed on the operating table in supine position After this the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg After this a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient s oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx The patient s larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one third up to the anterior third The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region The patient s anterior commissure appeared to be clear The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord Once the true vocal cord was retracted laterally there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one third aspect The patient s subglottic region was very edematous and with redundant mucosal tissue The areas of leukoplakia appeared to be cobblestoned in appearance irregularly bordered and very hard to the touch The left true vocal cord was then first addressed was stripped from posteriorly to anteriorly utilizing a 45 laryngeal forceps After this the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis The specimen was passed off the field and was sent to Pathology for evaluation Hemostasis was maintained on the left side Prior to taking this biopsy the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand The Zeiss operating microscope was then brought into view to directly visualize the vocal cords The biopsies were taken under direct visualization utilizing the Zeiss operating microscope After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed the scope was then pulled more cephalad and the piriform sinuses valecula and base of the tongue were all directly visualized which appeared normal except for the left base of tongue appeared to be full This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions A bimanual examination was then performed which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions There were no signs of any palpable cervical lymphadenopathy The tooth guard was removed and the patient was then turned back to anesthesia The patient did receive intraoperatively 10 mg of Decadron The patient tolerated the procedure well and was extubated in the operating room The patient was transferred to recovery room in stable condition and tolerated the procedure well The patient will be sent home with prescriptions for Medrol DOSEPAK Tylenol with Codeine Elixir and amoxicillin 250 mg per 5 cc Keywords surgery direct laryngoscopy zeiss operating microscope vocal cord lesions vocal cord cord vocal microscopic laryngoscopy hoarseness biopsy leukoplakia MEDICAL_TRANSCRIPTION,Description Lateral release with lengthening of the ECRB tendon Lateral epicondylitis Medical Specialty Surgery Sample Name Lateral Epicondylitis Release Transcription PREOPERATIVE DIAGNOSIS Lateral epicondylitis Keywords surgery lateral release ecrb tendon ecrl lateral epicondylitis tourniquet aponeurosis epicondyle antebrachial epicondylitis dissection extensor ecrb MEDICAL_TRANSCRIPTION,Description The patient needing to be reintubated due to a leaking ET tube The patient is recently postoperative Medical Specialty Surgery Sample Name Leaking ET tube Transcription ASSESSMENT The patient needed reintubation due to a leaking tube I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure Using Versed and succinylcholine we were able to sedate and paralyze him to perform the procedure His potassium this morning was normal Using an 8 5 ET tube under direct visualization the tube was passed through the cords The patient tolerated the procedure extremely well Auscultation of the lungs revealed bilateral equal breath sounds Chest x ray is pending CO2 monitor was positive Keywords surgery et tube reintubated postoperative leakingNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cystopyelogram and laser vaporization of the prostate Medical Specialty Surgery Sample Name Laser Vaporization of Prostate Transcription PREOPERATIVE DIAGNOSIS Benign prostatic hypertrophy POSTOPERATIVE DIAGNOSIS Benign prostatic hypertrophy SURGERY Cystopyelogram and laser vaporization of the prostate ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 67 year old male with a history of TURP presented to us with urgency frequency and dribbling The patient was started on alpha blockers with some help but had nocturia q 1h The patient was given anticholinergics with minimal to no help The patient had a cystoscopy done which showed enlargement of the left lateral lobes of the prostate At this point options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream Continuation of alpha blockers and adding another anti cholinergic at night to prevent bladder overactivity were discussed The patient was told that his symptoms may be related to the mild to moderate trabeculation in the bladder which can cause poor compliance The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream which in turn might help improve emptying of the bladder and might help his overactivity of the bladder The patient was told that he may need anticholinergics There could be increased risk of incontinence stricture erectile dysfunction other complications and the consent was obtained PROCEDURE IN DETAIL The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient was given preoperative antibiotics The patient was prepped and draped in the usual sterile fashion A 23 French scope was inserted inside the urethra into the bladder under direct vision Bilateral pyelograms were normal The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder There was enlargement of the lateral lobes of the prostate The old TUR scar was visualized right at the bladder neck Using diode side firing fiber the lateral lobes were taken down The verumontanum the external sphincter and the ureteral openings were all intact at the end of the procedure Pictures were taken and were shown to the family At the end of the procedure there was good hemostasis A total of about 15 to 20 minutes of lasering time was used A 22 3 way catheter was placed At the end of the procedure the patient was brought to recovery in stable condition Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night Keywords surgery laser vaporization of the prostate cystopyelogram benign prostatic hypertroph benign prostatic hypertrophy alpha blockers laser vaporization anticholinergics laser vaporization prostate bladder MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis Medical Specialty Surgery Sample Name Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis POSTOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis OPERATION PREFORMED Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis INDICATIONS FOR THE SURGERY The patient is a 76 year old white female with a history of subglottic upper tracheal stenosis She has had undergone multiple previous endoscopic procedures in the past last procedure was in January 2007 She returns with some increasing shortness of breath and dyspnea on exertion Endoscopic reevaluation is offered to her The patient has been considering laryngotracheal reconstruction however due to a recent death in the family she has postponed this but she has been having increasing symptoms An endoscopic treatment was offered to her Nature of the proposed procedure including risks and complications involving bleeding infection alteration of voice speech or swallowing hoarseness changing permanently recurrence of stenosis despite a surgical intervention airway obstruction necessitating a tracheostomy now or in the future cardiorespiratory and anesthetic risks were all discussed in length The patient states she understood and wished to proceed DESCRIPTION OF THE OPERATION The patient was taken to the operating room placed on table in supine position Following adequate general anesthesia the patient was prepared for endoscopy The top sliding laryngoscope was then inserted in the oral cavity pharynx and larynx examined In the oral cavity she had good dentition Tongue and buccal cavity mucosa were without ulcers masses or lesions The oropharynx was clear The larynx was then manually suspended Epiglottis area epiglottic folds false cords true vocal folds with some mild edema but otherwise without ulcers masses or lesions and the supraglottic and glottic airway were widely patent The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds At the base of the subglottis there was a narrowing and in the upper trachea restenosis had occurred Moderate amount of mucoid secretions these were suctioned following which the area of stenosis was dilated Remainder of the bronchi was then examined The mid and distal trachea were widely patent Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers lesions or evidence of scarring The scope was pulled back and removed and following this a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out Once this had been completed dramatic improvement in the subglottic upper tracheal airway accomplished Instrumentation was removed and a 6 endotracheal tube uncuffed was placed to allow smooth emerge from anesthesia The patient tolerated the procedure well without complication Keywords surgery stenosis epiglottis subglottic bronchoscope bronchoscopy endoscopic laryngoscopy laryngotracheal reconstruction larynx oral cavity pharynx tracheal true vocal folds vocal upper tracheal stenosis subglottic upper tracheal subglottic upper upper tracheal airway cavity patent MEDICAL_TRANSCRIPTION,Description Left orchiectomy scrotal exploration right orchidopexy Medical Specialty Surgery Sample Name Left Orchiectomy Right Orchidopexy Transcription PREOPERATIVE DIAGNOSIS Left testicular torsion POSTOPERATIVE DIAGNOSES 1 Left testicular torsion 2 Left testicular abscess 3 Necrotic testes SURGERY Left orchiectomy scrotal exploration right orchidopexy DRAINS Penrose drain on the left hemiscrotum The patient was given vancomycin Zosyn and Levaquin preop BRIEF HISTORY The patient is a 49 year old male who came into the emergency room with 2 week history of left testicular pain scrotal swelling elevated white count of 39 000 The patient had significant scrotal swelling and pain Ultrasound revealed necrotic testicle Options such as watchful waiting and removal of the testicle were discussed Due to elevated white count the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis The risks of anesthesia bleeding infection pain MI DVT PE scrotal issues other complications were discussed The patient was told about the morbidity and mortality of the procedure and wanted to proceed PROCEDURE IN DETAIL The patient was brought to the OR Anesthesia was applied The patient was prepped and draped in usual sterile fashion A midline scrotal incision was made There was very very thick scrotal skin There was no necrotic skin As soon as the left hemiscrotum was entered significant amount of pus poured out of the left hemiscrotum The testicle was completely filled with pus and had completely disintegrated with pus The pus just poured out of the left testicle The left testicle was completely removed Debridement was done of the scrotal wall to remove any necrotic tissue Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum There was good tissue left after all the irrigation and debridement A Penrose drain was placed in the bottom of the left hemiscrotum I worried about the patient may have torsed and then the testicle became necrotic so the plan was to pex the right testicle plus the right side also appeared very abnormal So the right hemiscrotum was opened The testicle had significant amount of swelling and scrotal wall was very thick The testicle appeared normal There was no pus coming out of the right hemiscrotum At this time a decision was made to place 4 0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion The hemiscrotum was closed using 2 0 Vicryl in interrupted stitches and the skin was closed using 2 0 PDS in horizontal mattress There was very minimal pus left behind and the skin was very healthy Decision was made to close it to help the patient heal better in the long run The patient was brought to the recovery in stable condition Keywords surgery testicular abscess necrotic testes orchiectomy scrotal exploration orchidopexy hemiscrotum testicular torsion penrose drain scrotal swelling scrotal wall testicle torsion MEDICAL_TRANSCRIPTION,Description Carbon dioxide laser photo ablation due to recurrent dysplasia of vulva Medical Specialty Surgery Sample Name Laser of Vulva Transcription PREOPERATIVE DIAGNOSIS Recurrent dysplasia of vulva POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Carbon dioxide laser photo ablation ANESTHESIA General laryngeal mask INDICATIONS FOR PROCEDURE The patient has a past history of recurrent vulvar dysplasia She has had multiple prior procedures for treatment She was counseled to undergo laser photo ablation FINDINGS Examination under anesthesia revealed several slightly raised and pigmented lesions predominantly on the left labia and perianal regions After staining with acetic acid several additional areas of acetowhite epithelium were seen on both sides and in the perianal region PROCEDURE The patient was brought to the operating room with an IV in place Anesthetic was administered after which she was placed in the lithotomy position Examination under anesthesia was performed after which she was prepped and draped Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid Setting was 25 watts using a 6 mm pattern size with the silk touch hand piece in the paint mode Excellent hemostasis was noted and Bacitracin was applied prophylactically The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords surgery laser of vulva recurrent dysplasia carbon dioxide laser photo ablation recurrent dysplasia of vulva dysplasia of vulva carbon dioxide laser photo ablation carbon dysplasia laser ablation MEDICAL_TRANSCRIPTION,Description LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh Medical Specialty Surgery Sample Name LEEP Transcription DIAGNOSIS 1 Broad based endocervical poly 2 Broad based pigmented raised nevus right thigh OPERATION 1 LEEP procedure of endocervical polyp 2 Electrical excision of pigmented mole of inner right thigh FINDINGS There was a 1 5 x 1 5 cm broad based pigmented nevus on the inner thigh that was excised with a wire loop Also there was a butt based 1 cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal PROCEDURE With the patient in the supine position general anesthesia was administered The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion An insulated posterior weighted retractor was put in Using the LEEP tenaculum we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting 30 coagulation The endocervical polyp on the posterior lip of the cervix was excised Then changing from a 50 of coagulation and 5 cutting the base of the polyp was electrocoagulated which controlled all the bleeding The wire loop was attached and the pigmented raised nevus on the inner thigh was excised with the wire loop Cautery of the base was done and then it was closed with figure of eight 3 0 Vicryl sutures A band aid was applied over this Rechecking the cervix no bleeding was noted The patient was laid flat on the table awakened and moved to the recovery room bed and sent to the recovery room in satisfactory condition Keywords surgery endocervical polyp pigmented mole polyp leep tenaculum leep cervix endocervical pigmented MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of the larynx Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy Medical Specialty Surgery Sample Name Laryngectomy Thyroid Lobectomy Transcription TITLE OF OPERATION Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy INDICATION FOR SURGERY A 58 year old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06 07 Subsequently biopsy confirmed tumor persistence in the right glottic region Risks benefits and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks benefits and alternatives He was accompanied by his wife and daughter Risks included but were not limited to anesthesia bleeding infection injury of the nerves including lower lip weakness tongue weakness tongue numbness shoulder weakness need for physical therapy possibility of total laryngectomy possibility of inability to speak or swallow difficulty eating wound care issues failure to heal need for additional treatment and the patient understood all of these issues and they wished to proceed PREOP DIAGNOSIS Squamous cell carcinoma of the larynx POSTOP DIAGNOSIS Squamous cell carcinoma of the larynx PROCEDURE DETAIL After identifying the patient the patient was placed supine on the operating room table After the establishment of the general anesthesia via oral endotracheal intubation the patient had his eyes protected with Tegaderm A 6 endotracheal tube was placed initially Direct laryngoscopy was performed with a Lindholm laryngoscope A 0 degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis Subsequently a decision was then made to go ahead and perform the surgical intervention A hemi apron incision was employed and 1 lidocaine with 1 100 000 epinephrine was injected A shoulder roll was applied after the patient was prepped and draped in a sterile fashion Subsequently a hemi apron incision was performed Subplatysmal flaps were raised at the hyoid bone into the clavicle Attention was then turned to the right side where a level 2 3 4 neck dissection was performed Submandibular fascia was appreciated inferiorly along the submandibular gland this was incised allowing for identification of the digastric muscle Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified Level 2A contents were then dissected off the floor of the neck including levels 3 and 4 Preservation of the phrenic nerve was obtained by identification and subsequently cross clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4 The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve Levels 2 3 4 neck dissection specimens were then labeled appropriately attached with staples and sent for histopathological evaluation Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed Subsequently the strap muscles were separated in the midline The trachea was identified in the midline The thyroid isthmus was plicated using the Harmonic scalpel and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage Once this was performed sinuses were mobilized from the thyroid cartilage both on the right and left side respectively The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular Attention was then turned to performing a cricothyrotomy Upon performing this it was obvious that there was tumor just above the level of the cricothyrotomy incision A 7 anode tube was then placed in this area and secured Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis Subsequently the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage and the thyroid cartilage was then intentionally fractured along the anterior spine It was evident that this tumor had extended more than 1 cm into the subglottic region Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly though it was evident that the cricoid cartilage was invaded Frozen section biopsy then confirmed this finding as read by Dr X of Surgical Pathology In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage the patient s case was then converted into a total laryngectomy Subsequently the trachea was transected at the level 3 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3 0 vertical mattress sutures for the skin A W plasty was also performed to allow for enlargement of the stoma Attention was then turned to identifying the common parting wall of the trachea and the esophagus Attention was then turned to resecting the hyoid bone The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism The wound was copiously irrigated Subsequently a tracheoesophageal puncture site was performed using a right angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect Once this was performed a running 3 0 canal stitch was used to close the pharynx Subsequently interrupted 4 0 chromic stitches were then used as reinforcement line from superior to inferior and fibrin glue was applied Two 10 JP drains were placed on the right side and one on the left side and secured appropriately with 3 0 nylon The wound was then closed using interrupted 3 0 Vicryl for the platysma and staples for the skin The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later Keywords surgery laryngectomy neck dissection tracheoesophageal cricopharyngeal myotomy thyroid lobectomy squamous cell carcinoma larynx thyroid cartilage cricoid cartilage total laryngectomy thyroid cartilage MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy and right salpingectomy Medical Specialty Surgery Sample Name Laparotomy Salpingectomy Transcription PREOPERATIVE DIAGNOSES 1 Right ectopic pregnancy 2 Severe abdominal pain 3 Tachycardia POSTOPERATIVE DIAGNOSES 1 Right ectopic pregnancy 2 Severe abdominal pain 3 Tachycardia PROCEDURE PERFORMED Exploratory laparotomy and right salpingectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 200 mL COMPLICATIONS None FINDINGS Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity Normal appearing ovaries bilaterally normal appearing left fallopian tube and normal appearing uterus INDICATIONS The patient is a 23 year old gravida P2 P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08 08 and treated appropriately and adequately with methotrexate Evaluation in the emergency room reveals a second right ectopic pregnancy Her beta quant was found to be approximately 13 000 The ultrasound showed right adnexal mass with crown rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy The procedure was discussed with the patient in detail including risks of bleeding infection injury to surrounding organs and possible need for further surgery Informed consult was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where general anesthesia was administered without difficulty The patient was prepped and draped in the usual sterile fashion A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to grasp the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors attention was then turned to the inferior aspect which was grasped with Kocher clamps elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors The rectus muscles were dissected in the midline The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder At this time the blood found in the abdomen was suctioned The bowel was packed with moist laparotomy sponge The right ectopic pregnancy was identified The fallopian tube was clamped x2 excised and ligated x2 using 0 Vicryl suture Hemostasis was visualized At this time the left tube and ovary were examined and were found to be normal in appearance The pelvis was cleared off clots and was copiously irrigated The fallopian tube was reexamined and it was noted to be hemostatic At this time the laparotomy sponges were removed The rectus muscles were reapproximated using 3 0 Vicryl The fascia was reapproximated with 0 Vicryl sutures The subcutaneous layer was closed with 3 0 plain gut The skin was closed with 4 0 Monocryl Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords surgery ectopic pregnancy salpingectomy exploratory laparotomy fallopian tube mayo scissors rectus muscles MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and rigid sigmoidoscopy Acute pain fever postoperatively hemostatic uterine perforation no bowel or vascular trauma Medical Specialty Surgery Sample Name Laparoscopy Sigmoidoscopy Transcription PREOPERATIVE DIAGNOSES 1 Acute pain 2 Fever postoperatively POSTOPERATIVE DIAGNOSIS 1 Acute pain 2 Fever postoperatively 3 Hemostatic uterine perforation 4 No bowel or vascular trauma PROCEDURE PERFORMED 1 Diagnostic laparoscopy 2 Rigid sigmoidoscopy by Dr X ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Scant SPECIMEN None INDICATIONS This is a 17 year old African American female gravida 1 para 1 and had a hysteroscopy and dilation curettage on 09 05 03 The patient presented later that evening after having increasing abdominal pain fever and chills at home with a temperature up to 101 2 The patient denied any nausea vomiting or diarrhea She does complain of some frequent urination Her vaginal bleeding is minimal FINDINGS On bimanual exam the uterus is approximately 6 week size anteverted and freely mobile with no adnexal masses appreciated On laparoscopic exam there is a small hemostatic perforation noted on the left posterior aspect of the uterus There is approximately 40 cc of serosanguineous fluid in the posterior cul de sac The bilateral tubes and ovaries appeared normal There is no evidence of endometriosis in the posterior cul de sac or along the bladder flap There is no evidence of injury to the bowel or pelvic sidewall The liver margin gallbladder and remainder of the bowel including the appendix appeared normal PROCEDURE After consent was obtained the patient was taken to the Operating Room where general anesthetic was administered The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion A sterile speculum was placed in the patient s vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterine manipulator was then placed into the patient s cervix and the vulsellum tenaculum and sterile speculum were removed Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made Veress needle was placed through this incision and the gas turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate A 11 mm trocar was then placed through this incision The camera was placed with the above findings noted A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs The serosanguineous fluid of the cul de sac was aspirated and the pelvis was copiously irrigated with sterile saline At this point Dr X was consulted He performed a rigid sigmoidoscopy please see his dictation for further details There does not appear to be any evidence of colonic injury The saline in the pelvis was then suctioned out using Nezhat Dorsey All instruments were removed The 5 mm trocar was removed under direct visualization with excellent hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar removed The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of 0 25 Marcaine was injected into the incision sites for postoperative pain relief Steri Strips were then placed across the incision The uterine manipulator was then removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of the procedure The patient was taken to the recovery room in satisfactory condition She will be followed immediately postoperatively within the hospital and started on IV antibiotics Keywords surgery uterine perforation vascular bowel diagnostic laparoscopy vulsellum tenaculum uterine manipulator excellent hemostasis rigid sigmoidoscopy laparoscopy sigmoidoscopy postoperatively trocar MEDICAL_TRANSCRIPTION,Description Laparoscopy laparotomy cholecystectomy with operative cholangiogram choledocholithotomy with operative choledochoscopy and T tube drainage of the common bile duct Medical Specialty Surgery Sample Name Laparoscopy Laparotomy Cholecystectomy Transcription PREOPERATIVE DIAGNOSES Cholelithiasis cholecystitis and recurrent biliary colic POSTOPERATIVE DIAGNOSES Severe cholecystitis cholelithiasis choledocholithiasis and morbid obesity PROCEDURES PERFORMED Laparoscopy laparotomy cholecystectomy with operative cholangiogram choledocholithotomy with operative choledochoscopy and T tube drainage of the common bile duct ANESTHESIA General INDICATIONS This is a 63 year old white male patient with multiple medical problems including hypertension diabetes end stage renal disease coronary artery disease and the patient is on hemodialysis who has had recurrent episodes of epigastric right upper quadrant pain The patient was found to have cholelithiasis on last admission He was being worked up for this including cardiac clearance However in the interim he returned again with another episode of same pain The patient had a HIDA scan done yesterday which shows nonvisualization of the gallbladder consistent with cystic duct obstruction Because of these laparoscopic cholecystectomy was advised with cholangiogram Possibility of open laparotomy and open procedure was also explained to the patient The procedure indications risks and alternatives were discussed with the patient in detail and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was put in supine position on the operating table under satisfactory general anesthesia The entire abdomen was prepped and draped A small transverse incision was made about 2 1 2 inches above the umbilicus in the midline under local anesthesia The patient has a rather long torso Fascia was opened vertically and stay sutures were placed in the fascia Peritoneal cavity was carefully entered Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2 Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area The patient was placed in reverse Trendelenburg and rotated to the left An 11 mm trocar was placed in the subxiphoid space and two 5 mm in the right subcostal region Slowly the dissection was carried out in the right subhepatic area Initially I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver Then some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection inflammation The visualization was extremely difficult because of the patient s obesity and a lot of fat intra abdominally although his abdominal wall is not that thick After evaluating this for a little while we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy The trocars were removed A right subcostal incision was made and peritoneal cavity was entered A Bookwalter retractor was put in place The dissection was then carried out on the undersurface of the liver Eventually the gallbladder was identified which was markedly scarred down and shrunk and appeared to have palpable stone in it Dissection was further carried down to what was felt to be the common bile duct which appeared to be somewhat larger than normal about a centimeter in size The duodenum was kocherized The gallbladder was partly intrahepatic Because of this I decided not to dig it out of the liver bed causing further bleeding and problem The inferior wall of the gallbladder was opened and two large stones one was about 3 cm long and another one about 1 5 x 2 cm long were taken out of the gallbladder It was difficult to tell where the cystic duct was Eventually after probing near the neck of the gallbladder I did find the cystic duct which was relatively very short Intraoperative cystic duct cholangiogram was done using C arm fluoroscopy This showed a rounded density at the lower end of the bile duct consistent with the stone At this time a decision was made to proceed with common duct exploration The common duct was opened between stay sutures of 4 0 Vicryl and immediately essentially clear bile came out After some pressing over the head of the pancreas through a kocherized maneuver the stone did fall into the opening in the common bile duct So it was about a 1 cm size stone which was removed Following this a 10 French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously No further stones were obtained The catheter went easily into the duodenum through the ampulla of Vater At this point a choledochoscope was inserted and proximally I did not see any evidence of any common duct stones or proximally into the biliary tree However a stone was found distally still floating around This was removed with stone forceps The bile ducts were irrigated again No further stones were removed A 16 French T tube was then placed into the bile duct and the bile duct was repaired around the T tube using 4 0 Vicryl interrupted sutures obtaining watertight closure A completion T tube cholangiogram was done at this time which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct although externally I was unable to see anything or palpate anything in this area Because of this the T tube was removed and I passed the choledochoscope proximally again and I was unable to see any evidence of any lesion or any stone in this area I felt at this time this was most likely an impression from the outside which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct The bile duct lumen was widely open T tube was again replaced into the bile duct and closed again and a completion T tube cholangiogram appeared to be more satisfactory at this time The cystic duct opening through which I had done earlier a cystic duct cholangiogram this was closed with a figure of eight suture of 2 0 Vicryl and this was actually done earlier and completion cholangiogram did not show any leak from this area The remaining gallbladder bed which was left in situ was cauterized both for hemostasis and to burn off the mucosal lining Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution Hemostasis was good A 10 mm Jackson Pratt drain was left in the foramen of Winslow and brought out through the lateral 5 mm port site The T tube was brought out through the middle 5 mm port site which was just above the incision Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and 1 Novafil running suture for the fascia Subcutaneous tissue was closed with 3 0 Vicryl running sutures in two layers Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0 25 Marcaine with epinephrine for postoperative pain control The umbilical incision was closed with 0 Vicryl figure of eight sutures for the fascia 2 0 Vicryl for the subcutaneous tissues and staples for the skin Sterile dressing was applied and the patient transferred to recovery room in stable condition Keywords surgery cholelithiasis cholecystitis biliary colic choledocholithiasis laparoscopy laparotomy cholecystectomy cholangiogram choledocholithotomy choledochoscopy t tube drainage cystic duct cholangiogram common bile duct peritoneal cavity gallbladder MEDICAL_TRANSCRIPTION,Description Laparotomy and myomectomy Enlarged fibroid uterus and blood loss anemia On bimanual exam the patient has an enlarged approximately 14 week sized uterus that is freely mobile and anteverted with no adnexal masses Surgically the patient has an enlarged fibroid uterus with a large fundal anterior fibroids Medical Specialty Surgery Sample Name Laparotomy Myomectomy Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Blood loss anemia PROCEDURE PERFORMED 1 Laparotomy 2 Myomectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than a 100 cc URINE OUTPUT 110 cc clear at the end of the procedure FLUIDS 500 cc during the procedure SPECIMENS Four uterine fibroids DRAINS Foley catheter to gravity COMPLICATIONS None FINDINGS On bimanual exam the patient has an enlarged approximately 14 week sized uterus that is freely mobile and anteverted with no adnexal masses Surgically the patient has an enlarged fibroid uterus with a large fundal anterior fibroids which is approximately 6 cm and several small submucosal fibroids within the endometrium Both ovaries and tubes appeared within normal limits PROCEDURE The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position After the general anesthetic was found to be adequate a Pfannenstiel skin incision was made with the first knife This was carried through the underlying layer of fascia with a second knife The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors The superior aspect of the fascial incision was then grasped with Ochsner clamps tented up and dissected off the underlying layer of rectus muscle bluntly It was then dissected in the middle with the Mayo scissors The inferior aspect of this incision was addressed in a similar manner The rectus muscles were separated in the midline bluntly The peritoneum was identified with hemostat clamps tented up and entered sharply with the Metzenbaum scissors The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly Next the uterus was grasped bluntly and removed from the abdomen The fundal fibroid was identified It was then injected with vasopressin 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels 15 cc was injected Next the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen The edges of the myometrium was grasped with Allis clamps tented up and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger The fibroid was easily and bluntly dissected out It was also grasped with Lahey clamp to prevent traction Once the blunt dissection of the large fibroid was complete it was handed off to the scrub nurse The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed At this point several smaller fibroids were noticed along the endometrial surface of the uterus Three of these were removed just by bluntly grasping with the Lahey clamp and twisting all three of these were approximately 1 cm to 2 cm in size These were also handed to the scrub tech Next the uterine incision was then closed with first two interrupted layers of 0 chromic in an interrupted figure of eight fashion and then with a 0 Vicryl in a running baseball stitch The uterus was seen to be completely hemostatic after closure Next a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed Next the greater omentum was replaced over the uterus The rectus muscles were then reapproximated with a single interrupted suture of 0 Vicryl in the midline Then the fascia was closed with 0 Vicryl in a running fashion Next the Scarpa s fascia was closed with 3 0 plain gut in a running fashion and the skin was closed with 4 0 undyed Vicryl in a running subcuticular fashion The incision was then dressed with 0 5 inch Steri Strips and bandaged appropriately After the patient was cleaned she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital Keywords surgery enlarged fibroid uterus blood loss anemia laparotomy myomectomy metzenbaum scissors uterus fibroid rectus fascia scissors fashion clamps enlarged incision bluntly MEDICAL_TRANSCRIPTION,Description Attempted laparoscopy open laparoscopy and fulguration of endometrial implant Chronic pelvic pain probably secondary to endometriosis Medical Specialty Surgery Sample Name Laparoscopy 3 Transcription PREOPERATIVE DIAGNOSIS Chronic pelvic pain probably secondary to endometriosis POSTOPERATIVE DIAGNOSIS Mild pelvic endometriosis PROCEDURE 1 Attempted laparoscopy 2 Open laparoscopy 3 Fulguration of endometrial implant ANESTHESIA General endotracheal BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS The patient is a 21 year old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone containing birth control pills either cyclically or daily as well as progestational medication only who had a negative GI workup recently including colonoscopy and desired definitive operative evaluation and diagnosis prior to initiation of a 6 month course of Depo Lupron PROCEDURE After an adequate plane of general anesthesia had been obtained the patient was placed in a dorsal lithotomy position She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery Bimanual examination revealed a mid position normal sized uterus with benign adnexal area In the high lithotomy position a weighted speculum was placed into the posterior vaginal wall The anterior lip of the cervix was grasped with a single tooth tenaculum A Hulka tenaculum was placed transcervically The other instruments were removed A Foley catheter was placed transurethrally to drain the bladder intraoperatively In the low lithotomy position and in steep Trendelenburg attention was turned to the infraumbilical region Here a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum The needle was removed the incision minimally enlarged and the 5 trocar and cannula were placed The trocar was removed and the scope placed confirming a preperitoneal insufflation The space was drained off the insufflated gas and 2 more attempts were made which failed due to the patient s adiposity Attention was turned back to the vaginal area where in the high lithotomy position attempts were made at a posterior vaginal apical insertion The Hulka tenaculum was removed the posterior lip of the cervix grasped with a single tooth tenaculum and the long Allis clamp used to grasp the posterior fornix on which was placed traction The first short and subsequently 15 cm Veress needles were attempted to be placed but after several passes no good pneumoperitoneum could be established via this route also It was elected not to do a transcervical intentional uterine perforation but to return to the umbilical area The 15 cm Veress needle was inserted several times but again a pneumo was preperitoneal Finally an open laparoscopic approach was undertaken The skin incision was expanded with a knife blade Blunt dissection was used to carry the dissection down to the fascia This was grasped with Kocher clamps entered sharply and opened transversely Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff Dissection continued between the rectus muscle and finally the anterior peritoneum was reached grasped elevated and entered At this juncture the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created a 10 scope was placed confirming the intraperitoneal positioning Under direct visualization a suprapubic 5 mm cannula and manipulative probe were placed Clockwise inspection of the pelvis revealed a benign vesicouterine pouch normal uterus and fundus normal right tube and ovary In the cul de sac there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting The left tube and ovary were normal There were no adhesions There was no evidence of acute pelvic inflammatory disease The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated Pictures were taken for confirmation both before and after the burn The carbon chars were irrigated and aspirated The smoke plume was removed without difficulty Approximately 50 mL of irrigant was left in the pelvis Due to the difficulty in placing and maintaining the Hasson cannula no attempts were made to view the upper abdominal quadrant specifically the liver and gallbladder The suprapubic cannula was removed under direct visualization the pneumo released the scope removed the stay sutures cut and the Hasson cannula removed The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site Finally the skin incisions were approximated with 3 0 Dexon subcuticularly They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies The vaginal instruments were removed All counts were correct The patient tolerated the procedure well and was taken to the recovery room in stable condition Keywords surgery endometriosis fulguration endometrial single tooth tenaculum endometrial implant hulka tenaculum veress needle hasson cannula pneumoperitoneum laparoscopy cannula MEDICAL_TRANSCRIPTION,Description Laparoscopy with ablation of endometriosis Allen Masters window in the upper left portion of the cul de sac bronze lesions of endometriosis in the central portion of the cul de sac as well as both the left uterosacral ligament flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul de sac Medical Specialty Surgery Sample Name Laparoscopy 4 Transcription PROCEDURE Laparoscopy with ablation of endometriosis DIAGNOSIS Endometriosis ANESTHESIA General ESTIMATED BLOOD LOSS None FINDINGS Allen Masters window in the upper left portion of the cul de sac bronze lesions of endometriosis in the central portion of the cul de sac as well as both the left uterosacral ligament flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul de sac Normal tubes and ovaries normal gallbladder smooth liver edge PROCEDURE The patient was taken to the operating room and placed under general anesthesia She was put in the dorsal lithotomy position and the perineum and abdomen were prepped and draped in a sterile manner Subumbilical area was injected with Marcaine and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated Scalpel was used to make a subumbilical incision through which a 5 mm trocar was placed Laparoscope was inserted through the cannula and the pelvis was visualized Under direct visualization two 5 mm trocars were placed in the right and left suprapubic midline Incision sites were transilluminated and injected with Marcaine prior to cutting Hulka manipulator was placed on the cervix Pelvis was inspected and blood tinged fluid was aspirated from the cul de sac The beginnings of an Allen Masters window in the left side of the cul de sac were visualized along with bronze lesions of endometriosis Some more lesions were noted above the left uterosacral ligament Flame lesions were noted above the right uterosacral ligament Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube There was a somewhat leathery appearance to the ovaries The lesions of endometriosis were ablated with the argon beam coagulator as was a region of the Allen Masters window Pelvis was irrigated and all operative sites were hemostatic No other abnormalities were visualized and all instruments were moved under direct visualization Approximately 200 mL of fluid remained in the abdominal cavity All counts were correct and the skin incisions were closed with 2 0 Vicryl after all CO2 was allowed to escape The patient was taken to the recovery in stable condition Keywords surgery ablation of endometriosis allen masters window uterosacral ligament endometriosis cul de sac laparoscopy lesions ablation MEDICAL_TRANSCRIPTION,Description Laparoscopic supracervical hysterectomy A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management Medical Specialty Surgery Sample Name Laparoscopic Supracervical Hysterectomy Transcription PREOPERATIVE DIAGNOSIS 1 Dysmenorrhea 2 Menorrhagia POSTOPERATIVE DIAGNOSIS 1 Dysmenorrhea 2 Menorrhagia PROCEDURE Laparoscopic supracervical hysterectomy ESTIMATED BLOOD LOSS 30 cc COMPLICATIONS None INDICATIONS FOR SURGERY A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management Please see clinic notes Risks of bleeding infection damage to other organs have been explained Informed consent was obtained OPERATIVE FINDINGS Slightly enlarged but otherwise normal appearing uterus Normal appearing adnexa bilaterally OPERATIVE PROCEDURE IN DETAIL After administration of general anesthesia the patient was placed in dorsal lithotomy position prepped and draped in the usual sterile fashion Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field A 5 mm incision was made umbilically after injecting 0 25 Marcaine 0 25 Marcaine was injected in all the incisional sites Veress needle was inserted position confirmed using the saline drop method After confirming an opening pressure of 4 mmHg of CO2 gas approximately four liters was insufflated in the abdominal cavity Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side All these were placed under direct visualization Pelvic cavity was examined with findings as noted above The left utero ovarian ligament was grasped and cauterized using the Gyrus Part of the superior aspect of the broad ligament was then cauterized as well Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment The remainder of the broad and cardinal ligament was then cauterized and excised A similar procedure was performed on the right side The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament After assuring that the bladder was well out of the way of the operative field bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments The area was irrigated extensively and cautery used to assure hemostasis A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination Hemostasis was again confirmed under low pressure Using Carter Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5 0 Monocryl suture Instruments removed from vagina Patient returned to supine position recalled from general anesthesia and transferred to recovery in satisfactory condition Sponge and needle counts correct at the conclusion of the case Estimated blood loss was 30 cc There were no complications Keywords surgery adnexa uterus laparoscopic supracervical hysterectomy veress needle bladder flap cardinal ligament uterine cauterized dysmenorrhea menorrhagia MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and laparoscopic appendectomy Right lower quadrant abdominal pain rule out acute appendicitis Medical Specialty Surgery Sample Name Laparoscopy Laparoscopic Appendectomy Transcription PREOPERATIVE DIAGNOSIS Right lower quadrant abdominal pain rule out acute appendicitis POSTOPERATIVE DIAGNOSIS Acute suppurative appendicitis PROCEDURE PERFORMED 1 Diagnostic laparoscopy 2 Laparoscopic appendectomy ANESTHESIA General endotracheal and injectable 1 lidocaine and 0 25 Marcaine ESTIMATED BLOOD LOSS Minimal SPECIMEN Appendix COMPLICATIONS None BRIEF HISTORY This is a 37 year old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain which progressed throughout its course starting approximately 12 hours prior to presentation She admits to some nausea associated with it There have been no fevers chills and or genitourinary symptoms The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant She had a leukocytosis of 12 8 She did undergo a CT of the abdomen and pelvis which was non diagnostic for an acute appendicitis Given the severity of her abdominal examination and her persistence of her symptoms we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy The risks benefits complications of the procedure she gave us informed consent to proceed OPERATIVE FINDINGS Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it it was slightly enlarged The left ovary revealed some follicular cysts There was no evidence of adnexal masses and or torsion of the fallopian tubes The uterus revealed no evidence of mass and or fibroid tumors The remainder of the abdomen was unremarkable OPERATIVE PROCEDURE The patient was brought to the operative suite placed in the supine position The abdomen was prepped and draped in the normal sterile fashion with Betadine solution The patient underwent general endotracheal anesthesia The patient also received a preoperative dose of Ancef 1 gram IV After adequate sedation was achieved a 10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg Once the abdomen was sufficiently insufflated a 10 mm bladed trocar was inserted into the abdomen without difficulty A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored Next a 5 mm port was inserted in the midclavicular line of the right upper quadrant region This was inserted under direct visualization Finally a suprapubic 12 mm portal was created This was performed with 10 blade scalpel to create a transverse incision A bladed trocar was inserted into the suprapubic region This was done again under direct visualization Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly Utilizing a endovascular stapling device the appendix was transected and doubly stapled with this device Next the mesoappendix was doubly stapled and transected with the endovascular stapling device The staple line was visualized and there was no evidence of bleeding The abdomen was fully irrigated with copious amounts of normal saline The abdomen was then aspirated There was no evidence of bleeding All ports were removed under direct visualization No evidence of bleeding from the port sites The infraumbilical and suprapubic ports were then closed The fascias were then closed with 0 Vicryl suture on a UR6 needle Once the fascias were closed all incisions were closed with 4 0 undyed Vicryl The areas were cleaned Steri Strips were placed across the wound Sterile dressing was applied The patient tolerated the procedure well She was extubated following the procedure returned to Postanesthesia Care Unit in stable condition She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course Keywords surgery lower quadrant diagnostic laparoscopy acute appendicitis laparoscopic appendectomy abdomen appendectomy laparoscopy appendix suprapubic MEDICAL_TRANSCRIPTION,Description Pelvic pain pelvic endometriosis and pelvic adhesions Laparoscopy Harmonic scalpel ablation of endometriosis lysis of adhesions and cervical dilation Laparoscopically the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa Medical Specialty Surgery Sample Name Laparoscopy Transcription PREOPERATIVE DIAGNOSIS Pelvic pain POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Pelvic endometriosis 3 Pelvic adhesions PROCEDURE PERFORMED 1 Laparoscopy 2 Harmonic scalpel ablation of endometriosis 3 Lysis of adhesions 4 Cervical dilation ANESTHESIA General SPECIMEN Peritoneal biopsy ESTIMATED BLOOD LOSS Scant COMPLICATIONS None FINDINGS On bimanual exam the patient has a small anteverted and freely mobile uterus with no adnexal masses Laparoscopically the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa There are adhesions involving the right ovary to the anterior abdominal wall and the bowel There are also adhesions from the omentum to the anterior abdominal wall near the liver The uterus and ovaries appear within normal limits other than the adhesions The left fallopian tube grossly appeared within normal limits The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized There was a large area of endometriosis approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul de sac There was also vesicular appearing endometriosis lesion in the posterior cul de sac PROCEDURE The patient was taken in the operating room and generalized anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion After exam under anesthetic weighted speculum was placed in the vagina The anterior lip of the cervix was grasped with vulsellum tenaculum The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank then the uterine manipulator was inserted and attached to the anterior lip of the cervix At this point the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife The superior aspect of the umbilicus was grasped with a towel clamp The abdomen was tented up and a Veress needle inserted through this incision When the Veress needle was felt to be in place deep position was checked by placing saline in the needle This was seen to freely drop in the abdomen so it was connected to CO2 gas Again this was started at the lowest setting was seen to flow freely so it was advanced to the high setting The abdomen was then insufflated to an adequate distention Once an adequate distention was reached the CO2 gas was disconnected The Veress needle was removed and a size 11 step trocar was placed Next the laparoscope was inserted through this port The medial port was connected to CO2 gas Next a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis Through this a Veress needle was inserted followed by size 5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size 5 trocar was also placed Next a grasper was placed through the suprapubic port This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions Bowel was carefully examined afterwards and no injuries or bleeding were seen Next the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty There was a small amount of bleeding from the anterior abdominal wall peritoneum This was ablated with the Harmonic scalpel The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul de sac Both of these areas were seen to be hemostatic Next a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul de sac This was sent to pathology Next the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed It was seen to be completely hemostatic Next the two size 5 ports were removed under direct visualization The camera was removed The abdomen was desufflated The size 11 introducer was replaced and the 11 port was removed Next all the ports were closed with 4 0 undyed Vicryl in a subcuticular interrupted fashion The incisions were dressed with Steri Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow up in one week in the clinic for pathology results and to have a postoperative check Keywords surgery pelvic pain endometriosis pelvic adhesions laparoscopy scalpel ablation lysis of adhesions cervical dilation peritoneal biopsy harmonic scalpel adhesions harmonic scalpel abdominal pelvic abdomen anterior MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and drainage of cyst Medical Specialty Surgery Sample Name Laparoscopy Drainage of Cyst Transcription PREOPERATIVE DIAGNOSIS Ovarian cyst persistent POSTOPERATIVE DIAGNOSIS Ovarian cyst ANESTHESIA General NAME OF OPERATION Diagnostic laparoscopy and drainage of cyst PROCEDURE The patient was taken to the operating room prepped and draped in the usual manner and adequate anesthesia was induced An infraumbilical incision was made and Veress needle placed without difficulty Gas was entered into the abdomen at two liters The laparoscope was entered and the abdomen was visualized The second puncture site was made and the second trocar placed without difficulty The cyst was noted on the left a 3 cm ovarian cyst This was needled and a hole cut in it with the scissors Hemostasis was intact Instruments were removed The patient was awakened and taken to the recovery room in good condition Keywords surgery ovarian cyst infraumbilical incision drainage of cyst diagnostic laparoscopy laparoscopy drainage ovarian MEDICAL_TRANSCRIPTION,Description Examination under anesthesia and laparoscopic right orchiopexy Medical Specialty Surgery Sample Name Laparoscopic Orchiopexy Transcription PREOPERATIVE DIAGNOSIS Bilateral undescended testes POSTOPERATIVE DIAGNOSIS Bilateral undescended testes bilateral intraabdominal testes PROCEDURE Examination under anesthesia and laparoscopic right orchiopexy ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 110 mL of crystalloid INTRAOPERATIVE FINDINGS Atrophic bilateral testes right is larger than left The left had atrophic or dysplastic vas and epididymis TUBES AND DRAINS No tubes or drains were used INDICATIONS FOR OPERATION The patient is a 7 1 2 month old boy with bilateral nonpalpable testes Plan is for exploration possible orchiopexy DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then palpated and again both testes were nonpalpable Because of this a laparoscopic approach was then elected We then sterilely prepped and draped the patient put an 8 French feeding tube in the urethra attached to bulb grenade for drainage We then made an infraumbilical incision with a 15 blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3 0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors Once we got into the peritoneum we placed a 5 mm port with 0 degree short lens Insufflation was then done with carbon dioxide up to 10 to 12 mmHg We then evaluated There was no bleeding noted He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas which was barely visualized The right side was also intraabdominal but slightly larger had better vessels had much more recognizable vas and it was closer to the internal ring So we elected to do an orchiopexy on the right side Using the laparoscopic 3 and 5 mm dissecting scissors we then opened up the window at the internal ring through the peritoneal tissue then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney mid way up the abdomen and across towards the bladder for the vas We then used the Maryland dissector to gently tease this tissue once it was incised The gubernaculum was then divided with electrocautery and the laparoscopic scissors We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side left side of the ring We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15 blade knife and extended down the subcutaneous tissue with electrocautery We used the curved tenotomy scissors to make a subdartos pouch Using a mosquito clamp we were able to go in through the previous internal ring opening grasped the testis and then pulled it through in a proper orientation Using the hook electrode we were able to dissect some more of the internal ring tissue to relax the vessels and the vas so there was no much traction Using 2 stay sutures of 4 0 chromic we tacked the testis to the base of scrotum into the middle portion of the testis We then closed the upper aspect of the subdartos pouch with a 4 0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4 0 chromic We again evaluated the left side and found again that the vessels were quite short The testis was more atrophic and the vas was virtually nonexistent We will go back at a later date to try to bring this down but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present We then removed the ports closed the fascial defects with figure of eight suture of 3 0 Monocryl closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath and then used 4 0 Rapide to close the skin defects and then using Dermabond tissue adhesives we covered all incisions At the end of the procedure the right testis was well descended within the scrotum and the feeding tube was removed The patient had IV Toradol and was in stable condition upon transfer to recovery room Keywords surgery laparoscopic right orchiopexy undescended testes orchiopexy bilateral undescended testes mosquito clamps subdartos pouch internal ring laparoscopic MEDICAL_TRANSCRIPTION,Description Laparoscopy with left salpingo oophorectomy Left adnexal mass ovarian lesion The labia and perineum were within normal limits The hymen was found to be intact Laparoscopic findings revealed a 4 cm left adnexal mass which appeared fluid filled Medical Specialty Surgery Sample Name Laparoscopy Salpingo oophorectomy Transcription PREOPERATIVE DIAGNOSIS Left adnexal mass POSTOPERATIVE DIAGNOSIS Left ovarian lesion PROCEDURE PERFORMED Laparoscopy with left salpingo oophorectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than 50 cc COMPLICATIONS None FINDINGS The labia and perineum were within normal limits The hymen was found to be intact Laparoscopic findings revealed a 4 cm left adnexal mass which appeared fluid filled There were a few calcifications on the surface of the mass The right ovary and fallopian tube appeared normal There was no evidence of endometriosis The uterus appeared normal in size There were no pelvic adhesions noted INDICATIONS The patient is a 55 year old gravida 0 para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5 3 cm She does complain of minimal discomfort Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen PROCEDURE IN DETAIL After informed consent was obtained the patient was taken back to the Operative Suite prepped and draped and placed in the dorsal lithotomy position A 1 cm skin incision was made in the infraumbilical vault While tenting up the abdominal wall the Veress needle was inserted without difficulty and the abdomen was insufflated This was done using appropriate flow and volume of CO2 The 11 step trocar was then placed without difficulty The above findings were confirmed A 12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization Two additional ports were placed one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall Both 12 step ports were done under direct visualization Using a grasper the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision The skin was extended around this incision and the fascia was extended using the Mayo scissors The specimen was removed intact in the Endocatch bag through this site Prior to desufflation of the abdomen the site where the left adnexa was removed was visualized to be hemostatic All the port sites were hemostatic as well The fascia of the suprapubic incision was then repaired using a running 0 Vicryl stitch on a UR6 needle The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion The remaining incisions were also closed with 4 0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated Steri Strips were placed on each of the incisions The patient tolerated the procedure well Sponge lap and needle count were x2 She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her Keywords surgery salpingo oophorectomy ovarian lesion adnexal mass salpingo oophorectomy abdominal wall intact adnexal laparoscopy mass MEDICAL_TRANSCRIPTION,Description Total laparoscopic hysterectomy with laparoscopic staging including paraaortic lymphadenectomy bilateral pelvic and obturator lymphadenectomy and washings Medical Specialty Surgery Sample Name Laparoscopic Hysterectomy Transcription PREOPERATIVE DIAGNOSIS Endometrial carcinoma POSTOPERATIVE DIAGNOSIS Endometrial carcinoma PROCEDURE PERFORMED Total laparoscopic hysterectomy with laparoscopic staging including paraaortic lymphadenectomy bilateral pelvic and obturator lymphadenectomy and washings ANESTHESIA General endotracheal tube SPECIMENS Pelvic washings for cytology uterus with attached right tube and ovary pelvic and paraaortic lymph node dissection obturator lymph node dissection INDICATIONS FOR PROCEDURE The patient was recently found to have a grade II endometrial cancer She was counseled to undergo laparoscopic staging FINDINGS During the laparoscopy the uterus was noted to be upper limits of normal size with a normal appearing right fallopian tubes and ovaries No ascites was present On assessment of the upper abdomen the stomach diaphragm liver gallbladder spleen omentum and peritoneal surfaces of the bowel were all unremarkable in appearance PROCEDURE The patient was brought into the operating room with an intravenous line in placed and anesthetic was administered She was placed in a low anterior lithotomy position using Allen stirrups The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon The laparoscopic port sites were anesthetized with intradermal injection of 0 25 Marcaine There were five ports placed including a 3 mm left subcostal port a 10 mm umbilical port a 10 mm suprapubic port and 5 mm right and left lower quadrant ports The Veress needle was placed through a small incision at the base of the umbilicus and a pneumoperitoneum was insufflated without difficulty The 3 mm port was then placed in the left subcostal position without difficulty and a 3 mm scope was placed There were no adhesions underlying the previous vertical midline scar The 10 mm port was placed in the umbilicus and the laparoscope was inserted Remaining ports were placed under direct laparoscopic guidance Washings were obtained from the pelvis and the abdomen was explored with the laparoscope with findings as noted Attention was then turned to lymphadenectomy An incision in the retroperitoneum was made over the right common iliac artery extending up the aorta to the retroperitoneal duodenum The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached Pedicles were sealed and divided with bipolar cutting forceps Excellent hemostasis was noted Boundaries of dissection included the ureters laterally common ileac arteries at uterine crossover inferiorly and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps The retroperitoneal space was then opened and the lymph nodes were dissected with boundaries of dissection being the bifurcation of the common iliac artery superiorly psoas muscle laterally inguinal ligament inferiorly and the anterior division of the hypogastric artery medially The posterior boundary was the obturator nerve which was carefully identified and preserved bilaterally The left common iliac lymph node was elevated and removed using the same technique Attention was then turned to the laparoscopic hysterectomy The right infundibulopelvic ligament was divided using the bipolar cutting forceps The mesovarium was skeletonized A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps and the peritoneum on the vesicouterine fold was incised to mobilize the bladder Once the Koh colpotomy ring was skeletonized and in position the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring The vagina was transected using a monopolar hook or bipolar spatula resulting in separation of the uterus and attached tubes and ovaries The uterus tubes and ovaries were then delivered through the vagina and the pneumo occluder balloon was reinserted to maintain pneumoperitoneum The vaginal vault was closed with interrupted figure of eight stitches of 0 Vicryl using the Endo Stitch device The abdomen was irrigated and excellent hemostasis was noted The insufflation pressure was reduced and no evidence of bleeding was seen The suprapubic port was then removed and the fascia was closed with a Carter Thomason device and 0 Vicryl suture The remaining ports were removed under direct laparoscopic guidance and the pneumoperitoneum was released The umbilical port was removed using laparoscopic guidance The umbilical fascia was closed with an interrupted figure of eight stitch using 2 0 Vicryl The skin was closed with interrupted subcuticular stitches using 4 0 Monocryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was awakened and taken to the post anesthesia care unit in stable condition Keywords surgery endometrial carcinoma laparoscopic hysterectomy total laparoscopic hysterectomy laparoscopic staging lymphadenectomy pelvic obturator lymph node dissection direct laparoscopic guidance tubes and ovaries bipolar cutting forceps node dissection koh colpotomy iliac artery infundibulopelvic ligament laparoscopic guidance retroperitoneal duodenum lymph node laparoscopic hysterectomy endometrial pneumoperitoneum washings vaginal retroperitoneal forceps bipolar MEDICAL_TRANSCRIPTION,Description Laparoscopic lysis of adhesions attempted laparoscopic pyeloplasty and open laparoscopic pyeloplasty Right ureteropelvic junction obstruction severe intraabdominal adhesions and retroperitoneal fibrosis Medical Specialty Surgery Sample Name Laparoscopic Pyeloplasty Transcription PREOPERATIVE DIAGNOSIS Right ureteropelvic junction obstruction POSTOPERATIVE DIAGNOSES 1 Right ureteropelvic junction obstruction 2 Severe intraabdominal adhesions 3 Retroperitoneal fibrosis PROCEDURES PERFORMED 1 Laparoscopic lysis of adhesions 2 Attempted laparoscopic pyeloplasty 3 Open laparoscopic pyeloplasty ANESTHESIA General INDICATION FOR PROCEDURE This is a 62 year old female with a history of right ureteropelvic junction obstruction with chronic indwelling double J ureteral stent The patient presents for laparoscopic pyeloplasty PROCEDURE After informed consent was obtained the patient was taken to the operative suite and administered general anesthetic The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient s positioning for bowel retraction Hassan technique was performed for the initial trocar placement in the periumbilical region Abdominal insufflation was performed There were significant adhesions noted A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two and half hours also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus an additional 5 mm port in the right upper quadrant subcostal and midclavicular After adhesions were taken down the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially The kidney was able to be palpated within Gerota s fascia The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction The renal pelvis was also identified and dissected free There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open An incision was made from the right upper quadrant port extending towards the midline This was carried down through the subcutaneous tissue anterior fascia muscle layers posterior fascia and peritoneum A Bookwalter retractor was placed The renal pelvis and the ureter were again identified Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery The tissue was sent down to Pathology for analysis Please note that upon entering the abdomen all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue At this point the indwelling double J ureteral stent was removed At this time the ureter was spatulated laterally and at the apex of this spatulation a 4 0 Vicryl suture was placed This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated The back wall of the ureteropelvic anastomosis was then approximated with running 4 0 Vicryl suture At this point a double J stent was placed with a guidewire down into the bladder The anterior wall of the uteropelvic anastomosis was then closed again with a 4 0 running Vicryl suture Renal sinus fat was then placed around the anastomosis and sutured in place Please note in the inferior pole of the kidney there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue This was repaired with horizontal mattress sutures 2 0 Vicryl FloSeal was placed over this and the renal capsule was placed over this A good hemostasis was noted A 10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis The initial trocar incision was closed with 0 Vicryl suture The abdominal incision was also then closed with running 0 Vicryl suture incorporating all layers of muscle and fascia The Scarpa s fascia was then closed with interrupted 3 0 Vicryl suture The skin edges were then closed with staples Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator We placed the patient on IV antibiotics and pain medications We will obtain KUB and x rays for stent placement Further recommendations to follow Keywords surgery retroperitoneal fibrosis pyeloplasty laparoscopic lysis of adhesions ureteropelvic junction obstruction laparoscopic pyeloplasty ureteropelvic junction junction ureteropelvic intraabdominal adhesions MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful Medical Specialty Surgery Sample Name Laparoscopic Gastric Bypass Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis ANESTHESIA General with endotracheal intubation INDICATION FOR PROCEDURE This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful She has been to our Bariatric Surgery Seminar received some handouts and signed the consent The risks and benefits of the procedure have been explained to the patient PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table All pressure points were carefully padded She was given general anesthesia with endotracheal intubation SCD stockings were placed on both legs Foley catheter was placed for bladder decompression The abdomen was then prepped and draped in standard sterile surgical fashion Marcaine was then injected through umbilicus A small incision was made A Veress needle was introduced into the abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg A 12 mm VersaStep port was placed through the umbilicus I then placed a 5 mm port just anterior to the midaxillary line and just subcostal on the right side I placed another 5 mm port in the midclavicular line just subcostal on the right side a few centimeters below and medial to that I placed a 12 mm VersaStep port On the left side just anterior to the midaxillary line and just subcostal I placed a 5 mm port A few centimeters below and medial to that I placed a 15 mm port I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device I then ran the distal bowel down approximately 100 cm and at 100 cm I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb and I passed a 45 white load stapler and fired a stapler creating a side to side anastomosis I reapproximated the edges of the defect I lifted it up and stapled across it with another white load stapler I then closed the mesenteric defect with interrupted Surgidac sutures I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic I then put the patient in reverse Trendelenburg I placed a liver retractor identified and dissected the angle of His I then dissected on the lesser curve approximately 2 5 cm below the gastroesophageal junction and got into a lesser space I fired transversely across the stomach with a 45 blue load stapler I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His thereby creating my gastric pouch I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil I pulled the anvil into place and I then opened up my 15 mm port site and passed my EEA stapler I passed that in the end of my Roux limb and had the spike come out antimesenteric I joined the spike with the anvil and fired a stapler creating an end to side anastomosis then divided across the redundant portion of my Roux limb with a white load GI stapler and removed it with an Endocatch bag I put some additional 2 0 Vicryl sutures in the anastomosis for further security I then placed a bowel clamp across the bowel I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch I distended gastric pouch with air There was no air leak seen I could pass the scope easily through the anastomosis There was no bleeding seen through the scope We closed the 15 mm port site with interrupted 0 Vicryl suture utilizing Carter Thomason I copiously irrigated out that incision with about 2 L of saline I then closed the skin of all incisions with running Monocryl Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well without any complications Keywords surgery gastric bypass eea anastomosis roux en y antegastric antecolic morbid obesity roux limb gastric pouch intubation laparoscopic bypass roux endotracheal anastomosis gastric MEDICAL_TRANSCRIPTION,Description Right hand assisted laparoscopic cryoablation of renal lesions x2 Lysis of adhesions and renal biopsy Medical Specialty Surgery Sample Name Laparoscopic Cryoablation Transcription PREOPERATIVE DIAGNOSIS Bilateral renal mass POSTOPERATIVE DIAGNOSIS Bilateral renal mass OPERATION Right hand assisted laparoscopic cryoablation of renal lesions x2 Lysis of adhesions and renal biopsy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 100 Ml FLUIDS Crystalloid The patient was bowel prepped and was given preoperative antibiotics BRIEF HISTORY The patient is a 73 year old male who presented to us with a referral from Dr X s office with bilateral renal mass and renal insufficiency The patient s baseline creatinine was around 1 6 to 1 7 The patient was found to have a 3 to 4 cm exophytic right renal mass 1 cm renal mass inferior to that and about 2 cm left renal mass Since the patient had bilateral renal disease and the patient had renal insufficiency the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy one kidney at a time The patient understood all his options had done some research on cryotherapy and wanted to proceed with the procedure The patient had a renal biopsy done which showed a possibility of an oncocytoma which also would indicate that if this is not truly a cancerous lesion but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney Risk of anesthesia bleeding infection pain hernia bowel obstruction ileus injury to bowel postoperative bleeding etc were discussed The patient understood the risk of delayed bleeding the needing for nephrectomy renal failure renal insufficiency etc and wanted to proceed with the procedure DETAILS OF THE OR The patient was brought to the OR Anesthesia was applied The patient was given preoperative antibiotics The patient was bowel prepped The patient was placed in right side up left side down semiflank with kidney rest up All the pressure points are very well padded using foam and towels The left knee was bent and the right knee was straight There was no tension on any of the joints All pressure points were well padded The patient was taped to the table using 2 inch wide tape all the way around A Foley catheter and OG tube were in place prior to prepping and draping the patient A periumbilical incision measuring about 6 cm was made The incision was carried through the subcutaneous tissue through the fascia using sharp dissection The peritoneum was open Abdomen was entered There were some adhesions on the right side of the abdomen which were released using metz Two 12 mm ports were placed in the anteroaxillary line and one in the midclavicular line A gel porter was placed Pneumoperitoneum was obtained All ports were placed under direct vision and the right colon was reflected medially Duodenum was cauterized Minimal dissection was done on the hilum and the Gerota s was opened laterally and the renal masses were clearly visualized all the way around Pictures were taken Superficial biopsies were taken of 2 renal lesions using 3 different probes The 2 lesions were frozen The 2 probes were 2 4 mm and the other one was 3 1 mm in diameter So the R3 8 and R2 4 long probes were used Freezing thawing two cycles were done The temperatures were 131 137 150 and the freezing time was 5 and 10 minutes each and passive sign was done The exact times or exact temperatures are on the chart There was a nice ice ball with each freezing and with passive sign The probes were removed The probes were placed directly percutaneously through the skin into the renal lesions After freezing thawing the probes were removed and to seal with Surgicel were placed Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding From the time the probes were removed until the time the laparoscope was removed was total of 30 minutes So the masses were visualized for a total of 30 minutes without any pneumoperitoneum Pneumoperitoneum was obtained again Fibrin glue was placed over it just for precautionary measure There was about a total of 100 mL of blood loss overall with the entire procedure Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ The kidney was kept in the left hand at all times Careful attention was drawn to make sure that the probe was deep enough at least 3 5 to 4 cm in to get the medial aspect of the tumors frozen The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions At the end of the procedure after freezing thawing and putting the fibrin glue Surgicel and EndoSeal the colon was reflected medially Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel Lap count was correct Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions No deeper biopsies were done to minimize the risk of bleeding The 12 mm ports were closed using 0 Vicryl and the middle incision The hand port incision was closed using looped 1 PDS from both sides and was tied in the middle Please note that the pneumoperitoneum was closed using 0 Vicryl in running fashion After closing the abdomen 4 0 Monocryl was used to close the skin and Dermabond was applied The patient was brought to recovery in a stable condition Keywords surgery hand assisted laparoscopic cryoablation laparoscopic cryoablation bilateral renal mass fibrin glue laparoscopic cryoablation renal insufficiency renal lesions renal biopsy renal mass insufficiency renal freezing thawing lesions MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis cholelithiasis and liver cyst Laparoscopic cholecystectomy and excision of liver cyst Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy Liver Cyst Excision Transcription PREOPERATIVE DIAGNOSES 1 Chronic cholecystitis 2 Cholelithiasis POSTOPERATIVE DIAGNOSES 1 Chronic cholecystitis 2 Cholelithiasis 3 Liver cyst PROCEDURES PERFORMED 1 Laparoscopic cholecystectomy 2 Excision of liver cyst ANESTHESIA General endotracheal and injectable 0 25 Marcaine with 1 lidocaine SPECIMENS Include 1 Gallbladder 2 Liver cyst ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None OPERATIVE FINDINGS Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder Additionally there was a notable liver cyst The remainder of the abdomen remained free of any adhesions BRIEF HISTORY This is a 66 year old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy The patient complained of intractable nausea vomiting and abdominal bloating after eating fatty foods She had had multiple attacks in the past of these complaints She was discovered to have had right upper quadrant pain on examination Additionally she had an ultrasound performed on 08 04 2003 which revealed cholelithiasis The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms She was explained the risks benefits and complications of the procedure and she gave informed consent to proceed OPERATIVE PROCEDURE The patient was brought to the operative suite and placed in the supine position The patient received preoperative antibiotics with Kefzol The abdomen was prepped and draped in the normal sterile fashion with Betadine solution The patient did undergo general endotracheal anesthesia Once the adequate sedation was achieved a supraumbilical transverse incision was created with a 10 blade scalpel Utilizing a Veress needle the Veress needle was inserted intra abdominally and was hooked to the CO2 insufflation The abdomen was insufflated to 15 mmHg After adequate insufflation was achieved the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder Decision to proceed with laparoscopic cystectomy was decided A subxiphoid transverse incision was created with a 10 blade scalpel and utilizing a bladed 12 mm trocar the trocar was inserted under direct visualization into the abdomen Two 5 mm ports were placed one at the midclavicular line 2 cm below the costal margin and a second at the axillary line one hand length approximately below the costal margin All ports were inserted with bladed 5 mm trocar then under direct visualization After all trocars were inserted the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder Adhesions adjacent were taken down with a Maryland dissector Once this was performed the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly This helped to better delineate the cystic duct as well as the cystic artery Utilizing Maryland dissector careful dissection of the cystic duct and cystic artery were created posteriorly behind each one Utilizing Endoclips clips were placed on the cystic duct and cystic artery one proximal to the gallbladder and two distally Utilizing endoscissors the cystic duct and cystic artery were ligated Next utilizing electrocautery the gallbladder was carefully dissected off the liver bed Electrocautery was used to stop any bleeding encountered along the way The gallbladder was punctured during dissection and cleared biliary contents did drained into the abdomen No evidence of stones were visualized Once the gallbladder was completely excised from the liver bed an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port This was sent off as an specimen a gallstone was identified within the gallbladder Next utilizing copious amounts of irrigation the abdomen was irrigated A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver This was also taken and sent off as specimen The abdomen was then copiously irrigated until clear irrigation was identified All laparoscopic ports were removed under direct visualization The abdomen was de insufflated Utilizing 0 Vicryl suture the abdominal fascia was approximated with a figure of eight suture in the supraumbilical and subxiphoid region All incisions were then closed with 4 0 undyed Vicryl Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures The areas were cleaned and dried Steri Strips were placed On the incisions sterile dressing was applied The patient tolerated the procedure well She was extubated following procedure She is seen to tolerate the procedure well and she will follow up with Dr X within one week for a follow up evaluation Keywords surgery excision of liver cyst gallbladder omentum cystic artery gallstone laparoscopic cholecystectomy cystic duct liver cyst liver abdomen electrocautery cholelithiasis cholecystectomy adhesions laparoscopic cyst cystic MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy Medical Specialty Surgery Sample Name Laparoscopic Gastric Bypass 1 Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy ANESTHESIA General with endotracheal intubation INDICATIONS FOR PROCEDURE This is a 50 year old male who has been overweight for many years and has tried multiple different weight loss diets and programs The patient has now begun to have comorbidities related to the obesity The patient has attended our bariatric seminar and met with our dietician and psychologist The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form PROCEDURE IN DETAIL The risks and benefits were explained to the patient Consent was obtained The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation A Foley catheter was placed for bladder decompression All pressure points were carefully padded and sequential compression devices were placed on the legs The abdomen was prepped and draped in standard sterile surgical fashion Marcaine was injected into the umbilicus Keywords surgery morbid obesity roux en y gastric bypass antecolic antegastric anastamosis esophagogastroduodenoscopy eea surgidac sutures roux limb port stapler laparoscopic intubation MEDICAL_TRANSCRIPTION,Description Symptomatic cholelithiasis Laparoscopic cholecystectomy and appendectomy CPT 47563 44970 The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis Laparoscopic cholecystectomy and appendectomy were recommended to her Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy Appendectomy Transcription PREOPERATIVE DIAGNOSIS Symptomatic cholelithiasis POSTOPERATIVE DIAGNOSIS Symptomatic cholelithiasis PROCEDURE Laparoscopic cholecystectomy and appendectomy CPT 47563 44970 ANESTHESIA General endotracheal INDICATIONS This is an 18 year old girl with sickle cell anemia who has had symptomatic cholelithiasis She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis Laparoscopic cholecystectomy and appendectomy were recommended to her The procedure was explained in detail including the risks of bleeding infection biliary injury retained common duct stones After answering her questions she wished to proceed and gave informed consent DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine on the operating table She was positively identified and the correct surgical site and procedure reviewed After successful administration of general endotracheal anesthesia the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped The infraumbilical skin was infiltrated with 0 25 bupivacaine with epinephrine and horizontal incision created The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg A 12 mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity Upper abdominal anatomy was normal Pelvic laparoscopy revealed bilaterally closed internal inguinal rings Additional trocars were placed under direct vision including a 5 mm reusable in the right lateral _____ There was a 12 mm expandable disposable in the right upper quadrant and a 5 mm reusable in the subxiphoid region Using these the gallbladder was grasped and retraced cephalad Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction A small ductotomy was created Reddick cholangiogram catheter was then placed within the duct and the balloon inflated Continuous fluoroscopy was used to instill contrast material This showed normal common bile duct which entered the duodenum without obstruction There was no evidence of common bile duct stones The cholangiogram catheter was removed The duct was doubly clipped and divided The artery was divided and cauterized The gallbladder was taken out of the gallbladder fossa It was then placed in Endocatch bag and left in the abdomen Attention was then paid to the appendix The appendix was identified and window was made in the mesoappendix at the base This was amputated with an Endo GIA stapler The mesoappendix was divided with an Endo GIA vascular stapler This was placed in another Endocatch bag The abdomen was then irrigated Hemostasis was satisfactory Both the appendix and gallbladder were removed and sent for pathology All trocars were removed The 12 mm port sites were closed with 2 0 PDS figure of eight fascial sutures The umbilical skin was reapproximated with interrupted 5 0 Vicryl Rapide The remaining skin incisions were closed with 5 0 Monocryl subcuticular suture The skin was cleaned Mastisol Steri Strips and band aids were applied The patient was awakened extubated in the operating room transferred to the recovery room in stable condition Keywords surgery endo gia endocatch bag symptomatic cholelithiasis laparoscopic cholecystectomy appendectomy cholangiogram mesoappendix abdomen appendix cholelithiasis endotracheal laparoscopic cholecystectomy gallbladder duct MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 9 Transcription PROCEDURE PERFORMED Laparoscopic cholecystectomy PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adapter in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer s lines spreading the subcutaneous tissues with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 3 other trocars were placed The first was a 10 11 mm trocar in the upper midline position The second was a 5 mm trocar placed in the anterior iliac spine The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder A laparoscopic dissector was then placed through the upper midline cannula fitted with a reducer and the structures within the triangle of Calot were meticulously dissected free A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally The duct was divided between the clips The clips were carefully placed to avoid occluding the juncture with the common bile duct The cystic artery was found medially and slightly posterior to the cystic duct It was carefully dissected free from its surrounding tissues A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally The artery was divided between the clips The 2 midline port sites were injected with 5 Marcaine After the complete detachment of the gallbladder from the liver the video laparoscope was removed and placed through the upper 10 11 mm cannula The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula As the gallbladder was pulled through the umbilical fascial defect the entire sheath and forceps were removed from the abdomen The neck of the gallbladder was removed from the abdomen Following gallbladder removal the remaining carbon dioxide was expelled from the abdomen Both midline fascial defects were then approximated using 0 Vicryl suture All skin incisions were approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied Dressings were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords surgery langer s lines laparoscope cystic duct cystic artery laparoscopic cholecystectomy midline cannula infraumbilical tonsil cholecystectomy fascia abdomen trocars cannula laparoscopic gallbladder MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with attempted intraoperative cholangiogram A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy Cholangiogram 1 Transcription PROCEDURE PERFORMED Laparoscopic cholecystectomy with attempted intraoperative cholangiogram PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adapter in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer s lines spreading the subcutaneous tissues with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 3 other trocars were placed The first was a 10 11 mm trocar in the upper midline position The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder A laparoscopic dissector was then placed through the upper midline cannula fitted with a reducer and the structures within the triangle of Calot were meticulously dissected free A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder The gallbladder was then grasped through the upper midline cannula and a fine tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips Several attempts at passing the cholangiocatheter into the ductotomy were made Despite numerous attempts at several angles the cholangiocatheter could not be inserted into the cystic duct After several such attempts and due to the fact that the anatomy was clear we aborted any further attempts at cholangiography The distal cystic duct was doubly clipped The duct was divided between the clips The clips were carefully placed to avoid occluding the juncture with the common bile duct The port sites were injected with 0 5 Marcaine The cystic artery was found medially and slightly posteriorly to the cystic duct It was carefully dissected free from its surrounding tissues A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally The artery was divided between the clips The port sites were injected with 0 5 Marcaine After the cystic duct and artery were transected the gallbladder was dissected from the liver bed using Bovie electrocautery Prior to complete dissection of the gallbladder from the liver the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none After the complete detachment of the gallbladder from the liver the video laparoscope was removed and placed through the upper 10 11 mm cannula The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula As the gallbladder was pulled through the umbilical fascial defect the entire sheath and forceps were removed from the abdomen The neck of the gallbladder was then secured with a Kocher clamp and the gallbladder was removed from the abdomen Following gallbladder removal the remaining carbon dioxide was expelled from the abdomen Both midline fascial defects were then approximated using 0 Vicryl suture All skin incisions were approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied Dressings were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords surgery intraoperative cholangiogram cystic artery laparoscopic cholecystectomy cystic duct gallbladder tonsil cholecystectomy cholangiogram abdomen laparoscopic cannula MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with cholangiogram Acute gangrenous cholecystitis with cholelithiasis The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy Cholangiogram Transcription PREOPERATIVE DIAGNOSIS Acute cholecystitis POSTOPERATIVE DIAGNOSIS Acute gangrenous cholecystitis with cholelithiasis OPERATION PERFORMED Laparoscopic cholecystectomy with cholangiogram FINDINGS The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder COMPLICATIONS None EBL Scant SPECIMEN REMOVED Gallbladder with stones DESCRIPTION OF PROCEDURE The patient was prepped and draped in the usual sterile fashion under general anesthesia A curvilinear incision was made below the umbilicus Through this incision the camera port was able to be placed into the peritoneal cavity under direct visualization Once this complete insufflation was begun Once insufflation was adequate additional ports were placed in the epigastrium as well as right upper quadrant Once all four ports were placed the right upper quadrant was then explored The patient had significant adhesions of omentum and colon to the liver the gallbladder constituting definitely an acute cholecystitis This was taken down using Bovie cautery to free up visualization of the gallbladder The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall Adhesions were further taken down between the omentum the colon and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area Once the adhesions were fully removed the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction At this point due to the patient s gallbladder being very necrotic it was deemed that the patient should have a drain placed The cystic duct and cystic artery were serially clipped and transected The gallbladder was removed from the gallbladder fossa removing the entire gallbladder Adequate hemostasis with Bovie cautery was achieved The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3 0 nylon suture Next the right upper quadrant was copiously irrigated out using the suction irrigator Once this was complete the additional ports were able to be removed The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure of 8 fashion All skin incisions were injected using Marcaine 1 4 percent plain The skin was reapproximated further using 4 0 Monocryl sutures in a subcuticular technique The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition Keywords surgery acute cholecystitis cholangiogram cholelithiasis cholecystitis gallbladder gangrenous cholecystitis bovie cautery cystic duct laparoscopic cholecystectomy laparoscopic cholecystectomy cystic duct MEDICAL_TRANSCRIPTION,Description Cholecystitis and cholelithiasis Laparoscopic cholecystectomy and intraoperative cholangiogram The patient received 1 gm of IV Ancef intravenously piggyback The abdomen was prepared and draped in routine sterile fashion Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 7 Transcription PREOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis POSTOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis TITLE OF PROCEDURE 1 Laparoscopic cholecystectomy 2 Intraoperative cholangiogram ANESTHESIA General PROCEDURE IN DETAIL The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic The patient received 1 gm of IV Ancef intravenously piggyback The abdomen was prepared and draped in routine sterile fashion A 1 cm incision was made at the umbilicus and a Veress needle was inserted Saline test was performed Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg The Veress needle was removed A 10 to 11 mm cannula was inserted Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it It was largely mobile The liver had a normal appearance as did the peritoneal cavity A 5 mm cannula was inserted in the right upper quadrant anterior axillary line A second 5 mm cannula was inserted in the subcostal space A 10 to 11 mm cannula was inserted into the upper midline The gallbladder was reflected in a cephalad direction The gallbladder was punctured with the aspirating needle and under C arm fluoroscopy was filled with contrast filling the intra and extrahepatic biliary trees which appeared normal Extra contrast was aspirated and the aspirating needle was removed The ampulla was grasped with a second grasper opening the triangle of Calot The cystic duct was dissected and exposed at its junction with the ampulla was controlled with a hemoclip digitally controlled with two clips and divided This was done while the common duct was in full visualization The cystic artery was similarly controlled and divided The gallbladder was dissected from its bed and separated from the liver brought to the outside through the upper midline cannula and removed The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution There was oozing and bleeding from the lateral 5 mm cannula site but this stopped spontaneously with removal of the cannula The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear Hemostasis was excellent CO2 was evacuated and the camera removed The umbilical fascia was closed with 2 0 Vicryl the subcu with 3 0 Vicryl and the skin was closed with 4 0 nylon Sterile dressings were applied Sponge and needle counts were correct Keywords surgery cholangiogram cholecystitis cholelithiasis ancef endotracheal umbilicus veress needle c arm fluoroscopy intraoperative cholangiogram laparoscopic cholecystectomy laparoscopic cholecystectomy gallbladder cannula MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis Laparoscopic cholecystectomy Patient with increasingly severe more frequent right upper quadrant abdominal pain more after meals had a positive ultrasound for significant biliary sludge Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 8 Transcription PREOPERATIVE DIAGNOSIS Chronic cholecystitis POSTOPERATIVE DIAGNOSIS Chronic cholecystitis PROCEDURE PERFORMED Laparoscopic cholecystectomy BLOOD LOSS Minimal ANESTHESIA General endotracheal anesthesia COMPLICATIONS None CONDITION Stable DRAINS None DISPOSITION To recovery room and to home FLUIDS Crystalloid FINDINGS Consistent with chronic cholecystitis Final pathology is pending INDICATIONS FOR THE PROCEDURE Briefly the patient is a 38 year old male referred with increasingly severe more frequent right upper quadrant abdominal pain more after meals had a positive ultrasound for significant biliary sludge He presented now after informed consent for the above procedure PROCEDURE IN DETAIL The patient was identified in the preanesthesia area then taken to the operating room placed in the supine position on the operating table and induced under general endotracheal anesthesia The patient was correctly positioned padded at all pressure points had antiembolic TED hose and Flowtrons in the lower extremities The anterior abdomen was then prepared and draped in a sterile fashion Preemptive local anesthetic was infiltrated with 1 lidocaine and 0 5 ropivacaine The initial incision was made sharply at the umbilicus with a 15 scalpel blade and carried down through deeper tissues with Bovie cautery down to the midline fascia with a 15 scalpel blade The blunt tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg The epigastric and right subcostal trocars were placed under direct vision The right upper quadrant was well visualized The gallbladder was noted to be significantly distended with surrounding dense adhesions The fundus of the gallbladder was grasped and retracted anteriorly and superiorly and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet nose Bovie dissector and the blunt Kittner peanut dissector Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right angle clamp The cystic duct was clipped x3 and then divided The cystic artery was dissected out in like fashion clipped x3 and then divided The gallbladder was then taken off the liver bed in a retrograde fashion using the hook tip Bovie cautery with good hemostasis Prior to removal of the gallbladder all irrigation fluid was clear No active bleeding or oozing was seen All clips were noted to be secured and intact and in place The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology The camera was placed back once again into the abdominal cavity through the umbilical port and all areas remained clean and dry and the trocar was removed under direct visualization The insufflation was allowed to escape The umbilical fascia was closed using interrupted 1 Vicryl sutures Finally the skin was closed in a layered subcuticular fashion with interrupted 3 0 and 4 0 Monocryl Sterile dressings were applied The patient tolerated the procedure well Keywords surgery abdomen bovie cautery endotracheal anesthesia laparoscopic cholecystectomy cystic duct chronic cholecystitis abdominal laparoscopic cholecystectomy cholecystitis gallbladder MEDICAL_TRANSCRIPTION,Description Cholelithiasis possible choledocholithiasis Laparoscopic cholecystectomy and intraoperative cholangiogram A small incision was made in the umbilicus and a Veress needle was introduced into the abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed into the umbilicus Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 6 Transcription PREOPERATIVE DIAGNOSIS Cholelithiasis possible choledocholithiasis Keywords surgery choledocholithiasis cholangiogram co2 insufflation umbilicus common bile duct bile duct laparoscopic cholecystectomy cystic duct intraoperative laparoscopic cholecystectomy cholelithiasis endotracheal gallbladder cystic duct MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Biliary colic and biliary dyskinesia The patient had a workup for her gallbladder which showed evidence of biliary dyskinesia Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 10 Transcription PREOPERATIVE DIAGNOSIS Biliary colic and biliary dyskinesia POSTOPERATIVE DIAGNOSIS Biliary colic and biliary dyskinesia PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General endotracheal COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition BRIEF HISTORY This patient is a 42 year old female who presented to Dr X s office with complaints of upper abdominal and back pain which was sudden onset for couple of weeks The patient is also diabetic The patient had a workup for her gallbladder which showed evidence of biliary dyskinesia The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia INTRAOPERATIVE FINDINGS The patient s abdomen was explored There was no evidence of any peritoneal studding or masses The abdomen was otherwise within normal limits The gallbladder was easily visualized There was an intrahepatic gallbladder There was no evidence of any inflammatory change PROCEDURE After informed written consent the risks and benefits of the procedure were explained to the patient The patient was brought into the operating suite After general endotracheal intubation the patient was prepped and draped in normal sterile fashion Next an infraumbilical incision was made with a 10 scalpel The skin was elevated with towel clips and a Veress needle was inserted The abdomen was then insufflated to 15 mmHg of pressure The Veress needle was removed and a 10 blade trocar was inserted without difficulty The laparoscope was then inserted through this 10 port and the abdomen was explored There was no evidence of any peritoneal studding The peritoneum was smooth The gallbladder was intrahepatic somewhat No evidence of any inflammatory change There were no other abnormalities noted in the abdomen Next attention was made to placing the epigastric 10 port which again was placed under direct visualization without difficulty The two 5 ports were placed one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization The gallbladder was then grasped out at its fundus elevated to patient s left shoulder Using a curved dissector the cystic duct was identified and freed up circumferentially Next an Endoclip was used to distal and proximal to the gallbladder Endoshears were used in between to transect the cystic duct The cystic artery was transected in similar fashion Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip It was done without difficulty The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology Hemostasis was maintained using electrobovie cautery The liver bed was then copiously irrigated and aspirated All the fluid and air was then aspirated and then all ports were removed under direct visualization The two 10 ports were then closed in the fascia with 0 Vicryl and a UR6 needle The skin was closed with a running subcuticular 4 0 undyed Vicryl 0 25 Marcaine was injected and Steri Strips and sterile dressings were applied The patient tolerated the procedure well and was transferred to Recovery in stable condition Keywords surgery electrobovie cautery laparoscopic cholecystectomy biliary colic biliary dyskinesia biliary laparoscopic cholecystectomy colic abdomen dyskinesia gallbladder MEDICAL_TRANSCRIPTION,Description Standard Laparoscopic Cholecystectomy Operative Note Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy Transcription The patient s abdomen was prepped and draped in the usual sterile fashion A subumbilical skin incision was made The Veress needle was inserted and the patient s abdominal cavity was insufflated with moderate pressure all times A subumbilical trocar was inserted The camera was inserted in the panoramic view The abdomen demonstrated some inflammation around the gallbladder A 10 mm midepigastric trocar was inserted A 2 mm and 5 mm trocars were inserted The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge Using the dissector the cystic duct was identified and double Hemoclips were invited well away from the cystic common duct junction The cystic artery was identified and double Hemoclips applied The gallbladder was taken down from the liver bed using Endoshears and electrocautery Hemostasis was obtained The gallbladder was removed from the midepigastric trocar site without difficulty The trocars were removed and the skin incisions were reapproximated using 4 0 Monocryl Steri Strips and sterile dressing were placed The patient tolerated the procedure well and was taken to the recovery room in stable condition Keywords surgery gallbladder laparoscopic cholecystectomy midepigastric trocar double hemoclips laparoscopic cholecystectomy midepigastric trocars hemoclips trocarNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Biliary colic Laparoscopic cholecystectomy Laparoscopic examination showed no injury from entry Marcaine was then injected just subxiphoid and a 5 mm port was placed under direct visualization for the laparoscope Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 5 Transcription PREOPERATIVE DIAGNOSIS Biliary colic Keywords surgery veress needle gallbladder laparoscope laparoscopic examination endotracheal intubation laparoscopic cholecystectomy biliary colic abdomen cholecystectomy endotracheal umbilicus laparoscopic MEDICAL_TRANSCRIPTION,Description Acute cholecystitis Laparoscopic cholecystectomy The abdominal area was prepped and draped in the usual sterile fashion A small skin incision was made below the umbilicus It was carried down in the transverse direction on the side of her old incision It was carried down to the fascia Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 4 Transcription PREOPERATIVE DIAGNOSIS Acute cholecystitis POSTOPERATIVE DIAGNOSIS Acute cholecystitis PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE The patient was taken to the operating room and after obtaining adequate general anesthesia the patient was placed in the supine position The abdominal area was prepped and draped in the usual sterile fashion A small skin incision was made below the umbilicus It was carried down in the transverse direction on the side of her old incision It was carried down to the fascia An open pneumoperitoneum was created with Hasson technique Three additional ports were placed in the usual fashion The gallbladder was found to be acutely inflamed distended and with some necrotic areas It was carefully retracted from the isthmus and the cystic structure was then carefully identified dissected and divided between double clips The gallbladder was then taken down from the gallbladder fossa with electrocautery There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones The fascia had to be opened The gallbladder had to be opened and the stones had to be extracted carefully When it was completed I went back to the abdomen and achieved complete hemostasis The ports were then removed under direct vision with the scope The fascia of the umbilical wound was closed with a figure of eight 0 Vicryl All the incisions were injected with 0 25 Marcaine closed with 4 0 Monocryl Steri Strips and sterile dressing The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition Keywords surgery laparoscopic cholecystectomy cholecystitis gallbladder fossa laparoscopic cholecystectomy acute cholecystitis gallbladder MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis without cholelithiasis Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 3 Transcription PREOPERATIVE DIAGNOSIS Chronic cholecystitis without cholelithiasis POSTOPERATIVE DIAGNOSIS Chronic cholecystitis without cholelithiasis PROCEDURE Laparoscopic cholecystectomy BRIEF DESCRIPTION The patient was brought to the operating room and anesthesia was induced The abdomen was prepped and draped and ports were placed The gallbladder was grasped and retracted The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak The ports were removed under direct vision with good hemostasis The Hasson was removed The abdomen was desufflated The gallbladder in its endo catch bag was removed The ports were closed The patient tolerated the procedure well Please see full hospital dictation Keywords surgery chronic cholecystitis without cholelithiasis laparoscopic cholecystectomy cystic duct cystic artery endo catch chronic cholecystitis laparoscopic cholecystectomy abdomen cholecystitis cholelithiasis gallbladder cystic MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 2 Transcription PREOPERATIVE DIAGNOSIS 1 Cholelithiasis 2 Chronic cholecystitis POSTOPERATIVE DIAGNOSIS 1 Cholelithiasis 2 Chronic cholecystitis NAME OF OPERATION Laparoscopic cholecystectomy ANESTHESIA General FINDINGS The gallbladder was thickened and showed evidence of chronic cholecystitis There was a great deal of inflammatory reaction around the cystic duct The cystic duct was slightly larger There was a stone impacted in the cystic duct with the gallbladder The gallbladder contained numerous stones which were small With the stone impacted in the cystic duct it was felt that probably none were within the common duct Other than rather marked obesity no other significant findings were noted on limited exploration of the abdomen PROCEDURE Under general anesthesia after routine prepping and draping the abdomen was insufflated with the Veress needle and the standard four trocars were inserted uneventfully Inspection was made for any entry problems and none were encountered After limited exploration the gallbladder was then retracted superiorly and laterally and the cystic duct was dissected out This was done with some difficulty due to the fibrosis around the cystic duct but care was taken to avoid injury to the duct and to the common duct In this manner the cystic duct and cystic artery were dissected out Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct The cystic duct and cystic artery were then doubly clipped and divided taking care to avoid injury to the common duct The gallbladder was then dissected free from the gallbladder bed Again the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding The gallbladder was extracted through the operating trocar site and the trocar was reinserted Inspection was made of the gallbladder bed One or two bleeding areas were fulgurated and bleeding was well controlled Keywords surgery cholelithiasis chronic inflammatory reaction cystic artery laparoscopic cholecystectomy common duct chronic cholecystitis gallbladder bed cystic duct cystic gallbladder duct inflammatory MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Medical Specialty Surgery Sample Name Laparoscopic Cholecystectomy 1 Transcription PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced The patient was then prepped and draped in the usual sterile fashion An 11 blade scalpel was used to make a small infraumbilical skin incision in the midline The fascia was elevated between two Ochsner clamps and then incised A figure of eight stitch of 2 0 Vicryl was placed through the fascial edges The 11 mm port without the trocar engaged was then placed into the abdomen A pneumoperitoneum was established After an adequate pneumoperitoneum had been established the laparoscope was inserted Three additional ports were placed all under direct vision An 11 mm port was placed in the epigastric area Two 5 mm ports were placed in the right upper quadrant The patient was placed in reverse Trendelenburg position and slightly rotated to the left The fundus of the gallbladder was retracted superiorly and laterally The infundibulum was retracted inferiorly and laterally Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder The triangle of Calot was carefully opened up The cystic duct was identified heading up into the base of the gallbladder The cystic artery was also identified within the triangle of Calot After the triangle of Calot had been carefully dissected a clip was then placed high up on the cystic duct near its junction with the gallbladder The cystic artery was clipped twice proximally and once distally Scissors were then introduced and used to make a small ductotomy in the cystic duct and the cystic artery was divided An intraoperative cholangiogram was obtained This revealed good flow through the cystic duct and into the common bile duct There was good flow into the duodenum without any filling defects The hepatic radicals were clearly visualized The cholangiocatheter was removed and two clips were then placed distal to the ductotomy on the cystic duct The cystic duct was then divided using scissors The gallbladder was then removed up away from the liver bed using electrocautery The gallbladder was easily removed through the epigastric port site The liver bed was then irrigated and suctioned All dissection areas were inspected They were hemostatic There was not any bile leakage All clips were in place The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry All ports were then removed under direct vision The abdominal cavity was allowed to deflate The fascia at the epigastric port site was closed with a stitch of 2 0 Vicryl The fascia at the umbilical port was closed by tying the previously placed stitch All skin incisions were then closed with subcuticular sutures of 4 0 Monocryl and 0 25 Marcaine with epinephrine was infiltrated into all port sites The patient tolerated the procedure well The patient is currently being aroused from general endotracheal anesthesia I was present during the entire case Keywords surgery laparoscopic calot ochsner clamps additional ports cholangiogram cholecystectomy cystic duct duodenum epigastric fascia gallbladder infraumbilical skin incision infundibulum pneumoperitoneum triangle of calot laparoscopic cholecystectomy liver bed epigastric port port site cystic artery triangle port duct cysticNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Appendicitis Laparoscopic appendectomy Infraumbilical incision was performed and taken down to the fascia The fascia was incised The peritoneal cavity was carefully entered Two other ports were placed in the right and left lower quadrants Medical Specialty Surgery Sample Name Laparoscopic Appendectomy 2 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was prepped and draped in sterile fashion Infraumbilical incision was performed and taken down to the fascia The fascia was incised The peritoneal cavity was carefully entered Two other ports were placed in the right and left lower quadrants The appendix was readily identified and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag All hemostasis was further reconfirmed No leakage of enteral contents was noted All trocars were removed under direct visualization The umbilical fascia was closed with interrupted 0 Vicryl sutures The skin was closed with 4 0 Monocryl subcuticular stitch and dressed with Steri Strips and 4 x 4 s The patient was extubated and taken to the recovery area in stable condition The patient tolerated the procedure well Keywords surgery mesoappendix endocatch laparoscopic appendectomy appendix umbilical laparoscopic appendectomy appendicitis fascia infraumbilical MEDICAL_TRANSCRIPTION,Description Dilatation and curettage D C and Laparoscopic ablation of endometrial implants Pelvic pain hypermenorrhea and mild pelvic endometriosis Medical Specialty Surgery Sample Name Laparoscopic Ablation of Eendometrial Implants Transcription PREOPERATIVE DIAGNOSES 1 Pelvic pain 2 Hypermenorrhea POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Hypermenorrhea 3 Mild pelvic endometriosis PROCEDURE PERFORMED 1 Dilatation and curettage D C 2 Laparoscopic ablation of endometrial implants ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc SPECIMEN Endometrial curettings INDICATIONS This is a 26 year old female with a history of approximately one year of heavy painful menses She did complain of some dyspareunia and wants a definitive diagnosis FINDINGS On bimanual exam the uterus is small and anteverted with mildly decreased mobility on the left side There are no adnexal masses appreciated On laparoscopic exam the uterus is normal appearing but slightly compressible The bilateral tubes and ovaries appear normal There is evidence of endometriosis on the left pelvic sidewall in the posterior cul de sac There was no endometriosis in the right pelvic sidewall or along the bladder flap There were some adhesions on the right abdominal sidewall from the previous appendectomy The liver margin gallbladder and bowel appeared normal The uterus was sounded to 9 cm PROCEDURE After consent was obtained the patient was taken to the operating room and general anesthetic was administered The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion Sterile speculum was placed in the patient s vagina The anterior lip of the cervix was grasped with vulsellum tenaculum The uterus was sounded to 9 cm The cervix was then serially dilated with Hank dilators A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium The moderate amount of tissue that was obtained was sent to Pathology The 20 Hank dilator was then replaced and the sterile speculum was removed Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made The Veress needle was placed into this incision and the gas was turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate The 11 mm trocar was then placed through this incision and a camera was placed with the above findings noted A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul de sac was removed to allow better visualization of the posterior cul de sac The lesions in the posterior cul de sac were then ablated using the Harmonic scalpel All instruments were then removed The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar was removed The skin was closed with 4 0 undyed Vicryl in subcuticular fashion Approximately 10 cc of 0 25 Marcaine was placed in the incision sites The dilator and vulsellum tenaculum were removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of procedure The patient was taken to the recovery room in satisfactory condition She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives Keywords surgery pelvic pain hypermenorrhea endometriosis dilatation and curettage d c endometrial implants ablation cul de sac vulsellum tenaculum hank dilators laparoscopic ablation bierman needle pelvic MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy The patient is a 42 year old female who presented with right lower quadrant pain She was evaluated and found to have a CT evidence of appendicitis Medical Specialty Surgery Sample Name Laparoscopic Appendectomy 5 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General endotracheal INDICATION FOR OPERATION The patient is a 42 year old female who presented with right lower quadrant pain She was evaluated and found to have a CT evidence of appendicitis She was subsequently consented for a laparoscopic appendectomy DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the operating room placed supine on the table The abdomen was prepared and draped in usual sterile fashion After the induction of satisfactory general endotracheal anesthesia supraumbilical incision was made A Veress needle was inserted Abdomen was insufflated to 15 mmHg A 5 mm port and camera placed The abdomen was visually explored There were no obvious abnormalities A 15 mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two Blunt dissection was used to isolate the appendix Appendix was separated from surrounding structures A window was created between the appendix and the mesoappendix GIA stapler was tossed across it and fired Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler Appendix was placed in an Endobag and removed from the patient Right lower quadrant was copiously irrigated All irrigation fluids were removed Hemostasis was verified The 15 mm port was removed and the port site closed with 0 Vicryl in the Endoclose device All other ports were irrigated infiltrated with 0 25 Marcaine and closed with 4 0 Vicryl subcuticular sutures Steri Strips and sterile dressings were applied Overall the patient tolerated this well was awakened and returned to recovery in good condition Keywords surgery gia stapler laparoscopic appendectomy appendectomy endotracheal mesoappendix laparoscopic appendicitis appendix MEDICAL_TRANSCRIPTION,Description Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots Right L4 S1 posterolateral fusion with local bone graft Left L4 through S1 segmental pedicle screw instrumentation Preparation harvesting of local bone graft Medical Specialty Surgery Sample Name Laminotomy Facetectomy Foraminotomy Transcription PREOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis POSTOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis OPERATION PERFORMED 1 Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots 2 Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots 3 Right L4 S1 posterolateral fusion with local bone graft 4 Left L4 through S1 segmental pedicle screw instrumentation 5 Preparation harvesting of local bone graft ANESTHESIA General endotracheal PREPARATION Povidone iodine INDICATION This is a gentleman with right sided lumbosacral radiculopathy MRI disclosed and lateral recess stenosis at the L4 5 L5 S1 foraminal narrowing in L4 and L5 roots The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain The patient understood major risks and complications such as death and paralysis seemingly rare main concern is a 10 to 15 of failure rate to respond to surgery for which further surgery may or may not be indicated small risk of wound infection spinal fluid leak The patient is understanding and agreed to proceed and signed the consent PROCEDURE The patient was brought to the operating room peripheral venous lines were placed General anesthesia was induced The patient was intubated Foley catheter was in place The patient laid prone onto the OSI table using 6 post pressure points were carefully padded the back was shaved sterilely prepped and draped A previous incision was infiltrated with local and incised with a scalpel The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4 L5 in the sacral ala Laminotomies were then performed at L4 L5 and L5 S1 in a similar fashion using Midas Rex drill with AM8 bit inferior portion of lamina below and superior portion of lamina above and the medial facet was drilled down to the thin shelf of bone The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison bone was harvested throughout to be used for bone grafting The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies L4 L5 roots were extensively decompressed Pars interarticularis were maintained Using angled 2 mm Kerrisons hypertrophied ligamentum flavum the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise Pedicle screws were placed L4 L5 and S1 on the right side Initial hole began with Midas Rex drill deepened with a gear shift and with 4 5 mm tap palpating with pedicle probe It showed no penetration outside the pedicle vertebral body At L4 L5 5 5 x 45 mm screws were placed and at S1 5 5 x 40 mm screw was placed Good bone purchase was obtained Gelfoam was placed over the roots laterally corticated transverse processes lateral facet joints were prepared small infuse sponge was placed posterolaterally on the right side then the local bone graft from L4 to S1 Traction was applied between the L4 L5 L5 S1 screws locking notes were tightened out heads were rotated fractured off about 2 3 mm traction were applied at each side further opening the foramen for the exiting roots Prior to placement of BMP the wound was irrigated with antibiotic irrigation Medium Hemovac drain was placed in the depth of wound brought out through a separate stab incision Deep fascia was closed with 1 Vicryl subcutaneous fascia with 1 Vicryl and subcuticular with 2 0 Vicryl Skin was stapled The drain was sutured in place with 2 0 Vicryl and connected to closed drain system The patient was laid supine on the bed extubated and taken to recovery room in satisfactory condition The patient tolerated the procedure well without apparent complication Final sponge and needle counts are correct Estimated blood loss 600 mL The patient received 200 mL of cell saver blood back Keywords surgery lumbosacral radiculopathy lumbar spondylolysis laminotomies medial facetectomies foraminotomies decompression nerve roots fusion bone graft segmental pedicle screw transverse processes bone facetectomies transpedicular graft pedicle MEDICAL_TRANSCRIPTION,Description Ruptured appendicitis Medical Specialty Surgery Sample Name Laparoscopic Appendectomy 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Ruptured appendicitis PROCEDURE Laparoscopic appendectomy INDICATIONS FOR PROCEDURE This patient is a 4 year old boy with less than 24 hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers The patient has elevated white count on exam and CT scan consistent with acute appendicitis DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s abdomen was prepped and draped in usual sterile fashion A periumbilical incision was made The fascia was incised Peritoneal cavity entered bluntly A 10 mm trocar and scope was passed Peritoneal cavity was insufflated Five mm ports placed in left lower and hypogastric areas On visualization of the right lower quadrant appendix was visualized stuck against the right anterior abdominal wall there is obvious site of perforation and leakage of content and pus We proceeded to take the mesoappendix down to the base and once the base was free we placed GIA stapler across the base fired the stapler removed the appendix through the periumbilical port site We irrigated and suctioned out the right lower and pelvic areas We then removed the ports under direct visualization closed the periumbilical port site fascia with 0 Vicryl all skin incisions with 5 0 Monocryl and dressed with Steri Strips The patient was extubated in the operating table and taken back to recovery room The patient tolerated the procedure well Keywords surgery ruptured appendicitis acute appendicitis laparoscopic appendectomy laparoscopic ruptured abdominal peritoneal periumbilical appendicitis appendectomy MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute appendicitis Medical Specialty Surgery Sample Name Laparoscopic Appendectomy Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis OPERATIVE PROCEDURE Laparoscopic appendectomy INTRAOPERATIVE FINDINGS Include inflamed non perforated appendix OPERATIVE NOTE The patient was seen by me in the preoperative holding area The risks of the procedure were explained She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery General anesthesia was carried out without difficulty and a Foley catheter was inserted The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion A 5 mm blunt port was inserted infra umbilically at the level of the umbilicus under direct vision of a 5 mm 0 degree laparoscope Once we were inside the abdominal cavity CO2 was instilled to attain an adequate pneumoperitoneum A left lower quadrant 5 mm port was placed under direct vision and a 12 mm port in the suprapubic region The 5 mm scope was introduced at the umbilical port and the appendix was easily visualized The base of the cecum was acutely inflamed but not perforated I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty I reloaded with a red vascular cartridge came across the mesoappendix without difficulty I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty I reinserted the suprapubic port and irrigated out the right lower quadrant until dry One final inspection revealed no bleeding from the staple line We then removed all ports under direct vision and there was no bleeding from the abdominal trocar sites The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0 Vicryl suture The skin incision was injected with 0 25 Marcaine and closed with 4 0 Monocryl suture Steri strips and sterile dressings were applied No complications Minimal blood loss Specimen is the appendix Brought to the recovery room in stable condition Keywords surgery appendix endobag laparoscopic appendectomy acute appendicitis appendectomy umbilically abdominal pneumoperitoneum laparoscopic appendicitis suprapubic mesoappendix MEDICAL_TRANSCRIPTION,Description Acute appendicitis with perforation Laparoscopic appendectomy A CT scan of abdomen showed evidence of appendicitis with perforation Medical Specialty Surgery Sample Name Laparoscopic Appendectomy 4 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis with perforation POSTOPERATIVE DIAGNOSIS Acute appendicitis with perforation ANESTHESIA General PROCEDURE Laparoscopic appendectomy INDICATIONS FOR PROCEDURE The patient is a 4 year old little boy who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia high fever and signs of peritonitis A CT scan of his abdomen showed evidence of appendicitis with perforation He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process He required several boluses of fluid for tachycardia and evidence of dehydration I met with Carlos parents and talked to them about the diagnosis of appendicis and surgical risks benefits and alternative treatment options All their questions have been answered and they agree with the surgical plan OPERATIVE FINDINGS The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well DESCRIPTION OF PROCEDURE The patient came to the operating room and had an uneventful induction of general anesthesia A Foley catheter was placed for decompression and his abdomen was prepared and draped in a standard fashion A 0 25 Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion We conducted our surgical timeout and reiterated all of Carlos unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure A 1 cm vertical infraumbilical incision was made and an open technique was used to place a 12 mm Step trocar through the umbilical fascia CO2 was insufflated to a pressure of 15 mmHg and then two additional 5 mm working ports were placed in areas that had been previously anesthetized There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum After these were gently separated we began to identify the appendix In the __________ due to the large amount of small bowel dilatation and distension I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix The base of the appendix was then ligated with 2 0 PDS Endoloops and the appendix was amputated and withdrawn through the umbilical port I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system When this was complete the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible The umbilical fascia was closed with figure of eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5 0 Monocryl and Steri Strips The patient tolerated the operation well He was awakened and taken to the recovery room in satisfactory condition His blood loss was less than 10 mL and he received only crystalloid fluid during the procedure Keywords surgery adhesions peritoneum purulent debris umbilical fascia peritoneal cavity laparoscopic appendectomy appendectomy constipation purulent debris umbilical appendix abdomen laparoscopic perforation appendicitis MEDICAL_TRANSCRIPTION,Description Appendicitis Laparoscopic appendectomy CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed through his umbilicus Medical Specialty Surgery Sample Name Laparoscopic Appendectomy 3 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE Laparoscopic appendectomy ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation His abdomen was prepped and draped in a standard sterile surgical fashion A Foley catheter was placed for bladder decompression Marcaine was injected into his umbilicus A small incision was made A Veress needle was introduced in his abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed through his umbilicus A 5 mm port was then placed just to the right side of the umbilicus Another 5 mm port was placed just suprapubic in the midline Upon inspection of the cecum I was able find an inflamed and indurated appendix I was able to clear the mesentery at the base of the appendix between the appendix and the cecum I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery and thereby divided the mesentery and freed the appendix I put the appendix in an Endocatch bag and removed it through the umbilicus I irrigated out the abdomen I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter Thomason and closed the skin of all incisions with a running Monocryl Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well without any complications Keywords surgery foley catheter co2 insufflation endotracheal intubation laparoscopic appendectomy appendectomy intubation cecum laparoscopic appendicitis endotracheal abdomen mesentery umbilicus appendix MEDICAL_TRANSCRIPTION,Description Patient status post lap band placement Medical Specialty Surgery Sample Name Lap Band Adjustment Transcription REASON FOR VISIT Lap band adjustment HISTORY OF PRESENT ILLNESS Ms A is status post lap band placement back in 01 09 and she is here on a band adjustment Apparently she had some problems previously with her adjustments and apparently she has been under a lot of stress She was in a car accident a couple of weeks ago and she has problems she does not feel full She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better PHYSICAL EXAMINATION On exam her temperature is 98 pulse 76 weight 197 7 pounds blood pressure 102 72 BMI is 38 5 she has lost 3 8 pounds since her last visit She was alert and oriented in no apparent distress PROCEDURE I was able to access her port She does have an AP standard low profile I aspirated 6 mL I did add 1 mL so she has got approximately 7 mL in her band she did tolerate water postprocedure ASSESSMENT The patient is status post lap band adjustments doing well has a total of 7 mL within her band tolerated water postprocedure She will come back in two weeks for another adjustment as needed Keywords surgery lap band adjustment lap band placement lap band MEDICAL_TRANSCRIPTION,Description L1 laminotomy microdissection retrieval of foreign body retained lumbar spinal catheter attempted insertion of new external lumbar drain and fluoroscopy Medical Specialty Surgery Sample Name Laminotomy Microdissection Transcription PREOPERATIVE DIAGNOSES 1 Fractured and retained lumbar subarachnoid spinal catheter 2 Pseudotumor cerebri benign intracranial hypertension PROCEDURES 1 L1 laminotomy 2 Microdissection 3 Retrieval of foreign body retained lumbar spinal catheter 4 Attempted insertion of new external lumbar drain 5 Fluoroscopy ANESTHESIA General HISTORY The patient had a lumbar subarachnoid drain placed yesterday All went well with the surgery The catheter stopped draining and on pulling back the catheter it fractured and CT scan showed that the remaining fragment is deep to the lamina The patient continues to have right eye blindness and headaches presumably from the pseudotumor cerebri DESCRIPTION OF PROCEDURE After induction of general anesthesia the patient was placed prone on the operating room table resting on chest rolls Her face was resting in a pink foam headrest Extreme care was taken positioning her because she weighs 92 kg There was a lot of extra padding for her limbs and her limbs were positioned comfortably The arms were not hyperextended Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance A Foley catheter was in place She received IV Cipro 400 mg because she is allergic to most antibiotics Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space The patient was then prepped and draped in a sterile manner A 7 cm incision was made over the L1 lamina The incision was carried down through the fascia all the way down to the spinous processes A self retaining McCullough retractor was placed The laminae were quite deep The microscope was brought in and using the Midas Rex drill with the AM 8 bit and removing some of the spinous process of L1 L2 with double action rongeurs the laminotomy was then done using the drill and great care was taken and using a 2 mm rongeur the last layer of lamina was removed exposing the epidural fat and dura The opening in the bone was 1 5 x 1 5 cm Occasionally bipolar cautery was used for bleeding of epidural veins but this cautery was kept to a minimum Under high magnification the dura was opened with an 11 blade and microscissors At first there was a linear incision vertically to the left of midline and I then needed to make a horizontal incision more towards the right The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus Microdissection under high magnification did not expose the catheter The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps The wound was irrigated with bacitracin irrigation At this point I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle Dr Y also tried Despite using the fluoroscope and our best attempts we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned It will be done at a later date I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location Under high magnification the dura was closed with 6 0 PDS interrupted sutures After the dura was closed a piece of Gelfoam was placed over the dura The paraspinous muscles were closed with 0 Vicryl interrupted sutures The subcutaneous fascia was also closed with 0 Vicryl interrupted suture The subcutaneous layer was closed with 2 0 Vicryl interrupted suture and the skin with 4 0 Vicryl Rapide The 4 0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room The patient tolerated procedure well No complications Sponge and needle counts correct Blood loss minimal none replaced This procedure took 5 hours This case was also extremely difficult due to patient s size and the difficulty of locating the catheter deep to the cauda equina Keywords surgery laminotomy microdissection lumbar spinal catheter external lumbar drain fluoroscopy lumbar subarachnoid spinal catheter intracranial hypertension vicryl interrupted sutures lumbar catheter MEDICAL_TRANSCRIPTION,Description Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty Vertebroplasties at T7 and T9 with insertion of prosthetic device Fracture of the T8 vertebra and T9 vertebra Medical Specialty Surgery Sample Name Kyphoplasty Vertebroplasty Transcription PREOPERATIVE DIAGNOSES 1 Pathologic insufficiency 2 Fracture of the T8 vertebrae and T9 vertebrae POSTOPERATIVE DIAGNOSES 1 Pathologic insufficiency 2 Fracture of the T8 vertebra and T9 vertebra PROCEDURE PERFORMED 1 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty 2 Vertebroplasties at T7 and T9 with insertion of prosthetic device ANESTHESIA Local with sedation SPECIMEN Bone from the T8 vertebra COMPLICATIONS None SURGICAL INDICATIONS The patient is an 80 year old female who had previous history of compression fractures She had recently undergone an additional compression fracture of the T8 vertebrae She was in extreme pain This pain interfered with activities of daily living and was unimproved with conservative treatment modalities She is understanding the risks benefits and potential complications as well as all treatment alternatives The patient provided informed consent OPERATIVE TECHNIQUE The patient was taken to OR 2 where she was placed prone on the Jackson spinal table She was given sedative The thoracodorsal spine was then sterilely prepped and draped in the usual fashion Biplanar image intensification was utilized to localize the T8 T7 and T9 vertebrae Local anesthetic of 1 Marcaine with epinephrine and lidocaine were 50 50 mixed Approximately 7 cc was instilled on the left side This was directly over the posterior aspect of the pedicle on the left Once this was localized the right side was localized as well Stab incisions were then created over the pedicles of T8 bilaterally Jamshidi needles were then placed percutaneously Their position was verified in both AP and lateral images They were advanced slowly under direct image intensification in biplanar fashion Once these were satisfactorily placed the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae The Jamshidi needles were then removed A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae This bone was then removed and sent to the lab The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images Once this was completed a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle This was advanced under direct image intensification in a biplanar fashion Once this was deemed satisfactory it was impacted The inner trocar was removed and a guidewire was then placed An injection cannula was then placed over the guidewire into the body of T7 In a similar fashion T9 was dressed on the left side as well A guidewire was then placed through the Jamshidi needle which was verified in both AP and lateral images The cement injection cannula was then placed over this entering the T9 vertebrae body Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae The balloons were inserted bilaterally The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg These were allowed to expand and reduce the fracture Once this was completed the balloons were deflated and removed The inner cannulas of all four entrance holes were removed and approximately 1 5 cc of cement was injected in each of the cannulas This was done directly under image intensification Once this was completed additional cement was injected into T9 as there was a larger vertebra The cement was allowed to cure The cannula was removed and final radiographs were obtained The stab incisions were then cleansed with water and antibiotic irrigation The wounds were then approximated with 4 0 Nylon in interrupted fashion Compression dressings were applied and fixed with tape She was aroused and moved to her inpatient bed She was moving all four extremities without deficit She had no significant pain Keywords surgery pathologic insufficiency vertebrae fracture fracture reduction vertebroplasties kyphoplasty prosthetic device jamshidi needles insertion prosthetic MEDICAL_TRANSCRIPTION,Description Complete laminectomy L4 and facetectomy L3 L4 level A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level Posterior spinal instrumentation L4 to S1 using Synthes Pangea System Posterior spinal fusion L4 to S1 Insertion of morselized autograft L4 to S1 Medical Specialty Surgery Sample Name Laminectomy Facetectomy Transcription PREOPERATIVE DIAGNOSIS Dural tear postoperative laminectomy L4 L5 POSTOPERATIVE DIAGNOSES 1 Dural tear postoperative laminectomy L4 L5 2 Laterolisthesis L4 L5 3 Spinal instability L4 L5 OPERATIONS PERFORMED 1 Complete laminectomy L4 2 Complete laminectomy plus facetectomy L3 L4 level 3 A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level 4 Posterior spinal instrumentation L4 to S1 using Synthes Pangea System 5 Posterior spinal fusion L4 to S1 6 Insertion of morselized autograft L4 to S1 ANESTHESIA General ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS None DRAINS Hemovac x1 DISPOSITION Vital signs stable taken to the recovery room in a satisfactory condition extubated INDICATIONS FOR OPERATION The patient is a 48 year old gentleman who has had a prior decompression several weeks ago He presented several days later with headaches as well as a draining wound He was subsequently taken back for a dural repair For the last 10 to 11 days he has been okay except for the last two days he has had increasing headaches has nausea vomiting as well as positional migraines He has fullness in the back of his wound The patient s risks and benefits have been conferred him due to the fact that he does have persistent spinal leak The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively PROCEDURE IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled back to the operating theater room 7 The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties The patient was given intraoperative antibiotics The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion Initially a midline incision was made from the cephalad to caudad level Full thickness skin flaps were developed It was seen immediately that there was large amount of copious fluid emanating from the wound clear like fluid which was the cerebrospinal fluid Cultures were taken aerobic anaerobic AFB fungal Once this was done the paraspinal muscles were affected from the posterior elements It was seen that there were no facet complexes on the right side at L4 L5 and L5 S1 It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4 5 level from the listhesis Once this was done however the fluid emanating from the dura could not be seen appropriately Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left Complete laminectomy at L3 was done Once this was done within the subarticular recess on the right side at the L4 pedicle level a rent in the dura was seen Once this was appropriately cleaned the dural edges were approximated using a running 6 0 Prolene suture A Valsalva confirmed no significant lead after the repair was made There was a significant laterolisthesis at L4 L5 and due to the fact that there were no facet complexes at L5 S1 and L4 L5 on the right side as well as there was a significant concavity on the right L4 L5 disk space which was demonstrated from intraoperative x rays and compared to preoperative x rays it was decided from an instrumentation The lateral pedicle screws were placed at L4 L5 and S1 using the standard technique of Magerl After this the standard starting point was made Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall Once this was done this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall The screws were subsequently placed Tricortical purchase was obtained at S1 ________ appropriate size screws Precontoured titanium rod was then appropriately planned and placed between the screws at L4 L5 and S1 This was done on the right side first The screw was torqued at S1 appropriately and subsequently at L5 Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4 Neutral compression distraction was obtained on the left side Screws were torqued at L4 L5 and S1 appropriately Good placement was seen both in AP and lateral planes using fluoroscopy Laterolisthesis corrected appropriately at L4 and L5 Posterior spinal fusion was completed by decorticating the posterior elements at L4 L5 and the sacral ala with a curette Once good bleeding subchondral bone was appreciated the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix This was placed in the posterior lateral gutters DuraGen was then placed over the dural repair and after this fibrin glue was placed appropriately Deep retractors then removed from the confines of the wound Fascia was closed using interrupted Prolene running suture 1 Once this was done suprafascial drain was placed appropriately Subcutaneous tissues were opposed using a 2 0 Prolene suture The dermal edges were approximated using staples Wound was dressed sterilely using bacitracin ointment Xeroform 4 x 4 s and tape The drain was connected appropriately The patient was rolled on stretcher in usual supine position extubated uneventfully and taken back to the recovery room in a satisfactory stable condition No complications arose Keywords MEDICAL_TRANSCRIPTION,Description Left knee arthroscopy with lateral capsular release Medical Specialty Surgery Sample Name Knee Arthroscopy Transcription PREOPERATIVE DIAGNOSIS Left patellar chondromalacia POSTOPERATIVE DIAGNOSIS Left patellar chondromalacia with tight lateral structures PROCEDURE Left knee arthroscopy with lateral capsular release ANESTHESIA Surgery performed under general anesthesia TOURNIQUET TIME 47 minutes MEDICATION The patient received 0 5 Marcaine local anesthetic 32 mL COMPLICATIONS No intraoperative complications DRAINS AND SPECIMENS None HISTORY AND PHYSICAL The patient is a 14 year old girl who started having left knee pain in the fall of 2007 She was not seen in Orthopedic Clinic until November 2007 The patient had an outside MRI performed that demonstrated left patellar chondromalacia only The patient was referred to physical therapy for patellar tracking exercises She was also given a brace The patient reported increasing pain with physical therapy and mother strongly desired other treatment It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy Her failure with nonoperative treatment is below the standard 6 month trial however given her symptoms and severe pain lateral capsular release was offered Risk and benefits of surgery were discussed Risks of surgery including risk of anesthesia infection bleeding changes in sensation and motion extremity failure of procedure to relieve pain need for postoperative rehab and significant postoperative swelling All questions were answered and mother and daughter agreed to the above plans PROCEDURE NOTE The patient was taken to the operating room and placed on the operating table General anesthesia was then administered The patient received Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of left thigh The extremity was then prepped and draped in the standard surgical fashion A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Esmarch was then removed Incisions were then made Camera was initially inserted into the lateral joint line Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation The patient did have congruent articulation about 30 degrees of knee flexion Visualization of the medial joint line revealed no loose bodies There was a small plica Visualization of the medial joint line revealed no significant chondromalacia Menisci was probed and tested with no signs of tears and instability ACL was noted to be intact The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology Lateral gutter also demonstrated no loose bodies or plica The camera was then removed and inserted into the anteromedial portal using two 18 gauge needles The extent of lateral capsular release was marked using a monopolar coblator lateral capsular release was performed The patient had significant improvement in anteromedial translation from 25 to 50 At the end of the case all instruments were removed The knee was injected with 32 mL of 0 5 Marcaine with additional epinephrine Please note the patient received 30 mL of 1 500 000 dilution epinephrine at the beginning of the case The portals were then closed using 4 0 Monocryl The wound was clean and dry and dressed with Steri Strips Xeroform and 4 x 4s The kneecap was translated medially under pressure and a bias placed The tourniquet was released at 47 minutes The patient was then placed in the knee immobilizer The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition POSTOPERATIVE PLAN The patient will weightbear as tolerated in the knee immobilizer She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening Intraoperative findings were relayed to the mother All questions were answered Keywords surgery knee arthroscopy lateral capsular release chondromalacia patellar lateral joint line medial joint line lateral joint medial joint capsular release joint line arthroscopy tourniquet knee MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee with medial meniscoplasty Internal derangement left knee Displaced bucket handle tear of medial meniscus left knee Medical Specialty Surgery Sample Name Knee Arthroscopy Medial Meniscoplasty Transcription PREOPERATIVE DIAGNOSIS Internal derangement left knee POSTOPERATIVE DIAGNOSIS Internal derangement left knee PROCEDURE PERFORMED Arthroscopy of the left knee with medial meniscoplasty ANESTHESIA LMA GROSS FINDINGS Displaced bucket handle tear of medial meniscus left knee PROCEDURE After informed consent was obtained the patient was taken to ABCD General Hospital Operating Room 1 where anesthesia was administered by the Department of Anesthesiology The patient was then transferred to the operating room table in supine position with Johnson knee holder well padded Tourniquet was placed around the left upper thigh The limb was then prepped and draped in usual sterile fashion Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed Patellofemoral joint showed frequent chondromalacia Examination of the medial compartment showed a displaced bucket handle tear of the medial meniscus involving the entire posterior parietal and portion of his anterior portion of the medial meniscus The medial femoral condyle and medial tibial plateau were unaffected Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus The femoral condyle and tibial plateau were all stable to probing Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors A shaver was then used to smooth all the edges until the margins were stable to probing The knee was then flushed with normal saline and suctioned dry 20 cc of 0 25 Marcaine was injected into the knee and into the arthroscopy portals A dressing consisting of Adaptic 4x4s ABDs and Webril were applied followed by a TED hose The patient was then transferred to the recovery room in stable condition Keywords surgery arthroscopy meniscoplasty derangement internal derangement knee displaced bucket handle tear femoral condyle tibial plateau medial meniscoplasty medial meniscus medial MEDICAL_TRANSCRIPTION,Description Left medial compartment osteoarthritis of the knee Left unicompartmental knee replacement Medical Specialty Surgery Sample Name Knee Replacement Transcription PREOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee POSTOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee PROCEDURE PERFORMED Left unicompartmental knee replacement COMPONENTS USED Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component COMPLICATIONS None TOURNIQUET TIME 59 minutes BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE A 55 year old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side She has done quite well with this She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought to the operating room and placed supine on the operating room table After appropriate anesthesia the left lower extremity was identified with a time out procedure Preoperative antibiotics were given Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet The tourniquet was insufflated after elevation of the limb and a standard medial parapatellar incision was used Soft tissue dissection was carried down the retinaculum was opened sharply to expose the joint meniscus that was visible along the tibia was removed The anterior fat pad was removed The knee was then examined The ACL was found to be intact The lateral compartment had very minimal arthritis There were some osteoarthritic changes of the patellofemoral joint but these were felt to be mild Following this the tibial external alignment guide was placed and pinned into place in the appropriate place Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection Following this resection the femoral intramedullary guide was placed without difficulty The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide Once in the appropriate position it was pinned and drilled This was removed and the posterior cutting block was inserted It was impacted into place Posterior bone cut was made for the medium femoral component Next a zero spigot was used and the distal femur was reamed Following this the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed so 1 spigot was used and this was reamed as well Next trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit Next the tibia was prepared The tibial tray was pinned into place and the cuts for the keel of the tibia were made These were removed with a small osteotome from the set Following this a trial tibial with the keel was placed and it did fit nicely After this all trial components were removed The knee was copiously irrigated Cement was begun mixing Drill holes were used along the femur for cement interdigitation The wound was cleaned and dried Cement was placed on the tibia Tibial tray was impacted into place Excess cement was removed Tibia was placed in the femur Femoral component was impacted into place Excess cement was removed It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened Following this it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size A 3 mm polyethylene was chosen and inserted in the knee without difficulty taken through range of motion and found to come out to full extension with no impingement and full flexion The intramedullary rod removed from the femur The wound was irrigated with normal saline The retinaculum was closed with 1 PDS 2 0 Monocryl was used for the subcutaneous tissue and staples used for the skin A sterile dressing was placed Tourniquet was then desufflated Sponge and needle counts were correct at the end of the procedure Dr Jinnah was present for the surgery The patient was transferred to the recovery room in stable condition She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis Prior to closure the posterior capsule was injected with the joint cocktail Keywords surgery knee replacement osteoarthritis osteoarthritis of the knee excess cement was removed medium femoral component medial compartment osteoarthritis unicompartmental knee replacement medium femoral femoral intramedullary intramedullary guide medial compartment femoral component tibial tray lower extremity unicompartmental knee tibial knee tourniquet intramedullary extension flexion compartment unicompartmental replacement femoral cement MEDICAL_TRANSCRIPTION,Description Bilateral knee degenerative arthritis Bilateral knee arthroplasty The Zimmer NexGen total knee system was utilized Medical Specialty Surgery Sample Name Knee Arthroplasty Bilateral Transcription PREOPERATIVE DIAGNOSIS Bilateral knee degenerative arthritis POSTOPERATIVE DIAGNOSIS Bilateral knee degenerative arthritis PROCEDURE PERFORMED Bilateral knee arthroplasty Please note this procedure was done by Dr X for the left total knee and Dr Y for the right total knee This operative note will discuss the right total knee arthroplasty ANESTHESIA General COMPLICATIONS None BLOOD LOSS Approximately 150 cc HISTORY This is a 79 year old female who has disabling bilateral knee degenerative arthritis She has been unresponsive to conservative measures All risks complications anticipated benefits and postoperative course were discussed The patient has agreed to proceed with surgery as described below GROSS FINDINGS There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis SPECIFICATIONS The Zimmer NexGen total knee system was utilized PROCEDURE The patient was taken to the operating room 2 and placed in supine position on the operating room table She was administered spinal anesthetic by Dr Z The tourniquet was placed about the proximal aspect of the right lower extremity The right lower extremity was then sterilely prepped and draped in the usual fashion An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg Longitudinal incision was made over the anterior aspect of the right knee Subcutaneous tissue was carefully dissected A medial parapatellar retinacular incision was made The patella was then everted and the above noted gross findings were appreciated A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place The appropriate cuts were made at the distal femur as well as with use of the chamfer guide The trial femoral component was then positioned in place and noted to have good fit Attention was then directed to proximal tibia the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments The remnants of the anterior cruciate ligament and menisci were resected The tibial trial was positioned in place Intraoperative radiographs were taken demonstrating satisfactory alignment of the tibial cut The tibial holes were then drilled The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate The knee was placed through range of motion with the trial components marked and then the appropriate components obtained The tibial tray was inserted with cement backed it into place excess methylmethacrylate was removed The femoral component was inserted with methylmethacrylate Any excessive methylmethacrylate and bony debris were removed from the joint Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm The methylmethacrylate was also used at the patella The prosthesis was positioned in place The patellar clamp held securely till the methylmethacrylate was firm After all three components were in place the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment This component was removed and revised to a stemmed component with better alignment and position The previous component removed the methylmethacrylate was removed Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached The trial tibial stemmed component was positioned in place Knee was placed through range of motion and the tracking was better Actual component was then obtained methyl methacrylate was placed within the tibia The stemmed tibial component was impacted into place with good fit The Poly was then positioned in place Knee held in full extension with compression longitudinally after methylmethacrylate was solidified The trial Poly was removed Wound was irrigated and the joint was inspected There was no debris Collateral ligaments and posterior cruciate ligaments remained intact Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component The tourniquet was deflated Hemostasis was satisfactory A drain was placed into the depths of the wound The medial retinacular incision was closed with one Ethibond suture in interrupted fashion The knee was placed through range of motion and there was no undue tissue tension good patellar tracking no excessive soft tissue laxity or constrain The subcutaneous tissue was closed with 2 0 undyed Vicryl in interrupted fashion The skin was closed with surgical clips The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity At the completion of the procedure distal pulses were intact Toes were pink warm with good capillary refill Distal neurovascular status was intact Postoperative x ray demonstrated satisfactory alignment of the prosthesis Prognosis is good in this 79 year old female with a significant degenerative arthritis Keywords surgery patellofemoral eburnation osteophyte articulation tibial femoral bilateral knee arthroplasty knee degenerative arthritis zimmer nexgen lower extremity arthroplasty patella methylmethacrylate MEDICAL_TRANSCRIPTION,Description Revision right total knee arthroplasty Right failed total knee arthroplasty Medical Specialty Surgery Sample Name Knee Arthroplasty Revision Transcription PREOPERATIVE DIAGNOSIS Right failed total knee arthroplasty POSTOPERATIVE DIAGNOSIS Right failed total knee arthroplasty PROCEDURE PERFORMED Revision right total knee arthroplasty FIRST ANESTHESIA Spinal ESTIMATED BLOOD LOSS Approximately 75 cc TOURNIQUET TIME 123 minutes Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes COMPONENTS A Zimmer NexGen Legacy knee size D right stemmed femoral component was used A NexGen femoral component with a distal femoral augmented block size 5 mm A NexGen tibial component size 3 mm was used A size 14 mm constrained polyethylene surface was used as well Original patellar component that the patient had was maintained COMPLICATIONS None BRIEF HISTORY The patient is a 68 year old female with a history of knee pain for 13 years She had previous total knee arthroplasty and revision at an outside facility She had continued pain snapping malalignment difficulty with ambulation and giving away and wished to undergo additional revision surgery PROCEDURE The patient was taken to the operative suite and placed on the operating table Department of Anesthesia administered the spinal anesthetic Once adequately anesthetized the patient was placed in a supine position Care was ensured and she was adequately secured and well padded in position Once this was obtained the right lower extremity was prepped and draped in the usual sterile fashion Tourniquet was inflated to approximately 325 mmHg on the right thigh At this point an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface There was noted to be no evidence of purulence or gross clinical appearance of infection however intraoperative cultures were taken to asses this as well At this point the previous articular surface was then removed using an osteotome until this was left free and then removed This was done without difficulty Attention was then directed removing the femoral component Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed After this was performed attention was then directed to the tibial component An osteotome was again inserted around the surface and this was easily pried loose There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation This was evaluated The bone stalk appeared to be adequate however there were noted to be some deficits where we need to trim cement so we elected to proceed with stemmed component The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component At this point the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12 At this point the distal femoral cutting guide based on the intramedullary head was then placed Care was ensured that this was aligned in proper rotation with the external epicondylar axis Once this was pinned in position approximately a six degree valgus cut was then made This allowed a portion of the medial condyle to be removed distally The anterior cut was checked next using the intramedullary guide The anterior surface cutting block was then placed This aligned us to anterior cutting block We ensured again that rotation was aligned with the epicondylar axis Once this was adequately aligned with this and gave us some external rotation this was pinned in position and new anterior cut was made It was noted that minimal bone was taken off the surface only a slight portion on the medial anterior surface _______ was then removed and the chamfer cutting guide was then placed on This allowed us to make a box cut and recut some of the angled cuts of the distal femur Once this was placed and pinned in position Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut It was noted that the anterior chamfers did not need to be cut take off no bone The posterior chamfers did remove some bony aspects This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component After all these cuts were taken the guides were then removed and the trial component with a medial 5 mm augment was then placed This appeared to have an adequate fit and then packed in position It appeared to be satisfactory At this point this was removed and attention was then directed to the tibia The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained At this point the intramedullary guide was used to evaluate a tibial cut This appeared to be adequate however we elected to remove 2 mm of bone to give us a new fresh bony surface The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod which allowed us to ensure that we had proper external rotation of this tibial component At this point this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component This was placed in a proper position A 10 mm articular surface was placed in the knee and this was taken through range of motion This was found to have better alignment and satisfactory position We elected to take an intraoperative x ray at this point to evaluate our cut The intraoperative x ray demonstrates satisfactory cuts and alignment of the prosthesis At this point all trials were removed The patella was then examined The rongeur was used to remove the surrounding synovium The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt however this was very mild and overall had a good position and was well fixed to the bone It was elected at this time to maintain this anatomic patella that was previously placed At this point the joint again was reevaluated and any bone loose fragments removed There was noted to be some posterior tightness and mild osteophytes These were removed with a rongeur At this time while preparing the canals the tourniquet was deflated due to it being 123 minutes Approximately 10 minutes did get by as the knee was copiously irrigated and suctioned dried The tourniquet was then reinflated The canals were prepped for cementing They were suction dried and cleaned The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial Once this was fixed and secured all extra cement was removed and attention was directed to the femoral component The stemmed femoral component was then impacted in position and cemented Again care was ensured that it was in adequate position and proper rotation A size 14 mm poly was then inserted in between to provide compression This was then taken through extension and held until cement cured This was then removed and the components were evaluated All excess cement was removed and they were well fixed Size 14 mm trial Poly was then placed and this was taken through range of motion This was found to have excellent range of motion and good stability It was elected at this time that we would go with the size 14 mm Poly This gave us extra Poly for ware and then provide excellent contact throughout the range of motion The final articular surface was then placed and tightened into position to allow to _______ secured The knee was then reduced and the knee was taken through range of motion The patella was tracking with no touch technique and adequately positioned At this point the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry All bleeding was cauterized using a Bovie cautery The retinaculum was then repaired using 1 Ethibond in a figure of eight fashion This was reinforced with a running 2 0 Vicryl The knee was then flexed and noted that the patella was tracking with good alignment The wound was again copiously irrigated and suctioned dry A drain was placed prior to retinaculum repair deep to this to provide adequate drainage At this point the subcutaneous tissue was closed with 2 0 Vicryl Skin was approximated with skin clips Sterile dressing of Adaptic 4x4 Webril and ABDs were then placed A large Dupre dressing was then placed up the entire lower extremity The patient was then transferred back to recovery in supine position DISPOSITION The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition Keywords surgery knee arthroplasty revision zimmer nexgen distal femoral intramedullary guide femoral component femoral knee arthroplasty intramedullary patellar medial tibial MEDICAL_TRANSCRIPTION,Description KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV R bone cement under low pressure at T12 and L1 levels and bone biopsy Medical Specialty Surgery Sample Name Kyphoplasty Transcription PRE OP DIAGNOSIS Osteoporosis pathologic fractures T12 L2 with severe kyphosis POST OP DIAGNOSIS Osteoporosis pathologic fractures T12 L2 with severe kyphosis PROCEDURE 1 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV R bone cement under low pressure at T12 and L1 levels 2 Bone biopsy medically necessary ANESTHESIA General COMPLICATIONS None BLOOD LOSS Minimal INDICATIONS Mrs Smith is a 75 year old female who has had severe back pain that began approximately three months ago and is debilitating She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics She presents with and is on medication therapy for COPD diabetes and hypertension other co morbidities may be present upon admission and should be documented in the operative note Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12 L1 and L2 In addition to the fractures she presents with kyphotic posture Films on 1 04 demonstrated L1 and L2 osteoporotic fractures Films on 2 04 demonstrated increased loss of height at L1 Films on 3 04 demonstrated a new compression fracture at T12 and further collapse of L1 The L2 fracture is documented on radiographic studies as being chronic and a year or more old The T12 fracture has the most significant kyphotic deformity Based on these findings we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures PROCEDURE The patient was brought to the operating room radiology suite and general anesthesia local sedation with endotracheal intubation was performed The patient was positioned prone on the Jackson table The back was prepped and draped The image intensifier C arm was brought into position and the T12 pedicles were identified and marked with a skin marker In view of the collapse of T12 a transpedicular approach to the vertebral body was appropriate An 11 gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side Positioning was confirmed on the AP and lateral plane Following satisfactory placement of the needle the stylet was removed A guide pin was inserted through the 11g to a point 3mm from the anterior cortex AP and lateral images were taken to verify position and trajectory Alongside of the guide pin a 1 cm paramedian incision was made The needle was then removed leaving the guide pin in place The osteointroducer was placed over the guide pin and advanced through the pedicle Once I was at the junction of the pedicle and the vertebral body a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall Through the cannula a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex creating a channel The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex After completing the entry into the vertebral body a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex The radiopaque marker bands on the bone tamp were identified using AP and lateral images The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body Once both bone tamps were in position they were inflated to 0 5 cc and 50 psi Expansion of the bone tamps was done sequentially in increments of 0 25 to 0 5 cc of contrast with careful attention being paid to the inflation pressures and balloon position The inflation was monitored with AP and lateral imaging The final balloon volume was 3 5 cc on the right side and 3 cc on the left There was no breach of the lateral wall or anterior cortex of the vertebral body Direct reduction of the fracture was achieved end plate movement was noted and approximately 5 mm of height restoration was achieved Under fluoroscopic imaging and the use of the bone void fillers internal fixation was achieved through a low pressure injection of KYPHON HV R bone cement The cavity was filled with a total volume of 3 5 cc on the right side and 3 cc on the left side Once the bone cement had hardened the cannulas were then removed At this time we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12 An entry needle was placed bilaterally through the pedicle into the vertebral body a cortical window was created inflation of the bone tamps directly reduced the fracture the bone tamps were removed and internal fixation by bone void filler insertion was achieved Throughout the procedure AP and lateral imaging monitored positioning Post procedure all incisions were closed with sutures The patient was kept in the prone position for approximately 10 minutes post cement injection She was then turned supine monitored briefly and returned to the floor She was moving both her lower extremities at this time Throughout the procedure there were no intraoperative complications Estimated blood loss was minimal Keywords surgery osteoporosis pathologic fractures kyphosis bone cement balloon kyphoplasty kyphon balloon kyphoplasty bone biopsy kyphon insertion of kyphon ap and lateral vertebral body kyphon balloon anterior cortex vertebral body fractures insertion bone kyphoplasty guide balloon pedicles cortex positioned therapy MEDICAL_TRANSCRIPTION,Description Arthroscopic procedure of the knee Medical Specialty Surgery Sample Name Knee Arthroscopy 1 Transcription PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed in the operating room table in supine position and given general anesthetic Ancef 1 g was given for infectious prophylaxis Once the patient was under general anesthesia the knee was prepped and draped in usual sterile fashion Once the knee was fully prepped and draped then we made 2 standard portals medial and lateral Through the lateral portal the camera was placed Through the medial portal tools were placed We proceeded to examine scarring of the patellofemoral joint Then we probed the patellofemoral joint A chondroplasty was performed using a shaver Then we moved down to the lateral gutter Some loose bodies were found using a shaver and dissection We moved down the medial gutter No plica was found We moved into the medial joint we found that the medial meniscus was intact We moved to the lateral joint and found that the lateral meniscus was intact Pictures were taken We drained the knee and washed out the knee with copious amounts of sterile saline solution The instruments were removed The 2 portals were closed using 3 0 nylon suture Xeroform 4 x 4s Kerlix x2 and TED stocking were placed The patient was successfully extubated and brought to the recovery room in stable condition I then spoke with the family going over the case postoperative instructions and followup care Keywords surgery chondroplasty knee meniscus patellofemoral arthroscopy portals jointNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Medical Specialty Surgery Sample Name Laminectomy Discectomy Facetectomy Transcription TITLE OF OPERATION Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP INDICATIONS FOR SURGERY Please refer to medical record but in short the patient is a 43 year old male known to me status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Risks and benefits of surgery were explained in detail including risk of bleeding infection stroke heart attack paralysis need for further surgery hardware failure persistent symptoms and death This list was inclusive but not exclusive An informed consent was obtained after all patient s questions were answered PREOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly POSTOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly ANESTHESIA General anesthesia and endotracheal tube intubation DISPOSITION The patient to PACU with stable vital signs PROCEDURE IN DETAIL The patient was taken to the operating room After adequate general anesthesia with endotracheal tube intubation was obtained the patient was placed prone on the Jackson table Lumbar spine was shaved prepped and draped in the usual sterile fashion An incision was carried out from L4 to S1 Hemostasis was obtained with bipolar and Bovie cauterization A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4 L5 and sacrum At this time laminectomy was carried out of L5 S1 Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space At this time the disk was entered with a 15 blade and bipolar The disk was entered with straight up and down biting pituitaries curettes and the high speed drill and we were able to takedown calcified herniated disk We were able to reestablish the disk space it was very difficult required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal very carefully holding the spinal canal out of harm s way as well as the exiting nerve root Once this was done we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic At this time Dr X will dictate the posterolateral fusion pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound There were no complications Keywords surgery revision laminectomy discectomy facetectomy arthrodesis lumbar spondylosis hypermobility collapsed disk space medial facetectomy interbody graft herniated disk interbody laminectomy disk therapy lumbar herniated space MEDICAL_TRANSCRIPTION,Description Procedure note on Keller Bunionectomy Medical Specialty Surgery Sample Name Keller Bunionectomy Transcription PROCEDURE Keller Bunionectomy For informed consent the more common risks benefits and alternatives to the procedure were thoroughly discussed with the patient An appropriate consent form was signed indicating that the patient understands the procedure and its possible complications This 59 year old female was brought to the operating room and placed on the surgical table in a supine position Following anesthesia the surgical site was prepped and draped in the normal sterile fashion Attention was then directed to the right foot where utilizing a 15 blade a 6 cm linear incision was made over the 1st metatarsal head taking care to identify and retract all vital structures The incision was medial to and parallel to the extensor hallucis longus tendon The incision was deepened through subcutaneous underscored retracted medially and laterally thus exposing the capsular structures below which were incised in a linear longitudinal manner approximately the length of the skin incision The capsular structures were sharply underscored off the underlying osseous attachments retracted medially and laterally Utilizing an osteotome and mallet the exostosis was removed and the head was remodeled with the Liston bone forceps and the bell rasp The surgical site was then flushed with saline The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm distal to the base and excised to toto from the surgical site Superficial closure was accomplished using Vicryl 5 0 in a running subcuticular fashion Site was dressed with a light compressive dressing The tourniquet was released Excellent capillary refill to all the digits was observed without excessive bleeding noted ANESTHESIA local HEMOSTASIS Accomplished with pinpoint electrocoagulation ESTIMATED BLOOD LOSS 10 cc MATERIALS None INJECTABLES Agent used for local anesthesia was Lidocaine 2 without epi PATHOLOGY Sent no specimen DRESSINGS Site was dressed with a light compressive dressing CONDITION Patient tolerated procedure and anesthesia well Vital signs stable Vascular status intact to all digits Patient recovered in the operating room SCHEDULING Return to clinic in 2 week s Keywords surgery keller bunionectomy metatarsal head incision capsular osteotome compressive dressing keller bunionectomy MEDICAL_TRANSCRIPTION,Description Left below the knee amputation Dressing change right foot Medical Specialty Surgery Sample Name Knee Amputation Transcription PREOPERATIVE DIAGNOSES 1 Left diabetic foot abscess and infection 2 Left calcaneus fracture with infection 3 Right first ray amputation POSTOP DIAGNOSES 1 Left diabetic foot abscess and infection 2 Left calcaneus fracture with infection 3 Right first ray amputation OPERATION AND PROCEDURE 1 Left below the knee amputation 2 Dressing change right foot ANESTHESIA General BLOOD LOSS Less than 100 mL TOURNIQUET TIME 24 minutes on the left 300 mmHg COMPLICATIONS None DRAINS A one eighth inch Hemovac INDICATIONS FOR SURGERY The patient is a 62 years of age with diabetes He developed left heel abscess He had previous debridements developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads After re inspecting the wound last week the plan was for possible debridement and he desired below the knee amputation We are going to change the dressing on the right side also The risks benefits and alternatives of surgery were discussed The risks of bleeding infection damage to nerves and blood vessels persistent wound healing problems and the need for future surgery He understood all the risks and desired operative treatment OPERATIVE PROCEDURE IN DETAIL After appropriate informed consent obtained the patient was taken to the operating room and placed in the supine position General anesthesia induced Once adequate anesthesia had been achieved cast padding placed on the left proximal thigh and tourniquet was applied The right leg was redressed I took the dressing down There was a small bit of central drainage but it was healing nicely Adaptic and new sterile dressings were applied The left lower extremity was then prepped and draped in usual sterile fashion A transverse incision made about the mid shaft of the tibia A long posterior flap was created It was taken to the subcutaneous tissues with electrocautery Please note that tourniquet had been inflated after exsanguination of the limb Superficial peroneal nerve identified clamped and cut Anterior compartment was divided The anterior neurovascular bundle identified clamped and cut The plane was taken between the deep and superficial compartments The superficial compartment was reflected posteriorly Tibial nerve identified clamped and cut Tibial vessels identified clamped and cut Periosteum of the tibia elevated proximally along with the fibula The tibia was then cut with Gigli saw It was beveled anteriorly and smoothed down with a rasp The fibula was cut about a cm and a half proximal to this using a large bone cutter The remaining posterior compartment was divided The peroneal bundle identified clamped and cut The leg was then passed off of the field Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie The nerves were each pulled at length injected with 0 25 Marcaine with epinephrine cut and later retracted proximally The tourniquet was released Good bleeding from the tissues and hemostasis obtained with electrocautery Copious irrigation performed using antibiotic impregnated solution A one eighth inch Hemovac drain placed in the depth of wound adhering on the medial side A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with 1 Vicryl in an interrupted fashion The remaining fascia was closed with 1 Vicryl Subcutaneous tissues were then closed with 2 0 PDS suture using 2 0 Monocryl suture in interrupted fashion Skin closed with skin staples Xeroform gauze 4 x 4 and a padded soft dressing applied He was placed in a well padded anterior and posterior slab splint with the knee in extension He was then awakened extubated and taken to recovery in stable condition There were no immediate operative complications and he tolerated the procedure well Keywords surgery infection adaptic gigli saw hemovac abscess amputation below the knee amputation calcaneus fracture debridement diabetic foot ray amputation tourniquet transverse incision knee amputation knee dressing clamped MEDICAL_TRANSCRIPTION,Description Exam under anesthesia Removal of intrauterine clots Postpartum hemorrhage Medical Specialty Surgery Sample Name Intrauterine Clots Removal Transcription PREOPERATIVE DIAGNOSIS Postpartum hemorrhage POSTOPERATIVE DIAGNOSIS Postpartum hemorrhage PROCEDURE Exam under anesthesia Removal of intrauterine clots ANESTHESIA Conscious sedation ESTIMATED BLOOD LOSS Approximately 200 mL during the procedure but at least 500 mL prior to that and probably more like 1500 mL prior to that COMPLICATIONS None INDICATIONS AND CONCERNS This is a 19 year old G1 P1 female status post vaginal delivery who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery I was called for persistent bleeding and passing large clots I examined the patient and found her to have at least 500 mL of clots in her uterus She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her I did advise her that I would recommend they came under anesthesia and dilation and curettage Risks and benefits of this procedure were discussed with Misty all of her questions were adequately answered and informed consent was obtained PROCEDURE The patient was taken to the operating room where satisfactory conscious sedation was performed She was placed in the dorsal lithotomy position prepped and draped in the usual fashion Bimanual exam revealed moderate amount of clot in the uterus I was able to remove most of the clots with my hands and an attempt at short curettage was performed but because of contraction of the uterus this was unable to be adequately performed I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found At this point the procedure was terminated Bleeding at this time was minimal Preop H H were 8 3 and 24 2 The patient tolerated the procedure well and was taken to the recovery room in good condition Keywords surgery uterus intrauterine clots postpartum hemorrhage intrauterine curettage hemorrhage bleeding postpartum clots MEDICAL_TRANSCRIPTION,Description Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft Medical Specialty Surgery Sample Name Juxtarenal Abdominal Aortic Aneurysm Repair Transcription PREOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm POSTOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm ANESTHESIA General endotracheal anesthesia OPERATIVE TIME Three hours ANESTHESIA TIME Four hours DESCRIPTION OF PROCEDURE After thorough preoperative evaluation the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A line general endotracheal anesthesia was induced A Foley catheter was placed and a right internal jugular central line was placed The chest abdomen both groin and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered A sterile Omni Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed With the exception of the vascular findings to be described there were no apparent intra abdominal abnormalities The transverse colon retracted superiorly The small bowel was wrapped in moist green towel and retracted in the right upper quadrant The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries The mid left renal artery was likewise identified The perirenal aorta was prepared for clamp superior to the inferior left renal artery During this portion of the dissection the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis The distal dissection was then completed exposing each common iliac artery The arteries were suitable for control The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time The aneurysm was repaired First the common carotid arteries were controlled with atraumatic clamps The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed There was a high grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site The vessel was controlled with a microvascular clamp Two pairs of lumbar arteries were oversewn with 2 0 silk A 14 mm Hemashield tube graft was selected and sewn end to end fashion to the proximal aorta using a semi continuous 3 0 Prolene suture At the completion of anastomosis three patch stitches of 3 0 Prolene were required for hemostasis The graft was cut to appropriate length and sewn end to end at the iliac bifurcation using semi continuous 3 0 Prolene suture Prior to completion of this anastomosis the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation The distal anastomosis was competent without leak The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous The colon was normal in appearance and this vessel was oversewn using 2 0 silk The aneurysm sac was then closed about the grafts snuggly using 3 0 PDS in a vest over pants fashion The posterior peritoneum was reapproximated using running 3 0 PDS The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location The midline fascia was then reapproximated using running 1 PDS suture The subcutaneous tissues were irrigated with bacitracin and kanamycin solution The skin edges coapted using surgical staples At the conclusion of the case sponge and needle counts were correct and a sterile occlusive compressive dressing was applied Keywords surgery inferior left renal artery semi continuous prolene suture juxtarenal abdominal aortic aneurysm inferior mesenteric artery continuous prolene suture abdominal aortic aneurysm hemashield tube inferior mesenteric renal artery aortic aneurysm aneurysm iliac endarterectomy viscera hemashield abdomen prolene arteries juxtarenal graft aortic endotracheal renal artery MEDICAL_TRANSCRIPTION,Description Bilateral degenerative arthritis of the knees Right total knee arthroplasty done in conjunction with a left total knee arthroplasty which will be dictated separately Medical Specialty Surgery Sample Name Knee Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Bilateral degenerative arthritis of the knees POSTOPERATIVE DIAGNOSIS Bilateral degenerative arthritis of the knees PROCEDURE PERFORMED Right total knee arthroplasty done in conjunction with a left total knee arthroplasty which will be dictated separately ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Bilateral procedure was 400 cc TOTAL TOURNIQUET TIME 75 minutes COMPONENTS Include the Zimmer NexGen complete knee solution system which include a size F right cruciate retaining femoral component a size 8 peg tibial component precoat a All Poly standard size 38 9 5 mm thickness patellar component and a prolonged highly cross linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height HISTORY OF PRESENT ILLNESS The patient is a 69 year old male who presented to the office complaining of bilateral knee pain for a couple of years The patient complained of clicking noises and stiffness which affected his daily activities of living PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedure was discussed at length the patient s informed consent was obtained Operative extremities were then confirmed with the operating surgeons as well as the nursing staff Department of Anesthesia and the patient The patient was then transferred to preoperative area to operative suite 2 and placed on the operating room table in supine position All bony prominences were well padded at this time At this time Department of Anesthesia administered general anesthetic to the patient The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left The nonsterile tourniquet was then applied to the right upper thigh of the patient but not inflated at this time The right lower extremity was sterilely prepped and draped in the usual sterile fashion The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg The patient was a consideration for a unicompartmental knee replacement So after all bony and soft tissue landmarks were identified a limited midline longitudinal incision was made directly over the patella A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon Next a medial parapatellar arthrotomy was performed using the 10 blade scalpel Upon viewing of the articular surfaces there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement At this time the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion Total incision now measured approximately 25 cm Retractors were placed Next attention was directed to establishing medial and lateral flaps of the proximal tibia Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia At this time the patella was then everted The knee was flexed up to 90 degrees Next using the large drill bit the femoral canal was then opened in appropriate position The intramedullary sizing guide was then placed and the knee was sized to a size F At this time the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline The guide was then removed The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation Next the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed Next soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut Upon checking it was noted to be flat with no oscillations The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus It was secured in place using nails The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws Again the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well The distal finishing guide was then removed and osteotome was then used to remove all resected bone The oscillating saw was then used to complete the femoral notch cut Upon viewing there appeared to be proper amount of bony resection and all bone was removed completely There was no posterior osteophytes noted and no fragments to the posterior aspect Next attention was directed towards the tibia The external tibial guide was reflected This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia Next collateral ligament retractors were placed as well as McGill retractors for the PCL Oscillating saw was then used to make the proximal tibial cut Osteotome was used to remove this excess resected bone The laminar spreader was then used to check the flexion and extension The gaps appeared to be equal The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray The knee was taken through range of motion and had very good flexion as well as full extension There appeared to be good varus and valgus stability as well Next attention was directed towards the patella There noted to be a sufficient ware and it was selected to replace the patella It was sized with caliper pre cut and noted to be 26 mm depth The sizing guide was then used and a size 51 resection guide selected A 51 mm reamer was then placed and sufficient amount of patella was then removed The calcar was then used to check again and there was noted to be 15 mm remaining The 38 mm patella guide was then placed on the patella It was noted to be in proper size and the three drill holes for the pegs were used A trial component was then placed The knee was taken through range of motion There was noted to be some subluxation lateral to the patellar component and a lateral release was performed After this the component appeared to be tracking very well There remained a good range of motion in the knee and extension as well as flexion At this time an AP x ray of the knee was taken with the trial components in place Upon viewing this x ray it appeared that the tibial cut was in neutral all components in proper positioning The knee was then copiously irrigated and dried The knee was then flexed ___________ placed and the peg drill guide was placed on the tibia in proper position held in place with nails The four peg holes were then drilled The knee again was copiously irrigated and suction dried The final components were then selected again consisting of size F femoral components A peg size 8 tibial component a 12 mm height articular surface size blue and a 38 mm 9 5 mm thickness All Poly patella Polymethyl methacrylate was then prepared at this time The proximal tibia was dried and the cement was then pressed into place The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning Next the proximal femur was cleaned and dried Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components This was then impacted in place as well At this time all excess cement was removed from both the tibial and femoral components A size 12 mm trial tibial articular surface was then put in place The knee was reduced and held in loading position throughout the remaining drying position of the cement Next the resected patella was cleaned and dried The cement was placed on the patella as well as the backside of the patellar component The component was then put in proper positioning and held in place with a clamp All excess polymethyl methacrylate was removed from this area as well This was held until the cement had hardened sufficiently Next the knee was examined All excess cement was then removed The knee was taken through range of motion with sufficient range of motion as well as stability The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position Again range of motion was noted to be sufficient The knee was copiously irrigated and suction dried once again A drain was then placed within the knee The wound was then closed first using 1 Ethibond to close the arthrotomy oversewn with a 1 Vicryl The knee was again copiously irrigated and dried The skin was closed using 2 0 Vicryl in subcuticular fashion followed by staples on the skin The ConstaVac was then _______ to the drain Sterile dressing was applied consisting of Adaptic 4x4 ABDs Kerlix and a 6 inch Dupre roll from foot to thigh Department of Anesthesia then reversed the anesthetic The patient was transferred back to the hospital gurney to Postanesthesia Care Unit The patient tolerated the procedure well and there were no complications Keywords surgery degenerative arthritis zimmer nexgen all poly cruciate patellar component total knee arthroplasty knee arthroplasty tibial component femoral patellar tibial knee arthroplasty anesthesia MEDICAL_TRANSCRIPTION,Description Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty A concurrent vitrectomy and endolaser was performed by the vitreoretinal team Medical Specialty Surgery Sample Name Intraocular Lens Implant Transcription TITLE OF OPERATION 1 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty 2 A concurrent vitrectomy and endolaser was performed by the vitreoretinal team INDICATION FOR SURGERY The patient is a 62 year old white male who underwent cataract surgery in 09 06 This was complicated by posterior capsule rupture An intraocular lens implant was not attempted He developed corneal edema and a preretinal hemorrhage He is aware of the risks benefits and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye vitrectomy endolaser and penetrating keratoplasty PREOP DIAGNOSIS 1 Preretinal hemorrhage 2 Diabetic retinopathy 3 Aphakia 4 Corneal edema POSTOP DIAGNOSIS 1 Preretinal hemorrhage 2 Diabetic retinopathy 3 Aphakia 4 Corneal edema ANESTHESIA General SPECIMEN 1 Donor corneal swab sent to Microbiology 2 Donor corneal scar rim sent to Eye Pathology 3 The patient s cornea sent to Eye Pathology PROS DEV IMPLANT ABC Laboratories 16 0 diopter posterior chamber intraocular lens serial number 123456 NARRATIVE Informed consent was obtained and all questions were answered The patient was brought to the preoperative holding area where the operative left eye was marked He was brought to the operating room and placed in the supine position EKG leads were placed General anesthesia was induced The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye A lid speculum was placed The posterior segment infusion was placed by the vitreoretinal service Peritomy was performed at the 3 and 9 o clock limbal positions A large Flieringa ring was then sutured to the conjunctival surface using 8 0 silk sutures tied in an interrupted fashion The cornea was then measured and was found to accommodate a 7 5 mm trephine The center of the cornea was marked The keratoprosthesis was identified A 7 5 mm trephine blade was then used to incise the anterior corneal surface This was done after a paracentesis was placed at the 1 o clock position and viscoelastic was used to dissect peripheral anterior synechiae Once the synechiae were freed the above mentioned trephination of the anterior cornea was performed Corneoscleral scissors were then used to excise completely the central cornea The keratoprosthesis was placed in position and was sutured with six interrupted 8 0 silk sutures This was done without difficulty At this point the case was turned over to the vitreoretinal team which will dictate under a separate note At the conclusion of the vitreoretinal procedure the patient was brought under the care of the cornea service The 9 0 Prolene sutures double armed were then placed on each lens haptic loop The keratoprosthesis was removed Prior to this removal scleral flaps were made partial thickness at the 3 o clock and 9 o clock positions underneath the peritomies Wet field cautery also was performed to achieve hemostasis The leading hepatic sutures were then passed through the bed of the scleral flap These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic The trailing hepatic was then placed into the posterior segment of the eye as well The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn These were tied securely into position with the IOL nicely centered At this point the donor cornea punched at 8 25 mm was then brought into the field This was secured with four cardinal sutures The corneal button was then sutured in place using a 16 bite 10 0 nylon running suture The knot was secured and buried after adequate tension was adjusted The corneal graft was watertight Attention was then turned back to the IOL sutures which were locked into position The ends were trimmed The flaps were secured with single 10 0 nylon sutures to the apex and the knots were buried At this point the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition having tolerated the procedure well No complications were noted The attending surgeon Dr X performed the entire procedure No complications of the procedure were noted The intraocular lens was selected from preoperative calculations No qualified resident was available to assist Keywords surgery vitrectomy endolaser keratoplasty intraocular lens implant preretinal hemorrhage scleral flaps intraocular keratoprosthesis chamber implant scleral vitreoretinal lens sutures eye MEDICAL_TRANSCRIPTION,Description Debridement left ischial ulcer Medical Specialty Surgery Sample Name Ischial Ulcer Debridement Transcription PREOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida POSTOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida PROCEDURE PERFORMED Debridement left ischial ulcer ANESTHESIA Local MAC INDICATIONS This is a 27 year old white male patient with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic The patient has a nonhealing decubitus ulcer in the left ischial region which is quite deep It appears to be right down to the bone MRI shows findings suggestive of osteomyelitis The patient is being brought to operating room for debridement of this ulcer Procedure indication and risks were explained to the patient Consent obtained PROCEDURE IN DETAIL The patient was put in right lateral position and left buttock and ischial region was prepped and draped Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base The ulcer does not appear to be going into the bone itself as there was a covering on the bone which appears to be quite healthy normal and bone itself appeared solid I did not rongeur the bone The deeper portion of the excised tissue was also sent for tissue cultures Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix Sterile dressing was applied The patient transferred to recovery room in stable condition Keywords surgery debridement ischial ulcer ischial region osteomyelitis paraplegia spina bifida decubitus ulcer MEDICAL_TRANSCRIPTION,Description Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail Left tibial shaft fracture status post gunshot wound Medical Specialty Surgery Sample Name Intramedullary Nail Fixation Transcription TITLE OF OPERATION Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail 10 x 390 with a one 5 mm proximal locking screw and three 5 mm distal locking screws CPT code is 27759 the ICD 9 code again is 823 2 for a tibial shaft fracture INDICATION FOR SURGERY The patient is a 19 year old male who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture The patient was admitted and splinted and had compartment checks The risks of surgery were discussed in detail including but not limited to infection bleeding injuries to nerves or vital structures nonunion or malunion need for reoperation compartment syndrome and the risk of anesthesia The patient understood these risks and wished to proceed PREOP DIAGNOSIS Left tibial shaft fracture status post gunshot wound CPT code 27759 POSTOP DIAGNOSIS Left tibial shaft fracture status post gunshot wound CPT code 27759 ANESTHESIA General endotracheal INTRAVENOUS FLUID 900 ESTIMATED BLOOD LOSS 100 COMPLICATIONS None DISPOSITION Stable to PACU PROCEDURE DETAIL The patient was met in the preoperative holding area and operative site was marked The patient was brought to the operating room and given preoperative antibiotics Left leg was then prepped and draped in the usual sterile fashion A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue The starting guidewire was used to localize the correct starting point which is on the medial aspect of the lateral tibial eminence This was advanced and confirmed on the AP and lateral fluoroscopic images The opening reamer was then used and the ball tip guidewire was passed The reduction was obtained over a large radiolucent triangle After passing the guidewire and achieving appropriate reduction the flexible reamers were then sequentially passed starting at 9 mm up to 11 5 mm reamer At this point a 10 x 390 mm was passed without difficulty The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws The final images were taken with fluoroscopy and a 15 mm end cap was placed The wounds were then irrigated and closed with 2 0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2 0 Vicryl and staples to the proximal incision The patient was placed in a short leg well padded splint was awakened and taken to recovery in good condition The plan will be nonweightbearing left lower extremity He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks Keywords surgery screw stryker tibia intramedullary nail fixation tibial shaft fracture intramedullary guidewire nail fracture tibial MEDICAL_TRANSCRIPTION,Description Displaced left subtrochanteric femur fracture Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85 mm helical blade Medical Specialty Surgery Sample Name Intramedullary Rod Transcription PREOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture POSTOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture OPERATION Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85 mm helical blade COMPLICATIONS None TOURNIQUET TIME None ESTIMATED BLOOD LOSS 50 mL ANESTHESIA General INDICATIONS The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities She was diagnosed with displaced left subcapital hip fracture now was asked to consult With this diagnosis she was indicated the above noted procedure This procedure as well as alternatives to this procedure was discussed at length with the patient and her son who has the power of attorney and they understood them well Risks and benefits were also discussed Risks include bleeding infection damage to blood vessels damage to nerves risk of further surgery chronic pain restricted range of motion risk of continued discomfort risk of malunion risk of nonunion risk of need for further reconstructive procedures risk of need for altered activities and altered gait risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed She understood these well and consented and the son signed the consent for the procedure as described DESCRIPTION OF PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment External positions were felt to be present At this point the left hip and left lower extremity was then prepped and draped in the usual sterile manner A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire An overlying drill was inserted to the proper depths A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth Proper rotation was obtained and the guide for the helical blade was inserted A small incision was made for this as well A guidewire was inserted and felt to be in proper position in the posterior aspect of the femoral head lateral and the center position on AP This placed the proper depths and lengths better The outer cortex was enlarged and an 85 mm helical blade was attached to the proper depths and proper fixation was done Appropriate size screw was then tightened down At this point a distal guide was then placed and drilled across both the cortices Length was better Appropriate size screw was then inserted Proper size and fit of the distal screw was also noted At this point on fluoroscopic control it was confirming in AP and lateral direction We did a near anatomical alignment to the fracture site and all hardware was properly fixed Proper size and fit was noted Excellent bony approximation was noted At this point both wounds were thoroughly irrigated hemostasis confirmed and closure was then begun The fascial layers were then reapproximated using 1 Vicryl in a figure of eight manner the subcutaneous tissues were reapproximated in layers using 1 and 2 0 Vicryl sutures and the skin was reapproximated with staples The area was then infiltrated with a mixture of a 0 25 Marcaine with Epinephrine and 1 plain lidocaine Sterile dressing was then applied No complication was encountered throughout the procedure The patient tolerated the procedure well The patient was taken to the recovery room in stable condition Keywords surgery displaced femur fracture subtrochanteric hip synthes intramedullary rod subtrochanteric femur trochanteric fixation helical blade tourniquet intramedullary trochanteric fixation helical blade guidewire fracture MEDICAL_TRANSCRIPTION,Description Laparoscopic right inguinal herniorrhaphy with mesh as well as a circumcision Recurrent right inguinal hernia as well as phimosis Medical Specialty Surgery Sample Name Inguinal Herniorrhaphy Circumcision Transcription PREOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis POSTOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis PROCEDURE PERFORMED Laparoscopic right inguinal herniorrhaphy with mesh as well as a circumcision ANESTHESIA General endotracheal COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery room in stable condition SPECIMEN Foreskin BRIEF HISTORY This patient is a 66 year old African American male who presented to Dr Y s office with recurrent right inguinal hernia for the second time requesting hernia repair The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right The patient also is requesting circumcision with phimosis at the same operating time setting INTRAOPERATIVE FINDINGS The patient was found to have a right inguinal hernia with omentum and bowel within the hernia which was easily reduced The patient was also found to have a phimosis which was easily removed PROCEDURE After informed consent the risks and benefits of the procedure were explained to the patient The patient was brought to operating suite after general endotracheal intubation prepped and draped in the normal sterile fashion An infraumbilical incision was made with a 15 Bard Parker scalpel The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg Next the Veress was removed and 10 bladed trocar was inserted without difficulty The 30 degree camera laparoscope was then inserted and the abdomen was explored There was evidence of a large right inguinal hernia which had omentum as well as bowel within it easily reducible Attention was next made to placing a 12 port in the right upper quadrant four fingerbreadths from the umbilicus Again a skin was made with a 15 blade scalpel and the 12 port was inserted under direct visualization A 5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization Next a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral The peritoneum was then spread using the blunt dissector opening up and identifying the iliopubic tract which was identified without difficulty Dissection was carried out freeing up the hernia sac from the peritoneum This was done without difficulty reducing the hernia in its entirety Attention was next made to placing a piece of Prolene mesh it was placed through the 12 port and placed into the desired position stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract The 4 8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re peritonealized re approximating edge of the perineum with the 4 8 mm staples This was done without difficulty All three ports were removed under direct visualization No evidence of bleeding and the 10 and 12 mm ports were closed with 0 Vicryl and UR6 needle Skin was closed with running subcuticular 4 0 undyed Vicryl Steri Strips and sterile dressings were applied Attention was next made to carrying out the circumcision The foreskin was retracted back over the penis head The desired amount of removing foreskin was marked out with a skin marker The foreskin was then put on tension using a clamp to protect the penis head A 15 blade scalpel was used to remove the foreskin and sending off as specimen This was done without difficulty Next the remaining edges were retracted hemostasis was obtained with Bovie electrocautery and the skin edges were re approximated with 2 0 plain gut in simple interrupted fashion and circumferentially This was done without difficulty maintaining hemostasis A petroleum jelly was applied with a Coban dressing The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition Keywords surgery herniorrhaphy with mesh laparoscopic blunt dissector inguinal herniorrhaphy inguinal hernia hernia inguinal peritoneum circumcision phimosis foreskin MEDICAL_TRANSCRIPTION,Description Acute on chronic renal failure and uremia Insertion of a right internal jugular vein hemodialysis catheter Medical Specialty Surgery Sample Name Internal Jugular Vein Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Acute on chronic renal failure 2 Uremia POSTOPERATIVE DIAGNOSES 1 Acute on chronic renal failure 2 Uremia PROCEDURE PERFORMED Insertion of a right internal jugular vein hemodialysis catheter ANESTHESIA 1 local lidocaine BLOOD LOSS Less than 5 cc COMPLICATIONS None HISTORY The patient is a 74 year old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time He is slightly short of breath with mild difficulty in breathing A pre procedure x ray was obtained which showed no pneumothorax He did have a significant right pleural effusion and a mild left pleural effusion We decided to insert the catheter on the right side PROCEDURE The patient was prepped and draped in the usual sterile fashion 1 lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein Using the same anesthetic needle the right internal jugular vein was used to cannulate with good venous blood return The tract was noted The needle was removed and a second 18 gauge thin walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty The needle was removed and an 11 blade was used to make a small skin incision provided skin and vein dilators were used The circle C 8 inch hemodialysis catheter was then inserted over the guidewire without difficulty The guidewire was removed Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty The ports were flushed with injectable normal saline secondary to the patient going for dialysis today Thus he will not need heparinization of the lines Again he tolerated the procedure well A postoperative x ray would be obtained to check catheter placement and rule out pneumothorax Keywords surgery uremia internal jugular vein hemodialysis catheter pneumothorax jugular vein dialysis chronic renal failure internal jugular vein pleural effusion hemodialysis catheter renal failure cannulate guidewire insertion jugular catheter hemodialysis vein MEDICAL_TRANSCRIPTION,Description Bassini inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Surgery Sample Name Inguinal Herniorrhaphy 2 Transcription PROCEDURE PERFORMED Bassini inguinal herniorrhaphy ANESTHESIA Local with MAC anesthesia PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table The patient was sedated and an adequate local anesthetic was administered using 1 lidocaine without epinephrine The patient was prepped and draped in the usual sterile manner A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Care was taken not to injure the ilioinguinal nerve Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and the sac was found anteromedially to the cord structures The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery Once preperitoneal fat was encountered the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2 0 silk suture ligature The sac was excised and sent to Pathology The stump was examined and no bleeding was noted The ends of the suture were then cut and the stump retracted back into the abdomen The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart s ligament to the conjoined tendon using a 2 0 Prolene starting at the pubic tubercle and running towards the internal ring In this manner an internal ring was created that admitted just the tip of my smallest finger The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 2 0 Vicryl in a running fashion thus reforming the external ring Marcaine 0 5 was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control The skin incision was approximated with skin staples A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords surgery ilioinguinal nerve adherent cremasteric muscle bassini inguinal herniorrhaphy external oblique aponeurosis inguinal herniorrhaphy metzenbaum scissors external ring blunt dissection cord structures bovie electrocautery inguinal electrocautery MEDICAL_TRANSCRIPTION,Description Direct inguinal hernia Rutkow direct inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Surgery Sample Name Inguinal Herniorrhaphy 1 Transcription PREOPERATIVE DIAGNOSIS Inguinal hernia POSTOPERATIVE DIAGNOSIS Direct inguinal hernia PROCEDURE PERFORMED Rutkow direct inguinal herniorrhaphy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident Preoperative antibiotics were given for prophylaxis against surgical infection The patient was prepped and draped in the usual sterile fashion A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was placed around the cord structures at the level of the pubic tubercle This Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and no sac was found The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels This was dissected back to the hernia opening The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring The plug was secured to the ring by interrupted 2 0 Prolene sutures The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2 0 Prolene sutures By reinforcing the floor with the onlay patch a new internal ring was thus formed The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 2 0 Vicryl in a running fashion thus reforming the external ring The skin incision was approximated with 4 0 Monocryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords surgery cremasteric muscle pubic tubercle external oblique aponeurosis inguinal herniorrhaphy inguinal hernia cord structures penrose drain bovie electrocautery inguinal herniorrhaphy metzenbaum bovie electrocautery cord hernia MEDICAL_TRANSCRIPTION,Description Left inguinal herniorrhaphy modified Bassini Left inguinal hernia direct Medical Specialty Surgery Sample Name Inguinal Herniorrhaphy 3 Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left inguinal hernia direct PROCEDURE Left inguinal herniorrhaphy modified Bassini DESCRIPTION OF PROCEDURE The patient was electively taken to the operating room In same day surgery Dr X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery Informed consent was obtained and the patient was transferred to the operating room where a time out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis which was opened The cord was isolated and protected It was dissected out The lipoma of the cord was removed and the sac was high ligated The main hernia was a direct hernia due to weakness of the floor A Bassini repair was performed We used a number of interrupted sutures of 2 0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl The dressing was applied and the patient tolerated the procedure well estimated blood loss was minimal was transferred to recovery room in satisfactory condition Keywords surgery inguinal herniorrhaphy modified bassini herniorrhaphy modified bassini hernia direct inguinal hernia inguinal bassini MEDICAL_TRANSCRIPTION,Description Repair of left inguinal hernia indirect The patient states that she noticed there this bulge and pain for approximately six days prior to arrival Upon examination in the office the patient was found to have a left inguinal hernia consistent with tear which was scheduled as an outpatient surgery Medical Specialty Surgery Sample Name Inguinal Hernia Repair Indirect Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left indirect inguinal hernia PROCEDURE PERFORMED Repair of left inguinal hernia indirect ANESTHESIA Spinal with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well was transferred to recovery in stable condition SPECIMEN Hernia sac BRIEF HISTORY The patient is a 60 year old female that presented to Dr X s office with complaints of a bulge in the left groin The patient states that she noticed there this bulge and pain for approximately six days prior to arrival Upon examination in the office the patient was found to have a left inguinal hernia consistent with tear which was scheduled as an outpatient surgery INTRAOPERATIVE FINDINGS The patient was found to have a left indirect inguinal hernia PROCEDURE After informed consent was obtained risks and benefits of the procedure were explained to the patient The patient was brought to the operating suite After spinal anesthesia and sedation given the patient was prepped and draped in normal sterile fashion In the area of the left inguinal region just superior to the left inguinal ligament tract the skin was anesthetized with 0 25 Marcaine Next a skin incision was made with a 10 blade scalpel Using Bovie electrocautery dissection was carried down to Scarpa s fascia until the external oblique was noted Along the side of the external oblique in the direction of the external ring incision was made on both sides of the external oblique and then grasped with a hemostat Next the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament Attention was next made to ligating the hernia sac at its base for removal The hernia sac was opened prior grasping with hemostats It was a sliding indirect hernia The bowel contents were returned to abdomen using a 0 Vicryl stick tie pursestring suture at its base The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen This was then sutured at the apex of the repair down to the conjoint tendon Next attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an 0 Vicryl suture and removed as specimen Attention was next made to reapproximate it at floor with a modified ______ repair Using a 2 0 Ethibond suture in simple interrupted fashion the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia Once this was done the external oblique was closed over reapproximated again with a 2 0 Ethibond suture catching each hump in between each repair from the prior floor repair This was done in simple interrupted fashion as well Next Scarpa s fascia was reapproximated with 3 0 Vicryl suture The skin was closed with running subcuticular 4 0 undyed Vicryl suture Steri Strips and sterile dressings were applied The patient tolerated the procedure very well and he was transferred to Recovery in stable condition The patient had an abnormal chest x ray in preop and is going for a CT of the chest in Recovery Keywords surgery bulge groin ethibond suture vicryl suture external oblique inguinal hernia hernia inguinal ligament oblique vicryl indirect sac suture repair MEDICAL_TRANSCRIPTION,Description Inguinal herniorrhaphy A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Surgery Sample Name Inguinal Herniorrhaphy Transcription PROCEDURE PERFORMED Inguinal herniorrhaphy PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery The external oblique aponeurosis was cleared of overlying adherent tissue and the external ring was delineated The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors Having exposed the inguinal canal the cord structures were separated from the canal using blunt dissection and a Penrose drain was placed around the cord structures at the level of the pubic tubercle This Penrose drain was then used to retract the cord structures as needed Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery The cord was then explored using a combination of sharp and blunt dissection and the sac was found anteromedially to the cord structures The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery Once preperitoneal fat was encountered the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2 0 silk suture ligature The sac was excised and went to Pathology The ends of the suture were then cut and the stump retracted back into the abdomen The Penrose drain was removed The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The incision in the external oblique was approximated using a 3 0 Vicryl in a running fashion thus reforming the external ring The skin incision was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped and draped with benzoin and Steri Strips were applied A dressing consisting of a 2 x 2 and OpSite was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords surgery inguinal canal cremasteric muscle pubic tubercl inguinal herniorrhaphy blunt dissection penrose drain bovie electrocautery cord structures inguinal electrocautery cord MEDICAL_TRANSCRIPTION,Description Left direct and indirect inguinal hernia Repair of left inguinal hernia with Prolene mesh The patient was found to have a left inguinal hernia increasing over the past several months The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh Medical Specialty Surgery Sample Name Inguinal Hernia Repair 2 Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left direct and indirect inguinal hernia PROCEDURE PERFORMED Repair of left inguinal hernia with Prolene mesh ANESTHESIA IV sedation with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to Recovery in stable condition SPECIMEN Hernia sac as well as turbid fluid with gram stain which came back with no organisms from the hernia sac BRIEF HISTORY This is a 53 year old male who presented to Dr Y s office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh INTRAOPERATIVE FINDINGS The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac The patient was also found to have some turbid fluid within the hernia sac which was sent down for gram stain and turned out to be negative with no organisms PROCEDURE After informed consent risks and benefits of the procedure were explained to the patient the patient was brought to the operative suite prepped and draped in the normal sterile fashion The left inguinal ligament was identified from the pubic tubercle to the ASIS Two fingerbreadths above the pubic tubercle a transverse incision was made First the skin was anesthetized with 1 lidocaine and then an incision was made with a 15 blade scalpel approximately 6 cm in length Dissection was then carried down with electro Bovie cautery through Scarpa s fascia maintaining hemostasis Once the external oblique was identified external oblique was incised in the length of its fibers with a 15 blade scalpel Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring Next the external oblique was grasped with Ochsner on both sides The cord cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it Next the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down grasped with two hemostats A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored There was some turbid fluid within the hernia sac which was sent down for cultures Gram stain was negative for organisms Next the hernia sac was to be ligated at its base and transected A peon was used at the base Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen An 0 Vicryl stick suture was used with 0 Vicryl loop suture to suture ligate the hernia sac at its base Next attention was made to placing a Prolene mesh to cover the floor The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures Attention was made to salvaging the ilioinguinal nerve which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact Attention was next made after suturing the mesh with the 2 0 Polydek suture The external oblique was then closed over the roof with a running 0 Vicryl suture taking care not to strangulate the cord and to recreate the external ring After injecting the external oblique and cord structures with Marcaine for anesthetic the Scarpa s fascia was approximated with interrupted 3 0 Vicryl sutures The skin was closed with a running subcuticular 4 0 undyed Vicryl suture Steri Strip with sterile dressings were applied The patient tolerated the procedure well and was transferred to Recovery in stable condition Keywords surgery left inguinal hernia prolene mesh hernia sac gram stain inguinal hernia repair inguinal hernial repair metzenbaum scissors cord structures inguinal hernia sac inguinal hernia metzenbaum prolene vicryl cord suture oblique mesh MEDICAL_TRANSCRIPTION,Description Right inguinal hernia Right inguinal hernia repair The patient is a 4 year old boy with a right inguinal bulge which comes and goes with Valsalva standing and some increased physical activity Medical Specialty Surgery Sample Name Inguinal Hernia Repair 6 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right inguinal hernia ANESTHESIA General PROCEDURE Right inguinal hernia repair INDICATIONS The patient is a 4 year old boy with a right inguinal bulge which comes and goes with Valsalva standing and some increased physical activity He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair We met with his parents and explained the surgical technique risks and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia All their questions have been answered and they agreed with the plan OPERATIVE FINDINGS The patient had a well developed but rather thin walled hernia sac on the right The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy Therefore high ligation was performed and we aborted the plan for laparoscopic view of the left side DESCRIPTION OF PROCEDURE The patient came to operating room and had an uneventful induction of general anesthesia Surgical time out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution During our time out we reiterated the patient s name medical record number weight allergies status and planned operative procedure I then infiltrated 0 25 Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique After the oblique layers were opened the cord structure were identified and elevated The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed I attempted to gently pass a 3 mm trocar through the hernia sac but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3 0 Vicryl The excess sac was trimmed and the spermatic cord structures were replaced The external oblique fascia and Scarpa layers were closed with interrupted 3 0 Vicryl and skin was closed with subcuticular 5 0 Monocryl and Steri Strips The patient tolerated the operation well Blood loss was less than 5 mL The hernia sac was submitted for specimen and he was then taken to the recovery room in good condition Keywords surgery laparoscopic external oblique fascia oblique fascia spermatic cord cord structures external oblique hernia sac inguinal hernia sac hernia inguinal fascia repair oblique MEDICAL_TRANSCRIPTION,Description Direct right inguinal hernia Marlex repair of right inguinal hernia Medical Specialty Surgery Sample Name Inguinal Hernia Repair 5 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Direct right inguinal hernia TITLE OF PROCEDURE Marlex repair of right inguinal hernia ANESTHESIA Spinal PROCEDURE IN DETAIL The patient was taken to the operative suite placed on the table in the supine position and given a spinal anesthetic The right inguinal region was shaved and prepped and draped in a routine sterile fashion The patient received 1 gm of Ancef IV push Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue The external oblique fascia was exposed and incised down to and through the external inguinal ring The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal The cord was surrounded with a Penrose drain The hernia sac was separated from the cord structures The floor of the inguinal canal which consisted of attenuated transversalis fascia was imbricated upon itself with a running locked suture of 2 0 Prolene Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord It was placed around the cord and sutured to itself with 2 0 Prolene The patch was then sutured medially to the pubic tubercle inferiorly to Cooper s ligament and inguinal ligaments and superiorly to conjoined tendon using 2 0 Prolene The area was irrigated with saline solution and 0 5 Marcaine with epinephrine was injected to provide prolonged postoperative pain relief The cord was returned to its position External oblique fascia was closed with a running 2 0 PDS subcu with 2 0 Vicryl and skin with running subdermal 4 0 Vicryl and Steri Strips Sponge and needle counts were correct Sterile dressing was applied Keywords surgery marlex repair inguinal region external oblique fascia inguinal ring direct right inguinal hernia inguinal hernia inguinal repair marlex oblique fascia hernia MEDICAL_TRANSCRIPTION,Description Right inguinal hernia Right direct inguinal hernia repair with PHS mesh system The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease Medical Specialty Surgery Sample Name Inguinal Hernia Repair 4 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right direct inguinal hernia PROCEDURE Right direct inguinal hernia repair with PHS mesh system ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was administered with endotracheal intubation The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease Dissection was taken down through the skin and subcutaneous tissue Scarpa s fascia was divided and the external ring was located The external oblique was divided from the external ring up towards the anterior superior iliac spine The cord structures were then encircled Careful inspection of the cord structures did not reveal any indirect sac along the cord structures I did however feel a direct sac with a direct defect I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac Once I cleared out the preperitoneal space I placed a PHS mesh system with a posterior mesh into the preperitoneal space and I made sure that it laid flat along Cooper s ligament and covered the myopectineal orifice I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring making sure that it was not too tight so that it did not strangulate the cord structures I then closed the external oblique with a running 3 0 Vicryl I closed the Scarpa s with interrupted 3 0 Vicryl and I closed the skin with a running Monocril Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well and without any complications Keywords surgery groin phs mesh inguinal hernia repair direct inguinal hernia preperitoneal space external oblique cord structures inguinal hernia inguinal hernia external oblique mesh MEDICAL_TRANSCRIPTION,Description A 9 year old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia taken to the operating room for inguinal hernia repair Medical Specialty Surgery Sample Name Inguinal Hernia Repair 1 Transcription PREOPERATIVE DIAGNOSIS Right inguinal hernia POSTOPERATIVE DIAGNOSIS Right inguinal hernia PROCEDURE Right inguinal hernia repair INDICATIONS FOR PROCEDURE This patient is a 9 year old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia The patient is being taken to the operating room for inguinal hernia repair DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s inguinal and scrotal area were prepped and draped in the usual sterile fashion An incision was made in the right inguinal skin crease The incision was taken down to the level of the aponeurosis of the external oblique which was incised up to the level of the external ring The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed The distal remnant was taken to its end and excised The testicle and cord structures were placed back in their native positions The aponeurosis of the external oblique was reapproximated with 3 0 Vicryl as well as the Scarpa s the skin closed with 5 0 Monocryl and dressed with Steri Strips The patient was extubated in the operating room and taken back to the recovery room The patient tolerated the procedure well Keywords surgery inguinal skin crease inguinal hernia repair external oblique hernia repair inguinal hernia inguinal hernia MEDICAL_TRANSCRIPTION,Description Bilateral inguinal hernia Bilateral direct inguinal hernia repair utilizing PHS system and placement of On Q pain pump Medical Specialty Surgery Sample Name Inguinal Hernia Repair 3 Transcription PREOPERATIVE DIAGNOSIS Bilateral inguinal hernia POSTOPERATIVE DIAGNOSIS Bilateral inguinal hernia PROCEDURE Bilateral direct inguinal hernia repair utilizing PHS system and placement of On Q pain pump ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard sterile surgical fashion I did an ilioinguinal nerve block on both sides injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides Keywords surgery phs system on q pump on q pain pump inguinal hernia repair bilateral inguinal hernia anterior superior iliac direct inguinal hernia subcutaneous tissue scarpa s fascia cord structures phs mesh ilioinguinal nerve external oblique inguinal hernia hernia oblique inguinal mesh MEDICAL_TRANSCRIPTION,Description Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally Medical Specialty Surgery Sample Name Inguinal Hernia Repair Transcription PREOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles POSTOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles PROCEDURES Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given ANESTHESIA General inhalational anesthetic ABNORMAL FINDINGS Same as above ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS RECEIVED 400 mL of Crystalloid DRAINS No tubes or drains were used COUNT Sponge and needle counts were correct x2 INDICATIONS FOR PROCEDURE The patient is a 7 year old boy with the history of fairly sizeable right inguinal hernia and hydrocele was found to have a second smaller one on evaluation with ultrasound and physical exam Plan is for repair of both DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized he was then placed in a supine position and sterilely prepped and draped A right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis The external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors Using a curved mosquito clamp we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal The cord structures were then dissected off the sac and then the sac itself was divided in the midline twisted upon itself and suture ligated up at the peritoneal reflection with 3 0 Vicryl suture This was done twice The distal end where a large hydrocele noted was gently milked into the lower aspect of the incision The hydrocele sac was then opened and drained and then the testis was delivered into the field The sac was then opened completely around the testis The appendix testis was cauterized We wrapped the sac around the back of the testis and tacked into place using the Lord maneuver using 4 0 Vicryl as a figure of eight suture Once this was done the testis was then placed back into the scrotum in the proper orientation Ilioinguinal nerve block and wound instillation was then done with 10 mL of 0 25 Marcaine A similar procedure was done on the left side also finding a small hernia which was divided and ligated with the 3 0 Vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a Lord maneuver after opening the sac completely Again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3 0 Vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure Scarpa fascia was closed with 4 0 chromic suture on each side and the skin was closed with 4 0 Rapide subcuticular closure Dermabond tissue adhesive was placed on both incisions IV Toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure The patient tolerated the procedure and was in stable condition upon transfer to the recovery room Keywords surgery bilateral hydrocele repair bilateral inguinal hernia external oblique fascia ilioinguinal nerve block bilateral hydroceles external oblique oblique fascia cord structures hydrocele sac lord maneuver nerve block bilateral inguinal ilioinguinal nerve inguinal hernia hernia inguinal hydrocele bilateral sac MEDICAL_TRANSCRIPTION,Description Left communicating hydrocele Left inguinal hernia and hydrocele repair The patient is a 5 year old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele MEDICAL_TRANSCRIPTION,Description This patient has reoccurring ingrown infected toenails Medical Specialty Surgery Sample Name Infected Toenails Transcription S This patient has reoccurring ingrown infected toenails He presents today for continued care O On examination the left great toenail is ingrown on the medial and lateral toenail border The right great toenail is ingrown on the lateral nail border only There is mild redness and granulation tissue growing on the borders of the toes One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe These lesions measure 0 5 cm in diameter each I really do not understand why this young man continues to develop ingrown nails and infections A 1 Onychocryptosis Keywords surgery infected toenails onychocryptosis benign lesions toenail border left great toe neosporin ointment hemostasis was achieved ointment and absorbent toenails ingrown lesions benign infected MEDICAL_TRANSCRIPTION,Description Right inguinal exploration left inguinal hernia repair bilateral hydrocele repair and excision of right appendix testis Medical Specialty Surgery Sample Name Inguinal Exploration Transcription PREOPERATIVE DIAGNOSES Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair cerebral palsy asthma seizure disorder developmental delay and gastroesophageal reflux disease POSTOPERATIVE DIAGNOSES Left inguinal hernia bilateral hydroceles and right torsed appendix testis PROCEDURE Right inguinal exploration left inguinal hernia repair bilateral hydrocele repair and excision of right appendix testis FLUIDS RECEIVED 700 mL of crystalloid ESTIMATED BLOOD LOSS 10 mL SPECIMENS Tissue sent to pathology is calcified right appendix testis TUBES DRAINS No tubes or drains were used COUNTS Sponge and needle counts were correct x2 ANESTHESIA General inhalational anesthetic and 0 25 Marcaine ilioinguinal nerve block 30 mL given per surgeon INDICATIONS FOR OPERATION The patient is a 14 1 2 year old boy with multiple medical problems primarily due to cerebral palsy asthma seizures gastroesophageal reflux disease and developmental delay He had a hernia repair done on the right in the past but developed a new hernia on the right and a smaller on the left The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then placed in the supine position IV antibiotics were given He was then sterilely prepped and draped A right inguinal incision was made in the previous incisional site with a 15 blade knife extended down through the subcutaneous tissue and Scarpa fascia with electrocautery Electrocautery was used for hemostasis The external oblique fascia was then visualized and incised There was a moderate amount of scar tissue noted but we were able to incise that and go down into the right inguinal canal Upon dissection there we did not find any hernias however he did have a fairly sizable hydrocele We went down towards the external ring and found that this was indeed tight without any hernias We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15 blade knife We then extended down to the subcutaneous tissue Electrocautery was used for hemostasis The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis which was then excised and sent to pathology We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection was up above so we then wrapped the sac around the back of the testis and closed it with a 4 0 chromic suture in a Lord maneuver We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4 0 chromic and placed the testis into the scrotum in the proper orientation We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0 25 Marcaine without epinephrine 15 mL was given We performed a similar procedure on the left incising it at the scrotal area first rather than below and found this tunica vaginalis and dissected it in a similar fashion and cauterized the appendix testis which was not torsed This was a smaller hydrocele but because of the __________ shunt we went up above and found that there was a very small connection which was then dissected off the cord structures gently twisted upon itself suture ligated with a 2 0 Vicryl suture The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0 25 Marcaine were then done by the surgeon as well The external oblique fascia was closed on both sides with a running suture of 2 0 Vicryl 4 0 chromic was then used to close the Scarpa fascia The skin was closed with a 4 0 Rapide subcuticular closure The scrotal incisions were closed with a subcutaneous and dartos closure using 4 0 chromic IV Toradol was given at the end of the procedure Dermabond tissue adhesive was placed on all 4 incisions The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room Keywords surgery inguinal exploration inguinal hernia repair hydrocele repair appendix testis ilioinguinal nerve block external oblique fascia tunica vaginalis ilioinguinal nerve inguinal hernia hernia repair hernia torsed inguinal hydrocele appendix testis MEDICAL_TRANSCRIPTION,Description Painful ingrown toenail left big toe Removal of an ingrown part of the left big toenail with excision of the nail matrix Medical Specialty Surgery Sample Name Ingrown Toenail Removal Transcription PREOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe POSTOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe OPERATION Removal of an ingrown part of the left big toenail with excision of the nail matrix DESCRIPTION OF PROCEDURE After obtaining informed consent the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1 Xylocaine after having been prepped and draped in the usual fashion The ingrown part of the toenail was freed from its bed and removed then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail The matrix was excised down to the bone and then the skin flap was placed over it Hemostasis had been achieved with a cautery A tubular dressing was performed to provide a bulky dressing The patient tolerated the procedure well Estimated blood loss was negligible The patient was sent back to Same Day Surgery for recovery Keywords surgery toenail nail matrix ingrown toenail painful ingrown MEDICAL_TRANSCRIPTION,Description Autologous iliac crest bone graft to maxilla and mandible under general anesthetic Maxillary atrophy severe mandibular atrophy acquired facial deformity and masticatory dysfunction Medical Specialty Surgery Sample Name Iliac Crest Bone Graft Maxilla Mandible Transcription PREOPERATIVE DIAGNOSES 1 Maxillary atrophy 2 Severe mandibular atrophy 3 Acquired facial deformity 4 Masticatory dysfunction POSTOPERATIVE DIAGNOSES 1 Maxillary atrophy 2 Severe mandibular atrophy 3 Acquired facial deformity 4 Masticatory dysfunction PROCEDURE PERFORMED Autologous iliac crest bone graft to maxilla and mandible under general anesthetic Dr X and company accompanied the patient to OR 6 at 7 30 a m Nasal trachea intubation was performed per routine The bilateral iliac crest harvest was first performed by Dr X and company under separate OR report Once the bone was harvested surgical templets were used to recontour initially the maxillary graft and the mandibular graft Then CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft Subsequent to the harvest of the bilateral ilium the intraoral region was scrubbed per routine Surgical team scrubbed and gowned in usual fashion and the patient was draped Xylocaine 1 1 100 000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa A primary incision was made in the maxilla starting on the patient s left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion Release incisions were made in the posterior region of the maxilla A full thickness periosteal reflexion first exposed the palatal region The contents of the neurovascular canal from the greater palatine foramina were identified The hard palate was directly observed The facial tissues were then reflected exposing the lateral aspect of the maxilla the zygomatic arch the infraorbital nerve artery and vein the lateral piriform rim the inferior piriform rim and the remaining issue of the nasal spine Similar features were reflected on the contralateral side The area was re contoured with rongeurs The block of bone which was formed and harvested from the left ilium was then placed and found to be stable A surgical mallet then compressed this bone further into the region A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla Particulate bone was then placed around the remaining block of bone A piece of AlloDerm mixed with Croften and patient s platelet rich plasma which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded the tissues were approximated for primary closure without tension using interrupted and continuous sutures 3 0 Gore Tex Attention was brought then to the mandible 1 Xylocaine 1 100 000 epinephrine was infiltrated in the labial mucosa 5 cc were given A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body The anterior body was found to be approximately 3 mm in height A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible A similar procedure was done on the contralateral side The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1 6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self tapping 2 mm diameter titanium screws The block of bone was further re contoured in situ Particulate bone was then injected into the posterior tunnels bilaterally A piece of AlloDerm was placed over those particulate segments The tissues were approximated for primary closure using 3 0 Gore Tex suture both interrupted and horizontal mattress in form The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap The estimated blood loss in the harvest of the hip was 100 cc The estimated blood loss in the intraoral procedure was 220 cc Total blood loss for the procedure 320 cc The fluid administered 300 cc The urine out 180 All sponges were counted encountered for as were sutures The patient was taken to Recovery at approximately 12 o clock noon Keywords surgery autologous iliac crest bone graft to mandible mandibular atrophy maxillary atrophy facial deformity masticatory dysfunction iliac crest bone graft mental foramina iliac crest bone autologous maxillary mandibular maxilla MEDICAL_TRANSCRIPTION,Description Insertion of left femoral circle C catheter indwelling catheter Chronic renal failure The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm A Cath was situated Medical Specialty Surgery Sample Name Indwelling Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Chronic renal failure POSTOPERATIVE DIAGNOSIS Chronic renal failure PROCEDURE PERFORMED Insertion of left femoral circle C catheter ANESTHESIA 1 lidocaine ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None HISTORY The patient is a 36 year old African American male presented to ABCD General Hospital on 08 30 2003 for evaluation of elevated temperature He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm A Cath was situated He did require a short term of Levophed for hypotension He is felt to have an infected dialysis catheter which was removed He was planned to undergo replacement of his Perm A Cath dialysis catheter however this was not possible He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long term indwelling catheter can be established for dialysis He was explained the risks benefits and complications of the procedure previously He gave us informed consent to proceed OPERATIVE PROCEDURE The patient was placed in the supine position The left inguinal region was shaved His left groin was then prepped and draped in normal sterile fashion with Betadine solution Utilizing 1 lidocaine the skin and subcutaneous tissue were anesthetized with 1 lidocaine Under direct aspiration technique the left femoral vein was cannulated Next utilizing an 18 gauge Cook needle the left femoral vein was cannulated Sutures were removed nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter The needle was then removed Utilizing 11 blade scalpel a small skin incision was made adjacent to the catheter Utilizing a 10 French dilator the skin subcutaneous tissue and left femoral vein were dilated over the Seldinger guidewire Dilator was removed and a preflushed circle C 8 inch catheter was inserted over the Seldinger guidewire The guidewire was retracted out from the blue distal port and grasped The catheter was then placed in the left femoral vessel _______ This catheter was then fixed to the skin with 3 0 silk suture A mesenteric dressing was then placed over the catheter site The patient tolerated the procedure well He was turned to the upright position without difficulty He will undergo dialysis today per Nephrology Keywords surgery chronic renal failure femoral circle c catheter indwelling catheter catheter insertion seldinger guidewire indwelling femoral dialysis MEDICAL_TRANSCRIPTION,Description Induction of vaginal delivery of viable male Apgars 8 and 9 Term pregnancy and oossible rupture of membranes prolonged Medical Specialty Surgery Sample Name Induction of Vaginal Delivery Transcription DIAGNOSES 1 Term pregnancy 2 Possible rupture of membranes prolonged PROCEDURE Induction of vaginal delivery of viable male Apgars 8 and 9 HOSPITAL COURSE The patient is a 20 year old female gravida 4 para 0 who presented to the office She had small amount of leaking since last night On exam she was positive Nitrazine no ferning was noted On ultrasound her AFI was about 4 7 cm Because of a variable cervix oligohydramnios and possible ruptured membranes we recommended induction She was brought to the hospital and begun on Pitocin Once she was in her regular pattern we ruptured her bag of water fluid was clear She went rapidly to completion over the next hour and a half She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation Upon delivery of the head the anterior and posterior arms were delivered and remainder of the baby without complications The baby was vigorous moving all extremities The cord was clamped and cut The baby was handed off to mom with nurse present Apgars were 8 and 9 Placenta was delivered spontaneously intact Three vessel cord with no retained placenta Estimated blood loss was about 150 mL There were no tears Keywords surgery induction of vaginal delivery vaginal delivery viable male pregnancy placenta vaginal membranes apgars MEDICAL_TRANSCRIPTION,Description Perirectal abscess Incision and drainage I D of perirectal abscess Medical Specialty Surgery Sample Name I D Perirectal Abscess Transcription PREOPERATIVE DIAGNOSIS Perirectal abscess POSTOPERATIVE DIAGNOSIS Perirectal abscess PROCEDURE Incision and drainage I D of perirectal abscess DESCRIPTION OF PROCEDURE The patient was taken to the operating room after obtaining an informed consent A spinal anesthetic was given and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion Prior to prepping I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope I found some small internal hemorrhoids and no fistulous tracts Then the patient was prepped and draped in the usual fashion and the abscess area which was in the left gluteal side was incised with a cruciate incision and drained All necrotic tissue was debrided The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area The cavity was irrigated with saline and then was packed with iodoform gauze and dressed Estimated blood loss was minimal The patient tolerated the procedure well and was sent for recovery in satisfactory condition Keywords surgery hemorrhoids incision and drainage perirectal abscess cavity i d perirectal MEDICAL_TRANSCRIPTION,Description Incision and drainage I D with primary wound closure of scalp lacerations The patient is a middle aged female who has had significant lacerations to her head from a motor vehicle accident The patient was taken to the operating room for an I D of the lacerations with wound closure Medical Specialty Surgery Sample Name I D Wound Closure Scalp Lacerations Transcription PREOPERATIVE DIAGNOSIS Scalp lacerations POSTOPERATIVE DIAGNOSIS Scalp lacerations OPERATION PERFORMED Incision and drainage I D with primary wound closure of scalp lacerations ANESTHESIA GET EBL Minimal COMPLICATIONS None DRAINS None DISPOSITION Vital signs stable and taken to the recovery room in a satisfactory condition INDICATION FOR PROCEDURE The patient is a middle aged female who has had significant lacerations to her head from a motor vehicle accident The patient was taken to the operating room for an I D of the lacerations with wound closure PROCEDURE IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled out to the operating theater room 5 Before the neck instrumentation was performed the patient s lacerations to her scalp were I D ed and closed It was noted that the head was significantly contaminated with blood as well as mangled It was decided at that time in order to repair the lacerations appropriately the patient would undergo cutting of her hair This was shaved appropriately with shavers Once this was done the scalp lacerations were copiously irrigated with a scrubbing brush hexedine solution together with peroxide Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp the wounds were significantly irrigated with normal saline No significant debris was appreciated Once this was done staples were used to oppose the dermal edges together The patient was subsequently dressed sterilely using bacitracin ointment Xeroform 4x4s and tape The neck procedure was subsequently performed Keywords surgery drainage incision primary wound closure lacerations wound closure scalp lacerations scalp i d MEDICAL_TRANSCRIPTION,Description Postoperative wound infection complicated Irrigation and debridement of postoperative wound infection Removal of foreign body Placement of vacuum assisted closure device Medical Specialty Surgery Sample Name I D ORIF Wound Transcription TITLE OF OPERATION 1 Irrigation and debridement of postoperative wound infection CPT code 10180 2 Removal of foreign body deep CPT code 28192 3 Placement of vacuum assisted closure device less than 50 centimeter squared CPT code 97605 PREOP DIAGNOSIS Postoperative wound infection complicated ICD 9 code 998 59 POSTOP DIAGNOSIS Postoperative wound infection complicated ICD 9 code 998 59 PROCEDURE DETAIL The patient is a 59 year old gentleman who is status post open reduction and internal fixation of bilateral calcanei He was admitted for a left wound breakdown with drainage He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap The risks of surgery were discussed in detail including but not limited to infection bleeding injuries to nerves and vital structures need for reoperation pain or stiffness arthritis fracture the risk of anesthesia The patient understood these risks and wished to proceed The patient was admitted and the operative site was marked The patient was brought to the operating room and given general anesthetic He was placed in the right lateral decubitus and all bony prominences were well padded An axillary roll was placed A well padded thigh tourniquet was placed on the left leg The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement Left leg was then prepped and draped in usual sterile fashion The previous five antibiotic spacer beads were removed without difficulty The wound was then rongeured and curetted and all bone was cleaned down to healthy bleeding bone The wound actually looked quite good with evidence of purulence or drainage Skin edges appeared to be viable Hardware all looked to be intact At this point the wound was irrigated with 9 liters of bibiotic solution A VAC sponge was then placed over the wound and the patient s leg was placed into a posterior splint The patient was awakened and then taken to recovery in good condition Dr X was present for the timeouts and for all critical portions of the procedure He was immediately available for any questions during the case PLAN 1 A CAM walker boots 2 A VAC change on Sunday by the nurse 3 A flap per Plastic Surgery Keywords surgery irrigation and debridement removal of foreign body vacuum assisted closure device foreign body postoperative wound wound infection infection wound orif debridement vacuum MEDICAL_TRANSCRIPTION,Description Incision and drainage of the penoscrotal abscess packing penile biopsy cystoscopy and urethral dilation Medical Specialty Surgery Sample Name I D Penoscrotal Abscess Transcription PREOPERATIVE DIAGNOSIS Penoscrotal abscess POSTOPERATIVE DIAGNOSIS Penoscrotal abscess OPERATION Incision and drainage of the penoscrotal abscess packing penile biopsy cystoscopy and urethral dilation BRIEF HISTORY The patient is a 75 year old male presented with penoscrotal abscess Options such as watchful waiting drainage and antibiotics were discussed Risks of anesthesia bleeding infection pain MI DVT PE completely the infection turning into necrotizing fascitis Fournier s gangrene were discussed The patient already had significant phimotic changes and disfigurement of the penis For further debridement the patient was told that his penis is not going to be viable he may need a total or partial penectomy now or in the future Risks of decreased penile sensation pain Foley other unexpected issues were discussed The patient understood all the complications and wanted to proceed with the procedure DETAIL OF THE OPERATION The patient was brought to the OR The patient was placed in dorsal lithotomy position The patient was prepped and draped in the usual fashion Pictures were taken prior to starting the procedure for documentation The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection The penile area was opened up distally to allow the pus to come out The dissection around the proximal scrotum was done to make sure there are no other pus pockets The corporal body was intact but the distal part of the corpora was completely eroded and had a fungating mass which was biopsied and sent for permanent pathology analysis Urethra was identified at the distal tip which was dilated and using 23 French cystoscope cystoscopy was done which showed some urethral narrowing in the distal part of the urethra The rest of the bladder appeared normal The prostatic urethra was slightly enlarged There are no stones or tumors inside the bladder There were moderate trabeculations inside the bladder Otherwise the bladder and the urethra appeared normal There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma Again biopsies were sent for pathology analysis Prior to urine irrigation anaerobic aerobic cultures were sent irrigation with over 2 L of fluid was performed After irrigation packing was done with Kerlix The patient was brought to recovery in a stable condition Please note that 18 French Foley was kept in place Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied The patient was brought to Recovery in a stable condition after applying 0 5 Marcaine about 20 mL were injected around for local anesthesia Keywords surgery i d penoscrotal penile biopsy cystoscopy urethral dilation incision and drainage fungating mass penoscrotal abscess abscess urethral MEDICAL_TRANSCRIPTION,Description Incision and drainage of left neck abscess Medical Specialty Surgery Sample Name I D Neck Abscess Transcription PREOPERATIVE DIAGNOSIS Left neck abscess POSTOPERATIVE DIAGNOSIS Left neck abscess OPERATIVE PROCEDURE Incision and drainage of left neck abscess ANESTHESIA General inhalational DESCRIPTION OF PROCEDURE The patient was taken to operating room and placed supine on the operating table General inhalational anesthesia was administered The patient was draped in usual fashion The prominent area of the left submandibular swelling was noted and a 1 cm incision was outlined with a marking pen and the area was infiltrated with 0 5 mL of local anesthetic using 1 Xylocaine with epinephrine 1 100 000 The incision was performed with a 15 blade An 18 gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity This was submitted for culture and sensitivity anaerobic cultures and Gram stain The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated The cavity was irrigated with peroxide and saline A 0 25 inch Penrose drain was placed and secured with a single 3 0 nylon suture A 4 x 4 dressing was applied Bleeding was negligible There were no untoward complications The patient tolerated the procedure well and was transferred to the recovery room in stable condition Keywords surgery i d incision and drainage neck abscess drainage cavity incision MEDICAL_TRANSCRIPTION,Description Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening Irrigation and debridement of skin subcutaneous tissues muscle and bone right forearm Open reduction right both bone forearm fracture with placement of long arm cast Medical Specialty Surgery Sample Name I D Open Reduction Forearm Transcription PREOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening POSTOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening OPERATIONS 1 Irrigation and debridement of skin subcutaneous tissues muscle and bone right forearm 2 Open reduction right both bone forearm fracture with placement of long arm cast COMPLICATIONS None TOURNIQUET None ESTIMATED BLOOD LOSS 25 mL ANESTHESIA General INDICATIONS The patient suffered injury at which time he fell over a concrete bench He landed mostly on the right arm He noted some bleeding at the time of the injury and a small puncture wound He was taken to the emergency room and diagnosed a compound both bone forearm fracture and based on this he was seen for malalignment He was indicated the above noted procedure This procedure as well as alternatives of this procedure was discussed at length with the patient s parents and they understood them well Risks and benefits were also discussed Risks such as bleeding infection damage to blood vessels damage to nerve roots need for further surgeries chronic pain on full range of motion risk of continued discomfort risk of need for repeat debridement risk of need for internal fixation risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed They understood these well All questions were answered and they signed the consent for procedure as described DESCRIPTION OF PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The right forearm was inspected There was noted to be a 3 mm puncture type wound over the volar aspect of the forearm in the middle one third overlying the radial one half There was bleeding in this region No gross contamination was seen At this point under fluoroscopic control I did attempt to see a fracture I was unable to do the forearm under the close reduction techniques At this point the right upper extremity was then prepped and draped in the usual sterile manner An incision was made through the puncture wound site extending this proximally and distally There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed I also did perform a light debridement of the nonviable subcutaneous tissue muscle and small bony fragments were also removed These were all completely debrided appropriately and then at this point a thorough irrigation was performed of the radius which I communicated through the puncture wound Both ends were clearly visualized and thorough irrigation was performed using total of 6 L of antibiotic solution All nonviable gross contaminated tissue was removed At this point with the bones in direct visualization I did reduce the bony ends to anatomic alignment with excellent bony approximation Proper alignment of tissue and angulation was confirmed At this point under fluoroscopic control confirmed the radius and ulna in anatomic position which will be completely displaced and shortened previously The ulna was now also noted to be in anatomic alignment At this point the region was thoroughly irrigated Hemostasis confirmed and closure then begun The skin was reapproximated using 3 0 nylon suture The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1 5 inch Nugauze with iodoform Sterile dressing applied and a long arm cast with the forearm in neutral position was applied X ray with fluoroscopic evaluation was performed which confirmed They maintained excellent bony approximation and the anatomic alignment The long arm cast was then completely mature No complications were encountered throughout the procedure The patient tolerated the procedure well The patient was then taken to the recovery room in stable condition Keywords surgery compound fracture mid shaft radius ulna open reduction irrigation and debridement subcutaneous tissues muscle bone forearm radius and ulna forearm fracture anatomic alignment arm cast puncture wound tourniquet i d fracture MEDICAL_TRANSCRIPTION,Description Incision and drainage I D of gluteal abscess Removal of pigtail catheter Limited exploratory laparotomy with removal of foreign body and lysis of adhesions Medical Specialty Surgery Sample Name I D Gluteal Abscess Transcription PREOPERATIVE DIAGNOSES 1 Postoperative wound infection 2 Left gluteal abscess 3 Intraperitoneal pigtail catheter POSTOPERATIVE DIAGNOSES 1 Postoperative wound infection There was an intraperitoneal foreign body 2 Left gluteal abscess 3 Intraperitoneal pigtail catheter PROCEDURES 1 Incision and drainage I D of gluteal abscess 2 Removal of pigtail catheter 3 Limited exploratory laparotomy with removal of foreign body and lysis of adhesions DESCRIPTION OF PROCEDURE After obtaining the informed consent the patient was transferred to the operating room where a time out process was followed Under general endotracheal anesthesia first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied Then the patient was placed in a supine position and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism It came out without any difficulty Then the colostomy was protected and draped apart and the patient s abdomen was prepped and draped in the usual fashion My initial idea was to just drain and debride the wound infection which had a sinus tract at lower end of the midline incision I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen Very carefully I started dividing the fascia Of course there were several small bowel loops adhered to the area The dissection was quite tedious for a while Initially I thought that may be there was an enterocutaneous fistula in the area but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen but later on this substance floated out by self and it was an elongated strip maybe about 6 cm which we sent to Pathology for examination Initially I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms I was very happy that we were not really dealing with enterocutaneous fistula The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure of eight sutures of heavy PPS The subcutaneous tissue and the skin were left open and packed with Betadine soaked sponges A dressing was applied A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area The patient tolerated the procedure well Estimated blood loss was minimal and he was sent to the ICU and also made acute care because of the need for a laparotomy which we were not anticipating Keywords surgery intraperitoneal pigtail catheter postoperative wound infection foreign body intraperitoneal exploratory laparotomy enterocutaneous fistula wound infection sinus tract gluteal abscess pigtail catheter i d abscess laparotomy fascia pigtail catheter gluteal incision foreign MEDICAL_TRANSCRIPTION,Description Incision and drainage and removal of foreign body right foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound Medical Specialty Surgery Sample Name I D Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body right foot PROCEDURE PERFORMED 1 Incision and drainage right foot 2 Removal of foreign body right foot HISTORY This 7 year old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap General anesthesia was administered by the Department of Anesthesia The foot was then prepped and draped in the usual sterile orthopedic fashion The stockinette was reflected and the foot was cleansed with wet and dry sponge There was noted to be some remaining periwound erythema There was noted to be some mild crepitation about 2 cm proximal from the entry wound The entry wound was noted to be over the third metatarsal head dorsally Upon inspection of the wound there was noted to be hard foreign filling substance deep within the wound The entry site from the foreign body was extended proximally approximately about 0 5 cm At this time a large wooden foreign body was visualized and removed with a straight stat The area was carefully inspected for any remaining piece of foreign body Several small pieces were noted and they were removed The area was palpated and there was no more remaining foreign body noted At this time the wound was inspected thoroughly There was noted to be an area along the third metatarsal head more distally that did probe to the bone There was no purulent drainage expressed Area was flushed with copious amounts of sterile saline Pulse lavage was performed with 3 liters of plain sterile saline Wound cultures were obtained aerobic and aerobic The wound was then again inspected for any remaining foreign body or purulent drainage None was noticed The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s ABDs Kling and Kerlix The patient tolerated the above procedure and anesthesia well without complications The patient was transported to the PACU with vital signs stable and vascular status intact The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry The patient had a postoperative pain prescription written for Tylenol Elixir with codeine as needed Keywords surgery incision and drainage removal of foreign body purulent drainage foreign body metatarsal head orthopedic metatarsal i d incision drainage foot MEDICAL_TRANSCRIPTION,Description Incision and drainage of right buccal space abscess and teeth extraction Medical Specialty Surgery Sample Name I D Buccal Space Abscess Transcription PREOPERATIVE DIAGNOSES 1 Right buccal space abscess cellulitis 2 Nonrestorable caries teeth 1 29 and 32 POSTOPERATIVE DIAGNOSES 1 Right buccal space abscess cellulitis 2 Nonrestorable caries teeth 1 29 and 32 PROCEDURE 1 Incision and drainage of right buccal space abscess 2 Extraction of teeth 1 29 and 32 ANESTHESIA GETA EBL 20 mL IV FLUIDS 900 mL URINE OUTPUT Not measured COMPLICATIONS None SPECIMENS 1 Aerobic culture was sent from the right buccal space abscess cellulitis 2 Anaerobic culture from the same space was also obtained PROCEDURE IN DETAIL The patient was identified in the appropriate holding area and transported to 13 The patient was intubated by anesthesia orotracheally using a 7 ET tube The patient was induced in effective sleep using a propofol and gas inhalation anesthetics Following intubation the patient s mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack At that point approximately 5 mL of 2 lidocaine with 1 20 000 epinephrine was injected for a right inferior alveolar block as well as local infiltration in the right long buccal nerve area as well as the right cheek area Local infiltration also was done near the tooth 32 At this point a periosteal elevator was used to loosen up the gingival tissue of the teeth 1 29 and 32 and all 3 teeth were extracted using simple extraction using elevators and forceps In addition the previous Penrose drain was removed by removing the suture and the incision that was used for I D on the previous day was extended laterally A hemostat was used to puncture through to the right buccal space Approximately 2 5 to 3 mL of purulence was drained and that was used for Gram stain and culture as mentioned above Following copious irrigation of the area following the extraction and following the incision and drainage 2 quarter inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space At this point copious irrigation was done again the throat pack was removed and the procedure was ended Note that the patient was extubated without incident Dr B was present for all critical aspects of patient care Keywords surgery abscess 7 et tube aerobic culture anaerobic culture extraction of teeth geta alveolar block buccal space caries cellulitis copious irrigation extraction teeth nonrestorable caries teeth buccal space abscess nonrestorable caries caries teeth throat pack buccal MEDICAL_TRANSCRIPTION,Description Placement of right external iliac artery catheter via left femoral approach arteriography of the right iliac arteries primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone Medical Specialty Surgery Sample Name Iliac Artery Catheter Stent Placement Arteriography Angioplasty Transcription PREOPERATIVE DIAGNOSIS External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function POSTOPERATIVE DIAGNOSIS External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function PROCEDURES 1 Placement of right external iliac artery catheter via left femoral approach 2 Arteriography of the right iliac arteries 3 Primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon 3 Open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone ANESTHESIA Local with intravenous sedation INDICATION FOR PROCEDURE He is a 67 year old white male who is well known to me He had severe peripheral vascular disease and recently underwent a kidney transplant He has had some troubles with increasing serum creatinine and hypertension Duplex suggests a high grade iliac stenosis just proximal to his transplant kidney He is brought to the operating room for arteriography and potential treatment of this DESCRIPTION OF PROCEDURE The patient was brought to operating room 14 A condom catheter was put in place Preoperative antibiotics were administered The patient s left arm was prepped and draped in the usual sterile fashion An incision was made over his brachial artery after anesthetizing the skin His brachial artery was dissected free and looped with vessel loops Under direct vision it was punctured with an 18 gauge needle and a short 3J guidewire and 6 French sheath put in place A 3J guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta This was then advanced down into the right common iliac artery The catheter was placed over this and arteriography performed After adjusting the image intensifier to unfold the origin of the renal artery from the iliac system We were able to demonstrate an approximately 60 70 stenosis of the external iliac artery Immediately preceding the origin of the artery for the transplant kidney which appeared to be widely patent We elected to try and treat this With catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery An 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated This inflation was held for one minute This was then deflated and a catheter positioned again in the proximal common iliac artery For this application we used a guide catheter that would allow us to inject contrast without losing our wire purchase This showed an improvement in the stenosis but a residual stenosis of at least 30 and we elected to stent this An 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery After this was completed the stent introduction balloon was removed and the catheter replaced Repeat angiography showed a widely patent segment with no evidence of any residual stenosis There was no evidence of any dissection or damage to the renal artery We interpreted this as satisfactory procedure Guidewires and sheaths were removed The brachial artery was repaired with two interrupted sutures of 7 0 Prolene The wound was irrigated and the subcutaneous tissue closed with a running suture of Vicryl The skin was reapproximated with a running intracuticular suture of Monocryl Steri Strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition Estimated blood loss for the procedure was less than 50 mL Total contrast employed was 37 5 mL Total fluoroscopy time was 12 minutes and 43 seconds Keywords surgery external iliac artery catheter catheter via left femoral external iliac artery stenosis impaired renal function common iliac artery iliac artery catheter external iliac artery iliac artery femoral approach iliac arteries transplanted kidney renovascular hypertension widely patent residual stenosis stent placement angioplasty balloon brachial artery renal artery iliac angioplasty artery guidewire arteriography kidney renal catheter stenosis MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C hysteroscopy and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid Thickened endometrium and tamoxifen therapy adnexal cyst endometrial polyp and right ovarian cyst Medical Specialty Surgery Sample Name Hysteroscopy Laproscopy with Salpingooophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Thickened endometrium and tamoxifen therapy 2 Adnexal cyst POSTOPERATIVE DIAGNOSES 1 Thickened endometrium and tamoxifen therapy 2 Adnexal cyst 3 Endometrial polyp 4 Right ovarian cyst PROCEDURE PERFORMED 1 Dilation and curettage D C 2 Hysteroscopy 3 Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid ANESTHESIA General ESTIMATED BLOOD LOSS Less than 20 cc COMPLICATIONS None INDICATIONS This patient is a 44 year old gravida 2 para 1 1 1 2 female who was diagnosed with breast cancer in December of 2002 She has subsequently been on tamoxifen Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst The above procedures were therefore performed FINDINGS On bimanual exam the uterus was found to be slightly enlarged and anteverted The external genitalia was normal Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium Laparoscopic findings revealed a normal appearing uterus and normal left ovary There was no evidence of endometriosis on the ovaries bilaterally the ovarian fossa the cul de sac or the vesicouterine peritoneum There was a cyst on the right ovary which appeared simple in nature The cyst was aspirated and the fluid was blood tinged Therefore the decision to perform oophorectomy was made The liver margins appeared normal and there were no pelvic or abdominal adhesions noted The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite prepped and draped and placed in the dorsal lithotomy position Her bladder was drained with a red Robinson catheter A bimanual exam was performed which revealed the above findings A weighted speculum was then placed in the posterior vaginal vault in the 12 o clock position and the cervix was grasped with vulsellum tenaculum The cervix was then sounded in the anteverted position to 10 cm The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10 The hysteroscope was then inserted and the above findings were noted A sharp curette was then introduced and the 4 cm polyp was removed The hysteroscope was then reinserted and the polyp was found to be completely removed at this point The polyp was sent to Pathology for evaluation The uterine elevator was then placed as a means to manipulate the uterus The weighted speculum was removed Gloves were changed Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made While tenting up the abdominal wall the Veress needle was inserted without difficulty Using a sterile saline drop test appropriate placement was confirmed The abdomen was then insufflated with appropriate volume inflow of CO2 The 11 step trocar was placed without difficulty The above findings were then visualized A 5 mm port was placed 2 cm above the pubic symphysis This was done under direct visualization and the grasper was inserted through this port for better visualization A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament Prior to this the cyst was aspirated using 60 cc syringe on a needle Approximately 20 cc of blood tinged fluid was obtained After the ovary and fallopian tube were completely transected this was placed in an EndoCatch bag and removed through the lateral port site The incision was found to be hemostatic The area was suction irrigated After adequate inspection the port sites were removed from the patient s abdomen and the abdomen was desufflated The infraumbilical port site and laparoscope were also removed The incisions were then repaired with 4 0 undyed Vicryl and dressed with Steri Strips 10 cc of 0 25 Marcaine was then injected locally The patient tolerated the procedure well The sponge lap and needle counts were correct x2 She will be followed up on an outpatient basis Keywords surgery adnexal cyst endometrial ovarian cyst dilation and curettage d c hysteroscopy laparoscopy salpingooophorectomy aspiration of cyst fluid thickened endometrium tamoxifen therapy abdominal wall cyst ovarian endometrium MEDICAL_TRANSCRIPTION,Description Incision and drainage I D of buttock abscess Medical Specialty Surgery Sample Name I D Buttock Abscess Transcription PRINCIPAL DIAGNOSIS Buttock abscess ICD code 682 5 PROCEDURE PERFORMED Incision and drainage I D of buttock abscess CPT CODE 10061 DESCRIPTION OF PROCEDURE Under general anesthesia skin was prepped and draped in usual fashion Two incisions were made along the right buttock approximately 5 mm diameter Purulent material was drained and irrigated with copious amounts of saline flush A Penrose drain was placed Penrose drain was ultimately sutured forming a circular drain The patient s drain will be kept in place for a period of 1 week and to be taken as an outpatient basis Anesthesia general endotracheal anesthesia Estimated blood loss approximately 5 mL Intravenous fluids 100 mL Tissue collected Purulent material from buttock abscess sent for usual cultures and chemistries Culture and sensitivity Gram stain A single Penrose drain was placed and left in the patient Dr X attending surgeon was present throughout the entire procedure Keywords surgery incision and drainage purulent material penrose drain buttock abscess i d drainage MEDICAL_TRANSCRIPTION,Description Hysteroscopy Essure tubal occlusion and ThermaChoice endometrial ablation Medical Specialty Surgery Sample Name Hysteroscopy Endometrial Ablation Transcription PREOPERATIVE DX 1 Menorrhagia 2 Desires permanent sterilization POSTOPERATIVE DX 1 Menorrhagia 2 Desires permanent sterilization OPERATIVE PROCEDURE Hysteroscopy Essure tubal occlusion and ThermaChoice endometrial ablation ANESTHESIA General with paracervical block ESTIMATED BLOOD LOSS Minimal FLUIDS On hysteroscopy 100 ml deficit of lactated Ringer s via IV 850 ml of lactated Ringer s COMPLICATIONS None PATHOLOGY None DISPOSITION Stable to recovery room FINDINGS A nulliparous cervix without lesions Uterine cavity sounding to 10 cm normal appearing tubal ostia bilaterally fluffy endometrium normal appearing cavity without obvious polyps or fibroids PROCEDURE The patient was taken to the operating room where general anesthesia was found to be adequate She was prepped and draped in the usual sterile fashion A speculum was placed into the vagina The anterior lip of the cervix was grasped with a single tooth tenaculum and a paracervical block was performed using 20 ml of 0 50 lidocaine with 1 200 000 of epinephrine The cervical vaginal junction at the 4 o clock position was injected and 5 ml was instilled The block was performed at 8 o clock as well with 5 ml at 10 and 2 o clock The lidocaine was injected into the cervix The cervix was minimally dilated with 17 Hanks dilator The 5 mm 30 degree hysteroscope was then inserted under direct visualization using lactated Ringer s as a distention medium The uterine cavity was viewed and the above normal findings were noted The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia The coil was advanced and easily placed and the device withdrawn There were three coils into the uterine cavity after removal of the insertion device The device was removed and reloaded The advice was to advance under direct visualization and the tip was inserted into the left ostia This passed easily and the device was inserted It was removed easily and three coils again were into the uterine cavity The hysteroscope was then removed and the ThermaChoice ablation was performed The uterus was then sounded to 9 5 to 10 cm The ThermaChoice balloon was primed and pressure was drawn to a negative 150 The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W The pressure was brought up to 170 and the cycle was initiated A full cycle of eight minutes was performed At no time there was a significant loss of pressure from the catheter balloon After the cycle was complete the balloon was deflated and withdrawn The tenaculum was withdrawn No bleeding was noted The patient was then awakened transferred and taken to the recovery room in satisfactory condition Keywords surgery menorrhagia essure hysteroscopy thermachoice uterine cavity endometrial ablation endometrium fibroids fluffy lactated ringer nulliparous paracervical block permanent sterilization polyps tubal occlusion tubal ostia lactated ringer s ablation uterine MEDICAL_TRANSCRIPTION,Description Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma Medical Specialty Surgery Sample Name I D Auricular Hematoma Transcription PREOPERATIVE DIAGNOSIS Recurrent severe right auricular hematoma POSTOPERATIVE DIAGNOSIS Recurrent severe right auricular hematoma TITLE OF PROCEDURE Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 2 mL COMPLICATIONS None FINDINGS Approximately 5 mL of serosanguineous drainage PROCEDURE The patient underwent an incision and drainage procedure with stay suture placement on 05 28 2008 by me and also by Dr X on 05 23 2008 for a large near 100 auricular hematoma She presents for suture removal however there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr X It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters Consent was obtained The patient is aware that the complications with this ear area severe and auricular deformity is inevitable however quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation The area was prepped in the usual manner localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted A through and through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression She tolerated this procedure very well Keywords surgery bolster dressing placement antihelix fold incision and drainage bolster dressing auricular hematoma auricular hematoma incision drainage MEDICAL_TRANSCRIPTION,Description Hypospadias repair TIP with tissue flap relocation and chordee release Nesbit tuck Medical Specialty Surgery Sample Name Hypospadias Repair Chordee Release 1 Transcription PREOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma POSTOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma PROCEDURE Hypospadias repair TIP with tissue flap relocation and chordee release Nesbit tuck ANESTHETIC General inhalational anesthetic with a caudal block FLUIDS RECEIVED 300 mL of crystalloid ESTIMATED BLOOD LOSS 20 mL TUBES DRAINS An 8 French Zaontz catheter INDICATIONS FOR OPERATION The patient is a 17 month old boy with hypospadias abnormality The plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized a caudal block was placed IV antibiotics were given He was then placed in the supine position The foreskin was retracted and cleansed He was then sterilely prepped and draped A stay stitch of 4 0 Prolene was then placed on the glans The urethra was calibrated with the lacrimal duct probes to an 8 French We then marked out the coronal cuff the penile shaft skin as well as the glanular plate for future surgery with a marking pen We then used a 15 blade knife to circumscribe the penis around the coronal cuff We then degloved the penis using the curved tenotomy scissors and electrocautery was used for hemostasis The patient had some splaying of the spongiosum tissue which was also incised laterally and rotated to make a secondary flap Once the penis was degloved and the excessive chordee tissue was released we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection He was still noted to have chordee so a midline incision through the Buck fascia was made with a 15 blade knife and Heineke Mikulicz closure using 5 0 Prolene was then used for the chordee Nesbit tuck We repeated the artificial erection and the penis was straight We then incised the urethral plate with an ophthalmic blade in the midline and then elevated the glanular wings using a 15 blade knife to elevate and then incise them Using the curved iris scissors we then also further mobilized the glanular wings The 8 French Zaontz was then placed while the tourniquet was still in place into the urethral plate The upper aspect of the distal meatus was then closed with an interrupted suture of 7 0 Vicryl and then using a running subcuticular closure we closed the urethral plates over the Zaontz catheter We then mobilized subcutaneous tissue from the penile shaft skin and the inner perpetual skin on the dorsum and then buttonholed the flap placed it over the head of the penis and then used it to cover of the hypospadias repair with tacking sutures of 7 0 Vicryl We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic 7 0 Vicryl was used for that as well 5 0 Vicryl was used to roll the glans with 2 deep sutures and then horizontal mattress sutures of 7 0 Vicryl were used to reconstitute the glans Interrupted sutures of 7 0 Vicryl were used to approximate the urethral meatus to the glans Once this was done we then excised the excessive penile shaft skin and used the interrupted sutures of 6 0 chromic to attach the penile shaft skin to the coronal cuff On the ventrum itself we used horizontal mattress sutures to close the defect At the end of the procedure the Zaontz catheter was sutured into place with a 4 0 Prolene suture Dermabond tissue adhesive and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place IV Toradol was given at the procedure The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room Keywords surgery coronal hypospadias with chordee coronal hypospadias tissue flap relocation nesbit tuck hypospadias with chordee horizontal mattress sutures chordee release zaontz catheter coronal cuff hypospadias repair penile shaft zaontz glans urethral repair coronal hypospadias penis chordee MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy right and left pelvic lymphadenectomy common iliac lymphadenectomy and endometrial cancer staging procedure Medical Specialty Surgery Sample Name Hysterectomy TAH BSO Transcription PREOPERATIVE DIAGNOSIS Endometrial cancer POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy right and left pelvic lymphadenectomy common iliac lymphadenectomy and endometrial cancer staging procedure ANESTHESIA General endotracheal tube SPECIMENS Pelvic washings for cytology uterus with attached tubes and ovaries right and left pelvic lymph nodes para aortic nodes INDICATIONS FOR PROCEDURE The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy She was counseled to undergo staging laparotomy FINDINGS Examination under anesthesia revealed a small uterus with no nodularity During the laparotomy the uterus was small mobile and did not show any evidence of extrauterine spread of disease Other abdominal viscera including the diaphragm liver spleen omentum small and large bowel and peritoneal surfaces were palpably normal There was no evidence of residual neoplasm after removal of the uterus The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthesia was induced after which she was examined prepped and draped A vertical midline incision was made and fascia was divided The peritoneum was entered without difficulty and washings were obtained The abdomen was explored with findings as noted A Bookwalter retractor was placed and bowel was packed Clamps were placed on the broad ligament for traction The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament The round ligaments were isolated divided and ligated The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder Retroperitoneal spaces were then opened allowing exposure of pelvic vessels and ureters The infundibulopelvic ligaments were isolated divided and doubly ligated The uterine artery pedicles were skeletonized clamped divided and suture ligated Additional pedicles were developed on each side of the cervix after which tissue was divided and suture ligated When the base of the cervix was reached the vagina was cross clamped and divided allowing removal of the uterus with attached tubes and ovaries Angle stitches of o Vicryl were placed incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure of eight stitches The pelvis was irrigated and excellent hemostasis was noted Retractors were repositioned to allow exposure for lymphadenectomy Metzenbaum scissors were used to incise lymphatic tissues Borders of the pelvic node dissection included the common iliac bifurcation superiorly the psoas muscle laterally the cross over of the deep circumflex iliac vein over the external iliac artery inferiorly and the anterior division of the hypogastric artery medially The posterior border of dissection was the obturator nerve which was carefully identified and preserved bilaterally Ligaclips were applied where necessary After the lymphadenectomy was performed bilaterally excellent hemostasis was noted Retractors were again repositioned to allow exposure of para aortic nodes Lymph node tissue was mobilized Ligaclips were applied and the tissue was excised The pelvis was again irrigated and excellent hemostasis was noted The bowel was run and no evidence of disease was seen All packs and retractors were removed and the abdominal wall was closed using a running Smead Jones closure with 1 permanent monofilament suture Subcutaneous tissues were irrigated and a Jackson Pratt drain was placed Scarpa s fascia was closed with a running stitch and skin was closed with a running subcuticular stitch The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords surgery tah bso lymphadenectomy endometrial total abdominal hysterectomy bilateral salpingo oophorectomy tubes and ovaries salpingo oophorectomy lymph nodes endometrial cancer abdominal hysterectomy oophorectomy hemostasis retractors washings laparotomy ligated pelvic uterus nodes MEDICAL_TRANSCRIPTION,Description Pelvic tumor cystocele rectocele and uterine fibroid Total abdominal hysterectomy bilateral salpingooophorectomy repair of bladder laceration appendectomy Marshall Marchetti Krantz cystourethropexy and posterior colpoperineoplasty She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Medical Specialty Surgery Sample Name Hysterectomy BSO Appendectomy Transcription 1 Pelvic tumor 2 Cystocele 3 Rectocele POSTOPERATIVE DIAGNOSES 1 Degenerated joint 2 Uterine fibroid 3 Cystocele 4 Rectocele PROCEDURE PERFORMED 1 Total abdominal hysterectomy 2 Bilateral salpingooophorectomy 3 Repair of bladder laceration 4 Appendectomy 5 Marshall Marchetti Krantz cystourethropexy 6 Posterior colpoperineoplasty GROSS FINDINGS The patient had a history of a rapidly growing mass on the abdomen extending from the pelvis over the past two to three months She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Curettings were negative for malignancy The patient did have a large cystocele and rectocele and a collapsed anterior and posterior vaginal wall Upon laparotomy there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five month pregnancy The ovaries appeared to be within normal limits There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation and during dissection a laceration inadvertently occurred and it was immediately recognized No other pathology noted from the abdominal cavity or adhesions The upper right quadrant of the abdomen compatible with a previous gallbladder surgery The appendix is in its normal anatomic position The ileum was within normal limits with no Meckel s diverticulum seen and no other gross pathology evident There was no evidence of metastasis or tumors in the left lobe of the liver Upon frozen section diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy OPERATIVE PROCEDURE The patient was taken to the Operating Room prepped and draped in the low lithotomy position under general anesthesia A midline incision was made around the umbilicus down to the lower abdomen With a 10 Bard Parker blade knife the incision was carried down through the fascia The fascia was incised in the midline muscle fibers were splint in the midline the peritoneum was grasped with hemostats and with a 10 Bard Parker blade after incision was made with Mayo scissors A Balfour retractor was placed into the wound This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care The infundibular ligament on the right side was isolated and ligated with 0 Vicryl suture brought to an avascular area doubly clamped and divided from the ovary and the ligament again re ligated with 0 Vicryl suture The right round ligament was ligated with 0 Vicryl suture brought to an avascular space within the broad ligament and divided from the uterus The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do and during dissection the bladder was inadvertently entered After this was immediately recognized the bladder flap was wiped away from the anterior surface of the uterus The bladder was then repaired with a running locking stitch 0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two layer closure of 0 Vicryl suture After removing the uterus the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors and the straight Ochsner was placed by 0 Vicryl suture thus controlling the uterine blood supply The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps divided from the uterus with 10 Bard Parker blade knife and a curved Ochsner was placed by 0 Vicryl suture The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using 10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors A single toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors The vaginal cuff was then closed using a running 0 Vicryl suture in locking stitch incorporating all layers of the vagina the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect The round ligaments were approximated to the vaginal cuff with 0 Vicryl suture and the bladder flap approximated to the round ligaments with 000 Vicryl suture The ______ was re peritonealized with 000 Vicryl suture and then the cecum brought into the incision The pelvis was irrigated with approximately 500 cc of water The appendix was grasped with Babcock forceps The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors The curved hemostats were placed with 00 Vicryl suture The base of the appendix was ligated with 0 plain gut suture doubly clamped and divided from the distal appendix with 10 Bard Parker blade knife and the base inverted with a pursestring suture with 00 Vicryl No bleeding was noted Sponge instrument and needle counts were found to be correct All packs and retractors were removed The peritoneum muscle fascia was closed in single layer closure using running looped 1 PDS but prior to closure a Marshall Marchetti Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted 0 Vicryl suture Following this the abdominal wall was closed as previously described and the skin was closed using skin staples Attention was then turned to the vagina where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa and flaps were created bilaterally In this fashion the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted 0 Vicryl suture Excess vaginal mucosa was excised and the vaginal mucosa closed with running 00 Vicryl suture The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted 00 Vicryl suture The skin was closed with a running 000 plain gut subcuticular stitch The vaginal vault was packed with a Betadine soaked Kling gauze sponge Sterile dressing was applied The patient was sent to recovery room in stable condition Keywords surgery marshall marchetti krantz cystourethropexy pelvic tumor cystocele rectocele uterine fibroid hysterectomy salpingooophorectomy bladder laceration appendectomy colpoperineoplasty marshall marchetti krantz cystourethropexy bard parker blade knife vicryl suture vaginal mucosa uterus vaginal uterine mucosa scissors ligament bladder MEDICAL_TRANSCRIPTION,Description Laparoscopic supracervical hysterectomy Menorrhagia and dysmenorrhea Medical Specialty Surgery Sample Name Hysterectomy Laparoscopic Supracervical Transcription PREOPERATIVE DIAGNOSES Menorrhagia and dysmenorrhea POSTOPERATIVE DIAGNOSES Menorrhagia and dysmenorrhea PROCEDURE Laparoscopic supracervical hysterectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 100 mL FINDINGS An 8 10 cm anteverted uterus right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid a normal appearing left ovary and normal appearing tubes bilaterally SPECIMENS Uterine fragments COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty The patient was placed in dorsal lithotomy position Examination under anesthesia revealed an anteverted uterus and no adnexal masses The patient was prepped and draped in normal sterile fashion A Foley catheter was placed in the patient s bladder The patient s cervix was visualized with speculum A single tooth tenaculum was placed on the anterior lip of the cervix A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated The tenaculum and speculum were then removed from the vagina Attention was then turned to the patient s abdomen where a small infraumbilical incision was made with scalpel Veress needle was placed through this incision and the patient s abdomen was inflated to a pressure of 15 mmHg Veress needle was removed and then 5 mm trocar was placed through the umbilical incision Laparoscope was placed through this incision and the patient s abdominal contents were visualized A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5 mm trocar was placed through this incision on direct visualization for laparoscope A trocar incision was made in the right lower quadrant A 10 mm trocar was placed through this incision under direct visualization with the laparoscope A ___ trocar incision was made in the left lower quadrant and a 2nd 10 mm trocar was placed through this incision under direct visualization with the laparoscope The patient s abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe The Gyrus cautery was used to cauterize and cut the right and left round ligaments The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment The right uteroovarian ligament was cauterized and cut using the Gyrus The uterine vessels were then bluntly dissected The Gyrus was then used to cauterize the right uterine vessels Gyrus was then used on the left side to cauterize and cut the left round ligament The anterior leaf of the broad ligament on the left side was bluntly dissected cauterized and cut Using the Gyrus the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected The left uterine vessels were then cauterized and cut using the Gyrus At this point as the uterine vessels had been cauterized on both sides the uterine body exhibited blanching At this point the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels The HUMI manipulator was removed prior to amputation of the uterine body After the uterine body was detached from the cervical stump morcellation of the uterine body was performed using the uterine morcellator The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision Once all fragments of the uterus were removed from the abdominal cavity the pelvis was irrigated The Harmonic scalpel was used to cauterize the remaining endocervical canal The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles The Harmonic scalpel was then used to incise the right ovarian simple cyst The right ovarian cyst was then drained yielding straw colored fluid The site of right ovarian cystotomy was noted to be hemostatic The pelvis was again inspected and noted to be hemostatic The ureters were identified on both sides and noted to be intact throughout the visualized course All instruments were then removed from the patient s abdomen and the abdomen was deflated The fascial defects at the 10 mm trocar sites were closed using figure of 8 sutures of 0 Vicryl and skin incisions were closed with a 4 0 Vicryl in subcuticular fashion The cervix was then visualized with the speculum Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks All instruments were removed from the patient s vagina and the patient was placed in normal supine position Sponge lap needle and instrument counts were correct x2 The patient was awoken from anesthesia and then transferred to the recovery room in stable condition Keywords surgery supracervical hysterectomy incision uterine uteroovarian hysterectomy supracervical menorrhagia dysmenorrhea cervical laparoscopic laparoscope cervix ligaments trocar MEDICAL_TRANSCRIPTION,Description Hypospadias repair TIT and tissue flap relocation and Nesbit tuck chordee release Medical Specialty Surgery Sample Name Hypospadias Repair Chordee Release Transcription PREOPERATIVE DIAGNOSIS Penoscrotal hypospadias with chordee POSTOPERATIVE DIAGNOSIS Penoscrotal hypospadias with chordee PROCEDURE Hypospadias repair TIT and tissue flap relocation and Nesbit tuck chordee release ANESTHESIA General inhalation anesthetic with a caudal block FLUIDS RECEIVED 300 mL of crystalloids ESTIMATED BLOOD LOSS 15 mL SPECIMENS No tissue sent to Pathology TUBES AND DRAINS An 8 French Zaontz catheter INDICATIONS FOR OPERATION The patient is a 1 1 2 year old boy with penoscrotal hypospadias plan is for repair DESCRIPTION OF PROCEDURE The patient was taken to the operating room where surgical consent operative site and the patient s identification was verified Once he was anesthetized a caudal block was placed IV antibiotic was given The dorsal hood was retracted and the patient was then sterilely prepped and draped A stay stitch of 4 0 Prolene was then placed in the glans for traction His urethra was calibrated it was quite thin to a 10 French with the straight sounds We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors Electrocautery was used for hemostasis The ventral chordee tissue was removed We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test which showed that he had a persistent chordee In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen We then used a Heinecke Mikulicz Nesbit tuck with 5 0 Prolene to straighten the penis Artificial erection again performed showed the penis was straight The knot was buried with figure of eight suture of 7 0 Vicryl in Buck fascia above it We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade We then elevated the glanular wings as well in the similar fashion An 8 French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7 0 Vicryl and then a running subcuticular closure of 7 0 Vicryl to close the defect We then put the stay sutures in the inter preputial skin with 7 0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors We buttonholed the flap and then placed it through the penis as a sleeve Interrupted sutures of 7 0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty Once this was done a two 5 0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis Interrupted sutures of 7 0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7 0 Vicryl used to reconstitute the glans We then removed the excessive preputial skin and using tacking sutures of 6 0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures We then closed the ventral defect Once this was done the stay suture in the glans was used to keep the Zaontz catheter to tack it into place We then used Surgicel Dermabond and Telfa dressing with Mastisol and an eye tape to keep the dressing in place IV Toradol was given at the end of the procedure The patient was in stable condition upon transfer to the recovery room Keywords surgery tissue flap relocation penoscrotal hypospadias urethra nesbit tuck chordee release horizontal mattress sutures hypospadias repair chordee release zaontz catheter urethral plate glans hypospadias penis chordee MEDICAL_TRANSCRIPTION,Description Left hydrocelectomy cystopyelogram bladder biopsy and fulguration for hemostasis Medical Specialty Surgery Sample Name Hydrocelectomy 1 Transcription PREOPERATIVE DIAGNOSES Bladder cancer and left hydrocele POSTOPERATIVE DIAGNOSES Bladder cancer and left hydrocele OPERATION Left hydrocelectomy cystopyelogram bladder biopsy and fulguration for hemostasis ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 66 year old male with history of smoking and hematuria had bladder tumor which was dissected He has received BCG The patient is doing well The patient was supposed to come to the OR for surveillance biopsy and pyelograms The patient had a large left hydrocele which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on etc Options such as watchful waiting drainage in the office and hydrocelectomy were discussed Risks of anesthesia bleeding infection pain MI DVT PE infection in the scrotum enlargement of the scrotum recurrence and pain were discussed The patient understood all the options and wanted to proceed with the procedure PROCEDURE IN DETAIL The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn The sac was turned upside down and sutures were placed Careful attention was made to ensure that the cord was open The testicle was in normal orientation throughout the entire procedure The testicle was placed back into the scrotal sac and was pexed with 4 0 Vicryl to the outside dartos to ensure that there was no risk of torsion Orchiopexy was done at 3 different locations Hemostasis was obtained using electrocautery The sac was closed using 4 0 Vicryl The sac was turned upside down so that when it heals the fluid would not recollect The dartos was closed using 2 0 Vicryl and the skin was closed using 4 0 Monocryl and Dermabond was applied Incision measured about 2 cm in size Subsequently using ACMI cystoscope a cystoscopy was performed The urethra appeared normal There was some scarring at the bulbar urethra but the scope went in through that area very easily into the bladder There was a short prostatic fossa The bladder appeared normal There was some moderate trabeculation throughout the bladder some inflammatory changes in the bag part but nothing of much significance There were no papillary tumors or stones inside the bladder Bilateral pyelograms were obtained using 8 French cone tip catheter which appeared normal A cold cup biopsy of the bladder was done and was fulgurated for hemostasis The patient tolerated the procedure well The patient was brought to recovery at the end of the procedure after emptying the bladder The patient was given antibiotics and was told to take it easy No heavy lifting pushing or pulling Plan was to follow up in about 2 months Keywords surgery hydrocele fulguration bladder biopsy hydrocelectomy cystopyelogram cystopyelogram bladder bladder cancer bladder MEDICAL_TRANSCRIPTION,Description Bilateral scrotal hydrocelectomies large for both and 0 5 Marcaine wound instillation 30 mL given Medical Specialty Surgery Sample Name Hydrocelectomy Transcription PREOPERATIVE DIAGNOSIS Bilateral hydroceles POSTOPERATIVE DIAGNOSIS Bilateral hydroceles PROCEDURE Bilateral scrotal hydrocelectomies large for both and 0 5 Marcaine wound instillation 30 mL given ESTIMATED BLOOD LOSS Less than 10 mL FLUIDS RECEIVED 800 mL TUBES AND DRAINS A 0 25 inch Penrose drains x4 INDICATIONS FOR OPERATION The patient is a 17 year old boy who has had fairly large hydroceles noted for some time Finally he has decided to have them get repaired Plan is for surgical repair DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized he was then shaved prepped and then sterilely prepped and draped IV antibiotics were given Ancef 1 g given A scrotal incision was then made in the right hemiscrotum with a 15 blade knife and further extended with electrocautery Electrocautery was used for hemostasis Once we got to the hydrocele sac itself we then opened and delivered the testis drained clear fluid There was moderate amount of scarring on the testis itself from the tunica vaginalis It was then wrapped around the back and sutured in place with a running suture of 4 0 chromic in a Lord maneuver Once this was done a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation A similar procedure was performed on the left which has also had a hydrocele of the cord which were both addressed and closed with Lord maneuver similarly This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this A similar drain was placed The testes were then placed back into the scrotum in a proper orientation and the local wound instillation and wound block was then placed using 30 mL of 0 5 Marcaine without epinephrine IV Toradol was given at the end of the procedure The skin was then sutured with a running interlocking suture of 3 0 Vicryl and the drains were sutured to place with 3 0 Vicryl Bacitracin dressing ABD dressing and jock strap were placed The patient was in stable condition upon transfer to the recovery room Keywords surgery bilateral scrotal hydrocelectomies bilateral hydroceles lord maneuver hydrocelectomy hydroceles MEDICAL_TRANSCRIPTION,Description Hypospadias repair Urethroplasty plate incision with tissue flap relocation and chordee release Medical Specialty Surgery Sample Name Hypospadias Repair Transcription PREOPERATIVE DIAGNOSIS Coronal hypospadias with chordee POSTOPERATIVE DIAGNOSIS Coronal hypospadias with chordee PROCEDURE Hypospadias repair urethroplasty plate incision with tissue flap relocation and chordee release ANESTHESIA General inhalation anesthetic with a 0 25 Marcaine dorsal block and ring block per surgeon 7 mL given TUBES AND DRAINS An 8 French Zaontz catheter ESTIMATED BLOOD LOSS 10 mL FLUIDS RECEIVED 300 mL INDICATIONS FOR OPERATION The patient is a 6 month old boy with the history of coronal hypospadias with chordee Plan is for repair DESCRIPTION OF OPERATION The patient was taken to the operating room with surgical consent operative site and the patient identification were verified Once he was anesthetized IV antibiotics were given The dorsal hood was retracted and cleansed He was then sterilely prepped and draped Stay suture of 4 0 Prolene was then placed in the glans His urethra was calibrated to 10 French bougie a boule We then marked the coronal cuff and the penile shaft skin as well as the periurethral meatal area on the ventrum Byers flaps were also marked Once this was done the skin was then incised around the coronal cuff with 15 blade knife and further extended with the curved tenotomy scissors to deglove the penis On the ventrum the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage Once this was done an electrocautery was used for hemostasis were then used A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee We then incised Buck fascia at the area of chordee in the ventrum and then used the 5 0 Prolene as a Heinecke Mikulicz advancement suture Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight We then left the tourniquet in place although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings Using the curved iris scissors we then elevated the wings even further Again electrocautery was used for hemostasis An 8 French Zaontz catheter was then placed into the urethral plate and then interrupted suture of 7 0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the 7 0 Vicryl suture There were two areas of coverage with the tissue flap relocation from the glanular wings The tissue flap that was rolled with the Byers flap was used to cover this as well as the chordee tissue with interrupted sutures of 7 0 Vicryl Once this was completed the glans itself had been rolled using two deep sutures of 5 0 Vicryl Interrupted sutures of 7 0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of 7 0 Vicryl used to roll the glans in the midline The extra dorsal hood tissue of preputial skin was then excised An interrupted sutures of 6 0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline The patient s scrotum was slightly asymmetric however this was due to the tissue configuration of the scrotum itself At the end of the procedure stay suture of 4 0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing Telfa and the surgical eye tape was then used for the final dressing IV Toradol was given The patient tolerated the procedure well and was in stable condition upon transfer to recovery room Keywords surgery tissue flap relocation urethroplasty plate incision penile shaft skin chordee release zaontz catheter penile shaft hypospadias repair flap relocation coronal cuff urethral plate tissue flap hypospadias flap chordee MEDICAL_TRANSCRIPTION,Description Wide Local Excision of the Vulva Radical anterior hemivulvectomy Posterior skinning vulvectomy Medical Specialty Surgery Sample Name Hemivulvectomy Transcription PREOPERATIVE DIAGNOSIS Recurrent vulvar melanoma POSTOPERATIVE DIAGNOSIS Recurrent vulvar melanoma OPERATION PERFORMED Radical anterior hemivulvectomy Posterior skinning vulvectomy SPECIMENS Radical anterior hemivulvectomy posterior skinning vulvectomy INDICATIONS FOR PROCEDURE The patient has a history of vulvar melanoma first diagnosed in November of 1995 She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris Biopsy obtained by The patient confirmed recurrence In addition biopsies on the posterior labia left side demonstrated melanoma in situ FINDINGS During the examination under anesthesia the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris No other obvious lesions were seen The room was darkened and a Woods lamp was used to inspect the epithelium A marking pen was used to outline all pigmented areas which included several patches on both the right and left labia PROCEDURE The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen The radical anterior hemivulvectomy was designed so that a 1 5 2 0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum After removal of the radical anterior portion the skin on the posterior labia and perineal body was mobilized Skin was incised with a scalpel and electrocautery was used to undermine After removal of the specimen the wounds were closed primarily with subcutaneous interrupted stitches of 3 0 Vicryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then taken to the Post Anesthesia Care Unit in stable condition Keywords surgery vulvar melanoma wide local excision radical anterior hemivulvectomy posterior skinning vulvectomy vulvectomy hemivulvectomy melanoma woods lamp recurrent vulvar melanoma anterior hemivulvectomy vulvar labia radical skinning MEDICAL_TRANSCRIPTION,Description Laparoscopic left inguinal hernia repair Medical Specialty Surgery Sample Name Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Left inguinal hernia POSTOPERATIVE DIAGNOSIS Left inguinal hernia ANESTHESIA General 0 25 Marcaine at trocar sites NAME OF OPERATION Laparoscopic left inguinal hernia repair PROCEDURE A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly The rectus muscle was retracted laterally Balloon dissector was passed below the muscle and above the peritoneum Insufflation and deinsufflation were done with the balloon removed The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide The other trocars were placed in the lower midline times two The hernia sac was easily identified and was well defined It was dissected off the cord anteromedially It was an indirect sac It was taken back down and reduced into the peritoneal cavity Mesh was then tailored and placed overlying the defect covering the femoral indirect and direct spaces tacked into place After this was completed there was good hemostasis The cord structures and vas were left intact The trocars were removed The wounds were closed with 0 Vicryl for the fascia 4 0 for the skin Steri Strips were applied The patient was awakened and carried to the recovery room in good condition having tolerated the procedure well Keywords surgery rectus fascia hernia laparoscopic left inguinal hernia inguinal hernia repair hernia repair laparoscopic rectus fascia repair balloon inguinal MEDICAL_TRANSCRIPTION,Description Placement of a subclavian single lumen tunneled Hickman central venous catheter Surgeon interpreted fluoroscopy Medical Specialty Surgery Sample Name Hickman Central Venous Catheter Placement Transcription PROCEDURE PERFORMED 1 Placement of a subclavian single lumen tunneled Hickman central venous catheter 2 Surgeon interpreted fluoroscopy OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and anesthesia was administered Next a 18 gauge needle was used to locate the subclavian vein After aspiration of venous blood a J wire was inserted through the needle using Seldinger technique The needle was withdrawn The distal tip location of the J wire was confirmed to be in adequate position with surgeon interpreted fluoroscopy Next a separate stab incision was made approximately 3 fingerbreadths below the wire exit site A subcutaneous tunnel was created and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff The catheter was cut to the appropriate length A dilator and sheath were passed over the J wire The dilator and J wire were removed and the distal tip of the Hickman catheter was threaded through the sheath which was simultaneously withdrawn The catheter was flushed and aspirated without difficulty The distal tip was confirmed to be in good location with surgeon interpreted fluoroscopy A 2 0 nylon was used to secure the cuff down to the catheter at the skin level The skin stab site was closed with a 4 0 Monocryl The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition Keywords surgery j wire distal tip stab incision tunneled hickman central venous catheter subclavian venous fluoroscopy hickman catheterNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Left hydrocelectomy This is a 67 year old male with pain left scrotum He has had an elevated PSA and also has erectile dysfunction He comes in now for a left hydrocelectomy Physical exam confirmed obvious hydrocele left scrotum Medical Specialty Surgery Sample Name Hydrocelectomy Transcription PREOPERATIVE DIAGNOSIS Left hydrocele OPERATION Left hydrocelectomy POSTOPERATIVE DIAGNOSIS Left hydrocele ANESTHESIA General INDICATIONS AND STUDIES This is a 67 year old male with pain left scrotum He has had an elevated PSA and also has erectile dysfunction He comes in now for a left hydrocelectomy Physical exam confirmed obvious hydrocele left scrotum approximately 8 cm Laboratory data included a hematocrit of 43 5 hemoglobin of 15 0 and white count 4700 Creatinine 1 3 sodium 141 and potassium 4 0 Calcium 8 6 Chest x ray was unremarkable EKG was normal PROCEDURE The patient was satisfactorily given general anesthesia prepped and draped in supine position and left scrotal incision was made carried down to the tunica vaginalis forming the hydrocele This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord In the fashion the hydrocele was excised and fluid drained Cord was infiltrated with 5 mL of 0 25 Marcaine The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3 0 Vicryl sutures for hemostasis The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3 0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia The left scrotal incision was closed first closing the Dartos fascia with interrupted 3 0 Vicryl sutures Skin was closed with an interrupted running 4 0 chromic suture A sterile dressing was applied The patient was sent to the recovery room in good condition upon awakening from general anesthesia Plan is to discharge the patient and see him back in the office in a week or 2 in followup Further plans will depend upon how he does Keywords surgery hydrocele erectile dysfunction spermatic cord tunica vaginalis vicryl sutures dartos fascia hydrocelectomy psa testicle scrotum scrotal MEDICAL_TRANSCRIPTION,Description Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root Medical Specialty Surgery Sample Name Hemilaminotomy Foraminotomy Transcription PRE AND POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy at C5 C6 OPERATION Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root After informed consent was obtained from the patient he was taken to the OR After general anesthesia had been induced Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted At this point the patient s was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position The patient s posterior cervical area was then prepped and draped in the usual sterile fashion At this time the patient s incision site was infiltrated with 1 percent Lidocaine with epinephrine A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes which could be palpated After dissection down to a spinous process using Bovie cautery a clamp was placed on this spinous processes and cross table lateral x ray was taken This showed the spinous process to be at the C4 level Therefore further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified After the muscle was dissected off the lamina laterally on the left side self retaining retractors were placed and after hemostasis was achieved a Penfield probe was placed in the interspace presumed to be C5 6 and another cross table lateral x ray of the C spine was taken This film confirmed our position at C5 6 and therefore the operating microscope was brought onto the field at this time At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur However progress was limited because of thickness of the bone Therefore at this time the Midas Rex drill the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area After the bone had been thinned out further bone was removed using the Kerrison rongeur At this point the nerve root was visually inspected and observed to be decompressed However there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery After hemostasis was achieved the surgical site was copiously irrigated with Bacitracin Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches The subcutaneous layer was then reapproximated using 000 Dexon The skin was reapproximated using a running 000 nylon Sterile dressings were applied The patient was then extubated in the OR and transferred to the Recovery room in stable condition ESTIMATED BLOOD LOSS minimal Keywords surgery foraminotomy with medial facetectomy facetectomy for microscopic decompression decompression of nerve root hemilaminotomy and foraminotomy decompression of nerve microscopic decompression medial facetectomy kerrison rongeur nerve root spinous processes facetectomy kerrison hemilaminotomy foraminotomy MEDICAL_TRANSCRIPTION,Description Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein End stage renal disease with failing AV dialysis fistula Medical Specialty Surgery Sample Name Hemodialysis Fistula Construction Transcription PREOPERATIVE DIAGNOSIS End stage renal disease with failing AV dialysis fistula POSTOPERATIVE DIAGNOSIS End stage renal disease with failing AV dialysis fistula PROCEDURE Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein ANESTHESIA Endotracheal DESCRIPTION OF OPERATIVE PROCEDURE General endotracheal anesthesia was initiated without difficulty The right arm axilla and chest wall were prepped and draped in sterile fashion Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent The draining veins are the deep brachial veins The primary vein was carefully dissected out and small tributaries clamped divided and ligated with 3 0 Vicryl suture A nice length of vein was obtained to the distal one third of the arm This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein which remains patent through a small collateral vein A transverse skin incision was made over the superior aspect of the old fistula vein This vein was carefully dissected out and encircled with vascular tapes The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula The patient was sensible was then systemically heparinized The existing fistula vein was clamped proximally and distally incised longitudinally for about a centimeter The brachial vein end was spatulated Subsequently a branchial vein to arterialized fistula vein anastomosis was then constructed using running 6 0 Prolene suture in routine fashion After the completion of the anastomosis the fistula vein was forebled and the branchial vein backbled The anastomosis was completed A nice thrill could be palpated over the outflow brachial vein Hemostasis was noted A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with 3 0 nylon suture The wounds were then closed using interrupted 4 0 Vicryl and deep subcutaneous tissue ___ staples closed the skin Sterile dressings were applied The patient was then x ray d and taken to Recovery in satisfactory condition Estimated blood loss 50 mL drains 8 mm Blake Operative complication none apparent final sponge needle and instrument counts reported as correct Keywords surgery end stage renal disease av dialysis fistula brachial vein upper arm hemodialysis fistula fistula vein hemodialysis av dialysis anastomosis brachial MEDICAL_TRANSCRIPTION,Description Left sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull Medical Specialty Surgery Sample Name Hemicraniectomy Transcription TITLE OF OPERATION Left sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure INDICATION FOR SURGERY The patient is a patient well known to my service She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull I took her to the operating a few days ago for a large right sided hemicraniectomy to save her life I spoke with the family the mom especially about the risks benefits and alternatives of this procedure most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes I discussed with them that this was a life saving procedure and the family agreed to proceed with surgery as a level 1 We went to the operating room at that time and we did a very large right sided hemicraniectomy The patient was put in the intensive care unit We had placed also at that time a left sided intracranial pressure monitor both which we took out a few days ago Over the last few days the patient began to slowly deteriorate little bit on her clinical examination that is she was at first localizing briskly with the right side and that began to be less brisk We obtained a CT scan at this point and we noted that she had a fair amount of swelling in the left hemisphere with about 1 5 cm of midline shift At this point once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left sided very large hemicraniectomy with this __________ this was once again a life saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side PROCEDURE IN DETAIL The patient was taken to the operating room She was already intubated and under general anesthesia The head was put in a 3 pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right hand side down and the left hand side up since on the right hand side she did not have a bone flap which complicated matters a little bit so we had to use a 3 pin Mayfield headholder The patient tolerated this well We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery so we incorporated this incision into the new incision and to be able to open the skin on the left side we did a T shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin We connected this Prior to this we brought in all surgical instrumentation under sterile and standard conditions We opened the skin as in opening a book and then we also did a myocutaneous flap We brought in the muscle with it We had a very good exposure of the skull We identified all the important landmarks including the zygoma inferiorly the superior sagittal suture as well as posteriorly and anteriorly We had very good landmarks so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly a very large decompression of the left side At this point we opened the dura and the dura as soon as it was opened there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly All this was irrigated thoroughly Once we made sure we had absolutely great hemostasis without any complications we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely We had absolutely good hemostasis We put a piece of Gelfoam over the brain We had opened the dura in a cruciate fashion and the brain clearly bulging out despite of the fact that it was in the dependent position I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place This running nylon we put in place in order not to put any absorbables although I put a few 0 popoffs just to approximate the skin nicely Once we had done this irrigated thoroughly once again the skin We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit The EBL was about 200 cubic centimeters Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct No complications The patient went back to the intensive care unit Keywords surgery large hemicraniectomy intracranial pressure multiple fractures skull traumatic brain injury mayfield headholder injury hemicraniectomyNOTE MEDICAL_TRANSCRIPTION,Description Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty Medical Specialty Surgery Sample Name Hemangioma Debulking Rhinoplasty Transcription PREOPERATIVE DIAGNOSIS Hemangioma nasal tip POSTOPERATIVE DIAGNOSIS Hemangioma nasal tip PROCEDURE PERFORMED 1 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach 2 Rhinoplasty ESTIMATED BLOOD LOSS Minimal FINDINGS Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes CONDITION Condition of the patient at end of the procedure stable transferred to recovery room INDICATIONS FOR THE PROCEDURE The patient is a 2 year old female with a history of a nasal tip hemangioma The hemangioma has involved at her upper tongue There has not been any change in the last 6 months We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma They understand the nature of the incision the nature of the surgery and the possibility of future revision surgeries They understand the risk of bleeding infection dehiscence scarring need for future revision surgery and minor asymmetry They wished to proceed with surgery Because of the procedure informed consent is obtained The patient is taken to operating room and placed in the supine position General anesthetic is administrated to an oroendotracheal tube The face is prepped and draped in the usual manner The incision is designed to the lower aspect of the hemangioma which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions The area is infiltrated with lidocaine with epinephrine We waited 7 minutes for the hemostatic effect and proceeded with the incision The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa then extended laterally and upward to follow the lower lateral cartilage This is done in both sides Further incision is done A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip The hemangioma is removed and is found to be involving the medial aspects of both medial crura This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion Hemostasis is achieved with electrocautery Then we proceed to place some interdomal stitches with the help of a 6 0 clear nylon and intercrural stitches are placed and then an interdomal stitch a single one was placed The skin is redraped and the nose found to have satisfactory shape The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella Portions of skin and hemangioma are taken laterally on both sides of the columella distally The skin was closed with 6 0 mild chromic stitches including the portion at the level of the columella and rim incisions medially The remaining of the internal incisions are closed with 5 0 chromic interrupted stitches The nose is irrigated and suctioned The patient tolerated the procedure without complications I was present and participated in all aspects of the procedure Sponge and instrument count were complete at the end of the procedure Keywords surgery rhinoplasty approach debulking of hemangioma nasal domes lower lateral cartilages nasal tip columella hemangioma debulking cartilages rhinoplasty nasal MEDICAL_TRANSCRIPTION,Description Austin Moore bipolar hemiarthroplasty left hip Subcapital left hip fracture Medical Specialty Surgery Sample Name Hemiarthroplasty Austin Moore Bipolar Transcription PREOPERATIVE DIAGNOSIS Subcapital left hip fracture POSTOPERATIVE DIAGNOSIS Subcapital left hip fracture PROCEDURE PERFORMED Austin Moore bipolar hemiarthroplasty left hip ANESTHESIA Spinal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 cc HISTORY The patient is an 86 year old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08 30 03 after sustaining a fall at her friend s house The patient states that she was knocked over by her friend s dog She sustained a subcapital left hip fracture Prior to admission she lived alone in Terrano was ambulating with a walker All risks benefits and potential complications of the procedure were then discussed with the patient and informed consent was obtained HARDWARE SPECIFICATIONS A 28 mm medium head was used a small cemented femoral stem was used and a 28 x 46 cup was used PROCEDURE All risks benefits and potential complications of the procedure were discussed with the patient informed consent was obtained She was then transferred from the preoperative care unit to operating suite 1 Department of Anesthesia administered spinal anesthetic without complications After this the patient was transferred to the operating table and positioned All bony prominences were well padded She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards The left lower extremity was then sterilely prepped and draped in the normal fashion A skin maker was then used to mark all bony prominences Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks A 10 blade Bard Parker scalpel was used to incise the skin through to the subcutaneous tissues A second 10 blade was then used to incise through the subcutaneous tissue down to the fascia lata This was then incised utilizing Metzenbaum scissors This was taken down to the bursa which was removed utilizing a rongeur Utilizing a periosteal elevator as well as the sponge the fat was then freed from the short external rotators of the left hip after these were placed and stretched The sciatic nerve was then visualized and retracted utilizing a Richardson retractor Bovie was used to remove the short external rotators from the greater trochanter which revealed the joint capsule The capsule was cleared and incised utilizing a T shape incision A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture A cork screw was then used to remove the fractured femoral head which was given to the scrub tech which was sized on the back table All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur Acetabulum was then inspected and found to be clear Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut An oscillating saw was then used to make the femoral cut Box osteotome was then used to remove the bone from proximal femur A Charnley awl was then used to open the femoral canal paying close attention to keep the awl in the lateral position Next attention was turned to broaching Initially a small broach was placed first making efforts to lateralize the broach then the femoral canal It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate Next the trial components were inserted consisting of the above mentioned component sizes The hip was taken through range of motion and tested to adduction internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip It was noted that these size were stable through the range of motion Next the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal The femoral component was then inserted and then held under pressure Extruding cement was removed from the proximal femur After the cement had fully hardened and dried the head and cup were applied The hip was subsequently reduced and taken again through range of motion which was felt to be stable Next the capsule was closed utilizing 1 Ethibond in figure of eight fashion Next the fascia lata was repaired utilizing a figure of eight Ethibond sutures The most proximal region at the musculotendinous junction was repaired utilizing a running 1 Vicryl suture The wound was then copiously irrigated again to suction dry Next the subcutaneous tissues were reapproximated using 2 0 Vicryl simple interrupted sutures The skin was then reapproximated utilizing skin clips Sterile dressing was applied consisting of Adaptic 4x4s ABDs as well as foam tape The patient was then transferred from the operating table to the gurney Leg lengths were checked which were noted to be equal and abduction pillow was placed The patient was then transferred to the Postoperative Care Unit in stable condition Keywords surgery austin moore bipolar hemiarthroplasty subcapital left hip fracture hip fracture austin moore bipolar hemiarthroplasty subcutaneous tissues hip hemiarthroplasty austin cemented femur subcapital fracture femoral MEDICAL_TRANSCRIPTION,Description Left heart catheterization coronary angiography left ventriculography Severe complex left anterior descending and distal circumflex disease with borderline probably moderate narrowing of a large obtuse marginal branch Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 7 Transcription PROCEDURE Left heart catheterization coronary angiography left ventriculography COMPLICATIONS None PROCEDURE DETAIL The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration A 6 French arterial sheath was placed in the usual fashion Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic The right coronary artery was difficult to cannulate because of its high anterior takeoff This was nondominant Several catheters were used Ultimately an AL1 diagnostic catheter was used A pigtail catheter was advanced across the aortic valve Left ventriculogram was then done in the RAO view using 30 mL of contrast Pullback gradient was obtained across the aortic valve Femoral angiogram was performed through the sheath which was above the bifurcation was removed with a Perclose device with good results There were no complications He tolerated this procedure well and returned to his room in good condition FINDINGS 1 Right coronary artery This has an unusual high anterior takeoff The vessel is nondominant has diffuse mild to moderate disease 2 Left main trunk A 30 to 40 distal narrowing is present 3 Left anterior descending Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch there is 80 to 90 narrowing The diagonal is a large vessel about 3 mm in size 4 Circumflex Dominant vessel 50 narrowing at the origin of the obtuse marginal After this there is 40 narrowing in the AV trunk The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch which has 70 ostial narrowing and then after this the posterior descending has 80 narrowing at its origin 5 Left ventriculogram Normal volume in diastole and systole Normal systolic function is present There is no mitral insufficiency or left ventricular outflow obstruction DIAGNOSES 1 Severe complex left anterior descending and distal circumflex disease with borderline probably moderate narrowing of a large obtuse marginal branch Dominant circumflex system Severe disease of the posterior descending Mild left main trunk disease 2 Normal left ventricular systolic function Given the complex anatomy of the predominant problem which is the left anterior descending given its ostial stenosis and involvement of the bifurcation of the diagonal would recommend coronary bypass surgery The patient also has severe disease of the circumflex which is dominant This anatomy is not appropriate for percutaneous intervention The case will be reviewed with a cardiac surgeon Keywords surgery heart catheterization coronary angiography left ventriculography arterial sheath coronary artery obtuse marginal branch angiography catheterization MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy lysis of adhesions and right hemicolectomy Right colon cancer ascites and adhesions Medical Specialty Surgery Sample Name Hemicolectomy Transcription PREOPERATIVE DIAGNOSIS Right colon tumor POSTOPERATIVE DIAGNOSES 1 Right colon cancer 2 Ascites 3 Adhesions PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Lysis of adhesions 3 Right hemicolectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 200 cc URINE OUTPUT 200 cc CRYSTALLOIDS GIVEN 2700 cc INDICATIONS FOR THIS PROCEDURE The patient is a 53 year old African American female who presented with near obstructing lesion at the hepatic flexure The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma The patient was NG decompressed preoperatively and was prepared for surgery The need for removal of the colon cancer was explained at length The patient was agreeable to proceed with the surgery and signed preoperatively informed consent PROCEDURE The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively She was given triple antibiotics IV Due to her near obstructive symptoms a formal ________ was not performed The abdomen was prepped and draped in the usual sterile fashion A midline laparotomy incision was made with a 10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia Once divided the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline Extensive fluid was seen upon entering the abdomen ascites fluid which was clear straw colored and this was sampled for cytology Next the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure colonic mass which was adherent to the surrounding tissues With mobilization of the colon along the line of Toldt down to the right gutter the entire ileocecal region up to the transverse colon was mobilized into the field Next a window was made 5 inches from the ileocecal valve and a GIA 75 was fired across the ileum Next a second GIA device was fired across the proximal transverse colon just sparring the middle colic artery The dissection was then carried down along the mesentry down to the root of the mesentry Several lymph nodes were sampled carefully and small radiopaque clips were applied along the base of the mesentry The mesentry vessels are hemostated and tied with 0 Vicryl suture sequentially ligated in between Once this specimen was submitted to pathology the wound was inspected There was no evidence of bleeding from any of the suture sites Next a side by side anastomosis was performed between the transverse colon and the terminal ileum A third GIA 75 was fired side by side and GIA 55 was used to close the anastomosis A patent anastomosis was palpated The anastomosis was then protected with a 2 0 Vicryl 0 muscular suture Next the mesenteric root was closed with a running 0 Vicryl suture to prevent any chance of internal hernia The suture sites were inspected and there was no evidence of leakage Next the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction Next the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression Keywords surgery colon tumor ascites adhesions lysis of adhesions exploratory laparotomy colon cancer transverse colon hemicolectomy laparotomy MEDICAL_TRANSCRIPTION,Description Hemiarthroplasty of left shoulder utilizing a global advantage system with an 8 mm cemented humeral stem and 48 x 21 mm modular head replacement Comminuted fracture dislocation left proximal humerus Medical Specialty Surgery Sample Name Hemiarthroplasty Shoulder Transcription PREOPERATIVE DIAGNOSIS Comminuted fracture dislocation left proximal humerus POSTOPERATIVE DIAGNOSIS Comminuted fracture dislocation left proximal humerus PROCEDURE PERFORMED Hemiarthroplasty of left shoulder utilizing a global advantage system with an 8 mm cemented humeral stem and 48 x 21 mm modular head replacement PROCEDURE The patient was taken to OR 2 administered general anesthetic He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus The left shoulder and upper extremities were then prepped and draped in the usual manner A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery Hemostasis was achieved with the cautery The deltoid fascia were identified skin flaps were then created The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein The deltoid was then retracted There was marked hematoma and swelling within the subdeltoid bursa This area was removed with rongeurs The biceps tendon was identified which was the landmark for the rotator interval Mayo scissors was utilized to split the remaining portion of the rotator interval The greater tuberosity portion with the rotator cuff was identified Excess bone was removed from the greater tuberosity side to allow for closure later The lesser tuberosity portion with the subscapularis was still attached to the humeral head therefore osteotome was utilized to separate the lesser tuberosity from the humeral head fragment Excess bone was removed from the lesser tuberosity as well Both of these were tagged with Ethibond sutures for later The humeral head was delivered out of the wound It was localized to the area of the anteroinferior glenoid region The glenoid was then inspected and noted to be intact The fracture was at the level of the surgical neck on the proximal humerus The canal was repaired with the broaches An 8 stem was chosen as it was going to be cemented into place The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion Trial reduction was performed The 48 x 21 mm head was the most appropriate size matching the patient s as well as the soft tissue tension on the shoulder At this point the wound was copiously irrigated with gentamycin solution The canal was copiously irrigated as well and suctioned dry Methyl methacrylate cement was mixed The cement gun was filled and the canal was filled with the cement The 8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured Excess cement was removed by sharp dissection Prior to cementation of the stem a hole was drilled in the shaft of proximal humerus and 2 fiber wires were placed through this hole for closure later Once the cement was cured the modular head was impacted on to the Morse taper It was stable and the shoulder was reduced The lesser tuberosity was then reapproximated back to the original site utilizing the 2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing 2 fiber wires as well The rotator interval was closed with 2 fiber wire in an interrupted fashion The biceps tendon was ________ within this closure The wound was copiously irrigated with gentamycin solution suctioned dry The deltoid fascia was then approximated with interrupted 2 0 Vicryl suture Subcutaneous layer was approximated with interrupted 2 0 Vicryl and skin approximated with staples Subcutaneous tissues were infiltrated with 0 25 Marcaine solution A bulky dressing was applied to the wound followed by application of a large arm sling Circulatory status was intact in the extremity at the completion of the case The patient was then transferred to recovery room in apparent satisfactory condition Keywords surgery dislocation proximal humerus comminuted fracture rotator interval tuberosity portion hemiarthroplasty fracture wound proximal deltoid rotator stem humeral humerus tuberosity cemented MEDICAL_TRANSCRIPTION,Description Left heart catheterization with left ventriculography and selective coronary angiography A 50 distal left main and two vessel coronary artery disease with normal left ventricular systolic function Frequent PVCs Metabolic syndrome Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 6 Transcription PREOPERATIVE DIAGNOSES 1 Dyspnea on exertion with abnormal stress echocardiography 2 Frequent PVCs 3 Metabolic syndrome POSTOPERATIVE DIAGNOSES 1 A 50 distal left main and two vessel coronary artery disease with normal left ventricular systolic function 2 Frequent PVCs 3 Metabolic syndrome PROCEDURES 1 Left heart catheterization with left ventriculography 2 Selective coronary angiography COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the Cardiac Catheterization Laboratory in fasting state Both groins were prepped and draped in the usual sterile fashion Xylocaine 1 was used as local anesthetic Versed and fentanyl were used for conscious sedation Next a 6 French sheath was placed in the right femoral artery using modified Seldinger technique Next selective angiography of the left coronary artery was performed in multiple views using 6 French JL4 catheter Next selective angiography of the right coronary artery was performed in multiple views using 6 French 3DRC catheter Next a 6 French angle pigtail catheter was advanced into the left ventricle The left ventricular pressure was then recorded Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds The left heart pull back was then performed The catheter was then removed Angiography of the right femoral artery was performed Hemostasis was obtained by Angio Seal closure device The patient left the Cardiac Catheterization Laboratory in stable condition HEMODYNAMICS 1 LV pressure was 163 0 with end diastolic pressure of 17 There was no significant gradient across the aortic valve 2 Left ventriculography showed old inferior wall hypokinesis Global left ventricular systolic function is normal Estimated ejection fraction was 58 There is no significant mitral regurgitation 3 Significant coronary artery disease 4 The left main is approximately 7 or 8 mm proximally It trifurcates into left anterior descending artery ramus intermedius artery and left circumflex artery The distal portion of the left main has an ulcerated excentric plaque up to about 50 in severity 5 The left anterior descending artery is around 4 mm proximally It extends slightly beyond the apex into the inferior wall It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators At the ostium of the left anterior descending artery there was an eccentric plaque up to 70 to 80 best seen in the shallow LAO with caudal angulation There was no other flow limiting disease noted in the rest of the left anterior descending artery or its major branches The ramus intermedius artery is around 3 mm proximally but shortly after its origin it bifurcates into two medium size branches There was no significant disease noted in the ramus intermedius artery however The left circumflex artery is around 2 5 mm proximally It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch The mid to distal circumflex has a moderate disease which is relatively diffuse up to about 40 to 50 The right coronary artery is around 4 mm in diameter It gives off conus branch two medium size acute marginal branches relatively large posterior descending artery and a posterior lateral branch In the mid portion of the right coronary artery at the origin of the first acute marginal branch there is a relatively discrete stenosis of about 80 to 90 Proximally there is an area of eccentric plaque but seem to be non flow limiting at best around 20 to 30 Additionally there is what appears to be like a shell like lesion in the proximal segment of the right coronary artery as well The posterior descending artery has an eccentric plaque of about 40 to 50 in its mid segment PLAN Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery Continue risk factor modification aspirin and beta blocker Keywords surgery heart catheterization ventriculography coronary angiography dyspnea metabolic syndrome two vessel coronary artery disease echocardiography selective coronary angiography anterior descending artery branches coronary angiography artery catheterization MEDICAL_TRANSCRIPTION,Description Left heart catheterization selective bilateral coronary angiography and left ventriculography Revascularization of the left anterior descending with angioplasty and implantation of a drug eluting stent Right heart catheterization and Swan Ganz catheter placement for monitoring Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 5 Transcription PREOPERATIVE DIAGNOSES 1 Acute coronary artery syndrome with ST segment elevation in anterior wall distribution 2 Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery last procedure in 2005 3 Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation He is intubated and ventilated POSTOPERATIVE DIAGNOSES Acute coronary artery syndrome with ST segment elevation in anterior wall distribution Primary ventricular arrhythmia Occluded left anterior descending artery successfully re canalized with angioplasty and implantation of the drug eluting stent Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery well collateralized PROCEDURES Left heart catheterization selective bilateral coronary angiography and left ventriculography Revascularization of the left anterior descending with angioplasty and implantation of a drug eluting stent Right heart catheterization and Swan Ganz catheter placement for monitoring DESCRIPTION OF PROCEDURE The patient arrived from the emergency room intubated and ventilated He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated The right femoral area was prepped and draped in usual sterile fashion Lidocaine 2 mL was then filled locally The right femoral artery was cannulated with an 18 guage needle followed by a 6 French vascular sheath A guiding catheter XB 3 5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery which is well collateralized An angioplasty wire with present wire was advanced into the left anterior descending artery and could cross the area of occlusion within the stent An angioplasty balloon measuring 2 0 x 15 was advanced and three inflations were obtained It successfully re canalized the artery There is evidence of residual stenosis within the distal aspect of the previous stents A drug eluting stent Xience 2 75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres The intermittent result was improved An additional inflation was obtained more proximally His blood pressure fluctuated and dropped in the 70s correlating with additional sedation There is patency of the left anterior descending artery and good antegrade flow The guiding catheter was replaced with a 5 French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve The right femoral vein was cannulated with an 18 guage needle followed by an 8 French vascular sheath A 8 French Swan Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle pulmonary artery and pulmonary capillary wedge position Cardiac catheter was determined by thermal dilution The procedure was then concluded well tolerated and without complications The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring Fluoroscopy time was 8 2 minutes Total amount of contrast was 113 mL HEMODYNAMICS The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization His initial blood pressure was 96 70 with a mean of 83 and the left ventricular pressure was 17 mmHg There was no gradient across the aortic valve Closing pressure was 97 68 with a mean of 82 Right heart catheterization with right atrial pressure at 13 right ventricle 31 9 pulmonary artery 33 19 with a mean of 25 and capillary wedge pressure of 19 Cardiac output was 5 87 by thermal dilution CORONARIES On fluoroscopy there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution A Left main coronary The left main coronary artery is of good caliber and has no evidence of obstructive lesions B Left anterior descending artery The left anterior descending artery was initially occluded within the previously stented proximal to mid segment There is minimal collateral flow C Circumflex Circumflex is a nondominant circulation It supplies a first obtuse marginal branch on good caliber There is an outline of the stent in the midportion which has mild 30 stenosis The rest of the vessel has no significant obstructive lesions It also supplies significant collaterals supplying the occluded right coronary artery D Right coronary artery The right coronary artery is a weekly dominant circulation The vessel is occluded in intermittent portion and has a minimal collateral flow distally ANGIOPLASTY The left anterior descending artery was the site of re canalization by angioplasty and implantation of a drug eluting stent Xience 15 mm length deployed at 2 9 mm final result is good with patency of the left anterior descending artery good antegrade flow and no evidence of dissection The stent was deployed proximal to the bifurcation with a second diagonal branch which has remained patent There is a septal branch overlapped by the stent which is also patent although presenting a proximal stenosis The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery There is good antegrade flow and no evidence of distal embolization CONCLUSION Acute coronary artery syndrome with ST segment elevation in anterior wall distribution complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery Acute coronary artery syndrome with ST segment elevation in anterior wall distribution related to in stent thrombosis of the left anterior descending artery successfully re canalized with angioplasty and a drug eluting stent There is mild to moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery well collateralized Right femoral arterial and venous vascular access RECOMMENDATION Integrilin infusion is maintained until tomorrow He received aspirin and Plavix per nasogastric tube Titrated doses of beta blockers and ACE inhibitors are initiated Additional revascularization therapy will be adjusted according to the clinical evaluation Keywords surgery ventricular arrhythmia coronary artery syndrome st segment elevation heart catheterization selective bilateral coronary angiography ventriculography catheterization swan ganz catheter anterior descending artery drug eluting stent coronary artery angioplasty stent coronary anterior angiography artery heart MEDICAL_TRANSCRIPTION,Description Left heart catheterization with left ventriculography and selective coronary angiography Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 4 Transcription NAME OF PROCEDURE 1 Left heart catheterization with left ventriculography and selective coronary angiography 2 Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery HISTORY This is a 58 year old male who presented with atypical chest discomfort The patient had elevated troponins which were suggestive of a myocardial infarction The patient is suspected of having significant obstructive coronary artery disease therefore he is undergoing cardiac catheterization PROCEDURE DETAILS Informed consent was given prior to the patient was brought to the catheterization laboratory The patient was brought to the catheterization laboratory in postabsorptive state The patient was prepped and draped in the usual sterile fashion 2 Xylocaine solution was used to anesthetize the right femoral region Using modified Seldinger technique a 6 French arterial sheath was placed Then the patient had already been on heparin Then a Judkins left 4 catheter was intubated into the left main coronary artery Several projections were obtained and the catheter was removed A 3DRC catheter was intubated into the right coronary artery Several projections were obtained and the catheter was removed Then a 3DRC guiding catheter was intubated into the right coronary artery Then a universal wire was advanced across the lesion into the distal right coronary artery Integrilin was given Then a 3 0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds Then a projection was obtained Then a 3 0 x 15 Vision stent was placed into the distal right coronary artery The stent was deployed at 15 atmospheres for 25 seconds Post stent the patient was given intracoronary nitroglycerin after one projection Then there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful Then a pilot 150 wire was advanced across the lesion Then attempt to place the 2 0 x 8 power saver across the lesion was performed However it was felt that there was adequate flow and no further intervention needed to be performed Then the stent delivery system was removed A pigtail catheter was placed into the left ventricle Hemodynamics followed by left ventriculography was performed Then a pullback gradient was performed and the catheter was removed Then the right femoral artery was visualized and using angiography and then an Angio Seal was applied The patient was transferred back to his room in good condition FINDINGS 1 Hemodynamics The opening aortic pressure was 116 61 with a mean of 64 The opening left ventricular pressure was 112 with end diastolic pressure of 23 LV pressure on pullback was 106 with end diastolic pressure of 21 Aortic pressure was 111 67 with a mean of 87 The closing pressure was 110 67 2 Left ventriculography The left ventricle was of normal cavity size and wall thickness There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis The overall systolic function appeared to be mildly reduced with ejection fraction between 40 and 45 The mitral valve had no significant prolapse or regurgitation The aortic valve appeared to be trileaflet and moved normally 3 Coronary angiography The left main is a normal caliber vessel This bifurcates into the left anterior descending and circumflex arteries The left main is free of any significant obstructive coronary artery disease The left anterior descending is a large vessel that extends to the apex It gives off approximately 10 septal perforators and 5 diagonal branches The first diagonal branch was large The left anterior descending had mild irregularities but no high grade disease The left circumflex is a nondominant vessel which gives rise to two obtuse marginal branches The two obtuse marginal branches are large There is a relatively small left atrial branch The left circumflex had a 50 stenosis after the first obtuse marginal branch The rest of the vessel is moderately irregular but no high grade disease The right coronary artery appears to be a dominant vessel which gives rise to three right ventricular branches four posterior lateral branches two right atrial branches and two small conus branches The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high grade disease However distal between the second and third posterolateral branch there is a 90 stenosis The rest of the vessels had mild irregularities but no high grade disease Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20 residual stenosis Then after stent placement there was 0 residual stenosis however there was partial occlusion of the third posterolateral branch Then a wire was advanced through this and there was improvement of flow There is improvement from TIMI grade 2 to TIMI grade 3 flow CLINICAL IMPRESSION 1 Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery 2 Two vessel coronary artery disease 3 Elevated left ventricular end diastolic pressure 4 Mild anterolateral and moderate inferoapical hypokinesis RECOMMENDATIONS 1 Integrilin 2 Bed rest 3 Risk factor modification 4 Thallium scintigraphy in approximately six weeks Keywords surgery heart catheterization ventriculography selective coronary angiography angioplasty stent placement transluminal percutaneous coronary artery coronary angiography coronary angioplasty diastolic pressure obtuse marginal percutaneous transluminal catheterization artery coronary angiography MEDICAL_TRANSCRIPTION,Description Selective coronary angiography left heart catheterization and left ventriculography Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 11 Transcription NAME OF PROCEDURES 1 Selective coronary angiography 2 Left heart catheterization 3 Left ventriculography PROCEDURE IN DETAIL The right groin was sterilely prepped and draped in the usual fashion The area of the right coronary artery was anesthetized with 2 lidocaine and a 4 French sheath was placed Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg A left 4 4 French Judkins catheter was placed and advanced through the ostium of the left main coronary artery Because of difficulty positioning the catheter the catheter was removed and a 6 French sheath was placed and a 6 French 4 left Judkins catheter was placed This was advanced through the ostium of the left main coronary artery where selective angiograms were performed Following this the 4 French right Judkins catheter was placed and angiograms of the right coronary were performed A pigtail catheter was placed and a left heart catheterization was performed followed by a left ventriculogram The left heart pullback was performed The catheter was removed and a small injection of contrast was given to the sheath The sheath was removed over a wire and an Angio Seal was placed There were no complications Total contrast media was 200 mL of Optiray 350 Fluoroscopy time 5 3 minutes Total x ray dose is 1783 mGy HEMODYNAMICS Rhythm is sinus throughout the procedure LV pressure of 155 22 mmHg aortic pressure of 160 80 mmHg LV pullback demonstrates no gradient The right coronary artery is a nondominant vessel and free of disease This also gives rise to the conus branch and two RV free wall branches The left main has minor plaquing in the inferior aspect measuring no more than 10 to 15 This vessel then bifurcates into the LAD and circumflex The circumflex is a large caliber vessel and is dominant This vessel gives rise to a large first marginal artery a moderate sized second marginal branch and additionally gives rise to a large third marginal artery and the PDA There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90 in severity The origin of the first marginal artery has a severe stenosis measuring approximately 90 in severity The distal circumflex has a 60 lesion just prior to the origin of the third marginal branch and PDA The proximal LAD is ectatic The LAD gives rise to a large first diagonal artery that has a 90 lesion in its origin and a subtotal occlusion midway down the diagonal Distal to the origin of this diagonal branch there is another area of ectasia in the LAD followed by an area of stenosis that in some views is approximately 50 in severity The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall The overall ejection fraction is preserved There is moderate dilatation of the aortic root The calculated ejection fraction is 63 IMPRESSION 1 Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall 2 Coronary artery disease with high grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery There is subtotal stenosis at the origin of the first obtuse marginal artery 3 A 60 stenosis in the distal circumflex 4 Ectasia of the proximal left anterior descending with 50 stenosis in the mid left anterior descending 5 Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch Keywords surgery coronary angiography catheterization ventriculography heart catheterization coronary artery stenosis artery angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization left ventriculography coronary angiography and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 1 Transcription PROCEDURE Left heart catheterization left ventriculography coronary angiography and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery This gentleman has had a non Q wave troponin positive myocardial infarction complicated by ventricular fibrillation PROCEDURE DETAILS The patient was brought to the catheterization lab the chart was reviewed and informed consent was obtained Right groin was prepped and draped sterilely and infiltrated 2 Xylocaine Using the Seldinger technique a 6 French sheath was placed in the right femoral artery ACT was checked and was low Additional heparin was given A 6 French pigtail catheter was passed Left ventriculography was performed The catheter was exchanged for a 6 French JL4 catheter Nitroglycerin was given in the left main Left coronary angiography was performed The catheter was exchanged for a 6 French __________ coronary catheter Nitroglycerin was given in the right main and right coronary angiography was performed Films were closely reviewed and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM Considering his age and his course it was elected to stent both these lesions ReoPro was started and the catheter was exchanged for a 6 French JR4 guide ReoPro was given in the RCA to prevent no reflow A 0 014 Universal wire was passed The lesion was measured A 4 5 x 18 mm stent was passed and deployed to moderate pressures with an excellent result The catheter was removed and exchanged for a 6 French JL4 guide The same wire was passed down the circumflex and the lesion measured A 2 75 x 15 mm stent was deployed to a moderate pressure with an excellent result Plavix was given The catheter was removed and sheath was in place The results were explained to the patient and his wife FINDINGS 1 Hemodynamics Please see attached sheet for details ED was 20 There is no gradient across the aortic valve 2 Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion in which there is a question of diffuse very minimal global hypokinesis There is mild MR noted 3 Coronary angiography a Left main normal b LAD Some very minimal luminal irregularities There is a 1st diagonal which has a branch that is 1 5 mm with a proximal 50 narrowing c Left circumflex is basically a marginal branch in which distally there was a long 98 lesion d The RCA is large dominant and has a mid somewhat long 70 lesion 4 Stenting a The RCA revealed a lesion that went from 70 to a 5 B The circumflex went from 95 to 5 CONCLUSION 1 Decreased left ventricular compliance 2 Borderline normal overall ejection fraction with mild mitral regurgitation 3 Triple vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex which is basically old 4 Successful stenting of the right coronary artery and the circumflex RECOMMENDATION ReoPro stent protocol Plavix for at least 9 months aggressive control of risk factors I have ordered Zocor and a fasting lipid panel AICD will be considered realizing when this gentleman becomes ischemic he is at high risk for fibrillating Keywords surgery heart catheterization ventriculography coronary angiography stenting distal circumflex coronary artery coronary lesion catheterization cardiac angiography heart rca artery circumflex MEDICAL_TRANSCRIPTION,Description Left heart catheterization left and right coronary angiography left ventricular angiography and intercoronary stenting of the right coronary artery Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 10 Transcription PROCEDURE Left heart catheterization left and right coronary angiography left ventricular angiography and intercoronary stenting of the right coronary artery PROCEDURE IN DETAIL The patient was brought to the Catheterization Laboratory After informed consent he was medicated with Versed and fentanyl The right groin was prepped and draped and infiltrated with 2 Xylocaine Percutaneously 6 French arterial sheath was placed Selective native left and right coronary angiography was performed followed by left ventricular angiography The patient had a totally occluded right coronary We initially started with a JR4 guide We were able to a sport wire through the total occlusion and saw a very tight stenosis We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated We then attempted to put a 30 x 12 mm stent across the stenosis but we had very little guide support the guide kept coming out We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion We finally had to go an AL2 guide we were concerned that this could cause some proximal dissection That guided seated we did have initial difficulty getting the wire back across the stenosis and we did see a little staining suggesting we did have some tearing from the guide tip The surgeons were put on notice in case we could not get this vessel open but we were able to re cross with a sport wire We then re dilated the area of stenosis and with good guide support we were able to get a 30 x 23 mm Vision stent where the lesion was and post dilated it to 18 atmospheres Routine angiography did show that the distal posterolateral branch seems to be occluded whether this was from distal wire dissection or distal thrombosis was unclear but we were able to re wire that area and get a 25 x12 Vision balloon and dilate the area and re establish flow to the small segment We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres Final angiography showed resolution of the dissection We could see a little staining extrinsic to the stent No perforation and excellent flow During the intervention we did give a bolus and drip of Angiomax At the end of the procedure we stopped the Angiomax and gave 600 mg of Plavix We did a right femoral angiogram however the Angio Seal plug could not take so we used manual pressure and a Femostop We transported the patient to his room in stable condition ANGIOGRAPHIC DATA Left main coronary is normal Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60 stenosis of the LAD before it bifurcates into diagonal The diagonal does appear to have about 50 osteal stenosis There is a lot of plaquing further down the diagonal but good flow The rest of the LAD looked good pass the proximal 60 stenosis and after the diagonal branch Circumflex artery was nondominant vessel consisting of an obtuse marginal vessel The first obtuse marginal had a long 50 narrowing and then the AV groove branch was free of any disease Some mild collaterals to the right were seen Right coronary angiography revealed a total occlusion of the right coronary just about 0 5 cm after its origin After we got a wire across the area of occlusion we could see some thrombosis and a 99 stenosis just at the curve Following the balloon angioplasty we established good flow down the distal vessel We still had about residual 70 stenosis When we had to go back with the AL2 guide we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection We re dilated and then deployed Repeat angiography now did show some hang up off dye distally We never did have the wire that far down so this was probably felt to be due to distal embolization of some thrombus After deploying the stent we had total resolution of the original lesion We then directed our attention to the posterolateral branch which the remainder of the vessel was patent giving off a large PDA The posterolateral branch appeared to be occluded in its mid portion We got a wire through and dilated this We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent Repeat angiography now showed no significant dissection a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch but this was excluded by the stent There were no filling defects in the stent and excellent flow The distal posterolateral branch did open up although it was little under filled and there may have been some mild residual disease there IMPRESSION Atherosclerotic heart disease with total occlusion of right coronary successfully stented to zero residual with repair of a small proximal dissection Minor distal disease of the posterolateral branch and 60 proximal left anterior descending coronary artery stenosis and 50 diagonal stenosis along with 50 stenosis of the first obtuse marginal branch Keywords surgery heart catheterization coronary angiography ventricular angiography intercoronary stenting intercoronary coronary stenting stenosis angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization with ventriculography selective coronary angiography Standard Judkins right groin Catheters used were a 6 French pigtail 6 French JL4 6 French JR4 Medical Specialty Surgery Sample Name Heart Catheterization Ventriculography Angiography 3 Transcription NAME OF PROCEDURE Left heart catheterization with ventriculography selective coronary angiography INDICATIONS Acute coronary syndrome TECHNIQUE OF PROCEDURE Standard Judkins right groin Catheters used were a 6 French pigtail 6 French JL4 6 French JR4 ANTICOAGULATION The patient was on heparin at the time COMPLICATIONS None I reviewed with the patient the pros cons alternatives risks of catheterization and sedation including myocardial infarction stroke death damage to nerve artery or vein in the leg perforation of a cardiac chamber dissection of an artery requiring countershock infection bleeding ATN allergy need for cardiac surgery All questions were answered and the patient desired to proceed HEMODYNAMIC DATA Aortic pressure was in the physiologic range No significant gradient across the aortic valve ANGIOGRAPHIC DATA 1 Ventriculogram The left ventricle is of normal size and shape normal wall motion normal ejection fraction 2 Right coronary artery Dominant There was insignificant disease in the system 3 Left coronary Left main left anterior descending and circumflex systems showed no significant disease CONCLUSIONS 1 Normal left ventricular systolic function 2 Insignificant coronary disease PLAN Based upon this study medical therapy is warranted Six French Angio Seal was used in the groin Keywords surgery standard judkins french pigtail selective coronary angiography heart catheterization ventriculography catheterization angiography MEDICAL_TRANSCRIPTION,Description Left heart cath selective coronary angiography LV gram right femoral arteriogram and Mynx closure device Normal stress test Medical Specialty Surgery Sample Name Heart Catheterization Angiography 1 Transcription CLINICAL INDICATION Normal stress test PROCEDURES PERFORMED 1 Left heart cath 2 Selective coronary angiography 3 LV gram 4 Right femoral arteriogram 5 Mynx closure device PROCEDURE IN DETAIL The patient was explained about all the risks benefits and alternatives of this procedure The patient agreed to proceed and informed consent was signed Both groins were prepped and draped in the usual sterile fashion After local anesthesia with 2 lidocaine a 6 French sheath was inserted in the right femoral artery Left and right coronary angiography was performed using 6 French JL4 and 6 French 3DRC catheters Then LV gram was performed using 6 French pigtail catheter Post LV gram LV to aortic gradient was obtained Then the right femoral arteriogram was performed Then the Mynx closure device was used for hemostasis There were no complications HEMODYNAMICS LVEDP was 9 There was no LV to aortic gradient CORONARY ANGIOGRAPHY 1 Left main is normal It bifurcates into LAD and left circumflex 2 Proximal LAD at the origin of big diagonal there is 50 to 60 calcified lesion present Rest of the LAD free of disease 3 Left circumflex is a large vessel and with minor plaque 4 Right coronary is dominant and also has proximal 40 stenosis SUMMARY 1 Nonobstructive coronary artery disease LAD proximal at the origin of big diagonal has 50 to 60 stenosis which is calcified 2 RCA has 40 proximal stenosis 3 Normal LV systolic function with LV ejection fraction of 60 PLAN We will treat with medical therapy If the patient becomes symptomatic we will repeat stress test If there is ischemic event the patient will need surgery for the LAD lesion For the time being we will continue with the medical therapy Keywords surgery selective coronary angiography lv gram femoral mynx heart cath mynx closure device heart catheterization femoral arteriogram stress test coronary angiography heart arteriogram catheterization lad coronary angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization and bilateral selective coronary angiography Left ventriculogram was not performed Medical Specialty Surgery Sample Name Heart Catheterization Angiography 2 Transcription PROCEDURES PERFORMED 1 Left heart catheterization 2 Bilateral selective coronary angiography 3 Left ventriculogram was not performed INDICATION Non ST elevation MI PROCEDURE After risks benefits and alternatives of the above mentioned procedure were explained in detail to the patient informed consent was obtained both verbally and in writing The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion 1 lidocaine solution was used to infiltrate the skin overlying the right femoral artery Once adequate anesthesia had been obtained a thin walled 18 gauge Argon needle was used to cannulate the right femoral artery A steel guidewire was inserted through the needle into the vascular lumen without resistance A small nick was then made in the skin The pressure was held The needle was removed over the guidewire Next a Judkins left 4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire The guidewire was removed The catheter was connected to the manifold and flushed The ostium of the left main coronary artery was engaged Using hand injections of nonionic contrast material the left coronary system was evaluated in several different views Once an adequate study had been performed the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter The catheter was then removed over the guidewire Next a Judkins right 4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire The guidewire was removed The catheter was connected to manifold and flushed The catheter did slip into the left ventricle During the rotation the LVEDP was then measured The ostium of the right coronary artery was then engaged Using hand injections of nonionic contrast material the right coronary system was evaluated in several different views Once adequate study has been performed the catheter was then removed The sheath was lastly flushed for the final time FINDINGS LEFT MAIN CORONARY ARTERY The left main coronary artery is a moderate caliber vessel which bifurcates into the left anterior descending and circumflex arteries There is no evidence of any hemodynamically significant stenosis LEFT ANTERIOR DESCENDING ARTERY The LAD is a moderate caliber vessel which is subtotaled in its mid portion for approximately 1 5 cm to 1 cm with subsequent TIMI I flow distally The distal portion was diffusely diseased The proximal portion otherwise shows minor luminal irregularities The first diagonal branch demonstrated minor luminal irregularities throughout CIRCUMFLEX ARTERY The circumflex is a moderate caliber vessel which traverses through the atrioventricular groove There is a 60 proximal lesion and a 90 mid lesion prior to the takeoff of the first obtuse marginal branch The first obtuse marginal branch demonstrates minor luminal irregularities throughout RIGHT CORONARY ARTERY The RCA is a moderate caliber vessel which demonstrates a 90 mid stenotic lesion The dominant coronary artery gives off the posterior descending artery and posterolateral artery The left ventricular end diastolic pressure was approximately 22 mmHg It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads which resolved after the injection was complete IMPRESSION 1 Three vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI I flow distally and 90 circumflex lesion and 90 right coronary artery lesion 2 Mildly elevated left sided filling pressures PLAN 1 The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting These findings and plan were discussed in detail with the patient and the patient s family The patient is agreeable 2 The patient will be continued on aggressive medical therapy including beta blocker aspirin ACE inhibitor and statin therapy The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting In light of the patient s history of cranial aneurysmal bleed the patient will be held off of Lovenox and Integrilin Keywords surgery non st elevation coronary angiography ventriculogram heart catheterization bypass grafting catheterization coronary artery angiography luminal branch descending circumflex vessel guidewire MEDICAL_TRANSCRIPTION,Description Left and right heart catheterization and selective coronary angiography Coronary artery disease severe aortic stenosis by echo Medical Specialty Surgery Sample Name Heart Catheterization Angiography Transcription INDICATION Coronary artery disease severe aortic stenosis by echo PROCEDURE PERFORMED 1 Left heart catheterization 2 Right heart catheterization 3 Selective coronary angiography PROCEDURE The patient was explained about all the risks benefits and alternatives to the procedure The patient agreed to proceed and informed consent was signed Both groins were prepped and draped in usual sterile fashion After local anesthesia with 2 lidocaine 6 French sheath was inserted in the right femoral artery and 7 French sheath was inserted in the right femoral vein Then right heart cath was performed using 7 French Swan Ganz catheter Catheter was placed in the pulmonary capillary wedge position Pulmonary capillary wedge pressure PA pressure was obtained cardiac output was obtained then RV RA pressures were obtained The right heart catheter _______ pulled out Then selective coronary angiography was performed using 6 French JL4 and 6 French 3DRC catheter Then attempt was made to cross the aortic valve with 6 French pigtail catheter but it was unsuccessful After the procedure catheters were pulled out sheath was pulled out and hemostasis was obtained by manual pressure The patient tolerated the procedure well There were no complications HEMODYNAMICS 1 Cardiac output was 4 9 per liter per minute Pulmonary capillary wedge pressure mean was 7 PA pressure was 20 14 RV 26 5 RA mean pressure was 5 2 Coronary angiography left main is calcified _______ dense complex 3 LAD proximal 70 calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate size vessel has 70 stenosis Left circumflex has diffuse luminal irregularities OM1 has 70 stenosis is a moderate size vessel Right coronary is dominant and has minimal luminal irregularities SUMMARY Three vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure RECOMMENDATION Aortic valve replacement with coronary artery bypass surgery Keywords surgery lad proximal femoral artery sheath catheter selective coronary angiography coronary artery disease pulmonary capillary wedge capillary wedge coronary angiography coronary artery heart catheterization catheterization heart artery stenosis angiography pressure coronary MEDICAL_TRANSCRIPTION,Description Right heart catheterization Refractory CHF to maximum medical therapy Medical Specialty Surgery Sample Name Heart Catheterization 2 Transcription PROCEDURE PERFORMED Right heart catheterization INDICATION Refractory CHF to maximum medical therapy PROCEDURE After risks benefits and alternatives of the above mentioned procedure were explained to the patient and the patient s family in detail informed consent was obtained both verbally and in writing The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion 1 lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein Once adequate anesthesia has been obtained a thin walled 18 gauge Argon needle was used to cannulate the right internal jugular vein A steel guidewire was then inserted through the needle into the vessel without resistance Small nick was then made in the skin and the needle was removed An 8 5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance The guidewire and dilator were then removed The sheath was then flushed A Swan Ganz catheter was inserted to 20 cm and the balloon was inflated Under fluoroscopic guidance the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position Hemodynamics were measured along the way Pulmonary artery saturation was obtained The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration The patient tolerated the procedure well The patient returned to the cardiac catheterization holding area in stable and satisfactory condition FINDINGS Body surface area equals 2 04 hemoglobin equals 9 3 O2 is at 2 liters nasal cannula Pulmonary artery saturation equals 37 8 Pulse oximetry on 2 liters nasal cannula equals 93 Right atrial pressure is 8 right ventricular pressure equals 59 9 pulmonary artery pressure equals 61 31 with mean of 43 pulmonary artery wedge pressure equals 21 cardiac output equals 3 3 by the Fick method cardiac index is 1 6 by the Fick method systemic vascular resistance equals 1821 and transpulmonic gradient equals 22 IMPRESSION Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38 on current medical therapy as well as elevated right sided filling pressures and a high systemic vascular resistance PLAN Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve the patient will need to be discharged home on Primacor The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia At this time we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy We will also increase his Lasix to 80 mg IV q d We will increase his amiodarone to 400 mg daily We will also continue with his Coumadin therapy As stated previously we will discontinue vasodilator therapy starting with the Isordil Keywords surgery chf cardiac catheterization swan ganz heart catheterization internal jugular pulmonary artery heart jugular cannulate vascular needle pulmonary therapy MEDICAL_TRANSCRIPTION,Description Removal of painful hardware first left metatarsal Excision of nonunion first left metatarsal Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal Medical Specialty Surgery Sample Name Hardware Removal Metatarsal Transcription TITLE OF OPERATION 1 Removal of painful hardware first left metatarsal 2 Excision of nonunion first left metatarsal 3 Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal PREOPERATIVE DIAGNOSES 1 Nonunion of fractured first left metatarsal osteotomy 2 Painful hardware first left metatarsal POSTOPERATIVE DIAGNOSES 1 Nonunion of fractured first left metatarsal osteotomy 2 Painful hardware first left metatarsal ANESTHESIA General anesthesia with local infiltration of 5 mL of 0 5 Marcaine and 1 lidocaine plain with 1 100 000 epinephrine preoperatively and 15 mL of 0 5 Marcaine postoperatively HEMOSTASIS Left ankle tourniquet set at 250 mmHg for 60 minutes ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl 5 0 Prolene as well as one corticocancellous allograft consisting of ASIS and one T type plate prebent with six screw holes and five 3 0 partially threaded cannulated screws and a single 3 0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal INJECTABLES 1 g Ancef IV 30 minutes preoperatively and the afore mentioned lidocaine DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After general anesthesia was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in normal sterile technique The left ankle tourniquet was then inflated Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8 cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the periosteum of the first left metatarsal All the tendinous neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact The screws were sent to pathology for examination The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0 045 Kirschner wire to induce bleeding The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy Provisional fixation with K wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished The bone graft was then stabilized with the use of a T type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft Removal of the K wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent The area was flushed copiously flushed with saline The periosteal and capsular tissues were approximated with 3 0 Vicryl and 2 0 Vicryl suture material All the subcutaneous tissues were approximated with 4 0 Vicryl suture material and 5 0 Prolene was used to approximate the skin edges at this time The left ankle tourniquet was deflated Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s left foot was placed in a surgical shoe The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels The patient was given specific instructions and education on how to continue caring for his left foot surgery The patient was also given pain medications instructions on how to control his postoperative pain The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for his first postoperative appointment Keywords surgery hardware removal metatarsal osteotomy painful hardware osteotomy excision of nonunion corticocancellous bone graft internal fixation subcutaneous tissues previous osteotomy vicryl suture suture material corticocancellous bone ankle tourniquet bone graft metatarsal tourniquet allograft fixation plates ankle vicryl nonunion screws MEDICAL_TRANSCRIPTION,Description Left distal medial hamstring release Medical Specialty Surgery Sample Name Hamstring Release Transcription PREOPERATIVE DIAGNOSIS Autism with bilateral knee flexion contractures POSTOPERATIVE DIAGNOSIS Autism with bilateral knee flexion contractures PROCEDURE Left distal medial hamstring release ANESTHESIA General anesthesia Local anesthetic 10 mL of 0 25 Marcaine local TOURNIQUET TIME 15 minutes ESTIMATED BLOOD LOSS Minimal COMPLICATIONS There were no intraoperative complications DRAIN None SPECIMENS None HISTORY AND PHYSICAL The patient is a 12 year old boy born at a 32 week gestation and with drug exposure in utero The patient has diagnosis of autism as well The patient presented with bilateral knee flexion contractures initially worse on right than left He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play The patient presents now with worsening left knee flexion contracture and desires the same procedure to be performed Risks and benefits of the surgery were discussed The risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion of extremity failure to restore normal anatomy continued contracture possible need for other procedures All questions were answered and mother and son agreed to above plan PROCEDURE NOTE The patient was taken to operating room and placed supine on operating table General anesthesia was administered The patient received Ancef preoperatively Nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The extremity was then prepped and draped in standard surgical fashion The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Esmarch was then removed A small 3 cm incision was made over the distal medial hamstring Hamstring tendons were isolated and released in order of semitendinosus semimembranosus and sartorius The wound was then irrigated with normal saline and closed used 2 0 Vicryl and then 4 0 Monocryl The wound was cleaned and dried and dressed with Steri Strips The area was infiltrated with total 10 mL of 0 25 Marcaine The wound was then covered with Xeroform 4 x 4s and Bias Tourniquet was released at 15 minutes The patient was then placed in knee immobilizer The patient tolerated the procedure well and subsequently taken to recovery in stable condition POSTOPERATIVE PLAN The patient may weight bear as tolerated in his brace He will start physical therapy in another week or two The patient restricted from any PE for at least 6 week He may return to school on 01 04 2008 He was given Vicodin for pain Keywords surgery medial hamstring release distal medial hamstring release bilateral knee flexion contractures bilateral knee hamstring release knee flexion tourniquet flexion contractures hamstring MEDICAL_TRANSCRIPTION,Description Right and left heart catheterization coronary angiography left ventriculography Medical Specialty Surgery Sample Name Heart Catheterization Transcription PROCEDURES 1 Right and left heart catheterization 2 Coronary angiography 3 Left ventriculography PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the cardiac catheterization laboratory Patient was prepped and draped in sterile fashion Via modified Seldinger technique the right femoral vein was punctured and a 6 French sheath was placed over a guide wire Via modified Seldinger technique right femoral artery was punctured and a 6 French sheath was placed over a guide wire The diagnostic procedure was performed using the JL 4 JR 4 and a 6 French pigtail catheter along with a Swan Ganz catheter The patient tolerated the procedure well and there were immediate complications were noted Angio Seal was used at the end of the procedure to obtain hemostasis CORONARY ARTERIES LEFT MAIN CORONARY ARTERY The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery No significant stenotic lesions were identified in the left main coronary artery LEFT ANTERIOR DESCENDING CORONARY ARTERY The left descending artery is a moderate sized vessel which gives rise to multiple diagonals and perforating branches No significant stenotic lesions were identified in the left anterior descending coronary artery system CIRCUMFLEX ARTERY The circumflex artery is a moderate sized vessel The vessel is a stenotic lesion After the right coronary artery the RCA is a moderate size vessel with no focal stenotic lesions HEMODYNAMIC DATA Capital wedge pressure was 22 The aortic pressure was 52 24 Right ventricular pressure was 58 14 RA pressure was 14 The aortic pressure was 127 73 Left ventricular pressure was 127 15 Cardiac output of 9 2 LEFT VENTRICULOGRAM The left ventriculogram was performed in the RAO projection only In the RAO projection the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50 Severe mitral regurgitation was also noted IMPRESSION 1 Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50 2 Severe mitral regurgitation 3 No significant coronary artery disease identified in the left main coronary artery left anterior descending coronary artery circumflex coronary artery or the right coronary artery Keywords surgery ventriculography catheterization seldinger hypokinesis estimated ejection fraction severe mitral regurgitation descending coronary artery coronary artery aortic pressure heart catheterization stenotic lesions coronary artery heart angiography anterior ventricular ventriculogram lesions MEDICAL_TRANSCRIPTION,Description Resection of infected bone left hallux proximal phalanx and distal phalanx Osteomyelitis left hallux Medical Specialty Surgery Sample Name Hallux Infected Bone Resection Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis left hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis left hallux PROCEDURES PERFORMED Resection of infected bone left hallux proximal phalanx and distal phalanx ANESTHESIA TIVA Local HISTORY This 77 year old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux The patient has a history of chronic osteomyelitis and non healing ulceration to the left hallux of almost 10 years duration He has failed outpatient antibiotic therapy and conservative methods At this time he desires to attempt surgical correction The patient is not interested in a hallux amputation at this time however he is consenting to removal of infected bone He was counseled preoperatively about the strong probability of the hallux being a floppy tail after the surgery and accepts the fact The risks versus benefits of the procedure were discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL The patient s wound was debrided with a 15 blade and down to good healthy tissue preoperatively The wound was on the planar medial distal and dorsal medial The wound s bases were fibrous They did not break the bone at this point They were each approximately 0 5 cm in diameter After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection Due to the patient s history of diabetes and marked calcifications on x ray a pneumatic ankle tourniquet was not applied Next a total of 3 cc of a 1 1 mixture of 0 5 Marcaine plain and 1 lidocaine plain was used to infiltrate the left hallux and perform a digital block Next the foot was prepped and draped in the usual aseptic fashion It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected Next a 10 blade was used to make a linear incision approximately 3 5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium Next the incision was deepened through the subcutaneous tissue A heavy amount of bleeding was encountered Therefore a Penrose drain was applied at the tourniquet which failed Next an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery Next the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon The long extensor tendon was thickened and overall exhibited signs of hypertrophy The transverse incision through the long extensor tendon was made with a 15 blade Immediately upon entering the joint yellow discolored fluid was drained from the interphalangeal joint Next the extensor tendon was peeled dorsally and distally off the bone Immediately the head of the proximal phalanx was found to be lytic disease friable crumbly and there were free fragments of the medial aspect of the bone the head of the proximal phalanx This bone was removed with a sharp dissection Next after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx a sagittal saw was used to resect the approximately one half of the proximal phalanx This was passed off as the infected bone specimen for microbiology and pathology Next the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx Next there was diseased soft tissue envelope around the bone which was also resected to good healthy tissue margins The pulse lavage was used to flush the wound with 1000 cc of gentamicin impregnated saline Next cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin This bone was found to be hard and healthy appearing The wound after irrigation was free of all debris and infected tissue Therefore anaerobic and aerobic cultures were taken and sent to microbiology Next OsteoSet beads tobramycin impregnated were placed Six beads were placed in the wound Next the extensor tendon was re approximated with 3 0 Vicryl The subcutaneous layer was closed with 4 0 Vicryl in a simple interrupted technique Next the skin was closed with 4 0 nylon in a horizontal mattress technique The Esmarch bandage was released and immediate hyperemic flush was noted at the digits A standard postoperative dressing was applied consisting of 4 x 4s Betadine soaked 0 1 silk Kerlix Kling and a loosely applied Ace wrap The patient tolerated the above anesthesia and procedure without complications He was transported via a cart to the Postanesthesia Care Unit His vitals signs were stable and vascular status was intact He was given a medium postop shoe that was well formed and fitting He is to elevate his foot but not apply ice He is to follow up with Dr X He was given emergency contact numbers He is to continue the Vicodin p r n pain that he was taking previously for his shoulder pain and has enough of the medicine at home The patient was discharged in stable condition Keywords surgery osteomyelitis proximal phalanx distal phalanx infected bone proximal bone phalanx healing hallux infected tissue distal MEDICAL_TRANSCRIPTION,Description Hardware removal in the left elbow Medical Specialty Surgery Sample Name Hardware Removal Elbow Transcription PREOPERATIVE DIAGNOSIS Retained hardware in left elbow POSTOPERATIVE DIAGNOSIS Retained hardware in left elbow PROCEDURE Hardware removal in the left elbow ANESTHESIA Procedure done under general anesthesia The patient also received 4 mL of 0 25 Marcaine of local anesthetic TOURNIQUET There is no tourniquet time ESTIMATED BLOOD LOSS Minimal COMPLICATIONS No intraoperative complications HISTORY AND PHYSICAL The patient is a 5 year 8 month old male who presented to me direct from ED with distracted left lateral condyle fracture He underwent screw compression for the fracture in October 2007 The fracture has subsequently healed and the patient presents for hardware removal The risks and benefits of surgery were discussed The risks of surgery include the risk of anesthesia infection bleeding changes in sensation and motion of extremity failure of removal of hardware failure to relieve pain or improved range of motion All questions were answered and the family agreed to the above plan PROCEDURE The patient was taken to the operating room placed supine on the operating table General anesthesia was then administered The patient s left upper extremity was then prepped and draped in standard surgical fashion Using his previous incision dissection was carried down through the screw A guide wire was placed inside the screw and the screw was removed without incident The patient had an extension lag of about 15 to 20 degrees Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex The washer was also removed without incident Wound was then irrigated and closed using 2 0 Vicryl and 4 0 Monocryl Wound was injected with 0 25 Marcaine The wound was then dressed with Steri Strips Xeroform 4 x4 and bias The patient tolerated the procedure well and subsequently taken to the recovery in stable condition DISCHARGE NOTE The patient will be discharged on date of surgery He is to follow up in one week s time for a wound check This can be done at his primary care physician s office The patient should keep his postop dressing for about 4 to 5 days He may then wet the wound but not scrub it The patient may resume regular activities in about 2 weeks The patient was given Tylenol with Codeine 10 mL p o every 3 to 4 hours p r n Keywords surgery retained hardware hardware removal tourniquet elbow hardware MEDICAL_TRANSCRIPTION,Description Hardware removal right ulnar Medical Specialty Surgery Sample Name Hardware Removal Ulnar Transcription PREOPERATIVE DIAGNOSIS Retained hardware right ulnar POSTOPERATIVE DIAGNOSIS Retained hardware right ulnar PROCEDURE Hardware removal right ulnar ANESTHESIA The patient received 2 5 mL of 0 25 Marcaine and local anesthetic COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 5 year 5 month old male who sustained a both bone forearm fracture in September 2007 The fracture healed uneventfully but then the patient subsequently suffered a refracture one month ago The patient had shortening in arms noted in both bones The parents opted for surgical stabilization with nailing This was performed one month ago on return visit His ulnar nail was quite prominent underneath the skin It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks Risks and benefits of the surgery were discussed with the mother Risk of surgery incudes risks of anesthesia infection bleeding changes in sensation in most of the extremity need for longer casting All questions were answered and mother agreed to above plan PROCEDURE IN DETAIL The patient was seen in the operative room placed supine on operating room table General anesthesia was then administered The patient was given Ancef preoperatively The left elbow was prepped and draped in a standard surgical fashion A small incision was made over the palm with K wire This was removed without incident The wound was irrigated The bursitis was curetted Wounds closed using 4 0 Monocryl The wound was clean and dry dressed with Xeroform 4 x 4s and Webril Please note the area infiltrated with 0 25 Marcaine The patient was then placed in a long arm cast The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will maintain the cast for 3 more weeks Intraoperative nail was given to the mother The patient to take Tylenol with Codeine as needed All questions were answered Keywords surgery both bone forearm fracture retained hardware hardware removal hardware forearm ulnar MEDICAL_TRANSCRIPTION,Description Chest pain and non Q wave MI with elevation of troponin I only Left heart catheterization left ventriculography and left and right coronary arteriography Medical Specialty Surgery Sample Name Heart Catheterization 1 Transcription PROCEDURES Left heart catheterization left ventriculography and left and right coronary arteriography INDICATIONS Chest pain and non Q wave MI with elevation of troponin I only TECHNIQUE The patient was brought to the procedure room in satisfactory condition The right groin was prepped and draped in routine fashion An arterial sheath was inserted into the right femoral artery Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively Cine coronary angiograms were done in multiple views Left heart catheterization was done using the 6 French pigtail catheter Appropriate pressures were obtained before and after the left ventriculogram which was done in the RAO view At the end of the procedure the femoral catheter was removed and Angio Seal was applied without any complications FINDINGS 1 LV is normal in size and shape with good contractility EF of 60 2 LMCA normal 3 LAD has 20 to 30 stenosis at the origin 4 LCX is normal 5 RCA is dominant and normal RECOMMENDATIONS Medical management diet and exercise Aspirin 81 mg p o daily p r n nitroglycerin for chest pain Follow up in the clinic Keywords surgery arteriography coronary arteriography heart catheterization ventriculography angiograms MEDICAL_TRANSCRIPTION,Description Left heart catheterization and bilateral selective coronary angiography The patient is a 65 year old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest Medical Specialty Surgery Sample Name Heart Cath Coronary Angiography Transcription PROCEDURE PERFORMED 1 Left heart catheterization 2 Bilateral selective coronary angiography ANESTHESIA 1 lidocaine and IV sedation including fentanyl 25 mcg INDICATION The patient is a 65 year old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest It was accompanied by diaphoresis and shortness of breath The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain He underwent adenosine Cardiolite which revealed 2 mm ST segment depression in leads II III aVF and V3 V4 and V5 Stress images revealed left ventricular dilatations suggestive of multivessel disease He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test PROCEDURE After risks benefits alternatives of the above mentioned procedure were explained to the patient in detail informed consent was obtained both verbally and writing The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner 1 lidocaine solution was used to anesthetize the right inguinal area Once adequate anesthesia had been obtained a thin walled Argon needle was used to cannulate the right femoral artery The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin The needle was removed and a pressure was held A 6 French arterial sheath was advanced over the guidewire without resistance The dilator and guidewire were removed and the sheath was flushed A Judkins left 4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire The guidewire was removed and the catheter was connected to the manifold and flushed The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter The catheter was removed over guidewire and a Judkins right 4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire The guidewire was removed and the catheter was connected to the manifold and flushed The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material the right coronary artery was evaluated in both diagonal views This catheter was removed The sheath was flushed the final time The patient was taken to the postcatheterization holding area in stable condition FINDINGS LEFT MAIN CORONARY ARTERY This vessel is seen to be heavily calcified throughout its course Begins as a moderate caliber vessel There is a 60 stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery LEFT ANTERIOR DESCENDING CORONARY ARTERY This vessel is heavily calcified in its proximal portion It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex There is a 90 stenosis in the proximal portion and 90 ostial stenosis in the first and second anterolateral branches There is sequential 80 and 90 stenosis in the mid portion of the vessel Otherwise the LAD is seen to be diffusely diseased LEFT CIRCUMFLEX CORONARY ARTERY This vessel is also calcified in its proximal portion There is a greater than 90 ostial stenosis which appears to be an extension of the lesion in the left main coronary artery There is a greater than 70 stenosis in the proximal portion of the first large obtuse marginal branch otherwise the circumflex system is seen to be diffusely diseased RIGHT CORONARY ARTERY This is a large caliber vessel and is the dominant system There is diffuse luminal irregularities throughout the vessel and a 80 to 90 stenosis at the bifurcation above the posterior descending artery and posterolateral branch IMPRESSION 1 Three vessel coronary artery disease as described above 2 Moderate mitral regurgitation per TEE 3 Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities 4 Long standing history of phlebitis PLAN Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement Keywords surgery left heart catheterization bilateral selective coronary angiography regurgitation gallops diaphoresis shortness of breath coronary angiography proximal portions catheterization artery coronary bilateral selective angiography mitral stenosis vessel guidewire MEDICAL_TRANSCRIPTION,Description Pyogenic granuloma left lateral thigh Excision of recurrent pyogenic granuloma Medical Specialty Surgery Sample Name Granuloma Excision Transcription PREOPERATIVE DIAGNOSIS Pyogenic granuloma left lateral thigh POSTOPERATIVE DIAGNOSIS Pyogenic granuloma left lateral thigh ANESTHESIA General PROCEDURE Excision of recurrent pyogenic granuloma INDICATIONS The patient is 12 year old young lady who has a hand sized congenital vascular malformation on her left lateral thigh below the greater trochanter which was described by her parents as a birthmark This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat slightly hyperpigmented lesion Although no isolated injury event can be recalled the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh and it has been treated with topical cautery in her primary care doctor s office but with recurrence She is here today for excision OPERATIVE FINDINGS The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation DESCRIPTION OF OPERATION The patient came to the operating room had an uneventful induction of general anesthesia We conducted a surgical time out reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today Preparation and draping was __________ ensued with a chlorhexidine based prep solution The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1 2 cm This entire area was infiltrated with 0 25 Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a 15 scalpel blade excising the pyogenic granuloma its base and a small rim of surrounding normal skin Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle tip electrocautery pencil The wound was closed in layers with a deep dermal roll of 5 0 Monocryl stitches supplemented by 5 0 intradermal Monocryl and Steri Strips for final skin closure The patient tolerated the procedure well This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma Blood loss was less than 5 mL and there were no complications Keywords surgery trochanter granuloma pyogenic granuloma vascular malformation pyogenic vascular malformation thigh MEDICAL_TRANSCRIPTION,Description Medical Specialty Surgery Sample Name G tube placement Transcription PREOPERATIVE DIAGNOSIS Neurologic devastation secondary to nonaccidental trauma POSTOPERATIVE DIAGNOSES Neurologic devastation secondary to nonaccidental trauma PROCEDURE Laparoscopic G tube placement 14 French 1 2 cm MIC Key INDICATIONS FOR PROCEDURE This patient is a 5 month old baby boy who presented unfortunately because of nonaccidental trauma The patient suffered neurologic devastation In order to facilitate enteral feedings the plan is to place a G tube as the patient cannot take by mouth Consent was obtained by court order as the patient is a ward of the state DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s abdomen was prepped and draped in the usual sterile fashion An incision was made through the umbilicus Peritoneal cavity entered bluntly A 5 mm trocar was introduced Abdomen was insufflated with a 5 mm scope No obvious pathology noted We visualized the stomach We chose the spot in the left upper quadrant for future G tube site I made a small incision on the skin there put another 5 mm trocar at that site Using a Babcock we grasped the stomach along the greater curvature site for further G tube I pulled a knuckle of stomach through the incision and secured with 4 0 Vicryl I then used 3 0 Prolene sutures as tacking sutures on either side of the future G tube site taking full thickness abdominal wall through stomach and back out the abdominal wall I then pulled the knuckle of stomach back up through the incision made a gastrotomy and then put a 4 0 pursestring around the gastrotomy site introduced the 14 1 2 cm MIC Key into the stomach The gastrotomy site insufflated with 5 mL of saline We then tied down the pursestring On the laparoscopy the G tube looked to be in good position I insufflated the stomach through the G tube which I did and removed air subsequently I then placed 2 x 2 underneath the G tube and tied down tacking sutures around the G tube itself placed the G tube to gravity desufflated the abdomen closed the umbilical port site fascia with 3 0 Vicryl closed skin with 5 0 Monocryl and dressed with bacitracin 2 x 2 and Steri Strips The patient was extubated in the operating room and taken back to recovery room The patient tolerated the procedure well Keywords surgery neurologic devastation g tube placement mic key laparoscopic g tube placement babcock g tube site gastrotomy mic key abdominal wall gastrotomy site nonaccidental trauma tube stomach MEDICAL_TRANSCRIPTION,Description Gastroscopy A short segment Barrett esophagus hiatal hernia and incidental fundic gland polyps in the gastric body otherwise normal upper endoscopy to the transverse duodenum Medical Specialty Surgery Sample Name Gastroscopy 3 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSIS Gastroesophageal reflux disease POSTOPERATIVE DIAGNOSIS Barrett esophagus MEDICATIONS MAC PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenum to the transverse duodenum The preparation was excellent and all surfaces were well seen The hypopharynx appeared normal The esophagus had a normal contour and normal mucosa throughout its distance but at the distal end there was a moderate sized hiatal hernia noted The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors Above the GE junction there were three fingers of columnar epithelium extending cephalad to a distance of about 2 cm This appears to be consistent with Barrett esophagus Multiple biopsies were taken from numerous areas in this region There was no active ulceration or inflammation and no stricture The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus The gastric body had normal mucosa throughout Numerous small fundic gland polyps were noted measuring 3 to 5 mm in size with an entirely benign appearance Biopsies were taken from the antrum to rule out Helicobacter pylori A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions The scope was passed through the pylorus which was patent and normal The mucosa throughout the duodenum in the first second and third portions was entirely normal The scope was withdrawn and the patient was sent to the recovery room He tolerated the procedure well FINAL DIAGNOSES 1 A short segment Barrett esophagus 2 Hiatal hernia 3 Incidental fundic gland polyps in the gastric body 4 Otherwise normal upper endoscopy to the transverse duodenum RECOMMENDATIONS 1 Follow up biopsy report 2 Continue PPI therapy 3 Follow up with Dr X as needed 4 Surveillance endoscopy for Barrett in 3 years if pathology confirms this diagnosis Keywords surgery olympus gastroscope barrett gastroesophageal reflux disease transverse duodenum barrett esophagus hiatal hernia gastroscopy endoscopy hiatal duodenum esophagus hernia MEDICAL_TRANSCRIPTION,Description Gangrene osteomyelitis right second toe The patient is a 58 year old female with poorly controlled diabetes with severe lower extremity lymphedema The patient has history of previous right foot infection requiring first ray resection Medical Specialty Surgery Sample Name Gangrene Surgery Transcription PREOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe POSTOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe OPERATIVE REPORT The patient is a 58 year old female with poorly controlled diabetes with severe lower extremity lymphedema The patient has history of previous right foot infection requiring first ray resection The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint which has failed to respond to conservative treatment The patient now has exposed bone and osteomyelitis in the second toe The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention After an IV was started by the Department of Anesthesia the patient was taken back to the operating room and placed on the operative table in the supine position A restraint belt was placed around the patient s waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient s right ankle and the patient was made comfortable by the Department of Anesthesia After adequate amounts of sedation had been given to the patient we administered a block of 10 cc of 0 5 Marcaine plain in proximal digital block around the second digit The foot and ankle were then prepped in the normal sterile orthopedic manner The foot was elevated and an Esmarch bandage applied to exsanguinate the foot The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table Using Band Aid scissors the stockinet was cut and reflected and using a wet and dry sponge the foot was wiped cleaned and the second toe identified Using a skin scrape a racket type incision was planned around the second toe to allow also remodelling of previous operative site Using a fresh 10 blade skin incision was made circumferentially in the racket shaped manner around the second digit Then using a fresh 15 blade the incision was deepened and was taken down to the level of the second metatarsophalangeal joint Care was taken to identify bleeders and cautery was used as necessary for hemostasis After cleaning up all the soft tissue attachments the second digit was disarticulated down to the level of the metatarsophalangeal joint The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination Attention was then directed to closure of the wound All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges Due to long standing lower extremity lymphedema and postoperative changes on previous surgery I thought that we were unable to close the incision in entirety Therefore after copious amounts of irrigation using sterile saline it was determined to use modified dental rolls using 4 0 gauze to remove tension from the skin Deep vertical mattress sutures were used in order to reapproximate more closely the skin edges and bring the plantar flap of skin up to the dorsal skin This was obtained using 2 0 nylon suture Following this the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads then using Kling and Kerlix and an ACE bandage to provide compression The tourniquet was deflated at 42 minutes time and hemostasis was noted to be achieved The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact as was evidenced by capillary bleeding which was present during the procedure Sedation was given postoperative introductions which include to remain nonweightbearing to her right foot The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary no more than 20 minutes each hour The patient was instructed to continue her regular medications The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q 4h p r n for moderate to severe pain 30 The patient will followup with Podiatry on Monday morning at 8 30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time The patient was instructed as to signs and symptoms of infection was instructed to return to the Emergency Department immediately if these should present The second digit was sent to Pathology for gross and micro Keywords surgery dorsally toe ulcerations foot infection ray resection metatarsophalangeal joint ace bandage gangrene osteomyelitis foot infection gangrene digital MEDICAL_TRANSCRIPTION,Description Esophagitis minor stricture at the gastroesophageal junction hiatal hernia Otherwise normal upper endoscopy to the transverse duodenum Medical Specialty Surgery Sample Name Gastroscopy Transcription PREOPERATIVE DIAGNOSES Dysphagia and esophageal spasm POSTOPERATIVE DIAGNOSES Esophagitis and esophageal stricture PROCEDURE Gastroscopy MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenum to the third portion of the duodenum The hypopharynx was normal and the upper esophageal sphincter was unremarkable The esophageal contour was normal with the gastroesophageal junction located at 38 cm from the incisors At this point there were several linear erosions and a sense of stricturing at 38 cm Below this there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors The mucosa within the hernia was normal The gastric lumen was normal with normal mucosa throughout The pylorus was patent permitting passage of the scope into the duodenum which was normal through the third portion During withdrawal of the scope additional views were obtained of the cardia confirming the presence of a small hiatal hernia It was decided to attempt dilation of the strictured area so an 18 mm TTS balloon was placed across the stricture and inflated to the recommended diameter When the balloon was fully inflated the lumen appeared to be larger than 18 mm diameter suggesting that the stricture was in fact not a significant one No stretching of the mucosa took place The balloon was deflated and the scope was withdrawn The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Esophagitis 2 Minor stricture at the gastroesophageal junction 3 Hiatal hernia 4 Otherwise normal upper endoscopy to the transverse duodenum RECOMMENDATIONS Continue proton pump inhibitor therapy Keywords surgery duodenum esophagus gastroscope stomach upper endoscopy transverse duodenum gastroesophageal junction hiatal hernia gastroscopy endoscopy esophagitis gastroesophageal hiatal esophageal hernia MEDICAL_TRANSCRIPTION,Description Gastrostomy a 6 week old with feeding disorder and Down syndrome Medical Specialty Surgery Sample Name Gastrostomy Transcription PREOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease POSTOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease OPERATION PERFORMED Gastrostomy ANESTHESIA General INDICATIONS This 6 week old female infant had been transferred to Children s Hospital because of Down syndrome and congenital heart disease She has not been able to feed well and in fact has to now be NG tube fed Her swallowing mechanism does not appear to be very functional and therefore it was felt that in order to aid in her home care that she would be better served with a gastrostomy OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in usual manner Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection The muscle was divided and the peritoneal cavity entered The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field The site for gastrostomy was selected and a pursestring suture of 4 0 Nurolon placed in the gastric wall A 14 French 0 8 cm Mic Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube Following this the stomach was returned to the abdominal cavity and the posterior fascia was closed using a 4 0 Nurolon affixing the stomach to the posterior fascia The anterior fascia was then closed with 3 0 Vicryl subcutaneous tissue with the same and the skin closed with 5 0 subcuticular Monocryl The balloon was inflated to the full 5 mL A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition Keywords surgery feeding disorder down syndrome congenital heart disease mic key tubeless nurolon subcutaneous tissue fascia syndrome stomach gastrostomy MEDICAL_TRANSCRIPTION,Description Full mouth dental rehabilitation in the operative room under general anesthesia Medical Specialty Surgery Sample Name Full Mouth Dental Rehabilitation 2 Transcription OPERATION PERFORMED Full mouth dental rehabilitation in the operative room under general anesthesia PREOPERATIVE DIAGNOSIS Severe dental caries POSTOPERATIVE DIAGNOSES 1 Severe dental caries 2 Non restorable teeth COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY 43 minutes BRIEF HISTORY The patient was first seen by me on 04 26 2007 She had a history of open heart surgery at 11 months of age She presented with severe anterior caries with most likely dental extractions needed Due to her young age I felt that she would be best served in the safety of the hospital operating room After consultation with the mother she agreed to have her treated in the safety of the hospital operating room at Children s Hospital OPERATIVE PREPARATION This child was brought to Hospital Day Surgery and is accompanied by her mother There I met with them and discussed the needs of the child types of restorations to be performed the risks and benefits of the treatment as well as the options and alternatives of the treatment After all their questions and concerns were addressed I gave the informed consent to proceed with the treatment The patient s history and physical examination was reviewed Once she was cleared by Anesthesia and the child was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with a nasal endotracheal tube and the tube was stabilized The head was wrapped and the eyes were taped shut for protection An angiocatheter was placed in the left hand and an IV was started The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath A moist continuous throat pack was placed beyond the tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative clinical photographs were taken Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography After the radiographs were taken the lead shield was removed Prophylaxis was then performed using prophy cup and fluoridated prophy paste The teeth were then rinsed well and the patient s oral cavity was suctioned clean Clinical and radiographic examinations followed and areas of decay were noted During the restorative phase these areas of decay were entered into and removed Entry was made to the level of the dental enamel junction and beyond as necessary to remove it Final caries was removed and was confirmed upon reaching hard firm sounding dentin Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement Non restorable primary teeth would be extracted Upon conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were then taken The continuous gauze throat pack was removed with continuous suction with visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene All primary teeth were present Dental caries were present on the following teeth Tooth D E F and G caries on all surfaces teeth J lingual caries The remainder of her teeth and soft tissues were within normal limits The following restorations and procedures were performed Tooth D E F and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam CONCLUSION The mother was informed of the completion of the procedure She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care They will contact to my office in the event of immediate postoperative complications After full recovery she was discharged from the recovery room in the care of her mother Keywords surgery full mouth dental rehabilitation dental rehabilitation full mouth dental caries non restorable teeth dental extractions throat pack oral cavity restorative phase primary teeth dental anesthesia mouth rehabilitation prophylaxis oral amalgam tooth MEDICAL_TRANSCRIPTION,Description Excision of ganglion of the left wrist A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist Medical Specialty Surgery Sample Name Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Ganglion of the left wrist POSTOPERATIVE DIAGNOSIS Ganglion of the left wrist OPERATION Excision of ganglion ANESTHESIA General ESTIMATED BLOOD LOSS Less than 5 mL OPERATION After a successful anesthetic the patient was positioned on the operating table A tourniquet applied to the upper arm The extremity was prepped in a usual manner for a surgical procedure and draped off The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist By blunt and sharp dissection it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted The small superficial vessels were electrocoagulated and instilled after closing the skin with 4 0 Prolene into the area was approximately 6 to 7 mL of 0 25 Marcaine with epinephrine A Jackson Pratt drain was inserted and then after the tourniquet was released it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room The dressings applied to the hand were that of Xeroform 4x4s ABD Kerlix and elastic wrap over a volar fiberglass splint The tourniquet was released Circulation returned to the fingers The patient then was allowed to awaken and left the operating room in good condition Keywords surgery curved incision superficial vessels tourniquet excision dorsal wrist ganglion MEDICAL_TRANSCRIPTION,Description Full mouth dental rehabilitation in the operating room under general anesthesia Medical Specialty Surgery Sample Name Full Mouth Dental Rehabilitation 1 Transcription OPERATION PERFORMED Full mouth dental rehabilitation in the operating room under general anesthesia PREOPERATIVE DIAGNOSES 1 Severe dental caries 2 Hemophilia POSTOPERATIVE DIAGNOSES 1 Severe dental caries 2 Hemophilia 3 Nonrestorable teeth COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY 1 hour and 22 minutes BRIEF HISTORY The patient was first seen by me on 08 23 2007 who is 4 year old with hemophilia who received infusion on Tuesdays and Thursdays and he has a MediPort Mom reported history of high fever after surgery and he has one seizure previously He has history of trauma to his front teeth and physician put him on antibiotics He was only cooperative for having me do a visual examination on his anterior teeth Visual examination revealed severe dental caries and dental abscess from tooth E and his maxillary anterior teeth needed to be extracted Due to his young age and hemophilia I felt that he would be best served to be taken to the hospital operating room OTHER PREPARATION The child was brought to the Hospital Day Surgery accompanied by his mother There I met with her and discussed the needs of the child types of restoration to be performed and the risks and benefits of the treatment as well as the options and alternatives of the treatment After all her questions and concerns were addressed she gave her informed consent to proceed with treatment The patient s history and physical examination was reviewed He was given factor for appropriately for his hemophilia prior to being taken back to the operating room Once he was cleared by Anesthesia the child was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with an oral tube and the tube was stabilized The head was wrapped and IV was started The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath A moist continuous throat pack was placed beyond tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative clinical photographs were taken Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph After the radiographs were taken the lead shield was removed Prophylaxis was then performed using a prophy cup and fluoridated prophy paste The patient s teeth were rinsed well The patient s oral cavity was suctioned clean Clinical and radiographic examination followed and areas of decay were noted During the restorative phase these areas of decay were incidentally removed Entry was made to the level of the dental enamel junction and beyond as necessary to remove it Final caries removal was confirmed upon reaching hard firm and sound dentin Teeth restored with composite ___________ bonded with a one step bonding agent Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement Non restorable primary teeth would be extracted The caries were extensive and invaded the pulp tissues pulp therapy was initiated using ViscoStat and then IRM pulpotomies Teeth treated in such a manner would then be crowned with stainless steel crowns Upon conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were then taken The continuous gauze throat pack was removed with continuous suction with visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room was taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene All primary teeth were present Dental carries were present on the following teeth Tooth B OL caries tooth C M L S caries tooth B caries on all surfaces tooth E caries on all surfaces tooth F caries on all surfaces tooth T caries on all surfaces tooth H lingual and facial caries tooth I caries on all surfaces tooth L caries on all surfaces and tooth S all caries The remainder of his teeth and soft tissues were within normal limits The following restoration and procedures were performed Tooth B OL amalgam tooth C M L S composite tooth D E F and G were extracted tooth H and L and separate F composite Tooth I is stainless steel crown tooth L pulpotomy and stainless steel crown and tooth S no amalgam Sutures were also placed at extraction site D E S and G CONCLUSION The mother was informed of the completion of the procedure She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care She is to contact to myself with an event of immediate postoperative complications and after full recovery he was discharged from recovery room in the care of his mother She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control Keywords MEDICAL_TRANSCRIPTION,Description Dysphagia possible stricture Retained gastric contents forming a partial bezoar suggestive of gastroparesis Medical Specialty Surgery Sample Name Gastroscopy 1 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSES Dysphagia possible stricture POSTOPERATIVE DIAGNOSIS Gastroparesis MEDICATION MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus stomach and duodenum The hypopharynx was normal The esophagus had a normal upper esophageal sphincter normal contour throughout and a normal gastroesophageal junction viewed at 39 cm from the incisors There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair There was no sign of reflux esophagitis On entering the gastric lumen a large bezoar of undigested food was seen occupying much of the gastric fundus and body It had 2 to 3 mm diameter This was broken up using a scope into smaller pieces There was no retained gastric liquid The antrum appeared normal and the pylorus was patent The scope passed easily into the duodenum which was normal through the second portion On withdrawal of the scope additional views of the cardia were obtained and there was no evidence of any tumor or narrowing The scope was withdrawn The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Normal postoperative hernia repair 2 Retained gastric contents forming a partial bezoar suggestive of gastroparesis 3 Otherwise normal upper endoscopy to the descending duodenum RECOMMENDATIONS 1 Continue proton pump inhibitors 2 Use Reglan 10 mg three to four times a day Keywords surgery MEDICAL_TRANSCRIPTION,Description Gastroscopy Dysphagia and globus No evidence of inflammation or narrowing to explain her symptoms Medical Specialty Surgery Sample Name Gastroscopy 2 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSIS Dysphagia and globus POSTOPERATIVE DIAGNOSIS Normal MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach and then through the gastrojejunal anastomosis into the efferent jejunal loop The preparation was good and all surfaces were well seen The hypopharynx was normal with no evidence of inflammation The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux damage or Barrett s Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food The gastrojejunal anastomosis was patent measuring about 12 mm with no inflammation or ulceration Beyond this there was a side to side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation The scope was withdrawn and the patient was sent to recovery room She tolerated the procedure well FINAL DIAGNOSES 1 Normal post gastric bypass anatomy 2 No evidence of inflammation or narrowing to explain her symptoms Keywords surgery olympus gastroscope gastric pouch gastrojejunal anastomosis dysphagia globus esophagus mucosa gastric gastroscopy gastrojejunal inflammation MEDICAL_TRANSCRIPTION,Description Cystoscopy and removal of foreign objects from the urethra Medical Specialty Surgery Sample Name Foreign Object Removal Urethra Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATION Cystoscopy and removal of foreign objects from the urethra BRACHYTHERAPY Iodine 125 ANESTHESIA General endotracheal The patient was given Levaquin 500 mg IV preoperatively Total seeds were 59 Activity of 0 439 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold 4 needles Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back BRIEF HISTORY This is a 72 year old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex Options such as watchful waiting brachytherapy radical prostatectomy cryotherapy and external beam radiation were discussed Risk of anesthesia bleeding infection pain MI DVT PE incontinence erectile dysfunction urethral stricture dysuria burning pain hematuria future procedures and failure of the procedure were all discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure The patient wanted to wait until he came back from his summer vacations so a one dose of Zoladex was given Prostate size measured about 15 g in the OR and about 22 g about two months ago Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient had a Foley catheter placed sterilely The scrotum was taped up using Ioban Transrectal ultrasound was done The prostate was measured 15 g Multiple images were taken A volume study was done This was given to the physicist Dr X was present who is radiation oncologist who helped with implanting of the seeds Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside They were done directly under transrectal ultrasound vision The seeds were placed directly under ultrasound guidance There was a nice distribution of the seeds A couple of more seeds were placed on the right side due to the location of the prostate cancer Subsequently at the end of the procedure fluoroscopy was done Couple of images were obtained Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra which was grasped and pulled out using grasper which was difficult to get the seed off of the spacers which was actually pulled out There were no further seeds visualized in the bladder The bladder appeared normal At the end of the procedure a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition Keywords surgery foreign objects foley catheter transrectal ultrasound prostate cancer cystoscopy ultrasound urethra endotracheal prostate MEDICAL_TRANSCRIPTION,Description Right frontotemporoparietal craniotomy evacuation of acute subdural hematoma Acute subdural hematoma right with herniation syndrome Medical Specialty Surgery Sample Name Frontotemporoparietal Craniotomy Transcription PREOPERATIVE DIAGNOSES Acute subdural hematoma right with herniation syndrome POSTOPERATIVE DIAGNOSES Acute subdural hematoma right with herniation syndrome OPERATION PERFORMED Right frontotemporoparietal craniotomy evacuation of acute subdural hematoma ANESTHESIA General endotracheal PREPARATION Povidone INDICATION This is an 83 year old male with herniation syndrome with large subdural hematoma 100 This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery DESCRIPTION OF PROCEDURE The patient was brought to the operating room intubated The patient previously was given fresh frozen plasma plus recombinant activated factor VII The patient had a roll placed on his right shoulder head was maintained three point fixation with a Mayfield headholder The right side of the head was shaved thoroughly prepped and draped a large scalp incision was marked infiltrated with local and incised with a scalpel Raney clips were applied to the scalp margins hemostasis temporalis muscle and fascia pericranium opened and aligned with incision flap was reflected anteriorly Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator then using Midas Rex drill with a B1 foot plate a free flap was turned The dura was opened in a cruciate fashion acute subdural hematoma was evacuated There was a small arterial bleeder in the anterior parietal region which was controlled with bipolar electrocautery Using suction and biopsy forceps acute clot was resected from the frontotemporoparietal and occipital poles subdural space was irrigated no further bleeders were encountered Dura was closed with 4 0 Nurolon A subdural Camino ICP catheter was placed in the subdural space Bone flaps secured in place with neuro clips with 5 mm screws central pack up suture was placed dural tack up sutures were placed using 4 0 Nurolon prior to placement of the bone flap The wound was irrigated with saline temporalis muscle and fascia closed with 2 0 Vicryl subgaleal Hemovac was placed galea was closed with 2 0 Vicryl and scalp with staples ICP monitor and the Hemovac were sutured in place with 2 0 Vicryl The patient was taken out of the head holder a sterile dressing placed The head was wrapped The patient was taken directly to ICU still intubated in guarded condition Brain was nicely soft and pulsatile At the termination of the procedure no significant contusion of the brain was identified Final sponge and needle counts are correct Estimated blood loss 400 cc Keywords surgery subdural hematoma craniotomy herniation subdural temporalis frontotemporoparietal hematoma MEDICAL_TRANSCRIPTION,Description Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot Medical Specialty Surgery Sample Name Foot Lesions Transcription S An 84 year old diabetic female 5 7 1 2 tall 148 pounds history of hypertension and diabetes She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot She also has a left great toenail that is giving her problems as well O Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1 1 cm in diameter There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1 1 cm in diameter These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening The first and fifth metatarsal heads are plantarflexed Vibratory sensation appears to be absent Dorsal pedal pulses are nonpalpable Varicose veins are visible to the skin on the patient s feet that are very thin almost transparent The medial aspect of the left great toenail has dried blood under the nail The nail itself is very opaque loose from the nailbed almost rotten opaque discolored hypertrophic All of the patient s toenails are elongated and discolored and opaque as well There is dried blood under the medial aspect of the left great toenail A 1 Painful feet Keywords surgery painful left foot lesions plantar metatarsal head hyperkeratotic lesion toenail nail matrix metatarsal metatarsal heads foot painful MEDICAL_TRANSCRIPTION,Description Excision of foreign body right foot and surrounding tissue This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot Medical Specialty Surgery Sample Name Foreign Body Removal Foot Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body in the right foot PROCEDURE PERFORMED Excision of foreign body right foot and surrounding tissue ANESTHESIA TIVA and local HISTORY This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot His family physician attempted to remove the wire but it only became deeper in the foot The wound eventually healed but a scar tissue was formed The patient has had constant pain with ambulation intermittently since the incident occurred He desires attempted surgical removal of the wire The risks and benefits of the procedure have been explained to the patient in detail by Dr X The consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient s protection After adequate IV sedation was administered by the Department of Anesthesia a total of 12 cc of 0 5 Marcaine plain was used to administer an ankle block Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered into the operative field and the sterile stockinet was reflected Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized This was the origin and entry point of the previous puncture wound from the wire This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area Next the Xi scan was draped and brought into the operating room A 25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire Next a 10 blade was used to make approximately a 3 cm curvilinear S shaped incision Next the 15 blade was used to carry the incision through the subcutaneous tissue The medial and lateral margins of the incision were undermined Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot the wires seemed to serve no benefit other then helping with the incision planning Therefore they were removed Once the wound was opened a hemostat was used to locate the wire very quickly and the wire was clamped A second hemostat was used to clamp the wire A 15 blade was used to carefully transect the fatty tissue around the tip of the hemostats which were visualized in the base of the wound The wire quickly came into visualization It measured approximately 4 mm in length and was approximately 1 mm in diameter The wire was green colored and metallic in nature It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament Next copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected Next a 3 0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space Next 4 0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique The standard postoperative dressing consisting of saline soaked Owen silk 4x4s Kling Kerlix and Coban were applied The pneumatic ankle tourniquet was released There was immediate hyperemic flush to the digits noted The patient s anesthesia was reversed He tolerated the above anesthesia and procedure without complications The patient was transported via cart to the Postanesthesia Care Unit Vital signs were stable and vascular status was intact to the right foot He was given OrthoWedge shoe Ice was applied behind the knee and his right lower extremity was elevated on to pillows He was given standard postoperative instructions consisting of rest ice and elevation to the right lower extremity He is to be non weightbearing for three weeks at which time the wound will be evaluated and sutures will be removed He is to follow up with Dr X on 08 22 2003 and was given emergency contact number to call if problems arise He was given a prescription for Tylenol 4 30 one p o q 4 6h p r n pain as well as Celebrex 200 mg 30 take two p o q d p c with 200 mg 12 hours later as a rescue dose He was given crutches He was discharged in stable condition Keywords surgery foreign body removal excision of foreign body ankle tourniquet plantar aspect foreign body foot ankle plantar wound MEDICAL_TRANSCRIPTION,Description Cellulitis with associated abscess and foreign body right foot Irrigation debridement and removal of foreign body of right foot Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads Medical Specialty Surgery Sample Name Foreign Body Removal Foot 1 Transcription PREOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot POSTOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot PROCEDURE PERFORMED 1 Irrigation debridement 2 Removal of foreign body of right foot ANESTHESIA Spinal with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal GROSS FINDINGS Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads HISTORY OF PRESENT ILLNESS The patient is a 61 year old Caucasian male with a history of uncontrolled diabetes mellitus The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics It was noted upon x ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity After a long discussion held with the patient it was elected to proceed with irrigation debridement and removal of the foreign body PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedures were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the patient operative surgeon the Department of Anesthesia and nursing staff The patient was then transferred to preoperative area to Operative Suite 5 and placed on the operating table in supine position All bony prominences were well padded at this time The Department of Anesthesia was administered spinal anesthetic to the patient Once this anesthesia was obtained the patient s right lower extremity was sterilely prepped and draped in the usual sterile fashion Upon viewing of the plantar aspect of the foot there was noted to be a swollen ecchymotic area with a small hole in it which purulent fluid was coming from At this time after all bony and soft tissue landmarks were identified as well as the localization of the pus a 2 cm longitudinal incision was made directly over this area which was located between the second and third metatarsal heads Upon incising this there was a foul smelling purulent fluid which flowed from this region Aerobic and anaerobic cultures were taken as well as gram stain The area was explored and it ________ to the dorsum of the foot There was no obvious joint involvement After all loculations were broken 3 liters antibiotic impregnated fluid were pulse evac through the wound The wound was again inspected with no more gross purulent or necrotic appearing tissue The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s floss and Kerlix covered by an Ace bandage At this time the Department of Anesthesia reversed the sedation The patient was transferred back to the hospital gurney to Postanesthesia Care Unit The patient tolerated the procedure well and there were no complications DISPOSITION The patient will be followed on a daily basis for possible repeat irrigation debridement Keywords surgery removal of foreign body purulent material metatarsal cellulitis abscess kerlix foreign body foot irrigation debridement purulent MEDICAL_TRANSCRIPTION,Description Microscopic hematuria with lateral lobe obstruction mild Medical Specialty Surgery Sample Name Flexible Cystoscopy BPH Transcription PREOPERATIVE DIAGNOSIS Microscopic hematuria POSTOPERATIVE DIAGNOSIS Microscopic hematuria with lateral lobe obstruction mild PROCEDURE PERFORMED Flexible cystoscopy COMPLICATIONS None CONDITION Stable PROCEDURE The patient was placed in the supine position and sterilely prepped and draped in the usual fashion After 2 lidocaine was instilled the anterior urethra is normal The prostatic urethra reveals mild lateral lobe obstruction There are no bladder tumors noted IMPRESSION The patient has some mild benign prostatic hyperplasia At this point in time we will continue with conservative observation PLAN The patient will follow up as needed Keywords surgery benign prostatic hyperplasia urethra lateral lobe obstruction flexible cystoscopy microscopic hematuria cystoscopy hematuria obstruction MEDICAL_TRANSCRIPTION,Description Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy Severe tracheobronchitis mild venous engorgement with question varicosities associated pulmonary hypertension right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy Medical Specialty Surgery Sample Name Flexible Fiberoptic Bronchoscopy Transcription PREOPERATIVE POSTOPERATIVE DIAGNOSES 1 Severe tracheobronchitis 2 Mild venous engorgement with question varicosities associated pulmonary hypertension 3 Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy PROCEDURE PERFORMED Flexible fiberoptic bronchoscopy with a Right lower lobe bronchoalveolar lavage b Right upper lobe endobronchial biopsy SAMPLES Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe INDICATIONS The patient with persistent hemoptysis of unclear etiology PROCEDURE After obtaining informed consent the patient was brought to Bronchoscopy Suite The patient had previously been on Coumadin and then heparin Heparin was discontinued approximately one and a half hours prior to the procedure The patient underwent topical anesthesia with 10 cc of 4 Xylocaine spray to the left nares and nasopharynx Blood pressure EKG and oximetry monitoring were applied and monitored continuously throughout the procedure Oxygen at two liters via nasal cannula was delivered with saturations in the 90 to 100 throughout the procedure The patient was premedicated with 50 mg of Demerol and 2 mg of Versed After conscious sedation was achieved the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx There was minimal redundant oral soft tissue in the oropharynx There was mild erythema Clear secretions were suctioned Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure a total of 16 cc of 2 Xylocaine was applied Vocal cord motion was normal The bronchoscope was then advanced through the larynx into the trachea There was evidence of moderate inflammation with prominent vascular markings and edema No frank blood was visualized The area was suction clear of copious amounts of clear white secretions Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem The bronchoscope was then sequentially advanced into each segment and sub segment of the left upper lobe and left lower lobe There was significant amount of inflammation induration and vascular tortuosity in these regions No frank blood was identified No masses or lesions were identified There was senile bronchiectasis with slight narrowing and collapse during the exhalation The air was suctioned clear The bronchoscope was withdrawn and advanced into the right main stem Bronchoscope was introduced into the right upper lobe and each sub segment was visualized Again significant amounts of tracheobronchitis was noted with vascular infiltration In the sub carina of the anterior segment of the right upper lobe there was evidence of a submucosal hematoma without frank mass underneath this The bronchoscope was removed and advanced into the right middle and right lower lobe There was marked injection and inflammation in these regions In addition there was marked vascular engorgement with near frank varicosities identified throughout the region Again white clear secretions were identified No masses or other processes were noted The area was suctioned clear A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe The bronchoscope was then withdrawn and readvanced into the right upper lobe Endobronchial biopsies of the carina of the sub segment and anterior segment of the right upper lobe were obtained Minimal hemorrhage occurred after the biopsy which stopped after 1 cc of 1 1000 epinephrine The area remained clear No further hemorrhage was identified The bronchoscope was subsequently withdrawn The patient tolerated the procedure well and was stable throughout the procedure No further hemoptysis was identified The patient was sent to Recovery in good condition Keywords surgery bronchoalveolar lavage endobronchial biopsy cytology microbiology tracheobronchitis venous engorgement varicosities pulmonary hypertension flexible fiberoptic bronchoscopy fiberoptic bronchoscopy lobe bronchoalveolar lavage endobronchial hemorrhage oropharynx vascular bronchoscopy biopsy submucosal bronchoscope MEDICAL_TRANSCRIPTION,Description Removal of foreign body of right thigh Foreign body of the right thigh sewing needle Medical Specialty Surgery Sample Name Foreign Body Removal Thigh Transcription PREPROCEDURE DIAGNOSIS Foreign body of the right thigh POSTOPERATIVE DIAGNOSIS Foreign body of the right thigh sewing needle PROCEDURE Removal of foreign body of right thigh HISTORY This is a 71 year old lady who has been referred because there is a mass in the right thigh The patient comes with an ultrasound and apparently was diagnosed with a blood clot On physical examination blood pressure was 152 76 and temperature was 95 0 The patient is 5 feet 1 inch and weighs 170 On examination of her right thigh there is a transverse area of ecchymosis in the upper third of the thigh There is a palpation of a very sharp object just under the skin The patient desires for this to be removed DESCRIPTION OF PROCEDURE After obtaining informed consent in our office the area was prepped and draped in usual fashion Xylocaine 1 was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1 1 2 inch sewing needle Compression was applied for a few minutes and then a Band Aid was applied The patient was given a tetanus toxoid 0 5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop Keywords surgery removal of foreign body sewing needle foreign body MEDICAL_TRANSCRIPTION,Description Flexor carpi radialis and palmaris longus repair Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration Medical Specialty Surgery Sample Name Flexor Carpi Radialis Palmaris Longus Repair Transcription PREOPERATIVE DIAGNOSIS Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration POSTOPERATIVE DIAGNOSIS Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration PROCEDURES PERFORMED 1 Repair flexor carpi radialis 2 Repair palmaris longus ANESTHETIC General TOURNIQUET TIME Less than 30 minutes CLINICAL NOTE The patient is a 21 year old who sustained a clean laceration off a teapot last night She had lacerated her flexor carpi radialis completely and 90 of her palmaris longus Both were repaired proximal to the carpal tunnel The postoperative plans are for a dorsal splint and early range of motion passive and active assist The wrist will be at approximately 30 degrees of flexion The MPJ is at 30 degrees of flexion the IP straight Splinting will be used until the 4 week postoperative point PROCEDURE Under satisfactory general anesthesia the right upper extremity was prepped and draped in the usual fashion There were 2 transverse lacerations Through the first laceration the flexor carpi radialis was completely severed The proximal end was found with a tendon retriever The distal end was just beneath the subcutaneous tissue A primary core stitch was used with a Kessler stitch This was with 4 0 FiberWire A second core stitch was placed again using 4 0 FiberWire The repair was oversewn with locking running 6 0 Prolene stitch Through the second incision the palmaris longus was seen to be approximately 90 severed It was an oblique laceration It was repaired with a 4 0 FiberWire core stitch and with a Kessler type stitch A secure repair was obtained She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair The fascia was released proximally and distally to give her more room for excursion of the repair The tourniquet was dropped bleeders were cauterized Closure was routine with interrupted 5 0 nylon A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted The splint was dorsal The patient was sent to the recovery room in good condition Keywords surgery kessler stitch flexor carpi radialis palmaris longus radialis laceration fiberwire flexor carpi palmaris longus repair MEDICAL_TRANSCRIPTION,Description Flexible nasal laryngoscopy Foreign body left vallecula at the base of the tongue Airway is patent and stable Medical Specialty Surgery Sample Name Flexible Nasal Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Oropharyngeal foreign body POSTOPERATIVE DIAGNOSES 1 Foreign body left vallecula at the base of the tongue 2 Airway is patent and stable PROCEDURE PERFORMED Flexible nasal laryngoscopy ANESTHESIA ______ with viscous lidocaine nasal spray INDICATIONS The patient is a 39 year old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken The patient felt that he had ingested a chicken bone tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body PROCEDURE After verbal informed consent was obtained the patient was placed in the upright position The fiberoptic nasal laryngoscope was inserted in the patient s right naris and then the left naris There was visualized some bilateral caudal spurring of the septum The turbinates were within normal limits There was some posterior nasoseptal deviation to the left The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity The nasal mucous membranes were pink and moist There was no evidence of mass ulceration lesion or obstruction The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally There was evidence of some mild erythema in the right fossa Rosenmüller There was no evidence of mass lesion or ulceration in this area however The eustachian tubes were patent without obstruction The scope was further advanced to the level of the oropharynx where the base of the tongue vallecula and epiglottis were visualized There was evidence of a 1 5 cm left vallecular white foreign body The rest of the oropharynx was without abnormality The epiglottis was within normal limits and was noted to be omega in shape There was no edema or erythema to the epiglottis The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords There was no evidence of erythema or edema of the posterior commissure arytenoid cartilage or superior surface of the vocal cords The laryngeal surface of the epiglottis was within normal limits There was no evidence of mass lesion or nodularity of the vocal cords The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam The glottic aperture was completely patent with inspiration The anterior commissure epiglottic folds false vocal cords and piriform sinuses were all within normal limits The scope was then removed without difficulty The patient tolerated the procedure well and remained in stable condition FINDINGS 1 A 1 5 cm white foreign body consistent with a chicken bone at the left vallecular region There is no evidence of supraglottic or piriform sinuses foreign body 2 Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller No mass is appreciated at this time PLAN The patient is to go to the operating room for direct laryngoscopy microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a m Airway precautions were instituted The patient currently remained in stable condition Keywords surgery oropharyngeal foreign body flexible nasal laryngoscopy nasal spray foreign body tongue laryngoscopy erythema epiglottis nasal oropharyngeal MEDICAL_TRANSCRIPTION,Description CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Medical Specialty Surgery Sample Name Frameless Stereotactic Radiosurgery Transcription PREOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation POSTOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation PROCEDURE PERFORMED CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Please note no qualified resident was available to assist in the procedure INDICATION The patient is a 30 year old male with a right occipital AVM He was referred for stereotactic radiosurgery The risks of the radiosurgical treatment were discussed with the patient including but not limited to failure to completely obliterate the AVM need for additional therapy radiation injury radiation necrosis headaches seizures visual loss or other neurologic deficits The patient understands these risks and would like to proceed PROCEDURE IN DETAIL The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment He was placed on the treatment table The Aquaplast mask was constructed Initial imaging was obtained by the CyberKnife system The patient was then transported over to the CT scanner at Stanford Under the supervision of Dr X 125 mL of Omnipaque 250 contrast was administered Dr X then supervised the acquisition of 1 2 mm contiguous axial CT slices These images were uploaded over the hospital network to the treatment planning computer and the patient was discharged home Treatment plan was then performed by me I outlined the tumor volume Inverse treatment planning was used to generate the treatment plan for this patient This resulted in a total dose of 20 Gy delivered to 84 isodose line using a 12 5 mm collimator The maximum dose within this center of treatment volume was 23 81 Gy The volume treated was 2 972 mL and the treated lesion dimensions were 1 9 x 2 7 x 1 6 cm The volume treated at the reference dose was 98 The coverage isodose line was 79 The conformality index was 1 74 and modified conformality index was 1 55 The treatment plan was reviewed by me and Dr Y of Radiation Oncology and the treatment plan was approved On the morning of May 14 2004 the patient arrived at the Outpatient CyberKnife Suite He was placed on the treatment table The Aquaplast mask was applied Initial imaging was used to bring the patient into optimal position The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin He tolerated the procedure well He was given 8 mg of Decadron for prophylaxis and discharged home Followup will consist of an MRI scan in 6 months The patient will return to our clinic once that study is completed I was present and participated in the entire procedure on this patient consisting of CT guided frameless stereotactic radiosurgery for the right occipital AVM Dr X was present during the entire procedure and will be dictating his own operative note Keywords surgery ct guided occipital cyberknife frameless stereotactic radiosurgery occipital arteriovenous malformation conformality index arteriovenous malformation malformation avm arteriovenous MEDICAL_TRANSCRIPTION,Description Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore Tex graft Chronic renal failure and thrombosed left forearm arteriovenous Gore Tex bridge fistula Medical Specialty Surgery Sample Name Fogarty Thrombectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula POSTOPERATIVE DIAGNOSIS 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula PROCEDURE PERFORMED 1 Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula 2 Revision of distal anastomosis with 7 mm interposition Gore Tex graft ANESTHESIA General with controlled ventillation GROSS FINDINGS The patient is a 58 year old black male with chronic renal failure He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality OPERATIVE PROCEDURE The patient was taken to the OR suite placed in supine position General anesthetic was administered Left arm was prepped and draped in appropriate manner A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop Transverse graftotomy was created A 4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow A fistulogram was performed and the above findings were noted In a retrograde fashion the proximal anastomosis was patent There was no narrowing within the forearm graft Both veins were flushed with heparinized saline and controlled with a vascular clamp A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia Utilizing both blunt and sharp dissection the brachial vein as well as distal anastomosis was isolated The distal anastomosis amputated off the fistula and oversewn with continuous running 6 0 Prolene suture tied upon itself The vein was controlled with vascular clamps Longitudinal venotomy created along the anteromedial wall A 7 mm graft was brought on to the field and this was cut to shape and size This was sewed to the graft in an end to side fashion with U clips anchoring the graft at the heel and toe with interrupted 6 0 Prolene sutures Good backflow bleeding was confirmed The vein flushed with heparinized saline and graft was controlled with vascular clamp The end of the insertion graft was cut to shape in length and sutured to the graft in an end to end fashion with continuous running 6 0 Prolene suture Good backflow bleeding was confirmed The graftotomy was then closed with interrupted 6 0 Prolene suture Flow through the fistula was permitted a good flow passed The wound was copiously irrigated with antibiotic solution Sponge needles instrument counts were correct All surgical sites were inspected Good hemostasis was noted The incision was closed in layers with absorbable sutures Sterile dressing was applied The patient tolerated the procedure well and returned to the recovery room in apparent stable condition Keywords surgery chronic renal failure thrombosed gore tex bridge fistula arteriovenous fogarty thrombectomy anastomosis gore tex bridge fogarty thrombectomy prolene suture renal failure distal anastomosis bridge fistula interposition renal prolene MEDICAL_TRANSCRIPTION,Description Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies Mild tracheobronchitis with history of granulomatous disease and TB rule out active TB miliary TB Medical Specialty Surgery Sample Name Flexible Fiberoptic Bronchoscopy 1 Transcription POSTOPERATIVE DIAGNOSIS Mild tracheobronchitis with history of granulomatous disease and TB rule out active TB miliary TB PROCEDURE PERFORMED Flexible fiberoptic bronchoscopy diagnostic with a Right middle lobe bronchoalveolar lavage b Right upper lobe bronchoalveolar lavage c Right lower lobe transbronchial biopsies COMPLICATIONS None Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe INDICATION The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis PROCEDURE After obtaining an informed consent the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions The patient had appropriate oxygen blood pressure heart rate and respiratory rate monitoring applied and monitored continuously throughout the procedure 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100 saturations achieved Topical anesthesia with 10 cc of 4 Xylocaine was applied to the right nares and oropharynx Subsequent to this the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg With this adequate consciousness sedation was achieved 3 cc of 4 viscous Xylocaine was applied to the right nares The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx The oropharynx and larynx were well visualized and showed mild erythema mild edema otherwise negative There was normal vocal cord motion without masses or lesions Additional topical anesthesia with 2 Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc The bronchoscope was then advanced through the larynx into the trachea The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions These were suctioned clear The bronchoscope was then advanced through the carina which was sharp Then advanced into the left main stem and each segment subsegement in the left upper lingula and lower lobe was visualized There was mild tracheobronchitis with mild friability throughout There was modest amounts of white secretion There were no other findings including evidence of mass anatomic distortions or hemorrhage The bronchoscope was subsequently withdrawn and advanced into the right mainstem Again each segment and subsegment was well visualized The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments No specific masses or other lesions were identified throughout the tracheobronchial tree on the right There was mild tracheal bronchitis with friability Upon coughing there was punctate hemorrhage The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe These again had no other anatomic lesions identified The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained The bronchoscope was withdrawn and the area was suctioned clear The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed Samples were taken and the bronchoscope was removed suctioned the area clear The bronchoscope was then re advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe Minimal hemorrhage was identified and suctioned clear without difficulty The bronchoscope was then withdrawn to the mainstem The area was suctioned clear Fluoroscopy revealed no evidence of pneumothorax The bronchoscope was then withdrawn The patient tolerated the procedure well without evidence of desaturation or complications Keywords surgery bronchoalveolar lavage lobe tracheobronchitis granulomatous miliary tb tb flexible fiberoptic bronchoscopy bronchoscope flexible fiberoptic transbronchial biopsies bronchoscopy oropharynx MEDICAL_TRANSCRIPTION,Description Recurring bladder infections with frequency and urge incontinence not helped with Detrol LA Normal cystoscopy with atrophic vaginitis Medical Specialty Surgery Sample Name Flexible Cystoscopy Atrophic Vaginitis Transcription PREOPERATIVE DIAGNOSIS Recurring bladder infections with frequency and urge incontinence not helped with Detrol LA POSTOPERATIVE DIAGNOSIS Normal cystoscopy with atrophic vaginitis PROCEDURE PERFORMED Flexible cystoscopy FINDINGS Atrophic vaginitis PROCEDURE The patient was brought in to the procedure suite prepped and draped in the dorsal lithotomy position The patient then had flexible scope placed through the urethral meatus and into the bladder Bladder was systematically scanned noting no suspicious areas of erythema tumor or foreign body Significant atrophic vaginitis is noted IMPRESSION Atrophic vaginitis with overactive bladder with urge incontinence PLAN The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks Keywords surgery urge incontinence frequency overactive bladder vesicare flexible cystoscopy bladder infections atrophic vaginitis incontinence cystoscopy vaginitis MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon Medical Specialty Surgery Sample Name Flex Sig 2 Transcription PROCEDURE IN DETAIL Following a barium enema prep and lidocaine ointment to the rectal vault perirectal inspection and rectal exam were normal The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon Withdrawal notes an otherwise normal descending rectosigmoid and rectum Retroflexion noted no abnormality of the internal ring No hemorrhoids were noted Withdrawal from the patient terminated the procedure Keywords surgery flexible sigmoidoscopy flex sig colonoscope olympus video colonoscope rectumNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Flexible bronchoscopy to evaluate the airway chronic wheezing Medical Specialty Surgery Sample Name Flexible Bronchoscopy Transcription PROCEDURE Flexible bronchoscopy PREOPERATIVE DIAGNOSIS ES Chronic wheezing INDICATIONS FOR PROCEDURE Evaluate the airway DESCRIPTION OF PROCEDURE This was done in the pediatric endoscopy suite with the aid of Anesthesia The patient was sedated with sevoflurane and propofol One mL of 1 lidocaine was used for airway anesthesia The 2 8 mm flexible pediatric bronchoscope was passed through the left naris The upper airway was visualized The epiglottis arytenoids and vocal cords were all normal The scope was passed below the cords The subglottic space was normal The patient had normal tracheal rings and a normal membranous portion of the trachea There was noted to be slight deviation of the trachea to the right At the carina the right and left mainstem were evaluated The right upper lobe right middle lobe and right lower lobe were all anatomically normal The scope was wedged in the right middle lobe 10 mL of saline was infused 10 was returned This was sent for cell count cytology lipid index and quantitative bacterial cultures The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle The left upper lobe and left lower lobe were normal The scope was withdrawn The patient tolerated the procedure well ENDOSCOPIC DIAGNOSIS Left mainstem bronchomalacia Keywords surgery flexible bronchoscopy airway arytenoids bronchomalacia bronchoscopy endoscopy suite epiglottis mainstem subglottic vocal cords wheezing chronic wheezing tracheal lobe MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy due to rectal bleeding Medical Specialty Surgery Sample Name Flex Sig 1 Transcription INDICATION Rectal bleeding PREMEDICATION See procedure nurse NCS form PROCEDURE Keywords surgery rectal bleeding digital rectal exam pentax video anal verge angiodysplasia colonic mucosa diverticula endoscope flexible flexible sigmoidoscopy hemorrhoids masses polyps rectum sigmoidoscopy sphincter tone internal hemorrhoids bleeding rectal MEDICAL_TRANSCRIPTION,Description Fiberoptic flexible bronchoscopy with lavage brushings and endobronchial mucosal biopsies of the right bronchus intermedius right lower lobe Right hyoid mass rule out carcinomatosis Chronic obstructive pulmonary disease Changes consistent with acute and chronic bronchitis Medical Specialty Surgery Sample Name Fiberoptic Flexible Bronchoscopy Transcription PREOPERATIVE DIAGNOSES 1 Right hyoid mass rule out carcinomatosis 2 Weight loss 3 Chronic obstructive pulmonary disease POSTOPERATIVE DIAGNOSES 1 Right hyoid mass rule out carcinomatosis 2 Weight loss 3 Chronic obstructive pulmonary disease 4 Changes consistent with acute and chronic bronchitis 5 Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes 6 Left vocal cord irregularity PROCEDURE PERFORMED Fiberoptic flexible bronchoscopy with lavage brushings and endobronchial mucosal biopsies of the right bronchus intermedius right lower lobe ANESTHESIA Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution LOCATION OF PROCEDURE Endoscopy suite 4 After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry noninvasive blood pressure and EKG monitoring Prior to starting the procedure the patient was noted to have a baseline oxygen saturation of 86 on room air Subsequently she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90 to 91 on room air The patient was placed on a supplemental oxygen as the patient was sedated with above stated medication As this occurred the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx The cords were noted to oppose bilaterally on phonation There was some slight mucosal irregularity noted on the vocal cord on the left side Additional topical lidocaine was instilled on the vocal cords at which point the bronchoscope was introduced into the trachea which was midline in nature The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled At this time the bronchoscope was further advanced through the main stem and additional lidocaine was instilled Bronchoscope was then further advanced into the right upper lobe which revealed no evidence of any endobronchial lesion The mucosa was diffusely friable throughout Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled At this point the bronchoscope was then advanced to the right bronchus intermedius At this time it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening The mucosal area throughout this region was severely friable Additional lidocaine was instilled as well as topical epinephrine At this time bronchoscope was maintained in this region and endobronchial biopsies were performed At the initial attempt of inserting biopsy forceps some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized At this time bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty At this time the biopsy forceps were easily passed and visualized in the right bronchus intermedius At this time multiple mucosal biopsies were performed with some mild oozing noted Several aliquots of normal saline lavage followed After completion of multiple biopsies there was good hemostasis Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments The bronchoscope was then withdrawn to the distal trachea At this time bronchoscope was then advanced to the left main stem Additional lidocaine was instilled The bronchoscope was advanced to the left upper and lower lobe subsegments There was no endobronchial lesion visualized There is mild diffuse erythema and fibromucosa was noted throughout No endobronchial lesion was visualized in the left bronchial system The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system At this time bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout The bronchoscope was subsequently withdrawn and the patient was sent to recovery room During the bronchoscopy the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93 to 94 The patient remained at this level of saturation or greater throughout the remaining of the procedure The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea This was confirmed by her daughter and mother who were also present at the bedside postprocedure The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well The patient also admitted to continued smoking in spite of all of the above The patient was extensively counseled regarding the continued smoking especially with her present symptoms She was advised regarding smoking cessation The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off The patient was also administered Solu Medrol 60 mg IV x1 in recovery room There was no significant bronchospastic component noted although because of the severity of the mucosal edema erythema and her complaints short course of steroids will be instituted The patient was also advised to refrain from using any aspirin or other nonsteroidal anti inflammatory medication because of her hemoptysis At this time the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea to either contact myself or return to ABCD Emergency Room for evaluation of possible admission However the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well Keywords surgery carcinomatosis chronic obstructive pulmonary disease fiberoptic flexible bronchoscopy lavage brushings endobronchial mucosal biopsies mucosal bronchoscope atrovent topical fiberoptic hemoptysis bronchoscopy endobronchial oropharynx MEDICAL_TRANSCRIPTION,Description Fiberoptic nasolaryngoscopy Dysphagia with no signs of piriform sinus pooling or aspiration Right parapharyngeal lesion likely thyroid cartilage nonhemorrhagic Medical Specialty Surgery Sample Name Fiberoptic Nasolaryngoscopy Transcription PREOPERATIVE DIAGNOSES 1 Dysphagia 2 Right parapharyngeal hemorrhagic lesion POSTOPERATIVE DIAGNOSES 1 Dysphagia with no signs of piriform sinus pooling or aspiration 2 No parapharyngeal hemorrhagic lesion noted 3 Right parapharyngeal lesion likely thyroid cartilage nonhemorrhagic PROCEDURE PERFORMED Fiberoptic nasolaryngoscopy ANESTHESIA None COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 93 year old Caucasian male who was admitted to ABCD General Hospital on 08 07 2003 secondary to ischemic ulcer on the right foot ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08 17 03 with a fiberoptic nasolaryngoscopy a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation The patient subsequently resolved with his dysphagia and workup of Speech was obtained which showed no aspiration no pooling minimal premature spillage with solids but good protection of the airway This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior PROCEDURE DETAILS The patient was brought in the semi Fowler s position a fiberoptic nasal laryngoscope was then passed into the patient s right nasal passage all the way to the nasopharynx The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx and down to the hypopharynx The patient s oro and nasopharynx all appeared normal with no signs of any gross lesions edema or ecchymosis Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx There were no signs of any obstruction The epiglottis piriform sinuses vallecula and base of tongue all appeared normal with no signs of any gross lesions The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions The scope was then pulled out and the patient tolerated the procedure well At this time we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion Keywords surgery parapharyngeal dysphagia sinus pooling piriform nasolaryngoscopy fiberoptic laryngoscope nasopharynx oropharynx fiberoptic nasolaryngoscopy hemorrhagic lesion aspiration cartilage hypopharynx lesion MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy Sigmoid and left colon diverticulosis otherwise normal flexible sigmoidoscopy to the proximal descending colon Medical Specialty Surgery Sample Name Flex Sig 3 Transcription PROCEDURE Flexible sigmoidoscopy PREOPERATIVE DIAGNOSIS Rectal bleeding POSTOPERATIVE DIAGNOSIS Diverticulosis MEDICATIONS None DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm reaching the proximal descending colon At this point stool occupied the lumen preventing further passage The colon distal to this was well cleaned out and easily visualized The mucosa was normal throughout the regions examined Numerous diverticula were seen There was no blood or old blood or active bleeding A retroflexed view of the anorectal junction showed no hemorrhoids He tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Sigmoid and left colon diverticulosis 2 Otherwise normal flexible sigmoidoscopy to the proximal descending colon 3 The bleeding was most likely from a diverticulum given the self limited but moderately severe quantity that he described RECOMMENDATIONS 1 Follow up with Dr X as needed 2 If there is further bleeding a full colonoscopy is recommended Keywords surgery olympus gastroscope rectal bleeding flexible sigmoidoscopy colon diverticulosis descending colon diverticulosis hemorrhoids flexible sigmoidoscopy colon MEDICAL_TRANSCRIPTION,Description Flexible Sigmoidoscopy Medical Specialty Surgery Sample Name Flex Sig Transcription MEDICATIONS None DESCRIPTION OF THE PROCEDURE After informed consent was obtained the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of cm to the proximal descending colon and then slowly withdrawn The mucosa appeared normal Retroflex examination of the rectum was normal Keywords surgery flexible sigmoidoscopy flex sig olympus video colonoscope colonoscopeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Emergent fiberoptic bronchoscopy with lavage Status post multiple trauma motor vehicle accident Acute respiratory failure Acute respiratory distress ventilator asynchrony Hypoxemia Complete atelectasis of left lung Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system Medical Specialty Surgery Sample Name Fiberoptic Bronchoscopy with Lavage Transcription PREOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung POSTOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung 6 Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system PROCEDURE PERFORMED Emergent fiberoptic plus bronchoscopy with lavage LOCATION OF PROCEDURE ICU Room 164 ANESTHESIA SEDATION Propofol drip Brevital 75 mg morphine 5 mg and Versed 8 mg HISTORY The patient is a 44 year old male who was admitted to ABCD Hospital on 09 04 03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions requiring ventilatory assistance The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation Chest x ray as noted above revealed complete atelectasis of the left lung The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy PROCEDURE DETAIL A bronchoscope was inserted through the oroendotracheal tube which was partially obstructed with blood clots These were lavaged with several aliquots of normal saline until cleared The bronchoscope required removal because the tissue clots were obstructing the bronchoscope The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina The endotracheal tube was noted to be in good position The bronchoscope was advanced through the distal trachea There was a white tissue completely obstructing the left main stem at the carina The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes There was diffuse mucus impactions tissue as well as intermittent clots There was no evidence of any active bleeding noted Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system There is no plugging or obstruction of the right bronchial system The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified approximately 4 cm above the main carina The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure Throughout the procedure pulse oximetry was greater than 95 throughout There is no hemodynamic instability or variability noted during the procedure Postprocedure chest x ray is pending at this time Keywords surgery multiple trauma motor vehicle accident acute respiratory failure acute respiratory distress ventilator asynchrony hypoxemia atelectasis bronchoscopy lavage fiberoptic bronchoscopy endotracheal tube acute respiratory asynchrony bronchoscope fiberoptic endotracheal bronchial ventilatory tube respiratory MEDICAL_TRANSCRIPTION,Description Bilateral facet Arthrogram and injections at L34 L45 L5S1 Interpretation of radiograph Low Back Syndrome Low Back Pain Medical Specialty Surgery Sample Name Facet Arthrogram Injection Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low Back Pain POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Bilateral facet Arthrogram at L34 L45 L5S1 2 Bilateral facet injections at L34 L45 L5S1 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x ray studies and imaging scans SUMMARY OF PROCEDURE The patient was admitted to the OR consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain EKG respiration and heart rate and at intervals of three minutes for blood pressure After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view A skin wheal was placed with 1 Lidocaine at the L34 facet region on the left Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side This was performed using the oblique view under fluoroscopy to the enable the view of the Scotty Dog After obtaining the Scotty Dog view the joints were easily seen Negative aspiration was carefully performed to verity that there was no venous arterial or cerebral spinal fluid flow After negative aspiration was verified 1 8th of a cc of Omnipaque 240 dye was then injected Negative aspiration was again performed and 1 2 cc of solution Solution consisting of 9 cc of 0 5 Marcaine with 1 cc of Triamcinolone was then injected into the joint The needle was then withdrawn out of the joint and 1 5 cc of this same solution was injected around the joint The 22 gauge needle was then removed Pressure was place over the puncture site for approximately one minute This exact same procedure was then repeated along the left sided facets at L45 and L5S1 This exact same procedure was then repeated on the right side At each level vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid The patient was noted to have tolerated the procedure well without any complications Interpretation of the radiograph revealed placement of the 22 gauge spinal needles into the left sided and right sided facet joints at L34 L45 and L5S1 Visualizing the Scotty Dog technique under fluoroscopy facilitated this Dye spread into each joint space is visualized No venous or arterial run off is noted No epidural run off is noted The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis Keywords surgery low back syndrome low back pain facet injection fluoroscopy iv sedation spinal fluid facet arthrogram aspiration arthrogram injection facet MEDICAL_TRANSCRIPTION,Description Incompetent glottis Fat harvesting from the upper thigh micro laryngoscopy fat injection thyroplasty Medical Specialty Surgery Sample Name Fat Harvesting Transcription PREOPERATIVE DIAGNOSIS Incompetent glottis POSTOPERATIVE DIAGNOSIS Incompetent glottis OPERATION PERFORMED 1 Fat harvesting from the upper thigh 2 Micro laryngoscopy 3 Fat injection thyroplasty FINDINGS AND PROCEDURE With the patient in the supine position under adequate general endotracheal anesthesia the operative area was prepped and draped in a routine fashion A 1 cm incision was made in the upper thigh and approximately 5 cc of fat was liposuctioned from the subcutaneous space After this had been accomplished the wound was closed with an interrupted subcuticular suture of 4 0 chromic and a light compression dressing was applied Next the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin After this had been accomplished it was placed in a 3 cc BD syringe and thence into the Stasney fat injector device Next a Dedo laryngoscope was used to visualize the larynx and approximately cc of fat was injected into the right TA muscle and cc of fat into the left TA muscle The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition Estimated blood loss was negligible Keywords surgery dedo laryngoscope physiosol micro laryngoscopy fat injection fat harvesting incompetent glottis laryngoscopy thyroplasty glottis thigh MEDICAL_TRANSCRIPTION,Description Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage Bilateral upper lobe cavitary lung masses Airway changes including narrowing of upper lobe segmental bronchi apical and posterior on the right and anterior on the left There are also changes of inflammation throughout Medical Specialty Surgery Sample Name Fiberoptic Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Bilateral upper lobe cavitary lung masses POSTOPERATIVE DIAGNOSES 1 Bilateral upper lobe cavitary lung masses 2 Final pending pathology 3 Airway changes including narrowing of upper lobe segmental bronchi apical and posterior on the right and anterior on the left There are also changes of inflammation throughout PROCEDURE PERFORMED Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage ANESTHESIA Conscious sedation was with Demerol 150 mg and Versed 4 mg IV OPERATIVE REPORT The patient is residing in the endoscopy suite After appropriate anesthesia and sedation the bronchoscope was advanced transorally due to the patient s recent history of epistaxis Topical lidocaine was utilized for anesthesia Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent This may be normal anatomic variant The scope was advanced into the trachea The main carina was sharp in appearance Right upper middle and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left No specific intrinsic masses were noted Under direct visualization the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe Also cytologic brushings and protected bacteriologic brushing specimens were obtained Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe During lavage some caseous appearing debris appeared intermittently The specimens were collected and sent to the lab Procedure was terminated with hemostasis having been verified The patient tolerated the procedure well Throughout the procedure the patient s vital signs and oximetry were monitored and remained within satisfactory limits The patient will be returned to her room with orders as per usual Keywords surgery inflammation lung masses lobe cavitary bronchoalveolar biopsies segmental bronchi fiberoptic bronchoscopy lavage cavitary segmental lobe MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy diagnostic Hemoptysis and history of lung cancer Tumor occluding right middle lobe with friability Medical Specialty Surgery Sample Name Fiberoptic Bronchoscopy 1 Transcription PREOPERATIVE DIAGNOSIS 1 Hemoptysis 2 History of lung cancer POSTOPERATIVE DIAGNOSIS Tumor occluding right middle lobe with friability PROCEDURE PERFORMED Fiberoptic bronchoscopy diagnostic LOCATION Endoscopy suite 4 ANESTHESIA General per Anesthesia Service ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain Due to her prior history it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis She was brought to endoscopy suite 4 and informed consent was obtained PROCEDURE DETAILS The patient was placed in the supine position and intubated by the Anesthesia Service Intravenous sedation was given as per Anesthesia The fiberoptic scope was passed through the 8 endotracheal tube into the main trachea The right mainstem bronchus was examined The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted Upon examining the right middle lobe there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe The clot was lavaged with normal saline and there was noted to be tumor behind this clot Tumor completely occluded both segments of the right middle lobe Scope was then passed to the subsegments of the right lower lobe which were individually examined and noted to be grossly free of endobronchial lesions Scope was pulled back to the level of the midtrachea passed into the left mainstem bronchus Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions There were some secretions noted throughout the left lung The scope was retracted and passed again to the right mainstem bronchus The area of the right middle lobe was reexamined The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation It did not appear as if a scope or cannula could be passed distal to the tumor Due to continued oozing 1 cc of epinephrine was applied topically with adequate hemostasis obtained The area was examined for approximately one minute for assurance of adequate hemostasis The scope was then retracted and the patient was sent to the recovery room in stable condition She will be extubated as per the Anesthesia Service Cytology and cultures were not sent due to the patient s known diagnosis Further recommendations are pending at this time Keywords surgery hemoptysis lung cancer tumor fiberoptic bronchoscopy endoscopy suite adequate hemostasis fiberoptic bronchoscopy endobronchial lesions middle lobe lobe MEDICAL_TRANSCRIPTION,Description External cephalic version A 39 week intrauterine pregnancy with complete breech presentation Medical Specialty Surgery Sample Name External Cephalic Version Transcription PREOPERATIVE DIAGNOSIS A 39 week intrauterine pregnancy with complete breech presentation POSTOPERATIVE DIAGNOSIS A 39 week intrauterine pregnancy in vertex presentation status post successful external cephalic version PROCEDURE External cephalic version COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained The patient was noted to have irregular contractions She was given 1 dose of subcutaneous terbutaline which resolved her contraction A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation There was noted to be adequate fluid Using manual pressure the breech was manipulated in a forward roll fashion until a vertex presentation was obtained Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring Following successful external cephalic version the patient was placed on continuous external fetal monitoring She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version She did not have regular contractions and therefore she was felt to be stable for discharge to home She was given appropriate labor instructions Keywords surgery intrauterine pregnancy vertex presentation complete breech presentation external cephalic version fetal contractions pregnancy breech intrauterine MEDICAL_TRANSCRIPTION,Description Left masticator space infection secondary to necrotic tooth 17 Extraoral incision and drainage of facial space infection and extraction of necrotic tooth 17 Medical Specialty Surgery Sample Name Extraoral I D Transcription PREOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth 17 POSTOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth 17 SURGICAL PROCEDURE Extraoral incision and drainage of facial space infection and extraction of necrotic tooth 17 FLUIDS 500 mL of crystalloid ESTIMATED BLOOD LOSS 60 mL SPECIMENS Cultures and sensitivities Aerobic and anaerobic were sent for micro studies DRAINS One 0 25 inch Penrose placed in the medial aspect of the masticator space CONDITION Good extubated breathing spontaneously to PACU INDICATIONS FOR PROCEDURE The patient is a 26 year old Caucasian male with a 2 week history of a toothache and 5 day history of increasing swelling of his left submandibular region presents to Clinic complaining of difficulty swallowing and breathing Oral surgery was consulted to evaluate the patient After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth 17 Risks benefits alternatives treatments were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was transported to operating room 4 at Clinic He was laid supine on the operating room table ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics The patient was prepped and draped in the usual oral and maxillofacial surgery fashion The surgeon approached the operating room table in sterile fashion Approximately 2 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left submandibular area in the area of the incision After waiting appropriate time for local anesthesia to take effect an 18 gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed This was sent for aerobic and anaerobic micro Using a 15 blade a 2 cm incision was made in the left submandibular region then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed The left masticator space was thoroughly explored as well as the left submandibular space and submental space Pus was drained from this site Copious amounts of sterile fluid were irrigated into the site Attention was then directed intraorally where a moistened Ray Tec sponge was placed in the posterior oropharynx to act as a throat pack Approximately 4 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left inferior alveolar nerve block Using a 15 blade a full thickness mucoperiosteal flap was developed around tooth 17 The tooth was elevated and delivered and the lingual area of tooth 17 was explored and more pus was expressed This pus was evacuated intraorally __________ suction The extraction site and the left masticator space were irrigated and it was noted that the irrigation was communicating with extraoral incision in the neck A 0 25 inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2 0 silk suture A tack stitch intraorally with 3 0 chromic suture was placed The throat pack was then removed An orogastric tube was placed and removed all other stomach contents and then removed At this point the procedure was then determined to be over The patient was extubated breathing spontaneously and transported to PACU in good condition Keywords surgery masticator space infection extraoral incision and drainage ray tec sponge submandibular space infection necrotic tooth masticator space space drainage necrotic incision masticator tooth MEDICAL_TRANSCRIPTION,Description Left supraorbital deep complex facial laceration measuring 6x2 cm Plastic closure of deep complex facial laceration measuring 6x2 cm The patient is a 23 year old male who was intoxicated and hit with an unknown object to his forehead The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site Medical Specialty Surgery Sample Name Facial Laceration Closure Transcription PREOPERATIVE DIAGNOSIS Left supraorbital deep complex facial laceration measuring 6x2 cm POSTOPERATIVE DIAGNOSIS Left supraorbital deep complex facial laceration measuring 6x2 cm PROCEDURE PERFORMED Plastic closure of deep complex facial laceration measuring 6x2 cm ANESTHESIA Local anesthesia with 1 lidocaine with 1 100 000 epinephrine total of 2 cc were used SPECIMENS None FINDINGS Deep complex left forehead laceration HISTORY The patient is a 23 year old male who was intoxicated and hit with an unknown object to his forehead The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site He was brought to the Emergency Room where a CAT scan of the head and facial bumps was performed which were negative Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks benefits alternatives and complications of the surgery to include infection bleeding cosmetic deformity significant scarring need for possible scar revision The patient was allowed to ask all questions he wanted and they were answered in a language he could understand He wished to pursue surgery and signed the informed consent PROCEDURE The patient was placed in the supine position The wound was copiously irrigated with normal saline on irrigating tip After one liter of irrigation the wound was prepped and draped in the usual sterile fashion The incision was then localized with a solution of 1 lidocaine with 1 100 000 epinephrine a total of less than 2 cc was used We then reapproximated the wound in double layered fashion with deep sutures of 5 0 Vicryl two interrupted sutures were used and then the skin was closed with interrupted sutures of 5 0 nylon The wound came together very nicely Tincture of Benzoin was placed Steri Strips were placed over the top and a small amount of bacitracin was placed over the Steri Strips The patient tolerated the procedure well with no complications Keywords surgery plastic closure facial laceration deep complex facial laceration steri strips closure bleeding sterile sutures forehead wound supraorbital facial laceration MEDICAL_TRANSCRIPTION,Description Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid Medical Specialty Surgery Sample Name Eyelid Squamous Cell Carcinoma Excision Transcription PREOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma POSTOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma PROCEDURE PERFORMED Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Local with sedation INDICATION The patient is a 65 year old male with a large squamous cell carcinoma on his right upper eyelid which had previous radiation DESCRIPTION OF PROCEDURE The patient was taken to the operating room laid supine administered intravenous sedation and prepped and draped in a sterile fashion He was anesthetized with a combination of 2 lidocaine and 0 5 Marcaine with Epinephrine on both upper eyelids The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact Following complete resection the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate The specimen was sent to pathology which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma Meticulous hemostasis was obtained with Bovie cautery and a full thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid The left upper eyelid incision was closed with 6 0 fast absorbing gut interrupted sutures and the skin graft was sutured in place with 6 0 fast absorbing gut interrupted sutures An eye patch was placed on the right side and the patient tolerated the procedure well and was taken to PACU in good condition Keywords surgery frozen section full thickness skin grafting squamous cell carcinoma eyelid orbicularis MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy Extensive lysis of adhesions Right salpingo oophorectomy Pelvic mass suspected right ovarian cyst Medical Specialty Surgery Sample Name Exploratory Laparotomy 2 Transcription PREOPERATIVE DIAGNOSES 1 Pelvic mass 2 Suspected right ovarian cyst POSTOPERATIVE DIAGNOSES 1 Pelvic mass 2 Suspected right ovarian cyst PROCEDURES 1 Exploratory laparotomy 2 Extensive lysis of adhesions 3 Right salpingo oophorectomy ANESTHESIA General ESTIMATED BLOOD LOSS 200 mL SPECIMENS Right tube and ovary COMPLICATIONS None FINDINGS Extensive adhesive disease with the omentum and bowel walling of the entire pelvis which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst tube and ovary in order to remove them The large and small bowels were completely enveloping a large right ovarian cystic mass Normal anatomy was difficult to see due to adhesions Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid Cyst wall tube and ovary were stripped away from the bowel Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube There was excellent postoperative hemostasis PROCEDURE The patient was taken to the operating room where general anesthesia was achieved without difficulty She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient s prior incision Incision was carried down carefully until the peritoneal cavity was reached Care was taken upon entry of the peritoneum to avoid injury of underlying structures At this point the extensive adhesive disease was noted again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery The omentum was carefully stripped away from the patient s right side developing a window This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum A large mass of bowel was noted to be adherent to itself causing a quite tortuous course Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis Excellent hemostasis was noted The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment the cyst was ruptured Large amount of turbid fluid was noted and was evacuated The cyst wall was then carefully placed under tension and stripped away from the patient s small and large bowel Once the bowel was freed the remnants of round ligament was identified elevated and the peritoneum was incised opening the retroperitoneal space The retroperitoneal space was opened following the line of the ovarian vessels which were identified and elevated and a window made inferior to the ovarian vessels but superior to the course of the ureter This pedicle was doubly clamped transected and tied with a free tie of 2 0 Vicryl A suture ligature of 0 Vicryl was used to obtain hemostasis Excellent hemostasis was noted at this pedicle The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary which was still densely adherent to the peritoneum Care was taken at the side of the remnant of the uterine vessels However a laceration of the uterine vessels did occur which was clamped with a right angle clamp and carefully sutured ligated with excellent hemostasis noted Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed The opposite tube and ovary were identified were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal It was then left in situ Hemostasis was achieved in the pelvis with the use of electrocautery The abdomen and pelvis were copiously irrigated with warm saline solution The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle and the ovarian vessel pedicle The areas of the bowel had previously been dissected and due to adhesive disease it was carefully inspected and excellent hemostasis was noted All instruments and packs removed from the patient s abdomen The abdomen was closed with a running mattress closure of 0 PDS beginning at the superior aspect of the incision and extending inferiorly Excellent closure of the incision was noted The subcutaneous tissues were then copiously irrigated Hemostasis was achieved with the use of cautery Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of 0 plain gut suture The skin was closed with staples Incision was sterilely clean and dressed The patient was awakened from general anesthesia and taken to the recovery room in stable condition All counts were noted correct times three Keywords surgery pelvic mass ovarian cyst exploratory laparotomy lysis of adhesions salpingo oophorectomy cyst bowel adhesions uterine abdomen pelvis ovary peritoneum ovarian hemostasis MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy lysis of adhesions and removal reversal of Hartmann s colostomy flexible sigmoidoscopy and cystoscopy with left ureteral stent Medical Specialty Surgery Sample Name Exploratory Laparotomy 1 Transcription PREOPERATIVE DIAGNOSIS History of perforated sigmoid diverticuli with Hartmann s procedure POSTOPERATIVE DIAGNOSES 1 History of perforated sigmoid diverticuli with Hartmann s procedure 2 Massive adhesions PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Lysis of adhesions and removal 3 Reversal of Hartmann s colostomy 4 Flexible sigmoidoscopy 5 Cystoscopy with left ureteral stent ANESTHESIA General HISTORY This is a 55 year old gentleman who had a previous perforated diverticula Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann s colostomy PROCEDURE The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion A cystoscope was introduced into the patient s urethra and to the bladder Immediately no evidence of cystitis was seen and the scope was introduced superiorly measuring the bladder and immediately a 5 French ____ was introduced within the left urethra The cystoscope was removed a Foley was placed and wide connection was placed attaching the left ureteral stent and Foley At this point immediately the patient was re prepped and draped and immediately after the ostomy was closed with a 2 0 Vicryl suture immediately at this point the abdominal wall was opened with a 10 blade Bard Parker down with electrocautery for complete hemostasis through the midline The incision scar was cephalad due to the severe adhesions in the midline Once the abdomen was entered in the epigastric area then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall Once the small bowel was completely free from the anterior abdominal wall at this point the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall Immediately at this point the bowel was dropped within the abdominal cavity and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis At this point the rectal stump where two previous sutures with Prolene were seen were brought with hemostats The rectal stump was free in a 360 degree fashion and immediately at this point a decision to perform the anastomosis was made First a self retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point immediately the rectal stump was well visualized no evidence of bleeding was seen and the towels were placed along the edges of the abdominal wound Immediately the pursestring device was fired approximately 1 inch from the skin and on the descending colon this was fired The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating 25 and 29 mushroom tip from the T8 Ethicon was placed within the colon and then 9 0 suture was tied Immediately from the anus the dilator 25 and 29 was introduced dilating the rectum The 29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it The EEA was then fired Once it was fired and was removed the pelvis was filled with fluid Immediately both doughnuts were ____ from the anastomosis A Doyen was placed in both the anastomosis Colonoscope was introduced No bubble or air was seen coming from the anastomosis There was no evidence of bleeding Pictures of the anastomosis were taken The scope then was removed from the patient s rectum Copious amount of irrigation was used within the peritoneal cavity Immediately at this point all complete sponge and instrument count was performed First the ostomy site was closed with interrupted figure of eight 0 Vicryl suture The peritoneum was closed with running 2 0 Vicryl suture Then the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle Subq tissue was copiously irrigated and the staples on the skin The iodoform packing was placed within the old ostomy site and then the staples on the skin as well The patient did tolerate the procedure well and will be followed during the hospitalization The left ureteral stent was removed at the end of the procedure _____ were performed Lysis of adhesions were performed Reversal of colostomy and EEA anastomosis 29 Ethicon Keywords surgery reversal of hartmann s colostomy flexible sigmoidoscopy cystoscopy ureteral stent lysis of adhesions exploratory laparotomy hartmann s colostomy abdominal wall immediately adhesions colostomy sigmoidoscopy bowel anastomosis abdominal MEDICAL_TRANSCRIPTION,Description Left little finger extensor tendon laceration Repair of left little extensor tendon Medical Specialty Surgery Sample Name Extensor Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Left little finger extensor tendon laceration POSTOPERATIVE DIAGNOSIS Left little finger extensor tendon laceration PROCEDURE PERFORMED Repair of left little extensor tendon COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Bier block INDICATIONS The patient is a 14 year old right hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon DESCRIPTION OF PROCEDURE The patient was taken to the operative room laid supine administered intervenous sedation with Bier block and prepped and draped in a sterile fashion The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon which is essentially in line with the tendon fibers This was just proximal to the PIP joint and on complete flexion of the PIP joint I did separate just a little bit that was not thought to be significantly dynamically unstable It was sutured with a single 4 0 Prolene interrupted figure of eight suture and on dynamic motion it did not separate at all The wound was irrigated and closed with 5 0 nylon interrupted sutures The patient tolerated the procedure well and was taken to the PCU in good condition Keywords surgery extensor tendon laceration bier block pip joint extensor tendon tendon repair finger laceration extensor MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy low anterior colon resection flexible colonoscopy and transverse loop colostomy and JP placement Colovesical fistula and intraperitoneal abscess Medical Specialty Surgery Sample Name Exploratory Laparotomy Colon Resection Transcription PREOPERATIVE DIAGNOSIS Colovesical fistula POSTOPERATIVE DIAGNOSES 1 Colovesical fistula 2 Intraperitoneal abscess PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Low anterior colon resection 3 Flexible colonoscopy 4 Transverse loop colostomy and JP placement ANESTHESIA General HISTORY This 74 year old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra The patient had retrograde cystogram which revealed colovesical fistula Recommendation for a surgery was made The patient was explained the risks and benefits as well as the two sons and the daughter They understood that the patient can even die from this procedure All the three procedures were explained without a colostomy with Hartmann s colostomy and with a transverse loop colostomy and out of the three procedures the patient s requested to have the loop colostomy and stated that the Hartmann s colostomy leaving the anastomosis with the risk of leaking PROCEDURE DETAILS The patient was taken to the operating room prepped and draped in the sterile fashion and was given general anesthetic An incision was performed in the midline below the umbilicus to the pubis with a 10 blade Bard Parker Electrocautery was used for hemostasis down to the fascia The fascia was grasped with Ochsner s and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery Once within the peritoneum adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall At this point immediately a small bowel was retracted cephalad The patient was taken to a slightly Trendelenburg position and the descending colon was seen The white line of Toldt was opened all the way down to the area of inflammation At this point meticulous dissection was carried to separate the small bowel from the attachment to the abscess When the small bowel was completely freed of abscess bulk of the bladder was seen anteriorly to the uterus The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized At this point the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum At this point decision to place a moist towel and retract old intestine superiorly as well as to place first self retaining retractor in the abdominal cavity with a bladder blade was placed Immediately a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA 55 balloon Roticulator was fired The specimen was cut with 10 blade Bard Parker and sent it to Pathology Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis A pursestring device was fired The staple line was cut The dilators were used using 25 and 29 then _________ 29 EEA was placed and the suture was tied At this point attention was directed down to the rectal stump where dilators 25 and 29 were passed from the anus into the rectum and then the 29 Ethicon GIA was introduced The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul de sac as well as the uterine was present in this patient Immediately the EEA was connected with a mushroom It was tied fired and a Doyen was placed above the anastomosis approximately four inches Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient s anus insufflating air No air was seen evolving from the staple line All fluid was removed and pictures of the staple line were taken The scope was removed at this point The case was passed to Dr X for repair of the vesicle fistula Dr X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon After this was performed copious amount of irrigation was used again More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area The incision was performed in the right upper quadrant This incision was performed with cutting in the cautery down into the fascia splitting the muscle and then the Penrose was passed under transverse colon and was grasped on pulling the transverse colon at the level of the skin The wire was passed under the transverse colon It was left in place Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis At this point immediately yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied Electrocautery for hemostasis and the subcutaneous tissue Copious amount of irrigation was used The skin was approximated with staples At this point immediately the wound was covered with a moist towel and decision to mature the loop colostomy was made The colostomy was opened longitudinally and then matured with interrupted 3 0 Vicryl suture through the skin edge One it was completely matured immediately the index finger was probed proximally and distally and both loops were completely opened As previously mentioned the Penrose was removed and the Bard was secured with a 3 0 nylon suture The JP was secured with 3 0 nylon suture as well At this point dressings were applied The patient tolerated the procedure well The stent from the left ureter was removed and the Foley was left in place The patient did tolerate the procedure well and will be followed up during the hospitalization Keywords surgery intraperitoneal abscess colovesical fistula low anterior colon resection flexible colonoscopy transverse loop colostomy jp placement exploratory laparotomy colon resection descending colon transverse colon colostomy colon laparotomy aparotomy fistula MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy release of small bowel obstruction and repair of periumbilical hernia Acute small bowel obstruction and incarcerated umbilical Hernia Medical Specialty Surgery Sample Name Exploratory Laparotomy Hernia Repair Transcription PREOPERATIVE DIAGNOSIS 1 Acute bowel obstruction 2 Umbilical hernia POSTOPERATIVE DIAGNOSIS 1 Acute small bowel obstruction 2 Incarcerated umbilical Hernia PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Release of small bowel obstruction 3 Repair of periumbilical hernia ANESTHESIA General with endotracheal intubation COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition SPECIMEN Hernia sac HISTORY The patient is a 98 year old female who presents from nursing home extended care facility with an incarcerated umbilical hernia intractable nausea and vomiting and a bowel obstruction Upon seeing the patient and discussing in extent with the family it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery INTRAOPERATIVE FINDINGS The patient was found to have an incarcerated umbilical hernia There was a loop of small bowel incarcerated within the hernia sac It showed signs of ecchymosis however no signs of any ischemia or necrosis It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities PROCEDURE After informed written consent risks and benefits of the procedure were explained to the patient and the patient s family The patient was brought to the operating suite After general endotracheal intubation prepped and draped in normal sterile fashion A midline incision was made around the umbilical hernia defect with a 10 blade scalpel Dissection was then carried down to the fascia Using a sharp dissection an incision was made above the defect superior to the defect entering the fascia The abdomen was entered under direct visualization The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic however no signs of ischemia were noted or necrosis The remaining of the fascia was then extended using Metzenbaum scissors The hernia sac was removed using Mayo scissors and sent off as specimen Next the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities The small bowel was then milked down removing all the fluid The bowel was decompressed distal to the obstruction Once returning the abdominal contents to the abdomen attention was next made in closing the abdomen and using 1 Vicryl suture in the figure of eight fashion the fascia was closed The umbilicus was then reapproximated to its anatomical position with a 1 Vicryl suture A 3 0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin Sterile dressings were applied The patient tolerated the procedure well and was transferred to recovery in stable condition Keywords surgery endotracheal intubation acute bowel obstruction umbilical hernia exploratory laparotomy release of small bowel obstruction repair of periumbilical hernia incarcerated umbilical hernia incarcerated bowel hernia exploratory laparotomy abdomen umbilical obstruction MEDICAL_TRANSCRIPTION,Description Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two layer closure Shave excision of the right nasal ala skin neoplasm Medical Specialty Surgery Sample Name Excision Skin Neoplasm Transcription PREOPERATIVE DIAGNOSES 1 Enlarging nevus of the left upper cheek 2 Enlarging nevus 0 5 x 1 cm left lower cheek 3 Enlarging superficial nevus 0 5 x 1 cm right nasal ala TITLE OF PROCEDURES 1 Excision of left upper cheek skin neoplasm 0 5 x 1 cm with two layer closure 2 Excision of the left lower cheek skin neoplasm 0 5 x 1 cm with a two layer plastic closure 3 Shave excision of the right nasal ala 0 5 x 1 cm skin neoplasm ANESTHESIA Local I used a total of 5 mL of 1 lidocaine with 1 100 000 epinephrine ESTIMATED BLOOD LOSS Less than 10 mL COMPLICATIONS None PROCEDURE The patient was evaluated preop and noted to be in stable condition Chart and informed consent were all reviewed preop All risks benefits and alternatives regarding the procedure have been reviewed in detail with the patient Risks including but not limited to bleeding infection scarring recurrence of the lesion need for further procedures have been all reviewed Each of these lesions appears to be benign nevi however they have been increasing in size The lesions involving the left upper and lower cheek appear to be deep These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision Each of these lesions was marked The skin was cleaned with a sterile alcohol swab Local anesthetic was infiltrated Sterile prep and drape were then performed Began first excision of the left upper cheek skin lesion This was excised with the 15 blade full thickness Once it was removed in its entirety undermining was performed and the wound was closed with 5 0 myochromic for the deep subcutaneous 5 0 nylon interrupted for the skin The lesion of the lower cheek was removed in a similar manner Again it was excised with a 15 blade with two layer plastic closure Both these lesions appear to be fairly deep nevi The right nasal ala nevus was superficially shaved using the radiofrequency wave unit Each of these lesions was sent as separate specimens The patient was discharged from my office in stable condition He had minimal blood loss The patient tolerated the procedure very well Postop care instructions were reviewed in detail We have scheduled a recheck in one week and we will make further recommendations at that time Keywords surgery enlarging nevus nevus skin neoplasm nasal ala cheek skin neoplasm shave excision superficial lesions neoplasm excision cheek MEDICAL_TRANSCRIPTION,Description Re excision of squamous cell carcinoma site right hand Medical Specialty Surgery Sample Name Excision of Squamous Cell Carcinoma Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised NAME OF OPERATION Re excision of squamous cell carcinoma site right hand ANESTHESIA Local with monitored anesthesia care INDICATIONS Patient 72 status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb The deep margin was positive Other margins were clear He was brought back for re excision PROCEDURE The patient was brought to the operating room and placed in the supine position He was given intravenous sedation The right hand was prepped and draped in the usual sterile fashion Three cubic centimeters of 1 Xylocaine mixed 50 50 with 0 5 Marcaine with epinephrine was instilled with local anesthetic around the site of the excision and the site of the cancer was re excised with an elliptical incision down to the extensor tendon sheath The tissue was passed off the field as a specimen The wound was irrigated with warm normal saline Hemostasis was assured with the electrocautery The wound was closed with running 3 0 nylon without complication The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied Keywords surgery monitored anesthesia care elliptical incision squamous cell carcinoma site squamous cell carcinoma squamous cell excision squamous carcinoma MEDICAL_TRANSCRIPTION,Description Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm Medical Specialty Surgery Sample Name Excision Keratotic Neoplasm Transcription PREOPERATIVE DIAGNOSES 1 Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm 2 Enlarging keratotic neoplasm of the left nasolabial fold measuring 0 5 x 0 5 cm 3 Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm POSTOPERATIVE DIAGNOSES 1 Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm 2 Enlarging keratotic neoplasm of the left nasolabial fold measuring 0 5 x 0 5 cm 3 Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm TITLE OF PROCEDURES 1 Excision of the left temple keratotic neoplasm final defect 1 8 x 1 5 cm with two layer plastic closure 2 Excision of the left nasolabial fold defect 0 5 x 0 5 cm with single layer closure 3 Excision of the right temple keratotic neoplasm final defect measuring 1 5 x 1 5 cm with two layer plastic closure ANESTHESIA Local using 3 mL of 1 lidocaine with 1 100 000 epinephrine ESTIMATED BLOOD LOSS Less than 30 mL COMPLICATIONS None PROCEDURE The patient was evaluated preoperatively and noted to be in stable condition Informed consent was obtained from the patient All risks benefits and alternatives regarding the surgery have been reviewed in detail with the patient This includes risks of bleeding infection scarring recurrence of lesion need for further procedures etc Each of the areas was cleaned with a sterile alcohol swab Planned excision site was marked with a marking pen Local anesthetic was infiltrated Sterile prep and drape were then performed We began first with excision of the left temple followed by the left nasolabial and right temple lesions The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm However it is somewhat deeper than the standard seborrheic keratosis The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region Once this was removed wide undermining was performed and the wound was closed in a two layer fashion using 5 0 myochromic for the deep subcutaneous and 5 0 nylon for the skin Excision of left cheek was a keratotic nevus It was excised with a defect 0 5 x 0 5 cm It was closed in a single layer fashion 5 0 nylon The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension Once it was excised full thickness the defect measure 1 5 x 1 5 cm Wide undermine was performed and it was closed in a two layer fashion using 5 0 myochromic for the deep subcutaneous 5 0 nylon that was used to close skin Sterile dressing was applied afterwards The patient was discharged in stable condition Postop care instructions reviewed in detail She is scheduled with me in one week and we will make further recommendations at that time Keywords surgery keratotic lesion keratotic neoplasm seborrheic keratotic neoplasm seborrheic keratotic neoplasm nasolabial two layer plastic closure nasolabial fold excision MEDICAL_TRANSCRIPTION,Description Excision of soft tissue mass on the right flank This 54 year old male was evaluated in the office with a large right flank mass He would like to have this removed Medical Specialty Surgery Sample Name Excision Soft Tissue Mass Transcription PREOPERATIVE DIAGNOSIS Right flank subcutaneous mass POSTOPERATIVE DIAGNOSIS Right flank subcutaneous mass PROCEDURE PERFORMED Excision of soft tissue mass on the right flank ANESTHESIA Sedation with local INDICATIONS FOR PROCEDURE This 54 year old male was evaluated in the office with a large right flank mass He would like to have this removed DESCRIPTION OF PROCEDURE Consent was obtained after all risks and benefits were described The patient was brought back into the operating room The aforementioned anesthesia was given Once the patient was properly anesthetized the area was prepped and draped in the sterile fashion With the area properly prepped and draped a needle was used to localize the area directly above the mass on the patient s right flank Then a 10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass The incision was extended down using electrocautery The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle The mass was sent off to Pathology for investigation Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a 3 0 Vicryl suture in interrupted fashion and the skin was reapproximated using a 4 0 undyed Vicryl suture in a running subcuticular fashion The patient s wound was cleaned Steri Strips were placed and sterile dressings were placed on top of this The patient tolerated the procedure well and will reevaluate in the office in one week s time Keywords surgery electrocautery soft tissue mass subcutaneous excision MEDICAL_TRANSCRIPTION,Description Leaking anastomosis from esophagogastrectomy Exploratory laparotomy and drainage of intra abdominal abscesses with control of leakage Medical Specialty Surgery Sample Name Exploratory Laparotomy Transcription PREOPERATIVE DIAGNOSIS Leaking anastomosis from esophagogastrectomy POSTOPERATIVE DIAGNOSIS Leaking anastomosis from esophagogastrectomy PROCEDURE Exploratory laparotomy and drainage of intra abdominal abscesses with control of leakage COMPLICATIONS None ANESTHESIA General oroendotracheal intubation PROCEDURE After adequate general anesthesia was administered the patient s abdomen was prepped and draped aseptically Sutures and staples were removed The abdomen was opened The were some very early stage adhesions that were easy to separate Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon This was retracted caudally to expose the stomach There were a number of adhesions to the stomach These were carefully dissected to expose initially the closure over the gastrotomy site Initially this looked like this was leaking but it was actually found to be intact The pyloroplasty was identified and also found to be intact with no evidence of leakage Further dissection up toward the hiatus revealed an abscess collection This was sent for culture and sensitivity and was aspirated and lavaged Cavity tracked up toward the hiatus Stomach itself appeared viable there was no necrotic sections Upper apex of the stomach was felt to be viable also I did not pull the stomach and esophagus down into the abdomen from the mediastinum but placed a sucker up into the mediastinum where additional turbid fluid was identified Carefully placed a 10 mm flat Jackson Pratt drain into the mediastinum through the hiatus to control this area of leakage Two additional Jackson Pratt drains were placed essentially through the gastrohepatic omentum This was the area that most of the drainage had collected in As I had previously discussed with Dr Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair Once the drains were secured they were brought out through the anterior abdominal wall and secured with 3 0 silk sutures and secured to bulb suction The midline fascia was then closed using running 2 Prolene sutures bolstered with retention sutures Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples Dry gauze dressing was placed The patient tolerated the procedure well there were no complications Keywords surgery drainage oroendotracheal intubation intra abdominal abdominal abscesses jackson pratt exploratory laparotomy anastomosis esophagogastrectomy mediastinum abdomen stomach MEDICAL_TRANSCRIPTION,Description Functional endoscopic sinus surgery bilateral maxillary antrostomy bilateral total ethmoidectomy bilateral nasal polypectomy and right middle turbinate reduction Medical Specialty Surgery Sample Name Ethmoidectomy Nasal Polypectomy Transcription PROCEDURES PERFORMED 1 Functional endoscopic sinus surgery 2 Bilateral maxillary antrostomy 3 Bilateral total ethmoidectomy 4 Bilateral nasal polypectomy 5 Right middle turbinate reduction ANESTHESIA General endotracheal tube BLOOD LOSS Approximately 50 cc INDICATION This is a 48 year old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally PROCEDURE After all risks benefits and alternatives have been discussed with the patient in detail informed consent was obtained The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10 cocaine solution were inserted into the nasal cavity The nasal septum as well as the turbinates were then localized with a mixture of 1 lidocaine with 1 100 000 epinephrine solution The patient was then prepped and draped in the usual fashion Attention was directed first to the left nasal cavity A zero degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate There was also polypoid disease present within the left middle meatus Nasopharynx was visualized with a patent eustachian tube At this point the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate The ostium to the sphenoid sinus was visualized and was not entered At this point the left middle turbinate was localized and then medialized with the use of a freer elevator A ball tip probe was then used to localize the openings for the natural maxillary ostium Side biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider The opening of the maxillary sinus was visualized The posterior fontanelle was taken down with the use of straight line forceps It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident The maxillary sinus ostia was then suctioned with Olive tip suction and maxillary wash was performed The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient s eyes for any vibration All polypoid tissue was collected in the microdebrider and sent as a surgical specimen Once all polypoid tissue has been removed the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes Attention was then directed to the right nasal cavity Again a sinus endoscope was inserted Inspection revealed a grossly hypertrophied turbinate It was felt that this enlarged and polypoid turbinate was contributing the patient s symptoms Therefore the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate which was then resected with use of side biting scissors as well the Takahashi forceps Sinus endoscope was then inserted all the way down through the nasopharynx Again the eustachian tube was visualized without any obstructing lesions or masses Upon retraction there was again polypoid tissue noted within the ethmoid sinuses The ball tip probe was again used to locate the right maxillary ostium The side biting forceps was used further take down the uncinate process The maxillary ostium was then widened with use of a XPS microdebrider A maxillary sinus wash was then performed Now the attention was directed to the ethmoid air cells It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient s eye Once all polypoid tissue have been removed some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner Once all bleeding has been controlled all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room At this point the procedure was felt to be complete The patient was awakened and taken to the recovery room without incident Keywords surgery endoscopic sinus surgery maxillary antrostomy ethmoidectomy nasal polypectomy turbinate reduction sinus surgery sinus endoscope maxillary sinus nasal cavity polypoid tissue sinus maxillary turbinate polypoid nasal total ostium microdebrider MEDICAL_TRANSCRIPTION,Description Esophagoscopy with removal of foreign body Esophageal foreign body no associated comorbidities are noted Medical Specialty Surgery Sample Name Esophagoscopy Foreign Body Removal 1 Transcription PRIMARY DIAGNOSIS Esophageal foreign body no associated comorbidities are noted PROCEDURE Esophagoscopy with removal of foreign body CPT CODE 43215 PRINCIPAL DIAGNOSIS Esophageal foreign body ICD 9 code 935 1 DESCRIPTION OF PROCEDURE Under general anesthesia flexible EGD was performed Esophagus was visualized The quarter was visualized at the aortic knob was removed with grasper Estimated blood loss 0 Intravenous fluids during time of procedure 100 mL No tissues No complications The patient tolerated the procedure well Dr X Pipkin attending pediatric surgeon was present throughout the entire procedure The patient was transferred from OR to PACU in stable condition Keywords surgery esophagus foreign body esophagoscopy esophageal MEDICAL_TRANSCRIPTION,Description Excision of bilateral chronic hydradenitis Medical Specialty Surgery Sample Name Excision Hydradenitis Transcription PREOPERATIVE DIAGNOSIS Bilateral hydradenitis chronic POSTOPERATIVE DIAGNOSIS Bilateral hydradenitis chronic NAME OF OPERATION Excision of bilateral chronic hydradenitis ANESTHESIA Local FINDINGS This patient had previously had excision of hydradenitis However she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis This now is controlled and it was found to be suitable for excision There was an area in each axilla which needed to be excised PROCEDURE Under local infiltration and after routine prepping and draping an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis This wound was then irrigated with saline The deeper layers were closed using interrupted 3 0 Vicryl The skin was closed using interrupted 5 0 nylon Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side This appeared to encompass all of the active area of hydradenitis The needle counts were all correct No intraoperative complications were encountered Dressings were applied and the patient was returned to the recovery room in satisfactory condition Keywords surgery hydradenitis elliptical incision bilateral hydradenitis chronic hydradenitis axilla excision chronic MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with pseudo and esophageal biopsy Hiatal hernia and reflux esophagitis The patient is a 52 year old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy with Biopsies 2 Transcription PREOPERATIVE DIAGNOSIS Refractory dyspepsia POSTOPERATIVE DIAGNOSIS 1 Hiatal hernia 2 Reflux esophagitis PROCEDURE PERFORMED Esophagogastroduodenoscopy with pseudo and esophageal biopsy ANESTHESIA Conscious sedation with Demerol and Versed SPECIMEN Esophageal biopsy COMPLICATIONS None HISTORY The patient is a 52 year old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough She has been on multiple medical regimens and continues with dyspeptic symptoms PROCEDURE After proper informed consent was obtained the patient was brought to the endoscopy suite She was placed in the left lateral position and was given IV Demerol and Versed for sedation When adequate level of sedation achieved the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated At the GE junction a hiatal hernia was present There were mild inflammatory changes consistent with reflux esophagitis The scope was then passed into the stomach It was insufflated and the scope was coursed along the greater curvature to the antrum The pylorus was patent There was evidence of bile reflux in the antrum The duodenal bulb and sweep were examined and were without evidence of mass ulceration or inflammation The scope was then brought back into the antrum A retroflexion was attempted multiple times however the patient was having difficulty holding the air and adequate retroflexion view was not visualized The gastroscope was then slowly withdrawn There were no other abnormalities noted in the fundus or body Once again at the GE junction esophageal biopsy was taken The scope was then completely withdrawn The patient tolerated the procedure and was transferred to the recovery room in stable condition She will return to the General Medical Floor We will continue b i d proton pump inhibitor therapy as well as dietary restrictions She should also attempt significant weight loss Keywords surgery refractory dyspepsia hiatal hernia reflux esophagitis esophagogastroduodenoscopy esophageal pseudo esophageal biopsy ge junction hiatal hernia esophagitis antrum gerd MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with gastric biopsies Antral erythema 2 cm polypoid pyloric channel tissue questionable inflammatory polyp which was biopsied duodenal erythema and erosion Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy with Biopsies 1 Transcription PROCEDURE Esophagogastroduodenoscopy with gastric biopsies INDICATION Abdominal pain FINDINGS Antral erythema 2 cm polypoid pyloric channel tissue questionable inflammatory polyp which was biopsied duodenal erythema and erosion MEDICATIONS Fentanyl 200 mcg and versed 6 mg SCOPE GIF Q180 PROCEDURE DETAIL Following the preprocedure patient assessment the procedure goals risks including bleeding perforation and side effects of medications and alternatives were reviewed Questions were answered Pause preprocedure was performed Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty The esophagus appeared to have normal motility and mucosa Regular Z line was located at 44 cm from incisors No erosion or ulceration No esophagitis Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus There was pyloric channel and antral erythema but no visible erosion or ulceration There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp This was biopsied and was placed separately in bottle 2 Random gastric biopsies from antrum incisura and body were obtained and placed in separate jar bottle 1 No active ulceration was found Upon entering the duodenal bulb there was extensive erythema and mild erosions less than 3 mm in length in first portion of duodenum duodenal bulb and junction of first and second part of the duodenum Postbulbar duodenum looked normal The patient was assessed upon completion of the procedure Okay to discharge once criteria met Follow up with primary care physician I met with patient afterward and discussed with him avoiding any nonsteroidal anti inflammatory medication Await biopsy results Keywords surgery gastric biopsies duodenal erythema inflammatory polyp pyloric channel tissue pyloric channel esophagogastroduodenoscopy pyloric duodenal duodenum polypoid MEDICAL_TRANSCRIPTION,Description Esophageal foreign body US penny Esophagoscopy with foreign body removal The patient had a penny lodged in the proximal esophagus in the typical location Medical Specialty Surgery Sample Name Esophagoscopy Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Esophageal foreign body POSTOPERATIVE DIAGNOSIS Esophageal foreign body US penny PROCEDURE Esophagoscopy with foreign body removal ANESTHESIA General INDICATIONS The patient is a 17 month old baby girl with biliary atresia who had a delayed diagnosis and a late attempted Kasai portoenterostomy which failed The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD The patient is fed by mouth and also with nasogastric enteral feeding supplements She has had an __________ cough and relatively disinterested in oral intake for the past month She was recently in the GI Clinic and an x ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted Based on the history it is quite possible this coin has been there close to a month She is brought to the operating room now for attempted removal I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time Hopefully there will be no coin migration or significant irrigation that would require prolonged hospitalization OPERATIVE FINDINGS The patient had a penny lodged in the proximal esophagus in the typical location There was no evidence of external migration and surrounding irritation was noted but did not appear to be excessive The coin actually came out with relative ease after which endoscopically identified DESCRIPTION OF OPERATION The patient came to the operating room and had induction of general anesthesia She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications After her endotracheal tube was placed and securely taped to the left side of her mouth I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism A rigid esophagoscope was then inserted into the proximal esophagus and the scope was gradually advanced with the lumen directly in frontal view This was facilitated by the nasoenteric feeding tube that was in place which I followed carefully until the edge of the coin could be seen At this location there was quite a bit of surrounding mucosal inflammation but the coin edge could be clearly seen and was secured with the coin grasping forceps I then withdrew the scope forceps and the coin as one unit and it was easily retrieved The patient tolerated the procedure well There were no intraoperative complications There was only one single coin noted and she was awakened and taken to the recovery room in good condition Keywords surgery portoenterostomy foreign body removal proximal esophagus coin esophagoscopy esophageal esophagus MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement Malnutrition and dysphagia with two antral polyps and large hiatal hernia Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 9 Transcription PREOPERATIVE DIAGNOSES Malnutrition and dysphagia POSTOPERATIVE DIAGNOSES Malnutrition and dysphagia with two antral polyps and large hiatal hernia PROCEDURES Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement ANESTHESIA IV sedation 1 Xylocaine locally CONDITION Stable OPERATIVE NOTE IN DETAIL After risk of operation was explained to this patient s family consent was obtained for surgery The patient was brought to the GI lab There she was placed in partial left lateral decubitus position She was given IV sedation by Anesthesia Her abdomen was prepped with alcohol and then Betadine Flexible gastroscope was passed down the esophagus through the stomach into the duodenum No lesions were noted in the duodenum There appeared to be a few polyps in the antral area two in the antrum Actually one appeared to be almost covering the pylorus The scope was withdrawn back into the antrum On retroflexion we could see a large hiatal hernia No other lesions were noted Biopsy was taken of one of the polyps The scope was left in position Anterior abdominal wall was prepped with Betadine 1 Xylocaine was injected in the left epigastric area A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall into the stomach followed by a thread was grasped with a snare using the gastroscope brought out through the patient s mouth Tied to the gastrostomy tube which was then pulled down and up through the anterior abdominal wall It was held in position with a dressing and a stent A connector was applied to the cut gastrostomy tube held in place with a 2 0 silk ligature The patient tolerated the procedure well She was returned to the floor in stable condition Keywords surgery antral polyps gastrostomy endoscopic gastrostomy hiatal hernia abdominal wall gastrostomy tube esophagogastroduodenoscopy malnutrition dysphagia abdominal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with photo Insertion of a percutaneous endoscopic gastrostomy tube Neuromuscular dysphagia Protein calorie malnutrition Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy Gastrostomy Tube Insertion Transcription PREOPERATIVE DIAGNOSES 1 Neuromuscular dysphagia 2 Protein calorie malnutrition POSTOPERATIVE DIAGNOSES 1 Neuromuscular dysphagia 2 Protein calorie malnutrition PROCEDURES PERFORMED 1 Esophagogastroduodenoscopy with photo 2 Insertion of a percutaneous endoscopic gastrostomy tube ANESTHESIA IV sedation and local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well without difficulty BRIEF HISTORY The patient is a 50 year old African American male who presented to ABCD General Hospital on 08 18 2003 secondary to right hemiparesis from a CVA The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator dependency with respiratory failure The patient also had neuromuscular dysfunction After extended period of time per the patient s family request and requested by the ICU staff decision to place a feeding tube was decided and scheduled for today INTRAOPERATIVE FINDINGS The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules PROCEDURE After informed written consent the risks and benefits of the procedure were explained to the patient and the patient s family First the EGD was to be performed The Olympus endoscope was inserted through the mouth oropharynx and into the esophagus Esophagitis was noted The scope was then passed through the esophagus into the stomach The cardia fundus body and antrum of the stomach were visualized There was evidence of gastritis The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus Next attention was made to transilluminating the anterior abdominal wall for the PEG placement The skin was then anesthetized with 1 lidocaine The finder needle was then inserted under direct visualization The catheter was then grasped via the endoscope and the wire was pulled back up through the patient s mouth The Ponsky PEG tube was attached to the wire A skin nick was made with a 11 blade scalpel The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position The endoscope was then replaced confirming position Photograph was taken The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well We will begin tube feeds later this afternoon Keywords surgery neuromuscular dysphagia protein calorie malnutrition esophagogastroduodenoscopy endoscopic gastrostomy percutaneous gastrostomy tube percutaneous endoscopic gastrostomy tube protein calorie malnutrition abdominal wall dysphagia stomach abdominal neuromuscular tube MEDICAL_TRANSCRIPTION,Description Positive peptic ulcer disease Gastritis Esophagogastroduodenoscopy with photography and biopsy The patient had a history of peptic ulcer disease epigastric abdominal pain x2 months being evaluated at this time for ulcer disease Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 7 Transcription PREOPERATIVE DIAGNOSIS Positive peptic ulcer disease POSTOPERATIVE DIAGNOSIS Gastritis PROCEDURE PERFORMED Esophagogastroduodenoscopy with photography and biopsy GROSS FINDINGS The patient had a history of peptic ulcer disease epigastric abdominal pain x2 months being evaluated at this time for ulcer disease Upon endoscopy gastroesophageal junction was at 40 cm no esophageal tumor varices strictures masses or no reflux esophagitis was noted Examination of the stomach reveals mild inflammation of the antrum of the stomach no ulcers erosions tumors or masses The profundus and the cardia of the stomach were unremarkable The pylorus was concentric The duodenal bulb and sweep with no inflammation tumors or masses OPERATIVE PROCEDURE The patient taken to the Endoscopy Suite prepped and draped in the left lateral decubitus position She was given IV sedation using Demerol and Versed Olympus videoscope was inserted in the hypopharynx upon deglutition passed into the esophagus Using air insufflation the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep The above gross findings noted The panendoscope was withdrawn back from the stomach deflected upon itself The lesser curve fundus and cardiac were well visualized Upon examination of these areas panendoscope was returned to midline Photographs and biopsies were obtained of the antrum of the stomach Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel Photographs and biopsies were obtained as appropriate The patient is sent to recovery room in stable condition Keywords surgery antrum esophageal tumor varices strictures masses duodenal bulb peptic ulcer duodenal esophagus esophagogastroduodenoscopy panendoscope peptic inflammation ulcer disease stomach MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsies Gastroesophageal reflux disease chronic dyspepsia alkaline reflux gastritis gastroparesis probable Billroth II anastomosis and status post Whipple s pancreaticoduodenectomy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy with Biopsies Transcription PREOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Chronic dyspepsia POSTOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Chronic dyspepsia 3 Alkaline reflux gastritis 4 Gastroparesis 5 Probable Billroth II anastomosis 6 Status post Whipple s pancreaticoduodenectomy PROCEDURE PERFORMED Esophagogastroduodenoscopy with biopsies INDICATIONS FOR PROCEDURE This is a 55 year old African American female who had undergone Whipple s procedure approximately five to six years ago for a benign pancreatic mass The patient has pancreatic insufficiency and is already on replacement She is currently using Nexium She has continued postprandial dyspepsia and reflux symptoms To evaluate this the patient was boarded for EGD The patient gave informed consent for the procedure GROSS FINDINGS At the time of EGD the patient was found to have alkaline reflux gastritis There was no evidence of distal esophagitis Gastroparesis was seen as there was retained fluid in the small intestine The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy Biopsies were taken and further recommendations will follow PROCEDURE The patient was taken to the Endoscopy Suite The heart and lungs examination were unremarkable The vital signs were monitored and found to be stable throughout the procedure The patient s oropharynx was anesthetized with Cetacaine spray She was placed in left lateral position The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx GE junction was in normal position There was no evidence of any hiatal hernia There was no evidence of distal esophagitis The gastric remnant was entered It was noted to be inflamed with alkaline reflux gastritis The anastomosis was open and patent The small intestine was entered There was retained fluid material in the stomach and small intestine and _______ gastroparesis Biopsies were performed Insufflated air was removed with withdrawal of the scope The patient s diet will be adjusted to postgastrectomy type diet Biopsies performed Diet will be reviewed The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis Reglan will also be added Further recommendations will follow Keywords surgery gastroesophageal reflux disease chronic dyspepsia alkaline reflux gastritis gastroparesis whipple s pancreaticoduodenectomy billroth ii anastomosis gastroesophageal reflux alkaline reflux reflux gastritis gif esophagogastroduodenoscopy dyspepsia gastritis anastomosis pancreaticoduodenectomy biopsies alkaline reflux MEDICAL_TRANSCRIPTION,Description Chronic abdominal pain and heme positive stool antral gastritis and duodenal polyp Esophagogastroduodenoscopy with photos and antral biopsy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 8 Transcription PREOPERATIVE DIAGNOSIS Chronic abdominal pain and heme positive stool POSTOPERATIVE DIAGNOSES 1 Antral gastritis 2 Duodenal polyp PROCEDURE PERFORMED Esophagogastroduodenoscopy with photos and antral biopsy ANESTHESIA Demerol and Versed DESCRIPTION OF PROCEDURE Consent was obtained after all risks and benefits were described The patient was brought back into the Endoscopy Suite The aforementioned anesthesia was given Once the patient was properly anesthetized bite block was placed in the patient s mouth Then the patient was given the aforementioned anesthesia Once he was properly anesthetized the endoscope was placed in the patient s mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach The air was insufflated down The scope was passed down to the level of the antrum where there was some evidence of gastritis seen The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen The scope was pulled back into the stomach in order to flex upon itself and straightened out Biopsies were taken for CLO and histology of the antrum The scope was pulled back The junction was visualized No other masses or lesions were seen The scope was removed The patient tolerated the procedure well We will recommend the patient be on some type of a H2 blocker Further recommendations to follow Keywords surgery endoscopy gastritis clo histology antrum heme positive stool esophagogastroduodenoscopy duodenal polyp antral MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 6 Transcription PROCEDURE IN DETAIL Following premedication with Vistaril 50 mg and Atropine 0 4 mg IM the patient received Versed 5 0 mg intravenously after Cetacaine spray to the posterior palate The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum The upper mid and lower portions of the esophagus the lesser and greater curves of the stomach anterior and posterior walls body and antrum pylorus duodenal bulb and duodenum were all normal No evidence of friability ulceration or tumor mass was encountered The instrument was withdrawn to the antrum and biopsies taken for CLO testing and then the instrument removed Keywords surgery cetacaine pylorus antrum duodenum upper esophagus esophagogastroduodenoscopy descending esophagusNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 4 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy INDICATIONS FOR PROCEDURE A 17 year old with history of 40 pound weight loss abdominal pain status post appendectomy with recurrent abscess formation and drainage Currently he has a fistula from his anterior abdominal wall out It does not appear to connect to the gastrointestinal tract but merely connect from the ventral surface of the rectus muscles out the abdominal wall CT scans show thickened terminal ileum which suggest that we are dealing with Crohn s disease Endoscopy is being done to evaluate for Crohn s disease MEDICATIONS General anesthesia INSTRUMENT Olympus GIF 160 and PCF 160 COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 5 mL FINDINGS With the patient in the supine position intubated under general anesthesia The endoscope was inserted without difficulty into the hypopharynx The scope was advanced down the esophagus which had normal mucosal coloration and vascular pattern Lower esophageal sphincter was located at 40 cm from the central incisors It appeared normal and appeared to function normally The endoscope was advanced into the stomach which was distended with excess air Rugal folds were flattened completely There were multiple superficial erosions scattered throughout the fundus body and antral portions consistent with Crohn s involvement of the stomach The endoscope was advanced through normal appearing pyloric valve into the first second and third portion of the duodenum which had normal mucosal coloration and fold pattern Biopsies were obtained x2 in the second portion of the duodenum antrum body and distal esophagus at 37 cm from the central incisors for histology Two additional biopsies were obtained in the antrum for CLO testing Excess air was evacuated from the stomach The scope was removed from the patient who tolerated that part of the procedure well The patient was turned and scope was changed for colonoscopy Prior to colonoscopy it was noted that there was a perianal fistula at 7 o clock The colonoscope was then inserted into the anal verge The colonic clean out was excellent The scope was advanced without difficulty to the cecum The cecal area had multiple ulcers with exudate The ileocecal valve was markedly distorted Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending transverse descending sigmoid and rectum The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon Biopsies were obtained in the cecum at 65 cm transverse colon 50 cm rectosigmoid 20 cm and rectum at 5 cm No fistulas were noted in the colon Excess air was evacuated from the colon The scope was removed The patient tolerated the procedure well and was taken to recovery in satisfactory condition IMPRESSION Normal esophagus and duodenum There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve All these findings are consistent with Crohn s disease PLAN Begin prednisone 30 mg p o daily Await PPD results and chest x ray results as well as cocci serology results If these are normal then we would recommend Remicade 5 mg kg IV infusion We would start Modulon 50 mL h for 20 hours to reverse the malnutrition state of this boy Check CMP and phosphate every Monday Wednesday and Friday for receding syndrome noted by following potassium and phosphate We will discuss with Dr X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy If he has no stricture formation in the small bowel we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn s in the small intestine that we cannot visualize with endoscopy Keywords surgery olympus gif 160 pcf 160 endoscopy crohn s disease aphthous ulcers esophagogastroduodenoscopy endoscope esophagus duodenum mucosal stomach biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy The Olympus video panendoscope was advanced under direct vision into the esophagus The esophagus was normal in appearance and configuration The gastroesophageal junction was normal Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 5 Transcription MEDICATIONS 1 Versed intravenously 2 Demerol intravenously DESCRIPTION OF THE PROCEDURE After informed consent the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx The patient was sedated with the above medications The Olympus video panendoscope was advanced under direct vision into the esophagus The esophagus was normal in appearance and configuration The gastroesophageal junction was normal The scope was advanced into the stomach where the fundic pool was aspirated and the stomach was insufflated with air The gastric mucosa appeared normal The pylorus was normal The scope was advanced through the pylorus into the duodenal bulb which was normal then into the second part of the duodenum which was normal as well The scope was pulled back into the stomach Retroflexed view showed a normal incisura lesser curvature cardia and fundus The scope was straightened out the air removed and the scope withdrawn The patient tolerated the procedure well There were no apparent complications Keywords surgery duodenal bulb gastric mucosa olympus video video panendoscope gastroesophageal junction esophagogastroduodenoscopy gastroesophageal pylorus stomach esophagus scopeNOTE MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy performed in the emergency department Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 13 Transcription PROCEDURE PERFORMED Esophagogastroduodenoscopy performed in the emergency department INDICATION Melena acute upper GI bleed anemia and history of cirrhosis and varices FINAL IMPRESSION 1 Scope passage massive liquid in stomach with some fresh blood near the fundus unable to identify source due to gastric contents 2 Endoscopy following erythromycin demonstrated grade I esophageal varices No stigmata of active bleeding Small amount of fresh blood within the hiatal hernia No definite source of bleeding seen PLAN 1 Repeat EGD tomorrow morning following aggressive resuscitation and transfusion 2 Proton pump inhibitor drip 3 Octreotide drip 4 ICU bed PROCEDURE DETAILS Prior to the procedure physical exam was stable During the procedure vital signs remained within normal limits Prior to sedation informed consent was obtained Risks benefits and alternatives including but not limited to risk of bleeding infection perforation adverse reaction to medication failure to identify pathology pancreatitis and death explained to the patient and his wife who accepted all risks The patient was prepped in the left lateral position IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin Scope tip of the Olympus gastroscope was passed into the esophagus Proximal middle and distal thirds of the esophagus were well visualized There was fresh blood in the esophagus which was washed thoroughly but no source was seen No evidence of varices was seen The stomach was entered The stomach was filled with very large clot and fresh blood and liquid which could not be suctioned due to the clot burden There was a small amount of bright red blood near the fundus but a source could not be identified due to the clot burden Because of this the gastroscope was withdrawn The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later the scope was repassed On the second look the esophagus was cleared The liquid gastric contents were cleared There was still a moderate amount of clot burden in the stomach but no active bleeding was seen There was a small grade I esophageal varices but no stigmata of bleed There was also a small amount of fresh blood within the hiatal hernia but no source of bleeding was identified The patient was hemodynamically stable therefore a decision was made for a second look in the morning The scope was withdrawn and air was suctioned The patient tolerated the procedure well and was sent to recovery without immediate complications Keywords surgery gi bleed anemia cirrhosis stomach fundus hiatal hernia esophagogastroduodenoscopy erythromycin varices esophagus MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 3 Transcription PROCEDURES Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy REASON FOR PROCEDURE Child with abdominal pain and rectal bleeding Rule out inflammatory bowel disease allergic enterocolitis rectal polyps and rectal vascular malformations CONSENT History and physical examination was performed The procedure indications alternatives available and complications i e bleeding perforation infection adverse medication reaction the possible need for blood transfusion and surgery should a complication occur were discussed with the parents who understood and indicated this Opportunity for questions was provided and informed consent was obtained MEDICATION General anesthesia INSTRUMENT Olympus GIF 160 COMPLICATIONS None FINDINGS With the patient in the supine position and intubated the endoscope was inserted without difficulty into the hypopharynx The esophageal mucosa and vascular pattern appeared normal The lower esophageal sphincter was located at 25 cm from the central incisors It appeared normal A Z line was identified within the lower esophageal sphincter The endoscope was advanced into the stomach which distended with excess air Rugal folds flattened completely Gastric mucosa appeared normal throughout No hiatal hernia was noted Pyloric valve appeared normal The endoscope was advanced into the first second and third portions of duodenum which had normal mucosa coloration and fold pattern Biopsies were obtained x2 in the second portion of duodenum antrum and distal esophagus at 22 cm from the central incisors for histology Additional 2 biopsies were obtained for CLO testing in the antrum Excess air was evacuated from the stomach The scope was removed from the patient who tolerated that part of procedure well The patient was turned and the scope was advanced with some difficulty to the terminal ileum The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile appearing polyp was noted Biopsies were obtained x2 in the terminal ileum cecum ascending colon transverse colon descending colon sigmoid and rectum Then the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2 second bursts x3 The polyp was severed There was no bleeding at the stalk after removal of the polyp head The polyp head was removed by suction Excess air was evacuated from the colon The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition Estimated blood loss approximately 5 mL IMPRESSION Normal esophagus stomach duodenum and colon as well as terminal ileum except for a 1 x 1 cm rectal polyp which was removed successfully by polypectomy snare PLAN Histologic evaluation and CLO testing I will contact the parents next week with biopsy results and further management plans will be discussed at that time Keywords surgery esophagus stomach duodenum rectal polyp polypectomy snare olympus gif 160 endoscope was advanced clo testing polyp head terminal ileum polypectomy biopsies esophagogastroduodenoscopy ileum mucosa colonoscopy MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 2 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy REASON FOR PROCEDURE The child with history of irritability and diarrhea with gastroesophageal reflux Rule out reflux esophagitis allergic enteritis and ulcer disease as well as celiac disease He has been on Prevacid 7 5 mg p o b i d with suboptimal control of this irritability Consent history and physical examinations were performed The procedure indications alternatives available and complications i e bleeding perforation infection adverse medication reactions possible need for blood transfusion and surgery associated complication occur were discussed with the mother who understood and indicated this Opportunity for questions was provided and informed consent was obtained MEDICATIONS General anesthesia INSTRUMENT Olympus GIF XQ 160 COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 5 mL FINDINGS With the patient in the supine position intubated under general anesthesia the endoscope was inserted without difficulty into the hypopharynx The proximal mid and distal esophagus had normal mucosal coloration and vascular pattern Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors A Z line was identified within the lower esophageal sphincter The endoscope was advanced into the stomach which was distended with excess air The rugal folds flattened completely The gastric mucosa was entirely normal No hiatal hernia was seen and the pyloric valve appeared normal The endoscope was advanced into first second and third portion of the duodenum which had normal mucosal coloration and fold pattern Ampule of Vater was identified and found to be normal Biopsies were obtained x2 in the second portion of duodenum antrum and distal esophagus at 22 cm from the central incisors for histology Additional two antral biopsies were obtained for CLO testing Excess air was evacuated from the stomach The scope was removed from the patient who tolerated the procedure well The patient was taken to recovery room in satisfactory condition IMPRESSION Normal esophagus stomach and duodenum PLAN Histologic evaluation and CLO testing Continue Prevacid 7 5 mg p o b i d I will contact the parents next week with biopsy results and further management plans will be discussed at that time Keywords surgery olympus gif xq 160 diarrhea gastroesophageal esophagitis reflux clo testing esophagogastroduodenoscopy with biopsy endoscope esophagus stomach duodenum esophagogastroduodenoscopy MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy photography and biopsy Gastroesophageal reflux disease hiatal hernia and enterogastritis Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 12 Transcription PREOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Hiatal hernia POSTOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Hiatal hernia 3 Enterogastritis PROCEDURE PERFORMED Esophagogastroduodenoscopy photography and biopsy GROSS FINDINGS The patient has a history of epigastric abdominal pain persistent in nature She has a history of severe gastroesophageal reflux disease takes Pepcid frequently She has had a history of hiatal hernia She is being evaluated at this time for disease process She does not have much response from Protonix Upon endoscopy the gastroesophageal junction is approximately 40 cm There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia There is no advancement of the gastric mucosa up into the lower one third of the esophagus However there appeared to be inflammation as stated previously in the gastroesophageal junction There was some mild inflammation at the antrum of the stomach The fundus of the stomach was within normal limits The cardia showed some laxity to the lower esophageal sphincter The pylorus is concentric The duodenal bulb and sweep are within normal limits No ulcers or erosions OPERATIVE PROCEDURE The patient is taken to the Endoscopy Suite prepped and draped in the left lateral decubitus position The patient was given IV sedation using Demerol and Versed Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus Using air insufflation panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted Panendoscope was slowly withdrawn carefully examining the lumen of the bowel Photographs were taken with the pathology present Biopsy was obtained of the antrum of the stomach and also CLO test The biopsy is also obtained of the gastroesophageal junction at 12 3 6 and 9 o clock positions to rule out occult Barrett s esophagitis Air was aspirated from the stomach and the panendoscope was removed The patient sent to recovery room in stable condition Keywords surgery biopsy gastroesophageal reflux gastroesophageal reflux disease duodenal bulb gastroesophageal junction hiatal hernia enterogastritis endoscopy esophagogastroduodenoscopy gastroesophageal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with bile aspirate Recurrent right upper quadrant pain with failure of antacid medical therapy Normal esophageal gastroduodenoscopy Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 11 Transcription PREOPERATIVE DIAGNOSIS Recurrent right upper quadrant pain with failure of antacid medical therapy POSTOPERATIVE DIAGNOSIS Normal esophageal gastroduodenoscopy PROCEDURE PERFORMED Esophagogastroduodenoscopy with bile aspirate ANESTHESIA IV Demerol and Versed in titrated fashion INDICATIONS This 41 year old female presents to surgical office with history of recurrent right upper quadrant abdominal pain Despite antacid therapy the patient s pain has continued Additional findings were concerning with possibility of a biliary etiology The patient was explained the risks and benefits of an EGD as well as a Meltzer Lyon test where upon bile aspiration was performed The patient agreed to the procedure and informed consent was obtained GROSS FINDINGS No evidence of neoplasia mucosal change or ulcer on examination Aspiration of the bile was done after the administration of 3 mcg of Kinevac PROCEDURE DETAILS The patient was placed in the supine position After appropriate anesthesia was obtained an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum Prior to this 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile At this time the patient as well complained of epigastric discomfort and nausea This pain was similar to her previous pain Bile was aspirated with a trap to enable the collection of the fluid This fluid was then sent to lab for evaluation for crystals Next photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________ gastroscope was retracted The gastroesophageal junction was noted at 20 cm No other evidence of disease was appreciated here Retraction of the gastroscope backed through the esophagus off the oropharynx removed from the patient The patient tolerated the procedure well We will await evaluation of bile aspirate Keywords surgery bile aspirate esophageal gastroduodenoscopy kinevac oropharynx esophagogastroduodenoscopy gastroscope MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy a 1 year 10 month old with a history of dysphagia to solids Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 1 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy PREOPERATIVE DIAGNOSIS A 1 year 10 month old with a history of dysphagia to solids The procedure was done to rule out organic disease POSTOPERATIVE DIAGNOSES Loose lower esophageal sphincter and duodenal ulcers CONSENT The consent is signed MEDICATIONS The procedure was done under general anesthesia given by Dr Marino Fernandez COMPLICATIONS None PROCEDURE IN DETAIL A history and physical examination were performed and the procedure indications potential complications including bleeding perforation the need for surgery infection adverse medical reaction risks benefits and alternatives available were explained to the parents who stated good understanding and consented to go ahead with the procedure The opportunity for questions was provided and informed consent was obtained Once the consent was obtained the patient was sedated with IV medications and intubated by Dr Fernandez and placed in the supine position Then the tip of the XP 160 videoscope was introduced into the oropharynx and under direct visualization we could advance the endoscope into the upper mid and lower esophagus We did not find any strictures in the upper esophagus but the patient had the lower esophageal sphincter totally loose Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus and then into the first portion of the duodenum We noticed that the patient had several ulcers in the first portion of the duodenum Then the tip of the endoscope was advanced down into the second portion of the duodenum one biopsy was taken there and then the tip of the endoscope was brought back to the first portion and two biopsies were taken there Then the tip of the endoscope was brought back to the antrum where two biopsies were taken and one biopsy for CLOtest By retroflexed view at the level of the body of the stomach I could see that the patient had the lower esophageal sphincter loose Finally the endoscope was unflexed and was brought back to the lower esophagus where two biopsies were taken At the end air was suctioned from the stomach and the endoscope was removed out of the patient s mouth The patient tolerated the procedure well with no complications FINAL IMPRESSION 1 Duodenal ulcers 2 Loose lower esophageal sphincter PLAN 1 To start omeprazole 20 mg a day 2 To review the biopsies 3 To return the patient back to clinic in 1 to 2 weeks Keywords surgery esophagogastroduodenoscopy esophageal biopsies endoscope MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy and snare polypectomy Iron deficiency anemia Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy and snare polypectomy INDICATION FOR THE PROCEDURE Iron deficiency anemia MEDICATIONS MAC The risks of the procedure were made aware to the patient and consisted of medication reaction bleeding perforation and aspiration PROCEDURE After informed consent and appropriate sedation the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum The duodenal mucosa was completely normal The pylorus was normal In the stomach there was evidence of diffuse atrophic appearing nodular gastritis Multiple biopsies were obtained There also was a 1 5 cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum There was mild ulceration on the tip of this polyp It was decided to remove the polyp via snare polypectomy Retroflexion was performed and this revealed a small hiatal hernia in the distal esophagus The Z line was identified and was unremarkable The esophageal mucosa was normal FINDINGS 1 Hiatal hernia 2 Diffuse nodular and atrophic appearing gastritis biopsies taken 3 A 1 5 cm polyp with ulceration along the greater curvature removed RECOMMENDATIONS 1 Follow up biopsies 2 Continue PPI 3 Hold Lovenox for 5 days 4 Place SCDs Keywords surgery esophagogastroduodenoscopy iron deficiency iron deficiency anemia anemia biopsy endoscope esophageal mucosa esophagus hiatal hernia polypectomy snare polypectomy esophagogastroduodenoscopy with biopsy iron deficiency anemia MEDICAL_TRANSCRIPTION,Description Ivor Lewis esophagogastrectomy feeding jejunostomy placement of two right sided 28 French chest tubes and right thoracotomy Medical Specialty Surgery Sample Name Esophagogastrectomy Jejunostomy Chest Tubes Transcription OPERATION 1 Ivor Lewis esophagogastrectomy 2 Feeding jejunostomy 3 Placement of two right sided 28 French chest tubes 4 Right thoracotomy ANESTHESIA General endotracheal anesthesia with a dual lumen tube OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Prior to administration of general anesthesia the patient had an epidural anesthesia placed In addition he had a dual lumen endotracheal tube placed The patient was placed in the supine position to begin the procedure His abdomen and chest were prepped and draped in the standard surgical fashion After applying sterile dressings a 10 blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus Dissection was carried down through the linea using Bovie electrocautery The abdomen was opened Next a Balfour retractor was positioned as well as a mechanical retractor Next our attention was turned to freeing up the stomach In an attempt to do so we identified the right gastroepiploic artery and arcade We incised the omentum and retracted it off the stomach and gastroepiploic arcade The omentum was divided using suture ligature with 2 0 silk We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2 0 silk Next we turned our attention to performing a Kocher maneuver This was done and the stomach was freed up We took down the falciform ligament as well as the caudate attachment to the diaphragm We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest We also did a portion of the esophageal dissection from the abdomen into the chest area The esophagus and the esophageal hiatus were identified in the abdomen We next turned our attention to the left gastric artery The left gastric artery was identified at the base of the stomach We first took the left gastric vein by ligating and dividing it using 0 silk ties The left gastric artery was next taken using suture ligature with silk ties followed by 2 0 stick tie reinforcement At this point the stomach was freely mobile We then turned our attention to performing our jejunostomy feeding tube A 2 0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz We then used Bovie electrocautery to open the jejunum at this site We placed a 16 French red rubber catheter through this site We tied down in place We then used 3 0 silk sutures to perform a Witzel Next the loop of jejunum was tacked up to the abdominal wall using 2 0 silk ties After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately we turned our attention to closing the abdomen This was done with 1 Prolene We put in a 2nd layer of 2 0 Vicryl The skin was closed with 4 0 Monocryl Next we turned our attention to performing the thoracic portion of the procedure The patient was placed in the left lateral decubitus position The right chest was prepped and draped appropriately We then used a 10 blade scalpel to make an incision in a posterolateral non muscle sparing fashion Dissection was carried down to the level of the ribs with Bovie electrocautery Next the ribs were counted and the 5th interspace was entered The lung was deflated We placed standard chest retractors Next we incised the peritoneum over the esophagus We dissected the esophagus to just above the azygos vein The azygos vein in fact was taken with 0 silk ligatures and reinforced with 2 0 stick ties As mentioned we dissected the esophagus both proximally and distally down to the level of the hiatus After doing this we backed our NG tube out to above the level where we planned to perform our pursestring We used an automatic pursestring and applied We then transected the proximal portion of the stomach with Metzenbaum scissors We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus The pursestring was then tied down without difficulty Next we tabularized our stomach using a 80 GIA stapler After doing so we chose a portion of the stomach more distally and opened it using Bovie electrocautery We placed our EEA stapler through it and then punched out through the gastric wall We connected our anvil to the EEA stapler This was then secured appropriately We checked to make sure that there was appropriate muscle apposition We then fired the stapler We obtained 2 complete rings 1 of the esophagus and 1 of the stomach which were sent for pathology We also sent the gastroesophageal specimen for pathology Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins We then turned our attention to closing the gastrostomy opening This was closed with 2 0 Vicryl in a running fashion We then buttressed this with serosal 3 0 Vicryl interrupted sutures We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it Next we placed two 28 French chest tubes 1 anteriorly and 1 posteriorly taking care not to place it near the anastomosis We then closed the chest with 2 Vicryl in an interrupted figure of eight fashion The lung was brought up We closed the muscle layers with 0 Vicryl followed by 0 Vicryl then we closed the subcutaneous layer with 2 0 Vicryl and the skin with 4 0 Monocryl Sterile dressing was applied The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition Keywords surgery ivor lewis esophagogastrectomy jejunostomy thoracotomy dual lumen tube chest tubes bovie electrocautery chest endotracheal electrocautery abdomen gastric esophagus tubes vicryl stomach MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy and esophagoscopy with removal of foreign body Medical Specialty Surgery Sample Name Esophageal Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Esophageal foreign body POSTOPERATIVE DIAGNOSIS Esophageal foreign body PROCEDURES PERFORMED 1 Direct laryngoscopy with intubation by surgeon 2 Rigid tracheoscopy 3 Rigid esophagoscopy with removal of foreign body INDICATIONS The patient is an 8 month old Hispanic male who presented to the Emergency Department with approximately 12 hour history of choking event and presumed for esophageal foreign body When seen in the Emergency Department he was having no difficulty managing his secretions or any signs of any airway compromise Imaging in the Emergency Department did demonstrate an esophageal foreign body at or above the level of the cricopharyngeus Due to this the patient was consented and taken urgently to the operating room for removal of this foreign body OPERATIVE DETAILS The patient was correctly identified in the preop holding area and brought to operating room 37 After informed consent was reviewed general anesthesia was induced initially with propofol the existing IV Following this after protective eye tape was placed 9 Parson s laryngoscope was introduced transorally and used to perform a direct laryngoscopy Normal anatomy was visualized Following this a 4 mm 20 rigid endoscope was introduced through the Parson s laryngoscope and used to perform a direct tracheoscopy The patient s supraglottis glottis and subglottis down to the level of the mid trachea were found to be benign with no abnormal appearing anatomy Following this the rigid endoscope was removed and the patient was intubated with a 4 0 endotracheal tube cuffed without difficulty After confirming bilateral breath sounds and positive end tidal CO2 this was secured to the patient by the anesthesia staff Following this the Parson s laryngoscope was removed and a size 4 rigid esophagoscope was inserted transorally and passed down to the level of the patient s cricopharyngeus were the foreign body was visualized At this point the coin grasper device was connected to the camera system and inserted through the existing esophagoscope This was used to grasp the coin and the coin was removed under direct visualization and handed off as a separate specimen Following this the 34 mm 0 degree scope was inserted through the esophagoscope once the esophagoscope was passed down to the patient s GE junction The entire esophageal mucosa was examined as the esophagoscope was backed out and there was only a minimal amount of superficial ulceration in the posterior wall of the esophagus near the level of the cricopharyngeus muscle There were no other lesions or signs of further esophageal damage Following this all instrumentation was removed and care of the patient was turned back to the anesthesia staff for stable wakeup FINDINGS 1 Normal supraglottic glottic and subglottic anatomy 2 Esophageal foreign body at the level of the cricopharyngeus COMPLICATIONS None ESTIMATED BLOOD LOSS None DISPOSITION Stable to the PACU and then home Keywords surgery rigid tracheoscopy rigid esophagoscopy subglottic supraglottic glottic removal of foreign body level of the cricopharyngeus esophageal foreign body foreign body rigid endoscope direct laryngoscopy emergency department parson s laryngoscope foreign esophagoscopy tracheoscopy transorally laryngoscopy anesthesia parson s laryngoscope endoscope cricopharyngeus esophagoscope esophageal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with antral biopsies for H pylori x2 with biopsy forceps Nausea and vomiting and upper abdominal pain Medical Specialty Surgery Sample Name Esophagogastroduodenoscopy 10 Transcription PREOPERATIVE DIAGNOSIS Nausea and vomiting and upper abdominal pain POST PROCEDURE DIAGNOSIS Normal upper endoscopy OPERATION Esophagogastroduodenoscopy with antral biopsies for H pylori x2 with biopsy forceps ANESTHESIA IV sedation 50 mg Demerol 8 mg of Versed PROCEDURE The patient was taken to the endoscopy suite After adequate IV sedation with the above medications hurricane was sprayed in the mouth as well as in the esophagus A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus stomach and pylorus The first second and third portions of the duodenum were normal The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H pylori The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone The scope was then removed throughout the esophagus which was normal The patient tolerated the procedure well The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal although previous ultrasounds several years ago showed a gallstone Keywords surgery h pylori forceps antral biopsies ge junction esophagogastroduodenoscopy pylori esophagus antral MEDICAL_TRANSCRIPTION,Description Endoscopic retrograde cholangiopancreatography ERCP with brush cytology and biopsy Medical Specialty Surgery Sample Name ERCP Transcription PROCEDURE Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy INDICATION FOR THE PROCEDURE Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis with a recent upper endoscopy showing an abnormal appearing ampulla MEDICATIONS General anesthesia The risks of the procedure were made aware to the patient and consisted of medication reaction bleeding perforation aspiration and post ERCP pancreatitis DESCRIPTION OF PROCEDURE After informed consent and appropriate sedation the duodenoscope was inserted into the oropharynx down the esophagus and into the stomach The scope was then advanced through the pylorus to the ampulla The ampulla had a markedly abnormal appearance as it was enlarged and very prominent It extended outward with an almost polypoid shape It had what appeared to be adenomatous appearing mucosa on the tip There also was ulceration noted on the tip of this ampulla The biliary and pancreatic orifices were identified This was located not at the tip of the ampulla but rather more towards the base Cannulation was performed with a Wilson Cooke TriTome sphincterotome with easy cannulation of the biliary tree The common bile duct was mildly dilated measuring approximately 12 mm The intrahepatic ducts were minimally dilated There were no filling defects identified There was felt to be a possible stricture within the distal common bile duct but this likely represented an anatomic variant given the abnormal shape of the ampulla The patient has no evidence of obstruction based on lab work and clinically Nevertheless it was decided to proceed with brush cytology of this segment This was done without any complications There was adequate drainage of the biliary tree noted throughout the procedure Multiple efforts were made to access the pancreatic ductal anatomy however because of the shape of the ampulla this was unsuccessful Efforts were made to proceed in a long scope position but still were unsuccessful Next biopsies were obtained of the ampulla away from the biliary orifice Four biopsies were taken There was some minor oozing which had ceased by the end of the procedure The stomach was then decompressed and the endoscope was withdrawn FINDINGS 1 Abnormal papilla with bulging polypoid appearance and looks adenomatous with ulceration on the tip biopsies taken 2 Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture although I think this is likely an anatomic variant brush cytology obtained 3 Unable to access the pancreatic duct RECOMMENDATIONS 1 NPO except ice chips today 2 Will proceed with MRCP to better delineate pancreatic ductal anatomy 3 Follow up biopsies and cytology Keywords surgery endoscopic retrograde cholangiopancreatography biopsy brush cytology cholangiopancreatography pancreatitis endoscopy duodenoscope wilson cooke tritome ampulla common bile duct ercp endoscopic biliary pancreatic duct biopsies cytology MEDICAL_TRANSCRIPTION,Description Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar Medical Specialty Surgery Sample Name Escharotomy Transcription PREOPERATIVE DIAGNOSES 32 total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity POSTOPERATIVE DIAGNOSES 32 total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity PROCEDURES PERFORMED 1 Lateral escharotomy of right upper arm burn eschar 2 Medial escharotomy of left upper extremity burns and eschar ANESTHESIA Propofol and Versed INDICATIONS FOR PROCEDURE The patient is a 72 year old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities neck and thorax The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand DESCRIPTION OF PROCEDURE After appropriate time out was performed indicating the correct procedure correct patient and all parties involved the patient s right upper extremity was placed in anatomical position An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient s right upper extremity Starting just below the right humeral head an incision was made through the burn eschar down to underlying subcutaneous tissue The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity All dermal bridging was taken down and was opened without any excessive bleeding Next a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity Again the incision was carried through the entire of the eschar down to underlying subcutaneous tissue All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down At the completion of the procedure the patient had improved right distal radial pulse and his compartment was much softer Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix The patient tolerated the procedure well and there were no adverse events during or after the procedure Keywords surgery lateral escharotomy medial escharotomy eschar anterior thorax underlying subcutaneous tissue bilateral upper extremities impending compartment syndrome arm burn extremity burns humeral head burn eschar compartment syndrome escharotomy humeral burns MEDICAL_TRANSCRIPTION,Description Epigastric herniorrhaphy Epigastric hernia Medical Specialty Surgery Sample Name Epigastric Herniorrhaphy Transcription PREOPERATIVE DIAGNOSIS Epigastric hernia POSTOPERATIVE DIAGNOSIS Epigastric hernia OPERATIONS Epigastric herniorrhaphy ANESTHESIA General inhalation PROCEDURE Following attainment of satisfactory anesthesia the patient s abdomen was prepped with Hibiclens and draped sterilely The hernia mass had been marked preoperatively This area was anesthetized with a mixture of Marcaine and Xylocaine A transverse incision was made over the hernia and dissection carried down to the entrapped fat Sharp dissection was carried around the fat down to the fascial edge The preperitoneal fat could not be reduced therefore it is trimmed away and the small fascial defect then closed with interrupted 0 Ethibond sutures The fascial edges were injected with the local anesthetic mixture Subcutaneous tissues were then closed with interrupted 4 0 Vicryl and skin edges closed with running subcuticular 4 0 Vicryl Steri Strips and a sterile dressing were applied to complete the closure The patient was then awakened and taken to the PACU in satisfactory condition ESTIMATED BLOOD LOSS 10 mL SPONGE AND NEEDLE COUNT Reported as correct COMPLICATIONS None Keywords surgery hibiclens epigastric herniorrhaphy epigastric hernia herniorrhaphy MEDICAL_TRANSCRIPTION,Description Epididymectomy Medical Specialty Surgery Sample Name Epididymectomy Transcription EPIDIDYMECTOMY OPERATIVE NOTE The patient was placed in the supine position and prepped and draped in the usual manner A transverse scrotal incision was made and carried down to the tunica vaginalis which was opened A small amount of clear fluid was expressed The tunica vaginalis was opened and the testicle was brought out through this incision The epididymis was separated off the surface of the testicle using a scalpel With blunt and sharp dissection the epididymis was dissected off the testicle Bovie was used for hemostasis The vessels going to the testicle were preserved without any obvious injury and a nice viable testicle was present after the epididymis was removed from this The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also There was no obvious bleeding The cord was infiltrated with 0 25 Marcaine as was the dartos tissue in the scrotum The testicle was replaced in the scrotum Skin was closed in two layers using 3 0 chromic catgut for the dartos and a subcuticular closure with the same material A dry sterile dressing and compression were applied and he was sent to the recovery room in stable condition Keywords surgery scrotal incision 0 25 marcaine bovie epididymectomy chromic catgut epididymis fluid scalpel scrotum sterile dressing testicle tunica vaginalisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Endotracheal intubation The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather PCO2 was 29 and pO2 was 66 on the 15 liters Medical Specialty Surgery Sample Name Endotracheal Intubation 1 Transcription PROCEDURE PERFORMED Endotracheal intubation INDICATION FOR PROCEDURE The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather PCO2 was 29 and pO2 was 66 on the 15 liters NARRATIVE OF PROCEDURE The patient was given a total of 5 mg of Versed 20 mg of etomidate and 10 mg of vecuronium He was intubated in a single attempt Cords were well visualized and a 8 endotracheal tube was passed using a curved blade Fiberoptically a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology AFB and fungal smear and culture A separate trap B was then lavaged for bacterial C S and Gram stain and was sent for those purposes The patient tolerated the procedure well Keywords surgery nonrebreather respiratory distress falling saturation endotracheal intubation lavage breathingNOTE MEDICAL_TRANSCRIPTION,Description A 60 total body surface area flame burns status post multiple prior excisions and staged graftings Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra not grafted on the back Medical Specialty Surgery Sample Name Epidermal Autograft Transcription PREOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings POSTOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings PROCEDURES PERFORMED 1 Epidermal autograft on Integra to the back 3520 cm2 2 Application of allograft to areas of the lost Integra not grafted on the back 970 cm2 ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 50 cc BLOOD PRODUCTS RECEIVED One unit of packed red blood cells COMPLICATIONS None INDICATIONS The patient is a 26 year old male who sustained a 60 total body surface area flame burn involving the head face neck chest abdomen back bilateral upper extremities hands and bilateral lower extremities He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites the extent they will provide coverage OPERATIVE FINDINGS 1 Variable take of Integra particularly centrally and inferiorly on the back A fair amount of lost Integra over the upper back and shoulders 2 No evidence of infection 3 Healthy viable wound beds prior to grafting PROCEDURE IN DETAIL The patient was brought to the operating room and positioned supine General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed He was then repositioned prone and perioperative IV antibiotics were administered He was prepped and draped in the usual sterile manner All staples were removed from the Integra and the adherent areas of Silastic were removed The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution Hemostasis of the wound bed was ensured using epinephrine soaked Telfa pads Following dermal tumescence of the buttocks epidermal autografts were harvested 8 one thousandths of an inch using the air Zimmer dermatome These grafts were passed to the back table where they were meshed 3 1 The donor sites were hemostased using epinephrine soaked Telfa and lap pads Once all the grafts were meshed we brought them back up onto the field positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment We were happy with the lie of the grafts and they were stapled into place The grafts were then overlaid with Conformant 2 which was also stapled into place Utilizing all of his buttocks skin we did not have enough to cover his entire back so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment Allograft was thawed and meshed 1 1 It was then brought up onto the field trimmed to fit and stapled into place over the wound Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied Donor sites on his buttocks were dressed in Acticoat and secured with staples He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications He was transported to PACU in stable condition Keywords surgery flame burns body surface area epidermal autograft autograft integra integra engraftment wound grafts epidermal allograft MEDICAL_TRANSCRIPTION,Description Evacuation of epidural hematoma and insertion of epidural drain Epidural hematoma cervical spine Status post cervical laminectomy C3 through C7 postop day 10 Central cord syndrome and acute quadriplegia Medical Specialty Surgery Sample Name Epidural Hematoma Evacuation Transcription PREOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia POSTOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia PROCEDURE PERFORMED 1 Evacuation of epidural hematoma 2 Insertion of epidural drain ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 200 cc HISTORY This is a 64 year old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction She was then transferred to Beaumont Hospital at which point she developed a sternal abscess The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren Michigan at which point she developed a second what was termed minor myocardial infarction The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later brings us to the month of August at which time she was at home ambulating with a walker or a cane and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI which showed record signal change The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery but objectively there was not much improvement Approximately 10 days after the surgery brings us to today s date the health officer was notified of the patient s labored breathing When she examined the patient she also noted that the patient was unable to move her extremities She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma On clinical examination there was swelling in the posterior aspect of the neck The patient has no active movement in the upper and lower extremity muscle groups Reflexes are absent in the upper and lower extremities Long track signs are absent Sensory level is at the C4 dermatome Rectal tone is absent I discussed the findings with the patient and also the daughter We discussed the possibility of this is permanent quadriplegia but at this time the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery OPERATIVE PROCEDURE The patient was taken to OR 1 at ABCD General Hospital on a gurney Department of Anesthesia administered fiberoptic intubation and general anesthetic A Foley catheter was placed in the bladder The patient was log rolled in a prone position on the Jackson table Bony prominences were well padded The patient s head was placed in the prone view anesthesia head holder At this point the wound was examined closely and there was hematoma at the caudal pole of the wound Next the patient was prepped and draped in the usual sterile fashion The previous skin incision was reopened At this point hematoma properly exits from the wound All sutures were removed and the epidural spaces were encountered at this time The self retaining retractors were placed in the depth of the wound Consolidated hematoma was now removed from the wound Next the epidural space was encountered There was no additional hematoma in the epidural space or on the thecal sac A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well Next the wound was irrigated copiously with one liter of saline using a syringe The walls of the wound were explored There was no active bleeding Retractors were removed at this time and even without pressure on the musculature there was no active bleeding A 19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space Fascia was reapproximated with 1 Vicryl sutures subcutaneous tissue with 3 0 Vicryl sutures Steri Strips covered the incision and dressing was then applied over the incision The patient was then log rolled in the supine position on the hospital gurney She remained intubated for airway precautions and transferred to the recovery room in stable condition Once in the recovery room she was alert She was following simple commands and using her head to nod but she did not have any active movement of her upper or lower extremities Prognosis for this patient is guarded Keywords surgery epidural hematoma cervical spine cervical laminectomy central cord syndrome acute quadriplegia insertion of epidural drain epidural drain epidural space hematoma epidural cervical laminectomy quadriplegia MEDICAL_TRANSCRIPTION,Description The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm 2 5 cm right common iliac artery aneurysm Medical Specialty Surgery Sample Name Endovascular Abdominal Aortic Aneurysm Repair Transcription PREOPERATIVE DIAGNOSIS Abdominal aortic aneurysm POSTOPERATIVE DIAGNOSIS Abdominal aortic aneurysm OPERATION PERFORMED Endovascular abdominal aortic aneurysm repair FINDINGS The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm 2 5 cm right common iliac artery aneurysm A Gore exclusive device was used 3 pieces were used to effect the repair We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm The right hypogastric artery had been previously coiled off Left common femoral artery was used for the _____ side We had small type 2 leak right underneath the take off the renal arteries this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery which commonly come off in this area It was felt that this would seal after reversal of the anticoagulation given sufficient time PROCEDURE With the patient supine position under general anesthesia the abdomen and lower extremities were prepped and draped in a sterile fashion Bilateral groin incisions were made and the common femoral arteries were dissected out bilaterally The patient was then heparinized The 7 French sheaths were then placed retrograde bilaterally A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side The calibrated aortogram was the done We marked the renal arteries aortic bifurcation and bifurcation common iliac arteries We then preceded placement of the main trunk by replacing the 7 French sheath in the left groin area with 18 french sheath and then deployed the trunk body just below the take off renal arteries Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery As noted above we then had to place an iliac extension down in the external iliac artery to exclude the right common iliac artery and resume completely Following completion of the above all arteries were ballooned appropriately A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries The area was ballooned aggressively It was felt that this would dissolve as discussed above Following completion of the above all wire sheaths etc were removed from both groin areas Both femoral arteries were repaired by primary suture technique Flow was then reestablished to the lower extremities and protamine was given to reverse the heparin Both surgical sites were then irrigated thoroughly Meticulous hemostasis was achieved Both wounds were then closed in a routine layered fashion Sterile antibiotic dressings were applied Sponge and needle counts were reported as correct The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition Keywords surgery gore common iliac artery aneurysm abdominal aortic aneurysm repair abdominal aortic aneurysm common iliac aortic aneurysm iliac artery artery aneurysm iliac abdominal aortic arteries MEDICAL_TRANSCRIPTION,Description Endotracheal intubation Respiratory failure The patient is a 52 year old male with metastatic osteogenic sarcoma He was admitted two days ago with small bowel obstruction Medical Specialty Surgery Sample Name Endotracheal Intubation Transcription PROCEDURE Endotracheal intubation INDICATION Respiratory failure BRIEF HISTORY The patient is a 52 year old male with metastatic osteogenic sarcoma He was admitted two days ago with small bowel obstruction He has been on Coumadin for previous PE and currently on heparin drip He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness A code blue was called On my arrival the patient s vital signs are stable His blood pressure is systolically in 140s and heart rate 80s He however has 0 respiratory effort and is unresponsive to even painful stimuli The patient was given etomidate 20 mg DESCRIPTION OF PROCEDURE The patient positioned appropriate equipment at the bedside given 20 mg of etomidate and 100 mg of succinylcholine Mac 4 blade was used A 7 5 ET tube placed to 24th teeth There is good color change on the capnographer with bilateral breath sounds Following intubation the patient s blood pressure began to drop He was given 2 L of bolus I started him on dopamine drip at 10 mcg Dr X was at the bedside who is the primary caregiver he assumed the care of the patient will be transferred to the ICU Chest x ray will be reviewed and Pulmonary will be consulted Keywords surgery metastatic osteogenic sarcoma respiratory failure bowel obstruction blood pressure endotracheal intubation endotracheal sarcoma MEDICAL_TRANSCRIPTION,Description Right L4 attempted L5 and S1 transforaminal epidurogram for neural mapping Medical Specialty Surgery Sample Name Epidurogram Transcription PREOPERATIVE DIAGNOSES 1 Right lower extremity radiculopathy with history of post laminectomy pain 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Right lower extremity radiculopathy with history of post laminectomy pain 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Right L4 attempted L5 and S1 transforaminal epidurogram for neural mapping ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion The patient was given sedation and monitored Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root The left side was quite open however that was not the side of her problem At this point using a oblique fluoroscopic projection and gun barrel technique a 22 gauge 3 5 inch spinal needle was placed at the superior articular process of L5 on the right stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location After negative aspiration 2 cc of Omnipaque 240 dye was injected through each needle There was a defect flowing in the medial epidural space at both sides There were no complications Keywords surgery laminectomy radiculopathy nerve root entrapment epidural fibrosis nerve root epidurogram neural epidural foramen nerve needle MEDICAL_TRANSCRIPTION,Description Upper endoscopy with biopsy The patient admitted for coffee ground emesis which has been going on for the past several days An endoscopy is being done to evaluate for source of upper GI bleeding Medical Specialty Surgery Sample Name Endoscopy With Biopsy Transcription PROCEDURE Upper endoscopy with biopsy PROCEDURE INDICATION This is a 44 year old man who was admitted for coffee ground emesis which has been going on for the past several days An endoscopy is being done to evaluate for source of upper GI bleeding Informed consent was obtained Outlining the risks benefits and alternatives of the procedure included but not to risks of bleeding infection perforation the patient agreed for the procedure MEDICATIONS Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient s pressures and vital signs PROCEDURE IN DETAIL The patient was placed in the left lateral decubitus position Medications were given After adequate sedation was achieved the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum Keywords surgery coffee ground emesis gi bleeding upper endoscopy iv push esophagus duodenum mucosa stomach endoscopy biopsy MEDICAL_TRANSCRIPTION,Description Upper gastrointestinal endoscopy Medical Specialty Surgery Sample Name Endoscopy Transcription PREOPERATIVE DIAGNOSIS Anemia PROCEDURE Upper gastrointestinal endoscopy POSTOPERATIVE DIAGNOSES 1 Severe duodenitis 2 Gastroesophageal junction small ulceration seen 3 No major bleeding seen in the stomach PROCEDURE IN DETAIL The patient was put in left lateral position Olympus scope was inserted from the mouth under direct visualization advanced to the upper part of the stomach upper part of esophagus middle of esophagus GE junction and some intermittent bleeding was seen at the GE junction Advanced into the upper part of the stomach into the antrum The duodenum showed extreme duodenitis and the scope was then brought back Retroflexion was performed which was normal Scope was then brought back slowly Duodenitis was seen and a little bit of ulceration seen at GE junction FINDING Severe duodenitis may be some source of bleeding from there but no active bleeding at this time Keywords surgery upper gastrointestinal endoscopy ge junction gastrointestinal esophagus endoscopy stomach duodenitis bleeding MEDICAL_TRANSCRIPTION,Description Normal upper GI endoscopy Medical Specialty Surgery Sample Name Endoscopy Template Transcription INDICATIONS Dysphagia PREMEDICATION Topical Cetacaine spray and Versed IV PROCEDURE The scope was passed into the esophagus under direct vision The esophageal mucosa was all unremarkable There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis The scope was passed on down into the stomach The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present The scope was then withdrawn IMPRESSION Normal upper GI endoscopy without any evidence of anatomical narrowing Keywords surgery dysphagia cetacaine spray esophagus esophageal mucosa duodenum scope was passed upper gi gi endoscopy gi endoscopy scope MEDICAL_TRANSCRIPTION,Description Intermittent rectal bleeding with abdominal pain Medical Specialty Surgery Sample Name Endoscopy 4 Transcription PROCEDURE Endoscopy CLINICAL INDICATIONS Intermittent rectal bleeding with abdominal pain ANESTHESIA Fentanyl 100 mcg and 5 mg of IV Versed PROCEDURE The patient was taken to the GI lab and placed in the left lateral supine position Continuous pulse oximetry and blood pressure monitoring were in place After informed consent was obtained the video endoscope was inserted over the dorsum of the tongue without difficulty With swallowing the scope was advanced down the esophagus into the body of the stomach The scope was further advanced down to the antrum and through the pylorus into the duodenum which was visualized into its second portion It appeared free of stricture neoplasm or ulceration Samples were obtained from the antrum and prepyloric area to check for Helicobacter rapid urease and additional samples were sent to pathology Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia The scope was then slowly removed The distal esophagus appeared benign with a normal appearing gastroesophageal sphincter and no esophagitis The remaining portion of the esophagus was normal IMPRESSION Abdominal pain Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia RECOMMENDATIONS Await results of CLO testing and biopsies Return to clinic with Dr Spencer in 2 weeks for further discussion Keywords surgery duodenum stomach hiatal hernia endoscopy antrum hiatal hernia gastroesophageal scope esophagus abdominal MEDICAL_TRANSCRIPTION,Description Endoscopic carpal tunnel release Left carpal tunnel syndrome Medical Specialty Surgery Sample Name Endoscopic Carpal Tunnel Rlease Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIONS PERFORMED Endoscopic carpal tunnel release ANESTHESIA I V sedation and local 1 Lidocaine ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE IN DETAIL With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mm Hg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the wrist between FCR and FCU one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A proximal forearm fasciotomy was performed under direct vision A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the hook of hamate The endoscopic instrument was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the endoscopic instrument was withdrawn dividing the transverse carpal ligament under direct vision After complete division o the transverse carpal ligament the instrument was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was confirmed The wound was then closed with running subcuticular stitch Steri Strips were applied and sterile dressing was applied over the Steri Strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition having tolerated the procedure well Keywords surgery fcr fcu antebrachial fascia endoscopic carpal tunnel release carpal tunnel release carpal tunnel syndrome carpal endoscopic ligament tourniquet transverse MEDICAL_TRANSCRIPTION,Description Upper endoscopy patient with dysphagia Medical Specialty Surgery Sample Name Endoscopy 1 Transcription PROCEDURE Upper endoscopy PREOPERATIVE DIAGNOSIS Dysphagia POSTOPERATIVE DIAGNOSIS 1 GERD biopsied 2 Distal esophageal reflux induced stricture dilated to 18 mm 3 Otherwise normal upper endoscopy MEDICATIONS Fentanyl 125 mcg and Versed 7 mg slow IV push INDICATIONS This is a 50 year old white male with dysphagia which has improved recently with Aciphex FINDINGS The patient was placed in the left lateral decubitus position and the above medications were administered The oropharynx was sprayed with Cetacaine The endoscope was passed under direct visualization into the esophagus The squamocolumnar junction was irregular and edematous Biopsies were obtained for histology There was a mild ring at the LES which was dilated with a 15 to 18 mm balloon with no resultant mucosal trauma The entire gastric mucosa was normal including a retroflexed view of the fundus The entire duodenal mucosa was normal to the second portion The patient tolerated the procedure well without complication IMPRESSION 1 Gastroesophageal reflux disease biopsied 2 Distal esophageal reflux induced stricture dilated to 18 mm 3 Otherwise normal upper endoscopy PLAN I will await the results of the biopsies The patient was told to continue maintenance Aciphex and anti reflux precautions He will follow up with me on a p r n basis Keywords surgery lateral decubitus position gastroesophageal reflux disease gerd normal upper endoscopy mucosa was normal esophageal reflux stricture dilated upper endoscopy distal esophageal aciphex biopsies dysphagia endoscopy reflux MEDICAL_TRANSCRIPTION,Description Endoscopic carpal tunnel release and de Quervain s release Left carpal tunnel syndrome and de Quervain s tenosynovitis Medical Specialty Surgery Sample Name Endoscopic Carpal Tunnel de Quervain s Release Transcription PREOPERATIVE DIAGNOSIS 1 Left carpal tunnel syndrome 2 de Quervain s tenosynovitis POSTOPERATIVE DIAGNOSIS 1 Left carpal tunnel syndrome 2 de Quervain s tenosynovitis OPERATIONS PERFORMED 1 Endoscopic carpal tunnel release 2 de Quervain s release ANESTHESIA I V sedation and local 1 Lidocaine ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE IN DETAIL ENDOSCOPIC CARPAL TUNNEL RELEASE With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mm Hg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the wrist between FCR and FCU one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A proximal forearm fasciotomy was performed under direct vision A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the hook of hamate The endoscopic instrument was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the endoscopic instrument was withdrawn dividing the transverse carpal ligament under direct vision After complete division o the transverse carpal ligament the instrument was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was confirmed The wound was then closed with running subcuticular stitch Steri Strips were applied and sterile dressing was applied over the Steri Strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition having tolerated the procedure well DE QUERVAIN S RELEASE With the patient under adequate regional anesthesia applied by surgeon using 1 plain Xylocaine the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated to 290 mm Hg A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel Using blunt dissection the radial sensory nerve branches were dissected and retracted out of the operative field The first dorsal tunnel was then identified The first dorsal tunnel was incised along the dorsal ulnar border completely freeing the stenosing tenosynovitis de Quervain s release EPB and APL tendons were inspected and found to be completely free The radial sensory nerve was inspected and found to be without damage The skin was closed with a running 3 0 Prolene subcuticular stitch and Steri Strips were applied and over the Steri Strips a sterile dressing and over the sterile dressing a volar splint with the hand in safe position The tourniquet was deflated The patient was returned to the holding area in satisfactory condition having tolerated the procedure well Keywords surgery de quervain s tenosynovitis de quervain s release carpal tunnel syndrome carpal tunnel release endoscopic carpal tunnel release tunnel transverse carpal tourniquet endoscopic MEDICAL_TRANSCRIPTION,Description Patient with dysphagia Medical Specialty Surgery Sample Name Endoscopy 3 Transcription PROCEDURES PERFORMED Endoscopy INDICATIONS Dysphagia POSTOPERATIVE DIAGNOSIS Esophageal ring and active reflux esophagitis PROCEDURE Informed consent was obtained prior to the procedure from the parents and patient The oral cavity is sprayed with lidocaine spray A bite block is placed Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments The GIF 160 diagnostic gastroscope used The patient was alert during the procedure The esophagus was intubated under direct visualization The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one third of the esophagus noted The stomach was unremarkable Retroflexed exam unremarkable Duodenum not intubated in order to minimize the time spent during the procedure The patient was alert although not combative A balloon was then inserted across the GE junction 15 mm to 18 mm and inflated to 3 4 7 and 7 ATM and left inflated at 18 mm for 45 seconds The balloon was then deflated The patient became uncomfortable and a good size adequate distal esophageal tear was noted The scope and balloon were then withdrawn The patient left in good condition IMPRESSION Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild PLAN I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed This has been discussed with the parents He was sent home with a prescription for omeprazole Keywords surgery active reflux esophagitis ge junction distal esophageal active reflux reflux esophagitis dysphagia esophagus scope ge junction endoscopy esophageal reflux esophagitis distal balloon MEDICAL_TRANSCRIPTION,Description Cystoscopy TUR and electrofulguration of recurrent bladder tumors Medical Specialty Surgery Sample Name Electrofulguration Bladder Tumor Transcription PREOPERATIVE DIAGNOSIS Recurrent bladder tumors POSTOPERATIVE DIAGNOSIS Recurrent bladder tumors OPERATION Cystoscopy TUR and electrofulguration of recurrent bladder tumors ANESTHESIA General INDICATIONS A 79 year old woman with recurrent bladder tumors of the bladder neck DESCRIPTION OF PROCEDURE The patient was brought to the operating room prepped and draped in lithotomy position under satisfactory general anesthesia A 21 French cystourethroscope was inserted into the bladder Examination of the bladder showed approximately a 3 cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice No other lesions were noted Using a cold punch biopsy forceps a random biopsy was obtained The entire area was electrofulgurated using the Bugbee electrode The patient tolerated the procedure well and left the operating room in satisfactory condition Keywords surgery bladder neck bladder tumors cystoscopy tur electrofulguration bladder MEDICAL_TRANSCRIPTION,Description Melena and solitary erosion over a fold at the GE junction gastric side Medical Specialty Surgery Sample Name Endoscopy 2 Transcription PREOPERATIVE DIAGNOSIS Melena POSTOPERATIVE DIAGNOSIS Solitary erosion over a fold at the GE junction gastric side PREMEDICATIONS Versed 5 mg IV REPORTED PROCEDURE The Olympus gastroscope was used The scope was placed in the upper esophagus under direct visit The esophageal mucosa was entirely normal There was no evidence of erosions or ulceration There was no evidence of varices The body and antrum of the stomach were normal They pylorus duodenum bulb and descending duodenum are normal There was no blood present within the stomach The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach When this was done a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold The lesion was not bleeding If this fold were in any other location of the stomach I would consider the fold but at this location one would have to consider that this would be an isolated gastric varix As such the erosion may be more significant There was no bleeding Obviously no manipulation of the lesion was undertaken The scope was then straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Solitary erosion overlying a prominent fold at the gastroesophageal junction gastric side may simply be an erosion or may be an erosion over a varix 2 Otherwise unremarkable endoscopy no evidence of a bleeding lesion of the stomach PLAN 1 Liver profile today 2 Being Nexium 40 mg a day 3 Scheduled colonoscopy for next week Keywords surgery ge junction melena olympus gastroscope solitary erosion descending duodenum esophageal mucosa esophagus gastric side pylorus duodenum bulb stomach liver profile colonoscopy ge junction gastric junction gastric endoscopy duodenum scope solitary junction gastric erosion MEDICAL_TRANSCRIPTION,Description Left elbow manipulation and hardware removal of left elbow Medical Specialty Surgery Sample Name Elbow Manipulation Transcription PREOPERATIVE DIAGNOSIS Left elbow with retained hardware POSTOPERATIVE DIAGNOSIS Left elbow with retained hardware PROCEDURE 1 Left elbow manipulation 2 Hardware removal of left elbow ANESTHESIA Surgery was performed under general anesthesia COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None INTRAOPERATIVE FINDING Preoperatively the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees LOCAL ANESTHETIC 10 mL of 0 25 Marcaine HISTORY AND PHYSICAL The patient is a 10 year old right hand dominant male who threw himself off a quad on 10 10 2007 The patient underwent open reduction and internal fixation of his left elbow fracture dislocation The patient also sustained a nondisplaced right glenoid neck fracture The patient s fracture has healed without incident although he had significant postoperative stiffness for which he is undergoing physical therapy as well as use of a Dynasplint The patient is neurologically intact distally Given the fact that his fracture has healed surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware Risks and benefits of the surgery were discussed The risks of surgery included the risk of anesthesia infection bleeding changes in sensation and motion of the extremities failure to remove hardware failure to relieve pain continued postoperative stiffness All questions were answered and the parents agreed to the above plan PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient s left upper extremity was then prepped and draped in a standard surgical fashion Using fluoroscopy the patient s K wire was located An incision was made over his previous scar A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles The K wires were easily palpable A small incision was made into the triceps which allowed for visualization of the two pins which were removed without incident The wound was then irrigated The triceps split was now closed using 2 0 Vicryl The subcutaneous tissue was also closed using 2 0 Vicryl and the skin with 4 0 Monocryl The wound was clean and dry and dressed with Steri Strips Xeroform and 4 x 4s as well as bias A total of 10 mL of 0 25 Marcaine was injected into the incision as well as the joint line At the beginning of the case prior to removal of the hardware the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees flexion to 130 degrees and pronation supination to about 40 degrees DIAGNOSTIC IMPRESSION The postoperative films demonstrated no fracture no retained hardware The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will restart physical therapy and Dynasplint in 3 days The patient is to follow up in 1 week s time for a wound check The patient was given Tylenol No 3 for pain Keywords surgery k wires dynasplint elbow manipulation hardware removal retained hardware elbow hardware MEDICAL_TRANSCRIPTION,Description Emergency cesarean section Medical Specialty Surgery Sample Name Emergency C section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Nonreassuring fetal heart tones with a prolonged deceleration POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Nonreassuring fetal heart tones with a prolonged deceleration PROCEDURE PERFORMED Emergency cesarean section ANESTHESIA General and endotracheal as well as local anesthesia ESTIMATED BLOOD LOSS 800 mL COMPLICATIONS None FINDINGS Female infant in cephalic presentation in OP position Normal uterus tubes and ovaries are noted Weight was 6 pounds and 3 ounces Apgars were 6 at 1 minute and 7 at 5 minutes and 9 at 10 minutes Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 21 year old Gravida 1 para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a m on the day of delivery The patient was admitted and cervix was found to be 1 cm dilated Pitocin augmentation of labor was started The patient was admitted by her primary obstetrician Dr Salisbury and was managed through the day by him at approximately 5 p m at change of shift care was assumed by me At this time the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline good variability was noted as well as accelerations variable deceleration despite position change was occurring with almost every contraction but was lasting for 60 to 90 seconds at the longest Vaginal exam was done Cervix was noted to be 4 cm dilated At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations At 19 20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section Clock in the operating room is noted to be 2 minutes faster then the time on trace view The OR delivery time was 19 36 Delivery of this infant was performed in 14 minutes from the onset of the deceleration Upon arrival to the operating room while prepping the patient for surgery and awaiting the arrival of the anesthesiologist heart tones were noted to be in 60s and slowly came up to the 80s Following the transfer of the patient to the operating room bed and prep of the abdomen the decision was made to begin the surgery under local anesthesia 2 lidocaine was obtained for this purpose PROCEDURE NOTE The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt 2 lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2 lidocaine As the incision site was being injected the anesthesiologist arrived The procedure was started prior to the patient being put under general anesthesia A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique The rectus muscles were separated in midline The peritoneum was bluntly dissected The bladder blade was inserted The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction The infant was subsequently delivered Immediately following delivery of the infant The infant was noted to be crying with good tones The cord was clammed and cut The infant was subsequently transferred or handed to the nursery nurse The placenta was delivered manually intact with a three vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic sutures Hemostasis was visualized The uterus was returned to the abdomen The pelvis was copiously irrigated The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was reapproximated with 0 Vicryl suture The subcutaneous layer was closed with 2 0 plain gut The skin was closed in the subcuticular stitch using 4 0 Monocryl Steri strips were applied Sponge laps and instrument counts were correct The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords surgery intrauterine pregnancy at term prolonged deceleration apgars emergency cesarean section fetal heart tones intrauterine MEDICAL_TRANSCRIPTION,Description Patient admitted because of recurrent nausea and vomiting with displacement of the GEJ feeding tube Medical Specialty Surgery Sample Name EGD with Biopsy 1 Transcription PROCEDURE PERFORMED EGD with biopsy INDICATION Mrs ABC is a pleasant 45 year old female with a history of severe diabetic gastroparesis who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago She was admitted because of recurrent nausea and vomiting with displacement of the GEJ feeding tube A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach The endoscopy is done to confirm this and remove it as well as determine if there are any other causes to account for her symptoms Physical examination done prior to the procedure was unremarkable apart from upper abdominal tenderness MEDICATIONS Fentanyl 25 mcg Versed 2 mg 2 lidocaine spray to the pharynx INSTRUMENT GIF 160 PROCEDURE REPORT Informed consent was obtained from Mrs ABC s sister after the risks and benefits of the procedure were carefully explained which included but were not limited to bleeding infection perforation and allergic reaction to the medications Consent was not obtained from Mrs Morales due to her recent narcotic administration Conscious sedation was achieved with the patient lying in the left lateral decubitus position The endoscope was then passed through the mouth into the esophagus the stomach where retroflexion was performed and it was advanced into the second portion of the duodenum FINDINGS 1 ESOPHAGUS There was evidence of grade C esophagitis with multiple white based ulcers seen from the distal to the proximal esophagus at 12 cm in length Multiple biopsies were obtained from this region and placed in jar 1 2 STOMACH Small hiatal hernia was noted within the cardia of the stomach There was an indentation scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach The remainder of the stomach examination was normal There was no feeding tube remnant seen within the stomach 3 DUODENUM This was normal COMPLICATIONS None ASSESSMENT 1 Grade C esophagitis seen within the distal mid and proximal esophagus 2 Small hiatal hernia 3 Evidence of scarring at the site of the previous feeding tube as well as suture line material seen in the body and antrum of the stomach PLAN Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube Keywords surgery recurrent nausea and vomiting egd with biopsy nausea and vomiting gastrojejunal feeding tube feeding tube remnant recurrent nausea gej feeding gastrojejunal feeding proximal esophagus hiatal hernia feeding tube egd biopsy nausea vomiting gej gastrojejunal duodenum esophagitis multiple distal biopsies hiatal hernia antrum esophagus feeding tube stomach MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy Patient has had biliary colic type symptoms for the past 3 1 2 weeks characterized by severe pain and brought on by eating greasy foods Medical Specialty Surgery Sample Name EGD with Biopsy 2 Transcription TYPE OF PROCEDURE Esophagogastroduodenoscopy with biopsy PREOPERATIVE DIAGNOSIS Abdominal pain POSTOPERATIVE DIAGNOSIS Normal endoscopy PREMEDICATION Fentanyl 125 mcg IV Versed 8 mg IV INDICATIONS This healthy 28 year old woman has had biliary colic type symptoms for the past 3 1 2 weeks characterized by severe pain and brought on by eating greasy foods She has had similar episodes couple of years ago and was told at one point that she had gallstones but after her pregnancy a repeat ultrasound was done and apparently was normal and nothing was done at that time She was evaluated in the emergency department recently when she developed this recurrent pain and laboratory studies were unrevealing Ultrasound was normal and a HIDA scan was done which showed a low normal ejection fraction of 40 and moderate reproduction of her pain Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy PROCEDURE The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication IMPRESSION Normal endoscopy PLAN Refer to a general surgeon for consideration of cholecystectomy Keywords surgery hida scan endoscopy gallstones olympus esophagogastroduodenoscopy with biopsy biliary colic colic type greasy foods normal endoscopy esophagogastroduodenoscopy biliary colic greasy foods cholecystectomy biopsy MEDICAL_TRANSCRIPTION,Description Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position Medical Specialty Surgery Sample Name Electronystagmogram Transcription PROCEDURE This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear FINDINGS Gaze testing did not reveal any evidence of nystagmus Saccadic movements did not reveal any evidence of dysmetria or overshoot Sinusoidal tracking was performed well for the patient s age Optokinetic nystagmus testing was performed poorly due to the patient s difficulty in following the commands Therefore adequate OKNs were not achieved The Dix Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus which was converted to a right beating nystagmus when she sat up again The patient complained of severe dizziness in this position There was no clear cut decremental response with repetition In the head hanging left position no significant nystagmus was identified Positional testing in the supine head hanging head right head left right lateral decubitus and left lateral decubitus positions did not reveal any evidence of nystagmus Caloric stimulation revealed a calculated unilateral weakness of 7 0 on the right normal 20 and left beating directional preponderance of 6 0 normal 20 30 IMPRESSION Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position No other significant nystagmus was noted There was no evidence of clear cut caloric stimulation abnormality This study would be most consistent with a right vestibular dysfunction Keywords surgery silver chloride biopotential electrodes inferior orbital margins lateral canthi vestibular dysfunction prominent nystagmus head hanging electronystagmogram eyes nystagmus MEDICAL_TRANSCRIPTION,Description EGD with dilation for dysphagia Medical Specialty Surgery Sample Name EGD with Dilation Transcription INDICATION Keywords surgery egd hurricaine spray olympus endoscope savary wire cricopharyngeus decubitus dilator duodenum dysphagia esophagus hiatal hernia peptic pylorus stomach tortuosity egd with dilation tortuous scope hiatal hernia MEDICAL_TRANSCRIPTION,Description Common description of EGD Medical Specialty Surgery Sample Name EGD Template 2 Transcription The patient was placed in the left lateral decubitus position medicated with the above medications to achieve and maintain a conscious sedation Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation The Olympus single channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum FINDINGS ESOPHAGUS Proximal and mid esophagus were without abnormalities STOMACH Insufflated and retroflexed visualization of the gastric cavity revealed DUODENUM Normal Keywords surgery gastric cavity lateral decubitus position endoscope olympus egd visualization cavity duodenum esophagusNOTE MEDICAL_TRANSCRIPTION,Description EGD with photos and biopsies This is a 75 year old female who presents with difficulty swallowing occasional choking and odynophagia She has a previous history of hiatal hernia She was on Prevacid currently Medical Specialty Surgery Sample Name EGD With Photos Biopsies Transcription 1 Odynophagia 2 Dysphagia 3 Gastroesophageal reflux disease rule out stricture POSTOPERATIVE DIAGNOSES 1 Antral gastritis 2 Hiatal hernia PROCEDURE PERFORMED EGD with photos and biopsies GROSS FINDINGS This is a 75 year old female who presents with difficulty swallowing occasional choking and odynophagia She has a previous history of hiatal hernia She was on Prevacid currently At this time an EGD was performed to rule out stricture At the time of EGD there was noted some antral gastritis and hiatal hernia There are no strictures tumors masses or varices present OPERATIVE PROCEDURE The patient was taken to the Endoscopy Suite in the lateral decubitus position She was given sedation by the Department Of Anesthesia Once adequate sedation was reached the Olympus gastroscope was inserted into oropharynx With air insufflation entered through the proximal esophagus to the GE junction The esophagus was without evidence of tumors masses ulcerations esophagitis strictures or varices There was a hiatal hernia present The scope was passed through the hiatal hernia into the body of the stomach In the distal antrum there was some erythema with patchy erythematous changes with small superficial erosions Multiple biopsies were obtained The scope was passed through the pylorus into the duodenal bulb and duodenal suite they appeared within normal limits The scope was pulled back from the stomach retroflexed upon itself _____ fundus and GE junction As stated multiple biopsies were obtained The scope was then slowly withdrawn The patient tolerated the procedure well and sent to recovery room in satisfactory condition Keywords surgery odynophagia dysphagia gastroesophageal reflux disease antral gastritis hiatal hernia difficulty swallowing esophagus stomach duodenal egd biopsies hiatal hernia MEDICAL_TRANSCRIPTION,Description EGD with PEG tube placement using Russell technique Protein calorie malnutrition intractable nausea vomiting and dysphagia and enterogastritis Medical Specialty Surgery Sample Name EGD PEG Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 protein calorie malnutrition 2 Intractable nausea vomiting and dysphagia POSTOPERATIVE DIAGNOSES 1 Protein calorie malnutrition 2 Intractable nausea vomiting and dysphagia 3 Enterogastritis PROCEDURE PERFORMED EGD with PEG tube placement using Russell technique ANESTHESIA IV sedation with 1 lidocaine for local ESTIMATED BLOOD LOSS None COMPLICATIONS None BRIEF HISTORY This is a 44 year old African American female who is well known to this service She has been hospitalized multiple times for intractable nausea and vomiting and dehydration She states that her decreased p o intake has been progressively worsening She was admitted to the service of Dr Lang and was evaluated by Dr Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube PROCEDURE After risks complications and benefits were explained to the patient and informed consent was obtained the patient was taken to the operating room She was placed in the supine position The area was prepped and draped in the sterile fashion After adequate IV sedation was obtained by anesthesia esophagogastroduodenoscopy was performed The esophagus stomach and duodenum were visualized without difficulty There was no gross evidence of any malignancy There was some enterogastritis which was noted upon exam The appropriate location was noted on the anterior wall of the stomach This area was localized externally with 1 lidocaine Large gauge needle was used to enter the lumen of the stomach under visualization A guide wire was then passed again under visualization and the needle was subsequently removed A scalpel was used to make a small incision next to the guidewire and ensuring that the underlying fascia was nicked as well A dilator with break away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break away sheath and visualized within the lumen of the stomach The balloon was then insufflated and the break away sheath was then pulled away Proper placement of the tube was ensured through visualization with a scope The tube was then sutured into place using nylon suture Appropriate sterile dressing was applied DISPOSITION The patient was transferred to the recovery in a stable condition She was subsequently returned to her room on the General Medical Floor Previous orders will be resumed We will instruct the Nursing that the PEG tube can be used at 5 p m this evening for medications if necessary and bolus feedings Keywords surgery protein calorie malnutrition nausea vomiting peg tube placement russell technique peg tube egd protein dysphagia malnutrition enterogastritis MEDICAL_TRANSCRIPTION,Description Common description of EGD Medical Specialty Surgery Sample Name EGD Template 3 Transcription without difficulty into the upper GI tract The anatomy and mucosa of the esophagus gastroesophageal junction stomach pylorus and small bowel were all carefully inspected All structures were visually normal in appearance Biopsies of the distal duodenum gastric antrum and distal esophagus were taken and sent for pathological evaluation The endoscope and insufflated air were slowly removed from the upper GI tract A repeat look at the structures involved again showed no visible abnormalities except for the biopsy sites The patient tolerated the procedure with excellent comfort and stable vital signs After a recovery period in the Endoscopy Suite the patient is discharged to continue recovering in the family s care at home The family knows to follow up with me today if there are concerns about the patient s recovery from the procedure They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made Keywords surgery gastric antrum distal duodenum distal esophagus esophagus duodenum clo test upper gi tract upper gi gi tract egd endoscope gi tract structures distal biopsyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description EGD and colonoscopy Blood loss anemia normal colon with no evidence of bleeding hiatal hernia fundal gastritis with polyps and antral mass Medical Specialty Surgery Sample Name EGD Colonoscopy Transcription PREOPERATIVE DIAGNOSIS Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Normal colon with no evidence of bleeding 2 Hiatal hernia 3 Fundal gastritis with polyps 4 Antral mass ANESTHESIA Conscious sedation with Demerol and Versed SPECIMEN Antrum and fundal polyps HISTORY The patient is a 66 year old African American female who presented to ABCD Hospital with mental status changes She has been anemic as well with no gross evidence of blood loss She has had a decreased appetite with weight loss greater than 20 lb over the past few months After discussion with the patient and her daughter she was scheduled for EGD and colonoscopy for evaluation PROCEDURE After informed consent was obtained the patient was brought to the endoscopy suite She was placed in the left lateral position and was given IV Demerol and Versed for sedation When adequate level of sedation was achieved a digital rectal exam was performed which demonstrated no masses and no hemorrhoids The colonoscope was inserted into the rectum and air was insufflated The scope was coursed through the rectum and sigmoid colon descending colon transverse colon ascending colon to the level of the cecum There were no polyps masses diverticuli or areas of inflammation The scope was then slowly withdrawn carefully examining all walls Air was aspirated Once in the rectum the scope was retroflexed There was no evidence of perianal disease No source of the anemia was identified Attention was then taken for performing an EGD The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx The esophagus was easily intubated and traversed There were no abnormalities of the esophagus The stomach was entered and was insufflated The scope was coursed along the greater curvature towards the antrum Adjacent to the pylorus towards the anterior surface was a mass like lesion with a central _______ It was not clear if this represents a healing ulcer or neoplasm Several biopsies were taken The mass was soft The pylorus was then entered The duodenal bulb and sweep were examined There was no evidence of mass ulceration or bleeding The scope was then brought back into the antrum and was retroflexed In the fundus and body there was evidence of streaking and inflammation There were also several small sessile polyps which were removed with biopsy forceps Biopsy was also taken for CLO A hiatal hernia was present as well Air was aspirated The scope was slowly withdrawn The GE junction was unremarkable The scope was fully withdrawn The patient tolerated the procedure well and was transferred to recovery room in stable condition She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes We will await the biopsy reports and further recommendations will follow Keywords surgery esophagus gastroscope hypopharynx rectum fundal gastritis antral mass hiatal hernia egd hernia polyps colonoscopy MEDICAL_TRANSCRIPTION,Description Problems with dysphagia to solids and had food impacted in the lower esophagus Upper endoscopy to evaluate the esophagus Medical Specialty Surgery Sample Name EGD 1 Transcription HISTORY OF PRESENT ILLNESS Briefly this is a 17 year old male who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved to look for any stricture that may need to be dilated or any other mucosal abnormality PROCEDURE PERFORMED EGD PREP Cetacaine spray 100 mcg of fentanyl IV and 5 mg of Versed IV FINDINGS The tip of the endoscope was introduced into the esophagus and the entire length of the esophagus was dotted with numerous white punctate lesions suggestive of eosinophilic esophagitis There were come concentric rings present There was no erosion or flame hemorrhage but there was some friability in the distal esophagus Biopsies throughout the entire length of the esophagus from 25 40 cm were obtained to look for eosinophilic esophagitis There was no stricture or Barrett mucosa The bony and the antrum of the stomach are normal without any acute peptic lesions Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia There were no acute lesions and no evidence of ulcer tumor or polyp The pylorus was easily entered and the first second and third portions of the duodenum are normal Adverse reactions None FINAL IMPRESSION Esophageal changes suggestive of eosinophilic esophagitis Biopsies throughout the length of the esophagus were obtained for microscopic analysis There was no evidence of stricture Barrett or other abnormalities in the upper GI tract Keywords surgery length of the esophagus food impacted lower esophagus upper endoscopy entire length eosinophilic esophagitis egd dysphagia solids impacted endoscopy mucosal endoscope biopsies barrett stomach stricture eosinophilic esophagitis esophagus MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy patient with dysphagia Medical Specialty Surgery Sample Name EGD 2 Transcription PROCEDURES PERFORMED Esophagogastroduodenoscopy PREPROCEDURE DIAGNOSIS Dysphagia POSTPROCEDURE DIAGNOSIS Active reflux esophagitis distal esophageal stricture ring due to reflux esophagitis dilated with balloon to 18 mm PROCEDURE Informed consent was obtained prior to the procedure with special attention to benefits risks alternatives Risks explained as bleeding infection bowel perforation aspiration pneumonia or reaction to the medications Vital signs were monitored by blood pressure heart rate and oxygen saturation Supplemental O2 given Specifics of the procedure discussed The procedure was discussed with father and mother as the patient is mentally challenged He has no complaints of dysphagia usually for solids better with liquids worsening over the last 6 months although there is an emergency department report from last year He went to the emergency department yesterday with beef jerky All of this reviewed The patient is currently on Cortef Synthroid Tegretol Norvasc lisinopril DDAVP He is being managed for extensive past history due to an astrocytoma brain surgery hypothyroidism endocrine insufficiency He has not yet undergone significant workup He has not yet had an endoscopy or barium study performed He is developmentally delayed due to the surgery panhypopituitarism His family history is significant for his father being of mine also having reflux issues without true heartburn but distal esophageal stricture The patient does not smoke does not drink He is living with his parents Since his emergency department visitation yesterday no significant complaints Large male no acute distress Vital signs monitored in the endoscopy suite Lungs clear Cardiac exam showed regular rhythm Abdomen obese but soft Extremity exam showed large hands He was a Mallampati score A ASA classification type 2 The procedure discussed with the patient the patient s mother Risks benefits and alternatives discussed Potential alternatives for dysphagia such as motility disorder given his brain surgery given the possibility of achalasia and similar discussed The potential need for a barium swallow modified barium swallow and similar discussed All questions answered At this point the patient will undergo endoscopy for evaluation of dysphagia with potential benefit of the possibility to dilate him should there be a stricture He may have reflux symptoms without complaining of heartburn He may benefit from a trial of PPI All of this reviewed All questions answered Keywords surgery distal esophageal stricture reflux esophagitis distal esophageal esophageal stricture barium swallow esophagogastroduodenoscopy esophagitis esophageal heartburn stricture endoscopy reflux dysphagia MEDICAL_TRANSCRIPTION,Description Repair of left ear laceration deformity Y V plasty 2 cm Repair of right ear laceration deformity complex repair 2 cm Medical Specialty Surgery Sample Name Ear Laceration Repair Transcription PREOPERATIVE DIAGNOSIS Bilateral ear laceration deformities POSTOPERATIVE DIAGNOSIS Bilateral ear laceration deformities PROCEDURE 1 Repair of left ear laceration deformity Y V plasty 2 cm 2 Repair of right ear laceration deformity complex repair 2 cm ANESTHESIA 1 Xylocaine 1 100 000 epinephrine local BRIEF CLINICAL NOTE This patient was brought to the operating room today for the above procedure OPERATIVE NOTE The patient was laid in supine position adequately anesthetized with the above anesthesia sterilely prepped and draped The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared The marsupialized epithelialized tracts were pared to raw tissue They were pared in a fashion to create a Y V plasty with de epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge The 5 0 chromic sutures were used to approximate anteriorly posteriorly and anterior centrifugal edge in the Y V plasty fashion to decrease the risk of notching Bacitracin Band Aid was placed Next attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly posteriorly to create raw edges This was not taken through the edge of the lobe to decrease the risk of notch deformity The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog ear deformity toward the edge The 5 0 chromic sutures were used in interrupted fashion for this The patient tolerated the procedure well Band Aid and bacitracin were placed She left the operating room in stable condition Keywords surgery bilateral ear laceration dog ear deformity ear laceration deformity band aid laceration deformity ear laceration laceration deformity ear repair MEDICAL_TRANSCRIPTION,Description Right ear examination under anesthesia Right tympanic membrane perforation along with chronic otitis media Medical Specialty Surgery Sample Name Ear Examination Transcription PREOPERATIVE DIAGNOSIS Right tympanic membrane perforation POSTOPERATIVE DIAGNOSIS Right tympanic membrane perforation along with chronic otitis media PROCEDURE Right ear examination under anesthesia INDICATIONS The patient is a 15 year old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss Exam in the office revealed a posterior superior right marginal tympanic perforation Risks and benefits of surgery including risk of bleeding general anesthesia hearing loss as well as recurrent perforation were discussed with the mother The mother wished to proceed with surgery FINDINGS The patient was brought to the room placed in supine position given general endotracheal anesthesia The postauricular crease was then injected with 1 Xylocaine with 1 200 000 epinephrine along with external meatus An area of the scalp was shaved above the ear and then also 1 Xylocaine with 1 200 000 epinephrine injected a total of 4 mL local anesthetic was used The ear was then prepped and draped in the usual sterile fashion The microscope was then brought into view and examining the marginal perforation the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum The granulation tissue was debrided as much as possible Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible The middle ear space was filled with Floxin drops The patient woke up anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge was correct Estimated blood loss minimal Keywords surgery chronic otitis media middle ear space tympanic membrane perforation otitis media hearing loss middle ear ear space ear examination membrane perforation tympanic membrane anesthesia membrane tympanic ear perforation MEDICAL_TRANSCRIPTION,Description Dual Chamber ICD Implantation fluoroscopy defibrillation threshold testing venography Medical Specialty Surgery Sample Name Dual Chamber ICD Implantation Transcription PROCEDURE 1 Implantation dual chamber ICD 2 Fluoroscopy 3 Defibrillation threshold testing 4 Venography PROCEDURE NOTE After informed consent was obtained the patient was taken to the operating room The patient was prepped and draped in a sterile fashion Using modified Seldinger technique the left subclavian vein was attempted to be punctured but unsuccessfully Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein Venogram was then performed Under fluoroscopy via modified Seldinger technique the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava then the right atrium and then into the inferior vena cava A second guidewire was placed in a similar fashion Approximately a 5 cm incision was made in the left upper anterior chest The skin and subcutaneous tissue was dissected out of the prepectoral fascia Both guide wires were brought into the pocket area A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava The dilator and guidewire were removed A Fixation ventricular lead under fluoroscopic guidance was placed through the sheath into the superior vena cava right atrium and then right ventricle Using straight and curved stylettes it was placed in position and screwed into the right ventricular apex After pacing and sensing parameters were established in the lead the collar on the lead was sutured to the pectoral muscle with Ethibond suture A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava The dilator and guidewire were removed An Active Fixation atrial lead was fluoroscopically passed through the sheath into the superior vena cava and then the right atrium Using straight and J shaped stylettes it was placed in the appropriate position and screwed in the right atrial appendage area After significant pacing parameters were established in the lead the collar on the lead was sutured to the pectoral muscles with Ethibond suture The tract was flushed with saline solution A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture Deep and superficial layers were closed with 3 0 Vicryl in a running fashion Steri strips were placed over the incision Tegaderm was placed over the Steri strips Pressure dressing was applied to the pocket area Keywords surgery venography defibrillation threshold testing venogram dual chamber icd implantation dual chamber icd superior vena cava seldinger technique pectoral muscle steri strips dual chamber ethibond suture superior vena vena cava dual chamber icd implantation fluoroscopy atrium pectoral vein fluoroscopically vena cava lead guidewire MEDICAL_TRANSCRIPTION,Description Left ear cartilage graft repair of nasal vestibular stenosis using an ear cartilage graft cosmetic rhinoplasty left inferior turbinectomy Medical Specialty Surgery Sample Name Ear Cartilage Graft Transcription PREOPERATIVE DIAGNOSES 1 Posttraumatic nasal deformity 2 Nasal obstruction 3 Nasal valve collapse 4 Request for cosmetic change with excellent appearance of nose POSTOPERATIVE DIAGNOSES 1 Posttraumatic nasal deformity 2 Nasal obstruction 3 Nasal valve collapse 4 Request for cosmetic change with excellent appearance of nose OPERATIVE PROCEDURES 1 Left ear cartilage graft 2 Repair of nasal vestibular stenosis using an ear cartilage graft 3 Cosmetic rhinoplasty 4 Left inferior turbinectomy ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair We discussed with the patient the indications risks benefits alternatives and complications of the proposed surgical procedure she had her questions asked and answered Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager The patient had questions asked and answered Informed consent was obtained PROCEDURE IN DETAIL The patient was taken to the operating room and placed in supine position The appropriate level of general endotracheal anesthesia was induced The patient was converted to the lounge chair position and the nose was anesthetized and vasoconstricted in the usual fashion Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum The septal angle was approached and submucoperichondrial flaps were elevated Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered The upper laterals were divided and medial and lateral osteotomies were carried out Inadequate septal cartilage was noted to be present for use as spreader graft therefore left postauricular incision was made and the conchal bowl cartilage graft was harvested and it was closed with 3 0 running locking chromic with a sterile cotton ball pressure dressing applied Ear cartilage graft was then placed to put two spreader grafts on the left and one the right The two on the left extended all the way up to the caudal tip the one on the right just primarily the medial wall It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum The upper lateral cartilage was noted to be of the same width and length in size Yet the left lower cartilage was scarred and adherent to the upper lateral cartilage The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages A middle crus stitch was used to unite the domes and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height The spreader brought an excellent aesthetic appearance to the nose We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height Mucoperichondrial flaps were closed with 4 0 plain gut suture The skin was closed with 5 0 chromic and 6 0 fast absorbing gut Doyle splints were placed on each side of nasal septum and secured with 3 0 nylon and a Denver splint was applied The patient was awakened in the operating room and taken to the recovery room in good condition Keywords surgery nasal deformity nasal obstruction nasal valve cartilage cartilaginous crural graft nasal fracture postauricular rhinoplasty septal cartilage submucoperichondrial turbinectomy vestibular ear cartilage graft posttraumatic nasal deformity vestibular stenosis ear cartilage cartilage graft cartilages caudal nasal nose obstruction repair stenosis MEDICAL_TRANSCRIPTION,Description Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block for sacroiliac joint pain Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Surgery Sample Name Dorsal Ramus Branch Block Transcription PROCEDURE Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The X ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table pillow under the chest and head rotated contralateral to the side being treated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 25 gauge 3 5 inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1 S2 and S3 Multiple fluoroscopic views were used to ensure proper needle placement Approximately 0 25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern Finally the treatment solution consisting of 0 5 of bupivacaine was injected to each area All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS This was then repeated on the left side COMPLICATIONS None DISCUSSION Postprocedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to resume normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at the PM R Spine Clinic in approximately 1 week Keywords surgery sacroiliac lateral branch block ramus block branch block sacroiliac joint dorsal ramus fluoroscopic branch dorsal ramus bilateral needle block MEDICAL_TRANSCRIPTION,Description Excision dorsal ganglion right wrist The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field Medical Specialty Surgery Sample Name Dorsal Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Dorsal ganglion right wrist POSTOPERATIVE DIAGNOSIS Dorsal ganglion right wrist OPERATIONS PERFORMED Excision dorsal ganglion right wrist ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon TOURNIQUET TIME minutes DESCRIPTION OF PROCEDURE With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated and the tourniquet was elevated to 290 mm Hg A transverse incision was made over the dorsal ganglion Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto Care was taken to protect ligament integrity Reactive synovium was then removed using soft tissue rongeur technique The wound was then infiltrated with 0 25 Marcaine The tendons were allowed to resume their normal anatomical position The skin was closed with 3 0 Prolene subcuticular stitch Sterile dressings were applied The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords surgery excision dorsal ganglion extensor tendon extensor retinaculum dorsal ganglion retinaculum ganglion MEDICAL_TRANSCRIPTION,Description Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger The patient is a 51 year old male with left Dupuytren disease which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort Medical Specialty Surgery Sample Name Dupuytren Disease Excision Transcription PREOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger POSTOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger PROCEDURE PERFORMED Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Bier block INDICATIONS The patient is a 51 year old male with left Dupuytren disease which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort DESCRIPTION OF PROCEDURE The patient was taken to the operating room laid supine administered a bier block and prepped and draped in the sterile fashion A zig zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region Skin flaps were elevated carefully dissecting Dupuytren contracture off the undersurface of the flaps Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally which essentially returned to normal appearing tissue The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped The wound was irrigated The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease The incisions were closed with 5 0 nylon interrupted sutures The patient tolerated the procedure well and was taken to the PACU in good condition Keywords surgery excision of dupuytren disease proximal interphalangeal joint dupuytren disease bier block pip joint disease dupuytren contractions metacarpophalangeal neurovascular bundles interphalangeal finger MEDICAL_TRANSCRIPTION,Description Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis Release of first dorsal extensor compartment Medical Specialty Surgery Sample Name Dorsal Extensor Compartment Release Transcription PREOPERATIVE DIAGNOSIS Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis POSTOPERATIVE DIAGNOSIS Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis PROCEDURE PERFORMED Release of first dorsal extensor compartment ASSISTANT None ANESTHESIA Bier block TOURNIQUET TIME 30 minutes COMPLICATIONS None INDICATIONS The above patient is a 47 year old right hand dominant black female who has signs and symptomology of de Quervain s stenosing tenosynovitis She was treated conservatively with steroid injections splinting and nonsteroidal anti inflammatory agents without relief She is presenting today for release of the first dorsal extensor compartment She is aware of the risks benefits alternatives and has consented to this operation PROCEDURE The patient was given intravenous prophylactic antibiotics She was taken to the operating suite under the auspices of Anesthesiology She was given a left upper extremity bier block Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution Afterwards a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment Dissection was carried down through the dermis into the subcutaneous tissue The dorsal radial sensory branches were kept out of harm s way They were retracted gently to the ulnar side of the wrist The retinaculum was incised with a 15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally Both the extensor pollices brevis and abductor pollices longus tendons were identified There was no pathology noted within the first dorsal extensor compartment The wound was irrigated Hemostasis was obtained with bipolar cautery The wound was infiltrated with _0 25 Marcaine solution and then closure performed with 6 0 nylon suture utilizing a horizontal mattress stitch Sterile occlusive dressing was applied along with the thumb spica splint The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition Keywords surgery dorsal extensor compartment de quervain tendonitis dorsal extensor quervain tendonitis retinaculum tenosynovitis tourniquet MEDICAL_TRANSCRIPTION,Description Insertion of a double lumen port through the left femoral vein radiological guidance Open exploration of the left subclavian and axillary vein Metastatic glossal carcinoma needing chemotherapy and a port Medical Specialty Surgery Sample Name Double Lumen Port Inserstion Transcription PREOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port POSTOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port PROCEDURES 1 Open exploration of the left subclavian axillary vein 2 Insertion of a double lumen port through the left femoral vein radiological guidance DESCRIPTION OF PROCEDURE After obtaining the informed consent the patient was electively taken to the operating room where he underwent a general anesthetic through his tracheostomy The left deltopectoral and cervical areas were prepped and draped in the usual fashion Local anesthetic was infiltrated in the area There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin which made us suspicious that may be __________ but at any rate I tried to cannulate it subcutaneously and I was unsuccessful Therefore I proceeded to make an incision and was able to isolate the vein which would look very sclerotic I tried to cannulate it but I could not advance the wire At that moment I decided that there was no way we are going to put a port though that area I packed the incision and we prepped and redraped the patient including both groins Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty The introducer was placed and then a wire and then the catheter of the double lumen port which had been trimmed to position it near the heart It was done with radiological guidance Again I was able to position the catheter in the junction of inferior vena cava and right atrium The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area The port had been aspirated satisfactorily and irrigated with heparin solution The drain incision was closed in layers including subcuticular suture with Monocryl Then we went up to the left shoulder and closed that incision in layers Dressings were applied The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition Keywords surgery axillary vein subclavian double lumen port femoral vein radiological guidance glossal carcinoma port inserstion femoral radiological metastatic carcinoma chemotherapy anesthetic catheter MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy and bronchoscopy Medical Specialty Surgery Sample Name Direct Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic stenosis POSTOPERATIVE DIAGNOSIS Subglottic stenosis OPERATIVE PROCEDURES Direct laryngoscopy and bronchoscopy ANESTHESIA General inhalation DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operative table General inhalational anesthesia was administered through the patient s tracheotomy tube The small Parsons laryngoscope was inserted and the 2 9 mm telescope was used to inspect the airway There was an estimated 60 70 circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds The stoma showed some suprastomal fibroma The remaining tracheobronchial passages were clear The patient s 3 5 neonatal tracheostomy tube was repositioned and secured with Velcro ties Bleeding was negligible There were no untoward complications The patient tolerated the procedure well and was transferred to recovery room in stable condition Keywords surgery laryngoscopy and bronchoscopy direct laryngoscopy subglottic stenosis bronchoscopy laryngoscopy subglottic stenosis MEDICAL_TRANSCRIPTION,Description Degenerative disk disease at L4 L5 and L5 S1 Anterior exposure diskectomy and fusion at L4 L5 and L5 S1 Medical Specialty Surgery Sample Name Diskectomy Fusion Transcription PREOPERATIVE DIAGNOSIS Degenerative disk disease at L4 L5 and L5 S1 POSTOPERATIVE DIAGNOSIS Degenerative disk disease at L4 L5 and L5 S1 PROCEDURE PERFORMED Anterior exposure diskectomy and fusion at L4 L5 and L5 S1 ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 150 mL PROCEDURE IN DETAIL Patient was prepped and draped in sterile fashion Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie and then preperitoneal space was opened The iliac veins were carefully mobilized medially and then the L4 L5 disk space was confirmed by fluoroscopy and diskectomy fusion which will be separately dictated by Dr X was performed after the adequate exposure was gained and then after this L4 L5 disk space was fused and the L5 S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips disk was carefully exposed Diskectomy and fusion which will be separately dictated by Dr X were performed Once this was completed all hemostasis was confirmed The preperitoneal space was reduced X ray confirmed adequate positioning and fusion Then the fascia was closed with 1 Vicryl sutures and then the skin was closed in 2 layers the first layer being 2 0 Vicryl subcutaneous tissues and then a 4 0 Monocryl subcuticular stitch then dressed with Steri Strips and 4 x 4 s Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities Keywords surgery anterior exposure degenerative disk disease disk disease disk space diskectomy fusion MEDICAL_TRANSCRIPTION,Description Traumatic injury to bilateral upper extremities Dressing change under anesthesia This 6 year old was involved in a traumatic accident She presents today for evaluation and dressing change Medical Specialty Surgery Sample Name Dressing Change Transcription PREOPERATIVE DIAGNOSIS Traumatic injury to bilateral upper extremities POSTOPERATIVE DIAGNOSIS Traumatic injury to bilateral upper extremities PROCEDURE Dressing change under anesthesia PREOPERATIVE INDICATIONS This 6 year old was involved in a traumatic accident She presents today for evaluation and dressing change OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operating room under the care of Dr X He called us intraoperatively to evaluate the hand that had previously been repaired We were involved to that extent After removing the bandages we recognized that more of the tissue had healed than was initially expected She had good perfusion although the distal aspect of her left long finger This was better than expected For this reason no debridement was done at this time Dressings were reapplied to include Xeroform and a splint General Surgery and Orthopedic then carried on the rest of the operation Keywords surgery bandages traumatic injury upper extremities dressing change traumatic dressing injury MEDICAL_TRANSCRIPTION,Description Fractional dilatation and curettage Medical Specialty Surgery Sample Name Dilatation Curettage D C Transcription PREOPERATIVE DIAGNOSIS Postmenopausal bleeding POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Fractional dilatation and curettage SPECIMENS Endocervical curettings endometrial curettings INDICATIONS FOR PROCEDURE The patient recently presented with postmenopausal bleeding An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os FINDINGS Examination under anesthesia revealed a retroverted retroflexed uterus with fundal diameter of 6 5 cm The uterine cavity was smooth upon curettage Curettings were fairly copious Sounding depth was 8 cm PROCEDURE The patient was brought to the Operating Room with an IV in place The patient was given a general anesthetic and was placed in the lithotomy position Examination under anesthesia was completed with findings as noted She was prepped and draped and a speculum was placed into the vagina Tenaculum was placed on the cervix The endocervical canal was curetted using a Kevorkian curette and the sound was used to measure the overall depth of the uterus The endocervical canal was dilated without difficulty to a size 16 French dilator A small sharp curette was passed into the uterine cavity and curettings were obtained After completion of the curettage polyp forceps were passed into the uterine cavity No additional tissue was obtained Upon completion of the dilatation and curettage minimum blood loss was noted The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition Keywords surgery postmenopausal bleeding endometrial fractional dilatation fractional dilatation and curettage endocervical dilatation and curettage endocervical canal uterine cavity curetted dilatation curettings curettage MEDICAL_TRANSCRIPTION,Description Dilation and evacuation 12 week incomplete miscarriage The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os this was teased out and then a D E was performed yielding significant amount of central tissue Medical Specialty Surgery Sample Name Dilation Evacuation Transcription PREOPERATIVE DIAGNOSIS 12 week incomplete miscarriage POSTOPERATIVE DIAGNOSIS 12 week incomplete miscarriage OPERATION PERFORMED Dilation and evacuation ANESTHESIA General OPERATIVE FINDINGS The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os this was teased out and then a D E was performed yielding significant amount of central tissue The fetus of 12 week had been delivered previously by Dr X in the ER ESTIMATED BLOOD LOSS Less than 100 mL COMPLICATIONS None SPONGE AND NEEDLE COUNT Correct DESCRIPTION OF OPERATION The patient was taken to the operating room placed in the operating table in supine position After adequate anesthesia the patient was placed in dorsal lithotomy position The vagina was prepped The patient was then draped A speculum was placed in the vagina Previously mentioned products of conception were teased out with a ring forceps The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10 mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12 week pregnancy A sharp curettage then was performed and followed by two repeat suction curettages The procedure was then terminated and the equipment removed from the vagina as well as the speculum The patient tolerated the procedure well Blood type is Rh negative We will see the patient back in my office in 2 weeks Keywords surgery incomplete miscarriage dilation evacuation vagina protruding protruding speculum miscarriage forceps curettages vagina MEDICAL_TRANSCRIPTION,Description Redo L4 5 diskectomy left recurrent herniation L4 5 disk with left radiculopathy Medical Specialty Surgery Sample Name Diskectomy Transcription PREOPERATIVE DIAGNOSIS ES Recurrent herniation L4 5 disk with left radiculopathy POSTOPERATIVE DIAGNOSIS ES Recurrent herniation L4 5 disk with left radiculopathy PROCEDURE Redo L4 5 diskectomy left COMPLICATIONS None ANTIBIOTIC S Vancomycin given preoperatively ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 10 mL BLOOD REPLACED None CRYSTALLOID GIVEN 800 mL DRAIN S None DESCRIPTION OF THE OPERATION The patient was brought to the operating room in supine position General endotracheal anesthesia was administered He was turned into the prone position on the operating table and positioned in the modified knee chest position with Andrews frame being used Care was taken to protect pressure points The back was shaved scrubbed with Betadine scrub rinsed with alcohol and prepped with DuraPrep and draped in the usual sterile fashion with Ioban drape being used A midline skin incision was made excising scar from previous surgery Dissection was carried down through the subcutaneous tissue with electrocautery technique The lumbosacral fascia was split to the left of the spinous process and subperiosteal dissection of the spinous process and lamina area of previous laminotomy was identified Cross table lateral was also made to confirm position The scar was then loosened from the inferior portion of 4 superior of L5 lamina and a portion of the lamina was removed I did identify normal dura The scar was then lysed from the medial wall Dura and nerve root were identified and protected with nerve root retractor The bulging disk fragment was still contained under the longitudinal ligament A rent was made with the Penfield and a moderately large fragment was removed The disk space was then entered with a cruciate cut in the annulus with additional nuclear material being received When no other fragments could be removed from the disk space no other fragments were felt in the central canal under the longitudinal ligament and a Murphy ball could be passed through the foramen without evidence of compression the decompression was complete Check was made for CSF leakage and no evidence of significant epidural bleeding was present The wound was irrigated with antibiotic solution Twenty milligrams of Depo Medrol was placed over the dura and nerve root A free fat graft from the subcutaneous tissue was then placed over the dura Closure was obtained with the lumbosacral fascia being reapproximated with 1 running Vicryl suture Subcutaneous closure was obtained in layers with 2 0 running Vicryl suture Skin closure was obtained with 3 0 Vicryl subcuticular suture Proxi Strips and sterile dressing was applied The skin had been infiltrated with 8 mL of 0 5 Marcaine with epinephrine After a sterile dressing was applied the patient was turned into the supine position on the waiting recovery room stretcher brought from under the effects of anesthesia and taken to the recovery room Keywords surgery herniation andrews frame csf leakage depo medrol l4 5 proxi strips diskectomy endotracheal anesthesia lumbosacral fascia modified knee chest position radiculopathy supine position nerve root duraprep MEDICAL_TRANSCRIPTION,Description She required augmentation with Pitocin to achieve a good active phase She achieved complete cervical dilation Medical Specialty Surgery Sample Name Delivery Note 9 Transcription DELIVERY NOTE This G1 P0 with EDC 12 23 08 presented with SROM about 7 30 this morning Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho Exam upon arrival 2 to 3 cm 100 effaced 1 station and by report pool of fluid was positive for Nitrazine and positive ferning She required augmentation with Pitocin to achieve a good active phase She achieved complete cervical dilation at 1900 At this time a bulging bag was noted which ruptured and thick meconium was present At 1937 hours she delivered a viable male infant left occiput anterior Mouth and nares suctioned well with a DeLee on the perineum No nuchal cord present Shoulders and body followed easily Infant re suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance Apgars 9 and 9 Pitocin 15 units infused via pump protocol Placenta followed complete and intact with fundal massage and general traction on the cord Three vessels are noted She sustained a bilateral periurethral lax on the left side this extended down to the labia minora became a second degree in the inferior portion and did have some significant bleeding in this area Therefore this was repaired with 3 0 Vicryl after 1 lidocaine infiltrated approximately 5 mL The remainder of the lacerations was not at all bleeding and no other lacerations present Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots however as the Pitocin infused and massage continued this improved significantly EBL was about 500 mL Bleeding appears much better however Cytotec 400 mcg was placed per rectum apparently prophylactically Mom and baby currently doing very well Keywords surgery augmentation with pitocin delivery cervical dilation perineum lacerations pitocin infantNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Dental restorations and extractions Dental caries He has had multiple severe carious lesions that warrant multiple extractions at this time Medical Specialty Surgery Sample Name Dental Restorations Extractions Transcription PREOPERATIVE DIAGNOSIS Dental caries POSTOPERATIVE DIAGNOSIS Dental caries PROCEDURE Dental restorations and extractions CLINICAL HISTORY This 23 year old male is a client of the ABC Center because of his disability the nature of which is unclear to me at this time however he reportedly has several issues that qualify him as disabled He has had multiple severe carious lesions that warrant multiple extractions at this time It is also unclear to me as to how his prior or existing restorations were accomplished In any case he has been cleared for the procedure today He has his history and physical in the chart PROCEDURE The patient was brought to the operating room at 11 o clock and placed in the supine position Dr X administered the general anesthetic after which a throat pack was placed Available full mouth x rays were reviewed These x rays were taken at another location Teeth 2 4 10 12 13 15 18 20 27 and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies All of these aforementioned teeth were extracted using combinations of forceps and elevators Hemostasis in all of these sites was accomplished with direct pressure using gauze packs Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal These carious lesions and his tooth were excavated and the tooth was restored with amalgam involving these surfaces Tooth 6 had caries on the facial surface which was excavated and the tooth was restored with composite Tooth 7 had caries involving the distal surface Tooth 8 likewise had caries involving the distal surface and both of these distal lesions extended into incisal area These carious lesions were excavated and both of these teeth were restored with composite Tooth 9 had caries in a mesial surface and a buccal surface which was excavated and this tooth was restored with composite Tooth 28 caries in the mesial surface extending to the occlusal which was excavated and the tooth was restored with amalgam and tooth 30 had carries in the buccal surface which was excavated and the tooth was restored with amalgam A prophylaxis was done primarily using a rotating rubber cup and some minor scaling and the mouth was irrigated and suctioned thoroughly The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 1330 hours There was negligible blood loss Keywords surgery extractions multiple extractions mesial surface buccal surface dental restorations dental caries distal surface composite tooth carious lesions tooth dental caries MEDICAL_TRANSCRIPTION,Description An 83 year old diabetic female presents today stating that she would like diabetic foot care Medical Specialty Surgery Sample Name Diabetic Foot Care Transcription S An 83 year old diabetic female presents today stating that she would like diabetic foot care O On examination the lateral aspect of her left great toenail is deeply ingrown Her toenails are thick and opaque Vibratory sensation appears to be intact Dorsal pedal pulses are 1 4 There is no hair growth seen on her toes feet or lower legs Her feet are warm to the touch All of her toenails are hypertrophic opaque elongated and discolored A 1 Onychocryptosis Keywords surgery onychocryptosis onychomycosis great toenail diabetic foot care diabetic foot foot toenail ingrown toenails diabetic MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy Acute pelvic inflammatory disease and periappendicitis The patient appears to have a significant pain requiring surgical evaluation It did not appear that the pain was pelvic in nature but more higher up in the abdomen more towards the appendix Medical Specialty Surgery Sample Name Diagnostic Laparoscopy 1 Transcription PREOPERATIVE DIAGNOSIS Acute abdominal pain rule out appendicitis versus other POSTOPERATIVE DIAGNOSIS Acute pelvic inflammatory disease and periappendicitis PROCEDURE PERFORMED Diagnostic laparoscopy COMPLICATIONS None CULTURES Intra abdominally are done HISTORY The patient is a 31 year old African American female patient who complains of sudden onset of pain and has seen in the Emergency Room The pain has started in the umbilical area and radiated to McBurney s point The patient appears to have a significant pain requiring surgical evaluation It did not appear that the pain was pelvic in nature but more higher up in the abdomen more towards the appendix The patient was seen by Dr Y at my request in the ER with me in attendance We went over the case He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed The patient on ultrasound had a 0 9 cm ovarian cyst on the right side The patient s cyst was not completely simple and they are concerns over the possibility of an abnormality The patient states that she has had chlamydia in the past but it was not a pelvic infection more vaginal infection The patient has had hospitalization for this The patient therefore signed informed in layman s terms with her understanding that perceivable risks and complications the alternative treatment the procedure itself and recovery All questions were answered PROCEDURE The patient was seen in the Emergency Room In the Emergency Room there is really no apparent vaginal discharge No odor or cervical motion tenderness Negative bladder sweep Adnexa were without abnormalities In the OR we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10 week size The patient had no adnexal fullness The patient then underwent an insertion of a uterine manipulator and Dr X was in the case at that time and he started the laparoscopic process i e inserting the laparoscope We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus The both fallopian tubes were seen There did not appear to be hydrosalpinx The ovaries were seen The left showed some adhesions into the ovarian fossa The cul de sac had a banded adhesions The patient on the right adnexa had a hemorrhagic ovarian cyst where the cyst was only about a centimeter enlarged The ovary did not appear to have pus in it but there was pus over the area of the bladder flap The patient s bowel was otherwise unremarkable The liver contained evidence of Fitz Hugh Curtis syndrome and prior PID The appendix was somewhat adherent into the retrocecal area and to the mid quadrant abdominal sidewall on the right The case was then turned over to Dr Y who was in the room at that time and Dr X had left The patient s case was turned over to him Dr Y was performed an appendectomy following which cultures and copious irrigation Dr Y was then closed the case The patient was placed on antibiotics We await the results of the cultures and as well further ______ therapy PRIMARY DIAGNOSES 1 Periappendicitis 2 Pelvic inflammatory disease 3 Chronic adhesive disease Keywords surgery periappendicitis pelvic inflammatory disease chronic adhesive disease abdominal pain appendicitis diagnostic laparoscopy laparoscopy pelvic MEDICAL_TRANSCRIPTION,Description The patient is a 22 year old woman with a possible ruptured ectopic pregnancy Medical Specialty Surgery Sample Name Diagnostic Laparoscopy Transcription TITLE OF OPERATION Diagnostic laparoscopy INDICATION FOR SURGERY The patient is a 22 year old woman with a possible ruptured ectopic pregnancy PREOP DIAGNOSIS Possible ruptured ectopic pregnancy POSTOP DIAGNOSIS No evidence of ectopic pregnancy or ruptured ectopic pregnancy ANESTHESIA General endotracheal SPECIMEN Peritoneal fluid EBL Minimal FLUIDS 900 cubic centimeters crystalloids URINE OUTPUT 400 cubic centimeters FINDINGS Adhesed left ovary with dilated left fallopian tube tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary perihepatic lesions consistent with history of PID approximately 1 200 cubic centimeters of more serous than sanguineous fluid No evidence of ectopic pregnancy COMPLICATIONS None PROCEDURE After obtaining informed consent the patient was taken to the operating room where general endotracheal anesthesia was administered She was examined under anesthesia An 8 10 cm anteverted uterus was noted The patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy Attention was then turned to the patient s abdomen where a 5 mm incision was made in the inferior umbilicus The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water No peritoneum was obtained without difficulty using 4 liters of CO2 gas The 5 mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope The above noted findings were visualized A 5 mm skin incision was made approximately one third of the way from the ASI to the umbilicus at McBurney s point Under direct visualization the trocar and sleeve were advanced without difficulty A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep The peritoneal fluid was aspirated and sent for culture and wash and cytology The abdomen and pelvis were surveyed with the above noted findings No active bleeding was noted No evidence of ectopic pregnancy was noted The instruments were removed from the abdomen under good visualization with good hemostasis noted The sponge on a sponge stick was removed from the vagina The patient tolerated the procedure well and was taken to the recovery room in stable condition The attending Dr X was present and scrubbed for the entire procedure Keywords surgery peritoneal fluid sanguineous fluid ruptured ectopic pregnancy diagnostic laparoscopy intrauterine pregnancy ectopic pregnancy trocar ruptured ectopic tortuous pregnancy MEDICAL_TRANSCRIPTION,Description Dental restoration Dental caries Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe Medical Specialty Surgery Sample Name Dental Restoration Transcription PREOPERATIVE DIAGNOSIS Dental caries POSTOPERATIVE DIAGNOSIS Dental caries PROCEDURE Dental restoration CLINICAL HISTORY This 2 year 10 month old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting He was referred to me for that reason to be treated under general anesthesia for his dental work Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe There are no contraindications to this procedure He is healthy His history and physical is in the chart PROCEDURE The patient was brought to the operating room at 10 15 and placed in the supine position Dr X administered the general anesthetic after which 2 bite wing and 2 periapical x rays were exposed and developed and his teeth were examined A throat pack was then placed Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite Teeth E and F had caries in the mesial and distal surfaces these carious lesions were excavated and the teeth were restored with composite Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary This was done using ferric sulfate and zinc oxide eugenol For final restorations amalgam restorations were placed involving the occlusal surfaces both teeth I and L A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11 30 There was no blood loss Keywords surgery cavities carious lesions throat pack composite teeth occlusal surfaces dental restoration dental caries dental teeth caries MEDICAL_TRANSCRIPTION,Description Dental prophylaxis under general anesthesia Medical Specialty Surgery Sample Name Dental Prophylaxis Transcription OPERATION PERFORMED Dental prophylaxis under general anesthesia PREOPERATIVE DIAGNOSES 1 Impacted wisdom teeth 2 Moderate gingivitis POSTOPERATIVE DIAGNOSES 1 Impacted wisdom teeth 2 Moderate gingivitis COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY One hour 17 minutes BRIEF HISTORY The patient was referred to me by Dr X He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him I agreed I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination This clinical and radiographic examination revealed no dental caries however she was in need of a good dental cleaning OPERATIVE PREPARATION The patient was brought to Hospital Day Surgery accompanied by her mother I met with them and discussed the needs of the child types of restoration to be performed and the risks and benefits of the treatment as well as the options and alternatives of the treatment After all their questions and concerns were addressed they gave their informed consent to proceed with the treatment The patient s history and physical examination was reviewed Once she was cleared by Anesthesia she was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with a nasal endotracheal tube and the tube was stabilized The head was wrapped and the eyes were taped shut for protection An Angiocath was previously placed in preop The head and neck were draped in sterile towels and the body was covered with lead apron and sterile sheath A moist continuous throat pack was placed beyond tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative digital intraoral photographs were taken No digital radiographs were taken in the operating room as I stated before I had a full set of digital radiographs taken in my office A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done She presented with moderate calculus on the buccal surfaces of her maxillary first molars and lower molars She did not require any restorative dentistry Upon the conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were taken The continuous gauze throat pack was removed with continuous suction and visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This patient presented in her permanent dentition Her teeth 1 16 17 and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr Alexander Oral hygiene was fair There was generalized plaque and calculus throughout She did not have any caries did not require any restorative dentistry CONCLUSION Following my dental surgery the patient continued to intubated and was prepped for oral surgery procedures by Dr X and his associates There were no postop pain requirements I did not have any specific requirements for the patient or her mother and that will be handled by Dr X and their instructions on soft foods etc and pain control will be managed by them Keywords surgery dental prophylaxis impacted wisdom teeth gingivitis wisdom teeth moderate gingivitis dental rehabilitation throat pack digital radiographs restorative dentistry impacted anesthesia restorative wisdom oral prophylaxis teeth dental MEDICAL_TRANSCRIPTION,Description Torn rotator cuff and subacromial spur with impingement syndrome right shoulder Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors Medical Specialty Surgery Sample Name Diagnostic Arthroscopy Transcription PREOPERATIVE DIAGNOSIS Torn rotator cuff right shoulder POSTOPERATIVE DIAGNOSES 1 Torn rotator cuff right shoulder 2 Subacromial spur with impingement syndrome right shoulder PROCEDURE PERFORMED 1 Diagnostic arthroscopy with subacromial decompression 2 Open repair of rotator cuff using three Panalok suture anchors ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Approximately 200 cc INTRAOPERATIVE FINDINGS There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity There is moderate amount of synovitis noted throughout the glenohumeral joint There is a small subacromial spur noted on the very anterolateral border of the acromion HISTORY This is a 62 year old female who previously underwent a repair of rotator cuff She continued to have pain within the shoulder She had a repeat MRI performed which confirmed the clinical diagnosis of re tear of the rotator cuff She wished to proceed with a repair All risks and benefits of the surgery were discussed with her at length She was in agreement with the above treatment plan PROCEDURE On 08 21 03 she was taken to the Operative Room at ABCD General Hospital She was placed supine on the operating table General anesthesia was applied by the Anesthesiology Department She was placed in the modified beachchair position Her upper extremity was sterilely prepped and draped in usual fashion A stab incision was made in the posterior aspect of the glenohumeral joint A camera was placed in the joint and was insufflated with saline solution Intraoperative pictures were obtained and the above findings were noted A second port site was initiated anteriorly Through this a probe was placed and the intraarticular structures were palpated and found to be intact A tear of the inner surface of the rotator cuff was identified The camera was then taken to the subacromial space A straight lateral portal was also used and a shaver was placed into the subacromial space Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur which had reformed The edges of the rotator cuff were then debrided The camera was then removed and the shoulder was suction and dried A lateral incision was made over the anterolateral border of the acromion Subcuticular tissues were carefully dissected Hemostasis was controlled with electrocautery The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur A trough was then made in the greater tuberosity using the rongeur Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff The ends of the suture were tied down from the fixating the rotator cuff within the trough The rotator cuff was then further oversewed using the Panalok suture The wound was then copiously irrigated and it was then suction dried The deltoid muscle was reapproximated using 1 Vicryl A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control The subcutaneous tissues were reapproximated with 2 0 Vicryl The skin was closed with 4 0 PDS running subcuticular stitch Sterile dressing was applied to the upper extremity She was then placed in a shoulder immobilizer She was transferred to the recovery room in apparent stable and satisfactory condition Prognosis for this patient was guarded She will begin pendulum exercises postoperative day 3 She will follow back in the office in 10 to 14 days for reevaluation Physical therapy initiated approximately six weeks postoperatively Keywords surgery subacromial decompression panalok suture repair of rotator cuff torn rotator cuff diagnostic arthroscopy subacromial space subacromial spur arthroscopy panalok shoulder subacromial MEDICAL_TRANSCRIPTION,Description Her cervix on admission was not ripe so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon she was having frequent contractions and fetal heart tracing was reassuring At a later time Pitocin was started Medical Specialty Surgery Sample Name Delivery Note 8 Transcription DELIVERY NOTE The patient is a very pleasant 22 year old primigravida with prenatal care with both Dr X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital The patient was admitted to labor and delivery on Tuesday December 22 2008 at 5 30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital Her cervix on admission was not ripe so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon she was having frequent contractions and fetal heart tracing was reassuring At a later time Pitocin was started The next day at about 9 o clock in the morning I checked her cervix and performed artifical rupture of membranes which did reveal Meconium stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started The patient did have labor epidural which worked well It should be noted that the patient s recent vaginal culture for group B strep did come back negative for group B strep The patient went on to have a normal spontaneous vaginal delivery of a live term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1 5 ounces at birth The intensive care nursery staff was present because of the presence of Meconium stained amniotic fluid DeLee suctioning was performed at the perineum A second degree midline episiotomy was repaired in layers in the usual fashion using 3 0 Vicryl The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm ESTIMATED BLOOD LOSS Approximately 300 mL Keywords surgery amniotic fluid contractions pitocin meconium cervix labor vaginal delivery intravaginallyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Her pregnancy is complicated by preterm contractions She was on bedrest since her 34th week She was admitted here and labor was confirmed with rupture of membranes Medical Specialty Surgery Sample Name Delivery Note 6 Transcription DELIVERY NOTE This is an 18 year old G2 P0 at 35 4 7th weeks by a stated EDC of 01 21 09 The patient is a patient of Dr X s Her pregnancy is complicated by preterm contractions She was on bedrest since her 34th week She also has a history of tobacco abuse with asthma She was admitted here and labor was confirmed with rupture of membranes She was initially 5 70 1 Her bag was ruptured IUPC was placed She received an epidural for pain control and Pitocin augmentation was performed She progressed for several hours to complete and to push then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation Delivery of the head was manual assisted The shoulders and the rest of body then followed without difficulty Baby was bulb suctioned had a vigorous cry Cord was clamped twice and cut and the infant was handed to the awaiting nursing team Placenta then delivered spontaneously and intact was noted to have a three vessel cord The inspection of the perineum revealed it to be intact There was a hymenal remnant skin tag that was protruding from the vaginal introitus I discussed this with the patient She opted to have it removed This was performed and I put a single interrupted suture 3 0 Vicryl for hemostasis Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair Overall EBL is 300 mL Mom and baby are currently doing well Cord gases are being sent due to prematurity Keywords surgery preterm rupture of membranes preterm contractions contractions pregnancy deliveryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Pitocin was started quickly to allow for delivery as quickly as possible Baby was delivered with a single maternal pushing effort with retraction by the forceps Medical Specialty Surgery Sample Name Delivery Note 2 Transcription Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete and then as she began to push there were additional decelerations of the baby s heart rate which were suspicions of cord around the neck These were variable decelerations occurring late in the contraction phase The baby was in a 2 at a 3 station in an occiput anterior position and so a low forceps delivery was performed with Tucker forceps using gentle traction and the baby was delivered with a single maternal pushing effort with retraction by the forceps The baby was a little bit depressed at birth because of the cord around the neck and the cord had to be cut before the baby was delivered because of the tension but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes The female infant seemed to weigh about 7 5 pounds but has not been officially weighed yet Cord gases were sent and the placenta was sent to Pathology The cervix the placenta and the rectum all seemed to be intact The second degree episiotomy was repaired with 2 O and 3 0 Vicryl Blood loss was about 400 mL Because of the hole in the dura plan is to keep the patient horizontal through the day and a Foley catheter is left in place She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter The baby s father was present for the delivery as was one of the patient s sisters All are relieved and pleased with the good outcome Keywords surgery labor delivery pitocin tucker forceps apnea cerebrospinal fluid contraction epidural episiotomy fetal heart tones baby was delivered baby s heart rate heart rate catheter placenta cordNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Artificial rupture of membrane was performed for clear fluid She did receive epidural anesthesia She progressed to complete and pushing Medical Specialty Surgery Sample Name Delivery Note 5 Transcription DELIVERY NOTE This is a 30 year old G7 P5 female at 39 4 7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away She was admitted and started on Pitocin Her cervix is 3 cm 50 effaced and 2 station Artificial rupture of membrane was performed for clear fluid She did receive epidural anesthesia She progressed to complete and pushing She pushed to approximately one contraction and delivered a live born female infant at 1524 hours Apgars were 8 at 1 minute and 9 at 5 minutes Placenta was delivered intact with three vessel cord The cervix was visualized No lacerations were noted Perineum remained intact Estimated blood loss is 300 mL Complications were none Mother and baby remained in the birthing room in good condition Keywords surgery perineum placenta rupture of membrane artificial rupture cervix delivery inductionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient had ultrasound done on admission that showed gestational age of 38 2 7 weeks The patient progressed to a normal spontaneous vaginal delivery over an intact perineum Medical Specialty Surgery Sample Name Delivery Note 10 Transcription DELIVERY NOTE This is a 30 year old G6 P5 0 0 5 with unknown LMP and no prenatal care who came in complaining of contractions and active labor The patient had ultrasound done on admission that showed gestational age of 38 2 7 weeks The patient progressed to a normal spontaneous vaginal delivery over an intact perineum Rupture of membranes occurred on 12 25 08 at 2008 hours via artificial rupture of membranes No meconium was noted Infant was delivered on 12 25 08 at 2154 hours Two doses of ampicillin was given prior to rupture of membranes GBS status unknown Intrapartum events no prenatal care The patient had epidural for anesthesia No observed abnormalities were noted on initial newborn exam Apgar scores were 9 and 9 at one and five minutes respectively There was a nuchal cord x1 nonreducible which was cut with two clamps and scissors prior to delivery of body of child Placenta was delivered spontaneously and was normal and intact There was a three vessel cord Baby was bulb suctioned and then sent to newborn nursery Mother and baby were in stable condition EBL was approximately 500 mL NSVD with postpartum hemorrhage No active bleeding was noted upon deliverance of the placenta Dr X attended the delivery with second year resident Dr X Upon deliverance of the placenta the uterus was massaged and there was good tone Pitocin was started following deliverance of the placenta Baby delivered vertex from OA position Mother following delivery had a temperature of 100 7 denied any specific complaints and was stable following delivery Keywords surgery spontaneous vaginal delivery rupture of membranes gestational age vaginal delivery intact perineum prenatal care gestational placentaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes She was found to be positive for Nitrazine pull and fern At that time she was not actually contracting Medical Specialty Surgery Sample Name Delivery Note 7 Transcription DELIVERY NOTE The patient is a 29 year old gravida 6 para 2 1 2 3 who has had an estimated date of delivery at 01 05 2009 The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12 26 2008 She was found to be positive for Nitrazine pull and fern At that time she was not actually contracting She was Group B Streptococcus positive however was 5 cm dilated The patient was started on Group B Streptococcus prophylaxis with ampicillin She received a total of three doses throughout her labor Her pregnancy was complicated by scanty prenatal care She would frequently miss visits At 37 weeks she claims that she had a suspicious bump on her left labia There was apparently no fluid or blistering of the lesion Therefore it was not cultured by the provider however the patient was sent for serum HSV antibody levels which she tested positive for both HSV1 and HSV2 I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr X who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery The patient requested an epidural anesthetic which she received with very good relief She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions She delivered a viable female infant on 12 27 2008 at 0626 hours delivering over an intact perineum The baby delivered in the occiput anterior position The baby was delivered to the mother s abdomen where she was warm dry and stimulated The umbilical cord was doubly clamped and then cut The baby s Apgars were 8 and 9 The placenta was delivered spontaneously intact There was a three vessel cord with normal insertion The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol The perineum was inspected and was found to be fully intact Estimated blood loss was approximately 400 mL The patient s blood type is A She is rubella immune and as previously mentioned GBS positive and she received three doses of ampicillin Keywords surgery nitrazine pull and fern rupture of membranes spontaneous membranes nitrazine streptococcus pitocin perineum hsv laborNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Delivery was via spontaneous vaginal delivery Nuchal cord x1 were tight and reduced Infant was DeLee suctioned at perineum Medical Specialty Surgery Sample Name Delivery Note 3 Transcription DELIVERY NOTE On 12 23 08 at 0235 hours a 23 year old G1 P0 white female GBS negative under epidural anesthesia delivered a viable female infant with Apgar scores of 7 and 9 Points taken of for muscle tone and skin color Weight and length are unknown at this time Delivery was via spontaneous vaginal delivery Nuchal cord x1 were tight and reduced Infant was DeLee suctioned at perineum Cord clamped and cut and infant handed to the awaiting nurse in attendance Cord blood sent for analysis intact Meconium stained placenta with three vessel cord was delivered spontaneously at 0243 hours A 15 units of Pitocin was started after delivery of the placenta Uterus cervix and vagina were explored and a mediolateral episiotomy was repaired with a 3 0 Vicryl in a normal fashion Estimated blood loss was approximately 400 mL The patient was taken to the recovery room in stable condition Infant was taken to Newborn Nursery in stable condition The patient tolerated the procedure well The only intrapartum event that occurred was thick meconium Otherwise there were no other complications The patient tolerated the procedure well Keywords surgery nuchal cord spontaneous nuchal delee delivered meconium placenta vaginal perineum delivery infantNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Spontaneous controlled sterile vaginal delivery performed without episiotomy Medical Specialty Surgery Sample Name Delivery Note 1 Transcription The patient presented in the early morning hours of February 12 2007 with contractions The patient was found to be in false versus early labor and managed as an outpatient The patient returned to labor and delivery approximately 12 hours later with regular painful contractions There was minimal cervical dilation but 80 effacement by nurse examination The patient was admitted Expected management was utilized initially Stadol was used for analgesia Examination did not reveal vulvar lesions Epidural was administered Membranes ruptured spontaneously Cervical dilation progressed Acceleration deceleration complexes were seen Overall fetal heart tones remained reassuring during the progress of labor The patient was allowed to labor down during second stage Early decelerations were seen as well as acceleration deceleration complexes Overall fetal heart tones were reassuring Good maternal pushing effort produced progressive descent Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck There was no loop or coil of cord Infant was vigorous female sex Oropharynx was aggressively aspirated Cord blood was obtained Placenta delivered spontaneously Following delivery uterus was explored without findings of significant tissue Examination of the cervix did not reveal lacerations Upper vaginal lacerations were not seen Multiple first degree lacerations were present Specific locations included the vestibula at 5 o clock left labia minora with short extension up the left sulcus right anterior labia minora at the vestibule and midline of the vestibule All mucosal lacerations were reapproximated with interrupted simple sutures of 4 0 Vicryl with the knots being buried Post approximation examination of the rectum showed smooth intact mucosa Blood loss with the delivery was 400 mL Plans for postpartum care include routine postpartum orders Nursing personnel will be notified of Gilbert s syndrome Keywords surgery delivery gilbert s syndrome membranes cervical dilation contractions labia minora labor labor and delivery trimester uterus vaginal delivery vaginal lacerations vulvar fetal heart tones fetal heart heart tones postpartum vaginal fetal lacerationsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Incision and drainage with extensive debridement left shoulder Removal total shoulder arthroplasty uncemented humeral Biomet component cemented glenoid component Implantation of antibiotic beads left shoulder Medical Specialty Surgery Sample Name Debridement Shoulder Transcription TITLE OF OPERATION 1 Incision and drainage with extensive debridement left shoulder 2 Removal total shoulder arthroplasty uncemented humeral Biomet component cemented glenoid component 3 Implantation of antibiotic beads left shoulder INDICATION FOR SURGERY The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain incomplete return of function fractures loss of bone medical complications surgical complications transfusion related complications etc The patient understood and wished to proceed PREOP DIAGNOSIS Presumed infection left total shoulder arthroplasty POSTOP DIAGNOSES 1 Deep extensive infection left total shoulder arthroplasty 2 Biceps tenosynovitis 3 Massive rotator cuff tear in left shoulder full thickness subscapularis tendon rupture 3 cm x 4 cm supraspinatus tendon rupture 3 cm x 3 cm infraspinatus tear 2 cm x 2 cm DESCRIPTION OF PROCEDURE The patient was anesthetized in the supine position a Foley catheter was placed in his bladder He was then placed Beach chair position and all bony prominences were well padded Pillows were placed around his knees to protect his sciatic nerve He was brought to the side of the table and secured with towels and tape The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch Left upper extremity was then prepped and draped in usual sterile fashion Unfortunately preoperative antibiotics were given prior to the procedure This occurred due to lack of communication between the surgical staff and the anesthesia staff The patient s extremity however was prepped a second time with a chlorhexidine prep after he had been draped Also Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder Deltopectoral incision was then made The patient s had a cephalic vein it was identified and protected throughout the case It was retracted laterally and once this has been completed the deltopectoral interval was developed as carefully as possible The patient did have significant scar from this point on and did bleed from many surfaces throughout the case As a result he was transfused 1 unit postoperatively He did not have any problems during the case except for one small drop of blood pressure However this was due primarily because of the extensive scarring of his proximal humerus He had scar between the anterior capsular structures and the conjoint tendon Also there was significant scar between the deltoid and the proximal humerus The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve Once the plane between the deltoid and underlying tissue was found the proximal humerus was discovered to have a large defect approximately 4 x 3 This was covered by rimmed fibrous tissue which was fairly compressible which felt to be purulent however when the needle was stuck into this area there was no return of fluid As a result this was finally opened and found to have fibrinous exudates which appeared to be old congealed purulent material There was some suggestion of a synovitis type reaction also inside this cystic area This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm All of the mucinous material and fibrinous material was removed from the proximal humerus This was fairly extensive debridement All of this was sent to pathology and also sent for culture and sensitivity It should be noted that Gram stain became as multiple white blood cells but no organism seen The pathology came back as fibrinous material with multiple white cells also with signs of chronic inflammation consistent with an infection Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous This was also removed Once this was removed though the capsule was found to be very thin there was essentially no subscapularis tendon whatsoever It should also noted the patient s proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever As a result the biceps tendon was finally identified just below the pectoralis tendon insertion The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps It was tracked proximally and transverse ligament released The biceps tendon was flat and somewhat erythematous As a result it released and tagged with an 0 Vicryl suture It was later tenodesed to the conjoint tendon using 2 0 Prolene sutures The joint was then entered and noted significant synovitis throughout the entire glenoid This was all very carefully removed using a rongeur and sharp dissection Next the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set Unfortunately this device would not hold the proximal humerus and we could not get the component to release As a result bone contact of the metal proximally was released using a straight osteotome Once this was completed another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed we abandoned use of that particular device and using a __________ we were able to hit the prosthesis lip from beneath and essentially remove it There was no cement There was exudate within the canal which was removed using a curette Using fluoroscopy sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate This was also thoroughly irrigated with irrigation antibiotic and impregnated irrigation to decrease any risk of infection It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point The attention was then directed to the glenoid The glenoid component was very carefully dissected free and found to be very loose It was essentially removed with digital dissection There was no remaining cement in the cavity itself The patient s glenoid was very carefully debrided The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself Next the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation Rather than place a spacer it was elected to use antiobiotic beads This was with antibiotic impregnated cement with one package with 3 gram of vancomycin These beads were then connected using Prolene and placed into the glenoid cavity itself also some were placed in the greater tuberosity region These three did not have a Prolene attached to them The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself The biceps tendon was then tenodesed under tension to the conjoint tendon There was essentially no capsule left purely to close over the proximal humerus It was electively the proximal humerus A portion of bone intact because it did have some bleeding surfaces Deltopectoral was then closed with 0 Vicryl sutures the deep subcutaneous tissues with 0 Vicryl sutures superficial subcutaneous tissues with 2 0 Vicryl sutures Skin was closed with staples A sterile bandage was applied along with a cold therapy device and shoulder immobilizer The patient was sent to recovery room in stable and satisfactory condition It should be noted that __________ is being requested for this case This was a significantly scarred patient which required extra dissection and attention Even though this was a standard revision case due to infection there was a significant more decision making and technical challenges in this case and this was present for typical revision case Similarly this case took approximately 30 to 40 more length of time due to bleeding and the attention to hemostasis The blood loss and operative findings indicates that this case was at least 30 to 40 more challenging than a standard total shoulder or revision case This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever Keywords surgery incision and drainage shoulder arthroplasty extensive debridement uncemented humeral biomet cemented antibiotic beads biceps tenosynovitis rotator cuff tear total shoulder arthroplasty proximal humerus vicryl sutures glenoid tendon proximal humerus beads shoulder incision MEDICAL_TRANSCRIPTION,Description She progressed in labor throughout the day Finally getting the complete and began pushing Pushed for about an hour and a half when she was starting to crown Medical Specialty Surgery Sample Name Delivery Note 4 Transcription DELIVERY NOTE The patient came in around 0330 hours in the morning on this date 12 30 08 in early labor and from a closed cervix very posterior yesterday she was 3 cm dilated Membranes ruptured this morning by me with some meconium An IUPC was placed Some Pitocin was started because the contractions were very weak She progressed in labor throughout the day Finally getting the complete at around 1530 hours and began pushing Pushed for about an hour and a half when she was starting to crown The Foley was already removed at some point during the pushing The epidural was turned down by the anesthesiologist because she was totally numb She pushed well and brought the head drown crowning at which time I arrived and setting her up delivery with prepping and draping She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed With delivery of the head I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance Exam revealed a good second degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact although I cannot see good fascia around the sphincter anteriorly The placenta separated with some bleeding seen and was assisted expressed and completely intact Uterus firmed up well with IV pit Repair of the tear with 2 0 Vicryl stitches and a 3 0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural Once this was complete mom and baby doing well Baby was a female infant Apgars 8 and 9 Keywords surgery iupc meconium pitocin epidural rectum sphincter labor perineum pushed deliveryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat Sharp excision of left distal foot plantar fascia Medical Specialty Surgery Sample Name Debridement Foot Ulcer Transcription PREOPERATIVE DIAGNOSES 1 Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint 2 Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx 3 Plantar fascitis of left distal lateral foot POSTOPERATIVE DIAGNOSES 1 Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint 2 Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx 3 Plantar fascitis of left distal lateral foot OPERATION PERFORMED 1 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat 2 Sharp excision of left distal foot plantar fascia ANESTHESIA None required INDICATIONS The patient is a 51 year old diabetic female with severe peripheral vascular disease who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation PROCEDURE IN DETAIL The procedure was performed in the patient s room The dressing was removed exposing about a 4 cm x 2 5 cm left distal lateral foot fifth ray amputation open wound Distally there is infarcted left fourth metatarsophalangeal joint capsule as well as plantar fat below the joint She has neuropathy allowing debridement of the tissues Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided There was complete infarction of the lateral joint capsule and the head of the phalanx as well as distal metatarsal head were chronically infected The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad The patient suffered no complications from the procedure Keywords surgery plantar fascia foot ulcer interosseous metatarsal cellulitis amputation osteomyelitis plantar fascitis joint capsule ray amputation debridement plantar foot MEDICAL_TRANSCRIPTION,Description Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise Fetal position is right occiput anterior Medical Specialty Surgery Sample Name Delivery Note Transcription HISTORY This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest unfortunately felt decreased fetal movement yesterday 12 29 08 presented to the hospital for evaluation on the evening of 12 29 08 At approximately 2030 hours and on admission no cardiac activity was noted by my on call partner Dr X This was confirmed by Dr Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks gestation SUMMARY She was admitted She was 3 cm dilated on admission She desired induction of labor Therefore Pitocin was started Epidural was placed for labor pain She did have a temperature of 100 7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy She remained febrile approximately 100 3 She then progressed On my initial exam at approximately 0730 hours she was 3 to 4 cm dilated She had reported previously some mucous discharge with no ruptured membranes Upon my exam no membranes were noted Attempted artificial rupture of membranes was performed No fluid noted and there was no fluid discharge noted all the way until the time of delivery Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor She progressed well and completely dilated pushed approximately three times and proceeded with delivery DELIVERY NOTE Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise Fetal position is right occiput anterior COMPLICATIONS Again intrauterine fetal demise Placenta delivery spontaneous Condition was intact with a three vessel cord Lacerations she had a small right periurethral laceration as well as a small second degree midline laceration These were both repaired postdelivery with 4 0 Vicryl on an SH and a 3 0 Vicryl on a CT 1 respectively Estimated blood loss was 200 mL Infant is a male infant appears grossly morphologically normal Apgars were 0 and 0 Weight pending at this time NARRATIVE OF DELIVERY I was called This patient was completely dilated I arrived She pushed for three contractions She was very comfortable She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant There was a tight nuchal cord x1 that was reduced after delivery of the fetus Cord was doubly clamped The infant was transferred to a bassinet cleaned by the nursing staff en route The placenta delivered spontaneously was carefully examined found to be intact No signs of abruption No signs of abnormal placentation or abnormal cord insertion The cord was examined and a three vessel cord was confirmed At this time IV Pitocin and bimanual massage Fundus firm as above with minimal postpartum bleeding The vagina and perineum were carefully inspected A small right periurethral laceration was noted was repaired with a 4 0 Vicryl on an SH needle followed by a small second degree midline laceration was repaired in a normal running fashion with a 3 0 Vicryl suture At this time the repair is intact She is hemostatic All instruments and sponges were removed from the vagina and the procedure was ended Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time We have called pastor in to baptize the baby as well as calling social work They are deciding on a burial versus cremation have decided against autopsy at this time She will be transferred to postpartum for her recovery She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders Keywords surgery decreased fetal movement labor pain preterm labor delivery note vaginal delivery fetal position fetal demise intrauterine delivery spontaneous dilated lacerations cord fetal MEDICAL_TRANSCRIPTION,Description Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System Medical Specialty Surgery Sample Name Decompressive Laminectomy Transcription PREOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression POSTOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression OPERATION PERFORMED Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click X System using 6 5 mm diameter x 40 mm length T11 screws and L1 screws 7 mm diameter x 45 mm length ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 400 mL replaced 2 units of packed cells Preoperative hemoglobin was less than 10 DRAINS None COMPLICATIONS None DESCRIPTION OF PROCEDURE With the patient prepped and draped in a routine fashion in the prone position on laminae support an x ray was taken and demonstrated a needle at the T12 L1 interspace An incision was made over the posterior spinous process of T10 T11 T12 L1 and L2 A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10 T11 T12 L1 and L2 An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent Initially on the patient s left side pedicle screws were placed in T11 and L1 The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle Placement confirmed with biplanar coaxial fluoroscopy The awl was in appropriate location and using a pedicle finder under fluoroscopic control the pedicle was probed to the mid portion of the body of T11 A 40 mm Click X screw 6 5 mm diameter with rod holder was then threaded into the T11 vertebral body Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra articular process was located using an AM 8 dissecting tool AM attachment to the Midas Rex instrumentation The area was decorticated an awl was placed and under fluoroscopic biplanar imaging noted to be at the pedicle in L1 Using a pedicle probe the pedicle was then probed to the mid body of L1 and a 7 mm diameter 45 mm in length Click X Synthes screw with rod holder was placed in the L1 vertebral body At this point an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient s ventral canal on the right side Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12 At this point a laminectomy was performed using 45 degree Kerrison rongeur both 2 mm and 4 mm and Leksell rongeur There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11 T12 interlaminar space Additionally there was marked instability of the facets bilaterally at T12 and L1 These facets were removed with 45 degree Kerrison rongeur and Leksell rongeur Bony compression both superiorly and laterally from fractured bony elements was removed with 45 degree Kerrison rongeur until the thecal sac was completely decompressed The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors and these nerve roots were noted to be completely free Hemostasis was controlled with bipolar coagulation At this point a Frazier dissector could be passed superiorly inferiorly medially and laterally to the T11 T12 nerve roots bilaterally and the thecal sac was noted to be decompressed both superiorly and inferiorly and noted to be quite pulsatile A 4 Penfield was then used to probe the floor of the spinal canal and no significant ventral compression remained on the thecal sac Copious antibiotic irrigation was used and at this point on the patient s right side pedicle screws were placed at T11 and L1 using the technique described for a left sided pedicle screw placement The anatomic landmarks being the transverse process at T11 the inferior articulating facet and the lateral aspect of the superior articular facet for T11 and at L1 the transverse process the junction of the intra articular process and the facet joint With the screws placed on the left side the elongated rod was removed from the patient s right side along with the locking caps which had been placed It was felt that distraction was not necessary A 75 mm rod could be placed on the patient s left side with reattachment of the locking screw heads with the rod cap locker in place however it was necessary to cut a longer rod for the patient s right side with the screws slightly greater distance apart ultimately settling on a 90 mm rod The locking caps were placed on the right side and after all 4 locking caps were placed the locking cap screws were tied to the cold weld Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11 T12 or T12 L1 with excellent positioning of the rods and screws A crosslink approximately 60 mm in width was then placed between the right and left rods and all 4 screws were tightened It should be noted that prior to the placement of the rods the patient s autologous bone which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11 T12 and L1 with AM 8 dissecting tool AM attachment as well as the lateral aspects of the facet joints This was done bilaterally prior to placement of the rods Following placement of the rods as noted above allograft bone chips were packed in addition on top of the patient s own allograft in these posterolateral gutters Gelfoam was used to cover the thecal sac and at this point the wound was closed by approximating the deep muscle with 0 Vicryl suture The fascia was closed with interrupted 0 Vicryl suture subcutaneous layer was closed with 2 0 Vicryl suture subcuticular layer was closed with 2 0 inverted interrupted Vicryl suture and the skin approximated with staples The patient appeared to tolerate the procedure well without complications Keywords surgery facetectomies decompression posterolateral fusion synthes click x system decompressive laminectomy leksell rongeur kerrison rongeur transverse processes thecal sac nerve roots pedicle screws spinous process pedicle process screws rods laminectomy decompressive spinous MEDICAL_TRANSCRIPTION,Description Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area Pannus and left peritoneal specimen sent to Pathology Medical Specialty Surgery Sample Name Debridement Necrotic Tissue Transcription PREOPERATIVE DIAGNOSIS Necrotizing infection of the left lower abdomen and left peritoneal area POSTOPERATIVE DIAGNOSIS Necrotizing infection of the left lower abdomen and left peritoneal area PROCEDURE PERFORMED Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area ANESTHESIA General FLUIDS 800 cc given ESTIMATED BLOOD LOSS 350 cc SPECIMEN Pannus and left peritoneal specimen sent to Pathology REASON FOR PROCEDURE This is a 53 year old white male who presented to ABCD General Hospital on 09 05 03 with a chief complaint of drainage from his left groin The patient is a diabetic who requires insulin but has been noncompliant and states that his blood sugars have been out of control He has had a groin abdominal wound drained for about four days The patient states that there has been pus that has saturated his sheath He has had a possible fever at home that he did not chart with a thermometer He has had the same groin infection twice in the past with tunneling lesions The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day Bowel habits and eating were essentially normal Urinary habits were normal The patient is morbidly obese and is approximately 450 lb He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications PAST MEDICAL HISTORY Diabetes morbid obesity and nephrolithiasis PAST SURGICAL HISTORY Appendectomy and stone extraction PROCEDURE The patient was examined in the Emergency Room by Dr X and was found to have multiple areas of erythematous tissue which could potentially be consistent with a necrotizing fascitis texture The patient had a white count of 11 4 and a hemoglobin of 13 4 Please note that the patient is a Jehovah s Witness and has adamantly refused receiving any blood products The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted In the operative suite he was prepped and draped in the usual sterile fashion The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized Approximately 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated The abdomen appeared to have a large erythematous border however the true indurated tissue was approximately the size of a deck of cards The area was incised using a 10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia The necrotic tissue was lifted out of the abdomen All bleeding was cauterized using the Bovie A solution of gentamicin and sterile saline was placed into a high powered water pump device and the wound was copiously irrigated and suctioned A wet Kerlix dressing was passed into the wound and it will be left opened with wet to dry dressing The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm The tissue was incised to the muscle layer of the muscle There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well There was a mild amount of pus that drained from the wound Cultures were taken from the groin wound and were sent to pathology The specimen was excised using traction with the Allis clamps as well as Bovie set on coag Once the tissue was excised from the ________ the area was fully irrigated using the gentamicin sterile saline solution in the high powered water irrigation unit After the irrigation the wound was packed using a wet Kerlix dressing and will be left open to heal It was determined at this time that both wounds will be left open to heal with the wet to dry dressings in place and we will come back and close the wounds at a later date The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology The patient tolerated the procedure well and was taken to recovery in good condition Keywords surgery debridement abdomen peritoneal pannus pathology necrotizing infection necrotic tissue tissue infection necrotizing groin wound MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C laparoscopy right salpingectomy lysis of adhesions and evacuation of hemoperitoneum Pelvic pain ectopic pregnancy and hemoperitoneum Medical Specialty Surgery Sample Name D C Laparoscopy Salpingectomy Transcription PREOPERATIVE DIAGNOSES 1 Pelvic pain 2 Ectopic pregnancy POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Ectopic pregnancy 3 Hemoperitoneum PROCEDURES PERFORMED 1 Dilation and curettage D C 2 Laparoscopy 3 Right salpingectomy 4 Lysis of adhesions 5 Evacuation of hemoperitoneum ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Scant from the operation however there was approximately 2 liters of clotted and old blood in the abdomen SPECIMENS Endometrial curettings and right fallopian tube COMPLICATIONS None FINDINGS On bimanual exam the patient has a small anteverted uterus it is freely mobile No adnexal masses however were appreciated on the bimanual exam Laparoscopically the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus There were also adhesions to the left fallopian tube and the right fallopian tube There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood There was some questionable gestational tissue ________ on the left sacrospinous ligament There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube PROCEDURE After an informed consent was obtained the patient was taken to the operating room and the general anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion Once the anesthetic was found to be adequate a bimanual exam was performed under anesthetic A weighted speculum was then placed in the vagina The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum The cervix was then serially dilated with Hank dilators to a size 20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology At this point the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed Next attention was then turned to the abdomen The surgeons all are removed the dirty gloves in the previous portion of the case Next a 2 cm incision was made immediately inferior to umbilicus The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision Next a syringe was used to inject normal saline into the Veress needle The normal saline was seen to drop freely so a Veress needle was connected to the CO2 gas which was started at its lowest setting The gas was seen to flow freely with normal resistance so the CO2 gas was advanced to a higher setting The abdomen was insufflated to an adequate distension Once an adequate distention was reached the CO2 gas was disconnected The Veress needle was removed and a size 11 step trocar was placed The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted Next a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera A Veress needle and a step sheath were inserted through this incision Next the Veress needle was removed and a size 5 trocar was inserted under direct visualization Next a size 5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion A size 12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes Next the Dorsey suction irrigator was used to copiously irrigate the abdomen Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen Once the majority of blood was cleaned from the abdomen the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with 12 port Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy An EndoCatch bag was then placed to the size 12 port and this was used to remove the right fallopian tube and ectopic pregnancy This was then sent to the pathology Next the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic The abdomen was further irrigated The liver was examined and appeared to be within normal limits At this point the two size 5 ports and a size 12 port were removed under direct visualization The camera was then removed The CO2 gas was disconnected and the abdomen was desufflated The introducer was then replaced in a size 11 port and the whole port and introducer was removed as a single unit All laparoscopic incisions were closed with a 4 0 undyed Vicryl in a subcuticular interrupted fashion They were then steri stripped and bandaged appropriately At the end of the procedure the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She was discharged home with a postoperative hemoglobin of 8 9 She was given iron 325 mg to be taken twice a day for five months and Darvocet N 100 mg to be taken every four to six hours for pain She will follow up within a week in the OB resident clinic Keywords surgery pelvic pain ectopic pregnancy hemoperitoneum d c dilation laparoscopy curettage salpingectomy lysis of adhesions bimanual exam veress needle fallopian tube umbilicus cervix ectopic pregnancy abdomen tube MEDICAL_TRANSCRIPTION,Description Debridement of wound fasciotomies debridement of muscle from the anterior compartment and application of vacuum assisted closure systems to fasciotomy wounds as well as traumatic wound Medical Specialty Surgery Sample Name Debridements Transcription PREOPERATIVE DIAGNOSIS Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle POSTOPERATIVE DIAGNOSIS Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment PROCEDURE Debridement of wound fasciotomies debridement of muscle from the anterior compartment and application of vacuum assisted closure systems to fasciotomy wounds as well as traumatic wound ANESTHESIA General COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient in the supine position under adequate general endotracheal anesthesia the patient s left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field The patient s traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient s leg there was some blistering of the skin The compartment pressures of the patient s four compartments were measured for the anterior and lateral compartments the measurement was 32 for the posterior compartment superficial and deep it was 34 With this information we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments Muscle in these compartments was contractile Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment The lateral compartment appeared contractile The anterior compartment appeared necrotic for most of the muscle in the compartments What appeared viable was left intact A vacuum assisted closure system was utilized on each fasciotomy wound Given the nature of the patient s foot we proceeded with a fasciotomy of the patient s foot medially and good contractile muscle was found there This was included in the VAC seal as well as the traumatic wound A good seal was obtained to through the fasciotomy wounds and traumatic wound and the patient was placed in a posterior plaster splint well padded He tolerated the procedure well was taken to the recovery room in good condition Keywords surgery left lower extremity debridement of wound fasciotomies debridement of muscle vacuum assisted closure systems status post motorcycle accident vacuum assisted closure systems vacuum assisted closure assisted closure systems wound fasciotomies fasciotomies debridement vacuum assisted closure systems lower extremity lateral compartments anterior compartment fasciotomy wounds traumatic wound wound anterior polytrauma motorcycle accident contractile vacuum debridements traumatic muscle fasciotomy compartment MEDICAL_TRANSCRIPTION,Description Complex right lower quadrant mass with possible ectopic pregnancy Right ruptured tubal pregnancy and pelvic adhesions Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy Medical Specialty Surgery Sample Name D C Tubal Pregnancy Removal Transcription PREOPERATIVE DIAGNOSIS Complex right lower quadrant mass with possible ectopic pregnancy POSTOPERATIVE DIAGNOSES 1 Right ruptured tubal pregnancy 2 Pelvic adhesions PROCEDURE PERFORMED 1 Dilatation and curettage 2 Laparoscopy with removal of tubal pregnancy and right partial salpingectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than 100 cc COMPLICATIONS None INDICATIONS The patient is a 25 year old African American female gravida 7 para 1 0 5 1 with two prior spontaneous abortions with three terminations who presents with pelvic pain She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900 Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy FINDINGS On bimanual exam the uterus was approximately 10 weeks in size mobile and anteverted There were no adnexal masses appreciated although there was some fullness in the right lower quadrant The cervical os appeared parous Laparoscopic findings revealed a right ectopic pregnancy which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary There were some pelvic adhesions in the right abdominal wall as well The left fallopian tube and ovary and uterus appeared normal There was no evidence of endometriosis There was a small amount of blood in the posterior cul de sac PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite prepped and draped placed under general anesthesia and placed in the dorsal lithotomy position The bimanual exam was performed which revealed the above findings A weighted speculum was placed in the patient s posterior vaginal vault and the 12 o clock position of the cervix was grasped with the vulsellum tenaculum The cervix was then serially dilated using Hank dilators up to a 10 A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue The tissue was sent to pathology for evaluation The uterine elevator was then placed in the patient s cervix Gloves were changed The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made While tenting up the abdominal wall the Veress needle was placed without difficulty The abdomen was then insufflated with appropriate volume and flow of CO2 The 11 step trocar was then placed without difficulty in abdominal wall The placement was confirmed with a laparoscope It was then decided to put a 5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents The above findings were then noted Because the tubal pregnancy was adherent to the ovary an additional port was placed in the right lateral aspect of the patient s abdomen A 12 step trocar port was placed under direct visualization Using a grasper Nezhat Dorsey suction irrigator the mass was hydro dissected off of the right ovary and further shelled away with graspers This was removed with the gallbladder grasper through the right lateral port site There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached Partial salpingectomy was therefore performed This was done using the LigaSure The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected Good hemostasis was obtained in all of the right adnexal structures The pelvis was then copiously suction irrigated The area again was then visualized and again found to be hemostatic The instruments were then removed from the patient s abdomen under direct visualization The abdomen was then desufflated and the 11 step trocar was removed The incisions were then repaired with 4 0 undyed Vicryl and dressed with Steri Strips The uterine elevator was removed from the patient s vagina The patient tolerated the procedure well The sponge lap and needle count were correct x2 She will follow up postoperatively as an outpatient Keywords surgery lower quadrant mass tubal pregnancy pelvic adhesions laparoscopy salpingectomy ectopic pregnancy abdominal wall pregnancy MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome and de Quervain s stenosing tenosynovitis Carpal tunnel release and de Quervain s release A longitudinal incision was made in line with the 4th ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis Medical Specialty Surgery Sample Name de Quervain Release Carpal Transcription PREOPERATIVE DIAGNOSIS 1 Carpal tunnel syndrome 2 de Quervain s stenosing tenosynovitis POSTOPERATIVE DIAGNOSIS 1 Carpal tunnel syndrome 2 de Quervain s stenosing tenosynovitis TITLE OF PROCEDURE 1 Carpal tunnel release 2 de Quervain s release ANESTHESIA MAC COMPLICATIONS None PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the 4th ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis The subcutaneous fat was dissected radially from 2 3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly and the distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with scissors After irrigating the wound with copious amounts of normal saline the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4 0 Vicryl Care was taken to avoid entrapping the motor branch of the median nerve in the suture A hemostat was placed under the repair to ensure that the median nerve was not compressed The skin was repaired with 5 0 nylon interrupted stitches The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches I released the compartment in a separate subsheath for the EPB on the dorsal side Both ends of the sheath were released to lengthen them and then these were repaired with 4 0 Vicryl It was checked to make sure that there was significant room remaining for the tendons This was done to prevent postoperative subluxation I then irrigated and closed the wounds in layers Marcaine with epinephrine was placed into all wounds and dressings and splint were placed The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery de quervain s release carpal tunnel syndrome tenosynovitis carpal incision aponeurosis tunnel cut MEDICAL_TRANSCRIPTION,Description Wrist de Quervain stenosing tenosynovitis de Quervain release Fascial lengthening flap of the 1st dorsal compartment Medical Specialty Surgery Sample Name de Quervain Release Wrist Transcription PREOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis POSTOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis TITLE OF PROCEDURES 1 de Quervain release 2 Fascial lengthening flap of the 1st dorsal compartment ANESTHESIA MAC COMPLICATIONS None PROCEDURE IN DETAIL After MAC anesthesia and appropriate antibiotics were administered the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision just distal to the radial styloid Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected Meticulous hemostasis was maintained with bipolar electrocautery I dissected the sheath superficially free of any other structures specifically the superficial radial nerve I then incised it under direct vision dorsal to its axis and incised it both proximally and distally The EPB subsheath was likewise released I irrigated the wound thoroughly In order to prevent tendon subluxation I then back cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position I did this with 3 0 Vicryl I then passed an instrument underneath to check and make sure that the sheath was not too tight I then irrigated it and closed the skin and then I dressed and splinted the wrist appropriately The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery de quervain tenosynovitis de quervain release fascial lengthening flap dorsal compartment sheath wrist dorsal tourniquet MEDICAL_TRANSCRIPTION,Description D C and hysteroscopy Abnormal uterine bleeding enlarged fibroid uterus hypermenorrhea intermenstrual spotting and thickened endometrium per ultrasound of a 2 cm lining MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C and hysteroscopy A female presents 7 months status post spontaneous vaginal delivery has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp Medical Specialty Surgery Sample Name D C Hysteroscopy 1 Transcription PREOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Status post spontaneous vaginal delivery POSTOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Status post spontaneous vaginal delivery PROCEDURE PERFORMED 1 Dilation and curettage D C 2 Hysteroscopy ANESTHESIA IV sedation with paracervical block ESTIMATED BLOOD LOSS Less than 10 cc INDICATIONS This is a 17 year old African American female that presents 7 months status post spontaneous vaginal delivery without complications at that time The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp PROCEDURE The patient was consented and seen in the preoperative suite She was taken to the operative suite placed in a dorsal lithotomy position and placed under IV sedation She was prepped and draped in the normal sterile fashion Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine A bimanual exam was done was performed by Dr X and Dr Z The uterus was found to be anteverted mobile fully involuted to a pre pregnancy stage The cervix and vagina were grossly normal with no obvious masses or deformities A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum The uterus was sounded to 8 cm The cervix was sterilely dilated with Hank dilator and then Hagar dilator At the time of blunt dilation it was noticed that the dilator passed posteriorly with greater ease than it had previously The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus Under direct visualization the ostia were within normal limits The endometrial lining was hyperplastic however there was no evidence of retained products or endometrial polyps The hyperplastic tissue did not appear to have calcification or other abnormalities There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation however this area was hemostatic no evidence of bowel involvement and was approximately 1 x 1 cm in nature The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul de sac There was a normal consistency of the cervix and the normal step off The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum The cervix was found to be hemostatic The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room The patient will be sent home once stable from anesthesia She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings The patient is sent home on Tylenol 3 prescription as she is allergic to Motrin The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks The patient is also instructed to contact us if she has any problems with further bleeding fevers or difficulty with urination Keywords surgery dilation and curettage hysteroscopy abnormal uterine bleeding spontaneous vaginal delivery endometrial curettings vaginal delivery uterine bleeding endometrial d c cervix vaginal uterine delivery MEDICAL_TRANSCRIPTION,Description Enlarged fibroid uterus hypermenorrhea and secondary anemia Dilatation and curettage and hysteroscopy Medical Specialty Surgery Sample Name D C Hysteroscopy Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Hypermenorrhea POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Hypermenorrhea 3 Secondary anemia PROCEDURE PERFORMED 1 Dilatation and curettage 2 Hysteroscopy GROSS FINDINGS Uterus was anteverted greatly enlarged irregular and firm The cervix is patulous and nulliparous without lesions Adnexal examination was negative for masses PROCEDURE The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia After bimanual examination the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum The uterus was sounded to a depth of 11 cm The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a 10 Hegar The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera The endometrial cavity was distended with fluids and the cavity visualized Multiple irregular areas of fibroid degeneration were noted throughout the cavity The coronal areas were visualized bilaterally with corresponding tubal ostia A moderate amount of proliferative appearing endometrium was noted There were no direct intraluminal lesions seen The patient tolerated the procedure well Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity A large sharp curet was then used to obtain a moderate amount of tissue which was the sent to pathologist for analysis The instrument was removed from the vaginal vault The patient was sent to recovery area in satisfactory postoperative condition Keywords surgery dilatation and curettage hysteroscopy anemia enlarged fibroid uterus endometrial cavity hypermenorrhea fibroid uterus MEDICAL_TRANSCRIPTION,Description Cystourethroscopy and tTransurethral resection of prostate TURP Urinary retention and benign prostate hypertrophy This is a 62 year old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound office cystoscopy confirmed this Medical Specialty Surgery Sample Name Cystourethroscopy TURP 1 Transcription PREOPERATIVE DIAGNOSES 1 Urinary retention 2 Benign prostate hypertrophy POSTOPERATIVE DIAGNOSES 1 Urinary retention 2 Benign prostate hypertrophy PROCEDURES PERFORMED 1 Cystourethroscopy 2 Transurethral resection of prostate TURP ANESTHESIA Spinal RESECTION TIME Less than one hour INDICATION FOR PROCEDURE This is a 62 year old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound office cystoscopy confirmed this PROCEDURE PROCEDURE Informed written consent was obtained The patient was taken to the operative suite administered spinal anesthetic and placed in dorsal lithotomy position She was sterilely prepped and draped in normal fashion A 27 French resectoscope was inserted utilizing the visual obturator blanching the bladder The bladder was visualized in all quadrants no bladder tumors or stones were noted Ureteral orifices were visualized and did appear to be near the enlarged median lobe Prostate showed trilobar prostatic enlargement There were some cellules and tuberculations noted The visual obturator was removed The resectoscope was then inserted utilizing the 26 French resectoscope loop Resection was performed initiating at the bladder neck and at the median lobe This was taken down to the circular capsular fibers Attention was then turned to the left lateral lobe and this was resected from 12 o clock to 3 o clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum Ureteral orifices were kept out of harm s way throughout the case Resection was then performed from the 3 o clock position to the 6 o clock position in similar fashion Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed Open prostatic fossa was noted All chips were evacuated via Ellik evacuator and 24 French three way Foley catheter was inserted and irrigated Clear return was noted The patient was then hooked up to better irrigation The patient was cleaned reversed for anesthetic and transferred to recovery room in stable condition PLAN We will admit with antibiotics pain control and bladder irrigation possible void trial in the morning Keywords surgery urinary retention transurethral resection of prostate prostate enlarged obstructive voiding symptoms benign prostate hypertrophy ureteral orifices prostate hypertrophy cystourethroscopy turp hypertrophy resectoscope urinary bladder resection MEDICAL_TRANSCRIPTION,Description Enlarged fibroid uterus infertility pelvic pain and probable bilateral tubal occlusion Dilatation and curettage and laparoscopy and injection of indigo carmine dye Medical Specialty Surgery Sample Name D C Laparoscopy Transcription PREOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Pelvic pain 3 Infertility POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Infertility 3 Pelvic pain 4 Probable bilateral tubal occlusion PROCEDURE PERFORMED 1 Dilatation and curettage 2 Laparoscopy 3 Injection of indigo carmine dye GROSS FINDINGS The uterus was anteverted firm enlarged irregular and mobile The cervix is nulliparous without lesions Adnexal examination was negative for masses PROCEDURE The patient was placed in the lithotomy position properly prepared and draped in sterile manner After bimanual examination the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum Uterus sounded to a depth of 10 5 cm Endocervical canal was progressively dilated with Hanks dilators to 20 French A medium sized sharp curet was used to obtain a moderated amount of tissue upon curettage which was taken from all uterine quadrants and sent to the pathologist for analysis A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted The laparoscope was then inserted through the trocar with visualization of the pelvic contents In steep Trendelenburg position the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria The ovaries also appeared normal bilaterally The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still Both fallopian tubes apparently were blocked The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum The patient tolerated the procedure well Instruments were removed from the vaginal vault and the abdomen Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two 4 0 undyed Vicryl sutures Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition Keywords surgery dilatation and curettage laparoscopy pelvic pain infertility enlarged fibroid uterus tubal occlusion indigo carmine dye fibroid uterus uterus infertility peritoneal cavity fallopian tubes indigo carmine endocervical uterine pelvic curettage uterus MEDICAL_TRANSCRIPTION,Description Benign prostatic hypertrophy and urinary retention Cystourethroscopy and transurethral resection of prostate TURP Medical Specialty Surgery Sample Name Cystourethroscopy TURP Transcription PREOPERATIVE DIAGNOSES 1 Benign prostatic hypertrophy 2 Urinary retention POSTOPERATIVE DIAGNOSES 1 Benign prostatic hypertrophy 2 Urinary retention PROCEDURE PERFORMED 1 Cystourethroscopy 2 Transurethral resection of prostate TURP ANESTHESIA Spinal DRAIN A 24 French three way Foley catheter SPECIMENS Prostatic resection chips ESTIMATED BLOOD LOSS 150 cc DISPOSITION The patient was transferred to the PACU in stable condition INDICATIONS AND FINDINGS This is an 84 year old male with history of BPH and subsequent urinary retention with failure of trial of void scheduled for elective TURP procedure FINDINGS At the time of surgery cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in the normal sterile fashion and a 21 French cystoscope inserted into urethra and into the bladder Cystoscopy performed with the above findings Cystoscope was removed A 27 French resectoscope with a 26 cutting loop was inserted into the bladder Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed ________ irrigator was used to evacuate the bladder of prostatic chips Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop Any obvious bleeding from the prostatic fossa was controlled with electrocautery Resectoscope was removed A 24 French three way Foley catheter inserted into the urethra and into the bladder Bladder was irrigated and connected to three way irrigation The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring Keywords surgery urinary retention cystourethroscopy transurethral resection of prostate foley catheter bph cystoscopy bladder benign prostatic hypertrophy turp MEDICAL_TRANSCRIPTION,Description Cystourethroscopy urethral dilation and bladder biopsy and fulguration Urinary hesitancy and weak stream urethral narrowing mild posterior wall erythema Medical Specialty Surgery Sample Name Cystourethroscopy Urethral Dilation Transcription PREOPERATIVE DIAGNOSIS Urinary hesitancy and weak stream POSTOPERATIVE DIAGNOSES 1 Urinary hesitancy and weak stream 2 Urethral narrowing 3 Mild posterior wall erythema PROCEDURE PERFORMED 1 Cystourethroscopy 2 Urethral dilation 3 Bladder biopsy and fulguration ANESTHESIA General SPECIMEN Urine culture sensitivity and cytology and bladder biopsy x1 DISPOSITION To PACU in stable condition INDICATIONS AND FINDINGS This is a 76 year old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past last cystoscopy approximately two years ago FINDINGS AT TIME OF SURGERY Cystourethroscopy revealed some mild narrowing of the urethra which was easily dilated to 23 French A midureteral polyp was noted Cystoscopy revealed multiple cellules and mild trabeculation of the bladder Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa No obvious raised bladder tumor was noted No foreign bodies were noted The ureteral orifices were noted on the trigone just proximal to the bladder neck DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was moved to the operating room general anesthesia was induced by the Department of Anesthesia The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate 23 French cystoscope Cystoscopy was performed in its entirety with the above findings The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area The bladder was drained cystoscope was removed scope was reinserted and bladder was again reexamined No evidence of active bleeding noted The bladder was drained cystoscope was removed and the patient was cleaned and sent to recovery room in stable condition to followup with Dr X in two weeks She is given prescription for Levaquin and Pyridium and given discharge instructions Keywords surgery bladder biopsy fulguration urethral dilation weak stream bladder cystoscopy cystoscope cystourethroscopy biopsy urethral MEDICAL_TRANSCRIPTION,Description Right hydronephrosis right flank pain atypical dysplastic urine cytology extrarenal pelvis on the right no evidence of obstruction or ureteral bladder lesions Cystoscopy bilateral retrograde ureteropyelograms right ureteral barbotage for urine cytology and right ureterorenoscopy Medical Specialty Surgery Sample Name Cystoscopy Ureteropyelogram Ureteral Barbotage Transcription PREOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology POSTOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology 4 Extrarenal pelvis on the right 5 No evidence of obstruction or ureteral bladder lesions PROCEDURE PERFORMED 1 Cystoscopy 2 Bilateral retrograde ureteropyelograms 3 Right ureteral barbotage for urine cytology 4 Right ureterorenoscopy diagnostic ANESTHESIA Spinal SPECIMEN TO PATHOLOGY Urine and saline wash barbotage from right ureter through the ureteral catheter ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE This is a 70 year old female who reports progressive intermittent right flank pain associated with significant discomfort and disability She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone She has some ureteral thickening in her distal right ureter She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia associated karyotypic profile She was brought to the operating room for further evaluation and treatment DESCRIPTION OF OPERATION After preoperative counseling the patient was taken to the operating room and administered a spinal anesthesia She was placed in the lithotomy position prepped and draped in the usual sterile fashion The 21 French cystoscope was inserted per urethra into the bladder The bladder was inspected and found to be without evidence of intravesical tumors stones or mucosal abnormalities The right ureteral orifice was visualized and cannulated with an open ended ureteral catheter This was gently advanced to the mid ureter Urine was collected for cytology Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter An 0 038 guidewire was then passed up through the open ended ureteral catheter The open ended ureteral catheter and cystoscope were removed and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis Using direct vision and fluoroscopy to confirm location the entire renal pelvis and calyces were inspected The renal pelvis demonstrated an extrarenal pelvis but no evidence of obstruction at the renal UPJ level There were no intrapelvic or calyceal stones The ureter demonstrated no significant mucosal abnormalities no visible tumors and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate The ureteroscope was then removed The cystoscope was reinserted Once again retrograde injection of contrast through an open ended ureteral catheter was undertaken in the right ureter and collecting system No evidence of extravasation or significant change in anatomy was visualized The left ureteral orifice was then visualized and cannulated with an open ended ureteral catheter and retrograde injection of contrast demonstrated a normal left ureter and collecting system The cystoscope was removed Foley catheter was inserted The patient was placed in the supine position and transferred to the recovery room in satisfactory condition Keywords surgery hydronephrosis ureteropyelogram ureterorenoscopy flank pain renal pelvis urine cytology ureteral cystoscopy barbotage cystoscope retrograde urine MEDICAL_TRANSCRIPTION,Description Cystourethroscopy right retrograde pyelogram right ureteral pyeloscopy right renal biopsy and right double J 4 5 x 26 mm ureteral stent placement Right renal mass and ureteropelvic junction obstruction and hematuria Medical Specialty Surgery Sample Name Cystourethroscopy Retrograde Pyelogram 1 Transcription PREOPERATIVE DIAGNOSES 1 Right renal mass 2 Hematuria POSTOPERATIVE DIAGNOSES 1 Right renal mass 2 Right ureteropelvic junction obstruction PROCEDURES PERFORMED 1 Cystourethroscopy 2 Right retrograde pyelogram 3 Right ureteral pyeloscopy 4 Right renal biopsy 5 Right double J 4 5 x 26 mm ureteral stent placement ANESTHESIA Sedation SPECIMEN Urine for cytology and culture sensitivity right renal pelvis urine for cytology and right upper pole biopsies INDICATION The patient is a 74 year old male who was initially seen in the office with hematuria He was then brought to the hospital for other medical problems and found to still have hematuria He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation PROCEDURE After consent was obtained the patient was brought to the operating room and placed in the supine position He was given IV sedation and placed in dorsal lithotomy position He was then prepped and draped in the standard fashion A 21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder The patient was noted to have mildly enlarged prostate however it was non obstructing Upon visualization of the bladder the patient was noted to have some tuberculation to the bladder There were no masses or any other abnormalities noted other than the tuberculation Attention was then turned to the right ureteral orifice and an open end of the catheter was then passed into the right ureteral orifice A retrograde pyelogram was performed Upon visualization there was no visualization of the upper collecting system on the right side At this point a guidewire was then passed through the open end of the ureteral catheter and the catheter was removed The bladder was drained and the cystoscope was removed The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction The wire was then again passed through the flexible scope and the flexible scope was removed A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system Upon visualization of the collecting system of the upper portion there was noted to be papillary mass within the collecting system The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass Once this was done the wire was left in place and the ureteroscope was removed The cystoscope was then placed back into the bladder and a 26 x 4 5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis The stent was noted to be clear within the right renal pelvis as well as in the bladder The bladder was drained and the cystoscope was removed The patient tolerated the procedure well He will be transferred to the recovery room and back to his room It has been discussed with his primary physician that the patient will likely need a nephrectomy He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday Keywords surgery renal mass hematuria ureteropelvic junction obstruction cystourethroscopy retrograde pyelogram ureteral pyeloscopy renal biopsy double j ureteral stent placement ureteropelvic junction flexible scope papillary mass ureteral stent renal pelvis ureteral orifice amplatz wire retrograde pyelogram ureteral cystoscope ureteroscope renal bladder MEDICAL_TRANSCRIPTION,Description Cystourethroscopy bilateral retrograde pyelogram and transurethral resection of bladder tumor of 1 5 cm in size Recurrent bladder tumor and history of bladder carcinoma Medical Specialty Surgery Sample Name Cystourethroscopy Retrograde Pyelogram Transcription PREOPERATIVE DIAGNOSES 1 Recurrent bladder tumor 2 History of bladder carcinoma POSTOPERATIVE DIAGNOSIS Keywords surgery recurrent bladder tumor bladder carcinoma bilateral retrograde pyelogram transurethral resection of bladder tumor lateral wall bladder tumor transurethral resection retrograde pyelogram tumor bladder cystourethroscopy pyelogram MEDICAL_TRANSCRIPTION,Description Cystoscopy Visual urethrotomy procedure Medical Specialty Surgery Sample Name Cystoscopy Visual Urethrotomy Transcription CYSTOSCOPY VISUAL URETHROTOMY OPERATIVE NOTE The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia A Storz urethrotome sheath was inserted into the urethra under direct vision Visualization revealed a stricture in the bulbous urethra This was intubated with a 0 038 Teflon coated guidewire and using the straight cold urethrotomy knife it was incised to 12 00 to allow free passage of the scope into the bladder Visualization revealed no other lesions in the bulbous or membranous urethra Prostatic urethra was normal for age No foreign bodies tumors or stones were seen within the bladder Over the guidewire a 16 French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water He was sent to the recovery room in stable condition Keywords surgery cystoscopy foley catheter storz urethrotome sheath teflon coated guidewire urethrotomy bladder bulbous urethra dorsal lithotomy position knife membranous urethra cystoscopy visual urethrotomy visual urethrotomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cystoscopy Transurethral resection of the prostate Medical Specialty Surgery Sample Name Cystoscopy TURP Transcription PREOPERATIVE DIAGNOSES 1 Ta grade III TIS transitional cell carcinoma of the urinary bladder 2 Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy 3 Inability to pass a Foley catheter x3 POSTOPERATIVE DIAGNOSES 1 Ta grade III TIS transitional cell carcinoma of the urinary bladder 2 Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy 3 Inability to pass a Foley catheter x3 PROCEDURES 1 Cystoscopy 2 Transurethral resection of the prostate TURP ANESTHESIA General laryngeal mask INDICATIONS This patient is a 61 year old white male who has been treated at the VA in Houston for a bladder cancer His history dates back to 2003 when he had a non muscle invasive bladder cancer He had multiple cystoscopies and followups since that time with no evidence of recurrence However on recent cystoscopy he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically there were no abnormalities I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms and there were still healing biopsy sites We elected to allow his bladder to recover before starting the BCG We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter I repeated a cystoscopy in the office with findings of a high bladder neck and BPH After a lengthy discussion with the patient and his wife we elected to proceed with TURP after a full informed consent FINDINGS At cystoscopy there was bilobular prostatic hyperplasia and a very high riding bladder neck which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ PROCEDURE IN DETAIL The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position his perineum and genitalia were sterilely prepped and draped in the usual fashion A cystourethroscopy was performed with a 23 French ACMI panendoscope and 70 degree lens with the findings as described We removed the cystoscope and passed a 28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to 32 French with van Buren sounds Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck The groove was cut at 6 o clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o clock to 5 o clock Hemostasis was achieved and then a similar procedure performed in the right side We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis Chips were removed with Ellik evacuator There was no bleeding at the conclusion of the procedure and the resectoscope was removed A 24 French three way Foley catheter was placed with efflux of clear irrigant The patient was returned to the supine position awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords surgery urinary bladder benign prostatic hypertrophy transurethral resection of the prostate turp acmi panendoscope van buren sounds transitional cell carcinoma foley catheter bladder neck bladder carcinoma cystoscopy MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy resection of small bowel lesion biopsy of small bowel mesentery bilateral extended pelvic and iliac lymphadenectomy including preaortic and precaval bilateral common iliac presacral bilateral external iliac lymph nodes salvage radical cystoprostatectomy very difficult due to previous chemotherapy and radiation therapy and continent urinary diversion with an Indiana pouch Medical Specialty Surgery Sample Name Cystoprostatectomy Transcription PREOPERATIVE DIAGNOSES 1 Clinical stage T2 NX MX transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy 2 New right hydronephrosis POSTOPERATIVE DIAGNOSES 1 Clinical stage T4a N3 M1 transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy 2 New right hydronephrosis 3 Carcinoid tumor of the small bowel TITLE OF OPERATION Exploratory laparotomy resection of small bowel lesion biopsy of small bowel mesentery bilateral extended pelvic and iliac lymphadenectomy including preaortic and precaval bilateral common iliac presacral bilateral external iliac lymph nodes salvage radical cystoprostatectomy very difficult due to previous chemotherapy and radiation therapy and continent urinary diversion with an Indiana pouch ANESTHESIA General endotracheal and epidural INDICATIONS This patient is a 65 year old white male who was diagnosed with a high grade invasive bladder cancer in June 2005 During the course of his workup of transurethral resection he had a heart attack when he was taken off Plavix after having had a drug eluting stent placed in He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event The patient has been followed regularly by myself and Dr X and has been continuously free of diseases since that time In that interval he had a coronary artery bypass graft and was taken off of Plavix Most recently he had a PET CT which showed new right hydronephrosis and a followup cystoscopy which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated I took him to the operating room and extensively resected this area with findings of a high grade muscle invasive bladder cancer We could not identify the right ureteral orifice and he had a right ureteral stent placed Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy He was interested in orthotopic neobladder and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier Therefore we planned on an Indiana pouch continent cutaneous diversion OPERATIVE FINDINGS On exploration there were multiple abnormalities outside the bladder as follows There were at least three small lesions within the distal small bowel the predominant one measured about 1 5 cm in diameter with a white scar on the surface There were two much smaller lesions also with a small white scar with very little palpable mass The larger of the two was resected and found to be a carcinoid tumor There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes The small bowel mesentry was fairly thickened at the base but no discrete abnormality noted Both common iliac and lymph node samples were very thickened and indurated and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect viability was unable to be determined There was a frozen section of the distal right external iliac lymph node that was negative The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures The external iliac lymph nodes were resected on both sides of the obturator the lymph packet however was very stuck and adherent to the pelvic sidewall and I elected not to remove that The rest of the large bowel appeared normal There were no masses in the liver and the gallbladder was surgically absent There was nasogastric tube in the stomach OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained having placed in the supine position and flexed over the anterior superior iliac spine his abdomen and genitalia were sterilely prepped and draped in usual fashion The radiologist placed a radial arterial line and an intravenous catheter Intravenous antibiotics were given for prophylaxis We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis deepened through the rectus fascia and the rectus muscles separated in the midline Exploration was carried out with the findings described The bladder was adherent and did appear immobile Moist wound towels and a Bookwalter retractor was placed for exposure We began by assessing the small and large bowel with the findings in the small bowel as described We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two layer running 4 0 Prolene suture We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum The ureters were carefully dissected out and down deep in the true pelvis The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber I kept the ureters intact until we were moving the bladder off as described above At that point we then ligated the ureters with the RP 45 vascular load and divided it We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes The common iliac lymph nodes remained stuck to the ureter Frozen section with the findings described on the left I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally I was however able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels Clips were used to control the lymphatics distally These lymph nodes were sent for frozen section which was negative We made no attempt to circumferentially mobilize the vessels but essentially swept the tissue off of the anterior surface and towards the bladder and then removed it The obturator nerve on the right side was sucked into the pelvic sidewall and I elected not to remove those On the left side things were a little bit more mobile in terms of the lymph nodes but still the obturator lymph nodes were left intact We then worked on the lateral pedicles on both sides and essentially determined that I can take these down I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate At this point I scrubbed out of the operation talked to the family and indicated that I felt the cystectomy was more palliative than therapeutic and I reiterated his desire to be free of any external appliance I then proceeded to take down the lateral pedicles with an RP 45 stapler on the right and clips distally The endopelvic fascia was incised I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically I was able to pass a 0 Vicryl suture along the dorsal venous complex tied this and then sealed and divided the complex with a LigaSure and oversewed it distally with 2 0 Vicryl figure of eight stitch I then divided the urethra distal to the apex of the prostate divided the Foley catheter between the clamps and then the posterior urethra I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum and the specimen was then free of all attachments and handed off the operative field The bivalved prostate appeared normal We then carefully inspected the rectal wall and noted to be intact The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis We then turned our attention to forming the Indiana pouch I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon The colon was divided proximal to the middle colic using a GIA 80 stapler I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum The mesentery was then sealed with a LigaSure device and divided and the bowel was divided with a GIA 60 stapler We then performed a side to side ileo transverse colostomy using a GIA 80 stapler closing the open end with a TA 60 The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures We then removed the staple line along the terminal ileum passed a 12 French Robinson catheter into the cecal segment and plicated the ileum with 3 firings of the GIA 60 stapler The ileocecal valve was then reinforced with interrupted 3 0 silk sutures as described by Rowland et al and following this passage of an 18 French Robinson catheter was associated with the characteristic pop indicating that we had adequately plicated the ileocecal valve As the patient had had a previous appendectomy we made an opening in the cecum in the area of the previous appendectomy We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3 0 Vicryl sutures The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb 75 Between the staple lines Vicryl sutures were placed and the defects closed with 3 0 Vicryl suture ligatures We then turned our attention to forming the ileocolonic anastomosis The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end to side anastomosis performed with an open technique using interrupted 4 0 Vicryl sutures and this was stented with a Cook 8 4 French ureteral stent and this was secured to the bowel lumen with a 5 0 chromic suture The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2 0 chromic suture A 24 French Malecot catheter was placed through the cecum and secured with a chromic suture The staple lines were then buried with a running 3 0 Vicryl two layer suture and the open end of the pouch closed with a TA 60 Polysorb suture The pouch was filled to 240 cc and noted to be watertight and the ureteral anastomoses were intact We then made a final inspection for hemostasis The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures We then matured our stoma through the umbilicus We removed the plug of skin through the umbilicus and delivered the ileal segment through this A portion of the ileum was removed and healthy well vascularized tissue was matured with interrupted 3 0 chromic sutures We left an 18 French Robinson through the stoma and secured this to the skin with silk sutures The Malecot and stents were also secured in a similar fashion The stoma was returned to the umbilicus after resecting the terminal ileum We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant Rectus fascia was closed with buried 2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia Interrupted stitches were placed as well The subcutaneous tissue was irrigated and skin closed with surgical clips The estimated blood loss was 2500 mL The patient received 5 units of packed red blood cells and 4 units of FFP The patient was then awakened extubated and taken on a stretcher to the recovery room in satisfactory condition Keywords MEDICAL_TRANSCRIPTION,Description Right lower pole renal stone and possibly infected stent Cysto stent removal Medical Specialty Surgery Sample Name Cysto Stent Removal Transcription PREOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent POSTOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent OPERATION Cysto stent removal ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid MEDICATIONS The patient was on vancomycin and Levaquin was given x1 dose The patient was on vancomycin for the last 5 days BRIEF HISTORY The patient is a 53 year old female who presented with Enterococcus urosepsis CT scan showed a lower pole stone with a stent in place The stent was placed about 2 months ago but when patient came in with a possibly UPJ stone with fevers of unknown etiology The patient had a stent placed at that time due to the fevers thinking that this was an urospetic stone There was some pus that came out The patient was cultured actually it was negative at that time The patient subsequently was found to have lower extremity DVT and then was started on Coumadin The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE The repeat films were taken which showed the stone had migrated into the pole The stent was intact The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin Cipro and Levaquin where treatment was little bit more complicated Due to drug interaction the patient was admitted for IV antibiotic treatment The thinking was that either the stone or the stent is infected since the stone is pretty small in size the stent is very likely possibility that it could have been infected and now it needs to be removed Since the stone is not obstructing there is no reason to replace the stent at this time We are unable to do the ureteroscopy or the shock wave lithotripsy when the patient is fully anticoagulated So the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin which would be probably about 4 months down the road Plan is to get rid of the stent and improve patient s urinary symptoms and to get rid of the infection and we will worry about the stone at later point DETAILS OF THE OR Consent had been obtained from the patient Risks benefits and options were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed The patient understood all the risks and benefits of removing the stent and wanted to proceed The patient was brought to the OR The patient was placed in dorsal lithotomy position The patient was given some IV pain meds The patient had received vancomycin and Levaquin preop Cystoscopy was performed using graspers The stent was removed without difficulty Plan was for repeat cultures and continuation of the IV antibiotics Keywords surgery infected stent cysto stent removal cysto stent renal stone lower pole infected stone stent cysto MEDICAL_TRANSCRIPTION,Description Residual stone status post right percutaneous nephrolithotomy attempted second look nephrolithotomy cysto with insertion of 6 French variable length double J stent Medical Specialty Surgery Sample Name Cysto Double J Stent Insersion Transcription PREOPERATIVE DIAGNOSIS Residual stone status post right percutaneous nephrolithotomy POSTOPERATIVE DIAGNOSES Residual stone status post right percutaneous nephrolithotomy attempted second look nephrolithotomy cysto with insertion of 6 French variable length double J stent ANESTHESIA General via endotracheal tube BLOOD LOSS Minimal DRAINS 16 French Foley 6 French variable length double J stent INTRAOPERATIVE COMPLICATIONS Unable to re access the collecting system DESCRIPTION OF PROCEDURE The patient was brought to the operating room and laid supine General anesthesia was accomplished A 16 French Foley was placed using aseptic technique The patient was then placed on the operating table prone His right flank was prepped and draped in a sterile fashion At this point contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed The 5 French Pollack catheter was used to pass a 0 38 super stiff Amplatz wire The wire would not go down the ureter Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track both with rigid dilator and the balloon dilator and access could not be obtained After multiple attempts access was lost At this point the tubes were left out of the kidney and sterile dressings were applied The patient was then placed on another operating table supine His genitalia were prepped and draped after removing his Foley catheter Flexible cystoscopy was performed and the right orifice identified which was edematous and erythematous The wire was passed up to kidney and a 5 French Pollack catheter was then passed over to after the removing the scope The wire was removed Contrast injection with good placement in the collecting system The wire was replaced The Pollack catheter removed and 6 French variable length double J stent was inserted using fluoroscopic guidance The wire was removed leaving the double J stent in good position _______ 16 French Foley was reinserted and connected to close drains Procedure was terminated at this point and had been well tolerated The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well Keywords surgery residual stone percutaneous cobra catheters amplatz double j stent pollack catheter cysto catheter nephrolithotomy stent french MEDICAL_TRANSCRIPTION,Description Holmium laser cystolithalopaxy A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self catheterization recent urinary tract infections The cystoscopy showed a large bladder calculus short but obstructing prostate Medical Specialty Surgery Sample Name Cystolithalopaxy Transcription PREOPERATIVE DIAGNOSES 1 Prostatism 2 Bladder calculus OPERATION Holmium laser cystolithalopaxy POSTOPERATIVE DIAGNOSES 1 Prostatism 2 Bladder calculus ANESTHESIA General INDICATIONS This is a 62 year old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self catheterization recent urinary tract infections The cystoscopy showed a large bladder calculus short but obstructing prostate He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy He is a diabetic with obesity LABORATORY DATA Includes urinalysis showing white cells too much to count 3 5 red cells occasional bacteria He had a serum creatinine of 1 2 sodium 138 potassium 4 6 glucose 190 calcium 9 1 Hematocrit 40 5 hemoglobin 13 8 white count 7 900 PROCEDURE The patient was satisfactorily given general anesthesia Prepped and draped in the dorsal lithotomy position A 27 French Olympus rectoscope was passed via the urethra into the bladder The bladder prostate and urethra were inspected He had an obstructing prostate He had marked catheter reaction in his bladder He had a lot of villous changes impossible to tell from frank tumor He had a huge bladder calculus It was white and round I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath and broke up the stone breaking up approximately 40 grams of stone There was still stone left at the end of the procedure Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik Then the scope was removed and a 24 French 3 way Foley catheter was passed via the urethra into the bladder The plan is to probably discharge the patient in the morning and then we will get a KUB We will probably bring him back for a second stage cystolithotripsy and ultimately do a TURP We broke up the stone for over an hour and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient Keywords surgery prostatism holmium laser cystolithalopaxy urinary tract infections holmium laser bladder calculus bladder cystolithalopaxy diabetic urethra urinary catheterization stone calculus prostate MEDICAL_TRANSCRIPTION,Description Cystoscopy and Bladder biopsy with fulguration History of bladder tumor with abnormal cytology and areas of erythema Medical Specialty Surgery Sample Name Cystoscopy Bladder Biopsy Transcription PREOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema POSTOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema PROCEDURE PERFORMED 1 Cystoscopy 2 Bladder biopsy with fulguration ANESTHESIA IV sedation with local SPECIMEN Urine cytology and right lateral wall biopsies PROCEDURE After the consent was obtained the patient was brought to the operating room and given IV sedation He was then placed in dorsal lithotomy position and prepped and draped in standard fashion A 21 French cystoscope was then used to visualized the entire urethra and bladder There was noted to be a narrowing of the proximal urethra however the scope was able to pass through The patient was noted to have a previously resected prostate On visualization of the bladder the patient did have areas of erythema on the right as well as the left lateral walls more significant on the right side The patient did have increased vascularity throughout the bladder The ________ two biopsies of the right lateral wall and those were sent for pathology The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema Bovie was also utilized to cauterize the areas of erythema on the left lateral wall No further bleeding was identified The bladder was drained and the cystoscope was removed The patient tolerated the procedure well and was transferred to the recovery room He will have his defibrillator restarted and will followup with Dr X in approximately two weeks for the result He will be discharged home with antibiotics as well as pain medications He is to restart his Coumadin not before Sunday Keywords surgery bladder biopsy with fulguration iv sedation bladder biopsy bladder tumor abnormal cytology bladder cystoscopy tumor cytology erythema MEDICAL_TRANSCRIPTION,Description Cystoscopy under anesthesia bilateral HIT STING with Deflux under general anesthetic Medical Specialty Surgery Sample Name Cystoscopy Transcription PREOPERATIVE DIAGNOSIS Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection POSTOPERATIVE DIAGNOSIS Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection PROCEDURE Cystoscopy under anesthesia bilateral HIT STING with Deflux under general anesthetic ANESTHESIA General inhalational anesthetic FLUIDS RECEIVED 250 mL crystalloids ESTIMATED BLOOD LOSS Less than 5 mL SPECIMENS Urine sent for culture ABNORMAL FINDINGS Gaping ureteral orifices right greater than left with Deflux not in or near the ureteral orifices Right ureteral orifice was HIT with 1 5 mL of Deflux and left with 1 2 mL of Deflux HISTORY OF PRESENT ILLNESS The patient is a 4 1 2 year old boy with history of reflux nephropathy and voiding and bowel dysfunction He has had a STING procedure performed but continues to have reflux bilaterally Plan is for another injection DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified Once he was anesthetized IV antibiotics were given He was then placed in a lithotomy position with adequate padding of his arms and legs His urethra was calibrated to 12 French with a bougie a boule A 9 5 French cystoscope was used and the offset system was then used His urethra was normal without valves or strictures His bladder was fairly normal with minimal trabeculations but no cystitis noted Upon evaluation the patient s right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone This was similarly found on the left side where the Deflux was not close to the orifice as well It was slightly more difficult because of the amount impacted upon our angle for injection We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1 5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect Once we injected this we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding Similar procedure was done on the left This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection At the end of the procedure the irrigant was drained and 2 lidocaine jelly was instilled in the urethra The patient tolerated the procedure well and was in stable condition upon transfer to Recovery A low dose of IV Toradol was given at the end of the procedure as well Keywords surgery bilateral vesicoureteral reflux deflux sting procedure hit technique cystoscopy under anesthesia hit sting with deflux vesicoureteral reflux ureteral orifices vesicoureteral cystoscopy urethra hit sting ureteral MEDICAL_TRANSCRIPTION,Description Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached Medical Specialty Surgery Sample Name Cystopyelogram Transcription PREOPERATIVE DIAGNOSIS Left distal ureteral stone POSTOPERATIVE DIAGNOSIS Left distal ureteral stone PROCEDURE PERFORMED Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached ANESTHESIA LMA EBL Minimal FLUIDS Crystalloid The patient was given antibiotics 1 g of Ancef and the patient was on oral antibiotics at home BRIEF HISTORY The patient is a 61 year old female with history of recurrent uroseptic stones The patient had stones x2 1 was already removed second one came down had recurrent episode of sepsis stent was placed Options were given such as watchful waiting laser lithotripsy shockwave lithotripsy etc Risks of anesthesia bleeding infection pain need for stent and removal of the stent were discussed The patient understood and wanted to proceed with the procedure DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A 0 035 glidewire was placed in the left system Using graspers left sided stent was removed A semirigid ureteroscopy was done A stone was visualized in the mid to upper ureter Using laser the stone was broken into 5 to 6 small pieces Using basket extraction all the pieces were removed Ureteroscopy all the way up to the UPJ was done which was negative There were no further stones Using pyelograms the rest of the system appeared normal The entire ureter on the left side was open and patent There were no further stones Due to the edema and the surgery plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours Over the 0 035 glidewire a 26 double J stent was placed There was a nice curl in the kidney and one in the bladder The patient tolerated the procedure well Please note that the string was kept in place and the patient was to remove the stent the next day The patient s family was instructed how to do so The patient had antibiotics and pain medications at home The patient was brought to recovery room in a stable condition Keywords surgery laser lithotripsy shockwave lithotripsy double j stent distal ureteral stone ureteral stone basket extraction cystopyelogram laser lithotripsy stones string ureteroscopy stone stent MEDICAL_TRANSCRIPTION,Description CT of abdomen with and without contrast CT guided needle placement biopsy Medical Specialty Surgery Sample Name CT Guided Needle Placement Biopsy Transcription EXAM CT of abdomen with and without contrast CT guided needle placement biopsy HISTORY Left renal mass TECHNIQUE Pre and postcontrast enhanced images were acquired through the kidneys FINDINGS Comparison made to the prior MRI There is re demonstration of multiple bilateral cystic renal lesions Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts There was however one cyst seen in the lower pole of the left kidney which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration This measured approximately 1 4 x 1 3 cm to the exophytic half of the lower pole No other enhancing renal masses were seen The visualized liver spleen pancreas and adrenal glands were unremarkable There are changes of cholecystectomy Mild prominence of the common bile duct is likely secondary to cholecystectomy There is no abdominal lymphadenopathy masses fluid collection or ascites Lung bases are clear No acute bony pathology was noted IMPRESSION Solitary apparently enhancing left renal mass in the lower pole as described Renal cell carcinoma cannot be excluded CT GUIDED NEEDLE BIOPSY LEFT KIDNEY MASS Following discussion of risks benefits and alternatives the patient wished to proceed with CT guided biopsy of left renal lesion The patient was placed in the decubitus position The region overlying the left renal mass of note was marked Area was prepped and draped in usual sterile fashion Local anesthesia was achieved with approximately 8 mL of 1 lidocaine with bicarbonate The Versed and fentanyl were given to achieve conscious sedation Utilizing an 18 x 15 gauge coaxial system 3 core biopsies were obtained through the mass in question and sent to pathology for analysis Following procedure scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia No perinephric fluid hematoma was identified The patient tolerated the procedure without immediate complications IMPRESSION Three core biopsies through the region of the left renal tumor as described Keywords surgery ct ct guided ct guided biopsy hounsfield units mri abdomen biopsy cholecystectomy contrast contrast administration decubitus position images needle postcontrast renal lesions renal mass renal tumor with and without ct guided needle placement ct of abdomen needle placement lower pole ct guided renal MEDICAL_TRANSCRIPTION,Description Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder Medical Specialty Surgery Sample Name Cystopyelogram 1 Transcription PREOPERATIVE DIAGNOSIS Gross hematuria POSTOPERATIVE DIAGNOSIS Gross hematuria OPERATIONS Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder ANESTHESIA Spinal FINDINGS Significant amount of bladder clots measuring about 150 to 200 mL two cupful of clots were removed There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side The right ureteral opening was difficult to visualize the left one was normal BRIEF HISTORY The patient is a 78 year old male with history of gross hematuria and recurrent UTIs The patient had hematuria Cystoscopy revealed atypical biopsy The patient came in again with gross hematuria The first biopsy was done about a month ago The patient was to come back and have repeat biopsies done but before that came into the hospital with gross hematuria The options of watchful waiting removal of the clots and biopsies were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed Morbidity and mortality of the procedure were discussed Consent was obtained from the daughter in law who has the power of attorney in Florida DESCRIPTION OF PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in the dorsal lithotomy position The patient was prepped and draped in the usual sterile fashion The patient had been off of the Coumadin for about 4 days and INR had been reversed The patient has significant amount of clot upon entering the bladder There was a tight bladder neck contracture The prostate was not enlarged Using ACMI 24 French sheath using Ellick irrigation about 2 cupful of clots were removed It took about half an hour to just remove the clots After removing the clots using 24 French cutting loop resectoscope tumor on the left upper wall near the dome or near the 2 o clock position was resected This was lateral to the left ureteral opening The base was coagulated for hemostasis Same thing was done at 10 o clock on the right side where there was some tumor that was visualized The back wall and the rest of the bladder appeared normal Using 8 French cone tip catheter left sided pyelogram was normal The right sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots The contrast did go up to what appeared to be the right ureteral opening but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening A little bit of contrast went out but the force was not made just to avoid any secondary stricture formation The patient did have CT with contrast which showed that the kidneys were normal At this time a 24 three way irrigation was started The patient was brought to Recovery room in stable condition Keywords surgery clot evacuation transurethral resection bladder tumor bladder neck gross hematuria bladder cystopyelogram hematuria clots MEDICAL_TRANSCRIPTION,Description Laparoscopic assisted vaginal hysterectomy bilateral salpingo oophorectomy culdoplasty and cystoscopy Chronic pelvic inflammatory disease pelvic adhesions pelvic pain fibroid uterus and enterocele Medical Specialty Surgery Sample Name Culdoplasty Vaginal Hysterectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic inflammatory disease 2 Pelvic adhesions 3 Pelvic pain 4 Fibroid uterus 5 Enterocele POSTOPERATIVE DIAGNOSES 1 Chronic pelvic inflammatory disease 2 Pelvic adhesions 3 Pelvic pain 4 Fibroid uterus 5 Enterocele PROCEDURE PERFORMED 1 Laparoscopic assisted vaginal hysterectomy bilateral salpingo oophorectomy 2 McCall s culdoplasty 3 Cystoscopy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 350 cc INDICATIONS The patient is a 45 year old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation uncontrolled with Anaprox DS also with complaints of dyspareunia On laparoscopy in May of 2003 PID adenomyosis and uterine fibroids were demonstrated The patient desires definitive treatment FINDINGS AT THE TIME OF SURGERY Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities On laparoscopic examination the uterus was quite soft and boggy consistent with the uterine adenomyosis There was also evidence of fibroid change in the right fundal aspect of the uterus There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes There were filmy adhesions to the right pelvic side wall as well as left pelvic side wall PROCEDURE The patient taken to the operative suite where anesthesia was found to be adequate She was then prepared and draped in the normal sterile fashion A Foley catheter was initially placed and was noted to be draining clear to yellow urine A weighted speculum was placed in the patient s vagina The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterus sounded to 7 cm and the cervix was then progressively dilated A 20 Hank dilator which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator At this time after the gloves were changed attention was then turned to the patient s abdomen A small approximately 1 cm infraumbilical incision was made with the scalpel A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures A 10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope On entrance into the patient s abdomen and pelvis survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance At this time under transillumination in the left anterior axillary line a second incision was made with a scalpel and through this site a 12 mm step trocar was inserted under direct visualization by the laparoscope A third incision was made in the right anterior axillary line under transillumination and through this site a second 12 mm step trocar was placed under direct visualization by the laparoscope Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a 5 mm step trocar was inserted through this site The uterus was elevated and deviated to the patient s right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper The Endo GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament transecting and stapling at the same time Attention was then turned to the right adnexa The uterus was brought over to the patient s left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper An Endo GIA was used to transect and staple this vasculature and down passed to the level of round ligament At this time there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic In addition on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted At this time the uterus was dropped and the vesicouterine peritoneum was grasped with graspers The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure At this time copious suction irrigation was performed and the operative sites were found to be hemostatic The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure The weighted speculum was placed into the patient s vagina At this time the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o clock position to 3 o clock position The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly Next using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly At this time two curved Heaney clamps were placed across the uterine artery on the right This was then transected and suture ligated with 0 Vicryl suture The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with 0 Vicryl suture Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps transected and suture ligated with 0 Vicryl suture This second clamp was then advanced to capture the vasculature and the cardinal ligament complex This was again transected and suture ligated with 0 Vicryl suture Next the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff Next the uterus ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology At this time the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure Next the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of 0 Chromic beginning at the 9 o clock position over to the 3 o clock position Next the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly The angles of the vaginal cuff were then closed with 0 Chromic suture figure of eight stitch with care taken to incorporate the anterior vaginal mucosa the anterior peritoneum and the previously closed posterior vaginal mucosa and the posterior peritoneum Two additional sutures medially were placed and these were tagged and not tied in place A 0 Vicryl suture on a UR6 needle was used to perform the McCall s culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized This was then tied in place and the remainder of the vaginal cuff was closed with 0 Chromic suture with figure of eight stitches At this time the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re insufflated and the patient was placed in Trendelenburg The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time The bladder was then drained and the Foley catheter was replaced and after gloves changed attention was turned to the abdomen with the laparoscopic instruments removed from the patient s abdomen The skin incisions were closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of 0 25 Marcaine in total were injected at incision site for additional analgesia The Steri Strips were placed The patient tolerated the procedure well and taken to recovery in stable condition Sponge lap and needle counts were correct x2 The specimens include the uterus cervix bilateral ovaries and fallopian tubes The patient will have her Foley catheter maintained for approximately 7 to 10 days Keywords surgery pelvic inflammatory disease pelvic adhesions pelvic pain fibroid uterus enterocele salpingo oophorectomy mccall s culdoplasty cystoscopy laparoscopic assisted vaginal hysterectomy foley catheter vaginal mucosa vaginal cuff bladder ligament clamps suture pelvic uterus vaginal inflammatory laparoscopic MEDICAL_TRANSCRIPTION,Description Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor Medical Specialty Surgery Sample Name Cystic Suprasellar Tumor Resection Transcription TITLE OF OPERATION Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor INDICATION FOR SURGERY She is a 3 year old girl who is known to have a head injury and CT in 2005 was normal presented with headache All endocrine labs were normal Surgery was recommended PREOP DIAGNOSIS Cystic suprasellar tumor POSTOP DIAGNOSIS Cystic suprasellar tumor PROCEDURE DETAIL The patient was brought to operating room underwent smooth induction of general endotracheal anesthesia head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended The patient was then prepped and draped in the usual sterile fashion With the assistance of fluoro and mapping the localization the right nostril was infiltrated Dr X will dictate the procedure of the approach Once the dura was visualized there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling Once the operating microscope was in the field at this point the drilling was completed The dura was opened in cruciate fashion revealing normal pituitary which was displaced and the cystic tumor This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down Once this was completed there was no evidence of any bleeding The endoscope was then used to remove any residual fragments __________ with the arachnoid Once this was completely ensured small piece of Duragel was placed and the closure will be dictated by Dr X She was reversed extubated and transported to the ICU in stable condition Blood loss minimal All sponge needle counts were correct Keywords surgery microsurgical transnasal resection cystic suprasellar tumor transnasal resection endoscopic transnasal microsurgical suprasellar cystic tumor MEDICAL_TRANSCRIPTION,Description CT guided needle placement CT guided biopsy of right renal mass and embolization of biopsy tract with gelfoam Medical Specialty Surgery Sample Name CT Guided Biopsy Kidney Transcription REASON FOR EXAM This 60 year old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr X PROCEDURE The procedure risks and possible complications including but not limited to severe hemorrhage which could result in emergent surgery were explained to the patient The patient understood All questions were answered and informed consent was obtained With the patient in the prone position noncontrasted CT localization images were obtained through the kidney Conscious sedation was utilized with the patient being monitored The patient was administered divided dose of Versed and fentanyl intravenously Following sterile preparation and local anesthesia to the posterior aspect of the right flank an 18 gauge co axial Temno type needle was directed into the inferior pole right renal mass from the posterior oblique approach Two biopsy specimens were obtained and placed in 10 formalin solution CT documented needle placement Following the biopsy there was active bleeding through the stylet as well as a small hematoma about the inferior aspect of the right kidney posteriorly I placed several torpedo pledgets of Gelfoam through the co axial sheath into the site of bleeding The bleeding stopped The co axial sheath was then removed Bandage was applied Hemostasis was obtained The patient was placed in the supine position Postbiopsy CT images were then obtained The patient s hematoma appeared stable The patient was without complaints of pain or discomfort The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged as stable The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr Fieldstone for the results and follow up care FINDINGS Initial noncontrasted CT localization images reveals the presence of an approximately 2 1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass There are small droplets of air within the hematoma No hydronephrosis is identified CONCLUSION 1 Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10 formalin solution 2 Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets Keywords surgery embolization ct localization gelfoam pledgets ct guided needle placement ct guided biopsy needle placement renal mass ct guided inferior pole ct biopsy hematoma kidney mass MEDICAL_TRANSCRIPTION,Description Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques Medical Specialty Surgery Sample Name Craniotomy Frontotemporal Transcription PREOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma POSTOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma TITLE OF THE OPERATION Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques ASSISTANT None INDICATIONS The patient is a 75 year old man with a 6 week history of decline following a head injury He was rendered unconscious by the head injury He underwent an extensive syncopal workup in Mississippi This workup was negative The patient does indeed have a heart pacemaker The patient was admitted to ABCD three days ago and yesterday underwent a CT scan which showed a large appearance of subdural hematoma There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity The patient and the family understood the nature indications and risk of the surgery and agreed to go ahead DESCRIPTION OF PROCEDURE The patient was brought to the operating room where general and endotracheal anesthesia was obtained The head was turned over to the left side and was supported on a cushion There was a roll beneath the right shoulder The right calvarium was shaved and prepared in the usual manner with Betadine soaked scrub followed by Betadine paint Markings were applied Sterile drapes were applied A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia Weitlaner retractors were inserted A single bur hole was placed underneath the temporalis muscle I placed the craniotomy a bit low in order to have better cosmesis A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm The bone was set aside The dura was clearly discolored and very tense The dura was opened in a cruciate fashion with a 15 blade There was immediate flow of a thin motor oil fluid under high pressure Literally the fluid shot out several inches with the first nick in the membranous cavity The dura was reflected back and biopsy of the membranes was taken and sent for permanent section The margins of the membrane were coagulated The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none The dura was then closed in a watertight fashion using running locking 4 0 Nurolon Tack up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system The wound was irrigated thoroughly once more and was closed in layers Muscle fascia and galea were closed in separate layers with interrupted inverted 2 0 Vicryl Finally the skin was closed with running locking 3 0 nylon Estimated blood loss for the case was less than 30 mL Sponge and needle counts were correct FINDINGS Chronic subdural hematoma with multiple septations and thickened subdural membrane I might add that the arachnoid was not violated at all during this procedure Also it was noted that there was no subarachnoid blood but only subdural blood Keywords surgery frontotemporal weitlaner calvarium cookie cutter type craniotomy dura frontotemporal craniotomy galea hematoma subdural subdural hematoma syncopal temporalis subacute subdural hematoma temporalis muscle MEDICAL_TRANSCRIPTION,Description Left temporal craniotomy and removal of brain tumor Medical Specialty Surgery Sample Name Craniotomy Temporal Transcription PREOPERATIVE DIAGNOSIS Brain tumor left temporal lobe POSTOPERATIVE DIAGNOSIS Brain tumor left temporal lobe glioblastoma multiforme OPERATIVE PROCEDURE 1 Left temporal craniotomy 2 Removal of brain tumor OPERATING MICROSCOPE Stealth PROCEDURE The patient was placed in the supine position shoulder roll and the head was turned to the right side The entire left scalp was prepped and draped in the usual fashion after having being placed in 2 point skeletal fixation Next we made an inverted U fashion base over the asterion over temporoparietal area of the skull A free flap was elevated after the scalp that was reflected using the burr hole and craniotome The bone flap was placed aside and soaked in the bacitracin solution The dura was then opened in an inverted U fashion Using the Stealth we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle We head through the vein of Labbe and we made great care to preserve this We saw where the tumor almost made to the surface Here we made a small corticectomy using the Stealth for guidance We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid This was submitted to pathology We biopsied this very abnormal tissue and submitted it to pathology They gave us a frozen section diagnosis of glioblastoma multiforme With the operating microscope and Greenwood bipolar forceps we then systematically debulked this tumor It was very vascular and we really continued to remove this tumor until all visible tumors was removed We appeared to get two gliotic planes circumferentially We could see it through the ventricle After removing all visible tumor grossly we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4 0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal The bone flap was then replaced and sutured with the Lorenz titanium plate system The muscle fascia galea was closed with interrupted 2 0 Vicryl sutures Skin staples were used for skin closure The blood loss of the operation was about 200 cc There were no complications of the surgery per se The needle count sponge count and the cottonoid count were correct COMMENT Operating microscope was quite helpful in this as we could use the light as well as the magnification to help us delineate the brain tumor gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic looking tumor of the brain Keywords surgery temporal lobe brain tumor lorenz titanium plate burr hole cortex corticectomy craniotome craniotomy frozen section glioblastoma multiforme temporal craniotomy temporoparietal ventricle white matter tumor temporal brain MEDICAL_TRANSCRIPTION,Description Acute left subdural hematoma Left frontal temporal craniotomy for evacuation of acute subdural hematoma CT imaging reveals an acute left subdural hematoma which is hemispheric Medical Specialty Surgery Sample Name Craniotomy Frontotemporal 1 Transcription PREOPERATIVE DIAGNOSIS Acute left subdural hematoma POSTOPERATIVE DIAGNOSIS Acute left subdural hematoma PROCEDURE Left frontal temporal craniotomy for evacuation of acute subdural hematoma DESCRIPTION OF PROCEDURE This is a 76 year old man who has a history of acute leukemia He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury His CT imaging reveals an acute left subdural hematoma which is hemispheric The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy The images were brought up on the electronic imaging and confirmed that this was a left sided condition He was fixed in a three point headrest His scalp was shaved and prepared with Betadine iodine and alcohol We made a small curved incision over the temporal parietal frontal region The scalp was reflected A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created After completing the bur hole flap the dura was opened and a gelatinous mass of subdural was peeled away from the brain The brain actually looked relatively relaxed and after removal of the hematoma the brain sort of slowly came back up We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline After we felt that we had an adequate decompression the dura was reapproximated and we filled the subdural space with saline We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates The scalp was reapproximated and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment Given that this actual skin looked good with apparent removal of about 80 of the subdural we elected to take patient to the Intensive Care Unit for further management I was present for the entire procedure and supervised this I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain Keywords surgery subdural hematoma temporal craniotomy craniotomy subdural space bur hole subdural hematoma MEDICAL_TRANSCRIPTION,Description Bilateral orbital frontal zygomatic craniotomy skull base approach bilateral orbital advancement with C shaped osteotomies down to the inferior orbital rim with bilateral orbital advancement with bone grafts bilateral forehead reconstruction with autologous graft Medical Specialty Surgery Sample Name Craniotomy Frontal Zygomatic Transcription PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly PROCEDURES 1 Bilateral orbital frontal zygomatic craniotomy skull base approach 2 Bilateral orbital advancement with C shaped osteotomies down to the inferior orbital rim with bilateral orbital advancement with bone grafts 3 Bilateral forehead reconstruction with autologous graft 4 Advancement of the temporalis muscle bilaterally 5 Barrel stave osteotomies of the parietal bones ANESTHESIA General PROCEDURE After induction of general anesthesia the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut Scalp was clipped He was prepped with ChloraPrep Incision was infiltrated with 0 5 Xylocaine with epinephrine 1 200 000 and he received antibiotics and he was then reprepped and draped in a sterile manner A bicoronal zigzag incision was made and Raney clips used for hemostasis Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly These were subgaleal flaps Bipolar and Bovie cautery were used for hemostasis The craniectomy was outlined with methylene blue The pericranium was incised exposing the bone along the outline of the craniotomy Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture One was just above the nasion and the other was near the bregma Also bilateral pterional bur holes were drilled There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes The dura was separated with a 4 Penfield dissector and then the craniotomies were fashioned or cut I should say with the Midas Rex drill using the V5 bit and the footplate attachment the bilateral craniotomies were cut and then the midline piece was elevated separately Great care was taken when removing the bone from the midline Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled The wound was irrigated with bacitracin irrigation The next step was to perform the orbital osteotomies with careful protection of the orbital contents Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally This was a very thick and vertically oriented orbital roof on each side Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet Bone wax was used for hemostasis It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit This was done with the Midas Rex drill using B5 bit Also the marked ridge just above the nasion was burred down with the Midas Rex drill The osteotomies were also carried down through the zygoma At this point with a gentle rocking motion and sustained pressure using the osteotomes it was then possible to carefully advance the orbital rims bilaterally first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally Dr X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim This created a shelf for the notched bone graft to lean against basically anteriorly The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly The left medial orbital rim greenstick fractured a bit but the bone graft appeared to stay in place Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with 3 0 Vicryl suture This helped fill in the indentation left by the orbital advancement at the temporal region Also I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel stave osteotomies in the parietal bones and then greenstick fractured these barrel staves outward to create a more normal contour of the bone slightly posteriorly At this point Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure The wound was then irrigated with bacitracin irrigation Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma At this point the reconstruction looked good The advancement was about 1 cm and we were pleased with the results The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with 4 0 and some 3 0 Vicryl interrupted suture and 5 0 mild chromic on the skin The patient tolerated procedure well No complications Sponge and needle counts were correct Again blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma Keywords surgery metopic synostosis trigonocephaly bilateral orbital frontal zygomatic craniotomy skull base approach orbital advancement c shaped osteotomies forehead reconstruction temporalis muscle midas rex drill frontal zygomatic sagittal sinus orbital roof orbital rim bone grafts forehead bone orbital craniotomy osteotomies MEDICAL_TRANSCRIPTION,Description Left retrosigmoid craniotomy and excision of acoustic neuroma Medical Specialty Surgery Sample Name Craniotomy Retrosigmoid Transcription PREOPERATIVE DIAGNOSIS Left acoustic neuroma POSTOPERATIVE DIAGNOSIS Left acoustic neuroma PROCEDURE PERFORMED Left retrosigmoid craniotomy and excision of acoustic neuroma ANESTHESIA General OPERATIVE FINDINGS This patient had a 3 cm acoustic neuroma The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve The facial nerve was stimulated at the brainstem at 0 05 milliamperes at the conclusion of the dissections PROCEDURE IN DETAIL Following induction of adequate general anesthetic the patient was positioned for surgery She was placed in a lateral position and her head was maintained with Mayfield pins The left periauricular area was shaved prepped and draped in the sterile fashion Transdermal electrodes for continuous facial nerve EMG monitoring were placed and no response was verified The proposed incision was injected with 1 Xylocaine with epinephrine Next T shaped incision was made approximately 5 cm behind the postauricular crease The incision was undermined at the level of temporalis fascia and the portion of the fascia was harvested for further use Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax Bergen retractors were used to maintain exposure Using a cutting bur with continuous suction and irrigation of craniotomy was performed The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly From these structures approximately 4 x 4 cm a window of bone was removed Bone shavings were collected during the dissection and placed in Siloxane suspension for later use The bone flap was also left at the site for further use Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base Bone wax was used to occlude air cells lateral to the sigmoid sinus There was extensively aerated temporal bone At this point Dr Trask entered the case in order to open the dura and expose the tumor The cerebellum was retracted away from the tumor and the retractor was placed to help maintain exposure Once initial exposure was completed attention was directed to the posterior aspect of the temporal bone The dura was excised from around the porous acusticus extending posteriorly along the bone Then using diamond burs the internal auditory canal was dissected out The bone was removed laterally for distance of approximately 8 mm There was considerable aeration around the internal auditory canal as well The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult Therefore Dr Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor With dissection he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem The eighth nerve was identified and transected Tumor debulking allowed for retraction of the tumor capsule away from the brainstem The facial nerve was difficult to identify at the brainstem as well It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve Attention was then redirected to the internal auditory canal where this portion of the tumor was removed The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus At this point plane of dissection was again indistinct The tumor had been released from the porous and could be rotated The tumor was further debulked and thinned but could not crucially visualize the nerve on the anterior face of the tumor The nerve could be stimulated but was quite splayed over the anterior face Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve both proximally and distally However the cerebellopontine angle portion of the nerve was not usually delineated However the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness It was released from the brainstem ventrally The tumor was then cauterized with bipolar electrocautery The facial nerve was stimulated at the brainstem and stimulated easily at 0 05 milliamperes Overall the remaining tumor volume would be of small percentage of the original volume At this point Dr Trask re inspected the posterior fossa to ensure complete hemostasis The air cells around the internal auditory canal were packed off with muscle and bone wax A piece of fascia was then laid over the bone defect Next the dura was closed with DuraGen and DuraSeal The bone flap and bone were then placed in the bone defect Postauricular musculature was then reapproximated using interrupted 3 0 Vicryl sutures The skin was also closed using interrupted subdermal 3 0 Vicryl sutures Running 4 0 nylon suture was placed at the skin levels Sterile mastoid dressing was then placed The patient tolerated the procedure well and was transported to the PACU in a stable condition All counts were correct at the conclusion of the procedure ESTIMATED BLOOD LOSS 100 mL Keywords surgery neuroma bergen retractors emissary veins mayfield pins acoustic acoustic neuroma cerebellopontine craniotomy facial nerve periauricular retrosigmoid retrosigmoid craniotomy internal auditory canal porous acusticus sigmoid sinus auditory canal bone brainstem nerve postauricular tumor MEDICAL_TRANSCRIPTION,Description Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA Medical Specialty Surgery Sample Name Craniotomy Occipital Transcription PREOPERATIVE DIAGNOSIS Brain tumors multiple POSTOPERATIVE DIAGNOSES Brain tumors multiple adenocarcinoma and metastasis from breast PROCEDURE Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA PROCEDURE The patient was placed in the prone position after general endotracheal anesthesia was administered The scalp was prepped and draped in the usual fashion The CUSA was brought in to supplement the use of operating microscope as well as the stealth which was used to localize the tumor Following this we then made a transverse linear incision the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor The bone flap was elevated The ultrasound was then used The ultrasound showed the tumors directly I believe are in the interhemispheric fissure We noticed that the dura was quite tense despite that the patient had slight hyperventilation We gave 4 ounce of mannitol the brain became more pulsatile We then used the stealth to perform a ventriculostomy Once this was done the brain began to pulsate nicely We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus After having done this we then used operating microscope and slight self retaining retraction was used We obtained access to the tumor We biopsied this and submitted it This was returned as a malignant brain tumor metastatic tumor adenocarcinoma compatible with breast cancer Following this we then debulked this tumor using CUSA and then removed it in total After gross total removal of this tumor the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery The next step was after removal of this tumor closure of the wound a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates The tumors self extend into the ventricle and after we had removed the tumor we could see our ventricular catheter in the occipital horn of the ventricle This being the case we left this ventricular catheter in brought it out through a separate incision and connected to sterile drainage The next step was to close the wound after reapproximating the bone flap The galea was closed with 2 0 Vicryl and the skin was closed with interrupted 3 0 nylon sutures inverted with mattress sutures The sterile dressings were applied to the scalp The patient returned to the recovery room in satisfactory condition Hemodynamically remained stable throughout the operation Once again we performed occipital craniotomy total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy The tumor was removed using the combination of CUSA ultrasound stealth guided ventriculostomy and the patient will have a second operation today we will perform a selective craniectomy to remove another large tumor in the posterior fossa Keywords surgery brain tumor cusa occipital adenocarcinoma bone flap craniotomy malignant metastatic scalp galea transverse linear incision ventriculostomy occipital craniotomy tumor stealth brain MEDICAL_TRANSCRIPTION,Description Biparietal craniotomy insertion of left lateral ventriculostomy right suboccipital craniectomy and excision of tumor Medical Specialty Surgery Sample Name Craniotomy Biparietal Transcription PREOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm POSTOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm TITLE OF THE OPERATION 1 Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer 2 Insertion of left lateral ventriculostomy under Stealth stereotactic guidance 3 Right suboccipital craniectomy and excision of tumor 4 Microtechniques for all the above 5 Stealth stereotactic guidance for all of the above and intraoperative ultrasound INDICATIONS The patient is a 48 year old woman with a diagnosis of breast cancer made five years ago A year ago she was diagnosed with cranial metastases and underwent whole brain radiation She recently has deteriorated such that she came to my office unable to ambulate in a wheelchair Metastatic workup does reveal multiple bone metastases but no spinal cord compression She had a consult with Radiation Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery but the lesions greater than 3 cm needed to be removed Consequently this operation is performed PROCEDURE IN DETAIL The patient underwent a planning MRI scan with Stealth protocol She was brought to the operating room with fiducial still on her scalp General endotracheal anesthesia was obtained She was placed on the Mayfield head holder and rolled into the prone position She was well padded secured and so forth The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint This was done only of course after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system Sterile drapes were applied and the accuracy of the system was confirmed A biparietal incision was performed A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation A biparietal craniotomy was carried out carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system The dura was opened and reflected back to the midline An inner hemispheric approach was used to reach the very large metastatic tumor This was very delicate removing the tumor and the co surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor The tumor was wrapped around and included the choroidal vessels At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region Bleeding was quite vigorous in some of the arteries and finally however was completely controlled Complete removal of the tumor was confirmed by intraoperative ultrasound Once the tumor had been removed and meticulous hemostasis was obtained this wound was left opened and attention was turned to the right suboccipital area A linear incision was made just lateral to the greater occipital nerve Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull A burr hole was placed down low using a craniotome A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor and this was draining CSF relieving pressure in the posterior fossa Upon opening the craniotomy in the parietal occipital region the brain was noted to be extremely tight thus necessitating placement of the ventriculostomy At the posterior fossa a corticectomy was accomplished and the tumor was countered directly The tumor as the one above was removed both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator A gross total excision of this tumor was obtained as well I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle however this was just over the lower cranial nerves and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss this lesion was left alone and to be radiated and that it is less than 3 cm in diameter Meticulous hemostasis was obtained for this wound as well The posterior fossa wound was then closed in layers The dura was closed with interrupted and running mattress of 4 0 Nurolon The dura was watertight and it was covered with blue glue Gelfoam was placed over the dural closure Then the muscle and fascia were closed in individual layers using 0 Ethibond Subcutaneous was closed with interrupted inverted 2 0 and 0 Vicryl and the skin was closed with running locking 3 0 Nylon For the cranial incision the ventriculostomy was brought out through a separate stab wound The bone flap was brought on to the field The dura was closed with running and interrupted 4 0 Nurolon At the beginning of the case dural tack ups had been made and these were still in place The sinuses both the transverse sinus and sagittal sinus were covered with thrombin soaked Gelfoam to take care of any small bleeding areas in the sinuses Once the dura was closed the bone flap was returned to the wound and held in place with the Lorenz microplates The wound was then closed in layers The galea was closed with multiple sutures of interrupted 2 0 Vicryl The skin was closed with a running locking 3 0 Nylon Estimated blood loss for the case was more than 1 L The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid Nevertheless her vitals remained stable throughout the case and we hopefully helped her survival and her long term neurologic status for this really nice lady Keywords surgery metastatic lesion biparietal mayfield head holder microtechniques stealth craniotomy excision fiducial infratentorial parietooccipital stereotactic suboccipital subtentorial ventriculostomy lesions to the brain removal of the tumor parietal occipital region running locking nylon biparietal craniotomy posterior fossa tumor brain dura lesions MEDICAL_TRANSCRIPTION,Description Cystoscopy cryosurgical ablation of the prostate Medical Specialty Surgery Sample Name Cryosurgical Ablation of Prostate Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the prostate clinical stage T1C POSTOPERATIVE DIAGNOSIS Carcinoma of the prostate clinical stage T1C TITLE OF OPERATION Cystoscopy cryosurgical ablation of the prostate FINDINGS After measurement of the prostate we decided to place 5 rows of needles row 1 had 3 needles row 2 at the level of the mid prostate had 4 needles row 3 had 2 needles in the right lateral peripheral zone row 4 was a single needle directly the urethra and in row 5 were 2 needles placed in the left lateral peripheral zone Because of the length of the prostate a pull back was performed pulling row 2 approximately 3 mm and rows 3 4 and 5 approximately 1 cm back before refreezing OPERATION IN DETAIL The patient was brought to the operating room and placed in the supine position After adequate general endotracheal anesthesia was obtained the patient was positioned in the dorsal lithotomy position Full bowel prep had been obtained prior to the procedure After performing flexible cystoscopy a Foley catheter was placed per urethra into the bladder Next the ultrasound probe was placed into the stabilizer and advanced into the rectum An excellent ultrasound image was visualized of the entire prostate which was re measured Next the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement Then 17 gauge needles were serially placed into the prostate from an anterior to posterior direction into the prostate Ultrasound guidance demonstrated that these needles numbering approximately 14 to 15 needles were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra Repeat cystoscopy demonstrated a single needle passing through the urethra and due to the high anterior location of this needle it was removed The CMS urethral warmer was then passed per urethra into the bladder and flow instituted After placing these 17 gauge needles the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature The urethral warmer was left on after the needles were removed and the patient brought to the recovery room The patient tolerated the procedure well and left the operating room in stable condition Keywords surgery carcinoma of the prostate ablation cystoscopy cryosurgical ablation prostate ultrasound cryosurgical urethra MEDICAL_TRANSCRIPTION,Description Right frontal craniotomy with resection of right medial frontal brain tumor Stereotactic image guided neuronavigation and microdissection and micro magnification for resection of brain tumor Medical Specialty Surgery Sample Name Craniotomy Neuronavigation Transcription PROCEDURES 1 Right frontal craniotomy with resection of right medial frontal brain tumor 2 Stereotactic image guided neuronavigation for resection of tumor 3 Microdissection and micro magnification for resection of brain tumor ANESTHESIA General via endotracheal tube INDICATIONS FOR THE PROCEDURE The patient is a 71 year old female with a history of left sided weakness and headaches She has a previous history of non small cell carcinoma of the lung treated 2 years ago An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor After informed consent was obtained the patient was brought to the operating room for surgery PREOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift POSTOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift probable metastatic lung carcinoma DESCRIPTION OF THE PROCEDURE The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube She was positioned on the operating room table in the Sugita frame with the head secured Using the preoperative image guided MRI we carefully registered the fiducials and then obtained the stereotactic image guided localization to guide us towards the tumor We marked external landmarks Then we shaved the head over the right medial frontal area This area was then sterilely prepped and draped Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted A horseshoe shaped flap was based on the right and then brought across to the midline This was opened and hemostasis obtained using Raney clips The skin flap was retracted medially Two burr holes were made and were carefully connected One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap Hemostasis was obtained Using the neuronavigation we identified where the tumor was The dura was then opened based on a horseshoe flap based on the medial sinus We retracted this medially and carefully identified the brain The brain surface was discolored and obviously irritated consistent with the tumor We used the stereotactic neuronavigation to identify the tumor margins Then we used a bipolar to coagulate a thin layer of brain over the tumor Subsequently we entered the tumor The tumor itself was extremely hard Specimens were taken and send for frozen section analysis which showed probable metastatic carcinoma We then carefully dissected around the tumor margins Using the microscope we then brought microscopic magnification and dissection into the case We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly medially inferiorly and laterally Then using the Cavitron we cored out the central part of the tumor Then we collapsed the tumor on itself and removed it entirely In this fashion microdissection and magnification resection of the tumor was carried out We resected the entire tumor Neuronavigation was used to confirm that no further tumor residual was remained Hemostasis was obtained using bipolar coagulation and Gelfoam We also lined the cavity with Surgicel The cavity was nicely dry and excellent hemostasis was obtained The dura was closed using multiple interrupted 4 0 Nurolon sutures in a watertight fashion Surgicel was placed over the dural closure The bone flap was repositioned and held in place using CranioFIX cranial fixators The galea was re approximated and the skin was closed with staples The wound was dressed The patient was returned to the intensive care unit She was awake and moving extremities well No apparent complications were noted Needle and sponge counts were listed as correct at the end of the procedure Estimated intraoperative blood loss was approximately 150 mL and none was replaced Keywords surgery stereotactic image guided neuronavigation micro magnification resection of brain tumor frontal craniotomy mass effect brain shift stereotactic image brain tumor brain tumor craniotomy endotracheal carcinoma neuronavigation microdissection MEDICAL_TRANSCRIPTION,Description Right sided craniotomy for evacuation of a right frontal intracranial hemorrhage Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull based brain tumor Medical Specialty Surgery Sample Name Craniotomy Transcription TITLE OF OPERATION Right sided craniotomy for evacuation of a right frontal intracranial hemorrhage INDICATION FOR SURGERY The patient is very well known to our service In brief the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull based brain tumor He was taken to the operating room for the orbitozygomatic approach Intraoperatively everything went well without any complications The brain at the end of the procedure was absolutely intact but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan developed a second seizure He was given Ativan for this and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe what appeared to be a hemorrhagic conversion of potential venous infarct I had a long discussion immediately with Dr X and Dr Y We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component It worried me and I think that we needed to go ahead and take him to the operating room immediately The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure The original plan was to do first a right sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma PREOP DIAGNOSIS Pituitary tumor with a large intracranial component status post resection and now development of an intracranial hemorrhage POSTOP DIAGNOSIS Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach ANESTHESIA General PROCEDURE IN DETAIL The patient was taken to the operating room In the supine position his head was put in a horseshoe without any complications The patient tolerated this very well and the prior incision was immediately opened The surgery had taken place a few hours prior to this the original orbitozygomatic approach At this point this was a life saving procedure We went ahead opened the old incision after everything was sterilely prepped and all the surgical instrumentation was brought into place We went ahead and opened the incision and took out the pterional bone flap without any complications We immediately opened the dura expeditiously and the brain was moderately under some pressure but not really bulging out So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead and over the next few hours very meticulously began to evacuate these clots without any complication whatsoever We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications and we had a very nice resection The brain was very relaxed We had a very good resection of the actual blood clot and the brain was very relaxed We irrigated thoroughly We identified the ventricles We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure All this was done very well and then we lined the cavity with Surgicel and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle and then after this everything was good We went ahead and closed back the actual dura back We had done a pericranial flap This was also put back in place and the dura was closed with 4 0 Surgilons We reconstructed everything The frontal sinus was reconstructed thoroughly without any complications We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place and went ahead and put the bone flap back and reconstructed very nicely once again with self tapping self drilling screws low profile plates Once everything was confirmed to be in place we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop offs and the skin with staples without any complications In summary the procedure was going back to the operating room for evacuation of a right sided intracranial hemorrhage most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications So everything was stable Estimated blood loss was about 100 cubic centimeters The sponges and needle counts were correct No specimens were sent to pathology DISPOSITION The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation Keywords surgery orbitozygomatic intracranial brain tumor intraparenchymal hematoma orbitozygomatic approach frontal lobe intracranial hemorrhage pituitary tumor craniotomy hemorrhage MEDICAL_TRANSCRIPTION,Description Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain Medical Specialty Surgery Sample Name Craniotomy Burr Hole Transcription PREOPERATIVE DIAGNOSIS Right chronic subdural hematoma POSTOPERATIVE DIAGNOSIS Right chronic subdural hematoma TYPE OF OPERATION Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS 100 cc OPERATIVE PROCEDURE In preoperative identification the patient was taken to the operating room and placed in supine position Following induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery Table was turned The right shoulder roll was placed The head was turned to the left and rested on a doughnut The scalp was shaved and then prepped and draped in usual sterile fashion Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss The parietal boss incision was opened It was about an inch and a half in length It was carried down to the skull Self retaining retractor was placed A bur hole was now fashioned with the perforator This was widened with a 2 mm Kerrison punch The dura was now coagulated with bipolar electrocautery It was opened in a cruciate type fashion The dural edges were coagulated back to the bony edges There was egress of a large amount of liquid Under pressure we irrigated for quite sometime until irrigation was returning mostly clear A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision It was secured with a 3 0 nylon suture The area was closed with interrupted inverted 2 0 Vicryl sutures The skin was closed with staples Sterile dressing was applied The patient was subsequently returned back to anesthesia He was extubated in the operating room and transported to PACU in satisfactory condition Keywords surgery hematoma burr hole craniotomy frontotemporal frontotemporal craniotomy subdural subdural drain subdural hematoma subdural space MEDICAL_TRANSCRIPTION,Description Anterior cranial vault reconstruction with fronto orbital bar advancement Medical Specialty Surgery Sample Name Cranial Vault Reconstruction Transcription INDICATION FOR OPERATION Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly PREOPERATIVE DIAGNOSIS Syndromic craniosynostosis POSTOPERATIVE DIAGNOSIS Syndromic craniosynostosis TITLE OF OPERATION Anterior cranial vault reconstruction with fronto orbital bar advancement SPECIMENS None DRAINS One subgaleal drain exiting from the left posterior aspect of wound DESCRIPTION OF PROCEDURE After satisfactory general endotracheal tube anesthesia was started the patient was placed on the operating table in supine position with the head held on a horseshoe shaped headrest and the head was prepped and draped down the routine manner Here the proposed scalp incision was infiltrated with 1 Xylocaine and then a zigzag scalp incision was made from one ear to the other ear posterior to the coronal suture Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion Using a craniotome several bur holes were made two on the either side of the midline posteriorly and then two posterolaterally The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right going paramedian along the superior sagittal sinus in the midline and then curving over the fronto orbital bar We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right which was abnormal The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs On the right the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof The orbital rim was then dissected out and then using the saw and chisels we were able to make the releasing cuts to free up the orbital rims zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate It was then replaced and advanced and then relaxing barrel staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position The bone flaps were then reapproximated using absorbable plates and screws as well as 2 0 Vicryl to secure back into place Some of the places were also secured in the midline posteriorly as well as off to the right where the bony defects were in place The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum The wounds were irrigated out A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast absorbing gut for the skin followed by sterile dressings The patient tolerated the procedure well and did receive blood transfusions Keywords surgery coronal synostosis syndromic craniosynostosis craniosynostosis plagiocephaly fronto orbital bar cranial vault reconstruction cranial vault orbital bar orbital cranial MEDICAL_TRANSCRIPTION,Description Selective coronary angiography Placement of overlapping 3 0 x 18 and 3 0 x 8 mm Xience stents in the proximal right coronary artery Abdominal aortography Medical Specialty Surgery Sample Name Coronary Angiography Abdominal Aortography Transcription NAME OF PROCEDURE 1 Selective coronary angiography 2 Placement of overlapping 3 0 x 18 and 3 0 x 8 mm Xience stents in the proximal right coronary artery 3 Abdominal aortography INDICATIONS The patient is a 65 year old gentleman with a history of exertional dyspnea and a cramping like chest pain Thallium scan has been negative He is undergoing angiography to determine if his symptoms are due to coronary artery disease NARRATIVE The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2 lidocaine Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg Received additional Versed and fentanyl during the procedure Please refer to the nurses notes for dosages and timing The right femoral artery was entered and a 4 French sheath was placed Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta Via the right Judkins catheter the guidewire was easily infiltrated to the thoracic aorta and over aortic arch The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed This revealed a very high grade lesion at the proximal right coronary artery This catheter was exchanged for a left 4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed The patient was found to have the above mentioned high grade lesion in the right coronary artery and a coronary intervention was performed A 6 French sheath and a right Judkins guide was placed The patient was started on bivalarudin A BMW wire was easily placed across the lesion and into the distal right coronary artery A 3 0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres The intermediate result was improved with TIMI 3 flow to the terminus of the vessel Following this a 3 0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection This was stented with a 3 0 x 8 mm Xience stent deployed again at 17 atmospheres Final angiograms revealed excellent result with TIMI 3 flow at the terminus of the right coronary artery and approximately 10 residual stenosis at the worst point of the narrowing The guiding catheter was withdrawn over wire and a pigtail was placed This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection The catheter was removed The bivalarudin was stopped at the termination of procedure A small injection of contrast given through arterial sheath and Angio Seal was placed without incident It should also be noted that an 8 French sheath was placed in the right femoral vein This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea Total contrast media 205 mL total fluoroscopy time was 7 5 minutes X ray dose 2666 milligray HEMODYNAMICS Rhythm was sinus throughout the procedure Aortic pressure was 170 81 mmHg The right coronary artery is a dominant vessel This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals In the proximal right coronary artery there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity After intervention there is TIMI 3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow There was approximately 10 residual stenosis at the worst part of the previous stenosis The left main is without disease and trifurcates into a moderate sized ramus intermedius the LAD and the circumflex The ramus intermedius is free of disease The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment This measures 25 to 30 at its worst point The circumflex is a large caliber vessel There is a proximal 15 to 20 stenosis and an area of ectasia in the proximal circumflex Distally this circumflex gives rise to a large bifurcating marginal artery and beyond that point the circumflex is a small vessel within the AV groove The aortogram demonstrates eccentric aneurysm formation This may represent a small retrograde dissection as well There was some dye hang up in the wall IMPRESSION 1 Successful stenting of subtotal stenosis of the proximal coronary artery 2 Non obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery 3 Left to right collateral filling noted prior to coronary intervention 4 Small area of eccentric aneurysm formation in the abdominal aorta Keywords surgery xience stents thallium scan coronary artery coronary angiography abdominal aortography artery coronary angiography stents flow vessel abdominal catheter circumflex stenosis proximal MEDICAL_TRANSCRIPTION,Description Postoperative hemorrhage Examination under anesthesia with control of right parapharyngeal space hemorrhage The patient is a 35 year old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy Medical Specialty Surgery Sample Name Control of Parapharyngeal Hemorrhage Transcription PREOPERATIVE DIAGNOSIS Postoperative hemorrhage POSTOPERATIVE DIAGNOSIS Postoperative hemorrhage SURGICAL PROCEDURE Examination under anesthesia with control of right parapharyngeal space hemorrhage ANESTHESIA General endotracheal technique SURGICAL FINDINGS Right lower pole bleeder cauterized with electrocautery with good hemostasis INDICATIONS FOR SURGERY The patient is a 35 year old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy Previously in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty However in the PACU after a coughing spell she began bleeding from the right oropharynx and was taken back to the operative suite for control of hemorrhage DESCRIPTION OF SURGERY The patient was placed supine on the operating room table and general anesthetic was administered once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage A Crowe Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa this area was cauterized with suction cautery and irrigated There was no other bleeding noted The patient was repositioned and the mouth gag the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined There was a small amount of oozing noted in the right tonsillar bed and this was cauterized with suction cautery No other bleeding was noted and the patient was recovered from general anesthetic She was extubated and left the operating room in good condition to postoperative recovery room area Prior to extubation the patient s tonsillar fossa were injected with a 6 mL of 0 25 Marcaine with 1 100 000 adrenalin solution to facilitate postoperative analgesia and hemostasis Keywords surgery obstructive adenotonsillar hypertrophy tonsillar fossa suction cautery postoperative hemorrhage parapharyngeal space anesthesia oropharynx parapharyngeal tonsillectomy hemorrhage MEDICAL_TRANSCRIPTION,Description Lateral and plantar condylectomy fifth left metatarsal Medical Specialty Surgery Sample Name Condylectomy Transcription TITLE OF OPERATION Lateral and plantar condylectomy fifth left metatarsal PREOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal POSTOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal ANESTHESIA Monitored anesthesia care with 10 mL of 1 1 mixture of both 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 30 minutes left ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 3 0 Vicryl and 4 0 Vicryl INJECTABLES Ancef 1 g IV 30 minutes preoperatively DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in a supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in a normal sterile technique The left ankle tourniquet was inflated Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4 cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe The incision was deepened through the subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the soft tissue attachments through the fifth left metatarsal head were mobilized The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved The bony prominences were removed and passed off the operating table to be sent to pathology for identification The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp The area was copiously flushed with saline Then 3 0 Vicryl and 4 0 Vicryl suture materials were used to approximate the periosteal capsular and subcutaneous tissues respectively The incision was reinforced with Steri Strips Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited The patient s left ankle tourniquet at this time was deflated Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage and the patient s left foot was placed in a surgical shoe The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels The patient was given pain medications and instructions on how to control her postoperative course She was discharged from Hospital according to nursing protocol and was will follow up with Dr X in one week s time for her first postoperative appointment Keywords surgery plantar condyle hypertrophy condyle hypertrophy subcutaneous tissues ankle tourniquet metatarsophalangeal joint metatarsal head plantar condylectomy tourniquet condylectomy plantar ankle metatarsal MEDICAL_TRANSCRIPTION,Description Selective coronary angiography left heart catheterization with hemodynamics LV gram with power injection right femoral artery angiogram closure of the right femoral artery using 6 French AngioSeal Medical Specialty Surgery Sample Name Coronary Angiography Transcription REASON FOR EXAM Dynamic ST T changes with angina PROCEDURE 1 Selective coronary angiography 2 Left heart catheterization with hemodynamics 3 LV gram with power injection 4 Right femoral artery angiogram 5 Closure of the right femoral artery using 6 French AngioSeal Procedure explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation The patient was draped and dressed in the usual sterile fashion The right groin area infiltrated with lidocaine solution Access to the right femoral artery was successful okayed with one attempt with anterior wall stick Over a J wire 6 French sheath was introduced using modified Seldinger technique Over the J wire a JL4 catheter was passed over the aortic arch The wire was removed Catheter was engaged into the left main Multiple pictures with RAO caudal AP cranial LAO cranial shallow RAO and LAO caudal views were all obtained Catheter disengaged and exchanged over J wire into a JR4 catheter the wire was removed Catheter with counter clock was rotating to the RCA one shot with LAO position was obtained The cath disengaged and exchanged over J wire into a pigtail catheter Pigtail catheter across the aortic valve Hemodynamics obtained LV gram with power injection of 36 mL of contrast was obtained The LV gram assessed followed by pullback hemodynamics The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6 French AngioSeal with no hematoma The patient tolerated the procedure well with no immediate postprocedure complication HEMODYNAMICS The aortic pressure was 117 61 with a mean pressure of 83 The left ventricular pressure was 119 9 to 19 with left ventricular end diastolic pressure of 17 to 19 mmHg The pullback across the aortic valve reveals zero gradient ANATOMY The left main showed minimal calcification as well as the proximal LAD No stenosis in the left main seen the left main bifurcates in to the LAD and left circumflex The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD The LAD gave off two early diagonal branches The second was the largest of the two and showed minimal lumen irregularities but no focal stenosis Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA The left circumflex was large and patent 6 0 mm in diameter All three obtuse marginal branches appeared to be with no significant stenosis The obtuse marginal branch the third OM3 showed at the origin about 30 to 40 minimal narrowing but no significant stenosis The PDA was wide patent with no focal stenosis The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal LV gram showed that the LV EF is preserved with EF of 60 No mitral regurgitation identified IMPRESSION 1 Patent coronary arteries with normal left anterior descending left circumflex and dominant left circumflex system 2 Nondominant right which is free of atheromatous plaque 3 Minimal plaque in the diagonal branch II and the obtuse marginal branch III with no focal stenosis 4 Normal left ventricular function 5 Evaluation for noncardiac chest pain would be recommended Keywords MEDICAL_TRANSCRIPTION,Description Cauterization of peri and intra anal condylomas Extensive perianal and intra anal condyloma which are likely represent condyloma acuminata Medical Specialty Surgery Sample Name Condyloma Cauterization Transcription PREOPERATIVE DIAGNOSIS Extensive perianal and intra anal condyloma POSTOPERATIVE DIAGNOSIS Extensive perianal and intra anal condyloma PROCEDURE PERFORMED Cauterization of peri and intra anal condylomas ANESTHESIA IV sedation and local SPECIMEN Multiple condylomas were sent to pathology ESTIMATED BLOOD LOSS 10 cc BRIEF HISTORY This is a 22 year old female who presented to the office complaining of condylomas she had noted in her anal region She has noticed approximately three to four weeks ago She denies any pain but does state that there is some itching No other symptoms associated GROSS FINDINGS We found multiple extensive perianal and intra anal condylomas which are likely represent condyloma acuminata PROCEDURE After risks benefits and complications were explained to the patient and a verbal consent was obtained the patient was taken to the operating room After the area was prepped and draped a local anesthesia was achieved with Marcaine Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure The condylomas were removed 350 degrees from the perianal and intra anal regions After all visible condylomas were removed the area was again washed with acetic acid solution Any residual condylomas were then cauterized at this time The area was then examined again for any residual bleeding and there was none DISPOSITION The patient was taken to Recovery in stable condition She will be sent home with prescriptions for a topical lidocaine and Vicodin She will be instructed to do sitz bath b i d and post bowel movement She will follow up in the office next week Keywords surgery intra anal perianal acuminata cauterization condyloma anal MEDICAL_TRANSCRIPTION,Description Cervical cone biopsy dilatation curettage Medical Specialty Surgery Sample Name Cone Biopsy Transcription PREOPERATIVE DIAGNOSIS Cervical carcinoma in situ POSTOPERATIVE DIAGNOSIS Cervical carcinoma in situ OPERATION PERFORMED Cervical cone biopsy dilatation curettage SPECIMENS Cone biopsy endocervical curettings endometrial curettings INDICATIONS FOR PROCEDURE The patient recently presented with a Pap smear showing probable adenocarcinoma in situ The patient was advised to have cone biopsy to fully assess endocervical glands FINDINGS During the examination under anesthesia the vulva vagina and cervix were grossly unremarkable The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthetic was administered and she was placed in the lithotomy position The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction Angle stitches of 0 Vicryl sutures were placed at 3 o clock and 9 o clock in the lateral vagina fornices The cervix was stained with Lugol s iodine solution After the cervix was stained a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os The specimen was removed intact after which the uterine cavity was sounded to a depth of 8 cm A Kevorkian curette was used to obtain endocervical curettings The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture Upon completion of the suture placement the endocervical canal was sounded to assure patency A prophylactic application of Monsel s solution completed the procedure The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition Final sponge needle and instrument counts were Keywords surgery cervical carcinoma in situ cervical cone biopsy endometrial curettings endocervical endometrial dilatation curettage carcinoma in situ cone biopsy dilatation curettage carcinoma vicryl curettings vagina sutures cervix cervical cone biopsy MEDICAL_TRANSCRIPTION,Description Colonoscopy with random biopsies and culture Medical Specialty Surgery Sample Name Colonoscopy with Biopsy 4 Transcription PREOPERATIVE DIAGNOSIS Antibiotic associated diarrhea POSTOPERATIVE DIAGNOSIS Antibiotic associated diarrhea OPERATION PERFORMED Colonoscopy with random biopsies and culture INDICATIONS The patient is a 50 year old woman who underwent hemorrhoidectomy approximately one year ago She has been having difficulty since that time with intermittent diarrhea and abdominal pain She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes She presents today for screening colonoscopy based on the same OPERATIVE COURSE The risks and benefits of colonoscopy were explained to the patient in detail She provided her consent The morning of the operation the patient was transported from the preoperative holding area to the endoscopy suite She was placed in the left lateral decubitus position In divided doses she was given 7 mg of Versed and 125 mcg of fentanyl A digital rectal examination was performed after which time the scope was intubated from the anus to the level of the hepatic flexure This was intubated fairly easily however the patient was clearly in some discomfort and was shouting out despite the amount of anesthesia she was provided In truth the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure While more medication could have been given the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse In addition she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk For this reason the procedure was aborted at the level of the hepatic flexure She was noted to have some pools of stool This was suctioned and sent to pathology for C difficile ova and parasites and fecal leukocytes Additionally random biopsies were performed of the colon itself It is unfortunate we were unable to complete this procedure as I would have liked to have taken biopsies of the terminal ileum However given the degree of discomfort she had again coupled with the relative ease of the procedure itself I am very suspicious of irritable bowel syndrome The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition where it is anticipated she will be discharged to home PLAN She needs to follow up with me in approximately 2 weeks time both to follow up with her biopsies and cultures She has been given a prescription for VSL3 a probiotic to assist with reculturing the rectum She may also benefit from an antispasmodic and or anxiolytic Lastly it should be noted that when she next undergoes endoscopic procedure propofol would be indicated Keywords surgery colonoscopy with random biopsies hepatic flexure topical culture antibiotic hepatic flexure diarrhea biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description Colpocleisis and rectocele repair Medical Specialty Surgery Sample Name Colpocleisis Transcription PREOPERATIVE DIAGNOSES Vault prolapse and rectocele POSTOPERATIVE DIAGNOSES Vault prolapse and rectocele OPERATION Colpocleisis and rectocele repair ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY OF THE PATIENT This is an 85 year old female who presented to us with a vaginal mass On physical exam the patient was found to have grade 3 rectocele and poor apical support and history of hysterectomy The patient had good anterior support at the bladder Options were discussed such as watchful waiting pessary repair with and without mesh and closing of the vagina colpocleisis were discussed Risk of anesthesia bleeding infection pain MI DVT PE morbidity and mortality of the procedure were discussed Risk of infection and abscess formation were discussed The patient understood all the risks and benefits and wanted to proceed with the procedure Risk of retention and incontinence were discussed Consent was obtained through the family members DETAILS OF THE OR The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient had a Foley catheter placed The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support A 1 lidocaine with epinephrine was applied for posterior hydrodissection which was very difficult to do due to the significant scarring of the posterior part Attempts were made to lift the vaginal mucosa off of the rectum which was very very difficult to do at this point due to the patient s overall poor medical condition in terms of poor mobility and significant scarring Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis Oral consent was obtained from the family and her surgery was preceded The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors Using 0 Vicryl 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus The vaginal mucosa was pretty much completely closed off all the way up to the introitus Indigo carmine was given Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings There was no injury to the bladder or kinking of the ureteral openings The bladder was normal Rectal exam was normal at the end of the colpocleisis repair There was good hemostasis At the end of the procedure Foley was removed and the patient was brought to recovery in a stable condition Keywords surgery vault prolapse rectocele repair rectocele vaginal mass metzenbaum scissors ureteral openings vaginal mucosa colpocleisis vaginal infection MEDICAL_TRANSCRIPTION,Description Completion thyroidectomy with limited right paratracheal node dissection Medical Specialty Surgery Sample Name Completion Thyroidectomy Transcription TITLE OF OPERATION Completion thyroidectomy with limited right paratracheal node dissection INDICATION FOR SURGERY A 49 year old woman with a history of a left dominant nodule in her thyroid gland who subsequently underwent left thyroid lobectomy and isthmusectomy was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus Consideration given to completion thyroidectomy Risks benefits and alternatives of this procedure was discussed with the patient in great detail Risks included but were not limited to anesthesia bleeding infection injury to nerves including vocal fold paralysis hoarseness low calcium scar cosmetic deformity need for thyroid hormone replacement and also need for further management The patient understood all of this and then wished to proceed PREOP DIAGNOSIS Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen POSTOP DIAGNOSIS Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen PROCEDURE DETAIL After identifying the patient the patient was placed supine in the operating room table After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube the eyes were protected with Tegaderm Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured The previous skin incision for a thyroidectomy was then planned then incorporated into an ellipse The patient was prepped and draped in a sterile fashion Subsequently the ellipse around the previous incision was deformed The scar was then excised Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side There was some dense fibrosis and inflammation surrounding the right thyroid lobe Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly then preserved Of note is that there were multiple lymph nodes in the paratracheal region on the right side These lymph nodes were carefully dissected away from the recurrent laryngeal nerve trachea and the carotid artery and sent as a separate specimen labeled right paratracheal lymph nodes The wound was copiously irrigated Valsalva maneuver was given Surgicel was placed in the wound bed Strap muscles were reapproximated in the midline with 3 0 Vicryl and incision was then closed with interrupted 3 0 Vicryl and Indermil for the skin The patient was extubated in the operating room table sent to the postanesthesia care unit in good condition Keywords surgery multifocal thyroid carcinoma thyroid lobectomy thyroid papillary thyroid lobe isthmus completion thyroidectomy thyroidectomy paratracheal lobectomy MEDICAL_TRANSCRIPTION,Description Colonoscopy with photos The patient is an 85 year old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia She underwent an EGD and attempted colonoscopy however due to a very poor prep only a flexible sigmoidoscopy was performed at that time A coloscopy is now being performed for completion Medical Specialty Surgery Sample Name Colonoscopy With Photos Transcription PREOPERATIVE DIAGNOSIS Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Diverticulosis coli 2 Internal hemorrhoids 3 Poor prep PROCEDURE PERFORMED Colonoscopy with photos ANESTHESIA Conscious sedation per Anesthesia SPECIMENS None HISTORY The patient is an 85 year old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia She underwent an EGD and attempted colonoscopy however due to a very poor prep only a flexible sigmoidoscopy was performed at that time A coloscopy is now being performed for completion PROCEDURE After proper informed consent was obtained the patient was brought to the Endoscopy Suite She was placed in the left lateral position and was given sedation by the Anesthesia Department A digital rectal exam was performed and there was no evidence of mass The colonoscope was then inserted into the rectum There was some solid stool encountered The scope was maneuvered around this There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon The scope was then passed through the transverse colon and ascending colon to the cecum No masses or polyps were noted Visualization of the portions of the colon was however somewhat limited There were scattered diverticuli noted in the sigmoid The scope was slowly withdrawn carefully examining all walls Once in the rectum the scope was retroflexed and nonsurgical internal hemorrhoids were noted The scope was then completely withdrawn The patient tolerated the procedure well and was transferred to recovery room in stable condition She will be placed on a high fiber diet and Colace and we will continue to monitor her hemoglobin Keywords surgery blood loss anemia diverticulosis coli internal hemorrhoids poor prep colonoscopy sigmoidoscopy hemoglobin coloscopy colonoscopy with photos attempted colonoscopy flexible sigmoidoscopy photos anemia scope MEDICAL_TRANSCRIPTION,Description A woman referred for colonoscopy secondary to heme positive stools Procedure done to rule out generalized diverticular change colitis and neoplasia Medical Specialty Surgery Sample Name Colonoscopy with Biopsy Transcription INDICATIONS FOR PROCEDURE A 79 year old Filipino woman referred for colonoscopy secondary to heme positive stools Procedure done to rule out generalized diverticular change colitis and neoplasia DESCRIPTION OF PROCEDURE The patient was explained the procedure in detail possible complications including infection perforation adverse reaction of medication and bleeding Informed consent was signed by the patient With the patient in left decubitus position had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol using Olympus video colonoscope under direct visualization was advanced to the cecum Photodocumentation of appendiceal orifice and the ileocecal valve obtained Cecum was slightly obscured with stool but the colon itself was adequately prepped There was no evidence of overt colitis telangiectasia or overt neoplasia There was moderately severe diverticular change which was present throughout the colon and photodocumented The rectal mucosa was normal and retroflexed with mild internal hemorrhoids The patient tolerated the procedure well without any complications IMPRESSION 1 Colonoscopy to the cecum with adequate preparation 2 Long tortuous spastic colon 3 Moderately severe diverticular changes present throughout 4 Mild internal hemorrhoids RECOMMENDATIONS 1 Clear liquid diet today 2 Follow up with primary care physician as scheduled from time to time 3 Increase fiber in diet strongly consider fiber supplementation Keywords surgery olympus video colonoscope advanced to the cecum heme positive stools diverticular change colitis colonoscopy to the cecum spastic colon colonoscopy with biopsy liver disease biopsy hepatitis chronic liver disease mucosa polyp rectal colonoscopy MEDICAL_TRANSCRIPTION,Description Small internal hemorrhoids and Ileal colonic anastomosis Medical Specialty Surgery Sample Name Colonoscopy with Biopsy 2 Transcription PROCEDURE PERFORMED Colonoscopy and biopsy INDICATIONS The patient is a 50 year old female who has had a history of a nonspecific colitis who was admitted 3 months ago at Hospital because of severe right sided abdominal pains was found to have multiple ulcers within the right colon and was then readmitted approximately 2 weeks later because of a cecal volvulus and had a right hemicolectomy Since then she has had persistent right abdominal pains as well as diarrhea with up to 2 4 bowel movements per day She has had problems with recurrent seizures and has been seen by Dr XYZ who started her recently on methadone MEDICATIONS Fentanyl 200 mcg Versed 10 mg Phenergan 25 mg intravenously given throughout the procedure INSTRUMENT PCF 160L PROCEDURE REPORT Informed consent was obtained from the patient after the risks and benefits of the procedure were carefully explained which included but were not limited to bleeding infection perforation and allergic reaction to the medications as well as the possibility of missing polyps within the colon A colonoscope was then passed through the rectum all the way toward the ileal colonic anastomosis seen within the proximal transverse colon The distal ileum was examined which was normal in appearance Random biopsies were obtained from the ileum and placed in jar 1 Random biopsies were obtained from the normal appearing colon and placed in jar 2 Small internal hemorrhoids were noted within the rectum on retroflexion COMPLICATIONS None ASSESSMENT 1 Small internal hemorrhoids 2 Ileal colonic anastomosis seen in the proximal transverse colon 3 Otherwise normal colonoscopy and ileum examination PLAN Followup results of biopsies If the biopsies are unremarkable the patient may benefit from a trial of tricyclic antidepressants if it s okay with Dr XYZ for treatment of her chronic abdominal pains Keywords surgery proximal transverse transverse colon internal hemorrhoids colonic anastomosis biopsy rectum transverse hemorrhoids colonic anastomosis abdominal ileum biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description The patient with a recent change in bowel function and hematochezia Medical Specialty Surgery Sample Name Colonoscopy with Biopsy 1 Transcription PREPROCEDURE DIAGNOSIS Change in bowel function POSTPROCEDURE DIAGNOSIS Proctosigmoiditis PROCEDURE PERFORMED Colonoscopy with biopsy ANESTHESIA IV sedation POSTPROCEDURE CONDITION Stable INDICATIONS The patient is a 33 year old with a recent change in bowel function and hematochezia He is here for colonoscopy He understands the risks and wishes to proceed PROCEDURE The patient was brought to the endoscopy suite where he was placed in left lateral Sims position underwent IV sedation Digital rectal examination was performed which showed no masses and a boggy prostate The colonoscope was placed in the rectum and advanced under direct vision to the cecum In the rectum and sigmoid there were ulcerations edema mucosal abnormalities and loss of vascular pattern consistent with proctosigmoiditis Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis RECOMMENDATIONS Follow up with me in 2 weeks and we will begin Canasa suppositories Keywords surgery change in bowel function iv sedation bowel function proctosigmoiditis sedation rectum bowel function colonoscopy hematochezia MEDICAL_TRANSCRIPTION,Description Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon Medical Specialty Surgery Sample Name Colonoscopy with Biopsy 3 Transcription PREPROCEDURE DIAGNOSIS Abdominal pain diarrhea and fever POSTPROCEDURE DIAGNOSIS Pending pathology PROCEDURES PERFORMED Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon Keywords surgery colonoscopy with multiple biopsies length of the colon diarrhea and fever terminal ileum cecum multiple biopsies ileum cecum cecum hepatic hepatic flexure terminal ileum sigmoid colon colonoscopy diarrhea cecum hepatic flexure inflammation biopsies terminal ileum sigmoid scope MEDICAL_TRANSCRIPTION,Description Total colonoscopy with biopsy and snare polypectomy Medical Specialty Surgery Sample Name Colonoscopy Polypectomy 3 Transcription PREOPERATIVE DIAGNOSIS Alternating hard and soft stools POSTOPERATIVE DIAGNOSIS Sigmoid diverticulosis Sessile polyp of the sigmoid colon Pedunculated polyp of the sigmoid colon PROCEDURE Total colonoscopy with biopsy and snare polypectomy PREP 4 4 DIFFICULTY 1 4 PREMEDICATION AND SEDATION Fentanyl 100 midazolam 5 INDICATION FOR PROCEDURE A 64 year old male who has developed alternating hard and soft stools He has one bowel movement a day FINDINGS There is extensive sigmoid diverticulosis without evidence of inflammation or bleeding There was a small sessile polyp in the sigmoid colon and a larger pedunculated polyp in the sigmoid colon both appeared adenomatous DESCRIPTION OF PROCEDURE Preoperative counseling including an explicit discussion of the risk and treatment of perforation was provided Preoperative physical examination was performed Informed consent was obtained The patient was placed in the left lateral decubitus position Premedications were given slowly by intravenous push Rectal examination was performed which was normal The scope was introduced and passed with minimal difficulty to the cecum This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice The scope was slowly withdrawn the mucosa carefully visualized It was normal in its entirety until reaching the sigmoid colon Sigmoid colon had extensive diverticular disease small mouth without inflammation or bleeding In addition there was a small sessile polyp which was cold biopsied and recovered and approximately an 8 mm pedunculated polyp A snare was placed on the stalk of the polyp and divided with electrocautery The polyp was recovered and sent for pathologic examination Examination of the stalk showed good hemostasis The scope was slowly withdrawn and the remainder of the examination was normal ASSESSMENT Diverticular disease A diverticular disease handout was given to the patient s wife and a high fiber diet was recommended In addition 2 polyps one of which is assuredly an adenoma Patient needs a repeat colonoscopy in 3 years Keywords surgery total colonoscopy with biopsy colonoscopy with biopsy total colonoscopy snare polypectomy sigmoid diverticulosis sessile polyp pedunculated polyp diverticular disease sigmoid colon colonoscopy polypectomy biopsy diverticulosis inflammation adenomatous sessile sigmoid MEDICAL_TRANSCRIPTION,Description Common description of colonoscopy Medical Specialty Surgery Sample Name Colonoscopy Template 4 Transcription A colonoscope was then passed through the rectum all the way toward the cecum which was identified by the presence of the appendiceal orifice and ileocecal valve This was done without difficulty and the bowel preparation was good The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed COMPLICATIONS None Keywords surgery cecum colonoscope bleeding infection perforation allergic reaction ileocecal valve informed allergic ileocecal valve colonoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Colonoscopy conscious sedation and snare polypectomy Medical Specialty Surgery Sample Name Colonoscopy Polypectomy 2 Transcription PREPROCEDURE DIAGNOSIS Colon cancer screening POSTPROCEDURE DIAGNOSIS Colon polyps diverticulosis hemorrhoids PROCEDURE PERFORMED Colonoscopy conscious sedation and snare polypectomy INDICATIONS The patient is a 63 year old male who has myelodysplastic syndrome who was referred for colonoscopy He has had previous colonoscopy There is no family history of bleeding no current problems with his bowels On examination he has internal hemorrhoids His prostate is enlarged and increased somewhat in firmness He has scattered diverticular disease of a moderate degree and he has two polyps one 1 cm in the mid ascending colon and one in the left transverse colon which is also 1 cm These were removed with snare polypectomy technique I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding PROCEDURE After explaining the operative procedure the risks and potential complications of bleeding and perforation the patient was given 175 mcg fentanyl and 8 mg Versed intravenously for conscious sedation Blood pressure 115 60 pulse 98 respiration 18 and saturation 92 A rectal examination was done and then the colonoscope was inserted through the anorectum rectosigmoid descending transverse and ascending colon to the ileocecal valve The scope was withdrawn to the mid ascending colon where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current then retrieved through the suction port The scope was withdrawn into the left transverse colon where the second polyp was identified It was encircled with a snare and removed with a mixture of cutting and coagulating current and then removed through the suction port as well The scope was then gradually withdrawn the remaining distance and removed The patient tolerated the procedure well Keywords surgery colon polyps diverticulosis hemorrhoids cutting and coagulating transverse colon snare polypectomy ascending colon colonoscopy polyps bowels coagulating sedation scope ascending snare polypectomy MEDICAL_TRANSCRIPTION,Description Patient with history of adenomas and irregular bowel habits Medical Specialty Surgery Sample Name Colonoscopy 7 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSIS Follow up adenomas POSTOPERATIVE DIAGNOSES 1 Two colon polyps removed 2 Small internal hemorrhoids 3 Otherwise normal examination of cecum MEDICATIONS Fentanyl 150 mcg and Versed 7 mg slow IV push INDICATIONS This is a 60 year old white female with a history of adenomas She does have irregular bowel habits FINDINGS The patient was placed in the left lateral decubitus position and the above medications were administered The colonoscope was advanced to the cecum as identified by the ileocecal valve appendiceal orifice and blind pouch The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made including a retroflexed view of the rectum There was a 4 mm descending colon polyp which was removed with jumbo forceps and sent for histology in bottle one There was a 10 mm pale flat polyp in the distal rectum which was removed with jumbo forceps and sent for histology in bottle 2 There were small internal hemorrhoids The remainder of the examination was normal to the cecum The patient tolerated the procedure well without complication IMPRESSION 1 Two colon polyps removed 2 Small internal hemorrhoids 3 Otherwise normal examination to cecum PLAN I will await the results of the colon polyp histology The patient was told the importance of daily fiber Keywords surgery colon polyps internal hemorrhoids rectum irregular bowel habits colon polyps removed irregular bowel bowel habits polyps removed bowel habits colonoscope hemorrhoids cecum forceps polyps colonoscopy adenomas MEDICAL_TRANSCRIPTION,Description Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies Hematochezia refractory dyspepsia colonic polyps at 35 cm and 15 cm diverticulosis coli and acute and chronic gastritis MEDICAL_TRANSCRIPTION,Description Colonoscopy to screen for colon cancer Medical Specialty Surgery Sample Name Colonoscopy 6 Transcription INDICATIONS This is a 55 year old female who is having a colonoscopy to screen for colon cancer There is no family history of colon cancer and there has been no blood in the stool PROCEDURE PERFORMED Colonoscopy PREP Fentanyl 100 mcg IV and 3 mg Versed IV PROCEDURE The tip of the endoscope was introduced into the rectum Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions The rest of the colon through to the cecum was well visualized The cecal strap ileocecal valve and light reflex in the right lower quadrant were all identified There was no evidence of tumor polyp mass ulceration or other focus of inflammation Adverse reactions none IMPRESSION Normal colonic mucosa through to the cecum There was no evidence of tumor or polyp Keywords surgery versed iv colon tumor polyp mass ulceration focus of inflammation tip of the endoscope evidence of tumor colon cancer endoscope cecum cancer colonoscopy MEDICAL_TRANSCRIPTION,Description Patient with history of polyps Medical Specialty Surgery Sample Name Colonoscopy 9 Transcription PREOPERATIVE DIAGNOSIS Prior history of polyps POSTOPERATIVE DIAGNOSIS Small polyps no evidence of residual or recurrent polyp in the cecum PREMEDICATIONS Versed 5 mg Demerol 100 mg IV REPORTED PROCEDURE The rectal chamber revealed no external lesions Prostate was normal in size and consistency The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum The position of the scope within the cecum was verified by identification of the ileocecal valve Navigation was difficult because it seemed that the cecum took an upward turn at its final turn but the examination was completed The cecum was extensively studied and no lesion was seen There was not even a scar representing the prior polyp I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago and I saw no lesion at all The scope was then slowly withdrawn In the mid transverse colon was a small submucosal lesion which appeared to be a lipoma It was freely mobile and very small with normal overlying mucosa There was a similar lesion in the descending colon Both of these appeared to be lipomatous so no attempt was made to remove them There were diverticula present in the sigmoid colon In addition there were two polyps in the sigmoid colon both of which were resected using electrocautery There was no bleeding The scope was then withdrawn The rectum was normal When the scope was retroflexed in the rectum two very small polyps were noted just at the anorectal margin and so these were obliterated using the electrocautery snare There was no specimen and there was no bleeding The scope was then straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Small polyps sigmoid colon resected them 2 Diverticulosis sigmoid colon 3 Small rectal polyps obliterated them 4 Submucosal lesions consistent with lipomata as described 5 No evidence of residual or recurrent neoplasm in the cecum Keywords surgery ileocecal valve sigmoid colon polyps ileocecal submucosal electrocautery bleeding rectum rectal sigmoid cecum scope colonoscopy MEDICAL_TRANSCRIPTION,Description Total colonoscopy and polypectomy Medical Specialty Surgery Sample Name Colonoscopy Polypectomy 1 Transcription PREOPERATIVE DIAGNOSIS History of colitis POSTOPERATIVE DIAGNOSIS Small left colon polyp PROCEDURE PERFORMED Total colonoscopy and polypectomy ANESTHESIA IV Versed 8 mg and 175 mcg of IV fentanyl CLINICAL HISTORY This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding He has been admitted to the hospital now for colonoscopy and polyp surveillance PROCEDURE The patient was prepped and draped in a left lateral decubitus position The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV directed monitor through the area of the rectum sigmoid colon left colon transverse colon right colon and cecum He had an excellent prep He had a 2 3 mm polyp in the left colon that was removed with a jumbo biopsy forceps He tolerated the procedure well There was no other evidence of any cancer growth tumor colitis or problems throughout the entire colon His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since Representative pictures were taken throughout the entire exam There was no other evidence any problems On withdrawal of the scope the same findings were noted FINAL IMPRESSION Small left colon polyp in a patient with intermittent colitis like symptoms and bleeding Keywords surgery anus lateral decubitus position colon colonoscopy and polypectomy total colonoscopy colon polyp colonoscopy bleeding colitis polypectomy intermittent MEDICAL_TRANSCRIPTION,Description Patient with active flare of Inflammatory Bowel Disease not responsive to conventional therapy including sulfasalazine cortisone local therapy Medical Specialty Surgery Sample Name Colonoscopy 8 Transcription PROCEDURES PERFORMED Colonoscopy INDICATIONS Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease not responsive to conventional therapy including sulfasalazine cortisone local therapy PROCEDURE Informed consent was obtained prior to the procedure with special attention to benefits risks alternatives Risks explained as bleeding infection bowel perforation aspiration pneumonia or reaction to the medications Vital signs were monitored by blood pressure heart rate and oxygen saturation Supplemental O2 given Specifics discussed Preprocedure physical exam performed Stable vital signs Lungs clear Cardiac exam showed regular rhythm Abdomen soft Her past history her past workup her past visitation with me for Inflammatory Bowel Disease well responsive to sulfasalazine reviewed She currently has a flare and is not responding therefore likely may require steroid taper At the same token her symptoms are mild She has rectal bleeding essentially only some rusty stools There is not significant diarrhea just some lower stools No significant pain Therefore it is possible that we are just dealing with a hemorrhoidal bleed therefore colonoscopy now needed Past history reviewed Specifics of workup need for followup and similar discussed All questions answered A normal digital rectal examination was performed The PCF 160 AL was inserted into the anus and advanced to the cecum without difficulty as identified by the ileocecal valve cecal stump and appendical orifice All mucosal aspects thoroughly inspected including a retroflexed examination Withdrawal time was greater than six minutes Unfortunately the terminal ileum could not be intubated despite multiple attempts Findings were those of a normal cecum right colon transverse colon descending colon A small cecal polyp was noted this was biopsy removed placed in bottle 1 Random biopsies from the cecum obtained bottle 2 random biopsies from the transverse colon obtained as well as descending colon obtained bottle 3 There was an area of inflammation in the proximal sigmoid colon which was biopsied placed in bottle 4 There was an area of relative sparing with normal sigmoid lining placed in bottle 5 randomly biopsied and then inflammation again in the distal sigmoid colon and rectum biopsied bottle 6 suggesting that we may be dealing with Crohn disease given the relative sparing of the sigmoid colon and junk lesion Retroflexed showed hemorrhoidal disease Scope was then withdrawn patient left in good condition IMPRESSION Active flare of Inflammatory Bowel Disease question of Crohn disease PLAN I will have the patient follow up with me will follow up on histology follow up on the polyps She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job If not she may be started on immune suppressive medication such as azathioprine or similar All of this has been reviewed with the patient All questions answered Keywords surgery sulfasalazine cortisone local therapy inflammatory bowel disease cortisone local local therapy crohn disease sigmoid colon bowel disease colonoscopy inflammatory rectal sulfasalazine cecum sigmoid bowel disease MEDICAL_TRANSCRIPTION,Description Colonoscopy Diarrhea suspected irritable bowel Medical Specialty Surgery Sample Name Colonoscopy 4 Transcription PREOPERATIVE DIAGNOSIS Diarrhea suspected irritable bowel POSTOPERATIVE DIAGNOSIS Normal colonoscopy PREMEDICATIONS Versed 5 mg Demerol 75 mg IV REPORTED PROCEDURE The rectal exam revealed no external lesions The prostate was normal in size and consistency The colonoscope was inserted into the cecum with ease The cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon sigmoid colon and rectum were normal The scope was retroflexed in the rectum and no abnormality was seen so the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION Normal colonoscopy no evidence of inflammatory disease polyp or other neoplasm These findings are certainly consistent with irritable bowel syndrome Keywords surgery diarrhea ascending colon cecum colonoscope colonoscopy descending colon hepatic flexure inflammatory disease irritable bowel syndrome irritable bowel polyp rectal exam rectum sigmoid colon splenic flexure transverse colon normal colonoscopy irritable bowel flexure irritable bowel MEDICAL_TRANSCRIPTION,Description Colonoscopy to evaluate prior history of neoplastic polyps Medical Specialty Surgery Sample Name Colonoscopy 3 Transcription PREOPERATIVE DIAGNOSIS Prior history of neoplastic polyps POSTOPERATIVE DIAGNOSIS Small rectal polyps removed and fulgurated PREMEDICATIONS Prior to the colonoscopy the patient complained of a sever headache and she was concerned that she might become ill I asked the nurse to give her 25 mg of Demerol IV Following the IV Demerol she had a nausea reaction She was then given 25 mg of Phenergan IV Following this her headache and nausea completely resolved She was then given a total of 7 5 mg of Versed with adequate sedation Rectal exam revealed no external lesions Digital exam revealed no mass REPORTED PROCEDURE The P160 colonoscope was used The scope was placed in the rectal ampulla and advanced to the cecum Navigation through the sigmoid colon was difficult Beginning at 30 cm was a very tight bend With gentle maneuvering the scope passed through and then entered the cecum The cecum ascending colon hepatic flexure transverse colon splenic flexure and descending colon were normal The sigmoid colon was likewise normal There were five very small punctate polyps in the rectum One was resected using the electrocautery snare and the other four were ablated using the snare and cautery There was no specimen because the polyps were so small The scope was retroflexed in the rectum and no further abnormality was seen so the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Five small polyps as described all fulgurated 2 Otherwise unremarkable colonoscopy Keywords surgery colonoscopy demerol phenergan rectal exam versed ascending colon cecum colonoscope descending colon fulgurated hepatic flexure neoplastic polyps punctate rectal ampulla splenic flexure transverse colon scope MEDICAL_TRANSCRIPTION,Description Colonoscopy and biopsies epinephrine sclerotherapy hot biopsy cautery and snare polypectomy Colon cancer screening Family history of colon polyps Medical Specialty Surgery Sample Name Colonoscopy 21 Transcription OPERATIVE PROCEDURES Colonoscopy and biopsies epinephrine sclerotherapy hot biopsy cautery and snare polypectomy PREOPERATIVE DIAGNOSES 1 Colon cancer screening 2 Family history of colon polyps POSTOPERATIVE DIAGNOSES 1 Multiple colon polyps 5 2 Diverticulosis sigmoid colon 3 Internal hemorrhoids ENDOSCOPE USED EC3870LK BIOPSIES Biopsies taken from all polyps Hot biopsy got applied to one Epinephrine sclerotherapy and snare polypectomy applied to four polyps ANESTHESIA Fentanyl 75 mcg Versed 6 mg and glucagon 1 5 units IV push in divided doses Also given epinephrine 1 20 000 total of 3 mL The patient tolerated the procedure well PROCEDURE The patient was placed in left lateral decubitus after appropriate sedation Digital rectal examination was done which was normal Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine Pedunculated polyp next to it was hard to see and there was a lot of peristalsis The scope then was advanced through rest of the transverse colon to ascending colon and cecum Terminal ileum was briefly reviewed appeared normal and so did cecum after copious amount of fecal material was irrigated out Ascending colon was unremarkable At hepatic flexure may be proximal transverse colon there was a sessile polyp about 1 2 cm x 1 cm that was removed in the same manner with a biopsy taken base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue which could be seen In transverse colon on withdrawal and relaxation with epinephrine an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy Then in the transverse colon additional larger polyp about 1 3 cm x 1 2 cm was removed in piecemeal fashion again with epinephrine sclerotherapy and snare polypectomy Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy The rest of the splenic flexure and descending colon were unremarkable Diverticulosis was again seen with almost constant spasm despite of glucagon Sigmoid colon did somewhat hinder the inspection of that area Rectum retroflexion posterior anal canal showed internal hemorrhoids moderate to large Excess of air insufflated was removed The endoscope was withdrawn PLAN Await biopsy report Pending biopsy report recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient s polyps Keywords surgery colon cancer colon polyps snare polypectomy cautery epinephrine sclerotherapy transverse colon polypectomy colonoscopy sigmoid endoscope sclerotherapy epinephrine biopsy MEDICAL_TRANSCRIPTION,Description Possible inflammatory bowel disease Polyp of the sigmoid colon Total colonoscopy with photography and polypectomy Medical Specialty Surgery Sample Name Colonoscopy 18 Transcription PREOPERATIVE DIAGNOSIS Possible inflammatory bowel disease POSTOPERATIVE DIAGNOSIS Polyp of the sigmoid colon PROCEDURE PERFORMED Total colonoscopy with photography and polypectomy GROSS FINDINGS The patient had a history of ischiorectal abscess He has been evaluated now for inflammatory bowel disease Upon endoscopy the colon prep was good We were able to reach the cecum without difficulty There are no diverticluli inflammatory bowel disease strictures or obstructing lesions There was a pedunculated polyp approximately 4 5 cm in size located in the sigmoid colon at approximately 35 cm This large polyp was removed using the snare technique OPERATIVE PROCEDURE The patient was taken to the endoscopy suite prepped and draped in left lateral decubitus position IV sedation was given by Anesthesia Department The Olympus videoscope was inserted into anus Using air insufflation the colonoscope was advanced through the anus to the rectum sigmoid colon descending colon transverse colon ascending colon and cecum the above gross findings were noted The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel When the polyp again was visualized the snare was passed around the polyp It required at least two to three passes of the snare to remove the polyp in its totality There was a large stalk on the polyp ________ the polyp had been removed down to the junction of the polyp in the stalk which appeared to be cauterized and no residual adenomatous tissue was present No bleeding was identified The colonoscope was then removed and patient was sent to recovery room in stable condition Keywords surgery polypectomy inflammatory bowel disease sigmoid colon rectum descending colon transverse colon ascending colon cecum total colonoscopy bowel disease inflammatory polyp colonoscopy colonoscope bowel MEDICAL_TRANSCRIPTION,Description Mild to moderate diverticulosis She was referred for a screening colonoscopy There is no family history of colon cancer No evidence of polyps or malignancy Medical Specialty Surgery Sample Name Colonoscopy 22 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES The patient is a 56 year old female She was referred for a screening colonoscopy The patient has bowel movements every other day There is no blood in the stool no abdominal pain She has hypertension dyslipidemia and gastroesophageal reflux disease She has had cesarean section twice in the past Physical examination is unremarkable There is no family history of colon cancer POSTOPERATIVE DIAGNOSIS Diverticulosis PROCEDURE IN DETAIL Procedure and possible complications were explained to the patient Ample opportunity was provided to her to ask questions Informed consent was obtained She was placed in left lateral position Inspection of perianal area was normal Digital exam of the rectum was normal Video Olympus colonoscope was introduced into the rectum The sigmoid colon is very tortuous The instrument was advanced to the cecum after placing the patient in a supine position The patient was well prepared and a good examination was possible The cecum was identified by the ileocecal valve and the appendiceal orifice Images were taken The instrument was then gradually withdrawn while examining the colon again in a circumferential manner Few diverticula were encountered in the sigmoid and descending colon Retroflex view of the rectum was unremarkable No polyps or malignancy was identified After obtaining images the air was suctioned Instrument was withdrawn from the patient The patient tolerated the procedure well There were no complications SUMMARY OF FINDINGS Colonoscopy was performed to cecum and demonstrates the following 1 Mild to moderate diverticulosis 2 RECOMMENDATION 1 The patient was provided information on diverticulosis including dietary advice 2 She was advised repeat colonoscopy after 10 years Keywords surgery screening colonoscopy colon cancer colonoscopy polyps malignancy sigmoid rectum cecum diverticulosis MEDICAL_TRANSCRIPTION,Description Colonoscopy Rectal bleeding and perirectal abscess Normal colonoscopy to the terminal ileum Opening in the skin at the external anal verge consistent with drainage from a perianal abscess with no palpable abscess at this time and with no evidence of fistulous connection to the bowel lumen Medical Specialty Surgery Sample Name Colonoscopy 16 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES Rectal bleeding and perirectal abscess POSTOPERATIVE DIAGNOSIS Perianal abscess MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum The preparation was excellent and all surfaces were well seen The mucosa throughout the colon and in the terminal ileum was normal with no evidence of colitis Special attention was paid to the rectum including retroflexed views of the distal rectum and the anorectal junction There was no evidence of either inflammation or a fistulous opening The scope was withdrawn A careful exam of the anal canal and perianal area demonstrated a jagged 8 mm opening at the anorectal junction posteriorly 12 o clock position Some purulent material could be expressed through the opening There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material Specifically the posterior wall of the distal rectum and anal canal were soft and unremarkable In addition scars were noted in the perianal area The first was a small dimpled scar 1 cm from the anal verge in the 11 o clock position The second was a dimpled scar about 5 cm from the anal verge on the left buttock s cheek There were no other abnormalities noted The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Normal colonoscopy to the terminal ileum 2 Opening in the skin at the external anal verge consistent with drainage from a perianal abscess with no palpable abscess at this time and with no evidence of fistulous connection to the bowel lumen RECOMMENDATIONS 1 Continue antibiotics 2 Followup with Dr X 3 If drainage persists consider surgical drainage Keywords surgery olympus colonoscope rectal bleeding perianal abscess terminal ileum anal verge anorectal fistulous ileum verge rectum anal perianal colonoscopy abscess MEDICAL_TRANSCRIPTION,Description Universal diverticulosis and nonsurgical internal hemorrhoids Total colonoscopy with photos The patient is a 62 year old white male who presents to the office with a history of colon polyps and need for recheck Medical Specialty Surgery Sample Name Colonoscopy 17 Transcription PREOPERATIVE DIAGNOSIS Colon polyps POSTOPERATIVE DIAGNOSES 1 Universal diverticulosis 2 Nonsurgical internal hemorrhoids PROCEDURE PERFORMED Total colonoscopy with photos ANESTHESIA Demerol 100 mg IV with Versed 3 mg IV SPECIMENS None ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE The patient is a 62 year old white male who presents to the office with a history of colon polyps and need for recheck PROCEDURE Informed consent was obtained All risks and benefits of the procedure were explained and all questions were answered The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained Upon appropriate anesthesia a digital rectal exam was performed which showed no masses The colonoscope was then placed into the anus and the air was insufflated The scope was then advanced under direct vision into the rectum rectosigmoid colon descending colon transverse colon ascending colon until it reached the cecum Upon entering the sigmoid colon and throughout the rest of the colon there was noted diverticulosis After reaching the cecum the scope was fully withdrawn visualizing all walls again noting universal diverticulosis Upon reaching the rectum the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids The scope was then subsequently removed The patient tolerated the procedure well and there were no complications Keywords surgery endoscopy rectum rectosigmoid colon descending colon transverse colon ascending colon total colonoscopy colon polyps colonoscopy cecum polyps diverticulosis hemorrhoids MEDICAL_TRANSCRIPTION,Description History of polyps Total colonoscopy and photography Normal colonoscopy left colonic diverticular disease 3 benign prostatic hypertrophy Medical Specialty Surgery Sample Name Colonoscopy 13 Transcription PREOPERATIVE DIAGNOSIS History of polyps POSTOPERATIVE DIAGNOSES 1 Normal colonoscopy left colonic diverticular disease 2 3 benign prostatic hypertrophy PROCEDURE PERFORMED Total colonoscopy and photography GROSS FINDINGS This is a 74 year old white male here for recheck colonoscopy for a history of polyps After signed informed consent blood pressure monitoring EKG monitoring and pulse oximetry monitoring he was brought to the Endoscopic Suite He was given 100 mg of Demerol 3 mg of Versed IV push slowly Digital examination revealed a large prostate for which he is following up with his urologist No nodules 3 BPH Anorectal canal was within normal limits No stricture tumor or ulcer The Olympus CF 20L video endoscope was inserted per anus The anorectal canal was visualized was normal The sigmoid descending splenic and transverse showed scattered diverticula The hepatic ascending cecum and ileocecal valve was visualized and was normal The colonoscope was removed The air was aspirated The patient was discharged with high fiber diverticular diet Recheck colonoscopy three years Keywords surgery digital examination benign prostatic hypertrophy anorectal canal diverticular disease photography anorectal colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum Medical Specialty Surgery Sample Name Colonoscopy 12 Transcription PROCEDURE IN DETAIL Following instructions and completion of an oral colonoscopy prep the patient having been properly informed of with signature consenting to total colonoscopy and indicated procedures the patient received premedications of Vistaril 50 mg Atropine 0 4 mg IM and then intravenous medications of Demerol 50 mg and Versed 5 mg IV Perirectal inspection was normal The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum No abnormalities were seen of the terminal ileum the ileocecal valve cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon rectosigmoid and rectum Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure Keywords surgery ileocecal valve cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon rectosigmoid rectum terminal ileum olympus video colonoscope flexure colonoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Screening colonoscopy Tiny polyps If adenomatous repeat exam in five years Medical Specialty Surgery Sample Name Colonoscopy 20 Transcription PREOPERATIVE DIAGNOSIS Screening POSTOPERATIVE DIAGNOSIS Tiny Polyps PROCEDURE PERFORMED Colonoscopy PROCEDURE The procedure indications and risks were explained to the patient who understood and agreed He was sedated with Versed 3 mg Demerol 25 mg during the examination A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner s finger into the rectum It was passed to the level of the cecum The ileocecal valve was identified as was the appendiceal orifice Slowly withdrawal through the colon revealed a small polyp in the transverse colon This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps In addition there was a 2 mm polyp versus lymphoid aggregate in the descending colon This was also removed using the cold biopsy forceps Further detail failed to reveal any other lesions with the exception of small hemorrhoids IMPRESSION Tiny polyps PLAN If adenomatous repeat exam in five years Otherwise repeat exam in 10 years Keywords surgery pentax video colonoscope biopsy forceps tiny polyps polyps adenomatous colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy in a patient with prior history of anemia and abdominal bloating Medical Specialty Surgery Sample Name Colonoscopy 2 Transcription PREOPERATIVE DIAGNOSES Prior history of anemia abdominal bloating POSTOPERATIVE DIAGNOSIS External hemorrhoids otherwise unremarkable colonoscopy PREMEDICATIONS Versed 5 mg Demerol 50 mg IV REPORT OF PROCEDURE Digital rectal exam revealed external hemorrhoids The colonoscope was inserted into the rectal ampulla and advanced to the cecum The position of the scope within the cecum was verified by identification of the appendiceal orifice The cecum the ascending colon hepatic flexure transverse colon splenic flexure descending colon and rectum were normal The scope was retroflexed in the rectum and no abnormality was seen So the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Normal colonoscopy 2 External hemorrhoids Keywords surgery colonoscopy digital rectal exam abdominal anemia ascending colon bloating cecum colonoscope descending colon hemorrhoids hepatic flexure rectal ampulla rectum splenic flexure transverse colon external hemorrhoids scope MEDICAL_TRANSCRIPTION,Description Colonoscopy The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon descending colon around the splenic flexure into the transverse colon around the hepatic flexure down the ascending colon into the cecum Medical Specialty Surgery Sample Name Colonoscopy 11 Transcription MEDICATIONS 1 Versed intravenously 2 Demerol intravenously DESCRIPTION OF THE PROCEDURE After informed consent was obtained the patient was placed in the left lateral decubitus position and sedated with the above medications The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon descending colon around the splenic flexure into the transverse colon around the hepatic flexure down the ascending colon into the cecum The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve The colonoscope was then advanced through the ileocecal valve into the terminal ileum which was normal on examination The scope was then pulled back into the cecum and then slowly withdrawn The mucosa was examined in detail The mucosa was entirely normal Upon reaching the rectum retroflex examination of the rectum was normal The scope was then straightened out the air removed and the scope withdrawn The patient tolerated the procedure well There were no apparent complications Keywords surgery olympus scope sigmoid colon descending colon splenic flexure transverse colon hepatic flexure ascending colon ileocecal valve ileocecal mucosa rectum colonoscope flexure cecum colonoscopyNOTE MEDICAL_TRANSCRIPTION,Description Colonoscopy with terminal ileum examination Iron deficiency anemia Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty Medical Specialty Surgery Sample Name Colonoscopy 19 Transcription INDICATION Iron deficiency anemia PROCEDURE Colonoscopy with terminal ileum examination POSTOPERATIVE DIAGNOSIS Normal examination WITHDRAWAL TIME 15 minutes SCOPE CF H180AL MEDICATIONS Fentanyl 100 mcg and versed 10 mg PROCEDURE DETAIL Following the preprocedure patient assessment the procedure goals risks including bleeding perforation missed polyp rate as well as side effects of medications and alternatives were reviewed Questions were answered Pause preprocedure was performed Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty The ileocecal valve looked normal Preparation was fair allowing examination of 85 of mucosa after washing and cleaning with tap water through the scope The terminal ileum was intubated through the ileocecal valve for a 5 cm extent Terminal ileum mucosa looked normal Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum No polyp no diverticulum and no bleeding source was identified The patient was assessed upon completion of the procedure Okay to discharge once criteria met RECOMMENDATIONS Follow up with primary care physician Keywords surgery polyp endoscope mucosa iron deficiency anemia ileocecal valve terminal ileum colonoscopy anemia rectum ileum MEDICAL_TRANSCRIPTION,Description Colon cancer screening and family history of polyps Sigmoid diverticulosis and internal hemorrhoids Medical Specialty Surgery Sample Name Colonoscopy 10 Transcription PREOPERATIVE DIAGNOSES Colon cancer screening and family history of polyps POSTOPERATIVE DIAGNOSIS Colonic polyps PROCEDURE Colonoscopy ANESTHESIA MAC DESCRIPTION OF PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum The preparation was excellent and all surfaces were well seen The mucosa was normal throughout the colon and in the terminal ileum Two polyps were identified and were removed The first was a 7 mm sessile lesion in the mid transverse colon at 110 cm removed with the snare without cautery and retrieved The second was a small 4 mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved No other lesions were identified Numerous diverticula were found in the sigmoid colon A retroflex through the anorectal junction showed moderate internal hemorrhoids The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Sigmoid diverticulosis 2 Colonic polyps in the transverse colon and sigmoid colon benign appearance removed 3 Internal hemorrhoids 4 Otherwise normal colonoscopy to the terminal ileum RECOMMENDATIONS 1 Follow up biopsy report 2 Follow up with Dr X as needed 3 Screening colonoscopy in 5 years Keywords surgery MEDICAL_TRANSCRIPTION,Description Colonoscopy Change in bowel habits and rectal prolapse Normal colonic mucosa to the cecum Medical Specialty Surgery Sample Name Colonoscopy 15 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES Change in bowel habits and rectal prolapse POSTOPERATIVE DIAGNOSIS Normal colonoscopy PROCEDURE The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice The preparation was poor but mucosa was visible after lavage and suction Small lesions might have been missed in certain places but no large lesions are likely to have been missed The mucosa was normal was visualized In particular there was no mucosal abnormality in the rectum and distal sigmoid which is reported to be prolapsing Biopsies were taken from the rectal wall to look for microscopic changes The anal sphincter was considerably relaxed with no tone and a gaping opening The patient tolerated the procedure well and was sent to recovery room FINAL DIAGNOSIS Normal colonic mucosa to the cecum No contraindications to consideration of a repair of the prolapse Keywords surgery olympus colonoscope bowel habits colonic mucosa colonic rectum rectal cecum mucosa colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy History of colon polyps and partial colon resection right colon Mild diverticulosis of the sigmoid colon Hemorrhoids Medical Specialty Surgery Sample Name Colonoscopy 14 Transcription PREPROCEDURE DIAGNOSIS History of colon polyps and partial colon resection right colon POSTPROCEDURE DIAGNOSES 1 Normal operative site 2 Mild diverticulosis of the sigmoid colon 3 Hemorrhoids PROCEDURE Total colonoscopy PROCEDURE IN DETAIL The patient is a 60 year old of Dr ABC s being evaluated for the above The patient also apparently had an x ray done at the Hospital and it showed a dark spot and because of this a colonoscopy was felt to be needed She was prepped the night before and on the morning of the test with oral Fleet s brought to the second floor and sedated with a total of 50 mg of Demerol and 3 75 mg of Versed IV push Digital rectal exam was done unremarkable At that point the Pentax video colonoscope was inserted The rectal vault appeared normal The sigmoid showed diverticula throughout mild to moderate in nature The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized The scope was passed a short distance up the ileum which appeared normal The scope was then withdrawn through the transverse descending sigmoid and rectal vault area The scope was then retroflexed and anal verge visualized showed some hemorrhoids The scope was then removed The patient tolerated the procedure well RECOMMENDATIONS Repeat colonoscopy in three years Keywords surgery partial colon resection diverticulosis colon polyps rectal vault colonoscopy polyps hemorrhoids sigmoid MEDICAL_TRANSCRIPTION,Description Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot Medical Specialty Surgery Sample Name Closing Wedge Osteotomy Transcription PREOPERATIVE DIAGNOSIS Tailor s bunion right foot POSTOPERATIVE DIAGNOSIS Tailor s bunion right foot PROCEDURE Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot ANESTHESIA Local infiltrate with IV sedation INDICATIONS FOR SURGERY The patient has had a longstanding history of foot problems The problem has been progressive in nature The preoperative discussion with the patient included alternative treatment options the procedure was explained and the risk factors such as infection swelling scar tissue numbness continued pain recurrence and the postoperative management were discussed The patient has been advised although no guarantee for success could be given most of the patient have less pain and improved function all questions were thoroughly answered The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity The purpose of the surgery is to alleviate pain and discomfort DETAILS OF PROCEDURE The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure The patient was brought to the operating room and placed in the supine position No tourniquet was utilized IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1 1 mixture of 0 25 Marcaine and 1 lidocaine with epinephrine was locally infiltrated proximal to the operative site The lower extremity was prepped and draped in the usual sterile manner Balanced anesthesia was obtained PROCEDURE Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1 5 cm from the base of the fifth metatarsal Care was taken to identify and retract all vital structures and when necessary vessels were ligated via electrocautery The extensor tendon was identified and retracted medially Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer A linear periosteal capsular incision was made in line with the skin incision The capsular tissue and periosteal layer was underscored free from its underlying osseous attachment and then reflected to expose the osseous surface Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration The both edges were rasped smooth Attention was then focused on the fifth metatarsal The periosteal layer proximal to the fifth metatarsal head was underscored free from its underlying attachment and then reflected to expose the osseous surface An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy Using an oscillating saw a vertically placed wedge shaped oblique ostomy was made with the apex being proximal lateral and the base medial and distal Generous amounts of lateral cortex were preserved for the lateral hinge The wedge was removed from the surgical field The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin which was then countersunk and a 3 0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position Good purchase was noted at the osteotomy site Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position The surgical site was flushed with copious amounts of normal saline irrigation The periosteal and capsular layers were closed with running sutures of 3 0 Vicryl The subcutaneous tissues were closed with 4 0 Vicryl and the skin edges were closed with 4 0 nylon in a running interrupted fashion A dressing consisting of Adaptic 4 x 4 confirming bandages and ACE wrap to provide mild compression was applied The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time and all digits were warm and pink A walker boot was dispensed and applied The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me Office visit will be in 4 days The patient was given prescriptions for Keflex 500 mg one p o t i d for 10 days and Ultram ER 15 one p o daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises After short recuperative period the patient was discharged home with a vital sign stable in no acute distress Keywords surgery internal screw fixation osteotomy closing wedge osteotomy tailor s bunion screw fixation periosteal layer metatarsal head wedge osteotomy metatarsal anesthesia MEDICAL_TRANSCRIPTION,Description Juxtaductal coarctation of the aorta dilated cardiomyopathy bicuspid aortic valve patent foramen ovale Medical Specialty Surgery Sample Name Coarctation of Aorta Transcription HISTORY The patient is a 4 month old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16 A bicuspid aortic valve was also seen without insufficiency or stenosis The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta PROCEDURE After sedation and general endotracheal anesthesia the patient was prepped and draped Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a percutaneous technique a 4 French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place There was good blood return from both the ports Using a 4 French sheath a 4 French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries The atrial septum was not probe patent Using a 4 French sheath a 4 French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ascending aorta and left ventricle A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery The transverse arch measured 5 mm Isthmus measured 4 7 mm and coarctation measured 2 9 x 1 8 mm at the descending aorta level The diaphragm measured 5 6 mm The pigtail catheter was exchanged for a wedge catheter which was then directed into the right innominate artery This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist Pressure pull back following angioplasty however demonstrated a residual of 15 20 mmHg gradient Repeat angiogram showed mild improvement in degree of aortic narrowing The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist The pigtail catheter was then reintroduced for a pressure pull back measurement and final angiogram Flows were calculated by the Fick technique using an assumed oxygen consumption Cineangiograms were obtained with injection in the descending aorta After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the pediatric intensive care unit in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was low due to mild systemic arterial desaturation and anemia There is no evidence of significant intracardiac shunt Further the heart was desaturated due to VQ mismatch Phasic right sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A wave similar to the normal left ventricular end diastolic pressure of 12 mmHg Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull back to the descending aorta The calculated flows were mildly increased Vascular resistances were normal A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels There is discrete juxtaductal coarctation of the aorta Flow within the intercostal arteries was retrograde Following balloon angioplasty of coarctation of the aorta there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull back to the descending aorta The calculated systemic flow fell to normal values Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries The narrowest diameter of the aorta measured 4 9 x 4 2 mm DIAGNOSES 1 Juxtaductal coarctation of the aorta 2 Dilated cardiomyopathy 3 Bicuspid aortic valve 4 Patent foramen ovale INTERVENTION Balloon dilation of coarctation of the aorta MANAGEMENT The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4 6 months The further cardiologic care will be directed by Dr X Keywords surgery coarctation juxtaductal dilated cardiomyopathy bicuspid aortic valve patent foramen ovale catheter was inserted mmhg systolic gradient mmhg systolic systolic gradient descending aorta catheterization mmhg ventricular aorta aortic foramen MEDICAL_TRANSCRIPTION,Description Closed reduction percutaneous pinning left distal humerus Closed type III supracondylar fracture left distal humerus Tethered brachial artery left elbow Medical Specialty Surgery Sample Name Closed Reduction Percutaneous Pinning Transcription PREOPERATIVE DIAGNOSIS Closed type III supracondylar fracture left distal humerus POSTOPERATIVE DIAGNOSES 1 Closed type III supracondylar fracture left distal humerus 2 Tethered brachial artery left elbow PROCEDURE PERFORMED Closed reduction percutaneous pinning left distal humerus SPECIFICATIONS The entire operative procedure was done in the inpatient operating suite room 2 at ABCD General Hospital A portion of the procedure was done in consult with Dr X with separate dictation by him HISTORY AND GROSS FINDINGS This is a 4 year old white male apparently dominantly right handed who suffered a severe injury to his left distal humerus after jumping off of a swing He apparently had not had previous problems with his left arm He was seen in the Emergency with a grossly deformed left elbow His parents were both present preoperatively His x ray exam as well as physical exam was consistent with a closed type III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region Gross neurologic exam revealed his ulnar median and radial nerves to be mostly intact although a complete exam was impossible He did have a radial pulse palpable PROCEDURE After discussing the alternatives of the case as well as advantages and disadvantages risks complications and expectations with the patient s parents including malunion nonunion gross deformity growth arrest infection loss of elbow motions stiffness instability need for surgery in the future nerve problems artery problems and compartment syndrome they elected to proceed The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department Closed reduction was accomplished in a sequential manner Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly Then a slow longitudinal traction was carried out The elbow was hyperflexed Pressure placed upon the olecranon tip and two 0 045 K wires placed first one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve The close reduction was deemed to be acceptable once viewed on C arm After this pulse was attempted to be palpated distally Prior to the procedure I talked to Dr X of Vascular Surgery at ABCD Hospital He had scrubbed in to the case to follow up on the loss of the radial artery distally This was not present palpatory but also by Doppler A weak ulnar artery pulse was present via Doppler Because of this the severe displacement of the injury and the fact that the Doppler sound had an occlusion type sound just above the fracture site or _______ A long discussion was carried out with Dr X and myself and we decided to proceed with exploration of the brachial artery Prior to this I went out to the waiting room to discuss with the patient s parents the reasoning what we are going to do and the reasoning for this I then came back in and then we proceeded He was prepped and draped in the usual sterile manner Please see Dr X s report for the discussion of the exploration and release of the brachial artery There was no indication that it was actually in the fracture site the soft tissue had tethered in its right angle towards the fracture site thus reducing its efficiency of providing blood distally Once it was released both clinically on the table as well as by Doppler the patient had bounding pulses We then proceeded to close utilizing a 4 0 Vicryl for subcutaneous fat closure and a running 5 0 Vicryl subcuticular stitch for skin closure Steri Strips were placed The patient s arm was placed in just a slight degree of flexion with a neutral position He was splinted posteriorly Adaptic and fluffs have been placed around the patient s pin sites K wires have been bent cut and pin caps placed Expected surgical prognosis on this patient is guarded for the obvious reasons noted above There is concern for growth plate disturbance He will be watched very closely for the potential development of re perfusing compartment syndrome A full and complete neurologic exam will be impossible tonight but will be carried on a sequential basis starting tomorrow morning There is always a potential for loss of elbow motion overall cosmetic elbow alignment and elbow function Keywords surgery closed reduction percutaneous pinning distal humeru supracondylar fracture tethered brachial artery artery supracondylar brachial pinning reduction fracture humerus elbow MEDICAL_TRANSCRIPTION,Description Colonoscopy due to rectal bleeding constipation abnormal CT scan rule out inflammatory bowel disease Medical Specialty Surgery Sample Name Colonoscopy 1 Transcription INDICATION Rectal bleeding constipation abnormal CT scan rule out inflammatory bowel disease PREMEDICATION See procedure nurse NCS form PROCEDURE Keywords surgery bleeding ct scan digital rectal exam pentax video rectal cecal strap cecum colonic mucosa colonoscope colonoscopy constipation hemorrhoids ileocecal valve inflammatory bowel disease lateral position bowel disease internal hemorrhoids inflammatory MEDICAL_TRANSCRIPTION,Description Left upper extremity amputation This 3 year old male suffered amputation of his left upper extremity with complications of injury He presents at this time for further attempts at closure Left abdominal flap 5 x 5 cm to left forearm debridement of skin subcutaneous tissue muscle and bone closure of wounds placement of VAC negative pressure wound dressing Medical Specialty Surgery Sample Name Closure of Amputation Wounds Transcription PREOPERATIVE DIAGNOSIS Left upper extremity amputation POSTOPERATIVE DIAGNOSIS Left upper extremity amputation PROCEDURES 1 Left abdominal flap 5 x 5 cm to left forearm 2 Debridement of skin subcutaneous tissue muscle and bone 3 Closure of wounds simple closure approximately 8 cm 4 Placement of VAC negative pressure wound dressing INDICATIONS This 3 year old male suffered amputation of his left upper extremity with complications of injury He presents at this time for further attempts at closure OPERATIVE FINDINGS A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory DESCRIPTION OF PROCEDURE Under inhalational anesthesia he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen chest and groin He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them In this fashion simple closure was accomplished and its total length was approximately 8 cm It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis At this time once we accomplished debridement and simple closure removing skin subcutaneous tissue muscle and bone as well as closing the arm we could design our flap for the abdomen The flap was designed as a slightly greater than 1 1 ellipse of skin from just below the costal margin This was elevated at the level of the external oblique and then laid on the left forearm The donor s site was closed using interrupted 4 0 Vicryl in the deep dermis and running subcuticular 4 0 Monocryl on the skin Steri Strips were applied At this time the flap was inset using again 4 0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition Keywords surgery abdominal flap debridement skin subcutaneous tissue muscle bone closure of wounds vac vac negative upper extremity closure wounds flap extremity amputation MEDICAL_TRANSCRIPTION,Description Iron deficiency anemia Diverticulosis in the sigmoid Medical Specialty Surgery Sample Name Colonoscopy Transcription PREOPERATIVE DIAGNOSIS Iron deficiency anemia POSTOPERATIVE DIAGNOSIS Diverticulosis PROCEDURE Colonoscopy MEDICATIONS MAC PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice Preparation was good although there was some residual material in the cecum that was difficult to clear completely The mucosa was normal throughout the colon No polyps or other lesions were identified and no blood was noted Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation A retroflex view of the anorectal junction showed no hemorrhoids The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Diverticulosis in the sigmoid 2 Otherwise normal colonoscopy to the cecum RECOMMENDATIONS 1 Follow up with Dr X as needed 2 Screening colonoscopy in 2 years 3 Additional evaluation for other causes of anemia may be appropriate Keywords surgery olympus colonoscope iron deficiency anemia diverticulosis sigmoid cecum anemia colonoscopy MEDICAL_TRANSCRIPTION,Description Closure of multiple complex lacerations Multiple complex lacerations of the periorbital area Medical Specialty Surgery Sample Name Closure of Complex Lacerations Transcription PREOPERATIVE DIAGNOSIS Multiple complex lacerations of the periorbital area POSTOPERATIVE DIAGNOSIS Multiple complex lacerations of the periorbital area PROCEDURE PERFORMED Closure of multiple complex lacerations ANESTHESIA Local 1 with epinephrine ESTIMATED BLOOD LOSS Minimal SPECIMEN None COMPLICATIONS None HISTORY The patient is a 19 year old Caucasian male who presented status post a bicycle versus MVA The patient obtained multiple complex lacerations of the right periorbital area PROCEDURE Informed consent was properly obtained from the patient and he was placed in a 45 degree angle Topical viscous lidocaine was applied for pain management and then 1 epinephrine was injected into the periorbital area for anesthetic effect A 5 0 Vicryl suture was used to close the deep layers and then 6 0 Prolene was used in interrupted fashion for superficial closure The patient was instructed to take Keflex antibiotic for 10 days He was also instructed and given prescription for erythromycin ophthalmic ointment to be applied to the periorbital areas t i d The patient is to ice the area and to follow up in one week for suture removal The patient tolerated the procedure well and he was discharged from the Emergency Room in stable condition Keywords surgery vicryl suture complex lacerations epinephrine closure periorbital lacerations MEDICAL_TRANSCRIPTION,Description Repair of bilateral cleft of the palate with vomer flaps Medical Specialty Surgery Sample Name Cleft Repair Transcription PREOPERATIVE DIAGNOSES Bilateral cleft lip and bilateral cleft of the palate POSTOPERATIVE DIAGNOSES Bilateral cleft lip and bilateral cleft of the palate PROCEDURE PERFORMED Repair of bilateral cleft of the palate with vomer flaps ESTIMATED BLOOD LOSS 40 mL COMPLICATIONS None ANESTHESIA General endotracheal anesthesia CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE Stable extubated and transferred to the recovery room in stable condition INDICATIONS FOR PROCEDURE The patient is a 10 month old baby with a history of a bilateral cleft of the lip and palate The patient has undergone cleft lip repair and she is here today for her cleft palate operation We have discussed with the mother the nature of the procedure risks and benefits the risks included but not limited to the risk of bleeding infection dehiscence scarring the need for future revision surgeries We will proceed with surgery DETAILS OF THE PROCEDURE The patient was taken into the operating room placed in the supine position and general anesthetic was administered A prophylactic dose of antibiotics was given The patient proceeded to have bilateral PE tube placement by Dr X from Ear Nose and Throat Surgery After he was done with his procedure the head of the bed was turned 90 degrees The patient was positioned with a shoulder roll and doughnut A Dingman retractor was placed The operative area was infiltrated with lidocaine with epinephrine 1 200 000 a total of 3 mL and then I proceeded with the prepping and draping The patient was prepped and draped I proceeded to do the palate repair The nature of the palate repair was done in the same way on the both sides I will describe one side The other side was done exactly in the same manner The 2 hemiuvulas are placed holding from a single hook and infiltrated with lidocaine with epinephrine 1 200 000 triangle in the nasal mucosa was previously marked This triangle of nasal mucosa was removed and excised This was done on both uvulas Then an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa A 1 mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better Once the incision was done up to the level of the hard palate the muscle was dissected off the surrounding tissue 2 mm from the nasal and the oral mucosa Then I proceeded to place an incision at the alveolopalatal junction with the help of 15 blade The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap Then the flap was lifted up with the help of a freer and then the remaining of the incision medially was completed Hemostasis was achieved with help of electrocautery and Surgicel The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator The greater auricular foramen was exposed and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially This procedure was done on both sides in the same manner and then __________ dissection was done including dissection of the hard palate from the nasal mucosa it was evident that the nasal mucosa would not reach medially to be placed together At this point the decision was made to proceed with vomer flaps The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book The incision was done with a 15C blade The vomer flaps were dissected and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate This was approximated on both sides with 5 0 chromic running and interrupted stitches and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5 0 chromic and a 4 0 chromic Then 2 stitches of 4 0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side on the other side and then coming back on the mucosa to evert the edges of the soft palate The remaining part of the soft palate was placed together with 4 0 Vicryl and 4 0 chromic interrupted stitches The throat pack was removed The palate was cleaned The Dingman retractor was removed and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2 0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm The patient tolerated the procedure without complications BSS is applied to the eye after removing the Tegaderm I was present and participated in all aspects of the procedure The sponge needle and instrument count were completed at the end of the procedure The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition Keywords surgery bilateral cleft cleft lip oral mucosa hard palate soft palate vomer flaps mucoperiosteal flap nasal mucosa flaps cleft mucosa palate mucoperiosteal bilateral nasal MEDICAL_TRANSCRIPTION,Description Trimalleolar ankle fracture and dislocation right ankle A comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well Closed open reduction and internal fixation of right ankle Medical Specialty Surgery Sample Name Closed ORIF Ankle Transcription PREOPERATIVE DIAGNOSES 1 Trimalleolar ankle fracture 2 Dislocation right ankle POSTOPERATIVE DIAGNOSES 1 Trimalleolar ankle fracture 2 Dislocation right ankle PROCEDURE PERFORMED Closed open reduction and internal fixation of right ankle ANESTHESIA Spinal with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME 75 minutes at 325 mmHg COMPONENTS Synthes small fragment set was used including a 2 5 mm drill bed A six hole one third tibial plate one 12 mm 3 5 mm cortical screw fully threaded and two 16 mm 3 5 mm cortical fully threaded screws There were two 20 mm 4 0 cancellous screws and one 18 mm 4 0 cancellous screw placed There were two 4 0 cancellous partially threaded screws placed GROSS FINDINGS Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well HISTORY OF PRESENT ILLNESS The patient is an 87 year old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall The patient noted while walking with a walker apparently tripped and fell The patient had significant comorbidities seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room At that time a closed reduction was performed and she was placed in a Robert Jones splint After complete medical workup and clearance we elected to take her to the operating room for definitive care PROCEDURE After all potential complications and risks as well as risks and benefits of the above mentioned procedure was discussed at length with the patient and family informed consent was obtained The upper extremity was then confirmed with the operating surgeon the patient the nursing staff and Department of Anesthesia The patient was then transferred to preoperative area in the Operative Suite 3 and placed on the operating room table in supine position At this time the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation All bony prominences were well padded at this time A nonsterile tourniquet was placed on the right upper thigh of the patient This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes Next after all bony and soft tissue landmarks were identified a 6 cm longitudinal incision was made directly over this vestibule on the right ankle A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures Once the bone was reached the fractured site was identified The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site The wound was copiously irrigated and dried Next the fracture was then reduced in anatomic position There was noted to be quite a bit of comminution as well as soft overall status of the bone It was held in place with reduction forceps A six hole one third tubular Synthes plate was then selected for instrumentation It was contoured using ________ and placed on the lateral aspect of the distal fibula Next the three most proximal holes were sequentially drilled using a 2 5 mm drill bed depth gauged and then a 3 5 mm fully threaded cortical screw was placed in each The most proximal was a 12 mm and the next two were 16 mm in length Next the three most distal holes were sequentially drilled using a 2 5 mm drill bed depth gauged and a 4 0 cancellous screw was placed in each hole The most distal with a 20 mm and two most proximal were 18 mm in length Next the Xi scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position all hardware was in good position There was no lateralization of the joints Attention was then directed towards the medial aspect of the ankle Again after all bony and soft tissue landmarks were identified a 4 cm longitudinal incision was made directly over the medial malleolus Again the dissection was carefully taken down the level of the fracture site The retractors were then placed to protect all neurovascular structures Once the fracture site was identified it was dried of all hematoma as well as excess periosteum The fracture site was then displaced and the ankle joint was visualized including the dome of the talus There appeared to be some minor degenerative changes of the talus but no loose bodies Next the wound was copiously irrigated and suctioned dry The medial malleolus was placed in reduced position and held in place with a 1 25 mm K wire Next the 2 5 mm drill bed was then used to sequentially drill holes to full depth and 4 0 cancellous screws were placed in each each with a 45 mm in length These appeared to hold the fracture site securely in an anatomic position Again Xi scan was brought in to confirm placement of the screws They were in good overall position and there was no lateralization of the joint At this time each wound was copiously irrigated and suctioned dry The wounds were then closed using 2 0 Vicryl suture in subcutaneous fashion followed by staples on the skin A sterile dressing was applied consistent with Adaptic 4x4s Kerlix and Webril A Robert Jones style splint was then placed on the right lower extremity This was covered by a 4 inch Depuy dressing At this time the Department of Anesthesia reversed the sedation The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit The patient tolerated the procedure well There were no complications Keywords surgery ankle fracture dislocation open reduction internal fixation orif trimalleolar ankle fracture cortical screw cancellous screws fracture site fracture ankle malleolus MEDICAL_TRANSCRIPTION,Description Clear corneal temporal incision no stitches A lid speculum was placed in the fissure of the right eye Medical Specialty Surgery Sample Name Clear Corneal Temporal Incision Transcription CLEAR CORNEAL TEMPORAL INCISION NO STITCHES DESCRIPTION OF OPERATION Under satisfactory local anesthesia the patient was appropriately prepped and draped A lid speculum was placed in the fissure of the right eye The secondary incision was then made through clear cornea using 1 mm diamond keratome at surgeon s 7 30 position and the anterior chamber re formed using viscoelastic The primary incision was then made using a 3 mm diamond keratome at the surgeon s 5 o clock position and additional viscoelastic injected into the anterior chamber as needed The capsulorrhexis was then performed in a standard circular tear fashion The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag The residual cortex was then aspirated from the bag and the bag re expanded using viscoelastic The posterior chamber intraocular lens was then inspected irrigated coated with Healon and folded and then placed into the capsular bag under direct visualization The lens was noted to center well The residual viscoelastic was then removed from the eye and the eye re formed using balanced salt solution The eye was then checked and found to be watertight therefore no suture was used The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment A shield was applied and the patient returned to the recovery room in good condition Keywords surgery clear corneal temporal incision intraocular lens corneal temporal incision lid speculum incision temporal chamber corneal viscoelastic eyeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right distal both bone forearm fracture Closed reduction under conscious sedation and application of a splint was warranted Medical Specialty Surgery Sample Name Closed Reduction 1 Transcription PREOPERATIVE DIAGNOSIS Right distal both bone forearm fracture POSTOPERATIVE DIAGNOSIS Right distal both bone forearm fracture INDICATIONS Mr ABC is a 10 year old boy who suffered a fall resulting in a right distal both bone forearm fracture Upon evaluation by Orthopedic Surgery team in the emergency department it was determined that a closed reduction under conscious sedation and application of a splint was warranted This was discussed with the parents who expressed verbal and written consent PROCEDURE Conscious sedation was achieved via propofol via the emergency department staff Afterwards traction with re creation of the injury pattern was utilized to achieve reduction of the patient s fracture This was confirmed with image intensifier Subsequently the patient was placed into a splint The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial median and ulnar nerve distributions and positive extensor pollicis longus flexor pollicis longus dorsal and palmar interossei DISPOSITION Post reduction x rays revealed good alignment in the AP x rays The lateral x rays also revealed adequate reduction At this time we will allow the patient to be discharged home and have him follow up with Dr XYZ in one week Keywords surgery closed reduction distal both bone forearm emergency department pollicis longus bone forearm forearm fracture conscious sedation emergency department pollicis longus splint distal bone forearm conscious sedation fracture reduction MEDICAL_TRANSCRIPTION,Description Left distal both bone forearm fracture Closed reduction with splint application with use of image intensifier Medical Specialty Surgery Sample Name Closed Reduction 2 Transcription PREOPERATIVE DIAGNOSIS Left distal both bone forearm fracture POSTOPERATIVE DIAGNOSIS Left distal both bone forearm fracture PROCEDURE Closed reduction with splint application with use of image intensifier INDICATIONS Mr ABC is an 11 year old boy who sustained a fall on 07 26 2008 Evaluation in the emergency department revealed both bone forearm fracture Considering the amount of angulation it was determined that we should proceed with conscious sedation and closed reduction After discussion with parents verbal and written consent was obtained DESCRIPTION OF PROCEDURE The patient was induced with propofol for conscious sedation via the emergency department staff After it was confirmed that appropriate sedation had been reached a longitudinal traction in conjunction with re creation of the injury maneuver was applied reducing the fracture Subsequently this was confirmed with image intensification a sugar tong splint was applied and again reduction was confirmed with image intensifier The patient was aroused from anesthesia and tolerated the procedure well Post reduction plain films revealed some anterior displacement of the distal fragment At this time it was determined this fracture proved to be unstable DISPOSITION After review of the reduction films it appears that there is some element of fracture causing displacement We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows Keywords surgery closed reduction reduction with splint application distal both bone forearm distal both bone splint application emergency department conscious sedation image intensifier bone forearm forearm fracture reduction emergency department conscious displacement splint sedation tong distal bone image intensifier forearm fracture MEDICAL_TRANSCRIPTION,Description Bilateral open mandible fracture open left angle and open symphysis fracture Closed reduction of mandible fracture with MMF Medical Specialty Surgery Sample Name Closed Reduction Mandible Fracture Transcription PREOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture POSTOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture PROCEDURE Closed reduction of mandible fracture with MMF ANESTHESIA General anesthesia via nasal endotracheal intubation FLUIDS 2 L of crystalloid ESTIMATED BLOOD LOSS Minimal HARDWARE None SPECIMENS None COMPLICATIONS None CONDITION The patient was extubated to PACU in good condition INDICATIONS FOR PROCEDURE The patient is a 17 year old female who is 2 days status post an altercation in which she sustained multiple blows to the face She was worked up on Friday night 2 days earlier at Hospital was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call The patient was worked up initially On initial exam it was noted that the patient had a left V3 paresthesia She had a gross malocclusion On the facial CT and panoramic x ray it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures Risks benefits and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient s mother DESCRIPTION OF PROCEDURE The patient was taken to the operating room 4 at Hospital and laid in a supine position on the operating room table Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics The patient was prepped and draped in the usual oromaxillofacial surgery fashion Surgeon approached the operating table in a sterile fashion Approximately 10 mL of 2 lidocaine with 1 100 000 epinephrine was injected into the oral vestibule in a nerve block fashion A moistened Ray Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse scrubbed with a toothbrush The Peridex was evacuated with Yankauer suction Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24 gauge surgical steel wire on the posterior teeth and 26 gauge surgical steel wire on the anterior teeth Same was done on the mandible The patient was then manipulated up in the maximum intercuspation and noted to be reproducible The throat pack was then removed The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics At this point in time the procedure was then determined to be over The patient was extubated and transferred to the PACU in good condition Keywords surgery open symphysis fracture closed reduction mmf endotracheal pacu bilateral open mandible fracture symphysis fracture mandible fracture fracture intubation angle mandible MEDICAL_TRANSCRIPTION,Description Newborn circumcision The penile foreskin was removed using Gomco Medical Specialty Surgery Sample Name Circumcision Newborn Transcription PROCEDURE Newborn circumcision INDICATIONS Parental preference ANESTHESIA Dorsal penile nerve block DESCRIPTION OF PROCEDURE The baby was prepared and draped in a sterile manner Lidocaine 1 4 mL without epinephrine was instilled into the base of the penis at 2 o clock and 10 o clock The penile foreskin was removed using a XXX Gomco Hemostasis was achieved with minimal blood loss There was no sign of infection The baby tolerated the procedure well Vaseline was applied to the penis and the baby was diapered by nursing staff Keywords surgery nerve block newborn circumcision foreskin gomco penis circumcision newborn penile MEDICAL_TRANSCRIPTION,Description Cleft soft palate Repair of cleft soft palate and excise accessory ear tag right ear Medical Specialty Surgery Sample Name Cleft Repair Soft Palate Transcription PREOPERATIVE DIAGNOSIS Cleft soft palate POSTOPERATIVE DIAGNOSIS Cleft soft palate PROCEDURES 1 Repair of cleft soft palate CPT 42200 2 Excise accessory ear tag right ear ANESTHESIA General DESCRIPTION OF PROCEDURE The patient was placed supine on the operating room table After anesthesia was administered time out was taken to ensure correct patient procedure and site The face was prepped and draped in a sterile fashion The right ear tag was examined first This was a small piece of skin and cartilaginous material protruding just from the tragus The lesion was excised and injected with 0 25 bupivacaine with epinephrine and then excised using an elliptical style incision Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus After this was done the wound was cauterized and then closed using interrupted 5 0 Monocryl Attention was then turned towards the palate The Dingman mouthgag was inserted and the palate was injected with 0 25 bupivacaine with epinephrine After giving this 5 minutes to take effect the palate was incised along its margins The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline The Z plasties were then designed so there would be opposing Z plasties from the nasal mucosa compared to the oral mucosa The nasal mucosa was sutured first using interrupted 4 0 Vicryl Next the muscle was reapproximated using interrupted 4 0 Vicryl with an attempt to overlap the muscle in the midline In addition the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate Following this the oral layer of mucosa was repaired using an opposing Z plasty compared to the nasal layer This was also sutured in place using interrupted 4 0 Vicryl The anterior and posterior open edges of the palatal were sewn together The patient tolerated the procedure well Suction of blood and mucus performed at the end of the case The patient tolerated the procedure well IMMEDIATE COMPLICATIONS None DISPOSITION In satisfactory condition to recovery Keywords surgery repair tragus oral mucosa nasal mucosa ear tag soft palate palate cleft soft MEDICAL_TRANSCRIPTION,Description Circumcision and release of ventral chordee Medical Specialty Surgery Sample Name Circumcision Chordee Release Transcription PREOPERATIVE DIAGNOSES Phimosis and adhesions POSTOPERATIVE DIAGNOSES Phimosis and adhesions PROCEDURES PERFORMED Circumcision and release of ventral chordee ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid The patient was given antibiotics preop BRIEF HISTORY This is a 43 year old male who presented to us with significant phimosis difficulty retracting the foreskin The patient had buried penis with significant obesity issues in the suprapubic area Options such as watchful waiting continuation of slowly retracting the skin applying betamethasone cream and circumcision were discussed Risk of anesthesia bleeding infection pain MI DVT PE and CVA risks were discussed The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix Consent had been obtained Risk of scarring decrease in penile sensation and unexpected complications were discussed The patient was told about removing the dressing tomorrow morning okay to shower after 48 hours etc Consent was obtained DESCRIPTION OF PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in supine position The patient was prepped and draped in usual sterile fashion Local MAC anesthesia was applied After draping 17 mL of mixture of 0 25 Marcaine and 1 lidocaine plain were applied around the dorsal aspect of the penis for dorsal block The patient had significant phimosis and slight ventral chordee Using marking pen the excess foreskin was marked off Using a knife the ventral chordee was released The urethra was intact The excess foreskin was removed Hemostasis was obtained using electrocautery A 5 0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done The patient tolerated the procedure well There was excellent hemostasis The penis was straight Vaseline gauze and Kerlix were applied The patient was brought to the recovery in stable condition Plan was for removal of the dressing tomorrow Okay to shower after 48 hours Keywords surgery phimosis adhesions release of ventral chordee ventral chordee circumcision penis chordee foreskin MEDICAL_TRANSCRIPTION,Description Normal penis The foreskin was normal in appearance and measured 1 6 cm There was no bleeding at the circumcision site Medical Specialty Surgery Sample Name Circumcision 7 Transcription PROCEDURE Circumcision ANESTHESIA EMLA FINDINGS Normal penis The foreskin was normal in appearance and measured 1 6 cm There was no bleeding at the circumcision site PROCEDURE Patient was placed on the circumcision restraint board EMLA had been applied approximately 90 minutes before A time out was completed satisfactorily per protocol The area was prepped with Betadine The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection A Mogen clamp was applied to the cervix The excess foreskin was excised with the scalpel The clamp was removed At this point the procedure was terminated Sterile Vaseline and gauze was applied to the glans penis There were no complications There was minimal blood loss Keywords surgery mogen clamp glans penis emla penis foreskin circumcision MEDICAL_TRANSCRIPTION,Description Circumcision Normal male phallus The infant is without evidence of hypospadias or chordee prior to the procedure Medical Specialty Surgery Sample Name Circumcision Infant Transcription PROCEDURE Circumcision PRE PROCEDURE DIAGNOSIS Normal male phallus POST PROCEDURE DIAGNOSIS Normal male phallus ANESTHESIA 1 lidocaine without epinephrine INDICATIONS The risks and benefits of the procedure were discussed with the parents The risks are infection hemorrhage and meatal stenosis The benefits are ease of care and cleanliness and fewer urinary tract infections The parents understand this and have signed a permit FINDINGS The infant is without evidence of hypospadias or chordee prior to the procedure TECHNIQUE The infant was given a dorsal penile block with 1 lidocaine without epinephrine using a tuberculin syringe and 0 5 cc of lidocaine was delivered subcutaneously at 10 30 and at 1 30 o clock at the dorsal base of the penis The infant was prepped then with Betadine and draped with a sterile towel in the usual manner Clamps were placed at 10 o clock and 2 o clock and the adhesions between the glans and mucosa were instrumentally lysed Dorsal hemostasis was established and a dorsal slit was made The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed The infant was fitted with a XX cm Plastibell The foreskin was retracted around the Plastibell and circumferential hemostasis was established The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis Keywords surgery dorsal slit hypospadias chordee epinephrine hemorrhage penis adhesions circumcision phallus lidocaine foreskin infant MEDICAL_TRANSCRIPTION,Description Circumcision A dorsal slit was made and the prepuce was dissected away from the glans penis Medical Specialty Surgery Sample Name Circumcision 6 Transcription PROCEDURE Circumcision Signed informed consent was obtained and the procedure explained DETAILS OF PROCEDURE The child was placed in a Circumstraint board and restrained in the usual fashion The area of the penis and scrotum were prepared with povidone iodine solution The area was draped with sterile drapes and the remainder of the procedure was done with sterile procedure A dorsal penile block was done using 2 injections of 0 3 cc each 1 plain lidocaine A dorsal slit was made and the prepuce was dissected away from the glans penis A Gomco clamp was properly placed for 5 minutes During this time the foreskin was sharply excised using a 10 blade With removal of the clamp there was a good cosmetic outcome and no bleeding The child appeared to tolerate the procedure well Care instructions were given to the parents Keywords surgery gomco clamp dorsal slit glans penis slit circumcision penisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Release of ventral chordee circumcision and repair of partial duplication of urethral meatus Medical Specialty Surgery Sample Name Circumcision 5 Transcription PROCEDURES 1 Release of ventral chordee 2 Circumcision 3 Repair of partial duplication of urethral meatus INDICATIONS The patient is an 11 month old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding He is here electively for surgical correction DESCRIPTION OF PROCEDURE The patient was brought back into operating room 35 After successful induction of general endotracheal anesthetic giving the patient preoperative antibiotics and after completing a preoperative time out the patient was prepped and draped in the usual sterile fashion A holding stitch was placed in the glans penis At this point we probed both urethral meatus Using the Crede maneuver we could see urine clearly coming out of the lower the more ventral meatus At this point we cannulated this with a 6 French hypospadias catheter We attempted to cannulate the dorsal opening however we were unsuccessful We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication At this point we identified the band connecting both the urethral meatus and incised it with tenotomy scissors We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans At this point we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee Once all the chordee had been adequately released we turned our attention to the circumcision Excessive dorsal foreskin was removed from the skin and glans Mucosal cuts were reapproximated with interrupted 5 0 chromic suture Dermabond was placed over this and bacitracin was placed on this once dry This ended the procedure DRAINS None ESTIMATED BLOOD LOSS Minimal URINE OUTPUT Unrecorded COMPLICATIONS None apparent DISPOSITION The patient will now go under the care of Dr XYZ Plastic Surgery for excision of scalp hemangioma Keywords surgery release of ventral chordee repair of partial duplication partial duplication ventral chordee urethral meatus glans penis circumcision ventral chordee urethral meatus MEDICAL_TRANSCRIPTION,Description Circumcision procedure in a baby Medical Specialty Surgery Sample Name Circumcision 3 Transcription CIRCUMCISION After informed consent was obtained the baby was placed on the circumcision tray He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion Then 0 2 mL of 1 lidocaine was injected at 10 and 2 o clock A ring block was also done using another 0 3 mL of lidocaine Glucose water is also used for anesthesia After several minutes the curved clamp was attached at 9 o clock with care being taken to avoid the meatus The blunt probe was then introduced again with care taken to avoid the meatus After initial adhesions were taken down the straight clamp was introduced to break down further adhesions Care was taken to avoid the frenulum The clamps where then repositioned at 12 and 6 o clock The Mogen clamp was then applied with a dorsal tilt After the clamp was applied for 1 minute the foreskin was trimmed After an additional minute the clamp was removed and the final adhesions were taken down Patient tolerated the procedure well with minimal bleeding noted Patient to remain for 20 minutes after procedure to insure no further bleeding is noted Routine care discussed with the family Need to clean the area with just water initially and later with soap and water or diaper wipes once healed Keywords surgery circumcision 1 lidocaine betadine glucose water adhesions circumcision tray diaper wipes foreskin frenulum meatus straight clamp sterile fashion clampNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Circumcision in an older person Medical Specialty Surgery Sample Name Circumcision 1 Transcription CIRCUMCISION OLDER PERSON OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating table General endotracheal anesthesia was administered The patient was prepped and draped in the usual sterile fashion A 4 0 silk suture is used as a stay stitch of the glans penis Next incision line was marked circumferentially on the outer skin 3 mm below the corona The incision was then carried through the skin and subcutaneous tissues down to within a layer of fascia Next the foreskin was retracted Another circumferential incision was made 3 mm proximal to the corona The intervening foreskin was excised Meticulous hemostasis was obtained with electrocautery Next the skin was reapproximated at the frenulum with a U stitch of 5 0 chromic followed by stitches at 12 3 and 9 o clock The stitches were placed equal distance among these to reapproximate all the skin edges Next good cosmetic result was noted with no bleeding at the end of the procedure Vaseline gauze Telfa and Elastoplast dressing was applied The stay stitch was removed and pressure held until bleeding stopped The patient tolerated the procedure well and was returned to the recovery room in stable condition Keywords surgery circumcision elastoplast meticulous hemostasis telfa vaseline gauze circumferential incision corona cosmetic result endotracheal anesthesia foreskin glans penis hemostasis stay stitch circumferentially stitchNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Normal Circumcision Medical Specialty Surgery Sample Name Circumcision 4 Transcription The patient tolerated the procedure well and was sent to the Recovery Room in stable condition Keywords surgery circumcision circumferential proximal incisions hemostasis vaseline soaked gauze catgut foreskin needlepoint bovie pain block shaft of the penis supine position penisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Left and right coronary system cineangiography Left ventriculogram PCI to the left circumflex with a 3 5 x 12 and a 3 5 x 8 mm Vision bare metal stents postdilated with a 3 75 mm noncompliant balloon x2 MEDICAL_TRANSCRIPTION,Description Left and right coronary system cineangiography cineangiography of SVG to OM and LIMA to LAD Left ventriculogram and aortogram Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent Medical Specialty Surgery Sample Name Cineangiography Transcription PROCEDURES UNDERTAKEN 1 Left coronary system cineangiography 2 Right coronary system cineangiography 3 Cineangiography of SVG to OM 4 Cineangiography of LIMA to LAD 5 Left ventriculogram 6 Aortogram 7 Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent NARRATIVE After all risks and benefits were explained to the patient informed consent was obtained The patient was brought to the cardiac catheterization suite The right groin was prepped in the usual sterile fashion Right common femoral artery was cannulated using a modified Seldinger technique and a long 6 French AO sheath was introduced secondary to tortuous aorta Next Judkins left catheter was used to engage the left coronary system Cineangiography was recorded in multiple views Next Judkins right catheter was used to engage the right coronary system Cineangiography was recorded in multiple views Next the Judkins right catheter was used to engage the SVG to OM Cineangiography was recorded Next the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J wire for a 4 French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views Next an angled pigtail catheter was advanced into the left ventricular cavity LV pressures were measured LV gram was done and a pullback gradient across the aortic valve was done and recorded Next an aortogram was done and recorded At this point I decided to proceed with percutaneous intervention of the left circumflex Therefore AVA 3 5 guide was used to engage the left coronary artery Angiomax bolus and drip was started Universal wire was advanced past the lesion and a 2 5 balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres Next we attempted to advance a 3 0 x 12 stent to the distal lesion however we were unable to pass the stent Next second dilatations were done again with the 2 5 balloon at 18 atmospheres however we are unable to break the lesion We next attempted a cutting balloon Again we are unable to cross the lesion therefore a buddy wire technique was used with a PT choice support wire Again we were unable to cross the lesion with the stent We then try to cross with a noncompliant balloon which we were unsuccessful We also try to cutting balloon again we were unsuccessful Despite multiple dilatations we were unable to cross anything beyond the noncompliant balloon across the lesion therefore finally the procedure was aborted Final images showed no evidence of dissection perforation or further complication The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results The patient tolerated the procedure very well without complications was taken off the operating table and transferred back to cardiac telemetry floor DIAGNOSTIC FINDINGS 1 The LV LVEDP was 4 LVES is approximately 50 55 with inferobasal hypokinesis No significant MR No gradient across the aortic valve 2 Aortogram The ascending aorta shows no significant dilatation or evidence of dissection The valve shows no significant aortic insufficiencies The abdominal aorta and distal aorta shows significant tortuosities 3 The left main The left main coronary artery is a large caliber vessel bifurcating the LAD and left circumflex with some mild distal disease of about 10 20 4 Left circumflex The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70 80 stenosis The mid left circumflex is a high grade 80 diffuse tortuous stenosis 5 LAD The LAD is a totally 100 occluded vessel The LIMA to LAD is patent with only a small to moderate caliber LAD There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60 70 The diagonal shows proximal 80 stenosis 6 The right coronary artery The right coronary artery is 100 occluded There are retrograde collaterals from left to right to the distal PDA and PLV branches The SVG to OM is 100 occluded at its take off The SVG to PDA is not found however presumed 100 occluded given that there is collateral flow to the distal right 7 LIMA to LAD is widely patent ASSESSMENT AND PLAN Attempted intervention to the left circumflex system only able to perform plano balloon angioplasty unable to pass stents noncompliant balloons or cutting balloon Final images showed some improvement however continued residual stenosis At this point the patient will be transferred back to telemetry floor and monitored We can attempt future intervention or continue aggressive medical management The patient continues to have residual stenosis in the diagonal however due to the length of this procedure I did not attempt intervention to that diagonal branch Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia focus on treatment to that lesion Keywords surgery coronary system cineangiography svg to om lima to lad ventriculogram aortogram percutaneous intervention circumflex obtuse marginal branch balloon angioplasty coronary artery balloon cineangiography lad MEDICAL_TRANSCRIPTION,Description Circumcision The child appeared to tolerate the procedure well Care instructions were given to the parents Medical Specialty Surgery Sample Name Circumcision Child Transcription PROCEDURE Circumcision Signed informed consent was obtained and the procedure explained The child was placed in a Circumstraint board and restrained in the usual fashion The area of the penis and scrotum were prepared with povidone iodine solution The area was draped with sterile drapes and the remainder of the procedure was done with sterile procedure A dorsal penile block was done using 2 injections of 0 3 cc each 1 plain lidocaine A dorsal slit was made and the prepuce was dissected away from the glans penis A Gomco clamp was properly placed for 5 minutes During this time the foreskin was sharply excised using a 10 blade With removal of the clamp there was a good cosmetic outcome and no bleeding The child appeared to tolerate the procedure well Care instructions were given to the parents Keywords surgery circumstraint dorsal slit gomco clamp circumcision childNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Placement of cholecystostomy tube under ultrasound guidance Acute acalculous cholecystitis Medical Specialty Surgery Sample Name Cholecystostomy Tube Placement Transcription PREOPERATIVE DIAGNOSIS Acute acalculous cholecystitis POSTOPERATIVE DIAGNOSIS Acute acalculous cholecystitis PROCEDURE Placement of cholecystostomy tube under ultrasound guidance ANESTHESIA Xylocaine 1 With Epinephrine INDICATIONS Patient is a pleasant 75 year old gentleman who is about one week status post an acute MI who also has acute cholecystitis Because it is not safe to take him to the operating room for general anesthetic I recommended he undergo the above named procedure Procedure purpose risks expected benefits potential complications and alternative forms of therapy were discussed with him and he was agreeable to surgery TECHNIQUE Patient was identified then taken to the Radiology suite where the area of interest was identified using ultrasound and prepped with Betadine solution draped in sterile fashion After infiltration with 1 Xylocaine and after multiple attempts the gallbladder was finally cannulated by Dr Kindred using the Cook 18 French needle The guidewire was then placed and via Seldinger technique a 10 French pigtail catheter was placed within the gallbladder secured using the Cook catheter method and dressings were applied and patient was taken to recovery room in stable condition Keywords surgery under ultrasound guidance cholecystostomy tube acalculous cholecystitis catheter cholecystostomy ultrasound acalculous cholecystitis MEDICAL_TRANSCRIPTION,Description Circumcision procedure neotal Medical Specialty Surgery Sample Name Circumcision 2 Transcription CIRCUMCISION NEONATAL PROCEDURE The procedure risks and benefits were explained to the patient s mom and a consent form was signed She is aware of the risk of bleeding infection meatal stenosis excess or too little foreskin removed and the possible need for revision in the future The infant was placed on the papoose board The external genitalia were prepped with Betadine A penile block was performed with a 30 gauge needle and 1 5 mL of Nesacaine without epinephrine Next the foreskin was clamped at the 12 o clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis The incision was made Next all the adhesions of the inner preputial skin were broken down The appropriate size bell was obtained and placed over the glans penis The Gomco clamp was then configured and the foreskin was pulled through the opening of the Gomco The bell was then placed and tightened down Prior to do this the penis was viewed circumferentially and there was no excess of skin gathered particularly in the area of the ventrum A blade was used to incise circumferentially around the bell The bell was removed There was no significant bleeding and a good cosmetic result was evident with the appropriate amount of skin removed Vaseline gauze was then placed The little boy was given back to his mom PLAN They have a new baby checkup in the near future with their primary care physician I will see them back on a p r n basis if there are any problems with the circumcision Keywords surgery neonatal circumcision gomco gomco clamp external genitalia foreskin glans glans penis infant meatal stenosis penile block penis preputial skin circumferentially infection bell MEDICAL_TRANSCRIPTION,Description The patient had spraying of urine and ballooning of the foreskin with voiding Medical Specialty Surgery Sample Name Circumcision Transcription PREOPERATIVE DIAGNOSIS Phimosis POSTOPERATIVE DIAGNOSES Phimosis OPERATIONS Circumcision ANESTHESIA LMA EBL Minimal FLUIDS Crystalloid BRIEF HISTORY This is a 3 year old male who was referred to us from Dr X s office with phimosis The patient had spraying of urine and ballooning of the foreskin with voiding The urine seemed to have collected underneath the foreskin and then would slowly drip out Options such as dorsal slit circumcision watchful waiting by gently pulling the foreskin back were discussed Risk of anesthesia bleeding infection pain scarring and expected complications were discussed The patient s family understood all the complications and wanted to proceed with the procedure Consent was obtained using interpreter DESCRIPTION OF PROCEDURE The patient was brought to the OR and anesthesia was applied The patient was placed in supine position The patient was prepped and draped in usual sterile fashion All the penile adhesions were released prior to the prepping The extra foreskin was marked off 1 x 3 Gamco clamp was used Hemostasis was obtained after removing the extra foreskin using the Gamco clamp Using 5 0 Monocryl 4 quadrant stitches were placed and horizontal mattress suturing was done There was excellent hemostasis Dermabond was applied The patient was brought to recovery at the end of the procedure in stable condition Keywords surgery ballooning of the foreskin spraying of urine gamco clamp spraying ballooning circumcision urine phimosis foreskin MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Gallstone pancreatitis Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially Medical Specialty Surgery Sample Name Cholecystectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Gallstone pancreatitis POSTOPERATIVE DIAGNOSIS Gallstone pancreatitis PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General endotracheal and local injectable Marcaine ESTIMATED BLOOD LOSS Minimal SPECIMEN Gallbladder COMPLICATIONS None OPERATIVE FINDINGS Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially These dense adhesions were associated with chronic inflammatory edematous changes The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified clipped with two clips proximally and one distally The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver There was no evidence of adhesions from the abdominal wall to the liver The remainder of the abdomen was unremarkable BRIEF HISTORY This is a 17 year old African American female who presented to ABCD General Hospital on 08 20 2003 with complaints of intractable right upper quadrant abdominal pain She had been asked to follow up and scheduled for surgery previously Her pain had now been intractable associated with anorexia She was noted on physical examination to be afebrile however she was having severe right upper quadrant pain with examination as well as a Murphy s sign and voluntary guarding with examination Her transaminases were markedly elevated She also developed pancreatitis secondary to gallstones Her common bile duct was dilated to 1 cm with no evidence of wall thickening but evidence of cholelithiasis She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis Following this she was scheduled for operative laparoscopic cholecystectomy Her parents were explained the risks benefits and complications of the procedure She gave us informed consent to proceed with surgery OPERATIVE PROCEDURE The patient brought to the operative suite and placed in the supine position Preoperatively the patient received IV antibiotics of Ancef sequential compression devices and subcutaneous heparin The abdomen was prepped and draped in the normal sterile fashion with Betadine solution Utilizing a 15 blade scalpel a transverse infraumbilical incision was created Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp the Veress needle was inserted without difficulty Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty The abdomen was then insufflated to 15 mmHg with carbon dioxide Once the abdomen was sufficiently insufflated a 10 mm bladed trocar was inserted into the abdomen without difficulty Video laparoscope was inserted and the above notable findings were identified in the operative findings The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed A 15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament Next two 5 mm trocars were inserted under direct visualization one in the midclavicular and one in the anterior midaxillary line These were inserted without difficulty The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder Utilizing Endoshears scissor a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions Next the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place Next the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor Once the clips were noted to be in place utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery The abdomen was then irrigated with copious amounts of normal saline The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port There was noted to be gallstones within the gallbladder Once the abdomen was re insufflated after removing the gallbladder and copious irrigation was performed all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall Utilizing 0 Vicryl suture a figure of eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia A 4 0 Vicryl suture was used to approximate all incisions The incisions were then injected with local injectable 0 25 Marcaine All ports were then cleaned dry Steri Strips were placed across and sterile pressure dressings were placed on top of this The patient tolerated the entire procedure well She was transferred to the Postanesthesia Care Unit in stable condition She will be followed closely in the postoperative course in General Medical Floor Keywords surgery gallstone gallbladder pancreatitis anterior abdominal wall video laparoscope laparoscopic cholecystectomy omental adhesions veress needle cystic duct injectable adhesions cholecystectomy laparoscopic abdomen MEDICAL_TRANSCRIPTION,Description Open cholecystectomy attempted laparoscopic cholecystectomy Medical Specialty Surgery Sample Name Cholecystectomy Open Transcription PREOPERATIVE DIAGNOSIS ES 1 Cholelithiasis 2 Cholecystitis POSTOPERATIVE DIAGNOSIS ES 1 Acute perforated gangrenous cholecystitis 2 Cholelithiasis PROCEDURE 1 Attempted laparoscopic cholecystectomy 2 Open cholecystectomy ANESTHESIA General endotracheal anesthesia COUNTS Correct COMPLICATIONS None apparent ESTIMATED BLOOD LOSS 275 mL SPECIMENS 1 Gallbladder 2 Lymph node DRAINS One 19 French round Blake DESCRIPTION OF THE OPERATION After consent was obtained and the patient was properly identified the patient was transported to the operating room and after induction of general endotracheal anesthesia the patient was prepped and draped in a normal sterile fashion After infiltration with local a vertical incision was made at the umbilicus and utilizing graspers the underlying fascia was incised and was divided sharply Dissecting further the peritoneal cavity was entered Once this done a Hasson trocar was secured with 1 Vicryl and the abdomen was insufflated without difficulty A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space A second trocar was placed in the standard fashion in the subxiphoid area this was a 10 12 mm non bladed trocar Once this was done a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin this was a 5 mm port placed it was non bladed and placed in the usual fashion under direct visualization without difficulty A grasper was used to mobilize free the omentum which was acutely friable and after a significant time consuming effort was made to mobilize the omentum it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open The trocars were removed and a right subcostal incision was made incorporating the 10 12 subxiphoid port The subcutaneous space was divided with electrocautery as well as the muscles and fascia The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space Then utilizing a right angle and electrocautery the omentum was freed from the gallbladder An ensuing retrograde cholecystectomy was performed in which electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa this was done down to the infundibulum After meticulous dissection the cystic artery was identified and it was ligated between 3 0 silks Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified was skeletonized and a 3 0 stick tie was placed on the proximal portion of it After it was divided the gallbladder was freed from the field Once this was done the liver bed was inspected for hemostasis and this was achieved with electrocautery Copious irrigation was also used A 19 French Blake drain was placed in Morrison s pouch lateral to the gallbladder fossa and was secured in place with 2 0 nylon this was a 19 French round Blake Once this was done the umbilical port was closed with 1 Vicryl in an interrupted fashion and then the wound was closed in two layers with 1 Vicryl in an interrupted fashion The skin was closed with and absorbable stitch The patient was then awakened from anesthesia extubated and transported to the recovery room in stable condition Keywords surgery cholelithiasis cholecystitis gangrenous cholecystectomy laparoscopic gallbladder blake omentum hasson electrocautery gallbladder fossa endotracheal subhepatic french MEDICAL_TRANSCRIPTION,Description Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy Medical Specialty Surgery Sample Name Cholangiopancreatography Endoscopic Transcription PROCEDURE Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy INDICATION FOR THE PROCEDURE Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis with a recent upper endoscopy showing an abnormal appearing ampulla MEDICATIONS General anesthesia The risks of the procedure were made aware to the patient and consisted of medication reaction bleeding perforation aspiration and post ERCP pancreatitis DESCRIPTION OF PROCEDURE After informed consent and appropriate sedation the duodenoscope was inserted into the oropharynx down the esophagus and into the stomach The scope was then advanced through the pylorus to the ampulla The ampulla had a markedly abnormal appearance as it was enlarged and very prominent It extended outward with an almost polypoid shape It had what appeared to be adenomatous appearing mucosa on the tip There also was ulceration noted on the tip of this ampulla The biliary and pancreatic orifices were identified This was located not at the tip of the ampulla but rather more towards the base Cannulation was performed with a Wilson Cooke TriTome sphincterotome with easy cannulation of the biliary tree The common bile duct was mildly dilated measuring approximately 12 mm The intrahepatic ducts were minimally dilated There were no filling defects identified There was felt to be a possible stricture within the distal common bile duct but this likely represented an anatomic variant given the abnormal shape of the ampulla The patient has no evidence of obstruction based on lab work and clinically Nevertheless it was decided to proceed with brush cytology of this segment This was done without any complications There was adequate drainage of the biliary tree noted throughout the procedure Multiple efforts were made to access the pancreatic ductal anatomy however because of the shape of the ampulla this was unsuccessful Efforts were made to proceed in a long scope position but still were unsuccessful Next biopsies were obtained of the ampulla away from the biliary orifice Four biopsies were taken There was some minor oozing which had ceased by the end of the procedure The stomach was then decompressed and the endoscope was withdrawn FINDINGS 1 Abnormal papilla with bulging polypoid appearance and looks adenomatous with ulceration on the tip biopsies taken 2 Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture although I think this is likely an anatomic variant brush cytology obtained 3 Unable to access the pancreatic duct RECOMMENDATIONS 1 NPO except ice chips today 2 Will proceed with MRCP to better delineate pancreatic ductal anatomy 3 Follow up biopsies and cytology Keywords surgery cholangiogram ercp endoscopic endoscopic retrograde cholangiopancreatography mrcp wilson cooke tritome sphincterotome abdominal pain ampulla bile duct brush cytology cholangiopancreatography pancreatitis papilla polypoid retrograde cholangiopancreatography cholangiopancreatography with brush cytology brush cytology and biopsy shape of the ampulla pancreatic ductal anatomy common bile duct cannulation brush pancreatic cytology MEDICAL_TRANSCRIPTION,Description Resection of left chest wall tumor partial resection of left diaphragm left lower lobe lung wedge resection left chest wall reconstruction with Gore Tex mesh Medical Specialty Surgery Sample Name Chest Wall Tumor Resection Transcription PREOPERATIVE DIAGNOSIS Left chest wall tumor spindle cell histology POSTOPERATIVE DIAGNOSIS Left chest wall tumor spindle cell histology with pathology pending PROCEDURE Resection of left chest wall tumor partial resection of left diaphragm left lower lobe lung wedge resection left chest wall reconstruction with Gore Tex mesh ANESTHESIA General endotracheal SPECIMEN Left chest wall with tumor and left lower lobe lung wedge resection to pathology INDICATIONS FOR PROCEDURE The patient is a 79 year old male who began to experience back pain approximately 2 years ago which increased Chest x ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening A biopsy was performed at an outside hospital Kaiser and pathology was consistent with mesothelioma The patient had a metastatic workup which was negative including a brain MRI and bone scan The bone scan showed only signal positivity in the left 9th rib near the tumor The patient has a significant past medical history consisting of coronary artery disease hypertension non insulin dependent diabetes longstanding atrial fibrillation anemia and hypercholesterolemia He and his family were apprised of the high risk nature of this surgery preoperatively and informed consent was obtained PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position The patient was intubated with a double lumen endotracheal tube Intravenous antibiotics were given A Foley catheter was placed The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass The skin and subcutaneous tissues were dissected sharply with the electrocautery Good hemostasis was obtained The tumor was easily palpable and clearly involving the 8th to 9th rib A thoracotomy was initially made above the mass in approximately the 7th intercostal space Inspection of the pleural cavity revealed multiple adhesions which were taken down with a combination of blunt and sharp dissection The thoracotomy was extended anteriorly and posteriorly It was clear that in order to obtain an adequate resection of the tumor approximately 4 rib segment of the chest wall would need to be resected The ribs of the chest wall were first cut at their anterior aspect The ribs 7 8 9 and 10 were serially transected after the interspaces were dissected with electrocautery Hemostasis was obtained with both electrocautery and clips The chest wall segment to be resected was retracted laterally and posteriorly It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement Inferiorly the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor The spleen and the stomach were identified and were protected Inferiorly the resection of the chest wall was continued in the 10th interspace The dissection was then carried posteriorly to the level of the spine The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe which provided a complete resection of all palpable and visible tumor in the lung A 2 0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection Posteriorly the chest wall segment was noted to have an area at the level of approximately T8 and T9 where the tumor involved the vertebral bodies The ribs were disarticulated closed to or at their articulations with the spine Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery There was no disease grossly involving or encasing the aorta The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section The specimen was oriented for the pathologist who came to the room Hemostasis was obtained The vent in the diaphragm was then closed primarily with a series of figure of 8 1 Ethibond sutures This produced a satisfactory diaphragmatic repair without undue tension A single 32 French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly This was secured with a 1 silk suture The Gore Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect A series of 1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually The resulting mesh closure was snug and deemed adequate The serratus muscle was reapproximated with figure of 8 0 Vicryl The latissimus was reapproximated with a two 1 Vicryl placed in running fashion Of note two 10 JP drains were placed over the mesh repair of the chest wall The subcutaneous tissues were closed with a running 3 0 Vicryl suture and the skin was closed with a 4 0 Monocryl The wounds were dressed The patient was brought from the operating room directly to the North ICU intubated in stable condition All counts were correct Keywords surgery chest wall tumor resection diaphragm left lower lobe lung wedge resection chest wall reconstruction chest wall segment gore tex mesh chest wall tumor chest wall pleural cavity lower lobe wedge resection resection tumor wall chest anesthesia electrocautery wedge mesh lung MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with cholangiogram Medical Specialty Surgery Sample Name Cholecystectomy Cholangiogram Transcription PREOPERATIVE DIAGNOSES 1 Cholelithiasis 2 Acute cholecystitis POSTOPERATIVE DIAGNOSES 1 Acute on chronic cholecystitis 2 Cholelithiasis PROCEDURE PERFORMED Laparoscopic cholecystectomy with cholangiogram ANESTHESIA General INDICATIONS This is a 38 year old diabetic Hispanic female patient with ongoing recurrent episodes of right upper quadrant pain associated with nausea Ultrasound revealed cholelithiasis The patient also had somewhat thickened gallbladder wall The patient was admitted through emergency room last night with acute onset right upper quadrant pain Clinically it was felt the patient had acute cholecystitis Laparoscopic cholecystectomy with cholangiogram was advised Procedure indication risk and alternative were discussed with the patient in detail preoperatively and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was put in supine position on the operating table under satisfactory general anesthesia and abdomen was prepped and draped A small transverse incision was made just above the umbilicus under local anesthesia Fascia was opened vertically Stay sutures were placed in the fascia Peritoneal cavity was carefully entered Hasson cannula was inserted and peritoneal cavity was insufflated with CO2 Laparoscopic camera was inserted and the patient was placed in reverse Trendelenburg rotated to the left A 11 mm trocar was placed in the subxiphoid space and two 5 mm in the right subcostal region Examination at this time showed no free fluid no acute inflammatory changes Liver was grossly normal Gallbladder was noted to be thickened Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema consistent with acute cholecystitis The fundus of the gallbladder was retracted superiorly and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated It was clipped distally and using C arm fluoroscopy intraoperative cystic duct cholangiogram was done which was interpreted as normal There was slight dilatation noted at the junction of the right and left hepatic duct but no filling defects or any other pathology was noted It was presumed that this was probably a congenital anomaly The cystic duct was clipped twice proximally and divided beyond the clips Cystic artery was identified isolated clipped twice proximally once distally and divided The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port Specimen was sent for histopathology Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution Hemostasis was good Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2 Umbilical area fascia was closed with 0 Vicryl figure of eight sutures required extra sutures to close the fascial defect Some difficulty was encountered closing the fascia initially because of the patient s significant amount of subcutaneous fat In the end the repair appears to be quite satisfactory Rest of the incisions closed with 3 0 Vicryl for the subcutaneous tissues and staples for the skin Sterile dressing was applied The patient transferred to recovery room in stable condition Keywords surgery cholelithiasis acute cholecystitis laparoscopic cholecystectomy cholangiogram laparoscopic cholecystectomy gallbladder MEDICAL_TRANSCRIPTION,Description Left pleural effusion parapneumonic loculated Left chest tube placement Medical Specialty Surgery Sample Name Chest Tube Placement Transcription PREOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated POSTOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated OPERATION Left chest tube placement IV SEDATION 5 mg of Versed total given under pulse ox monitoring 1 lidocaine local infiltration PROCEDURE With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion A 1 lidocaine was liberally infiltrated into the skin subcutaneous tissue deep fascia and the anterior axillary line just below the level of the nipple The incision was made and deepened through the different layers to reach the intercostal space The pleura was entered on top of the underlying rib and finger digital palpation was performed Multiple loculations were encountered Break up of loculations was performed posteriorly and a chest tube was directed posteriorly Only a small amount of fluid was noted to come out initially This was sent for various studies Soft adhesions were encountered The plan was to obtain a chest x ray and start Activase installation Keywords surgery activase chest tube placement pleural effusion chest tube lidocaine infiltration parapneumonic loculated pleural chest MEDICAL_TRANSCRIPTION,Description Delayed primary chest closure Open chest status post modified stage 1 Norwood operation The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Medical Specialty Surgery Sample Name Chest Closure Transcription PROCEDURE Delayed primary chest closure INDICATIONS The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Given the magnitude of the operation and the size of the patient 2 5 kg we have elected to leave the chest open to facilitate postoperative management He is now taken back to the operative room for delayed primary chest closure PREOP DX Open chest status post modified stage 1 Norwood operation POSTOP DX Open chest status post modified stage 1 Norwood operation ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma He tolerated the procedure well DETAILS OF PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position Following general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion The previously placed AlloDerm membrane was removed Mediastinal cultures were obtained and the mediastinum was then profusely irrigated and suctioned Both cavities were also irrigated and suctioned The drains were flushed and repositioned Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line The sternum was then smeared with a vancomycin paste The proximal aspect of the 5 mm RV PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches The skin was closed with interrupted nylon sutures and a sterile dressing was placed The peritoneal dialysis catheter atrial and ventricular pacing wires were removed The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Keywords surgery open chest stage 1 norwood operation hypoplastic left heart syndrome delayed primary chest closure chest closure norwood operation MEDICAL_TRANSCRIPTION,Description Removal of chest wall mass The area of the mass which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected Medical Specialty Surgery Sample Name Chest Wall Mass Removal Transcription PREOPERATIVE DIAGNOSIS Chest wall mass left POSTOPERATIVE DIAGNOSIS Chest wall mass left PROCEDURE Removal of chest wall mass DESCRIPTION OF PROCEDURE After obtaining the informed consent the patient was brought to the operating room where he underwent a general endotracheal anesthetic The time out process was followed and preoperative antibiotics were given The patient was in the supine position and was prepped and draped in the usual fashion The area of the mass which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected An incision was made directly on the mass and carried down to the ribs This is where the several chondral cartilages of the lower ribs meet So I believe they were isolated in 9th rib anteriorly and I was able to encircle it The medial area was __________ There was no way to perform same procedure there so what I did I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs There was also a separate sharp growth of the mass growing superiorly Apparently I was able to excise the mass and actually it was much larger than it was palpated externally This may be due to an extension towards the inside of his chest Hemostasis was revised The internal mammary was intact and there was no obvious penetration of the pleural cavity The specimen was sent to Pathology and then we proceeded to close the defect Obviously the space between the ribs cannot be approximated So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl The patient tolerated the procedure well Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition Keywords surgery chest wall mass local anesthetic lower ribs chest wall mass cartilages wall chest ribs MEDICAL_TRANSCRIPTION,Description Chest tube insertion done by two physicians in ER spontaneous pneumothorax secondary to barometric trauma Medical Specialty Surgery Sample Name Chest Tube Insertion in ER Transcription PREOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis POSTOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis INFORMED CONSENT Not obtained This patient is obtunded intubated and septic This is an emergent procedure with 2 physician emergency consent signed and on the chart PROCEDURE The patient s right chest was prepped and draped in sterile fashion The site of insertion was anesthetized with 1 Xylocaine and an incision was made Blunt dissection was carried out 2 intercostal spaces above the initial incision site The chest wall was opened and a 32 French chest tube was placed into the thoracic cavity after examination with the finger making sure that the thoracic cavity had been entered correctly The chest tube was placed A postoperative chest x ray is pending at this time The patient tolerated the procedure well and was taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 10 mL COMPLICATIONS None SPONGE COUNT Correct x2 Keywords surgery spontaneous pneumothorax barometric trauma respiratory failure sepsis pneumonia blunt dissection chest wall thoracic cavity chest x ray chest tube insertion chest tube pneumothorax tube chest insertion MEDICAL_TRANSCRIPTION,Description Right hemothorax Insertion of a 32 French chest tube on the right hemithorax This is a 54 year old female with a newly diagnosed carcinoma of the cervix The patient is to have an Infuse A Port insertion Medical Specialty Surgery Sample Name Chest Tube Insertion Transcription PREOPERATIVE DIAGNOSIS Right hemothorax POSTOPERATIVE DIAGNOSIS Right hemothorax PROCEDURE PERFORMED Insertion of a 32 French chest tube on the right hemithorax ANESTHESIA 1 Lidocaine and sedation INDICATIONS FOR PROCEDURE This is a 54 year old female with a newly diagnosed carcinoma of the cervix The patient is to have an Infuse A Port insertion today Postoperatively from that she started having a blood tinged pink frothy sputum Chest x ray was obtained and showed evidence of a hemothorax on the right hand side opposite side of the Infuse A Port and a wider mediastinum The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room DESCRIPTION OF PROCEDURE The area was prepped and draped in the sterile fashion The area was anesthetized with 1 Lidocaine solution The patient was given sedation A 10 blade scalpel was used to make an incision approximately 1 5 cm long Then a curved scissor was used to dissect down to the level of the rib A blunt peon was then used to again enter into the right hemithorax Immediately a blood tinged effusion was released The chest tube was placed and directed in a posterior and superior direction The chest tube was hooked up to the Pleur evac device which was ________ tip suction The chest tube was tied in with a 0 silk suture in a U stitch fashion It was sutured in place with sterile dressing and silk tape The patient tolerated this procedure well We will obtain a chest x ray in postop to ensure proper placement and continue to follow the patient very closely Keywords surgery hemothorax hemithorax pleur evac device infuse a port insertion chest tube carcinoma MEDICAL_TRANSCRIPTION,Description Bilateral pleural effusion Removal of bilateral 32 French chest tubes with closure of wound Medical Specialty Surgery Sample Name Chest Tube Removal Transcription PREOPERATIVE DIAGNOSIS Bilateral pleural effusion POSTOPERATIVE DIAGNOSIS Bilateral pleural effusion PROCEDURE PERFORMED Removal of bilateral 32 French chest tubes with closure of wound COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 66 year old African American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts this necessitated to close the wounds with sutures The patient was agreeable to proceed OPERATIVE PROCEDURE The patient was prepped and draped at the bedside over both chest tube sites The pressures applied over the sites and the skin was closed with interrupted 3 0 Ethilon sutures The skin was then cleansed and Vaseline occlusive dressing was applied over the sites The same procedure was performed on the other side The chest tubes were removed on full inspiration Vital signs remained stable throughout the procedure The patient will remain in the intensive care unit for continued monitoring Keywords surgery serous drainage bilateral pleural effusion pleural effusion chest tubes effusion pleural chest MEDICAL_TRANSCRIPTION,Description Repeat low transverse cesarean section bilateral tubal ligation BTL extensive anterior abdominal wall uterine bladder adhesiolysis Term pregnancy and desires permanent sterilization Medical Specialty Surgery Sample Name Cesarean Section BTL Transcription PREOPERATIVE DIAGNOSES 1 Term pregnancy 2 Desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Term pregnancy 2 Desires permanent sterilization PROCEDURE 1 Repeat low transverse cesarean section 2 Bilateral tubal ligation 3 Extensive anterior abdominal wall uterine bladder adhesiolysis ANESTHESIA Spinal epidural with good effect FINDINGS Delivered vigorous male infant from cephalic presentation Apgars 9 9 Birth weight 6 pounds 14 ounces Infant suctioned with a bulb upon delivery of the head and body Cord clamped and cut and infant passed to pediatric team present Complete placenta manually extracted intact with three vessel cord Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision In addition the bladder was involved in adhesion mass complex A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries Bilateral tubal ligation performed without difficulty via Parkland technique ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS None URINE OUTPUT Per anesthesia records Urine cleared postoperatively IV FLUIDS Per anesthesia records The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs OPERATIVE TECHNIQUE The patient was placed in a supine position after spinal epidural anesthesia She was prepped and draped in the usual manner for repeat cesarean section A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife This incision was extended laterally with Mayo scissors Dense fibromuscular layer was encountered from the patient s previous surgeries Upon entry incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision Fascia was previously separated superiorly and inferiorly from the muscular layer A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall Inferiorly difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall These adhesions likewise were surgically transacted via sharp blunt and electrocautery dissection This was successfully done without anterior entry into the bladder Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus The uterus was then incised using a sharp knife and low transverse incision This was extended with bandage scissors The infant was delivered easily from a cephalic presentation Bulb suction was done following delivery of the head and body The cord clamped and cut and the infant passed to pediatric team present Cord segment and cord blood was obtained Complete placenta manually extracted intact with three vessel cord Vigorous male infant Apgars 9 9 weight 6 pounds 14 ounces Complete placenta with three vessels retrieved Uterus was exteriorized from the abdominal cavity Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining Pennington clamps placed at the uterine incision angles and the inferior incision lip A 1 chromic suture closed the uterus in running continuous interlocking closure Good hemostasis upon completion of the closure Laparotomy pads placed in the posterior cul de sac to remove any blood or clots The uterus was returned to the abdominal cavity after using 1 chromic suture to close the anterior uterine incision that was partial thickness through the serosal end of the muscular layer at midline adhesion This was closed with chromic suture in a running continuous interlocking closure with good hemostasis Attention was then focused on the bilateral tubal ligation Babcock clamp placed in the mid fallopian tube and elevated Cautery was used to make a window in the avascular segment of the mesosalpinx Proximal and distal 1 chromic suture ligation with mid fallopian tube transection performed The ligated proximal and distal stumps were then cauterized with Bovie cautery This tubal ligation procedure was done in a bilateral fashion Upon completion of tubal ligation uterus was returned to the abdominal cavity Left and right gutters examined and found to be clean and dry Evaluation of the low uterine segment incision revealed continued hemostasis Oozing was encountered in the inferior bladder of dissection and 2 0 chromic suture in running continuous fashion partial thickness of the bladder to control the oozing at this site was successfully done Interceed was then placed on the low uterine incision and the low anterior uterine aspect The midline rectus including peritoneum was re approximated with simple interrupted chromic sutures Irrigation of the muscular layer with good hemostasis noted The fascia was closed with 1 Vicryl in a running continuous closure Subcutaneous tissue was irrigated additional hemostasis with Bovie cautery The skin was closed with staples Keywords surgery term pregnancy sterilization low transverse cesarean section bilateral tubal ligation adhesiolysis anterior uterus abdominal cavity cesarean section chromic suture tubal ligation adhesions uterus abdominal infant anterior cesarean hemostasis chromic uterine MEDICAL_TRANSCRIPTION,Description Laparoscopic resection of cecal polyp Local anesthetic was infiltrated into the right upper quadrant where a small incision was made Blunt dissection was carried down to the fascia which was grasped with Kocher clamps Medical Specialty Surgery Sample Name Cecal Polyp Resection Transcription PREOPERATIVE DIAGNOSIS Cecal polyp POSTOPERATIVE DIAGNOSIS Cecal polyp PROCEDURE Laparoscopic resection of cecal polyp COMPLICATIONS None ANESTHESIA General oral endotracheal intubation PROCEDURE After adequate general anesthesia was administered the patient s abdomen was prepped and draped aseptically Local anesthetic was infiltrated into the right upper quadrant where a small incision was made Blunt dissection was carried down to the fascia which was grasped with Kocher clamps A bladed 11 mm port was inserted without difficulty Pneumoperitoneum was obtained using C02 Under direct vision 2 additional non bladed 11 mm trocars were placed one in the left lower quadrant and one in the right lower quadrant There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice The appendix was somewhat retrocecal in position but otherwise looked normal The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye There was enough however in the wall to identify the location of the polyp The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely The specimen was then removed through the 12 mm port and examined on the back table The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon This new staple line was then opened on the back table and examined There was some residual polypoid material noted but the margins this time appeared to be clear The peritoneal cavity was then lavaged with antibiotic solution There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery The trocars were removed under direct vision No bleeding was noted The bladed trocar site was closed using a figure of eight O Vicryl suture All skin incisions were closed with running 4 0 Monocryl subcuticular sutures Mastisol and Steri Strips were placed followed by sterile Tegaderm dressing The patient tolerated the procedure well without any complications Keywords surgery polyp laparoscopic resection blunt dissection kocher clamps ileocecal valve gia stapler peritoneal cavity cecal polyp infiltrated anesthetic MEDICAL_TRANSCRIPTION,Description Right subclavian triple lumen central line placement Medical Specialty Surgery Sample Name Central Line Placement Transcription PREOPERATIVE DIAGNOSIS 1 Severe chronic obstructive coronary disease 2 Respiratory failure POSTOPERATIVE DIAGNOSIS 1 Severe chronic obstructive coronary disease 2 Respiratory failure OPERATION Right subclavian triple lumen central line placement ANESTHESIA Local Xylocaine INDICATIONS FOR OPERATION This 50 year old gentleman with severe respiratory failure is mechanically ventilated He is currently requiring multiple intravenous drips and Dr X has kindly requested central line placement INFORMED CONSENT The patient was unable to provide his own consent secondary to mechanical ventilation and sedation No available family to provide conservator ship was located either PROCEDURE With the patient in his Intensive Care Unit bed mechanically ventilated in the Trendelenburg position The right neck was prepped and draped with Betadine in a sterile fashion Single needle stick aspiration of the right subclavian vein was accomplished without difficulty and the guide wire was advanced The dilator was advanced over the wire The triple lumen catheter was cannulated over the wire and the wire then removed No PVCs were encountered during the procedure All three ports to the catheter aspirated and flushed blood easily and they were all flushed with normal saline The catheter was anchored to the chest wall with butterfly phalange using 3 0 silk suture Betadine ointment and a sterile Op Site dressing were applied Stat upright chest x ray was obtained at the completion of the procedure and final results are pending FINDINGS SPECIMENS REMOVED None COMPLICATIONS None ESTIMATED BLOOD LOSS Nil Keywords surgery respiratory failure central line placement chronic obstructive coronary disease normal saline subclavian subclavian triple lumen central line placement subclavian vein triple lumen triple lumen central line lumen central line placement central line line placement respiratory xylocaine MEDICAL_TRANSCRIPTION,Description Insertion of central venous line and arterial line and transesophageal echocardiography probe Medical Specialty Surgery Sample Name Central Venous Arterial Line Transcription INDICATIONS FOR PROCEDURES Impending open heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure The patient was already under general anesthesia in the operating room Antibiotic prophylaxis with cephazolin and gentamicin were already given A strict aseptic technique was used including use of gowns mask and gloves etc The skin was cleansed with alcohol and then prepped with ChloraPrep solution PROCEDURE 1 Insertion of central venous line DESCRIPTION OF PROCEDURE 1 Attention was directed to the right groin A Cook 4 French double lumen 12 cm long central venous heparin coated catheter kit was opened Using the 21 gauge needle that comes with this kit the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery There was good venous blood return on the first try Using the Seldinger technique the soft J end of the wire was inserted through the needle without resistance approximately 15 cm It was then exchanged for a 5 French dilator followed by the 4 French double lumen catheter and the wire was removed intact There was good blood return from both lumens which were flushed with heparinized saline The catheter was sutured to the skin at three points with 4 0 silk for stabilization PROCEDURE 2 Insertion of arterial line DESCRIPTION OF PROCEDURE 2 Attention was directed to the left wrist which was placed on wrist rest The Allen test was normal A Cook 2 5 French 5 cm long arterial catheter kit was opened A 22 gauge IV cannula was used to enter the artery which was done on the first try with good pulsatile blood return Using the Seldinger technique the catheter was exchanged for a 2 5 French catheter and the wire was removed intact There was pulsatile blood return and the catheter was flushed with heparinized saline solution It was sutured to the skin with 4 0 silk at three points for stabilization Both catheters functioned well throughout the procedure The distal circulation of the leg and the hand was intact immediately after insertion approximately 20 minutes later and at the end of the procedure There were no complications PROCEDURE 3 Insertion of transesophageal echocardiography probe DESCRIPTION OF PROCEDURE 3 The probe was inserted under direct vision because initially there was some resistance to insertion Under direct vision using the 2 Miller blade the upper esophageal opening was visualized and the probe was passed easily without resistance There was good visualization of the heart The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography The probe was removed at the end There was no trauma and there was no blood tingeing Keywords surgery open heart surgery central venous line arterial line transesophageal echocardiography probe glenn procedure atrial septectomy aseptic technique pulsatile blood central venous blood return arterial central probe insertion catheter MEDICAL_TRANSCRIPTION,Description Central line insertion Empyema thoracis and need for intravenous antibiotics Medical Specialty Surgery Sample Name Central Line Insertion Transcription PREOPERATIVE DIAGNOSES 1 Empyema thoracis 2 Need for intravenous antibiotics POSTOPERATIVE DIAGNOSES 1 Empyema thoracis 2 Need for intravenous antibiotics PROCEDURE Central line insertion DESCRIPTION OF PROCEDURE With the patient in his room after obtaining the informed consent his left deltopectoral area was prepped and draped in the usual fashion Xylocaine 1 was infiltrated and with the patient in the Trendelenburg position the left subclavian vein was subcutaneously cannulated without any difficulty The triple lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline The catheter was fixed to the skin with sutures The dressing was applied and then the chest x ray was obtained which showed no complications of the procedure and good position of the catheter Keywords surgery thoracis intravenous central line insertion empyema catheter MEDICAL_TRANSCRIPTION,Description Cauterization of epistaxis left nasal septum Fiberoptic nasal laryngoscopy Atrophic dry nasal mucosa Epistaxis Atrophic laryngeal changes secondary to inhaled steroid use Medical Specialty Surgery Sample Name Cauterization Epistaxis Transcription PREOPERATIVE DIAGNOSIS Epistaxis and chronic dysphonia POSTOPERATIVE DIAGNOSES 1 Atrophic dry nasal mucosa 2 Epistaxis 3 Atrophic laryngeal changes secondary to inhaled steroid use PROCEDURE PERFORMED 1 Cauterization of epistaxis left nasal septum 2 Fiberoptic nasal laryngoscopy ANESTHESIA Neo Synephrine with lidocaine nasal spray FINDINGS 1 Atrophic dry cracked nasal mucosa 2 Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation INDICATIONS The patient is a 37 year old African American female who was admitted to ABCD General Hospital with a left wrist abscess The patient was taken to the operating room for incision and drainage Postoperatively the patient was placed on nasal cannula oxygen and developed subsequent epistaxis Upon evaluating the patient the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery The patient does report of having endotracheal tube intubation during anesthesia The patient also gives a history of inhaled steroid use for her asthma The patient was extubated after surgery without difficulty but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia PROCEDURE DETAILS After the procedure was described the patient was placed in the seated position The fiberoptic nasal laryngoscope was then inserted into the patient s left naris The nasal mucosal membranes were dry and atrophic throughout There was no evidence of any mass lesions The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity There was no evidence of mass ulceration lesion or obstruction The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic dry supraglottic and glottic changes There was no evidence of any local mass lesion nodule or ulcerations There was no evidence of any erythema Upon phonation the vocal cords approximated completely and upon inspiration the true vocal cords were abducted in a normal fashion and was symmetric The airway was stable and patent throughout the entire examination The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx The eustachian tube was completely visualized and was patent without obstruction The scope was then further removed without difficulty The patient tolerated the procedure well and remained in stable condition RECOMMENDATIONS AND PLAN The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris At this time we were unable to discontinue the patient s inhaled steroids that she is using for her asthma If this becomes possible in the future this may provide her some relief of her chronic dysphonia The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems Keywords surgery laryngeal inhaled steroid use dry nasal mucosa fiberoptic nasal laryngoscopy nasal mucosa atrophic cauterization mucosa supraglottic laryngoscope fiberoptic dysphonia lesions epistaxis MEDICAL_TRANSCRIPTION,Description Ultrasound guided placement of multilumen central venous line left femoral vein Medical Specialty Surgery Sample Name Catheter Placement Transcription PROCEDURE PERFORMED Ultrasound guided placement of multilumen central venous line left femoral vein INDICATIONS Need for venous access in a patient on a ventilator and on multiple IV drugs CONSENT Consent obtained from patient s sister PREOPERATIVE MEDICATIONS Local anesthesia with 1 plain lidocaine PROCEDURE IN DETAIL The ultrasound was used to localize the left femoral vein and to confirm it s patency and course The left inguinal area was then prepped and draped in a sterile manner The overlying soft tissues were anesthetized with 1 plain lidocaine Under direct ultrasound visualization the femoral vein was cannulated without difficulty and a guidewire advanced This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself Finally the multilumen catheter itself was inserted over the guidewire Once the catheter was fully inserted the guidewire was completely withdrawn Placement was confirmed by the withdrawal of dark venous blood from all ports all ports were then flushed the catheter sewn into place and the dressing applied He tolerated the procedure very well without complications Keywords surgery plain lidocaine femoral vein ultrasound venous femoral guidewire placement vein catheter access MEDICAL_TRANSCRIPTION,Description Temporal cheek neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek neck and jowl lipotosis and facial rhytides Medical Specialty Surgery Sample Name Cheek Neck Facelift Transcription PREOPERATIVE DIAGNOSIS Facial and neck skin ptosis Cheek neck and jowl lipotosis Facial rhytides POSTOPERATIVE DIAGNOSIS Same PROCEDURE Temporal cheek neck facelift CPT 15825 Submental suction assisted lipectomy CPT 15876 ANESTHESIA General DESCRIPTION OF PROCEDURE This patient is a 65 year old female who has progressive aging changes of the face and neck The patient demonstrates the deformities described above and has requested surgical correction The procedure risks limitations and alternatives in this individual case have been very carefully discussed with the patient The patient has consented to surgery The patient was brought into the operating room and placed in the supine position on the operating table An intravenous line was started and anesthesia was maintained throughout the case The patient was monitored for cardiac blood pressure and oxygen saturation continuously The hair was prepared and secured with rubber bands and micropore tape along the incision line A marking pen had been used to outline the area of the incisions which included the preauricular area to the level of the tragus the post tragal region the post auricular region and into the hairline In addition the incision was marked in the temporal area in the event of a temporal lift then across the coronal scalp for the forehead lift The incision was marked in the submental crease for the submental lipectomy and liposuction The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline The areas to be operated on were injected with 1 Lidocaine containing 1 100 000 Epinephrine This provided local anesthesia and vasoconstriction The total of Lidocaine used throughout the procedure was maintained at no more than 500mg SUBMENTAL SUCTION ASSISTED LIPECTOMY The incision was made as previously outlined in the submental crease in a transverse direction through the skin and subcutaneous tissue and hemostasis was obtained with bipolar cautery A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly The tunnels were enlarged with a 6mm flat liposuction cannula Then with the Wells Johnson liposuction machine 27 29 inches of underwater mercury suction was accomplished in all tunnels Care was taken not to turn the opening of the suction cannula up to the dermis but it was rotated in and out taking a symmetrical amount of fat from each area A similar procedure was performed with the 4 mm cannula cleaning the area Bilateral areas were palpated for symmetry and any remaining fat was then suctioned directly A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle A plication stitch of 3 0 Vicryl was placed When a satisfactory visible result had been accomplished from the liposuction the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion 5 0 plain catgut was used for closure in a running interlocking fashion The wound was cleaned at the end dried and Mastisol applied Then tan micropore tape was placed for support to the entire area FACE LIFT After waiting approximately 10 15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal A gentle curve was then made and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region A preauricular incision was carried into the natural crease superior to the tragus curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin The incision was made in the temporal area beveling parallel with the hair follicles The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim At the superior level of the zygoma and at the level of the sideburn dissection was brought more superficially in order to avoid the nerves and vessels in the areas specifically the frontalis branch of the facial nerve The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8 10cm in the neck region When the areas of dissection had been connected carefully hemostasis was obtained and all areas inspected At no point were muscle fibers or major vessels or nerves encountered in the dissection The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM The SMAS flap was then advanced posteriorly and superiorly The SMAS was split at the level of the earlobe and the inferior portion was sutured to the mastoid periosteum The excess SMAS was trimmed and excised from the portion anterior to the auricle The SMAS was then imbricated with 2 0 Surgidak interrupted sutures The area was then inspected for any bleeding points and careful hemostasis obtained The flaps were then rotated and advanced posteriorly and then superiorly and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2 0 Tycron suture The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period Skin closure was accomplished in the hairbearing areas with 5 0 Nylon in the preauricular tuft and 4 0 Nylon interrupted in the post auricular area The pre auricular area was closed first with 5 0 Dexon at the ear lobules and 6 0 Nylon at the lobules and 5 0 plain catgut in a running interlocking fashion 5 0 Plain catgut was used in the post auricular area as well leaving ample room for serosanguinous drainage into the dressing The post tragal incisin was closed with interrupted and running interlocking 5 0 plain catgut The exact similar procedure was repeated on the left side At the end of this procedure all flaps were inspected for adequate capillary filling or any evidence of hematoma formation Any small amount of fluid was expressed post auricularly A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines ABD padding over 4X4 gauze was used to cover the pre and post auricular areas This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non constricting but secured fashion The entire dressing complex was secured with a pre formed elastic stretch wrap device All branches of the facial nerve were checked and appeared to be functioning normally The procedures were completed without complication and tolerated well The patient left the operating room in satisfactory condition A follow up appointment was scheduled routine post op medications prescribed and post op instructions given to the responsible party The patient was released to home in satisfactory condition Keywords surgery neck skin ptosis lipotosis rhytides facelift submental suction assisted lipectomy pre and post auricular cheek neck facelift auricular region neck facelift cheek neck post auricular auricular incision postoperative cheek submental dissection neck MEDICAL_TRANSCRIPTION,Description Refractory priapism Cavernosaphenous shunt The patient presented with priapism x48 hours on this visit The patient underwent corporal aspiration and Winter s shunt both of which failed Medical Specialty Surgery Sample Name Cavernosaphenous Shunt Priapism Transcription PREOPERATIVE DIAGNOSIS Refractory priapism POSTOPERATIVE DIAGNOSIS Refractory priapism PROCEDURE PERFORMED Cavernosaphenous shunt ANESTHESIA General ESTIMATED BLOOD LOSS 400 cc FLUIDS IV fluids 1600 crystalloids one liter packed red blood cells INDICATIONS FOR PROCEDURE This is a 34 year old African American male who is known to our service with a history of recurrent priapism The patient presented with priapism x48 hours on this visit The patient underwent corporal aspiration and Winter s shunt both of which failed and then subsequently underwent _______ procedure The patient s priapism did return following this and he was scheduled for cavernosaphenous shunt PROCEDURE Informed written consent was obtained The patient was taken to the operative suite and administered anesthetic The patient was sterilely prepped and draped in the supine fashion A 15 French Foley catheter was inserted under sterile conditions Incision was made in the left base of the penile shaft on the lateral aspect approximately 3 cm in length Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum The fascia was incised in elliptical fashion for approximately 2 cm A 14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted Attention was then turned to the left groin and the superficial saphenous vein was harvested Due to incisions brought up into the initial incision after gauging enough length this was then spatulated with Potts scissors for approximately 2 cm Vein was irrigated One branching vessel was noted to be leaking this was tied off and repeat injection with heparinized saline showed no additional leaks Tunnel was then created from the superior most groin region to the incision in the penile shaft Saphenous vein was then passed through this tunnel with the aid of a hemostat Anastomosis was performed using 5 0 Prolene suture in a running fashion from proximal to distal There were no leaks noted There was good flow noted within the saphenous vein graft Penis was noted to be in a flaccid state All incisions were irrigated copiously and closed in several layers Sterile dressings were applied The patient was cleaned transferred to recovery room in stable condition PLAN We will continue with antibiotics for pain control maintain Foley catheter Further recommendations to follow Keywords surgery corporal aspiration winter s shunt foley catheter corpora cavernosum refractory priapism saphenous vein cavernosaphenous shunt corporal priapism aspiration MEDICAL_TRANSCRIPTION,Description Normal cataract surgery Medical Specialty Surgery Sample Name Cataract Surgery Transcription NORMAL CATARACT SURGERY PROCEDURE DETAILS The patient was taken to the operating room where the Rand Stein anesthesia protocol was followed using alfentanil and Brevital Topical tetracaine drops were applied The operative eye was prepped and draped in the usual sterile fashion A lid speculum was inserted Under the Zeiss operating microscope a lateral clear corneal approach was utilized A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic A 3 mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome A 5 to 5 5 mm anterior capsulorrhexis was created The nucleus was hydrodissected and hydrodelineated and was freely movable in the capsular bag The nucleus was then phacoemulsified using a quadrantic divide and conquer technique Following the deep groove formation the lens was split bimanually and the resultant quadrants and epicortex removed under high vacuum burst mode phacoemulsification Peripheral cortex was removed with the irrigation and aspiration handpiece The posterior capsule was polished The capsular bag was expanded with viscoelastic The implant was inspected under the microscope and found to be free of defects The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag The trailing haptic was positioned with the cartridge system Residual viscoelastic was removed from the anterior chamber and from behind the implant The corneal wound was hydrated with balanced salt solution The anterior chamber was fully re formed through the side port incision The wound was inspected and found to be watertight The intraocular pressure was adjusted as necessary The lid speculum was removed Topical Timoptic drops Eserine and Dexacidin ointment were applied The eye was shielded The patient appeared to tolerate the procedure well and left the operating room in stable condition Followup appointment is with Dr X on the first postoperative day Keywords surgery zeiss peripheral cortex phacoemulsified hydrodissected rand stein lid speculum anterior chamber capsular bag cataract viscoelasticNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens left eye Medical Specialty Surgery Sample Name Cataract Extraction 2 Transcription PREOPERATIVE DIAGNOSIS Cataract left eye POSTOPERATIVE DIAGNOSIS Cataract left eye PROCEDURE PERFORMED Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens left eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE After the induction of topical anesthesia with 4 Xylocaine drops the left eye was prepped and draped in the usual fashion A speculum was inserted and the microscope was moved into position A 3 2 mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o clock position and 0 1 cc of 1 Xylocaine without preservative was instilled into the anterior chamber It was then filled with viscoelastic A stab incision was made into the anterior chamber at the limbus at 5 o clock position with a microblade A cystitome was used to make a capsulotomy and the capsulorrhexis forceps were used to complete a circular capsulorrhexis The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26 gauge cannula and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision The irrigation aspiration handpiece was used to systematically aspirate cortex 360 degrees The posterior capsule was vacuumed it was clear and intact The capsular bag and the anterior chamber were filled with viscoelastic A model MA30AC lens power 21 5 diopters serial number 864414 095 was folded grasped with the lens insertion forceps and inserted into the capsular bag The trailing loop was placed inside the bag The viscoelastic was removed with the irrigation aspiration handpiece The lens centered well A single 10 0 nylon suture was placed to close the wound It was checked and ascertained to be watertight Decadron 0 25 cc 0 25 cc of antibiotic and 0 25 cc of Xylocaine were injected subconjunctivally Dexacidin ointment was placed in the eye and the procedure was terminated The procedure was well tolerated by the patient who was returned to the recovery room in good condition Keywords surgery anterior chamber keratome limbus intraocular lens cataract extraction extracapsular phacoemulsification capsular cataract chamber intraocular MEDICAL_TRANSCRIPTION,Description Cataract to right eye Cataract extraction with intraocular lens implant of the right eye anterior vitrectomy of the right eye Medical Specialty Surgery Sample Name Cataract Extraction Vitrectomy Transcription PREOPERATIVE DIAGNOSIS Cataract to right eye POSTOPERATIVE DIAGNOSIS Cataract to right eye PROCEDURE PERFORMED Cataract extraction with intraocular lens implant of the right eye anterior vitrectomy of the right eye LENS IMPLANT USED See below COMPLICATIONS Posterior capsular hole vitreous prolapse ANESTHESIA Topical PROCEDURE IN DETAIL The patient was identified in the preoperative holding area before being escorted back to the operating room suite Hemodynamic monitoring was begun Time out was called and the patient eye operated upon and lens implant intended were verbally verified Three drops of tetracaine were applied to the operative eye The patient was then prepped and draped in usual sterile fashion for intraocular surgery A lid speculum was placed Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife The anterior chamber was irrigated with a dilute 0 25 solution of non preserved lidocaine and filled with Viscoat The clear corneal temporal incision was fashioned The anterior chamber was entered by introducing a keratome The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco chop technique Following removal of the last nuclear quadrant there was noted to be a posterior capsular hole nasally This area was tamponaded with Healon The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area The sulcus area of the lens was then inflated using Healon and a V9002 16 0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus There was noted to be good support Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat Gentle bimanual irrigation aspiration was performed to remove remaining viscoelastic agents anteriorly The pupil was noted to constrict symmetrically Wounds were checked with Weck cels and found to be free of vitreous BSS was used to re inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12 All corneal wounds were then hydrated checked and found to be watertight and free of vitreous A single 10 0 nylon suture was placed temporarily as prophylaxis and the knot buried Lid speculum was removed TobraDex ointment light patch and a Soft Shield were applied The patient was taken to the recovery room awake and comfortable We will follow up in the morning for postoperative check He will not be given Diamox due to his sulfa allergy The intraoperative course was discussed with both he and his wife Keywords surgery intraocular lens implant lid speculum cataract extraction anterior vitrectomy anterior chamber eye intraocular extraction hemodynamic implant vitrectomy vitreous cataract lens MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release and right index and middle fingers release A1 pulley Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis Medical Specialty Surgery Sample Name Carpal Tunnel Release 8 Transcription PREOPERATIVE DIAGNOSES 1 Right carpal tunnel syndrome 2 Right index finger and middle fingers tenosynovitis POSTOPERATIVE DIAGNOSES 1 Right carpal tunnel syndrome 2 Right index finger and middle fingers tenosynovitis PROCEDURES PERFORMED 1 Right carpal tunnel release 2 Right index and middle fingers release A1 pulley TOURNIQUET TIME 70 minutes BLOOD LOSS Minimal GROSS INTRAOPERATIVE FINDINGS 1 A compressed median nerve at the carpal tunnel which was flattened 2 A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers After the A1 pulley was released there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons HISTORY This is a 78 year old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left He had positive EMG findings as well as clinical findings The patient did undergo an injection which only provided him with temporary relief and is for this reason he has consented to undergo the above named procedure All risks as well as complications were discussed with the patient and consent was obtained PROCEDURE The patient was wheeled back to the operating room 1 at ABCD General Hospital on 08 29 03 He was placed supine on the operating room table Next a non sterile tourniquet was placed on the right forearm but not inflated At this time 8 cc of 0 25 Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia In addition an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers At this time the extremity was then prepped and draped in usual sterile fashion for this procedure First we went for release of the carpal tunnel Approximately 2 5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region First dissection through the skin in the superficial fascia was performed with a self retractor placed in addition to Ragnells retracting proximally and distally The palmaris brevis muscle was then identified and sharply transected At this time we identified the transverse carpal tunnel ligament and a 15 blade was used to sharply and carefully release that fascia Once the fascia of the transverse carpal ligament was transected the identification of the median nerve was visualized The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly At this time a neurolysis was performed and no evidence of space occupying lesions were identified within the carpal tunnel At this time copious irrigation was used to irrigate the wound The wound was suctioned dry At this time we proceeded to the release of the A1 pulleys Approximately a 1 5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers First we went for the index finger Once the skin incision was made Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley A 15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally Once this was performed a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons Once a thorough release was performed copious irrigation was used to irrigate that wound In the similar fashion a 1 5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger A Littler scissor was used to bluntly dissect in the longitudinal fashion With the Ragnell retractors we identified the A1 pulley of the right middle finger Using a 15 blade the A1 pulley was scored with the 15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity Again there was evidence of some synovitis as well as fraying of both tendons The girth of both tendons and both wounds were within normal limits At this time copious irrigation was used to irrigate the wound The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively In addition he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact At this time 5 0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery At this time a short arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll The patient was then carefully taken off of the operating room table to Recovery in stable condition Keywords surgery compressed median nerve stenosing tenosynovitis carpal tunnel release carpal tunnel syndrome middle fingers carpal tunnel littler scissors median nerve copious irrigation volar aspect tunnel pulley carpal fingers index tourniquet ligament tenosynovitis superficialis tendons MEDICAL_TRANSCRIPTION,Description Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty Medical Specialty Surgery Sample Name Cartilage Loose Body Removal Transcription PREOPERATIVE DIAGNOSIS Left knee medial femoral condyle osteochondritis dissecans POSTOPERATIVE DIAGNOSIS Left knee medial femoral condyle osteochondritis dissecans PROCEDURES Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty ANESTHESIA General TOURNIQUET TIME Thirty seven minutes MEDICATIONS The patient also received 30 mL of 0 5 Marcaine local anesthetic at the end of the case COMPLICATIONS No intraoperative complications DRAINS AND SPECIMENS None INTRAOPERATIVE FINDINGS The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera This loose body was then subsequently removed It measured 24 x 14 mm This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle HISTORY AND PHYSICAL The patient is 13 year old male with persistent left knee pain He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee The patient presented here for a second opinion Surgery was recommended grossly due to the instability of the fragment Risks and benefits of surgery were discussed The risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion extremity failure to relieve pain or restore the articular cartilage possible need for other surgical procedures and possible early arthritis All questions were answered and parents agreed to the above plan DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The extremity was then prepped and draped in standard surgical fashion The standard portals were marked on the skin The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg The portal incisions were then made by an 11 blade Camera was inserted into the lateral joint line There was a noted large cartilage loose body in the suprapatellar pouch This was subsequently removed with extension of the anterolateral portal Visualization of the rest of the knee revealed significant synovitis The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle The remainder of the knee demonstrated no other significant cartilage lesions loose bodies plica or meniscal pathology ACL was also visualized to be intact in the intracondylar notch Attention was then turned back to the large defect The loose cartilage was debrided using a shaver Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites All instruments were then removed The portals were closed using 4 0 Monocryl A total of 30 mL of 0 5 Marcaine was injected into the knee Wounds were then cleaned and dried and dressed in Steri Strips Xeroform 4 x 4s and bias The patient was then placed in a knee immobilizer The patient tolerated the procedure well The tourniquet was released at 37 minutes He was taken to recovery in stable condition POSTOPERATIVE PLAN The loose cartilage fragment was given to the family The intraoperative findings were relayed with intraoperative photos There was a large deficit in the weightbearing portion of medial femoral condyle His prognosis is guarded given the fact of the fragile lesion and location but in advantages of his age and his rehab potential down the road if the patient still has symptoms he may be a candidate for osteochondral autograft a procedure which is not performed at Children s or possible cartilaginous transplant All questions were answered The patient will follow up in 10 days may wet the wound in 5 days Keywords surgery knee arthroscopy chondroplasty medial femoral condyle cartilage loose body loose cartilage knee arthroscopy tourniquet microfracture orthopedic femoral cartilage MEDICAL_TRANSCRIPTION,Description Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification A peribulbar block was given to the eye using 8 cc of a mixture of 0 5 Marcaine without epinephrine mixed with Wydase plus one half of 2 lidocaine without epinephrine Medical Specialty Surgery Sample Name Cataract Extraction 1 Transcription PROCEDURE PERFORMED Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification ANESTHESIA Peribulbar COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo Synephrine drops A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg A peribulbar block was given to the eye using 8 cc of a mixture of 0 5 Marcaine without epinephrine mixed with Wydase plus one half of 2 lidocaine without epinephrine The Honan balloon was then re placed over the eye for an additional 10 minutes at 20 mmHg The eye was prepped with a Betadine solution and draped in the usual sterile fashion A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade followed by instillation of 0 1 cc of preservative free lidocaine 1 into the anterior chamber followed by viscoelastic A 2 8 mm keratome was used to create a self sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap The Utrata forceps were used to complete a continuous tear capsulorrhexis and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula Phacoemulsification in a quartering and cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit Gentle vacuuming of the central posterior capsule was performed The capsular bag was re expanded with viscoelastic and then the wound was opened to a 3 4 mm size with an additional keratome to allow insertion of the intraocular lens The intraocular lens was folded inserted into the capsular bag and then un folded The trailing haptic was tucked underneath the anterior capsular rim The lens was shown to center very well Therefore the viscoelastic was removed with the irrigation and aspiration unit and one 10 0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction The wound was shown to be watertight Therefore TobraDex ointment was applied to the eye an eye pad loosely applied and a Fox shield taped firmly in place The patient tolerated the procedure well and left the operating room in good condition Keywords surgery phacoemulsification hydrodissection peribulbar block irrigation and aspiration honan balloon anterior chamber anterior capsular aspiration unit capsular bag cataract extraction intraocular lens cataract extraction peribulbar lidocaine viscoelastic chamber epinephrine anterior capsular lens intraocular eye MEDICAL_TRANSCRIPTION,Description Cataract extraction with lens implantation right eye The lens was inspected and found to be free of defects folded and easily inserted into the capsular bag and unfolded Medical Specialty Surgery Sample Name Cataract Extraction Transcription PROCEDURE PERFORMED Cataract extraction with lens implantation right eye DESCRIPTION OF PROCEDURE The patient was brought to the operating room The patient was identified and the correct operative site was also identified A retrobulbar block using 5 ml of 2 lidocaine without epinephrine was done after adequate anesthetic was assured and the eye was massaged to reduce risk of bleeding The patient was prepped and draped in the usual fashion A lid speculum was applied A groove incision at the 12 o clock position was made with a 5700 blade This was beveled anteriorly in a lamellar fashion using the crescent knife Then the anterior chamber was entered with a slit knife The chamber was deepened with Viscoat Then a paracentesis at the 3 o clock position was created using a super sharp blade A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps Hydrodissection was employed using BSS on a blunt 27 gauge needle The phaco tip was then introduced into the eye and the eye was divided into 4 grooves Then a second instrument was used a Sinskey hook to crack these grooves and the individual quadrants were brought into the central zone and phacoemulsified I A proceeded without difficulty using the irrigation aspiration cannula The capsule was felt to be clear and intact The capsular bag was then expanded with ProVisc The internal corneal wound was increased using the slit knife The lens was inspected and found to be free of defects folded and easily inserted into the capsular bag and unfolded A corneal light shield was then used as the wound was sutured with a figure of eight 10 0 nylon suture Then the Viscoat was removed using I A and the suture drawn up and tied The 0 2 ml of gentamicin was injected subconjunctivally Maxitrol ointment was instilled into the conjunctival sac The eye was covered with a double patch and shield and the patient was discharged Keywords surgery lens implantation anterior chamber lid speculum eye sinskey hook cataract extraction capsular bag cataract capsular knife lens MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release Left carpal tunnel syndrome Severe compression of the median nerve on the left at the wrist Medical Specialty Surgery Sample Name Carpal Tunnel Release 6 Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIVE PROCEDURE PERFORMED Left carpal tunnel release FINDINGS Showed severe compression of the median nerve on the left at the wrist SPECIMENS None FLUIDS 500 mL of crystalloids URINE OUTPUT No Foley catheter COMPLICATIONS None ANESTHESIA General through a laryngeal mask ESTIMATED BLOOD LOSS None CONDITION Resuscitated with stable vital signs INDICATION FOR THE OPERATION This is a case of a very pleasant 65 year old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6 7 followed by anterior cervical discectomy with anterior interbody fusion at C5 6 and C6 7 with spinal instrumentation At the time of initial consultation the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now Operation expected outcome risks and benefits were discussed with him for most of the risk would be that of infection because of the patient s diabetes and a previous history of infection in the form of pneumonia There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection He understood this risk and agreed to have the procedure performed DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room awake alert not in any form of distress After smooth induction of anesthesia and placement of a laryngeal mask he remained supine on the operating table The left upper extremity was then prepped with Betadine soap and antiseptic solution After sterile drapes were laid out an incision was made following inflation of blood pressure cuff to 250 mmHg Clamp time approximately 30 minutes An incision was then made right in the mid palm area between the thenar and hypothenar eminence Meticulous hemostasis of any bleeders were done The fat was identified The palmar aponeurosis was identified and cut and this was traced down to the wrist There was severe compression of the median nerve Additional removal of the aponeurosis was performed to allow for further decompression After this was all completed the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4 0 as interrupted vertical mattress stitches Dressing was applied The patient was brought to the recovery Keywords surgery compression wrist carpal tunnel release carpal tunnel syndrome median nerve tunnel carpal MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome Open carpal tunnel release A longitudinal incision was made in line with the 4th ray The dissection was carried down to the superficial aponeurosis which was cut The distal edge of the transverse carpal ligament was identified with a hemostat Medical Specialty Surgery Sample Name Carpal Tunnel Release Open Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome TITLE OF PROCEDURE Open carpal tunnel release COMPLICATIONS None PROCEDURE IN DETAIL After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the 4th ray The dissection was carried down to the superficial aponeurosis which was cut The distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with scissors After irrigating the wound with copious amounts of normal saline the skin was repaired with 4 0 nylon interrupted stitches Marcaine with epinephrine was injected into the wound which was then dressed and splinted The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery carpal ligament carpal tunnel release carpal tunnel syndrome transverse carpal ligament transverse ligament hemostat tunnel incision MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release Right carpal tunnel syndrome This is a 54 year old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management Medical Specialty Surgery Sample Name Carpal Tunnel Release 9 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome PROCEDURE Right carpal tunnel release ANESTHESIA Bier block to the right hand TOTAL TOURNIQUET TIME 20 minutes COMPLICATIONS None DISPOSITION Stable to PACU ESTIMATED BLOOD LOSS Less than 10 cc GROSS OPERATIVE FINDINGS We did find a compressed right median nerve upon entering the carpal tunnel otherwise the structures of the carpal canal are otherwise unremarkable No evidence of tumor was found BRIEF HISTORY OF PRESENT ILLNESS This is a 54 year old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management PROCEDURE The patient was taken to the operative room and placed in the supine position The patient underwent a Bier block by the Department of Anesthesia on the upper extremity The upper extremity was prepped and draped in usual sterile fashion and left free Attention was drawn then to the palm of the hand We did identify area of incision that we would make which was located over the carpal tunnel Approximately 1 5 cm incision was made using a 10 blade scalpel Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a 10 scalpel We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament We found no evidence of tumor or space occupying lesion in the carpal tunnel We then irrigated copiously Tourniquet was taken down at that time and pressure was held There was no evidence of obvious bleeders We approximated the skin with nylon and placed a postoperative dressing with a volar splint The patient tolerated the procedure well She was placed back in the gurney and taken to PACU Keywords surgery carpal tunnel release carpal tunnel syndrome median nerve bier block carpal ligament tunnel carpal transverse median MEDICAL_TRANSCRIPTION,Description Right carpal tunnel syndrome Right carpal tunnel release Medical Specialty Surgery Sample Name Carpal Tunnel Release 7 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome PROCEDURE PERFORMED Right carpal tunnel release PROCEDURE NOTE The right upper extremity was prepped and draped in the usual fashion IV sedation was supplied by the anesthesiologist A local block using 6 cc of 0 5 Marcaine was used at the transverse wrist crease using a 25 gauge needle superficial to the transverse carpal ligament The upper extremity was exsanguinated with a 6 inch ace wrap Tourniquet time was less than 10 minutes at 250 mmHg An incision was used in line with the third web space just to the ulnar side of the thenar crease It was carried sharply down to the transverse wrist crease The transverse carpal ligament was identified and released under direct vision Proximal to the transverse wrist crease it was released subcutaneously During the entire procedure care was taken to avoid injury to the median nerve proper the recurrent median the palmar cutaneous branch the ulnar neurovascular bundle and the superficial palmar arch The nerve appeared to be mildly constricted Closure was routine with running 5 0 nylon A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition Keywords surgery superficial palmar arch carpal tunnel release carpal tunnel syndrome transverse wrist crease superficial ligament MEDICAL_TRANSCRIPTION,Description Right open carpal tunnel release and cortisone injection left carpal tunnel Medical Specialty Surgery Sample Name Carpal Tunnel Release 4 Transcription PREOPERATIVE DIAGNOSIS Bilateral carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Bilateral carpal tunnel syndrome PROCEDURES 1 Right open carpal tunnel release 2 Cortisone injection left carpal tunnel ANESTHESIA General LMA ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS This patient is a 50 year old male with bilateral carpal tunnel syndrome which is measured out as severe He is scheduled for the above mentioned procedures The planned procedures were discussed with the patient including the associated risks The risks included but are not limited to bleeding infection nerve damage failure to heal possible need for reoperation possible recurrence or any associated risk of the anesthesia He voiced understanding and agreed to proceed as planned DESCRIPTION OF PROCEDURE The patient was identified in the holding area and correct operative site was identified by the surgeon s mark Informed consent was obtained The patient was then brought to the operating room and transferred to the operating table in supine position Time out was then performed at which point the surgeon nursing staff and anesthesia staff all confirmed the correct identification After adequate general LMA anesthesia was obtained a well padded tourniquet was placed on the patient s right upper arm The right upper extremity was then prepped and draped in the usual sterile fashion Planned skin incision was marked along the base of the patient s right palm Right upper extremity was then exsanguinated using Esmarch The tourniquet was then inflated to 250 mmHg Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision Bleeding points were identified with electrocautery using bipolar electrocautery Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament and this was then divided longitudinally under direct vision Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed This was confirmed by visually and palpably Next baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision Carpal canal was then inspected The median nerve was flattened and injected No other abnormalities were noted Wounds were then irrigated with normal saline and antibiotic additive Decadron 4 mg was then placed adjacent to the median nerve Skin incision was then closed with interrupted 5 0 nylon suture The wound was then dressed with Adaptic 4 x 4s Kling and Coban The tourniquet was then deflated Attention was then directed to the left side Using sterile technique the left carpal canal was injected with a mixture of 40 mg of Depo Medrol 1 cc of 1 lidocaine and 1 cc of 0 25 Marcaine Band Aid was then placed over the injection site The patient was then awakened extubated and transferred over to his hospital bed He was transported to recovery room in stable condition There were no intraoperative or immediate postoperative complications All counts were reported as correct Keywords surgery carpal tunnel syndrome 4 x 4s adaptic carpal canal coban cortisone injection esmarch kling metzenbaum carpal tunnel release electrocautery fibrous band palmar fascia tourniquet transverse carpal ligament bilateral carpal tunnel baby metzenbaum scissors carpal ligament bilateral carpal metzenbaum scissors carpal tunnel carpal tunnel MEDICAL_TRANSCRIPTION,Description Bilateral open carpal tunnel release Medical Specialty Surgery Sample Name Carpal Tunnel Release 5 Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome bilateral POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome bilateral ANESTHESIA General NAME OF OPERATION Bilateral open carpal tunnel release FINDINGS AT OPERATION The patient had identical very thick transverse carpal ligaments with dull synovium PROCEDURE Under satisfactory anesthesia the patient was prepped and draped in a routine manner on both upper extremities The right upper extremity was exsanguinated and the tourniquet inflated A curved incision was made at the the ulnar base carried through the subcutaneous tissue and superficial fascia down to the transverse carpal ligament This was divided under direct vision along its ulnar border and wound closed with interrupted nylon The wound was injected and a dry sterile dressing was applied An identical procedure was done to the opposite side The patient left the operating room in satisfactory condition Keywords surgery bilateral open carpal tunnel carpal tunnel syndrome carpal tunnel release carpal tunnel release tourniquet bilateral tunnel carpal MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome Endoscopic carpal tunnel release After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg Medical Specialty Surgery Sample Name Carpal Tunnel Release Endoscopic Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome TITLE OF PROCEDURE Endoscopic carpal tunnel release ANESTHESIA MAC PROCEDURE After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease Dissection was carried down to the antebrachial fascia which was cut in a distally based fashion Bipolar electrocautery was used to maintain meticulous hemostasis I then performed an antebrachial fasciotomy proximally I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side Great care was taken with placement A good plane was positively identified I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament Again I felt the hook of the hamate ulnar to me I had my thumb on the distal aspect of the transverse carpal ligament I then partially deployed the blade and starting 1 mm from the distal edge the transverse carpal ligament was positively identified I pulled back and cut and partially tightened the transverse carpal ligament I then feathered through the distal ligament and performed a full thickness incision through the distal half of the ligament I then checked to make sure this was properly performed and then cut the proximal aspect I then entered the carpal tunnel again and saw that the release was complete meaning that the cut surfaces of the transverse carpal ligament were separated and with the scope rotated I could see only one in the field at a time Great care was taken and at no point was there any longitudinal structure cut Under direct vision through the incision I made sure that the distal antebrachial fascia was cut Following this I irrigated and closed the skin The patient was dressed and sent to the recovery room in good condition Keywords surgery endoscopic carpal tunnel syndrome carpal tunnel release carpal ligament tourniquet carpal esmarch tunnel transverse ligament MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release left ulnar nerve anterior submuscular transposition at the elbow lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve Medical Specialty Surgery Sample Name Carpal Tunnel Release 3 Transcription PREOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 354 0 2 Left ulnar nerve entrapment at the elbow 354 2 POSTOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 354 0 2 Left ulnar nerve entrapment at the elbow 354 2 OPERATIONS PERFORMED 1 Left carpal tunnel release 64721 2 Left ulnar nerve anterior submuscular transposition at the elbow 64718 3 Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve 25280 ANESTHESIA General anesthesia with intubation INDICATIONS OF PROCEDURE This patient is insulin dependant diabetic He is also has end stage renal failure and has chronic hemodialysis Additionally the patient has had prior heart transplantation He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity However it is our contention that this patient s prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger These started initially as unrecognized paper cuts Additionally the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve but also to the little finger Finally this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger Thus we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary Thirdly this patient does have chronic distal ischemic problems with evidence of ping pong ball sign due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers However this patient has no clinical sign at all of tissue necrosis at the finger tips at this time The patient has also previously had an arteriovenous shunt in the forearm which has been deactivated within the last 3 weeks Thus we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve This patient had electro diagnostic studies performed which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel DESCRIPTION OF PROCEDURE After general anesthesia being induced and the patient intubated he is given intravenous Ancef The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion A sterile tourniquet and webril are placed higher on the arm The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease Dissection continued through subcutaneous tissue to the palmer aponeurosis which is divided longitudinally from distal to proximal I next encountered the transverse carpal ligament which in turn is also divided longitudinally from distal to proximal and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm Having confirmed a complete release of the transverse carpal ligament I next evaluated the contents of the carpal tunnel The synovium was somewhat thickened but not unduly so There was some erythema along the length of the median nerve indicating chronic compression The motor branch of the median nerve was clearly identified The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5 0 nylon sutures I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap I now gained access to the radial border of the flexor pronator muscle mass dissected down the radial side until I identified the median nerve I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm The entire medial intramuscular septum is now excised The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures Larger penetrating vascular tributaries to the muscle ligated between hemoclips I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques In this way the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension free manner Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other So that in effect a lengthening is performed Fascial repair is done with interrupted figure of eight 0 Ethibond sutures I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension free coverage of the muscle without any impingement on the nerve The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside I then unwrap the arm and check for hemostasis Wound is copiously irrigated with normal saline and then a 15 French Round Blake drainage placed through a separate stab incision and laid along the length of the wound A layered wound closure is done with interrupted Vicryl subcutaneously and a running subcuticular Monocryl to the skin A 0 25 plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment followed by a well fluffed gauze and a Kerlix dressing and confirming Kerlix and webril and an above elbow sugar tong splint is applied extending to the support of the wrist Fingers and femoral were free to move The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition Sponge and needle counts reported as correct at the end of the procedure Keywords surgery carpal tunnel syndrome ace bandage kerlix carpal tunnel release curvilinear incision flexor pronator muscle ping pong ball sign synovium ulnar artery ulnar nerve ulnar nerve entrapment pronator muscle mass transverse carpal carpal ligament tunnel release flexor pronator pronator muscle carpal tunnel tunnel carpal nerve pronator forearm MEDICAL_TRANSCRIPTION,Description Endoscopic release of left transverse carpal ligament Medical Specialty Surgery Sample Name Carpal Ligament Release 1 Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome PROCEDURE Endoscopic release of left transverse carpal ligament ANESTHESIA Monitored anesthesia care with regional anesthesia provided by surgeon TOURNIQUET TIME 12 minutes OPERATIVE PROCEDURE IN DETAIL With the patient under adequate monitored anesthesia the left upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mmHg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the palm between FCR and FCU one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the Hood of Hamate The Agee Inside Job was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the Agee Inside Job was withdrawn dividing transverse carpal ligament under direct vision After complete division of transverse carpal ligament the Agee Inside Job was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished One cc of Celestone was then introduced into the carpal tunnel and irrigated free The wound was then closed with a running 3 0 Prolene subcuticular stitch Steri strips were applied and a sterile dressing was applied over the Steri strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords surgery carpal tunnel syndrome antebrachial fascia carpal ligament palmar synovium tourniquet transverse carpal ligament transverse incision agee inside job transverse carpal carpal ligament carpal tunnel antebrachial release endoscopic MEDICAL_TRANSCRIPTION,Description Endoscopic release of left transverse carpal ligament Steroid injection stenosing tenosynovitis of right middle finger Medical Specialty Surgery Sample Name Carpal Ligament Release 2 Transcription PREOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 2 Stenosing tenosynovitis of right middle finger trigger finger POSTOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 2 Stenosing tenosynovitis of right middle finger trigger finger PROCEDURES 1 Endoscopic release of left transverse carpal ligament 2 Steroid injection stenosing tenosynovitis of right middle finger ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon TOURNIQUET TIME Left upper extremity was 15 minutes OPERATIVE PROCEDURE IN DETAIL With the patient under adequate monitored anesthesia the left upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mmHg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the palm between FCR and FCU one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the Hood of Hamate The Agee Inside Job was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the Agee Inside Job was withdrawn dividing transverse carpal ligament under direct vision After complete division of transverse carpal ligament the Agee Inside Job was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished One mL of Celestone was then introduced into the carpal tunnel and irrigated free The wound was then closed with a running 3 0 Prolene subcuticular stitch Steri strips were applied and a sterile dressing was applied over the Steri strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Attention was turned to the right palm where after a sterile prep the right middle finger flexor sheath was injected with 0 5 mL of 1 plain Xylocaine and 0 5 mL of Depo Medrol 40 mg mL A Band Aid dressing was then applied The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords surgery carpal tunnel syndrome agee inside job steroid injection antebrachial fascia forearm ring ray synovial elevator tenosynovitis tourniquet transverse incision trigger finger tenosynovitis of right middle transverse carpal ligament transverse carpal carpal ligament steri strips stenosing tenosynovitis middle finger ligament carpal endoscopic finger MEDICAL_TRANSCRIPTION,Description Left endoscopic carpal tunnel release and endotracheal fasciotomy Medical Specialty Surgery Sample Name Carpal Tunnel Release 2 Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIVE PROCEDURE 1 Left endoscopic carpal tunnel release 2 Endotracheal fasciotomy ANESTHESIA General COMPLICATIONS None INDICATION The patient is a 62 year old lady with the aforementioned diagnosis refractory to nonoperative management All risks and benefits were explained Questions answered Options discussed No guarantees were made She wished to proceed with surgery PROCEDURE After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease Dissection was carried down to the antebrachial fascia which was cut in a distally based fashion Bipolar electrocautery was used to maintain meticulous hemostasis I then performed an antebrachial fasciotomy proximally I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side Great care was taken with placement A good plane was positively identified I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament Again I felt the hook of the hamate ulnar to me I had my thumb on the distal aspect of the transverse carpal ligament I then partially deployed the blade and starting 1 mm from the distal edge the transverse carpal ligament was positively identified I pulled back and cut and partially tightened the transverse carpal ligament I then feathered through the distal ligament and performed a full thickness incision through the distal half of the ligament I then checked to make sure this was properly performed and then cut the proximal aspect I then entered the carpal tunnel again and saw that the release was complete meaning that the cut surfaces of the transverse carpal ligament were separated and with the scope rotated I could see only one in the field at a time Great care was taken and at no point was there any longitudinal structure cut Under direct vision through the incision I made sure that the distal antebrachial fascia was cut Following this I irrigated and closed the skin The patient was dressed and sent to the recovery room in good condition Keywords surgery carpal tunnel syndrome antebrachial fascia antebrachial fasciotomy carpal tunnel release electrocautery fasciotomy hamate wrist crease endoscopic carpal tunnel release transverse carpal ligament carpal tunnel transverse carpal carpal ligament carpal antebrachial transverse ligament MEDICAL_TRANSCRIPTION,Description Right common carotid endarterectomy internal carotid endarterectomy external carotid endarterectomy and Hemashield patch angioplasty of the right common internal and external carotid arteries Medical Specialty Surgery Sample Name Carotid Endarterectomy 1 Transcription PREOPERATIVE DIAGNOSIS Right common internal and external carotid artery stenosis POSTOPERATIVE DIAGNOSIS Right common internal and external carotid artery stenosis OPERATIONS 1 Right common carotid endarterectomy 2 Right internal carotid endarterectomy 3 Right external carotid endarterectomy 4 Hemashield patch angioplasty of the right common internal and external carotid arteries ANESTHESIA General endotracheal anesthesia URINE OUTPUT Not recorded OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next the right neck was prepped and draped in the standard surgical fashion A 10 blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors The common internal and external carotid arteries were identified The facial vein was ligated with 3 0 silk The hypoglossal nerve was identified and preserved as it coursed across the carotid artery After dissecting out an adequate length of common internal and external carotid artery heparin was given Next an umbilical tape was passed around the common carotid artery A 0 silk suture was passed around the internal and external carotid arteries The hypoglossal nerve was identified and preserved An appropriate sized Argyle shunt was chosen A Hemashield patch was cut to the appropriate size Next vascular clamps were placed on the external carotid artery DeBakey pickups were used to control the internal carotid artery and common carotid artery A 11 blade scalpel was used to make an incision on the common carotid artery The arteriotomy was lengthened onto the internal carotid artery Next the Argyle shunt was placed It was secured in place Next an endarterectomy was performed and this was done on the common internal carotid and external carotid arteries An inversion technique was used on the external carotid artery The artery was irrigated and free debris was removed Next we sewed the Hemashield patch onto the artery using 6 0 Prolene in a running fashion Prior to completion of our anastomosis we removed our shunt We completed the anastomosis Next we removed our clamp from the external carotid artery followed by the common carotid artery and lastly by the internal carotid artery There was no evidence of bleeding Full dose protamine was given The incision was closed with 0 Vicryl followed by 2 0 Vicryl followed by 4 0 PDS in a running subcuticular fashion A sterile dressing was applied Keywords surgery angioplasty common carotid artery external carotid artery hemashield patch common carotid carotid endarterectomy external artery carotid hemashield endarterectomy MEDICAL_TRANSCRIPTION,Description Carpal tunnel release Nerve conduction study tests diagnostic of carpal tunnel syndrome The patient failed to improve satisfactorily on conservative care including anti inflammatory medications and night splints Medical Specialty Surgery Sample Name Carpal Tunnel Release Transcription PROCEDURE PERFORMED Carpal tunnel release INDICATIONS FOR SURGERY Nerve conduction study tests diagnostic of carpal tunnel syndrome The patient failed to improve satisfactorily on conservative care including anti inflammatory medications and night splints PROCEDURE The patient was brought to the operating room and following a Bier block to the operative arm the arm was prepped and draped in the usual manner Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament It was identified at its distal edge Using a hemostat to probe the carpal tunnel sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal to proximal direction in its entirety The canal was probed with a small finger to verify no evidence of any bone prominences The nerve was examined for any irregularity There was slight hyperemia of the nerve and a slight hourglass deformity Following an irrigation the skin was approximated using interrupted simple and horizontal mattress 5 nylon suture A sterile dressing was applied The patient was taken to the recovery room in satisfactory condition The time of the Bier block was 30 minutes COMPLICATIONS None noted Keywords surgery carpal tunnel syndrome carpal ligament nerve conduction study carpal tunnel release bier block carpal tunnel tunnel carpal MEDICAL_TRANSCRIPTION,Description Carpal tunnel release with transverse carpal ligament reconstruction A longitudinal incision was made in line with the fourth ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis Medical Specialty Surgery Sample Name Carpal Ligament Reconstruction Transcription PROCEDURE Carpal tunnel release with transverse carpal ligament reconstruction PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the fourth ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis The subcutaneous fat was dissected radially for 2 3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly and the distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with a scissor After irrigating the wound with copious amounts of normal saline the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4 0 Vicryl Care was taken to avoid entrapping the motor branch of the median nerve in the suture A hemostat was placed under the repair to ensure that the median nerve was not compressed The skin was repaired with 5 0 nylon interrupted stitches Marcaine with epinephrine was injected into the wound which was then dressed and splinted The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords surgery carpal tunnel carpal ligament reconstruction transverse carpal ligament ulnar hemostat transverse superficial ligament carpal MEDICAL_TRANSCRIPTION,Description Right carotid stenosis and prior cerebrovascular accident Right carotid endarterectomy with patch angioplasty Medical Specialty Surgery Sample Name Carotid Endarterectomy Transcription PREOPERATIVE DIAGNOSES 1 Right carotid stenosis 2 Prior cerebrovascular accident POSTOPERATIVE DIAGNOSES 1 Right carotid stenosis 2 Prior cerebrovascular accident PROCEDURE PERFORMED Right carotid endarterectomy with patch angioplasty ESTIMATED BLOOD LOSS 250 cc OPERATIVE FINDINGS The common and internal carotid arteries were opened A high grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting PROCEDURE The patient was taken to the operating room placed in supine position prepped and draped in the usual sterile manner with Betadine solution Longitudinal incisions were made along the anterior border of the sternocleidomastoid carried down through subcutaneous fat and fascia Hemostasis was obtained with electrocautery The platysmal muscle was divided The carotid sheath was identified and opened The vagus nerve ansa cervicalis and hypoglossal nerves were identified and avoided The common internal and external carotids were then freed from the surrounding tissue At this point 10 000 units of aqueous heparin were administered and allowed to take effect The external and common carotids were then clamped The patient s neurological status was evaluated and found to be unchanged from preoperative levels Once sufficient time had lapsed we proceeded with the procedure The carotid bulb was opened with a 11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external The plaque tapered nicely on the internal and no tacking sutures were necessary Heparinized saline was injected and no evidence of flapping or other debris was noted The remaining carotid was examined under magnification which showed no debris of flaps present At this point a Dacron patch was brought on to the field cut to appropriate length and size and anastomosed to the artery using 6 0 Prolene in a running fashion Prior to the time of last stitch the internal carotid was back bled through this The last stitch was tied Hemostasis was excellent The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system At this point a total of 50 mg of Protamine was administered and allowed to take effect Hemostasis was excellent The wound was irrigated with antibiotic solution and closed in layers using 3 0 Vicryl and 4 0 undyed Vicryl The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well Sponge needles and instrument count were correct Estimated blood loss was 250 cc Keywords surgery carotid stenosis cerebrovascular platysmal dacron patch carotid endarterectomy cerebrovascular accident internal carotid carotid stenosis carotids endarterectomy MEDICAL_TRANSCRIPTION,Description Direct current cardioversion This is a 53 year old gentleman with history of paroxysmal atrial fibrillation for 3 years Successful DC cardioversion of atrial fibrillation Medical Specialty Surgery Sample Name Cardioversion Direct Current 1 Transcription PROCEDURE Direct current cardioversion BRIEF HISTORY This is a 53 year old gentleman with history of paroxysmal atrial fibrillation for 3 years He had a wide area of circumferential ablation done on November 9th for atrial fibrillation He did develop recurrent atrial fibrillation the day before yesterday and this is persistent Therefore he came in for cardioversion today He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion The patient was in the SDI unit attached to noninvasive monitoring devices After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s He tolerated it well He will be observed for couple hours and discharged home later today He will continue on his current medications He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself CONCLUSIONS FINAL DIAGNOSES Successful DC cardioversion of atrial fibrillation Keywords surgery direct current cardioversion circumferential ablation paroxysmal atrial dc cardioversion direct current atrial fibrillation ablation cardioversion MEDICAL_TRANSCRIPTION,Description Cardioversion Unsuccessful direct current cardioversion with permanent atrial fibrillation Medical Specialty Surgery Sample Name Cardioversion Unsuccessful Transcription REASON FOR EXAM Atrial flutter cardioversion PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed The pads were applied in the anterior posterior approach The synchronized cardioversion with biphasic energy delivered at 150 J First attempt was unsuccessful Second attempt at 200 J with anterior posterior approach With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function the success of the rate without antiarrhythmic may be low IMPRESSION Unsuccessful direct current cardioversion with permanent atrial fibrillation Keywords surgery atrial flutter cardioversion anterior posterior transesophageal atrial fibrillation flutter cardioversion fibrillation atrial MEDICAL_TRANSCRIPTION,Description Direct current cardioversion Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication Medical Specialty Surgery Sample Name Cardioversion Direct Current Transcription PROCEDURE Direct current cardioversion REASON FOR PROCEDURE Atrial fibrillation PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits including risk of stroke The patient understands as well as her husband The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium There was spontaneous echocardiogram contrast noticed The patient was on anticoagulation with Lovenox received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed The pads applied in the anterior and posterior approach With synchronized biphasic waveform at 150 J one shock was successful in restoring sinus rhythm The patient had some occasional PACs noticed with occasional sinus tachycardia The patient had no immediate post procedure complications The rhythm was maintained and 12 lead EKG was requested IMPRESSION Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication Keywords surgery thrombus atrium echocardiogram transesophageal direct current cardioversion atrial fibrillation sinus rhythm sinus rhythm cardioversion MEDICAL_TRANSCRIPTION,Description Left carotid endarterectomy with endovascular patch angioplasty Critical left carotid stenosis The external carotid artery was occluded at its origin When the endarterectomy was performed the external carotid artery back bled nicely The internal carotid artery had good backflow bleeding noted Medical Specialty Surgery Sample Name Carotid Endarterectomy Angioplasty Transcription PREOPERATIVE DIAGNOSIS Critical left carotid stenosis POSTOPERATIVE DIAGNOSIS Critical left carotid stenosis PROCEDURE PERFORMED Left carotid endarterectomy with endovascular patch angioplasty ANESTHESIA Cervical block GROSS FINDINGS The patient is a 57 year old black female with chronic renal failure She does have known critical carotid artery stenosis She wishes to undergo bilateral carotid endarterectomy however it was felt necessary by Dr X to perform cardiac catheterization She was admitted to the hospital yesterday with chest pain She has been considered for coronary artery bypass grafting I have been asked to address the carotid stenosis left being more severe this was addressed first Intraoperatively an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery The internal carotid artery is quite torturous The external carotid artery was occluded at its origin When the endarterectomy was performed the external carotid artery back bled nicely The internal carotid artery had good backflow bleeding noted OPERATIVE PROCEDURE The patient was taken to the OR suite and placed in the supine position Then neck shoulder and chest wall were prepped and draped in appropriate manner Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery Utilizing both blunt and sharp dissections the common carotid artery the internal carotid artery beyond the atherosclerotic back the external carotid artery and the superior thyroid artery were isolated and encircled with a umbilical tape During the dissection facial veins were ligated with 4 0 silk ligature prior to dividing them Also during the dissection ansa cervicalis hypoglossal and vagus nerve identified and preserved There was some inflammation above the carotid bulb but this was not problematic The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips The common carotid artery was controlled with profunda clamp The patient remained neurologically intact A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery This was extended across the lobe on to the internal carotid artery An endarterectomy was then performed The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline As mentioned before the internal carotid artery is quite torturous This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of 7 0 Prolene suture The wound was copiously irrigated rather an endovascular patch was then brought on to the field This was cut to shape and length This was sutured in place with continuous running 6 0 Prolene suture The suture line began at both sites The suture was tied in the center along the anterior and posterior walls Prior to completing the closure the common carotid artery was flushed The internal carotid artery permitted to back bleed The clamp was placed after completing the closure The clamp was placed at the origin of the internal carotid artery Flow was first directed into the external carotid artery then into the internal carotid artery The patient remained neurologically intact Topical ________ Gelfoam was utilized Of note during the endarterectomy the patient did receive an additional 7000 units of aqueous heparin The wound was copiously irrigated with antibiotic solution Sponge needle and all counts were correct All surgical sites were inspected Good hemostasis noted The incision was closed in layers with absorbable suture Stainless steel staples approximated skin Sterile dressings were applied The patient tolerated the procedure well grossly neurologically intact Keywords surgery carotid stenosis carotid endarterectomy endovascular patch angioplasty cervical block carotid artery common carotid artery external carotid artery endovascular patch common carotid external carotid angioplasty artery endovascular neurologically carotid stenosis endarterectomy MEDICAL_TRANSCRIPTION,Description Left heart cardiac catheterization Medical Specialty Surgery Sample Name Cardiac Catheterization 8 Transcription PROCEDURE PERFORMED 1 Right femoral artery access 2 Selective right and left coronary angiogram 3 Left heart catheterization 4 Left ventriculogram INDICATIONS FOR PROCEDURE A 50 year old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20 to 25 This was a sharp decline from a previous LVEF of 50 to 55 We therefore decided to proceed with coronary angiography TECHNIQUE After obtaining informed consent the patient was brought to the cardiac catheterization suite in post absorptive and non sedated state The right groin was prepped and draped in the usual sterile manner 2 Lidocaine was used for infiltration anesthesia Using modified Seldinger technique a 6 French sheath was introduced into the right femoral artery 6 French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram A 6 French pigtail catheter was used to perform the LV gram in the RAO projection HEMODYNAMIC DATA LVEDP of 11 There was no gradient across the aortic valve upon pullback ANGIOGRAPHIC FINDINGS 1 The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery 2 The left main coronary artery is free of any disease 3 The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease 4 The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches One of its secondary branches which is a small caliber has an ostial 70 stenosis 5 The left anterior descending artery has a patent stent in the proximal LAD The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss There appears to be 30 narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery The diagonal branches are free of any disease 6 The right coronary artery is a dominant vessel and has mild luminal irregularities Its midsegment has a focal area of 30 narrowing as well The rest of the right coronary artery is free of any disease 7 The LV gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55 RECOMMENDATION Continue with optimum medical therapy Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment I have discussed this matter with Dr XYZ and we have decided to proceed with a repeat 2D echocardiogram The mild disease in the distal left anterior descending artery with mild in stent re stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia Keywords surgery heart catheterization ventriculogram femoral artery access coronary angiogram lvef distal left anterior descending circumflex coronary artery anterior descending artery femoral artery systolic function cardiac catheterization circumflex coronary anterior descending coronary artery coronary artery catheterization descending MEDICAL_TRANSCRIPTION,Description Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth 32 Extraction of teeth Medical Specialty Surgery Sample Name Carious Teeth Extraction Transcription PREOPERATIVE DIAGNOSIS Carious teeth and periodontal disease affecting all remaining teeth POSTOPERATIVE DIAGNOSIS Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth 32 PROCEDURE Extraction of remaining teeth numbers 2 3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 and 32 ANESTHESIA General oral endotracheal COMPLICATIONS None CONDITION Stable to PACU PROCEDURE Patient was brought to the operating room placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia the patient was prepped and draped in the usual fashion for an intraoral procedure Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9 10 11 12 13 14 15 and 16 were removed with elevators and forceps extraction Moving to the lower quadrant on the left side tooth numbers 17 18 19 20 21 22 23 and 24 were removed with elevators and routine forceps extraction The flaps were then closed with 3 0 gut sutures and upon completion of the two quadrants on the left side the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right Teeth numbers 2 3 4 5 7 and 8 were then removed with elevators and routine forceps extraction It was noted that tooth 6 was missing could not be seen whether tooth 6 was palately impacted but the tooth was not encountered On the lower right quadrant teeth numbers 25 26 27 28 29 30 and 31 were removed with elevators and routine forceps extraction Tooth 32 was partially bony impacted but exposed so it was removed by removing bone on buccal aspect with high speed drill with a round bur Tooth was then luxated from the socket The flaps were then closed on both quadrants with 3 0 gut sutures The area was irrigated thoroughly with normal saline solution and a total of 8 5 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of bupivacaine 0 5 with epinephrine 1 200 000 Upon completion of the procedure the throat pack was removed The pharynx was suctioned An oral gastric tube was passed and small amount of stomach contents were suctioned The patient was then extubated and taken to PACU in stable condition Keywords surgery intraoral procedure partial bony impacted tooth teeth extraction forceps extraction periodontal disease carious teeth periodontal carious MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release Medical Specialty Surgery Sample Name Carpal Tunnel Release 1 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome TITLE OF THE PROCEDURE Right carpal tunnel release COMPLICATIONS There were no complications during the procedure SPECIMEN The specimen was sent to pathology INSTRUMENTS All counts were correct at the end of the case and no complications were encountered INDICATIONS This is a 69 year old female who have been complaining of right hand pain which was steadily getting worse over a prolonged period of time The patient had tried nonoperative therapy which did not assist the patient The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve As a result of these findings the patient was sent to my office presenting with this history and was carefully evaluated On initial evaluation the patient had the symptomology of carpal tunnel syndrome The patient at the time had the risks benefits and alternatives thoroughly explained to her All questions were answered No guarantees were given The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed DETAILS OF THE PROCEDURE The patient was brought to the operating room placed supine on the operating room table prepped and draped in the sterile fashion and was given sedation The patient was then given sedation Once this was complete the area overlying the carpal ligament was carefully injected with 1 lidocaine with epinephrine The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete a 15 blade knife was then used to incise the skin opposite the radial aspect of the fourth ray Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament This was then carefully incised using a 15 blade knife and once entry was again into the carpal canal a Freer elevator was then inserted and under direct visualization the carpal ligament was then released The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt The area was well hemostased with the 1 lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times Palmar fascia was released both proximally and distally as well as the transverse carpal ligament Direct palpation of the carpal canal demonstrated a full and complete release Observation of the median nerve revealed an area of hyperemia in the distal two thirds of the nerve which demonstrated the likely area of compression Once this was complete hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4 0 chromic suture in a horizontal mattress and interrupted stitch Xeroform was then applied to the incision A bulky dressing was then applied consisting of Kerlix and Ace wrap and the patient was taken to the recovery room in stable condition without any complications Keywords surgery carpal tunnel syndrome ace wrap emg freer elevator kerlix weitlaner retractor bulky dressing carpal tunnel carpal tunnel release palmar fascia subcutaneous fat lidocaine with epinephrine transverse carpal ligament carpal ligament carpal tunnel ligament MEDICAL_TRANSCRIPTION,Description Cardioversion An 86 year old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation Medical Specialty Surgery Sample Name Cardioversion Transcription HISTORY The patient is an 86 year old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia incomplete compliance with obstructive sleep apnea therapy with CPAP chocolate caffeine ingestion and significant mental stress Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation I have discussed in detail with the patient regarding risks benefits and alternatives of the procedure After an in depth discussion of the procedure please see my initial consultation for further details I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday The patient declined I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate PROCEDURE NOTE The appropriate time out procedure was performed as per Medical Center protocol including proper identification of the patient physician procedure documentation and there were no safety issues identified by myself nor the staff The patient participated actively in this She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm This was confirmed on 12 lead EKG IMPRESSION PLAN Successful resumption of normal sinus rhythm from recurrent atrial fibrillation The patient s electrolytes are now normal and that will need close watching to avoid hypokalemia in the future as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p o b i d metoprolol 50 mg p o b i d Diltiazem CD 240 mg p o daily and digoxin 0 125 mg p o daily and to be clear she does have a permanent pacemaker implanted She will follow up with her regular cardiologist Dr X for whom I am covering this weekend This was all discussed in detail with the patient as well as her granddaughter with the patient s verbal consent at the bedside Keywords surgery atrial fibrillation aortic valve paroxysmal normal sinus rhythm sinus rhythm cpap cardioversion fibrillation atrial MEDICAL_TRANSCRIPTION,Description White male with onset of chest pain with history of on and off chest discomfort over the past several days Medical Specialty Surgery Sample Name Cardiac Catheterization 3 Transcription INDICATIONS FOR PROCEDURE This is a 61 year old white male with onset of chest pain at 04 30 this morning with history of on and off chest discomfort over the past several days CPK is already over 1000 There is ST elevation in leads II and aVF as well as a Q wave The chest pain is now gone mild residual shortness of breath no orthopnea Cardiac monitor shows resolution of ST elevation lead III DESCRIPTION OF PROCEDURE Following sterile prep and drape of the right groin installation of 1 Xylocaine anesthesia the right common femoral artery was percutaneously entered and 6 French sheath inserted ACT approximately 165 seconds on heparin Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed Selective left and right coronary injections performed using Judkins coronary catheters with a 6 French pigtail catheter used to obtain left ventricular pressures and left ventriculography Left pullback pressure Sheath injection Hemostasis obtained with a 6 French Angio Seal device He tolerated the procedure well and was transported to the Cardiac Step Down Unit in stable condition HEMODYNAMIC DATA Left ventricular end diastolic pressure elevated post A wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback ANGIOGRAPHIC FINDINGS I Left coronary artery The left main coronary artery is unremarkable The left anterior descending has 30 to 40 narrowing with tortuosity in its proximal portion patent first septal perforator branch The first diagonal branch is a 2 mm vessel with a 90 ostial stenosis The second diagonal branch is unremarkable as are the tiny distal diagonal branches The intermediate branch is a small normal vessel The ostial non dominant circumflex has some contrast thinning but no stenosis normal obtuse marginal branch and small AV sulcus circumflex branch II Right coronary artery The right coronary artery is a large dominant vessel which gives off large posterior descending and posterolateral left ventricular branches There are luminal irregularities less than 25 within the proximal to mid vessel Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches A 25 smooth narrowing at the origin of the posterior descending branch Posterolateral branch is unremarkable and quite large with secondary and tertiary branches III Left ventriculogram The left ventricle is normal in size Ejection fraction estimated at 40 to 45 No mitral regurgitation Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion DISCUSSION Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation Left coronary system has one hemodynamically significant stenosis a 90 ostial stenosis at the first diagonal branch which is a 2 mm vessel Left ventricular function is reduced with ejection fraction 40 to 45 with inferior wall motion abnormality PLAN Medical treatment including Plavix and nitrates in addition to beta blocker aspirin and aggressive lipid reduction Keywords surgery cpk q wave st elevation french angio seal pigtail catheter st segment ejection fraction wall motion diagonal branch posterior descending coronary artery catheterization circumflex rca cardiac st elevation ventricular stenosis artery coronary branch MEDICAL_TRANSCRIPTION,Description Left heart catheterization with coronary angiography vein graft angiography and left ventricular pressure measurement and angiography Medical Specialty Surgery Sample Name Cardiac Catheterization 5 Transcription PROCEDURE PERFORMED 1 Left heart catheterization with coronary angiography vein graft angiography and left ventricular pressure measurement and angiography 2 Right femoral selective angiogram 3 Closure device the seal the femoral arteriotomy using an Angio Seal INDICATIONS FOR PROCEDURE The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease who had her last coronary arteriogram performed in 2004 She has had complaints of progressive chest discomfort and has ongoing risks including current smoking diabetes hypertension hyperlipidemia to name a few The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression DESCRIPTION OF PROCEDURE After informed consent was obtained The patient was taken to cardiac catheterization lab where her procedure was performed She was prepped and prepared on the table after which her right groin was locally anesthetized with 1 lidocaine Then a 6 French sheath was inserted into the right femoral artery over a standard 0 035 guide wire Coronary angiography and left ventricular measurement and angiography were performed using a 6 French JL4 diagnostic catheter to image the left coronary artery A 6 French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit Subsequently a 6 French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection a left ventriculogram at 8 mL per second for a total of 30 mL At the conclusion of the diagnostic evaluation the patient had selective arteriography of her right femoral artery which showed the right femoral artery to be free of significant atherosclerotic plaque Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation As such an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery As such the Perclose was never deployed and was removed intact over the wire from the system We then replaced this with a 6 French Angio Seal which was used to seal the femoral arteriotomy with achievement of hemostasis The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home HEMODYNAMIC DATA Opening aortic pressure 125 60 left ventricular pressure 108 4 with an end diastolic pressure of 16 There was no significant gradient across the aortic valve on pullback from the left ventricle Left ventricular ejection fraction was 55 Mitral regurgitation was less than or equal to 1 There was normal wall motion in the RAO projection CORONARY ANGIOGRAM The left main coronary artery had mild atherosclerotic plaque The proximal LAD was 100 occluded The left circumflex had mild diffuse atherosclerotic plaque The obtuse marginal branch which operates as an OM 2 had a mid approximately 80 stenosis at a kink in the artery This appears to be the area of a prior anastomosis the saphenous vein graft to the OM This is a very small caliber vessel and is 1 5 mm in diameter at best The right coronary artery is dominant The native right coronary artery had mild proximal and mid atherosclerotic plaque The distal right coronary artery has an approximate 40 stenosis The posterior left ventricular branch has a proximal 50 to 60 stenosis The proximal PDA has a 40 to 50 stenosis The saphenous vein graft to the right PDA is widely patent There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above There is also some retrograde filling of the right coronary artery from the runoff of this graft The saphenous vein graft to the left anterior descending is widely patent The LAD beyond the distal anastomosis is a relatively small caliber vessel There is some retrograde filling that allows some filling into a more proximal diagonal branch The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004 Overall this study does not look markedly different than the procedure performed in 2004 CONCLUSION 100 proximal LAD mild left circumflex disease with an OM that is a small caliber vessel with an 80 lesion at a kink that is no amenable to percutaneous intervention The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease The saphenous vein graft to the OM is known to be 100 occluded The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open Normal left ventricular systolic function PLAN The plan will be for continued medical therapy and risk factor modification Aggressive antihyperlipidemic and antihypertensive control The patient s goal LDL will be at or below 70 with triglyceride level at or below 150 and it is very imperative that the patient stop smoking After her bedrest is complete she will be dispositioned to home after which she will be following up with me in the office within 1 month We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits Keywords surgery catheterization vein graft angiography angiogram angio seal closure device coronary atherosclerotic heart disease saphenous vein graft ventricular pressure coronary artery saphenous vein atherosclerotic coronary artery bifurcation pda ventricular saphenous MEDICAL_TRANSCRIPTION,Description Cardiac catheterization Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis Medical Specialty Surgery Sample Name Cardiac Catheterization 12 Transcription PREOPERATIVE DIAGNOSIS Coronary artery disease POSTOPERATIVE DIAGNOSIS Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis DESCRIPTION OF PROCEDURE LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY Under local anesthesia with 2 lidocaine with premedication a right groin preparation was done Using the percutaneous Seldinger technique via the right femoral artery a left heart catheterization was performed Coronary arteriography was performed with 6 French performed coronary catheters We used a 6 French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries After using the JR4 6 French catheter nitroglycerin was administered because of the possibility of ostial spasm and following that we used a 5 French JR4 catheter for additional cineangiograms of the right coronary artery A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm as there was dense calcification in the mid abdominal aorta ANALYSIS OF PRESSURE DATA Left ventricular end diastolic pressure was 5 mmHg On continuous tracing from the left ventricle to the ascending aorta there is no gradient across the aortic valve The aortic pressures were normal Contours of intracardiac pressure were normal ANALYSIS OF ANGIOGRAMS Selective cineangiograms were obtained with injection of contrast to the left ventricle coronary arteries and mid abdominal aorta A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position The mitral valve is competent and demonstrates normal mobility The left ventricular cavity is normal in size with excellent contractility Aneurysmal dilatation and or dyskinesia absent The aortic valve is tricuspid and normal mobility The ascending aorta appeared normal Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries An abdominal aortic injection was performed Under fluoroscopy we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis The abdominal aortogram reveals wide patency of that area with mild intimal irregularity There is a normal left renal artery normal right renal artery The celiac seems to be normal but what I believe is the splenic artery seen initially at its origin is normal The common left iliac and common right iliac arteries are essentially normal in this area CORONARY ANATOMY One notes ostial coronary calcification of the right coronary artery Cineangiogram obtained with 6 French JR4 and 5 French JR4 catheters Prior to the introduction of the 5 French JR4 nitroglycerin was administered sublingually The 6 French JR4 catheters appeared to a show an ostial lesion of over 50 There was backwash of dye into the aorta although there is a fine funneling of the ostium towards the proximal right coronary artery In the proximal portion of the right coronary artery just into the Shepherd turn there is a 50 smooth tapering of the right coronary artery in the proximal third Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel The distal portion of the vessel is free of disease The conus branch is seen arising right at the beginning part of the right coronary artery We then removed the 6 French catheter and following nitroglycerin and sublingually we placed a 5 French catheter and again finding a stenosis may be less than 50 At the ostium of the right coronary artery calcification again is identified Backwash of dye noted at the proximal lesion looked about the same 50 along the proximal turn of the Shepherd turn area The left coronary artery is normal although there is a rim of ostial calcification but there is no tapering or stenosis It forms the left anterior descending artery the ramus branch and the circumflex artery The left anterior descending artery is a very large vessel very tortuous in its proximal segment very tortuous in its mid and distal segment There appears to be some mild stenosis of 10 in the proximal segment It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease The remaining portion of the left anterior descending artery is free of disease Upon injection of the left coronary artery we see what I believe is the dye enters probably directly into the left ventricle but via fistula excluding the coronary sinus and we get a ventriculogram performed I could not identify an isolated area but it seems to be from the interventricular septal collaterals that this is taking place The ramus branch is normal and free of disease The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease The patient has a predominantly right coronary system There is no _______ circulation connecting the right and left coronary systems The patient tolerated the procedure well The catheter was removed Hemostasis was achieved The patient was transferred to the recovery room in a stable condition IMPRESSION 1 Excellent left ventricular contractility with normal left ventricular cavity size 2 Calcification of the mid abdominal aorta with wide patency of all vessels The left and right renal arteries are normal The external iliac arteries are normal 3 Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula 4 Ostial stenosis of the right coronary artery that appears to be about 50 or greater The proximal right coronary artery has 50 stenosis as well 5 Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries RECOMMENDATIONS The patient has heavy calcification of the coronary arteries and continued risk factor management is needed The ostial lesion of the right coronary artery may be severe It is at least 50 but it could be worse Therefore she will be evaluated for the possibility of an IVUS and or _______ analysis of the proximal right coronary artery We will reevaluate her stress nuclear study as well Continue aggressive medical therapy Keywords surgery intimal calcification stenosis coronary artery disease mid abdominal aorta coronary artery cardiac catheterization coronary arteries descending artery calcification mid proximal aorta catheterization abdominal cardiac intimal coronary artery MEDICAL_TRANSCRIPTION,Description Left Heart Catheterization Chest pain coronary artery disease prior bypass surgery Left coronary artery disease native Patent vein graft with obtuse marginal vessel and also LIMA to LAD Native right coronary artery is patent mild disease Medical Specialty Surgery Sample Name Cardiac Catheterization 10 Transcription EXAM Left Heart Catheterization REASON FOR EXAM Chest pain coronary artery disease prior bypass surgery INTERPRETATION The procedure and complications were explained to the patient in detail and formal consent was obtained The patient was brought to the cath lab The right groin was draped in the usual sterile manner Using modified Seldinger technique a 6 French arterial sheath was introduced in the right common femoral artery A JL4 catheter was used to cannulate the left coronary arteries A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts The same catheter was used to cannulate the vein graft and also LIMA I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful A 6 French pigtail catheter was used to perform left ventriculography and pullback was done No gradient was noted Arterial sheath was removed Hemostasis was obtained with manual compression The patient tolerated the procedure very well without any complications FINDINGS 1 Native coronary arteries The left main is patent The left anterior descending artery is not clearly visualized The circumflex artery appears to be patent The proximal segment gives rise to small caliber obtuse marginal vessel 2 Right coronary artery is patent with mild distal and mid segment No evidence of focal stenosis or dominant system 3 Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site There appears to be possible _______ graft to the diagonal 1 vessel The distal LAD wraps around the apex No stenosis following the anastomotic site noted 4 Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel 5 No other bypass grafts are noted by left ventriculography and also aortic root shot 6 Left ventriculography with an ejection fraction of 60 IMPRESSION 1 Left coronary artery disease native 2 Patent vein graft with obtuse marginal vessel and also LIMA to LAD _______ graft to the diagonal 1 vessel 3 Native right coronary artery is patent mild disease RECOMMENDATIONS Medical treatment Keywords surgery chest pain coronary artery disease bypass surgery heart catheterization lima lad obtuse marginal vessel vein graft obtuse marginal marginal vessel coronary artery catheterization coronary artery obtuse marginal bypass vessel graft MEDICAL_TRANSCRIPTION,Description Left heart catheterization LV cineangiography selective coronary angiography and right heart catheterization with cardiac output by thermodilution technique with dual transducer Medical Specialty Surgery Sample Name Cardiac Catheterization Transcription EXAMINATION Cardiac catheterization PROCEDURE PERFORMED Left heart catheterization LV cineangiography selective coronary angiography and right heart catheterization with cardiac output by thermodilution technique with dual transducer INDICATION Syncope with severe aortic stenosis COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained from the patient the patient was brought to the cardiac catheterization laboratory in a post observed state The right groin was prepped and draped in the usual sterile fashion After adequate conscious sedation and local anesthesia was obtained a 6 French sheath was placed in the right common femoral artery and a 8 French sheath was placed in the right common femoral vein Following this a 7 5 French Swan Ganz catheter was advanced into the right atrium where the right atrial pressure was 10 7 mmHg The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37 10 4 mmHg The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg The pulmonary arterial pressures were noted to be 31 14 21 mmHg Following this the catheter was removed the sheath was flushed and a 6 French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views Following this the catheter was exchanged over the guidewire for 6 French JR4 diagnostic catheter We were unable to cannulate the right coronary artery Therefore we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views Following this this catheter was exchanged over a guidewire for a 6 French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed Following this the catheters were removed Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6 French Angio Seal device The patient tolerated the procedure well There were no complications DESCRIPTION OF FINDINGS The left main coronary artery is a large vessel which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions The left circumflex artery is a short vessel which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches There is a 70 ostial lesion in the first diagonal branch and the second diagonal branch has mild to moderate luminal irregularities The right coronary artery is a very large dominant vessel with a 60 to 70 lesion in its descending mid portion The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions The left ventricle appears to be normal sized The aortic valve is heavily calcified The estimated ejection fraction is approximately 60 There was 4 mitral regurgitation noted The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0 89 cm2 CONCLUSION 1 Moderate to severe coronary artery disease with a high grade lesion seen at the ostium of the first diagonal artery as well as a 60 to 70 lesion seen at the mid portion of the right coronary artery 2 Moderate to severe aortic stenosis with an aortic valve area of 0 89 cm2 3 4 mitral regurgitation PLAN The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair replacement and possible surgical revascularization Keywords surgery heart catheterization cineangiography selective coronary angiography thermodilution technique transducer diffuse luminal irregularities cardiac catheterization luminal irregularities aortic valve coronary artery artery catheterization regurgitation angiography thermodilution coronary MEDICAL_TRANSCRIPTION,Description The patient with atypical type right arm discomfort and neck discomfort Medical Specialty Surgery Sample Name Cardiac Catheterization 2 Transcription INDICATIONS FOR PROCEDURE The patient has presented with atypical type right arm discomfort and neck discomfort She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis Of note there was bidirectional flow in the right vertebral artery as well as 250 cm per second velocities in the right subclavian Duplex ultrasound showed at least a 50 stenosis APPROACH Right common femoral artery ANESTHESIA IV sedation with cardiac catheterization protocol Local infiltration with 1 Xylocaine COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 10 ml ESTIMATED CONTRAST Less than 250 ml PROCEDURE PERFORMED Right brachiocephalic angiography right subclavian angiography selective catheterization of the right subclavian selective aortic arch angiogram right iliofemoral angiogram 6 French Angio Seal placement DESCRIPTION OF PROCEDURE The patient was brought to the cardiac catheterization lab in the usual fasting state She was laid supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion 1 Xylocaine was infiltrated into the right femoral vessels Next a 6 French sheath was introduced into the right femoral artery via the modified Seldinger technique AORTIC ARCH ANGIOGRAM Next a pigtail catheter was advanced to the aortic arch Aortic arch angiogram was then performed with injection of 45 ml of contrast rate of 20 ml per second maximum pressure 750 PSI in the 4 degree LAO view SELECTIVE SUBCLAVIAN ANGIOGRAPHY Next the right subclavian was selectively cannulated It was injected in the standard AP as well as the RAO view Next pull back pressures were measured across the right subclavian stenosis No significant gradient was measured ANGIOGRAPHIC DETAILS The right brachiocephalic artery was patent The proximal portion of the right carotid was patent The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50 stenosis IMPRESSION 1 Moderate grade stenosis in the right subclavian artery 2 Patent proximal edge of the right carotid Keywords surgery discomfort subclavian stenosis artery french angio seal lao view rao view aortic arch angiogram arch angiogram cardiac catheterization aortic arch brachiocephalic cardiac angiography aortic angiogram stenosis catheterization atypical subclavian MEDICAL_TRANSCRIPTION,Description Percutaneous intervention with drug eluting stent placement to the ostium of the PDA Medical Specialty Surgery Sample Name Cardiac Catheterization 4 Transcription PROCEDURES PERFORMED 1 Left heart catheterization with coronary angiography and left ventricular pressure measurement 2 Left ventricular angiography was not performed 3 Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting 4 Right femoral artery angiography 5 Perclose to seal the right femoral arteriotomy INDICATIONS FOR PROCEDURE Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non ST elevation myocardial infarction He was subsequently dispositioned to the cardiac catheterization lab for further evaluation DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the cardiac catheterization lab where his procedure was performed The patient was appropriately prepped and prepared on the table after which his right groin was locally anesthetized with 1 lidocaine Then a 6 French sheath was inserted into the right femoral artery Over a standard 0 035 guidewire coronary angiography and left ventricular pressure measurements were performed using a 6 French JL4 diagnostic catheter to image the left coronary artery a 6 French JR4 diagnostic catheter to image the right coronary artery a 6 French angled pigtail catheter to measure left ventricular pressure At the conclusion of the diagnostic study the case was progressed to percutaneous coronary intervention which will be described below Subsequently right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque and an arteriotomy that was suitable for a closure device Then a Perclose was used to seal the right femoral arteriotomy HEMODYNAMIC DATA The opening aortic pressure was 91 63 The left ventricular pressure was 94 13 with an end diastolic pressure of 24 Left ventricular ejection fraction was not assessed as ventriculogram was not performed The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible CORONARY ANGIOGRAM The left main coronary artery was angiographically okay The LAD had mild diffuse disease There appeared to be distal tapering of the LAD The left circumflex had mild diffuse disease In the very distal aspect of the circumflex after OM 3 and OM 4 type branch there was a long severely diseased segment that appeared to be chronic and subtotal in one area The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory and there was not much to salvage by approaching this lesion The right coronary artery had mild diffuse disease The PLV branch was 100 occluded at its ostium at the crux The PDA at the ostium had an 80 stenosis The PDA was a fairly sizeable vessel with a long course The right coronary is dominant CONCLUSION Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion This circumflex appears to be chronically diseased and has areas that appear to be subtotal There is a 100 PLV branch which is also chronic and reported in his angiogram in the 1990s There is an ostial 80 right PDA lesion The plan is to proceed with percutaneous intervention to the right PDA The case was then progressed to percutaneous intervention of the right PDA A 6 French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium The lesion was crossed with a long BMW 0 014 guidewire Then we ballooned the lesion with a 2 5 x 9 mm Maverick balloon Subsequently we stented the lesion with a 2 5 x 16 mm Taxus drug eluting stent with a nice angiographic result The patient tolerated the procedure very well without complications ANGIOPLASTY CONCLUSION Successful percutaneous intervention with drug eluting stent placement to the ostium of the PDA RECOMMENDATIONS Aspirin indefinitely and Plavix 75 mg p o daily for no less than six months The patient will be dispositioned back to telemetry for further monitoring TOTAL MEDICATIONS DURING PROCEDURE Versed 1 mg and fentanyl 25 mcg for conscious sedation Heparin 8400 units IV was given for anticoagulation Ancef 1 g IV was given for closure device prophylaxis CONTRAST ADMINISTERED 200 mL FLUOROSCOPY TIME 12 4 minutes Keywords surgery coronary angiography ventricular pressure coronary angioplasty french pda drug eluting stent coronary artery disease cardiac catheterization lab plv branch cardiac catheterization femoral artery coronary artery artery coronary angioplasty angiogram angiographically arteriotomy angiography cardiac circumflex ostium ventricular femoral percutaneous catheterization MEDICAL_TRANSCRIPTION,Description Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only He has been referred for cardiac catheterization Medical Specialty Surgery Sample Name Cardiac Catheterization 11 Transcription The patient and his wife had the opportunity to ask questions all of which were answered for them and the patient stated in a clear competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate PROCEDURE NOTE The patient was brought to the Cardiac Catheterization Lab in a fasting state All appropriate labs had been reviewed Bilateral groins were prepped and draped in the usual fashion for sterile conditions The appropriate time out procedure was performed with appropriate identification of the patient procedure physician position and documentation all done under my direct supervision and there were no safety issues raised by the staff He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect Bilateral groins had been prepped and draped in the usual fashion Right femoral inguinal fossa was anesthetized with 1 topical lidocaine and a 6 French vascular sheath was put into place percutaneously via guide wire exchanger with a finder needle All catheters were passed using a J tipped guide wire Left heart catheterization and left ventriculography performed using a 6 French pigtail catheter Left system coronary angiography performed using a 6 French JL4 catheter Right system coronary angiography performed using a 6 French CDRC catheter Following the procedure all catheters were removed Manual pressure was held with the Neptune pad and the patient was discharged back to his room I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses There were no apparent complications A total of 77 cc of Isovue dye and 1 4 minutes of fluoroscopy time were utilized during the case FINDINGS HEMODYNAMICS LV pressure is 120 EDP is 20 aortic pressure 120 62 mean of 82 LV function is normal EF 60 no wall motion abnormalities CORONARY ANATOMY 1 Left main demonstrates 30 40 distal left main lesion which is tapering not felt significantly obstructive 2 The LAD demonstrates proximal moderate 50 lesion and a severe mid LAD lesion immediately after the take off of this large diagonal of 99 which is quite severe with TIMI 3 flow throughout the LAD and the left main 3 The left circumflex demonstrates mid 90 severe lesion with TIMI 3 flow 4 The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity There is a moderate distal PDA lesion of 60 seen IMPRESSION 1 Mild to moderate left main stenosis 2 Very severe mid LAD stenosis with severe mid left circumflex stenosis and moderate prox LAD CAD We are going to continue the patient s aspirin beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg deciliter or less but in the past the patient s LDL had been higher or high Keywords surgery wall motion abnormalities cardiac catheterization mid lad timi flow femoral arteriotomy catheterization ischemia angina distal stenosis stress artery coronary lad cardiac MEDICAL_TRANSCRIPTION,Description Left cardiac catheterization with selective right and left coronary angiography Post infarct angina Medical Specialty Surgery Sample Name Cardiac Cath Selective Coronary Angiography Transcription PREOPERATIVE DIAGNOSIS Post infarct angina TYPE OF PROCEDURE Left cardiac catheterization with selective right and left coronary angiography PROCEDURE After informed consent was obtained the patient was brought to the Cardiac Catheterization Laboratory and the groin was prepped in the usual fashion Using 1 lidocaine the right groin was infiltrated and using the Seldinger technique the right femoral artery was cannulated Through this a moveable guidewire was then advance to the level of the diaphragm and through it a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained Catheter was then withdrawn and a 6 French non bleed back sidearm sheath was then introduced and through this a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium engaged Cineangiograms were obtained of the left coronary system This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium engaged Cineangiograms were obtained and the catheter and sheath were then withdrawn The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition No evidence of hematoma formation or active bleeding COMPLICATIONS None TOTAL CONTRAST 110 cc of Hexabrix TOTAL FLUOROSCOPY TIME 1 8 minutes MEDICATIONS Reglan 10 mg p o 5 mg p o Valium Benadryl 50 mg p o and heparin 3 000 units IV push Keywords surgery selective angiography post infarct angina engaged cineangiograms coronary angiography hemodynamic monitoring cardiac catheterization catheterization cineangiograms cardiac coronary MEDICAL_TRANSCRIPTION,Description Left calcaneal lengthening osteotomy with allograft partial plantar fasciotomy posterior subtalar and tibiotalar capsulotomy and short leg cast placed Medical Specialty Surgery Sample Name Calcaneal Lengthening Osteotomy Transcription PREOPERATIVE DIAGNOSES Left calcaneal valgus split POSTOPERATIVE DIAGNOSES Left calcaneal valgus split PROCEDURES 1 Left calcaneal lengthening osteotomy with allograft 2 Partial plantar fasciotomy 3 Posterior subtalar and tibiotalar capsulotomy 4 Short leg cast placed ANESTHESIA Surgery performed under general anesthesia TOURNIQUET TIME 69 minutes The patient in local anesthetic of 20 mL of 0 25 Marcaine plain COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 13 year old female who had previous bilateral feet correction at 1 year of age Since that time the patient has developed significant calcaneal valgus deformity with significant pain Radiographs confirmed collapse of the spinal arch as well as valgus position of the foot Given the patient s symptoms surgery is recommended for calcaneal osteotomy and Achilles lengthening Risks and benefits of surgery were discussed with the mother Risks of surgery include risk of anesthesia infection bleeding changes in sensation in most of extremity hardware failure need for later hardware removal possible nonunion possible failure to correct all the deformity and need for other surgical procedures The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months All questions were answered and parents agreed to the above surgical plan DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A bump was placed underneath the left buttock A nonsterile tourniquet was placed on the upper aspect of the left thigh The extremity was then prepped and draped in a standard surgical fashion The patient had a previous incision along the calcaneocuboid lateral part of the foot This was marked and extended proximally through the Achilles tendon Extremity was wrapped in Esmarch Tourniquet inflation was noted to be 250 mmHg Decision was then made to protect the sural nerve There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way Dissection was carried down to Achilles tendon which was subsequently de lengthened with the distal half performed down the lateral thigh Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end on end at length with the heel in neutral Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons which were removed from the sheath and retracted dorsally At this time we also noted that calcaneocuboid joint appeared to be fused The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy This was performed with a saw After a partial plantar fasciotomy was performed this was released off an abductor digiti minimi The osteotomy was completed with an osteotome and distracted with the lamina spreader A tricortical allograft was then shaped and subsequently impacted into this area Final positioning was checked with multiple views of fluoroscopy It was subsequently fixed using a 0 94 K wire and drilled from the heel anteriorly A pin was subsequently bent and cut short at the level of the skin The wound was then irrigated with normal saline The Achilles was repaired with this tie Please note during the case it was noted the patient had continued significant stiffness despite the Achilles lengthening A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion Wound was then closed using 2 0 Vicryl and 4 0 Monocryl The surgical field was irrigated with 0 25 Marcaine and subsequently injected with more Marcaine at the end of the case The wound was clean and dry and dressed with Steri Strips and Xeroform Skin was dressed with Xeroform and 4 x 4 s Everything was wrapped with 4 x 4 s in sterile Webril The tourniquet was released after 69 minutes A short leg cast was then placed with good return of capillary refill to his toes The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will be hospitalized overnight for elevation ice packs neurovascular checks and pain control The patient to be strict nonweightbearing We will arrange for her to get a wheelchair The patient will then follow up in about 10 to 14 days for a cast check as well as pain control The patient will need an AFO script at that time Intraoperative findings are relayed to the parents Keywords surgery calcaneal lengthening osteotomy allograft plantar fasciotomy capsulotomy calcaneal valgus split partial plantar fasciotomy short leg cast achilles lengthening calcaneal valgus tourniquet plantar valgus achilles calcaneal MEDICAL_TRANSCRIPTION,Description Capsulotomy left breast and flat advancement V to Y left breast for correction of lower pole defect breast assymetry status post previous breast surgery Medical Specialty Surgery Sample Name Capsulotomy Flat Advancement Left Breast Transcription PREOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery POSTOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery OPERATION Capsulotomy left breast flat advancement V to Y left breast for correction lower pole defect ANESTHESIA LMA FINDINGS AND PROCEDURE The patient is a 35 year old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast The nipple inframammary fold distance is approximately 1 5 cm shorter than the fuller right breast The patient has bilateral Mentor Smooth round moderate projection jell filled mammary prosthesis 225 cc The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance She was then brought to the operating room and after satisfactory LMA anesthesia had been induced the patient was prepped and draped in the usual manger The patient received a gram of Kefzol prior to beginning the procedure The previous inverted T scar was excised down to the underlying capsule of the breast implant The breast was carefully dissected off of the underlying capsule Care being taken to preserve the vascular supply to the skin and breast flap When the anterior portion of the breast was dissected free of the underlying capsule the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2 0 Monocryl statures Care was taken to avoid as much exposure of the implant as well as damage to the implant When the flap had been created and advanced hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50 000 units Kefzol 1 g gentamicin 80 mg and 500 cc of saline The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2 0 Biosyn This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast The remainder of the inverted T was closed with interrupted sutures of 3 and 2 0 Biosyn and the skin was closed with continuous suture of 5 0 nylon Bacitracin and a standard breast dressing were applied The anesthesia was terminated and the patient was recovered in the operating room Sponge instrument needle count reported as corrected Estimated blood loss negligible Keywords surgery capsulotomy biosyn breast breast assymetry kefzol mentor smooth breast surgeries flat advancement inframammary fold lower pole defect mammary mammary prosthesis nipple breast surgery assymetry inframammary capsule MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting CABG x2 left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex St Jude proximal anastomosis used for vein graft Off pump Medtronic technique for left internal mammary artery and a BIVAD technique for the circumflex Medical Specialty Surgery Sample Name CABG 2 Transcription PREOPERATIVE DIAGNOSIS Angina and coronary artery disease POSTOPERATIVE DIAGNOSIS Angina and coronary artery disease NAME OF OPERATION Coronary artery bypass grafting CABG x2 left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex St Jude proximal anastomosis used for vein graft Off pump Medtronic technique for left internal mammary artery and a BIVAD technique for the circumflex ANESTHESIA General PROCEDURE DETAILS The patient was brought to the operating room and placed in the supine position upon the table After adequate general anesthesia the patient was prepped with Betadine soap and solution in the usual sterile manner Elbows were protected to avoid ulnar neuropathy chest wall expansion avoided to avoid ulnar neuropathy phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case A midline sternal skin incision was made and carried down through the sternum which was divided with the saw Pericardial and thymus fat pad was divided The left internal mammary artery was harvested and spatulated for anastomosis Heparin was given Vein resected from the thigh side branches secured using 4 0 silk and Hemoclips The thigh was closed multilayer Vicryl and Dexon technique A Pulsavac wash was done drain was placed The left internal mammary artery is sewn to the left anterior descending using 7 0 running Prolene technique with the Medtronic off pump retractors After this was done the patient was fully heparinized cannulated with a 6 5 atrial cannula and a 2 stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia Medtronic retractors used to expose the circumflex Prior to going on pump we stapled the vein graft in place to the aorta Then on pump we did the distal anastomosis with a 7 0 running Prolene technique The right side graft was brought to the posterior descending artery using running 7 0 Prolene technique Deairing procedure was carried out The bulldogs were removed The patient maintained good normal sinus rhythm with good mean perfusion The patient was weaned from cardiopulmonary bypass The arterial and venous lines were removed and doubly secured Protamine was delivered Meticulous hemostasis was present Platelets were given for coagulopathy Chest tube was placed and meticulous hemostasis was present The anatomy and the flow in the grafts was excellent Closure was begun The sternum was closed with wire followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double layer technique The skin was closed with subcuticular 4 0 Dexon suture technique The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3 0 Keywords surgery coronary artery disease angina coronary artery bypass grafting internal mammary artery coronary artery vein graft artery bivad cabg medtronic anastomosis mammary vein circumflex MEDICAL_TRANSCRIPTION,Description Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass open sternotomy covered with Ioban insertion of Mahurkar catheter for hemofiltration via the left common femoral vein Medical Specialty Surgery Sample Name Cardiac Allograft Transplant Transcription PREOPERATIVE DIAGNOSES 1 Ischemic cardiomyopathy 2 Status post redo coronary artery bypass 3 Status post insertion of intraaortic balloon POSTOPERATIVE DIAGNOSES 1 Ischemic cardiomyopathy 2 Status post redo coronary artery bypass 3 Status post insertion of intraaortic balloon 4 Postoperative coagulopathy OPERATIVE PROCEDURE 1 Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass 2 Open sternotomy covered with Ioban 3 Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein ANESTHESIA General endotracheal OPERATIVE PROCEDURE With the patient in the supine position he was prepped from shin to knees and draped in a sterile field A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm freeing up the right atrium and the ascending aorta and anterior right ventricle The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3 mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava After satisfactory heparinization has been obtained the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium After the heart was brought to the operating room and triggered the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place A cardiectomy was then performed by starting in the right atrium The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan Ganz catheter was brought out into the operative field Cardiectomy was then performed first resecting the anterior portion of the right atrium and then transecting the aorta the pulmonary artery the septum between the right and left atriums and then the heart was removed The right and left atrium aorta and pulmonary artery were prepared for the transplant First we did a side to side anastomosis continued to the left atrium and this was performed using 3 0 Prolene suture and a right atrial anastomosis side to side was performed using 3 0 Prolene suture The pulmonary artery was then anastomosed using 5 0 Prolene and the aorta was anastomosed with 4 0 Prolene The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood Air was evacuated and the sutures were tied down The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass Blood factors and factor VII were given to try and correct the coagulopathy Because of excessive transfusions that were required a Mahurkar catheter was inserted through the left common femoral vein first placing a needle into the vein and then guidewire removed and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2 0 nylon suture Hemofiltration was started in the operating room at this time After he had satisfactory hemostasis we decided to do the chest open and cover it with Ioban which we did and one chest tube was inserted into the mediastinum through a separate stab wound The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively This was left in place and the pulse generation the pacemaker was in a right infraclavicular position which was left in place because of the coagulopathy The patient received 11 units of packed red blood cells 7 platelets 23 fresh frozen plasma 20 cryoprecipitates and factor VII Urine output for the procedure was 520 mL The preservation time of the heart is in the anesthesia sheet The estimated blood loss was at least 6 L The patient was taken to the intensive care unit in guarded condition Keywords surgery cardiomyopathy ioban ischemic ischemic cardiomyopathy mahurkar catheter orthostatic seldinger swan ganz allograft aorta balloon cardiac cardiopulmonary bypass catheter coagulopathy coronary artery bypass femoral vein hemofiltration intraaortic intraaortic balloon sternotomy transplantation ventricle inferior vena cava cardiac allograft common femoral vena cava pulmonary artery atrium insertion cardiopulmonary artery MEDICAL_TRANSCRIPTION,Description Cardiac Catheterization An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease presents with an acute myocardial infarction with elevated enzymes Medical Specialty Surgery Sample Name Cardiac Catheterization 1 Transcription INDICATIONS FOR PROCEDURE A 51 year old obese white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes The chest pain occurred early Tuesday morning She was treated with Plavix Lovenox etc and transferred for coronary angiography and possible PCI The plan was discussed with the patient and all questions answered PROCEDURE NOTE Following sterile prep and drape the right groin and instillation of 1 Xylocaine anesthesia the right femoral artery was percutaneously entered with a single wall puncture A 6 French sheath inserted Selective left and right coronary injections performed using Judkins coronary catheters with a 6 French pigtail catheter used to obtain left ventricle pressures and a left ventriculography The left pullback pressure The catheters withdrawn Sheath injection Hemostasis obtained with a 6 French Angio Seal device She tolerated the procedure well Left ventricular end diastolic pressure equals 25 mmHg post A wave No aortic valve or systolic gradient on pullback ANGIOGRAPHIC FINDINGS I Left coronary artery The left main coronary artery is normal The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel Normal diagonal branches Normal septal perforator branches The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches II Right coronary artery The proximal right coronary artery has a focal calcification There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20 at most The right coronary artery is a dominant system which gives off normal posterior descending and posterior lateral branches TIMI 3 flow is present III Left ventriculogram The left ventricle is slightly enlarged with normal contraction of the base but with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion Ejection fraction estimated 40 1 mitral regurgitation echocardiogram ordered DISCUSSION Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end diastolic pressure post A wave but only minor residual coronary artery plaque with calcification proximal right coronary artery PLAN Medical treatment is contemplated including ACE inhibitor a beta blocker aspirin Plavix nitrates An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction Keywords surgery cardiac catheterization hodgkin disease beta blocker coronary angiography coronary artery coronary disease elevated enzymes inferoapical myocardial infarction ventriculogram ventriculography acute myocardial infarction proximal right coronary diastolic pressure ejection fraction coronary echocardiogram cardiac catheterization myocardial enzymes infarction artery MEDICAL_TRANSCRIPTION,Description Redo coronary bypass grafting x3 right and left internal mammary left anterior descending reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection Placement of a right femoral intraaortic balloon pump Medical Specialty Surgery Sample Name CABG Redo Transcription OPERATIVE PROCEDURE 1 Redo coronary bypass grafting x3 right and left internal mammary left anterior descending reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection 2 Placement of a right femoral intraaortic balloon pump DESCRIPTION The patient was brought to the operating room and placed in the supine position After adequate endotracheal anesthesia was induced appropriate monitoring lines were placed Chest abdomen an legs were prepped and draped in sterile fashion The femoral artery on the right was punctured and a guidewire was placed The track was dilated and intraaortic balloon pump was placed in the appropriate position sewn in place and ballooning started The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4 0 silk and flushed with vein solution The leg was closed with running 3 0 Dexon subcu and running 4 0 Dexon on the skin The old mediastinal incision was opened The wires were cut and removed The sternum was divided in the midline Retrosternal attachments were taken down The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine soaked gauze The heart was dissected free of its adhesions The patient was fully heparinized and cannulated with a single aorta and single venous cannula Retrograde cardioplegia cannula was attempted to be placed but could not be fitted into the coronary sinus safely therefore it was banded and oversewn with 5 0 Prolene An antegrade cardioplegia needle sump was placed and secured to the ascending aorta Cardiopulmonary bypass ensued The ascending aorta was cross clamped Cold blood potassium cardioplegia was given antegrade a total of 10 cc kg It was followed by sumping the ascending aorta The obtuse marginal was identified and opened and an end to side anastomosis was performed with a running 7 0 Prolene suture The vein was cut to length Antegrade cardioplegia was given a total of 200 cc The posterior descending branch of the right coronary artery was identified opened and end to side anastomosis then performed with a running 7 0 Prolene suture The vein was cut to length Antegrade cardioplegia was given The mammary was clipped distally divided and spatulated for anastomosis The anterior descending was identified opened and end to side anastomosis then performed with running 8 0 Prolene suture and warm blood potassium cardioplegia was given The cross clamp was removed A partial occlusion clamp was placed Aortotomies were made The vein was cut to fit these and sutured in place with running 5 0 Prolene suture The partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Atrial and ventricular pacing wires were placed The patient was fully warmed and ventilation was commenced The patient was weaned from cardiopulmonary bypass ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass The patient was decannulated in routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire The linea alba was closed with figure of eight of 1 Vicryl the sternal fascia closed with running 1 Vicryl the subcu closed with running 2 0 Dexon skin with running 4 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords surgery coronary bypass grafting internal mammary cardiopulmonary intraaortic femoral artery cabg running prolene suture intraaortic balloon balloon pump ascending aorta prolene suture cardiopulmonary bypass potassium aorta anastomosis prolene coronary cardioplegia bypass MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting CABG x4 Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function Medical Specialty Surgery Sample Name CABG x4 Transcription PREOPERATIVE DIAGNOSES Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function POSTOPERATIVE DIAGNOSES Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function OPERATIVE PROCEDURE Coronary artery bypass grafting CABG x4 GRAFTS PERFORMED LIMA to LAD left radial artery from the aorta to the PDA left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal INDICATIONS FOR PROCEDURE The patient is a 74 year old gentleman who presented with six month history of progressively worsening exertional angina He had a positive stress test and cardiac cath showed severe triple vessel coronary artery disease including left main disease with preserved LV function He was advised surgical revascularization of his coronaries FINDINGS DURING THE PROCEDURE The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp Left internal mammary artery and saphenous vein grafts were good quality conduits Radial artery graft was a smaller sized conduit otherwise good quality All distal targets showed heavy plaque involvement with calcification present The smallest target was the PDA which was about 1 5 mm in size All the other targets were about 2 mm in size or greater The patient came off cardiopulmonary bypass without any problems He was transferred on Neo Synephrine nitroglycerin Precedex drips Cross clamp time was 102 minutes bypass time was 120 minutes DETAILS OF THE PROCEDURE The patient was brought into the operating room and laid supine on the table After he had been interfaced with the appropriate monitors general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple lumen catheter and Cordis catheter right radial A line Foley catheter TEE probes were placed and interfaced appropriately The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion proper time out was conducted and site identification was performed and subsequently incision was made overlying the sternum and median sternotomy was performed Left internal mammary artery was taken down Simultaneously left forearm radial artery was harvested using endoscopic harvesting techniques Simultaneously endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques Subsequent to harvest the incisions were closed in layers during the course of the procedure Heparin was given Pericardium was opened and suspended During the takedown of the left internal mammary artery it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery Pericardium was opened and suspended Pursestring sutures were placed Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass With satisfactory flow the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart PDA was exposed first The right coronary artery was calcified along its course all the way to its terminal bifurcation Even in the PDA calcification was noted in a spotty fashion Arteriotomy on the PDA was performed in a soft area and 1 5 probe was noted to be accommodated in both directions End radial to side PDA anastomosis was constructed using running 7 0 Prolene Next the posterolateral obtuse marginal was exposed Arteriotomy was performed An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7 0 Prolene This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side to side anastomosis was constructed using running 7 0 Prolene Next a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD LAD was exposed Arteriotomy was performed An end LIMA to side LAD anastomosis was constructed using running 7 0 Prolene LIMA was tacked down to the epicardium securely utilizing its fascial pedicle Two stab incisions were made in the ascending aorta and enlarged using 4 mm punch Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta and the proximal end of the radial artery graft and the side of the aorta separately using running 6 0 Prolene The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de airing maneuvers were performed Following this the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity Temporary V pacing wires were placed Blake drains were placed in the left chest the right chest as well as in the mediastinum Left chest Blake drain was placed just in the medial section where dissection had been performed After an adequate period of rewarming during which time temporary V pacing wires were also placed the patient was successfully weaned off cardiopulmonary bypass without any problems With satisfactory hemodynamics good LV function on TEE and baseline EKG heparin was reversed using protamine Decannulation was performed after volume resuscitation Hemostasis was assured Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves heavy Vicryl for musculofascial closure and Monocryl for subcuticular skin closure Dressings were applied The patient was transferred to the ICU in stable condition He tolerated the procedure well All counts were correct at the termination of the procedure Cross clamp time was 102 minutes Bypass time was 120 minutes The patient was transferred on Neo Synephrine nitroglycerin and Precedex drips Keywords surgery radial artery lima pda obtuse marginal exertional angina coronary artery disease triple vessel graft conduit ij triple lumen catheter cordis catheter a line foley catheter tee probes coronary artery bypass grafting cross clamp mammary artery saphenous vein coronary artery artery cabg coronary grafting aorta angina bypass MEDICAL_TRANSCRIPTION,Description Coronary bypass graft x2 utilizing left internal mammary artery the left anterior descending reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection Medical Specialty Surgery Sample Name CABG 1 Transcription PREOPERATIVE DIAGNOSIS Coronary occlusive disease POSTOPERATIVE DIAGNOSIS Coronary occlusive disease OPERATION PROCEDURE Coronary bypass graft x2 utilizing left internal mammary artery the left anterior descending reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection INDICATION FOR THE PROCEDURE The patient was a 71 year old female transferred from an outside facility with the left main proximal left anterior descending and proximal circumflex severe coronary occlusive disease ejection fraction about 40 FINDINGS The LAD was 2 mm vessel and good mammary was good and obtuse marginal was 2 mm vessel and good and the main was good DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring devices were placed The chest abdomen and legs were prepped and draped in the sterile fashion The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4 0 Surgilon and flushed with heparinized blood Hemostasis was achieved in the legs and closed with running 2 0 Dexon in the subcutaneous tissue and running 3 0 Dexon subcuticular in the skin Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The pericardium was opened The pericardial cradle was created The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted A retrograde cardioplegic cannula was placed with a pursestring suture of 4 0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4 0 Prolene Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg The obtuse marginal coronary was identified and opened End to side anastomosis was performed with a running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde potassium cardioplegia were given The mammary artery was clipped distally divided and spatulated for anastomosis The anterior descending was identified and opened End to side anastomosis was performed with running 8 0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross clamp was removed The partial occlusion clamp was placed Aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture A partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Ventilation was commenced The patient was fully warm and the patient was then wean from cardiopulmonary bypass The patient was decannulated in routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire plus two 5 mm Mersiline tapes The linea alba was closed with figure of eight of 1 Vicryl the sternal fascia closed with running 1 Vicryl the subcu closed with running 2 0 Dexon skin with running 4 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords surgery coronary occlusive disease coronary bypass graft cabg myocardial mammary artery obtuse marginal cardiopulmonary bypass potassium cardioplegia prolene suture bypass artery anastomosis autogenous obtuse marginal cardiopulmonary potassium retrograde cardioplegia antegrade coronary MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting times three utilizing the left internal mammary artery left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection Medical Specialty Surgery Sample Name CABG Transcription TITLE OF PROCEDURE Coronary artery bypass grafting times three utilizing the left internal mammary artery left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring devices were placed The chest abdomen and legs were prepped and draped in the sterile fashion The right greater saphenous vein was harvested and prepared by ligating all branches with 4 0 Surgilon and flushed with heparinized blood Hemostasis was achieved in the legs and closed with running 2 0 Dexon in the subcutaneous tissue and running 3 0 Dexon subcuticular in the skin Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The pericardium was opened The pericardial cradle was created The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted A retrograde cardioplegic cannula was placed with a pursestring suture of 4 0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4 0 Prolene The ascending aorta was crossclamped Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia The obtuse marginal coronary artery was identified and opened and end to side anastomosis was performed to the reversed autogenous saphenous vein with running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened End to side anastomosis was performed with a running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde potassium cardioplegia were given The mammary artery was clipped distally divided and spatulated for anastomosis The anterior descending was identified and opened End to side anastomosis was performed through the left internal mammary artery with running 8 0 Prolene suture The mammary pedicle was sutured to the heart with interrupted 5 0 Prolene suture A warm antegrade and retrograde cardioplegia were given The aortic crossclamp was removed The partial occlusion clamp was placed Aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture A partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Ventricular and atrial pacing wires were placed The patient was fully warmed and weaned from cardiopulmonary bypass The patient was decannulated in the routine fashion and Protamine was given Good hemostasis was noted A single mediastinal and left pleural chest tube were placed The sternum was closed with interrupted wire linea alba with running 0 Prolene the sternal fascia was closed with running 0 Prolene the subcutaneous tissue with running 2 0 Dexon and the skin with running 3 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords surgery cabg cardioplegia potassium cardiopulmonary coronary artery marginal obtuse myocardial autogenous coronary artery bypass grafting running prolene suture saphenous vein ascending aorta prolene suture artery coronary bypassNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left and arthroplasty left second toe Bunion left foot and hammertoe left second toe Medical Specialty Surgery Sample Name Bunionectomy Metatarsal Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe POSTOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe PROCEDURE PERFORMED 1 Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left 2 Arthroplasty left second toe HISTORY This 39 year old female presents to ABCD General Hospital with the above chief complaint The patient states that she has had bunion for many months It has been progressively getting more painful at this time The patient attempted conservative treatment including wider shoe gear without long term relief of symptoms and desires surgical treatment PROCEDURE An IV was instituted by the Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff After adequate sedation was achieved by the Department of Anesthesia a total of 15 cc of 0 5 Marcaine plain was injected in a Mayo and digital block to the left foot The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table The stockinette was reflected The foot was cleansed with wet and dry sponge Attention was then directed to the first metatarsophalangeal joint of the left foot An incision was created over this area approximately 6 cm in length The incision was deepened with a 15 blade All vessels encountered were ligated for hemostasis The skin and subcutaneous tissue was then dissected from the capsule Care was taken to preserve the neurovascular bundle Dorsal linear capsular incision was then created The capsule was then reflected from the head of the first metatarsal Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected A lateral capsulotomy was performed Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence The incision was then extended proximally with further dissection down to the level of the bone Two 0 45 K wires were then inserted as access guides for the SCARF osteotomy A standard SCARF osteotomy was then performed The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle After adequate reduction of the bunion deformity was noted the bone was temporarily fixated with a 0 45 K wire A 3 0 x 12 mm screw was then inserted in the standard AO fashion with compression noted A second 3 0 x 14 mm screw was also inserted with tight compression noted The remaining prominent medial eminence medially was then resected with a sagittal saw Reciprocating rasps were then used to smooth any sharp bony edges The temporary fixation wires were then removed The screws were again checked for tightness which was noted Attention was directed to the medial capsule where a medial capsulorrhaphy was performed A straight stat was used to assist in removing a portion of the capsule The capsule was then reapproximated with 2 0 Vicryl medially Dorsal capsule was then reapproximated with 3 0 Vicryl in a running fashion The subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular stitch with 5 0 Vicryl The skin was then closed with 4 0 nylon in a horizontal mattress type fashion Attention was then directed to the left second toe A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe The incision was deepened with a 15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally An incision was made on either side of the extensor digitorum longus tendon A curved mosquito stat was then used to reflex the tendon laterally The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx A sagittal saw was then used to resect the head of the proximal head The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto The extensor digitorum longus tendon was inspected and noted to be intact Any sharp edges were then smoothed with reciprocating rasp The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon Dressings consisted of Owen silk 4x4s Kling Kerlix and Coban Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact to the left foot The patient is to follow up with Dr X in his clinic as directed Keywords surgery hammertoe osteotomy internal screw fixation scarf type extensor digitorum metatarsal osteotomy foot toe metatarsal bunionectomy MEDICAL_TRANSCRIPTION,Description Bunion left foot Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot Medical Specialty Surgery Sample Name Bunionectomy Akin Osteotomy Transcription PREOPERATIVE DIAGNOSIS Bunion left foot POSTOPERATIVE DIAGNOSIS Bunion left foot PROCEDURE PERFORMED 1 Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation 2 Akin osteotomy with internal wire fixation of left foot HISTORY This 19 year old Caucasian female presents to ABCD General Hospital with the above chief complaint The patient states she has had worsening bunion deformity for as long as she could not remember She does have a history of Charcot Marie tooth disease and desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field The stockinette was reflected the foot was cleansed with a wet and dry sponge Approximately 5 cm incision was made dorsomedially over the first metatarsal The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis Care was taken to preserve the extensor digitorum longus tendon The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone Capsule and periosteum was reflected off the first metatarsal head At this time the cartilage was inspected and noted to be white shiny and healthy cartilage There was noted to be a prominent medial eminence Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release The abductor tendon attachments were identified and transected The lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Attention was then directed to the prominent medial eminence which was resected with a sagittal saw Intraoperative assessment of pes was performed and pes was noted to be normal At this time a regional incision was carried more approximately about 1 5 cm The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal The first metatarsal cuneiform joint was identified A 0 45 K wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface This K wire was used as an access guide for a Juvaro type oblique base wedge osteotomy The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial The osteotomy site was then feathered and tilted with tight estimation of the bony edges The cortical hinge was maintained A 0 27 x 24 mm screw was then inserted in a standard AO fashion At this time there was noted to be tight compression of the osteotomy site A second 2 7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted The ________ angle was noted to be significantly released Reciprocating rasp was then used to smoothen any remaining sharp edges The 0 45 k wire was removed The foot was loaded and was noted to fill the remaining abduction of the hallux At this time it was incised to perform an Akin osteotomy Original incision was then extended distally approximately 1 cm The incision was then deepened down to the level of capsule over the base of the proximal phalanx Again care was taken to preserve the extensor digitorum longus tendon The capsule was reflected off of the base of the proximal phalanx An Akin osteotomy was performed with the apex being lateral and the base being medial After where the bone was resected it was feathered until tight compression was noted without tension at the osteotomy site Care was taken to preserve the lateral hinge At 1 5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire The 28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted The remaining edge of the wire was then buried in the medial most distal drill hole The area was then inspected and the foot was noted with significant reduction of the bunion deformity The area was then flushed with copious amounts of sterile saline Capsule was closed with 3 0 Vicryl followed by subcutaneous closure with 4 0 Vicryl in order to decrease tension of the incision site A running 5 0 subcuticular stitch was then performed Steri Strips were applied Total of 1 cc dexamethasone phosphate was then injected into the surgical site Dressings consisted of Owen silk 4x4s Kling Kerlix The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot Posterior splint was then placed on the patient in the operating room The patient tolerated the above procedure and anesthesia well without complications The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot The patient was given postoperative instructions to be strictly nonweightbearing on the left foot The patient was given postop pain prescriptions for Vicodin and instructed to take one q 4 6h p r n for pain as well as Naprosyn 500 mg p o q b i d The patient is to follow up with Dr X in his office in four to five days as directed Keywords surgery bunionectomy akin osteotomy internal wire fixation internal screw fixation osteotomy metatarsal metatarsal osteotomy extensor digitorum drill hole osteotomy site foot MEDICAL_TRANSCRIPTION,Description Austin akin bunionectomy right foot Bunion right foot The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful Medical Specialty Surgery Sample Name Bunionectomy Austin Akin Transcription PREOPERATIVE DIAGNOSIS Bunion right foot POSTOPERATIVE DIAGNOSIS Bunion right foot PROCEDURE PERFORMED Austin akin bunionectomy right foot HISTORY This 77 year old African American female presents to ABCD General Hospital with the above chief complaint The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful The patient has attempted conservative treatment without long term relief of symptoms and desires surgical treatment PROCEDURE DETAILS An IV was instituted by Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain was injected in a Mayo block type fashion The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated to the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg The foot was lowered to the operating field and the stockinet was reflected The foot was cleansed with wet and dry sponge Attention was directed to the bunion deformity on the right foot An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint The incision was then deepened with a 15 blade All vessels encountered were ligated with hemostasis The skin and subcutaneous tissue were then undermined off of the capsule medially A dorsal linear capsular incision was then created over the first metatarsophalangeal joint The periosteum and capsule were then reflected off of the first metatarsal There was noted to be a prominent medial eminence The articular cartilage was healthy for patient s age and race Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified The adductor tendons were transected as well as a lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon Attention was then directed to medial eminence which was resected with a sagittal saw Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted The head was intact A 0 45 K wire was inserted through subcutaneously from proximal medial to distal lateral A second K wire was then inserted from distal lateral to proximal plantar medial Adequate fixation was noted at the osteotomy site The K wires were bent cut and pin caps were placed Attention was then directed to the proximal phalanx of the hallux The capsular periostem was reflected off of the base of the proximal phalanx A sagittal was then used to create an akin osteotomy closing wedge The apex was lateral and the base of the wedge was medial The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression Two 0 45 K wires were then inserted one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site Adequate fixation was noted at the osteotomy site and the osteotomy was closed The toe was noted to be in a markedly more rectus position Sagittal saw was then used to resect the remaining prominent medial eminence The area was then smoothed with a reciprocating rasp There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp The area was then inspected for any remaining short bony edges none were noted Copious amounts of sterile saline was then used to flush the surgical site The capsule was closed with 3 0 Vicryl Subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular 5 0 Vicryl Steri Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site Dressings consisted of 0 1 silk copious Betadine 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot A _______ cast was then applied postoperatively The patient tolerated the above procedure and anesthesia well without complications The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot The patient was given postoperative pain prescription for Tylenol 3 and instructed to take one q4 6h p o p r n for pain The patient is to follow up with Dr X in his office as directed Keywords surgery austin akin bunionectomy hallucis brevis bunion deformity extensor hallucis osteotomy site foot austin bunionectomy MEDICAL_TRANSCRIPTION,Description A 60 year old female presents today for care of painful calluses and benign lesions Medical Specialty Surgery Sample Name Bunions and Calluses Transcription S A 60 year old female presents today for care of painful calluses and benign lesions O On examination the patient has bilateral bunions at the first metatarsophalangeal joint She states that they do not hurt No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot She has a small intractable plantar keratoma plantar to her left second metatarsal head which measures 0 5 cm in diameter This is a central plug She also has a very very painful lesion plantar to her right fourth metatarsal head which measures 3 1 x 1 8 cm in diameter This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines A 1 Bilateral bunions Keywords surgery painful calluses hibiclens scrubbed ointment and absorbent heloma durum plantar aspect minimal hemostasis neosporin ointment absorbent dressing benign lesions metatarsophalangeal bunions calluses plantar MEDICAL_TRANSCRIPTION,Description Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site Medical Specialty Surgery Sample Name Buccal Mucosal Lesion Excision Transcription PREOPERATIVE DIAGNOSIS Left buccal mucosal verrucous squamous cell carcinoma POSTOPERATIVE DIAGNOSIS Left buccal mucosal verrucous squamous cell carcinoma PROCEDURE PERFORMED 1 Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region 2 Adjacent tissue transfer closure of the left supraclavicular grafting site ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 16 year old Caucasian female with a history of left verrucous squamous cell carcinoma of the buccal mucosa present for a number of months that was diagnosed in the office after two biopsies After risks complications consequences and questions were addressed with the patient medical clearance was obtained with the patient and a written consent was obtained PROCEDURE The patient was brought to operative suite by Anesthesia The patient was placed on the operative table in supine position After this the patient was then placed under general endotracheal intubation anesthesia The operating bed was then turned 90 degrees away from anesthesia A shoulder roll was then placed followed by the patient s oral lesion being localized with 1 lidocaine with epinephrine 1 1000 approximately 5 cc total After this the patient was then prepped and draped in the usual sterile fashion including the left shoulder region After this sweetheart retractor along with a Minnesota retractor were utilized to lift the upper and lower lips along with tongue to gain access to this oral cavity lesion A 15 Bard Parker was then utilized to make an incision circumferentially around this lesion or mass with approximately a 1 cm margin The lesion was then grasped with a DeBakey forceps and grasped through in order to dissect this from the buccal mucosal sites with a 15 blade along with a curved sharp Joseph scissors After this the 12 6 and 3 o clock positions were marked with marking suture and the specimen was finally passed off the field It was sent to the frozen section s Pathology Hemostasis was maintained with bipolar cauterization Pathology called back into the room and verified that the regions from 12 to 3 and from 6 to 12 were still involved A second margin was obtained from the 6 o clock position all the way to the 3 o clock position with sutures again placed in the 12 6 and 3 o clock regions This was cut utilizing the 15 Bard Parker and grasped with the DeBakey forceps It was passed off the field and sent to Pathology Pathology then called back into the room and verified that margins were clear After this the bipolar cauterization was then utilized to control a further bleeding After this the superior and inferior aspects of the defect were reapproximated with approximately one 4 0 Vicryl suture After this the left shoulder that was prepped previously was unveiled Surgical gloves were all changed and a 3 x 4 cm elliptical skin graft was taken from the left supraclavicular region First a 15 Bard Parker was utilized to make an incision in the skin in elliptical fashion After this the skin was then grasped and a full thickness graft was taken with undermining performed by the 15 Bard Parker After this the underlying subcutaneous tissue was then hemostatically controlled with bipolar cauterization After this the tissue was then reapproximated in multiple interrupted 4 0 undyed Vicryl followed by reapproximation of the skin with a 5 0 Prolene After this the skin graft was then defatted with a curved Joseph scissors It was then placed in the oral defect Circumferentially it was sutured down to the edge of the buccal mucosa with multiple interrupted 4 0 undyed Vicryl sutures It was then ________ with a 15 Bard Parker and sutured in from the midportion of the multiple areas with multiple interrupted 4 0 undyed Vicryl After this the patient was then thoroughly cleaned and Mastisol Steri Strips were then placed on the left shoulder defect along with the sterile dressing The patient was then turned back to the Anesthesia extubated in the operating room and transferred to recovery room in stable condition The patient tolerated the procedure well and will be admitted to hospital for observation Keywords surgery buccal mucosal verrucous squamous cell carcinoma skin graft closure supraclavicular buccal mucosal lesion squamous cell carcinoma supraclavicular region bard parker MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Akin bunionectomy right toe with internal wire fixation Medical Specialty Surgery Sample Name Bunionectomy Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot POSTOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot PROCEDURES PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Akin bunionectomy right toe with internal wire fixation ANESTHESIA TIVA local HISTORY This 51 year old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot The patient has a history of gradual onset of a painful bunion over the past several years She has tried conservative methods such as wide shoes accommodative padding on an outpatient basis with Dr X all of which have provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril After adequate IV sedation was administered by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 0 5 Marcaine plain and 1 Lidocaine plain was injected into the foot in a standard Mayo block fashion The foot was elevated off the table Esmarch bandages were used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operative field and the sterile stockinet was reflected A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia which was found to be adequate Attention was directed to the first metatarsophalangeal joint which was found to be contracted laterally deviated and had decreased range of motion A 10 blade was used to make a 4 cm dorsolinear incision A 15 blade was used to deepen the incision through the subcutaneous layer All superficial subcutaneous vessels were ligated with electrocautery Next a linear capsular incision was made down the bone with a 15 blade The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head The medial plantar aspect of the metatarsal head had some erosive changes and eburnation Next a 0 45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it A sagittal saw was used to make a long arm Austin osteotomy in the usual fashion Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex The capital head was shifted laterally and impacted on the residual metatarsal head Nice correction was achieved and excellent bone to bone contact was achieved The bone stock was slightly decreased but adequate Next a 0 45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment A 2 7 x 18 mm Synthes cortical screw was thrown using standard AO technique Excellent rigid fixation was achieved A second 2 0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head Again an excellent rigid fixation was obtained and the screws were tight The temporary fixation was removed A medial overhanging bone was resected with a sagittal saw The foot was loaded and the hallux was found to have an interphalangeus deformity present A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx leaving a lateral intact cortical hinge A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done After the wedge bone was removed the saw blade was reinserted and used to tether the osteotomy with counter pressure used to close down the osteotomy A 15 drill blade was used to drill two converging holes on the medial aspect of the bone A 28 gauge monofilament wire was inserted loop to loop and pulled through the bone The monofilament wire was twisted down and tapped into the distal drill hole The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved Next reciprocating rasps were used to smooth all bony surfaces Copious amounts of sterile saline was used to flush the joint Next a 3 0 Vicryl was used to reapproximate the capsular periosteal tissue layer Next 4 0 Vicryl was used to close the subcutaneous layer 5 0 Vicryl was used to the close the subcuticular layer in a running fashion Next 1 cc of dexamethasone phosphate was then instilled in the joint The Steri Strips were applied followed by standard postoperative dressing consisting of Owen silk 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She is to be partial weightbearing with crutches She is to follow with Dr X She was given emergency contact numbers and instructions to call if problems arise She was given prescription for Vicodin ES 25 one p o q 4 6h p r n pain and Naprosyn one p o b i d 500 mg She was discharged in stable condition Keywords surgery hallux interphalangeus osteotomy bunionectomy akin wire fixation screw fixation painful bunion metatarsophalangeal joint pneumatic ankle metatarsal head foot toe sagittal metatarsal MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Proximal interphalangeal joint arthroplasty bilateral fifth toes Distal interphalangeal joint arthroplasty bilateral third and fourth toes Flexor tenotomy bilateral third toes Medical Specialty Surgery Sample Name Bunionectomy Flexor Tenotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes PROCEDURE PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Proximal interphalangeal joint arthroplasty bilateral fifth toes 3 Distal interphalangeal joint arthroplasty bilateral third and fourth toes 4 Flexor tenotomy bilateral third toes HISTORY This is a 36 year old female who presented to ABCD preoperative holding area after keeping herself n p o since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet The patient has a history of sharp pain which is aggravated by wearing shoes and ambulation She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding all of which provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed in detail by Dr Kaczander with the patient and the consent is available on the chart PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril After adequate IV sedation was administered a total of 18 cc of a 0 5 Marcaine plain was used to anesthetize the right foot performing a Mayo block and a bilateral third fourth and fifth digital block Next the foot was prepped and draped in the usual aseptic fashion bilaterally The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg The foot was lowered into operative field and the sterile stockinet was reflected proximally Attention was directed to the right first metatarsophalangeal joint it was found to be contracted and there was lateral deviation of the hallux There was decreased range of motion of the first metatarsophalangeal joint A dorsolinear incision was made with a 10 blade approximately 4 cm in length The incision was deepened to the subcutaneous layer with a 15 blade Any small veins traversing the subcutaneous layer were ligated with electrocautery Next the medial and lateral wound margins were undermined sharply Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon Next the first metatarsal joint capsule was identified A 15 blade was used to make a linear capsular incision down to the bone The capsular periosteal tissues were elevated off the bone with a 15 blade and the metatarsal head was delivered into the wound The PASA was found to be within normal limits There was a hypertrophic medial eminence noted A sagittal saw was used to remove the hypertrophic medial eminence A 0 045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide A standard lateral release was performed The fibular sesamoid was found to be in the interspace but was relocated onto the metatarsal head properly Next a sagittal saw was used to perform a long arm Austin osteotomy The K wire was removed The capital fragment was shifted laterally and impacted into the head A 0 045 inch Kirschner wire was used to temporarily fixate the osteotomy A 2 7 x 16 mm Synthes fully threaded cortical screw was throne using standard AO technique A second screw was throne which was a 2 0 x 12 mm Synthes cortical screw Excellent fixation was achieved and the screws tightly perched the bone Next the medial overhanging wedge was removed with a sagittal saw A reciprocating rasp was used to smooth all bony prominences The 0 045 inch Kirschner wire was removed The screws were checked again for tightness and found to be very tight The joint was flushed with copious amounts of sterile saline A 3 0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique A 4 0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique A 5 0 Monocryl was used to close the skin in a running subcuticular fashion Attention was directed to the right third digit which was found to be markedly contracted at the distal interphalangeal joint A 15 blade was used to make two convergent semi elliptical incisions over the distal interphalangeal joint The incision was deepened with a 15 blade The wedge of skin was removed in full thickness The long extensor tendon was identified and the distal and proximal borders of the wound were undermined The 15 blade was used to transect the long extensor tendon which was reflected proximally The distal interphalangeal joint was identified and the 15 blade was placed in the joint and the medial and lateral collateral ligaments were released Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx Next a double action bone cutter was used to resect the head of the middle phalanx The toe was dorsiflexed and was found to have an excellent rectus position A hand rasp was used to smooth all bony surfaces The joint was flushed with copious amounts of sterile saline The flexor tendon was found to be contracted therefore a flexor tenotomy was performed through the dorsal incision Next 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin and excellent cosmetic result was achieved Attention was directed to the fourth toe which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated An oblique skin incision with two converging semi elliptical incisions was created using 15 blade The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot All the same suture materials were used However there was no flexor tenotomy performed on this toe only on the third toe bilaterally Attention was directed to the fifth right digit which was found to be contracted at the proximal interphalangeal joint A linear incision approximately 2 cm in length was made with a 15 blade over the proximal interphalangeal joint Next a 15 blade was used to deepen the incision to the subcutaneous layer The medial and lateral margins were undermined sharply to the level of the long extensor tendon The proximal interphalangeal joint was identified and the tendon was transected with the 15 blade The tendon was reflected proximally off the head of the proximal phalanx The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound A double action bone nibbler was used to remove the head of the proximal phalanx A hand rasp was used to smooth residual bone The joint was flushed with copious amounts of saline A 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures A standard postoperative dressing consisting of saline soaked 0 1 silk 4 x 4s Kerlix Kling and Coban were applied The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits Attention was directed to the left foot The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg Attention was directed to the left fifth toe which was found to be contracted at the proximal interphalangeal joint The exact same procedure performed to the right fifth digit was performed on this toe with the same materials being used for suture and closure Attention was then directed to the left fourth digit which was found to contracted and slightly abducted and varus rotated The exact same procedure as performed to the right fourth toe was performed consisting of two semi elliptical skin incisions in an oblique angle The same suture material were used to close the incision Attention was directed to the left third digit which was found to be contracted at the distal interphalangeal joint The same procedure performed on the right third digit was also performed The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot She was given postoperative shoes and will be partial weighbearing with crutches She was admitted short stay to Dr Kaczander for pain control She was placed on Demerol 50 and Vistaril 25 mg IM q3 4h p r n for pain She will have Vicodin 5 500 one to two p o q 4 6h p r n for moderate pain She was placed on Subq heparin and given incentive spirometry 10 times an hour She will be discharged tomorrow She is to ice and elevate both feet today and rest as much as possible Physical Therapy will teach her crutch training today X rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities Keywords surgery hallux abductovalgus hammertoe bunionectomy flexor tenotomy interphalangeal arthroplasty screw fixation osteotomy interphalangeal joint arthroplasty distal interphalangeal joint interphalangeal joint flexor tenotomy proximal interphalangeal joint arthroplasty distal interphalangeal distal blade proximal foot joint toes tendon MEDICAL_TRANSCRIPTION,Description Lumbar osteomyelitis and need for durable central intravenous access Placement of left subclavian 4 French Broviac catheter Medical Specialty Surgery Sample Name Broviac Catheter Placement Transcription PREOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access POSTOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access ANESTHESIA General PROCEDURE Placement of left subclavian 4 French Broviac catheter INDICATIONS The patient is a toddler admitted with a limp and back pain who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas The patient needs prolonged IV antibiotic therapy but attempt at a PICC line failed She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement I met with the patient s mom With the help of a Spanish interpreter I explained the technique for Broviac placement We discussed the surgical risks and alternatives most of which have been exhausted All their questions have been answered and the patient is fit for operation today DESCRIPTION OF OPERATION The patient came to the operating room and had an uneventful induction of general anesthesia We conducted a surgical time out to reiterate all of the patient s important identifying information and to confirm that we were here to place the Broviac catheter Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed A flexible guidewire was inserted into the central location and then a 4 French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines The peel away sheath was passed over the guidewire and then the 4 French catheter was deployed through the peel away sheath There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein then it was withdrawn and easily replaced in the superior vena cava The catheter insertion site was closed with one buried 5 0 Monocryl stitch and the same 5 0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred Heparinized saline solution was used to flush the line A sterile occlusive dressing was applied and the line was prepared for immediate use The patient was transported to the recovery room in good condition There were no intraoperative complications and her blood loss was between 5 and 10 mL during the line placement portion of the procedure Keywords surgery lumbar osteomyelitis central intravenous access subclavian osteomyelitis broviac catheter catheter toddler intravenous MEDICAL_TRANSCRIPTION,Description Hairline biplanar temporal browlift quadrilateral blepharoplasty canthopexy cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy Medical Specialty Surgery Sample Name Browlift Blepharoplasty Rhytidectomy Transcription PREOPERATIVE DIAGNOSES 1 Eyebrow ptosis 2 Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid 3 Cervical facial aging with submental lipodystrophy OPERATION 1 Hairline biplanar temporal browlift 2 Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid 3 Cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy ASSISTANT None ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in a supine position and prepped with general endotracheal anesthesia Local infiltration anesthesia with 1 Xylocaine and 1 100 000 epinephrine was infiltrated in upper and lower eyelids Markings were made and fusiform ellipse of skin was resected from the upper eyelid The lower limb of the fusiform ellipse was at the superior palpebral fold A 9 mm of upper eyelid skin was resected at the widest portion of the lips which extended from medial canthal area to the lateral orbital rim This was performed bilaterally and symmetrically and the skin was removed Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket An incision was made over the superior orbital rim Subperiosteal dissection was performed over the forehead The dissection proceeded medially The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized Hemostasis was achieved with electrocautery in this fashion A 4 cm incision was made and the forehead at the hairline subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid The incision was made in the lower lid just beneath the lashline Subcutaneous dissection was performed over the pretarsal and preseptal muscle Dissection was then proceeded down to the inferior orbital rim The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum which was separated from the inferior orbital rim The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5 0 Vicryl on a P2 needle The upper eyelid incision was closed with a running subcuticular 6 0 Prolene suture bilaterally The forehead was then elevated and the nonhairbearing forehead skin was resected 1 5 cm wide raising the tail of the eyebrow The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided A lateral canthopexy was performed with 5 0 Prolene suture on a C1 double arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides Closure was performed with interrupted 6 0 silk suture for the lower lid The eyebrow hairline brow lift was closed with interrupted 4 0 PDS suture deep subcutaneous tissue and dermis and the skin closed with a running 5 0 Prolene suture Attention then was directed to the cervical facial rhytidectomy and purse string SMAS elevation with submental lipectomy Incisions were made in preauricular area postauricular area mastoid and occipital area Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline Submental lipectomy was performed through the incision in the submental crease Fat was directly removed from the fascia Hemostasis was achieved with electrocautery A SMAS elevation was performed with a purse string suture of 2 0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia This was performed bilaterally and symmetrically Hemostasis was achieved with electrocautery The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed The skin of the cheek and neck were resected which was redundant after the posteriorly and superiorly in the neck and transversely in the cheek Closure was performed with interrupted 3 0 and 4 0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5 0 Prolene suture Drains were placed prior to final closure A 7 mm flat Jackson Pratt was then secured with 3 0 silk suture Dressing consisting of fluffs and Kerlix and a 4 inch Ace were applied to support mildly compressive dressing Scleral eye protectors were removed Maxitrol eye ointment was placed followed by Swiss therapy eye pads The patient tolerated the procedure well and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings TED hose two Jackson Pratt drains and an IV Keywords surgery eyebrow ptosis dermatochalasia hairline jackson pratt swiss therapy arcus marginalis blepharoplasty browlift canthopexy fat transposition inferior orbital rim lipectomy lipodystrophy lower eyelid purse string rhytidectomy string smas elevation suborbicularis oculi frontalis muscle pds suture smas elevation submental lipectomy upper eyelid subperiosteal dissection lower lid prolene suture lower eyelids orbital rim lower eyelids sutured subcutaneous eyebrow orbital MEDICAL_TRANSCRIPTION,Description Plastic piece foreign body in the right main stem bronchus Rigid bronchoscopy with foreign body removal Medical Specialty Surgery Sample Name Bronchoscopy Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Foreign body in airway POSTOPERATIVE DIAGNOSIS Plastic piece foreign body in the right main stem bronchus PROCEDURE Rigid bronchoscopy with foreign body removal INDICATIONS FOR PROCEDURE This patient is 7 month old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom The patient had a chest x ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general mask anesthesia Using a 3 5 rigid bronchoscope we visualized between the cords into the trachea There were some secretions but that looked okay Got down at the level of the carina to see a foreign body flapping in the right main stem I then used graspers to grasp to try to pull into the scope itself I could not do that I thus had to pull the scope out along with the foreign body that was held on to with a grasper It appeared to be consisting of some type of plastic piece that had broke off some different object I took the scope and put it back down into the airway again Again there was secretion in the trachea that we suctioned out We looked down into the right bronchus intermedius There was no other pathology noted just some irritation in the right main stem area I looked down the left main stem as well and that looked okay as well I then withdrew the scope Trachea looked fine as well as the cords I put the patient back on mask oxygen to wake the patient up The patient tolerated the procedure well Keywords surgery main stem bronchus bronchoscopy airway foreign body removal rigid bronchoscopy MEDICAL_TRANSCRIPTION,Description Bronchoscopy with brush biopsies Persistent pneumonia right upper lobe of the lung possible mass Medical Specialty Surgery Sample Name Bronchoscopy 8 Transcription PREOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass POSTOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass PROCEDURE Bronchoscopy with brush biopsies DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was taken to the operating room where he underwent a general endotracheal anesthesia A time out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4 lidocaine had been infused into the endotracheal tube First the trachea and the carina had normal appearance The scope was passed into the left side and the bronchial system was found to be normal There were scars and mucoid secretions Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB First the basal lobes were explored and found to be normal Then the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated Then the bronchi going to the three segments were visualized and no abnormalities or mass were found Brush biopsy was obtained from one of the segments and sent to Pathology The procedure had to be interrupted several times because of the patient s desaturation but after a few minutes of Ambu bagging he recovered satisfactorily At the end the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition Keywords surgery persistent pneumonia bronchoscopy brush biopsies endotracheal tube biopsies bronchial abnormalities pneumonia secretions endotracheal MEDICAL_TRANSCRIPTION,Description Bronchoscopy with aspiration and left upper lobectomy Carcinoma of the left upper lobe Medical Specialty Surgery Sample Name Bronchoscopy Lobectomy Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the left upper lobe PROCEDURES PERFORMED 1 Bronchoscopy with aspiration 2 Left upper lobectomy PROCEDURE DETAILS With patient in supine position under general anesthesia with endotracheal tube in place the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina The carina was in the midline and sharp Moving directly to the right side the right upper and middle lower lobes were examined and found to be free of obstructions Aspiration was carried out for backlog ________ examination We then moved to left side left upper lobe There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction No anatomic lesions were demonstrated The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter After proper position utilizing Betadine solution they were draped A posterolateral left thoracotomy incision was performed Hemostasis was secured with electrocoagulation The chest wall muscle was then divided over the sixth rib The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully At this time the mass was felt in the left upper lobe which measures greater than 3 cm by palpation We examined the superior mediastinum No lymph nodes were demonstrated as well as in the anterior mediastinum Direction was then moved to the fascia where by utilizing sharp and blunt dissection lingual artery was separated into the left upper lobe Casual dissection was carried out with superior segmental arteries and left lower lobe was examined Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue From the top side the bronchus was then separated away from the pulmonary artery anteriorly thus exposing the apical posterior artery which was short Tumor mass was close to the artery at this time We then directed ourselves once again to the lingual artery which was doubly ligated and cut free The posterior artery of the superior branch was doubly ligated and cut free also At this time the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished We then moved anteriorly to doubly ligate the pulmonary vein using 00 silk sutures for ligation and a transection 00 silk suture was used to fixate the vein Using sharp and blunt dissection the bronchus through the left upper lobe was freed proximal Using the TA 50 the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished The anterior artery was seen in the clamp also and was separated and ligated and separated At this time the entire tumor in the left upper lobe was then removed Direction was carried to the suture where 000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place The clamp was then removed No bleeding was seen at this time Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position At this time two chest tubes 28 and 32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture The chest cavity was then closed After reexamination no bleeding was seen with three pericostal sutures of 1 chromic double strength A 2 0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi 000 chromic subcutaneous tissue skin clips to the skin The chest tubes were attached to the Pleur Evac drainage and placed on suction at this time The patient was extubated in the room without difficulty and sent to Recovery in satisfactory Keywords surgery ng tube chest tubes endotracheal tube pulmonary vein artery aspiration lobectomy bronchoscopy tumor vein bronchus pulmonary MEDICAL_TRANSCRIPTION,Description Bronchoscopy with bronchoalveolar lavage Refractory pneumonitis A 69 year old man status post trauma slightly prolonged respiratory failure status post tracheostomy requires another bronchoscopy for further evaluation of refractory pneumonitis Medical Specialty Surgery Sample Name Bronchoscopy Bronchoalveolar Lavage Transcription PREOPERATIVE DIAGNOSIS Refractory pneumonitis POSTOPERATIVE DIAGNOSIS Refractory pneumonitis PROCEDURE PERFORMED Bronchoscopy with bronchoalveolar lavage ANESTHESIA 5 mg of Versed INDICATIONS A 69 year old man status post trauma slightly prolonged respiratory failure status post tracheostomy requires another bronchoscopy for further evaluation of refractory pneumonitis PROCEDURE The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube Bronchoscope was advanced Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially lavaged out Relatively few tenacious secretions were noted These were lavaged out Specimen collected for culture No obvious other abnormalities were noted The patient tolerated the procedure well without complication Keywords surgery respiratory failure bronchoalveolar lavage refractory pneumonitis tracheostomy bronchoalveolar bronchoscopy pneumonitis MEDICAL_TRANSCRIPTION,Description Diagnostic fiberoptic bronchoscopy Medical Specialty Surgery Sample Name Bronchoscopy 7 Transcription PROCEDURE Diagnostic fiberoptic bronchoscopy ANESTHESIA Plain lidocaine 2 was given intrabronchially for local anesthesia PREOPERATIVE MEDICATIONS 1 Lortab 10 mg plus Phenergan 25 mg p o 1 hour before the procedure 2 Versed a total of 5 mg given IV push during the procedure INDICATIONS Keywords surgery fiberoptic intrabronchially larynx distal trachea diagnostic fiberoptic bronchoscopy bronchoscopy bronchoscope MEDICAL_TRANSCRIPTION,Description Bronchoscopy brushings washings and biopsies Patient with a bilateral infiltrates immunocompromised host and pneumonia Medical Specialty Surgery Sample Name Bronchoscopy Brushings Transcription OPERATIVE PROCEDURE Bronchoscopy brushings washings and biopsies HISTORY This is a 41 year old woman admitted to Medical Center with a bilateral pulmonary infiltrate immunocompromise INDICATIONS FOR THE PROCEDURE Bilateral infiltrates immunocompromised host and pneumonia Prior to procedure the patient was intubated with 8 French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress DESCRIPTION OF PROCEDURE Under MAC and fluoroscopy fiberoptic bronchoscope was passed through the ET tube ET tube was visualized approximately 2 cm above the carina Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings The patient tolerated the procedure well Postprocedure the patient is to be placed on a ventilator as well as postprocedure chest x ray pending Specimens are sent for immunocompromise panel including PCP stains POSTPROCEDURE DIAGNOSIS Pneumonia infiltrates Keywords surgery mac fluoroscopy fiberoptic bronchoscope bronchoscopy brushings fiberoptic bronchoscope bronchoscopy biopsies pneumonia immunocompromised MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy with endobronchial biopsies A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6 cm right hilar mass consistent with a primary lung carcinoma Medical Specialty Surgery Sample Name Bronchoscopy Fiberoptic Transcription HISTORY OF PRESENT ILLNESS A 67 year old gentleman who presented to the emergency room with chest pain cough hemoptysis shortness of breath and recent 30 pound weight loss He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6 cm right hilar mass consistent with a primary lung carcinoma There was also a question of liver metastases at that time OPERATION PERFORMED Fiberoptic bronchoscopy with endobronchial biopsies The bronchoscope was passed into the airway and it was noted that there was a large friable tumor blocking the bronchus intermedius on the right The tumor extended into the carina involving the lingula and the left upper lobe appearing malignant Approximately 15 biopsies were taken of the tumor Attention was then directed at the left upper lobe and lingula Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review Approximately eight biopsies were taken of the left upper lobe Keywords surgery endobronchial intermedius fiberoptic bronchoscopy lung carcinoma bronchoscopy fiberoptic chest tumor lobeNOTE MEDICAL_TRANSCRIPTION,Description Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2 Bilateral bronchopneumonia and empyema of the chest left Medical Specialty Surgery Sample Name Bronchoscopy Thoracotomy Transcription PREOPERATIVE DIAGNOSES 1 Bilateral bronchopneumonia 2 Empyema of the chest left POSTOPERATIVE DIAGNOSES 1 Bilateral bronchopneumonia 2 Empyema of the chest left PROCEDURES 1 Diagnostic bronchoscopy 2 Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2 DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was taken to the operating room where a time out process was followed Initially the patient was intubated with a 6 French tube because of the presence of previous laryngectomy Because of this I proceeded to use a pediatric bronchoscope which provided limited visualization but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology although there was some mucus secretion that was aspirated Then with the patient properly anesthetized and looking very stable we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope Therefore we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems Some brownish secretions were obtained particularly from the right side and were sent for culture and sensitivity both aerobic and anaerobic fungi and acid fast Then the patient was turned with left side up and prepped for a left thoracotomy He was properly draped I had recently re inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space Immediately it was evident that there was a large amount of pus in the left chest We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus Then we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung We spent several minutes trying to clean up this area Initially I had planned only to drain the empyema because the patient was in a very poor condition but at this particular moment he was more stable and well oxygenated and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure On the upper part of the chest we had limited access but overall we obtained a large amount of solid exudate and we were able to break out loculations We followed by irrigation with 2000 cc of warm normal saline and then insertion of two 32 chest tubes which are the largest one available in this institution one we put over the diaphragm and the other one going up and down towards the apex The limited thoracotomy was closed with heavy intercostal sutures of Vicryl then interrupted sutures of 0 Vicryl to the muscle layers and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus The chest tubes were secured with sutures and then connected to Pleur evac Then the patient was transported Estimated blood loss was minimal and the patient tolerated the procedure well He was extubated in the operating room and he was transferred to the ICU to be admitted A chest x ray was ordered stat Keywords surgery chest tubes insertion partial pulmonary decortication thoracotomy bronchoscopy empyema bronchopneumonia diagnostic bronchoscopy pulmonary decortication bilateral bronchopneumonia decortication intercostal pulmonary tubes MEDICAL_TRANSCRIPTION,Description Bronchoscopy for hypoxia and increasing pulmonary secretions Medical Specialty Surgery Sample Name Bronchoscopy 6 Transcription PREOPERATIVE DIAGNOSIS Hypoxia and increasing pulmonary secretions POSTOPERATIVE DIAGNOSIS Hypoxia and increasing pulmonary secretions OPERATION Bronchoscopy ANESTHESIA Moderate bedside sedation COMPLICATIONS None FINDINGS Abundant amount of clear thick secretions throughout the main airways INDICATIONS The patient is a 43 year old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion This morning the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube The patient also had new appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x ray Given these findings it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be OPERATION The patient was given additional fentanyl Versed as well as paralytics for the procedure Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus Extensive secretions extended down into the secondary airways This was lavaged with saline and suctioned dry There is no overt specific occlusion of airways nor was there any purulent appearing sputum The bronchoscope was then advanced into the left mainstem bronchus and there was noted to be a small amount of similar appearing secretions which was likewise suctioned and cleaned The bronchoscope was removed and the patient was increased to PEEP of 10 on the ventilator Please note that prior to starting bronchoscopy he was pre oxygenated with 100 O2 The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture Keywords surgery pulmonary secretions bronchoscopy hypoxia peep smv occlusion atelectasis bedside sedation bronchoscope chest x ray mainstem right lower lobe mainstem bronchus MEDICAL_TRANSCRIPTION,Description Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end stage chemotherapy and radiation induced pulmonary fibrosis Medical Specialty Surgery Sample Name Bronchoscopy 2 Transcription INDICATIONS FOR PROCEDURE Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end stage chemotherapy and radiation induced pulmonary fibrosis PREMEDICATION 1 Demerol 50 mg 2 Phenergan 25 mg 3 Atropine 0 6 mg IM 4 Nebulized 4 lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4 lidocaine gel through the right naris 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords PROCEDURE DETAILS With the patient breathing oxygen by nasal cannula being monitored by noninvasive blood pressure cuff and continuous pulse oximetry the Olympus bronchoscope was introduced through the right naris to the level of the cords The cords move normally with phonation and ventilation Two times 2 mL of 1 lidocaine were instilled on the cords and the cords were traversed Further 2 mL of 1 lidocaine was instilled in the trachea just distal to the cords at mid trachea above the carina and on the right and on the left mainstem bronchus Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted Upper lobe and lingula were unremarkable There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment one almost had to pop the bronchoscope around to go down the left mainstem This had been a change from the prior bronchoscopy of unclear significance Distal to this there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns which were faintly hemorrhagic The scope was then removed re introduced up to the right upper lobe middle lobe superior segment right lower anterior lateral and posterior basal subsegments were all evaluated and unremarkable The scope was withdrawn The patient s saturation remained 93 95 throughout the procedure Blood pressure was 103 62 Heart rate at the end of the procedure was about 100 The patient tolerated the procedure well Samples were sent as follows Washings for AFB Gram stain Nocardia Aspergillus and routine culture Lavage for AFB Gram stain Nocardia Aspergillus cell count with differential cytology viral mycoplasma and Chlamydia culture GMS staining RSV by antigen and Legionella and Chlamydia culture Keywords surgery cough bronchoscopy olympus bronchoscope nasal insufflation oral antibiotics pulse oximetry sputum ventilation antibiotics nocardia aspergillus chlamydia atropine lidocaine cords topical MEDICAL_TRANSCRIPTION,Description Rigid bronchoscopy with dilation excision of granulation tissue tumor application of mitomycin C endobronchial ultrasound Medical Specialty Surgery Sample Name Bronchoscopy 4 Transcription PREOPERATIVE DIAGNOSIS Tracheal stenosis and metal stent complications POSTOPERATIVE DIAGNOSIS Tracheal stenosis and metal stent complications ANESTHESIA General endotracheal ENDOSCOPIC FINDINGS 1 Normal true vocal cords 2 Subglottic stenosis down to 5 mm with mature cicatrix 3 Tracheal granulation tissue growing through the stents at the midway point of the stents 5 Three metallic stents in place in the proximal trachea 6 Distance from the true vocal cords to the proximal stent 2 cm 7 Distance from the proximal stent to the distal stent 3 5 cm 8 Distance from the distal stent to the carina 8 cm 9 Distal airway is clear PROCEDURES 1 Rigid bronchoscopy with dilation 2 Excision of granulation tissue tumor 3 Application of mitomycin C 4 Endobronchial ultrasound TECHNIQUE IN DETAIL After informed consent was obtained from the patient and her husband she was brought to the operating theater after sequence induction was done She had a Dedo laryngoscope placed Her airways were inspected thoroughly with findings as described above She was intermittently ventilated with an endotracheal tube placed through the Dedo scope Her granulation tissue was biopsied and then removed with a microdebrider Her proximal trachea was dilated with a combination of balloon Bougie and rigid scopes She tolerated the procedure well was extubated and brought to the PACU Keywords surgery tracheal stenosis dedo scope bronchoscopy cicatrix dilation endotracheal granulation metal stent mitomycin c proximal trachea vocal cords endobronchial ultrasound granulation tissue proximal tracheal stent MEDICAL_TRANSCRIPTION,Description Excision of left breast mass The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin Medical Specialty Surgery Sample Name Breast Mass Excision 2 Transcription PREOPERATIVE DIAGNOSIS Breast mass left POSTOPERATIVE DIAGNOSIS Breast mass left PROCEDURE Excision of left breast mass OPERATION After obtaining an informed consent the patient was taken to the operating room where he underwent general endotracheal anesthesia The time out process was followed Preoperative antibiotic was given The patient was prepped and draped in the usual fashion The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia The whole of specimen including the skin the mass and surrounding subcutaneous tissue and fascia were excised en bloc Hemostasis was achieved with the cautery The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl A small pressure dressing was applied Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition Keywords surgery breast mass excision freely mobile breast mass endotracheal fascia specimen MEDICAL_TRANSCRIPTION,Description Bronchoscopy right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration Medical Specialty Surgery Sample Name Bronchoscopy 1 Transcription PROCEDURE Bronchoscopy right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration DETAILS OF THE PROCEDURE The risks alternatives and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed The patient received topical lidocaine by nebulization The flexible fiberoptic bronchoscope was introduced orally The patient had normal teeth normal tongue normal jaw and her vocal cords moved symmetrically and were without lesions I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies Followup fluoroscopy was negative for pneumothorax I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes I then proceeded to inspect the rest of the tracheobronchial tree which was without lesions I performed a bronchial washing after the biopsies in the right upper lobe I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area All of these samples were sent for histology and cytology respectively Estimated blood loss was approximately 5 cc Good hemostasis was achieved The patient received a total of 12 5 mg of Demerol and 3 mg of Versed and tolerated the procedure well Her ASA score was 2 Keywords surgery bronchoscopy wang needle biopsy bronchial washing bronchoscope bronchus fiberoptic hemostasis lidocaine nebulization right upper lobe transbronchial transbronchial needle aspiration needle aspiration transbronchial needle upper lobe bronchial precarinal biopsies needle lobeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Rigid bronchoscopy removal of foreign body excision of granulation tissue tumor bronchial dilation Argon plasma coagulation placement of a tracheal and bilateral bronchial stents Medical Specialty Surgery Sample Name Bronchoscopy 5 Transcription PREOPERATIVE DIAGNOSIS Airway stenosis with self expanding metallic stent complication POSTOPERATIVE DIAGNOSIS Airway stenosis with self expanding metallic stent complication PROCEDURES 1 Rigid bronchoscopy with removal of foreign body prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation 2 Excision of granulation tissue tumor 3 Bronchial dilation with a balloon bronchoplasty right main bronchus 4 Argon plasma coagulation to control bleeding in the trachea 5 Placement of a tracheal and bilateral bronchial stents with a silicon wire stent ENDOSCOPIC FINDINGS 1 Normal true vocal cords 2 Proximal trachea with high grade occlusion blocking approximately 90 of the trachea due to granulation tissue tumor and break down of metallic stent 3 Multiple stent fractures in the mid portion of the trachea with granulation tissue 4 High grade obstruction of the right main bronchus by stent and granulation tissue 5 Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent 6 All in all a high grade terrible airway obstruction with involvement of the carina left and right main stem bronchus mid distal and proximal trachea TECHNIQUE IN DETAIL After informed consent was obtained from the patient he was brought into the operating field A rapid sequence induction was done He was intubated with a rigid scope Jet ventilation technique was carried out using a rigid and flexible scope A thorough airway inspection was carried out with findings as described above Dr D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway It should be noted that Dr Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments Nevertheless all the visible stent was removed and the airway was much better after with the dilation of balloon and the rigid scope We took measurements and decided to place stents in the trachea left and right main bronchus using a Dumon Y stent It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter The right main stem stent was 2 25 cm in length the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length After it was placed excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords The patient tolerated the procedure well and was brought to the recovery room extubated Keywords surgery airway argon plasma coagulation bronchial dilation balloon bronchoplasty bronchoscopy bronchus foreign body granulation metallic stent stenosis vocal cords granulation tissue tumor plasma coagulation granulation tissue tracheal argon stents bronchial metallic MEDICAL_TRANSCRIPTION,Description Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage Medical Specialty Surgery Sample Name Bronchoalveolar lavage Transcription POSTOPERATIVE DIAGNOSIS Fever PROCEDURES Bronchoalveolar lavage INDICATIONS FOR PROCEDURE The patient is a 28 year old male status post abdominal trauma splenic laceration and splenectomy performed at the outside hospital who was admitted to the Trauma Intensive Care Unit on the evening of August 4 2008 Greater than 24 hours postoperative the patient began to run a fever in excess of 102 Therefore evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage DESCRIPTION OF PROCEDURE The patient was preoxygenated with 100 FIO2 for approximately 5 to 10 minutes prior to the procedure The correct patient and procedure was identified by time out by all members of the team The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter each time suctioning out the sample into the Lukens trap A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology The patient tolerated the procedure well and had no episodes of desaturation apnea or cardiac arrhythmia A postoperative chest x ray was obtained Keywords surgery abdominal trauma bal lavage lukens trap suction splenectomy splenic laceration bronchoalveolar lavage fever catheter bronchoalveolar lavage airwayNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right breast excisional biopsy with needle localization The patient is a 41 year old female with abnormal mammogram with a strong family history of breast cancer requesting needle localized breast biopsy for nonpalpable breast mass Medical Specialty Surgery Sample Name Breast Excisional Biopsy Transcription PREOPERATIVE DIAGNOSIS Right breast mass with abnormal mammogram POSTOPERATIVE DIAGNOSIS Right breast mass with abnormal mammogram PROCEDURE PERFORMED Right breast excisional biopsy with needle localization ANESTHESIA Local with sedation COMPLICATIONS None SPECIMEN Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition BRIEF HISTORY The patient is a 41 year old female who presented to Dr X s office with abnormal mammogram with a strong family history of breast cancer requesting needle localized breast biopsy for nonpalpable breast mass PROCEDURE After informed consent the risks and benefits of the procedure were explained to the patient The patient was brought into the operating suite After IV sedation was given the patient was prepped and draped in normal sterile fashion A radial incision was made in the right lateral breast with a 10 blade scalpel The needle was brought into the field An Allis was used to grasp the breast mass and breast tissue using the 10 scalpel The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen Hemostasis was then obtained with electrobovie cautery The skin was then closed with 4 0 Monocryl in a running subcuticular fashion Steri Strips and sterile dressings were applied The patient tolerated the procedure well and was transferred to Recovery in stable condition Keywords surgery breast mass mammogram breast excisional biopsy needle localization excisional biopsy abnormal mammogram breast radiology scalpel excisional biopsy needle specimen mass MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus Medical Specialty Surgery Sample Name Bronchoscopy 3 Transcription PROCEDURE Fiberoptic bronchoscopy PREOPERATIVE DIAGNOSIS Right lung atelectasis POSTOPERATIVE DIAGNOSIS Extensive mucus plugging in right main stem bronchus PROCEDURE IN DETAIL Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0 5 mg intravenously given in 2 aliquots The patient was breathing supplemental nasal and mask oxygen throughout the procedure Saturations and vital signs remained stable throughout A flexible fiberoptic bronchoscope was passed through the right naris The vocal cords were visualized Secretions in the larynx were as aspirated As before he had a mucocele at the right anterior commissure that did not obstruct the glottic opening The ports were anesthetized and the trachea entered There was no cough reflex helping explain the propensity to aspiration and mucus plugging Tracheal secretions were aspirated The main carinae were sharp However there were thick sticky grey secretions filling the right mainstem bronchus up to the level of the carina This was gradually lavaged clear Saline and Mucomyst solution were used to help dislodge remaining plugs The airways appeared slightly friable but were patent after the airways were suctioned O2 saturations remained in the mid to high 90s The patient tolerated the procedure well Specimens were submitted for microbiologic examination Despite his frail status he tolerated bronchoscopy quite well Keywords surgery bronchoscopy fiberoptic mucomyst atelectasis bronchoscope bronchus carinae larynx main stem mucus nasal plugging trachea fiberoptic bronchoscopy mucus plugging secretions MEDICAL_TRANSCRIPTION,Description Left breast mass and hypertrophic scar of the left breast Excision of left breast mass and revision of scar The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site Medical Specialty Surgery Sample Name Breast Mass Excision 1 Transcription PREOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast POSTOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast PROCEDURE PERFORMED Excision of left breast mass and revision of scar ANESTHESIA Local with sedation SPECIMEN Scar with left breast mass DISPOSITION The patient tolerated the procedure well and transferred to the recover room in stable condition BRIEF HISTORY The patient is an 18 year old female who presented to Dr X s office The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site The patient also has a hypertrophic scar Thus the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass INTRAOPERATIVE FINDINGS A hypertrophic scar was found and removed The cicatrix was removed in its entirety and once opening the wound the area of tissue where the palpable mass was was excised as well and sent to the lab PROCEDURE After informed consent risks and benefits of the procedure were explained to the patient and the patient s family the patient was brought to the operating suite prepped and draped in the normal sterile fashion Elliptical incision was made over the previous cicatrix The total length of the incision was 5 5 cm Removing the cicatrix in its entirety with a 15 blade Bard Parker scalpel after anesthetizing with local solution with 0 25 Marcaine Next the area of tissue just inferior to the palpable mass where the palpable was removed with electro Bovie cautery Hemostasis was maintained Attention was next made to approximating the deep dermal layers An interrupted 4 0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges Steri Strips as well as bacitracin and sterile dressings were applied The patient tolerated the procedure well and was transferred to recovery in stable condition Keywords surgery hypertrophic scar palpable mass fibrocystic scar fibrocystic disease breast mass breast cicatrix excision biopsy hypertrophic palpable MEDICAL_TRANSCRIPTION,Description Bronchoscopy Atelectasis and mucous plugging Medical Specialty Surgery Sample Name Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Atelectasis POSTOPERATIVE DIAGNOSIS Mucous plugging PROCEDURE PERFORMED Bronchoscopy ANESTHESIA Lidocaine topical 2 Versed 3 mg IV Conscious sedation PROCEDURE At bedside a bronchoscope was passed down the tracheostomy tube under monitoring The main carina was visualized The trachea was free of any secretions The right upper lobe middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema Left mainstem appeared patent Left lower lobe had slight plugging in the left base but much better that previous bronchoscopy findings The area was lavaged with some saline and cleared The patient tolerated the procedure well Keywords surgery MEDICAL_TRANSCRIPTION,Description Excisional breast biopsy with needle localization The skin overlying the needle tip was incised in a curvilinear fashion Medical Specialty Surgery Sample Name Breast Biopsy Transcription PROCEDURE PERFORMED Excisional breast biopsy with needle localization ANESTHESIA General PROCEDURE After informed consent was obtained the patient was brought to the radiology suite where needle localization was performed with mammographic guidance I reviewed the localizing films with the radiologist and the patient was then brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner The skin overlying the needle tip was incised in a curvilinear fashion Dissection down to the needle tip was performed using a combination of Metzenbaum scissors and Bovie electrocautery Every attempt was made to get approximately 1 cm of normal tissue around the lesion The wire was released and the lesion having been excised was removed from the wound and sent to Radiology for confirmation of excision The wound was copiously irrigated with sterile water and hemostasis was obtained using Bovie electrocautery Once Radiology called and confirmed complete excision of the mass the skin incision was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords surgery curvilinear fashion bovie electrocautery breast biopsy needle localization needle tip curvilinear breast biopsy needle MEDICAL_TRANSCRIPTION,Description Needle localization and left breast biopsy for left breast mass Medical Specialty Surgery Sample Name Breast Biopsy 2 Transcription PREOPERATIVE DIAGNOSIS Left breast mass POSTOPERATIVE DIAGNOSIS Left breast mass PROCEDURE PERFORMED Needle localization and left breast biopsy ANESTHESIA General FLUIDS 1000 cc ESTIMATED BLOOD LOSS Minimal DRAINS None COMPLICATIONS None SPECIMEN Breast biopsy specimen with localizing needle FINDINGS Breast tissue surrounding needle localization while no palpable mass HISTORY The patient is a very pleasant 51 year old African American female who presented to the office with a mass in the left breast She was seen and evaluated On routine mammography revealed a density in the left breast approximately at 4 o clock position several centimeters lateral to the nipple complex She was readmitted for excisional biopsy Due to the nonpalpable nature of this lesion the patient underwent first needle localization of the breast at the Hospital and was taken to the operating room PROCEDURE IN DETAIL After informed consent was obtained from the patient the patient taken to the operating room and placed in the supine position on the operating table After appropriate general endotracheal anesthesia has been administered to the patient the left breast was prepped and draped in a standard surgical fashion using Betadine solution The localization wire was cut at skin The patient had previously had a reduction mammoplasty in the lateral aspect of the transverse where an incision was re incised to distance of about 4 cm The wire was entering the skin about 2 cm above the incision Superior skin flap was raised using electrocautery and the needle localization wire was brought into the incision At this point a core breast tissue of approximately 2 cm surrounding the needle was excised superiorly inferiorly medially and laterally until the tissue specimen was well below the hook of the needle localization wire The breast specimen was then removed from breast and silk sutures were used to mark the superior and lateral margins This specimen was then sent for mammography Pathologist called in the room to verify that the entire needle localization wire and hook were intact in the specimen At this point the breast cavity was palpated and no other abnormalities were noted The wound was irrigated Bleeding points were easily controlled using electrocautery The wound was closed in two layers using 3 0 Vicryl and 4 0 Monocryl suture in a subcuticular fashion Benzoin Steri Strips 2 x 2 s Tegaderm were placed The patient was aroused from anesthesia and transported to the recovery room in stable condition There were no complications All instrument needle and sponge counts were correct x2 at the end of the case Keywords surgery breast mass needle localization steri strips tegaderm biopsy breast biopsy breast cavity excisional biopsy localization wire room in stable condition skin flap specimen needle localization wire needle breast mammography localization MEDICAL_TRANSCRIPTION,Description Left excisional breast biopsy due to atypical ductal hyperplasia of left breast Medical Specialty Surgery Sample Name Breast Biopsy 1 Transcription PREOPERATIVE DIAGNOSIS Atypical ductal hyperplasia of left breast POSTOPERATIVE DIAGNOSIS Atypical ductal hyperplasia of left breast PROCEDURE Left excisional breast biopsy ANESTHESIA General INDICATIONS This is a 66 year old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001 On recent mammogram she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia Excisional biopsy was therefore recommended Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38 FINDINGS The area in question was excised See details below There was no gross evidence of malignancy Final evaluation will per the permanent sections PROCEDURE Earlier today the patient underwent a wire localization by Dr A She was then taken to the operating room and placed in the supine position The left breast was prepped and draped in the usual sterile fashion A curvilinear incision was made in the upper outer quadrant to include a wire The skin was incised Hemostasis was achieved with cautery device where the breast tissue was excised around the wire The specimens were marked for the long stitch laterally and short stitch superiorly and fair length superficially It was noted that the wire was fairly close to the superior deep aspect of the specimen I therefore excised a new superior deep margin This was performed with electrocautery device the suture marks and new marks on the specimens The main specimen itself was sent for and gross inspection The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections First I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr A This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue The specimens were then cut in serial fashion by Dr Rust the pathologist There was no gross evidence of malignancy As noted above I previously excised the new superior deep margin and this was sent for permanent section The wound was thoroughly irrigated and hemostasis was carefully achieved The subdermal layer was closed with 4 0 PDS in simple interrupted fashion The skin was closed with 4 0 Monocryl in a running subcuticular fashion Steri Strips and dressings were applied All sponge needle and instrument counts were correct The patient tolerated the procedure well and was taken to PACU in stable condition ESTIMATED BLOOD LOSS 5 mL COMPLICATIONS None DRAINS None SPECIMENS Left breast tissue and new superior deep margin Keywords surgery breast atypical ductal hyperplasia breast biopsy carcinoma in situ excisional hyperplasia instrument counts mammogram needle pathology specimen sponge superior deep margin ductal hyperplasia deep margin hemostasis biopsy MEDICAL_TRANSCRIPTION,Description Excision of right breast mass Right breast mass with atypical proliferative cells on fine needle aspiration Medical Specialty Surgery Sample Name Breast Mass Excision Transcription PREOPERATIVE DIAGNOSIS Right breast mass with atypical proliferative cells on fine needle aspiration POSTOPERATIVE DIAGNOSIS Benign breast mass ANESTHESIA General NAME OF OPERATION Excision of right breast mass PROCEDURE With the patient in the supine position the right breast was prepped and draped in a sterile fashion A curvilinear incision was made directly over the mass in the upper outer quadrant of the right breast Dissection was carried out around a firm mass which was dissected with surrounding margins of breast tissue Hemostasis was obtained using electrocautery Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma but appeared benign The breast tissues were approximated using 4 0 Vicryl The skin was closed using 5 0 Vicryl running subcuticular stitches A sterile bandage was applied The patient tolerated the procedure well Keywords surgery atypical proliferative cells fine needle aspiration proliferative cells breast mass breast needle aspiration fibroadenoma excision proliferative mass MEDICAL_TRANSCRIPTION,Description Brachytherapy iodine 125 seed implantation and cystoscopy Medical Specialty Surgery Sample Name Brachytherapy Transcription PREOPERATIVE DIAGNOSIS Prostate cancer POSTOPERATIVE DIAGNOSIS Prostate cancer OPERATIONS Brachytherapy iodine 125 seed implantation and cystoscopy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal Total number of seeds placed 63 Needles 24 BRIEF HISTORY OF THE PATIENT This is a 57 year old male who was seen by us for elevated PSA The patient had a prostate biopsy with T2b disease Gleason 6 Options such as watchful waiting robotic prostatectomy seed implantation with and without radiation were discussed Risks of anesthesia bleeding infection pain MI DVT PE incontinence rectal dysfunction voiding issues burning pain unexpected complications such as fistula rectal injury urgency frequency bladder issues need for chronic Foley for six months etc were discussed The patient understood all the risks benefits and options and wanted to proceed with the procedure The patient was told that there could be other unexpected complications The patient has history of urethral stricture The patient was told about the risk of worsening of the stricture with radiation Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR Anesthesia was applied The patient was placed in the dorsal lithotomy position The patient had SCDs on The patient was given preop antibiotics The patient had done bowel prep the day before Transrectal ultrasound was performed The prostate was measured at about 32 gm The images were transmitted to the computer system for radiation oncologist to determine the dosing etc Based on the computer analysis the grid was placed Careful attention was drawn to keep the grid away from the patient There was a centimeter distance between the skin and the grid Under ultrasound guidance the needles were placed first in the periphery of the prostate a total of 63 seeds were placed throughout the prostate A total of 24 needles was used Careful attention was drawn to stay away from the urethra Under longitudinal ultrasound guidance all the seeds were placed There were no seeds visualized in the bladder under ultrasound There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position Other than that all the seeds were very well distributed throughout the prostate under fluoroscopy Please note that the Foley catheter was in place throughout the procedure Prior to the seed placement the Foley was attempted to be placed but we had to do it using a Glidewire to get the Foley in and we used a Councill tip catheter The patient has had history of bulbar urethral stricture Pictures were taken of the strictures in the pre seed placement cysto time frame We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in At the end of the procedure again cystoscopy was done the entire bladder was visualized The stricture was wide open The prostate was slightly enlarged The bladder appeared normal There was no sheath inside the urethra or in the bladder The cysto was done using 30 degree and 70 degree lens At the end of the procedure a Glidewire was placed and 18 Councill tip catheter was placed The plan was for Foley to be left in place overnight since the patient has history of urethral strictures The patient is to follow up tomorrow to have the Foley removed The patient could also be shown to have it removed at home The patient was brought to Recovery in stable condition at the end of the procedure The patient tolerated the procedure well Keywords surgery iodine 125 seed implantation seed implantation prostate cancer cystoscopy brachytherapy councill tip catheter brachytherapy iodine ultrasound catheter urethral prostate MEDICAL_TRANSCRIPTION,Description Bilateral myringotomy and tube placement tonsillectomy and adenoidectomy Medical Specialty Surgery Sample Name BMT T A Transcription PREOPERATIVE DIAGNOSES Chronic otitis media and tonsillar adenoid hypertrophy POSTOPERATIVE DIAGNOSES Chronic otitis media and tonsillar adenoid hypertrophy PROCEDURES Bilateral myringotomy and tube placement tonsillectomy and adenoidectomy INDICATIONS FOR PROCEDURE The patient is a 3 1 2 year old child with history of recurrent otitis media as well as snoring and chronic mouth breathing Risks and benefits of surgery including risk of bleeding general anesthesia tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents FINDINGS The patient was brought to the operating room placed in supine position given general endotracheal anesthesia The left ear was then draped in a clean fashion Under microscopic visualization the ear canal was cleaned of the wax Myringotomy incision was made in the anterior inferior quadrant There was no fluid in the middle ear space A Micron Bobbin tube was easily placed Floxin drops were placed in the ear The same was performed on the right side with similar findings The patient was then turned to be placed in Rose position The patient draped in clean fashion A small McIvor mouth gag was used to hold open the oral cavity The soft palate was palpated There was no submucous cleft felt Using a 1 1 mixture of 1 Xylocaine with 1 100 000 epinephrine and 0 25 Marcaine both tonsillar pillars and the fossae injected with approximately 7 mL total Using a curved Allis the right tonsil was grasped and pulled medially Tonsil was dissected off the tonsillar fossa using a Coblator The left tonsil was removed in the similar fashion Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting The soft palate was then retracted using red rubber catheter Under mirror visualization the patient was found to have enlarged adenoids The adenoids were removed using the Coblator Hemostasis was also achieved using the Coblator on coagulation setting The rubber catheter was then removed Reexamining the oropharynx small bleeding points were cauterized with the Coblator Stomach contents were then aspirated with saline sump The patient was woken up from anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge correct Estimated blood loss minimal Keywords surgery bilateral myringotomy tube placement tonsillectomy adenoidectomy micron bobbin myringotomy and tube tonsillectomy and adenoidectomy chronic otitis media tonsillar adenoid tonsillar fossa rubber catheter otitis media adenoids myringotomy otitis media tonsillar coblator MEDICAL_TRANSCRIPTION,Description Tailor s bunion right foot Removal of bone right fifth metatarsal head Medical Specialty Surgery Sample Name Bone Removal Metatarsal Head Transcription PREOPERATIVE DIAGNOSIS Tailor s bunion right foot POSTOPERATIVE DIAGNOSIS Tailor s bunion right foot PROCEDURE PERFORMED Removal of bone right fifth metatarsal head ANESTHESIA TIVA local HISTORY This 60 year old male presents to ABCD Preoperative Holding Area after keeping himself n p o since mid night for surgery on his painful right Tailor s bunion The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr X At this time he desires surgical correction as the ulcer has been refractory to conservative treatment Incidentally the ulcer is noninfective and practically healed at this date The consent is available on the chart for review and Dr X has discussed the risks versus benefits of this procedure to the patient in detail PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room placed on the operating table in supine position and a safety strap was placed across his waist for his protection A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient s protection After adequate IV sedation was administered by the Department of Anesthesia a total of 10 cc of 1 1 mixture of 1 lidocaine and 0 5 Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operating field and a sterile stockinet was reflected The Betadine was cleansed with saline soaked gauze and dried Anesthesia was tested with a one tooth pickup and found to be adequate A 10 blade was used to make 3 5 cm linear incision over the fifth metatarsophalangeal joint A 15 blade was used to deepen the incision to the subcutaneous layer Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally Using a combination of sharp and blunt dissection the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia A linear capsular incision was made with a 15 blade down to the bone The capsular periosteal tissues were elevated off the bone with a 15 blade Metatarsal head was delivered into the wound There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer The ulcer on the skin was approximately 2 x 2 mm it was partial skin thickness and did not probe A sagittal saw was used to resect the hypertrophic lateral eminence The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity Next a reciprocating rasp was used to smoothen all bony surfaces The bone stock had an excellent healthy appearance and did not appear to be infected Copious amount of sterile gentamicin impregnated saline were used to flush the wound The capsuloperiosteal tissues were reapproximated with 3 0 Vicryl in simple interrupted technique The subcutaneous layer was closed with 4 0 Vicryl in simple interrupted technique Next the skin was closed with 4 0 nylon in a horizontal mattress suture technique A standard postoperative dressing was applied consisting of Betadine soaked Owen silk 4x4s Kerlix and Kling The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits The patient tolerated the above anesthesia and procedure without complications He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot He was given a postop shoe and will be full weightbearing He has prescription already at home for hydrocodone and does not need to refill He is to follow up with Dr X and was given emergency contact numbers He was discharged in stable condition Keywords surgery pneumatic ankle metatarsal head tailor s bunion head pneumatic ulceration metatarsal bone MEDICAL_TRANSCRIPTION,Description Surgical removal of completely bony impacted teeth 1 16 17 and 32 Completely bony impacted teeth 1 16 17 and 32 Medical Specialty Surgery Sample Name Bony Impacted Teeth Removal Transcription PREOPERATIVE DIAGNOSIS Completely bony impacted teeth 1 16 17 and 32 POSTOPERATIVE DIAGNOSIS Completely bony impacted teeth 1 16 17 and 32 PROCEDURE Surgical removal of completely bony impacted teeth 1 16 17 and 32 ANESTHESIA General nasotracheal COMPLICATIONS None CONDITION Stable to PACU DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure A gauze throat pack was placed and local anesthetic was administered in all four quadrants a total of 7 2 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of bupivacaine 0 5 with 1 200 000 epinephrine Beginning on the upper right tooth 1 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal aspect with straight elevator Potts elevator was then used to luxate the tooth from the socket Remnants of the follicle were then removed with hemostat The area was irrigated and then closed with 3 0 gut suture On the lower right tooth 32 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal and distal aspect with a high speed drill with a round bur Tooth was then sectioned with the bur and removed in several pieces Remnants of the follicle were removed with a curved hemostat The area was irrigated with normal saline solution and closed with 3 0 gut sutures Moving to 16 on the upper left incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal aspect with straight elevator Potts elevator was then used to luxate the tooth from the socket Remnants of the follicle were removed with a curved hemostat The area was irrigated with normal saline solution and closed with 3 0 gut sutures Moving to the lower left 17 incision was made with a 15 blade Envelope flap was raised with the periosteal elevator and bone was removed on the buccal and distal aspect with high speed drill with a round bur Then the bur was used to section the tooth vertically Tooth was removed in several pieces followed by the removal of the remnants of the follicle The area was irrigated with normal saline solution and closed with 3 0 gut sutures Upon completion of the procedure the throat pack was removed and the pharynx was suctioned An NG tube was then inserted and small amount of gastric contents were suctioned Patient was then awakened extubated and taken to the PACU in stable condition Keywords surgery intraoral bony impacted teeth throat pack buccal aspect saline solution gut sutures envelope flap periosteal elevator MEDICAL_TRANSCRIPTION,Description Bilateral myringotomy tubes and adenoidectomy Medical Specialty Surgery Sample Name BMT Adenoidectomy Transcription PREOPERATIVE DIAGNOSIS Chronic otitis media POSTOPERATIVE DIAGNOSIS Chronic otitis media PROCEDURE PERFORMED Bilateral myringotomy tubes and adenoidectomy INDICATIONS FOR PROCEDURE The patient is an 8 year old child with history of recurrent otitis media The patient has had previous tube placement Tubes have since plugged and are no more functioning The patient has had recent recurrent otitis media Risks and benefits in terms of bleeding anesthesia and tympanic membrane perforation were discussed with the mother Mother wished to proceed with the surgery PROCEDURE IN DETAIL The patient was brought to the room placed supine The patient was given general endotracheal anesthesia Starting on the left ear under microscopic visualization the ear was cleaned of wax A Bobbin tube was found stuck to the tympanic membrane This was removed After removing the tube the patient was found to have microperforation through which serous fluid was draining A fresh myringotomy was made in the anterior inferior quadrant More serous fluid was aspirated from middle ear space The new Bobbin tube was easily placed Floxin drops were placed in the ear In the right ear again under microscopic visualization the ear was cleaned the tube was removed off tympanic membrane There was no perforation seen however there was some granulation tissue on the surface of tympanic membrane A fresh myringotomy incision was made in the anterior inferior quadrant More serous fluid was drained out of middle ear space The tube was easily placed and Floxin drops were placed in the ear This completes tube portion of the surgery The patient was then turned and placed in the Rose position Shoulder roll was placed for neck extension Using a small McIvor mouth gag mouth was held open Using a rubber catheter the soft palate was retracted Under mirror visualization the nasopharynx was examined The patient was found to have minimal adenoidal tissue This was removed using a suction Bovie The patient was then awakened from anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge count correct Estimated blood loss none Keywords surgery chronic otitis media bilateral myringotomy tubes adenoidectomy myringotomy tubes and adenoidectomy middle ear space bilateral myringotomy bobbin tube fresh myringotomy serous fluid otitis media tympanic membrane tubes myringotomy otitis media membrane MEDICAL_TRANSCRIPTION,Description Frontal craniotomy for placement of deep brain stimulator electrode Microelectrode recording of deep brain structures Intraoperative programming and assessment of device Medical Specialty Surgery Sample Name Brain Stimulator Electrode Transcription PREOPERATIVE DIAGNOSIS Tremor dystonic form POSTOPERATIVE DIAGNOSIS Tremor dystonic form COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 mL ANESTHESIA MAC monitored anesthesia care with local anesthesia TITLE OF PROCEDURES 1 Left frontal craniotomy for placement of deep brain stimulator electrode 2 Right frontal craniotomy for placement of deep brain stimulator electrode 3 Microelectrode recording of deep brain structures 4 Stereotactic volumetric CT scan of head for target coordinate determination 5 Intraoperative programming and assessment of device INDICATIONS The patient is a 61 year old woman with a history of dystonic tremor The movements have been refractory to aggressive medical measures felt to be candidate for deep brain stimulation The procedure is discussed below I have discussed with the patient in great deal the risks benefits and alternatives She fully accepted and consented to the procedure PROCEDURE IN DETAIL The patient was brought to the holding area and to the operating room in stable condition She was placed on the operating table in seated position Her head was shaved Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50 50 mixture of 0 5 Marcaine and 2 lidocaine in all planes IV antibiotics were administered as was the sedation She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken The images were then transported to the surgery planned work station where a 3 D reconstruction was performed and the target coordinates were then chosen Target coordinates chosen were 20 mm to the left of the AC PC midpoint 3 mm anterior to the AC PC midpoint and 4 mm below the AC PC midpoint Each coordinate was then transported to the operating room as Leksell coordinates The patient was then placed on the operating table in a seated position once again Foley catheter was placed and she was secured to the table using the Mayfield unit At this point then the patient s right frontal and left parietal bossings were cleaned shaved and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes Sterile drapes placed around the perimeter of the field This same scalp region was then anesthetized with same local anesthetic mixture A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings Bur holes were created on either side of the midline just behind the coronal suture Hemostasis was controlled using bipolar and Bovie and self retaining retractors had been placed in the field Using the drill then two small grooves were cut in the frontal bone with a 5 mm cutting burs and Stryker drill The bur holes were then curetted free the dura cauterized and then opened in a cruciate manner on both sides with a 11 blade The cortical surface was then nicked with a 11 blade on both sides as well The Leksell arc with right sided coordinate was dialed in was then secured to the frame Microelectrode drive was secured to the arc Microelectrode recording was then performed The signatures of the cells were recognized Microelectrode unit was removed Deep brain stimulating electrode holding unit was mounted The DBS electrode was then loaded into target and intraoperative programming and testing was performed Using the screener box and standard parameters the patient experienced some relief of symptoms on her left side This electrode was secured in position using bur hole ring and cap system Attention was then turned to the left side where left sided coordinates were dialed into the system The microelectrode unit was then remounted Microelectrode recording was then undertaken After multiple passes the microelectrode unit was removed Deep brain stimulator electrode holding unit was mounted at the desired trajectory The DBS electrode was loaded into target and intraoperative programming and testing was performed once again using the screener box Using standard parameters the patient experienced similar results on her right side This electrode was secured using bur hole ring and cap system The arc was then removed A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel We then closed the electrode replaced subgaleally Copious amounts of Betadine irrigation were used Hemostasis was controlled using the bipolar only Closure was instituted using 3 0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples Sterile dressings were applied The Leksell arc was then removed She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition All needle sponge cottonoid and blade counts were correct x2 as verified by the nurses Keywords surgery dystonic ac pc ct scan dbs electrode intraoperative programming microelectrode stereotactic tremor brain stimulator craniotomy device dystonic tremor electrode frontal screener box target coordinate volumetric deep brain stimulator electrode brain stimulator electrode volumetric ct stimulator brain MEDICAL_TRANSCRIPTION,Description Lower lid blepharoplasty Medical Specialty Surgery Sample Name Blepharoplasty Lower Lid Transcription An orbital block was done An infraorbital block was also performed with a 25 gauge needle A skin muscle flap was elevated by sharp dissection down to the orbital rim area The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade teasing the periorbital fat out cross clamping the fat and removing the fat with a scissor over the clamp The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade The remaining fat was left to fall back into the orbit This was done in three compartments the middle medial and lateral compartments Fat was removed from all three compartments Then with the mouth open and the eyes in upward gaze the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6 0 silk sutures Bleeding was minimal The patient tolerated the procedure well Keywords surgery lower lid wydase blepharoplasty infraorbital block muscle flap orbital rim area orbital septum periorbital fat subciliary incision upward gaze orbital clampingNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 Removal of benign cyst and extraction of full bone impacted tooth 17 Medical Specialty Surgery Sample Name Bone Impacted Tooth Removal Transcription PREOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 POSTOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 PROCEDURE Removal of benign cyst and extraction of full bone impacted tooth 17 ANESTHESIA General anesthesia with nasal endotracheal intubation SPECIMEN Cyst and section tooth 17 ESTIMATED BLOOD LOSS 10 mL FLUIDS 1200 of Lactated Ringer s COMPLICATIONS None CONDITION The patient was extubated and transported to the PACU in good condition Breathing spontaneously INDICATION FOR PROCEDURE The patient is a 38 year old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible Preoperatively a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible it was determined that the patient would benefit from removal of the cyst and removal of tooth 17 under general anesthesia in the operating room Risks benefits and alternatives of treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was taken to the operating room 1 at Hospital and laid in the supine fashion on the operating room table As stated general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics The patient was prepped and draped in usual oro maxillofacial surgery fashion Approximately 6 mL of 2 lidocaine with 1 100 000 epinephrine was injected in the usual nerve block fashion After waiting appropriate time for local anesthesia to take effect a moistened Ray Tec sponge was placed in the posterior pharynx Peridex mouth rinse was used to prep the oral cavity This was removed with suction Using a 15 blade a sagittal split osteotomy incision was made along the left ramus A full thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super erupted since the biopsy 6 weeks earlier Using a Hall drill a buccal osteotomy was developed the tooth was sectioned in half fractured with an elevator and delivered in two pieces Using a double ended curette the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review The area was irrigated with copious amounts of sterile water and closed with 3 0 chromic gut suture The throat pack was removed The procedure was then determined to be over and the patient was extubated breathing spontaneously and transported to the PACU in good condition Keywords surgery dentigerous wisdom tooth extraction bone impacted tooth nasal endotracheal dentigerous cyst cyst intubation osteotomy mandible MEDICAL_TRANSCRIPTION,Description Blepharoplasty with direct brow repair Medical Specialty Surgery Sample Name Blepharoplasty Direct Brow Repair Transcription PREOPERATIVE DX Dermatochalasis mechanical ptosis brow ptosis POSTOPERATIVE DX Same PROCEDURE Upper lid blepharoplasty and direct brow lift ANESTHESIA Local with sedation INDICATIONS FOR SURGERY In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction Visual field testing showed superior hemifield loss on the right and superior hemifield loss on the left These field losses resolved with upper eyelid taping which simulates the expected surgical correction Photodocumentation also showed the upper eyelids resting on the upper eyelashes as well as a decrease in the effective superior marginal reflex distance The risks benefits limitations alternatives and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation DESCRIPTION OF PROCEDURE On the day of surgery the surgical site and procedure were verified by the physician with the patient An informed consent was signed and witnessed EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia Two drops of topical proparacaine eye drops were placed on the ocular surface The skin was cleaned with alcohol prep pads The patient received 3 to 4 mL of 2 Lidocaine with epinephrine and 0 5 Marcaine mixture to each upper lid 5 to 6 mL of local were also given to the brow region along the entire length Pressure was applied over each site for 5 minutes The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side The contour of the outline was created to provide a greater temporal lift Care was taken to preserve a natural contour to the brow shape consistent with the patient s desired features Using a 15 blade the initial incision was placed just inside the superior most row of brow hairs in parallel with the follicle growth orientation The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line The dimensions of the redundant tissue measured horizontally and vertically The redundant tissue was removed sharply with Westcott scissors Hemostasis was maintained with hand held cautery and or electrocautery The closure was carried out in multiple layers The deepest muscular subcutaneous tissue was closed with 4 0 transparent nylon in a horizontal mattress fashion The intermediate layer was closed with 5 0 Vicryl similarly The skin was closed with 6 0 nylon in a running lock fashion Iced saline gauze pads were placed over the incision sites This completed the brow repair portion of the case Using a surgical marking pen a vertical line was drawn from the superior punctum to the eyebrow An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow These lines served as the relative boundary for the horizontal length of the blepharoplasty incision The desired amount of redundant tissue to be excised was carefully pinched together with 0 5 forceps This tissue was outlined with a surgical marking pen Care was taken to avoid excessive skin removal near the brow region A surgical ruler was used to ensure symmetry The skin and superficial orbicularis were incised with a 15 blade on the first upper lid This layer was removed with Westcott scissors Hemostasis was achieved with high temp hand held pen cautery The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified amount of central preaponeurotic fat was removed with cautery amount of nasal fat pad was removed in the same fashion Care was taken to not disturb the levator aponeurosis A symmetric amount of fat was removed from each side Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6 0 nylon Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface Saline gauze and cold packs were placed over the upper lids The patient was taken from the surgical suite in good condition DISCHARGE In the recovery area the results of surgery were discussed with the patient and their family Specific instructions to resume all p o oral medications including anticoagulants antiplatelets were given Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member Instructions on antibiotic ointment use were reviewed The incision sites were checked prior to release The patient was released to home with a driver after vital signs were deemed stable Keywords surgery dermatochalasis erythromycin ophthalmic saline gauze blepharoplasty brow ptosis cold packs direct brow lift follicle growth hemifield loss marginal reflex mechanical ptosis ocular surface superficial orbicularis visual field surgical marking pen direct brow redundant tissue incision sites incision brow ptosis surgical MEDICAL_TRANSCRIPTION,Description Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging Medical Specialty Surgery Sample Name Blepharoplasty Quad Transcription PREOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging POSTOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging PROCEDURE Quad blepharoplasty ANESTHESIA General ESTIMATED BLOOD LOSS Minimal CONDITION The patient did well PROCEDURE The patient had marks and measurements prior to surgery Additional marks and measurements were made at the time of surgery these were again checked At this point the area was injected with 0 5 lidocaine with 1 200 000 epinephrine Appropriate time waited for the anesthetic and epinephrine effect Beginning on the left upper lid the skin excision was completed The muscle was opened herniated adipose tissue pad in the middle and medial aspect was brought forward cross clamped excised cauterized and allowed to retract The eyes were kept irrigated and protected throughout the procedure Attention was turned to the opposite side Procedure was carried out in the similar manner At the completion the wounds were then closed with a running 6 0 Prolene skin adhesives and Steri Strips Attention was turned to the right lower lid A lash line incision was made A skin flap was elevated and the muscle was opened Large herniated adipose tissue pads were present in each of the three compartments They were individually elevated cross clamped excised cauterized and allowed to retract At the completion a gentle tension was placed on the facial skin and several millimeters of the skin excised Attention was turned to he opposite side The procedure was carried out as just described The contralateral side was reexamined and irrigated Hemostasis was good and it was closed with a running 6 0 Prolene The opposite side was closed in a similar manner Skin adhesives and Steri Strips were applied The eyes were again irrigated and cool Swiss Eye compresses applied At the completion of the case the patient was extubated in the operating room breathing on her own doing well and transferred in good condition from operating room to recovering room Keywords surgery blepharochalasia lower lid swiss eye compresses adipose tissue pad bagging blepharoplasty lash line incision quad blepharoplasty MEDICAL_TRANSCRIPTION,Description Excisional biopsy of skin nevus and two layer plastic closure Trichloroacetic acid treatment to left lateral nasal skin 2 5 cm to treat actinic keratosis Medical Specialty Surgery Sample Name Biopsy Skin Nevus Transcription PREOPERATIVE DIAGNOSES 1 Left back skin nevus 2 cm 2 Right mid back skin nevus 1 cm 3 Right shoulder skin nevus 2 5 cm 4 Actinic keratosis left lateral nasal skin 2 5 cm POSTOPERATIVE DIAGNOSES 1 Left back skin nevus 2 cm 2 Right mid back skin nevus 1 cm 3 Right shoulder skin nevus 2 5 cm 4 Actinic keratosis left lateral nasal skin 2 5 cm PATHOLOGY Pending TITLE OF PROCEDURES 1 Excisional biopsy of left back skin nevus 2 cm two layer plastic closure 2 Excisional biopsy of mid back skin nevus 1 cm one layer plastic closure 3 Excisional biopsy of right shoulder skin nevus 2 5 cm one layer plastic closure 4 Trichloroacetic acid treatment to left lateral nasal skin 2 5 cm to treat actinic keratosis ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 8 mL BLOOD LOSS Minimal COMPLICATIONS None PROCEDURE Consent was obtained The areas were prepped and draped and localized in the usual manner First attention was drawn to the left back An elliptical incision was made with a 15 blade scalpel The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse After dissection the skin was undermined Radiofrequency cautery was used for hemostasis and using a 5 0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4 0 nylon interrupted suture Next attention was drawn to the mid back The skin was incised with a vertical elliptical incision with a 15 blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors Afterwards the skin was approximated using 4 0 nylon interrupted sutures Next attention was drawn to the shoulder lesion It was previously marked and a 15 blade scalpel was used to make an elliptical incision into the skin Next the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis Next subcuticular plain was closed with 5 0 undyed Vicryl interrupted suture Skin was closed with 4 0 nylon suture interrupted Lastly trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed Please refer to separate operative report for details The patient tolerated this procedure very well and we will follow up next week for postoperative re evaluation or sooner if there are any problems Keywords surgery mid back skin nevus actinic keratosis trichloroacetic acid treatment bishop forceps skin nevus plastic closure curved iris iris scissors nasal skin nevus biopsy nasal forceps MEDICAL_TRANSCRIPTION,Description Right axillary adenopathy thrombocytopenia and hepatosplenomegaly Right axillary lymph node biopsy Medical Specialty Surgery Sample Name Biopsy Axillary Lymph Node Transcription PREOPERATIVE DIAGNOSES 1 Right axillary adenopathy 2 Thrombocytopenia 3 Hepatosplenomegaly POSTOPERATIVE DIAGNOSES 1 Right axillary adenopathy 2 Thrombocytopenia 3 Hepatosplenomegaly PROCEDURE PERFORMED Right axillary lymph node biopsy ANESTHESIA Local with sedation COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to the recovery room in stable condition BRIEF HISTORY The patient is a 37 year old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly The working diagnosis is lymphoma however the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis Thus the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery INTRAOPERATIVE FINDINGS The patient was found to have a large right axillary lymphadenopathy one of the lymph node was sent down as a fresh specimen PROCEDURE After informed written consent risks and benefits of this procedure were explained to the patient The patient was brought to the operating suite prepped and draped in a normal sterile fashion Multiple lymph nodes were palpated in the right axilla however the most inferior node was to be removed First the skin was anesthetized with 1 lidocaine solution Next using a 15 blade scalpel an incision was made approximately 4 cm in length transversally in the inferior axilla Next using electro Bovie cautery maintaining hemostasis dissection was carried down to the lymph node The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab Several hemostats were used suture ligated with 3 0 Vicryl suture and hemostasis was maintained Next the deep dermal layers were approximated with 3 0 Vicryl suture After the wound has been copiously irrigated the skin was closed with running subcuticular 4 0 undyed Vicryl suture and the pathology is pending The patient did tolerated the procedure well Steri Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition Keywords surgery hepatosplenomegaly thrombocytopenia axillary adenopathy axillary lymph node biopsy axillary lymph node lymph node biopsy lymph node lymph node axillary adenopathy hemostasis suture biopsy MEDICAL_TRANSCRIPTION,Description Repair of entropion left upper lid with excision of anterior lamella and cryotherapy Repairs of blepharon entropion right lower lid with mucous membrane graft Medical Specialty Surgery Sample Name Blepharon Entropion Repair Transcription PREOPERATIVE DIAGNOSES 1 Entropion left upper lid 2 Entropion and some blepharon right lower lid TITLE OF OPERATION 1 Repair of entropion left upper lid with excision of anterior lamella and cryotherapy 2 Repairs of blepharon entropion right lower lid with mucous membrane graft PROCEDURE IN DETAIL The patient was brought to the operating room and prepped and draped in the usual fashion The left upper lid and right lower lid were all infiltrated with 2 Xylocaine with Epinephrine The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0 5 mm in thickness The graft was placed in saline and a 4 x 4 was placed over the lower lid Attention was then drawn to the left upper lid and the operating microscope was found to place An incision was made in the gray line nasally in the area of trichiasis and entropion and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised Bleeding was controlled with the wet field cautery and the cryoprobe was then used with a temperature of 8 degree centigrade in the freeze thaw refreeze technique to treat the bed of the excised area Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade Some of the blepharon were dissected from the globe and bleeding was controlled with the wet field cautery An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6 0 chromic catgut suture anteriorly and posteriorly The graft was in good position and everything was satisfactory at the end of procedure Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied No patch was applied to the left eye The patient tolerated the procedure well and was sent to recovery room in good condition Keywords surgery entropion blepharon catgut suture cryoprobe cryotherapy freeze thaw refreeze lamella lid lower lid tarsal plate trichiasis upper lid mucous membrane graft anterior lamella mucous membrane membrane MEDICAL_TRANSCRIPTION,Description Cystoscopy bladder biopsies and fulguration Bladder lesions with history of previous transitional cell bladder carcinoma pathology pending Medical Specialty Surgery Sample Name Bladder Biopsies Fulguration Transcription PREOPERATIVE DIAGNOSIS Bladder lesions with history of previous transitional cell bladder carcinoma POSTOPERATIVE DIAGNOSIS Bladder lesions with history of previous transitional cell bladder carcinoma pathology pending OPERATION PERFORMED Cystoscopy bladder biopsies and fulguration ANESTHESIA General INDICATION FOR OPERATION This is a 73 year old gentleman who was recently noted to have some erythematous somewhat raised bladder lesions in the bladder mucosa at cystoscopy He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months Recent cystoscopy raises suspicion of another recurrence OPERATIVE FINDINGS The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder Scarring was noted along the base of the bladder from the patient s previous cysto TURBT Ureteral orifice on the right side was not able to be identified The left side was unremarkable DESCRIPTION OF OPERATION The patient was taken to the operating room He was placed on the operating table General anesthesia was administered after which the patient was placed in the dorsal lithotomy position The genitalia and lower abdomen were prepared with Betadine and draped subsequently The urethra and bladder were inspected under video urology equipment 25 French panendoscope with the findings as noted above Cup biopsies were taken in two areas from the right lateral wall of the bladder the posterior wall of bladder and the bladder neck area Each of these biopsy sites were fulgurated with Bugbee electrodes Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear The patient s bladder was then emptied Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area There were no apparent complications and the patient appeared to tolerate the procedure well Estimated blood loss was less than 15 mL Keywords surgery cystoscope carcinoma transitional cell bladder carcinoma bladder lesions bladder fulguration biopsies cystoscopy MEDICAL_TRANSCRIPTION,Description Excisional biopsy of right cervical lymph node Medical Specialty Surgery Sample Name Biopsy Cervical Lymph Node Transcription PREOPERATIVE DIAGNOSIS Cervical lymphadenopathy POSTOPERATIVE DIAGNOSIS Cervical lymphadenopathy PROCEDURE Excisional biopsy of right cervical lymph node ANESTHESIA General endotracheal anesthesia SPECIMEN Right cervical lymph node EBL 10 cc COMPLICATIONS None FINDINGS Enlarged level 2 lymph node was identified and removed and sent for pathologic examination FLUIDS Please see anesthesia report URINE OUTPUT None recorded during the case INDICATIONS FOR PROCEDURE This is a 43 year old female with a several year history of persistent cervical lymphadenopathy She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic After risks and benefits of surgery were discussed with the patient an informed consent was obtained She was scheduled for an excisional biopsy of the right cervical lymph node PROCEDURE IN DETAIL The patient was taken to the operating room and placed in the supine position She was anesthetized with general endotracheal anesthesia The neck was then prepped and draped in the sterile fashion Again noted on palpation there was an enlarged level 2 cervical lymph node A 3 cm horizontal incision was made over this lymph node Dissection was carried down until the sternocleidomastoid muscle was identified The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation The area was then explored for any other enlarged lymph nodes None were identified and hemostasis was achieved with electrocautery A quarter inch Penrose drain was placed in the wound The wound was then irrigated and closed with 3 0 interrupted Vicryl sutures for a deep closure followed by a running 4 0 Prolene subcuticular suture Mastisol and Steri Strip were placed over the incision and sterile bandage was applied The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition She will return to the office tomorrow in followup to have the Penrose drain removed Keywords surgery lymphadenopathy excisional biopsy fna mastisol penrose drain cervical cervical lymph node endotracheal anesthesia lymph node sternocleidomastoid cervical lymph lymph anesthesia MEDICAL_TRANSCRIPTION,Description Blepharoplasty procedure Medical Specialty Surgery Sample Name Blepharoplasty Transcription BLEPHAROPLASTY The patient was prepped and draped The upper lid skin was marked out in a lazy S fashion and the redundant skin marked out with a Green forceps Then the upper lids were injected with 2 Xylocaine and 1 100 000 epinephrine and 1 mL of Wydase per 20 mL of solution The upper lid skin was then excised within the markings Gentle pressure was placed on the upper eyelids and the fat in each of the compartments was teased out using a scissor and cotton applicator and then the fat was cross clamped cut and the clamp cauterized This was done in the all compartments of the middle and medial compartments of the upper eyelid and then the skin sutured with interrupted 6 0 nylon sutures The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin This created a significant crisp supratarsal fold The upper lid skin was closed in this fashion and then attention was turned to the lower lid An incision was made under the lash line and slightly onto the lateral canthus The 15 blade was used to delineate the plane in the lateral portion of the incision and then using a scissor the skin was cut at the marking Then the skin muscle flap was elevated with sharp dissection The fat was located and using a scissor the three eyelid compartments were opened Fat was teased out cross clamped the fat removed and then the clamp cauterized Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze and then the excess skin removed The suture line was sutured with interrupted 6 0 silk sutures Once this was done the procedure was finished The patient left the OR in satisfactory condition The patient was given 50 mg of Demerol IM with 25 mg of Phenergan Keywords surgery blepharoplasty green forceps wydase applicator canthus lash line lazy s lazy s fashion muscle flap periorbital muscle prepped and draped supratarsal fold upper lid upward gaze upper lid skin eyelidsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Closure of bladder laceration during cesarean section Medical Specialty Surgery Sample Name Bladder Laceration Closure Transcription PREOPERATIVE DIAGNOSES Bladder laceration POSTOPERATIVE DIAGNOSES Bladder laceration NAME OF OPERATION Closure of bladder laceration FINDINGS The patient was undergoing a cesarean section for twins During the course of the procedure a bladder laceration was notices and urology was consulted Findings were a laceration on the dome of the bladder PROCEDURE Initially there as a mucosal layer of suture already placed This was done with 3 0 chromic catgut The bladder was distended and while the bladder was distended with physiologic saline a second layer of 3 0 chromic catgut created a watertight closure The second layer included the mucosa an dinner layer of the detrusor muscle A third layer of 2 0 Dexon was used Each of these were placed in a continuous running locked suture technique There was complete watertight closure of the bladder Hemostasis was assured and a Jackson Pratt drain was brought out through a separate stab wound The remaining portion of the operation both the cesarean section and the wound closure will be dictated by Dr Redmond Keywords surgery mucosal layer closure of bladder laceration watertight closure cesarean section bladder laceration bladder cesarean closure laceration MEDICAL_TRANSCRIPTION,Description Cystoscopy cystocele repair BioArc midurethral sling Medical Specialty Surgery Sample Name BioArc Midurethral Sling Transcription PREOPERATIVE DIAGNOSIS Stress urinary incontinence intrinsic sphincter deficiency POSTOPERATIVE DIAGNOSES Stress urinary incontinence intrinsic sphincter deficiency OPERATIONS Cystoscopy cystocele repair BioArc midurethral sling ANESTHESIA Spinal EBL Minimal FLUIDS Crystalloid BRIEF HISTORY The patient is a 69 year old female with a history of hysterectomy complained of urgency frequency and stress urinary incontinence The patient had urodynamics done and a cystoscopy which revealed intrinsic sphincter deficiency Options such as watchful waiting Kegel exercises broad based sling to help with ISD versus Coaptite bulking agents were discussed Risks and benefits of all the procedures were discussed The patient understood and wanted to proceed with BioArc Risk of failure of the procedure recurrence of incontinence due to urgency mesh erosion exposure etc were discussed Risk of MI DVT PE and bleeding etc were discussed The patient understood the risk of infection and wanted to proceed with the procedure The patient was told that due to the intrinsic sphincter deficiency we will try to make the sling little bit tighter to allow better urethral closure which may put her a high risk of retention versus if we make it too loose then she may leak afterwards The patient understood and wanted to proceed with the procedure DETAILS OF THE OPERATION The patient was brought to the OR and anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A Foley catheter was placed Bladder was emptied Two Allis clamps were placed on the anterior vaginal mucosa Lidocaine 1 with epinephrine was applied and hydrodissection was done Incision was made A bladder was lifted off of the vaginal mucosa The bladder cystocele was reduced Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal Using BioArc needle the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed The mesh was right at the bladder neck to the mid urethra completely covering over the entire urethra The sling was kept little tight even though the right angle was easily placed between the urethra and the BioArc material The urethra was coapted very nicely At the end of the procedure cystoscopy was done and there was no injury to the bladder There was good efflux of urine with indigo carmine coming through from both the ureteral openings The urethra was normal seemed to have closed up very nicely with the repair The vaginal mucosa was closed using 0 Vicryl in interrupted fashion The lateral thigh incisions were closed using Dermabond Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement The mesh was placed in antibiotic solution prior to the placement in the body The patient tolerated the procedure well After closure Premarin cream was applied The patient was told to use Premarin cream postop The patient was brought to Recovery in stable condition The patient was told not to do any heavy lifting pushing pulling and no tub bath etc for at least 2 months The patient understood The patient was to follow up as an outpatient Keywords surgery cystoscopy cystocele repair bioarc midurethral sling sphincter urinary incontinence stress urinary incontinence intrinsic sphincter deficiency intrinsic sphincter sphincter deficiency incontinence mesh urethral bioarc MEDICAL_TRANSCRIPTION,Description Bilateral vasovasostomy surgery sample Medical Specialty Surgery Sample Name Bilateral Vasovasostomy Transcription Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens This incision was carried down to the area of the previous vasectomy A towel clip was placed around this Next the scarred area was dissected free back to normal vas proximally and distally Approximately 4 cm of vas was freed up Next the vas was amputated above and below the scar tissue Fine hemostats were used to grasp the adventitial tissue on each side of the vas both the proximal and distal ends Both ends were then dilated very carefully with lacrimal duct probes up to a 2 successfully After accomplishing this fluid could be milked from the proximal vas which was encouraging Next the reanastomosis was performed Three 7 0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen This was all done with 3 5 loupe magnification Next the vas ends were pulled together by tying the sutures A good reapproximation was noted Next in between each of these sutures two to three of the 7 0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid tight There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum The subcuticular layers were closed with a running 3 0 chromic and the skin was closed with three interrupted 3 0 chromic sutures Next an identical procedure was done on the left side The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition Antibiotic ointment fluffs and a scrotal support were placed Keywords surgery vasovasostomy adventitial tissue anastomosis fluffs hemiscrotum loupe magnification lumen muscle layer scrotal support subcuticular vas deferens vas ends bilateral vasovasostomy chromic suturesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Excisional biopsy of actinic keratosis and skin nevus two layer and one layer plastic closures Medical Specialty Surgery Sample Name Biopsy Actinic Keratosis Transcription PREOPERATIVE DIAGNOSES 1 Left chest actinic keratosis 2 cm 2 Left medial chest actinic keratosis 1 cm 3 Left shoulder actinic keratosis 1 cm POSTOPERATIVE DIAGNOSES 1 Left chest actinic keratosis 2 cm 2 Left medial chest actinic keratosis 1 cm 3 Left shoulder actinic keratosis 1 cm TITLE OF PROCEDURES 1 Excisional biopsy of left chest 2 cm actinic keratosis 2 Two layer plastic closure 3 Excisional biopsy of left chest medial actinic keratosis 1 cm with one layer plastic closure 4 Excisional biopsy of left should skin nevus 1 cm one layer plastic closure ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 6 mL ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None PROCEDURE All areas were prepped draped and localized in the usual manner Afterwards elliptical incisions were placed with a 15 blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions After all were removed they were closed with one layer technique for the shoulder and medial lesion and the larger left chest lesion was closed with two layer closure using Monocryl 5 0 for subcuticular closure and 5 0 nylon for skin closure She tolerated this procedure very well and postoperative care instructions were provided She will follow up next week for suture removal Of note she had an episode of hemoptysis which could not be explained prompting an emergency room visit and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made Keywords surgery two layer plastic closure one layer plastic closure skin nevus actinic keratosis plastic closures keratosis actinic biopsy forceps layer closures chest MEDICAL_TRANSCRIPTION,Description Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z osteotomies and bilateral forehead reconstruction with autologous graft Medical Specialty Surgery Sample Name Bilateral Orbital Frontozygomatic Craniotomy Transcription PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly PROCEDURES PERFORMED 1 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z osteotomies 2 Bone grafts 3 Bilateral forehead reconstruction with autologous graft ANESTHESIA General endotracheal anesthesia COMPLICATIONS None CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE Stable transferred to recovery room ESTIMATED BLOOD LOSS 300 mL CRYSTALLOIDS Packed red blood cells 440 mL FFP 100 mL URINARY OUTPUT 160 mL INDICATIONS FOR PROCEDURE The patient is a 9 month old baby with a history of trigonocephaly and metopic synostosis We have discussed locations the nature of trigonocephaly s repair metopic synostosis repair with bilateral fronto orbital advancement forehead reconstruction and bone graft We have discussed risks and benefits Risks included but not limited to risk of bleeding infection dehiscence scarring need for future revision surgeries minimal possibility of death the alternatives devastating bleeding anesthesia death dehiscence infection The parents understand decide to proceed with surgery Informed consent was obtained and we proceed with surgery DESCRIPTION OF PROCEDURE The patient was taken into the operating room placed in the supine position General anesthetic was administered Prophylactic dose of antibiotic was given Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees The patient was once more positioned and padded in the usual manner The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time then the definitive prep and draping of the area was done The procedure began with an incision through the full thickness of the skin into the subcutaneous tissue down to the subgaleal plane The subgaleal plane was developed and reflected anteriorly and slightly posteriorly Hemostasis achieved with electrocautery Raney clips were applied to both flaps to prevent significant bleeding Then we proceed with craniotomy part and Dr Y proceeded with this part of the procedure I assisted her and this will be described in a different operative report Then the area corresponding to the C shaped osteotomy was marked and then we proceed in conjunction with Dr Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor The osteotomies were done with the Midas and some irrigation There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim This was done on both sides Hemostasis achieved with bone wax and electrocautery Once the osteotomies were completed __________ of the osteotomy sites allowed advancements On the left side there was a minor fracture to the superior orbital rim that was plated The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3 0 Vicryl interrupted stitches The forehead flaps were attached with the help of absorbable mesh The forehead portions were applied to the fronto orbital advancement of fronto orbital piece with the help of Synthes mesh and 3 mm screws Hemostasis was checked The flaps were retracted back into position The wound was closed with 3 0 Vicryl interrupted sutures 4 0 Vicryl interrupted stitches and 5 0 running fast absorbing gut Dressing was applied with Xeroform bacitracin and ABDs and a burn net The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition I was present and participated in all aspects of the procedure Sponge needle and instrument counts were completed at the end of the procedure Keywords surgery metopic synostosis craniotomy z osteotomies orbital advancement bone grafts frontozygomatic forehead reconstruction autologous graft bilateral orbital frontozygomatic craniotomy orbital osteotomies forehead MEDICAL_TRANSCRIPTION,Description Desires permanent sterilization Laparoscopic bilateral tubal occlusion with Hulka clips Medical Specialty Surgery Sample Name Bilateral Tubal Occlusion Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Desires permanent sterilization POSTOPERATIVE DIAGNOSIS Desires permanent sterilization PROCEDURE PERFORMED Laparoscopic bilateral tubal occlusion with Hulka clips ANESTHESIA General ESTIMATED BLOOD LOSS Less than 20 cc COMPLICATIONS None FINDINGS On bimanual exam the uterus was found to be anteverted at approximately six weeks in size There were no adnexal masses appreciated The vulva and perineum appeared normal Laparoscopic findings revealed normal appearing uterus fallopian tubes bilaterally as well as ovaries bilaterally There was a functional cyst on the left ovary There was filmy adhesion in the left pelvic sidewall There were two clear lesions consistent with endometriosis one was on the right fallopian tube and the other one was in the cul de sac The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis The liver was visualized and appeared normal The spleen was also visualized INDICATIONS This patient is a 34 year old gravida 4 para 4 0 0 4 Caucasian female who desires permanent sterilization She recently had a spontaneous vaginal delivery in June and her family planning is complete PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite and placed under general anesthesia She was then prepped and draped and placed in the dorsal lithotomy position A bimanual exam was performed and the above findings were noted Prior to beginning the procedure her bladder was drained with a red Robinson catheter A weighted speculum was placed in the patient s posterior vagina and the 12 o clock position of the cervix was grasped with a single toothed tenaculum The cervix was dilated so that the uterine elevator could be placed Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips a 1 cm infraumbilical skin incision was made The Veress needle was then inserted and using sterile saline ______ the pelvic cavity The abdomen was then insufflated with appropriate volume and flow of CO2 The 11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization a 7 mm bladed trocar was placed without difficulty Using the Hulka clip applicator the left fallopian tube was identified followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube A second Hulka clip was then placed across the entire diameter just proximal to this There was good hemostasis at the fallopian tube The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle A second Hulka clip was placed just distal to this again across the entire diameter Good hemostasis was obtained At this point the abdomen was desufflated and after it was desufflated the suprapubic port site was visualized and found to be hemostatic The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed The umbilical incision was then closed with two interrupted 4 0 undyed Vicryl The suprapubic incision was then closed with Steri Strips The uterine elevator was removed and the single toothed tenaculum site was found to be hemostatic The patient tolerated that procedure well The sponge lap and needle counts were correct x2 She will follow up postoperatively for followup care Keywords surgery laparoscopic bilateral tubal occlusion bilateral tubal occlusion hulka clips fallopian tubes anesthesia laparoscope endometriosis laparoscopic sterilization fallopian tubes clips MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies placement of ventilating tubes nasal endoscopy and adenoidectomy Medical Specialty Surgery Sample Name Bilateral Myringotomies Transcription PREOPERATIVE DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy POSTOPERATIVE DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy FINAL DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy 4 Acute and chronic adenoiditis OPERATIONS PERFORMED 1 Bilateral myringotomies 2 Placement of ventilating tubes 3 Nasal endoscopy 4 Adenoidectomy DESCRIPTION OF OPERATIONS The patient was brought to the operating room endotracheal intubation carried out by Dr X Both sides of the patient s nose were then sprayed with Afrin Ears were inspected then with the operating microscope The anterior inferior quadrant myringotomy incisions were performed Then a modest amount of serous and a trace of mucoid material encountered that was evacuated The middle ear mucosa looked remarkably clean Armstrong tubes were inserted Ciprodex drops were instilled Ciprodex will be planned for two postoperative days as well Nasal endoscopy was carried out and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products The adenoids were shaved back flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts and representative cultures were taken Additional adenoid tissue was shaved backwards with the RADenoid shaver Electrocautery was used to establish hemostasis and repeat nasal endoscopy accomplished The patient still had residual evidence of inter choanal adenoid tissue and video photos were taken That remaining material was resected guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx Electrocautery again used to establish hemostasis Bleeding was trivial Extensive irrigation accomplished No additional bleeding was evident The patient was awakened extubated taken to the recovery room in a stable condition Discharge anticipated later in the day on Augmentin 400 mg twice daily Lortab or Tylenol p r n for pain Office recheck would be anticipated if stable and doing well in approximately two weeks Parents were instructed to call however regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic Keywords surgery bilateral middle ear effusions recurrent acute otitis media chronic rhinitis recurrent adenoiditis with adenoid hypertrophy adenoiditis bilateral myringotomies ventilating tubes nasal endoscopy adenoidectomy adenoid hypertrophy myringotomies otitis media hypertrophy endoscopy intubation nasal MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies with Armstrong grommet tubes Adenoidectomy and Tonsillectomy Medical Specialty Surgery Sample Name Bilateral Myringotomies 1 Transcription PREOPERATIVE DIAGNOSES OM chronic serous simple or unspecified Adenoid hyperplasia Hypertrophy of tonsils POSTOPERATIVE DIAGNOSIS Same as preoperative diagnosis OPERATION Bilateral myringotomies with Armstrong grommet tubes Adenoidectomy and Tonsillectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DRAINS None CONSENT The procedure benefits and risks were discussed in detail preoperatively The parentsagreed to proceed after all questions were answered TECHNIQUE The patient was brought to the operating room and placed in the supine position After general mask anesthesia was adequately obtained the right external auditory canal was cleaned out under the microscope Serous fluid was aspirated from the middle ear space An Armstrong grommet tube was placed down through the incision and rotated into place The opposite ear was then cleaned out under the microscope Serous fluid was aspirated from the middle ear space An Armstrong grommet tube was placed down through the incision and rotated into place Cortisporin suspension was placed in both ear canals Then the patient was intubated A Crowe Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate The adenoid fossa was visualized with the mirror The adenoids were removed using the microdebrider Two adenoid packs were placed The packs were removed one by one Using mirror and suction bovie adequate hemostasis was achieved The tonsils were quite large and cryptic The tenaculum was placed on the superior pole of the right tonsil Cheesy material came out from the crypts The tonsils were retracted medially The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar and the plane was developed between the tonsil and the musculature The tonsil was completely dissected out of this plane preserving both the anterior and posterior tonsillar pillars All bleeders were cauterized as they were encountered The tenaculum was then placed on the superior pole of the left tonsil Cheesy material came out from the crypts The tonsils were retracted medially The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar and the plane was developed between the tonsil and the musculature The tonsil was completely dissected out of this plane preserving both the anterior and posterior tonsillar pillars All bleeders were cauterized as they were encountered Both tonsil beds were then re cauterized paying particular attention to the inferior and superior poles The stomach was evacuated with the nasogastric tube The patient was then awakened in the operating room extubated and taken to the recovery room in satisfactory condition Keywords surgery adenoid hyperplasia om adenoidectomy tonsillectomy auditory canal serous fluid crowe davis mouth gag tonsils adenoidectomy and tonsillectomy armstrong grommet tubes bovie electrocautery tonsillar pillar bilateral myringotomies armstrong tubes grommet tonsillar bilateral myringotomies tenaculum MEDICAL_TRANSCRIPTION,Description 3 1 2 year old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias Medical Specialty Surgery Sample Name Bilateral Inguinal Herniorrhaphy Transcription PREOPERATIVE DIAGNOSIS Bilateral inguinal hernias POSTOPERATIVE DIAGNOSIS Bilateral inguinal hernias OPERATION PERFORMED Bilateral inguinal herniorrhaphy ANESTHESIA General INDICATIONS This 3 1 2 year old presents with bilateral scrotal swellings which both reduce and are consistent with bilateral inguinal hernias He comes to the operating room today for the repair OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen and perineum were prepped and draped in usual manner Transverse right lower quadrant skin fold incision was made and carried down through skin and subcutaneous tissue with sharp dissection The external oblique fascia identified upon course of its fibers The hernia sac was identified and brought into the operative field Hernia sac was grasped with hemostat and the cord structures were carefully stripped away from it until the entire circumference of the sac could be identified The sac clamped and divided The distal sac was then dissected down to where the large hydrocele with the testicle would be brought up and the sac opened the fluid drained and a portion of the sac removed The testicle was returned to the scrotum The proximal sac was then dissected free of the cord up to the peritoneal reflection at the internal ring where it was ligated with a 3 0 Vicryl stick tie and a 3 0 Vicryl free tie The excess removed The cord returned to the inguinal canal and external oblique fascia closed with interrupted sutures of 3 0 Vicryl and subcutaneous tissue with the same skin closed with 5 0 subcuticular Monocryl Sterile dressing applied Attention was then turned to the left side where an identical procedure was carried out for his left hernia although the only difference being with the sac was somewhat smaller and did not have the large hydrocele around the testicle Otherwise the procedure was carried down in identical manner Sterile dressings were then applied to both sides The child awakened and taken to the recovery room in satisfactory condition Keywords surgery perineum hernia sac bilateral inguinal herniorrhaphy external oblique fascia bilateral inguinal hernias inguinal herniorrhaphy scrotal swellings subcutaneous tissue oblique fascia inguinal scrotal herniorrhaphy testicle hernias MEDICAL_TRANSCRIPTION,Description Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis Medical Specialty Surgery Sample Name Bilateral Upper Lid Blepharoplasty Transcription PREOPERATIVE DIAGNOSIS Bilateral upper eyelid dermatochalasis POSTOPERATIVE DIAGNOSIS Same PROCEDURE Bilateral upper lid blepharoplasty CPT 15822 ANESTHESIA Lidocaine with 1 100 000 epinephrine DESCRIPTION OF PROCEDURE This 65 year old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction The procedure alternatives risks and limitations in this individual case have been very carefully discussed with the patient All questions have been thoroughly answered and the patient understands the surgery indicated She has requested this corrective repair be undertaken and a consent was signed The patient was brought into the operating room and placed in the supine position on the operating table An intravenous line was started and sedation and sedation anesthesia was administered IV after preoperative p o sedation The patient was monitored for cardiac rate blood pressure and oxygen saturation continuously The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured and the incisions were marked for fusiform excision with a marking pen The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally The upper eyelid areas were bilaterally injected with 1 Lidocaine with 1 100 000 Epinephrine for anesthesia and vasoconstriction The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally The face was prepped and draped in the usual sterile manner After waiting a period of approximately ten minutes for adequate vasoconstriction the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection Hemostasis was obtained with a bipolar cautery A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right The defect in the orbital septum was identified and herniated orbital fat was exposed The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit A similar procedure was performed exposing herniated portion of the nasal pocket Great care was taken to obtain perfect hemostasis with this maneuver A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion Careful hemostasis had been obtained on the upper lid areas The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7 0 blue Prolene sutures At the end of the operation the patient s vision and extraocular muscle movements were checked and found to be intact There was no diplopia no ptosis no ectropion Wounds were reexamined for hemostasis and no hematomas were noted Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally The procedures were completed without complication and tolerated well The patient left the operating room in satisfactory condition A follow up appointment was scheduled routine post op medications prescribed and post op instructions given to the responsible party The patient was released to return home in satisfactory condition Keywords surgery bilateral upper eyelid dermatochalasis blepharoplasty upper lid bilateral upper lid eyelid bilateral upper lid blepharoplasty upper lid blepharoplasty eyelid dermatochalasis lid blepharoplasty orbital septum upper eyelid anesthesia dermatochalasis hemostasis MEDICAL_TRANSCRIPTION,Description Bilateral Myringotomy with placement of PE tubes Medical Specialty Surgery Sample Name Bilateral Myringotomies 2 Transcription PREOPERATIVE DIAGNOSES Bilateral chronic otitis media POSTOPERATIVE DIAGNOSES Bilateral chronic otitis media ANESTHESIA General mask NAME OF OPERATION Bilateral Myringotomy with placement of PE tubes PROCEDURE The patient was taken to the operating room and placed in the supine position After adequate general inhalation anesthesia was obtained the operating microscope with brought in for full use throughout the case First the left and then the right tympanic membrane was approached An anterior inferior radial incision was made in the left tympanic membrane Suction revealed a substantial amount of mucopurulent drainage A Sheehy pressure equalization tube was placed in the myringotomy site Floxin drops were added The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage The patient tolerated the procedure well and returned to the recovery room awake and in stable condition Keywords surgery placement of pe tubes bilateral chronic otitis media chronic otitis media bilateral myringotomy pe tubes chronic otitis otitis media tympanic membrane mucopurulent drainage tympanic membrane mucopurulent myringotomy tubes MEDICAL_TRANSCRIPTION,Description Bilateral carotid cerebral angiogram and right femoral popliteal angiogram Medical Specialty Surgery Sample Name Bilateral Carotid Cerebral Angiogram Transcription PREOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease POSTOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease OPERATIONS PERFORMED 1 Bilateral carotid cerebral angiogram 2 Right femoral popliteal angiogram FINDINGS The right carotid cerebral system was selectively catheterized and visualized The right internal carotid artery was found to be very tortuous with kinking in its cervical portions but no focal stenosis was noted Likewise the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery The left carotid cerebral system was selectively catheterized and visualized The cervical portion of the left internal carotid artery showed a 30 to 40 stenosis with small ulcer crater present The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery Visualization of the right lower extremity showed no significant disease PROCEDURE With the patient in supine position under local anesthesia plus intravenous sedation the groin areas were prepped and draped in a sterile fashion The common femoral artery was punctured in a routine retrograde fashion and a 5 French introducer sheath was advanced under fluoroscopic guidance A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above Following completion of the above the catheter and introducer sheath were removed Heparin had been initially given which was reversed with protamine Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and sandbag compression The patient tolerated the procedure well throughout Keywords surgery femoral popliteal angiogram carotid cerebral angiogram internal carotid artery carotid artery angiogram carotid cerebral artery MEDICAL_TRANSCRIPTION,Description Ruptured distal biceps tendon right elbow Repair of distal biceps tendon right elbow Medical Specialty Surgery Sample Name Biceps Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow POSTOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow PROCEDURE PERFORMED Repair of distal biceps tendon right elbow PROCEDURE The patient was taken to OR Room 2 and administered a general anesthetic The right upper extremity was then prepped and draped in the usual manner A sterile tourniquet was placed on the proximal aspect of the right upper extremity The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg Tourniquet time was 74 minutes A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin Hemostasis was achieved utilizing electrocautery Subcutaneous fat was separated and the skin flaps elevated The _________ was identified It was incised The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found There was some serosanguineous fluid from the previous rupture This area was suctioned clean The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface At this point the 2 fiber wire was then passed through the tendon Two fiber wires were utilized in a Krackow type suture Once this was completed dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously The radial tuberosity was palpated Just ulnar to this a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow A skin incision was made over this area Approximately two inches down to the skin and subcutaneous tissues the fascia was split and the extensor muscle was also split A stat was then attached through the tip of that stat and passed back up through the antecubital fossa The tails of the fiber wire suture were grasped and pulled down through the second incision At this point they were placed to the side Attention was directed at exposure of the radial tuberosity with a forearm fully pronated The tuberosity came into view The margins were cleared with periosteal elevator and sharp dissection Utilizing the power bur a trough approximately 1 5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity Three small drill holes were then placed along the margin for passage of the suture The area was then copiously irrigated with gentamicin solution A 4 0 pullout wire was utilized to pass the sutures through the drill holes one on each outer hole and two in the center hole The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated The suture was tied over the bone islands Both wounds were then copiously irrigated with gentamicin solution and suctioned dry Muscle fascia was closed with running 2 0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted 2 0 Vicryl and small staples The anterior incision was approximated with interrupted 2 0 Vicryl for Subq and then skin was approximated with small staples Both wounds were infiltrated with a total of 30 cc of 0 25 Marcaine solution for postop analgesia A bulky fluff dressing was applied to the elbow followed by application of a long arm plaster splint maintaining the forearm in the supinated position Tourniquet was inflated prior to application of the splint Circulatory status returned to the extremity immediately The patient was awakened He was rather boisterous during his awakening but care was taken to protect the right upper extremity He was then transferred to the recovery room in apparent satisfactory condition Keywords surgery ruptured distal biceps tendon gentamicin solution antecubital fossa distal biceps biceps tendon tendon tuberosity biceps elbow MEDICAL_TRANSCRIPTION,Description Belly button piercing for insertion of belly button ring Medical Specialty Surgery Sample Name Belly Button Piercing Transcription PROCEDURE Belly button piercing for insertion of belly button ring DESCRIPTION OF PROCEDURE The patient was prepped after informed consent was given of risk of infection and foreign body reaction The area was marked by the patient and then prepped The area was injected with 2 Xylocaine 1 100 000 epinephrine Then a 14 gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the 14 gauge needle and pulled through A small ball was placed over the end of the ring This terminated the procedure The patient tolerated the procedure well Postop instructions were given regarding maintenance Patient left the office in satisfactory condition Keywords surgery belly button piercing 2 xylocaine belly button postop instructions the patient tolerated the procedure well foreign body gauge needle needle piercing ring satisfactory condition umbilical button piercing belly buttonNOTE MEDICAL_TRANSCRIPTION,Description Hematemesis in a patient with longstanding diabetes Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis Mallory Weiss tear successful BICAP cautery Medical Specialty Surgery Sample Name BICAP Cautery Transcription PREOPERATIVE DIAGNOSIS Hematemesis in a patient with longstanding diabetes POSTOPERATIVE DIAGNOSIS Mallory Weiss tear submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis PROCEDURE The procedure indications explained and he understood and agreed He was sedated with Versed 3 Demerol 25 and topical Hurricane spray to the oropharynx A bite block was placed The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision Esophagus revealed distal ulcerations Additionally the patient had a Mallory Weiss tear This was subjected to bicap cautery with good ablation The stomach was entered which revealed areas of submucosal hemorrhage consistent with trauma from vomiting There were no ulcerations or erosions in the stomach The duodenum was entered which was unremarkable The instrument was then removed The patient tolerated the procedure well with no complications IMPRESSION Mallory Weiss tear successful BICAP cautery We will keep the patient on proton pump inhibitors The patient will remain on antiemetics and be started on a clear liquid diet Keywords surgery mallory weiss tear submucosal hemorrhage esophagitis vomiting bicap cautery mallory weiss diabetes esophagus submucosal hemorrhage trauma hematemesis MEDICAL_TRANSCRIPTION,Description Bifrontal cranioplasty cranial defect greater than 10 cm in diameter in the frontal region Medical Specialty Surgery Sample Name Bifrontal Cranioplasty Transcription PREOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region POSTOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region PROCEDURE Bifrontal cranioplasty ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS Nil INDICATIONS FOR PROCEDURE The patient is a 66 year old gentleman who has a history of prior chondrosarcoma that he had multiple resections for The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty After discussing the risks benefits and alternatives of surgery the decision was made to proceed with operative intervention in the form of a cranioplasty He had previously undergone a CT scan Premanufactured cranioplasty made for him that was sterile and ready to implant DESCRIPTION OF PROCEDURE After induction of adequate general endotracheal anesthesia an appropriate time out was performed We identified the patient the location of surgery the appropriate surgical procedure and the appropriate implant He was given intravenous antibiotics with ceftriaxone vancomycin and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis The scalp was prepped and draped in the usual sterile fashion A previous incision was reopened and the scalp flap was reflected forward We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap We freed up the bony edges circumferentially but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base We did explore laterally and saw a little bit of the mesh on the lateral orbit Once we had the bony edges explored we took the performed plate and secured it in a place with titanium plates and screws We had achieved good hemostasis The wound was closed in multiple layers in usual fashion over a Blake drain At the end of the procedure all sponge and needle counts were correct A sterile dressing was applied to the incision The patient was transported to the recovery room in good condition after having tolerated the procedure well I was personally present and scrubbed and performed supervised all key portions Keywords surgery cranial defect frontal region bifrontal cranioplasty cranioplasty chondrosarcoma scalp flap bony edges bone flap bifrontal cranial endotracheal frontal MEDICAL_TRANSCRIPTION,Description Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft Medical Specialty Surgery Sample Name BCCa Excision Lower Lid Transcription PREOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid POSTOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid TITLE OF OPERATION Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft PROCEDURE The patient was brought into the operating room and prepped and draped in usual fashion Xylocaine 2 with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid A frontal nerve block was also given on the right upper lid The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect The area was marked with a marking pen with margins of 3 to 4 mm and a 15 Bard Parker blade was used to make an incision at the nasal and temporal margins of the lesion The incision was carried inferiorly and using a Steven scissors the normal skin muscle and conjunctiva was excised inferiorly The specimen was then marked and sent to pathology for frozen section Bleeding was controlled with a wet field cautery and the right upper lid was everted and an incision was made 3 mm above the lid margin with the Bard Parker blade in the entire length of the upper lid The incision reached the orbicularis and Steven scissors were used to separate the tarsus from the underlying orbicularis Vertical cuts were made nasally and temporally and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly It was placed into the defect in the lower lid and sutured with multiple interrupted 6 0 Vicryl sutures nasally temporally and inferiorly The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region The defect was closed with interrupted 5 0 Prolene sutures and the preauricular graft was sutured in place with multiple interrupted 6 0 silk sutures The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied The patient tolerated the procedure well and was sent to recovery room in good condition Keywords surgery basal cell carcinoma cryotherapy steven scissors conjunctiva conjunctival flap frontal nerve block frozen section lower lid orbicularis skin graft nasal and temporal margins dorsal conjunctival flap upper lid basal carcinoma preauricular incision conjunctival MEDICAL_TRANSCRIPTION,Description Excision of nasal tip basal carcinoma previous positive biopsy Medical Specialty Surgery Sample Name BCCa Excision Nasal Tip Transcription PREOPERATIVE DIAGNOSIS Basal cell carcinoma nasal tip previous positive biopsy POSTOPERATIVE DIAGNOSIS Basal cell carcinoma nasal tip previous positive biopsy OPERATION PERFORMED Excision of nasal tip basal carcinoma Total area of excision approximately 1 cm to 12 mm frozen section x2 final margins clear INDICATION A 66 year old female for excision of nasal basal cell carcinoma This area is to be excised accordingly and closed We had multiple discussions regarding types of closure SUMMARY The patient was brought to the OR in satisfactory condition and placed supine on the OR table Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision The area was injected after sterile prep and drape with Marcaine 0 25 with 1 200 000 adrenaline The specimen was sent to pathology Margins were still positive at the inferior 6 o clock margin and this was resubmitted accordingly Final margins were clear Closure consisted of undermining circumferentially Advancement closure with dog ear removal distally and proximally was accomplished without difficulty Closure with interrupted 5 0 Monocryl running 7 0 nylon followed by Xeroform gauze light pressure dressing and Steri Strips The patient is discharged on minocycline and Darvocet N 100 NOTE The 2 6 mm loupe magnification was utilized throughout the procedure No complications noted with excellent and all clear margins at the termination An advancement closure technique was utilized Keywords surgery basal cell carcinoma closure steri strips xeroform gauze excision light pressure dressing loupe magnification nasal tip basal carcinoma basal cell cell carcinoma biopsy basal carcinoma nasal MEDICAL_TRANSCRIPTION,Description Excision basal cell carcinoma right medial canthus with frozen section and reconstruction of defect with glabellar rotation flap Medical Specialty Surgery Sample Name BCCa Excision Canthus Transcription PREOPERATIVE DIAGNOSIS Basal cell carcinoma 0 8 cm diameter right medial canthus POSTOPERATIVE DIAGNOSIS Basal cell carcinoma 0 8 cm diameter right medial canthus OPERATION Excision basal cell carcinoma 0 8 cm diameter right medial canthus with frozen section and reconstruction of defect 1 2 cm diameter with glabellar rotation flap ANESTHESIA Monitored anesthesia care JUSTIFICATION The patient is an 80 year old white female with a biopsy proven basal cell carcinoma of the right medial canthus She was scheduled for elective excision with frozen section under local anesthesia as an outpatient PROCEDURE With an intravenous infusing and under suitable premedication the patient was placed supine on the operative table The face was prepped with pHisoHex draped The right medial canthal region and the glabellar region were anesthetized with 1 Xylocaine with 1 100 000 epinephrine Under loupe magnification the lesion was excised with 2 mm margins oriented with sutures and submitted for frozen section pathology The report was basal cell carcinoma with all margins free of tumor Hemostasis was controlled with the Bovie Excised lesion diameter was 1 2 cm The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin The flap was elevated with a scalpel and Bovie rotated into the defect without tension to the defect with scissors and inset in layer with interrupted 5 0 Vicryl for the dermis and running 5 0 Prolene for the skin Donor site was closed in V Y fashion with similar suture technique The wounds were dressed with bacitracin ointment The patient was returned to the recovery room in satisfactory condition She tolerated the procedure satisfactorily and then no complications Blood loss was essentially nil Keywords surgery basal cell carcinoma excision bacitracin canthal region canthus frozen section glabellar glabellar region loupe magnification phisohex rotation flap loupe excision basal cell carcinoma medial canthus basal cell cell carcinoma basal cell carcinoma MEDICAL_TRANSCRIPTION,Description Right basilic vein transposition End stage renal disease with need for a long term hemodialysis access Excellent flow through fistula following the procedure Medical Specialty Surgery Sample Name Basilic Vein Transposition Transcription PREOPERATIVE DIAGNOSIS End stage renal disease with need for a long term hemodialysis access POSTOPERATIVE DIAGNOSIS End stage renal disease with need for a long term hemodialysis access PROCEDURE Right basilic vein transposition ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Excellent flow through fistula following the procedure STATEMENT OF MEDICAL NECESSITY The patient is a 68 year old black female who recently underwent a brachiobasilic AV fistula but without transposition She has good flow excellent physical exam and now is ready for superficialization of the basilic vein After discussing the risks and benefits of the procedure with the patient preoperatively the patient voiced understanding and signed informed consent PROCEDURE IN DETAIL The patient was taken to the operating room placed supine on the operating table After adequate general endotracheal anesthesia was obtained the right arm was circumferentially prepped and draped in a standard sterile fashion A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein There was noted to be excellent flow through the vein A pocket was then created just lateral to the incision in the subcutaneous tissue The vein was then placed into this pocket securing with multiple interrupted 3 0 Vicryl sutures The bed of dissection of the basilic vein was then treated with fibrin sealant The subcutaneous tissue was then reapproximated with 3 0 Vicryl sutures in interrupted fashion The skin was closed using 4 0 Monocryl suture for a subcuticular stitch Dermabond was applied to the incision Again there was noted to be good palpable thrill throughout the superficialized vein The patient was then awakened and taken to the recovery room in stable condition Keywords surgery end stage renal disease hemodialysis av fistula brachiobasilic basilic vein transposition hemodialysis access vein basilic MEDICAL_TRANSCRIPTION,Description Creation of autologous right brachiobasilic arteriovenous fistula first stage Medical Specialty Surgery Sample Name AV Fistula 4 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease 2 Left subclavian vein occlusion 3 Status post chronic tracheostomy 4 Status post coronary artery bypass grafting 5 Right subclavian vein stenosis POSTOPERATIVE DIAGNOSES 1 End stage renal disease 2 Left subclavian vein occlusion 3 Status post chronic tracheostomy 4 Status post coronary artery bypass grafting 5 Right subclavian vein stenosis OPERATIVE PROCEDURE Creation of autologous right brachiobasilic arteriovenous fistula first stage INDICATIONS FOR THE PROCEDURE This patient has a known left subclavian vein occlusion The right subclavian vein has an estimated 50 stenosis The patient has a catheter traversed in the right innominate vein The right basilic vein was judged to be suitable for usage on vein mapping OPERATIVE FINDINGS The basilic vein was of an adequate size but somewhat sclerotic A first stage autologous right brachiobasilic arteriovenous fistula was created A grade 2 was felt at completion OPERATIVE PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the operating room The patient was placed in the supine position The patient received regional nerve block The patient also received intravenous sedation The right arm was prepped and draped in the usual sterile fashion We used ultrasound to locate the basilic vein at the cubital fossa A small transverse incision was made slightly above the basilic vein The basilic vein was identified and immobilized The basilic vein was of a good size but somewhat sclerotic The underlying fascia was incised and the brachial artery was identified and immobilized The brachial artery was normal We then divided the basilic vein distally The distal end was ligated using silk suture The brachial artery was clamped proximally and distally A small longitudinal arteriotomy was made in the brachial artery We did not give heparin The end of the basilic vein was then sewn end to side to the brachial artery using a running 7 0 Prolene suture Just prior to completion of the anastomosis it was flushed and anastomosis was completed Flow was then established A grade 2 was felt in the outflow basilic fistula Hemostasis was secured The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4 0 Monocryl subcuticular suture for the skin A sterile dry dressing was applied The patient tolerated the procedure well There were no operative complications The sponge instrument and needle counts were correct at the end of the case I was present and participated in all aspects of the procedure The patient was transferred to the recovery room in satisfactory condition Keywords surgery end stage renal disease left subclavian vein occlusion arteriovenous fistula artery bypass grafting autologous basilic vein brachial artery brachiobasilic clamped fistula sclerotic subclavian vein subclavian vein stenosis tracheostomy brachiobasilic arteriovenous fistula subclavian vein occlusion vein occlusion subclavian basilic artery MEDICAL_TRANSCRIPTION,Description Left axillary dissection with incision and drainage of left axillary mass Right axillary mass excision and incision and drainage Bilateral axillary masses rule out recurrent Hodgkin s disease Medical Specialty Surgery Sample Name Axillary Dissection Mass Excision Transcription PREOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease POSTOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease PROCEDURE PERFORMED 1 Left axillary dissection with incision and drainage of left axillary mass 2 Right axillary mass excision and incision and drainage ANESTHESIA LMA SPECIMENS Left axillary mass with nodes and right axillary mass ESTIMATED BLOOD LOSS Less than 30 cc INDICATION This 56 year old male presents to surgical office with history of bilateral axillary masses Upon evaluation it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter The patient had been continued on antibiotics preoperatively The patient with history of Hodgkin s lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time Consent for possible recurrence of Hodgkin s lymphoma warranted exploration and excision of these masses The patient was explained the risks and benefits of the procedure and informed consent was obtained GROSS FINDINGS Upon dissection of the left axillary mass the mass was removed in toto and noted to have a cavity within it consistent with an abscess No loose structures were identified and sent for frozen section which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma however the confirmed pathology report is pending at this time The right axillary mass was excised without difficulty without requiring full axillary dissection PROCEDURE The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete A 10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis Identification of the axillary anatomy was made and care was made to avoid injury to nerve vessel or musculature Once this mass was removed in toto lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture Upon revaluation of the incisional site it was noted to be hemostatic Warm lap sponge was then left in place at this site Next attention was turned to the right axilla where a 10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with 3 0 Vicryl suture followed by 4 0 Vicryl running subcuticular stitch Steri Strips were applied Attention was returned back left axilla which upon re exploration was noted to be hemostatic and a 7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision This was placed within the incision site ________ drainage of the axillary potential space Approximation of the deep dermal tissues were then done with 3 0 Vicryl in an interrupted technique followed by 4 0 Vicryl with running subcuticular technique Steri Strips and sterile dressings were applied JP bulb was then placed to suction and sterile dressings were applied to both axilla The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1 2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise Keywords surgery incision and drainage axillary mass excision axillary dissection hodgkin s disease axillary mass mass incision axillary MEDICAL_TRANSCRIPTION,Description Left forearm arteriovenous fistula between cephalic vein and radial artery Medical Specialty Surgery Sample Name AV Fistula 5 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease hypertension diabetes need for chronic arteriovenous access 2 Ischemic cardiomyopathy ejection fraction 20 POSTOPERATIVE DIAGNOSES 1 End stage renal disease hypertension diabetes need for chronic arteriovenous access 2 Ischemic cardiomyopathy ejection fraction 20 OPERATION Left forearm arteriovenous fistula between cephalic vein and radial artery INDICATION FOR SURGERY This is a patient referred by Dr Michael Campbell He is a 44 year old African American who has end stage renal disease and also ischemic cardiomyopathy This morning he received coronary angiogram by Dr A which was reportedly normal after which he was brought to the operating room for an AV fistula All the advantages disadvantages risks and benefits of the procedure were explained to him for which he had consented ANESTHESIA Monitored anesthesia care DESCRIPTION OF PROCEDURE The patient was identified brought to the operating room placed supine and IV sedation given This was done under monitored anesthesia care He was prepped and draped in the usual sterile fashion He received local infiltration of 0 25 Marcaine with epinephrine in the region of the proposed incision Incision was about 2 5 cm long between the cephalic vein and the distal part of the forearm and the radial artery Incision was deepened down through the subcutaneous fascia The vein was identified dissected for a good length and then the artery was identified and dissected Heparin 5000 units was given The artery clamped proximally and distally opened up in the middle It was found to have Monckeberg s arteriosclerosis of a moderate intensity The vein was of good caliber and size The vein was clipped distally fashioned to size and shape and arteriotomy created in the distal radial artery and end to side anastomosis was performed using 7 0 Prolene and bled prior to tying it down Thrill was immediately felt and heard The incision was closed in two layers and sterile dressing applied Keywords surgery end stage renal disease av fistula marcaine with epinephrine monckeberg s monitored anesthesia care angiogram arteriosclerosis arteriovenous fistula cephalic vein ischemic cardiomyopathy radial artery subcutaneous fascia arteriovenous forearm ischemic MEDICAL_TRANSCRIPTION,Description Creation of AV fistula left wrist in the anatomic snuffbox Medical Specialty Surgery Sample Name AV Fistula 3 Transcription TITLE OF PROCEDURE Creation of AV fistula left wrist in the anatomic snuffbox PREOPERATIVE DIAGNOSIS End stage renal disease need for chronic access POSTOPERATIVE DIAGNOSIS End stage renal disease need for chronic access INDICATION OF THE PROCEDURE This 74 year old lady was referred by Dr P for placement of an AV fistula She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein She undergoes dialysis on Monday Wednesday and Friday at DaVita in Alameda and is under the care of Dr P She underwent coronary bypass surgery in 2000 and her cardiologist is Dr T She lives with her husband and she also has a son at home and she is a very active lady She is right handed The plan was to place an AV fistula at the left wrist The risks and benefits were fully explained to her She elected to proceed as planned PROCEDURE IN DETAIL In the operating room under monitored anesthesia care with intravenous sedation she was prepped and draped surgically Lidocaine 1 was used for local anesthesia in the anatomic snuffbox at the left wrist The cephalic vein was exposed The superficial branch of the radial artery was carefully protected and the radial artery was exposed There was moderate calcification of the radial artery The patient was heparinized and end to side anastomosis was performed between the cephalic vein and radial artery using a 7 0 Prolene suture There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion The wound was closed using absorbable suture and she was transferred to Recovery There were no complications Keywords surgery av fistula end stage renal disease permcath chronic access jugular vein monitored anesthesia monitored anesthesia care prepped and draped snuffbox superficial branch creation of av fistula cephalic vein radial artery radial artery fistula MEDICAL_TRANSCRIPTION,Description Creation of right brachiocephalic arteriovenous fistula Medical Specialty Surgery Sample Name AV Fistula 2 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease 2 Diabetes POSTOPERATIVE DIAGNOSES 1 End stage renal disease 2 Diabetes OPERATIVE PROCEDURE Creation of right brachiocephalic arteriovenous fistula INDICATIONS FOR THE PROCEDURE This patient has end stage renal disease Although the patient is right handed preoperative vein mapping demonstrated much better vein in the right arm Hence a right brachiocephalic fistula is being planned OPERATIVE FINDINGS The right cephalic vein at the elbow is chosen to be suitable It is slightly sporadic but of an adequate size An end to side right brachiocephalic arteriovenous fistula was created At completion there was a great thrill OPERATIVE PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the operating room The patient was placed in the supine position The patient received a regional nerve block The patient also received intravenous sedation The right arm was prepped and draped in the usual sterile fashion We made a small transverse incision in the right cubital fossa The cephalic vein was identified and mobilized The fascia was incised and the brachial artery was also identified and mobilized The brachial artery was free off significant disease A good pulse was noted The cephalic vein was mobilized proximally and distally The brachial artery was mobilized proximally and distally We did not give heparin The brachial artery was then clamped proximally and distally The cephalic vein was also clamped proximally and distally Longitudinal arteriotomy was made in brachial artery and a longitudinal venotomy was made in the cephalic vein We then sewn the vein to the artery in a side to side fashion using a running 7 0 Prolene suture Just prior to completion of the anastomosis it was flushed and the anastomosis was then completed A great thrill was noted We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it This surrounded the anastomosis as an end to side functionally A great thrill remained in the fistula Hemostasis was secured We then closed the wound using interrupted PDS sutures for the fascia and a running 4 0 Monocryl subcuticular suture for the skin Sterile dry dressing was applied The patient tolerated the procedure well There were no operative complications The sponge instrument and needle counts were correct at the end of the case I was present and participated in all aspects of the procedure The patient was then transferred to the recovery room in satisfactory condition A great thrill was felt in the fistula completion There was also a palpable radial pulse distally Keywords surgery end stage renal disease prolene suture brachial artery brachiocephalic brachiocephalic arteriovenous fistula cephalic vein fistula general anesthetic prepped and draped proximally and distally renal disease av cephalic artery vein MEDICAL_TRANSCRIPTION,Description Tailor s bunionectomy with metatarsal osteotomy of the left fifth metatarsal Excision of nerve lesion with implantation of the muscle belly of the left second interspace Excision of nerve lesion in the left third interspace MEDICAL_TRANSCRIPTION,Description Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula Medical Specialty Surgery Sample Name AV Fistula 1 Transcription PREOPERATIVE DIAGNOSIS End stage renal disease POSTOPERATIVE DIAGNOSIS End stage renal disease PROCEDURE Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula ANESTHESIA General DESCRIPTION OF PROCEDURE The patient was taken to the operating room where after induction of general anesthetic the patient s arm was prepped and draped in a sterile fashion The IV catheter was inserted into the vein on the lower surface of the left forearm Venogram was performed which demonstrated adequate appearance of the cephalic vein above the elbow Through a transverse incision the cephalic vein and brachial artery were both exposed at the antecubital fossa The cephalic vein was divided and the proximal end was anastomosed to the artery in an end to side fashion with a running 6 0 Prolene suture The clamps were removed establishing flow through the fistula Hemostasis was obtained The wound was closed in layers with PDS sutures Sterile dressing was applied The patient was taken to recovery room in stable condition Keywords surgery end stage renal disease prolene suture venogram antecubital fossa arteriovenous arteriovenous fistula brachiocephalic arteriovenous fistula cephalic vein fistula prepped and draped brachiocephalic cephalic vein MEDICAL_TRANSCRIPTION,Description Austin Moore bipolar hemiarthroplasty left hip utilizing a medium fenestrated femoral stem with a medium 0 8 mm femoral head a 50 mm bipolar cup Displace subcapital fracture left hip Medical Specialty Surgery Sample Name Austin Moore Bipolar Hemiarthroplasty Transcription PREOPERATIVE DIAGNOSIS Displace subcapital fracture left hip POSTOPERATIVE DIAGNOSIS Displace subcapital fracture left hip PROCEDURE PERFORMED Austin Moore bipolar hemiarthroplasty left hip utilizing a medium fenestrated femoral stem with a medium 0 8 mm femoral head a 50 mm bipolar cup PROCEDURE The patient was taken to OR 2 administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table The right lower extremity was protectively padded The left leg was propped with multiple blankets The hip was then prepped and draped in the usual manner A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues Hemostasis was achieved utilizing electrocautery Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly The external rotators were identified after removal of the trochanteric bursa Hemostat was utilized to separate the external rotators from the underlying capsule they were then transected off from their attachment at the posterior intertrochanteric line They were then reflected distally The capsule was then opened in a T fashion utilizing the cutting cautery Fraction hematoma exuded from the hip joint The cork screw was then impacted into the femoral head and it was removed from the acetabulum Bone fragments were removed from the neck and acetabulum The acetabulum was then inspected and noted to be free from debris The proximal femur was then delivered into the wound with the hip internally rotated A mortise chisel was then utilized to take the cancellous bone from the proximal femur The T handle broach was then passed down the canal The canal was then sequentially broached up to a medium broach The calcar was then plained with the hand plainer The trial components were positioned into place The medium component fit fairly well with the medium 28 mm femoral head Once the trial reduction was performed the hip was taken through range of motion There was physiologic crystalling with longitudinal traction There was no tendency towards dislocation with flexion of the hip past 90 degrees The trial implants were then removed The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit The implant was then impacted into place The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup The acetabulum was once again inspected was free of debris The hip was reduced It was taken through full range of motion There was no tendency for dislocation The wound was copiously irrigated with gentamicin solution The capsule was then repaired with interrupted 1 Ethibond suture External rotators were then reapproximated to the posterior intertrochanteric line utilizing 1 Ethibond in a modified Kessler type stitch The wound was once again copiously irrigated with gentamicin solution and suctioned dry Gluteus fascia was approximated with interrupted 1 Ethibond Subcutaneous layers were approximated with interrupted 2 0 Vicryl and skin approximated with staples A bulky dressing was applied to the wound The patient was then transferred to the hospital bed an abductor pillow was positioned into place Circulatory status was intact to the extremity at completion of the case Keywords surgery austin moore bipolar hemiarthroplasty femoral head femoral hip hemiarthroplasty ethibond acetabulum MEDICAL_TRANSCRIPTION,Description Austin bunionectomy with internal screw fixation first metatarsal left foot Medical Specialty Surgery Sample Name Austin Bunionectomy Transcription TITLE OF OPERATION Austin bunionectomy with internal screw fixation first metatarsal left foot PREOPERATIVE DIAGNOSIS Bunion deformity left foot POSTOPERATIVE DIAGNOSIS Bunion deformity left foot ANESTHESIA Monitored anesthesia care with 15 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 45 minutes left ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl as well as a 16 mm and an 18 mm partially threaded cannulated screw from the OsteoMed Screw Fixation System DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in a supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in normal sterile technique The left ankle tourniquet was inflated Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6 cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint All the tendinous neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal and capsular attachments were mobilized from the head of the first left metatarsal The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw The same saw was used to perform an Austin type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction The same wires were also used as guide wires for the insertion of a 16 mm and an 18 mm partially threaded screws from the 3 0 OsteoMed System upon insertion of the screws which was accomplished using AO technique The wires were removed Fixation on the table was found to be excellent Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw The area was copiously flushed with saline The periosteal and capsular tissues were approximated with 2 0 and 3 0 Vicryl suture material 4 0 Vicryl was used to approximate the subcutaneous tissues The incision site was reinforced with Steri Strips At this time the patient s left ankle tourniquet was deflated The time was 45 minutes Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and an Ace bandage The patient s left foot was then placed in a surgical shoe The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels The patient was given pain medication and instructions on how to control her postoperative course The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr X in one week s time for her first postoperative appointment Keywords surgery internal screw fixation first metatarsal bunion deformity osteomed screw fixation system subcutaneous tissues metatarsal head austin bunionectomy screw fixation ankle tourniquet metatarsophalangeal joint austin tourniquet metatarsophalangeal bunionectomy foot metatarsal MEDICAL_TRANSCRIPTION,Description Austin Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint Weil osteotomy with internal screw fixation first right metatarsal Arthroplasty second right PIP joint Medical Specialty Surgery Sample Name Austin Akin Bunionectomy Transcription TITLE OF OPERATION 1 Austin Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint 2 Weil osteotomy with internal screw fixation first right metatarsal 3 Arthroplasty second right PIP joint PREOPERATIVE DIAGNOSES 1 Bunion deformity right foot 2 Dislocated second right metatarsophalangeal joint 3 Hammertoe deformity second right digit POSTOPERATIVE DIAGNOSES 1 Bunion deformity right foot 2 Dislocated second right metatarsophalangeal joint 3 Hammertoe deformity second right digit ANESTHESIA Monitored anesthesia care with 20 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 60 minutes a right ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL PREOPERATIVE INJECTABLES 1 g Ancef IV 30 minutes preoperatively MATERIALS USED 3 0 Vicryl 4 0 Vicryl 5 0 Prolene as well as two 16 mm partially treaded cannulated screws of the OsteoMed system one 18 mm partially treaded cannulated screw of the OsteoMed system of the 3 0 size One 10 mm 2 0 partially threaded cannulated screw of the OsteoMed system DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s right foot to anesthetize the future surgical sites The right ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg The right foot was then prepped scrubbed and draped in a normal sterile technique The right ankle tourniquet was then inflated Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6 cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint Using sharp and dull dissection the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy The two screws from the 3 0 OsteoMed system were inserted over the wires using AO technique One screw measured 16 mm second screw measured 18 mm in length Both 3 0 screws were then evaluated for the fixation of the osteotomy after the wires were removed Fixation of the osteotomy was found to be excellent The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw To improve the correction of the hallux abductus angle an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally Upon removal of the base wedge from the base of the proximal phalanx the osteotomy was reduced with the OsteoMed smooth wire which was also used as a guidewire for the insertion of a 16 mm partially threaded cannulated screw from the OsteoMed 3 0 system Upon insertion of the screw using AO technique the wire was removed The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe Fixation of the osteotomy was found to be excellent Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical Range of motion of that joint was uninhibited The area was flushed copiously with saline Then 3 0 suture material was used to approximate the periosteum and capsular tissues 4 0 was used to approximate the subcutaneous tissues and Steri Strips were used to reinforce the incision Attention was directed over the neck of the second right metatarsal head where a 3 cm linear incision was placed directly over the surgical neck of the second right metatarsal The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the surgical neck of the second right metatarsal was adequately exposed and then Weil type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal The 2 0 Osteo Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10 mm partially threaded 2 0 cannulated screw Upon insertion of the screw using AO technique the wire was then removed Fixation of the osteotomy with 2 0 screw was found to be excellent The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced Range of motion of the second right metatarsophalangeal joint was found to be excellent Then 3 0 Vicryl suture material was used to approximate the periosteal tissues Then 4 0 Vicryl was used to approximate the skin incision Attention was then directed at the level of the PIP joint of the second right toe where two semi elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint The island of skin between the two semi elliptical incisions was resected in toto The dissection was carried down to the level of extensor digitorum longus of the second right toe which was resected transversely at the level of the PIP joint A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed Using the double action bone cutter the head of the proximal phalanx of the second right toe was then resected The area was copiously flushed with saline The capsular and periosteal tissues were approximated with 2 0 Vicryl and 3 0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe A 5 0 Prolene was used to approximate the skin edges of the two semi elliptical incisions Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical At this time the patient s three incisions were covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s right ankle tourniquet was deflated time was 60 minutes Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs The patient s right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels The patient was given instructions and education on how to continue caring for her right foot surgery The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for her first postoperative appointment Keywords surgery austin akin bunionectomy weil osteotomy internal screw fixation first right metatarsal metatarsophalangeal joint hammertoe deformity extensor digitorum longus austin akin bunionectomy threaded cannulated screw semi elliptical incisions ankle tourniquet surgical neck cannulated screws pip joint proximal phalanx fixation metatarsophalangeal proximal screw metatarsal osteotomy austin joint tourniquet osteomed phalanx incision MEDICAL_TRANSCRIPTION,Description Erythema of the right knee and leg possible septic knee Aspiration through the anterolateral portal of knee joint Medical Specialty Surgery Sample Name Aspiration Knee Joint Transcription PREOPERATIVE DIAGNOSES Erythema of the right knee and leg possible septic knee POSTOPERATIVE DIAGNOSES Erythema of the right knee superficial and leg right septic knee ruled out INDICATIONS Mr ABC is a 52 year old male who has had approximately eight days of erythema over his knee He has been to multiple institutions as an outpatient for this complaint He has had what appears to be prepatellar bursa aspirated with little to no success He has been treated with Kefzol and 1 g of Rocephin one point He also reports in the emergency department today an attempt was made to aspirate his actual knee joint which was unsuccessful Orthopedic Surgery was consulted at this time Considering the patient s physical exam there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee After discussion of risks and benefits the patient elected to proceed with aspiration through the anterolateral portal of his knee joint PROCEDURE The patient s right anterolateral knee area was prepped with Betadine times two and a 20 gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella The 20 gauge spinal needle was inserted and entered the knee joint Approximately 4 cc of clear yellow fluid was aspirated The patient tolerated the procedure well DISPOSITION Based upon the appearance of this synovial fluid we have a very low clinical suspicion of a septic joint We will send this fluid to the lab for cell count crystal exam as well as culture and Gram stain We will follow these results After discussion with the emergency department staff it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics Keywords surgery knee and leg anterolateral portal emergency department spinal needle septic knee knee joint knee emergency department gauge spinal needle aspiration anterolateral portal aspirated fluid septic erythema joint aspiraion MEDICAL_TRANSCRIPTION,Description Ash split venous port insertion The right anterior chest and supraclavicular fossa area neck and left side of chest were prepped with Betadine and draped in a sterile fashion Medical Specialty Surgery Sample Name Ash Split Venous Port Transcription ASH SPLIT VENOUS PORT PROCEDURE DETAILS The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist The right anterior chest and supraclavicular fossa area neck and left side of chest were prepped with Betadine and draped in a sterile fashion Xylocaine 1 was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter The patient was placed into Trendelenburg position The right internal jugular vein was accessed by a supraclavicular 19 gauge thin walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle Under fluoroscopic control a J wire was advanced into the right atrium The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel A second incision was made 5 cm inferior to the right midclavicular line through which an Ash split catheter was advanced using the tunneling rod in a gently curving pass to exit the skin of the neck incision The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter Sequential dilators were advanced over the J wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control The dilator and wire were removed leaving the sheath in position through which a double lumen catheter was advanced into the central venous system The sheath was peeled away leaving the catheter into position Each port of the catheter was flushed with dilute heparinized saline The patient was returned to the flat position The catheter was secured to the skin of the anterior chest using 2 0 Ethilon suture placed through the suture wings The neck incision was closed with 3 0 Vicryl subcuticular closure and pressure dressing applied Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position The patient was returned to the recovery room for postoperative care Keywords surgery ash split venous port venous port anterior chest incision dilators sheath port supraclavicular needle fluoroscopic venous insertion catheter MEDICAL_TRANSCRIPTION,Description Hemarthrosis left knee status post total knee replacement rule out infection Arthrotomy irrigation and debridement and polyethylene exchange left knee No complications were encountered throughout the procedure Medical Specialty Surgery Sample Name Arthrotomy I D Transcription PREOPERATIVE DIAGNOSIS Hemarthrosis left knee status post total knee replacement rule out infection POSTOPERATIVE DIAGNOSIS Hemarthrosis left knee status post total knee replacement rule out infection OPERATIONS 1 Arthrotomy left total knee 2 Irrigation and debridement left knee 3 Polyethylene exchange left knee COMPLICATION None TOURNIQUET TIME 58 minutes ESTIMATED BLOOD LOSS Minimal ANESTHESIA General INDICATIONS This patient underwent an uncomplicated left total knee replacement Postoperatively unfortunately did not follow up with PT INR blood test and he was taking Coumadin His INR was seemed to elevated and developed hemarthrosis Initially it did look very benign although over the last 24 hours it did become irritable and inflamed and he therefore was indicated with the above noted procedure This procedure as well as alternatives was discussed in length with the patient and he understood them well Risks and benefits were also discussed Risks such as bleeding infection damage to blood vessels damage to nerve roots need for further surgeries chronic pain with range of motion risk of continued discomfort risk of need for further reconstructive procedures risk of need for total knee revision risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed He understood them well All questions were answered and he signed consent for the procedure as described DESCRIPTION OF PROCEDURE The patient was placed on operating table and general anesthesia was achieved The left lower extremity was then prepped and draped in the usual sterile manner The leg was elevated and the tourniquet was inflated to 325 mmHg A longitudinal incision was then made and carried down through subcutaneous tissues This was made through the prior incision site There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site Medial and lateral flaps were then made The prior suture was identified the suture removed and then a medial parapatellar arthrotomy was then performed Effusion within the knee was noted All hematoma was evacuated I then did flex the knee and removed the polyethylene Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution Further debridement was performed of all inflamed tissue and thickened synovial tissue A 6 x 16 mm Stryker polyethylene was then snapped back in position The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline The knee was placed in a flexed position and the extensor mechanism was reapproximated using 2 Ethibond suture in a figure of eight manner The subcutaneous tissue was reapproximated in layers using 1 and 2 0 Vicryl sutures and the skin was reapproximated using staples Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint No complications were encountered throughout the procedure and the patient tolerated the procedure well The patient was taken to recovery room in stable condition Keywords surgery MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee left arthroscopic medial meniscoplasty of medial femoral condyle and chondroplasty of the left knee as well Chondromalacia of medial femoral condyle Medial meniscal tear left knee Medical Specialty Surgery Sample Name Arthroscopy Meniscoplasty Chondroplasty Transcription PREOPERATIVE DIAGNOSIS Medial meniscal tear left knee POSTOPERATIVE DIAGNOSIS Chondromalacia of medial femoral condyle PROCEDURE PERFORMED 1 Arthroscopy of the left knee 2 Left arthroscopic medial meniscoplasty of medial femoral condyle 3 Chondroplasty of the left knee as well ESTIMATED BLOOD LOSS 80 cc TOTAL TOURNIQUET TIME 19 minutes DISPOSITION The patient was taken to PACU in stable condition HISTORY OF PRESENT ILLNESS The patient is a 41 year old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain He has had a positive symptomology of locking and pain since then He had no frank instability to it however GROSS OPERATIVE FINDINGS We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle OPERATIVE PROCEDURE The patient was taken to the operating room The left lower extremity was prepped and draped in the usual sterile fashion Tourniquet was applied to the left thigh with adequate Webril padding not inflated at this time After the left lower extremity had been prepped and draped in the usual sterile fashion we applied an Esmarch tourniquet exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes We established the lateral port of the knee with 11 blade scalpel We put in the arthroscopic trocar instilled with water and inserted the camera On inspection of the patellofemoral joint it was found to be quite smooth Pictures were taken there There was no evidence of chondromalacia cracking or fissuring of the articular cartilage The patella was well centered over the trochlear notch We then directed the arthroscope to the medial compartment of the knee It was felt that there was a tear to the medial meniscus We also saw large area of chondromalacia with grade IV changes to bone over the medial femoral condyle This area was debrided with forceps and the arthroscopic shaver The cartilage was also smoothened over the medial femoral condyle This was curetted after the medial meniscus had been trimmed We looked into the notch We saw the ACL appeared stable saw attachments to tibial as well as the femoral insertion with some evidence of laxity wear and tear Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment All instruments were removed All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end We removed all instruments Marcaine was injected into the portal sites We placed a sterile dressing and stockinet on the left lower extremity He was transferred to the gurney and taken to PACU in stable condition Keywords surgery medial meniscoplasty arthroscopic chondroplasty arthroscopy medial femoral condyle medial meniscus knee meniscal cartilage meniscoplasty meniscus chondromalacia condyle femoral MEDICAL_TRANSCRIPTION,Description Arthrotomy removal humeral head implant right shoulder Repair of torn subscapularis tendon rotator cuff tendon acute tear Debridement glenohumeral joint Biopsy and culturing the right shoulder Medical Specialty Surgery Sample Name Arthrotomy Subscapularis Tendon Repair Transcription TITLE OF OPERATION 1 Arthrotomy removal humeral head implant right shoulder 2 Repair of torn subscapularis tendon rotator cuff tendon acute tear 3 Debridement glenohumeral joint 4 Biopsy and culturing the right shoulder INDICATION FOR SURGERY The patient had done well after a previous total shoulder arthroplasty performed by Dr X However the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis Risks and benefits of the procedure had been discussed with the patient at length including but not exclusive of infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain incomplete return of function continued instability retearing of the tendon need for revision of his arthroplasty permanent nerve or artery damage etc The patient understood and wished to proceed PREOP DIAGNOSIS 1 Torn subscapularis tendon right shoulder 2 Right total shoulder arthroplasty Biomet system POSTOP DIAGNOSIS 1 Torn subscapularis tendon right shoulder 2 Right total shoulder arthroplasty Biomet system 3 Diffuse synovitis right shoulder PROCEDURE The patient was anesthetized in the supine position A Foley catheter was placed in his bladder He was then placed in a beach chair position He was brought to the side of the table and the torso secured with towels and tape His head was then placed in the neutral position with no lateral bending or extension It was secured with paper tape over his forehead Care was taken to stay off his auricular cartilages and his orbits Right upper extremity was then prepped and draped in the usual sterile fashion The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection Once he had been prepped and draped with the standard prep he was prepped a second time with a chlorhexidine type skin prep This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection Also preoperatively the patient had his pacemaker defibrillator function turned off as a result during this case Bipolar type cautery had to be used as opposed to monopolar cautery The patient s deltopectoral incision was then opened and extended proximally and distally The patient had significant amount of scar already in this interval Once we got down to the deltoid and pectoralis muscle there was no apparent cephalic vein present as a result the rotator cuff interval had to be developed through an area of scar This created a significant amount of bleeding As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus Care was taken to stay above the pectoralis minor and the conjoint tendon The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus Similarly the deltoid insertion had to be released approximately 50 of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity The soft tissue in this area was significantly scarred down to the conjoint tendon which had to be very meticulously released The brachial plexus was identified as was the axillary nerve Once this was completed an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later This revealed sanguineous fluid inside the joint We did not feel it was infected based upon the fluid that came from the joint The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone which was fortunate because in that we could use the bone later for securing the sutures The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring This was done also very meticulously The upper one half of the latissimus dorsi tendon was also released Once this was completed the humerus could be subluxed enough laterally that we could remove the head This was done with no difficulty Fortunately the humeral component stayed intact There were some exudates beneath the humeral head which were somewhat mucinous However these do not really appear to be infected however we sent them to pathology for a frozen section This frozen section later returned as possible purulent material I discussed this personally with the pathologist at that point We told him that the procedure is only 3 weeks old but he was concerned that there might be more white blood cells in the tissue than he would expect As a result all the mucinous exudates were carefully removed We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components but also we irrigated the joint throughout the case with antibiotic impregnated irrigation At that point we also had sent portions of this mucinous material to pathology for a stat Gram stain This came back as no organisms seen We also sent portions for culture and sensitivity both aerobic and anaerobic Once this was completed attention was then directed to the glenoid The patient had significant amount of scar already The subscapularis itself was significantly scarred down to the anterior rim As a result the adhesions along the anterior edge were released using a knife Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis The subscapularis was then tagged with multiple number 2 Tycron sutures Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees the subscapularis could reach the calcar region without tension As a result seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus These all had excellent security in bone Once the joint had been debrided and irrigated the real humeral head was then placed back on the proximal humerus Care was taken to remove fluid off the Morse taper The head was then impacted It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient Unfortunately any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus As a result it was felt to place the offset head back on the humerus we did insert a new component as opposed to using the old component The old component was given to the family postoperatively With the arm in internal rotation the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion Also it should be noted that the rotator cuff interval had to be released as part of the exposure We started the repair by closing the rotator cuff interval Anterior and posterior translation was then performed and was found to be very stable The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two layer repair of the subscapularis tendon After the tendon had been repaired there was no tension on repair until 0 degrees external rotation was reached with the arm to the side Similarly with the arm abducted 90 degrees tension was on repair at 0 degrees of external rotation It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation The rotator cuff interval was closed with multiple number 2 Tycron sutures It was reinforced with 0 Vicryl sutures Two Hemovac drains were then placed inferiorly at the deltoid The deltopectoral interval was then closed with 0 Vicryl sutures A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections This was sewn into place with the drain pulled out superiorly Once all the sutures have been secured and the drain visualized throughout this part of the closure the drain was pulled distally until it was completely covered There were no signs that it had been tagged or hung up by any sutures The superficial subcutaneous tissues were closed with interrupted with 2 0 Vicryl sutures Skin was closed with staples A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer The patient was sent to the intensive care unit in stable and satisfactory condition Due to the significant amount of scar and bleeding in this patient a 22 modifier is being requested for this case This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement Similarly the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant This was being dictated for insurance purposes only and reflects no inherent difficulties with this case The complexity and the time involved in this case was approximately 30 greater than that of a standard shoulder replacement or of a rotator cuff repair This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient s situation with his pacemaker This patient also had multiple medical concerns which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation Keywords surgery arthrotomy repair of torn subscapularis tendon glenohumeral joint biomet system arthroplasty diffuse synovitis proximal humerus torn subscapularis tendon subscapularis tendon rotator cuff humerus sutures tendon head shoulder subscapularis torn MEDICAL_TRANSCRIPTION,Description Diagnostic arthroscopy exam under anesthesia left shoulder Debridement of chondral injury left shoulder Debridement superior glenoid left shoulder Arthrotomy Bankart lesion repair Capsular shift left shoulder Mitek suture anchors absorbable anchors with nonabsorbable sutures Medical Specialty Surgery Sample Name Arthroscopy Arthrotomy Bankart lesion repair Transcription TITLE OF OPERATION 1 Diagnostic arthroscopy exam under anesthesia left shoulder 2 Debridement of chondral injury left shoulder 3 Debridement superior glenoid left shoulder 4 Arthrotomy 5 Bankart lesion repair 6 Capsular shift left shoulder Mitek suture anchors absorbable anchors with nonabsorbable sutures INDICATION FOR SURGERY The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder Risks and benefits of the procedure had been discussed in length including but not exclusive of infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain continued instability recurrent instability medical complications surgical complications and anesthesia complications The patient understood and wishes to proceed PREOP DIAGNOSIS Anterior instability left shoulder POSTOP DIAGNOSES 1 Anterior instability left shoulder 2 Grade 4 chondromalacia 10 humeral head chondral defect 1 cm squared left shoulder 3 Type 1 superior labrum anterior and posterior lesion left shoulder 4 Anteroinferior glenoid erosions 10 bony surface left shoulder 5 Bankart lesion left shoulder PROCEDURE The patient was placed in a supine position and both shoulders examined systematically She had full range of motion with no joint adhesions She had equal range of motion bilaterally She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders This was the same when the arm was in neutral or in external rotation The patient was then turned to right lateral decubitus position axillary roll was placed and beanbag was inflated Peroneal nerve was well protected All bony prominences were well protected The left upper extremity was then prepped and draped in the usual sterile fashion The patient was given antibiotics well before the start of the procedure to decrease the risk of infection The arm was placed in a arm holder with 10 pounds of traction A posterior portal was created in the usual manner by isolating gently with the spinal needle it was insufflated with 30 cubic centimeters of saline A small incision was made after infiltrating the skin with Marcaine and epinephrine The scope was introduced into the shoulder with no difficulty It was then examined systematically The patient did have diffuse synovitis throughout her shoulder Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head She also had an area 1 cm in diameter which was on more central portion of the head and more inferiorly which appeared to be more of an impaction type injury This had some portions of fibrillated and loose cartilage hanging from the edges These were later debrided but the dissection was proximally 10 to 15 of the humeral surface The biceps tendon appeared to be normal The supraspinatus infraspinatus tendons were normal The inferior pouch was normal with no capsular tearing and no HAGL lesions The posteroinferior labrum was normal as well as the posterosuperior labrum There was some fraying in the posterosuperior labrum which was later debrided It was found essentially to be a type 1 lesion anteriorly and superiorly The anterosuperior labrum appeared to be detached which appeared to be more consistent with a sublabral hole The middle glenohumeral ligament was present as an entire sheath but attach to the labrum The labrum did appeared to be detached from the anterior glenoid from the 11 o clock position all the way down to the 6 o clock position The biceps anchor itself was later probed and found to be stable and normal The subscapularis tendon was normal The anterior band of the glenohumeral ligament was present but it was clearly avulsed off the glenoid There was some suggestion of anteroinferior bony erosions which was later substantiated when the shoulder was opened The patient was missing about 10 to 15 of her anteroinferior glenoid rim The patient had a positive drive through sign The arm was then moved to lateral and placed through range of motion There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees maximum flexion was 150 degrees The arm abducted and externally rotated There was contact to the rotator cuff with posterosuperior labrum This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees maximum external rotation was 95 degrees The patient did have a positive relocation maneuver The posterior labrum did appear to tilt off but did not appear to peel off The arm was then placed back in the arm holder Anterior portal was created with Wissinger rod A blue cannula was inserted into the shoulder without difficulty Shaver was introduced in the labrum Also the area of chondromalacia as mentioned above was debrided The labrum was found to be stable with only a type 1 SLAP lesion and there was no evidence as there was really a type 2 SLAP lesion The instruments were then removed along with excess fluid The posterior portals were closed with single 4 0 nylon suture The anterior portal was left open The patient was then placed in a supine position and the extremity was reprepped and draped in anticipation of performing open capsular shift The patient s anterior incision made just lateral to the coracoid in the skin line Mediolateral skin flaps were developed and cephalic vein was identified and protected throughout the case The interval was developed down the clavipectoral fascia The conjoined tendon was retracted medially and the deltoid laterally The patient s subscapularis was intact and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers The capsule could easily be detached from the muscle and the interval developed very easily A retractor was placed inferiorly to protect the axillary nerve Then Gelpi retractor was used to hold the subscapularis split open Next an arthrotomy was made down at the 9 o clock position The labrum was identified and found to be attached all the way down to 6 o clock position The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture The patient s glenoid rim did have some erosion as mentioned above with some bone loss and flattening This was debrided with the soft tissue Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck These were absorbable anchors with nonabsorbable sutures They had excellent fixation once they had been placed Next the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti Cron sutures as an outside in and then inside out technique This brought the capsule right up to the edge of the glenoid rim With the arm in internal rotation and posterior pressure on the head the capsule was then secured to the rim with no difficulty under direct visualization The capsule did come right up into the joint as expected with this type of repair The superior flap was then closed the inferior flap over the superior anchor The interval between two flaps was closed with multiple number 2 Ti Cron sutures Once this has been completed there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached The arm abducted 90 degrees There was tension on the repair until 20 degrees of external rotation reached The wound was thoroughly irrigated throughout with antibiotic impregnated irrigation The subscapularis split was closed with interrupted 0 Vicryl sutures The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures The superficial subcutaneous tissues were closed with number 2 0 Vicryl sutures The skin was closed with 4 0 subcuticular Prolene reinforced with Steri Strips A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer The patient was sent to the recovery room in stable and satisfactory condition Keywords surgery diagnostic arthroscopy chondral injury debridement superior glenoid arthrotomy bankart lesion capsular shift mitek suture absorbable anchors anterior instability chondromalacia superior labrum glenoid erosion glenoid rim external rotation glenoid labrum shoulder arthroscopy MEDICAL_TRANSCRIPTION,Description Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle right knee Soft tissue mass and osteophyte lateral femoral condyle right knee Medical Specialty Surgery Sample Name Arthrotomy Ostectomy Capsular Mass Excision Transcription PREOPERATIVE DIAGNOSIS Soft tissue mass right knee POSTOPERATIVE DIAGNOSES 1 Soft tissue mass right knee 2 Osteophyte lateral femoral condyle right knee PROCEDURES PERFORMED Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle right knee SPECIFICATION The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under a local and IV sedation via the Anesthesia Department HISTORY AND GROSS FINDINGS This is a 37 year old African American male with a mass present at the posterolateral aspect of his right knee On aspiration it was originally attempted to no avail There was a long standing history of this including two different MRIs one about a year ago and one very recently both of which did not delineate the mass present During aspiration previously the patient had experienced neuritic type symptoms down his calf which have mostly resolved by the time that this had occurred The patient continued to complain of pain and dysfunction to his calf This was discussed with him at length He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness swelling and peroneal nerve palsy With this he decided to proceed Upon observation preoperatively the patient was noted to have a hard mass present to the posterolateral aspect of the right knee It was noted to be tender It was marked preoperatively prior to an anesthetic Upon dissection the patient was noted to have significant thickening of the posterior capsule The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle There was also noted to be prominence of the lateral femoral condyle ridge The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present OPERATIVE PROCEDURE The patient was laid supine upon the operating table After receiving IV sedation he was placed prone Thigh tourniquet was placed He was prepped and draped in the usual sterile manner A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized The nerve was identified and carefully retracted throughout the case Both nerves were identified and carefully retracted throughout the case There was noted to be no neuroma present This was taken down until the gastroc was split There was gross thickening of the joint capsule and after arthrotomy a section of the capsule was excised The lateral femoral condyle was then osteophied We then smoothed off with a rongeur After this we could not palpate any mass whatsoever placing pressure upon the area of the nerve Tourniquet was deflated It was checked again There was no excessive swelling Swanson drain was placed to the depth of the wound and interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and 4 0 nylon was utilized for skin closure Adaptic 4x4s ABDs and Webril were placed for compression dressing Digits were warm _______ pulses distally at the end of the case The tourniquet as stated has been deflated prior to closure and hemostasis was controlled Expected surgical prognosis on this patient is guarded Keywords surgery soft tissue mass osteophyte lateral femoral condyle excision capsular mass arthrotomy ostectomy knee soft tissue femoral condyle mass subcutaneous capsular tourniquet femoral condyle MEDICAL_TRANSCRIPTION,Description Partial rotator cuff tear left shoulder Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement soft tissue decompression of the subacromial space of the left shoulder Medical Specialty Surgery Sample Name Arthroscopy Shoulder Transcription PREOPERATIVE DIAGNOSIS Partial rotator cuff tear left shoulder POSTOPERATIVE DIAGNOSIS Partial rotator cuff tear left shoulder PROCEDURE PERFORMED Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement soft tissue decompression of the subacromial space of the left shoulder ANESTHESIA Scalene block with general anesthesia ESTIMATED BLOOD LOSS 30 cc COMPLICATIONS None DISPOSITION The patient went to the PACU stable GROSS OPERATIVE FINDINGS There was no overt pathology of the biceps tendon There was some softening and loss of the articular cartilage over the glenoid The labrum was ________ attached permanently to the glenoid The biceps tendon was nonsubluxable Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space There was reconstitution of the bursa noted as well HISTORY OF PRESENT ILLNESS This is a 51 year old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder MRI shows partial rotator cuff tear PROCEDURE The patient was taken to the operating room and placed in a beachchair position After all bony prominences were adequately padded the head was placed in the headholder with no excessive extension in the neck on flexion The left extremity was prepped and draped in usual fashion The 18 gauge needles were inserted into the left shoulder to locate the AC joint the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect We took an 11 blade scalpel and made a small 1 cm skin incision posteriorly approximately 4 cm inferior and medial to the lateral port of the acromion A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using 11 blade on the skin and inserted bluntly the trocar and the cannula The operative findings found intra articularly were as described previously gross operative findings We did not see any evidence of acute pathology We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal All this was done and hemostasis was achieved The rotator cuff was examined from the bursal side and showed no evidence of tears There was some fraying out laterally near its attachment over the greater tuberosity which was debrided with the arthroscopic shaver We removed all of our instruments and suctioned the subacromial space dry A 4 0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling She was placed back on the gurney extubated and taken to the PACU in stable condition Keywords surgery subacromial space arthroscopic biceps tendon labrum glenoid cartilage partial rotator cuff tear rotator cuff tear shoulder arthroscopy rotator cuff arthroscopy shoulder tissue subacromial rotator cuff MEDICAL_TRANSCRIPTION,Description Diagnostic arthroscopy with partial chondroplasty of patella lateral retinacular release and open tibial tubercle transfer with fixation of two 4 5 mm cannulated screws Grade IV chondromalacia patella and patellofemoral malalignment syndrome Medical Specialty Surgery Sample Name Arthroscopy Chondroplasty Transcription PREOPERATIVE DIAGNOSES 1 Chondromalacia patella 2 Patellofemoral malalignment syndrome POSTOPERATIVE DIAGNOSES 1 Grade IV chondromalacia patella 2 Patellofemoral malalignment syndrome PROCEDURE PERFORMED 1 Diagnostic arthroscopy with partial chondroplasty of patella 2 Lateral retinacular release 3 Open tibial tubercle transfer with fixation of two 4 5 mm cannulated screws ANESTHESIA General COMPLICATIONS None TOURNIQUET TIME Approximately 70 minutes at 325 mmHg INTRAOPERATIVE FINDINGS Grade IV chondromalacia noted to the central and lateral facet of the patella There was a grade II to III chondral changes to the patellar groove The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle The medial lateral meniscus showed small amounts of degeneration but no frank tears were seen The articular surfaces and the remainder of the knee appeared intact Cruciate ligaments also appeared intact to direct stress testing HISTORY This is a 36 year old Caucasian female with a long standing history of right knee pain She has been diagnosed in the past with chondromalacia patella She has failed conservative therapy It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer anterior medialization of the tibial tubercle to release stress from her femoral patellofemoral joint She elected to proceed with the surgical intervention All risks and benefits of the surgery were discussed with her She was in agreement with the treatment plan PROCEDURE On 09 04 03 she was taken to Operating Room at ABCD General Hospital She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion A stab incision was made in inferolateral and parapatellar regions Through this the cannula was placed and the knee was inflated with saline solution Intraoperative pictures were obtained The above findings were noted Second portal site was initiated in the inferomedial parapatellar region Through this a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris Next the camera was placed through the inferomedial portal An arthroscopic Bovie was placed through the inferolateral portal A release of lateral retinaculum was then performed using the Bovie Hemostasis was controlled with electrocautery Next the knee was suctioned dry An Esmarch was used to exsanguinate the lower extremity Tourniquet was inflated to 325 mmHg An oblique incision was made along the medial parapatellar region of the knee The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery The retinaculum was then incised in line with the incision The patellar tendon was identified The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris Next an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact The tubercle was then pushed anteriorly and medially decreasing her Q angle and anteriorizing the tibial tubercle It was then held in place with a Steinmann pin Following this a two 4 5 mm cannulated screws partially threaded were drilled in place using standard technique to help fixate the tibial tubercle There was excellent fixation noted The Q angle was noted to be decreased to approximately 15 degrees She was transferred approximately 1 cm in length The wound was copiously irrigated and suctioned dry The medial retinaculum was then plicated causing further medialization of the patella The retinaculum was reapproximated using 0 Vicryl Subcuticular tissue were reapproximated with 2 0 Vicryl Skin was closed with 4 0 Vicryl running PDS suture Sterile dressing was applied to the lower extremities She was placed in a Donjoy knee immobilizer locked in extension It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet She was transferred to recovery room in apparent stable and satisfactory condition Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia Keywords surgery diagnostic arthroscopy patellofemoral malalignment syndrome cannulated partial chondroplasty retinacular chondromalacia patella tibial tubercle patella tubercle arthroscopy tourniquet chondroplasty chondromalacia patellofemoral MEDICAL_TRANSCRIPTION,Description Rotator cuff tear right shoulder Superior labrum anterior and posterior lesion peel back right shoulder Arthroscopy with arthroscopic SLAP lesion Repair of soft tissue subacromial decompression rotator cuff repair right shoulder Medical Specialty Surgery Sample Name Arthroscopic SLAP lesion Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear right shoulder POSTOPERATIVE DIAGNOSIS Superior labrum anterior and posterior lesion peel back right shoulder PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic SLAP lesion 2 Repair of soft tissue subacromial decompression rotator cuff repair right shoulder SPECIFICATIONS The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position HISTORY AND GROSS FINDINGS This is a 54 year old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention She had an injury to her right shoulder when she fell off a bike She was diagnosed preoperatively with a rotated cuff tear Intra articularly besides we noted a large SLAP lesion superior and posterior to the attachment of the glenoid labrum from approximately 12 30 back to 10 30 This acted as a peel back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid This was an obvious avulsion into subchondral bone with bone exposed The anterior aspect had degenerative changes but did not have evidence of avulsion The subscapular was noted to be intact On the joint side of the supraspinatus there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid aspect of the supraspinatus attachment This was confirmed subacromially The patient had a type I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression but soft tissue release of the CA ligament in a releasing resection type fashion OPERATIVE PROCEDURE The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department She was safely placed in a modified beachchair position She was prepped and draped in the usual sterile manner The portals were created from outside the ends posterior to the scope and anteriorly for an intraoperative portal and then laterally She had at least two other portals appropriate for both repair mechanisms described above Attention was then turned to the SLAP lesion The edges were debrided both on the bony side as well as soft tissue side We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum Further debridement was carried out here A drill hole was made just on the articular surface superiorly for a knotless anchor A pull through suture of 2 fiber wire was utilized with the ________ This was pulled through It was tied to the leader suture of the knotless anchor This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet There was excellent fixation of the superior labrum It was noted to be solid and intact The anchor was placed safely in the bone There was no room for further knotless or other anchors After probing was carried out hard copy Polaroid was obtained Attention was then turned to the articular side for the rotator cuff It was debrided Subchondral debridement was carried out to the tuberosity also Care was taken to go to the subchondral region but not beyond The bone was satisfactory Scope was then placed in the subacromial region Gross bursectomy was carried out with in the lateral portal This was done throughout as well as in the gutters anterolaterally and posteriorly Debridement was carried out further to the rotator cuff Two types of fixation were carried out one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch There was an excellent reduction of the tear posteriorly and then anteriorly Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal This was done with a sliding stitch and then two half stitches There was excellent reduction of the tear Attention was then turned to the CA ligament It was released along with periosteum and the undersurface of the anterior acromion The CA ligament was not only released but resected There was noted to be no evidence of significant spurring with only a mostly type I acromion Thus it was not elected to perform subacromial decompression for bone with soft tissue only A pain buster catheter was placed separately It was cut to length An interrupted 4 0 nylon was utilized for portal closure A 0 5 Marcaine was instilled subacromially Adaptic 4x4s ABDs and Elastoplast tape placed for dressing The patient s arm was placed in a arm sling She was transferred to PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords surgery rotator cuff tear shoulder labrum lesion decompression subacromial arthroscopic slap lesion slap lesion rotator cuff anterior arthroscopy arthroscopic slap cuff MEDICAL_TRANSCRIPTION,Description Arthroscopic rotator cuff repair arthroscopic subacromial decompression and arthroscopic extensive debridement superior labrum anterior and posterior tear Medical Specialty Surgery Sample Name Arthroscopic Rotator Cuff Repair 2 Transcription PROCEDURES 1 Arthroscopic rotator cuff repair 2 Arthroscopic subacromial decompression 3 Arthroscopic extensive debridement superior labrum anterior and posterior tear PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed on the operating room table in supine position and given general anesthetic Once the patient was under general anesthetic a careful examination of the shoulder was performed It revealed no patholigamentous laxity The patient was then carefully positioned into a beach chair position We maintained the natural alignment of the head neck and thorax at all times The shoulder and upper extremity was then prepped and draped in the usual sterile fashion Once we fully prepped and draped we then began the surgery We injected the glenohumeral joint with sterile saline with a spinal needle This consisted of 60 cc of fluid We then made a posterior incision for our portal 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion Through this incision a blunt trocar and cannula were placed in the glenohumeral joint Through the cannula a camera was placed and the shoulder was insufflated with sterile saline through a preoperative feed We then carefully examined the glenohumeral joint We found the articular surface to be in good condition There was a superior labral tear SLAP This was extensively debrided using a shaver through an anterior portal We also found a full thickness rotator cuff tear We then drained the glenohumeral joint We redirected our camera into the subacromial space An anterolateral portal was made both superior and inferior We then proceeded to perform a subacromial decompression using high speed shaver The bursa was extensively debrided We then abraded the bone over the footprint of where the rotator cuff is usually attached The corkscrew anchors were used to perform a rotator cuff repair Pictures were taken Through a separate incision an indwelling pain catheter was then placed It was carefully positioned Pictures were taken We then drained the joint All instruments were removed The patient did receive IV antibiotic preoperatively All portals were closed using 4 0 nylon sutures Xeroform 4 x 4s and OpSite were applied over the pain pump ABD tape and a sling were also applied A Cryo Cuff was also placed over the shoulder The patient was taken out of the beach chair position maintaining the neutral alignment of the head neck and thorax The patient was extubated and brought to the recovery room in stable condition I then went out and spoke with the family going over the case postoperative instructions and followup care Keywords surgery debridement superior labrum patholigamentous laxity arthroscopic rotator cuff repair subacromial decompression glenohumeral joint rotator cuff arthroscopic decompression repair glenohumeral subacromial rotator cuff MEDICAL_TRANSCRIPTION,Description Arthroscopy of the arthroscopic glenoid labrum rotator cuff debridement shaving glenoid and humeral head and biceps tenotomy right shoulder Massive rotator cuff tear right shoulder near complete biceps tendon tear of right shoulder chondromalacia of glenohumeral joint or right shoulder and glenoid labrum tear of right shoulder Medical Specialty Surgery Sample Name Arthroscopy Glenoid Labrum Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear right shoulder POSTOPERATIVE DIAGNOSES 1 Massive rotator cuff tear right shoulder 2 Near complete biceps tendon tear right shoulder 3 Chondromalacia of glenohumeral joint right shoulder 4 Glenoid labrum tear right shoulder PROCEDURE PERFORMED 1 Arthroscopy of the arthroscopic glenoid labrum 2 Rotator cuff debridement shaving glenoid and humeral head 3 Biceps tenotomy right shoulder SPECIFICATION The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under interscalene block anesthetic in the modified beachchair position HISTORY AND GROSS FINDINGS This is a 61 year old white male who is dominantly right handed He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention This was gradually done over a period of time No specific accident or injury could be seen or pointed He was refractory to conservative outpatient therapy After discussing alternatives of the care as well as the advantages disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Preoperatively the patient did not have limitation of motion He had gross weakness to his supraspinatus mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic Intraarticularly the patient had an 80 biceps tendon tear that was dislocated His rotator interval was resolved as well as his subscapularis with tearing The supraspinatus was completely torn retracted back beyond the level of the labrum and approximately one third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe Glenoid labrum had degenerative tear in the inferior surface Gross chondromalacia was present to approximately 50 of the humeral head and approximately the upper 40 of the glenoid surface OPERATIVE PROCEDURE The patient was laid supine upon the operative table After receiving interscalene block anesthetic by the Anesthesia Department he was safely placed in a modified beachchair position He was prepped and draped in the usual sterile manner The portals were created outside the end posteriorly and then anteriorly A full and complete diagnostic arthroscopy was carried out with the above noted findings The shaver was placed anteriorly Debridement was carried out to the glenoid labrum tear and the last 20 of the biceps tendon tear was completed Debridement was carried out to the end or attachment of the bicep itself Debridement was carried out to what could be seen of the remaining rotator cuff there but then the scope was redirected in a subacromial direction and gross bursectomy carried out Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity No osteophytes were present Because of the massive nature of the tear the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring There was concern because of instability that could be present at the end of this Another portal was created laterally to do all of this We did what we could to mobilize all sections of the rotator cuff superiorly posteriorly and anteriorly We took this back to the level of coracoid base We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn Because of this further debridement was carried out Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge Care was taken to not to debride deeper than that This was done prior to the above All instrumentation was removed A Pain Buster catheter was placed into a separate anterolateral portal cut to length Interrupted 4 0 nylon was utilized for portal closures Adaptic 4x4s ABDs Elastoplast tape were placed for a compression dressing The patient s arm was placed in an arm sling He was transferred to his cart and to the PACU in apparent satisfactory condition Expected surgical prognosis on this patient is quite guarded because of the above noted pathology Keywords surgery modified beachchair position rotator cuff tear glenoid labrum tear glenohumeral joint interscalene block glenoid labrum rotator cuff rotator debridement glenoid shoulder tear arthroscopy arthroscopic tenotomy glenohumeral supraspinatus infraspinatus subscapularis chondromalacia biceps labrum cuff MEDICAL_TRANSCRIPTION,Description Arthroscopy with arthroscopic subacromial decompression of the left shoulder Impingement syndrome left shoulder Rule out superior labrum anterior and posterior lesion left shoulder Medical Specialty Surgery Sample Name Arthroscopic Subacromial Decompression Shoulder Transcription PREOPERATIVE DIAGNOSES 1 Impingement syndrome left shoulder 2 Rule out superior labrum anterior and posterior lesion left shoulder POSTOPERATIVE DIAGNOSES Impingement syndrome left shoulder PROCEDURE PERFORMED Arthroscopy with arthroscopic subacromial decompression of the left shoulder ANESTHESIA The procedure was done under an interscalene block and subsequent general anesthetic in the modified beachchair position SPECIFICATIONS The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital HISTORY AND GROSS FINDINGS This is a 30 year old white female suffering increasing left shoulder pain for a number of months prior to surgical intervention She was completely refractory to conservative outpatient therapy She had subacromial injection which relieved the majority of her pain She also had medial bordered scapular pain unrelated directly to the present problem She had plus minus SLAP lesion testing preoperatively Operative findings in the joint included labrum was intact long head of the biceps intact laxity of 1 all around but clinically intact and without laxity Subacromially type II plus acromion and no evidence of significant rotator cuff tear with scuffing only She also had evidence of calcium deposition in the CA ligament and undersurface of the AC joint OPERATIVE PROCEDURE The patient was laid supine upon the operative table After receiving interscalene block general anesthetic by Anesthesia Department she was placed in modified beachchair position She was prepped and draped in the usual sterile manner Portals were created outside the end anterior and posterior posterior and anterior and subsequently laterally A full and complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint with the above noted findings Attention was then turned to the subacromial region The scope was placed A lateral portal was created Gross bursectomy was carried out This was done with a 4 2 meniscal shaver as well as a hot Bovie Calcium deposition mentioned was removed With the rotator cuff intact the periosteum was burned off the undersurface of the acromion and the CA ligament released anteriorly A subacromial decompression sequentially from laterally to medially was then carried out There was an excellent decompression Debridement was carried out to the bursa The portals were ultimately closed with 4 0 after Pain Buster catheter had been placed Subacromial region was flooded with 0 5 Marcaine at approximately 15 cc or so Adaptic 4x4s ABDs and Elastoplast tape placed for dressing The patient was awoken and transferred to PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords surgery impingement syndrome shoulder arthroscopic subacromial decompression beachchair position subacromial region arthroscopic interscalene arthroscopy impingement labrum acromion portals decompression subacromial MEDICAL_TRANSCRIPTION,Description Right shoulder arthroscopy subacromial decompression distal clavicle excision bursectomy and coracoacromial ligament resection carpal tunnel release left knee arthroscopy and partial medial and lateral meniscectomy Medical Specialty Surgery Sample Name Arthroscopy Shoulder Knee Transcription PREOPERATIVE DIAGNOSES 1 Medial meniscal tear posterior horn of left knee 2 Carpal tunnel syndrome chronic right hand with intractable pain numbness and tingling 3 Impingement syndrome right shoulder with acromioclavicular arthritis bursitis and chronic tendonitis POSTOPERATIVE DIAGNOSES 1 Carpal tunnel syndrome right hand severe 2 Bursitis tendonitis impingement and AC arthritis right shoulder 3 Medial and lateral meniscal tears posterior horn old left knee PROCEDURE 1 Right shoulder arthroscopy subacromial decompression distal clavicle excision bursectomy and coracoacromial ligament resection 2 Right carpal tunnel release 3 Left knee arthroscopy and partial medial and lateral meniscectomy ANESTHESIA General with regional COMPLICATIONS None DISPOSITION To recovery room in awake alert and in stable condition OPERATIVE INDICATIONS A very active 50 year old gentleman who had the above problems and workup revealed the above problems He failed nonoperative management We discussed the risks benefits and possible complications of operative and continued nonoperative management and he gave his fully informed consent to the following procedure OPERATIVE REPORT IN DETAIL The patient was brought to the operating room and placed in the supine position on the operating room table After adequate induction of general anesthesia he was placed in the left lateral decubitus position All bony prominences were padded The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments articular surfaces and labrum Subacromial space was entered Visualization was poor due to the hemorrhagic bursitis and this was resected back It was essentially a type 3 acromion which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur Rotator cuff was little bit fray but otherwise intact Thus the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed The burr was then introduced to the anterior portal and the distal clavicle excision carried out The width of burr about 6 mm being careful to preserve the ligaments in the capsule but removing the spurs and the denuded arthritic joint The patient tolerated the procedure very well The shoulder was then copiously irrigated drained free of any residual debris The wound was closed with 3 0 Prolene Sterile compressive dressing applied The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep The attention was first turned to the right hand where it was elevated exsanguinated using an Esmarch bandage and the tourniquet was inflated to 250 mmHg for about 25 minutes Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis Tenotomy and forceps dissection carried out through the superficial palmar fascia carried down to the volar carpal ligament which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures Cautery was used for hemostasis The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament and so a small amount of Celestone was dripped onto the nerve to help quite it down The patient tolerated this portion of the procedure very well The hand was then irrigated closed with Monocryl and Prolene and sterile compressive dressing was applied and the tourniquet deflated Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars After entering the knee through inferomedial and inferolateral standard arthroscopic portals examination of the knee showed a displaced bucket handle tear in the medial meniscus and a radial tear at the lateral meniscus These were resected back to the stable surface using a basket forceps and full radius shaver There was no evidence of any other significant arthritis in the knee There was a lot of synovitis and so after the knee was irrigated out and free of any residual debris the knee was injected with Celestone and Marcaine with epinephrine The patient tolerated the procedure very well and the wounds were closed with 3 0 Prolene and sterile compressive dressing was applied and then the patient was taken to the recovery room extubated awake alert and in stable condition Keywords MEDICAL_TRANSCRIPTION,Description Recurrent anterior dislocating left shoulder Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder Medical Specialty Surgery Sample Name Arthroscopic Debridement Shoulder Transcription PREOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder POSTOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder PROCEDURE PERFORMED Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder PROCEDURE The patient was taken to OR 2 administered general anesthetic after ineffective interscalene block had been administered in the preop area The patient was positioned in the modified beachchair position utilizing the Mayfield headrest The left shoulder was propped posteriorly with a rolled towel His head was secured to the Mayfield headrest The left shoulder and upper extremity were then prepped and draped in the usual manner A posterior lateral port was made for _____ the arthroscopic cannula The scope was introduced into the glenohumeral joint There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11 30 extending down inferiorly to about 6 o clock The labrum was adherent to the underlying capsule The margin of the glenoid was frayed in this area The biceps tendon was noted to be intact The articular surface of the glenoid was fairly well preserved The articular surface on the humeral head was intact however there was a large Hill Sachs lesion on the posterolateral aspect of the humeral head The rotator cuff was visualized and noted to be intact The axillary pouch was visualized and it was free of injury There were some cartilaginous fragments within the axillary pouch Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum Utilizing the Chirotech system through the anterior cannula the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o clock position A second tack was then placed at about the 8 o clock position The labrum was then probed and was noted to be stable With some general ranging of the shoulder the tissue was pulled out from the tacks An attempt was made at placement of two other tacks however the tissue was not of good quality to be held in position Therefore all tacks were either buried down to a flat surface or were removed from the anterior glenoid area At this point it was deemed that an open Bankart arthroplasty was necessary The arthroscopic instruments were removed An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold The skin incision was taken down through the skin Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis The deltopectoral fascia was identified It was split at the deltopectoral interval and the deltoid was reflected laterally The subdeltoid bursa was then removed with rongeurs The conjoint tendon was identified The deltoid and conjoint tendons were then retracted with a self retaining retractor The subscapularis tendon was identified It was separated about a centimeter from its insertion leaving the tissue to do sew later The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially This allowed for visualization of the capsule The capsule was split near the humeral head insertion leaving a tag for repair It was then split longitudinally towards the glenoid at approximately 9 o clock position This provided visualization of the glenohumeral joint The friable labral and capsular tissue was identified The glenoid neck was already prepared for suturing therefore three Mitek suture anchors were then positioned to place at approximately 7 o clock 9 o clock and 10 o clock The sutures were passed through the labral capsular tissue and tied securely At this point the anterior glenoid rim had been recreated The joint was then copiously irrigated with gentamicin solution and suctioned dry The capsule was then repaired with interrupted 1 Vicryl suture and repaired back to its insertion site with 1 Vicryl suture This later was then copiously irrigated with gentamicin solution and suctioned dry Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted 1 Vicryl suture This later was then copiously irrigated as well and suctioned dry The deltoid fascia was approximated with running 2 0 Vicryl suture Subcutaneous tissues were approximated with interrupted 2 0 Vicryl and the skin was approximated with a running 4 0 subcuticular Vicryl followed by placement of Steri Strips 0 25 Marcaine was placed in the subcutaneous area for postoperative analgesia The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied The patient was then transferred to the recovery room in apparent satisfactory condition Keywords surgery dislocating bankart arthroplasty bankart repair arthroscopic debridement anterior arthroscopic debridement deltoid glenoid humeral interrupted shoulder subscapularis MEDICAL_TRANSCRIPTION,Description Arthroplasty of the right second digit Hammertoe deformity of the right second digit Medical Specialty Surgery Sample Name Arthroplasty Hammertoe Transcription PREOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit POSTOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit PROCEDURE PERFORMED Arthroplasty of the right second digit The patient is a 77 year old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe The patient presents n p o since mid night last night and consented to sign in the chart H P is complete PROCEDURE IN DETAIL After an IV was instituted by the Department of Anesthesia in the preoperative holding area the patient was escorted to the operating room and placed on the table in the supine position Using Webril the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle but left deflated at this time Restraining a lap belt was then placed around the patient s abdomen while laying on the table After adequate anesthesia was administered by the Department of Anesthesia a local digital block using 5 cc of 0 5 Marcaine plain was used to provide local anesthesia The foot was then prepped and draped in the normal sterile orthopedic manner The foot was then elevated and Esmarch bandage was applied after which time the tourniquet was inflated to 250 mmHg The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx Then using a fresh 15 blade a dorsolinear incision was made partial thickness through the skin after testing anesthesia with one to two pickup Then using a fresh 15 blade incision was deepened and using medial to lateral pressure the incision was opened into the subcutaneous tissue Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin This was performed with the combination of blunt and dull dissection Care was taken to avoid proper digital arteries and neurovascular bundles as were identified Attention was then directed to the proximal interphalangeal joint and after identifying the joint line a transverse linear incision was made over the dorsal surface of the joint The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure Following this the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson Brown pickup It was elevated with fresh 15 blade The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally Following this the distal portion of the tendon was identified in a like manner The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone The proximal interphalangeal joint was then distracted and using careful technique 15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head Following this the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues Then using a sagittal saw with a 139 blade the head of he proximal phalanx was resected Care was taken to avoid the deep flexor tendon The head of the proximal phalanx was taken with the Adson Brown and using a 15 blade the plantar periosteal tissue was freed up and the head was removed and sent to pathology The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment The digit was also noted to be in rectus alignment Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity Then using a 3 0 Vicryl suture three simple interrupted sutures were placed for closure of the tendon and capsular tissue Then following this 4 0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site Following this the incision was dressed using a sterile Owen silk soaked in saline and gentamicin The toe was bandaged using 4 x 4s Kling and Coban The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe Total tourniquet time for the case was 30 minutes While in the recovery the patient was given postoperative instructions to include ice and elevation to his right foot The patient was given pain medications of Tylenol 3 quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain The patient was also given prescription for cane to aid in ambulation The patient will followup with Dr X on Tuesday in his office for postoperative care The patient was instructed to keep the dressings clean dry and intact and to not remove them before his initial office visit The patient tolerated the procedure well and the anesthesia with no complications Keywords surgery hammertoe deformity arthroplasty digit proximal interphalangeal joint periosteal tissue interrupted sutures interphalangeal joint proximal phalanx proximal painful tourniquet hammertoe phalanx head incisional tendon MEDICAL_TRANSCRIPTION,Description Hammertoe deformity left fifth digit and ulceration of the left fifth digit plantolaterally Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size Medical Specialty Surgery Sample Name Arthroplasty Transcription PREOPERATIVE DIAGNOSES 1 Hammertoe deformity left fifth digit 2 Ulceration of the left fifth digit plantolaterally POSTOPERATIVE DIAGNOSIS 1 Hammertoe deformity left fifth toe 2 Ulceration of the left fifth digit plantolaterally PROCEDURE PERFORMED 1 Arthroplasty of the left fifth digit proximal interphalangeal joint laterally 2 Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size OPERATIVE PROCEDURE IN DETAIL The patient is a 38 year old female with longstanding complaint of painful hammertoe deformity of her left fifth toe The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time After an IV was instituted by the Department of Anesthesia the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position After adequate amount of IV sedation was administered by Anesthesia Department the patient was given a digital block to the left fifth toe using 0 5 Marcaine plain with 1 lidocaine plain in 1 1 mixture totaling 6 cc Following this the patient was draped and prepped in a normal sterile orthopedic manner An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table The stockinette was then cut and reflected and held in place using towel clamp The skin was then cleansed using the wet and dry Ray Tec sponge and then the plantar lesion was outlined The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit Then using a fresh 15 blade skin incision was made Following this the incision was then deepened using a fresh 15 blade down to the level of the subcutaneous tissue Using a combination of sharp and blunt dissection the skin was reflected distally and proximally to the lesion The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx however did not show any evidence of extending beyond the level of a periosteum Remaining tissues were inspected and appeared healthy The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a 15 blade the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx The capsule was also reflected to expose the prominent lateral osseous portion of this joint Using a sagittal saw and 139 blade the lateral osseous prominence was resected This was removed in entirety Then using power oscillating rasp the sharp edges were smoothed and recontoured to the desirable anatomic condition Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin Following this the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion Following this using 4 0 nylon in a combination of horizontal mattress and simple interrupted sutures the lesion wound was closed and skin was approximated well without tension to the surface skin Following this the incision site was dressed using Owen silk 4x4s Kling and Coban in a normal fashion The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot The patient was then escorted from the operative table into the Postanesthesia Care Unit The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact In the recovery the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q 6h as needed The patient will follow up on Friday with Dr X in office for further evaluation The patient was also given instructions as to signs of infection and to monitor her operative site The patient was instructed to keep daily dressings intact clean dry and to not remove them Keywords surgery hammertoe deformity plantolaterall ulceration arthroplasty plantar ulceration interphalangeal painful hammertoe proximal interphalangeal joint interphalangeal joint digit toe blade deformity incision hammertoe lesion MEDICAL_TRANSCRIPTION,Description Torn lateral meniscus and chondromalacia of the patella right knee Arthroscopic lateral meniscoplasty and patellar shaving of the right knee Medical Specialty Surgery Sample Name Arthroscopic Meniscoplasty Transcription PREOPERATIVE DIAGNOSES 1 Torn lateral meniscus right knee 2 Chondromalacia of the patella right knee POSTOPERATIVE DIAGNOSES 1 Torn lateral meniscus right knee 2 Chondromalacia of the patella right knee PROCEDURE PERFORMED 1 Arthroscopic lateral meniscoplasty 2 Patellar shaving of the right knee ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME Zero GROSS FINDINGS A complex tear involving the lateral and posterior horns of the lateral meniscus and grade II chondromalacia of the patella HISTORY OF PRESENT ILLNESS The patient is a 45 year old Caucasian male presented to the office complaining of right knee pain He complained of pain on the medial aspect of his right knee after an injury at work which he twisted his right knee PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedures were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the operative surgeon the patient the Department of Anesthesia and the nursing staff The patient was then transferred to preoperative area to Operative Suite 2 placed on the operating table in supine position Department of Anesthesia administered general anesthetic to the patient All bony prominences were well padded at this time The right lower extremity was then properly positioned in a Johnson knee holder At this time 1 lidocaine with epinephrine 20 cc was administered to the right knee intra articularly under sterile conditions The right lower extremity was then sterilely prepped and draped in usual sterile fashion Next after all bony soft tissue landmarks were identified an inferolateral working portal was established by making a 1 cm transverse incision at the level of the joint line lateral to the patellar tendon The cannula and trocar were then inserted through this putting the patellofemoral joint An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint the medial and lateral gutters medial lateral joints and the femoral notch Upon viewing of the patellofemoral joint there was noted to be grade II chondromalacia changes of the patella There were no loose bodies noted in the either gutter Upon viewing of the medial compartment there was no chondromalacia or meniscal tear was noted While in this area attention was directed to establish the inferomedial instrument portal This was first done using a spinal needle for localization followed by 1 cm transverse incision at the joint line A probe was then inserted through this portal and the meniscus was further probed Again there was noted to be no meniscal tear The knee was taken through range of motion and there was no chondromalacia Upon viewing of the femoral notch there was noted to be intact ACL with negative drawer sign PCL was also noted to be intact Upon viewing of the lateral compartment there was noted to be a large bucket handle tear involving the lateral and posterior horns It was reduced from the place however involved the white and red white area was elected to excise the bucket handle An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee Pictures were taken both pre meniscal resection and post meniscal resection The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact Next attention was directed to the inner surface of the patella This was debrided using the 2 5 arthroscopic shaver It was noted to be quite smooth and postprocedure the patient was taken ________ well The knee was then copiously irrigated and suctioned dry and all instrumentation was removed 20 cc of 0 25 Marcaine was then administered to each portal as well as intra articularly Sterile dressing was then applied consisting of Adaptic 4x4s ABDs and sterile Webril and a stockinette to the right lower extremity At this time Department of Anesthesia reversed the anesthetic The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit The patient tolerated the procedure and there were no complications Keywords surgery patella chondromalacia lateral meniscus complex tear torn lateral meniscus femoral notch meniscal tear bucket handle meniscal resection arthroscopic shaver patellofemoral joint arthroscopic knee torn meniscoplasty meniscal joint meniscus MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute appendicitis Medical Specialty Surgery Sample Name Appendectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis PROCEDURE Laparoscopic appendectomy ANESTHESIA General endotracheal INDICATIONS Patient is a pleasant 31 year old gentleman who presented to the hospital with acute onset of right lower quadrant pain History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan I evaluated the patient in the emergency room and recommended that he undergo the above named procedure The procedure purpose risks expected benefits potential complications alternative forms of therapy were discussed with him and he was agreeable with surgery FINDINGS Patient was found to have acute appendicitis with an inflamed appendix which was edematous but essentially no suppuration TECHNIQUE The patient was identified and then taken into the operating room where after induction of general endotracheal anesthesia the abdomen was prepped with Betadine solution and draped in sterile fashion An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia which was grasped with an Allis clamp and two stay sutures of 2 0 Vicryl were placed on either side of the midline The fascia was tented and incised and the peritoneum entered by blunt finger dissection A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained Patient was placed in the Trendelenburg position rotated to his left whereupon under direct vision the 12 mm midline as well as 5 mm midclavicular and anterior axillary ports were placed The appendix was easily visualized grasped with a Babcock s A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum The mesoappendix was divided using the Endo GIA with vascular staples The appendix was placed within an Endo bag and delivered from the abdominal cavity The intra abdominal cavity was irrigated Hemostasis was assured within the mesentery and at the base of the cecum All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution The infraumbilical defect was closed with a figure of eight 0 Vicryl suture The remaining wounds were irrigated and then everything was closed subcuticular with 4 0 Vicryl suture and Steri Strips Patient tolerated the procedure well dressings were applied and he was taken to recovery room in stable condition Keywords surgery endo gia babcock s laparoscopic appendectomy direct vision abdominal cavity acute appendicitis appendectomy hemostasis laparoscopic infraumbilical appendix appendicitis endotracheal MEDICAL_TRANSCRIPTION,Description Femoroacetabular impingement Left hip arthroscopic debridement femoral neck osteoplasty and labral repair Medical Specialty Surgery Sample Name Arthroscopic Debridement Labral Repair Hip Transcription PREOPERATIVE DIAGNOSIS Femoroacetabular impingement POSTOPERATIVE DIAGNOSIS Femoroacetabular impingement OPERATIONS PERFORMED 1 Left hip arthroscopic debridement 2 Left hip arthroscopic femoral neck osteoplasty 3 Left hip arthroscopic labral repair ANESTHESIA General OPERATION IN DETAIL The patient was taken to the operating room where he underwent general anesthetic His bilateral lower extremities were placed under traction on the Hana table His right leg was placed first The traction post was left line and the left leg was placed in traction Sterile Hibiclens and alcohol prep and drape were then undertaken A fluoroscopic localization was undertaken Gentle traction was applied Narrow arthrographic effect was obtained Following this the ProTrac portal was made under the fluoro visualization and then a direct anterolateral portal made and a femoral neck portal made under direct visualization The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum For this reason the acetabular articular cartilage was taken down and stabilized This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair The labrum was repaired using absorbable Smith Nephew anchors with a sliding SMC knot After stabilization of the labrum and the acetabulum the ligamentum teres was assessed and noted to be stable The remnant articular surface of the femoral artery and acetabulum was stable The posterior leg was stable The traction was left half off and the anterolateral aspect of the head and neck junction was identified A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly This terminated with the hip coming out of traction and indeterminable flexion A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression The decompression was completed with thorough irrigation of the hip The cannula was removed and the portals were closed using interrupted nylon The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room He tolerated the procedure very well with no signs of complications Keywords surgery labral repair femoral neck osteoplasty arthroscopic debridement femoroacetabular impingement arthroscopic femoroacetabular impingement debridement osteoplasty acetabulum MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute suppurative appendicitis A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis There was no evidence of colitis on the CAT scan Medical Specialty Surgery Sample Name Appendectomy Laparoscopic 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute suppurative appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General endotracheal and Marcaine 0 25 local INDICATIONS This 29 year old female presents to ABCD General Hospital Emergency Department on 08 30 2003 with history of acute abdominal pain On evaluation it was noted that the patient has clinical findings consistent with acute appendicitis However the patient with additional history of loose stools for several days prior to event Therefore a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis There was no evidence of colitis on the CAT scan With this in mind and the patient s continued pain at present the patient was explained the risks and benefits of appendectomy She agreed to procedure and informed consent was obtained GROSS FINDINGS The appendix was removed without difficulty with laparoscopic approach The appendix itself noted to have a significant inflammation about it There was no evidence of perforation of the appendix PROCEDURE DETAILS The patient was placed in supine position After appropriate anesthesia was obtained and sterile prep and drape completed a 10 blade scalpel was used to make a curvilinear infraumbilical incision Through this incision a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg The Veress needle was then removed A 10 mm trocar was then introduced through this incision into the abdomen A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation Initially bilateral ovarian cysts were appreciated however there was no evidence of acute disease on evaluation Photodocumentation was obtained A 5 mm port was then placed in the right upper quadrant This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix Next a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization Through this port the dissector was utilized to create a small window in the mesoappendix Next an EndoGIA with GI staples was utilized to fire across the base of the appendix which was done noting it to be at the base of the appendix Next staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples Two 6 X loupe wires with EndoGIA were utilized in this prior portion of the procedure Next an EndoCatch was placed through the 12 mm port and the appendix was placed within it The appendix was then removed from the 12 mm port site and taken off the surgical site The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated The base of the appendix was reevaluated and noted to be hemostatic Aspiration of warm saline irrigant then done and noted to be clear There was a small adhesion appreciated in the region of the surgical site This was taken down with blunt dissection without difficulty There was no evidence of other areas of disease Upon re exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact The instruments were removed from the patient and the port sites were then taken off under direct visualization The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with 0 Vicryl ligature x2 Marcaine 0 25 was then utilized in all three incision sites and 4 0 Vicryl suture was used to approximate the skin and all three incision sites Steri Strips and sterile dressings were applied The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics pain medications and return to diet Keywords surgery abdomen pelvis laparoscopic appendectomy suppurative appendicitis veress needle acute appendicitis appendix appendectomy pneumoperitoneum laparoscopic appendicitis MEDICAL_TRANSCRIPTION,Description Bilateral Crawford subtalar arthrodesis with open Achilles Z lengthening and bilateral long leg cast Medical Specialty Surgery Sample Name Arthrodesis Transcription PREOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet POSTOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet PROCEDURE Bilateral Crawford subtalar arthrodesis with open Achilles Z lengthening and bilateral long leg cast ANESTHESIA Surgery performed under general anesthesia The patient received 6 mL of 0 25 Marcaine local anesthetic on each side TOURNIQUET TIME Tourniquet time was 53 minutes on the left and 45 minutes on the right COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None HARDWARE USED Staple 7 8 inch x1 on each side HISTORY AND PHYSICAL The patient is a 5 year 4 month old male who presents for evaluation of feet He has been having significant feet pain with significant planovalgus deformity The patient was noted to have flexible vertical talus It was decided that the patient would benefit by subtalar arthrodesis possible autograft and Achilles lengthening This was explained to the mother in detail This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature Risks of surgery include risks of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure need for other surgical procedures need to be nonweightbearing for some time All questions were answered and the mother agreed to the above plan PROCEDURE NOTE The patient was taken to the operating room placed supine on the operating room general anesthesia was administered The patient received Ancef preoperatively Bilateral nonsterile tourniquets were placed on each thigh A bump was placed underneath the left buttock Both the extremities were then prepped and draped in standard surgical fashion Attention was first turned towards the left side Intended incision was marked on the skin The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint The sinus tarsi was then identified using a U shaped flap to tack muscles and periosteum was retracted distally Once the foot was reduced a Steinman pin was used to hold it in position This position was first checked on the fluoroscopy The 7 8th inch staple was then placed across the sinus tarsi to maintain the reduction This was also checked with fluoroscopy The incision was then extended posteriorly to allow for visualization of the Achilles which was Z lengthened with the release of the lateral distal half This was sutured using 2 0 Ethibond and that was also oversewn The wound was irrigated with normal saline The periosteal flap was sutured over the staple using 2 0 Vicryl Skin was closed using 2 0 Vicryl interrupted and then with 4 0 Monocryl The area was injected with 6 mL of 0 25 Marcaine local anesthetic The wound was cleaned and dried dressed with Steri Strips Xeroform and 4 x 4s and Webril Tourniquet was released after 53 minutes The exact same procedure was repeated on the right side with no changes or complications Tourniquet time on the right side was 45 minutes The patient tolerated the procedure well Bilateral long leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch The patient was subsequently was taken to Recovery in stable condition POSTOPERATIVE PLAN The patient will be hospitalized overnight for pain as per parents request The patient is to be strict nonweightbearing for at least 6 weeks He is to follow up in the next 10 days for a check We will plan of changing to short leg casts in about 4 weeks postop Keywords surgery myotonic muscular dystrophy muscular dystrophy planovalgus feet achilles z lengthening subtalar arthrodesis bilateral crawford subtalar arthrodesis bilateral long leg cast sinus tarsi leg casts tourniquet time arthrodesis intraoperative fluoroscopy tourniquet subtalar achilles anesthesia planovalgus foot bilateral MEDICAL_TRANSCRIPTION,Description Acute appendicitis gangrenous Appendectomy Medical Specialty Surgery Sample Name Appendectomy 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis gangrenous PROCEDURE Appendectomy DESCRIPTION OF PROCEDURE The patient was taken to the operating room under urgent conditions After having obtained an informed consent he was placed in the operating room and under anesthesia Followed by a time out process his abdominal wall was prepped and draped in the usual fashion Antibiotics had been given prior to incision A McBurney incision was performed and it carried out through the peritoneal cavity Immediately there was purulent material seen in the area Samples were taken for culture and sensitivity of aerobic and anaerobic sets The appendix was markedly swollen particularly in its distal three fourth where the distal appendix showed an abscess formation and devitalization of the wall There was quite a bit of local peritonitis The mesoappendix was clamped divided and ligated and then the appendix was ligated and divided and the stump buried with a pursestring suture of Vicryl and then a Z stitch The area was abundantly irrigated with normal saline and also the pelvis The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond The patient tolerated the procedure well Estimated blood loss was minimal and the patient was sent to the recovery room for recovery in satisfactory condition Keywords surgery mcburney incision abdominal small bowel acute appendicitis appendectomy gangrenous appendix MEDICAL_TRANSCRIPTION,Description Acute appendicitis and 29 week pregnancy Appendectomy Medical Specialty Surgery Sample Name Appendectomy 2 Transcription PREOPERATIVE DIAGNOSES 1 Acute appendicitis 2 29 week pregnancy POSTOPERATIVE DIAGNOSES 1 Acute appendicitis 2 29 week pregnancy OPERATION Appendectomy DESCRIPTION OF THE PROCEDURE After obtaining the informed consent including all risks and benefits of the procedure the patient was urgently taken to the operating room where a spinal anesthetic was given and the patient s abdomen was prepped and draped in a usual fashion Preoperative antibiotics were given A time out process was followed Local anesthetics were infiltrated in the area of the proposed incision A modified McBurney incision was performed A very abnormal appendix was immediately found There was a milky fluid around the area and this was cultured both for aerobic and anaerobic cultures The distal end of the appendix had transformed itself into an abscess The proximal portion was normal The appendix was very friable and a no touch technique was used It was carefully dissected off the cecum and then it was ligated and excised after the mesoappendix had been taken care of Then the stump was buried with a pursestring of 2 0 Vicryl The operative area was abundantly irrigated with warm saline and then closed in layers The layer was further irrigated A subcuticular suture of Monocryl was performed in the skin followed by the application of Dermabond Further local anesthetic was infiltrated at the end of the procedure in the operative area and the patient tolerated the procedure well and with an estimated blood loss that was not consequential was transferred from recovery to ICU in a satisfactory condition Keywords surgery mcburney incision appendectomy appendicitis appendix MEDICAL_TRANSCRIPTION,Description Aortoiliac occlusive disease Aortobifemoral bypass The aorta was of normal size and consistency consistent with arteriosclerosis A 16x8 mm Gore Tex graft was placed without difficulty The femoral vessels were small somewhat thin and there was posterior packing but satisfactory bypass was performed Medical Specialty Surgery Sample Name Aortobifemoral Bypass Transcription PREOPERATIVE DIAGNOSIS Aortoiliac occlusive disease POSTOPERATIVE DIAGNOSIS Aortoiliac occlusive disease PROCEDURE PERFORMED Aortobifemoral bypass OPERATIVE FINDINGS The patient was taken to the operating room The abdominal contents were within normal limits The aorta was of normal size and consistency consistent with arteriosclerosis A 16x8 mm Gore Tex graft was placed without difficulty The femoral vessels were small somewhat thin and there was posterior packing but satisfactory bypass was performed PROCEDURE The patient was taken to the operating room placed in a supine position and prepped and draped in the usual sterile manner with Betadine solution A longitudinal incision was made after a Betadine coated drape was placed over the incisional area Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia Hemostasis was obtained with electrocautery The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges Attention was then turned to the abdomen where a longitudinal incision was made from the pubis xiphoid carried down subcutaneous fat and fascia Hemostasis was obtained with electrocautery The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery Mild adhesions were lysed The omentum was freed The small and large intestine were run with no evidence of abnormalities The liver and gallbladder were within normal limits No abnormalities were noted At this point the Bookwalter retractor was placed NG tube was placed in the stomach and placed on suction The intestines were gently packed intraabdominally and laterally The rest of the peritoneum was then opened The aorta was cleared both proximally and distally The left iliac was completely occluded The right iliac was to be cleansed At this point 5000 units of aqueous heparin was administered to allow take effect The aorta was then clamped below the renal arteries and opened in a longitudinal fashion A single lumbar was ligated with 3 0 Prolene The inferior mesenteric artery was occluded intraluminally and required no suture closure Care was taken to preserve collaterals The aorta was measured and a 16 mm Gore Tex graft was brought on the field and anastomosed to the proximal aorta using 3 0 Prolene in a running fashion Last stitch was tied Hemostasis was excellent The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis At this point strong pulses were present within the graft The limbs were vented and irrigated Using bimanual technique the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin The grafts were then brought through these care being taken to avoid twisting of the graft At this point the right iliac was then ligated using 0 Vicryl and the clamp was removed Hemostasis was excellent The right common femoral artery was then clamped proximally and distally opened with 11 blade extended with Potts scissors The graft was _____ and anastomosed to the artery using 5 0 Prolene in a continuous fashion with a stitch _______ running fashion Prior to tying the last stitch the graft and artery were vented and the last stitch was tied Flow was initially restored proximally then distally with good results Attention was then turned to the left groin and the artery grafts were likewise exposed cleared proximally and distally The artery was opened extended with a Potts scissors and anastomosis was performed with 5 0 Prolene again with satisfactory hemostasis The last stitch was tied Strong pulses were present within the artery and graft itself At this point 25 mg of protamine was administered The wounds were irrigated with antibiotic solution The groins were repacked Attention was then returned to the abdomen The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft The intraabdominal contents were then allowed to resume their normal position There was no evidence of ischemia to the large or small bowel At this point the omentum and stomach were repositioned The abdominal wall was closed in a running single layer fashion using 1 PDS The skin was closed with skin staples The groins were again irrigated closed with 3 0 Vicryl and 4 0 undyed Vicryl and Steri Strips The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well Sponges and instrument counts were correct Estimated blood loss 900 cc Keywords surgery aorta bypass arteriosclerosis abdominal contents aortoiliac occlusive disease gore tex graft aortobifemoral bypass longitudinal incision aortobifemoral hemostasis artery graft MEDICAL_TRANSCRIPTION,Description Aortogram with bilateral segmental lower extremity run off Left leg claudication The patient presents with lower extremity claudication Medical Specialty Surgery Sample Name Aortogram Leg claudication Transcription PREPROCEDURE DIAGNOSIS Left leg claudication POSTPROCEDURE DIAGNOSIS Left leg claudication OPERATION PERFORMED Aortogram with bilateral segmental lower extremity run off ANESTHESIA Conscious sedation INDICATION FOR PROCEDURE The patient presents with lower extremity claudication She is a 68 year old woman who is very fearful of the aforementioned procedures Risks and benefits of the procedure were explained to her to include bleeding infection arterial trauma requiring surgery access issues and recurrence She appears to understand and agrees to proceed DESCRIPTION OF PROCEDURE The patient was taken to the Angio Suite placed in a supine position After adequate conscious sedation both groins were prepped with Chloraseptic prep Cloth towels and paper drapes were placed Local anesthesia was administered in the common femoral artery and using ultrasound guidance the common femoral artery was accessed Guidewire was threaded followed by a 4 French sheath Through the 4 French sheath a 4 French Omni flush catheter was placed The glidewire was removed and contrast administered to identify the level of the renal artery Using power injector an aortogram proceeded The catheter was then pulled down to the aortic bifurcation A timed run off view of both legs was performed and due to a very abnormal and delayed run off in the left I opted to perform an angiogram of the left lower extremity with an isolated approach The catheter was pulled down to the aortic bifurcation and using a glidewire I obtained access to the contralateral left external iliac artery The Omni flush catheter was advanced to the left distal external iliac artery The glidewire rather exchanged for an Amplatz stiff wire This was left in place and the 4 French sheath removed and replaced with a 6 French destination 45 cm sheath This was advanced into the proximal superficial femoral artery and an angiogram performed I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty The patient was given 5000 units of heparin and this was allowed to circulate A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels A 4 mm x 4 cm angioplasty balloon was used to dilate the area in question Final views after dilatation revealed a dissection A search for a 5 mm stent was performed but none of this was available For this reason I used a 6 mm x 80 mm marked stent and placed this at the distal superficial femoral artery Post dilatation was performed with a 4 mm angioplasty balloon Further views of the left lower extremity showed irregular change in the popliteal artery No significant stenosis could be identified in the left popliteal artery and noninvasive scan For this reason I chose not to treat any further areas in the left leg I then performed closure of the right femoral artery with a 6 French Angio Seal device Attention was turned to the left femoral artery and local anesthesia administered Access was obtained with the ultrasound and the femoral artery identified Guidewire was threaded followed by a 4 French sheath This was immediately exchanged for the 6 French destination sheath after the glidewire was used to access the distal external iliac artery The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath The destination was placed in the proximal superficial femoral artery and angiogram obtained Initial views had been obtained from the right femoral sheath before removal Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery For this reason I performed the angioplasty of the superficial femoral artery using the 4 mm balloon A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation No further significant abnormality was identified To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery A 3 mm balloon was chosen to dilate a 50 to 79 popliteal artery stenosis Reasonable use were obtained and possibly a 4 mm balloon could have been used However due to her propensity for dissection I opted not to I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length This was placed into the left posterior tibial artery A 2 mm balloon was used to dilate the orifice of the posterior tibial artery I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel Final images showed improved run off to the right calf The destination sheath was pulled back into the left external iliac artery and an Angio Seal deployed FINDINGS Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma No evidence of renal artery stenosis is noted bilaterally There is a single left renal artery The infrarenal aorta both common iliac and the external iliac arteries are normal On the right a superficial femoral artery is widely patent and normal proximally At the distal third of the thigh there is diffuse disease with moderate stenosis noted Moderate stenosis is also noted in the popliteal artery and single vessel run off through the posterior tibial artery is noted The perineal artery is functionally occluded at the midcalf The dorsal pedal artery filled by collateral at the high ankle level On the left the proximal superficial femoral artery is patent Again at the distal third of the thigh there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery This was successfully treated with angioplasty and a stent placement The popliteal artery is diffusely diseased without focal stenosis The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice IMPRESSION 1 Normal bilateral renal arteries with a small accessory right renal artery 2 Normal infrarenal aorta as well as normal bilateral common and external iliac arteries 3 The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries Successful angioplasty with reasonable results in the distal superficial femoral popliteal and proximal posterior tibial artery as described 4 Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement Run off to the left lower extremity is via a patent perineal and posterior tibial artery Keywords surgery claudication extremity run off angio suite superficial femoral artery popliteal superficial femoral aortogram artery balloon glidewire angioplasty stenosis renal MEDICAL_TRANSCRIPTION,Description Rotated cuff tear right shoulder Glenoid labrum tear Arthroscopy with arthroscopic glenoid labrum debridement subacromial decompression and rotator cuff repair right shoulder Medical Specialty Surgery Sample Name Arthroscopic Rotator Cuff Repair 1 Transcription PREOPERATIVE DIAGNOSIS Rotated cuff tear right shoulder POSTOPERATIVE DIAGNOSES 1 Rotated cuff tear right shoulder 2 Glenoid labrum tear PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic glenoid labrum debridement 2 Subacromial decompression 3 Rotator cuff repair right shoulder SPECIFICATIONS Intraoperative procedure was done at Inpatient Operative Suite room 1 at ABCD Hospital This was done under interscalene and subsequent general anesthetic in the modified beach chair position HISTORY AND GROSS FINDINGS The patient is a 48 year old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention He was completely refractory to conservative outpatient therapy After discussing the alternative care as well as the advantages disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Intraarticularly the joint was observed There was noted to be a degenerative glenoid labrum tear The biceps complex was otherwise intact There were minimal degenerative changes at the glenohumeral joint Rotator cuff tear was appreciated on the inner surface Subacromially the same was true This was an elliptical to V type tear The patient has a grossly positive type III acromion OPERATIVE PROCEDURE The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department He was safely placed in modified beach chair position He was prepped and draped in the usual sterile manner Portals were created outside to end posterior to anterior and ultimately laterally in the typical fashion Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint a 4 2 meniscus shaver was placed anteriorly with the scope posteriorly Debridement was carried out to the glenoid labrum The biceps was probed and noted to be intact Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment After this instrumentation was removed The scope was placed subacromially and a lateral portal created Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters An anterolateral portal was created Sutures were placed via express silk as well as other sutures with a 2 fiber wire With passing of the suture they were tied with a slip tight knot and then two half stitches There was excellent reduction of the tear Superolateral portal was then created A 1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone _______ suture was placed The implant was put into place The loop was grabbed and it was impacted in the previously drilled holes There was excellent reduction of the tear Trial range of motion was carried out and seemed to be satisfactory Prior to this a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie A 4 8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion After all was done copious irrigation was carried out throughout the joint Gross bursectomy lightly was carried out to remove all bony elements A pain buster catheter was placed through a separate portal and cut to length 0 5 Marcaine was instilled after portals were closed with 4 0 nylon Adaptic 4 x 4s ABDs and Elastoplast tape placed for dressing The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition Expected surgical prognosis of this patient is fair Keywords surgery subacromial decompression rotator cuff repair arthroscopic glenoid labrum debridement arthroscopy glenoid labrum tear glenoid labrum cuff tear arthroscopic subacromial decompression debridement rotator glenoid labrum shoulder MEDICAL_TRANSCRIPTION,Description Aortic valve replacement using a mechanical valve and two vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery Medical Specialty Surgery Sample Name Aortic Valve Replacement Transcription DIAGNOSIS Aortic valve stenosis with coronary artery disease associated with congestive heart failure The patient has diabetes and is morbidly obese PROCEDURES Aortic valve replacement using a mechanical valve and two vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery ANESTHESIA General endotracheal INCISION Median sternotomy INDICATIONS The patient presented with severe congestive heart failure associated with the patient s severe diabetes The patient was found to have moderately stenotic aortic valve In addition The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient s right system It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure FINDINGS The left ventricle is certainly hypertrophied The aortic valve leaflet is calcified and a severe restrictive leaflet motion It is a tricuspid type of valve The coronary artery consists of a large left anterior descending artery which is associated with 60 stenosis but a large obtuse marginal artery which has a tight proximal stenosis The radial artery was used for the left anterior descending artery Flow was excellent Looking at the targets in the posterior descending artery territory there did not appear to be any large branches On the angiogram these vessels appeared to be quite small Because this is a chronically occluded vessel and the patient has limited conduit due to the patient s massive obesity attempt to bypass to this area was not undertaken The patient was brought to the operating room PROCEDURE The patient was brought to the operating room and placed in supine position A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh The patient weighs nearly three hundred pounds There was concern as to taking down the left internal mammary artery Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory The patient was cannulated after the aorta and atrium were exposed and full heparinization The patient went on cardiopulmonary bypass and the aortic cross clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner The patient was cooled to 32 degrees Iced slush was applied to the heart The aortic valve was then exposed through the aortic root by transverse incision The valve leaflets were removed and the 23 St Jude mechanical valve was secured into position by circumferential pledgeted sutures At this point aortotomy was closed The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow Proximal anastomosis was then carried out to the foot of the aorta The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end to side manner The two proximal anastomoses were then carried out to the root of the aorta The patient came off cardiopulmonary bypass after aortic cross clamp was released The patient was adequately warmed Protamine was given without adverse effect Sternal closure was then done using wires The subcutaneous layers were closed using Vicryl suture The skin was approximated using staples Keywords surgery coronary artery bypass grafting saphenous vein graft radial artery graft coronary artery disease congestive heart failure descending artery territory aortic cross clamp aortic valve replacement coronary artery bypass obtuse marginal artery anterior descending artery mechanical valve artery bypass bypass grafting marginal artery radial artery aortic valve coronary artery anterior descending descending artery valve artery aortic grafting MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy and peritoneal toilet and photos Pelvic inflammatory disease and periappendicitis Medical Specialty Surgery Sample Name Appendectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSES 1 Pelvic inflammatory disease 2 Periappendicitis PROCEDURE PERFORMED 1 Laparoscopic appendectomy 2 Peritoneal toilet and photos ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 10 cc INDICATIONS FOR PROCEDURE The patient is a 31 year old African American female who presented with right lower quadrant abdominal pain presented with acute appendicitis She also had mild leukocytosis with bright blood cell count of 12 000 The necessity for diagnostic laparoscopy was explained and possible appendectomy The patient is agreeable to proceed and signed preoperatively informed consent PROCEDURE The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department The preoperative Foley antibiotics and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a 10 blade scalpel with anterior and superior traction on the abdominal wall A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation At this point the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view With the aid of a laparoscope the pelvis was visualized The ovaries are brought in views and photos are taken There is evidence of a purulence in the cul de sac and ________ with a right ovarian hemorrhagic cyst Attention was then turned on the right lower quadrant The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears Attention was turned to the suprapubic area The 12 mm port was introduced under direct visualization and the mesoappendix was identified A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line Next ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline Next attention was turned to the right upper quadrant There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz Hugh Curtis syndrome also a prior pelvic inflammatory disease All free fluid is aspirated and patient s all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology Once the ports are removed the pneumoperitoneum is allowed to escape for patient s postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with 0 Vicryl suture on a UR 6 needle Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and 4 0 Vicryl subcuticular closure is performed with undyed Vicryl Steri Strips are applied along with sterile dressings The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad spectrum IV antibiotics in the General Medical Floor Routine postoperative care will be continued on this patient Keywords surgery acute appendicitis periappendicitis peritoneal toilet pelvic inflammatory disease abdominal wall direct visualization toilet appendectomy mesoappendix laparoscopic port inflammatory MEDICAL_TRANSCRIPTION,Description Appendicitis nonperforated Appendectomy A transverse right lower quadrant incision was made directly over the point of maximal tenderness Medical Specialty Surgery Sample Name Appendectomy Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis nonperforated PROCEDURE PERFORMED Appendectomy ANESTHESIA General endotracheal PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A transverse right lower quadrant incision was made directly over the point of maximal tenderness Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia The fascia of the external oblique was incised in the direction of the fibers and the muscle was spread with a clamp The internal oblique fascia was similarly incised and its muscular fibers were similarly spread The transversus abdominis muscle transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident Upon entering the peritoneal cavity the peritoneal fluid was noted to be clean The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound After the appendix was fully visualized the mesentery was divided between Kelly clamps and ligated with 2 0 Vicryl ties The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix The base was ligated with 2 0 Vicryl tie over the crushed area and the appendix amputated along the clamp The stump of the appendix was cauterized and the cecum was returned to the abdomen The peritoneum was irrigated with warm sterile saline The mesoappendix and cecum were examined for hemostasis which was present The wound was closed in layers using 2 0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers The skin incision was approximated with 4 0 Monocryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was placed on the wound All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords surgery peritoneal cavity peritoneal fluid abdominal cavity abdominis muscle transversalis fascia peritoneum internal oblique fascia vicryl ties appendectomy appendicitis appendix MEDICAL_TRANSCRIPTION,Description Irrigation and debridement of skin subcutaneous tissue fascia and bone associated with an open fracture and placement of antibiotic impregnated beads Open calcaneus fracture on the right Medical Specialty Surgery Sample Name Antibiotic Impregnated Beads Placement Transcription PREOPERATIVE DIAGNOSIS Open calcaneus fracture on the right POSTOPERATIVE DIAGNOSIS Open calcaneus fracture on the right PROCEDURES 1 Irrigation and debridement of skin subcutaneous tissue fascia and bone associated with an open fracture 2 Placement of antibiotic impregnated beads ANESTHESIA General BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Healing skin with no gross purulence identified some fibrinous material around the beads SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained her right leg was sterilely prepped and draped in a normal fashion The tourniquet was inflated and the previous wound was opened Dr X came in to look at the wound and the beads were removed all 25 beads were extracted and pulsatile lavage and curette etc were used to debride the wound The wound margins were healthy with the exception of very central triangular incision area The edges were debrided and then 19 antibiotic impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today The skin edges were approximated under minimal tension The soft dressing was placed An Ace was placed She was awakened from the anesthesia and taken to recovery room in a stable condition Final needle instrument and sponge counts were correct Keywords surgery open calcaneus fracture irrigation and debridement antibiotic impregnated beads irrigation subcutaneous placement debridement calcaneus fracture wound beads antibiotic MEDICAL_TRANSCRIPTION,Description Dementia and aortoiliac occlusive disease bilaterally Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft Medical Specialty Surgery Sample Name Aortobifemoral Bypass 1 Transcription PREOPERATIVE DIAGNOSIS 1 Aortoiliac occlusive disease bilaterally 2 Dementia POSTOPERATIVE DIAGNOSIS 1 Aortoiliac occlusive disease bilaterally 2 Dementia OPERATION Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 300 cc INTRAVENOUS FLUIDS 1200 cc of crystalloid URINE OUTPUT 250 cc OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Note that previously the patient was found to have some baseline dementia although slight The patient was seen and evaluated by the neurology team who cleared the patient for surgery The patient was taken to the operating room and general endotracheal anesthesia was administered The abdomen was prepped and draped in the standard surgical fashion We first began our dissection by using a 10 blade scalpel to incise the skin over the femoral artery in the groin bilaterally Dissection was carried down to the level of the femoral vessels using Bovie electrocautery The common femoral superficial femoral and profunda femoris arteries were encircled and dissected out peripherally Vessel loops were placed around the aforementioned arteries After doing so we turned our attention to beginning our abdominal dissection We used a 10 blade scalpel to make a midline laparotomy incision Dissection was carried down to the level of the fascia using Bovie electrocautery The abdomen was opened and an Omni retractor was positioned The aorta was dissected out in the abdomen The left femoral vein was identified There was a nicely clampable portion of aorta visible We as mentioned placed our Omni retractor and then turned our attention to performing our anastomosis Full dose heparin was given Next vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels A 11 blade scalpel was used to make an arteriotomy in the aorta which was lengthened both proximally and distally using Potts scissors We then beveled our proximal graft and constructed an end graft to side artery anastomosis using 3 0 Prolene in a running fashion Upon completion of our anastomosis we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis We then created our tunnels over the iliac vessels We pulled the distal limbs over our ABF graft into the groin We then proceeded to perform our right anastomosis first We applied vascular clamps on the proximal common femoral profunda and superficial femoral arteries We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6 0 Prolene in a running fashion Upon completion of our anastomosis we flushed the common femoral SFA and profunda femoris arteries We then removed our clamp We opened the limb more proximally in the abdomen on the right side We then turned our attention to the left side and similarly placed our vascular clamps We used a 11 blade scalpel to make an arteriotomy in the vessel We then lengthened our arteriotomy both proximally and distally again onto the SFA We constructed a footed end graft to side artery anastomosis using 6 0 Prolene in a running fashion Upon completion of our anastomosis we opened our clamps There was no noticeable leak from the newly constructed anastomosis We checked our proximal graft to aortic anastomosis which was noted to be in good condition We then gave full dose protamine We closed the peritoneum over the graft with 4 0 Vicryl in a running fashion The abdomen was closed with 1 nylon in a running fashion The skin was closed with subcuticular 4 0 Monocryl in a running subcuticular fashion The instrument and sponge count was correct at end of case Patient tolerated the procedure well and was transferred to the intensive care unit in good condition Keywords surgery bifurcated hemashield graft aortoiliac occlusive disease aortobifemoral bypass vascular clamps common femoral graft femoral anastomosis aortobifemoral aortoiliac proximal arteriotomy bypass artery endotracheal vessels MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion C5 C6 utilizing Bengal cage Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Interbody Fusion 3 Transcription PREOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 POSTOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 PROCEDURES 1 Anterior cervical discectomy at C5 C6 for neural decompression 63075 2 Anterior interbody fusion C5 C6 22554 utilizing Bengal cage 22851 3 Anterior cervical instrumentation at C5 C6 for stabilization by Uniplate construction at C5 C6 22845 with intraoperative x ray x2 SERVICE Neurosurgery ANESTHESIA Keywords surgery spondylosis neck pain headaches decompression uniplate anterior cervical discectomy neural decompression cervical stenosis prevertebral space antibiotic solution cervical discectomy interbody fusion bengal cage interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5 C6 utilizing Bengal cage Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Interbody Fusion 2 Transcription PREOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 POSTOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 with spinal cord and spinal canal decompression 63075 2 Anterior interbody fusion at C5 C6 22554 utilizing Bengal cage 22851 3 Anterior instrumentation for stabilization by Uniplate construction C5 C6 22845 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected only in a subplatysmal manner bluntly and with only blunt dissection at the prevertebral space where a localizing intraoperative x ray was obtained once self retaining retractors were placed along the mesial edge of a cauterized longus colli muscle to protect surrounding tissues throughout the remainder of the case A prominent anterior osteophyte at C5 C6 was then localized compared to preoperative studies in the usual fashion intraoperatively and the osteophyte was excised with a rongeur and bony fragments saved This allowed for an annulotomy which was carried out with a 11 blade and discectomy removed with straight disc forceps portions of the disc which were sent to Pathology for a permanent section Residual osteophytes and disc fragments were removed with 1 and 2 mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace a sign of a decompressed status At no time during the case was evidence of CSF leakage and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation Once the decompression was inspected with a double ball dissector and all found to be completely decompressed and the dura bulged at the interspace and pulsated then a Bengal cage was filled with the patient s own bone elements and fusion putty and countersunk into position and was quite tightly applied Further stability was added nonetheless with an appropriate size Uniplate which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner The wound was inspected and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was Steri Stripped for reinforcement and a sterile dressing was applied incorporating a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner Once the sterile dressing was applied the patient was taken from the operating room to the recovery area having left in stable condition At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords surgery herniated nucleus pulposus myelopathy cervical spondylosis cervical stenosis anterior instrumentation uniplate decompression anterior cervical discectomy spinal cord spinal canal sterile dressing interbody fusion bengal cage interbody cervical anterior discectomy MEDICAL_TRANSCRIPTION,Description Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate Severe low back pain Medical Specialty Surgery Sample Name Anterior Lumbar Fusion Transcription PREOPERATIVE DIAGNOSIS Severe low back pain POSTOPERATIVE DIAGNOSIS Severe low back pain OPERATIONS PERFORMED Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 50 mL DRAINS None COMPLICATIONS None PATHOLOGICAL FINDINGS Dr X made the approach and once we were at the L5 S1 disk space we removed the disk and we placed a 13 mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body This was filled with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug At L4 L5 we used a 13 mm PEEK vertebral spacer with structural autograft and BMP and then we placed a two level 87 mm Integra sacral plate with 28 x 6 mm screws two each at L4 and L5 and 36 x 6 mm screws at S1 OPERATION IN DETAIL The patient was placed under general endotracheal anesthesia The abdomen was prepped and draped in the usual fashion Dr X made the approach and once the L5 S1 disk space was identified we incised this with a knife and then removed a large core of bone taking rotating cutters I was able to remove additional disk space and score the vertebral bodies The rest of the disk removal was done with the curette scraping the endplates I tried various sized spacers and at this point we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug Half of this was used to fill the spacer at L5 S1 BMP was placed in the spacer as well and then it was tapped into place We then moved the vessels over the opposite way approaching the L4 L5 disk space laterally and the disk was removed in a similar fashion and we also used a 13 mm PEEK vertebral spacer but this is the variety that we could put in from one side This was filled with bone and BMP as well Once this was done we were able to place an 87 mm Integra sacral plate down over the three vertebral bodies and place these screws Following this bleeding points were controlled and Dr X proceeded with the closure of the abdomen SUMMARY This is a 51 year old man who reports 15 year history of low back pain and intermittent bilateral leg pain and achiness He has tried multiple conservative treatments including physical therapy epidural steroid injections etc MRI scan shows a very degenerated disk at L5 S1 less so at L3 L4 and L4 L5 A discogram was positive with the lower 3 levels but he has pain which starts below the iliac crest and I feel that the L3 L4 disk is probably that symptomatic An anterior lumbar interbody fusion was suggested Procedure risks and complications were explained Keywords surgery peek vertebral spacer autograft anterior lumbar fusion lumbar fusion vertebral body vertebral spacer vertebral spacer anterior lumbar fusion MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction Removal of loose bodies Medial femoral chondroplasty and meniscoplasty Medical Specialty Surgery Sample Name Anterior Cruciate Ligament Reconstruction Transcription PREOPERATIVE DIAGNOSIS Anterior cruciate ligament rupture POSTOPERATIVE DIAGNOSES 1 Anterior cruciate ligament rupture 2 Medial meniscal tear 3 Medial femoral chondromalacia 4 Intraarticular loose bodies PROCEDURE PERFORMED 1 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction 2 Removal of loose bodies 3 Medial femoral chondroplasty 4 Medial meniscoplasty OPERATIVE PROCEDURE The patient was taken to the operative suite placed in supine position and administered a general anesthetic by the Department of Anesthesia Following this the knee was sterilely prepped and draped as discussed for this procedure The inferolateral and inferomedial portals were then established however prior to this a graft was harvested from the semitendinosus and gracilis region After the notch was identified then ACL was confirmed and ruptured There was noted to be a torn slipped up area of the medial meniscus which was impinging and impinged on the articular surface The snare was smoothed out Entire area was thoroughly irrigated Following this there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing There were multiple loose bodies noted in the knee and these were then __________ and then removed The tibial and femoral drill holes were then established and the graft was then put in place both which locations after a notchplasty was performed The knee was taken through a full range of motion without any impingement An Endobutton was used for proximal fixation Distal fixation was obtained with an independent screw and a staple The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure Keywords surgery femoral chondroplasty intraarticular loose bodies anterior cruciate ligament reconstruction anterior arthroscopy meniscoplasty fixation reconstruction chondroplasty ligament femoral intraarticular medial MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy allograft fusion and anterior plating Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 8 Transcription PROCEDURES PERFORMED C5 C6 anterior cervical discectomy allograft fusion and anterior plating ESTIMATED BLOOD LOSS 10 mL CLINICAL NOTE This is a 57 year old gentleman with refractory neck pain with single level degeneration of the cervical spine and there was also some arm pain We decided go ahead with anterior cervical discectomy at C5 C6 and fusion The risks of lack of pain relief paralysis hoarse voice nerve injuries and infection were explained and the patient agreed to proceed DESCRIPTION OF PROCEDURE The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut He had tape placed over the shoulders during intraoperative x rays and his elbows were well padded The tape was placed and his arms were well padded He was prepped and draped in a sterile fashion A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle We then dissected sharply medial to carotid artery which we palpated to the prevertebral region We placed Caspar retractors for medial and lateral exposure over the C5 C6 disc space which we confirmed with the lateral cervical spine x ray including 18 gauge needle in the disc space We then marked the disc space We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space We then under magnification removed all the disc material we could possibly see down to bleeding bone and both the endplates We took down posterior longitudinal ligament as well We incised the 6 mm cornerstone bone We placed a 6 mm parallel medium bone nicely into the disc space We then sized a 23 mm plate We inserted the screws nicely above and below We tightened down the lock nuts We irrigated the wound We assured hemostasis using bone wax prior to placing the plate We then assured hemostasis once again We reapproximated the platysma using 3 0 Vicryl in a simple interrupted fashion The subcutaneous level was closed using 3 0 Vicryl in a simple buried fashion The skin was closed with 3 0 Monocryl in a running subcuticular stitch Steri Strips were applied Dry sterile dressing with Telfa was applied over this We obtained an intraoperative x ray to confirm the proper level and good position of both plates and screw construct on the lateral x ray and the patient was transferred to the recovery room moving all four extremities with stable vital signs I was present as a primary surgeon throughout the entire case Keywords surgery allograft fusion anterior cervical discectomy neck pain cervical spine discectomy fusion sternocleidomastoid muscle assured hemostasis anterior cervical cervical discectomy disc space cervical anterior allograft MEDICAL_TRANSCRIPTION,Description C4 C5 C5 C6 anterior cervical discectomy and fusion The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 7 Transcription PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PROCEDURE C4 C5 C5 C6 anterior cervical discectomy and fusion COMPLICATIONS None ANESTHESIA General INDICATIONS OF PROCEDURE The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 I discussed the procedure as well as risks and complications She wishes to proceed with surgery Risks will include but are not limited to infection hemorrhage spinal fluid leak worsened neurologic deficit recurrent stenosis requiring further surgery difficulty with fusion requiring further surgery long term hoarseness of voice difficulty swallowing medical anesthesia risk PROCEDURE The patient was taken to the operating room on 10 02 2007 She was intubated for anesthesia TEDS and boots as well as Foley catheter were placed She was placed in a supine position with her neck in neutral position Appropriate pads were also used The area was prepped and draped in usual sterile fashion Preoperative localization was taken _____ not changed Incision was made on the right side in transverse fashion over C5 vertebral body level This was made with a 10 blade knife and further taken down with pickups and scissors The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine Intraoperative x ray was taken Longus colli muscles were retracted laterally Caspar retractors were used Intraoperative x ray was taken I first turned by attention at C5 C6 interspace This was opened with 15 blade knife Disc material was taken out using pituitary as well as Kerrison rongeur Anterior aspects were taken down End plates were arthrodesed using curettes This was done under distraction Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur Bilateral foraminotomies were done At this point I felt that there was a good decompression The foramen appeared to be opened Medtronic cage was then encountered and sent few millimeters This was packed with demineralized bone matrix The distraction was then taken down The cage appeared to be strong This procedure was then repeated at C4 C5 A 42 mm AcuFix plate was then placed between C4 and C6 This was carefully screwed and locked The instrumentation appeared to be strong Intraoperative x ray was taken Irrigation was used Hemostasis was achieved The platysmas was closed with 3 0 Vicryl stitches The subcutaneous was closed with 4 0 Vicryl stitches The skin was closed with Steri strips The area was clean and dry and dressed with Telfa and Tegaderm Soft cervical collar was placed for the patient She was extubated per anesthesia and brought to the recovery in stable condition Keywords surgery anterior cervical discectomy fusion infection hemorrhage spinal fluid leak anesthesia foley catheter teds anterior cervical cervical discectomy anterior cervical discectomy stenosis MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4 C5 C5 C6 and C6 C7 utilizing Bengal cages times three Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Interbody Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C4 C5 C5 C6 and C6 C7 for neural decompression 63075 63076 63076 2 Anterior interbody fusion at C4 C5 C5 C6 and C6 C7 22554 22585 22585 utilizing Bengal cages times three 22851 3 Anterior instrumentation for stabilization by Slim LOC plate C4 C5 C6 and C7 22846 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border and self retaining retractors were placed to reveal the anterior osteophytic spaces Large osteophytes were excised with a rongeur at C4 5 C5 C6 and C6 C7 revealing a collapsed disc space and a 11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4 C5 then at C5 C6 then at C6 C7 sending specimen for permanent section to Pathology in a routine and separate manner Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament which was removed in a similar piecemeal fashion with 1 and 2 mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes widely laterally bilaterally at each interspace with one at C4 C5 more right sided The most prominent osteophyte and compression was at C5 C6 followed by C6 C7 and C4 C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels once the ligaments were proximally removed as well and similarly a sign of a decompressed status The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away Appropriate size Bengal cages were filled with the patient s own bone elements and countersunk into position filled along with fusion putty and once these were quite tightly applied and checked further stability was added by the placement of a Slim LOC plate of appropriate size with appropriate size screws and a post placement x ray showed well aligned elements The wound was irrigated with antibiotic solution again and inspected and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was sterilely dressed and incorporated a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords surgery herniated nucleus pulposus radiculopathy cervical stenosis anterior instrumentation stabilization slim loc neural decompression anterior cervical discectomy cord compression interbody fusion bengal cages interbody compression anterior fusion decompression discectomy cervical MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 9 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 PROCEDURE Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification FIRST ASSISTANT Nurse practitioner PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion for anterior discectomy and fusion An incision was made midline to the anterior body of the sternocleidomastoid at C5 C6 level The skin subcutaneous tissue and platysma muscle was divided exposing the carotid sheath which was retracted laterally Trachea and esophagus were retracted medially After placing the self retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x rays we then proceeded with the discectomy We then cleaned out the disc at C5 C6 after incising the annulus fibrosis We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes and the next step was to clean out the disc space totally With this having been done we then turned our attention with the operating microscope to the osteophytes We drilled off the vertebral osteophytes at C5 C6 as well as the uncovertebral osteophytes This was removed along with the posterior longitudinal ligament After we had done this the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion We observed that there was a ____________ in the posterior longitudinal ligament There was a free fragment disc which had broken through the posterior longitudinal ligament just to the right of midline The next step was to obtain the bone from the back bone using cortical cancellous graft 10 mm in size after we had estimated the size That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor After we had tapped in the bone plug we then removed the distraction and the bone plug was fitting nicely We then use the Aesculap cervical titanium instrumentation with the 16 mm screws After securing the C5 C6 disc with four screws and titanium plate x rays showed good alignment of the spine good placement of the bone graft and after x rays showed excellent position of the bone graft and instrumentation we then placed in a Jackson Pratt drain in the prevertebral space brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and skin was closed with Steri Strips Blood loss during the operation was less than 10 mL No complications of the surgery Needle count sponge count and cottonoid count were correct Keywords surgery aesculap titanium dynamic plating system anterior cervical discectomy herniated nucleus pulposus cervical discectomy operating microscope longitudinal ligament discectomy anterior instrumentation cervical titanium MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression of spinal cord Anterior cervical fusion Anterior cervical instrumentation Insertion of intervertebral device Use of operating microscope Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 6 Transcription PREOPERATIVE DIAGNOSIS Symptomatic disk herniation C7 T1 FINAL DIAGNOSIS Symptomatic disk herniation C7 T1 PROCEDURES PERFORMED 1 Anterior cervical discectomy with decompression of spinal cord C7 T1 2 Anterior cervical fusion C7 T1 3 Anterior cervical instrumentation anterior C7 T1 4 Insertion of intervertebral device C7 T1 5 Use of operating microscope ANESTHESIOLOGY General endotracheal ESTIMATED BLOOD LOSS A 30 mL PROCEDURE IN DETAIL The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service He was placed in the supine position on an OR table His arms were carefully taped down He was sterilely prepped and draped in the usual fashion A 4 cm incision was made obliquely over the left side of his neck Subcutaneous tissue was dissected down to the level of the platysma The platysma was incised using electrocautery Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle This allowed us to get right down on to the anterior cervical spine Blunt dissection was done to sweep off the longus colli We isolated the C7 T1 interspace An x ray was taken to verify we were indeed at the C7 T1 interspace Shadow Line retractor was placed as well as Caspar pins This provided very very good access to the C7 T1 disk At this point the operating microscope was brought into the decompression A thorough and aggressive C7 T1 discectomy was done using a succession of curettes pituitary rongeur 4 mm cutting bur and a 2 Kerrison rongeur At the end of the discectomy the cartilaginous endplates were carefully removed using 4 mm cutting burr The posterior longitudinal ligament was carefully resected using 2 Kerrison rongeur Left sided C8 foraminotomy was accomplished using nerve hook and a 2 mm Kerrison rongeur At the end of the decompression there was no further compression on the left C8 nerve root A Synthes cortical cancellous ____________ bone was placed in the interspace Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed two in the body of C7 and two in the body of T1 An x ray was taken It showed good placement of the plate and screws A deep drain was placed The platysma layer was closed in running fashion using 1 Vicryl Subcutaneous tissue was closed in an interrupted fashion using 2 0 Vicryl Skin was closed in a running fashion using 4 0 Monocryl Steri Strips and dressings were applied All counts were correct There were no complications Keywords surgery disk herniation cervical discectomy decompression spinal cord anterior cervical fusion anterior cervical discectomy kerrison rongeur anterior cervical instrumentation cervical anterior platysma kerrison fashion interspace rongeur discectomy herniation MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure Cervical spondylotic myelopathy with cord compression and cervical spondylosis Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion Transcription PREOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis POSTOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis In addition to this he had a large herniated disk at C3 C4 in the midline PROCEDURE Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure PROCEDURE IN DETAIL The patient placed in the supine position the neck was prepped and draped in the usual fashion Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4 Skin subcutaneous tissue and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4 C5 It appeared that the C5 C6 disk area had fused spontaneously We then confirmed that position by taking intraoperative x rays and then proceeded to do discectomy and fusion at C3 C4 C4 C5 After placing distraction screws and self retaining retractors with the teeth beneath the bellies of the longus colli muscles we then meticulously removed the disk at C3 C4 C4 C5 using the combination of angled strip pituitary rongeurs and curettes after we had incised the anulus fibrosus with 15 blade Next step was to totally decompress the spinal cord using the operating microscope and high speed cutting followed by the diamond drill with constant irrigation We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments This was then removed with 2 mm Kerrison rongeur After we removed the posterior longitudinal ligament we could see the dura pulsating nicely We did foraminotomies at C3 C4 as well as C4 C5 as well After having totally decompressed both the cord as well as the nerve roots of C3 C4 C4 C5 we proceeded to the next step which was a fusion We sized two 8 mm cortical cancellous grafts and after distracting the bone at C3 C4 C4 C5 we gently tapped the grafts into place The distraction was removed and the grafts were now within We went to the next step for the procedure which was the instrumentation and stabilization of the fused area We then placed a titanium ABC plate from C3 C5 secured it with 16 mm titanium screws X rays showed good position of the screws end plate The next step was to place Jackson Pratt drain to the vertebral fascia Meticulous hemostasis was obtained The wound was closed in layers using 2 0 Vicryl for the subcutaneous tissue Steri Strips were used for skin closure Blood loss less than about 200 mL No complications of the surgery Needle counts sponge count and cottonoid count was correct Keywords surgery titanium plates fixation bone black bone procedure anterior cervical discectomy titanium plates cervical discectomy spondylotic myelopathy cord compression cervical spondylosis foraminotomies cervical anterior MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression and anterior interbody fusion at C5 C6 and C6 C7 utilizing Bengal cages x2 Anterior instrumentation by Uniplate construction C5 C6 and C7 with intraoperative x ray x2 Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 5 Transcription PREOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 POSTOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression 63075 63076 2 Anterior interbody fusion at C5 C6 and C6 C7 22554 22585 utilizing Bengal cages x2 22851 3 Anterior instrumentation by Uniplate construction C5 C6 and C7 22845 with intraoperative x ray x2 ANESTHESIA General OPERATIONS The patient was brought to the operating room and placed in the supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then with only blunt dissection the prevertebral space was encountered and localizing intraoperative x ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self retaining retractors for exposure of tissues Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5 C6 and then at C6 C7 with rongeur allowing for an annulotomy with an 11 blade through collapsed disc space at C5 6 and even more collapsed at C6 C7 Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels sending to Pathology in a routine fashion as disc specimen This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6 C7 removing large osteophytes and process residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well This allowed for the bulging into the interspace of the dura sign of decompressed status and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam Once hemostasis well achieved Bengal cage was filled with the patient s own bone elements of appropriate size and this was countersunk into position and quite tightly applied it at first C5 C6 then secondly at C6 C7 These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size The appropriate size screws and post placement x ray showed well aligned elements and removal of osteophytes etc The wound was again irrigated with antibiotic solution inspected and finally closed in a multiple layered closure by approximation of platysma with interrupted 3 0 Vicryl and the skin with subcuticular stitch of 4 0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin and later incorporated itself into sterile bandage Once the bandage was placed the patient was taken extubated from the operating room to the Recovery area having in stable but guarded condition At the conclusion of the case all instrument needle and sponge counts were accurate and correct There were no intraoperative complications of any type Keywords surgery cervical spondylosis anterior cervical discectomy anterior instrumentation annulotomy kerrison rongeurs surgifoam vertebral space uniplate construction bengal cages neural decompression anterior cervical cervical discectomy interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 with spinal stenosis Anterior cervical discectomy with fusion C5 C6 Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 2 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis PROCEDURE Anterior cervical discectomy with fusion C5 C6 PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion An incision was made from midline to the anterior border of the sternocleidomastoid in the right side Skin and subcutaneous tissue were divided sharply Trachea and esophagus were retracted medially Carotid sheath was retracted laterally Longus colli muscles were dissected away from the vertebral bodies of C5 C6 We confirmed our position by taking intraoperative x rays We then used the operating microscope and cleaned out the disk completely We then sized the interspace and then tapped in a 7 mm cortical cancellous graft We then used the DePuy Dynamic plate with 14 mm screws Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed in layers using 2 0 Vicryl for muscle and fascia The blood loss was less than 10 20 mL No complication Needle count sponge count and cottonoid count was correct Keywords surgery carotid sheath jackson pratt drain anterior cervical discectomy herniated nucleus pulposus cervical discectomy herniated nucleus nucleus pulposus spinal stenosis discectomy fusion herniated nucleus pulposus spinal stenosis anterior MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression anterior cervical fusion anterior cervical instrumentation and Allograft C5 C6 Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Decompression 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 POSTOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 PROCEDURES 1 Anterior cervical discectomy with decompression C5 C6 2 Anterior cervical fusion C5 C6 3 Anterior cervical instrumentation C5 C6 4 Allograft C5 C6 ANESTHESIA General endotracheal COMPLICATIONS None PATIENT STATUS Taken to recovery room in stable condition INDICATIONS The patient is a 36 year old female who has had severe recalcitrant right upper extremity pain numbness tingling shoulder pain axial neck pain and headaches for many months Nonoperative measures failed to relieve her symptoms and surgical intervention was requested We discussed reasonable risks benefits and alternatives of various treatment options Continuation of nonoperative care versus the risks associated with surgery were discussed She understood the risks including bleeding nerve vessel damage infection hoarseness dysphagia adjacent segment degeneration continued worsening pain failed fusion and potential need for further surgery Despite these risks she felt that current symptoms will be best managed operatively SUMMARY OF SURGERY IN DETAIL Following informed consent and preoperative administration of antibiotics the patient was brought to the operating suite General anesthetic was administered The patient was placed in the supine position All prominences and neurovascular structures were well accommodated The patient was noted to have pulse in this position Preoperative x rays revealed appropriate levels for skin incision Ten pound inline traction was placed via Gardner Wells tongs and shoulder roll was placed The patient was then prepped and draped in sterile fashion Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease Subcutaneous tissue was dissected down to the level of the omohyoid which was transected Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally This was taken down to the prevertebral fascia which was bluntly split Intraoperative x ray was taken to ensure proper levels Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli thus placing no new traction on the surrounding vital structures Inferior spondylosis was removed with high speed bur A scalpel and curette was used to remove the disc Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally Disc herniation was removed from the right posterolateral aspect of the interspace High speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura No further evidence of compression was identified Hemostasis was achieved with thrombin soaked Gelfoam Interspace was then distracted with Caspar pin distractions set gently Interspace was then gently retracted with the Caspar pin distraction set An 8 mm allograft was deemed in appropriate fit This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit The graft was stable to pull out forces Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14 mm self drilling screws Plate and screws were then locked to the plate Final x rays revealed proper positioning of the plate excellent distraction in the disc space and apposition of the endplates and allograft Wounds were copiously irrigated with normal saline Omohyoid was approximated with 3 0 Vicryl Running 3 0 Vicryl was used to close the platysma Subcuticular Monocryl and Steri Strips were used to close the skin A deep drain was placed prior to wound closure The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition There were no intraoperative complications All needle and sponge counts were correct Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal Keywords surgery cervical spondylosis cervical fusion decompression instrumentation anterior cervical discectomy anterior cervical herniated disc cervical discectomy anterior cervical fusion allograft discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusion C2 C3 C3 C4 Removal of old instrumentation C4 C5 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 PROCEDURES 1 Anterior cervical discectomy C3 C4 C2 C3 2 Anterior cervical fusion C2 C3 C3 C4 3 Removal of old instrumentation C4 C5 4 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates PROCEDURE IN DETAIL The patient was placed in the supine position The neck was prepped and draped in the usual fashion for anterior cervical discectomy A high incision was made to allow access to C2 C3 Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially This exposed the vertebral bodies of C2 C3 and C4 C5 which was bridged by a plate We placed in self retaining retractors With the tooth beneath the blades the longus colli muscles were dissected away from the vertebral bodies of C2 C3 C4 and C5 After having done this we used the all purpose instrumentation to remove the instrumentation at C4 C5 we could see that fusion at C4 C5 was solid We next proceeded with the discectomy at C2 C3 and C3 C4 with disc removal In a similar fashion using a curette to clean up the disc space and the space was fairly widened as well as drilling up the vertebral joints using high speed cutting followed by diamond drill bit It was obvious that the C3 C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis With the operating microscope however we had good visualization of these nerve roots and we were able to ___________ both at C2 C3 and C3 C4 We then placed the ABC 55 mm plate from C2 down to C4 These were secured with 16 mm titanium screws after excellent purchase We took an x ray which showed excellent position of the plate the screws and the graft themselves The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and Steri Strips used to close the skin Blood loss was about 50 mL No complication of the surgery Needle count sponge count cottonoid count was correct The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb At the time of surgery he had total collapse of the C2 C3 and C4 disc with osteophyte formation At both levels he has high grade spinal stenosis at these levels especially foramen stenosis causing the compression neck pain headaches and arm and shoulder pain He does have degenerative changes at C5 C6 C6 C7 C7 T1 however they do not appear to be symptomatic although x rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form Keywords surgery abc plates osteophyte cervical discectomy cervical fusion herniated nucleus pulposus anterior cervical discectomy nucleus pulposus vertebral bodies osteophyte formation spinal stenosis cervical discectomy anterior instrumentation vertebral stenosis fusion MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws Cervical spondylosis and herniated nucleus pulposus of C4 C5 Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Arthrodesis 2 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 POSTOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 TITLE OF OPERATION Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws ESTIMATED BLOOD LOSS Less than 100 mL OPERATIVE PROCEDURE IN DETAIL After identification the patient was taken to the operating room and placed in supine position Following the induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position A preoperative x ray was obtained to identify the operative level and neck position An incision was marked at the C4 C5 level on the right side The incision was opened with 10 blade knife Dissection was carried down through subcutaneous tissues using Bovie electrocautery The platysma muscle was divided with the cautery and mobilized rostrally and caudally The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia This was opened with scissors and dissected rostrally and caudally with the peanut dissectors The operative level was confirmed with an intraoperative x ray The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5 Self retaining retractor was placed in submuscular position and distraction pins were placed in the vertebral bodies of C4 and C5 and distraction was instituted We then incise the annulus of C4 C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes Operating microscope was draped and brought into play Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch There was a transligamentous disc herniation which was removed during this process We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent Cord was seen to be pulsating freely behind the dura There appeared to be no complications and the decompression appeared adequate We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body An 8 mm lordotic trial was used and appeared perfect We then used a corticocancellous 8 mm lordotic graft This was tapped into position Distraction was released appeared to be in excellent position We then positioned an 18 mm Vector plate over the inner space Intraoperative x ray was obtained with the stay screw in place plates appeared to be in excellent position We then use a 14 mm self tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion All of the screws locked to the plate and this was confirmed on visual inspection Intraoperative x ray was again obtained Construct appeared satisfactory Attention was then directed to closure The wound was copiously irrigated All of the self retaining retractors were removed Bleeding points were controlled with bone wax and bipolar electrocautery The platysma layer was now closed with interrupted 3 0 Vicryl sutures The skin was closed with running 3 0 Vicryl subcuticular stitch Steri Strips were applied A sterile bandage was applied All sponge needle and cottonoid counts were reported as correct The patient tolerated the procedure well He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition Keywords surgery synthes vector plate lordotic acf spacer corticocancellous arthrodesis anterior cervical discectomy herniated nucleus pulposus anterior cervical spacer screws discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 6 and placement of artificial disk replacement Right C5 C6 herniated nucleus pulposus Medical Specialty Surgery Sample Name Anterior Cervical Discectomy 2 Transcription ADMITTING DIAGNOSIS Right C5 C6 herniated nucleus pulposus PRIMARY OPERATIVE PROCEDURE Anterior cervical discectomy at C5 6 and placement of artificial disk replacement SUMMARY This is a pleasant 43 year old woman who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs She underwent another MRI and significant degenerative disease at C5 6 with a central and right sided herniation was noted Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery She was interested in participating in the artificial disk replacement study and was entered into that study She was randomly picked for the artificial disk and underwent the above named procedure on 08 27 2007 She has done well postoperatively with a sensation of right arm pain and numbness in her fingers She will have x rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well She will follow up with Dr X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x rays with ring prior to the appointment She will contact our office prior to her appointment if she has problems Prescriptions were written for Flexeril 10 mg 1 p o t i d p r n 50 with 1 refill and Lortab 7 5 500 mg 1 to 2 q 6 h p r n 60 with 1 refill Keywords surgery herniated nucleus pulposus anterior cervical discectomy artificial disk replacement cervical discectomy nucleusNOTE MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy arthrodesis partial corpectomy Machine bone allograft placement of anterior cervical plate with a Zephyr MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus Anterior cervical decompression anterior spine instrumentation anterior cervical spine fusion and application of machined allograft Medical Specialty Surgery Sample Name Anterior Cervical Decompression Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 PROCEDURE PERFORMED 1 Anterior cervical decompression C5 C6 2 Anterior cervical decompression C6 C7 3 Anterior spine instrumentation 4 Anterior cervical spine fusion C5 C6 5 Anterior cervical spine fusion C6 C7 6 Application of machined allograft at C5 C6 7 Application of machined allograft at C6 C7 8 Allograft structural at C5 C6 9 Allograft structural at C6 C7 ANESTHESIA General PREOPERATIVE NOTE This patient is a 47 year old male with chief complaint of severe neck pain and left upper extremity numbness and weakness Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5 C6 and C6 C7 on the left The patient has failed epidural steroid injections Risks and benefits of the above procedure were discussed with the patient including bleeding infection muscle loss nerve damage paralysis and death OPERATIVE REPORT The patient was taken to the OR and placed in the supine position After general endotracheal anesthesia was obtained the patient s neck was sterilely prepped and draped in the usual fashion A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body It was taken down through the subcutaneous tissues exposing the platysmus muscle The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine An 18 gauge needle was placed in the C5 C6 interspace and the intraoperative x ray confirmed that this was the appropriate level Next the longus colli muscles were resected laterally on both the right and left side and then a complete anterior cervical discectomy was performed The disk was very degenerated and brown in color There was an acute disk herniation through posterior longitudinal ligament The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed Approximately 5 mm of the nerve root on both the right and left side was visualized A ball ended probe could be passed up the foramen Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates of C5 and C6 were prepared using a high speed burr and a 6 mm lordotic machined allograft was malleted into place There was good bony apposition both proximally and distally Next attention was placed at the C6 C7 level Again the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6 C7 was performed The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left The posterior longitudinal ligament was removed A bilateral foraminotomy was performed Approximately 5 mm of the C7 nerve root was visualized on both sides A micro nerve hook was able to be passed up the foramen easily Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates at C6 C7 were then prepared using a high speed burr and then a 7 mm machined lordotic allograft was malleted into place There was good bony apposition both proximally and distally Next a 44 mm Blackstone low profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws Intraoperative x ray confirmed appropriate positioning of the plate and the graft The wound was then copiously irrigated with normal saline and bacitracin There was no active bleeding upon closure of the wound A small drain was placed deep The platysmal muscle was closed with 3 0 Vicryl The skin was closed with 4 0 Monocryl Mastisol and Steri Strips were applied The patient was monitored throughout the procedure with free running EMGs and SSEPs and there were no untoward events The patient was awoken and taken to the recovery room in satisfactory condition Keywords surgery herniated nucleus pulposus anterior cervical decompression spine fusion cervical spine allograft anterior cervical spine anterior cervical MEDICAL_TRANSCRIPTION,Description Arthrodesis anterior interbody technique anterior cervical discectomy anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws implantation of machine bone implant Disc herniation with right arm radiculopathy Medical Specialty Surgery Sample Name Anterior Cervical Discectomy Arthrodesis 1 Transcription PREOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy POSTOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy PROCEDURE 1 C5 C6 arthrodesis anterior interbody technique 2 C5 C6 anterior cervical discectomy 3 C5 C6 anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws 4 Implantation of machine bone implant 5 Microsurgical technique ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL BACKGROUND INFORMATION AND SURGICAL INDICATIONS The patient is a 45 year old right handed gentleman who presented with neck and right arm radicular pain The pain has become more and more severe It runs to the thumb and index finger of the right hand and it is accompanied by numbness If he tilts his neck backwards the pain shoots down the arm If he is working with the computer it is very difficult to use his mouse He tried conservative measures and failed to respond so he sought out surgery Surgery was discussed with him in detail A C5 C6 anterior cervical discectomy and fusion was recommended He understood and wished to proceed with surgery Thus he was brought in same day for surgery on 07 03 2007 DESCRIPTION OF PROCEDURE He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR There general endotracheal anesthesia was induced He was positioned on the OR table with an IV bag between the scapulae The neck was slightly extended and taped into position A metal arch was placed across the neck and intraoperative x ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle The incision was extended through skin subcutaneous fat and platysma Hemostasis was assured with Bovie cautery The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6 C7 disk based on x rays and then around the C5 C6 disk space An intraoperative x ray confirmed C5 C6 disk space had been localized and then the self retained distraction system was inserted to maintain exposure A 15 blade knife was used to incise the C5 C6 disk and remove disk material and distraction pins were inserted into C5 C6 and distraction placed across the disk space The operating microscope was then brought into the field and used throughout the case except for the closure Various pituitaries 15 blade knife and curette were used to evacuate the disk as best as possible Then the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina A small amount of disk material was found at the right neural foramen After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure the wound was thoroughly irrigated A spacing mechanism was intact into the disk space and it was determined that a 7 spacer was appropriate So a 7 machine bone implant was taken and tapped into disk space and slightly counter sunk The wound was thoroughly irrigated and inspected for hemostasis A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5 C6 to hold the bone into position and the wound was once again irrigated The patient was valsalved There was no further bleeding seen and intraoperative x ray confirmed a good position near the bone plate and screws and the wound was enclosed in layers The 3 0 Vicryl was used to approximate platysma and 3 0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin The wound was cleaned Mastisol was placed on the skin and Steri strips were used to approximate skin margins Sterile dressing was placed on the patient s neck He was extubated in the OR and transported to the recovery room in stable condition There were no complications Keywords surgery herniation radiculopathy interbody mystique bone implant anterior cervical discectomy neural foramina mystique plate disc herniation arm radiculopathy cervical discectomy disk space disk cervical anterior wound discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy removal of herniated disc and osteophytes bilateral C4 nerve root decompression harvesting of bone for autologous vertebral bodies for creation of arthrodesis grafting of fibular allograft bone for creation of arthrodesis creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies and placement of anterior spinal instrumentation using the operating microscope and microdissection technique Medical Specialty Surgery Sample Name Anterior Cervical Discectomy 1 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression POSTOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression OPERATION PERFORMED 1 Anterior cervical discectomy of C3 C4 2 Removal of herniated disc and osteophytes 3 Bilateral C4 nerve root decompression 4 Harvesting of bone for autologous vertebral bodies for creation of arthrodesis 5 Grafting of fibular allograft bone for creation of arthrodesis 6 Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies 7 Placement of anterior spinal instrumentation using the operating microscope and microdissection technique INDICATIONS FOR PROCEDURE This 62 year old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain Conservative therapy has failed to improve the problem Imaging studies showed severe spondylosis of C3 C4 with neuroforaminal narrowing and spinal cord compression A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives He clearly understood it and had no further questions and requested that I proceed PROCEDURE IN DETAIL The patient was placed on the operating room table and was intubated using a fiberoptic technique The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses The neck was carefully prepped and draped in the usual sterile manner A transverse incision was made on a skin crease on the left side of the neck Dissection was carried down through the platysmal musculature and the anterior spine was exposed The medial borders of the longus colli muscles were dissected free from their attachments to the spine A needle was placed and it was believed to be at the C3 C4 interspace and an x ray properly localized this space Castoff self retaining pins were placed into the body of the C3 and C4 Self retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles The annulus was incised and a discectomy was performed Quite a bit of overhanging osteophytes were identified and removed As I worked back to the posterior lips of the vertebral body the operating microscope was utilized There was severe overgrowth of spondylitic spurs A high speed diamond bur was used to slowly drill these spurs away I reached the posterior longitudinal ligament and opened it and exposed the underlying dura Slowly and carefully I worked out towards the C3 C4 foramen The dura was extremely thin and I could see through it in several areas I removed the bony compression in the foramen and identified soft tissue and veins overlying the root All of these were not stripped away for fear of tearing this very tissue paper thin dura However radical decompression was achieved removing all the bony compression in the foramen out to the pedicle and into the foramen An 8 mm of the root was exposed although I left the veins over the root intact The microscope was angled to the left side where a similar procedure was performed Once the decompression was achieved a high speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration Bone thus from the drilling was preserved for use for the arthrodesis Attention was turned to creation of the arthrodesis As I had drilled quite a bit into the bodies I selected a large 12 mm graft and distracted the space maximally Under distraction the graft was placed and fit well An x ray showed good graft placement Attention was turned to spinal instrumentation A Synthes Short Stature plate was used with four 3 mm screws Holes were drilled with all four screws were placed with pretty good purchase Next the locking screws were then applied An x ray was obtained which showed good placement of graft plate and screws The upper screws were near the upper endplate of C3 The C3 vertebral body that remained was narrow after drilling off the spurs Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate Attention was turned to closure A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin The wound was then carefully closed in layers Sterile dressings were applied along with a rigid Philadelphia collar The operation was then terminated The patient tolerated the procedure well and left for the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisted of bone and soft tissue as well as C3 C4 disc material Keywords surgery herniated osteophytes nerve root decompression harvesting autologous vertebral arthrodesis anterior technique anterior cervical discectomy spinal cord compression fibular allograft bone creation of arthrodesis cervical discectomy spinal instrumentation cord compression vertebral body vertebral bodies spinal cord bone instrumentation cervical anterior grafting spinal discectomy allograft MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy bone bank allograft and anterior cervical plate Left cervical radiculopathy Medical Specialty Surgery Sample Name Anterior Cervical Discectomy 4 Transcription PREOPERATIVE DIAGNOSIS Left cervical radiculopathy POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy PROCEDURES PERFORMED 1 C5 C6 anterior cervical discectomy 2 Bone bank allograft 3 Anterior cervical plate TUBES AND DRAINS LEFT IN PLACE None COMPLICATIONS None SPECIMEN SENT TO PATHOLOGY None ANESTHESIA General endotracheal INDICATIONS This is a middle aged man who presented to me with left arm pain He had multiple levels of disease but clinically it was C6 radiculopathy We tested him in the office and he had weakness referable to that nerve The procedure was done at that level DESCRIPTION OF PROCEDURE The patient was taken to the operating room at which time an intravenous line was placed General endotracheal anesthesia was obtained He was positioned supine in the operative area and the right neck was prepared An incision was made and carried down to the ventral spine on the right in the usual manner An x ray confirmed our location We were impressed by the degenerative change and the osteophyte overgrowth As we had excepted the back of the disk space was largely closed off by osteophytes We patiently drilled through them to the posterior ligament We went through that until we saw the dura We carefully went to the patient s symptomatic left side The C6 foramen was narrowed by uncovertebral joint overgrowth The foramen was open widely An allograft was placed An anterior Steffee plate was placed Closure was commenced The wound was closed in layers with Steri Strips on the skin A dressing was applied It should be noted that the above operation was done also with microscopic magnification and illumination Keywords surgery cervical radiculopathy anterior cervical discectomy bank allograft cervical discectomy anterior cervical foramen discectomy allograft radiculopathy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy two levels and C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used Medical Specialty Surgery Sample Name Anterior Cervical Discectomy 3 Transcription PREOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain POSTOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain PROCEDURES C5 C6 and C6 C7 anterior cervical discectomy two levels C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used ANESTHESIA General endotracheal COMPLICATIONS None INDICATION FOR THE PROCEDURE This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain numbness weakness with MRI showing significant disk protrusions with the associate complexes at C5 C6 and C6 C7 with associated cervical radiculopathy After failure of conservative treatment this patient elected to undergo surgery DESCRIPTION OF PROCEDURE The patient was brought to the OR and after adequate general endotracheal anesthesia she was placed supine on the OR table with the head of the bed about 10 degrees A shoulder roll was placed and the head supported on a donut support The cervical region was prepped and draped in the standard fashion A transverse cervical incision was made from the midline which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle In a transverse fashion the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done Then the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia which was gently dissected and released superiorly and inferiorly Spinal needles were placed into the displaced C5 C6 and C6 C7 to confirm these disk levels using lateral fluoroscopy Following this monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5 C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly A 15 scalpel was used to do a discectomy at C5 C6 from endplate to endplate and uncovertebral joint On the uncovertebral joint a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect This was done under the microscope A high speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the 15 scalpel and then Kerrison punches 1 mm and then 2 mm were used to decompress further disk calcified material at the C5 C6 level This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen Then at the C6 C7 level in a similar fashion 15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate to endplate using a 15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate and then high speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released Then using the Kerrison punches we used 1 mm and 2 mm to remove disk calcified material which was extending more posteriorly to the left and the right This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots With this done the wound was irrigated Hemostasis was ensured with bipolar coagulation Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6 mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5 C6 and C6 C7 discectomy sites Then the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate Danek windows titanium plates was then taken and sized and placed A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5 two in the vertebral body of C6 and two in the vertebral body of C7 The holes were then drilled and after this self tapping screws were placed into the vertebral body of C5 C6 and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5 C6 and C7 With this done operative fluoroscopy was used to check good alignment of the graft screw and plate and then the wound was irrigated Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down A 10 round Jackson Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site Then the platysma was approximated using 2 0 Vicryl inverted interrupted stitches and the skin closed with 4 0 Vicryl running subcuticular stitch Steri Strips and sterile dressings were applied The patient remained hemodynamically stable throughout the procedure Throughout the procedure the microscope had been used for the disk decompression and high speed drilling In addition intraoperative SSEP EMG monitoring and motor evoked potentials remained stable throughout the procedure The patient remained stable throughout the procedure Keywords surgery cervical disk protrusions cervical radiculopathy cervical pain cervical plate fixation sofamor danek titanium window plate anterior cervical discectomy vertebral body vertebral disk intraoperative anterior decompression fluoroscopy radiculopathy discectomy cervical MEDICAL_TRANSCRIPTION,Description Selective coronary angiography of the right coronary artery left main LAD left circumflex artery left ventricular catheterization left ventricular angiography angioplasty of totally occluded mid RCA arthrectomy using 6 French catheter stenting of the mid RCA stenting of the proximal RCA femoral angiography and Perclose hemostasis Medical Specialty Surgery Sample Name Angiography Catheterization 1 Transcription INDICATION Acute coronary syndrome CONSENT FORM The procedure of cardiac catheterization PCI risks included but not restricted to death myocardial infarction cerebrovascular accident emergent open heart surgery bleeding hematoma limb loss renal failure requiring dialysis blood loss infection had been explained to him He understands All questions answered and is willing to sign consent PROCEDURE PERFORMED Selective coronary angiography of the right coronary artery left main LAD left circumflex artery left ventricular catheterization left ventricular angiography angioplasty of totally occluded mid RCA arthrectomy using 6 French catheter stenting of the mid RCA stenting of the proximal RCA femoral angiography and Perclose hemostasis NARRATIVE The patient was brought to the cardiac catheterization laboratory in a fasting state Both groins were draped and sterilized in the usual fashion Local anesthesia was achieved with 2 lidocaine to the right groin area and a 6 French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery Selective coronary angiography was performed with 6 French JL4 catheter for the left coronary system and a 6 French JR4 catheter of the right coronary artery Left ventricular catheterization and angiography was performed at the end of the procedure with a 6 French angle pigtail catheter FINDINGS 1 Hemodynamics systemic blood pressure 140 70 mmHg LVEDP at the end of the procedure was 13 mmHg 2 The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20 angiographic stenosis at the take off of the left circumflex artery The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30 angiographic stenosis The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate to severe ostium The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk The LAD is calcified and diffusely disease in the proximal and mid portion There is mild nonobstructive disease in the proximal LAD resulting in less than 20 angiographic stenosis 3 The right coronary artery is dominant It is septal to be occluded in the mid portion The findings were discussed with the patient and she opted for PCI Angiomax bolus was started The ACT was checked It was higher in 300 I have given the patient 600 mg of oral Plavix The right coronary artery was engaged using a 6 French JR4 guide catheter I was unable to cross through this lesion using a BMW wire and a 3 0x8 mm balloon support I was unable to cross with this lesion using a whisper wire I was unable to cross with this lesion using Cross IT 100 wire I have also used second 6 French Amplatz right I guide catheter At one time I have lost flow in the distal vessel The patient experienced severe chest pain ST segment elevation bradycardia and hypotension which responded to intravenous fluids and atropine along with intravenous dopamine Dr X was notified Eventually an Asahi grand slam wire using the same 3 0 x 8 mm Voyager balloon support I was able to cross into the distal vessel I have performed careful balloon angioplasty of the mid RCA I have given nitroglycerin under the nursing several times during the procedure I then performed arthrectomy using 5 French export catheter I performed more balloon predilation using a 3 0 x16 mm Voyager balloon I then deployed 4 0 x15 mm excised and across the mid RCA at 18 atmospheres with good angiographic result Proximal to the proximal edge of the stent there was still some persistent haziness most likely just diseased artery diffuse plaquing I decided to cover this segment using a second 4 0 x 15 mm excised and two stents were overlapped the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result Left ventricular catheterization was performed with 6 French angle pigtail catheter The left ventricle is rather smaller in size The mid inferior wall is minimally hypokinetic ejection fraction is 70 There is no evidence of aortic wall stenosis or mitral regurgitation Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis CONCLUSIONS 1 Normal left ventricular size and function Ejection fraction is 65 to 70 No MR 2 Successful angioplasty and stenting of the subtotally closed mid RCA This was hard organized thrombus very difficult to penetrate I have deployed two overlapping 4 0 x15 mm excised and with excellent angiographic result The RCA is dominant 3 No moderate disease in the distal left main Moderate disease in the ostium of the left circumflex artery Mild disease in the proximal LAD PLAN Recommend smoking cessation Continue aspirin lifelong and continue Plavix for at least 12 months Keywords surgery acute coronary syndrome circumflex artery ventricular catheterization ventricular angiography angioplasty coronary artery coronary angiography arthrectomy femoral angiography perclose hemostasis selective coronary angiography angiographic stenosis rca coronary catheterization artery angiography hemostasis wire lad femoral angiographic stenting proximal MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy primary patient under age 12 Medical Specialty Surgery Sample Name Adenotonsillectomy Transcription PREOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis POSTOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis OPERATIVE PROCEDURE Adenotonsillectomy primary patient under age 12 ANESTHESIA General endotracheal anesthesia PROCEDURE IN DETAIL This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron She was placed supine on the operating room table General endotracheal anesthesia was induced without difficulty In the holding area her allergies were reviewed It is unclear whether she is actually allergic to penicillin Codeine caused her to be excitable but she did not actually have an allergic reaction to codeine She might be allergic to BACTRIM and SULFA After positioning a small shoulder roll and draping sterilely McIvor mouthgag 3 blade was inserted and suspended from the Mayo stand There was no bifid uvula or submucous cleft She had 3 cryptic tonsils with significant debris in the tonsillar crypts Injection at each peritonsillar area with 0 25 with Marcaine with 1 200 000 Epinephrine approximately 1 5 mL total volume The left superior tonsillar pole was then grasped with curved Allis forceps _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7 3 Mouthgag was released reopened no bleeding was seen The right tonsil was then removed in the same fashion The mouthgag released reopened and no bleeding was seen Small red rubber catheter in the nasal passage was used to retract the soft palate She had mild to moderate adenoidal tissue residual It was removed with Coblation Evac Xtra gently curved Wand on 9 5 Red rubber catheter was then removed Mouthgag was again released reopened no bleeding was seen Orogastric suction carried out with only scant clear stomach contents Mouthgag was then removed Teeth and lips were inspected and were in their preoperative condition The patient then awakened extubated and taken to recovery room in good condition TOTAL BLOOD LOSS FROM TONSILLECTOMY Less than 2 mL TOTAL BLOOD LOSS FROM ADENOIDECTOMY Less than 2 mL COMPLICATIONS No intraoperative events or complications occurred PLAN Family will be counseled postoperatively Postoperatively the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days Lortab Elixir for pain _______ and promethazine if needed for nausea and vomiting Keywords surgery hypertrophic adenotonsillitis adenotonsillitis endotracheal anesthesia coblation evac xtra wand lortab elixir red rubber catheter total blood loss adenotonsillectomy forceps mouthgag MEDICAL_TRANSCRIPTION,Description Adenoidectomy Adenoid hypertrophy The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied Medical Specialty Surgery Sample Name Adenoidectomy 1 Transcription PREOPERATIVE DIAGNOSIS Adenoid hypertrophy POSTOPERATIVE DIAGNOSIS Adenoid hypertrophy PROCEDURE PERFORMED Adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction The nasopharynx was inspected with the laryngeal mirror Serial passages of the curettes were utilized to remove the nasopharyngeal tissue following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0 25 Neo Synephrine and tannic acid powder Attention was then redirected to the oropharynx The McIvor was reopened packs removed and the bleeding was controlled with the suction Bovie unit The catheters were removed and the nasal passages and oropharynx were suctioned free of debris The McIvor was then removed and the procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords surgery palate nasal passage mcivor mouth gag oral cavity nasal nasopharynx oropharynx hypertrophy oral cavity mcivor tongue adenoidectomy MEDICAL_TRANSCRIPTION,Description The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8 0 nylon sutures The knots were trimmed Medical Specialty Surgery Sample Name Ahmed Shunt Placement Transcription PROCEDURE IN DETAIL While in the holding area the patient received a peripheral IV from the nursing staff In addition pilocarpine 1 was placed into the operative eye two times separated by 10 minutes The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines Through the IV the patient received IV sedation in the form of propofol and once somnolent from this a retrobulbar block was administrated consisting of 2 Xylocaine plain Approximately 3 mL were administered The patient then underwent a Betadine prep with respect to the face lens lashes and eye During the draping process care was taken to isolate the lashes A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva Approximately 8 to 10 mm posterior to limbus the conjunctiva was incised and dissected forward to the limbus Blunt dissection was carried out in the superotemporal quadrant Next a 2 x 3 mm scleral flap was outlined that was one half scleral depth in thickness This flap was cut forward to clear cornea using a crescent blade The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8 0 nylon sutures The knots were trimmed The tube was then cut to an appropriate length to enter the anterior chamber The anterior chamber was then entered after a paracentesis wound had been made temporally A trabeculectomy was done and then the tube was threaded through the trabeculectomy site The tube was sutured in place with a multi wrapped 8 0 nylon suture The scleral flap was then sutured in place with two 10 0 nylon sutures The knots were trimmed rotated and buried A scleral patch was then placed of an appropriate size over the two It was sutured in place with interrupted 8 0 nylon sutures The knots were trimmed The overlying conjunctiva was then closed with a running 8 0 Vicryl suture with a BV needle The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft A good flow was established with irrigation into the anterior chamber Homatropine Econopred and Vigamox drops were placed into the eye A patch and shield were placed over the eye after removing the draping and the speculum The patient tolerated the procedure well He was taken to the recovery in good condition He will be seen in followup in the office tomorrow Keywords surgery cornea ahmed shunt nylon sutures trabeculectomy conjunctiva chamberNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair Patient with a 5 5 cm diameter nonfunctioning mass in his right adrenal Medical Specialty Surgery Sample Name Adrenalectomy Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia POSTOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia OPERATION PERFORMED Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair ANESTHESIA General CLINICAL NOTE This is a 52 year old inmate with a 5 5 cm diameter nonfunctioning mass in his right adrenal Procedure was explained including risks of infection bleeding possibility of transfusion possibility of further treatments being required Alternative of fully laparoscopic are open surgery or watching the lesion DESCRIPTION OF OPERATION In the right flank up position table was flexed He had a Foley catheter in place Incision was made from just above the umbilicus about 5 5 cm in diameter The umbilical hernia was taken down An 11 mm trocar was placed in the midline superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin A liver retractor was placed to this The colon was reflected medially by incising the white line of Toldt The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly The vena cava was identified The main renal vein was identified Coming superior to the main renal vein staying right on the vena cava all small vessels were clipped and then divided Coming along the superior pole of the kidney the tumor was dissected free from top of the kidney with clips and Bovie The harmonic scalpel was utilized superiorly and laterally Posterior attachments were divided between clips and once the whole adrenal was mobilized the adrenal vein and one large adrenal artery were noted doubly clipped and divided Specimen was placed in a collection bag removed intact Hemostasis was excellent The umbilical hernia had been completely taken down The edges were freshened up Vicryl 1 was utilized to close the incision and 2 0 Vicryl was used to close the fascia of the trocar Skin closed with clips He tolerated the procedure well All sponge and instrument counts were correct Estimated blood loss less than 100 mL The patient was awakened extubated and returned to recovery room in satisfactory condition Keywords surgery adrenalectomy laparoscopic hand assisted umbilical hernia repair vena cava renal vein hernia repair laparoscopic umbilical hernia MEDICAL_TRANSCRIPTION,Description Adenoidectomy procedure Medical Specialty Surgery Sample Name Adenoidectomy Transcription ADENOIDECTOMY PROCEDURE The patient was brought into the operating room suite anesthesia administered via endotracheal tube Following this the patient was draped in standard fashion The Crowe Davis mouth gag was inserted in the oral cavity The palate and tonsils were inspected the palate was suspended with a red rubber catheter passed through the right nostril Following this the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer The adenoid pad was removed without difficulty The nasopharynx was packed Following this the nasopharynx was unpacked several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated The Crowe Davis was released The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery Keywords surgery adenoidectomy crowe davis adenoid pad electrocautery endotracheal tube gently coagulated mouth gag nasopharynx oral cavity red rubber catheter vomer palate tonsilsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy Adenotonsillitis with hypertrophy The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms Adenotonsillectomy is indicated Medical Specialty Surgery Sample Name Adenotonsillectomy 2 Transcription POSTOPERATIVE DIAGNOSIS Adenotonsillitis with hypertrophy OPERATION PERFORMED Adenotonsillectomy ANESTHESIA General endotracheal INDICATIONS The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms Adenotonsillectomy is indicated DESCRIPTION OF PROCEDURE The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion A McIvor mouth gag was applied The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly The adenoids were removed with suction electrocautery under mere visualization The left tonsil was grasped with a curved Allis forceps retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion The inferior middle and superior pole vessels were further cauterized with suction electrocautery Copious saline irrigation of the oral cavity was then performed There was no further identifiable bleeding at the termination of the procedure The estimated blood loss was less than 10 mL The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords surgery hypertrophy adenotonsillitis tonsillar pillar bovie electrocautery adenotonsillectomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy Recurrent tonsillitis The adenoid bed was examined and was moderately hypertrophied Adenoid curettes were used to remove this tissue and packs placed Medical Specialty Surgery Sample Name Adenotonsillectomy 1 Transcription PREOPERATIVE DIAGNOSIS Recurrent tonsillitis POSTOPERATIVE DIAGNOSIS Recurrent tonsillitis PROCEDURE Adenotonsillectomy COMPLICATIONS None PROCEDURE DETAILS The patient was brought to the operating room and under general endotracheal anesthesia in supine position the table turned and a McIvor mouthgag placed The adenoid bed was examined and was moderately hypertrophied Adenoid curettes were used to remove this tissue and packs placed Next the right tonsil was grasped with a curved Allis and using the gold laser the anterior tonsillar pillar incised and with this laser dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed A similar procedure was performed on the contralateral tonsil Following meticulous hemostasis saline was used to irrigate and no further bleeding noted The patient was then allowed to awaken and was brought to the recovery room in stable condition Keywords surgery curved allis tonsillitis hypertrophied curettes tonsillar adenoid adenotonsillectomy MEDICAL_TRANSCRIPTION,Description Bilateral open Achilles lengthening with placement of short leg walking cast Medical Specialty Surgery Sample Name Achilles Lengthening Transcription PREOPERATIVE DIAGNOSIS Idiopathic toe walker POSTOPERATIVE DIAGNOSIS Idiopathic toe walker PROCEDURE Bilateral open Achilles lengthening with placement of short leg walking cast ANESTHESIA Surgery performed under general anesthesia A total of 10 mL of 0 5 Marcaine local anesthetic was used COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None TOURNIQUET TIME On the left side was 30 minutes on the right was 21 minutes HISTORY AND PHYSICAL The patient is a 10 year old boy who has been a toe walker since he started ambulating at about a year The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally He does not walk with a crouched gait but does toe walk Given his tightness surgery versus observation was recommended to the family Family however wanted to correct his toe walking Surgery was then discussed Risks of surgery include risks of anesthesia infection bleeding changes in sensation and motion of the extremities failure to resolve toe walking possible stiffness cast and cast problems All questions were answered and parents agreed to above surgical plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively The patient was then subsequently placed prone with all bony prominences padded Two bilateral nonsterile tourniquets were placed on each thigh Both extremities were then prepped and draped in a standard surgical fashion We turned our attention first towards the left side A planned incision of 1 cm medial to the Achilles tendon was marked on the skin The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Incision was then made and carried down through subcutaneous fat down to the tendon sheath Achilles tendon was identified and Z lengthening was done with the medial distal half cut Once Z lengthening was completed proximally the length of the Achilles tendon was then checked This was trimmed to obtain an end on end repair with 0 Ethibond suture This was also oversewn Wound was then irrigated Achilles tendon sheath was reapproximated using 2 0 Vicryl as well as the subcutaneous fat The skin was closed using 4 0 Monocryl Once the wound was cleaned and dried and dressed with Steri Strips and Xeroform the area was injected with 0 5 Marcaine It was then dressed with 4 x 4 and Webril Tourniquet was released at 30 minutes The same procedure was repeated on the right side with tourniquet time of 21 minutes While the patient was still prone two short leg walking casts were then placed The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition POSTOPERATIVE PLAN The patient will be discharged on the day of surgery He may weightbear as tolerated in his cast which he will have for about 4 to 6 weeks He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs which he will need up to 6 months The patient may or may not need physical therapy while his Achilles lengthenings are healing The patient is not to participate in any PE for at least 6 months The patient is given Tylenol No 3 for pain Keywords surgery toe walker achilles lengthening idiopathic toe walker short leg walking subcutaneous fat tendon sheath leg walking achilles tendon toe tourniquet tendon intraoperative MEDICAL_TRANSCRIPTION,Description Adenoidectomy and tonsillectomy and lingual frenulectomy Chronic adenotonsillitis and ankyloglossia Medical Specialty Surgery Sample Name Adenoidectomy Tonsillectomy Lingual Frenulectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic adenotonsillitis 2 Ankyloglossia POSTOPERATIVE DIAGNOSES 1 Chronic adenotonsillitis 2 Ankyloglossia PROCEDURE PERFORMED 1 Adenoidectomy and tonsillectomy 2 Lingual frenulectomy ANESTHESIA General endotracheal FINDINGS SPECIMEN Tonsil and adenoid tissue COMPLICATIONS None CONDITION The patient is stable and tolerated the procedure well and sent to PACU HISTORY OF PRESENT ILLNESS This is a 3 year old child with a history of adenotonsillitis PROCEDURE The patient was prepped and draped in the usual sterile fashion A curved hemostat was used to grasp the lingual frenulum The stat was removed and Metzenbaum scissors were used to free the lingual frenulum Cautery was used to allow hemostasis The patient was then turned McIvor mouth gag was inserted Tonsils and adenoids were exposed The patient s right tonsil was first grasped with a curved hemostat Needle tip cautery was used to free the superior pole of tonsil The tonsil was then grasped in medial superior aspect with a straight hemostat The tonsil fascia planes were identified with Bovie dissection along the plane The tonsil was freed from anterior pillar and posterior pillar Amputation occurred along the same plane as the patient s tongue Suction cautery was then used to allow for hemostasis The patient s adenoids were then viewed with an adenoid mirror An adenoid curet was used to remove the patient s adenoid tissue Specimen sent Suction cautery was used to allow for hemostasis Superior pole of left tonsil was then grasped with a curved hemostat Superior pole was freed using needle tip Bovie dissection Beginning with 15 desiccate after superior pole was free Bovie was switched to 15 fulgurate and the tonsil was stripped from anterior and posterior pillars The tonsil was then amputated at the same plane as tongue base Hemostasis was achieved with using suction cautery Mouth gag was removed Dual position and occlusion were tested The patient was extubated and tolerated the procedure well and sent back to PACU Keywords surgery adenotonsillitis ankyloglossia adenoidectomy tonsillectomy frenulectomy tonsil adenoid tissue metzenbaum scissors lingual frenulectomy chronic adenotonsillitis curved hemostat suction cautery hemostat hemostasis lingual cautery MEDICAL_TRANSCRIPTION,Description Achilles tendon rupture left lower extremity Primary repair left Achilles tendon The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg The patient was placed in posterior splint and followed up at ABC orthopedics for further care Medical Specialty Surgery Sample Name Achilles Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Achilles tendon rupture left lower extremity POSTOPERATIVE DIAGNOSIS Achilles tendon rupture left lower extremity PROCEDURE PERFORMED Primary repair left Achilles tendon ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME 40 minutes at 325 mmHg POSITION Prone HISTORY OF PRESENT ILLNESS The patient is a 26 year old African American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg The patient was placed in posterior splint and followed up at ABC orthopedics for further care PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedure were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the patient the operative surgeon Department Of Anesthesia and nursing staff While in this hospital the Department Of Anesthesia administered general anesthetic to the patient The patient was then transferred to the operative table and placed in the prone position All bony prominences were well padded at this time A nonsterile tourniquet was placed on the left upper thigh of the patient but not inflated at this time Left lower extremity was sterilely prepped and draped in the usual sterile fashion Once this was done the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes After all bony and soft tissue land marks were identified a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal Careful dissection was then taken down to the level of the peritenon Once this was reached full thickness flaps were performed medially and laterally Next retractor was placed All neurovascular structures were protected A longitudinal incision was then made in the peritenon and opened up exposing the tendon There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point The plantar tendon was noted to be intact The tendon was debrided at this time of hematoma as well as frayed tendon Wound was copiously irrigated and dried Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair Next 0 PDS on a taper needle was selected and a Krackow stitch was then performed Two sutures were then used and tied individually ________ from the tendon The tendon came together very well and with a tight connection Next a 2 0 Vicryl suture was then used to close the peritenon over the Achilles tendon The wound was once again copiously irrigated and dried A 2 0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by 4 0 suture in the subcuticular closure on the skin Steri Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s Kerlix roll sterile Kerlix and a short length fiberglass cast in a plantar position At this time the Department of anesthesia reversed the anesthetic The patient was transferred back to hospital gurney to the Postanesthesia Care Unit The patient tolerated the procedure well There were no complications Keywords surgery repair achilles tendon rupture longitudinal incision tendon rupture achilles tendon tendon achilles rupture extremity MEDICAL_TRANSCRIPTION,Description Removal of the hardware and revision of right AC separation Loose hardware with superior translation of the clavicle implants Arthrex bioabsorbable tenodesis screws Medical Specialty Surgery Sample Name AC Separation Revision Hardware Removal Transcription PREOPERATIVE DIAGNOSIS Right AC separation POSTOPERATIVE DIAGNOSIS Right AC separation PROCEDURES Removal of the hardware and revision of right AC separation ANESTHESIA General BLOOD LOSS 100 cc COMPLICATIONS None FINDINGS Loose hardware with superior translation of the clavicle implants IMPLANTS Arthrex bioabsorbable tenodesis screws SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion The incision was reopened and the hardware was removed without difficulty The AC joint was inspected and reduced An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle And two separate areas that were split one taken medially and one taken laterally and then sewed together for further stability This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied He was awakened from anesthesia and taken to recovery room in a stable condition Final needle and instrument counts were correct Keywords surgery loose hardware superior translation clavicle implants ac separation removal of the hardware arthrex bioabsorbable tenodesis screws bioabsorbable tenodesis tenodesis screws translation implants bioabsorbable tenodesis clavicle separation hardware MEDICAL_TRANSCRIPTION,Description Excision of abscess removal of foreign body Repair of incisional hernia Recurrent re infected sebaceous cyst of abdomen Abscess secondary to retained foreign body and incisional hernia Medical Specialty Surgery Sample Name Abscess Excision Transcription PREOPERATIVE DIAGNOSIS Recurrent re infected sebaceous cyst of abdomen POSTOPERATIVE DIAGNOSES 1 Abscess secondary to retained foreign body 2 Incisional hernia PROCEDURES 1 Excision of abscess removal of foreign body 2 Repair of incisional hernia ANESTHESIA LMA INDICATIONS Patient is a pleasant 37 year old gentleman who has had multiple procedures including a laparotomy related to trauma The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision which he says gets larger and then it drains internally causing him to be quite ill He presented to my office and I recommended that he undergo exploration of this area and removal The procedure purpose risks expected benefits potential complications and alternative forms of therapy were discussed with him and he was agreeable to surgery FINDINGS The patient was found upon excision of the cyst that it contained a large Prolene suture which is multiply knotted as it always is beneath this was a very small incisional hernia the hernia cavity which contained omentum the hernia was easily repaired DESCRIPTION OF PROCEDURE The patient was identified then taken into the operating room where after induction of an LMA anesthetic his abdomen was prepped with Betadine solution and draped in sterile fashion The puncta of the wound lesion was infiltrated with methylene blue and peroxide The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors the cyst was excised down to its base In doing so we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia The cyst was removed in its entirety divided from the omentum using a Metzenbaum and tying with 2 0 silk ties The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures The wound was then irrigated and closed with 3 0 Vicryl subcutaneous and 4 0 Vicryl subcuticular and Steri Strips Patient tolerated the procedure well Dressings were applied and he was taken to recovery room in stable condition Keywords surgery sebaceous cyst prolene suture incisional hernia incisional abscess hernia abdomen omentum excision cyst MEDICAL_TRANSCRIPTION,Description Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak Diffuse intestinal and mesenteric lymphangiectasia Medical Specialty Surgery Sample Name Abdominal Exploration Transcription PREOPERATIVE DIAGNOSES 1 Congenital chylous ascites and chylothorax 2 Rule out infradiaphragmatic lymphatic leak POSTOPERATIVE DIAGNOSES Diffuse intestinal and mesenteric lymphangiectasia ANESTHESIA General INDICATION The patient is an unfortunate 6 month old baby boy who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition but he had repeated chylothoraces Last week Dr X took the patient to the operating room in hopes that with thoracotomy a thoracic duct leak could be found which would be successfully closed surgically However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen Dr X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole This was closed and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease We met with his parents and talked to them about this and he is here today for that attempt OPERATIVE FINDINGS The patient s abdomen was relatively soft minimally distended Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum the cecum and the portion of the ascending colon It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery There was about one quarter to one third of the jejunum that did not appear to be grossly involved but I did not think that resection of three quarters of the patient s small bowel would be viable surgical option Instead we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that The lymphatic abnormality was extensive They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery They were small aneurysm like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well No other major retroperitoneal structure or correctable structure was identified Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well DESCRIPTION OF OPERATION The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow We conducted a surgical time out and reiterated all of the patient s important identifying information and confirmed the operative plan as described above Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia As the peritoneal cavity was entered we divided the umbilical vein ligamentum teres remnant between Vicryl ties and we were able to readily identify a large amount of chylous ascites that had been previously described The bowel was eviscerated and then with careful inspection we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient s chylous ascites The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected but did not appear that resection of 75 of the small intestine and colon would be a satisfactory tradeoff for The patient but would likely render him with significant short bowel and nutritional and metabolic problems Furthermore it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option We suctioned free all of the chylous accumulations replaced the intestines to their peritoneal cavity and then closed the patient s abdominal incision with 4 0 PDS on the posterior sheath and 3 0 PDS on the anterior rectus sheath Subcuticular 5 0 Monocryl and Steri Strips were used for skin closure The patient tolerated the procedure well He lost minimal blood but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time Keywords surgery intestinal mesenteric lymphangiectasia ascites chylothorax lymphatic leak infradiaphragmatic abdominal exploration congenital chylous mesenteric lymphangiectasia peritoneal cavity chylous abdominal congenital abdomen lymphatic MEDICAL_TRANSCRIPTION,Description Incision and drainage I D of abdominal abscess excisional debridement of nonviable and viable skin subcutaneous tissue and muscle then removal of foreign body Medical Specialty Surgery Sample Name Abdominal Abscess I D Transcription PREOPERATIVE DIAGNOSIS Abdominal wall abscess POSTOPERATIVE DIAGNOSIS Abdominal wall abscess PROCEDURE Incision and drainage I D of abdominal abscess excisional debridement of nonviable and viable skin subcutaneous tissue and muscle then removal of foreign body ANESTHESIA LMA INDICATIONS Patient is a pleasant 60 year old gentleman who initially had a sigmoid colectomy for diverticular abscess subsequently had a dehiscence with evisceration Came in approximately 36 hours ago with pain across his lower abdomen CT scan demonstrated presence of an abscess beneath the incision I recommended to the patient he undergo the above named procedure Procedure purpose risks expected benefits potential complications alternatives forms of therapy were discussed with him and he was agreeable to surgery FINDINGS The patient was found to have an abscess that went down to the level of the fascia The anterior layer of the fascia was fibrinous and some portions necrotic This was excisionally debrided using the Bovie cautery and there were multiple pieces of suture within the wound and these were removed as well TECHNIQUE Patient was identified then taken into the operating room where after induction of appropriate anesthesia his abdomen was prepped with Betadine solution and draped in a sterile fashion The wound opening where it was draining was explored using a curette The extent of the wound marked with a marking pen and using the Bovie cautery the abscess was opened and drained I then noted that there was a significant amount of undermining These margins were marked with a marking pen excised with Bovie cautery the curette was used to remove the necrotic fascia The wound was irrigated cultures sent prior to irrigation and after achievement of excellent hemostasis the wound was packed with antibiotic soaked gauze A dressing was applied The finished wound size was 9 0 x 5 3 x 5 2 cm in size Patient tolerated the procedure well Dressing was applied and he was taken to recovery room in stable condition Keywords surgery excisional debridement subcutaneous tissue abdominal wall abscess foreign body abdominal abscess bovie cautery abdominal i d wound incision abscess MEDICAL_TRANSCRIPTION,Description Speech therapy discharge summary The patient was admitted for skilled speech therapy secondary to cognitive linguistic deficits Medical Specialty Speech Language Sample Name Speech Therapy Discharge Summary Transcription LONG TERM GOALS Both functional and cognitive linguistic ability to improve safety and independence at home and in the community This goal has been met based on the patient and husband reports the patient is able to complete all activities which she desires to do at home During the last reevaluation the patient had a significant progress and all cognitive domains evaluated which are attention memory executive functions language and visuospatial skill She continues to have an overall mild cognitive linguistic deficit but this is significantly improved from her initial evaluation which showed severe impairment The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued The patient and her husband both agreed with the patient s discharge Keywords speech language narrative memory executive function attention speech therapy visuospatial accuracy linguistic cognitive speechNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Global aphasia The patient is referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy status post stroke Medical Specialty Speech Language Sample Name Speech Therapy Evaluation Transcription MEDICAL DIAGNOSIS Strokes SPEECH AND LANGUAGE THERAPY DIAGNOSIS Global aphasia SUBJECTIVE The patient is a 44 year old female who is referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy status post stroke The patient s sister in law was present throughout this assessment and provided all the patient s previous medical history Based on the sister in law s report the patient had a stroke on 09 19 08 The patient spent 6 weeks at XY Medical Center where she was subsequently transferred to XYZ for therapy for approximately 3 weeks ABCD brought the patient to home the Monday before Thanksgiving because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson The patient s previous medical history includes a long history of illegal drug use to include cocaine crystal methamphetamine and marijuana In March of 2008 the patient had some type of potassium issue and she was hospitalized at that time Prior to the stroke the patient was not working and ABCD reported that she believes the patient completed the ninth grade but she did not graduate from high school During the case history I did pose several questions to the patient but her response was often no She was very emotional during this evaluation and crying occurred multiple times OBJECTIVE To evaluate the patient s overall communication ability a Western Aphasia Battery was completed Also tests were not done due to time constraint and the patient s severe difficulty and emotional state Speech automatic tests were also completed to determine if the patient had any functional speech ASSESSMENT Based on the results of the Weston aphasia battery the patient s deficits most closely resemble global aphasia On the spontaneous speech subtest the patient responded no to all questions asked except for how are you today where she gave a thumbs up She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly The patient s sister in law did state that the patient wore glasses but she currently does not have them and she did not know the extent the patient s visual deficit On the auditory verbal comprehension portion of the Western Aphasia Battery the patient answered no to all yes no questions The auditory word recognition subtest the patient had 5 out of 60 responses correct With the sequential command she had 10 out of 80 corrects She was able to shut her eyes point to the window and point to the pen after directions With repetition subtest she repeated bed correctly but no other stimuli At this time the patient became very emotional and repeatedly stated I can t During the naming subtest of the Western Aphasia Battery the patient s responses contained numerous paraphasias and her speech was often unintelligible due to jargon The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech In regards to speech automatics the patient is able to count from 1 to 9 accurately however stated 7 instead of 10 at the end of the task She is not able to state the days of the week or months in the year or her name at this time She cannot identify the day on calendar and was unable to verbally state the date or month DIAGNOSTIC IMPRESSION The patient s communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication She does perseverate and is very emotional due to probable frustration Outpatient skilled speech therapy is recommended to improve the patient s functional communication skills PATIENT GOAL Her sister in law stated that they would like to improve upon the patient s speech to allow her to communicate more easily at home PLAN OF CARE Outpatient skilled speech therapy two times a week for the next 12 weeks Therapy to include aphasia treatment and home activities SHORT TERM GOALS 8 WEEKS 1 The patient will answer simple yes no questions with greater than 90 accuracy with minimal cueing 2 The patient will be able to complete speech automatic tasks with greater than 80 accuracy without models or cueing 3 The patient will be able to complete simple sentence completion and or phrase completion with greater than 80 accuracy with minimal cueing 4 The patient will be able to follow simple one step commands with greater than 80 accuracy with minimal cueing 5 The patient will be able to name 10 basic everyday objects with greater than 80 accuracy with minimal cueing SHORT TERM GOALS 12 WEEKS Functional communication abilities to allow the patient to express her basic wants and needs Keywords speech language speech automatic tasks minimal cueing sentence completion western aphasia battery skilled speech therapy global aphasia speech therapy speech aphasia MEDICAL_TRANSCRIPTION,Description The patient was referred for outpatient skilled speech therapy secondary to right hemisphere disorder status post stroke The patient attended nine outpatient skilled speech therapy sessions Medical Specialty Speech Language Sample Name Speech Therapy Discharge Summary 2 Transcription The patient made some progress during therapy She accomplished two and a half out of her five short term therapy goals We did complete an oral mechanism examination and clinical swallow evaluation which showed her swallowing to be within functional limits The patient improved on her turn taking skills during conversation and she was able to listen to a narrative and recall the main idea plus five details after a three minute delay independently The patient continues to have difficulty with visual scanning in cancellation task secondary to her significant left neglect She also did not accomplish her sustained attention goal which required her to complete tasks greater than 80 accuracy for at least 15 minutes independently Thus she also continued to have difficulty with reading comprehension secondary to the significance of her left neglect The patient was initially authorized for 12 outpatient speech therapy sessions but once again she only attended 9 Her last session occurred on 01 09 09 She has not made any additional followup sessions with me for over three weeks so she is discharged from my services at this time Keywords speech language outpatient speech therapy swallow evaluation swallowing skilled speech therapy hemisphere disorder speech therapy speechNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety Medical Specialty Speech Language Sample Name Speech Therapy Discharge Summary 1 Transcription HISTORY The patient is a 67 year old female was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety At the onset of therapy on 03 26 08 the patient was NPO with a G tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3 6 100 based on the Western Aphasia Battery Since the initial evaluation the patient has attended 60 outpatient speech therapy sessions which have focussed on her receptive communication expressive language multimodality communication skills and swallowing function and safety SHORT TERM GOALS 1 The patient met 3 out of 4 original short term therapy goals which were to complete a modified barium swallow study which she did do and which revealed no aspiration At this time the patient is eating and drinking and taking all medications by mouth however her G tube is still present The patient was instructed to talk to the primary care physician about removal of her feeding tube 2 The patient will increase accuracy of yes no responses to greater than 80 accuracy She did accomplish this goal The patient is also able to identify named objects with greater than 80 accuracy ADDITIONAL GOALS Following the completion of these goals additional goals were established Based on reevaluation the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90 accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80 accuracy independently The patient continues to have difficulty stating verbally yes or no to questions as well as accurately using head gestures and to respond to yes no questions The patient continues to have marked difficulty with her expressive language abilities She is able to write simple words to help express her basic wants and needs She has made great strides however with her receptive communication she is able to read words as well as short phrases and able to point to named objects and answer simple to moderate complex yes no questions A reevaluation completed on 12 01 08 revealed an aphasia quotient of 26 4 Once again she made significant improvement and comprehension but continues to have unintelligible speech An alternative communication device was discussed with the patient and her husband but at this time the patient does not want to utilize a communication device If in the future the patient continues to struggle with her expressive communication an alternative augmented communication device would be a benefit to her Please reconsult at that time if and when the patient is ready to use a speech generating device The patient is discharged from my services at this time due to a plateau in her progress Numerous home activities were recommended to allow her to continue to make progress at home Keywords speech language communication skills g tube aphasia language evaluation western aphasia battery skilled speech therapy swallowing function speech therapy therapy swallowing aspiration speech communication MEDICAL_TRANSCRIPTION,Description Abdominosacrocolpopexy enterocele repair cystoscopy and lysis of adhesions Medical Specialty Surgery Sample Name Abdominosacrocolpopexy Transcription PREOPERATIVE DIAGNOSES 1 Vault prolapse 2 Enterocele PREOPERATIVE DIAGNOSES 1 Vault prolapse 2 Enterocele OPERATIONS 1 Abdominosacrocolpopexy 2 Enterocele repair 3 Cystoscopy 4 Lysis of adhesions ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL SPECIMEN None BRIEF HISTORY The patient is a 53 year old female with history of hysterectomy presented with vaginal vault prolapse The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse Options such as watchful waiting pessary abdominal surgery robotic sacrocolpopexy versus open sacrocolpopexy were discussed The patient already had multiple abdominal scars Risk of open surgery was little bit higher for the patient After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy Risks of anesthesia bleeding infection pain MI DVT PE mesh erogenic exposure complications with mesh were discussed The patient understood the risks of recurrence etc and wanted to proceed with the procedure The patient was told to perform no heavy lifting for 3 months etc The patient was bowel prepped preoperative antibiotics were given DETAILS OF THE OPERATION The patient was brought to the OR anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A Pfannenstiel low abdominal incision was done at the old incision site The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle The muscle was split in the middle and peritoneum was entered using sharp mets There was no injury to the bowel upon entry There were significant adhesions which were unleashed All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released similarly colon was mobilized There was minimal space everything was packed Bookwalter placed then over the sacral bone The middle of the sacral bone was identified The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened The ligament over the sacral or sacral __________ was easily identified 0 Ethibond stitches were placed x3 A 1 cm x 5 cm mesh was cut out This was a Prolene soft mesh which was tied at the sacral ligament The bladder was clearly off the vault area which was exposed in the raw surface 0 Ethibond stitches were placed x3 The mesh was attached The apex was clearly up enterocele sac was closed using 4 0 Vicryl without much difficulty The ureter was not involved at all in this process The peritoneum was closed over the mesh Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel Prior to closure antibiotic irrigation was done using Ancef solution The mesh has been exposed in antibiotic solution prior to the usage After a through irrigation with L and half of antibiotic solution All the solution was removed Good hemostasis was obtained All the packing was removed Count was correct Rectus abdominus muscle was brought together using 4 0 Vicryl The fascia was closed using loop 1 PDS in running fascia from both sides and was tied in the middle Subcutaneous tissue was closed using 4 0 Vicryl and the skin was closed using 4 0 Monocryl in subcuticular fashion Cystoscopy was done at the end of the procedure Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure Cystoscopy was done and indigo carmine has been given There was good efflux of indigo carmine in both of the ureteral opening There was no injury to the rectum or the bladder The bladder appeared completely normal The rectal exam was done at the end of the procedure after the cystoscopy After the cysto was done the scope was withdrawn Foley was placed back The patient was brought to recovery in the stable condition Keywords surgery enterocele repair cystoscopy lysis of adhesions enterocele ethibond stitches indigo carmine vault prolapse sacrocolpopexy peritoneum abdominosacrocolpopexy MEDICAL_TRANSCRIPTION,Description Status post brain tumor with removal The patient did receive skilled speech therapy while in the acute rehab which focused on higher level cognitive and linguistic skills such as attention memory mental flexibility and improvement of her executive function Medical Specialty Speech Language Sample Name Speech Therapy Evaluation 1 Transcription DIAGNOSIS Status post brain tumor with removal SUBJECTIVE The patient is a 64 year old female with previous medical history of breast cancer that has metastasized to her lung liver spleen and brain status post radiation therapy The patient stated that on 10 24 08 she had a brain tumor removed with subsequent left sided weakness The patient was readmitted to ABC Hospital on 12 05 08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling The patient remained at the acute rehab at ABC until she was discharged home on 01 05 09 The patient did receive skilled speech therapy while in the acute rehab which focused on higher level cognitive and linguistic skills such as attention memory mental flexibility and improvement of her executive function The patient also complains of difficulty with word retrieval and slurring of speech The patient denies any difficulty with swallowing at this time OBJECTIVE Portions of the cognitive linguistic quick test was administered An oral mechanism exam was performed A motor speech protocol was completed The cognitive linguistic subtests of recalling personal facts symbol cancellation confrontational naming clock drawing story retelling generative naming design and memory and completion of mazes was administered The patient was 100 accurate with recalling personal facts completion of the symbol cancellation tasks and with confrontational naming She had no difficulty with the clock drawing task however she has considerable hand tremors which makes writing difficult In the storytelling task she scored within normal limits She was also within normal limits for generative naming She did have difficulty with the design memory and mazes subtests She was unable to complete the second maze during the allotted time The design generation subtest was also completed She was able to draw four unique designs and toward the end of the tasks was no longer able to recall the stated direction ORAL MECHANISM EXAMINATION The patient has mild left facial droop with decreased nasolabial fold Tongue is at midline and lingual range of motion and strength are within functional limit The patient does complain of biting her tongue on occasion but denied biting the inside of her cheeks Her AMRs are judged to be within functional limit Her rate of speech is decreased with a monotonous vocal quality The decreased rate may be a compensation for decreased word retrieval ability The patient s speech is judged to be 100 intelligible without background noise DIAGNOSTIC IMPRESSION The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility memory and executive function PLAN OF CARE Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment SHORT TERM GOALS THREE WEEKS 1 The patient will complete deductive reasoning and mental flexibility tasks with greater than 90 accuracy independently 2 The patient will complete perspective memory test with 100 accuracy using compensatory strategy 3 The patient will complete visual perceptual activities which focus on scanning flexibility and problem solving with greater than 90 accuracy with minimal cueing 4 The patient will listen to and or read a lengthy narrative and be able to recall at least 6 details after a 15 minute delay independently PATIENT S GOAL To improve functional independence and cognitive abilities LONG TERM GOAL FOUR WEEKS Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver Keywords speech language linguistic skills memory mental flexibility deductive reasoning skilled speech therapy speech therapy cognitive linguistic therapy linguistic speech cognitive MEDICAL_TRANSCRIPTION,Description Cognitive linguistic impairment secondary to stroke The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits Medical Specialty Speech Language Sample Name Cognitive Linguistic Impairment Discharge Transcription DIAGNOSIS Cognitive linguistic impairment secondary to stroke NUMBER OF SESSIONS COMPLETED 5 HOSPITAL COURSE The patient is a 73 year old female who was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits Based on the initial evaluation completed 12 29 08 the patient had mild difficulty with generative naming and auditory comprehension and recall The patient s skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities At this time the patient has accomplished all 5 of her short term therapy goals She is able to complete functional mass tasks with 100 accuracy independently She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently She is able to state 15 items in a broad category within a minute and a half independently The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100 accuracy independently The patient also met her long term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home The patient is no longer in need of skilled speech therapy and is discharged from my services She did quite well in therapy and also agreed with this discharge Keywords speech language stroke linguistic deficits speech therapy skilled speech therapy linguistic impairment cognitive linguistic cognitive linguistic MEDICAL_TRANSCRIPTION,Description The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Medical Specialty SOAP Chart Progress Notes Sample Name Uterine Papillary Serous Carcinoma Transcription HISTORY OF PRESENT ILLNESS The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Her last cycle of chemotherapy was finished on 01 18 08 and she complains about some numbness in her right upper extremity This has not gotten worse recently and there is no numbness in her toes She denies any tingling or burning REVIEW OF SYSTEMS Negative for any fever chills nausea vomiting headache chest pain shortness of breath abdominal pain constipation diarrhea melena hematochezia or dysuria The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head PHYSICAL EXAMINATION VITAL SIGNS Temperature 35 6 blood pressure 143 83 pulse 65 respirations 18 and weight 66 5 kg GENERAL She is a middle aged white female not in any distress HEENT No lymphadenopathy or mucositis CARDIOVASCULAR Regular rate and rhythm LUNGS Clear to auscultation bilaterally EXTREMITIES No cyanosis clubbing or edema NEUROLOGICAL No focal deficits noted PELVIC Normal appearing external genitalia Vaginal vault with no masses or bleeding LABORATORY DATA None today RADIOLOGIC DATA CT of the chest abdomen and pelvis from 01 28 08 revealed status post total abdominal hysterectomy bilateral salpingo oophorectomy with an unremarkable vaginal cuff No local or distant metastasis Right probably chronic gonadal vein thrombosis ASSESSMENT This is a 67 year old white female with history of uterine papillary serous carcinoma status post total abdominal hysterectomy and bilateral salpingo oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy She is doing well with no evidence of disease clinically or radiologically PLAN 1 Plan to follow her every 3 months and CT scans every 6 months for the first 2 years 2 The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated 3 The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now 4 The patient was advised about doing Kegel exercises for urinary incontinence and we will address this issue again during next clinic visit if it is persistent Keywords soap chart progress notes chemotherapy uterine papillary serous carcinoma oophorectomy carboplatin taxol abdominal uterine papillary carcinoma MEDICAL_TRANSCRIPTION,Description This is a pleasant 50 year old female who has undergone an APR secondary to refractory ulcerative colitis Overall her quality of life has significantly improved since she had her APR She is functioning well with her ileostomy Medical Specialty SOAP Chart Progress Notes Sample Name Wound Check Status Post APR Transcription HISTORY OF PRESENT ILLNESS Ms Connor is a 50 year old female who returns to clinic for a wound check The patient underwent an APR secondary to refractory ulcerative colitis Subsequently she developed a wound infection which has since healed On our most recent visit to our clinic she has her perineal stitches removed and presents today for followup of her perineal wound She describes no drainage or erythema from her bottom She is having good ostomy output She does not describe any fevers chills nausea or vomiting The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy She has been taking Percocet for this pain and it does work She has since run out has been trying extra strength Tylenol which will occasionally help this intermittent pain She is requesting additional pain medications for this occasional abdominal pain which she still experiences PHYSICAL EXAMINATION Temperature 95 8 pulse 68 blood pressure 132 73 and weight 159 pounds This is a pleasant female in no acute distress The patient s abdomen is soft nontender nondistended with a well healed midline scar There is an ileostomy in the right hemiabdomen which is pink patent productive and protuberant There are no signs of masses or hernias over the patient s abdomen ASSESSMENT AND PLAN This is a pleasant 50 year old female who has undergone an APR secondary to refractory ulcerative colitis Overall her quality of life has significantly improved since she had her APR She is functioning well with her ileostomy She did have concerns or questions about her diet and we discussed the BRAT diet which consisted of foods that would slow down the digestive tract such as bananas rice toast cheese and peanut butter I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less I have counseled her on refraining from soft drinks and fruit drinks I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy She also had questions about her occasional abdominal pain I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain The patient then brought up some right hand and arm numbness which has been there postsurgically and was thought to be from positioning during surgery This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping I told her that I felt that this would continue to improve as it has done over the past two months since her surgery I told her to continue doing hand exercises as she has been doing and this seems to be working for her Overall I think she has healed from her surgery and is doing very well Again her quality of life is significantly improved She is happy with her performance We will see her back in six months just for a general routine checkup and see how she is doing at that time Keywords soap chart progress notes perineal wound wound infection wound wound check ulcerative colitis apr ileostomyNOTE MEDICAL_TRANSCRIPTION,Description Followup on weight loss on phentermine Medical Specialty SOAP Chart Progress Notes Sample Name Weight Loss on Phentermine Transcription SUBJECTIVE She is here for a followup on her weight loss on phentermine She has gained another pound since she was here last We talked at length about the continued plateau she has had with her weight She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136 She is frustrated with this as well We agree that if she continues to plateau she really should not stay on phentermine We would not want her to take it to maintain her weight but only to help her get her weight down and she may have really lost any benefit from it and she agrees REVIEW OF SYSTEMS Otherwise negative She has no specific complaints No shortness of breath chest pain or palpitations PHYSICAL EXAM Vital signs Her blood pressure is fine Her diastolic is a little bit high but otherwise okay General She appears in good spirits No apparent distress HEENT Negative Neck Supple without bruits Chest Clear Cardiac exam Regular without extra sounds ASSESSMENT Weight loss on phentermine really has plateaued PLAN If she does not lose weight in the next month we will probably consider having her go off the phentermine If she does lose a couple of pounds then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop She agrees with this plan Keywords soap chart progress notes followup phentermine plateau weight weight loss weight loss on phentermine loss MEDICAL_TRANSCRIPTION,Description Chronic laryngitis hoarseness The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties Medical Specialty Speech Language Sample Name Laryngitis Discharge Transcription DIAGNOSIS Chronic laryngitis hoarseness HISTORY The patient is a 68 year old male was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties The patient attended initial evaluation plus 3 outpatient speech therapy sessions which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions The patient made great progress and he came in to discuss with an appointment on 12 23 08 stating that his voice had finally returned to normal SHORT TERM GOALS 1 To be independent with relaxation and stretching exercises and Lessac Madsen Resonant Voice Therapy Protocol 2 He also met short term goal therapy 3 and he is independent with resonant voice therapy tasks 3 We did not complete his __________ ratio during his last session so I am unsure if he had met his short term goal number 2 4 To be referred for a videostroboscopy but at this time the patient is not in need of this evaluation However in the future if hoarseness returns it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy LONG TERM GOALS 1 The patient did reach his long term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty 2 The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy The patient is discharged from my services at this time with a home program to continue to promote normal voicing Keywords speech language vocal hygiene voice activities hoarseness skilled speech therapy chronic laryngitis voice therapy resonant voice videostroboscopy laryngitis MEDICAL_TRANSCRIPTION,Description Medical Specialty Speech Language Sample Name Barium Swallow Study Speech Evaluation 1 Transcription SUBJECTIVE The patient is a 60 year old female who complained of coughing during meals Her outpatient evaluation revealed a mild to moderate cognitive linguistic deficit which was completed approximately 2 months ago The patient had a history of hypertension and TIA stroke The patient denied history of heartburn and or gastroesophageal reflux disorder A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration OBJECTIVE Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr ABC The patient was seated upright in a video imaging chair throughout this assessment To evaluate the patient s swallowing function and safety she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid teaspoon x2 cup sip x2 nectar thick liquid teaspoon x2 cup sip x2 puree consistency teaspoon x2 and solid food consistency 1 4 cracker x1 ASSESSMENT ORAL STAGE Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid Decreased tongue base retraction which contributed to vallecular pooling after the swallow PHARYNGEAL STAGE No aspiration was observed during this evaluation Penetration was noted with cup sips of thin liquid only Trace residual on the valleculae and on tongue base with nectar thick puree and solid consistencies The patient s hyolaryngeal elevation and anterior movement are within functional limits Epiglottic inversion is within functional limits CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus which may be contributing to the patient s complaint of globus sensation DIAGNOSTIC IMPRESSION No aspiration was noted during this evaluation Penetration with cup sips of thin liquid The patient did cough during this evaluation but that was noted related to aspiration or penetration PROGNOSTIC IMPRESSION Based on this evaluation the prognosis for swallowing and safety is good PLAN Based on this evaluation and following recommendations are being made 1 The patient to take small bite and small sips to help decrease the risk of aspiration and penetration 2 The patient should remain upright at a 90 degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation 3 The patient should be referred to a gastroenterologist for further evaluation of her esophageal function The patient does not need any skilled speech therapy for her swallowing abilities at this time and she is discharged from my services Keywords speech language gastroesophageal reflux disorder cognitive linguistic deficit tia stroke swallowing function swallow study barium swallow study globus sensation esophageal penetration MEDICAL_TRANSCRIPTION,Description Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm Medical Specialty SOAP Chart Progress Notes Sample Name Wasp Sting SOAP Transcription SUBJECTIVE He is a 29 year old white male who is a patient of Dr XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm He says that he has been stung by wasps before and had similar reactions He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past He has had a lot of swelling but no anaphylaxis type reactions in the past no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past no racing heart beat or anxiety feeling just a lot of localized swelling where the sting occurs OBJECTIVE Vitals His temperature is 98 4 Respiratory rate is 18 Weight is 250 pounds Extremities Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm extending up to the elbow He says that it is really not painful or anything like that It is really not all that red and no signs of infection at this time ASSESSMENT Wasp sting to the right wrist area PLAN 1 Solu Medrol 125 mg IM X 1 2 Over the counter Benadryl ice and elevation of that extremity 3 Follow up with Dr XYZ if any further evaluation is needed Keywords soap chart progress notes yellow jacket wasp wasp sting swelling solu medrol lot of swelling stung sting wasp MEDICAL_TRANSCRIPTION,Description Evaluation of possible tethered cord She underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age Medical Specialty SOAP Chart Progress Notes Sample Name Tethered Cord Evaluation Transcription REASON FOR VISIT The patient referred by Dr X for evaluation of her possible tethered cord HISTORY OF PRESENT ILLNESS Briefly she is a 14 year old right handed female who is in 9th grade who underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age The last surgery was in 03 95 She did well however in the past several months has had some leg pain in both legs out laterally worsening at night and requiring Advil Motrin as well as Tylenol PM Denies any new bowel or bladder dysfunction or increased sensory loss She had some patchy sensory loss from L4 to S1 MEDICATIONS Singulair for occasional asthma FINDINGS She is awake alert and oriented x 3 Pupils equal and reactive EOMs are full Motor is 5 out of 5 She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus There is no evidence of clonus There is diminished sensation from L4 to S1 having proprioception ASSESSMENT AND PLAN Possible tethered cord I had a thorough discussion with the patient and her parents I have recommended a repeat MRI scan The prescription was given today MRI of the lumbar spine was just completed I would like to see her back in clinic We did discuss the possible symptoms of this tethering Keywords soap chart progress notes tethering lipomyomeningocele repair sensory loss tethered cord mri cord lipomyomeningocele MEDICAL_TRANSCRIPTION,Description Sore throat Upper respiratory infection Medical Specialty SOAP Chart Progress Notes Sample Name URI SOAP Transcription SUBJECTIVE Mom brings patient in today because of sore throat starting last night Eyes have been very puffy He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday He has had low grade fever and just felt very run down appearing very tired He is still eating and drinking well and his voice has been hoarse but no coughing No shortness of breath vomiting diarrhea or abdominal pain PAST MEDICAL HISTORY Unremarkable There is no history of allergies He does have some history of some episodes of high blood pressure and his weight is up about 14 pounds from the last year FAMILY HISTORY Noncontributory No one else at home is sick OBJECTIVE General A 13 year old male appearing tired but in no acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally gray in color Good light reflex Oropharynx pink and moist No erythema or exudate Some drainage is seen in the posterior pharynx Nares Swollen red No drainage seen No sinus tenderness Eyes are clear Chest Respirations are regular and nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry and pink moist mucous membranes No rash LABORATORY Strep test is negative Strep culture is negative RADIOLOGY Water s View of the sinuses is negative for any sinusitis or acute infection ASSESSMENT Upper respiratory infection PLAN At this point just treat symptomatically I gave him some samples of Levall for the congestion and as an expectorant Push fluids and rest May use ibuprofen or Tylenol for discomfort Keywords soap chart progress notes soap uri upper respiratory infection water s view congestion light reflex sore throat respiratory strep infection MEDICAL_TRANSCRIPTION,Description Postoperative day 1 total abdominal hysterectomy Normal postoperative course Medical Specialty SOAP Chart Progress Notes Sample Name Total Abdominal Hysterectomy Followup Transcription POSTOPERATIVE DAY 1 TOTAL ABDOMINAL HYSTERECTOMY SUBJECTIVE The patient is alert and oriented x3 and sitting up in bed The patient has been ambulating without difficulty The patient is still NPO The patient denies any new symptomatology from 6 10 2009 The patient has complaints of incisional tenderness The patient was given a full explanation about her clinical condition and all her questions were answered OBJECTIVE VITAL SIGNS Afebrile now Other vital signs are stable GU Urinating through Foley catheter ABDOMEN Soft negative rebound EXTREMITIES Without Homans nontender BACK Without CVA tenderness GENITALIA Vagina slight spotting Wound dry and intact ASSESSMENT Normal postoperative course PLAN 1 Follow clinically 2 Continue present therapy 3 Ambulate with nursing assistance only Keywords soap chart progress notes postoperative course total abdominal hysterectomy postoperative MEDICAL_TRANSCRIPTION,Description The patient comes for three week postpartum checkup complaining of allergies Medical Specialty SOAP Chart Progress Notes Sample Name Three Week Postpartum Checkup Transcription CHIEF COMPLAINT The patient comes for three week postpartum checkup complaining of allergies HISTORY OF PRESENT ILLNESS She is doing well postpartum She has had no headache She is breastfeeding and feels like her milk is adequate She has not had much bleeding She is using about a mini pad twice a day not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish She has not yet had sexual intercourse She does complain that she has had a little pain with the bowel movement and every now and then she notices a little bright red bleeding She has not been particularly constipated but her husband says she is not eating her vegetables like she should Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes runny nose sneezing and kind of a pressure sensation in her ears MEDICATIONS Prenatal vitamins ALLERGIES She thinks to Benadryl FAMILY HISTORY Mother is 50 and healthy Dad is 40 and healthy Half sister age 34 is healthy She has a sister who is age 10 who has some yeast infections PHYSICAL EXAMINATION VITALS Weight 124 pounds Blood pressure 96 54 Pulse 72 Respirations 16 LMP 10 18 03 Age 39 HEENT Head is normocephalic Eyes EOMs intact PERRLA Conjunctiva clear Fundi Discs flat cups normal No AV nicking hemorrhage or exudate Ears TMs intact Mouth No lesion Throat No inflammation She has allergic rhinitis with clear nasal drainage clear watery discharge from the eyes Abdomen Soft No masses Pelvic Uterus is involuting Rectal She has one external hemorrhoid which has inflamed Stool is guaiac negative and using anoscope no other lesions are identified ASSESSMENT PLAN Satisfactory three week postpartum course seasonal allergies We will try Patanol eyedrops and Allegra 60 mg twice a day She was cautioned about the possibility that this may alter her milk supply She is to drink extra fluids and call if she has problems with that We will try ProctoFoam HC For the hemorrhoids also increase the fiber in her diet That prescription was written as well as one for Allegra and Patanol She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy which is their ultimate plan for birth control and she anticipates that happening fairly soon She will call and return if she continues to have problems with allergies Meantime rechecking in three weeks for her final six week postpartum checkup Keywords soap chart progress notes checkup allergies postpartum complaining of allergies seasonal allergies postpartum checkup MEDICAL_TRANSCRIPTION,Description Patient with immune thrombocytopenia Medical Specialty SOAP Chart Progress Notes Sample Name Thrombocytopenia SOAP Note Transcription SUBJECTIVE I am following the patient today for immune thrombocytopenia Her platelets fell to 10 on 01 09 07 and shortly after learning of that result I increased her prednisone to 60 mg a day Repeat on 01 16 07 revealed platelets up at 43 No bleeding problems have been noted I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day The patient had been on 20 mg every other day at least for a while and her platelets hovered at least above 20 or so PHYSICAL EXAMINATION Vitals As in chart The patient is alert pleasant and cooperative She is in no apparent distress The petechial areas on her legs have resolved ASSESSMENT AND PLAN Patient with improvement of her platelet count on burst of prednisone We will decrease her prednisone to 40 mg for 3 days then go down to 20 mg a day Basically thereafter over time I may try to sneak it back a little bit further She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D We will arrange to have a CBC drawn weekly Keywords soap chart progress notes platelets platelet count thrombocytopenia prednisone MEDICAL_TRANSCRIPTION,Description Persistent frequency and urgency in a patient with a history of neurogenic bladder and history of stroke Medical Specialty SOAP Chart Progress Notes Sample Name Urinary Frequency Urgency Followup Transcription HISTORY OF PRESENT ILLNESS This is a 55 year old female with a history of stroke who presents today for followup of frequency and urgency with urge incontinence This has been progressively worsening and previously on VESIcare with no improvement She continues to take Enablex 50 mg and has not noted any improvement of her symptoms The nursing home did not do a voiding diary She is accompanied by her power of attorney No dysuria gross hematuria fever or chills No bowel issues and does use several Depends a day Recent urodynamics in April 2008 here in the office revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes and cystoscopy was unremarkable IMPRESSION Persistent frequency and urgency in a patient with a history of neurogenic bladder and history of stroke This has not improved on VESIcare as well as Enablex Options are discussed We discussed other options of pelvic floor rehabilitation InterStim by Dr X as well as more invasive procedure The patient and the power of attorney would like him to proceed with meeting Dr X to discuss InterStim which was briefly reviewed here today and brochure for this is provided today Prior to discussion the nursing home will do an extensive voiding diary for one week while she is on Enablex and if this reveals no improvement the patient will be started on Ventura twice daily and prescription is provided They will see Dr X with a prior voiding diary which is again discussed All questions answered PLAN As above the patient will be scheduled to meet with Dr X to discuss option of InterStim and will be accompanied by her power of attorney In the meantime Sanctura prescription is provided and voiding diaries are provided All questions answered Keywords soap chart progress notes neurogenic bladder urge incontinence urgency frequency vesicare enablex persistent frequency and urgency frequency and urgency persistent frequency voiding diary voiding MEDICAL_TRANSCRIPTION,Description The patient noted for improving retention of urine postop vaginal reconstruction very concerned of possible vaginal prolapse Medical Specialty SOAP Chart Progress Notes Sample Name Urinary Retention Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup No dysuria gross hematuria fever chills She continues to have urinary incontinence especially while changing from sitting to standing position as well as urge incontinence She is voiding daytime every 1 hour in the morning especially after taking Lasix which tapers off in the afternoon nocturia time 0 No incontinence No straining to urinate Good stream emptying well No bowel issues however she also indicates that while using her vaginal cream she has difficulty doing this as she feels protrusion in the vagina and very concerned if she has a prolapse IMPRESSION 1 The patient noted for improving retention of urine postop vaginal reconstruction very concerned of possible vaginal prolapse especially while using the cream 2 Rule out ascites with no GI issues other than lower extremity edema PLAN Following a detailed discussion with the patient she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily She will follow up next week request Dr X to do a pelvic exam and in the meantime she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention All questions answered Keywords soap chart progress notes urinary retention dysuria gross hematuria postop vaginal reconstruction vaginal reconstruction vaginal prolapse urinary retention prolapse vaginal incontinence MEDICAL_TRANSCRIPTION,Description He got addicted to drugs He decided it would be a good idea to get away from the bad crowd and come up and live with his mom Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Substance Abuse Transcription SUBJECTIVE This patient presents to the office today with his mom for checkup He used to live in the city He used to go to college down in the city He got addicted to drugs He decided it would be a good idea to get away from the bad crowd and come up and live with his mom He has a history of doing heroin He was injecting into his vein He was seeing a physician in the city They were prescribing methadone for some time He says that did help He was on 10 mg of methadone He was on it for three to four months He tried to wean down on the methadone a couple of different times but failed He has been intermittently using heroin He says one of the big problems is that he lives in a household full of drug users and he could not get away from it All that changed now that he is living with his mom The last time he did heroin was about seven to eight days ago He has not had any methadone in about a week either He is coming in today specifically requesting methadone He also admits to being depressed He is sad a lot and down He does not have much energy He does not have the enthusiasm He denies any suicidal or homicidal ideations at the present time I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms His past medical history is significant for no medical problems Surgical history he voluntarily donated his left kidney Family and social history were reviewed per the nursing notes His allergies are no known drug allergies Medications he takes no medications regularly OBJECTIVE His weight is 164 pounds blood pressure 108 60 pulse 88 respirations 16 and temperature was not taken General He is nontoxic and in no acute distress Psychiatric Alert and oriented times 3 Skin I examined his upper extremities He showed me his injection sites I can see marks but they seem to be healing up nicely I do not see any evidence of cellulitis There is no evidence of necrotizing fasciitis ASSESSMENT Substance abuse PLAN I had a long talk with the patient and his mom I am not prescribing him any narcotics or controlled substances I am not in the practice of trading one addiction for another It has been one week without any sort of drugs at all I do not think he needs weaning I think right now it is mostly psychological although there still could be some residual physical addiction However once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time I do believe that his depression needs to be treated I gave him fluoxetine 20 mg one tablet daily I discussed the side effects in detail I did also warn him that all antidepressant medications carry an increased risk of suicide If he should start to feel any of these symptoms he should call 911 or go to the emergency room immediately If he has any problems or side effects he was also directed to call me here at the office After hours he can go to the emergency room or call 911 I am going to see him back in three weeks for the depression I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group We are unable to make a referral for him to do that He has to call on his own He has no insurance However I think fluoxetine is very affordable He can get it for 4 per month at Wal Mart His mom is going to keep an eye on him as well He is going to be staying there It sounds like he is looking for a job Keywords soap chart progress notes addicted to drugs substance abuse abuse heroin methadone MEDICAL_TRANSCRIPTION,Description The patient is admitted for shortness of breath continues to do fairly well The patient has chronic atrial fibrillation on anticoagulation INR of 1 72 The patient did undergo echocardiogram which shows aortic stenosis severe The patient does have an outside cardiologist Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Shortness of Breath Transcription SUBJECTIVE The patient is admitted for shortness of breath continues to do fairly well The patient has chronic atrial fibrillation on anticoagulation INR of 1 72 The patient did undergo echocardiogram which shows aortic stenosis severe The patient does have an outside cardiologist I understand she was scheduled to undergo workup in this regard PHYSICAL EXAMINATION VITAL SIGNS Pulse of 78 and blood pressure 130 60 LUNGS Clear HEART A soft systolic murmur in the aortic area ABDOMEN Soft and nontender EXTREMITIES No edema IMPRESSION 1 Status shortness of breath responding well to medical management 2 Atrial fibrillation chronic on anticoagulation 3 Aortic stenosis RECOMMENDATIONS 1 Continue medications as above 2 The patient would like to follow with her cardiologist regarding aortic stenosis She may need a surgical intervention in this regard which I explained to her The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days In the interim if she changes her mind or if she has any concerns I have requested to call me back Keywords soap chart progress notes shortness of breath medical management atrial fibrillation aortic stenosis atrial fibrillation breath stenosis cardiologist aortic anticoagulation inr MEDICAL_TRANSCRIPTION,Description She is a 79 year old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago The patient has required conversion to an open procedure due to difficult anatomy Her postoperative course has been lengthened due to a prolonged ileus which resolved with tetracycline and Reglan The patient is starting to improve gain more strength She is tolerating her regular diet Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Cholecystitis Transcription SUBJECTIVE She is a 79 year old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago The patient has required conversion to an open procedure due to difficult anatomy Her postoperative course has been lengthened due to a prolonged ileus which resolved with tetracycline and Reglan The patient is starting to improve gain more strength She is tolerating her regular diet PHYSICAL EXAMINATION VITAL SIGNS Today her temperature is 98 4 heart rate 84 respirations 20 and BP is 140 72 LUNGS Clear to auscultation No wheezes rales or rhonchi HEART Regular rhythm and rate ABDOMEN Soft less tender LABORATORY DATA Her white count continues to come down Today it is 11 6 H H of 8 8 and 26 4 platelets 359 000 We have ordered type and cross for 2 units of packed red blood cells If it drops below 25 she will receive a transfusion Her electrolytes today show a glucose of 107 sodium 137 potassium 4 0 chloride 103 2 bicarbonate 29 7 Her AST is 43 ALT is 223 her alkaline phosphatase is 214 and her bilirubin is less than 0 10 ASSESSMENT AND PLAN She had a bowel movement today and is continuing to improve I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count Keywords soap chart progress notes laparoscopic cholecystectomy anatomy acute cholecystitis prolonged ileus white count cholecystitis MEDICAL_TRANSCRIPTION,Description Pulmonary disorder with lung mass pleural effusion and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder The patient is admitted for lung mass and also pleural effusion The patient had a chest tube placement which has been taken out The patient has chronic atrial fibrillation on anticoagulation Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Lung Mass Transcription SUBJECTIVE The patient is admitted for lung mass and also pleural effusion The patient had a chest tube placement which has been taken out The patient has chronic atrial fibrillation on anticoagulation The patient is doing fairly well This afternoon she called me because heart rate was in the range of 120 to 140 The patient is lying down She does have shortness of breath but denies any other significant symptoms PAST MEDICAL HISTORY History of mastectomy chest tube placement and atrial fibrillation chronic MEDICATIONS 1 Cardizem which is changed to 60 mg p o t i d 2 Digoxin 0 25 mg daily 3 Coumadin adjusted dose 4 Clindamycin PHYSICAL EXAMINATION VITAL SIGNS Pulse 122 and blood pressure 102 68 LUNGS Air entry decreased HEART PMI is displaced S1 and S2 are irregular ABDOMEN Soft and nontender IMPRESSION 1 Pulmonary disorder with lung mass 2 Pleural effusion 3 Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder RECOMMENDATIONS 1 From cardiac standpoint follow with pulmonary treatment 2 The patient has an INR of 2 09 She is on anticoagulation Atrial fibrillation is chronic with the rate increased Adjust the medications accordingly as above Keywords soap chart progress notes lung mass pleural effusion chest tube placement chest tube pulmonary disorder atrial fibrillation chest anticoagulation effusion lung pulmonary atrial fibrillation MEDICAL_TRANSCRIPTION,Description Numbness and tingling in the right upper extremity intermittent and related to the positioning of the wrist Carpal tunnel syndrome suspected Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Numbness Tingling Transcription SUBJECTIVE This patient presents to the office today because of some problems with her right hand It has been going tingling and getting numb periodically over several weeks She just recently moved her keyboard down at work She is hoping that will help She is worried about carpal tunnel She does a lot of repetitive type activities It is worse at night If she sleeps on it a certain way she will wake up and it will be tingling then she can usually shake out the tingling but nonetheless it is very bothersome for her It involves mostly the middle finger although she says it also involves the first and second digits on the right hand She has some pain in her thumb as well She thinks that could be arthritis OBJECTIVE Weight 213 2 pounds blood pressure 142 84 pulse 92 respirations 16 General The patient is nontoxic and in no acute distress Musculoskeletal The right hand was examined It appears to be within normal limits and the appearance is similar to the left hand She has good and equal grip strength noted bilaterally She has negative Tinel s bilaterally She has a positive Phalen s test The fingers on the right hand are neurovascularly intact with a normal capillary refill ASSESSMENT Numbness and tingling in the right upper extremity intermittent and related to the positioning of the wrist I suspect carpal tunnel syndrome PLAN The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock up wrist splint We are going to try this for two weeks and if the condition is still present then we are going to proceed with EMG test at that time She is going to let me know While she is here I am going to also get her the blood test she needs for her diabetes I am noting that her blood pressure is elevated but improved from the last visit I also noticed that she has lost a lot of weight She is working on diet and exercise and she is doing a great job Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve Keywords soap chart progress notes tinel s phalen s positioning of the wrist numbness and tingling carpal tunnel syndrome carpal tunnel numbness tingling MEDICAL_TRANSCRIPTION,Description MRI demonstrated right contrast enhancing temporal mass Medical Specialty SOAP Chart Progress Notes Sample Name SOAP Temporal Mass Transcription SUBJECTIVE The patient is a 55 year old African American male that was last seen in clinic on 07 29 2008 with diagnosis of new onset seizures and an MRI scan which demonstrated right contrast enhancing temporal mass Given the characteristics of this mass and his new onset seizures it is significantly concerning for a high grade glioma OBJECTIVE The patient is alert and oriented times three GCS of 15 Cranial nerves II to XII are grossly intact Motor exam demonstrates 5 5 strength in all four extremities Sensation is intact to light touch pain temperature and proprioception Cerebellar exam is intact Gait is normal and tandem on heels and toes Speech is appropriate Judgment is intact Pupils are equal and reactive to light ASSESSMENT AND PLAN The patient is a 55 year old African American male with a new diagnosis of rim enhancing right temporal mass Given the characteristics of the MRI scan it is highly likely that he demonstrates high grade glioma and concerning for glioblastoma multiforme We have discussed in length the possible benefits of biopsy surgical resection medical management as well as chemotherapy radiation treatments and doing nothing Given the high probability that the mass represents a high grade glioma the patient after weighing the risks and the benefits of surgery has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high grade glioma The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor He agrees that he will be n p o after mid night on Wednesday night He is sent for preoperative assessment with the Anesthesiology tomorrow morning He has undergone vocational rehab assessment Keywords soap chart progress notes new onset seizures temporal mass cerebellar exam glioma temporal massNOTE MEDICAL_TRANSCRIPTION,Description The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission Medical Specialty SOAP Chart Progress Notes Sample Name Shortness Of Breath Progress Note Transcription She was evaluated this a m and was without any significant clinical change Her white count has been improving and down to 12 000 A chest x ray obtained today showed some bilateral infiltrates but no acute cardiopulmonary change There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia She has been on Zosyn for the infection Throughout her hospitalization we have been trying to adjust her pain medications She states that the methadone did not work for her She was immune to oxycodone She had been on tramadol before and was placed back on that There was some question that this may have been causing some dizziness She also was on clonazepam and alprazolam for the underlying bipolar disorder Apparently her husband was in this afternoon He had a box of her pain medications It is unclear whether she took a bunch of these or precisely what happened I was contacted that she was less responsive She periodically has some difficulty to arouse due to pain medications which she has been requesting repeatedly though at times does not appear to have objective signs of ongoing pain The nurse found her and was unable to arouse her at this point There was a concern that she had taken some medications from home She was given Narcan and appeared to come around some Breathing remained somewhat labored and she had some diffuse scattered rhonchi which certainly changed from this a m Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity With O2 via mask oxygenation was stable at 90 to 95 after initial hypoxia was noted A chest x ray was obtained at this time An ECG was obtained which shows a sinus tachycardia noted to have ischemic abnormalities In light of the acute decompensation she was then transferred to the ICU We will continue the IV Zosyn Respiratory protocol with respiratory management Continue alprazolam p r n but avoid if she appears sedated We will attempt to avoid additional pain medications but we will continue with the Dilaudid for time being I suspect she will need something to control her bipolar disorder Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission At this juncture she does not appear to need an intubation Pending chest x ray she may require additional IV furosemide Keywords soap chart progress notes shortness of breath pulmonary medicine bipolar disorder icuNOTE MEDICAL_TRANSCRIPTION,Description Followup of moderate to severe sleep apnea The patient returns today to review his response to CPAP Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction Medical Specialty SOAP Chart Progress Notes Sample Name Sleep Apnea Transcription REASON FOR VISIT Mr ABC is a 30 year old man who returns in followup of his still moderate to severe sleep apnea He returns today to review his response to CPAP HISTORY OF PRESENT ILLNESS The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner He was found to have moderate to severe sleep apnea predominantly hypopnea was treated with nasal CPAP at 10 cm H2O nasal pressure He has been on CPAP now for several months and returns for followup to review his response to treatment The patient reports that the CPAP has limited his snoring at night Occasionally his bed partner wakes him in the middle of the night when the mask comes off and reminds him to replace the mask The patient estimates that he uses the CPAP approximately 5 to 7 nights per week and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night The patient s sleep pattern consists of going to bed between 11 00 and 11 30 at night and awakening between 6 to 7 a m on weekdays On weekends he might sleep until 8 to 9 a m On Saturday night he might go to bed approximately mid night As noted the patient is not snoring on CPAP He denies much tossing and turning and does not awaken with the sheets in disarray He awakens feeling relatively refreshed In the past few months the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures He continues to work at Smith Barney in downtown Baltimore He generally works from 8 to 8 30 a m until approximately 5 to 5 30 p m He is involved in training purpose to how to sell managed funds and accounts The patient reports no change in daytime stamina He has no difficulty staying awake during the daytime or evening hours The past medical history is notable for allergic rhinitis MEDICATIONS He is maintained on Flonase and denies much in the way of nasal symptoms ALLERGIES Molds FINDINGS Vital signs Blood pressure 126 75 pulse 67 respiratory rate 16 weight 172 pounds height 5 feet 9 inches temperature 98 4 degrees and SaO2 is 99 on room air at rest The patient has adenoidal facies as noted previously Laboratories The patient forgot to bring his smart card in for downloading today ASSESSMENT Moderate to severe sleep apnea I have recommended the patient continue CPAP indefinitely He will be sending me his smart card for downloading to determine his CPAP usage pattern In addition he will continue efforts to maintain his weight at current levels or below Should he succeed in reducing further we might consider re running a sleep study to determine whether he still requires a CPAP PLANS In the meantime if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction He will be returning for routine followup in 6 months Keywords soap chart progress notes daytime stamina fiberoptic ent exam moderate to severe smart card sleep apnea cpap apnea sleep MEDICAL_TRANSCRIPTION,Description Refractory hypertension much improved history of cardiac arrhythmia and history of pacemaker secondary to AV block history of GI bleed and history of depression Medical Specialty SOAP Chart Progress Notes Sample Name Refractory Hypertension Followup Transcription PROBLEM LIST 1 Refractory hypertension much improved 2 History of cardiac arrhythmia and history of pacemaker secondary to AV block 3 History of GI bleed in 1995 4 History of depression HISTORY OF PRESENT ILLNESS This is a return visit to the renal clinic for this patient She is an 85 year old woman with history as noted above Her last visit was approximately four months ago Since that time the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously She is not reporting any untoward side effect She is not having weakness dizziness lightheadedness nausea vomiting constipation diarrhea abdominal pain chest pain shortness of breath or difficulty breathing She has no orthopnea Her exercise capacity is about the same The only problem she has is musculoskeletal and that pain in the right buttock she thinks originating from her spine No history of extremity pain CURRENT MEDICATIONS 1 Triamterene hydrochlorothiazide 37 5 25 mg 2 Norvasc 10 mg daily 3 Atenolol 50 mg a day 4 Atacand 32 mg a day 5 Cardura 4 mg a day PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 2 pulse 47 respirations 16 and blood pressure 157 56 THORAX Revealed lungs that are clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 I could not hear murmur today ABDOMEN Above plane but nontender EXTREMITIES Revealed no edema ASSESSMENT This is a return visit for this patient who has refractory hypertension This seems to be doing very well given her current blood pressure reading at least much improved from what she had been previously We had discussed with her in the past beginning to see an internist at the senior center She apparently had an appointment scheduled and it was missed We are going to reschedule that today given her overall state of well being and the fact that she has no evidence of GFR that is greater than 60 PLAN The plan will be for her to follow up at the senior center for her routine health care and should the need arise for further management of blood pressure a referral back to us In the meantime we will discharge her from our practice Should there be confusion or difficulty getting in the senior center we can always see her back in followup Keywords soap chart progress notes cardiac arrhythmia av block refractory hypertension blood pressure pacemaker atenolol arrhythmia MEDICAL_TRANSCRIPTION,Description A 33 year old black male with main complaint of sexual dysfunction would like to try Cialis Medical Specialty SOAP Chart Progress Notes Sample Name Sexual Dysfunction Chart Note Transcription SUBJECTIVE The patient is a 33 year old black male who comes in to the office today main complaint of sexual dysfunction Patient reports that he would like to try Cialis to see if it will improve his erectile performance Patient states that he did a quiz on line at the Cialis web site and did not score in the normal range so he thought he should come in Patient states that perhaps his desire has been slightly decreased but that has not been the primary problem In discussing with me directly patient primarily expresses that he would like to have his erections last longer However looking at the quiz as he filled it out he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration However he only reports that it is slightly difficult to maintain the erection until completion of intercourse Patient has no significant past medical history He has never had any previous testicular infections He denies any history of injuries to the groin and he has never been told that he has a hernia CURRENT MEDICATIONS None ALLERGIES No drug allergies SOCIAL Only occasionally drinks alcohol and he is a nonsmoker He currently is working as a nurse aid second shift at a nursing home He states that he did not enroll in Wichita State this semester Stating he just was tired and wanted to take some time off He states he is in a relationship with one partner and denies any specific stress in the relationship OBJECTIVE General He appears in no distress Vital Signs Blood pressure With large cuff is 120 90 Lungs Clear to auscultation Cardiovascular Normal S1 S2 without murmur Abdomen Soft nontender Femoral pulses are 2 GU Testicles descended bilaterally No evidence of masses No evidence of inguinal hernias ASSESSMENT Sexual dysfunction PLAN We will check a free and total testosterone level as he does note some diminished desire He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful He will follow up here p r n Lastly I did give him a blood pressure recording card as his blood pressure is borderline today He will have that checked weekly at his workplace and follow up if they remain elevated Keywords soap chart progress notes cialis able to maintain erectile sexual activity sexual dysfunction blood pressure maintain dysfunction erections sexual MEDICAL_TRANSCRIPTION,Description Epicondylitis history of lupus Injected with 40 mg of Kenalog mixed with 1 cc of lidocaine Medical Specialty SOAP Chart Progress Notes Sample Name Rheumatology Progress Note Transcription SUBJECTIVE The patient is here for a follow up The patient has a history of lupus currently on Plaquenil 200 mg b i d Eye report was noted and appreciated The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago She denied having any trauma She states that the pain is bothering her She denies having any fevers chills or any joint effusion or swelling at this point She noted also that there is some increase in her hair loss in the recent times OBJECTIVE The patient is alert and oriented General physical exam is unremarkable Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows no effusion Hand examination is unremarkable today The rest of the musculoskeletal exam is unremarkable ASSESSMENT Epicondylitis both elbows possibly secondary to lupus flare up PLAN We will inject both elbows with 40 mg of Kenalog mixed with 1 cc of lidocaine The posterior approach was chosen under sterile conditions The patient tolerated both procedures well I will obtain CBC and urinalysis today If the patient s pain does not improve I will consider adding methotrexate to her therapy Sample Doctor M D Keywords soap chart progress notes rheumatology 1 cc of lidocaine epicondylitis kenalog kenalog mixed with 1 cc of lidocaine progress note aches and pains history of lupus lidocaine lupus methotrexate kenalog mixed injected MEDICAL_TRANSCRIPTION,Description Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema Medical Specialty SOAP Chart Progress Notes Sample Name Pulmonary Medicine Clinic Followup Transcription SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema She was last seen in the clinic in March 2004 Since that time she has been hospitalized for psychiatric problems and now is in a nursing facility She is very frustrated with her living situation and would like to return to her own apartment however some believes she is to ill to care for herself At the present time respiratory status is relatively stable She is still short of breath with activity but all in all her pulmonary disease has not changed significantly since her last visit She does have occasional cough and a small amount of sputum production No fever or chills No chest pains CURRENT MEDICATIONS The patient s current medications are as outlined ALLERGIES TO MEDICATIONS Erythromycin REVIEW OF SYSTEMS Significant for problems with agitated depression Her respiratory status is unchanged as noted above EXAMINATION General The patient is in no acute distress Vital signs Blood pressure is 152 80 pulse 80 and respiratory rate 16 HEENT Nasal mucosa was mild to moderately erythematous and edematous Oropharynx was clear Neck Supple without palpable lymphadenopathy Chest Chest demonstrates decreased breath sounds throughout all lung fields coarse but relatively clear Cardiovascular Distant heart tones Regular rate and rhythm Abdomen Soft and nontender Extremities Without edema Oxygen saturation was checked today on room air at rest it was 90 ASSESSMENT 1 Chronic obstructive pulmonary disease emphysema severe but stable 2 Mild hypoxemia however oxygen saturation at rest is stable without supplemental oxygen 3 History of depression and schizophrenia PLAN At this point I have recommended that she continue current respiratory medicine I did suggest that she would not use her oxygen when she is simply sitting watching television or reading I have recommended that she use it with activity and at night I spoke with her about her living situation Encouraged her to speak with her family as well as primary care physician about making efforts for her to return to her apartment Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be Keywords soap chart progress notes respiratory copd chronic obstructive pulmonary disease pulmonary medicine clinic depression emphysema followup hypoxemia oxygen schizophrenia oxygen saturation pulmonary medicine medicine clinic chest medicine pulmonary MEDICAL_TRANSCRIPTION,Description Followup left sided rotator cuff tear and cervical spinal stenosis Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis Medical Specialty SOAP Chart Progress Notes Sample Name Rotator Cuff Tear Transcription REASON FOR VISIT Followup left sided rotator cuff tear and cervical spinal stenosis HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy I had last seen her on 06 21 07 At that time she had been referred to me Dr X and Dr Y for evaluation of her left sided C6 radiculopathy She also had a significant rotator cuff tear and is currently being evaluated for left sided rotator cuff repair surgery I believe on approximately 07 20 07 At our last visit I only had a report of her prior cervical spine MRI I did not have any recent images I referred her for cervical spine MRI and she returns today She states that her symptoms are unchanged She continues to have significant left sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr Y She also has a second component of pain which radiates down the left arm in a C6 distribution to the level of the wrist She has some associated minimal weakness described in detail in our prior office note No significant right upper extremity symptoms No bowel bladder dysfunction No difficulty with ambulation FINDINGS On examination she has 4 plus over 5 strength in the left biceps and triceps muscle groups 4 out of 5 left deltoid 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities Light touch sensation is minimally decreased in the left C6 distribution otherwise intact Biceps and brachioradialis reflexes are 1 plus Hoffmann sign normal bilaterally Motor strength is 5 out of 5 in all muscle groups in lower extremities Hawkins and Neer impingement signs are positive at the left shoulder An EMG study performed on 06 08 07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity Cervical spine MRI dated 06 28 07 is reviewed It is relatively limited study due to artifact He does demonstrate evidence of minimal to moderate stenosis at the C5 C6 level but without evidence of cord impingement or cord signal change There appears to be left paracentral disc herniation at the C5 C6 level although axial T2 weighted images are quite limited ASSESSMENT AND PLAN Ms ABC s history physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis I agree with the plan to go ahead and continue with rotator cuff surgery With regard to the radiculopathy I believe this can be treated non operatively to begin with I am referring her for consideration of cervical epidural steroid injections The improvement in her pain may help her recover better from the shoulder surgery I will see her back in followup in 3 months at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine I will also be in touch with Dr Y to let him know this information prior to the surgery in several weeks Keywords soap chart progress notes upper extremity radiculopathy rotator cuff repair cervical spinal stenosis rotator cuff tear physical examination cuff impingement stenosis extremity surgery tear shoulder rotator cervical MEDICAL_TRANSCRIPTION,Description A 6 year old male with attention deficit hyperactivity disorder doing fairly well with the Adderall Medical Specialty SOAP Chart Progress Notes Sample Name Recheck of ADHD Meds Transcription SUBJECTIVE This is a 6 year old male who comes in rechecking his ADHD medicines We placed him on Adderall first time he has been on a stimulant medication last month Mother said the next day he had a wonderful improvement and he has been doing very well with the medicine She has two concerns It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in It wears off about 2 and they have problems in the evening with him He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible The patient even commented that he thought he needed his medication PAST HISTORY Reviewed from appointment on 08 16 2004 CURRENT MEDICATIONS He is on Adderall XR 10 mg once daily ALLERGIES To medicines are none FAMILY AND SOCIAL HISTORY Reviewed from appointment on 08 16 2004 REVIEW OF SYSTEMS He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well sleeping okay Review of systems is otherwise negative OBJECTIVE Weight is 46 5 pounds which is down just a little bit from his appointment last month He was 49 pounds but otherwise fairly well controlled not all that active in the exam room Physical exam itself was deferred today because he has otherwise been very healthy ASSESSMENT At this point is attention deficit hyperactivity disorder doing fairly well with the Adderall PLAN Discussed with mother two options Switch him to the Ritalin LA which I think has better release of the medicine early in the morning or to increase his Adderall dose As far as the afternoon if she really wanted him to be on the medication we will do a small dose of the Adderall which she would prefer So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon Mother is to watch his diet We would like to recheck his weight if he is doing very well in two months But if there are any problems especially in the morning then we would do the Ritalin LA Mother understands and will call if there are problems Approximately 25 minutes spent with patient all in discussion Keywords soap chart progress notes adhd attention deficit hyperactivity disorder adderall xr recheck medicines adderall MEDICAL_TRANSCRIPTION,Description Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis Medical Specialty SOAP Chart Progress Notes Sample Name Pulmonary Followup Note Transcription SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis She was last seen in the Pulmonary Medicine Clinic in January 2004 Since that time her respiratory status has been quite good She has had no major respiratory difficulties however starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort She denies any problems with cough or sputum production No fevers or chills Recently she has had a bit more problems with fatigue For the most part she has had no pulmonary limitations to her activity CURRENT MEDICATIONS Synthroid 0 112 mg daily Prilosec 20 mg daily prednisone she was 2 5 mg daily but discontinued this on 06 16 2004 Plaquenil 200 mg b i d Imuran 100 mg daily Advair one puff b i d Premarin 0 3 mg daily Lipitor 10 mg Monday through Friday Actonel 35 mg weekly and aspirin 81 mg daily She is also on calcium vitamin D vitamin E vitamin C and a multivitamin ALLERGIES Penicillin and also intolerance to shellfish REVIEW OF SYSTEMS Noncontributory except as outlined above EXAMINATION General The patient was in no acute distress Vital signs Blood pressure 122 60 pulse 72 and respiratory rate 16 HEENT Nasal mucosa was mild to moderately erythematous and edematous Oropharynx was clear Neck Supple without palpable lymphadenopathy Chest Chest demonstrates decreased breath sounds but clear Cardiovascular Regular rate and rhythm Abdomen Soft and nontender Extremities Without edema No skin lesions O2 saturation was checked at rest On room air it was 96 and on ambulation it varied between 94 and 96 Chest x ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis She has not had the previous chest x ray with which to compare however I did compare the markings was less prominent when compared with previous CT scan ASSESSMENT 1 Lupus with mild pneumonitis 2 Respiratory status is stable 3 Increasing back and joint pain possibly related to patient s lupus however in fact may be related to recent discontinuation of prednisone PLAN At this time I have recommended to continue her current medications We would like to see her back in approximately four to five months at which time I would like to recheck her pulmonary function test as well as check CAT scan At that point it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control Keywords soap chart progress notes pulmonary medicine clinic cat scan lupus respiratory status chest x ray interstitial disease lupus pneumonitis pneumonitis pulmonary function test pulmonary status respiratory difficulties chest x ray interstitial respiratory chest pulmonary MEDICAL_TRANSCRIPTION,Description A 16 year old male with Q fever endocarditis Medical Specialty SOAP Chart Progress Notes Sample Name Q Fever Endocarditis Transcription HISTORY OF PRESENT ILLNESS This is a follow up visit on this 16 year old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q fever endocarditis He is also taking digoxin aspirin warfarin and furosemide Mother reports that he does have problems with 2 3 loose stools per day since September but tolerates this relatively well This has not increased in frequency recently Mark recently underwent surgery at Children s Hospital and had on 10 15 2007 replacement of pulmonary homograft valve resection of a pulmonary artery pseudoaneurysm and insertion of Gore Tex membrane pericardial substitute He tolerated this procedure well He has been doing well at home since that time PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 5 pulse 84 respirations 19 blood pressure 101 57 weight 77 7 kg and height 159 9 cm GENERAL APPEARANCE Well developed well nourished slightly obese slightly dysmorphic male in no obvious distress HEENT Remarkable for the badly degenerated left lower molar Funduscopic exam is unremarkable NECK Supple without adenopathy CHEST Clear including the sternal wound CARDIOVASCULAR A 3 6 systolic murmur heard best over the upper left sternal border ABDOMEN Soft He does have an enlarged spleen however given his obesity I cannot accurately measure its size GU Deferred EXTREMITIES Examination of extremities reveals no embolic phenomenon SKIN Free of lesions NEUROLOGIC Grossly within normal limits LABORATORY DATA Doxycycline level obtained on 10 05 2007 as an outpatient was less than 0 5 Hydroxychloroquine level obtained at that time was undetectable Of note is that doxycycline level obtained while in the hospital on 10 21 2007 was 6 5 mcg mL Q fever serology obtained on 10 05 2007 was positive for phase I antibodies in 1 2 6 and phase II antibodies at 1 128 which is an improvement over previous elevated titers Studies on the pulmonary valve tissue removed at surgery are pending IMPRESSION Q fever endocarditis PLAN 1 Continue doxycycline and hydroxychloroquine I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications She assures me that he is compliant with his medications We will however repeat his hydroxychloroquine and doxycycline levels 2 Repeat Q fever serology 3 Comprehensive metabolic panel and CBC 4 Return to clinic in 4 weeks 5 Clotting times are being followed by Dr X Keywords soap chart progress notes q fever q fever endocarditis endocarditis doxycycline fever MEDICAL_TRANSCRIPTION,Description Moderately differentiated adenocarcinoma 1 enlarged prostate with normal seminal vesicles Medical Specialty SOAP Chart Progress Notes Sample Name Prostate Adenocarcinoma 3 Transcription PHYSICAL EXAMINATION The patient is a 63 year old executive who was seen by his physician for a company physical He stated that he was in excellent health and led an active life His physical examination was normal for a man of his age Chest x ray and chemical screening blood work were within normal limits His PSA was elevated IMAGING Chest x ray Normal CT scan of abdomen and pelvis No abnormalities LABORATORY PSA 14 6 PROCEDURES Ultrasound guided sextant biopsy of prostate Digital rectal exam performed at the time of the biopsy showed a 1 enlarged prostate with normal seminal vesicles PATHOLOGY Prostate biopsy Left apex adenocarcinoma moderately differentiated Gleason s score 3 4 7 10 Maximum linear extent in apex of tumor was 6 mm Left mid region prostate moderately differentiated adenocarcinoma Gleason s 3 2 5 10 Left base right apex and right mid region and right base negative for carcinoma TREATMENT The patient opted for low dose rate interstitial prostatic implants of I 125 It was performed as an outpatient on 8 10 Keywords soap chart progress notes sextant biopsy vesicles seminal apex interstitial prostatic implants moderately differentiated adenocarcinoma normal seminal vesicles enlarged prostate gleason s moderately differentiated prostate adenocarcinoma MEDICAL_TRANSCRIPTION,Description Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate Medical Specialty SOAP Chart Progress Notes Sample Name Prostate Adenocarcinoma 2 Transcription PHYSICAL EXAMINATION This 71 year old man went to his primary care physician for a routine physical His only complaints were nocturia times two and a gradual slowing down feeling The physical examination on 1 29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity R L PSA was elevated The differential diagnosis for the visit was abnormal prostate suggestive of CA IMAGING CT pelvis Irregular indentation of bladder Seminal vesicles enlarged Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus Impression prostatic malignancy with extracapsular extension and probable regional node metastasis Bone scan Negative for distant metastasis LABORATORY PSA 32 1 PROCEDURES Transrectal needle biopsy of prostate Pelvic lymphadenectomy and radical prostatectomy PATHOLOGY Prostate biopsy Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate Lymphadenectomy and prostatectomy Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa Therefore the radical prostatectomy was canceled Final pathology diagnosis Pelvic lymphadenectomy left obturator fossa single negative lymph node Right obturator fossa metastatic adenocarcinoma in 1 5 lymph nodes Largest involved node 1 5 cm TREATMENT Patient began external beam radiation therapy to the pelvis Keywords soap chart progress notes nocturia asymmetric prostate gland periprostatic metastasis poorly differentiated adenocarcinoma differentiated adenocarcinoma radical prostatectomy metastatic adenocarcinoma lymph nodes prostatectomy prostate lymphadenectomy adenocarcinoma MEDICAL_TRANSCRIPTION,Description Prostate gland showing moderately differentiated infiltrating adenocarcinoma Excised prostate including capsule pelvic lymph nodes seminal vesicles and small portion of bladder neck Medical Specialty SOAP Chart Progress Notes Sample Name Prostate Adenocarcinoma 4 Transcription PHYSICAL EXAMINATION Patient is a 46 year old white male seen for annual physical exam and had an incidental PSA elevation of 4 0 All other systems were normal PROCEDURES Sextant biopsy of the prostate Radical prostatectomy Excised prostate including capsule pelvic lymph nodes seminal vesicles and small portion of bladder neck PATHOLOGY Prostate biopsy Right lobe negative Left lobe small focus of adenocarcinoma Gleason s 3 3 in approximately 5 of the tissue Radical prostatectomy Negative lymph nodes Prostate gland showing moderately differentiated infiltrating adenocarcinoma Gleason 3 2 extending to the apex involving both lobes of the prostate mainly right Tumor overall involved less than 5 of the tissue Surgical margin was reported and involved at the apex The capsule and seminal vesicles were free DISCHARGE NOTE Patient has made good post op recovery other than mild urgency incontinence His post op PSA is 0 1 mg ml Keywords soap chart progress notes capsule bladder neck surgical margin moderately differentiated infiltrating adenocarcinoma pelvic lymph nodes prostate gland infiltrating adenocarcinoma radical prostatectomy seminal vesicles gleason s seminal vesicles adenocarcinoma prostate MEDICAL_TRANSCRIPTION,Description Complete urinary obstruction underwent a transurethral resection of the prostate adenocarcinoma of the prostate Medical Specialty SOAP Chart Progress Notes Sample Name Prostate Adenocarcinoma 1 Transcription HISTORY This 75 year old man was transferred from the nursing home where he lived to the hospital late at night on 4 11 through the Emergency Department in complete urinary obstruction After catheterization the patient underwent cystoscopy on 4 13 On 4 14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved Final diagnosis was adenocarcinoma of the prostate Because of his mental status and general debility the patient s family declined additional treatment LABORATORY None PROCEDURES Cystoscopy Blockage of the urethra by a markedly enlarged prostate Transurethral resection of prostate 45 grams of tissue were sent to the Pathology Department for analysis PATHOLOGY Well differentiated adenocarcinoma microacinar type in 1 of 25 chips of prostatic tissue Keywords soap chart progress notes urinary obstruction voiding resection of the prostate adenocarcinoma of the prostate complete urinary obstruction prostate adenocarcinoma transurethral resection cystoscopy transurethral resection prostate adenocarcinoma MEDICAL_TRANSCRIPTION,Description Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis Medical Specialty SOAP Chart Progress Notes Sample Name Progress Note Supraglottitis Transcription HISTORY A 59 year old male presents in followup after being evaluated and treated as an in patient by Dr X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis admitted on 05 23 2008 discharged on 05 24 2008 Please refer to chart for history and physical and review of systems and medical record PROCEDURES PERFORMED Fiberoptic laryngoscopy identifying about 30 positive Muller maneuver No supraglottic edema 2 4 tonsils with small tonsil cyst mid tonsil left IMPRESSION 1 Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis 2 Possible obstructive sleep apnea however the patient describes no known history of this phenomenon 3 Hypercholesterolemia 4 History of anxiety 5 History of coronary artery disease 6 Hypertension RECOMMENDATIONS Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr X Cultures are still pending and follow up with Dr X in the next few weeks for re evaluation I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this but we will leave this open for him to talk with Dr X on his followup and he will pay more attention on his sleep pattern Keywords soap chart progress notes acute supraglottic edema obstructive sleep apnea acute supraglottitis airway obstruction parapharyngeal cellulitis peritonsillar cellulitis supraglottic edema supraglottitis tonsils cellulitis MEDICAL_TRANSCRIPTION,Description Patient seen initially with epigastric and right upper quadrant abdominal pain nausea dizziness and bloating Medical Specialty SOAP Chart Progress Notes Sample Name Progress Note Liver Cirrhosis Transcription HISTORY OF PRESENT ILLNESS The patient is a 55 year old Hispanic male who was seen initially in the office February 15 2006 with epigastric and right upper quadrant abdominal pain nausea dizziness and bloating The patient at that time stated that he had established diagnosis of liver cirrhosis Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before Dr X in Las Cruces and his primary care physician in Silver City and unfortunately we did not get any information from anybody Also the patient had admission in Gila Medical Center with epigastric pain diarrhea and confusion He spent 3 days in the hospital He was followed by Dr X and unfortunately we also do not have the information of what was wrong with the patient From the patient s report he was diagnosed with some kind of viral infection At the time of admission he had a lot of epigastric pain nausea vomiting fever and chills PHYSICAL EXAMINATION VITAL SIGNS Weight 107 height 6 feet 1 inch blood pressure 128 67 heart rate 74 saturation 98 pain is 3 10 with localization of the pain in the epigastric area HEENT PERRLA EOM intact Oropharynx is clear of lesions NECK Supple No lymphadenopathy No thyromegaly LUNGS Clear to auscultation and percussion bilateral CARDIOVASCULAR Regular rate and rhythm No murmurs rubs or gallops ABDOMEN Not tender not distended Splenomegaly about 4 cm under the costal margin No hepatomegaly Bowel sounds present MUSCULOSKELETAL No cyanosis no clubbing no pitting edema NEUROLOGIC Nonfocal No asterixis No costovertebral tenderness PSYCHE The patient is oriented x4 alert and cooperative LABORATORY DATA We were able to collect lab results from Medical Center we got only CMP from the hospital which showed glucose level 79 BUN 9 creatinine 0 6 sodium 136 potassium 3 5 chloride 104 CO2 23 7 calcium 7 3 total protein 5 9 albumin 2 5 total bilirubin 5 63 His AST 56 ALT 37 alkaline phosphatase 165 and his ammonia level was 53 We do not have any other results back No hepatitis panels No alpha fetoprotein level The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive but we do not have this result despite calling medical records in the hospital to release this information ASSESSMENT AND PLAN The patient is a 55 year old with established diagnosis of liver cirrhosis unknown cause 1 Epigastric pain The patient had chronic pain syndrome he had multiple back surgeries and he has taken opiate for a prolonged period of time In the office twice the patient did not have any abdominal pain on physical exam His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously He probably requires increased level of pain control with increased dose of opiates which should be addressed with his primary care physician 2 End stage liver disease Of course we need to find out the cause of the liver cirrhosis We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before We do not have any information of any type of investigation in the past Again patient was seen by gastroenterologist already in Las Cruces Dr X The patient was advised to contact Dr X by himself to convince him to send available information because we already send release information form signed by the patient without any result It will be not reasonable to repeat unnecessary tests in that point in time We are waiting for the hepatitis panel and alpha fetoprotein level We will also need to get information about ultrasound which was done in Gila Medical Center but obviously no tumor was found on this exam of the liver We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B Until now we do not know exactly what the cause of the patient s end stage liver disease is and my differential diagnosis probably is hepatitis C The patient denied any excessive alcohol intake but I could not preclude alcohol related liver cirrhosis also We will need to look for nuclear antibody if it is not done before PSC is extremely unlikely but possible Wilson disease also possible diagnosis but again we first have to figure out if these tests were done for the patient or not Alpha1 antitrypsin deficiency will be extremely unlikely because the patient has no lung problem On his end stage liver disease we already know that he had low platelet count splenomegaly We know that his bilirubin is elevated and albumin is very low I suspect that at the time of admission to the hospital the patient presented with encephalopathy We do not know if INR was checked to look for coagulopathy The patient had an EGD in 2005 as well as colonoscopy in Silver City We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that At this point in time I recommended the patient to continue to take lactulose 50 mL 3 times daily The patient tolerated it well no diarrhea at this point in time I also recommended for him to contact his primary care physician for increased dose of opiates for him As a primary prophylaxis of GI bleeding in patient with end stage liver disease we will try to use Inderal The patient got a prescription for 10 mg pills He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25 from 75 to probably 60 58 The patient was educated how to use Inderal and he was explained why we decided to use this medication The patient will hold this medication if he is orthostatic or bradycardic Again the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above We also discussed nutrition issues The patient was provided information that his protein intake is supposed to be about 25 g per day He was advised not to over eat protein and advised not to starve He also was advised to stay away from alcohol His next visit is in 2 weeks with all results available Keywords soap chart progress notes abdominal pain nausea dizziness liver disease epigastric pain liver cirrhosis liver abdominal cirrhosis epigastric hepatitis MEDICAL_TRANSCRIPTION,Description Polycythemia rubra vera The patient is an 83 year old female with a history of polycythemia vera She comes in to clinic today for followup She has not required phlebotomies for several months Medical Specialty SOAP Chart Progress Notes Sample Name Polycythemia Rubra Vera Transcription CHIEF COMPLAINT Polycythemia rubra vera HISTORY OF PRESENT ILLNESS The patient is an 83 year old female with a history of polycythemia vera She comes in to clinic today for followup She has not required phlebotomies for several months The patient comes to clinic unaccompanied CURRENT MEDICATIONS Levothyroxine 200 mcg q d Nexium 40 mg q d Celebrex 200 mg q d vitamin D3 2000 IU q d aspirin 81 mg q d selenium 200 mg q d Aricept 10 mg q d Skelaxin 800 mg q d ropinirole 1 mg q d vitamin E 1000 IU q d vitamin C 500 mg q d flaxseed oil 100 mg daily fish oil 100 units q d Vicodin q h s and stool softener q d ALLERGIES Penicillin REVIEW OF SYSTEMS The patient s chief complaint is her weight She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key She has questions as to whether or not there would be any contra indications to her going on the diet Otherwise she feels great She had family reunion in Iowa once in four days out there She continues to volunteer Hospital and is walking and enjoying her summer She denies any fevers chills or night sweats She has some mild constipation problem but has had under control The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords soap chart progress notes polycythemia rubra vera phlebotomy hematocrit polycythemia MEDICAL_TRANSCRIPTION,Description This patient is one day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia She has had an uneventful postoperative night Medical Specialty SOAP Chart Progress Notes Sample Name Postop Parathyroid Exploration Parathyroidectomy Transcription SUMMARY This patient is one day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia She has had an uneventful postoperative night She put out 1175 mL of urine since surgery Her incision looks good IV site and extremities are unremarkable LABORATORY DATA Her calcium level was 7 5 this morning She has been on three Tums orally b i d and I am increasing three Tums orally q i d before meals and at bedtime PLAN I will heparin lock her IV advance her diet and ambulate her I have asked her to increase her prednisone when she goes home She will double her regular dose for the next five days I will advance her diet I will continue to monitor her calcium levels throughout the day If they stabilize I am hopeful that she will be ready for discharge either later today or tomorrow She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p r n pain dispensed 240 mL with one refill Her final calcium dosage will be determined prior to discharge I will plan to see her back in the office on the 12 30 08 and she has been instructed to call or return sooner for any problems Keywords soap chart progress notes parathyroid hyperplasia parathyroid exploration pth hyperplasia parathyroidectomy parathyroidNOTE MEDICAL_TRANSCRIPTION,Description Followup for polycythemia vera with secondary myelofibrosis JAK 2 positive myeloproliferative disorder He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy Medical Specialty SOAP Chart Progress Notes Sample Name Polycythemia Vera Followup Transcription DIAGNOSIS Polycythemia vera with secondary myelofibrosis REASON FOR VISIT Followup of the above condition CHIEF COMPLAINT Left shin pain HISTORY OF PRESENT ILLNESS A 55 year old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis Diagnosis was made some time in 2005 2006 Initially he underwent phlebotomy He subsequently transferred his care here In the past he has been on hydroxyurea and interferon but did not tolerate both of them He is JAK 2 positive He does not have any siblings for a match related transplant He was seen for consideration of a MUD transplant but was deemed not to be a candidate because of the social support as well as his reasonably good health At our institution the patient received a trial of lenalidomide and prednisone for a short period He did well with the combination Subsequently he developed intolerance to lenalidomide He complained of severe fatigue and diarrhea This was subsequently stopped The patient reports some injury to his left leg last week His left leg apparently was swollen He took steroids for about 3 days and stopped Left leg swelling has disappeared The patient denies any other complaints at this point in time He admits to smoking marijuana He says this gives him a great appetite and he has actually gained some weight Performance status in the ECOG scale is 1 PHYSICAL EXAMINATION VITAL SIGNS He is afebrile Blood pressure 144 85 pulse 86 weight 61 8 kg and respiratory rate 18 per minute GENERAL He is in no acute distress HEENT There is no pallor icterus or cervical adenopathy that is noted Oral cavity is normal to exam CHEST Clear to auscultation CARDIOVASCULAR S1 and S2 normal with regular rate and rhythm ABDOMEN Soft and nontender with no hepatomegaly Spleen is palpable 4 fingerbreadths below the left costal margin There is no guarding tenderness rebound or rigidity noted Bowel sounds are present EXTREMITIES Reveal no edema Palpation of the left tibia revealed some mild tenderness However I do not palpate any bony abnormalities There is no history of deep venous thrombosis LABORATORY DATA CBC from today is significant for a white count of 41 900 with an absolute neutrophil count of 34 400 hemoglobin 14 8 with an MCV of 56 7 and platelet count 235 000 ASSESSMENT AND PLAN 1 JAK 2 positive myeloproliferative disorder The patient has failed pretty much all available options He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy I have e mailed Dr X to see whether he will be a candidate for the LBH trial Hopefully we can get a JAK 2 inhibitor trial quickly on board 2 I am concerned about the risk of thrombosis with his elevated white count He is on aspirin prophylaxis The patient has been told to call me with any complaints 3 Left shin pain I have ordered x rays of the left tibia and knee today The patient will return to the clinic in 3 weeks He is to call me in the interim for any problems Keywords soap chart progress notes jak 2 positive myeloproliferative disorder secondary myelofibrosis mud transplant ecog scale myeloproliferative disorder radioactive phosphorus jak positive polycythemia vera thrombosis myelofibrosis MEDICAL_TRANSCRIPTION,Description Plantar fascitis heel spur syndrome The patient was given injections of 3 cc 2 1 mixture of 1 lidocaine plain with dexamethasone phospate Medical Specialty SOAP Chart Progress Notes Sample Name Podiatry Progress Note Transcription SUBJECTIVE Mr Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel The patient states that the heel has been painful for approximately two weeks it is starts with the first step in the morning and gets worse with activity during the day The patient states that he is currently doing no treatment for it He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch The patient states that he has no change in the past medical history since his last visit and denies any fever chills vomiting headache chest or shortness of breath OBJECTIVE Upon removal of shoes and socks bilaterally neurovascular status remains unchanged since the last visit There is tenderness to palpation to the medial tubercle of the right foot The pain is elicited along the medial arch as well There are no open areas or signs of infection noted ASSESSMENT Plantar fascitis heel spur syndrome right foot PLAN The patient was given injections of 3 cc 2 1 mixture of 1 lidocaine plain with dexamethasone phospate He was given a low dye strapping and a heel lift was placed in his right shoe The patient will be seen back in approximately one month for further evaluation if necessary He was told to call if anything should occur before that The patient was told to continue with the good work on his diabetic control Keywords soap chart progress notes progress note plantar fascitis podiatry soap dexamethasone phospate heel lift heel spur syndrome lidocaine low dye strapping mixture of 1 lidocaine dexamethasone phospate injections heel MEDICAL_TRANSCRIPTION,Description Posttransplant lymphoproliferative disorder chronic renal insufficiency squamous cell carcinoma of the skin anemia secondary to chronic renal insufficiency and chemotherapy and hypertension The patient is here for followup visit and chemotherapy Medical Specialty SOAP Chart Progress Notes Sample Name Posttransplant Lymphoproliferative Disorder Transcription CHIEF COMPLAINT The patient is here for followup visit and chemotherapy DIAGNOSES 1 Posttransplant lymphoproliferative disorder 2 Chronic renal insufficiency 3 Squamous cell carcinoma of the skin 4 Anemia secondary to chronic renal insufficiency and chemotherapy 5 Hypertension HISTORY OF PRESENT ILLNESS A 51 year old white male diagnosed with PTLD in latter half of 2007 He presented with symptoms of increasing adenopathy abdominal pain weight loss and anorexia He did not seek medical attention immediately He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin which showed diagnosis of large cell lymphoma He was discussed at the hematopathology conference Chemotherapy with rituximab plus cyclophosphamide daunorubicin vincristine and prednisone was started First cycle of chemotherapy was complicated by sepsis despite growth factor support He also appeared to have become disoriented either secondary to sepsis or steroid therapy The patient has received 5 cycles of chemotherapy to date He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well His therapy has been interrupted for infection related to squamous cell cancer skin surgery as well as complaints of chest infection The patient is here for the sixth and final cycle of chemotherapy He states he feels well He denies any nausea vomiting cough shortness of breath chest pain or fatigue He denies any tingling or numbness in his fingers Review of systems is otherwise entirely negative Performance status on the ECOG scale is 1 PHYSICAL EXAMINATION VITAL SIGNS He is afebrile Blood pressure 161 80 pulse 65 weight 71 5 kg which is essentially unchanged from his prior visit There is mild pallor noted There is no icterus adenopathy or petechiae noted CHEST Clear to auscultation CARDIOVASCULAR S1 and S2 normal with regular rate and rhythm Systolic flow murmur is best heard in the pulmonary area ABDOMEN Soft and nontender with no organomegaly Renal transplant is noted in the right lower quadrant with a scar present EXTREMITIES Reveal no edema LABORATORY DATA CBC from today shows white count of 9 6 with a normal differential ANC of 7400 hemoglobin 8 9 hematocrit 26 5 with an MCV of 109 and platelet count of 220 000 ASSESSMENT AND PLAN 1 Diffuse large B cell lymphoma following transplantation The patient is to receive his sixth and final cycle of chemotherapy today PET scan has been ordered to be done within 2 weeks He will see me back for the visit in 3 weeks with CBC CMP and LDH 2 Chronic renal insufficiency 3 Anemia secondary to chronic renal failure and chemotherapy He is to continue on his regimen of growth factor support 4 Hypertension This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled His CMP is pending from today 5 Squamous cell carcinoma of the skin The scalp is well healed He still has an open wound on the right posterior aspect of his trunk This has no active drainage but it is yet to heal This probably will heal by secondary intention once chemotherapy is finished Prescription for prednisone as part of his chemotherapy has been given to him Keywords soap chart progress notes anemia chemotherapy posttransplant lymphoproliferative disorder squamous cell carcinoma chronic renal insufficiency renal insufficiency adenopathy lymphoproliferative MEDICAL_TRANSCRIPTION,Description A 44 year old 250 pound male presents with extreme pain in his left heel Medical Specialty SOAP Chart Progress Notes Sample Name Plantar Fasciitis Transcription S A 44 year old 250 pound male presents with extreme pain in his left heel This is his chief complaint He says that he has had this pain for about two weeks He works on concrete floors He says that in the mornings when he gets up or after sitting he has extreme pain and great difficulty in walking He also has a macular blotching of skin on his arms face legs feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old He also has redness and infection of the right toes O The patient apparently has a pigmentation disorder which may or may not change with time on his arms legs and other parts of his body including his face He has an erythematous moccasin pattern tinea pedis of the plantar aspects of both feet He has redness of the right toes 2 3 and 4 Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel A 1 Plantar fasciitis Keywords soap chart progress notes plantar fasciitis tinea pedis tinea purpura heel fasciitis plantar MEDICAL_TRANSCRIPTION,Description Six month follow up visit for paroxysmal atrial fibrillation PAF She reports that she is getting occasional chest pains with activity Sometimes she feels that at night when she is lying in bed and it concerns her Medical Specialty SOAP Chart Progress Notes Sample Name PAF 6 Month Followup Transcription REASON FOR VISIT Six month follow up visit for paroxysmal atrial fibrillation PAF She reports that she is getting occasional chest pains with activity Sometimes she feels that at night when she is lying in bed and it concerns her She is frustrated by her inability to lose weight even though she is hyperthyroid MEDICATIONS Tapazole 10 mg b i d atenolol chlorthalidone 50 25 mg b i d Micro K 10 mEq q d Lanoxin 0 125 mg q d spironolactone 25 mg q d Crestor 10 mg q h s famotidine 20 mg Bayer Aspirin 81 mg q d Vicodin p r n and Nexium 40 mg given samples of this today REVIEW OF SYSTEMS No palpitations No lightheadedness or presyncope She is having mild pedal edema but she drinks a lot of fluid PEX BP 112 74 PR 70 WT 223 pounds up three pounds Cardiac Regular rate and rhythm with a 1 6 murmur at the upper sternal border Chest Nontender Lungs Clear Abdomen Moderately overweight Extremities Trace edema EKG Sinus bradycardia at 58 beats per minute mild inferolateral ST abnormalities IMPRESSION 1 Chest pain Mild Her EKG is mildly abnormal Her last stress echo was in 2001 I am going to have her return for one just to make sure it is nothing serious I suspect however that is more likely due to her weight and acid reflux I gave her samples of Nexium 2 Mild pedal edema Has to cut down on fluid intake weight loss will help as well continue with the chlorthalidone 3 PAF Due to hypertension hyperthyroidism and hypokalemia Staying in sinus rhythm 4 Hyperthyroidism Last TSH was mildly suppressed she had been out of her Tapazole for a while now back on it 5 Dyslipidemia Samples of Crestor given 6 LVH 7 Menometrorrhagia PLAN 1 Return for stress echo 2 Reduce the fluid intake to help with pedal edema 3 Nexium trial Keywords soap chart progress notes atrial fibrillation ekg paroxysmal atrial fibrillation chest pains pedal edema hyperthyroidism paf atrial MEDICAL_TRANSCRIPTION,Description Pain management sample progress note Medical Specialty SOAP Chart Progress Notes Sample Name Pain Management Progress Note Transcription DIAGNOSES 1 Cervical dystonia 2 Post cervical laminectomy pain syndrome Ms XYZ states that the pain has now shifted to the left side She has noticed a marked improvement on the right side which was subject to a botulinum toxin injection about two weeks ago She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased but she is still on the oxycodone and methadone The patient s husband confirms the fact that she is doing a lot better that she is more active but there are still issues yet regarding anxiety depression and frustration regarding the pain in her neck PHYSICAL EXAMINATION The patient is appropriate She is well dressed and oriented x3 She still smells of some cigarette smoke Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals trapezius and splenius capitis muscles There are no trigger points felt and her range of motion of the neck is still somewhat guarded but much improved On the left side however there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding This extends down into the trapezius muscle but the splenius capitis seems to be not involved TREATMENT PLAN After a long discussion with the patient and the husband we have decided to go ahead and do botulinum toxin injection into the left multifidus trapezius muscles A total of 400 units of Botox is anticipated The procedure is being scheduled The patient s medications are refilled She will continue to see Dr Berry and continue her therapy with Mary Hotchkinson in Victoria Keywords soap chart progress notes progress note management muscle MEDICAL_TRANSCRIPTION,Description Overactive bladder with microscopic hematuria Medical Specialty SOAP Chart Progress Notes Sample Name Overactive Bladder Transcription REASON FOR VISIT Overactive bladder with microscopic hematuria HISTORY OF PRESENT ILLNESS The patient is a 56 year old noted to have microscopic hematuria with overactive bladder Her cystoscopy performed was unremarkable She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night No gross hematuria dysuria pyuria no other outlet obstructive and or irritative voiding symptoms The patient had been previously on Ditropan and did not do nearly as well At this point what we will try is a different medication Renal ultrasound is otherwise unremarkable notes no evidence of any other disease IMPRESSION Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted She has no other significant findings other than her overactive bladder which had continued At this juncture what I would like to do is try a different anticholinergic medication She has never had any side effects from her medication PLAN The patient will discontinue Ditropan We will start Sanctura XR and we will follow up as scheduled Otherwise we will continue to follow her urinalysis over the next year or so Keywords soap chart progress notes overactive bladder with microscopic hematuria irritative voiding symptoms anticholinergic microscopic hematuria overactive bladder ditropan microscopic hematuria bladder overactive MEDICAL_TRANSCRIPTION,Description The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures as well as open reduction nasal fracture He is on his eighth hospital day Medical Specialty SOAP Chart Progress Notes Sample Name ORIF Facial Fractures Followup Transcription Mr ABC was transferred to room 123 this afternoon We discussed this with the nurses and it was of course cleared by Dr X The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures as well as open reduction nasal fracture He is on his eighth hospital day The patient had nasal packing in place which was removed this evening This will make it much easier for him to swallow This will facilitate p o fluids and IMF diet Examination of the face revealed some decreased swelling today He had good occlusion with intact intermaxillary fixation His tracheotomy tube is in place It is a size 8 Shiley nonfenestrated He is being suctioned comfortably The patient is in need of something for sleep in the evening so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed Tomorrow we will go ahead and change his trach to a noncuffed or a fenestrated tube so he may communicate and again this will facilitate his swallowing Hopefully we can decannulate the tracheotomy tube in the next few days Overall I believe this patient is doing well and we will look forward to being able to transfer him to the prison infirmary Keywords soap chart progress notes fenestrated tube nasal fracture facial fractures orif tracheotomy tube fractures MEDICAL_TRANSCRIPTION,Description A 47 year old white female presents with concern about possible spider bite to the left side of her neck Medical Specialty SOAP Chart Progress Notes Sample Name Possible Spider Bite Transcription SUBJECTIVE This 47 year old white female presents with concern about possible spider bite to the left side of her neck She is not aware of any specific injury She noticed a little tenderness and redness on her left posterior shoulder about two days ago It seems to be getting a little bit larger in size and she saw some red streaks extending up her neck She has had no fever The area is very minimally tender but not particularly so CURRENT MEDICATIONS Generic Maxzide Climara patch multivitamin Tums Claritin and vitamin C ALLERGIES No known medicine allergies OBJECTIVE Vital Signs Weight is 150 pounds Blood pressure 122 82 Extremities Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter In the center is a tiny mark which could certainly be an insect or spider bite There is no eschar there but just a tiny marking There are a couple of erythematous streaks extending towards the neck ASSESSMENT Possible insect bite with lymphangitis PLAN 1 Duricef 1 g daily for seven days 2 Cold packs to the area 3 Discussed symptoms that were suggestive of the worsening in which case she would need to call me 4 Incidentally she has noticed a little bit of dryness and redness on her eyelids particularly the upper ones and the lower lateral areas I suspect she has a mild contact dermatitis and suggested hydrocortisone 1 cream to be applied sparingly at bedtime only Keywords soap chart progress notes spider bite injury tenderness redness insect bite lymphangitis streaks spider neck bite MEDICAL_TRANSCRIPTION,Description Maculopapular rash in kind of a linear pattern over arms legs and chest area which are consistent with a poison ivy or a poison oak Medical Specialty SOAP Chart Progress Notes Sample Name Poison Ivy SOAP Transcription SUBJECTIVE He is a 24 year old male who said that he had gotten into some poison ivy this weekend while he was fishing He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it he said that the last time he was here he got a steroid injection by Dr Blackman it looked like it was Depo Medrol 80 mg He said that it worked fairly well although it seemed to still take awhile to get rid of it He has been using over the counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest legs arms and back OBJECTIVE Vitals Temperature is 99 2 His weight is 207 pounds Skin Examination reveals a raised maculopapular rash in kind of a linear pattern over his arms legs and chest area which are consistent with a poison ivy or a poison oak ASSESSMENT AND PLAN Poison ivy Plan would be Solu Medrol 125 mg IM X 1 Continue over the counter Benadryl or Rx allergy medicine that he was given the last time he was here which is a one a day allergy medicine he can not exactly remember what it is which would also be fine rather than the over the counter Benadryl if he would like to use that instead Keywords soap chart progress notes poison ivy steroid injection depo medrol maculopapular rash poison oak maculopapular chest ivy poison MEDICAL_TRANSCRIPTION,Description Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture Medical Specialty SOAP Chart Progress Notes Sample Name ORIF Followup Transcription REASON FOR VISIT Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture HISTORY OF PRESENT ILLNESS The patient is now approximately week status post removal of Ex Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture The patient states that this pain is well controlled He has had no fevers chills or night sweats He has had some mild drainage from his pin sites He just started doing range of motion type exercises for his right knee He has had no numbness or tingling FINDINGS On exam his pin sites had no erythema There is some mild drainage but they have been dressing with bacitracin it looks like there may be part of the fluid noted The patient had 3 5 strength in the EHL FHL He has intact sensation to light touch in a DP SP and tibial nerve distribution X rays taken include three views of the right knee It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment ASSESSMENT Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix PLANS I gave the patient a prescription for aggressive range of motion of the right knee I would like to really work on this as he has not had much up to this time He should remain nonweightbearing I would like to have him return in 2 weeks time to assess his knee range of motion He should not need x rays at that time Keywords soap chart progress notes external fixator open reduction internal fixation tibial plateau fracture ex fix tibial plateau fracture internal fixation tibial plateau orif MEDICAL_TRANSCRIPTION,Description Ophthalmology followup visit note Medical Specialty SOAP Chart Progress Notes Sample Name Ophthalmology Progress Note 2 Transcription A fluorescein angiogram was ordered at today s visit to rule out macular edema We have asked her to return in one to two weeks time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress A copy of the angiogram is enclosed for your records Keywords soap chart progress notes visual acuities 78 diopter lens extraocular muscle movement afferent angiogram applanation detachment dilated fundus examination fluorescein hemorrhages intraocular intraocular lenses left eye posterior chamber pupillary retinopathy right eye slit lamp ophthalmology lensesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Ophthalmology followup visit note Medical Specialty SOAP Chart Progress Notes Sample Name Ophthalmology Progress Note 1 Transcription She is stable at this time and does not require any intervention at today s visit I have asked her to return in six months for a followup dilated examination but would be happy to see her sooner should you or she notice any changes in her vision Keywords soap chart progress notes visual acuities extraocular muscle intraocular pressure pupils afferent applanation binocular dilated fundus left eye lens movements ophthalmoscope pigmentary retina retinal right eye ophthalmology acuitiesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Septic from nephrolithiasis Nephrolithiasis status post lithotripsy and stent placed in the left ureter urinary incontinence recent sepsis Medical Specialty SOAP Chart Progress Notes Sample Name Nephrolithiasis Progress Note Transcription SUBJECTIVE The patient returns today for a followup She was recently in the hospital and was found to be septic from nephrolithiasis This was all treated She did require a stent in the left ureter Dr XYZ took care of this She had a stone which was treated with lithotripsy She is now back here for followup I had written out all of her medications with their dose and schedule on a progress sheet I had given her instructions regarding follow up here and follow with Dr F Unfortunately that piece of paper was lost Somehow between the hospital and home she lost it and has not been able to find it She has no followup appointment with Dr F The day after she was dismissed her nephew called me stating that the prescriptions were lost instructions were lost etc Later she apparently found the prescriptions and they were filled She tells me she is taking the antibiotic which I believe was Levaquin and she has one more to take She had no clue as to seeing Dr XYZ again She says she is still not feeling very well and feels somewhat sick like She has no clue as to still having a ureteral stent I explained this to she and her husband again today ALLERGIES Sulfa CURRENT MEDICATIONS As I have given are Levaquin Prinivil 20 mg a day Bumex 0 5 mg a day Levsinex 0 375 mg a day cimetidine 400 mg a day potassium chloride 8 mEq a day and atenolol 25 mg a day REVIEW OF SYSTEMS She says she is voiding okay She denies fever chills or sweats OBJECTIVE General She was able to get up on the table by herself although she is quite unstable Vital Signs Blood pressure was okay at about 120 70 by me Neck Supple Lungs Clear Heart Regular rate and rhythm Abdomen Soft Extremities There is no edema IMPRESSION 1 Hypertension controlled 2 Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr F 3 Urinary incontinence 4 Recent sepsis PLAN 1 I discussed at length with she and her husband again the need to get into at least an assisted living apartment 2 I gave her instructions in writing to stop by Dr F s office on the way out today to get an appointment for followup regarding her stent 3 See me back here in two months 4 I made no changes in her medications Keywords soap chart progress notes nephrolithiasis septic lithotripsy nephrolithiasis status post lithotripsy septic from nephrolithiasis urinary incontinence incontinence atenolol stent medications MEDICAL_TRANSCRIPTION,Description A woman with end stage peritoneal mesothelioma with multiple bowel perforations Medical Specialty SOAP Chart Progress Notes Sample Name Mesothelioma Chart Note Transcription The patient s home regimen includes Duragesic patch at 125 mcg every 3 days She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout Dilaudid boluses 2 mg q 3 h p r n Ativan 2 mg q 4 h Tylenol per rectum The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses neurolytic block The patient s family and she will continue to think about these pain procedures and let us know if they are interested in either For the moment we will not make any further recommendations on her current medical management We did ask Dr X a psychiatrist who works for the Pain Service to come in and see Ms A as anxiety is a large component of her suffering at this time Keywords soap chart progress notes pleurodesis abdominal pain multiple bowel perforations peritoneal mesothelioma mesothelioma peritonealNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient with multiple medical problems Alzheimer s dementia gradual weight loss fatigue etc Medical Specialty SOAP Chart Progress Notes Sample Name Multiple Medical Problems Transcription SUBJECTIVE The patient was seen today by me at Nursing Home for her multiple medical problems The nurses report that she has been confused at times having incontinent stool in the sink one time but generally she does not do that poorly She does have trouble walking which she attributes to weak legs She fell a couple of months ago Her eating has been fair She has been losing weight a little bit She denies diarrhea She does complain of feeling listless and unambitious and would like to try some Ensure CURRENT MEDICATIONS Her meds are fairly extensive and include B12 1000 mg IM monthly Digitek 250 p o every other day alternating with 125 mcg p o every other day aspirin 81 mg daily Theragran M daily Toprol XL 25 mg daily vitamin B6 100 mg daily Prevacid 30 mg daily Oyster Shell calcium with D 500 mg t i d Aricept 5 mg daily Tylenol 650 mg q 4h p r n furosemide 20 mg daily p r n and sublingual Nitro p r n and alprazolam 0 25 mg p r n ALLERGIES Sulfa and trimethoprim OBJECTIVE General She is a well developed well nourished elderly female in no acute distress Vital Signs Her age is 90 Temperature is 98 5 degrees Blood pressure 100 54 Pulse 60 Respirations 18 Weight was 132 6 about a week ago which is down one pound from couple of months ago HEENT Head was normocephalic Neck Supple Lungs Clear Heart Regular rate and rhythm Abdomen Soft nontender without hepatosplenomegaly or mass Extremities No calf tenderness or significant ankle edema x 2 in the lower extremities is noted Mental Status Exam She was uncertain what season we are in She thought we were almost in winter She did know that today of the week was Friday She seemed to recognize me ASSESSMENT 1 Alzheimer s dementia 2 Gradual weight loss 3 Fatigue 4 B12 deficiency 5 Osteoporosis 6 Hypertension PLAN I ordered yearly digoxin levels Increased her Aricept to 10 mg daily She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin We will plan to recheck her in a couple of months Ordered health supplement to be offered after each meal due to her weight loss Keywords soap chart progress notes progress note alzheimer s dementia b12 deficiency fatigue hypertension osteoporosis digoxin incontinent stool multiple medical problems weak weight loss multiple dementia alzheimer s incontinent MEDICAL_TRANSCRIPTION,Description Obesity hypoventilation syndrome A 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study Medical Specialty SOAP Chart Progress Notes Sample Name Obesity Hypoventilation Syndrome Transcription HISTORY OF PRESENT ILLNESS This is a 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep She returns today to review results of an inpatient study performed approximately two weeks ago In the meantime the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex She also takes Lasix for lower extremity edema The patient reports that she generally initiates sleep on CPAP but rips her mask off tosses and turns throughout the night and has terrible quality sleep MEDICATIONS Current medications are as previously noted Changes include reduction in prednisone from 9 to 6 mg by mouth every morning She continues to take Ativan 1 mg every six hours as needed She takes imipramine 425 mg at bedtime Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation 45 to 75 mg by mouth every 8 hours as needed FINDINGS Vital signs Blood pressure 153 81 pulse 90 respiratory rate 20 weight 311 8 pounds up 10 pounds from earlier this month height 5 feet 6 inches temperature 98 4 degrees SaO2 is 88 on room air at rest Chest is clear Extremities show lower extremity pretibial edema with erythema LABORATORIES An arterial blood gas on room air showed a pH of 7 38 PCO2 of 52 and PO2 of 57 CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used She used it for greater than 4 hours per night on 67 of night surveyed Her estimated apnea hypopnea index was 3 per hour Her average leak flow was 67 liters per minute The patient s overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy She slept for a total sleep time of 257 minutes out of 272 minutes in bed sleep efficiency approximately 90 Sleep stage distribution was relatively normal with 2 stage I 72 stage II 24 stage III IV and 2 stage REM sleep There were no periodic limb movements during sleep There was evidence of a severe predominantly central sleep apnea during non REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour Oxyhemoglobin saturations during non REM sleep fluctuated from the baseline of 92 to an average low of 82 During REM sleep the baseline oxyhemoglobin saturation was 87 decreased to 81 with sleep disordered breathing episodes Of note the sleep study was performed on CPAP at 10 5 cm of H2O with oxygen at 8 liters per minute ASSESSMENT 1 Obesity hypoventilation syndrome The patient has evidence of a well compensated respiratory acidosis which is probably primarily related to severe obesity In addition there may be contribution from large doses of opiates and standing doses of gabapentin 2 Severe central sleep apnea on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute The breathing pattern is that of cluster or Biot s breathing throughout sleep The primary etiology is probably opiate use with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation and worsen desaturations during apneic episodes 3 Mononeuritis multiplex with pain requiring significant substantial doses of analgesia 4 Hypoxemia primarily due to obesity hypoventilation and presumably basilar atelectasis and a combination of V Q mismatch and shunt on that basis PLANS My overall impression is that we should treat this patient s sleep disruption with measures to decrease central sleep apnea during sleep These will include 1 Decrease in evening doses of MS Contin 2 Modest weight loss of approximately 10 to 20 pounds and 3 Instituting Automated Servo Ventilation via nasal mask With regard to latter the patient will be returning for a trial of ASV to examine its effect on sleep disordered breathing patterns In addition the patient will benefit from modest diuresis with improvement of oxygenation as well as nocturnal desaturation and oxygen requirements I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time She was instructed to take between one and two K Tab with her evening dose of Lasix 10 to 20 mEq In addition we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation Further workup for hypoxemia may include high resolution CT scanning if evidence for significant pulmonary restriction and or reductions in diffusion capacity is evident on pulmonary function testing Keywords soap chart progress notes polyarteritis nodosa obesity hypoventilation syndrome pulmonary function obesity hypoventilation mononeuritis multiplex sleep apnea sleep study rem sleep ativan sleep hypoventilation obesity MEDICAL_TRANSCRIPTION,Description Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Medical Specialty SOAP Chart Progress Notes Sample Name Melena ICU Followup Transcription HISTORY Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient Over the last 24 hours the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value He also underwent EGD earlier today with Dr X I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding Dr X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough now producing yellow brown sputum with increasing frequency but he has had no further episodes of melena since transfer to the ICU He is also complaining of some laryngitis and some pharyngitis but is denying any abdominal complaints nausea or diarrhea PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 100 54 heart rate 80 and temperature 98 8 Is and Os negative fluid balance of 1 4 liters in the last 24 hours GENERAL This is a somnolent 68 year old male who arouses to voice wakes up seems to have good appetite has continuing cough Pallor is improved EYES Conjunctivae are now pink ENT Oropharynx is clear CARDIOVASCULAR Reveals distant heart tones with regular rate and rhythm LUNGS Have coarse breath sounds with wheezes rhonchi and soft crackles in the bases ABDOMEN Soft and nontender with no organomegaly appreciated EXTREMITIES Showed no clubbing cyanosis or edema Capillary refill time is now normal in the fingertips NEUROLOGICAL Cranial nerves II through XII are grossly intact with no focal neurological deficits LABORATORY DATA Laboratories drawn at 1449 today WBC 10 hemoglobin and hematocrit 11 5 and 33 1 and platelets 288 000 This is up from 8 6 and 24 7 Platelets are stable Sodium is 134 potassium 4 0 chloride 101 bicarb 26 BUN 19 creatinine 1 0 glucose 73 calcium 8 4 INR 0 96 iron 13 saturations 4 TIBC 312 TSH 0 74 CEA elevated at 8 6 ferritin 27 5 and occult blood positive EGD final results pending per Dr X s note and conversation with me earlier ulcerative esophagitis without signs of active bleeding at this time IMPRESSION PLAN 1 Melena secondary to ulcerative esophagitis We will continue to monitor the patient overnight to ensure there is no further bleeding If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation 2 Chronic obstructive pulmonary disease exacerbation The patient is doing well taking PO We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments We will add guaifenesin and N acetyl cysteine in a hope to mobilize some of his secretions This does appear to be improving His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications 3 Elevated CEA The patient will need colonoscopy on an outpatient basis He has refused this today We would like to encourage him to do so Of note the patient when he came in was on bloodless protocol but with urging did accept the transfusion Similarly I am hoping that with proper counseling the patient will consent to further examination with colonoscopy given his guaiac positive status elevated CEA and risk factors 4 Anemia normochromic normocytic with low total iron binding capacity This appears to be anemia of chronic disease However this is likely some iron deficiency superimposed on top of this given his recent bleeding with consider iron vitamin C folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding Total critical care time spent today discussing the case with Dr X examining the patient reviewing laboratory trends adjusting medications and counseling the patient in excess is 35 minutes Keywords soap chart progress notes anemia gi bleeding hemoglobin ulcerative esophagitis obstructive pulmonary disease icu followup infection obstructive pulmonary egd melena bleeding MEDICAL_TRANSCRIPTION,Description Neurologic examination sample Medical Specialty SOAP Chart Progress Notes Sample Name Neurologic Examination Transcription NEUROLOGICAL EXAMINATION At present the patient is awake alert and fully oriented There is no evidence of cognitive or language dysfunction Cranial nerves Visual fields are full Funduscopic examination is normal Extraocular movements full Pupils equal round react to light There is no evidence of nystagmus noted Fifth nerve function is normal There is no facial asymmetry noted Lower cranial nerves are normal Manual motor testing reveals good tone and bulk throughout There is no evidence of pronator drift or decreased fine finger movements Muscle strength is 5 5 throughout Deep tendon reflexes are 2 throughout with downgoing toes Sensory examination is intact to all modalities including stereognosis graphesthesia TESTING OF STATION AND GAIT The patient is able to walk toe heel and tandem walk Finger to nose and heel to shin moves are normal Romberg sign negative I appreciate no carotid bruits or cardiac murmurs Noncontrast CT scan of the head shows no evidence of acute infarction hemorrhage or extra axial collection Keywords soap chart progress notes station motor testing nerve function neurologic examination cranial nerves cranial extraocular movementsNOTE MEDICAL_TRANSCRIPTION,Description Extensive stage small cell lung cancer Chemotherapy with carboplatin and etoposide Left scapular pain status post CT scan of the thorax Medical Specialty SOAP Chart Progress Notes Sample Name Lung Cancer Followup Transcription CHIEF COMPLAINT 1 Extensive stage small cell lung cancer 2 Chemotherapy with carboplatin and etoposide 3 Left scapular pain status post CT scan of the thorax HISTORY OF PRESENT ILLNESS The patient is a 67 year old female with extensive stage small cell lung cancer She is currently receiving treatment with carboplatin and etoposide She completed her fifth cycle on 08 12 10 She has had ongoing back pain and was sent for a CT scan of the thorax She comes into clinic today accompanied by her daughters to review the results CURRENT MEDICATIONS Levothyroxine 88 mcg daily Soriatane 25 mg daily Timoptic 0 5 solution b i d Vicodin 5 500 mg one to two tablets q 6 hours p r n ALLERGIES No known drug allergies REVIEW OF SYSTEMS The patient continues to have back pain some time she also take two pain pill She received platelet transfusion the other day and reported mild fever She denies any chills night sweats chest pain or shortness of breath The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords soap chart progress notes small cell lung cancer carboplatin etoposide pet ct pleural base base mass extensive stage ct scan lung cancer lung cancer MEDICAL_TRANSCRIPTION,Description Patient is here to discuss possible open lung biopsy Medical Specialty SOAP Chart Progress Notes Sample Name Lung Biopsy Discussion Transcription CHART NOTE She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow Dr XYZ had seen her because of her complaints of shortness of breath Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis but wanted her to have an open lung biopsy so he had her see Dr XYZ Estep He had concurred with Dr XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy She was ready to go ahead with this and felt that it was important she find out why she is short of breath She is very concerned about the findings on her CAT scan and pulmonary function test She seemed alarmed to report that Dr XYZ had found that her lung capacity was reduced to 60 of what should be normal However I told her that two years ago Dr XYZ did pulmonary function studies which showed the same change in function And that really her pulmonary function test at least compared from two years ago had not really changed over this period of time After discussing the serious nature of an open lung biopsy the fact that her pulmonary function studies have not changed in two years the fact that she likely has a number of other things that are contributing to her being out of breath which is deconditioning and obesity she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy In fact when I called Dr XYZ to talk to him about cancelling the procedure he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed I also explained to patient that I did not think Dr XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those And also I spoke with Dr XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities I had a 30 minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan x ray and pulmonary function tests And if there was some sign that this was a progressive problem she could still go ahead with the lung biopsy But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful We are going to see her back in a month to see how her breathing is doing We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time I told her I would try to talk to her sister sometime in the next day or two Keywords soap chart progress notes discuss interstitial pneumonitis lung biopsy lung capacity pulmonary function test shortness of breath pulmonary function studies pulmonary function function biopsy lung interstitial pulmonaryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A female who has pain in her legs at nighttime that comes and goes radiates from her buttocks to her legs sometimes in her ankle Medical Specialty SOAP Chart Progress Notes Sample Name Leg Pain Bone Pain Transcription CHIEF COMPLAINT Leg pain HISTORY OF PRESENT ILLNESS This is a 56 year old female who has pain in her legs at nighttime and when she gets up it comes and goes radiates from her buttocks to her legs sometimes it is her ankle She has noticed it since she has been on Lipitor She has had some night sweats occasionally She has had a little bit of fever and nausea She has noticed her blood sugars have been low She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita She has noticed her fasting blood sugars have been ranging from 100 to 120 Blood sugars one and a half hours after meals have been 185 She is coming in for a diabetic checkup in one month and wants lab prior to that time She has been eating more meat recently and has not been on a diet for cholesterol CURRENT MEDICATIONS Include Lipitor 80 mg q d discontinued today Vioxx 25 mg q d Maxzide 37 25 q d Protonix 40 mg q d hydroxyzine pamoate 50 mg at h s aspirin 81 mg q d Glucovance 1 25 250 b i d decreased to one a day today Monopril 20 mg q d estradiol one mg q d and glucosamine 1000 mg q d ALLERGIES Cipro sulfa Bactrim and Demerol OBJECTIVE Vital Signs Weight is 248 pounds which is a 12 pound drop from January Blood pressure 120 70 Pulse 68 General This is a well developed adult female awake alert and in no acute distress HEENT Oropharynx and HEENT are within normal limits Lungs Clear Heart Regular rhythm and rate Abdomen Soft nontender and nondistended without organomegaly GU Palpation of femurs do not cause pain rotation of hips do not cause pain and compression of the hips do not cause pain Neurologic Deep tendon reflexes are normal Extremities Pulses in lower extremities are normal Straight leg lifts are normal ASSESSMENT PLAN 1 Leg pain bone pain I am going to check her CMP I think this possibly is a side effect from Lipitor We will stop Lipitor have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time Certainly if her pain improves might consider something like Crestor which is more water soluble which may cause less adverse effects We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay may need an x ray of back hip and legs at that time if symptoms are not gone 2 Hypercholesterolemia this is somewhat bothersome as she is a diabetic Did discuss with her that we need to stick to the diet especially after going off of Lipitor We will see how she does with her bone pain leg pain off of Lipitor If she has improvement may consider Crestor in one month I am going to check her lipid panel and a CMP Apparently she is going to get this at a different site Mapleridge in Wichita 3 Type II diabetes We will decrease her Glucovance because she is having frequent low blood sugars Her previous hemoglobin A1c was 5 6 so we will see if this improves her symptoms I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment Keywords soap chart progress notes cmp hypercholesterolemia leg pain type ii diabetes ankle blood sugars bone pain buttocks pain radiates from her buttocks leg pain bone leg sugars weight MEDICAL_TRANSCRIPTION,Description Patient status post lap band placement Medical Specialty SOAP Chart Progress Notes Sample Name Lap Band Adjustment Transcription REASON FOR VISIT Lap band adjustment HISTORY OF PRESENT ILLNESS Ms A is status post lap band placement back in 01 09 and she is here on a band adjustment Apparently she had some problems previously with her adjustments and apparently she has been under a lot of stress She was in a car accident a couple of weeks ago and she has problems she does not feel full She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better PHYSICAL EXAMINATION On exam her temperature is 98 pulse 76 weight 197 7 pounds blood pressure 102 72 BMI is 38 5 she has lost 3 8 pounds since her last visit She was alert and oriented in no apparent distress PROCEDURE I was able to access her port She does have an AP standard low profile I aspirated 6 mL I did add 1 mL so she has got approximately 7 mL in her band she did tolerate water postprocedure ASSESSMENT The patient is status post lap band adjustments doing well has a total of 7 mL within her band tolerated water postprocedure She will come back in two weeks for another adjustment as needed Keywords soap chart progress notes lap band adjustment lap band placement lap band MEDICAL_TRANSCRIPTION,Description The patient is a 65 year old female who underwent left upper lobectomy for stage IA non small cell lung cancer She returns for a routine surveillance visit The patient has no evidence of disease now status post left upper lobectomy for stage IA non small cell lung cancer 13 months ago Medical Specialty SOAP Chart Progress Notes Sample Name Lobectomy Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 65 year old female who underwent left upper lobectomy for stage IA non small cell lung cancer She returns for a routine surveillance visit She has undergone since her last visit an abdominopelvic CT which shows an enlarging simple cyst of the left kidney She underwent barium swallow which demonstrates a small sliding hiatal hernia with minimal reflux She has a minimal delayed emptying secondary tertiary contractions PA and lateral chest x ray from the 11 23 09 was also reviewed which demonstrates no lesions or infiltrates Review of systems the patient continues to have periodic odynophagia and mid thoracic dysphagia This most likely is secondary to tertiary contractions with some delayed emptying She has also had increased size of the left calf without tenderness which has not resolved over the past several months She has had a previous DVT in 1975 and 1985 She denies weight loss anorexia fevers chills headaches new aches or pains cough hemoptysis shortness of breath at rest or dyspnea on exertion MEDICATIONS Aspirin 81 mg p o q d Spiriva 10 mcg q d and albuterol p r n PHYSICAL EXAMINATION BP 117 78 RR 18 P 93 WT 186 lbs RAS 100 HEENT Mucous membranes are moist No cervical or supraclavicular lymphadenopathy LUNGS Clear to auscultation bilaterally CARDIAC Regular rate and rhythm without murmurs EXTREMITIES No cyanosis clubbing or edema NEURO Alert and oriented x3 Cranial nerves II through XII intact ASSESSMENT The patient has no evidence of disease now status post left upper lobectomy for stage IA non small cell lung cancer 13 months ago PLAN She is to return to clinic in six months with a chest CT She was given a prescription for an ultrasound of the left lower extremity to rule out DVT She will be called with the results She was given a prescription for nifedipine 10 mg p o t i d p r n esophageal spasm Keywords soap chart progress notes non small cell lung cancer lobectomy lung cancer non small cell lung cancer MEDICAL_TRANSCRIPTION,Description Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation Medical Specialty SOAP Chart Progress Notes Sample Name Laminectomy Foraminotomy Followup Transcription REASON FOR VISIT Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup status post L4 L5 laminectomy and bilateral foraminotomies and posterior spinal fusion on 06 08 07 Preoperatively her symptoms those of left lower extremity are radicular pain She had not improved immediately postoperatively She had a medial breech of a right L4 pedicle screw We took her back to the operating room same night and reinserted the screw Postoperatively her pain had improved I had last seen her on 06 28 07 at which time she was doing well She had symptoms of what she thought was restless leg syndrome at that time She has been put on ReQuip for this She returned I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative She states that she had recurrent left lower extremity pain which was similar to the pain she had preoperatively but in a different distribution further down the leg Thus I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation She states that overall she is improved compared to preoperatively She is ambulating better than she was preoperatively The pain is not as severe as it was preoperatively The right leg pain is improved The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side She denies any significant low back pain No right lower extremity symptoms No infectious symptoms whatsoever No fever chills chest pain shortness of breath No drainage from the wound No difficulties with the incision FINDINGS On examination Ms ABC is a pleasant well developed well nourished female in no apparent distress Alert and oriented x 3 Normocephalic atraumatic Respirations are normal and nonlabored Afebrile to touch Left tibialis anterior strength is 3 out of 5 extensor hallucis strength is 2 out of 5 Gastroc soleus strength is 3 to 4 out of 5 This has all been changed compared to preoperatively Motor strength is otherwise 4 plus out of 5 Light touch sensation decreased along the medial aspect of the left foot Straight leg raise test normal bilaterally The incision is well healed There is no fluctuance or fullness with the incision whatsoever No drainage Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws Lumbar spine MRI performed on 07 03 07 is also reviewed It demonstrates evidence of adequate decompression at L4 and L5 There is a moderate size subcutaneous fluid collection seen which does not appear compressive and may be compatible with normal postoperative fluid collection especially given the fact that she had a revision surgery performed ASSESSMENT AND PLAN Ms ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies and posterior spinal fusion with instrumentation on 07 08 07 The case is significant for merely misdirected right L4 pedicle screw which was reoriented with subsequent resolution of symptoms I am uncertain with regard to the etiology of the symptoms However it does appear that the radiographs demonstrate appropriate positioning of the instrumentation no hardware shift and the MRI demonstrates only a postoperative suprafascial fluid collection I do not see any indication for another surgery at this time I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection My recommendation at this time is that the patient is to continue with mobilization I have reassured her that her spine appears stable at this time She is happy with this I would like her to continue ambulating as much as possible She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested I have also her referred to Mrs Khan at Physical Medicine and Rehabilitation for continued aggressive management I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve She knows that if she has any difficulties she may follow up with me sooner Keywords soap chart progress notes spinal fusion restless leg syndrome posterior spinal fusion pedicle screw lumbar spine bilateral foraminotomies fluid collection foraminotomy instrumentation laminectomy screw spine MEDICAL_TRANSCRIPTION,Description This patient has reoccurring ingrown infected toenails Medical Specialty SOAP Chart Progress Notes Sample Name Infected Toenails Transcription S This patient has reoccurring ingrown infected toenails He presents today for continued care O On examination the left great toenail is ingrown on the medial and lateral toenail border The right great toenail is ingrown on the lateral nail border only There is mild redness and granulation tissue growing on the borders of the toes One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe These lesions measure 0 5 cm in diameter each I really do not understand why this young man continues to develop ingrown nails and infections A 1 Onychocryptosis Keywords soap chart progress notes infected toenails onychocryptosis benign lesions toenail border left great toe neosporin ointment hemostasis was achieved ointment and absorbent toenails ingrown lesions benign infected MEDICAL_TRANSCRIPTION,Description Patient with hypertension syncope and spinal stenosis for recheck Medical Specialty SOAP Chart Progress Notes Sample Name Hypertension Progress Note Transcription SUBJECTIVE The patient is a 78 year old female who returns for recheck She has hypertension She denies difficulty with chest pain palpations orthopnea nocturnal dyspnea or edema PAST MEDICAL HISTORY SURGERY HOSPITALIZATIONS Reviewed and unchanged from the dictation on 12 03 2003 MEDICATIONS Atenolol 50 mg daily Premarin 0 625 mg daily calcium with vitamin D two to three pills daily multivitamin daily aspirin as needed and TriViFlor 25 mg two pills daily She also has Elocon cream 0 1 and Synalar cream 0 01 that she uses as needed for rash ALLERGIES Benadryl phenobarbitone morphine Lasix and latex FAMILY HISTORY PERSONAL HISTORY Reviewed Mother died from congestive heart failure Father died from myocardial infarction at the age of 56 Family history is positive for ischemic cardiac disease Brother died from lymphoma She has one brother living who has had angioplasties x 2 She has one brother with asthma PERSONAL HISTORY Negative for use of alcohol or tobacco REVIEW OF SYSTEMS Bones and Joints She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg She had been followed by Dr Mills but decided to see Dr XYZ who referred to her Dr Isaac She underwent several tests She did have magnetic resonance angiography of the lower extremities and the aorta which were normal She had nerve conduction study that showed several peripheral polyneuropathy She reports that she has myelogram last week but has not got results of this She reports that the rest of her tests have been normal but it seems that vertebrae shift when she stands and then pinches the nerve She is now seeing Dr XYZ who comes to Hutchison from KU Medical Center and she thinks that she probably will have surgery in the near future Genitourinary She has occasional nocturia PHYSICAL EXAMINATION Vital Signs Weight 227 2 pounds Blood pressure 144 72 Pulse 80 Temperature 97 5 degrees General Appearance She is an elderly female patient who is not in acute distress Mouth Posterior pharynx is clear Neck Without adenopathy or thyromegaly Chest Lungs are resonant to percussion Auscultation reveals normal breath sounds Heart Normal S1 and S2 without gallops or rubs Abdomen Without masses or tenderness to palpation Extremities Without edema IMPRESSION PLAN 1 Hypertension She is advised to continue with the same medication 2 Syncope She previously had an episode of syncope around Thanksgiving She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias 3 Spinal stenosis She still is being evaluated for this and possibly will have surgery in the near future Keywords soap chart progress notes progress note hypertension spinal stenosis syncope spinal stenosis infarction orthopnea MEDICAL_TRANSCRIPTION,Description Upper respiratory tract infection persistent Tinea pedis Wart on the finger Hyperlipidemia Tobacco abuse Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 9 Transcription SUBJECTIVE This patient presents to the office today for a checkup He has several things to go over and discuss First he is sick He has been sick for a month intermittently but over the last couple of weeks it is worse He is having a lot of yellow phlegm when he coughs It feels likes it is in his chest He has been taking Allegra D intermittently but he is almost out and he needs a refill The second problem his foot continues to breakout It seems like it was getting a lot better and now it is bad again He was diagnosed with tinea pedis previously but he is about out of the Nizoral cream I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence He works in the flint and it is really hot where he works and it has been quite humid lately The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger He is interested in getting that frozen today Apparently he tells me I froze a previous wart on him in the past and it went away Next he is interested in getting some blood test done He specifically mentions the blood test for his prostate which I informed him is called the PSA He is 50 years old now He will also be getting his cholesterol checked again because he has a history of high cholesterol He made a big difference in his cholesterol by quitting smoking but unfortunately after taking his social history today he tells me that he is back to smoking He says it is difficult to quit He tells me he did quit chewing tobacco I told him to keep trying to quit smoking REVIEW OF SYSTEMS General With this illness he has had no problems with fever HEENT Some runny nose more runny nose than congestion Respiratory Denies shortness of breath Skin He has a peeling skin on the bottom of his feet mostly the right foot that he is talking about today At times it is itchy OBJECTIVE His weight is 238 4 pounds blood pressure 128 74 temperature 97 8 pulse 80 and respirations 16 General exam The patient is nontoxic and in no acute distress Ears Tympanic membranes pearly gray bilaterally Mouth No erythema ulcers vesicles or exudate noted Neck is supple No lymphadenopathy Lungs Clear to auscultation No rales rhonchi or wheezing Cardiac Regular rate and rhythm without murmur Extremities No edema cyanosis or clubbing Skin exam I checked out the bottom of his right foot He has peeling skin visible consistent with tinea pedis On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart The size of this wart is approximately 3 mm in diameter ASSESSMENT 1 Upper respiratory tract infection persistent 2 Tinea pedis 3 Wart on the finger 4 Hyperlipidemia 5 Tobacco abuse PLAN The patient is getting a refill on Allegra D I am giving him a refill on the Nizoral 2 cream that he should use to the foot area twice a day I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work His wart has been present for some time now and he would like to get it frozen I offered him the liquid nitrogen treatment and he did agree to it I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart He tolerated the procedure very well I froze it once and I allowed for a 3 mm freeze zone I gave him verbal wound care instructions after the procedure Lastly when he is fasting I am going to send him to the lab with a slip which I gave him today for a basic metabolic profile CBC fasting lipid profile and a screening PSA test Lastly for the upper respiratory tract infection I am giving him amoxicillin 500 mg three times a day for 10 days Keywords soap chart progress notes hyperlipidemia allegra d upper respiratory tract infection tinea pedis wart tobacco abuse blood test runny nose peeling skin tinea pedis abuse infection wart MEDICAL_TRANSCRIPTION,Description Patient today with multiple issues Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 8 Transcription SUBJECTIVE I am following the patient today for multiple issues He once again developed gross hematuria which was unprovoked His Coumadin has been held The patient has known BPH and is on Flomax He is being treated with Coumadin because of atrial fibrillation and stroke This is the second time he has had significant gross hematuria this month He also fell about a week ago and is complaining of buttock pain and leg pain We did get x rays of hips knees and ankles Clearly he has significant degenerative disease in all these areas No fractures noted however He felt that the pain is pretty severe and particularly worse in the morning His sinuses are bothering him He wonders about getting some nasal saline spray We talked about Coumadin stroke risk etc in the setting of atrial fibrillation PHYSICAL EXAMINATION Vitals As in chart The patient is alert pleasant and cooperative He is not in any apparent distress He is comfortable in a seated position I did not examine him further today ASSESSMENT AND PLAN 1 Hematuria Coumadin needs to be stopped so we will evaluate what is going on which is probably just some BPH We will also obtain a repeat UA as he did describe to me some dysuria However I do not think this would account for the gross hematuria He will be started on an aspirin 81 mg p o daily 2 For the pain we will try him on Lortab He will get a Lortab everyday in the morning 5 500 prior to getting out of bed and then he will have the option of having a few more throughout the day if he requires it 3 We will see about getting him set up with massage therapy and or physical therapy as well for his back pain 4 For his sinuses we will arrange for him to have saline nasal spray at the bedside for p r n use Keywords soap chart progress notes multiple issues atrial fibrillation gross hematuria multiple bph fibrillation hematuria MEDICAL_TRANSCRIPTION,Description Human immunodeficiency virus disease with stable control on Atripla Resolving left gluteal abscess completing Flagyl Diabetes mellitus currently on oral therapy Hypertension depression and chronic musculoskeletal pain of unclear etiology Medical Specialty SOAP Chart Progress Notes Sample Name HIV Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 41 year old white male with a history of HIV disease His last CD4 count was 425 viral load was less than 50 in 08 07 He was recently hospitalized for left gluteal abscess for which he underwent I D and he has newly diagnosed diabetes mellitus He also has a history of hypertension and hypertriglyceridemia He had been having increased urination and thirst He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess The endocrine team apparently felt that insulin might be best for this patient but because of financial issues elected to place him on Glucophage and glyburide The patient reports that he has been taking the medication He is in general feeling better He says that his gluteal abscess is improving and he will be following up with Surgery today CURRENT MEDICATIONS 1 Gabapentin 600 mg at night 2 Metformin 1000 mg twice a day 3 Glipizide 5 mg a day 4 Flagyl 500 mg four times a day 5 Flexeril 10 mg twice a day 6 Paroxetine 20 mg a day 7 Atripla one at night 8 Clonazepam 1 mg twice a day 9 Blood pressure medicine name unknown REVIEW OF SYSTEMS He otherwise has a negative review of systems PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 6 blood pressure 145 90 pulse 123 respirations 20 and weight is 89 9 kg 198 pounds HEENT Unremarkable except for some submandibular lymph nodes His fundi are benign NECK Supple LUNGS Clear to auscultation and percussion CARDIAC Reveals regular rate and rhythm without murmur rub or gallop ABDOMEN Soft and nontender without organomegaly or mass EXTREMITIES Show no cyanosis clubbing or edema GU Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions IMPRESSION 1 Human immunodeficiency virus disease with stable control on Atripla 2 Resolving left gluteal abscess completing Flagyl 3 Diabetes mellitus currently on oral therapy 4 Hypertension 5 Depression 6 Chronic musculoskeletal pain of unclear etiology PLAN The patient will continue his current medications He will have laboratory studies done in 3 to 4 weeks and we will see him a few weeks thereafter He has been encouraged to keep his appointment with his psychologist Keywords soap chart progress notes human immunodeficiency virus disease diabetes mellitus atripla hiv depression musculoskeletal diabetes hypertension MEDICAL_TRANSCRIPTION,Description Patient with several medical problems mouth being sore cough right shoulder pain and neck pain Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 6 Transcription SUBJECTIVE The patient is in with several medical problems He complains his mouth being sore since last week and also some trouble with my eyes He states that they feel funny but he is seeing okay He denies any more diarrhea or abdominal pain Bowels are working okay He denies nausea or diarrhea Eating is okay He is emptying his bladder okay He denies dysuria His back is hurting worse He complains of right shoulder pain and neck pain over the last week but denies any injury He reports that his cough is about the same CURRENT MEDICATIONS Metronidazole 250 mg q i d Lortab 5 500 b i d Allegra 180 mg daily Levothroid 100 mcg daily Lasix 20 mg daily Flomax 0 4 mg at h s aspirin 81 mg daily Celexa 40 mg daily verapamil SR 180 mg one and a half tablet daily Zetia 10 mg daily Feosol b i d ALLERGIES Lamisil Equagesic Bactrim Dilatrate cyclobenzaprine OBJECTIVE General He is a well developed well nourished elderly male in no acute distress Vital Signs His age is 66 Temperature 97 7 Blood pressure 134 80 Pulse 88 Weight 201 pounds HEENT Head was normocephalic Examination of the throat reveals it to be clear He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis Neck Supple without adenopathy or thyromegaly Lungs Clear Heart Regular rate and rhythm Extremities He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder Back has limited range of motion He is nontender to his back Deep tendon reflexes are 2 bilaterally in lower extremities Straight leg raising is positive for back pain on the right side at 90 degrees Abdomen Soft nontender without hepatosplenomegaly or mass He has normal bowel sounds ASSESSMENT 1 Clostridium difficile enteritis improved 2 Right shoulder pain 3 Chronic low back pain 4 Yeast thrush 5 Coronary artery disease 6 Urinary retention which is doing better PLAN I put him on Diflucan 200 mg daily for seven days We will have him stop his metronidazole little earlier at his request He can drop it down to t i d until Friday of this week and then finish Friday s dose and then stop the metronidazole and that will be more than a 10 day course I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr XYZ p r n for his eye discomfort and his left eye pterygium which is noted on exam minimal redness is noted to the conjunctiva on the left side but no mattering was seen Recheck with me in two to three weeks Keywords soap chart progress notes clostridium difficile enteritis coronary artery disease urinary retention yeast thrush cough neck pain several medical problems shoulder pain range of motion soap metronidazole shoulder neck MEDICAL_TRANSCRIPTION,Description The patient has recently had an admission for pneumonia with positive blood count She returned after vomiting and a probable seizure Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 11 Transcription SUBJECTIVE The patient has recently had an admission for pneumonia with positive blood count She was treated with IV antibiotics and p o antibiotics she improved on that She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102 She was found to have strep She was treated with penicillin and sent home She returned about 8 o clock after vomiting and a probable seizure Temperature was 104 5 she was lethargic after that She had an LP which was unremarkable She had blood cultures which have not grown anything The CSF has not grown anything at this point PHYSICAL EXAMINATION She is alert recovering from anesthesia Head eyes ears nose and throat are unremarkable Chest is clear to auscultation and percussion Abdomen is soft Extremities are unremarkable LAB STUDIES White count in the emergency room was 9 8 with a slight shift CSF glucose was 68 protein was 16 and there were no cells The Gram stain was unremarkable ASSESSMENT I feel that this patient has a febrile seizure PLAN My plan is to readmit the patient to control her temperature and assess her white count I am going to observe her overnight Keywords soap chart progress notes antibiotics febrile seizure temperature blood count white count pneumonia seizure MEDICAL_TRANSCRIPTION,Description The patient has NG tube in place for decompression Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 10 Transcription SUBJECTIVE The patient has NG tube in place for decompression She says she is feeling a bit better PHYSICAL EXAMINATION VITAL SIGNS She is afebrile Pulse is 58 and blood pressure is 110 56 SKIN There is good skin turgor GENERAL She is not in acute distress CHEST Clear to auscultation There is good air movement bilaterally CARDIOVASCULAR First and second sounds are heard No murmurs appreciated ABDOMEN Less distended Bowel sounds are absent EXTREMITIES She has 3 pedal swelling NEUROLOGICAL The patient is alert and oriented x3 Examination is nonfocal LABORATORY DATA White count is down from 20 000 to 12 5 hemoglobin is 12 hematocrit 37 and platelets 199 000 Glucose is 157 BUN 14 creatinine 0 6 sodium is 131 potassium is 4 0 and CO2 is 31 ASSESSMENT AND PLAN 1 Small bowel obstruction paralytic ileus rule out obstipation Continue with less aggressive decompression Follow surgeon s recommendation 2 Pulmonary fibrosis status post biopsy Manage as per pulmonologist 3 Leukocytosis improving Continue current antibiotics 4 Bilateral pedal swelling Ultrasound of the lower extremity negative for DVT 5 Hyponatremia improving 6 DVT prophylaxis 7 GI prophylaxis Keywords soap chart progress notes small bowel obstruction paralytic ileus decompression ng tube pedal swelling prophylaxis MEDICAL_TRANSCRIPTION,Description Patient with NIDDM hypertension CAD status post CABG hyperlipidemia etc Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 2 Transcription SUBJECTIVE Overall she has been doing well Her blood sugars have usually been less than or equal to 135 by home glucose monitoring Her fasting blood sugar today is 120 by our Accu Chek She is exercising three times per week Review of systems is otherwise unremarkable OBJECTIVE Her blood pressure is 110 60 Other vitals are stable HEENT Unremarkable Neck Unremarkable Lungs Clear Heart Regular Abdomen Unchanged Extremities Unchanged Neurologic Unchanged ASSESSMENT 1 NIDDM with improved control 2 Hypertension 3 Coronary artery disease status post coronary artery bypass graft 4 Degenerative arthritis 5 Hyperlipidemia 6 Hyperuricemia 7 Renal azotemia 8 Anemia 9 Fibroglandular breasts PLAN We will get follow up labs today We will continue with current medications and treatment We will arrange for a follow up mammogram as recommended by the radiologist in six months which will be approximately Month DD YYYY The patient is advised to proceed with previous recommendations She is to follow up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow up as directed Keywords soap chart progress notes general medicine accu chek heent unremarkable hyperlipidemia hypertension lungs clear niddm neck unremarkable progress note soap coronary artery bypass graft follow up labs glucose monitoring coronary artery MEDICAL_TRANSCRIPTION,Description Short term followup Hypertension depression osteoporosis and osteoarthritis Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 8 Transcription SUBJECTIVE The patient is an 89 year old lady She actually turns 90 later this month seen today for a short term followup Actually the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended She apparently did not feel well with the higher dose so she just went back to her previous dose of 1 mg daily She thinks she also has an element of office hypertension Also since she is on Mavik plus verapamil she could switch over to the combined drug Tarka However when we gave her samples of that she thought they were too big for her to swallow Basically she is just back on her previous blood pressure regimen However her blood pressure seems to be better today Her daughter says that they do check it periodically and it is similar to today s reading Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade We did do a C spine and right shoulder x ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder but this does not seem to cause her any problems She has some vague stomach problems although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve She takes Tylenol p r n which seems to be enough for her She does not think she has any acid reflux symptoms or heartburn She does take Tums t i d and also Mylanta at night She has had dentures for many many years and just recently I guess in the last few months although she was somewhat vague on this she has had some sores in her mouth They do heal up but then she will get another one She also thinks since she has been on the Lexapro she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor They do think the Lexapro has helped to some extent ALLERGIES None MEDICATION Verapamil 240 mg a day Mavik 1 mg a day Lipitor 10 mg one and half daily vitamins daily Ocuvite daily Tums t i d Tylenol 2 3 daily p r n and Mylanta at night REVIEW OF SYSTEMS Mostly otherwise as above OBJECTIVE General She is a pleasant elderly lady She is in no acute distress accompanied by daughter Vital signs Blood pressure 128 82 Pulse 68 Weight 143 pounds HEENT No acute changes Atraumatic normocephalic On mouth exam she does have dentures She removed her upper denture I really do not see any sores at all Her mouth exam was unremarkable Neck No adenopathy tenderness JVD bruits or mass Lungs Clear Heart Regular rate and rhythm Extremities No significant edema Reasonable pulses No clubbing or cyanosis may be just a minimal tremor in head and hands but it is very subtle and hardly noticeable No other focal or neurological deficits grossly IMPRESSION 1 Hypertension better reading today 2 Right arm symptoms resolved 3 Depression probably somewhat improved with Lexapro and she will just continue that She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it 4 Perhaps a very subtle tremor I will just watch that 5 Osteoporosis 6 Osteoarthritis PLAN I think I will just watch everything for now I would continue the Lexapro we gave her more samples plus a prescription for the 20 mg that she can cut in half I offered to see her for again short term followup However they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner She might get a flu shot here in the next few weeks Daughter mentioned here today that she thinks her mom is doing pretty well especially given that she is turning 90 here later this month and I would tend to agree with that Keywords soap chart progress notes osteoporosis osteoarthritis hypertension depression short term followup blood pressure progress blood pressure dose MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Patient with shoulder bursitis pharyngitis attention deficit disorder Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 5 Transcription S The patient is here today with his mom for several complaints Number one he has been having issues with his right shoulder Approximately 10 days ago he fell slipping on ice did not hit his head but fell straight on his shoulder He has been having issues ever since He is having difficulties raising his arm over his head He does have some intermittent numbness in his fingers at night He is not taking any anti inflammatories or pain relievers He is also complaining of a sore throat He did have some exposure to Strep and he has a long history of strep throat Denies any fevers rashes nausea vomiting diarrhea and constipation He is also being seen for ADHD by Dr B Adderall and Zoloft He takes these once a day He does notice when he does not take his medication He is doing well in school He is socializing well He is maintaining his weight and tolerating the medications However he is having issues with anger control He realizes when he has anger outbursts that it is a problem His mom is concerned He actually was willing to go to counseling and was wondering if there was anything available for him at this time PAST MEDICAL SURGICAL SOCIAL HISTORY Reviewed and unchanged O VSS In general patient is A Ox3 NAD Heart RRR Lungs CTA HEENT Unremarkable He does have 2 tonsils no erythema or exudate noted except for some postnasal drip Musculoskeletal Limited in range of motion active on the right He stops at about 95 degrees No muscle weakness Neurovascularly intact Negative biceps tenderness Psych No suicidal homicidal ideations Answering questions appropriately No hallucinations Keywords soap chart progress notes general medicine adhd attention deficit disorde pharyngitis anger control anti inflammatories bursitis diarrhea fevers nausea numbness rashes shoulder strep throat vomiting attention deficit deficit disorder anti inflammatories soap anger intermittent MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 3 Transcription S XYZ is in today not feeling well for the last three days She is a bit sick with bodyaches She is coughing She has a sore throat especially when she coughs Her cough is productive of green colored sputum She has had some chills No vomiting No diarrhea She is sleeping okay She does not feel like she needs anything for the cough She did call in yesterday and got a refill of her Keflex She took two Keflex this morning and she is feeling a little bit better now She is tearful just tired of feeling ran down O Vital signs as per chart Respirations 15 Exam Nontoxic No acute distress Alert and oriented HEENT TMs are clear bilaterally without erythema or bulging Clear external canals Clear tympanic Conjunctivae are clear Clear nasal mucosa Clear oropharynx with moist mucous membranes NECK is soft and supple without lymphadenopathy LUNGS are coarse with no severe rhonchi or wheezes HEART is regular rate and rhythm without murmur ABDOMEN is soft and nontender Chest x ray reveals no obvious consolidation or infiltrates We will send the x ray for over read Influenza test is negative Rapid strep screen is negative A Bronchitis URI P 1 Motrin as needed for fever and discomfort 2 Push fluids 3 Continue on the Keflex 4 Follow up with Dr ABC if symptoms persist or worsen otherwise as needed Keywords soap chart progress notes bodyaches alert and oriented no acute distress soap diarrhea general medicine lymphadenopathy regular rate and rhythm rhonchi soft and nontender supple vomiting wheezes coughing keflex oriented MEDICAL_TRANSCRIPTION,Description Palpitations possibly related to anxiety Fatigue Loose stools with some green color and also some nausea Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP Transcription SUBJECTIVE This patient presents to the office today because he has not been feeling well He was in for a complete physical on 05 02 2008 According to the chart the patient gives a history of feeling bad for about two weeks At first he thought it was stress and anxiety and then he became worried it was something else He says he is having a lot of palpitations He gets a fluttering feeling in his chest He has been very tired over two weeks as well His job has been really getting to him He has been feeling nervous and anxious It seems like when he is feeling stressed he has more palpitations sometimes they cause chest pain These symptoms are not triggered by exertion He had similar symptoms about 9 or 10 years ago At that time he went through a full workup Everything ended up being negative and they gave him something that he took for his nerves and he says that helped Unfortunately he does not remember what it was Also over the last three days he has had some intestinal problems He has had some intermittent nausea and his stools have been loose He has been having some really funny green color to his bowel movements There has been no blood in the stool He is not having any abdominal pain just some nausea He does not have much of an appetite He is a nonsmoker OBJECTIVE His weight today is 168 4 pounds blood pressure 142 76 temperature 97 7 pulse 68 and respirations 16 General exam The patient is nontoxic and in no acute distress There is no labored breathing Psychiatric He is alert and oriented times 3 Ears Tympanic membranes pearly gray bilaterally Mouth No erythema ulcers vesicles or exudate noted Eyes Pupils equal round and reactive to light bilaterally Neck is supple No lymphadenopathy Lungs Clear to auscultation No rales rhonchi or wheezing Cardiac Regular rate and rhythm without murmur Extremities No edema cyanosis or clubbing ASSESSMENT 1 Palpitations possibly related to anxiety 2 Fatigue 3 Loose stools with some green color and also some nausea There has been no vomiting possibly a touch of gastroenteritis going on here PLAN The patient admits he has been putting this off now for about two weeks He says his work is definitely contributing to some of his symptoms and he feels stressed He is leaving for a vacation very soon Unfortunately he is actually leaving Wednesday for XYZ which puts us into a bit of a bind in terms of doing testing on him My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis A 12 lead EKG was performed on him in the office today This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted which is definitely a good news I am going to send him to the lab from our office to get the following tests done Comprehensive metabolic profile CBC urinalysis with reflex to culture and we will also get a chest X ray Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital We were able to squeeze him in His appointment is at 8 15 in the morning He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck I am not going to be here so he is going to see Dr X Dr X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ Certainly if something comes up we may need to postpone his trip We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago In the meantime I have given him Ativan 0 5 mg one tablet two to three times a day as needed for anxiety I talked about Ativan how it works I talked about the side effects I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck I took him off of work today and tomorrow so he could rest Keywords soap chart progress notes palpitations nausea loose stools fatigue related to anxiety stress test anxiety MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 1 Transcription SUBJECTIVE Keywords soap chart progress notes progress note clear to auscultation s1 s2 s3 s4 blood pressure clubbing cyanosis general medicine peripheral edema rubs tenderness abdomen pressure soap blood MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med SOAP 4 Transcription S ABC is in today for a followup of her atrial fibrillation They have misplaced the Cardizem She is not on this and her heart rate is up just a little bit today She does complain of feeling dizziness some vertigo some lightheadedness and has attributed this to the Coumadin therapy She is very adamant that she wants to stop the Coumadin She is tired of blood draws We have had a difficult time getting her regulated No chest pains No shortness of breath She is moving around a little bit better Her arm does not hurt her Her back pain is improving as well O Vital signs as per chart Respirations 15 Exam Nontoxic No acute distress Alert and oriented HEENT TMs are clear bilaterally without erythema or bulging Clear external canals Clear tympanic Conjunctivae are clear Clear nasal mucosa Clear oropharynx with moist mucous membranes NECK is soft and supple LUNGS are clear to auscultation HEART is irregularly irregular mildly tachycardic ABDOMEN is soft and nontender EXTREMITIES No cyanosis no clubbing no edema EKG shows atrial fibrillation with a heart rate of 104 A 1 Keywords soap chart progress notes soap alert and oriented no acute distress no cyanosis atrial fibrillation blood draw dizziness general medicine irregularly irregular lightheadedness no clubbing no edema shortness of breath soft and nontender vertigo heart fibrillation coumadin atrial MEDICAL_TRANSCRIPTION,Description Multiple problems including left leg swelling history of leukocytosis joint pain left shoulder low back pain obesity frequency with urination and tobacco abuse Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 9 Transcription SUBJECTIVE The patient is a 44 year old white female who is here today with multiple problems The biggest concern she has today is her that left leg has been swollen It is swollen for three years to some extent but worse for the past two to three months It gets better in the morning when she is up but then through the day it begins to swell again Lately it is staying bigger and she somewhat uncomfortable with it being so large The right leg also swells but not nearly like the left leg The other problem she had was she has had pain in her shoulder and back These occurred about a year ago but the pain in her left shoulder is of most concern to her She feels like the low back pain is just a result of a poor mattress She does not remember hurting her shoulder but she said gradually she has lost some mobility It is hard time to get her hands behind her back or behind her head She has lost strength in the left shoulder As far as the blood count goes she had an elevated white count In April of 2005 Dr XYZ had asked Dr XYZ to see her because of the persistent leukocytosis however Dr XYZ felt that this was not a problem for the patient and asked her to just return here for follow up She also complains of a lot of frequency with urination and nocturia times two to three She has gained weight she thinks about 12 pounds since March She now weighs 284 Fortunately her blood pressure is staying stable She takes atenolol 12 5 mg per day and takes Lasix on a p r n basis but does not like to take it because it causes her to urinate so much She denies chest pain but she does feel like she is becoming gradually more short of breath She works for the city of Wichita as bus dispatcher so she does sit a lot and just really does not move around much Towards the end of the day her leg was really swollen I reviewed her lab work Other than the blood count her lab work has been pretty normal but she does need to have a cholesterol check OBJECTIVE General The patient is a very pleasant 44 year old white female quite obese Vital Signs Blood pressure 122 70 Temperature 98 6 HEENT Head Normocephalic Ears TMs intact Eyes Pupils round and equal Nose Mucosa normal Throat Mucosa normal Lungs Clear Heart Regular rate and rhythm Abdomen Soft and obese Extremities A lot of fluid in both legs but especially the left leg is really swollen At least 2 pedal edema The right leg just has a trace of edema She has pain in her low back with range of motion She has a lot of pain in her left shoulder with range of motion It is hard for her to get her hand behind her back She cannot get it up behind her head She has pain in the anterior left shoulder in that area ASSESSMENT 1 Multiple problems including left leg swelling 2 History of leukocytosis 3 Joint pain involving the left shoulder probably impingement syndrome 4 Low back pain chronic with obesity 5 Obesity 6 Frequency with urination 7 Tobacco abuse PLAN 1 I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel We will start her on Detrol 0 4 mg one daily and also started on Mobic 15 mg per day 2 Elevate her leg as much as possible and wear support hose if possible Keep her foot up during the day We will see her back in two weeks We will have the results of the Doppler the lab work and see how she is doing with the Detrol and the joint pain If her shoulder pain is not any better we probably should refer her on over to orthopedist We did do x rays of her shoulder today that did not show anything remarkable See her in two weeks or p r n Keywords soap chart progress notes leg swelling leukocytosis joint pain left shoulder low back pain obesity frequency with urination tobacco abuse multiple problems blood count blood pressure leg shoulder tobacco swelling weight MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 2 Transcription CHIEF COMPLAINT Followup on hypertension and hypercholesterolemia SUBJECTIVE This is a 78 year old male who recently had his right knee replaced and also back surgery about a year and a half ago He has done well with that He does most of the things that he wants to do He travels at every chance he has and he just got back from a cruise He denies any type of chest pain heaviness tightness pressure shortness of breath with stairs only cough or palpitations He sees Dr Ferguson He is known to have Crohn s and he takes care of that for him He sees Dr Roszhart for his prostate check He is a nonsmoker and denies swelling in his ankles MEDICATIONS Refer to chart ALLERGIES Refer to chart PHYSICAL EXAMINATION Vitals Wt 172 lbs up 2 lbs B P 150 60 T 96 4 P 72 and regular General A 78 year old male who does not appear to be in any acute distress Glasses Good dentition CV Distant S1 S2 without murmur or gallop No carotid bruits P 2 all around Lungs Diminished with increased AP diameter Abdomen Soft bowel sounds active x 4 quadrants No tenderness no distention no masses or organomegaly noted Extremities Well healed surgical scar on the right knee No edema Hand grasps are strong and equal Back Surgical scar on the lower back Neuro Intact A O Moves all four with no focal motor or sensory deficits IMPRESSION 1 Hypertension 2 Hypercholesterolemia 3 Osteoarthritis 4 Fatigue PLAN We will check a BMP lipid liver profile CPK and CBC Refill his medications x 3 months I gave him a copy of Partners in Prevention Increase his Altace to 5 mg day for better blood pressure control Diet exercise and weight loss and we will see him back in three months and p r n Keywords soap chart progress notes progress note fatigue osteoarthritis back surgery chest pain cough general medicine heaviness hypercholesterolemia hypertension palpitations pressure shortness of breath tightness surgical scar progress MEDICAL_TRANSCRIPTION,Description A 3 year old male brought in by his mother with concerns about his eating a very particular eater not eating very much in general Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 6 Transcription SUBJECTIVE This 3 year old male is brought by his mother with concerns about his eating He has become a very particular eater and not eating very much in general However her primary concern was he was vomiting sometimes after particular foods They had noted that when he would eat raw carrots within 5 to 10 minutes he would complain that his stomach hurt and then vomit After this occurred several times they stopped giving him carrots Last week he ate some celery and the same thing happened They had not given him any of that since He eats other foods without any apparent pain or vomiting Bowel movements are normal He does have a history of reactive airway disease intermittently He is not diagnosed with intrinsic asthma at this time and takes no medication regularly CURRENT MEDICATIONS He is on no medications ALLERGIES He has no known medicine allergies OBJECTIVE Vital Signs Weight 31 5 pounds which is an increase of 2 5 pounds since May Temperature is 97 1 He certainly appears in no distress He is quite interested in looking at his books Neck Supple without adenopathy Lungs Clear Cardiac Regular rate and rhythm without murmurs Abdomen Soft without organomegaly masses or tenderness ASSESSMENT Report of vomiting and abdominal pain after eating raw carrots and celery Etiology of this is unknown PLAN I talked with mother about this Certainly it does not suggest any kind of an allergic reaction nor obstruction At this time they will simply avoid those foods In the future they may certainly try those again and see how he tolerates those I did encourage a wide variety of fruits and vegetables in his diet as a general principle If worsening symptoms she is welcome to contact me again for reevaluation Keywords soap chart progress notes eating foods vomiting reactive airway disease raw carrots carrots MEDICAL_TRANSCRIPTION,Description Patient with a three day history of emesis and a four day history of diarrhea Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 7 Transcription SUBJECTIVE The patient is a 7 year old male who comes in today with a three day history of emesis and a four day history of diarrhea Apparently his brother had similar symptoms They had eaten some chicken and then ate some more of it the next day and I could not quite understand what the problem was because there is a little bit of language barrier although dad was trying very hard to explain to me what had happened But any way after he and his brother got done eating with chicken they both felt bad and have continued to feel bad The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days He has not had any emesis today He has urinated this morning His parents are both concerned because he had a fever of 103 last night Also he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis He has been drinking Pedialyte Gatorade white grape juice and 7Up otherwise he has not been eating anything MEDICATIONS None ALLERGIES He has no known drug allergies REVIEW OF SYSTEMS Negative as far as sore throat earache or cough PHYSICAL EXAMINATION General He is awake and alert no acute distress Vital Signs Blood pressure 106 75 Temperature 99 Pulse 112 Weight is 54 pounds HEENT His TMs are normal bilaterally Posterior pharynx is unremarkable Neck Without adenopathy or thyromegaly Lungs Clear to auscultation Heart Regular rate and rhythm without murmur Abdomen Benign Skin Turgor is intact His capillary refill is less than 3 seconds LABORATORY White blood cell count is 5 3 with 69 segs 15 lymphs and 13 monos His platelet count on his CBC is 215 ASSESSMENT Viral gastroenteritis PLAN The parents did point out to me a rash that he had on his buttock There were some small almost pinpoint erythematous patches of papules that have a scab on them I did not see any evidence of petechiae Therefore I just reassured them that this is a viral gastroenteritis I recommended that they stop giving him juice and just go with the Gatorade and water He is to stay away from milk products until his diarrhea and stomach upset have calmed down We talked about BRAT diet and slowly advancing his diet as he tolerates They have used some Kaopectate which did not really help with the diarrhea Otherwise follow up as needed Keywords soap chart progress notes diarrhea emesis history of gastroenteritis viral brat diet progress note MEDICAL_TRANSCRIPTION,Description The patient is in complaining of headaches and dizzy spells Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 4 Transcription SUBJECTIVE The patient is in complaining of headaches and dizzy spells as well as a new little rash on the medial right calf She describes her dizziness as both vertigo and lightheadedness She does not have a headache at present but has some intermittent headaches neck pains and generalized myalgias She has noticed a few more bruises on her legs No fever or chills with slight cough She has had more chest pains but not at present She does have a little bit of nausea but no vomiting or diarrhea She complains of some left shoulder tenderness and discomfort She reports her blood sugar today after lunch was 155 CURRENT MEDICATIONS She is currently on her nystatin ointment to her lips q i d p r n She is still using a triamcinolone 0 1 cream t i d to her left wrist rash and her Bactroban ointment t i d p r n to her bug bites on her legs Her other meds remain as per the dictation of 07 30 2004 with the exception of her Klonopin dose being 4 mg in a m and 6 mg at h s instead of what the psychiatrist had recommended which should be 6 mg and 8 mg ALLERGIES Sulfa erythromycin Macrodantin and tramadol OBJECTIVE General She is a well developed well nourished obese female in no acute distress Vital Signs Her age is 55 Temperature 98 2 Blood pressure 110 70 Pulse 72 Weight 174 pounds HEENT Head was normocephalic Throat Clear TMs clear Neck Supple without adenopathy Lungs Clear Heart Regular rate and rhythm without murmur Abdomen Soft nontender without hepatosplenomegaly or mass Extremities Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted Her shoulders have full range of motion She has minimal tenderness to the left shoulder anteriorly Skin There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin ASSESSMENT 1 Headaches 2 Dizziness 3 Atypical chest pains 4 Chronic renal failure 5 Type II diabetes 6 Myalgias 7 Severe anxiety affect is still quite anxious PLAN I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended which should be 6 mg in the a m and 8 mg in the p m I sent her to lab for CPK due to her myalgias and pro time for monitoring her Coumadin Recheck in one week I think her dizziness is multifactorial and due to enlarged part of her anxiety I do note that she does have a few new bruises on her extremities which is likely due to her Coumadin Keywords soap chart progress notes headaches and dizzy spells chest pains shoulder progress headaches MEDICAL_TRANSCRIPTION,Description Sepsis due to urinary tract infection Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 13 Transcription SUBJECTIVE The patient states she is feeling a bit better OBJECTIVE VITAL SIGNS Temperature is 95 4 Highest temperature recorded over the past 24 hours is 102 1 CHEST Examination of the chest is clear to auscultation CARDIOVASCULAR First and second heart sounds were heard No murmurs appreciated ABDOMEN Benign Right renal angle is tender Bowel sounds are positive EXTREMITIES There is no swelling NEUROLOGIC The patient is alert and oriented x3 Examination is nonfocal LABORATORY DATA White count is down from 35 000 to 15 5 Hemoglobin is 9 5 hematocrit is 30 and platelets are 269 000 BUN is down to 22 creatinine is within normal limits ASSESSMENT AND PLAN 1 Sepsis due to urinary tract infection Urine culture shows Escherichia coli resistant to Levaquin We changed to doripenem 2 Urinary tract infection we will treat with doripenem change Foley catheter 3 Hypotension Resolved continue intravenous fluids 4 Ischemic cardiomyopathy No evidence of decompensation we with monitor 5 Diabetes type 2 Uncontrolled Continue insulin sliding scale 6 Recent pulmonary embolism INR is above therapeutic range Coumadin is on hold we will monitor 7 History of coronary artery disease Troponin indeterminate Cardiologist intends no further workup Continue medical treatment Most likely troponin is secondary to impaired clearance Keywords soap chart progress notes sepsis escherichia coli urinary tract infection doripenem troponin urinary infection MEDICAL_TRANSCRIPTION,Description Rhabdomyolysis acute on chronic renal failure anemia leukocytosis elevated liver enzyme hypertension elevated cardiac enzyme obesity Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 12 Transcription SUBJECTIVE The patient was seen and examined He feels much better today improved weakness and decreased muscular pain No other complaints PHYSICAL EXAMINATION GENERAL Not in acute distress awake alert and oriented x3 VITAL SIGNS Blood pressure 147 68 heart rate 82 respiratory rate 20 temperature 97 7 O2 saturation 99 on 3 L HEENT NC T PERRLA EOMI NECK Supple HEART Regular rate and rhythm RESPIRATORY Clear bilateral ABDOMEN Soft and nontender EXTREMITIES No edema Pulses present bilateral LABORATORY DATA Total CK coming down 70 142 from 25 573 total CK is 200 troponin is 2 3 from 1 9 yesterday BNP blood sugar 93 BUN of 55 7 creatinine 2 7 sodium 137 potassium 3 9 chloride 108 and CO2 of 22 Liver function test AST 704 ALT 298 alkaline phosphatase 67 total bilirubin 0 3 CBC WBC count 9 1 hemoglobin 9 9 hematocrit 29 2 and platelet count 204 Blood cultures are still pending Ultrasound of abdomen negative abdomen both kidneys were echogenic cortices suggesting chronic medical renal disease Doppler of lower extremities negative for DVT ASSESSMENT AND PLAN 1 Rhabdomyolysis most likely secondary to statins gemfibrozil discontinue it on admission Continue IV fluids We will monitor 2 Acute on chronic renal failure We will follow up with Nephrology recommendation 3 Anemia drop in hemoglobin most likely hemodilutional Repeat CBC in a m 4 Leukocytosis improving 5 Elevated liver enzyme most likely secondary to rhabdomyolysis The patient denies any abdominal pain and ultrasound is unremarkable 6 Hypertension Blood pressure controlled 7 Elevated cardiac enzyme follow up with Cardiology recommendation 8 Obesity 9 Deep venous thrombosis prophylaxis Continue Lovenox 40 mg subcu daily Keywords soap chart progress notes rhabdomyolysis acute on chronic renal failure anemia leukocytosis elevated liver enzyme hypertension elevated cardiac enzyme obesity cardiac enzyme blood pressure MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 1 Transcription CHIEF COMPLAINT Followup on diabetes mellitus status post cerebrovascular accident SUBJECTIVE This is a 70 year old male who has no particular complaints other than he has just discomfort on his right side We have done EMG studies He has noticed it since his stroke about five years ago He has been to see a neurologist We have tried different medications and it just does not seem to help He checks his blood sugars at home two to three times a day He kind of adjusts his own insulin himself Re evaluation of symptoms is essentially negative He has a past history of heavy tobacco and alcohol usage MEDICATIONS Refer to chart ALLERGIES Refer to chart PHYSICAL EXAMINATION Vitals Wt 118 lbs B P 108 72 T 96 5 P 80 and regular General A 70 year old male who does not appear to be in acute distress but does look older than his stated age He has some missing dentition Skin Dry and flaky CV Heart tones are okay adequate carotid pulsations He has 2 pedal pulse on the left and 1 on the right Lungs Diminished but clear Abdomen Scaphoid Rectal His prostate check was normal per Dr Gill Neuro Sensation with monofilament testing is better on the left than it is on the right IMPRESSION 1 Diabetes mellitus 2 Neuropathy 3 Status post cerebrovascular accident PLAN Refill his medications x 3 months We will check an A1c and BMP I have talked to him several times about a colonoscopy which he has refused and so we have been doing stools for occult blood We will check a PSA Continue with yearly eye exams foot exams Accu Cheks and we will see him in three months and p r n Keywords soap chart progress notes diabetes mellitus neuropathy genernal medicine post cerebrovascular accident progerss note post cerebrovascular cerebrovascular accident accident cerebrovascular neurologist insulin MEDICAL_TRANSCRIPTION,Description Patient having foot pain Medical Specialty SOAP Chart Progress Notes Sample Name Foot Pain SOAP Transcription SUBJECTIVE This 32 year old female comes in again still having not got a primary care physician She said she was at Dr XYZ office today for her appointment and they cancelled her appointment because she has not gotten her Project Access insurance into affect She says that Project Access is trying to find her a doctor She is not currently on Project Access and so she is here to get something for the pain in her foot I did notice that she went in to see Dr XYZ for a primary care physician on 05 14 2004 She said she does not have a primary care physician She was in here just last week and saw Dr XYZ for back pain and was put on pain medicines and muscle relaxers She has been in here multiple times for different kinds of pain This pain she is having is in her foot She had surgery on it and she has plates and screws She said she was suppose to see Dr XYZ about getting some of the hardware out of it The appointment was cancelled and that is why she came here It started hurting a lot yesterday but she had this previous appointment with Dr XYZ so she thought she would take care of it there but they would not see her She did not injure her foot in any way recently It is chronically painful Every time she does very much exercise it hurts more We have x rayed it in the past She has some hardware there It does not appear to be grossly abnormal or causing any loosening or problems on x ray PHYSICAL EXAM Examination of her foot shows some well healed surgical scars On the top of her foot she has two and then on the lateral aspect below her ankle she has a long scar They are all old and the surgery was done over a year ago She is walking with a very slight limp There is no redness No heat No swelling of the foot or the ankle It is mildly tender around the medial side of the foot just inferior to the medial malleolus It is not warm or red ASSESSMENT Foot pain PLAN She has been in here before She seems very pleasant Thought maybe she certainly might be having some significant pain so I gave her some Lortab 7 5 to take with a refill After she left I got to thinking about it and looked into her record She has been in here multiple times for pain medicine She has a primary care physician and now she is telling us she does not have a primary care physician even though she had seen Dr XYZ not too long ago We called Dr XYZ office Dr XYZ nurse said that the patient did not have an appointment today She has an appointment on June 15 2004 for a postop check They did not tell her they would not see her today because of insurance so the patient was lying to me We will keep that in mind the next time she returns because she will likely be back She did say that Project Access will be approving her insurance next week so she will be able to see Dr XYZ soon Keywords soap chart progress notes soap foot pain primary care physician project access insurance foot project access care appointment MEDICAL_TRANSCRIPTION,Description The patient states that he feels sick and weak Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note Transcription SUBJECTIVE The patient states that he feels sick and weak PHYSICAL EXAMINATION VITAL SIGNS Highest temperature recorded over the past 24 hours was 101 1 and current temperature is 99 2 GENERAL The patient looks tired HEENT Oral mucosa is dry CHEST Clear to auscultation He states that he has a mild cough not productive CARDIOVASCULAR First and second heart sounds were heard No murmur was appreciated ABDOMEN Soft and nontender Bowel sounds are positive Murphy s sign is negative EXTREMITIES There is no swelling NEURO The patient is alert and oriented x 3 Examination is nonfocal LABORATORY DATA White count is normal at 6 8 hemoglobin is 15 8 and platelets 257 000 Glucose is in the low 100s Comprehensive metabolic panel is unremarkable UA is negative for infection ASSESSMENT AND PLAN 1 Fever of undetermined origin probably viral since white count is normal Would continue current antibiotics empirically 2 Dehydration Hydrate the patient 3 Prostatic hypertrophy Urologist Dr X 4 DVT prophylaxis with subcutaneous heparin Keywords soap chart progress notes fever dehydration prophylaxis white count is normal white count sick weak temperature MEDICAL_TRANSCRIPTION,Description Followup of laparoscopic fundoplication and gastrostomy Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access Medical Specialty SOAP Chart Progress Notes Sample Name Fundoplication Gastrostomy Followup Transcription REASON FOR VISIT Followup of laparoscopic fundoplication and gastrostomy HISTORY OF PRESENT ILLNESS The patient is a delightful baby girl who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty Dr X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber The patient had a laparoscopic fundoplication and gastrostomy on 10 05 2007 She has done well since that time She has had some episodes of retching intermittently and these seemed to be unpredictable She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved The patient currently takes about 1 ounce to 1 5 ounce of her feedings by mouth and the rest is given by G tube She seems otherwise happy and is not having an excessive amount of stools Her parents have not noted any significant problems with the gastrostomy site The patient s exam today is excellent Her belly is soft and nontender All of her laparoscopic trocar sites are healing with a normal amount of induration but there is no evidence of hernia or infection We removed The patient s gastrostomy button today and showed her parents how to reinsert one without difficulty The site of the gastrostomy is excellent There is not even a hint of granulation tissue or erythema and I am very happy with the overall appearance IMPRESSION The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy Hopefully the exquisite control of acid reflux by fundoplication will help her airway heal and if she does well allow decannulation in the future If she does require laryngotracheoplasty the protection from acid reflux will be important to healing of that procedure as well PLAN The patient will follow up as needed for problems related to gastrostomy We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future Keywords soap chart progress notes decannulation enteral feeding feeding access laparoscopic fundoplication gastrostomy airway laryngotracheoplasty laparoscopic fundoplication MEDICAL_TRANSCRIPTION,Description Follow up consultation second opinion foreskin Medical Specialty SOAP Chart Progress Notes Sample Name Foreskin Followup Transcription REASON FOR VISIT Follow up consultation second opinion foreskin HISTORY OF PRESENT ILLNESS A 2 week old who at this point has otherwise been doing well He has a relatively unremarkable foreskin At this point in time he otherwise seems to be doing reasonably well The question is about the foreskin He otherwise has no other significant issues Severity low ongoing since birth two weeks Thank you for allowing me to see this patient in consultation PHYSICAL EXAMINATION Male exam Normal and under the penis report normal uncircumcised 2 week old He has a slightly insertion on the penile shaft from the median raphe of the scrotum IMPRESSION Slightly high insertion of the median raphe I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision This kid should otherwise do reasonably well PLAN Follow up as needed But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age but may do well with a person who is very accomplished doing a Gomco circumcision Keywords soap chart progress notes formal circumcision median raphe penis gomco circumcision gomco circumcision foreskin MEDICAL_TRANSCRIPTION,Description 5 month recheck on type II diabetes mellitus as well as hypertension Medical Specialty SOAP Chart Progress Notes Sample Name Gen Med Progress Note 11 Transcription SUBJECTIVE The patient is a 66 year old female who presents to the clinic today for a five month recheck on her type II diabetes mellitus as well as hypertension While here she had a couple of other issues as well She stated that she has been having some right shoulder pain She denies any injury but certain range of motion does cause it to hurt No weakness numbness or tingling As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100 She has not been checking any two hours after meals Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her No other issues or concerns Upon review of her chart it did show that she had a benign breast biopsy done back on 06 11 04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well ALLERGIES None MEDICATIONS She is on Hyzaar 50 12 5 one half p o daily coated aspirin daily lovastatin 40 mg one half tab p o daily multivitamin daily metformin 500 mg one tab p o b i d however she has been skipping her second dose during the day SOCIAL HISTORY She is a nonsmoker REVIEW OF SYSTEMS As noted above OBJECTIVE Vital Signs Temperature 98 2 Pulse 64 Respirations 16 Blood pressure 110 56 Weight 169 General Alert and oriented x 3 No acute distress noted Neck No lymphadenopathy thyromegaly JVD or bruits Lungs Clear to auscultation Heart Regular rate and rhythm without murmur or gallops present Breasts Exam performed with a female nurse present The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery There is no axillary adenopathy or tenderness Breasts appear to be symmetric There was no nipple discharge or retraction No breast tissue retraction noted in either the sitting or the supine position Upon palpation there were no palpable lumps or bumps and no palpable discharge Musculoskeletal She did have full range of motion of her shoulders She did have tenderness upon palpation over the right bicipital tendon There is no swelling crepitus or discoloration noted MEDICAL DECISION MAKING Most recent hemoglobin A1c was 5 6 back in October 2004 Most recent lipid checks were obtained back in July 2004 We have not had this checked since that time ASSESSMENT 1 Type II diabetes mellitus 2 Hypertension 3 Right shoulder pain 4 Hyperlipidemia PLAN 1 She is going to go to lab to obtain a hemoglobin A1c BMP lipids CPK liver enzymes and quantitative microalbumin 2 We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst 3 I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week 4 She is going to follow up in the clinic in three months for a complete comprehensive examination If any questions concerns or problems arise between now and then she should let us know Keywords MEDICAL_TRANSCRIPTION,Description Chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies and history of asthma Medical Specialty SOAP Chart Progress Notes Sample Name Evaluation of Allergies Transcription HISTORY A 55 year old female presents self referred for the possibility of evaluation and treatment of allergies diminished taste xerostomia gastroesophageal reflux disease possible food allergies chronic GI irritability asthma and environmental inhalant allergies Please refer to chart for history and physical and review of systems and detailed medical history IMPRESSION 1 Chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies history of asthma 2 History of fibromyalgia 3 History of peptic ulcer disease history of gastritis history of gastroesophageal disease 4 History of chronic fatigue 5 History of hypothyroidism 6 History of depression 7 History of dysphagia RECOMMENDATIONS RAST allergy testing was ordered for food allergy evaluation The patient had previous allergy testing done less than one year ago iby Dr X which was requested The patient will follow up after RAST allergy testing for further treatment recommendations At this point no changes in her medication were prescribed until her followup visit Keywords soap chart progress notes chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies environmental inhalant allergies rast allergy testing rast inhalant food allergy MEDICAL_TRANSCRIPTION,Description Fifth disease with sinusitis Medical Specialty SOAP Chart Progress Notes Sample Name Fifth Disease SOAP Transcription SUBJECTIVE Grandfather brings the patient in today because of headaches mostly in her face She is feeling pressure there with a lot of sniffles Last night she complained of sore throat and a loose cough Over the last three days she has had a rash on her face back and arms A lot of fifth disease at school She says it itches and they have been doing some Benadryl for this She has not had any wheezing lately and is not taking any ongoing medications for her asthma PAST MEDICAL HISTORY Asthma and allergies FAMILY HISTORY Sister is dizzy but no other acute illnesses OBJECTIVE General The patient is an 11 year old female Alert and cooperative No acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally gray in color and good light reflex Oropharynx is pink and moist No erythema or exudates She has postnasal discharge Nares are swollen and red Purulent discharge in the posterior turbinates Both maxillary sinuses are tender She has some mild tenderness in the left frontal sinus Eyes are puffy and she has dark circles Chest Respirations are regular and nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry and pink Moist mucous membranes Red lacey rash from the wrists to the elbows both sides It is very faint on the lower back and she has reddened cheeks as well ASSESSMENT Fifth disease with sinusitis PLAN Omnicef 300 mg daily for 10 days May use some Zyrtec for the itching Samples are given Keywords soap chart progress notes fifth disease soap asthma headaches sinusitis sore throat oropharynx MEDICAL_TRANSCRIPTION,Description Preop evaluation regarding gastric bypass surgery Medical Specialty SOAP Chart Progress Notes Sample Name Gastric Bypass Preop Eval Transcription REASON FOR VISIT Preop evaluation regarding gastric bypass surgery The patient has gone through the evaluation process and has been cleared from psychological nutritional and cardiac standpoint also had great success on the preop Medifast diet PHYSICAL EXAMINATION The patient is alert and oriented x3 Temperature of 97 9 pulse of 76 blood pressure of 114 74 weight of 247 4 pounds Abdomen Soft nontender and nondistended ASSESSMENT AND PLAN The patient is currently in stable condition with morbid obesity scheduled for gastric bypass surgery in less than two weeks Risks and benefits of the procedure were reiterated with the patient and significant other and mother which included but not limited to death pulmonary embolism anastomotic leak reoperation prolonged hospitalization stricture small bowel obstruction bleeding and infection Questions regarding hospital course and recovery were addressed We will continue on the Medifast diet until the time of surgery and cleared for surgery Keywords soap chart progress notes medifast medifast diet preop evaluation gastric bypass surgery bypass surgery gastric bypass MEDICAL_TRANSCRIPTION,Description Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot Medical Specialty SOAP Chart Progress Notes Sample Name Foot Lesions Transcription S An 84 year old diabetic female 5 7 1 2 tall 148 pounds history of hypertension and diabetes She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot She also has a left great toenail that is giving her problems as well O Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1 1 cm in diameter There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1 1 cm in diameter These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening The first and fifth metatarsal heads are plantarflexed Vibratory sensation appears to be absent Dorsal pedal pulses are nonpalpable Varicose veins are visible to the skin on the patient s feet that are very thin almost transparent The medial aspect of the left great toenail has dried blood under the nail The nail itself is very opaque loose from the nailbed almost rotten opaque discolored hypertrophic All of the patient s toenails are elongated and discolored and opaque as well There is dried blood under the medial aspect of the left great toenail A 1 Painful feet Keywords soap chart progress notes painful left foot lesions plantar metatarsal head hyperkeratotic lesion toenail nail matrix metatarsal metatarsal heads foot painful MEDICAL_TRANSCRIPTION,Description Evaluation and recommendations regarding facial rhytids Medical Specialty SOAP Chart Progress Notes Sample Name Facial Rhytids Transcription HISTORY This 57 year old female who presented today for evaluation and recommendations regarding facial rhytids In summary the patient is a healthy 57 year old female nonsmoker with no history of skin disease who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds RECOMMENDATIONS I do believe a facelift procedure would be of maximum effect for the patient s areas of concern and a quick lift type procedure certainly would address these issues I went over risks and benefits with the patient along with the preoperative and postoperative care and risks include but are not limited to bleeding infection discharge scar formation need for further surgery facial nerve injury numbness asymmetry of face problems with hypertrophic scarring problems with dissatisfaction with anticipated results and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center Keywords soap chart progress notes quick lift hypertrophic scarring facial rhytids mid face region nasolabial folds liftNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively Medical Specialty SOAP Chart Progress Notes Sample Name Followup Screw Fixation Transcription REASON FOR VISIT Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively HISTORY OF PRESENT ILLNESS The patient is a 59 year old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures He is currently at home and has left nursing home facility He states that his pain is well controlled He has been working with physical therapy two to three times a week He has had no drainage or fever He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy FINDINGS On physical exam his incision is near well healed He has no effusion noted His range of motion is 10 to 105 degrees He has no pain or crepitance On examination of his right foot he is nontender to palpation of the metatarsal heads He has 4 out of 5 strength in EHL FHL tibialis and gastroc soleus complex He does have decreased sensation to light touch in the L4 L5 distribution of his feet bilaterally X rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures These appear to be extraarticular They are all in a bayonet arrangement but there appears to be bridging callus between the fragments on the oblique film ASSESSMENT Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures PLANS I would like the patient to continue working with physical therapy He may be weightbearing as tolerated on his right side I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion I also would like him to work on ambulation and strengthening I discussed with the patient his concerning symptoms of paresthesias He said he has had the left thigh for a number of years and has been followed by a neurologist for this He states that he has had some right sided paresthesias now for a number of weeks He claims he has no other symptoms of any worsening stenosis I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot Keywords soap chart progress notes metatarsal head fractures tibial plateau fracture schatzker percutaneous screw fixation tibial plateau metatarsal head screw fixation head screw fixation metatarsal MEDICAL_TRANSCRIPTION,Description Dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult Weight Reduction Transcription SUBJECTIVE This is a 56 year old female who comes in for a dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction The patient states that her husband has been diagnosed with high blood cholesterol as well She wants some support with some dietary recommendations to assist both of them in healthier eating The two of them live alone now and she is used to cooking for large portions She is having a hard time adjusting to preparing food for the two of them She would like to do less food preparation in fact She is starting a new job this week OBJECTIVE Her reported height is 5 feet 4 inches Today s weight was 170 pounds BMI is approximately 29 A diet history was obtained I instructed the patient on a 1200 calorie meal plan emphasizing low saturated fat sources with moderate amounts of sodium as well Information on fast food eating was supplied and additional information on low fat eating was also supplied ASSESSMENT The patient s basal energy expenditure is estimated at 1361 calories a day Her total calorie requirement for weight maintenance is estimated at 1759 calories a day Her diet history reflects that she is making some very healthy food choices on a regular basis She does emphasize a lot of fruits and vegetables trying to get a fruit or a vegetable or both at most meals She also is emphasizing lower fat selections Her physical activity level is moderate at this time She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long term basis for weight reduction We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well We discussed menu selection as well as food preparation techniques The patient appears to have been influenced by the current low carb high protein craze and had really limited her food selections based on that I was able to give her some more room for variety including some moderate portions of potatoes pasta and even on occasion breading her meat as long as she prepares it in a low fat fashion which was discussed PLAN Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week This translates into a 1200 calorie meal plan I encouraged the patient to keep food records in order to better track calories consumed I recommended low fat selections and especially those that are lower in saturated fats Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well This was a one hour consultation I provided my name and number should additional needs arise Keywords soap chart progress notes hyperlipidemia hypertension gastroesophageal reflux disease weight reduction dietary recommendations healthier eating meal plan dietary consultation low fat physical activity weight gastroesophageal dietary calories food MEDICAL_TRANSCRIPTION,Description Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection Medical Specialty SOAP Chart Progress Notes Sample Name E Coli UTI Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup recently noted for E coli urinary tract infection She was treated with Macrobid for 7 days and only took one nighttime prophylaxis She discontinued this medication to due to skin rash as well as hives Since then this had resolved Does not have any dysuria gross hematuria fever chills Daytime frequency every two to three hours nocturia times one no incontinence improving stress urinary incontinence after Prometheus pelvic rehabilitation Renal ultrasound August 5 2008 reviewed no evidence of hydronephrosis bladder mass or stone Discussed Previous urine cultures have shown E coli November 2007 May 7 2008 and July 7 2008 CATHETERIZED URINE Discussed agreeable done using standard procedure A total of 30 mL obtained IMPRESSION Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection completed the therapeutic dose but stopped the prophylactic Macrodantin due to hives This has resolved PLAN We will send the urine for culture and sensitivity if no infection patient will call results on Monday and she will be placed on Keflex nighttime prophylaxis otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr X All questions answered Keywords soap chart progress notes urinary tract infection escherichia coli prophylactic macrodantin e coli infection MEDICAL_TRANSCRIPTION,Description Stage IIIC endometrial cancer Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 Medical Specialty SOAP Chart Progress Notes Sample Name Endometrial Cancer Followup Transcription CHIEF COMPLAINT 1 Stage IIIC endometrial cancer 2 Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane HISTORY OF PRESENT ILLNESS The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 In March 2010 she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus CT scan of the abdomen on 03 22 2010 showed an enlarged uterus thickening of the endometrium and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis On 04 01 2010 she had a robotic modified radical hysterectomy with bilateral salpingo oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy The pathology was positive for grade III endometrial adenocarcinoma 9 5 cm in size with 2 cm of invasion Four of 30 lymph nodes were positive for disease The left ovary was positive for metastatic disease Postsurgical PET CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup Of note we had sent off genetic testing which was denied back in June I have been trying to get this testing completed CURRENT MEDICATIONS Synthroid q d ferrous sulfate 325 mg b i d multivitamin q d Ativan 0 5 mg q 4 hours p r n nausea and insomnia gabapentin one tablet at bedtime ALLERGIES Keywords soap chart progress notes adjuvant adjuvant chemotherapy cisplatin adriamycin abraxane endometrial cancer lymphadenectomy chemotherapy endometrial disease MEDICAL_TRANSCRIPTION,Description Some improvement of erectile dysfunction on low dose of Cialis with no side effects Medical Specialty SOAP Chart Progress Notes Sample Name Erectile Dysfunction Followup Transcription HISTORY OF PRESENT ILLNESS The patient presents today for followup history of erectile dysfunction last visit started on Cialis 10 mg He indicates that he has noticed some mild improvement of his symptoms with no side effect On this dose he is having firm erection able to penetrate lasting for about 10 or so minutes No chest pain no nitroglycerin usage no fever no chills No dysuria gross hematuria fever chills Daytime frequency every three hours nocturia times 0 good stream He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN mid left biopsy with two specimens being too small to evaluate PSA 11 6 Dr X s notes are reviewed IMPRESSION 1 Some improvement of erectile dysfunction on low dose of Cialis with no side effects The patient has multiple risk factors but denies using any nitroglycerin or any cardiac issues at this time We reviewed options of increasing the medication versus trying other medications options of penile prosthesis Caverject injection use as well as working pump is reviewed 2 Elevated PSA in a patient with a recent biopsy showing high grade PIN as well as two specimens not being large enough to evaluate The patient tells me he has met with his primary care physician and after discussion he is in consideration of repeating a prostate ultrasound and biopsy However he would like to meet with Dr X to discuss these prior to biopsy PLAN Following detailed discussion the patient wishes to proceed with Cialis 20 mg samples are provided as well as Levitra 10 mg may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed The patient not to use them at the same time Will call if any other concern In the meantime he is scheduled to meet with Dr X with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy He declined scheduling this at this time All questions answered Keywords soap chart progress notes improvement of erectile dysfunction erectile dysfunction erectile dysfunction cialis psa biopsy MEDICAL_TRANSCRIPTION,Description A 46 year old white male with Down s syndrome presents for followup of hypothyroidism as well as onychomycosis Medical Specialty SOAP Chart Progress Notes Sample Name Down s syndrome Transcription SUBJECTIVE This 46 year old white male with Down s syndrome presents with his mother for followup of hypothyroidism as well as onychomycosis He has finished six weeks of Lamisil without any problems He is due to have an ALT check today At his appointment in April I also found that he was hypothyroid with elevated TSH He was started on Levothroid 0 1 mg and has been taking that daily We will recheck a TSH today as well His mother notes that although he does not like to take the medications he is taking it with encouragement His only other medications are some eyedrops for his cornea OBJECTIVE Weight was 149 pounds which is up 2 pounds Blood pressure was 120 80 Pulse is 80 and regular Neck Supple without adenopathy No thyromegaly or nodules were palpable Cardiac Regular rate and rhythm without murmurs Skin Examination of the toenails showed really no change yet They are still quite thickened and yellowed ASSESSMENT 1 Down s syndrome 2 Onychomycosis 3 Hypothyroidism PLAN 1 Recheck ALT and TSH today and call results 2 Lamisil 250 mg 30 one p o daily with one refill They will complete the next eight weeks of therapy as long as the ALT is normal I again reviewed the symptoms of liver dysfunction 3 Continue Levothroid 0 1 mg daily unless dosage need to be adjusted based on the TSH Keywords soap chart progress notes down s syndrome hypothyroidism onychomycosis hypothyroid tsh down s MEDICAL_TRANSCRIPTION,Description Followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult Hyperlipidemia Transcription SUBJECTIVE This is a followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome The patient reports that she has worked hard for a number of weeks following the meal plan prescribed but felt like she was gaining weight and not losing weight on it She is not sure that she was following it accurately She is trying to walk 1 1 2 to 2 miles every other day but is increasing her time in the garden and doing other yard work as well Once she started experiencing some weight gain she went back to her old South Beach Diet and felt like she was able to take some of that weight off However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low fat eating OBJECTIVE Weight is 275 pounds Food records were reviewed ASSESSMENT The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago I did carefully review her food records and evaluated calories consumed While she was carefully tracking the volume of protein and carbohydrates she was getting some excess calories from the fatty proteins selected Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates While this still is not as much carbohydrate as I would normally recommend I am certainly willing to work with her on how she feels her body best handles weight reduction We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time PLAN A new 1500 calorie meal plan was developed based on 35 of the calories coming from protein 40 of the calories from carbohydrate and 25 of the calories from fat This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack This also translates in to 2 ounces of protein at breakfast 6 ounces at lunch 2 ounces in the afternoon snack 6 ounces at supper and 2 ounces in the evening snack We have eliminated the morning snack The patient will now track the grams of fat in her meats as well as added fats Her goal for total fats over the course of the day is no more than 42 grams of fat per day This was a half hour consultation We will plan to see the patient back in one month for support Keywords soap chart progress notes hyperlipidemia hypertension metabolic syndrome meal food records south beach diet dietary consultation meal plan carbohydrates snack dietary calories weight MEDICAL_TRANSCRIPTION,Description The patient is brought in by an assistant with some of his food diary sheets Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult 3 Transcription SUBJECTIVE The patient is brought in by an assistant with some of his food diary sheets They wonder if the patient needs to lose anymore weight OBJECTIVE The patient s weight today is 186 1 2 pounds which is down 1 1 2 pounds in the past month He has lost a total of 34 1 2 pounds I praised this I went over his food diary and praised all of his positive food choices reported especially his use of sugar free Kool Aid sugar free pudding and diet pop I encouraged him to continue all of that as well as his regular physical activity ASSESSMENT The patient is losing weight at an acceptable rate He needs to continue keeping a food diary and his regular physical activity PLAN The patient plans to see Dr XYZ at the end of May 2005 I recommended that they ask Dr XYZ what weight he would like for the patient to be at Follow up will be with me June 13 2005 Keywords soap chart progress notes weight kool aid food diary sheets diary sheets physical activity food diary dietary sheets diary food MEDICAL_TRANSCRIPTION,Description Dietary consultation for gestational diabetes Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult Gestational Diabetes Transcription SUBJECTIVE This is a 38 year old female who comes for dietary consultation for gestational diabetes Patient reports that she is scared to eat because of its impact on her blood sugars She is actually trying not to eat while she is working third shift at Wal Mart Historically however she likes to eat out with a high frequency She enjoys eating rice as part of her meals She is complaining of feeling fatigued and tired all the time because she works from 10 p m to 7 a m at Wal Mart and has young children at home She sleeps two to four hours at a time throughout the day She has been testing for ketones first thing in the morning when she gets home from work OBJECTIVE Today s weight 155 5 pounds Weight from 10 07 04 was 156 7 pounds A diet history was obtained Blood sugar records for the last three days reveal the following fasting blood sugars 83 84 87 77 two hour postprandial breakfast 116 107 97 pre lunch 85 108 77 two hour postprandial lunch 86 131 100 pre supper 78 91 100 two hour postprandial supper 125 121 161 bedtime 104 90 and 88 I instructed the patient on dietary guidelines for gestational diabetes The Lily Guide for Meal Planning was provided and reviewed Additional information on gestational diabetes was applied A sample 2000 calorie meal plan was provided with a carbohydrate budget established ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1336 calories a day Her total calorie requirements including a physical activity factor as well as additional calories for pregnancy totals to 2036 calories per day Her diet history reveals that she has somewhat irregular eating patterns In the last 24 hours when she was working at Wal Mart she ate at 5 a m but did not eat anything prior to that since starting work at 10 p m We discussed the need for small frequent eating We identified carbohydrate as the food source that contributes to the blood glucose response We identified carbohydrate sources in the food supply recognizing that they are all good for her The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars In regard to use of her traditional foods of rice I pulled out a one third cup measuring cup to identify a 15 gram equivalent of rice We discussed the need for moderating the portion of carbohydrates consumed at one given time Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake Her weight loss was discouraged Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time PLAN The meal plan provided has a carbohydrate content that represents 40 percent of a 2000 calorie meal plan The meal plan was devised to distribute her carbohydrates more evenly throughout the day The meal plan was meant to reflect an example for her eating while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time The meal plan is as follows breakfast 2 carbohydrate servings snack 1 carbohydrate serving lunch 2 3 carbohydrate servings snack 1 carbohydrate serving dinner 2 3 carbohydrate servings bedtime snack 1 2 carbohydrate servings Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep Encouraged adequate rest Also recommend adequate calories to sustain weight gain of one half to one pound per week If the meal plan reflected does not support slow gradual weight gain then we will need to add more foods accordingly This was a one hour consultation I provided my name and number should additional needs arise Keywords soap chart progress notes blood sugars fatigued total calorie carbohydrate content consultation for gestational diabetes dietary consultation weight gain gestational diabetes carbohydrate servings meal planning meals weight carbohydrate dietary servings planning MEDICAL_TRANSCRIPTION,Description Counting calorie points exercising pretty regularly seems to be doing well Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult 4 Transcription SUBJECTIVE The patient is keeping a food journal that she brought in She is counting calorie points which ranged 26 to 30 per day She is exercising pretty regularly She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia The patient requests information on diabetic exchanges She said she is feeling better since she has lost weight OBJECTIVE Vital Signs The patient s weight today is 209 pounds which is down 22 pounds since I last saw her on 06 07 2004 I praised her weight loss and her regular exercising I looked at her food journal I praised her record keeping I gave her a list of the diabetic exchanges and explained them I also gave her a food dairy sheet so that she could record exchanges I encouraged her to continue ASSESSMENT The patient seems happy with her progress and she seems to be doing well She needs to continue PLAN Followup is on a p r n basis She is always welcome to call or return Keywords soap chart progress notes overeaters anonymous diabetic exchanges exercising pretty regularly food journal diabetic exercising exchanges regularly MEDICAL_TRANSCRIPTION,Description Dietary consultation for diabetes during pregnancy Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult Diabetes 1 Transcription SUBJECTIVE This is a 28 year old female who comes for dietary consultation for diabetes during pregnancy Patient reports that she had gestational diabetes with her first pregnancy She did use insulin at that time as well She does not fully understand what ketones are She walks her daughter to school and back home each day which takes 20 minutes each way She is not a big milk drinker but she does try to drink some OBJECTIVE Weight is 238 3 pounds Weight from last week s visit was 238 9 pounds Prepregnancy weight is reported at 235 pounds Height is 62 3 4 inches Prepregnancy BMI is approximately 42 1 2 Insulin schedule is NovoLog 70 30 20 units in the morning and 13 units at supper time Blood sugar records for the last week reveal the following Fasting blood sugars ranging from 92 to 104 with an average of 97 two hour postprandial breakfast readings ranging from 172 to 196 with an average of 181 two hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two hour postprandial dinner readings ranging from 109 to 121 with an average of 116 Overall average is 140 A diet history was obtained Expected date of confinement is May 1 2005 Instructed the patient on dietary guidelines for gestational diabetes A 2300 meal plan was provided and reviewed The Lily Guide for Meal Planning was provided and reviewed ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day Her total calorie requirements including physical activity factors as well as additional calories for pregnancy totals 2367 calories a day Her diet history reveals that she is eating three meals a day and three snacks The snacks were just added last week following presence of ketones in her urine We identified carbohydrate sources in the food supply recognizing that they are the foods that raise blood sugar the most We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1 2 a pound a week through the duration of the pregnancy We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars While a sample meal plan was provided reflecting the patient s carbohydrate budget I emphasized the need for her to eat according to her appetite but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates PLAN Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45 of the calories from carbohydrate Breakfast Three carbohydrate servings Morning snack One carbohydrate serving Lunch Four carbohydrate servings Afternoon snack One carbohydrate serving Supper Four carbohydrate servings Bedtime snack One carbohydrate serving Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy Recommend patient include a fruit or a vegetable with most of her meals Also recommend including solid protein with each meal as well as with the bedtime snack Charlie Athene reviewed blood sugars at this consultation as well and made the following insulin adjustment Morning 70 30 will increase from 20 units up to 24 units and evening 70 30 we will increase from 13 units up to 16 units Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two hour postprandial Provided my name and number should there be additional dietary questions Keywords soap chart progress notes diabetes during pregnancy diabetes insulin gestational diabetes adjusted for obesity calorie requirements dietary consultation carbohydrate postprandial meal calories dietary pregnancy servings snacks MEDICAL_TRANSCRIPTION,Description The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult 2 Transcription SUBJECTIVE The patient s assistant brings in her food diary sheets The patient says she stays active by walking at the mall OBJECTIVE Weight today is 201 pounds which is down 3 pounds in the past month She has lost a total of 24 pounds I praised this and encouraged her to continue I went over her food diary I praised her three meal pattern and all of her positive food choices especially the use of sugar free Kool Aid sugar free Jell O sugar free lemonade diet pop as well as the variety of foods she is using in her three meal pattern I encouraged her to continue all of this ASSESSMENT The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity She needs to continue all this PLAN Followup is set for 06 13 05 to check the patient s weight her food diary and answer any questions Keywords soap chart progress notes food diary sheets active balanced diet three meal pattern weight loss sugar free food diary dietary weight meal diary sheets food MEDICAL_TRANSCRIPTION,Description Patient today with ongoing issues with diabetic control Medical Specialty SOAP Chart Progress Notes Sample Name Diabetes Mellitus SOAP Note 2 Transcription SUBJECTIVE I am asked to see the patient today with ongoing issues around her diabetic control We have been fairly aggressively downwardly adjusting her insulins both the Lantus insulin which we had been giving at night as well as her sliding scale Humalog insulin prior to meals Despite frequent decreases in her insulin regimen she continues to have somewhat low blood glucoses most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units which is a considerable change What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin The staff reports to me that her appetite is good and that she is eating as well as ever I talked to Anna today She feels a little fatigued Otherwise she is doing well PHYSICAL EXAMINATION Vitals as in the chart The patient is a pleasant and cooperative She is in no apparent distress ASSESSMENT AND PLAN Diabetes still with some problematic low blood glucoses most notably in the morning To address this situation I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning She will get 55 units in the morning I am also decreasing once again her Humalog sliding scale insulin prior to meals I will review the blood glucoses again next week Keywords soap chart progress notes diabetic control insulin prior to meals low blood glucoses sliding scale lantus insulin diabetes mellitus lantus glucoses MEDICAL_TRANSCRIPTION,Description Dietary consult for a 79 year old African American female diagnosed with type 2 diabetes in 1983 Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult Diabetes 2 Transcription SUBJECTIVE The patient is a 79 year old African American female with a self reported height of 5 foot 3 inches and weight of 197 pounds She was diagnosed with type 2 diabetes in 1983 She is not allergic to any medicines DIABETES MEDICATIONS Her diabetes medications include Humulin insulin 70 30 44 units at breakfast and 22 units at supper Also metformin 500 mg at supper OTHER MEDICATIONS Other medications include verapamil Benicar Toprol clonidine and hydrochlorothiazide ASSESSMENT The patient and her daughter completed both days of diabetes education in a group setting Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician Fasting blood sugars are 127 80 and 80 Two hour postprandial breakfast reading was 105 two hour postprandial lunch reading was 88 and two hour postprandial dinner reading was 73 and 63 Her diet was excellent Seven hours of counseling about diabetes mellitus was provided on this date Blood glucose values obtained at 10 a m were 84 and at 2 30 p m were 109 Assessment of her knowledge is completed at the end of the counseling session She demonstrated increased knowledge in all areas and had no further questions She also completed an evaluation of the class The patient s feet were examined during the education session She had flat feet bilaterally Skin color was pink temperature warm Pedal pulses 2 Her right second and third toes lay on each other Also the same on her left foot However there was no skin breakdown She had large bunions medial aspect of the ball of both feet She had positive sensitivity to most areas of her feet however she had negative sensitivity to the medial and lateral aspect of the balls of her left foot During the education session she set behavioral goals for self care First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels Second goal is to eat a well balanced meal at 1200 calories in order to lose one half pound of weight per week and improve her blood glucose control Third goal is to exercise by walking for 15 to 30 minutes a day three to five days a week to increase her blood glucose control Her success in achieving these goals will be followed in three months by a letter from the diabetes education class RECOMMENDATIONS Since she is doing so well with her diet changes her blood sugars have been within normal limits and sometimes on the low side especially considering the fact that she has low blood sugar unawareness She is to followup with Dr XYZ for possible reduction in her insulin doses Keywords soap chart progress notes dietary consult diabetes education glucose control blood sugars blood glucose dietary diabetes MEDICAL_TRANSCRIPTION,Description Elevated PSA with nocturia and occasional daytime frequency Medical Specialty SOAP Chart Progress Notes Sample Name Elevated PSA Chart Note Transcription REASON FOR VISIT Elevated PSA with nocturia and occasional daytime frequency HISTORY A 68 year old male with a history of frequency and some outlet obstructive issues along with irritative issues The patient has had history of an elevated PSA and PSA in 2004 was 5 5 In 2003 he had undergone a biopsy by Dr X which was negative for adenocarcinoma of the prostate The patient has had PSAs as high as noted above His PSAs have been as low as 1 6 but those were on Proscar He otherwise appears to be doing reasonably well off the Proscar otherwise does have some irritative symptoms This has been ongoing for greater than five years No other associated symptoms or modifying factors Severity is moderate PSA relatively stable over time IMPRESSION Stable PSA over time although he does have some irritative symptoms After our discussion it does appear that if he is not drinking close to going to bed he notes that his nocturia has significantly decreased At this juncture what I would like to do is to start with behavior modification There were no other associated symptoms or modifying factors PLAN The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed He already knows that this does decrease his nocturia He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha blocker to something of more efficacious Keywords soap chart progress notes daytime frequency psa irritative symptoms elevated psa frequency nocturia MEDICAL_TRANSCRIPTION,Description Followup diabetes mellitus type 1 Medical Specialty SOAP Chart Progress Notes Sample Name Diabetes Mellitus SOAP Note 1 Transcription CHIEF COMPLAINT Followup diabetes mellitus type 1 SUBJECTIVE Patient is a 34 year old male with significant diabetic neuropathy He has been off on insurance for over a year Has been using NPH and Regular insulin to maintain his blood sugars States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago Reports that his blood sugar dropped too low which caused the accident Since this point in time he has been unwilling to let his blood sugars fall within a normal range for fear of hypoglycemia Also reports that he regulates his blood sugars with how he feels rarely checking his blood sugar with a glucometer Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time Reports that he had some indications of kidney damage when first diagnosed His urine microalbumin today is 100 His last hemoglobin A1C drawn at the end of December is 11 9 Reports that at one point he was on Lantus which worked well and he did not worry about his blood sugars dropping too low While using Lantus he was able to get his hemoglobin A1C down to 7 His last CMP shows an elevated alkaline phosphatase level of 168 He denies alcohol or drug use and is a non smoker Reports he quit drinking 3 years ago I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today Patient also has a history of gastroparesis and impotence Patient requests Nexium and Viagra neither of which are covered under the Health Plan Patient reports that he was in a scooter accident one week ago fell off his scooter hit his head Was not wearing a helmet Reports that he did not go to the emergency room and had a headache for several days after this incident Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room Patient did not comply Reports that the headache has resolved Denies any dizziness nausea vomiting or other neurological abnormalities PHYSICAL EXAMINATION WD WN Slender 34 year old white male VITAL SIGNS Blood sugar 145 blood pressure 120 88 heart rate 104 respirations 16 Microalbumin 100 SKIN There appears to be 2 skin lacerations on the left parietal region of the scalp each approximately 1 inch long No signs of infection Wound is closed with new granulation tissue Appears to be healing well HEENT Normocephalic PERRLA EOMI TMs pearly gray with landmarks present Nares patent Throat with no redness or swelling Nontender sinuses NECK Supple Full ROM No LAD CARDIAC Keywords soap chart progress notes diabetes mellitus nph regular insulin sggt diabetic neuropathy dizziness followup glucometer hypoglycemia microalbumin nausea neurological vomiting mellitus type blood sugars blood diabetes mellitus sugars MEDICAL_TRANSCRIPTION,Description Hand dermatitis Medical Specialty SOAP Chart Progress Notes Sample Name Dermatitis SOAP Transcription SUBJECTIVE This is a 29 year old Vietnamese female established patient of dermatology last seen in our office on 07 13 04 She comes in today as a referral from ABC D O for a reevaluation of her hand eczema I have treated her with Aristocort cream Cetaphil cream increased moisturizing cream and lotion and wash her hands in Cetaphil cleansing lotion She comes in today for reevaluation because she is flaring Her hands are very dry they are cracked she has been washing with soap She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin She has been wearing some gloves also apparently The patient is single She is unemployed FAMILY SOCIAL AND ALLERGY HISTORY The patient has asthma sinus hives and history of psoriasis No known drug allergies MEDICATIONS The patient is a nonsmoker No bad sunburns or blood pressure problems in the past CURRENT MEDICATIONS Claritin and Zyrtec p r n PHYSICAL EXAMINATION The patient has very dry cracked hands bilaterally IMPRESSION Hand dermatitis TREATMENT 1 Discussed further treatment with the patient and her interpreter 2 Apply Aristocort ointment 0 1 and equal part of Polysporin ointment t i d and p r n itch 3 Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion 4 Keflex 500 mg b i d times two weeks with one refill Return in one month if not better otherwise on a p r n basis and send Dr XYZ a letter on this office visit Keywords soap chart progress notes cetaphil cleansing lotion hand dermatitis aristocort wash ointment hand lotion dermatitis MEDICAL_TRANSCRIPTION,Description An 83 year old diabetic female presents today stating that she would like diabetic foot care Medical Specialty SOAP Chart Progress Notes Sample Name Diabetic Foot Care Transcription S An 83 year old diabetic female presents today stating that she would like diabetic foot care O On examination the lateral aspect of her left great toenail is deeply ingrown Her toenails are thick and opaque Vibratory sensation appears to be intact Dorsal pedal pulses are 1 4 There is no hair growth seen on her toes feet or lower legs Her feet are warm to the touch All of her toenails are hypertrophic opaque elongated and discolored A 1 Onychocryptosis Keywords soap chart progress notes onychocryptosis onychomycosis great toenail diabetic foot care diabetic foot foot toenail ingrown toenails diabetic MEDICAL_TRANSCRIPTION,Description The patient is a 40 year old female with a past medical history of repair of deviated septum with complication of a septal perforation At this time the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis Medical Specialty SOAP Chart Progress Notes Sample Name Deviated Septum Repair Followup Transcription CHIEF COMPLAINT Septal irritation HISTORY OF PRESENT ILLNESS The patient is a 39 year old African American female status post repair of septal deviation but unfortunately ultimately ended with a large septal perforation The patient has been using saline nasal wash 2 3 times daily however she states that she still has discomfort in her nose with a stretching like pressure She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose She has no other complaints at this time PHYSICAL EXAM GENERAL This is a pleasant African American female resting in the examination room chair in no apparent distress ENT External auditory canals are clear Tympanic membrane shows no perforation is intact NOSE The patient has a slightly deviated right septum Septum has a large perforation in the anterior 2 3rd of the septum This appears to be well healed There is no sign of crusting in the nose ORAL CAVITY No lesions or sores Tonsils show no exudate or erythema NECK No cervical lymphadenopathy VITAL SIGNS Temperature 98 degrees Fahrenheit pulse 77 respirations 18 blood pressure 130 73 ASSESSMENT AND PLAN The patient is a 40 year old female with a past medical history of repair of deviated septum with complication of a septal perforation At this time the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis At this time I counseled the patient on the risks and benefits of surgery She will consider surgery but at this time would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting which she will apply with the edge of a Q tip We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash we will consider setting the patient for surgery at that time Keywords soap chart progress notes saline nasal wash deviated septum saline nasal septal perforation nose septum septal perforation MEDICAL_TRANSCRIPTION,Description Elevated cholesterol and is on medication to lower it Medical Specialty SOAP Chart Progress Notes Sample Name Dietary Consult 1 Transcription SUBJECTIVE His brother although he is a vegetarian has elevated cholesterol and he is on medication to lower it The patient started improving his diet when he received the letter explaining his lipids are elevated He is consuming less cappuccino quiche crescents candy from vending machines etc He has started packing his lunch three to four times per week instead of eating out so much He is exercising six to seven days per week by swimming biking running lifting weights one and a half to two and a half hours each time He is in training for a triathlon He says he is already losing weight due to his efforts OBJECTIVE Height 6 foot 2 inches Weight 204 pounds on 03 07 05 Ideal body weight 190 pounds plus or minus ten percent He is 107 percent standard of midpoint ideal body weight BMI 26 189 A 48 year old male Lab on 03 15 05 Cholesterol 251 LDL 166 VLDL 17 HDL 68 Triglycerides 87 I explained to the patient the dietary guidelines to help improve his lipids I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2 300 calories since he is interested in losing weight I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read I encouraged him to continue as he is doing ASSESSMENT Basal energy expenditure 1960 x 1 44 activity factor is approximately 2 800 calories His 24 hour recall shows he is making many positive changes already to lower his fat and cholesterol intake He needs to continue as he is doing He verbalized understanding and seemed receptive PLAN The patient plans to recheck his lipids through Dr XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet Keywords soap chart progress notes vegetarian lipids cholesterol intake elevated cholesterol losing weight body weight dietary cholesterol MEDICAL_TRANSCRIPTION,Description Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin Medical Specialty SOAP Chart Progress Notes Sample Name Diabetes Mellitus Followup Transcription PROBLEM LIST 1 Type 1 diabetes mellitus insulin pump 2 Hypertension 3 Hyperlipidemia HISTORY OF PRESENT ILLNESS The patient is a 39 year old woman returns for followup management of type 1 diabetes mellitus Her last visit was approximately 4 months ago Since that time the patient states her health had been good and her glycemic control had been good however within the past 2 weeks she had a pump malfunction had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks She is not reporting any severe hypoglycemic events but is having some difficulty with hyperglycemia both fasting and postprandial She is not reporting polyuria polydipsia or polyphagia She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well She is working on a full time basis and so eats on the run a lot probably eats more than she should and not making the best choices little time for physical activity She is keeping up with all her other appointments and has recently had a good eye examination She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144 CURRENT MEDICATIONS 1 Zoloft 50 mg p o once daily 2 Lisinopril 40 mg once daily 3 Symlin 60 micrograms not taking at this point 4 Folic acid 2 by mouth every day 5 NovoLog insulin via insulin pump about 90 units of insulin per day REVIEW OF SYSTEMS She denies fever chills sweats nausea vomiting diarrhea constipation abdominal pain chest pain shortness of breath difficulty breathing dyspnea on exertion or change in exercise tolerance She is not having painful urination or blood in the urine She is not reporting polyuria polydipsia or polyphagia PHYSICAL EXAMINATION GENERAL Today showed a very pleasant well nourished woman in no acute distress VITAL SIGNS Temperature not taken pulse 98 respirations 20 blood pressure 148 89 and weight 91 19 kg THORAX Revealed lungs clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 no S4 auscultated ABDOMEN Nontender EXTREMITIES Showed no clubbing cyanosis or edema SKIN Intact and do not appear atrophic Deep tendon reflexes were 2 4 without a delayed relaxation phase LABORATORY DATA Dated 10 05 08 showed a total cholesterol of 223 triglyceride 140 HDL 54 and LDL 144 The hemoglobin A1c was 6 4 and the spot urine for microalbumin was 9 2 micrograms of protein 1 mg of creatinine Sodium 136 potassium 4 5 chloride 102 CO2 30 mEq BUN 11 mg dL creatinine 0 6 mg estimated GFR greater than 60 blood sugar 118 calcium 9 4 and her LFTs were unremarkable TSH is 1 07 and free T4 is 0 81 ASSESSMENT AND PLAN 1 This is a return visit to the endocrine clinic for the patient a 39 year old woman with history as noted above Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin Basal rate is as follows 12 a m 1 5 02 30 a m 1 75 and 6 a m 1 5 Her correction factor is 19 Her carb insulin ratio is 6 Her active insulin time is 5 and her targets are at 12 a m 110 and 6 a m to midnight is 100 We made adjustments to her pump and the plan will be to see her back in approximately 2 months 2 Hyperlipidemia The patient is not taking statin therefore we will prescribe Lipitor 20 mg one p o once daily Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now 3 We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well Keywords soap chart progress notes endocrine clinic insulin pump diabetes mellitus insulin glycemic fasting polyuria polydipsia polyphagia diabetes MEDICAL_TRANSCRIPTION,Description Acute on chronic COPD exacerbation and community acquired pneumonia both resolving However she may need home O2 for a short period of time Medical Specialty SOAP Chart Progress Notes Sample Name COPD Pneumonia SOAP Transcription SUBJECTIVE Review of the medical record shows that the patient is a 97 year old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation The patient does have a longstanding history of COPD However she does not use oxygen at her independent assisted living home Yesterday she had made improvement since being here at the hospital She needed oxygen She was tested for home O2 and qualified for it yesterday also Her lungs were very tight She did have wheezes bilaterally and rhonchi on the right side mostly She appeared to be a bit weak and although she was requesting to be discharged home she did not appear to be fit for it Overnight the patient needed to use the rest room She stated that she needed to urinate She awoke decided not to call for assistance She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker She attempted to walk to the rest room on her own She sustained a fall She stated that she just felt weak She bumped her knee and her elbow She had femur x rays knee x rays also There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side This morning she denied any headache back pain or neck pain She complained mostly of right anterior knee pain for which she had some bruising and swelling OBJECTIVE VITAL SIGNS The patient s max temperature over the past 24 hours was 36 5 her blood pressure is 148 77 her pulse is 87 to 106 She is 95 on 2 L via nasal cannula HEART Regular rate and rhythm without murmur gallop or rub LUNGS Reveal no expiratory wheezing throughout She does have some rhonchi on the right mid base She did have a productive cough this morning and she is coughing green purulent sputum finally ABDOMEN Soft and nontender Her bowel sounds x4 are normoactive NEUROLOGIC She is alert and oriented x3 Her pupils are equal and reactive She has got a good head and facial muscle strength Her tongue is midline She has got clear speech Her extraocular motions are intact Her spine is nontender on palpation from neck to lumbar spine She has good range of motion with regard to her shoulders elbows wrists and fingers Her grip strengths are equal bilaterally Both elbows are strong from extension to flexion Her hip flexors and extenders are also strong and equal bilaterally Extension and flexion of the knee bilaterally and ankles also are strong Palpation of her right knee reveals no crepitus She does have suprapatellar inflammation with some ecchymosis and swelling She has got good joint range of motion however SKIN She did have a skin tear involving her right forearm lateral which is approximately 2 to 2 5 inches in length and is at this time currently Steri Stripped and wrapped with Coban and is not actively bleeding ASSESSMENT 1 Acute on chronic COPD exacerbation 2 Community acquired pneumonia both resolving However she may need home O2 for a short period of time 3 Generalized weakness and deconditioning secondary to the above Also sustained a fall secondary to instability and not using her walker or calling for assistance The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed PLAN 1 I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i e walker Myself and one of her daughter s spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living 2 We will obtain an orthopedic consult secondary to her fall to evaluate her x rays and function Keywords soap chart progress notes community acquired pneumonia copd exacerbation home o2 acute on chronic pneumonia exacerbation copd MEDICAL_TRANSCRIPTION,Description The patient is a 61 year old female who was treated with CyberKnife therapy to a right upper lobe stage IA non small cell lung cancer CyberKnife treatment was completed one month ago She is now being seen for her first post CyberKnife treatment visit Medical Specialty SOAP Chart Progress Notes Sample Name CyberKnife Treatment Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 61 year old female who was treated with CyberKnife therapy to a right upper lobe stage IA non small cell lung cancer CyberKnife treatment was completed one month ago She is now being seen for her first post CyberKnife treatment visit Since undergoing CyberKnife treatment she has had low level nausea without vomiting She continues to have pain with deep inspiration and resolving dysphagia She has no heartburn cough hemoptysis rash or palpable rib pain MEDICATIONS Dilantin 100 mg four times a day phenobarbital 30 mg three times per day levothyroxine 0 025 mg p o q day Tylenol with Codeine b i d prednisone 5 mg p r n citalopram 10 mg p o q day Spiriva q day Combivent inhaler p r n omeprazole 20 mg p o q day Lidoderm patch every 12 hours Naprosyn 375 mg p o b i d oxaprozin 600 mg p o b i d Megace 40 mg p o b i d and Asacol p r n PHYSICAL EXAMINATION BP 122 86 Temp 96 8 HR 79 RR 26 RAS 100 HEENT Normocephalic Pupils are equal and reactive to light and accommodation EOMs intact NECK Supple without masses or lymphadenopathy LUNGS Clear to auscultation bilaterally CARDIAC Regular rate and rhythm without rubs murmurs or gallops EXTREMITIES No cyanosis clubbing or edema ASSESSMENT The patient has done well with CyberKnife treatment of a stage IA non small cell lung cancer right upper lobe one month ago PLAN She is to return to clinic in three months with a PET CT Keywords soap chart progress notes non small cell lung cancer cyberknife therapy lung cancer cell lung cancer cyberknife MEDICAL_TRANSCRIPTION,Description Postoperative visit for craniopharyngioma with residual disease According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved Medical Specialty SOAP Chart Progress Notes Sample Name Craniopharyngioma Postop Transcription REASON FOR VISIT Postoperative visit for craniopharyngioma HISTORY OF PRESENT ILLNESS Briefly a 16 year old right handed boy who is in eleventh grade who presents with some blurred vision and visual acuity difficulties was found to have a suprasellar tumor He was brought to the operating room on 01 04 07 underwent a transsphenoidal resection of tumor Histology returned as craniopharyngioma There is some residual disease however the visual apparatus was decompressed According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved MEDICATIONS Synthroid 100 mcg per day FINDINGS On exam he is awake alert and oriented x 3 Pupils are equal and reactive EOMs are full His visual acuity is 20 25 in the right improved from 20 200 and the left is 20 200 improved from 20 400 He has a bitemporal hemianopsia which is significantly improved and wider His motor is 5 out of 5 There are no focal motor or sensory deficits The abdominal incision is well healed There is no evidence of erythema or collection The lumbar drain was also well healed The postoperative MRI demonstrates small residual disease Histology returned as craniopharyngioma ASSESSMENT Postoperative visit for craniopharyngioma with residual disease PLANS I have recommended that he call I discussed the options with our radiation oncologist Dr X They will schedule the appointment to see him In addition he probably will need an MRI prior to any treatment to follow the residual disease Keywords soap chart progress notes visual acuity blurred vision tinnitus headaches residual disease tumor histology craniopharyngioma MEDICAL_TRANSCRIPTION,Description Still having diarrhea decreased appetite Medical Specialty SOAP Chart Progress Notes Sample Name Clostridium Difficile Colitis Followup Transcription SUBJECTIVE The patient seen and examined feels better today Still having diarrhea decreased appetite Good urine output 600 mL since 7 o clock in the morning Afebrile PHYSICAL EXAMINATION GENERAL Nonacute distress awake alert and oriented x3 VITAL SIGNS Blood pressure 102 64 heart rate of 89 respiratory rate of 12 temperature 96 8 and O2 saturation 94 on room air HEENT PERRLA EOMI NECK Supple CARDIOVASCULAR Regular rate and rhythm RESPIRATORY Clear to auscultation bilaterally ABDOMEN Bowel sounds are positive soft and nontender EXTREMITIES No edema Pulses present bilaterally LABORATORY DATA CBC WBC count today down 10 9 from 17 3 yesterday 26 9 on admission hemoglobin 10 2 hematocrit 31 3 and platelet count 370 000 BMP BUN of 28 3 from 32 2 creatinine 1 8 from 1 89 from 2 7 Calcium of 8 2 Sodium 139 potassium 3 9 chloride 108 and CO2 of 22 Liver function test is unremarkable Stool positive for Clostridium difficile Blood culture was 131 O2 saturation result is pending ASSESSMENT AND PLAN 1 Most likely secondary to Clostridium difficile colitis and urinary tract infection improving The patient hemodynamically stable leukocytosis improved and today he is afebrile 2 Acute renal failure secondary to dehydration BUN and creatinine improving 3 Clostridium difficile colitis Continue Flagyl evaluation Dr X in a m 4 Urinary tract infection continue Levaquin for last during culture 5 Leucocytosis improving 6 Minimal elevated cardiac enzyme on admission Followup with Cardiology recommendations 7 Possible pneumonia continue vancomycin and Levaquin 8 The patient may be transferred to telemetry Keywords soap chart progress notes decreased appetite acute renal failure urinary tract infection leucocytosis clostridium difficile colitis MEDICAL_TRANSCRIPTION,Description D C and hysteroscopy Abnormal uterine bleeding enlarged fibroid uterus hypermenorrhea intermenstrual spotting and thickened endometrium per ultrasound of a 2 cm lining MEDICAL_TRANSCRIPTION,Description Followup circumcision The patient had a pretty significant phimosis and his operative course was smooth Satisfactory course after circumcision for severe phimosis with no perioperative complications Medical Specialty SOAP Chart Progress Notes Sample Name Circumcision Followup Transcription REASON FOR VISIT Followup circumcision HISTORY OF PRESENT ILLNESS The patient had his circumcision performed on 09 16 2007 here at Children s Hospital The patient had a pretty significant phimosis and his operative course was smooth He did have a little bit of bleeding when he woke in recovery room which required placement of some additional sutures but after that his recovery has been complete His mom did note that she had to him a couple of days of oral analgesics but he seems to be back to normal and pain free now He is having no difficulty urinating and his bowel function remains normal PHYSICAL EXAMINATION Today The patient looks healthy and happy We examined his circumcision site His Monocryl sutures are still in place The healing is excellent and there is only a mild amount of residual postoperative swelling There was one area where he had some recurrent adhesions at the coronal sulcus and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed IMPRESSION Satisfactory course after circumcision for severe phimosis with no perioperative complications PLAN The patient came in followup for his routine care with Dr X but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound If that does occur we will be happy to see him back at any time Keywords soap chart progress notes circumcision adhesions followup circumcision sutures phimosis MEDICAL_TRANSCRIPTION,Description Chronic kidney disease stage IV secondary to polycystic kidney disease Hypertension which is finally better controlled Metabolic bone disease and anemia Medical Specialty SOAP Chart Progress Notes Sample Name Chronic Kidney Disease Followup Transcription HISTORY OF PRESENT ILLNESS This is a followup for this 69 year old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease His creatinine has ranged between 4 and 4 5 over the past 6 months since I have been following him I have been trying to get him educated about end stage kidney disease and we have been unsuccessful in getting him into classes On his last visit I really stressed the importance of him taking his medications adequately and not missing some of the doses and he returns today with much better blood pressure control He has also brought a machine at home and states his blood pressure readings have been better He has not gone to the transplant orientation class yet and has not been to dialysis education yet and both of these I have discussed with him in the past He also needs followup for his elevated PSA in the past which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant REVIEW OF SYSTEMS Really negative He continues to feel well He denies any problems with shortness of breath chest pain swelling in his legs nausea or vomiting and his appetite remains good CURRENT MEDICATIONS 1 Vytorin 10 40 mg one a day 2 Rocaltrol 0 25 micrograms a day 3 Carvedilol 12 5 mg twice a day 4 Cozaar 50 mg twice a day 5 Lasix 40 mg a day PHYSICAL EXAMINATION VITAL SIGNS On exam his blood pressure is 140 57 pulse 58 current weight is 67 1 kg and again his blood pressure is markedly improved over his previous readings GENERAL He is a thin African American gentleman in no distress LUNGS Clear CARDIOVASCULAR Regular rate and rhythm Normal S1 and S2 I did not appreciate a murmur ABDOMEN Soft He has a very soft systolic murmur at the left lower sternal border No rubs or gallops EXTREMITIES No significant edema LABORATORY DATA Today indicates that his creatinine is 4 5 and stable ionized calcium 8 5 intact PTH 458 and hemoglobin stable at 10 9 He is not on EPO yet His UA has been negative IMPRESSION 1 Chronic kidney disease stage IV secondary to polycystic kidney disease His estimated GFR is 16 mL per minute He has no uremic symptoms 2 Hypertension which is finally better controlled 3 Metabolic bone disease 4 Anemia RECOMMENDATION He needs a number of things done in terms of followup and education I gave him more information again about dialysis education and transplant and instructed him he needs to go to these classes I also gave him websites that he can get on to find out more information I have not made any changes in his medications He is getting blood work done prior to his next visit with me I will check a PSA on him but he needs to get back into see urology as his last PSA that I see was 37 and this was from 02 05 He will see me back in about 4 to 6 weeks Keywords soap chart progress notes metabolic bone disease anemia polycystic kidney disease chronic kidney disease blood pressure transplant metabolic kidney MEDICAL_TRANSCRIPTION,Description Followup evaluation and management of chronic medical conditions Congestive heart failure stable on current regimen Diabetes type II A1c improved with increased doses of NPH insulin Hyperlipidemia chronic renal insufficiency and arthritis Medical Specialty SOAP Chart Progress Notes Sample Name Chronic Medical Conditions Followup Transcription REASON FOR VISIT Followup evaluation and management of chronic medical conditions HISTORY OF PRESENT ILLNESS The patient has been doing quite well since he was last seen He comes in today with his daughter He has had no symptoms of CAD or CHF He had followup with Dr X and she thought he was doing quite well as well He has had no symptoms of hyperglycemia or hypoglycemia He has had no falls His right knee does pain him at times and he is using occasional doses of Tylenol for that He wonders whether he could use a knee brace to help him with that issue as well His spirits are good He has had no incontinence His memory is clear as is his thinking MEDICATIONS 1 Bumex 2 mg daily 2 Aspirin 81 mg daily 3 Lisinopril 40 mg daily 4 NPH insulin 65 units in the morning and 25 units in the evening 5 Zocor 80 mg daily 6 Toprol XL 200 mg daily 7 Protonix 40 mg daily 8 Chondroitin glucosamine no longer using MAJOR FINDINGS Weight 240 blood pressure by nurse 160 80 by me 140 78 pulse 91 and regular and O2 saturation 94 He is afebrile JVP is normal without HJR CTAP RRR S1 and S2 Aortic murmur unchanged Abdomen Soft NT without HSM normal BS Extremities No edema on today s examination Awake alert attentive able to get up on to the examination table under his own power Able to get up out of a chair with normal get up and go Bilateral OA changes of the knee Creatinine 1 7 which was down from 2 3 A1c 7 6 down from 8 5 Total cholesterol 192 HDL 37 and triglycerides 487 ASSESSMENTS 1 Congestive heart failure stable on current regimen Continue 2 Diabetes type II A1c improved with increased doses of NPH insulin Doing self blood glucose monitoring with values in the morning between 100 and 130 Continue current regimen Recheck A1c on return 3 Hyperlipidemia at last visit he had 3 protein in his urine TSH was normal We will get a 24 hour urine to rule out nephrosis as the cause of his hypertriglyceridemia In the interim both Dr X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia Specifically we were considering TriCor fenofibrate Given his problems with high CPK values in the past for now we have decided not to engage in that strategy We will leave open for the future Check fasting lipid panel today 4 Chronic renal insufficiency improved with reduction in dose of Bumex over time 5 Arthritis stable I told the patient he could use Extra Strength Tylenol up to 4 grams a day but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day He states he will inch that up slowly With regard to a brace he stated he used one in the past and that did not help very much I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease For now he will continue with his cane and walker 6 Health maintenance flu vaccination today PLANS Followup in 3 months by phone sooner as needed Keywords soap chart progress notes congestive heart failure diabetes hyperlipidemia chronic renal insufficiency arthritis chronic medical conditions heart MEDICAL_TRANSCRIPTION,Description Postoperative followup note Cervicalgia cervical radiculopathy and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate Medical Specialty SOAP Chart Progress Notes Sample Name Cervicalgia Transcription FAMILY HISTORY Her father died at the age of 80 from prostate cancer Her mother died at the age of 67 She did abuse alcohol She had a brother died at the age of 70 from bone and throat cancer She has two sons ages 37 and 38 years old who are healthy She has two daughters ages 60 and 58 years old both with cancer She describes cancer hypertension nervous condition kidney disease lung disease and depression in her family SOCIAL HISTORY She is married and has support at home Denies tobacco alcohol and illicit drug use ALLERGIES Aspirin MEDICATIONS The patient does not list any current medications PAST MEDICAL HISTORY Hypertension depression and osteoporosis PAST SURGICAL HISTORY She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr L She is G10 P7 no cesarean sections REVIEW OF SYSTEMS HEENT Headaches vision changes dizziness and sore throat GI Difficulty swallowing Musculoskeletal She is right handed with joint pain stiffness decreased range of motion and arthritis Respiratory Shortness of breath and cough Cardiac Chest pain and swelling in her feet and ankle Psychiatric Anxiety and depression Urinary Negative and noncontributory Hem Onc Negative and noncontributory Vascular Negative and noncontributory Genital Negative and noncontributory PHYSICAL EXAMINATION On physical exam she is 5 feet tall and currently weighs 110 pounds weight one year ago was 145 pounds BP 138 78 pulse is 64 General A well developed well nourished female in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth she does have some poor dentition She does say that she needs some of her teeth pulled on her lower mouth Cranial nerves II III IV and VI vision is intact and visual fields are full to confrontation EOMs are full bilaterally Pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movements Cranial nerve VIII hearing is intact although decreased bilaterally right worse than left Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cranial nerve XI strong and symmetrical shoulder shrugs against resistance Cardiac regular rate and rhythm Chest and lungs are clear bilaterally Skin is warm and dry Normal turgor and texture No rashes or lesions are noted General musculoskeletal exam reveals no gross deformity fasciculations and atrophy Peripheral vascular no cyanosis clubbing or edema She does have some tremoring of her bilateral upper arms as she said Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted She is about 4 5 in the deltoids biceps triceps wrist flexors wrist extensors dorsal interossei and grip strength It is much more painful for her on the left Deep tendon reflexes are 2 bilaterally only at biceps triceps and brachioradialis knees and ankles No ankle clonus is elicited Hoffmann s is negative bilaterally Sensation is intact She ambulates with slow short steps No spastic gait is noted She has appropriate station and gait with no assisted devices although she states that she is supposed to be using a cane She does not bring one in with her today FINDINGS Patient brings in cervical spine x rays and she has had an MRI taken but does not bring that in with her today She will obtain that and x rays which showed at cervical plate C3 C4 C5 C6 and C7 anteriorly with some lifting with the most lifted area at the C3 level No fractures are noted ASSESSMENT Cervicalgia cervical radiculopathy and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate PLAN We went ahead and obtained an EKG in the office today which demonstrated normal sinus rhythm She went ahead and obtained her x rays and will pick her MRI and return to the office for surgical consultation with Dr L first available She would like the plate removed so that she can eat and drink better so that she can proceed with her shoulder surgery All questions and concerns were addressed with her Warning signs and symptoms were gone over with her If she should have any further questions concerns or complications she will contact our office immediately otherwise we will see her as scheduled I am quite worried about the pain that she is having in her arms so I would like to see the MRI as well Case was reviewed and discussed with Dr L Keywords soap chart progress notes c3 through c7 pain scale mris x rays cervical discectomy and fusion cervical radiculopathy cervical fusion cervical discectomy cervical plate difficulty swallowing cranial nerves radiculopathy discectomy cervicalgia postoperative fusion swallowing MEDICAL_TRANSCRIPTION,Description A lady was admitted to the hospital with chest pain and respiratory insufficiency She has chronic lung disease with bronchospastic angina Medical Specialty SOAP Chart Progress Notes Sample Name Chest Pain Respiratory Insufficiency Transcription We discovered new T wave abnormalities on her EKG There was of course a four vessel bypass surgery in 2001 We did a coronary angiogram This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease She may continue in the future to have angina and she will have nitroglycerin available for that if needed Her blood pressure has been elevated and so instead of metoprolol we have started her on Coreg 6 25 mg b i d This should be increased up to 25 mg b i d as preferred antihypertensive in this lady s case She also is on an ACE inhibitor So her discharge meds are as follows 1 Coreg 6 25 mg b i d 2 Simvastatin 40 mg nightly 3 Lisinopril 5 mg b i d 4 Protonix 40 mg a m 5 Aspirin 160 mg a day 6 Lasix 20 mg b i d 7 Spiriva puff daily 8 Albuterol p r n q i d 9 Advair 500 50 puff b i d 10 Xopenex q i d and p r n I will see her in a month to six weeks She is to follow up with Dr X before that Keywords soap chart progress notes chest pain respiratory insufficiency chronic lung disease bronchospastic angina insufficiency chest angina respiratory bronchospastic MEDICAL_TRANSCRIPTION,Description Patient follows up for cataract extraction with lens implant 2 weeks ago Recovering well from her cataract operation in the right eye with residual corneal swelling which should resolve in the next 2 to 3 weeks Medical Specialty SOAP Chart Progress Notes Sample Name Cataract Extraction Followup Transcription Her past medical history includes insulin requiring diabetes mellitus for the past 28 years She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease She is scheduled to see a gastroenterologist in the near future She is taking Econopred 8 times a day to the right eye and Nevanac OD three times a day She is allergic to penicillin The visual acuity today was 20 50 pinholing no improvement in the right eye In the left eye the visual acuity was 20 80 pinholing no improvement The intraocular pressure was 14 OD and 9 OS Anterior segment exam shows normal lids OU The conjunctiva is quiet in the right eye In the left eye she has an area of sectoral scleral hyperemia superonasally in the left eye The cornea on the right eye shows a paracentral area of mild corneal edema In the left eye cornea is clear Anterior chamber in the right eye shows trace cell In the left eye the anterior chamber is deep and quiet She has a posterior chamber intraocular lens well centered and in sulcus of the left eye The lens in the left eye shows 3 nuclear sclerosis Vitreous is clear in both eyes The optic nerves appear healthy in color and normal in size with cup to disc ratio of approximately 0 48 The maculae are flat in both eyes The retinal periphery is flat in both eyes Ms ABC is recovering well from her cataract operation in the right eye with residual corneal swelling which should resolve in the next 2 to 3 weeks She will continue her current drops In the left eye she has an area of what appears to be sectoral scleritis I did a comprehensive review of systems today and she reports no changes in her pulmonary dermatologic neurologic gastroenterologic or musculoskeletal systems She is however being evaluated for inflammatory bowel disease The mild scleritis in the left eye may be a manifestation of this We will notify her gastroenterologist of this possibility of scleritis and will start Ms ABC on a course of indomethacin 25 mg by mouth two times a day I will see her again in one week She will check with her primary physician prior to starting the Indocin Keywords soap chart progress notes visual acuity photophobia lens implant cataract extraction eye cataract cornealNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support Medical Specialty SOAP Chart Progress Notes Sample Name Care Conference With Family Transcription REASON FOR FOLLOWUP Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support HISTORY OF PRESENT ILLNESS This is a 65 year old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA 125 and a complex mass located in the ovary As the patient was showing signs of improvement with some speech and ability to follow commands decision was made to continue to pursue an aggressive level of care treat her dysphagia hypertension debilitation and this was being done However last night the patient had apparently catastrophic event around 2 40 in the morning Rapid response was called and the patient was intubated started on pressure support and given CPR This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care The patient was seen and examined she was intubated and sedated Limbs were cool Cardiovascular exam revealed tachycardia Lungs had coarse breath sounds Abdomen was soft Extremities were cool to the touch Pupils were 6 to 2 mm doll s eyes were not intact They were not responsive to light Based on discussion with all family members involved including both sons daughter and daughter in law a decision was made to proceed with terminal wean and comfort care measures All pressure support was discontinued The patient was started on intravenous morphine and respiratory was requested to remove the ET tube Monitors were turned off and the patient was made as comfortable as possible Family is at the bedside at this time The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month this is a very reasonable and appropriate approach given the patient s failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities Total time spent at the bedside today in critical care services medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes Keywords soap chart progress notes full code status terminal wean comfort care cpr advanced cardiac life support care conference family bedsideNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 60 year old female presents today for care of painful calluses and benign lesions Medical Specialty SOAP Chart Progress Notes Sample Name Bunions and Calluses Transcription S A 60 year old female presents today for care of painful calluses and benign lesions O On examination the patient has bilateral bunions at the first metatarsophalangeal joint She states that they do not hurt No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot She has a small intractable plantar keratoma plantar to her left second metatarsal head which measures 0 5 cm in diameter This is a central plug She also has a very very painful lesion plantar to her right fourth metatarsal head which measures 3 1 x 1 8 cm in diameter This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines A 1 Bilateral bunions Keywords soap chart progress notes painful calluses hibiclens scrubbed ointment and absorbent heloma durum plantar aspect minimal hemostasis neosporin ointment absorbent dressing benign lesions metatarsophalangeal bunions calluses plantar MEDICAL_TRANSCRIPTION,Description Problem of essential hypertension Symptoms that suggested intracranial pathology Medical Specialty SOAP Chart Progress Notes Sample Name Cardiology Progress Note Transcription SUBJECTIVE The patient is a 78 year old female with the problem of essential hypertension She has symptoms that suggested intracranial pathology but so far work up has been negative She is taking hydrochlorothiazide 25 mg once a day and K Dur 10 mEq once a day with adequate control of her blood pressure She denies any chest pain shortness of breath PND ankle swelling or dizziness OBJECTIVE Heart rate is 80 and blood pressure is 130 70 Head and neck are unremarkable Heart sounds are normal Abdomen is benign Extremities are without edema ASSESSMENT AND PLAN The patient reports that she had an echocardiogram done in the office of Dr Sample Doctor4 and was told that she had a massive heart attack in the past I have not had the opportunity to review any investigative data like chest x ray echocardiogram EKG etc So I advised her to have a chest x ray and an EKG done before her next appointment and we will try to get hold of the echocardiogram on her from the office of Dr Sample Doctor4 In the meantime she is doing quite well and she was advised to continue her current medication and return to the office in three months for followup Keywords soap chart progress notes cardiology ekg k dur progerss note soap ankle swelling blood pressure chest x ray echocardiogram essential hypertension heart attack hydrochlorothiazide hypertension pathology chest heart intracranial MEDICAL_TRANSCRIPTION,Description He is a 67 year old man who suffers from chronic anxiety and coronary artery disease and DJD He has been having some chest pains but overall he does not sound too concerning He does note some more shortness of breath than usual He has had no palpitations or lightheadedness No problems with edema Medical Specialty SOAP Chart Progress Notes Sample Name CAD 6 Month Followup Transcription REASON FOR VISIT Six month follow up visit for CAD He is a 67 year old man who suffers from chronic anxiety and coronary artery disease and DJD He has been having a lot of pain in his back and pain in his left knee He is also having trouble getting his nerves under control He is having stomach pains and occasional nausea His teeth are bad and need to be pulled He has been having some chest pains but overall he does not sound too concerning He does note some more shortness of breath than usual He has had no palpitations or lightheadedness No problems with edema MEDICATIONS Lipitor 40 mg q d metoprolol 25 mg b i d Plavix 75 mg q d discontinued enalapril 10 mg b i d aspirin 325 mg reduced to 81 mg Lorcet 10 650 given a 60 pill prescription and Xanax 0 5 mg b i d given a 60 pill prescription REVIEW OF SYSTEMS Otherwise unremarkable PEX BP 140 78 HR 65 WT 260 pounds which is up one pound There is no JVD No carotid bruit Cardiac Regular rate and rhythm and distant heart sounds with a 1 6 murmur at the upper sternal border Lungs Clear Abdomen Mildly tender throughout the epigastrium Extremities No edema EKG Sinus rhythm left axis deviation otherwise unremarkable Echocardiogram for dyspnea and CAD Normal systolic and diastolic function Moderate LVH Possible gallstones seen IMPRESSION 1 CAD Status post anterior wall MI 07 07 and was found to a have multivessel CAD He has a stent in his LAD and his obtuse marginal Fairly stable 2 Dyspnea Seems to be due to his weight and the disability from his knee His echocardiogram shows no systolic or diastolic function 3 Knee pain We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills 4 Dyslipidemia Excellent numbers today with cholesterol of 115 HDL 45 triglycerides 187 and LDL 33 samples of Lipitor given 5 Panic attacks and anxiety Xanax 0 5 mg b i d 60 pills with no refills given 6 Abdominal pain Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q d 7 Prevention I do not think he needs to be on the Plavix any more as he has been relatively stable for two years PLAN 1 Discontinue Plavix 2 Aspirin reduced to 81 mg a day 3 Lorcet and Xanax prescriptions given 4 Refer over to Scotland Orthopedics 5 Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted Keywords MEDICAL_TRANSCRIPTION,Description Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction Medical Specialty SOAP Chart Progress Notes Sample Name Cardiology Progress Note 1 Transcription SUBJECTIVE The patient is not in acute distress PHYSICAL EXAMINATION VITAL SIGNS Blood pressure of 121 63 pulse is 75 and O2 saturation is 94 on room air HEAD AND NECK Face is symmetrical Cranial nerves are intact CHEST There is prolonged expiration CARDIOVASCULAR First and second heart sounds are heard No murmur was appreciated ABDOMEN Soft and nontender Bowel sounds are positive EXTREMITIES He has 2 pedal swelling NEUROLOGIC The patient is asleep but easily arousable LABORATORY DATA PTT is 49 INR is pending BUN is improved to 20 6 creatinine is 0 7 sodium is 123 and potassium is 3 8 AST is down to 45 and ALT to 99 DIAGNOSTIC STUDIES Nuclear stress test showed moderate size mostly fixed defect involving the inferior wall with a small area of peri infarct ischemia Ejection fraction is 25 ASSESSMENT AND PLAN 1 Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction Continue current treatment as per Cardiology We will consider adding ACE inhibitors as renal function improves 2 Acute pulmonary edema resolved 3 Rapid atrial fibrillation rate controlled The patient is on beta blockers and digoxin Continue Coumadin Monitor INR 4 Coronary artery disease with ischemic cardiomyopathy Continue beta blockers 5 Urinary tract infection Continue Rocephin 6 Bilateral perfusion secondary to congestive heart failure We will monitor 7 Chronic obstructive pulmonary disease stable 8 Abnormal liver function due to congestive heart failure with liver congestion improving 9 Rule out hypercholesterolemia We will check lipid profile 10 Tobacco smoking disorder The patient has been counseled 11 Hyponatremia stable This is due to fluid overload Continue diuresis as per Nephrology 12 Deep venous thrombosis prophylaxis The patient is on heparin drip Keywords soap chart progress notes atrial fibrillation systolic dysfunction ace inhibitors coronary artery disease rapid atrial fibrillation congestive heart failure beta blockers heart failure congestive heart asleep MEDICAL_TRANSCRIPTION,Description Dietary consultation for carbohydrate counting for type I diabetes Medical Specialty SOAP Chart Progress Notes Sample Name Carbohydrate Counting Transcription SUBJECTIVE This is a 62 year old female who comes for dietary consultation for carbohydrate counting for type I diabetes The patient reports that she was hospitalized over the weekend for DKA She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477 She gave herself in smaller increments a total of 70 extra units of her Humalog Ten of those units were injectable the others were in the forms of pump Her blood sugar was over 600 when she went to the hospital later that day She is here at this consultation complaining of not feeling well still because she has a cold She realizes that this is likely because her immune system was so minimized in the hospital OBJECTIVE Current insulin doses on her insulin pump are boluses set at 5 units at breakfast 6 units at lunch and 11 units at supper Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30 5 units per 24 hours A diet history was obtained I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg dl was also recommended The Lilly guide for meal planning was provided and reviewed Additional carbohydrate counting book was provided ASSESSMENT The patient was taught an insulin to carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago which she does not recall It is based on the 500 rule which suggests this ratio We did identify carbohydrate sources in the food supply recognizing 15 g equivalents We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources She does seem to have a pattern of fixing blood sugars later in the day after they are elevated We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals With this in mind she was recommended to follow with three servings or 45 g of carbohydrate at breakfast three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately PLAN Recommend the patient use 1 unit of insulin for every 10 g carbohydrate load consumed Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day This was a one hour consultation Provided my name and number should additional needs arise Keywords soap chart progress notes insulin pump carbohydrate load immune system dietary consultation carbohydrate ratio blood sugars carbohydrate counting carbohydrate dietary blood counting insulin MEDICAL_TRANSCRIPTION,Description The patient seeks evaluation for a second opinion concerning cataract extraction Medical Specialty SOAP Chart Progress Notes Sample Name Cataract Second Opinion Transcription SUBJECTIVE The patient seeks evaluation for a second opinion concerning cataract extraction She tells me cataract extraction has been recommended in each eye however she is nervous to have surgery Past ocular surgery history is significant for neurovascular age related macular degeneration She states she has had laser four times to the macula on the right and two times to the left she sees Dr X for this OBJECTIVE On examination visual acuity with correction measures 20 400 OU Manifest refraction does not improve this There is no afferent pupillary defect Visual fields are grossly full to hand motions Intraocular pressure measures 17 mm in each eye Slit lamp examination is significant for clear corneas OU There is early nuclear sclerosis in both eyes There is a sheet like 1 2 posterior subcapsular cataract on the left Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes ASSESSMENT PLAN Advanced neurovascular age related macular degeneration OU this is ultimately visually limiting Cataracts are present in both eyes I doubt cataract removal will help increase visual acuity however I did discuss with the patient especially in the left cataract surgery will help Dr X better visualize the macula for future laser treatment so that her current vision can be maintained This information was conveyed with the use of a translator Keywords soap chart progress notes advanced neurovascular age related macular degeneration neurovascular age macular degeneration visual acuity cataract extraction neurovascular degeneration visual eyes macular cataract MEDICAL_TRANSCRIPTION,Description Breast radiation therapy followup note Left breast adenocarcinoma stage T3 N1b M0 stage IIIA Medical Specialty SOAP Chart Progress Notes Sample Name Breast Radiation Therapy Followup Transcription DIAGNOSIS Left breast adenocarcinoma stage T3 N1b M0 stage IIIA She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes CURRENT MEDICATIONS 1 Glucosamine complex 2 Toprol XL 3 Alprazolam 4 Hydrochlorothiazide 5 Dyazide 6 Centrum Dr X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck She previously received a total of 46 8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area As such I feel that we could safely re treat the lower neck Her weight has increased to 189 5 from 185 2 She does complain of some coughing and fatigue PHYSICAL EXAMINATION NECK On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present RESPIRATORY Good air entry bilaterally Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected No lumps bumps or evidence of disease involving the right breast is present ABDOMEN Normal bowel sounds no hepatomegaly No tenderness on deep palpation She has just started her last cycle of chemotherapy today and she wishes to visit her daughter in Brooklyn New York After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time I look forward to keeping you informed of her progress Thank you for having allowed me to participate in her care Keywords soap chart progress notes carboplatin taxol radiation therapy breast adenocarcinoma beam radiotherapy chest wall radiotherapy supraclavicular lymphadenopathy adenocarcinoma breast MEDICAL_TRANSCRIPTION,Description Atrial fibrillation with rapid ventricular response Wolff Parkinson White Syndrome recent aortic valve replacement with bioprosthetic Medtronic valve and hyperlipidemia Medical Specialty SOAP Chart Progress Notes Sample Name Atrial Fibrillation SOAP Transcription SUBJECTIVE The patient states that she feels better She is on IV amiodarone the dosage pattern is appropriate for ventricular tachycardia Researching the available records I find only an EMS verbal statement that tachycardia of wide complex was seen There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm The patient states that for a week she has been home postoperative from aortic valve replacement on 12 01 08 at ABC Medical Center The aortic stenosis was secondary to a congenital bicuspid valve by her description She states that her shortness of breath with exertion has been stable but has yet to improve from its preoperative condition She has not had any decline in her postoperative period of her tolerance to exertion The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days Last night she had a prolonged episode for which she contacted EMS Her medications at home had been uninterrupted and without change from those listed being Toprol XL 100 mg q a m Dyazide 25 37 5 mg Nexium 40 mg all taken once a day She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively She states that she has been taking her aspirin at 325 mg q a m She remains on Zyrtec 10 mg q a m Her only allergy is listed to latex OBJECTIVE VITAL SIGNS Temperature 36 1 heart rate 60 respirations 14 room air saturation 98 and blood pressure 108 60 The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC GENERAL She is alert and in no apparent distress HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are clear bilaterally to auscultation The incision is well healed and without evidence of significant cellulitis HEART Shows a regular rate and rhythm without murmur gallop heave click thrill or rub There is an occasional extra beat noted which corresponds to a premature atrial contraction on the monitor ABDOMEN Soft and benign without hepatosplenomegaly rebound rigidity or guarding EXTREMITIES Show no evidence of DVT acute arthritis cellulitis or pedal edema NEUROLOGIC Nonfocal without lateralizing findings for cranial or peripheral nervous systems strength sensation and cerebellar function Gait and station were not tested MENTAL STATUS Shows the patient to be alert coherent with full capacity for decision making BACK Negative to inspection or percussion LABORATORY DATA Shows from 12 15 08 2100 hemoglobin 11 6 white count 12 9 and platelets 126 000 INR 1 0 Electrolytes are normal with exception potassium 3 3 GFR is decreased at 50 with creatinine of 1 1 Glucose was 119 Magnesium was 2 3 Phosphorus 3 8 Calcium was slightly low at 7 8 The patient has had ionized calcium checked at Munson that was normal at 4 5 prior to her discharge Troponin is negative x2 from 2100 and repeat at 07 32 This morning her BNP was 163 at admission Her admission chest x ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion Her current EKG tracing from 05 42 shows a sinus bradycardia with Wolff Parkinson White Pattern a rate of 58 beats per minute and a corrected QT interval of 557 milliseconds Her PR interval was 0 12 We received a call from Munson Medical Center that a bed had been arranged for the patient I contacted Dr Varner and we reviewed the patient s managed to this point All combined impression is that the patient was likely to not have had actual ventricular tachycardia This is based on her EP study from October showing her to be non inducible In addition she had a cardiac catheterization that showed no evidence of coronary artery disease What is most likely that the patient has postoperative atrial fibrillation Her WPW may have degenerated into a ventricular tachycardia but this is unlikely At this point we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period I will recheck her potassium magnesium calcium and phosphorus at this point and make adjustments if indicated Dr Varner will be making arrangements for an outpatient Holter monitor and further followup post discharge IMPRESSION 1 Atrial fibrillation with rapid ventricular response 2 Wolff Parkinson White Syndrome 3 Recent aortic valve replacement with bioprosthetic Medtronic valve 4 Hyperlipidemia Keywords soap chart progress notes ventricular tachycardia wolff parkinson white syndrome ventricular response medtronic valve wolff parkinson white syndrome aortic valve replacement atrial fibrillation atrial aortic tachycardia fibrillation ventricular valve medtronic MEDICAL_TRANSCRIPTION,Description A nurse with a history of breast cancer enrolled is clinical trial C40502 Her previous treatments included Zometa Faslodex and Aromasin She was found to have disease progression first noted by rising tumor markers Medical Specialty SOAP Chart Progress Notes Sample Name Breast Cancer Followup Transcription CHIEF COMPLAINT 1 Metastatic breast cancer 2 Enrolled is clinical trial C40502 3 Sinus pain HISTORY OF PRESENT ILLNESS She is a very pleasant 59 year old nurse with a history of breast cancer She was initially diagnosed in June 1994 Her previous treatments included Zometa Faslodex and Aromasin She was found to have disease progression first noted by rising tumor markers PET CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU C40502 She was randomized to the ixabepilone plus Avastin She experienced dose limiting toxicity with the fourth cycle The Ixempra was skipped on day 1 and day 8 She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy Early in the month she had concerned about possible perforated septum She was seen by ENT urgently She was found to have nasal septum intact She comes into clinic today for day eight Ixempra CURRENT MEDICATIONS Zometa monthly calcium with Vitamin D q d multivitamin q d Ambien 5 mg q h s Pepcid AC 20 mg q d Effexor 112 mg q d Lyrica 100 mg at bedtime Tylenol p r n Ultram p r n Mucinex one to two tablets b i d Neosporin applied to the nasal mucosa b i d nasal rinse daily ALLERGIES Compazine REVIEW OF SYSTEMS The patient is comfort in knowing that she does not have a septal perforation She has progressive neuropathy and decreased sensation in her fingertips She makes many errors when keyboarding I would rate her neuropathy as grade 2 She continues to have headaches respond to Ultram which she takes as needed She occasionally reports pain in her right upper quadrant as well as right sternum He denies any fevers chills or night sweats Her diarrhea has finally resolved and her bowels are back to normal The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords soap chart progress notes zometa faslodex aromasin dose limiting toxicity metastatic breast cancer perforated septum nasal septum clinical trial breast cancer disease metastatic breast cancer MEDICAL_TRANSCRIPTION,Description School reports continuing difficulties with repetitive questioning obsession with cleanness on a daily basis concerned about his inability to relate this well in the classroom Asperger disorder Obsessive compulsive disorder Medical Specialty SOAP Chart Progress Notes Sample Name Asperger Disorder Transcription SUBJECTIVE School reports continuing difficulties with repetitive questioning obsession with cleanness on a daily basis concerned about his inability to relate this well in the classroom He appears confused and depressed at times Mother also indicates that preservative questioning had come down but he started collecting old little toys that he did in the past He will attend social skills program in the summer ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis There is lessening of tremoring in both hands since discontinuation of Zoloft He is now currently taking Abilify at 7 5 mg OBJECTIVE He came in less perseverative questioning asked appropriate question about whether I talked to ABCD or not greeted me with Japanese word to say hello seemed less I also note that his tremors were less from the last time ASSESSMENT 299 8 Asperger disorder 300 03 obsessive compulsive disorder PLAN Decrease Abilify from 7 5 mg to 5 mg tablet one a day no refills needed I am introducing slow Luvox 25 mg tablet one half a m for OCD symptoms if no side effects in one week we will to tablet one up to therapeutic level I also will call ABCD regarding the referral to psychologists for functional behavioral analysis Parents will call me in two weeks I will see him for medication review in four weeks Mother signed informed consent I reviewed side effects to observe including behavioral activation Abilify has been helpful in decreasing high emotional arousal Combination of medication and behavioral intervention is recommended Keywords soap chart progress notes repetitive questioning obsession with cleanness inability to relate obsessive compulsive disorder functional behavioral analysis asperger disorder inability asperger MEDICAL_TRANSCRIPTION,Description A 75 year old female comes in with concerns of having a stroke Medical Specialty SOAP Chart Progress Notes Sample Name Bell s Palsy Transcription SUBJECTIVE The patient is a 75 year old female who comes in today with concerns of having a stroke She states she feels like she has something in her throat She started with some dizziness this morning and some left hand and left jaw numbness She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr XYZ for that who gave her some Antivert She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face as well as the left side of her neck She said she had an earache a day or so ago She has not had any cold symptoms ALLERGIES Demerol and codeine MEDICATIONS Lotensin Lopid metoprolol and Darvocet REVIEW OF SYSTEMS The patient says that she feels little bit nauseated at times She denies chest pain or shortness of breath and again feels like she has something in her throat She has been able to swallow liquids okay She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth She does say that she occasionally has numbness in her left hand prior to today PHYSICAL EXAMINATION General She is awake and alert no acute distress Vital Signs Blood pressure 175 86 Temperature She is afebrile Pulse 78 Respiratory rate 20 O2 sat 93 on room air HEENT Her TMs are normal bilaterally Posterior pharynx is unremarkable It should be noted that her uvula did not deviate and neither did her tongue When she smiles though she has some drooping of the left side of her face as well as some mild nasolabial fold flattening Neck Without adenopathy or thyromegaly Carotids pulses are brisk without bruits Lungs Clear to auscultation Heart Regular rate and rhythm without murmur Extremities Her muscle strength is symmetrical and intact bilaterally DTRs are 2 4 bilaterally and muscle strength is intact in the upper extremities She has a positive Tinel s sign on her left wrist Neurological I also took monofilament and she could sense it easily when testing her sensation on her face ASSESSMENT Bell s Palsy PLAN We did get an EKG showed some ST segment changes anterolaterally The only EKG I have here is from 1998 and she actually had bypass in 1999 but there certainly does not appear to be anything acute on his EKG I assured her that it does not look like she has a stroke If she wants to prevent a stroke obviously quitting her smoking would help It should be noted she also takes Synthroid and Zocor We are going to give her Valtrex 1 g t i d for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face she needs to come back but I will not start her on steroids at this time which she agreed with Keywords soap chart progress notes stroke bell s palsy st segment changes ekg dizziness numbness dizzy muscle strength palsy bell s MEDICAL_TRANSCRIPTION,Description A critically ill 67 year old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate Medical Specialty SOAP Chart Progress Notes Sample Name Atrial Flutter Progress Note Transcription HISTORY OF PRESENT ILLNESS Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response which was resistant to treatment with diltiazem and amiodarone being followed by Dr X of cardiology through most of the day This afternoon when I am seeing the patient nursing informs me that rate has finally been controlled with esmolol but systolic blood pressures have dropped to the 70s with a MAP of 52 Dr X was again consulted from the bedside We agreed to try fluid boluses and then to consider Neo Synephrine pressure support if this is not successful In addition over the last 24 hours extensive discussions have been held with the family and questions answered by nursing staff concerning the patient s possible move to Tahoe Pacific or a long term acute care Other issues requiring following up today are elevated transaminases continuing fever pneumonia resolving adult respiratory distress syndrome ventilatory dependent respiratory failure hypokalemia non ST elevation MI hypernatremia chronic obstructive pulmonary disease BPH atrial flutter inferior vena cava filter and diabetes PHYSICAL EXAMINATION VITAL SIGNS T max 103 2 blood pressure at this point is running in the 70s mid 40s with a MAP of 52 heart rate is 100 GENERAL The patient is much more alert appearing than my last examination of approximately 3 weeks ago He denies any pain appears to have intact mentation and is in no apparent distress EYES Pupils round reactive to light anicteric with external ocular motions intact CARDIOVASCULAR Reveals an irregularly irregular rhythm LUNGS Have diminished breath sounds but are clear anteriorly ABDOMEN Somewhat distended but with no guarding rebound or obvious tenderness to palpation EXTREMITIES Show trace edema with no clubbing or cyanosis NEUROLOGICAL The patient is moving all extremities without focal neurological deficits LABORATORY DATA Sodium 149 this is down from 151 yesterday Potassium 3 9 chloride 114 bicarb 25 BUN 35 creatinine 1 5 up from 1 2 yesterday hemoglobin 12 4 hematocrit 36 3 WBC 16 5 platelets 231 000 INR 1 4 Transaminases are continuing to trend upwards of SGOT 546 SGPT 256 Also noted is a scant amount of very concentrated appearing urine in the bag IMPRESSION Overall impressions continues to be critically ill 67 year old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate PLAN 1 Hypotension I would aggressively try and fluid replete the patient giving him another liter of fluids If this does not work as discussed with Dr X we will start some Neo Synephrine but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started 2 Increased transaminases Presumably this is from increased congestion This is certainly concerning We will continue to follow this Ultrasound of the liver was apparently negative 3 Fever and elevated white count The patient does have a history of pneumonia and empyema We will continue current antibiotics per infectious disease and continue to follow the patient s white count He is not exceptionally toxic appearing at this time Indeed he does look improved from my last examination 4 Ventilatory dependent respiratory failure The patient has received a tracheostomy since my last examination Vent management per PMA 5 Hypokalemia This has resolved Continue supplementation 6 Hypernatremia This is improving somewhat I am hoping that with increased fluids this will continue to do so 7 Diabetes mellitus Fingerstick blood glucoses are reviewed and are at target We will continue current management This is a critically ill patient with multiorgan dysfunction and signs of worsening renal hepatic and cardiovascular function with extremely guarded prognosis Total critical care time spent today 37 minutes Keywords soap chart progress notes rapid ventricular response volume depletion atrial flutter atrial hypotension flutter MEDICAL_TRANSCRIPTION,Description Return visit to the endocrine clinic for acquired hypothyroidism papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992 and diabetes mellitus Medical Specialty SOAP Chart Progress Notes Sample Name Acquired Hypothyroidism Followup Transcription PROBLEM LIST 1 Acquired hypothyroidism 2 Papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992 3 Diabetes mellitus 4 Insomnia with sleep apnea HISTORY OF PRESENT ILLNESS This is a return visit to the endocrine clinic for the patient with history as noted above She is 45 years old Her last visit was about 6 months ago Since that time the patient states her health has remained unchanged Currently primary complaint is one of fatigue that she feels throughout the day She states however she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day In terms of her thyroid issues the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism She is not reporting temperature intolerance palpitations muscle weakness tremors nausea vomiting constipation hyperdefecation or diarrhea Her weight has been stable She is not reporting proximal muscle weakness CURRENT MEDICATIONS 1 Levothyroxine 125 micrograms p o once daily 2 CPAP 3 Glucotrol 4 Avandamet 5 Synthroid 6 Byetta injected twice daily REVIEW OF SYSTEMS As stated in the HPI She is not reporting polyuria polydipsia or polyphagia She is not reporting fevers chills sweats visual acuity changes nausea vomiting constipation or diarrhea She is not having any lightheadedness weakness chest pain shortness of breath difficulty breathing orthopnea or dyspnea on exertion PHYSICAL EXAMINATION GENERAL She is an overweight very pleasant woman in no acute distress VITAL SIGNS Temperature 96 9 pulse 85 respirations not counted blood pressure 135 65 and weight 85 7 kg NECK Reveals well healed surgical scar in the anteroinferior aspect of the neck There is no palpable thyroid tissue noted on this examination today There is no lymphadenopathy THORAX Reveals lungs that are clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 no S4 is auscultated EXTREMITIES Deep tendon reflexes 2 4 without a delayed relaxation phase No fine resting tremor of the outstretched upper extremity SKIN HAIR AND NAILS All are unremarkable LABORATORY DATABASE Lab data on 08 29 07 showed the following Thyroglobulin quantitative less than 0 5 and thyroglobulin antibody less than 20 free T4 1 35 and TSH suppressed at 0 121 ASSESSMENT AND PLAN This is a 45 year old woman with history as noted above 1 Acquired hypothyroidism status post total thyroidectomy for papillary carcinoma in 1992 2 Plan to continue following thyroglobulin levels 3 Plan to obtain a free T4 TSH and thyroglobulin levels today 4 Have the patient call the clinic next week for followup and continued management of her hypothyroid state 5 Plan today is to repeat her thyroid function studies This case was discussed with Dr X and the recommendation We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0 41 or less Therefore labs have been drawn We plan to see the patient back in approximately 6 months or sooner A repeat body scan will not been done the one in 03 06 was negative Keywords soap chart progress notes thyroid function studies thyroid gland diabetes mellitus papillary carcinoma total thyroidectomy acquired hypothyroidism carcinoma thyroidectomy thyroglobulin hypothyroidism MEDICAL_TRANSCRIPTION,Description Acne with folliculitis Medical Specialty SOAP Chart Progress Notes Sample Name Acne SOAP Transcription SUBJECTIVE The patient is a 49 year old white female established patient to Dermatology last seen in the office on 08 10 2004 She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest stomach neck and back On examination this is a flaring of her acne with small folliculitis lesions The patient has been taking amoxicillin 500 mg b i d and using Tazorac cream 0 1 and her face is doing well but she has been out of her medicine now for three days also She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products etc The patient is married She is a secretary FAMILY SOCIAL AND ALLERGY HISTORY She has hay fever eczema sinus and hives She has no melanoma or skin cancers or psoriasis Her mother had oral cancer The patient is a nonsmoker No blood tests Had some sunburn in the past She is on benzoyl peroxide and Daypro CURRENT MEDICATIONS Lexapro Effexor Ditropan aspirin vitamins PHYSICAL EXAMINATION The patient is well developed appears stated age Overall health is good She has a couple of acne lesions one on her face and neck but there are a lot of small folliculitis like lesions on her abdomen chest and back IMPRESSION Acne with folliculitis TREATMENT 1 Discussed condition and treatment with the patient 2 Continue the amoxicillin 500 mg two at bedtime 3 Add Septra DS every morning with extra water 4 Continue the Tazorac cream 0 1 it is okay to use on back and chest also 5 Referred to ABC clinic for an aesthetic consult Return in two months for followup evaluation of her acne Keywords soap chart progress notes acne with folliculitis tazorac cream acne dermatology tazorac cream folliculitis MEDICAL_TRANSCRIPTION,Description EEG during wakefulness drowsiness and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity Medical Specialty Sleep Medicine Sample Name Video EEG 2 Transcription IMPRESSION EEG during wakefulness drowsiness and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity Keywords sleep medicine ekg artifact video monitoring wakefulness drowsiness eegNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 23 year old white female presents with complaint of allergies Medical Specialty SOAP Chart Progress Notes Sample Name Allergic Rhinitis Transcription SUBJECTIVE This 23 year old white female presents with complaint of allergies She used to have allergies when she lived in Seattle but she thinks they are worse here In the past she has tried Claritin and Zyrtec Both worked for short time but then seemed to lose effectiveness She has used Allegra also She used that last summer and she began using it again two weeks ago It does not appear to be working very well She has used over the counter sprays but no prescription nasal sprays She does have asthma but doest not require daily medication for this and does not think it is flaring up MEDICATIONS Her only medication currently is Ortho Tri Cyclen and the Allegra ALLERGIES She has no known medicine allergies OBJECTIVE Vitals Weight was 130 pounds and blood pressure 124 78 HEENT Her throat was mildly erythematous without exudate Nasal mucosa was erythematous and swollen Only clear drainage was seen TMs were clear Neck Supple without adenopathy Lungs Clear ASSESSMENT Allergic rhinitis PLAN 1 She will try Zyrtec instead of Allegra again Another option will be to use loratadine She does not think she has prescription coverage so that might be cheaper 2 Samples of Nasonex two sprays in each nostril given for three weeks A prescription was written as well Keywords soap chart progress notes allergic rhinitis allergies asthma nasal sprays rhinitis nasal erythematous allegra sprays allergic MEDICAL_TRANSCRIPTION,Description Chronic lymphocytic leukemia CLL autoimmune hemolytic anemia and oral ulcer The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis Medical Specialty SOAP Chart Progress Notes Sample Name Anemia Leukemia Followup Transcription CHIEF COMPLAINT 1 Chronic lymphocytic leukemia CLL 2 Autoimmune hemolytic anemia 3 Oral ulcer HISTORY OF PRESENT ILLNESS The patient is a 72 year old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008 He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day He comes in to clinic today for follow up and complete blood count At his last office visit we discontinued this prophylactic antivirals and antibacterial CURRENT MEDICATIONS Prilosec 20 mg b i d levothyroxine 50 mcg q d Lopressor 75 mg q d vitamin C 500 mg q d multivitamin q d simvastatin 20 mg q d and prednisone 5 mg q o d ALLERGIES Vicodin REVIEW OF SYSTEMS The patient reports ulcer on his tongue and his lip He has been off of Valtrex for five days He is having some difficulty with his night vision with his left eye He has a known cataract He denies any fevers chills or night sweats He continues to have headaches The rest of his review of systems is negative PHYSICAL EXAM VITALS Keywords soap chart progress notes oral ulcer leukemia anemia hemolysis blood count chronic lymphocytic leukemia autoimmune hemolytic anemia hemolytic cll lymphocytic autoimmune MEDICAL_TRANSCRIPTION,Description EEG during wakefulness and light sleep is abnormal with independent positive sharp wave activity seen in both frontotemporal head regions more predominant in the right frontotemporal region Medical Specialty Sleep Medicine Sample Name Video EEG 3 Transcription PROCEDURE EEG during wakefulness demonstrates background activity consisting of moderate amplitude beta activity seen bilaterally The EEG background is symmetric Independent small positive sharp wave activity is seen in the frontotemporal regions bilaterally with sharp slow wave discharges seen more predominantly in the right frontotemporal head region No clinical signs of involuntary movements are noted during synchronous video monitoring Recording time is 22 minutes and 22 seconds There is attenuation of the background faster activity during drowsiness and some light sleep is recorded No sustained epileptogenic activity is evident but the independent bilateral sharp wave activity is seen intermittently Photic stimulation induced a bilaterally symmetric photic driving response IMPRESSION EEG during wakefulness and light sleep is abnormal with independent positive sharp wave activity seen in both frontotemporal head regions more predominant in the right frontotemporal region The EEG findings are consistent with potentially epileptogenic process Clinical correlation is warranted Keywords sleep medicine epileptogenic wakefulness eeg frontotemporal activityNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient has a history of epilepsy and has also had non epileptic events in the past Video EEG monitoring is performed to assess whether it is epileptic seizures or non epileptic events Medical Specialty Sleep Medicine Sample Name Video EEG 1 Transcription DATE OF EXAMINATION Start 12 29 2008 at 1859 hours End 12 30 2008 at 0728 hours TOTAL RECORDING TIME 12 hours 29 minutes PATIENT HISTORY This is a 46 year old female with a history of events concerning for seizures The patient has a history of epilepsy and has also had non epileptic events in the past Video EEG monitoring is performed to assess whether it is epileptic seizures or non epileptic events VIDEO EEG DIAGNOSES 1 Awake Normal 2 Sleep Activation of a single left temporal spike seen maximally at T3 3 Clinical events None DESCRIPTION Approximately 12 hours of continuous 21 channel digital video EEG monitoring was performed During the waking state there is a 9 Hz dominant posterior rhythm The background of the record consists primarily of alpha frequency activity At times during the waking portion of the record there appears to be excessive faster frequency activity No activation procedures were performed Approximately four hours of intermittent sleep was obtained A single left temporal T3 spike is seen in sleep Vertex waves and sleep spindles were present and symmetric The patient had no clinical events during the recording CLINICAL INTERPRETATION This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep The patient had no clinical events during the recording period Clinical correlation is required Keywords sleep medicine non epileptic events temporal spike eeg monitoring video eeg epilepsy frequency eeg epileptic MEDICAL_TRANSCRIPTION,Description This is a 43 year old female with a history of events concerning for seizures Video EEG monitoring is performed to capture events and or identify etiology Medical Specialty Sleep Medicine Sample Name Video EEG Transcription TIME SEEN 0734 hours and 1034 hours TOTAL RECORDING TIME 27 hours 4 minutes PATIENT HISTORY This is a 43 year old female with a history of events concerning for seizures Video EEG monitoring is performed to capture events and or identify etiology VIDEO EEG DIAGNOSES 1 AWAKE Normal 2 SLEEP No activation 3 CLINICAL EVENTS None DESCRIPTION Approximately 27 hours of continuous 21 channel digital video EEG monitoring was performed The waking background is unchanged from that previously reported Hyperventilation produced no changes in the resting record Photic stimulation failed to elicit a well developed photic driving response Approximately five and half hours of spontaneous intermittent sleep was obtained Sleep spindles were present and symmetric The patient had no clinical events during the recording CLINICAL INTERPRETATION This is normal video EEG monitoring for a patient of this age No interictal epileptiform activity was identified The patient had no clinical events during the recording Clinical correlation is required Keywords sleep medicine electroencephalography eeg monitoring video eeg seizures eeg MEDICAL_TRANSCRIPTION,Description Chronic snoring in children Medical Specialty Sleep Medicine Sample Name Snoring Transcription CHRONIC SNORING Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome Both conditions may lead to sleep fragmentation and or intermittent oxygen desaturation both of which have significant health implications including poor sleep quality and stress on the cardiovascular system Symptoms like daytime somnolence fatigue hyperactivity behavior difficulty i e ADHD and decreased school performance have been reported with these conditions In addition the most severe cases may be associated with right ventricular hypertrophy pulmonary and or systemic hypertension and even cor pulmonale In this patient the risks for a sleep disordered breathing include obesity and the tonsillar hypertrophy It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed Keywords sleep medicine snoring chronic snoring behavior difficulty fatigue hyperactivity obstructive sleep apnea oxygen oxygen desaturation polysomnogram poor sleep quality right ventricular hypertrophy school performance sleep fragmentation somnolence systemic hypertension upper airway upper airway resistant syndrome snoring chronic hypertrophy sleepNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient underwent an overnight polysomnogram Medical Specialty Sleep Medicine Sample Name Overnight Polysomnogram Transcription The patient underwent an overnight polysomnogram on 09 22 06 and the details of the polysomnographic study are reported separately The highlights of the study include the following A Obstructive apneas and hypopneas were identified with an overall apnea hypopnea index of 15 2 events per hour in the supine position All events occurred in the supine position and were more prominent during stage REM sleep Minimum oxygen saturation was 88 B Periodic limb movements in sleep were identified with an overall index of 32 events per hour of sleep C The patient s sleep efficiency was reduced to 89 2 There was significant sleep fragmentation due to the obstructive apneas and hypopneas as well as due to the periodic limb movements in sleep disorder The patient did not achieve any stage III IV sleep and stage REM sleep was diminished at 12 7 There was a corresponding increase in stage I sleep and stage II sleep at 10 8 and 65 7 respectively DIAGNOSTIC IMPRESSION 1 Obstructive sleep apnea syndrome supine position dependent moderate 780 53 0 2 Periodic limb movement in sleep disorder moderate 780 53 4 CASE DISCUSSION Thank you once again for allowing us to participate in the care of the patient here at the Sleep Clinic The patient exhibits obstructive sleep apnea a condition associated with increased risk of myocardial infarction stroke and sudden death Furthermore patients with this condition are susceptible to excessive daytime sleepiness while driving and there is a higher incidence of automobile accident The patient should be warned with regards to these possibilities Patients with this condition can be successfully treated with nasal CPAP continuous positive airway pressure so that the patient should return to the sleep laboratory for repeat overnight polysomnogram with CPAP titration The sleep laboratory if necessary can introduce the patient to the proper use of the CPAP equipment and to determine a necessary pressure to prevent apneas It is reported that the patient undergo careful ENT maxillofacial evaluation by a physician familiar with sleep disorders Anatomical abnormalities in the upper airway often cause or predispose to this condition Surgical intervention may be helpful or necessary if such conditions exist Alternatively ________ may be of benefit in some patients depending upon the anatomical abnormalities Obstructive sleep apnea is worsened by obesity The patient should be encouraged to lose weight Patients usually lose weight more effectively when involved in a behavioral weight loss program It is sometimes difficult for patients to lose weight until the OSA is adequately treated because excessive daytime sleepiness results in decreased physical activity in the daytime Patient may have worsening obstructive sleep apnea by nasal airway obstruction and nasal congestion If present these conditions should be treated In addition any home allergens such as pets down bedding or other factors should be removed from the sleep environment The patient should be informed that obstructive sleep apnea may be worsened by the use of alcohol or sedative medications particularly taken in the evening Therefore the evening use of sedative medications and alcohol are to be avoided The patient also exhibits periodic limb movements in sleep disorder This may require treatment However it will be appropriate to obtain the repeat overnight polysomnogram with CPAP titration to see if the PLMS continues to be troublesome If so treatment recommendations will be made Keywords sleep medicine periodic limb movement cpap limb movements in sleep obstructive sleep apnea overnight polysomnogram sleep overnight polysomnogram obstructive apneas MEDICAL_TRANSCRIPTION,Description Followup of moderate to severe sleep apnea The patient returns today to review his response to CPAP Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction Medical Specialty Sleep Medicine Sample Name Sleep Apnea Transcription REASON FOR VISIT Mr ABC is a 30 year old man who returns in followup of his still moderate to severe sleep apnea He returns today to review his response to CPAP HISTORY OF PRESENT ILLNESS The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner He was found to have moderate to severe sleep apnea predominantly hypopnea was treated with nasal CPAP at 10 cm H2O nasal pressure He has been on CPAP now for several months and returns for followup to review his response to treatment The patient reports that the CPAP has limited his snoring at night Occasionally his bed partner wakes him in the middle of the night when the mask comes off and reminds him to replace the mask The patient estimates that he uses the CPAP approximately 5 to 7 nights per week and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night The patient s sleep pattern consists of going to bed between 11 00 and 11 30 at night and awakening between 6 to 7 a m on weekdays On weekends he might sleep until 8 to 9 a m On Saturday night he might go to bed approximately mid night As noted the patient is not snoring on CPAP He denies much tossing and turning and does not awaken with the sheets in disarray He awakens feeling relatively refreshed In the past few months the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures He continues to work at Smith Barney in downtown Baltimore He generally works from 8 to 8 30 a m until approximately 5 to 5 30 p m He is involved in training purpose to how to sell managed funds and accounts The patient reports no change in daytime stamina He has no difficulty staying awake during the daytime or evening hours The past medical history is notable for allergic rhinitis MEDICATIONS He is maintained on Flonase and denies much in the way of nasal symptoms ALLERGIES Molds FINDINGS Vital signs Blood pressure 126 75 pulse 67 respiratory rate 16 weight 172 pounds height 5 feet 9 inches temperature 98 4 degrees and SaO2 is 99 on room air at rest The patient has adenoidal facies as noted previously Laboratories The patient forgot to bring his smart card in for downloading today ASSESSMENT Moderate to severe sleep apnea I have recommended the patient continue CPAP indefinitely He will be sending me his smart card for downloading to determine his CPAP usage pattern In addition he will continue efforts to maintain his weight at current levels or below Should he succeed in reducing further we might consider re running a sleep study to determine whether he still requires a CPAP PLANS In the meantime if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction He will be returning for routine followup in 6 months Keywords sleep medicine daytime stamina fiberoptic ent exam moderate to severe smart card sleep apnea cpap apnea sleep MEDICAL_TRANSCRIPTION,Description Sleep study patient with symptoms of obstructive sleep apnea with snoring Medical Specialty Sleep Medicine Sample Name Sleep Study Interpretation Transcription PROCEDURE Sleep study CLINICAL INFORMATION This patient is a 56 year old gentleman who had symptoms of obstructive sleep apnea with snoring hypertension The test was done 01 24 06 The patient weighed 191 pounds five feet seven inches tall SLEEP QUESTIONNAIRE According to the patient s own estimate the patient took about 15 minutes to fall asleep slept for six and a half hours did have some dreams Did not wake up and the sleep was less refreshing He was sleepy in the morning STUDY PROTOCOL An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph After the scalp was prepared Ag AgCl electrodes were applied to the scalp according to the International 10 20 System EEG was monitored from C4 A1 C3 A2 O2 A1 and O2 A1 EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively Nasal and oral airflow were monitored using a triple port Thermistor Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt Blood oxygen saturation was continuously monitored by pulse oximetry Heart rate and rhythm were monitored by surface electrocardiography Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs Body position and snoring level were also monitored TECHNICAL QUALITY OF STUDY Good ELECTROPHYSIOLOGIC MEASUREMENTS Total recording time 406 minutes total sleep time 365 minutes sleep latency 25 5 minutes REM latency 49 minutes _____ 90 sleep latency measured 86 _____ period was obtained The patient spent 10 of the time awake in bed Stage I 3 8 Stage II 50 5 Stage III 14 Stage REM 21 7 The patient had relatively good sleep architecture except for excessive waking RESPIRATORY MEASUREMENTS Total apnea hypopnea 75 age index 12 3 per hour REM age index 15 per hour Total arousal 101 arousal index 15 6 per hour Oxygen desaturation was down to 88 Longest event 35 second hypopnea with an FiO2 of 94 Total limb movements 92 PRM index 15 1 per hour PRM arousal index 8 9 per hour ELECTROCARDIOGRAPHIC OBSERVATIONS Heart rate while asleep 60 to 64 per minute while awake 70 to 78 per minute CONCLUSIONS Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea hypopnea index RECOMMENDATIONS AXIS B Overnight polysomnography AXIS C Hypertension The patient should return for nasal CPAP titration Sleep apnea if not treated may lead to chronic hypertension which may have cardiovascular consequences Excessive daytime sleepiness dysfunction and memory loss may also occur Keywords sleep medicine sleep study obstructive sleep apnea snoring hypertension polysomnogram compumedics polysomnograph ag agcl electrodes triple port thermistor rem latency polysomnography cpap titration sleep latency apnea sleep obstructive index MEDICAL_TRANSCRIPTION,Description Obesity hypoventilation syndrome A 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study Medical Specialty Sleep Medicine Sample Name Obesity Hypoventilation Syndrome Transcription HISTORY OF PRESENT ILLNESS This is a 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep She returns today to review results of an inpatient study performed approximately two weeks ago In the meantime the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex She also takes Lasix for lower extremity edema The patient reports that she generally initiates sleep on CPAP but rips her mask off tosses and turns throughout the night and has terrible quality sleep MEDICATIONS Current medications are as previously noted Changes include reduction in prednisone from 9 to 6 mg by mouth every morning She continues to take Ativan 1 mg every six hours as needed She takes imipramine 425 mg at bedtime Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation 45 to 75 mg by mouth every 8 hours as needed FINDINGS Vital signs Blood pressure 153 81 pulse 90 respiratory rate 20 weight 311 8 pounds up 10 pounds from earlier this month height 5 feet 6 inches temperature 98 4 degrees SaO2 is 88 on room air at rest Chest is clear Extremities show lower extremity pretibial edema with erythema LABORATORIES An arterial blood gas on room air showed a pH of 7 38 PCO2 of 52 and PO2 of 57 CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used She used it for greater than 4 hours per night on 67 of night surveyed Her estimated apnea hypopnea index was 3 per hour Her average leak flow was 67 liters per minute The patient s overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy She slept for a total sleep time of 257 minutes out of 272 minutes in bed sleep efficiency approximately 90 Sleep stage distribution was relatively normal with 2 stage I 72 stage II 24 stage III IV and 2 stage REM sleep There were no periodic limb movements during sleep There was evidence of a severe predominantly central sleep apnea during non REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour Oxyhemoglobin saturations during non REM sleep fluctuated from the baseline of 92 to an average low of 82 During REM sleep the baseline oxyhemoglobin saturation was 87 decreased to 81 with sleep disordered breathing episodes Of note the sleep study was performed on CPAP at 10 5 cm of H2O with oxygen at 8 liters per minute ASSESSMENT 1 Obesity hypoventilation syndrome The patient has evidence of a well compensated respiratory acidosis which is probably primarily related to severe obesity In addition there may be contribution from large doses of opiates and standing doses of gabapentin 2 Severe central sleep apnea on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute The breathing pattern is that of cluster or Biot s breathing throughout sleep The primary etiology is probably opiate use with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation and worsen desaturations during apneic episodes 3 Mononeuritis multiplex with pain requiring significant substantial doses of analgesia 4 Hypoxemia primarily due to obesity hypoventilation and presumably basilar atelectasis and a combination of V Q mismatch and shunt on that basis PLANS My overall impression is that we should treat this patient s sleep disruption with measures to decrease central sleep apnea during sleep These will include 1 Decrease in evening doses of MS Contin 2 Modest weight loss of approximately 10 to 20 pounds and 3 Instituting Automated Servo Ventilation via nasal mask With regard to latter the patient will be returning for a trial of ASV to examine its effect on sleep disordered breathing patterns In addition the patient will benefit from modest diuresis with improvement of oxygenation as well as nocturnal desaturation and oxygen requirements I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time She was instructed to take between one and two K Tab with her evening dose of Lasix 10 to 20 mEq In addition we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation Further workup for hypoxemia may include high resolution CT scanning if evidence for significant pulmonary restriction and or reductions in diffusion capacity is evident on pulmonary function testing Keywords sleep medicine polyarteritis nodosa obesity hypoventilation syndrome pulmonary function obesity hypoventilation mononeuritis multiplex sleep apnea sleep study rem sleep ativan sleep hypoventilation obesity MEDICAL_TRANSCRIPTION,Description Electroencephalogram electromyogram of the chin and lower extremities electrooculogram electrocardiogram air flow from the nose and mouth respiratory effort at the chest and abdomen and finger oximetry Medical Specialty Sleep Medicine Sample Name Sleep Difficulties Transcription CLINICAL HISTORY This is a 16 year old man evaluated for sleep difficulties He states he is feeling bad in the mornings that he has daytime somnolence and whenever I wake up I experience dizziness weakness stomachache loss of appetite drowsiness overall sore body and a general feeling of unwell He does state that he has only rarely he got anything suggestive of restless leg syndrome is unaware of any apnea or like symptoms He has a mouth breather He states he wakens up during the night usually goes to bed at 10 to 11 gets up at 7 to 7 30 In the weekends he stays up late and sleeps until 1 in the afternoon He lists sporadic use of melatonin and Benadryl and Tylenol PM for sleep His other medicines are Accutane Nasonex and oxymetazoline There is no smoking no alcohol intake He does have three caffeinated beverages a week He is 75 inches 185 pounds BMI 23 1 He rated himself 4 7 on the Stanford Sleepiness Scale at the onset of the study and 6 on the Epworth Sleeping Scale said that his night sleep in the lab was characterized by a longer than usual sleep onset latency with more arousals than usual He woke up feeling equally rested and the only comment he made on the post sleep questionnaire was some of the wires is the source of problems TECHNIQUE The study was performed with the following parameters measured throughout the entirety of the recording Electroencephalogram electromyogram of the chin and lower extremities electrooculogram electrocardiogram air flow from the nose and mouth respiratory effort at the chest and abdomen and finger oximetry The record was scored for sleep and the various other parameters in 30 second epochs RESULTS This study was performed in 61 minutes in duration during which he slept 432 minutes after 19 minutes sleep onset latency thereafter he had 10 awakenings for 6 minutes of wakefulness giving him a normal sleep efficiency of 95 Sleep staging was actually fairly deep and normal for age with 5 stage I 51 stage II 22 slow wave sleep and 22 REM He had 5 REM periods during the night The first beginning 66 minutes after sleep onset He did have 63 arousals giving him a borderline elevated arousal index of 8 8 16 were driven by limb movements 41 of unclear origin 6 from hypopneas EEG PARAMETERS No abnormalities EKG PARAMETERS Normal sinus rhythm mean rate 76 no ectopics noted EMG PARAMETERS 88 PLMs were noted There was fairly small excursion with a movement index of 12 only 16 led to arousals with a movement arousal index of 2 2 not considered as a significant feature for sleep fragmentation RESPIRATORY PARAMETERS Breathing rate in the high teens reaching as high as 20 in REM There was really no snoring noted He slept in all positions and during the night had 9 respiratory events one was a postarousal central event the other eight were obstructive hypopneas mean duration 26 seconds little worse in the supine position where his AHI was 4 7 but overall his AHI was 1 3 This is only a marginal abnormality and is well below the threshold for CPAP intervention IMPRESSION Largely normal polysomnogram demonstrating very modest obstructive sleep apnea in the supine position and a very modest periodic limb movement disturbance Keywords sleep medicine sleep sleep difficulties mouth breather epworth sleeping scale stanford sleepiness scale sleep onset latency arousals electroencephalogram electromyogram electrooculogram electrocardiogram polysomnogram sleep apnea periodic limb movement hypopneas accutane MEDICAL_TRANSCRIPTION,Description The patient was monitored for EEG EOG jaw and leg EMG thoracoabdominal impedance oral nasal thermistors EKG and oximetry The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings Medical Specialty Sleep Medicine Sample Name Polysomnography Transcription PROCEDURE The test was performed in an observed hospital laboratory The patient was monitored for EEG EOG jaw and leg EMG thoracoabdominal impedance oral nasal thermistors EKG and oximetry The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings The patient s height 6 feet 1 inch and his weight 260 pounds DETAILS Total sleep period 377 minutes total sleep time 241 minutes sleep onset 33 minutes and sleep efficiency 64 Stage I 9 stage II 59 stage III 23 and REM stage 9 There were 306 apneas and hypopnea with apnea hypopnea index 76 Out of them 109 apneas and 197 hypopneas There were 40 arousals with index 9 9 Mean oxygen saturation 91 with lowest oxygen saturation 70 A 19 of sleep time was spent with oxygen saturation less than 90 and 1 with less than 80 Oxygen saturation during awake 95 The patient slept in supine left side and right side no preferred body position identified for apneas Average pulse 85 BPMs with lowest 61 and highest 116 BPMs No significant snoring throughout the study No significant leg jerk movement SUMMARY Severe obstructive sleep apnea with apnea hypopnea index 76 and respiratory disturbance index 9 9 Suggest weight loss thyroid function evaluation and CPAP titration study Keywords sleep medicine thoracoabdominal impedance oral nasal thermistors obstructive sleep apnea titration study eeg eog emgs cpap sleep MEDICAL_TRANSCRIPTION,Description Abnormal electroencephalogram revealing generalized poorly organized slowing with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally somewhat more prevalent on the right Medical Specialty Sleep Medicine Sample Name Electroencephalogram 3 Transcription IMPRESSION Abnormal electroencephalogram revealing generalized poorly organized slowing with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally somewhat more prevalent on the right Clinical correlation is suggested Keywords sleep medicine sleep vertex activity muscle artifact sharp wave activity electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Electroencephalogram EEG This is an 18 channel recording obtained using the standard scalp and referential electrodes observing the 10 20 international system Medical Specialty Sleep Medicine Sample Name Electroencephalogram 2 Transcription REPORT This is an 18 channel recording obtained using the standard scalp and referential electrodes observing the 10 20 international system The patient was reported to be cooperative and was awake throughout the recording CLINICAL NOTE This is a 51 year old male who is being evaluated for dizziness Spontaneous activity is fairly well organized characterized by low to medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region Eye opening caused a bilateral symmetrical block on the first run In addition to the above description movement of muscle and other artifacts are seen On subsequent run no additional findings were seen During subsequent run again no additional findings were seen Hyperventilation was omitted Photic stimulation was performed but no clear cut photic driving was seen EKG was monitored during this recording and it showed normal sinus rhythm when monitored IMPRESSION This record is essentially within normal limits Clinical correlation is recommended Keywords sleep medicine referential electrodes scalp hyperventilation photic stimulation electroencephalogram MEDICAL_TRANSCRIPTION,Description Electroencephalographic findings and interpretation Medical Specialty Sleep Medicine Sample Name Electroencephalography Transcription HISTORY This is a digital EEG performed on a 75 year old male with seizures BACKGROUND ACTIVITY The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region This rhythm is also accompanied by some beta activity which occurs infrequently There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson s Part of the EEG is obscured by the muscle contraction artifact There are also left temporal sharps occurring infrequently during the tracing At one point of time there was some slowing occurring in the right frontal head region ACTIVATION PROCEDURES Photic stimulation was performed and did not show any significant abnormality SLEEP PATTERNS No sleep architecture was observed during this tracing IMPRESSION This awake alert drowsy EEG is abnormal due to the presence of slowing in the right frontal head region due to the presence of sharps arising in the left temporal head region and due to the tremors The slowing can be consistent with underlying structural abnormalities so a stroke subdural hematoma etc should be ruled out The tremor probably represents a Parkinson s tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities so clinical correlation is recommended Keywords sleep medicine electroencephalography eeg hz rhythm parkinson s tremor photic stimulation frontal head region temporal head region muscle contractions seizures parkinson s temporal MEDICAL_TRANSCRIPTION,Description Electroencephalogram EEG Photic stimulation reveals no important changes Essentially normal Medical Specialty Sleep Medicine Sample Name Electroencephalogram 1 Transcription REPORT The electroencephalogram shows background activity at about 9 10 cycle second bilaterally Little activity in the beta range is noted Waves of 4 7 cycle second of low amplitude were occasionally noted Abundant movements and technical artifacts are noted throughout this tracing Hyperventilation was not performed Photic stimulation reveals no important changes CLINICAL INTERPRETATION The electroencephalogram is essentially normal Keywords sleep medicine beta range hyperventilation photic stimulation electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 21 channel digital electroencephalogram was performed on a patient in the awake state Medical Specialty Sleep Medicine Sample Name Electroencephalogram 4 Transcription PROCEDURE A 21 channel digital electroencephalogram was performed on a patient in the awake state Per the technician s notes the patient is taking Depakene The recording consists of symmetric 9 Hz alpha activity Throughout the recording repetitive episodes of bursts of 3 per second spike and wave activity are noted The episodes last from approximately1 to 7 seconds The episodes are exacerbated by hyperventilation IMPRESSION Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation This activity could represent true petit mal epilepsy Clinical correlation is suggested Keywords sleep medicine alpha activity wave activity hyperventilation electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient was monitored for EEG EOG jaw and leg EMG thoracoabdominal impedance oral nasal thermistors EKG and oximetry Medical Specialty Sleep Medicine Sample Name CPAP Titration Study Transcription PROCEDURE The test was performed in an observed hospital laboratory due to the evidence of obstructive sleep apnea The patient was monitored for EEG EOG jaw and leg EMG thoracoabdominal impedance oral nasal thermistors EKG and oximetry CPAP TITRATION STUDY Total sleep time 425 minutes sleep onset 7 8 minutes and sleep efficiency 95 Stage I 6 stage II 53 stage III 20 and REM stage 15 and awake 5 Number of awakenings 6 Total arousals 36 with index 5 4 mild leg jerk movement with index 10 1 There was one apnea and 17 hypopneas with apnea hypopnea index 2 7 The pressures required to prevent apnea hypopnea varied between 5 and 11 cm H2O The optimal pressure was 11 cm H2O which prevented all of the apneas hypopneas The patient spent all his sleeping time in supine position Average oxygen saturation 94 with lowest oxygen saturation 89 Only less than 0 2 minutes was spent with oxygen saturation less than 90 SUMMARY Weight loss PFTs if not done and CPAP with nasal mask at 11 cm H2O Keywords sleep medicine obstructive sleep apnea cpap titration study cpap titration oral nasal thermistors thermistors ekg oxygen saturation eeg eog emg thoracoabdominal thermistors ekg oximetry apnea cpap oral nasalNOTE MEDICAL_TRANSCRIPTION,Description A sample note on Rheumatoid Arthritis Medical Specialty Rheumatology Sample Name Rheumatoid Arthritis Transcription RHEUMATOID ARTHRITIS or RA is a chronic systemic condition with primary involvement of the joints Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue Specifically the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels The cause of rheumatoid arthritis is obscure but it is associated with a family history genetic and autoimmune problems people ages 20 60 female gender 3 1 or a Native American background SIGNS AND SYMPTOMS Joint pain swelling redness warmth Commonly involved joints are the small joints of the hands and feet and the ankles wrists knees shoulders and elbows Multiple swollen joints more than 3 with simultaneous involvement of same joints on opposite side of the body Morning stiffness that lasts longer than 30 minutes Difficulty making a fist poor grip strength Night pain Feeling sick low fever loss of appetite tiredness generalized aching and stiffness weakness Rheumatoid nodules under the skin usually along the surface of tendons or over bony prominences Disease may lead to deformed joints decreased vision anemia muscle weakness peripheral nerve problems pericarditis enlarged spleen increased frequency of infections Blood tests will reveal a positive rheumatoid factor RF to be present the majority of the time TREATMENT To diagnose RA blood studies are done to detect a substance known as rheumatoid factor and x rays may show typical findings Night splints for involved joints Avoid putting a pillow under the knees as this will contribute to joint contracture Heat helps relieve the pain hot water soaks whirlpool baths heat lamps heating pads etc applied to affected joints 15 20 minutes 3 times per day is helpful Sleep on a firm mattress and sleep at least 10 12 hours per night Get rest during the day take naps Get bed rest during an active flare up until symptoms subside Avoid humid weather if possible NSAIDs non steroidal anti inflammatory drugs DMARDs disease modifying anti rheumatic drugs gold compounds D penicillamine sulfasalazine methotrexate antimalarials Immunosuppressive drugs Acetaminophen Tylenol for pain relief only when necessary Oral corticosteroids short term corticosteroid injection into joint can temporarily relieve pain and inflammation Exercise as recommended by your physician Exercise helps keep the joints limber and increases strength Swimming and water activities are a good way to workout Put all your joints through their full ranges of motion every day to prevent contractures Physical therapy may be recommended Surgical intervention Lose excess weight as being overweight will only stress the joints further Eat a normal well balanced diet Keywords rheumatology ra rheumatoid arthritis joint inflammation swollen joints arthritis joints inflammation corticosteroids rheumatoid MEDICAL_TRANSCRIPTION,Description Normal awake and drowsy stage I sleep EEG for patient s age Medical Specialty Sleep Medicine Sample Name Electroencephalogram Transcription DESCRIPTION OF RECORD This tracing was obtained utilizing 27 paste on gold plated surface disc electrodes placed according to the International 10 20 system Electrode impedances were measured and reported at less than 5 kilo ohms each FINDINGS In general the background rhythms are bilaterally symmetrical During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well modulated 9 10 Hz alpha activity best seen posteriorly The alpha activity attenuates with eye opening During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity There is no evidence of focal slowing or paroxysmal activity IMPRESSION Normal awake and drowsy stage I sleep EEG for patient s age Keywords sleep medicine gold plated surface disc electrodes paroxysmal activity eeg drowsy stage sleep eeg stage sleep electrodes awake moderate activity MEDICAL_TRANSCRIPTION,Description Epicondylitis history of lupus Injected with 40 mg of Kenalog mixed with 1 cc of lidocaine Medical Specialty Rheumatology Sample Name Rheumatology Progress Note Transcription SUBJECTIVE The patient is here for a follow up The patient has a history of lupus currently on Plaquenil 200 mg b i d Eye report was noted and appreciated The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago She denied having any trauma She states that the pain is bothering her She denies having any fevers chills or any joint effusion or swelling at this point She noted also that there is some increase in her hair loss in the recent times OBJECTIVE The patient is alert and oriented General physical exam is unremarkable Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows no effusion Hand examination is unremarkable today The rest of the musculoskeletal exam is unremarkable ASSESSMENT Epicondylitis both elbows possibly secondary to lupus flare up PLAN We will inject both elbows with 40 mg of Kenalog mixed with 1 cc of lidocaine The posterior approach was chosen under sterile conditions The patient tolerated both procedures well I will obtain CBC and urinalysis today If the patient s pain does not improve I will consider adding methotrexate to her therapy Sample Doctor M D Keywords rheumatology 1 cc of lidocaine epicondylitis kenalog kenalog mixed with 1 cc of lidocaine progress note aches and pains history of lupus lidocaine lupus methotrexate kenalog mixed injected MEDICAL_TRANSCRIPTION,Description A 7 year old white male started to complain of pain in his fingers elbows and neck This patient may have had reactive arthritis Medical Specialty Rheumatology Sample Name Pediatric Rheumatology Consult Transcription HISTORY We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic He was sent here with a chief complaint of joint pain in several joints for few months This is a 7 year old white male who has no history of systemic disease who until 2 months ago was doing well and 2 months ago he started to complain of pain in his fingers elbows and neck At this moment this is better and is almost gone but for several months he was having pain to the point that he would cry at some point He is not a complainer according to his mom and he is a very active kid There is no history of previous illness to this or had gastrointestinal problems He has problems with allergies especially seasonal allergies and he takes Claritin for it Other than that he has not had any other problem Denies any swelling except for that doctor mentioned swelling on his elbow There is no history of rash no stomach pain no diarrhea no fevers no weight loss no ulcers in his mouth except for canker sores No lymphadenopathy no eye problems and no urinary problems MEDICATIONS His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis ALLERGIES He has no allergies to any drugs BIRTH HISTORY Pregnancy and delivery with no complications He has no history of hospitalizations or surgeries FAMILY HISTORY Positive for arthritis in his grandmother No history of pediatric arthritis There is history of psoriasis in his dad SOCIAL HISTORY He lives with mom dad brother sister and everybody is healthy They live in Easton They have 4 dogs 3 cats 3 mules and no deer At school he is in second grade and he is doing PE without any limitation PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 7 pulse is 96 respiratory rate is 24 height is 118 1 cm weight is 22 1 kg and blood pressure is 61 44 GENERAL He is alert active in no distress very cooperative HEENT He has no facial rash No lymphadenopathy Oral mucosa is clear No tonsillitis His ear canals are clear and pupils are reactive to light and accommodation CHEST Clear to auscultation HEART Regular rhythm and no murmur ABDOMEN Soft nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation in any of his joints or active swelling today He has no tenderness either in any of his joints Muscle strength is 5 5 in proximal muscles LABORATORY DATA Includes an arthritis panel It has normal uric acid sedimentation rate of 2 rheumatoid factor of 6 and antinuclear antibody that is negative and C reactive protein that is 7 1 His mother stated that this was done while he was having symptoms ASSESSMENT AND PLAN This patient may have had reactive arthritis He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis I do not see any problems at this moment on his laboratories or on his physical examination This may have been related to recent episode of viral infection or infection of some sort Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints I will be glad to see him back If you have any question on further assessment and plan please do no hesitate to contact us Keywords rheumatology pediatric reactive arthritis psoriatic arthritis psoriasis joints swelling arthritis MEDICAL_TRANSCRIPTION,Description A 71 year old female who I am seeing for the first time She has a history of rheumatoid arthritis for the last 6 years She is not on DMARD but as she recently had a surgery followed by a probable infection Medical Specialty Rheumatology Sample Name Rheumatoid Arthritis Consult Transcription HISTORY OF PRESENT ILLNESS A 71 year old female who I am seeing for the first time She has a history of rheumatoid arthritis for the last 6 years She was followed by another rheumatologist She says she has been off and on on prednisone and Arava The rheumatologist as per the patient would not want her to be on a long term medicine so he would give her prednisone and then switch to Arava and then switch her back to prednisone She says she had been on prednisone for the last 6 to 9 months She is on 5 mg a day She recently had a left BKA and there was a question of infection so it had to be debrided I was consulted to see if her prednisone is to be continued The patient denies any joint pains at the present time She says when this started she had significant joint pains and was unable to walk She had pain in the hands and feet Currently she has no pain in any of her joints REVIEW OF SYSTEMS Denies photosensitivity oral or nasal ulcer seizure psychosis and skin rashes PAST MEDICAL HISTORY Significant for hypertension peripheral vascular disease and left BKA FAMILY HISTORY Noncontributory SOCIAL HISTORY Denies tobacco alcohol or illicit drugs PHYSICAL EXAMINATION VITAL SIGNS BP 130 70 heart rate 80 and respiratory rate 14 HEENT EOMI PERRLA NECK Supple No JVD No lymphadenopathy CHEST Clear to auscultation HEART S1 and S2 No S3 no murmurs ABDOMEN Soft and nontender No organomegaly EXTREMITIES No edema NEUROLOGIC Deferred ARTICULAR She has swelling of bilateral wrists but no significant tenderness LABORATORY DATA Labs in chart was reviewed ASSESSMENT AND PLAN A 71 year old female with a history of rheumatoid arthritis on longstanding prednisone She is not on DMARD but as she recently had a surgery followed by a probable infection I will hold off on that As she has no pain I have decreased the prednisone to 2 5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow If in a couple of weeks her symptoms stay the same then I would discontinue the prednisone I would defer that to Dr X If she flares up at that point prednisone may have to be restarted with a DMARD so that eventually she could stay off the prednisone I discussed this at length with the patient and she is in full agreement with the plan I explained to her that if she is to be discharged if she wishes she could follow up with me in clinic or if she goes back to Victoria then see her rheumatologist over there Keywords rheumatology prednisone joint pains rheumatoid arthritis arthritis dmard rheumatologist rheumatoid pains MEDICAL_TRANSCRIPTION,Description A 12 year old with discoid lupus on the control with optimal regimen Medical Specialty Rheumatology Sample Name Discoid Lupus Transcription HISTORY A is 12 year old female who comes today for follow up appointment and a CCS visit She has the diagnosis of discoid lupus and we have been following her for her conditions her treatments and also to watch her for any development of her systemic lupus A has been doing well with just Plaquenil alone and mother said that during the summer the rash gets brighter but now that it is getting darker and she is at school the rash is starting to become lighter again She has been using her cream which is hydrocortisone at night and applying it with no problems She denies any hair losses denies any decrease in appetite actually she has been gaining some weight She denies any ulcerations in her mouth eye problems or any lumps in her body She denies any fevers or any problems with the urine PHYSICAL EXAMINATION VITAL SIGNS Today temperature is 100 1 weight is 73 5 kg blood pressure is 121 61 height is 158 and pulse is 84 GENERAL She is alert active and oriented in no distress HEENT She had a head full of hair with no bald spots She has a macular rash on her cheeks bilaterally with hyperpigmented circles No scales no excoriations and no palpable erythema Oral mucosa is clear with no ulcerations NECK Soft with no masses She does have acanthosis nigricans on the base of the neck CHEST Clear to auscultation HEART Regular rhythm with no murmur ABDOMEN Soft and nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation swelling or tenderness in any of her joints SKIN Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size but most of them are about 1 cm in diameter which are hyperpigmented No erythema no purpura no petechiae and no raised borders They look more like cigarette points She has this in her upper extremities especially in the forearms and also on her lower extremities on the legs but just very few lesions and very light She has some periungual erythema as well as some palmar erythema but this is minimal LABORATORY DATA Laboratories today done we have a CBC with a white blood cell count of 7 9 hemoglobin is 14 3 platelet count is 321 000 sed rate is only 11 and CMP shows no abnormalities Pending is antinuclear antibody complement level ASSESSMENT She is 12 year old with discoid lupus on the control with optimal regimen We are going to switch her to Protopic at night especially in the face Continue on Plaquenil get some laboratories and wait for the results Diet evaluation today because of the gaining weight and acanthosis nigricans and will see her back in about 3 months for follow up Future plans will be depending on whether or not she evolves into a full blown lupus I discussed the plan with her mother and they had no further questions Keywords rheumatology lupus systemic lupus acanthosis nigricans discoid lupus extremities rash erythema discoid MEDICAL_TRANSCRIPTION,Description A lady with symptoms consistent with possible oligoarticular arthritis of her knees Medical Specialty Rheumatology Sample Name Oligoarticular Arthritis 2 Transcription HISTORY A is a young lady who came here with a diagnosis of seizure disorder and history of Henoch Schonlein purpura with persistent proteinuria A was worked up for collagen vascular diseases and is here to find out the results Also was recommended to take 7 5 mg of Mobic every day for her joint pains She states that she continues with some joint pain and feeling tired all the time Mother states that also her seizure has continued without any control so far She is having some studies in the next few days She is mostly stiff on her legs neck and also on her hands The rest of the review of systems is in the chart PHYSICAL EXAMINATION VITAL SIGNS Temperature today is 99 2 degrees Fahrenheit weight is 45 9 kg blood pressure is 123 59 height is 149 5 cm and pulse is 94 HEENT She has no facial rashes no lymphadenopathy no alopecia no oral ulcerations Pupils are reactive to accommodation Funduscopic examination is within normal limits NECK No neck masses CHEST Clear to auscultation HEART Regular rhythm with no murmur ABDOMEN Soft nontender with no visceromegaly SKIN No rashes today MUSCULOSKELETAL Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities but she does have minus plus swelling of her knees with flexion contracture bilaterally on both LABORATORY DATA Laboratories were not done recently but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease but shows some evidence of decreased calcium and vitamin D levels ASSESSMENT This is a patient who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D She also has chronic proteinuria and seizure disorder My recommendation is to start her on vitamin D and calcium supplements and also increase the Mobic to 50 mg which is one of the few things she can tolerate with all the medication she is taking We are going to refer her to physical therapy and see her back in 2 months for followup The plan was discussed with A and her parents and they have no further questions Keywords rheumatology arthralgias deficiency vitamin d collagen vascular diseases seizure disorder vascular diseases joint pains oligoarticular arthritis arthritis oligoarticular MEDICAL_TRANSCRIPTION,Description Ultrasound examination of the scrotum due to scrotal pain Duplex and color flow imaging as well as real time gray scale imaging of the scrotum and testicles was performed Medical Specialty Radiology Sample Name Ultrasound Scrotum Transcription EXAM Ultrasound examination of the scrotum REASON FOR EXAM Scrotal pain FINDINGS Duplex and color flow imaging as well as real time gray scale imaging of the scrotum and testicles was performed The left testicle measures 5 1 x 2 8 x 3 0 cm There is no evidence of intratesticular masses There is normal Doppler blood flow The left epididymis has an unremarkable appearance There is a trace hydrocele The right testicle measures 5 3 x 2 4 x 3 2 cm The epididymis has normal appearance There is a trace hydrocele No intratesticular masses or torsion is identified There is no significant scrotal wall thickening IMPRESSION Trace bilateral hydroceles which are nonspecific otherwise unremarkable examination Keywords radiology scrotal pain epididymis torsion ultrasound examination intratesticular masses ultrasound scrotal testicles scrotum MEDICAL_TRANSCRIPTION,Description X RAY of the soft tissues of the neck Medical Specialty Radiology Sample Name X RAY Neck Soft Tissues Transcription EXAM Two views of the soft tissues of the neck HISTORY Patient has swelling of the left side of his neck TECHNIQUE Frontal and lateral views of the soft tissues of the neck were evaluated There were no soft tissues of the neck radiographs for comparison However there was an ultrasound of the neck performed on the same day FINDINGS Frontal and lateral views of the soft tissues of the neck were evaluated and reveal there is an asymmetry seen to the left sided soft tissues of the patient s neck which appear somewhat enlarged when compared to patient s right side However the trachea appears to be normal caliber and contour Lateral views show a patent airway The adenoids and tonsils appear normal caliber without evidence of hypertrophy Airway appears patent Osseous structures appear grossly normal IMPRESSION 1 Patent airway No evidence of any soft tissue swelling involving the patient s adenoids tonsils epiglottis or aryepiglottic folds No evidence of any prevertebral soft tissue swelling 2 Slight asymmetry seen to the soft tissues of the left side of the patient s neck which appears somewhat larger when compared to the right side Keywords radiology swelling soft tissues ultrasound tonsils adenoids osseous structures epiglottis aryepiglottic folds frontal and lateral normal caliber frontal asymmetry MEDICAL_TRANSCRIPTION,Description A 17 year old male with oligoarticular arthritis of his right knee Medical Specialty Rheumatology Sample Name Oligoarticular Arthritis 1 Transcription HISTORY A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic A is a 17 year old male with oligoarticular arthritis of his right knee He had a joint injection back in 03 2007 and since then he has been doing relatively well He is taking Indocin only as needed even though he said he has pain regularly and he said that his knee has not changed since the beginning but he said he only takes the medicine when he has pain which is not every day but almost every day He denies any swelling more than what it was before and he denies any other joints are affected at this moment Denies any fevers or any rashes PHYSICAL EXAMINATION On physical examination his temperature is 98 6 weight is 104 6 kg which is 4 4 kg less than before 108 70 is his blood pressure weight is 91 0 kg and his pulse is 80 He is alert active and oriented in no distress He has no facial rashes no lymphadenopathy no alopecia Funduscopic examination is within normal limit He has no cataracts and symmetric pupils to light and accommodation His chest is clear to auscultation The heart has a regular rhythm with no murmur The abdomen is soft and nontender with no visceromegaly Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness Lower extremities He still has some weakness of the knees hip areas and the calf muscles He does have minus plus swelling of the right knee with a very hypermobile patella There is no limitation in his range of motion and the swelling is very minimal with some mild tenderness In terms of his laboratories they were not done today ASSESSMENT This is a 17 year old male with oligoarticular arthritis He is HLA B27 negative PLAN In terms of the plan I discussed with him what things he should be taking and the fact that since he has persistent symptoms he should be on medication every day I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints and if he does not respond to this or continue with the symptoms we may need to get an MRI We will see him back in three months He was evaluated by our physical therapist who gave him some recommendations in terms of exercise for his lower extremities Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI Today he received his flu shot Discussed this with A and his aunt and they had no further questions Keywords rheumatology rheumatology clinic lower extremities oligoarticular arthritis arthritis oligoarticular knee swelling MEDICAL_TRANSCRIPTION,Description Whole body radionuclide bone scan due to prostate cancer Medical Specialty Radiology Sample Name Whole Body Radionuclide Bone Scan Transcription INDICATION Prostate Cancer TECHNIQUE 3 5 hours following the intravenous administration of 26 5 mCi of Technetium 99m MDP the skeleton was imaged in the anterior and posterior projections FINDINGS There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull The uptake in the remainder of the skeleton is within normal limits The kidneys image normally There is increased activity in the urinary bladder suggesting possible urinary retention CONCLUSION 1 Focus of abnormal increased tracer activity overlying the right parietal region of the skull CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated 2 There is probably some degree of urinary retention Keywords radiology prostate cancer technetium whole body urinary retention bone scan radionuclide MEDICAL_TRANSCRIPTION,Description Pregnant female with nausea vomiting and diarrhea OB ultrasound less than 14 weeks transvaginal Medical Specialty Radiology Sample Name Ultrasound OB 8 Transcription REASON FOR EXAM Pregnant female with nausea vomiting and diarrhea FINDINGS The uterus measures 8 6 x 4 4 x 5 4 cm and contains a gestational sac with double decidual sac sign A yolk sac is visualized What appears to represent a crown rump length measures 3 3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09 28 09 Please note however that no fetal heart tones are seen However fetal heart tones would be expected at this age The right ovary measures 3 1 x 1 6 x 2 3 cm The left ovary measures 3 3 x 1 9 x 3 5 cm No free fluid is detected IMPRESSION Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09 28 09 A live intrauterine pregnancy however could not be confirmed as a sonographic fetal heart rate would be expected at this time A close interval followup in correlation with beta hCG is necessary as findings may represent an inevitable abortion Keywords radiology intrauterine pregnancy estimated date of delivery nausea vomiting fetal heart tones ovary measures fetal heart ultrasound ob ovary pregnancy sac fetal intrauterine MEDICAL_TRANSCRIPTION,Description Ultrasound a 22 year old pregnant female Medical Specialty Radiology Sample Name Ultrasound OB 6 Transcription GENERAL EVALUATION Fetal Cardiac Activity Normal at 140 BPM Fetal Position Variable Placenta Posterior without evidence of placenta previa Uterus Normal Cervix Keywords radiology pregnant female fetal anatomy pregnant placenta gestational ultrasound fetal MEDICAL_TRANSCRIPTION,Description A 34 year old female with no fetal heart motion noted on office scan Medical Specialty Radiology Sample Name Ultrasound OB 2 Transcription FINDINGS By dates the patient is 8 weeks 2 days There is a gestational sac within the endometrial cavity measuring 2 1cm consistent with 6 weeks 4 days There is a fetal pole measuring 7mm consistent with 6 weeks 4 days There was no fetal heart motion on Doppler or on color Doppler There is no fluid within the endometrial cavity There is a 2 8 x 1 2cm right adnexal cyst IMPRESSION Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days By dates the patient is 8 weeks 2 days A preliminary report was called by the ultrasound technologist to the referring physician Keywords radiology fetal heart motion gestational sac endometrial cavity fetal pole fetal heart heart motion gestational fetal MEDICAL_TRANSCRIPTION,Description Ultrasound of pelvis menorrhagia Medical Specialty Radiology Sample Name Ultrasound Pelvis Transcription EXAM Ultrasound of pelvis HISTORY Menorrhagia FINDINGS Uterus is enlarged measuring 11 0 x 7 5 x 11 0 cm It appears to be completely replaced by multiple ill defined fibroids The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids The right ovary measures 3 9 x 1 9 x 2 3 cm The left ovary is not seen No complex cystic adnexal masses are identified IMPRESSION Essential replacement of the uterus by fibroids It is difficult to measure given their heterogenous and diffuse nature MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization Keywords radiology pelvis mri menorrhagia ultrasound adnexa echo complex endometrial fibroids ovary uterine fibroid uterus ultrasound of pelvis MEDICAL_TRANSCRIPTION,Description Transvaginal ultrasound to evaluate pelvic pain Medical Specialty Radiology Sample Name Ultrasound Transvaginal Transcription EXAM Transvaginal ultrasound HISTORY Pelvic pain FINDINGS The right ovary measures 1 6 x 3 4 x 2 0 cm There are several simple appearing probable follicular cysts There is no abnormal flow to suggest torsion on the right Left ovary is enlarged demonstrating a 6 0 x 3 5 x 3 7 cm complex cystic mass of uncertain etiology This could represent a large hemorrhagic cyst versus abscess There is no evidence for left ovarian torsion There is a small amount of fluid in the cul de sac likely physiologic The uterus measures 7 7 x 5 0 cm The endometrial echo is normal at 6 mm IMPRESSION 1 No evidence for torsion 2 Large complex cystic left ovarian mass as described This could represent a large hemorrhagic cyst however an abscess neoplasm cannot be excluded Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature Keywords radiology ultrasound pelvic pain transvaginal cul de sac cystic mass echo endometrial flow follicular cysts hemorrhagic cyst laparoscopic neoplasm ovarian ovary uterus transvaginal ultrasound complex cystic torsion MEDICAL_TRANSCRIPTION,Description OB Ultrasound A 29 year old female requests for size and date of pregnancy Medical Specialty Radiology Sample Name Ultrasound OB 1 Transcription EXAM OB Ultrasound HISTORY A 29 year old female requests for size and date of pregnancy FINDINGS A single live intrauterine gestation in the cephalic presentation fetal heart rate is measured 147 beats per minute Placenta is located posteriorly grade 0 without previa Cervical length is 4 2 cm There is normal amniotic fluid index of 12 2 cm There is a 4 chamber heart There is spontaneous body limb motion The stomach bladder kidneys cerebral ventricles heel spine extremities and umbilical cord are unremarkable BIOMETRIC DATA BPD 7 77 cm 31 weeks 1 day HC 28 26 cm 31 weeks 1 day AC 26 63 cm 30 weeks 5 days FL 6 06 cm 31 weeks 4 days Composite sonographic age 30 weeks 6 days plus minus 17 days ESTIMATED DATE OF DELIVERY Month DD YYYY Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces IMPRESSION Single live intrauterine gestation without complications as described Keywords radiology ultrasound ac bpd cervical length estimated date of delivery fl hc placenta single live amniotic fluid bladder cephalic cephalic presentation cerebral ventricles extremities fetal heart rate fetal weight gestation heel intrauterine kidneys pregnancy previa spine stomach umbilical cord live intrauterine intrauterine gestation MEDICAL_TRANSCRIPTION,Description Bilateral lower extremity ultrasound for deep venous thrombus Medical Specialty Radiology Sample Name Ultrasound Lower Extremity Transcription EXAM Bilateral lower extremity ultrasound for deep venous thrombus REASON FOR EXAM Lower extremity edema bilaterally TECHNIQUE Colored grayscale and Doppler imaging is all employed FINDINGS This examination is limited There is prominent edema bilaterally and there is large body habitus These two limit assessment especially of the right lower extremity As visualized there is no gross evidence of DVT The right leg grayscale images are limited No obvious clot identified on the color flow or Doppler images The left leg is better visualized than the right but again is limited No definite clot is seen IMPRESSION Limited study secondary to body habitus and edema No obvious DVT as visualized Keywords radiology edema grayscale images deep venous thrombus lower extremity grayscale doppler ultrasound extremity MEDICAL_TRANSCRIPTION,Description AP abdomen and ultrasound of kidney Medical Specialty Radiology Sample Name Ultrasound Kidney Transcription EXAM AP abdomen and ultrasound of kidney HISTORY Ureteral stricture AP ABDOMEN FINDINGS Comparison is made to study from Month DD YYYY There is a left lower quadrant ostomy There are no dilated bowel loops suggesting obstruction There is a double J right ureteral stent which appears in place There are several pelvic calcifications which are likely vascular No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters Overall findings are stable versus most recent exam IMPRESSION Properly positioned double J right ureteral stent No evidence for calcified renal or ureteral stones ULTRASOUND KIDNEYS FINDINGS The right kidney is normal in cortical echogenicity of solid mass stone hydronephrosis measuring 9 0 x 2 9 x 4 3 cm There is a right renal ureteral stent identified There is no perinephric fluid collection The left kidney demonstrates moderate to severe hydronephrosis No stone or solid masses seen The cortex is normal The bladder is decompressed IMPRESSION 1 Left sided hydronephrosis 2 No visible renal or ureteral calculi 3 Right ureteral stent Keywords radiology ureteral stricture ap abdomen bowel loops calcified calculi double j echogenicity hydronephrosis kidney left lower quadrant obstruction ostomy perinephric renal solid mass stent ultrasound ureteral stent ureteral stones ureters ureteral MEDICAL_TRANSCRIPTION,Description Ultrasound left lower extremity duplex venous due to swelling and to rule out DVT Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed Medical Specialty Radiology Sample Name Ultrasound Lower Extremity 1 Transcription EXAM Ultrasound left lower extremity duplex venous REASON FOR EXAM Swelling and rule out DVT FINDINGS Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed Compressibility augmentation and color flow as well as Doppler flow was demonstrated within the common femoral vein superficial femoral vein and popliteal vein The posterior tibial vein also demonstrated flow along its proximal visualized extent IMPRESSION No evidence of left lower extremity deep venous thrombosis Keywords radiology color doppler superficial femoral vein popliteal vein common femoral vein deep venous lower extremity ultrasound doppler duplex vein venous MEDICAL_TRANSCRIPTION,Description Bilateral carotid ultrasound to evaluate pain Medical Specialty Radiology Sample Name Ultrasound Carotid 2 Transcription EXAM Ultrasound carotid bilateral REASON FOR EXAMINATION Pain COMPARISON None FINDINGS Bilateral common carotid arteries branches demonstrate minimal predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery There are no different colors or spectral Doppler waveform abnormalities PARAMETRIC DATA Right CCA PSV 0 72 m s Right ICA PSV is 0 595 m s Right ICA EDV 0 188 m s Right vertebral 0 517 m s Right IC CC is 0 826 Left CCA PSV 0 571 m s left ICA PSV 0 598 m s Left ICA EDV 0 192 m s Left vertebral 0 551 m s Left IC CC is 1 047 IMPRESSION 1 No evidence for clinically significant stenosis 2 Minimal predominantly soft plaquing Keywords radiology carotid cca psv doppler ic cc ica edv ica psv ultrasound arteries calcific plaquing common carotid internal carotid artery spectral stenosis waveform ultrasound carotid bilateral ultrasound carotid plaquing MEDICAL_TRANSCRIPTION,Description Ultrasound OB followup for fetal growth Medical Specialty Radiology Sample Name Ultrasound OB Transcription REASON FOR EXAM Followup for fetal growth INTERPRETATION Real time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented FETAL BIOMETRY BPD 8 3 cm 33 weeks 4 days HC 30 2 cm 33 weeks 4 days AC 27 9 cm 32 weeks 0 days FL 6 4 cm 33 weeks 1 day The head to abdomen circumference ratio is normal at 1 08 and the femur length to abdomen circumference ratio is normal at 23 0 Estimated fetal weight is 2 001 grams The amniotic fluid volume appears normal and the calculated index is normal for the age at 13 7 cm A detailed fetal anatomic exam was not performed at this setting this being a limited exam for growth The placenta is posterofundal and grade 2 IMPRESSION Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks 5 days plus or minus 17 days giving and estimated date of confinement of 8 04 05 There has been normal progression of fetal growth compared to the two prior exams of 2 11 05 and 4 04 05 The examination of 4 04 05 questioned an echogenic focus within the left ventricle The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle Keywords radiology amniotic fluid volume placenta posterofundal intrauterine pregnancy followup for fetal growth ultrasound ob cephalic presentation abdomen circumference circumference ratio echogenic focus fetal growth fetal MEDICAL_TRANSCRIPTION,Description Ultrasound of the right mandibular region Medical Specialty Radiology Sample Name Ultrasound Neck Soft Tissue Transcription EXAM Ultrasound neck soft tissue head HISTORY Right sided facial swelling and draining wound TECHNIQUE AND FINDINGS Ultrasound of the right mandibular region was performed No focal collection is identified This whole region appears to be phlegmonous It is hard to adequately delineate the exact margins of this region IMPRESSION Abnormal appearing right mandibular region has more phlegmonous changes No focal fluid collection Had a discussion with Dr xx Consider CT for further evaluation Keywords radiology soft tissue mandibular region tissue draining phlegmonous mandibular ultrasound MEDICAL_TRANSCRIPTION,Description Transesophageal Echocardiogram A woman admitted to the hospital with a large right MCA CVA causing a left sided neurological deficit incidentally found to have atrial fibrillation on telemetry Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 6 Transcription HISTORY OF PRESENT ILLNESS I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr A and Neurology Please see also my cardiovascular consultation dictated separately But essentially this is a pleasant 72 year old woman admitted to the hospital with a large right MCA CVA causing a left sided neurological deficit incidentally found to have atrial fibrillation on telemetry She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult I discussed the procedure in detail with the patient as well as with her daughter who was present at the patient s bedside with the patient s verbal consent I then performed a risk benefit alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts alternatives being transthoracic echo imaging which she had already had with an inherent false negativity for this indication as well as empiric medical management which the patient was not interested in risks including but not limited to and the patient was aware this was not an all inclusive list of oversedation from conscious sedation risk of aspiration pneumonia from regurgitation of stomach contents risk of oropharyngeal esophageal oral tracheal pulmonary and or gastric perforation hemorrhage or tear The patient expressed understanding of this risk benefit alternative analysis had the opportunity to ask questions which I invited from her and her daughter all of which were answered to their self stated satisfaction The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram PROCEDURE The appropriate time out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient position physician procedure documentation there were no safety issues identified by staff nor myself She received 20 cc of viscous lidocaine for topical oral anesthetic effect She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect The multi plane probe was passed using digital guidance for several passes after an oral bite block had been put into place for protection of oral dentition This was placed into the posterior oropharynx and advanced into the esophagus then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout She was recovered as per the Medical Center conscious sedation protocol and there were no apparent complications of the procedure FINDINGS Normal left ventricular size and systolic function LVEF of 60 Mild left atrial enlargement Normal right atrial size Normal right ventricular size and systolic function No left ventricular wall motion abnormalities identified The four pulmonary veins are identified The left atrial appendage is interrogated including with Doppler and color flow and while there is good to and fro motion seen echo smoke is seen and in fact an intracardiac thrombus is identified and circumscribed at 1 83 cm in circumference at the base of the left atrial appendage No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves The mitral valve is seen There is mild mitral regurgitation with two jets No mitral stenosis Four pulmonary veins were identified without reversible pulmonary venous flow There are three cusps of the aortic valve seen No aortic stenosis There is trace aortic insufficiency There is trace pulmonic insufficiency The pulmonary artery is seen and is within normal limits There is trace to mild tricuspid regurgitation Unable to estimate PA systolic pressure accurately however on the recent transthoracic echocardiogram which I would direct the reader to on January 5 2010 RVSP was calculated at 40 mmHg on that study E wave velocity on average is 0 95 m sec with a deceleration time of 232 milliseconds The proximal aorta is within normal limits annulus 1 19 cm sinuses of Valsalva 2 54 cm ascending aorta 2 61 cm The intra atrial septum is identified as are the SVC and IVC and these are within normal limits The intra atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting including no atrial septal defect nor patent foramen ovale No pericardial effusion There is mild nonmobile descending aortic atherosclerosis seen IMPRESSION 1 Normal left ventricular size and systolic function Left ventricular ejection fraction visually estimated at 60 without regional wall motion abnormalities 2 Mild left atrial enlargement 3 Intracardiac thrombus identified at the base of the left atrial appendage 4 Mild mitral regurgitation with two jets 5 Mild nonmobile descending aortic atherosclerosis Compared to the transthoracic echocardiogram done previously other than identification of the intracardiac thrombus other findings appear quite similar These results have been discussed with Dr A of inpatient Internal Medicine service as well as the patient who was recovering from conscious sedation and her daughter with the patient s verbal consent Keywords radiology echo thrombus intracardiac cardiovascular pulmonary veins intracardiac thrombus transesophageal echocardiogram echocardiogram atrial mca cva transesophageal pulmonary ventricular aortic MEDICAL_TRANSCRIPTION,Description Coronary artery bypass surgery and aortic stenosis Transthoracic echocardiogram was performed of technically limited quality Concentric hypertrophy of the left ventricle with left ventricular function Moderate mitral regurgitation Severe aortic stenosis severe Medical Specialty Radiology Sample Name Transthoracic Echocardiography Transcription REASON FOR EXAM Coronary artery bypass surgery and aortic stenosis FINDINGS Transthoracic echocardiogram was performed of technically limited quality The left ventricle was normal in size and dimensions with normal LV function Ejection fraction was 50 to 55 Concentric hypertrophy noted with interventricular septum measuring 1 6 cm posterior wall measuring 1 2 cm Left atrium is enlarged measuring 4 42 cm Right sided chambers are normal in size and dimensions Aortic root has normal diameter Mitral and tricuspid valve reveals annular calcification Fibrocalcific valve leaflets noted with adequate excursion Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets Atrial and ventricular septum are intact Pericardium is intact without any effusion No obvious intracardiac mass or thrombi noted Doppler study reveals mild to moderate mitral regurgitation Severe aortic stenosis with peak velocity of 2 76 with calculated ejection fraction 50 to 55 with severe aortic stenosis There is also mitral stenosis IMPRESSION 1 Concentric hypertrophy of the left ventricle with left ventricular function 2 Moderate mitral regurgitation 3 Severe aortic stenosis severe RECOMMENDATIONS Transesophageal echocardiogram is clinically warranted to assess the aortic valve area Keywords radiology coronary artery bypass surgery aortic stenosis annular calcification tricuspid mitral regurgitation severe aortic stenosis concentric hypertrophy mitral regurgitation transthoracic echocardiogram hypertrophy ventricular valve stenosis aortic MEDICAL_TRANSCRIPTION,Description Ultrasound Abdomen elevated liver function tests Medical Specialty Radiology Sample Name Ultrasound Abdomen 1 Transcription EXAM Ultrasound Abdomen REASON FOR EXAM Elevated liver function tests INTERPRETATION The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration The gallbladder is surgically absent There is no fluid collection in the cholecystectomy bed There is dilatation of the common bile duct up to 1 cm There is also dilatation of the pancreatic duct that measures up to 3 mm There is caliectasis in the right kidney The bladder is significantly distended measuring 937 cc in volume The caliectasis in the right kidney may be secondary to back pressure from the distended bladder The aorta is normal in caliber IMPRESSION 1 Dilated common duct as well as pancreatic duct as described Given the dilatation of these two ducts ERCP versus MRCP is recommended to exclude obstructing mass The findings could reflect changes of cholecystectomy 2 Significantly distended bladder with probably resultant caliectasis in the right kidney Clinical correlation recommended Keywords radiology aorta dilated common duct mrcp ercp elevated liver function tests pancreatic duct distended bladder ultrasound abdomen cholecystectomy ultrasound abdomen liver dilatation caliectasis kidney bladder duct MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 4 Transcription PROCEDURE NOTE The patient was brought to the transesophageal echo laboratory after informed consent was obtained The patient was seen by Anesthesia for MAC anesthesia The patient s posterior pharynx was anesthetized with local Cetacaine spray The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty FINDINGS 1 Left ventricle is normal in size and function ejection fraction approximately 60 2 Right ventricle is normal in size and function 3 Left atrium and right atrium are normal in size 4 Mitral valve aortic valve tricuspid valve and pulmonic valve with no evidence of vegetation Aortic valve is only minimally thickened 5 Mild mitral regurgitation and mild tricuspid regurgitation 6 No left ventricular thrombus 7 No pericardial effusion 8 There is evidence of patent foramen ovale by contrast study The patient tolerated the procedure well and is sent to recovery in stable condition He should be n p o x4 hours then liquid then increase as tolerated Once his infection is cleared he should follow up with us with regard to followup of patent foramen ovale Keywords radiology ventricle atrium mitral valve aortic valve tricuspid valve pulmonic valve regurgitation transesophageal probe transesophageal echocardiogram posterior pharynx transesophageal valve MEDICAL_TRANSCRIPTION,Description Right and Left carotid ultrasound Medical Specialty Radiology Sample Name Ultrasound Carotid 1 Transcription RIGHT 1 Mild heterogeneous plaque seen in common carotid artery 2 Moderate heterogeneous plaque seen in the bulb and internal carotid artery 3 Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70 4 Peak systolic velocity is normal in common carotid bulb and internal carotid artery 5 Peak systolic velocity is 280 cm sec in external carotid artery with moderate spectral broadening LEFT 1 Mild heterogeneous plaque seen in common carotid artery and external carotid artery 2 Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50 3 Peak systolic velocity is normal in common carotid artery and in the bulb 4 Peak systolic velocity is 128 cm sec in internal carotid artery and 156 cm sec in external carotid artery VERTEBRALS Antegrade flow seen bilaterally Keywords radiology carotid ultrasound antegrade flow peak systolic velocity bulb carotid artery homogeneous plaque plaque spectral broadening bulb and internal carotid velocity is normal common carotid artery internal carotid artery external carotid artery internal carotid external carotid peak systolic systolic velocity artery carotid ultrasound velocity heterogeneous MEDICAL_TRANSCRIPTION,Description Ultrasound abdomen complete Medical Specialty Radiology Sample Name Ultrasound Abdomen Transcription EXAM Ultrasound abdomen complete HISTORY 38 year old male admitted from the emergency room 04 18 2009 decreased mental status and right upper lobe pneumonia The patient has diffuse abdominal pain There is a history of AIDS TECHNIQUE An ultrasound examination of the abdomen was performed FINDINGS The liver has normal echogenicity The liver is normal sized The gallbladder has a normal appearance without gallstones or sludge There is no gallbladder wall thickening or pericholecystic fluid The common bile duct has a normal caliber at 4 6 mm The pancreas is mostly obscured by gas A small portion of the head of pancreas is visualized which has a normal appearance The aorta has a normal caliber The aorta is smooth walled No abnormalities are seen of the inferior vena cava The right kidney measures 10 8 cm in length and the left kidney 10 5 cm No masses cysts calculi or hydronephrosis is seen There is normal renal cortical echogenicity The spleen is somewhat prominent with a maximum diameter of 11 2 cm There is no ascites The urinary bladder is distended with urine and shows normal wall thickness without masses The prostate is normal sized with normal echogenicity IMPRESSION 1 Spleen size at the upper limits of normal 2 Except for small portions of pancreatic head the pancreas could not be visualized because of bowel gas The visualized portion of the head had a normal appearance 3 The gallbladder has a normal appearance without gallstones There are no renal calculi Keywords radiology echogenicity gallbladder ultrasound abdomen complete ultrasound abdomen abdomen liver gallstones kidney calculi renal spleen pancreas ultrasound MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram MRSA bacteremia rule out endocarditis The patient has aortic stenosis Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 5 Transcription CLINICAL INDICATIONS MRSA bacteremia rule out endocarditis The patient has aortic stenosis DESCRIPTION OF PROCEDURE The transesophageal echocardiogram was performed after getting verbal and a written consent signed Then a multiplane TEE probe was introduced into the upper esophagus mid esophagus lower esophagus and stomach and multiple views were obtained There were no complications The patient s throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl FINDINGS 1 Aortic valve is thick and calcified a severely restricted end opening and there is 0 6 x 8 mm vegetation attached to the right coronary cusp The peak velocity across the aortic valve was 4 6 m sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0 6 sq cm by planimetry 2 Mitral valve is calcified and thick No vegetation seen There is mild to moderate MR present There is mild AI present also 3 Tricuspid valve and pulmonary valve are structurally normal 4 There is a mild TR present 5 There is no clot seen in the left atrial appendage The velocity in the left atrial appendage was 0 6 m sec 6 Intraatrial septum was intact There is no clot or mass seen 7 Normal LV and RV systolic function 8 There is thick raised calcified plaque seen in the thoracic aorta and arch SUMMARY 1 There is a 0 6 x 0 8 cm vegetation present in the aortic valve with severe aortic stenosis Calculated aortic valve area was 0 6 sq cm 2 Normal LV systolic function Keywords radiology endocarditis aortic stenosis tee probe mrsa bacteremia transesophageal echocardiogram aortic echocardiogram esophagus vegetation transesophageal MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram for aortic stenosis Normal left ventricular size and function Benign Doppler flow pattern Doppler study essentially benign Aorta essentially benign Atrial septum intact Study was negative Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 1 Transcription INDICATION Aortic stenosis PROCEDURE Transesophageal echocardiogram INTERPRETATION Procedure and complications explained to the patient in detail Informed consent was obtained The patient was anesthetized in the throat with lidocaine spray Subsequently 3 mg of IV Versed was given for sedation The patient was positioned and transesophageal probe was introduced without any difficulty Images were taken The patient tolerated the procedure very well without any complications Findings as mentioned below FINDINGS 1 Left ventricle is in normal size and dimension Normal function Ejection fraction of 60 2 Left atrium and right sided chambers are of normal size and dimension 3 Mitral tricuspid and pulmonic valves are structurally normal 4 Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion 5 Left atrial appendage is clean without any clot or smoke effect 6 Atrial septum intact Study was negative 7 Doppler study essentially benign 8 Aorta essentially benign 9 Aortic valve planimetry valve area average about 1 3 cm2 consistent with moderate aortic stenosis SUMMARY 1 Normal left ventricular size and function 2 Benign Doppler flow pattern 3 Aortic valve area of 1 3 cm2 planimetry Keywords radiology aortic valve ejection fraction planimetry ventricular transesophageal echocardiogram atrial septum septum intact transesophageal echocardiogram aortic stenosis doppler aortic valves MEDICAL_TRANSCRIPTION,Description Left testicular swelling for one day Testicular Ultrasound Hypervascularity of the left epididymis compatible with left epididymitis Bilateral hydroceles Medical Specialty Radiology Sample Name Testicular Ultrasound Transcription TESTICULAR ULTRASOUND REASON FOR EXAM Left testicular swelling for one day FINDINGS The left testicle is normal in size and attenuation it measures 3 2 x 1 7 x 2 3 cm The right epididymis measures up to 9 mm There is a hydrocele on the right side Normal flow is seen within the testicle and epididymis on the right The left testicle is normal in size and attenuation it measures 3 9 x 2 1 x 2 6 cm The left testicle shows normal blood flow The left epididymis measures up to 9 mm and shows a markedly increased vascular flow There is mild scrotal wall thickening A hydrocele is seen on the left side IMPRESSION 1 Hypervascularity of the left epididymis compatible with left epididymitis 2 Bilateral hydroceles Keywords radiology hypervascularity bilateral hydroceles epididymis epididymitis testicular ultrasound ultrasound flow hydroceles testicle testicular MEDICAL_TRANSCRIPTION,Description Nerve root decompression at L45 on the left side Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left Interpretation of radiograph Medical Specialty Radiology Sample Name Tun L Catheter Placement Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low back pain with left greater than right lower extremity radiculopathy POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Nerve root decompression at L45 on the left side 2 Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION FOR PROCEDURE Severe and excruciating pain in the lumbar spine and lower extremity MRI shows disc pathology as well as facet arthrosis SUMMARY OF PROCEDURE The patient was admitted to the operating room consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels After the towels were places then sterile drapes were placed on top of that After which time the Epimed catheter was then placed this was done by first repositioning the C Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5 verifying the sacral hiatus The skin over the sacral hiatus was then injected with 1 Lidocaine and an 18 gauge needle was used for skin puncture The 18 gauge needle was inserted off of midline A 16 gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss of resistance technique the needle was placed Negative aspiration was carefully performed Omnipaque 240 dye was then injected through the 16 gauge RK needle The classical run off was noted A filling defect was noted L45 nerve root on the left side After which time 10 cc of 0 25 Marcaine Triamcinolone 9 1 mixture was then infused through the 16 R K Needle Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique An Epimed Tun L catheter was then inserted through the 16 gauage R K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized The tip of the catheter was noted to be L45 level on the left side After this the 16 gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side After this was successfully done the catheter was then secured in place this was done with Neosporin ointment a Split 2x2 Op site and Hypofix tape The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected The classical run off was noted in the lumbar region Some lyses of adhesions were also visualized at this time with barbotage technique Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect After which time negative aspiration was again performed through the Epimed Tun L catheter and then 10 cc of solution was then infused through the catheter this was done over a 10 minute period with initial 3 cc test dose Approximately 3 minutes elapsed and then the remaining 7 cc were infused Solution consisting of 8 cc of 0 25 Marcaine 2 cc of Triamcinolone and 1 cc of Wydase The catheter was then capped with a bacterial filter The patient was noted to have tolerated the procedure well without any complications Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure This verified positive nerve root decompression The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side Positive myelogram without dural puncture was noted during this procedure no sub dural spread of Omnipaque 240 dye was noted This patient did not report any problems and reported pain reduction Keywords radiology low back syndrome low back pain nerve root decompression steroid solution c arm epimed tun l catheter nerve root negative aspiration omnipaque dye filling defect nerve root catheter adhesions injection needle MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiographic examination report Aortic valve replacement Assessment of stenotic valve Evaluation for thrombus on the valve Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 3 Transcription REASON FOR EXAM Aortic valve replacement Assessment of stenotic valve Evaluation for thrombus on the valve PREOPERATIVE DIAGNOSIS Atrial valve replacement POSTOPERATIVE DIAGNOSES Moderate stenosis of aortic valve replacement Mild mitral regurgitation Normal left ventricular function PROCEDURES IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control The oropharynx anesthetized with benzocaine spray and lidocaine solution Esophageal intubation was done with no difficulty with the second attempt In a semi Fowler position the probe was passed to transthoracic views at about 40 to 42 cm Multiple pictures obtained Assessment of the peak velocity was done later The probe was pulled to the mid esophageal level Different pictures including short axis views of the aortic valve was done Extubation done with no problems and no blood on the probe The patient tolerated the procedure well with no immediate postprocedure complications INTERPRETATION The left atrium was mildly dilated No masses or thrombi were seen The left atrial appendage was free of thrombus Pulse wave interrogation showed peak velocities of 60 cm per second The left ventricle was normal in size and contractility with mild LVH EF is normal and preserved The right atrium and right ventricle were both normal in size Mitral valve showed no vegetations or prolapse There was mild to moderate regurgitation on color flow interrogation Aortic valve was well seated mechanical valve bileaflet with acoustic shadowing beyond the valve noticed No perivalvular leak was noticed There was increased velocity across the valve with peak velocity of 3 2 m sec with calculated aortic valve area by continuity equation at 1 2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves No AIC Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve Overall showed no abnormalities The tricuspid valve was structurally normal Interatrial septum appeared to be intact confirmed by color flow interrogation as well as agitated saline contrast study The aorta and aortic arch were unremarkable No dissection IMPRESSION 1 Mildly dilated left atrium 2 Mild to moderate regurgitation 3 Well seated mechanical aortic valve with peak velocity of 3 2 m sec and calculated valve area of 1 2 cm2 consistent with moderate aortic stenosis Reevaluation in two to three years with transthoracic echocardiogram will be recommended Keywords radiology aortic valve replacement stenotic valve thrombus stenosis ventricular esophageal peak velocity valve replacement aortic valve aortic transesophageal valve oropharynx atrium interrogation atrial moderate MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram due to vegetation and bacteremia Normal left ventricular size and function Echodensity involving the aortic valve suggestive of endocarditis and vegetation Doppler study as above most pronounced being moderate to severe aortic insufficiency Medical Specialty Radiology Sample Name Transesophageal Echocardiogram 2 Transcription REASON FOR EXAM Vegetation and bacteremia PROCEDURE Transesophageal echocardiogram INTERPRETATION The procedure and its complications were explained to the patient in detail and formal consent was obtained The patient was brought to special procedure unit His throat was anesthetized with lidocaine spray Subsequently 2 mg of IV Versed was given for sedation The patient was positioned Probe was introduced without any difficulty The patient tolerated the procedure very well Probe was taken out No complications were noted Findings are as mentioned below FINDINGS 1 Left ventricle has normal size and dimensions with normal function Ejection fraction of 60 2 Left atrium and right sided chambers were of normal size and dimensions 3 Left atrial appendage is clean without any clot or smoke effect 4 Atrial septum is intact Bubble study was negative 5 Mitral valve is structurally normal 6 Aortic valve reveals echodensity suggestive of vegetation 7 Tricuspid valve was structurally normal 8 Doppler reveals moderate mitral regurgitation and moderate to severe aortic regurgitation 9 Aorta is benign IMPRESSION 1 Normal left ventricular size and function 2 Echodensity involving the aortic valve suggestive of endocarditis and vegetation 3 Doppler study as above most pronounced being moderate to severe aortic insufficiency Keywords radiology ventricle atrium atrial septum mitral valv aortic valve tricuspid valve doppler ventricular size transesophageal echocardiogram severe aortic bacteremia transesophageal echocardiogram echodensity vegetation valve aortic MEDICAL_TRANSCRIPTION,Description Pain Three views of the right ankle Three views of the right ankle are obtained Medical Specialty Radiology Sample Name Three Views Ankle Transcription EXAM Three views of the right ankle INDICATIONS Pain FINDINGS Three views of the right ankle are obtained There is no evidence of fractures or dislocations No significant degenerative changes or destructive osseous lesions of the ankle are noted There is a small plantar calcaneal spur There is no significant surrounding soft tissue swelling IMPRESSION Negative right ankle Keywords radiology three views calcaneal plantar spur osseous ankle MEDICAL_TRANSCRIPTION,Description Tailor bunionectomy right foot Weil type with screw fixation Hallux abductovalgus deformity and tailor bunion deformity right foot Medical Specialty Radiology Sample Name Tailor Bunionectomy with Screw Fixation Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot PROCEDURES PERFORMED Tailor bunionectomy right foot Weil type with screw fixation ANESTHESIA Local with MAC local consisting of 20 mL of 0 5 Marcaine plain HEMOSTASIS Pneumatic ankle tourniquet at 200 mmHg INJECTABLES A 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate MATERIAL A 2 4 x 14 mm 2 4 x 16 mm and 2 0 x 10 mm OsteoMed noncannulated screw A 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl and 5 0 nylon COMPLICATIONS None SPECIMENS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was brought to the operating room and placed on the operating table in the usual supine position At this time a pneumatic ankle tourniquet was placed on the patient s right ankle for the purpose of maintaining hemostasis Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site The right foot was then scrubbed prepped and draped in the usual aseptic manner An Esmarch bandage was then used to exsanguinate the patient s right foot and the pneumatic ankle tourniquet inflated to 200 mmHg Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3 5 cm in length was made The incision was carried deep utilizing both sharp and blunt dissections All major neurovascular structures were avoided At this time through the original skin incision attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified This was then incised fully exposing the tendon and the abductor hallucis muscle This was then resected from his osseous attachments and a small tenotomy was performed At this time a small lateral capsulotomy was also performed Lateral contractures were once again reevaluated and noted to be grossly reduced Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw the head of the first metatarsal and medial eminence was resected and passed from the operative field A 0 045 inch K wire was then driven across the first metatarsal head in order to act as an access dye The patient was then placed in the frog leg position and two osteotomy cuts were made one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position The dorsal arm was made longer than the plantar arm to accommodate for fixation At this time the capital fragment was resected and shifted laterally into a more corrected position At this time three portions of the 0 045 inch K wire were placed across the osteotomy site in order to access temporary forms of fixation Two of the three of these K wires were removed in sequence and following the standard AO technique two 3 4 x 15 mm and one 2 4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site Compression was noted to be excellent All guide wires and 0 045 inch K wires were then removed Utilizing an oscillating bone saw the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field The wound was then once again flushed with copious amounts of sterile normal saline At this time utilizing both 2 0 and 3 0 Vicryl the periosteal and capsular layers were then reapproximated At this time the skin was then closed in layers utilizing 4 0 Vicryl and 4 0 nylon At this time attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal Utilizing an oscillating bone saw the lateral eminence was resected and passed from the operative field Utilizing the sagittal saw a Weil type osteotomy was made at the fifth metatarsal head The head was then shifted medially into a more corrected position A 0 045 inch K wire was then used as a temporary fixation and a 2 0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site This was noted to be in correct position and compression was noted to be excellent Utilizing a small bone rongeur the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field The wound was once again flushed with copious amounts of sterile normal saline The periosteal and capsular layers were reapproximated utilizing 3 0 Vicryl and the skin was then closed utilizing 4 0 Vicryl and 4 0 nylon At this time 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site The right foot was then dressed with Xeroform gauze fluffs Kling and Ace wrap all applied in mild compressive fashion The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot After a brief period of postoperative monitoring the patient was discharged to home with proper written and verbal discharge instructions which included to keep dressing clean dry and intact and to follow up with Dr A The patient is to be nonweightbearing to the right foot The patient was given a prescription for pain medications on nonsteroidal anti inflammatory drugs and was educated on these The patient tolerated the procedure and anesthesia well Dr A was present throughout the entire case Keywords radiology tailor bunionectomy weil type screw fixation hallux abductovalgus bunion tailor deformity metatarsal phalangeal capsulotomy abductor hallucis MEDICAL_TRANSCRIPTION,Description Right foot trauma Three views of the right foot Three views of the right foot were obtained Medical Specialty Radiology Sample Name Three Views Foot Transcription EXAM Three views of the right foot REASON FOR EXAM Right foot trauma FINDINGS Three views of the right foot were obtained There are no comparison studies There is no evidence of fractures or dislocations No significant degenerative changes or obstructive osseous lesions were identified There are no radiopaque foreign bodies IMPRESSION Negative right foot Keywords radiology three views radiopaque fractures foot trauma MEDICAL_TRANSCRIPTION,Description Chest pain Chest wall tenderness occurred with exercise Medical Specialty Radiology Sample Name Stress Test Graded Exercise Treadmill Transcription INDICATIONS Chest pain PROCEDURE DONE Graded exercise treadmill stress test STRESS ECG RESULTS The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol The heart rate increased from 68 beats per minute to 178 beats per minute which is 100 of the maximum predicted target heart rate The blood pressure increased from 120 70 to 130 80 The baseline resting electrocardiogram reveals a regular sinus rhythm The tracing is within normal limits Symptoms of chest pain occurred with exercise The pain persisted during the recovery process and was aggravated by deep inspiration Marked chest wall tenderness noted There were no ischemic ST segment changes seen during exercise or during the recovery process CONCLUSIONS 1 Stress test is negative for ischemia 2 Chest wall tenderness occurred with exercise 3 Blood pressure response to exercise is normal Keywords radiology stress test blood pressure bruce protocol chest pain graded exercise graded exercise treadmill electrocardiogram ischemia sinus rhythm treadmill chest wall tenderness chest wall stress chest MEDICAL_TRANSCRIPTION,Description Thallium stress test for chest pain Medical Specialty Radiology Sample Name Stress Test Thallium Transcription INDICATIONS Chest pain STRESS TECHNIQUE Keywords radiology chest pain ecg stress thallium stress test aerobic capacity ejection fraction gated tomographic spect system myocardial perfusion thallous chloride ventricle wall motion stress test stress MEDICAL_TRANSCRIPTION,Description Chest pain hypertension Stress test negative for dobutamine induced myocardial ischemia Normal left ventricular size regional wall motion and ejection fraction Medical Specialty Radiology Sample Name Stress Test Dobutamine Myoview Transcription INDICATIONS Chest pain hypertension type II diabetes mellitus PROCEDURE DONE Dobutamine Myoview stress test STRESS ECG RESULTS The patient was stressed by dobutamine infusion at a rate of 10 mcg kg minute for three minutes 20 mcg kg minute for three minutes and 30 mcg kg minute for three additional minutes Atropine 0 25 mg was given intravenously eight minutes into the dobutamine infusion The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute QS pattern in leads V1 and V2 and diffuse nonspecific T wave abnormality The heart rate increased from 86 beats per minute to 155 beats per minute which is about 90 of the maximum predicted target heart rate The blood pressure increased from 130 80 to 160 70 A maximum of 1 mm J junctional depression was seen with fast up sloping ST segments during dobutamine infusion No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process MYOCARDIAL PERFUSION IMAGING Resting myocardial perfusion SPECT imaging was carried out with 10 9 mCi of Tc 99m Myoview Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29 2 mCi of Tc 99m Myoview The lung heart ratio is 0 36 Myocardial perfusion images were normal both at rest and with stress Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67 CONCLUSIONS 1 Stress test is negative for dobutamine induced myocardial ischemia 2 Normal left ventricular size regional wall motion and ejection fraction Keywords radiology chest pain dobutamine myoview dobutamine myoview stress test spect imaging stress test dobutamine infusion ejection fraction hypertension myocardial ischemia myocardial perfusion ventricular size wall motion dobutamine stress myocardial myoview ischemia ventricular perfusion MEDICAL_TRANSCRIPTION,Description Dobutrex stress test for abnormal EKG Medical Specialty Radiology Sample Name Stress Test Dobutrex Transcription INDICATIONS Keywords radiology dobutrex stress test abnormal ekg dobutrex inferior abnormality ischemic heart disease ventricle µg kg minute stress test stress MEDICAL_TRANSCRIPTION,Description Dobutamine stress test for atrial fibrillation Medical Specialty Radiology Sample Name Stress Test Dobutamine Transcription INDICATIONS Atrial fibrillation coronary disease STRESS TECHNIQUE The patient was infused with dobutamine to a maximum heart rate of 142 ECG exhibits atrial fibrillation IMAGE TECHNIQUE The patient was injected with 5 2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system IMAGE ANALYSIS It should be noted that the images are limited slightly by the patient s obesity with a weight of 263 pounds There is normal LV myocardial perfusion The LV systolic ejection fraction is normal at 65 There is normal global and regional wall motion CONCLUSIONS 1 Basic rhythm of atrial fibrillation with no change during dobutamine stress maximum heart rate of 142 2 Normal LV myocardial perfusion 3 Normal LV systolic ejection fraction of 65 4 Normal global and regional wall motion Keywords radiology dobutamine stress test atrial fibrillation lv myocardial perfusion lv systolic ejection fraction coronary disease dobutamine ejection fraction gated tomographic spect system thallous chloride wall motion stress fibrillation atrial MEDICAL_TRANSCRIPTION,Description Frontal and lateral views of the hip and pelvis Medical Specialty Radiology Sample Name Slipped Capital Femoral Epiphysis SCFE Transcription EXAM Two views of the pelvis HISTORY This is a patient post surgery 2 1 2 months The patient has a history of slipped capital femoral epiphysis SCFE bilaterally TECHNIQUE Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM DD YYYY Lateral view of the right hip was evaluated FINDINGS Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient s most recent priors dated MM DD YYYY Current films reveal stable appearing post surgical changes Again demonstrated is a single intramedullary screw across the left femoral neck and head There are 2 intramedullary screws through the greater trochanter of the right femur There is a lucency along the previous screw track extending into the right femoral head and neck There has been interval removal of cutaneous staples and or surgical clips These were previously seen along the lateral aspect of the right hip joint Deformity related to the previously described slipped capital femoral epiphysis is again seen IMPRESSION 1 Stable appearing right hip joint status post pinning 2 Interval removal of skin staples as described above Keywords radiology scfe frontal and lateral views slipped capital femoral epiphysis lateral views slipped capital epiphysis frontal pelvis femoral hip MEDICAL_TRANSCRIPTION,Description Stress test Adenosine Myoview Ischemic cardiomyopathy Inferoseptal and apical transmural scar Medical Specialty Radiology Sample Name Stress Test Adenosine Myoview Transcription INDICATIONS Ischemic cardiomyopathy status post inferior wall myocardial infarction status post left anterior descending PTCA and stenting PROCEDURE DONE Adenosine Myoview stress test STRESS ECG RESULTS The patient was stressed by intravenous adenosine 140 mcg kg minute infused over four minutes The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute Underlying atrial fibrillation noted very wide QRS complexes The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140 80 to 110 70 with adenosine infusion Keywords radiology stress test adenosine adenosine myoview stress test ischemic cardiomyopathy spect cardiomyopathy electrocardiogram myocardial infarction stress test adenosine myoview adenosine myoview stress myoview stress test ptca and stenting myoview stress transmural scar adenosine infusion septal motion adenosine myoview myocardial perfusion hypokinesis inferoseptal ischemic myocardial myoview perfusion scan MEDICAL_TRANSCRIPTION,Description HCT SAH Contusion Skull fracture Medical Specialty Radiology Sample Name SAH Contusion Skull Fracture Transcription CC Headache HX This 51 y o RHM was moving furniture several days prior to presentation when he struck his head vertex against a door panel He then stepped back and struck his back on a trailer hitch There was no associated LOC but he felt dazed He complained a HA since the accident The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting He has been lying in bed most of the time since the accident He also complained of transient left lower extremity weakness The night before admission he went to his bedroom and his girlfriend heard a loud noise She found him on the floor unable to speak or move his left side well He was taken to a local ER In the ER experienced a spell in which he stared to the right for approximately one minute During this time he was unable to speak and did not seem to comprehend verbal questions This resolved ER staff noted decreased left sided movement and a left Babinski sign He was given valium 5 mg and DPH 1 0g A HCT was performed and he was transferred to UIHC PMH DM Coronary Artery Disease Left femoral neuropathy of unknown etiology Multiple head trauma in past falls fights MEDS unknown oral med for DM SHX 10 pack year h o Tobacco use quit 2 years ago 6 pack beer week No h o illicit drug use FHX unknown EXAM 70BPM BP144 83 16RPM 36 0C MS Alert and oriented to person place time Fluent speech CN left lower facial weakness with right gaze preference Pupils 3 3 decreasing to 2 2 on exposure to light Optic disks flat MOTOR decreased spontaneous movement of left sided extremities 5 4 strength in both upper and lower extremities Normal muscle tone and bulk SENSORY withdrew equally to noxious stimulation in all four extremities GAIT STATION COORDINATION not tested The general physical exam was unremarkable During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward and his right hand twitched The entire spell lasted one minute During the episode he was verbally unresponsive He appeared groggy and lethargic after the event HCT without contrast 11 18 92 right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma as well as some adjacent subarachnoid blood and brain contusion LABS CBC GS PT PTT were all WNL COURSE The patient was diagnosed with a right frontal SAH contusion and post traumatic seizures DPH was continued and he was given a Librium taper for possible alcoholic withdrawal A neurosurgical consult was obtained He did not receive surgical intervention and was discharged 12 1 92 Neuropsychological testing on 11 25 92 revealed poor orientation to time or place and poor attention Anterograde verbal and visual memory was severely impaired Speech became mildly dysarthric when fatigued Defective word finding Difficulty copying 2 of 3 three dimensional figures Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits Keywords radiology sah contusion skull fracture headache post traumatic seizures lower extremity weakness loud noise hct weakness skull hematoma fracture MEDICAL_TRANSCRIPTION,Description Chest Single view post OP for ASD Atrial Septal Defect Medical Specialty Radiology Sample Name Single Frontal View of Chest Transcription EXAM Single frontal view of the chest HISTORY Atelectasis Patient is status post surgical correction for ASD TECHNIQUE A single frontal view of the chest was evaluated and correlated with the prior film dated mm dd yy FINDINGS Current film reveals there is a right sided central venous catheter the distal tip appears to be in the superior vena cava Endotracheal tube with the distal tip appears to be in appropriate position approximately 2 cm superior to the carina Sternotomy wires are noted They appear in appropriate placement There are no focal areas of consolidation to suggest pneumonia Once again seen is minimal amount of bilateral basilar atelectasis The cardiomediastinal silhouette appears to be within normal limits at this time No evidence of any pneumothoraces or pleural effusions IMPRESSION 1 There has been interval placement of a right sided central venous catheter endotracheal tube and sternotomy wires secondary to patient s most recent surgical intervention 2 Minimal bilateral basilar atelectasis with no significant interval changes from the patient s most recent prior 3 Interval decrease in the patient s heart size which may be secondary to the surgery versus positional and technique Keywords radiology atrial septal defect central venous catheter bilateral basilar atelectasis single frontal view distal tip endotracheal tube sternotomy wires basilar atelectasis atrial venous catheter endotracheal tube sternotomy atelectasis chest asd MEDICAL_TRANSCRIPTION,Description Single frontal view of the chest Respiratory distress The patient has a history of malrotation Medical Specialty Radiology Sample Name Single Frontal View Chest Pediatric Transcription EXAM Single frontal view of the chest HISTORY Respiratory distress The patient has a history of malrotation The patient is back for a re anastomosis of the bowel with no acute distress TECHNIQUE Single frontal view of the chest was evaluated and correlated with the prior film dated MM DD YY FINDINGS A single frontal view of the chest was evaluated It reveals interval placement of an ET tube and an NG tube ET tube is midway between the patient s thoracic inlet and carina NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm There is no evidence of any focal areas of consolidation pneumothoraces or pleural effusions The mediastinum seen was slightly prominent however this may be secondary to thymus and or technique There is a slight increase seen with regards to the central pulmonary vessels Again this may represent a minimal amount of pulmonary vascular congestion There is paucity of bowel gas seen in the upper abdomen The osseous thorax appears to be grossly intact and symmetrical Slightly low lung volumes however this may be secondary to the film being taken on the expiratory phase of respiration IMPRESSION 1 No evidence of any focal areas of consolidation pneumothoraces or pleural effusions 2 Slight prominence to the mediastinum which may be secondary to thymus and or technique 3 Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion Keywords radiology malrotation consolidation pneumothoraces single frontal view respiratory distress vascular congestion frontal view effusions mediastinum vascular congestion respiratory anastomosis pulmonary single frontal chest MEDICAL_TRANSCRIPTION,Description Complex Regional Pain Syndrome Type I Stellate ganglion RFTC radiofrequency thermocoagulation left side and interpretation of Radiograph Medical Specialty Radiology Sample Name Radiofrequency Thermocoagulation 2 Transcription PREOPERATIVE DIAGNOSIS Complex Regional Pain Syndrome Type I POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Stellate ganglion RFTC radiofrequency thermocoagulation left side 2 Interpretation of Radiograph ANESTHESIA IV Sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS Patient with reflex sympathetic dystrophy left side Positive for allodynia pain mottled appearance skin changes upper extremities as well as swelling SUMMARY OF PROCEDURE Patient is admitted to the Operating Room Monitors placed including EKG Pulse oximeter and BP cuff Patient had a pillow placed under the shoulder blades The head and neck was allowed to fall back into hyperextension The neck region was prepped and draped in sterile fashion with Betadine and alcohol Four sterile towels were placed The cricothyroid membrane was palpated then going one finger s breadth lateral from the cricothyroid membrane and one finger s breadth inferior the carotid pulse was palpated and the sheath was retracted laterally A 22 gauge SMK 5 mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially The needle is advanced prudently through the tissues avoiding the carotid artery laterally The tip of the needle is perceived to intersect with the vertebral body of Cervical 7 and this was visualized by fluoroscopy Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand No venous or arterial blood return is noted No cerebral spinal fluid is noted Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0 0 1 volts and negative motor stimulation was elicited from 1 10 volts at 2 Hz After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed 5 cc of solution solution consisting of 5 cc of 0 5 Marcaine 1 cc of triamcinolone was then injected into the stellate ganglion region This was done with intermittent aspiration vigilantly verifying negative aspiration The stylet was then promptly replaced and neurolysis nerve decompression was then carried out for 60 seconds at 80 degrees centigrade This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band Aid was placed over the puncture site Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion Interpretation of radiograph reveals placement of the 22 gauge SMK 5 mm bare tipped needle in the region of the stellate ganglion on the affected side Four lesions were carried out Keywords radiology sheath vertebral body regional pain syndrome radiofrequency thermocoagulation stellate ganglion rftc radiofrequency radiograph cricothyroid thermocoagulation ganglion MEDICAL_TRANSCRIPTION,Description Ultrasound kidneys renal for renal failure neurogenic bladder status post cystectomy Medical Specialty Radiology Sample Name Renal Ultrasound Transcription EXAM Renal ultrasound HISTORY Renal failure neurogenic bladder status post cystectomy TECHNIQUE Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes COMPARISON Most recently obtained mm dd yy FINDINGS The right kidney measures 12 x 5 2 x 4 6 cm and the left kidney measures 12 2 x 6 2 x 4 4 cm The imaged portions of the kidneys fail to demonstrate evidence of mass hydronephrosis or calculus There is no evidence of cortical thinning Incidentally there is a rounded low attenuation mass within the inferior aspect of the right lobe of the liver measuring 2 1 x 1 5 x 1 9 cm which has suggestion of some peripheral blood flow IMPRESSION 1 No evidence of hydronephrosis 2 Mass within the right lobe of the liver The patient apparently has a severe iodine allergy Further evaluation with MRI is recommended 3 The results of this examination were given to XXX in Dr XXX office on mm dd yy at XXX Keywords radiology lobe of the liver status post cystectomy renal ultrasound renal failure neurogenic bladder bladder status neurogenic bladder cystectomy hydronephrosis lobe liver ultrasound mass renal kidneys renal MEDICAL_TRANSCRIPTION,Description Elevated cardiac enzymes fullness in chest abnormal EKG and risk factors No evidence of exercise induced ischemia at a high myocardial workload This essentially excludes obstructive CAD as a cause of her elevated troponin Medical Specialty Radiology Sample Name Radionuclide Stress Test Transcription INDICATION FOR STUDY Elevated cardiac enzymes fullness in chest abnormal EKG and risk factors MEDICATIONS Femara verapamil Dyazide Hyzaar glyburide and metformin BASELINE EKG Sinus rhythm at 84 beats per minute poor anteroseptal R wave progression mild lateral ST abnormalities EXERCISE RESULTS 1 The patient exercised for 3 minutes stopping due to fatigue No chest pain 2 Heart rate increased from 84 to 138 or 93 of maximum predicted heart rate Blood pressure rose from 150 88 to 210 100 There was a slight increase in her repolorization abnormalities in a non specific pattern NUCLEAR PROTOCOL Same day rest stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test NUCLEAR RESULTS 1 Nuclear perfusion imaging review of the raw projection data reveals adequate image acquisition The resting images showed decreased uptake in the anterior wall However the apex is spared of this defect There is no significant change between rest and stress images The sum score is 0 2 The Gated SPECT shows moderate LVH with slightly low EF of 48 IMPRESSION 1 No evidence of exercise induced ischemia at a high myocardial workload This essentially excludes obstructive CAD as a cause of her elevated troponin 2 Mild hypertensive cardiomyopathy with an EF of 48 3 Poor exercise capacity due to cardiovascular deconditioning 4 Suboptimally controlled blood pressure on today s exam Keywords radiology sinus rhythm cardiac enzymes abnormal ekg stress test elevated troponin heart rate blood pressure radionuclide chest ekg stress ischemia MEDICAL_TRANSCRIPTION,Description Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain Medical Specialty Radiology Sample Name Radiofrequency Thermocoagulation 1 Transcription PROCEDURE Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion The patient was given sedation and monitored Lidocaine 1 5 for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body A 20 gauge 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body At this time a negative motor stimulation was obtained Injection of 10 cc of 0 5 Marcaine plus 10 mg of Depo Medrol was performed Coagulation was then carried out for 90oC for 90 seconds At the conclusion of this the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated This was repeated one more time with a 5 mm withdrawal and coagulation At that time attention was directed to the L3 body where the needle was placed to the upper one third distal two thirds junction and the sequence of injection coagulation and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated There were no compilations from this The patient was discharged to operating room recovery in stable condition Keywords radiology lumbar sympathetic chain vertebral body radiofrequency thermocoagulation motor stimulation thermocoagulation radiofrequency coagulation needle MEDICAL_TRANSCRIPTION,Description Bilateral renal ultrasound Medical Specialty Radiology Sample Name Renal Ultrasound 1 Transcription EXAM Bilateral renal ultrasound CLINICAL INDICATION UTI TECHNIQUE Transverse and longitudinal sonograms of the kidneys were obtained FINDINGS The right kidney is of normal size and echotexture and measures 5 7 x 2 2 x 3 8 cm The left kidney is of normal size and echotexture and measures 6 2 x 2 8 x 3 0 cm There is no evidence for HYDRONEPHROSIS or PERINEPHRIC fluid collections The bladder is of normal size and contour The bladder contains approximately 13 mL of urine after recent voiding This is a small postvoid residual IMPRESSION Normal renal ultrasound Small postvoid residual Keywords radiology bilateral renal ultrasound postvoid residual renal ultrasound residual kidneys renal ultrasound MEDICAL_TRANSCRIPTION,Description Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation Medical Specialty Radiology Sample Name Radiofrequency Thermocoagulation Transcription PROCEDURE Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position The back prepped with Betadine The patient was given sedation and monitored Under fluoroscopy the right sacral alar notch was identified After placement of a 20 gauge 10 cm SMK needle into the notch a positive sensory negative motor stimulation was obtained Following negative aspiration 5 cc of 0 5 of Marcaine and 20 mg of Depo Medrol were injected Coagulation was then carried out at 90oC for 90 seconds The SMK needle was then moved to the mid inferior third of the right sacroiliac joint Again the steps dictated above were repeated The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen then followed by steroid injected and coagulation as above There were no complications The patient was returned to outpatient recovery in stable condition Keywords radiology posterior rami sacroiliac joint sacral alar notch radiofrequency thermocoagulation thermocoagulation radiofrequency sacroiliac sacral alar notch MEDICAL_TRANSCRIPTION,Description Cervical lumbosacral thoracic spine flexion and extension to evaluate back and neck pain Medical Specialty Radiology Sample Name Radiologic Exam Spine Transcription EXAM Cervical lumbosacral thoracic spine flexion and extension HISTORY Back and neck pain CERVICAL SPINE FINDINGS AP lateral with flexion and extension and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable Keywords radiology radiologic exam ap back cervical oblique views alignment disc space extension fixation flexion foramina intervertebral lateral views lumbosacral neck neck pain oblique odontoid view pain physiologic projections spine subluxation thoracic flexion and extension thoracic spine vertebral MEDICAL_TRANSCRIPTION,Description Prostate Brachytherapy Prostate I 125 Implantation Medical Specialty Radiology Sample Name Prostate Brachytherapy Transcription PROSTATE BRACHYTHERAPY PROSTATE I 125 IMPLANTATION This patient will be treated to the prostate with ultrasound guided I 125 seed implantation The original consultation and treatment planning will be separately performed At the time of the implantation special coordination will be required Stepping ultrasound will be performed and utilized in the pre planning process Some discrepancies are frequently identified based on the positioning edema and or change in the tumor since the pre planning process Re assessment is required at the time of surgery evaluating the pre plan and comparing to the stepping ultrasound Modifications will be made in real time to add or subtract needles and seeds as required This may be integrated with the loading of the seeds performed by the brachytherapist as well as coordinated with the urologist dosimetrist or physicist The brachytherapy must be customized to fit the individual s tumor and prostate Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder Keywords radiology i 125 implantation tumor prostate prostate brachytherapy implantationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right foot series after a foot injury Medical Specialty Radiology Sample Name Right Foot Series Transcription EXAM Right foot series REASON FOR EXAM Injury FINDINGS Three images of the right foot were obtained On the AP image only there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal Also on a single image there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only Fractures in these bones cannot be completely excluded There is soft tissue swelling seen overlying the calcaneus within this region IMPRESSION Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals Recommend correlation with site of pain in addition to conservative management and followup imaging A phone call will be placed to the emergency room regarding these findings Keywords radiology sclerosis calcaneus metatarsal foot series MEDICAL_TRANSCRIPTION,Description Ultrasound Guided Paracentesis for Ascites Medical Specialty Radiology Sample Name Paracentesis Ultrasound Guided Transcription EXAM Ultrasound guided paracentesis HISTORY Ascites TECHNIQUE AND FINDINGS Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained Ultrasound demonstrates free fluid in the abdomen The area of interest was localized with ultrasonography The region was sterilely prepped and draped in the usual manner Local anesthetic was administered A 5 French Yueh catheter needle combination was taken Upon crossing into the peritoneal space and aspiration of fluid the catheter was advanced out over the needle A total of approximately 5500 mL of serous fluid was obtained The catheter was then removed The patient tolerated the procedure well with no immediate postprocedure complications IMPRESSION Ultrasound guided paracentesis as above Keywords radiology yueh catheter aspiration of fluid ultrasound guided paracentesis ultrasound guided needle catheter paracentesis ultrasound ascites MEDICAL_TRANSCRIPTION,Description Left breast cancer Nuclear medicine lymphatic scan A 16 hour left anterior oblique imaging was performed with and without shielding of the original injection site Medical Specialty Radiology Sample Name Nuclear Medicine Lymphatic Scan Transcription EXAM Nuclear medicine lymphatic scan REASON FOR EXAM Left breast cancer TECHNIQUE 1 0 mCi of Technetium 99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations A 16 hour left anterior oblique imaging was performed with and without shielding of the original injection site FINDINGS There are two small foci of increased activity in the left axilla This is consistent with the sentinel lymph node No other areas of activity are visualized outside of the injection site and two axillary lymph nodes IMPRESSION Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node Keywords radiology technetium 99m mci biopsy breast cancer nuclear medicine lymphatic scan lymph node nuclear breast MEDICAL_TRANSCRIPTION,Description Nuclear cardiac stress report Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy Medical Specialty Radiology Sample Name Nuclear Cardiac Stress Report Transcription NUCLEAR CARDIOLOGY CARDIAC STRESS REPORT INDICATION FOR STUDY Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy PROCEDURE The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg kg min delivered over a total of 4 minutes At completion of the second minute of infusion the patient received technetium Cardiolite per protocol During this interval the blood pressure 150 86 dropped to near 136 80 and returned to near 166 84 at completion No diagnostic electrocardiographic abnormalities were elaborated during this study REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease yet no active ischemia at this time A fixed defect is seen in the high anterolateral segment A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum There is no evidence for active ischemia in either distribution Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity When viewed from the vertical projection the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall A limited segment of apical myocardium is still viable No gated wall motion study was obtained CONCLUSIONS Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above There is no indication for active ischemia at this time Keywords radiology angina pectoris ischemic cardiomyopathy myocardial perfusion adenosine provocation cardiolite perfusion nuclear cardiac stress report coronary artery disease active ischemia ischemic angina MEDICAL_TRANSCRIPTION,Description Whole body PET scanning Medical Specialty Radiology Sample Name PET Report Whole Body Scan Transcription INDICATION Lung carcinoma Whole body PET scanning was performed with 11 mCi of 18 FDG Axial coronal and sagittal imaging was performed over the neck chest abdomen and pelvis FINDINGS There is normal physiologic activity identified in the myocardium liver spleen ureters kidneys and bladder There is abnormal FDG avid activity identified in the posterior left paraspinal region best seen on axial images 245 257 with an SUV of 3 8 no definite bone lesion is identified on the CT scan or the bone scan dated 08 14 2007 It may be purely lytic Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18 1 the adjacent atelectasis as likely post obstructive in nature Additionally although there is no definite lesion identified on CT there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5 0 The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3 7 in the mediastinum IMPRESSION No prior PET scans for comparison there is a large lesion identified in the area of the left hilum with an SUV of 18 1 likely causing the obstructive atelectasis seen on the CT scan There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5 0 There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion However no lesion is identified on bone scan or CT scan There is a hypermetabolic lymph node identified The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3 7 Keywords radiology whole body scan pet scanning lung carcinoma axial coronal sagittal imaging pet scans hypermetabolic lymph node hypermetabolic lymph lymph node pulmonary window ct scan scan fdg pet suv ct MEDICAL_TRANSCRIPTION,Description Nuclear medicine tumor localization whole body status post subtotal thyroidectomy for thyroid carcinoma Medical Specialty Radiology Sample Name Nuclear Medicine Tumor Localization Transcription EXAM Nuclear medicine tumor localization whole body HISTORY Status post subtotal thyroidectomy for thyroid carcinoma histology not provided FINDINGS Following the oral administration of 4 3 mCi Iodine 131 whole body planar images were obtained in the anterior and posterior projections at 24 48 and 72 hours There is increased uptake in the left upper quadrant which persists throughout the examination There is a focus of increased activity in the right lower quadrant which becomes readily apparent at 72 hours Physiologic uptake in the liver spleen and transverse colon is noted Physiologic urinary bladder uptake is also appreciated There is low grade uptake in the oropharyngeal region IMPRESSION Iodine avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis Anatomical evaluation i e CT is advised to determine if there are corresponding mesenteric lesions Ultimately provided that the original pathology of the thyroid tumor with iodine avid PET scanning may be necessary No evidence of iodine added locoregional metastasis Keywords radiology nuclear medicine iodine 131 pet scanning anterior left upper quadrant liver localization oropharyngeal planar images posterior spleen thyroid carcinoma thyroidectomy transverse colon tumor urinary bladder nuclear medicine tumor localization thyroidectomy for thyroid tumor localization nuclear medicine iodine MEDICAL_TRANSCRIPTION,Description Bilateral L5 S1 S2 and S3 radiofrequency ablation for sacroiliac joint pain Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Radiology Sample Name Radiofrequency Ablation Transcription PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 20 gauge 10 mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen for the lateral branches of S1 S2 and S3 Also fluoroscopic views were used to ensure proper needle placement The following technique was used to confirm correct placement Motor stimulation was applied at 2 Hz with 1 millisecond duration No extremity movement was noted at less than 2 volts Following this the needle trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 0 5 mL of 1 lidocaine was injected to anesthetize the lateral branch and the surrounding tissue After completion a lesion was created at that level with a temperature of 80 degrees for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS None COMPLICATIONS None DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at PM R Spine Clinic in approximately one to two weeks Keywords radiology sacroiliac joint pain sacroiliac teflon coated needle fluoroscopy needle placement radiofrequency ablation ablation tissue lidocaine needle MEDICAL_TRANSCRIPTION,Description Resting Myoview perfusion scan and gated myocardial scan Findings consistent with an inferior non transmural scar Medical Specialty Radiology Sample Name Myoview Perfusion Scan Transcription INDICATIONS Previously markedly abnormal dobutamine Myoview stress test and gated scan PROCEDURE DONE Resting Myoview perfusion scan and gated myocardial scan MYOCARDIAL PERFUSION IMAGING Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32 6 mCi of Tc 99m Myoview Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD YYYY The lung heart ratio is 0 34 There appears to be a moderate size inferoapical perfusion defect of moderate degree The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55 CONCLUSIONS Study done at rest only revealed findings consistent with an inferior non transmural scar of moderate size and moderate degree The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD YYYY We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed Keywords radiology myoview perfusion scan rest study spect imaging dobutamine myoview stress test ejection fraction gated myocardial scan hypokinesis ventricular systolic function resting myoview perfusion scan myoview stress test resting myoview myocardial perfusion myoview perfusion perfusion scan myocardial scan myocardial myoview perfusion MEDICAL_TRANSCRIPTION,Description Myocardial perfusion imaging patient with history of MI stents placement and chest pain Medical Specialty Radiology Sample Name Myocardial Perfusion Imaging 1 Transcription MEDICATIONS Plavix atenolol Lipitor and folic acid CLINICAL HISTORY This is a 41 year old male patient who comes in with chest pain had had a previous MI in 07 2003 and stents placement in 2003 who comes in for a stress myocardial perfusion scan With the patient at rest 10 3 mCi of Cardiolite technetium 99 m sestamibi was injected and myocardial perfusion imaging was obtained PROCEDURE AND INTERPRETATION The patient exercised for a total of 12 minutes on the standard Bruce protocol The peak workload was 12 8 METS The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute which was 69 of the age predicted maximum heart rate response The blood pressure response was normal with a resting blood pressure of 130 100 and a peak blood pressure of 158 90 The test was stopped due to fatigue and leg pain EKG at rest showed normal sinus rhythm The peak stress EKG did not reveal any ischemic ST T wave abnormalities There was ventricular bigeminy seen during exercise but no sustained tachycardia was seen At peak there was no chest pain noted The test was stopped due to fatigue and left pain At peak stress the patient was injected with 30 3 mCi of Cardiolite technetium 99 m sestamibi and myocardial perfusion imaging was obtained and was compared to resting myocardial perfusion imaging MYOCARDIAL PERFUSION IMAGING 1 The overall quality of the scan was good 2 There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging 3 The left ventricular cavity appeared normal in size 4 Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis Overall left ventricular systolic function was low normal with calculated ejection fraction of 46 at rest CONCLUSIONS 1 Good exercise tolerance 2 Less than adequate cardiac stress The patient was on beta blocker therapy 3 No EKG evidence of stress induced ischemia 4 No chest pain with stress 5 Mild ventricular bigeminy with exercise 6 No diagnostic abnormality on the rest and stress myocardial perfusion imaging 7 Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46 at rest Keywords radiology myocardial perfusion imaging bruce protocol cardiolite ekg mets mi spect st t bigeminy blood pressure chest pain exercise tolerance myocardial perfusion normal sinus rhythm peak workload sestamibi stents stress tachycardia ventricular ventricular cavity stress myocardial perfusion perfusion imaging myocardial perfusion mci hypokinesis imaging MEDICAL_TRANSCRIPTION,Description Myocardial perfusion study at rest and stress gated SPECT wall motion study at stress and calculation of ejection fraction Medical Specialty Radiology Sample Name Myocardial Perfusion Imaging 3 Transcription DIAGNOSIS Shortness of breath Fatigue and weakness Hypertension Hyperlipidemia INDICATION To evaluate for coronary artery disease Keywords radiology myocardial perfusion imaging spect wall motion study at stress rest and stress perfusion study at rest calculation of ejection fraction normal left ventricular wall spect wall motion study ventricular wall motion myocardial perfusion study perfusion imaging blood pressure nonspecific st ventricular wall gated spect spect wall motion study stress test heart rate ejection fraction myocardial perfusion technetium tetrofosmin ischemia ekg imaging spect heart ventricular mci resting perfusion stress myocardial MEDICAL_TRANSCRIPTION,Description Patient with wrist pain and swelling status post injury Medical Specialty Radiology Sample Name MRI Wrist 1 Transcription FINDINGS There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic There is no acute marrow edema series 12 images 5 7 Marrow signal is otherwise normal in the distal radius and ulna throughout the carpals and throughout the proximal metacarpals There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid series 6 image 5 series 8 images 22 36 There is tearing of the membranous portion of the ligament The dorsal component is intact The lunatotriquetral ligament is thickened and lax but intact series 8 image 32 There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage series 6 image 7 There is a mildly positive ulnar variance Normal ulnar collateral ligament The patient was positioned in dorsiflexion Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments series 14 image 9 There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis series 4 images 8 16 series 3 images 9 16 There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons series 4 image 12 There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment series 4 image 13 Normal flexor tendons within the carpal tunnel There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement series 3 image 7 series 4 image 7 There are no pathological cysts or soft tissue masses IMPRESSION Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate There is thickening and laxity of the lunatotriquetral ligament Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve Keywords radiology fourth dorsal compartment tendon sheath thickening tendon sheaths dorsal compartment volar carpals tear ulnar synovitis sheaths ligament thickening dorsal tendon injury MEDICAL_TRANSCRIPTION,Description Skull complete five images Medical Specialty Radiology Sample Name Multiple Images of Skull Pediatric Transcription EXAM Skull complete five images HISTORY Plagiocephaly TECHNIQUE Multiple images of the skull were evaluated There are no priors for comparison FINDINGS Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure There is no evidence of any craniosynostosis There is no radiographic evidence of plagiocephaly IMPRESSION No evidence of craniosynostosis or radiographic characteristics for plagiocephaly Keywords radiology craniosynostosis plagiocephaly complete five images multiple images radiographic images skull MEDICAL_TRANSCRIPTION,Description MRI L Spine Bilateral lower extremity numbness Medical Specialty Radiology Sample Name Normal L Spine MRI Transcription CC Bilateral lower extremity numbness HX 21 y o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11 5 96 The symptoms became maximal over a 12 24 hour period and have not changed since The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space He denied bowel bladder problems or weakness or numbness elsewhere Hot showers may improve his symptoms He has suffered no recent flu like illness Past medical and family histories are unremarkable He was on no medications EXAM Unremarkable except for mild distal vibratory sensation loss in the toes R L LAB CBC Gen Screen TSH FT4 SPE ANA were all WNL MRI L SPINE Normal COURSE Normal exam and diminished symptoms at following visit 4 23 93 Keywords radiology bilateral lower extremity numbness mri l spine bilateral lower extremity lower extremity numbness bilateral spine mri extremities numbness MEDICAL_TRANSCRIPTION,Description Myocardial perfusion imaging patient had previous abnormal stress test Stress test with imaging for further classification of CAD and ischemia Medical Specialty Radiology Sample Name Myocardial Perfusion Imaging 2 Transcription CLINICAL HISTORY This is a 64 year old male patient who had a previous stress test which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia PERTINENT MEDICATIONS Include Tylenol Robitussin Colace Fosamax multivitamins hydrochlorothiazide Protonix and flaxseed oil With the patient at rest 10 5 mCi of Cardiolite technetium 99 m sestamibi was injected and myocardial perfusion imaging was obtained PROCEDURE AND INTERPRETATION The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol The peak workload was 7 METs The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute which was 85 of the age predicted maximum heart rate response The blood pressure response was normal with the resting blood pressure 126 86 and the peak blood pressure of 134 90 EKG at rest showed normal sinus rhythm with a right bundle branch block The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6 which remained abnormal till about 6 to 8 minutes into recovery There were occasional PVCs but no sustained arrhythmia The patient had an episode of supraventricular tachycardia at peak stress The ischemic threshold was at a heart rate of 118 beats per minute and at 4 6 METs At peak stress the patient was injected with 30 3 mCi of Cardiolite technetium 99 m sestamibi and myocardial perfusion imaging was obtained and was compared to resting images MYOCARDIAL PERFUSION IMAGING 1 The overall quality of the scan was fair in view of increased abdominal uptake increased bowel uptake seen 2 There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex This appeared to be partially reversible in the resting images 3 The left ventricle appeared normal in size 4 Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening The calculated ejection fraction was 70 at rest CONCLUSIONS 1 Average exercise tolerance 2 Adequate cardiac stress 3 Abnormal EKG response to stress consistent with ischemia No symptoms of chest pain at rest 4 Myocardial perfusion imaging was abnormal with a large sized moderate intensity partially reversible inferior wall and inferior apical defect consistent with inferior wall ischemia and inferior apical ischemia 5 The patient had run of SVT at peak stress 6 Gated SPECT images revealed normal wall motion and normal left ventricular systolic function Keywords radiology stress test arrhythmia baseline heart rate bruce chest pain mets protocol peak heart rate spect st segment response svt aerobic capacity blood pressure exercise heart rate ischemia ventricular systolic function myocardial perfusion imaging cardiolite technetium inferior apical myocardial perfusion perfusion imaging stress myocardial imaging perfusion MEDICAL_TRANSCRIPTION,Description The thoracic spine was examined in the AP lateral and swimmer s projections Medical Specialty Radiology Sample Name MRI T Spine 1 Transcription EXAM Thoracic Spine REASON FOR EXAM Injury INTERPRETATION The thoracic spine was examined in the AP lateral and swimmer s projections There is mild chronic appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies A mild amount of anterior osteophytic lipping is seen involving the thoracic spine There is a suggestion of generalized osteoporosis The intervertebral disc spaces appear generally well preserved The pedicles appear intact IMPRESSION 1 Mild chronic appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies 2 Mild degenerative changes of the thoracic spine 3 Osteoporosis Keywords radiology thoracic spine swimmer s projections osteoporosis osteophytic lipping anterior wedging vertebral bodies thoracic spine MEDICAL_TRANSCRIPTION,Description MRI T spine and CXR Aortic Dissection Medical Specialty Radiology Sample Name MRI T Spine Transcription CC BLE weakness HX This 82y o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia He was in his usual state of health until 5 30PM on 4 6 95 when he developed sudden pressure like epigastric discomfort associated with bilateral lower extremity weakness SOB lightheadedness and diaphoresis He knelt down to the floor and went to sleep The Emergency Medical Service was alert and arrived within minutes at which time he was easily aroused though unable to move or feel his lower extremities No associated upper extremity or bulbar dysfunction was noted He was taken to a local hospital where an INR was found to be 9 1 He was given vitamin K 15mg and transferred to UIHC to rule out spinal epidural hemorrhage An MRI scan of the T spine was obtained and the preliminary reading was normal The Neurology service was then asked to evaluate the patient MEDS Coumadin 2mg qd Digoxin 0 25mg qd Prazosin 2mg qd PMH 1 HTN 2 A Fib on coumadin 3 Peripheral vascular disease s p left Femoral popliteal bypass 8 94 and graft thrombosis thrombolisis 9 94 4 Adenocarcinoma of the prostate s p TURP 1992 FHX unremarkable SHX Farmer Married no Tobacco ETOH illicit drug use EXAM BP165 60 HR86 RR18 34 2C SAO2 98 on room air MS A O to person place time In no acute distress Lucid CN unremarkable MOTOR 5 5 strength in BUE Flaccid paraplegia in BLE Sensory T6 sensory level to LT PP bilaterally Decreased vibratory sense in BLE in a stocking distribution distally Coord Intact FNF and RAM in BUE Unable to do HKS Station no pronator drift Gait not done Reflexes 2 2 BUE Absent in BLE plantar responses were flexor bilaterally Rectal decreased rectal tone GEN EXAM No carotid bruitts Lungs bibasilar crackles CV Irregular rate and rhythm with soft diastolic murmur at the left sternal border Abdomen flat soft non tender without bruitt or pulsatile mass Distal pulses were strong in all extremities COURSE Hgb 12 6 Hct 40 WBC 11 7 Plt 154k INR 7 6 PTT 50 CK 41 the GS was normal EKG showed A Fib at 75BPM with competing junctional pacemaker essentially unchanged from 9 12 94 It was suspected that the patient sustained an anterior cervico thoracic spinal cord infarction with resultant paraplegia and T6 sensory level A CXR was done in the ER prior to admission This revealed cardiomegaly and a widened mediastinum He returned from the x ray suite and suddenly became unresponsive and went into cardiopulmonary arrest Resuscitative measures failed Pericardiocentesis was unremarkable Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma The dissection was seen in retrospect on the MRI T spine Keywords radiology mri a o aortic dissection cxr irregular rate and rhythm mri scan neurology service t spine carotid bruitts epidural hemorrhage mediastinum paraplegia person place stocking distribution time weakness mri t spine sensory level neurology spine MEDICAL_TRANSCRIPTION,Description A 51 year old female with left shoulder pain and restricted external rotation and abduction x 6 months Medical Specialty Radiology Sample Name MRI Shoulder 2 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 51 year old female with left shoulder pain and restricted external rotation and abduction x 6 months Received for second opinion Study performed on 10 04 05 FINDINGS The patient was scanned in a 1 5 Tesla magnet There is a flat undersurface of the acromion Type I morphology with anterior downsloping orientation There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the axial gradient echo T2 series 3 images 6 9 There is edema with thickening of the superior glenohumeral ligament axial T2 series 3 image 7 There is flattening of the long biceps tendon as it enters the bicipital groove axial T2 series 3 image 9 10 but no subluxation The findings suggest early changes of a hidden lesion Normal biceps labral complex and superior labrum and there is no demonstrated superior labral tear There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon axial T2 series 3 image 10 There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits Normal anterior and posterior glenoid labra Normal supraspinatus infraspinatus and teres minor tendons Normal muscles of the rotator cuff and there is no muscular atrophy There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior superior labrum sagittal T2 series 7 image 5 coronal T2 series 5 image 7 but there is no demonstrated posterior superior labral tear or paralabral cyst or ganglion Normal acromioclavicular articulation IMPRESSION Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament Flattening of the long biceps tendon as it enters the bicipital groove but no subluxation Findings suggest early changes of a hidden lesion Mild tendinitis of the distal insertion of the subscapularis tendon but no tendon tear Normal supraspinatus infraspinatus and teres minor tendons and muscular complexes Type I morphology with an anterior downsloping orientation of the acromion but no inferior acromial osteophyte Keywords radiology insertion of the subscapularis supraspinatus infraspinatus and teres infraspinatus and teres minor axial t series supraspinatus infraspinatus teres minor minor tendons posterior superior biceps tendon rotator capsule glenohumeral tendon series superior MEDICAL_TRANSCRIPTION,Description A 69 year old male with pain in the shoulder Evaluate for rotator cuff tear Medical Specialty Radiology Sample Name MRI Shoulder 4 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 69 year old male with pain in the shoulder Evaluate for rotator cuff tear FINDINGS Examination was performed on 9 1 05 There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface extending into the myotendinous junction as well There is still a small rim of tendon along the bursal surface although there may be a small tear at the level of the rotator interval There is no retracted tendon or muscular atrophy series 6 images 6 17 Normal infraspinatus tendon There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval series 9 images 8 13 series 3 images 8 14 There is no complete tear gap or fiber retraction and there is no muscular atrophy There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove and there is high grade near complete partial tearing of the intracapsular portion of the tendon The biceps anchor is intact There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o clock position series 6 images 12 14 series 3 images 8 10 series 9 images 5 8 There is a small sublabral foramen at the eleven o clock position series 9 image 6 There is no osseous Bankart lesion Normal superior middle and inferior glenohumeral ligaments There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction which in the appropriate clinical setting is an MRI manifestation of an impinging lesion series 8 images 3 12 Normal coracoacromial coracohumeral and coracoclavicular ligaments There is minimal fluid within the glenohumeral joint There is no atrophy of the deltoid muscle IMPRESSION There is extensive supraspinatus tendinosis and partial tearing as described There is no retracted tendon or muscular atrophy but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval and this associated partial tearing of the superior most fibers of the subscapularis tendon There is also a high grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament There is no evidence of a complete tear or retracted tendon Small nondisplaced posterior superior labral tear Outlet narrowing from the acromioclavicular joint which in the appropriate clinical setting is an MRI manifestation of an impinging lesion Keywords radiology level of the rotator impinging lesion rotator interval retracted tendon muscular atrophy partial tearing tendon mri shoulder rotator superior tear MEDICAL_TRANSCRIPTION,Description MRI left shoulder Medical Specialty Radiology Sample Name MRI Shoulder 5 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 26 year old with a history of instability Examination was preformed on 12 20 2005 FINDINGS There is supraspinatus tendinosis without a full thickness tear gap or fiber retraction and there is no muscular atrophy series 105 images 4 6 Normal infraspinatus and subscapularis tendons Normal long biceps tendon within the bicipital groove There is medial subluxation of the tendon under the transverse humeral ligament and there is tendinosis of the intracapsular portion of the tendon with partial tearing but there is no complete tear or discontinuity Biceps anchor is intact series 105 images 4 7 series 102 images 10 22 There is a very large Hill Sachs fracture involving almost the entire posterior half of the humeral head series 102 images 13 19 This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation series 104 images 10 14 series 102 images 18 28 There is medial and inferior displacement of the fragment There are multiple interarticular bodies some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter These are too numerous to count There is marked stretching attenuation and areas of thickening of the inferior and middle glenohumeral ligaments compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion series 105 images 5 10 Normal superior glenohumeral ligament There is no SLAP tear Normal acromioclavicular joint without narrowing of the subacromial space Normal coracoacromial coracohumeral and coracoclavicular ligaments There is fluid in the glenohumeral joint and biceps tendon sheath IMPRESSION There is a very large Hill Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion There are multiple intraarticular bodies and there is a partial tear of the inferior and middle glenohumeral ligaments There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion Keywords radiology inferior and middle glenohumeral biceps tendon partial tearing glenohumeral ligaments mri shoulder ligament ligaments biceps humeral glenohumeral tear tendons MEDICAL_TRANSCRIPTION,Description A 32 year old male with shoulder pain Medical Specialty Radiology Sample Name MRI Shoulder 3 Transcription EXAM MRI RIGHT SHOULDER CLINICAL A 32 year old male with shoulder pain FINDINGS This is a second opinion interpretation of the examination performed on 02 16 06 Normal supraspinatus tendon without surface fraying gap or fiber retraction and there is no muscular atrophy Normal infraspinatus and subscapularis tendons Normal long biceps tendon within the bicipital groove There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal Normal humeral head without fracture or subluxation There is myxoid degeneration within the superior labrum oblique coronal images 47 48 but there is no discrete tear The remaining portions of the labrum are normal without osseous Bankart lesion Normal superior middle and inferior glenohumeral ligaments There is a persistent os acromiale and there is minimal reactive marrow edema on both sides of the synchondrosis suggesting that there may be instability axial images 3 and 4 There is no diastasis of the acromioclavicular joint itself There is mild narrowing of the subacromial space secondary to the os acromiale in the appropriate clinical setting this may be acting as an impinging lesion sagittal images 56 59 Normal coracoacromial coracohumeral and coracoclavicular ligaments There are no effusions or masses IMPRESSION Changes in the superior labrum compatible with degeneration without a discrete surfacing tear There is a persistent os acromiale and there is reactive marrow edema on both sides of the synchondrosis suggesting instability There is also mild narrowing of the subacromial space secondary to the os acromiale This may be acting as an impinging lesion in the appropriate clinical setting There is no evidence of a rotator cuff tear Keywords radiology impinging lesion os acromiale shoulder tendon acromiale osseous MEDICAL_TRANSCRIPTION,Description MRI of the Cervical Thoracic and Lumbar Spine Medical Specialty Radiology Sample Name MRI Spine Transcription INTERPRETATION MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal At C4 C5 there were minimal uncovertebral osteophytes with mild associated right foraminal compromise At C5 C6 there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac but no cord deformity or foraminal compromise At C6 C7 there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina MRI of the thoracic spine showed normal vertebral body height and alignment There was evidence of disc generation especially anteriorly at the T5 T6 level There was no significant central canal or foraminal compromise Thoracic cord normal in signal morphology MRI of the lumbar spine showed normal vertebral body height and alignment There is disc desiccation at L4 L5 and L5 S1 with no significant central canal or foraminal stenosis at L1 L2 L2 L3 and L3 L4 There was a right paracentral disc protrusion at L4 L5 narrowing of the right lateral recess The transversing nerve root on the right was impinged at that level The right foramen was mildly compromised There was also a central disc protrusion seen at the L5 S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise IMPRESSION Overall impression was mild degenerative changes present in the cervical thoracic and lumbar spine without high grade central canal or foraminal narrowing There was narrowing of the right lateral recess at L4 L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion This was also seen on a prior study Keywords radiology cervical spine mri cervical thoracic lumbar transversing nerve root vertebral body height vertebral body disc protrusion foraminal compromise central foraminal disc spineNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57 year old Medical Specialty Radiology Sample Name MRI of Brain w o Contrast Transcription EXAM MRI of the brain without contrast HISTORY Daily headaches for 6 months in a 57 year old TECHNIQUE Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting FINDINGS The brain is normal in signal intensity and morphology for age There are no extraaxial fluid collections There is no hydrocephalus midline shift Posterior fossa 7th and 8th nerve complexes and intraorbital contents are within normal limits The normal vascular flow volumes are maintained The paranasal sinuses are clear Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct IMPRESSION Normal MRI brain Specifically no findings to explain the patient s headaches are identified Keywords radiology mri diffusion posterior fossa axial brain contrast extraaxial flow fluid collections headaches hydrocephalus intraorbital morphology paranasal sagittal sinuses vascular weighting without contrast mri of the brain noncontrast MEDICAL_TRANSCRIPTION,Description MRI of lumbar spine without contrast to evaluate chronic back pain Medical Specialty Radiology Sample Name MRI of Lumbar Spine w o Contrast Transcription EXAM MRI of lumbar spine without contrast HISTORY A 24 year old female with chronic back pain TECHNIQUE Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting FINDINGS The visualized cord is normal in signal intensity and morphology with conus terminating in proper position Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture contusion compression deformity or marrow replacement process There are no paraspinal masses Disc heights signal and vertebral body heights are maintained throughout the lumbar spine L5 S1 Central canal neural foramina are patent L4 L5 Central canal neural foramina are patent L3 L4 Central canal neural foramen is patent L2 L3 Central canal neural foramina are patent L1 L2 Central canal neural foramina are patent The visualized abdominal aorta is normal in caliber Incidental note has been made of multiple left sided ovarian probable physiologic follicular cysts IMPRESSION No acute disease in the lumbar spine Keywords radiology mri central canal noncontrast abdominal aorta axial back pain contrast follicular cysts images lumbar spine morphology neural foramina sagittal signal intensity without contrast mri of lumbar spine mri of lumbar lumbar foramina neural patent spine MEDICAL_TRANSCRIPTION,Description MRI L spine History of progressive lower extremity weakness right frontal glioblastoma with lumbar subarachnoid seeding Medical Specialty Radiology Sample Name MRI L Spine Subarachnoid Seeding Transcription CC Progressive lower extremity weakness HX This 52y o RHF had a h o right frontal glioblastoma multiforme GBM diagnosed by brain biopsy partial resection on 1 15 1991 She had been healthy until 1 6 91 when she experienced a generalized tonic clonic type seizure during the night She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture There was minimal associated edema and no mass effect Following extirpation of the tumor mass she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions In 11 91 she received BCNU and Procarbazine chemotherapy protocols This was followed by four courses of 5FU Carboplatin 3 92 6 92 9 92 10 92 chemotherapy On 10 12 92 she presented for her 4th course of 5FU Carboplatin and complained of non radiating dull low back pain and proximal lower extremity weakness but was still able to ambulate She denied any bowel bladder difficulty PMH s p oral surgery for wisdom tooth extraction FHX SHX 1 2 ppd cigarettes rare ETOH use Father died of renal CA MEDS Decadron 12mg day EXAM Vitals unremarkable MS Unremarkable Motor 5 5 BUE LE 4 5 prox 5 5 distal to hips Normal tone and muscle bulk Sensory No deficits appreciated Coord Unremarkable Station No mention in record of being tested Gait Mild difficulty climbing stairs Reflexes 1 1 throughout and symmetric Plantar responses were down going bilaterally INITIAL IMPRESSION Steroid myopathy Though there was enough of a suspicion of drop metastasis that an MRI of the L spine was obtained COURSE The MRI L spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris suggestive of subarachnoid seeding of tumor No focal mass or cord compression was visualized CSF examination revealed 19RBC 22WBC 17 Lymphocytes and 5 histiocytes Glucose 56 Protein 150 Cytology negative The patient was discharged home on 10 17 92 but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months She was last seen on 3 3 93 and showed signs of worsening weakness left hemiplegia R L as her tumor grew and spread She then entered a hospice Keywords radiology glioblastoma multiforme gbm steroid myopathy hemiplegia progressive lower extremity weakness mri l spine lower extremity weakness frontal glioblastoma subarachnoid seeding lower extremity glioblastoma subarachnoid spine mri lower weakness MEDICAL_TRANSCRIPTION,Description MRI Orbit Face Neck with MR Angiography of the Head An infant with facial mass Medical Specialty Radiology Sample Name MRI Orbit Face Neck Transcription EXAM MRI orbit face neck with and without contrast MR angiography of the head CLINICAL HISTORY 1 day old female with facial mass TECHNIQUE 1 Multisequence multiplanar images of the orbits face neck were obtained with and without contrast 0 5 ml Magnevist was used as the intravenous contrast agent 2 MR angiography of the head was obtained using a time of flight technique 3 The patient was under general anesthesia during the exam FINDINGS MRI orbits face neck There is a pedunculated mass measuring 5 7 x 4 4 x 6 7 cm arising from the patient s lip on the right side The mass demonstrates a heterogeneous signal There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam The origin of the mass from the upper lip demonstrates intact soft tissue planes Limited evaluation of the head demonstrates normal appearing midline structures Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa The mastoid air cells on the right are opacified while the left demonstrates appropriate aeration MR angiography of the head Angiography is limited such that the vessel feeding the mass cannot be identified with certainty The right external carotid artery is noted to be asymmetrically larger than the left the phenomenon likely related to provision of feeding vessels to the mass There is no carotid stenosis IMPRESSION 1 The mass arising from the right upper lip measures 5 7 x 4 4 x 6 7 cm with a heterogeneous appearance and enhancement pattern Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms 2 MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty Keywords radiology orbit face neck multisequence multiplanar time of flight angiography of the head facial mass upper lip feeding vessels angiography head mri mass MEDICAL_TRANSCRIPTION,Description Left shoulder pain Evaluate for rotator cuff tear Medical Specialty Radiology Sample Name MRI Shoulder 1 Transcription EXAM MRI UP EXT JOINT LEFT SHOULDER CLINICAL Left shoulder pain Evaluate for rotator cuff tear FINDINGS Multiple T1 and gradient echo axial images were obtained as well as T1 and fat suppressed T2 weighted coronal images The rotator cuff appears intact and unremarkable There is no significant effusion seen Osseous structures are unremarkable There is no significant downward spurring at the acromioclavicular joint The glenoid labrum is intact and unremarkable IMPRESSION Unremarkable MRI of the left shoulder Keywords radiology rotator cuff tear cuff tear rotator cuff joint mri rotator cuff shoulder tear MEDICAL_TRANSCRIPTION,Description MRI Right parietal metastatic adenocarcinoma LUNG metastasis Medical Specialty Radiology Sample Name MRI of Lung Adenocarcinoma Transcription CC Found unresponsive HX 39 y o RHF complained of a severe HA at 2AM 11 4 92 It was unclear whether she had been having HA prior to this She took an unknown analgesic then vomited then lay down in bed with her husband When her husband awoke at 8AM he found her unresponsive with stiff straight arms and a strange breathing pattern A Brain CT scan revealed a large intracranial mass She was intubated and hyperventilated to ABG 7 43 36 398 Other local lab values included WBC 9 8 RBC 3 74 Hgb 13 8 Hct 40 7 Cr 0 5 BUN 8 5 Glucose 187 Na 140 K 4 0 Cl 107 She was given Mannitol 1gm kg IV load DPH 20mg kg IV load and transferred by helicopter to UIHC PMH 1 Myasthenia Gravis for 15 years s p Thymectomy MEDS Imuran Prednisone Mestinon Mannitol DPH IV NS FHX SHX Married Tobacco 10 pack year quit nearly 10 years ago ETOH Substance Abuse unknown EXAM 35 8F 99BPM BP117 72 Mechanically ventilated at a rate of 22RPM on 00 FiO2 Unresponsive to verbal stimulation CN Pupils 7mm 5mm and unresponsive to light fixed No spontaneous eye movement or blink to threat No papilledema or intraocular hemorrhage noted Trace corneal reflexes bilaterally No gag reflex No oculocephalic reflex MOTOR SENSORY No spontaneous movement On noxious stimulation Deep nail bed pressure she either extended both upper extremities RUE LUE or withdrew the stimulated extremity right left Gait Station Coordination no tested Reflexes 1 on right and 2 on left with bilateral Babinski signs HCT 11 4 92 Large heterogeneous mass in the right temporal parietal region causing significant parenchymal distortion and leftward subfalcine effect There is low parenchymal density within the white matter A hyperdense ring lies peripherally and may represent hemorrhage or calcification The mass demonstrates inhomogeneous enhancement with contrast COURSE Head of bed elevated to 30 degrees Mannitol and DPH were continued MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures She underwent surgical resection of the tumor Pathological analysis was consistent with adenocarcinoma GYN exam CT Abdomen and Pelvis Bone scan were unremarkable CXR revealed an right upper lobe lung nodule She did not undergo thoracic biopsy due to poor condition She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center In March 1993 the patient exhibited right ptosis poor adduction and abduction OD 4 4 strength in the upper extremities and 5 5 strength in the lower extremities She was ambulatory with an ataxic gait She was admitted on 7 12 93 for lower cervical and upper thoracic pain paraparesis and T8 sensory level MRI brainstem spine on that day revealed decreased T1 signal in the C2 C3 C6 vertebral bodies increased T2 signal in the anterior medulla and tectum and spinal cord C7 T3 Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7 T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and or metastasis The patient was treated with Decadron and analgesics and discharged to a hospice center her choice She died a few months later Keywords radiology mri lung metastatic adenocarcinoma parietal breathing pattern cranial xrt t1 signal sensory level iv load adenocarcinoma metastatic leptomeningeal MEDICAL_TRANSCRIPTION,Description MRI L S Spine for Cauda Equina Syndrome secondary to L3 4 disc herniation Low Back Pain LBP with associated BLE weakness Medical Specialty Radiology Sample Name MRI L S Spine Cauda Equina Syndrome Transcription CC Low Back Pain LBP with associated BLE weakness HX This 75y o RHM presented with a 10 day h o progressively worsening LBP The LBP started on 12 3 95 began radiating down the RLE on 12 6 95 then down the LLE on 12 9 95 By 12 10 95 he found it difficult to walk On 12 11 95 he drove himself to his local physician but no diagnosis was rendered He was given some NSAID and drove home By the time he got home he had great difficulty walking due to LBP and weakness in BLE but managed to feed his pets and himself On 12 12 95 he went to see a local orthopedist but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain He also had had BLE numbness since 12 11 95 He was evaluated locally and an L S Spine CT scan and L S Spine X rays were negative He was then referred to UIHC MEDS SLNTC Coumadin 4mg qd Propranolol Procardia XL Altace Zaroxolyn PMH 1 MI 11 9 78 2 Cholecystectomy 3 TURP for BPH 1980 s 4 HTN 5 Amaurosis Fugax OD 8 95 Mayo Clinic evaluation TEE but Carotid Doppler but non surgical so placed on Coumadin FHX Father died age 59 of valvular heart disease Mother died of DM Brother had CABG 8 95 SHX retired school teacher 0 5 1 0 pack cigarettes per day for 60 years EXAM BP130 56 HR68 RR16 Afebrile MS A O to person place time Speech fluent without dysarthria Lucid Appeared uncomfortable CN Unremarkable MOTOR 5 5 strength in BUE Lower extremity strength Hip flexors extensors 4 4 Hip abductors 3 3 Hip adductors 5 5 Knee flexors extensors 4 4 Ankle flexion 4 4 Tibialis Anterior 2 2 Peronei 3 3 Mild atrophy in 4 extremities Questionable fasciculations in BLE Spasms illicited on striking quadriceps with reflex hammer percussion myotonia No rigidity and essential normal muscle tone on passive motion SENSORY Decreased vibratory sense in stocking distribution from toes to knees in BLE worse on right No sensory level PP LT TEMP testing unremarkable COORD Normal FNF RAM Slowed HKS due to weakness Station No pronator drift Romberg testing not done Gait Unable to stand Reflexes 2 2 BUE 1 trace patellae 0 0 Achilles Plantar responses were flexor bilaterally Abdominal reflex was present in all four quadrants Anal reflex was illicited from all four quadrants No jaw jerk or palmomental reflexes illicited Rectal normal rectal tone guaiac negative stool GEN EXAM Bilateral Carotid Bruits No lymphadenopathy right inguinal hernia rhonchi and inspiratory wheeze in both lung fields COURSE WBC 11 6 Hgb 13 4 Hct 38 Plt 295 ESR 40 normal 0 14 CRP 1 4 normal 0 4 INR 1 5 PTT 35 normal Creatinine 2 1 CK 346 EKG normal The differential diagnosis included Amyotrophy Polymyositis Epidural hematoma Disc Herniation and Guillain Barre syndrome An MRI of the lumbar spine was obtained 12 13 95 This revealed an L3 4 disc herniation extending inferiorly and behind the L4 vertebral body This disc was located more on the right than on the left compromised the right neural foramen and narrowed the spinal canal The patient underwent a L3 4 laminectomy and diskectomy and subsequently improved He was never seen in follow up at UIHC Keywords radiology ble weakness carotid doppler disc herniation guillain barre syndrome amyotrophy polymyositis epidural hematoma mri l s spine cauda equina syndrome flexors extensors cauda equina herniation cauda equina extensors reflexes mri hip flexors weakness MEDICAL_TRANSCRIPTION,Description MRI left knee without contrast Medical Specialty Radiology Sample Name MRI Knee 4 Transcription EXAM MRI OF THE LEFT KNEE WITHOUT CONTRAST CLINICAL Left knee pain Twisting injury FINDINGS The images reveal a sizable joint effusion The joint effusion appears to be complex with mixed signal intensity material within The patella is slightly laterally tilted towards the left The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected Mildly increased bone signal overlying the inferolateral portion of the patella is identified No significant degenerative changes about the patella can be seen The quadriceps tendon as well as the infrapatellar ligament both look intact There is some prepatellar soft tissue edema The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia NO significant areas of bone edema are appreciated There is soft tissue edema along the lateral aspect of the knee There is a partial tear of the lateral collateral ligament complex The medial collateral ligament complex looks intact A small amount of edema is identified immediately adjacent to the medial collateral ligament complex The posterior cruciate ligament looks intact The anterior cruciate ligament is thickened with significant increased signal I suspect at least a high grade partial tear The posterior horn of the medial meniscus shows some myxoid degenerative changes The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes I don t see a definite tear extending to the articular surface IMPRESSION Sizeable joint effusion which is complex and may contain blood products Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear Soft tissue swelling and partial tear of the lateral collateral ligament complex At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure The posterior cruciate ligament is intact Injury to the patellar cartilage as above Keywords radiology lateral collateral ligament medial collateral ligament posterior cruciate ligament anterior cruciate ligament collateral ligament complex myxoid degenerative partial tear collateral ligament ligament complex cruciate ligament mri effusion cartilage collateral cruciate knee tear ligament MEDICAL_TRANSCRIPTION,Description MRI left knee Medical Specialty Radiology Sample Name MRI Knee 3 Transcription EXAM MRI LEFT KNEE CLINICAL This is a 41 year old male with knee pain mobility loss and swelling The patient had a twisting injury one week ago on 8 5 05 The examination was performed on 8 10 05 FINDINGS There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear There is intrasubstance degeneration within the lateral meniscus and there is a probable small tear in the anterior horn along the undersurface at the meniscal root There is an interstitial sprain partial tear of the anterior cruciate ligament There is no complete tear or discontinuity and the ligament has a celery stick appearance Normal posterior cruciate ligament Normal medial collateral ligament There is a sprain of the femoral attachment of the fibular collateral ligament without complete tear or discontinuity The fibular attachment is intact Normal biceps femoris tendon popliteus tendon and iliotibial band Normal quadriceps and patellar tendons There are no fractures There is arthrosis with high grade changes in the patellofemoral compartment particularly along the midline patellar ridge and lateral facet There are milder changes within the medial femorotibial compartments There are subcortical cystic changes subjacent to the tibial spine which appear chronic There is a joint effusion There is synovial thickening IMPRESSION Probable small tear in the anterior horn of the lateral meniscus at the meniscal root Interstitial sprain partial tear of the anterior cruciate ligament Arthrosis joint effusion and synovial hypertrophy There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles Keywords radiology mri left knee interstitial sprain partial tear anterior cruciate ligament lateral meniscus cruciate ligament synovial mri meniscus sprain partial cruciate knee ligament MEDICAL_TRANSCRIPTION,Description MRI right knee without gadolinium Medical Specialty Radiology Sample Name MRI Knee 5 Transcription EXAM MRI RIGHT KNEE WITHOUT GADOLINIUM CLINICAL This is a 21 year old male with right knee pain after a twisting injury on 7 31 05 Patient has had prior lateral meniscectomy in 2001 FINDINGS Examination was performed on 8 3 05 Normal medial meniscus without intrasubstance degeneration surface fraying or discrete meniscal tear There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus likely reflecting previous partial meniscectomy and contouring although subtle surface tearing cannot be excluded particularly along the undersurface of the lateral meniscus series 3 image 17 There is no displaced tear or displaced meniscal fragment There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity Normal posterior cruciate ligament Normal medial collateral ligament There is a strain of the popliteus muscle and tendon without complete tear There is a sprain of the posterolateral and posterocentral joint capsule series 5 images 10 18 There is marrow edema within the posterolateral corner of the tibia and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended series 6 images 4 7 Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear Normal quadriceps and patellar tendons There is contusion within the posterior non weight bearing surface of the medial femoral condyle as well as in the posteromedial corner of the tibia There is linear vertically oriented signal within the distal tibial diaphyseal metaphyseal junction series 7 image 8 series 2 images 4 5 There is no discrete fracture line and this is of uncertain significance but this should be correlated with radiographs The patellofemoral joint is congruent without patellar tilt or subluxation Normal medial and lateral patellar retinacula There is a joint effusion IMPRESSION Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re contouring although a subtle undersurface tear in the anterior horn may be present Mild anterior cruciate ligament interstitial sprain There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs Keywords radiology mri right knee posterolateral and posterocentral posterocentral joint capsule lateral meniscus cruciate ligament mri meniscectomy cruciate tendon posterolateral patellar ligament tear MEDICAL_TRANSCRIPTION,Description Pain and swelling in the right foot peroneal tendon tear Medical Specialty Radiology Sample Name MRI Foot 1 Transcription EXAM MRI LOW EX NOT JNT RT W O CONTRAST CLINICAL Pain and swelling in the right foot peroneal tendon tear FINDINGS Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone A small effusion is noted within the peroneal tendon sheath There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone consistent with an avulsion There is no sign of cuboid fracture The fifth metatarsal base appears intact The calcaneus is also normal in appearance IMPRESSION Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone Keywords radiology peroneus longus tendon peroneal tendon lateral margin peroneus longus longus tendon cuboid bone foot peroneal peroneus longus avulsion tendon bones cuboid MEDICAL_TRANSCRIPTION,Description MRI Head W WO Contrast Medical Specialty Radiology Sample Name MRI Head Transcription EXAM MRI Head W WO Contrast REASON FOR EXAM Dyspnea COMPARISON None TECHNIQUE MRI of the head performed without and with 12 ml of IV gadolinium Magnevist INTERPRETATION There are no abnormal unexpected foci of contrast enhancement There are no diffusion weighted signal abnormalities There are minimal predominantly periventricular deep white matter patchy foci of FLAIR T2 signal hyperintensity the rest of the brain parenchyma appearing unremarkable in signal The ventricles and sulci are prominent but proportionate Per T2 weighted sequence there is no hyperdense vascularity There are no calvarial signal abnormalities There is no significant mastoid air cell fluid No significant sinus mucosal disease per MRI IMPRESSION 1 No abnormal unexpected foci of contrast enhancement specifically no evidence for metastases or masses 2 No evidence for acute infarction 3 Mild scattered patchy chronic small vessel ischemic disease changes 4 Diffuse cortical volume loss consistent with patient s age 5 Preliminary report was issued at the time of dictation Keywords radiology dyspnea mri of the head foci of contrast patchy foci white matter w wo contrast mri head mri MEDICAL_TRANSCRIPTION,Description A 49 year old female with ankle pain times one month without a specific injury Medical Specialty Radiology Sample Name MRI Foot 3 Transcription EXAM MRI LEFT FOOT CLINICAL A 49 year old female with ankle pain times one month without a specific injury Patient complains of moderate to severe pain worse with standing or walking on hard surfaces with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon FINDINGS Received for second opinion interpretations is an MRI examination performed on 05 27 2005 There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle There is edema of the subcutis adipose space posterior to the Achilles tendon Findings suggest altered biomechanics with crural fascial strains There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus axial inversion recovery image 16 which is a possible hypertrophic tear less than 50 in cross sectional diameter The study has been performed with the foot in neutral position Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons Normal peroneal tendons There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear Normal extensor hallucis longus and extensor digitorum tendons Normal Achilles tendon There is a low lying soleus muscle that extends to within 2cm of the teno osseous insertion of the Achilles tendon Normal distal tibiofibular syndesmotic ligamentous complex Normal lateral subtalar and deltoid ligamentous complexes There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force Normal plantar fascia There is no plantar calcaneal spur There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves Normal tibiotalar subtalar talonavicular and calcaneocuboid articulations The metatarsophalangeal joint of the hallux was partially excluded from the field of view of this examination IMPRESSION Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying tearing of the tendon immediately distal to the tip of the medial malleolus however confirmation of this finding would require additional imaging Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain Mild tendinosis of the tibialis anterior tendon with mild tendon thickening Normal plantar fascia and no plantar fasciitis Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves Keywords radiology lateral plantar cutaneous plantar cutaneous nerves posterior tibialis tendon medial and lateral subcutis adipose adipose space achilles tendon tendon thickening hallucis longus lateral plantar plantar cutaneous cutaneous nerves medial malleolus posterior tibialis tibialis tendon plantar tendon posterior flexor tibialis medial MEDICAL_TRANSCRIPTION,Description A 53 year old female with left knee pain being evaluated for ACL tear Medical Specialty Radiology Sample Name MRI Knee 2 Transcription EXAM MRI LEFT KNEE WITHOUT CONTRAST CLINICAL This is a 53 year old female with left knee pain being evaluated for ACL tear FINDINGS This examination was performed on 10 14 05 Normal medial meniscus without intrasubstance degeneration surface fraying or discrete meniscal tear There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body there is no discrete tear series 6 images 7 12 There is a near complete or complete tear of the femoral attachment of the anterior cruciate ligament The ligament has a balled up appearance consistent with at least partial retraction of most of the fibers of the ligament There may be a few fibers still intact series 4 images 12 14 series 5 images 12 14 The tibial fibers are normal Normal posterior cruciate ligament There is a sprain of the medial collateral ligament with mild separation of the deep and superficial fibers at the femoral attachment series 7 images 6 12 There is no complete tear or discontinuity and there is no meniscocapsular separation There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components Normal iliotibial band Normal quadriceps and patellar tendons There is contusion within the posterolateral corner of the tibia There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening series 8 images 10 13 The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity Normal lateral patellar retinaculum There is a joint effusion and plica IMPRESSION Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body Near complete if not complete tear of the femoral attachment of the anterior cruciate ligament Medial capsule sprain with associated strain of the vastus medialis oblique muscle There is focal contusion within the patella at the midline patella ridge Joint effusion and plica Keywords radiology vastus medialis oblique muscle medialis oblique oblique muscle patellar retinaculum joint effusion femoral attachment cruciate ligament complete tear meniscus superficial cruciate sprain femoral medial ligament tear patellar MEDICAL_TRANSCRIPTION,Description MRI head without contrast Medical Specialty Radiology Sample Name MRI Head 1 Transcription EXAM MRI head without contrast REASON FOR EXAM Severe headaches INTERPRETATION Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla Correlation is made with the head CT of 4 18 05 On the diffusion sequence there is no significant bright signal to indicate acute infarction There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease There is mild chronic ischemic change involving the pons bilaterally slightly greater on the right and when correlating with the recent scan there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy There is an old moderate sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution No abnormal mass effect is identified There are no findings to suggest active hydrocephalus No abnormal extra axial collection is identified There is normal flow void demonstrated in the major vascular systems The sagittal sequence demonstrates no Chiari malformation The region of the pituitary optic chiasm grossly appears normal The mastoids and paranasal sinuses are clear IMPRESSION 1 No definite acute findings identified involving the brain 2 There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes There is an old moderate sized infarct of the superior portion of the right cerebellar hemisphere 3 Moderate to moderately advanced atrophy Keywords radiology severe headaches chiari malformation cerebral ischemic change mri head without contrast cerebellar hemisphere superior portion mri head cerebellar infarction ischemic MEDICAL_TRANSCRIPTION,Description MRI left knee without contrast Medical Specialty Radiology Sample Name MRI Knee 1 Transcription EXAM MRI LEFT KNEE WITHOUT CONTRAST CLINICAL Left knee pain FINDINGS Comparison is made with 10 13 05 radiographs There is a prominent suprapatellar effusion Patient has increased signal within the medial collateral ligament as well as fluid around it compatible with type 2 sprain There is fluid around the lateral collateral ligament without increased signal within the ligament itself compatible with type 1 sprain Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration No tear is seen Anterior cruciate and posterior cruciate ligaments are intact There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm There is suggestion of some mild posterior aspect of the lateral tibial plateau MR signal on the bone marrow is otherwise normal IMPRESSION Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet Keywords radiology collateral ligament mri knee collateral sprain medial ligament MEDICAL_TRANSCRIPTION,Description MRI of elbow A middle aged female with moderate pain severe swelling and a growth on the arm Medical Specialty Radiology Sample Name MRI Elbow 2 Transcription FINDINGS There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle extending to the olecranon process and along the superficial aspect of the epicondylo olecranon ligament There is no demonstrated solid cystic or lipomatous mass lesion There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel There is inflammation with mild laxity of the epicondylo olecranon ligament The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel There is no accessory muscle within the cubital tunnel The common flexor tendon origin is normal Normal ulnar collateral ligamentous complex There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis There is no demonstrated common extensor tendon tear Normal radial collateral ligamentous complex Normal radiocapitellum and ulnotrochlear articulations Normal triceps and biceps tendon insertions There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon IMPRESSION Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo olecranon ligament Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis The above combined findings suggest a subluxing ulnar nerve Mild epimysial sheath strain of the pronator teres muscle but no muscular tear Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon Peritendinous edema of the brachialis tendon insertion No solid cystic or lipomatous mass lesion Keywords radiology growth on the arm subluxing ulnar nerve collateral ligamentous complex common extensor tendon posteromedial aspect epimysial sheath extensor tendon tendon insertions ulnar nerve elbow edema olecranon inflammation nerve ulnar tendon MEDICAL_TRANSCRIPTION,Description MRI report Cervical Spine Chiropractic Specific Medical Specialty Radiology Sample Name MRI Cervical Spine Chiropractic Specific Transcription FINDINGS Normal foramen magnum Normal brainstem cervical cord junction There is no tonsillar ectopia Normal clivus and craniovertebral junction Normal anterior atlantoaxial articulation C2 3 There is disc desiccation but no loss of disc space height disc displacement endplate spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina C3 4 There is disc desiccation with a posterior central disc herniation of the protrusion type The small posterior central disc protrusion measures 3 x 6mm AP x transverse in size and is producing ventral thecal sac flattening CSF remains present surrounding the cord The residual AP diameter of the central canal measures 9mm There is minimal right sided uncovertebral joint arthrosis but no substantial foraminal compromise C4 5 There is disc desiccation slight loss of disc space height with a right posterior lateral pre foraminal disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis The disc osteophyte complex measures approximately 5mm in its AP dimension There is minimal posterior annular bulging measuring approximately 2mm The AP diameter of the central canal has been narrowed to 9mm CSF remains present surrounding the cord There is probable radicular impingement upon the exiting right C5 nerve root C5 6 There is disc desiccation moderate loss of disc space height with a posterior central disc herniation of the protrusion type The disc protrusion measures approximately 3 x 8mm AP x transverse in size There is ventral thecal sac flattening with effacement of the circumferential CSF cleft The residual AP diameter of the central canal has been narrowed to 7mm Findings indicate a loss of the functional reserve of the central canal but there is no cord edema There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise C6 7 There is disc desiccation mild loss of disc space height with 2mm of posterior annular bulging There is bilateral uncovertebral and apophyseal joint arthrosis left greater than right with probable radicular impingement upon the bilateral exiting C7 nerve roots C7 T1 T1 2 There is disc desiccation with no disc displacement Normal central canal and intervertebral neural foramina T3 4 There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord IMPRESSION Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above C3 4 posterior central disc herniation of the protrusion type but no cord impingement C4 5 right posterior lateral disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root C5 6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal C6 7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots T3 4 degenerative disc disease with posterior annular bulging Keywords radiology exiting c nerve roots loss of disc space posterior central disc herniation herniation of the protrusion uncovertebral and apophyseal joint intervertebral neural foramina ventral thecal sac thecal sac flattening disc osteophyte complex disc space height central disc herniation apophyseal joint arthrosis posterior annular bulging degenerative disc disease posterior central disc csf cleft osteophyte complex radicular impingement disc disease central disc annular bulging disc desiccation joint arthrosis central canal cervical degenerative csf foraminal bulging impingement protrusion uncovertebral arthrosis canal MEDICAL_TRANSCRIPTION,Description MRI C spine C4 5 Transverse Myelitis Medical Specialty Radiology Sample Name MRI C spine Transcription CC Left hemibody numbness HX This 44y o RHF awoke on 7 29 93 with left hemibody numbness without tingling weakness ataxia visual or mental status change She had no progression of her symptoms until 7 7 93 when she notices her right hand was stiff and clumsy She coincidentally began listing to the right when walking She denied any recent colds flu like illness or history of multiple sclerosis She denied symptoms of Lhermitte s or Uhthoff s phenomena MEDS none PMH 1 Bronchitis twice in past year last 2 months ago FHX Father with HTN and h o strokes at ages 45 and 80 now 82 years old Mother has DM and is age 80 SHX Denies Tobacco ETOH illicit drug use EXAM BP112 76 HR52 RR16 36 8C MS unremarkable CN unremarkable Motor 5 5 strength throughout except for slowing of right hand fine motor movement There was mildly increased muscle tone in the RUE and RLE Sensory decreased PP below T2 level on left and some dysesthesias below L1 on the left Coord positive rebound in RUE Station Gait unremarkable Reflexes 3 3 throughout all four extremities Plantar responses were flexor bilaterally Rectal exam not done Gen exam reportedly normal COURSE GS CBC PT PTT ESR Serum SSA SSB dsDNA B12 were all normal MRI C spine 7 145 93 showed an area of decreased T1 and increased T2 signal at the C4 6 levels within the right lateral spinal cord The lesion appeared intramedullary and eccentric and peripherally enhanced with gadolinium Lumbar puncture 7 16 93 revealed the following CSF analysis results RBC 0 WBC 1 lymphocyte Protein 28mg dl Glucose 62mg dl CSF Albumin 16 normal 14 20 Serum Albumin 4520 normal 3150 4500 CSF IgG 4 1mg dl normal 0 6 2 CSF IgG total CSF protein 15 normal 1 14 CSF IgG index 1 1 normal 0 0 7 Oligoclonal bands were present She was discharged home The patient claimed her symptoms resolved within one month She did not return for a scheduled follow up MRI C spine Keywords radiology mri c spine c spine lhermitte s myelitis transverse myelitis uhthoff s ataxia clumsy hemibody numbness mental status numbness tingling weakness mri c spine hemibody mri spine csf MEDICAL_TRANSCRIPTION,Description MRI C spine to evaluate right shoulder pain C5 6 disk herniation Medical Specialty Radiology Sample Name MRI C Spine C5 6 Disk Herniation Transcription CC Right shoulder pain HX This 46 y o RHF presented with a 4 month history of right neck and shoulder stiffness and pain The symptoms progressively worsened over the 4 month course 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain The later was described as a throbbing pain She also experienced numbness in both lower extremities and pain in the coccygeal region The pains worsened at night and impaired sleep She denied any visual change bowel or bladder difficulties and symptoms involving the LUE She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck Lhermitte s phenomena She denied any history of neck back head trauma She had been taking Naprosyn with little relief PMH 1 Catamenial Headaches 2 Allergy to Macrodantin SHX FHX Smokes 2ppd cigarettes EXAM Vital signs were unremarkable CN unremarkable Motor full strength throughout Normal tone and muscle bulk Sensory No deficits on LT PP VIB TEMP PROP testing Coord Gait Station Unremarkable Reflexes 2 2 in BUE except 2 at left biceps 1 1 BLE except an absent right ankle reflex Plantar responses were flexor bilaterally Rectal exam normal tone IMPRESSION C spine lesion COURSE MRI C spine revealed a central C5 6 disk herniation with compression of the spinal cord at that level EMG NCV showed normal NCV but 1 sharps and fibrillations in the right biceps C5 6 brachioradialis C5 6 triceps C7 8 and teres major and 2 sharps and fibrillations in the right pronator terres There was increased insertional activity in all muscles tested on the right side The findings were consistent with a C6 7 radiculopathy The patient subsequently underwent C5 6 laminectomy and her symptoms resolved Keywords radiology shoulder pain stiffness numbness lhermitte s phenomena c spine lesion disk herniation mri c spine reflexes biceps mri disk shoulder spine herniation MEDICAL_TRANSCRIPTION,Description MRI Elbow A middle aged female complaining of elbow pain Medical Specialty Radiology Sample Name MRI Elbow 1 Transcription FINDINGS There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation coronal T2 image 1452 sagittal T2 image 1672 There is irregularity of the deep surface of the tendon consistent with mild fraying 1422 and 1484 however there is no distinct tear There is a joint effusion of the radiocapitellar articulation with mild fluid distention The radial collateral proper ligament remains intact There is periligamentous inflammation of the lateral ulnar collateral ligament coronal T2 image 1484 of the radial collateral ligamentous complex There is no articular erosion or osteochondral defect with no intra articular loose body There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon axial T2 image 1324 The common flexor tendon otherwise is normal There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament coronal T2 image 1516 axial T2 image 1452 with an intrinsically normal ligament The ulnotrochlear articulation is normal The brachialis and biceps tendons are normal with a normal triceps tendon The anterior posterior medial and lateral muscular compartments are normal The radial median and ulnar nerves are normal with no apparent ulnar neuritis IMPRESSION Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying without a discrete tendon tear Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra articular loose body Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament Keywords radiology radial collateral ligamentous complex intra articular loose body axial t image ulnar collateral ligament common flexor tendon mri elbow ligamentous complex radial collateral ulnar collateral collateral ligament flexor tendon periligamentous inflammation mri tendon MEDICAL_TRANSCRIPTION,Description MRI cervical spine Medical Specialty Radiology Sample Name MRI Cervical Spine 1 Transcription EXAM MRI CERVICAL SPINE CLINICAL A57 year old male Received for outside consultation is an MRI examination performed on 11 28 2005 FINDINGS Normal brainstem cervical cord junction Normal cisterna magna with no tonsillar ectopia Normal clivus with a normal craniovertebral junction Normal anterior atlantoaxial articulation C2 3 Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina with no cord or radicular impingement C3 4 There is disc desiccation with minimal annular bulging The residual AP diameter of the central canal measures approximately 10mm CSF remains present surrounding the cord C4 5 There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema There is minimal uncovertebral joint arthrosis C5 6 There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm AP x transverse The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement C6 7 There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft There is a left posterolateral disc osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root C7 T1 T1 2 Minimal disc desiccation with no disc displacement or endplate spondylosis IMPRESSION Multilevel degenerative disc disease as described above C4 5 borderline central canal stenosis with mild bilateral foraminal compromise C5 6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion C6 7 degenerative disc disease and endplate spondylosis with a left posterolateral disc osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis Normal cervical cord Keywords radiology borderline central canal stenosis mri cervical spine borderline central canal central canal stenosis degenerative disc annular bulging ap diameter endplate spondylosis borderline central canal stenosis disc desiccation central canal cervical disc spondylosis stenosis cord canal MEDICAL_TRANSCRIPTION,Description MRI Brain Subacute right thalamic infarct Medical Specialty Radiology Sample Name MRI Brain Thalamic Infarct Transcription CC Left hemiplegia HX A 58 y o RHF awoke at 1 00AM on 10 23 92 with left hemiplegia and dysarthria which cleared within 15 minutes She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable She was admitted locally She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour She was placed on IV Heparin following the 3rd episode and was transferred to UIHC She had not been taking ASA PMH 1 HTN 2 Psoriasis SHX denied ETOH Tobacco illicit drug use FHX Unknown MEDS Heparin only EXAM BP160 90 HR145 supine BP105 35 HR128 light headed standing RR12 T37 7C MS Dysarthria only Lucid thought process CN left lower facial weakness only Motor mild left hemiparesis with normal muscle bulk Mildly increased left sided muscle tone Sensory unremarkable Coordination impaired secondary to weakness on left Otherwise unremarkable Station left pronator drift Romberg testing not done Gait not tested Reflexes symmetric 2 throughout Gen Exam CV Tachycardic without murmur COURSE The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures She was immediately placed in a reverse Trendelenburg position and given IV fluids Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms PT PTT GS CBC ABG were unremarkable EKG revealed sinus tachycardia with rate dependent junctional changes CXR unremarkable MRI Brain was obtained and showed an evolving right thalamic lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images Over the ensuing days of admission she had significant fluctuations of her BP 200mmHG to 140mmHG systolic Her symptoms worsened with falls in BP Her BP was initially controlled with esmolol or labetalol Renal Ultrasound abdominal pelvic CT renal function scan serum and urine osmolality urine catecholamines metanephrine studies were unremarkable Carotid doppler study revealed 0 15 BICA stenosis and antegrade vertebral artery flow bilaterally Transthoracic echocardiogram was unremarkable Cerebral angiogram was performed to r o vasculitis This revealed narrowing of the M1 segment of the right MCA This was thought secondary to atherosclerosis and not vasculitis She was discharged on ASA Procardia XL and Labetalol Keywords radiology mri brain ct brain heparin dysarthria hemiplegia infarct neurological exam thalamic thalamic infarct mri brain MEDICAL_TRANSCRIPTION,Description MRI Cervical Spine without contrast Medical Specialty Radiology Sample Name MRI Cervical Spine 2 Transcription EXAM MRI SPINAL CORD CERVICAL WITHOUT CONTRAST CLINICAL Right arm pain numbness and tingling FINDINGS Vertebral alignment and bone marrow signal characteristics are unremarkable The C2 3 and C3 4 disk levels appear unremarkable At C4 5 broad based disk osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour A discrete cord signal abnormality is not identified There may also be some narrowing of the neuroforamina at this level At C5 6 central disk osteophyte contacts and mildly impresses on the ventral cord contour Distinct neuroforaminal narrowing is not evident At C6 7 mild diffuse disk osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface Distinct cord compression is not evident There may be mild narrowing of the neuroforamina at his level A specific abnormality is not identified at the C7 T1 level IMPRESSION Disk osteophyte at C4 5 through C6 7 with contact and may mildly indent the ventral cord contour at these levels Some possible neuroforaminal narrowing is also noted at levels as stated above Keywords radiology mri cervical spine ventral cord contour cervical spine spinal cord cord contour ventral cord mri narrowing ventral cord MEDICAL_TRANSCRIPTION,Description MRI Brain T spine Demyelinating disease Medical Specialty Radiology Sample Name MRI Brain T spine Demyelinating disease Transcription CC Sensory loss HX 25y o RHF began experiencing pruritus in the RUE above the elbow and in the right scapular region on 10 23 92 In addition she had paresthesias in the proximal BLE and toes of the right foot Her symptoms resolved the following day On 10 25 92 she awoke in the morning and her legs felt asleep with decreased sensation The sensory loss gradually progressed rostrally to the mid chest She felt unsteady on her feet and had difficulty ambulating In addition she also began to experience pain in the right scapular region She denied any heat or cold intolerance fatigue weight loss MEDS None PMH Unremarkable FHX GF with CAD otherwise unremarkable SHX Married unemployed 2 children Patient was born and raised in Iowa Denied any h o Tobacco ETOH illicit drug use EXAM BP121 66 HR77 RR14 36 5C MS A O to person place and time Speech normal with logical lucid thought process CN mild optic disk pallor OS No RAPD EOM full and smooth No INO The rest of the CN exam was unremarkable MOTOR Full strength throughout all extremities except for 5 4 hip extensors Normal muscle tone and bulk Sensory Decreased PP LT below T4 5 on the left side down to the feet Decreased PP LT VIB in BLE left worse than right Allodynic in RUE Coord Intact FNF HKS and RAM bilaterally Station No pronator drift Romberg s test not documented Gait Unsteady wide based Able to TT and HW Poor TW Reflexes 3 3 BUE Hoffman s signs were present bilaterally 4 4 patellae 3 3 Achilles with 3 4 beat nonsustained clonus Plantar responses were extensor on the right and flexor on the left Gen Exam Unremarkable COURSE CBC GS PT PTT ESR FT4 TSH ANA Vit B12 Folate VDRL and Urinalysis were normal MRI T spine 10 27 92 was unremarkable MRI Brain 10 28 92 revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum periventricular region brachium pontis and right pons The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis 10 28 92 Lumbar puncture revealed the following CSF results RBC 1 WBC 9 8 lymphocytes 1 histiocyte Glucose 55mg dl Protein 46mg dl normal 15 45 CSF IgG 7 5mg dl normal 0 0 6 2 CSF IgG index 1 3 normal 0 0 0 7 agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample Beta 2 microglobulin was unremarkable An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing Visual and Brainstem Auditory evoked potentials were normal HTLV 1 titers were negative CSF cultures and cytology were negative She was not treated with medications as her symptoms were primarily sensory and non debilitating and she was discharged home She returned on 11 7 92 as her symptoms of RUE dysesthesia lower extremity paresthesia and weakness all worsened On 11 6 92 she developed slow slurred speech and had marked difficulty expressing her thoughts She also began having difficulty emptying her bladder Her 11 7 92 exam was notable for normal vital signs lying motionless with eyes open and nodding and rhythmically blinking every few minutes She was oriented to place and time of day but not to season day of the week and she did not know who she was She had a leftward gaze preference and right lower facial weakness Her RLE was spastic with sustained ankle clonus There was dysesthetic sensory perception in the RUE Jaw jerk and glabellar sign were present MRI brain 11 7 92 revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale The right peritrigonal region is more prominent than on prior study The left centrum semiovale lesion has less enhancement than previously Multiple other white matter lesions are demonstrated on the right side in the posterior limb of the internal capsule the anterior periventricular white matter optic radiations and cerebellum The peritrigonal lesions on both sides have increased in size since the 10 92 MRI The findings were felt more consistent with demyelinating disease and less likely glioma Post viral encephalitis Rapidly progressive demyelinating disease and tumor were in the differential diagnosis Lumbar Puncture 11 8 92 revealed RBC 2 WBC 12 12 lymphocytes Glucose 57 Protein 51 elevated cytology and cultures were negative HIV 1 titer was negative Urine drug screen negative A stereotactic brain biopsy of the right parieto occipital region was consistent with demyelinating disease She was treated with Decadron 6mg IV qhours and Cytoxan 0 75gm m2 1 25gm On 12 3 92 she has a focal motor seizure with rhythmic jerking of the LUE loss of consciousness and rightward eye deviation EEG revealed diffuse slowing with frequent right sided sharp discharges She was placed on Dilantin She became depressed Keywords radiology sensory loss lumbar puncture peritrigonal region centrum semiovale mri brain white matter demyelinating disease csf demyelinating mri brain MEDICAL_TRANSCRIPTION,Description MRI Brain MRI C T spine Multiple hemangioblastoma in Von Hippel Lindau Disease Medical Specialty Radiology Sample Name MRI Brain and C T Spine Transcription CC Weakness HX This 30 y o RHM was in good health until 7 93 when he began experiencing RUE weakness and neck pain He was initially treated by a chiropractor and after an unspecified length of time developed atrophy and contractures of his right hand He then went to a local neurosurgeon and a cervical spine CT scan 9 25 92 revealed an intramedullary lesion at C2 3 and an extramedullary lesion at C6 7 He underwent a C6 T1 laminectomy with exploration and decompression of the spinal cord His clinical condition improved over a 3 month post operative period and then progressively worsened He developed left sided paresthesia and upper extremity weakness right worse than left He then developed ataxia nausea vomiting and hyperreflexia On 8 31 93 MRI C spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa On 9 1 93 he underwent suboccipital craniotomy with tumor excision decompression and biopsy which was consistent with hemangioblastoma His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9 93 through 1 19 94 He was evaluated in the NeuroOncology clinic on 10 26 95 for consideration of chemotherapy He complained of progressive proximal weakness of all four extremities and dysphagia He had difficulty putting on his shirt and raising his arms and he had been having increasing difficulty with manual dexterity e g unable to feed himself with utensils He had difficulty going down stairs but could climb stairs He had no bowel or bladder incontinence or retention MEDS none PMH see above FHX Father with Von Hippel Lindau Disease SHX retired truck driver smokes 1 3 packs of cigarettes per day but denied alcohol use He is divorced and has two sons who are healthy He lives with his mother ROS noncontributory EXAM Vital signs were unremarkable MS A O to person place and time Speech fluent and without dysarthria Thought process lucid and appropriate CN unremarkable exept for 4 4 strength of the trapezeii No retinal hemangioblastoma were seen MOTOR 4 4 strength in proximal and distal upper extremities There is diffuse atrophy and claw hands bilaterally He is unable to manipulate hads to any great extent 4 4 strength throughout BLE There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities SENSORY There was a right T3 and left T8 cord levels to PP on the posterior thorax Decreased LT in throughout the 4 extremities COORD difficult to assess due to weakness Station BUE pronator drift Gait stands without assistance but can only manage to walk a few steps Spastic gait Reflexes Hyperreflexic on left 3 and Hyporeflexic on right 1 Babinski signs were present bilaterally Gen exam unremarkable COURSE 9 8 95 GS normal By 11 14 95 he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies MRI Brain 2 19 96 revealed several lesions hemangioblastoma in the cerebellum and brain stem There were postoperative changes and a cyst in the medulla On 10 25 96 he presented with a 1 5 week h o numbness in BLE from the mid thighs to his toes and worsening BLE weakness He developed decubitus ulcers on his buttocks He also had had intermittent urinary retention for month chronic SOB and dysphagia He had been sitting all day long as he could not move well and had no daytime assistance His exam findings were consistent with his complaints He had had no episodes of diaphoresis headache or elevated blood pressures An MRI of the C T spine 10 26 96 revealed a prominent cervicothoracic syrinx extending down to T10 There was evidence of prior cervical laminectomy of C6 T1 with expansion of the cord in the thecalsac at that region Multiple intradural extra spinal nodular lesions hyperintense on T2 isointense on T1 enhanced gadolinium were seen in the cervical spine and cisterna magna The largest of which measures 1 1 x 1 0 x 2 0cm There are also several large ring enhancing lesions in cerebellum The lesions were felt to be consistent with hemangioblastoma No surgical or medical intervention was initiated Visiting nursing was provided He has since been followed by his local physician Keywords MEDICAL_TRANSCRIPTION,Description Bilateral breast MRI with without IV contrast Medical Specialty Radiology Sample Name MRI Breast 1 Transcription FINDINGS There are post biopsy changes seen in the retroareolar region middle third aspect of the left breast at the post biopsy site There is abnormal enhancement seen in this location compatible with patient s history of malignancy There is increased enhancement seen in the inferior aspect of the left breast at the 6 00 o clock N 5 5 cm position measuring 1 2 cm Further work up with ultrasound is indicated There are other multiple benign appearing enhancing masses seen in both the right and left breasts None of the remaining masses appear worrisome for malignancy based upon MRI criteria IMPRESSION BIRADS CATEGORY M 5 There is a malignant appearing area of enhancement in the left breast which does correspond to the patient s history of recent diagnosis of malignancy She has been scheduled to see a surgeon as well as Medical Oncologist Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6 00 o clock N 5 5 cm position for further evaluation of the mass At that same time ultrasonography of the remaining masses should also be performed Please note however that the remaining masses have primarily benign features based upon MRI criteria However further evaluation with ultrasound should be performed Keywords radiology breast cancer bilateral breast mri bilateral breast iv contrast contrast ultrasound ultrasonography malignancy mri benign masses breast MEDICAL_TRANSCRIPTION,Description MRI Brain and Brainstem Falling Multiple System Atrophy Medical Specialty Radiology Sample Name MRI Brain and Brainstem Transcription CC Falling HX This 67y o RHF was diagnosed with Parkinson s Disease in 9 1 95 by a local physician For one year prior to the diagnosis the patient experienced staggering gait falls and episodes of lightheadedness She also noticed that she was slowly losing her voice and that her handwriting was becoming smaller and smaller Two months prior to diagnosis she began experienced bradykinesia but denied any tremor She noted no improvement on Sinemet which was started in 9 95 At the time of presentation 2 13 96 she continued to have problems with coordination and staggering gait She felt weak in the morning and worse as the day progressed She denied any fever chills nausea vomiting HA change in vision seizures or stroke like events or problems with upper extremity coordination MEDS Sinemet CR 25 100 1tab TID Lopressor 25mg qhs Vitamin E 1tab TID Premarin 1 25mg qd Synthroid 0 75mg qd Oxybutynin 2 5mg has isocyamine 0 125mg qd PMH 1 Hysterectomy 1965 2 Appendectomy 1950 s 3 Left CTR 1975 and Right CTR 1978 4 Right oophorectomy 1949 for tumor 5 Bladder repair 1980 for unknown reason 6 Hypothyroidism dx 4 94 7 HTN since 1973 FHX Father died of MI age 80 Mother died of MI age73 Brother died of Brain tumor age 9 SHX Retired employee of Champion Automotive Co Denies use of TOB ETOH Illicit drugs EXAM BP supine 182 113 HR supine 94 BP standing 161 91 HR standing 79 RR16 36 4C MS A O to person place and time Speech fluent and without dysarthria No comment regarding hypophonia CN Pupils 5 5 decreasing to 2 2 on exposure to light Disks flat Remainder of CN exam unremarkable Motor 5 5 strength throughout NO tremor noted at rest or elicited upon movement or distraction Sensory Unremarkable PP VIB testing Coord Did not show sign of dysmetria dyssynergia or dysdiadochokinesia There was mild decrement on finger tapping and clasping unclasping hands right worse than left Gait Slow gait with difficulty turning on point Difficulty initiating gait There was reduced BUE swing on walking right worse than left Station 3 4step retropulsion Reflexes 2 2 and symmetric throughout BUE and patellae 1 1 Achilles Plantar responses were flexor Gen Exam Inremarkable HEENT unremarkable COURSE The patient continued Sinemet CR 25 100 1tab TID and was told to monitor orthostatic BP at home The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia She was seen again on 5 28 96 and reported no improvement in her condition In addition she complained of worsening lightheadedness upon standing and had an episode 1 week prior to 5 28 96 in which she was at her kitchen table and became unable to move There were no involuntary movements or alteration in sensorium mental status During the episode she recalled wanting to turn but could not Two weeks prior to 5 28 96 she had an episode of orthostatic syncope in which she struck her head during a fall She discontinued Sinemet 5 days prior to 5 28 96 and felt better She felt she was moving slower and that her micrographia had worsened She had had recent difficulty rolling over in bed and has occasional falls when turning She denied hypophonia dysphagia or diplopia On EXAM BP supine 153 110 with HR 88 BP standing 110 80 with HR 96 Myerson s sign and mild hypomimia but no hypophonia There was normal blinking and EOM Motor strength was full throughout No resting tremor but mild postural tremor present No rigidity noted Mild decrement on finger tapping noted Reflexes were symmetric No Babinski signs and no clonus Gait was short stepped with mild anteroflexed posture She was unable to turn on point 3 4 step Retropulsion noted The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy Drager syndrome It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20 30 degrees at night Indomethacin was suggested to improve BP in future Keywords radiology myerson s sign falling dysautonomia mri brain and brainstem brain and brainstem mri brain sinemet cr mri brainstem ctr tumor retropulsion parkinsonism brain lightheadedness hypophonia standing sinemet MEDICAL_TRANSCRIPTION,Description MRI brain Cerebral Angiogram CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes Medical Specialty Radiology Sample Name MRI Brain Cerebral Angiogram Transcription CC Difficulty with word finding HX This 27y o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2 19 96 She denied any associated dysphagia diplopia numbness or weakness of her extremities She went to sleep with her symptoms on 2 19 96 and awoke with them on 2 20 96 She also awoke with a headache HA and mild neck stiffness She took a shower and her HA and neck stiffness resolved Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech That evening she began to experience numbness and weakness in the lower right face She felt like there was a rubber band wrapped around her tongue For 3 weeks prior to presentation she experienced transient episodes of a boomerang shaped field cut in the left eye The episodes were not associated with any other symptoms One week prior to presentation she went to a local ER for menorrhagia She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months Local evaluation included an unremarkable carotid duplex scan However a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion An MRI brain scan on 2 20 96 revealed nonspecific white matter changes in the right periventricular region EEG reportedly showed diffuse slowing CRP was reportedly too high to calibrate MEDS Ortho Novum 7 7 7 started 2 3 96 and ASA started 2 20 96 PMH 1 ventral hernia repair 10 years ago 2 mild concussion suffered during a MVA without loss of consciousness 5 93 3 Anxiety disorder 4 One childbirth FHX She did not know her father and was not in contact with her mother SHX Lives with boyfriend Smokes one pack of cigarettes every three days and has done so for 10 years Consumes 6 bottles of beers one day a week Unemployed and formerly worked at an herbicide plant EXAM BP150 79 HR77 RR22 37 4C MS A O to person place and time Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors Comprehension naming and reading were intact She was able to repeat though her repetition was occasionally marked by phonemic paraphasic errors She had no difficulty with calculation CN VFFTC Pupils 5 5 decreasing to 3 3 EOM intact No papilledema or hemorrhages seen on fundoscopy No RAPD or INO There was right lower facial weakness Facial sensation was intact bilaterally The rest of the CN exam was unremarkable MOTOR 5 5 strength throughout with normal muscle bulk and tone Sensory No deficits Coord Station Gait unremarkable Reflexes 2 2 throughout Plantar responses were flexor bilaterally Gen Exam unremarkable COURSE CRP 1 2 elevated ESR 10 RF 20 ANA 1 40 ANCA 1 40 TSH 2 0 FT4 1 73 Anticardiolipin antibody IgM 10 8GPL units normal 10 9 Anticardiolipin antibody IgG 14 8GPL normal 22 9 SSA and SSB were normal Urine beta hCG pregnancy and drug screen were negative EKG CXR and UA were negative MRI brain 2 21 96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere In addition there were subtle T2 signal changes in the right frontal right parietal and left parietal regions as seen previously on her local MRI can In addition special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia She underwent Cerebral Angiography on 2 22 96 This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe These changes corresponded to the areas of ischemic changes seen on MRI There was also segmental narrowing of the caliber of the vessels in the circle of Willis There was a small aneurysm at the origin of the LPCA There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments The study was highly suggestive of vasculitis 2 23 96 Neuro ophthalmology evaluation revealed no evidence of retinal vasculitic change Neuropsychologic testing the same day revealed slight impairment of complex attention only She was started on Prednisone 60mg qd and Tagamet 400mg qhs On 2 26 96 she underwent a right frontal brain biopsy Pathologic evaluation revealed evidence of focal necrosis stroke infarct but no evidence of vasculitis Immediately following the brain biopsy while still in the recovery room she experienced sudden onset right hemiparesis and transcortical motor type aphasia Initial HCT was unremarkable An EEG was consistent with a focal lesion in the left hemisphere However a 2 28 96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus This was felt consistent with vasculitis She began q2month cycles of Cytoxan 1 575mg IV on 2 29 96 She became pregnant after her 4th cycle of Cytoxan despite warnings to the contrary After extensive discussions with OB GYN it was recommended she abort the pregnancy She underwent neuropsychologic testing which revealed no significant cognitive deficits She later agreed to the abortion She has undergone 9 cycles of Cytoxan one cycle every 2 months as of 4 97 She had complained of one episode of paresthesias of the LUE in 1 97 MRI then showed no new signs ischemia Keywords MEDICAL_TRANSCRIPTION,Description MRI Brain Thrombus in torcula of venous sinuses Medical Specialty Radiology Sample Name MRI Brain Thrombus Transcription CC Motor vehicle bicycle collision HX A 5 y o boy admitted 10 17 92 He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth He was intubated and ventilated in the field and then transferred to UIHC PMH FHX SHX unremarkable MEDS none EXAM BP 127 91 HR69 RR30 MS unconscious and intubated Glasgow coma scale 4 CN Pupils 6 6 fixed Corneal reflex trace OD absent OS Gag present on manipulation of endotracheal tube MOTOR SENSORY bilateral decorticate posturing to noxious stimulation chest Reflexes bilaterally Laceration of mid forehead exposing calvarium COURSE Emergent Brain CT scan revealed Displaced fracture of left calvarium Left frontoparietal intraparenchymal hemorrhage Right ventricular collection of blood Right cerebral intraparenchymal hemorrhage Significant mass effect with deviation of the midline structures to right The left ventricle was compressed with obliteration of the suprasellar cistern Air within the soft tissues in the left infra temporal region C spine XR Abdominal Chest CT were unremarkable Patient was taken to the OR emergently and underwent bifrontal craniotomy evacuation of a small epidural and subdural hematomas and duraplasty He was given mannitol enroute to the OR and hyperventilated during and after the procedure Postoperatively he continued to manifest decerebrate posturing On 11 16 92 he underwent VP shunting with little subsequent change in his neurological status On 11 23 92 he underwent tracheostomy On 12 11 92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy By the time of discharge 1 14 93 he tracked relatively well OD but had a CN3 palsy OS He had relatively severe extensor rigidity in all extremities R L His tracheotomy was closed prior to discharge A 11 16 92 Brain MRI demonstrated infarction in the upper brain stem particularly in the Pons left cerebellum right basil ganglia and thalamus He was initially treated for seizure prophylaxis with DPH but developed neutropenia so it was discontinued He developed seizures within several months of discharge and was placed on VPA Depakene This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol 10 8 93 Brain MRI one year after MVA revealed interval appearance of hydrocephalus abnormal increased T2 signal in the medulla right pons both basal ganglia right frontal and left occipital regions a small mid brain and a right subdural fluid collection These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion and signs of a previous right subdural hematoma He was last seen 10 30 96 in the pediatric neurology clinic age 9 years He was averaging 2 3 seizures per day characterized by extension of BUE with tremor and audible cry or laughter on Tegretol and Diazepam In addition he experiences 24 48hour periods of startle response myoclonic movement of the shoulders with or without stimulation every 6 weeks He had limited communication skills sparse speech On exam he had disconjugate gaze dilated fixed left pupil spastic quadriplegia Keywords radiology mri brain brain mri thrombus intraparenchymal hemorrhage motor vehicle prophylaxis sinuses torcula venous sinuses venous brain thrombus bilateral decorticate decorticate posturing subdural hematomas subdural mri brain torcula MEDICAL_TRANSCRIPTION,Description MRI Brain Left Basal Ganglia Posterior temporal lobe and Left cerebellar lacunar infarctions with Wernickes Aphasia Medical Specialty Radiology Sample Name MRI Brain Wernicke aphasia Transcription CC Difficulty with speech HX This 72 y o RHM awoke early on 8 14 95 to prepare to play golf He felt fine However at 6 00AM on 8 14 95 he began speaking abnormally His wife described his speech as word salad and complete gibberish She immediately took him to a local hospital Enroute he was initially able to understand what was spoken to him By the time he arrived at the hospital at 6 45AM he was unable to follow commands His speech was reportedly unintelligible the majority of the time and some of the health care workers thought he was speaking a foreign language There were no other symptoms or signs He had no prior history of cerebrovascular disease Blood pressure 130 70 and Pulse 82 upon admission to the local hospital on 8 14 95 Evaluation at the local hospital included 1 HCT scan revealed an old left putaminal hypodensity but no acute changes or evidence of hemorrhage 2 Carotid Duplex scan showed ICA stenosis of 40 bilaterally He was placed on heparin and transferred to UIHC on 8 16 95 In addition he had noted memory and word finding difficulty for 2 months prior to presentation He had undergone a gastrectomy 16 years prior for peptic ulcer disease His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation He and his wife felt that this resulted in improvement of his language and cognitive skills MEDS Heparin IV Vitamin B12 injection q week Lopressor Folate MVI PMH 1 Hypothyroidism reportedly resolved 2 Gastrectomy 3 Vitamin B12 deficiency FHX Mother died of MI age 70 Father died of prostate cancer age 80 Bother died of CAD and prostate cancer age 74 SHX Married 3 children who are alive and well Semi retired Attorney Denied h o tobacco ETOH illicit drug use EXAM BP 110 70 HR 50 RR 14 Afebrile MS A O to person and place but not time Oral comprehension was poor beyond the simplest of conversational phrases Speech was fluent but consisted largely of word salad When asked how he was he replied abadeedleedlebadle Repetition was defective especially with long phrases On rare occasions he uttered short comments appropriately Speech was marred by semantic and phonemic paraphasias He named colors and described most actions well although he described a faucet dripping as a faucet drop He called red reed Reading comprehension was better than aural comprehension He demonstrated excellent written calculations Spoken calculations were accurate except when the calculations became more complex For example he said that ten percent of 100 was equal to 1 200 CN Pupils 2 3 decreasing to 1 1 on exposure to light VFFTC There were no field cuts or evidence of visual neglect EOM were intact Face moved symmetrically The rest of the CN exam was unremarkable MOTOR Full strength throughout with normal muscle tone and bulk There was no evidence of drift SENSORY unremarkable COORD unremarkable Station unremarkable Gait mild difficulty with TW Reflexes 2 2 in BUE 2 2 patellae 1 1 Achilles Plantar responses were flexor on the left and equivocal on the right Gen Exam unremarkable COURSE Lab data on admission Glucose 97 BUN 20 Na 134 K 4 0 Cr 1 3 Chloride 98 CO2 24 PT 11 PTT 42 WBC 12 0 normal differential Hgb 11 4 Hct 36 Plt 203k UA normal TSH 6 0 FT4 0 88 Vit B12 876 Folate 19 1 He was admitted and continued on heparin MRI scan 8 16 95 revealed increased signal on T2 weighted images in Wernicke s area in the left temporal region Transthoracic echocardiogram on 8 17 95 was unremarkable Transesophageal echocardiogram on 8 18 95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve LAE 4 8cm and spontaneous echo contrast in the left atrium were noted There was no evidence of intracardiac shunt or clot Carotid duplex scan on 8 16 95 revealed 0 15 BICA stenosis with anterograde vertebral artery flow bilaterally Neuropsychologic testing revealed a Wernicke s aphasia The impression was that the patient had had a cardioembolic stroke involving a lower division branch of the left MCA He was subsequently placed on warfarin Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge 8 21 95 He has had no further stroke like episodes up until his last follow up visit in 1997 Keywords radiology mri brain difficulty with speech left basal ganglia posterior temporal lobe wernicke s area wernickes aphasia cerebellar infarctions lacunar word finding difficulty carotid duplex scan aphasia wernicke s mri brain MEDICAL_TRANSCRIPTION,Description Right pontine pyramidal tract infarct Medical Specialty Radiology Sample Name MRI Brain Pontine Stroke Transcription CC Left sided weakness HX 74 y o RHF awoke from a nap at 11 00 AM on 11 22 92 and felt weak on her left side She required support on that side to ambulate In addition she felt spoke as though she was drunk Nevertheless she was able to comprehend what was being spoken around her Her difficulty with speech completely resolved by 12 00 noon She was brought to UIHC ETC at 8 30AM on 11 23 92 for evaluation MEDS none ALLERGIES ASA PCN both cause rash PMH 1 HTN 2 COPD 3 h o hepatitis unknown type 4 Macular degeneration SHX Widowed lives alone Denied ETOH Tobacco illicit drug use FHX unremarkable EXAM BP191 89 HR68 RR16 37 2C MS A O to person place and time Speech fluent without dysarthria Intact naming comprehension and repetition CN Central scotoma OS old Mild upper lid ptosis OD old per picture Lower left facial weakness Motor Mild Left hemiparesis 4 to 5 strength throughout affected side No mention of muscle tone in chart Sensory unremarkable Coord impaired FNF and HKS movement secondary to weakness Station Left pronator drift No Romberg sign seen Gait Left hemiparetic gait with decreased LUE swing Reflexes 3 3 biceps and triceps 3 3 patellae 2 3 ankles with 3 4beats of non sustained ankle clonus on left Plantars Left babinski sign and flexor on right General Exam 2 6 SEM at left sternal border COURSE GS CBC PT PTT CK ESR were within normal limits ABC 7 4 46 63 on room air EKG showed a sinus rhythm with right bundle branch block MRI brain 11 23 95 revealed a right pontine pyramidal tract infarction She was treated with Ticlopidine 250mg bid On 11 26 92 her left hemiparesis worsened A HCT 11 27 92 was unremarkable The patient was treated with IV Heparin This was discontinued the following day when her strength returned to that noted on 11 23 95 On 11 27 92 she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies Carotid duplex showed 0 15 bilateral ICA stenosis and antegrade vertebral artery flow bilaterally Transthoracic echocardiogram revealed aortic insufficiency only Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation aortic valvular fibrosis There was calcification and possible thrombus seen in the descending aorta Cardiology did not feel the later was an indication for anticoagulation She was discharged home on Isordil 20 tid Metoprolol 25mg q12hours and Ticlid 250mg bid Keywords radiology mri brain pontine stroke difficulty with speech hemiparesis pontine pyramidal tract infarct weakness mri brain pyramidal echocardiogram pontine infarct MEDICAL_TRANSCRIPTION,Description A middle aged female with memory loss Medical Specialty Radiology Sample Name MRI Brain Memory Loss Transcription FINDINGS There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces There is confluent white matter hyperintensity in a bi hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra axial or extraaxial mass lesions There is a cavum velum interpositum normal variant There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space Normal basal ganglia and thalami Normal internal and external capsules Normal midbrain There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease There are areas of T2 hyperintensity involving the bilateral brachium pontis left greater than right with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology Interval reassessment of this lesion is recommended There is a remote lacunar infarction of the right cerebellar hemisphere Normal left cerebellar hemisphere and vermis There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery Normal flow within the carotid arteries and circle of Willis Normal calvarium central skull base and temporal bones There is no demonstrated calvarium metastases IMPRESSION Severe generalized cerebral atrophy Extensive chronic white matter ischemic changes in a bi hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation Interval reassessment of this lesion is recommended Remote lacunar infarction in the right cerebellar hemisphere Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or lacunar infarction No demonstrated calvarial metastases Keywords radiology white matter ischemic remote lacunar infarction memory loss matter ischemic remote lacunar cerebellar hemisphere lacunar infarction brachium pontis white matter basilar calvarium ischemic enhancement cerebellar hemispheres hyperintensity infarction brachium MEDICAL_TRANSCRIPTION,Description A middle aged male with increasing memory loss and history of Lyme disease Medical Specialty Radiology Sample Name MRI Brain Lyme Disease Transcription FINDINGS There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica This mass lesions measures approximately 16 x 18 x 18mm craniocaudal x AP x mediolateral in size Keywords radiology increasing memory loss intrasellar mass lesion memory loss sella turcica cavernous sinus sphenoid sinus ct imaging white matter retention cyst maxillary antrum lyme disease mass lesion disease cavernous cortical mass lesion MEDICAL_TRANSCRIPTION,Description MRI Brain to evaluate sudden onset blindness Basilar bilateral thalamic strokes Medical Specialty Radiology Sample Name MRI Brain Bilateral Thalamic Strokes Transcription CC Sudden onset blindness HX This 58 y o RHF was in her usual healthy state until 4 00PM 1 8 93 when she suddenly became blind Tongue numbness and slurred speech occurred simultaneously with the loss of vision The vision transiently improved to severe blurring enroute to a local ER but worsened again once there While being evaluated she became unresponsive even to deep noxious stimuli She was transferred to UIHC for further evaluation Upon arrival at UIHC her signs and symptoms were present but markedly improved PMH 1 Hysterectomy many years previous 2 Herniorrhaphy in past 3 DJD relieved with NSAIDs FHX SHX Married x 27yrs Husband denied Tobacco ETOH illicit drug use for her Unremarkable FHx MEDS none EXAM Vitals 36 9C HR 93 BP 151 93 RR 22 98 O2Sat MS somnolent but arousable to verbal stimulation minimal speech followed simple commands on occasion CN Blinked to threat from all directions EOM appeared full Pupils 2 2 decreasing to 1 1 Corneas Winced to PP in all areas of Face Gag Tongue midline Oculocephalic reflex intact Motor UE 4 5 proximally Full strength in all other areas Normal tone and muscle bulk Sensory Withdrew to PP in all extremities Gait ND Reflexes 2 2 throughout UE 3 3 patella 2 2 ankles Plantar responses were flexor bilaterally Gen exam unremarkable COURSE MRI Brain revealed bilateral thalamic strokes Transthoracic echocardiogram TTE showed an intraatrial septal aneurysm with right to left shunt Transesophageal echocardiogram TEE revealed the same No intracardiac thrombus was found Lower extremity dopplers were unremarkable Carotid duplex revealed 0 15 bilateral ICA stenosis Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU diminished up and down gaze Neuropsychologic assessment 1 12 15 93 revealed severe impairment of anterograde verbal and visual memory including acquisition and delayed recall and recognition Speech was effortful and hypophonic with very defective verbal associative fluency Reading comprehension was somewhat preserved though she complained that despite the ability to see type clearly she could not make sense of words There was impairment of 2 D constructional praxis A follow up Neuropsychology evaluation in 7 93 revealed little improvement Laboratory studies TSH FT4 CRP ESR GS PT PTT were unremarkable Total serum cholesterol 195 Triglycerides 57 HDL 43 LDL 141 She was placed on ASA and discharged1 19 93 She was last seen on 5 2 95 and was speaking fluently and lucidly She continued to have mild decreased vertical eye movements Coordination and strength testing were fairly unremarkable She continues to take ASA 325 mg qd Keywords radiology blindness mri transthoracic echocardiogram transesophageal echocardiogram tsh ft4 crp esr gs pt ptt bilateral thalamic strokes sudden onset blindness mri brain thalamic strokes brain thalamic strokes MEDICAL_TRANSCRIPTION,Description MRI Brain Progressive Multifocal Leukoencephalopathy PML occurring in an immunosuppressed patient with polymyositis Medical Specialty Radiology Sample Name MRI Brain Leukoencephalopathy Transcription CC Progressive left visual field loss HX This 46y o RHF with polymyositis since 1988 presented with complaint of visual field loss since 12 94 The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia She began experiencing stiffness numbness tingling and incoordination of her left hand 6 weeks prior to this admission These symptoms were initially attributed to carpal tunnel syndrome MRI scan of the brain done locally on 6 23 95 revealed increased periventricular white matter signal on T2 images particularly in the left temporo occipital and right parietal lobes There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images There was gyral enhancement near the right Sylvian fissure Cerebral angiogram on 7 19 95 done locally was unremarkable Lumbar puncture on 7 19 95 was unremarkable She complained of frequent holocranial throbbing headaches for the past 6 months the HA s are associated with photophobia phonophobia and nausea but no vomiting She has also been experiencing chills and night sweats for the past 2 3 weeks She denies weight loss but acknowledged decreased appetite and increased generalized fatigue for the past 3 4 months She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness She has been on immunosuppressive drugs since 1988 including Prednisone Prednisone and methotrexate Cyclosporin Imuran Cytoxan and Plaquenil At present she in ambulatory with use of walker Her last CK 3 125 and ESR 16 on 6 28 95 MEDS Prednisone 20mg qd Cytoxan 75mg qd Zantac 150mg bid Vasotec 10mg bid Premarin 0 625 qd Provera 2 5mg qd CaCO3 500mg bid Vit D 50 000units qweek Vit E qd MVI 1 tab qd PMH 1 polymyositis diagnosed in 1988 by muscle biopsy 2 hypertension 3 lichen planus 4 Lower extremity deep venous thrombosis one year ago placed on Coumadin and this resulted in postmenopausal bleeding FHX Mother is alive and has a h o HTN and stroke Father died in motor vehicle accident at age 40 years SHX Married 3 children who are healthy She denied any Tobacco ETOH Illicit drug use EXAM BP160 74 HR95 RR12 35 8C Wt 86 4kg Ht 5 6 MS A O to person place and time Speech was normal Mood euthymic with appropriate affect CN Pupils 4 4 decreasing to 2 2 on exposure to light No RAPD noted Optic Disk were flat EOM testing unremarkable Confrontational visual field testing revealed a left homonymous hemianopsia The rest of the CN exam was unremarkable MOTOR Upper extremities 5 5 proximally 5 4 elbow wrist hand Lower extremities 4 4 proximally and 5 5 and below knees SENSORY unremarkable COORD Dyssynergia of LUE FNF movement Slowed finger tapping on left HNS movements were normal bilaterally Station LUE drift and fix on arm roll No Romberg sign elicited Gait Waddling gait but could TT and stand on both heels She had difficulty with tandem walking but did not fall to any particular side Reflexes 2 2 brachioradialis and biceps 2 2 triceps 1 1 patellae 1 1 Achilles Plantar responses were flexor on the right and withdrawal response on the left GEN EXAM No rashes II VI systolic ejection murmur at the left sternal border COURSE Electrolytes PT PTT Urinalysis and CXR were normal ESR 38 normal 20 CRP1 4 normal 0 4 CK 2 917 LDH 356 AST 67 MRI Brain 8 8 95 revealed slight improvement of the abnormal white matter changes seen on previous outside MRI In addition new sphenoid sinus disease suggestive of sinusitis was seen She underwent stereotactic biopsy of the right parietal region on 8 10 95 which on H E and LFB stained sections revealed multiple discrete areas of demyelination containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic ground glass nuclei enlarged astrocytes and sparse perivascular lymphocytic infiltrates In situ hybridization performed on block A2 at the university of Pittsburgh is positive for JC virus The ultrastructural studies demonstrated no viral particles She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable She had a seizure in 12 95 and was placed on Dilantin Her neurologic deficits worsened slightly but reached a plateau by 10 96 as indicated by a 4 14 97 Neurology clinic visit note 1 22 96 MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres worse on the right side There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto occipital regions There was progression of abnormal signal in the Basal Ganglia worse on the right and new involvement of the brainstem Keywords radiology mri brain pml progressive multifocal leukoencephalopathy polymyositis visual field loss leukoencephalopathy lower extremity field loss white matter visual field signal brain mri MEDICAL_TRANSCRIPTION,Description MRI Brain Pilocytic Astrocytoma in thalamus and caudate Medical Specialty Radiology Sample Name MRI Brain Pilocytic Astrocytoma Transcription CC Headache HX The patient is an 8y o RHM with a 2 year history of early morning headaches 3 00 6 00AM intermittently relieved by vomiting only He had been evaluated 2 years ago and an EEG was normal then but no brain imaging was performed His headaches progressively worsened especially in the past two months prior to this presentation For 2 weeks prior to his 1 25 93 evaluation at UIHC he would awake screaming His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and Vermox was prescribed and arrangements were made for a neurologic evaluation On the evening of 1 24 93 the patient awoke screaming and began to vomit This was followed by a 10 min period of tonic clonic type movements and postictal lethargy He was taken to a local ER and a brain CT revealed an intracranial mass He was given Decadron and Phenytoin and transferred to UIHC for further evaluation MEDS noted above PMH 1 Born at 37 5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother Pregnancy complicated by vaginal bleeding at 7 months Met developmental milestones without difficulty 2 Frequent otitis media now resolved 3 Immunizations were up to date FHX non contributory SHX lives with biologic father and mother No siblings In 3rd grade mainstream and maintaining good marks in schools EXAM BP121 57mmHg HR103 RR16 36 9C MS Sleepy but cooperative CN EOM full and smooth Advanced papilledema OU VFFTC Pupils 4 4 decreasing to 2 2 Right lower facial weakness Tongue midline upon protrusion Corneal reflexes intact bilaterally Motor 5 5 strength Slightly increased muscle on right side Sensory No deficit to PP VIB noted Coord normal FNF HKS and RAM bilaterally Station Mild truncal ataxia Tends to fall backward Reflexes BUE 2 2 Patellar 3 3 Ankles 3 3 with 6 beats of nonsustained clonus bilaterally Gen exam unremarkable COURSE The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs Brain MRI 1 26 93 revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images There were areas of cystic formation at its periphery The mass appeared to enhance on post gadolinium images there was associated white matter edema and compression of the left lateral ventricle and midline shift to the right There was no sign of uncal herniation He underwent bilateral VP shunting on 1 26 93 and then subtotal resection left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum on 1 28 93 He then received 5040cGy of radiation therapy in 28 fractions completed on 3 25 93 A 3 20 95 neuropsychological evaluation revealed low average intellect on the WISC III There were also signs of memory attention reading and spelling deficits and mild right sided motor incoordination and mood variability He remained in mainstream classes at school but his physical and cognitive performance began to deteriorate in 4 95 Neurosurgical evaluation in 4 95 noted increased right hemiplegia and right homonymous hemianopia MRI revealed tumor progression and he was subsequently placed on Carboplatin VP 16 CG 9933 protocol chemotherapy regimen A He was last seen on 4 96 and was having difficulty in the 6th grade he was also undergoing physical therapy for his right hemiplegia Keywords radiology mri brain pilocytic astrocytoma caudate thalamus headache astrocytoma hemiplegia pilocytic mri MEDICAL_TRANSCRIPTION,Description MRI Brain Olfactory groove meningioma Medical Specialty Radiology Sample Name MRI Brain Meningioma Olfactory Transcription CC Progressive visual loss HX 76 y o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation He continues to be anosmic but has also recently noted decreased vision OD He denies any headaches weakness numbness weight loss or nasal discharge MEDS none PMH 1 Diabetes Mellitus dx 1 year ago 2 Benign Prostatic Hypertrophy s p TURP 3 Right shoulder surgery DJD FHX noncontributory SHX Denies history of Tobacco ETOH illicit drug use EXAM BP132 66 HR78 RR16 36 0C MS A O to person place and time No other specifics given in Neurosurgery Otolaryngology Neuro ophthalmology notes CN Visual acuity has declined from 20 40 to 20 400 OD 20 30 OS No RAPD EOM was full and smooth and without nystagmus Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS OD worse with a normal periphery Intraocular pressures were 15 14 OD OS There was moderate pallor of the disc OD Facial sensation was decreased on the right side V1 distribution Motor Sensory Coord Station Gait were all unremarkable Reflexes 2 2 and symmetric throughout Plantars were flexor bilaterally Gen Exam unremarkable COURSE MRI Brain 10 7 92 revealed a large 6x5x6cm slightly heterogeneous mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove The mass extends approximately 3 6cm superior to the planum into both frontal regions with edema in both frontal lobes The mass extends 2 5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses It also extends into the superomedial aspect of the right maxillary sinus There is probable partial encasement of both internal carotid arteries just above the siphon The optic nerves are difficult to visualize but there is also probable encasement of these structures as well The mass enhances significantly with gadolinium contrast These finds are consistent with Meningioma The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma Postoperatively he lost visual acuity OS but this gradually returned to baseline His 9 6 96 neuro ophthalmology evaluation revealed visual acuity of 20 25 3 OD and 20 80 2 OS His visual fields continued to abnormal but improved and stable when compared to 10 92 His anosmia never resolved Keywords radiology mri brain olfactory groove headaches meningioma nasal discharge numbness visual loss weakness weight loss visual acuity mri brain isointense sinuses visual MEDICAL_TRANSCRIPTION,Description MRI right ankle Medical Specialty Radiology Sample Name MRI Ankle 2 Transcription EXAM MRI OF THE RIGHT ANKLE CLINICAL Pain FINDINGS The bone marrow demonstrates normal signal intensity There is no evidence of bone contusion or fracture There is no evidence of joint effusion Tendinous structures surrounding the ankle joint are intact No abnormal mass or fluid collection is seen surrounding the ankle joint IMPRESSION NORMAL MRI OF THE RIGHT ANKLE Keywords radiology ankle joint bone mri ankle MEDICAL_TRANSCRIPTION,Description MRI Brain Ventriculomegaly of the lateral 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus unencapsulated in a non immune suppressed HIV negative individual Medical Specialty Radiology Sample Name MRI Brain Cryptococcus Transcription CC Headache HX This 37y o LHM was seen one month prior to this presentation for HA nausea and vomiting Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home These symptoms had been recurrent since onset At presentation he complained of mild blurred vision OU difficulty concentrating and HA which worsened upon sitting up The headaches were especially noticeable in the early morning He described them as non throbbing headaches They begin in the bifrontal region and radiate posteriorly They occurred up to 6 times day The HA improved with lying down or dropping the head down between the knees towards the floor The headaches were associated with blurred vision nausea vomiting photophobia and phonophobia He denied any scotomata or positive visual phenomena He denies any weakness numbness tingling dysarthria or diplopia His weight has fluctuated from 163 to 148 over the past 3 months and at present he weighs 154 His appetite has been especially poor in the past month MEDS Sulfasalazine qid Tylenol 650mg q4hours PMH 1 Ulcerative Colitis dx 1989 2 HTN 3 occasional HAs since the early 1980s which are different in character and much less severe than his current HAs They were not associated with nausea vomiting photophobia phonophobia or difficulty thinking FHX MGF with h o stroke Mother and Father were healthy No h o of migraine in family SHX Single Works as a newpaper printing press worker Denies tobacco ETOH or illicit drug use but admits he was a heavy drinker until the last 1970s when he quit EXAM BP159 92 HR 48 sitting BP126 70 HR48 supine RR14 36 2C MS A O to person place and time Speech clear Appears uncomfortable but acts appropriately and cooperatively No difficulty with short and long term memory CN Grad 2 3 papilledema OS Grade 1 papilledema 2 o clock OD Pupils 4 4 decreasing to 2 2 on exposure to light Bilateral horizontal sustained nystagmus on right and leftward gaze Bilateral vertical sustained nystagmus on up and downward gaze Face symmetric with full movement and PP sensation Tongue midline with full ROM Gag and SCM were intact bilaterally Motor Full strength throughout with normal muscle bulk and tone Sensory Unremarkable Coord Mild dysynergia on FNF movements in BUE HNS and RAM were unremarkable Station Unsteady with and without eyes open on Romberg test No drift in any particular direction Gait Wide based ataxic and to some degree magnetic and apraxic Gen Exam Unremarkable COURSE Urinalysis revealed 1 2RBC 2 3WBC and bacteria were noted Repeat Urinalysis was negative the next day PT PTT CXR and GS were normal CBC revealed 10 4WBC with 7 1Granulocytes HCT 10 18 95 revealed hydrocephalus MRI 10 18 95 revealed ventriculomegaly of the lateral 3rd and 4th ventricles There was enhancement of the meninges about the prepontine cisterna and internal auditory canals and enhancement of a scar or inflammed lining of the foramen of Magendie These changes were felt suggestive of bacterial or granulomatous meningitis The patient underwent ventriculostomy on 10 19 94 CSF taken on 10 19 94 via V P shunt insertion revealed 22 WBC 21 lymphocytes 1 monocyte 380 RBC Glucose 58 Protein 29 GS negative Cultures bacterial fungal AFB negative Cryptococcal Antigen and India Ink were negative Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg dl Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions VDRL and HIV testing was unremarkable 10 27 94 and 10 31 94 CSF cultures taken from the cervical region eventually grew non encapsulated crytococcus neoformans The patient was treated with amphotericin and showed some improvement However scarring had probably occurred by then and the V P shunt was left in place Keywords radiology ventriculomegaly foramen of magendie mri brain blurred vision headache brain ventricles cryptococcus foramen csf MEDICAL_TRANSCRIPTION,Description Lexiscan myoview stress study Chest discomfort Normal stress rest cardiac perfusion with no indication of ischemia Normal LV function and low likelihood of significant epicardial coronary narrowing Medical Specialty Radiology Sample Name Mayoview 2 Transcription LEXISCAN MYOVIEW STRESS STUDY REASON FOR THE EXAM Chest discomfort INTERPRETATION The patient exercised according to the Lexiscan study received a total of 0 4 mg of Lexiscan IV injection At peak hyperemic effect 24 9 mCi of Myoview were injected for the stress imaging and earlier 8 2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars Sinai software The patient did not walk because of prior history of inability to exercise long enough on treadmill The resting heart rate was 57 with the resting blood pressure 143 94 Maximum heart rate achieved was 90 with a maximum blood pressure unchanged EKG at rest showed sinus rhythm with no significant ST T wave changes of reversible ischemia or injury Subtle nonspecific in III and aVF were seen Maximum stress test EKG showed inverted T wave from V4 to V6 Normal response to Lexiscan CONCLUSION Maximal Lexiscan perfusion with subtle abnormalities non conclusive Please refer to the Myoview interpretation MYOVIEW INTERPRETATION The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end diastolic volume of 115 and end systolic of 51 EF estimated and calculated at 56 Cardiac perfusion reviewed showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring IMPRESSION 1 Normal stress rest cardiac perfusion with no indication of ischemia 2 Normal LV function and low likelihood of significant epicardial coronary narrowing Keywords radiology chest discomfort lexiscan myoview stress study mci spect gated spect myoview lexiscan stress test ekg lexiscan myoview lv function coronary narrowing heart rate blood pressure myoview interpretation cardiac perfusion cardiac ischemia perfusion stress MEDICAL_TRANSCRIPTION,Description Left lower extremity venous Doppler ultrasound Medical Specialty Radiology Sample Name Lower Extremity Venous Doppler Transcription LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND REASON FOR EXAM Status post delivery five weeks ago presenting with left calf pain INTERPRETATIONS There was normal flow compression and augmentation within the right common femoral superficial femoral and popliteal veins Lymph nodes within the left inguinal region measure up to 1 cm in short axis IMPRESSION Lymph nodes within the left inguinal region measure up to 1 cm in short axis otherwise no evidence for left lower extremity venous thrombosis Keywords radiology popliteal veins superficial femoral common femoral inguinal region lymph nodes venous doppler lower extremity lymph inguinal axis doppler extremity venous MEDICAL_TRANSCRIPTION,Description Lexiscan Nuclear Myocardial Perfusion Scan Chest pain Patient unable to walk on a treadmill Nondiagnostic Lexiscan Normal nuclear myocardial perfusion scan Medical Specialty Radiology Sample Name Lexiscan Nuclear Scan Transcription EXAM Lexiscan Nuclear Myocardial Perfusion Scan INDICATION Chest pain TYPE OF TEST Lexiscan unable to walk on a treadmill INTERPRETATION Resting heart rate of 96 blood pressure of 141 76 EKG normal sinus rhythm nonspecific ST T changes left bundle branch block Post Lexiscan 0 4 mg injected intravenously by standard protocol Peak heart rate was 105 blood pressure of 135 72 EKG remains the same No symptoms are noted SUMMARY 1 Nondiagnostic Lexiscan 2 Nuclear interpretation as below NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL Resting and stress images were obtained with 10 4 32 5 mCi of tetrofosmin injected intravenously by standard protocol Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake There is no evidence of reversible or fixed defect Gated SPECT revealed mild global hypokinesis more pronounced in the septal wall possibly secondary to prior surgery Ejection fraction calculated at 41 End diastolic volume of 115 end systolic volume of 68 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction 41 by gated SPECT Keywords radiology lexiscan nuclear myocardial perfusion scan treadmill bundle branch block mci tetrofosmin nuclear myocardial perfusion scan blood pressure gated spect ejection fraction myocardial perfusion ejection fraction myocardial lexiscan nuclear MEDICAL_TRANSCRIPTION,Description Myoview nuclear stress study Angina coronary artery disease Large fixed defect inferior and apical wall related to old myocardial infarction Medical Specialty Radiology Sample Name Mayoview 1 Transcription MYOVIEW NUCLEAR STRESS STUDY REASON FOR THE TEST Angina coronary artery disease FINDINGS The patient exercised according to the Lexiscan nuclear stress study received a total of 0 4 mg of Lexiscan At peak hyperemic effect 25 8 mCi of Myoview injected for the stress imaging and earlier 8 1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest stress sequence The data analyzed using Cedars Sinai software The resting heart rate was 49 with the resting blood pressure of 149 86 Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172 76 EKG at rest showed to be abnormal with sinus rhythm left atrial enlargement and inverted T wave in 1 2 and aVL as well as from V4 to V6 with LVH Maximal stress test EKG showed no change from baseline IMPRESSION Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test please refer to the Myoview interpretation MYOVIEW INTERPRETATIONS FINDINGS The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end diastolic volume of 227 end systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall EF was calculated at 32 estimated 35 to 40 Cardiac perfusion reviewed showed a large area of moderate to severe intensity in the inferior wall and small to medium area of severe intensity at the apex and inferoapical wall Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI No reversible defects indicative of myocardium at risk The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near normal perfusion IMPRESSION 1 Large fixed defect inferior and apical wall related to old myocardial infarction 2 No reversible ischemia identified 3 Moderately reduced left ventricular function with ejection fraction of about 35 consistent with ischemic cardiomyopathy Keywords radiology myoview myoview interpretations spect gated spect protocol myoview nuclear stress study nuclear stress study stress study stress test stress lexiscan ekg inferoapical angina wall resting MEDICAL_TRANSCRIPTION,Description Magnified Airway Study An 11 month old female with episodes of difficulty in breathing cough Medical Specialty Radiology Sample Name Magnified Airway Study Transcription EXAM Magnified airway CLINICAL HISTORY An 11 month old female with episodes of difficulty in breathing cough TECHNIQUE Multiple fluoroscopic spot images of the pharyngeal airway trachea and mainstem bronchi were performed in various phases of respiration FINDINGS The airway is patent throughout its course Specifically the trachea and both mainstem bronchi do not demonstrate evidence of dynamic collapse greater than 50 No filling defects are identified The vocal cords demonstrate normal opening and closing IMPRESSION Normal magnified airway examination Keywords radiology magnified airway study difficulty in breathing airway study breathing cough mainstem bronchi magnified airway cough trachea mainstem bronchi airway MEDICAL_TRANSCRIPTION,Description Lumbar discogram L2 3 L3 4 L4 5 and L5 S1 Low back pain Medical Specialty Radiology Sample Name Lumbar Discogram Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE PERFORMED 1 Lumbar discogram L2 3 2 Lumbar discogram L3 4 3 Lumbar discogram L4 5 4 Lumbar discogram L5 S1 ANESTHESIA IV sedation PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed prone onto a radiolucent table The C arm was brought into the operative field and AP left right oblique and lateral fluoroscopic images of the L1 2 through L5 S1 levels were obtained We then proceeded to prepare the low back with a Betadine solution and draped sterile Using an oblique approach to the spine the L5 S1 level was addressed using an oblique projection angled C arm in order to allow for perpendicular penetration of the disc space A metallic marker was then placed laterally and a needle entrance point was determined A skin wheal was raised with 1 Xylocaine and an 18 gauge needle was advanced up to the level of the disc space using AP oblique and lateral fluoroscopic projections A second needle 22 gauge 6 inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections was placed into the center of the nucleus We then proceeded to perform a similar placement of needles at the L4 5 L3 4 and L2 3 levels A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting we then proceeded to inject the disc spaces sequentially Keywords radiology back pain c arm fluoroscopic projections disc space lumbar discogram fluoroscopic needle MEDICAL_TRANSCRIPTION,Description Resting Myoview and adenosine Myoview SPECT Medical Specialty Radiology Sample Name Mayoview Transcription PROCEDURE DONE Resting Myoview and adenosine Myoview SPECT INDICATIONS Chest pain PROCEDURE 13 3 mCi of Tc 99m tetrofosmin was injected and resting Myoview SPECT was obtained Pharmacologic stress testing was done using adenosine infusion Patient received 38 mg of adenosine infused at 140 mcg kg minute over a period of four minutes Two minutes during adenosine infusion 31 6 mCi of Tc 99m tetrofosmin was injected Resting heart rate was 90 beats per minute Resting blood pressure was 130 70 Peak heart rate obtained during adenosine infusion was 102 beats per minute Blood pressure obtained during adenosine infusion was 112 70 During adenosine infusion patient experienced dizziness and shortness of breath No significant ST segment T wave changes or arrhythmias were seen Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77 Lung heart ratio was 0 40 TID ratio was 0 88 IMPRESSION Normal adenosine Myoview myocardial perfusion SPECT Normal left ventricular regional and global function with left ventricular ejection fraction of 77 Keywords radiology myoview gated dynamic imaging myoview spect resting myoview spect tc 99m adenosine myoview adenosine infusion ejection fraction myocardium systolic thickening tetrofosmin adenosine myoview spect adenosine MEDICAL_TRANSCRIPTION,Description Lower Extremity Arterial Doppler Medical Specialty Radiology Sample Name Lower Extremity Arterial Doppler Transcription RIGHT LOWER EXTREMITY The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0 8 LEFT LOWER EXTREMITY The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery with biphasic waveform at the posterior tibial artery Ankle brachial index of 0 9 IMPRESSION Mild bilateral lower extremity arterial obstructive disease Keywords radiology lower extremity arterial doppler posterior tibial artery ankle brachial index arterial doppler triphasic waveform common femoral biphasic waveform tibial artery ankle brachial brachial index lower extremity doppler triphasic femoral popliteal brachial waveform extremity arterial MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and drainage of cyst Medical Specialty Radiology Sample Name Laparoscopy Drainage of Cyst Transcription PREOPERATIVE DIAGNOSIS Ovarian cyst persistent POSTOPERATIVE DIAGNOSIS Ovarian cyst ANESTHESIA General NAME OF OPERATION Diagnostic laparoscopy and drainage of cyst PROCEDURE The patient was taken to the operating room prepped and draped in the usual manner and adequate anesthesia was induced An infraumbilical incision was made and Veress needle placed without difficulty Gas was entered into the abdomen at two liters The laparoscope was entered and the abdomen was visualized The second puncture site was made and the second trocar placed without difficulty The cyst was noted on the left a 3 cm ovarian cyst This was needled and a hole cut in it with the scissors Hemostasis was intact Instruments were removed The patient was awakened and taken to the recovery room in good condition Keywords radiology ovarian cyst infraumbilical incision drainage of cyst diagnostic laparoscopy laparoscopy drainage ovarian MEDICAL_TRANSCRIPTION,Description Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome Medical Specialty Radiology Sample Name IV Procainamide Infusion Transcription PREOPERATIVE DIAGNOSIS Syncopal episodes with injury See electrophysiology consultation POSTOPERATIVE DIAGNOSES 1 Normal electrophysiologic studies 2 No inducible arrhythmia 3 Procainamide infusion negative for Brugada syndrome PROCEDURES 1 Comprehensive electrophysiology studies with attempted arrhythmia induction 2 IV Procainamide infusion for Brugada syndrome DESCRIPTION OF PROCEDURE The patient gave informed consent for comprehensive electrophysiologic studies She received small amounts of intravenous fentanyl and Versed for conscious sedation Then 1 lidocaine local anesthesia was used Three catheters were placed via the right femoral vein 5 French catheters to the right ventricular apex and right atrial appendage and a 6 French catheter to the His bundle Later in the procedure the RV apical catheter was moved to RV outflow tract ELECTROPHYSIOLOGICAL FINDINGS Conduction intervals in sinus rhythm were normal Sinus cycle length 768 ms PA interval 24 ms AH interval 150 ms HV interval 46 ms Sinus node recovery times were also normal at 1114 ms Corrected sinus node recovery time was normal at 330 ms One to one AV conduction was present to cycle length 480 ms AH interval 240 ms HV interval 54 ms AV nodal effective refractory period was normal 440 ms at drive cycle length 600 ms RA ERP was 250 ms With ventricular pacing there was VA disassociation present Since there was no evidence for dual AV nodal pathways and poor retrograde conduction isoproterenol infusion was not performed to look for SVT Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts Drive cycle length 600 500 and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms or refractoriness There was no inducible VT Longest run was 5 beats of polymorphic VT which is a nonspecific finding From the apex 400 600 with 2 extrastimuli were delivered again with no inducible VT Procainamide was then infused 20 mg kg over 10 minutes There were no ST segment changes HV interval after IV Procainamide remained normal at 50 ms ASSESSMENT Normal electrophysiologic studies No evidence for sinus node dysfunction or atrioventricular block No inducible supraventricular tachycardia or ventricular tachycardia and no evidence for Brugada syndrome PLAN The patient will follow up with Dr X She recently had an ambulatory EEG I will plan to see her again on a p r n basis should she develop a recurrent syncopal episodes Reveal event monitor was considered but not placed since she has only had one single episode Keywords radiology arrhythmia attempted arrhythmia induction conduction sinus rhythm electrophysiologic studies sinus node iv procainamide brugada syndrome electrophysiology sinus ventricular MEDICAL_TRANSCRIPTION,Description Nuclear Medicine Therapy Intraarterial Particulate Administration Medical Specialty Radiology Sample Name Intraarterial Particulate Administration Transcription EXAM Therapy intraarterial particulate administration HISTORY Hepatocellular carcinoma TECHNIQUE The patient was brought to the interventional radiology suite where catheterization of the right hepatic artery was performed The patient had previously given oral and written consent to the radioembolization procedure After confirmation of proper positioning of the hepatic artery catheter 3 78 GBq of yttrium 90 TheraSphere microspheres were infused through the catheter under strict radiation safety procedures FINDINGS There were no apparent complications Using data on tumor burden right lobe liver volume vascularity of the tumor obtained from angiography and quantitative CT and measurement of residual activity tumor the expected radiation dose to the tumor burden in the right lobe of the liver was calculated at 201 Gy The expected dose to the remaining right liver parenchyma is 30 Gy Following the procedure there was no evidence of radioactive contamination of the room equipment or personnel IMPRESSION Radioembolization therapy of hepatocellular carcinoma in the right lobe of the liver using 3 78 GBq of yttrium 90 microspheres TheraSphere Keywords radiology lobe of the liver intraarterial particulate administration hepatocellular carcinoma hepatic artery tumor burden particulate administration hepatocellular carcinoma hepatic artery radioembolization therasphere microspheres radiation gy therapy particulate administration catheterization tumor liver intraarterial MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with cholangiogram Acute gangrenous cholecystitis with cholelithiasis The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder Medical Specialty Radiology Sample Name Laparoscopic Cholecystectomy Cholangiogram Transcription PREOPERATIVE DIAGNOSIS Acute cholecystitis POSTOPERATIVE DIAGNOSIS Acute gangrenous cholecystitis with cholelithiasis OPERATION PERFORMED Laparoscopic cholecystectomy with cholangiogram FINDINGS The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder COMPLICATIONS None EBL Scant SPECIMEN REMOVED Gallbladder with stones DESCRIPTION OF PROCEDURE The patient was prepped and draped in the usual sterile fashion under general anesthesia A curvilinear incision was made below the umbilicus Through this incision the camera port was able to be placed into the peritoneal cavity under direct visualization Once this complete insufflation was begun Once insufflation was adequate additional ports were placed in the epigastrium as well as right upper quadrant Once all four ports were placed the right upper quadrant was then explored The patient had significant adhesions of omentum and colon to the liver the gallbladder constituting definitely an acute cholecystitis This was taken down using Bovie cautery to free up visualization of the gallbladder The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall Adhesions were further taken down between the omentum the colon and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area Once the adhesions were fully removed the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction At this point due to the patient s gallbladder being very necrotic it was deemed that the patient should have a drain placed The cystic duct and cystic artery were serially clipped and transected The gallbladder was removed from the gallbladder fossa removing the entire gallbladder Adequate hemostasis with Bovie cautery was achieved The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3 0 nylon suture Next the right upper quadrant was copiously irrigated out using the suction irrigator Once this was complete the additional ports were able to be removed The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure of 8 fashion All skin incisions were injected using Marcaine 1 4 percent plain The skin was reapproximated further using 4 0 Monocryl sutures in a subcuticular technique The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition Keywords radiology acute cholecystitis cholangiogram cholelithiasis cholecystitis gallbladder gangrenous cholecystitis bovie cautery cystic duct laparoscopic cholecystectomy laparoscopic cholecystectomy cystic duct MEDICAL_TRANSCRIPTION,Description Sellar HCT Pituitary mass Medical Specialty Radiology Sample Name HCT Pituitary Mass Transcription CC HA and vision loss HX 71 y o RHM developed a cataclysmic headache on 11 5 92 associated with a violent sneeze The headache lasted 3 4 days On 11 7 92 he had acute pain and loss of vision in the left eye Over the following day his left pupil enlarged and his left upper eyelid began to droop He was seen locally and a brain CT showed no sign of bleeding but a tortuous left middle cerebral artery was visualized The patient was transferred to UIHC 11 12 92 FHX HTN stroke coronary artery disease melanoma SHX Quit smoking 15 years ago MEDS Lanoxin Capoten Lasix KCL ASA Voltaren Alupent MDI PMH CHF Atrial Fibrillation Obesity Anemia Duodenal Ulcer Spinal AVM resection 1986 with residual T9 sensory level hyperreflexia and bilateral babinski signs COPD EXAM 35 5C BP 140 91 P86 RR20 Alert and oriented to person place and time CN No light perception OS Pupils 3 7 decreasing to 2 7 on exposure to light i e fixed dilated pupil OS Upon neutral gaze the left eye deviated laterally and inferiorly There was complete ptosis OS On downward gaze their was intorsion OS The left eye could not move superiorly medially or effectively downward but could move laterally EOM were full OD The rest of the CN exam was unremarkable Motor Coordination Station and Gait testing were unremarkable Sensory exam revealed decreased pinprick and light touch below T9 old Muscle stretch reflexes were increased 3 3 in both lower extremities and there were bilateral babinski signs old The upper extremity reflexes were symmetrical 2 2 Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally The rest of the general exam was unremarkable LAB CBC PT PTT General Screen were unremarkable except for a BUN 21mg DL CSF protein 88mg DL glucose 58mg DL RBC 2800 mm3 WBC 1 mm3 ANA RF TSH FT4 were WNL IMPRESSION CN3 palsy and loss of vision Differential diagnosis temporal arteritis aneurysm intracranial mass COURSE The outside Brain CT revealed a tortuous left MCA A four vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA There was no evidence of aneursym Transesophageal Echocardiogram revealed atrial enlargement only Neuroopthalmologic evaluation revealed Loss of color vision and visual acuity OS RAPD OS bilateral optic disk pallor OS OD CN3 palsy and bilateral temporal field loss OS OD ESR CRP MRI were recommended to rule out temporal arteritis and intracranial mass ESR 29mm Hr CRP 4 3mg DL high The patient was placed on prednisone Temporal artery biopsy showed no evidence of vasculitis MRI scan could not be obtained due to patient weight Sellar CT was done instead coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass In retrospect sellar enlargement could be seen on the angiogram X rays Differential consideration was given to cystic pituitary adenoma noncalcified craniopharyngioma or Rathke s cleft cyst with solid component The patient refused surgery He was seen in Neuroopthalmology Clinic 2 18 93 and was found to have mild recovery of vision OS and improved visual fields Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil OS on adduction downgaze and upgaze The upper eyelid OS elevated on adduction and down gaze OS EOM movements were otherwise full and there was no evidence of ptosis In retrospect he was felt to have suffered pituitary apoplexy in 11 92 Keywords radiology sellar hct htn pituitary aneurysm brain ct cataclysmic coronary artery disease headache intracranial mass loss of vision mass melanoma palsy sneeze stroke temporal arteritis vision loss bilateral babinski signs sellar enlargement pituitary mass temporal vision MEDICAL_TRANSCRIPTION,Description Intensity modulated radiation therapy simulation note The patient will receive intensity modulated radiation therapy in order to deliver high dose treatment to sensitive structures Medical Specialty Radiology Sample Name Intensity Modulated Radiation Therapy Simulation Transcription INTENSITY MODULATED RADIATION THERAPY SIMULATION The patient will receive intensity modulated radiation therapy in order to deliver high dose treatment to sensitive structures The target volume is adjacent to significant radiosensitive structures Initially the preliminary isocenter is set on a fluoroscopically based simulation unit The patient is appropriately immobilized using a customized immobilization device Preliminary simulation films are obtained and approved by me The patient is marked and transferred to the CT scanner Sequential images are obtained and transferred electronically to the treatment planning software Extensive analysis then occurs The target volume including margins for uncertainty patient movement and occult tumor extension are selected In addition organs at risk are outlined Appropriate doses are selected both for the target as well as constraints for organs at risk Inverse treatment planning is performed by the physics staff under my supervision These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance Keywords radiology target volume intensity modulated radiation therapy simulationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right upper quadrant pain Nuclear medicine hepatobiliary scan Radiopharmaceutical 6 9 mCi of Technetium 99m Choletec Medical Specialty Radiology Sample Name Hepatobiliary Scan Transcription NUCLEAR MEDICINE HEPATOBILIARY SCAN REASON FOR EXAM Right upper quadrant pain COMPARISONS CT of the abdomen dated 02 13 09 and ultrasound of the abdomen dated 02 13 09 Radiopharmaceutical 6 9 mCi of Technetium 99m Choletec FINDINGS Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time There is normal accumulation within the gallbladder After the injection of 2 1 mcg of intravenous cholecystic _______ the gallbladder ejection fraction at 30 minutes was calculated to be 32 normal is greater than 35 The patient experienced 2 10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea IMPRESSION 1 Negative for acute cholecystitis or cystic duct obstruction 2 Gallbladder ejection fraction just under the lower limits of normal at 32 that can be seen with very mild chronic cholecystitis Keywords radiology radiopharmaceutical gallbladder ejection fraction nuclear medicine hepatobiliary hepatobiliary scan quadrant nuclear technetium choletec ejection fraction cholecystitis scan abdomen injection gallbladder hepatobiliary medicine MEDICAL_TRANSCRIPTION,Description Intensity modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices Medical Specialty Radiology Sample Name Intensity Modulated Radiation Therapy Transcription INTENSITY MODULATED RADIATION THERAPY Intensity modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices The treatment planning process requires at least 4 hours of physician time The technology is appropriate in this patient s case due to the fact that the target volume is adjacent to significant radiosensitive structures Sequential CT scans are obtained and transferred to the treatment planning software Extensive analysis occurs The target volumes including margins for uncertainty patient movement and occult tumor extension are selected In addition organs at risk are outlined Doses are selected both for targets as well as for organs at risk Associated dose constraints are placed Inverse treatment planning is then performed in conjunction with the physics staff These are reviewed by the physician and ultimately performed only following approval by the physician Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease while minimizing exposure to organs at risk This is performed in hopes of minimizing associated complications The physician delineates the treatment type number of fractions and total volume During the time of treatment there is extensive physician intervention monitoring the patient set up and tolerance In addition specific QA is performed by the physics staff under the physician s direction In view of the above the special procedure code 77470 is deemed appropriate Keywords radiology multiple beam arrangements intensity modulated radiation therapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral Screening Mammogram Full Field Digital Mammography FFDM Benign Findings Medical Specialty Radiology Sample Name Full Field Digital Mammogram FFDM 1 Transcription EXAM Digital screening mammogram HISTORY 51 year old female presents for screening mammography Patient denies personal history of breast cancer Breast cancer was reported in her maternal aunt TECHNIQUE Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm dd yy Comparison is made with the previous performed on mm dd yy iCAD Second Look proprietary software was utilized FINDINGS The breasts demonstrate a mixture of adipose and fibroglandular elements Composition appears similar Multiple tiny punctate benign appearing calcifications are visualized bilaterally No dominant mass areas of architecture distortion or malignant type calcifications are seen Skin overlying both breasts is unremarkable IMPRESSION Stable and benign mammographic findings Continued yearly mammographic screening is recommended BIRADS Classification 2 Benign MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD SecondLook Software Version 7 2 was utilized Keywords radiology mediolateral craniocaudal fibroglandular bilateral screening mammogram breast cancer screening mammogram mammographic mammogram breasts screening mammography MEDICAL_TRANSCRIPTION,Description Hyperfractionation This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy Medical Specialty Radiology Sample Name Hyperfractionation Transcription HYPERFRACTIONATION This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy The radiotherapy will be given in a hyperfractionated fraction decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing previously irradiated or poorly oxygenated tumors The dose per fraction and the total dose are calculated by me and this is individualized for each patient according to radiobiologic principles During the hyperfractionated radiotherapy the chance of severe acute side effects is increased so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly Keywords radiology irradiated oxygenated tumors malignancy radiobiologic hyperfractionation hyperfractionated radiotherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Sample Radiology report of knee growth arrest lines Medical Specialty Radiology Sample Name Five views of the right knee Transcription EXAM Five views of the right knee HISTORY Pain The patient is status post surgery he could not straighten his leg pain in the back of the knee TECHNIQUE Five views of the right knee were evaluated There are no priors for comparison FINDINGS Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures dislocations or subluxations There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia There is also appearance of a high riding patella suggestive of patella alta IMPRESSION 1 No evidence of any displaced fractures dislocations or subluxations 2 Growth arrest lines seen in the distal femur and proximal tibia 3 Questionable appearance of a slightly high riding patella possibly suggesting patella alta Keywords radiology fractures dislocations or subluxations femur and proximal growth arrest lines patella alta fractures dislocations subluxations distal femur patella MEDICAL_TRANSCRIPTION,Description HDR Brachytherapy Medical Specialty Radiology Sample Name HDR Brachytherapy Transcription HDR BRACHYTHERAPY The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified Simulation films were obtained documenting its positioning The 3 dimensional treatment planning process was accomplished utilizing the CT derived data A treatment plan was selected utilizing sequential dwell positions within a single catheter The patient was taken to the treatment area The patient was appropriately positioned and the position of the intracavitary device was checked Catheter length measurements were taken Appropriate measurements of the probe dimensions and assembly were also performed The applicator was attached to the HDR after loader device The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication The brachytherapy source was appropriately removed back to the brachytherapy safe within the device Radiation screening was performed with the Geiger Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate Following completion of the procedure the intracavitary device was removed without difficulty The patient was in no apparent distress and was discharged home Keywords radiology geiger muller treatment planning hdr brachytherapy intracavitary applicator brachytherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Mammogram bilateral full field digital mammography FFDM patient with positive history of breast cancer Medical Specialty Radiology Sample Name Full Field Digital Mammogram FFDM 2 Transcription EXAM Screening full field digital mammogram HISTORY Screening examination of a 58 year old female who currently denies complaints Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy The patient s sister was also diagnosed with breast cancer at the age of 59 TECHNIQUE Standard digital mammographic imaging was performed The examination was performed with iCAD Second Look Version 7 2 COMPARISON Most recently obtained __________ FINDINGS The right breast is again smaller than the left There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously dense fibroglandular tissue There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes A few benign appearing microcalcifications are present No dominant malignant appearing mass lesion developing area of architectural distortion or suspicious appearing cluster of microcalcifications are identified The skin is stable No enlarged axillary lymph node is seen IMPRESSION 1 No significant interval changes are seen No mammographic evidence of malignancy is identified 2 Annual screening mammography is recommended or sooner if clinical symptoms warrant BIRADS Classification 2 Benign MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD Second Look Software Version 7 2 was utilized Keywords radiology digital mammography full field digital mammogram ffdm second look version field digital mammogram digital mammogram breast cancer mammographic icad microcalcifications mammogram screening digital mammography breast MEDICAL_TRANSCRIPTION,Description Bilateral facet Arthrogram and injections at L34 L45 L5S1 Interpretation of radiograph Low Back Syndrome Low Back Pain Medical Specialty Radiology Sample Name Facet Arthrogram Injection Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low Back Pain POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Bilateral facet Arthrogram at L34 L45 L5S1 2 Bilateral facet injections at L34 L45 L5S1 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x ray studies and imaging scans SUMMARY OF PROCEDURE The patient was admitted to the OR consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain EKG respiration and heart rate and at intervals of three minutes for blood pressure After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view A skin wheal was placed with 1 Lidocaine at the L34 facet region on the left Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side This was performed using the oblique view under fluoroscopy to the enable the view of the Scotty Dog After obtaining the Scotty Dog view the joints were easily seen Negative aspiration was carefully performed to verity that there was no venous arterial or cerebral spinal fluid flow After negative aspiration was verified 1 8th of a cc of Omnipaque 240 dye was then injected Negative aspiration was again performed and 1 2 cc of solution Solution consisting of 9 cc of 0 5 Marcaine with 1 cc of Triamcinolone was then injected into the joint The needle was then withdrawn out of the joint and 1 5 cc of this same solution was injected around the joint The 22 gauge needle was then removed Pressure was place over the puncture site for approximately one minute This exact same procedure was then repeated along the left sided facets at L45 and L5S1 This exact same procedure was then repeated on the right side At each level vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid The patient was noted to have tolerated the procedure well without any complications Interpretation of the radiograph revealed placement of the 22 gauge spinal needles into the left sided and right sided facet joints at L34 L45 and L5S1 Visualizing the Scotty Dog technique under fluoroscopy facilitated this Dye spread into each joint space is visualized No venous or arterial run off is noted No epidural run off is noted The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis Keywords radiology low back syndrome low back pain facet injection fluoroscopy iv sedation spinal fluid facet arthrogram aspiration arthrogram injection facet MEDICAL_TRANSCRIPTION,Description HCT for memory loss and for calcification of basal ganglia globus pallidi Medical Specialty Radiology Sample Name HCT Calcification of Basal Ganglia Transcription CC Memory loss HX This 77 y o RHF presented with a one year history of progressive memory loss Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8 15AM Sunday morning That Sunday she went to pick up her sister at her sister s home and when her sister was not there because the sister had gone to pick up the patient the patient left She later called the sister and asked her if she sister had overslept During her UIHC evaluation she denied she knew anything about the incident No other complaints were brought forth by the patients family PMH Unremarkable MEDS None FHX Father died of an MI Mother had DM type II SHX Denies ETOH illicit drug Tobacco use ROS Unremarkable EXAM Afebrile 80BPM BP 158 98 16RPM Alert and oriented to person place time Euthymic 29 30 on Folstein s MMSE with deficit on drawing Recalled 2 6 objects at five minutes and could not recite a list of 6 objects in 6 trials Digit span was five forward and three backward CN mild right lower facial droop only MOTOR Full strength throughout SENSORY No deficits to PP Vib Prop LT Temp COORD Poor RAM in LUE only GAIT NB and ambulated without difficulty STATION No drift or Romberg sign REFLEXES 3 bilaterally with flexor plantar responses There were no frontal release signs LABS CMB General Screen FT4 TSH VDRL were all WNL NEUROPSYCHOLOGICAL EVALUATION 12 7 92 Verbal associative fluency was defective Verbal memory including acquisition and delayed recall and recognition was severely impaired Visual memory including immediate and delayed recall was also severely impaired Visuoperceptual discrimination was mildly impaired as was 2 D constructional praxis HCT 12 7 92 Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient s age Calcification is seen in both globus pallidi and this was felt to be a normal variant Keywords radiology memory loss romberg sign hct cerebral atrophy calcification of basal ganglia basal ganglia globus pallidi basal ganglia globus pallidi calcification MEDICAL_TRANSCRIPTION,Description Exercise myocardial perfusion study The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59 Medical Specialty Radiology Sample Name Exercise Myocardial Perfusion Study Transcription CLINICAL INDICATION Chest pain INTERPRETATION The patient received 14 9 mCi of Cardiolite for the rest portion of the study and 11 5 mCi of Cardiolite for the stress portion of the study The patient s baseline EKG was normal sinus rhythm The patient was stressed according to Bruce protocol by Dr X Exercise test was supervised and interpreted by Dr X Please see the separate report for stress portion of the study The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen which is most likely secondary to soft tissue attenuation artifact There is however mild partially reversible perfusion defect seen which is more pronounced in the stress images and short axis view suggestive of minimal ischemia in the inferolateral wall The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59 CONCLUSION 1 The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall 2 Normal LV systolic function with LV ejection fraction of 59 Keywords radiology chest pain cardiolite ekg spect lv systolic function lv ejection fraction myocardial perfusion study spect study ejection fraction myocardial perfusion ischemia MEDICAL_TRANSCRIPTION,Description Endovascular Brachytherapy EBT Medical Specialty Radiology Sample Name Endovascular Brachytherapy Transcription ENDOVASCULAR BRACHYTHERAPY EBT The patient is to undergo a course of angioplasty for in stent restenosis The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site After this a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function Keywords radiology endovascular brachytherapy ebt angioplasty stent vessel atherectomy endovascular brachytherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient is status post C3 C4 anterior cervical discectomy and fusion Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 5 Transcription She has an extensive past medical history of rheumatoid arthritis fibromyalgia hypertension hypercholesterolemia and irritable bowel syndrome She has also had bilateral carpal tunnel release On examination normal range of movement of C spine She has full strength in upper and lower extremities Normal straight leg raising Reflexes are 2 and symmetric throughout No Babinski She has numbness to light touch in her right big toe NERVE CONDUCTION STUDIES The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude Bilateral tibial motor nerves could not be obtained technical The remaining nerves tested revealed normal distal latencies evoked response amplitudes conduction velocities F waves and H reflexes NEEDLE EMG Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI It revealed 2 spontaneous activity in the right APB and FDI and 1 spontaneous activity in lower cervical paraspinals lower and middle lumbosacral paraspinals right extensor digitorum communis muscle and right pronator teres There was evidence of chronic denervation in the right first dorsal interosseous pronator teres abductor pollicis brevis and left first dorsal interosseous IMPRESSION This electrical study is abnormal It reveals the following 1 An active right C8 T1 radiculopathy Electrical abnormalities are moderate 2 An active right C6 C7 radiculopathy Electrical abnormalities are mild 3 Evidence of chronic left C8 T1 denervation No active denervation 4 Mild right lumbosacral radiculopathies This could not be further localized because of normal EMG testing in the lower extremity muscles 5 There is evidence of mild sensory carpal tunnel on the right she has had previous carpal tunnel release Results were discussed with the patient It appears that she has failed conservative therapy and I have recommended to her that she return to Dr X for his assessment for possible surgery to her C spine She will continue with conservative therapy for the mild lumbosacral radiculopathies Keywords radiology emg nerve conduction study needle emg paraspinal muscles radiculopathy electrical abnormalities carpal tunnel release evoked response lumbosacral radiculopathies conservative therapy carpal tunnel conduction emg nerve MEDICAL_TRANSCRIPTION,Description The patient is a 39 year old gravida 3 para 2 who is now at 20 weeks and 2 days gestation This pregnancy is a twin gestation The patient presents for her fetal anatomical survey Medical Specialty Radiology Sample Name Fetal Anatomical Survey Transcription PAST MEDICAL HISTORY The patient denies any significant past medical history PAST SURGICAL HISTORY The patient denies any significant surgical history MEDICATIONS The patient takes no medications ALLERGIES No known drug allergies SOCIAL HISTORY She denies use of cigarettes alcohol or drugs FAMILY HISTORY No family history of birth defects mental retardation or any psychiatric history DETAILS I performed a transabdominal ultrasound today using a 4 MHz transducer There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins The fetal biometry of twin A is as follows The biparietal diameter is 4 9 cm consistent with 20 weeks and 5 days head circumference 17 6 cm consistent with 20 weeks and 1 day the abdominal circumference is 15 0 cm consistent with 20 weeks and 2 days and femur length is 3 1 cm consistent with 19 weeks and 5 days and the humeral length is 3 0 cm consistent with 20 weeks and 0 day The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g The following structures are seen as normal on the fetal anatomical survey the shape of the fetal head the choroid plexuses the cerebellum nuchal fold thickness the fetal spine and fetal face the four chamber view of the fetal heart the outflow tracts of the fetal heart the stomach the kidneys and cord insertion site the bladder the extremities the genitalia the cord which appeared to have three vessels and the placenta Limited in views of baby A with a nasolabial region The following is the fetal biometry for twin B The biparietal diameter is 4 7 cm consistent with 20 weeks and 2 days head circumference 17 5 cm consistent with 20 weeks and 0 day the abdominal circumference is 15 5 cm consistent with 20 weeks and 5 days the femur length is 3 3 cm consistent with 20 weeks and 3 days and the humeral length is 3 1 cm consistent with 20 weeks and 2 days the average gestational age by ultrasound is 22 weeks and 2 days and the estimated fetal weight is 384 g The following structures were seen as normal on the fetal anatomical survey The shape of the fetal head the choroid plexuses the cerebellum nuchal fold thickness the fetal spine and fetal face the four chamber view of the fetal heart the outflow tracts of the fetal heart the stomach the kidneys and cord insertion site the bladder the extremities the genitalia the cord which appeared to have three vessels and the placenta Limited on today s ultrasound the views of nasolabial region In summary this is a twin gestation which may well be monochorionic at 20 weeks and 1 day There is like gender and a single placenta One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today I sat with the patient and her husband and discussed alternative findings and the complications We focused our discussion today on the association of twin pregnancy with preterm delivery We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks gestation while the average twin delivery occurs at 35 weeks gestation We discussed the fact that 15 of twins deliver prior to 32 weeks gestation These are the twins which we have the most concern regarding the long term prospects of prematurity We discussed several etiologies of preterm delivery including preterm labor incompetent cervix premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth We discussed the need for frequent office visits to screen for preeclampsia We also discussed treatment options such as cervical cerclage bedrest tocolytic medications and antenatal steroids I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well being In closing I do want to thank you very much for involving me in the care of your delightful patient I did review all of the above findings and recommendations with the patient today at the time of her visit Please do not hesitate to contact me if I could be of any further help to you Total visit time 40 minutes Keywords radiology vaginal delivery transducer transabdominal ultrasound placenta amniotic fluid fetal anatomical survey preterm delivery twin gestation gestation infant fetal anatomical delivery ultrasound MEDICAL_TRANSCRIPTION,Description A woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities Abnormal electrodiagnostic study Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 8 Transcription REFERRING DIAGNOSIS Motor neuron disease PERTINENT HISTORY AND EXAMINATION Briefly the patient is an 83 year old woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities SUMMARY The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity The right ulnar sensory amplitude was reduced with slowing of the conduction velocity The right radial sensory amplitude was reduced with slowing of the conduction velocity The right sural and left sural sensory responses were absent The right median motor response showed a prolonged distal latency across the wrist with proximal slowing The distal amplitude was very reduced and there was a reduction with proximal stimulation The right ulnar motor amplitude was borderline normal with slowing of the conduction velocity across the elbow The right common peroneal motor response showed a decreased amplitude when recorded from the EDB with mild slowing of the proximal conduction velocity across the knee The right tibial motor response showed a reduced amplitude with prolongation of the distal latency The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing The left tibial motor response showed a decreased amplitude with a borderline normal distal latency The minimum F wave latencies were normal with the exception of a mild prolongation of the ulnar F wave latency and the tibial F wave latency as indicated above With repetitive nerve stimulation there was no significant decrement noted in either the right nasalis or the right trapezius muscles Concentric needle EMG studies were performed in the right lower extremity right upper extremity thoracic paraspinals and in the tongue There was evidence of increased insertional activity in the right tibialis anterior muscle with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue In addition there was evidence of increased amplitude long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above INTERPRETATION Abnormal electrodiagnostic study There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow Even despite the patient s age the decrease in sensory responses is concerning and makes it difficult to be certain about the diagnosis of motor neuron disease However the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease The patient will return for further evaluation Keywords radiology electrodiagnostic study electrodiagnostic edb latency nerve conduction study emg motor neuron disease distal latency motor response motor amplitude conduction MEDICAL_TRANSCRIPTION,Description Common Excretory Urogram IVP template Medical Specialty Radiology Sample Name Excretory Urogram IVP Transcription There is normal and symmetrical filling of the caliceal system Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects The postvoid films demonstrate normal emptying of the collecting system including the urinary bladder IMPRESSION Negative intravenous urogram Keywords radiology intravenous urogram caliceal system urinary bladder excretory urogram collecting systems ivp urogram intravenousNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident with no specific injury at that time Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 3 Transcription HISTORY The patient is a 56 year old right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident in September of 2005 At that time she did not notice any specific injury Five days later she started getting abnormal right low back pain At this time it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf Symptoms are worse when sitting for any length of time such as driving a motor vehicle Mild symptoms when walking for long periods of time Relieved by standing and lying down She denies any left leg symptoms or right leg weakness No change in bowel or bladder function Symptoms have slowly progressed She has had Medrol Dosepak and analgesics which have not been very effective She underwent a spinal epidural injection which was effective for the first few hours but she had recurrence of the pain by the next day This was done four and a half weeks ago On examination lower extremities strength is full and symmetric Straight leg raising is normal OBJECTIVE Sensory examination is normal to all modalities Full range of movement of lumbosacral spine Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint Deep tendon reflexes are 2 and symmetric at the knees 2 at the left ankle and 1 at the right ankle NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the lower extremities Right tibial H reflex is slightly prolonged when compared to the left tibial H reflex NEEDLE EMG Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle There were signs of chronic denervation in right tibialis anterior peroneus longus gastrocnemius medialis and left gastrocnemius medialis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A mild right L5 versus S1 radiculopathy 2 Left S1 nerve root irritation There is no evidence of active radiculopathy 3 There is no evidence of plexopathy myopathy or peripheral neuropathy MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5 S1 neuroforaminal stenosis slightly worse on the right Results were discussed with the patient and her daughter I would recommend further course of spinal epidural injections with Dr XYZ If she has no response then surgery will need to be considered She agrees with this approach and will followup with you in the near future Keywords radiology emg nerve conduction study radiculopathy peripheral neuropathy nerve root irritation motor vehicle accident lumbosacral paraspinal muscles spinal epidural lumbosacral spine peroneus longus gastrocnemius medialis lower extremities emg nerve conduction needle MEDICAL_TRANSCRIPTION,Description Patient had movor vehicle accirdent and may have had a brief loss of consciousness Shortly thereafter she had some blurred vision Since that time she has had right low neck pain and left low back pain Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 7 Transcription HISTORY The patient is a 34 year old right handed female who states her symptoms first started after a motor vehicle accident in September 2005 She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision which lasted about a week and then resolved Since that time she has had right low neck pain and left low back pain She has been extensively worked up and treated for this MRI of the C T spine and LS spine has been normal She has improved significantly but still complains of pain In June of this year she had different symptoms which she feels are unrelated She had some chest pain and feeling of tightness in the left arm and leg and face By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg Symptoms lasted for about two days and then resolved However since that time she has had intermittent numbness in the left hand and leg The face numbness has completely resolved Symptoms are mild She denies any previous similar episodes She denies associated dizziness vision changes incoordination weakness change in gait or change in bowel or bladder function There is no associated headache Brief examination reveals normal motor examination with no pronator drift and no incoordination Normal gait Cranial nerves are intact Sensory examination reveals normal facial sensation She has normal and symmetrical light touch temperature and pinprick in the upper extremities In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot In this area she has normal light touch and pinprick She describes it as a strange unusual sensation NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the left arm and leg NEEDLE EMG Needle EMG was performed in the left leg lumbosacral paraspinal right tibialis anterior and right upper thoracic paraspinal muscles using a disposable concentric needle It revealed normal insertional activity no spontaneous activity and normal motor unit action potential form in all muscles tested IMPRESSION This electrical study is normal There is no evidence for peripheral neuropathy entrapment neuropathy plexopathy or lumbosacral radiculopathy EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident This was normal Based on her history of sudden onset of left face arm and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year Symptoms are now very mild but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms Once she has the test done she will phone me and further management will be based on the results Keywords radiology nerve conduction studies motor sensory distal latencies evoked response conduction velocities needle emg loss of consciousness motor vehicle accident thoracic paraspinal needle paraspinal conduction MEDICAL_TRANSCRIPTION,Description EMG Nerve Conduction Study showing sensory motor length dependent neuropathy consistent with diabetes severe left ulnar neuropathy and moderate to severe left median neuropathy Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 4 Transcription NERVE CONDUCTION STUDIES Bilateral ulnar sensory responses are absent Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude The left radial sensory response is normal and robust Left sural response is absent Left median motor distal latency is prolonged with attenuated evoked response amplitude Conduction velocity across the forearm is mildly slowed Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow Conduction velocities across the forearm and across the elbow are prolonged Conduction velocity proximal to the elbow is normal The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist There is mild diminution of response around the elbow Conduction velocity slows across the elbow The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head F waves are prolonged NEEDLE EMG Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle It revealed spontaneous activity in lower cervical paraspinals left abductor pollicis brevis and first dorsal interosseous muscles There were signs of chronic reinnervation in triceps extensor digitorum communis flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A sensory motor length dependent neuropathy consistent with diabetes 2 A severe left ulnar neuropathy This is probably at the elbow although definitive localization cannot be made 3 Moderate to severe left median neuropathy This is also probably at the carpal tunnel although definitive localization cannot be made 4 Right ulnar neuropathy at the elbow mild 5 Right median neuropathy at the wrist consistent with carpal tunnel syndrome moderate 6 A left C8 radiculopathy double crush syndrome 7 There is no evidence for thoracic radiculitis The patient has made very good response with respect to his abdominal pain since starting Neurontin He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch He is still scheduled for MRI of C spine and T spine I will see him in followup after the above scans Keywords radiology emg nerve conduction study nerve conduction studies needle emg electrical study neuropathy ulnar neuropathy median neuropathy severely attenuated evoked response normal evoked response amplitude attenuated evoked response amplitude median motor distal latency motor distal latency abductor pollicis pollicis brevis dorsal interosseous carpal tunnel conduction emg nerve needle MEDICAL_TRANSCRIPTION,Description Patient with a past medical history of a left L5 S1 lumbar microdiskectomy with complete resolution of left leg symptoms Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 6 Transcription HISTORY The patient is a 46 year old right handed gentleman with a past medical history of a left L5 S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms who now presents with a four month history of gradual onset of right sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle Symptoms are worsened by any activity and relieved by rest He also feels that when the pain is very severe he has some subtle right leg weakness No left leg symptoms No bowel or bladder changes On brief examination full strength in both lower extremities No sensory abnormalities Deep tendon reflexes are 2 and symmetric at the patellas and absent at both ankles Positive straight leg raising on the right MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5 S1 encroaching upon the right exiting S1 nerve root NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes and conduction velocities are normal in the lower extremities The right common peroneal F wave is minimally prolonged The right tibial H reflex is absent NEEDLE EMG Needle EMG was performed on the right leg left gastrocnemius medialis muscle and right lumbosacral paraspinal muscles using a disposable concentric needle It revealed spontaneous activity in the right gastrocnemius medialis gluteus maximus and lower lumbosacral paraspinal muscles There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles IMPRESSION This electrical study is abnormal It reveals an acute right S1 radiculopathy There is no evidence for peripheral neuropathy or left or right L5 radiculopathy Results were discussed with the patient and he is scheduled to follow up with Dr X in the near future Keywords radiology microdiskectomy needle emg nerve conduction studies lumbosacral paraspinal muscles lumbar microdiskectomy lower extremities lumbosacral paraspinal paraspinal muscles gluteus maximus leg symptoms gastrocnemius medialis emg nerve conduction lumbosacral needle gastrocnemius medialis muscles MEDICAL_TRANSCRIPTION,Description A ight handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 2 Transcription HISTORY The patient is a 78 year old right handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain which radiates down into her buttocks and down to posterior aspect of her thigh into her knee This has required large amounts of opioid analgesics to control She has been basically bedridden because of this She was brought into hospital for further investigations PHYSICAL EXAMINATION On examination she has positive straight leg rising on the right with severe shooting radicular type pain with right leg movement Difficult to assess individual muscles but strength is largely intact Sensory examination is symmetric Deep tendon reflexes reveal hyporeflexia in both patellae which probably represents a cervical myelopathy from prior cord compression She has slightly decreased right versus left ankle reflexes The Babinski s are positive On nerve conduction studies motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in lower extremities NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles There is evidence of denervation in right gastrocnemius medialis muscle IMPRESSION This electrical study is abnormal It reveals the following 1 Inactive right S1 L5 radiculopathy 2 There is no evidence of left lower extremity radiculopathy peripheral neuropathy or entrapment neuropathy Results were discussed with the patient and she is scheduled for imaging studies in the next day Keywords radiology needle emg radiculopathy electrical study emg nerve conduction study cervical spinal stenosis lumbosacral paraspinal muscles gastrocnemius medialis muscles spinal stenosis post decompression lumbosacral paraspinal paraspinal muscles gastrocnemius medialis medialis muscles decompression emg nerve conduction cervical spinal needle muscles MEDICAL_TRANSCRIPTION,Description This is a 95 5 hour continuous video EEG monitoring study Medical Specialty Radiology Sample Name EEG Monitoring Study Transcription TECHNICAL SUMMARY The patient was recorded from 2 15 p m on 08 21 06 through 1 55 p m on 08 25 06 The patient was recorded digitally using the 10 20 system of electrode placement Additional temporal electrodes and single channels of EOG and EKG were also recorded The patient s medications valproic acid Zonegran and Keppra were weaned progressively throughout the study The occipital dominant rhythm is 10 to 10 5 Hz and well regulated Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally HYPERVENTILATION There are no significant changes with 4 minutes of adequate overbreathing PHOTIC STIMULATION There are no significant changes with various frequencies of flickering light SLEEP There are no focal or lateralizing features and no abnormal waveforms INDUCED EVENT On the final day of study a placebo induction procedure was performed to induce a clinical event The patient was informed that we would be doing prolonged photic stimulation and hyperventilation which might induce a seizure At 1 38 p m the patient was instructed to begin hyperventilation Approximately four minutes later photic stimulation with random frequencies of flickering light was initiated Approximately 8 minutes into the procedure the patient became unresponsive to verbal questioning Approximately 1 minute later she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed She persisted with the shaking and some side to side movements of her head for approximately 1 minute before abruptly stopping Approximately 30 seconds later she became slowly responsive initially only uttering a few words and able to say her name When asked what had just occurred she replied that she was asleep and did not remember any event When later asked she did admit that this was consistent with the seizures she is experiencing at home EEG There are no significant changes to the character of the background EEG activity present in the minutes preceding during or following this event Of note while her eyes were closed and she was non responsive there is a well regulated occipital dominant rhythm present IMPRESSION The findings of this patient s 95 5 hour continuous video EEG monitoring study are within the range of normal variation No epileptiform activity is present One clinical event was induced with hyperventilation and photic stimulation The clinical features of this event are described in the technical summary above There was no epileptiform activity associated with this event This finding is consistent with a non epileptic pseudoseizure Keywords radiology video eeg monitoring study eog ekg abnormal waveforms photic stimulation hyperventilation eeg monitoring study eeg monitoring monitoring study eeg monitoring MEDICAL_TRANSCRIPTION,Description Echocardiographic Examination Report Angina and coronary artery disease Mild biatrial enlargement normal thickening of the left ventricle with mildly dilated ventricle and EF of 40 mild mitral regurgitation diastolic dysfunction grade 2 mild pulmonary hypertension Medical Specialty Radiology Sample Name Echocardiogram 3 Transcription REASON FOR EXAM 1 Angina 2 Coronary artery disease INTERPRETATION This is a technically acceptable study DIMENSIONS Anterior septal wall 1 2 posterior wall 1 2 left ventricular end diastolic 6 0 end systolic 4 7 The left atrium is 3 9 FINDINGS Left atrium was mildly to moderately dilated No masses or thrombi were seen The left ventricle was mildly dilated with mainly global hypokinesis more prominent in the inferior septum and inferoposterior wall The EF was moderately reduced with estimated EF of 40 with near normal thickening The right atrium was mildly dilated The right ventricle was normal in size Mitral valve showed to be structurally normal with no prolapse or vegetation There was mild mitral regurgitation on color flow interrogation The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction The aortic valve appeared to be structurally normal Normal peak velocity No significant AI Pulmonic valve showed mild PI Tricuspid valve showed mild tricuspid regurgitation Based on which the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg Anterior septum appeared to be intact No pericardial effusion was seen CONCLUSION 1 Mild biatrial enlargement 2 Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40 3 Mild mitral regurgitation 4 Diastolic dysfunction grade 2 5 Mild pulmonary hypertension Keywords radiology angina coronary artery disease septal ventricular diastolic systolic pulmonary hypertension mitral regurgitation septum tricuspid thickening dysfunction wall ef regurgitation atrium valve dilated mitral ventricle mildly MEDICAL_TRANSCRIPTION,Description Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position Medical Specialty Radiology Sample Name Electronystagmogram Transcription PROCEDURE This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear FINDINGS Gaze testing did not reveal any evidence of nystagmus Saccadic movements did not reveal any evidence of dysmetria or overshoot Sinusoidal tracking was performed well for the patient s age Optokinetic nystagmus testing was performed poorly due to the patient s difficulty in following the commands Therefore adequate OKNs were not achieved The Dix Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus which was converted to a right beating nystagmus when she sat up again The patient complained of severe dizziness in this position There was no clear cut decremental response with repetition In the head hanging left position no significant nystagmus was identified Positional testing in the supine head hanging head right head left right lateral decubitus and left lateral decubitus positions did not reveal any evidence of nystagmus Caloric stimulation revealed a calculated unilateral weakness of 7 0 on the right normal 20 and left beating directional preponderance of 6 0 normal 20 30 IMPRESSION Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position No other significant nystagmus was noted There was no evidence of clear cut caloric stimulation abnormality This study would be most consistent with a right vestibular dysfunction Keywords radiology silver chloride biopotential electrodes inferior orbital margins lateral canthi vestibular dysfunction prominent nystagmus head hanging electronystagmogram eyes nystagmus MEDICAL_TRANSCRIPTION,Description History of numbness in both big toes and up the lateral aspect of both calves She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness Medical Specialty Radiology Sample Name EMG Nerve Conduction Study Transcription HISTORY The patient is a 52 year old female with a past medical history of diet controlled diabetes diffuse arthritis plantar fasciitis and muscle cramps who presents with a few month history of numbness in both big toes and up the lateral aspect of both calves Symptoms worsened considerable about a month ago This normally occurs after being on her feet for any length of time She was started on amitriptyline and this has significantly improved her symptoms She is almost asymptomatic at present She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness On brief examination straight leg raising is normal The patient is obese There is mild decreased vibration and light touch in distal lower extremities Strength is full and symmetric Deep tendon reflexes at the knees are 2 and symmetric and absent at the ankles NERVE CONDUCTION STUDIES Bilateral sural sensory responses are absent Bilateral superficial sensory responses are present but mildly reduced The right radial sensory response is normal The right common peroneal and tibial motor responses are normal Bilateral H reflexes are absent NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle Lumbar paraspinals were attempted but were too painful to get a good assessment IMPRESSION This electrical study is abnormal It reveals the following 1 A very mild purely sensory length dependent peripheral neuropathy 2 Mild bilateral L5 nerve root irritation There is no evidence of active radiculopathy Based on the patient s history and exam her new symptoms are consistent with mild bilateral L5 radiculopathies Symptoms have almost completely resolved over the last month since starting Elavil I would recommend MRI of the lumbosacral spine if symptoms return With respect to the mild neuropathy this is probably related to her mild glucose intolerance early diabetes However I would recommend a workup for other causes to include the following Fasting blood sugar HbA1c ESR RPR TSH B12 serum protein electrophoresis and Lyme titer Keywords radiology nerve conduction studies needle emg numbness tibialis posterior muscle sensory responses muscle tibialis toes MEDICAL_TRANSCRIPTION,Description Echocardiographic examination Borderline left ventricular hypertrophy with normal ejection fraction at 60 mitral annular calcification with structurally normal mitral valve no intracavitary thrombi is seen interatrial septum was somewhat difficult to assess but appeared to be intact on the views obtained Medical Specialty Radiology Sample Name Echocardiography Transcription REASON FOR EXAM CVA INDICATIONS CVA This is technically acceptable There is some limitation related to body habitus DIMENSIONS The interventricular septum 1 2 posterior wall 10 9 left ventricular end diastolic 5 5 and end systolic 4 5 the left atrium 3 9 FINDINGS The left atrium was mildly dilated No masses or thrombi were seen The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening EF of 60 The right atrium and right ventricle are normal in size Mitral valve showed mitral annular calcification in the posterior aspect of the valve The valve itself was structurally normal No vegetations seen No significant MR Mitral inflow pattern was consistent with diastolic dysfunction grade 1 The aortic valve showed minimal thickening with good exposure and coaptation Peak velocity is normal No AI Pulmonic and tricuspid valves were both structurally normal Interatrial septum was appeared to be intact in the views obtained A bubble study was not performed No pericardial effusion was seen Aortic arch was not assessed CONCLUSIONS 1 Borderline left ventricular hypertrophy with normal ejection fraction at 60 2 Mitral annular calcification with structurally normal mitral valve 3 No intracavitary thrombi is seen 4 Interatrial septum was somewhat difficult to assess but appeared to be intact on the views obtained Keywords radiology ventricular hypertrophy normal wall motion ventricle atrium annular calcification mitral valve interatrial septum hypertrophy annular thrombi ventricular structurally septum valve mitral MEDICAL_TRANSCRIPTION,Description The patient with longstanding bilateral arm pain which is predominantly in the medial aspect of arms and hands as well as left hand numbness worse at night and after doing repetitive work with left hand Medical Specialty Radiology Sample Name EMG Nerve Conduction Study 1 Transcription HISTORY The patient is a 52 year old right handed female with longstanding bilateral arm pain which is predominantly in the medial aspect of her arms and hands as well as left hand numbness worse at night and after doing repetitive work with her left hand She denies any weakness No significant neck pain change in bowel or bladder symptoms change in gait or similar symptoms in the past She is on Lyrica for the pain which has been somewhat successful Examination reveals positive Phalen s test on the left Remainder of her neurological examination is normal NERVE CONDUCTION STUDIES The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity The left median sensory distal latency is prolonged with an attenuated evoked response amplitude The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude The right median motor distal latency and evoked response amplitude is normal Left ulnar motor and sensory and left radial sensory responses are normal Left median F wave is normal NEEDLE EMG Needle EMG was performed on the left arm right first dorsal interosseous muscle and bilateral cervical paraspinal muscles It revealed spontaneous activity in the left abductor pollicis brevis muscle There is increased insertional activity in the right first dorsal interosseous muscle Both interosseous muscles showed signs of reinnervation Left extensor digitorum communis muscle showed evidence of reduced recruitment Cervical paraspinal muscles were normal IMPRESSION This electrical study is abnormal It reveals the following A left median neuropathy at the wrist consistent with carpal tunnel syndrome Electrical abnormalities are moderate to mild bilateral C8 radiculopathies This may be an incidental finding I have recommended MRI of the spine without contrast and report will be sent to Dr XYZ She will follow up with Dr XYZ with respect to treatment of the above conditions Keywords radiology nerve conduction study emg neuropathy median motor distal latency median sensory distal latency attenuated evoked response amplitude emg nerve conduction study sensory distal latency attenuated evoked response dorsal interosseous muscle cervical paraspinal muscles emg nerve conduction conduction study median motor needle emg distal latency evoked response emg nerve bilateral evoked conduction MEDICAL_TRANSCRIPTION,Description Echocardiogram was performed including 2 D and M mode imaging Medical Specialty Radiology Sample Name Echocardiogram 1 Transcription EXAM Echocardiogram INTERPRETATION Echocardiogram was performed including 2 D and M mode imaging Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M mode Cardiac chamber dimensions left atrial enlargement 4 4 cm Left ventricle right ventricle and right atrium are grossly normal LV wall thickness and wall motion appeared normal LV ejection fraction is estimated at 65 Aortic root and cardiac valves appeared normal No evidence of pericardial effusion No evidence of intracardiac mass or thrombus Doppler analysis outflow velocity through the aortic valve normal inflow velocities through the mitral valve are normal There is mild tricuspid regurgitation Calculated pulmonary systolic pressure 42 mmHg ECHOCARDIOGRAPHIC DIAGNOSES 1 LV Ejection fraction estimated at 65 2 Mild left atrial enlargement 3 Mild tricuspid regurgitation 4 Mildly elevated pulmonary systolic pressure Keywords radiology lv ejection fraction ejection fraction tricuspid regurgitation systolic pressure valves atrial echocardiogram MEDICAL_TRANSCRIPTION,Description Possible cerebrovascular accident The EEG was obtained using 21 electrodes placed in scalp to scalp and scalp to vertex montages Medical Specialty Radiology Sample Name EEG Transcription DIAGNOSIS Possible cerebrovascular accident DESCRIPTION The EEG was obtained using 21 electrodes placed in scalp to scalp and scalp to vertex montages The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7 8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session Transient periods of drowsiness occurred naturally producing irregular 5 7 cycle per second activity mostly over the anterior regions Hyperventilation was not performed No epileptiform activity or any definite lateralizing findings were seen IMPRESSION Mildly abnormal study The findings are suggestive of a generalized cerebral disorder Due to the abundant amount of movement artifacts any lateralizing findings if any cannot be well appreciated Clinical correlation is recommended Keywords radiology scalp to scalp scalp to vertex montages electrodes amplitude epileptiform activity cerebrovascular accident eegNOTE MEDICAL_TRANSCRIPTION,Description Echocardiogram with color flow and conventional Doppler interrogation Medical Specialty Radiology Sample Name Echocardiogram Transcription REASON FOR EXAMINATION Cardiac arrhythmia INTERPRETATION No significant pericardial effusion was identified The aortic root dimensions are within normal limits The four cardiac chambers dimensions are within normal limits No discrete regional wall motion abnormalities are identified The left ventricular systolic function is preserved with an estimated ejection fraction of 60 The left ventricular wall thickness is within normal limits The aortic valve is trileaflet with adequate excursion of the leaflets The mitral valve and tricuspid valve motion is unremarkable The pulmonic valve is not well visualized Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg Doppler interrogation of the mitral in flow pattern is within normal limits for age IMPRESSION 1 Preserved left ventricular systolic function 2 Mild mitral regurgitation 3 Mild tricuspid regurgitation Keywords radiology arrhythmia wall motion ventricular systolic function color flow conventional doppler systolic function mitral regurgitation mild tricuspid tricuspid regurgitation echocardiogram doppler cardiac ventricular systolic tricuspid valve mitral regurgitation MEDICAL_TRANSCRIPTION,Description Echocardiogram for aortic stenosis Transthoracic echocardiogram was performed of adequate technical quality Concentric hypertrophy of the left ventricle with normal function Doppler study as above most pronounced being moderate aortic stenosis valve area of 1 1 sq cm Medical Specialty Radiology Sample Name Echocardiogram 2 Transcription EXAM Echocardiogram INDICATION Aortic stenosis INTERPRETATION Transthoracic echocardiogram was performed of adequate technical quality Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function Ejection fraction is 60 without any obvious wall motion abnormality Left atrium and right side chambers are of normal size and dimensions Aortic root has normal diameter Mitral and tricuspid valves are structurally normal except for minimal annular calcification Valvular leaflet excursion is adequate Aortic valve reveals annular calcification Fibrocalcific valve leaflets with decreased excursion Atrial and ventricular septum are intact Pericardium is intact without any effusion No obvious intracardiac mass or thrombi noted Doppler reveals mild mitral regurgitation mild to moderate tricuspid regurgitation Estimated pulmonary pressure of 48 Systolic consistent with mild to moderate pulmonary hypertension Peak velocity across the aortic valve is 3 0 with a peak gradient of 37 mean gradient of 19 valve area calculated at 1 1 sq cm consistent with moderate aortic stenosis IN SUMMARY 1 Concentric hypertrophy of the left ventricle with normal function 2 Doppler study as above most pronounced being moderate aortic stenosis valve area of 1 1 sq cm Keywords radiology moderate aortic stenosis annular calcification concentric hypertrophy aortic stenosis echocardiogram stenosis valve aortic MEDICAL_TRANSCRIPTION,Description Duplex ultrasound of legs Medical Specialty Radiology Sample Name Duplex Ultrasound Legs Transcription DUPLEX ULTRASOUND OF LEGS RIGHT LEG Duplex imaging was carried out according to normal protocol with a 7 5 Mhz imaging probe using B mode ultrasound Deep veins were imaged at the level of the common femoral and popliteal veins All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity The long saphenous system displayed compressibility without evidence of thrombosis The long saphenous vein measured cm at the proximal thigh with reflux of seconds after release of distal compression and cm at the knee with reflux of seconds after release of distal compression The small saphenous system measured cm at the proximal calf with reflux of seconds after release of distal compression LEFT LEG Duplex imaging was carried out according to normal protocol with a 7 5 Mhz imaging probe using B mode ultrasound Deep veins were imaged at the level of the common femoral and popliteal veins All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity The long saphenous system displayed compressibility without evidence of thrombosis The long saphenous vein measured cm at the proximal thigh with reflux of seconds after release of distal compression and cm at the knee with reflux of seconds after release of distal compression The small saphenous system measured cm at the proximal calf with reflux of seconds after release of distal compression Keywords radiology duplex ultrasound b mode ultrasound duplex imaging compression echogenicity femoral intraluminal thrombus popliteal saphenous vein thrombosis release of distal compression calf with reflux distal compression duplex ultrasound legs saphenous release distal veins MEDICAL_TRANSCRIPTION,Description Dobutamine Stress Echocardiogram Chest discomfort evaluation for coronary artery disease Maximal dobutamine stress echocardiogram test achieving more than 85 of age predicted heart rate Negative EKG criteria for ischemia Medical Specialty Radiology Sample Name Dobutamine Stress Test 1 Transcription DOBUTAMINE STRESS ECHOCARDIOGRAM REASON FOR EXAM Chest discomfort evaluation for coronary artery disease PROCEDURE IN DETAIL The patient was brought to the cardiac center Cardiac images at rest were obtained in the parasternal long and short axis apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg kg per minute for low dose increased every 2 to 3 minutes by 10 mcg kg per minute The patient maximized at 30 mcg kg per minute Images were obtained at that level after adding 0 7 mg of atropine to reach maximal heart rate of 145 Maximal images were obtained in the same windows of parasternal long and short axis apical four and apical two windows Wall motion assessed at all levels as well as at recovery The patient got nauseated had some mild shortness of breath No angina during the procedure and the maximal amount of dobutamine was 30 mcg kg per minute The resting heart rate was 78 with the resting blood pressure 186 98 Heart rate reduced by the vasodilator effects of dobutamine to 130 80 Maximal heart rate achieved was 145 which is 85 of age predicted heart rate The EKG at rest showed sinus rhythm with no ST T wave depression suggestive of ischemia or injury Incomplete right bundle branch block was seen The maximal stress test EKG showed sinus tachycardia There was subtle upsloping ST depression in III and aVF which is a normal response to the tachycardia with dobutamine but no significant depression suggestive of ischemia and no ST elevation seen No ventricular tachycardia or ventricular ectopy seen during the test The heart rate recovered in a normal fashion after using metoprolol 5 mg The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior anteroseptal inferior lateral and septal walls at low dose All walls mentioned were augmented in a normal fashion At maximum dose all walls were augmented on all views except for the short axis was foreshortened was uncertain about the anterolateral wall at peak exercise however of the other views the lateral wall was showing normal thickening and normal augmentation EF improved to about 70 The wall motion score was unchanged IMPRESSION 1 Maximal dobutamine stress echocardiogram test achieving more than 85 of age predicted heart rate 2 Negative EKG criteria for ischemia 3 Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view This is considered the negative dobutamine stress echocardiogram test medical management Keywords radiology chest discomfort coronary artery disease predicted heart rate dobutamine stress echocardiogram anterolateral wall echocardiogram test wall motion stress echocardiogram short axis dobutamine stress heart rate dobutamine stress ekg echocardiogram artery ischemia heart MEDICAL_TRANSCRIPTION,Description Diagnostic cerebral angiogram and transcatheter infusion of papaverine Medical Specialty Radiology Sample Name Diagnostic Cerebral Angiogram Transcription EXAM 1 Diagnostic cerebral angiogram 2 Transcatheter infusion of papaverine ANESTHESIA General anesthesia FLUORO TIME 19 5 minutes CONTRAST Visipaque 270 100 mL INDICATIONS FOR PROCEDURE The patient is a 13 year old boy who had clipping for a left ICA bifurcation aneurysm He was referred for a routine postop check angiogram He is doing fine clinically All questions were answered risks explained informed consent taken and patient was brought to angio suite TECHNIQUE After informed consent was taken patient was brought to angio suite both groin sites were prepped and draped in sterile manner Patient was placed under general anesthesia for entire duration of the procedure Groin access was obtained with a stiff micropuncture wire and a 4 French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush A 4 French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections The images showed spasm of the left internal carotid artery and the left A1 it was thought planned to infused papaverine into the ICA and the left A1 After that the diagnostic catheter was taken up into the distal internal carotid artery SL 10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery Post papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1 The catheter was then removed from the patient pressure was held for 10 minutes leading to hemostasis Patient was then transferred back to the ICU in the Children s Hospital where he was extubated without any deficits INTERPRETATION OF IMAGES 1 LEFT COMMON INTERNAL CAROTID ARTERY INJECTIONS The left internal carotid artery is of normal caliber In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1 There is poor filling of the A2 through left internal carotid artery injection There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution 2 RIGHT INTERNAL CAROTID ARTERY INJECTION The right internal carotid artery is of normal caliber There is opacification of the right ophthalmic and the posterior communicating artery The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery Right MCA along with the distal branches are filling normally Capillary filling and venous drainage are normal 3 POST PAPAVERINE INJECTION The post papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm IMPRESSION 1 Well clipped left ICA bifurcation aneurysm 2 Moderately severe spasm of the internal carotid artery and left A1 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels Keywords radiology transcatheter infusion of papaverine internal carotid artery heparinized saline flush diagnostic cerebral angiogram ica bifurcation aneurysm anterior cerebral artery carotid artery internal carotid saline flush venous drainage papaverine injection ica bifurcation bifurcation aneurysm anterior cerebral cerebral artery artery injections infusion carotid artery angiogram diagnostic ica aneurysm cerebral papaverine MEDICAL_TRANSCRIPTION,Description Diagnostic Mammogram and ultrasound of the breast Medical Specialty Radiology Sample Name Diagnostic Mammogram Transcription EXAM Bilateral diagnostic mammogram and right breast ultrasound History of palpable abnormality at 10 o clock in the right breast Family history of a sister with breast cancer at age 43 TECHNIQUE CC and MLO views of both breasts were obtained Spot compression views of the palpable area were also obtained Right breast ultrasound was performed Comparison is made with mm dd yy FINDINGS The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue No new mass or architectural distortion is evident Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged There is no suspicious cluster of microcalcifications Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass IMPRESSION 1 Stable mammographic appearance from mm dd yy 2 No sonographic evidence of a mass at 10 o clock in the right breast to correspond to the palpable abnormality The need for further assessment of a palpable abnormality should be determined clinically BIRADS Classification 2 Benign Keywords radiology diagnostic mammogram diagnostic mammogram ultrasound palpable MEDICAL_TRANSCRIPTION,Description CT Brain unshunted hydrocephalus Dandy Walker Malformation Medical Specialty Radiology Sample Name Dandy Walker Malformation Transcription CC Seizure D O HX 29 y o male with cerebral palsy non shunted hydrocephalus spastic quadriplegia mental retardation bilateral sensory neural hearing loss severe neurogenic scoliosis and multiple contractures of the 4 extremities neurogenic bowel and bladder incontinence and a history of seizures He was seen for evaluation of seizures which first began at age 27 years two years before presentation His typical episodes consist of facial twitching side not specified unresponsive pupils and moaning The episodes last approximately 1 2 minutes in duration and are followed by post ictal fatigue He was placed on DPH but there was no record of an EEG prior to presentation He had had no seizure events in over 1 year prior to presentation while on DPH 100mg O 200mg He also complained of headaches for the past 10 years BIRTH HX Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother Birth weight 7 10oz No instrumentation required Labor 11hours Light gas anesthesia given Apgars unknown Mother reportedly had the flu in the 7th or 8th month of gestation Patient discharged 5 days post partum Development spoke first words between 1 and 2 years of age Rolled side to side at age 2 but did not walk Fed self with hands at age 2 years Never toilet trained PMH 1 Hydrocephalus manifested by macrocephaly by age 2 3 months Head circumference 50 5cm at 4 months of age wide sutures and bulging fontanels Underwent ventriculogram age 4 months which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle The cortex of the cerebral hemisphere was less than 1cm in thickness especially in the occipital regions where only a thin rim of tissue was left Neurosurgical intervention was not attempted and the patient deemed inoperable at the time By 31 months of age the patients head circumference was 68cm at which point the head size arrested Other problems mentioned above SHX institutionalized at age 18 years FHX unremarkable EXAM Vitals unknown MS awake with occasional use of intelligible but inappropriately used words CN Rightward beating nystagmus increase on leftward gaze Right gaze preference Corneal responses were intact bilaterally Fundoscopic exam not noted Motor spastic quadriparesis moves RUE more than other extremities Sensory withdrew to PP in 4 extremities Coord ND Station ND Gait ND wheel chair bound Reflexes RUE 2 LUE 3 RLE 4 with sustained cross adductor clonus in the right quadriceps LLE 3 Other Macrocephaly measurement not given Scoliosis Rest of general exam unremarkable except for numerous abdominal scars COURSE EEG 8 26 92 Abnormal with diffuse slowing and depressed background left worse than right and poorly formed background activity at 5 7hz Right posterior sharp transients and rhythmic delta theta bursts from the right temporal region The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin Keywords radiology seizure dandy walker malformation eeg macrocephaly bilateral sensory neural hearing loss hydrocephalus hythmic delta theta bursts mental retardation neurogenic bowel and bladder incontinence severe neurogenic scoliosis spastic quadriplegia unshunted hydrocephalus dandy walker malformation dandy walker head circumference presentation gestation headaches incontinence MEDICAL_TRANSCRIPTION,Description CT of abdomen with and without contrast CT guided needle placement biopsy Medical Specialty Radiology Sample Name CT Guided Needle Placement Biopsy Transcription EXAM CT of abdomen with and without contrast CT guided needle placement biopsy HISTORY Left renal mass TECHNIQUE Pre and postcontrast enhanced images were acquired through the kidneys FINDINGS Comparison made to the prior MRI There is re demonstration of multiple bilateral cystic renal lesions Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts There was however one cyst seen in the lower pole of the left kidney which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration This measured approximately 1 4 x 1 3 cm to the exophytic half of the lower pole No other enhancing renal masses were seen The visualized liver spleen pancreas and adrenal glands were unremarkable There are changes of cholecystectomy Mild prominence of the common bile duct is likely secondary to cholecystectomy There is no abdominal lymphadenopathy masses fluid collection or ascites Lung bases are clear No acute bony pathology was noted IMPRESSION Solitary apparently enhancing left renal mass in the lower pole as described Renal cell carcinoma cannot be excluded CT GUIDED NEEDLE BIOPSY LEFT KIDNEY MASS Following discussion of risks benefits and alternatives the patient wished to proceed with CT guided biopsy of left renal lesion The patient was placed in the decubitus position The region overlying the left renal mass of note was marked Area was prepped and draped in usual sterile fashion Local anesthesia was achieved with approximately 8 mL of 1 lidocaine with bicarbonate The Versed and fentanyl were given to achieve conscious sedation Utilizing an 18 x 15 gauge coaxial system 3 core biopsies were obtained through the mass in question and sent to pathology for analysis Following procedure scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia No perinephric fluid hematoma was identified The patient tolerated the procedure without immediate complications IMPRESSION Three core biopsies through the region of the left renal tumor as described Keywords radiology ct ct guided ct guided biopsy hounsfield units mri abdomen biopsy cholecystectomy contrast contrast administration decubitus position images needle postcontrast renal lesions renal mass renal tumor with and without ct guided needle placement ct of abdomen needle placement lower pole ct guided renal MEDICAL_TRANSCRIPTION,Description CT guided needle placement CT guided biopsy of right renal mass and embolization of biopsy tract with gelfoam Medical Specialty Radiology Sample Name CT Guided Biopsy Kidney Transcription REASON FOR EXAM This 60 year old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr X PROCEDURE The procedure risks and possible complications including but not limited to severe hemorrhage which could result in emergent surgery were explained to the patient The patient understood All questions were answered and informed consent was obtained With the patient in the prone position noncontrasted CT localization images were obtained through the kidney Conscious sedation was utilized with the patient being monitored The patient was administered divided dose of Versed and fentanyl intravenously Following sterile preparation and local anesthesia to the posterior aspect of the right flank an 18 gauge co axial Temno type needle was directed into the inferior pole right renal mass from the posterior oblique approach Two biopsy specimens were obtained and placed in 10 formalin solution CT documented needle placement Following the biopsy there was active bleeding through the stylet as well as a small hematoma about the inferior aspect of the right kidney posteriorly I placed several torpedo pledgets of Gelfoam through the co axial sheath into the site of bleeding The bleeding stopped The co axial sheath was then removed Bandage was applied Hemostasis was obtained The patient was placed in the supine position Postbiopsy CT images were then obtained The patient s hematoma appeared stable The patient was without complaints of pain or discomfort The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged as stable The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr Fieldstone for the results and follow up care FINDINGS Initial noncontrasted CT localization images reveals the presence of an approximately 2 1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass There are small droplets of air within the hematoma No hydronephrosis is identified CONCLUSION 1 Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10 formalin solution 2 Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets Keywords radiology embolization ct localization gelfoam pledgets ct guided needle placement ct guided biopsy needle placement renal mass ct guided inferior pole ct biopsy hematoma kidney mass MEDICAL_TRANSCRIPTION,Description Modified Barium swallow Deglutition Study for Dysphagia with possible aspiration Medical Specialty Radiology Sample Name Deglutition Study Modified Barium swallow Transcription EXAM Modified barium swallow SYMPTOM Dysphagia with possible aspiration FINDINGS A cookie deglutition study was performed The patient was examined in the direct lateral position Patient was challenged with thin liquids thick liquid semisolids and solids Persistently demonstrable is the presence of penetration with thin liquids This is not evident with thick liquids semisolids or solids There is weakness in the oral phase of deglutition Subglottic region appears normal There is no evidence of aspiration demonstrated IMPRESSION Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition Keywords radiology aspiration deglutition study thin liquids thick liquid semisolids solids modified barium swallow barium swallow dysphagia deglutition MEDICAL_TRANSCRIPTION,Description Dobutamine stress test for chest pain as the patient was unable to walk on a treadmill and allergic to adenosine Nondiagnostic dobutamine stress test Normal nuclear myocardial perfusion scan Medical Specialty Radiology Sample Name Dobutamine Stress Test Transcription EXAM Dobutamine Stress Test INDICATION Chest pain TYPE OF TEST Dobutamine stress test as the patient was unable to walk on a treadmill and allergic to adenosine INTERPRETATION Resting heart rate of 66 and blood pressure of 88 45 EKG normal sinus rhythm Post dobutamine increment dose his peak heart rate achieved was 125 which is 87 of the target heart rate Blood pressure 120 42 EKG remained the same No symptoms were noted IMPRESSION 1 Nondiagnostic dobutamine stress test 2 Nuclear interpretation as below NUCLEAR INTERPRETATION Resting and stress images were obtained with 10 8 30 2 mCi of tetrofosmin injected intravenously by standard protocol Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect Gated and SPECT revealed normal wall motion and ejection fraction of 75 End diastolic volume was 57 and end systolic volume of 12 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction of 75 by gated SPECT Keywords radiology nuclear myocardial perfusion scan dobutamine stress test ejection fraction myocardial perfusion perfusion scan dobutamine stress stress test myocardial perfusion nuclear dobutamine stress MEDICAL_TRANSCRIPTION,Description Brain CT with contrast Abnormal Gyriform enhancing lesion stroke in the left parietal region not seen on non contrast HCTs Medical Specialty Radiology Sample Name CT Scan of Brain with Contrast Transcription CC Confusion HX A 71 y o RHM with a history of two strokes one in 11 90 and one in 11 91 had been in a stable state of health until 12 31 92 when he became confused and displayed left sided weakness and difficulty speaking The symptoms resolved within hours and recurred the following day He was then evaluated locally and HCT revealed an old right parietal stroke Carotid duplex scan revealed a high grade stenosis of the RICA Cerebral Angiogram revealed 90 RICA and 50 LICA stenosis He was then transferred to UIHC Vascular Surgery for carotid endarterectomy His confusion persisted and he was evaluated by Neurology on 1 8 93 and transferred to Neurology on 1 11 93 PMH 1 cholecystectomy 2 inguinal herniorrhaphies bilaterally 3 ETOH abuse 3 10 beers day 4 Right parietal stroke 10 87 with residual left hemiparesis Leg worse than arm 5 2nd stoke in distant past of unspecified type MEDS None on admission FHX Alzheimer s disease and stroke on paternal side of family SHX 50 pack yr cigarette use ROS no weight loss poor appetite selective eater EXAM BP137 70 HR81 RR13 O2Sat 95 Afebrile MS Oriented to city and month but did not know date or hospital Naming and verbal comprehension were intact He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2 3 objects in two minutes but both with assistance only Incorrectly spelled world backward as dlow CN unremarkable except neglects left visual field to double simultaneous stimulation Motor Deltoids 4 4 biceps 5 4 triceps 5 4 grip 4 4 HF4 4 HE 4 4 Hamstrings 5 5 AE 5 5 AF 5 5 Sensory intact PP LT Vib Coord dysdiadochokinesis on RAM bilaterally Station dyssynergic RUE on FNF movement Gait ND Reflexes 2 2 throughout BUE and at patellae Absent at ankles Right plantar was flexor and Left plantar was equivocal COURSE CBC revealed normal Hgb Hct Plt and WBC but Mean corpuscular volume was large at 103FL normal 82 98 Urinalysis revealed 20 WBC GS TSH FT4 VDRL ANA and RF were unremarkable He was treated for a UTI with amoxacillin Vitamin B12 level was reduced at 139pg ml normal 232 1137 Schillings test was inconclusive dure to inability to complete a 24 hour urine collection He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days then qMonth He was also placed on Thiamine 100mg qd Folate 1mg qd and ASA 325mg qd His ESR and CRP were elevated on admission but fell as his UTI was treated EEG showed diffuse slowing and focal slowing in the theta delta range in the right temporal area HCT with contrast on 1 19 93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct and an old right parietal hypodensity infarct His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency He was lost to follow up and did not undergo carotid endarterectomy Keywords radiology ct scan abnormal gyriform enhancing lesion brain ct ct with contrast carotid duplex scan confusion hct difficulty speaking left sided weakness non contrast hct parietal region stroke theta delta with contrast gyriform enhancing lesion gyriform enhancing enhancing lesion parietal stroke carotid endarterectomy ct scan gyriform endarterectomy contrast hcts brain parietal MEDICAL_TRANSCRIPTION,Description Noncontrast CT abdomen and pelvis per renal stone protocol Medical Specialty Radiology Sample Name CT Stone Protocol Transcription EXAM CT stone protocol REASON FOR EXAM History of stones rule out stones TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol FINDINGS Correlation is made with a prior examination dated 01 20 09 Again identified are small intrarenal stones bilaterally These are unchanged There is no hydronephrosis or significant ureteral dilatation There is no stone along the expected course of the ureters or within the bladder There is a calcification in the low left pelvis not in line with ureter this finding is stable and is compatible with a phlebolith There is no asymmetric renal enlargement or perinephric stranding The appendix is normal There is no evidence of a pericolonic inflammatory process or small bowel obstruction Scans through the pelvis disclose no free fluid or adenopathy Lung bases aside from very mild dependent atelectasis appear clear Given the lack of contrast liver spleen adrenal glands and the pancreas are grossly unremarkable The gallbladder is present There is no abdominal free fluid or pathologic adenopathy IMPRESSION 1 Bilateral intrarenal stones no obstruction 2 Normal appendix Keywords radiology noncontrast ct abdomen and pelvis renal stone protocol renal stone intrarenal stones stone protocol ureteral adenopathy renal ct protocol pelvis intrarenal stone abdomen noncontrast MEDICAL_TRANSCRIPTION,Description CT Scan of brain without contrast Medical Specialty Radiology Sample Name CT Scan of Brain w o Contrast Transcription REASON FOR EXAMINATION Face asleep COMPARISON EXAMINATION None TECHNIQUE Multiple axial images were obtained of the brain 5 mm sections were acquired 2 5 mm sections were acquired without injection of intravenous contrast Reformatted sagittal and coronal images were obtained DISCUSSION No acute intracranial abnormalities appreciated No evidence for hydrocephalus midline shift space occupying lesions or abnormal fluid collections No cortical based abnormalities appreciated The sinuses are clear No acute bony abnormalities identified Preliminary report given to emergency room at conclusion of exam by Dr Xyz IMPRESSION No acute intracranial abnormalities appreciated Keywords radiology ct scan multiple axial images asleep brain coronal coronal images hydrocephalus intracranial intravenous contrast sagittal without contrast ct scan contrast abnormalities MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan Medical Specialty Radiology Sample Name CT Scan of Abdomen Pelvis with Contrast Transcription EXAM CT scan of the abdomen and pelvis with contrast REASON FOR EXAM Abdominal pain COMPARISON EXAM None TECHNIQUE Multiple axial images of the abdomen and pelvis were obtained 5 mm slices were acquired after injection of 125 cc of Omnipaque IV In addition oral ReadiCAT was given Reformatted sagittal and coronal images were obtained DISCUSSION There are numerous subcentimeter nodules seen within the lung bases The largest measures up to 6 mm No hiatal hernia is identified Consider chest CT for further evaluation of the pulmonary nodules The liver gallbladder pancreas spleen adrenal glands and kidneys are within normal limits No dilated loops of bowel There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat In addition there is soft tissue stranding seen of the lower pelvis In addition the uterus is not identified Correlate with history of recent surgery There is no free fluid or lymphadenopathy seen within the abdomen or pelvis The bladder is within normal limits for technique No acute bony abnormalities appreciated No suspicious osteoblastic or osteolytic lesions IMPRESSION 1 Postoperative changes seen within the pelvis without appreciable evidence for free fluid 2 Numerous subcentimeter nodules seen within the lung bases Consider chest CT for further characterization Keywords radiology ct scan abdominal pain multiple axial images abdomen and pelvis adrenal glands chest ct coronal gallbladder kidneys liver lymphadenopathy nodules osteoblastic osteolytic pancreas sagittal spleen with contrast free fluid ct abdomen pelvis MEDICAL_TRANSCRIPTION,Description CT of chest with contrast Abnormal chest x ray demonstrating a region of consolidation versus mass in the right upper lobe Medical Specialty Radiology Sample Name CT of Chest with Contrast Transcription EXAM CT chest with contrast HISTORY Abnormal chest x ray which demonstrated a region of consolidation versus mass in the right upper lobe TECHNIQUE Post contrast enhanced spiral images were obtained through the chest FINDINGS There are several discrete patchy air space opacities in the right upper lobe which have the appearance most compatible with infiltrates The remainder of the lung parenchyma is clear There is no pneumothorax or effusion The heart size and pulmonary vessels appear unremarkable There was no axillary hilar or mediastinal lymphadenopathy Images of the upper abdomen are unremarkable Osseous windows are without acute pathology IMPRESSION Several discrete patchy air space opacities in the right upper lobe compatible with pneumonia Keywords radiology ct chest air space axillary chest x ray consolidation contrast contrast enhanced effusion hilar infiltrates lung lymphadenopathy mass mediastinal parenchyma patchy air space pneumonia pneumothorax right upper lobe spiral images with contrast air space opacities upper lobe opacities ct lobe chest MEDICAL_TRANSCRIPTION,Description CT of the facial bones without contrast due to hit in nose Medical Specialty Radiology Sample Name CT of Facial Wones w o Contrast Transcription EXAM CT of the facial bones without contrast REASON FOR EXAM Hit in nose COMPARISON EXAM Plain films of the same date TECHNIQUE Multidetector helicoaxial images were acquired in the axial plane and were reconstructed in bone and soft tissue algorithms for viewing in multiplanar format FINDINGS There is a fracture of the frontal process of the maxilla on both sides with displacement with angulation to the right and very minimal displacement of the distal fragments In addition there is slight comminution of the right nasal bone without displacement The bony portion of the nasal septum is intact although it is bowed to the left Soft tissue swelling is seen overlying the left side of the nose There is no nasoseptal hematoma Moderate mucosal thickening is seen in both maxillary sinuses The right maxillary sinus is hypoplastic Moderate mucosal thickening is seen in the left ethmoid sinus and marked mucosal thickening in the left sphenoid sinus The right sphenoid sinus is hypoplastic No abnormality of the orbits is seen The imaged portions of the brain are unremarkable IMPRESSION 1 Bilateral fractures of the frontal process of the maxilla and with displacement to the right 2 The findings were reported to Dr Xyz of the emergency room on 04 30 07 at 1715 hours Keywords radiology plain films ct multidetector axial plane bone contrast frontal helicoaxial maxilla mucosal thickening multiplanar nasal bone nasoseptal hematoma sinus soft tissue sphenoid without contrast sinus is hypoplastic facial mucosal thickening MEDICAL_TRANSCRIPTION,Description CT of Lumbar Spine without Contrast Patient with history of back pain after a fall Medical Specialty Radiology Sample Name CT of Lumbar Spine w o Contrast Transcription EXAM Lumbar spine CT without contrast HISTORY Back pain after a fall TECHNIQUE Noncontrast axial images were acquired through the lumbar spine Coronal and sagittal reconstruction views were also obtained FINDINGS There is no evidence for acute fracture or subluxation There is no spondylolysis or spondylolisthesis The central canal and neuroforamen are grossly patent at all levels There are no abnormal paraspinal masses There is no wedge compression deformity There is intervertebral disk space narrowing to a mild degree at L2 3 and L4 5 Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta which is not dilated There was incompletely visualized probable simple left renal cyst exophytic at the lower pole IMPRESSION 1 No evidence for acute fracture or subluxation 2 Mild degenerative changes 3 Probable left simple renal cyst Keywords radiology lumbar spine back pain ct coronal atherosclerotic axial images central canal compression deformity degenerative disk space fracture intervertebral neuroforamen sagittal spondylolisthesis spondylolysis subluxation wedge without contrast contrast spine lumbar noncontrast MEDICAL_TRANSCRIPTION,Description CT maxillofacial for trauma CT examination of the maxillofacial bones was performed without contrast Coronal reconstructions were obtained for better anatomical localization Medical Specialty Radiology Sample Name CT Maxillofacial Transcription EXAM CT maxillofacial for trauma FINDINGS CT examination of the maxillofacial bones was performed without contrast Coronal reconstructions were obtained for better anatomical localization There is normal appearance to the orbital rims The ethmoid sphenoid and frontal sinuses are clear There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally The nasal bones appear intact The zygomatic arches are intact The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes The mandible and maxilla are intact There is soft tissue swelling seen involving the right cheek IMPRESSION 1 Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally 2 Mild soft tissue swelling about the right cheek Keywords radiology ethmoid sphenoid frontal sinuses mandible maxilla ct examination maxillofacial bones mucosal thickening maxillary sinuses ct maxillofacial MEDICAL_TRANSCRIPTION,Description CT REPORT Soft Tissue Neck Medical Specialty Radiology Sample Name CT Neck 2 Transcription FINDINGS There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2 4 X 3 9 X 3 0cm AP X transverse X craniocaudal in size The lesion is well demarcated There is a solid peripheral rim with a mean attenuation coefficient of 56 3 There is a central cystic appearing area with a mean attenuation coefficient of 28 1 HU suggesting an area of central necrosis There is the suggestion of mild peripheral rim enhancement This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve Primary consideration is of a benign mixed tumor pleomorphic adenoma however other solid mass lesions cannot be excluded for which histologic evaluation would be necessary for definitive diagnosis The right parotid gland is normal There is mild enlargement of the left jugulodigastric node measuring 1 1cm in size with normal morphology image 33 68 There is mild enlargement of the right jugulodigastric node measuring 1 2cm in size with normal morphology image 38 68 There are demonstrated bilateral deep lateral cervical nodes at the midlevel measuring 0 6cm on the right side and 0 9cm on the left side image 29 68 There is a second midlevel deep lateral cervical node demonstrated on the left side image 20 68 measuring 0 7cm in size There are small bilateral low level nodes involving the deep lateral cervical nodal chain image 15 68 measuring 0 5cm in size There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains The right parotid gland is normal and there is no right parotid gland mass lesion Normal bilateral submandibular glands Normal parapharyngeal retropharyngeal and perivertebral spaces Normal carotid spaces IMPRESSION Large well demarcated mass lesion of the deep lobe of the left parotid gland with probable involvement of the left facial nerve See above for size morphology and pattern enhancement Primary consideration is of a benign mixed tumor pleomorphic adenoma however other solid mass lesions cannot be excluded for which histologic evaluation is necessary for specificity Multiple visualized nodes of the bilateral deep lateral cervical nodal chain within normal size and morphology most compatible with mild hyperplasia Keywords radiology cervical nodal mass lesion deep lobe deep lateral lateral cervical parotid gland cervical lesion gland parotid deep MEDICAL_TRANSCRIPTION,Description CT REPORT Soft Tissue Neck Medical Specialty Radiology Sample Name CT Neck 1 Transcription FINDINGS There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm mediolateral x AP x craniocaudal in size There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds There is marked enlargement of the bilateral aryepiglottic folds left greater than right There is thickening of the glossoepiglottic fold There is an infiltrative mass like lesion extending into the pre epiglottic space There is no demonstrated effacement of the piriform sinuses The mass obliterates the right vallecula The paraglottic spaces are normal The true and false cords appear normal Normal thyroid cricoid and arytenoid cartilages There is lobulated thickening of the right side of the tongue base for which invasion of the tongue cannot be excluded A MRI examination would be of benefit for further evaluation of this finding There is a 14 x 5 x 12 mm node involving the left submental region Level I There is borderline enlargement of the bilateral jugulodigastric nodes Level II The left jugulodigastric node measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node with a probable necrotic center There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease There is no demonstrated pretracheal prelaryngeal or superior mediastinal nodes There is no demonstrated retropharyngeal adenopathy There is thickening of the adenoidal pad without a mass lesion of the nasopharynx The torus tubarius and fossa of Rosenmuller appear normal IMPRESSION Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre epiglottic space with invasion of the bilateral aryepiglottic folds Lobulated tongue base for which tongue invasion cannot be excluded An MRI may be of benefit for further assessment of this finding Borderline enlargement of a submental node suggesting Level I adenopathy Bilateral deep cervical nodal disease involving bilateral Level II Level III and left Level IV Keywords radiology deep cervical node epiglottic mass epiglottic space aryepiglottic folds jugulodigastric nodes level deep cervical node deep cervical node jugulodigastric aryepiglottic deep cervical MEDICAL_TRANSCRIPTION,Description This is a middle aged female with two month history of low back pain and leg pain Medical Specialty Radiology Sample Name CT Lumbar Spine 2 Transcription FINDINGS Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes Preliminary scout film demonstrates anterior end plate spondylosis at T11 12 and T12 L1 L1 2 There is normal disc height anterior end plate spondylosis very minimal vacuum change with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints image 4 L2 3 There is mild decreased disc height anterior end plate spondylosis circumferential disc protrusion measuring 4 6mm AP and right extraforaminal osteophyte disc complex There is mild non compressive right neural foraminal narrowing minimal facet arthrosis normal central canal and left neural foramen image 13 L3 4 There is normal disc height anterior end plate spondylosis and circumferential non compressive annular disc bulging The disc bulging flattens the ventral thecal sac and there is minimal non compressive right neural foraminal narrowing minimal to mild facet arthrosis with vacuum change on the right normal central canal and left neural foramen image 25 L4 5 Keywords radiology anterior end plate spondylosis compressive right neural foraminal compressive annular disc bulging anterior end plate annular disc bulging normal central canal plate spondylosis central canal vacuum change disc bulging neural foraminal facet arthrosis anterior spondylosis neural lumbar disc bulging foraminal arthrosis facet MEDICAL_TRANSCRIPTION,Description Common CT Neck template Medical Specialty Radiology Sample Name CT Neck Transcription TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast FINDINGS Scans through the base of the brain are unremarkable The oropharynx and nasopharynx are within normal limits The airway is patent The epiglottis and epiglottic folds are normal The thyroid submandibular and parotid glands enhance homogenously The vascular and osseous structures in the neck are intact There is no lymphadenopathy The visualized lung apices are clear IMPRESSION No acute abnormalities Keywords radiology sequential axial ct images optiray parotid glands epiglottic folds epiglottis base of the brain ct neckNOTE MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Radiology Sample Name CT Head Facial Bones Cervical Spine 1 Transcription CT HEAD WITHOUT CONTRAST CT FACIAL BONES WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD TECHNIQUE Noncontrast axial CT images of the head were obtained without contrast FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved No calvarial fracture is seen IMPRESSION Negative for acute intracranial disease CT FACIAL BONES WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions FINDINGS There is no facial bone fracture The maxilla and mandible are intact The visualized paranasal sinuses are clear The temporomandibular joints are intact The nasal bone is intact The orbits are intact The extra ocular muscles and orbital nerves are normal The orbital globes are normal IMPRESSION No evidence for a facial bone fracture CT CERVICAL SPINE WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions FINDINGS There is a normal lordosis of the cervical spine no fracture or subluxation is seen The vertebral body heights are normal The intervertebral disk spaces are well preserved The atlanto dens interval is normal No abnormal anterior cervical soft tissue swelling is seen There is no spinal compression deformity IMPRESSION Negative for a facial bone fracture Keywords radiology intracranial disease motor vehicle collision orbital nerves extra ocular muscles cervical spine ct cervical spine ct facial bones ct head axial ct images facial bone fracture facial bones ct noncontrast intracranial axial spine fracture cervical contrast facial bones MEDICAL_TRANSCRIPTION,Description CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Radiology Sample Name CT Head Facial Bones Cervical Spine Transcription EXAM CT head without contrast CT facial bones without contrast and CT cervical spine without contrast REASON FOR EXAM A 68 year old status post fall with multifocal pain COMPARISONS None TECHNIQUE Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast Additional high resolution sagittal and or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures INTERPRETATIONS HEAD There is mild generalized atrophy Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes There are subtle areas of increased attenuation seen within the frontal lobes bilaterally Given the patient s clinical presentation these likely represent small hemorrhagic contusions Other differential considerations include cortical calcifications which are less likely The brain parenchyma is otherwise normal in attenuation without evidence of mass midline shift hydrocephalus extra axial fluid or acute infarction The visualized paranasal sinuses and mastoid air cells are clear The bony calvarium and skull base are unremarkable FACIAL BONES The osseous structures about the face are grossly intact without acute fracture or dislocation The orbits and extra ocular muscles are within normal limits There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses The remaining visualized paranasal sinuses and mastoid air cells are clear Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture CERVICAL SPINE There is mild generalized osteopenia There are diffuse multilevel degenerative changes identified extending from C4 C7 with disk space narrowing sclerosis and marginal osteophyte formation The remaining cervical vertebral body heights are maintained without acute fracture dislocation or spondylolisthesis The central canal is grossly patent The pedicles and posterior elements appear intact with multifocal facet degenerative changes There is no prevertebral or paravertebral soft tissue masses identified The atlanto dens interval and dens are maintained IMPRESSION 1 Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions There is no associated shift or mass effect at this time Less likely this finding could be secondary to cortical calcifications The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated 2 Atrophy and chronic small vessel ischemic changes in the brain 3 Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture 4 Osteopenia and multilevel degenerative changes in the cervical spine as described above 5 Findings were discussed with Dr X from the emergency department at the time of interpretation Keywords radiology sagittal coronal soft tissue swelling paranasal sinuses mastoid air acute fracture maxillary sinuses tissue swelling underlying fracture multilevel degenerative ct head soft tissue facial bones cervical spine ct facial bones spine cervical MEDICAL_TRANSCRIPTION,Description The patient is a 79 year old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan The patient s subdural effusions are still noticeable but they are improving Medical Specialty Radiology Sample Name CT Head 2 Transcription REASON FOR CT SCAN The patient is a 79 year old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16 2008 I changed the shunt setting from 1 5 to 2 0 on February 12 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving CT scan from 03 11 2008 demonstrates frontal horn span at the level of foramen of Munro of 2 6 cm The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm There is a single shunt which enters on the right occipital side and ends in the left lateral ventricle He has symmetric bilateral subdurals that are less than 1 cm in breadth each which is a reduction from the report from January 16 2008 which states that he had a subdural hygroma maximum size 1 3 cm on the right and 1 1 cm on the left ASSESSMENT The patient s subdural effusions are still noticeable but they are improving at the setting of 2 0 PLAN I would like to see the patient with a new head CT in about three months at which time we can decide whether 2 0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting Keywords radiology ct scan subdural adult hydrocephalus bilateral effusions shunt setting subdural effusions hydrocephalus ventricular scan ct MEDICAL_TRANSCRIPTION,Description Left arm and hand numbness CT head without contrast Noncontrast axial CT images of the head were obtained with 5 mm slice thickness Medical Specialty Radiology Sample Name CT Head 3 Transcription REASON FOR EXAM Left arm and hand numbness TECHNIQUE Noncontrast axial CT images of the head were obtained with 5 mm slice thickness FINDINGS There is an approximately 5 mm shift of the midline towards the right side Significant low attenuation is seen throughout the white matter of the right frontal parietal and temporal lobes There is loss of the cortical sulci on the right side These findings are compatible with edema Within the right parietal lobe a 1 8 cm rounded hyperintense mass is seen No hydrocephalus is evident The calvarium is intact The visualized paranasal sinuses are clear IMPRESSION A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal parietal and temporal lobes A 1 8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density A postcontrast MRI is required for further characterization of this mass Gradient echo imaging should be obtained Keywords radiology numbness head ct images frontal parietal temporal axial ct images parietal and temporal ct head slice thickness white matter frontal parietal temporal lobes parietal lobe edema intact noncontrast mass ct lobes arm MEDICAL_TRANSCRIPTION,Description Noncontrast CT scan of the lumbar spine Left lower extremity muscle spasm Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested Medical Specialty Radiology Sample Name CT Lumbar Spine Transcription EXAM Noncontrast CT scan of the lumbar spine REASON FOR EXAM Left lower extremity muscle spasm COMPARISONS None FINDINGS Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested No abnormal paraspinal masses are identified There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally There is marked intervertebral disk space narrowing at the L5 S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes Posterior disk osteophyte complex is present most marked in the left paracentral to lateral region extending into the lateral recess on the left This most likely will affect the S1 nerve root on the left There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly There is mild neural foraminal stenosis present Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root There is facet sclerosis bilaterally Mild lateral recess stenosis just on the right there is prominent anterior spondylosis At the L4 5 level mild bilateral facet arthrosis is present There is broad based posterior annular disk bulging or protrusion which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally No moderate or high grade central canal or neural foraminal stenosis is identified At the L3 4 level anterior spondylosis is present There are endplate degenerative changes with mild posterior annular disk bulging but no evidence of moderate or high grade central canal or neural foraminal stenosis At the L2 3 level there is mild bilateral ligamentum flavum hypertrophy Mild posterior annular disk bulging is present without evidence of moderate or high grade central canal or neural foraminal stenosis At the T12 L1 and L1 2 levels there is no evidence of herniated disk protrusion central canal or neural foraminal stenosis There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation No bony destructive changes or acute fractures are identified CONCLUSIONS 1 Advanced degenerative disk disease at the L5 S1 level 2 Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5 S1 level laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis 3 Mild bilateral neural foraminal stenosis at the L5 S1 level 4 Posterior disk bulging at the L2 3 L3 4 and L4 5 levels without evidence of moderate or high grade central canal stenosis 5 Facet arthrosis to the lower lumbar spine 6 Arteriosclerotic vascular disease Keywords radiology noncontrast ct scan lower extremity muscle spasm neural foraminal stenosis lumbar spine spine disk lumbar ct intervertebral canal foraminal noncontrast stenosis MEDICAL_TRANSCRIPTION,Description This is a middle aged female with low back pain radiating down the left leg and foot for one and a half years Medical Specialty Radiology Sample Name CT Lumbar Spine 1 Transcription FINDINGS High resolution computerized tomography was performed from T12 L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed COMPARISON Previous MRI examination 10 13 2004 There is minimal curvature of the lumbar spine convex to the left T12 L1 L1 2 L2 3 There is normal disc height with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints L3 4 There is normal disc height and non compressive circumferential annular disc bulging eccentrically greater to the left Normal central canal and facet joints image 255 L4 5 There is normal disc height circumferential annular disc bulging left L5 hemilaminectomy and posterior central right paramedian broad based disc protrusion measuring 4mm AP contouring the rightward aspect of the thecal sac Orthopedic hardware is noted posteriorly at the L5 level Normal central canal facet joints and intervertebral neural foramina image 58 L5 S1 There is minimal decreased disc height postsurgical change with intervertebral disc spacer posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position The orthopedic hardware creates mild streak artifact which mildly degrades images There is a laminectomy defect spondylolisthesis with 3 5mm of anterolisthesis of L5 posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root There is fusion of the facet joints normal central canal and right neural foramen image 69 70 135 There is no bony destructive change noted There is no perivertebral soft tissue abnormality There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery IMPRESSION Minimal curvature of the lumbar spine convex to the left L3 4 posterior non compressive annular disc bulging eccentrically greater to the left L4 5 circumferential annular disc bulging non compressive central right paramedian disc protrusion left L5 laminectomy L5 S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position intervertebral disc spacer spondylolisthesis laminectomy defect posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement Minimal to mild arteriosclerotic vascular calcifications Keywords radiology posterior annular disc circumferential annular disc normal central canal annular disc bulging lumbar spine posterior annular facet joints annular disc disc bulging tomography disc lumbar orthopedic postsurgical spine annular bulging MEDICAL_TRANSCRIPTION,Description Common CT Head template Medical Specialty Radiology Sample Name CT Head Transcription TECHNIQUE Sequential axial CT images were obtained from the vertex to the skull base without contrast FINDINGS There is mild generalized atrophy Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes The brain parenchyma is otherwise normal in attenuation with no evidence of mass hemorrhage midline shift hydrocephalus extra axial fluid or acute infarction The visualized paranasal sinuses and mastoid air cells are clear The bony calvarium and skull base are within normal limits IMPRESSION No acute abnormalities Keywords radiology decreased attenuation skull base sequential axial ct images bony calvarium extra axial fluid ct head attenuationNOTE MEDICAL_TRANSCRIPTION,Description Common CT Facial template Medical Specialty Radiology Sample Name CT Facial Transcription TECHNIQUE Sequential axial CT images were obtained through the facial bones without contrast Additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures FINDINGS The osseous structures within the face are intact with no evidence of fracture or dislocation The visualized paranasal sinuses and mastoid air cells are clear The orbits and extra ocular muscles are within normal limits The soft tissues are unremarkable IMPRESSION No acute abnormalities Keywords radiology sequential axial ct image ct facial osseous structuresNOTE MEDICAL_TRANSCRIPTION,Description Noncontrast CT abdomen and pelvis per renal stone protocol Medical Specialty Radiology Sample Name CT KUB Transcription EXAM CT KUB REASON FOR EXAM Flank pain TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol Correlation is made with the prior examination dated 01 16 09 FINDINGS There is no intrarenal stone or obstruction bilaterally There is no hydronephrosis ureteral dilatation There are calcifications about the pelvis including one in the left upper pelvis but these are stable from the prior study and there is no upstream ureteral dilatation the findings therefore are favored to represent phleboliths The bladder is nearly completely decompressed There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction The appendix is normal There is no evidence for a pericolonic inflammatory process or small bowel obstruction Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths There is no pelvic free fluid or adenopathy Lung bases appear clear Given the lack of contrast liver spleen adrenal glands and the pancreas appear grossly unremarkable The gallbladder has been resected There is no abdominal free fluid or pathologic adenopathy IMPRESSION 1 No renal stone or evidence of obstruction Stable appearing pelvic calcifications likely indicate phleboliths 2 Normal appendix Keywords radiology pericolonic inflammatory process phleboliths renal stone protocol ct kub ct abdomen ureteral dilatation free fluid renal stone noncontrast kub adenopathy abdomen ct renal stone obstruction pelvis MEDICAL_TRANSCRIPTION,Description CT cervical spine for trauma CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Medical Specialty Radiology Sample Name CT C Spine 2 Transcription EXAM CT cervical spine C spine for trauma FINDINGS CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Cervical vertebral body height alignment and interspacing are maintained There is no evidence of fractures or destructive osseous lesions There are no significant degenerative endplate or facet changes No significant osseous central canal or foraminal narrowing is present IMPRESSION Negative cervical spine Keywords radiology c spine anatomical degenerative endplate ct examination cervical spine coronal ct spine cervicalNOTE MEDICAL_TRANSCRIPTION,Description Noncontrast CT head due to seizure disorder Medical Specialty Radiology Sample Name CT Head 1 Transcription EXAM CT head REASON FOR EXAM Seizure disorder TECHNIQUE Noncontrast CT head FINDINGS There is no evidence of an acute intracranial hemorrhage or infarction There is no midline shift intracranial mass or mass effect There is no extra axial fluid collection or hydrocephalus Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening IMPRESSION No acute process in the brain Keywords radiology mass effect extra axial fluid hydrocephalus midline shift intracranial mass paranasal sinuses mastoid air cells frontal sinus mucosal thickening seizure disorder ct head seizure sinuses ct head noncontrast MEDICAL_TRANSCRIPTION,Description Axial images through the cervical spine with coronal and sagittal reconstructions Medical Specialty Radiology Sample Name CT C Spine 1 Transcription EXAM CT cervical spine REASON FOR EXAM MVA feeling sleepy headache shoulder and rib pain TECHNIQUE Axial images through the cervical spine with coronal and sagittal reconstructions FINDINGS There is reversal of the normal cervical curvature at the vertebral body heights The intervertebral disk spaces are otherwise maintained There is no prevertebral soft tissue swelling The facets are aligned The tip of the clivus and occiput appear intact On the coronal reconstructed sequence there is satisfactory alignment of C1 on C2 no evidence of a base of dens fracture The included portions of the first and second ribs are intact There is no evidence of a posterior element fracture Included portions of the mastoid air cells appear clear There is no CT evidence of a moderate or high grade stenosis IMPRESSION No acute process cervical spine Keywords radiology c spine axial images sagittal reconstructions cervical spine sagittal fracture coronal spine axial cervical ct MEDICAL_TRANSCRIPTION,Description CT head without contrast Assaulted positive loss of consciousness rule out bleed CT examination of the head was performed without intravenous contrast administration Medical Specialty Radiology Sample Name CT Head 4 Transcription EXAM CT head without contrast INDICATIONS Assaulted positive loss of consciousness rule out bleed TECHNIQUE CT examination of the head was performed without intravenous contrast administration There are no comparison studies FINDINGS There are no abnormal extraaxial fluid collections There is no midline shift or mass effect Ventricular system demonstrates no dilatation There is no evidence of acute intracranial hemorrhage The calvarium is intact There is a laceration in the left parietal region of the scalp without underlying calvarial fractures The mastoid air cells are clear IMPRESSION No acute intracranial process Keywords radiology extraaxial fluid intracranial hemorrhage parietal region scalp loss of consciousness ct examination ct head intracranial intravenous contrast MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast and CT cervical spine without contrast Noncontrast axial CT images of the head were obtained Medical Specialty Radiology Sample Name CT Head and C Spine Transcription CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the head were obtained FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved There is no calvarial fracture The visualized paranasal sinuses and mastoid air cells are clear IMPRESSION Negative for acute intracranial disease CT CERVICAL SPINE TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained Sagittal and coronal images were obtained FINDINGS Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms No fracture or subluxation is seen Anterior and posterior osteophyte formation is seen at C5 C6 No abnormal anterior cervical soft tissue swelling is seen No spinal compression is noted The atlanto dens interval is normal There is a large retention cyst versus polyp within the right maxillary sinus IMPRESSION 1 Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms 2 Degenerative disk and joint disease at C5 C6 3 Retention cyst versus polyp of the right maxillary sinus Keywords radiology muscle spasms cervical lordosis intracranial hemorrhage motor vehicle collision axial ct images ct head ct anterior cyst polyp maxillary contrast intracranial sinuses spine axial head cervical noncontrast MEDICAL_TRANSCRIPTION,Description Common CT Chest template Medical Specialty Radiology Sample Name CT Chest Transcription TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast FINDINGS The heart size is normal and there is no pericardial effusion The aorta and great vessels are normal in caliber The central pulmonary arteries are patent with no evidence of embolus There is no significant mediastinal hilar or axillary lymphadenopathy The trachea and mainstem bronchi are patent The esophagus is normal in course and caliber The lungs are clear with no infiltrates effusions or masses There is no pneumothorax Scans through the upper abdomen are unremarkable The osseous structures in the chest are intact IMPRESSION No acute abnormalities Keywords radiology sequential axial ct images optiray pericardial effusion mediastinal hilar axillary lymphadenopathy ct chest upper abdomenNOTE MEDICAL_TRANSCRIPTION,Description Common CT C Spine template Medical Specialty Radiology Sample Name CT C Spine Transcription TECHNIQUE Sequential axial CT images were obtained through the cervical spine without contrast Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures FINDINGS The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture dislocation or spondylolisthesis The vertebral body heights and disc spaces are maintained The central canal is patent The pedicles and posterior elements are intact The paravertebral soft tissues are within normal limits The atlanto dens interval and the dens are intact The visualized lung apices are clear IMPRESSION No acute abnormalities Keywords radiology sequential axial ct images atlanto dens interval dens ct c spine cervical spineNOTE MEDICAL_TRANSCRIPTION,Description Stroke in distribution of recurrent artery of Huebner left Medical Specialty Radiology Sample Name CT Brain Stroke Transcription CC Falls HX This 51y o RHF fell four times on 1 3 93 because her legs suddenly gave out She subsequently noticed weakness involving the right leg and often required the assistance of her arms to move it During some of these episodes she appeared mildly pale and felt generally weak her husband would give her 3 teaspoons of sugar and she would appear to improve thought not completely During one episode she held her RUE in an odd fisted posture She denied any other focal weakness sensory change dysarthria diplopia dysphagia or alteration of consciousness She did not seek medical attention despite her weakness Then last night 1 4 93 she fell again and because her weakness did not subsequently improve she came to UIHC for evaluation on 1 5 93 MEDS Micronase 5mg qd HCTZ quit ASA 6 months ago tired of taking it PMH 1 DM type 2 dx 6 months ago 2 HTN 3 DJD 4 s p Vitrectomy and retinal traction OU for retinal detachment 7 92 5 s p Cholecystemomy 1968 6 Cataract implant OU 1992 7 s p C section FHX Grand Aunt stroke MG CAD Mother CAD died MI age 63 Father with unknown CA Sisters HTN No DM in relatives SHX Married lives with husband 4 children alive and well Denied tobacco ETOH illicit drug use ROS intermittent diarrhea for 20 years EXAM BP164 82 HR64 RR18 36 0C MS A O to person place time Speech fluent and without dysarthria Intact naming comprehension reading CN Pupils 4 5 irregular 4 0 irregular and virtually fixed Optic disks flat EOM intact VFFTC Right lower facial weakness The rest of the CN exam was unremarkable Motor 5 5 BUE with some question of breakaway LE HF and HE 4 5 KF5 5 AF and AE 5 5 Normal muscle bulk and tone Sensory intact PP VIB PROP LT T graphesthesia Coord slowed FNF and HKS worse on right Station no pronator drift or Romberg sign Gait Unsteady wide based gait Unable to heel walk on right Reflexes 2 2 throughout Slightly more brisk on right Plantar responses were downgoing bilaterally HEENT N0 Carotid or cranial bruits Gen Exam unremarkable COURSE CBC GS including glucose PT PTT EKG CXR on admission 1 5 93 were unremarkable HCT 1 5 93 revealed a hypodensity in the left caudate consistent with ischemic change Carotid Duplex 0 15 RICA 16 49 LICA antegrade vertebral artery flow bilaterally Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function No valvular abnormalities or thrombus were seen The patient s history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness Keywords MEDICAL_TRANSCRIPTION,Description A 68 year old white male with recently diagnosed adenocarcinoma by sputum cytology An abnormal chest radiograph shows right middle lobe infiltrate and collapse Patient needs staging CT of chest with contrast Medical Specialty Radiology Sample Name CT Chest 2 Transcription CLINICAL HISTORY A 68 year old white male with recently diagnosed adenocarcinoma by sputum cytology An abnormal chest radiograph shows right middle lobe infiltrate and collapse Patient needs staging CT of chest with contrast Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam TECHNIQUE Multiple transaxial images utilized in 10 mm sections were obtained through the chest Intravenous contrast was administered FINDINGS There is a large 3 x 4 cm lymph node seen in the right supraclavicular region There is a large right paratracheal lymph node best appreciated on image 16 which measures 3 x 2 cm A subcarinal lymph node is enlarged also It measures 6 x 2 cm Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm There is also a soft tissue density best appreciated on image 36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit The liver parenchyma is normal without evidence of any dominant masses The right kidney demonstrates a solitary cyst in the mid pole of the right kidney IMPRESSION 1 Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm 2 Extensive mediastinal adenopathy as described above 3 No lesion seen within the left lung at this time 4 Supraclavicular adenopathy Keywords radiology supraclavicular cervical adenopathy pulmonary nodules lymph node adenopathy pulmonary chest MEDICAL_TRANSCRIPTION,Description CT of Brain Subacute SDH Medical Specialty Radiology Sample Name CT Brain Subdural hematoma Transcription CC Progressive unsteadiness following head trauma HX A7 7 y o male fell as he was getting out of bed and struck his head 4 weeks prior to admission He then began to experience progressive unsteadiness and gait instability for several days after the fall He was then evaluated at a local ER and prescribed meclizine This did not improve his symptoms and over the past one week prior to admission began to develop left facial LUE LLE weakness He was seen by a local MD on the 12 8 92 and underwent and MRI Brain scan This showed a right subdural mass He was then transferred to UIHC for further evaluation PMH 1 cardiac arrhythmia 2 HTN 3 excision of lip lesion 1 yr ago SHX FHX Unremarkable No h o ETOH abuse MEDS Meclizine Procardia XL EXAM Afebrile BP132 74 HR72 RR16 MS A O x 3 Speech fluent Comprehension naming repetition were intact CN Left lower facial weakness only MOTOR Left hemiparesis 4 5 throughout Sensory intact PP TEMP LT PROP VIB Coordination ND Station left pronator drift Gait left hemiparesis evident by decreased LUE swing and LLE drag Reflexes 2 3 in UE 2 2 LE Right plantar downgoing Left plantar equivocal Gen Exam unremarkable COURSE Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto occipital regions on the right There was effacement of the right lateral ventricle and a 0 5 cm leftward midline shift He underwent a HCT on admission 12 8 92 which showed a right subdural hematoma He then underwent emergent evacuation of this hematoma He was discharged home 6 days after surgery Keywords radiology ct brain mri sdh subdural hematoma gait instability head trauma hematoma subacute subdural weakness hemiparesis MEDICAL_TRANSCRIPTION,Description CT chest with contrast Medical Specialty Radiology Sample Name CT Chest 1 Transcription EXAM CT chest with contrast REASON FOR EXAM Pneumonia chest pain short of breath and coughing up blood TECHNIQUE Postcontrast CT chest 100 mL of Isovue 300 contrast FINDINGS This study demonstrates a small region of coalescent infiltrates consolidation in the anterior right upper lobe There are linear fibrotic or atelectatic changes associated with this Recommend followup to ensure resolution There is left apical scarring There is no pleural effusion or pneumothorax There is lingular and right middle lobe mild atelectasis or fibrosis Examination of the mediastinal windows disclosed normal inferior thyroid Cardiac and aortic contours are unremarkable aside from mild atherosclerosis The heart is not enlarged There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions Very limited assessment of the upper abdomen demonstrates no definite abnormalities There are mild degenerative changes in the thoracic spine IMPRESSION 1 Anterior small right upper lobe infiltrate consolidation Recommend followup to ensure resolution given its consolidated appearance 2 Bilateral atelectasis versus fibrosis Keywords radiology pneumonia chest pain short of breath coughing up blood upper lobe infiltrate ct chest ct chest isovue MEDICAL_TRANSCRIPTION,Description CT Brain Subarachnoid hemorrhage Medical Specialty Radiology Sample Name CT Brain SAH Transcription CC Headache HX This 16 y o RHF was in good health until 11 00PM the evening of 11 27 87 when she suddenly awoke from sleep with severe headache Her parents described her as holding her head between her hands She had no prior history of severe headaches 30 minutes later she felt nauseated and vomited The vomiting continued every 30 minutes and she developed neck stiffness At 2 00AM on 11 28 97 she got up to go to the bathroom and collapsed in her mother s arms Her mother noted she appeared weak on the left side Shortly after this she experienced fecal and urinary incontinence She was taken to a local ER and transferred to UIHC PMH FHX SHX completely unremarkable FHx Has boyfriend and is sexually active Denied drug ETOH Tobacco use MEDS Oral Contraceptive pill QD EXAM BP152 82 HR74 RR16 T36 9C MS Somnolent and difficult to keep awake Prefer to lie on right side because of neck pain stiffness Answers appropriately though when questioned CN No papilledema noted Pupils 4 4 decreasing to 2 2 EOM Intact Face left facial weakness The rest of the CN exam was unremarkable Motor Upper extremities 5 3 with left pronator drift Lower extremities 5 4 with LLE weakness evident throughout Coordination left sided weakness evident Station left pronator drift Gait left hemiparesis Reflexes 2 2 throughout No clonus Plantars were flexor bilaterally Gen Exam unremarkable COURSE The patient underwent emergent CT Brain This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region She then underwent a 4 vessel cerebral angiogram This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus This suggested straight sinus thromboses MRI Brain was then done this was unremarkable and did not show sign of central venous thrombosis CBC Blood Cx ESR PT PTT GS CSF Cx ANA were negative Lumbar puncture on 12 1 87 revealed an opening pressure of 55cmH20 RBC18550 WBC25 18neutrophils 7lymphocytes Protein25mg dl Glucose47mg dl Cx negative The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use She recovered well but returned to Neurology at age 32 for episodic blurred vision and lightheadedness EEG was compatible with seizure tendency right greater than left theta bursts from the mid temporal regions and she was recommended an anticonvulsant which she refused Keywords radiology ct brain sah cerebral angiogram blurred vision lightheadedness central venous thrombosis subarachnoid hemorrhage pronator drift venous thrombosis ct brain subarachnoid hemorrhage pronator venous thrombosis weakness MEDICAL_TRANSCRIPTION,Description CT Brain Midbrain hemangioma Medical Specialty Radiology Sample Name CT Brain Hemangioma Transcription CC Horizontal diplopia HX This 67 y oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic The diplopia began acutely and continued intermittently for one year During this time he was twice evaluated for myasthenia gravis details of evaluation not known and was told he probably did not have this disease He received no treatment and the diplopia spontaneously resolved He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia The diplopia continues to occur daily and intermittently and lasts for only a few minutes in duration It resolves when he covers one eye It is worse when looking at distant objects and objects off to either side of midline There are no other symptoms associated with the diplopia PMH 1 4Vessel CABG and pacemaker placement 4 84 2 Hypercholesterolemia 3 Bipolar Affective D O FHX HTN Colon CA and a daughter with unknown type of dystonia SHX Denied Tobacco ETOH illicit drug use ROS no recent weight loss fever chills night sweats CP SOB He occasionally experiences bilateral lower extremity cramping claudication after walking for prolonged periods MEDS Lithium 300mg bid Accupril 20mg bid Cellufresh Ophthalmologic Tears ASA 325mg qd EXAM BP216 108 HR72 RR14 Wt81 6kg T36 6C MS unremarkable CN horizontal binocular diplopia on lateral gaze in both directions No other CN deficits noted Motor 5 5 full strength throughout with normal muscle bulk and tone Sensory unremarkable Coord mild ataxia of RAM left right Station no pronator drift or Romberg sign Gait unremarkable Reflexes 2 2 symmetric throughout Plantars bilateral dorsiflexion STUDIES COURSE Gen Screen unremarkable Brain CT revealed 1 0 x 1 5 cm area of calcific density within the medial two thirds of the left cerebral peduncle This shows no mass effect but demonstrates mild contrast enhancement There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease The midbrain findings are most suggestive of a hemangioma though another consideration would be a low grade astrocytoma this would likely show less enhancement Metastatic lesions could show calcification but one would expect to see some degree of edema The long standing clinical history suggest the former i e hemangioma No surgical or neuroradiologic intervention was done and the patient was simply followed He was lost to follow up in 1993 Keywords radiology hemangioma brain ct ct brain binocular diplopia calcific density diplopia horizontal binocular diplopia myasthenia gravis horizontal binocular midbrain binocular ct horizontal MEDICAL_TRANSCRIPTION,Description HCT Subdural hemorrhage Medical Specialty Radiology Sample Name CT Brain Subdural Hemorrhage Transcription CC Difficulty with speech HX This 84 y o RHF presented with sudden onset word finding and word phonation difficulties She had an episode of transient aphasia in 2 92 during which she had difficulty with writing written and verbal comprehension and exhibited numerous semantic and phonemic paraphasic errors of speech These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation Workup at that time revealed a right to left shunt on trans thoracic echocardiogram Carotid doppler studies showed 0 15 BICA stenosis and a LICA aneurysm mentioned above Brain CT was unremarkable She was placed on ASA after the 2 92 event In 5 92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only This was not felt to be a contusion nevertheless she was placed on Dilantin seizure prophylaxis Her left arm was casted and she returned home 5 hours prior to presentation today the patient began having difficulty finding words and putting them into speech She was able to comprehend speech This continued for an hour then partially resolved for one hour then returned then waxed and waned There was no reported weakness numbness incontinence seizure like activity incoordination HA nausea vomiting or lightheadedness MEDS ASA DPH Tenormin Premarin HCTZ PMH 1 transient fluent aphasia 2 92 which resolved 2 bilateral carotid endarterectomies 1986 3 HTN 4 distal left internal carotid artery aneurysm EXAM BP 168 70 Pulse 82 RR 16 35 8F MS A O x 3 Difficulty following commands Speech fluent and without dysarthria There were occasional phonemic paraphasic errors CN Unremarkable Motor 5 5 throughout except for 4 right wrist extension and right knee flexion Sensory unremarkable Coordination mild left finger nose finger dysynergia and dysmetria Gait mildly unsteady tandem walk Station no Romberg sign Reflexes slightly more brisk at the left patella than on the right Plantar responses were flexor bilaterally The remainder of the neurologic exam and the general physical exam were unremarkable LABS CBC WNL Gen Screen WNL PT PTT WNL DPH 26 2mcg ml CXR WNL EKG LBBB HCT revealed a left subdural hematoma COURSE Patient was taken to surgery and the subdural hematoma was evacuated Her mental status language skills improved dramatically The DPH dosage was adjusted appropriately Keywords radiology ct brain ct difficulty with speech hct subdural hemorrhage hemorrhage phonation difficulties subdural transient fluent aphasia phonemic paraphasic errors hematoma carotid speech MEDICAL_TRANSCRIPTION,Description CT Brain to evaluate episodic mental status change RUE numbness chorea and calcification of Basal Ganglia globus pallidi Medical Specialty Radiology Sample Name CT Brain Calcification of Basal Ganglia Transcription CC Episodic mental status change and RUE numbness and chorea found on exam HX This 78y o RHM was referred for an episode of unusual behavior and RUE numbness In 9 91 he experienced near loss of consciousness generalized weakness headache and vomiting Evaluation at that time revealed an serum glucose of 500mg dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms Since then he became progressively more forgetful and at the time of evaluation 1 17 93 had lost his ability to perform his job repairing lawn mowers His wife had taken over the family finances He had also been stumbling when ambulating for 2 months prior to presentation He was noted to be occasionally confused upon awakening for last several months On 1 15 93 he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason There had been no change in sleep appetite or complaint of depression In addition for two months prior to presentation he had been experiencing 10 15minute episodes of RUE numbness There was no face or lower extremity involvement During the last year he had developed unusual movements of his extremities MEDS NPH Humulin 12U qAM and 6U qPM Advil prn PMH 1 Traumatic amputation of the 4th and 5th digits of his left hand 2 Hospitalized for an unknown nervous condition in the 1940 s SHX FHX Retired small engine mechanic who worked in a poorly ventilated shop Married with 13 children No history of ETOH Tobacco or illicit drug use Father had tremors following a stroke Brother died of brain aneurysm No history of depression suicide or Huntington s disease in family ROS no history of CAD Renal or liver disease SOB Chest pain fevers chills night sweats or weight loss No report of sign of bleeding EXAM BP138 63 HR65 RR15 36 1C MS Alert and oriented to self season but not date year or place Latent verbal responses and direction following Intact naming but able to repeat only simple but not complex phrases Slowed speech with mild difficulty with word finding 2 3 recall at one minute and 0 3 at 3 minutes Knew the last 3 presidents 14 27 on MMSE unable to spell world backwards Unable to read write for complaint of inability to see without glasses CN II XII appeared grossly intact EOM were full and smooth and without unusual saccadic pursuits OKN intact Choreiform movements of the tongue were noted Motor 5 5 strength throughout with Guggenheim type resistance there were choreiform type movements of all extremities bilaterally No motor impersistence noted Sensory unreliable Cord normal FNF HKS and RAM bilaterally Station No Romberg sign Gait unsteady and wide based Reflexes BUE 2 2 Patellar 2 2 Ankles Trace Trace Plantars were flexor bilaterally Gen Exam 2 6 Systolic ejection murmur in aortic area COURSE No family history of Huntington s disease could be elicited from relatives Brain CT 1 18 93 bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact Carotid duplex 1 18 93 RICA 0 15 LICA 16 49 stenosis and normal vertebral artery flow bilaterally Transthoracic Echocardiogram TTE 1 18 93 revealed severe aortic fibrosis or valvular calcification with severe aortic stenosis in the face of normal LV function Cardiology felt the patient the patient had asymptomatic aortic stenosis EEG 1 20 93 showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant MRI Brain 1 22 93 multiple focal and more confluent areas of increased T2 signal in the periventricular white matter more prominent on the left in addition there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres and age related atrophy incidentally there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses Impression diffuse bilateral age related ischemic change age related atrophy and maxillary sinus disease There were no masses or areas of abnormal enhancement TSH FT4 Vit B12 VDRL Urine drug and heavy metal screens were unremarkable CSF 1 19 93 glucose 102 serum glucose 162mg dL Protein 45mg dL RBC O WBC O Cultures negative SPEP negative However serum and CSF beta2 microglobulin levels were elevated at 2 5 and 3 1mg L respectively Hematology felt these may have been false positives CBC 1 17 93 Hgb 10 4g dL low HCT 31 low RBC 3 34mil mm3 low WBC 5 8K mm3 Plt 201K mm3 Retic 30 1K mm3 normal Serum Iron 35mcg dL low TIBC 201mcg dL low FeSat 17 low CRP 0 1mg dL normal ESR 83mm hr high Bone Marrow Bx normal with adequate iron stores Hematology felt the finding were compatible with anemia of chronic disease Neuropsychologic evaluation on 1 17 93 revealed significant impairments in multiple realms of cognitive function visuospatial reasoning verbal and visual memory visual confrontational naming impaired arrhythmatic dysfluent speech marked by use of phrases no longer than 5 words frequent word finding difficulty and semantic paraphasic errors most severe for expressive language attention and memory The pattern of findings reveals an atypical aphasia suggestive of left temporo parietal dysfunction The patient was discharged1 22 93 on ASA 325mg qd He was given a diagnosis of senile chorea and dementia unspecified type 6 18 93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia Keywords radiology episodic mental status change huntington s disease brain ct transthoracic echocardiogram carotid duplex mental status change ct brain basal ganglia mental status globus pallidi aortic stenosis maxillary sinuses rue numbness basal ganglia globus pallidi therapy chorea ct rue brain MEDICAL_TRANSCRIPTION,Description CT Brain Suprasellar aneurysm pre and post bleed Medical Specialty Radiology Sample Name CT Brain Aneurysm Transcription CC Decreasing visual acuity HX This 62 y o RHF presented locally with a 2 month history of progressive loss of visual acuity OD She had a 2 year history of progressive loss of visual acuity OS and is now blind in that eye She denied any other symptomatology Denied HA PMH 1 depression 2 Blind OS MEDS None SHX FHX unremarkable for cancer CAD aneurysm MS stroke No h o Tobacco or ETOH use EXAM T36 0 BP121 85 HR 94 RR16 MS Alert and oriented to person place and time Speech fluent and unremarkable CN Pale optic disks OU Visual acuity 20 70 OD and able to detect only shadow of hand movement OS Pupils were pharmacologically dilated earlier The rest of the CN exam was unremarkable MOTOR 5 5 throughout with normal bulk and tone Sensory no deficits to LT PP VIB PROP Coord FNF RAM HKS intact bilaterally Station No pronator drift Gait ND Reflexes 3 3 BUE 2 2 BLE Plantar responses were flexor bilaterally Gen Exam unremarkable No carotid cranial bruits COURSE CT Brain showed large enhancing 4 x 4 x 3 cm suprasellar sellar mass without surrounding edema Differential dx included craniopharyngioma pituitary adenoma and aneurysm MRI Brain findings were consistent with an aneurysm The patient underwent 3 vessel cerebral angiogram on 12 29 92 This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis Emergent HCT showed no evidence of hemorrhage or sign of infarct Emergent carotid duplex showed no significant stenosis or clot The patient was left with an expressive aphasia and right hemiparesis SPECT scans were obtained on 1 7 93 and 2 24 93 They revealed hypoperfusion in the distribution of the left MCA and decreased left basal ganglia perfusion which may represent in part a mass effect from the LICA aneurysm She was discharged home and returned and underwent placement of a Selverstone Clamp on 3 9 93 The clamp was gradually and finally closed by 3 14 93 She did well and returned home On 3 20 93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia A HCT then showed SAH around her aneurysm which had thrombosed She was place on Nimodipine Her clinical status improved then on 3 25 93 she rapidly deteriorated over a 2 hour period to the point of lethargy complete expressive aphasia and right hemiplegia An emergent HCT demonstrated a left ACA and left MCA infarction She required intubation and worsened as cerebral edema developed She was pronounced brain dead Her organs were donated for transplant Keywords radiology ct brain hct mri brain suprasellar suprasellar aneurysm aneurysm cerebral angiogram craniopharyngioma internal carotid artery loss of visual acuity pituitary adenoma suprasellar sellar mass visual acuity expressive aphasia cerebral ct hemiparesis aphasia brain MEDICAL_TRANSCRIPTION,Description Abdominal pain CT examination of the abdomen and pelvis with intravenous contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis OB GYN Transcription EXAM CT examination of the abdomen and pelvis with intravenous contrast INDICATIONS Abdominal pain TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue 300 contrast administration Oral contrast was not administered There was no comparison of studies FINDINGS CT PELVIS Within the pelvis the uterus demonstrates a thickened appearing endometrium There is also a 4 4 x 2 5 x 3 4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology There is also a 2 5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid Several smaller fibroids were also suspected The ovaries are unremarkable in appearance There is no free pelvic fluid or adenopathy CT ABDOMEN The appendix has normal appearance in the right lower quadrant There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis The small and large bowels are otherwise unremarkable The stomach is grossly unremarkable There is no abdominal or retroperitoneal adenopathy There are no adrenal masses The kidneys liver gallbladder and pancreas are in unremarkable appearance The spleen contains several small calcified granulomas but no evidence of masses It is normal in size The lung bases are clear bilaterally The osseous structures are unremarkable other than mild facet degenerative changes at L4 L5 and L5 S1 IMPRESSION 1 Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4 4 x 2 5 x 3 4 cm 2 Multiple uterine fibroids 3 Prominent endometrium 4 Followup pelvic ultrasound is recommended Keywords radiology ovaries pelvic fluid adenopathy uterine segment cervix hypodense mass ct examination fibroids pelvic ct pelvis isovue abdomen MEDICAL_TRANSCRIPTION,Description Lower quadrant pain with nausea vomiting and diarrhea CT abdomen without contrast and CT pelvis without contrast Noncontrast axial CT images of the abdomen and pelvis are obtained Medical Specialty Radiology Sample Name CT Abdomen Pelvis 7 Transcription REASON FOR EXAM Lower quadrant pain with nausea vomiting and diarrhea TECHNIQUE Noncontrast axial CT images of the abdomen and pelvis are obtained FINDINGS Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material Gallstones are seen within the gallbladder lumen No abnormal pericholecystic fluid is seen The liver is normal in size and attenuation The spleen is normal in size and attenuation A 2 2 x 1 8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas No pancreatic ductal dilatation is seen There is no abnormal adjacent stranding No suspected pancreatitis is seen The kidneys show no stone formation or hydronephrosis The large and small bowels are normal in course and caliber There is no evidence for obstruction The appendix appears within normal limits In the pelvis the urinary bladder is unremarkable There is a 4 2 cm cystic lesion of the right adnexal region No free fluid free air or lymphadenopathy is detected There is left basilar atelectasis IMPRESSION 1 A 2 2 cm low attenuation lesion is seen at the pancreatic tail This is felt to be originating from the pancreas a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised Additionally when the patient s creatinine improves a contrast enhanced study utilizing pancreatic protocol is needed Alternatively an MRI may be obtained 2 Cholelithiasis 3 Left basilar atelectasis 4 A 4 2 cm cystic lesion of the right adnexa correlation with pelvic ultrasound is advised Keywords radiology ct abdomen ct pelvis neoplasm lesion attenuation hydronephrosis stone formation ct images cystic lesion abdomen cystic pancreatic ct pelvis intravenous noncontrast MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain nausea diarrhea and recent colonic resection CT abdomen with and without contrast and CT pelvis with contrast Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 Medical Specialty Radiology Sample Name CT Abdomen Pelvis 8 Transcription CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain nausea diarrhea and recent colonic resection in 11 08 TECHNIQUE Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 FINDINGS The liver is normal in size and attenuation The gallbladder is normal The spleen is normal in size and attenuation The adrenal glands and pancreas are unremarkable The kidneys are normal in size and attenuation No hydronephrosis is detected Free fluid is seen within the right upper quadrant within the lower pelvis A markedly thickened loop of distal small bowel is seen This segment measures at least 10 cm long No definite pneumatosis is appreciated No free air is apparent at this time Inflammatory changes around this loop of bowel Mild distention of adjacent small bowel loops measuring up to 3 5 cm is evident No complete obstruction is suspected as there is contrast material within the colon Postsurgical changes compatible with the partial colectomy are noted Postsurgical changes of the anterior abdominal wall are seen Mild thickening of the urinary bladder wall is seen IMPRESSION 1 Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis An inflammatory process such as infection or ischemia must be considered Close interval followup is necessary 2 Thickening of the urinary bladder wall is nonspecific and may be due to under distention However evaluation for cystitis is advised Keywords radiology abdominal pain nausea diarrhea colonic resection axial ct images ct abdomen isovue inflammatory urinary bladder abdominal colonic wall thickening axial bowel contrast attenuation pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description Chest pain shortness of breath and cough evaluate for pulmonary arterial embolism CT angiography chest with contrast Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 Medical Specialty Radiology Sample Name CT Angiography Transcription CT ANGIOGRAPHY CHEST WITH CONTRAST REASON FOR EXAM Chest pain shortness of breath and cough evaluate for pulmonary arterial embolism TECHNIQUE Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 FINDINGS There is no evidence for pulmonary arterial embolism The lungs are clear of any abnormal airspace consolidation pleural effusion or pneumothorax No abnormal mediastinal or hilar lymphadenopathy is seen Limited images of the upper abdomen are unremarkable No destructive osseous lesion is detected IMPRESSION Negative for pulmonary arterial embolism Keywords radiology airspace consolidation pleural effusion pneumothorax lymphadenopathy hilar ct angiography pulmonary arterial arterial embolism angiography ct chest arterial pulmonary embolism isovue MEDICAL_TRANSCRIPTION,Description CT abdomen without contrast and pelvis without contrast reconstruction Medical Specialty Radiology Sample Name CT Abdomen Pelvis 5 Transcription EXAM CT abdomen without contrast and pelvis without contrast reconstruction REASON FOR EXAM Right lower quadrant pain rule out appendicitis TECHNIQUE Noncontrast CT abdomen and pelvis An intravenous line could not be obtained for the use of intravenous contrast material FINDINGS The appendix is normal There is a moderate amount of stool throughout the colon There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process Examination of the extreme lung bases appear clear no pleural effusions The visualized portions of the liver spleen adrenal glands and pancreas appear normal given the lack of contrast There is a small hiatal hernia There is no intrarenal stone or evidence of obstruction bilaterally There is a questionable vague region of low density in the left anterior mid pole region this may indicate a tiny cyst but it is not well seen given the lack of contrast This can be correlated with a followup ultrasound if necessary The gallbladder has been resected There is no abdominal free fluid or pathologic adenopathy There is abdominal atherosclerosis without evidence of an aneurysm Dedicated scans of the pelvis disclosed phleboliths but no free fluid or adenopathy There are surgical clips present There is a tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection IMPRESSION 1 Normal appendix 2 Moderate stool throughout the colon 3 No intrarenal stones 4 Tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection The report was faxed upon dictation Keywords radiology reconstruction appendicitis urinary tract infection ct abdomen abdomen ct pelvis contrast noncontrast MEDICAL_TRANSCRIPTION,Description Shortness of breath for two weeks and a history of pneumonia CT angiography chest with contrast Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 Medical Specialty Radiology Sample Name CT Angiography 1 Transcription CT ANGIOGRAPHY CHEST WITH CONTRAST REASON FOR EXAM Shortness of breath for two weeks and a history of pneumonia The patient also has a history of left lobectomy TECHNIQUE Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 FINDINGS There is no evidence of any acute pulmonary arterial embolism The main pulmonary artery is enlarged showing a diameter of 4 7 cm Cardiomegaly is seen with mitral valvular calcifications Postsurgical changes of a left upper lobectomy are seen Left lower lobe atelectasis is noted A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe image 12 A small left pleural effusion is noted Right lower lobe atelectasis is present There is a right pleural effusion greater than as seen on the left side A right lower lobe pulmonary nodule measures 1 5 cm There is a calcified granuloma within the right lower lobe IMPRESSION 1 Negative for pulmonary arterial embolism 2 Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension 3 Cardiomegaly with mitral valvular calcifications 4 Postsurgical changes of a left upper lobectomy 5 Bilateral pleural effusions right greater than left with bilateral lower lobe atelectasis 6 Bilateral lower lobe nodules pulmonary nodules and interval followup in three months to confirm stability versus further characterization with prior studies is advised Keywords radiology shortness of breath pneumonia pulmonary embolism isovue 300 axial ct images ct angiography lower lobe pulmonary lobectomy isovue angiography arterial atelectasis pleural ct embolism MEDICAL_TRANSCRIPTION,Description Right sided abdominal pain with nausea and fever CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Radiology Sample Name CT Abdomen Pelvis 6 Transcription REASON FOR EXAM Right sided abdominal pain with nausea and fever TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas gallbladder adrenal glands and kidney are unremarkable CT PELVIS Within the right lower quadrant the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant Findings are compatible with acute appendicitis The large and small bowels are normal in course and caliber without obstruction The urinary bladder is normal The uterus appears unremarkable Mild free fluid is seen in the lower pelvis No destructive osseous lesions are seen The visualized lung bases are clear IMPRESSION Acute appendicitis Keywords radiology adrenal glands appendicitis gallbladder kidney liver pancreas spleen acute appendicitis ct pelvis ct abdomen abdominal contrast fluid abdomen inflammatory pelvis ct MEDICAL_TRANSCRIPTION,Description CT brain post craniectomy RMCA stroke and SBE Medical Specialty Radiology Sample Name CT Brain Transcription CC Left sided weakness HX This 28y o RHM was admitted to a local hospital on 6 30 95 for a 7 day history of fevers chills diaphoresis anorexia urinary frequency myalgias and generalized weakness He denied foreign travel IV drug abuse homosexuality recent dental work or open wound Blood and urine cultures were positive for Staphylococcus Aureus oxacillin sensitive He was place on appropriate antibiotic therapy according to sensitivity A 7 3 95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation Later that day he developed left sided weakness and severe dysarthria and aphasia HCT on 7 3 95 revealed mild attenuated signal in the right hemisphere On 7 4 95 he developed first degree AV block and was transferred to UIHC MEDS Nafcillin 2gm IV q4hrs Rifampin 600mg q12hrs Gentamicin 130mg q12hrs PMH 1 Heart murmur dx age 5 years FHX Unremarkable SHX Employed cook Denied ETOH Tobacco illicit drug use EXAM BP 123 54 HR 117 RR 16 37 0C MS Somnolent and arousable only by shaking and repetitive verbal commands He could follow simple commands only He nodded appropriately to questioning most of the time Dysarthric speech with sparse verbal output CN Pupils 3 3 decreasing to 2 2 on exposure to light Conjugate gaze preference toward the right Right hemianopia by visual threat testing Optic discs flat and no retinal hemorrhages or Roth spots were seen Left lower facial weakness Tongue deviated to the left Weak gag response bilaterally Weak left corneal response MOTOR Dense left flaccid hemiplegia SENSORY Less responsive to PP on left COORD Unable to test Station and Gait Not tested Reflexes 2 3 throughout more brisk on the left side Left ankle clonus and a Left Babinski sign were present GEN EXAM Holosystolic murmur heard throughout the precordium Janeway lesions were present in the feet and hands No Osler s nodes were seen COURSE 7 6 95 HCT showed a large RMCA stroke with mass shift His neurologic exam worsened and he was intubated hyperventilated and given IV Mannitol He then underwent emergent left craniectomy and duraplasty He tolerated the procedure well and his brain was allowed to swell He then underwent mitral valve replacement on 7 11 95 with a St Judes valve His post operative recovery was complicated by pneumonia pericardial effusion and dysphagia He required temporary PEG placement for feeding The 7 27 95 8 6 95 and 10 18 96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke His 10 18 96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop His proximal LLE strength was rated at a 4 His LUE was plegic He had a seizure 6 days prior to his 10 18 96 evaluation This began as a Jacksonian march of shaking in the LUE then involved the LLE There was no LOC or tongue biting He did have urinary incontinence He was placed on DPH His speech was dysarthric but fluent He appeared bright alert and oriented in all spheres Keywords radiology ct brain rmca anorexia chills craniectomy diaphoresis fevers myalgias stroke urinary frequency echocardiogram holosystolic murmur pneumonia pericardial effusion tongue biting sided weakness mitral valve rmca stroke ct hct weakness MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain with swelling at the site of the ileostomy CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Radiology Sample Name CT Abdomen Pelvis 9 Transcription CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain with swelling at the site of the ileostomy TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas adrenal glands and kidneys are unremarkable Punctate calcifications in the gallbladder lumen likely represent a gallstone CT PELVIS Postsurgical changes of a left lower quadrant ileostomy are again seen There is no evidence for an obstruction A partial colectomy and diverting ileostomy is seen within the right lower quadrant The previously seen 3 4 cm subcutaneous fluid collection has resolved Within the left lower quadrant a 3 4 cm x 2 5 cm loculated fluid collection has not significantly changed This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded No obstruction is seen The appendix is not clearly visualized The urinary bladder is unremarkable IMPRESSION 1 Resolution of the previously seen subcutaneous fluid collection 2 Left pelvic 3 4 cm fluid collection has not significantly changed in size or appearance These findings may be due to a pelvic abscess 3 Right lower quadrant ileostomy has not significantly changed 4 Cholelithiasis Keywords radiology axial ct images isovue 300 ct pelvis ct abdomen fluid collection abdomen obstruction subcutaneous abscess pelvic fluid collection pelvis ileostomy ct isovue MEDICAL_TRANSCRIPTION,Description Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT abdomen without contrast and CT pelvis without contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis 10 Transcription CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST REASON FOR EXAM Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT ABDOMEN There is no evidence for a retroperitoneal hematoma The liver spleen adrenal glands and pancreas are unremarkable Within the superior pole of the left kidney there is a 3 9 cm cystic lesion A 3 3 cm cystic lesion is also seen within the inferior pole of the left kidney No calcifications are noted The kidneys are small bilaterally CT PELVIS Evaluation of the bladder is limited due to the presence of a Foley catheter the bladder is nondistended The large and small bowels are normal in course and caliber There is no obstruction Bibasilar pleural effusions are noted IMPRESSION 1 No evidence for retroperitoneal bleed 2 There are two left sided cystic lesions within the kidney correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam 3 The kidneys are small in size bilaterally 4 Bibasilar pleural effusions Keywords radiology cystic lesion superior pole kidney ct pelvis ct abdomen retroperitoneal hematoma lesion kidneys bladder bibasilar pleural effusions lesions pelvis hematoma retroperitoneal cystic ct abdomen MEDICAL_TRANSCRIPTION,Description CT abdomen and pelvis without contrast stone protocol reconstruction Medical Specialty Radiology Sample Name CT Abdomen Pelvis 4 Transcription EXAM CT abdomen and pelvis without contrast stone protocol reconstruction REASON FOR EXAM Flank pain TECHNIQUE Noncontrast CT abdomen and pelvis with coronal reconstructions FINDINGS There is no intrarenal stone bilaterally However there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right The right renal pelvis is not dilated There is no stone along the course of the ureter I cannot exclude the possibility of recent stone passage although the findings are ultimately technically indeterminate and clinical correlation is advised There is no obvious solid appearing mass given the lack of contrast Scans of the pelvis disclose no evidence of stone within the decompressed bladder No pelvic free fluid or adenopathy There are few scattered diverticula There is a moderate amount of stool throughout the colon There are scattered diverticula but no CT evidence of acute diverticulitis The appendix is normal There are mild bibasilar atelectatic changes Given the lack of contrast visualized portions of the liver spleen adrenal glands and the pancreas are grossly unremarkable The gallbladder is present There is no abdominal free fluid or pathologic adenopathy There are degenerative changes of the lumbar spine IMPRESSION 1 Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding There is no stone identified along the course of the left ureter or in the bladder Could this patient be status post recent stone passage Clinical correlation is advised 2 Diverticulosis 3 Moderate amount of stool throughout the colon 4 Normal appendix Keywords radiology coronal reconstructions stone protocol renal pelvic dilatation proximal ureteral dilatation ct abdomen and pelvis stone protocol reconstruction abdomen and pelvis perinephric stranding free fluid scattered diverticula renal dilatation contrast ureteral ct abdomen pelvis stone noncontrast MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis without and with intravenous contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis 2 Transcription EXAM CT scan of the abdomen and pelvis without and with intravenous contrast CLINICAL INDICATION Left lower quadrant abdominal pain COMPARISON None FINDINGS CT scan of the abdomen and pelvis was performed without and with intravenous contrast Total of 100 mL of Isovue was administered intravenously Oral contrast was also administered The lung bases are clear The liver is enlarged and decreased in attenuation There are no focal liver masses There is no intra or extrahepatic ductal dilatation The gallbladder is slightly distended The adrenal glands pancreas spleen and left kidney are normal A 12 mm simple cyst is present in the inferior pole of the right kidney There is no hydronephrosis or hydroureter The appendix is normal There are multiple diverticula in the rectosigmoid There is evidence of focal wall thickening in the sigmoid colon image 69 with adjacent fat stranding in association with a diverticulum These findings are consistent with diverticulitis No pneumoperitoneum is identified There is no ascites or focal fluid collection The aorta is normal in contour and caliber There is no adenopathy Degenerative changes are present in the lumbar spine IMPRESSION Findings consistent with diverticulitis Please see report above Keywords radiology extrahepatic ductal dilatation gallbladder glands pancreas spleen kidney adrenal abdomen and pelvis ct scan intravenous abdomen MEDICAL_TRANSCRIPTION,Description Abnormal liver enzymes and diarrhea CT pelvis with contrast and ct abdomen with and without contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis 11 Transcription EXAM CT pelvis with contrast and ct abdomen with and without contrast INDICATIONS Abnormal liver enzymes and diarrhea TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration Pre contrast images through the abdomen were also obtained COMPARISON There were no comparison studies FINDINGS The lung bases are clear The liver demonstrates mild intrahepatic biliary ductal dilatation These findings may be secondary to the patient s post cholecystectomy state The pancreas spleen adrenal glands and kidneys are unremarkable There is a 13 mm peripheral enhancing fluid collection in the anterior pararenal space of uncertain etiology There are numerous nonspecific retroperitoneal and mesenteric lymph nodes These may be reactive however an early neoplastic process would be difficult to totally exclude There is a right inguinal hernia containing a loop of small bowel This may produce a partial obstruction as there is mild fluid distention of several small bowel loops particularly in the right lower quadrant The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine The urinary bladder is unremarkable The uterus is not visualized IMPRESSION 1 Right inguinal hernia containing small bowel Partial obstruction is suspected 2 Nonspecific retroperitoneal and mesenteric lymph nodes 3 Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology 4 Diverticulosis without evidence of diverticulitis 5 Status post cholecystectomy with mild intrahepatic biliary ductal dilatation 6 Osteopenia and degenerative changes of the spine and pelvis Keywords radiology pre contrast images contrast biliary ductal dilatation pancreas spleen adrenal glands kidneys mesenteric lymph nodes fluid collection inguinal hernia ct abdomen hernia diverticulosis diverticulitis osteopenia degenerative spine bowel pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description CT of the abdomen and pelvis without contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis 3 Transcription EXAM CT of the abdomen and pelvis without contrast HISTORY Lower abdominal pain FINDINGS Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis There is a 1 6 cm nodular density at the left posterior sulcus Noncontrast technique limits evaluation of the solid abdominal organs Cardiomegaly and atherosclerotic calcifications are seen Hepatomegaly is observed There is calcification within the right lobe of the liver likely related to granulomatous changes Subtle irregularity of the liver contour is noted suggestive of cirrhosis There is splenomegaly seen There are two low attenuation lesions seen in the posterior aspect of the spleen which are incompletely characterized that may represent splenic cyst The pancreas appears atrophic There is a left renal nodule seen which measures 1 9 cm with a Hounsfield unit density of approximately 29 which is indeterminate There is mild bilateral perinephric stranding There is an 8 mm fat density lesion in the anterior inner polar region of the left kidney compatible in appearance with angiomyolipoma There is a 1 cm low attenuation lesion in the upper pole of the right kidney likely representing a cyst but incompletely characterized on this examination Bilateral ureters appear normal in caliber along their visualized course The bladder is partially distended with urine but otherwise unremarkable Postsurgical changes of hysterectomy are noted There are pelvic phlebolith seen There is a calcified soft tissue density lesion in the right pelvis which may represent an ovary with calcification as it appears continuous with the right gonadal vein Scattered colonic diverticula are observed The appendix is within normal limits The small bowel is unremarkable There is an anterior abdominal wall hernia noted containing herniated mesenteric fat The hernia neck measures approximately 2 7 cm There is stranding of the fat within the hernia sac There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis Degenerative changes of the spine are observed IMPRESSION 1 Anterior abdominal wall hernia with mesenteric fat containing stranding suggestive of incarcerated fat 2 Nodule in the left lower lobe recommend follow up in 3 months 3 Indeterminate left adrenal nodule could be further assessed with dedicated adrenal protocol CT or MRI 4 Hepatomegaly with changes suggestive of cirrhosis There is also splenomegaly observed 5 Low attenuation lesions in the spleen may represent cyst that are incompletely characterized on this examination 6 Fat density lesion in the left kidney likely represents angiomyolipoma 7 Fat density soft tissue lesion in the region of the right adnexa this contains calcifications and may represent an ovary or possibly dermoid cyst Keywords radiology abdominal pain cardiomegaly atherosclerotic calcifications hepatomegaly perinephric stranding low attenuation lesions abdominal calcifications lesions abdomen MEDICAL_TRANSCRIPTION,Description CT Abdomen and Pelvis with contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis 1 Transcription EXAM CT Abdomen and Pelvis with contrast REASON FOR EXAM Nausea vomiting diarrhea for one day Fever Right upper quadrant pain for one day COMPARISON None TECHNIQUE CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement CT ABDOMEN Lung bases are clear The liver gallbladder spleen pancreas and bilateral adrenal kidneys are unremarkable The aorta is normal in caliber There is no retroperitoneal lymphadenopathy CT PELVIS The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change Per CT the colon and small bowel are unremarkable The bladder is distended No free fluid air Visualized osseous structures demonstrate no definite evidence for acute fracture malalignment or dislocation IMPRESSION 1 Unremarkable exam specifically no evidence for acute appendicitis 2 No acute nephro ureterolithiasis 3 No secondary evidence for acute cholecystitis Results were communicated to the ER at the time of dictation Keywords radiology liver gallbladder spleen pancreas adrenal kidneys lymphadenopathy abdomen and pelvis contrast ct MEDICAL_TRANSCRIPTION,Description CT Abdomen Pelvis W WO Contrast Medical Specialty Radiology Sample Name CT Abdomen Pelvis Transcription EXAM CT Abdomen Pelvis W WO Contrast REASON FOR EXAM Status post aortobiiliac graft repair TECHNIQUE 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement No oral or rectal contrast was utilized Comparison is made with the prior CT abdomen and pelvis dated 10 20 05 There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3 7 cm transversely x 3 4 AP Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips The size of the native aneurysm component at this level is stable at 5 5 cm in diameter with mural thrombus surrounding the enhancing endolumen There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak Further distally there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either No exoluminal leakage is identified at any level There is no retroperitoneal hematoma present The findings are unchanged from the prior exam The liver spleen pancreas adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present There is advanced atrophy of the left kidney No hydronephrosis is present No acute findings are identified elsewhere in the abdomen The lung bases are clear Concerning the remainder of the pelvis no acute pathology is identified There is prominent streak artifact from the left total hip replacement There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis The bladder grossly appears normal A hysterectomy has been performed IMPRESSION 1 No complications identified regarding endoluminal aortoiliac graft repair as described The findings are stable compared to the study of 10 20 04 2 Stable mild aneurysm of aortic aneurysm centered roughly at renal artery level 3 No other acute findings noted 4 Advanced left renal atrophy Keywords radiology aortobiiliac graft repair renal atrophy ct abdomen pelvis w wo contrast aortic aneurysm renal artery mural thrombus endoluminal leak ct abdomen ct contrast pelvis abdomen MEDICAL_TRANSCRIPTION,Description CCTA with Cardiac Function Calcium Scoring Medical Specialty Radiology Sample Name Coronary CT Angiography CCTA 2 Transcription CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY PROCEDURE Breath hold cardiac CT was performed using a 64 channel CT scanner with a 0 5 second rotation time Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL sec Retrospective ECG gating was performed The patient received 0 4 milligrams of sublingual nitroglycerin prior to the to the scan The average heart rate was 62 beats min The patient had no adverse reaction to the contrast Multiphase retrospective reconstructions were performed Small field of view cardiac and coronary images were analyzed on a 3D work station Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease CORONARY CTA 1 The technical quality of the scan is adequate 2 The coronary ostia are in their normal position The coronary anatomy is right dominant 3 LEFT MAIN The left main coronary artery is patent without angiographic stenosis 4 LEFT ANTERIOR DESCENDING ARTERY The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30 in stenosis severity Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities 5 The ramus intermedius is a small vessel with minor irregularities 6 LEFT CIRCUMFLEX The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis 7 RIGHT CORONARY ARTERY The right coronary artery is a large and dominant vessel It demonstrates within its mid segment calcified atherosclerosis less than 50 stenosis severity Left ventricular ejection fraction is calculated to be 69 There are no wall motion abnormalities 8 Coronary calcium score was calculated to be 79 indicating at least mild atherosclerosis within the coronary vessels ANCILLARY FINDINGS None FINAL IMPRESSION 1 Mild coronary artery disease with a preserved left ventricular ejection fraction of 69 2 Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy Thank you for referring this patient to us Keywords radiology coronary ct angiography ventricular ejection fraction anterior descending artery coronary artery disease coronary ct ct angiography cardiac ct obtuse marginal ventricular ejection ejection fraction coronary artery artery angiography coronary ccta atherosclerosis ventricular beats min anterior vessel stenosis ct cardiac disease MEDICAL_TRANSCRIPTION,Description Coronary Artery CTA with Calcium Scoring and Cardiac Function Medical Specialty Radiology Sample Name Coronary CT Angiography CCTA 3 Transcription EXAM Coronary artery CTA with calcium scoring and cardiac function HISTORY Chest pain TECHNIQUE AND FINDINGS Coronary artery CTA was performed on a Siemens dual source CT scanner Post processing on a Vitrea workstation 150 mL Ultravist 370 was utilized as the intravenous contrast agent Patient did receive nitroglycerin sublingually prior to the contrast HISTORY Significant for high cholesterol overweight chest pain family history Patient s total calcium score Agatston is 10 his places the patient just below the 75th percentile for age The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque The distal LAD was unreadable while the proximal was normal The mid and distal right coronary artery are not well delineated due to beam hardening artifact The circumflex is diminutive in size along its proximal portion Distal is not readable Cardiac wall motion within normal limits No gross pulmonary artery abnormality however they are not well delineated A full report was placed on the patient s chart Report was saved to PACS Keywords radiology coronary artery cta calcium scoring cardiac function coronary artery ct scoring lad midportion cta calcium cardiac coronary artery angiography MEDICAL_TRANSCRIPTION,Description Conformal simulation with coplanar beams This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated Medical Specialty Radiology Sample Name Conformal Simulation Transcription CONFORMAL SIMULATION WITH COPLANAR BEAMS This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated It allows us to highly focus the beam of radiation and shape the beam to the target volume delivering a homogenous dosage through it while sparing the surrounding more radiosensitive normal tissues This will allow us to give the optimum chance of tumor control while minimizing the acute and long term side effects A conformal simulation is a simulation which involves extended physician therapist and dosimetrist time and effort The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized One then approximates the field sizes and arrangements gantry angles collimator angles and number of fields Radiographs are taken and these fields are marked on the patient s skin The patient is then transferred to the diagnostic facility and placed on a flat CT scan table Scans are then performed through the targeted area The CT scans are evaluated by the radiation oncologist and the tumor volume target volume and critical structures are outlined on each slice of the CT scan The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures This volume is then reconstructed in 3 dimensional space Utilizing the beam s eye view features the appropriate blocks are designed Multiplane computerized dosimetry is performed throughout the volume Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan each individual slice is then reviewed by the physician The beam s eye view block design and appropriate volumes are also printed and reviewed by the physician Once these are approved Cerrobend blocks will be custom fabricated If significant changes are made in the field arrangements from the original simulation the patient is brought back to the simulator where the computer designed fields are re simulated Keywords radiology coplanar beams ct scan target volume conformal simulation beamsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description CCTA with cardiac function and calcium scoring Medical Specialty Radiology Sample Name Coronary CT Angiography CCTA 1 Transcription HISTORY Coronary artery disease TECHNIQUE AND FINDINGS Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual source CT scanner with postprocessing on Vitrea workstation Patient received oral Metoprolol 100 milligrams 100 ml Ultravist 370 was utilized as the contrast agent 0 4 milligrams of nitroglycerin was given Patient s calcium score 164 volume 205 this places the patient between the 75th and 90th percentile for age There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible Cardiac wall motion was within normal limits Left ventricular ejection fraction calculated to be 82 End diastolic volume 98 mL end systolic volume calculated to be 18 mL There is normal coronary artery origins There is codominance between the right coronary artery and the circumflex artery There is mild to moderate stenosis of the proximal LAD with mixed plaque Mild stenosis mid LAD with mixed plaque No stenosis Distal LAD with the distal vessel becoming diminutive in size Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque Once again the distal vessel becomes diminutive in size Circumflex shows mild stenosis due to focal calcified plaque proximally No stenosis is seen involving the mid or distal circumflex The distal circumflex also becomes diminutive in size The left main shows small amount of focal calcified plaque without stenosis Myocardium pericardium and wall motion was unremarkable as seen IMPRESSION 1 Atherosclerotic coronary artery disease with values as above There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery 2 Consider cardiology consult and further evaluation if clinically indicated 3 Full report was sent to the PACS Report will be mailed to Dr ABC Keywords radiology coronary ct angiography vitrea workstation cardiac wall motion proximal lad distal lad focal calcified plaque coronary artery disease cardiac function calcium scoring wall motion distal vessel calcified plaque distal circumflex artery disease mild stenosis coronary artery ccta scoring atherosclerotic vessel calcium calcified lad circumflex distal plaque coronary artery stenosis MEDICAL_TRANSCRIPTION,Description Chest PA Lateral to evaluate shortness of breath and pneumothorax versus left sided effusion Medical Specialty Radiology Sample Name Chest PA Lateral Transcription EXAM Chest PA Lateral REASON FOR EXAM Shortness of breath evaluate for pneumothorax versus left sided effusion INTERPRETATION There has been interval development of a moderate left sided pneumothorax with near complete collapse of the left upper lobe The lower lobe appears aerated There is stable diffuse bilateral interstitial thickening with no definite acute air space consolidation The heart and pulmonary vascularity are within normal limits Left sided port is seen with Groshong tip at the SVC RA junction No evidence for acute fracture malalignment or dislocation IMPRESSION 1 Interval development of moderate left sided pneumothorax with corresponding left lung atelectasis 2 Rest of visualized exam nonacute stable 3 Left central line appropriately situated and stable 4 Preliminary report was issued at time of dictation Dr X was called for results Keywords radiology effusion interstitial thickening chest pa lateral shortness of breath chest pneumothorax MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms Medical Specialty Radiology Sample Name Cerebral Angiogram MRA Transcription CC Transient visual field loss HX This 58 y o RHF had a 2 yr h o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations She was evaluated by a local physician several days prior to this presentation 1 7 91 for clumsiness of her right hand and falling HCT and MRI brain revealed bilateral posterior clinoid masses MEDS Colace Quinidine Synthroid Lasix Lanoxin KCL Elavil Tenormin PMH 1 Obesity 2 VBG 1990 3 A Fib 4 HTN 5 Hypothyroidism 6 Hypercholesterolemia 7 Briquet s syndrome h o of hysterical paralysis 8 CLL dx 1989 in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil prednisone chemotherapy 10 95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil prednisone 1 10 96 she received 3000cGy to right parotid mass 9 SNHL FHX Father died MI age 61 SHX Denied Tobacco ETOH illicit drug use EXAM Vitals were unremarkable The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face diffusely about the left upper and lower face per neurosurgery notes The neuro ophthalmologic exam was unremarkable per Neuro ophthalmology COURSE She underwent Cerebral Angiography on 1 8 91 This revealed a 15x17x20mm LICA paraclinoid ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid ophthalmic artery aneurysm On 1 16 91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped She has complained of headaches since Keywords radiology visual field loss transient visual field cerebral angiography ophthalmic paraclinoid aneurysm paraclinoid ophthalmic cavernous frontotemporal craniotomy exam was unremarkable artery aneurysms mra visual parotid cerebral artery neurologic aneurysms angiogram MEDICAL_TRANSCRIPTION,Description Chest CT Thymoma and history of ocular myasthenia gravis Medical Specialty Radiology Sample Name Chest CT Myasthenia Gravis Transcription CC Intermittent binocular horizontal vertical and torsional diplopia HX 70y o RHM referred by Neuro ophthalmology for evaluation of neuromuscular disease In 7 91 he began experiencing intermittent binocular horizontal vertical and torsional diplopia which was worse and frequent at the end of the day and was eliminated when closing one either eye An MRI Brain scan at that time was unremarkable He was seen at UIHC Strabismus Clinic in 5 93 for these symptoms On exam he was found to have intermittent right hypertropia in primary gaze and consistent diplopia in downward and rightward gaze This was felt to possibly represent Grave s disease Thyroid function studies were unremarkable but orbital echography suggested Graves orbitopathy The patient was then seen in the Neuro ophthalmology clinic on 12 23 92 His exam remained unchanged He underwent Tensilon testing which was unremarkable On 1 13 93 he was seen again in Neuro ophthalmology His exam remained relatively unchanged and repeat Tensilon testing was unremarkable He then underwent a partial superior rectus resection OD with only mild improvement of his diplopia During his 8 27 96 Neuro ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid His diplopia subsequently improved but did not resolve The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid At present he denied any fatigue on repetitive movement He denied dysphagia SOB dysarthria facial weakness fevers chills night sweats weight loss or muscle atrophy MEDS Viokase Probenecid Mestinon 30mg tid PMH 1 Gastric ulcer 30 years ago 2 Cholecystectomy 3 Pancreatic insufficiency 4 Gout 5 Diplopia FHX Mother died age 89 of old age Father died age 89 of stroke Brother age 74 with CAD Sister died age 30 of cancer SHX Retired insurance salesman and denies history of tobacco or illicit drug us He has no h o ETOH abuse and does not drink at present EXAM BP 155 104 HR 92 RR 12 Temp 34 6C WT 76 2kg MS Unremarkable Normal speech with no dysarthria CN Right hypertropia worse on rightward gaze and less on leftward gaze Minimal to no ptosis OD No ptosis OS VFFTC No complaint of diplopia The rest of the CN exam was unremarkable MOTOR 5 5 strength throughout with normal muscle bulk and tone SENSORY No deficits appreciated on PP VIB LT PROP TEMP testing Coordination Station Gait Unremarkable Reflexes 2 2 throughout Plantar responses were flexor on the right and withdrawal on the left HEENT and GEN EXAM Unremarkable COURSE EMG NCV 9 26 96 Repetitive stimulation studies of the median facial and spinal accessory nerves showed no evidence of decrement at baseline and at intervals up to 3 minutes following exercise The patient had been off Mestinon for 8 hours prior to testing Chest CT with contrast 9 26 96 revealed a 4x2 5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch This was highly suggestive of a thymoma There were diffuse emphysematous disease with scarring in the lung bases A few nodules suggestive of granulomas and few calcified perihilar lymph nodes He underwent thoracotomy and resection of the mass Pathologic analysis was consistent with a thymoma lymphocyte predominant type with capsular and pleural invasion and extension to the phrenic nerve resection margin Acetylcholine Receptor binding antibody titer 12 8nmol L normal 0 7 Acetylcholine receptor blocking antibody 10 normal Acetylcholine receptor modulating antibody 42 normal 19 Striated muscle antibody 1 320 normal 1 10 Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma He was subsequently treated with XRT and continued to complain of fatigue at his 4 18 97 Oncology visit Keywords radiology diplopia neuromuscular disease muscle antibody titers chest ct intermittent binocular rightward gaze striated muscle myasthenia gravis intermittent torsional binocular myasthenia chest thymoma ophthalmology antibody MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery Medical Specialty Radiology Sample Name Cerebral Angiogram Left ICA PCA Aneurysm Transcription CC Fluctuating level of consciousness HX 59y o male experienced a pop in his head on 10 10 92 while showering in Cheyenne Wyoming He was visiting his son at the time He was found unconscious on the shower floor 1 5 hours later His son then drove him Back to Iowa Since then he has had recurrent headaches and fluctuating level of consciousness according to his wife He presented at local hospital this AM 10 13 92 A HCT there demonstrated a subarachnoid hemorrhage He was then transferred to UIHC MEDS none PMH 1 Right hip and clavicle fractures many years ago 2 All of his teeth have been removed FHX Not noted SHX Cigar smoker Truck driver EXAM BP 193 73 HR 71 RR 21 Temp 37 2C MS A O to person place and time No note regarding speech or thought process CN Subhyaloid hemorrhages OU Pupils 4 4 decreasing to 2 2 on exposure to light Face symmetric Tongue midline Gag response difficult to elicit Corneal responses not noted MOTOR 5 5 strength throughout Sensory Intact PP VIB Reflexes 2 2 throughout Plantars were flexor bilaterally Gen Exam unremarkable COURSE The patient underwent Cerebral Angiography on 10 13 92 This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery The patient subsequently underwent clipping of this aneurysm He recovery was complicated severe vasospasm and bacterial meningitis HCT on 10 19 92 revealed multiple low density areas in the left hemisphere in the LACA LPCA watershed left fronto parietal area and left thalamic region He was left with residual right hemiparesis urinary incontinence some unspecified degree of mental dysfunction He was last seen 2 26 93 in Neurosurgery clinic and had stable deficits Keywords radiology consciousness level of consciousness hct subhyaloid hemorrhages cerebral angiography carotid artery communication artery laca lpca fluctuating level of consciousness internal carotid artery lobulated aneurysm lobulated supraclinoid cerebral aneurysm artery angiogram MEDICAL_TRANSCRIPTION,Description Postcontrast CT chest pulmonary embolism protocol 100 mL of Isovue 300 contrast is utilized Medical Specialty Radiology Sample Name Chest Pulmonary Angio Transcription EXAM CTA chest pulmonary angio REASON FOR EXAM Evaluate for pulmonary embolism TECHNIQUE Postcontrast CT chest pulmonary embolism protocol 100 mL of Isovue 300 contrast is utilized FINDINGS There are no filling defects in the main or main right or left pulmonary arteries No central embolism The proximal subsegmental pulmonary arteries are free of embolus but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal findings would be discussed in more detail below There is no evidence of a central embolism As seen on the prior examination there is a very large heterogeneous right chest wall mass which measures at least 10 x 12 cm based on axial image 35 Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3 3 cm Given the short interval time course from the prior exam dated 01 23 09 this finding has not significantly changed However there is considerable change in the appearance of the lung fields There are now bilateral pleural effusions small on the right and moderate on the left with associated atelectasis There are also extensive right lung consolidations all new or increased significantly from the prior examination Again identified is a somewhat spiculated region of increased density at the right lung apex which may indicate fibrosis or scarring but the possibility of primary or metastatic disease cannot be excluded There is no pneumothorax in the interval On the mediastinal windows there is presumed subcarinal adenopathy with one lymph node measuring roughly 12 mm suggestive of metastatic disease here There is aortic root and arch and descending thoracic aortic calcification There are scattered regions of soft plaque intermixed with this The heart is not enlarged The left axilla is intact in regards to adenopathy The inferior thyroid appears unremarkable Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe this finding is indeterminate and if there is need for additional imaging in regards to hepatic metastatic disease follow up ultrasound Spleen adrenal glands and upper kidneys appear unremarkable Visualized portions of the pancreas are unremarkable There is extensive rib destruction in the region of the chest wall mass There are changes suggesting prior trauma to the right clavicle IMPRESSION 1 Again demonstrated is a large right chest wall mass 2 No central embolus distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings are not well assessed 3 New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung 4 See above regarding other findings Keywords radiology chest pulmonary embolism chest pulmonary embolism protocol bilateral pleural effusions chest wall mass metastatic disease pulmonary isovue subsegmental metastatic disease mass lung embolism chest angio MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram Lateral medullary syndrome secondary to left vertebral artery dissection Medical Specialty Radiology Sample Name Cerebral Angiogram Lateral Medullary Syndrome Transcription CC Falling to left HX 26y oRHF fell and struck her head on the ice 3 5 weeks prior to presentation There was no associated loss of consciousness She noted a dull headache and severe sharp pain behind her left ear 8 days ago The pain lasted 1 2 minutes in duration The next morning she experienced difficulty walking and consistently fell to the left In addition the left side of her face had become numb and she began choking on food Family noted her pupils had become unequal in size She was seen locally and felt to be depressed and admitted to a psychiatric facility She was subsequently transferred to UIHC following evaluation by a local ophthalmologist MEDS Prozac and Ativan both recently started at the psychiatric facility PMH 1 Right esotropia and hyperopia since age 1year 2 Recurrent UTI FHX Unremarkable SHX Divorced Lives with children No spontaneous abortions Denied ETOH Tobacco Illicit Drug use EXAM BP 138 110 HR 85 RR 16 Temp 37 2C MS A O to person place time Speech fluent and without dysarthria Intact naming comprehension repetition CN Pupils 4 2 decreasing to 3 1 on exposure to light Optic Disks flat VFFTC Esotropia OD otherwise EOM full Horizontal nystagmus on leftward gaze Decreased corneal reflex OS Decreased PP TEMP sensation on left side of face Light touch testing normal Decreased gag response on left Uvula deviates to right The rest of the CN exam was unremarkable Motor 5 5 strength throughout with normal muscle bulk and tone Sensory Decreased PP and TEMP on right side of body PROP VIB intact Coord Difficulty with FNF HKS RAM on left Normal on right side Station No pronator drift Romberg test not noted Gait unsteady with tendency to fall to left Reflexes 3 3 throughout BUE and Patellae 2 2 Achilles Plantar responses were flexor bilaterally Gen Exam Obese In no acute distress Otherwise unremarkable HEENT No carotid vertebral cranial bruits COURSE PT PTT GS CBC TSH FT4 and Cholesterol screen were all within normal limits HCT on admission was negative MRI Brain done locally 2 2 93 was reviewed and a left lateral medullary stroke was appreciated The patient underwent a cerebral angiogram on 2 3 93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery There is severe irregular narrowing of the horizontal portion above the posterior arch of C1 The findings were felt consistent with a left vertebral artery dissection Neuro opthalmology confirmed a left Horner s pupil by clinical exam and history Cookie swallow study was unremarkable The Patient was placed on Heparin then converted to Coumadin The PT on discharge was 17 She remained on Coumadin for 3 months and then was switched to ASA for 1 year An Otolaryngologic evaluation on 10 96 noted true left vocal cord paralysis with full glottic closure A prosthesis was made and no surgical invention was done Keywords radiology horner s pupil mri brain otolaryngologic cerebral angiogram cerebral angiogram lateral medullary syndrome vertebral artery angiogram syndrome falling narrowing medullary vertebral cerebral MEDICAL_TRANSCRIPTION,Description Concomitant chemoradiotherapy for curative intent patients Medical Specialty Radiology Sample Name Concomitant Chemoradiotherapy Transcription CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer The chemotherapy is given in addition to the radiotherapy not only to act as a cytotoxic agent on its own but also to potentiate and enhance the effect of radiotherapy on tumor cells It has been shown in the literature that this will maximize the chance of control During the course of the treatment the patient s therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held This combined treatment usually produces greater side effects than either treatment alone and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects In accordance this requires more frequency consultation and coordination with the medical oncologist Therefore this becomes a very time intensive treatment and justifies CPT Code 77470 Keywords radiology tumor cells concomitant chemoradiotherapy chemotherapy radiotherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient with chest pains CAD and cardiomyopathy Medical Specialty Radiology Sample Name Cardiac Radionuclide Stress Test Transcription INDICATION FOR STUDY Chest pains CAD and cardiomyopathy MEDICATIONS Humulin lisinopril furosemide spironolactone omeprazole carvedilol pravastatin aspirin hydrocodone and diazepam BASELINE EKG Sinus rhythm at 71 beats per minute left anterior fascicular block LVBB PERSANTINE RESULTS Heart rate increased from 70 to 72 Blood pressure decreased from 160 84 to 130 78 The patient felt slightly dizziness but there was no chest pain or EKG changes NUCLEAR PROTOCOL Same day rest stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test 53 mg of Persantine were used reversed with 125 mg of aminophylline NUCLEAR RESULTS 1 Nuclear perfusion imaging review of the raw projection data reveals adequate image acquisition The resting images are normal The post Persantine images show mildly decreased uptake in the septum The sum score is 0 2 The Gated SPECT shows enlarged heart with a preserved EF of 52 IMPRESSION 1 Mild septal ischemia Likely due to the left bundle branch block 2 Mild cardiomyopathy EF of 52 3 Mild hypertension at 160 84 4 Left bundle branch block Keywords radiology cardiac radionuclide spect sinus rhythm cardiac radionuclide stress test bundle branch block stress test bundle branch chest pains stress test cardiomyopathy nuclear MEDICAL_TRANSCRIPTION,Description Carotid and cerebral arteriogram abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery Medical Specialty Radiology Sample Name Carotid Cerebral Arteriograms Transcription EXAM Carotid and cerebral arteriograms INDICATION Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery IMPRESSION 1 Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin 2 Mild stenosis of the right internal carotid artery measured at 20 3 Patent bilateral vertebral arteries 4 No significant disease was identified of the anterior cerebral vessels DISCUSSION Carotid and cerebral arteriograms were performed on Month DD YYYY previous studies are not available for comparison The right groin was sterilely cleansed and draped Lidocaine 1 buffered with sodium bicarbonate was used as local anesthetic A 19 French needle was then advanced into the common femoral artery and a wire was advanced Over the wire a sheath was placed A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire Flushed arteriogram was performed Arteriogram demonstrated no significant disease of the great vessels at their origins There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin The vertebral arteries were widely patent Following this the flushed catheter was exchanged for catheter and selective catheterization of the common carotid artery on the right was performed Carotid and cerebral arteriograms were performed The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable The external carotid artery on the right is quite tortuous in its appearance The internal carotid artery demonstrates a mild plaque creating stenosis which is measured approximately 20 Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal No significant stenosis identified There is complete cross filling into the left brain via the right No significant stenosis was appreciated Following this the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion The patient tolerated the procedure well No complications occurred during or immediately after the procedure Stasis was achieved of the puncture site using a VasoSeal The patient will be observed for at least 2 1 2 hours prior to being discharged to home Keywords radiology carotid arteriogram bulb carotid duplex catheter cerebral distal femoral artery internal carotid artery needle occlusion sheath stenosis vertebral arteries vessels cerebral arteriograms carotid artery artery arteriograms wire MEDICAL_TRANSCRIPTION,Description Cardiolite treadmill exercise stress test The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2 3 METS Medical Specialty Radiology Sample Name Cardiolite Treadmill Stress Test Transcription CARDIOLITE TREADMILL EXERCISE STRESS TEST CLINICAL DATA This is a 72 year old female with history of diabetes mellitus hypertension and right bundle branch block PROCEDURE The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2 3 METS There was a normal blood pressure response The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest no other significant electrographic abnormalities were observed Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc 99 Cardiolite At peak pharmacological effect the patient was injected with 30 mCi Tc 99 Cardiolite Gating poststress tomographic imaging was performed 30 minutes after the stress FINDINGS 1 The overall quality of the study is fair 2 The left ventricular cavity appears to be normal on the rest and stress studies 3 SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and or reperfusion defect 4 The left ventricular ejection fraction was normal and estimated to be 78 IMPRESSION Myocardial perfusion imaging is normal Result of this test suggests low probability for significant coronary artery disease Keywords radiology peak heart rate bundle branch block perfusion imaging stress test mci ventricular cardiolite treadmill MEDICAL_TRANSCRIPTION,Description Bilateral carotid ultrasound Medical Specialty Radiology Sample Name Carotid Ultrasound Transcription EXAM Bilateral carotid ultrasound REASON FOR EXAM Headache TECHNIQUE Color grayscale and Doppler analysis is employed FINDINGS On the grayscale images the right common carotid artery demonstrates patency with mild intimal thickening only At the level of the carotid bifurcation there is heterogeneous hard plaque present but without grayscale evidence of greater than 50 stenosis Right common carotid waveform is normal with a peak systolic velocity of 0 474 m second and an end diastolic velocity of 0 131 m second The right ECA is patent as well with the velocity measurement 0 910 m second The right internal carotid artery at the bifurcation demonstrates plaque formation but no evidence of greater than 50 stenosis Proximal peak systolic velocity in the internal carotid artery is 0 463 m second with proximal end diastolic velocity of 0 170 The mid internal carotid peak systolic velocity is 0 564 m second and mid ICA end diastolic velocity is 0 199 m second Right ICA distal PSV 0 580 m second right ICA distal EDV 0 204 m second Vertebral flow is antegrade on the right at 0 469 m second On the left the common carotid artery demonstrates intimal thickening but is otherwise patent At the level of the bifurcation however there is more pronounced plaque formation with approximately 50 stenosis by the grayscale analysis See the velocity measurements below Left carotid ECA measurement 0 938 m second Left common carotid PSV 0 686 m second and left common carotid end diastolic velocity 0 137 m second Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50 stenosis This should be further assessed with CTA for more precise measurement The left proximal ICA PSV 0 955 m second left proximal ICA EDV 0 287 m second There is spectral broadening in the proximal aspect of the carotid waveform The left carotid ICA mid PSV 0 895 left carotid ICA mid EDV 0 278 with also spectral broadening present The left distal ICA PSV 0 561 left distal ICA EDV 0 206 again the spectral broadening present Vertebral flow is antegrade at 0 468 m second IMPRESSION The study demonstrates bilateral hard plaque at the bifurcation left greater than right There is at least 50 stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment Keywords radiology doppler analysis headache edv ica eca psv distal ica edv hard plaque bilateral carotid ultrasound peak systolic velocity internal carotid artery plaque formation carotid ultrasound carotid artery carotid stenosis proximal artery velocity MEDICAL_TRANSCRIPTION,Description Carotid Ultrasonic Color Flow Imaging Medical Specialty Radiology Sample Name Carotid Doppler Report Transcription Grade II Atherosclerotic plaques are seen which appear to be causing 40 60 obstruction Grade III Atherosclerotic plaques are seen which appear to be causing greater than 60 obstruction Grade IV The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it RIGHT CAROTID SYSTEM The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease The internal carotid artery shows intimal thickening with some mixed plaques but no increase in velocity and no evidence for any significant obstructive disease The external carotid artery shows no disease The vertebral was present and was antegrade LEFT CAROTID SYSTEM The common carotid artery and bulb area shows mild intimal thickening but no increase in velocity and no evidence for any significant obstructive disease the internal carotid artery shows some intimal thickening with mixed plaques but no increase in velocity and no evidence for any significant obstructive disease The external carotid artery shows no disease The vertebral was present and was antegrade IMPRESSION Bilateral atherosclerotic changes with no evidence for any significant obstructive disease Keywords radiology atherosclerotic atherosclerotic plaques obstructive disease carotid artery carotid artery and bulb common carotid artery mild intimal thickening external carotid artery common carotid internal carotid external carotid intimal thickening carotid intimal plaques artery MEDICAL_TRANSCRIPTION,Description Bilateral Mammogram abnormal additional views requested Medical Specialty Radiology Sample Name Bilateral Mammogram Transcription EXAM Mammographic screening FFDM HISTORY 40 year old female who is on oral contraceptive pills She has no present symptomatic complaints No prior history of breast surgery nor family history of breast CA TECHNIQUE Standard CC and MLO views of the breasts COMPARISON This is the patient s baseline study FINDINGS The breasts are composed of moderately to significantly dense fibroglandular tissue The overlying skin is unremarkable There are a tiny cluster of calcifications in the right breast near the central position associated with 11 30 on a clock There are benign appearing calcifications in both breasts as well as unremarkable axillary lymph nodes There are no spiculated masses or architectural distortion IMPRESSION Tiny cluster of calcifications at the 11 30 position of the right breast Recommend additional views spot magnification in the MLO and CC views of the right breast BIRADS Classification 0 Incomplete MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD Second Look Software Version 7 2 was utilized Keywords radiology ffdm mammographic screening tiny cluster of calcifications bilateral mammogram additional views bilateral mammogram cluster breasts calcifications mammography MEDICAL_TRANSCRIPTION,Description Carotid artery angiograms Medical Specialty Radiology Sample Name Bilateral Carotid Angiography Transcription PROCEDURE PERFORMED 1 Selective ascending aortic arch angiogram 2 Selective left common carotid artery angiogram 3 Selective right common carotid artery angiogram 4 Selective left subclavian artery angiogram 5 Right iliac angio with runoff 6 Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections INDICATIONS FOR PROCEDURE TIA aortic stenosis postoperative procedure Moderate carotid artery stenosis ESTIMATED BLOOD LOSS 400 ml SPECIMENS REMOVED Not applicable TECHNIQUE OF PROCEDURE After obtaining informed consent the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state The right groin was prepped and draped in the usual sterile fashion Lidocaine 2 was used for infiltration anesthesia Using modified Seldinger technique a 6 French sheath was placed into the right common femoral artery and vein without complication Using injection through the side port of the sheath a right iliac angiogram with runoff was performed Following this straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed Following this selective engagement in left common carotid artery right common carotid artery and left subclavian artery angiograms were performed with a V Tech catheter over an 0 035 inch wire ANGIOGRAPHIC FINDINGS 1 Type 2 aortic arch 2 Left subclavian artery was patent 3 Left vertebral artery was patent 4 Left internal carotid artery had a 40 to 50 lesion with ulceration not treated and there was no cerebral cross over 5 Right common carotid artery had a 60 to 70 lesion which was heavily calcified and was not treated with the summed left to right cross over flow 6 Closure was with a 6 French Angio Seal of the artery and the venous sheath was sutured in PLAN Continue aspirin Plavix and Coumadin to an INR of 2 with a carotid duplex followup Keywords radiology aortic arch angiogram carotid artery angiogram artery was patent common carotid artery arch angiogram subclavian artery aortic arch carotid artery carotid angiography artery angiograms subclavian catheterization aortic angiogram MEDICAL_TRANSCRIPTION,Description Ultrasound BPP Advanced maternal age and hypertension Medical Specialty Radiology Sample Name Biophysical Profile 1 Transcription HISTORY Advanced maternal age and hypertension FINDINGS There is a single live intrauterine pregnancy with a vertex lie posterior placenta and adequate amniotic fluid The amniotic fluid index is 23 2 cm Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03 28 08 Based on fetal measurements obtained today estimated fetal weight is 3249 plus or minus 396 g 7 pounds 3 ounces plus or minus 14 ounces which places the fetus in the 66th percentile for the estimated gestational age Fetal heart motion at a rate of 156 beats per minute is documented The cord Doppler ratio is normal at 2 2 The biophysical profile score assessing fetal breathing movement gross body movement fetal tone and qualitative amniotic fluid volume is 8 8 IMPRESSION 1 Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03 28 08 2 Biophysical profile BPP score 8 8 Keywords radiology ultrasound bpp maternal age intrauterine pregnancy biophysical profile amniotic fluid gestational age amniotic gestational fetal MEDICAL_TRANSCRIPTION,Description Diagnostic mammogram full field digital ultrasound of the breast and mammotome core biopsy of the left breast Medical Specialty Radiology Sample Name Breast Ultrasound Biopsy Transcription EXAM Bilateral diagnostic mammogram left breast ultrasound and biopsy HISTORY 30 year old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder The patient has a family history of breast cancer within her mother at age 58 Patient denies personal history of breast cancer TECHNIQUE AND FINDINGS Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm dd yy An additional lateromedial projection of the right breast was obtained The breasts demonstrate heterogeneously dense fibroglandular tissue Within the upper outer aspect of the left breast there is evidence of a circumscribed density measuring approximately 1 cm x 0 7 cm in diameter No additional dominant mass areas of architectural distortion or malignant type calcifications are seen Multiple additional benign appearing calcifications are visualized bilaterally Skin overlying both breasts is unremarkable Bilateral breast ultrasound was subsequently performed which demonstrated an ovoid mass measuring approximately 0 5 x 0 5 x 0 4 cm in diameter located within the anteromedial aspect of the left shoulder This mass demonstrates isoechoic echotexture to the adjacent muscle with no evidence of internal color flow This may represent benign fibrous tissue or a lipoma Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o clock position measuring 0 7 x 0 7 x 0 8 cm in diameter At this time the lesion was determined to be amenable by ultrasound guided core biopsy The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o clock position of the left breast Informed consent was obtained The lesion was re localized under ultrasound guidance The left breast was prepped and draped in the usual sterile fashion 2 lidocaine was administered locally for anesthesia Additional lidocaine with epinephrine was administered around the distal aspect of the lesion A small skin nick was made Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides The lateral to medial approach was performed with an 11 gauge Mammotome device The device was advanced under ultrasound guidance with the superior aspect of the lesion placed within the aperture Two core biopsies were obtained The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion consistent with a rapidly expanding hematoma Arterial blood was visualized exiting the access site A biopsy clip was attempted to be placed however could not be performed secondary to the active hemorrhage Therefore the Mammotome was removed and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved Postprocedural imaging of the 2 o clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1 9 x 4 4 x 1 3 cm in diameter The left breast was re cleansed with a ChloraPrep and a pressure bandage and ice packing were applied to the left breast The patient was observed in the ultrasound department for the following 30 minutes without complaints The patient was subsequently discharged with information and instructions on utilizing the ice bandage The obtained specimens were sent to pathology for further analysis IMPRESSION 1 A mixed solid and cystic lesion at the 2 o clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument and multiple core biopsies were obtained Transient arterial hemorrhage was noted at the biopsy site resulting in a localized 4 cm hematoma Pressure was applied until hemostasis was achieved The patient was monitored for approximately 30 minutes after the procedure and was ultimately discharged in good condition The core biopsies were submitted to pathology for further analysis 2 Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow and likely represents fibrotic changes or a lipoma 3 Suspicious mammographic findings The circumscribed density measuring approximately 8 mm at the 2 o clock position of the left breast was subsequently biopsied Further pathologic analysis is pending BIRADS Classification 4 Suspicious findings MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD SecondLook Software Version 7 2 was utilized Keywords radiology mammotome core biopsy diagnostic mammogram breast cancer bilateral breasts circumscribed density ovoid mass breast ultrasound core biopsy lesion biopsy breast hematoma mammotome mammography ultrasound MEDICAL_TRANSCRIPTION,Description BPP of Gravida 1 para 0 at 33 weeks 5 days by early dating The patient is developing gestational diabetes Medical Specialty Radiology Sample Name Biophysical Profile Transcription CLINICAL HISTORY Gravida 1 para 0 at 33 weeks 5 days by early dating The patient is developing gestational diabetes Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation The placenta was posterior in position There was normal fetal breathing movement gross body movement and fetal tone and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18 2 cm The following measurements were obtained Biparietal diameter 8 54 cm head circumference 30 96 cm abdominal circumference 29 17 cm and femoral length 6 58 cm These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation CONCLUSION Normal biophysical profile BPP with a score of 8 out of possible 8 The fetus is size appropriate for gestation Keywords radiology biophysical profile gestational diabetes amniotic fluid bpp gravida para diabetes fetus fetalNOTE MEDICAL_TRANSCRIPTION,Description Brain CT and MRI suprasellar mass pituitary adenoma Medical Specialty Radiology Sample Name Brain MRI Pituitary Adenoma Transcription CC Orthostatic lightheadedness HX This 76 y o male complained of several months of generalized weakness and malaise and a two week history of progressively worsening orthostatic dizziness The dizziness worsened when moving into upright positions In addition he complained of intermittent throbbing holocranial headaches which did not worsen with positional change for the past several weeks He had lost 40 pounds over the past year and denied any recent fever SOB cough vomiting diarrhea hemoptysis melena hematochezia bright red blood per rectum polyuria night sweats visual changes or syncopal episodes He had a 100 pack year history of tobacco use and continued to smoke 1 to 2 packs per day He has a history of sinusitis EXAM BP 98 80 mmHg and pulse 64 BPM supine BP 70 palpable mmHG and pulse 84BPM standing RR 12 Afebrile Appeared fatigued CN unremarkable Motor and Sensory exam unremarkable Coord Slowed but otherwise unremarkable movements Reflexes 2 2 and symmetric throughout all 4 extremities Plantar responses were flexor bilaterally The rest of the neurologic and general physical exam was unremarkable LAB Na 121 meq L K 4 2 meq L Cl 90 meq L CO2 20meq L BUN 12mg DL CR 1 0mg DL Glucose 99mg DL ESR 30mm hr CBC WNL with nl WBC differential Urinalysis SG 1 016 and otherwise WNL TSH 2 8 IU ML FT4 0 9ng DL Urine Osmolality 246 MOSM Kg low Urine Na 35 meq L COURSE The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved but returned within 24 48hrs Further laboratory studies revealed Aldosterone serum 2ng DL low 30 minute Cortrosyn Stimulation test pre 6 9ug DL borderline low post 18 5ug DL normal stimulation rise Prolactin 15 5ng ML no baseline given FSH and LH were within normal limits for males Testosterone 33ng DL wnl Sinus XR series done for history of headache showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids There was also an abnormal calcification seen in the middle of the sellar region A left maxillary sinus opacity with air fluid level was seen Goldman visual field testing was unremarkable Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma He was treated with Fludrocortisone 0 05 mg BID and within 24hrs despite discontinuation of IV fluids remained hemodynamically stable and free of symptoms of orthostatic hypotension His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing 1 1997 though he has developed dementia felt secondary to cerebrovascular disease stroke TIA Keywords radiology brain ct goldman mri orthostatic adenoma generalized weakness hypotension lightheadedness malaise pituitary sinus opacity suprasellar mass brain ct and mri orthostatic hypotension pituitary adenoma brain sinusitis sellar MEDICAL_TRANSCRIPTION,Description Barium enema history of encopresis and constipation Medical Specialty Radiology Sample Name Barium Enema Transcription EXAM Barium enema CLINICAL HISTORY A 4 year old male with a history of encopresis and constipation TECHNIQUE A single frontal scout radiograph of the abdomen was performed A rectal tube was inserted in usual sterile fashion and retrograde instillation of barium contrast was followed via spot fluoroscopic images A post evacuation overhead radiograph of the abdomen was performed FINDINGS The scout radiograph demonstrates a nonobstructive gastrointestinal pattern There are no suspicious calcifications seen or evidence of gross free intraperitoneal air The visualized lung bases and osseous structures are within normal limits The rectum and colon is of normal caliber throughout its course There is no evidence of obstruction as contrast is seen to flow without difficulty into the right colon and cecum A small amount of contrast is seen to opacify small bowel loops on the post evacuation image There is also opacification of a normal appearing appendix documented IMPRESSION Normal barium enema Keywords radiology encopresis and constipation scout radiograph post evacuation barium enema encopresis constipation evacuation colon radiograph contrast enema barium MEDICAL_TRANSCRIPTION,Description Arterial imaging of bilateral lower extremities Medical Specialty Radiology Sample Name Arterial Imaging Transcription INDICATIONS Peripheral vascular disease with claudication RIGHT 1 Normal arterial imaging of right lower extremity 2 Peak systolic velocity is normal 3 Arterial waveform is triphasic 4 Ankle brachial index is 0 96 LEFT 1 Normal arterial imaging of left lower extremity 2 Peak systolic velocity is normal 3 Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic 4 Ankle brachial index is 1 06 IMPRESSION Normal arterial imaging of both lower extremities Keywords radiology peripheral vascular disease ankle brachial index arterial waveform peak systolic velocity arterial imaging biphasic claudication lower extremities lower extremity posterior tibial artery triphasic systolic velocity is normal arterial waveform is triphasic waveform is triphasic normal arterial imaging systolic velocity brachial index velocity brachial imaging arterial MEDICAL_TRANSCRIPTION,Description MRI brain PET scan Dementia of Alzheimer type with primary parietooccipital involvement Medical Specialty Radiology Sample Name Alzheimer Disease Transcription CC Memory difficulty HX This 64 y o RHM had had difficulty remembering names phone numbers and events for 12 months prior to presentation on 2 28 95 This had been called to his attention by the clerical staff at his parish he was a Catholic priest He had had no professional or social faux pas or mishaps due to his memory He could not tell whether his problem was becoming worse so he brought himself to the Neurology clinic on his own referral MEDS None PMH 1 appendectomy 2 tonsillectomy 3 childhood pneumonia 4 allergy to sulfa drugs FHX Both parents experienced memory problems in their ninth decades but not earlier 5 siblings have had no memory trouble There are no neurological illnesses in his family SHX Catholic priest Denied Tobacco ETOH illicit drug use EXAM BP131 74 HR78 RR12 36 9C Wt 77kg Ht 178cm MS A O to person place and time 29 30 on MMSE 2 3 recall at 5 minutes 2 10 word recall at 10 minutes Unable to remember the name of the President Clinton 23words 60 sec on Category fluency testing normal Mild visual constructive deficit The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted COURSE TSH 5 1 T4 7 9 RPR non reactive Neuropsychological evaluation 3 6 95 revealed 1 well preserved intellectual functioning and orientation 2 significant deficits in verbal and visual memory proper naming category fluency and working memory 3 performances which were below expectations on tests of speed of reading visual scanning visual construction and clock drawing 4 limited insight into the scope and magnitude of cognitive dysfunction The findings indicated multiple areas of cerebral dysfunction With the exception of the patient s report of minimal occupational dysfunction which may reflect poor insight the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer s disease MRI brain 3 6 95 showed mild generalized atrophy more severe in the occipital parietal regions In 4 96 his performance on repeat neuropsychological evaluation was relatively stable His verbal learning and delayed recognition were within normal limits whereas delayed recall was moderately severely impaired Immediate and delayed visual memory were slightly below expectations Temporal orientation and expressive language skills were below expectation especially in word retrieval These findings were suggestive of particular but not exclusive involvement of the temporal lobes On 9 30 96 he was evaluated for a 5 minute spell of visual loss OU The episode occurred on Friday 9 27 96 in the morning while sitting at his desk doing paperwork He suddenly felt that his gaze was pulled toward a pile of letters then a curtain came down over both visual fields like everything was in the shade During the episode he felt fully alert and aware of his surroundings He concurrently heard a grating sound in his head After the episode he made several phone calls during which he reportedly sounded confused and perseverated about opening a bank account He then drove to visit his sister in Muscatine Iowa without accident He was reportedly normal when he reached her house He was able to perform Mass over the weekend without any difficulty Neurologic examination 9 30 96 was notable for 1 category fluency score of 18items 60 sec 2 VFFTC and EOM were intact There was no RAPD INO loss of visual acuity Glucose 178 elevated ESR Lipid profile GS CBC with differential Carotid duplex scan EKG and EEG were all normal MRI brain 9 30 96 was unchanged from previous 3 6 95 On 1 3 97 he had a 30 second spell of lightheadedness without vertigo but with balance difficulty after picking up a box of books The episode was felt due to orthostatic changes 1 8 97 neuropsychological evaluation was stable and his MMSE score was 25 30 with deficits in visual construction orientation and 2 3 recall at 1 minute Category fluency score 23 items 60 sec Neurologic exam was notable for graphesthesia in the left hand In 2 97 he had episodes of anxiety marked fluctuations in job performance and resigned his pastoral position His neurologic exam was unchanged An FDG PET scan on 2 14 97 revealed decreased uptake in the right posterior temporal parietal and lateral occipital regions Keywords radiology dementia a o to person alzheimer s disease alzheimer s type mmse mmse score mri brain memory difficulty neuropsychological balance difficulty category fluency faux pas minimal occupational dysfunction parieto occipital progressive dementia syndrome visual acuity visual loss visual memory pet scan neuropsychological evaluation alzheimer s neurological memory MEDICAL_TRANSCRIPTION,Description Left heart cath selective coronary angiogram right common femoral angiogram and StarClose closure of right common femoral artery Medical Specialty Radiology Sample Name Angiogram StarClose Closure Transcription EXAM Left heart cath selective coronary angiogram right common femoral angiogram and StarClose closure of right common femoral artery REASON FOR EXAM Abnormal stress test and episode of shortness of breath PROCEDURE Right common femoral artery 6 French sheath JL4 JR4 and pigtail catheters were used FINDINGS 1 Left main is a large caliber vessel It is angiographically free of disease 2 LAD is a large caliber vessel It gives rise to two diagonals and septal perforator It erupts around the apex LAD shows an area of 60 to 70 stenosis probably in its mid portion The lesion is a type A finishing before the takeoff of diagonal 1 The rest of the vessel is angiographically free of disease 3 Diagonal 1 and diagonal 2 are angiographically free of disease 4 Left circumflex is a small to moderate caliber vessel gives rise to 1 OM It is angiographically free of disease 5 OM 1 is angiographically free of disease 6 RCA is a large dominant vessel gives rise to conus RV marginal PDA and one PL RCA has a tortuous course and it has a 30 to 40 stenosis in its proximal portion 7 LVEDP is measured 40 mmHg 8 No gradient between LV and aorta is noted Due to contrast concern due to renal function no LV gram was performed Following this right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery IMPRESSION 1 60 to 70 mid left anterior descending stenosis 2 Mild 30 to 40 stenosis of the proximal right coronary artery 3 Status post StarClose closure of the right common femoral artery PLAN Plan will be to perform elective PCI of the mid LAD Keywords radiology heart cath selective coronary angiogram common femoral angiogram abnormal stress test common femoral artery starclose closure femoral artery angiogram angiographically artery femoral MEDICAL_TRANSCRIPTION,Description CT Brain arachnoid cyst Arachnoid cyst diagnosed by CT brain Medical Specialty Radiology Sample Name Arachnoid Cyst Transcription CC Seizures HX The patient was initially evaluated at UIHC at 7 years of age He had been well until 7 months prior to evaluation when he started having spells which were described as dizzy spells lasting from several seconds to one minute in duration They occurred quite infrequently and he was able to resume activity immediately following the episodes The spell became more frequent and prolonged and by the time of initial evaluation were occurring 2 3 times per day and lasting 2 3 minutes in duration In addition in the 3 months prior to evaluation the right upper extremity would become tonic and flexed during the episodes and he began to experience post ictal fatigue BIRTH HX 32 weeks gestation to a G4 mother and weighed 4 11oz He was placed in an incubator for 3 weeks He was jaundiced but there was no report that he required treatment PMH Single febrile convulsion lasting 3 hours at age 2 years MEDS none EXAM Appears healthy and in no acute distress Unremarkable general and neurologic exam Impression Psychomotor seizures Studies Skull X Rays were unremarkable EEG showed minimal spike activity during hyperventilation as well as random sharp delta activity over the left temporal area in drowsiness and sleep This record also showed moderate amplitude asymmetry left greater than right over the frontal central and temporal areas which is a peculiar finding COURSE The patient was initially treated with Phenobarbital then Dilantin was added early 1970 s then Depakene was added early 1980 s due to poor seizure control An EEG on 8 22 66 showed Left mid temporal spike focus with surrounding slow abnormality especially posterior to the anterior temporal areas sparing the parasagittal region In addition the right lateral anterior hemisphere voltage is relatively depressed this suggests two separate areas of cerebral pathology He underwent his first HCT scan in Sioux City in 1981 and this revealed an right temporal arachnoid cyst The patient had behavioral problems throughout elementary junior high high school He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted He was placed on numerous antiepileptic medication combinations including Tegretol Dilantin Phenobarbital Depakote Acetazolamide and Mysoline Despite this he averaged 2 3 spells a month He was last seen 6 19 95 and was taking Dilantin and Tegretol His typical spells were described as sudden in onset and without aura He frequently becomes tonic or undergoes tonic clonic movement and falls with associated loss of consciousness He usually has rapid recovery and can return to work in 20 minutes He works at a Turkey packing plant Serial HCT scans showed growth in the arachnoid cyst until 1991 when growth arrest appeared to have occurred Keywords radiology arachnoid cyst hct scan seizures serial hct scans dizzy spells drowsiness hyperventilation loss of consciousness moderate amplitude asymmetry temporal area tonic clonic movement phenobarbital dilantin cyst temporal arachnoid MEDICAL_TRANSCRIPTION,Description Adenosine with nuclear scan as the patient unable to walk on a treadmill Nondiagnostic adenosine stress test Normal nuclear myocardial perfusion scan Medical Specialty Radiology Sample Name Adenosine Nuclear Scan Transcription INDICATION Chest pain TYPE OF TEST Adenosine with nuclear scan as the patient unable to walk on a treadmill INTERPRETATION Resting heart rate of 67 blood pressure of 129 86 EKG normal sinus rhythm Post Lexiscan 0 4 mg heart rate was 83 blood pressure 142 74 EKG remained the same No symptoms were noted SUMMARY 1 Nondiagnostic adenosine stress test 2 Nuclear interpretation as below NUCLEAR INTERPRETATION Resting and stress images were obtained with 10 4 33 1 mCi of tetrofosmin injected intravenously by standard protocol Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect Gated SPECT revealed normal wall motion ejection fraction of 58 End diastolic volume of 74 end systolic volume of 31 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction 58 by gated SPECT Keywords radiology adenosine nuclear myocardial perfusion scan chest pain adenosine stress test nuclear myocardial perfusion scan gated spect spect mci myocardial perfusion scan myocardial perfusion adenosine nuclear MEDICAL_TRANSCRIPTION,Description MRI Arteriovenous malformation with hemorrhage Medical Specialty Radiology Sample Name AVM with Hemorrhage Transcription CC Headache HX 63 y o RHF first seen by Neurology on 9 14 71 for complaint of episodic vertigo During that evaluation she described a several year history of migraine headaches She experienced her first episode of vertigo in 1969 The vertigo clockwise typically began suddenly after lying down and was not associated with nausea vomiting headache The vertigo had not been consistently associated with positional change and could last hours to days On 3 15 71 after 5 day bout of vertigo right ear ache and difficulty ambulating secondary to the vertigo she sought medical attention and underwent an audiogram which reportedly showed a 20 decline in low tone acuity AD She complained of associated tinnitus which she described as a whistle In addition her symptoms appeared to worsen with changes in head position i e looking up or down The symptoms gradually resolved and she did well until 8 71 when she experienced a 19 day episode of vertigo tinnitus and intermittent headaches She was seen 9 14 71 in Neurology and admitted for evaluation Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region The AVM was primarily fed by the right MCA Otolaryngologic evaluation concluded that she probably also suffered from Meniere s disease On 10 14 74 she underwent a 21 day admission for SAH secondary to right parietal AVM On 11 23 91 she was admitted for left sided weakness LUE LLE headache and transient visual change Neurological exam confirmed left sided weakness and dysesthesia of the LUE only Brain CT confirmed a 3 x 4 cm left parietal hemorrhage She underwent unsuccessful embolization Neuroradiology had planned to do 3 separate embolizations but during the first via the left MCA they were unable to cannulate many of the AVM vessels and abandoned the procedure She recovered with residual left hemisensory loss In 12 92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention In 1 93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix AZ Keywords radiology arteriovenous malformation avm brain ct cerebral angiogram headache neurology audiogram carotid bruits difficulty ambulating hemorrhage interventricular hemorrhage migraine tinnitus vertigo visual change weakness episode of vertigo evaluation MEDICAL_TRANSCRIPTION,Description MRI Right temporal lobe astrocytoma Medical Specialty Radiology Sample Name Astrocytoma Transcription CC Episodic confusion HX This 65 y o RHM reportedly suffered a stroke on 1 17 92 He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode The stroke was reportedly verified on MRI scan dated 1 17 92 He was subsequently placed on ASA and DPH He admitted that there had been short periods 1 2 days duration since then during which he had forgotten to take his DPH However even when he had been taking his DPH regularly he continued to experience the spells mentioned above He denied any associated tonic clonic movement incontinence tongue biting HA visual change SOB palpitation weakness or numbness The episodes of confusion and memory loss last 1 2 minutes in duration and have been occurring 2 3 times per week PMH Bilateral Hearing Loss of unknown etiology S P bilateral ear surgery many years ago MEDS DPH and ASA SHX FHX 2 4 Beers day 1 2 packs of cigarettes per day EXAM BP 111 68 P 68BPM 36 8C Alert and Oriented to person place and time 30 30 on mini mental status test Speech fluent and without dysarthria CN Left superior quandranopia only Motor 5 5 strength throughout Sensory unremarkable except for mild decreased vibration sense in feet Coordination unremarkable Gait and station testing were unremarkable He was able to tandem walk without difficulty Reflexes 2 and symmetric throughout Flexor plantar responses bilaterally LAB Gen Screen CBC PT PTT all WNL DPH 4 6mcg ml Review of outside MRI Brain done 1 17 92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus The area did not enhance with gadolinium contrast CXR 8 31 92 5 x 6 mm spiculated opacity in apex right lung EEG 8 24 92 normal awake and asleep MRI Brain with without contrast 8 31 92 Decreased T1 and increased T2 signal in the right temporal lobe The lesion increased in size and enhances more greatly when compared to the 1 17 92 MRI exam There is also edema surrounding the affected area and associated mass effect NEUROPSYCHOLOGICAL TESTING Low average digit symbol substitution mildly impaired verbal learning and severely defective delayed recall There was relative preservation of other cognitive functions The findings were consistent with left mesiotemporal dysfunction COURSE Patient underwent right temporal lobectomy on 9 16 92 following initial treatment with Decadron Pathologic analysis was consistent with a Grade 2 astrocytoma GFAP staining positive Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed Keywords radiology confusion gfap gfap staining mri scan astrocytoma hippocampus memory loss palpitation signal stroke temporal lobe tongue biting tonic clonic movement weakness increased t signal mri brain mri temporal MEDICAL_TRANSCRIPTION,Description 2 D Echocardiogram Medical Specialty Radiology Sample Name 2 D Echocardiogram 2 Transcription 1 The left ventricular cavity size and wall thickness appear normal The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70 to 75 There is near cavity obliteration seen There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination 2 The left atrium appears mildly dilated 3 The right atrium and right ventricle appear normal 4 The aortic root appears normal 5 The aortic valve appears calcified with mild aortic valve stenosis calculated aortic valve area is 1 3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm 6 There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation 7 The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension Estimated pulmonary artery systolic pressure is 49 mmHg Estimated right atrial pressure of 10 mmHg 8 The pulmonary valve appears normal with trace pulmonary insufficiency 9 There is no pericardial effusion or intracardiac mass seen 10 There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum 11 The study was somewhat technically limited and hence subtle abnormalities could be missed from the study Keywords radiology 2 d doppler echocardiogram annular aortic root aortic valve atrial atrium calcification cavity ejection fraction mitral obliteration outflow regurgitation relaxation pattern stenosis systolic function tricuspid valve ventricular ventricular cavity wall motion pulmonary artery MEDICAL_TRANSCRIPTION,Description 3 Dimensional Simulation This patient is undergoing 3 dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures Medical Specialty Radiology Sample Name 3 Dimensional Simulation Transcription 3 DIMENSIONAL SIMULATION This patient is undergoing 3 dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures This optimizes the chance of controlling tumor while diminishing the acute and long term side effects With conformal 3 dimensional simulation there is extended physician therapist and dosimetrist effort and time expended The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized Preliminary filed sizes and arrangements including gantry angles collimator angles and number of fields are conceived Radiographs are taken and these films are approved by the physician Appropriate marks are placed on the patient s skin or on the immobilization device The patient is transferred to the diagnostic facility and placed on a flat CT scan table Scans are performed through the targeted area The scans are evaluated by the radiation oncologist and the tumor volume target volume and critical structures are outlined on the CT images The dosimetrist then evaluates the slices in the treatment planning computer with appropriately marked structures This volume is reconstructed in a virtual 3 dimensional space utilizing the beam s eye view features Appropriate blocks are designed Multiplane computerized dosimetry is performed throughout the volume Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan the individual slices are then reviewed by the physician The beam s eye view block design and appropriate volumes are also printed and reviewed by the physician Once these are approved physical blocks or multi leaf collimator equivalents will be devised If significant changes are made in the field arrangements from the original simulation the patient is brought back to the simulator where computer designed fields are re simulated In view of the extensive effort and time expenditure required this procedure justifies the special procedure code 77470 Keywords radiology 3 dimensional simulation planned radiation therapy ct scan ct images beam s eye view field arrangements normal structures therapy dimensional simulationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description 2 D Echocardiogram Medical Specialty Radiology Sample Name 2 D Echocardiogram 3 Transcription 2 D ECHOCARDIOGRAM Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships Cardiac function is normal There is no significant chamber enlargement or hypertrophy There is no pericardial effusion or vegetations seen Doppler interrogation including color flow imaging reveals systemic venous return to the right atrium with normal tricuspid inflow Pulmonary outflow is normal at the valve Pulmonary venous return is to the left atrium The interatrial septum is intact Mitral inflow and ascending aorta flow are normal The aortic valve is trileaflet The coronary arteries appear to be normal in their origins The aortic arch is left sided and patent with normal descending aorta pulsatility Keywords radiology 2 d echocardiogram cardiac function doppler echocardiogram multiple views aortic valve coronary arteries descending aorta great vessels heart hypertrophy interatrial septum intracardiac pericardial effusion tricuspid vegetation venous pulmonaryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Echocardiogram and Doppler Medical Specialty Radiology Sample Name 2 D Echocardiogram 4 Transcription DESCRIPTION 1 Normal cardiac chambers size 2 Normal left ventricular size 3 Normal LV systolic function Ejection fraction estimated around 60 4 Aortic valve seen with good motion 5 Mitral valve seen with good motion 6 Tricuspid valve seen with good motion 7 No pericardial effusion or intracardiac masses DOPPLER 1 Trace mitral regurgitation 2 Trace tricuspid regurgitation IMPRESSION 1 Normal LV systolic function 2 Ejection fraction estimated around 60 Keywords radiology ejection fraction lv systolic function cardiac chambers regurgitation tricuspid normal lv systolic function normal lv systolic ejection fraction estimated normal lv lv systolic systolic function function ejection echocardiogram doppler lv systolic ejection mitral valve MEDICAL_TRANSCRIPTION,Description A 6 year old male with attention deficit hyperactivity disorder doing fairly well with the Adderall Medical Specialty Psychiatry Psychology Sample Name Recheck of ADHD Meds Transcription SUBJECTIVE This is a 6 year old male who comes in rechecking his ADHD medicines We placed him on Adderall first time he has been on a stimulant medication last month Mother said the next day he had a wonderful improvement and he has been doing very well with the medicine She has two concerns It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in It wears off about 2 and they have problems in the evening with him He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible The patient even commented that he thought he needed his medication PAST HISTORY Reviewed from appointment on 08 16 2004 CURRENT MEDICATIONS He is on Adderall XR 10 mg once daily ALLERGIES To medicines are none FAMILY AND SOCIAL HISTORY Reviewed from appointment on 08 16 2004 REVIEW OF SYSTEMS He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well sleeping okay Review of systems is otherwise negative OBJECTIVE Weight is 46 5 pounds which is down just a little bit from his appointment last month He was 49 pounds but otherwise fairly well controlled not all that active in the exam room Physical exam itself was deferred today because he has otherwise been very healthy ASSESSMENT At this point is attention deficit hyperactivity disorder doing fairly well with the Adderall PLAN Discussed with mother two options Switch him to the Ritalin LA which I think has better release of the medicine early in the morning or to increase his Adderall dose As far as the afternoon if she really wanted him to be on the medication we will do a small dose of the Adderall which she would prefer So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon Mother is to watch his diet We would like to recheck his weight if he is doing very well in two months But if there are any problems especially in the morning then we would do the Ritalin LA Mother understands and will call if there are problems Approximately 25 minutes spent with patient all in discussion Keywords psychiatry psychology adhd attention deficit hyperactivity disorder adderall xr recheck medicines adderall MEDICAL_TRANSCRIPTION,Description 2 D M Mode Doppler Medical Specialty Radiology Sample Name 2 D Echocardiogram 1 Transcription 2 D M MODE 1 Left atrial enlargement with left atrial diameter of 4 7 cm 2 Normal size right and left ventricle 3 Normal LV systolic function with left ventricular ejection fraction of 51 4 Normal LV diastolic function 5 No pericardial effusion 6 Normal morphology of aortic valve mitral valve tricuspid valve and pulmonary valve 7 PA systolic pressure is 36 mmHg DOPPLER 1 Mild mitral and tricuspid regurgitation 2 Trace aortic and pulmonary regurgitation Keywords radiology 2 d m mode doppler aortic valve atrial enlargement diastolic function ejection fraction mitral mitral valve pericardial effusion pulmonary valve regurgitation systolic function tricuspid tricuspid valve normal lv MEDICAL_TRANSCRIPTION,Description Psychological Testing for ADHD Medical Specialty Psychiatry Psychology Sample Name Psychological Testing Transcription REFERRAL QUESTIONS Mr Abcd was referred for psychological assessment by his primary medical provider to help clarify his diagnosis especially with respect to Attention Deficit Hyperactivity Disorder a depression or a Bipolar Spectrum Disorder The information will be used for treatment planning BACKGROUND INFORMATION Mr Abcd is a 33 year old married man who lives with his wife and three children He has been married since 1995 and lost a son to SIDS over seven years ago He served in the army for two years and did attend some college at UAA He still wants to get a degree in engineering Mr Abcd indicated that he did use THC at the time of his initial intake with me in January 2006 but there are no other substance abuse issues as an adult so far as I am aware He has had multiple stressors including a bankruptcy in 2000 as well as his wife s significant health problems He also reported having herniated discs incurred in an injury over a year ago He has received counseling in the past and did try both Lexapro and Wellbutrin which he stopped taking in October 2005 He indicated these medications tended to decrease libido and flatten all of his emotions He indicated that he thought he might have Attention Deficit Hyperactivity Disorder but that this had not been formally evaluated or treated There is no reported bipolar illness in his immediate family but there is some depression A recent stressor involved OCS involvement apparently because his infant child tested positive for THC So far as I am aware this case is closed at this time BEHAVIORAL OBSERVATIONS Mr Abcd arrived on time for his testing session dressed casually and with good hygiene and grooming Mood is reported to be generally okay though with some stress Affect was bright and appropriate to the situation Speech was a little pressured but was of normal content and was at all times coherent and goal directed He was a very pleasant and cooperative testing subject who appeared to give a good effort on the tasks requested of him The results appear to provide a useful sample of his current attitudes opinions and functional levels in the areas assessed ASSESSMENT RESULTS Mr Abcd s responses to a brief self report instrument given to him by Dr Starks was suggestive of symptoms that could be consistent with Attention Deficit Hyperactivity Disorder I therefore had him complete the Conners CPT II which showed good performance and no indications of attention problems The Confidence Index associated with ADHD was over 58 percent that no clinical attention problems are present While a diagnosis of Attention Deficit Hyperactivity Disorder should not unequivocally be ruled out based on the results of this test there is nothing in the CPT II measures indicating attention problems and that diagnosis appears to be unlikely The MMPI 2 profile is a technically valid and interpretable one The Modified Welsh Code is as follows 49 86 231 570 F LK The high F scale may reflect some moodiness restlessness dissatisfaction and changeableness in his typical behavior The Basic Clinical Profile is similar to persons who tend to get into trouble for violating social norms and rules Such persons are more likely to experience conflicts with authority They also are prone to impulsivity self indulgence problems with delay of gratification exercise problematic judgment and often have low frustration tolerance Those with similar scores tend to be moody irritable extraverted and often do not trust others very much Mr Abcd may tend to keep others at a distance yet feel rather insecure and dependent A bipolar diagnosis is a possibility and an antisocial personality disorder cannot be entirely ruled out either though I am less confident that that is correct The MMPI 2 Content Scale scores indicate some mild depression and family stressors and the Supplementary Scales has a single clinical elevation on Addiction Admission which is entirely consistent with his interview data Posttraumatic stress scales are not elevated at a clear clinical level on the MMPI 2 SUMMARY AND RECOMMENDATIONS Keywords psychiatry psychology psychological testing adhd attention deficit hyperactivity disorder bipolar spectrum disorder cpt ii mmpi 2 posttraumatic stress disorder welsh code depression psychological assessment personality disorder family stressors posttraumatic stress disorder attention psychological MEDICAL_TRANSCRIPTION,Description Normal left ventricle moderate biatrial enlargement and mild tricuspid regurgitation but only mild increase in right heart pressures Medical Specialty Radiology Sample Name 2 D Doppler Transcription 2 D STUDY 1 Mild aortic stenosis widely calcified minimally restricted 2 Mild left ventricular hypertrophy but normal systolic function 3 Moderate biatrial enlargement 4 Normal right ventricle 5 Normal appearance of the tricuspid and mitral valves 6 Normal left ventricle and left ventricular systolic function DOPPLER 1 There is 1 to 2 aortic regurgitation easily seen but no aortic stenosis 2 Mild tricuspid regurgitation with only mild increase in right heart pressures 30 35 mmHg maximum SUMMARY 1 Normal left ventricle 2 Moderate biatrial enlargement 3 Mild tricuspid regurgitation but only mild increase in right heart pressures Keywords radiology 2 d study doppler tricuspid regurgitation heart pressures stenosis ventricular heart ventricle tricuspid regurgitation MEDICAL_TRANSCRIPTION,Description She was admitted following an overdose of citalopram and warfarin The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage Medical Specialty Psychiatry Psychology Sample Name Psychiatric Consult 2 Transcription HISTORY OF PRESENT ILLNESS This is a 41 year old registered nurse R N She was admitted following an overdose of citalopram and warfarin The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage She notes starting in January her husband of five years seemed to be quite withdrawn It turned out he was having an affair with one of her best friends and he subsequently moved in with this woman The patient is distressed as over the five years of their marriage she has gotten herself into considerable debt supporting him and trying to find a career that would work for him They had moved to ABCD where he had recently been employed as a restaurant manager She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her She has history of seasonal affective disorder winter depressions characterized by increased sleep increased irritability impatience and fatigue Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder In January she went on citalopram She reports since that time she has lost 40 pounds of weight has trouble sleeping at night thinks perhaps her mood got worse on the citalopram which is possible though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood PAST AND DEVELOPMENTAL HISTORY She was born in XYZ She describes the family as being somewhat dysfunctional Father was a truckdriver She is an only child She reports that she had a history of anorexia and bulimia as a teenager In her 20s she served six years in Naval Reserve She was previously married for four years She described that as an abusive relationship She had a history of being in counseling with ABC but does not think this therapist who is now by her estimate 80 years old is still in practice PHYSICAL EXAMINATION GENERAL This is an alert and cooperative woman VITAL SIGNS Temperature 98 1 pulse 60 respirations 18 blood pressure 95 54 oxygen saturation 95 and weight is 132 PSYCHIATRIC She makes good eye contact Speech is normal in rate volume grammar and vocabulary There is no thought disorder She denies being suicidal Her affect is appropriate for material being discussed She has a sense of future wants to get back to work has plans to return to counseling She appeared to have normal orientation concentration memory and judgment Medical history is notable for factor V Leiden deficiency history of pulmonary embolus restless legs syndrome She has been off her Mirapex I did encourage her to go back on the Mirapex which would likely lead to some improvement in mood by facilitating better sleep The patient at this time can contract for safety She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with LABORATORY DATA INR which is still 8 8 In 1998 she had a normal MRI Electrolytes BUN creatinine and CBC were all normal DIAGNOSES 1 Seasonal depressive disorder 2 Restless legs syndrome 3 Overdose of citalopram and warfarin RECOMMENDATIONS The patient reports she has been feeling better since discontinuing antidepressants I therefore recommend she stay off antidepressants at present If needed she can take Prozac which has been effective for her in the past and she plans to see a psychiatrist for consultation She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac this will be an appropriate agent to try as needed in the future but given the situational nature of the depression she primarily appears to need counseling Please feel free to contact me at digital pager if there is additional information I can provide Keywords psychiatry psychology citalopram depressive disorder overdose warfarin restless legs syndrome disorder mood MEDICAL_TRANSCRIPTION,Description The patient was discharged by court as a voluntary drop by prosecution Medical Specialty Psychiatry Psychology Sample Name Psychiatric Discharge Summary Transcription DISCHARGE DISPOSITION The patient was discharged by court as a voluntary drop by prosecution This was AMA against hospital advice DISCHARGE DIAGNOSES AXIS I Schizoaffective disorder bipolar type AXIS II Deferred AXIS III Hepatitis C AXIS IV Severe AXIS V 19 CONDITION OF PATIENT ON DISCHARGE The patient remained disorganized The patient was suffering from prolactinemia secondary to medications DISCHARGE FOLLOWUP To be arranged per the patient as the patient was discharged by court DISCHARGE MEDICATIONS A 2 week supply of the following was phoned into the patient s pharmacy Seroquel 25 mg p o nightly Zyprexa 5 mg p o b i d MENTAL STATUS AT THE TIME OF DISCHARGE Attitude was cooperative Appearance showed fair hygiene and grooming Psychomotor behavior showed restlessness No EPS or TD was noted Affect was restricted Mood remained anxious and speech was pressured Thoughts remained tangential and the patient endorsed paranoid delusions The patient denied auditory hallucinations The patient denied suicidal or homicidal ideation was oriented to person and place Overall insight into her illness remained impaired HISTORY AND HOSPITAL COURSE The patient is a 22 year old female with a history of bipolar affective disorder was initially admitted for evaluation of increasing mood lability disorganization and inappropriate behaviors The patient reportedly was asking her father to have sex with her and tried to pull down her mother s pants The patient took her clothing off was noted to be very disorganized sexually and religiously preoccupied and endorsed auditory hallucinations of voices telling her to calm herself and others The patient has a history of depression versus bipolar disorder last hospitalized in Pierce County in 2008 but without recent treatment The patient on admission interview was noted to be labile and disorganized The patient was initiated on Risperdal M Tab 2 mg p o b i d for psychosis and mood lability and also medically evaluated by Rebecca Richardson MD The patient remained labile and suspicious during her hospital stay The patient continued to be sexually preoccupied and had poor insight into her need for treatment The patient denied further auditory hallucinations The patient was treated with Seroquel for persistent mood lability and psychosis The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge The patient remained disorganized but was given a voluntary drop by prosecution against medical advice when she went to court on 01 11 2010 The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies The patient was thus discharged in symptomatic condition Keywords psychiatry psychology schizoaffective disorder bipolar type mood lability disorganization bipolar affective disorder voluntary drop auditory hallucinations psychiatric axis MEDICAL_TRANSCRIPTION,Description Bipolar disorder apparently stable on medications Mild organic brain syndrome presumably secondary to her chronic inhalant paint abuse Medical Specialty Psychiatry Psychology Sample Name Psychiatric Consult 1 Transcription HISTORY OF PRESENT ILLNESS This is a 53 year old widowed woman she lives at ABC Hotel She presented with a complaint of chest pain evaluations revealed severe aortic stenosis She has been refusing cardiac catheter and she may well need aortic valve replacement She states that she does not want heart surgery or valve replacement She has a history of bipolar disorder and has been diagnosed at times with schizophrenia She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel She denies hallucinations psychosis paranoia and suicidal ideation at this time States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature surgery does present some additional risks The patient notes that she has a long history of substance abuse primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting violation of orders to abstain from substance abuse and the longest confinement of these was 100 days The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care PAST AND DEVELOPMENTAL HISTORY She was born in XYZ She is a high school graduate from ABCD High School She did have an abusive childhood She is married four times She notes she developed depression when a number of her children died PHYSICAL EXAMINATION GENERAL This is an obese woman in bed She is somewhat restless and moving during the interview VITAL SIGNS Temperature of 97 3 pulse 70 respirations 18 blood pressure 113 68 and oxygen saturation 94 on 3 L of oxygen PSYCHIATRY Speech is normal rate volume grammar and vocabulary consistent with her educational level There is no overt thought disorder She does not appear psychotic She is not suicidal on formal testing She gives the date as Sunday 05 19 2007 when it is the 20th and 207 when it is 2007 She is oriented to place She can memorize four times repeats two at five minutes gets the other two with category hints this places short term memory in normal limits She had difficulty with serial three subtractions counting on her fingers and had difficulty naming the months in reverse order stating December November September October June July August September but recognizes this was not right and then said March April May She is able to name objects appropriately LABORATORY DATA Chest x ray showing no acute changes Carotid duplex shows no stenosis Electrolytes and liver function tests are normal TSH normal Hematocrit 31 Triglycerides 152 DIAGNOSES 1 Bipolar disorder apparently stable on medications 2 Mild organic brain syndrome presumably secondary to her chronic inhalant paint abuse 3 Aortic stenosis 4 Sleep apnea 5 Obesity 6 Anemia 7 Gastroesophageal reflux disease RECOMMENDATIONS It is my impression at present that the patient retains ability to make decisions on her own behalf Given this lady s underlying mental problems I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel While she may well need surgery and cardiac catheter she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her She clearly at this time wants to leave this hospital she normally gets her care through XYZ Health Again in summary I would consider her to retain the ability to make decisions on her own behalf Please feel free to contact me at digital pager if additional information is needed Keywords psychiatry psychology organic brain syndrom substance abuse bipolar disorder mental abuse MEDICAL_TRANSCRIPTION,Description Psychiatric consultation has been requested as the patient has been noncompliant with treatment leave the unit does not return when requested and it was unclear as to whether this is secondary to confusion or willful behavior Medical Specialty Psychiatry Psychology Sample Name Psychiatric Consult Transcription HISTORY OF PRESENT ILLNESS This is a 23 year old married man who had an onset of aplastic anemia in December underwent a bone marrow transplant in the end of March has developed very severe graft versus host reaction Psychiatric consultation has been requested as the patient has been noncompliant with treatment leave the unit does not return when requested and it was unclear as to whether this is secondary to confusion or willful behavior The patient gives a significant history of behavioral problems from late adolescence until the onset of illness states he had lot of trouble with law he was convicted of assault he was also arrested with small amount of cannabis states he served one year incarcerated in ABCD that was about two years ago Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program he was discharged from that on 05 28 2006 and states he has been clean and sober since then Prior to going to rehabilitation he was using intravenous heroin couple of times a week since age 17 which would have been over a period of about five years reports heavy use of cannabis smoking pot up to five times a day if he could He would drink up to half of a fifth of rum on a daily basis when available The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime He complained of some depressive and some anxiety symptoms but these do not appear to be out of proportion to his medical issues and for this individual the frustrations of his treatments He would have a limited support system here in Colorado He married in January and states that the marriage is not going particularly well being young sick and hospitalized has not helped his relationship with his new wife who apparently is expecting a child in July I would recommend some couples counseling as a part of their treatment here The patient was fairly drowsy during the interview and full past and developmental history was not obtained The patient s comment is that he grew up all over that his parents had separated that he lived with his mother that he dropped out of school in eleventh grade at that time was living in XYZ area because he did not like school PHYSICAL EXAMINATION GENERAL This is a cooperative man speech is soft and difficult to understand There is no thought disorder and no hallucination He denies being suicidal but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital VITAL SIGNS Temperature 97 2 pulse 117 respirations 16 blood pressure 127 74 oxygen saturation 97 and weight is 154 pounds PSYCHIATRY There is no thought disorder no paranoia no delusions and no psychotic symptoms Activities of daily living ADLs appear intact On formal testing he is oriented to place He can give a reasonable recitation of his medical history He is oriented to the year knows it is the 15th but gave the month as June instead of May He can memorize four items repeats three out of four at five minutes gives the fourth through the category which places short term memory in normal limits He can do serial three subtractions accurately can name objects appropriately LABORATORY DATA Sodium of 135 BUN of 24 and glucose 119 GGT of 355 ALT of 97 LDH of 703 and alk phos of 144 FK506 is 28 8 which is elevated tacrolimus level Hematocrit 29 and white count is 7000 DIAGNOSES AXIS I Depressive disorder secondary to the underlying medical condition of graft versus host reaction AXIS II Personality disorder not otherwise specified NOS AXIS III History of polysubstance abuse in remission RECOMMENDATIONS 1 This patient appears to retain the ability to make decisions on his own behalf I think he is mentally competent Unfortunately his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness If the patient refuses treatment he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die 2 The patient does complain of depressed mood also of anxiety We did discuss medications He appeared somewhat sedated at the time of my interview I would recommend that we try Seroquel 25 mg twice daily on an as needed basis to see if this diminishes anxiety I will have Dr X followup with him Please feel free to contact me at digital pager if additional information is needed My overall recommendation would be that the patient be on some random urine drug screening that he use cell phone if he goes off the unit to be called back up when treatments are scheduled and hopefully he will be agreeable to complying with this Keywords psychiatry psychology noncompliant confusion graft versus host reaction psychiatric consultation willful behavior cannabis MEDICAL_TRANSCRIPTION,Description Psychiatric History and Physical Patient with major depression Medical Specialty Psychiatry Psychology Sample Name Psych H P 1 Transcription HISTORY OF PRESENT ILLNESS This 40 year old white single man was hospitalized at XYZ Hospital in the mental health ward issues were filled up by his sister and his mother The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr Silverberg became concerned about his behavior called the family and told them to have him put in the hospital and at one point called the police because the patient was throwing cellphones and having tantrums in his office The history includes the fact that the patient is the 3rd of 4 children A brother who is approximately 8 years older sexually abused brother who is 4 years older The brother who is 8 years older lives in California and will contact the family has had minimal contact for many years That brother in California is gay The brother who is 4 years older sexually abused the patient from age 8 to 12 on a regular basis He said he told his mother several years ago but she did nothing about it The patient finished high school and with some struggle completed college at the University of Houston He has a sister who is approximately a year and half younger than he is who was sexually abused by the brothers will but only on one occasion She has been concerned about patient s behavior and was instrumental in having him committed Reportedly the patient ran away from home at the age of 12 or 13 because of the abuse but was not able to tell his family what happened He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time He states he injured his back about 10 yeas ago He told he had disk problems but never had surgery He subsequently was put on psychiatric disability for depression states he has been unable to get out of bed at times and isolates and keeps to himself He has been on a variety of different medications including Celexa 40 mg and ADD medication different times and reportedly has used amphetamines in the past although he denies it at this time He minimizes any alcohol use which appears not to be a problem but what does appear to be a problem is he isolates stays at home has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed He has never been psychiatrically hospitalized before MENTAL STATUS EXAMINATION Revealed a somewhat disheveled 40 year old man who was clearly quite depressed and somewhat shocked at his family s commitment He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother s wife what had happened The brother has a child and wife became very upset with him Normocephalic Pleasant cooperative disheveled man with about 37 to 40 thoughts were somewhat guarded His affect was anxious and depressed and he denied being suicidal although the family said that he has talked about it at times Recent past memory were intact DIAGNOSES Axis I Major depression rule out substance abuse Axis II Deferred at this time Axis III Noncontributory Axis IV Family financial and social pressures Axis V Global Assessment of Functioning 40 RECOMMENDATION The patient will be hospitalized to assess Along the issues the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree He says he has had several part time jobs but never been able to sustain employment although he would like to Keywords psychiatry psychology history of present illness global assessment of functioning mental status examination major depression psychiatric abuse behavior depression mental health mental health ward psychiatric disability sexually abused substance abuse health MEDICAL_TRANSCRIPTION,Description Patient with a history of PTSD depression and substance abuse Medical Specialty Psychiatry Psychology Sample Name Psych Consult Psychosis Transcription IDENTIFYING DATA Psychosis HISTORY OF PRESENT ILLNESS The patient is a 28 year old Samoan female who was her grandmother s caretaker Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior She had lived with her parents and son but parents removed son from the home secondary to the patient s erratic behavior Recently she was picked up by Kent Police Department leaping on Highway 99 PAST MEDICAL HISTORY PTSD depression and substance abuse PAST SURGICAL HISTORY Unknown ALLERGIES Unknown MEDICATIONS Unknown REVIEW OF SYSTEMS Unable to obtain secondary to the patient being in seclusion OBJECTIVE Vital signs that were previously taken revealed a blood pressure of 152 86 pulse of 106 respirations of 18 and temperature is 97 6 degrees Fahrenheit General appearance HEENT and history and physical examination was unable to be obtained today as patient was put into seclusion LABORATORY DATA Laboratory reviewed reveals a BMP slightly elevated glucose at 100 2 Previous urine tox was positive for THC Urinalysis was negative but did note positive UA wbc s CBC slightly elevated leukocytosis at 12 0 normal range is 4 to 11 ASSESSMENT AND PLAN AXIS I Psychosis Inpatient Psychiatric Team to follow AXIS II Deferred AXIS III We were unable to perform physical examination on the patient today secondary to her being in seclusion Laboratory was reviewed revealing leukocytosis possibly secondary to a UTI We will wait until the patient is out of seclusion to perform examination Should she have some complaints of dysuria or any suprapubic pain then we will begin on appropriate antimicrobial therapy We will followup with the patient should any new medical issues arise Keywords psychiatry psychology ptsd depression psychosis psychiatric substance abuse erratic behavior behavior axis MEDICAL_TRANSCRIPTION,Description Psychiatric Consultation of patient with dementia Medical Specialty Psychiatry Psychology Sample Name Psych Consult Dementia Transcription REASON FOR CONSULT Dementia HISTORY OF PRESENT ILLNESS The patient is a 33 year old black female referred to the hospital by a neurologist in Tyler Texas for disorientation and illusions Symptoms started in June of 2006 when the patient complained of vision problems and disorientation The patient was seen wearing clothes inside out along with other unusual behaviors In August or September of 2006 the patient reported having a sudden onset of headaches loss of vision and talking sporadically without making any sense The patient sought treatment from an ophthalmologist We did not find any abnormality in the Behavior Center in Tyler Texas The Behavior Center referred the patient to Dr Abc a neurologist in Tyler who then referred the patient to this hospital According to the mother the patient has had no past major medical or psychiatric illnesses The patient was functioning normally before June 2006 working as accounting tech after having completed 2 years of college She reports of worsening in symptoms mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety Currently the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006 Sleeping patterns and the amount is unknown Appetite is okay PAST PSYCHIATRIC HISTORY The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler Texas where she was given Effexor She stopped taking it soon after since they worsened her eye vision and balance PAST MEDICAL HISTORY In 2001 diagnosed with Meniere disease was treated such that she could function normally in everyday activities including work No current medications Denies history of seizures strokes diabetes hypertension heart disease or head injury FAMILY MEDICAL HISTORY Father s grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient s mother Both the mother s father and father s mother had nervous breakdowns but at unknown dates SOCIAL HISTORY The patient lives with a mother who takes care of the patient s ADLs The patient completed school up to two years in college and worked as accounting tech for eight years Denies use of alcohol tobacco or illicit drugs MENTAL STATUS EXAMINATION The patient is 33 year old black female wearing clean clothes a small towel on her head and over a wheel chair with her head rested on a pillow and towel Decreased motor activity but did blink her eyes often but arrhythmically Poor eye contact Speech illogic Concentration was not able to be assessed Mood is unknown Flat and constricted affect Thought content thought process and perception could not be assessed Sensorial memory information intelligence judgment and insight could not be evaluated due to lack of communication by the patient MINI MENTAL STATUS EXAM Unable to be performed AXIS I Rapidly progressing early onset of dementia rule out dementia secondary to general medical condition rule out dementia secondary to substance abuse AXIS II Deferred AXIS III Deferred AXIS IV Deferred AXIS V 1 ASSESSMENT The patient is a 32 year old black female with rapid and early onset of dementia with no significant past medical history There is no indication as to what precipitated these symptoms as the mother is not aware of any factors and the patient is unable to communicate The patient presented with headaches vision forms and disorientation in June 2006 She currently presents with ataxia vision loss and illusions PLAN Wait for result of neurological tests Thank you very much for the consultation Keywords psychiatry psychology reason for consult concentration dementia mood psychiatric consultation sensorial memory affect disorientation illusions information insight intelligence judgment loss of vision motor activity neurologist thought process unusual behaviors mental status examination consultation headaches MEDICAL_TRANSCRIPTION,Description The patient was referred due to a recent admission for pseudoseizures Medical Specialty Psychiatry Psychology Sample Name Pseudoseizures Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of the Hospitalist Service at Children s Hospital due to a recent admission for pseudoseizures This was a 90 minute initial intake completed on 10 19 2007 with the patient s mother I have reviewed with her the boundaries of confidentiality and the treatment consent form and she stated that she had understood these concepts PRESENTING PROBLEM It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity These were confirmed by video EEG and consist of trembling shaking and things of that nature She does have a history of focal seizures and perhaps simple seizures which were diagnosed when she was 5 years old but the seizure activity that was documented during the hospital stay is of a significant different quality I had met with them in the hospital and introduced myself and gathered some basic background information but this is a supplement to that information which is contained within this chart It was reported to me that she has been under considerable stress First of all it should be noted that the patient is developmentally delayed Although she is 17 years old she operates at about a fourth grade level Mother reported that The patient becomes stressed because she thinks that everyone is against her that she cannot do anything unless someone is there that she needs a lot of direction that she gets confused easily that she thinks that people become angry at her that she misinterprets what people are saying and thinks that they are upset It is reported the patient feels that her mother yells at her and that is mad at her often It was reported that in addition she recently has had change in her visitation with her father that she within the last 6 months has started seeing her father every other weekend after he had been discharged from prison She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him also additional stressor is at school She reports that she has no friends that she feels unwanted and picked on She gets confused easily at school worries about things and believes that the teachers become angry with her In regards to her mood mother reported that she is usually happy unless things do not go her way and then she becomes upset and says that nobody cares about her She sits in the couch she become angry does not speak Mother sends her to her room and she calms down takes a couple of deep breaths and that passes It is reported that the patient has always been this way and that is not a change in her behavior Mother did think that she did seem a little more depressed that she seems more lonely Over the last few months she has seemed a little bit more down because she does not have any friends and that she is bored Mother reported that she frequently complains of being bored but has always been this way No sleep disturbance was noted No changes in weight No suicidal ideation No deficits in energy were noted Mother did report that she does tend to worry but her worries tend to be because she gets confused does not understand what she needs to do and is quite rigid but mother did not feel that the worry was actually affecting her functioning on a daily basis DEVELOPMENTAL HISTORY The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery She was delivered at 36 weeks gestation Mother reported that she received prenatal care Difficulties during the pregnancy were denied The use of drugs alcohol tobacco during the pregnancy were denied No eating or sleeping difficulties during the perinatal period were reported Temperament was described as easy The patient is described as a cuddly baby In terms of serious injuries they were denied Serious illnesses She has been diagnosed since age 5 with seizures Mother was not able to tell me the exact kind of seizures but it would appear from I could gather that they are focal seizures and possibly simple to complex partial seizures The patient does not have a history of allergy or toileting problems She is currently taking Trileptal 450 mg b i d and she is currently taking Depakote although she is going to be weaned off the Depakote by her neurologist She is taking Prevacid and ibuprofen The neurologist that she sees is Dr Y here at Children s Hospital FAMILY BACKGROUND In terms of family background the patient lives with her mother age 38 and her mother s partner who is age 40 and with her 16 year old sister who does not have any developmental delays Mother had been married to the patient s father but they were together as a couple beginning 1990 married in 1997 separated in 2002 and divorced in 2003 he lives in the ABC area and visits them every other Saturday but there are no overnight visits The paternal grandparents are both living here in California but are separated They are 3 paternal uncles and 2 paternal aunts In terms of the maternal family maternal grandmother and grandfather are deceased Maternal grandfather deceased in 1991 due to cancer Maternal grandmother deceased in 2001 due to cancer There are 5 maternal aunts and 2 maternal uncles all who live in California She reported that the patient is particularly close to her maternal aunt whose name is Carmen Mother s partner had been married previously he has 2 children from that relationship a 23 year old and a 20 year old female who really are not part of the patient s daily life In terms of other family background it was reported that the mother s partner gets frustrated with The patient does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things The sister was described as having some resentment towards her older sister that she feels like she was just to watch out for her care for her and that sister has always wanted to follow her around and do the things that she does The biological father allegedly was in jail for a year due to drug possession Mother reported that he had a problem with methamphetamine In addition she reported there is an accusation that he had molested their niece however she stated that there was a trial and he was found to be not guilty of that She stated there was no evidence that he had ever molested the patient or her sister There had been quite a bit of chaos in the family when the mother and father were together There was a lot of arguing There were a lot of moves there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother s report The patient did observe this After the separation it was reported that there were continued difficulties that the father took the patient and her sister from school without mother s knowledge and had filed to get custody of them and actually ended up having custody of them for a month and told the patient and her sister that the mother had abandoned them Mother reported that they went to court and there was a court order giving the mother custody back after the father went to jail Mother stated that was approximately 5 years ago In terms of current mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday Wednesday s and Friday s but she does have the weekends off The patient was reported also to have a job through her school on several weeknights Mother reported that she graduated from high school had a year of college She was an average student had learning difficulties in reading No psychological or drug or alcohol history was reported by mother In terms of the biological father mother stated that he graduated from high school had a couple of years of college was a good student no learning problems or psychological problems for him were reported Mother reported that he had a history of methamphetamine use Other psychiatric history in the family was denied SOCIAL HISTORY She reported that the patient feels like she does not have any friends that she is lonely and bored really does not do much for fun Her fun consists primarily of doing crafts with mother sewing painting drawing beadwork and things like that It was reported that she really feels that she is bored and does not have much to do ACADEMIC BACKGROUND The patient is in the 11th grade at High School She has 2 regular education classes mother could not tell me what they were but the rest of her classes are special education Mother could not tell me what her IQ was although she noticed she works at about a 4th or 5th grade level Mother reported that the terminology most often used with the patient was developmental delay Her counselor s name is Mr XYZ but she reported that overall she is a good student but she does have sometimes some difficulties at school becoming upset or angry regarding the little things that she does not seem to understand It is reported that the patient feels that she has no friends at school that she is lonely and that is she does not really care for school She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p m where she stocks shelves It is reported that she does not like to go to school because she feels like nobody likes her She is not involved in any kind of clubs or groups at school Mother reported that she is also not receiving CVRC services PREVIOUS COUNSELING Mother reported that she has been in counseling before but mother could not give me any information about that who did the counseling or what it was about She does receive evidently some peer counseling at school because she gets upset and needs help in calming down DIAGNOSTIC SUMMARY AND IMPRESSION It appears that the patient best qualifies for a diagnosis of conversion disorder and information from Neurology suggests that the seizure episodes are not true seizures but appear to be pseudoseizures The patient is experiencing quite bit of stress with a lot of changes in her life also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand PLAN My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her and then to begin teaching coping skills as well as explore ways for reducing her stress DSM IV DIAGNOSES AXIS I Conversion disorder 300 11 AXIS II Diagnoses deferred AXIS III Seizure disorder AXIS IV Problems with primary support group peer problems and educational problems AXIS V Global assessment of functioning equals 60 Keywords psychiatry psychology conversion disorder global assessment of functioning primary support group peer problems developmental delays seizures developmentally axis pseudoseizures MEDICAL_TRANSCRIPTION,Description The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness Medical Specialty Psychiatry Psychology Sample Name Neuropsychological Evaluation 5 Transcription PROBLEMS AND ISSUES 1 Headaches nausea and dizziness consistent with a diagnosis of vestibular migraine recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment 2 Some degree of peripheral neuropathy consistent with diabetic neuropathy encouraged her to watch her diet and exercise daily HISTORY OF PRESENT ILLNESS The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness I obtained and documented a full history and physical examination I reviewed the new patient questionnaire which she completed prior to her arrival today I also reviewed the results of tests which she had brought with her Briefly she is a 60 year old woman initially from Ukraine who had headaches since age 25 She recalls that in 1996 when her husband died her headaches became more frequent They were pulsating She was given papaverine which was successful in reducing the severity of her symptoms After six months of taking papaverine she no longer had any headaches In 2004 her headaches returned She also noted that she had zig zag lines in her vision Sometimes she would not see things in her peripheral visions She had photophobia and dizziness which was mostly lightheadedness On one occasion she almost had a syncope Again she has started taking Russian medications which did help her The dizziness and headaches have become more frequent and now occur on average once to twice per week They last two hours since she takes papaverine which stops the symptoms within 30 minutes PAST MEDICAL HISTORY Her past medical history is significant for injury to her left shoulder gastroesophageal reflux disorder diabetes anxiety and osteoporosis MEDICATIONS Her medications include hydrochlorothiazide lisinopril glipizide metformin vitamin D Centrum multivitamin tablets Actos lorazepam as needed Vytorin and Celexa ALLERGIES She has no known drug allergies FAMILY HISTORY There is family history of migraine and diabetes in her siblings SOCIAL HISTORY She drinks alcohol occasionally REVIEW OF SYSTEMS Her review of systems was significant for headaches pain in her left shoulder sleeping problems and gastroesophageal reflex symptoms Remainder of her full 14 point review of system was unremarkable PHYSICAL EXAMINATION On examination the patient was pleasant She was able to speak English fairly well Her blood pressure was 130 84 Heart rate was 80 Respiratory rate was 16 Her weight was 188 pounds Her pain score was 0 10 Her general exam was completely unremarkable Her neurological examination showed subtle weakness in her left arm due to discomfort and pain She had reduced vibration sensation in her left ankle and to some degree in her right foot There was no ataxia She was able to walk normally Reflexes were 2 throughout She had had a CT scan with constant which per Dr X s was unremarkable She reports that she had a brain MRI two years ago which was also unremarkable IMPRESSION AND PLAN The patient is a delightful 60 year old chemist from Ukraine who has had episodes of headaches with nausea photophobia and dizziness since her 20s She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms Her diagnosis is consistent with vestibular migraine I do not see evidence of multiple sclerosis Ménière s disease or benign paroxysmal positional vertigo I talked to her in detail about the importance of following a migraine diet I gave her instructions including a list of foods times which worsen migraine I reviewed this information for more than half the clinic visit I would like to start her on amitriptyline at a dose of 10 mg at time She will take Motrin at a dose of 800 mg as needed for her severe headaches She will make a diary of her migraine symptoms so that we can find any triggering food items which worsen her symptoms I encouraged her to walk daily in order to improve her fitness which helps to reduce migraine symptoms Keywords psychiatry psychology nausea dizziness migraine peripheral neuropathy diabetic neuropathy neuropathy positional vertigo photophobia and dizziness neurology consultation tunnel vision vestibular migraine migraine symptoms headaches photophobia ataxia MEDICAL_TRANSCRIPTION,Description Mental status changes after a fall She sustained a concussion with postconcussive symptoms and syndrome that has resolved Medical Specialty Psychiatry Psychology Sample Name Mental Status Changes Consult Transcription CHIEF COMPLAINT Mental status changes after a fall HISTORY Ms ABC is a 76 year old female with Alzheimer s apparently is normally very talkative active independent but with advanced Alzheimer s Apparently she tripped backwards hitting her head on a wheelchair and had although no loss consciousness had altered mental status changes She was very confused incomprehensible speech and was not responding appropriately She was transported here stable with no significant changes She ultimately upon arrival here was unchanged in that she was not responding appropriately She would have garbled speech somewhat inappropriate at times and unable to follow commands No other history was able to be obtained All pertinent history is documented within the records Physical examination also documented in the records essentially as above PHYSICAL EXAMINATION HEENT Without any obvious signs of trauma Pupils are equal and reactive Extraocular movements are difficult to assess with her eyes closed but she will open to voice TMs canals are normal without any signs of hemotympanum Nasal mucosa and oropharynx are normal NECK Nontender full range of motion was not examined initially a collar was placed HEART Regular LUNGS Clear CHEST BACK ABDOMEN Without trauma SKIN With multiple excoriations from scratching and itching NEUROLOGIC Otherwise she has good sensation withdrawals to pain When lifting the arm she will hold them up and draw let them down slowly With movement of the legs she did straighten them back out slowly DTRs were intact and equal bilaterally Otherwise the remainder of the examination was unable to be done because of patient s non cooperation and mental status change LABORATORY DATA CT scan of the head was negative as was cervical spine She has a history of being on Coumadin Her INR is 1 92 CBC was with a white count of 3 8 50 neutrophils 8 bands CMP did note a potassium which was elevated at 5 9 troponin was normal mag is 2 5 valproic acid level 24 3 ASSESSMENT AND PLAN Ms ABC is a 76 year old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours has completely resolved It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved At this time she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation I have discussed this with her son he agrees Otherwise she has improved significantly The patient was discussed with XYZ who will admit the patient for further evaluation and treatment Keywords psychiatry psychology alzheimer s no loss consciousness mental status MEDICAL_TRANSCRIPTION,Description Patient presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus Medical Specialty Psychiatry Psychology Sample Name Major Depressive Disorder IME Consult Transcription IDENTIFYING DATA Mr T is a 45 year old white male CHIEF COMPLAINT Mr T presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus His confidence and self esteem are significantly low He stated he has excessive somnolence his energy level is extremely low motivation is low and he has a lack for personal interests He has had suicidal ideation but this is currently in remission Furthermore he continues to have hopeless thoughts and crying spells Mr T stated these symptoms appeared approximately two months ago HISTORY OF PRESENT ILLNESS On March 25 2003 Mr T was fired from his job secondary to an event at which he stated he was first being harassed by another employee This other employee had confronted Mr T with a very aggressive verbal style where this employee had placed his face directly in front of Mr T was spitting on him and called him bitch Mr T then retaliated and went to hit the other employee Due to this event Mr T was fired It should be noted that Mr T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to deal with it There are no other apparent stressors in Mr T s life at this time or in recent months Mr T stated that work was his entire life and he based his entire identity on his work ethic It should be noted that Mr T was a process engineer for Plum Industries for the past 14 years PAST PSYCHIATRIC HISTORY There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr T s family physician Dr B at which point Mr T was placed on Lexapro with an unknown dose at this time Mr T is currently seeing Dr J for psychotherapy where he has been in treatment since April 2003 PAST PSYCHIATRIC REVIEW OF SYSTEMS Mr T denied any history throughout his childhood adolescence and early adulthood for depressive anxiety or psychotic disorders He denied any suicide attempts or profound suicidal or homicidal ideation Mr T furthermore stated that his family psychiatric history is unremarkable SUBSTANCE ABUSE HISTORY Mr T stated he used alcohol following his divorce in 1993 but has not used it for the last two years No other substance abuse was noted LEGAL HISTORY Currently charges are pending over the above described incident MEDICAL HISTORY Mr T denied any hospitalizations surgeries or current medications use for any heart disease lung disease liver disease kidney disease gastrointestinal disease neurological disease closed head injury endocrine disease infectious blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia PERSONAL AND SOCIAL HISTORY Mr T was born in Dwyne Missouri with no complications associated with his birth Originally he was raised by both parents but they separated at an early age When he was about seven years old he was raised by his mother and stepfather He did not sustain a relationship with his biological father from that time on He stated his parents moved a lot and because this many times he was picked on in his new environments Mr T stated he was at times a rebellious teenager but he denied any significant inability to socialize and denied any learning disabilities or the need for special education Mr T stated his stepfather was somewhat verbally abusive and that he committed suicide when Mr T was 18 years old He graduated from high school and began work at Dana Corporation for two to three years after which he worked as an energy auditor for a gas company He then became a homemaker while his wife worked for Chrysler for approximately two years Mr T was married for eleven years and divorced in 1993 He has a son who is currently 20 years old After being a home maker Mr T worked for his mother in a restaurant and moved on from there to work for Borg Warner corporation for one to two years before beginning at Plum Industries where he worked for 14 years and worked his way up to lead engineer Mental Status Exam Mr T presented with a hyper vigilant appearance his eye contact was appropriate to the interview and his motor behavior was tense At times he showed some involuntary movements that would be more akin to a resting tremor There was no psychomotor retardation but there was some mild psychomotor excitement His speech was clear concise but pressured His attitude was overly negative and his mood was significant for moderate depression anxiety anhedonia and loneliness and mild evidence of anger There was no evidence of euphoria or diurnal mood variation His affective expression was restricted range but there was no evidence of lability At times his affective tone and facial expressions were inappropriate to the interview There was no evidence of auditory visual olfactory gustatory tactile or visceral hallucinations There was no evidence of illusions depersonalizations or derealizations Mr T presented with a sequential and goal directed stream of thought There was no evidence of incoherence irrelevance evasiveness circumstantiality loose associations or concrete thinking There was no evidence of delusions however there was some ambivalence guilt and self derogatory thoughts There was evidence of concreteness for similarities and proverbs His intelligence was average His concentration was mildly impaired and there was no evidence of distractibility He was oriented to time place person and situation There was no evidence of clouded consciousness or dissociation His memory was intact for immediate recent and remote events He presented with poor appetite easily fatigued and decreased libidinal drive as well as excessive somnolence There was a moderate preoccupation with his physical health pertaining to his headaches His judgment was poor for finances family relations social relations employment and at this time he had no future plans Mr T s insight is somewhat moderate as he is aware of his contribution to the problem His motivation for getting well is good as he accepts offered treatment complies with recommended treatment and seeks effective treatments He has a well developed empathy for others and capacity for affection There was no evidence of entitlement egocentricity controllingness intimidation or manipulation His credibility seemed good There was no evidence for potential self injury suicide or violence The reliability and completeness of information was very good and there were no barriers to communication The information gathered was based on the patient s self report and objective testing and observation His attitude toward the examiner was neutral and his attitude toward the examination process was neutral There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings and there was no lack of cooperation with the evaluation or poor compliance with treatment and no evidence of antisocial personality disorder IMPRESSIONS Major Depressive Disorder single episode RECOMMENDATIONS AND PLAN I recommend Mr T continue with psychopharmacologic care as well as psychotherapy At this time the excessive amount of psychiatric symptoms would impede Mr T from seeking employment Furthermore it appears that the primary precipitating event had occurred on March 25 2003 when Mr T was fired from his job after being harassed for over a year As Mr T placed his entire identity and sense of survival on his work this was a deafening blow to his psychological functioning Furthermore it only appears logical that this would precipitate a major depressive episode Keywords psychiatry psychology muscle tremor headaches excessive nervousness poor concentration independent medical evaluation psychopharmacologic poor ability to focus major depressive disorder tremor depressive psychiatric MEDICAL_TRANSCRIPTION,Description Bender Gestalt Neurological Battery and Beck testing Medical Specialty Psychiatry Psychology Sample Name Neurobehavioral Assessment Transcription BENDER GESTALT TEST Not organic BECK TESTING Depression 37 Anxiety 41 Hopelessness 10 Suicide Ideation 18 SUMMARY The patient was cooperative and appeared to follow the test instructions There is no evidence of organicity on the Bender He endorsed symptoms of depression and anxiety He has moderately negative expectancies regarding his future and is expressing suicidal ideation Great care should be taken to confirm the accuracy of the results as the patients seems over medicated and or drunk Keywords psychiatry psychology bender gestalt neurological battery beck anxiety inventory beck depression inventory beck hopelessness scale beck scale suicide ideation bender gestalt test beck testing bender gestalt beck MEDICAL_TRANSCRIPTION,Description Sample for Neuropsychological Evaluation Medical Specialty Psychiatry Psychology Sample Name Neuropsychological Evaluation 1 Transcription REASON FOR EVALUATION The patient is a 37 year old white single male admitted to the hospital through the emergency room I had seen him the day before in my office and recommended him to go into the hospital He had just come from a trip to Taho in Nevada and he became homicidal while there He started having thoughts about killing his mother He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him HISTORY OF PRESENT ILLNESS This is a patient that has been suffering from a chronic psychotic condition now for a number of years He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too The patient has not used any drugs since age 25 However he has continued having intense and frequent psychotic bouts I have seen him now for approximately one year He has been quite refractory to treatment We tried different types of combination of medications which have included Clozaril Risperdal lithium and Depakote with partial response and usually temporary The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days The dosages that we have used have been very high He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level However he has not responded He has delusions of antichrist He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals He has paranoid delusions He also gets homicidal like prior to this admission PAST PSYCHIATRIC HISTORY As mentioned before this patient has been psychotic off and on for about 20 years now He has had years in which he did better on Clozaril and also his other medications With typical anti psychotics he has done well at times but he eventually gets another psychotic bout PAST MEDICAL HISTORY He has a history of obesity and also of diabetes mellitus However most recently he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa The patient has chronic bronchitis He smokes cigarettes constantly up to 60 a day DRUG HISTORY He stopped using drugs when he was 25 He has got a lapse but he was more than 10 years and he has been clean ever since then As mentioned before he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis PSYCHOSOCIAL STATUS The patient lives with his mother and has been staying with her for a few years now We have talked to her She is very supportive His only sister is also very supportive of him He has lived in the ABCD houses in the past He has done poorly in some of them MENTAL STATUS EXAMINATION The patient appeared alert oriented to time place and person His affect is flat He talked about auditory hallucinations which are equivocal in nature He is not homicidal in the hospital as he was when he was at home His voice and speech are normal He believes in telepathy His memory appears intact and his intelligence is calculated as average INITIAL DIAGNOSES AXIS I Schizophrenia AXIS II Deferred AXIS III History of diabetes mellitus obesity and chronic bronchitis AXIS IV Moderate AXIS V GAF of 35 on admission INITIAL TREATMENT AND PLAN Since the patient has been on high dosages of medications we will give him a holiday and a structured environment We will put him on benzodiazepines and make a decision anti psychotic later We will make sure that he is safe and that he addresses his medical needs well Keywords psychiatry psychology neuropsychological gaf schizophrenia anti psychotic chronic psychotic condition delusions hallucination homicidal marijuana psychological psychotic smokes cigarettes smoking neuropsychological evaluation clozaril bronchitis axis MEDICAL_TRANSCRIPTION,Description The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder Medical Specialty Psychiatry Psychology Sample Name Conversion Disorder Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of Children s Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time After his discharge the patient was scheduled to see me for followup services This was a 90 minute intake that was completed on 10 10 2007 with the patient s mother I reviewed with her the treatment consent form as well as the boundaries of confidentiality and she stated that she understood these concepts PRESENTING PROBLEMS Please see the inpatient hospital progress note contained in his chart for additional background information The patient s mother reported that he continues with his conversion episodes She noted that they are occurring approximately 6 times a day They consist primarily of tremors arching his back and by her report doing some gang signs during the episode She reported that the conversion reactions had decreased after his hospitalization and he had none for 3 days but then they began picking up again From information gathered from mother it would suggest that she frequently does status checks where she asks him how he is doing and that after she began checking on him more that he began having more conversion reactions In terms of what she does when he has a conversion reaction she reported that primarily that she tries to keep him safe She puts a sheath under him because the carpeting is dirty She removes any furniture she wraps his legs together so they do not knock together she sits with him and she gives him attention and says calm down breathe and after it is over she continues to tell him to be calm and to breathe She denied that she gives them any more attention I strongly encouraged her to stop doing status checks as this likely is reinforcing the behavior I also noted that while he certainly needs to be kept safe that she does not want to give a lot of attention to this behavior and that over time we will teach him ways of coping with this independently In regards to his mood she reported that his mood is quite good She denied any sadness or irritability She denied anhedonia She reports that he is a little bit hard to get up in the morning He is going to bed at about 11 getting up at 8 or 9 No changes in weight or eating were noted No changes in concentration suicidal ideation and any suicidal history was denied She denied symptoms of anxiety although she did note that she thought he worried a little about going to school and some financial stress Other symptoms of psychopathology were denied DEVELOPMENTAL HISTORY The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery Mother reported that she did receive prenatal care The use of alcohol drugs or tobacco during the pregnancy were denied She denied that he had any feeding or sleeping problems in the perinatal period She described him as a fussy and active baby but he was described as a cuddly baby She noted that the pediatricians never expressed any concerns regarding his developmental milestones SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN Serious injures or toileting problems were denied as were a history of seizures FAMILY BACKGROUND The patient currently lives with his mother who is age 57 and with her partner who is age 40 They have been together since 1994 and he is the only father figure that the patient has even known The father was previously in a relationship that resulted in an 11 year old daughter who visits the patient s home every other weekend The patient s father s whereabouts are unknown There is no information on his family Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient and the patient has never met him As noted there is no information on the paternal side of the family In terms of the mother s side of family the maternal grandfather died in his 60s due to what mother described as hardening of the arteries and the maternal grandmother died in 2003 due to stroke There were 4 maternal aunts one of them died at age 9 months from pneumonia one of them died at 19 years old from what was described as a brain tumor and there are 3 maternal uncles In terms of family relationships it was reported that overall the patient tends to get along fairly well with his parents who reported that the patient and her partner tend to compete for mother s attention and she noted this is difficult at times She reported that the patient and her partner do not really do anything together Mother reported that there is no domestic violence in the home but there is some marital conflict and this is may be difficult for The patient as it is carried on in Spanish and he does not speak Spanish There also is some stress in the home due to the stepdaughter as there are some concerns that her mother may be involved in drugs The mother reported that she attended high school did not attend any college She denied learning problems She denied psychological problems or any drug alcohol history In terms of the biological father she reported he did not graduate from high school She did not know of learning problems psychological problems She denied that he had a drug alcohol history There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather It should be noted that the patient and his family live in a small 4 bedroom apartment where privacy is very difficult SOCIAL BACKGROUND She reported that the patient is able to make and keep friends but he enjoys lifting weights skateboarding and that he recently had an opportunity to do rock climbing he really enjoyed that I encouraged her to have him involved in physical activity as this is good for discharge the stress to encourage the weightlifting as well as the skateboarding Mother is going to check further information regarding the rock climbing that the patient had been involved in which was at it sounds like by her description as some sort of boys and girls type of club Abuse of drugs or alcohol were denied The patient was not described as being sexually active ACADEMIC BACKGROUND The patient is currently in the 10th grade At present he is on independent studies which began after his hospitalization The mother reported that the teacher who had come to school saw one of his episodes and stated that they would not want him to be attending school I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies that he needed to be returned to his normal school environment He has never had an episode at school and he needs to be back with his peers back in a regular environment where he is under normal expectations I spoke with her regarding my concerns regarding the fact that he is unsupervised during the day and we do not want this turning into one big long vacation where he is not getting his work done and he gets himself in trouble Normally he would be attending at High School The mother stated that she would contact them as well as check into possibly a 504 Plan She reported that he really does not to go back to High School He says the kids are bad however she denied that he has any history of fighting She noted that he is stressed by the school there have been some peer problems possibly some bullying I noted these need to be addressed with the school as she had not done so She stated that she would speak with a counselor She noted however that he has a history of not liking school and avoiding going to school She noted that he is somewhat behind in his work due to the hospitalization His grades traditionally are C s She denied any Special Education Services PREVIOUS COUNSELING Denied DIAGNOSTIC SUMMARY AND IMPRESSION Similar to my impression at the hospital it would appear that the patient clearly qualifies for a diagnosis of conversion disorder It appears that there are multiple stressors in the family and that the mother is reinforcing his conversion reaction I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing DSM IV DIAGNOSES AXIS I Conversion disorder 300 11 AXIS II No diagnosis V71 09 AXIS III No diagnosis AXIS IV Problems with primary support group educational problems and peer problems AXIS V Global Assessment of Functioning equals 60 Keywords psychiatry psychology developmental history academic background global assessment of functioning normal school environment conversion reactions conversion disorder conversion background environment peers disorder axis MEDICAL_TRANSCRIPTION,Description Painful enlarged navicula right foot Osteochondroma of right fifth metatarsal Partial tarsectomy navicula and partial metatarsectomy right foot Medical Specialty Podiatry Sample Name Tarsectomy Transcription PREOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal POSTOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal PROCEDURE PERFORMED 1 Partial tarsectomy navicula right foot 2 Partial metatarsectomy right foot HISTORY This 41 year old Caucasian female who presents to ABCD General Hospital with the above chief complaint The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin She states that she has been diagnosed with hereditary osteochondromas She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back The patient desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 5 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal Foot was then prepped and draped in the usual sterile orthopedic fashion Foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was then inflated to 250 mmHg The foot was lowered as well as the operating table The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge Attention was then directed to the navicular region on the right foot The area was palpated until the bony prominence was noted A curvilinear incision was made over the area of bony prominence At that time a total of 10 cc with addition of 1 additional lidocaine plain was injected into the surgical site The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis The dissection was carried down to the level of the capsule and periosteum A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone The periosteum and the capsule were then reflected from the navicular bone at this time A bony prominence was noted both medially and plantarly to the navicular bone An osteotome and mallet were then used to resect the enlarged portion of the navicular bone After resection with an osteotome there was noted to be a large plantar shelf The surrounding soft tissues were then freed from this plantar area Care was taken to protect the attachments of the posterior tibial tendon as much as possible Only minimal resection of its attachment to the fiber was performed in order to expose the bone Sagittal saw was then used to resect the remaining plantar medial prominent bone The area was then smoothed with reciprocating rasp until no sharp edges were noted The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with 3 0 Vicryl The subcutaneous tissues were then reapproximated with 4 0 Vicryl to reduce tension from the incision and running 5 0 Vicryl subcuticular stitch was performed Attention was then directed to the fifth metatarsal There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal The incision was then deepened with 15 blade Care was taken to preserve the extensor tendon The incision was then created over the capsule and periosteum of the fifth metatarsal head Capsule and periosteum were reflected both dorsally laterally and plantarly At that time there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal A sagittal saw was used to resect both of these osteal prominences All remaining sharp edges were then smoothed with reciprocating rasp The area was inspected for the remaining bony prominences and none was noted The area was flushed with copious amounts of sterile saline The capsule and periosteum were then reapproximated with 3 0 Vicryl Subcutaneous closure was then performed with 4 0 Vicryl in order to reduce tension around the incision line Running 5 0 subcutaneous stitch was then performed Steri Strips were applied to both surgical sites Dressings consisted of Adaptic soaked in Betadine 4x4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot The patient tolerated the above procedure and anesthesia well without complications The patient was transferred to the PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated The patient is to follow up with Dr X in his office as directed or sooner if any problems or questions arise Keywords podiatry navicula metatarsal osteochondroma tarsectomy metatarsectomy painful enlarged navicula navicular bone foot bony capsule periosteum navicular incision bone MEDICAL_TRANSCRIPTION,Description Right foot trauma Three views of the right foot Three views of the right foot were obtained Medical Specialty Podiatry Sample Name Three Views Foot Transcription EXAM Three views of the right foot REASON FOR EXAM Right foot trauma FINDINGS Three views of the right foot were obtained There are no comparison studies There is no evidence of fractures or dislocations No significant degenerative changes or obstructive osseous lesions were identified There are no radiopaque foreign bodies IMPRESSION Negative right foot Keywords podiatry three views radiopaque fractures foot trauma MEDICAL_TRANSCRIPTION,Description School reports continuing difficulties with repetitive questioning obsession with cleanness on a daily basis concerned about his inability to relate this well in the classroom Asperger disorder Obsessive compulsive disorder Medical Specialty Psychiatry Psychology Sample Name Asperger Disorder Transcription SUBJECTIVE School reports continuing difficulties with repetitive questioning obsession with cleanness on a daily basis concerned about his inability to relate this well in the classroom He appears confused and depressed at times Mother also indicates that preservative questioning had come down but he started collecting old little toys that he did in the past He will attend social skills program in the summer ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis There is lessening of tremoring in both hands since discontinuation of Zoloft He is now currently taking Abilify at 7 5 mg OBJECTIVE He came in less perseverative questioning asked appropriate question about whether I talked to ABCD or not greeted me with Japanese word to say hello seemed less I also note that his tremors were less from the last time ASSESSMENT 299 8 Asperger disorder 300 03 obsessive compulsive disorder PLAN Decrease Abilify from 7 5 mg to 5 mg tablet one a day no refills needed I am introducing slow Luvox 25 mg tablet one half a m for OCD symptoms if no side effects in one week we will to tablet one up to therapeutic level I also will call ABCD regarding the referral to psychologists for functional behavioral analysis Parents will call me in two weeks I will see him for medication review in four weeks Mother signed informed consent I reviewed side effects to observe including behavioral activation Abilify has been helpful in decreasing high emotional arousal Combination of medication and behavioral intervention is recommended Keywords psychiatry psychology repetitive questioning obsession with cleanness inability to relate obsessive compulsive disorder functional behavioral analysis asperger disorder inability asperger MEDICAL_TRANSCRIPTION,Description Excision of mass left second toe and distal Symes amputation left hallux with excisional biopsy Mass left second toe Tumor Left hallux bone invasion of the distal phalanx Medical Specialty Podiatry Sample Name Symes Amputation Hallux Transcription PREOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux bone invasion of the distal phalanx POSTOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux with bone invasion of the distal phalanx PROCEDURE PERFORMED 1 Excision of mass left second toe 2 Distal Syme s amputation left hallux with excisional biopsy HISTORY This 47 year old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size The patient also has history of shave biopsy in the past The patient does state that he desires surgical excision at this time PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 6 cc mixed with 1 lidocaine plain with 0 5 Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses The foot was lowered to the operating table The stockinet was reflected and the foot was cleansed with wet and dry sponge A distal Syme s incision was planned over the distal aspect of the left hallux The incision was performed with a 10 blade and deepened with 15 down to the level of bone The dorsal skin flap was removed and dissected in toto off of the distal phalanx There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx The tissue was sent to Pathology where Dr Green stated that a frozen sample would be of less use for examining for cancer Dr Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen At this time a sagittal saw was then used to resect all ends of bone of the distal phalanx The area was inspected for any remaining suspicious tissues Any suspicious tissue was removed The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon with a combination of simple and vertical mattress sutures Attention was then directed to the left second toe There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe A linear incision was made just medial to the tissue mass The mass was then dissected from the overlying skin and off of the underlying capsule This tissue mass was hard round and pearly gray in appearance It does not invade into any other surrounding tissues The area was then flushed with copious amounts of sterile saline and the skin was closed with 4 0 nylon Dressings consisted of Owen silk soaked in Betadine 4x4s Kling Kerlix and an Ace wrap The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr Bonnani in his office as directed The patient will be contacted immediately pending the results of pathology Cultures obtained in the case were aerobic and anaerobic gram stain Silver stain and a CBC Keywords podiatry distal phalanx mass tumor hallux bone phalanx symes amputation excisional biopsy distal amputation invasion toe symes incision flushed excision tissue hallux MEDICAL_TRANSCRIPTION,Description The patient was referred due to concerns regarding behavioral acting out as well as encopresis Medical Specialty Psychiatry Psychology Sample Name Adjustment Disorder Encopresis Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of the Clinic due to concerns regarding behavioral acting out as well as encopresis This is a 90 minute initial intake completed on 10 03 2007 I met with the patient s mother individually for the entire session I reviewed with her the treatment consent form as well as the boundaries of confidentiality and she stated that she understood these concepts PRESENTING PROBLEMS Mother reported that her primary concern in regard to the patient had to do with his oppositionality She was more ambivalent regarding addressing the encopresis In regards to his oppositionality she reported that the onset of his oppositionality was approximately at 4 years of age that before that he had been a very compliant and happy child and that he has slowly worsened over time She noted that the oppositionality occurred approximately after his brother who has multiple medical problems was born At that time mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year She reported that in terms of the behaviors that he loses his temper frequently he argues with her that he defies her authority that she has to ask him many times to do things that she has to repeat instructions that he ignores her that he whines and this is when he is told to do something that he does not want to do She reported that he deliberately annoys other people that he can be angry and resentful She reported that he does not display these behaviors with the father nor does he display them at home but they are specific to her She reported that her response to him typically is that she repeats what she wants him to do many many times that eventually she gets upset She yells at him talks with him and tries to make him go and do what she wants him to do Mother also noted that she probably ignores some his misbehaviors She stated that the father tends to be more firm and more direct with him and that the father sometimes thinks that the mother is too easy on him In regards to symptoms of depression she denied symptoms of depression noting that he tends to only become unhappy when he has to do something that he does not want to do such as go to school or follow through on a command She denied any suicidal ideation She denied all symptoms of anxiety PTSD was denied ADHD symptoms were denied as were all other symptoms of psychopathology In regards to the encopresis she reported that he has always soiled he does so 2 to 3 times a day She reported that he is concerned about this issue He currently wears underwear and had a pull up She reported that he was seen at the Gastroenterology Department here several years ago and has more recently been seen at the Diseases Center seen by Dr Y reported that the last visit was several months ago that he is on MiraLax He does sit on the toilet may be 2 times a day although that is not consistent Mother believes that he is probably constipated or impacted again He refuses to eat any fiber In regards to what happens when he soils mother basically takes full responsibility She cleans and changes his underwear thinks of things that she has tried she mostly gets frustrated makes negative comments even though she knows that he really cannot help it She has never provided him with any sort of rewards because she feels that this is something he just needs to learn to do In regards to other issues she noted that he becomes frustrated quite easily especially around homework that when mother has to correct him or when he has had difficulty doing something that he becomes upset that he will cry and he will get angry Mother s response to him is that either she gets agitated and raises her voice tells him to stop etc Mother reported it is not only with homework but also with other tasks such as if he is trying to build with his LEGOs and things do not go well DEVELOPMENTAL BACKGROUND The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery The patient presented in a breech position Mother denied the use of drugs alcohol or tobacco during the pregnancy No sleeping or eating issues were present in the perinatal period Temperament was described as easy He was described as a cuddly baby No concerns expressed regarding his developmental milestones No serious injuries reported No hospitalizations or surgeries No allergies The patient has been encopretic for all of his life He currently is taking MiraLax FAMILY BACKGROUND The patient lives with his mother who is age 37 and is primarily a homemaker but does work approximately 48 hours a month as a beautician with his father age 35 who is a police officer and also with his younger brother who is age 3 and has significant medical problems as will be noted in a moment Mother and father have been together since 1997 married in 1999 The maternal grandmother and grandfather are living and are together and live in the Central California Coast Area There is one maternal aunt age 33 and then two adopted maternal aunt and uncle age 18 and age 13 In regards to the father s side of the family the paternal grandparents are divorced Grandfather was in Arkansas grandmother lives in Dos Palos The patient does not see his grandfather Mother stated that her relationship with her child was as described that he very much stresses her out that she wishes that he was not so defiant that she finds him to be a very stressful child to deal with In regards to the relationship with the father it was reported that the father tends to leave most of the parenting over to the mother unless she specifically asks him to do something and then he will follow through and do it He will step in and back mother up in terms of parenting tell the child not to speak to his mother that way etc Mother reported that he does spend some time with the children but not as much as mother would like him to but occasionally he will go outside and do things with them The mother reported that sometimes she has a problem in interfering with his parenting that she steps in and defends The patient It was reported that mother stated that she tries the parenting technique primarily of yelling and tried time out although her description suggests that she is not doing time out correctly as he simply gets up from his time out and she does not follow through Mother reported that she and the patient are very much alike in temperament and this has made things more difficult Mother tends to be stubborn and gets angry easily also Mother reported becoming fatigued in her parenting that she lets him get away with things sometimes because she does not want to punish him all day long sometimes ignores problems that she probably should not ignore There was reported to be jealousy between The patient and his brother B B evidently has some heart problems and feeding issues and because of that tends to get more attention in terms of his medical needs and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get and that there is some tension between the brothers They do play well together however The patient does tend to be somewhat intrusive gets in his space and then B will hit him Mother reported that she graduated from high school went to Community College and was an average student No learning problems Mother has a history of depression She has currently been taking 100 mg of Zoloft administered by her primary medical doctor She is not receiving counseling She has been on the medications for the last 5 years Her dosage has not been changed in a year She feels that she is getting more irritable and more angry I encouraged her to see a primary medical doctor Mother has no drug or alcohol history Father graduated from high school went to the Police Academy average student No learning problems no psychological problems no drug or alcohol problems are reported In terms of extended family maternal grandmother as well as maternal great grandfather have a history of depression Other psychiatric symptoms were denied in the family Mother reported that the marriage is generally okay that there is some arguing She reported that it was in the normal range ACADEMIC BACKGROUND The patient attends the Roosevelt Elementary School where he is in a regular first grade classroom with Mrs The patient This is in the Kingsburg Unified School District No behavior problems academic problems were reported He does not receive special education services SOCIAL HISTORY The patient was described as being able to make and keep friends but at this point in time there has been no teasing regarding smell from the encopresis He does have kids over to play at the house PREVIOUS COUNSELING Denied DIAGNOSTIC SUMMARY AND IMPRESSION My impression is that the patient has a long history of constipation and impaction which has been treated medically but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting increased fiber regular medication so that the problem has likely continued She also has not used any sort of rewards as a way to encourage him in the encopresis The patient clearly qualifies for a diagnosis of disruptive behavior disorder not otherwise specified and possibly oppositional defiant disorder It would appear that mother needs help in her parenting and that she tends to mostly use yelling and anger as a way and tends to repeat herself a lot and does not have a strategy for how to follow through and to deal with defiant behavior Also mother and father may not be on the same page in terms of parenting PLAN In terms of my plan I will meet with the child in the next couple of weeks I also asked the mother to bring the father in so he could be involved in the treatment also and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher DSM IV DIAGNOSES AXIS I Adjustment disorder with disturbance of conduct 309 3 Encopresis without constipation overflow incontinence 307 7 AXIS II No diagnoses V71 09 AXIS III No diagnoses AXIS IV Problems with primary support group AXIS V Global assessment of functioning equals 65 Keywords psychiatry psychology developmental background axis dsm iv adjustment disorder behavioral adjustment depression oppositionality encopresis MEDICAL_TRANSCRIPTION,Description Pain Three views of the right ankle Three views of the right ankle are obtained Medical Specialty Podiatry Sample Name Three Views Ankle Transcription EXAM Three views of the right ankle INDICATIONS Pain FINDINGS Three views of the right ankle are obtained There is no evidence of fractures or dislocations No significant degenerative changes or destructive osseous lesions of the ankle are noted There is a small plantar calcaneal spur There is no significant surrounding soft tissue swelling IMPRESSION Negative right ankle Keywords podiatry three views calcaneal plantar spur osseous ankle MEDICAL_TRANSCRIPTION,Description Right foot series after a foot injury Medical Specialty Podiatry Sample Name Right Foot Series Transcription EXAM Right foot series REASON FOR EXAM Injury FINDINGS Three images of the right foot were obtained On the AP image only there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal Also on a single image there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only Fractures in these bones cannot be completely excluded There is soft tissue swelling seen overlying the calcaneus within this region IMPRESSION Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals Recommend correlation with site of pain in addition to conservative management and followup imaging A phone call will be placed to the emergency room regarding these findings Keywords podiatry sclerosis calcaneus metatarsal foot series MEDICAL_TRANSCRIPTION,Description Plantar fascitis heel spur syndrome The patient was given injections of 3 cc 2 1 mixture of 1 lidocaine plain with dexamethasone phospate Medical Specialty Podiatry Sample Name Podiatry Progress Note Transcription SUBJECTIVE Mr Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel The patient states that the heel has been painful for approximately two weeks it is starts with the first step in the morning and gets worse with activity during the day The patient states that he is currently doing no treatment for it He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch The patient states that he has no change in the past medical history since his last visit and denies any fever chills vomiting headache chest or shortness of breath OBJECTIVE Upon removal of shoes and socks bilaterally neurovascular status remains unchanged since the last visit There is tenderness to palpation to the medial tubercle of the right foot The pain is elicited along the medial arch as well There are no open areas or signs of infection noted ASSESSMENT Plantar fascitis heel spur syndrome right foot PLAN The patient was given injections of 3 cc 2 1 mixture of 1 lidocaine plain with dexamethasone phospate He was given a low dye strapping and a heel lift was placed in his right shoe The patient will be seen back in approximately one month for further evaluation if necessary He was told to call if anything should occur before that The patient was told to continue with the good work on his diabetic control Keywords podiatry progress note plantar fascitis soap dexamethasone phospate heel lift heel spur syndrome lidocaine low dye strapping mixture of 1 lidocaine dexamethasone phospate injections heel MEDICAL_TRANSCRIPTION,Description Acute episode of agitation She was complaining that she felt she might have been poisoned at her care facility Medical Specialty Psychiatry Psychology Sample Name Agitation ER Visit Transcription HISTORY OF PRESENT ILLNESS This is a 91 year old female who was brought in by family Apparently she was complaining that she felt she might have been poisoned at her care facility The daughter who accompanied the patient states that she does not think anything is actually wrong but she became extremely agitated and she thinks that is the biggest problem with the patient right now The patient apparently had a little bit of dry heaves but no actual vomiting She had just finished eating dinner No one else in the facility has been ill PAST MEDICAL HISTORY Remarkable for previous abdominal surgeries She has a pacemaker She has a history of recent collarbone fracture REVIEW OF SYSTEMS Very difficult to get from the patient herself She seems to deny any significant pain or discomfort but really seems not particularly intent on letting me know what is bothering her She initially stated that everything was wrong but could not specify any specific complaints Denies chest pain back pain or abdominal pain Denies any extremity symptoms or complaints SOCIAL HISTORY The patient is a nonsmoker She is accompanied here with daughter who brought her over here They were visiting the patient when this episode occurred MEDICATIONS Please see list ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile actually has a very normal vital signs including normal pulse oximetry at 99 on room air GENERAL The patient is an elderly frail looking little lady lying on the gurney She is awake alert and not really wanted to answer most of the questions I asked her She does have a tremor with her mouth which the daughter states has been there for many years HEENT Eye exam is unremarkable Oral mucosa is still moist and well hydrated Posterior pharynx is clear NECK Supple LUNGS Actually clear with good breath sounds There are no wheezes no rales or rhonchi Good air movement CARDIAC Without murmur ABDOMEN Soft I do not elicit any tenderness There is no abdominal distention Bowel sounds are present in all quadrants SKIN Skin is without rash or petechiae There is no cyanosis EXTREMITIES No evidence of any trauma to the extremities EMERGENCY DEPARTMENT COURSE I had a long discussion with the family and they would like the patient receive something for agitation so she was given 0 5 mg of Ativan intramuscularly After about half an hour I came back to talk to the patient and the family the patient states that she feels better Family states she seems more calm They do not want to pursue any further workup at this time IMPRESSION ACUTE EPISODE OF AGITATION PLAN At this time I had reviewed the patient s records and it is not particularly enlightening as to what could have triggered off this episode The patient herself has good vital signs She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given a small quantity was given to the patient Family and daughter specifically did not want to pursue any workup at this point which at this point I think is reasonable and we will have her follow up with ABC She is discharged in stable condition Keywords psychiatry psychology acute episode of agitation agitation MEDICAL_TRANSCRIPTION,Description A 44 year old 250 pound male presents with extreme pain in his left heel Medical Specialty Podiatry Sample Name Plantar Fasciitis Transcription S A 44 year old 250 pound male presents with extreme pain in his left heel This is his chief complaint He says that he has had this pain for about two weeks He works on concrete floors He says that in the mornings when he gets up or after sitting he has extreme pain and great difficulty in walking He also has a macular blotching of skin on his arms face legs feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old He also has redness and infection of the right toes O The patient apparently has a pigmentation disorder which may or may not change with time on his arms legs and other parts of his body including his face He has an erythematous moccasin pattern tinea pedis of the plantar aspects of both feet He has redness of the right toes 2 3 and 4 Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel A 1 Plantar fasciitis Keywords podiatry plantar fasciitis tinea pedis tinea purpura heel fasciitis plantar MEDICAL_TRANSCRIPTION,Description Plantar fascitis left foot Partial plantar fasciotomy Medical Specialty Podiatry Sample Name Plantar Fasciotomy Transcription PREOPERATIVE DIAGNOSIS Plantar fascitis left foot POSTOPERATIVE DIAGNOSIS Plantar fascitis left foot PROCEDURE PERFORMED Partial plantar fasciotomy left foot ANESTHESIA 10 cc of 0 5 Marcaine plain with TIVA HISTORY This 35 year old Caucasian female presents to ABCD General Hospital with above chief complaint The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long term relief of symptoms and desires surgical treatment The patient has been NPO since mid night Consent is signed and in the chart No known drug allergies Details Of Procedure An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 10 cc of 0 5 Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia The foot was then prepped and draped in the usual sterile orthopedic fashion An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg The foot was then reflected on the operating stockinet reflected and the foot cleansed with a wet and dry sponge Attention was then directed to the plantar medial aspect of the left heel An approximately 0 75 cm incision was then created in the plantar fat pad over the area of maximal tenderness The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated A 15 blade was then used to transect the medial and central bands of the plantar fascia Care was taken to preserve the lateral fibroids The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted The air was then flushed with copious amounts of sterile saline The skin incision was then closed with 3 0 nylon in simple interrupted fashion Dressings consisted of 0 1 silk 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot Intraoperatively an additional 80 cc of 1 lidocaine was injected for additional anesthesia in the case The patient is to be nonweightbearing on the left lower extremity with crutches The patient is given postoperative pain prescriptions for Vicodin ES one q3 4h p o p r n for pain as well as Celebrex 200 mg one p o b i d The patient is to follow up with Dr X as directed Keywords podiatry foot plantar fasciotomy plantar fascitis plantar fascia plantar fasciotomy ankle medially fascitis fascia MEDICAL_TRANSCRIPTION,Description Excision of neuroma third interspace left foot Morton s neuroma third interspace left foot Medical Specialty Podiatry Sample Name Neuroma Excision Transcription PREOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot POSTOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot OPERATION PERFORMED Excision of neuroma third interspace left foot ANESTHESIA General local was confirmed by surgeon HEMOSTASIS Ankle pneumatic tourniquet 225 mmHg TOURNIQUET TIME 18 minutes Electrocautery was necessary INJECTABLES 50 50 mixture of 0 5 Marcaine and 1 Xylocaine both plain Also 0 5 mL dexamethasone phosphate 4 mg mL INDICATIONS Please see dictated H P for specifics PROCEDURE After proper identification was made the patient was brought to the operating room and placed on the table in supine position The patient was then placed under general anesthesia A local block was then injected into the third ray of the left foot The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures Identification of the neuroma was made following plantar flexion of the digits It was grasped with a hemostat and it was dissected in toto and removed It was then sent to pathology The area was then flushed with copious amounts of sterile saline Closure was with 4 0 Vicryl in the subcutaneous tissue and then running subcuticular 4 0 nylon suture in the skin Steri Strips were then placed over that area A sterile compressive dressing consisting of saline soaked gauze ABD Kling Coban was placed over the foot The tourniquet was then released Good flow was noted to return to all digits The patient did tolerate the procedure well He left the operating room with all vital signs stable and neurovascular status intact The patient went to the recovery The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain The patient will follow up with me in approximately 4 days for dressing change Keywords podiatry interspace ankle pneumatic pneumatic tourniquet morton s neuroma tourniquet neuroma foot anesthesia MEDICAL_TRANSCRIPTION,Description Amputation distal phalanx and partial proximal phalanx right hallux Osteomyelitis right hallux Medical Specialty Podiatry Sample Name Phalanx Amputation Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis right hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis right hallux PROCEDURE PERFORMED Amputation distal phalanx and partial proximal phalanx right hallux ANESTHESIA TIVA local HISTORY This 44 year old male patient was admitted to ABCD General Hospital on 09 02 2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics which he failed The patient after a multiple conservative treatments such as wound care antibiotics the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis The patient desires to attempt a surgical correction The risks versus benefits of the procedure were discussed with the patient in detail by Dr X The consent was available on the chart for review PROCEDURE IN DETAIL After patient was taken to the operating room via cart and placed on the operating table in the supine position a safety strap was placed across his waist Adequate IV sedation was administered by the Department of Anesthesia and a total of 3 5 cc of 1 1 mixture 1 lidocaine and 0 5 Marcaine plain were injected into the right hallux as a digital block The foot was prepped and draped in the usual aseptic fashion lowering the operative field Attention was directed to the hallux where there was a full thickness ulceration to the distal tip of the hallux measuring 0 5 cm x 0 5 cm There was a ________ tract which probed through the distal phalanx and along the sides of the proximal phalanx laterally The toe was 2 5 times to the normal size There were superficial ulcerations in the medial arch of both feet secondary to history of a burn which were not infected The patient had dorsalis pedis and posterior tibial pulses that were found to be 2 4 bilaterally preoperatively X ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx A 10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact Next the distal phalanx was disarticulated at the interphalangeal joint and removed The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology Next the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected Therefore a sagittal saw was used to resect approximately 0 75 cm of the distal aspect of head of the proximal phalanx This bone was also sent off for culture and was labeled proximal margin Next the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected The flexor tendon distally was gray discolored and was not viable A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally None was found No purulent drainage or abscess was found The proximal margin of the surgical site tissue was viable and healthy There was no malodor Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology Next copious amounts of gentamicin and impregnated saline were instilled into the wound A 3 0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension The plantar flap was viable and was debulked with Metzenbaum scissors The flap was folded dorsally and reapproximated carefully with 3 0 nylon with a combination of simple interrupted and vertical mattress sutures Iris scissors were used to modify and remodel the plantar flap An excellent cosmetic result was achieved No tourniquet was used in this case The patient tolerated the above anesthesia and surgery without apparent complications A standard postoperative dressing was applied consisting of saline soaked Owen silk 4x4s Kerlix and Coban The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot He will be readmitted to Dr Katzman where we will continue to monitor his blood pressure and regulate his medications Plan is to continue the antibiotics until further IV recommendations He will be nonweightbearing to the right foot and use crutches He will elevate his right foot and rest the foot keep it clean and dry He is to follow up with Dr X on Monday or Tuesday of next week Keywords podiatry osteomyelitis phalanx phalanx amputation proximal margin plantar flap distal phalanx proximal phalanx proximal hallux amputation foot plantarly distal MEDICAL_TRANSCRIPTION,Description Onychomycosis present 1 2 3 4 and 5 right and left Medical Specialty Podiatry Sample Name Onychomycosis 1 Transcription S The patient presents to podiatry clinic today at the request of her primary physician Dr XYZ for initial examination evaluation and treatment of her nails The patient has last seen primary in December 2006 PRIMARY MEDICAL HISTORY Edema venous insufficiency schizophrenia and anemia ALLERGIES THE PATIENT HAS NO KNOWN ALLERGIES MEDICATIONS Refer to chart O The patient presents in wheelchair verbal and alert Vascular She has absent pedal pulses bilaterally Trophic changes include absent hair growth and mycotic nails Skin texture is dry Skin color is rubor Classic findings include temperature change and edema 1 Nails Hypertrophic with crumbly subungual debris 1 2 3 4 and 5 right and 1 2 3 4 and 5 left A 1 Onychomycosis present 1 2 3 4 and 5 right and left 2 Peripheral vascular disease as per classic findings 3 Pain on palpation P Nails 1 2 3 4 and 5 right and 1 2 3 4 and 5 left were debrided for length and thickness The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails Keywords podiatry debrided thickness mycotic nails onychomycosis nails MEDICAL_TRANSCRIPTION,Description A 49 year old female with ankle pain times one month without a specific injury Medical Specialty Podiatry Sample Name MRI Foot 3 Transcription EXAM MRI LEFT FOOT CLINICAL A 49 year old female with ankle pain times one month without a specific injury Patient complains of moderate to severe pain worse with standing or walking on hard surfaces with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon FINDINGS Received for second opinion interpretations is an MRI examination performed on 05 27 2005 There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle There is edema of the subcutis adipose space posterior to the Achilles tendon Findings suggest altered biomechanics with crural fascial strains There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus axial inversion recovery image 16 which is a possible hypertrophic tear less than 50 in cross sectional diameter The study has been performed with the foot in neutral position Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons Normal peroneal tendons There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear Normal extensor hallucis longus and extensor digitorum tendons Normal Achilles tendon There is a low lying soleus muscle that extends to within 2cm of the teno osseous insertion of the Achilles tendon Normal distal tibiofibular syndesmotic ligamentous complex Normal lateral subtalar and deltoid ligamentous complexes There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force Normal plantar fascia There is no plantar calcaneal spur There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves Normal tibiotalar subtalar talonavicular and calcaneocuboid articulations The metatarsophalangeal joint of the hallux was partially excluded from the field of view of this examination IMPRESSION Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying tearing of the tendon immediately distal to the tip of the medial malleolus however confirmation of this finding would require additional imaging Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain Mild tendinosis of the tibialis anterior tendon with mild tendon thickening Normal plantar fascia and no plantar fasciitis Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves Keywords podiatry lateral plantar cutaneous plantar cutaneous nerves posterior tibialis tendon medial and lateral subcutis adipose adipose space achilles tendon tendon thickening hallucis longus lateral plantar plantar cutaneous cutaneous nerves medial malleolus posterior tibialis tibialis tendon plantar tendon posterior flexor tibialis medial MEDICAL_TRANSCRIPTION,Description Onychomycosis present 1 right and 1 left Medical Specialty Podiatry Sample Name Onychomycosis 2 Transcription S The patient presents to Podiatry Clinic today for initial examination evaluation and treatment of her nails PRIMARY MEDICAL HISTORY Adenocarcinoma delirium recent dehydration anemia history of hypertension and hyperlipidemia MEDICATIONS Refer to chart ALLERGIES PENICILLIN AND ASPIRIN O The patient presents in wheelchair verbal and alert Vascular She has absent pedal pulses bilaterally Trophic changes include absent hair growth and mycotic nails Skin texture is dry and shiny Skin color is rubor Classic findings are temperature change and edema 1 Nails Hypertrophic with crumbly subungual debris 1 right and 1 left A 1 Onychomycosis present 1 right and 1 left 2 Peripheral vascular disease as per classic findings 3 Pain on palpation P Nails 1 right and 1 left were debrided for length and thickness All the nails were reduced The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails Keywords podiatry length and thickness mycotic nails classic findings onychomycosis nails MEDICAL_TRANSCRIPTION,Description Pain and swelling in the right foot peroneal tendon tear Medical Specialty Podiatry Sample Name MRI Foot 1 Transcription EXAM MRI LOW EX NOT JNT RT W O CONTRAST CLINICAL Pain and swelling in the right foot peroneal tendon tear FINDINGS Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone A small effusion is noted within the peroneal tendon sheath There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone consistent with an avulsion There is no sign of cuboid fracture The fifth metatarsal base appears intact The calcaneus is also normal in appearance IMPRESSION Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone Keywords podiatry peroneus longus tendon peroneal tendon lateral margin peroneus longus longus tendon cuboid bone foot peroneal peroneus longus avulsion tendon bones cuboid MEDICAL_TRANSCRIPTION,Description Painful ingrown toenail left big toe Removal of an ingrown part of the left big toenail with excision of the nail matrix Medical Specialty Podiatry Sample Name Ingrown Toenail Removal Transcription PREOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe POSTOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe OPERATION Removal of an ingrown part of the left big toenail with excision of the nail matrix DESCRIPTION OF PROCEDURE After obtaining informed consent the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1 Xylocaine after having been prepped and draped in the usual fashion The ingrown part of the toenail was freed from its bed and removed then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail The matrix was excised down to the bone and then the skin flap was placed over it Hemostasis had been achieved with a cautery A tubular dressing was performed to provide a bulky dressing The patient tolerated the procedure well Estimated blood loss was negligible The patient was sent back to Same Day Surgery for recovery Keywords podiatry toenail nail matrix ingrown toenail painful ingrown MEDICAL_TRANSCRIPTION,Description Excision of soft tissue mass right foot The patient is a 51 year old female with complaints of soft tissue mass over the dorsum of the right foot Medical Specialty Podiatry Sample Name Mass Excision Foot Transcription PREOPERATIVE DIAGNOSIS Soft tissue mass right foot POSTOPERATIVE DIAGNOSIS Soft tissue mass right foot PROCEDURE PERFORMED Excision of soft tissue mass right foot HISTORY The patient is a 51 year old female with complaints of soft tissue mass over the dorsum of the right foot The patient has had previous injections to the site which have caused the mass to decrease in size however the mass continues to be present and is irritated and painful with shoes The patient has requested surgical intervention at this time PROCEDURE After an IV was instituted by the Department of Anesthesia the patient was escorted from the preoperative holding area to the operating room The patient was then placed on the operating room table in the supine position and a towel was placed around the patient s abdomen and secured her to the table Using copious amounts of Webril a pneumatic ankle tourniquet was applied to her right ankle Using a Skin Skribe the area of the soft tissue mass was outlined over the dorsum of her foot After adequate amount of anesthesia was provided by the Department of Anesthesia a local ankle block was given using 10 cc of 4 5 mL of 1 lidocaine plain 4 5 mL of 0 5 Marcaine plain and 1 0 mL of Solu Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner Following this the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg The foot was then brought back down to the table using bandage scissors The stockinette was reflected and the right foot was exposed Using a fresh 10 blade a curvilinear incision was performed over the dorsum of the right foot Then using a 15 blade the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted Following this the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified Further dissection was then performed in the medial direction in the area of the soft tissue mass The intermediate dorsal cutaneous nerve was identified and gently retracted laterally Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle Using careful dissection adipose tissue in this area was removed and saved for pathology Following removal of adipose tissue in this area and identification of no more adipose tissue attention was directed lateral to the belly of the extensor digitorum brevis muscle which was also noted to have large amounts of adipose tissue in this area as well Using careful dissection from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology There was noted to be no other fluid filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well Following this feeling adequately that no other mass remained in the area the incision was flushed using copious amounts of sterile saline The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue The tendon and muscle belly of the extensor digitorum brevis muscle the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially all appeared intact No deficits were noted No abnormal appearing tissue was present within the surgical site Following this the skin edges were reapproximated using 4 0 Vicryl deep closure of the subcutaneous layer was performed Then using 4 0 nylon and simple interrupted suture the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders The patient was also given 7 cc of 1 lidocaine plain throughout the procedure to augment local anesthesia Following this the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads dorsal and plantar for compression and using Kling Kerlix and Coban The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe The patient was then given postoperative instructions to include ice and elevation to her right foot The patient was cleared for ambulation as tolerated but was instructed that with increased ambulation will come increased swelling and pain The patient will follow up with Dr X in his office on Tuesday 08 26 03 for further follow up The patient was given prescription for Vicoprofen 25 taken one tablet q 4h p r n moderate to severe pain and also prescription for Keflex 20 500 mg tablets to be taken b i d x10 days The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit Keywords podiatry excision digitorum brevis muscle soft tissue mass adipose tissue soft tissue mass injections foot tissue xeroform dorsum belly extensor digitorum brevis ankle adipose muscle MEDICAL_TRANSCRIPTION,Description This patient has reoccurring ingrown infected toenails Medical Specialty Podiatry Sample Name Infected Toenails Transcription S This patient has reoccurring ingrown infected toenails He presents today for continued care O On examination the left great toenail is ingrown on the medial and lateral toenail border The right great toenail is ingrown on the lateral nail border only There is mild redness and granulation tissue growing on the borders of the toes One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe These lesions measure 0 5 cm in diameter each I really do not understand why this young man continues to develop ingrown nails and infections A 1 Onychocryptosis Keywords podiatry infected toenails onychocryptosis benign lesions toenail border left great toe neosporin ointment hemostasis was achieved ointment and absorbent toenails ingrown lesions benign infected MEDICAL_TRANSCRIPTION,Description Procedure note on Keller Bunionectomy Medical Specialty Podiatry Sample Name Keller Bunionectomy Transcription PROCEDURE Keller Bunionectomy For informed consent the more common risks benefits and alternatives to the procedure were thoroughly discussed with the patient An appropriate consent form was signed indicating that the patient understands the procedure and its possible complications This 59 year old female was brought to the operating room and placed on the surgical table in a supine position Following anesthesia the surgical site was prepped and draped in the normal sterile fashion Attention was then directed to the right foot where utilizing a 15 blade a 6 cm linear incision was made over the 1st metatarsal head taking care to identify and retract all vital structures The incision was medial to and parallel to the extensor hallucis longus tendon The incision was deepened through subcutaneous underscored retracted medially and laterally thus exposing the capsular structures below which were incised in a linear longitudinal manner approximately the length of the skin incision The capsular structures were sharply underscored off the underlying osseous attachments retracted medially and laterally Utilizing an osteotome and mallet the exostosis was removed and the head was remodeled with the Liston bone forceps and the bell rasp The surgical site was then flushed with saline The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm distal to the base and excised to toto from the surgical site Superficial closure was accomplished using Vicryl 5 0 in a running subcuticular fashion Site was dressed with a light compressive dressing The tourniquet was released Excellent capillary refill to all the digits was observed without excessive bleeding noted ANESTHESIA local HEMOSTASIS Accomplished with pinpoint electrocoagulation ESTIMATED BLOOD LOSS 10 cc MATERIALS None INJECTABLES Agent used for local anesthesia was Lidocaine 2 without epi PATHOLOGY Sent no specimen DRESSINGS Site was dressed with a light compressive dressing CONDITION Patient tolerated procedure and anesthesia well Vital signs stable Vascular status intact to all digits Patient recovered in the operating room SCHEDULING Return to clinic in 2 week s Keywords podiatry keller bunionectomy metatarsal head incision capsular osteotome compressive dressing keller bunionectomy MEDICAL_TRANSCRIPTION,Description MRI right ankle Medical Specialty Podiatry Sample Name MRI Ankle 2 Transcription EXAM MRI OF THE RIGHT ANKLE CLINICAL Pain FINDINGS The bone marrow demonstrates normal signal intensity There is no evidence of bone contusion or fracture There is no evidence of joint effusion Tendinous structures surrounding the ankle joint are intact No abnormal mass or fluid collection is seen surrounding the ankle joint IMPRESSION NORMAL MRI OF THE RIGHT ANKLE Keywords podiatry ankle joint bone mri ankle MEDICAL_TRANSCRIPTION,Description Right hallux abductovalgus deformity Right McBride bunionectomy Right basilar wedge osteotomy with OrthoPro screw fixation Medical Specialty Podiatry Sample Name McBride Bunionectomy Wedge Osteotomy Transcription PREOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity POSTOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity PROCEDURES PERFORMED 1 Right McBride bunionectomy 2 Right basilar wedge osteotomy with OrthoPro screw fixation ANESTHESIA Local with IV sedation HEMOSTASIS With pneumatic ankle cuff DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in a supine position The right foot was prepared and draped in usual sterile manner Anesthesia was achieved utilizing a 50 50 mixture of 2 lidocaine plain with 0 5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg At this time attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection Using a microsagittal saw the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp At this time attention was directed to the first inner space using sharp and blunt dissection Dissection was carried down to the underling level of the adductor hallucis tendon which was isolated and freed from its phalangeal sesamoidal and metatarsal attachments The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0 5 cm to help prevent any re fibrous attachment At this time the lateral release was stressed and was found to be complete The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0 5 cm resection The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw The area was again copiously flushed and inspected for any abnormalities and or prominences and none were noted At this time attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption At this time there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint At this time 0 5 cm was measured distal to that lateral measurement and using microsagittal saw a wedge osteotomy was taken from the base with the apex of the osteotomy being medial taking care to keep the medial cortex intact as a hinge The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3 0 x 22 mm The screw was placed following proper technique The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy The packing of the cancellous bone was held in place with bone wax The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed At this time a deep closure was achieved utilizing 2 0 Vicryl suture subcuticular closure was achieved using 4 0 Vicryl suture and skin repair was achieved at both surgical sites with 5 0 nylon suture in a running interlocking fashion The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site At this time the surgical site was postoperatively injected with 0 5 Marcaine plain as well as dexamethasone 4 mg primarily The surgical sites were then dressed with sterile Xeroform sterile 4x4s cascading and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion The tourniquet was dropped and color and temperature of all digits returned to normal The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions problems or concerns at any time with the numbers provided The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot Keywords podiatry hallux abductovalgus bunionectomy mcbride basilar wedge osteotomy orthopro screw fixation wedge osteotomy MEDICAL_TRANSCRIPTION,Description Resection of infected bone left hallux proximal phalanx and distal phalanx Osteomyelitis left hallux Medical Specialty Podiatry Sample Name Hallux Infected Bone Resection Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis left hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis left hallux PROCEDURES PERFORMED Resection of infected bone left hallux proximal phalanx and distal phalanx ANESTHESIA TIVA Local HISTORY This 77 year old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux The patient has a history of chronic osteomyelitis and non healing ulceration to the left hallux of almost 10 years duration He has failed outpatient antibiotic therapy and conservative methods At this time he desires to attempt surgical correction The patient is not interested in a hallux amputation at this time however he is consenting to removal of infected bone He was counseled preoperatively about the strong probability of the hallux being a floppy tail after the surgery and accepts the fact The risks versus benefits of the procedure were discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL The patient s wound was debrided with a 15 blade and down to good healthy tissue preoperatively The wound was on the planar medial distal and dorsal medial The wound s bases were fibrous They did not break the bone at this point They were each approximately 0 5 cm in diameter After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection Due to the patient s history of diabetes and marked calcifications on x ray a pneumatic ankle tourniquet was not applied Next a total of 3 cc of a 1 1 mixture of 0 5 Marcaine plain and 1 lidocaine plain was used to infiltrate the left hallux and perform a digital block Next the foot was prepped and draped in the usual aseptic fashion It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected Next a 10 blade was used to make a linear incision approximately 3 5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium Next the incision was deepened through the subcutaneous tissue A heavy amount of bleeding was encountered Therefore a Penrose drain was applied at the tourniquet which failed Next an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery Next the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon The long extensor tendon was thickened and overall exhibited signs of hypertrophy The transverse incision through the long extensor tendon was made with a 15 blade Immediately upon entering the joint yellow discolored fluid was drained from the interphalangeal joint Next the extensor tendon was peeled dorsally and distally off the bone Immediately the head of the proximal phalanx was found to be lytic disease friable crumbly and there were free fragments of the medial aspect of the bone the head of the proximal phalanx This bone was removed with a sharp dissection Next after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx a sagittal saw was used to resect the approximately one half of the proximal phalanx This was passed off as the infected bone specimen for microbiology and pathology Next the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx Next there was diseased soft tissue envelope around the bone which was also resected to good healthy tissue margins The pulse lavage was used to flush the wound with 1000 cc of gentamicin impregnated saline Next cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin This bone was found to be hard and healthy appearing The wound after irrigation was free of all debris and infected tissue Therefore anaerobic and aerobic cultures were taken and sent to microbiology Next OsteoSet beads tobramycin impregnated were placed Six beads were placed in the wound Next the extensor tendon was re approximated with 3 0 Vicryl The subcutaneous layer was closed with 4 0 Vicryl in a simple interrupted technique Next the skin was closed with 4 0 nylon in a horizontal mattress technique The Esmarch bandage was released and immediate hyperemic flush was noted at the digits A standard postoperative dressing was applied consisting of 4 x 4s Betadine soaked 0 1 silk Kerlix Kling and a loosely applied Ace wrap The patient tolerated the above anesthesia and procedure without complications He was transported via a cart to the Postanesthesia Care Unit His vitals signs were stable and vascular status was intact He was given a medium postop shoe that was well formed and fitting He is to elevate his foot but not apply ice He is to follow up with Dr X He was given emergency contact numbers He is to continue the Vicodin p r n pain that he was taking previously for his shoulder pain and has enough of the medicine at home The patient was discharged in stable condition Keywords podiatry osteomyelitis proximal phalanx distal phalanx infected bone proximal bone phalanx healing hallux infected tissue distal MEDICAL_TRANSCRIPTION,Description Incision and drainage and removal of foreign body right foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound Medical Specialty Podiatry Sample Name I D Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body right foot PROCEDURE PERFORMED 1 Incision and drainage right foot 2 Removal of foreign body right foot HISTORY This 7 year old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap General anesthesia was administered by the Department of Anesthesia The foot was then prepped and draped in the usual sterile orthopedic fashion The stockinette was reflected and the foot was cleansed with wet and dry sponge There was noted to be some remaining periwound erythema There was noted to be some mild crepitation about 2 cm proximal from the entry wound The entry wound was noted to be over the third metatarsal head dorsally Upon inspection of the wound there was noted to be hard foreign filling substance deep within the wound The entry site from the foreign body was extended proximally approximately about 0 5 cm At this time a large wooden foreign body was visualized and removed with a straight stat The area was carefully inspected for any remaining piece of foreign body Several small pieces were noted and they were removed The area was palpated and there was no more remaining foreign body noted At this time the wound was inspected thoroughly There was noted to be an area along the third metatarsal head more distally that did probe to the bone There was no purulent drainage expressed Area was flushed with copious amounts of sterile saline Pulse lavage was performed with 3 liters of plain sterile saline Wound cultures were obtained aerobic and aerobic The wound was then again inspected for any remaining foreign body or purulent drainage None was noticed The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s ABDs Kling and Kerlix The patient tolerated the above procedure and anesthesia well without complications The patient was transported to the PACU with vital signs stable and vascular status intact The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry The patient had a postoperative pain prescription written for Tylenol Elixir with codeine as needed Keywords podiatry incision and drainage removal of foreign body purulent drainage foreign body metatarsal head orthopedic metatarsal i d incision drainage foot MEDICAL_TRANSCRIPTION,Description Gangrene osteomyelitis right second toe The patient is a 58 year old female with poorly controlled diabetes with severe lower extremity lymphedema The patient has history of previous right foot infection requiring first ray resection Medical Specialty Podiatry Sample Name Gangrene Surgery Transcription PREOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe POSTOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe OPERATIVE REPORT The patient is a 58 year old female with poorly controlled diabetes with severe lower extremity lymphedema The patient has history of previous right foot infection requiring first ray resection The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint which has failed to respond to conservative treatment The patient now has exposed bone and osteomyelitis in the second toe The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention After an IV was started by the Department of Anesthesia the patient was taken back to the operating room and placed on the operative table in the supine position A restraint belt was placed around the patient s waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient s right ankle and the patient was made comfortable by the Department of Anesthesia After adequate amounts of sedation had been given to the patient we administered a block of 10 cc of 0 5 Marcaine plain in proximal digital block around the second digit The foot and ankle were then prepped in the normal sterile orthopedic manner The foot was elevated and an Esmarch bandage applied to exsanguinate the foot The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table Using Band Aid scissors the stockinet was cut and reflected and using a wet and dry sponge the foot was wiped cleaned and the second toe identified Using a skin scrape a racket type incision was planned around the second toe to allow also remodelling of previous operative site Using a fresh 10 blade skin incision was made circumferentially in the racket shaped manner around the second digit Then using a fresh 15 blade the incision was deepened and was taken down to the level of the second metatarsophalangeal joint Care was taken to identify bleeders and cautery was used as necessary for hemostasis After cleaning up all the soft tissue attachments the second digit was disarticulated down to the level of the metatarsophalangeal joint The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination Attention was then directed to closure of the wound All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges Due to long standing lower extremity lymphedema and postoperative changes on previous surgery I thought that we were unable to close the incision in entirety Therefore after copious amounts of irrigation using sterile saline it was determined to use modified dental rolls using 4 0 gauze to remove tension from the skin Deep vertical mattress sutures were used in order to reapproximate more closely the skin edges and bring the plantar flap of skin up to the dorsal skin This was obtained using 2 0 nylon suture Following this the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads then using Kling and Kerlix and an ACE bandage to provide compression The tourniquet was deflated at 42 minutes time and hemostasis was noted to be achieved The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact as was evidenced by capillary bleeding which was present during the procedure Sedation was given postoperative introductions which include to remain nonweightbearing to her right foot The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary no more than 20 minutes each hour The patient was instructed to continue her regular medications The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q 4h p r n for moderate to severe pain 30 The patient will followup with Podiatry on Monday morning at 8 30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time The patient was instructed as to signs and symptoms of infection was instructed to return to the Emergency Department immediately if these should present The second digit was sent to Pathology for gross and micro Keywords podiatry dorsally toe ulcerations foot infection ray resection metatarsophalangeal joint ace bandage gangrene osteomyelitis foot infection gangrene digital MEDICAL_TRANSCRIPTION,Description Cellulitis with associated abscess and foreign body right foot Irrigation debridement and removal of foreign body of right foot Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads Medical Specialty Podiatry Sample Name Foreign Body Removal Foot 1 Transcription PREOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot POSTOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot PROCEDURE PERFORMED 1 Irrigation debridement 2 Removal of foreign body of right foot ANESTHESIA Spinal with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal GROSS FINDINGS Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads HISTORY OF PRESENT ILLNESS The patient is a 61 year old Caucasian male with a history of uncontrolled diabetes mellitus The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics It was noted upon x ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity After a long discussion held with the patient it was elected to proceed with irrigation debridement and removal of the foreign body PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedures were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the patient operative surgeon the Department of Anesthesia and nursing staff The patient was then transferred to preoperative area to Operative Suite 5 and placed on the operating table in supine position All bony prominences were well padded at this time The Department of Anesthesia was administered spinal anesthetic to the patient Once this anesthesia was obtained the patient s right lower extremity was sterilely prepped and draped in the usual sterile fashion Upon viewing of the plantar aspect of the foot there was noted to be a swollen ecchymotic area with a small hole in it which purulent fluid was coming from At this time after all bony and soft tissue landmarks were identified as well as the localization of the pus a 2 cm longitudinal incision was made directly over this area which was located between the second and third metatarsal heads Upon incising this there was a foul smelling purulent fluid which flowed from this region Aerobic and anaerobic cultures were taken as well as gram stain The area was explored and it ________ to the dorsum of the foot There was no obvious joint involvement After all loculations were broken 3 liters antibiotic impregnated fluid were pulse evac through the wound The wound was again inspected with no more gross purulent or necrotic appearing tissue The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s floss and Kerlix covered by an Ace bandage At this time the Department of Anesthesia reversed the sedation The patient was transferred back to the hospital gurney to Postanesthesia Care Unit The patient tolerated the procedure well and there were no complications DISPOSITION The patient will be followed on a daily basis for possible repeat irrigation debridement Keywords podiatry removal of foreign body purulent material metatarsal cellulitis abscess kerlix foreign body foot irrigation debridement purulent MEDICAL_TRANSCRIPTION,Description Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot Medical Specialty Podiatry Sample Name Foot Lesions Transcription S An 84 year old diabetic female 5 7 1 2 tall 148 pounds history of hypertension and diabetes She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot She also has a left great toenail that is giving her problems as well O Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1 1 cm in diameter There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1 1 cm in diameter These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening The first and fifth metatarsal heads are plantarflexed Vibratory sensation appears to be absent Dorsal pedal pulses are nonpalpable Varicose veins are visible to the skin on the patient s feet that are very thin almost transparent The medial aspect of the left great toenail has dried blood under the nail The nail itself is very opaque loose from the nailbed almost rotten opaque discolored hypertrophic All of the patient s toenails are elongated and discolored and opaque as well There is dried blood under the medial aspect of the left great toenail A 1 Painful feet Keywords podiatry painful left foot lesions plantar metatarsal head hyperkeratotic lesion toenail nail matrix metatarsal metatarsal heads foot painful MEDICAL_TRANSCRIPTION,Description Abscess of the left foot etiology unclear at this time Possibility of foreign body Medical Specialty Podiatry Sample Name Foot Infection Management Transcription REASON FOR CONSULTATION Management for infection of the left foot HISTORY The patient is a 26 year old short Caucasian male who appears in excellent health presented a week ago as he felt some pain in the ball of his left foot He noticed a small dark spot He did not remember having had any injuries to that area specifically no puncture wounds He had not been doing any outdoor works or activities No history of working outdoors has not been to the beach or to the lake has not been out of town His swelling progressed so he went to see Dr X 4 days ago The area was debrided in the office and he was placed on Keflex It was felt that may be he had a foreign body but nothing was found in the office and x ray was negative for opaque foreign bodies His foot got worse with more swelling and at this time purulent too red and was admitted to the hospital today is scheduled for surgical exploration this evening Ancef and Cipro were prescribed today He denies any fever chills red streaks lymphadenitis He had a tetanus shot in 2002 most recently He had childhood asthma He uses alcohol socially He works full time He is an electrician ALLERGIES ACCUTANE PHYSICAL EXAMINATION GENERAL Well developed well nourished adult Caucasian male in no acute distress VITAL SIGNS His weight is 190 pounds height 69 inches temperature 98 respirations 20 pulse 78 and blood pressure 143 63 O2 sat 98 on room air HEENT Mouth unremarkable NECK Supple LUNGS Clear HEART Regular rate rhythm No murmur or gallop ABDOMEN Soft and nontender EXTREMITIES Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema There is bloodied blister around it The area is tender to touch warm with a slight edema of the rest of the foot with very faint erythema There is some mild intertrigo between the fourth and fifth left toes Palpable pedal pulses Leg unremarkable No femoral or inguinal lymphadenopathy LABORATORY Labs show white cell count of 6300 hemoglobin 13 6 platelet count of _____ with 80 monos 17 eos _____ creatinine 1 3 BUN of 16 glucose 110 Calcium ferritin albumin bilirubin ALT AST alkaline phosphatase are normal PT and PTT normal and the sed rate was 35 mm per hour IMPRESSION Abscess of the left foot etiology unclear at this time Possibility of foreign body RECOMMENDATIONS PLAN He is going to be discharged in about half an hour Cultures Gram stain fungal cultures and smear to be obtained I have changed his antibiotic to vancomycin plus Maxipime He is currently on tetanus immunizations so no need for booster at this time Keywords podiatry accutane possibility of foreign body foot etiology foreign body infection foot abscess MEDICAL_TRANSCRIPTION,Description Excision of foreign body right foot and surrounding tissue This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot Medical Specialty Podiatry Sample Name Foreign Body Removal Foot Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body in the right foot PROCEDURE PERFORMED Excision of foreign body right foot and surrounding tissue ANESTHESIA TIVA and local HISTORY This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot His family physician attempted to remove the wire but it only became deeper in the foot The wound eventually healed but a scar tissue was formed The patient has had constant pain with ambulation intermittently since the incident occurred He desires attempted surgical removal of the wire The risks and benefits of the procedure have been explained to the patient in detail by Dr X The consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient s protection After adequate IV sedation was administered by the Department of Anesthesia a total of 12 cc of 0 5 Marcaine plain was used to administer an ankle block Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered into the operative field and the sterile stockinet was reflected Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized This was the origin and entry point of the previous puncture wound from the wire This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area Next the Xi scan was draped and brought into the operating room A 25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire Next a 10 blade was used to make approximately a 3 cm curvilinear S shaped incision Next the 15 blade was used to carry the incision through the subcutaneous tissue The medial and lateral margins of the incision were undermined Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot the wires seemed to serve no benefit other then helping with the incision planning Therefore they were removed Once the wound was opened a hemostat was used to locate the wire very quickly and the wire was clamped A second hemostat was used to clamp the wire A 15 blade was used to carefully transect the fatty tissue around the tip of the hemostats which were visualized in the base of the wound The wire quickly came into visualization It measured approximately 4 mm in length and was approximately 1 mm in diameter The wire was green colored and metallic in nature It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament Next copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected Next a 3 0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space Next 4 0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique The standard postoperative dressing consisting of saline soaked Owen silk 4x4s Kling Kerlix and Coban were applied The pneumatic ankle tourniquet was released There was immediate hyperemic flush to the digits noted The patient s anesthesia was reversed He tolerated the above anesthesia and procedure without complications The patient was transported via cart to the Postanesthesia Care Unit Vital signs were stable and vascular status was intact to the right foot He was given OrthoWedge shoe Ice was applied behind the knee and his right lower extremity was elevated on to pillows He was given standard postoperative instructions consisting of rest ice and elevation to the right lower extremity He is to be non weightbearing for three weeks at which time the wound will be evaluated and sutures will be removed He is to follow up with Dr X on 08 22 2003 and was given emergency contact number to call if problems arise He was given a prescription for Tylenol 4 30 one p o q 4 6h p r n pain as well as Celebrex 200 mg 30 take two p o q d p c with 200 mg 12 hours later as a rescue dose He was given crutches He was discharged in stable condition Keywords podiatry foreign body removal excision of foreign body ankle tourniquet plantar aspect foreign body foot ankle plantar wound MEDICAL_TRANSCRIPTION,Description The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails Medical Specialty Podiatry Sample Name Dystrophic Nails Transcription S The patient presents for evaluation at the request of his primary physician for treatment for nails He has last seen the primary physician in December 2006 PRIMARY MEDICAL HISTORY Femoral embolectomy GI bleed hypertension PVD hypothyroid GERD osteoarthritis diabetes CAD renal artery stenosis COPD and atrial fibrillation MEDICATIONS Refer to chart O The patient presents in wheelchair verbal and alert Vascular He has absent pedal pulses bilaterally Trophic changes include absent hair growth and dystrophic nails Skin texture is dry and shiny Skin color is rubor Classic findings include temperature change and edema 2 Nails Thickened and hypertrophic 1 2 3 4 and 5 right and 1 2 3 4 and 5 left A 1 Dystrophic nails 2 Peripheral vascular disease as per classic findings 3 Pain on palpation 4 Diabetes P Nails 1 2 3 4 and 5 right and 1 2 3 4 and 5 left were debrided The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails Keywords podiatry debrided nails dystrophic nails dystrophic MEDICAL_TRANSCRIPTION,Description An 83 year old diabetic female presents today stating that she would like diabetic foot care Medical Specialty Podiatry Sample Name Diabetic Foot Care Transcription S An 83 year old diabetic female presents today stating that she would like diabetic foot care O On examination the lateral aspect of her left great toenail is deeply ingrown Her toenails are thick and opaque Vibratory sensation appears to be intact Dorsal pedal pulses are 1 4 There is no hair growth seen on her toes feet or lower legs Her feet are warm to the touch All of her toenails are hypertrophic opaque elongated and discolored A 1 Onychocryptosis Keywords podiatry onychocryptosis onychomycosis great toenail diabetic foot care diabetic foot foot toenail ingrown toenails diabetic MEDICAL_TRANSCRIPTION,Description A 60 year old female presents today for care of painful calluses and benign lesions Medical Specialty Podiatry Sample Name Bunions and Calluses Transcription S A 60 year old female presents today for care of painful calluses and benign lesions O On examination the patient has bilateral bunions at the first metatarsophalangeal joint She states that they do not hurt No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot She has a small intractable plantar keratoma plantar to her left second metatarsal head which measures 0 5 cm in diameter This is a central plug She also has a very very painful lesion plantar to her right fourth metatarsal head which measures 3 1 x 1 8 cm in diameter This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines A 1 Bilateral bunions Keywords podiatry painful calluses hibiclens scrubbed ointment and absorbent heloma durum plantar aspect minimal hemostasis neosporin ointment absorbent dressing benign lesions metatarsophalangeal bunions calluses plantar MEDICAL_TRANSCRIPTION,Description Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat Sharp excision of left distal foot plantar fascia Medical Specialty Podiatry Sample Name Debridement Foot Ulcer Transcription PREOPERATIVE DIAGNOSES 1 Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint 2 Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx 3 Plantar fascitis of left distal lateral foot POSTOPERATIVE DIAGNOSES 1 Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint 2 Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx 3 Plantar fascitis of left distal lateral foot OPERATION PERFORMED 1 Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat 2 Sharp excision of left distal foot plantar fascia ANESTHESIA None required INDICATIONS The patient is a 51 year old diabetic female with severe peripheral vascular disease who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation PROCEDURE IN DETAIL The procedure was performed in the patient s room The dressing was removed exposing about a 4 cm x 2 5 cm left distal lateral foot fifth ray amputation open wound Distally there is infarcted left fourth metatarsophalangeal joint capsule as well as plantar fat below the joint She has neuropathy allowing debridement of the tissues Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided There was complete infarction of the lateral joint capsule and the head of the phalanx as well as distal metatarsal head were chronically infected The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad The patient suffered no complications from the procedure Keywords podiatry plantar fascia foot ulcer interosseous metatarsal cellulitis amputation osteomyelitis plantar fascitis joint capsule ray amputation debridement plantar foot MEDICAL_TRANSCRIPTION,Description Bunion left foot Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot Medical Specialty Podiatry Sample Name Bunionectomy Akin Osteotomy Transcription PREOPERATIVE DIAGNOSIS Bunion left foot POSTOPERATIVE DIAGNOSIS Bunion left foot PROCEDURE PERFORMED 1 Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation 2 Akin osteotomy with internal wire fixation of left foot HISTORY This 19 year old Caucasian female presents to ABCD General Hospital with the above chief complaint The patient states she has had worsening bunion deformity for as long as she could not remember She does have a history of Charcot Marie tooth disease and desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field The stockinette was reflected the foot was cleansed with a wet and dry sponge Approximately 5 cm incision was made dorsomedially over the first metatarsal The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis Care was taken to preserve the extensor digitorum longus tendon The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone Capsule and periosteum was reflected off the first metatarsal head At this time the cartilage was inspected and noted to be white shiny and healthy cartilage There was noted to be a prominent medial eminence Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release The abductor tendon attachments were identified and transected The lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Attention was then directed to the prominent medial eminence which was resected with a sagittal saw Intraoperative assessment of pes was performed and pes was noted to be normal At this time a regional incision was carried more approximately about 1 5 cm The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal The first metatarsal cuneiform joint was identified A 0 45 K wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface This K wire was used as an access guide for a Juvaro type oblique base wedge osteotomy The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial The osteotomy site was then feathered and tilted with tight estimation of the bony edges The cortical hinge was maintained A 0 27 x 24 mm screw was then inserted in a standard AO fashion At this time there was noted to be tight compression of the osteotomy site A second 2 7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted The ________ angle was noted to be significantly released Reciprocating rasp was then used to smoothen any remaining sharp edges The 0 45 k wire was removed The foot was loaded and was noted to fill the remaining abduction of the hallux At this time it was incised to perform an Akin osteotomy Original incision was then extended distally approximately 1 cm The incision was then deepened down to the level of capsule over the base of the proximal phalanx Again care was taken to preserve the extensor digitorum longus tendon The capsule was reflected off of the base of the proximal phalanx An Akin osteotomy was performed with the apex being lateral and the base being medial After where the bone was resected it was feathered until tight compression was noted without tension at the osteotomy site Care was taken to preserve the lateral hinge At 1 5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire The 28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted The remaining edge of the wire was then buried in the medial most distal drill hole The area was then inspected and the foot was noted with significant reduction of the bunion deformity The area was then flushed with copious amounts of sterile saline Capsule was closed with 3 0 Vicryl followed by subcutaneous closure with 4 0 Vicryl in order to decrease tension of the incision site A running 5 0 subcuticular stitch was then performed Steri Strips were applied Total of 1 cc dexamethasone phosphate was then injected into the surgical site Dressings consisted of Owen silk 4x4s Kling Kerlix The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot Posterior splint was then placed on the patient in the operating room The patient tolerated the above procedure and anesthesia well without complications The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot The patient was given postoperative instructions to be strictly nonweightbearing on the left foot The patient was given postop pain prescriptions for Vicodin and instructed to take one q 4 6h p r n for pain as well as Naprosyn 500 mg p o q b i d The patient is to follow up with Dr X in his office in four to five days as directed Keywords podiatry bunionectomy akin osteotomy internal wire fixation internal screw fixation osteotomy metatarsal metatarsal osteotomy extensor digitorum drill hole osteotomy site foot MEDICAL_TRANSCRIPTION,Description Arthroplasty of the right second digit Hammertoe deformity of the right second digit Medical Specialty Podiatry Sample Name Arthroplasty Hammertoe Transcription PREOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit POSTOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit PROCEDURE PERFORMED Arthroplasty of the right second digit The patient is a 77 year old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe The patient presents n p o since mid night last night and consented to sign in the chart H P is complete PROCEDURE IN DETAIL After an IV was instituted by the Department of Anesthesia in the preoperative holding area the patient was escorted to the operating room and placed on the table in the supine position Using Webril the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle but left deflated at this time Restraining a lap belt was then placed around the patient s abdomen while laying on the table After adequate anesthesia was administered by the Department of Anesthesia a local digital block using 5 cc of 0 5 Marcaine plain was used to provide local anesthesia The foot was then prepped and draped in the normal sterile orthopedic manner The foot was then elevated and Esmarch bandage was applied after which time the tourniquet was inflated to 250 mmHg The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx Then using a fresh 15 blade a dorsolinear incision was made partial thickness through the skin after testing anesthesia with one to two pickup Then using a fresh 15 blade incision was deepened and using medial to lateral pressure the incision was opened into the subcutaneous tissue Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin This was performed with the combination of blunt and dull dissection Care was taken to avoid proper digital arteries and neurovascular bundles as were identified Attention was then directed to the proximal interphalangeal joint and after identifying the joint line a transverse linear incision was made over the dorsal surface of the joint The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure Following this the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson Brown pickup It was elevated with fresh 15 blade The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally Following this the distal portion of the tendon was identified in a like manner The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone The proximal interphalangeal joint was then distracted and using careful technique 15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head Following this the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues Then using a sagittal saw with a 139 blade the head of he proximal phalanx was resected Care was taken to avoid the deep flexor tendon The head of the proximal phalanx was taken with the Adson Brown and using a 15 blade the plantar periosteal tissue was freed up and the head was removed and sent to pathology The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment The digit was also noted to be in rectus alignment Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity Then using a 3 0 Vicryl suture three simple interrupted sutures were placed for closure of the tendon and capsular tissue Then following this 4 0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site Following this the incision was dressed using a sterile Owen silk soaked in saline and gentamicin The toe was bandaged using 4 x 4s Kling and Coban The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe Total tourniquet time for the case was 30 minutes While in the recovery the patient was given postoperative instructions to include ice and elevation to his right foot The patient was given pain medications of Tylenol 3 quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain The patient was also given prescription for cane to aid in ambulation The patient will followup with Dr X on Tuesday in his office for postoperative care The patient was instructed to keep the dressings clean dry and intact and to not remove them before his initial office visit The patient tolerated the procedure well and the anesthesia with no complications Keywords podiatry hammertoe deformity arthroplasty digit proximal interphalangeal joint periosteal tissue interrupted sutures interphalangeal joint proximal phalanx proximal painful tourniquet hammertoe phalanx head incisional tendon MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Akin bunionectomy right toe with internal wire fixation Medical Specialty Podiatry Sample Name Bunionectomy Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot POSTOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot PROCEDURES PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Akin bunionectomy right toe with internal wire fixation ANESTHESIA TIVA local HISTORY This 51 year old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot The patient has a history of gradual onset of a painful bunion over the past several years She has tried conservative methods such as wide shoes accommodative padding on an outpatient basis with Dr X all of which have provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril After adequate IV sedation was administered by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 0 5 Marcaine plain and 1 Lidocaine plain was injected into the foot in a standard Mayo block fashion The foot was elevated off the table Esmarch bandages were used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operative field and the sterile stockinet was reflected A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia which was found to be adequate Attention was directed to the first metatarsophalangeal joint which was found to be contracted laterally deviated and had decreased range of motion A 10 blade was used to make a 4 cm dorsolinear incision A 15 blade was used to deepen the incision through the subcutaneous layer All superficial subcutaneous vessels were ligated with electrocautery Next a linear capsular incision was made down the bone with a 15 blade The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head The medial plantar aspect of the metatarsal head had some erosive changes and eburnation Next a 0 45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it A sagittal saw was used to make a long arm Austin osteotomy in the usual fashion Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex The capital head was shifted laterally and impacted on the residual metatarsal head Nice correction was achieved and excellent bone to bone contact was achieved The bone stock was slightly decreased but adequate Next a 0 45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment A 2 7 x 18 mm Synthes cortical screw was thrown using standard AO technique Excellent rigid fixation was achieved A second 2 0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head Again an excellent rigid fixation was obtained and the screws were tight The temporary fixation was removed A medial overhanging bone was resected with a sagittal saw The foot was loaded and the hallux was found to have an interphalangeus deformity present A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx leaving a lateral intact cortical hinge A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done After the wedge bone was removed the saw blade was reinserted and used to tether the osteotomy with counter pressure used to close down the osteotomy A 15 drill blade was used to drill two converging holes on the medial aspect of the bone A 28 gauge monofilament wire was inserted loop to loop and pulled through the bone The monofilament wire was twisted down and tapped into the distal drill hole The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved Next reciprocating rasps were used to smooth all bony surfaces Copious amounts of sterile saline was used to flush the joint Next a 3 0 Vicryl was used to reapproximate the capsular periosteal tissue layer Next 4 0 Vicryl was used to close the subcutaneous layer 5 0 Vicryl was used to the close the subcuticular layer in a running fashion Next 1 cc of dexamethasone phosphate was then instilled in the joint The Steri Strips were applied followed by standard postoperative dressing consisting of Owen silk 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She is to be partial weightbearing with crutches She is to follow with Dr X She was given emergency contact numbers and instructions to call if problems arise She was given prescription for Vicodin ES 25 one p o q 4 6h p r n pain and Naprosyn one p o b i d 500 mg She was discharged in stable condition Keywords podiatry hallux interphalangeus osteotomy bunionectomy akin wire fixation screw fixation painful bunion metatarsophalangeal joint pneumatic ankle metatarsal head foot toe sagittal metatarsal MEDICAL_TRANSCRIPTION,Description Austin akin bunionectomy right foot Bunion right foot The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful Medical Specialty Podiatry Sample Name Bunionectomy Austin Akin Transcription PREOPERATIVE DIAGNOSIS Bunion right foot POSTOPERATIVE DIAGNOSIS Bunion right foot PROCEDURE PERFORMED Austin akin bunionectomy right foot HISTORY This 77 year old African American female presents to ABCD General Hospital with the above chief complaint The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful The patient has attempted conservative treatment without long term relief of symptoms and desires surgical treatment PROCEDURE DETAILS An IV was instituted by Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain was injected in a Mayo block type fashion The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated to the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg The foot was lowered to the operating field and the stockinet was reflected The foot was cleansed with wet and dry sponge Attention was directed to the bunion deformity on the right foot An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint The incision was then deepened with a 15 blade All vessels encountered were ligated with hemostasis The skin and subcutaneous tissue were then undermined off of the capsule medially A dorsal linear capsular incision was then created over the first metatarsophalangeal joint The periosteum and capsule were then reflected off of the first metatarsal There was noted to be a prominent medial eminence The articular cartilage was healthy for patient s age and race Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified The adductor tendons were transected as well as a lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon Attention was then directed to medial eminence which was resected with a sagittal saw Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted The head was intact A 0 45 K wire was inserted through subcutaneously from proximal medial to distal lateral A second K wire was then inserted from distal lateral to proximal plantar medial Adequate fixation was noted at the osteotomy site The K wires were bent cut and pin caps were placed Attention was then directed to the proximal phalanx of the hallux The capsular periostem was reflected off of the base of the proximal phalanx A sagittal was then used to create an akin osteotomy closing wedge The apex was lateral and the base of the wedge was medial The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression Two 0 45 K wires were then inserted one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site Adequate fixation was noted at the osteotomy site and the osteotomy was closed The toe was noted to be in a markedly more rectus position Sagittal saw was then used to resect the remaining prominent medial eminence The area was then smoothed with a reciprocating rasp There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp The area was then inspected for any remaining short bony edges none were noted Copious amounts of sterile saline was then used to flush the surgical site The capsule was closed with 3 0 Vicryl Subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular 5 0 Vicryl Steri Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site Dressings consisted of 0 1 silk copious Betadine 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot A _______ cast was then applied postoperatively The patient tolerated the above procedure and anesthesia well without complications The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot The patient was given postoperative pain prescription for Tylenol 3 and instructed to take one q4 6h p o p r n for pain The patient is to follow up with Dr X in his office as directed Keywords podiatry austin akin bunionectomy hallucis brevis bunion deformity extensor hallucis osteotomy site foot austin bunionectomy MEDICAL_TRANSCRIPTION,Description A simple note on Athlete s foot tinea pedis a very common fungal skin infection of the foot Medical Specialty Podiatry Sample Name Athlete s Foot Transcription ATHLETE S FOOT TINEA PEDIS is a very common fungal skin infection of the foot It often first appears between the toes It can be a one time occurrence or it can be chronic The fungus known as Trichophyton thrives under warm damp conditions so people whose feet sweat a great deal are more susceptible It is easily transmitted in showers and pool walkways Those people with immunosuppressive conditions such as diabetes mellitus are also more susceptible to athlete s foot SIGNS AND SYMPTOMS Itchy feet White or red and soft scaling on feet usually in between toes Small blisters may be present Bad foot odor Very rare involvement of hands and simultaneously called an Id reaction TREATMENT Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope A bacterial infection may also be suspected in which case a skin culture will confirm this Try a non prescription antifungal powder or cream available in drugstores your doctor can prescribe a stronger topical antifungal medication if necessary Oral antibiotics may be prescribed for a possible bacterial infection Keep feet as dry as possible Change socks twice a day if necessary and wear those made of natural fibers such as cotton Go barefoot when you have a chance or wear sandals Dry thoroughly in between toes after swimming or bathing A special powder to absorb moisture on feet is also available in drugstores Ask the pharmacist about this Spray your shower at home with a 10 bleach solution after bathing This may help decrease the chance that other family members will be infected Wear sandals or thongs in public showers and around pools Keep in mind that it may take up to a month or more to get rid of your athlete s foot Be diligent in using the antifungal medication Unfortunately recurrence of athlete s foot is common Luckily the condition does not cause serious problems for the majority of people who have it Call the office if your athlete s foot spreads or worsens despite treatment PLANTAR FASCIAL STRETCHES 1 Raise toes toward you while bending your ankle as high as you can 2 Hold this position for 15 seconds 3 Alternate doing this with the opposite foot 10 times 4 Perform this exercise 2 3 times a day WOUND CARE INSTRUCTIONS 1 Clean the area daily with soap and water 2 Every day apply a thin coat of polysporin ointment 3 Change the dressing daily and keep the area covered with an adhesive bandage until completely healed 4 Notify the office if you have any increasing wound pain or any evidence of infection Keywords podiatry tinea pedis infection foot athlete s foot trichophyton itchy athlete s foot tinea pedis fungal skin infection fungal athlete s MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Proximal interphalangeal joint arthroplasty bilateral fifth toes Distal interphalangeal joint arthroplasty bilateral third and fourth toes Flexor tenotomy bilateral third toes Medical Specialty Podiatry Sample Name Bunionectomy Flexor Tenotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes PROCEDURE PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Proximal interphalangeal joint arthroplasty bilateral fifth toes 3 Distal interphalangeal joint arthroplasty bilateral third and fourth toes 4 Flexor tenotomy bilateral third toes HISTORY This is a 36 year old female who presented to ABCD preoperative holding area after keeping herself n p o since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet The patient has a history of sharp pain which is aggravated by wearing shoes and ambulation She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding all of which provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed in detail by Dr Kaczander with the patient and the consent is available on the chart PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril After adequate IV sedation was administered a total of 18 cc of a 0 5 Marcaine plain was used to anesthetize the right foot performing a Mayo block and a bilateral third fourth and fifth digital block Next the foot was prepped and draped in the usual aseptic fashion bilaterally The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg The foot was lowered into operative field and the sterile stockinet was reflected proximally Attention was directed to the right first metatarsophalangeal joint it was found to be contracted and there was lateral deviation of the hallux There was decreased range of motion of the first metatarsophalangeal joint A dorsolinear incision was made with a 10 blade approximately 4 cm in length The incision was deepened to the subcutaneous layer with a 15 blade Any small veins traversing the subcutaneous layer were ligated with electrocautery Next the medial and lateral wound margins were undermined sharply Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon Next the first metatarsal joint capsule was identified A 15 blade was used to make a linear capsular incision down to the bone The capsular periosteal tissues were elevated off the bone with a 15 blade and the metatarsal head was delivered into the wound The PASA was found to be within normal limits There was a hypertrophic medial eminence noted A sagittal saw was used to remove the hypertrophic medial eminence A 0 045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide A standard lateral release was performed The fibular sesamoid was found to be in the interspace but was relocated onto the metatarsal head properly Next a sagittal saw was used to perform a long arm Austin osteotomy The K wire was removed The capital fragment was shifted laterally and impacted into the head A 0 045 inch Kirschner wire was used to temporarily fixate the osteotomy A 2 7 x 16 mm Synthes fully threaded cortical screw was throne using standard AO technique A second screw was throne which was a 2 0 x 12 mm Synthes cortical screw Excellent fixation was achieved and the screws tightly perched the bone Next the medial overhanging wedge was removed with a sagittal saw A reciprocating rasp was used to smooth all bony prominences The 0 045 inch Kirschner wire was removed The screws were checked again for tightness and found to be very tight The joint was flushed with copious amounts of sterile saline A 3 0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique A 4 0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique A 5 0 Monocryl was used to close the skin in a running subcuticular fashion Attention was directed to the right third digit which was found to be markedly contracted at the distal interphalangeal joint A 15 blade was used to make two convergent semi elliptical incisions over the distal interphalangeal joint The incision was deepened with a 15 blade The wedge of skin was removed in full thickness The long extensor tendon was identified and the distal and proximal borders of the wound were undermined The 15 blade was used to transect the long extensor tendon which was reflected proximally The distal interphalangeal joint was identified and the 15 blade was placed in the joint and the medial and lateral collateral ligaments were released Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx Next a double action bone cutter was used to resect the head of the middle phalanx The toe was dorsiflexed and was found to have an excellent rectus position A hand rasp was used to smooth all bony surfaces The joint was flushed with copious amounts of sterile saline The flexor tendon was found to be contracted therefore a flexor tenotomy was performed through the dorsal incision Next 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin and excellent cosmetic result was achieved Attention was directed to the fourth toe which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated An oblique skin incision with two converging semi elliptical incisions was created using 15 blade The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot All the same suture materials were used However there was no flexor tenotomy performed on this toe only on the third toe bilaterally Attention was directed to the fifth right digit which was found to be contracted at the proximal interphalangeal joint A linear incision approximately 2 cm in length was made with a 15 blade over the proximal interphalangeal joint Next a 15 blade was used to deepen the incision to the subcutaneous layer The medial and lateral margins were undermined sharply to the level of the long extensor tendon The proximal interphalangeal joint was identified and the tendon was transected with the 15 blade The tendon was reflected proximally off the head of the proximal phalanx The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound A double action bone nibbler was used to remove the head of the proximal phalanx A hand rasp was used to smooth residual bone The joint was flushed with copious amounts of saline A 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures A standard postoperative dressing consisting of saline soaked 0 1 silk 4 x 4s Kerlix Kling and Coban were applied The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits Attention was directed to the left foot The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg Attention was directed to the left fifth toe which was found to be contracted at the proximal interphalangeal joint The exact same procedure performed to the right fifth digit was performed on this toe with the same materials being used for suture and closure Attention was then directed to the left fourth digit which was found to contracted and slightly abducted and varus rotated The exact same procedure as performed to the right fourth toe was performed consisting of two semi elliptical skin incisions in an oblique angle The same suture material were used to close the incision Attention was directed to the left third digit which was found to be contracted at the distal interphalangeal joint The same procedure performed on the right third digit was also performed The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot She was given postoperative shoes and will be partial weighbearing with crutches She was admitted short stay to Dr Kaczander for pain control She was placed on Demerol 50 and Vistaril 25 mg IM q3 4h p r n for pain She will have Vicodin 5 500 one to two p o q 4 6h p r n for moderate pain She was placed on Subq heparin and given incentive spirometry 10 times an hour She will be discharged tomorrow She is to ice and elevate both feet today and rest as much as possible Physical Therapy will teach her crutch training today X rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities Keywords podiatry hallux abductovalgus hammertoe bunionectomy flexor tenotomy interphalangeal arthroplasty screw fixation osteotomy interphalangeal joint arthroplasty distal interphalangeal joint interphalangeal joint flexor tenotomy proximal interphalangeal joint arthroplasty distal interphalangeal distal blade proximal foot joint toes tendon MEDICAL_TRANSCRIPTION,Description Tailor s bunion right foot Removal of bone right fifth metatarsal head Medical Specialty Podiatry Sample Name Bone Removal Metatarsal Head Transcription PREOPERATIVE DIAGNOSIS Tailor s bunion right foot POSTOPERATIVE DIAGNOSIS Tailor s bunion right foot PROCEDURE PERFORMED Removal of bone right fifth metatarsal head ANESTHESIA TIVA local HISTORY This 60 year old male presents to ABCD Preoperative Holding Area after keeping himself n p o since mid night for surgery on his painful right Tailor s bunion The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr X At this time he desires surgical correction as the ulcer has been refractory to conservative treatment Incidentally the ulcer is noninfective and practically healed at this date The consent is available on the chart for review and Dr X has discussed the risks versus benefits of this procedure to the patient in detail PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room placed on the operating table in supine position and a safety strap was placed across his waist for his protection A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient s protection After adequate IV sedation was administered by the Department of Anesthesia a total of 10 cc of 1 1 mixture of 1 lidocaine and 0 5 Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operating field and a sterile stockinet was reflected The Betadine was cleansed with saline soaked gauze and dried Anesthesia was tested with a one tooth pickup and found to be adequate A 10 blade was used to make 3 5 cm linear incision over the fifth metatarsophalangeal joint A 15 blade was used to deepen the incision to the subcutaneous layer Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally Using a combination of sharp and blunt dissection the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia A linear capsular incision was made with a 15 blade down to the bone The capsular periosteal tissues were elevated off the bone with a 15 blade Metatarsal head was delivered into the wound There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer The ulcer on the skin was approximately 2 x 2 mm it was partial skin thickness and did not probe A sagittal saw was used to resect the hypertrophic lateral eminence The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity Next a reciprocating rasp was used to smoothen all bony surfaces The bone stock had an excellent healthy appearance and did not appear to be infected Copious amount of sterile gentamicin impregnated saline were used to flush the wound The capsuloperiosteal tissues were reapproximated with 3 0 Vicryl in simple interrupted technique The subcutaneous layer was closed with 4 0 Vicryl in simple interrupted technique Next the skin was closed with 4 0 nylon in a horizontal mattress suture technique A standard postoperative dressing was applied consisting of Betadine soaked Owen silk 4x4s Kerlix and Kling The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits The patient tolerated the above anesthesia and procedure without complications He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot He was given a postop shoe and will be full weightbearing He has prescription already at home for hydrocodone and does not need to refill He is to follow up with Dr X and was given emergency contact numbers He was discharged in stable condition Keywords podiatry pneumatic ankle metatarsal head tailor s bunion head pneumatic ulceration metatarsal bone MEDICAL_TRANSCRIPTION,Description Acute foot or ankle sprain possible small fracture Medical Specialty Podiatry Sample Name Ankle pain Transcription CHIEF COMPLAINT Ankle pain HISTORY OF PRESENT ILLNESS The patient is a pleasant 17 year old gentleman who was playing basketball today in gym Two hours prior to presentation he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now It hurts to move or bear weight No other injuries noted He does not think he has had injuries to his ankle in the past PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None SOCIAL HISTORY He does not drink or smoke ALLERGIES Unknown MEDICATIONS Adderall and Accutane REVIEW OF SYSTEMS As above Ten systems reviewed and are negative PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 6 pulse 70 respirations 16 blood pressure 120 63 and pulse oximetry 100 on room air GENERAL Keywords podiatry accutane foot or ankle sprain ankle sprain ankle sprain splint fracture MEDICAL_TRANSCRIPTION,Description Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left and arthroplasty left second toe Bunion left foot and hammertoe left second toe Medical Specialty Podiatry Sample Name Bunionectomy Metatarsal Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe POSTOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe PROCEDURE PERFORMED 1 Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left 2 Arthroplasty left second toe HISTORY This 39 year old female presents to ABCD General Hospital with the above chief complaint The patient states that she has had bunion for many months It has been progressively getting more painful at this time The patient attempted conservative treatment including wider shoe gear without long term relief of symptoms and desires surgical treatment PROCEDURE An IV was instituted by the Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff After adequate sedation was achieved by the Department of Anesthesia a total of 15 cc of 0 5 Marcaine plain was injected in a Mayo and digital block to the left foot The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table The stockinette was reflected The foot was cleansed with wet and dry sponge Attention was then directed to the first metatarsophalangeal joint of the left foot An incision was created over this area approximately 6 cm in length The incision was deepened with a 15 blade All vessels encountered were ligated for hemostasis The skin and subcutaneous tissue was then dissected from the capsule Care was taken to preserve the neurovascular bundle Dorsal linear capsular incision was then created The capsule was then reflected from the head of the first metatarsal Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected A lateral capsulotomy was performed Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence The incision was then extended proximally with further dissection down to the level of the bone Two 0 45 K wires were then inserted as access guides for the SCARF osteotomy A standard SCARF osteotomy was then performed The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle After adequate reduction of the bunion deformity was noted the bone was temporarily fixated with a 0 45 K wire A 3 0 x 12 mm screw was then inserted in the standard AO fashion with compression noted A second 3 0 x 14 mm screw was also inserted with tight compression noted The remaining prominent medial eminence medially was then resected with a sagittal saw Reciprocating rasps were then used to smooth any sharp bony edges The temporary fixation wires were then removed The screws were again checked for tightness which was noted Attention was directed to the medial capsule where a medial capsulorrhaphy was performed A straight stat was used to assist in removing a portion of the capsule The capsule was then reapproximated with 2 0 Vicryl medially Dorsal capsule was then reapproximated with 3 0 Vicryl in a running fashion The subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular stitch with 5 0 Vicryl The skin was then closed with 4 0 nylon in a horizontal mattress type fashion Attention was then directed to the left second toe A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe The incision was deepened with a 15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally An incision was made on either side of the extensor digitorum longus tendon A curved mosquito stat was then used to reflex the tendon laterally The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx A sagittal saw was then used to resect the head of the proximal head The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto The extensor digitorum longus tendon was inspected and noted to be intact Any sharp edges were then smoothed with reciprocating rasp The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon Dressings consisted of Owen silk 4x4s Kling Kerlix and Coban Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact to the left foot The patient is to follow up with Dr X in his clinic as directed Keywords podiatry hammertoe osteotomy internal screw fixation scarf type extensor digitorum metatarsal osteotomy foot toe metatarsal bunionectomy MEDICAL_TRANSCRIPTION,Description Incision and drainage first metatarsal head left foot with culture and sensitivity Medical Specialty Podiatry Sample Name Abscess with Cellulitis Discharge Summary Transcription ADMITTING DIAGNOSIS Abscess with cellulitis left foot DISCHARGE DIAGNOSIS Status post I D left foot PROCEDURES Incision and drainage first metatarsal head left foot with culture and sensitivity HISTORY OF PRESENT ILLNESS The patient presented to Dr X s office on 06 14 07 complaining of a painful left foot The patient had been treated conservatively in office for approximately 5 days but symptoms progressed with the need of incision and drainage being decided MEDICATIONS Ancef IV ALLERGIES ACCUTANE SOCIAL HISTORY Denies smoking or drinking PHYSICAL EXAMINATION Palpable pedal pulses noted bilaterally Capillary refill time less than 3 seconds digits 1 through 5 bilateral Skin supple and intact with positive hair growth Epicritic sensation intact bilateral Muscle strength 5 5 dorsiflexors plantar flexors invertors evertors Left foot with erythema edema positive tenderness noted left forefoot area LABORATORY White blood cell count never was abnormal The remaining within normal limits X ray is negative for osteomyelitis On 06 14 07 the patient was taken to the OR for incision and drainage of left foot abscess The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q 12h after surgery and later changed Ancef 2 g IV every 8 hours Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06 19 07 in excellent condition DISCHARGE MEDICATIONS Lorcet 10 650 mg dispense 24 tablets one tablet to be taken by mouth q 6h as needed for pain The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics DISCHARGE INSTRUCTIONS Included keeping the foot elevated with long periods of rest The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation The patient to keep dressing dry and intact left foot The patient to contact Dr X for all followup care if any problems arise The patient was given written and oral instruction about wound care before discharge Prior to discharge the patient was noted to be afebrile All vitals were stable The patient s questions were answered and the patient was discharged in apparent satisfactory condition Followup care was given via Dr X office Keywords podiatry accutane metatarsal head left foot abscess with cellulitis culture and sensitivity incision and drainage metatarsal head foot cellulitis ancef abscess incision drainage MEDICAL_TRANSCRIPTION,Description Hammertoe deformity left fifth digit and ulceration of the left fifth digit plantolaterally Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size Medical Specialty Podiatry Sample Name Arthroplasty Transcription PREOPERATIVE DIAGNOSES 1 Hammertoe deformity left fifth digit 2 Ulceration of the left fifth digit plantolaterally POSTOPERATIVE DIAGNOSIS 1 Hammertoe deformity left fifth toe 2 Ulceration of the left fifth digit plantolaterally PROCEDURE PERFORMED 1 Arthroplasty of the left fifth digit proximal interphalangeal joint laterally 2 Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size OPERATIVE PROCEDURE IN DETAIL The patient is a 38 year old female with longstanding complaint of painful hammertoe deformity of her left fifth toe The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time After an IV was instituted by the Department of Anesthesia the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position After adequate amount of IV sedation was administered by Anesthesia Department the patient was given a digital block to the left fifth toe using 0 5 Marcaine plain with 1 lidocaine plain in 1 1 mixture totaling 6 cc Following this the patient was draped and prepped in a normal sterile orthopedic manner An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table The stockinette was then cut and reflected and held in place using towel clamp The skin was then cleansed using the wet and dry Ray Tec sponge and then the plantar lesion was outlined The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit Then using a fresh 15 blade skin incision was made Following this the incision was then deepened using a fresh 15 blade down to the level of the subcutaneous tissue Using a combination of sharp and blunt dissection the skin was reflected distally and proximally to the lesion The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx however did not show any evidence of extending beyond the level of a periosteum Remaining tissues were inspected and appeared healthy The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a 15 blade the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx The capsule was also reflected to expose the prominent lateral osseous portion of this joint Using a sagittal saw and 139 blade the lateral osseous prominence was resected This was removed in entirety Then using power oscillating rasp the sharp edges were smoothed and recontoured to the desirable anatomic condition Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin Following this the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion Following this using 4 0 nylon in a combination of horizontal mattress and simple interrupted sutures the lesion wound was closed and skin was approximated well without tension to the surface skin Following this the incision site was dressed using Owen silk 4x4s Kling and Coban in a normal fashion The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot The patient was then escorted from the operative table into the Postanesthesia Care Unit The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact In the recovery the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q 6h as needed The patient will follow up on Friday with Dr X in office for further evaluation The patient was also given instructions as to signs of infection and to monitor her operative site The patient was instructed to keep daily dressings intact clean dry and to not remove them Keywords podiatry hammertoe deformity plantolaterall ulceration arthroplasty plantar ulceration interphalangeal painful hammertoe proximal interphalangeal joint interphalangeal joint digit toe blade deformity incision hammertoe lesion MEDICAL_TRANSCRIPTION,Description Therapeutic recreation initial evaluation Patient is a 54 year old male admitted with diagnosis of CVA with right hemiparesis Medical Specialty Physical Medicine Rehab Sample Name Therapeutic Recreation Initial Evaluation Transcription HISTORY Patient is a 54 year old male admitted with diagnosis of CVA with right hemiparesis Patient is currently living in ABC with his son as this was closer his to his job At discharge he will live with his spouse in a new job The home is single level with no steps Prior to admission his wife reports that he was independent with all activities He was working full time for an oil company Past medical history includes hypertension and diabetes mental status and dysphagia Ability to follow instruction rules Not able to identify cognitive status as of yet COMMUNICATION SKILLS No initiation of conversation He answered 1 yes no question PHYSICAL STATUS Fall safety Aspiration precautions Endurance Ball activities 4 to 5 minutes Restorator 25 minutes Standing and rolling type of 3 minutes LEISURE LIFESTYLE Level of participation activities involved in Reading and housework INFORMATION OBTAINED Interview observation and chart review TREATMENT PLAN Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas Patient scored 10 11 in physical domain due to decreased endurance He scored 11 11 in the cognitive and social domain Patient will attend 1 session per day focusing on Endurance activities Patient will attend 1 2 group sessions per week focusing on leisure awareness and postdischarge resources GOALS PATIENT GOALS Not able to identify but cooperative with all activities He answered yes that he enjoyed the restorator SHORT TERM GOALS ONE WEEK GOALS 1 Patient to increase tolerance for ball activities to 7 minutes 2 Patient provided to use the restorator as he enjoys and it is good for endurance LONG TERM GOALS Patient to increase standing tolerance standing leisure activities to 7 to 10 minutes Patient has concurred with the above treatment planning goals Keywords physical medicine rehab endurance ball activities therapeutic recreation hemiparesis tolerance recreation restorator leisure therapeutic MEDICAL_TRANSCRIPTION,Description Occupational therapy discharge summary Traumatic brain injury cervical musculoskeletal strain Medical Specialty Physical Medicine Rehab Sample Name Occupational Therapy Discharge Summary Transcription DIAGNOSES Traumatic brain injury cervical musculoskeletal strain DISCHARGE SUMMARY The patient was seen for evaluation on 12 11 06 followed by 2 treatment sessions Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion strength and coordination functional mobility training self care training cognitive retraining caregiver instruction and home exercise program Goals were not achieved as the patient was admitted to inpatient rehabilitation center RECOMMENDATIONS Discharged from OT this date as the patient has been admitted to Inpatient Rehabilitation Center Thank you for this referral Keywords physical medicine rehab musculoskeletal strain occupational therapy traumatic brain cervical musculoskeletal rehabilitation MEDICAL_TRANSCRIPTION,Description Patient with a past medical history of a left L5 S1 lumbar microdiskectomy with complete resolution of left leg symptoms Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 6 Transcription HISTORY The patient is a 46 year old right handed gentleman with a past medical history of a left L5 S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms who now presents with a four month history of gradual onset of right sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle Symptoms are worsened by any activity and relieved by rest He also feels that when the pain is very severe he has some subtle right leg weakness No left leg symptoms No bowel or bladder changes On brief examination full strength in both lower extremities No sensory abnormalities Deep tendon reflexes are 2 and symmetric at the patellas and absent at both ankles Positive straight leg raising on the right MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5 S1 encroaching upon the right exiting S1 nerve root NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes and conduction velocities are normal in the lower extremities The right common peroneal F wave is minimally prolonged The right tibial H reflex is absent NEEDLE EMG Needle EMG was performed on the right leg left gastrocnemius medialis muscle and right lumbosacral paraspinal muscles using a disposable concentric needle It revealed spontaneous activity in the right gastrocnemius medialis gluteus maximus and lower lumbosacral paraspinal muscles There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles IMPRESSION This electrical study is abnormal It reveals an acute right S1 radiculopathy There is no evidence for peripheral neuropathy or left or right L5 radiculopathy Results were discussed with the patient and he is scheduled to follow up with Dr X in the near future Keywords physical medicine rehab microdiskectomy needle emg nerve conduction studies lumbosacral paraspinal muscles lumbar microdiskectomy lower extremities lumbosacral paraspinal paraspinal muscles gluteus maximus leg symptoms gastrocnemius medialis emg nerve conduction lumbosacral needle gastrocnemius medialis muscles MEDICAL_TRANSCRIPTION,Description A woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities Abnormal electrodiagnostic study Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 8 Transcription REFERRING DIAGNOSIS Motor neuron disease PERTINENT HISTORY AND EXAMINATION Briefly the patient is an 83 year old woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities SUMMARY The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity The right ulnar sensory amplitude was reduced with slowing of the conduction velocity The right radial sensory amplitude was reduced with slowing of the conduction velocity The right sural and left sural sensory responses were absent The right median motor response showed a prolonged distal latency across the wrist with proximal slowing The distal amplitude was very reduced and there was a reduction with proximal stimulation The right ulnar motor amplitude was borderline normal with slowing of the conduction velocity across the elbow The right common peroneal motor response showed a decreased amplitude when recorded from the EDB with mild slowing of the proximal conduction velocity across the knee The right tibial motor response showed a reduced amplitude with prolongation of the distal latency The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing The left tibial motor response showed a decreased amplitude with a borderline normal distal latency The minimum F wave latencies were normal with the exception of a mild prolongation of the ulnar F wave latency and the tibial F wave latency as indicated above With repetitive nerve stimulation there was no significant decrement noted in either the right nasalis or the right trapezius muscles Concentric needle EMG studies were performed in the right lower extremity right upper extremity thoracic paraspinals and in the tongue There was evidence of increased insertional activity in the right tibialis anterior muscle with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue In addition there was evidence of increased amplitude long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above INTERPRETATION Abnormal electrodiagnostic study There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow Even despite the patient s age the decrease in sensory responses is concerning and makes it difficult to be certain about the diagnosis of motor neuron disease However the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease The patient will return for further evaluation Keywords physical medicine rehab electrodiagnostic study electrodiagnostic edb latency nerve conduction study emg motor neuron disease distal latency motor response motor amplitude conduction MEDICAL_TRANSCRIPTION,Description A right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident with no specific injury at that time Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 3 Transcription HISTORY The patient is a 56 year old right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident in September of 2005 At that time she did not notice any specific injury Five days later she started getting abnormal right low back pain At this time it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf Symptoms are worse when sitting for any length of time such as driving a motor vehicle Mild symptoms when walking for long periods of time Relieved by standing and lying down She denies any left leg symptoms or right leg weakness No change in bowel or bladder function Symptoms have slowly progressed She has had Medrol Dosepak and analgesics which have not been very effective She underwent a spinal epidural injection which was effective for the first few hours but she had recurrence of the pain by the next day This was done four and a half weeks ago On examination lower extremities strength is full and symmetric Straight leg raising is normal OBJECTIVE Sensory examination is normal to all modalities Full range of movement of lumbosacral spine Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint Deep tendon reflexes are 2 and symmetric at the knees 2 at the left ankle and 1 at the right ankle NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the lower extremities Right tibial H reflex is slightly prolonged when compared to the left tibial H reflex NEEDLE EMG Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle There were signs of chronic denervation in right tibialis anterior peroneus longus gastrocnemius medialis and left gastrocnemius medialis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A mild right L5 versus S1 radiculopathy 2 Left S1 nerve root irritation There is no evidence of active radiculopathy 3 There is no evidence of plexopathy myopathy or peripheral neuropathy MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5 S1 neuroforaminal stenosis slightly worse on the right Results were discussed with the patient and her daughter I would recommend further course of spinal epidural injections with Dr XYZ If she has no response then surgery will need to be considered She agrees with this approach and will followup with you in the near future Keywords physical medicine rehab emg nerve conduction study radiculopathy peripheral neuropathy nerve root irritation motor vehicle accident lumbosacral paraspinal muscles spinal epidural lumbosacral spine peroneus longus gastrocnemius medialis lower extremities emg nerve conduction needle MEDICAL_TRANSCRIPTION,Description EMG Nerve Conduction Study showing sensory motor length dependent neuropathy consistent with diabetes severe left ulnar neuropathy and moderate to severe left median neuropathy Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 4 Transcription NERVE CONDUCTION STUDIES Bilateral ulnar sensory responses are absent Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude The left radial sensory response is normal and robust Left sural response is absent Left median motor distal latency is prolonged with attenuated evoked response amplitude Conduction velocity across the forearm is mildly slowed Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow Conduction velocities across the forearm and across the elbow are prolonged Conduction velocity proximal to the elbow is normal The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist There is mild diminution of response around the elbow Conduction velocity slows across the elbow The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head F waves are prolonged NEEDLE EMG Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle It revealed spontaneous activity in lower cervical paraspinals left abductor pollicis brevis and first dorsal interosseous muscles There were signs of chronic reinnervation in triceps extensor digitorum communis flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A sensory motor length dependent neuropathy consistent with diabetes 2 A severe left ulnar neuropathy This is probably at the elbow although definitive localization cannot be made 3 Moderate to severe left median neuropathy This is also probably at the carpal tunnel although definitive localization cannot be made 4 Right ulnar neuropathy at the elbow mild 5 Right median neuropathy at the wrist consistent with carpal tunnel syndrome moderate 6 A left C8 radiculopathy double crush syndrome 7 There is no evidence for thoracic radiculitis The patient has made very good response with respect to his abdominal pain since starting Neurontin He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch He is still scheduled for MRI of C spine and T spine I will see him in followup after the above scans Keywords physical medicine rehab emg nerve conduction study nerve conduction studies needle emg electrical study neuropathy ulnar neuropathy median neuropathy severely attenuated evoked response normal evoked response amplitude attenuated evoked response amplitude median motor distal latency motor distal latency abductor pollicis pollicis brevis dorsal interosseous carpal tunnel conduction emg nerve needle MEDICAL_TRANSCRIPTION,Description The patient is status post C3 C4 anterior cervical discectomy and fusion Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 5 Transcription She has an extensive past medical history of rheumatoid arthritis fibromyalgia hypertension hypercholesterolemia and irritable bowel syndrome She has also had bilateral carpal tunnel release On examination normal range of movement of C spine She has full strength in upper and lower extremities Normal straight leg raising Reflexes are 2 and symmetric throughout No Babinski She has numbness to light touch in her right big toe NERVE CONDUCTION STUDIES The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude Bilateral tibial motor nerves could not be obtained technical The remaining nerves tested revealed normal distal latencies evoked response amplitudes conduction velocities F waves and H reflexes NEEDLE EMG Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI It revealed 2 spontaneous activity in the right APB and FDI and 1 spontaneous activity in lower cervical paraspinals lower and middle lumbosacral paraspinals right extensor digitorum communis muscle and right pronator teres There was evidence of chronic denervation in the right first dorsal interosseous pronator teres abductor pollicis brevis and left first dorsal interosseous IMPRESSION This electrical study is abnormal It reveals the following 1 An active right C8 T1 radiculopathy Electrical abnormalities are moderate 2 An active right C6 C7 radiculopathy Electrical abnormalities are mild 3 Evidence of chronic left C8 T1 denervation No active denervation 4 Mild right lumbosacral radiculopathies This could not be further localized because of normal EMG testing in the lower extremity muscles 5 There is evidence of mild sensory carpal tunnel on the right she has had previous carpal tunnel release Results were discussed with the patient It appears that she has failed conservative therapy and I have recommended to her that she return to Dr X for his assessment for possible surgery to her C spine She will continue with conservative therapy for the mild lumbosacral radiculopathies Keywords physical medicine rehab emg nerve conduction study needle emg paraspinal muscles radiculopathy electrical abnormalities carpal tunnel release evoked response lumbosacral radiculopathies conservative therapy carpal tunnel conduction emg nerve MEDICAL_TRANSCRIPTION,Description A ight handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 2 Transcription HISTORY The patient is a 78 year old right handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain which radiates down into her buttocks and down to posterior aspect of her thigh into her knee This has required large amounts of opioid analgesics to control She has been basically bedridden because of this She was brought into hospital for further investigations PHYSICAL EXAMINATION On examination she has positive straight leg rising on the right with severe shooting radicular type pain with right leg movement Difficult to assess individual muscles but strength is largely intact Sensory examination is symmetric Deep tendon reflexes reveal hyporeflexia in both patellae which probably represents a cervical myelopathy from prior cord compression She has slightly decreased right versus left ankle reflexes The Babinski s are positive On nerve conduction studies motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in lower extremities NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles There is evidence of denervation in right gastrocnemius medialis muscle IMPRESSION This electrical study is abnormal It reveals the following 1 Inactive right S1 L5 radiculopathy 2 There is no evidence of left lower extremity radiculopathy peripheral neuropathy or entrapment neuropathy Results were discussed with the patient and she is scheduled for imaging studies in the next day Keywords physical medicine rehab needle emg radiculopathy electrical study emg nerve conduction study cervical spinal stenosis lumbosacral paraspinal muscles gastrocnemius medialis muscles spinal stenosis post decompression lumbosacral paraspinal paraspinal muscles gastrocnemius medialis medialis muscles decompression emg nerve conduction cervical spinal needle muscles MEDICAL_TRANSCRIPTION,Description 1 month old for a healthy checkup Well child check Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 7 Transcription SUBJECTIVE This is a 1 month old who comes in for a healthy checkup Mom says things are gone very well He is kind of acting like he has got a little bit of sore throat but no fevers He is still eating well He is up to 4 ounces every feeding He has not been spitting up Voiding and stooling well PAST MEDICAL HISTORY Reviewed very healthy CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None DIETARY His formula fed on Enfamil Lipil Voiding and stooling well Growth chart reviewed with Mom DEVELOPMENTAL He is starting to track with his eyes He is smiling a little bit moving hands and feet symmetrically PHYSICAL EXAMINATION In general well developed well nourished male in no acute distress DERMATOLOGIC Without rash or lesion HEENT Head normocephalic and atraumatic Anterior fontanel soft and flat Eyes Pupils equal round and reactive to light Extraocular movements intact Red reflexes present bilaterally Does appear to have conjugate gaze Ears Tympanic membranes are pink to gray translucent neutral position normal light reflex and mobility Nares are patent pink mucosa moist Oropharynx clear with pink mucosa normal moisture NECK Supple without masses CHEST Clear to auscultation and percussion with easy respirations and no accessory muscle use CARDIOVASCULAR Regular rate and rhythm without murmurs rubs heaves or gallops ABDOMEN Soft nontender nondistended without hepatosplenomegaly GU EXAM Normal Tanner I male Testes descended bilaterally No hernias noted EXTREMITIES Pink and warm Moving all extremities well No subluxation of the hips and leg creases appear symmetric NEUROLOGIC Alert otherwise nonfocal 2 deep tendon reflexes at the knees Fixes and follows appropriately to both voice and face ASSESSMENT Well child check PLAN 1 Diet growth and safety discussed 2 Immunizations discussed and updated with hepatitis B 3 Return to clinic at two months of age Call if problems Keywords MEDICAL_TRANSCRIPTION,Description Patient had movor vehicle accirdent and may have had a brief loss of consciousness Shortly thereafter she had some blurred vision Since that time she has had right low neck pain and left low back pain Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 7 Transcription HISTORY The patient is a 34 year old right handed female who states her symptoms first started after a motor vehicle accident in September 2005 She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision which lasted about a week and then resolved Since that time she has had right low neck pain and left low back pain She has been extensively worked up and treated for this MRI of the C T spine and LS spine has been normal She has improved significantly but still complains of pain In June of this year she had different symptoms which she feels are unrelated She had some chest pain and feeling of tightness in the left arm and leg and face By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg Symptoms lasted for about two days and then resolved However since that time she has had intermittent numbness in the left hand and leg The face numbness has completely resolved Symptoms are mild She denies any previous similar episodes She denies associated dizziness vision changes incoordination weakness change in gait or change in bowel or bladder function There is no associated headache Brief examination reveals normal motor examination with no pronator drift and no incoordination Normal gait Cranial nerves are intact Sensory examination reveals normal facial sensation She has normal and symmetrical light touch temperature and pinprick in the upper extremities In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot In this area she has normal light touch and pinprick She describes it as a strange unusual sensation NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the left arm and leg NEEDLE EMG Needle EMG was performed in the left leg lumbosacral paraspinal right tibialis anterior and right upper thoracic paraspinal muscles using a disposable concentric needle It revealed normal insertional activity no spontaneous activity and normal motor unit action potential form in all muscles tested IMPRESSION This electrical study is normal There is no evidence for peripheral neuropathy entrapment neuropathy plexopathy or lumbosacral radiculopathy EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident This was normal Based on her history of sudden onset of left face arm and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year Symptoms are now very mild but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms Once she has the test done she will phone me and further management will be based on the results Keywords physical medicine rehab nerve conduction studies motor sensory distal latencies evoked response conduction velocities needle emg loss of consciousness motor vehicle accident thoracic paraspinal needle paraspinal conduction MEDICAL_TRANSCRIPTION,Description The patient with longstanding bilateral arm pain which is predominantly in the medial aspect of arms and hands as well as left hand numbness worse at night and after doing repetitive work with left hand Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study 1 Transcription HISTORY The patient is a 52 year old right handed female with longstanding bilateral arm pain which is predominantly in the medial aspect of her arms and hands as well as left hand numbness worse at night and after doing repetitive work with her left hand She denies any weakness No significant neck pain change in bowel or bladder symptoms change in gait or similar symptoms in the past She is on Lyrica for the pain which has been somewhat successful Examination reveals positive Phalen s test on the left Remainder of her neurological examination is normal NERVE CONDUCTION STUDIES The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity The left median sensory distal latency is prolonged with an attenuated evoked response amplitude The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude The right median motor distal latency and evoked response amplitude is normal Left ulnar motor and sensory and left radial sensory responses are normal Left median F wave is normal NEEDLE EMG Needle EMG was performed on the left arm right first dorsal interosseous muscle and bilateral cervical paraspinal muscles It revealed spontaneous activity in the left abductor pollicis brevis muscle There is increased insertional activity in the right first dorsal interosseous muscle Both interosseous muscles showed signs of reinnervation Left extensor digitorum communis muscle showed evidence of reduced recruitment Cervical paraspinal muscles were normal IMPRESSION This electrical study is abnormal It reveals the following A left median neuropathy at the wrist consistent with carpal tunnel syndrome Electrical abnormalities are moderate to mild bilateral C8 radiculopathies This may be an incidental finding I have recommended MRI of the spine without contrast and report will be sent to Dr XYZ She will follow up with Dr XYZ with respect to treatment of the above conditions Keywords physical medicine rehab nerve conduction study emg neuropathy median motor distal latency median sensory distal latency attenuated evoked response amplitude emg nerve conduction study sensory distal latency attenuated evoked response dorsal interosseous muscle cervical paraspinal muscles emg nerve conduction conduction study median motor needle emg distal latency evoked response emg nerve bilateral evoked conduction MEDICAL_TRANSCRIPTION,Description History of numbness in both big toes and up the lateral aspect of both calves She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness Medical Specialty Physical Medicine Rehab Sample Name EMG Nerve Conduction Study Transcription HISTORY The patient is a 52 year old female with a past medical history of diet controlled diabetes diffuse arthritis plantar fasciitis and muscle cramps who presents with a few month history of numbness in both big toes and up the lateral aspect of both calves Symptoms worsened considerable about a month ago This normally occurs after being on her feet for any length of time She was started on amitriptyline and this has significantly improved her symptoms She is almost asymptomatic at present She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness On brief examination straight leg raising is normal The patient is obese There is mild decreased vibration and light touch in distal lower extremities Strength is full and symmetric Deep tendon reflexes at the knees are 2 and symmetric and absent at the ankles NERVE CONDUCTION STUDIES Bilateral sural sensory responses are absent Bilateral superficial sensory responses are present but mildly reduced The right radial sensory response is normal The right common peroneal and tibial motor responses are normal Bilateral H reflexes are absent NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle Lumbar paraspinals were attempted but were too painful to get a good assessment IMPRESSION This electrical study is abnormal It reveals the following 1 A very mild purely sensory length dependent peripheral neuropathy 2 Mild bilateral L5 nerve root irritation There is no evidence of active radiculopathy Based on the patient s history and exam her new symptoms are consistent with mild bilateral L5 radiculopathies Symptoms have almost completely resolved over the last month since starting Elavil I would recommend MRI of the lumbosacral spine if symptoms return With respect to the mild neuropathy this is probably related to her mild glucose intolerance early diabetes However I would recommend a workup for other causes to include the following Fasting blood sugar HbA1c ESR RPR TSH B12 serum protein electrophoresis and Lyme titer Keywords physical medicine rehab nerve conduction studies needle emg numbness tibialis posterior muscle sensory responses muscle tibialis toes MEDICAL_TRANSCRIPTION,Description A 3 month well child check Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 6 Transcription SUBJECTIVE Patient presents with Mom and Dad for her 5 year 3 month well child check Family has not concerns stating patient has been doing well overall since last visit Taking in a well balanced diet consisting of milk and dairy products fruits vegetables proteins and grains with minimal junk food and snack food No behavioral concerns Gets along well with peers as well as adults Is excited to start kindergarten this upcoming school year Does attend daycare Normal voiding and stooling pattern No concerns with hearing or vision Sees the dentist regularly Growth and development Denver II normal passing all developmental milestones per age in areas of fine motor gross motor personal and social interaction and speech and language development See Denver II form in the chart ALLERGIES None MEDICATIONS None FAMILY SOCIAL HISTORY Unchanged since last checkup Lives at home with mother father and sibling No smoking in the home REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Vital Signs Weight 43 pounds Height 42 1 4 inches Temperature 97 7 Blood pressure 90 64 General Well developed well nourished cooperative alert and interactive 5 year 3month old white female in no acute distress HEENT Atraumatic normocephalic Pupils equal round and reactive Sclerae clear Red reflex present bilaterally Extraocular muscles intact TMs clear bilaterally Oropharynx Mucous membranes moist and pink Good dentition Neck Supple no lymphadenopathy Chest Clear to auscultation bilaterally No wheeze or crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender Nondistended Positive bowel sounds No masses or organomegaly GU Tanner I female genitalia Femoral pulses equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Back Straight No scoliosis Integument Warm dry and pink without lesions Neurological Alert Good muscle tone and strength Cranial nerves II XII grossly intact DTRs 2 4 bilaterally ASSESSMENT PLAN 1 Well 5 year 3 month old white female 2 Anticipatory guidance for growth and diet development and safety issues as well as immunizations Will receive MMR DTaP and IPV today Discussed risks and benefits as well as possible side effects and symptomatic treatment Gave 5 year well child check handout to mom Completed school pre participation physical Copy in the chart Completed vision and hearing screening Reviewed results with family 3 Follow up in one year for next well child check or as needed for acute care Keywords pediatrics neonatal denver ii child check mom diet growth denver family development child check MEDICAL_TRANSCRIPTION,Description 1 year well child check Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 4 Transcription SUBJECTIVE The patient presents with Mom and Dad for her 1 year well child check The family has no concerns stating the patient has been doing well overall since the last visit taking in a well balanced diet consisting of formula transitioning to whole milk fruits vegetables proteins and grains Normal voiding and stooling pattern No concerns with hearing or vision Growth and development Denver II normal passing all developmental milestones per age in areas of fine motor gross motor personal and social interaction as well as speech and language development See Denver II form in the chart PAST MEDICAL HISTORY Allergies None Medications Tylenol this morning in preparation for vaccines and a multivitamin daily FAMILY SOCIAL HISTORY Unchanged since last checkup REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Weight 24 pounds 1 ounce Height 30 inches Head circumference 46 5 cm Temperature afebrile General A well developed well nourished cooperative alert and interactive 1 year old white female smiling happy and drooling HEENT Atraumatic normocephalic Anterior fontanel is closed Pupils equally round and reactive Sclerae are clear Red reflex present bilaterally Extraocular muscles intact TMs are clear bilaterally Oropharynx Mucous membranes are moist and pink Good dentition Drooling and chewing with teething behavior today Neck is supple No lymphadenopathy Chest Clear to auscultation bilaterally No wheeze No crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender Nondistended Positive bowel sounds No mass No organomegaly Genitourinary Tanner I female genitalia Femoral pulses equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Negative Ortolani and Barlow maneuver Back Straight No scoliosis Integument Warm dry and pink without lesions Neurological Alert Good muscle tone and strength Cranial nerves II through XII are grossly intact ASSESSMENT AND PLAN 1 Well 1 year old white female 2 Anticipatory guidance Reviewed growth diet development and safety issues as well as immunizations Will receive Pediarix and HIB today Discussed risks and benefits as well as possible side effects and symptomatic treatment Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available Gave 1 year well child checkup handout to Mom and Dad 3 Follow up for the 15 month well child check or as needed for acute care Keywords pediatrics neonatal well child check denver ii child check checkup check child MEDICAL_TRANSCRIPTION,Description A well child check with concern of some spitting up quite a bit Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 5 Transcription SUBJECTIVE The patient presents with Mom for a first visit to our office for a well child check with concern of some spitting up quite a bit Mom wants to make sure that this is normal The patient is nursing well every two to three hours She does have some spitting up on occasion It has happened two or three times with some curdled appearance x 1 No projectile in nature nonbilious Normal voiding and stooling pattern Growth and Development Denver II normal passing all developmental milestones per age See Denver II form in the chart PAST MEDICAL HISTORY Mom reports uncomplicated pregnancy with prenatal care provided by Dr XYZ in Wichita Kansas Delivery after induction secondary to postdate at St Joseph Hospital Infant delivered by SVD with birth weight of 6 pounds 13 ounce Length of 19 inches Did well after delivery and dismissed to home with Mom Received hepatitis B 1 prior to dismissal No other hospitalizations No surgeries No known medical allergies No medications Mom has tried Mylicon drops on occasion FAMILY HISTORY Significant for cardiovascular disease hypertension diabetes mellitus and thyroid problems in maternal and paternal grandparents Healthy Mother Father There is also history of breast colon and ovarian cancer on the maternal side of the family her grandmother who is present at visit today There is history of asthma in the patient s father SOCIAL HISTORY The patient lives at home with 23 year old mother who is a homemaker and 24 year old father John who is a supervisor at Excel The family lives in Bentley Kansas No smoking in the home Family does have one pet cat REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Weight 7 pounds 12 ounces Height 21 inches Head circumference 35 cm Temperature 97 2 degrees General Well developed well nourished cooperative alert interactive 2 week old white female in no acute distress HEENT Atraumatic normocephalic Anterior fontanel is soft and flat Pupils are equal round and reactive Sclerae clear Red reflexes present bilaterally TMs are clear bilaterally Oropharynx Mucous membranes are moist and pink Neck Supple no lymphadenopathy Chest Clear to auscultation bilaterally No wheeze or crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender nondistended Positive bowel sounds No mass nor organomegaly Genitourinary Tanner I female genitalia Femoral pulses are equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Negative Ortolani or Barlow maneuver Back Straight No scoliosis Integument Warm dry and pink without lesions Neurologic Alert Good muscle tone and strength ASSESSMENT PLAN 1 Well 2 week old white female 2 Anticipatory guidelines for growth diet development safety issues as well as immunizations and visitation schedule Gave 2 week well child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family 3 Call the office or on call physician if the patient has fever feeding problems or breathing problems Otherwise plan to recheck at 1 month of age Keywords pediatrics neonatal well child check denver ii child check growth development denver cardiovascular maternal mother spitting father child check asthma family mom MEDICAL_TRANSCRIPTION,Description A 9 month well child check Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 2 Transcription SUBJECTIVE This 9 month old Hispanic male comes in today for a 9 month well child check They are visiting from Texas until the end of April 2004 Mom says he has been doing well since last seen He is up to date on his immunizations per her report She notes that he has developed some bumps on his chest that have been there for about a week Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics Mom says he has been doing fine since then She has no concerns about him PAST MEDICAL HISTORY Significant for term vaginal delivery without complications MEDICATIONS None ALLERGIES None SOCIAL HISTORY Lives with parents There is no smoking in the household REVIEW OF SYSTEMS Developmentally is appropriate No fevers No other rashes No cough or congestion No vomiting or diarrhea Eating normally OBJECTIVE His weight is 16 pounds 9 ounces Height is 26 1 4 inches Head circumference is 44 75 cm Pulse is 124 Respirations are 26 Temperature is 98 1 degrees Generally this is a well developed well nourished 9 month old male who is active alert and playful in no acute distress HEENT Normocephalic atraumatic Anterior fontanel is soft and flat Tympanic membranes are clear bilaterally Conjunctivae are clear Pupils equal round and reactive to light Nares without turbinate edema Oropharynx is nonerythematous NECK Supple without lymphadenopathy thyromegaly carotid bruit or JVD CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm without murmur ABDOMEN Soft nontender nondistended normoactive bowel sounds No masses or organomegaly to palpation GU Normal male external genitalia Uncircumcised penis Bilaterally descended testes Femoral pulses 2 4 EXTREMITIES Moves all four extremities equally Minimal tibial torsion SKIN Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest ASSESSMENT PLAN 1 Well child check Is doing well Will recommend a followup well child check at 1 year of age and immunizations at that time Discussed safety issues including poisons choking hazards pet safety appropriate nutrition with Mom She is given a parenting guide handout 2 Molluscum contagiosum Described the viral etiology of these Told her they are self limited and we will continue to monitor at this time 3 Left otitis media resolved Continue to monitor We will plan on following up in three months if they are still in the area or p r n Keywords pediatrics neonatal well child check otitis media molluscum contagiosum immunizations developed atraumatic child MEDICAL_TRANSCRIPTION,Description Bilateral tympanostomy with myringotomy tube placement The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy Medical Specialty Pediatrics Neonatal Sample Name Tympanostomy Myringotomy Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss POSTOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss PROCEDURE PERFORMED Bilateral tympanostomy with myringotomy tube placement _______ split tube 1 0 mm ANESTHESIA Total IV general mask airway ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy After risks complications consequences and questions were addressed with the family a written consent was obtained for the procedure PROCEDURE The patient was brought to the operative suite by Anesthesia The patient was placed on the operating table in supine position After this the patient was then placed under general mask airway and the patient s head was then turned to the left The Zeiss operative microscope and medium sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to 5 suction After this the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a 5 suction demonstrating dry contents A _____ split tube 1 0 mm was then placed in the myringotomy incision utilizing a alligator forcep Cortisporin Otic drops were placed followed by cotton balls Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed The external auditory canal was removed off of its cerumen with a 5 suction which led to the direct visualization of the tympanic membrane The tympanic membrane appeared with no signs of retraction pockets cholesteatoma or air fluid levels A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1 0 mm was then placed with an alligator forcep After this the patient had Cortisporin Otic drops followed by cotton balls placed The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears Keywords pediatrics neonatal chronic otitis media with effusion conductive hearing loss bilateral tympanostomy myringotomy tube placement cortisporin otic drops otitis media tympanostomy tympanic membrane otitis media effusion conductive hearing ear tube myringotomy MEDICAL_TRANSCRIPTION,Description Viral upper respiratory infection URI with sinus and eustachian congestion Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain Medical Specialty Pediatrics Neonatal Sample Name URI Eustachian Congestion Transcription HISTORY OF PRESENT ILLNESS Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain She has had a dry cough and a fever as high as 100 but this has not been since the first day She denies any vomiting or diarrhea She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe but she does not think that this has helped FAMILY HISTORY The patient s younger sister has recently had respiratory infection complicated by pneumonia and otitis media REVIEW OF SYSTEMS The patient does note some pressure in her sinuses She denies any skin rash SOCIAL HISTORY Patient lives with her mother who is here with her Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp is 38 1 pulse is elevated at 101 other vital signs are all within normal limits Room air oximetry is 100 GENERAL Patient is a healthy appearing white female adolescent who is sitting on the stretcher and appears only mildly ill HEENT Head is normocephalic atraumatic Pharynx shows no erythema tonsillar edema or exudate Both TMs are easily visualized and are clear with good light reflex and no erythema Sinuses do show some mild tenderness to percussion NECK No meningismus or enlarged anterior posterior cervical lymph nodes HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes SKIN No rash ASSESSMENT Viral upper respiratory infection URI with sinus and eustachian congestion PLAN I did educate the patient about her problem and urged her to switch to Advil Cold Sinus for the next three to five days for better control of her sinus and eustachian discomfort I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses If she is unimproved in five days follow up with her PCP for re exam Keywords pediatrics neonatal upper respiratory infection eustachian congestion erythema uri nasal cough eustachian respiratory sinus congestion infection tonsillar MEDICAL_TRANSCRIPTION,Description Well child Left lacrimal duct stenosis Medical Specialty Pediatrics Neonatal Sample Name Well Child Check 1 Transcription CHIEF COMPLAINT Well child check HISTORY OF PRESENT ILLNESS This is a 12 month old female here with her mother for a well child check Mother states she has been doing well She is concerned about drainage from her left eye Mother states she was diagnosed with a blocked tear duct on that side shortly after birth and normally she has crusted secretions every morning She states it is worse when the child gets a cold She has been using massaging when she can remember to do so The patient is drinking whole milk without problems She is using solid foods three times a day She sleeps well without problems Her bowel movements are regular without problems She does not attend daycare DEVELOPMENTAL ASSESSMENT Social She can feed herself with fingers She is comforted by parent s touch She is able to separate and explore Fine motor She scribbles She has a pincer grasp She can drink from a cup Language She says dada She says one to two other words and she indicates her wants Gross motor She can stand alone She cruises She walks alone She stoops and recovers PHYSICAL EXAMINATION General She is alert in no distress Vital signs Weight 25th percentile Height 25th percentile Head circumference 50th percentile HEENT Normocephalic atraumatic Pupils are equal round and reactive to light Left eye with watery secretions and crusted lashes Conjunctiva is clear TMs are clear bilaterally Nares are patent Mild nasal congestion present Oropharynx is clear Neck Supple Lungs Clear to auscultation Heart Regular No murmur Abdomen Soft Positive bowel sounds No masses No hepatosplenomegaly GU Female external genitalia Extremities Symmetrical Femoral pulses are 2 bilaterally Full range of motion of all extremities Neurologic Grossly intact Skin Normal turgor Testing Hearing and vision assessments grossly normal ASSESSMENT 1 Well child 2 Left lacrimal duct stenosis PLAN MMR 1 and Varivax 1 today VIS statements given to Mother after discussion Evaluation and treatment as needed with Dr XYZ with respect to the blocked tear duct Anticipatory guidance for age She is to return to the office in three months Keywords pediatrics neonatal well child check drainage eye lacrimal duct stenosis lacrimal duct mmr varivax vis statements tear duct lacrimal percentile mother child MEDICAL_TRANSCRIPTION,Description The patient is a 4 month old who presented with supraventricular tachycardia and persistent cyanosis Medical Specialty Pediatrics Neonatal Sample Name Supraventricular Tachycardia Consult Transcription HISTORY The patient is a 4 month old who presented today with supraventricular tachycardia and persistent cyanosis The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised Parents however did note the patient to be quite dusky since the time of her birth however were reassured by the pediatrician that this was normal The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness some irritability and rapid heart rate Parents do state that she does appear to breathe rapidly tires somewhat with the feeding with increased respiratory effort and diaphoresis The patient is exclusively breast fed and feeding approximately 2 hours Upon arrival at Children s Hospital the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement northwest axis and poor R wave progression possible right ventricular hypertrophy FAMILY HISTORY Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed REVIEW OF SYSTEMS A complete review of systems including neurologic respiratory gastrointestinal genitourinary are otherwise negative PHYSICAL EXAMINATION GENERAL Physical examination that showed a sedated acyanotic infant who is in no acute distress VITAL SIGNS Heart rate of 170 respiratory rate of 65 saturation it is nasal cannula oxygen of 74 with a prostaglandin infusion at 0 5 mcg kg minute HEENT Normocephalic with no bruit detected She had symmetric shallow breath sounds clear to auscultation She had full symmetrical pulses HEART There is normoactive precordium without a thrill There is normal S1 single loud S2 and a 2 6 continuous shunt type of murmur could be appreciated at the left upper sternal border ABDOMEN Soft Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected X RAYS Review of the chest x ray demonstrated a normal situs normal heart size and adequate pulmonary vascular markings There is a prominent thymus An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs a left superior vena cava draining into the left atrium a criss cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left sided morphologic left ventricle The left atrium drained through the tricuspid valve into a right sided morphologic right ventricle There is a large inlet ventricular septal defect as pulmonary atresia The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch There was a small vertical ductus as a sole source of pulmonary artery blood flow The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter Biventricular function is well maintained FINAL IMPRESSION The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function The saturations are now also adequate on prostaglandin E1 RECOMMENDATION My recommendation is that the patient be continued on prostaglandin E1 The patient s case was presented to the cardiothoracic surgical consultant Dr X The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention The patient will require some form of systemic to pulmonary shunt modified pelvic shunt or central shunt as a durable source of pulmonary blood flow Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age These findings and recommendations were reviewed with the parents via a Spanish interpreter Keywords pediatrics neonatal congenital heart disease cyanotic ductal dependent pulmonary blood flow ventricular septal defect blood flow supraventricular tachycardia tachycardia ventricular supraventricular shunt heart pulmonary MEDICAL_TRANSCRIPTION,Description Single frontal view of the chest Respiratory distress The patient has a history of malrotation Medical Specialty Pediatrics Neonatal Sample Name Single Frontal View Chest Pediatric Transcription EXAM Single frontal view of the chest HISTORY Respiratory distress The patient has a history of malrotation The patient is back for a re anastomosis of the bowel with no acute distress TECHNIQUE Single frontal view of the chest was evaluated and correlated with the prior film dated MM DD YY FINDINGS A single frontal view of the chest was evaluated It reveals interval placement of an ET tube and an NG tube ET tube is midway between the patient s thoracic inlet and carina NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm There is no evidence of any focal areas of consolidation pneumothoraces or pleural effusions The mediastinum seen was slightly prominent however this may be secondary to thymus and or technique There is a slight increase seen with regards to the central pulmonary vessels Again this may represent a minimal amount of pulmonary vascular congestion There is paucity of bowel gas seen in the upper abdomen The osseous thorax appears to be grossly intact and symmetrical Slightly low lung volumes however this may be secondary to the film being taken on the expiratory phase of respiration IMPRESSION 1 No evidence of any focal areas of consolidation pneumothoraces or pleural effusions 2 Slight prominence to the mediastinum which may be secondary to thymus and or technique 3 Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion Keywords pediatrics neonatal malrotation consolidation pneumothoraces single frontal view respiratory distress vascular congestion frontal view effusions mediastinum vascular congestion respiratory anastomosis pulmonary single frontal chest MEDICAL_TRANSCRIPTION,Description Sports physical with normal growth and development Medical Specialty Pediatrics Neonatal Sample Name Sports Physical 1 Transcription HISTORY This child is seen for a sports physical NUTRITIONAL HISTORY She takes meats vegetables and fruits Eats well Has may be 1 to 2 cups a day of milk Her calcium intake could be better She does not drink that much pop but she likes koolaid Her stools are normal Brushes her teeth Sees a dentist DEVELOPMENTAL HISTORY She did well in school last year Hearing and vision no problems She wears corrective lenses She will be in 8th grade and involved in volleyball basketball and she will be moving to Texas She did go to Burton this last year She also plays clarinet and will be involved also in cheerleading She likes to swim in the summer time Her menarche was January 2004 It occurs every 7 weeks No particular problems at this time OTHER ACTIVITIES TV time about 2 to 3 hours a day She does not use drugs alcohol or smoke and denies sexual activity MEDICATIONS Advair 250 50 b i d Flonase b i d Allegra q d 120 mg Xopenex and albuterol p r n ALLERGIES No known drug allergies OBJECTIVE Vital Signs Blood pressure 98 60 Temperature 96 6 tympanic Weight 107 pounds which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64 1 2 inches Her body mass index is 18 1 which is 40th percentile Pulse 68 HEENT Normocephalic Fundi benign Pupils are equal and reactive to light and accommodation Conjunctivae were non injected Her pupils were equal and reactive to light and accommodation No strabismus She wears glasses Her vision was 20 20 in both eyes TMs are bilaterally clear Nonerythematous Hearing in the ears she was able to pass 40 decibel to 30 decibel With the right ear she has some problems but the left ear she passed Throat was clear Nonerythematous Good dentition Neck Supple Thyroid normal sized No increased lymphadenopathy in the submandibular nodes and no axillary nodes Respiratory Clear No wheezes and no crackles No tachypnea and no retractions Cardiovascular Regular rate and rhythm S1 and S2 normal No murmur Abdomen Soft No organomegaly and no masses No hepatosplenomegaly GU Normal female genitalia Tanner stage III in breast and pubic hair development and she was given a breast exam Negative for any masses Skin Without rash Extremities Deep tendon reflexes 2 4 bilaterally and equal Neurological Romberg negative Back No scoliosis She had good circumduction at the shoulder joints and duck walk is normal ASSESSMENT Sports physical with normal growth and development PLAN If problems continue she will need to have her hearing rechecked Hopefully in the school there will be a screening mat She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months We reviewed her immunizations for tetanus and her last acellular DPT was 11 25 1996 When she goes to Texas Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release We talked about her menarche Recommended the exam of the breast regularly Talked about other anticipatory guidance including sunscreen use of seat belts and drugs alcohol and smoking and sexual activity and avoidance at her age and to continue on her present medications She also has had problems with her ankles in the past She had no limitation here but we gave her some ankle strengthening exercise handouts while she was in the office Keywords MEDICAL_TRANSCRIPTION,Description Repair of total anomalous pulmonary venous connection ligation of patent ductus arteriosus repair secundum type atrial septal defect autologous pericardial patch subtotal thymectomy and insertion of peritoneal dialysis catheter Medical Specialty Pediatrics Neonatal Sample Name Septal Defect Repair Transcription TITLE OF OPERATION 1 Repair of total anomalous pulmonary venous connection 2 Ligation of patent ductus arteriosus 3 Repair secundum type atrial septal defect autologous pericardial patch 4 Subtotal thymectomy 5 Insertion of peritoneal dialysis catheter INDICATION FOR SURGERY This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection Following initial stabilization she was transferred to the Hospital for complete correction PREOP DIAGNOSIS 1 Total anomalous pulmonary venous connection 2 Atrial septal defect 3 Patent ductus arteriosus 4 Operative weight less than 4 kilograms 3 2 kilograms COMPLICATIONS None CROSS CLAMP TIME 63 minutes CARDIOPULMONARY BYPASS TIME MONITOR 35 minutes profound hypothermic circulatory arrest time 4 plus 19 equals 23 minutes Low flow perfusion 32 minutes FINDINGS Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left sided veins Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence Nonobstructed ascending vein ligated Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin At completion of the procedure right ventricular pressure approximating one half of systemic normal sinus rhythm good biventricular function by visual inspection PROCEDURE After the informed consent the patient was brought to the operating room and placed on the operating room table in supine position Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines The patient was prepped and draped in the usual sterile fashion from chin to groins A median sternotomy incision was performed Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw A subtotal thymectomy was performed Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure Pursestrings were deployed on the ascending aorta on the right Atrial appendage The aorta was then cannulated with an 8 French aorta cannula and the right atrium with an 18 French Polystan right angle cannula With an ACT greater than 400 greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2 0 silk tie Systemic cooling was started and the head was packed and iced and systemic steroids were administered During cooling traction suture was placed in the apex of the left ventricle After 25 minutes of cooling the aorta was cross clamped and the heart arrested by administration of 30 cubic centimeter kilogram of cold blood cardioplegia delivered directly within the aortic root following the aorta cross clamping Following successful cardioplegic arrest a period of low flow perfusion was started and a 10 French catheter was inserted into the right atrial appendage substituting the 18 French Polystan venous cannula The heart was then rotated to the right side and the venous confluence was exposed It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed The two openings were then anastomosed in an end to side fashion with several interlocking sutures to avoid pursestring effect with a running 7 0 PDS suture Following completion of the anastomosis the heart was returned into the chest and the patient s blood volume was drained into the reservoir A right atriotomy was then performed during the period of circulatory arrest The atrial septal defect was very difficult to expose but it was sealed with an autologous pericardial patch was secured in place with a running 6 0 Prolene suture The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6 0 Prolene sutures The venous cannula was reinserted Cardiopulmonary bypass restarted and the aorta cross clamp was released The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which following a prolonged period of rewarming allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15 French Blake drains Venous decannulation was followed by aortic decannulation and administration of protamine sulfate All cannulation sites were oversewn with 6 0 Prolene sutures and the anastomotic sites noticed to be hemostatic With good hemodynamics and hemostasis the sternum was then smeared with vancomycin placing closure with stainless steel wires The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred in very stable condition to the pediatric intensive care unit I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Given the magnitude of the operation the unavailability of an appropriate level cardiac surgical resident Mrs X attending pediatric cardiac surgery at the Hospital participated during the cross clamp time of the procedure in quality of first assistant Keywords pediatrics neonatal total anomalous pulmonary venous connection patent ductus arteriosus ligation secundum type atrial septal defect atrial septal defect subtotal thymectomy peritoneal dialysis catheter cross clamp cardiopulmonary bypass pulmonary venous atrial septal septal defect anomalous venous atrial arteriosus patent ductus septal aorta pulmonary MEDICAL_TRANSCRIPTION,Description Frontal and lateral views of the hip and pelvis Medical Specialty Pediatrics Neonatal Sample Name Slipped Capital Femoral Epiphysis SCFE Transcription EXAM Two views of the pelvis HISTORY This is a patient post surgery 2 1 2 months The patient has a history of slipped capital femoral epiphysis SCFE bilaterally TECHNIQUE Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM DD YYYY Lateral view of the right hip was evaluated FINDINGS Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient s most recent priors dated MM DD YYYY Current films reveal stable appearing post surgical changes Again demonstrated is a single intramedullary screw across the left femoral neck and head There are 2 intramedullary screws through the greater trochanter of the right femur There is a lucency along the previous screw track extending into the right femoral head and neck There has been interval removal of cutaneous staples and or surgical clips These were previously seen along the lateral aspect of the right hip joint Deformity related to the previously described slipped capital femoral epiphysis is again seen IMPRESSION 1 Stable appearing right hip joint status post pinning 2 Interval removal of skin staples as described above Keywords pediatrics neonatal scfe frontal and lateral views slipped capital femoral epiphysis lateral views slipped capital epiphysis frontal pelvis femoral hip MEDICAL_TRANSCRIPTION,Description This patient was seen in clinic for a school physical Medical Specialty Pediatrics Neonatal Sample Name School Physical 1 Transcription SUBJECTIVE This patient was seen in clinic for a school physical NUTRITIONAL HISTORY She eats well takes meats vegetables and fruits but her calcium intake is limited She does not drink a whole lot of pop Her stools are normal Brushes her teeth sees a dentist Developmental History Hearing and vision is okay She did well in school last year She will be going to move to Texas will be going to Bowie High School She will be involved in cheerleading track volleyball and basketball She will be also playing the clarinet and will be a freshman in that school Her menarche was 06 30 2004 PAST MEDICAL HISTORY She is still on medications for asthma She has a problem with her eye lately this has been bothering her and she also has had a rash in the left leg She had been pulling weeds on 06 25 2004 and then developed a rash on 06 27 2004 Review of her immunizations her last tetanus shot was 06 17 2003 MEDICATIONS Advair 100 50 b i d Allegra 60 mg b i d Flonase q d Xopenex Intal and albuterol p r n ALLERGIES No known drug allergies OBJECTIVE Vital Signs Weight 112 pounds about 40th percentile Height 63 1 4 inches also the 40th percentile Her body mass index was 19 7 40th percentile Temperature 97 7 tympanic Pulse 80 Blood pressure 96 64 HEENT Normocephalic Fundi benign Pupils equal and reactive to light and accommodation No strabismus Her vision was 20 20 in both eyes and each with contacts Hearing She passed that test Her TMs are bilaterally clear and nonerythematous Throat was clear Good mucous membrane moisture and good dentition Neck Supple Thyroid normal sized No increased lymphadenopathy in the submandibular nodes and no axillary nodes Abdomen No hepatosplenomegaly Respiratory Clear No wheezes No crackles No tachypnea No retractions Cardiovascular Regular rate and rhythm S1 and S2 normal No murmur Abdomen Soft No organomegaly and no masses GU Normal female genitalia Tanner stage 3 breast development and pubic hair development Examination of the breasts was negative for any masses or abnormalities or discharge from her areola Extremities She has good range of motion of upper and lower extremities Deep tendon reflexes were 2 4 bilaterally and equal Romberg negative Back No scoliosis She had good circumduction at shoulder joint and her duck walk was normal SKIN She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption No honey crusting was noted on the skin She also had some mild rash on the anterior abdominal area near the panty line similar to that rash It was raised and blanch with pressure it was slightly erythematous ASSESSMENT AND PLAN 1 Sports physical 2 The patient received her first hepatitis A vaccine She will get a booster in 6 to 12 months Prescription for Atarax 10 mg tablets one to two tablets p o q 4 6h p r n and a prescription for Elocon ointment to be applied topically except for the face once a day with a refill She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician We talked about anticipatory guidance including breast exam which we have reviewed with her today seatbelt use and sunscreen We talked about avoidance of drugs and alcohol and sexual activity Continue on her present medications and if her rash is not improved and goes to the neck or the face she will need to be on PO steroid medication but presently that was held and moved to treatment with Atarax and Elocon Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing Keywords pediatrics neonatal school physical calcium intake hearing and vision hepatitis a vaccine booster anticipatory guidance developmental percentile physical school rash MEDICAL_TRANSCRIPTION,Description A 7 year old white male started to complain of pain in his fingers elbows and neck This patient may have had reactive arthritis Medical Specialty Pediatrics Neonatal Sample Name Pediatric Rheumatology Consult Transcription HISTORY We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic He was sent here with a chief complaint of joint pain in several joints for few months This is a 7 year old white male who has no history of systemic disease who until 2 months ago was doing well and 2 months ago he started to complain of pain in his fingers elbows and neck At this moment this is better and is almost gone but for several months he was having pain to the point that he would cry at some point He is not a complainer according to his mom and he is a very active kid There is no history of previous illness to this or had gastrointestinal problems He has problems with allergies especially seasonal allergies and he takes Claritin for it Other than that he has not had any other problem Denies any swelling except for that doctor mentioned swelling on his elbow There is no history of rash no stomach pain no diarrhea no fevers no weight loss no ulcers in his mouth except for canker sores No lymphadenopathy no eye problems and no urinary problems MEDICATIONS His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis ALLERGIES He has no allergies to any drugs BIRTH HISTORY Pregnancy and delivery with no complications He has no history of hospitalizations or surgeries FAMILY HISTORY Positive for arthritis in his grandmother No history of pediatric arthritis There is history of psoriasis in his dad SOCIAL HISTORY He lives with mom dad brother sister and everybody is healthy They live in Easton They have 4 dogs 3 cats 3 mules and no deer At school he is in second grade and he is doing PE without any limitation PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 7 pulse is 96 respiratory rate is 24 height is 118 1 cm weight is 22 1 kg and blood pressure is 61 44 GENERAL He is alert active in no distress very cooperative HEENT He has no facial rash No lymphadenopathy Oral mucosa is clear No tonsillitis His ear canals are clear and pupils are reactive to light and accommodation CHEST Clear to auscultation HEART Regular rhythm and no murmur ABDOMEN Soft nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation in any of his joints or active swelling today He has no tenderness either in any of his joints Muscle strength is 5 5 in proximal muscles LABORATORY DATA Includes an arthritis panel It has normal uric acid sedimentation rate of 2 rheumatoid factor of 6 and antinuclear antibody that is negative and C reactive protein that is 7 1 His mother stated that this was done while he was having symptoms ASSESSMENT AND PLAN This patient may have had reactive arthritis He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis I do not see any problems at this moment on his laboratories or on his physical examination This may have been related to recent episode of viral infection or infection of some sort Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints I will be glad to see him back If you have any question on further assessment and plan please do no hesitate to contact us Keywords pediatrics neonatal rheumatology pediatric reactive arthritis psoriatic arthritis psoriasis joints swelling arthritis MEDICAL_TRANSCRIPTION,Description 9 month old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing cough and shortness of breath over the last several months Medical Specialty Pediatrics Neonatal Sample Name Pediatric Letter Transcription Sample Address RE Sample Patient Dear Doctor We had the pleasure of seeing Abc and his mother in the clinic today As you certainly know he is now a 9 month old male product of a twin gestation complicated by some very mild prematurity He has been having problems with wheezing cough and shortness of breath over the last several months You and your partners have treated him aggressively with inhaled steroids and bronchodilator Despite this however he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course Although there is no smoke exposure there is a significant family history with both Abc s father and uncle having problems with asthma as well as his older sister The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father s house On exam today Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy We spent the majority of our 45 minute just reviewing basic principles of asthma management and I believe that Abc s mother is fairly well versed in this I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1 5 milligrams 0 5 milliliters on alternate days I have encouraged his mother to contact our office so that we can answer questions if necessary by phone Thanks so much for allowing us to be involved in his care Sincerely Keywords pediatrics neonatal gestation bronchodilator childhood childhood asthma cough father healthy letter mother pediatric prematurity shortness of breath sister wheezing wheezing cough asthma MEDICAL_TRANSCRIPTION,Description He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally Medical Specialty Pediatrics Neonatal Sample Name Pediatric Urology Letter Transcription XYZ M D Suite 123 ABC Avenue City STATE 12345 RE XXXX XXXX MR 0000000 Dear Dr XYZ XXXX was seen in followup in the Pediatric Urology Clinic I appreciate you speaking with me while he was in clinic He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally When I examined him he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region however on actual physical examination he seems to complain of pain through his entire right side His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration They also feel that since he has been on Detrol his pain levels have been somewhat worse and so I have given them the option of stopping the Detrol initially I think he should stay on MiraLax for management of his bowels I would also suggest that he be referred to Pediatric Gastroenterology for evaluation If they do not find any abnormalities from a gastrointestinal perspective then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain Thank you for following XXXX along with us in Pediatric Urology Clinic If you have any questions please feel free to contact me Sincerely yours Keywords pediatrics neonatal differential function diuretic renal scan abdominal pain renal scan pediatric urology MEDICAL_TRANSCRIPTION,Description Increasing oxygen requirement Baby boy has significant pulmonary hypertension Medical Specialty Pediatrics Neonatal Sample Name Pulmonary Hypertension Pediatric Consult Transcription INDICATION FOR CONSULTATION Increasing oxygen requirement HISTORY Baby boy XYZ is a 29 3 7 week gestation infant His mother had premature rupture of membranes on 12 20 08 She then presented to the Labor and Delivery with symptoms of flu The baby was then induced and delivered The mother had a history of premature babies in the past This baby was doing well and then we had a significant increasing oxygen requirement from room air up to 85 He is now on 60 FiO2 PHYSICAL FINDINGS GENERAL He appears to be pink well perfused and slightly jaundiced VITAL SIGNS Pulse 156 56 respiratory rate 92 sat and 59 28 mmHg blood pressure SKIN He was pink He was on the high frequency ventilator with good wiggle His echocardiogram showed normal structural anatomy He has evidence for significant pulmonary hypertension A large ductus arteriosus was seen with bidirectional shunt A foramen ovale shunt was also noted with bidirectional shunt The shunting for both the ductus and the foramen ovale was equal left to right and right to left IMPRESSION My impression is that baby boy XYZ has significant pulmonary hypertension The best therapy for this is to continue oxygen If clinically worsens he may require nitric oxide Certainly Indocin should not be used at this time He needs to have lower pulmonary artery pressures for that to be considered Thank you very much for allowing me to be involved in baby XYZ s care Keywords pediatrics neonatal high frequency ventilator structural anatomy foramen ovale oxygen requirement hypertension pulmonary MEDICAL_TRANSCRIPTION,Description Ligation clip interruption of patent ductus arteriosus This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch Medical Specialty Pediatrics Neonatal Sample Name Patent Ductus Arteriosus Ligation Transcription TITLE OF OPERATION Ligation clip interruption of patent ductus arteriosus INDICATION FOR SURGERY This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch She has now been put forward for operative intervention PREOP DIAGNOSIS 1 Patent ductus arteriosus 2 Severe prematurity 3 Operative weight less than 4 kg 600 grams COMPLICATIONS None FINDINGS Large patent ductus arteriosus with evidence of pulmonary over circulation After completion of the procedure left recurrent laryngeal nerve visualized and preserved Substantial rise in diastolic blood pressure DETAILS OF THE PROCEDURE After obtaining information consent the patient was positioned in the neonatal intensive care unit cribbed in the right lateral decubitus and general endotracheal anesthesia was induced The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion It was then test occluded and then interrupted with a medium titanium clip There was preserved pulsatile flow in the descending aorta The left recurrent laryngeal nerve was identified and preserved With excellent hemostasis the intercostal space was closed with 4 0 Vicryl sutures and the muscular planes were reapproximated with 5 0 Caprosyn running suture in two layers The skin was closed with a running 6 0 Caprosyn suture A sterile dressing was placed Sponge and needle counts were correct times 2 at the end of the procedure The patient was returned to the supine position in which palpable bilateral femoral pulses were noted I was the surgical attending present in the neonatal intensive care unit and in charge of the surgical procedure throughout the entire length of the case Keywords pediatrics neonatal clip interruption ligation patent ductus arteriosus premature baby intercostal space arteriosus interruption pulmonary circulation MEDICAL_TRANSCRIPTION,Description Fever otitis media and possible sepsis Medical Specialty Pediatrics Neonatal Sample Name Otitis Media Discharge Summary Transcription ADMITTING DIAGNOSES 1 Fever 2 Otitis media 3 Possible sepsis HISTORY OF PRESENT ILLNESS The patient is a 10 month old male who was seen in the office 1 day prior to admission He has had a 2 day history of fever that has gone up to as high as 103 6 degrees F He has also had intermittent cough nasal congestion and rhinorrhea and no history of rashes He has been taking Tylenol and Advil to help decrease the fevers but the fever has continued to rise He was noted to have some increased workup of breathing and parents returned to the office on the day of admission PAST MEDICAL HISTORY Significant for being born at 33 weeks gestation with a birth weight of 5 pounds and 1 ounce PHYSICAL EXAMINATION On exam he was moderately ill appearing and lethargic HEENT Atraumatic normocephalic Pupils are equal round and reactive to light Tympanic membranes were red and yellow and opaque bilaterally Nares were patent Oropharynx was slightly moist and pink Neck was soft and supple without masses Heart is regular rate and rhythm without murmurs Lungs showed increased workup of breathing moderate tachypnea No rales rhonchi or wheezes were noted Abdomen Soft nontender nondistended Active bowel sounds Neurologic exam showed good muscle strength normal tone Cranial nerves II through XII are grossly intact LABORATORY FINDINGS He had electrolytes BUN and creatinine and glucose all of which were within normal limits White blood cell count was 8 6 with 61 neutrophils 21 lymphocytes 17 monocytes suggestive of a viral infection Urinalysis was completely unremarkable Chest x ray showed a suboptimal inspiration but no evidence of an acute process in the chest HOSPITAL COURSE The patient was admitted to the hospital and allowed a clear liquid diet Activity is as tolerates CBC with differential blood culture electrolytes BUN and creatinine glucose UA and urine culture all were ordered Chest x ray was ordered as well with 2 views to evaluate for a possible pneumonia Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94 Gave D5 and quarter of normal saline at 45 mL per hour which was just slightly above maintenance rate to help with hydration He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis and I will add Tylenol and ibuprofen as needed for fevers Overnight he did have his oxygen saturations drop and went into oxygen overnight His lungs remained clear but because of the need for O2 we instituted albuterol aerosols every 6 hours to help maintain good lung function The nurses were instructed to attempt to wean O2 if possible and advance the diet He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient He did well the following evening with no further oxygen requirement He continued to spike fevers but last fever was around 13 45 on the previous day At the time of exam he had 100 oxygen saturations on room air with temperature of 99 3 degrees F with clear lungs He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning CONDITION OF THE PATIENT AT DISCHARGE He was at 100 oxygen saturations on room air with no further dips at night He has become afebrile and was having no further increased work of breathing DISCHARGE DIAGNOSES 1 Bilateral otitis media 2 Fever PLAN Recommended discharge No restrictions in diet or activity He was continued Omnicef 125 mg 5 mL one teaspoon p o once daily and instructed to follow up with Dr X his primary doctor on the following Tuesday Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy Keywords pediatrics neonatal sepsis cough nasal congestion rhinorrhea oxygen saturations otitis media otitis breathing lungs oropharynx fever MEDICAL_TRANSCRIPTION,Description Normal newborn infant physical exam A well developed infant in no acute respiratory distress Medical Specialty Pediatrics Neonatal Sample Name Normal Newborn Infant Physical Exam Transcription GENERAL A well developed infant in no acute respiratory distress VITAL SIGNS Initial temperature was XX pulse XX respirations XX Weight XX grams length XX cm head circumference XX cm HEENT Head is normocephalic with anterior fontanelle open soft and non bulging Eyes Red reflex elicited bilaterally TMs occluded with vernix and not well visualized Nose and throat are patent without palatal defect NECK Supple without clavicular fracture LUNGS Clear to auscultation HEART Regular rate without murmur click or gallop present Pulses are 2 4 for brachial and femoral ABDOMEN Soft with bowel sounds present No masses or organomegaly GENITALIA Normal EXTREMITIES Without evidence of hip defects NEUROLOGIC The infant has good Moro grasp and suck reflexes SKIN Warm and dry without evidence of rash Keywords pediatrics neonatal fontanelle normocephalic newborn infant physical exam acute respiratory newborn respiratory distress head infant MEDICAL_TRANSCRIPTION,Description The patient is an 1812 g baby boy born by vaginal delivery to a 32 year old gravida 3 para 2 at 34 weeks of gestation Mother had two previous C sections Medical Specialty Pediatrics Neonatal Sample Name Neonatal Discharge Summary Transcription HOSPITAL COURSE The patient is an 1812 g baby boy born by vaginal delivery to a 32 year old gravida 3 para 2 at 34 weeks of gestation Mother had two previous C sections Baby was born at 5 57 on 07 30 2006 Mother received ampicillin 2 g 4 hours prior to delivery Mother came with preterm contractions with progressive active labor in spite of the terbutaline and magnesium sulfate Baby was born with Apgar scores of 8 and 9 at delivery Fluid was cleared Nuchal cord x1 Prenatal was at ABC Valley Prenatal labs were O positive antibody negative rubella immune RPR nonreactive Baby was suctioned on perineum with good support The baby was admitted to the NICU for prematurity and to rule out sepsis Baby s cry was good Color tone and __________ mild retractions CBC CRP blood cultures were done IV fluids of D10 at a rate of 6 mL an hour Ampicillin and gentamicin were started via protocol At the time of admission the patient was stable on room air and has feeding issues Baby was fed EBM 22 and NeoSure per os Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours The patient continues on feeding issues will not suck properly was kept in the NICU and put on OG tube for a couple of days after which p o feeds were advanced Also the baby was able to suck properly and was tolerating feeds The baby was fed EBM 22 and NeoSure was added a day before discharge At the time of discharge baby was stable on room air baby was tolerated p o foods and was sucking properly was taking ad lib feeds and gaining weight ADMISSION DIAGNOSES Respiratory distress rule out sepsis and prematurity DISCHARGE DIAGNOSES Stable ex 34 week preemie Pediatrician after discharge will be Dr X DISCHARGE INSTRUCTIONS To follow up with Dr X in 2 to 3 days an appointment was made for 08 14 2006 CPR teaching was completed on 08 11 2006 to parents Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed Ad lib feeding on demand Keywords pediatrics neonatal gestation preemie prematurity sepsis neosure feeds born delivery perineum discharge MEDICAL_TRANSCRIPTION,Description Normal child physical exam template Medical Specialty Pediatrics Neonatal Sample Name Normal Child Exam Template Transcription CHILD PHYSICAL EXAMINATION VITAL SIGNS Birth weight is grams length occipitofrontal circumference Character of cry was lusty GENERAL APPEARANCE Well BREATHING Unlabored SKIN Clear No cyanosis pallor or icterus Subcutaneous tissue is ample HEAD Normal Fontanelles are soft and flat Sutures are opposed EYES Normal with red reflex x2 EARS Patent Normal pinnae canals TMs NOSE Patent nares MOUTH No cleft THROAT Clear NECK No masses CHEST Normal clavicles LUNGS Clear bilaterally HEART Regular rate and rhythm without murmur ABDOMEN Soft flat No hepatosplenomegaly The cord is three vessel GENITALIA Normal genitalia with testes descended bilaterally ANUS Patent SPINE Straight and without deformity EXTREMITIES Equal movements MUSCLE TONE Good REFLEXES Moro grasp and suck are normal HIPS No click or clunk Keywords pediatrics neonatal child physical examination physical genitalia child MEDICAL_TRANSCRIPTION,Description Skull complete five images Medical Specialty Pediatrics Neonatal Sample Name Multiple Images of Skull Pediatric Transcription EXAM Skull complete five images HISTORY Plagiocephaly TECHNIQUE Multiple images of the skull were evaluated There are no priors for comparison FINDINGS Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure There is no evidence of any craniosynostosis There is no radiographic evidence of plagiocephaly IMPRESSION No evidence of craniosynostosis or radiographic characteristics for plagiocephaly Keywords pediatrics neonatal craniosynostosis plagiocephaly complete five images multiple images radiographic images skull MEDICAL_TRANSCRIPTION,Description Respiratory distress syndrome intrauterine growth restriction thrombocytopenia hypoglycemia retinal immaturity The baby is an ex 32 weeks small for gestational age infant with birth weight 1102 Medical Specialty Pediatrics Neonatal Sample Name Neonatal Discharge Summary 1 Transcription ADMITTING DIAGNOSES Respiratory distress syndrome intrauterine growth restriction thrombocytopenia hypoglycemia retinal immaturity HISTORY OF PRESENTING ILLNESS The baby is an ex 32 weeks small for gestational age infant with birth weight 1102 Baby was born at ABCD Hospital at 1333 on 07 14 2006 Mother is a 20 year old gravida 1 para 0 female who received prenatal care Prenatal course was complicated by low amniotic fluid index and hypertension She was evaluated for evolving preeclampsia and had a C section secondary to the nonreassuring fetal status Baby delivered operatively Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children s Hospital Infant was transferred to Children s Hospital for higher level of care stayed at Children s Hospital for approximately 2 weeks and was transferred back to ABCD where he stayed until he was discharged on 08 16 2006 HOSPITAL COURSE At the time of transfer to ABCD these were the following issues FEEDING AND NUTRITION Baby was on TPN and p o feeds had been started and were advanced 1 ml q 6h Baby was tolerating p o feeds of expressed breast milk and baby began to experience some abdominal distention The p o feeds were held and IV D10 water was given Baby was started on Mylicon drops and glycerin suppositories Abdominal ultrasound showed gaseous distention without signs of obstruction OG tube was passed Baby improved after couple of days when p o feedings were restarted Baby was also given Reglan At the time of discharge baby was tolerating p o feeds well of BM fortified with 22 cal NeoSure Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams RESPIRATIONS At the time of admission baby was not having any apnea spells no bradycardia or desaturations was saturating well on room air and continued to do well on room air until the time of discharge HYPOGLYCEMIA Baby began to experience hypoglycemic episodes on 07 24 2006 Blood glucose level was as low as 46 D10 was given initially as bolus Baby continued to experience hypoglycemic episodes Diazoxide was started 5 mg kg per os every 8 hours and fingersticks were done to monitor blood glucose level The baby improved with diazoxide hypoglycemic issues resolved and then began again Diazoxide was discontinued but the hypoglycemic issues restarted The Diazoxide was restarted again Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg kg and then the diazoxide was discontinued At the time of discharge blood glucose levels were not being stable for 24 hours CARDIOVASCULAR Infant was hemodynamically stable on admission from Madera Infant has a closed PDA Infant had two cardiac echograms done The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery then the circumflex coronary artery CNS Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage The ultrasound was negative for intracranial hemorrhage INFECTIOUS DISEASE The patient had been on antibiotics during the stay at Madera At the time of admission to the ABCD the patient was not on any antibiotics and his clinically condition has remained stable HEMATOLOGY The patient is status post phototherapy at Madera and was started on iron OPHTHALMOLOGY Exam on 07 17 2006 showed immature retina The patient is to get followup exam after discharge DISCHARGE DIAGNOSIS Stable ex 32 weeks preemie DISCHARGE INSTRUCTIONS The patient has been educated on CPR measures Followup appointment has been made at Kid s Care Calcium challenge has been done The patient s parents are comfortable with feeding The patient has been discharged on NeoSure and expressed breast milk Keywords pediatrics neonatal delivered preeclampsia immaturity intrauterine prenatal coronary artery blood glucose discharge baby coronary intracranial hypoglycemia hypoglycemic infant MEDICAL_TRANSCRIPTION,Description Suspected mastoiditis ruled out right acute otitis media and severe ear pain resolving The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis Medical Specialty Pediatrics Neonatal Sample Name Mastoiditis Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Suspected mastoiditis ruled out 2 Right acute otitis media 3 Severe ear pain resolving HISTORY OF PRESENT ILLNESS The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis The child has had very severe ear pain and blood draining from the right ear The child had a temperature maximum of 101 4 in the ER The patient was admitted and started on IV Unasyn which he tolerated well and required Morphine and Vicodin for pain control In the first 12 hours after admission the patient s pain decreased and also swelling of his cervical area decreased The patient was evaluated by Dr X from the ENT while in house After reviewing the CT scan it was felt that the CT scan was not consistent with mastoiditis The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge At the time of discharge his pain is markedly decreased about 2 10 and swelling in the area has improved The patient is also able to take p o well DISCHARGE PHYSICAL EXAMINATION GENERAL The patient is alert in no respiratory distress VITAL SIGNS His temperature is 97 6 heart rate 83 blood pressure 105 57 respiratory rate 16 on room air HEENT Right ear shows no redness The area behind his ear is nontender There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly NECK Supple CHEST Clear breath sounds CARDIAC Normal S1 S2 without murmur ABDOMEN Soft There is no hepatosplenomegaly or tenderness SKIN Warm and well perfused DISCHARGE WEIGHT 38 7 kg DISCHARGE CONDITION Good DISCHARGE DIET Regular as tolerated DISCHARGE MEDICATIONS 1 Ciprodex Otic Solution in the right ear twice daily 2 Augmentin 500 mg three times daily x10 days FOLLOW UP 1 Dr Y in one week ENT 2 The primary care physician in 2 to 3 days TIME SPENT Approximate discharge time is 28 minutes Keywords MEDICAL_TRANSCRIPTION,Description Mediastinal exploration and delayed primary chest closure The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification Medical Specialty Pediatrics Neonatal Sample Name Mediastinal Exploration Transcription TITLE OF OPERATION Mediastinal exploration and delayed primary chest closure INDICATION FOR SURGERY The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification The patient experienced an unexplained cardiac arrest at the completion of the procedure which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago She did not meet the criteria for delayed primary chest closure PREOP DIAGNOSIS Open chest status post modified stage I Norwood procedure POSTOP DIAGNOSIS Open chest status post modified stage I Norwood procedure ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma At completion of the procedure no major changes in hemodynamic performance DETAILS OF THE PROCEDURE After obtaining informed consent the patient was brought to the room placed on the operating room table in supine position Following the administration of general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned Through a separate incision and another 15 French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV PA connection as well as inferior most aspect of the ventriculotomy The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires The subcutaneous tissue and skin were closed in layers There was no evidence of significant increase in central venous pressure or desaturation The patient tolerated the procedure well Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case Keywords pediatrics neonatal mediastinal exploration delayed primary chest closure extracorporeal membrane oxygenation stage i norwood procedure sano modification chest closure infant mediastinal exploration closure endotracheal chest MEDICAL_TRANSCRIPTION,Description This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR Medical Specialty Pediatrics Neonatal Sample Name Kawasaki Disease Discharge Summary Transcription ADMITTING DIAGNOSIS Kawasaki disease DISCHARGE DIAGNOSIS Kawasaki disease resolving HOSPITAL COURSE This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR When he was sent to the hospital he had a fever of 102 Subsequently the patient was evaluated and based on the criteria he was started on high dose of aspirin and IVIG Echocardiogram was also done which was negative IVIG was done x1 and between 12 hours of IVIG he spiked fever again it was repeated twice and then after second IVIG he did not spike any more fever Today his fever and his rash have completely resolved He does not have any conjunctivitis and no redness of mucous membranes He is more calm and quite and taking good p o so with a very close followup and a cardiac followup he will be sent home DISCHARGE ACTIVITIES Ad lib DISCHARGE DIET PO ad lib DISCHARGE MEDICATIONS Aspirin high dose 340 mg q 6h for 1 day and then aspirin low dose 40 mg q d for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p o once a day He will be followed by his primary doctor in 2 to 3 days Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG all the live virus vaccine and if he gets any rashes any fevers should go to primary care doctor as soon as possible Keywords pediatrics neonatal mucous membranes conjunctivitis ad lib kawasaki disease vaccine fever aspirin MEDICAL_TRANSCRIPTION,Description Left communicating hydrocele Left inguinal hernia and hydrocele repair The patient is a 5 year old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele MEDICAL_TRANSCRIPTION,Description 4 day old with hyperbilirubinemia and heart murmur Medical Specialty Pediatrics Neonatal Sample Name Hyperbilirubinemia 4 day old Transcription HISTORY The patient is a 4 day old being transferred here because of hyperbilirubinemia and some hypoxia Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic but her oxygen came up with minimal supplemental oxygen She was also noted to have periodic breathing The patient is breast and bottle fed and has been feeding well There has been no diarrhea or vomiting Voiding well Bowels have been regular According to the report from referring facility because the patient had periodic breathing and was hypoxic it was thought the patient was septic and she was given a dose of IM ampicillin The patient was born at 37 weeks gestation to gravida 3 para 3 female by repeat C section Birth weight was 8 pounds 6 ounces and the mother s antenatal other than was normal except for placenta previa The patient s mother apparently went into labor and then underwent a cesarean section FAMILY HISTORY Positive for asthma and diabetes and there is no exposure to second hand smoke PHYSICAL EXAMINATION VITAL SIGNS The patient has a temperature of 36 8 rectally pulse of 148 per minute respirations 50 per minute oxygen saturation is 96 on room air but did go down to 90 and the patient was given 1 liter by nasal cannula GENERAL The patient is icteric well hydrated Does have periodic breathing Color is pink and also icterus is noted scleral and skin HEENT Normal NECK Supple CHEST Clear HEART Regular with a soft 3 6 murmur Femorals are well palpable Cap refill is immediate ABDOMEN Soft small umbilical hernia is noted which is reducible EXTERNAL GENITALIA Those of a female child SKIN Color icteric Nonspecific rash on the body which is sparse The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area EXTREMITIES The patient moves all extremities well Has a normal tone and a good suck EMERGENCY DEPARTMENT COURSE It was indicated to the parents that I would be repeating labs and also catheterize urine specimen Parents were made aware of the fact that child did have a murmur I spoke to Dr X who suggested doing an EKG which was normal and since the patient will be admitted for hyperbilirubinemia an echo could be done in the morning The case was discussed with Dr Y and he will be admitting this child for hyperbilirubinemia CBC done showed a white count of 15 700 hemoglobin 18 gm hematocrit 50 6 platelets 245 000 10 bands 44 segs 34 lymphs and 8 monos Chemistries done showed sodium of 142 mEq L potassium 4 5 mEq L chloride 104 mEq L CO2 28 mmol L glucose 75 mg BUN 8 mg creatinine 0 7 mg and calcium 8 0 mg Total bilirubin was 25 4 mg all of which was unconjugated CRP was 0 3 mg Blood culture was drawn Catheterized urine specimen was normal Parents were kept abreast of what was going on all the time and the need for admission Phototherapy was instituted in the ER almost after the baby got to the emergency room IMPRESSION Hyperbilirubinemia and heart murmur DIFFERENTIAL DIAGNOSES Considered breast milk jaundice ABO incompatibility galactosemia and ventricular septal defect Keywords pediatrics neonatal hypoxia periodic breathing heart murmur urine specimen yellow bilirubin heart murmur hyperbilirubinemia MEDICAL_TRANSCRIPTION,Description Gastrostomy a 6 week old with feeding disorder and Down syndrome Medical Specialty Pediatrics Neonatal Sample Name Gastrostomy Transcription PREOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease POSTOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease OPERATION PERFORMED Gastrostomy ANESTHESIA General INDICATIONS This 6 week old female infant had been transferred to Children s Hospital because of Down syndrome and congenital heart disease She has not been able to feed well and in fact has to now be NG tube fed Her swallowing mechanism does not appear to be very functional and therefore it was felt that in order to aid in her home care that she would be better served with a gastrostomy OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in usual manner Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection The muscle was divided and the peritoneal cavity entered The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field The site for gastrostomy was selected and a pursestring suture of 4 0 Nurolon placed in the gastric wall A 14 French 0 8 cm Mic Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube Following this the stomach was returned to the abdominal cavity and the posterior fascia was closed using a 4 0 Nurolon affixing the stomach to the posterior fascia The anterior fascia was then closed with 3 0 Vicryl subcutaneous tissue with the same and the skin closed with 5 0 subcuticular Monocryl The balloon was inflated to the full 5 mL A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition Keywords pediatrics neonatal feeding disorder down syndrome congenital heart disease mic key tubeless nurolon subcutaneous tissue fascia syndrome stomach gastrostomy MEDICAL_TRANSCRIPTION,Description Followup of laparoscopic fundoplication and gastrostomy Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access Medical Specialty Pediatrics Neonatal Sample Name Fundoplication Gastrostomy Followup Transcription REASON FOR VISIT Followup of laparoscopic fundoplication and gastrostomy HISTORY OF PRESENT ILLNESS The patient is a delightful baby girl who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty Dr X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber The patient had a laparoscopic fundoplication and gastrostomy on 10 05 2007 She has done well since that time She has had some episodes of retching intermittently and these seemed to be unpredictable She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved The patient currently takes about 1 ounce to 1 5 ounce of her feedings by mouth and the rest is given by G tube She seems otherwise happy and is not having an excessive amount of stools Her parents have not noted any significant problems with the gastrostomy site The patient s exam today is excellent Her belly is soft and nontender All of her laparoscopic trocar sites are healing with a normal amount of induration but there is no evidence of hernia or infection We removed The patient s gastrostomy button today and showed her parents how to reinsert one without difficulty The site of the gastrostomy is excellent There is not even a hint of granulation tissue or erythema and I am very happy with the overall appearance IMPRESSION The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy Hopefully the exquisite control of acid reflux by fundoplication will help her airway heal and if she does well allow decannulation in the future If she does require laryngotracheoplasty the protection from acid reflux will be important to healing of that procedure as well PLAN The patient will follow up as needed for problems related to gastrostomy We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future Keywords pediatrics neonatal decannulation enteral feeding feeding access laparoscopic fundoplication gastrostomy airway laryngotracheoplasty laparoscopic fundoplication MEDICAL_TRANSCRIPTION,Description Pediatric Gastroenterology History of gagging Medical Specialty Pediatrics Neonatal Sample Name Gagging 3 year old Transcription HISTORY OF PRESENT ILLNESS This is a 3 year old female patient who was admitted today with a history of gagging She was doing well until about 2 days ago when she developed gagging No vomiting No fever She has history of constipation She normally passes stool every two days after giving an enema No rectal bleeding She was brought to the Hospital with some loose stool She was found to be dehydrated She was given IV fluid bolus but then she started bleeding from G tube site There was some fresh blood coming out of the G tube site She was transferred to PICU She is hypertensive Intensivist Dr X requested me to come and look at her and do upper endoscopy to find the site of bleeding PAST MEDICAL HISTORY PEHO syndrome infantile spasm right above knee amputation developmental delay G tube fundoplication PAST SURGICAL HISTORY G tube fundoplication on 05 25 2007 Right above knee amputation ALLERGIES None DIET She is NPO now but at home she is on PediaSure 4 ounces 3 times a day through G tube 12 ounces of water per day MEDICATIONS Albuterol Pulmicort MiraLax 17 g once a week carnitine phenobarbital Depakene and Reglan FAMILY HISTORY Positive for cancer PAST LABORATORY EVALUATION On 12 27 2007 WBC 9 3 hemoglobin 7 6 hematocrit 22 1 platelet 132 000 KUB showed large stool with dilated small and large bowel loops Sodium 140 potassium 4 4 chloride 89 CO2 21 BUN 61 creatinine 2 AST 92 increased ALT 62 increased albumin 5 3 total bilirubin 0 1 Earlier this morning she had hemoglobin of 14 5 hematocrit 41 3 platelets 491 000 PT 58 increased INR 6 6 increased PTT 75 9 increased PHYSICAL EXAMINATION VITAL SIGNS Temperature 99 degrees Fahrenheit pulse 142 per minute respirations 34 per minute weight 8 6 kg GENERAL She is intubated HEENT Atraumatic She is intubated LUNGS Good air entry bilaterally No rales or wheezing ABDOMEN Distended Decreased bowel sounds GENITALIA Grossly normal female CNS She is sedated IMPRESSION A 3 year old female patient with history of passage of blood through G tube site with coagulopathy She has a history of G tube fundoplication developmental delay PEHO syndrome which is progressive encephalopathy optic atrophy PLAN Plan is to give vitamin K FFP blood transfusion Consider upper endoscopy Procedure and informed consent discussed with the family Keywords pediatrics neonatal g tube peho syndrome tube site gagging constipation endoscopy peho hemoglobin hematocrit intubated bleeding blood fundoplication tube MEDICAL_TRANSCRIPTION,Description Questionable foreign body right nose Belly and back pain Mild constipation Medical Specialty Pediatrics Neonatal Sample Name Foreign Body Right Nose Transcription CHIEF COMPLAINT Questionable foreign body right nose Belly and back pain SUBJECTIVE Mr ABC is a 2 year old boy who is brought in by parents stating that the child keeps complaining of belly and back pain This does not seem to be slowing him down They have not noticed any change in his urine or bowels They have not noted him to have any fevers or chills or any other illness They state he is otherwise acting normally He is eating and drinking well He has not had any other acute complaints although they have noted a foul odor coming from his nose Apparently he was seen here a few weeks ago for a foreign body in the right nose which was apparently a piece of cotton this was removed and placed on antibiotics His nose got better and then started to become malodorous again Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there Otherwise he has not had any runny nose earache no sore throat He has not had any cough congestion He has been acting normally Eating and drinking okay No other significant complaints He has not had any pain with bowel movement or urination nor have they noted him to be more frequently urinating then again he is still on a diaper PAST MEDICAL HISTORY Otherwise negative ALLERGIES No allergies MEDICATIONS No medications other than recent amoxicillin SOCIAL HISTORY Parents do smoke around the house PHYSICAL EXAMINATION VITAL SIGNS Stable He is afebrile GENERAL This is a well nourished well developed 2 year old little boy who is appearing very healthy normal for his stated age pleasant cooperative in no acute distress looks very healthy afebrile and nontoxic in appearance HEENT TMs canals are normal Left naris normal Right naris there is some foul odor as well as questionable purulent drainage Examination of the nose there was a foreign body noted which was the appearance of a cotton ball in the right nose that was obviously infected and malodorous This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual There was some erythema No other purulent drainage noted There was some bloody drainage This was suctioned and all mucous membranes were visualized and are negative NECK Without lymphadenopathy No other findings HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN His abdomen is entirely benign soft nontender nondistended Bowel sounds active No organomegaly or mass noted BACK Without any findings Diaper area normal GU No rash or infections Skin is intact ED COURSE He also had a P Bag placed but did not have any urine Therefore a straight catheter was done which was done with ease without complication and there was no leukocytes noted within the urine There was a little bit of blood from catheterization but otherwise normal urine X ray noted some stool within the vault Child is acting normally He is jumping up and down on the bed without any significant findings ASSESSMENT 1 Infected foreign body right naris 2 Mild constipation PLAN As far as the abdominal pain is concerned they are to observe for any changes Return if worse follow up with the primary care physician The right nose I will place the child on amoxicillin 125 per 5 mL 1 teaspoon t i d Return as needed and observe for more foreign bodies I suspect the child had placed this cotton ball in his nose again after the first episode Keywords MEDICAL_TRANSCRIPTION,Description Circumcision Normal male phallus The infant is without evidence of hypospadias or chordee prior to the procedure Medical Specialty Pediatrics Neonatal Sample Name Circumcision Infant Transcription PROCEDURE Circumcision PRE PROCEDURE DIAGNOSIS Normal male phallus POST PROCEDURE DIAGNOSIS Normal male phallus ANESTHESIA 1 lidocaine without epinephrine INDICATIONS The risks and benefits of the procedure were discussed with the parents The risks are infection hemorrhage and meatal stenosis The benefits are ease of care and cleanliness and fewer urinary tract infections The parents understand this and have signed a permit FINDINGS The infant is without evidence of hypospadias or chordee prior to the procedure TECHNIQUE The infant was given a dorsal penile block with 1 lidocaine without epinephrine using a tuberculin syringe and 0 5 cc of lidocaine was delivered subcutaneously at 10 30 and at 1 30 o clock at the dorsal base of the penis The infant was prepped then with Betadine and draped with a sterile towel in the usual manner Clamps were placed at 10 o clock and 2 o clock and the adhesions between the glans and mucosa were instrumentally lysed Dorsal hemostasis was established and a dorsal slit was made The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed The infant was fitted with a XX cm Plastibell The foreskin was retracted around the Plastibell and circumferential hemostasis was established The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis Keywords pediatrics neonatal dorsal slit hypospadias chordee epinephrine hemorrhage penis adhesions circumcision phallus lidocaine foreskin infant MEDICAL_TRANSCRIPTION,Description Newborn circumcision The penile foreskin was removed using Gomco Medical Specialty Pediatrics Neonatal Sample Name Circumcision Newborn Transcription PROCEDURE Newborn circumcision INDICATIONS Parental preference ANESTHESIA Dorsal penile nerve block DESCRIPTION OF PROCEDURE The baby was prepared and draped in a sterile manner Lidocaine 1 4 mL without epinephrine was instilled into the base of the penis at 2 o clock and 10 o clock The penile foreskin was removed using a XXX Gomco Hemostasis was achieved with minimal blood loss There was no sign of infection The baby tolerated the procedure well Vaseline was applied to the penis and the baby was diapered by nursing staff Keywords pediatrics neonatal nerve block newborn circumcision foreskin gomco penis circumcision newborn penile MEDICAL_TRANSCRIPTION,Description Circumcision The child appeared to tolerate the procedure well Care instructions were given to the parents Medical Specialty Pediatrics Neonatal Sample Name Circumcision Child Transcription PROCEDURE Circumcision Signed informed consent was obtained and the procedure explained The child was placed in a Circumstraint board and restrained in the usual fashion The area of the penis and scrotum were prepared with povidone iodine solution The area was draped with sterile drapes and the remainder of the procedure was done with sterile procedure A dorsal penile block was done using 2 injections of 0 3 cc each 1 plain lidocaine A dorsal slit was made and the prepuce was dissected away from the glans penis A Gomco clamp was properly placed for 5 minutes During this time the foreskin was sharply excised using a 10 blade With removal of the clamp there was a good cosmetic outcome and no bleeding The child appeared to tolerate the procedure well Care instructions were given to the parents Keywords pediatrics neonatal circumstraint dorsal slit gomco clamp circumcision childNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth Medical Specialty Pediatrics Neonatal Sample Name Chronic Otitis Media Transcription CHIEF COMPLAINT Chronic otitis media HISTORY OF PRESENT ILLNESS This is a 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth There is also associated chronic nasal congestion There had been no bouts of spontaneous tympanic membrane perforation but there had been elevations of temperature up to 102 during the acute infection He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia ALLERGIES None MEDICATIONS None FAMILY HISTORY Noncontributory MEDICAL HISTORY Mild reflux PREVIOUS SURGERIES None SOCIAL HISTORY The patient is not in daycare There are no pets in the home There is no secondhand tobacco exposure PHYSICAL EXAMINATION Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present Left ear is still little bit black Nose moderate inferior turbinate hypertrophy No polyps or purulence Oral cavity oropharynx 2 tonsils No exudates Neck no nodes masses or thyromegaly Lungs are clear to A P Cardiac exam regular rate and rhythm No murmurs Abdomen is soft and nontender Positive bowel sounds IMPRESSION Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media and wax accumulation PLAN The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia Keywords pediatrics neonatal chronic nasal congestion tympanic membrane perforation chronic otitis media tube insertion facemask anesthesia otitis media otitis media MEDICAL_TRANSCRIPTION,Description Lumbar osteomyelitis and need for durable central intravenous access Placement of left subclavian 4 French Broviac catheter Medical Specialty Pediatrics Neonatal Sample Name Broviac Catheter Placement Transcription PREOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access POSTOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access ANESTHESIA General PROCEDURE Placement of left subclavian 4 French Broviac catheter INDICATIONS The patient is a toddler admitted with a limp and back pain who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas The patient needs prolonged IV antibiotic therapy but attempt at a PICC line failed She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement I met with the patient s mom With the help of a Spanish interpreter I explained the technique for Broviac placement We discussed the surgical risks and alternatives most of which have been exhausted All their questions have been answered and the patient is fit for operation today DESCRIPTION OF OPERATION The patient came to the operating room and had an uneventful induction of general anesthesia We conducted a surgical time out to reiterate all of the patient s important identifying information and to confirm that we were here to place the Broviac catheter Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed A flexible guidewire was inserted into the central location and then a 4 French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines The peel away sheath was passed over the guidewire and then the 4 French catheter was deployed through the peel away sheath There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein then it was withdrawn and easily replaced in the superior vena cava The catheter insertion site was closed with one buried 5 0 Monocryl stitch and the same 5 0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred Heparinized saline solution was used to flush the line A sterile occlusive dressing was applied and the line was prepared for immediate use The patient was transported to the recovery room in good condition There were no intraoperative complications and her blood loss was between 5 and 10 mL during the line placement portion of the procedure Keywords pediatrics neonatal lumbar osteomyelitis central intravenous access subclavian osteomyelitis broviac catheter catheter toddler intravenous MEDICAL_TRANSCRIPTION,Description Delayed primary chest closure Open chest status post modified stage 1 Norwood operation The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Medical Specialty Pediatrics Neonatal Sample Name Chest Closure Transcription PROCEDURE Delayed primary chest closure INDICATIONS The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Given the magnitude of the operation and the size of the patient 2 5 kg we have elected to leave the chest open to facilitate postoperative management He is now taken back to the operative room for delayed primary chest closure PREOP DX Open chest status post modified stage 1 Norwood operation POSTOP DX Open chest status post modified stage 1 Norwood operation ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma He tolerated the procedure well DETAILS OF PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position Following general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion The previously placed AlloDerm membrane was removed Mediastinal cultures were obtained and the mediastinum was then profusely irrigated and suctioned Both cavities were also irrigated and suctioned The drains were flushed and repositioned Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line The sternum was then smeared with a vancomycin paste The proximal aspect of the 5 mm RV PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches The skin was closed with interrupted nylon sutures and a sterile dressing was placed The peritoneal dialysis catheter atrial and ventricular pacing wires were removed The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Keywords pediatrics neonatal open chest stage 1 norwood operation hypoplastic left heart syndrome delayed primary chest closure chest closure norwood operation MEDICAL_TRANSCRIPTION,Description 1 year black female for initial evaluation of a lifelong history of atopic eczema Medical Specialty Pediatrics Neonatal Sample Name Atopic Eczema Transcription SUBJECTIVE This 1 year black female new patient in dermatology sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema The patient s mom is from Tanzania The patient has been treated with Elidel cream b i d for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson s Baby Oil on her The patient is a well developed baby Appears stated age Overall health is good FAMILY SOCIAL AND ALLERGY HISTORY The patient has eczema and a positive atopic family history No psoriasis No known drug allergies CURRENT MEDICATIONS None PHYSICAL EXAMINATION The patient has eczematous changes today on her face trunk and extremities IMPRESSION Atopic eczema TREATMENT 1 Discussed condition and treatment with Mom 2 Continue bathing twice a week 3 Discontinue hot soapy water 4 Discontinue Elidel for now 5 Add Aristocort cream 0 25 Polysporin ointment Aquaphor b i d and p r n itch We will see her in one month if not better otherwise on a p r n basis Send a letter to ABC Practice program Keywords pediatrics neonatal dermatology elidel cream johnson s baby oil polysporin ointment atopic eczema eczema eczematous hot soapy water atopic elidel MEDICAL_TRANSCRIPTION,Description Nerve root decompression at L45 on the left side Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left Interpretation of radiograph Medical Specialty Pain Management Sample Name Tun L Catheter Placement Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low back pain with left greater than right lower extremity radiculopathy POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Nerve root decompression at L45 on the left side 2 Tun L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION FOR PROCEDURE Severe and excruciating pain in the lumbar spine and lower extremity MRI shows disc pathology as well as facet arthrosis SUMMARY OF PROCEDURE The patient was admitted to the operating room consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels After the towels were places then sterile drapes were placed on top of that After which time the Epimed catheter was then placed this was done by first repositioning the C Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5 verifying the sacral hiatus The skin over the sacral hiatus was then injected with 1 Lidocaine and an 18 gauge needle was used for skin puncture The 18 gauge needle was inserted off of midline A 16 gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss of resistance technique the needle was placed Negative aspiration was carefully performed Omnipaque 240 dye was then injected through the 16 gauge RK needle The classical run off was noted A filling defect was noted L45 nerve root on the left side After which time 10 cc of 0 25 Marcaine Triamcinolone 9 1 mixture was then infused through the 16 R K Needle Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique An Epimed Tun L catheter was then inserted through the 16 gauage R K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized The tip of the catheter was noted to be L45 level on the left side After this the 16 gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side After this was successfully done the catheter was then secured in place this was done with Neosporin ointment a Split 2x2 Op site and Hypofix tape The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected The classical run off was noted in the lumbar region Some lyses of adhesions were also visualized at this time with barbotage technique Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect After which time negative aspiration was again performed through the Epimed Tun L catheter and then 10 cc of solution was then infused through the catheter this was done over a 10 minute period with initial 3 cc test dose Approximately 3 minutes elapsed and then the remaining 7 cc were infused Solution consisting of 8 cc of 0 25 Marcaine 2 cc of Triamcinolone and 1 cc of Wydase The catheter was then capped with a bacterial filter The patient was noted to have tolerated the procedure well without any complications Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure This verified positive nerve root decompression The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side Positive myelogram without dural puncture was noted during this procedure no sub dural spread of Omnipaque 240 dye was noted This patient did not report any problems and reported pain reduction Keywords pain management low back syndrome low back pain nerve root decompression steroid solution c arm epimed tun l catheter nerve root negative aspiration omnipaque dye filling defect nerve root catheter adhesions injection needle MEDICAL_TRANSCRIPTION,Description Trigger Point Injection The area over the myofascial spasm was prepped with alcohol utilizing sterile technique Medical Specialty Pain Management Sample Name Trigger Point Injection Transcription OPERATION Keywords pain management myofascial spasm trigger point injection trigger injection spasm MEDICAL_TRANSCRIPTION,Description Transforaminal Epidural lumbar Template Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 lidocaine Medical Specialty Pain Management Sample Name Transforaminal Epidural Steroid Injection 1 Transcription PROCEDURE Transforaminal Epidural lumbar INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The X ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table with a pillow under the lower abdomen to reduce the natural lumbar lordosis The skin over and surrounding the treatment area was cleaned with betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 lidocaine With fluoroscopy a spinal needle was gently guided into the superior anterior neuroforamin lateral to the mid pedicular line at Multiple fluoroscopic views were used to ensure proper needle placement Approximately of non ionic contrast agent was injected into the joint under real time fluoroscopic observation Correct needle placement was confirmed by production of an appropriate epidurogram and radiculogram without concurrent vascular dye pattern Finally the treatment solution consisting of was injected All injected medications were preservative free Sterile techniques were used throughout the procedure COMPLICATIONS None No complications The patient tolerated the procedure well and was sent to the recovery room in good condition DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made in approximately 1 week Keywords pain management epidural lumbar facet joints transforaminal epidural injection transforaminal epidural lumbar fluoroscopy needle MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm Medical Specialty Pain Management Sample Name Tenosynovectomy Cortisone Injection Transcription PREOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm POSTOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm PROCEDURE Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm ANESTHESIA Local plus IV sedation MAC ESTIMATED BLOOD LOSS Zero SPECIMENS None DRAINS None PROCEDURE DETAIL Patient brought to the operating room After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release 10 cc of a mixture of 1 Xylocaine and 0 5 Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery Routine prep and drape was employed Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure Hand was positioned palm up in the lead hand holder A short curvilinear incision about the base of the thenar eminence was made Skin was sharply incised Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm Proximally the antebrachial fascia was released for a distance of 2 3 cm proximal to the wrist crease to insure complete decompression of the median nerve Retinacular flap was retracted radially to expose the contents of the carpal canal Median nerve was identified seen to be locally compressed with moderate erythema and mild narrowing Locally adherent tenosynovium was present and this was carefully dissected free Additional tenosynovium was dissected from the flexor tendons individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5 0 nylon horizontal mattress sutures A syringe with 3 cc of Kenalog 10 and 3 cc of 1 Xylocaine using a 25 gauge short needle was then selected 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique 1 cc was injected into the fourth finger A1 A2 pulley tendon sheath using standard tendon sheath injection technique 1 cc was injected into the Dupuytren s nodule in the midpalm to relieve local discomfort Routine postoperative hand dressing with well padded well molded volar plaster splint and lightly compressive Ace wrap was applied Tourniquet was deflated Good vascular color and capillary refill were seen to return to the tips of all digits Patient discharged to the ambulatory recovery area and from there discharged home Discharge medication is Darvocet N 100 30 tablets one to two PO q 4h p r n Patient asked to begin gentle active flexion extension and passive nerve glide exercises beginning 24 48 hours after surgery She was asked to keep the dressings clean dry and intact and follow up in my office Keywords pain management carpal tunnel syndrome pulley dupuytren s tenosynovitis tenosynovectomy carpal tunnel release flexor tenosynovectomy cortisone injection dupuytren s nodule injection cortisone MEDICAL_TRANSCRIPTION,Description Thoracic epidural steroid injection without fluoroscopy An 18 gauge Tuohy needle was then placed into the epidural space using loss of resistance technique Medical Specialty Pain Management Sample Name Thoracic epidural steroid injection Transcription PROCEDURE Thoracic epidural steroid injection without fluoroscopy ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the sitting position and the back was prepped with Betadine Lidocaine 1 5 was used for skin wheal made between __________ An 18 gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted After negative aspiration a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo Medrol was injected Neosporin and band aid were applied over the puncture site The patient was discharged to recovery room in stable condition Keywords pain management loss of resistance cerebrospinal fluid thoracic epidural steroid injection fluoroscopy thoracic steroid epidural injection MEDICAL_TRANSCRIPTION,Description Flexible Bronchoscopy pediatric Medical Specialty Pediatrics Neonatal Sample Name Bronchoscopy Pediatric Transcription FLEXIBLE BRONCHOSCOPY The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit I explained to the parents that the possible risks include irritation of the nasal mucosa which can be associated with some bleeding risk of contamination of the lower airways by passage of the scope in the nasopharynx respiratory depression from sedation and a very small risk of pneumothorax A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back The sample will then be sent for testing The flexible bronchoscopy is mainly diagnostic any therapeutic intervention if deemed necessary will be planned and will require a separate procedure The parents seem to understand had the opportunity to ask questions and were satisfied with the information A booklet containing the description of the procedure and other information was provided Keywords pediatrics neonatal flexible bronchoscopy pediatric intensive care unit bleeding bronchi bronchoalveolar lavage bronchoscopy conscious sedation nasal mucosa nasopharynx pneumothorax respiratory pediatric flexible bronchoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter Medical Specialty Pain Management Sample Name SynchroMed Pump Placement Transcription PROCEDURES 1 Placement of SynchroMed infusion pump 2 Tunneling of SynchroMed infusion pump catheter 3 Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter DESCRIPTION OF PROCEDURE Under general endotracheal anesthesia the patient was placed in a lateral decubitus position The patient was prepped and draped in a sterile manner The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle A pursestring suture of 3 0 Prolene was placed around the needle in the paraspinous muscle The needle was withdrawn The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak The catheter demonstrated free flow of cerebrospinal fluid throughout the RV procedure The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3 0 Prolene Antibiotic irrigation and antibiotic soak sponge were placed into the wound and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed pump pocket was created Then I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery A pocket was created that would encompass the SynchroMed fusion pump A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision and a SynchroMed pump catheter was placed to the tunneling device The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision The intrathecal catheter was trimmed A clear plastic boot was placed over the intrathecal catheter and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together The clear plastic boot was then placed over the connection and it was anchored in place with 0 silk ties Good CSF was then demonstrated flowing through the SynchroMed pump catheter The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0 silk tie Excess catheter was coiled and placed behind the pump The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2 0 Prolene 4 of the sutures were placed The subcutaneous tissues were irrigated with normal saline The subcutaneous tissue of both wounds was closed with running suture of 3 0 Vicryl The skin of both wounds was closed with staples Antibiotic ointment and a sterile dressing were applied The patient was awake and taken to the recovery room The patient tolerated the procedure well and was stable at the completion of the procedure All sponge and lap needle and instrument counts were correct at the completion of the procedure Keywords pain management intrathecal catheter paraspinous cerebrospinal synchromed infusion pump synchromed pump catheter synchromed pump paraspinous muscle cerebrospinal fluid tunneling device infusion pump subcutaneous tissue infusion synchromed pump incision MEDICAL_TRANSCRIPTION,Description Consultation for right shoulder pain Medical Specialty Pain Management Sample Name Shoulder Pain Consult Transcription CHIEF COMPLAINT Right shoulder pain HISTORY OF PRESENT PROBLEM Keywords pain management shoulder pain history of present problem cortisone shot no numbness or tingling rhomboids scapula shoulder impingement focal findings shoulder MEDICAL_TRANSCRIPTION,Description Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation Medical Specialty Pain Management Sample Name Radiofrequency Thermocoagulation Transcription PROCEDURE Right sacral alar notch and sacroiliac joint posterior rami radiofrequency thermocoagulation ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position The back prepped with Betadine The patient was given sedation and monitored Under fluoroscopy the right sacral alar notch was identified After placement of a 20 gauge 10 cm SMK needle into the notch a positive sensory negative motor stimulation was obtained Following negative aspiration 5 cc of 0 5 of Marcaine and 20 mg of Depo Medrol were injected Coagulation was then carried out at 90oC for 90 seconds The SMK needle was then moved to the mid inferior third of the right sacroiliac joint Again the steps dictated above were repeated The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen then followed by steroid injected and coagulation as above There were no complications The patient was returned to outpatient recovery in stable condition Keywords pain management posterior rami sacroiliac joint sacral alar notch radiofrequency thermocoagulation thermocoagulation radiofrequency sacroiliac sacral alar notch MEDICAL_TRANSCRIPTION,Description Superior Gluteal Nerve Block Left Superior Gluteal Neuralgia Neurapraxia impingement Syndrome Medical Specialty Pain Management Sample Name Superior Gluteal Nerve Block Transcription PRE OPERATIVE DIAGNOSIS Superior Gluteal Neuralgia Neurapraxia impingement Syndrome POST OPERATIVE DIAGNOSIS Same PROCEDURE Superior Gluteal Nerve Block Left After verbal informed consent whereby the patient is made aware of the risks of the procedure the patient was placed in the standing position with the arms flaccid by the side Alcohol was used to prep the skin 3 times and a 27 gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle in close proximity to the Superior Gluteal Nerve Aspiration was negative and the mixture was easily injected Aseptic technique was observed at all times and there were no complications noted INJECTATE INCLUDED Methyl Prednisolone DepoMedrol 20 mg Ketorolac Toradol 6 mg Sarapin 1 cc Bupivacaine Marcaine Q S 2 cc The procedures above were performed for diagnostic as well as therapeutic purposes This treatment plan is medically necessary to decrease pain and suffering increase activities of daily living and improve sleep ZUNG SELF RATING DEPRESSION SCALE SDS RESULTS The patient scored as mildly depressed NOTE The pain was gone post procedure consistent with the diagnosis as well as with adequacy of medication placement Keywords pain management neurapraxia impingement syndrome neuralgia superior gluteal superior gluteal nerve block gluteus medius muscle gluteus maximus muscle gluteus medius nerve block gluteal nerve block gluteus nerve gluteal MEDICAL_TRANSCRIPTION,Description Bilateral L5 S1 S2 and S3 radiofrequency ablation for sacroiliac joint pain Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Pain Management Sample Name Radiofrequency Ablation Transcription PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 20 gauge 10 mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen for the lateral branches of S1 S2 and S3 Also fluoroscopic views were used to ensure proper needle placement The following technique was used to confirm correct placement Motor stimulation was applied at 2 Hz with 1 millisecond duration No extremity movement was noted at less than 2 volts Following this the needle trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 0 5 mL of 1 lidocaine was injected to anesthetize the lateral branch and the surrounding tissue After completion a lesion was created at that level with a temperature of 80 degrees for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS None COMPLICATIONS None DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at PM R Spine Clinic in approximately one to two weeks Keywords pain management sacroiliac joint pain sacroiliac teflon coated needle fluoroscopy needle placement radiofrequency ablation ablation tissue lidocaine needle MEDICAL_TRANSCRIPTION,Description Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain Medical Specialty Pain Management Sample Name Radiofrequency Thermocoagulation 1 Transcription PROCEDURE Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion The patient was given sedation and monitored Lidocaine 1 5 for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body A 20 gauge 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body At this time a negative motor stimulation was obtained Injection of 10 cc of 0 5 Marcaine plus 10 mg of Depo Medrol was performed Coagulation was then carried out for 90oC for 90 seconds At the conclusion of this the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated This was repeated one more time with a 5 mm withdrawal and coagulation At that time attention was directed to the L3 body where the needle was placed to the upper one third distal two thirds junction and the sequence of injection coagulation and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated There were no compilations from this The patient was discharged to operating room recovery in stable condition Keywords pain management lumbar sympathetic chain vertebral body radiofrequency thermocoagulation motor stimulation thermocoagulation radiofrequency coagulation needle MEDICAL_TRANSCRIPTION,Description Complex regional pain syndrome right upper extremity Stellate ganglion block Medical Specialty Pain Management Sample Name Stellate Ganglion Block Transcription PREOPERATIVE DIAGNOSIS Complex Regional Pain Syndrome right upper extremity POSTOPERATIVE DIAGNOSIS Same OPERATION Keywords pain management chassaignac s tubercle horner s sign stellate ganglion block sheath vertebral stellate ganglion cervical block MEDICAL_TRANSCRIPTION,Description Pain management sample progress note Medical Specialty Pain Management Sample Name Pain Management Progress Note Transcription DIAGNOSES 1 Cervical dystonia 2 Post cervical laminectomy pain syndrome Ms XYZ states that the pain has now shifted to the left side She has noticed a marked improvement on the right side which was subject to a botulinum toxin injection about two weeks ago She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased but she is still on the oxycodone and methadone The patient s husband confirms the fact that she is doing a lot better that she is more active but there are still issues yet regarding anxiety depression and frustration regarding the pain in her neck PHYSICAL EXAMINATION The patient is appropriate She is well dressed and oriented x3 She still smells of some cigarette smoke Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals trapezius and splenius capitis muscles There are no trigger points felt and her range of motion of the neck is still somewhat guarded but much improved On the left side however there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding This extends down into the trapezius muscle but the splenius capitis seems to be not involved TREATMENT PLAN After a long discussion with the patient and the husband we have decided to go ahead and do botulinum toxin injection into the left multifidus trapezius muscles A total of 400 units of Botox is anticipated The procedure is being scheduled The patient s medications are refilled She will continue to see Dr Berry and continue her therapy with Mary Hotchkinson in Victoria Keywords pain management progress note management muscle MEDICAL_TRANSCRIPTION,Description Injection of Morton s neuroma Medical Specialty Pain Management Sample Name Mortons Neuroma Injection Transcription POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management injection depo medrol morton s neuroma gauge needle inflammation metatarsal ligament metatarsal space neuroma redness swelling morton sNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cervical spondylosis Radiofrequency thermocoagulation RFTC medial branch posterior sensory rami Medical Specialty Pain Management Sample Name Radiofrequency Thermocoagulation 3 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis POSTOPERATIVE DIAGNOSIS Cervical spondylosis OPERATION PERFORMED Radiofrequency thermocoagulation RFTC medial branch posterior sensory rami of cervical at SURGEON Ralph Menard M D ANESTHESIA Local and IV COMPLICATIONS None DESCRIPTION OF PROCEDURE After proper consent was obtained the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place The neck was placed in a flexed position The patient was monitored with blood pressure cuff EKG and pulse oximetry and given oxygen via nasal cannula The patient was lightly sedated The skin was prepped and draped in a sterile classical fashion Under fluoroscopy control the waists of the articular pillars were identified and marked Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points Once the anesthesia was established an insulated 10 cm 22 gauge needle with a 5 mm non insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle For C3 to C6 medial branch RFTC s the needles are placed along the ventral aspect of a line that connects the greatest antero posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging For a C7 medial branch RFTC the needle tip is positioned more superiorly such that it overlies the superior articular process For a C8 medial branch RFTC the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1 Sensory stimulation was carried out at 50 Hz from 0 to 2 0 volts Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve or it caused replication of their concordant pain The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2 0 volts or until motor stimulation was found at that level If motor stimulation occurred the needle was repositioned to abolish it but still cause concordant pain or the RFTC was aborted at this level If the sensory stimulation caused concordant pain without motor stimulation the area was then anesthetized with 1 cc of Marcaine 0 5 with 5 mg of methyl prednisolone acetate Once the anesthesia was established a radiofrequency lesioning was then done at 65 degrees for 60 seconds The same procedure was carried out at all the affected levels The patient tolerated the procedure well without any difficulties or complications Keywords pain management rami fluoroscopic control radiofrequency thermocoagulation cervical spondylosis articular pillars motor stimulation medial branch thermocoagulation rftc needle cervical stimulation MEDICAL_TRANSCRIPTION,Description Right sacral alar notch and sacroiliac joint posterior rami injections with without fluoroscopy Medical Specialty Pain Management Sample Name Sacral Alar Notch Injection Transcription PROCEDURE Right sacral alar notch and sacroiliac joint posterior rami injections with fluoroscopy ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the operating room with intravenous line in place and intravenous sedation was given The patient was in the prone position The back was prepped with Betadine Under fluoroscopy the right sacral alar notch was identified and after placement of a 22 gauge 3 1 2 inch spinal needle in to the notch negative aspiration was performed and 5 cc of 0 5 Marcaine plus 20 mg of Depo Medrol was injected The needle was then placed in to the right sacroiliac joint distal third and the same local anesthetic mixture was injected This was repeated for the right sacral alar notch and the right sacroiliac joint distal third The needle was withdrawn The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen then followed by steroid injection and coagulation as above There were no complications Needles removed Band aids were applied over the puncture sites The patient was discharged to operating room recovery in stable condition Keywords pain management fluoroscopy sacroiliac joint sacral alar notch posterior rami sacroiliac alar sacral notch MEDICAL_TRANSCRIPTION,Description Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection Medical Specialty Pain Management Sample Name Neuroplasty Transcription PREOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room status post transforaminal epidurogram see operative note for further details Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen 375 units of Wydase was injected through each needle After two minutes 3 5 cc of 0 5 Marcaine and 80 mg of Depo Medrol was injected through each needle These needles were removed and the patient was discharged in stable condition Keywords pain management nerve root decompression discectomy epidural fibrosis nerve root entrapment transforaminal neuroplasty neural foramen nerve root foramen neuroplasty transforaminal needle epidural MEDICAL_TRANSCRIPTION,Description Complex Regional Pain Syndrome Type I Stellate ganglion RFTC radiofrequency thermocoagulation left side and interpretation of Radiograph Medical Specialty Pain Management Sample Name Radiofrequency Thermocoagulation 2 Transcription PREOPERATIVE DIAGNOSIS Complex Regional Pain Syndrome Type I POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Stellate ganglion RFTC radiofrequency thermocoagulation left side 2 Interpretation of Radiograph ANESTHESIA IV Sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS Patient with reflex sympathetic dystrophy left side Positive for allodynia pain mottled appearance skin changes upper extremities as well as swelling SUMMARY OF PROCEDURE Patient is admitted to the Operating Room Monitors placed including EKG Pulse oximeter and BP cuff Patient had a pillow placed under the shoulder blades The head and neck was allowed to fall back into hyperextension The neck region was prepped and draped in sterile fashion with Betadine and alcohol Four sterile towels were placed The cricothyroid membrane was palpated then going one finger s breadth lateral from the cricothyroid membrane and one finger s breadth inferior the carotid pulse was palpated and the sheath was retracted laterally A 22 gauge SMK 5 mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially The needle is advanced prudently through the tissues avoiding the carotid artery laterally The tip of the needle is perceived to intersect with the vertebral body of Cervical 7 and this was visualized by fluoroscopy Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand No venous or arterial blood return is noted No cerebral spinal fluid is noted Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0 0 1 volts and negative motor stimulation was elicited from 1 10 volts at 2 Hz After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed 5 cc of solution solution consisting of 5 cc of 0 5 Marcaine 1 cc of triamcinolone was then injected into the stellate ganglion region This was done with intermittent aspiration vigilantly verifying negative aspiration The stylet was then promptly replaced and neurolysis nerve decompression was then carried out for 60 seconds at 80 degrees centigrade This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band Aid was placed over the puncture site Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion Interpretation of radiograph reveals placement of the 22 gauge SMK 5 mm bare tipped needle in the region of the stellate ganglion on the affected side Four lesions were carried out Keywords pain management sheath vertebral body regional pain syndrome radiofrequency thermocoagulation stellate ganglion rftc radiofrequency radiograph cricothyroid thermocoagulation ganglion MEDICAL_TRANSCRIPTION,Description Plantar Fascia Injection Medical Specialty Pain Management Sample Name Plantar Fascia Injection Transcription PROCEDURE Informed consent was obtained from the patient Special mention was made of the possibility of infection and necrosis of the heel pad The patient was placed in the supine position The tender area in the medial aspect of the heel was identified by palpation After proper preparation with antiseptic solution of the skin a syringe containing 2 mL of 1 lidocaine was attached to 1 5 27 gauge needle The needle was carefully advanced through the carefully identified point at a right angle to the skin directly towards the central and medial aspect of the calcaneus The needle was advanced very slowly until the needle impinged on the bone and then was withdrawn slowly The contents of the syringe were then gently injected Subsequently the needle was left in place and a syringe containing 2 mL of 0 25 Marcaine and 1 mL of Depo Medrol was attached to the needle and injected after aspiration at this site Subsequently the needle was removed Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place a small bandage was applied POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management plantar fascia injection plantar fascia calcaneus heel pad necrosis depo medrol bandage medial aspect heel syringe injection needleNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Lumbar epidural steroid injection L5 S1 Low back pain Medical Specialty Pain Management Sample Name Lumbar Epidural Steroid Injection 2 Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE Lumbar epidural steroid injection L5 S1 ANESTHESIA Local SPECIAL EQUIPMENT Fluoroscopic unit DETAILS OF PROCEDURE The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed prepped and draped in a sterile fashion with Betadine solution The lumbar area was then draped with sterile towels and sterile drapes The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection The fluoroscopy x ray unit was then brought into the sterile field for a PA x ray visualization of the spine A Steinmann pin was then placed across the spine to localize the level of the planned injection Local infiltration using 0 5 preservative free Xylocaine via a 25 gauge needle was then placed into the dermis and subcutaneous tissue A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues Continuous injection of 0 5 preservative free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues A solution of 80 mg of Depo Medrol with 2 cc of 1 Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space Keywords pain management back pain lumbar epidural steroid injection tuohy needle steroid injection subcutaneous epidural steroid lumbar sterile injection MEDICAL_TRANSCRIPTION,Description Lumbar epidural steroid injection for lumbar radiculopathy Medical Specialty Pain Management Sample Name Lumbar Epidural Steroid Injection 3 Transcription PREOPERATIVE DIAGNOSIS Lumbar radiculopathy 724 4 POSTOPERATIVE DIAGNOSIS Lumbar radiculopathy 724 4 PROCEDURE Lumbar epidural steroid injection ANESTHESIOLOGIST Monitored anesthesia care INJECTATE USED 10 mL of 0 5 lidocaine and 80 mg of Depo Medrol ESTIMATED BLOOD LOSS None COMPLICATIONS None DETAILS OF THE PROCEDURE The patient arrived at the preoperative holding area where informed consent stable vital signs and intravenous access were obtained A thorough discussion of the potential risks benefits and complications was made prior to the procedure including potential for post dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and or nerve root injury infection bleeding and even death There were no known EKG chest X ray or laboratory contraindications to the procedure The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort The L4 L5 interspace was identified fluoroscopically A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0 5 Lidocaine initially through a 25 gauge 5 8 inch needle later a 22 gauge 1 1 2 inch needle A number 18 gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5 Needle tip position was confirmed in the anterior posterior fluoroscopic view The epidural space was located with the loss of pulsation technique Aspiration of the syringe was negative for blood or cerebrospinal fluid One millimeter of 0 9 preservative was injected with good loss resistance noted DISCHARGE SUMMARY Following the completion of this procedure the patient underwent monitoring in the recovery room and was discharged to be followed as an outpatient Keywords pain management MEDICAL_TRANSCRIPTION,Description Medial branch rhizotomy lumbosacral Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Pain Management Sample Name Medial Branch Rhizotomy Transcription PROCEDURE Medial branch rhizotomy lumbosacral INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed SEDATION The patient was given conscious sedation and monitored throughout the procedure Oxygenation was given The patient s oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs PROCEDURE The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a Teflon coated needle was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of Specifically each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra or for sacral vertebrae at the lateral superior border of the posterior sacral foramen Needle localization was confirmed with AP and lateral radiographs The following technique was used to confirm placement at the Medial Branch nerves Sensory stimulation was applied to each level at 50 Hz paresthesias were noted at volts Motor stimulation was applied at 2 Hz with 1 millisecond duration corresponding paraspinal muscle twitching without extremity movement was noted at volts Following this the needle Trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 1cc 1 lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure COMPLICATIONS None No complications The patient tolerated the procedure well and was sent to the recovery room in good condition DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made in approximately 1 week Keywords pain management lumbosacral medial branch rhizotomy medial branch nerves rhizotomy fluoroscopy MEDICAL_TRANSCRIPTION,Description Lumbar discogram L2 3 L3 4 L4 5 and L5 S1 Low back pain Medical Specialty Pain Management Sample Name Lumbar Discogram Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE PERFORMED 1 Lumbar discogram L2 3 2 Lumbar discogram L3 4 3 Lumbar discogram L4 5 4 Lumbar discogram L5 S1 ANESTHESIA IV sedation PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed prone onto a radiolucent table The C arm was brought into the operative field and AP left right oblique and lateral fluoroscopic images of the L1 2 through L5 S1 levels were obtained We then proceeded to prepare the low back with a Betadine solution and draped sterile Using an oblique approach to the spine the L5 S1 level was addressed using an oblique projection angled C arm in order to allow for perpendicular penetration of the disc space A metallic marker was then placed laterally and a needle entrance point was determined A skin wheal was raised with 1 Xylocaine and an 18 gauge needle was advanced up to the level of the disc space using AP oblique and lateral fluoroscopic projections A second needle 22 gauge 6 inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections was placed into the center of the nucleus We then proceeded to perform a similar placement of needles at the L4 5 L3 4 and L2 3 levels A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting we then proceeded to inject the disc spaces sequentially Keywords pain management back pain c arm fluoroscopic projections disc space lumbar discogram fluoroscopic needle MEDICAL_TRANSCRIPTION,Description Lumbar epidural steroid injection without fluoroscopy A 18 gauge Tuohy needle was placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted Medical Specialty Pain Management Sample Name Lumbar Epidural Steroid Injection Transcription PROCEDURE Lumbar epidural steroid injection without fluoroscopy ANESTHESIA Local sedation VITAL SIGNS See nurse s records COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the sitting position and the back was prepped with Betadine Lidocaine 1 5 was used for skin wheal made between __________ A 18 gauge Tuohy needle was placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted After negative aspiration a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo Medrol was injected Neosporin and a band aid were applied over the puncture site The patient was then placed in supine position The patient was discharged to the recovery room in stable condition Keywords pain management neosporin band aid epidural space lumbar epidural steroid injection loss of resistance tuohy needle fluoroscopy cerebrospinal lumbar epidural injection MEDICAL_TRANSCRIPTION,Description Bilateral lumbar sympathetic block The patient was in the prone position and the back prepped with Betadine The patient was given sedation and monitored Medical Specialty Pain Management Sample Name Lumbar Sympathetic Block Transcription PROCEDURE Bilateral lumbar sympathetic block ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the prone position and the back prepped with Betadine The patient was given sedation and monitored Xylocaine 1 5 for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made A 20 gauge 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection it was noted to be along the anterior vertebral body at the junction of the upper two thirds lower one third of the body After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body After negative aspiration 18 cc of 0 25 Marcaine was injected Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third lower two third of L3 At this point after confirmation of the linear spread of dye along the anterior portion of the body negative aspiration was performed and 18 cc of 0 25 Marcaine was injected Neosporin and band aids were applied over the sites The patient was taken to the outpatient recovery room in stable condition Keywords pain management transverse process fluoroscopic guidance lateral projection lumbar sympathetic block vertebral body sympathetic betadine needle aspiration lumbar MEDICAL_TRANSCRIPTION,Description Osteoarthritis of the right knee Right knee joint steroid injection Medical Specialty Pain Management Sample Name Knee Injection 1 Transcription PROCEDURE Right knee joint steroid injection PREOPERATIVE DIAGNOSIS Osteoarthritis of the right knee POSTOPERATIVE DIAGNOSIS Osteoarthritis of the right knee PROCEDURE The patient was apprised of the risks and the benefits of the procedure and consented The patient s right knee was sterilely prepped with Betadine A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1 lidocaine The patient was injected with a 1 5 inch 25 gauze needle at the medial aspect of his right flexed knee There were no complications The patient tolerated the procedure well There was minimal bleeding The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days The patient was instructed to go to the emergency room with any usual pain swelling or redness occurred in the injected area The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain Keywords pain management injection knee joint steroid injection osteoarthritis knee MEDICAL_TRANSCRIPTION,Description Lumbar facet injections done under fluoroscopic control Lumbar spondylosis Medical Specialty Pain Management Sample Name Lumbar Facet Injections Transcription PREOPERATIVE DIAGNOSIS Lumbar spondylosis POSTOPERATIVE DIAGNOSIS Lumbar spondylosis OPERATION PERFORMED Lumbar facet injections done under fluoroscopic control ANESTHESIA Local and IV COMPLICATIONS None DESCRIPTION OF PROCEDURE After proper consent was obtained the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place The skin was prepped and draped in a sterile classical fashion The patient was monitored with blood pressure cuff electrocardiogram and pulse oximeter The patient was given oxygen intravenous sedation and analgesics as needed The facets were identified and marked under fluoroscopic control by rotating the C arm obliquely laterally and caudocranial as needed for optimal visualization of the facet joint s Scottie dog and the opening of the facet After each facet joint was identified and marked local anesthesia was infiltrated subcutaneously and deep over each of the identified facets A 22 gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique After negative aspiration 0 25 0 5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule After another negative aspiration 1cc of a 10cc solution of Marcaine 0 5 and 100 milligrams of methyl prednisolone acetate was injected into each facet The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted Keywords pain management fluoroscopic control c arm lumbar facet injections lumbar spondylosis fluoroscopy spondylosis fluoroscopic lumbar injections facet MEDICAL_TRANSCRIPTION,Description Lumbar epidural steroid injection intralaminar approach seated position An 18 gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline filled syringe Medical Specialty Pain Management Sample Name Lumbar Epidural Steroid Injection 1 Transcription OPERATION Lumbar epidural steroid injection intralaminar approach seated position ANESTHESIA Keywords pain management loss of resistance technique methylprednisolone acetate lumbar epidural steroid injection epidural steroid injection tuohy needle steroid injection epidural space intralaminar approach injection intralaminar saline epidural MEDICAL_TRANSCRIPTION,Description She is a 14 year old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee although she has complaints of arthralgias in multiple joints Under general anesthesia 20 mg of Aristospan were injected on the left knee Medical Specialty Pain Management Sample Name Knee Injection 2 Transcription INDICATIONS FOR PROCEDURE The patient was here for joint injection She is a 14 year old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee although she has complaints of arthralgias in multiple joints What bother her the most is the joint swelling of her left knee that has been for several months She has been taking Naprosyn on her last visit She was feeling better but still has significant symptoms especially when she was active After evaluation in the clinic she decided to have a joint injection as it was discussed before I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic but she decided that she did not want to do it in the clinic and she wanted to be sedated for this DESCRIPTION OF PROCEDURE So under aseptic technique and under general anesthesia 20 mg of Aristospan were injected on the left knee No fluid was obtained Her swelling was about 1 No complications No bleeding was observed and the patient tolerated the procedure without any complications or side effects After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re evaluation in a few weeks after the procedure If the patient has any problems overnight she is going to call us If she had any fevers or strange swelling she is to call us for advice We will see her in the clinic as scheduled Keywords pain management arthralgias aristospan pauciarticular arthritis joint injection injection swelling arthritis joints kneeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Intercostal block from fourth to tenth intercostal spaces left Chest pain secondary to fractured ribs unmanageable with narcotics Medical Specialty Pain Management Sample Name Intercostal block 1 Transcription PREPROCEDURE DIAGNOSIS Chest pain secondary to fractured ribs unmanageable with narcotics POSTPROCEDURE DIAGNOSIS Chest pain secondary to fractured ribs unmanageable with narcotics PROCEDURE Intercostal block from fourth to tenth intercostal spaces left INDICATIONS I was requested by Dr X to do an intercostal block on this lady who fell and has fractured ribs whose chest pain is paralyzing and not responding well to increasing doses of narcotics PROCEDURE DETAIL After obtaining an informed consent with the patient on her bedside she was placed in the right decubitus position with the left side up The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1 Xylocaine 20 mL and Marcaine 0 25 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized A total of 30 mL worth of solution was used I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area The patient tolerated the procedure well She had no respiratory distress Immediately the patient felt some relief from the pain Chest x ray was ordered for the following day Keywords pain management xylocaine marcaine intercostal spaces intercostal block fractured ribs intercostal fractured narcotics chest MEDICAL_TRANSCRIPTION,Description Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance The patient is a 78 year old female with back pain referring into the left side Medical Specialty Pain Management Sample Name Kenalog Injection Transcription PROCEDURE Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance INDICATIONS The patient is a 78 year old female with back pain referring into the left side She has had a couple of epidurals in the past both of which led to only short term improvement with intralaminar and caudal placements Therefore transforaminal approach was selected for today s procedure Risks and benefits were discussed with the patient She agreed to accept the risks and signed informed consent to proceed PROCEDURE DETAILS The patient was placed prone on the table The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1 lidocaine A 5 inch 22 gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root Once bony contact was made a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space Then an AP view was obtained which showed the needle tip to be below the 6 o clock position of the pedicle EPIDUROGRAM Omnipaque 300 1 mL was placed through the foraminal opening of the L5 nerve root on the left This did show dye spread pattern which was narrowed consistent with foraminal stenosis The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space It was also spreading peripherally along the L5 nerve root The patient tolerated the procedure well She did feel that the needle tip was placed at the epicenter of her pain and this was improved with the placement of the anesthetic I will see the patient back in the office in the next few weeks to monitor response of the injection Keywords pain management transforaminal approach epidural steroid injection nerve root needle tip kenalog transforaminal fluoroscopic guidance foraminal injection MEDICAL_TRANSCRIPTION,Description Knee injection Medical Specialty Pain Management Sample Name Knee Injection Transcription The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15 20 minutes every 6 hours The patient was advised to protect the knee by limiting repetitive bending squatting kneeling and excessive heavy use for a week Also they were asked to follow up in two weeks p r n Keywords pain management knee injection hibistat xylocaine bending epinephrine knee joint kneeling needle patella squatting superolateral approach cleansed kneeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Hip injection Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach The femoral artery was located by palpation of the pulse The skin subcutaneous tissue and muscle within the planned needle approach were anesthetized with 1 Lidocaine Medical Specialty Pain Management Sample Name Hip Injection Transcription PROCEDURE Hip injection INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The X ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach The femoral artery was located by palpation of the pulse The skin subcutaneous tissue and muscle within the planned needle approach were anesthetized with 1 Lidocaine All injected medications were preservative free With fluoroscopy a spinal needle was gently guided into the Multiple fluoroscopic views were used to ensure proper needle placement Approximately nonionic contrast agent was injected under direct real time fluoroscopic observation Correct needle placement was confirmed by production of an appropriate arthrogram without concurrent vascular dye pattern Finally the treatment solution consisting of All injected medications were preservative free Sterile technique was used throughout the procedure COMPLICATIONS None No complications The patient tolerated the procedure well and was sent to the recovery room in good condition DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made in approximately 1 week Keywords pain management boney landmarks fluoroscopy femoral artery planned needle approach hip injection injection hip needle MEDICAL_TRANSCRIPTION,Description Standard hypogastric plexus block procedure note Medical Specialty Pain Management Sample Name Hypogastric Plexus Block Transcription NAME OF PROCEDURE Hypogastric plexus block ANESTHESIA Local PROCEDURE The patient was in the operating room in the prone position with the back prepped and draped in sterile fashion Local anesthesia was used to make a skin wheal 8 10 cm lateral to the L4 spinous process bilaterally from the midline Starting from the left side a 20 gauge 6 inch needle was placed to the left L5 S1 facet level under AP fluoroscopic view On lateral view the tip of the needle was at the inferior one third of the LS vertebral body anterior aspect Next 5 cc of Omnipaque dye was injection showing a linear spread along the anterior portion of L5 down the sacral promontory After negative aspiration 18 cc of 0 25 Marcaine plus 40 mg of Depo Medrol was injection There were no complications The above sequence was repeated for the right side There were no complications The patient was discharged back to outpatient recovery in stable condition Keywords pain management vertebral body fluoroscopic view omnipaque hypogastric plexus blockNOTE MEDICAL_TRANSCRIPTION,Description Caudal epidural steroid injection without fluoroscopy Medical Specialty Pain Management Sample Name Epidural Steroid Injection 2 Transcription PROCEDURE Caudal epidural steroid injection without fluoroscopy ANESTHESIA Local sedation VITAL SIGNS See nurse s records PROCEDURE DETAILS INT was placed The patient was in the prone position The back was prepped with Betadine Lidocaine 1 5 was used to make a skin wheal over the sacral hiatus A 18 gauge Tuohy needle was then placed into the epidural space There were no complications from this no blood or CSF After negative aspiration was performed a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo Medrol was injected Neosporin and band aid were applied over the puncture site The patient was then placed in supine position The patient was discharged to outpatient recovery in stable condition Keywords pain management epidural space epidural steroid injection caudal epidural caudal fluoroscopy steroid epidural injection MEDICAL_TRANSCRIPTION,Description Intercostal block left Severe post thoracotomy pain Medical Specialty Pain Management Sample Name Intercostal Block Transcription PREOPERATIVE DIAGNOSIS Severe post thoracotomy pain POSTOPERATIVE DIAGNOSIS Severe post thoracotomy pain PROCEDURE Intercostal block left PROCEDURE DETAIL With the patient in the ICU bed who was having a large amount of intravenous narcotic to control his thoracotomy pain after obtaining informed consent his left posterior chest was prepped and draped in the usual fashion and Marcaine 0 025 was injected in the spaces four to eight sequentially A total of 40 mL of Marcaine was used The patient tolerated the procedure well and experienced immediate benefit out of the procedure Keywords pain management thoracotomy pain intercostal block marcaine thoracotomy intercostal MEDICAL_TRANSCRIPTION,Description Bilateral facet Arthrogram and injections at L34 L45 L5S1 Interpretation of radiograph Low Back Syndrome Low Back Pain Medical Specialty Pain Management Sample Name Facet Arthrogram Injection Transcription PREOPERATIVE DIAGNOSIS Low Back Syndrome Low Back Pain POSTOPERATIVE DIAGNOSIS Same PROCEDURE 1 Bilateral facet Arthrogram at L34 L45 L5S1 2 Bilateral facet injections at L34 L45 L5S1 3 Interpretation of radiograph ANESTHESIA IV sedation with Versed and Fentanyl ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATION Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x ray studies and imaging scans SUMMARY OF PROCEDURE The patient was admitted to the OR consent was obtained and signed The patient was taken to the Operating room and was placed in the prone position Monitors were placed including EKG pulse oximeter and blood pressure monitoring Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain EKG respiration and heart rate and at intervals of three minutes for blood pressure After adequate IV sedation with Versed and Fentanyl the procedure was begun The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view A skin wheal was placed with 1 Lidocaine at the L34 facet region on the left Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side This was performed using the oblique view under fluoroscopy to the enable the view of the Scotty Dog After obtaining the Scotty Dog view the joints were easily seen Negative aspiration was carefully performed to verity that there was no venous arterial or cerebral spinal fluid flow After negative aspiration was verified 1 8th of a cc of Omnipaque 240 dye was then injected Negative aspiration was again performed and 1 2 cc of solution Solution consisting of 9 cc of 0 5 Marcaine with 1 cc of Triamcinolone was then injected into the joint The needle was then withdrawn out of the joint and 1 5 cc of this same solution was injected around the joint The 22 gauge needle was then removed Pressure was place over the puncture site for approximately one minute This exact same procedure was then repeated along the left sided facets at L45 and L5S1 This exact same procedure was then repeated on the right side At each level vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid The patient was noted to have tolerated the procedure well without any complications Interpretation of the radiograph revealed placement of the 22 gauge spinal needles into the left sided and right sided facet joints at L34 L45 and L5S1 Visualizing the Scotty Dog technique under fluoroscopy facilitated this Dye spread into each joint space is visualized No venous or arterial run off is noted No epidural run off is noted The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis Keywords pain management low back syndrome low back pain facet injection fluoroscopy iv sedation spinal fluid facet arthrogram aspiration arthrogram injection facet MEDICAL_TRANSCRIPTION,Description Epidural steroid injection A total of 5 mL containing 4 mL of 0 25 bupivacaine and 80 mg of methylprednisolone acetate were infiltrated Medical Specialty Pain Management Sample Name Epidural Steroid Injection 3 Transcription PROCEDURE NOTE The patient was placed in a prone position The neck was sterilely prepped using a cervical prep set A lidocaine skin wheal was raised over the C5 6 interspace A 20 gauge Tuohy needle was used Loss of resistance was obtained using hanging drop technique This was followed by 2 mL of radiograph contrast material which showed spread of the dye into the epidural space A total of 5 mL containing 4 mL of 0 25 bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated Following the infiltration the patient noted warming of his arms and dramatic improvement of his symptoms He was observed for 30 minutes and discharged home in good condition There were no apparent complications to the procedure Keywords pain management methylprednisolone acetate steroid bupivacaine methylprednisolone acetate epidural injectionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description L3 L5 epidural steroid injection with epidural catheter under fluoroscopy Medical Specialty Pain Management Sample Name Epidural Steroid Injection 1 Transcription PREOPERATIVE DIAGNOSIS Herniated lumbar disk with intractable back pain POSTOPERATIVE DIAGNOSIS Herniated lumbar disk with intractable back pain OPERATION PERFORMED L3 L5 epidural steroid injection with epidural catheter under fluoroscopy ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion The patient was given sedation and monitored Local anesthetic was used to insufflate the skin over sacral hiatus A 16 gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood A Racz tunnel catheter was then placed to the needle and guided up to the L3 L4 level After negative aspiration 4 cc of 0 5 Marcaine and 80 mg of Depo Medrol were injected The catheter was then repositioned at the L4 L5 level where after negative aspiration same local anesthetic steroid mixture was injected Needle and catheter were removed intact The patient was discharged in stable condition Keywords pain management epidural catheter epidural steroid injection lumbar disk steroid injection fluoroscopy herniated lumbar needle steroid epidural catheter injection MEDICAL_TRANSCRIPTION,Description Right L4 attempted L5 and S1 transforaminal epidurogram for neural mapping Medical Specialty Pain Management Sample Name Epidurogram Transcription PREOPERATIVE DIAGNOSES 1 Right lower extremity radiculopathy with history of post laminectomy pain 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Right lower extremity radiculopathy with history of post laminectomy pain 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Right L4 attempted L5 and S1 transforaminal epidurogram for neural mapping ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion The patient was given sedation and monitored Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root The left side was quite open however that was not the side of her problem At this point using a oblique fluoroscopic projection and gun barrel technique a 22 gauge 3 5 inch spinal needle was placed at the superior articular process of L5 on the right stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location After negative aspiration 2 cc of Omnipaque 240 dye was injected through each needle There was a defect flowing in the medial epidural space at both sides There were no complications Keywords pain management laminectomy radiculopathy nerve root entrapment epidural fibrosis nerve root epidurogram neural epidural foramen nerve needle MEDICAL_TRANSCRIPTION,Description Transforaminal epidural steroid block with fluoroscopy Medical Specialty Pain Management Sample Name Epidural Steroid Block Transcription DIAGNOSIS Left sciatica ANESTHESIA Intravenous sedation NAME OF OPERATION 1 Left L5 S1 transforaminal epidural steroid block with fluoroscopy 2 Left L4 5 transforaminal epidural steroid block with fluoroscopy 3 Monitored intravenous Versed sedation PROCEDURE The patient was taken to the block room He was placed prone on the fluoroscopy table He was monitored appropriately He was administered Versed 2 mg IV His O2 saturation remained greater than 90 His back was prepped and draped The C arm was brought in The endplates at L5 S1 were squared off The C arm was rotated to the left The L5 pedicle the superior articular process of the L5 S1 facet and the neck of the scotty dog were all visualized After adequate local anesthesia a 22 gauge 3 1 2 inch spinal needle was inserted using down the barrel of the needle technique The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o clock position on the pedicle No paresthesias were noted One half cc of contrast was injected and spread medially around the pedicle and into the epidural space and the L5 nerve root was visualized Depo Medrol 80 mg plus 1 cc of 4 preservative free lidocaine was injected The needle was flushed and removed I then went up to the L4 5 level and using a similar technique injected the patient transforaminally at the L4 5 level Depo Medrol 80 mg plus 1 cc of 4 preservative free lidocaine was injected at the L4 5 level just as at the L5 S1 level The patient had pain down his left leg during the injection primarily at the L5 S1 level similar to what he normally experiences He was awake and alert and taken to the recovery room in good condition His left leg pain was relieved Keywords pain management c arm epidural steroid block with fluoroscopy sciatica transforaminal steroid block with fluoroscopy epidural steroid block depo medrol transforaminal epidural steroid block fluoroscopy epidural intravenous steroid MEDICAL_TRANSCRIPTION,Description Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block for sacroiliac joint pain Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Pain Management Sample Name Dorsal Ramus Branch Block Transcription PROCEDURE Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The X ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table pillow under the chest and head rotated contralateral to the side being treated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 25 gauge 3 5 inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1 S2 and S3 Multiple fluoroscopic views were used to ensure proper needle placement Approximately 0 25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern Finally the treatment solution consisting of 0 5 of bupivacaine was injected to each area All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS This was then repeated on the left side COMPLICATIONS None DISCUSSION Postprocedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to resume normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at the PM R Spine Clinic in approximately 1 week Keywords pain management sacroiliac lateral branch block ramus block branch block sacroiliac joint dorsal ramus fluoroscopic branch dorsal ramus bilateral needle block MEDICAL_TRANSCRIPTION,Description Epidural Blood Patch An 18 gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe Medical Specialty Pain Management Sample Name Epidural Blood Patch Transcription OPERATION Keywords pain management epidural space loss of resistance technique epidural blood patch tuohy needle tourniquet epidural MEDICAL_TRANSCRIPTION,Description Epidural steroid injection epidurogram fluroscopy Low back pain herniated disc lumbosacral Facet arthropathy Medical Specialty Pain Management Sample Name Epidural Steroid Injection Transcription PRE OP DIAGNOSES Low back pain 724 2 Herniated disc 722 10 Lumbosacral Facet arthropathy 724 4 POST OP DIAGNOSES Low back pain 724 2 Herniated disc 722 10 Lumbosacral Facet arthropathy 724 4 INTERVAL HISTORY Plans risks and options were reviewed with the patient in detail The patient understands and agrees to proceed ANESTHESIA General Anesthesia PROCEDURE PERFORMED Epidural steroid injection epidurogram fluroscopy PROCEDURE After informed consent the patient was taken to the procedure room and placed in the prone position EKG blood pressure and pulse oximetry were monitored and remained stable throughout the procedure The area was prepped and draped in the usual sterile fashion Local anesthetic was infiltrated at the appropriate level Fluoroscopic guidance was used to place a 20 gauge Tuohy epidural needle gently into the epidural space at L4 L5 using a paramedian approach No blood or CSF was obtained on aspiration RADIOLOGY Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging The Needle was injected with Depo Medrol 80 mg with Bupivacaine 1 16th 8 cc total vol Patient tolerated procedure well and was transferred to recovery room Patient was discharged home with escort Discharge instructions were given POST OP PLAN I will see the patient back in my office in two weeks Continue p r n medications as needed Keywords pain management back pain herniated disc lumbosacral facet epidural needle lumbosacral facet arthropathy epidural steroid injection facet arthropathy epidural space injection epidurogram fluroscopy herniated lumbosacral steroid arthropathy epidural MEDICAL_TRANSCRIPTION,Description Cervical Selective Nerve Root Block Medical Specialty Pain Management Sample Name Cervical Selective Nerve Root Block Transcription CERVICAL SELECTIVE NERVE ROOT BLOCK PREPROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form The patient was placed in the prone position and standard ASA monitors applied Intravenous access was established and IV sedation was used For further details of IV sedation and infusion please refer to anesthesia notes The patient was able to respond appropriately throughout the procedure Fluoroscopy was used to identify the appropriate anatomy The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure PROCEDURE DETAILS The patient was laid supine Oblique placement was achieved by placing pillow below the shoulder and turning the head The C neural foramina was identified by counting down from the C2 3 foramen The external carotid artery was marked off by palpation The neck was aseptically prepared 1 lidocaine was used for local infiltration and subsequently a 25 gauge spinal needle was passed down to the C neural foramen under fluoroscopic control The posterior inferior edge of the foramen bone was contacted The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters Care was taken to remain in the posterior inferior edge of the foramen Positioning was checked by AP view in which the needle tip extended no further medially than the midpoint of the adjacent pedicle 1 mL of contrast was used to confirm position under fluoroscopy after aspiration Acceptable dye pattern was seen Subsequent 1 mL of 1 lidocaine was injected after aspiration and the patient was monitored No adverse affects with 1 lidocaine were noted and subsequently 1 mL of Celestone was injected Compression bandage was applied to the neck and no complications were noted POSTPROCEDURE EVALUATION After a 30 minute recovery period during which no complications were noted the patient was discharged home Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95 with no respiratory distress observed Keywords pain management nerve root block 1 lidocaine asa monitors cervical selective nerve root block fluoroscopy iv sedation nerve root oblique selective nerve root carotid artery foramen neural foramina edge of the foramen selective nerve root block cervical MEDICAL_TRANSCRIPTION,Description Coccygeal injection Medical Specialty Pain Management Sample Name Coccygeal injection Transcription COCCYGEAL INJECTION PROCEDURE Informed consent was obtained from the patient A gloved little finger was inserted into the anal region and the sacral coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain After aseptic cleaning a 25 gauge needle was inserted through the skin into the sacral coccygeal joint It was confirmed that the needle was not entering the rectal cavity by finger placed in the rectum After aspiration 1 mL of cortisone and 2 mL of 0 25 Marcaine were injected at the site Postprocedure the needle was withdrawn A small pressure dressing was placed and no hematoma was observed to form POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management coccygeal injection 0 25 marcaine 1 ml of cortisone coccygeal joint coccyx fevers inflammation redness sacral swelling coccygeal injectionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cervical spondylosis Cervical medial branch blocks under fluoroscopic control Medical Specialty Pain Management Sample Name Cervical Medial Branch Blocks Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis POSTOPERATIVE DIAGNOSIS Cervical spondylosis OPERATION PERFORMED Cervical Medial Branch Blocks under fluoroscopic control ANESTHESIA Local and IV COMPLICATIONS None DESCRIPTION OF PROCEDURE After proper consent was obtained the patient was taken to the fluoroscopy suite and place on a fluoroscopy table in a prone position with a chest roll in place The neck was placed in a flexed position The patient was monitored with blood pressure cuff EKG and pulse oximetry and given oxygen via nasal cannula The patient was lightly sedated The skin was prepped and draped in a sterile classical fashion Under fluoroscopy control the waists of the articular pillars were identified and marked Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points Once the anesthesia was established a 10 cm 22 gauge needle was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned This was done under direct fluoroscopic control with PA views initially for orientation utilizing a gun barrel technique and then a lateral view to determine the depth of the needle The needle tip was positioned such that the tip was at the posterior aspect of the articular pillar s waist and was then incrementally advanced until the tip was at the center of the pedicle where the medial branch lies For C3 to C6 the medial branch is along the ventral aspect of a line that connects the greatest antero posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging For a C7 medial branch block the needle tip is positioned more superiorly such that it overlies the superior articular process For a C8 medial branch block the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1 Once the needles were in place each level was then injected with 1cc of a 10 cc solution of Marcaine 0 5 mixed with 50mg on methyl prednisolone acetate The patient tolerated the procedure well without any difficulties or complications Keywords pain management fluoroscopic control fluoroscopy cervical medial branch blocks medial branch blocks cervical spondylosis articular pillars cervical anesthesia spondylosis fluoroscopic blocks needle medial branch MEDICAL_TRANSCRIPTION,Description Costochondral Cartilage Injection Medical Specialty Pain Management Sample Name Costochondral Cartilage Injection Transcription COSTOCHONDRAL CARTILAGE INJECTION PROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form The patient was placed in the supine position Intravenous access was established The patient was given mild narcotics for sedation For further details please refer to anesthesia note DESCRIPTION OF PROCEDURE The area of discomfort was palpated under fluoroscopy and the costochondral cartilages that were symptomatic were marked out After careful asepsis local anesthesia was given subcutaneously and a 0 25 gauge hypodermic needle was inserted into the costochondral cartilage junction taking care not to stray from the rib Fluoroscopy in AP and lateral positions confirmed good position of the needle in the costochondral junction and subsequently after aspiration 0 5 mL of Depo Medrol 80 and 0 5 mL of 0 5 Marcaine was injected The same procedure was carried out at the costochondral junction POSTPROCEDURE INSTRUCTIONS 1 After a period of 30 minutes of observation during which there was no distress and good relief of symptoms was noted the patient was discharged home 2 The patient has been given instructions on watching for possible pneumothorax and any respiratory distress The patient will call us if any inflammation swelling or other associated discomfort arises We will call the patient in 48 hours Keywords pain management costochondral cartilage injection 0 5 marcaine ap and lateral costochondral depo medrol costochondral junction fluoroscopy hypodermic needle pneumothorax subcutaneously supine position cartilage injection costochondral cartilage needle distress cartilage injection MEDICAL_TRANSCRIPTION,Description Caudal epidural steroid injection Medical Specialty Pain Management Sample Name Caudal Epidural Steroid Injection Transcription CAUDAL EPIDURAL STEROID INJECTION PROCEDURE 1 Caudal epidural steroid injection with contrast 2 Utilization of fluoroscopy for confirmation of needle placement PREPROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form The patient was placed in the prone position and standard ASA monitors applied Intravenous access was established and IV sedation was used For further details of IV sedation and infusion please refer to anesthesia notes Fluoroscopy was used to identify the appropriate anatomy The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure PROCEDURE DETAILS Keywords pain management steroid injection 1 lidocaine ap and lateral asa monitors caudal epidural steroid injection epidural fluoroscopy ligament needle placement sacral hiatus sacrococcygeal caudal epidural epidural steroid caudal steroid injection MEDICAL_TRANSCRIPTION,Description Cervical epidural steroid injection without fluoroscopy An 18 gauge Tuohy needle was placed into the epidural space using loss of resistance technique Medical Specialty Pain Management Sample Name Cervical Epidural Steroid Injection Transcription PROCEDURE Cervical epidural steroid injection without fluoroscopy ANESTHESIA Local sedation VITAL SIGNS See nurse s notes COMPLICATIONS None DETAILS OF PROCEDURE INT was placed The patient was in the sitting position The posterior neck and upper back were prepped with Betadine Lidocaine 1 5 was used for skin wheal made between C7 T1 ________ An 18 gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted After negative aspiration a mixture of 5 cc preservative free normal saline plus 160 mg Depo Medrol was injected Neosporin and band aid were applied over the site The patient discharged to recovery room in stable condition Keywords pain management epidural space loss of resistance cervical epidural steroid injection fluoroscopy lidocaine steroid epidural cervical injection MEDICAL_TRANSCRIPTION,Description Right L5 S1 intralaminar epidural steroid injection with 120 mg of Depo Medrol under fluoroscopic guidance The patient is a 51 year old female with back pain referring into the right leg Medical Specialty Pain Management Sample Name Depo Medrol Injection Transcription PROCEDURE Right L5 S1 intralaminar epidural steroid injection with 120 mg of Depo Medrol under fluoroscopic guidance INDICATION The patient is a 51 year old female with back pain referring into the right leg RISKS VERSUS BENEFITS The risks and benefits were discussed with the patient prior to the procedure She agrees to accept the risks and signs a written consent to proceed with the procedure DESCRIPTION OF PROCEDURE The patient was placed prone on the table The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze The subcutaneous intramuscular and interligamentous region was anesthetized with 4 lidocaine A 3 1 2 inch 20 gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina Once the lamina was detected the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space EPIDUROGRAM Omnipaque 300 1 5 mL was placed just to the right of the midline This was viewed on the AP and lateral projections It showed typical epidural spread pattern with good cephalad and caudad flow and the flow was unrestricted Depo Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5 S1 The patient tolerated the procedure well without procedural complications She will follow up with me in the office in the next few weeks to monitor her response to the injection Keywords pain management epidural steroid injection fluoroscopic guidance depo medrol injection MEDICAL_TRANSCRIPTION,Description Standard celiac plexus block procedure note Medical Specialty Pain Management Sample Name Celiac Plexus Block Transcription NAME OF PROCEDURE Celiac plexus block ANESTHESIA Local IV sedation COMPLICATIONS None PROCEDURE INT was placed The patient was in the prone position back prepped and draped in sterile fashion Then 1 5 of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1 L2 vertebral junction A 20 gauge 15 cm needle was then placed in a cephalad medial 45o direction the tip of the needle was just inside the L1 vertebral body On lateral view this was noted to be approximately 1 5 2 5 cm anterior to the vertebral body At this time 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed Following this a mixture of 18 cc of 0 5 Marcaine was injected on each side Neosporin and band aids was applied over the puncture sites The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed The patient was discharged to operating room recovery in stable condition Keywords pain management omnipaque vertebral body puncture sites celiac plexus block celiac plexus block vertebral MEDICAL_TRANSCRIPTION,Description Cervical epidural steroid injection C5 6 The C arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5 6 level Medical Specialty Pain Management Sample Name Cervical Epidural Steroid Injection 2 Transcription PROCEDURE PERFORMED Cervical epidural steroid injection C5 6 ASSISTANT None ANESTHESIA Local DETAILS OF PROCEDURE The patient was brought to the operating theater and placed prone onto the radiolucent table Subsequent monitored anesthesia care was administered The C arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5 6 level The neck area was then prepped with Betadine solution and draped sterile A metallic marker was placed over the C5 6 lamina and a skin wheal was raised in the skin A 20 gauge Tuohy needle was then advanced into the spinal canal using 1 Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined The needle was redirected into the interlaminar space and advanced to the previously determined level A 10 cc syringe was then placed onto the end of the needle and using an air negative technique the needle was advanced into the epidural space When a free flow of air was produced a solution of 80 mg Depo Medrol 2 cc of 1 Xylocaine injectable and 5 cc of normal saline was then injected into the epidural space The Tuohy needle was removed Betadine was cleansed from the skin A bandage was placed over the needle entrance point The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia The patient was taken to the recovery room in stable condition Keywords pain management c arm cervical epidural steroid injection ap view lumbar spine tuohy needle epidural steroid steroid injection MEDICAL_TRANSCRIPTION,Description Cervical facet joint injection with contrast Medical Specialty Pain Management Sample Name Cervical Facet Joint Injection Transcription CERVICAL FACET JOINT INJECTION WITH CONTRAST PREPROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form the patient was placed in the prone position and standard ASA monitors applied Intravenous access was established and IV sedation was used For further details of IV sedation and infusion please refer to anesthesia notes Fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure PROCEDURE DETAILS The patient was laid supine Appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head The neck was aseptically prepared 1 lidocaine was used for local infiltration and subsequently a 25 gauge spinal needle was passed down to the C4 5 facet joint under fluoroscopic control Positioning was checked and 0 2 mL of dye was injected Acceptable dye pattern was seen Subsequent 1 mL of a mixture of 0 5 mL of 1 lidocaine and 0 5 mL of Celestone was injected after aspiration and the patient was monitored Needle was removed and same procedure carried out on the other side Postprocedure no complications were noted Keywords pain management injection 1 lidocaine asa monitors cervical cervical facet joint injection celestone facet joint facet joint injection fluoroscopy iv sedation facet joints spinal needle cervical facet joint joint injection joint facetNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cervical epidural steroid injection C7 T1 An 18 gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline filled syringe utilizing a midline intralaminar approach Medical Specialty Pain Management Sample Name Cervical Epidural Steroid Injection 1 Transcription OPERATION PERFORMED Cervical epidural steroid injection C7 T1 ANESTHESIA Local and Versed 2 mg IV COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest The head and cervical spine were restrained The patient was monitored with a blood pressure cuff EKG and pulse oximetry The skin was prepped and draped in sterile classical fashion Excess cleansing solution was removed from the skin Local anesthesia was injected at C7 T1 An 18 gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline filled syringe utilizing a midline intralaminar approach Once the epidural space was identified a negative aspiration for heme or CSF was done This was followed by the injection of 6 cc of saline mixed with methyl prednisolone acetate 120 mg in aliquots of 2 cc Negative aspirations were done prior to each injection The needle was cleared with saline prior to its withdrawal The patient tolerated the procedure well without any apparent difficulties or complications Keywords pain management tuohy needle cleansing solution epidural space loss of resistance cervical epidural steroid injection resistance technique steroid injection injection intralaminar steroid epidural MEDICAL_TRANSCRIPTION,Description Acromioclavicular joint injection Medical Specialty Pain Management Sample Name Acromioclavicular Joint Injection Transcription ACROMIOCLAVICULAR JOINT INJECTION PROCEDURE Informed consent was obtained from the patient All possible complications were mentioned including joint swelling infection and bruising The joint was prepared with Betadine and alcohol Then 1 mL of Depo Medrol and 2 mL of 0 25 Marcaine were injected using the anterior approach This was injected easily using a 25 gauge needle with the patient sitting and the shoulder propped up on a pillow The joint was entered easily without any great difficulty Aspiration was performed prior to the injection to make sure there was no intravascular injection There were no complications and good relief of symptoms POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management acromioclavicular joint injection acromioclavicular betadine depo medrol alcohol fevers inflammation intravascular injection joint injection redness swelling acromioclavicular joint injection jointNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot Medical Specialty Orthopedic Sample Name Youngswick Osteotomy Transcription TITLE OF OPERATION Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot PREOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot POSTOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot ANESTHESIA Monitored anesthesia care with 15 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain ESTIMATED BLOOD LOSS Less than 10 mL HEMOSTASIS Right ankle tourniquet set at 250 mmHg for 35 minutes MATERIALS USED 3 0 Vicryl 4 0 Vicryl and two partially threaded cannulated screws from 3 0 OsteoMed System for internal fixation INJECTABLES Ancef 1 g IV 30 minutes preoperatively DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s right foot to anesthetize the future surgical site The right ankle was then covered with cast padding and an 18 inch ankle tourniquet was placed around the right ankle and set at 250 mmHg The right ankle tourniquet was then inflated The right foot was prepped scrubbed and draped in normal sterile technique Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6 cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe The incision was deepened through the subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed multiple osteophytes were encountered Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint which were consistent with a medical history that is positive for gout for this patient Using sharp and dull dissection all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions Using the sagittal saw all the osteophytes were removed from the dorsal medial and lateral aspect of the first right metatarsal head as well as the dorsal medial and lateral aspect of the base of the proximal phalanx of the right great toe Although some improvement of the range of motion was encountered after the removal of the osteophytes some tightness and restriction was still present The decision was thus made to perform a Youngswick type osteotomy on the head of the first right metatarsal The osteotomy consistent of two dorsal cuts and a plantar cut in a V pattern with the apex of the osteotomy distal and the base of the osteotomy proximal The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy The wires were also used as guidewires for the insertion of two 16 mm proximally threaded cannulated screws from the OsteoMed System The 2 screws were inserted using AO technique Upon insertion of the screws the two wires were removed Fixation of the osteotomy on the table was found to be excellent The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation The capsule and periosteal tissues were then reapproximated with 3 0 Vicryl suture material 4 0 Vicryl was used to approximate the subcutaneous tissues Steri Strips were used to approximate and reinforce the skin edges At this time the right ankle tourniquet was deflated Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff The patient s surgical site was then covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels The patient was given instructions and education on how to continue caring for her right foot surgery at home The patient was also given pain medication instructions on how to control her postoperative pain The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for her first postoperative appointment Keywords orthopedic hallux limitus deformity metatarsophalangeal joint plantar cut youngswick osteotomy dorsal cuts ankle tourniquet proximal phalanx anesthesia tourniquet youngswick phalanx metatarsophalangeal proximal metatarsal dorsal osteotomy MEDICAL_TRANSCRIPTION,Description Injection of bilateral carpal tunnels Medical Specialty Pain Management Sample Name Bilateral Carpal Tunnels Injection Transcription POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management injection carpal tunnel bilateral carpal tunnels inflammation longus tendon palmaris longus palmaris longus tendon redness rolled up towel swelling volar aspect wrist wrist crease bilateral carpal carpal tunnels paresthesias carpal tunnels towelNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral sacroiliac joint injections Medical Specialty Pain Management Sample Name Bilateral sacroiliac joint injections Transcription BILATERAL SACROILIAC JOINT INJECTIONS PROCEDURE Informed consent was obtained from the patient The patient was placed in the prone position After preparation and local anesthetic administration and image intensifier control a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach A small amount of contrast material was administered to outline the recesses of the joints Verification of the initial needle position with contrast administration 1 mL of solution was administered at this site after aspiration consisting of 0 5 mL of 0 25 Marcaine and 0 5 mL of Celestone Postprocedure the needles were withdrawn and dressing was applied Postprocedure no complications were noted POST PROCEDURE INSTRUCTIONS The patient has been asked to report to us any redness swelling inflammation or fevers The patient has been asked to restrict the use of the extremity for the next 24 hours Keywords pain management bilateral sacroiliac joint injections 0 25 marcaine celestone postprocedure fevers image intensifier inflammation posterior approach redness sacroiliac joint spinal needle swelling bilateral sacroiliac joint sacroiliac joint injections sacroiliac injectionsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Austin Youngswick bunionectomy with Biopro implant Screw fixation left foot Medical Specialty Orthopedic Sample Name Youngswick Bunionectomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux rigidus left foot 2 Elevated first metatarsal left foot POSTOPERATIVE DIAGNOSES 1 Hallux rigidus left foot 2 Elevated first metatarsal left foot PROCEDURE PERFORMED 1 Austin Youngswick bunionectomy with Biopro implant 2 Screw fixation left foot HISTORY This 51 year old male presents to ABCD General Hospital with the above chief complaint The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time The patient desires surgical treatment PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 7 cc of 0 5 Marcaine plain was injected in a Mayo type block The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was then inflated to 250 mmHg The foot was lowered to the operating table the stockinet was reflected and the foot was cleansed with wet and dry sponge Attention was then directed to the left first metatarsophalangeal joint Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint just medial to the extensor hallucis longus tendon The incision was then deepened with a 15 blade All vessels encountered were ligated for hemostasis The skin and subcutaneous tissue was undermined medially off of the joint capsule A dorsal linear capsular incision was then made Care was taken to identify and preserve the extensor hallucis longus tendon The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx There was noted to be a significant degenerative joint disease There was little to no remaining healthy articular cartilage left on the head of the first metatarsal There was significant osteophytic formation medially dorsally and laterally in the first metatarsal head as well as at the base of the proximal phalanx A sagittal saw was then used to resect the base of the proximal phalanx Care was taken to ensure that the resection was parallel to the nail After the bone was removed in toto the area was inspected and the flexor tendon was noted to be intact The sagittal saw was then used to resect the osteophytic formation medially dorsally and laterally on the first metatarsal The first metatarsal was then re modelled and smoothed in a more rounded position with a reciprocating rasp The sizers were then inserted for the Biopro implant A large was noted to be of the best size There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx Following inspection the sagittal saw was used to clean both the medial and lateral sides of the base A small bar drill was then used to pre drill for the Biopro sizer The bone was noted to be significantly hardened The sizer was placed and a large Biopro was deemed to be the correct size implant The sizer was removed and bar drill was then again used to ream the medullary canal The hand reamer with a Biopro set was then used to complete the process The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit There was noted to be distally increased range of motion after insertion of the implant Attention was then directed to the first metatarsal A long dorsal arm Austin osteotomy was then created A second osteotomy was then created just plantar and parallel to the first osteotomy site The wedge was then removed in toto The area was feathered to ensure high compression of the osteotomy site The head was noted to be in a more plantar flexed position The capital fragment was then temporarily fixated with two 0 45 K wires A 2 7 x 16 mm screw was then inserted in the standard AO fashion A second more proximal 2 7 x 60 mm screw was also inserted in a standard AO fashion With both screws there was noted to be tight compression at the osteotomy sites The K wires were removed and the areas were then smoothed with reciprocating rash A screw driver was then used to check and ensure screw tightness The area was then flushed with copious amounts of sterile saline Subchondral drilling was performed with a 1 5 drill bit The area was then flushed with copious amounts of sterile saline Closure consisted of capsular closure with 3 0 Vicryl followed by subcutaneous closure with 4 0 Vicryl followed by running subcuticular stitch of 5 0 Vicryl Dressings consisted of Steri Strips Owen silk 4x4s Kling Kerlix and Coban A total of 10 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain was injected intraoperatively for further anesthesia The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well The patient was transported to PACU with vital signs stable and vascular status intact to the right foot The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q 4 6h p o p r n pain The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema The patient is to follow up with Dr X in his office as directed Keywords orthopedic hallux rigidus metatarsal youngswick bunionectomy screw fixation ankle tourniquet metatarsophalangeal joint biopro implant proximal phalanx foot austin anesthesia osteotomy screw MEDICAL_TRANSCRIPTION,Description Consultation for wrist pain Medical Specialty Orthopedic Sample Name Wrist Pain Transcription CHIEF COMPLAINT Left wrist pain HISTORY OF PRESENT PROBLEM Keywords orthopedic wrist pain scapholunate tenderness to palpation three views traumatic wrist injury ulnar styloid nonunion ulnar styloid wrist union soreness styloid ulnar MEDICAL_TRANSCRIPTION,Description Excision of dorsal wrist ganglion Made a transverse incision directly over the ganglion Dissection was carried down through the extensor retinaculum identifying the 3rd and the 4th compartments and retracting them Medical Specialty Orthopedic Sample Name Wrist Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Wrist ganglion POSTOPERATIVE DIAGNOSIS Wrist ganglion TITLE OF PROCEDURE Excision of dorsal wrist ganglion PROCEDURE After administering appropriate antibiotics and general anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg I made a transverse incision directly over the ganglion Dissection was carried down through the extensor retinaculum identifying the 3rd and the 4th compartments and retracting them I then excised the ganglion and its stalk In addition approximately a square centimeter of the dorsal capsule was removed at the origin of stalk leaving enough of a defect to prevent formation of a one way valve We then identified the scapholunate ligament which was uninjured I irrigated and closed in layers and injected Marcaine with epinephrine I dressed and splinted the wound The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic origin of stalk extensor retinaculum wrist ganglion incision excision dorsal tourniquet wrist ganglion MEDICAL_TRANSCRIPTION,Description Unilateral transpedicular T11 vertebroplasty Medical Specialty Orthopedic Sample Name Vertebroplasty Transcription PREOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain POSTOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain OPERATION PERFORMED Unilateral transpedicular T11 vertebroplasty ANESTHESIA Local with IV sedation COMPLICATIONS None SUMMARY The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion The patient was given sedation and monitored Using AP and lateral fluoroscopic projections the T11 compression fracture was identified Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o clock position of the lateral aspect of the T11 pedicle on the left The 13 gauge needle and trocar were then taken and placed to 10 o clock position on the pedicle At this point using AP and lateral fluoroscopic views the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times Once the vertebral body was entered then using lateral fluoroscopic views the needle was advanced to the junction of the anterior one third and posterior two thirds of the body At this point polymethylmethacrylate was mixed for 60 seconds Once the consistency had hardened and the __________ was gone incremental dose of the cement were injected into the vertebral body It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra A total 1 2 cc of cement was injected On lateral view the cement crushed to the right side as well There was some dye infiltration into the disk space There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal At this point as the needle was slowly withdrawn under lateral fluoroscopic images visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space Once the needle was withdrawn safely pressure was held over the site for three minutes There were no complications The patient was taken back to the recovery area in stable condition and kept flat for one hour Should be followed up the next morning Keywords orthopedic transpedicular vertebroplasty fluoroscopic views fluoroscopic images epidural space compression fracture vertebral body compression pedicle fluoroscopic vertebral needle MEDICAL_TRANSCRIPTION,Description Trigger thumb release Right trigger thumb The A 1 pulley was divided along its radial border completely freeing the stenosing tenosynovitis trigger release Medical Specialty Orthopedic Sample Name Trigger Thumb Release 1 Transcription PREOPERATIVE DIAGNOSIS Right trigger thumb POSTOPERATIVE DIAGNOSIS Right trigger thumb OPERATIONS PERFORMED Trigger thumb release ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon with local COMPLICATIONS Keywords orthopedic trigger thumb trigger thumb release tenosynovitis trigger tenosynovitis release thumb tourniquet trigger MEDICAL_TRANSCRIPTION,Description Right ulnar nerve transposition right carpal tunnel release and right excision of olecranon bursa Right cubital tunnel syndrom carpal tunnel syndrome and olecranon bursitis Medical Specialty Orthopedic Sample Name Ulnar Nerve Transposition Olecranon Bursa Excision Transcription PREOPERATIVE DIAGNOSIS 1 Right cubital tunnel syndrome 2 Right carpal tunnel syndrome 3 Right olecranon bursitis POSTOPERATIVE DIAGNOSIS 1 Right cubital tunnel syndrome 2 Right carpal tunnel syndrome 3 Right olecranon bursitis PROCEDURES 1 Right ulnar nerve transposition 2 Right carpal tunnel release 3 Right excision of olecranon bursa ANESTHESIA General BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Thickened transverse carpal ligament and partially subluxed ulnar nerve SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained his right arm was sterilely prepped and draped in normal fashion After elevation and exsanguination with an Esmarch the tourniquet was inflated The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues The palmar fascia was divided exposing the transverse carpal ligament which was incised longitudinally A Freer was then inserted beneath the ligament and dissection was carried out proximally and distally After adequate release has been formed the wound was irrigated and closed with nylon The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected A medial antebrachial cutaneous nerve was identified and protected throughout the case The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed The ulnar nerve was freed proximally and distally The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided The intraarticular branch and the first branch to the SCU were transected and then the nerve was transposed it did not appear to have any significant tension or sharp turns The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight The wound was irrigated The tourniquet was deflated and the wound had excellent hemostasis The subcutaneous tissues were closed with 2 0 Vicryl and the skin was closed with staples Prior to the tourniquet being deflated the subcutaneous dissection was carried out over to the olecranon bursa where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa A posterior splint was applied Marcaine was injected into the incisions and the splint was reinforced with tape He was awakened from the anesthesia and taken to recovery room in a stable condition Final needle instrument and sponge counts were correct Keywords orthopedic cubital tunnel syndrome carpal tunnel syndrome olecranon bursitis ulnar nerve transposition carpal tunnel release excision of olecranon bursa transposition ligament tourniquet excision bursa syndrome subcutaneous ulnar olecranon carpal nerve tunnel MEDICAL_TRANSCRIPTION,Description Subcutaneous ulnar nerve transposition A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Medical Specialty Orthopedic Sample Name Ulnar Nerve Transposition Transcription PROCEDURE Subcutaneous ulnar nerve transposition PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected Osborne s fascia was released an ulnar neurolysis performed and the ulnar nerve was mobilized Six cm of the medial intermuscular septum was excised and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly The subcutaneous plane just superficial to the flexor pronator mass was developed Meticulous hemostasis was maintained with bipolar electrocautery The nerve was transposed anteriorly superficial to the flexor pronator mass Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve A semicircular medially based flap of flexor pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating The subcutaneous tissue and skin were closed with simple interrupted sutures Marcaine with epinephrine was injected into the wound The elbow was dressed and splinted The patient was awakened and sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic neurolysis ulnar periosteal flexor pronator mass ulnar nerve transposition medial intermuscular septum nerve transposition intermuscular septum flexor pronator ulnar nerve nerve MEDICAL_TRANSCRIPTION,Description Trigger finger release A longitudinal incision was made over the digit s A1 pulley Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The sheath was opened under direct vision with a scalpel and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease Medical Specialty Orthopedic Sample Name Trigger Finger Release Transcription PROCEDURE Trigger finger release PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made over the digit s A1 pulley Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The sheath was opened under direct vision with a scalpel and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease Meticulous hemostasis was maintained with bipolar electrocautery The tendons were identified and atraumatically pulled to ensure that no triggering remained The patient then actively moved the digit and no triggering was noted After irrigating out the wound with copious amounts of sterile saline the skin was closed with 5 0 nylon simple interrupted sutures The wound was dressed and the patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic a1 pulley neurovascular bundles trigger finger release proximal digital digital crease trigger finger trigger finger sheath incision MEDICAL_TRANSCRIPTION,Description Decompression of the ulnar nerve left elbow Left cubital tunnel syndrome and ulnar nerve entrapment Medical Specialty Orthopedic Sample Name Ulnar Nerve Decompression Transcription PREOPERATIVE DIAGNOSES Left cubital tunnel syndrome and ulnar nerve entrapment POSTOPERATIVE DIAGNOSES Left cubital tunnel syndrome and ulnar nerve entrapment PROCEDURE PERFORMED Decompression of the ulnar nerve left elbow ANESTHESIA General FINDINGS OF THE OPERATION The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel There was presence of hourglass constriction of the ulnar nerve PROCEDURE The patient was brought to the operating room and once an adequate general anesthesia was achieved his left upper extremity was prepped and draped in standard sterile fashion A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg Perioperative antibiotics were infused Time out procedure was called The medial epicondyle and the olecranon tip were well palpated The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3 4 cm proximally and 6 8 cm distally The ulnar nerve was identified proximally It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers which was released sharply The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches The ulnar nerve was well isolated before it entered the cubital tunnel The arch of the FCU was well defined The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization Distally the dissection was carried between the 2 heads of the FCU Decompression of the nerve was performed between the heads of the FCU The muscular branches were well protected Similarly the cutaneous branches in the arm and forearm were well protected The venous plexus proximally and distally were well protected The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it Proximally multiple vascular leashes were defined near the incision of the septum into the medial epicondyle which were also protected Once the in situ decompression of the ulnar nerve was performed proximally and distally the elbow was flexed and extended There was no evidence of any subluxation Satisfactory decompression was performed Tourniquet was released Hemostasis was achieved Subcutaneous layer was closed with 2 0 Vicryl and skin was approximated with staples A well padded dressing was applied The patient was then extubated and transferred to the recovery room in stable condition There were no intraoperative complications noted The patient tolerated the procedure very well Keywords orthopedic ulnar nerve entrapment ulnar nerve ulnar nerve decompression cubital tunnel syndrome ulnar nerve fascia decompression cubital tunnel MEDICAL_TRANSCRIPTION,Description Total knee replacement A midline incision was made centered over the patella Dissection was sharply carried down through the subcutaneous tissues A median parapatellar arthrotomy was performed Medical Specialty Orthopedic Sample Name Total Knee Replacement 1 Transcription PROCEDURES Total knee replacement PROCEDURE DESCRIPTION The patient was bought to the operating room and placed in the supine position After induction of anesthesia a tourniquet was placed on the upper thigh Sterile prepping and draping proceeded The tourniquet was inflated to 300 mmHg A midline incision was made centered over the patella Dissection was sharply carried down through the subcutaneous tissues A median parapatellar arthrotomy was performed The lateral patellar retinacular ligaments were released and the patella was retracted laterally Proximal medial tibia was denuded with mild release of medial soft tissues The ACL and PCL were released The medial and lateral menisci and suprapatellar fat pad were removed These releases allowed for anterior subluxation of tibia An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau perpendicular to the axis of the tibia Its alignment was checked with the rod and found to be adequate The tibia was then allowed to relocate under the femur An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted and the block was pinned in appropriate position judging correct rotation using a variety of techniques An anterior rough cut was made The distal cutting jig was placed atop this cut surface and pinned to the distal femur and the rod was removed The distal cut was performed A spacer block was placed and adequate balance in extension was adjusted and confirmed as was knee alignment Femoral sizing was performed with the sizer and the appropriate size femoral 4 in 1 chamfer cutting block was pinned in place and the cuts were made The notch cutting block was pinned to the cut surface slightly laterally and the notch cut was then made The trial femoral component was impacted onto the distal femur and found to have an excellent fit A trial tibial plate and polyethylene were inserted and stability was judged and found to be adequate in all planes Appropriate rotation of the tibial component was identified and marked The trials were removed and the tibia was brought forward again The tibial plate size was checked and the plate was pinned to plateau A keel guide was placed and the keel was then made The femoral intramedullary hole was plugged with bone from the tibia The trial tibial component and poly placed and after placement of the femoral component range of motion and stability were checked and found to be adequate in various ranges of flexion and extension The patella was held in a slightly everted position with knee in extension Patellar width was checked with calipers A free hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers Sizing was then performed and 3 lug holes were drilled with the jig in place taking care to medialize and superiorize the component as much as possible given bony anatomy Any excess lateral patellar bone was recessed The trial patellar component was placed and found to have adequate tracking The trials were removed and as the cement was mixed all cut surfaces were thoroughly washed and dried The cement was applied to the components and the cut surfaces with digital pressurization and then the components were impacted The excess cement was removed from the gutters and anterior and posterior parts of the knee The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened Once the cement had hardened the tourniquet was deflated The knee was dislocated again and any excess cement was removed with an osteotome Thorough irrigation and hemostasis were performed The real polyethylene component was placed and pinned Further vigorous power irrigation was performed and adequate hemostasis was obtained and confirmed The arthrotomy was closed using 0 Ethibond and Vicryl sutures The subcutaneous tissues were closed after further irrigation with 2 0 Vicryl and Monocryl sutures The skin was sealed with staples Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap The patient was transferred to the recovery room in stable condition having tolerated the procedure well Keywords orthopedic proximal medial tibia total knee replacement parapatellar arthrotomy subcutaneous tissues tibial plateau incision cutting patella femur femoral component knee MEDICAL_TRANSCRIPTION,Description Right total knee arthroplasty Osteoarthritis right knee Medical Specialty Orthopedic Sample Name Total Knee Arthroplasty Right Transcription PREOPERATIVE DIAGNOSIS ES Osteoarthritis right knee POSTOPERATIVE DIAGNOSIS ES Osteoarthritis right knee PROCEDURE Right total knee arthroplasty DESCRIPTION OF THE OPERATION The patient was brought to the Operating Room and after the successful placement of an epidural as well as general anesthesia administration 1 gm of Ancef preoperatively the patient s right thigh knee and leg were scrubbed prepped and draped in the usual sterile fashion The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg A straight anterior incision was carried down through the skin and subcutaneous tissue Unilateral flaps were developed and a median retinacular parapatellar incision was made The extensor mechanism was partially divided and the patella was everted Some of the femoral bone spurs were resected using an osteotome and a rongeur Ascending drill hole was made in the distal femur and the distal femoral cut anterior and posterior and chamfer cuts were accomplished for a 67 5 femoral component At this point the ACL was resected Some of the fat pad and synovium were resected as well as both medial and lateral menisci A posterior cruciate retractor was utilized the tibia brought forward and a centering drill hole made in the tibia The intramedullary guide was used for cutting the tibia It was set at 8 mm An additional 2 mm was resected because of a moderate defect medially A trial reduction was done with a 71 tibial baseplate This was pinned and drilled and then trial reduction done with a 10 mm insert This gave good stability and a full range of motion The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw A 34 mm component was drilled for A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces A packet of cement was hand mixed pressurized with a spatula into the proximal tibia Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic The tibia baseplate was secured and the patella was inserted held with a clamp The extraneous cement was removed At this point the tibial baseplate was locked into place and the femoral component also seated solidly The knee was extended held in this position for another 5 6 minutes until the cement was cured Further extraneous cement was removed The pneumatic tourniquet was released hemostasis was obtained with electrocoagulation Retinaculum quadriceps and extensor were repaired with multiple figure of eight 1 Vicryl sutures the subcutaneous tissue with 2 0 and the skin with skin staples A sterile bulky compression dressing was placed The patient was stable on operative release Keywords orthopedic osteoarthritis arthroplasty knee patella retinacular parapatellar total knee arthroplasty total knee knee arthroplasty baseplate femoral tibia MEDICAL_TRANSCRIPTION,Description Total left knee replacement Degenerative arthritis of the left knee Degenerative ware of three compartments of the trochlea the medial as well as the lateral femoral condyles as well was the plateau Medical Specialty Orthopedic Sample Name Total Knee Replacement Transcription PREOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee POSTOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee PROCEDURE PERFORMED Total left knee replacement on 08 19 03 The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr X TOURNIQUET TIME 76 minutes BLOOD LOSS 150 cc ANESTHESIA General IMPLANT USED FOR PROCEDURE NexGen size F femur on the left with 8 size peg tibial tray a 12 mm polyethylene insert and this a cruciate retaining component The patella on the left was not resurfaced GROSS INTRAOPERATIVE FINDINGS Degenerative ware of three compartments of the trochlea the medial as well as the lateral femoral condyles as well was the plateau The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component HISTORY This is a 69 year old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living He attempted conservative treatment which includes anti inflammatory medications as well as cortisone and Synvisc This has only provided him with temporary relief It is for that reason he is elected to undergo the above named procedure All risks as well as complications were discussed with the patient which include but are not limited to infection deep vein thrombosis pulmonary embolism need for further surgery and further pain He has agreed to undergo this procedure and a consent was obtained preoperatively PROCEDURE The patient was wheeled back to operating room 2 at ABCD General Hospital on 08 19 03 and was placed supine on the operating room table At this time a nonsterile tourniquet was placed on the left upper thigh but not inflated An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure The tourniquet was then inflated to 325 mmHg At this time a standard midline incision was made towards the total knee We did discuss preoperatively for a possible unicompartmental knee replacement for this patient but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus We did start off with a small midline skin incision in case we were going to do a unicompartmental Once we exposed the medial parapatellar mini arthrotomy and visualized the lateral femoral condyle we decided that this patient would not be an optimal candidate for unicompartmental knee replacement It is for this reason that we extended the incision and underwent with the total knee replacement Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella Once the patella was everted we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee At this time a femoral sizer was then placed with reference to the posterior condyles and we measured a size F Once this was performed three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur At this time the intramedullary guide was then inserted and placed in three degrees of external rotation Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues Next this was removed and the distal femoral cutting guide was then placed in five degrees of valgus This was pinned to the distal femur and with careful protection of the collateral ligaments a distal femoral cut was performed At this time the intramedullary guide was removed and a final cutting block was placed This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking At this time the block was pinned and screwed in place with spring pins with careful protection of the soft tissues An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut Peg holes were then drilled The block was then removed and an osteotome was then used to remove all the bony cut pieces At this time with a better exposure of the proximal tibia we placed external tibial guide This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia At this time with careful soft tissue retraction and protection an oscillating saw was used to make a proximal tibial osteotomy Prior to the osteotomy the cut was checked with a depth gauge in order to assure appropriate bony resection At this time a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut which had soft tissue attachments Once this was removed we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface The knee was taken through range of motion and revealed excellent femorotibial articulation The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason we performed a minimal small incision lateral retinacular release Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis At this time an intraoperative x ray was performed which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut At this time the prosthesis was removed A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia Once the drill holes were performed we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components At this time polymethyl methacrylate cement was then mixed The cement was placed on the tibial surface as well as the underneath surface of the component The component was then placed and impacted with excess cement removed In a similar fashion the femoral component was also placed A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content Once the cement was fully hardened the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone Once this was performed copious irrigation was used to irrigate the wound and the wound was then suctioned dry The knee was again taken through range of motion with a 12 mm plastic as well as 14 The 14 appeared to be a bit too tight especially in extremes of flexion We decided to go with a 12 mm polyethylene tray At this time this was placed to the tibial articulation and then left in place This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact A drain was placed and cut to length At this time the knee was irrigated and copiously suction dried 1 0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure of eight fashion A tight capsular closure was performed This was reinforced with a 1 0 running Vicryl suture At this time the knee was again taken through range of motion to assure tight capsular closure At this time copious irrigation was used to irrigate the superficial wound 2 0 Vicryl was used to approximate the wound with figure of eight inverted suture The skin was then approximated with staples The leg was then cleansed Sterile dressing consisting of Adaptic 4x4 ABDs and Kerlix roll were then applied At this time the patient was extubated and transferred to recovery in stable condition Prognosis is good for this patient Keywords orthopedic degenerative arthritis nexgen polyethylene cruciate total knee replacement proximal tibia knee replacement femoral cutting tibial knee arthritis femur cementation MEDICAL_TRANSCRIPTION,Description Trigger thumb release A transverse incision was made over the MPJ crease of the thumb Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles Medical Specialty Orthopedic Sample Name Trigger Thumb Release Transcription PROCEDURE Trigger thumb release PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual sterile fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A transverse incision was made over the MPJ crease of the thumb Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles The flexor sheath was opened under direct vision with a scalpel and then a scissor was used to release the A1 pulley under direct vision on the radial side from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx Meticulous hemostasis was maintained with bipolar electrocautery The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained The patient then actively moved the thumb and no triggering was noted After irrigating out the wound with copious amounts of sterile saline the skin was closed with 5 0 nylon simple interrupted sutures The wound was dressed and the patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic neurovascular a1 pulley trigger thumb release mpj crease trigger thumb flexor sheath triggering sheath proximal incision MEDICAL_TRANSCRIPTION,Description Right knee total arthroplasty Degenerative osteoarthritis right knee Medical Specialty Orthopedic Sample Name Total Knee Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee POSTOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee PROCEDURE PERFORMED Right knee total arthroplasty ANESTHESIA The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized TOTAL TOURNIQUET TIME Approximately 90 minutes SPECIFICATIONS The entire procedure is done in the inpatient operating suite in the Room 1 at ABCD General Hospital The following sizes of NexGen system were utilized E on right femur cemented 5 tibial stem tray with a 10 mm polyethylene insert and a 32 mm patellar button HISTORY AND GROSS FINDINGS This is a 58 year old white female suffering increasing right knee pain for number of years prior to surgical intervention She was completely refractory to conservative outpatient therapy She had undergone two knee arthroscopies in the years preceding this They were performed by myself She ultimately failed this treatment and developed a collapsing type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live Medial compartment had minor changes present There was no contracture of the lateral collateral ligament but instead mild laxity on both sides There was no significant flexion contracture preoperatively OPERATIVE PROCEDURE The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department Thigh tourniquet was placed upon the patient s right leg She was prepped and draped in the usual sterile manner The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time A straight incision was carried down through the skin and subcutaneous tissue Hemostasis was controlled with electrocoagulation Medial parapatellar arthrotomy was created and the knee cap was everted The ligaments were balanced A portion of the fat pad was removed and the ACL was completely removed Drill hole was made in the distal femur The size to an E right Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side This was checked with the epicondylar abscess and with three degrees of external rotation drill holes were made Intramedullary guide was then placed pegged and anterior cut carried out There was excellent resection It was flat Distal cutting guide was then placed in five degrees of valgus Appropriate cuts were carried out The standard cut was utilized The finishing guide for E was held with pins as well as screws Cutting was carried out posterior to anterior then posterior chamfer and anterior chamfer femoral sulcus cut was carried out and drill holes for pegs were made The cutting guide was then removed The bone was removed Excess bone was taken out posteriorly The posterior capsule was loosened up There were two different fabellas in the posterolateral compartment and they were loosened Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner An extramedullary tibial cutting guide was then placed pinned and held A cut was carried out parallel to the foot Hard copy ________ was obtained deemed to be satisfactory after evening up the edges Trial range of motion was satisfactory It was necessary to perform a lateral retinacular release to the patella The patella was isolated Approximately 10 mm to 11 mm were reamed off The size to 32 mm button and drill hole guide was placed impacted and drilled Trial range of motion was satisfactory The tibial guide was then pinned Drill hole was placed broached and utilized Copious irrigation was carried out Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella The implants were sequentially placed in tibia to femur to patella Once excess methylmethacrylate was removed and cured 10 mm Poly was placed There was excellent ligament balancing A separate portal was utilized for subcutaneous drain Tourniquet was deflated and hemostasis was controlled with electrocoagulation Interrupted 1 Ethibond suture was utilized for parapatellar closure running 1 Vicryl suture was utilized for overstitch Trial range of motion was satisfactory Interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin Adaptic 4x4s ABDs and Webril were placed for compression dressing Digits were pink and warm with brawny pulses distally at the end of the case The patient was then transferred to PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords orthopedic arthroplasty knee degenerative osteoarthritis subcutaneous osteoarthritis degenerative tourniquet drill MEDICAL_TRANSCRIPTION,Description Foraminal disc herniation of left L3 L4 Enlarged dorsal root ganglia of the left L3 nerve root Transpedicular decompression of the left L3 L4 with discectomy Medical Specialty Orthopedic Sample Name Transpedicular Decompression Transcription PREOPERATIVE DIAGNOSIS Foraminal disc herniation of left L3 L4 POSTOPERATIVE DIAGNOSES 1 Foraminal disc herniation of left L3 L4 2 Enlarged dorsal root ganglia of the left L3 nerve root PROCEDURE PERFORMED Transpedicular decompression of the left L3 L4 with discectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal SPECIMEN None HISTORY This is a 55 year old female with a four month history of left thigh pain An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root which appears to be a foraminal disc herniation effacing the L3 nerve root Upon exploration of the nerve root it appears that there was a small disc herniation in the foramen but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body so otherwise the surrounding anatomy is normal I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer at this point I was not able to perform this biopsy without prior consent from the patient So surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations OPERATIVE PROCEDURE The patient was taken to OR 5 at ABCD General Hospital in a gurney Department of Anesthesia administered general anesthetic Endotracheal intubation followed The patient received the Foley catheter She was then placed in a prone position on a Jackson table Bony prominences were well padded Localizing x rays were obtained at this time and the back was prepped and draped in the usual sterile fashion A midline incision was made over the L3 L4 disc space taking through subcutaneous tissues sharply dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3 Retractors were placed into the wound to retract the musculature At this point the pars interarticularis was identified and the facet joint of L2 L3 was identified A marker was placed over the pedicle of L3 and confirmed radiographically Next a microscope was brought onto the field The remainder of the procedure was noted with microscopic visualization A high speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis At this point soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen As the disc space of L3 L4 is identified there is a small prominence of the disc but not as impressive as I would expect on the MRI A discectomy was performed at this time removing only small portions of the lateral aspect of the disc Next the nerve root was clearly dissected out and visualized the lateral aspect of the nerve root appears to be normal in structural appearance The medial aspect with the axilla of the nerve root appears to be enlarged The color of the tissue was consistent with a nerve root tissue There was no identifiable plane and this is a gentle enlargement of the nerve root There are no circumscribed lesions or masses that can easily be separated from the nerve root As I described in the initial paragraph since I was not prepared to perform a biopsy on the nerve and the patient had not been consented I do not think it is reasonable to take the patient to this procedure because she will have persistent weakness and pain in the leg following this procedure So at this point there is no further decompression A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral The pedicle was palpated inferiorly and medially and there was no compression as the nerve root can be easily moved medially The wound was then irrigated copiously and suctioned dry A concoction of Duramorph and ______ was then placed over the nerve root for pain control The retractors were removed at this point The fascia was reapproximated with 1 Vicryl sutures subcutaneous tissues with 2 Vicryl sutures and Steri Strips covering the incision The patient transferred to the hospital gurney extubated by Anesthesia and subsequently transferred to Postanesthesia Care Unit in stable condition Keywords orthopedic dorsal root ganglia nerve root discectomy foraminal disc herniation transpedicular decompression lateral aspects disc herniation nerve anesthesia foraminal MEDICAL_TRANSCRIPTION,Description Total hip arthroplasty on the left Left hip degenerative arthritis Severe degenerative changes within the femoral head as well as the acetabulum anterior as well as posterior osteophytes Medical Specialty Orthopedic Sample Name Total Hip Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Left hip degenerative arthritis POSTOPERATIVE DIAGNOSIS Left hip degenerative arthritis PROCEDURE PERFORMED Total hip arthroplasty on the left ANESTHESIA General BLOOD LOSS 800 cc The patient was positioned with the left hip exposed on the beanbag IMPLANT SPECIFICATION A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner a 28 mm cobalt chrome head with a zero neck length head and a 12 mm porous proximal collared femoral component GROSS INTRAOPERATIVE FINDINGS Severe degenerative changes within the femoral head as well as the acetabulum anterior as well as posterior osteophytes The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis This was revealed once we removed the trochanteric bursa HISTORY This is a 56 year old obese female with a history of bilateral degenerative hip arthritis She underwent a right total hip arthroplasty by Dr X in the year of 2000 and over the past three years the symptoms in her left hip had increased tremendously especially in the past few months Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication the patient has elected to undergo the above named procedure All risks as well complications were discussed with the patient including but not limited to infection scar dislocation need for further surgery risk of anesthesia deep vein thrombosis and implant failure The patient understood all these risks and was willing to continue further on with the procedure PROCEDURE The patient was wheeled back to the Operating Room 2 at ABCD General Hospital on 08 27 03 The general anesthetic was first performed by the Department of Anesthesia The patient was then positioned with the left hip exposed on the beanbag in the lateral position Kidney rests were also used because of the patient s size An axillary roll was also inserted for comfort in addition to a Foley catheter which was inserted by the OR nurse All her bony prominences were well padded At this time the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure At this time an anterolateral approach was then performed first incising through the skin in approximately 5 to 6 inches of subcutaneous fat The tensor fascia lata was then identified A self retainer was then inserted to expose the operative field Bovie cautery was used for hemostasis At this time a fresh blade was then used to incise the tensor fascia lata over the posterior one third of the greater trochanter At this time a blunt dissection was taken proximally The tensor fascia lata was occluded with a hip retractor At this time after hemostasis was obtained Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor the gluteus medius At this time a periosteal elevator was used to expose anterior hip capsule A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle Once this was performed Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck At this time a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum At this point a large bone hook was then inserted over the neck and with gentle traction and external rotation the femoral head was dislocated out of the acetabulum At this time we had an exposure of the femoral head which did reveal degenerative changes of the femoral head and once the acetabulum was visualized we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum At this time a femoral stem guide was then used to measure proximal femoral neck cut We made a cut approximately a fingerbreadth above the lesser trochanter At this time with protection of the soft tissues an oscillating saw was used to make femoral neck cut The femoral head was then removed At this time we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum A long handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum With better exposure of the acetabulum we started reaming the acetabulum We started with a size 44 and progressively reamed to a size 50 At the size 50 mm reamer we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum We then reamed up to size 52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in Once the cup was impacted in place we did visualize that the cup was well seated on to the internal portion of the acetabulum At this time two screws were the placed within the superior table for better approaches securing the acetabular cup At this time a plastic liner was then inserted for protection The leg was then placed back in the bag A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time we began working on the femur A rongeur was used to lateralize over the greater trochanter A Box osteotome was used to remove the cancellous portion of the femoral neck A Charnley awl was then used to cannulate through the proximal femoral canal A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem At this time we began broaching We started with a size 10 and progressively worked up to a size 12 mm broach Once the 12 mm broach was inserted in place it was seated approximately 1 mm below the calcar A calcar reamer was then placed and the calcar was reamed smoothly A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed Once this was performed the hip was taken to range of motion with external rotation longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation At this time we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum This was impacted and placed and checked to assure that it was well seated with no loosening Once this was performed we then exposed the proximal femur one more time We copiously irrigated within the canal and then suctioned it dry At this time a 12 mm porous proximal collared stem a femoral component was then impacted in place Once it was well seated on the calcar we double checked to assure that there was no evidence of calcar fractures which there were none The 28 mm zero neck length cobalt chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________ Next the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction external rotation as well as hip flexion We were satisfied with components as well as the alignment of the components Copious irrigation was then used to irrigate the wound 1 Ethibond was then used to approximate the anterior hip capsule 1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter Next a 1 Ethibond was then used to approximate the tensor fascia lata with figure of eight closure A tight closure was performed Since the patient did have a lot of subcutaneous fat multiple 2 0 Vicryl sutures were then used to approximate the bed space and then 2 0 Vicryl for the subcutaneous skin Staples were then used for skin closure The patient s hip was then cleansed Sterile dressings consisting of Adaptic 4 x 4 ABDs and foam tape were then placed A drain was placed prior to wound closure for postoperative drainage After the dressing was applied the patient was extubated safely and transferred to recovery in stable condition Prognosis is good Keywords orthopedic degenerative arthritis total hip arthroplasty tensor fascia lata vastus lateralis gluteus medius femoral neck femoral head head femoral acetabulum hip attachment arthroplasty MEDICAL_TRANSCRIPTION,Description Total hip replacement An incision was made centered over the greater trochanter Dissection was sharply carried down through the subcutaneous tissues Medical Specialty Orthopedic Sample Name Total Hip Replacement 1 Transcription PROCEDURE Total hip replacement PROCEDURE DESCRIPTION The patient was bought to the operating room and placed in the supine position After induction of anesthesia the patient was turned on the side and secured in the hip table An incision was made centered over the greater trochanter Dissection was sharply carried down through the subcutaneous tissues The gluteus maximus was incised and split proximally The piriformis and external rotators were identified These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule The hip was dislocated A femoral neck cut was made using the guidance of preoperative templating The femoral head was removed Extensive degenerative disease was found on the femoral head as well as in the acetabulum Baseline leg length measurements were taken The femur was retracted anteriorly and a complete labrectomy was performed Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas The trial shell was placed and found to have an excellent fit The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction Screws were placed by drilling into the pelvis measuring and placing the appropriate length screw Excellent purchase was obtained The trial liner was placed The femur was then flexed and internally rotated The extra trochanteric bone was removed as was any leftover lateral soft tissue at the piriformis insertion An intramedullary hole was drilled into the femur to define the canal Reaming was performed until the appropriate size was reached The broaches were then used to prepare the femur with the appropriate amount of version Once the appropriate size broach was reached it was used as a trial with head and neck placement Hip range of motion was checked in all planes including flexion internal rotation the position of sleep and extension external rotation The hip was found to have excellent stability with the final chosen head neck combination Leg length measurements were taken and found to be within acceptable range given the necessity for stability The real stem was opened and impacted into position The real head was impacted atop the stem If cement was used the canal was thoroughly washed and dried and plugged with a restrictor and then the cement was injected and pressurized and the stem was implanted in the appropriate version Excess cement was removed from the edges of the component Range of motion and stability were once again checked and found to be excellent Adequate hemostasis was obtained Vigorous power irrigation was used to remove all debris from the joint prior to final reduction The arthrotomy and rotators were closed using 1 Ethibond through drill holes in the bone recreating the posterior hip structural anatomy The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl The subcutaneous tissues were closed after further irrigation with 2 0 Vicryl and Monocryl sutures The skin was closed with nylon Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap The patient was transferred to the recovery room in stable condition having tolerated the procedure well Keywords orthopedic range of motion hip total hip replacement gluteus maximus femoral head subcutaneous tissues incision ethibond trochanter subcutaneous acetabulum femur MEDICAL_TRANSCRIPTION,Description Right total knee arthroplasty using a Biomet cemented components 62 5 mm right cruciate retaining femoral component 71 mm Maxim tibial component and 12 mm polyethylene insert with 31 mm patella All components were cemented with Cobalt G Medical Specialty Orthopedic Sample Name Total Knee Arthoplasty Right 1 Transcription PREOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee POSTOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee PROCEDURE Right total knee arthroplasty using a Biomet cemented components 62 5 mm right cruciate retaining femoral component 71 mm Maxim tibial component and 12 mm polyethylene insert with 31 mm patella All components were cemented with Cobalt G ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME Less than 60 minutes The patient was taken to the Postanesthesia Care Unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 51 year old female complaining of worsening right knee pain The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling The patient requested surgical intervention and need for total knee replacement All risks benefits expectations and complications of surgery were explained to her in great detail and she signed informed consent All risks including nerve and vessel damage infection and revision of surgery as well as component failure were explained to the patient and she did sign informed consent The patient was given antibiotics preoperatively PROCEDURE DETAIL The patient was taken to the operating suite and placed in supine position on the operating table She was placed in the seated position and a spinal anesthetic was placed which the patient tolerated well The patient was then moved to supine position again and a well padded tourniquet was placed on the right thigh Right lower extremity was prepped and draped in sterile fashion All extremities were padded prior to this The right lower extremity after being prepped and draped in the sterile fashion the tourniquet was elevated and maintained for less than 60 minutes in this case A midline incision was made over the right knee and medial parapatellar arthrotomy was performed Patella was everted The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed The posterior cruciate ligament was intact There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild to moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case At the extramedullary tibial guide an extended cut was made adjusting for her alignment Once this was performed excess bone was removed The reamer was placed along on the femoral canal after which a 6 degree valgus distal cut was made along the distal femur Once this was performed the distal femoral size in 3 degrees external rotation 62 5 mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion Excess bone was removed Next the tibia was brought anterior and excised to 71 mm It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia Once this was performed a 71 mm tibial trial was placed as well as a 62 5 mm femoral trial was placed with a 12 mm polyethylene insert Next the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed The knee was taken for range of motion had excellent flexion and extension as well as adequate varus and valgus stability There was no loosening appreciated There is no laxity appreciated along the posterior cruciate ligament Once this was performed the trial components were removed The knee was irrigated with fluid and antibiotics after which the cement was put on the back table this being Cobalt G it was placed on the tibia The tibial components were tagged in position and placed on the femur The femoral components were tagged into position All excess cement was removed ___ placement of patella It was tagged in position A 12 mm polyethylene insert was placed knee was held in extension and all excess cement was removed The cement hardened with the knee in full extension after which any extra cement was removed The wounds were copiously irrigated with saline and antibiotics and medial parapatellar arthrotomy was closed with 2 Vicryl Subcutaneous tissue was approximated with 2 0 Vicryl and the skin was closed with staples The patient was awakened from general anesthetic transferred to the gurney and taken into postanesthesia care unit in stable condition The patient tolerated the procedure well Keywords orthopedic degenerative joint disease knee total knee arthroplasty biomet cemented cobalt g arthoplasty osteoarthritis polyethylene cruciate ligament patella femoral tibial MEDICAL_TRANSCRIPTION,Description Right hip osteoarthritis Total hip replacement on the right side Medical Specialty Orthopedic Sample Name Total Hip Replacement Transcription PREOPERATIVE DIAGNOSIS Right hip osteoarthritis POSTOPERATIVE DIAGNOSIS Right hip osteoarthritis PROCEDURES PERFORMED Total hip replacement on the right side using the following components 1 Zimmer trilogy acetabular system 10 degree elevated rim located at the 12 o clock position 2 Trabecular metal modular acetabular system 48 mm in diameter 3 Femoral head 32 mm diameter 0 mm neck length 4 Alloclassic SL offset stem uncemented for taper ANESTHESIA Spinal DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up After review of allergies antibiotics were administered and time out was performed The right lower extremity was prepped and draped in a sterile fashion A 15 cm to 25 cm in length an incision was made over the greater trochanter This was angled posteriorly Access to the tensor fascia lata was performed This was incised with the use of scissors Gluteus maximus was separated The bursa around the hip was identified and the bleeders were coagulated with the use of Bovie Hemostasis was achieved The piriformis fossa was identified and the piriformis fossa tendon was elevated with the use of a Cobb It was detached from the piriformis fossa and tagged with 2 0 Vicryl Access to the capsule was performed The capsule was excised from the posterior and superior aspects It was released also in the front with the use of a Mayo scissors The hip was then dislocated With the use of an oscillating saw the femoral neck cut was performed The acetabulum was then visualized and debrided from soft tissues and osteophytes Reaming was initiated and completed for a 48 mm diameter cap without complications The trial component was put in place and was found to be stable in an anatomic position The actual component was then impacted in the acetabulum A 10 degree lip polyethylene was also placed in the acetabular cap Our attention was then focused to the femur With the use of a cookie cutter the femoral canal was accessed The broaching process was initiated for No 4 trial component Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation In addition in full extension and external rotation there was no dislocation The actual component was inserted in place and hemostasis was achieved again The wound was irrigated with normal saline The wound was then closed in layers Before performing that the medium sized Hemovac drain was placed in the wound The tensor fascia lata was closed with 0 PDS and the wound was closed with 2 0 Monocryl Staples were used for the skin The patient recovered from anesthesia without complications EBL 50 mL IV FLUIDS 2 liters DRAINS One medium sized Hemovac COMPLICATIONS None DISPOSITION The patient was transferred to the PACU in stable condition She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions We will start the DVT prophylaxis after the removal of the epidural catheter Keywords orthopedic total hip replacement epidural catheter tensor fascia lata hemostasis was achieved medium sized hemovac tensor fascia fascia lata trial component medium sized sized hemovac total hip hip replacement hip osteoarthritis piriformis fossa total hip acetabular extremity tensor fascia hemostasis acetabulum dislocation hemovac replacement osteoarthritis femoral piriformis fossa components anesthesia MEDICAL_TRANSCRIPTION,Description NexGen left total knee replacement Degenerative arthritis of left knee The patient is a 72 year old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs Medical Specialty Orthopedic Sample Name Total Knee Replacement NexGen Transcription PREOPERATIVE DIAGNOSIS Degenerative arthritis of left knee POSTOPERATIVE DIAGNOSIS Degenerative arthritis of left knee PROCEDURE PERFORMED NexGen left total knee replacement ANESTHESIA Spinal TOURNIQUET TIME Approximately 66 minutes COMPLICATIONS None ESTIMATED BLOOD LOSS Approximately 50 cc COMPONENTS A NexGen stemmed tibial component size 5 was used 10 mm cruciate retaining polyethylene surface a NexGen cruciate retaining size E femoral component and a size 38 9 5 mm thickness All Poly Patella BRIEF HISTORY The patient is a 72 year old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs She wishes to proceed with arthroplasty at this time PROCEDURE The patient was taken to the Operative Suite at ABCD General Hospital on 09 11 03 She was placed on the operating table Department of Anesthesia administered a spinal anesthetic Once adequately anesthetized the left lower extremity was prepped and draped in the usual sterile fashion An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle Care was then ensured that the patellar tendon was not violated The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed Rongeur was used to take out any osteophytes and the size of approximately size E At this point the epicondyle axis guide was then inserted and aligned in a proper orientation The anterior cutting guide was then placed Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur After this was performed this was removed and the distal femoral cutting guide was then placed The left knee placed in 5 degrees of valgus guide was then placed and a standard distal cut was then taken After the cuts were ensured further to be leveled and they were and we proceeded to place the finishing guide size E and distal femur This was placed slightly in lateral position and secured in position with spring tense and head lift tense Once adequately secured and placed in the appropriate orientation the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws After this was performed the guide was removed and all bony fragments were then removed Attention was then directed to the tibia The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position Care was ensured if it is was a varus or valgus and the appropriate The femur gauge was then used to provide us appropriate amount of bony resection This was then pinned and secured into place Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability The trial components were then removed The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment After it was stemmed and broached these were removed and the patella was then incised a size 41 patella reamer blade was then used and was taken down a size 38 patella button was then placed intact Again the trial components were placed back into position Patella button was placed and the tracking was evaluated They tracked centrally with no touch technique Again all components were now removed and the knee was then copiously irrigated and suctioned dry Once adequately suctioned dry the tibial portion was cemented and packed into place Also excess cement was removed The femoral component was then cemented into position All excess cement was removed A size 12 poly was then inserted in trial to provide compression at cement adhered The patella was then cemented and held into place All components were held under compression until cement had adequately adhered all excess cement was then removed The knee was then taken through range of motion and size 12 felt to be slightly too big this was removed and the size 10 trial was replaced and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice The knee was again copiously irrigated and suctioned dry One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed there were none found and a final articulating surface was impacted and locked into place After this the knee was taken again for final range of motion and found to have excellent position stability and good alignment of the components The knee was once again copiously irrigated and the tourniquet was deflated Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained A drain was then placed deep to the retinaculum and the retinaculum repair was performed using 2 0 Ethibond and oversewn with a 1 Vicryl This was flexed and the repair was found held securely At this point the knee was again copiously irrigated and suctioned dry The subcutaneous tissue was closed with 2 0 Vicryl and the skin was approximated with skin staples Sterile dressing with Adaptic 4x4s ABDs and Kerlix rolls was then applied The patient was then transferred back to the gurney in a supine position DISPOSITION The patient tolerated well with no complications to PACU in satisfactory condition Keywords orthopedic degenerative arthritis nexgen stemmed tibial component all poly patella nexgen cruciate total knee replacement patellar tendon proximal tibia epicondyle axis bony fragments patella button tibial knee arthritis nexgen patella MEDICAL_TRANSCRIPTION,Description Transforaminal lumbar interbody fusion placement of intervertebral prosthetic device Medical Specialty Orthopedic Sample Name TLIF Transcription PREOPERATIVE DIAGNOSIS ES L4 L5 and L5 S1 degenerative disk disease disk protrusions spondylosis with radiculopathy POSTOPERATIVE DIAGNOSIS ES L4 L5 and L5 S1 degenerative disk disease disk protrusions spondylosis with radiculopathy PROCEDURE 1 Left L4 L5 and L5 S1 Transforaminal Lumbar Interbody Fusion TLIF 2 L4 to S1 fixation Danek M8 system 3 Right posterolateral L4 to S1 fusion 4 Placement of intervertebral prosthetic device Danek Capstone spacers L4 L5 and L5 S1 5 Vertebral autograft plus bone morphogenetic protein BMP COMPLICATIONS None ANESTHESIA General endotracheal SPECIMENS Portions of excised L4 L5 and L5 S1 disks ESTIMATED BLOOD LOSS 300 mL FLUIDS GIVEN IV crystalloid OPERATIVE INDICATIONS The patient is a 37 year old male presenting with a history of chronic persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management Preoperative imaging studies revealed the above noted abnormalities After a detailed review of management considerations with the patient and his wife he was elected to proceed as noted above Operative indications methods potential benefits risks and alternatives were reviewed The patient and his wife expressed understanding and consented to proceed as above OPERATIVE FINDINGS L4 L5 and L5 S1 disk protrusion with configuration as anticipated from preoperative imaging studies Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site In addition all pedicle screws were stimulated with findings of above threshold noted at all sites Spacer snugness and positioning appeared satisfactory Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported DESCRIPTION OF THE OPERATION After obtaining proper patient identification and appropriate preoperative informed consent the patient was taken to the operating room on a hospital stretcher in the supine position After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed The patient s posterior lumbosacral region was thoroughly cleansed and shaved The patient was then scrubbed prepped and draped in the usual manner After local infiltration with 1 lidocaine with 1 200 000 epinephrine solution a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum Dissection was continued in the midline to the level of the posterior fascia Self retaining retractors were placed and subsequently readjusted as needed The fascia was opened in the midline and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3 L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally _____ by completing the exposure pedicle screw fixation was carried out in the following manner Screws were placed in systematic caudal in a cranial fashion The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed Cortical openings were created at these sites using a small burr The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder They were then probed and subsequently tapped employing fluoroscopic guidance as needed Each site was under tapped and reprobed with satisfactory findings noted as above Screws in the following dimensions were placed 6 5 mm diameter screws were placed at all sites At S1 40 mm length screws were placed bilaterally At L5 40 mm length screws were placed bilaterally and at L4 40 mm length screws were placed bilaterally with findings as noted above The rod was then contoured to span from the L4 to the S1 screws on the right The distraction was placed across the L4 L5 interspace and the connections were temporarily secured Using a matchstick burr a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level This was longitudinally oriented A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression working from caudally to cranially and medially to laterally again using curettes and Kerrison rongeurs under direct visualization In this manner the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed Local epidural veins were coagulated with bipolar and divided Gelfoam was then placed in this area This process was then repeated in similar fashion thereby exposing the posterolateral aspect of the left L5 S1 disk space As noted distraction had previously been placed at L4 L5 this was released Distraction was placed across the L5 S1 interspace After completing satisfactory exposure as noted a annulotomy was made in the posterolateral left aspect of the L5 S1 disk space Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure The disk space was entered and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate Herniated portions of the disk were also removed in routine fashion The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion After completing this disk space preparation Gelfoam was again placed The decompression was assessed and appeared to be satisfactory The distraction was released and attention was redirected at L4 L5 where again distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion After completing the disk space preparation attention was redirected to L5 S1 Distraction was released at L4 L5 and again reapplied at L5 S1 incrementally increasing size Trial spaces were used and a 10 mm height by 26 mm length spacer was chosen A medium BMP kit was appropriately reconstituted A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space The spacer was then carefully impacted into position The distraction was released The spacer was checked with satisfactory snugness and positioning noted This process was then repeated in similar fashion at L4 L5 again with placement of a 10 mm height by 26 mm length Capstone spacer again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace This spacer was also checked again with satisfactory snugness and positioning noted The prior placement of the spacers and BMP the wound was thoroughly irrigated and dried with satisfactory hemostasis noted Surgicel was placed over the exposed dura and disk space The distraction was released on the right and compression plates across the L5 S1 and L4 L5 interspaces and the connections fully tightened in routine fashion The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4 L5 and L5 S1 facets on the right in a routine fashion A left sided rod was appropriated contoured and placed to span between the L4 to S1 screws Again compression was placed across the L4 L5 and L5 S1 segments and these connections were fully secured Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically The wound was closed using multiple simple interrupted 0 Vicryl sutures to reapproximate the deep paraspinal musculature in the midline The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0 Vicryl sutures The suprafascial subcutaneous layers were closed using multiple simple interrupted 0 and 2 0 Vicryl sutures The skin was then closed using staples Sterile dressings were then applied and secured in place The patient tolerated the procedure well and was to the recovery room in satisfactory condition Keywords orthopedic degenerative disk disease disk protrusions spondylosis radiculopathy tlif transforaminal lumbar interbody fusio danek m8 intervertebral prosthetic device danek capstone matchstick burr capstone bmp vertebral autograft screws were placed bilaterally pedicle screw kerrison rongeurs disk space disk spacers kerrison interbody rongeurs pedicle lumbar screws MEDICAL_TRANSCRIPTION,Description Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer Removal of antibiotic spacer and revision total hip arthroplasty Medical Specialty Orthopedic Sample Name Total Hip Arthroplasty Revision Transcription PREOPERATIVE DIAGNOSIS Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer POSTOPERATIVE DIAGNOSIS Infected right hip bipolar arthroplasty status post excision and placement of antibiotic spacer PROCEDURES 1 Removal of antibiotic spacer 2 Revision total hip arthroplasty IMPLANTS 1 Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6 5 x 30 mm screws 2 Zimmer femoral component 13 5 x 220 mm with a size AA femoral body 3 A 32 mm femoral head with a 0 neck length ANESTHESIA Regional ESTIMATED BLOOD LOSS 500 cc COMPLICATIONS None DRAINS Hemovac times one and incisional VAC times one INDICATIONS The patient is a 66 year old female with a history of previous right bipolar hemiarthroplasty for trauma This subsequently became infected She has undergone removal of this prosthesis and placement of antibiotic spacer She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip DESCRIPTION OF PROCEDURE The patient was brought to the operating room by anesthesia personnel She was placed supine on the operating table A Foley catheter was inserted A formal time out was obtained in identifying the correct patient operative site Preoperative antibiotics were held for intraoperative cultures The patient was placed into the lateral decubitus position with the right side up The previous surgical incision was identified The right lower extremity was prepped and draped in standard fashion The old surgical incision was reopened along its proximal extent Immediately encountered was a large amount of fibrous scar tissue Dissection was carried sharply down through this scar tissue Soft tissue plains were extremely difficult to visualize due to all the scarring There was no native tissue to orient oneself with We carried our dissection down through the scar tissue to what seemed to be a fascial layer We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed This was used as a landmark to orient remainder of the dissection The antibiotic spacer was exposed and followed distally to expose the proximal femur Dissection was continued posteriorly and proximally to expose the acetabulum A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure Once improved visualization was obtained the antibiotic spacer was removed from the femur This allowed further improved visualization of the acetabulum The acetabulum was filled with soft tissue debris and scar tissue This was removed with sharp excision with a knife as well as with a rongeur and a Bovie Once soft tissue was removed the acetabulum was reamed Reaming was started with a 46 mm reamer and carried up sequentially to prepare for 50 mm shell The 50 mm shell was trialed and had good stability and fit Attention was then turned to continue preparation of the femur The canal was then debrided with femoral canal curettes Some fibrous tissue was removed from the canal The length of the femoral stem was then checked with this canal curette in place Following x rays we prepared to begin reaming the femur This femur was reamed over a guide rod using flexible reaming rods The canal was reamed up to 13 5 mm distally in preparation for 14 mm stem The stem was selected and initially size A body was placed in trial The body was too tight proximally to fit The proximal canal was then reamed for a size AA body A longer stem with an anterior bow was selected and a size AA trial was assembled This fit nicely in the canal and had good fit and fill Intraoperative radiographs were obtained to determine component position Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur The remainder of the trial was then assembled and the hip was relocated and trialed Initially it was found to be unstable posteriorly We changed from a 10 degree lip liner to 20 degree lip liner Again the hip was trialed and found to be unstable posteriorly This was due to reversion of the femoral component As we attempted to seat the prosthesis the stent continued to attempt to turn in retroversion The stem was extracted and retrialed Improved stability was obtained and we decided to proceed with the real components A 20 degree liner was inserted into the acetabular shell The real femoral components were assembled and inserted into the femoral canal Again the hip was trialed The components were found to be in relative retroversion The real components were then backed down and the neck was placed in the more anteversion and reinserted Again the stem attempted to follow in the relative retroversion Along with this time however it was improved from previous attempts The femoral head trial was placed back on the components and the hip relocated It was taken to a range of motion and found to have improved stability compared to previous trialing Decision was made to accept the component position The real femoral head was selected and implanted The hip was then taken again to a range of motion It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation The patient reached full extension and had no instability anteriorly The wound was then irrigated again with pulsatile lavage Six liters of pulsatile lavage was used during the procedure The wound was then closed in a layered fashion A Hemovac drain was placed deep to the fascial layer The subcutaneous tissues were closed with 1 PDS 2 0 PDS and staples in the skin An incisional VAC was then placed over the wound as well Sponge and needle counts were correct at the close of the case DISPOSITION The patient will be weightbearing as tolerated with posterior hip precautions Keywords orthopedic infected bipolar arthroplasty antibiotic spacer revision placement of antibiotic spacer total hip arthroplasty scar tissue soft tissue antibiotic spacer femoral hip arthroplasty total acetabulum femur MEDICAL_TRANSCRIPTION,Description History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy Wound debridement x2 including skin subcutaneous and muscle Insertion of tissue expander to the medial and lateral wound Medical Specialty Orthopedic Sample Name Tissue Expander Insertion Transcription PREOPERATIVE DIAGNOSES History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy POSTOPERATIVE DIAGNOSES History of compartment syndrome right lower extremity status post 4 compartments fasciotomy to do incision for compartment fasciotomy OPERATIONS 1 Wound debridement x2 including skin subcutaneous and muscle 2 Insertion of tissue expander to the medial wound 3 Insertion of tissue expander to the lateral wound COMPLICATIONS None TOURNIQUET None ANESTHESIA General INDICATIONS This patient developed a compartment syndrome She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg She was doing very well and was obviously improving The swelling was reduced A compartment pressure had obviously improved based on examination She was therefore indicated for placement of tissue expander for ventral wound closure The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well Risks and benefits were all discussed risk of bleeding infection damage to blood vessels damage to nerve roots need for further surgery chronic pain with range of motion risk of continued discomfort risk of need for further reconstructive procedures risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed She understood them well All questions were answered and she signed the consent for the procedure as described DESCRIPTION OF THE PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The medial wound was noted to be approximately 10 5 cm in length x 4 cm The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width Both wounds were then thoroughly debrided The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides At this point adequate debridement was performed and healthy tissue did appear to be present Initially on the medial wound I did place the DermaClose RC continuous external tissue expander On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor I then did place adequate tension on the sutures Continued tension will be noted after engaging the tension controller At this point I performed the similar procedure to the lateral wound The skin anchors were placed separately and appropriately on either side of the skin margin The line loop from the tension controller was placed in lace like manner through the skin anchors The tension controller was then attached to the mid anchor and appropriate tension was applied It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained Adequate tension was placed in this region A non thick dressing was then applied to the open wound region and sterile dressing was then applied No complications were encountered throughout the procedure and the patient tolerated the procedure well The patient was taken to recovery room in stable condition Keywords orthopedic fasciotomy subcutaneous muscle wound debridement insertion of tissue expander compartment syndrome compartment fasciotomy lateral wound medial wound tension controller tissue expander wound tissue compartment MEDICAL_TRANSCRIPTION,Description Pain Three views of the right ankle Three views of the right ankle are obtained Medical Specialty Orthopedic Sample Name Three Views Ankle Transcription EXAM Three views of the right ankle INDICATIONS Pain FINDINGS Three views of the right ankle are obtained There is no evidence of fractures or dislocations No significant degenerative changes or destructive osseous lesions of the ankle are noted There is a small plantar calcaneal spur There is no significant surrounding soft tissue swelling IMPRESSION Negative right ankle Keywords orthopedic three views calcaneal plantar spur osseous ankle MEDICAL_TRANSCRIPTION,Description Right foot trauma Three views of the right foot Three views of the right foot were obtained Medical Specialty Orthopedic Sample Name Three Views Foot Transcription EXAM Three views of the right foot REASON FOR EXAM Right foot trauma FINDINGS Three views of the right foot were obtained There are no comparison studies There is no evidence of fractures or dislocations No significant degenerative changes or obstructive osseous lesions were identified There are no radiopaque foreign bodies IMPRESSION Negative right foot Keywords orthopedic three views radiopaque fractures foot trauma MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm Medical Specialty Orthopedic Sample Name Tenosynovectomy Cortisone Injection Transcription PREOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm POSTOPERATIVE DIAGNOSES 1 EMG proven left carpal tunnel syndrome 2 Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level 3 Dupuytren s nodule in the palm PROCEDURE Left carpal tunnel release with flexor tenosynovectomy cortisone injection of trigger fingers left third and fourth fingers injection of Dupuytren s nodule left palm ANESTHESIA Local plus IV sedation MAC ESTIMATED BLOOD LOSS Zero SPECIMENS None DRAINS None PROCEDURE DETAIL Patient brought to the operating room After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release 10 cc of a mixture of 1 Xylocaine and 0 5 Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery Routine prep and drape was employed Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure Hand was positioned palm up in the lead hand holder A short curvilinear incision about the base of the thenar eminence was made Skin was sharply incised Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm Proximally the antebrachial fascia was released for a distance of 2 3 cm proximal to the wrist crease to insure complete decompression of the median nerve Retinacular flap was retracted radially to expose the contents of the carpal canal Median nerve was identified seen to be locally compressed with moderate erythema and mild narrowing Locally adherent tenosynovium was present and this was carefully dissected free Additional tenosynovium was dissected from the flexor tendons individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5 0 nylon horizontal mattress sutures A syringe with 3 cc of Kenalog 10 and 3 cc of 1 Xylocaine using a 25 gauge short needle was then selected 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique 1 cc was injected into the fourth finger A1 A2 pulley tendon sheath using standard tendon sheath injection technique 1 cc was injected into the Dupuytren s nodule in the midpalm to relieve local discomfort Routine postoperative hand dressing with well padded well molded volar plaster splint and lightly compressive Ace wrap was applied Tourniquet was deflated Good vascular color and capillary refill were seen to return to the tips of all digits Patient discharged to the ambulatory recovery area and from there discharged home Discharge medication is Darvocet N 100 30 tablets one to two PO q 4h p r n Patient asked to begin gentle active flexion extension and passive nerve glide exercises beginning 24 48 hours after surgery She was asked to keep the dressings clean dry and intact and follow up in my office Keywords orthopedic carpal tunnel syndrome pulley dupuytren s tenosynovitis tenosynovectomy carpal tunnel release flexor tenosynovectomy cortisone injection dupuytren s nodule injection cortisone MEDICAL_TRANSCRIPTION,Description Painful enlarged navicula right foot Osteochondroma of right fifth metatarsal Partial tarsectomy navicula and partial metatarsectomy right foot Medical Specialty Orthopedic Sample Name Tarsectomy Transcription PREOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal POSTOPERATIVE DIAGNOSES 1 Painful enlarged navicula right foot 2 Osteochondroma of right fifth metatarsal PROCEDURE PERFORMED 1 Partial tarsectomy navicula right foot 2 Partial metatarsectomy right foot HISTORY This 41 year old Caucasian female who presents to ABCD General Hospital with the above chief complaint The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin She states that she has been diagnosed with hereditary osteochondromas She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back The patient desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 5 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal Foot was then prepped and draped in the usual sterile orthopedic fashion Foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was then inflated to 250 mmHg The foot was lowered as well as the operating table The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge Attention was then directed to the navicular region on the right foot The area was palpated until the bony prominence was noted A curvilinear incision was made over the area of bony prominence At that time a total of 10 cc with addition of 1 additional lidocaine plain was injected into the surgical site The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis The dissection was carried down to the level of the capsule and periosteum A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone The periosteum and the capsule were then reflected from the navicular bone at this time A bony prominence was noted both medially and plantarly to the navicular bone An osteotome and mallet were then used to resect the enlarged portion of the navicular bone After resection with an osteotome there was noted to be a large plantar shelf The surrounding soft tissues were then freed from this plantar area Care was taken to protect the attachments of the posterior tibial tendon as much as possible Only minimal resection of its attachment to the fiber was performed in order to expose the bone Sagittal saw was then used to resect the remaining plantar medial prominent bone The area was then smoothed with reciprocating rasp until no sharp edges were noted The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with 3 0 Vicryl The subcutaneous tissues were then reapproximated with 4 0 Vicryl to reduce tension from the incision and running 5 0 Vicryl subcuticular stitch was performed Attention was then directed to the fifth metatarsal There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal The incision was then deepened with 15 blade Care was taken to preserve the extensor tendon The incision was then created over the capsule and periosteum of the fifth metatarsal head Capsule and periosteum were reflected both dorsally laterally and plantarly At that time there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal A sagittal saw was used to resect both of these osteal prominences All remaining sharp edges were then smoothed with reciprocating rasp The area was inspected for the remaining bony prominences and none was noted The area was flushed with copious amounts of sterile saline The capsule and periosteum were then reapproximated with 3 0 Vicryl Subcutaneous closure was then performed with 4 0 Vicryl in order to reduce tension around the incision line Running 5 0 subcutaneous stitch was then performed Steri Strips were applied to both surgical sites Dressings consisted of Adaptic soaked in Betadine 4x4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot The patient tolerated the above procedure and anesthesia well without complications The patient was transferred to the PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated The patient is to follow up with Dr X in his office as directed or sooner if any problems or questions arise Keywords orthopedic navicula metatarsal osteochondroma tarsectomy metatarsectomy painful enlarged navicula navicular bone foot bony capsule periosteum navicular incision bone MEDICAL_TRANSCRIPTION,Description Tailor bunionectomy right foot Weil type with screw fixation Hallux abductovalgus deformity and tailor bunion deformity right foot Medical Specialty Orthopedic Sample Name Tailor Bunionectomy with Screw Fixation Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus deformity right foot 2 Tailor bunion deformity right foot PROCEDURES PERFORMED Tailor bunionectomy right foot Weil type with screw fixation ANESTHESIA Local with MAC local consisting of 20 mL of 0 5 Marcaine plain HEMOSTASIS Pneumatic ankle tourniquet at 200 mmHg INJECTABLES A 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate MATERIAL A 2 4 x 14 mm 2 4 x 16 mm and 2 0 x 10 mm OsteoMed noncannulated screw A 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl and 5 0 nylon COMPLICATIONS None SPECIMENS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was brought to the operating room and placed on the operating table in the usual supine position At this time a pneumatic ankle tourniquet was placed on the patient s right ankle for the purpose of maintaining hemostasis Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site The right foot was then scrubbed prepped and draped in the usual aseptic manner An Esmarch bandage was then used to exsanguinate the patient s right foot and the pneumatic ankle tourniquet inflated to 200 mmHg Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3 5 cm in length was made The incision was carried deep utilizing both sharp and blunt dissections All major neurovascular structures were avoided At this time through the original skin incision attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified This was then incised fully exposing the tendon and the abductor hallucis muscle This was then resected from his osseous attachments and a small tenotomy was performed At this time a small lateral capsulotomy was also performed Lateral contractures were once again reevaluated and noted to be grossly reduced Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw the head of the first metatarsal and medial eminence was resected and passed from the operative field A 0 045 inch K wire was then driven across the first metatarsal head in order to act as an access dye The patient was then placed in the frog leg position and two osteotomy cuts were made one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position The dorsal arm was made longer than the plantar arm to accommodate for fixation At this time the capital fragment was resected and shifted laterally into a more corrected position At this time three portions of the 0 045 inch K wire were placed across the osteotomy site in order to access temporary forms of fixation Two of the three of these K wires were removed in sequence and following the standard AO technique two 3 4 x 15 mm and one 2 4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site Compression was noted to be excellent All guide wires and 0 045 inch K wires were then removed Utilizing an oscillating bone saw the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field The wound was then once again flushed with copious amounts of sterile normal saline At this time utilizing both 2 0 and 3 0 Vicryl the periosteal and capsular layers were then reapproximated At this time the skin was then closed in layers utilizing 4 0 Vicryl and 4 0 nylon At this time attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal Utilizing an oscillating bone saw the lateral eminence was resected and passed from the operative field Utilizing the sagittal saw a Weil type osteotomy was made at the fifth metatarsal head The head was then shifted medially into a more corrected position A 0 045 inch K wire was then used as a temporary fixation and a 2 0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site This was noted to be in correct position and compression was noted to be excellent Utilizing a small bone rongeur the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field The wound was once again flushed with copious amounts of sterile normal saline The periosteal and capsular layers were reapproximated utilizing 3 0 Vicryl and the skin was then closed utilizing 4 0 Vicryl and 4 0 nylon At this time 10 mL of 0 5 Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site The right foot was then dressed with Xeroform gauze fluffs Kling and Ace wrap all applied in mild compressive fashion The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot After a brief period of postoperative monitoring the patient was discharged to home with proper written and verbal discharge instructions which included to keep dressing clean dry and intact and to follow up with Dr A The patient is to be nonweightbearing to the right foot The patient was given a prescription for pain medications on nonsteroidal anti inflammatory drugs and was educated on these The patient tolerated the procedure and anesthesia well Dr A was present throughout the entire case Keywords orthopedic tailor bunionectomy weil type screw fixation hallux abductovalgus bunion tailor deformity metatarsal phalangeal capsulotomy abductor hallucis MEDICAL_TRANSCRIPTION,Description Excision of mass left second toe and distal Symes amputation left hallux with excisional biopsy Mass left second toe Tumor Left hallux bone invasion of the distal phalanx Medical Specialty Orthopedic Sample Name Symes Amputation Hallux Transcription PREOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux bone invasion of the distal phalanx POSTOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux with bone invasion of the distal phalanx PROCEDURE PERFORMED 1 Excision of mass left second toe 2 Distal Syme s amputation left hallux with excisional biopsy HISTORY This 47 year old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size The patient also has history of shave biopsy in the past The patient does state that he desires surgical excision at this time PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 6 cc mixed with 1 lidocaine plain with 0 5 Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses The foot was lowered to the operating table The stockinet was reflected and the foot was cleansed with wet and dry sponge A distal Syme s incision was planned over the distal aspect of the left hallux The incision was performed with a 10 blade and deepened with 15 down to the level of bone The dorsal skin flap was removed and dissected in toto off of the distal phalanx There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx The tissue was sent to Pathology where Dr Green stated that a frozen sample would be of less use for examining for cancer Dr Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen At this time a sagittal saw was then used to resect all ends of bone of the distal phalanx The area was inspected for any remaining suspicious tissues Any suspicious tissue was removed The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon with a combination of simple and vertical mattress sutures Attention was then directed to the left second toe There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe A linear incision was made just medial to the tissue mass The mass was then dissected from the overlying skin and off of the underlying capsule This tissue mass was hard round and pearly gray in appearance It does not invade into any other surrounding tissues The area was then flushed with copious amounts of sterile saline and the skin was closed with 4 0 nylon Dressings consisted of Owen silk soaked in Betadine 4x4s Kling Kerlix and an Ace wrap The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr Bonnani in his office as directed The patient will be contacted immediately pending the results of pathology Cultures obtained in the case were aerobic and anaerobic gram stain Silver stain and a CBC Keywords orthopedic distal phalanx mass tumor hallux bone phalanx symes amputation excisional biopsy distal amputation invasion toe symes incision flushed excision tissue hallux MEDICAL_TRANSCRIPTION,Description Arthroscopic irrigation and debridement of same with partial synovectomy Septic left total knee arthroplasty Medical Specialty Orthopedic Sample Name Synovectomy Partial Transcription PREOPERATIVE DIAGNOSIS Septic left total knee arthroplasty POSTOPERATIVE DIAGNOSIS Septic left total knee arthroplasty OPERATION PERFORMED Arthroscopic irrigation and debridement of same with partial synovectomy ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None DRAINS None INDICATIONS The patient is an 81 year old female who is approximately 10 years status post total knee replacement performed in another state who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection The patient knee was aspirated in the office and cultures were positive for Escherichia coli She presents for operative therapy DESCRIPTION OF OPERATION After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position The left upper extremity was prepped and draped without a tourniquet The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created The arthroscopy was inserted and a complete diagnostic was performed Arthroscopic pictures were taken throughout the procedure The knee was copiously irrigated with 9 L of irrigant A partial synovectomy was performed in all compartments Minimal amount of polyethylene wear was noted The total knee components were identified arthroscopically for future revision surgery The knee was then drained and the arthroscopic instruments were removed The portals were closed with 4 0 nylon and local anesthetic was injected A sterile dressing was applied and the patient was placed in a knee immobilizer awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well Keywords orthopedic total knee arthroplasty arthroscopic irrigation debridement partial synovectomy knee arthroscopic irrigation arthroscopy synovectomy MEDICAL_TRANSCRIPTION,Description Excision of volar radial wrist mass inflammatory synovitis and radial styloidectomy right wrist Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion Medical Specialty Orthopedic Sample Name Styloidectomy Transcription PREOPERATIVE DIAGNOSIS Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion POSTOPERATIVE DIAGNOSIS Right wrist pain with an x ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst synovitis was debrided and removed PROCEDURE Excision of volar radial wrist mass inflammatory synovitis and radial styloidectomy right wrist ANESTHESIA Axillary block plus IV sedation ESTIMATED BLOOD LOSS Zero SPECIMENS 1 Inflammatory synovitis from the volar radial wrist area 2 Inflammatory synovitis from the dorsal wrist area DRAINS None PROCEDURE DETAIL Patient brought to the operating room After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff Routine prep and drape was employed Patient received 1 gm of IV Ancef preoperatively Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet Tourniquet inflated to 250 mmHg pressure Hand positioned palm up in a lead hand holder A longitudinal zigzag incision over the volar radial wrist mass was made Skin was sharply incised Careful blunt dissection was used in the subcutaneous tissue Antebrachial fascia was bluntly dissected and incised to reveal the radial artery Radial artery was mobilized preserving its dorsal and palmar branches Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery Wrist mass was exposed by blunt dissection This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule This was debrided down to the wrist capsule with visualization of the joint through a small capsular window After complete volar synovectomy the capsular window was closed with 4 0 Mersilene figure of eight suture Subcutaneous tissue was closed with 4 0 PDS and the skin was closed with a running subcuticular 4 0 Prolene Forearm was pronated and C arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision An oblique incision overlying the radial styloid centered on the second extensor compartment was made Skin was sharply incised Blunt dissection was used in the subcutaneous tissue Care was taken to identify and protect the superficial radial nerve Blunt dissection was carried out in the extensor retinaculum This was incised longitudinally over the second extensor compartment EPL tendon was identified mobilized and released to facilitate retraction and prevent injury The interval between the ECRL and the ECRB was developed down to bone Dorsal capsulotomy was made and local synovitis was identified This was debrided and sent as second pathologic specimen Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard eburnated subchondral bone consistent with a SLAC pattern arthritis Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer Dorsally the styloidectomy was beveled smooth and contoured with a rongeur Final x rays documenting the styloidectomy were obtained Local synovitis beneath the joint capsule was debrided Remnants of the scapholunate interosseous which was completely deteriorated were debrided The joint capsule was closed anatomically with 4 0 PDS and extensor retinaculum was closed with 4 0 PDS Subcutaneous tissues closed with 4 0 Vicryl Skin was closed with running subcuticular 4 0 Prolene Steri Strips were applied to wound edge closure 10 cc of 0 5 plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied Tourniquet was deflated Good vascular color and capillary refill were seen to return to the tips of all digits Patient discharged to the ambulatory recovery area and from there discharged home DISCHARGE PRESCRIPTIONS 1 Keflex 500 mg tablets 20 one PO q 6h x 5 days 2 Vicodin 40 tablets one to two PO q 4h p r n 3 Percocet 20 tablets one to two PO q 3 4h p r n severe pain Keywords orthopedic osteophytic spurring ganglion synovitis volar radial wrist mass excision inflammatory synovitis radial styloidectomy inflammatory styloidectomy volar wrist radial mass MEDICAL_TRANSCRIPTION,Description Posterior spinal fusion and spinal instrumentation Posterior osteotomy posterior elements to include laminotomy foraminotomy and decompression of the nerve roots Medical Specialty Orthopedic Sample Name Spinal Fusion Instrumentation Transcription PREOPERATIVE DIAGNOSIS Severe scoliosis ANESTHESIA General Lines were placed by Anesthesia to include an A line PROCEDURES 1 Posterior spinal fusion from T2 L2 2 Posterior spinal instrumentation from T2 L2 3 A posterior osteotomy through T7 T8 and T8 T9 Posterior elements to include laminotomy foraminotomy and decompression of the nerve roots IMPLANT Sofamor Danek Medtronic Legacy 5 5 Titanium system MONITORING SSEPs and the EPs were available INDICATIONS The patient is a 12 year old female who has had a very dysmorphic scoliosis She had undergone a workup with an MRI which showed no evidence of cord abnormalities Therefore the risks benefits and alternatives were discussed with Surgery with the mother to include infections bleeding nerve injuries vascular injuries spinal cord injury with catastrophic loss of motor function and bowel and bladder control I also discussed ___________ and need for revision surgery The mom understood all this and wished to proceed PROCEDURE The patient was taken to the operating room and underwent general anesthetic She then had lines placed and was then placed in a prone position Monitoring was then set up and it was then noted that we could not obtain motor evoked potentials The SSEPs were clear and were compatible with the preoperative but no preoperative motors had been done and there was a concern that possibly this could be from the result of the positioning It was then determined at that time that we would go ahead and proceed to wake her up and make sure she could move her feet She was then lightened under anesthesia and she could indeed dorsiflex and plantarflex her feet so therefore it was determined to go ahead and proceed with only monitoring with the SSEPs The patient after being prepped and draped sterilely a midline incision was made and dissection was carried down The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes This occurred from T2 L2 Fluoroscopy was brought in to verify positions and levels Once this was done and all bleeding was controlled retractors were then placed Attention was then turned towards placing screws first on the left side Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance The area was opened with a high speed burr and then the track was defined with a blunt probe and a ball tipped feeler was then utilized to verify all walls were intact They were then tapped and then screws were then placed This technique was used at L1 and L2 both the right and left At T12 a direct straight ahead technique was utilized where the facet was removed and then the position was chosen under the fluoroscopy and then it was spurred the track was defined and then probed and tapped and it was felt to be in good position Two screws in the right and left were placed at T12 as well reduction screws on the left The same technique was used for T11 where right and left screws were placed as well as T10 on the left At T9 a screw was placed on the left and this was a reduction screw On the left at T8 a screw could not be placed due to the dysmorphic nature of the pedicle It was not felt to be intact therefore a screw was left out of this On the right a thoracic screw was placed as well as at 7 and 6 This was the dysmorphic portion of this Screws were attempted to be placed up they could not be placed so attention was then turned towards placing pedicle hooks Pedicle hooks were done by first making a box out of the pedicle removing the complete pedicle feeling the undersurface of the pedicle with a probe and then seating the hook Upgoing pedicle hooks were placed at T3 T4 and T5 A downgoing laminar hook was placed at the T7 level Screws had been placed at T6 and T7 on the right An upgoing pedicle hook was also placed at T3 on the right and then downgoing laminar hooks were placed at T2 This was done by first using a transverse process lamina finders to go around the transverse process and then ___________ laminar hooks Once all hooks were in place spinal osteotomies were performed at T7 T8 and T8 T9 This was the level of the kyphosis to bring her back out of her kyphoscoliosis First the ligamentum flavum was resected using a large Kerrisons Next the laminotomy was performed and then a Kerrison was used to remove the ligamentum flavum at the level of the facet Once this was accomplished a laminotomy was performed by removing more of the lamina and to create a small wedge that could be closed down later to correct the kyphosis This was then brought out with resection of bone out to the foramen doing a foraminotomy to free up the foramen on both sides This was done also between the T8 T9 Once this was completed Gelfoam was then placed Next we observed and measured and contoured The rods were then seated on the left and then a derotation maneuver was performed Hooks had come loose so the rod was removed on the left The hooks were then replaced and the rod was reseated Again it was derotated to give excellent correction Hooks were then well seated underneath and therefore they were then locked A second rod was then chosen on the right and was measured contoured and then seated Next once this was done the rods were locked in the midsubstance and then the downgoing pedicle hook which had been placed at T7 was then helped to compress T8 as was the pedicle screw and then this compressed the osteotomy sites quite nicely Next distraction was then utilized to further correct at the spine and to correct on the left the left concave curve which gave excellent correction On the right compression was used to bring it down and then in the lower lumbar areas distraction and compression were used to level out L2 Once this was done all screws were tightened Fluoroscopy was then brought in to verify L1 was level and the first ribs were also level and it gave a nice balanced spine Everything was copiously irrigated ___________ Next a wake up test was performed and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet The patient was then again sedated and brought back under general anesthesia Next a high speed burr was used for decortication After final tightening had been accomplished and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound The open canal areas had been protected with Gelfoam Once this was accomplished the deep fascia was closed with multiple figure of eight 1 s oversewn with a running 1 _________ were then placed in the subcutaneous spaces which were then closed with 3 0 Vicryl and then the skin was closed with 3 0 Monocryl and Dermabond Sterile dressing was applied Drains had been placed in the subcutaneous layer x2 The patient during the case had no changes in the SSEPs had a normal wake up test and had received Ancef and clindamycin during the case She was taken from the operating room in good condition Keywords orthopedic osteotomy laminotomy foraminotomy sofamor danek sseps spinal fusion transverse processes pedicle hooks pedicle laminotomy hooks screws instrumentation decompression scoliosis sofamor foraminotomy spinal MEDICAL_TRANSCRIPTION,Description Thoracic right sided discectomy at T8 T9 The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 Medical Specialty Orthopedic Sample Name Thoracic Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 OPERATION PERFORMED Thoracic right sided discectomy at T8 T9 BRIEF HISTORY AND INDICATION FOR OPERATION The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 She has failed conservative measures and sought operative intervention for relief of her symptoms For details of workup please see the dictated operative report DESCRIPTION OF OPERATION Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected Second check was made prior to prepping and draping Following this we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8 T9 level We then made an approach through a midline incision and came out over the pars We dissected down carefully to identify the pars We then went on the outside of the pars and identified the foramen and then we took another series of x rays to confirm the T8 T9 level We did this under live fluoroscopy We confirmed T8 T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars The pars was then drilled out We identified the disc even further and found the disc herniation material that was under the spinal cord We then took a combination of small pituitaries and removed the disc material without difficulty Once we had disc material out we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further Once we had done that we inspected up by the nerve root found some more disc material there and removed that as well We could trace the nerve root out freely and easily We made sure there was no evidence of further disc material We used an Epstein curette and placed a nerve hook under the nerve root The Epstein curette removed some more disc material Once we had done this we were satisfied with the decompression We irrigated the wound copiously to make sure there is no further disc material and then ready for closure We did place some steroid over the nerve root and readied for closure Hemostasis was meticulous The wound was closed with 1 Vicryl suture for the fascial layer 2 Vicryl suture for the skin and Monocryl and Steri Strips applied Dressing was applied The patient was awoken from anesthesia and taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 150 mL COMPLICATIONS None DISPOSITION To PACU in stable condition having tolerated the procedure well to mobilize routinely when she is comfortable to go to her home Keywords orthopedic thoracic right sided discectomy herniated nucleus pulposus discectomy thoracic herniated MEDICAL_TRANSCRIPTION,Description Repeat irrigation and debridement of Right distal femoral subperiosteal abscess Medical Specialty Orthopedic Sample Name Subperiosteal Abscess Debridement Transcription PREOPERATIVE DIAGNOSIS Right distal femoral subperiosteal abscess POSTOPERATIVE DIAGNOSIS Right distal femoral subperiosteal abscess OPERATION Repeat irrigation and debridement of above ANESTHESIA General BLOOD LOSS Minimal FLUID Per anesthesia DRAINS Hemovac times two COMPLICATIONS None apparent SPECIMENS To microbiology INDICATIONS She is a 10 year old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur I am bringing her back to the operating room for another exploration of this area and washout This will be the third procedure for this At the last time there was gross purulence that was encountered Since that time the patient has defervesced Her white count is slowly coming down Her C reactive protein is slowly coming down PROCEDURE IN DETAIL After informed consent was obtained operative site marked and after preoperative antibiotics were given the patient was brought back to the operating room and placed supine on the operating table where Anesthesia induced general anesthesia The patient s right lower extremity was prepped and draped in normal sterile fashion Surgical timeout occurred verifying the patient s identification surgical site surgical procedure and administration of antibiotics The patient s previous incision sites had the sutures removed We bluntly dissected down through to the IT band These deep stitches were then removed We exposed the area of the subperiosteal abscess The tissue looked much better than at the last surgery We irrigated this area with three liters of saline containing bacitracin Next we made our small medial window to assist with washout of the joint itself We put another three liters of saline containing bacitracin through the knee joint Lastly we did another three liters into the area of the distal femur with three liters of plain saline We then placed two Hemovac drains one in the metaphysis and one superficially We closed the deep fascia with 1 PDS Subcutaneous layers with 2 0 Monocryl and closed the skin with 2 0 nylon We placed a sterile dressing We then turned the case over to Dr Petty for dressing change and skin graft PLAN Our plan will be to pull the drains in 48 hours We will then continue to watch the patient s fever curve and follow her white count to see how she is responding to the operative and medical therapies Keywords orthopedic repeat irrigation and debridement repeat irrigation distal femur distal femoral femoral subperiosteal subperiosteal abscess hemovac femur debridement irrigation saline anesthesia distal subperiosteal abscess MEDICAL_TRANSCRIPTION,Description Subcutaneous transposition of the right ulnar nerve Right carpal tunnel syndrome and right cubital tunnel syndrome Medical Specialty Orthopedic Sample Name Subcutaneous Transposition of Ulnar Nerve Transcription PREOPERATIVE DIAGNOSIS 1 Right carpal tunnel syndrome 2 Keywords orthopedic subcutaneous transposition ulnar nerve carpal tunnel syndrome cubital tunnel syndrome tourniquet subcutaneous epicondyle antebrachial syndrome cubital ulnar nerve tunnel MEDICAL_TRANSCRIPTION,Description Anterior spine fusion from T11 L3 Posterior spine fusion from T3 L5 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft Medical Specialty Orthopedic Sample Name Spine Fusion Transcription PREOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis POSTOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis PROCEDURES 1 Anterior spine fusion from T11 L3 2 Posterior spine fusion from T3 L5 3 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft ESTIMATED BLOOD LOSS 500 mL FINDINGS The patient was found to have a severe scoliosis This was found to be moderately corrected Hardware was found to be in good positions on AP and lateral projections using fluoroscopy INDICATIONS The patient has a history of severe neurogenic scoliosis He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression Risks and benefits were discussed at length with the family over many visits They wished to proceed PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position General anesthesia was induced without incident He was given a weight adjusted dose of antibiotics Appropriate lines were then placed He had a neuromonitoring performed as well He was then initially placed in the lateral decubitus position with his left side down and right side up An oblique incision was then made over the flank overlying the 10th rib Underlying soft tissues were incised down at the skin incision The rib was then identified and subperiosteal dissection was performed The rib was then removed and used for autograft placement later The underlying pleura was then split longitudinally This allowed for entry into the pleural space The lung was then packed superiorly with wet lap The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine Once the spine was achieved subperiosteal dissection was performed over the visualized vertebral bodies This required cauterization of the segmental vessels Once the subperiosteal dissection was performed to the posterior and anterior extents possible the diskectomies were performed These were performed from T11 L3 This was over 5 levels Disks and endplates were then removed Once this was performed morcellized rib autograft was placed into the spaces The table had been previously bent to allow for easier access of the spine This was then straightened to allow for compression and some correction of the curvature The diaphragm was then repaired as was the pleura overlying the thoracic cavity The ribs were held together with 1 Vicryl sutures Muscle layers were then repaired using a running 2 0 PDS sutures and the skin was closed using running inverted 2 0 PDS suture as well Skin was closed as needed with running 4 0 Monocryl This was dressed with Xeroform dry sterile dressings and tape The patient was then rotated into a prone position The spine was prepped and draped in a standard fashion Longitudinal incision was made from T2 L5 The underlying soft tissues were incised down at the skin incision Electrocautery was then used to maintain hemostasis The spinous processes were then identified and the overlying apophyses were split This allowed for subperiosteal dissection over the spinous processes lamina facet joints and transverse processes Once this was completed the C arm was brought in which allowed for easy placement of screws in the lumbar spine These were placed at L4 and L5 The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum This was done using a rongeur as well as a Kerrison rongeur Spinous processes were then harvested for morcellized autograft Once all the interspaces were prepared Songer wires were then passed These were placed from L3 T3 Once the wires were placed a unit rod was then positioned This was secured initially at the screws distally on both the left and right side The wires were then tightened in sequence from the superior extent to the inferior extent first on the left sided spine where I was operating and then on the right side spine This allowed for excellent correction of the scoliotic curvature Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin This was done using pulsed lavage The wound was then closed in layers The deep fascia was closed using running 1 PDS suture subcutaneous tissue was closed using running inverted 2 0 PDS suture the skin was closed using 4 0 Monocryl as needed The wound was then dressed with Steri Strips Xeroform dry sterile dressings and tape The patient was awakened from anesthesia and taken to the intensive care unit in stable condition All instrument sponge and needle counts were correct at the end of the case The patient will be managed in the ICU and then on the floor as indicated Keywords orthopedic anterior spine fusion posterior spine fusion spine segmental instrumentation dry sterile dressings autograft and allograft pds sutures spinous processes spine fusion spine instrumentation morcellized allograft fusion autograft MEDICAL_TRANSCRIPTION,Description Superior labrum anterior and posterior lesion repair Medical Specialty Orthopedic Sample Name Superior Labrum Lesions Repair Transcription PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed on the operating room table in supine position and given anesthetic Once adequate anesthesia had been achieved a careful examination of the shoulder was performed It revealed no patholigamentous laxity We then placed the patient into a beach chair position maintaining a neutral alignment of the head neck and thorax The shoulder was then prepped and draped in the usual sterile fashion We then injected the glenohumeral joint with 60 cc of sterile saline solution A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion Through this incision a blunt trocar was placed We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint We found that the articular surface was in good condition The biceps was found to be intact There was a SLAP tear noted just posterior to the biceps Pictures were taken No Bankart or Hill Sachs lesions were noted The rotator cuff was examined and there were no undersurface tears Pictures were again taken We then made a lateral portal going through the muscle belly of the rotator cuff A drill hole was made and then knotless suture anchor was placed to repair this Pictures were taken We then washed out the joint with copious amounts of sterile saline solution It was drained Our 3 incisions were closed using 3 0 nylon suture A pain pump catheter was introduced into the shoulder joint Xeroform 4 x 4s ABDs tape and sling were placed The patient was successfully taken out of the beach chair position extubated and brought to the recovery room in stable condition I then went out and spoke with the patient s family going over the case postoperative instructions and followup care Keywords orthopedic laxity patholigamentous superior labrum saline solution anterior superior lesions repair sterile joint shoulder MEDICAL_TRANSCRIPTION,Description Spinal Manipulation under Anesthesia Sacro iliitis lumbo sacral segmental dysfunction thoraco lumbar segmental dysfunction associated with myalgia fibromyositis Medical Specialty Orthopedic Sample Name Spinal Manipulation Transcription PREOPERATIVE DIAGNOSIS Sacro iliitis 720 2 lumbo sacral segmental dysfunction 739 3 thoraco lumbar segmental dysfunction 739 2 associated with myalgia fibromyositis 729 1 POSTOPERATIVE DIAGNOSIS Sacro iliitis 720 2 lumbo sacral segmental dysfunction 739 3 thoraco lumbar segmental dysfunction 739 2 associated with myalgia fibromyositis 729 1 ANESTHESIA Conscious Sedation INFORMED CONSENT After adequate explanation of the medical surgical and procedural options this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia MUA The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results INDICATION This patient has failed extended conservative care of condition dysfunction by means of aggressive physical medical and pharmacological intervention COMMENTS This patient understands the essence of the diagnosis and the reasons for the MUA The associated risks of the procedure including anesthesia complications fracture vascular accidents disc herniation and post procedure discomfort were thoroughly discussed with the patient Alternatives to the procedure including the course of the condition without MUA were discussed The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome The patient has given both verbal and written informed consent for the listed procedure PROCEDURE IN DETAIL The patient was draped in the appropriate gowning and accompanied to the operative area Following their sacral block injection they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure When the patient and I were ready the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching mobilization and adjustments necessary for the completion of the outcome I desired THORACIC SPINE With the patient in the supine position on the operative table the upper extremities were flexed at the elbow and crossed over the patient s chest to achieve maximum traction to the patient s thoracic spine The first assistant held the patient s arms in the proper position and assisted in rolling the patient for the adjusting procedure With the help of the first assist the patient was rolled to their right side selection was made for the contact point and the patient was rolled back over the doctor s hand The elastic barrier of resistance was found and a low velocity thrust was achieved using a specific closed reduction anterior to posterior superior manipulative procedure The procedure was completed at the level of TI TI2 Cavitation was achieved LUMBAR SPINE SACRO ILIAC JOINTS With the patient supine on the procedure table the primary physician addressed the patient s lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal Linear force was used to increase the hip flexion gradually during this maneuver Simultaneously the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane lateral oblique cephalad traction and medial oblique cephalad traction maneuver The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance a piriformis myofascial release was accomplished at this time This was repeated with the opposite lower extremity Following this a Patrick Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance With the assisting physician stabling the pelvis and femoral head as necessary the primary physician extended the right lower extremity in the sagittal plane and while applying controlled traction gradually stretched the para articular holding elements of the right hip by means gradually describing an approximately 30 35 degree horizontal arc The lower extremity was then tractioned and straight caudal and internal rotation was accomplished Using traction the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees This procedure was then repeated using external rotation to stretch the para articular holding elements of the hips bilaterally These procedures were then repeated on the opposite lower extremity By approximating the patient s knees to the abdomen in a knee chest fashion ankles crossed the lumbo pelvic musculature was stretched in the sagittal plane by both the primary and first assist contacting the base of the sacrum and raising the lower torso cephalad resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance Keywords orthopedic fibromyositis myalgia segmental dysfunction sacro iliitis spinal manipulation under anesthesia lumbar segmental dysfunction informed consent iliac joints spinal manipulation sacro iliitis lower extremity spinal mua cephalad dysfunction segmental lumbar MEDICAL_TRANSCRIPTION,Description Frontal and lateral views of the hip and pelvis Medical Specialty Orthopedic Sample Name Slipped Capital Femoral Epiphysis SCFE Transcription EXAM Two views of the pelvis HISTORY This is a patient post surgery 2 1 2 months The patient has a history of slipped capital femoral epiphysis SCFE bilaterally TECHNIQUE Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM DD YYYY Lateral view of the right hip was evaluated FINDINGS Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient s most recent priors dated MM DD YYYY Current films reveal stable appearing post surgical changes Again demonstrated is a single intramedullary screw across the left femoral neck and head There are 2 intramedullary screws through the greater trochanter of the right femur There is a lucency along the previous screw track extending into the right femoral head and neck There has been interval removal of cutaneous staples and or surgical clips These were previously seen along the lateral aspect of the right hip joint Deformity related to the previously described slipped capital femoral epiphysis is again seen IMPRESSION 1 Stable appearing right hip joint status post pinning 2 Interval removal of skin staples as described above Keywords orthopedic scfe frontal and lateral views slipped capital femoral epiphysis lateral views slipped capital epiphysis frontal pelvis femoral hip MEDICAL_TRANSCRIPTION,Description Arthroscopic subacromial decompression and repair of rotator cuff through mini arthrotomy Medical Specialty Orthopedic Sample Name Rotator Cuff Repair Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear left POSTOPERATIVE DIAGNOSES 1 Sixty percent rotator cuff tear joint side 2 Impingement syndrome ANESTHESIA General NAME OF OPERATION 1 Arthroscopic subacromial decompression 2 Repair of rotator cuff through mini arthrotomy FINDINGS AT OPERATION The patient s glenohumeral joint was completely clear other than obvious tear of the rotator cuff The midportion of this appeared to be complete but for the most part this was about a 60 rupture of the tendon This was confirmed later when the bursal side was opened up Note the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted PROCEDURE He was given an anesthetic examined prepped and draped in a sterile fashion in a beach chair position The shoulder was instilled with fluid from posteriorly followed by the arthroscope The shoulder was instilled with fluid from posteriorly followed by the arthroscope Arthroscopy was then carried out in standard fashion using a 30 degree Dionic scope With the scope in the posterior portal the above findings were noted and an anterior portal was established A curved shaver was placed for debridement of the tear I established this was about a 60 70 tear with a probable complete area of tear which was very small There were no problems at the biceps or the rest of the joint The subacromial space showed findings as noted above and a thorough subacromial decompression was carried out with a Bovie rotary shaver and bur I did not debride the acromioclavicular joint The lateral portal was then extended to a mini arthrotomy and subacromial space was entered by blunt dissection through the deltoid The area of weakness of the tendon was found and was transversely cut and findings were confirmed The diseased tissue was removed and the greater tuberosity was abraded with a rongeur Tendon to tendon repair was then carried out with buried sutures of 2 0 Ethibond giving a very nice repair The shoulder was carried through a range of motion I could see no evidence of impingement Copious irrigation was carried out The deltoid deep fascia was anatomically closed as was the superficial fascia The subcutaneous tissue and skin were closed in layers A sterile dressing was applied The patient appeared to tolerate the procedure well Keywords orthopedic rotator cuff tear mini arthrotomy repair of rotator cuff arthroscopic subacromial decompression arthroscopic subacromial cuff tear subacromial space subacromial decompression mini arthrotomy acromioclavicular joint rotator cuff arthroscopic decompression acromioclavicular impingement rotator cuff MEDICAL_TRANSCRIPTION,Description Left shoulder injury A 41 year old male presenting for initial evaluation of his left shoulder Medical Specialty Orthopedic Sample Name Shoulder Contusion Transcription CHIEF COMPLAINT Keywords orthopedic shoulder injury two views shoulder contusion MEDICAL_TRANSCRIPTION,Description Consultation for right shoulder pain Medical Specialty Orthopedic Sample Name Shoulder Pain Consult Transcription CHIEF COMPLAINT Right shoulder pain HISTORY OF PRESENT PROBLEM Keywords orthopedic shoulder pain history of present problem cortisone shot no numbness or tingling rhomboids scapula shoulder impingement focal findings shoulder MEDICAL_TRANSCRIPTION,Description Followup left sided rotator cuff tear and cervical spinal stenosis Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis Medical Specialty Orthopedic Sample Name Rotator Cuff Tear Transcription REASON FOR VISIT Followup left sided rotator cuff tear and cervical spinal stenosis HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy I had last seen her on 06 21 07 At that time she had been referred to me Dr X and Dr Y for evaluation of her left sided C6 radiculopathy She also had a significant rotator cuff tear and is currently being evaluated for left sided rotator cuff repair surgery I believe on approximately 07 20 07 At our last visit I only had a report of her prior cervical spine MRI I did not have any recent images I referred her for cervical spine MRI and she returns today She states that her symptoms are unchanged She continues to have significant left sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr Y She also has a second component of pain which radiates down the left arm in a C6 distribution to the level of the wrist She has some associated minimal weakness described in detail in our prior office note No significant right upper extremity symptoms No bowel bladder dysfunction No difficulty with ambulation FINDINGS On examination she has 4 plus over 5 strength in the left biceps and triceps muscle groups 4 out of 5 left deltoid 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities Light touch sensation is minimally decreased in the left C6 distribution otherwise intact Biceps and brachioradialis reflexes are 1 plus Hoffmann sign normal bilaterally Motor strength is 5 out of 5 in all muscle groups in lower extremities Hawkins and Neer impingement signs are positive at the left shoulder An EMG study performed on 06 08 07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity Cervical spine MRI dated 06 28 07 is reviewed It is relatively limited study due to artifact He does demonstrate evidence of minimal to moderate stenosis at the C5 C6 level but without evidence of cord impingement or cord signal change There appears to be left paracentral disc herniation at the C5 C6 level although axial T2 weighted images are quite limited ASSESSMENT AND PLAN Ms ABC s history physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis I agree with the plan to go ahead and continue with rotator cuff surgery With regard to the radiculopathy I believe this can be treated non operatively to begin with I am referring her for consideration of cervical epidural steroid injections The improvement in her pain may help her recover better from the shoulder surgery I will see her back in followup in 3 months at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine I will also be in touch with Dr Y to let him know this information prior to the surgery in several weeks Keywords orthopedic upper extremity radiculopathy rotator cuff repair cervical spinal stenosis rotator cuff tear physical examination cuff impingement stenosis extremity surgery tear shoulder rotator cervical MEDICAL_TRANSCRIPTION,Description Scarf bunionectomy procedure of the first metatarsal of the left foot Hallux abductovalgus deformity with bunion of the left foot Medical Specialty Orthopedic Sample Name Scarf Bunionectomy Transcription PREOPERATIVE DIAGNOSIS Hallux abductovalgus deformity with bunion of the left foot POSTOPERATIVE DIAGNOSIS Hallux abductovalgus deformity with bunion of the left foot PROCEDURE PERFORMED Scarf bunionectomy procedure of the first metatarsal of the left foot ANESTHESIA IV sedation with local HISTORY This patient is a 55 year old female who presents to ABCD preoperative holding area after keeping herself n p o since mid night for surgery for her painful left bunion The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes The patient has failed to conservative treatment and desires surgical correction at this time Risks versus benefits of the procedure have been explained in detail by Dr X and consent is available on the chart for review PROCEDURE IN DETAIL After an IV established by the Department of Anesthesia the patient was given preoperatively 600 mg of clindamycin intravenously The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection Next a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient s protection After adequate IV sedation was applied the patient was given a local injection consisting of 17 cc of 4 5 cc 1 lidocaine plain 4 5 cc of 0 5 Marcaine plain and 1 0 cc of Solu Medrol mixture in the standard Mayo block to the left foot The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was then elevated the Esmarch was applied and the tourniquet was inflated to 250 mmHg The foot was then lowered to the operating field A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot After sufficient anesthesia using a 10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally just near to the extensor hallucis longus tendon Then using a fresh 15 blade this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery A neurovascular bundle was identified and reflected medially Laterally the extensor hallucis longus tendon was identified and protected with retraction as well Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully The first metatarsophalangeal joint capsule was then identified and using a 15 blade a linear incision made down to the bone through the joint capsule The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint The bone cortex was noted to be intact and in good condition Following this using a sagittal saw with a 138 blade the attention was directed to the medial hypertrophic bone of the first metatarsal head In the sagittal plane with the blade angulated from dorsolateral to proximal medial the medial eminence of bone was resected Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well Following this bone cut 0 45 K wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head Then using the Reese osteotomy guide the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal A second 0 45 K wire was inserted proximally as well Following this using the sagittal saw with the 138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made This began with the dorsal distal cut which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal Following this attention was directed proximally and an incision osteotomy cut through the bone was made directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone Following this the distal portion of the osteotomy cut was freely movable and was able to be translocated medially The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone Following this the bone was stabilized using a 0 45 K wire distally as well as proximally directed from dorsal to planar direction Next using the normal AO manner the distal cortex was drilled from dorsal to plantar with a 2 0 mm drill bit and then over drilled proximally with the cortex using a 2 7 mm drill bit The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex Then using 2 7 mm tap the thread holes were placed and using an 18 x 2 7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved Intramedullary sludge was noted to exit from the osteotomy cut Following this attention was directed proximally and the 0 45 K wire was removed and the holes were predrilled using a 2 0 mm screw then over drilled using 2 7 mm screw and counter sucked Following this the holes were measured found to 20 mm in length and the drill hole was tapped using a 2 7 mm tap Following this a 20 mm full threaded screw was inserted and tightened Good intramedullary sludge was noted and compression was achieved Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite Following this range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted Based on this a lateral release was performed The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a 15 blade into the first interspace The incision was then deepened with sharp and blunt dissection and using a curved hemostat the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament Upon completion of this the hallux was noted to be in a rectus position with good alignment The area was then flushed and irrigated with copious amounts of sterile saline After this attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using 3 0 Vicryl suture Subcutaneous tissues were closed using 3 0 and 4 0 Vicryl sutures to close in layers The skin was then reapproximated and closed using 5 0 Monocryl suture Following this the incisions were dressed and bandaged in the normal manner using Owen silk 4x4s Kling and Kerlix as well as Coban dressing The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit Following this the patient was given prescription for Vicoprofen total 20 to be taken one every six hours as necessary for moderate to severe pain The patient was also given prescription for clindamycin to be taken 300 mg four times a day The patient was given surgical shoe and was placed in a posterior sling The patient was given crutches and instructed to use them for ambulation The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend The patient will follow up with Dr X on Tuesday morning at 11 o clock in his Livonia office The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that The patient has Dr X s pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise X rays were taken and the patient was discharged home upon completion of this Keywords orthopedic hallux abductovalgus deformity scarf bunionectomy metatarsal bunion hallux abductovalgus metatarsophalangeal joint dorsally foot bone abductovalgus MEDICAL_TRANSCRIPTION,Description Right shoulder hemi resurfacing using a size 5 Biomet Copeland humeral head component noncemented Severe degenerative joint disease of the right shoulder Medical Specialty Orthopedic Sample Name Shoulder Hemi resurfacing Transcription PREOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right shoulder POSTOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right shoulder PROCEDURE Right shoulder hemi resurfacing using a size 5 Biomet Copeland humeral head component noncemented ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL COMPLICATIONS None The patient was taken to Postanesthesia Care Unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 55 year old female who has had increased pain in to her right shoulder X rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi resurfacing was appropriate for her right shoulder focusing in the humeral head All risks benefits expectations and complications of surgery were explained to her in detail including nerve and vessel damage infection potential for hardware failure the need for revision surgery with potential of some problems even with surgical intervention The patient still wanted to proceed forward with surgical intervention The patient did receive 1 g of Ancef preoperatively PROCEDURE The patient was taken to the operating suite placed in supine position on the operating table The Department of anesthesia administered a general endotracheal anesthetic which the patient tolerated well The patient was moved to a beach chair position All extremities were well padded Her head was well padded to the table Her right upper extremity was draped in sterile fashion A saber incision was made from the coracoid down to the axilla Skin was incised down to the subcutaneous tissue the cephalic vein was retracted as well as all neurovascular structures were retracted in the case Dissecting through the deltopectoral groove the subscapularis tendon was found as well as the bicipital tendon 1 finger breadth medial to the bicipital tendon an incision was made Subscapularis tendon was released The humeral head was brought in to there were large osteophytes that were removed with an osteotome The glenoid then was evaluated and noted to just have mild arthrosis but there was no need for surgical intervention in this region A sizer was placed It was felt that size 5 was appropriate for this patient after which the guide was used to place the stem and pin This was placed after which a reamer was placed along the humeral head and reamed to a size 5 All extra osteophytes were excised The supraspinatus and infraspinatus tendons were intact Next the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation The arm had excellent range of motion There are no signs of gross dislocation Drill holes were made into the humeral head after which a size 5 Copeland hemi resurfacing component was placed into the humeral head kept down in appropriate position had excellent fixation into the humeral head Excess bone that had been reamed was placed into the Copeland metal component after which this was tapped into position After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion had adequate range of motion full internal and external rotation as well as forward flexion and abduction There was no gross sign of dislocation Wound site once again it was copiously irrigated with saline antibiotics The subscapularis tendon was approximated back into position with 2 Ethibond after which the bicipital tendon did have significant tear to it therefore it was tenodesed in to the pectoralis major tendon After which the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2 0 Vicryl The skin was closed with staples A sterile dressing was placed The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition Keywords orthopedic degenerative joint disease hemi resurfacing biomet copeland shoulder hemi resurfacing humeral head degenerative glenoid subscapularis antibiotics resurfacing tendon shoulder MEDICAL_TRANSCRIPTION,Description Right shoulder hemiarthroplasty Right shoulder rotator cuff tear Glenohumeral rotator cuff arthroscopy Degenerative joint disease Medical Specialty Orthopedic Sample Name Right Shoulder Hemiarthroplasty Transcription PREOPERATIVE DIAGNOSES 1 Right shoulder rotator cuff tear 2 Glenohumeral rotator cuff arthroscopy 3 Degenerative joint disease POSTOPERATIVE DIAGNOSES 1 Right shoulder rotator cuff tear 2 Glenohumeral rotator cuff arthroscopy 3 Degenerative joint disease PROCEDURE PERFORMED Right shoulder hemiarthroplasty ANESTHESIA General ESTIMATED BLOOD LOSS Approximately 125 cc COMPLICATIONS None COMPONENTS A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used BRIEF HISTORY The patient is an 82 year old right hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment PROCEDURE The patient was taken to the operative suite placed on the operative field Department of Anesthesia administered general anesthetic Once adequately sedated the patient was placed in the beach chair position Care was ensured that she was well positioned adequately secured and padded At this point the right upper extremity was then prepped and draped in the usual sterile fashion A deltopectoral approach was used and taken down to the skin with a 15 blade scalpel At this point blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue Any perforating bleeders were cauterized with Bovie to obtain hemostasis Once the bursa was seen it was removed with a Rongeur and subscapular tendon could be easily visualized At this point the rotator cuff in the subacromial region was evaluated There was noted to be a large rotator cuff which was irreparable There was eburnated bone on the greater tuberosity noted The articular surface could be visualized The biceps tendon was intact There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface The under surface of the acromion it was felt there was mild ware on this as well At this point the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture It was separated from the capsule to have a two layered repair at closure The capsule was also reflected posterior At this point the glenoid surface could be easily visualized It was evaluated and had good cartilage contact and appeared to be intact The humeral head was evaluated There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head At this point decision was made to proceed with the arthroplasty since the rotator cuff tear was irreparable and there was significant ware of the humoral head The arm was adequately positioned An oscillating saw was used to make the head articular cut This was done at the margin of the articular surface with the anatomic neck This was taken down to appropriate level until this articular surface was adequately removed At this point the intramedullary canal and cancellous bone could be easily visualized The opening hand reamers were then used and this was advanced to a size 10 Under direct visualization this was performed easily At this point the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins This was then removed A trial component was then impacted into place which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured It did not appear overstuffed with evidence of excellent range of motion and no impingement At this point the trial component was removed Wound was copiously irrigated and suctioned dry Cement was then placed with a cement gun into the canal and taken up to the level of the cut The prosthesis was then inserted into place and held under direct visualization All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself This _______ cement was adequately hard at this point The final component of the head was impacted into place secured on the Morris taper and checked and this was reduced The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position The wound was again copiously irrigated and suctioned dry At this point the capsule was then reattached to its insertion site in the anterior portion Once adequately sutured with 1 Vicryl attention was directed to the subscapular The subscapular was advanced superiorly and anchored not only to the biceps tendon region but also to the top anterior portion of the greater tuberosity This was opened to allow some type of coverage points of the massive rotator cuff tear This was secured to the tissue and interosseous sutures with size 2 fiber wire After this was adequately secured the wound was again copiously irrigated and suctioned dry The deltoid fascial split was then repaired using interrupted 2 0 Vicryl subcutaneous tissue was then approximated using interrupted 24 0 Vicryl skin was approximated using a running 4 0 Vicryl Steri Strips and Adaptic 4 x 4s and ABDs were then applied The patient was then placed in a sling and transferred back to the gurney reversed by Department of Anesthesia DISPOSITION The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition Keywords orthopedic glenohumeral rotator cuff arthroscopy degenerative joint disease shoulder hemiarthroplasty rotator cuff subscapular shoulder MEDICAL_TRANSCRIPTION,Description Release of A1 pulley right thumb Stenosing tendinosis right thumb trigger finger There was noted to be thickening of the A1 pulley There was a fibrous nodule noted within the flexor tendon of the thumb which caused triggering sensation to the thumb Medical Specialty Orthopedic Sample Name Release of A1 Pulley 1 Transcription PREOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger POSTOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger PROCEDURE PERFORMED Release of A1 pulley right thumb ANESTHESIA IV regional with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME Approximately 20 minutes at 250 mmHg INTRAOPERATIVE FINDINGS There was noted to be thickening of the A1 pulley There was a fibrous nodule noted within the flexor tendon of the thumb which caused triggering sensation to the thumb HISTORY This is a 51 year old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb She was actually able to spontaneously trigger the thumb She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley All risks and benefits of the surgery was discussed with her at length She was in agreement with the above treatment plan PROCEDURE On 08 21 03 she was taken to operating room at ABCD General Hospital and placed supine on the operating table A regional anesthetic was applied by the Anesthesia Department Tourniquet was placed on her proximal arm The upper extremity was sterilely prepped and draped in the usual fashion An incision was made over the proximal crease of the thumb Subcuticular tissues were carefully dissected Hemostasis was controlled with electrocautery The nerves were identified and retracted throughout the entire procedure The fibers of the A1 pulley were identified They were sharply dissected to release the tendon The tendon was then pulled up into the wound and inspected There was no evidence of gross tear noted Fibrous nodule was noted within the tendon itself There was no evidence of continuous locking Once release of the pulley had been performed the wound was copiously irrigated It was then reapproximated using 5 0 nylon simple interrupted and horizontal mattress sutures Sterile dressing was applied to the upper extremity Tourniquet was deflated It was noted that the thumb was warm and pink with good capillary refill The patient was transferred to Recovery in apparent stable and satisfactory condition Prognosis is fair Keywords orthopedic release of a1 pulley tendinosis thumb flexor tendon trigger finger fibrous nodule stenosing tendinosis tourniquet stenosing tendon release pulley MEDICAL_TRANSCRIPTION,Description Epicondylitis history of lupus Injected with 40 mg of Kenalog mixed with 1 cc of lidocaine Medical Specialty Orthopedic Sample Name Rheumatology Progress Note Transcription SUBJECTIVE The patient is here for a follow up The patient has a history of lupus currently on Plaquenil 200 mg b i d Eye report was noted and appreciated The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago She denied having any trauma She states that the pain is bothering her She denies having any fevers chills or any joint effusion or swelling at this point She noted also that there is some increase in her hair loss in the recent times OBJECTIVE The patient is alert and oriented General physical exam is unremarkable Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows no effusion Hand examination is unremarkable today The rest of the musculoskeletal exam is unremarkable ASSESSMENT Epicondylitis both elbows possibly secondary to lupus flare up PLAN We will inject both elbows with 40 mg of Kenalog mixed with 1 cc of lidocaine The posterior approach was chosen under sterile conditions The patient tolerated both procedures well I will obtain CBC and urinalysis today If the patient s pain does not improve I will consider adding methotrexate to her therapy Sample Doctor M D Keywords orthopedic rheumatology 1 cc of lidocaine epicondylitis kenalog kenalog mixed with 1 cc of lidocaine progress note aches and pains history of lupus lidocaine lupus methotrexate kenalog mixed injected MEDICAL_TRANSCRIPTION,Description The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley Medical Specialty Orthopedic Sample Name Release of A1 Pulley Transcription PREOPERATIVE DIAGNOSIS Right trigger thumb POSTOPERATIVE DIAGNOSIS Right trigger thumb SURGERY Release of A1 pulley CPT code 26055 ANESTHESIA General LMA TOURNIQUET TIME 9 minutes at 200 torr FINDINGS The patient was found to have limitations to extension at the IP joint to the right thumb He was found to have full extension after release of A1 pulley INDICATIONS The patient is 2 1 2 year old He has a history of a trigger thumb This was evaluated in the office He was indicated for release of A1 pulley to allow for full excursion Risks and benefits including recurrence infection and problems with anesthesia were discussed at length with the family They wanted to proceed PROCEDURE The patient was brought into the operating room and placed on the operating table in supine position General anesthesia was induced without incident He was given a weight adjusted dose of antibiotics The right upper extremity was then prepped and draped in a standard fashion Limb was exsanguinated with an Esmarch bandage Tourniquet was raised to 200 torr Transverse incision was then made at the base of thumb The underlying soft tissues were carefully spread in line longitudinally The underlying tendon was then identified The accompanied A1 pulley was also identified This was incised longitudinally using 11 blade Inspection of the entire tendon then demonstrated good motion both in flexion and extension The leaflets of the pulley were easily identified The wound was then irrigated and closed The skin was closed using interrupted 4 0 Monocryl simple sutures The area was injected with 5 mL of 0 25 Marcaine The wound was dressed with Xeroform dry sterile dressings hand dressing Kerlix and Coban The patient was awakened from anesthesia and taken to the recovery room in good condition There were no complications All instrument sponge needle counts were correct at the end of case PLAN The patient will be discharged home He will return in 1 1 2 weeks for wound inspection Keywords orthopedic a1 pulley release of a1 pulley trigger thumb limitations to extension ip joint MEDICAL_TRANSCRIPTION,Description Application of PMT large halo crown and vest Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion Medical Specialty Orthopedic Sample Name PMT Halo Crown Vest Transcription PREOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion POSTOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion and potentially unstable cervical spine OPERATIVE PROCEDURE Application of PMT large halo crown and vest ESTIMATED BLOOD LOSS None ANESTHESIA Local conscious sedation with Morphine and Versed COMPLICATIONS None Post fixation x rays nonalignment no new changes Post fixation neurologic examination normal CLINICAL HISTORY The patient is a 41 year old female who presented to me with severe cervical spondylosis and myelopathy She was referred to me by Dr X The patient underwent a complicated anterior cervical discectomy 2 level corpectomy spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate Surgery had gone well and the patient has done well in the last 2 days She is neurologically improved and is moving all four extremities No airway issues It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller She was consented for the procedure and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest The patient had this procedure done at the bedside in the SICU room 1 I used a combination of some morphine 1 mg and Versed 2 mg for this procedure I also used local anesthetic with 1 Xylocaine and epinephrine a total of 15 to 20 cc PROCEDURE DETAILS The patient s head was positioned on some towels the retroauricular region was shaved and the forehead and the posterolateral periauricular regions were prepped with Betadine A large PMT crown was brought in and fixed to the skull with pins under local anesthetic Excellent fixation achieved It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae I then put the vest on by sitting the patient up stabilizing her neck The vest was brought in from the front as well and connected Head was tilted appropriately slightly extended and in the midline All connections were secured and pins were torqued and tightened During the procedure the patient did fine with no significant pain Post procedure she is neurologically intact and she remained intact throughout X rays of the cervical spine AP lateral and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes The patient will be subjected to a CT scan to further define the alignment and barring any problems she will be ambulating with the halo on The patient will undergo pin site care as per protocol and likely she will go in the next 2 to 3 days Her prognosis indeed is excellent and she is already about 90 or so better from her surgery She is also on a short course of Decadron which we will wean off in due course The matter was discussed with the patient and the patient s family Keywords orthopedic cervical spondylosis anterior cervical discectomy corpectomy decompression fusion pmt crown vest pmt halo cervical MEDICAL_TRANSCRIPTION,Description A sample note on RICE Therapy Medical Specialty Orthopedic Sample Name RICE Therapy Transcription RICE stands for the most important elements of treatment for many injuries rest ice compression and elevation REST Stop using the injured part as soon as you realize that an injury has taken place Use crutches to avoid bearing weight on injuries of the foot ankle knee or leg Use splints for injuries of the hand wrist elbow or arm Continued exercise or activity could cause further injury increased pain or a delay in healing ICE Ice helps stop bleeding from injured blood vessels and capillaries Sudden cold causes the small blood vessels to contract This contraction decreases the amount of blood that can collect around the wound The more blood that collects the longer the healing time Ice can be safely applied in many ways For injuries to small areas such as a finger toe foot or wrist immerse the injured area for 15 to 35 minutes in a bucket of ice water Use ice cubes to keep the water cold adding more as the ice cubes dissolve For injuries to larger areas use ice packs Avoid placing the ice directly on the skin Before applying the ice place a towel cloth or one or two layers of an elasticized compression bandage on the skin to be iced To make the ice pack put ice chips or ice cubes in a plastic bag or wrap them in a thin towel Place the ice pack over the cloth The pack may sit directly on the injured part or it may be wrapped in place Ice the injured area for about 30 minutes Remove the ice to allow the skin to warm for 15 minutes Reapply the ice Repeat the icing and warming cycles for 3 hours Follow the instructions below for compression and elevation If pain and swelling persist after 3 hours call our office You may need to change the icing schedule after the first 3 hours Regular ice treatment is often discontinued after 24 to 48 hours At that point heat is sometimes more comfortable COMPRESSION Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site Without compression fluid from adjacent normal tissue seeps into the injured area To apply compression safely to an injury Use an elasticized bandage Ace bandage for compression if possible If you do not have one available any kind of cloth will suffice for a short time Wrap the injured part firmly wrapping over the ice Begin wrapping below the injury site and extend above the injury site Be careful not to compress the area so tightly that the blood supply is impaired Signs of deprivation of the blood supply include pain numbness cramping and blue or dusky nails Remove the compression bandage immediately if any of theses symptoms appears Leave the bandage off until all signs of impaired circulation disappear Then rewrap the area less tightly this time ELEVATION Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site Elevate the iced compressed area in whatever way is most convenient Prop an injured leg on a solid object or pillows Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across Keywords orthopedic rest ice compression and elevation foot ankle knee leg splints hand wrist elbow arm ace bandage compression and elevation rice therapy compression bandage ice packs rice elevation swelling bandage therapy MEDICAL_TRANSCRIPTION,Description Cervical lumbosacral thoracic spine flexion and extension to evaluate back and neck pain Medical Specialty Orthopedic Sample Name Radiologic Exam Spine Transcription EXAM Cervical lumbosacral thoracic spine flexion and extension HISTORY Back and neck pain CERVICAL SPINE FINDINGS AP lateral with flexion and extension and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable Keywords orthopedic radiologic exam ap back cervical oblique views alignment disc space extension fixation flexion foramina intervertebral lateral views lumbosacral neck neck pain oblique odontoid view pain physiologic projections spine subluxation thoracic flexion and extension thoracic spine vertebral MEDICAL_TRANSCRIPTION,Description Closed reduction and pinning of the right ulna with placement of a long arm cast Medical Specialty Orthopedic Sample Name Pinning Ulna Transcription PREOPERATIVE DIAGNOSIS Right both bone forearm refracture POSTOPERATIVE DIAGNOSIS Right both bone forearm refracture PROCEDURE Closed reduction and pinning of the right ulna with placement of a long arm cast ANESTHESIA Surgery performed under general anesthesia Local anesthetic was 10 mL of 0 25 Marcaine plain COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HARDWARE Hardware was 0 79 K wire HISTORY AND PHYSICAL The patient is a 5 year old male who sustained refracture of his right forearm on 12 05 2007 The patient was seen in the emergency room The patient had a complete fracture of both bones with shortening bayonet apposition Treatment options were offered to the family including casting versus closed reduction and pinning The parents opted for the latter Risks and benefits of surgery were discussed Risks of surgery included risk of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure and need for later hardware removal cast tightness All questions were answered and the parents agreed to the above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was then administered The patient received Ancef preoperatively The right upper extremity was then prepped and draped in standard surgical fashion A small incision was made at the tip of the olecranon Initially a 1 11 guidewire was placed but this was noted to be too wide for this canal This was changed for a 0 79 K wire This was driven up to the fracture site The fracture was manually reduced and then the K wire passed through the distal segment This demonstrated adequate fixation and reduction of both bones The pin was then cut short The fracture site and pin site was infiltrated with 0 25 Marcaine The incision was closed using 4 0 Monocryl The wounds were cleaned and dried Dressed with Xeroform 4 x 4 The patient was then placed in a well moulded long arm cast He tolerated the procedure well He was subsequently taken to Recovery in stable condition POSTOPERATIVE PLAN The patient will be maintain current pin and long arm cast for 4 weeks at which time he will return for cast removal X rays of the right forearm will be taken The patient may need additional mobilization time Once the fracture has healed we will take the pin out usually at the earliest 3 to 4 months Intraoperative findings were relayed to the parents All questions were answered Keywords orthopedic closed reduction pinning forearm refracture fracture site arm cast MEDICAL_TRANSCRIPTION,Description Bilateral L5 S1 S2 and S3 radiofrequency ablation for sacroiliac joint pain Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Orthopedic Sample Name Radiofrequency Ablation Transcription PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 20 gauge 10 mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen for the lateral branches of S1 S2 and S3 Also fluoroscopic views were used to ensure proper needle placement The following technique was used to confirm correct placement Motor stimulation was applied at 2 Hz with 1 millisecond duration No extremity movement was noted at less than 2 volts Following this the needle trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 0 5 mL of 1 lidocaine was injected to anesthetize the lateral branch and the surrounding tissue After completion a lesion was created at that level with a temperature of 80 degrees for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS None COMPLICATIONS None DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at PM R Spine Clinic in approximately one to two weeks Keywords orthopedic sacroiliac joint pain sacroiliac teflon coated needle fluoroscopy needle placement radiofrequency ablation ablation tissue lidocaine needle MEDICAL_TRANSCRIPTION,Description External fixation of left pilon fracture and closed reduction of left great toe T1 fracture Due to the comminuted nature of her tibia fracture as well as soft tissue swelling the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation Medical Specialty Orthopedic Sample Name Pilon Fracture External Fixation Transcription PREOP DIAGNOSES 1 Left pilon fracture 2 Left great toe proximal phalanx fracture POSTOP DIAGNOSES 1 Left pilon fracture 2 Left great toe proximal phalanx fracture OPERATION PERFORMED 1 External fixation of left pilon fracture 2 Closed reduction of left great toe T1 fracture ANESTHESIA General BLOOD LOSS Less than 10 mL Needle instrument and sponge counts were done and correct DRAINS AND TUBES None SPECIMENS None INDICATION FOR OPERATION The patient is a 58 year old female who was involved in an auto versus a tree accident on 6 15 2009 The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention Due to the comminuted nature of her tibia fracture as well as soft tissue swelling the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation The patient had swollen lower extremities however compartments were soft and she had no sign of compartment syndrome Risks and benefits of procedure were discussed in detail with the patient and her husband All questions were answered and consent was obtained The risks including damage to blood vessels and nerves with painful neuroma or numbness limb altered function loss of range of motion need for further surgery infection complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery FINDINGS 1 There was a comminuted distal tibia fracture with a fibular shaft fracture Following traction there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula the fracture fragments were out to length 2 The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step off and approximately 1 mm displacement As the reduction was stable with buddy taping no pinning was performed 3 Her compartments were full but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed OPERATIVE REPORT IN DETAIL The patient was identified in the preoperative holding area The left leg was identified and marked at the surgical site of the patient She was then taken to the operating room where she was transferred to the operating room in the supine position placed under general anesthesia by the anesthesiology team She received Ancef for antibiotic prophylaxis A time out was then undertaken verifying the correct patient extremity visibility of preoperative markings availability of equipment and administration of preoperative antibiotics When all was verified by the surgeon anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion At this point intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length but not overly distract the fracture and restore coronal and sagittal alignment as much as able When this was adequate the fixator apparatus was locked in place and x ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture Attention was then turned to the left great toe where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive X rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture At this point the pins were cut short and capped to protect the sharp ends The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition Please note there was no break in sterile technique throughout the case PLAN The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication She will maintain her buddy taping in regards to her great toe fracture Keywords orthopedic phalanx fracture schantz pins toe fracture tibia fracture pilon fracture external fixation proximal phalanx fracture toe pilon phalanx reduction tibia proximal fixation MEDICAL_TRANSCRIPTION,Description Revision and in situ pinning of the right hip Medical Specialty Orthopedic Sample Name Pinning Hip Transcription PREOPERATIVE DIAGNOSIS Right acute on chronic slipped capital femoral epiphysis POSTOPERATIVE DIAGNOSIS Right acute on chronic slipped capital femoral epiphysis PROCEDURE Revision and in situ pinning of the right hip ANESTHESIA Surgery performed under general anesthesia COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None LOCAL 10 mL of 0 50 Marcaine local anesthetic HISTORY AND PHYSICAL The patient is a 13 year old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis She underwent in situ pinning The patient on followup however noted to have intraarticular protrusion of her screw This was not noted intraoperatively on previous fluoroscopic views Given this finding I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one Risks and benefits of surgery were discussed Risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion of the extremity failure to remove the screw possible continued joint stiffness or damage All questions were answered and parents agreed to above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A small bump was placed underneath her right buttock The right upper thigh was then prepped and draped in standard surgical fashion The upper aspect of the incision was reincised The dissection was carried down to the crew which was easily found A guidewire was placed inside the screw with subsequent removal of the previous screw The previous screw measured 65 mm A 60 mm screw was then placed under direct visualization with fluoroscopy The hip was taken through full range of motion to check on the length of the screw which demonstrated no intraarticular protrusion The guidewire was removed The wound was then irrigated and closed using 2 0 Vicryl in the fascial layer as well as the subcutaneous fat The skin was closed with 4 0 Monocryl The wound was cleaned and dried dressed with Steri Strips Xeroform 4 x 4s and tape The area was infiltrated with total 10 mL of 0 5 Marcaine local anesthetic POSTOPERATIVE PLAN The patient will be discharged on the day of surgery She should continue toe touch weightbearing on her leg The wound may be wet in approximately 5 days The patient should follow up in clinic in about 10 days The patient is given Vicodin for pain Intraoperative findings were relayed to the mother Keywords orthopedic guidewire capital femoral epiphysis intraarticular protrusion femoral epiphysis pinning screw MEDICAL_TRANSCRIPTION,Description Amputation distal phalanx and partial proximal phalanx right hallux Osteomyelitis right hallux Medical Specialty Orthopedic Sample Name Phalanx Amputation Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis right hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis right hallux PROCEDURE PERFORMED Amputation distal phalanx and partial proximal phalanx right hallux ANESTHESIA TIVA local HISTORY This 44 year old male patient was admitted to ABCD General Hospital on 09 02 2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics which he failed The patient after a multiple conservative treatments such as wound care antibiotics the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis The patient desires to attempt a surgical correction The risks versus benefits of the procedure were discussed with the patient in detail by Dr X The consent was available on the chart for review PROCEDURE IN DETAIL After patient was taken to the operating room via cart and placed on the operating table in the supine position a safety strap was placed across his waist Adequate IV sedation was administered by the Department of Anesthesia and a total of 3 5 cc of 1 1 mixture 1 lidocaine and 0 5 Marcaine plain were injected into the right hallux as a digital block The foot was prepped and draped in the usual aseptic fashion lowering the operative field Attention was directed to the hallux where there was a full thickness ulceration to the distal tip of the hallux measuring 0 5 cm x 0 5 cm There was a ________ tract which probed through the distal phalanx and along the sides of the proximal phalanx laterally The toe was 2 5 times to the normal size There were superficial ulcerations in the medial arch of both feet secondary to history of a burn which were not infected The patient had dorsalis pedis and posterior tibial pulses that were found to be 2 4 bilaterally preoperatively X ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx A 10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact Next the distal phalanx was disarticulated at the interphalangeal joint and removed The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology Next the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected Therefore a sagittal saw was used to resect approximately 0 75 cm of the distal aspect of head of the proximal phalanx This bone was also sent off for culture and was labeled proximal margin Next the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected The flexor tendon distally was gray discolored and was not viable A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally None was found No purulent drainage or abscess was found The proximal margin of the surgical site tissue was viable and healthy There was no malodor Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology Next copious amounts of gentamicin and impregnated saline were instilled into the wound A 3 0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension The plantar flap was viable and was debulked with Metzenbaum scissors The flap was folded dorsally and reapproximated carefully with 3 0 nylon with a combination of simple interrupted and vertical mattress sutures Iris scissors were used to modify and remodel the plantar flap An excellent cosmetic result was achieved No tourniquet was used in this case The patient tolerated the above anesthesia and surgery without apparent complications A standard postoperative dressing was applied consisting of saline soaked Owen silk 4x4s Kerlix and Coban The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot He will be readmitted to Dr Katzman where we will continue to monitor his blood pressure and regulate his medications Plan is to continue the antibiotics until further IV recommendations He will be nonweightbearing to the right foot and use crutches He will elevate his right foot and rest the foot keep it clean and dry He is to follow up with Dr X on Monday or Tuesday of next week Keywords orthopedic osteomyelitis phalanx phalanx amputation proximal margin plantar flap distal phalanx proximal phalanx proximal hallux amputation foot plantarly distal MEDICAL_TRANSCRIPTION,Description Open repair of right pectoralis major tendon Right pectoralis major tendon rupture On MRI evaluation a complete rupture of a portion of the pectoralis major tendon was noted Medical Specialty Orthopedic Sample Name Pectoralis Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Right pectoralis major tendon rupture POSTOPERATIVE DIAGNOSIS Right pectoralis major tendon rupture OPERATION PERFORMED Open repair of right pectoralis major tendon ANESTHESIA General with an interscalene block COMPLICATIONS None Needle and sponge counts were done and correct INDICATION FOR OPERATION The patient is a 26 year old right hand dominant male who works in sales who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder The patient presented with mild bruising over the proximal arm of the right side with x ray showing no fracture Over concerns for pectoralis tendon tear he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted Due to the patient s young age and active lifestyle surgical treatment was recommended in order to obtain best result The risks and benefits of the procedure were discussed in detail with the patient including but not limited to scarring infection damage to blood vessels and nerves re rupture need further surgery loss of range of motion inability to return to heavy activity such as weight lifting complex usual pain syndrome and deep vein thrombosis as well as anesthetic risks Understanding all risks and benefits the patient desires to proceed with surgery as planned FINDINGS 1 Following deltopectoral approach to the right shoulder the pectoralis major tendon was encountered The clavicular head was noted to be intact There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion 2 Following freeing of adhesions using tracks and sutures the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps 3 A soft tissue repair was performed with 5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site Following repair of soft tissue and using the bone anchor there was noted to be good apposition of the tendon with edges and a solid repair OPERATIVE REPORT IN DETAIL The patient was identified in the preop holding area His right shoulder was identified marked his appropriate surgical site after verification with the patient He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team He then received prophylactic antibiotics A time out was then undertaken verifying the correct patient extremity surgery performed administration of antibiotics and the availability of equipment At this point the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes The right upper extremity was then prepped and draped in the usual sterile fashion Preoperative markings were still visible at this point A deltopectoral incision was made utilizing the inferior portion Dissection was carried down The deltoid was retracted laterally The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion There was a small cuff of tissue left on the proximal humerus associated with the clavicular head Gentle probing medially revealed the end of the sternal retracted portion traction sutures of 5 Ethibond were used in this to allow for retraction and freeing from light adhesion This allowed reapproximation of the retracted tendon to the tendon stump At this point a repair using 5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site At this point a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site however the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone For this reason the starting hole was tapped and a 5x5 bioabsorbable anchor was placed doubly loaded The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair At this point there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation Aggressive external rotation was not performed The wound was then copiously irrigated The cephalic vein was not injured during the case The skin was then closed using a 2 0 Vicryl followed by a 3 0 subcuticular Prolene suture with Steri Strips Sterile dressing was then placed Anesthesia was then performed interscalene block The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated Plan for this patient the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days We will then start a gentle Codman type exercises and having limited motion until the 4 6 week point based on the patient s progression Keywords orthopedic tendon rupture interscalene block pectoralis major tendon rupture pectoralis major tendon repair pectoralis interscalene tendon rupture sutures MEDICAL_TRANSCRIPTION,Description Specimen labeled sesamoid bone left foot Medical Specialty Orthopedic Sample Name Pathology Sesamoid Bone Transcription GROSS DESCRIPTION Specimen labeled sesamoid bone left foot is received in formalin and consists of three irregular fragments of grey brown hard bony tissue admixed with multiple fragments of brown tan rubbery fibrocollagenous soft tissue altogether measuring 3 1 x 1 5 x 0 9 cm The specimen is entirely submitted after decalcification DIAGNOSIS Acute Osteomyelitis with foci of marrow fibrosis Focal acute and chronic inflammation of fascia and soft tissue Arteriosclerosis severely occlusive Keywords orthopedic marrow fibrosis osteomyelitis arteriosclerosis inflammation of fascia specimen fragmentsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 7 year old white male started to complain of pain in his fingers elbows and neck This patient may have had reactive arthritis Medical Specialty Orthopedic Sample Name Pediatric Rheumatology Consult Transcription HISTORY We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic He was sent here with a chief complaint of joint pain in several joints for few months This is a 7 year old white male who has no history of systemic disease who until 2 months ago was doing well and 2 months ago he started to complain of pain in his fingers elbows and neck At this moment this is better and is almost gone but for several months he was having pain to the point that he would cry at some point He is not a complainer according to his mom and he is a very active kid There is no history of previous illness to this or had gastrointestinal problems He has problems with allergies especially seasonal allergies and he takes Claritin for it Other than that he has not had any other problem Denies any swelling except for that doctor mentioned swelling on his elbow There is no history of rash no stomach pain no diarrhea no fevers no weight loss no ulcers in his mouth except for canker sores No lymphadenopathy no eye problems and no urinary problems MEDICATIONS His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis ALLERGIES He has no allergies to any drugs BIRTH HISTORY Pregnancy and delivery with no complications He has no history of hospitalizations or surgeries FAMILY HISTORY Positive for arthritis in his grandmother No history of pediatric arthritis There is history of psoriasis in his dad SOCIAL HISTORY He lives with mom dad brother sister and everybody is healthy They live in Easton They have 4 dogs 3 cats 3 mules and no deer At school he is in second grade and he is doing PE without any limitation PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 7 pulse is 96 respiratory rate is 24 height is 118 1 cm weight is 22 1 kg and blood pressure is 61 44 GENERAL He is alert active in no distress very cooperative HEENT He has no facial rash No lymphadenopathy Oral mucosa is clear No tonsillitis His ear canals are clear and pupils are reactive to light and accommodation CHEST Clear to auscultation HEART Regular rhythm and no murmur ABDOMEN Soft nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation in any of his joints or active swelling today He has no tenderness either in any of his joints Muscle strength is 5 5 in proximal muscles LABORATORY DATA Includes an arthritis panel It has normal uric acid sedimentation rate of 2 rheumatoid factor of 6 and antinuclear antibody that is negative and C reactive protein that is 7 1 His mother stated that this was done while he was having symptoms ASSESSMENT AND PLAN This patient may have had reactive arthritis He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis I do not see any problems at this moment on his laboratories or on his physical examination This may have been related to recent episode of viral infection or infection of some sort Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints I will be glad to see him back If you have any question on further assessment and plan please do no hesitate to contact us Keywords orthopedic rheumatology pediatric reactive arthritis psoriatic arthritis psoriasis joints swelling arthritis MEDICAL_TRANSCRIPTION,Description Patellar tendon and medial and lateral retinaculum repair right knee Patellar tendon retinaculum ruptures right knee Medical Specialty Orthopedic Sample Name Patellar Tendon Retinaculum Repair Transcription PREOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee POSTOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee PROCEDURE PERFORMED Patellar tendon and medial and lateral retinaculum repair right knee SPECIFICATIONS Intraoperative procedure done at Inpatient Operative Suite room 2 of ABCD Hospital This was done under subarachnoid block anesthetic in supine position HISTORY AND GROSS FINDINGS The patient is a 45 year old African American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x ray the evening before surgical intervention He did this while playing basketball He had a massive deficit at the inferior pole of his patella on exam Once opened he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum Minimal cartilaginous pieces were at the patellar tendon He had grade II changes to his femoral sulcus as well as grade I II changes to the undersurface of the patella OPERATIVE PROCEDURE The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department A thigh high tourniquet was placed He is prepped and draped in the usual sterile manner Limb was elevated exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes Straight incision is carried down through skin and subcutaneous tissue anteriorly Hemostasis was controlled via electrocoagulation Patellar tendon was isolated along with the patella itself A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape The inferior pole was freshened up Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer This was tied over the bony bridge superiorly There was excellent reduction of the tendon to the patella Interrupted running 1 Vicryl suture was utilized for over silk A running 2 0 Vicryl for synovial closure medial and laterally as well as 1 Vicryl medial and lateral retinaculum There was excellent repair Copious irrigation was carried out Tourniquet was dropped and hemostasis controlled via electrocoagulation Interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin Adaptic 4 x 4s ABDs and sterile Webril were placed for compression dressing Digits were warm and no brawny pulses present at the end of the case The patient s leg was placed in a Don Joy brace 0 to 20 degrees of flexion He will leave this until seen in the office Expected surgical prognosis on this patient is fair Keywords orthopedic subarachnoid patellar tendon retinaculum tendon patellar tourniquet knee ruptures retinaculum MEDICAL_TRANSCRIPTION,Description Pain management sample progress note Medical Specialty Orthopedic Sample Name Pain Management Progress Note Transcription DIAGNOSES 1 Cervical dystonia 2 Post cervical laminectomy pain syndrome Ms XYZ states that the pain has now shifted to the left side She has noticed a marked improvement on the right side which was subject to a botulinum toxin injection about two weeks ago She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased but she is still on the oxycodone and methadone The patient s husband confirms the fact that she is doing a lot better that she is more active but there are still issues yet regarding anxiety depression and frustration regarding the pain in her neck PHYSICAL EXAMINATION The patient is appropriate She is well dressed and oriented x3 She still smells of some cigarette smoke Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals trapezius and splenius capitis muscles There are no trigger points felt and her range of motion of the neck is still somewhat guarded but much improved On the left side however there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding This extends down into the trapezius muscle but the splenius capitis seems to be not involved TREATMENT PLAN After a long discussion with the patient and the husband we have decided to go ahead and do botulinum toxin injection into the left multifidus trapezius muscles A total of 400 units of Botox is anticipated The procedure is being scheduled The patient s medications are refilled She will continue to see Dr Berry and continue her therapy with Mary Hotchkinson in Victoria Keywords orthopedic progress note management muscle MEDICAL_TRANSCRIPTION,Description Distal metaphyseal osteotomy and bunionectomy with internal screw fixation right foot Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx right foot Medical Specialty Orthopedic Sample Name Osteotomy Bunionectomy Transcription PREOPERATIVE DIAGNOSES 1 Metatarsus primus varus with bunion deformity right foot 2 Hallux abductovalgus with angulation deformity right foot POSTOPERATIVE DIAGNOSES 1 Metatarsus primus varus with bunion deformity right foot 2 Hallux abductovalgus with angulation deformity right foot PROCEDURES 1 Distal metaphyseal osteotomy and bunionectomy with internal screw fixation right foot 2 Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx right foot ANESTHESIA Local infiltrate with IV sedation INDICATION FOR SURGERY The patient has had a longstanding history of foot problems The foot problem has been progressive in nature and has not been responsive to conservative treatment The preoperative discussion with the patient included the alternative treatment options The procedure was explained in detail and risk factors such as infection swelling scarred tissue numbness continued pain recurrence and postoperative management were explained in detail The patient has been advised although no guaranty for success could be given most patients have improved function and less pain All questions were thoroughly answered The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities The purpose of the surgery is to alleviate the pain and discomfort DETAILS OF PROCEDURE The patient was brought to the operating room and placed in a supine position No tourniquet was utilized IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1 1 mixture of 0 25 Marcaine and 1 lidocaine with epinephrine was locally infiltrated proximal to the operative site The lower extremity was prepped and draped in the usual sterile manner Balanced anesthesia was obtained PROCEDURE 1 Distal metaphyseal osteotomy with internal screw fixation with bunionectomy right foot A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx Care was taken to identify and retract the vital structures and when necessary vessels were ligated via electrocautery Sharp and blunt dissection was carried down through the subcutaneous tissue superficial fascia and then down to the capsular and periosteal layer which was visualized A linear periosteal capsular incision was made in line with the skin incision The capsular tissue and periosteal layer were underscored free from its underlying osseous attachments and they refracted to expose the osseous surface Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head The head of the first metatarsal was dissected free from its attachment medially and dorsally delivered dorsally and may be into the wound Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition The sesamoid was in satisfactory condition An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration Care was taken to preserve the sagittal groove The rough edges were then smoothed with a rasp Attention was then focused on the medial mid portion of the first metatarsal head where a K wire access guide was positioned to define the apex and direction of displacement for the capital fragment The access guide was noted to be in good position A horizontally placed through and through osteotomy with the apex distal and the base proximal was completed The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal The capital fragment was distracted off the first metatarsal moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head The capital fragment was impacted upon the metatarsal Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment It was then fixated with 1 screw A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction The length was measured __________ mm cannulated cortical screw was placed over the guide pin and secured in position Compression and fixation were noted to be satisfactory Inspection revealed good fixation and alignment at the operative site Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally All rough edges were rasped smooth Examination revealed there was still lateral deviation of the hallux A second procedure the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated PROCEDURE 2 Reposition osteotomy with internal screw fixation to correct angulation deformity proximal phalanx right hallux The original skin incision was extended from the point just distal to the interphalangeal joint All vital structures were identified and retracted Sharp and blunt dissection was carried down through the subcutaneous tissue superficial fascia and down to the periosteal layer which was underscored free from its underlying osseous attachments and reflected to expose the osseous surface The focus of the deformity was noted to be more distal on the hallux Utilizing an oscillating saw a more distal wedge shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin which was then measured __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position Inspection revealed good fixation and alignment at the osteotomy site The alignment and contour of the first way was now satisfactorily improved The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation The periosteal and capsular layer was closed with running sutures of 3 0 Vicryl The subcutaneous tissue was closed with 4 0 Vicryl and the skin edges coapted well with 4 0 nylon with running simples reinforced with Steri Strips Approximately 6 mL total in a 1 1 mixture of 0 25 Marcaine and 1 lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted followed by confirming bandages and an ACE wrap to provide mild compression The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time A walker boot was dispensed and applied The patient should wear it when walking or standing The next office visit will be in 4 days The patient was given prescriptions for Percocet 5 mg 40 one p o q 4 6h p r n pain along with written and oral home instructions The patient was discharged home with vital signs stable in no acute distress Keywords MEDICAL_TRANSCRIPTION,Description Pain management for post laminectomy low back syndrome and radiculopathy Medical Specialty Orthopedic Sample Name Pain Management Consult 1 Transcription Mr XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice For all these reasons this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient The patient was seen late because he had not filled in the patient questionnaire To summarize the history here Mr XYZ who is not very clear on events from the past sustained a work related injury some time in 1998 At that time he was driving an 18 wheeler truck The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer He experienced severe low back pain and eventually a short while later underwent a fusion of L4 L5 and L5 S1 The patient had an uneventful hospital course from the surgery which was done somewhere in Florida by a surgeon who he does not remember He was able to return to his usual occupation but then again had a second work related injury in May of 2005 At that time he was required to boat trucks to his rig and also to use a chain pulley system to raise and lower the vehicles Mr XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital He was MRI ed at that time which apparently showed a re herniation of an L5 S1 disc and then he somehow ended up in Houston where he underwent fusion by Dr W from L3 through S2 This was done on 12 15 2005 Initially he did fairly well and was able to walk and move around but then gradually the pain reappeared and he started getting severe left sided leg pain going down the lateral aspect of the left leg into his foot He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg The patient was referred to Dr A pain management specialist and Dr A has maintained him on opioid medications consisting of Norco 10 325 mg for breakthrough pain and oxycodone 30 mg t i d with Lunesta 3 mg q h s for sleep Carisoprodol 350 mg t i d and Lyrica 100 mg q daily The patient states that he is experiencing no side effects from medications and takes medications as required He has apparently been drug screened and his drug screening has been found to be normal The patient underwent an extensive behavioral evaluation on 05 22 06 by TIR Rehab Center At that time it was felt that Mr XYZ showed a degree of moderate level of depression There were no indications in the evaluation that Mr XYZ showed any addictive or noncompliant type behaviors It was felt at that time that Mr XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications Of concern to the therapist at that time was the patient s untreated and unmonitored hypertension and diabetes Mr XYZ indicated at that time they had not purchased any prescription medications or any of these health related issues because of financial limitations He still apparently is not under really good treatment for either of these conditions and on today s evaluation he actually denies that he had diabetes The impression was that the patient had axis IV diagnosis of chronic functional limitations financial loss and low losses with no axis III diagnosis This was done by Rhonda Ackerman Ph D a psychologist It was also suggested at that time that the patient should quit smoking Despite these evaluations Mr XYZ really did not get involved in psychotherapy and there was poor attendance of these visits there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke reduced mental clarity and future falls It was felt that any surgical interventions should be put on hold at that time In September of 2006 the patient was evaluated at Baylor College of Medicine in the Occupational Health Program The evaluation was done by a physician at that time whose report is clearly documented in the record Evaluation was done by Dr B At present Mr XYZ continues on with his oxycodone and Norco These were prescribed by Dr A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks The patient states that there has been no recent change in either the severity or the distribution of his pain He is unable to sleep because of pain and his activities of daily living are severely limited He spends most of his day lying on the floor watching TV and occasionally will walk a while from detailed questioning shows that his activities of daily living are practically zero The patient denies smoking at this time He denies alcohol use or aberrant drug use He obtains no pain medications from no other sources Review of MRI done on 02 10 06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4 5 and S1 nerve roots which appear to be retracted posteriorly There is a small right posterior herniation at L1 L2 PAST MEDICAL HISTORY Significant for hypertension hypercholesterolemia and non insulin dependent diabetes mellitus The patient does not know what medications he is taking for diabetes and denies any diabetes CABG in July of 2006 with no preoperative angina shortness of breath or myocardial infarction History of depression lumbar fusion surgery in 2000 left knee surgery 25 years ago SOCIAL HISTORY The patient is on disability He does not smoke He does not drink alcohol He is single He lives with a girlfriend He has minimal activities of daily living The patient cannot recollect when last a urine drug screen was done REVIEW OF SYSTEMS No fevers no headaches chest pain nausea shortness of breath or change in appetite Depressive symptoms of crying and decreased self worth have been noted in the past No neurological history of strokes epileptic seizures Genitourinary negative Gastrointestinal negative Integumentary negative Behavioral depression PHYSICAL EXAMINATION The patient is short of hearing His cognitive skills appear to be significantly impaired The patient is oriented x3 to time and place Weight 185 pounds temperature 97 5 blood pressure 137 92 pulse 61 The patient is complaining of pain of a 9 10 Musculoskeletal The patient s gait is markedly antalgic with predominant weightbearing on the left leg There is marked postural deviation to the left Because of pain the patient is unable to heel toe or tandem gait Examination of the neck and cervical spine are within normal limits Range of motion of the elbow shoulders are within normal limits No muscle spasm or abnormal muscle movements noted in the neck and upper extremities Head is normocephalic Examination of the anterior neck is within normal limits There is significant muscle wasting of the quadriceps and hamstrings on the left as well as of the calf muscles Skin is normal Hair distribution normal Skin temperature normal in both the upper and lower extremities The lumbar spine curvature is markedly flattened There is a well healed central scar extending from T12 to L1 The patient exhibits numerous positive Waddell s signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding worse on the left than the right Range of motion testing of the lumbar spine is labored in all directions It is interesting that the patient cannot flex more than 5 in the standing position but is able to sit without any problem There is a marked degree of sciatic notch tenderness on the left No abnormal muscle spasms or muscle movements were noted Patrick s test is negative bilaterally There are no provocative facetal signs in either the left or right quadrants of the lumbar area Neurological exam Cranial nerves II through XII are within normal limits Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps triceps and brachioradialis reflexes Neurological exam of the lower extremities shows a 2 right patellar reflex and 1 on the left There is no ankle clonus Babinski is negative Sensory testing shows a minimal degree of sensory loss on the right L5 distribution Muscle testing shows decreased L4 L5 on the left with extensor hallucis longus 2 5 Ankle extensors are 3 on the left and 5 on the right Dorsiflexors of the left ankle are 2 on the left and 5 on the right Straight leg raising test is positive on the left at about 35 There is no ankle clonus Hoffman s test and Tinel s test are normal in the upper extremities Respiratory Breath sounds normal Trachea is midline Cardiovascular Heart sounds normal No gallops or murmurs heard Carotid pulses present No carotid bruits Peripheral pulses are palpable Abdomen Hernia site is intact No hepatosplenomegaly No masses No areas of tenderness or guarding IMPRESSION 1 Post laminectomy low back syndrome 2 Left L5 S1 radiculopathy 3 Severe cognitive impairment with minimal for rehabilitation or return to work 4 Opioid dependence for pain control TREATMENT PLAN The patient will continue on with his medications prescribed by Dr Chang and I will see him in two weeks time and probably suggest switching over from OxyContin to methadone I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment I will get a behavioral evaluation from Mr Tom Welbeck and refer the patient for ongoing physical therapy The prognosis here for any improvement or return to work is zero Keywords orthopedic pain management opioid dependence patrick s test behavioral evaluation cognitive impairment low back syndrome motor strength pain control physical therapy radiculopathy spinal cord stimulation activities of daily living neurological exam laminectomy hearing diabetes muscle syndrome MEDICAL_TRANSCRIPTION,Description Plantar flex third metatarsal and talus bunion right foot Third metatarsal osteotomy talus bunionectomy and application of short leg cast right foot Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding all of which provided inadequate relief At this time she desires to attempt a surgical correction Medical Specialty Orthopedic Sample Name Osteotomy Bunionectomy 1 Transcription PREOPERATIVE DIAGNOSES 1 Plantar flex third metatarsal right foot 2 Talus bunion right foot POSTOPERATIVE DIAGNOSES 1 Plantar flex third metatarsal right foot 2 Talus bunion right foot PROCEDURE PERFORMED 1 Third metatarsal osteotomy right foot 2 Talus bunionectomy right foot 3 Application of short leg cast right foot ANESTHESIA TIVA local HISTORY This 31 year old female presents to ABCD Preoperative Holding Area after keeping herself n p o since mid night for surgery on her painful right third plantar flex metatarsal In addition she complains of a painful right talus bunion to the right foot She has tried conservative methods such as wide shoes and serial debridement and accommodative padding all of which provided inadequate relief At this time she desires to attempt a surgical correction The risks versus benefits of the procedure have been explained to the patient by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department Of Anesthesia the patient was taken to the operating room via cart She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction Next copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied Next after adequate IV sedation was administered by the Department Of Anesthesia a total of 10 cc mixture of 4 5 cc of 1 lidocaine 4 5 cc of 0 5 Marcaine 1 cc of Kenalog was injected into the right foot in an infiltrative type block Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg Next the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head A previous cicatrix was noted with slight hypertrophic scarring Using a 10 blade a lazy S type incision was created over the dorsal aspect of the third metatarsal approximately 3 5 cm in length Two semi elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen Next the 15 blade was used to deepen the incision down to the subcutaneous tissue Any small traversing veins were ligated with electrocautery Next a combination of blunt and sharp dissection were used to undermine the long extensor tendon which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue Next the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified A linear incision down to bone was made with a 15 blade to the capsuloperiosteal tissues Next the capsuloperiosteal tissues were elevated using a sharp dissection with a 15 blade off of the third metatarsal McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed A moderate amount of plantar adhesions were encountered The third toe was plantar flex and the third metatarsal was delivered into the wound Next a V shaped osteotomy with an apex distally was created using a sagittal saw The metatarsal head was allowed to float The wound was flushed with copious amounts of sterile saline 3 0 Vicryl was used to close the capsuloperiosteal tissues which kept the metatarsal head contained Next 4 0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique Next 4 0 nylon was used to close the skin in a simple interrupted technique Attention was directed to the right fifth metatarsal There was a large palpable hypertrophic prominence which is the area of maximal pain which the patient complained of preoperatively A 10 blade was used to make a 3 cm incision through the skin Next a 15 blade was used to deepen the incision through the subcutaneous tissue Next the medial and lateral aspects were undermined The abductor tendon was identified and retracted A capsuloperiosteal incision was made with a 15 blade in a linear fashion down to the bone The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a 15 blade Next the sagittal saw was used to resect the large hypertrophic dorsal exostosis A reciprocating rasp was used to smooth all bony prominences The wound was flushed with copious amount of sterile saline 3 0 Vicryl was used to close the capsuloperiosteal tissues 4 0 Vicryl was used to close subcutaneous layer with a simple interrupted suture Next 4 0 nylon was used to close the skin in a simple interrupted technique Next attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head A 15 blade was used to make a small linear incision under the third metatarsal head The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa The wound was flushed and two simple interrupted sutures with 4 0 nylon were applied Standard postoperative dressing was applied consisting of Xeroform 4x4s Kerlix Kling and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits A sterile stockinet was placed on the toes just below the knee Copious amounts of Webril were placed on all bony prominences 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well padded well moulded cast One was able to insert two fingers to the distal and proximal aspects of the _cast The capillary refill time to the digits was less than three seconds after cast application The patient tolerated the above anesthesia and procedures without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She was given standard postoperative instructions to rest ice and elevate her right foot She was counseled on smoking cessation She was given Vicoprofen 30 1 p o q 4 6h p r n pain She was given Keflex 30 1 p o t i d She is to follow up with Dr X on Monday She is to be full weightbearing with a cast boot She was given emergency contact numbers to call us if problem arises Keywords orthopedic plantar flex talus bunion talus bunionectomy metatarsal osteotomy osteotomy short leg cast hypertrophic scarring subcutaneous tissue sharp dissection linear incision foot talus pneumatic ankle capsuloperiosteal tissues plantar foot metatarsal capsuloperiosteal bunionectomy MEDICAL_TRANSCRIPTION,Description OssaTron extracorporeal shockwave therapy to right lateral epicondyle Right lateral epicondylitis Medical Specialty Orthopedic Sample Name OssaTron Extracorporeal Shockwave Therapy Transcription PREOPERATIVE DIAGNOSIS Right lateral epicondylitis POSTOPERATIVE DIAGNOSIS Right lateral epicondylitis OPERATION PERFORMED OssaTron extracorporeal shockwave therapy to right lateral epicondyle ANESTHESIA Bier block DESCRIPTION OF PROCEDURE With the patient under adequate Bier block anesthesia the patient was positioned for extracorporeal shockwave therapy The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient s input of maximum pain Then using standard extracorporeal shockwave protocol the OssaTron treatment was applied to the lateral epicondyle of the elbow After completion of the treatment the tourniquet was deflated and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well Keywords orthopedic epicondylitis ossatron extracorporeal shockwave therapy bier block epicondyle ossatron extracorporeal shockwave MEDICAL_TRANSCRIPTION,Description Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip Osteosynthesis of acetabular fracture on the left complex variety and total hip replacement Medical Specialty Orthopedic Sample Name Osteosynthesis Transcription PREOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip POSTOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip PROCEDURES 1 Osteosynthesis of acetabular fracture on the left complex variety 2 Total hip replacement ANESTHESIA General COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient in the left side up lateral position under adequate general endotracheal anesthesia the patient s left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion draped with sterile towels and drapes so as to create a sterile field Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion tagged and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column The major transverse fracture was freed of infolded soft tissue clotted blood and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7 hole 3 5 mm reconstruction plate with the montage including two interfragmentary screws It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface Once a stable fixation of the reduced fracture of the acetabulum was accomplished it should be mentioned that in the process of doing this the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall Once this was accomplished the procedure was turned over to Dr X and his team who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same This will be dictated in separate note The patient tolerated the procedure well The sciatic nerve was well protected and directly visualized to the level of the notch Keywords orthopedic hip replacement osteosynthesis intertrochanteric variety femoral insertion acetabular fracture fracture acetabular intertrochanteric femoral MEDICAL_TRANSCRIPTION,Description Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints Medical Specialty Orthopedic Sample Name Orthopedic Consult 4 Transcription CHIEF COMPLAINT Chronic low back left buttock and leg pain HISTORY OF PRESENT ILLNESS This is a pleasant 49 year old gentleman post lumbar disc replacement from January 2005 Unfortunately the surgery and interventional procedures have not been helpful in alleviating his pain He has also tried acupuncture TENS unit physical therapy chiropractic treatment and multiple neuropathic medications including Elavil Topamax Cymbalta Neurontin and Lexapro which he discontinued either due to side effects or lack of effectiveness in decreasing his pain Most recently he has had piriformis injections which did give him a brief period of relief however he reports that the Botox procedure that was done on March 8 2006 has not given him any relief from his buttock pain He states that approximately 75 of his pain is in his buttock and leg and 25 in his back He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back He rated his pain today as 6 10 describing it is shooting sharp and aching It is increased with lifting prolonged standing or walking and squatting decreased with ice reclining and pain medication It is constant but variable in degree It continues to affect activities and sleep at night as well as mood at times He is currently not satisfied completely with his level of pain relief MEDICATIONS Kadian 30 mg b i d Zanaflex one half to one tablet p r n spasm and Advil p r n ALLERGIES No known drug allergies REVIEW OF SYSTEMS Complete multisystem review was noted and signed in the chart SOCIAL HISTORY Unchanged from prior visit PHYSICAL EXAMINATION Blood pressure 123 87 pulse 89 respirations 18 and weight 220 lbs He is a well developed obese male in no acute distress He is alert and oriented x3 and displays normal mood and affect with no evidence of acute anxiety or depression He ambulates with normal gait and has normal station He is able to heel and toe walk He denies any sensory changes ASSESSMENT PLAN This is a pleasant 49 year old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints We discussed treatment options at length and he is willing to undergo a trial of Lyrica He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation Keywords orthopedic radiculitis myofascial acupuncture tens unit physical therapy chiropractic treatment lumbar disk replacement lumbar disk disk replacement MEDICAL_TRANSCRIPTION,Description Degenerative disk disease of the right hip low back pain with lumbar scoliosis post laminectomy syndrome lumbar spinal stenosis facet and sacroiliac joint syndrome and post left hip arthroplasty Medical Specialty Orthopedic Sample Name Orthopedic Consult 2 Transcription SUBJECTIVE The patient comes back to see me today She is a pleasant 77 year old Caucasian female who had seen Dr XYZ with right leg pain She has a history of prior laminectomy for spinal stenosis She has seen Dr XYZ with low back pain and lumbar scoliosis post laminectomy syndrome lumbar spinal stenosis and clinical right L2 radiculopathy which is symptomatic Dr XYZ had performed two right L2 L3 transforaminal epidural injections last one in March 2005 She was subsequently seen and Dr XYZ found most of her remaining symptoms are probably coming from her right hip An x ray of the hip showed marked degenerative changes with significant progression of disease compared to 08 04 2004 study Dr XYZ had performed right intraarticular hip injection on 04 07 2005 She was last seen on 04 15 2005 At that time she had the hip injection that helped her briefly with her pain She is not sure whether or not she wants to proceed with hip replacement We recommend she start using a cane and had continued her on some pain medicines The patient comes back to see me today She continues to complain of significant pain in her right hip especially with weightbearing or with movement She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her She is taking Ultracet or other the generic it sounds like up to four times daily She states she can take this much more frequently as she still has significant pain symptoms She is using a cane to help her ambulate PAST MEDICAL HISTORY Essentially unchanged from her visit of 04 15 2005 PHYSICAL EXAMINATION General Reveals a pleasant Caucasian female Vital Signs Height is 5 feet 4 inches Weight is 149 pounds She is afebrile HEENT Benign Neck Shows functional range of movements with a negative Spurling s Musculoskeletal Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half grade weakness of her right hip adductors and right quadriceps as compared to the left Straight leg raises are negative bilaterally Posterior tibials are palpable bilaterally Skin and Lymphatics Examination of the skin does not reveal any additional scars rashes cafe au lait spots or ulcers No significant lymphadenopathy noted Spine Examination shows lumbar scoliosis with surgical scar with no major tenderness Spinal movements are limited but functional Neurological She is alert and oriented with appropriate mood and affect She has normal tone and coordination Reflexes are 2 and symmetrical Sensations are intact to pinprick FUNCTIONAL EXAMINATION Gait has a normal stance and swing phase with no antalgic component to it IMPRESSION 1 Degenerative disk disease of the right hip symptomatic 2 Low back syndrome lumbar spinal stenosis clinically right L2 radiculopathy stable 3 Low back pain with lumbar scoliosis post laminectomy syndrome stable 4 Facet and sacroiliac joint syndrome on the right stable 5 Post left hip arthroplasty 6 Chronic pain syndrome RECOMMENDATIONS The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement In the interim her Ultracet is not quite taking care of her pain I have asked her to discontinue it and we will start her on Tylenol 3 up to four times a day I have written a prescription for this for 120 tablets and two refills The patient will call for the refills when she needs them I will plan further follow up in six months sooner if needed She voiced understanding and is in agreement with this plan Physical exam findings history of present illness and recommendations were performed with and in agreement with Dr Goel s findings Keywords orthopedic scoliosis lumbar laminectomy spinal stenosis radiculopathy chronic pain syndrome low back pain facet and sacroiliac joint degenerative disk disease sacroiliac joint syndrome lumbar spinal stenosis disk disease sacroiliac joint hip arthroplasty hip injection hip replacement lumbar scoliosis injections hip MEDICAL_TRANSCRIPTION,Description Low back pain lumbar degenerative disc disease lumbar spondylosis facet and sacroiliac joint syndrome lumbar spinal stenosis primarily bilateral recess intermittent lower extremity radiculopathy DJD of both knees bilateral pes anserinus bursitis and chronic pain syndrome Medical Specialty Orthopedic Sample Name Orthopedic Consult 1 Transcription SUBJECTIVE The patient comes back to see me today She is a pleasant 73 year old Caucasian female who had seen Dr XYZ with low back pain lumbar degenerative disc disease lumbar spondylosis facet and sacroiliac joint syndrome lumbar spinal stenosis primarily bilateral recess intermittent lower extremity radiculopathy DJD of both knees bilateral pes anserinus bursitis and chronic pain syndrome Dr XYZ had performed right and left facet and sacroiliac joint injections subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1 She was subsequently seen with some mid back pain and she had right T8 T9 and T9 T10 facet injections on 10 28 2004 She was last seen on 04 08 2005 with recurrent pain in her low back on the right Dr XYZ repeated her radiofrequency ablation on the right side from L3 S1 on 05 04 2005 The patient comes back to see me today She states that the radiofrequency ablation has helped her significantly there but she still has one spot in her low back that seems to be hurting her on the right and seems to be pointing to her right sacroiliac joint She is also complaining of pain in both knees She says that 20 years ago she had a cortisone shot in her knees which helped her significantly She has not had any x rays for quite some time She is taking some Lortab 7 5 mg tablets up to four daily which help her with her pain symptoms She is also taking Celebrex through Dr S office PAST MEDICAL HISTORY Essentially unchanged from my visit of 04 08 2005 PHYSICAL EXAMINATION General Reveals a pleasant Caucasian female Vital Signs Height is 5 feet 5 inches Weight is 183 pounds She is afebrile HEENT Benign Neck Shows functional range of movements with a negative Spurling s Musculoskeletal Examination shows degenerative joint disease of both knees with medial and lateral joint line tenderness with tenderness at both pes anserine bursa Straight leg raises are negative bilaterally Posterior tibials are palpable bilaterally Skin and Lymphatics Examination of the skin does not reveal any additional scars rashes cafe au lait spots or ulcers No significant lymphadenopathy noted Spine Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint She has no other major tenderness Spinal movements are limited but functional Neurological She is alert and oriented with appropriate mood and affect She has normal tone and coordination Reflexes are 2 and symmetrical Sensation is intact to pinprick FUNCTIONAL EXAMINATION Gait has a normal stance and swing phase with no antalgic component to it IMPRESSION 1 Low back syndrome with lumbar degenerative disc disease lumbar spinal stenosis and facet joint syndrome on the right L4 5 and L5 S1 2 Improved spinal right L3 S1 radiofrequency ablation 3 Right sacroiliac joint sprain strain symptomatic 4 Left lumbar facet joint syndrome stable 6 Right thoracic facet joint syndrome stable 7 Lumbar spinal stenosis primarily lateral recess with intermittent lower extremity radiculopathy stable 8 Degenerative disc disease of both knees symptomatic 9 Pes anserinus bursitis bilaterally symptomatic 10 Chronic pain syndrome RECOMMENDATIONS Dr XYZ and I discussed with the patient her pathology She has some symptoms in her low back on the right side at the sacroiliac joint Dr XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy She is also having pain in both knees We will plan on x rays of both knees AP and lateral and plan on seeing her back on Monday or Friday for possible intraarticular and or pes anserine bursa injections bilaterally I explained the rationale for each of these injections possible complications and she wishes to proceed In the interim she can continue on Lortab and Celebrex We will plan for the follow up following these interventions sooner if needed She voiced understanding and agreement Physical exam findings history of present illness and recommendations were performed with and in agreement with Dr Goel s findings Keywords orthopedic low back pain lumbar degenerative disc disease lumbar spondylosis facet sacroiliac joint syndrome lumbar spinal stenosis intermittent lower extremity radiculopathy djd of both knees bilateral pes anserinus bursitis chronic pain syndrome degenerative disc disease pes anserinus bursitis pes anserine bursa sacroiliac joint joint syndrome degenerative disc lumbar spinal bilateral recess lumbar joint intermittent djd pes spinal spondylosis sacroiliac syndrome MEDICAL_TRANSCRIPTION,Description A 19 year old right handed male injured in a motor vehicle accident Medical Specialty Orthopedic Sample Name Ortho Letter 1 Transcription XYZ D C Re ABC Dear Dr XYZ I had the pleasure of seeing your patient ABC today MM DD YYYY in consultation He is an unfortunate 19 year old right handed male who was injured in a motor vehicle accident on MM DD YYYY where he was the driver of an automobile which was struck on the front passenger s side The patient sustained impact injuries to his neck and lower back There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures He was taken to Hospital x rays were taken apparently which were negative and he was released At the present time he complains of neck and lower back pain radiating into his right arm and right leg with weakness numbness paraesthesia and tingling in his right arm and right leg He has had no difficulty with bowel or bladder function He does experience intermittent headaches associated with his neck pain with no other associated symptoms PAST HEALTH He was injured in a prior motor vehicle accident on MM DD YYYY At the time of his most recent injuries he was completely symptom free and under no active therapy There is no history of hypertension diabetes heart disease neurological disorders ulcers or tuberculosis SOCIAL HISTORY He denies tobacco or alcohol consumption ALLERGIES No known drug allergies CURRENT MEDICATIONS None FAMILY HISTORY Otherwise noncontributory FUNCTIONAL INQUIRY Otherwise noncontributory REVIEW OF DIAGNOSTIC STUDIES Includes an MRI scan of the cervical spine dated MM DD YYYY which showed evidence for disc bulging at the C6 C7 level MRI scan of the lumbar spine on MM DD YYYY showed evidence of a disc herniation at the L1 L2 level as well as a disc protrusion at the L2 L3 level with disc herniations at the L3 L4 and L4 L5 level and disc protrusion at the L5 S1 level PHYSICAL EXAMINATION Reveals an alert and oriented male with normal language function Vital Signs Blood pressure was 105 68 in the left arm sitting Heart rate was 70 and regular Height was 5 feet 8 inches Weight was 182 pounds Cranial nerve evaluation was unremarkable Pupils were equal and reactive Funduscopic evaluation was clear There was no evidence for nystagmus There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree with tenderness and spasm in the paraspinal musculature Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left Motor strength was 5 5 on the MRC scale Reflexes were 2 symmetrical and active No pathological responses were noted Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity Cerebellar function was normal There was normal station and gait Chest and cardiovascular evaluations were unremarkable Heart sounds were normal There were no extra sounds or murmurs Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature CLINICAL IMPRESSION Reveals a 19 year old male suffering from a posttraumatic cervical and lumbar radiculopathy secondary to traumatic injuries sustained in a motor vehicle accident on MM DD YYYY In view of the persistent radicular complaints associated with the weakness numbness paraesthesia and tingling as well as the objective sensory loss noted on today s evaluation as well as the non specific nature of the radiculopathy I have scheduled him for an EMG study on his right upper and right lower extremity in two week s time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms Palpable trigger points were noted on today s evaluation He is suffering from ongoing myofascitis His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks time I have encouraged him to continue with his ongoing treatment program under your care and supervision I will be following him in two weeks time Once again thank you kindly for allowing me to participate in this patient s care and management Yours sincerely Keywords orthopedic numbness paraesthesia and tingling paraesthesia and tingling cervical and lumbar motor vehicle accident mri scan disc protrusion paraspinal musculature letter musculature radiculopathy nerve trigger vehicle accident cervical lumbar evaluation disc ortho MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of the right wrist using an Acumed locking plate Closed displaced angulated fracture of the right distal radius Medical Specialty Orthopedic Sample Name ORIF Wrist Acumed Locking Plate Transcription PREOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius POSTOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius PROCEDURE Open reduction and internal fixation ORIF of the right wrist using an Acumed locking plate ANESTHESIA General laryngeal mask airway ESTIMATED BLOOD LOSS Minimal TOURNIQUET TIME 40 minutes COMPLICATIONS None The patient was taken to the postanesthesia care unit in stable condition The patient tolerated the procedure well INDICATIONS The patient is a 23 year old gentleman who was involved in a crush injury to his right wrist He was placed into a well molded splint after reduction was performed in the emergency department Further x rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted All risks benefits expectations and complications of the surgery were explained to the patient in detail and he signed the informed consent for ORIF of the right wrist PROCEDURE The patient was taken to the operating suite placed in supine position on the operative table The Department of anesthesia administered a general endotracheal anesthetic which the patient tolerated well The right upper extremity had a well padded tourniquet placed on the right arm which was insufflated and maintained for 40 minutes at 250 mmHg pressure The right upper extremity was prepped and draped in a sterile fashion A 5 cm incision was made over the flexor carpi radialis of the right wrist The skin was incised down to the subcutaneous tissue the deep tissue was retracted blunt dissection was performed down to the pronator quadratus Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue Next a reduction was performed placing the distal fragment into appropriate alignment This was checked under fluoroscopy and was noted to be adequately reduced and in appropriate position An Acumed Accu lock plate was placed along the volar aspect of the distal radius This was checked under AP and lateral views with C arm noted to be in appropriate alignment A 3 5 mm cortical screw was placed through the proximal aspect of the plate positioned it into position Two distal locking screws were placed along the plate itself The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture AP and lateral views were taken of these screw placements again None of these screws were into the joint and all had appropriate length into the dorsal cortex Two more 3 5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws Bicortical purchase was appreciated and no screws were placed into the joint The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2 0 Vicryl and the skin was closed with running 4 0 nylon stitch 10 mL of 0 5 Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint The patient was awakened from general anesthetic transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition The patient tolerated the procedure well Keywords orthopedic open reduction angulated fracture distal radius acumed locking plate internal fixation tourniquet acumed orif reduction fracture wrist MEDICAL_TRANSCRIPTION,Description The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints Medical Specialty Orthopedic Sample Name Ortho Office Visit Transcription Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature Motor strength was 5 5 on the MRC scale Reflexes were 2 and symmetrical Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally Palpable trigger points were noted on today s evaluation She is suffering from ongoing myofascitis Her treatment plan will consist of a series of trigger point injections which were performed today She tolerated the procedure well I have asked her to ice the region intermittently for 15 minutes off and on x 3 She will be followed in four weeks time for repeat trigger point injections if indicated Keywords orthopedic back pain trigger point injections paraspinal musculature lumbar paraspinal musculature palpable injections evaluation triggerNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of comminuted C2 fracture Posterior spinal instrumentation C1 C3 using Synthes system Posterior cervical fusion C1 C3 Insertion of morselized allograft at C1to C3 Medical Specialty Orthopedic Sample Name ORIF Cervical Fusion Transcription PREOPERATIVE DIAGNOSIS Fracture dislocation C2 POSTOPERATIVE DIAGNOSIS Fracture dislocation C2 OPERATION PERFORMED 1 Open reduction and internal fixation ORIF of comminuted C2 fracture 2 Posterior spinal instrumentation C1 C3 using Synthes system 3 Posterior cervical fusion C1 C3 4 Insertion of morselized allograft at C1to C3 ANESTHESIA GETA ESTIMATED BLOOD LOSS 100 mL COMPLICATIONS None DRAINS Hemovac x1 Spinal cord monitoring is stable throughout the entire case DISPOSITION Vital signs are stable extubated and taken back to the ICU in a satisfactory and stable condition INDICATIONS FOR OPERATION The patient is a middle aged female who has had a significantly displaced C2 comminuted fracture This is secondary to a motor vehicle accident and it was translated appropriately 1 cm Risks and benefits have been conferred with the patient as well as the family they wish to proceed The patient was taken to the operating room for a C1 C3 posterior cervical fusion instrumentation open reduction and internal fixation OPERATION IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled back to the operating theater room 5 The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties Spinal cord monitoring was induced No changes were seen from the beginning to the end of the case Mayfield tongues were placed appropriately This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls The patient s Mayfield tongue was fixated in the usual standard fashion The patient was subsequently prepped and draped in the usual sterile fashion Midline incision was extended from the base of the skull down to the C4 spinous process Full thickness skin fascia developed The fascia was incised at midline and the posterior elements at C1 C2 C3 as well as the inferior aspect of the occiput was exposed Intraoperative x ray confirmed the level to be C2 Translaminar screws were placed at C2 bilaterally Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done two 3 5 mm translaminar screws were placed bilaterally at C2 Good placement was seen both in the AP and lateral planes using fluoroscopy Facet screws were then placed at C3 Using standard technique of Magerl starting in the inferomedial quadrant 14 mm trajectories in the 25 degree caudad cephalad direction as well as 25 degrees in the medial lateral direction was made This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory A 14 x 3 5 mm screws were then placed appropriately Lateral masteries at C1 endplate were placed appropriately The medial and lateral borders were demarcated with a Penfield The great occipital nerve was retracted out the way Starting point was made with a high speed power bur and midline and lateral mass bilaterally Using a 20 degree caudad cephalad trajectory as well as 10 degree lateral to medial direction the trajectory was completed in 8 mm increments this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory Once this was done 24 x 3 5 mm smooth Schanz screws were placed appropriately Precontoured titanium rods were then placed between the screws at the C1 C2 C3 and casts were placed appropriately Once this was done all end caps were appropriately torqued This completed the open reduction and internal fixation of the C2 fracture which showed perfect alignment It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access Once the screws were torqued bilaterally good alignment was seen both in the AP and lateral planes using fluoroscopy this completed instrumentation as well as open reduction and internal fixation of C2 The cervical fusion was completed by decorticating the posterior elements of C1 C2 and C3 Once this was done the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements The fascia was closed using interrupted 1 Vicryl suture figure of 8 Superficial drain was placed appropriately Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes The subcutaneous tissues were closed using a 2 0 Vicryl suture The dermal edges were approximated using staples The wound was then dressed sterilely using Bacitracin ointment Xeroform 4x4s and tape and the drain was connected appropriately The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position Mayfield tongues were subsequently released No significant bleeding was appreciated The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition No complications arose Keywords orthopedic fracture dislocation spinal instrumentatio comminuted fracture morselized allograft vicryl suture mayfield tongues cervical fusion internal fixation orif cervical fusion fixation spinal reduction instrumentation MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long arm posterior well molded splint and closed reduction casting of the right forearm Medical Specialty Orthopedic Sample Name ORIF Closed Reduction Transcription PREOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction attempts 2 right radial shaft fracture with volar apex angulation POSTOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction attempts 2 right radial shaft fracture with volar apex angulation PROCEDURES 1 Open reduction internal fixation of the left medial epicondyle fracture with placement in a long arm posterior well molded splint 2 Closed reduction casting of the right forearm ANESTHESIA Surgery performed under general anesthesia Local anesthetic was 10 mL of 0 5 Marcaine TOURNIQUET TIME On the left was 29 minutes COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 13 year old right hand dominant girl who fell off a swing at school around 1 30 today The patient was initially seen at an outside facility and brought here by her father given findings on x ray a closed reduction was attempted on the left elbow After the attempted reduction the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure Given this finding the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve At that same time the patient s mildly angulated radial shaft fracture will be reduced This was explained to the father The risks of surgery included the risk of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure need for later hardware removal and possible continuous nerve symptoms All questions were answered The father agreed to the above plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was then administered The patient received Ancef preoperatively The left upper extremity was then prepped and draped in the standard surgical fashion Attempts to remove the incarcerated medial epicondyle with supination valgus stress and with extension were unsuccessful It was decided at this time that she would need open reduction The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg The Esmarch was then removed An incision was then made Care was taken to avoid any injury to the ulnar nerve The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint This was easily removed The ulnar nerve was also identified and appeared to be intact The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3 2 drill bit and subsequently a 44 mm 4 5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place After fixation of the fragment the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement The wound was then irrigated with normal saline and closed using 2 0 Vicryl and 4 0 Monocryl The wound was clean and dry dressed with Steri Strips and Xeroform The area was infiltrated with 0 5 Marcaine The patient was then placed in a long arm posterior well molded splint with 90 degrees of flexion and neutral rotation The tourniquet was released at 30 minutes prior to placement of the dressing showed no significant bleeding Attention was then turned to right side the arm was then manipulated and a well molded long arm cast placed The final position in the cast revealed a very small residual volar apex angulation which is quite acceptable in this age The patient tolerated the procedure well was subsequently extubated and taken to recovery in a stable condition POSTOPERATIVE PLAN The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days The father was made aware of the intraoperative findings All questions answered Keywords orthopedic orif elbow fracture dislocation open reduction internal fixation closed reduction left medial epicondyle fracture long arm posterior well molded splint splint radial shaft fracture volar apex angulation medial epicondyle fracture medial epicondyle internal fixation epicondyle fracture ulnar nerve epicondyle fracture reduction tourniquet ulnar nerve MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left atrophic mandibular fracture removal of failed dental implant from the left mandible The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture Medical Specialty Orthopedic Sample Name ORIF Mandibular Fracture Dental Implant Removal Transcription PREOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant POSTOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant PROCEDURE PERFORMED Open reduction and internal fixation ORIF of left atrophic mandibular fracture removal of failed dental implant from the left mandible ANESTHESIA General nasotracheal ESTIMATED BLOOD LOSS 125 mL FLUIDS GIVEN 1 L of crystalloids SPECIMEN Soft tissue from the fracture site sent for histologic diagnosis CULTURES Also sent for Gram stain aerobic and anaerobic culture and sensitivity INDICATIONS FOR THE PROCEDURE The patient is a 79 year old male who fell in his hometown following an episode of syncope He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above mentioned fracture He was admitted to hospital in Harleton Texas where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass His mandible fracture was not noted initially The patient also has a history of prostate cancer and a renal cell carcinoma The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending The patient later saw a local oral surgeon He diagnosed his mandible fracture and advised him to seek treatment in Houston He presented to my office for evaluation on January 18 2010 and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant which had been placed approximately 15 years ago The patient had significant discomfort and could eat foods and drink fluids with difficulty Due to the nature of his fracture and the complex medical history he was sent to the hospital for admission and following cardiac clearance he was scheduled for surgery today PROCEDURE IN DETAIL The patient was taken to the operating room and placed in a supine position Following a nasal intubation and induction of general anesthesia the surgeon then scrubbed gowned and gloved in the normal sterile fashion The patient was then prepped and draped in a manner consistent with sterile procedures A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region approximately 1 5 cm medial to the inferior border of the mandible A 1 mL of lidocaine 1 with 1 100 000 epinephrine was then infiltrated along the incision and then a 15 blade was used to incise through the skin and subcutaneous tissue A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible Electrocautery as well as 4 0 silk ties were used for hemostasis A 15 blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11 hole Synthes reconstruction plate was then used to stand on the fracture site Since there was an area of weakness in the right parasymphysis region in the location of another dental implant the bone plate was extended posterior to that site When the plate was adapted to the mandible it was then secured to the bone with 9 screws each being 2 mm in diameter and each screw was placed bicortically All the screws were also locking screws Following placement of the screws there was felt to be excellent stability of the fracture so the wound was irrigated with a copious amount of normal saline The incision was closed in multiple layers with 4 0 Vicryl in the muscular and subcutaneous layers and 5 0 nylon in the skin A sterile dressing was then placed over the incision The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs Estimated blood loss is 125 mL Keywords orthopedic atrophic mandibular fracture dental implant open reduction and internal fixation orif mandibular fracture mandible atrophic mandibular dental implant MEDICAL_TRANSCRIPTION,Description Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness paraesthesia and tingling in both arms Medical Specialty Orthopedic Sample Name Ortho Letter 2 Transcription XYZ D C 60 Evergreen Place Suite 902 East Orange NJ 07018 Re Keywords orthopedic paraspinal musculature palpable trigger points trigger point injections lumbar region paraspinal musculature injections trigger MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left distal radius Medical Specialty Orthopedic Sample Name ORIF of Left Distal Radius Transcription PREOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular POSTOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular PROCEDURE Open reduction and internal fixation of left distal radius IMPLANTS Wright Medical Micronail size 2 ANESTHESIA LMA TOURNIQUET TIME 49 minutes BLOOD LOSS Minimal COMPLICATIONS None PATHOLOGY None TIME OUT Time out was performed before the procedure started INDICATIONS The patient was a 42 year old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis The patient was in early stage of gestation Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor DESCRIPTION OF PROCEDURE Supine position LMA anesthesia well padded arm tourniquet Hibiclens alcohol prep and sterile drape Exsanguination achieved tourniquet inflated to 250 mmHg First under fluoroscopy the fracture was reduced A 0 045 K wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction A 2 cm radial incision superficial radial nerve was exposed and protected Dissecting between the first and second dorsal extensor retinaculum the second dorsal extensor compartment was elevated off from the distal radius The guidewire was inserted under fluoroscopy A cannulated drill was used to drill antral hole Antral awl was inserted Then we reamed the canal to size 2 Size 2 Micronail was inserted to the medullary canal Using distal locking guide three locking screws were inserted distally The second dorsal incision was made The deep radial dorsal surface was exposed Using locking guide two proximal shaft screws were inserted and locked the nail to the radius Fluoroscopic imaging was taken and showing restoration of the height tilt and inclination of the radius At this point tourniquet was deflated hemostasis achieved wounds irrigated and closed in layers Sterile dressing applied The patient then was extubated and transferred to the recovery room under stable condition Postoperatively the patient will see a therapist within five days We will immobilize wrist for two weeks and then starting flexion extension and prosupination exercises Keywords orthopedic distal radius fracture dorsal extensor locking guide radius fracture extraarticular metaphyseal guidewire fracture dorsal distal MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left tibia Medical Specialty Orthopedic Sample Name ORIF Left Tibia Transcription PREOPERATIVE DIAGNOSIS Left tibial tubercle avulsion fracture POSTOPERATIVE DIAGNOSIS Comminuted left tibial tubercle avulsion fracture with intraarticular extension PROCEDURE Open reduction and internal fixation of left tibia ANESTHESIA General The patient received 10 ml of 0 5 Marcaine local anesthetic TOURNIQUET TIME 80 minutes ESTIMATED BLOOD LOSS Minimal DRAINS One JP drain was placed COMPLICATIONS No intraoperative complications or specimens Hardware consisted of two 4 5 K wires One 6 5 60 mm partially threaded cancellous screw and one 45 60 mm partially threaded cortical screw and 2 washers HISTORY AND PHYSICAL The patient is a 14 year old male who reported having knee pain for 1 month Apparently while he was playing basketball on 12 22 2007 when he had gone up for a jump he felt a pop in his knee The patient was seen at an outside facility where he was splinted and subsequently referred to Children s for definitive care Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta Surgery is recommended to the grandmother and subsequently to the father by phone Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal Risks of surgery include the risks of anesthesia infection bleeding changes on sensation in most of the extremity hardware failure need for later hardware removal failure to restore extensor mechanism tension and need for postoperative rehab All questions were answered and father and grandmother agreed to the above plan PROCEDURE The patient was taken to the operating and placed supine on the operating table General anesthesia was then administered The patient was given Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The patient s extremity was then prepped and draped in the standard surgical fashion Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch Finally the patient had tourniquet that turned in 75 mmHg Esmarch was then removed The incision was then made The patient had significant tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement We were able to see the underside of the anterior horn of both medial and lateral meniscus The intraarticular cartilage was restored using two 45 K wires Final position was checked via fluoroscopy and the corners were buried in the cartilage There was a large free floating metaphyseal piece that included parts of proximal tibial physis This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6 5 60 mm cancellous screw with a washer The cortical screw did not provide good compression and fixation at this distal fragment Retinaculum was repaired using 0 Vicryl suture as best as possible The hematoma was evacuated at the beginning of the case as well as the end The knee was copiously irrigated with normal saline The subcutaneous tissue was re approximated using 2 0 Vicryl and the skin with 4 0 Monocryl The wound was cleaned dried and dressed with Steri Strips Xeroform and 4 x4s Tourniquet was released at 80 minutes JP drain was placed on the medium gutter The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes The patient was then placed in a knee mobilizer The patient tolerated the procedure well Subsequently extubated and taken to the recovery in stable condition POSTOP PLAN The patient hospitalized overnight to decrease swelling and as well as manage his pain He may weightbear as tolerated using knee mobilizer Postoperative findings relayed to the grandmother The patient will need subsequent hardware removal The patient also was given local anesthetic at the end of the case Keywords orthopedic intraarticular extension tibial tubercle avulsion fracture tubercle avulsion fracture jp drain cortical screw hardware removal tibial tubercle tourniquet orif tubercle tibial MEDICAL_TRANSCRIPTION,Description Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture Medical Specialty Orthopedic Sample Name ORIF Followup Transcription REASON FOR VISIT Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture HISTORY OF PRESENT ILLNESS The patient is now approximately week status post removal of Ex Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture The patient states that this pain is well controlled He has had no fevers chills or night sweats He has had some mild drainage from his pin sites He just started doing range of motion type exercises for his right knee He has had no numbness or tingling FINDINGS On exam his pin sites had no erythema There is some mild drainage but they have been dressing with bacitracin it looks like there may be part of the fluid noted The patient had 3 5 strength in the EHL FHL He has intact sensation to light touch in a DP SP and tibial nerve distribution X rays taken include three views of the right knee It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment ASSESSMENT Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix PLANS I gave the patient a prescription for aggressive range of motion of the right knee I would like to really work on this as he has not had much up to this time He should remain nonweightbearing I would like to have him return in 2 weeks time to assess his knee range of motion He should not need x rays at that time Keywords orthopedic external fixator open reduction internal fixation tibial plateau fracture ex fix tibial plateau fracture internal fixation tibial plateau orif MEDICAL_TRANSCRIPTION,Description Hawkins IV talus fracture Open reduction internal fixation of the talus medial malleolus osteotomy and repair of deltoid ligament Medical Specialty Orthopedic Sample Name ORIF Talus Transcription PREOPERATIVE DIAGNOSIS Hawkins IV talus fracture POSTOPERATIVE DIAGNOSIS Hawkins IV talus fracture PROCEDURE PERFORMED 1 Open reduction internal fixation of the talus 2 Medial malleolus osteotomy 3 Repair of deltoid ligament ANESTHESIA Spinal TOURNIQUET TIME 90 min BLOOD LOSS 50 cc The patient is in the semilateral position on the beanbag INTRAOPERATIVE FINDINGS A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament There was no evidence of osteochondral defects of the talar dome HISTORY This is a 50 year old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement There was no open injury The patient fell approximately 10 feet off his liner landing on his left foot There was evidence of gross deformity of the ankle An x ray was performed in the Emergency Room which revealed a grade IV Hawkins classification talus fracture He was distal neurovascularly intact The patient denied any other complaints besides pain in the ankle It was for this reason we elected to undergo the above named procedure in order to reduce and restore the blood supply to the talus body Because of its tenuous blood supply the patient is at risk for avascular necrosis The patient has agreed to undergo the above named procedure and consent was obtained All risks as well as complications were discussed PROCEDURE The patient was brought back to operative room 4 of ABCD General Hospital on 08 20 03 A spinal anesthetic was administered A nonsterile tourniquet was placed on the left upper thigh but not inflated He was then positioned on the beanbag The extremity was then prepped and draped in the usual sterile fashion for this procedure An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg At this time an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site At this time a 15 blade was used to make approximately 10 cm incision over the medial malleolus This was curved anteromedial along the root of the saphenous vein The saphenous vein was located Its tributaries going plantar were cauterized and the vein was retracted anterolaterally At this time we identified the medial malleolus There was evidence of approximately 80 avulsion rupture of the deltoid ligament off of the medial malleolus This was a major blood feeder to the medial malleolus and we were concerned once we were going to do the osteotomy that this would later create healing problem It is for this reason that the pedicle which was attached to the medial malleolus was left intact This pedicle was the anterior portion of the deltoid ligament At this time a MicroChoice saw was then used to make a box osteotomy of the medial malleolus Once this was performed the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply This provided us with excellent exposure to the fracture site of the medial side At this time any loose comminuted pieces were removed The dome of the talus was also checked and did not reveal any osteochondral defects There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw this would tend to extend the fracture site It is for this reason we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site At this time a reduction was performed The 7 0 partially threaded cannulated screws were used in order to fix the fracture At this time a 3 2 mm guidewire was placed going from posterolateral to anteromedial This was placed slightly lateral to the Achilles tendon percutaneously inserted and then drilled in the according fashion across the fracture site Once this was performed a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in A depth gauze was then used to measure screw length A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw A 55 mm partially threaded 7 0 cannulated screw was then placed with excellent compression at the fracture site Once this was obtained we checked the reduction again using intraoperative Xi Scan in the AP and lateral direction This projection gave us excellent view of our screw placement and excellent compression across the fracture site At this time we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft This was placed using a freer elevator into the fracture site where the comminution was At this time we copiously irrigated the wound The osteotomy site was then repaired first clamped using two large tenaculum reduction clamps Two partially threaded 4 0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws Next a 1 0 Vicryl was then used to repair the deltoid ligament which was ruptured via the injury A tight repair was performed of the deltoid ligament At this time again copious irrigation was used to irrigate the wound A 2 0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision At this time the leg was cleansed Adaptic 4 x 4 and Kerlix roll were then applied The patient was then placed in a plaster splint for mobilization The tourniquet was then released The patient was then transferred off the operating table to recovery in stable condition The prognosis for this fracture is guarded There is a high rate of avascular necrosis of the talar body approximately anywhere from 40 60 risk The patient is aware of this and he will be followed as an outpatient for this problem Keywords orthopedic deltoid ligament medial malleolus osteotomy open reduction internal fixation of the talus hawkins iv talus fracture medial malleolus fracture site malleolus talus medial fracture tourniquet ligament osteotomy MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left lateral malleolus Left lateral malleolus fracture Medical Specialty Orthopedic Sample Name ORIF Malleolus Transcription PREOPERATIVE DIAGNOSIS Left lateral malleolus fracture POSTOPERATIVE DIAGNOSIS Left lateral malleolus fracture PROCEDURE PERFORMED Open reduction and internal fixation of left lateral malleolus ANESTHESIA General TOURNIQUET TIME 59 minutes COMPLICATIONS None BLOOD LOSS Negligible CLOSURE 2 0 Vicryl and staples INDICATIONS FOR SURGERY This is a young gentleman with soccer injury to his left ankle and an x ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently OPERATIVE PROCEDURE The patient was taken to the operative room where general anesthesia was successfully introduced The right ankle was prepped and draped in standard fashion The tourniquet was applied about the right upper thigh An Esmarch tourniquet was used to exsanguinate the ankle The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes An approximately 6 inch longitudinal incision was made just over the lateral malleolus Care was taken to spare overlying nerves and vessels An elevator was used to expose the fracture The fracture was freed of old hematoma and reduced with a reducing clamp An interfragmentary cortical screw was placed of 28 mm with excellent purchase The intraoperative image showed excellent reduction A 5 hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally Excellent stability of fracture was achieved Final fluoroscopy showed a reduction to be anatomic in 2 planes The wound was irrigated with copious amounts of normal saline Deep tissue was closed with 2 0 Vicryl The skin was approximated with 2 0 Vicryl and closed with staples Dry sterile dressing was applied The patient tolerated the procedure was awakened and taken to the recovery room in stable condition Keywords orthopedic open reduction and internal fixation esmarch internal fixation malleolus fracture lateral malleolus tourniquet orif fixation ankle reduction fracture malleolus MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation high grade Frykman VIII distal radius fracture Medical Specialty Orthopedic Sample Name ORIF 2 Transcription PREOPERATIVE DIAGNOSIS Severely comminuted fracture of the distal radius left POSTOPERATIVE DIAGNOSIS Severely comminuted fracture of the distal radius left OPERATIVE PROCEDURE Open reduction and internal fixation high grade Frykman VIII distal radius fracture ANESTHESIA General endotracheal PREOPERATIVE INDICATIONS This is a 52 year old patient of mine who I have repaired both shoulder rotator cuffs the most recent one in the calendar year 2007 While he was climbing a ladder recently in the immediate postop stage he fell suffering the aforementioned heavily comminuted Frykman fracture This fracture had a fragment that extended in the distal radial ulnar joint a die punch fragment in the center of the radius The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions He presented to my office the morning of April 3 2007 having had a left reduction done elsewhere a day ago The reduction although adequate had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1 8 this was essentially an 8 The best results have been either with external fixation or internal fixation most recently volar plating of a locking variety has been popular and I felt that this would be appropriate in his case Risks and benefits otherwise described were bleeding infection need to do operative revise or removal of hardware He is taking a job out of state in the next couple of months Hence I felt that even with close followup this is a particularly difficult fracture as far as the morbidity of the injury proceeds OPERATIVE NOTE After adequate general endotracheal anesthesia was obtained one gram of Ancef was given intravenously The left upper extremity was prepped and draped in supine position with the left hand in the arm table magnification was used throughout The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient A small C arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them specifically the distal radial ulnar joint and die punch fragment At this point a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws The ulnar styloid was not affixed in any portion of this repair The plate was viewed under the image intensification device i e x ray and the screws were placed in this order The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach a locking 12 mm screw through 16 mm screws were placed in the following order Most proximal on the radial shaft of the plate then the radial styloid i e the most distal and lateral screw the next most proximal shaft screw followed by the distal radial ulnar joint screw Three screws were locking across the die punch fragment The remaining two screws were placed into the radial shaft All of these were locking screws of 2 mm in diameter and as the construct was created the relative motion of the intra articular fragment in dorsal comminution all diminished greatly although the exposure as well as the amount of reduction force used was substantial The tourniquet time was 1 5 hours At this point the tourniquet was let down The entire construct was irrigated with copious amounts of bacitracin and normal saline Closure was affected with 0 Vicryl underneath the skin surface followed by 3 0 Prolene in interrupted sutures in the volar wound Several image intensification x rays were taken at the conclusion of the case to check screw length Screw lengths were changed out during the case as needed based on the x ray findings The wound was injected with Marcaine lidocaine Depo Medrol and Kantrex A very heavily padded fluffy cotton Jones type dressing was applied with a volar splint Estimated blood loss was 10 mL There were no specimens Tourniquet time was 1 5 hours Keywords orthopedic distal radius c arm depo medrol frykman jones type dressing kantrex marcaine open reduction and internal fixation die punch intra articular lidocaine pronator quadratus radial styloid ulnar styloid distal radial ulnar joint radial ulnar joint distal screws orif fracture radial MEDICAL_TRANSCRIPTION,Description Fractured right fifth metatarsal Open reduction and internal screw fixation right fifth metatarsal Application of short leg splint Medical Specialty Orthopedic Sample Name ORIF Fifth Metatarsal Transcription PREOPERATIVE DIAGNOSIS Fractured right fifth metatarsal POSTOPERATIVE DIAGNOSIS Fractured right fifth metatarsal PROCEDURE PERFORMED 1 Open reduction and internal screw fixation right fifth metatarsal 2 Application of short leg splint ANESTHESIA TIVA local HISTORY This 32 year old female presents to Preoperative Holding Area after keeping herself n p o since mid night for open reduction and internal fixation of a fractured right fifth metatarsal The patient relates that approximately in mid June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot She continued to walk on the foot and found nothing was wrong despite the pain She was recently seen by Dr X and was referred to Dr Y for surgery The risks versus benefits of the procedure had been explained to the patient in detail by Dr Y The consent is available on the chart for review The urine beta was taken in the preoperative area and was negative PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operating table in the supine position A safety strap was placed across her waist for her protection Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied After adequate IV sedation was administered by the Department of Anesthesia a total of 10 cc of 0 5 Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operative field and a sterile stocking was reflected Attention was directed to the right fifth metatarsal base The Xi scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal An avulsion fracture of the right fifth metatarsal base was visualized The fracture was linear in nature from distal lateral to proximal medial There appeared to be a pseudoarthrosis on the lateral view A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve A linear incision was created with a 10 blade A 15 blade was used to deepen the incision through the subcutaneous tissue All small veins traversing the subcutaneous tissue were ligated with electrocautery Next using combination of sharp and blunt dissection the deep fascia was reached Next a linear capsuloperiosteal incision was made down to the bone using a 15 blade Next using a periosteal elevator and a 15 blade the capsuloperiosteal tissues were stripped from the bone The fracture site was not clearly visualized due to bony callus A 25 gauge needle was introduced into the fracture site under fluoroscopy The fracture site was easily found An osteotome was used to separate the pseudoarthrosis A curette was used to remove the hypertrophic excessive pseudoarthrotic bone Next a small ball burr was used to resect the remaining hypertrophic bone Next a 1 0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone Next a bone clamp was applied and the fracture was reduced Next a threaded K wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally A 4 0 mm Synthes partially threaded cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly All this was done under fluoroscopy Next the wound was flushed with copious amounts of sterile saline The fracture site was found to have rigid compression The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed Next the capsuloperiosteal tissues were closed with 3 0 Vicryl in a simple interrupted fashion A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl Next the subcutaneous layer was closed with 4 0 Vicryl in a simple interrupted suture technique Next the skin was closed with 5 0 Prolene in a horizontal mattress technique A postoperative fluoroscopic x ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance A dressing consisting of Owen silk 4x4s fluff and Kerlix were applied A sterile stockinet was applied over the foot Next copious amounts of Webril were applied to pad all bony prominences The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits Next 4 inch pre moulded well padded posterior splint was applied The capillary refill time of the digits was less than three seconds The patient tolerated the above anesthesia and procedure without complications After anesthesia was reversed she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She was given Vicodin 5 500 mg 30 1 2 p o q 4 6h p r n pain Naprosyn 500 mg p o b i d p c Keflex 500 mg 30 one p o t i d till gone She was given standard postoperative instructions to be non weightbearing and was dispensed with crutches She will rest ice and elevate her right leg She is to follow up in the clinic on 08 26 03 at 10 30 a m She was given emergency contact numbers and will call or return if problems arise earlier Keywords orthopedic metatarsal internal screw fixation leg splint fractured right fifth metatarsal pneumatic ankle tourniquet ankle tourniquet metatarsal base fracture site fractured hypertrophic bernstein orif MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of right distal radius fracture intraarticular four piece fracture and right carpal tunnel release Medical Specialty Orthopedic Sample Name ORIF 1 Transcription PREOPERATIVE DIAGNOSES 1 Displaced intraarticular fracture right distal radius 2 Right carpal tunnel syndrome PREOPERATIVE DIAGNOSES 1 Displaced intraarticular fracture right distal radius 2 Right carpal tunnel syndrome OPERATIONS PERFORMED 1 Open reduction and internal fixation of right distal radius fracture intraarticular four piece fracture 2 Right carpal tunnel release ANESTHESIA General CLINICAL SUMMARY The patient is a 37 year old right hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago This was an intraarticular four part fracture that was displaced dorsally In addition the patient previously undergone a carpal tunnel release but had symptoms of carpal tunnel preop She is admitted for reconstructive operation The symptoms of carpal tunnel were present preop and worsened after the injury OPERATION The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia Once adequate anesthesia had been obtained the right upper extremity was prepped and draped in the usual sterile manner Tourniquet was placed around the right upper extremity The upper extremity was then elevated and exsanguinated using an Esmarch dressing The tourniquet was elevated to 250 mmHg The entire operation was performed with 4 5 loop magnification At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally This was carried down to the flexor carpi radialis which was then retracted ulnarly The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin It was then elevated off of the fracture site exposing the fracture site which was dorsally displaced This was an intraarticular four part fracture Under image control the two volar pieces and dorsal pieces were then carefully manipulated and reduced Then 2 06 two inch K wires were drilled radial into the volar ulnar fragment and then a second K wire was then drilled from the dorsal radial to the dorsal ulnar piece A third K wire was then drilled from the volar radial to the dorsal ulnar piece The fracture was then manipulated The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it Further K wires were then placed through the radial styloid into the proximal fragment A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K wires At this time the distal screws were then placed The distal screws were the small screws These were non locking screws all eight screws were placed They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth Again these were 18 20 mm screws After placing three of the screws it was necessary to remove the K wires There was excellent reduction of the fragments and the fracture excellent reduction of the intraarticular component and the fracture After the distal screws were placed the fracture was reduced and held in place with K wires which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit The screws were then placed These were 12 mm screws They were placed 4 in number The K wires were then removed Finally a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist This was carried down to the transverse carpal ligament which was divided throughout the length of the incision upon entering the carpal canal the median nerve was found to be adherent to the undersurface of the structure It was dissected free from the structure out to its trifurcation The motor branches seen entering the thenar fascia and obstructed The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm In this area careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon Incisions were then copiously irrigated with normal saline Homeostasis was maintained with electrocautery The pronator quadratus was closed with 3 0 Vicryl and the above skin incisions were closed proximally with 4 0 nylon and palmar incision with 5 0 nylon in the horizontal mattress fashion A large bulky dressing was then applied with a volar short arm splint maintaining the wrist in neutral position The tourniquet was let down The fingers were immediately pink The patient was awakened and taken to the recovery room in good condition There were no operative complications The patient tolerated the procedure well Keywords orthopedic intraarticular fracture esmarch k wires open reduction and internal fixation tourniquet carpal tunnel release carpal tunnel syndrome flexor carpi radialis flexor pronator muscles intraarticular right distal radius transverse carpal ligament volar flexion crease pronator quadratus flexor carpi carpi radialis flexion crease carpal ligament carpal tunnel carpal volar MEDICAL_TRANSCRIPTION,Description MRI L Spine Bilateral lower extremity numbness Medical Specialty Orthopedic Sample Name Normal L Spine MRI Transcription CC Bilateral lower extremity numbness HX 21 y o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11 5 96 The symptoms became maximal over a 12 24 hour period and have not changed since The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space He denied bowel bladder problems or weakness or numbness elsewhere Hot showers may improve his symptoms He has suffered no recent flu like illness Past medical and family histories are unremarkable He was on no medications EXAM Unremarkable except for mild distal vibratory sensation loss in the toes R L LAB CBC Gen Screen TSH FT4 SPE ANA were all WNL MRI L SPINE Normal COURSE Normal exam and diminished symptoms at following visit 4 23 93 Keywords orthopedic bilateral lower extremity numbness mri l spine bilateral lower extremity lower extremity numbness bilateral spine mri extremities numbness MEDICAL_TRANSCRIPTION,Description Repair of nerve and tendon right ring finger and exploration of digital laceration Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger Medical Specialty Orthopedic Sample Name Nerve Tendon Repair Finger Transcription PREOPERATIVE DIAGNOSIS Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury POSTOPERATIVE DIAGNOSES 1 Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis 2 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger PROCEDURE PERFORMED 1 Repair of nerve and tendon right ring finger 2 Exploration of digital laceration ANESTHESIA General ESTIMATED BLOOD LOSS Less than 10 cc TOTAL TOURNIQUET TIME 57 minutes COMPLICATIONS None DISPOSITION To PACU in stable condition BRIEF HISTORY OF PRESENT ILLNESS This is a 13 year old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger GROSS OPERATIVE FINDINGS After wound exploration it was found there was a 100 laceration to the ulnar digital neurovascular bundle The FDS had a partial ulnar slip laceration and the FDP had a 25 transverse laceration as well The radial neurovascular bundle was found to be completely intact OPERATIVE PROCEDURE The patient was taken to the operating room and placed in the supine position All bony prominences were adequately padded Tourniquet was placed on the right upper extremity after being packed with Webril but not inflated at this time The right upper extremity was prepped and draped in the usual sterile fashion The hand was inspected Palmar surface revealed approximally 0 5 cm laceration at the base of the right ring finger at the base of proximal phalanx which was approximated with nylon suture The sutures were removed and the wound was explored It was found that the ulnar digital neurovascular bundle was 100 transected The radial neurovascular bundle on the right ring finger was found to be completely intact We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25 laceration in a transverse fashion to the FDP We copiously irrigated the wound Repair was undertaken of the FDS with 3 0 undyed Ethibond suture The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact Attention during our repair at the flexor tendon the A1 pulley was incised for better visualization as well as better tendon excursion after repair Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury The digital nerve was dissected proximally and distally to likely visualize the nerve The nerve was then approximated using microvascular technique with 8 0 nylon suture The hands were well approximated The nerve was not under undue tension The wound was then copiously irrigated and the skin was closed with 4 0 nylon interrupted horizontal mattress alternating with simple suture Sterile dressing was placed and a dorsal extension Box splint was placed The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition Overall prognosis is good Keywords orthopedic laceration flexor tendon volar laceration digital laceration ulnar slip flexor digitorum neurovascular bundle nerve injury ring finger neurovascular fds bundle tendon repair flexor digital ulnar MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of right Schatzker III tibial plateau fracture with partial medial meniscectomy Medical Specialty Orthopedic Sample Name ORIF Discharge Summary Transcription ADMISSION DIAGNOSIS Right tibial plateau fracture DISCHARGE DIAGNOSES Right tibial plateau fracture and also medial meniscus tear on the right side PROCEDURES PERFORMED Open reduction and internal fixation ORIF of right Schatzker III tibial plateau fracture with partial medial meniscectomy CONSULTATIONS To rehab Dr X and to Internal Medicine for management of multiple medical problems including hypothyroid diabetes mellitus type 2 bronchitis and congestive heart failure HOSPITAL COURSE The patient was admitted and consented for operation and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence The patient seemed to be recovering well The patient spent the next several days on the floor nonweightbearing with CPM machine in place developed a brief period of dyspnea which seems to have resolved and may have been a combination of bronchitis thick secretions and fluid overload The patient was given nebulizer treatment and Lasix increased the same to resolve the problem The patient was comfortable stabilized breathing well On day 12 was transferred to ABCD DISCHARGE INSTRUCTIONS The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy DIET Regular ACTIVITY AND LIMITATIONS Nonweightbearing to the right lower extremity The patient is to continue CPM machine while in bed along with antiembolic stockings The patient will require nursing physical therapy occupational therapy and social work consults DISCHARGE MEDICATIONS Resume home medications but increase Lasix to 80 mg every morning Lovenox 30 mg subcu daily x2 weeks Vicodin 5 500 mg one to two every four to six hours p r n pain Combivent nebulizer every four hours while awake for difficulty breathing Zithromax one week 250 mg daily and guaifenesin long acting one twice a day b i d FOLLOWUP Follow up with Dr Y in 7 to 10 days in office CONDITION ON DISCHARGE Stable Keywords orthopedic open reduction internal fixation schatzker iii tibial plateau fracture meniscectomy tibial plateau fracture orif schatzker fixation reduction tibial fracture plateau MEDICAL_TRANSCRIPTION,Description Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection Medical Specialty Orthopedic Sample Name Neuroplasty Transcription PREOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room status post transforaminal epidurogram see operative note for further details Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen 375 units of Wydase was injected through each needle After two minutes 3 5 cc of 0 5 Marcaine and 80 mg of Depo Medrol was injected through each needle These needles were removed and the patient was discharged in stable condition Keywords orthopedic nerve root decompression discectomy epidural fibrosis nerve root entrapment transforaminal neuroplasty neural foramen nerve root foramen neuroplasty transforaminal needle epidural MEDICAL_TRANSCRIPTION,Description Incision and drainage and excision of the olecranon bursa left elbow Acute infected olecranon bursitis left elbow Medical Specialty Orthopedic Sample Name Olecranon Bursa Excision Transcription PREOPERATIVE DIAGNOSIS Acute infected olecranon bursitis left elbow POSTOPERATIVE DIAGNOSIS Infection left olecranon bursitis PROCEDURE PERFORMED 1 Incision and drainage left elbow 2 Excision of the olecranon bursa left elbow ANESTHESIA Local with sedation COMPLICATIONS None NEEDLE AND SPONGE COUNT Correct SPECIMENS Excised bursa and culture specimens sent to the microbiology INDICATION The patient is a 77 year old male who presented with 10 day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage He was then scheduled for I D and excision of the bursa Risks and benefits were discussed No guarantees were made or implied PROCEDURE The patient was brought to the operating room and once an adequate sedation was achieved the left elbow was injected with 0 25 plain Marcaine The left upper extremity was prepped and draped in standard sterile fashion On examination of the left elbow there was presence of thickening of the bursal sac There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted An incision was made midline of the olecranon bursa with an elliptical incision around the open wound which was excised with skin The incision was carried proximally and distally The olecranon bursa was significantly thickened and scarred Excision of the olecranon bursa was performed There was significant evidence of thickening of the bursa with some evidence of adhesions Satisfactory olecranon bursectomy was performed The wound margins were debrided The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution There was no evidence of a loose body There was no bleeding or drainage After completion of the bursectomy and I D the skin margins which were excised were approximated with 2 0 nylon in horizontal mattress fashion The open area of the skin which was excised was left _________ and was dressed with 0 25 inch iodoform packing Sterile dressings were placed including Xeroform 4x4 ABD and Bias The patient tolerated the procedure very well He was then extubated and transferred to the recovery room in a stable condition There were no intraoperative complications noticed Keywords orthopedic incision and drainage infected olecranon olecranon bursitis olecranon bursa olecranon wound excision drainage elbow bursa MEDICAL_TRANSCRIPTION,Description Chronic plantar fasciitis right foot Open plantar fasciotomy right foot Medical Specialty Orthopedic Sample Name Open Plantar Fasciotomy Transcription PREOPERATIVE DIAGNOSIS Chronic plantar fasciitis right foot POSTOPERATIVE DIAGNOSIS Chronic plantar fasciitis right foot PROCEDURE Open plantar fasciotomy right foot ANESTHESIA Local infiltrate with IV sedation INDICATIONS FOR SURGERY The patient has had a longstanding history of foot problems The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care The preoperative discussion with the patient including alternative treatment options the procedure itself was explained and risk factors such as infection swelling scar tissue numbness continued pain recurrence falling arch digital contracture and the postoperative management were discussed The patient has been advised although no guarantee for success could be given most of the patients have improved function and less pain All questions were thoroughly answered The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities The purpose of the surgery is to alleviate the pain and discomfort DETAILS OF THE PROCEDURE The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure The patient was brought to the operating room and placed in the supine position Following a light IV sedation a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL and a 1 1 mixture of 1 lidocaine with epinephrine and 0 25 Marcaine was affected The lower extremity was prepped and draped in the usual sterile manner Balance anesthesia was obtained PROCEDURE Plantar fasciotomy right foot The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands creating a small and narrow soft tissue tunnel Utilizing a Metzenbaum scissor transection of the medial two third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band extending to the lateral two thirds of the band The lateral plantar fascial band was left intact Visualization and finger probe confirmed adequate transection The surgical site was flushed with normal saline irrigation The deep layer was closed with 3 0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples The dressing consisted of Adaptic 4 x 4 conforming bandages and an ACE wrap to provide mild compression The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact A walker boot was dispensed and applied The patient will be allowed to be full weightbearing to tolerance in the boot to encourage physiological lengthening of the release of plantar fascial band The next office visit will be in 4 days The patient was given prescriptions for Keflex 500 mg 1 p o three times a day x10 days and Lortab 5 mg 40 1 to 2 p o q 4 6 h p r n pain 2 refills along with written and oral home instructions After a short recuperative period the patient was discharged home with vital signs stable and in no acute distress Keywords orthopedic plantar fascial band plantar fasciitis plantar fasciotomy plantar fascial anesthesia plantar fascia fasciotomy fascial band foot MEDICAL_TRANSCRIPTION,Description Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis Medical Specialty Orthopedic Sample Name Neck Pain Discharge Summary Transcription ADMISSION DIAGNOSES 1 Neck pain with right upper extremity radiculopathy 2 Cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis DISCHARGE DIAGNOSES 1 Neck pain with right upper extremity radiculopathy 2 Cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis OPERATIVE PROCEDURES 1 Anterior cervical discectomy with decompression C4 C5 C5 C6 and C6 C7 2 Arthrodesis with anterior interbody fusion C4 C5 C5 C6 and C6 C7 3 Spinal instrumentation C4 through C7 4 Implant 5 Allograft COMPLICATIONS None COURSE ON ADMISSION This is the case of a very pleasant 41 year old Caucasian female who was seen in clinic as an initial consultation on 09 13 07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient s hand The patient s symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now The patient has been treated with medications which has been unrelenting The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4 C5 C5 C6 and C6 C7 The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness which was treated well with IV morphine The patient has resolution of the pain down the arm but she does have some tingling of the right thumb and right index finger The patient apparently is doing well with slight dysphagia we treated her with Decadron and we will send her home with Medrol The patient will have continued pain medication coverage with Darvocet and Flexeril The patient will follow up with me as scheduled Instructions have been given Keywords orthopedic radiculopathy cervical spondylosis neck pain anterior cervical discectomy herniated nucleus pulposus cervical anterior herniated MEDICAL_TRANSCRIPTION,Description Patient with wrist pain and swelling status post injury Medical Specialty Orthopedic Sample Name MRI Wrist 1 Transcription FINDINGS There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic There is no acute marrow edema series 12 images 5 7 Marrow signal is otherwise normal in the distal radius and ulna throughout the carpals and throughout the proximal metacarpals There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid series 6 image 5 series 8 images 22 36 There is tearing of the membranous portion of the ligament The dorsal component is intact The lunatotriquetral ligament is thickened and lax but intact series 8 image 32 There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage series 6 image 7 There is a mildly positive ulnar variance Normal ulnar collateral ligament The patient was positioned in dorsiflexion Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments series 14 image 9 There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis series 4 images 8 16 series 3 images 9 16 There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons series 4 image 12 There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment series 4 image 13 Normal flexor tendons within the carpal tunnel There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement series 3 image 7 series 4 image 7 There are no pathological cysts or soft tissue masses IMPRESSION Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate There is thickening and laxity of the lunatotriquetral ligament Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve Keywords orthopedic fourth dorsal compartment tendon sheath thickening tendon sheaths dorsal compartment volar carpals tear ulnar synovitis sheaths ligament thickening dorsal tendon injury MEDICAL_TRANSCRIPTION,Description MRI T spine and CXR Aortic Dissection Medical Specialty Orthopedic Sample Name MRI T Spine Transcription CC BLE weakness HX This 82y o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia He was in his usual state of health until 5 30PM on 4 6 95 when he developed sudden pressure like epigastric discomfort associated with bilateral lower extremity weakness SOB lightheadedness and diaphoresis He knelt down to the floor and went to sleep The Emergency Medical Service was alert and arrived within minutes at which time he was easily aroused though unable to move or feel his lower extremities No associated upper extremity or bulbar dysfunction was noted He was taken to a local hospital where an INR was found to be 9 1 He was given vitamin K 15mg and transferred to UIHC to rule out spinal epidural hemorrhage An MRI scan of the T spine was obtained and the preliminary reading was normal The Neurology service was then asked to evaluate the patient MEDS Coumadin 2mg qd Digoxin 0 25mg qd Prazosin 2mg qd PMH 1 HTN 2 A Fib on coumadin 3 Peripheral vascular disease s p left Femoral popliteal bypass 8 94 and graft thrombosis thrombolisis 9 94 4 Adenocarcinoma of the prostate s p TURP 1992 FHX unremarkable SHX Farmer Married no Tobacco ETOH illicit drug use EXAM BP165 60 HR86 RR18 34 2C SAO2 98 on room air MS A O to person place time In no acute distress Lucid CN unremarkable MOTOR 5 5 strength in BUE Flaccid paraplegia in BLE Sensory T6 sensory level to LT PP bilaterally Decreased vibratory sense in BLE in a stocking distribution distally Coord Intact FNF and RAM in BUE Unable to do HKS Station no pronator drift Gait not done Reflexes 2 2 BUE Absent in BLE plantar responses were flexor bilaterally Rectal decreased rectal tone GEN EXAM No carotid bruitts Lungs bibasilar crackles CV Irregular rate and rhythm with soft diastolic murmur at the left sternal border Abdomen flat soft non tender without bruitt or pulsatile mass Distal pulses were strong in all extremities COURSE Hgb 12 6 Hct 40 WBC 11 7 Plt 154k INR 7 6 PTT 50 CK 41 the GS was normal EKG showed A Fib at 75BPM with competing junctional pacemaker essentially unchanged from 9 12 94 It was suspected that the patient sustained an anterior cervico thoracic spinal cord infarction with resultant paraplegia and T6 sensory level A CXR was done in the ER prior to admission This revealed cardiomegaly and a widened mediastinum He returned from the x ray suite and suddenly became unresponsive and went into cardiopulmonary arrest Resuscitative measures failed Pericardiocentesis was unremarkable Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma The dissection was seen in retrospect on the MRI T spine Keywords orthopedic mri a o aortic dissection cxr irregular rate and rhythm mri scan neurology service t spine carotid bruitts epidural hemorrhage mediastinum paraplegia person place stocking distribution time weakness mri t spine sensory level neurology spine MEDICAL_TRANSCRIPTION,Description The thoracic spine was examined in the AP lateral and swimmer s projections Medical Specialty Orthopedic Sample Name MRI T Spine 1 Transcription EXAM Thoracic Spine REASON FOR EXAM Injury INTERPRETATION The thoracic spine was examined in the AP lateral and swimmer s projections There is mild chronic appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies A mild amount of anterior osteophytic lipping is seen involving the thoracic spine There is a suggestion of generalized osteoporosis The intervertebral disc spaces appear generally well preserved The pedicles appear intact IMPRESSION 1 Mild chronic appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies 2 Mild degenerative changes of the thoracic spine 3 Osteoporosis Keywords orthopedic thoracic spine swimmer s projections osteoporosis osteophytic lipping anterior wedging vertebral bodies thoracic spine MEDICAL_TRANSCRIPTION,Description Arthroscopy with arthroscopic rotator cuff debridement anterior acromioplasty and Mumford procedure left shoulder Partial rotator cuff tear with impingement syndrome Degenerative osteoarthritis of acromioclavicular joint left shoulder rule out slap lesion Medical Specialty Orthopedic Sample Name Mumford Procedure Acromioplasty Transcription PREOPERATIVE DIAGNOSES 1 Partial rotator cuff tear with impingement syndrome 2 Degenerative osteoarthritis of acromioclavicular joint left shoulder rule out slap lesion POSTOPERATIVE DIAGNOSES 1 Partial rotator cuff tear with impingement syndrome 2 Degenerative osteoarthritis of acromioclavicular joint left shoulder PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic rotator cuff debridement 2 Anterior acromioplasty 3 Mumford procedure left shoulder SPECIFICATIONS The entire operative procedure was done in Inpatient Operative Suite Room 1 at ABCD General Hospital This was done in a modified beach chair position with interscalene and subsequent general anesthetic HISTORY AND GROSS FINDINGS This is a 38 year old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention He was refractory to conservative outpatient therapy He had injection of his AC joint which removed symptoms but was not long lasting After discussing the alternatives of the care as well as advantages and disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side All else was noted to be intact including the glenohumeral joint the long head of the biceps and the labrum The remainder of the rotator cuff observed was noted to be intact Subacromially the patient was noted to have increased synovitis Degenerative changes were noted upon observation of the distal clavicle OPERATIVE PROCEDURE The patient was laid supine upon the operative table After receiving interscalene block anesthetic by Anesthesia Department the patient was placed in modified beach chair position He was prepped and draped in the usual sterile manner Portals were created posteriorly and anteriorly from outside to in A full and complete diagnostic intraarticular arthroscopy was carried out Debridement was carried out through a 3 5 meniscal shaver to the 4 2 meniscal shaver to the undersurface of the partial tear of the rotator cuff Retrospectively it was approximately 25 of the generalized thickness Attention was then turned to the subacromial region The scope was directed subacromially A portal was created laterally Ultimately the patient needed a general anesthetic once we were closer to the distal clavicle Gross bursectomy was carried out with a 4 2 meniscal shaver 18 gauge spinal needles have been placed to outline the anterior acromion prior to this It was difficult to control the patient s blood pressure with systolics ranging anywhere from 165 or 170 up to 200 Because of this and difficulties with his anesthetic it was elected to change to an open procedure Thus the patient was anesthetized safely and secured An oblique incision was carried at the cross Langer s line across the outlet of the shoulder through the skin and subcutaneous tissue Hemostasis was controlled via electrocoagulation Flaps were created Anterior deltoid was reflected inferiorly Anterior acromioplasty was carried out with a saw then a Micro Aire and then a beaver tail rasp An excellent decompression was present CA ligament had been previously resected We then took the incision over the distal clavicle The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro Aire saw The beaver tail rasp was utilized to smooth off the edges Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted 1 Vicryl Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same A superficial running 2 0 Vicryl suture was utilized for deltoid closure distally Interrupted 2 0 Vicryl was utilized to subcutaneous fat closure running 4 0 subcuticular stitch for skin closure and Adaptic 4x4s ABDs and Elastoplast tape placed for compression dressing 0 25 Marcaine was flooded into the joint prior to the skin closure Pain buster catheter was hooked up The patient s arm was placed in arm sling He was safely transferred to the PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords orthopedic slap lesion acromioclavicular joint impingement syndrome mumford procedure acromioplasty arthroscopy arthroscopic arthroscopic rotator cuff debridement anterior acromioplasty rotator cuff tear arthroscopic rotator meniscal shaver cuff tear rotator cuff debridement osteoarthritis acromioclavicular clavicle deltoid rotator cuff shoulder joint MEDICAL_TRANSCRIPTION,Description MRI left shoulder Medical Specialty Orthopedic Sample Name MRI Shoulder 5 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 26 year old with a history of instability Examination was preformed on 12 20 2005 FINDINGS There is supraspinatus tendinosis without a full thickness tear gap or fiber retraction and there is no muscular atrophy series 105 images 4 6 Normal infraspinatus and subscapularis tendons Normal long biceps tendon within the bicipital groove There is medial subluxation of the tendon under the transverse humeral ligament and there is tendinosis of the intracapsular portion of the tendon with partial tearing but there is no complete tear or discontinuity Biceps anchor is intact series 105 images 4 7 series 102 images 10 22 There is a very large Hill Sachs fracture involving almost the entire posterior half of the humeral head series 102 images 13 19 This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation series 104 images 10 14 series 102 images 18 28 There is medial and inferior displacement of the fragment There are multiple interarticular bodies some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter These are too numerous to count There is marked stretching attenuation and areas of thickening of the inferior and middle glenohumeral ligaments compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion series 105 images 5 10 Normal superior glenohumeral ligament There is no SLAP tear Normal acromioclavicular joint without narrowing of the subacromial space Normal coracoacromial coracohumeral and coracoclavicular ligaments There is fluid in the glenohumeral joint and biceps tendon sheath IMPRESSION There is a very large Hill Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion There are multiple intraarticular bodies and there is a partial tear of the inferior and middle glenohumeral ligaments There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion Keywords orthopedic inferior and middle glenohumeral biceps tendon partial tearing glenohumeral ligaments mri shoulder ligament ligaments biceps humeral glenohumeral tear tendons MEDICAL_TRANSCRIPTION,Description A 69 year old male with pain in the shoulder Evaluate for rotator cuff tear Medical Specialty Orthopedic Sample Name MRI Shoulder 4 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 69 year old male with pain in the shoulder Evaluate for rotator cuff tear FINDINGS Examination was performed on 9 1 05 There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface extending into the myotendinous junction as well There is still a small rim of tendon along the bursal surface although there may be a small tear at the level of the rotator interval There is no retracted tendon or muscular atrophy series 6 images 6 17 Normal infraspinatus tendon There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval series 9 images 8 13 series 3 images 8 14 There is no complete tear gap or fiber retraction and there is no muscular atrophy There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove and there is high grade near complete partial tearing of the intracapsular portion of the tendon The biceps anchor is intact There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o clock position series 6 images 12 14 series 3 images 8 10 series 9 images 5 8 There is a small sublabral foramen at the eleven o clock position series 9 image 6 There is no osseous Bankart lesion Normal superior middle and inferior glenohumeral ligaments There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction which in the appropriate clinical setting is an MRI manifestation of an impinging lesion series 8 images 3 12 Normal coracoacromial coracohumeral and coracoclavicular ligaments There is minimal fluid within the glenohumeral joint There is no atrophy of the deltoid muscle IMPRESSION There is extensive supraspinatus tendinosis and partial tearing as described There is no retracted tendon or muscular atrophy but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval and this associated partial tearing of the superior most fibers of the subscapularis tendon There is also a high grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament There is no evidence of a complete tear or retracted tendon Small nondisplaced posterior superior labral tear Outlet narrowing from the acromioclavicular joint which in the appropriate clinical setting is an MRI manifestation of an impinging lesion Keywords orthopedic level of the rotator impinging lesion rotator interval retracted tendon muscular atrophy partial tearing tendon mri shoulder rotator superior tear MEDICAL_TRANSCRIPTION,Description MRI of the Cervical Thoracic and Lumbar Spine Medical Specialty Orthopedic Sample Name MRI Spine Transcription INTERPRETATION MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal At C4 C5 there were minimal uncovertebral osteophytes with mild associated right foraminal compromise At C5 C6 there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac but no cord deformity or foraminal compromise At C6 C7 there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina MRI of the thoracic spine showed normal vertebral body height and alignment There was evidence of disc generation especially anteriorly at the T5 T6 level There was no significant central canal or foraminal compromise Thoracic cord normal in signal morphology MRI of the lumbar spine showed normal vertebral body height and alignment There is disc desiccation at L4 L5 and L5 S1 with no significant central canal or foraminal stenosis at L1 L2 L2 L3 and L3 L4 There was a right paracentral disc protrusion at L4 L5 narrowing of the right lateral recess The transversing nerve root on the right was impinged at that level The right foramen was mildly compromised There was also a central disc protrusion seen at the L5 S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise IMPRESSION Overall impression was mild degenerative changes present in the cervical thoracic and lumbar spine without high grade central canal or foraminal narrowing There was narrowing of the right lateral recess at L4 L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion This was also seen on a prior study Keywords orthopedic cervical spine mri cervical thoracic lumbar transversing nerve root vertebral body height vertebral body disc protrusion foraminal compromise central foraminal disc spineNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description MRI of lumbar spine without contrast to evaluate chronic back pain Medical Specialty Orthopedic Sample Name MRI of Lumbar Spine w o Contrast Transcription EXAM MRI of lumbar spine without contrast HISTORY A 24 year old female with chronic back pain TECHNIQUE Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting FINDINGS The visualized cord is normal in signal intensity and morphology with conus terminating in proper position Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture contusion compression deformity or marrow replacement process There are no paraspinal masses Disc heights signal and vertebral body heights are maintained throughout the lumbar spine L5 S1 Central canal neural foramina are patent L4 L5 Central canal neural foramina are patent L3 L4 Central canal neural foramen is patent L2 L3 Central canal neural foramina are patent L1 L2 Central canal neural foramina are patent The visualized abdominal aorta is normal in caliber Incidental note has been made of multiple left sided ovarian probable physiologic follicular cysts IMPRESSION No acute disease in the lumbar spine Keywords orthopedic mri central canal noncontrast abdominal aorta axial back pain contrast follicular cysts images lumbar spine morphology neural foramina sagittal signal intensity without contrast mri of lumbar spine mri of lumbar lumbar foramina neural patent spine MEDICAL_TRANSCRIPTION,Description MRI L spine History of progressive lower extremity weakness right frontal glioblastoma with lumbar subarachnoid seeding Medical Specialty Orthopedic Sample Name MRI L Spine Subarachnoid Seeding Transcription CC Progressive lower extremity weakness HX This 52y o RHF had a h o right frontal glioblastoma multiforme GBM diagnosed by brain biopsy partial resection on 1 15 1991 She had been healthy until 1 6 91 when she experienced a generalized tonic clonic type seizure during the night She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture There was minimal associated edema and no mass effect Following extirpation of the tumor mass she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions In 11 91 she received BCNU and Procarbazine chemotherapy protocols This was followed by four courses of 5FU Carboplatin 3 92 6 92 9 92 10 92 chemotherapy On 10 12 92 she presented for her 4th course of 5FU Carboplatin and complained of non radiating dull low back pain and proximal lower extremity weakness but was still able to ambulate She denied any bowel bladder difficulty PMH s p oral surgery for wisdom tooth extraction FHX SHX 1 2 ppd cigarettes rare ETOH use Father died of renal CA MEDS Decadron 12mg day EXAM Vitals unremarkable MS Unremarkable Motor 5 5 BUE LE 4 5 prox 5 5 distal to hips Normal tone and muscle bulk Sensory No deficits appreciated Coord Unremarkable Station No mention in record of being tested Gait Mild difficulty climbing stairs Reflexes 1 1 throughout and symmetric Plantar responses were down going bilaterally INITIAL IMPRESSION Steroid myopathy Though there was enough of a suspicion of drop metastasis that an MRI of the L spine was obtained COURSE The MRI L spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris suggestive of subarachnoid seeding of tumor No focal mass or cord compression was visualized CSF examination revealed 19RBC 22WBC 17 Lymphocytes and 5 histiocytes Glucose 56 Protein 150 Cytology negative The patient was discharged home on 10 17 92 but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months She was last seen on 3 3 93 and showed signs of worsening weakness left hemiplegia R L as her tumor grew and spread She then entered a hospice Keywords orthopedic glioblastoma multiforme gbm steroid myopathy hemiplegia progressive lower extremity weakness mri l spine lower extremity weakness frontal glioblastoma subarachnoid seeding lower extremity glioblastoma subarachnoid spine mri lower weakness MEDICAL_TRANSCRIPTION,Description MRI right knee without gadolinium Medical Specialty Orthopedic Sample Name MRI Knee 5 Transcription EXAM MRI RIGHT KNEE WITHOUT GADOLINIUM CLINICAL This is a 21 year old male with right knee pain after a twisting injury on 7 31 05 Patient has had prior lateral meniscectomy in 2001 FINDINGS Examination was performed on 8 3 05 Normal medial meniscus without intrasubstance degeneration surface fraying or discrete meniscal tear There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus likely reflecting previous partial meniscectomy and contouring although subtle surface tearing cannot be excluded particularly along the undersurface of the lateral meniscus series 3 image 17 There is no displaced tear or displaced meniscal fragment There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity Normal posterior cruciate ligament Normal medial collateral ligament There is a strain of the popliteus muscle and tendon without complete tear There is a sprain of the posterolateral and posterocentral joint capsule series 5 images 10 18 There is marrow edema within the posterolateral corner of the tibia and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended series 6 images 4 7 Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear Normal quadriceps and patellar tendons There is contusion within the posterior non weight bearing surface of the medial femoral condyle as well as in the posteromedial corner of the tibia There is linear vertically oriented signal within the distal tibial diaphyseal metaphyseal junction series 7 image 8 series 2 images 4 5 There is no discrete fracture line and this is of uncertain significance but this should be correlated with radiographs The patellofemoral joint is congruent without patellar tilt or subluxation Normal medial and lateral patellar retinacula There is a joint effusion IMPRESSION Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re contouring although a subtle undersurface tear in the anterior horn may be present Mild anterior cruciate ligament interstitial sprain There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs Keywords orthopedic mri right knee posterolateral and posterocentral posterocentral joint capsule lateral meniscus cruciate ligament mri meniscectomy cruciate tendon posterolateral patellar ligament tear MEDICAL_TRANSCRIPTION,Description MRI left knee Medical Specialty Orthopedic Sample Name MRI Knee 3 Transcription EXAM MRI LEFT KNEE CLINICAL This is a 41 year old male with knee pain mobility loss and swelling The patient had a twisting injury one week ago on 8 5 05 The examination was performed on 8 10 05 FINDINGS There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear There is intrasubstance degeneration within the lateral meniscus and there is a probable small tear in the anterior horn along the undersurface at the meniscal root There is an interstitial sprain partial tear of the anterior cruciate ligament There is no complete tear or discontinuity and the ligament has a celery stick appearance Normal posterior cruciate ligament Normal medial collateral ligament There is a sprain of the femoral attachment of the fibular collateral ligament without complete tear or discontinuity The fibular attachment is intact Normal biceps femoris tendon popliteus tendon and iliotibial band Normal quadriceps and patellar tendons There are no fractures There is arthrosis with high grade changes in the patellofemoral compartment particularly along the midline patellar ridge and lateral facet There are milder changes within the medial femorotibial compartments There are subcortical cystic changes subjacent to the tibial spine which appear chronic There is a joint effusion There is synovial thickening IMPRESSION Probable small tear in the anterior horn of the lateral meniscus at the meniscal root Interstitial sprain partial tear of the anterior cruciate ligament Arthrosis joint effusion and synovial hypertrophy There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles Keywords orthopedic mri left knee interstitial sprain partial tear anterior cruciate ligament lateral meniscus cruciate ligament synovial mri meniscus sprain partial cruciate knee ligament MEDICAL_TRANSCRIPTION,Description A 32 year old male with shoulder pain Medical Specialty Orthopedic Sample Name MRI Shoulder 3 Transcription EXAM MRI RIGHT SHOULDER CLINICAL A 32 year old male with shoulder pain FINDINGS This is a second opinion interpretation of the examination performed on 02 16 06 Normal supraspinatus tendon without surface fraying gap or fiber retraction and there is no muscular atrophy Normal infraspinatus and subscapularis tendons Normal long biceps tendon within the bicipital groove There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal Normal humeral head without fracture or subluxation There is myxoid degeneration within the superior labrum oblique coronal images 47 48 but there is no discrete tear The remaining portions of the labrum are normal without osseous Bankart lesion Normal superior middle and inferior glenohumeral ligaments There is a persistent os acromiale and there is minimal reactive marrow edema on both sides of the synchondrosis suggesting that there may be instability axial images 3 and 4 There is no diastasis of the acromioclavicular joint itself There is mild narrowing of the subacromial space secondary to the os acromiale in the appropriate clinical setting this may be acting as an impinging lesion sagittal images 56 59 Normal coracoacromial coracohumeral and coracoclavicular ligaments There are no effusions or masses IMPRESSION Changes in the superior labrum compatible with degeneration without a discrete surfacing tear There is a persistent os acromiale and there is reactive marrow edema on both sides of the synchondrosis suggesting instability There is also mild narrowing of the subacromial space secondary to the os acromiale This may be acting as an impinging lesion in the appropriate clinical setting There is no evidence of a rotator cuff tear Keywords orthopedic impinging lesion os acromiale shoulder tendon acromiale osseous MEDICAL_TRANSCRIPTION,Description A 51 year old female with left shoulder pain and restricted external rotation and abduction x 6 months Medical Specialty Orthopedic Sample Name MRI Shoulder 2 Transcription EXAM MRI LEFT SHOULDER CLINICAL This is a 51 year old female with left shoulder pain and restricted external rotation and abduction x 6 months Received for second opinion Study performed on 10 04 05 FINDINGS The patient was scanned in a 1 5 Tesla magnet There is a flat undersurface of the acromion Type I morphology with anterior downsloping orientation There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the axial gradient echo T2 series 3 images 6 9 There is edema with thickening of the superior glenohumeral ligament axial T2 series 3 image 7 There is flattening of the long biceps tendon as it enters the bicipital groove axial T2 series 3 image 9 10 but no subluxation The findings suggest early changes of a hidden lesion Normal biceps labral complex and superior labrum and there is no demonstrated superior labral tear There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon axial T2 series 3 image 10 There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits Normal anterior and posterior glenoid labra Normal supraspinatus infraspinatus and teres minor tendons Normal muscles of the rotator cuff and there is no muscular atrophy There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior superior labrum sagittal T2 series 7 image 5 coronal T2 series 5 image 7 but there is no demonstrated posterior superior labral tear or paralabral cyst or ganglion Normal acromioclavicular articulation IMPRESSION Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament Flattening of the long biceps tendon as it enters the bicipital groove but no subluxation Findings suggest early changes of a hidden lesion Mild tendinitis of the distal insertion of the subscapularis tendon but no tendon tear Normal supraspinatus infraspinatus and teres minor tendons and muscular complexes Type I morphology with an anterior downsloping orientation of the acromion but no inferior acromial osteophyte Keywords orthopedic insertion of the subscapularis supraspinatus infraspinatus and teres infraspinatus and teres minor axial t series supraspinatus infraspinatus teres minor minor tendons posterior superior biceps tendon rotator capsule glenohumeral tendon series superior MEDICAL_TRANSCRIPTION,Description MRI L S Spine for Cauda Equina Syndrome secondary to L3 4 disc herniation Low Back Pain LBP with associated BLE weakness Medical Specialty Orthopedic Sample Name MRI L S Spine Cauda Equina Syndrome Transcription CC Low Back Pain LBP with associated BLE weakness HX This 75y o RHM presented with a 10 day h o progressively worsening LBP The LBP started on 12 3 95 began radiating down the RLE on 12 6 95 then down the LLE on 12 9 95 By 12 10 95 he found it difficult to walk On 12 11 95 he drove himself to his local physician but no diagnosis was rendered He was given some NSAID and drove home By the time he got home he had great difficulty walking due to LBP and weakness in BLE but managed to feed his pets and himself On 12 12 95 he went to see a local orthopedist but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain He also had had BLE numbness since 12 11 95 He was evaluated locally and an L S Spine CT scan and L S Spine X rays were negative He was then referred to UIHC MEDS SLNTC Coumadin 4mg qd Propranolol Procardia XL Altace Zaroxolyn PMH 1 MI 11 9 78 2 Cholecystectomy 3 TURP for BPH 1980 s 4 HTN 5 Amaurosis Fugax OD 8 95 Mayo Clinic evaluation TEE but Carotid Doppler but non surgical so placed on Coumadin FHX Father died age 59 of valvular heart disease Mother died of DM Brother had CABG 8 95 SHX retired school teacher 0 5 1 0 pack cigarettes per day for 60 years EXAM BP130 56 HR68 RR16 Afebrile MS A O to person place time Speech fluent without dysarthria Lucid Appeared uncomfortable CN Unremarkable MOTOR 5 5 strength in BUE Lower extremity strength Hip flexors extensors 4 4 Hip abductors 3 3 Hip adductors 5 5 Knee flexors extensors 4 4 Ankle flexion 4 4 Tibialis Anterior 2 2 Peronei 3 3 Mild atrophy in 4 extremities Questionable fasciculations in BLE Spasms illicited on striking quadriceps with reflex hammer percussion myotonia No rigidity and essential normal muscle tone on passive motion SENSORY Decreased vibratory sense in stocking distribution from toes to knees in BLE worse on right No sensory level PP LT TEMP testing unremarkable COORD Normal FNF RAM Slowed HKS due to weakness Station No pronator drift Romberg testing not done Gait Unable to stand Reflexes 2 2 BUE 1 trace patellae 0 0 Achilles Plantar responses were flexor bilaterally Abdominal reflex was present in all four quadrants Anal reflex was illicited from all four quadrants No jaw jerk or palmomental reflexes illicited Rectal normal rectal tone guaiac negative stool GEN EXAM Bilateral Carotid Bruits No lymphadenopathy right inguinal hernia rhonchi and inspiratory wheeze in both lung fields COURSE WBC 11 6 Hgb 13 4 Hct 38 Plt 295 ESR 40 normal 0 14 CRP 1 4 normal 0 4 INR 1 5 PTT 35 normal Creatinine 2 1 CK 346 EKG normal The differential diagnosis included Amyotrophy Polymyositis Epidural hematoma Disc Herniation and Guillain Barre syndrome An MRI of the lumbar spine was obtained 12 13 95 This revealed an L3 4 disc herniation extending inferiorly and behind the L4 vertebral body This disc was located more on the right than on the left compromised the right neural foramen and narrowed the spinal canal The patient underwent a L3 4 laminectomy and diskectomy and subsequently improved He was never seen in follow up at UIHC Keywords orthopedic ble weakness carotid doppler disc herniation guillain barre syndrome amyotrophy polymyositis epidural hematoma mri l s spine cauda equina syndrome flexors extensors cauda equina herniation cauda equina extensors reflexes mri hip flexors weakness MEDICAL_TRANSCRIPTION,Description Left shoulder pain Evaluate for rotator cuff tear Medical Specialty Orthopedic Sample Name MRI Shoulder 1 Transcription EXAM MRI UP EXT JOINT LEFT SHOULDER CLINICAL Left shoulder pain Evaluate for rotator cuff tear FINDINGS Multiple T1 and gradient echo axial images were obtained as well as T1 and fat suppressed T2 weighted coronal images The rotator cuff appears intact and unremarkable There is no significant effusion seen Osseous structures are unremarkable There is no significant downward spurring at the acromioclavicular joint The glenoid labrum is intact and unremarkable IMPRESSION Unremarkable MRI of the left shoulder Keywords orthopedic rotator cuff tear cuff tear rotator cuff joint mri rotator cuff shoulder tear MEDICAL_TRANSCRIPTION,Description MRI left knee without contrast Medical Specialty Orthopedic Sample Name MRI Knee 1 Transcription EXAM MRI LEFT KNEE WITHOUT CONTRAST CLINICAL Left knee pain FINDINGS Comparison is made with 10 13 05 radiographs There is a prominent suprapatellar effusion Patient has increased signal within the medial collateral ligament as well as fluid around it compatible with type 2 sprain There is fluid around the lateral collateral ligament without increased signal within the ligament itself compatible with type 1 sprain Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration No tear is seen Anterior cruciate and posterior cruciate ligaments are intact There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm There is suggestion of some mild posterior aspect of the lateral tibial plateau MR signal on the bone marrow is otherwise normal IMPRESSION Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet Keywords orthopedic collateral ligament mri knee collateral sprain medial ligament MEDICAL_TRANSCRIPTION,Description A 53 year old female with left knee pain being evaluated for ACL tear Medical Specialty Orthopedic Sample Name MRI Knee 2 Transcription EXAM MRI LEFT KNEE WITHOUT CONTRAST CLINICAL This is a 53 year old female with left knee pain being evaluated for ACL tear FINDINGS This examination was performed on 10 14 05 Normal medial meniscus without intrasubstance degeneration surface fraying or discrete meniscal tear There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body there is no discrete tear series 6 images 7 12 There is a near complete or complete tear of the femoral attachment of the anterior cruciate ligament The ligament has a balled up appearance consistent with at least partial retraction of most of the fibers of the ligament There may be a few fibers still intact series 4 images 12 14 series 5 images 12 14 The tibial fibers are normal Normal posterior cruciate ligament There is a sprain of the medial collateral ligament with mild separation of the deep and superficial fibers at the femoral attachment series 7 images 6 12 There is no complete tear or discontinuity and there is no meniscocapsular separation There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components Normal iliotibial band Normal quadriceps and patellar tendons There is contusion within the posterolateral corner of the tibia There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening series 8 images 10 13 The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity Normal lateral patellar retinaculum There is a joint effusion and plica IMPRESSION Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body Near complete if not complete tear of the femoral attachment of the anterior cruciate ligament Medial capsule sprain with associated strain of the vastus medialis oblique muscle There is focal contusion within the patella at the midline patella ridge Joint effusion and plica Keywords orthopedic vastus medialis oblique muscle medialis oblique oblique muscle patellar retinaculum joint effusion femoral attachment cruciate ligament complete tear meniscus superficial cruciate sprain femoral medial ligament tear patellar MEDICAL_TRANSCRIPTION,Description MRI left knee without contrast Medical Specialty Orthopedic Sample Name MRI Knee 4 Transcription EXAM MRI OF THE LEFT KNEE WITHOUT CONTRAST CLINICAL Left knee pain Twisting injury FINDINGS The images reveal a sizable joint effusion The joint effusion appears to be complex with mixed signal intensity material within The patella is slightly laterally tilted towards the left The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected Mildly increased bone signal overlying the inferolateral portion of the patella is identified No significant degenerative changes about the patella can be seen The quadriceps tendon as well as the infrapatellar ligament both look intact There is some prepatellar soft tissue edema The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia NO significant areas of bone edema are appreciated There is soft tissue edema along the lateral aspect of the knee There is a partial tear of the lateral collateral ligament complex The medial collateral ligament complex looks intact A small amount of edema is identified immediately adjacent to the medial collateral ligament complex The posterior cruciate ligament looks intact The anterior cruciate ligament is thickened with significant increased signal I suspect at least a high grade partial tear The posterior horn of the medial meniscus shows some myxoid degenerative changes The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes I don t see a definite tear extending to the articular surface IMPRESSION Sizeable joint effusion which is complex and may contain blood products Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear Soft tissue swelling and partial tear of the lateral collateral ligament complex At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure The posterior cruciate ligament is intact Injury to the patellar cartilage as above Keywords orthopedic lateral collateral ligament medial collateral ligament posterior cruciate ligament anterior cruciate ligament collateral ligament complex myxoid degenerative partial tear collateral ligament ligament complex cruciate ligament mri effusion cartilage collateral cruciate knee tear ligament MEDICAL_TRANSCRIPTION,Description A 49 year old female with ankle pain times one month without a specific injury Medical Specialty Orthopedic Sample Name MRI Foot 3 Transcription EXAM MRI LEFT FOOT CLINICAL A 49 year old female with ankle pain times one month without a specific injury Patient complains of moderate to severe pain worse with standing or walking on hard surfaces with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon FINDINGS Received for second opinion interpretations is an MRI examination performed on 05 27 2005 There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle There is edema of the subcutis adipose space posterior to the Achilles tendon Findings suggest altered biomechanics with crural fascial strains There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus axial inversion recovery image 16 which is a possible hypertrophic tear less than 50 in cross sectional diameter The study has been performed with the foot in neutral position Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons Normal peroneal tendons There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear Normal extensor hallucis longus and extensor digitorum tendons Normal Achilles tendon There is a low lying soleus muscle that extends to within 2cm of the teno osseous insertion of the Achilles tendon Normal distal tibiofibular syndesmotic ligamentous complex Normal lateral subtalar and deltoid ligamentous complexes There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force Normal plantar fascia There is no plantar calcaneal spur There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves Normal tibiotalar subtalar talonavicular and calcaneocuboid articulations The metatarsophalangeal joint of the hallux was partially excluded from the field of view of this examination IMPRESSION Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying tearing of the tendon immediately distal to the tip of the medial malleolus however confirmation of this finding would require additional imaging Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain Mild tendinosis of the tibialis anterior tendon with mild tendon thickening Normal plantar fascia and no plantar fasciitis Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves Keywords orthopedic lateral plantar cutaneous plantar cutaneous nerves posterior tibialis tendon medial and lateral subcutis adipose adipose space achilles tendon tendon thickening hallucis longus lateral plantar plantar cutaneous cutaneous nerves medial malleolus posterior tibialis tibialis tendon plantar tendon posterior flexor tibialis medial MEDICAL_TRANSCRIPTION,Description Pain and swelling in the right foot peroneal tendon tear Medical Specialty Orthopedic Sample Name MRI Foot 1 Transcription EXAM MRI LOW EX NOT JNT RT W O CONTRAST CLINICAL Pain and swelling in the right foot peroneal tendon tear FINDINGS Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone A small effusion is noted within the peroneal tendon sheath There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone consistent with an avulsion There is no sign of cuboid fracture The fifth metatarsal base appears intact The calcaneus is also normal in appearance IMPRESSION Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone Keywords orthopedic peroneus longus tendon peroneal tendon lateral margin peroneus longus longus tendon cuboid bone foot peroneal peroneus longus avulsion tendon bones cuboid MEDICAL_TRANSCRIPTION,Description MRI C spine C4 5 Transverse Myelitis Medical Specialty Orthopedic Sample Name MRI C spine Transcription CC Left hemibody numbness HX This 44y o RHF awoke on 7 29 93 with left hemibody numbness without tingling weakness ataxia visual or mental status change She had no progression of her symptoms until 7 7 93 when she notices her right hand was stiff and clumsy She coincidentally began listing to the right when walking She denied any recent colds flu like illness or history of multiple sclerosis She denied symptoms of Lhermitte s or Uhthoff s phenomena MEDS none PMH 1 Bronchitis twice in past year last 2 months ago FHX Father with HTN and h o strokes at ages 45 and 80 now 82 years old Mother has DM and is age 80 SHX Denies Tobacco ETOH illicit drug use EXAM BP112 76 HR52 RR16 36 8C MS unremarkable CN unremarkable Motor 5 5 strength throughout except for slowing of right hand fine motor movement There was mildly increased muscle tone in the RUE and RLE Sensory decreased PP below T2 level on left and some dysesthesias below L1 on the left Coord positive rebound in RUE Station Gait unremarkable Reflexes 3 3 throughout all four extremities Plantar responses were flexor bilaterally Rectal exam not done Gen exam reportedly normal COURSE GS CBC PT PTT ESR Serum SSA SSB dsDNA B12 were all normal MRI C spine 7 145 93 showed an area of decreased T1 and increased T2 signal at the C4 6 levels within the right lateral spinal cord The lesion appeared intramedullary and eccentric and peripherally enhanced with gadolinium Lumbar puncture 7 16 93 revealed the following CSF analysis results RBC 0 WBC 1 lymphocyte Protein 28mg dl Glucose 62mg dl CSF Albumin 16 normal 14 20 Serum Albumin 4520 normal 3150 4500 CSF IgG 4 1mg dl normal 0 6 2 CSF IgG total CSF protein 15 normal 1 14 CSF IgG index 1 1 normal 0 0 7 Oligoclonal bands were present She was discharged home The patient claimed her symptoms resolved within one month She did not return for a scheduled follow up MRI C spine Keywords orthopedic mri c spine c spine lhermitte s myelitis transverse myelitis uhthoff s ataxia clumsy hemibody numbness mental status numbness tingling weakness mri c spine hemibody mri spine csf MEDICAL_TRANSCRIPTION,Description MRI of elbow A middle aged female with moderate pain severe swelling and a growth on the arm Medical Specialty Orthopedic Sample Name MRI Elbow 2 Transcription FINDINGS There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle extending to the olecranon process and along the superficial aspect of the epicondylo olecranon ligament There is no demonstrated solid cystic or lipomatous mass lesion There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel There is inflammation with mild laxity of the epicondylo olecranon ligament The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel There is no accessory muscle within the cubital tunnel The common flexor tendon origin is normal Normal ulnar collateral ligamentous complex There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis There is no demonstrated common extensor tendon tear Normal radial collateral ligamentous complex Normal radiocapitellum and ulnotrochlear articulations Normal triceps and biceps tendon insertions There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon IMPRESSION Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo olecranon ligament Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis The above combined findings suggest a subluxing ulnar nerve Mild epimysial sheath strain of the pronator teres muscle but no muscular tear Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon Peritendinous edema of the brachialis tendon insertion No solid cystic or lipomatous mass lesion Keywords orthopedic growth on the arm subluxing ulnar nerve collateral ligamentous complex common extensor tendon posteromedial aspect epimysial sheath extensor tendon tendon insertions ulnar nerve elbow edema olecranon inflammation nerve ulnar tendon MEDICAL_TRANSCRIPTION,Description MRI Elbow A middle aged female complaining of elbow pain Medical Specialty Orthopedic Sample Name MRI Elbow 1 Transcription FINDINGS There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation coronal T2 image 1452 sagittal T2 image 1672 There is irregularity of the deep surface of the tendon consistent with mild fraying 1422 and 1484 however there is no distinct tear There is a joint effusion of the radiocapitellar articulation with mild fluid distention The radial collateral proper ligament remains intact There is periligamentous inflammation of the lateral ulnar collateral ligament coronal T2 image 1484 of the radial collateral ligamentous complex There is no articular erosion or osteochondral defect with no intra articular loose body There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon axial T2 image 1324 The common flexor tendon otherwise is normal There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament coronal T2 image 1516 axial T2 image 1452 with an intrinsically normal ligament The ulnotrochlear articulation is normal The brachialis and biceps tendons are normal with a normal triceps tendon The anterior posterior medial and lateral muscular compartments are normal The radial median and ulnar nerves are normal with no apparent ulnar neuritis IMPRESSION Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying without a discrete tendon tear Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra articular loose body Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament Keywords orthopedic radial collateral ligamentous complex intra articular loose body axial t image ulnar collateral ligament common flexor tendon mri elbow ligamentous complex radial collateral ulnar collateral collateral ligament flexor tendon periligamentous inflammation mri tendon MEDICAL_TRANSCRIPTION,Description MRI Cervical Spine without contrast Medical Specialty Orthopedic Sample Name MRI Cervical Spine 2 Transcription EXAM MRI SPINAL CORD CERVICAL WITHOUT CONTRAST CLINICAL Right arm pain numbness and tingling FINDINGS Vertebral alignment and bone marrow signal characteristics are unremarkable The C2 3 and C3 4 disk levels appear unremarkable At C4 5 broad based disk osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour A discrete cord signal abnormality is not identified There may also be some narrowing of the neuroforamina at this level At C5 6 central disk osteophyte contacts and mildly impresses on the ventral cord contour Distinct neuroforaminal narrowing is not evident At C6 7 mild diffuse disk osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface Distinct cord compression is not evident There may be mild narrowing of the neuroforamina at his level A specific abnormality is not identified at the C7 T1 level IMPRESSION Disk osteophyte at C4 5 through C6 7 with contact and may mildly indent the ventral cord contour at these levels Some possible neuroforaminal narrowing is also noted at levels as stated above Keywords orthopedic mri cervical spine ventral cord contour cervical spine spinal cord cord contour ventral cord mri narrowing ventral cord MEDICAL_TRANSCRIPTION,Description MRI Brain MRI C T spine Multiple hemangioblastoma in Von Hippel Lindau Disease Medical Specialty Orthopedic Sample Name MRI Brain and C T Spine Transcription CC Weakness HX This 30 y o RHM was in good health until 7 93 when he began experiencing RUE weakness and neck pain He was initially treated by a chiropractor and after an unspecified length of time developed atrophy and contractures of his right hand He then went to a local neurosurgeon and a cervical spine CT scan 9 25 92 revealed an intramedullary lesion at C2 3 and an extramedullary lesion at C6 7 He underwent a C6 T1 laminectomy with exploration and decompression of the spinal cord His clinical condition improved over a 3 month post operative period and then progressively worsened He developed left sided paresthesia and upper extremity weakness right worse than left He then developed ataxia nausea vomiting and hyperreflexia On 8 31 93 MRI C spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa On 9 1 93 he underwent suboccipital craniotomy with tumor excision decompression and biopsy which was consistent with hemangioblastoma His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9 93 through 1 19 94 He was evaluated in the NeuroOncology clinic on 10 26 95 for consideration of chemotherapy He complained of progressive proximal weakness of all four extremities and dysphagia He had difficulty putting on his shirt and raising his arms and he had been having increasing difficulty with manual dexterity e g unable to feed himself with utensils He had difficulty going down stairs but could climb stairs He had no bowel or bladder incontinence or retention MEDS none PMH see above FHX Father with Von Hippel Lindau Disease SHX retired truck driver smokes 1 3 packs of cigarettes per day but denied alcohol use He is divorced and has two sons who are healthy He lives with his mother ROS noncontributory EXAM Vital signs were unremarkable MS A O to person place and time Speech fluent and without dysarthria Thought process lucid and appropriate CN unremarkable exept for 4 4 strength of the trapezeii No retinal hemangioblastoma were seen MOTOR 4 4 strength in proximal and distal upper extremities There is diffuse atrophy and claw hands bilaterally He is unable to manipulate hads to any great extent 4 4 strength throughout BLE There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities SENSORY There was a right T3 and left T8 cord levels to PP on the posterior thorax Decreased LT in throughout the 4 extremities COORD difficult to assess due to weakness Station BUE pronator drift Gait stands without assistance but can only manage to walk a few steps Spastic gait Reflexes Hyperreflexic on left 3 and Hyporeflexic on right 1 Babinski signs were present bilaterally Gen exam unremarkable COURSE 9 8 95 GS normal By 11 14 95 he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies MRI Brain 2 19 96 revealed several lesions hemangioblastoma in the cerebellum and brain stem There were postoperative changes and a cyst in the medulla On 10 25 96 he presented with a 1 5 week h o numbness in BLE from the mid thighs to his toes and worsening BLE weakness He developed decubitus ulcers on his buttocks He also had had intermittent urinary retention for month chronic SOB and dysphagia He had been sitting all day long as he could not move well and had no daytime assistance His exam findings were consistent with his complaints He had had no episodes of diaphoresis headache or elevated blood pressures An MRI of the C T spine 10 26 96 revealed a prominent cervicothoracic syrinx extending down to T10 There was evidence of prior cervical laminectomy of C6 T1 with expansion of the cord in the thecalsac at that region Multiple intradural extra spinal nodular lesions hyperintense on T2 isointense on T1 enhanced gadolinium were seen in the cervical spine and cisterna magna The largest of which measures 1 1 x 1 0 x 2 0cm There are also several large ring enhancing lesions in cerebellum The lesions were felt to be consistent with hemangioblastoma No surgical or medical intervention was initiated Visiting nursing was provided He has since been followed by his local physician Keywords MEDICAL_TRANSCRIPTION,Description MRI C spine to evaluate right shoulder pain C5 6 disk herniation Medical Specialty Orthopedic Sample Name MRI C Spine C5 6 Disk Herniation Transcription CC Right shoulder pain HX This 46 y o RHF presented with a 4 month history of right neck and shoulder stiffness and pain The symptoms progressively worsened over the 4 month course 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain The later was described as a throbbing pain She also experienced numbness in both lower extremities and pain in the coccygeal region The pains worsened at night and impaired sleep She denied any visual change bowel or bladder difficulties and symptoms involving the LUE She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck Lhermitte s phenomena She denied any history of neck back head trauma She had been taking Naprosyn with little relief PMH 1 Catamenial Headaches 2 Allergy to Macrodantin SHX FHX Smokes 2ppd cigarettes EXAM Vital signs were unremarkable CN unremarkable Motor full strength throughout Normal tone and muscle bulk Sensory No deficits on LT PP VIB TEMP PROP testing Coord Gait Station Unremarkable Reflexes 2 2 in BUE except 2 at left biceps 1 1 BLE except an absent right ankle reflex Plantar responses were flexor bilaterally Rectal exam normal tone IMPRESSION C spine lesion COURSE MRI C spine revealed a central C5 6 disk herniation with compression of the spinal cord at that level EMG NCV showed normal NCV but 1 sharps and fibrillations in the right biceps C5 6 brachioradialis C5 6 triceps C7 8 and teres major and 2 sharps and fibrillations in the right pronator terres There was increased insertional activity in all muscles tested on the right side The findings were consistent with a C6 7 radiculopathy The patient subsequently underwent C5 6 laminectomy and her symptoms resolved Keywords orthopedic shoulder pain stiffness numbness lhermitte s phenomena c spine lesion disk herniation mri c spine reflexes biceps mri disk shoulder spine herniation MEDICAL_TRANSCRIPTION,Description MRI cervical spine Medical Specialty Orthopedic Sample Name MRI Cervical Spine 1 Transcription EXAM MRI CERVICAL SPINE CLINICAL A57 year old male Received for outside consultation is an MRI examination performed on 11 28 2005 FINDINGS Normal brainstem cervical cord junction Normal cisterna magna with no tonsillar ectopia Normal clivus with a normal craniovertebral junction Normal anterior atlantoaxial articulation C2 3 Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina with no cord or radicular impingement C3 4 There is disc desiccation with minimal annular bulging The residual AP diameter of the central canal measures approximately 10mm CSF remains present surrounding the cord C4 5 There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema There is minimal uncovertebral joint arthrosis C5 6 There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm AP x transverse The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement C6 7 There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft There is a left posterolateral disc osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root C7 T1 T1 2 Minimal disc desiccation with no disc displacement or endplate spondylosis IMPRESSION Multilevel degenerative disc disease as described above C4 5 borderline central canal stenosis with mild bilateral foraminal compromise C5 6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion C6 7 degenerative disc disease and endplate spondylosis with a left posterolateral disc osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis Normal cervical cord Keywords orthopedic borderline central canal stenosis mri cervical spine borderline central canal central canal stenosis degenerative disc annular bulging ap diameter endplate spondylosis borderline central canal stenosis disc desiccation central canal cervical disc spondylosis stenosis cord canal MEDICAL_TRANSCRIPTION,Description MRI right ankle Medical Specialty Orthopedic Sample Name MRI Ankle 2 Transcription EXAM MRI OF THE RIGHT ANKLE CLINICAL Pain FINDINGS The bone marrow demonstrates normal signal intensity There is no evidence of bone contusion or fracture There is no evidence of joint effusion Tendinous structures surrounding the ankle joint are intact No abnormal mass or fluid collection is seen surrounding the ankle joint IMPRESSION NORMAL MRI OF THE RIGHT ANKLE Keywords orthopedic ankle joint bone mri ankle MEDICAL_TRANSCRIPTION,Description MRI report Cervical Spine Chiropractic Specific Medical Specialty Orthopedic Sample Name MRI Cervical Spine Chiropractic Specific Transcription FINDINGS Normal foramen magnum Normal brainstem cervical cord junction There is no tonsillar ectopia Normal clivus and craniovertebral junction Normal anterior atlantoaxial articulation C2 3 There is disc desiccation but no loss of disc space height disc displacement endplate spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina C3 4 There is disc desiccation with a posterior central disc herniation of the protrusion type The small posterior central disc protrusion measures 3 x 6mm AP x transverse in size and is producing ventral thecal sac flattening CSF remains present surrounding the cord The residual AP diameter of the central canal measures 9mm There is minimal right sided uncovertebral joint arthrosis but no substantial foraminal compromise C4 5 There is disc desiccation slight loss of disc space height with a right posterior lateral pre foraminal disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis The disc osteophyte complex measures approximately 5mm in its AP dimension There is minimal posterior annular bulging measuring approximately 2mm The AP diameter of the central canal has been narrowed to 9mm CSF remains present surrounding the cord There is probable radicular impingement upon the exiting right C5 nerve root C5 6 There is disc desiccation moderate loss of disc space height with a posterior central disc herniation of the protrusion type The disc protrusion measures approximately 3 x 8mm AP x transverse in size There is ventral thecal sac flattening with effacement of the circumferential CSF cleft The residual AP diameter of the central canal has been narrowed to 7mm Findings indicate a loss of the functional reserve of the central canal but there is no cord edema There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise C6 7 There is disc desiccation mild loss of disc space height with 2mm of posterior annular bulging There is bilateral uncovertebral and apophyseal joint arthrosis left greater than right with probable radicular impingement upon the bilateral exiting C7 nerve roots C7 T1 T1 2 There is disc desiccation with no disc displacement Normal central canal and intervertebral neural foramina T3 4 There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord IMPRESSION Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above C3 4 posterior central disc herniation of the protrusion type but no cord impingement C4 5 right posterior lateral disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root C5 6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal C6 7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots T3 4 degenerative disc disease with posterior annular bulging Keywords orthopedic exiting c nerve roots loss of disc space posterior central disc herniation herniation of the protrusion uncovertebral and apophyseal joint intervertebral neural foramina ventral thecal sac thecal sac flattening disc osteophyte complex disc space height central disc herniation apophyseal joint arthrosis posterior annular bulging degenerative disc disease posterior central disc csf cleft osteophyte complex radicular impingement disc disease central disc annular bulging disc desiccation joint arthrosis central canal cervical degenerative csf foraminal bulging impingement protrusion uncovertebral arthrosis canal MEDICAL_TRANSCRIPTION,Description MRI Brain T spine Demyelinating disease Medical Specialty Orthopedic Sample Name MRI Brain T spine Demyelinating disease Transcription CC Sensory loss HX 25y o RHF began experiencing pruritus in the RUE above the elbow and in the right scapular region on 10 23 92 In addition she had paresthesias in the proximal BLE and toes of the right foot Her symptoms resolved the following day On 10 25 92 she awoke in the morning and her legs felt asleep with decreased sensation The sensory loss gradually progressed rostrally to the mid chest She felt unsteady on her feet and had difficulty ambulating In addition she also began to experience pain in the right scapular region She denied any heat or cold intolerance fatigue weight loss MEDS None PMH Unremarkable FHX GF with CAD otherwise unremarkable SHX Married unemployed 2 children Patient was born and raised in Iowa Denied any h o Tobacco ETOH illicit drug use EXAM BP121 66 HR77 RR14 36 5C MS A O to person place and time Speech normal with logical lucid thought process CN mild optic disk pallor OS No RAPD EOM full and smooth No INO The rest of the CN exam was unremarkable MOTOR Full strength throughout all extremities except for 5 4 hip extensors Normal muscle tone and bulk Sensory Decreased PP LT below T4 5 on the left side down to the feet Decreased PP LT VIB in BLE left worse than right Allodynic in RUE Coord Intact FNF HKS and RAM bilaterally Station No pronator drift Romberg s test not documented Gait Unsteady wide based Able to TT and HW Poor TW Reflexes 3 3 BUE Hoffman s signs were present bilaterally 4 4 patellae 3 3 Achilles with 3 4 beat nonsustained clonus Plantar responses were extensor on the right and flexor on the left Gen Exam Unremarkable COURSE CBC GS PT PTT ESR FT4 TSH ANA Vit B12 Folate VDRL and Urinalysis were normal MRI T spine 10 27 92 was unremarkable MRI Brain 10 28 92 revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum periventricular region brachium pontis and right pons The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis 10 28 92 Lumbar puncture revealed the following CSF results RBC 1 WBC 9 8 lymphocytes 1 histiocyte Glucose 55mg dl Protein 46mg dl normal 15 45 CSF IgG 7 5mg dl normal 0 0 6 2 CSF IgG index 1 3 normal 0 0 0 7 agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample Beta 2 microglobulin was unremarkable An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing Visual and Brainstem Auditory evoked potentials were normal HTLV 1 titers were negative CSF cultures and cytology were negative She was not treated with medications as her symptoms were primarily sensory and non debilitating and she was discharged home She returned on 11 7 92 as her symptoms of RUE dysesthesia lower extremity paresthesia and weakness all worsened On 11 6 92 she developed slow slurred speech and had marked difficulty expressing her thoughts She also began having difficulty emptying her bladder Her 11 7 92 exam was notable for normal vital signs lying motionless with eyes open and nodding and rhythmically blinking every few minutes She was oriented to place and time of day but not to season day of the week and she did not know who she was She had a leftward gaze preference and right lower facial weakness Her RLE was spastic with sustained ankle clonus There was dysesthetic sensory perception in the RUE Jaw jerk and glabellar sign were present MRI brain 11 7 92 revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale The right peritrigonal region is more prominent than on prior study The left centrum semiovale lesion has less enhancement than previously Multiple other white matter lesions are demonstrated on the right side in the posterior limb of the internal capsule the anterior periventricular white matter optic radiations and cerebellum The peritrigonal lesions on both sides have increased in size since the 10 92 MRI The findings were felt more consistent with demyelinating disease and less likely glioma Post viral encephalitis Rapidly progressive demyelinating disease and tumor were in the differential diagnosis Lumbar Puncture 11 8 92 revealed RBC 2 WBC 12 12 lymphocytes Glucose 57 Protein 51 elevated cytology and cultures were negative HIV 1 titer was negative Urine drug screen negative A stereotactic brain biopsy of the right parieto occipital region was consistent with demyelinating disease She was treated with Decadron 6mg IV qhours and Cytoxan 0 75gm m2 1 25gm On 12 3 92 she has a focal motor seizure with rhythmic jerking of the LUE loss of consciousness and rightward eye deviation EEG revealed diffuse slowing with frequent right sided sharp discharges She was placed on Dilantin She became depressed Keywords orthopedic sensory loss lumbar puncture peritrigonal region centrum semiovale mri brain white matter demyelinating disease csf demyelinating mri brain MEDICAL_TRANSCRIPTION,Description Right hallux abductovalgus deformity Right McBride bunionectomy Right basilar wedge osteotomy with OrthoPro screw fixation Medical Specialty Orthopedic Sample Name McBride Bunionectomy Wedge Osteotomy Transcription PREOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity POSTOPERATIVE DIAGNOSIS Right hallux abductovalgus deformity PROCEDURES PERFORMED 1 Right McBride bunionectomy 2 Right basilar wedge osteotomy with OrthoPro screw fixation ANESTHESIA Local with IV sedation HEMOSTASIS With pneumatic ankle cuff DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in a supine position The right foot was prepared and draped in usual sterile manner Anesthesia was achieved utilizing a 50 50 mixture of 2 lidocaine plain with 0 5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg At this time attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection Using a microsagittal saw the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp At this time attention was directed to the first inner space using sharp and blunt dissection Dissection was carried down to the underling level of the adductor hallucis tendon which was isolated and freed from its phalangeal sesamoidal and metatarsal attachments The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0 5 cm to help prevent any re fibrous attachment At this time the lateral release was stressed and was found to be complete The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0 5 cm resection The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw The area was again copiously flushed and inspected for any abnormalities and or prominences and none were noted At this time attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption At this time there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint At this time 0 5 cm was measured distal to that lateral measurement and using microsagittal saw a wedge osteotomy was taken from the base with the apex of the osteotomy being medial taking care to keep the medial cortex intact as a hinge The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3 0 x 22 mm The screw was placed following proper technique The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy The packing of the cancellous bone was held in place with bone wax The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed At this time a deep closure was achieved utilizing 2 0 Vicryl suture subcuticular closure was achieved using 4 0 Vicryl suture and skin repair was achieved at both surgical sites with 5 0 nylon suture in a running interlocking fashion The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site At this time the surgical site was postoperatively injected with 0 5 Marcaine plain as well as dexamethasone 4 mg primarily The surgical sites were then dressed with sterile Xeroform sterile 4x4s cascading and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion The tourniquet was dropped and color and temperature of all digits returned to normal The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions problems or concerns at any time with the numbers provided The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot Keywords orthopedic hallux abductovalgus bunionectomy mcbride basilar wedge osteotomy orthopro screw fixation wedge osteotomy MEDICAL_TRANSCRIPTION,Description Arthroscopy medial meniscoplasty lateral meniscoplasty medial femoral chondroplasty and medical femoral microfracture right knee Patellar chondroplasty Lateral femoral chondroplasty Meniscal tear osteochondral lesion degenerative joint disease and chondromalacia Medical Specialty Orthopedic Sample Name Meniscoplasty Chondroplasty Transcription PREOPERATIVE DIAGNOSIS Medial meniscal tear of the right knee POSTOPERATIVE DIAGNOSES 1 Medial meniscal tear right knee 2 Lateral meniscal tear right knee 3 Osteochondral lesion medial femoral condyle right knee 4 Degenerative joint disease right knee 5 Patella grade II chondromalacia 6 Lateral femoral condyle grade II III chondromalacia PROCEDURE PERFORMED 1 Arthroscopy right knee 2 Medial meniscoplasty right knee 3 Lateral meniscoplasty right knee 4 Medial femoral chondroplasty right knee 5 Medical femoral microfracture right knee 6 Patellar chondroplasty 7 Lateral femoral chondroplasty ANESTHESIA General ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None BRIEF HISTORY AND INDICATION FOR PROCEDURE The patient is a 47 year old female who has knee pain since 03 10 03 after falling on ice The patient states she has had inability to bear significant weight and had swelling popping and giving away failing conservative treatment and underwent an operative procedure PROCEDURE The patient was taken to the Operative Suite at ABCD General Hospital on 09 08 03 placed on the operative table in supine position Department of Anesthesia administered general anesthetic Once adequately anesthetized the right lower extremity was placed in a Johnson knee holder Care was ensured that all bony prominences were well padded and she was positioned and secured After adequately positioned the right lower extremity was prepped and draped in the usual sterile fashion Attention was then directed to creation of the arthroscopic portals both medial and lateral portal were made for arthroscope and instrumentation respectively The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch All compartments were then examined in sequential order with photodocumentation of each compartment The patella was noted to have grade II changes of the inferior surface otherwise appeared to track within the trochlear groove There was mild grooving of the trochlear cartilage The medial gutter was visualized There was no evidence of loose body The medial compartment was then entered There was noted to be a large defect on the medial femoral condyle grade III IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken At this point a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed This gave a smooth shoulder to the chondral lesion After this the meniscus was debrided until it had been smooth over the frayed edges At this point the shaver was removed The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge The probe was then reintroduced and the shaver removed the meniscus was probed ___________ and now found to be stable At this point attention was directed to the rest of the knee The ACL was examined It was intact and stable The lateral compartment was then entered There was noted to be a grade II III changes of the lateral femoral condyle Again with the edge of some friability at the shoulder of this cartilage lesion There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus The probe was introduced and the remaining meniscus appeared stable This was then removed and the stapler was introduced A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over The lateral gutter was then visualized There was no evidence of loose bodies Attention was then redirected back to the medial and femoral condyles At this point a 0 62 K wire was then placed in through the initial portal medial portal as well as an additional poke hole so we can gain access and proper orientation to the medial femoral lesion Microfacial technique was then used to introduce the K wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion After this was performed the shaver was then reintroduced and the loose bodies and loose fragments were further debrided At this point the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided Again all compartments were then re visualized and there was no further evidence of other pathology or loose bodies The knee was then copiously irrigated and suctioned dry All instrumentation was removed Approximately 20 cc of 0 25 plain Marcaine was injected into the portal site and the remaining portion intraarticular Sterile dressings of Adaptic 4x4s ABDs and Webril were then applied The patient was then transferred back to the gurney in supine position DISPOSITION The patient tolerated the procedure well with no complications The patient was transferred to PACU in satisfactory condition Keywords MEDICAL_TRANSCRIPTION,Description Low back pain lumbar radiculopathy degenerative disc disease lumbar spinal stenosis history of anemia high cholesterol and hypothyroidism Medical Specialty Orthopedic Sample Name Lumbar Radiculopathy Consult Transcription FAMILY HISTORY Her father died from leukemia Her mother died from kidney and heart failure She has two brothers five sisters one with breast cancer two sons and a daughter She describes cancer hypertension nervous condition kidney disease high cholesterol and depression in her family SOCIAL HISTORY She is divorced She does not have support at home She denies tobacco alcohol and illicit drug use ALLERGIES Hypaque dye when she had x rays for her kidneys MEDICATIONS Prempro q d Levoxyl 75 mcg q d Lexapro 20 mg q d Fiorinal as needed currently she is taking it three times a day and aspirin as needed She also takes various supplements including multivitamin q d calcium with vitamin D b i d magnesium b i d Ester C b i d vitamin E b i d flax oil and fish oil b i d evening primrose 1000 mg b i d Quercetin 500 mg b i d Policosanol 20 mg two a day glucosamine chondroitin three a day coenzyme Q 10 30 mg two a day holy basil two a day sea vegetables two a day and very green vegetables PAST MEDICAL HISTORY Anemia high cholesterol and hypothyroidism PAST SURGICAL HISTORY In 1979 tubal ligation and three milk ducts removed In 1989 she had a breast biopsy and in 2007 a colonoscopy She is G4 P3 with no cesarean section REVIEW OF SYSTEMS HEENT For headaches and sore throat Musculoskeletal She is right handed with joint pain stiffness and decreased range of motion Cardiac For heart murmur GI Negative and noncontributory Respiratory Negative and noncontributory Urinary Negative and noncontributory Hem Onc Negative and noncontributory Vascular Negative and noncontributory Psychiatric Negative and noncontributory Genital Negative and noncontributory She denies any bowel or bladder dysfunction or loss of sensation in her genital area PHYSICAL EXAMINATION She is 5 feet 2 inches tall Current weight is 132 pounds weight one year ago was 126 pounds BP is 122 68 On physical exam patient is alert and oriented with normal mentation and appropriate speech in no acute distress General a well developed and well nourished female in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth good dentition Cranial nerves II III IV and VI vision is intact visual fields are full to confrontation EOMs full bilaterally and pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movement Cranial nerve VIII hearing intact Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cranial nerve XI strong and symmetrical shoulder shrugs against resistance Cardiac regular rate and rhythm Chest and lungs are clear bilaterally Skin is warm and dry normal turgor and texture No rashes or lesions are noted General musculoskeletal exam reveals no gross deformities fasciculations or atrophy Peripheral vascular no cyanosis clubbing or edema Examination of the low back reveals some mild paralumbar spasms She is nontender to palpation of her spinous processes SI joints and paralumbar musculature She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation Deep tendon reflexes are 2 bilateral knees and ankles No ankle clonus is elicited Babinski toes are downgoing Straight leg raising is negative bilaterally Strength on manual exam is 5 5 and equal bilateral lower extremity She is able to ambulate on her toes and her heels without any difficulty She is able to get up standing on one foot on to the toes She does have some difficulty getting up on to her heels when standing on one foot She has trouble with this on the left and right She complains of increased pain while doing this as well She also has positive Patrick FABER on the right with pain with internal and external rotation negative on the left Sensation is intact She has good accuracy to pinprick dull versus sharp FINDINGS The patient brings in lumbar spine MRI dated November 20 2007 which demonstrates degenerative disc disease throughout At L4 L5 there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged At L5 S1 in the right neuroforamina there appears to be soft tissue density just lateral and posterior to the nerve root which may cause some displacement but it is unclear This could represent a facet synovial cyst This is lateral to the facet She does not have x rays for review She has had hip and knee x rays taken but does not bring them in with her ASSESSMENT Low back pain lumbar radiculopathy degenerative disc disease lumbar spinal stenosis history of anemia high cholesterol and hypothyroidism PLAN We discussed treatment options with this patient including 1 Do nothing 2 Conservative therapies 3 Surgery She seems to have some issues with her right hip so I would like for her to fax us over the report of her hip and knee x rays We will also order some x rays of her lumbar spine as well as lower extremity EMG At this point the patient has not exhausted conservative measures and would like to start with epidural steroid injections so we will go ahead and send her out for that After she has gotten her second epidural injection she will return to the office for a followup visit to see how she is doing All questions and concerns were addressed If she should have any further questions concerns or complications she will contact our office immediately Otherwise we will see her as scheduled Case was reviewed and discussed with Dr L Keywords orthopedic back pain hip pain low back pain x rays lumbar spinal stenosis degenerative disc disease spinal stenosis lumbar spine lumbar radiculopathy cranial nerves lumbar degenerative anemia MEDICAL_TRANSCRIPTION,Description Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation Medical Specialty Orthopedic Sample Name Lumbar Re exploration Transcription PREOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation POSTOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation PROCEDURE Lumbar re exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4 5 and L5 S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4 5 and L5 S1 followed by placement of the pedicle screw fixation devices at L3 L4 L5 and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1 2 and then at L3 L4 L4 L5 and L5 S1 bilaterally DESCRIPTION OF PROCEDURE This is a 68 year old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2 She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area There was no evidence of infection on the imaging or with her laboratory studies In addition she developed a pretty profound stenosis at L4 L5 and L5 S1 that appeared to be recurrent as well She now presents for revision of her hardware extension of fusion and decompression The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia She was placed on the operative table in the prone position Back was prepared with Betadine iodine and alcohol We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it After these were removed it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase We then dressed the L4 L5 and L5 S1 levels which were profoundly stenotic This was a combination of scar and overgrown bone She had previously undergone bilateral hemilaminectomies at L4 5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels After completing this we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels We used 10 x 32 mm spacers at both L4 L5 and L5 S1 This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4 L5 and S1 tightened the pedicle screws in L3 This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level Once we placed the plate onto the screws and locked them in position we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4 L5 and L5 S1 and L3 L4 again the goal being to create a dorsal fusion and enhance the interbody fusion as well The wound was then irrigated copiously with bacitracin solution and then we closed in layers using 1 Vicryl in muscle and fascia 3 0 in subcutaneous tissue and approximated staples in the skin Prior to closing the skin we confirmed correct sponge and needle count We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies The Cell Saver blood was recycled and she was given two units of packed red blood cells as well I was present for and performed the entire procedure myself or supervised Keywords orthopedic degenerative spondylolisthesis spondylolisthesis stenosis lumbar re exploration internal fixation plate hemilaminectomy diskectomy synthetic spacers pedicle screws fusion lumbar pedicle fixation hardware MEDICAL_TRANSCRIPTION,Description Medial branch rhizotomy lumbosacral Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Orthopedic Sample Name Medial Branch Rhizotomy Transcription PROCEDURE Medial branch rhizotomy lumbosacral INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible of vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed SEDATION The patient was given conscious sedation and monitored throughout the procedure Oxygenation was given The patient s oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs PROCEDURE The patient remained awake throughout the procedure in order to interact and give feedback The x ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a Teflon coated needle was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of Specifically each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra or for sacral vertebrae at the lateral superior border of the posterior sacral foramen Needle localization was confirmed with AP and lateral radiographs The following technique was used to confirm placement at the Medial Branch nerves Sensory stimulation was applied to each level at 50 Hz paresthesias were noted at volts Motor stimulation was applied at 2 Hz with 1 millisecond duration corresponding paraspinal muscle twitching without extremity movement was noted at volts Following this the needle Trocar was removed and a syringe containing 1 lidocaine was attached At each level after syringe aspiration with no blood return 1cc 1 lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds All injected medications were preservative free Sterile technique was used throughout the procedure COMPLICATIONS None No complications The patient tolerated the procedure well and was sent to the recovery room in good condition DISCUSSION Post procedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to be in relative rest for 1 day but then could resume all normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made in approximately 1 week Keywords orthopedic lumbosacral medial branch rhizotomy medial branch nerves rhizotomy fluoroscopy MEDICAL_TRANSCRIPTION,Description Injection for myelogram and microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain Medical Specialty Orthopedic Sample Name Lumbar Laminectomy Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain PROCEDURE PERFORMED 1 Injection for myelogram 2 Microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left on 08 28 03 BLOOD LOSS Approximately 25 cc ANESTHESIA General POSITION Prone on the Jackson table INTRAOPERATIVE FINDINGS Extruded nucleus pulposus at the level of L5 S1 HISTORY This is a 34 year old male with history of back pain with radiation into the left leg in the S1 nerve root distribution The patient was lifting at work on 08 27 03 and felt immediate sharp pain from his back down to the left lower extremity He denied any previous history of back pain or back surgeries Because of his intractable pain as well as severe weakness in the S1 nerve root distribution the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on After an informed consent was obtained all risks as well as complications were discussed with the patient PROCEDURE DETAIL He was wheeled back to Operating Room 5 at ABCD General Hospital on 08 28 03 After a general anesthetic was administered a Foley catheter was inserted The patient was then turned prone on the Jackson table All of his bony prominences were well padded At this time a myelogram was then performed After the lumbar spine was prepped a 20 gauge needle was then used to perform a myelogram The needle was localized to the level of L3 L4 region Once inserted into the thecal sac we immediately got cerebrospinal fluid through the spinal needle At this time approximately 10 cc of Conray injected into the thecal sac The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast The myelogram did reveal that there was some space occupying lesion most likely disc at the level of L5 S1 on the left There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C arm fluoroscopy At this point the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy A long spinal needle was then inserted into region of surgery on the right The surgery was going to be on the left Once the spinal needle was inserted a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5 S1 nerve root region At this time an approximately 2 cm skin incision was made over the lumbar region dissected down to the deep lumbar fascia At this time a Weitlaner was inserted Bovie cautery was used to obtain hemostasis We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left hand side At this time a Taylor retractor was then inserted and held there for retraction Suction as well as Bovie cautery was used to obtain hemostasis At this time a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression Once the laminotomy was performed a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots Once the ligamentum flavum was removed we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root which was compressive We removed the extruded disc with further freeing up of the S1 nerve root A nerve root retractor was then placed Identification of disc space was then performed A 15 blade was then inserted and small a key hole into the disc space was then performed with a 15 blade A small pituitary was then inserted within the disc space and more disc material was freed and removed The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc Once this was performed we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free At this time copious irrigation was used to irrigate the wound We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur At this time a small piece of Gelfoam was then used to cover the exposed nerve root We did not have any dural leaks during this case 1 0 Vicryl was then used to approximate the deep lumbar fascia 2 0 Vicryl was used to approximate the superficial lumbar fascia and 4 0 running Vicryl for the subcutaneous skin Sterile dressings were then applied The patient was then carefully slipped over into the supine position extubated and transferred to Recovery in stable condition At this time we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level Keywords orthopedic microscopic assisted lumbar laminectomy discectomy nerve root lumbar laminectomy herniated nucleus thecal sac spinal needle nucleus pulposus disc space root nerve weakness lumbar laminectomy nucleus pulposus myelogram MEDICAL_TRANSCRIPTION,Description Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques and repair of CSF fistula microtechniques L5 S1 application of DuraSeal Lumbar stenosis and cerebrospinal fluid fistula Medical Specialty Orthopedic Sample Name Lumbar Laminectomy Transcription PREOPERATIVE DIAGNOSIS Lumbar stenosis POSTOPERATIVE DIAGNOSES Lumbar stenosis and cerebrospinal fluid fistula TITLE OF THE OPERATION 1 Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques 2 Repair of CSF fistula microtechniques L5 S1 application of DuraSeal INDICATIONS The patient is an 82 year old woman who has about a four month history now of urinary incontinence and numbness in her legs and hands and difficulty ambulating She was evaluated with an MRI scan which showed a very high grade stenosis in her lumbar spine and subsequent evaluation included a myelogram which demonstrated cervical stenosis at C4 C5 C5 C6 and C6 C7 as well as a complete block of the contrast at L4 L5 and no contrast at L5 S1 either and stenosis at L3 L4 and all the way up but worse at L3 L4 L4 L5 and L5 S1 Yesterday she underwent an anterior cervical discectomy and fusions C4 C5 C5 C6 C6 C7 and had some improvement of her symptoms and increased strength even in the recovery room She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation though she has been cardioverted She and her son understand the nature indications and risks of the surgery and agreed to go ahead PROCEDURE The patient was brought from the Neuro ICU to the operating room where general endotracheal anesthesia was obtained She was rolled in a prone position on the Wilson frame The back was prepared in the usual manner with Betadine soak followed by Betadine paint Markings were applied Sterile drapes were applied Using the usual anatomical landmarks linear midline incision was made presumed over L4 L5 and L5 S1 Sharp dissection was carried down into subcutaneous tissue then Bovie electrocautery was used to isolate the spinous processes A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5 S1 The incision was extended rostrally and deep Gelpi s were inserted to expose the spinous processes and lamina of L3 L4 L5 and S1 Using the Leksell rongeur the spinous processes of L4 and L5 were removed completely and the caudal part of L3 A high speed drill was then used to thin the caudal lamina of L3 all of the lamina of L4 and of L5 Then using various Kerrison punches I proceeded to perform a laminectomy Removing the L5 lamina there was a dural band attached to the ligamentum flavum and this caused about a 3 mm tear in the dura There was CSF leak The lamina removal was continued ligamentum flavum was removed to expose all the dura Then using 4 0 Nurolon suture a running locking suture was used to close the approximate 3 mm long dural fistula There was no CSF leak with Valsalva I then continued the laminectomy removing all of the lamina of L5 and of L4 removing the ligamentum flavum between L3 L4 L4 L5 and L5 S1 Foraminotomies were accomplished bilaterally The caudal aspect of the lamina of L3 also was removed The dura came up quite nicely I explored out along the L4 L5 and S1 nerve roots after completing the foraminotomies the roots were quite free Further more the thecal sac came up quite nicely In order to ensure no CSF leak we would follow the patient out of the operating room The dural closure was covered with a small piece of fat This was all then covered with DuraSeal glue Gelfoam was placed on top of this then the muscle was closed with interrupted 0 Ethibond The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion Scarpa s fascia was closed with a running 0 Vicryl and finally the skin was closed with a running locking 3 0 nylon The wound was blocked with 0 5 plain Marcaine ESTIMATED BLOOD LOSS Estimated blood loss for the case was about 100 mL SPONGE AND NEEDLE COUNTS Correct FINDINGS A very tight high grade stenosis at L3 L4 L4 L5 and L5 S1 There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis The patient tolerated the procedure well with stable vitals throughout Keywords orthopedic microtechniques fistula duraseal foraminotomies lumbar stenosis cerebrospinal lumbar laminectomy ligamentum flavum csf laminectomy lamina MEDICAL_TRANSCRIPTION,Description Lumbar puncture A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained Medical Specialty Orthopedic Sample Name Lumbar Puncture 2 Transcription PROCEDURE PERFORMED Lumbar puncture The procedure benefits risks including possible risks of infection were explained to the patient and his father who is signing the consent form Alternatives were explained They agreed to proceed with the lumbar puncture Permit was signed and is on the chart The indication was to rule out toxoplasmosis or any other CNS infection DESCRIPTION The area was prepped and draped in a sterile fashion Lidocaine 1 of 5 mL was applied to the L3 L4 spinal space after the area had been prepped with Betadine three times A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained The spinal needle was then withdrawn and the area cleaned and dried and a Band Aid applied to the clean dry area COMPLICATIONS None The patient was resting comfortably and tolerated the procedure well ESTIMATED BLOOD LOSS None DISPOSITION The patient was resting comfortably with nonlabored breathing and the incision was clean dry and intact Labs and cultures were sent for the usual in addition to some extra tests that had been ordered The opening pressure was 292 the closing pressure was 190 Keywords orthopedic spinal needle lumbar puncture lumbar gauge csf MEDICAL_TRANSCRIPTION,Description Lumbar discogram L2 3 L3 4 L4 5 and L5 S1 Low back pain Medical Specialty Orthopedic Sample Name Lumbar Discogram Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE PERFORMED 1 Lumbar discogram L2 3 2 Lumbar discogram L3 4 3 Lumbar discogram L4 5 4 Lumbar discogram L5 S1 ANESTHESIA IV sedation PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed prone onto a radiolucent table The C arm was brought into the operative field and AP left right oblique and lateral fluoroscopic images of the L1 2 through L5 S1 levels were obtained We then proceeded to prepare the low back with a Betadine solution and draped sterile Using an oblique approach to the spine the L5 S1 level was addressed using an oblique projection angled C arm in order to allow for perpendicular penetration of the disc space A metallic marker was then placed laterally and a needle entrance point was determined A skin wheal was raised with 1 Xylocaine and an 18 gauge needle was advanced up to the level of the disc space using AP oblique and lateral fluoroscopic projections A second needle 22 gauge 6 inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections was placed into the center of the nucleus We then proceeded to perform a similar placement of needles at the L4 5 L3 4 and L2 3 levels A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting we then proceeded to inject the disc spaces sequentially Keywords orthopedic back pain c arm fluoroscopic projections disc space lumbar discogram fluoroscopic needle MEDICAL_TRANSCRIPTION,Description Lumbar muscle strain and chronic back pain Patient has a history of chronic back pain dating back to an accident that he states he suffered two years ago Medical Specialty Orthopedic Sample Name Lower back pain Transcription HISTORY OF PRESENT ILLNESS Patient is a 50 year old white male complaining of continued lower back pain Patient has a history of chronic back pain dating back to an accident that he states he suffered two years ago He states he helped a friend unload a motorcycle from a vehicle two and a half days ago after which he felt it in his lower back The following day two days ago he states he rode to Massachusetts and Maine to pick up clients He feels that this aggravated his chronic back pain as well He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture He is being prescribed Ultram Celebrex gabapentin and amitriptyline by his PCP for his chronic back pain He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain The patient did self refer to another physician who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives particularly the medications that the patient feels that he needs Patient states he did not do this because he was feeling well at that time The patient did present to our emergency room last night at which time he saw Dr X He was given a prescription for 12 Vicodin as well as some to take home last night The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines He is on several medications the list of which is attached to the chart MEDICATIONS In addition to the aforementioned medications he is on Cymbalta pantoprazole and a multivitamin ALLERGIES HE IS ALLERGIC TO RELAFEN ITCHING SOCIAL HISTORY The patient is married and lives with his wife Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Pulse is elevated at 105 Temp and other vitals signs are all within normal limits GENERAL Patient is a middle aged white male who is sitting on the stretcher in no acute distress BACK Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine more so on the right than on the left There is a well healed upper lumbar incision from his previous L1 L2 fusion There is no erythema ecchymosis or soft tissue swelling Mobility is generally very good without obvious signs of discomfort HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes MUSCULOSKELETAL With the patient supine there is some discomfort in the lower back with bent knee flexion of both hips as well as with straight leg abduction of the left leg There is some mild discomfort on internal and external rotation of the hips as well DTRs are 1 at the knees and trace at the ankles I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication which the patient feels that he needs and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a good day I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe then on a bad day he will have nowhere else to turn I explained to him that some emergency physicians do chose to use opiates for a short term as Dr X did last night It is unclear if the patient is looking for a different opiate medication but I do not think it is wise to give him more particularly as he has not even filled the prescription that was given to him last night I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back Celebrex tramadol amitriptyline gabapentin and the Vicodin that he was given last night I did suggest that we could try a different anti inflammatory if he felt that the Celebrex is not helping The patient is agreeable to this ASSESSMENT 1 Lumbar muscle strain 2 Chronic back pain PLAN At this point in time I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible Rx for Voltaren 75 mg tabs dispensed 20 sig one p o q 12h for pain instead of Celebrex He may continue with his other medications as directed but not the methadone or Darvocet I did urge him to reschedule his pain clinic appointment as he was urged to do originally If unimproved this week he should follow up with Dr Y Keywords orthopedic back pain lumbar muscle strain chronic back pain illness lower medications MEDICAL_TRANSCRIPTION,Description Microscopic lumbar discectomy left L5 S1 Extruded herniated disc left L5 S1 Left S1 radiculopathy acute Morbid obesity Medical Specialty Orthopedic Sample Name Lumbar Discectomy Microscopic Transcription PREOPERATIVE DIAGNOSES 1 Extruded herniated disc left L5 S1 2 Left S1 radiculopathy acute 3 Morbid obesity POSTOPERATIVE DIAGNOSES 1 Extruded herniated disc left L5 S1 2 Left S1 radiculopathy acute 3 Morbid obesity PROCEDURE PERFORMED Microscopic lumbar discectomy left L5 S1 ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 50 cc HISTORY This is a 40 year old female with severe intractable left leg pain from a large extruded herniated disc at L5 S1 She has been dealing with these symptoms for greater than three months She comes to my office with severe pain left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery I have discussed the MRI findings with the patient and the potential risks and complications She was scheduled to go to surgery through my office but because of her severe symptoms she was unable to keep that appointment and reported right to the Emergency Room We discussed the diagnosis and the operative procedure in detail I have reviewed the potential risks and complications and she had agreed to proceed with the surgery Due to the patient s weight which exceeds 340 lb there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient s back and abdomen and I have discussed this with her She is aware that she will have a much larger incision than what is standard and has agreed to accept this OPERATIVE PROCEDURE The patient was taken to OR 5 at ABCD General Hospital While in the hospital gurney Department of Anesthesia administered general anesthetic endotracheal intubation was followed A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing The table reportedly does have a limit of 500 lb but the table has never been stressed above 275 lb Once the table was reinforced the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded A marker was placed in from the back at this time and an x ray was obtained for incision localization The back is now prepped and draped in the usual sterile fashion A midline incision was made over the L5 S1 disc space taking through subcutaneous tissue sharply with a 10 Bard Parker scalpel The lumbar dorsal fascia was then encountered and incised to the left of midline In the subperiosteal fashion the musculature was elevated off the lamina at L5 and S1 after facet joint but not disturbing the capsule A second marker was now placed and an intraoperative x ray confirms our location at the L5 S1 disc space The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina Ligaments and fragments were encountered and removed at this time The epidural space was now encountered The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening This disc fragment was removed and the nerve root was much more supple it was carefully retracted The nerve root was now retracted and using a series of downgoing curettes additional disc material was removed from around the disc space and from behind the body of S1 and L5 At this point all disc fragments were removed from the epidural space Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify The disc space was now encountered and loose disc fragments were removed from within the disc space The disc space was then irrigated The nerve root was then reassessed and found to be quite supple At this point the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device At this point the wound was irrigated copiously and suctioned dry Gelfoam was used to cover the epidural space The retractors were removed at this point The fascia was reapproximated with 1 Vicryl suture subcutaneous tissue with 2 0 Vicryl suture and Steri Strips for curved incision The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia subsequently transferred to Postanesthesia Care Unit in stable condition Keywords orthopedic extruded herniated disc radiculopathy microscopic lumbar discectomy lumbar discectomy morbid obesity herniated disc epidural space nerve root disc space space intractable lamina epidural incision nerve herniated MEDICAL_TRANSCRIPTION,Description New patient consultation Low back pain degenerative disc disease spinal stenosis diabetes and history of prostate cancer status post radiation Medical Specialty Orthopedic Sample Name Low Back Pain Consult Transcription FAMILY HISTORY His parents are deceased He has two brothers ages 68 and 77 years old who are healthy He has siblings a brother and a sister who were twins who died at birth He has two sons 54 and 57 years old who are healthy He describes history of diabetes and heart attack in his family SOCIAL HISTORY He is married and has support at home He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week ALLERGIES Garamycin MEDICATIONS Insulin 20 to 25 units twice a day Lorazepam 0 05 mg he has a history of using this medication but most recently stopped taking it Glipizide 5 mg with each meal Advair 250 as needed aspirin q h s cod liver oil b i d Centrum AZ q d PAST MEDICAL HISTORY The patient has been diabetic for 35 years has been insulin dependent for the last 20 years He also has a history of prostate cancer which was treated by radiation He says his PSA is at 0 01 PAST SURGICAL HISTORY In 1985 he had removal of a testicle due to enlarged testicle he is not quite sure of the cause but he states it was not cancer REVIEW OF SYSTEMS Musculoskeletal He is right handed Respiratory For shortness of breath Urinary For frequent urination GI He denies any bowel or bladder dysfunction Genital He denies any loss of sensation or erectile problems HEENT Negative and noncontributory Hem Onc Negative and noncontributory Cardiac Negative and noncontributory Vascular Negative and noncontributory Psychiatric Negative and noncontributory PHYSICAL EXAMINATION He is 5 feet 10 inches tall Current weight is 204 pounds weight one year ago was 212 BP is 130 66 Pulse is 78 On physical exam the patient is alert and oriented with normal mentation and appropriate speech in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth poor dentition Cranial nerves II III IV and VI vision intact visual fields full to confrontation EOMs full bilaterally and pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movements Cranial nerve VIII hearing is intact Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cardiac regular rate a holosystolic murmur is also noted which is about grade 1 to 2 Chest and lungs are clear bilaterally Skin is warm and dry normal turgor and texture No rashes or lesions are noted Peripheral vascular no cyanosis clubbing or edema is noted General musculoskeletal exam reveals no gross deformities fasciculations or atrophy Station and gait are appropriate He ambulates well without any difficulties or assistance No antalgic or spastic gait is noted Examination of the low back reveals no paralumbar spasms He is nontender to palpation over his spinous process SI joints or paralumbar musculature Deep tendon reflexes are 2 bilaterally at the knees and 1 at the ankles No ankle clonus is elicited Babinski toes are downgoing Sensation is intact He does have some decreased sensation to pinprick dull versus sharp over the right lower extremity compared to that of the left Strength is 5 5 and equal bilateral lower extremities He is able to ambulate on his toes and his heels without any weakness noted He has negative straight leg raising bilaterally FINDINGS The patient brings in lumbar spine MRI for 11 15 2007 which demonstrates degenerative disc disease throughout At L4 L5 and L5 S1 he has severe disc space narrowing At L3 L4 he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge which caused moderate neuroforaminal narrowing At L4 L5 degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis At L5 S1 there is an annular disc bulge more to the right causing right sided neuroforaminal stenosis which is quite severe compared to that on the left ASSESSMENT Low back pain degenerative disc disease spinal stenosis diabetes and history of prostate cancer status post radiation PLAN We discussed treatment options with this patient including 1 Do nothing 2 Conservative therapies 3 Surgery The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam I did phone the patient s primary care doctor Dr O Unfortunately Dr O is out of the country and I did speak with Dr K who is covering for Dr O I informed Dr K that the patient had a new onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before so I obtained an EKG A copy was provided to the patient and the patient was referred back to his primary care physician for workup He was also released from our care at this time to a p r n basis but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications which he will receive from his primary doctor All questions and concerns were addressed If he should have any further questions concerns or complications he will contact our office immediately Otherwise we will see him p r n Warning signs and symptoms were gone over with him Case was reviewed and discussed with Dr L Keywords orthopedic back pain ligamentum flavum hypertrophy annular disc bulge degenerative disc disease spinal stenosis cranial nerves degenerative MEDICAL_TRANSCRIPTION,Description Microscopic assisted lumbar laminotomy with discectomy at L5 S1 on the left Herniated nucleus pulposus of L5 S1 on the left MEDICAL_TRANSCRIPTION,Description Ligament reconstruction and tendon interposition arthroplasty of right wrist Medical Specialty Orthopedic Sample Name Ligament Reconstruction Tendon Interposition Arthroplasty Transcription OPERATION PERFORMED Ligament reconstruction and tendon interposition arthroplasty of right wrist DESCRIPTION OF PROCEDURE With the patient under adequate anesthesia the right upper extremity was prepped and draped in a sterile manner Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field Further blunt dissection exposed the radial artery which was dissected and retracted off the trapezium An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint Sharp dissection exposed the trapezium which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon The radial beak of the trapezoid was then osteotomized off the head of the scaphoid The proximal metacarpal was then fenestrated with a 4 5 mm drill bit Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision The FCR tendon was divided and this incision was closed with 4 0 nylon sutures Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound The FCR tendon was then threaded through the fenestration in the metacarpal A bone anchor was then placed distal to the metacarpal fenestration The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect The MP joint was brought into extension and the capsule closed using interrupted 3 0 Tycron sutures Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0 035 Kirschner wire The pin was cut at the level of the skin All incisions were closed with running 3 0 Prolene subcuticular stitch Sterile dressings were then applied The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords orthopedic arthroplasty ligament tendon fcr tendon interposition arthroplasty ligament reconstruction reconstruction trapezium metacarpal joint interposition MEDICAL_TRANSCRIPTION,Description Closed reduction and placement of long arm cast Medical Specialty Orthopedic Sample Name Long Arm Cast Transcription PREOPERATIVE DIAGNOSIS Left distal radius fracture displaced POSTOPERATIVE DIAGNOSIS Left distal radius fracture displaced SURGERY Closed reduction and placement of long arm cast CPT code 25605 ANESTHESIA General LMA FINDINGS The patient was found to have a displaced fracture She was found to be in perfect alignment after closed reduction and placement of cast The radial deviation was well corrected INDICATIONS The patient is 5 years old She was seen in our office today 1 week after being placed into a cast for a displaced fracture She was noted to have significant loss of alignment especially on the lateral view She was indicated for closed reduction and placed of the long arm cast Risks and benefits were discussed at length with the family They wished to proceed PROCEDURE The patient was brought to the operating room and placed on the operating table in supine position General anesthesia was induced without incident Previous cast was previously removed An arm was approached and a closed reduction was performed This was checked under AP and lateral projection and was found to be in adequate alignment There was very mild residual dorsiflexion deformity noted A long arm cast was then placed with plaster and molding Repeat x rays demonstrated adequate alignment on both views The cast was then reinforced with fiberglass The patient was awakened from anesthesia and taken to recovery room in good condition There were no complications All instruments sponge and needle counts were correct at the end of case PLAN The patient will be discharged home She will return in 3 weeks for cast removal and clinical examination She would likely be placed into a wrist guard at that time She has a prescription for Tylenol with codeine elixir Keywords orthopedic long arm cast closed reduction displaced fracture radial deviation distal radius fracture arm cast MEDICAL_TRANSCRIPTION,Description Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon a 40 mm bioabsorbable femoral pin and a 9 mm bioabsorbable tibial pin Repair of lateral meniscus using two fast fixed meniscal repair sutures Partial medial meniscectomy Partial chondroplasty of patella Lateral retinacular release Open medial plication as well of the right knee Medical Specialty Orthopedic Sample Name Ligament Reconstruction Meniscus Repair Transcription PREOPERATIVE DIAGNOSES 1 Torn anterior cruciate ligament right knee 2 Patellofemoral instability right knee 3 Possible torn medial meniscus POSTOPERATIVE DIAGNOSES 1 Complete tear anterior cruciate ligament right knee 2 Complex tear of the posterior horn lateral meniscus 3 Tear of posterior horn medial meniscus 4 Patellofemoral instability 5 Chondromalacia patella PROCEDURES PERFORMED 1 Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon a 40 mm bioabsorbable femoral pin and a 9 mm bioabsorbable tibial pin 2 Repair of lateral meniscus using two fast fixed meniscal repair sutures 3 Partial medial meniscectomy 4 Partial chondroplasty of patella 5 Lateral retinacular release 6 Open medial plication as well of the right knee ANESTHESIA General COMPLICATIONS None TOURNIQUET TIME 130 minutes at 325 mmHg INTRAOPERATIVE FINDINGS There was noted to be a grade II chondromalacia patellofemoral joint The patella was noted to be situated laterally past the lateral femoral condyle There was a tear to the posterior horn of the medial meniscus within the white zone There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus There was a complete tear of the anterior cruciate ligament The posterior cruciate ligament appeared intact Preoperatively she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability HISTORY This is a 39 year old female who has sustained a twisting injury to her knee while on trampoline in late August She was diagnosed per MRI An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint All risks and benefits of surgery were discussed with her at length She was in agreement with the treatment plan PROCEDURE On 09 11 03 she was taken to the operating room at ABCD General Hospital She was placed supine on the operating table General anesthetic was applied by the Anesthesiology Department Tourniquet was placed on the proximal thigh and it was then placed in a knee holder She was sterilely prepped and draped in the usual fashion An Esmarch was used to exsanguinate the lower extremity Tourniquet was inflated to 325 mmHg Longitudinal incision was made just medial to the tibial tubercle The subcutaneous tissue was carefully dissected Hemostasis was controlled with electrocautery The tendons of gracilis and semitendinosus were identified and isolated and then stripped off the musculotendinous junction They were taken on the back table The soft tissue debris was removed from the tendons The ends of the tendons were sewn together using 5 Tycron whip type sutures The tendons were measured on back table and found to be 8 mm as the most adequate size they were then placed under tension on the back table Stab incision was made in the inferolateral parapatellar region through this camera was placed in the knee The knee was inflated with saline solution and operative pictures were obtained The above findings were noted A second port site was initiated in the inferomedial parapatellar region Through this a probe was placed Tear in the posterior horn medial meniscus was identified It was resected using a meniscal resector It was then further contoured using arthroscopic shaver Attention was then taken to the lateral compartment A partial meniscectomy was performed using the resector and the shaver The posterior periphery of the lateral meniscus was also noticed to be unstable A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon There was noted to be excellent fixation The shaver was then taken into the intrachondral notch First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint Next the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle Next a tibial guide was placed through the anterior medial portal A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament This tibial tunnel was then drilled using 8 mm cannulated drill Next an over the top guide was then placed at approximately the 11 30 position A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm Next the U shape guide was placed through tibial tunnel into the femur A pin was then placed through the distal femur from lateral to medial through the U shaped guide a puller wire was then passed through the distal femur It was then pulled out through the tibial tunnel using the You shaped guide The tendon was then placed around the wire The wire was pulled back up through the tibial into the femoral tunnel A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons Attention was then pulled through the tibial tunnel The knee was cycled approximately 20 times A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft There was noted definite fixation of the graft There was no evidence of impingement either in full flexion or full extension The knee was copiously irrigated and it was then suctioned dry A longitudinal incision was made just medial to the patellofemoral joint Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision Following this a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication The medial retinaculum was then plicated using 1 Ethibond sutures and then oversewn with 0 Vicryl suture The subcuticular tissues were reapproximated with 2 0 Vicryl simple interrupted sutures followed by a 4 0 PDS running subcuticular stitch She was placed in a DonJoy knee immobilizer The tourniquet was deflated It was noted the lower extremity was warm and pink with good capillary refill She was transferred to the recovery room in apparent stable and satisfactory condition Prognosis for this patient is guarded She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension She may remove her dressing two to three days however follow back in the office in 10 to 14 days for suture removal She will require one to two more physical therapy to help regain motion and strength to the lower extremity Keywords MEDICAL_TRANSCRIPTION,Description Lateral release with lengthening of the ECRB tendon Lateral epicondylitis Medical Specialty Orthopedic Sample Name Lateral Epicondylitis Release Transcription PREOPERATIVE DIAGNOSIS Lateral epicondylitis Keywords orthopedic lateral release ecrb tendon ecrl lateral epicondylitis tourniquet aponeurosis epicondyle antebrachial epicondylitis dissection extensor ecrb MEDICAL_TRANSCRIPTION,Description Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots Right L4 S1 posterolateral fusion with local bone graft Left L4 through S1 segmental pedicle screw instrumentation Preparation harvesting of local bone graft Medical Specialty Orthopedic Sample Name Laminotomy Facetectomy Foraminotomy Transcription PREOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis POSTOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis OPERATION PERFORMED 1 Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots 2 Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots 3 Right L4 S1 posterolateral fusion with local bone graft 4 Left L4 through S1 segmental pedicle screw instrumentation 5 Preparation harvesting of local bone graft ANESTHESIA General endotracheal PREPARATION Povidone iodine INDICATION This is a gentleman with right sided lumbosacral radiculopathy MRI disclosed and lateral recess stenosis at the L4 5 L5 S1 foraminal narrowing in L4 and L5 roots The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain The patient understood major risks and complications such as death and paralysis seemingly rare main concern is a 10 to 15 of failure rate to respond to surgery for which further surgery may or may not be indicated small risk of wound infection spinal fluid leak The patient is understanding and agreed to proceed and signed the consent PROCEDURE The patient was brought to the operating room peripheral venous lines were placed General anesthesia was induced The patient was intubated Foley catheter was in place The patient laid prone onto the OSI table using 6 post pressure points were carefully padded the back was shaved sterilely prepped and draped A previous incision was infiltrated with local and incised with a scalpel The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4 L5 in the sacral ala Laminotomies were then performed at L4 L5 and L5 S1 in a similar fashion using Midas Rex drill with AM8 bit inferior portion of lamina below and superior portion of lamina above and the medial facet was drilled down to the thin shelf of bone The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison bone was harvested throughout to be used for bone grafting The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies L4 L5 roots were extensively decompressed Pars interarticularis were maintained Using angled 2 mm Kerrisons hypertrophied ligamentum flavum the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise Pedicle screws were placed L4 L5 and S1 on the right side Initial hole began with Midas Rex drill deepened with a gear shift and with 4 5 mm tap palpating with pedicle probe It showed no penetration outside the pedicle vertebral body At L4 L5 5 5 x 45 mm screws were placed and at S1 5 5 x 40 mm screw was placed Good bone purchase was obtained Gelfoam was placed over the roots laterally corticated transverse processes lateral facet joints were prepared small infuse sponge was placed posterolaterally on the right side then the local bone graft from L4 to S1 Traction was applied between the L4 L5 L5 S1 screws locking notes were tightened out heads were rotated fractured off about 2 3 mm traction were applied at each side further opening the foramen for the exiting roots Prior to placement of BMP the wound was irrigated with antibiotic irrigation Medium Hemovac drain was placed in the depth of wound brought out through a separate stab incision Deep fascia was closed with 1 Vicryl subcutaneous fascia with 1 Vicryl and subcuticular with 2 0 Vicryl Skin was stapled The drain was sutured in place with 2 0 Vicryl and connected to closed drain system The patient was laid supine on the bed extubated and taken to recovery room in satisfactory condition The patient tolerated the procedure well without apparent complication Final sponge and needle counts are correct Estimated blood loss 600 mL The patient received 200 mL of cell saver blood back Keywords orthopedic lumbosacral radiculopathy lumbar spondylolysis laminotomies medial facetectomies foraminotomies decompression nerve roots fusion bone graft segmental pedicle screw transverse processes bone facetectomies transpedicular graft pedicle MEDICAL_TRANSCRIPTION,Description Complete laminectomy L4 and facetectomy L3 L4 level A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level Posterior spinal instrumentation L4 to S1 using Synthes Pangea System Posterior spinal fusion L4 to S1 Insertion of morselized autograft L4 to S1 Medical Specialty Orthopedic Sample Name Laminectomy Facetectomy Transcription PREOPERATIVE DIAGNOSIS Dural tear postoperative laminectomy L4 L5 POSTOPERATIVE DIAGNOSES 1 Dural tear postoperative laminectomy L4 L5 2 Laterolisthesis L4 L5 3 Spinal instability L4 L5 OPERATIONS PERFORMED 1 Complete laminectomy L4 2 Complete laminectomy plus facetectomy L3 L4 level 3 A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level 4 Posterior spinal instrumentation L4 to S1 using Synthes Pangea System 5 Posterior spinal fusion L4 to S1 6 Insertion of morselized autograft L4 to S1 ANESTHESIA General ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS None DRAINS Hemovac x1 DISPOSITION Vital signs stable taken to the recovery room in a satisfactory condition extubated INDICATIONS FOR OPERATION The patient is a 48 year old gentleman who has had a prior decompression several weeks ago He presented several days later with headaches as well as a draining wound He was subsequently taken back for a dural repair For the last 10 to 11 days he has been okay except for the last two days he has had increasing headaches has nausea vomiting as well as positional migraines He has fullness in the back of his wound The patient s risks and benefits have been conferred him due to the fact that he does have persistent spinal leak The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively PROCEDURE IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled back to the operating theater room 7 The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties The patient was given intraoperative antibiotics The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion Initially a midline incision was made from the cephalad to caudad level Full thickness skin flaps were developed It was seen immediately that there was large amount of copious fluid emanating from the wound clear like fluid which was the cerebrospinal fluid Cultures were taken aerobic anaerobic AFB fungal Once this was done the paraspinal muscles were affected from the posterior elements It was seen that there were no facet complexes on the right side at L4 L5 and L5 S1 It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4 5 level from the listhesis Once this was done however the fluid emanating from the dura could not be seen appropriately Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left Complete laminectomy at L3 was done Once this was done within the subarticular recess on the right side at the L4 pedicle level a rent in the dura was seen Once this was appropriately cleaned the dural edges were approximated using a running 6 0 Prolene suture A Valsalva confirmed no significant lead after the repair was made There was a significant laterolisthesis at L4 L5 and due to the fact that there were no facet complexes at L5 S1 and L4 L5 on the right side as well as there was a significant concavity on the right L4 L5 disk space which was demonstrated from intraoperative x rays and compared to preoperative x rays it was decided from an instrumentation The lateral pedicle screws were placed at L4 L5 and S1 using the standard technique of Magerl After this the standard starting point was made Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall Once this was done this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall The screws were subsequently placed Tricortical purchase was obtained at S1 ________ appropriate size screws Precontoured titanium rod was then appropriately planned and placed between the screws at L4 L5 and S1 This was done on the right side first The screw was torqued at S1 appropriately and subsequently at L5 Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4 Neutral compression distraction was obtained on the left side Screws were torqued at L4 L5 and S1 appropriately Good placement was seen both in AP and lateral planes using fluoroscopy Laterolisthesis corrected appropriately at L4 and L5 Posterior spinal fusion was completed by decorticating the posterior elements at L4 L5 and the sacral ala with a curette Once good bleeding subchondral bone was appreciated the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix This was placed in the posterior lateral gutters DuraGen was then placed over the dural repair and after this fibrin glue was placed appropriately Deep retractors then removed from the confines of the wound Fascia was closed using interrupted Prolene running suture 1 Once this was done suprafascial drain was placed appropriately Subcutaneous tissues were opposed using a 2 0 Prolene suture The dermal edges were approximated using staples Wound was dressed sterilely using bacitracin ointment Xeroform 4 x 4 s and tape The drain was connected appropriately The patient was rolled on stretcher in usual supine position extubated uneventfully and taken back to the recovery room in a satisfactory stable condition No complications arose Keywords MEDICAL_TRANSCRIPTION,Description Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation Medical Specialty Orthopedic Sample Name Laminectomy Foraminotomy Followup Transcription REASON FOR VISIT Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup status post L4 L5 laminectomy and bilateral foraminotomies and posterior spinal fusion on 06 08 07 Preoperatively her symptoms those of left lower extremity are radicular pain She had not improved immediately postoperatively She had a medial breech of a right L4 pedicle screw We took her back to the operating room same night and reinserted the screw Postoperatively her pain had improved I had last seen her on 06 28 07 at which time she was doing well She had symptoms of what she thought was restless leg syndrome at that time She has been put on ReQuip for this She returned I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative She states that she had recurrent left lower extremity pain which was similar to the pain she had preoperatively but in a different distribution further down the leg Thus I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation She states that overall she is improved compared to preoperatively She is ambulating better than she was preoperatively The pain is not as severe as it was preoperatively The right leg pain is improved The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side She denies any significant low back pain No right lower extremity symptoms No infectious symptoms whatsoever No fever chills chest pain shortness of breath No drainage from the wound No difficulties with the incision FINDINGS On examination Ms ABC is a pleasant well developed well nourished female in no apparent distress Alert and oriented x 3 Normocephalic atraumatic Respirations are normal and nonlabored Afebrile to touch Left tibialis anterior strength is 3 out of 5 extensor hallucis strength is 2 out of 5 Gastroc soleus strength is 3 to 4 out of 5 This has all been changed compared to preoperatively Motor strength is otherwise 4 plus out of 5 Light touch sensation decreased along the medial aspect of the left foot Straight leg raise test normal bilaterally The incision is well healed There is no fluctuance or fullness with the incision whatsoever No drainage Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws Lumbar spine MRI performed on 07 03 07 is also reviewed It demonstrates evidence of adequate decompression at L4 and L5 There is a moderate size subcutaneous fluid collection seen which does not appear compressive and may be compatible with normal postoperative fluid collection especially given the fact that she had a revision surgery performed ASSESSMENT AND PLAN Ms ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies and posterior spinal fusion with instrumentation on 07 08 07 The case is significant for merely misdirected right L4 pedicle screw which was reoriented with subsequent resolution of symptoms I am uncertain with regard to the etiology of the symptoms However it does appear that the radiographs demonstrate appropriate positioning of the instrumentation no hardware shift and the MRI demonstrates only a postoperative suprafascial fluid collection I do not see any indication for another surgery at this time I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection My recommendation at this time is that the patient is to continue with mobilization I have reassured her that her spine appears stable at this time She is happy with this I would like her to continue ambulating as much as possible She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested I have also her referred to Mrs Khan at Physical Medicine and Rehabilitation for continued aggressive management I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve She knows that if she has any difficulties she may follow up with me sooner Keywords orthopedic spinal fusion restless leg syndrome posterior spinal fusion pedicle screw lumbar spine bilateral foraminotomies fluid collection foraminotomy instrumentation laminectomy screw spine MEDICAL_TRANSCRIPTION,Description A 13 year old new patientfor evaluation of thoracic kyphosis Family history of kyphosis in a maternal aunt and grandfather She was noted by her parents to have round back posture Medical Specialty Orthopedic Sample Name Kyphosis Transcription REASON FOR VISIT Kyphosis HISTORY OF PRESENT ILLNESS The patient is a 13 year old new patient is here for evaluation of thoracic kyphosis The patient has a family history in a maternal aunt and grandfather of kyphosis She was noted by her parents to have round back posture They have previously seen another orthopedist who recommended observation at this time She is here for a second opinion in regards to kyphosis The patient denies any pain in her back or any numbness tingling or weakness in her upper or lower extremities No problems with her bowels or bladder PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Bilateral pinning of her ears SOCIAL HISTORY She is currently an eighth grader at Middle School and is interested in basketball She lives with both of her parents and has a 9 year old brother She had menarche beginning in September FAMILY HISTORY Of kyphosis in great grandmother and second cousin REVIEW OF SYSTEMS She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness MEDICATIONS She is currently on Zyrtec Flonase and Ceftin for an ear infection ALLERGIES No known drug allergies FINDINGS On physical exam she is alert oriented and in no acute distress standing 63 inches tall In regards to her back her skin is intact with no rashes lesions and or no dimpling or hair spots No cafe au lait spots She is not tender to palpation from her occiput to her sacrum There is no evidence of paraspinal muscle spasm On forward bending there is a mild kyphosis She is not able to touch her toes indicating her hamstring tightness She has a full 5 out of 5 in all muscle groups Her lower extremities including iliopsoas quadriceps gastroc soleus tibialis anterior and extensor hallucis longus Her sensation intact to light touch in L1 through L2 dermatomal distributions She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes X rays today included PA and lateral sclerosis series She has approximately 46 degree kyphosis ASSESSMENT Kyphosis PLANS The patient s kyphosis is quite mild While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home At this time three options were discussed with the parents including observation physical therapy and bracing At this juncture given that she has continued to grow they are Risser 0 She may benefit from continued observation with physical therapy bracing would be a more aggressive option certainly that thing would be lost with following at this time As such she was given a prescription for physical therapy for extension based strengthening exercises flexibility range of motion exercises postural training with no forward bending We will see her back in 3 months time for repeat radiographs at that time including PA and lateral standing of scoliosis series Should she show evidence of continued progression of her kyphotic deformity discussions of bracing would be held at time We will see her back in 3 months time for repeat evaluation Keywords orthopedic thoracic kyphosis round back posture physical therapy kyphosis patientfor orthopedist MEDICAL_TRANSCRIPTION,Description Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Medical Specialty Orthopedic Sample Name Laminectomy Discectomy Facetectomy Transcription TITLE OF OPERATION Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP INDICATIONS FOR SURGERY Please refer to medical record but in short the patient is a 43 year old male known to me status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Risks and benefits of surgery were explained in detail including risk of bleeding infection stroke heart attack paralysis need for further surgery hardware failure persistent symptoms and death This list was inclusive but not exclusive An informed consent was obtained after all patient s questions were answered PREOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly POSTOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly ANESTHESIA General anesthesia and endotracheal tube intubation DISPOSITION The patient to PACU with stable vital signs PROCEDURE IN DETAIL The patient was taken to the operating room After adequate general anesthesia with endotracheal tube intubation was obtained the patient was placed prone on the Jackson table Lumbar spine was shaved prepped and draped in the usual sterile fashion An incision was carried out from L4 to S1 Hemostasis was obtained with bipolar and Bovie cauterization A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4 L5 and sacrum At this time laminectomy was carried out of L5 S1 Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space At this time the disk was entered with a 15 blade and bipolar The disk was entered with straight up and down biting pituitaries curettes and the high speed drill and we were able to takedown calcified herniated disk We were able to reestablish the disk space it was very difficult required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal very carefully holding the spinal canal out of harm s way as well as the exiting nerve root Once this was done we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic At this time Dr X will dictate the posterolateral fusion pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound There were no complications Keywords orthopedic revision laminectomy discectomy facetectomy arthrodesis lumbar spondylosis hypermobility collapsed disk space medial facetectomy interbody graft herniated disk interbody laminectomy disk therapy lumbar herniated space MEDICAL_TRANSCRIPTION,Description KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV R bone cement under low pressure at T12 and L1 levels and bone biopsy Medical Specialty Orthopedic Sample Name Kyphoplasty Transcription PRE OP DIAGNOSIS Osteoporosis pathologic fractures T12 L2 with severe kyphosis POST OP DIAGNOSIS Osteoporosis pathologic fractures T12 L2 with severe kyphosis PROCEDURE 1 KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV R bone cement under low pressure at T12 and L1 levels 2 Bone biopsy medically necessary ANESTHESIA General COMPLICATIONS None BLOOD LOSS Minimal INDICATIONS Mrs Smith is a 75 year old female who has had severe back pain that began approximately three months ago and is debilitating She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics She presents with and is on medication therapy for COPD diabetes and hypertension other co morbidities may be present upon admission and should be documented in the operative note Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12 L1 and L2 In addition to the fractures she presents with kyphotic posture Films on 1 04 demonstrated L1 and L2 osteoporotic fractures Films on 2 04 demonstrated increased loss of height at L1 Films on 3 04 demonstrated a new compression fracture at T12 and further collapse of L1 The L2 fracture is documented on radiographic studies as being chronic and a year or more old The T12 fracture has the most significant kyphotic deformity Based on these findings we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures PROCEDURE The patient was brought to the operating room radiology suite and general anesthesia local sedation with endotracheal intubation was performed The patient was positioned prone on the Jackson table The back was prepped and draped The image intensifier C arm was brought into position and the T12 pedicles were identified and marked with a skin marker In view of the collapse of T12 a transpedicular approach to the vertebral body was appropriate An 11 gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side Positioning was confirmed on the AP and lateral plane Following satisfactory placement of the needle the stylet was removed A guide pin was inserted through the 11g to a point 3mm from the anterior cortex AP and lateral images were taken to verify position and trajectory Alongside of the guide pin a 1 cm paramedian incision was made The needle was then removed leaving the guide pin in place The osteointroducer was placed over the guide pin and advanced through the pedicle Once I was at the junction of the pedicle and the vertebral body a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall Through the cannula a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex creating a channel The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex After completing the entry into the vertebral body a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex The radiopaque marker bands on the bone tamp were identified using AP and lateral images The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body Once both bone tamps were in position they were inflated to 0 5 cc and 50 psi Expansion of the bone tamps was done sequentially in increments of 0 25 to 0 5 cc of contrast with careful attention being paid to the inflation pressures and balloon position The inflation was monitored with AP and lateral imaging The final balloon volume was 3 5 cc on the right side and 3 cc on the left There was no breach of the lateral wall or anterior cortex of the vertebral body Direct reduction of the fracture was achieved end plate movement was noted and approximately 5 mm of height restoration was achieved Under fluoroscopic imaging and the use of the bone void fillers internal fixation was achieved through a low pressure injection of KYPHON HV R bone cement The cavity was filled with a total volume of 3 5 cc on the right side and 3 cc on the left side Once the bone cement had hardened the cannulas were then removed At this time we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12 An entry needle was placed bilaterally through the pedicle into the vertebral body a cortical window was created inflation of the bone tamps directly reduced the fracture the bone tamps were removed and internal fixation by bone void filler insertion was achieved Throughout the procedure AP and lateral imaging monitored positioning Post procedure all incisions were closed with sutures The patient was kept in the prone position for approximately 10 minutes post cement injection She was then turned supine monitored briefly and returned to the floor She was moving both her lower extremities at this time Throughout the procedure there were no intraoperative complications Estimated blood loss was minimal Keywords orthopedic osteoporosis pathologic fractures kyphosis bone cement balloon kyphoplasty kyphon balloon kyphoplasty bone biopsy kyphon insertion of kyphon ap and lateral vertebral body kyphon balloon anterior cortex vertebral body fractures insertion bone kyphoplasty guide balloon pedicles cortex positioned therapy MEDICAL_TRANSCRIPTION,Description Left medial compartment osteoarthritis of the knee Left unicompartmental knee replacement Medical Specialty Orthopedic Sample Name Knee Replacement Transcription PREOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee POSTOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee PROCEDURE PERFORMED Left unicompartmental knee replacement COMPONENTS USED Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component COMPLICATIONS None TOURNIQUET TIME 59 minutes BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE A 55 year old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side She has done quite well with this She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought to the operating room and placed supine on the operating room table After appropriate anesthesia the left lower extremity was identified with a time out procedure Preoperative antibiotics were given Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet The tourniquet was insufflated after elevation of the limb and a standard medial parapatellar incision was used Soft tissue dissection was carried down the retinaculum was opened sharply to expose the joint meniscus that was visible along the tibia was removed The anterior fat pad was removed The knee was then examined The ACL was found to be intact The lateral compartment had very minimal arthritis There were some osteoarthritic changes of the patellofemoral joint but these were felt to be mild Following this the tibial external alignment guide was placed and pinned into place in the appropriate place Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection Following this resection the femoral intramedullary guide was placed without difficulty The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide Once in the appropriate position it was pinned and drilled This was removed and the posterior cutting block was inserted It was impacted into place Posterior bone cut was made for the medium femoral component Next a zero spigot was used and the distal femur was reamed Following this the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed so 1 spigot was used and this was reamed as well Next trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit Next the tibia was prepared The tibial tray was pinned into place and the cuts for the keel of the tibia were made These were removed with a small osteotome from the set Following this a trial tibial with the keel was placed and it did fit nicely After this all trial components were removed The knee was copiously irrigated Cement was begun mixing Drill holes were used along the femur for cement interdigitation The wound was cleaned and dried Cement was placed on the tibia Tibial tray was impacted into place Excess cement was removed Tibia was placed in the femur Femoral component was impacted into place Excess cement was removed It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened Following this it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size A 3 mm polyethylene was chosen and inserted in the knee without difficulty taken through range of motion and found to come out to full extension with no impingement and full flexion The intramedullary rod removed from the femur The wound was irrigated with normal saline The retinaculum was closed with 1 PDS 2 0 Monocryl was used for the subcutaneous tissue and staples used for the skin A sterile dressing was placed Tourniquet was then desufflated Sponge and needle counts were correct at the end of the procedure Dr Jinnah was present for the surgery The patient was transferred to the recovery room in stable condition She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis Prior to closure the posterior capsule was injected with the joint cocktail Keywords orthopedic knee replacement osteoarthritis osteoarthritis of the knee excess cement was removed medium femoral component medial compartment osteoarthritis unicompartmental knee replacement medium femoral femoral intramedullary intramedullary guide medial compartment femoral component tibial tray lower extremity unicompartmental knee tibial knee tourniquet intramedullary extension flexion compartment unicompartmental replacement femoral cement MEDICAL_TRANSCRIPTION,Description The patient with an L5 compression fracture is to come to the hospital for bilateral L5 kyphoplasty The patient has a history of back and buttock pain for some time Medical Specialty Orthopedic Sample Name Kyphoplasty Consult Transcription HISTORY The patient is to come to the hospital for bilateral L5 kyphoplasty The patient is an 86 year old female with an L5 compression fracture The patient has a history of back and buttock pain for some time She was found to have an L5 compression fracture She was treated conservatively over several months but did not improve Unfortunately she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture but without complete healing The patient has had continued pain and at this time is felt to be a candidate for kyphoplasty She denies bowel or bladder incontinence She does complain of back pain She has been wearing a back brace and corset She does not have weakness PAST MEDICAL HISTORY The patient has a history of multiple medical problems including hypothyroidism hypertension and gallbladder difficulties PAST SURGICAL HISTORY She has had multiple previous surgeries including bowel surgery hysterectomy rectocele repair and appendectomy She also has a diagnosis of polymyalgia rheumatica CURRENT MEDICATIONS She is on multiple medications currently ALLERGIES SHE IS ALLERGIC TO CODEINE PENICILLIN AND CEPHALOSPORINS FAMILY HISTORY The patient s parents are deceased PERSONAL AND SOCIAL HISTORY The patient lives locally She is a widow She does not smoke cigarettes or use illicit drugs PHYSICAL EXAMINATION GENERAL The patient is an elderly frail white female in no distress LUNGS Clear HEART Sounds are regular ABDOMEN She has a protuberant abdomen She has tenderness to palpation in the lumbosacral area Sciatic notch tenderness is not present Straight leg raise testing evokes back pain NEUROLOGICAL She is awake alert and oriented Speech is intact Comprehension is normal Strength is intact in the upper extremities She has giveaway strength in the lower extremities Reflexes are diminished at the knees and ankles Gait is otherwise normal DATA REVIEWED Plain studies of the lumbar spine show an L5 compression fracture A CT scan has shown some healing of this fracture She has degenerative change at the L4 L5 level with a very slight spondylolisthesis at this level ASSESSMENT AND PLAN The patient is a woman with a history of longstanding back buttock and leg pain She has a documented L5 compression fracture which has not healed despite appropriate conservative treatments At this point I believe the patient is a good candidate for L5 kyphoplasty I have discussed the procedure with her and I have reviewed with her and her family risks benefits and alternatives to surgery Risks of surgery including but not limited to bleeding infection stroke paralysis death failure to improve spinal fluid leak need for further surgery cement extravasation failure to improve her pain and other potential complications have all been discussed The patient understands the issues involved She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01 18 08 Keywords orthopedic leg pain lumbar spine l5 compression fracture compression fracture kyphoplasty buttock surgery fracture MEDICAL_TRANSCRIPTION,Description Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty Vertebroplasties at T7 and T9 with insertion of prosthetic device Fracture of the T8 vertebra and T9 vertebra Medical Specialty Orthopedic Sample Name Kyphoplasty Vertebroplasty Transcription PREOPERATIVE DIAGNOSES 1 Pathologic insufficiency 2 Fracture of the T8 vertebrae and T9 vertebrae POSTOPERATIVE DIAGNOSES 1 Pathologic insufficiency 2 Fracture of the T8 vertebra and T9 vertebra PROCEDURE PERFORMED 1 Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty 2 Vertebroplasties at T7 and T9 with insertion of prosthetic device ANESTHESIA Local with sedation SPECIMEN Bone from the T8 vertebra COMPLICATIONS None SURGICAL INDICATIONS The patient is an 80 year old female who had previous history of compression fractures She had recently undergone an additional compression fracture of the T8 vertebrae She was in extreme pain This pain interfered with activities of daily living and was unimproved with conservative treatment modalities She is understanding the risks benefits and potential complications as well as all treatment alternatives The patient provided informed consent OPERATIVE TECHNIQUE The patient was taken to OR 2 where she was placed prone on the Jackson spinal table She was given sedative The thoracodorsal spine was then sterilely prepped and draped in the usual fashion Biplanar image intensification was utilized to localize the T8 T7 and T9 vertebrae Local anesthetic of 1 Marcaine with epinephrine and lidocaine were 50 50 mixed Approximately 7 cc was instilled on the left side This was directly over the posterior aspect of the pedicle on the left Once this was localized the right side was localized as well Stab incisions were then created over the pedicles of T8 bilaterally Jamshidi needles were then placed percutaneously Their position was verified in both AP and lateral images They were advanced slowly under direct image intensification in biplanar fashion Once these were satisfactorily placed the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae The Jamshidi needles were then removed A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae This bone was then removed and sent to the lab The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images Once this was completed a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle This was advanced under direct image intensification in a biplanar fashion Once this was deemed satisfactory it was impacted The inner trocar was removed and a guidewire was then placed An injection cannula was then placed over the guidewire into the body of T7 In a similar fashion T9 was dressed on the left side as well A guidewire was then placed through the Jamshidi needle which was verified in both AP and lateral images The cement injection cannula was then placed over this entering the T9 vertebrae body Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae The balloons were inserted bilaterally The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg These were allowed to expand and reduce the fracture Once this was completed the balloons were deflated and removed The inner cannulas of all four entrance holes were removed and approximately 1 5 cc of cement was injected in each of the cannulas This was done directly under image intensification Once this was completed additional cement was injected into T9 as there was a larger vertebra The cement was allowed to cure The cannula was removed and final radiographs were obtained The stab incisions were then cleansed with water and antibiotic irrigation The wounds were then approximated with 4 0 Nylon in interrupted fashion Compression dressings were applied and fixed with tape She was aroused and moved to her inpatient bed She was moving all four extremities without deficit She had no significant pain Keywords orthopedic pathologic insufficiency vertebrae fracture fracture reduction vertebroplasties kyphoplasty prosthetic device jamshidi needles insertion prosthetic MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee with medial meniscoplasty Internal derangement left knee Displaced bucket handle tear of medial meniscus left knee Medical Specialty Orthopedic Sample Name Knee Arthroscopy Medial Meniscoplasty Transcription PREOPERATIVE DIAGNOSIS Internal derangement left knee POSTOPERATIVE DIAGNOSIS Internal derangement left knee PROCEDURE PERFORMED Arthroscopy of the left knee with medial meniscoplasty ANESTHESIA LMA GROSS FINDINGS Displaced bucket handle tear of medial meniscus left knee PROCEDURE After informed consent was obtained the patient was taken to ABCD General Hospital Operating Room 1 where anesthesia was administered by the Department of Anesthesiology The patient was then transferred to the operating room table in supine position with Johnson knee holder well padded Tourniquet was placed around the left upper thigh The limb was then prepped and draped in usual sterile fashion Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed Patellofemoral joint showed frequent chondromalacia Examination of the medial compartment showed a displaced bucket handle tear of the medial meniscus involving the entire posterior parietal and portion of his anterior portion of the medial meniscus The medial femoral condyle and medial tibial plateau were unaffected Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus The femoral condyle and tibial plateau were all stable to probing Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors A shaver was then used to smooth all the edges until the margins were stable to probing The knee was then flushed with normal saline and suctioned dry 20 cc of 0 25 Marcaine was injected into the knee and into the arthroscopy portals A dressing consisting of Adaptic 4x4s ABDs and Webril were applied followed by a TED hose The patient was then transferred to the recovery room in stable condition Keywords orthopedic arthroscopy meniscoplasty derangement internal derangement knee displaced bucket handle tear femoral condyle tibial plateau medial meniscoplasty medial meniscus medial MEDICAL_TRANSCRIPTION,Description Right knee injury suggestive of a recurrent anterior cruciate ligament tear possible internal derangement While playing tennis she had a non contact injury in which she injured the right knee She had immediate pain and swelling Medical Specialty Orthopedic Sample Name Knee Injury Transcription HISTORY OF PRESENT ILLNESS The patient is an 18 year old girl brought in by her father today for evaluation of a right knee injury She states that approximately 3 days ago while playing tennis she had a non contact injury in which she injured the right knee She had immediate pain and swelling At this time she complains of pain and instability in the knee The patient s past medical history is significant for having had an ACL injury to the knee in 2008 She underwent anterior cruciate ligament reconstruction by Dr X at that time subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently she sought attention from Dr Y who performed a revision ACL reconstruction at the end of 2008 The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury PAST MEDICAL HISTORY She claims no chronic illnesses PAST SURGICAL HISTORY She had an anterior cruciate ligament reconstruction in 03 2008 and subsequently had a revision ACL reconstruction in 12 2008 She has also had arm surgery when she was 6 years old MEDICATIONS She takes no medications on a regular basis ALLERGIES She is allergic to Keflex and has skin sensitivity to Steri Strips SOCIAL HISTORY The patient is single She is a full time student at University Uses no tobacco alcohol or illicit drugs She exercises weekly mainly tennis and swelling REVIEW OF SYSTEMS Significant for recent weight gain occasional skin rashes The remainder of her systems negative PHYSICAL EXAMINATION GENERAL The patient is 4 foot 10 inches tall weighs 110 pounds EXTREMITIES She ambulates with some difficulty with a marked limp on the right side Inspection of the knee reveals a significant effusion in the knee She has difficulty with passive range of motion of the knee secondary to pain She does have tenderness to palpation at the medial joint line and has a positive Lachman s exam NEUROVASCULAR She is neurovascularly intact IMPRESSION Right knee injury suggestive of a recurrent anterior cruciate ligament tear possible internal derangement PLAN The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft In the meantime she will continue to use ice as needed Moderate her activities and use crutches She will follow up as soon as the MRI is performed Keywords orthopedic acl graft acl reconstruction knee anterior cruciate ligament internal derangement contact injury knee injury injury cruciate acl anterior MEDICAL_TRANSCRIPTION,Description Left knee arthroscopy with lateral capsular release Medical Specialty Orthopedic Sample Name Knee Arthroscopy Transcription PREOPERATIVE DIAGNOSIS Left patellar chondromalacia POSTOPERATIVE DIAGNOSIS Left patellar chondromalacia with tight lateral structures PROCEDURE Left knee arthroscopy with lateral capsular release ANESTHESIA Surgery performed under general anesthesia TOURNIQUET TIME 47 minutes MEDICATION The patient received 0 5 Marcaine local anesthetic 32 mL COMPLICATIONS No intraoperative complications DRAINS AND SPECIMENS None HISTORY AND PHYSICAL The patient is a 14 year old girl who started having left knee pain in the fall of 2007 She was not seen in Orthopedic Clinic until November 2007 The patient had an outside MRI performed that demonstrated left patellar chondromalacia only The patient was referred to physical therapy for patellar tracking exercises She was also given a brace The patient reported increasing pain with physical therapy and mother strongly desired other treatment It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy Her failure with nonoperative treatment is below the standard 6 month trial however given her symptoms and severe pain lateral capsular release was offered Risk and benefits of surgery were discussed Risks of surgery including risk of anesthesia infection bleeding changes in sensation and motion extremity failure of procedure to relieve pain need for postoperative rehab and significant postoperative swelling All questions were answered and mother and daughter agreed to the above plans PROCEDURE NOTE The patient was taken to the operating room and placed on the operating table General anesthesia was then administered The patient received Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of left thigh The extremity was then prepped and draped in the standard surgical fashion A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Esmarch was then removed Incisions were then made Camera was initially inserted into the lateral joint line Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation The patient did have congruent articulation about 30 degrees of knee flexion Visualization of the medial joint line revealed no loose bodies There was a small plica Visualization of the medial joint line revealed no significant chondromalacia Menisci was probed and tested with no signs of tears and instability ACL was noted to be intact The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology Lateral gutter also demonstrated no loose bodies or plica The camera was then removed and inserted into the anteromedial portal using two 18 gauge needles The extent of lateral capsular release was marked using a monopolar coblator lateral capsular release was performed The patient had significant improvement in anteromedial translation from 25 to 50 At the end of the case all instruments were removed The knee was injected with 32 mL of 0 5 Marcaine with additional epinephrine Please note the patient received 30 mL of 1 500 000 dilution epinephrine at the beginning of the case The portals were then closed using 4 0 Monocryl The wound was clean and dry and dressed with Steri Strips Xeroform and 4 x 4s The kneecap was translated medially under pressure and a bias placed The tourniquet was released at 47 minutes The patient was then placed in the knee immobilizer The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition POSTOPERATIVE PLAN The patient will weightbear as tolerated in the knee immobilizer She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening Intraoperative findings were relayed to the mother All questions were answered Keywords orthopedic knee arthroscopy lateral capsular release chondromalacia patellar lateral joint line medial joint line lateral joint medial joint capsular release joint line arthroscopy tourniquet knee MEDICAL_TRANSCRIPTION,Description Arthroscopic procedure of the knee Medical Specialty Orthopedic Sample Name Knee Arthroscopy 1 Transcription PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed in the operating room table in supine position and given general anesthetic Ancef 1 g was given for infectious prophylaxis Once the patient was under general anesthesia the knee was prepped and draped in usual sterile fashion Once the knee was fully prepped and draped then we made 2 standard portals medial and lateral Through the lateral portal the camera was placed Through the medial portal tools were placed We proceeded to examine scarring of the patellofemoral joint Then we probed the patellofemoral joint A chondroplasty was performed using a shaver Then we moved down to the lateral gutter Some loose bodies were found using a shaver and dissection We moved down the medial gutter No plica was found We moved into the medial joint we found that the medial meniscus was intact We moved to the lateral joint and found that the lateral meniscus was intact Pictures were taken We drained the knee and washed out the knee with copious amounts of sterile saline solution The instruments were removed The 2 portals were closed using 3 0 nylon suture Xeroform 4 x 4s Kerlix x2 and TED stocking were placed The patient was successfully extubated and brought to the recovery room in stable condition I then spoke with the family going over the case postoperative instructions and followup care Keywords orthopedic chondroplasty knee meniscus patellofemoral arthroscopy portals jointNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Painful right knee status post total knee arthroplasty many years ago Status post poly exchange right knee total knee arthroplasty Medical Specialty Orthopedic Sample Name Knee Arthroplasty Discharge Summary Transcription ADMISSION DIAGNOSIS Painful right knee status post total knee arthroplasty many years ago The patient had gradual onset of worsening soreness and pain in this knee X ray showed that the poly seems to be worn out significantly in this area DISCHARGE DIAGNOSIS Status post poly exchange right knee total knee arthroplasty CONDITION ON DISCHARGE Stable PROCEDURES PERFORMED Poly exchange total knee right CONSULTATIONS Anesthesia managed femoral nerve block on the patient HOSPITAL COURSE The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components The patient recovered well after this Working with PT she was able to ambulate with minimal assistance Nerve block was removed by anesthesia The patient did well on oral pain medications The patient was discharged home She is actually going to home with her son who will be able to assist her and look after her for anything she might need The patient is comfortable with this understands the therapy regimen and is very satisfied after the procedure DISCHARGE INSTRUCTIONS AND MEDICATIONS The patient is to be discharged home to the care of the son Diet is regular Activity weight bear as tolerated right lower extremity Continue to do physical therapy exercises The patient will be discharged home on Coumadin 4 mg a day as the INR was 1 9 on discharge with twice weekly lab checks Vicodin 5 500 mg take one to two tablets p o q 4 6h Resume home medications Call the office or return to the emergency room for any concerns including increased redness swelling drainage fever or any concerns regarding operation or site of incision The patient is to follow up with Dr ABC in two weeks Keywords orthopedic painful right knee total knee arthroplasty poly exchange femoral nerve block patellar tibial poly knee arthroplasty knee arthroplasty MEDICAL_TRANSCRIPTION,Description Revision right total knee arthroplasty Right failed total knee arthroplasty Medical Specialty Orthopedic Sample Name Knee Arthroplasty Revision Transcription PREOPERATIVE DIAGNOSIS Right failed total knee arthroplasty POSTOPERATIVE DIAGNOSIS Right failed total knee arthroplasty PROCEDURE PERFORMED Revision right total knee arthroplasty FIRST ANESTHESIA Spinal ESTIMATED BLOOD LOSS Approximately 75 cc TOURNIQUET TIME 123 minutes Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes COMPONENTS A Zimmer NexGen Legacy knee size D right stemmed femoral component was used A NexGen femoral component with a distal femoral augmented block size 5 mm A NexGen tibial component size 3 mm was used A size 14 mm constrained polyethylene surface was used as well Original patellar component that the patient had was maintained COMPLICATIONS None BRIEF HISTORY The patient is a 68 year old female with a history of knee pain for 13 years She had previous total knee arthroplasty and revision at an outside facility She had continued pain snapping malalignment difficulty with ambulation and giving away and wished to undergo additional revision surgery PROCEDURE The patient was taken to the operative suite and placed on the operating table Department of Anesthesia administered the spinal anesthetic Once adequately anesthetized the patient was placed in a supine position Care was ensured and she was adequately secured and well padded in position Once this was obtained the right lower extremity was prepped and draped in the usual sterile fashion Tourniquet was inflated to approximately 325 mmHg on the right thigh At this point an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface There was noted to be no evidence of purulence or gross clinical appearance of infection however intraoperative cultures were taken to asses this as well At this point the previous articular surface was then removed using an osteotome until this was left free and then removed This was done without difficulty Attention was then directed removing the femoral component Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed After this was performed attention was then directed to the tibial component An osteotome was again inserted around the surface and this was easily pried loose There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation This was evaluated The bone stalk appeared to be adequate however there were noted to be some deficits where we need to trim cement so we elected to proceed with stemmed component The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component At this point the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12 At this point the distal femoral cutting guide based on the intramedullary head was then placed Care was ensured that this was aligned in proper rotation with the external epicondylar axis Once this was pinned in position approximately a six degree valgus cut was then made This allowed a portion of the medial condyle to be removed distally The anterior cut was checked next using the intramedullary guide The anterior surface cutting block was then placed This aligned us to anterior cutting block We ensured again that rotation was aligned with the epicondylar axis Once this was adequately aligned with this and gave us some external rotation this was pinned in position and new anterior cut was made It was noted that minimal bone was taken off the surface only a slight portion on the medial anterior surface _______ was then removed and the chamfer cutting guide was then placed on This allowed us to make a box cut and recut some of the angled cuts of the distal femur Once this was placed and pinned in position Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut It was noted that the anterior chamfers did not need to be cut take off no bone The posterior chamfers did remove some bony aspects This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component After all these cuts were taken the guides were then removed and the trial component with a medial 5 mm augment was then placed This appeared to have an adequate fit and then packed in position It appeared to be satisfactory At this point this was removed and attention was then directed to the tibia The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained At this point the intramedullary guide was used to evaluate a tibial cut This appeared to be adequate however we elected to remove 2 mm of bone to give us a new fresh bony surface The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod which allowed us to ensure that we had proper external rotation of this tibial component At this point this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component This was placed in a proper position A 10 mm articular surface was placed in the knee and this was taken through range of motion This was found to have better alignment and satisfactory position We elected to take an intraoperative x ray at this point to evaluate our cut The intraoperative x ray demonstrates satisfactory cuts and alignment of the prosthesis At this point all trials were removed The patella was then examined The rongeur was used to remove the surrounding synovium The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt however this was very mild and overall had a good position and was well fixed to the bone It was elected at this time to maintain this anatomic patella that was previously placed At this point the joint again was reevaluated and any bone loose fragments removed There was noted to be some posterior tightness and mild osteophytes These were removed with a rongeur At this time while preparing the canals the tourniquet was deflated due to it being 123 minutes Approximately 10 minutes did get by as the knee was copiously irrigated and suctioned dried The tourniquet was then reinflated The canals were prepped for cementing They were suction dried and cleaned The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial Once this was fixed and secured all extra cement was removed and attention was directed to the femoral component The stemmed femoral component was then impacted in position and cemented Again care was ensured that it was in adequate position and proper rotation A size 14 mm poly was then inserted in between to provide compression This was then taken through extension and held until cement cured This was then removed and the components were evaluated All excess cement was removed and they were well fixed Size 14 mm trial Poly was then placed and this was taken through range of motion This was found to have excellent range of motion and good stability It was elected at this time that we would go with the size 14 mm Poly This gave us extra Poly for ware and then provide excellent contact throughout the range of motion The final articular surface was then placed and tightened into position to allow to _______ secured The knee was then reduced and the knee was taken through range of motion The patella was tracking with no touch technique and adequately positioned At this point the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry All bleeding was cauterized using a Bovie cautery The retinaculum was then repaired using 1 Ethibond in a figure of eight fashion This was reinforced with a running 2 0 Vicryl The knee was then flexed and noted that the patella was tracking with good alignment The wound was again copiously irrigated and suctioned dry A drain was placed prior to retinaculum repair deep to this to provide adequate drainage At this point the subcutaneous tissue was closed with 2 0 Vicryl Skin was approximated with skin clips Sterile dressing of Adaptic 4x4 Webril and ABDs were then placed A large Dupre dressing was then placed up the entire lower extremity The patient was then transferred back to recovery in supine position DISPOSITION The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition Keywords orthopedic knee arthroplasty revision zimmer nexgen distal femoral intramedullary guide femoral component femoral knee arthroplasty intramedullary patellar medial tibial MEDICAL_TRANSCRIPTION,Description Left below the knee amputation Dressing change right foot Medical Specialty Orthopedic Sample Name Knee Amputation Transcription PREOPERATIVE DIAGNOSES 1 Left diabetic foot abscess and infection 2 Left calcaneus fracture with infection 3 Right first ray amputation POSTOP DIAGNOSES 1 Left diabetic foot abscess and infection 2 Left calcaneus fracture with infection 3 Right first ray amputation OPERATION AND PROCEDURE 1 Left below the knee amputation 2 Dressing change right foot ANESTHESIA General BLOOD LOSS Less than 100 mL TOURNIQUET TIME 24 minutes on the left 300 mmHg COMPLICATIONS None DRAINS A one eighth inch Hemovac INDICATIONS FOR SURGERY The patient is a 62 years of age with diabetes He developed left heel abscess He had previous debridements developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads After re inspecting the wound last week the plan was for possible debridement and he desired below the knee amputation We are going to change the dressing on the right side also The risks benefits and alternatives of surgery were discussed The risks of bleeding infection damage to nerves and blood vessels persistent wound healing problems and the need for future surgery He understood all the risks and desired operative treatment OPERATIVE PROCEDURE IN DETAIL After appropriate informed consent obtained the patient was taken to the operating room and placed in the supine position General anesthesia induced Once adequate anesthesia had been achieved cast padding placed on the left proximal thigh and tourniquet was applied The right leg was redressed I took the dressing down There was a small bit of central drainage but it was healing nicely Adaptic and new sterile dressings were applied The left lower extremity was then prepped and draped in usual sterile fashion A transverse incision made about the mid shaft of the tibia A long posterior flap was created It was taken to the subcutaneous tissues with electrocautery Please note that tourniquet had been inflated after exsanguination of the limb Superficial peroneal nerve identified clamped and cut Anterior compartment was divided The anterior neurovascular bundle identified clamped and cut The plane was taken between the deep and superficial compartments The superficial compartment was reflected posteriorly Tibial nerve identified clamped and cut Tibial vessels identified clamped and cut Periosteum of the tibia elevated proximally along with the fibula The tibia was then cut with Gigli saw It was beveled anteriorly and smoothed down with a rasp The fibula was cut about a cm and a half proximal to this using a large bone cutter The remaining posterior compartment was divided The peroneal bundle identified clamped and cut The leg was then passed off of the field Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie The nerves were each pulled at length injected with 0 25 Marcaine with epinephrine cut and later retracted proximally The tourniquet was released Good bleeding from the tissues and hemostasis obtained with electrocautery Copious irrigation performed using antibiotic impregnated solution A one eighth inch Hemovac drain placed in the depth of wound adhering on the medial side A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with 1 Vicryl in an interrupted fashion The remaining fascia was closed with 1 Vicryl Subcutaneous tissues were then closed with 2 0 PDS suture using 2 0 Monocryl suture in interrupted fashion Skin closed with skin staples Xeroform gauze 4 x 4 and a padded soft dressing applied He was placed in a well padded anterior and posterior slab splint with the knee in extension He was then awakened extubated and taken to recovery in stable condition There were no immediate operative complications and he tolerated the procedure well Keywords orthopedic infection adaptic gigli saw hemovac abscess amputation below the knee amputation calcaneus fracture debridement diabetic foot ray amputation tourniquet transverse incision knee amputation knee dressing clamped MEDICAL_TRANSCRIPTION,Description A 66 year old female with knee osteoarthrosis who failed conservative management Medical Specialty Orthopedic Sample Name Knee Osteoarthrosis Discharge Summary Transcription PRINCIPAL DIAGNOSIS Knee osteoarthrosis PRINCIPAL PROCEDURE Total knee arthroplasty HISTORY AND PHYSICAL A 66 year old female with knee osteoarthrosis Failed conservative management Risks and benefits of different treatment options were explained Informed consent was obtained PAST SURGICAL HISTORY Right knee surgery cosmetic surgery and carotid sinus surgery MEDICATIONS Mirapex ibuprofen and Ambien ALLERGIES QUESTIONABLE PENICILLIN ALLERGIES PHYSICAL EXAMINATION GENERAL Female who appears younger than her stated age Examination of her gait reveals she walks without assistive devices HEENT Normocephalic and atraumatic CHEST Clear to auscultation CARDIOVASCULAR Regular rate and rhythm ABDOMEN Soft EXTREMITIES Grossly neurovascularly intact HOSPITAL COURSE The patient was taken to the operating room OR on 03 15 2007 She underwent right total knee arthroplasty She tolerated this well She was taken to the recovery room After uneventful recovery room course she was brought to regular surgical floor Mechanical and chemical deep venous thrombosis DVT prophylaxis were initiated Routine postoperative antibiotics were administered Hemovac drain was discontinued on postoperative day 2 Physical therapy was initiated Continuous passive motion CPM was also initiated She was able to spontaneously void She transferred to oral pain medication Incision remained clean dry and intact during the hospital course No pain with calf squeeze She was felt to be ready for discharge home on 03 19 2007 DISPOSITION Discharged to home FOLLOW UP Follow up with Dr X in one week Prescriptions were written for Percocet and Coumadin INSTRUCTIONS Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing Keywords orthopedic total knee arthroplasty conservative management knee arthroplasty physical therapy knee osteoarthrosis arthroplasty osteoarthrosis knee MEDICAL_TRANSCRIPTION,Description Bilateral degenerative arthritis of the knees Right total knee arthroplasty done in conjunction with a left total knee arthroplasty which will be dictated separately Medical Specialty Orthopedic Sample Name Knee Arthroplasty Transcription PREOPERATIVE DIAGNOSIS Bilateral degenerative arthritis of the knees POSTOPERATIVE DIAGNOSIS Bilateral degenerative arthritis of the knees PROCEDURE PERFORMED Right total knee arthroplasty done in conjunction with a left total knee arthroplasty which will be dictated separately ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Bilateral procedure was 400 cc TOTAL TOURNIQUET TIME 75 minutes COMPONENTS Include the Zimmer NexGen complete knee solution system which include a size F right cruciate retaining femoral component a size 8 peg tibial component precoat a All Poly standard size 38 9 5 mm thickness patellar component and a prolonged highly cross linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height HISTORY OF PRESENT ILLNESS The patient is a 69 year old male who presented to the office complaining of bilateral knee pain for a couple of years The patient complained of clicking noises and stiffness which affected his daily activities of living PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedure was discussed at length the patient s informed consent was obtained Operative extremities were then confirmed with the operating surgeons as well as the nursing staff Department of Anesthesia and the patient The patient was then transferred to preoperative area to operative suite 2 and placed on the operating room table in supine position All bony prominences were well padded at this time At this time Department of Anesthesia administered general anesthetic to the patient The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left The nonsterile tourniquet was then applied to the right upper thigh of the patient but not inflated at this time The right lower extremity was sterilely prepped and draped in the usual sterile fashion The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg The patient was a consideration for a unicompartmental knee replacement So after all bony and soft tissue landmarks were identified a limited midline longitudinal incision was made directly over the patella A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon Next a medial parapatellar arthrotomy was performed using the 10 blade scalpel Upon viewing of the articular surfaces there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement At this time the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion Total incision now measured approximately 25 cm Retractors were placed Next attention was directed to establishing medial and lateral flaps of the proximal tibia Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia At this time the patella was then everted The knee was flexed up to 90 degrees Next using the large drill bit the femoral canal was then opened in appropriate position The intramedullary sizing guide was then placed and the knee was sized to a size F At this time the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline The guide was then removed The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation Next the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed Next soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut Upon checking it was noted to be flat with no oscillations The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus It was secured in place using nails The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws Again the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well The distal finishing guide was then removed and osteotome was then used to remove all resected bone The oscillating saw was then used to complete the femoral notch cut Upon viewing there appeared to be proper amount of bony resection and all bone was removed completely There was no posterior osteophytes noted and no fragments to the posterior aspect Next attention was directed towards the tibia The external tibial guide was reflected This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia Next collateral ligament retractors were placed as well as McGill retractors for the PCL Oscillating saw was then used to make the proximal tibial cut Osteotome was used to remove this excess resected bone The laminar spreader was then used to check the flexion and extension The gaps appeared to be equal The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray The knee was taken through range of motion and had very good flexion as well as full extension There appeared to be good varus and valgus stability as well Next attention was directed towards the patella There noted to be a sufficient ware and it was selected to replace the patella It was sized with caliper pre cut and noted to be 26 mm depth The sizing guide was then used and a size 51 resection guide selected A 51 mm reamer was then placed and sufficient amount of patella was then removed The calcar was then used to check again and there was noted to be 15 mm remaining The 38 mm patella guide was then placed on the patella It was noted to be in proper size and the three drill holes for the pegs were used A trial component was then placed The knee was taken through range of motion There was noted to be some subluxation lateral to the patellar component and a lateral release was performed After this the component appeared to be tracking very well There remained a good range of motion in the knee and extension as well as flexion At this time an AP x ray of the knee was taken with the trial components in place Upon viewing this x ray it appeared that the tibial cut was in neutral all components in proper positioning The knee was then copiously irrigated and dried The knee was then flexed ___________ placed and the peg drill guide was placed on the tibia in proper position held in place with nails The four peg holes were then drilled The knee again was copiously irrigated and suction dried The final components were then selected again consisting of size F femoral components A peg size 8 tibial component a 12 mm height articular surface size blue and a 38 mm 9 5 mm thickness All Poly patella Polymethyl methacrylate was then prepared at this time The proximal tibia was dried and the cement was then pressed into place The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning Next the proximal femur was cleaned and dried Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components This was then impacted in place as well At this time all excess cement was removed from both the tibial and femoral components A size 12 mm trial tibial articular surface was then put in place The knee was reduced and held in loading position throughout the remaining drying position of the cement Next the resected patella was cleaned and dried The cement was placed on the patella as well as the backside of the patellar component The component was then put in proper positioning and held in place with a clamp All excess polymethyl methacrylate was removed from this area as well This was held until the cement had hardened sufficiently Next the knee was examined All excess cement was then removed The knee was taken through range of motion with sufficient range of motion as well as stability The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position Again range of motion was noted to be sufficient The knee was copiously irrigated and suction dried once again A drain was then placed within the knee The wound was then closed first using 1 Ethibond to close the arthrotomy oversewn with a 1 Vicryl The knee was again copiously irrigated and dried The skin was closed using 2 0 Vicryl in subcuticular fashion followed by staples on the skin The ConstaVac was then _______ to the drain Sterile dressing was applied consisting of Adaptic 4x4 ABDs Kerlix and a 6 inch Dupre roll from foot to thigh Department of Anesthesia then reversed the anesthetic The patient was transferred back to the hospital gurney to Postanesthesia Care Unit The patient tolerated the procedure well and there were no complications Keywords orthopedic degenerative arthritis zimmer nexgen all poly cruciate patellar component total knee arthroplasty knee arthroplasty tibial component femoral patellar tibial knee arthroplasty anesthesia MEDICAL_TRANSCRIPTION,Description Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail Left tibial shaft fracture status post gunshot wound Medical Specialty Orthopedic Sample Name Intramedullary Nail Fixation Transcription TITLE OF OPERATION Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail 10 x 390 with a one 5 mm proximal locking screw and three 5 mm distal locking screws CPT code is 27759 the ICD 9 code again is 823 2 for a tibial shaft fracture INDICATION FOR SURGERY The patient is a 19 year old male who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture The patient was admitted and splinted and had compartment checks The risks of surgery were discussed in detail including but not limited to infection bleeding injuries to nerves or vital structures nonunion or malunion need for reoperation compartment syndrome and the risk of anesthesia The patient understood these risks and wished to proceed PREOP DIAGNOSIS Left tibial shaft fracture status post gunshot wound CPT code 27759 POSTOP DIAGNOSIS Left tibial shaft fracture status post gunshot wound CPT code 27759 ANESTHESIA General endotracheal INTRAVENOUS FLUID 900 ESTIMATED BLOOD LOSS 100 COMPLICATIONS None DISPOSITION Stable to PACU PROCEDURE DETAIL The patient was met in the preoperative holding area and operative site was marked The patient was brought to the operating room and given preoperative antibiotics Left leg was then prepped and draped in the usual sterile fashion A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue The starting guidewire was used to localize the correct starting point which is on the medial aspect of the lateral tibial eminence This was advanced and confirmed on the AP and lateral fluoroscopic images The opening reamer was then used and the ball tip guidewire was passed The reduction was obtained over a large radiolucent triangle After passing the guidewire and achieving appropriate reduction the flexible reamers were then sequentially passed starting at 9 mm up to 11 5 mm reamer At this point a 10 x 390 mm was passed without difficulty The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws The final images were taken with fluoroscopy and a 15 mm end cap was placed The wounds were then irrigated and closed with 2 0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2 0 Vicryl and staples to the proximal incision The patient was placed in a short leg well padded splint was awakened and taken to recovery in good condition The plan will be nonweightbearing left lower extremity He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks Keywords orthopedic screw stryker tibia intramedullary nail fixation tibial shaft fracture intramedullary guidewire nail fracture tibial MEDICAL_TRANSCRIPTION,Description Displaced left subtrochanteric femur fracture Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85 mm helical blade Medical Specialty Orthopedic Sample Name Intramedullary Rod Transcription PREOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture POSTOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture OPERATION Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85 mm helical blade COMPLICATIONS None TOURNIQUET TIME None ESTIMATED BLOOD LOSS 50 mL ANESTHESIA General INDICATIONS The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities She was diagnosed with displaced left subcapital hip fracture now was asked to consult With this diagnosis she was indicated the above noted procedure This procedure as well as alternatives to this procedure was discussed at length with the patient and her son who has the power of attorney and they understood them well Risks and benefits were also discussed Risks include bleeding infection damage to blood vessels damage to nerves risk of further surgery chronic pain restricted range of motion risk of continued discomfort risk of malunion risk of nonunion risk of need for further reconstructive procedures risk of need for altered activities and altered gait risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed She understood these well and consented and the son signed the consent for the procedure as described DESCRIPTION OF PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment External positions were felt to be present At this point the left hip and left lower extremity was then prepped and draped in the usual sterile manner A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire An overlying drill was inserted to the proper depths A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth Proper rotation was obtained and the guide for the helical blade was inserted A small incision was made for this as well A guidewire was inserted and felt to be in proper position in the posterior aspect of the femoral head lateral and the center position on AP This placed the proper depths and lengths better The outer cortex was enlarged and an 85 mm helical blade was attached to the proper depths and proper fixation was done Appropriate size screw was then tightened down At this point a distal guide was then placed and drilled across both the cortices Length was better Appropriate size screw was then inserted Proper size and fit of the distal screw was also noted At this point on fluoroscopic control it was confirming in AP and lateral direction We did a near anatomical alignment to the fracture site and all hardware was properly fixed Proper size and fit was noted Excellent bony approximation was noted At this point both wounds were thoroughly irrigated hemostasis confirmed and closure was then begun The fascial layers were then reapproximated using 1 Vicryl in a figure of eight manner the subcutaneous tissues were reapproximated in layers using 1 and 2 0 Vicryl sutures and the skin was reapproximated with staples The area was then infiltrated with a mixture of a 0 25 Marcaine with Epinephrine and 1 plain lidocaine Sterile dressing was then applied No complication was encountered throughout the procedure The patient tolerated the procedure well The patient was taken to the recovery room in stable condition Keywords orthopedic displaced femur fracture subtrochanteric hip synthes intramedullary rod subtrochanteric femur trochanteric fixation helical blade tourniquet intramedullary trochanteric fixation helical blade guidewire fracture MEDICAL_TRANSCRIPTION,Description Bilateral knee degenerative arthritis Bilateral knee arthroplasty The Zimmer NexGen total knee system was utilized Medical Specialty Orthopedic Sample Name Knee Arthroplasty Bilateral Transcription PREOPERATIVE DIAGNOSIS Bilateral knee degenerative arthritis POSTOPERATIVE DIAGNOSIS Bilateral knee degenerative arthritis PROCEDURE PERFORMED Bilateral knee arthroplasty Please note this procedure was done by Dr X for the left total knee and Dr Y for the right total knee This operative note will discuss the right total knee arthroplasty ANESTHESIA General COMPLICATIONS None BLOOD LOSS Approximately 150 cc HISTORY This is a 79 year old female who has disabling bilateral knee degenerative arthritis She has been unresponsive to conservative measures All risks complications anticipated benefits and postoperative course were discussed The patient has agreed to proceed with surgery as described below GROSS FINDINGS There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis SPECIFICATIONS The Zimmer NexGen total knee system was utilized PROCEDURE The patient was taken to the operating room 2 and placed in supine position on the operating room table She was administered spinal anesthetic by Dr Z The tourniquet was placed about the proximal aspect of the right lower extremity The right lower extremity was then sterilely prepped and draped in the usual fashion An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg Longitudinal incision was made over the anterior aspect of the right knee Subcutaneous tissue was carefully dissected A medial parapatellar retinacular incision was made The patella was then everted and the above noted gross findings were appreciated A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place The appropriate cuts were made at the distal femur as well as with use of the chamfer guide The trial femoral component was then positioned in place and noted to have good fit Attention was then directed to proximal tibia the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments The remnants of the anterior cruciate ligament and menisci were resected The tibial trial was positioned in place Intraoperative radiographs were taken demonstrating satisfactory alignment of the tibial cut The tibial holes were then drilled The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate The knee was placed through range of motion with the trial components marked and then the appropriate components obtained The tibial tray was inserted with cement backed it into place excess methylmethacrylate was removed The femoral component was inserted with methylmethacrylate Any excessive methylmethacrylate and bony debris were removed from the joint Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm The methylmethacrylate was also used at the patella The prosthesis was positioned in place The patellar clamp held securely till the methylmethacrylate was firm After all three components were in place the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment This component was removed and revised to a stemmed component with better alignment and position The previous component removed the methylmethacrylate was removed Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached The trial tibial stemmed component was positioned in place Knee was placed through range of motion and the tracking was better Actual component was then obtained methyl methacrylate was placed within the tibia The stemmed tibial component was impacted into place with good fit The Poly was then positioned in place Knee held in full extension with compression longitudinally after methylmethacrylate was solidified The trial Poly was removed Wound was irrigated and the joint was inspected There was no debris Collateral ligaments and posterior cruciate ligaments remained intact Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component The tourniquet was deflated Hemostasis was satisfactory A drain was placed into the depths of the wound The medial retinacular incision was closed with one Ethibond suture in interrupted fashion The knee was placed through range of motion and there was no undue tissue tension good patellar tracking no excessive soft tissue laxity or constrain The subcutaneous tissue was closed with 2 0 undyed Vicryl in interrupted fashion The skin was closed with surgical clips The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity At the completion of the procedure distal pulses were intact Toes were pink warm with good capillary refill Distal neurovascular status was intact Postoperative x ray demonstrated satisfactory alignment of the prosthesis Prognosis is good in this 79 year old female with a significant degenerative arthritis Keywords orthopedic patellofemoral eburnation osteophyte articulation tibial femoral bilateral knee arthroplasty knee degenerative arthritis zimmer nexgen lower extremity arthroplasty patella methylmethacrylate MEDICAL_TRANSCRIPTION,Description Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening Irrigation and debridement of skin subcutaneous tissues muscle and bone right forearm Open reduction right both bone forearm fracture with placement of long arm cast Medical Specialty Orthopedic Sample Name I D Open Reduction Forearm Transcription PREOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening POSTOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid shaft radius and ulna with complete displacement and shortening OPERATIONS 1 Irrigation and debridement of skin subcutaneous tissues muscle and bone right forearm 2 Open reduction right both bone forearm fracture with placement of long arm cast COMPLICATIONS None TOURNIQUET None ESTIMATED BLOOD LOSS 25 mL ANESTHESIA General INDICATIONS The patient suffered injury at which time he fell over a concrete bench He landed mostly on the right arm He noted some bleeding at the time of the injury and a small puncture wound He was taken to the emergency room and diagnosed a compound both bone forearm fracture and based on this he was seen for malalignment He was indicated the above noted procedure This procedure as well as alternatives of this procedure was discussed at length with the patient s parents and they understood them well Risks and benefits were also discussed Risks such as bleeding infection damage to blood vessels damage to nerve roots need for further surgeries chronic pain on full range of motion risk of continued discomfort risk of need for repeat debridement risk of need for internal fixation risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed They understood these well All questions were answered and they signed the consent for procedure as described DESCRIPTION OF PROCEDURE The patient was placed on the operating table and general anesthesia was achieved The right forearm was inspected There was noted to be a 3 mm puncture type wound over the volar aspect of the forearm in the middle one third overlying the radial one half There was bleeding in this region No gross contamination was seen At this point under fluoroscopic control I did attempt to see a fracture I was unable to do the forearm under the close reduction techniques At this point the right upper extremity was then prepped and draped in the usual sterile manner An incision was made through the puncture wound site extending this proximally and distally There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed I also did perform a light debridement of the nonviable subcutaneous tissue muscle and small bony fragments were also removed These were all completely debrided appropriately and then at this point a thorough irrigation was performed of the radius which I communicated through the puncture wound Both ends were clearly visualized and thorough irrigation was performed using total of 6 L of antibiotic solution All nonviable gross contaminated tissue was removed At this point with the bones in direct visualization I did reduce the bony ends to anatomic alignment with excellent bony approximation Proper alignment of tissue and angulation was confirmed At this point under fluoroscopic control confirmed the radius and ulna in anatomic position which will be completely displaced and shortened previously The ulna was now also noted to be in anatomic alignment At this point the region was thoroughly irrigated Hemostasis confirmed and closure then begun The skin was reapproximated using 3 0 nylon suture The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1 5 inch Nugauze with iodoform Sterile dressing applied and a long arm cast with the forearm in neutral position was applied X ray with fluoroscopic evaluation was performed which confirmed They maintained excellent bony approximation and the anatomic alignment The long arm cast was then completely mature No complications were encountered throughout the procedure The patient tolerated the procedure well The patient was then taken to the recovery room in stable condition Keywords orthopedic compound fracture mid shaft radius ulna open reduction irrigation and debridement subcutaneous tissues muscle bone forearm radius and ulna forearm fracture anatomic alignment arm cast puncture wound tourniquet i d fracture MEDICAL_TRANSCRIPTION,Description Postoperative wound infection complicated Irrigation and debridement of postoperative wound infection Removal of foreign body Placement of vacuum assisted closure device Medical Specialty Orthopedic Sample Name I D ORIF Wound Transcription TITLE OF OPERATION 1 Irrigation and debridement of postoperative wound infection CPT code 10180 2 Removal of foreign body deep CPT code 28192 3 Placement of vacuum assisted closure device less than 50 centimeter squared CPT code 97605 PREOP DIAGNOSIS Postoperative wound infection complicated ICD 9 code 998 59 POSTOP DIAGNOSIS Postoperative wound infection complicated ICD 9 code 998 59 PROCEDURE DETAIL The patient is a 59 year old gentleman who is status post open reduction and internal fixation of bilateral calcanei He was admitted for a left wound breakdown with drainage He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap The risks of surgery were discussed in detail including but not limited to infection bleeding injuries to nerves and vital structures need for reoperation pain or stiffness arthritis fracture the risk of anesthesia The patient understood these risks and wished to proceed The patient was admitted and the operative site was marked The patient was brought to the operating room and given general anesthetic He was placed in the right lateral decubitus and all bony prominences were well padded An axillary roll was placed A well padded thigh tourniquet was placed on the left leg The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement Left leg was then prepped and draped in usual sterile fashion The previous five antibiotic spacer beads were removed without difficulty The wound was then rongeured and curetted and all bone was cleaned down to healthy bleeding bone The wound actually looked quite good with evidence of purulence or drainage Skin edges appeared to be viable Hardware all looked to be intact At this point the wound was irrigated with 9 liters of bibiotic solution A VAC sponge was then placed over the wound and the patient s leg was placed into a posterior splint The patient was awakened and then taken to recovery in good condition Dr X was present for the timeouts and for all critical portions of the procedure He was immediately available for any questions during the case PLAN 1 A CAM walker boots 2 A VAC change on Sunday by the nurse 3 A flap per Plastic Surgery Keywords orthopedic irrigation and debridement removal of foreign body vacuum assisted closure device foreign body postoperative wound wound infection infection wound orif debridement vacuum MEDICAL_TRANSCRIPTION,Description Persistent left hip pain Left hip avascular necrosis Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing Medical Specialty Orthopedic Sample Name Hip Pain Transcription CHIEF COMPLAINT Keywords orthopedic hip pain radiculopathy degenerative changes avascular necrosis hip resurfacing arthrodesis hip replacement avn MEDICAL_TRANSCRIPTION,Description Incision and drainage and removal of foreign body right foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound Medical Specialty Orthopedic Sample Name I D Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body right foot PROCEDURE PERFORMED 1 Incision and drainage right foot 2 Removal of foreign body right foot HISTORY This 7 year old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot The patient has had previous I D but continues to have to purulent drainage The patient s parents agreed to performing a surgical procedure to further clean the wound PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap General anesthesia was administered by the Department of Anesthesia The foot was then prepped and draped in the usual sterile orthopedic fashion The stockinette was reflected and the foot was cleansed with wet and dry sponge There was noted to be some remaining periwound erythema There was noted to be some mild crepitation about 2 cm proximal from the entry wound The entry wound was noted to be over the third metatarsal head dorsally Upon inspection of the wound there was noted to be hard foreign filling substance deep within the wound The entry site from the foreign body was extended proximally approximately about 0 5 cm At this time a large wooden foreign body was visualized and removed with a straight stat The area was carefully inspected for any remaining piece of foreign body Several small pieces were noted and they were removed The area was palpated and there was no more remaining foreign body noted At this time the wound was inspected thoroughly There was noted to be an area along the third metatarsal head more distally that did probe to the bone There was no purulent drainage expressed Area was flushed with copious amounts of sterile saline Pulse lavage was performed with 3 liters of plain sterile saline Wound cultures were obtained aerobic and aerobic The wound was then again inspected for any remaining foreign body or purulent drainage None was noticed The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s ABDs Kling and Kerlix The patient tolerated the above procedure and anesthesia well without complications The patient was transported to the PACU with vital signs stable and vascular status intact The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry The patient had a postoperative pain prescription written for Tylenol Elixir with codeine as needed Keywords orthopedic incision and drainage removal of foreign body purulent drainage foreign body metatarsal head metatarsal i d incision drainage foot MEDICAL_TRANSCRIPTION,Description Painful ingrown toenail left big toe Removal of an ingrown part of the left big toenail with excision of the nail matrix Medical Specialty Orthopedic Sample Name Ingrown Toenail Removal Transcription PREOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe POSTOPERATIVE DIAGNOSIS Painful ingrown toenail left big toe OPERATION Removal of an ingrown part of the left big toenail with excision of the nail matrix DESCRIPTION OF PROCEDURE After obtaining informed consent the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1 Xylocaine after having been prepped and draped in the usual fashion The ingrown part of the toenail was freed from its bed and removed then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail The matrix was excised down to the bone and then the skin flap was placed over it Hemostasis had been achieved with a cautery A tubular dressing was performed to provide a bulky dressing The patient tolerated the procedure well Estimated blood loss was negligible The patient was sent back to Same Day Surgery for recovery Keywords orthopedic toenail nail matrix ingrown toenail painful ingrown MEDICAL_TRANSCRIPTION,Description Hemiarthroplasty of left shoulder utilizing a global advantage system with an 8 mm cemented humeral stem and 48 x 21 mm modular head replacement Comminuted fracture dislocation left proximal humerus Medical Specialty Orthopedic Sample Name Hemiarthroplasty Shoulder Transcription PREOPERATIVE DIAGNOSIS Comminuted fracture dislocation left proximal humerus POSTOPERATIVE DIAGNOSIS Comminuted fracture dislocation left proximal humerus PROCEDURE PERFORMED Hemiarthroplasty of left shoulder utilizing a global advantage system with an 8 mm cemented humeral stem and 48 x 21 mm modular head replacement PROCEDURE The patient was taken to OR 2 administered general anesthetic He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus The left shoulder and upper extremities were then prepped and draped in the usual manner A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery Hemostasis was achieved with the cautery The deltoid fascia were identified skin flaps were then created The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein The deltoid was then retracted There was marked hematoma and swelling within the subdeltoid bursa This area was removed with rongeurs The biceps tendon was identified which was the landmark for the rotator interval Mayo scissors was utilized to split the remaining portion of the rotator interval The greater tuberosity portion with the rotator cuff was identified Excess bone was removed from the greater tuberosity side to allow for closure later The lesser tuberosity portion with the subscapularis was still attached to the humeral head therefore osteotome was utilized to separate the lesser tuberosity from the humeral head fragment Excess bone was removed from the lesser tuberosity as well Both of these were tagged with Ethibond sutures for later The humeral head was delivered out of the wound It was localized to the area of the anteroinferior glenoid region The glenoid was then inspected and noted to be intact The fracture was at the level of the surgical neck on the proximal humerus The canal was repaired with the broaches An 8 stem was chosen as it was going to be cemented into place The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion Trial reduction was performed The 48 x 21 mm head was the most appropriate size matching the patient s as well as the soft tissue tension on the shoulder At this point the wound was copiously irrigated with gentamycin solution The canal was copiously irrigated as well and suctioned dry Methyl methacrylate cement was mixed The cement gun was filled and the canal was filled with the cement The 8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured Excess cement was removed by sharp dissection Prior to cementation of the stem a hole was drilled in the shaft of proximal humerus and 2 fiber wires were placed through this hole for closure later Once the cement was cured the modular head was impacted on to the Morse taper It was stable and the shoulder was reduced The lesser tuberosity was then reapproximated back to the original site utilizing the 2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing 2 fiber wires as well The rotator interval was closed with 2 fiber wire in an interrupted fashion The biceps tendon was ________ within this closure The wound was copiously irrigated with gentamycin solution suctioned dry The deltoid fascia was then approximated with interrupted 2 0 Vicryl suture Subcutaneous layer was approximated with interrupted 2 0 Vicryl and skin approximated with staples Subcutaneous tissues were infiltrated with 0 25 Marcaine solution A bulky dressing was applied to the wound followed by application of a large arm sling Circulatory status was intact in the extremity at the completion of the case The patient was then transferred to recovery room in apparent satisfactory condition Keywords orthopedic dislocation proximal humerus comminuted fracture rotator interval tuberosity portion hemiarthroplasty fracture wound proximal deltoid rotator stem humeral humerus tuberosity cemented MEDICAL_TRANSCRIPTION,Description Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root Medical Specialty Orthopedic Sample Name Hemilaminotomy Foraminotomy Transcription PRE AND POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy at C5 C6 OPERATION Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root After informed consent was obtained from the patient he was taken to the OR After general anesthesia had been induced Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted At this point the patient s was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position The patient s posterior cervical area was then prepped and draped in the usual sterile fashion At this time the patient s incision site was infiltrated with 1 percent Lidocaine with epinephrine A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes which could be palpated After dissection down to a spinous process using Bovie cautery a clamp was placed on this spinous processes and cross table lateral x ray was taken This showed the spinous process to be at the C4 level Therefore further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified After the muscle was dissected off the lamina laterally on the left side self retaining retractors were placed and after hemostasis was achieved a Penfield probe was placed in the interspace presumed to be C5 6 and another cross table lateral x ray of the C spine was taken This film confirmed our position at C5 6 and therefore the operating microscope was brought onto the field at this time At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur However progress was limited because of thickness of the bone Therefore at this time the Midas Rex drill the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area After the bone had been thinned out further bone was removed using the Kerrison rongeur At this point the nerve root was visually inspected and observed to be decompressed However there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery After hemostasis was achieved the surgical site was copiously irrigated with Bacitracin Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches The subcutaneous layer was then reapproximated using 000 Dexon The skin was reapproximated using a running 000 nylon Sterile dressings were applied The patient was then extubated in the OR and transferred to the Recovery room in stable condition ESTIMATED BLOOD LOSS minimal Keywords orthopedic foraminotomy with medial facetectomy facetectomy for microscopic decompression decompression of nerve root hemilaminotomy and foraminotomy decompression of nerve microscopic decompression medial facetectomy kerrison rongeur nerve root spinous processes facetectomy kerrison hemilaminotomy foraminotomy MEDICAL_TRANSCRIPTION,Description Left hip fracture The patient is a 53 year old female with probable pathological fracture of the left proximal femur Medical Specialty Orthopedic Sample Name Hip Fracture ER Consult Transcription REASON FOR CONSULTATION Left hip fracture HISTORY OF PRESENT ILLNESS The patient is a pleasant 53 year old female with a known history of sciatica apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight History was obtained from the patient As per the history she reported that she has been having back pain with left leg pain since past 4 weeks She has been using a walker for ambulation due to disabling pain in her left thigh and lower back She was seen by her primary care physician and was scheduled to go for MRI yesterday However she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall Since then she was unable to ambulate The patient called paramedics and was brought to the emergency room She denied any history of fall She reported that she stepped the wrong way causing the pain to become worse She is complaining of severe pain in her lower extremity and back pain Denies any tingling or numbness Denies any neurological symptoms Denies any bowel or bladder incontinence X rays were obtained which were remarkable for left hip fracture Orthopedic consultation was called for further evaluation and management On further interview with the patient it is noted that she has a history of malignant melanoma which was diagnosed approximately 4 to 5 years ago She underwent surgery at that time and subsequently she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3 2008 PAST MEDICAL HISTORY Sciatica and melanoma PAST SURGICAL HISTORY As discussed above surgery for melanoma and hysterectomy ALLERGIES NONE SOCIAL HISTORY Denies any tobacco or alcohol use She is divorced with 2 children She lives with her son PHYSICAL EXAMINATION GENERAL The patient is well developed well nourished in mild distress secondary to left lower extremity and back pain MUSCULOSKELETAL Examination of the left lower extremity there is presence of apparent shortening and external rotation deformity Tenderness to palpation is present Leg rolling is positive for severe pain in the left proximal hip Further examination of the spine is incomplete secondary to severe leg pain She is unable to perform a straight leg raising EHL EDL 5 5 2 pulses are present distally Calf is soft and nontender Homans sign is negative Sensation to light touch is intact IMAGING AP view of the hip is reviewed Only 1 limited view is obtained This is a poor quality x ray with a lot of soft tissue shadow This x ray is significant for basicervical type femoral neck fracture Lesser trochanter is intact This is a high intertrochanteric fracture basicervical There is presence of lytic lesion around the femoral neck which is not well delineated on this particular x ray We need to order repeat x rays including AP pelvis femur and knee LABS Have been reviewed ASSESSMENT The patient is a 53 year old female with probable pathological fracture of the left proximal femur DISCUSSION AND PLAN Nature and course of the diagnosis has been discussed with the patient Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma this appears to be a pathological fracture of the left proximal hip At the present time I would recommend obtaining a bone scan and repeat x rays which will include AP pelvis femur hip including knee She denies any pain elsewhere She does have a past history of back pain and sciatica but at the present time this appears to be a metastatic bone lesion with pathological fracture I have discussed the case with Dr X and recommended oncology consultation With the above fracture and presentation she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty cemented type Indication risk and benefits of left hip hemiarthroplasty has been discussed with the patient which includes but not limited to bleeding infection nerve injury blood vessel injury dislocation early and late persistent pain leg length discrepancy myositis ossificans intraoperative fracture prosthetic fracture need for conversion to total hip replacement surgery revision surgery DVT pulmonary embolism risk of anesthesia need for blood transfusion and cardiac arrest She understands above and is willing to undergo further procedure The goal and the functional outcome have been explained Further plan will be discussed with her once we obtain the bone scan and the radiographic studies We will also await for the oncology feedback and clearance Thank you very much for allowing me to participate in the care of this patient I will continue to follow up Keywords orthopedic calcar proximal femur pathological fracture hip fracture hemiarthroplasty melanoma MEDICAL_TRANSCRIPTION,Description Austin Moore bipolar hemiarthroplasty left hip Subcapital left hip fracture Medical Specialty Orthopedic Sample Name Hemiarthroplasty Austin Moore Bipolar Transcription PREOPERATIVE DIAGNOSIS Subcapital left hip fracture POSTOPERATIVE DIAGNOSIS Subcapital left hip fracture PROCEDURE PERFORMED Austin Moore bipolar hemiarthroplasty left hip ANESTHESIA Spinal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 cc HISTORY The patient is an 86 year old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08 30 03 after sustaining a fall at her friend s house The patient states that she was knocked over by her friend s dog She sustained a subcapital left hip fracture Prior to admission she lived alone in Terrano was ambulating with a walker All risks benefits and potential complications of the procedure were then discussed with the patient and informed consent was obtained HARDWARE SPECIFICATIONS A 28 mm medium head was used a small cemented femoral stem was used and a 28 x 46 cup was used PROCEDURE All risks benefits and potential complications of the procedure were discussed with the patient informed consent was obtained She was then transferred from the preoperative care unit to operating suite 1 Department of Anesthesia administered spinal anesthetic without complications After this the patient was transferred to the operating table and positioned All bony prominences were well padded She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards The left lower extremity was then sterilely prepped and draped in the normal fashion A skin maker was then used to mark all bony prominences Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks A 10 blade Bard Parker scalpel was used to incise the skin through to the subcutaneous tissues A second 10 blade was then used to incise through the subcutaneous tissue down to the fascia lata This was then incised utilizing Metzenbaum scissors This was taken down to the bursa which was removed utilizing a rongeur Utilizing a periosteal elevator as well as the sponge the fat was then freed from the short external rotators of the left hip after these were placed and stretched The sciatic nerve was then visualized and retracted utilizing a Richardson retractor Bovie was used to remove the short external rotators from the greater trochanter which revealed the joint capsule The capsule was cleared and incised utilizing a T shape incision A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture A cork screw was then used to remove the fractured femoral head which was given to the scrub tech which was sized on the back table All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur Acetabulum was then inspected and found to be clear Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut An oscillating saw was then used to make the femoral cut Box osteotome was then used to remove the bone from proximal femur A Charnley awl was then used to open the femoral canal paying close attention to keep the awl in the lateral position Next attention was turned to broaching Initially a small broach was placed first making efforts to lateralize the broach then the femoral canal It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate Next the trial components were inserted consisting of the above mentioned component sizes The hip was taken through range of motion and tested to adduction internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip It was noted that these size were stable through the range of motion Next the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal The femoral component was then inserted and then held under pressure Extruding cement was removed from the proximal femur After the cement had fully hardened and dried the head and cup were applied The hip was subsequently reduced and taken again through range of motion which was felt to be stable Next the capsule was closed utilizing 1 Ethibond in figure of eight fashion Next the fascia lata was repaired utilizing a figure of eight Ethibond sutures The most proximal region at the musculotendinous junction was repaired utilizing a running 1 Vicryl suture The wound was then copiously irrigated again to suction dry Next the subcutaneous tissues were reapproximated using 2 0 Vicryl simple interrupted sutures The skin was then reapproximated utilizing skin clips Sterile dressing was applied consisting of Adaptic 4x4s ABDs as well as foam tape The patient was then transferred from the operating table to the gurney Leg lengths were checked which were noted to be equal and abduction pillow was placed The patient was then transferred to the Postoperative Care Unit in stable condition Keywords orthopedic austin moore bipolar hemiarthroplasty subcapital left hip fracture hip fracture austin moore bipolar hemiarthroplasty subcutaneous tissues hip hemiarthroplasty austin cemented femur subcapital fracture femoral MEDICAL_TRANSCRIPTION,Description Hemiarthroplasty right hip Fracture of the right femoral neck also history of Alzheimer s dementia hypothyroidism and status post hemiarthroplasty of the hip Medical Specialty Orthopedic Sample Name Hemiarthroplasty Discharge Summary Transcription ADMISSION DIAGNOSES Fracture of the right femoral neck also history of Alzheimer s dementia and hypothyroidism DISCHARGE DIAGNOSES Fracture of the right femoral neck also history of Alzheimer s dementia hypothyroidism and status post hemiarthroplasty of the hip PROCEDURE PERFORMED Hemiarthroplasty right hip CONSULTATIONS Medicine for management of multiple medical problems including Alzheimer s HOSPITAL COURSE The patient was admitted on 08 06 2007 after a fall with subsequent fracture of the right hip The patient was admitted to Orthopedics and consulted Medicine The patient was actually taken to the operating room consent signed by durable power of attorney taken on 08 06 2007 had right hip hemiarthroplasty recovered without incidence The patient had continued confusion and dementia which is apparently his baseline secondary to his Alzheimer s Brief elevation of white count following the surgery which did subside Studies UA and blood culture were negative The patient was stable and was discharged to Heartland CONDITION ON DISCHARGE Stable DISCHARGE INSTRUCTIONS Transfer to ABC for rehab and continued care Diabetic diet Activity ambulate as tolerated with posterior hip precautions Rehab potential fair He will need nursing Social Work PT OT and nutrition consults Resume home meds DVT prophylaxis aspirin and compression stockings Follow up Dr X in one to two weeks call 123 4567 for an appointment Keywords orthopedic femoral neck orthopedics rehab femoral neck fracture dementia hemiarthroplasty hip MEDICAL_TRANSCRIPTION,Description Hardware removal in the left elbow Medical Specialty Orthopedic Sample Name Hardware Removal Elbow Transcription PREOPERATIVE DIAGNOSIS Retained hardware in left elbow POSTOPERATIVE DIAGNOSIS Retained hardware in left elbow PROCEDURE Hardware removal in the left elbow ANESTHESIA Procedure done under general anesthesia The patient also received 4 mL of 0 25 Marcaine of local anesthetic TOURNIQUET There is no tourniquet time ESTIMATED BLOOD LOSS Minimal COMPLICATIONS No intraoperative complications HISTORY AND PHYSICAL The patient is a 5 year 8 month old male who presented to me direct from ED with distracted left lateral condyle fracture He underwent screw compression for the fracture in October 2007 The fracture has subsequently healed and the patient presents for hardware removal The risks and benefits of surgery were discussed The risks of surgery include the risk of anesthesia infection bleeding changes in sensation and motion of extremity failure of removal of hardware failure to relieve pain or improved range of motion All questions were answered and the family agreed to the above plan PROCEDURE The patient was taken to the operating room placed supine on the operating table General anesthesia was then administered The patient s left upper extremity was then prepped and draped in standard surgical fashion Using his previous incision dissection was carried down through the screw A guide wire was placed inside the screw and the screw was removed without incident The patient had an extension lag of about 15 to 20 degrees Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex The washer was also removed without incident Wound was then irrigated and closed using 2 0 Vicryl and 4 0 Monocryl Wound was injected with 0 25 Marcaine The wound was then dressed with Steri Strips Xeroform 4 x4 and bias The patient tolerated the procedure well and subsequently taken to the recovery in stable condition DISCHARGE NOTE The patient will be discharged on date of surgery He is to follow up in one week s time for a wound check This can be done at his primary care physician s office The patient should keep his postop dressing for about 4 to 5 days He may then wet the wound but not scrub it The patient may resume regular activities in about 2 weeks The patient was given Tylenol with Codeine 10 mL p o every 3 to 4 hours p r n Keywords orthopedic retained hardware hardware removal tourniquet elbow hardware MEDICAL_TRANSCRIPTION,Description New patient visit for right hand pain Punched the wall 3 days prior to presentation complained of ulnar sided right hand pain and was seen in the emergency room Medical Specialty Orthopedic Sample Name Hand Pain Consult Transcription REASON FOR VISIT New patient visit for right hand pain HISTORY OF PRESENT ILLNESS The patient is a 28 year old right hand dominant gentleman who punched the wall 3 days prior to presentation He complained of ulnar sided right hand pain and was seen in the emergency room Reportedly he had some joints in his hand pushed back and placed by somebody in emergency room Today he admits that his pain is much better Currently since that time he has been in the splint with minimal pain He has had no numbness tingling or other concerning symptoms PAST MEDICAL HISTORY Negative SOCIAL HISTORY The patient is a nonsmoker and does not use illegal drugs Occasionally drinks REVIEW OF SYSTEMS A 12 point review of systems is negative MEDICATIONS None ALLERGIES No known drug allergies FINDINGS On physical exam he has swelling and tenderness over the ulnar dorsum of his hand He has a normal cascade He has 70 degrees of MCP flexion and full IP flexion and extension He has 3 to 5 strength in his grip and intrinsics He has intact sensation to light touch in the radial ulnar and median nerve distribution Two plus radial pulse X rays taken from today were reviewed include three views of the right hand They show possible small fractures of the base of the fourth and third metacarpals Joint appears to be located A 45 degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals His injury films from 09 15 07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals ASSESSMENT Status post right third and fourth metacarpal carpometacarpal dislocations PLANS The patient was placed into a short arm cast and intrinsic plus I would like him to wear this for 2 weeks and then follow up with us At that time we will transition him to an OT splint and begin range of motion activities of the fingers and wrist We should see him back in 2 weeks time at which time he should obtain three views of the right hand and a 45 degree oblique view out of cast Keywords orthopedic hand pain pain hand metacarpals MEDICAL_TRANSCRIPTION,Description Removal of painful hardware first left metatarsal Excision of nonunion first left metatarsal Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal Medical Specialty Orthopedic Sample Name Hardware Removal Metatarsal Transcription TITLE OF OPERATION 1 Removal of painful hardware first left metatarsal 2 Excision of nonunion first left metatarsal 3 Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal PREOPERATIVE DIAGNOSES 1 Nonunion of fractured first left metatarsal osteotomy 2 Painful hardware first left metatarsal POSTOPERATIVE DIAGNOSES 1 Nonunion of fractured first left metatarsal osteotomy 2 Painful hardware first left metatarsal ANESTHESIA General anesthesia with local infiltration of 5 mL of 0 5 Marcaine and 1 lidocaine plain with 1 100 000 epinephrine preoperatively and 15 mL of 0 5 Marcaine postoperatively HEMOSTASIS Left ankle tourniquet set at 250 mmHg for 60 minutes ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl 5 0 Prolene as well as one corticocancellous allograft consisting of ASIS and one T type plate prebent with six screw holes and five 3 0 partially threaded cannulated screws and a single 3 0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal INJECTABLES 1 g Ancef IV 30 minutes preoperatively and the afore mentioned lidocaine DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After general anesthesia was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in normal sterile technique The left ankle tourniquet was then inflated Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8 cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the periosteum of the first left metatarsal All the tendinous neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact The screws were sent to pathology for examination The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0 045 Kirschner wire to induce bleeding The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy Provisional fixation with K wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished The bone graft was then stabilized with the use of a T type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft Removal of the K wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent The area was flushed copiously flushed with saline The periosteal and capsular tissues were approximated with 3 0 Vicryl and 2 0 Vicryl suture material All the subcutaneous tissues were approximated with 4 0 Vicryl suture material and 5 0 Prolene was used to approximate the skin edges at this time The left ankle tourniquet was deflated Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s left foot was placed in a surgical shoe The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels The patient was given specific instructions and education on how to continue caring for his left foot surgery The patient was also given pain medications instructions on how to control his postoperative pain The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for his first postoperative appointment Keywords orthopedic hardware removal metatarsal osteotomy painful hardware osteotomy excision of nonunion corticocancellous bone graft internal fixation subcutaneous tissues previous osteotomy vicryl suture suture material corticocancellous bone ankle tourniquet bone graft metatarsal tourniquet allograft fixation plates ankle vicryl nonunion screws MEDICAL_TRANSCRIPTION,Description Hardware removal right ulnar Medical Specialty Orthopedic Sample Name Hardware Removal Ulnar Transcription PREOPERATIVE DIAGNOSIS Retained hardware right ulnar POSTOPERATIVE DIAGNOSIS Retained hardware right ulnar PROCEDURE Hardware removal right ulnar ANESTHESIA The patient received 2 5 mL of 0 25 Marcaine and local anesthetic COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 5 year 5 month old male who sustained a both bone forearm fracture in September 2007 The fracture healed uneventfully but then the patient subsequently suffered a refracture one month ago The patient had shortening in arms noted in both bones The parents opted for surgical stabilization with nailing This was performed one month ago on return visit His ulnar nail was quite prominent underneath the skin It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks Risks and benefits of the surgery were discussed with the mother Risk of surgery incudes risks of anesthesia infection bleeding changes in sensation in most of the extremity need for longer casting All questions were answered and mother agreed to above plan PROCEDURE IN DETAIL The patient was seen in the operative room placed supine on operating room table General anesthesia was then administered The patient was given Ancef preoperatively The left elbow was prepped and draped in a standard surgical fashion A small incision was made over the palm with K wire This was removed without incident The wound was irrigated The bursitis was curetted Wounds closed using 4 0 Monocryl The wound was clean and dry dressed with Xeroform 4 x 4s and Webril Please note the area infiltrated with 0 25 Marcaine The patient was then placed in a long arm cast The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will maintain the cast for 3 more weeks Intraoperative nail was given to the mother The patient to take Tylenol with Codeine as needed All questions were answered Keywords orthopedic both bone forearm fracture retained hardware hardware removal hardware forearm ulnar MEDICAL_TRANSCRIPTION,Description Left distal medial hamstring release Medical Specialty Orthopedic Sample Name Hamstring Release Transcription PREOPERATIVE DIAGNOSIS Autism with bilateral knee flexion contractures POSTOPERATIVE DIAGNOSIS Autism with bilateral knee flexion contractures PROCEDURE Left distal medial hamstring release ANESTHESIA General anesthesia Local anesthetic 10 mL of 0 25 Marcaine local TOURNIQUET TIME 15 minutes ESTIMATED BLOOD LOSS Minimal COMPLICATIONS There were no intraoperative complications DRAIN None SPECIMENS None HISTORY AND PHYSICAL The patient is a 12 year old boy born at a 32 week gestation and with drug exposure in utero The patient has diagnosis of autism as well The patient presented with bilateral knee flexion contractures initially worse on right than left He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play The patient presents now with worsening left knee flexion contracture and desires the same procedure to be performed Risks and benefits of the surgery were discussed The risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion of extremity failure to restore normal anatomy continued contracture possible need for other procedures All questions were answered and mother and son agreed to above plan PROCEDURE NOTE The patient was taken to operating room and placed supine on operating table General anesthesia was administered The patient received Ancef preoperatively Nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The extremity was then prepped and draped in standard surgical fashion The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Esmarch was then removed A small 3 cm incision was made over the distal medial hamstring Hamstring tendons were isolated and released in order of semitendinosus semimembranosus and sartorius The wound was then irrigated with normal saline and closed used 2 0 Vicryl and then 4 0 Monocryl The wound was cleaned and dried and dressed with Steri Strips The area was infiltrated with total 10 mL of 0 25 Marcaine The wound was then covered with Xeroform 4 x 4s and Bias Tourniquet was released at 15 minutes The patient was then placed in knee immobilizer The patient tolerated the procedure well and subsequently taken to recovery in stable condition POSTOPERATIVE PLAN The patient may weight bear as tolerated in his brace He will start physical therapy in another week or two The patient restricted from any PE for at least 6 week He may return to school on 01 04 2008 He was given Vicodin for pain Keywords orthopedic medial hamstring release distal medial hamstring release bilateral knee flexion contractures bilateral knee hamstring release knee flexion tourniquet flexion contractures hamstring MEDICAL_TRANSCRIPTION,Description Excision of foreign body right foot and surrounding tissue This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot Medical Specialty Orthopedic Sample Name Foreign Body Removal Foot Transcription PREOPERATIVE DIAGNOSIS Foreign body right foot POSTOPERATIVE DIAGNOSIS Foreign body in the right foot PROCEDURE PERFORMED Excision of foreign body right foot and surrounding tissue ANESTHESIA TIVA and local HISTORY This 41 year old male presents to preoperative holding area after keeping himself n p o since mid night for removal of painful retained foreign body in his right foot The patient works in the Electronics Robotics field and relates that he stepped on a wire at work which somehow got into his shoe The wire entered his foot His family physician attempted to remove the wire but it only became deeper in the foot The wound eventually healed but a scar tissue was formed The patient has had constant pain with ambulation intermittently since the incident occurred He desires attempted surgical removal of the wire The risks and benefits of the procedure have been explained to the patient in detail by Dr X The consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient s protection After adequate IV sedation was administered by the Department of Anesthesia a total of 12 cc of 0 5 Marcaine plain was used to administer an ankle block Next the foot was prepped and draped in the usual aseptic fashion An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered into the operative field and the sterile stockinet was reflected Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized This was the origin and entry point of the previous puncture wound from the wire This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area Next the Xi scan was draped and brought into the operating room A 25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire Next a 10 blade was used to make approximately a 3 cm curvilinear S shaped incision Next the 15 blade was used to carry the incision through the subcutaneous tissue The medial and lateral margins of the incision were undermined Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot the wires seemed to serve no benefit other then helping with the incision planning Therefore they were removed Once the wound was opened a hemostat was used to locate the wire very quickly and the wire was clamped A second hemostat was used to clamp the wire A 15 blade was used to carefully transect the fatty tissue around the tip of the hemostats which were visualized in the base of the wound The wire quickly came into visualization It measured approximately 4 mm in length and was approximately 1 mm in diameter The wire was green colored and metallic in nature It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament Next copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected Next a 3 0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space Next 4 0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique The standard postoperative dressing consisting of saline soaked Owen silk 4x4s Kling Kerlix and Coban were applied The pneumatic ankle tourniquet was released There was immediate hyperemic flush to the digits noted The patient s anesthesia was reversed He tolerated the above anesthesia and procedure without complications The patient was transported via cart to the Postanesthesia Care Unit Vital signs were stable and vascular status was intact to the right foot He was given OrthoWedge shoe Ice was applied behind the knee and his right lower extremity was elevated on to pillows He was given standard postoperative instructions consisting of rest ice and elevation to the right lower extremity He is to be non weightbearing for three weeks at which time the wound will be evaluated and sutures will be removed He is to follow up with Dr X on 08 22 2003 and was given emergency contact number to call if problems arise He was given a prescription for Tylenol 4 30 one p o q 4 6h p r n pain as well as Celebrex 200 mg 30 take two p o q d p c with 200 mg 12 hours later as a rescue dose He was given crutches He was discharged in stable condition Keywords orthopedic foreign body removal excision of foreign body ankle tourniquet plantar aspect foreign body foot ankle plantar wound MEDICAL_TRANSCRIPTION,Description Excision of ganglion of the left wrist A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist Medical Specialty Orthopedic Sample Name Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Ganglion of the left wrist POSTOPERATIVE DIAGNOSIS Ganglion of the left wrist OPERATION Excision of ganglion ANESTHESIA General ESTIMATED BLOOD LOSS Less than 5 mL OPERATION After a successful anesthetic the patient was positioned on the operating table A tourniquet applied to the upper arm The extremity was prepped in a usual manner for a surgical procedure and draped off The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist By blunt and sharp dissection it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted The small superficial vessels were electrocoagulated and instilled after closing the skin with 4 0 Prolene into the area was approximately 6 to 7 mL of 0 25 Marcaine with epinephrine A Jackson Pratt drain was inserted and then after the tourniquet was released it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room The dressings applied to the hand were that of Xeroform 4x4s ABD Kerlix and elastic wrap over a volar fiberglass splint The tourniquet was released Circulation returned to the fingers The patient then was allowed to awaken and left the operating room in good condition Keywords orthopedic curved incision superficial vessels tourniquet excision dorsal wrist ganglion MEDICAL_TRANSCRIPTION,Description Consultation for left foot pain Medical Specialty Orthopedic Sample Name Foot pain Consultation Transcription CHIEF COMPLAINT Left foot pain HISTORY XYZ is a basketball player for University of Houston who sustained an injury the day prior They were traveling He came down on another player s foot sustaining what he describes as an inversion injury Swelling and pain onset immediately He was taped but was able to continue playing He was examined by John Houston the trainer and had tenderness around the navicular so was asked to come over and see me for evaluation He has been in a walking boot He has been taped firmly Pain with weightbearing activities He is limping a bit No significant foot injuries in the past Most of his pain is located around the dorsal aspect of the hindfoot and midfoot PHYSICAL EXAM He does have some swelling from the hindfoot out toward the midfoot His arch is maintained His motion at the ankle and subtalar joints is preserved Forefoot motion is intact He has pain with adduction and abduction across the hindfoot Most of this discomfort is laterally His motor strength is grossly intact His sensation is intact and his pulses are palpable and strong His ankle is not tender He has minimal to no tenderness over the ATFL He has no medial tenderness along the deltoid or the medial malleolus His anterior drawer is solid His external rotation stress is not painful at the ankle His tarsometatarsal joints specifically 1 2 and 3 are nontender His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus Some tenderness over the dorsolateral side of the talonavicular joint as well The medial talonavicular joint is not tender RADIOGRAPHS Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic I don t see a definite fracture The tarsometarsal joints are anatomically aligned Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified Review of an MR scan of the ankle dated 12 01 05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area Also some changes along the dorsal talonavicular joint I don t see any significant marrow edema or definitive fracture line IMPRESSION Left Chopart joint sprain PLAN I have spoken to XYZ about this Continue with ice and boot for weightbearing activities We will start him on a functional rehab program and progress him back to activities when his symptoms allow He is clear on the prolonged duration of recovery for these hindfoot type injuries Keywords orthopedic foot pain calcaneocuboid joint dorsal aspect dorsal talonavicular joint foot injuries hindfoot midfoot rehab program walking boot weightbearing talonavicular joint dorsal talonavicular ankle foot tenderness MEDICAL_TRANSCRIPTION,Description Resection of infected bone left hallux proximal phalanx and distal phalanx Osteomyelitis left hallux Medical Specialty Orthopedic Sample Name Hallux Infected Bone Resection Transcription PREOPERATIVE DIAGNOSIS Osteomyelitis left hallux POSTOPERATIVE DIAGNOSIS Osteomyelitis left hallux PROCEDURES PERFORMED Resection of infected bone left hallux proximal phalanx and distal phalanx ANESTHESIA TIVA Local HISTORY This 77 year old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux The patient has a history of chronic osteomyelitis and non healing ulceration to the left hallux of almost 10 years duration He has failed outpatient antibiotic therapy and conservative methods At this time he desires to attempt surgical correction The patient is not interested in a hallux amputation at this time however he is consenting to removal of infected bone He was counseled preoperatively about the strong probability of the hallux being a floppy tail after the surgery and accepts the fact The risks versus benefits of the procedure were discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL The patient s wound was debrided with a 15 blade and down to good healthy tissue preoperatively The wound was on the planar medial distal and dorsal medial The wound s bases were fibrous They did not break the bone at this point They were each approximately 0 5 cm in diameter After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection Due to the patient s history of diabetes and marked calcifications on x ray a pneumatic ankle tourniquet was not applied Next a total of 3 cc of a 1 1 mixture of 0 5 Marcaine plain and 1 lidocaine plain was used to infiltrate the left hallux and perform a digital block Next the foot was prepped and draped in the usual aseptic fashion It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected Next a 10 blade was used to make a linear incision approximately 3 5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium Next the incision was deepened through the subcutaneous tissue A heavy amount of bleeding was encountered Therefore a Penrose drain was applied at the tourniquet which failed Next an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery Next the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon The long extensor tendon was thickened and overall exhibited signs of hypertrophy The transverse incision through the long extensor tendon was made with a 15 blade Immediately upon entering the joint yellow discolored fluid was drained from the interphalangeal joint Next the extensor tendon was peeled dorsally and distally off the bone Immediately the head of the proximal phalanx was found to be lytic disease friable crumbly and there were free fragments of the medial aspect of the bone the head of the proximal phalanx This bone was removed with a sharp dissection Next after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx a sagittal saw was used to resect the approximately one half of the proximal phalanx This was passed off as the infected bone specimen for microbiology and pathology Next the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx Next there was diseased soft tissue envelope around the bone which was also resected to good healthy tissue margins The pulse lavage was used to flush the wound with 1000 cc of gentamicin impregnated saline Next cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin This bone was found to be hard and healthy appearing The wound after irrigation was free of all debris and infected tissue Therefore anaerobic and aerobic cultures were taken and sent to microbiology Next OsteoSet beads tobramycin impregnated were placed Six beads were placed in the wound Next the extensor tendon was re approximated with 3 0 Vicryl The subcutaneous layer was closed with 4 0 Vicryl in a simple interrupted technique Next the skin was closed with 4 0 nylon in a horizontal mattress technique The Esmarch bandage was released and immediate hyperemic flush was noted at the digits A standard postoperative dressing was applied consisting of 4 x 4s Betadine soaked 0 1 silk Kerlix Kling and a loosely applied Ace wrap The patient tolerated the above anesthesia and procedure without complications He was transported via a cart to the Postanesthesia Care Unit His vitals signs were stable and vascular status was intact He was given a medium postop shoe that was well formed and fitting He is to elevate his foot but not apply ice He is to follow up with Dr X He was given emergency contact numbers He is to continue the Vicodin p r n pain that he was taking previously for his shoulder pain and has enough of the medicine at home The patient was discharged in stable condition Keywords orthopedic osteomyelitis proximal phalanx distal phalanx infected bone proximal bone phalanx healing hallux infected tissue distal MEDICAL_TRANSCRIPTION,Description Cellulitis with associated abscess and foreign body right foot Irrigation debridement and removal of foreign body of right foot Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads Medical Specialty Orthopedic Sample Name Foreign Body Removal Foot 1 Transcription PREOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot POSTOPERATIVE DIAGNOSES 1 Cellulitis with associated abscess right foot 2 Foreign body right foot PROCEDURE PERFORMED 1 Irrigation debridement 2 Removal of foreign body of right foot ANESTHESIA Spinal with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal GROSS FINDINGS Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads HISTORY OF PRESENT ILLNESS The patient is a 61 year old Caucasian male with a history of uncontrolled diabetes mellitus The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics It was noted upon x ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity After a long discussion held with the patient it was elected to proceed with irrigation debridement and removal of the foreign body PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedures were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the patient operative surgeon the Department of Anesthesia and nursing staff The patient was then transferred to preoperative area to Operative Suite 5 and placed on the operating table in supine position All bony prominences were well padded at this time The Department of Anesthesia was administered spinal anesthetic to the patient Once this anesthesia was obtained the patient s right lower extremity was sterilely prepped and draped in the usual sterile fashion Upon viewing of the plantar aspect of the foot there was noted to be a swollen ecchymotic area with a small hole in it which purulent fluid was coming from At this time after all bony and soft tissue landmarks were identified as well as the localization of the pus a 2 cm longitudinal incision was made directly over this area which was located between the second and third metatarsal heads Upon incising this there was a foul smelling purulent fluid which flowed from this region Aerobic and anaerobic cultures were taken as well as gram stain The area was explored and it ________ to the dorsum of the foot There was no obvious joint involvement After all loculations were broken 3 liters antibiotic impregnated fluid were pulse evac through the wound The wound was again inspected with no more gross purulent or necrotic appearing tissue The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s floss and Kerlix covered by an Ace bandage At this time the Department of Anesthesia reversed the sedation The patient was transferred back to the hospital gurney to Postanesthesia Care Unit The patient tolerated the procedure well and there were no complications DISPOSITION The patient will be followed on a daily basis for possible repeat irrigation debridement Keywords orthopedic removal of foreign body purulent material metatarsal cellulitis abscess kerlix foreign body foot irrigation debridement purulent MEDICAL_TRANSCRIPTION,Description Flexor carpi radialis and palmaris longus repair Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration Medical Specialty Orthopedic Sample Name Flexor Carpi Radialis Palmaris Longus Repair Transcription PREOPERATIVE DIAGNOSIS Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration POSTOPERATIVE DIAGNOSIS Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90 suspected radial artery laceration PROCEDURES PERFORMED 1 Repair flexor carpi radialis 2 Repair palmaris longus ANESTHETIC General TOURNIQUET TIME Less than 30 minutes CLINICAL NOTE The patient is a 21 year old who sustained a clean laceration off a teapot last night She had lacerated her flexor carpi radialis completely and 90 of her palmaris longus Both were repaired proximal to the carpal tunnel The postoperative plans are for a dorsal splint and early range of motion passive and active assist The wrist will be at approximately 30 degrees of flexion The MPJ is at 30 degrees of flexion the IP straight Splinting will be used until the 4 week postoperative point PROCEDURE Under satisfactory general anesthesia the right upper extremity was prepped and draped in the usual fashion There were 2 transverse lacerations Through the first laceration the flexor carpi radialis was completely severed The proximal end was found with a tendon retriever The distal end was just beneath the subcutaneous tissue A primary core stitch was used with a Kessler stitch This was with 4 0 FiberWire A second core stitch was placed again using 4 0 FiberWire The repair was oversewn with locking running 6 0 Prolene stitch Through the second incision the palmaris longus was seen to be approximately 90 severed It was an oblique laceration It was repaired with a 4 0 FiberWire core stitch and with a Kessler type stitch A secure repair was obtained She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair The fascia was released proximally and distally to give her more room for excursion of the repair The tourniquet was dropped bleeders were cauterized Closure was routine with interrupted 5 0 nylon A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted The splint was dorsal The patient was sent to the recovery room in good condition Keywords orthopedic kessler stitch flexor carpi radialis palmaris longus radialis laceration fiberwire flexor carpi palmaris longus repair MEDICAL_TRANSCRIPTION,Description Consultation for FCR tendinitis Medical Specialty Orthopedic Sample Name FCR tendinitis Transcription HISTORY OF PRESENT PROBLEM XYZ was seen by Dr ABC for an FCR tendinitis We do not have his reports but by history she has had two cortisone shots She plays musical instruments and it does bother her from time to time She was considering surgery but she takes ibuprofen and it seems to be well controlled She is here now for consultation CLINICAL PHYSICAL EXAMINATION General The patient is alert and oriented times three in no acute distress Skin No skin breakdown or hyperhidrosis Vascular 2 radial and ulnar artery pulses Musculoskeletal Wrist elbow shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability The DRUJ is stable Flexion extension of the fingers is all intact Forearm elbow and shoulder exams reveal no other focal tenderness to palpation Neurologic Negative Tinel s Phalen s and compression median nerve test APB EPL and first dorsal interosseous have 5 5 strength Forearm elbow and shoulder exams reveal no neurologic compromise Gait Normal Neck Negative Spurling sign Negative signs of thoracic outlet HEENT Pupils equal and reactive with no asymmetry CLINICAL IMPRESSION By history possible FCR tendinitis EVALUATION TREATMENT PLAN At this point we have asked her some questions again She is not that sore at this point and she has had a couple of cortisone shots Without being the initial treating physician she has FCR tendinitis that fails to respond to cortisone shots She is a candidate for an FCR tunnel release It has been described and is effective for those patients with that problem My only consideration would be if the patient should choose to get an MRI when she is symptomatic to confirm the FCR tendinitis She will followup with Dr ABC as needed or come back to us when she is thinking more along the lines of surgery Keywords orthopedic fcr tendinitis fcr tunnel release cortisone shot tendinitis tunnel release signs oriented shoulder fcr MEDICAL_TRANSCRIPTION,Description Sample Radiology report of knee growth arrest lines Medical Specialty Orthopedic Sample Name Five views of the right knee Transcription EXAM Five views of the right knee HISTORY Pain The patient is status post surgery he could not straighten his leg pain in the back of the knee TECHNIQUE Five views of the right knee were evaluated There are no priors for comparison FINDINGS Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures dislocations or subluxations There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia There is also appearance of a high riding patella suggestive of patella alta IMPRESSION 1 No evidence of any displaced fractures dislocations or subluxations 2 Growth arrest lines seen in the distal femur and proximal tibia 3 Questionable appearance of a slightly high riding patella possibly suggesting patella alta Keywords orthopedic fractures dislocations or subluxations femur and proximal growth arrest lines patella alta fractures dislocations subluxations distal femur patella MEDICAL_TRANSCRIPTION,Description Endoscopic carpal tunnel release Left carpal tunnel syndrome Medical Specialty Orthopedic Sample Name Endoscopic Carpal Tunnel Rlease Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIONS PERFORMED Endoscopic carpal tunnel release ANESTHESIA I V sedation and local 1 Lidocaine ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE IN DETAIL With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mm Hg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the wrist between FCR and FCU one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A proximal forearm fasciotomy was performed under direct vision A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the hook of hamate The endoscopic instrument was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the endoscopic instrument was withdrawn dividing the transverse carpal ligament under direct vision After complete division o the transverse carpal ligament the instrument was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was confirmed The wound was then closed with running subcuticular stitch Steri Strips were applied and sterile dressing was applied over the Steri Strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition having tolerated the procedure well Keywords orthopedic fcr fcu antebrachial fascia endoscopic carpal tunnel release carpal tunnel release carpal tunnel syndrome carpal endoscopic ligament tourniquet transverse MEDICAL_TRANSCRIPTION,Description Left little finger extensor tendon laceration Repair of left little extensor tendon Medical Specialty Orthopedic Sample Name Extensor Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Left little finger extensor tendon laceration POSTOPERATIVE DIAGNOSIS Left little finger extensor tendon laceration PROCEDURE PERFORMED Repair of left little extensor tendon COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Bier block INDICATIONS The patient is a 14 year old right hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon DESCRIPTION OF PROCEDURE The patient was taken to the operative room laid supine administered intervenous sedation with Bier block and prepped and draped in a sterile fashion The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon which is essentially in line with the tendon fibers This was just proximal to the PIP joint and on complete flexion of the PIP joint I did separate just a little bit that was not thought to be significantly dynamically unstable It was sutured with a single 4 0 Prolene interrupted figure of eight suture and on dynamic motion it did not separate at all The wound was irrigated and closed with 5 0 nylon interrupted sutures The patient tolerated the procedure well and was taken to the PCU in good condition Keywords orthopedic extensor tendon laceration bier block pip joint extensor tendon tendon repair finger laceration extensor MEDICAL_TRANSCRIPTION,Description Consultation for finger triggering and locking Medical Specialty Orthopedic Sample Name Finger triggering and locking Transcription CHIEF COMPLAINT Right middle finger triggering and locking as well as right index finger soreness at the PIP joint HISTORY OF OCCUPATIONAL INJURY OR ILLNESS The patient has been followed elsewhere and we reviewed his records Essentially he has had a trigger finger and a mucocyst and he has had injections This has been going on for several months He is now here for active treatment because the injections were not helpful nonoperative treatment has not worked and he would like to move forward in order to prevent this from keeping on locking and causing his pain He is referred over here for evaluation regarding that SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY General health review of systems See H P Allergies See H P Medications See H P Social History See H P Family History See H P Previous Hospitalizations See H P CLINICAL ASSESSMENT AND FINDINGS Musculoskeletal Shows point tenderness to palpation to the right middle finger A1 pulley The right index finger has some small soreness at the PIP joint but at this time no obvious mucocyst He has flexion extension of his fingers intact There is no crepitation at the wrist forearm elbow or shoulder with full range of motion Contralateral arm exam for comparison reveals no focal findings Neurological APB EPL and first dorsal interosseous 5 5 LABORATORY RADIOGRAPHIC AND OR IMAGING TESTS ORDERS RESULTS Special lab studies CLINICAL IMPRESSION 1 Tendinitis left middle finger 2 PIP joint synovitis and mucocyst but controlled on nonoperative treatment 3 Middle finger trigger failed nonoperative treatment requiring a trigger finger release to the right middle finger EVALUATION TREATMENT PLAN Risks benefits and alternatives were discussed All questions were answered No guarantees were made We will schedule for surgery We would like to move forward in order to help him significantly improve since he has failed injections All questions were answered Followup appointment was given Keywords orthopedic finger triggering a1 pulley pip joint tendinitis crepitation locking mucocyst synovitis trigger finger middle finger triggering triggering and locking index finger finger triggering MEDICAL_TRANSCRIPTION,Description Endoscopic carpal tunnel release and de Quervain s release Left carpal tunnel syndrome and de Quervain s tenosynovitis Medical Specialty Orthopedic Sample Name Endoscopic Carpal Tunnel de Quervain s Release Transcription PREOPERATIVE DIAGNOSIS 1 Left carpal tunnel syndrome 2 de Quervain s tenosynovitis POSTOPERATIVE DIAGNOSIS 1 Left carpal tunnel syndrome 2 de Quervain s tenosynovitis OPERATIONS PERFORMED 1 Endoscopic carpal tunnel release 2 de Quervain s release ANESTHESIA I V sedation and local 1 Lidocaine ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE IN DETAIL ENDOSCOPIC CARPAL TUNNEL RELEASE With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mm Hg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the wrist between FCR and FCU one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A proximal forearm fasciotomy was performed under direct vision A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the hook of hamate The endoscopic instrument was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the endoscopic instrument was withdrawn dividing the transverse carpal ligament under direct vision After complete division o the transverse carpal ligament the instrument was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was confirmed The wound was then closed with running subcuticular stitch Steri Strips were applied and sterile dressing was applied over the Steri Strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition having tolerated the procedure well DE QUERVAIN S RELEASE With the patient under adequate regional anesthesia applied by surgeon using 1 plain Xylocaine the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated to 290 mm Hg A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel Using blunt dissection the radial sensory nerve branches were dissected and retracted out of the operative field The first dorsal tunnel was then identified The first dorsal tunnel was incised along the dorsal ulnar border completely freeing the stenosing tenosynovitis de Quervain s release EPB and APL tendons were inspected and found to be completely free The radial sensory nerve was inspected and found to be without damage The skin was closed with a running 3 0 Prolene subcuticular stitch and Steri Strips were applied and over the Steri Strips a sterile dressing and over the sterile dressing a volar splint with the hand in safe position The tourniquet was deflated The patient was returned to the holding area in satisfactory condition having tolerated the procedure well Keywords orthopedic de quervain s tenosynovitis de quervain s release carpal tunnel syndrome carpal tunnel release endoscopic carpal tunnel release tunnel transverse carpal tourniquet endoscopic MEDICAL_TRANSCRIPTION,Description Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively Medical Specialty Orthopedic Sample Name Followup Screw Fixation Transcription REASON FOR VISIT Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively HISTORY OF PRESENT ILLNESS The patient is a 59 year old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures He is currently at home and has left nursing home facility He states that his pain is well controlled He has been working with physical therapy two to three times a week He has had no drainage or fever He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy FINDINGS On physical exam his incision is near well healed He has no effusion noted His range of motion is 10 to 105 degrees He has no pain or crepitance On examination of his right foot he is nontender to palpation of the metatarsal heads He has 4 out of 5 strength in EHL FHL tibialis and gastroc soleus complex He does have decreased sensation to light touch in the L4 L5 distribution of his feet bilaterally X rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures These appear to be extraarticular They are all in a bayonet arrangement but there appears to be bridging callus between the fragments on the oblique film ASSESSMENT Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures PLANS I would like the patient to continue working with physical therapy He may be weightbearing as tolerated on his right side I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion I also would like him to work on ambulation and strengthening I discussed with the patient his concerning symptoms of paresthesias He said he has had the left thigh for a number of years and has been followed by a neurologist for this He states that he has had some right sided paresthesias now for a number of weeks He claims he has no other symptoms of any worsening stenosis I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot Keywords orthopedic metatarsal head fractures tibial plateau fracture schatzker percutaneous screw fixation tibial plateau metatarsal head screw fixation head screw fixation metatarsal MEDICAL_TRANSCRIPTION,Description Left elbow manipulation and hardware removal of left elbow Medical Specialty Orthopedic Sample Name Elbow Manipulation Transcription PREOPERATIVE DIAGNOSIS Left elbow with retained hardware POSTOPERATIVE DIAGNOSIS Left elbow with retained hardware PROCEDURE 1 Left elbow manipulation 2 Hardware removal of left elbow ANESTHESIA Surgery was performed under general anesthesia COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None INTRAOPERATIVE FINDING Preoperatively the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees LOCAL ANESTHETIC 10 mL of 0 25 Marcaine HISTORY AND PHYSICAL The patient is a 10 year old right hand dominant male who threw himself off a quad on 10 10 2007 The patient underwent open reduction and internal fixation of his left elbow fracture dislocation The patient also sustained a nondisplaced right glenoid neck fracture The patient s fracture has healed without incident although he had significant postoperative stiffness for which he is undergoing physical therapy as well as use of a Dynasplint The patient is neurologically intact distally Given the fact that his fracture has healed surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware Risks and benefits of the surgery were discussed The risks of surgery included the risk of anesthesia infection bleeding changes in sensation and motion of the extremities failure to remove hardware failure to relieve pain continued postoperative stiffness All questions were answered and the parents agreed to the above plan PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient s left upper extremity was then prepped and draped in a standard surgical fashion Using fluoroscopy the patient s K wire was located An incision was made over his previous scar A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles The K wires were easily palpable A small incision was made into the triceps which allowed for visualization of the two pins which were removed without incident The wound was then irrigated The triceps split was now closed using 2 0 Vicryl The subcutaneous tissue was also closed using 2 0 Vicryl and the skin with 4 0 Monocryl The wound was clean and dry and dressed with Steri Strips Xeroform and 4 x 4s as well as bias A total of 10 mL of 0 25 Marcaine was injected into the incision as well as the joint line At the beginning of the case prior to removal of the hardware the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees flexion to 130 degrees and pronation supination to about 40 degrees DIAGNOSTIC IMPRESSION The postoperative films demonstrated no fracture no retained hardware The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will restart physical therapy and Dynasplint in 3 days The patient is to follow up in 1 week s time for a wound check The patient was given Tylenol No 3 for pain Keywords orthopedic k wires dynasplint elbow manipulation hardware removal retained hardware elbow hardware MEDICAL_TRANSCRIPTION,Description Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger The patient is a 51 year old male with left Dupuytren disease which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort Medical Specialty Orthopedic Sample Name Dupuytren Disease Excision Transcription PREOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger POSTOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger PROCEDURE PERFORMED Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Bier block INDICATIONS The patient is a 51 year old male with left Dupuytren disease which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort DESCRIPTION OF PROCEDURE The patient was taken to the operating room laid supine administered a bier block and prepped and draped in the sterile fashion A zig zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region Skin flaps were elevated carefully dissecting Dupuytren contracture off the undersurface of the flaps Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally which essentially returned to normal appearing tissue The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped The wound was irrigated The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease The incisions were closed with 5 0 nylon interrupted sutures The patient tolerated the procedure well and was taken to the PACU in good condition Keywords orthopedic excision of dupuytren disease proximal interphalangeal joint dupuytren disease bier block pip joint disease dupuytren contractions metacarpophalangeal neurovascular bundles interphalangeal finger MEDICAL_TRANSCRIPTION,Description Excision dorsal ganglion right wrist The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field Medical Specialty Orthopedic Sample Name Dorsal Ganglion Excision Transcription PREOPERATIVE DIAGNOSIS Dorsal ganglion right wrist POSTOPERATIVE DIAGNOSIS Dorsal ganglion right wrist OPERATIONS PERFORMED Excision dorsal ganglion right wrist ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon TOURNIQUET TIME minutes DESCRIPTION OF PROCEDURE With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner The arm was exsanguinated and the tourniquet was elevated to 290 mm Hg A transverse incision was made over the dorsal ganglion Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto Care was taken to protect ligament integrity Reactive synovium was then removed using soft tissue rongeur technique The wound was then infiltrated with 0 25 Marcaine The tendons were allowed to resume their normal anatomical position The skin was closed with 3 0 Prolene subcuticular stitch Sterile dressings were applied The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords orthopedic excision dorsal ganglion extensor tendon extensor retinaculum dorsal ganglion retinaculum ganglion MEDICAL_TRANSCRIPTION,Description Left elbow pain Fracture of the humerus spiral Possible nerve injuries to the radial and median nerve possibly neurapraxia Medical Specialty Orthopedic Sample Name Elbow Pain Consult Transcription CHIEF COMPLAINT Left elbow pain HISTORY OF PRESENT ILLNESS This 17 year old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow causing sudden pain He also has pain in his left ankle but he is able to walk normally He has had previous pain in his left knee He denies any passing out any neck pain at this time even though he did get hit in the head He has no chest or abdominal pain Apparently no knives or guns were involved PAST MEDICAL HISTORY He has had toe problems and left knee pain in the past REVIEW OF SYSTEMS No coughing sputum production dyspnea or chest pain No vomiting or abdominal pain No visual changes No neurologic deficits other than some numbness in his left hand SOCIAL HISTORY He is in Juvenile Hall for about 25 more days He is a nonsmoker ALLERGIES MORPHINE CURRENT MEDICATIONS Abilify PHYSICAL EXAMINATION VITAL SIGNS Stable HEENT PERRLA EOMI Conjunctivae anicteric Skull is normocephalic He is not complaining of bruising HEENT TMs and canals are normal There is no Battle sign NECK Supple He has good range of motion Spinal processes are normal to palpation LUNGS Clear CARDIAC Regular rate No murmurs or rubs EXTREMITIES Left elbow is tender He does not wish to move it at all Shoulder and clavicle are within normal limits Wrist is normal to inspection He does have some pain to palpation Hand has good capillary refill He seems to have decreased sensation in all three dermatomes He has moderately good abduction of all fingers He has moderate opponens strength with his thumb He has very good extension of all of his fingers with good strength We did an x ray of his elbow He has a spiral fracture of the distal one third of the humerus about 13 cm in length The proximal part looks like it is in good position The distal part has about 6 mm of displacement There is no significant angulation The joint itself appears to be intact The fracture line ends where it appears above the joint I do not see any extra blood in the joint I do not see any anterior or posterior Siegert sign I spoke with Dr X He suggests we go ahead and splint him up and he will follow the patient up At this point it does not seem like there needs to be any surgical revision The chance of a compartment syndrome seems very low at this time Using 4 inch Ortho Glass and two assistants we applied a posterior splint to immobilize his fingers hand and wrist all the way up to his elbow to well above the elbow He had much better comfort once this was applied There was good color to his fingers and again much better comfort Once that was on I took some 5 inch Ortho Glass and put in extra reinforcement around the elbow so he would not be moving it straightening it or breaking the fiberglass We then gave him a sling We gave him 2 Vicodin p o and 4 to go Gave him a prescription for 15 more and warned him to take it only at nighttime and use Tylenol or Motrin and ice in the daytime I gave him the name and telephone number of Dr X whom they can follow up with They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems DIAGNOSES 1 Fracture of the humerus spiral 2 Possible nerve injuries to the radial and median nerve possibly neurapraxia 3 Psychiatric disorder unspecified DISPOSITION The patient will follow up as mentioned above They can return here anytime as needed Keywords MEDICAL_TRANSCRIPTION,Description Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis Release of first dorsal extensor compartment Medical Specialty Orthopedic Sample Name Dorsal Extensor Compartment Release Transcription PREOPERATIVE DIAGNOSIS Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis POSTOPERATIVE DIAGNOSIS Stenosing tenosynovitis first dorsal extensor compartment de Quervain tendonitis PROCEDURE PERFORMED Release of first dorsal extensor compartment ASSISTANT None ANESTHESIA Bier block TOURNIQUET TIME 30 minutes COMPLICATIONS None INDICATIONS The above patient is a 47 year old right hand dominant black female who has signs and symptomology of de Quervain s stenosing tenosynovitis She was treated conservatively with steroid injections splinting and nonsteroidal anti inflammatory agents without relief She is presenting today for release of the first dorsal extensor compartment She is aware of the risks benefits alternatives and has consented to this operation PROCEDURE The patient was given intravenous prophylactic antibiotics She was taken to the operating suite under the auspices of Anesthesiology She was given a left upper extremity bier block Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution Afterwards a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment Dissection was carried down through the dermis into the subcutaneous tissue The dorsal radial sensory branches were kept out of harm s way They were retracted gently to the ulnar side of the wrist The retinaculum was incised with a 15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally Both the extensor pollices brevis and abductor pollices longus tendons were identified There was no pathology noted within the first dorsal extensor compartment The wound was irrigated Hemostasis was obtained with bipolar cautery The wound was infiltrated with _0 25 Marcaine solution and then closure performed with 6 0 nylon suture utilizing a horizontal mattress stitch Sterile occlusive dressing was applied along with the thumb spica splint The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition Keywords orthopedic dorsal extensor compartment de quervain tendonitis dorsal extensor quervain tendonitis retinaculum tenosynovitis tourniquet MEDICAL_TRANSCRIPTION,Description Trauma ATV accident resulting in left open humerus fracture Medical Specialty Orthopedic Sample Name Discharge Summary ATV Accident Transcription ADMITTING DIAGNOSIS Trauma ATV accident resulting in left open humerus fracture DISCHARGE DIAGNOSIS Trauma ATV accident resulting in left open humerus fracture SECONDARY DIAGNOSIS None HISTORY OF PRESENT ILLNESS For complete details please see dictated history and physical by Dr X dated July 23 2008 Briefly the patient is a 10 year old male who presented to the Hospital Emergency Department following an ATV accident He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters The patient denies any loss of consciousness He was not amnestic to the event He was taken by family members to the Iredell County Hospital where he was initially evaluated Due to the extent of his injuries he was immediately transferred to Hospital Emergency Department for further evaluation HOSPITAL COURSE Upon arrival in the Hospital Emergency Department he was noted to have an open left humerus fracture No other apparent injuries This was confirmed with radiographic imaging showing that the chest and pelvis x rays were negative for any acute injury and that the cervical spine x ray was negative for fracture malalignment The left upper extremity x ray did demonstrate an open left distal humerus fracture The orthopedic surgery team was then consulted and upon their evaluation the patient was taken emergently to the operating room for surgical repair of his left humerus fracture In the operating room the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture In the operating room his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures Throughout the duration of the procedure the patient had a palpable distal radial pulse The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture A wound VAC was then placed over the wound at the conclusion of the procedure The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring His diet was advanced and his pain was controlled with pain medication The day following his surgery the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C collar was removed at that point Once his C spine had been cleared and the absence of a closed head injury was confirmed The patient was then transferred from the Intensive Care Unit to the General Floor bed His clinical status continued to improve and on July 26 2008 he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound He again tolerated this procedure well on his return to the General Pediatrics Floor Throughout his stay there was concern for compartment syndrome due to the nature and extent of his injuries However frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity Moreover the patient had no complaints of paresthesia There was no demonstration of pallor or pain on passive motion There was good capillary refill to the digits of the left hand By the date of the discharge the patient was on a full pediatric select diet and was tolerating this well He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies He was afebrile and his vital signs were stable and once cleared by Orthopedics he was deemed appropriate for discharge PROCEDURES DURING THIS HOSPITALIZATION 1 Irrigation and debridement of open type 3 subcondylar left distal humerus fracture July 23 2008 2 Open reduction and internal fixation of the left supracondylar humerus fracture July 23 2008 3 Negative pressure wound dressing July 23 2008 4 Irrigation and debridement of left elbow fracture July 26 2008 5 CT of the brain without contrast July 24 2008 DISPOSITION Home with parents INVASIVE LINES None DISCHARGE INSTRUCTIONS The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities move furniture lift heavy objects or use his left upper extremity He was asked to followup with return appointment in one week to see Dr Y in Orthopedics Additionally he was told to call his pediatrician if he develops any fevers pain loss of sensation loss of pulse or discoloration of his fingers or paleness to his hand Keywords orthopedic humerus fracture trauma irrigation and debridement atv accident upper extremity humerus fracture MEDICAL_TRANSCRIPTION,Description Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block for sacroiliac joint pain Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine Medical Specialty Orthopedic Sample Name Dorsal Ramus Branch Block Transcription PROCEDURE Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block INDICATION Sacroiliac joint pain INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient The patient was given opportunity to ask questions regarding the procedure its indications and the associated risks The risk of the procedure discussed include infection bleeding allergic reaction dural puncture headache nerve injuries spinal cord injury and cardiovascular and CNS side effects with possible vascular entry of medications I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives narcotics nonionic contrast agents anesthetics and corticosteroids The patient was informed both verbally and in writing The patient understood the informed consent and desired to have the procedure performed PROCEDURE Oxygen saturation and vital signs were monitored continuously throughout the procedure The patient remained awake throughout the procedure in order to interact and give feedback The X ray technician was supervised and instructed to operate the fluoroscopy machine The patient was placed in the prone position on the treatment table pillow under the chest and head rotated contralateral to the side being treated The skin over and surrounding the treatment area was cleaned with Betadine The area was covered with sterile drapes leaving a small window opening for needle placement Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach The skin subcutaneous tissue and muscle within the planned approach were anesthetized with 1 Lidocaine With fluoroscopy a 25 gauge 3 5 inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1 S2 and S3 Multiple fluoroscopic views were used to ensure proper needle placement Approximately 0 25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern Finally the treatment solution consisting of 0 5 of bupivacaine was injected to each area All injected medications were preservative free Sterile technique was used throughout the procedure ADDITIONAL DETAILS This was then repeated on the left side COMPLICATIONS None DISCUSSION Postprocedure vital signs and oximetry were stable The patient was discharged with instructions to ice the injection site as needed for 15 20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day The patient was told to resume all medications The patient was told to resume normal activities The patient was instructed to seek immediate medical attention for shortness of breath chest pain fever chills increased pain weakness sensory or motor changes or changes in bowel or bladder function Follow up appointment was made at the PM R Spine Clinic in approximately 1 week Keywords orthopedic sacroiliac lateral branch block ramus block branch block sacroiliac joint dorsal ramus fluoroscopic branch dorsal ramus bilateral needle block MEDICAL_TRANSCRIPTION,Description Redo L4 5 diskectomy left recurrent herniation L4 5 disk with left radiculopathy Medical Specialty Orthopedic Sample Name Diskectomy Transcription PREOPERATIVE DIAGNOSIS ES Recurrent herniation L4 5 disk with left radiculopathy POSTOPERATIVE DIAGNOSIS ES Recurrent herniation L4 5 disk with left radiculopathy PROCEDURE Redo L4 5 diskectomy left COMPLICATIONS None ANTIBIOTIC S Vancomycin given preoperatively ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 10 mL BLOOD REPLACED None CRYSTALLOID GIVEN 800 mL DRAIN S None DESCRIPTION OF THE OPERATION The patient was brought to the operating room in supine position General endotracheal anesthesia was administered He was turned into the prone position on the operating table and positioned in the modified knee chest position with Andrews frame being used Care was taken to protect pressure points The back was shaved scrubbed with Betadine scrub rinsed with alcohol and prepped with DuraPrep and draped in the usual sterile fashion with Ioban drape being used A midline skin incision was made excising scar from previous surgery Dissection was carried down through the subcutaneous tissue with electrocautery technique The lumbosacral fascia was split to the left of the spinous process and subperiosteal dissection of the spinous process and lamina area of previous laminotomy was identified Cross table lateral was also made to confirm position The scar was then loosened from the inferior portion of 4 superior of L5 lamina and a portion of the lamina was removed I did identify normal dura The scar was then lysed from the medial wall Dura and nerve root were identified and protected with nerve root retractor The bulging disk fragment was still contained under the longitudinal ligament A rent was made with the Penfield and a moderately large fragment was removed The disk space was then entered with a cruciate cut in the annulus with additional nuclear material being received When no other fragments could be removed from the disk space no other fragments were felt in the central canal under the longitudinal ligament and a Murphy ball could be passed through the foramen without evidence of compression the decompression was complete Check was made for CSF leakage and no evidence of significant epidural bleeding was present The wound was irrigated with antibiotic solution Twenty milligrams of Depo Medrol was placed over the dura and nerve root A free fat graft from the subcutaneous tissue was then placed over the dura Closure was obtained with the lumbosacral fascia being reapproximated with 1 running Vicryl suture Subcutaneous closure was obtained in layers with 2 0 running Vicryl suture Skin closure was obtained with 3 0 Vicryl subcuticular suture Proxi Strips and sterile dressing was applied The skin had been infiltrated with 8 mL of 0 5 Marcaine with epinephrine After a sterile dressing was applied the patient was turned into the supine position on the waiting recovery room stretcher brought from under the effects of anesthesia and taken to the recovery room Keywords orthopedic herniation andrews frame csf leakage depo medrol l4 5 proxi strips diskectomy endotracheal anesthesia lumbosacral fascia modified knee chest position radiculopathy supine position nerve root duraprep MEDICAL_TRANSCRIPTION,Description Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System Medical Specialty Orthopedic Sample Name Decompressive Laminectomy Transcription PREOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression POSTOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression OPERATION PERFORMED Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click X System using 6 5 mm diameter x 40 mm length T11 screws and L1 screws 7 mm diameter x 45 mm length ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 400 mL replaced 2 units of packed cells Preoperative hemoglobin was less than 10 DRAINS None COMPLICATIONS None DESCRIPTION OF PROCEDURE With the patient prepped and draped in a routine fashion in the prone position on laminae support an x ray was taken and demonstrated a needle at the T12 L1 interspace An incision was made over the posterior spinous process of T10 T11 T12 L1 and L2 A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10 T11 T12 L1 and L2 An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent Initially on the patient s left side pedicle screws were placed in T11 and L1 The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle Placement confirmed with biplanar coaxial fluoroscopy The awl was in appropriate location and using a pedicle finder under fluoroscopic control the pedicle was probed to the mid portion of the body of T11 A 40 mm Click X screw 6 5 mm diameter with rod holder was then threaded into the T11 vertebral body Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra articular process was located using an AM 8 dissecting tool AM attachment to the Midas Rex instrumentation The area was decorticated an awl was placed and under fluoroscopic biplanar imaging noted to be at the pedicle in L1 Using a pedicle probe the pedicle was then probed to the mid body of L1 and a 7 mm diameter 45 mm in length Click X Synthes screw with rod holder was placed in the L1 vertebral body At this point an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient s ventral canal on the right side Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12 At this point a laminectomy was performed using 45 degree Kerrison rongeur both 2 mm and 4 mm and Leksell rongeur There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11 T12 interlaminar space Additionally there was marked instability of the facets bilaterally at T12 and L1 These facets were removed with 45 degree Kerrison rongeur and Leksell rongeur Bony compression both superiorly and laterally from fractured bony elements was removed with 45 degree Kerrison rongeur until the thecal sac was completely decompressed The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors and these nerve roots were noted to be completely free Hemostasis was controlled with bipolar coagulation At this point a Frazier dissector could be passed superiorly inferiorly medially and laterally to the T11 T12 nerve roots bilaterally and the thecal sac was noted to be decompressed both superiorly and inferiorly and noted to be quite pulsatile A 4 Penfield was then used to probe the floor of the spinal canal and no significant ventral compression remained on the thecal sac Copious antibiotic irrigation was used and at this point on the patient s right side pedicle screws were placed at T11 and L1 using the technique described for a left sided pedicle screw placement The anatomic landmarks being the transverse process at T11 the inferior articulating facet and the lateral aspect of the superior articular facet for T11 and at L1 the transverse process the junction of the intra articular process and the facet joint With the screws placed on the left side the elongated rod was removed from the patient s right side along with the locking caps which had been placed It was felt that distraction was not necessary A 75 mm rod could be placed on the patient s left side with reattachment of the locking screw heads with the rod cap locker in place however it was necessary to cut a longer rod for the patient s right side with the screws slightly greater distance apart ultimately settling on a 90 mm rod The locking caps were placed on the right side and after all 4 locking caps were placed the locking cap screws were tied to the cold weld Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11 T12 or T12 L1 with excellent positioning of the rods and screws A crosslink approximately 60 mm in width was then placed between the right and left rods and all 4 screws were tightened It should be noted that prior to the placement of the rods the patient s autologous bone which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11 T12 and L1 with AM 8 dissecting tool AM attachment as well as the lateral aspects of the facet joints This was done bilaterally prior to placement of the rods Following placement of the rods as noted above allograft bone chips were packed in addition on top of the patient s own allograft in these posterolateral gutters Gelfoam was used to cover the thecal sac and at this point the wound was closed by approximating the deep muscle with 0 Vicryl suture The fascia was closed with interrupted 0 Vicryl suture subcutaneous layer was closed with 2 0 Vicryl suture subcuticular layer was closed with 2 0 inverted interrupted Vicryl suture and the skin approximated with staples The patient appeared to tolerate the procedure well without complications Keywords orthopedic facetectomies decompression posterolateral fusion synthes click x system decompressive laminectomy leksell rongeur kerrison rongeur transverse processes thecal sac nerve roots pedicle screws spinous process pedicle process screws rods laminectomy decompressive spinous MEDICAL_TRANSCRIPTION,Description Wrist de Quervain stenosing tenosynovitis de Quervain release Fascial lengthening flap of the 1st dorsal compartment Medical Specialty Orthopedic Sample Name de Quervain Release Wrist Transcription PREOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis POSTOPERATIVE DIAGNOSIS Wrist de Quervain stenosing tenosynovitis TITLE OF PROCEDURES 1 de Quervain release 2 Fascial lengthening flap of the 1st dorsal compartment ANESTHESIA MAC COMPLICATIONS None PROCEDURE IN DETAIL After MAC anesthesia and appropriate antibiotics were administered the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision just distal to the radial styloid Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected Meticulous hemostasis was maintained with bipolar electrocautery I dissected the sheath superficially free of any other structures specifically the superficial radial nerve I then incised it under direct vision dorsal to its axis and incised it both proximally and distally The EPB subsheath was likewise released I irrigated the wound thoroughly In order to prevent tendon subluxation I then back cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position I did this with 3 0 Vicryl I then passed an instrument underneath to check and make sure that the sheath was not too tight I then irrigated it and closed the skin and then I dressed and splinted the wrist appropriately The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic de quervain tenosynovitis de quervain release fascial lengthening flap dorsal compartment sheath wrist dorsal tourniquet MEDICAL_TRANSCRIPTION,Description Degenerative disk disease at L4 L5 and L5 S1 Anterior exposure diskectomy and fusion at L4 L5 and L5 S1 Medical Specialty Orthopedic Sample Name Diskectomy Fusion Transcription PREOPERATIVE DIAGNOSIS Degenerative disk disease at L4 L5 and L5 S1 POSTOPERATIVE DIAGNOSIS Degenerative disk disease at L4 L5 and L5 S1 PROCEDURE PERFORMED Anterior exposure diskectomy and fusion at L4 L5 and L5 S1 ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 150 mL PROCEDURE IN DETAIL Patient was prepped and draped in sterile fashion Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie and then preperitoneal space was opened The iliac veins were carefully mobilized medially and then the L4 L5 disk space was confirmed by fluoroscopy and diskectomy fusion which will be separately dictated by Dr X was performed after the adequate exposure was gained and then after this L4 L5 disk space was fused and the L5 S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips disk was carefully exposed Diskectomy and fusion which will be separately dictated by Dr X were performed Once this was completed all hemostasis was confirmed The preperitoneal space was reduced X ray confirmed adequate positioning and fusion Then the fascia was closed with 1 Vicryl sutures and then the skin was closed in 2 layers the first layer being 2 0 Vicryl subcutaneous tissues and then a 4 0 Monocryl subcuticular stitch then dressed with Steri Strips and 4 x 4 s Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities Keywords orthopedic anterior exposure degenerative disk disease disk disease disk space diskectomy fusion MEDICAL_TRANSCRIPTION,Description Torn rotator cuff and subacromial spur with impingement syndrome right shoulder Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors Medical Specialty Orthopedic Sample Name Diagnostic Arthroscopy Transcription PREOPERATIVE DIAGNOSIS Torn rotator cuff right shoulder POSTOPERATIVE DIAGNOSES 1 Torn rotator cuff right shoulder 2 Subacromial spur with impingement syndrome right shoulder PROCEDURE PERFORMED 1 Diagnostic arthroscopy with subacromial decompression 2 Open repair of rotator cuff using three Panalok suture anchors ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Approximately 200 cc INTRAOPERATIVE FINDINGS There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity There is moderate amount of synovitis noted throughout the glenohumeral joint There is a small subacromial spur noted on the very anterolateral border of the acromion HISTORY This is a 62 year old female who previously underwent a repair of rotator cuff She continued to have pain within the shoulder She had a repeat MRI performed which confirmed the clinical diagnosis of re tear of the rotator cuff She wished to proceed with a repair All risks and benefits of the surgery were discussed with her at length She was in agreement with the above treatment plan PROCEDURE On 08 21 03 she was taken to the Operative Room at ABCD General Hospital She was placed supine on the operating table General anesthesia was applied by the Anesthesiology Department She was placed in the modified beachchair position Her upper extremity was sterilely prepped and draped in usual fashion A stab incision was made in the posterior aspect of the glenohumeral joint A camera was placed in the joint and was insufflated with saline solution Intraoperative pictures were obtained and the above findings were noted A second port site was initiated anteriorly Through this a probe was placed and the intraarticular structures were palpated and found to be intact A tear of the inner surface of the rotator cuff was identified The camera was then taken to the subacromial space A straight lateral portal was also used and a shaver was placed into the subacromial space Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur which had reformed The edges of the rotator cuff were then debrided The camera was then removed and the shoulder was suction and dried A lateral incision was made over the anterolateral border of the acromion Subcuticular tissues were carefully dissected Hemostasis was controlled with electrocautery The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur A trough was then made in the greater tuberosity using the rongeur Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff The ends of the suture were tied down from the fixating the rotator cuff within the trough The rotator cuff was then further oversewed using the Panalok suture The wound was then copiously irrigated and it was then suction dried The deltoid muscle was reapproximated using 1 Vicryl A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control The subcutaneous tissues were reapproximated with 2 0 Vicryl The skin was closed with 4 0 PDS running subcuticular stitch Sterile dressing was applied to the upper extremity She was then placed in a shoulder immobilizer She was transferred to the recovery room in apparent stable and satisfactory condition Prognosis for this patient was guarded She will begin pendulum exercises postoperative day 3 She will follow back in the office in 10 to 14 days for reevaluation Physical therapy initiated approximately six weeks postoperatively Keywords orthopedic subacromial decompression panalok suture repair of rotator cuff torn rotator cuff diagnostic arthroscopy subacromial space subacromial spur arthroscopy panalok shoulder subacromial MEDICAL_TRANSCRIPTION,Description Incision and drainage with extensive debridement left shoulder Removal total shoulder arthroplasty uncemented humeral Biomet component cemented glenoid component Implantation of antibiotic beads left shoulder Medical Specialty Orthopedic Sample Name Debridement Shoulder Transcription TITLE OF OPERATION 1 Incision and drainage with extensive debridement left shoulder 2 Removal total shoulder arthroplasty uncemented humeral Biomet component cemented glenoid component 3 Implantation of antibiotic beads left shoulder INDICATION FOR SURGERY The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain incomplete return of function fractures loss of bone medical complications surgical complications transfusion related complications etc The patient understood and wished to proceed PREOP DIAGNOSIS Presumed infection left total shoulder arthroplasty POSTOP DIAGNOSES 1 Deep extensive infection left total shoulder arthroplasty 2 Biceps tenosynovitis 3 Massive rotator cuff tear in left shoulder full thickness subscapularis tendon rupture 3 cm x 4 cm supraspinatus tendon rupture 3 cm x 3 cm infraspinatus tear 2 cm x 2 cm DESCRIPTION OF PROCEDURE The patient was anesthetized in the supine position a Foley catheter was placed in his bladder He was then placed Beach chair position and all bony prominences were well padded Pillows were placed around his knees to protect his sciatic nerve He was brought to the side of the table and secured with towels and tape The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch Left upper extremity was then prepped and draped in usual sterile fashion Unfortunately preoperative antibiotics were given prior to the procedure This occurred due to lack of communication between the surgical staff and the anesthesia staff The patient s extremity however was prepped a second time with a chlorhexidine prep after he had been draped Also Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder Deltopectoral incision was then made The patient s had a cephalic vein it was identified and protected throughout the case It was retracted laterally and once this has been completed the deltopectoral interval was developed as carefully as possible The patient did have significant scar from this point on and did bleed from many surfaces throughout the case As a result he was transfused 1 unit postoperatively He did not have any problems during the case except for one small drop of blood pressure However this was due primarily because of the extensive scarring of his proximal humerus He had scar between the anterior capsular structures and the conjoint tendon Also there was significant scar between the deltoid and the proximal humerus The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve Once the plane between the deltoid and underlying tissue was found the proximal humerus was discovered to have a large defect approximately 4 x 3 This was covered by rimmed fibrous tissue which was fairly compressible which felt to be purulent however when the needle was stuck into this area there was no return of fluid As a result this was finally opened and found to have fibrinous exudates which appeared to be old congealed purulent material There was some suggestion of a synovitis type reaction also inside this cystic area This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm All of the mucinous material and fibrinous material was removed from the proximal humerus This was fairly extensive debridement All of this was sent to pathology and also sent for culture and sensitivity It should be noted that Gram stain became as multiple white blood cells but no organism seen The pathology came back as fibrinous material with multiple white cells also with signs of chronic inflammation consistent with an infection Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous This was also removed Once this was removed though the capsule was found to be very thin there was essentially no subscapularis tendon whatsoever It should also noted the patient s proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever As a result the biceps tendon was finally identified just below the pectoralis tendon insertion The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps It was tracked proximally and transverse ligament released The biceps tendon was flat and somewhat erythematous As a result it released and tagged with an 0 Vicryl suture It was later tenodesed to the conjoint tendon using 2 0 Prolene sutures The joint was then entered and noted significant synovitis throughout the entire glenoid This was all very carefully removed using a rongeur and sharp dissection Next the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set Unfortunately this device would not hold the proximal humerus and we could not get the component to release As a result bone contact of the metal proximally was released using a straight osteotome Once this was completed another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed we abandoned use of that particular device and using a __________ we were able to hit the prosthesis lip from beneath and essentially remove it There was no cement There was exudate within the canal which was removed using a curette Using fluoroscopy sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate This was also thoroughly irrigated with irrigation antibiotic and impregnated irrigation to decrease any risk of infection It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point The attention was then directed to the glenoid The glenoid component was very carefully dissected free and found to be very loose It was essentially removed with digital dissection There was no remaining cement in the cavity itself The patient s glenoid was very carefully debrided The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself Next the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation Rather than place a spacer it was elected to use antiobiotic beads This was with antibiotic impregnated cement with one package with 3 gram of vancomycin These beads were then connected using Prolene and placed into the glenoid cavity itself also some were placed in the greater tuberosity region These three did not have a Prolene attached to them The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself The biceps tendon was then tenodesed under tension to the conjoint tendon There was essentially no capsule left purely to close over the proximal humerus It was electively the proximal humerus A portion of bone intact because it did have some bleeding surfaces Deltopectoral was then closed with 0 Vicryl sutures the deep subcutaneous tissues with 0 Vicryl sutures superficial subcutaneous tissues with 2 0 Vicryl sutures Skin was closed with staples A sterile bandage was applied along with a cold therapy device and shoulder immobilizer The patient was sent to recovery room in stable and satisfactory condition It should be noted that __________ is being requested for this case This was a significantly scarred patient which required extra dissection and attention Even though this was a standard revision case due to infection there was a significant more decision making and technical challenges in this case and this was present for typical revision case Similarly this case took approximately 30 to 40 more length of time due to bleeding and the attention to hemostasis The blood loss and operative findings indicates that this case was at least 30 to 40 more challenging than a standard total shoulder or revision case This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever Keywords orthopedic incision and drainage shoulder arthroplasty extensive debridement uncemented humeral biomet cemented antibiotic beads biceps tenosynovitis rotator cuff tear total shoulder arthroplasty proximal humerus vicryl sutures glenoid tendon proximal humerus beads shoulder incision MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome and de Quervain s stenosing tenosynovitis Carpal tunnel release and de Quervain s release A longitudinal incision was made in line with the 4th ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis Medical Specialty Orthopedic Sample Name de Quervain Release Carpal Transcription PREOPERATIVE DIAGNOSIS 1 Carpal tunnel syndrome 2 de Quervain s stenosing tenosynovitis POSTOPERATIVE DIAGNOSIS 1 Carpal tunnel syndrome 2 de Quervain s stenosing tenosynovitis TITLE OF PROCEDURE 1 Carpal tunnel release 2 de Quervain s release ANESTHESIA MAC COMPLICATIONS None PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the 4th ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis The subcutaneous fat was dissected radially from 2 3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly and the distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with scissors After irrigating the wound with copious amounts of normal saline the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4 0 Vicryl Care was taken to avoid entrapping the motor branch of the median nerve in the suture A hemostat was placed under the repair to ensure that the median nerve was not compressed The skin was repaired with 5 0 nylon interrupted stitches The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches I released the compartment in a separate subsheath for the EPB on the dorsal side Both ends of the sheath were released to lengthen them and then these were repaired with 4 0 Vicryl It was checked to make sure that there was significant room remaining for the tendons This was done to prevent postoperative subluxation I then irrigated and closed the wounds in layers Marcaine with epinephrine was placed into all wounds and dressings and splint were placed The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic de quervain s release carpal tunnel syndrome tenosynovitis carpal incision aponeurosis tunnel cut MEDICAL_TRANSCRIPTION,Description CT REPORT Soft Tissue Neck Medical Specialty Orthopedic Sample Name CT Neck 1 Transcription FINDINGS There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm mediolateral x AP x craniocaudal in size There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds There is marked enlargement of the bilateral aryepiglottic folds left greater than right There is thickening of the glossoepiglottic fold There is an infiltrative mass like lesion extending into the pre epiglottic space There is no demonstrated effacement of the piriform sinuses The mass obliterates the right vallecula The paraglottic spaces are normal The true and false cords appear normal Normal thyroid cricoid and arytenoid cartilages There is lobulated thickening of the right side of the tongue base for which invasion of the tongue cannot be excluded A MRI examination would be of benefit for further evaluation of this finding There is a 14 x 5 x 12 mm node involving the left submental region Level I There is borderline enlargement of the bilateral jugulodigastric nodes Level II The left jugulodigastric node measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node with a probable necrotic center There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease There is no demonstrated pretracheal prelaryngeal or superior mediastinal nodes There is no demonstrated retropharyngeal adenopathy There is thickening of the adenoidal pad without a mass lesion of the nasopharynx The torus tubarius and fossa of Rosenmuller appear normal IMPRESSION Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre epiglottic space with invasion of the bilateral aryepiglottic folds Lobulated tongue base for which tongue invasion cannot be excluded An MRI may be of benefit for further assessment of this finding Borderline enlargement of a submental node suggesting Level I adenopathy Bilateral deep cervical nodal disease involving bilateral Level II Level III and left Level IV Keywords orthopedic deep cervical node epiglottic mass epiglottic space aryepiglottic folds jugulodigastric nodes level deep cervical node deep cervical node jugulodigastric aryepiglottic deep cervical MEDICAL_TRANSCRIPTION,Description Noncontrast CT scan of the lumbar spine Left lower extremity muscle spasm Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested Medical Specialty Orthopedic Sample Name CT Lumbar Spine Transcription EXAM Noncontrast CT scan of the lumbar spine REASON FOR EXAM Left lower extremity muscle spasm COMPARISONS None FINDINGS Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested No abnormal paraspinal masses are identified There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally There is marked intervertebral disk space narrowing at the L5 S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes Posterior disk osteophyte complex is present most marked in the left paracentral to lateral region extending into the lateral recess on the left This most likely will affect the S1 nerve root on the left There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly There is mild neural foraminal stenosis present Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root There is facet sclerosis bilaterally Mild lateral recess stenosis just on the right there is prominent anterior spondylosis At the L4 5 level mild bilateral facet arthrosis is present There is broad based posterior annular disk bulging or protrusion which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally No moderate or high grade central canal or neural foraminal stenosis is identified At the L3 4 level anterior spondylosis is present There are endplate degenerative changes with mild posterior annular disk bulging but no evidence of moderate or high grade central canal or neural foraminal stenosis At the L2 3 level there is mild bilateral ligamentum flavum hypertrophy Mild posterior annular disk bulging is present without evidence of moderate or high grade central canal or neural foraminal stenosis At the T12 L1 and L1 2 levels there is no evidence of herniated disk protrusion central canal or neural foraminal stenosis There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation No bony destructive changes or acute fractures are identified CONCLUSIONS 1 Advanced degenerative disk disease at the L5 S1 level 2 Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5 S1 level laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis 3 Mild bilateral neural foraminal stenosis at the L5 S1 level 4 Posterior disk bulging at the L2 3 L3 4 and L4 5 levels without evidence of moderate or high grade central canal stenosis 5 Facet arthrosis to the lower lumbar spine 6 Arteriosclerotic vascular disease Keywords orthopedic noncontrast ct scan lower extremity muscle spasm neural foraminal stenosis lumbar spine spine disk lumbar ct intervertebral canal foraminal noncontrast stenosis MEDICAL_TRANSCRIPTION,Description CT of Lumbar Spine without Contrast Patient with history of back pain after a fall Medical Specialty Orthopedic Sample Name CT of Lumbar Spine w o Contrast Transcription EXAM Lumbar spine CT without contrast HISTORY Back pain after a fall TECHNIQUE Noncontrast axial images were acquired through the lumbar spine Coronal and sagittal reconstruction views were also obtained FINDINGS There is no evidence for acute fracture or subluxation There is no spondylolysis or spondylolisthesis The central canal and neuroforamen are grossly patent at all levels There are no abnormal paraspinal masses There is no wedge compression deformity There is intervertebral disk space narrowing to a mild degree at L2 3 and L4 5 Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta which is not dilated There was incompletely visualized probable simple left renal cyst exophytic at the lower pole IMPRESSION 1 No evidence for acute fracture or subluxation 2 Mild degenerative changes 3 Probable left simple renal cyst Keywords orthopedic lumbar spine back pain ct coronal atherosclerotic axial images central canal compression deformity degenerative disk space fracture intervertebral neuroforamen sagittal spondylolisthesis spondylolysis subluxation wedge without contrast contrast spine lumbar noncontrast MEDICAL_TRANSCRIPTION,Description This is a middle aged female with low back pain radiating down the left leg and foot for one and a half years Medical Specialty Orthopedic Sample Name CT Lumbar Spine 1 Transcription FINDINGS High resolution computerized tomography was performed from T12 L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed COMPARISON Previous MRI examination 10 13 2004 There is minimal curvature of the lumbar spine convex to the left T12 L1 L1 2 L2 3 There is normal disc height with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints L3 4 There is normal disc height and non compressive circumferential annular disc bulging eccentrically greater to the left Normal central canal and facet joints image 255 L4 5 There is normal disc height circumferential annular disc bulging left L5 hemilaminectomy and posterior central right paramedian broad based disc protrusion measuring 4mm AP contouring the rightward aspect of the thecal sac Orthopedic hardware is noted posteriorly at the L5 level Normal central canal facet joints and intervertebral neural foramina image 58 L5 S1 There is minimal decreased disc height postsurgical change with intervertebral disc spacer posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position The orthopedic hardware creates mild streak artifact which mildly degrades images There is a laminectomy defect spondylolisthesis with 3 5mm of anterolisthesis of L5 posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root There is fusion of the facet joints normal central canal and right neural foramen image 69 70 135 There is no bony destructive change noted There is no perivertebral soft tissue abnormality There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery IMPRESSION Minimal curvature of the lumbar spine convex to the left L3 4 posterior non compressive annular disc bulging eccentrically greater to the left L4 5 circumferential annular disc bulging non compressive central right paramedian disc protrusion left L5 laminectomy L5 S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position intervertebral disc spacer spondylolisthesis laminectomy defect posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement Minimal to mild arteriosclerotic vascular calcifications Keywords orthopedic posterior annular disc circumferential annular disc normal central canal annular disc bulging lumbar spine posterior annular facet joints annular disc disc bulging tomography disc lumbar postsurgical spine annular bulging MEDICAL_TRANSCRIPTION,Description This is a middle aged female with two month history of low back pain and leg pain Medical Specialty Orthopedic Sample Name CT Lumbar Spine 2 Transcription FINDINGS Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes Preliminary scout film demonstrates anterior end plate spondylosis at T11 12 and T12 L1 L1 2 There is normal disc height anterior end plate spondylosis very minimal vacuum change with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints image 4 L2 3 There is mild decreased disc height anterior end plate spondylosis circumferential disc protrusion measuring 4 6mm AP and right extraforaminal osteophyte disc complex There is mild non compressive right neural foraminal narrowing minimal facet arthrosis normal central canal and left neural foramen image 13 L3 4 There is normal disc height anterior end plate spondylosis and circumferential non compressive annular disc bulging The disc bulging flattens the ventral thecal sac and there is minimal non compressive right neural foraminal narrowing minimal to mild facet arthrosis with vacuum change on the right normal central canal and left neural foramen image 25 L4 5 Keywords orthopedic anterior end plate spondylosis compressive right neural foraminal compressive annular disc bulging anterior end plate annular disc bulging normal central canal plate spondylosis central canal vacuum change disc bulging neural foraminal facet arthrosis anterior spondylosis neural lumbar disc bulging foraminal arthrosis facet MEDICAL_TRANSCRIPTION,Description CT REPORT Soft Tissue Neck Medical Specialty Orthopedic Sample Name CT Neck 2 Transcription FINDINGS There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2 4 X 3 9 X 3 0cm AP X transverse X craniocaudal in size The lesion is well demarcated There is a solid peripheral rim with a mean attenuation coefficient of 56 3 There is a central cystic appearing area with a mean attenuation coefficient of 28 1 HU suggesting an area of central necrosis There is the suggestion of mild peripheral rim enhancement This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve Primary consideration is of a benign mixed tumor pleomorphic adenoma however other solid mass lesions cannot be excluded for which histologic evaluation would be necessary for definitive diagnosis The right parotid gland is normal There is mild enlargement of the left jugulodigastric node measuring 1 1cm in size with normal morphology image 33 68 There is mild enlargement of the right jugulodigastric node measuring 1 2cm in size with normal morphology image 38 68 There are demonstrated bilateral deep lateral cervical nodes at the midlevel measuring 0 6cm on the right side and 0 9cm on the left side image 29 68 There is a second midlevel deep lateral cervical node demonstrated on the left side image 20 68 measuring 0 7cm in size There are small bilateral low level nodes involving the deep lateral cervical nodal chain image 15 68 measuring 0 5cm in size There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains The right parotid gland is normal and there is no right parotid gland mass lesion Normal bilateral submandibular glands Normal parapharyngeal retropharyngeal and perivertebral spaces Normal carotid spaces IMPRESSION Large well demarcated mass lesion of the deep lobe of the left parotid gland with probable involvement of the left facial nerve See above for size morphology and pattern enhancement Primary consideration is of a benign mixed tumor pleomorphic adenoma however other solid mass lesions cannot be excluded for which histologic evaluation is necessary for specificity Multiple visualized nodes of the bilateral deep lateral cervical nodal chain within normal size and morphology most compatible with mild hyperplasia Keywords orthopedic cervical nodal mass lesion deep lobe deep lateral lateral cervical parotid gland cervical lesion gland parotid deep MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Orthopedic Sample Name CT Head Facial Bones Cervical Spine 1 Transcription CT HEAD WITHOUT CONTRAST CT FACIAL BONES WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD TECHNIQUE Noncontrast axial CT images of the head were obtained without contrast FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved No calvarial fracture is seen IMPRESSION Negative for acute intracranial disease CT FACIAL BONES WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions FINDINGS There is no facial bone fracture The maxilla and mandible are intact The visualized paranasal sinuses are clear The temporomandibular joints are intact The nasal bone is intact The orbits are intact The extra ocular muscles and orbital nerves are normal The orbital globes are normal IMPRESSION No evidence for a facial bone fracture CT CERVICAL SPINE WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions FINDINGS There is a normal lordosis of the cervical spine no fracture or subluxation is seen The vertebral body heights are normal The intervertebral disk spaces are well preserved The atlanto dens interval is normal No abnormal anterior cervical soft tissue swelling is seen There is no spinal compression deformity IMPRESSION Negative for a facial bone fracture Keywords orthopedic intracranial disease motor vehicle collision orbital nerves extra ocular muscles cervical spine ct cervical spine ct facial bones ct head axial ct images facial bone fracture facial bones ct noncontrast intracranial axial spine fracture cervical contrast facial bones MEDICAL_TRANSCRIPTION,Description Common CT C Spine template Medical Specialty Orthopedic Sample Name CT C Spine Transcription TECHNIQUE Sequential axial CT images were obtained through the cervical spine without contrast Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures FINDINGS The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture dislocation or spondylolisthesis The vertebral body heights and disc spaces are maintained The central canal is patent The pedicles and posterior elements are intact The paravertebral soft tissues are within normal limits The atlanto dens interval and the dens are intact The visualized lung apices are clear IMPRESSION No acute abnormalities Keywords orthopedic sequential axial ct images atlanto dens interval dens ct c spine cervical spineNOTE MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast and CT cervical spine without contrast Noncontrast axial CT images of the head were obtained Medical Specialty Orthopedic Sample Name CT Head and C Spine Transcription CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the head were obtained FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved There is no calvarial fracture The visualized paranasal sinuses and mastoid air cells are clear IMPRESSION Negative for acute intracranial disease CT CERVICAL SPINE TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained Sagittal and coronal images were obtained FINDINGS Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms No fracture or subluxation is seen Anterior and posterior osteophyte formation is seen at C5 C6 No abnormal anterior cervical soft tissue swelling is seen No spinal compression is noted The atlanto dens interval is normal There is a large retention cyst versus polyp within the right maxillary sinus IMPRESSION 1 Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms 2 Degenerative disk and joint disease at C5 C6 3 Retention cyst versus polyp of the right maxillary sinus Keywords orthopedic muscle spasms cervical lordosis intracranial hemorrhage motor vehicle collision axial ct images ct head ct anterior cyst polyp maxillary contrast intracranial sinuses spine axial head cervical noncontrast MEDICAL_TRANSCRIPTION,Description CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Orthopedic Sample Name CT Head Facial Bones Cervical Spine Transcription EXAM CT head without contrast CT facial bones without contrast and CT cervical spine without contrast REASON FOR EXAM A 68 year old status post fall with multifocal pain COMPARISONS None TECHNIQUE Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast Additional high resolution sagittal and or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures INTERPRETATIONS HEAD There is mild generalized atrophy Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes There are subtle areas of increased attenuation seen within the frontal lobes bilaterally Given the patient s clinical presentation these likely represent small hemorrhagic contusions Other differential considerations include cortical calcifications which are less likely The brain parenchyma is otherwise normal in attenuation without evidence of mass midline shift hydrocephalus extra axial fluid or acute infarction The visualized paranasal sinuses and mastoid air cells are clear The bony calvarium and skull base are unremarkable FACIAL BONES The osseous structures about the face are grossly intact without acute fracture or dislocation The orbits and extra ocular muscles are within normal limits There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses The remaining visualized paranasal sinuses and mastoid air cells are clear Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture CERVICAL SPINE There is mild generalized osteopenia There are diffuse multilevel degenerative changes identified extending from C4 C7 with disk space narrowing sclerosis and marginal osteophyte formation The remaining cervical vertebral body heights are maintained without acute fracture dislocation or spondylolisthesis The central canal is grossly patent The pedicles and posterior elements appear intact with multifocal facet degenerative changes There is no prevertebral or paravertebral soft tissue masses identified The atlanto dens interval and dens are maintained IMPRESSION 1 Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions There is no associated shift or mass effect at this time Less likely this finding could be secondary to cortical calcifications The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated 2 Atrophy and chronic small vessel ischemic changes in the brain 3 Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture 4 Osteopenia and multilevel degenerative changes in the cervical spine as described above 5 Findings were discussed with Dr X from the emergency department at the time of interpretation Keywords orthopedic sagittal coronal soft tissue swelling paranasal sinuses mastoid air acute fracture maxillary sinuses tissue swelling underlying fracture multilevel degenerative ct head soft tissue facial bones cervical spine ct facial bones spine cervical MEDICAL_TRANSCRIPTION,Description The patient has been suffering from intractable back and leg pain Medical Specialty Orthopedic Sample Name Consult Back Leg Pain Transcription Her axial back pain is greatly improved but not completely eradicated There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption PAST MEDICAL HISTORY Significant for anxiety disorder PAST SURGICAL HISTORY Foot surgery abdominal surgery and knee surgery CURRENT MEDICATIONS Lipitor and Lexapro ALLERGIES She is allergic to sulfa medications SOCIAL HISTORY She is married retired Denies tobacco or ethanol use FAMILY HISTORY Father died of mesothelioma Mother gastric problems REVIEW OF SYSTEMS No recent history of night sweats fevers weight loss visual changes loss of consciousness convulsion or dysphagia Otherwise review of systems is unremarkable and a detailed history can be found in the patient s chart PHYSICAL EXAMINATION Physical exam can be found in great detail in the patient s chart ASSESSMENT AND PLAN The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome Her lumbar facet joints were denervated approximately 6 months ago The denervation procedure helped her axial back pain approximately 40 when standing With extension and rotation it helped her axial back pain approximately 70 She is now able to swing a golf club She was unable to swing a golf club due to the rotational movements before her rhizotomy She is currently playing golf Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p o b i d We will follow her up in 1 month s time Keywords orthopedic multilevel lumbar internal disc disruption denervation procedure lumbar facet joint syndrome swing a golf lumbar internal disc internal disc disruption lumbar internal internal disc disc disruption intractable surgery disc lumbar MEDICAL_TRANSCRIPTION,Description Lateral and plantar condylectomy fifth left metatarsal Medical Specialty Orthopedic Sample Name Condylectomy Transcription TITLE OF OPERATION Lateral and plantar condylectomy fifth left metatarsal PREOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal POSTOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal ANESTHESIA Monitored anesthesia care with 10 mL of 1 1 mixture of both 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 30 minutes left ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 3 0 Vicryl and 4 0 Vicryl INJECTABLES Ancef 1 g IV 30 minutes preoperatively DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in a supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in a normal sterile technique The left ankle tourniquet was inflated Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4 cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe The incision was deepened through the subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the soft tissue attachments through the fifth left metatarsal head were mobilized The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved The bony prominences were removed and passed off the operating table to be sent to pathology for identification The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp The area was copiously flushed with saline Then 3 0 Vicryl and 4 0 Vicryl suture materials were used to approximate the periosteal capsular and subcutaneous tissues respectively The incision was reinforced with Steri Strips Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited The patient s left ankle tourniquet at this time was deflated Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage and the patient s left foot was placed in a surgical shoe The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels The patient was given pain medications and instructions on how to control her postoperative course She was discharged from Hospital according to nursing protocol and was will follow up with Dr X in one week s time for her first postoperative appointment Keywords orthopedic plantar condyle hypertrophy condyle hypertrophy subcutaneous tissues ankle tourniquet metatarsophalangeal joint metatarsal head plantar condylectomy tourniquet condylectomy plantar ankle metatarsal MEDICAL_TRANSCRIPTION,Description Closed reduction percutaneous pinning left distal humerus Closed type III supracondylar fracture left distal humerus Tethered brachial artery left elbow Medical Specialty Orthopedic Sample Name Closed Reduction Percutaneous Pinning Transcription PREOPERATIVE DIAGNOSIS Closed type III supracondylar fracture left distal humerus POSTOPERATIVE DIAGNOSES 1 Closed type III supracondylar fracture left distal humerus 2 Tethered brachial artery left elbow PROCEDURE PERFORMED Closed reduction percutaneous pinning left distal humerus SPECIFICATIONS The entire operative procedure was done in the inpatient operating suite room 2 at ABCD General Hospital A portion of the procedure was done in consult with Dr X with separate dictation by him HISTORY AND GROSS FINDINGS This is a 4 year old white male apparently dominantly right handed who suffered a severe injury to his left distal humerus after jumping off of a swing He apparently had not had previous problems with his left arm He was seen in the Emergency with a grossly deformed left elbow His parents were both present preoperatively His x ray exam as well as physical exam was consistent with a closed type III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region Gross neurologic exam revealed his ulnar median and radial nerves to be mostly intact although a complete exam was impossible He did have a radial pulse palpable PROCEDURE After discussing the alternatives of the case as well as advantages and disadvantages risks complications and expectations with the patient s parents including malunion nonunion gross deformity growth arrest infection loss of elbow motions stiffness instability need for surgery in the future nerve problems artery problems and compartment syndrome they elected to proceed The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department Closed reduction was accomplished in a sequential manner Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly Then a slow longitudinal traction was carried out The elbow was hyperflexed Pressure placed upon the olecranon tip and two 0 045 K wires placed first one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve The close reduction was deemed to be acceptable once viewed on C arm After this pulse was attempted to be palpated distally Prior to the procedure I talked to Dr X of Vascular Surgery at ABCD Hospital He had scrubbed in to the case to follow up on the loss of the radial artery distally This was not present palpatory but also by Doppler A weak ulnar artery pulse was present via Doppler Because of this the severe displacement of the injury and the fact that the Doppler sound had an occlusion type sound just above the fracture site or _______ A long discussion was carried out with Dr X and myself and we decided to proceed with exploration of the brachial artery Prior to this I went out to the waiting room to discuss with the patient s parents the reasoning what we are going to do and the reasoning for this I then came back in and then we proceeded He was prepped and draped in the usual sterile manner Please see Dr X s report for the discussion of the exploration and release of the brachial artery There was no indication that it was actually in the fracture site the soft tissue had tethered in its right angle towards the fracture site thus reducing its efficiency of providing blood distally Once it was released both clinically on the table as well as by Doppler the patient had bounding pulses We then proceeded to close utilizing a 4 0 Vicryl for subcutaneous fat closure and a running 5 0 Vicryl subcuticular stitch for skin closure Steri Strips were placed The patient s arm was placed in just a slight degree of flexion with a neutral position He was splinted posteriorly Adaptic and fluffs have been placed around the patient s pin sites K wires have been bent cut and pin caps placed Expected surgical prognosis on this patient is guarded for the obvious reasons noted above There is concern for growth plate disturbance He will be watched very closely for the potential development of re perfusing compartment syndrome A full and complete neurologic exam will be impossible tonight but will be carried on a sequential basis starting tomorrow morning There is always a potential for loss of elbow motion overall cosmetic elbow alignment and elbow function Keywords orthopedic closed reduction percutaneous pinning distal humeru supracondylar fracture tethered brachial artery artery supracondylar brachial pinning reduction fracture humerus elbow MEDICAL_TRANSCRIPTION,Description Patient with complaint of left knee pain Patient is obese and will be starting Medifast Diet Medical Specialty Orthopedic Sample Name Consult Knee Pain Transcription CHIEF COMPLAINT Left knee pain SUBJECTIVE This is a 36 year old white female who presents to the office today with a complaint of left knee pain She is approximately five days after a third Synvisc injection She states that the knee is 35 to 40 better but continues to have a constant pinching pain when she full weight bears cannot handle having her knee in flexion has decreased range of motion with extension Rates her pain in her knee as a 10 10 She does alternate ice and heat She is using Tylenol No 3 p r n and ibuprofen OTC p r n with minimal relief ALLERGIES 1 PENICILLIN 2 KEFLEX 3 BACTRIM 4 SULFA 5 ACE BANDAGES MEDICATIONS 1 Toprol 2 Xanax 3 Advair 4 Ventolin 5 Tylenol No 3 6 Advil REVIEW OF SYSTEMS Will be starting the Medifast diet has discussed this with her PCP who encouraged her to have gastric bypass but the patient would like to try this Medifast diet first Other than this denies any further problems with her eyes ears nose throat heart lungs GI GU musculoskeletal nervous system except what is noted above and below PHYSICAL EXAMINATION VITAL SIGNS Pulse 72 blood pressure 130 88 respirations 16 height 5 feet 6 5 inches GENERAL This is a 36 year old white female who is A O x3 in no apparent distress with a pleasant affect She is well developed well nourished appears her stated age EXTREMITIES Orthopedic evaluation of the left knee reveals there to be well healed portholes She does have some medial joint line swelling Negative ballottement She has significant pain to palpation of the medial joint line none of the lateral joint line She has no pain to palpation on the popliteal fossa Range of motion is approximately 5 degrees to 95 degrees of flexion It should be noted that she has extreme hyperextension on the right with 95 degrees of flexion on the right She has a click with McMurray Negative anterior posterior drawer No varus or valgus instability noted Positive patellar grind test Calf is soft and nontender Gait is stable and antalgic on the left ASSESSMENT 1 Osteochondral defect torn meniscus left knee 2 Obesity PLAN I have encouraged the patient to work on weight reduction as this will only benefit her knee I did discuss treatment options at length with the patient but I think the best plan for her would be to work on weight reduction She questions whether she needs a total knee I don t believe she needs total knee replacement She may however at some point need an arthroscopy I have encouraged her to start formal physical therapy and a home exercise program Will use ice or heat p r n I have given her refills on Tylenol No 3 Flector patch and Relafen not to be taken with any other anti inflammatory She does have some abdominal discomfort with the anti inflammatories was started on Nexium 20 mg one p o daily She will follow up in our office in four weeks If she has not gotten any relief with formal physical therapy and the above noted treatments we will discuss with Dr X whether she would benefit from another knee arthroscopy The patient shows a good understanding of this treatment plan and agrees Keywords orthopedic medifast medifast diet obesity gastric bypass knee pain weight reduction knee MEDICAL_TRANSCRIPTION,Description Axial images through the cervical spine with coronal and sagittal reconstructions Medical Specialty Orthopedic Sample Name CT C Spine 1 Transcription EXAM CT cervical spine REASON FOR EXAM MVA feeling sleepy headache shoulder and rib pain TECHNIQUE Axial images through the cervical spine with coronal and sagittal reconstructions FINDINGS There is reversal of the normal cervical curvature at the vertebral body heights The intervertebral disk spaces are otherwise maintained There is no prevertebral soft tissue swelling The facets are aligned The tip of the clivus and occiput appear intact On the coronal reconstructed sequence there is satisfactory alignment of C1 on C2 no evidence of a base of dens fracture The included portions of the first and second ribs are intact There is no evidence of a posterior element fracture Included portions of the mastoid air cells appear clear There is no CT evidence of a moderate or high grade stenosis IMPRESSION No acute process cervical spine Keywords orthopedic c spine axial images sagittal reconstructions cervical spine sagittal fracture coronal spine axial cervical ct MEDICAL_TRANSCRIPTION,Description CT cervical spine for trauma CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Medical Specialty Orthopedic Sample Name CT C Spine 2 Transcription EXAM CT cervical spine C spine for trauma FINDINGS CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Cervical vertebral body height alignment and interspacing are maintained There is no evidence of fractures or destructive osseous lesions There are no significant degenerative endplate or facet changes No significant osseous central canal or foraminal narrowing is present IMPRESSION Negative cervical spine Keywords orthopedic c spine anatomical degenerative endplate ct examination cervical spine coronal ct spine cervicalNOTE MEDICAL_TRANSCRIPTION,Description Trimalleolar ankle fracture and dislocation right ankle A comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well Closed open reduction and internal fixation of right ankle Medical Specialty Orthopedic Sample Name Closed ORIF Ankle Transcription PREOPERATIVE DIAGNOSES 1 Trimalleolar ankle fracture 2 Dislocation right ankle POSTOPERATIVE DIAGNOSES 1 Trimalleolar ankle fracture 2 Dislocation right ankle PROCEDURE PERFORMED Closed open reduction and internal fixation of right ankle ANESTHESIA Spinal with sedation COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME 75 minutes at 325 mmHg COMPONENTS Synthes small fragment set was used including a 2 5 mm drill bed A six hole one third tibial plate one 12 mm 3 5 mm cortical screw fully threaded and two 16 mm 3 5 mm cortical fully threaded screws There were two 20 mm 4 0 cancellous screws and one 18 mm 4 0 cancellous screw placed There were two 4 0 cancellous partially threaded screws placed GROSS FINDINGS Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well HISTORY OF PRESENT ILLNESS The patient is an 87 year old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall The patient noted while walking with a walker apparently tripped and fell The patient had significant comorbidities seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room At that time a closed reduction was performed and she was placed in a Robert Jones splint After complete medical workup and clearance we elected to take her to the operating room for definitive care PROCEDURE After all potential complications and risks as well as risks and benefits of the above mentioned procedure was discussed at length with the patient and family informed consent was obtained The upper extremity was then confirmed with the operating surgeon the patient the nursing staff and Department of Anesthesia The patient was then transferred to preoperative area in the Operative Suite 3 and placed on the operating room table in supine position At this time the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation All bony prominences were well padded at this time A nonsterile tourniquet was placed on the right upper thigh of the patient This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes Next after all bony and soft tissue landmarks were identified a 6 cm longitudinal incision was made directly over this vestibule on the right ankle A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures Once the bone was reached the fractured site was identified The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site The wound was copiously irrigated and dried Next the fracture was then reduced in anatomic position There was noted to be quite a bit of comminution as well as soft overall status of the bone It was held in place with reduction forceps A six hole one third tubular Synthes plate was then selected for instrumentation It was contoured using ________ and placed on the lateral aspect of the distal fibula Next the three most proximal holes were sequentially drilled using a 2 5 mm drill bed depth gauged and then a 3 5 mm fully threaded cortical screw was placed in each The most proximal was a 12 mm and the next two were 16 mm in length Next the three most distal holes were sequentially drilled using a 2 5 mm drill bed depth gauged and a 4 0 cancellous screw was placed in each hole The most distal with a 20 mm and two most proximal were 18 mm in length Next the Xi scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position all hardware was in good position There was no lateralization of the joints Attention was then directed towards the medial aspect of the ankle Again after all bony and soft tissue landmarks were identified a 4 cm longitudinal incision was made directly over the medial malleolus Again the dissection was carefully taken down the level of the fracture site The retractors were then placed to protect all neurovascular structures Once the fracture site was identified it was dried of all hematoma as well as excess periosteum The fracture site was then displaced and the ankle joint was visualized including the dome of the talus There appeared to be some minor degenerative changes of the talus but no loose bodies Next the wound was copiously irrigated and suctioned dry The medial malleolus was placed in reduced position and held in place with a 1 25 mm K wire Next the 2 5 mm drill bed was then used to sequentially drill holes to full depth and 4 0 cancellous screws were placed in each each with a 45 mm in length These appeared to hold the fracture site securely in an anatomic position Again Xi scan was brought in to confirm placement of the screws They were in good overall position and there was no lateralization of the joint At this time each wound was copiously irrigated and suctioned dry The wounds were then closed using 2 0 Vicryl suture in subcutaneous fashion followed by staples on the skin A sterile dressing was applied consistent with Adaptic 4x4s Kerlix and Webril A Robert Jones style splint was then placed on the right lower extremity This was covered by a 4 inch Depuy dressing At this time the Department of Anesthesia reversed the sedation The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit The patient tolerated the procedure well There were no complications Keywords orthopedic ankle fracture dislocation open reduction internal fixation orif trimalleolar ankle fracture cortical screw cancellous screws fracture site fracture ankle malleolus MEDICAL_TRANSCRIPTION,Description Right distal both bone forearm fracture Closed reduction under conscious sedation and application of a splint was warranted Medical Specialty Orthopedic Sample Name Closed Reduction 1 Transcription PREOPERATIVE DIAGNOSIS Right distal both bone forearm fracture POSTOPERATIVE DIAGNOSIS Right distal both bone forearm fracture INDICATIONS Mr ABC is a 10 year old boy who suffered a fall resulting in a right distal both bone forearm fracture Upon evaluation by Orthopedic Surgery team in the emergency department it was determined that a closed reduction under conscious sedation and application of a splint was warranted This was discussed with the parents who expressed verbal and written consent PROCEDURE Conscious sedation was achieved via propofol via the emergency department staff Afterwards traction with re creation of the injury pattern was utilized to achieve reduction of the patient s fracture This was confirmed with image intensifier Subsequently the patient was placed into a splint The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial median and ulnar nerve distributions and positive extensor pollicis longus flexor pollicis longus dorsal and palmar interossei DISPOSITION Post reduction x rays revealed good alignment in the AP x rays The lateral x rays also revealed adequate reduction At this time we will allow the patient to be discharged home and have him follow up with Dr XYZ in one week Keywords orthopedic closed reduction distal both bone forearm emergency department pollicis longus bone forearm forearm fracture conscious sedation emergency department pollicis longus splint distal bone forearm conscious sedation fracture reduction MEDICAL_TRANSCRIPTION,Description Postoperative followup note Cervicalgia cervical radiculopathy and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate Medical Specialty Orthopedic Sample Name Cervicalgia Transcription FAMILY HISTORY Her father died at the age of 80 from prostate cancer Her mother died at the age of 67 She did abuse alcohol She had a brother died at the age of 70 from bone and throat cancer She has two sons ages 37 and 38 years old who are healthy She has two daughters ages 60 and 58 years old both with cancer She describes cancer hypertension nervous condition kidney disease lung disease and depression in her family SOCIAL HISTORY She is married and has support at home Denies tobacco alcohol and illicit drug use ALLERGIES Aspirin MEDICATIONS The patient does not list any current medications PAST MEDICAL HISTORY Hypertension depression and osteoporosis PAST SURGICAL HISTORY She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr L She is G10 P7 no cesarean sections REVIEW OF SYSTEMS HEENT Headaches vision changes dizziness and sore throat GI Difficulty swallowing Musculoskeletal She is right handed with joint pain stiffness decreased range of motion and arthritis Respiratory Shortness of breath and cough Cardiac Chest pain and swelling in her feet and ankle Psychiatric Anxiety and depression Urinary Negative and noncontributory Hem Onc Negative and noncontributory Vascular Negative and noncontributory Genital Negative and noncontributory PHYSICAL EXAMINATION On physical exam she is 5 feet tall and currently weighs 110 pounds weight one year ago was 145 pounds BP 138 78 pulse is 64 General A well developed well nourished female in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth she does have some poor dentition She does say that she needs some of her teeth pulled on her lower mouth Cranial nerves II III IV and VI vision is intact and visual fields are full to confrontation EOMs are full bilaterally Pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movements Cranial nerve VIII hearing is intact although decreased bilaterally right worse than left Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cranial nerve XI strong and symmetrical shoulder shrugs against resistance Cardiac regular rate and rhythm Chest and lungs are clear bilaterally Skin is warm and dry Normal turgor and texture No rashes or lesions are noted General musculoskeletal exam reveals no gross deformity fasciculations and atrophy Peripheral vascular no cyanosis clubbing or edema She does have some tremoring of her bilateral upper arms as she said Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted She is about 4 5 in the deltoids biceps triceps wrist flexors wrist extensors dorsal interossei and grip strength It is much more painful for her on the left Deep tendon reflexes are 2 bilaterally only at biceps triceps and brachioradialis knees and ankles No ankle clonus is elicited Hoffmann s is negative bilaterally Sensation is intact She ambulates with slow short steps No spastic gait is noted She has appropriate station and gait with no assisted devices although she states that she is supposed to be using a cane She does not bring one in with her today FINDINGS Patient brings in cervical spine x rays and she has had an MRI taken but does not bring that in with her today She will obtain that and x rays which showed at cervical plate C3 C4 C5 C6 and C7 anteriorly with some lifting with the most lifted area at the C3 level No fractures are noted ASSESSMENT Cervicalgia cervical radiculopathy and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate PLAN We went ahead and obtained an EKG in the office today which demonstrated normal sinus rhythm She went ahead and obtained her x rays and will pick her MRI and return to the office for surgical consultation with Dr L first available She would like the plate removed so that she can eat and drink better so that she can proceed with her shoulder surgery All questions and concerns were addressed with her Warning signs and symptoms were gone over with her If she should have any further questions concerns or complications she will contact our office immediately otherwise we will see her as scheduled I am quite worried about the pain that she is having in her arms so I would like to see the MRI as well Case was reviewed and discussed with Dr L Keywords orthopedic c3 through c7 pain scale mris x rays cervical discectomy and fusion cervical radiculopathy cervical fusion cervical discectomy cervical plate difficulty swallowing cranial nerves radiculopathy discectomy cervicalgia postoperative fusion swallowing MEDICAL_TRANSCRIPTION,Description Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot Medical Specialty Orthopedic Sample Name Closing Wedge Osteotomy Transcription PREOPERATIVE DIAGNOSIS Tailor s bunion right foot POSTOPERATIVE DIAGNOSIS Tailor s bunion right foot PROCEDURE Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot ANESTHESIA Local infiltrate with IV sedation INDICATIONS FOR SURGERY The patient has had a longstanding history of foot problems The problem has been progressive in nature The preoperative discussion with the patient included alternative treatment options the procedure was explained and the risk factors such as infection swelling scar tissue numbness continued pain recurrence and the postoperative management were discussed The patient has been advised although no guarantee for success could be given most of the patient have less pain and improved function all questions were thoroughly answered The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity The purpose of the surgery is to alleviate pain and discomfort DETAILS OF PROCEDURE The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure The patient was brought to the operating room and placed in the supine position No tourniquet was utilized IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1 1 mixture of 0 25 Marcaine and 1 lidocaine with epinephrine was locally infiltrated proximal to the operative site The lower extremity was prepped and draped in the usual sterile manner Balanced anesthesia was obtained PROCEDURE Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1 5 cm from the base of the fifth metatarsal Care was taken to identify and retract all vital structures and when necessary vessels were ligated via electrocautery The extensor tendon was identified and retracted medially Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer A linear periosteal capsular incision was made in line with the skin incision The capsular tissue and periosteal layer was underscored free from its underlying osseous attachment and then reflected to expose the osseous surface Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration The both edges were rasped smooth Attention was then focused on the fifth metatarsal The periosteal layer proximal to the fifth metatarsal head was underscored free from its underlying attachment and then reflected to expose the osseous surface An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy Using an oscillating saw a vertically placed wedge shaped oblique ostomy was made with the apex being proximal lateral and the base medial and distal Generous amounts of lateral cortex were preserved for the lateral hinge The wedge was removed from the surgical field The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin which was then countersunk and a 3 0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position Good purchase was noted at the osteotomy site Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position The surgical site was flushed with copious amounts of normal saline irrigation The periosteal and capsular layers were closed with running sutures of 3 0 Vicryl The subcutaneous tissues were closed with 4 0 Vicryl and the skin edges were closed with 4 0 nylon in a running interrupted fashion A dressing consisting of Adaptic 4 x 4 confirming bandages and ACE wrap to provide mild compression was applied The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time and all digits were warm and pink A walker boot was dispensed and applied The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me Office visit will be in 4 days The patient was given prescriptions for Keflex 500 mg one p o t i d for 10 days and Ultram ER 15 one p o daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises After short recuperative period the patient was discharged home with a vital sign stable in no acute distress Keywords orthopedic internal screw fixation osteotomy closing wedge osteotomy tailor s bunion screw fixation periosteal layer metatarsal head wedge osteotomy metatarsal anesthesia MEDICAL_TRANSCRIPTION,Description Cervical spondylosis and kyphotic deformity She had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Medical Specialty Orthopedic Sample Name Cervical Spondylosis Neuro Consult Transcription REASON FOR NEUROLOGICAL CONSULTATION Cervical spondylosis and kyphotic deformity The patient was seen in conjunction with medical resident Dr X I personally obtained the history performed examination and generated the impression and plan HISTORY OF PRESENT ILLNESS The patient is a 45 year old African American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain This has subsequently resolved She started vigorous workouts in November 2005 In March of this year she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician By her report she had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Symptoms progressed to sensory symptoms of her knees elbows and left middle toe She then started getting sensory sensations in the left hand and arm She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg Symptoms have been mildly progressive She is unaware of any trigger other than the vigorous workouts as mentioned above She has no associated bowel or bladder symptoms No particular position relieves her symptoms Workup has included two MRIs of the C spine which were personally reviewed and are discussed below She saw you for consultation and the possibility of surgical decompression was raised At this time she is somewhat reluctant to go through any surgical procedure PAST MEDICAL HISTORY 1 Ocular migraines 2 Myomectomy 3 Infertility 4 Hyperglycemia 5 Asthma 6 Hypercholesterolemia MEDICATIONS Lipitor Pulmicort Allegra Xopenex Patanol Duac topical gel Loprox cream and Rhinocort ALLERGIES Penicillin and aspirin Family history social history and review of systems are discussed above as well as documented in the new patient information sheet Of note she does not drink or smoke She is married with two adopted children She is a paralegal specialist She used to exercise vigorously but of late has been advised to stop exercising and is currently only walking REVIEW OF SYSTEMS She does complain of mild blurred vision but these have occurred before and seem associated with headaches PHYSICAL EXAMINATION On examination blood pressure 138 82 pulse 90 respiratory rate 14 and weight 176 5 pounds Pain scale is 0 A full general and neurological examination was personally performed and is documented on the chart Of note she has a normal general examination Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk She has mild postural tremor in both arms She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities Motor examination reveals no weakness to individual muscle testing but on gait she does have a very subtle left hemiparesis She has hyperreflexia in her lower extremities worse on the left Babinski s are downgoing PERTINENT DATA MRI of the brain from 05 02 06 and MRI of the C spine from 05 02 06 and 07 25 06 were personally reviewed MRI of the brain is broadly within normal limits MRI of the C spine reveals large central disc herniation at C6 C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema There is also a fairly large disc at C3 C4 with cord deformity and partial effacement of the subarachnoid space I do not appreciate any cord edema at this level IMPRESSION AND PLAN The patient is a 45 year old female with cervical spondylosis with a large C6 C7 herniated disc with mild cord compression and signal change at that level She has a small disc at C3 C4 with less severe and only subtle cord compression History and examination are consistent with signs of a myelopathy Results were discussed with the patient and her mother I am concerned about progressive symptoms Although she only has subtle symptoms now we made her aware that with progression of this process she may have paralysis If she is involved in any type of trauma to the neck such as motor vehicle accident she could have an acute paralysis I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem I have recommended that she wear a hard collar while driving The results of my consultation were discussed with you telephonically Keywords orthopedic kyphotic cervical radiculopathy myelopathy kyphotic deformity cord compression cervical spondylosis toe spondylosis cord MEDICAL_TRANSCRIPTION,Description Left distal both bone forearm fracture Closed reduction with splint application with use of image intensifier Medical Specialty Orthopedic Sample Name Closed Reduction 2 Transcription PREOPERATIVE DIAGNOSIS Left distal both bone forearm fracture POSTOPERATIVE DIAGNOSIS Left distal both bone forearm fracture PROCEDURE Closed reduction with splint application with use of image intensifier INDICATIONS Mr ABC is an 11 year old boy who sustained a fall on 07 26 2008 Evaluation in the emergency department revealed both bone forearm fracture Considering the amount of angulation it was determined that we should proceed with conscious sedation and closed reduction After discussion with parents verbal and written consent was obtained DESCRIPTION OF PROCEDURE The patient was induced with propofol for conscious sedation via the emergency department staff After it was confirmed that appropriate sedation had been reached a longitudinal traction in conjunction with re creation of the injury maneuver was applied reducing the fracture Subsequently this was confirmed with image intensification a sugar tong splint was applied and again reduction was confirmed with image intensifier The patient was aroused from anesthesia and tolerated the procedure well Post reduction plain films revealed some anterior displacement of the distal fragment At this time it was determined this fracture proved to be unstable DISPOSITION After review of the reduction films it appears that there is some element of fracture causing displacement We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows Keywords orthopedic closed reduction reduction with splint application distal both bone forearm distal both bone splint application emergency department conscious sedation image intensifier bone forearm forearm fracture reduction emergency department conscious displacement splint sedation tong distal bone image intensifier forearm fracture MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome Endoscopic carpal tunnel release After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg Medical Specialty Orthopedic Sample Name Carpal Tunnel Release Endoscopic Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome TITLE OF PROCEDURE Endoscopic carpal tunnel release ANESTHESIA MAC PROCEDURE After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease Dissection was carried down to the antebrachial fascia which was cut in a distally based fashion Bipolar electrocautery was used to maintain meticulous hemostasis I then performed an antebrachial fasciotomy proximally I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side Great care was taken with placement A good plane was positively identified I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament Again I felt the hook of the hamate ulnar to me I had my thumb on the distal aspect of the transverse carpal ligament I then partially deployed the blade and starting 1 mm from the distal edge the transverse carpal ligament was positively identified I pulled back and cut and partially tightened the transverse carpal ligament I then feathered through the distal ligament and performed a full thickness incision through the distal half of the ligament I then checked to make sure this was properly performed and then cut the proximal aspect I then entered the carpal tunnel again and saw that the release was complete meaning that the cut surfaces of the transverse carpal ligament were separated and with the scope rotated I could see only one in the field at a time Great care was taken and at no point was there any longitudinal structure cut Under direct vision through the incision I made sure that the distal antebrachial fascia was cut Following this I irrigated and closed the skin The patient was dressed and sent to the recovery room in good condition Keywords orthopedic endoscopic carpal tunnel syndrome carpal tunnel release carpal ligament tourniquet carpal esmarch tunnel transverse ligament MEDICAL_TRANSCRIPTION,Description Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty Medical Specialty Orthopedic Sample Name Cartilage Loose Body Removal Transcription PREOPERATIVE DIAGNOSIS Left knee medial femoral condyle osteochondritis dissecans POSTOPERATIVE DIAGNOSIS Left knee medial femoral condyle osteochondritis dissecans PROCEDURES Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty ANESTHESIA General TOURNIQUET TIME Thirty seven minutes MEDICATIONS The patient also received 30 mL of 0 5 Marcaine local anesthetic at the end of the case COMPLICATIONS No intraoperative complications DRAINS AND SPECIMENS None INTRAOPERATIVE FINDINGS The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera This loose body was then subsequently removed It measured 24 x 14 mm This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle HISTORY AND PHYSICAL The patient is 13 year old male with persistent left knee pain He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee The patient presented here for a second opinion Surgery was recommended grossly due to the instability of the fragment Risks and benefits of surgery were discussed The risks of surgery include risk of anesthesia infection bleeding changes in sensation and motion extremity failure to relieve pain or restore the articular cartilage possible need for other surgical procedures and possible early arthritis All questions were answered and parents agreed to the above plan DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A nonsterile tourniquet was placed on the upper aspect of the patient s left thigh The extremity was then prepped and draped in standard surgical fashion The standard portals were marked on the skin The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg The portal incisions were then made by an 11 blade Camera was inserted into the lateral joint line There was a noted large cartilage loose body in the suprapatellar pouch This was subsequently removed with extension of the anterolateral portal Visualization of the rest of the knee revealed significant synovitis The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle The remainder of the knee demonstrated no other significant cartilage lesions loose bodies plica or meniscal pathology ACL was also visualized to be intact in the intracondylar notch Attention was then turned back to the large defect The loose cartilage was debrided using a shaver Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites All instruments were then removed The portals were closed using 4 0 Monocryl A total of 30 mL of 0 5 Marcaine was injected into the knee Wounds were then cleaned and dried and dressed in Steri Strips Xeroform 4 x 4s and bias The patient was then placed in a knee immobilizer The patient tolerated the procedure well The tourniquet was released at 37 minutes He was taken to recovery in stable condition POSTOPERATIVE PLAN The loose cartilage fragment was given to the family The intraoperative findings were relayed with intraoperative photos There was a large deficit in the weightbearing portion of medial femoral condyle His prognosis is guarded given the fact of the fragile lesion and location but in advantages of his age and his rehab potential down the road if the patient still has symptoms he may be a candidate for osteochondral autograft a procedure which is not performed at Children s or possible cartilaginous transplant All questions were answered The patient will follow up in 10 days may wet the wound in 5 days Keywords orthopedic knee arthroscopy chondroplasty medial femoral condyle cartilage loose body loose cartilage knee arthroscopy tourniquet microfracture femoral cartilage MEDICAL_TRANSCRIPTION,Description Carpal tunnel syndrome Open carpal tunnel release A longitudinal incision was made in line with the 4th ray The dissection was carried down to the superficial aponeurosis which was cut The distal edge of the transverse carpal ligament was identified with a hemostat Medical Specialty Orthopedic Sample Name Carpal Tunnel Release Open Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome TITLE OF PROCEDURE Open carpal tunnel release COMPLICATIONS None PROCEDURE IN DETAIL After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the 4th ray The dissection was carried down to the superficial aponeurosis which was cut The distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with scissors After irrigating the wound with copious amounts of normal saline the skin was repaired with 4 0 nylon interrupted stitches Marcaine with epinephrine was injected into the wound which was then dressed and splinted The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic carpal ligament carpal tunnel release carpal tunnel syndrome transverse carpal ligament transverse ligament hemostat tunnel incision MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release Right carpal tunnel syndrome This is a 54 year old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 9 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome PROCEDURE Right carpal tunnel release ANESTHESIA Bier block to the right hand TOTAL TOURNIQUET TIME 20 minutes COMPLICATIONS None DISPOSITION Stable to PACU ESTIMATED BLOOD LOSS Less than 10 cc GROSS OPERATIVE FINDINGS We did find a compressed right median nerve upon entering the carpal tunnel otherwise the structures of the carpal canal are otherwise unremarkable No evidence of tumor was found BRIEF HISTORY OF PRESENT ILLNESS This is a 54 year old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management PROCEDURE The patient was taken to the operative room and placed in the supine position The patient underwent a Bier block by the Department of Anesthesia on the upper extremity The upper extremity was prepped and draped in usual sterile fashion and left free Attention was drawn then to the palm of the hand We did identify area of incision that we would make which was located over the carpal tunnel Approximately 1 5 cm incision was made using a 10 blade scalpel Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a 10 scalpel We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament We found no evidence of tumor or space occupying lesion in the carpal tunnel We then irrigated copiously Tourniquet was taken down at that time and pressure was held There was no evidence of obvious bleeders We approximated the skin with nylon and placed a postoperative dressing with a volar splint The patient tolerated the procedure well She was placed back in the gurney and taken to PACU Keywords orthopedic carpal tunnel release carpal tunnel syndrome median nerve bier block carpal ligament tunnel carpal transverse median MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release Left carpal tunnel syndrome Severe compression of the median nerve on the left at the wrist Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 6 Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIVE PROCEDURE PERFORMED Left carpal tunnel release FINDINGS Showed severe compression of the median nerve on the left at the wrist SPECIMENS None FLUIDS 500 mL of crystalloids URINE OUTPUT No Foley catheter COMPLICATIONS None ANESTHESIA General through a laryngeal mask ESTIMATED BLOOD LOSS None CONDITION Resuscitated with stable vital signs INDICATION FOR THE OPERATION This is a case of a very pleasant 65 year old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6 7 followed by anterior cervical discectomy with anterior interbody fusion at C5 6 and C6 7 with spinal instrumentation At the time of initial consultation the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now Operation expected outcome risks and benefits were discussed with him for most of the risk would be that of infection because of the patient s diabetes and a previous history of infection in the form of pneumonia There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection He understood this risk and agreed to have the procedure performed DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room awake alert not in any form of distress After smooth induction of anesthesia and placement of a laryngeal mask he remained supine on the operating table The left upper extremity was then prepped with Betadine soap and antiseptic solution After sterile drapes were laid out an incision was made following inflation of blood pressure cuff to 250 mmHg Clamp time approximately 30 minutes An incision was then made right in the mid palm area between the thenar and hypothenar eminence Meticulous hemostasis of any bleeders were done The fat was identified The palmar aponeurosis was identified and cut and this was traced down to the wrist There was severe compression of the median nerve Additional removal of the aponeurosis was performed to allow for further decompression After this was all completed the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4 0 as interrupted vertical mattress stitches Dressing was applied The patient was brought to the recovery Keywords orthopedic compression wrist carpal tunnel release carpal tunnel syndrome median nerve tunnel carpal MEDICAL_TRANSCRIPTION,Description Right carpal tunnel syndrome Right carpal tunnel release Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 7 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome PROCEDURE PERFORMED Right carpal tunnel release PROCEDURE NOTE The right upper extremity was prepped and draped in the usual fashion IV sedation was supplied by the anesthesiologist A local block using 6 cc of 0 5 Marcaine was used at the transverse wrist crease using a 25 gauge needle superficial to the transverse carpal ligament The upper extremity was exsanguinated with a 6 inch ace wrap Tourniquet time was less than 10 minutes at 250 mmHg An incision was used in line with the third web space just to the ulnar side of the thenar crease It was carried sharply down to the transverse wrist crease The transverse carpal ligament was identified and released under direct vision Proximal to the transverse wrist crease it was released subcutaneously During the entire procedure care was taken to avoid injury to the median nerve proper the recurrent median the palmar cutaneous branch the ulnar neurovascular bundle and the superficial palmar arch The nerve appeared to be mildly constricted Closure was routine with running 5 0 nylon A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition Keywords orthopedic superficial palmar arch carpal tunnel release carpal tunnel syndrome transverse wrist crease superficial ligament MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release and right index and middle fingers release A1 pulley Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 8 Transcription PREOPERATIVE DIAGNOSES 1 Right carpal tunnel syndrome 2 Right index finger and middle fingers tenosynovitis POSTOPERATIVE DIAGNOSES 1 Right carpal tunnel syndrome 2 Right index finger and middle fingers tenosynovitis PROCEDURES PERFORMED 1 Right carpal tunnel release 2 Right index and middle fingers release A1 pulley TOURNIQUET TIME 70 minutes BLOOD LOSS Minimal GROSS INTRAOPERATIVE FINDINGS 1 A compressed median nerve at the carpal tunnel which was flattened 2 A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers After the A1 pulley was released there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons HISTORY This is a 78 year old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left He had positive EMG findings as well as clinical findings The patient did undergo an injection which only provided him with temporary relief and is for this reason he has consented to undergo the above named procedure All risks as well as complications were discussed with the patient and consent was obtained PROCEDURE The patient was wheeled back to the operating room 1 at ABCD General Hospital on 08 29 03 He was placed supine on the operating room table Next a non sterile tourniquet was placed on the right forearm but not inflated At this time 8 cc of 0 25 Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia In addition an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers At this time the extremity was then prepped and draped in usual sterile fashion for this procedure First we went for release of the carpal tunnel Approximately 2 5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region First dissection through the skin in the superficial fascia was performed with a self retractor placed in addition to Ragnells retracting proximally and distally The palmaris brevis muscle was then identified and sharply transected At this time we identified the transverse carpal tunnel ligament and a 15 blade was used to sharply and carefully release that fascia Once the fascia of the transverse carpal ligament was transected the identification of the median nerve was visualized The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly At this time a neurolysis was performed and no evidence of space occupying lesions were identified within the carpal tunnel At this time copious irrigation was used to irrigate the wound The wound was suctioned dry At this time we proceeded to the release of the A1 pulleys Approximately a 1 5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers First we went for the index finger Once the skin incision was made Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley A 15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally Once this was performed a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons Once a thorough release was performed copious irrigation was used to irrigate that wound In the similar fashion a 1 5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger A Littler scissor was used to bluntly dissect in the longitudinal fashion With the Ragnell retractors we identified the A1 pulley of the right middle finger Using a 15 blade the A1 pulley was scored with the 15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity Again there was evidence of some synovitis as well as fraying of both tendons The girth of both tendons and both wounds were within normal limits At this time copious irrigation was used to irrigate the wound The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively In addition he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact At this time 5 0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery At this time a short arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll The patient was then carefully taken off of the operating room table to Recovery in stable condition Keywords orthopedic compressed median nerve stenosing tenosynovitis carpal tunnel release carpal tunnel syndrome middle fingers carpal tunnel littler scissors median nerve copious irrigation volar aspect tunnel pulley carpal fingers index tourniquet ligament tenosynovitis superficialis tendons MEDICAL_TRANSCRIPTION,Description Bilateral open carpal tunnel release Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 5 Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome bilateral POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome bilateral ANESTHESIA General NAME OF OPERATION Bilateral open carpal tunnel release FINDINGS AT OPERATION The patient had identical very thick transverse carpal ligaments with dull synovium PROCEDURE Under satisfactory anesthesia the patient was prepped and draped in a routine manner on both upper extremities The right upper extremity was exsanguinated and the tourniquet inflated A curved incision was made at the the ulnar base carried through the subcutaneous tissue and superficial fascia down to the transverse carpal ligament This was divided under direct vision along its ulnar border and wound closed with interrupted nylon The wound was injected and a dry sterile dressing was applied An identical procedure was done to the opposite side The patient left the operating room in satisfactory condition Keywords orthopedic bilateral open carpal tunnel carpal tunnel syndrome carpal tunnel release carpal tunnel release tourniquet bilateral tunnel carpal MEDICAL_TRANSCRIPTION,Description Left endoscopic carpal tunnel release and endotracheal fasciotomy Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 2 Transcription PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome OPERATIVE PROCEDURE 1 Left endoscopic carpal tunnel release 2 Endotracheal fasciotomy ANESTHESIA General COMPLICATIONS None INDICATION The patient is a 62 year old lady with the aforementioned diagnosis refractory to nonoperative management All risks and benefits were explained Questions answered Options discussed No guarantees were made She wished to proceed with surgery PROCEDURE After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion the arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease Dissection was carried down to the antebrachial fascia which was cut in a distally based fashion Bipolar electrocautery was used to maintain meticulous hemostasis I then performed an antebrachial fasciotomy proximally I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side Great care was taken with placement A good plane was positively identified I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament Again I felt the hook of the hamate ulnar to me I had my thumb on the distal aspect of the transverse carpal ligament I then partially deployed the blade and starting 1 mm from the distal edge the transverse carpal ligament was positively identified I pulled back and cut and partially tightened the transverse carpal ligament I then feathered through the distal ligament and performed a full thickness incision through the distal half of the ligament I then checked to make sure this was properly performed and then cut the proximal aspect I then entered the carpal tunnel again and saw that the release was complete meaning that the cut surfaces of the transverse carpal ligament were separated and with the scope rotated I could see only one in the field at a time Great care was taken and at no point was there any longitudinal structure cut Under direct vision through the incision I made sure that the distal antebrachial fascia was cut Following this I irrigated and closed the skin The patient was dressed and sent to the recovery room in good condition Keywords orthopedic carpal tunnel syndrome antebrachial fascia antebrachial fasciotomy carpal tunnel release electrocautery fasciotomy hamate wrist crease endoscopic carpal tunnel release transverse carpal ligament carpal tunnel transverse carpal carpal ligament carpal antebrachial transverse ligament MEDICAL_TRANSCRIPTION,Description Right open carpal tunnel release and cortisone injection left carpal tunnel Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 4 Transcription PREOPERATIVE DIAGNOSIS Bilateral carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Bilateral carpal tunnel syndrome PROCEDURES 1 Right open carpal tunnel release 2 Cortisone injection left carpal tunnel ANESTHESIA General LMA ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS This patient is a 50 year old male with bilateral carpal tunnel syndrome which is measured out as severe He is scheduled for the above mentioned procedures The planned procedures were discussed with the patient including the associated risks The risks included but are not limited to bleeding infection nerve damage failure to heal possible need for reoperation possible recurrence or any associated risk of the anesthesia He voiced understanding and agreed to proceed as planned DESCRIPTION OF PROCEDURE The patient was identified in the holding area and correct operative site was identified by the surgeon s mark Informed consent was obtained The patient was then brought to the operating room and transferred to the operating table in supine position Time out was then performed at which point the surgeon nursing staff and anesthesia staff all confirmed the correct identification After adequate general LMA anesthesia was obtained a well padded tourniquet was placed on the patient s right upper arm The right upper extremity was then prepped and draped in the usual sterile fashion Planned skin incision was marked along the base of the patient s right palm Right upper extremity was then exsanguinated using Esmarch The tourniquet was then inflated to 250 mmHg Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision Bleeding points were identified with electrocautery using bipolar electrocautery Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament and this was then divided longitudinally under direct vision Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed This was confirmed by visually and palpably Next baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision Carpal canal was then inspected The median nerve was flattened and injected No other abnormalities were noted Wounds were then irrigated with normal saline and antibiotic additive Decadron 4 mg was then placed adjacent to the median nerve Skin incision was then closed with interrupted 5 0 nylon suture The wound was then dressed with Adaptic 4 x 4s Kling and Coban The tourniquet was then deflated Attention was then directed to the left side Using sterile technique the left carpal canal was injected with a mixture of 40 mg of Depo Medrol 1 cc of 1 lidocaine and 1 cc of 0 25 Marcaine Band Aid was then placed over the injection site The patient was then awakened extubated and transferred over to his hospital bed He was transported to recovery room in stable condition There were no intraoperative or immediate postoperative complications All counts were reported as correct Keywords orthopedic carpal tunnel syndrome 4 x 4s adaptic carpal canal coban cortisone injection esmarch kling metzenbaum carpal tunnel release electrocautery fibrous band palmar fascia tourniquet transverse carpal ligament bilateral carpal tunnel baby metzenbaum scissors carpal ligament bilateral carpal metzenbaum scissors carpal tunnel carpal tunnel MEDICAL_TRANSCRIPTION,Description Right carpal tunnel release Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 1 Transcription PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome TITLE OF THE PROCEDURE Right carpal tunnel release COMPLICATIONS There were no complications during the procedure SPECIMEN The specimen was sent to pathology INSTRUMENTS All counts were correct at the end of the case and no complications were encountered INDICATIONS This is a 69 year old female who have been complaining of right hand pain which was steadily getting worse over a prolonged period of time The patient had tried nonoperative therapy which did not assist the patient The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve As a result of these findings the patient was sent to my office presenting with this history and was carefully evaluated On initial evaluation the patient had the symptomology of carpal tunnel syndrome The patient at the time had the risks benefits and alternatives thoroughly explained to her All questions were answered No guarantees were given The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed DETAILS OF THE PROCEDURE The patient was brought to the operating room placed supine on the operating room table prepped and draped in the sterile fashion and was given sedation The patient was then given sedation Once this was complete the area overlying the carpal ligament was carefully injected with 1 lidocaine with epinephrine The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete a 15 blade knife was then used to incise the skin opposite the radial aspect of the fourth ray Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament This was then carefully incised using a 15 blade knife and once entry was again into the carpal canal a Freer elevator was then inserted and under direct visualization the carpal ligament was then released The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt The area was well hemostased with the 1 lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times Palmar fascia was released both proximally and distally as well as the transverse carpal ligament Direct palpation of the carpal canal demonstrated a full and complete release Observation of the median nerve revealed an area of hyperemia in the distal two thirds of the nerve which demonstrated the likely area of compression Once this was complete hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4 0 chromic suture in a horizontal mattress and interrupted stitch Xeroform was then applied to the incision A bulky dressing was then applied consisting of Kerlix and Ace wrap and the patient was taken to the recovery room in stable condition without any complications Keywords orthopedic carpal tunnel syndrome ace wrap emg freer elevator kerlix weitlaner retractor bulky dressing carpal tunnel carpal tunnel release palmar fascia subcutaneous fat lidocaine with epinephrine transverse carpal ligament carpal ligament carpal tunnel ligament MEDICAL_TRANSCRIPTION,Description Carpal tunnel release with transverse carpal ligament reconstruction A longitudinal incision was made in line with the fourth ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis Medical Specialty Orthopedic Sample Name Carpal Ligament Reconstruction Transcription PROCEDURE Carpal tunnel release with transverse carpal ligament reconstruction PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A longitudinal incision was made in line with the fourth ray from Kaplan s cardinal line proximally to 1 cm distal to the volar wrist crease The dissection was carried down to the superficial aponeurosis The subcutaneous fat was dissected radially for 2 3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly and the distal edge of the transverse carpal ligament was identified with a hemostat The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel and the ligament was cut on its ulnar side with a knife directly onto the hemostat The antebrachial fascia was cut proximally under direct vision with a scissor After irrigating the wound with copious amounts of normal saline the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4 0 Vicryl Care was taken to avoid entrapping the motor branch of the median nerve in the suture A hemostat was placed under the repair to ensure that the median nerve was not compressed The skin was repaired with 5 0 nylon interrupted stitches Marcaine with epinephrine was injected into the wound which was then dressed and splinted The patient was sent to the recovery room in good condition having tolerated the procedure well Keywords orthopedic carpal tunnel carpal ligament reconstruction transverse carpal ligament ulnar hemostat transverse superficial ligament carpal MEDICAL_TRANSCRIPTION,Description Endoscopic release of left transverse carpal ligament Medical Specialty Orthopedic Sample Name Carpal Ligament Release 1 Transcription PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome PROCEDURE Endoscopic release of left transverse carpal ligament ANESTHESIA Monitored anesthesia care with regional anesthesia provided by surgeon TOURNIQUET TIME 12 minutes OPERATIVE PROCEDURE IN DETAIL With the patient under adequate monitored anesthesia the left upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mmHg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the palm between FCR and FCU one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the Hood of Hamate The Agee Inside Job was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the Agee Inside Job was withdrawn dividing transverse carpal ligament under direct vision After complete division of transverse carpal ligament the Agee Inside Job was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished One cc of Celestone was then introduced into the carpal tunnel and irrigated free The wound was then closed with a running 3 0 Prolene subcuticular stitch Steri strips were applied and a sterile dressing was applied over the Steri strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords orthopedic carpal tunnel syndrome antebrachial fascia carpal ligament palmar synovium tourniquet transverse carpal ligament transverse incision agee inside job transverse carpal carpal ligament carpal tunnel antebrachial release endoscopic MEDICAL_TRANSCRIPTION,Description Left carpal tunnel release left ulnar nerve anterior submuscular transposition at the elbow lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve Medical Specialty Orthopedic Sample Name Carpal Tunnel Release 3 Transcription PREOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 354 0 2 Left ulnar nerve entrapment at the elbow 354 2 POSTOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 354 0 2 Left ulnar nerve entrapment at the elbow 354 2 OPERATIONS PERFORMED 1 Left carpal tunnel release 64721 2 Left ulnar nerve anterior submuscular transposition at the elbow 64718 3 Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve 25280 ANESTHESIA General anesthesia with intubation INDICATIONS OF PROCEDURE This patient is insulin dependant diabetic He is also has end stage renal failure and has chronic hemodialysis Additionally the patient has had prior heart transplantation He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity However it is our contention that this patient s prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger These started initially as unrecognized paper cuts Additionally the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve but also to the little finger Finally this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger Thus we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary Thirdly this patient does have chronic distal ischemic problems with evidence of ping pong ball sign due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers However this patient has no clinical sign at all of tissue necrosis at the finger tips at this time The patient has also previously had an arteriovenous shunt in the forearm which has been deactivated within the last 3 weeks Thus we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve This patient had electro diagnostic studies performed which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel DESCRIPTION OF PROCEDURE After general anesthesia being induced and the patient intubated he is given intravenous Ancef The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion A sterile tourniquet and webril are placed higher on the arm The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease Dissection continued through subcutaneous tissue to the palmer aponeurosis which is divided longitudinally from distal to proximal I next encountered the transverse carpal ligament which in turn is also divided longitudinally from distal to proximal and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm Having confirmed a complete release of the transverse carpal ligament I next evaluated the contents of the carpal tunnel The synovium was somewhat thickened but not unduly so There was some erythema along the length of the median nerve indicating chronic compression The motor branch of the median nerve was clearly identified The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5 0 nylon sutures I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap I now gained access to the radial border of the flexor pronator muscle mass dissected down the radial side until I identified the median nerve I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm The entire medial intramuscular septum is now excised The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures Larger penetrating vascular tributaries to the muscle ligated between hemoclips I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques In this way the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension free manner Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other So that in effect a lengthening is performed Fascial repair is done with interrupted figure of eight 0 Ethibond sutures I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension free coverage of the muscle without any impingement on the nerve The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside I then unwrap the arm and check for hemostasis Wound is copiously irrigated with normal saline and then a 15 French Round Blake drainage placed through a separate stab incision and laid along the length of the wound A layered wound closure is done with interrupted Vicryl subcutaneously and a running subcuticular Monocryl to the skin A 0 25 plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment followed by a well fluffed gauze and a Kerlix dressing and confirming Kerlix and webril and an above elbow sugar tong splint is applied extending to the support of the wrist Fingers and femoral were free to move The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition Sponge and needle counts reported as correct at the end of the procedure Keywords orthopedic carpal tunnel syndrome ace bandage kerlix carpal tunnel release curvilinear incision flexor pronator muscle ping pong ball sign synovium ulnar artery ulnar nerve ulnar nerve entrapment pronator muscle mass transverse carpal carpal ligament tunnel release flexor pronator pronator muscle carpal tunnel tunnel carpal nerve pronator forearm MEDICAL_TRANSCRIPTION,Description Left calcaneal lengthening osteotomy with allograft partial plantar fasciotomy posterior subtalar and tibiotalar capsulotomy and short leg cast placed Medical Specialty Orthopedic Sample Name Calcaneal Lengthening Osteotomy Transcription PREOPERATIVE DIAGNOSES Left calcaneal valgus split POSTOPERATIVE DIAGNOSES Left calcaneal valgus split PROCEDURES 1 Left calcaneal lengthening osteotomy with allograft 2 Partial plantar fasciotomy 3 Posterior subtalar and tibiotalar capsulotomy 4 Short leg cast placed ANESTHESIA Surgery performed under general anesthesia TOURNIQUET TIME 69 minutes The patient in local anesthetic of 20 mL of 0 25 Marcaine plain COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None HISTORY AND PHYSICAL The patient is a 13 year old female who had previous bilateral feet correction at 1 year of age Since that time the patient has developed significant calcaneal valgus deformity with significant pain Radiographs confirmed collapse of the spinal arch as well as valgus position of the foot Given the patient s symptoms surgery is recommended for calcaneal osteotomy and Achilles lengthening Risks and benefits of surgery were discussed with the mother Risks of surgery include risk of anesthesia infection bleeding changes in sensation in most of extremity hardware failure need for later hardware removal possible nonunion possible failure to correct all the deformity and need for other surgical procedures The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months All questions were answered and parents agreed to the above surgical plan DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively A bump was placed underneath the left buttock A nonsterile tourniquet was placed on the upper aspect of the left thigh The extremity was then prepped and draped in a standard surgical fashion The patient had a previous incision along the calcaneocuboid lateral part of the foot This was marked and extended proximally through the Achilles tendon Extremity was wrapped in Esmarch Tourniquet inflation was noted to be 250 mmHg Decision was then made to protect the sural nerve There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way Dissection was carried down to Achilles tendon which was subsequently de lengthened with the distal half performed down the lateral thigh Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end on end at length with the heel in neutral Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons which were removed from the sheath and retracted dorsally At this time we also noted that calcaneocuboid joint appeared to be fused The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy This was performed with a saw After a partial plantar fasciotomy was performed this was released off an abductor digiti minimi The osteotomy was completed with an osteotome and distracted with the lamina spreader A tricortical allograft was then shaped and subsequently impacted into this area Final positioning was checked with multiple views of fluoroscopy It was subsequently fixed using a 0 94 K wire and drilled from the heel anteriorly A pin was subsequently bent and cut short at the level of the skin The wound was then irrigated with normal saline The Achilles was repaired with this tie Please note during the case it was noted the patient had continued significant stiffness despite the Achilles lengthening A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion Wound was then closed using 2 0 Vicryl and 4 0 Monocryl The surgical field was irrigated with 0 25 Marcaine and subsequently injected with more Marcaine at the end of the case The wound was clean and dry and dressed with Steri Strips and Xeroform Skin was dressed with Xeroform and 4 x 4 s Everything was wrapped with 4 x 4 s in sterile Webril The tourniquet was released after 69 minutes A short leg cast was then placed with good return of capillary refill to his toes The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition POSTOPERATIVE PLAN The patient will be hospitalized overnight for elevation ice packs neurovascular checks and pain control The patient to be strict nonweightbearing We will arrange for her to get a wheelchair The patient will then follow up in about 10 to 14 days for a cast check as well as pain control The patient will need an AFO script at that time Intraoperative findings are relayed to the parents Keywords orthopedic calcaneal lengthening osteotomy allograft plantar fasciotomy capsulotomy calcaneal valgus split partial plantar fasciotomy short leg cast achilles lengthening calcaneal valgus tourniquet plantar valgus achilles calcaneal MEDICAL_TRANSCRIPTION,Description Carpal tunnel release Nerve conduction study tests diagnostic of carpal tunnel syndrome The patient failed to improve satisfactorily on conservative care including anti inflammatory medications and night splints Medical Specialty Orthopedic Sample Name Carpal Tunnel Release Transcription PROCEDURE PERFORMED Carpal tunnel release INDICATIONS FOR SURGERY Nerve conduction study tests diagnostic of carpal tunnel syndrome The patient failed to improve satisfactorily on conservative care including anti inflammatory medications and night splints PROCEDURE The patient was brought to the operating room and following a Bier block to the operative arm the arm was prepped and draped in the usual manner Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament It was identified at its distal edge Using a hemostat to probe the carpal tunnel sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal to proximal direction in its entirety The canal was probed with a small finger to verify no evidence of any bone prominences The nerve was examined for any irregularity There was slight hyperemia of the nerve and a slight hourglass deformity Following an irrigation the skin was approximated using interrupted simple and horizontal mattress 5 nylon suture A sterile dressing was applied The patient was taken to the recovery room in satisfactory condition The time of the Bier block was 30 minutes COMPLICATIONS None noted Keywords orthopedic carpal tunnel syndrome carpal ligament nerve conduction study carpal tunnel release bier block carpal tunnel tunnel carpal MEDICAL_TRANSCRIPTION,Description Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left and arthroplasty left second toe Bunion left foot and hammertoe left second toe Medical Specialty Orthopedic Sample Name Bunionectomy Metatarsal Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe POSTOPERATIVE DIAGNOSES 1 Bunion left foot 2 Hammertoe left second toe PROCEDURE PERFORMED 1 Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left 2 Arthroplasty left second toe HISTORY This 39 year old female presents to ABCD General Hospital with the above chief complaint The patient states that she has had bunion for many months It has been progressively getting more painful at this time The patient attempted conservative treatment including wider shoe gear without long term relief of symptoms and desires surgical treatment PROCEDURE An IV was instituted by the Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff After adequate sedation was achieved by the Department of Anesthesia a total of 15 cc of 0 5 Marcaine plain was injected in a Mayo and digital block to the left foot The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table The stockinette was reflected The foot was cleansed with wet and dry sponge Attention was then directed to the first metatarsophalangeal joint of the left foot An incision was created over this area approximately 6 cm in length The incision was deepened with a 15 blade All vessels encountered were ligated for hemostasis The skin and subcutaneous tissue was then dissected from the capsule Care was taken to preserve the neurovascular bundle Dorsal linear capsular incision was then created The capsule was then reflected from the head of the first metatarsal Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected A lateral capsulotomy was performed Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence The incision was then extended proximally with further dissection down to the level of the bone Two 0 45 K wires were then inserted as access guides for the SCARF osteotomy A standard SCARF osteotomy was then performed The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle After adequate reduction of the bunion deformity was noted the bone was temporarily fixated with a 0 45 K wire A 3 0 x 12 mm screw was then inserted in the standard AO fashion with compression noted A second 3 0 x 14 mm screw was also inserted with tight compression noted The remaining prominent medial eminence medially was then resected with a sagittal saw Reciprocating rasps were then used to smooth any sharp bony edges The temporary fixation wires were then removed The screws were again checked for tightness which was noted Attention was directed to the medial capsule where a medial capsulorrhaphy was performed A straight stat was used to assist in removing a portion of the capsule The capsule was then reapproximated with 2 0 Vicryl medially Dorsal capsule was then reapproximated with 3 0 Vicryl in a running fashion The subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular stitch with 5 0 Vicryl The skin was then closed with 4 0 nylon in a horizontal mattress type fashion Attention was then directed to the left second toe A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe The incision was deepened with a 15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally An incision was made on either side of the extensor digitorum longus tendon A curved mosquito stat was then used to reflex the tendon laterally The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx A sagittal saw was then used to resect the head of the proximal head The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto The extensor digitorum longus tendon was inspected and noted to be intact Any sharp edges were then smoothed with reciprocating rasp The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon Dressings consisted of Owen silk 4x4s Kling Kerlix and Coban Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact to the left foot The patient is to follow up with Dr X in his clinic as directed Keywords orthopedic hammertoe osteotomy internal screw fixation scarf type extensor digitorum metatarsal osteotomy foot toe metatarsal bunionectomy MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Akin bunionectomy right toe with internal wire fixation Medical Specialty Orthopedic Sample Name Bunionectomy Osteotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot POSTOPERATIVE DIAGNOSES 1 Hallux valgus right foot 2 Hallux interphalangeus right foot PROCEDURES PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Akin bunionectomy right toe with internal wire fixation ANESTHESIA TIVA local HISTORY This 51 year old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot The patient has a history of gradual onset of a painful bunion over the past several years She has tried conservative methods such as wide shoes accommodative padding on an outpatient basis with Dr X all of which have provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed with the patient in detail by Dr X and the consent is available on the chart for review PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril After adequate IV sedation was administered by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 0 5 Marcaine plain and 1 Lidocaine plain was injected into the foot in a standard Mayo block fashion The foot was elevated off the table Esmarch bandages were used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated to 250 mmHg The foot was lowered in the operative field and the sterile stockinet was reflected A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia which was found to be adequate Attention was directed to the first metatarsophalangeal joint which was found to be contracted laterally deviated and had decreased range of motion A 10 blade was used to make a 4 cm dorsolinear incision A 15 blade was used to deepen the incision through the subcutaneous layer All superficial subcutaneous vessels were ligated with electrocautery Next a linear capsular incision was made down the bone with a 15 blade The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head The medial plantar aspect of the metatarsal head had some erosive changes and eburnation Next a 0 45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it A sagittal saw was used to make a long arm Austin osteotomy in the usual fashion Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex The capital head was shifted laterally and impacted on the residual metatarsal head Nice correction was achieved and excellent bone to bone contact was achieved The bone stock was slightly decreased but adequate Next a 0 45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment A 2 7 x 18 mm Synthes cortical screw was thrown using standard AO technique Excellent rigid fixation was achieved A second 2 0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head Again an excellent rigid fixation was obtained and the screws were tight The temporary fixation was removed A medial overhanging bone was resected with a sagittal saw The foot was loaded and the hallux was found to have an interphalangeus deformity present A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx leaving a lateral intact cortical hinge A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done After the wedge bone was removed the saw blade was reinserted and used to tether the osteotomy with counter pressure used to close down the osteotomy A 15 drill blade was used to drill two converging holes on the medial aspect of the bone A 28 gauge monofilament wire was inserted loop to loop and pulled through the bone The monofilament wire was twisted down and tapped into the distal drill hole The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved Next reciprocating rasps were used to smooth all bony surfaces Copious amounts of sterile saline was used to flush the joint Next a 3 0 Vicryl was used to reapproximate the capsular periosteal tissue layer Next 4 0 Vicryl was used to close the subcutaneous layer 5 0 Vicryl was used to the close the subcuticular layer in a running fashion Next 1 cc of dexamethasone phosphate was then instilled in the joint The Steri Strips were applied followed by standard postoperative dressing consisting of Owen silk 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot She is to be partial weightbearing with crutches She is to follow with Dr X She was given emergency contact numbers and instructions to call if problems arise She was given prescription for Vicodin ES 25 one p o q 4 6h p r n pain and Naprosyn one p o b i d 500 mg She was discharged in stable condition Keywords orthopedic hallux interphalangeus osteotomy bunionectomy akin wire fixation screw fixation painful bunion metatarsophalangeal joint pneumatic ankle metatarsal head foot toe sagittal metatarsal MEDICAL_TRANSCRIPTION,Description Endoscopic release of left transverse carpal ligament Steroid injection stenosing tenosynovitis of right middle finger Medical Specialty Orthopedic Sample Name Carpal Ligament Release 2 Transcription PREOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 2 Stenosing tenosynovitis of right middle finger trigger finger POSTOPERATIVE DIAGNOSES 1 Left carpal tunnel syndrome 2 Stenosing tenosynovitis of right middle finger trigger finger PROCEDURES 1 Endoscopic release of left transverse carpal ligament 2 Steroid injection stenosing tenosynovitis of right middle finger ANESTHESIA Monitored anesthesia care with regional anesthesia applied by surgeon TOURNIQUET TIME Left upper extremity was 15 minutes OPERATIVE PROCEDURE IN DETAIL With the patient under adequate monitored anesthesia the left upper extremity was prepped and draped in a sterile manner The arm was exsanguinated The tourniquet was elevated at 290 mmHg Construction lines were made on the left palm to identify the ring ray A transverse incision was made in the palm between FCR and FCU one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin Blunt dissection exposed the antebrachial fascia Hemostasis was obtained with bipolar cautery A distal based window in the antebrachial fascia was then fashioned Care was taken to protect the underlying contents A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface Hamate sounds were then used to palpate the Hood of Hamate The Agee Inside Job was then inserted into the proximal incision The transverse carpal ligament was easily visualized through the portal Using palmar pressure transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end The distal end of the transverse carpal ligament was then identified in the window The blade was then elevated and the Agee Inside Job was withdrawn dividing transverse carpal ligament under direct vision After complete division of transverse carpal ligament the Agee Inside Job was reinserted Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished One mL of Celestone was then introduced into the carpal tunnel and irrigated free The wound was then closed with a running 3 0 Prolene subcuticular stitch Steri strips were applied and a sterile dressing was applied over the Steri strips The tourniquet was deflated The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Attention was turned to the right palm where after a sterile prep the right middle finger flexor sheath was injected with 0 5 mL of 1 plain Xylocaine and 0 5 mL of Depo Medrol 40 mg mL A Band Aid dressing was then applied The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well Keywords orthopedic carpal tunnel syndrome agee inside job steroid injection antebrachial fascia forearm ring ray synovial elevator tenosynovitis tourniquet transverse incision trigger finger tenosynovitis of right middle transverse carpal ligament transverse carpal carpal ligament steri strips stenosing tenosynovitis middle finger ligament carpal endoscopic finger MEDICAL_TRANSCRIPTION,Description Bunion left foot Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot Medical Specialty Orthopedic Sample Name Bunionectomy Akin Osteotomy Transcription PREOPERATIVE DIAGNOSIS Bunion left foot POSTOPERATIVE DIAGNOSIS Bunion left foot PROCEDURE PERFORMED 1 Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation 2 Akin osteotomy with internal wire fixation of left foot HISTORY This 19 year old Caucasian female presents to ABCD General Hospital with the above chief complaint The patient states she has had worsening bunion deformity for as long as she could not remember She does have a history of Charcot Marie tooth disease and desires surgical treatment at this time PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field The stockinette was reflected the foot was cleansed with a wet and dry sponge Approximately 5 cm incision was made dorsomedially over the first metatarsal The incision was then deepened with 15 blade All vessels encountered were ligated for hemostasis Care was taken to preserve the extensor digitorum longus tendon The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone Capsule and periosteum was reflected off the first metatarsal head At this time the cartilage was inspected and noted to be white shiny and healthy cartilage There was noted to be a prominent medial eminence Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release The abductor tendon attachments were identified and transected The lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Attention was then directed to the prominent medial eminence which was resected with a sagittal saw Intraoperative assessment of pes was performed and pes was noted to be normal At this time a regional incision was carried more approximately about 1 5 cm The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal The first metatarsal cuneiform joint was identified A 0 45 K wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface This K wire was used as an access guide for a Juvaro type oblique base wedge osteotomy The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial The osteotomy site was then feathered and tilted with tight estimation of the bony edges The cortical hinge was maintained A 0 27 x 24 mm screw was then inserted in a standard AO fashion At this time there was noted to be tight compression of the osteotomy site A second 2 7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted The ________ angle was noted to be significantly released Reciprocating rasp was then used to smoothen any remaining sharp edges The 0 45 k wire was removed The foot was loaded and was noted to fill the remaining abduction of the hallux At this time it was incised to perform an Akin osteotomy Original incision was then extended distally approximately 1 cm The incision was then deepened down to the level of capsule over the base of the proximal phalanx Again care was taken to preserve the extensor digitorum longus tendon The capsule was reflected off of the base of the proximal phalanx An Akin osteotomy was performed with the apex being lateral and the base being medial After where the bone was resected it was feathered until tight compression was noted without tension at the osteotomy site Care was taken to preserve the lateral hinge At 1 5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire The 28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted The remaining edge of the wire was then buried in the medial most distal drill hole The area was then inspected and the foot was noted with significant reduction of the bunion deformity The area was then flushed with copious amounts of sterile saline Capsule was closed with 3 0 Vicryl followed by subcutaneous closure with 4 0 Vicryl in order to decrease tension of the incision site A running 5 0 subcuticular stitch was then performed Steri Strips were applied Total of 1 cc dexamethasone phosphate was then injected into the surgical site Dressings consisted of Owen silk 4x4s Kling Kerlix The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot Posterior splint was then placed on the patient in the operating room The patient tolerated the above procedure and anesthesia well without complications The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot The patient was given postoperative instructions to be strictly nonweightbearing on the left foot The patient was given postop pain prescriptions for Vicodin and instructed to take one q 4 6h p r n for pain as well as Naprosyn 500 mg p o q b i d The patient is to follow up with Dr X in his office in four to five days as directed Keywords orthopedic bunionectomy akin osteotomy internal wire fixation internal screw fixation osteotomy metatarsal metatarsal osteotomy extensor digitorum drill hole osteotomy site foot MEDICAL_TRANSCRIPTION,Description Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot Proximal interphalangeal joint arthroplasty bilateral fifth toes Distal interphalangeal joint arthroplasty bilateral third and fourth toes Flexor tenotomy bilateral third toes Medical Specialty Orthopedic Sample Name Bunionectomy Flexor Tenotomy Transcription PREOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes POSTOPERATIVE DIAGNOSES 1 Hallux abductovalgus right foot 2 Hammertoe bilateral third fourth and fifth toes PROCEDURE PERFORMED 1 Bunionectomy with distal first metatarsal osteotomy and internal screw fixation right foot 2 Proximal interphalangeal joint arthroplasty bilateral fifth toes 3 Distal interphalangeal joint arthroplasty bilateral third and fourth toes 4 Flexor tenotomy bilateral third toes HISTORY This is a 36 year old female who presented to ABCD preoperative holding area after keeping herself n p o since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet The patient has a history of sharp pain which is aggravated by wearing shoes and ambulation She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding all of which provided inadequate relief At this time she desires attempted surgical correction The risks versus benefits of the procedure have been discussed in detail by Dr Kaczander with the patient and the consent is available on the chart PROCEDURE IN DETAIL After IV was established by the Department of Anesthesia the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril After adequate IV sedation was administered a total of 18 cc of a 0 5 Marcaine plain was used to anesthetize the right foot performing a Mayo block and a bilateral third fourth and fifth digital block Next the foot was prepped and draped in the usual aseptic fashion bilaterally The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg The foot was lowered into operative field and the sterile stockinet was reflected proximally Attention was directed to the right first metatarsophalangeal joint it was found to be contracted and there was lateral deviation of the hallux There was decreased range of motion of the first metatarsophalangeal joint A dorsolinear incision was made with a 10 blade approximately 4 cm in length The incision was deepened to the subcutaneous layer with a 15 blade Any small veins traversing the subcutaneous layer were ligated with electrocautery Next the medial and lateral wound margins were undermined sharply Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon Next the first metatarsal joint capsule was identified A 15 blade was used to make a linear capsular incision down to the bone The capsular periosteal tissues were elevated off the bone with a 15 blade and the metatarsal head was delivered into the wound The PASA was found to be within normal limits There was a hypertrophic medial eminence noted A sagittal saw was used to remove the hypertrophic medial eminence A 0 045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide A standard lateral release was performed The fibular sesamoid was found to be in the interspace but was relocated onto the metatarsal head properly Next a sagittal saw was used to perform a long arm Austin osteotomy The K wire was removed The capital fragment was shifted laterally and impacted into the head A 0 045 inch Kirschner wire was used to temporarily fixate the osteotomy A 2 7 x 16 mm Synthes fully threaded cortical screw was throne using standard AO technique A second screw was throne which was a 2 0 x 12 mm Synthes cortical screw Excellent fixation was achieved and the screws tightly perched the bone Next the medial overhanging wedge was removed with a sagittal saw A reciprocating rasp was used to smooth all bony prominences The 0 045 inch Kirschner wire was removed The screws were checked again for tightness and found to be very tight The joint was flushed with copious amounts of sterile saline A 3 0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique A 4 0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique A 5 0 Monocryl was used to close the skin in a running subcuticular fashion Attention was directed to the right third digit which was found to be markedly contracted at the distal interphalangeal joint A 15 blade was used to make two convergent semi elliptical incisions over the distal interphalangeal joint The incision was deepened with a 15 blade The wedge of skin was removed in full thickness The long extensor tendon was identified and the distal and proximal borders of the wound were undermined The 15 blade was used to transect the long extensor tendon which was reflected proximally The distal interphalangeal joint was identified and the 15 blade was placed in the joint and the medial and lateral collateral ligaments were released Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx Next a double action bone cutter was used to resect the head of the middle phalanx The toe was dorsiflexed and was found to have an excellent rectus position A hand rasp was used to smooth all bony surfaces The joint was flushed with copious amounts of sterile saline The flexor tendon was found to be contracted therefore a flexor tenotomy was performed through the dorsal incision Next 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin and excellent cosmetic result was achieved Attention was directed to the fourth toe which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated An oblique skin incision with two converging semi elliptical incisions was created using 15 blade The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot All the same suture materials were used However there was no flexor tenotomy performed on this toe only on the third toe bilaterally Attention was directed to the fifth right digit which was found to be contracted at the proximal interphalangeal joint A linear incision approximately 2 cm in length was made with a 15 blade over the proximal interphalangeal joint Next a 15 blade was used to deepen the incision to the subcutaneous layer The medial and lateral margins were undermined sharply to the level of the long extensor tendon The proximal interphalangeal joint was identified and the tendon was transected with the 15 blade The tendon was reflected proximally off the head of the proximal phalanx The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound A double action bone nibbler was used to remove the head of the proximal phalanx A hand rasp was used to smooth residual bone The joint was flushed with copious amounts of saline A 3 0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures A 4 0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures A standard postoperative dressing consisting of saline soaked 0 1 silk 4 x 4s Kerlix Kling and Coban were applied The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits Attention was directed to the left foot The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg Attention was directed to the left fifth toe which was found to be contracted at the proximal interphalangeal joint The exact same procedure performed to the right fifth digit was performed on this toe with the same materials being used for suture and closure Attention was then directed to the left fourth digit which was found to contracted and slightly abducted and varus rotated The exact same procedure as performed to the right fourth toe was performed consisting of two semi elliptical skin incisions in an oblique angle The same suture material were used to close the incision Attention was directed to the left third digit which was found to be contracted at the distal interphalangeal joint The same procedure performed on the right third digit was also performed The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits The patient tolerated the above anesthesia and procedure without complications She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot She was given postoperative shoes and will be partial weighbearing with crutches She was admitted short stay to Dr Kaczander for pain control She was placed on Demerol 50 and Vistaril 25 mg IM q3 4h p r n for pain She will have Vicodin 5 500 one to two p o q 4 6h p r n for moderate pain She was placed on Subq heparin and given incentive spirometry 10 times an hour She will be discharged tomorrow She is to ice and elevate both feet today and rest as much as possible Physical Therapy will teach her crutch training today X rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities Keywords orthopedic hallux abductovalgus hammertoe bunionectomy flexor tenotomy interphalangeal arthroplasty screw fixation osteotomy interphalangeal joint arthroplasty distal interphalangeal joint interphalangeal joint flexor tenotomy proximal interphalangeal joint arthroplasty distal interphalangeal distal blade proximal foot joint toes tendon MEDICAL_TRANSCRIPTION,Description Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet recurrent bunion deformity right forefoot pes planovalgus deformity bilateral feet Medical Specialty Orthopedic Sample Name Bunion Pes Planovalgus Deformity Transcription HISTORY OF PRESENT ILLNESS The patient is a 57 year old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet right greater than left The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well The patient had prior surgery performed approximately 13 years ago She states that since the time of the original surgery the deformity has slowly recurred and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete PAST MEDICAL HISTORY FAMILY HISTORY SOCIAL HISTORY REVIEW OF SYSTEMS See Patient History sheet which was reviewed with the patient and is signed in the chart Past medical history on the patient past surgical history current medications drug related allergies and social history have all been updated and reviewed and enclosed in the chart PHYSICAL EXAMINATION Physical exam reveals a pleasant 57 year old female who is 5 feet 4 inches and 150 pounds She has palpable pulses Neurologic sensation is intact Examination of the extremities shows the patient as having well healed surgical sites from her arthroplasty second digits bilaterally and prior bunionectomy There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw toe deformity of the second and third toes to the left foot and to a lesser degree the second toe to the right Gait analysis The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet X RAY INTERPRETATION X rays taken today three views to the right foot shows presence of internal K wire and wire from prior bunionectomy Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle No evidence of arthrosis in the joint is noted Significant shift to the fibular sesamoid is present ASSESSMENT 1 Recurrent bunion deformity right forefoot 2 Pes planovalgus deformity bilateral feet PLAN TREATMENT 1 Today we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal Anticipated length of healing was noted for the patient as were potential risks and complications The patient ultimately would probably require surgery on her left foot at a later date as well 2 The patient will explore her ability to get out of work for the above mentioned period of time and will be in touch with regards regarding scheduling at a later date 3 All questions were answered Keywords orthopedic x rays pain mtp joint pes planovalgus deformity pes planovalgus bunion deformity planovalgus forefoot foot deformity bunionectomy bunion MEDICAL_TRANSCRIPTION,Description Austin akin bunionectomy right foot Bunion right foot The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful Medical Specialty Orthopedic Sample Name Bunionectomy Austin Akin Transcription PREOPERATIVE DIAGNOSIS Bunion right foot POSTOPERATIVE DIAGNOSIS Bunion right foot PROCEDURE PERFORMED Austin akin bunionectomy right foot HISTORY This 77 year old African American female presents to ABCD General Hospital with the above chief complaint The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful The patient has attempted conservative treatment without long term relief of symptoms and desires surgical treatment PROCEDURE DETAILS An IV was instituted by Department of Anesthesia in the preop holding area The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 15 cc of 1 1 mixture of 1 lidocaine plain and 0 5 Marcaine plain was injected in a Mayo block type fashion The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated to the operating table and exsanguinated with an Esmarch bandage The pneumatic ankle tourniquet was inflated to 250 mmHg The foot was lowered to the operating field and the stockinet was reflected The foot was cleansed with wet and dry sponge Attention was directed to the bunion deformity on the right foot An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint The incision was then deepened with a 15 blade All vessels encountered were ligated with hemostasis The skin and subcutaneous tissue were then undermined off of the capsule medially A dorsal linear capsular incision was then created over the first metatarsophalangeal joint The periosteum and capsule were then reflected off of the first metatarsal There was noted to be a prominent medial eminence The articular cartilage was healthy for patient s age and race Attention was then directed to the first interspace where a lateral release was performed A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified The adductor tendons were transected as well as a lateral capsulotomy was performed The extensor digitorum brevis tendon was identified and transected Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon Attention was then directed to medial eminence which was resected with a sagittal saw Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted The head was intact A 0 45 K wire was inserted through subcutaneously from proximal medial to distal lateral A second K wire was then inserted from distal lateral to proximal plantar medial Adequate fixation was noted at the osteotomy site The K wires were bent cut and pin caps were placed Attention was then directed to the proximal phalanx of the hallux The capsular periostem was reflected off of the base of the proximal phalanx A sagittal was then used to create an akin osteotomy closing wedge The apex was lateral and the base of the wedge was medial The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression Two 0 45 K wires were then inserted one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site Adequate fixation was noted at the osteotomy site and the osteotomy was closed The toe was noted to be in a markedly more rectus position Sagittal saw was then used to resect the remaining prominent medial eminence The area was then smoothed with a reciprocating rasp There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp The area was then inspected for any remaining short bony edges none were noted Copious amounts of sterile saline was then used to flush the surgical site The capsule was closed with 3 0 Vicryl Subcutaneous closure was performed with 4 0 Vicryl followed by running subcuticular 5 0 Vicryl Steri Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site Dressings consisted of 0 1 silk copious Betadine 4 x 4s Kling Kerlix and Coban The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot A _______ cast was then applied postoperatively The patient tolerated the above procedure and anesthesia well without complications The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot The patient was given postoperative pain prescription for Tylenol 3 and instructed to take one q4 6h p o p r n for pain The patient is to follow up with Dr X in his office as directed Keywords orthopedic austin akin bunionectomy hallucis brevis bunion deformity extensor hallucis osteotomy site foot austin bunionectomy MEDICAL_TRANSCRIPTION,Description A woman presenting to our clinic for the first time for evaluation of hip pain right greater than left of greater than 2 years duration The pain is located laterally as well as anteriorly into the groin Medical Specialty Orthopedic Sample Name Bilateral Hip Pain Transcription HISTORY OF PRESENT ILLNESS The patient is a 38 year old woman presenting to our clinic for the first time for evaluation of hip pain right greater than left of greater than 2 years duration The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip The pain is located laterally as well as anteriorly into the groin She states that the pain is present during activities such as walking and she does get some painful popping and clicking in the right hip She is here for evaluation for the first time She sought no previous medical attention for this PAST MEDICAL HISTORY Significant for depression and reflux disease PAST SURGICAL HISTORY Cesarean section x 2 CURRENT MEDICATIONS Listed in the chart and reviewed with the patient ALLERGIES The patient has no known drug allergies SOCIAL HISTORY The patient is married She is employed as an office manager She does smoke cigarettes one pack per day for the last 20 years She consumes alcohol 3 to 5 drinks daily She uses no illicit drugs She exercises monthly mainly walking and low impact aerobics She also likes to play softball REVIEW OF SYSTEMS Significant for occasional indigestion and nausea as well as anxiety and depression The remainder of the systems negative PHYSICAL EXAMINATION The patient is 5 foot 2 inches tall weighs 155 pounds The patient ambulates independently without an assist device with normal stance and gait Inspection of the hips reveals normal contour and appearance and good symmetry The patient is able to do an active straight leg raise against gravity and against resistance bilaterally She has no significant trochanteric tenderness She does however have some tenderness in the groin bilaterally There is no crepitus present with passive or active range of motion of the hips She is grossly neurologically intact in the bilateral lower extremities DIAGNOSTIC DATA X rays performed today in the clinic include an AP view of the pelvis and a frog leg lateral of the right hip There are no acute findings No fractures or dislocations There are minimal degenerative changes noted in the joint There is however the suggestion of an exostosis on the superior femoral neck which could be consistent with femoroacetabular impingement IMPRESSION Bilateral hip pain right worse than left possibly suggesting femoroacetabular impingement based on x rays and her clinical picture is also consistent with possible labral tear PLAN After discussing possible diagnoses with the patient I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip We will get that done as soon as possible In the meantime she is asked to moderate her activities She will follow up as soon as the MRIs are performed Keywords orthopedic bilateral hip pain femoroacetabular impingement hip MEDICAL_TRANSCRIPTION,Description Tailor s bunionectomy with metatarsal osteotomy of the left fifth metatarsal Excision of nerve lesion with implantation of the muscle belly of the left second interspace Excision of nerve lesion in the left third interspace MEDICAL_TRANSCRIPTION,Description Back injury with RLE radicular symptoms The patient is a 52 year old male who is here for independent medical evaluation Medical Specialty Orthopedic Sample Name Back Injury IME Transcription PAST MEDICAL CONDITION None ALLERGIES None CURRENT MEDICATION Zyrtec and hydrocodone 7 5 mg one every 4 to 6 hours p r n for pain CHIEF COMPLAINT Back injury with RLE radicular symptoms HISTORY OF PRESENT ILLNESS The patient is a 52 year old male who is here for independent medical evaluation The patient states that he works for ABC ABC as a temporary worker He worked for ABCD too The patient s main job was loading and unloading furniture and appliances for the home The patient was approximately there for about two and a half weeks Date of injury occurred back in October The patient stating that he had history of previous back problems ongoing however he states that on this particular day back in October he was unloading an 18 wheeler at ABC and he was bending down picking up boxes to unload and load Unfortunately at this particular event the patient had sharp pain in his lower back Soon afterwards he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee This became progressively worse He also states that some of his radiating pain went down to his left leg as well He noticed increase in buttock spasm and also noticed spasm in his buttocks He initially saw Dr Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch I believe The patient states that after this treatment his symptoms still persisted At this point the patient later on was referred to Dr XYZ through the workmen s comp and he was initially evaluated back in April After the evaluation the patient was sent for MRI was provided with pain medications such as short acting opioids He was put on restricted duty The MRI essentially came back negative but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr XYZ in June with maximum medical improvement Unfortunately the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr XYZ again and at this point the patient was provided with further medication management and sent for Pain Clinic referral The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr ABC without any significant relief The patient also was sent for EMG and nerve conduction study which was performed by Dr ABCD and the MRI EMG and nerve conduction study came back essentially negative for radiculopathy which was performed by Dr ABCD The patient states that he continues to have pain with extended sitting he has radiating symptoms down to his lower extremity on the right side of his leg increase in pain with stooping He has difficulty sleeping at nighttime because of increase in pain Ultimately the patient was returned back to work in June and deemed with maximum medical improvement back in June The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg worse than the left side The patient also went to see Dr X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long term relief in his overall radicular symptoms PHYSICAL EXAMINATION The patient was examined with the gown on Lumbar flexion was moderately decreased Extension was normal Side bending to the right was decreased Side bending to the left was within normal limits Rotation and extension to the right side was causing increasing pain Extension and side bending to the left was within normal limits without significant pain on the left side While seated straight leg was negative on the LLE at 90 and also negative on the RLE at 90 There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position In supine position straight leg was negative in the LLE and also negative on the RLE Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits Deep tendon reflex at the patella was 2 4 bilaterally but there was a decrease in reflex in the Achilles tendon 1 4 on the right side and essentially 2 4 on the left side Medial hamstring reflex was 2 4 on both hamstrings as well On prone position there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area right side was worse than the left side Increase in pain at deep palpatory examination in midline of the L5 and S1 level MEDICAL RECORD REVIEW I had the opportunity to review Dr XYZ s medical records Also reviewed Dr ABC procedural note which was the epidural steroid injection block that was performed in December Also reviewed Dr X s medical record notes and an EMG and nerve study that was performed by Dr ABCD which was essentially normal The MRI of the lumbar spine that was performed back in April which showed no evidence of herniated disc DIAGNOSIS Residual from low back injury with right lumbar radicular symptomatology EVALUATION RECOMMENDATION The patient has an impairment based on AMA Guides Fifth Edition and it is permanent The patient appears to have re aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18 wheel truck Essentially there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left The patient also has increase in back pain with lumbar flexion and rotational movement to the right side With these ongoing symptoms the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function Therefore the patient is assigned 8 impairment of the whole person We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide Using page 384 table 15 3 the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury In this particular section it states that the patient s clinical history and examination findings are compatible with specific injury and finding may include significant muscle guarding or spasm observed at the time of examination a symmetric loss of range of motion or non verifiable radicular complaints define his complaints of radicular pain without objective findings no alteration of the structural integrity and no significant radiculopathy The patient also has decrease in activities of daily living therefore the patient is assigned at the higher impairment rating of 8 WPI In the future the patient should avoid prolonged walking standing stooping squatting hip bending climbing excessive flexion extension and rotation of his back His one time weight limit should be determined by work trial although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology the patient also should be monitored closely for specific dependency to short acting opioids in the near future by specialist who could monitor and closely follow his overall pain management The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future Keywords orthopedic rle radicular symptoms independent medical evaluation injury lle deep tendon reflex emg mri lumbar radicular symptomatology MEDICAL_TRANSCRIPTION,Description Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy Chronic pain syndrome Medical Specialty Orthopedic Sample Name Back Leg Pain Discharge Summary Transcription ADMISSION DIAGNOSIS Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy SECONDARY DIAGNOSIS Chronic pain syndrome PRINCIPAL PROCEDURE L5 Gill procedure with interbody and posterolateral 360 degrees circumferential arthrodesis using cages bone graft recombinant bone morphogenic protein and pedicle fixation This was performed by Dr X on 01 08 08 BRIEF HISTORY OF HOSPITAL COURSE The patient is a man with a history of longstanding back buttock and bilateral leg pain He was evaluated and found to have bilateral pars defects at L5 S1 with spondylolysis and instability He was admitted and underwent an uncomplicated surgical procedure as noted above In the postoperative period he was up and ambulatory He was taking p o fluids and diet well He was afebrile His wounds were healing well Subsequently the patient was discharged home DISCHARGE MEDICATIONS Discharge medications included his usual preoperative pain medication as well as other medications FOLLOWUP At this time the patient will follow up with me in the office in six weeks time The patient understands discharge plans and is in agreement with the discharge plan He will follow up as noted Keywords orthopedic chronic pain syndrome spinal instability pars defects radiculopathy spondylolysis leg MEDICAL_TRANSCRIPTION,Description Ruptured distal biceps tendon right elbow Repair of distal biceps tendon right elbow Medical Specialty Orthopedic Sample Name Biceps Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow POSTOPERATIVE DIAGNOSIS Ruptured distal biceps tendon right elbow PROCEDURE PERFORMED Repair of distal biceps tendon right elbow PROCEDURE The patient was taken to OR Room 2 and administered a general anesthetic The right upper extremity was then prepped and draped in the usual manner A sterile tourniquet was placed on the proximal aspect of the right upper extremity The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg Tourniquet time was 74 minutes A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin Hemostasis was achieved utilizing electrocautery Subcutaneous fat was separated and the skin flaps elevated The _________ was identified It was incised The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found There was some serosanguineous fluid from the previous rupture This area was suctioned clean The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface At this point the 2 fiber wire was then passed through the tendon Two fiber wires were utilized in a Krackow type suture Once this was completed dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously The radial tuberosity was palpated Just ulnar to this a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow A skin incision was made over this area Approximately two inches down to the skin and subcutaneous tissues the fascia was split and the extensor muscle was also split A stat was then attached through the tip of that stat and passed back up through the antecubital fossa The tails of the fiber wire suture were grasped and pulled down through the second incision At this point they were placed to the side Attention was directed at exposure of the radial tuberosity with a forearm fully pronated The tuberosity came into view The margins were cleared with periosteal elevator and sharp dissection Utilizing the power bur a trough approximately 1 5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity Three small drill holes were then placed along the margin for passage of the suture The area was then copiously irrigated with gentamicin solution A 4 0 pullout wire was utilized to pass the sutures through the drill holes one on each outer hole and two in the center hole The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated The suture was tied over the bone islands Both wounds were then copiously irrigated with gentamicin solution and suctioned dry Muscle fascia was closed with running 2 0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted 2 0 Vicryl and small staples The anterior incision was approximated with interrupted 2 0 Vicryl for Subq and then skin was approximated with small staples Both wounds were infiltrated with a total of 30 cc of 0 25 Marcaine solution for postop analgesia A bulky fluff dressing was applied to the elbow followed by application of a long arm plaster splint maintaining the forearm in the supinated position Tourniquet was inflated prior to application of the splint Circulatory status returned to the extremity immediately The patient was awakened He was rather boisterous during his awakening but care was taken to protect the right upper extremity He was then transferred to the recovery room in apparent satisfactory condition Keywords orthopedic ruptured distal biceps tendon gentamicin solution antecubital fossa distal biceps biceps tendon tendon tuberosity biceps elbow MEDICAL_TRANSCRIPTION,Description Austin Moore bipolar hemiarthroplasty left hip utilizing a medium fenestrated femoral stem with a medium 0 8 mm femoral head a 50 mm bipolar cup Displace subcapital fracture left hip Medical Specialty Orthopedic Sample Name Austin Moore Bipolar Hemiarthroplasty Transcription PREOPERATIVE DIAGNOSIS Displace subcapital fracture left hip POSTOPERATIVE DIAGNOSIS Displace subcapital fracture left hip PROCEDURE PERFORMED Austin Moore bipolar hemiarthroplasty left hip utilizing a medium fenestrated femoral stem with a medium 0 8 mm femoral head a 50 mm bipolar cup PROCEDURE The patient was taken to OR 2 administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table The right lower extremity was protectively padded The left leg was propped with multiple blankets The hip was then prepped and draped in the usual manner A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues Hemostasis was achieved utilizing electrocautery Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly The external rotators were identified after removal of the trochanteric bursa Hemostat was utilized to separate the external rotators from the underlying capsule they were then transected off from their attachment at the posterior intertrochanteric line They were then reflected distally The capsule was then opened in a T fashion utilizing the cutting cautery Fraction hematoma exuded from the hip joint The cork screw was then impacted into the femoral head and it was removed from the acetabulum Bone fragments were removed from the neck and acetabulum The acetabulum was then inspected and noted to be free from debris The proximal femur was then delivered into the wound with the hip internally rotated A mortise chisel was then utilized to take the cancellous bone from the proximal femur The T handle broach was then passed down the canal The canal was then sequentially broached up to a medium broach The calcar was then plained with the hand plainer The trial components were positioned into place The medium component fit fairly well with the medium 28 mm femoral head Once the trial reduction was performed the hip was taken through range of motion There was physiologic crystalling with longitudinal traction There was no tendency towards dislocation with flexion of the hip past 90 degrees The trial implants were then removed The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit The implant was then impacted into place The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup The acetabulum was once again inspected was free of debris The hip was reduced It was taken through full range of motion There was no tendency for dislocation The wound was copiously irrigated with gentamicin solution The capsule was then repaired with interrupted 1 Ethibond suture External rotators were then reapproximated to the posterior intertrochanteric line utilizing 1 Ethibond in a modified Kessler type stitch The wound was once again copiously irrigated with gentamicin solution and suctioned dry Gluteus fascia was approximated with interrupted 1 Ethibond Subcutaneous layers were approximated with interrupted 2 0 Vicryl and skin approximated with staples A bulky dressing was applied to the wound The patient was then transferred to the hospital bed an abductor pillow was positioned into place Circulatory status was intact to the extremity at completion of the case Keywords orthopedic austin moore bipolar hemiarthroplasty femoral head femoral hip hemiarthroplasty ethibond acetabulum MEDICAL_TRANSCRIPTION,Description Diagnostic arthroscopy exam under anesthesia left shoulder Debridement of chondral injury left shoulder Debridement superior glenoid left shoulder Arthrotomy Bankart lesion repair Capsular shift left shoulder Mitek suture anchors absorbable anchors with nonabsorbable sutures Medical Specialty Orthopedic Sample Name Arthroscopy Arthrotomy Bankart lesion repair Transcription TITLE OF OPERATION 1 Diagnostic arthroscopy exam under anesthesia left shoulder 2 Debridement of chondral injury left shoulder 3 Debridement superior glenoid left shoulder 4 Arthrotomy 5 Bankart lesion repair 6 Capsular shift left shoulder Mitek suture anchors absorbable anchors with nonabsorbable sutures INDICATION FOR SURGERY The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder Risks and benefits of the procedure had been discussed in length including but not exclusive of infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain continued instability recurrent instability medical complications surgical complications and anesthesia complications The patient understood and wishes to proceed PREOP DIAGNOSIS Anterior instability left shoulder POSTOP DIAGNOSES 1 Anterior instability left shoulder 2 Grade 4 chondromalacia 10 humeral head chondral defect 1 cm squared left shoulder 3 Type 1 superior labrum anterior and posterior lesion left shoulder 4 Anteroinferior glenoid erosions 10 bony surface left shoulder 5 Bankart lesion left shoulder PROCEDURE The patient was placed in a supine position and both shoulders examined systematically She had full range of motion with no joint adhesions She had equal range of motion bilaterally She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders This was the same when the arm was in neutral or in external rotation The patient was then turned to right lateral decubitus position axillary roll was placed and beanbag was inflated Peroneal nerve was well protected All bony prominences were well protected The left upper extremity was then prepped and draped in the usual sterile fashion The patient was given antibiotics well before the start of the procedure to decrease the risk of infection The arm was placed in a arm holder with 10 pounds of traction A posterior portal was created in the usual manner by isolating gently with the spinal needle it was insufflated with 30 cubic centimeters of saline A small incision was made after infiltrating the skin with Marcaine and epinephrine The scope was introduced into the shoulder with no difficulty It was then examined systematically The patient did have diffuse synovitis throughout her shoulder Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head She also had an area 1 cm in diameter which was on more central portion of the head and more inferiorly which appeared to be more of an impaction type injury This had some portions of fibrillated and loose cartilage hanging from the edges These were later debrided but the dissection was proximally 10 to 15 of the humeral surface The biceps tendon appeared to be normal The supraspinatus infraspinatus tendons were normal The inferior pouch was normal with no capsular tearing and no HAGL lesions The posteroinferior labrum was normal as well as the posterosuperior labrum There was some fraying in the posterosuperior labrum which was later debrided It was found essentially to be a type 1 lesion anteriorly and superiorly The anterosuperior labrum appeared to be detached which appeared to be more consistent with a sublabral hole The middle glenohumeral ligament was present as an entire sheath but attach to the labrum The labrum did appeared to be detached from the anterior glenoid from the 11 o clock position all the way down to the 6 o clock position The biceps anchor itself was later probed and found to be stable and normal The subscapularis tendon was normal The anterior band of the glenohumeral ligament was present but it was clearly avulsed off the glenoid There was some suggestion of anteroinferior bony erosions which was later substantiated when the shoulder was opened The patient was missing about 10 to 15 of her anteroinferior glenoid rim The patient had a positive drive through sign The arm was then moved to lateral and placed through range of motion There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees maximum flexion was 150 degrees The arm abducted and externally rotated There was contact to the rotator cuff with posterosuperior labrum This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees maximum external rotation was 95 degrees The patient did have a positive relocation maneuver The posterior labrum did appear to tilt off but did not appear to peel off The arm was then placed back in the arm holder Anterior portal was created with Wissinger rod A blue cannula was inserted into the shoulder without difficulty Shaver was introduced in the labrum Also the area of chondromalacia as mentioned above was debrided The labrum was found to be stable with only a type 1 SLAP lesion and there was no evidence as there was really a type 2 SLAP lesion The instruments were then removed along with excess fluid The posterior portals were closed with single 4 0 nylon suture The anterior portal was left open The patient was then placed in a supine position and the extremity was reprepped and draped in anticipation of performing open capsular shift The patient s anterior incision made just lateral to the coracoid in the skin line Mediolateral skin flaps were developed and cephalic vein was identified and protected throughout the case The interval was developed down the clavipectoral fascia The conjoined tendon was retracted medially and the deltoid laterally The patient s subscapularis was intact and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers The capsule could easily be detached from the muscle and the interval developed very easily A retractor was placed inferiorly to protect the axillary nerve Then Gelpi retractor was used to hold the subscapularis split open Next an arthrotomy was made down at the 9 o clock position The labrum was identified and found to be attached all the way down to 6 o clock position The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture The patient s glenoid rim did have some erosion as mentioned above with some bone loss and flattening This was debrided with the soft tissue Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck These were absorbable anchors with nonabsorbable sutures They had excellent fixation once they had been placed Next the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti Cron sutures as an outside in and then inside out technique This brought the capsule right up to the edge of the glenoid rim With the arm in internal rotation and posterior pressure on the head the capsule was then secured to the rim with no difficulty under direct visualization The capsule did come right up into the joint as expected with this type of repair The superior flap was then closed the inferior flap over the superior anchor The interval between two flaps was closed with multiple number 2 Ti Cron sutures Once this has been completed there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached The arm abducted 90 degrees There was tension on the repair until 20 degrees of external rotation reached The wound was thoroughly irrigated throughout with antibiotic impregnated irrigation The subscapularis split was closed with interrupted 0 Vicryl sutures The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures The superficial subcutaneous tissues were closed with number 2 0 Vicryl sutures The skin was closed with 4 0 subcuticular Prolene reinforced with Steri Strips A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer The patient was sent to the recovery room in stable and satisfactory condition Keywords orthopedic diagnostic arthroscopy chondral injury debridement superior glenoid arthrotomy bankart lesion capsular shift mitek suture absorbable anchors anterior instability chondromalacia superior labrum glenoid erosion glenoid rim external rotation glenoid labrum shoulder arthroscopy MEDICAL_TRANSCRIPTION,Description Austin bunionectomy with internal screw fixation first metatarsal left foot Medical Specialty Orthopedic Sample Name Austin Bunionectomy Transcription TITLE OF OPERATION Austin bunionectomy with internal screw fixation first metatarsal left foot PREOPERATIVE DIAGNOSIS Bunion deformity left foot POSTOPERATIVE DIAGNOSIS Bunion deformity left foot ANESTHESIA Monitored anesthesia care with 15 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 45 minutes left ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL MATERIALS USED 2 0 Vicryl 3 0 Vicryl 4 0 Vicryl as well as a 16 mm and an 18 mm partially threaded cannulated screw from the OsteoMed Screw Fixation System DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in a supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s left foot to anesthetize the future surgical sites The left ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the left ankle and set at 250 mmHg The left foot was then prepped scrubbed and draped in normal sterile technique The left ankle tourniquet was inflated Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6 cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint All the tendinous neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal and capsular attachments were mobilized from the head of the first left metatarsal The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw The same saw was used to perform an Austin type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction The same wires were also used as guide wires for the insertion of a 16 mm and an 18 mm partially threaded screws from the 3 0 OsteoMed System upon insertion of the screws which was accomplished using AO technique The wires were removed Fixation on the table was found to be excellent Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw The area was copiously flushed with saline The periosteal and capsular tissues were approximated with 2 0 and 3 0 Vicryl suture material 4 0 Vicryl was used to approximate the subcutaneous tissues The incision site was reinforced with Steri Strips At this time the patient s left ankle tourniquet was deflated The time was 45 minutes Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff The patient s incision was covered with Xeroform copious amounts of fluff and Kling stockinette and an Ace bandage The patient s left foot was then placed in a surgical shoe The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels The patient was given pain medication and instructions on how to control her postoperative course The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr X in one week s time for her first postoperative appointment Keywords orthopedic internal screw fixation first metatarsal bunion deformity osteomed screw fixation system subcutaneous tissues metatarsal head austin bunionectomy screw fixation ankle tourniquet metatarsophalangeal joint austin tourniquet metatarsophalangeal bunionectomy foot metatarsal MEDICAL_TRANSCRIPTION,Description Hemarthrosis left knee status post total knee replacement rule out infection Arthrotomy irrigation and debridement and polyethylene exchange left knee No complications were encountered throughout the procedure Medical Specialty Orthopedic Sample Name Arthrotomy I D Transcription PREOPERATIVE DIAGNOSIS Hemarthrosis left knee status post total knee replacement rule out infection POSTOPERATIVE DIAGNOSIS Hemarthrosis left knee status post total knee replacement rule out infection OPERATIONS 1 Arthrotomy left total knee 2 Irrigation and debridement left knee 3 Polyethylene exchange left knee COMPLICATION None TOURNIQUET TIME 58 minutes ESTIMATED BLOOD LOSS Minimal ANESTHESIA General INDICATIONS This patient underwent an uncomplicated left total knee replacement Postoperatively unfortunately did not follow up with PT INR blood test and he was taking Coumadin His INR was seemed to elevated and developed hemarthrosis Initially it did look very benign although over the last 24 hours it did become irritable and inflamed and he therefore was indicated with the above noted procedure This procedure as well as alternatives was discussed in length with the patient and he understood them well Risks and benefits were also discussed Risks such as bleeding infection damage to blood vessels damage to nerve roots need for further surgeries chronic pain with range of motion risk of continued discomfort risk of need for further reconstructive procedures risk of need for total knee revision risk of blood clots pulmonary embolism myocardial infarction and risk of death were discussed He understood them well All questions were answered and he signed consent for the procedure as described DESCRIPTION OF PROCEDURE The patient was placed on operating table and general anesthesia was achieved The left lower extremity was then prepped and draped in the usual sterile manner The leg was elevated and the tourniquet was inflated to 325 mmHg A longitudinal incision was then made and carried down through subcutaneous tissues This was made through the prior incision site There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site Medial and lateral flaps were then made The prior suture was identified the suture removed and then a medial parapatellar arthrotomy was then performed Effusion within the knee was noted All hematoma was evacuated I then did flex the knee and removed the polyethylene Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution Further debridement was performed of all inflamed tissue and thickened synovial tissue A 6 x 16 mm Stryker polyethylene was then snapped back in position The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline The knee was placed in a flexed position and the extensor mechanism was reapproximated using 2 Ethibond suture in a figure of eight manner The subcutaneous tissue was reapproximated in layers using 1 and 2 0 Vicryl sutures and the skin was reapproximated using staples Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint No complications were encountered throughout the procedure and the patient tolerated the procedure well The patient was taken to recovery room in stable condition Keywords orthopedic MEDICAL_TRANSCRIPTION,Description Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle right knee Soft tissue mass and osteophyte lateral femoral condyle right knee Medical Specialty Orthopedic Sample Name Arthrotomy Ostectomy Capsular Mass Excision Transcription PREOPERATIVE DIAGNOSIS Soft tissue mass right knee POSTOPERATIVE DIAGNOSES 1 Soft tissue mass right knee 2 Osteophyte lateral femoral condyle right knee PROCEDURES PERFORMED Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle right knee SPECIFICATION The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under a local and IV sedation via the Anesthesia Department HISTORY AND GROSS FINDINGS This is a 37 year old African American male with a mass present at the posterolateral aspect of his right knee On aspiration it was originally attempted to no avail There was a long standing history of this including two different MRIs one about a year ago and one very recently both of which did not delineate the mass present During aspiration previously the patient had experienced neuritic type symptoms down his calf which have mostly resolved by the time that this had occurred The patient continued to complain of pain and dysfunction to his calf This was discussed with him at length He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness swelling and peroneal nerve palsy With this he decided to proceed Upon observation preoperatively the patient was noted to have a hard mass present to the posterolateral aspect of the right knee It was noted to be tender It was marked preoperatively prior to an anesthetic Upon dissection the patient was noted to have significant thickening of the posterior capsule The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle There was also noted to be prominence of the lateral femoral condyle ridge The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present OPERATIVE PROCEDURE The patient was laid supine upon the operating table After receiving IV sedation he was placed prone Thigh tourniquet was placed He was prepped and draped in the usual sterile manner A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized The nerve was identified and carefully retracted throughout the case Both nerves were identified and carefully retracted throughout the case There was noted to be no neuroma present This was taken down until the gastroc was split There was gross thickening of the joint capsule and after arthrotomy a section of the capsule was excised The lateral femoral condyle was then osteophied We then smoothed off with a rongeur After this we could not palpate any mass whatsoever placing pressure upon the area of the nerve Tourniquet was deflated It was checked again There was no excessive swelling Swanson drain was placed to the depth of the wound and interrupted 2 0 Vicryl was utilized for subcutaneous fat closure and 4 0 nylon was utilized for skin closure Adaptic 4x4s ABDs and Webril were placed for compression dressing Digits were warm _______ pulses distally at the end of the case The tourniquet as stated has been deflated prior to closure and hemostasis was controlled Expected surgical prognosis on this patient is guarded Keywords orthopedic soft tissue mass osteophyte lateral femoral condyle excision capsular mass arthrotomy ostectomy knee soft tissue femoral condyle mass subcutaneous capsular tourniquet femoral condyle MEDICAL_TRANSCRIPTION,Description Austin Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint Weil osteotomy with internal screw fixation first right metatarsal Arthroplasty second right PIP joint Medical Specialty Orthopedic Sample Name Austin Akin Bunionectomy Transcription TITLE OF OPERATION 1 Austin Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint 2 Weil osteotomy with internal screw fixation first right metatarsal 3 Arthroplasty second right PIP joint PREOPERATIVE DIAGNOSES 1 Bunion deformity right foot 2 Dislocated second right metatarsophalangeal joint 3 Hammertoe deformity second right digit POSTOPERATIVE DIAGNOSES 1 Bunion deformity right foot 2 Dislocated second right metatarsophalangeal joint 3 Hammertoe deformity second right digit ANESTHESIA Monitored anesthesia care with 20 mL of 1 1 mixture of 0 5 Marcaine and 1 lidocaine plain HEMOSTASIS 60 minutes a right ankle tourniquet set at 250 mmHg ESTIMATED BLOOD LOSS Less than 10 mL PREOPERATIVE INJECTABLES 1 g Ancef IV 30 minutes preoperatively MATERIALS USED 3 0 Vicryl 4 0 Vicryl 5 0 Prolene as well as two 16 mm partially treaded cannulated screws of the OsteoMed system one 18 mm partially treaded cannulated screw of the OsteoMed system of the 3 0 size One 10 mm 2 0 partially threaded cannulated screw of the OsteoMed system DESCRIPTION OF THE PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position After adequate sedation was achieved by the anesthesia team the above mentioned anesthetic mixture was infiltrated directly into the patient s right foot to anesthetize the future surgical sites The right ankle was covered with cast padding and an 18 inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg The right foot was then prepped scrubbed and draped in a normal sterile technique The right ankle tourniquet was then inflated Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6 cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint Using sharp and dull dissection the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy The two screws from the 3 0 OsteoMed system were inserted over the wires using AO technique One screw measured 16 mm second screw measured 18 mm in length Both 3 0 screws were then evaluated for the fixation of the osteotomy after the wires were removed Fixation of the osteotomy was found to be excellent The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw To improve the correction of the hallux abductus angle an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally Upon removal of the base wedge from the base of the proximal phalanx the osteotomy was reduced with the OsteoMed smooth wire which was also used as a guidewire for the insertion of a 16 mm partially threaded cannulated screw from the OsteoMed 3 0 system Upon insertion of the screw using AO technique the wire was removed The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe Fixation of the osteotomy was found to be excellent Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical Range of motion of that joint was uninhibited The area was flushed copiously with saline Then 3 0 suture material was used to approximate the periosteum and capsular tissues 4 0 was used to approximate the subcutaneous tissues and Steri Strips were used to reinforce the incision Attention was directed over the neck of the second right metatarsal head where a 3 cm linear incision was placed directly over the surgical neck of the second right metatarsal The incision was deepened through subcutaneous tissues All the bleeders were identified cut clamped and cauterized The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal All the tendinous and neurovascular structures were identified and retracted from the site to be preserved Using sharp and dull dissection the surgical neck of the second right metatarsal was adequately exposed and then Weil type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal The 2 0 Osteo Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10 mm partially threaded 2 0 cannulated screw Upon insertion of the screw using AO technique the wire was then removed Fixation of the osteotomy with 2 0 screw was found to be excellent The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced Range of motion of the second right metatarsophalangeal joint was found to be excellent Then 3 0 Vicryl suture material was used to approximate the periosteal tissues Then 4 0 Vicryl was used to approximate the skin incision Attention was then directed at the level of the PIP joint of the second right toe where two semi elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint The island of skin between the two semi elliptical incisions was resected in toto The dissection was carried down to the level of extensor digitorum longus of the second right toe which was resected transversely at the level of the PIP joint A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed Using the double action bone cutter the head of the proximal phalanx of the second right toe was then resected The area was copiously flushed with saline The capsular and periosteal tissues were approximated with 2 0 Vicryl and 3 0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe A 5 0 Prolene was used to approximate the skin edges of the two semi elliptical incisions Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical At this time the patient s three incisions were covered with Xeroform copious amounts of fluff and Kling stockinette and Ace bandage The patient s right ankle tourniquet was deflated time was 60 minutes Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs The patient s right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels The patient was given instructions and education on how to continue caring for her right foot surgery The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr X s office in one week s time for her first postoperative appointment Keywords orthopedic austin akin bunionectomy weil osteotomy internal screw fixation first right metatarsal metatarsophalangeal joint hammertoe deformity extensor digitorum longus austin akin bunionectomy threaded cannulated screw semi elliptical incisions ankle tourniquet surgical neck cannulated screws pip joint proximal phalanx fixation metatarsophalangeal proximal screw metatarsal osteotomy austin joint tourniquet osteomed phalanx incision MEDICAL_TRANSCRIPTION,Description Erythema of the right knee and leg possible septic knee Aspiration through the anterolateral portal of knee joint Medical Specialty Orthopedic Sample Name Aspiration Knee Joint Transcription PREOPERATIVE DIAGNOSES Erythema of the right knee and leg possible septic knee POSTOPERATIVE DIAGNOSES Erythema of the right knee superficial and leg right septic knee ruled out INDICATIONS Mr ABC is a 52 year old male who has had approximately eight days of erythema over his knee He has been to multiple institutions as an outpatient for this complaint He has had what appears to be prepatellar bursa aspirated with little to no success He has been treated with Kefzol and 1 g of Rocephin one point He also reports in the emergency department today an attempt was made to aspirate his actual knee joint which was unsuccessful Orthopedic Surgery was consulted at this time Considering the patient s physical exam there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee After discussion of risks and benefits the patient elected to proceed with aspiration through the anterolateral portal of his knee joint PROCEDURE The patient s right anterolateral knee area was prepped with Betadine times two and a 20 gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella The 20 gauge spinal needle was inserted and entered the knee joint Approximately 4 cc of clear yellow fluid was aspirated The patient tolerated the procedure well DISPOSITION Based upon the appearance of this synovial fluid we have a very low clinical suspicion of a septic joint We will send this fluid to the lab for cell count crystal exam as well as culture and Gram stain We will follow these results After discussion with the emergency department staff it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics Keywords orthopedic knee and leg anterolateral portal emergency department spinal needle septic knee knee joint knee emergency department gauge spinal needle aspiration anterolateral portal aspirated fluid septic erythema joint aspiraion MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee left arthroscopic medial meniscoplasty of medial femoral condyle and chondroplasty of the left knee as well Chondromalacia of medial femoral condyle Medial meniscal tear left knee Medical Specialty Orthopedic Sample Name Arthroscopy Meniscoplasty Chondroplasty Transcription PREOPERATIVE DIAGNOSIS Medial meniscal tear left knee POSTOPERATIVE DIAGNOSIS Chondromalacia of medial femoral condyle PROCEDURE PERFORMED 1 Arthroscopy of the left knee 2 Left arthroscopic medial meniscoplasty of medial femoral condyle 3 Chondroplasty of the left knee as well ESTIMATED BLOOD LOSS 80 cc TOTAL TOURNIQUET TIME 19 minutes DISPOSITION The patient was taken to PACU in stable condition HISTORY OF PRESENT ILLNESS The patient is a 41 year old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain He has had a positive symptomology of locking and pain since then He had no frank instability to it however GROSS OPERATIVE FINDINGS We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle OPERATIVE PROCEDURE The patient was taken to the operating room The left lower extremity was prepped and draped in the usual sterile fashion Tourniquet was applied to the left thigh with adequate Webril padding not inflated at this time After the left lower extremity had been prepped and draped in the usual sterile fashion we applied an Esmarch tourniquet exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes We established the lateral port of the knee with 11 blade scalpel We put in the arthroscopic trocar instilled with water and inserted the camera On inspection of the patellofemoral joint it was found to be quite smooth Pictures were taken there There was no evidence of chondromalacia cracking or fissuring of the articular cartilage The patella was well centered over the trochlear notch We then directed the arthroscope to the medial compartment of the knee It was felt that there was a tear to the medial meniscus We also saw large area of chondromalacia with grade IV changes to bone over the medial femoral condyle This area was debrided with forceps and the arthroscopic shaver The cartilage was also smoothened over the medial femoral condyle This was curetted after the medial meniscus had been trimmed We looked into the notch We saw the ACL appeared stable saw attachments to tibial as well as the femoral insertion with some evidence of laxity wear and tear Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment All instruments were removed All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end We removed all instruments Marcaine was injected into the portal sites We placed a sterile dressing and stockinet on the left lower extremity He was transferred to the gurney and taken to PACU in stable condition Keywords orthopedic medial meniscoplasty arthroscopic chondroplasty arthroscopy medial femoral condyle medial meniscus knee meniscal cartilage meniscoplasty meniscus chondromalacia condyle femoral MEDICAL_TRANSCRIPTION,Description Arthrotomy removal humeral head implant right shoulder Repair of torn subscapularis tendon rotator cuff tendon acute tear Debridement glenohumeral joint Biopsy and culturing the right shoulder Medical Specialty Orthopedic Sample Name Arthrotomy Subscapularis Tendon Repair Transcription TITLE OF OPERATION 1 Arthrotomy removal humeral head implant right shoulder 2 Repair of torn subscapularis tendon rotator cuff tendon acute tear 3 Debridement glenohumeral joint 4 Biopsy and culturing the right shoulder INDICATION FOR SURGERY The patient had done well after a previous total shoulder arthroplasty performed by Dr X However the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis Risks and benefits of the procedure had been discussed with the patient at length including but not exclusive of infection nerve or artery damage stiffness loss of range of motion incomplete relief of pain incomplete return of function continued instability retearing of the tendon need for revision of his arthroplasty permanent nerve or artery damage etc The patient understood and wished to proceed PREOP DIAGNOSIS 1 Torn subscapularis tendon right shoulder 2 Right total shoulder arthroplasty Biomet system POSTOP DIAGNOSIS 1 Torn subscapularis tendon right shoulder 2 Right total shoulder arthroplasty Biomet system 3 Diffuse synovitis right shoulder PROCEDURE The patient was anesthetized in the supine position A Foley catheter was placed in his bladder He was then placed in a beach chair position He was brought to the side of the table and the torso secured with towels and tape His head was then placed in the neutral position with no lateral bending or extension It was secured with paper tape over his forehead Care was taken to stay off his auricular cartilages and his orbits Right upper extremity was then prepped and draped in the usual sterile fashion The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection Once he had been prepped and draped with the standard prep he was prepped a second time with a chlorhexidine type skin prep This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection Also preoperatively the patient had his pacemaker defibrillator function turned off as a result during this case Bipolar type cautery had to be used as opposed to monopolar cautery The patient s deltopectoral incision was then opened and extended proximally and distally The patient had significant amount of scar already in this interval Once we got down to the deltoid and pectoralis muscle there was no apparent cephalic vein present as a result the rotator cuff interval had to be developed through an area of scar This created a significant amount of bleeding As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus Care was taken to stay above the pectoralis minor and the conjoint tendon The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus Similarly the deltoid insertion had to be released approximately 50 of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity The soft tissue in this area was significantly scarred down to the conjoint tendon which had to be very meticulously released The brachial plexus was identified as was the axillary nerve Once this was completed an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later This revealed sanguineous fluid inside the joint We did not feel it was infected based upon the fluid that came from the joint The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone which was fortunate because in that we could use the bone later for securing the sutures The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring This was done also very meticulously The upper one half of the latissimus dorsi tendon was also released Once this was completed the humerus could be subluxed enough laterally that we could remove the head This was done with no difficulty Fortunately the humeral component stayed intact There were some exudates beneath the humeral head which were somewhat mucinous However these do not really appear to be infected however we sent them to pathology for a frozen section This frozen section later returned as possible purulent material I discussed this personally with the pathologist at that point We told him that the procedure is only 3 weeks old but he was concerned that there might be more white blood cells in the tissue than he would expect As a result all the mucinous exudates were carefully removed We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components but also we irrigated the joint throughout the case with antibiotic impregnated irrigation At that point we also had sent portions of this mucinous material to pathology for a stat Gram stain This came back as no organisms seen We also sent portions for culture and sensitivity both aerobic and anaerobic Once this was completed attention was then directed to the glenoid The patient had significant amount of scar already The subscapularis itself was significantly scarred down to the anterior rim As a result the adhesions along the anterior edge were released using a knife Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis The subscapularis was then tagged with multiple number 2 Tycron sutures Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees the subscapularis could reach the calcar region without tension As a result seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus These all had excellent security in bone Once the joint had been debrided and irrigated the real humeral head was then placed back on the proximal humerus Care was taken to remove fluid off the Morse taper The head was then impacted It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient Unfortunately any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus As a result it was felt to place the offset head back on the humerus we did insert a new component as opposed to using the old component The old component was given to the family postoperatively With the arm in internal rotation the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion Also it should be noted that the rotator cuff interval had to be released as part of the exposure We started the repair by closing the rotator cuff interval Anterior and posterior translation was then performed and was found to be very stable The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two layer repair of the subscapularis tendon After the tendon had been repaired there was no tension on repair until 0 degrees external rotation was reached with the arm to the side Similarly with the arm abducted 90 degrees tension was on repair at 0 degrees of external rotation It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation The rotator cuff interval was closed with multiple number 2 Tycron sutures It was reinforced with 0 Vicryl sutures Two Hemovac drains were then placed inferiorly at the deltoid The deltopectoral interval was then closed with 0 Vicryl sutures A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections This was sewn into place with the drain pulled out superiorly Once all the sutures have been secured and the drain visualized throughout this part of the closure the drain was pulled distally until it was completely covered There were no signs that it had been tagged or hung up by any sutures The superficial subcutaneous tissues were closed with interrupted with 2 0 Vicryl sutures Skin was closed with staples A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer The patient was sent to the intensive care unit in stable and satisfactory condition Due to the significant amount of scar and bleeding in this patient a 22 modifier is being requested for this case This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement Similarly the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant This was being dictated for insurance purposes only and reflects no inherent difficulties with this case The complexity and the time involved in this case was approximately 30 greater than that of a standard shoulder replacement or of a rotator cuff repair This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient s situation with his pacemaker This patient also had multiple medical concerns which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation Keywords orthopedic arthrotomy repair of torn subscapularis tendon glenohumeral joint biomet system arthroplasty diffuse synovitis proximal humerus torn subscapularis tendon subscapularis tendon rotator cuff humerus sutures tendon head shoulder subscapularis torn MEDICAL_TRANSCRIPTION,Description Partial rotator cuff tear left shoulder Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement soft tissue decompression of the subacromial space of the left shoulder Medical Specialty Orthopedic Sample Name Arthroscopy Shoulder Transcription PREOPERATIVE DIAGNOSIS Partial rotator cuff tear left shoulder POSTOPERATIVE DIAGNOSIS Partial rotator cuff tear left shoulder PROCEDURE PERFORMED Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement soft tissue decompression of the subacromial space of the left shoulder ANESTHESIA Scalene block with general anesthesia ESTIMATED BLOOD LOSS 30 cc COMPLICATIONS None DISPOSITION The patient went to the PACU stable GROSS OPERATIVE FINDINGS There was no overt pathology of the biceps tendon There was some softening and loss of the articular cartilage over the glenoid The labrum was ________ attached permanently to the glenoid The biceps tendon was nonsubluxable Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space There was reconstitution of the bursa noted as well HISTORY OF PRESENT ILLNESS This is a 51 year old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder MRI shows partial rotator cuff tear PROCEDURE The patient was taken to the operating room and placed in a beachchair position After all bony prominences were adequately padded the head was placed in the headholder with no excessive extension in the neck on flexion The left extremity was prepped and draped in usual fashion The 18 gauge needles were inserted into the left shoulder to locate the AC joint the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect We took an 11 blade scalpel and made a small 1 cm skin incision posteriorly approximately 4 cm inferior and medial to the lateral port of the acromion A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using 11 blade on the skin and inserted bluntly the trocar and the cannula The operative findings found intra articularly were as described previously gross operative findings We did not see any evidence of acute pathology We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal All this was done and hemostasis was achieved The rotator cuff was examined from the bursal side and showed no evidence of tears There was some fraying out laterally near its attachment over the greater tuberosity which was debrided with the arthroscopic shaver We removed all of our instruments and suctioned the subacromial space dry A 4 0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling She was placed back on the gurney extubated and taken to the PACU in stable condition Keywords orthopedic subacromial space arthroscopic biceps tendon labrum glenoid cartilage partial rotator cuff tear rotator cuff tear shoulder arthroscopy rotator cuff arthroscopy shoulder tissue subacromial rotator cuff MEDICAL_TRANSCRIPTION,Description Right shoulder arthroscopy subacromial decompression distal clavicle excision bursectomy and coracoacromial ligament resection carpal tunnel release left knee arthroscopy and partial medial and lateral meniscectomy Medical Specialty Orthopedic Sample Name Arthroscopy Shoulder Knee Transcription PREOPERATIVE DIAGNOSES 1 Medial meniscal tear posterior horn of left knee 2 Carpal tunnel syndrome chronic right hand with intractable pain numbness and tingling 3 Impingement syndrome right shoulder with acromioclavicular arthritis bursitis and chronic tendonitis POSTOPERATIVE DIAGNOSES 1 Carpal tunnel syndrome right hand severe 2 Bursitis tendonitis impingement and AC arthritis right shoulder 3 Medial and lateral meniscal tears posterior horn old left knee PROCEDURE 1 Right shoulder arthroscopy subacromial decompression distal clavicle excision bursectomy and coracoacromial ligament resection 2 Right carpal tunnel release 3 Left knee arthroscopy and partial medial and lateral meniscectomy ANESTHESIA General with regional COMPLICATIONS None DISPOSITION To recovery room in awake alert and in stable condition OPERATIVE INDICATIONS A very active 50 year old gentleman who had the above problems and workup revealed the above problems He failed nonoperative management We discussed the risks benefits and possible complications of operative and continued nonoperative management and he gave his fully informed consent to the following procedure OPERATIVE REPORT IN DETAIL The patient was brought to the operating room and placed in the supine position on the operating room table After adequate induction of general anesthesia he was placed in the left lateral decubitus position All bony prominences were padded The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments articular surfaces and labrum Subacromial space was entered Visualization was poor due to the hemorrhagic bursitis and this was resected back It was essentially a type 3 acromion which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur Rotator cuff was little bit fray but otherwise intact Thus the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed The burr was then introduced to the anterior portal and the distal clavicle excision carried out The width of burr about 6 mm being careful to preserve the ligaments in the capsule but removing the spurs and the denuded arthritic joint The patient tolerated the procedure very well The shoulder was then copiously irrigated drained free of any residual debris The wound was closed with 3 0 Prolene Sterile compressive dressing applied The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep The attention was first turned to the right hand where it was elevated exsanguinated using an Esmarch bandage and the tourniquet was inflated to 250 mmHg for about 25 minutes Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis Tenotomy and forceps dissection carried out through the superficial palmar fascia carried down to the volar carpal ligament which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures Cautery was used for hemostasis The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament and so a small amount of Celestone was dripped onto the nerve to help quite it down The patient tolerated this portion of the procedure very well The hand was then irrigated closed with Monocryl and Prolene and sterile compressive dressing was applied and the tourniquet deflated Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars After entering the knee through inferomedial and inferolateral standard arthroscopic portals examination of the knee showed a displaced bucket handle tear in the medial meniscus and a radial tear at the lateral meniscus These were resected back to the stable surface using a basket forceps and full radius shaver There was no evidence of any other significant arthritis in the knee There was a lot of synovitis and so after the knee was irrigated out and free of any residual debris the knee was injected with Celestone and Marcaine with epinephrine The patient tolerated the procedure very well and the wounds were closed with 3 0 Prolene and sterile compressive dressing was applied and then the patient was taken to the recovery room extubated awake alert and in stable condition Keywords MEDICAL_TRANSCRIPTION,Description Arthroscopy of the arthroscopic glenoid labrum rotator cuff debridement shaving glenoid and humeral head and biceps tenotomy right shoulder Massive rotator cuff tear right shoulder near complete biceps tendon tear of right shoulder chondromalacia of glenohumeral joint or right shoulder and glenoid labrum tear of right shoulder Medical Specialty Orthopedic Sample Name Arthroscopy Glenoid Labrum Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear right shoulder POSTOPERATIVE DIAGNOSES 1 Massive rotator cuff tear right shoulder 2 Near complete biceps tendon tear right shoulder 3 Chondromalacia of glenohumeral joint right shoulder 4 Glenoid labrum tear right shoulder PROCEDURE PERFORMED 1 Arthroscopy of the arthroscopic glenoid labrum 2 Rotator cuff debridement shaving glenoid and humeral head 3 Biceps tenotomy right shoulder SPECIFICATION The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under interscalene block anesthetic in the modified beachchair position HISTORY AND GROSS FINDINGS This is a 61 year old white male who is dominantly right handed He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention This was gradually done over a period of time No specific accident or injury could be seen or pointed He was refractory to conservative outpatient therapy After discussing alternatives of the care as well as the advantages disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Preoperatively the patient did not have limitation of motion He had gross weakness to his supraspinatus mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic Intraarticularly the patient had an 80 biceps tendon tear that was dislocated His rotator interval was resolved as well as his subscapularis with tearing The supraspinatus was completely torn retracted back beyond the level of the labrum and approximately one third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe Glenoid labrum had degenerative tear in the inferior surface Gross chondromalacia was present to approximately 50 of the humeral head and approximately the upper 40 of the glenoid surface OPERATIVE PROCEDURE The patient was laid supine upon the operative table After receiving interscalene block anesthetic by the Anesthesia Department he was safely placed in a modified beachchair position He was prepped and draped in the usual sterile manner The portals were created outside the end posteriorly and then anteriorly A full and complete diagnostic arthroscopy was carried out with the above noted findings The shaver was placed anteriorly Debridement was carried out to the glenoid labrum tear and the last 20 of the biceps tendon tear was completed Debridement was carried out to the end or attachment of the bicep itself Debridement was carried out to what could be seen of the remaining rotator cuff there but then the scope was redirected in a subacromial direction and gross bursectomy carried out Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity No osteophytes were present Because of the massive nature of the tear the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring There was concern because of instability that could be present at the end of this Another portal was created laterally to do all of this We did what we could to mobilize all sections of the rotator cuff superiorly posteriorly and anteriorly We took this back to the level of coracoid base We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn Because of this further debridement was carried out Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge Care was taken to not to debride deeper than that This was done prior to the above All instrumentation was removed A Pain Buster catheter was placed into a separate anterolateral portal cut to length Interrupted 4 0 nylon was utilized for portal closures Adaptic 4x4s ABDs Elastoplast tape were placed for a compression dressing The patient s arm was placed in an arm sling He was transferred to his cart and to the PACU in apparent satisfactory condition Expected surgical prognosis on this patient is quite guarded because of the above noted pathology Keywords orthopedic modified beachchair position rotator cuff tear glenoid labrum tear glenohumeral joint interscalene block glenoid labrum rotator cuff rotator debridement glenoid shoulder tear arthroscopy arthroscopic tenotomy glenohumeral supraspinatus infraspinatus subscapularis chondromalacia biceps labrum cuff MEDICAL_TRANSCRIPTION,Description Diagnostic arthroscopy with partial chondroplasty of patella lateral retinacular release and open tibial tubercle transfer with fixation of two 4 5 mm cannulated screws Grade IV chondromalacia patella and patellofemoral malalignment syndrome Medical Specialty Orthopedic Sample Name Arthroscopy Chondroplasty Transcription PREOPERATIVE DIAGNOSES 1 Chondromalacia patella 2 Patellofemoral malalignment syndrome POSTOPERATIVE DIAGNOSES 1 Grade IV chondromalacia patella 2 Patellofemoral malalignment syndrome PROCEDURE PERFORMED 1 Diagnostic arthroscopy with partial chondroplasty of patella 2 Lateral retinacular release 3 Open tibial tubercle transfer with fixation of two 4 5 mm cannulated screws ANESTHESIA General COMPLICATIONS None TOURNIQUET TIME Approximately 70 minutes at 325 mmHg INTRAOPERATIVE FINDINGS Grade IV chondromalacia noted to the central and lateral facet of the patella There was a grade II to III chondral changes to the patellar groove The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle The medial lateral meniscus showed small amounts of degeneration but no frank tears were seen The articular surfaces and the remainder of the knee appeared intact Cruciate ligaments also appeared intact to direct stress testing HISTORY This is a 36 year old Caucasian female with a long standing history of right knee pain She has been diagnosed in the past with chondromalacia patella She has failed conservative therapy It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer anterior medialization of the tibial tubercle to release stress from her femoral patellofemoral joint She elected to proceed with the surgical intervention All risks and benefits of the surgery were discussed with her She was in agreement with the treatment plan PROCEDURE On 09 04 03 she was taken to Operating Room at ABCD General Hospital She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion A stab incision was made in inferolateral and parapatellar regions Through this the cannula was placed and the knee was inflated with saline solution Intraoperative pictures were obtained The above findings were noted Second portal site was initiated in the inferomedial parapatellar region Through this a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris Next the camera was placed through the inferomedial portal An arthroscopic Bovie was placed through the inferolateral portal A release of lateral retinaculum was then performed using the Bovie Hemostasis was controlled with electrocautery Next the knee was suctioned dry An Esmarch was used to exsanguinate the lower extremity Tourniquet was inflated to 325 mmHg An oblique incision was made along the medial parapatellar region of the knee The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery The retinaculum was then incised in line with the incision The patellar tendon was identified The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris Next an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact The tubercle was then pushed anteriorly and medially decreasing her Q angle and anteriorizing the tibial tubercle It was then held in place with a Steinmann pin Following this a two 4 5 mm cannulated screws partially threaded were drilled in place using standard technique to help fixate the tibial tubercle There was excellent fixation noted The Q angle was noted to be decreased to approximately 15 degrees She was transferred approximately 1 cm in length The wound was copiously irrigated and suctioned dry The medial retinaculum was then plicated causing further medialization of the patella The retinaculum was reapproximated using 0 Vicryl Subcuticular tissue were reapproximated with 2 0 Vicryl Skin was closed with 4 0 Vicryl running PDS suture Sterile dressing was applied to the lower extremities She was placed in a Donjoy knee immobilizer locked in extension It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet She was transferred to recovery room in apparent stable and satisfactory condition Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia Keywords orthopedic diagnostic arthroscopy patellofemoral malalignment syndrome cannulated partial chondroplasty retinacular chondromalacia patella tibial tubercle patella tubercle arthroscopy tourniquet chondroplasty chondromalacia patellofemoral MEDICAL_TRANSCRIPTION,Description Torn lateral meniscus and chondromalacia of the patella right knee Arthroscopic lateral meniscoplasty and patellar shaving of the right knee Medical Specialty Orthopedic Sample Name Arthroscopic Meniscoplasty Transcription PREOPERATIVE DIAGNOSES 1 Torn lateral meniscus right knee 2 Chondromalacia of the patella right knee POSTOPERATIVE DIAGNOSES 1 Torn lateral meniscus right knee 2 Chondromalacia of the patella right knee PROCEDURE PERFORMED 1 Arthroscopic lateral meniscoplasty 2 Patellar shaving of the right knee ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME Zero GROSS FINDINGS A complex tear involving the lateral and posterior horns of the lateral meniscus and grade II chondromalacia of the patella HISTORY OF PRESENT ILLNESS The patient is a 45 year old Caucasian male presented to the office complaining of right knee pain He complained of pain on the medial aspect of his right knee after an injury at work which he twisted his right knee PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedures were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the operative surgeon the patient the Department of Anesthesia and the nursing staff The patient was then transferred to preoperative area to Operative Suite 2 placed on the operating table in supine position Department of Anesthesia administered general anesthetic to the patient All bony prominences were well padded at this time The right lower extremity was then properly positioned in a Johnson knee holder At this time 1 lidocaine with epinephrine 20 cc was administered to the right knee intra articularly under sterile conditions The right lower extremity was then sterilely prepped and draped in usual sterile fashion Next after all bony soft tissue landmarks were identified an inferolateral working portal was established by making a 1 cm transverse incision at the level of the joint line lateral to the patellar tendon The cannula and trocar were then inserted through this putting the patellofemoral joint An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint the medial and lateral gutters medial lateral joints and the femoral notch Upon viewing of the patellofemoral joint there was noted to be grade II chondromalacia changes of the patella There were no loose bodies noted in the either gutter Upon viewing of the medial compartment there was no chondromalacia or meniscal tear was noted While in this area attention was directed to establish the inferomedial instrument portal This was first done using a spinal needle for localization followed by 1 cm transverse incision at the joint line A probe was then inserted through this portal and the meniscus was further probed Again there was noted to be no meniscal tear The knee was taken through range of motion and there was no chondromalacia Upon viewing of the femoral notch there was noted to be intact ACL with negative drawer sign PCL was also noted to be intact Upon viewing of the lateral compartment there was noted to be a large bucket handle tear involving the lateral and posterior horns It was reduced from the place however involved the white and red white area was elected to excise the bucket handle An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee Pictures were taken both pre meniscal resection and post meniscal resection The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact Next attention was directed to the inner surface of the patella This was debrided using the 2 5 arthroscopic shaver It was noted to be quite smooth and postprocedure the patient was taken ________ well The knee was then copiously irrigated and suctioned dry and all instrumentation was removed 20 cc of 0 25 Marcaine was then administered to each portal as well as intra articularly Sterile dressing was then applied consisting of Adaptic 4x4s ABDs and sterile Webril and a stockinette to the right lower extremity At this time Department of Anesthesia reversed the anesthetic The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit The patient tolerated the procedure and there were no complications Keywords orthopedic patella chondromalacia lateral meniscus complex tear torn lateral meniscus femoral notch meniscal tear bucket handle meniscal resection arthroscopic shaver patellofemoral joint arthroscopic knee torn meniscoplasty meniscal joint meniscus MEDICAL_TRANSCRIPTION,Description Rotated cuff tear right shoulder Glenoid labrum tear Arthroscopy with arthroscopic glenoid labrum debridement subacromial decompression and rotator cuff repair right shoulder Medical Specialty Orthopedic Sample Name Arthroscopic Rotator Cuff Repair 1 Transcription PREOPERATIVE DIAGNOSIS Rotated cuff tear right shoulder POSTOPERATIVE DIAGNOSES 1 Rotated cuff tear right shoulder 2 Glenoid labrum tear PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic glenoid labrum debridement 2 Subacromial decompression 3 Rotator cuff repair right shoulder SPECIFICATIONS Intraoperative procedure was done at Inpatient Operative Suite room 1 at ABCD Hospital This was done under interscalene and subsequent general anesthetic in the modified beach chair position HISTORY AND GROSS FINDINGS The patient is a 48 year old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention He was completely refractory to conservative outpatient therapy After discussing the alternative care as well as the advantages disadvantages risks complications and expectations he elected to undergo the above stated procedure on this date Intraarticularly the joint was observed There was noted to be a degenerative glenoid labrum tear The biceps complex was otherwise intact There were minimal degenerative changes at the glenohumeral joint Rotator cuff tear was appreciated on the inner surface Subacromially the same was true This was an elliptical to V type tear The patient has a grossly positive type III acromion OPERATIVE PROCEDURE The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department He was safely placed in modified beach chair position He was prepped and draped in the usual sterile manner Portals were created outside to end posterior to anterior and ultimately laterally in the typical fashion Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint a 4 2 meniscus shaver was placed anteriorly with the scope posteriorly Debridement was carried out to the glenoid labrum The biceps was probed and noted to be intact Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment After this instrumentation was removed The scope was placed subacromially and a lateral portal created Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters An anterolateral portal was created Sutures were placed via express silk as well as other sutures with a 2 fiber wire With passing of the suture they were tied with a slip tight knot and then two half stitches There was excellent reduction of the tear Superolateral portal was then created A 1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone _______ suture was placed The implant was put into place The loop was grabbed and it was impacted in the previously drilled holes There was excellent reduction of the tear Trial range of motion was carried out and seemed to be satisfactory Prior to this a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie A 4 8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion After all was done copious irrigation was carried out throughout the joint Gross bursectomy lightly was carried out to remove all bony elements A pain buster catheter was placed through a separate portal and cut to length 0 5 Marcaine was instilled after portals were closed with 4 0 nylon Adaptic 4 x 4s ABDs and Elastoplast tape placed for dressing The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition Expected surgical prognosis of this patient is fair Keywords orthopedic subacromial decompression rotator cuff repair arthroscopic glenoid labrum debridement arthroscopy glenoid labrum tear glenoid labrum cuff tear arthroscopic subacromial decompression debridement rotator glenoid labrum shoulder MEDICAL_TRANSCRIPTION,Description Arthroscopic rotator cuff repair arthroscopic subacromial decompression and arthroscopic extensive debridement superior labrum anterior and posterior tear Medical Specialty Orthopedic Sample Name Arthroscopic Rotator Cuff Repair 2 Transcription PROCEDURES 1 Arthroscopic rotator cuff repair 2 Arthroscopic subacromial decompression 3 Arthroscopic extensive debridement superior labrum anterior and posterior tear PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified The patient was placed on the operating room table in supine position and given general anesthetic Once the patient was under general anesthetic a careful examination of the shoulder was performed It revealed no patholigamentous laxity The patient was then carefully positioned into a beach chair position We maintained the natural alignment of the head neck and thorax at all times The shoulder and upper extremity was then prepped and draped in the usual sterile fashion Once we fully prepped and draped we then began the surgery We injected the glenohumeral joint with sterile saline with a spinal needle This consisted of 60 cc of fluid We then made a posterior incision for our portal 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion Through this incision a blunt trocar and cannula were placed in the glenohumeral joint Through the cannula a camera was placed and the shoulder was insufflated with sterile saline through a preoperative feed We then carefully examined the glenohumeral joint We found the articular surface to be in good condition There was a superior labral tear SLAP This was extensively debrided using a shaver through an anterior portal We also found a full thickness rotator cuff tear We then drained the glenohumeral joint We redirected our camera into the subacromial space An anterolateral portal was made both superior and inferior We then proceeded to perform a subacromial decompression using high speed shaver The bursa was extensively debrided We then abraded the bone over the footprint of where the rotator cuff is usually attached The corkscrew anchors were used to perform a rotator cuff repair Pictures were taken Through a separate incision an indwelling pain catheter was then placed It was carefully positioned Pictures were taken We then drained the joint All instruments were removed The patient did receive IV antibiotic preoperatively All portals were closed using 4 0 nylon sutures Xeroform 4 x 4s and OpSite were applied over the pain pump ABD tape and a sling were also applied A Cryo Cuff was also placed over the shoulder The patient was taken out of the beach chair position maintaining the neutral alignment of the head neck and thorax The patient was extubated and brought to the recovery room in stable condition I then went out and spoke with the family going over the case postoperative instructions and followup care Keywords orthopedic debridement superior labrum patholigamentous laxity arthroscopic rotator cuff repair subacromial decompression glenohumeral joint rotator cuff arthroscopic decompression repair glenohumeral subacromial rotator cuff MEDICAL_TRANSCRIPTION,Description Rotator cuff tear right shoulder Superior labrum anterior and posterior lesion peel back right shoulder Arthroscopy with arthroscopic SLAP lesion Repair of soft tissue subacromial decompression rotator cuff repair right shoulder Medical Specialty Orthopedic Sample Name Arthroscopic SLAP lesion Transcription PREOPERATIVE DIAGNOSIS Rotator cuff tear right shoulder POSTOPERATIVE DIAGNOSIS Superior labrum anterior and posterior lesion peel back right shoulder PROCEDURE PERFORMED 1 Arthroscopy with arthroscopic SLAP lesion 2 Repair of soft tissue subacromial decompression rotator cuff repair right shoulder SPECIFICATIONS The entire operative procedure was done in Inpatient Operating Suite room 1 at ABCD General Hospital This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position HISTORY AND GROSS FINDINGS This is a 54 year old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention She had an injury to her right shoulder when she fell off a bike She was diagnosed preoperatively with a rotated cuff tear Intra articularly besides we noted a large SLAP lesion superior and posterior to the attachment of the glenoid labrum from approximately 12 30 back to 10 30 This acted as a peel back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid This was an obvious avulsion into subchondral bone with bone exposed The anterior aspect had degenerative changes but did not have evidence of avulsion The subscapular was noted to be intact On the joint side of the supraspinatus there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid aspect of the supraspinatus attachment This was confirmed subacromially The patient had a type I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression but soft tissue release of the CA ligament in a releasing resection type fashion OPERATIVE PROCEDURE The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department She was safely placed in a modified beachchair position She was prepped and draped in the usual sterile manner The portals were created from outside the ends posterior to the scope and anteriorly for an intraoperative portal and then laterally She had at least two other portals appropriate for both repair mechanisms described above Attention was then turned to the SLAP lesion The edges were debrided both on the bony side as well as soft tissue side We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum Further debridement was carried out here A drill hole was made just on the articular surface superiorly for a knotless anchor A pull through suture of 2 fiber wire was utilized with the ________ This was pulled through It was tied to the leader suture of the knotless anchor This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet There was excellent fixation of the superior labrum It was noted to be solid and intact The anchor was placed safely in the bone There was no room for further knotless or other anchors After probing was carried out hard copy Polaroid was obtained Attention was then turned to the articular side for the rotator cuff It was debrided Subchondral debridement was carried out to the tuberosity also Care was taken to go to the subchondral region but not beyond The bone was satisfactory Scope was then placed in the subacromial region Gross bursectomy was carried out with in the lateral portal This was done throughout as well as in the gutters anterolaterally and posteriorly Debridement was carried out further to the rotator cuff Two types of fixation were carried out one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch There was an excellent reduction of the tear posteriorly and then anteriorly Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal This was done with a sliding stitch and then two half stitches There was excellent reduction of the tear Attention was then turned to the CA ligament It was released along with periosteum and the undersurface of the anterior acromion The CA ligament was not only released but resected There was noted to be no evidence of significant spurring with only a mostly type I acromion Thus it was not elected to perform subacromial decompression for bone with soft tissue only A pain buster catheter was placed separately It was cut to length An interrupted 4 0 nylon was utilized for portal closure A 0 5 Marcaine was instilled subacromially Adaptic 4x4s ABDs and Elastoplast tape placed for dressing The patient s arm was placed in a arm sling She was transferred to PACU in apparent satisfactory condition Expected surgical prognosis on this patient is fair Keywords orthopedic rotator cuff tear shoulder labrum lesion decompression subacromial arthroscopic slap lesion slap lesion rotator cuff anterior arthroscopy arthroscopic slap cuff MEDICAL_TRANSCRIPTION,Description Femoroacetabular impingement Left hip arthroscopic debridement femoral neck osteoplasty and labral repair Medical Specialty Orthopedic Sample Name Arthroscopic Debridement Labral Repair Hip Transcription PREOPERATIVE DIAGNOSIS Femoroacetabular impingement POSTOPERATIVE DIAGNOSIS Femoroacetabular impingement OPERATIONS PERFORMED 1 Left hip arthroscopic debridement 2 Left hip arthroscopic femoral neck osteoplasty 3 Left hip arthroscopic labral repair ANESTHESIA General OPERATION IN DETAIL The patient was taken to the operating room where he underwent general anesthetic His bilateral lower extremities were placed under traction on the Hana table His right leg was placed first The traction post was left line and the left leg was placed in traction Sterile Hibiclens and alcohol prep and drape were then undertaken A fluoroscopic localization was undertaken Gentle traction was applied Narrow arthrographic effect was obtained Following this the ProTrac portal was made under the fluoro visualization and then a direct anterolateral portal made and a femoral neck portal made under direct visualization The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum For this reason the acetabular articular cartilage was taken down and stabilized This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair The labrum was repaired using absorbable Smith Nephew anchors with a sliding SMC knot After stabilization of the labrum and the acetabulum the ligamentum teres was assessed and noted to be stable The remnant articular surface of the femoral artery and acetabulum was stable The posterior leg was stable The traction was left half off and the anterolateral aspect of the head and neck junction was identified A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly This terminated with the hip coming out of traction and indeterminable flexion A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression The decompression was completed with thorough irrigation of the hip The cannula was removed and the portals were closed using interrupted nylon The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room He tolerated the procedure very well with no signs of complications Keywords orthopedic labral repair femoral neck osteoplasty arthroscopic debridement femoroacetabular impingement arthroscopic femoroacetabular impingement debridement osteoplasty acetabulum MEDICAL_TRANSCRIPTION,Description Arthroplasty of the right second digit Hammertoe deformity of the right second digit Medical Specialty Orthopedic Sample Name Arthroplasty Hammertoe Transcription PREOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit POSTOPERATIVE DIAGNOSIS Hammertoe deformity of the right second digit PROCEDURE PERFORMED Arthroplasty of the right second digit The patient is a 77 year old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe The patient presents n p o since mid night last night and consented to sign in the chart H P is complete PROCEDURE IN DETAIL After an IV was instituted by the Department of Anesthesia in the preoperative holding area the patient was escorted to the operating room and placed on the table in the supine position Using Webril the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle but left deflated at this time Restraining a lap belt was then placed around the patient s abdomen while laying on the table After adequate anesthesia was administered by the Department of Anesthesia a local digital block using 5 cc of 0 5 Marcaine plain was used to provide local anesthesia The foot was then prepped and draped in the normal sterile orthopedic manner The foot was then elevated and Esmarch bandage was applied after which time the tourniquet was inflated to 250 mmHg The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx Then using a fresh 15 blade a dorsolinear incision was made partial thickness through the skin after testing anesthesia with one to two pickup Then using a fresh 15 blade incision was deepened and using medial to lateral pressure the incision was opened into the subcutaneous tissue Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin This was performed with the combination of blunt and dull dissection Care was taken to avoid proper digital arteries and neurovascular bundles as were identified Attention was then directed to the proximal interphalangeal joint and after identifying the joint line a transverse linear incision was made over the dorsal surface of the joint The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure Following this the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson Brown pickup It was elevated with fresh 15 blade The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally Following this the distal portion of the tendon was identified in a like manner The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone The proximal interphalangeal joint was then distracted and using careful technique 15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head Following this the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues Then using a sagittal saw with a 139 blade the head of he proximal phalanx was resected Care was taken to avoid the deep flexor tendon The head of the proximal phalanx was taken with the Adson Brown and using a 15 blade the plantar periosteal tissue was freed up and the head was removed and sent to pathology The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment The digit was also noted to be in rectus alignment Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity Then using a 3 0 Vicryl suture three simple interrupted sutures were placed for closure of the tendon and capsular tissue Then following this 4 0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site Following this the incision was dressed using a sterile Owen silk soaked in saline and gentamicin The toe was bandaged using 4 x 4s Kling and Coban The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe Total tourniquet time for the case was 30 minutes While in the recovery the patient was given postoperative instructions to include ice and elevation to his right foot The patient was given pain medications of Tylenol 3 quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain The patient was also given prescription for cane to aid in ambulation The patient will followup with Dr X on Tuesday in his office for postoperative care The patient was instructed to keep the dressings clean dry and intact and to not remove them before his initial office visit The patient tolerated the procedure well and the anesthesia with no complications Keywords orthopedic hammertoe deformity arthroplasty digit proximal interphalangeal joint periosteal tissue interrupted sutures interphalangeal joint proximal phalanx proximal painful tourniquet hammertoe phalanx head incisional tendon MEDICAL_TRANSCRIPTION,Description Recurrent anterior dislocating left shoulder Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder Medical Specialty Orthopedic Sample Name Arthroscopic Debridement Shoulder Transcription PREOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder POSTOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder PROCEDURE PERFORMED Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder PROCEDURE The patient was taken to OR 2 administered general anesthetic after ineffective interscalene block had been administered in the preop area The patient was positioned in the modified beachchair position utilizing the Mayfield headrest The left shoulder was propped posteriorly with a rolled towel His head was secured to the Mayfield headrest The left shoulder and upper extremity were then prepped and draped in the usual manner A posterior lateral port was made for _____ the arthroscopic cannula The scope was introduced into the glenohumeral joint There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11 30 extending down inferiorly to about 6 o clock The labrum was adherent to the underlying capsule The margin of the glenoid was frayed in this area The biceps tendon was noted to be intact The articular surface of the glenoid was fairly well preserved The articular surface on the humeral head was intact however there was a large Hill Sachs lesion on the posterolateral aspect of the humeral head The rotator cuff was visualized and noted to be intact The axillary pouch was visualized and it was free of injury There were some cartilaginous fragments within the axillary pouch Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum Utilizing the Chirotech system through the anterior cannula the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o clock position A second tack was then placed at about the 8 o clock position The labrum was then probed and was noted to be stable With some general ranging of the shoulder the tissue was pulled out from the tacks An attempt was made at placement of two other tacks however the tissue was not of good quality to be held in position Therefore all tacks were either buried down to a flat surface or were removed from the anterior glenoid area At this point it was deemed that an open Bankart arthroplasty was necessary The arthroscopic instruments were removed An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold The skin incision was taken down through the skin Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis The deltopectoral fascia was identified It was split at the deltopectoral interval and the deltoid was reflected laterally The subdeltoid bursa was then removed with rongeurs The conjoint tendon was identified The deltoid and conjoint tendons were then retracted with a self retaining retractor The subscapularis tendon was identified It was separated about a centimeter from its insertion leaving the tissue to do sew later The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially This allowed for visualization of the capsule The capsule was split near the humeral head insertion leaving a tag for repair It was then split longitudinally towards the glenoid at approximately 9 o clock position This provided visualization of the glenohumeral joint The friable labral and capsular tissue was identified The glenoid neck was already prepared for suturing therefore three Mitek suture anchors were then positioned to place at approximately 7 o clock 9 o clock and 10 o clock The sutures were passed through the labral capsular tissue and tied securely At this point the anterior glenoid rim had been recreated The joint was then copiously irrigated with gentamicin solution and suctioned dry The capsule was then repaired with interrupted 1 Vicryl suture and repaired back to its insertion site with 1 Vicryl suture This later was then copiously irrigated with gentamicin solution and suctioned dry Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted 1 Vicryl suture This later was then copiously irrigated as well and suctioned dry The deltoid fascia was approximated with running 2 0 Vicryl suture Subcutaneous tissues were approximated with interrupted 2 0 Vicryl and the skin was approximated with a running 4 0 subcuticular Vicryl followed by placement of Steri Strips 0 25 Marcaine was placed in the subcutaneous area for postoperative analgesia The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied The patient was then transferred to the recovery room in apparent satisfactory condition Keywords orthopedic dislocating bankart arthroplasty bankart repair arthroscopic debridement anterior arthroscopic debridement deltoid glenoid humeral interrupted shoulder subscapularis MEDICAL_TRANSCRIPTION,Description Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate Severe low back pain Medical Specialty Orthopedic Sample Name Anterior Lumbar Fusion Transcription PREOPERATIVE DIAGNOSIS Severe low back pain POSTOPERATIVE DIAGNOSIS Severe low back pain OPERATIONS PERFORMED Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 50 mL DRAINS None COMPLICATIONS None PATHOLOGICAL FINDINGS Dr X made the approach and once we were at the L5 S1 disk space we removed the disk and we placed a 13 mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body This was filled with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug At L4 L5 we used a 13 mm PEEK vertebral spacer with structural autograft and BMP and then we placed a two level 87 mm Integra sacral plate with 28 x 6 mm screws two each at L4 and L5 and 36 x 6 mm screws at S1 OPERATION IN DETAIL The patient was placed under general endotracheal anesthesia The abdomen was prepped and draped in the usual fashion Dr X made the approach and once the L5 S1 disk space was identified we incised this with a knife and then removed a large core of bone taking rotating cutters I was able to remove additional disk space and score the vertebral bodies The rest of the disk removal was done with the curette scraping the endplates I tried various sized spacers and at this point we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug Half of this was used to fill the spacer at L5 S1 BMP was placed in the spacer as well and then it was tapped into place We then moved the vessels over the opposite way approaching the L4 L5 disk space laterally and the disk was removed in a similar fashion and we also used a 13 mm PEEK vertebral spacer but this is the variety that we could put in from one side This was filled with bone and BMP as well Once this was done we were able to place an 87 mm Integra sacral plate down over the three vertebral bodies and place these screws Following this bleeding points were controlled and Dr X proceeded with the closure of the abdomen SUMMARY This is a 51 year old man who reports 15 year history of low back pain and intermittent bilateral leg pain and achiness He has tried multiple conservative treatments including physical therapy epidural steroid injections etc MRI scan shows a very degenerated disk at L5 S1 less so at L3 L4 and L4 L5 A discogram was positive with the lower 3 levels but he has pain which starts below the iliac crest and I feel that the L3 L4 disk is probably that symptomatic An anterior lumbar interbody fusion was suggested Procedure risks and complications were explained Keywords orthopedic peek vertebral spacer autograft anterior lumbar fusion lumbar fusion vertebral body vertebral spacer vertebral spacer anterior lumbar fusion MEDICAL_TRANSCRIPTION,Description Hammertoe deformity left fifth digit and ulceration of the left fifth digit plantolaterally Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size Medical Specialty Orthopedic Sample Name Arthroplasty Transcription PREOPERATIVE DIAGNOSES 1 Hammertoe deformity left fifth digit 2 Ulceration of the left fifth digit plantolaterally POSTOPERATIVE DIAGNOSIS 1 Hammertoe deformity left fifth toe 2 Ulceration of the left fifth digit plantolaterally PROCEDURE PERFORMED 1 Arthroplasty of the left fifth digit proximal interphalangeal joint laterally 2 Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size OPERATIVE PROCEDURE IN DETAIL The patient is a 38 year old female with longstanding complaint of painful hammertoe deformity of her left fifth toe The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time After an IV was instituted by the Department of Anesthesia the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position After adequate amount of IV sedation was administered by Anesthesia Department the patient was given a digital block to the left fifth toe using 0 5 Marcaine plain with 1 lidocaine plain in 1 1 mixture totaling 6 cc Following this the patient was draped and prepped in a normal sterile orthopedic manner An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table The stockinette was then cut and reflected and held in place using towel clamp The skin was then cleansed using the wet and dry Ray Tec sponge and then the plantar lesion was outlined The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit Then using a fresh 15 blade skin incision was made Following this the incision was then deepened using a fresh 15 blade down to the level of the subcutaneous tissue Using a combination of sharp and blunt dissection the skin was reflected distally and proximally to the lesion The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx however did not show any evidence of extending beyond the level of a periosteum Remaining tissues were inspected and appeared healthy The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a 15 blade the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx The capsule was also reflected to expose the prominent lateral osseous portion of this joint Using a sagittal saw and 139 blade the lateral osseous prominence was resected This was removed in entirety Then using power oscillating rasp the sharp edges were smoothed and recontoured to the desirable anatomic condition Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin Following this the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion Following this using 4 0 nylon in a combination of horizontal mattress and simple interrupted sutures the lesion wound was closed and skin was approximated well without tension to the surface skin Following this the incision site was dressed using Owen silk 4x4s Kling and Coban in a normal fashion The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot The patient was then escorted from the operative table into the Postanesthesia Care Unit The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact In the recovery the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q 6h as needed The patient will follow up on Friday with Dr X in office for further evaluation The patient was also given instructions as to signs of infection and to monitor her operative site The patient was instructed to keep daily dressings intact clean dry and to not remove them Keywords orthopedic hammertoe deformity plantolaterall ulceration arthroplasty plantar ulceration interphalangeal painful hammertoe proximal interphalangeal joint interphalangeal joint digit toe blade deformity incision hammertoe lesion MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4 C5 C5 C6 and C6 C7 utilizing Bengal cages times three Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Interbody Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C4 C5 C5 C6 and C6 C7 for neural decompression 63075 63076 63076 2 Anterior interbody fusion at C4 C5 C5 C6 and C6 C7 22554 22585 22585 utilizing Bengal cages times three 22851 3 Anterior instrumentation for stabilization by Slim LOC plate C4 C5 C6 and C7 22846 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border and self retaining retractors were placed to reveal the anterior osteophytic spaces Large osteophytes were excised with a rongeur at C4 5 C5 C6 and C6 C7 revealing a collapsed disc space and a 11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4 C5 then at C5 C6 then at C6 C7 sending specimen for permanent section to Pathology in a routine and separate manner Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament which was removed in a similar piecemeal fashion with 1 and 2 mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes widely laterally bilaterally at each interspace with one at C4 C5 more right sided The most prominent osteophyte and compression was at C5 C6 followed by C6 C7 and C4 C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels once the ligaments were proximally removed as well and similarly a sign of a decompressed status The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away Appropriate size Bengal cages were filled with the patient s own bone elements and countersunk into position filled along with fusion putty and once these were quite tightly applied and checked further stability was added by the placement of a Slim LOC plate of appropriate size with appropriate size screws and a post placement x ray showed well aligned elements The wound was irrigated with antibiotic solution again and inspected and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was sterilely dressed and incorporated a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords orthopedic herniated nucleus pulposus radiculopathy cervical stenosis anterior instrumentation stabilization slim loc neural decompression anterior cervical discectomy cord compression interbody fusion bengal cages interbody compression anterior fusion decompression discectomy cervical MEDICAL_TRANSCRIPTION,Description Bilateral Crawford subtalar arthrodesis with open Achilles Z lengthening and bilateral long leg cast Medical Specialty Orthopedic Sample Name Arthrodesis Transcription PREOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet POSTOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet PROCEDURE Bilateral Crawford subtalar arthrodesis with open Achilles Z lengthening and bilateral long leg cast ANESTHESIA Surgery performed under general anesthesia The patient received 6 mL of 0 25 Marcaine local anesthetic on each side TOURNIQUET TIME Tourniquet time was 53 minutes on the left and 45 minutes on the right COMPLICATIONS There were no intraoperative complications DRAINS None SPECIMENS None HARDWARE USED Staple 7 8 inch x1 on each side HISTORY AND PHYSICAL The patient is a 5 year 4 month old male who presents for evaluation of feet He has been having significant feet pain with significant planovalgus deformity The patient was noted to have flexible vertical talus It was decided that the patient would benefit by subtalar arthrodesis possible autograft and Achilles lengthening This was explained to the mother in detail This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature Risks of surgery include risks of anesthesia infection bleeding changes in sensation and motion of the extremity hardware failure need for other surgical procedures need to be nonweightbearing for some time All questions were answered and the mother agreed to the above plan PROCEDURE NOTE The patient was taken to the operating room placed supine on the operating room general anesthesia was administered The patient received Ancef preoperatively Bilateral nonsterile tourniquets were placed on each thigh A bump was placed underneath the left buttock Both the extremities were then prepped and draped in standard surgical fashion Attention was first turned towards the left side Intended incision was marked on the skin The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint The sinus tarsi was then identified using a U shaped flap to tack muscles and periosteum was retracted distally Once the foot was reduced a Steinman pin was used to hold it in position This position was first checked on the fluoroscopy The 7 8th inch staple was then placed across the sinus tarsi to maintain the reduction This was also checked with fluoroscopy The incision was then extended posteriorly to allow for visualization of the Achilles which was Z lengthened with the release of the lateral distal half This was sutured using 2 0 Ethibond and that was also oversewn The wound was irrigated with normal saline The periosteal flap was sutured over the staple using 2 0 Vicryl Skin was closed using 2 0 Vicryl interrupted and then with 4 0 Monocryl The area was injected with 6 mL of 0 25 Marcaine local anesthetic The wound was cleaned and dried dressed with Steri Strips Xeroform and 4 x 4s and Webril Tourniquet was released after 53 minutes The exact same procedure was repeated on the right side with no changes or complications Tourniquet time on the right side was 45 minutes The patient tolerated the procedure well Bilateral long leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch The patient was subsequently was taken to Recovery in stable condition POSTOPERATIVE PLAN The patient will be hospitalized overnight for pain as per parents request The patient is to be strict nonweightbearing for at least 6 weeks He is to follow up in the next 10 days for a check We will plan of changing to short leg casts in about 4 weeks postop Keywords orthopedic myotonic muscular dystrophy muscular dystrophy planovalgus feet achilles z lengthening subtalar arthrodesis bilateral crawford subtalar arthrodesis bilateral long leg cast sinus tarsi leg casts tourniquet time arthrodesis intraoperative fluoroscopy tourniquet surgery subtalar achilles anesthesia planovalgus foot bilateral MEDICAL_TRANSCRIPTION,Description Irrigation and debridement of skin subcutaneous tissue fascia and bone associated with an open fracture and placement of antibiotic impregnated beads Open calcaneus fracture on the right Medical Specialty Orthopedic Sample Name Antibiotic Impregnated Beads Placement Transcription PREOPERATIVE DIAGNOSIS Open calcaneus fracture on the right POSTOPERATIVE DIAGNOSIS Open calcaneus fracture on the right PROCEDURES 1 Irrigation and debridement of skin subcutaneous tissue fascia and bone associated with an open fracture 2 Placement of antibiotic impregnated beads ANESTHESIA General BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Healing skin with no gross purulence identified some fibrinous material around the beads SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained her right leg was sterilely prepped and draped in a normal fashion The tourniquet was inflated and the previous wound was opened Dr X came in to look at the wound and the beads were removed all 25 beads were extracted and pulsatile lavage and curette etc were used to debride the wound The wound margins were healthy with the exception of very central triangular incision area The edges were debrided and then 19 antibiotic impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today The skin edges were approximated under minimal tension The soft dressing was placed An Ace was placed She was awakened from the anesthesia and taken to recovery room in a stable condition Final needle instrument and sponge counts were correct Keywords orthopedic open calcaneus fracture irrigation and debridement antibiotic impregnated beads irrigation subcutaneous placement debridement calcaneus fracture wound beads antibiotic MEDICAL_TRANSCRIPTION,Description Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction Removal of loose bodies Medial femoral chondroplasty and meniscoplasty Medical Specialty Orthopedic Sample Name Anterior Cruciate Ligament Reconstruction Transcription PREOPERATIVE DIAGNOSIS Anterior cruciate ligament rupture POSTOPERATIVE DIAGNOSES 1 Anterior cruciate ligament rupture 2 Medial meniscal tear 3 Medial femoral chondromalacia 4 Intraarticular loose bodies PROCEDURE PERFORMED 1 Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction 2 Removal of loose bodies 3 Medial femoral chondroplasty 4 Medial meniscoplasty OPERATIVE PROCEDURE The patient was taken to the operative suite placed in supine position and administered a general anesthetic by the Department of Anesthesia Following this the knee was sterilely prepped and draped as discussed for this procedure The inferolateral and inferomedial portals were then established however prior to this a graft was harvested from the semitendinosus and gracilis region After the notch was identified then ACL was confirmed and ruptured There was noted to be a torn slipped up area of the medial meniscus which was impinging and impinged on the articular surface The snare was smoothed out Entire area was thoroughly irrigated Following this there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing There were multiple loose bodies noted in the knee and these were then __________ and then removed The tibial and femoral drill holes were then established and the graft was then put in place both which locations after a notchplasty was performed The knee was taken through a full range of motion without any impingement An Endobutton was used for proximal fixation Distal fixation was obtained with an independent screw and a staple The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure Keywords orthopedic femoral chondroplasty intraarticular loose bodies anterior cruciate ligament reconstruction anterior arthroscopy meniscoplasty fixation reconstruction chondroplasty ligament femoral intraarticular medial MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion C5 C6 utilizing Bengal cage Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Interbody Fusion 3 Transcription PREOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 POSTOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 PROCEDURES 1 Anterior cervical discectomy at C5 C6 for neural decompression 63075 2 Anterior interbody fusion C5 C6 22554 utilizing Bengal cage 22851 3 Anterior cervical instrumentation at C5 C6 for stabilization by Uniplate construction at C5 C6 22845 with intraoperative x ray x2 SERVICE Neurosurgery ANESTHESIA Keywords orthopedic spondylosis neck pain headaches decompression uniplate anterior cervical discectomy neural decompression cervical stenosis prevertebral space antibiotic solution cervical discectomy interbody fusion bengal cage interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5 C6 utilizing Bengal cage Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Interbody Fusion 2 Transcription PREOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 POSTOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 with spinal cord and spinal canal decompression 63075 2 Anterior interbody fusion at C5 C6 22554 utilizing Bengal cage 22851 3 Anterior instrumentation for stabilization by Uniplate construction C5 C6 22845 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected only in a subplatysmal manner bluntly and with only blunt dissection at the prevertebral space where a localizing intraoperative x ray was obtained once self retaining retractors were placed along the mesial edge of a cauterized longus colli muscle to protect surrounding tissues throughout the remainder of the case A prominent anterior osteophyte at C5 C6 was then localized compared to preoperative studies in the usual fashion intraoperatively and the osteophyte was excised with a rongeur and bony fragments saved This allowed for an annulotomy which was carried out with a 11 blade and discectomy removed with straight disc forceps portions of the disc which were sent to Pathology for a permanent section Residual osteophytes and disc fragments were removed with 1 and 2 mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace a sign of a decompressed status At no time during the case was evidence of CSF leakage and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation Once the decompression was inspected with a double ball dissector and all found to be completely decompressed and the dura bulged at the interspace and pulsated then a Bengal cage was filled with the patient s own bone elements and fusion putty and countersunk into position and was quite tightly applied Further stability was added nonetheless with an appropriate size Uniplate which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner The wound was inspected and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was Steri Stripped for reinforcement and a sterile dressing was applied incorporating a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner Once the sterile dressing was applied the patient was taken from the operating room to the recovery area having left in stable condition At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords orthopedic herniated nucleus pulposus myelopathy cervical spondylosis cervical stenosis anterior instrumentation uniplate decompression anterior cervical discectomy spinal cord spinal canal sterile dressing interbody fusion bengal cage interbody cervical anterior discectomy MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy allograft fusion and anterior plating Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 8 Transcription PROCEDURES PERFORMED C5 C6 anterior cervical discectomy allograft fusion and anterior plating ESTIMATED BLOOD LOSS 10 mL CLINICAL NOTE This is a 57 year old gentleman with refractory neck pain with single level degeneration of the cervical spine and there was also some arm pain We decided go ahead with anterior cervical discectomy at C5 C6 and fusion The risks of lack of pain relief paralysis hoarse voice nerve injuries and infection were explained and the patient agreed to proceed DESCRIPTION OF PROCEDURE The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut He had tape placed over the shoulders during intraoperative x rays and his elbows were well padded The tape was placed and his arms were well padded He was prepped and draped in a sterile fashion A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle We then dissected sharply medial to carotid artery which we palpated to the prevertebral region We placed Caspar retractors for medial and lateral exposure over the C5 C6 disc space which we confirmed with the lateral cervical spine x ray including 18 gauge needle in the disc space We then marked the disc space We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space We then under magnification removed all the disc material we could possibly see down to bleeding bone and both the endplates We took down posterior longitudinal ligament as well We incised the 6 mm cornerstone bone We placed a 6 mm parallel medium bone nicely into the disc space We then sized a 23 mm plate We inserted the screws nicely above and below We tightened down the lock nuts We irrigated the wound We assured hemostasis using bone wax prior to placing the plate We then assured hemostasis once again We reapproximated the platysma using 3 0 Vicryl in a simple interrupted fashion The subcutaneous level was closed using 3 0 Vicryl in a simple buried fashion The skin was closed with 3 0 Monocryl in a running subcuticular stitch Steri Strips were applied Dry sterile dressing with Telfa was applied over this We obtained an intraoperative x ray to confirm the proper level and good position of both plates and screw construct on the lateral x ray and the patient was transferred to the recovery room moving all four extremities with stable vital signs I was present as a primary surgeon throughout the entire case Keywords orthopedic allograft fusion anterior cervical discectomy neck pain cervical spine discectomy fusion sternocleidomastoid muscle assured hemostasis anterior cervical cervical discectomy disc space cervical anterior allograft MEDICAL_TRANSCRIPTION,Description C4 C5 C5 C6 anterior cervical discectomy and fusion The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 7 Transcription PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PROCEDURE C4 C5 C5 C6 anterior cervical discectomy and fusion COMPLICATIONS None ANESTHESIA General INDICATIONS OF PROCEDURE The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 I discussed the procedure as well as risks and complications She wishes to proceed with surgery Risks will include but are not limited to infection hemorrhage spinal fluid leak worsened neurologic deficit recurrent stenosis requiring further surgery difficulty with fusion requiring further surgery long term hoarseness of voice difficulty swallowing medical anesthesia risk PROCEDURE The patient was taken to the operating room on 10 02 2007 She was intubated for anesthesia TEDS and boots as well as Foley catheter were placed She was placed in a supine position with her neck in neutral position Appropriate pads were also used The area was prepped and draped in usual sterile fashion Preoperative localization was taken _____ not changed Incision was made on the right side in transverse fashion over C5 vertebral body level This was made with a 10 blade knife and further taken down with pickups and scissors The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine Intraoperative x ray was taken Longus colli muscles were retracted laterally Caspar retractors were used Intraoperative x ray was taken I first turned by attention at C5 C6 interspace This was opened with 15 blade knife Disc material was taken out using pituitary as well as Kerrison rongeur Anterior aspects were taken down End plates were arthrodesed using curettes This was done under distraction Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur Bilateral foraminotomies were done At this point I felt that there was a good decompression The foramen appeared to be opened Medtronic cage was then encountered and sent few millimeters This was packed with demineralized bone matrix The distraction was then taken down The cage appeared to be strong This procedure was then repeated at C4 C5 A 42 mm AcuFix plate was then placed between C4 and C6 This was carefully screwed and locked The instrumentation appeared to be strong Intraoperative x ray was taken Irrigation was used Hemostasis was achieved The platysmas was closed with 3 0 Vicryl stitches The subcutaneous was closed with 4 0 Vicryl stitches The skin was closed with Steri strips The area was clean and dry and dressed with Telfa and Tegaderm Soft cervical collar was placed for the patient She was extubated per anesthesia and brought to the recovery in stable condition Keywords orthopedic anterior cervical discectomy fusion infection hemorrhage spinal fluid leak anesthesia foley catheter teds anterior cervical cervical discectomy anterior cervical discectomy stenosis MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 9 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 PROCEDURE Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification FIRST ASSISTANT Nurse practitioner PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion for anterior discectomy and fusion An incision was made midline to the anterior body of the sternocleidomastoid at C5 C6 level The skin subcutaneous tissue and platysma muscle was divided exposing the carotid sheath which was retracted laterally Trachea and esophagus were retracted medially After placing the self retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x rays we then proceeded with the discectomy We then cleaned out the disc at C5 C6 after incising the annulus fibrosis We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes and the next step was to clean out the disc space totally With this having been done we then turned our attention with the operating microscope to the osteophytes We drilled off the vertebral osteophytes at C5 C6 as well as the uncovertebral osteophytes This was removed along with the posterior longitudinal ligament After we had done this the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion We observed that there was a ____________ in the posterior longitudinal ligament There was a free fragment disc which had broken through the posterior longitudinal ligament just to the right of midline The next step was to obtain the bone from the back bone using cortical cancellous graft 10 mm in size after we had estimated the size That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor After we had tapped in the bone plug we then removed the distraction and the bone plug was fitting nicely We then use the Aesculap cervical titanium instrumentation with the 16 mm screws After securing the C5 C6 disc with four screws and titanium plate x rays showed good alignment of the spine good placement of the bone graft and after x rays showed excellent position of the bone graft and instrumentation we then placed in a Jackson Pratt drain in the prevertebral space brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and skin was closed with Steri Strips Blood loss during the operation was less than 10 mL No complications of the surgery Needle count sponge count and cottonoid count were correct Keywords orthopedic aesculap titanium dynamic plating system anterior cervical discectomy herniated nucleus pulposus cervical discectomy operating microscope longitudinal ligament discectomy anterior instrumentation cervical titanium MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy and moderate stenosis C5 6 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion Discharge Summary Transcription FINAL DIAGNOSES 1 Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy 2 Moderate stenosis C5 6 OPERATION On 06 25 07 anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray This is a 60 year old white male who was in the office on 05 01 07 because of neck pain with left radiculopathy and tension headaches In the last year or so he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right He has some neck pain at times and has seen Dr X for an epidural steroid injection which was very helpful More recently he saw Dr Y and went through some physical therapy without much relief Cervical MRI scan was obtained and revealed a large right sided disc herniation at C4 5 with significant midline herniations at C5 6 and a large left HNP at C6 7 In view of the multiple levels of pathology I was not confident that anything short of surgical intervention would give him significant relief The procedure and its risk were fully discussed and he decided to proceed with the operation HOSPITAL COURSE Following admission the procedure was carried out without difficulty Blood loss was about 125 cc Postop x ray showed good alignment and positioning of the cages plate and screws After surgery he was able to slowly increase his activity level with assistance from physical therapy He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck He also had some nausea with the PCA He had a low grade fever to 100 2 and was started on incentive spirometry Over the next 12 hours his fever resolved and he was able to start getting up and around much more easily By 06 27 07 he was ready to go home He has been counseled regarding wound care and has received a neck sheet for instruction He will be seen in two weeks for wound check and for a followup evaluation x rays in about six weeks He has prescriptions for Lortab 7 5 mg and Robaxin 750 mg He is to call if there are any problems Keywords orthopedic slimlock herniated nucleuses pulposus anterior cervical discectomy bengal cages anterior herniated cervical radiculopathy discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression of spinal cord Anterior cervical fusion Anterior cervical instrumentation Insertion of intervertebral device Use of operating microscope Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 6 Transcription PREOPERATIVE DIAGNOSIS Symptomatic disk herniation C7 T1 FINAL DIAGNOSIS Symptomatic disk herniation C7 T1 PROCEDURES PERFORMED 1 Anterior cervical discectomy with decompression of spinal cord C7 T1 2 Anterior cervical fusion C7 T1 3 Anterior cervical instrumentation anterior C7 T1 4 Insertion of intervertebral device C7 T1 5 Use of operating microscope ANESTHESIOLOGY General endotracheal ESTIMATED BLOOD LOSS A 30 mL PROCEDURE IN DETAIL The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service He was placed in the supine position on an OR table His arms were carefully taped down He was sterilely prepped and draped in the usual fashion A 4 cm incision was made obliquely over the left side of his neck Subcutaneous tissue was dissected down to the level of the platysma The platysma was incised using electrocautery Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle This allowed us to get right down on to the anterior cervical spine Blunt dissection was done to sweep off the longus colli We isolated the C7 T1 interspace An x ray was taken to verify we were indeed at the C7 T1 interspace Shadow Line retractor was placed as well as Caspar pins This provided very very good access to the C7 T1 disk At this point the operating microscope was brought into the decompression A thorough and aggressive C7 T1 discectomy was done using a succession of curettes pituitary rongeur 4 mm cutting bur and a 2 Kerrison rongeur At the end of the discectomy the cartilaginous endplates were carefully removed using 4 mm cutting burr The posterior longitudinal ligament was carefully resected using 2 Kerrison rongeur Left sided C8 foraminotomy was accomplished using nerve hook and a 2 mm Kerrison rongeur At the end of the decompression there was no further compression on the left C8 nerve root A Synthes cortical cancellous ____________ bone was placed in the interspace Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed two in the body of C7 and two in the body of T1 An x ray was taken It showed good placement of the plate and screws A deep drain was placed The platysma layer was closed in running fashion using 1 Vicryl Subcutaneous tissue was closed in an interrupted fashion using 2 0 Vicryl Skin was closed in a running fashion using 4 0 Monocryl Steri Strips and dressings were applied All counts were correct There were no complications Keywords orthopedic disk herniation cervical discectomy decompression spinal cord anterior cervical fusion anterior cervical discectomy kerrison rongeur anterior cervical instrumentation cervical anterior platysma kerrison fashion interspace rongeur discectomy herniation MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression and anterior interbody fusion at C5 C6 and C6 C7 utilizing Bengal cages x2 Anterior instrumentation by Uniplate construction C5 C6 and C7 with intraoperative x ray x2 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 5 Transcription PREOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 POSTOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression 63075 63076 2 Anterior interbody fusion at C5 C6 and C6 C7 22554 22585 utilizing Bengal cages x2 22851 3 Anterior instrumentation by Uniplate construction C5 C6 and C7 22845 with intraoperative x ray x2 ANESTHESIA General OPERATIONS The patient was brought to the operating room and placed in the supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then with only blunt dissection the prevertebral space was encountered and localizing intraoperative x ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self retaining retractors for exposure of tissues Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5 C6 and then at C6 C7 with rongeur allowing for an annulotomy with an 11 blade through collapsed disc space at C5 6 and even more collapsed at C6 C7 Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels sending to Pathology in a routine fashion as disc specimen This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6 C7 removing large osteophytes and process residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well This allowed for the bulging into the interspace of the dura sign of decompressed status and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam Once hemostasis well achieved Bengal cage was filled with the patient s own bone elements of appropriate size and this was countersunk into position and quite tightly applied it at first C5 C6 then secondly at C6 C7 These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size The appropriate size screws and post placement x ray showed well aligned elements and removal of osteophytes etc The wound was again irrigated with antibiotic solution inspected and finally closed in a multiple layered closure by approximation of platysma with interrupted 3 0 Vicryl and the skin with subcuticular stitch of 4 0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin and later incorporated itself into sterile bandage Once the bandage was placed the patient was taken extubated from the operating room to the Recovery area having in stable but guarded condition At the conclusion of the case all instrument needle and sponge counts were accurate and correct There were no intraoperative complications of any type Keywords orthopedic cervical spondylosis anterior cervical discectomy anterior instrumentation annulotomy kerrison rongeurs surgifoam vertebral space uniplate construction bengal cages neural decompression anterior cervical cervical discectomy interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 with spinal stenosis Anterior cervical discectomy with fusion C5 C6 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 2 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis PROCEDURE Anterior cervical discectomy with fusion C5 C6 PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion An incision was made from midline to the anterior border of the sternocleidomastoid in the right side Skin and subcutaneous tissue were divided sharply Trachea and esophagus were retracted medially Carotid sheath was retracted laterally Longus colli muscles were dissected away from the vertebral bodies of C5 C6 We confirmed our position by taking intraoperative x rays We then used the operating microscope and cleaned out the disk completely We then sized the interspace and then tapped in a 7 mm cortical cancellous graft We then used the DePuy Dynamic plate with 14 mm screws Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed in layers using 2 0 Vicryl for muscle and fascia The blood loss was less than 10 20 mL No complication Needle count sponge count and cottonoid count was correct Keywords orthopedic carotid sheath jackson pratt drain anterior cervical discectomy herniated nucleus pulposus cervical discectomy herniated nucleus nucleus pulposus spinal stenosis discectomy fusion herniated nucleus pulposus spinal stenosis anterior MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws Cervical spondylosis and herniated nucleus pulposus of C4 C5 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Arthrodesis 2 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 POSTOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 TITLE OF OPERATION Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws ESTIMATED BLOOD LOSS Less than 100 mL OPERATIVE PROCEDURE IN DETAIL After identification the patient was taken to the operating room and placed in supine position Following the induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position A preoperative x ray was obtained to identify the operative level and neck position An incision was marked at the C4 C5 level on the right side The incision was opened with 10 blade knife Dissection was carried down through subcutaneous tissues using Bovie electrocautery The platysma muscle was divided with the cautery and mobilized rostrally and caudally The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia This was opened with scissors and dissected rostrally and caudally with the peanut dissectors The operative level was confirmed with an intraoperative x ray The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5 Self retaining retractor was placed in submuscular position and distraction pins were placed in the vertebral bodies of C4 and C5 and distraction was instituted We then incise the annulus of C4 C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes Operating microscope was draped and brought into play Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch There was a transligamentous disc herniation which was removed during this process We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent Cord was seen to be pulsating freely behind the dura There appeared to be no complications and the decompression appeared adequate We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body An 8 mm lordotic trial was used and appeared perfect We then used a corticocancellous 8 mm lordotic graft This was tapped into position Distraction was released appeared to be in excellent position We then positioned an 18 mm Vector plate over the inner space Intraoperative x ray was obtained with the stay screw in place plates appeared to be in excellent position We then use a 14 mm self tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion All of the screws locked to the plate and this was confirmed on visual inspection Intraoperative x ray was again obtained Construct appeared satisfactory Attention was then directed to closure The wound was copiously irrigated All of the self retaining retractors were removed Bleeding points were controlled with bone wax and bipolar electrocautery The platysma layer was now closed with interrupted 3 0 Vicryl sutures The skin was closed with running 3 0 Vicryl subcuticular stitch Steri Strips were applied A sterile bandage was applied All sponge needle and cottonoid counts were reported as correct The patient tolerated the procedure well He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition Keywords orthopedic synthes vector plate lordotic acf spacer corticocancellous arthrodesis anterior cervical discectomy herniated nucleus pulposus anterior cervical spacer screws discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure Cervical spondylotic myelopathy with cord compression and cervical spondylosis Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion Transcription PREOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis POSTOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis In addition to this he had a large herniated disk at C3 C4 in the midline PROCEDURE Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure PROCEDURE IN DETAIL The patient placed in the supine position the neck was prepped and draped in the usual fashion Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4 Skin subcutaneous tissue and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4 C5 It appeared that the C5 C6 disk area had fused spontaneously We then confirmed that position by taking intraoperative x rays and then proceeded to do discectomy and fusion at C3 C4 C4 C5 After placing distraction screws and self retaining retractors with the teeth beneath the bellies of the longus colli muscles we then meticulously removed the disk at C3 C4 C4 C5 using the combination of angled strip pituitary rongeurs and curettes after we had incised the anulus fibrosus with 15 blade Next step was to totally decompress the spinal cord using the operating microscope and high speed cutting followed by the diamond drill with constant irrigation We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments This was then removed with 2 mm Kerrison rongeur After we removed the posterior longitudinal ligament we could see the dura pulsating nicely We did foraminotomies at C3 C4 as well as C4 C5 as well After having totally decompressed both the cord as well as the nerve roots of C3 C4 C4 C5 we proceeded to the next step which was a fusion We sized two 8 mm cortical cancellous grafts and after distracting the bone at C3 C4 C4 C5 we gently tapped the grafts into place The distraction was removed and the grafts were now within We went to the next step for the procedure which was the instrumentation and stabilization of the fused area We then placed a titanium ABC plate from C3 C5 secured it with 16 mm titanium screws X rays showed good position of the screws end plate The next step was to place Jackson Pratt drain to the vertebral fascia Meticulous hemostasis was obtained The wound was closed in layers using 2 0 Vicryl for the subcutaneous tissue Steri Strips were used for skin closure Blood loss less than about 200 mL No complications of the surgery Needle counts sponge count and cottonoid count was correct Keywords orthopedic titanium plates fixation bone black bone procedure anterior cervical discectomy titanium plates cervical discectomy spondylotic myelopathy cord compression cervical spondylosis foraminotomies cervical anterior MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy bone bank allograft and anterior cervical plate Left cervical radiculopathy Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy 4 Transcription PREOPERATIVE DIAGNOSIS Left cervical radiculopathy POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy PROCEDURES PERFORMED 1 C5 C6 anterior cervical discectomy 2 Bone bank allograft 3 Anterior cervical plate TUBES AND DRAINS LEFT IN PLACE None COMPLICATIONS None SPECIMEN SENT TO PATHOLOGY None ANESTHESIA General endotracheal INDICATIONS This is a middle aged man who presented to me with left arm pain He had multiple levels of disease but clinically it was C6 radiculopathy We tested him in the office and he had weakness referable to that nerve The procedure was done at that level DESCRIPTION OF PROCEDURE The patient was taken to the operating room at which time an intravenous line was placed General endotracheal anesthesia was obtained He was positioned supine in the operative area and the right neck was prepared An incision was made and carried down to the ventral spine on the right in the usual manner An x ray confirmed our location We were impressed by the degenerative change and the osteophyte overgrowth As we had excepted the back of the disk space was largely closed off by osteophytes We patiently drilled through them to the posterior ligament We went through that until we saw the dura We carefully went to the patient s symptomatic left side The C6 foramen was narrowed by uncovertebral joint overgrowth The foramen was open widely An allograft was placed An anterior Steffee plate was placed Closure was commenced The wound was closed in layers with Steri Strips on the skin A dressing was applied It should be noted that the above operation was done also with microscopic magnification and illumination Keywords orthopedic cervical radiculopathy anterior cervical discectomy bank allograft cervical discectomy anterior cervical foramen discectomy allograft radiculopathy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression anterior cervical fusion anterior cervical instrumentation and Allograft C5 C6 Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Decompression 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 POSTOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 PROCEDURES 1 Anterior cervical discectomy with decompression C5 C6 2 Anterior cervical fusion C5 C6 3 Anterior cervical instrumentation C5 C6 4 Allograft C5 C6 ANESTHESIA General endotracheal COMPLICATIONS None PATIENT STATUS Taken to recovery room in stable condition INDICATIONS The patient is a 36 year old female who has had severe recalcitrant right upper extremity pain numbness tingling shoulder pain axial neck pain and headaches for many months Nonoperative measures failed to relieve her symptoms and surgical intervention was requested We discussed reasonable risks benefits and alternatives of various treatment options Continuation of nonoperative care versus the risks associated with surgery were discussed She understood the risks including bleeding nerve vessel damage infection hoarseness dysphagia adjacent segment degeneration continued worsening pain failed fusion and potential need for further surgery Despite these risks she felt that current symptoms will be best managed operatively SUMMARY OF SURGERY IN DETAIL Following informed consent and preoperative administration of antibiotics the patient was brought to the operating suite General anesthetic was administered The patient was placed in the supine position All prominences and neurovascular structures were well accommodated The patient was noted to have pulse in this position Preoperative x rays revealed appropriate levels for skin incision Ten pound inline traction was placed via Gardner Wells tongs and shoulder roll was placed The patient was then prepped and draped in sterile fashion Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease Subcutaneous tissue was dissected down to the level of the omohyoid which was transected Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally This was taken down to the prevertebral fascia which was bluntly split Intraoperative x ray was taken to ensure proper levels Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli thus placing no new traction on the surrounding vital structures Inferior spondylosis was removed with high speed bur A scalpel and curette was used to remove the disc Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally Disc herniation was removed from the right posterolateral aspect of the interspace High speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura No further evidence of compression was identified Hemostasis was achieved with thrombin soaked Gelfoam Interspace was then distracted with Caspar pin distractions set gently Interspace was then gently retracted with the Caspar pin distraction set An 8 mm allograft was deemed in appropriate fit This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit The graft was stable to pull out forces Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14 mm self drilling screws Plate and screws were then locked to the plate Final x rays revealed proper positioning of the plate excellent distraction in the disc space and apposition of the endplates and allograft Wounds were copiously irrigated with normal saline Omohyoid was approximated with 3 0 Vicryl Running 3 0 Vicryl was used to close the platysma Subcuticular Monocryl and Steri Strips were used to close the skin A deep drain was placed prior to wound closure The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition There were no intraoperative complications All needle and sponge counts were correct Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal Keywords orthopedic cervical spondylosis cervical fusion decompression instrumentation anterior cervical discectomy anterior cervical herniated disc cervical discectomy anterior cervical fusion allograft discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusion C2 C3 C3 C4 Removal of old instrumentation C4 C5 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 PROCEDURES 1 Anterior cervical discectomy C3 C4 C2 C3 2 Anterior cervical fusion C2 C3 C3 C4 3 Removal of old instrumentation C4 C5 4 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates PROCEDURE IN DETAIL The patient was placed in the supine position The neck was prepped and draped in the usual fashion for anterior cervical discectomy A high incision was made to allow access to C2 C3 Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially This exposed the vertebral bodies of C2 C3 and C4 C5 which was bridged by a plate We placed in self retaining retractors With the tooth beneath the blades the longus colli muscles were dissected away from the vertebral bodies of C2 C3 C4 and C5 After having done this we used the all purpose instrumentation to remove the instrumentation at C4 C5 we could see that fusion at C4 C5 was solid We next proceeded with the discectomy at C2 C3 and C3 C4 with disc removal In a similar fashion using a curette to clean up the disc space and the space was fairly widened as well as drilling up the vertebral joints using high speed cutting followed by diamond drill bit It was obvious that the C3 C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis With the operating microscope however we had good visualization of these nerve roots and we were able to ___________ both at C2 C3 and C3 C4 We then placed the ABC 55 mm plate from C2 down to C4 These were secured with 16 mm titanium screws after excellent purchase We took an x ray which showed excellent position of the plate the screws and the graft themselves The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and Steri Strips used to close the skin Blood loss was about 50 mL No complication of the surgery Needle count sponge count cottonoid count was correct The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb At the time of surgery he had total collapse of the C2 C3 and C4 disc with osteophyte formation At both levels he has high grade spinal stenosis at these levels especially foramen stenosis causing the compression neck pain headaches and arm and shoulder pain He does have degenerative changes at C5 C6 C6 C7 C7 T1 however they do not appear to be symptomatic although x rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form Keywords orthopedic abc plates osteophyte cervical discectomy cervical fusion herniated nucleus pulposus anterior cervical discectomy nucleus pulposus vertebral bodies osteophyte formation spinal stenosis cervical discectomy anterior instrumentation vertebral stenosis fusion MEDICAL_TRANSCRIPTION,Description Arthrodesis anterior interbody technique anterior cervical discectomy anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws implantation of machine bone implant Disc herniation with right arm radiculopathy Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy Arthrodesis 1 Transcription PREOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy POSTOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy PROCEDURE 1 C5 C6 arthrodesis anterior interbody technique 2 C5 C6 anterior cervical discectomy 3 C5 C6 anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws 4 Implantation of machine bone implant 5 Microsurgical technique ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL BACKGROUND INFORMATION AND SURGICAL INDICATIONS The patient is a 45 year old right handed gentleman who presented with neck and right arm radicular pain The pain has become more and more severe It runs to the thumb and index finger of the right hand and it is accompanied by numbness If he tilts his neck backwards the pain shoots down the arm If he is working with the computer it is very difficult to use his mouse He tried conservative measures and failed to respond so he sought out surgery Surgery was discussed with him in detail A C5 C6 anterior cervical discectomy and fusion was recommended He understood and wished to proceed with surgery Thus he was brought in same day for surgery on 07 03 2007 DESCRIPTION OF PROCEDURE He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR There general endotracheal anesthesia was induced He was positioned on the OR table with an IV bag between the scapulae The neck was slightly extended and taped into position A metal arch was placed across the neck and intraoperative x ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle The incision was extended through skin subcutaneous fat and platysma Hemostasis was assured with Bovie cautery The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6 C7 disk based on x rays and then around the C5 C6 disk space An intraoperative x ray confirmed C5 C6 disk space had been localized and then the self retained distraction system was inserted to maintain exposure A 15 blade knife was used to incise the C5 C6 disk and remove disk material and distraction pins were inserted into C5 C6 and distraction placed across the disk space The operating microscope was then brought into the field and used throughout the case except for the closure Various pituitaries 15 blade knife and curette were used to evacuate the disk as best as possible Then the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina A small amount of disk material was found at the right neural foramen After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure the wound was thoroughly irrigated A spacing mechanism was intact into the disk space and it was determined that a 7 spacer was appropriate So a 7 machine bone implant was taken and tapped into disk space and slightly counter sunk The wound was thoroughly irrigated and inspected for hemostasis A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5 C6 to hold the bone into position and the wound was once again irrigated The patient was valsalved There was no further bleeding seen and intraoperative x ray confirmed a good position near the bone plate and screws and the wound was enclosed in layers The 3 0 Vicryl was used to approximate platysma and 3 0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin The wound was cleaned Mastisol was placed on the skin and Steri strips were used to approximate skin margins Sterile dressing was placed on the patient s neck He was extubated in the OR and transported to the recovery room in stable condition There were no complications Keywords orthopedic herniation radiculopathy interbody mystique bone implant anterior cervical discectomy neural foramina mystique plate disc herniation arm radiculopathy cervical discectomy disk space disk cervical anterior wound discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy arthrodesis partial corpectomy Machine bone allograft placement of anterior cervical plate with a Zephyr MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy two levels and C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy 3 Transcription PREOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain POSTOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain PROCEDURES C5 C6 and C6 C7 anterior cervical discectomy two levels C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used ANESTHESIA General endotracheal COMPLICATIONS None INDICATION FOR THE PROCEDURE This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain numbness weakness with MRI showing significant disk protrusions with the associate complexes at C5 C6 and C6 C7 with associated cervical radiculopathy After failure of conservative treatment this patient elected to undergo surgery DESCRIPTION OF PROCEDURE The patient was brought to the OR and after adequate general endotracheal anesthesia she was placed supine on the OR table with the head of the bed about 10 degrees A shoulder roll was placed and the head supported on a donut support The cervical region was prepped and draped in the standard fashion A transverse cervical incision was made from the midline which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle In a transverse fashion the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done Then the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia which was gently dissected and released superiorly and inferiorly Spinal needles were placed into the displaced C5 C6 and C6 C7 to confirm these disk levels using lateral fluoroscopy Following this monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5 C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly A 15 scalpel was used to do a discectomy at C5 C6 from endplate to endplate and uncovertebral joint On the uncovertebral joint a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect This was done under the microscope A high speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the 15 scalpel and then Kerrison punches 1 mm and then 2 mm were used to decompress further disk calcified material at the C5 C6 level This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen Then at the C6 C7 level in a similar fashion 15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate to endplate using a 15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate and then high speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released Then using the Kerrison punches we used 1 mm and 2 mm to remove disk calcified material which was extending more posteriorly to the left and the right This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots With this done the wound was irrigated Hemostasis was ensured with bipolar coagulation Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6 mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5 C6 and C6 C7 discectomy sites Then the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate Danek windows titanium plates was then taken and sized and placed A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5 two in the vertebral body of C6 and two in the vertebral body of C7 The holes were then drilled and after this self tapping screws were placed into the vertebral body of C5 C6 and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5 C6 and C7 With this done operative fluoroscopy was used to check good alignment of the graft screw and plate and then the wound was irrigated Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down A 10 round Jackson Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site Then the platysma was approximated using 2 0 Vicryl inverted interrupted stitches and the skin closed with 4 0 Vicryl running subcuticular stitch Steri Strips and sterile dressings were applied The patient remained hemodynamically stable throughout the procedure Throughout the procedure the microscope had been used for the disk decompression and high speed drilling In addition intraoperative SSEP EMG monitoring and motor evoked potentials remained stable throughout the procedure The patient remained stable throughout the procedure Keywords orthopedic cervical disk protrusions cervical radiculopathy cervical pain cervical plate fixation sofamor danek titanium window plate anterior cervical discectomy vertebral body vertebral disk intraoperative anterior decompression fluoroscopy radiculopathy discectomy cervical MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 6 and placement of artificial disk replacement Right C5 C6 herniated nucleus pulposus Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy 2 Transcription ADMITTING DIAGNOSIS Right C5 C6 herniated nucleus pulposus PRIMARY OPERATIVE PROCEDURE Anterior cervical discectomy at C5 6 and placement of artificial disk replacement SUMMARY This is a pleasant 43 year old woman who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs She underwent another MRI and significant degenerative disease at C5 6 with a central and right sided herniation was noted Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery She was interested in participating in the artificial disk replacement study and was entered into that study She was randomly picked for the artificial disk and underwent the above named procedure on 08 27 2007 She has done well postoperatively with a sensation of right arm pain and numbness in her fingers She will have x rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well She will follow up with Dr X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x rays with ring prior to the appointment She will contact our office prior to her appointment if she has problems Prescriptions were written for Flexeril 10 mg 1 p o t i d p r n 50 with 1 refill and Lortab 7 5 500 mg 1 to 2 q 6 h p r n 60 with 1 refill Keywords orthopedic herniated nucleus pulposus anterior cervical discectomy artificial disk replacement cervical discectomy nucleusNOTE MEDICAL_TRANSCRIPTION,Description Achilles tendon rupture left lower extremity Primary repair left Achilles tendon The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg The patient was placed in posterior splint and followed up at ABC orthopedics for further care Medical Specialty Orthopedic Sample Name Achilles Tendon Repair Transcription PREOPERATIVE DIAGNOSIS Achilles tendon rupture left lower extremity POSTOPERATIVE DIAGNOSIS Achilles tendon rupture left lower extremity PROCEDURE PERFORMED Primary repair left Achilles tendon ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal TOTAL TOURNIQUET TIME 40 minutes at 325 mmHg POSITION Prone HISTORY OF PRESENT ILLNESS The patient is a 26 year old African American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg The patient was placed in posterior splint and followed up at ABC orthopedics for further care PROCEDURE After all potential complications risks as well as anticipated benefits of the above named procedure were discussed at length with the patient informed consent was obtained The operative extremity was then confirmed with the patient the operative surgeon Department Of Anesthesia and nursing staff While in this hospital the Department Of Anesthesia administered general anesthetic to the patient The patient was then transferred to the operative table and placed in the prone position All bony prominences were well padded at this time A nonsterile tourniquet was placed on the left upper thigh of the patient but not inflated at this time Left lower extremity was sterilely prepped and draped in the usual sterile fashion Once this was done the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes After all bony and soft tissue land marks were identified a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal Careful dissection was then taken down to the level of the peritenon Once this was reached full thickness flaps were performed medially and laterally Next retractor was placed All neurovascular structures were protected A longitudinal incision was then made in the peritenon and opened up exposing the tendon There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point The plantar tendon was noted to be intact The tendon was debrided at this time of hematoma as well as frayed tendon Wound was copiously irrigated and dried Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair Next 0 PDS on a taper needle was selected and a Krackow stitch was then performed Two sutures were then used and tied individually ________ from the tendon The tendon came together very well and with a tight connection Next a 2 0 Vicryl suture was then used to close the peritenon over the Achilles tendon The wound was once again copiously irrigated and dried A 2 0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by 4 0 suture in the subcuticular closure on the skin Steri Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s Kerlix roll sterile Kerlix and a short length fiberglass cast in a plantar position At this time the Department of anesthesia reversed the anesthetic The patient was transferred back to hospital gurney to the Postanesthesia Care Unit The patient tolerated the procedure well There were no complications Keywords orthopedic repair achilles tendon rupture longitudinal incision tendon rupture achilles tendon tendon achilles rupture extremity MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy removal of herniated disc and osteophytes bilateral C4 nerve root decompression harvesting of bone for autologous vertebral bodies for creation of arthrodesis grafting of fibular allograft bone for creation of arthrodesis creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies and placement of anterior spinal instrumentation using the operating microscope and microdissection technique Medical Specialty Orthopedic Sample Name Anterior Cervical Discectomy 1 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression POSTOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression OPERATION PERFORMED 1 Anterior cervical discectomy of C3 C4 2 Removal of herniated disc and osteophytes 3 Bilateral C4 nerve root decompression 4 Harvesting of bone for autologous vertebral bodies for creation of arthrodesis 5 Grafting of fibular allograft bone for creation of arthrodesis 6 Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies 7 Placement of anterior spinal instrumentation using the operating microscope and microdissection technique INDICATIONS FOR PROCEDURE This 62 year old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain Conservative therapy has failed to improve the problem Imaging studies showed severe spondylosis of C3 C4 with neuroforaminal narrowing and spinal cord compression A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives He clearly understood it and had no further questions and requested that I proceed PROCEDURE IN DETAIL The patient was placed on the operating room table and was intubated using a fiberoptic technique The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses The neck was carefully prepped and draped in the usual sterile manner A transverse incision was made on a skin crease on the left side of the neck Dissection was carried down through the platysmal musculature and the anterior spine was exposed The medial borders of the longus colli muscles were dissected free from their attachments to the spine A needle was placed and it was believed to be at the C3 C4 interspace and an x ray properly localized this space Castoff self retaining pins were placed into the body of the C3 and C4 Self retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles The annulus was incised and a discectomy was performed Quite a bit of overhanging osteophytes were identified and removed As I worked back to the posterior lips of the vertebral body the operating microscope was utilized There was severe overgrowth of spondylitic spurs A high speed diamond bur was used to slowly drill these spurs away I reached the posterior longitudinal ligament and opened it and exposed the underlying dura Slowly and carefully I worked out towards the C3 C4 foramen The dura was extremely thin and I could see through it in several areas I removed the bony compression in the foramen and identified soft tissue and veins overlying the root All of these were not stripped away for fear of tearing this very tissue paper thin dura However radical decompression was achieved removing all the bony compression in the foramen out to the pedicle and into the foramen An 8 mm of the root was exposed although I left the veins over the root intact The microscope was angled to the left side where a similar procedure was performed Once the decompression was achieved a high speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration Bone thus from the drilling was preserved for use for the arthrodesis Attention was turned to creation of the arthrodesis As I had drilled quite a bit into the bodies I selected a large 12 mm graft and distracted the space maximally Under distraction the graft was placed and fit well An x ray showed good graft placement Attention was turned to spinal instrumentation A Synthes Short Stature plate was used with four 3 mm screws Holes were drilled with all four screws were placed with pretty good purchase Next the locking screws were then applied An x ray was obtained which showed good placement of graft plate and screws The upper screws were near the upper endplate of C3 The C3 vertebral body that remained was narrow after drilling off the spurs Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate Attention was turned to closure A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin The wound was then carefully closed in layers Sterile dressings were applied along with a rigid Philadelphia collar The operation was then terminated The patient tolerated the procedure well and left for the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisted of bone and soft tissue as well as C3 C4 disc material Keywords orthopedic herniated osteophytes nerve root decompression harvesting autologous vertebral arthrodesis anterior technique anterior cervical discectomy spinal cord compression fibular allograft bone creation of arthrodesis cervical discectomy spinal instrumentation cord compression vertebral body vertebral bodies spinal cord bone instrumentation cervical anterior grafting spinal discectomy allograft MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus Anterior cervical decompression anterior spine instrumentation anterior cervical spine fusion and application of machined allograft Medical Specialty Orthopedic Sample Name Anterior Cervical Decompression Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 PROCEDURE PERFORMED 1 Anterior cervical decompression C5 C6 2 Anterior cervical decompression C6 C7 3 Anterior spine instrumentation 4 Anterior cervical spine fusion C5 C6 5 Anterior cervical spine fusion C6 C7 6 Application of machined allograft at C5 C6 7 Application of machined allograft at C6 C7 8 Allograft structural at C5 C6 9 Allograft structural at C6 C7 ANESTHESIA General PREOPERATIVE NOTE This patient is a 47 year old male with chief complaint of severe neck pain and left upper extremity numbness and weakness Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5 C6 and C6 C7 on the left The patient has failed epidural steroid injections Risks and benefits of the above procedure were discussed with the patient including bleeding infection muscle loss nerve damage paralysis and death OPERATIVE REPORT The patient was taken to the OR and placed in the supine position After general endotracheal anesthesia was obtained the patient s neck was sterilely prepped and draped in the usual fashion A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body It was taken down through the subcutaneous tissues exposing the platysmus muscle The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine An 18 gauge needle was placed in the C5 C6 interspace and the intraoperative x ray confirmed that this was the appropriate level Next the longus colli muscles were resected laterally on both the right and left side and then a complete anterior cervical discectomy was performed The disk was very degenerated and brown in color There was an acute disk herniation through posterior longitudinal ligament The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed Approximately 5 mm of the nerve root on both the right and left side was visualized A ball ended probe could be passed up the foramen Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates of C5 and C6 were prepared using a high speed burr and a 6 mm lordotic machined allograft was malleted into place There was good bony apposition both proximally and distally Next attention was placed at the C6 C7 level Again the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6 C7 was performed The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left The posterior longitudinal ligament was removed A bilateral foraminotomy was performed Approximately 5 mm of the C7 nerve root was visualized on both sides A micro nerve hook was able to be passed up the foramen easily Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates at C6 C7 were then prepared using a high speed burr and then a 7 mm machined lordotic allograft was malleted into place There was good bony apposition both proximally and distally Next a 44 mm Blackstone low profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws Intraoperative x ray confirmed appropriate positioning of the plate and the graft The wound was then copiously irrigated with normal saline and bacitracin There was no active bleeding upon closure of the wound A small drain was placed deep The platysmal muscle was closed with 3 0 Vicryl The skin was closed with 4 0 Monocryl Mastisol and Steri Strips were applied The patient was monitored throughout the procedure with free running EMGs and SSEPs and there were no untoward events The patient was awoken and taken to the recovery room in satisfactory condition Keywords orthopedic herniated nucleus pulposus anterior cervical decompression spine fusion cervical spine allograft anterior cervical spine anterior cervical MEDICAL_TRANSCRIPTION,Description Removal of the hardware and revision of right AC separation Loose hardware with superior translation of the clavicle implants Arthrex bioabsorbable tenodesis screws Medical Specialty Orthopedic Sample Name AC Separation Revision Hardware Removal Transcription PREOPERATIVE DIAGNOSIS Right AC separation POSTOPERATIVE DIAGNOSIS Right AC separation PROCEDURES Removal of the hardware and revision of right AC separation ANESTHESIA General BLOOD LOSS 100 cc COMPLICATIONS None FINDINGS Loose hardware with superior translation of the clavicle implants IMPLANTS Arthrex bioabsorbable tenodesis screws SUMMARY After informed consent was obtained and verified the patient was brought to the operating room and placed supine on the operating table After uneventful general anesthesia was obtained he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion The incision was reopened and the hardware was removed without difficulty The AC joint was inspected and reduced An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle And two separate areas that were split one taken medially and one taken laterally and then sewed together for further stability This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied He was awakened from anesthesia and taken to recovery room in a stable condition Final needle and instrument counts were correct Keywords orthopedic loose hardware superior translation clavicle implants ac separation removal of the hardware arthrex bioabsorbable tenodesis screws bioabsorbable tenodesis tenodesis screws translation implants bioabsorbable tenodesis clavicle separation hardware MEDICAL_TRANSCRIPTION,Description Right Achilles tendon rupture Medical Specialty Orthopedic Sample Name Achilles Ruptured Tendon Transcription CHIEF COMPLAINT Achilles ruptured tendon HISTORY Mr XYZ is 41 years of age who works for Chevron and lives in Angola He was playing basketball in Angola back last Wednesday Month DD YYYY when he was driving toward the basket and felt a pop in his posterior leg He was seen locally and diagnosed with an Achilles tendon rupture He has been on crutches and has been nonweightbearing since that time He had no pain prior to his injury He has had some swelling that is mild He has just been on aspirin a day due to his traveling time Pain currently is minimal PAST MEDICAL HISTORY Denies diabetes cardiovascular disease or pulmonary disease CURRENT MEDICATIONS Malarone which is an anti malarial ALLERGIES NKDA SOCIAL HISTORY He is a petroleum engineer for Chevron Drinks socially Does not use tobacco PHYSICAL EXAM Pleasant gentleman in no acute distress He has some mild swelling on the right ankle and hindfoot He has motion that is increased into dorsiflexion He has good plantarflexion Good subtalar Chopart and forefoot motion His motor function is intact although weak into plantarflexion Sensation is intact Pulses are strong In the prone position he has diminished tension on the affected side There is some bruising around the posterior heel He has a palpable defect about 6 8 cm proximal to the insertion site that is tender for him Squeezing the calf causes no plantarflexion of the foot RADIOGRAPHS Of his right ankle today show a preserved joint space I don t see any evidence of fracture noted Radiographs of the heel show no fracture noted with good alignment IMPRESSION Right Achilles tendon rupture PLAN I have gone over with Mr XYZ the options available We have discussed the risks benefits and alternatives to operative versus nonoperative treatment Based on his age and his activity level I think his best option is for operative fixation We went over the risks of bleeding infection damage to nerves and blood vessels rerupture of the tendon weakness and the need for future surgery We have discussed doing this as an outpatient procedure He would be nonweightbearing in a splint for 10 days nonweightbearing in a dynamic brace for 4 weeks and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼ lift He understands a 6 9 month return to sports overall He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola Today we will put him in a high tide boot that he will need at six weeks and we will put him in a 1 lift also He can weight bear until surgery and we will have it set up this week His questions were all answered today Keywords orthopedic achilles tendon rupture alignment crutches joint space nonweightbearing plantarflexion achilles ruptured tendon achilles ruptured ruptured tendon achilles tendon tendon rupture achilles MEDICAL_TRANSCRIPTION,Description This patient has undergone cataract surgery and vision is reduced in the operated eye due to presence of a secondary capsular membrane The patient is being brought in for YAG capsular discission Medical Specialty Ophthalmology Sample Name YAG Laser Capsulotomy 1 Transcription PREOPERATIVE DIAGNOSIS Secondary capsular membrane right eye POSTOPERATIVE DIAGNOSIS Secondary capsular membrane right eye PROCEDURE PERFORMED YAG laser capsulotomy right eye INDICATIONS This patient has undergone cataract surgery and vision is reduced in the operated eye due to presence of a secondary capsular membrane The patient is being brought in for YAG capsular discission PROCEDURE The patient was seated at the YAG laser the pupil having been dilated with 1 Mydriacyl and Iopidine was instilled The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied A total of Keywords ophthalmology abraham capsulotomy yag yag laser capsulotomy capsulotomy laser membrane eye capsular MEDICAL_TRANSCRIPTION,Description Bilateral open Achilles lengthening with placement of short leg walking cast Medical Specialty Orthopedic Sample Name Achilles Lengthening Transcription PREOPERATIVE DIAGNOSIS Idiopathic toe walker POSTOPERATIVE DIAGNOSIS Idiopathic toe walker PROCEDURE Bilateral open Achilles lengthening with placement of short leg walking cast ANESTHESIA Surgery performed under general anesthesia A total of 10 mL of 0 5 Marcaine local anesthetic was used COMPLICATIONS No intraoperative complications DRAINS None SPECIMENS None TOURNIQUET TIME On the left side was 30 minutes on the right was 21 minutes HISTORY AND PHYSICAL The patient is a 10 year old boy who has been a toe walker since he started ambulating at about a year The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally He does not walk with a crouched gait but does toe walk Given his tightness surgery versus observation was recommended to the family Family however wanted to correct his toe walking Surgery was then discussed Risks of surgery include risks of anesthesia infection bleeding changes in sensation and motion of the extremities failure to resolve toe walking possible stiffness cast and cast problems All questions were answered and parents agreed to above surgical plan PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered The patient received Ancef preoperatively The patient was then subsequently placed prone with all bony prominences padded Two bilateral nonsterile tourniquets were placed on each thigh Both extremities were then prepped and draped in a standard surgical fashion We turned our attention first towards the left side A planned incision of 1 cm medial to the Achilles tendon was marked on the skin The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg Incision was then made and carried down through subcutaneous fat down to the tendon sheath Achilles tendon was identified and Z lengthening was done with the medial distal half cut Once Z lengthening was completed proximally the length of the Achilles tendon was then checked This was trimmed to obtain an end on end repair with 0 Ethibond suture This was also oversewn Wound was then irrigated Achilles tendon sheath was reapproximated using 2 0 Vicryl as well as the subcutaneous fat The skin was closed using 4 0 Monocryl Once the wound was cleaned and dried and dressed with Steri Strips and Xeroform the area was injected with 0 5 Marcaine It was then dressed with 4 x 4 and Webril Tourniquet was released at 30 minutes The same procedure was repeated on the right side with tourniquet time of 21 minutes While the patient was still prone two short leg walking casts were then placed The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition POSTOPERATIVE PLAN The patient will be discharged on the day of surgery He may weightbear as tolerated in his cast which he will have for about 4 to 6 weeks He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs which he will need up to 6 months The patient may or may not need physical therapy while his Achilles lengthenings are healing The patient is not to participate in any PE for at least 6 months The patient is given Tylenol No 3 for pain Keywords orthopedic toe walker achilles lengthening idiopathic toe walker short leg walking subcutaneous fat tendon sheath leg walking achilles tendon toe tourniquet tendon intraoperative MEDICAL_TRANSCRIPTION,Description Combined closed vitrectomy with membrane peeling fluid air exchange and endolaser right eye Medical Specialty Ophthalmology Sample Name Vitrectomy 1 Transcription PREOPERATIVE DIAGNOSIS Vitreous hemorrhage and retinal detachment right eye POSTOPERATIVE DIAGNOSIS Vitreous hemorrhage and retinal detachment right eye NAME OF PROCEDURE Combined closed vitrectomy with membrane peeling fluid air exchange and endolaser right eye ANESTHESIA Local with standby PROCEDURE The patient was brought to the operating room and an equal mixture of Marcaine 0 5 and lidocaine 2 was injected in a retrobulbar fashion As soon as satisfactory anesthesia and akinesia had been achieved the patient was prepped and draped in the usual manner for sterile ophthalmic surgery A wire lid speculum was inserted Three modified sclerotomies were selected at 9 10 and 1 o clock At the 9 o clock position the Accurus infusion line was put in place and tied with a preplaced 7 0 Vicryl suture The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position and closed vitrectomy was begun Initially formed core vitrectomy was performed and formed anterior vitreous was removed After this was completed attention was placed in the posterior segment Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata After all the vitreous had been removed and the membranes released the retina was completely mobilized Total fluid air exchange was carried out with complete settling of the retina Endolaser was applied around the margins of the retinal tears and altogether several 100 applications were placed in the periphery Good reaction was achieved The eye was inspected with an indirect ophthalmoscope The retina was noted to be completely attached The instruments were removed from the eye The sclerotomy sites were closed with 7 0 Vicryl suture The infusion line was removed from the eye and tied with a 7 0 Vicryl suture The conjunctivae and Tenon s were closed with 6 0 plain gut suture A collagen shield soaked with Tobrex placed over the surface of the globe and a pressure bandage was put in place The patient left the operating room in a good condition Keywords ophthalmology vitreous hemorrhage retinal detachment combined closed vitrectomy vitrectomy membrane peeling fluid air exchange endolaser vitrectomy with membrane peeling membrane peeling hemorrhage detachment vicryl eye retinal MEDICAL_TRANSCRIPTION,Description Visually significant posterior capsule opacity right eye YAG laser posterior capsulotomy right eye Medical Specialty Ophthalmology Sample Name YAG Laser Capsulotomy Transcription PREOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye POSTOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye OPERATIVE PROCEDURES YAG laser posterior capsulotomy right eye ANESTHESIA Topical anesthesia using tetracaine ophthalmic drops INDICATIONS FOR SURGERY This patient was found to have a visually significant posterior capsule opacity in the right eye The patient has had a mild decrease in visual acuity which has been a gradual change The posterior capsule opacity was felt to be related to the decline in vision The risks benefits and alternatives including observation were discussed I feel the patient had a good understanding of the proposed procedure and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified Pupil was dilated per protocol Patient was positioned at the YAG laser Then of energy were used to perform a circular posterior laser capsulotomy through the visual axis A total of shots were used Total energy was The patient tolerated the procedure well and there were no complications The lens remained well centered and stable Postoperative instructions were provided Alphagan P ophthalmic drops times two were instilled prior to his dismissal Post laser intraocular pressure measured mmHg Postoperative instructions were provided and the patient had no further questions Keywords ophthalmology capsule opacity yag ophthalmic yag laser posterior capsulotomy capsulotomy opacity laser visually eye anesthesia MEDICAL_TRANSCRIPTION,Description Vitrectomy under local anesthesia Medical Specialty Ophthalmology Sample Name Vitrectomy Local Anesthesia Transcription DESCRIPTION OF PROCEDURE After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table After intravenous sedation was administered a retrobulbar block consisting of 2 Xylocaine with 0 75 Marcaine and Wydase was administered to the right eye without difficulty The patient s right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants A lens ring was secured to the eye using 7 0 Vicryl suture Keywords ophthalmology lid speculum conjunctival peritomy vitrectomy operating superonasally anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Vitreous hemorrhage right eye Vitrectomy right eye A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus Medical Specialty Ophthalmology Sample Name Vitrectomy Transcription PREOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye POSTOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye PROCEDURE Vitrectomy right eye PROCEDURE IN DETAIL The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia Initially a 5 cc retrobulbar injection was performed with 2 Xylocaine during monitored anesthesia control A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus MVR incisions were made 4 mm posterior to the limbus in the and o clock meridians following which the infusion apparatus was positioned in the o clock site and secured with a 5 0 Vicryl suture Then under indirect ophthalmoscopic control the vitrector was introduced through the o clock site and a complete vitrectomy was performed All strands of significance were removed Tractional detachment foci were apparent posteriorly along the temporal arcades Next endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control Finally an air exchange procedure was performed also under indirect ophthalmoscopic control The intraocular pressure was within the normal range The globe was irrigated with a topical antibiotic The MVR incisions were closed with 7 0 Vicryl No further manipulations were necessary The conjunctiva was closed with 6 0 plain catgut An eye patch was applied and the patient was sent to the recovery area in good condition Keywords ophthalmology ophthalmoscopic vitrectomy endolaser lancaster lid speculum vitreous hemorrhage vitreous hemorrhage conjunctiva MEDICAL_TRANSCRIPTION,Description Vitrectomy under general anesthesia Medical Specialty Ophthalmology Sample Name Vitrectomy General Anesthesia Transcription DESCRIPTION OF PROCEDURE After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty The patient s right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants A lens ring was secured to the eye using 7 0 Vicryl suture Keywords ophthalmology ophthalmic fashion vitrectomy operating superonasally anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Vitrectomy A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Medical Specialty Ophthalmology Sample Name Vitrectomy 3 Transcription DESCRIPTION OF OPERATION The patient was brought to the operating room and appropriately identified Local anesthesia was obtained with a 50 50 mixture of 2 lidocaine and 0 75 bupivacaine given as a peribulbar block The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Calipers were set at 3 5 mm and a mark was made 3 5 mm posterior to the limbus in the inferotemporal quadrant A 5 0 nylon suture was passed through partial thickness sclera on either side of this mark The MVR blade was used to make a sclerotomy between the pre placed sutures An 8 0 nylon suture was then pre placed for later sclerotomy closure The infusion cannula was inspected and found to be in good working order The infusion cannula was placed in the vitreous cavity and secured with the pre placed sutures The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on Additional sclerotomies were made 3 5 mm posterior to the limbus in the supranasal and supratemporal quadrants The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed There was moderately severe vitreous hemorrhage which was removed Once a view of the posterior pole could be obtained there were some diabetic membranes emanating along the arcades These were dissected with curved scissors and judicious use of the vitrectomy cutter There was some bleeding from the inferotemporal frond This was managed by raising the intraocular pressure and using intraocular cautery The surgical view became cloudy and the corneal epithelium was removed with a beaver blade This improved the view There is an area suspicious for retinal break near where the severe traction was inferotemporally The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears holes or dialyses were seen There was some residual hemorrhagic vitreous skirt seen The soft tip cannula was then used to perform an air fluid exchange Additional laser was placed around the suspicious area inferotemporally The sclerotomies were then closed with 8 0 nylon suture in an X fashion the infusion cannula was removed and it sclerotomy closed with the pre existing 8 0 nylon suture The conjunctiva was closed with 6 0 plain gut A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye The lid speculum was removed Maxitrol ointment was instilled over the eye and the eye was patched The patient was brought to the recovery room in stable condition Keywords ophthalmology conjunctival peritomy westcott scissors lid speculum inferotemporal quadrants inferotemporal conjunctival scissors supranasal supratemporal sclerotomy eye vitreous vitrectomy infusion cannulaNOTE MEDICAL_TRANSCRIPTION,Description The patient with recurrent nongranulomatous anterior iritis and most recently pain in left eye associated with headache and photophobia Medical Specialty Ophthalmology Sample Name Uveitis Transcription PAST MEDICAL HISTORY Significant for GERD history of iron deficiency anemia and asthma for which she takes an inhaler REVIEW OF SYSTEMS Positive for only for left knee arthritis She has no exposure to tuberculosis or syphilis she has no mouth or genital ulcers She has no skin rashes She has no connective tissue disorders PAST OCULAR HISTORY Significant for cataract and glaucoma surgery of the right eye PHYSICAL EXAMINATION On examination visual acuity measures hand motions on the right and 20 25 in the left There is an afferent pupillary defect on the right On examination there is a right hypertropia There is dense anterior chamber inflammation on the right eye with a stagnant aqueous There is either neovascularization on the iris or reactive iris vessels it is difficult to discern This seems to be complete iris synechia to the anterior lens capsule There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface The anterior chamber appears narrow On the left there is also dense inflammation at 4 cell There is 1 nuclear sclerosis Dilated fundus examination cannot be performed on the right secondary to intense inflammation On the left there is no evidence of active posterior uveitis There is some inferior vitreous debris ASSESSMENT PLAN Chronic bilateral recurrent nongranulomatous diffuse uveitis Currently there is very severe right eye inflammation and severe left eye I discussed at length with the patient that this will likely take an oral steroid to quite her down Since she has only one seeing eye I am anxious to obtain a decreased inflammation as soon as possible She has been on oral steroids in the past We also discussed considering the aggressive recurrent nature of this process it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left I anticipate we will likely start methotrexate in the near future In this acute phase I have recommended oral steroids at a dose of 60 mg a day hourly topical Pred Forte as well as atropine sulfate We will watch her closely in clinic I am sending a copy of this dictation to her primary care doctor she said she has had a negative HLA B27 rheumatoid factor and ANA in the past At this stage to be thorough I would ask Dr X to assist us in repeating her chest x ray PPD if not current and an RPR Additionally in anticipation of need for methotrexate it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C Keywords ophthalmology iritis nongranulomatous uveitis eye inflammation photophobia recurrent nongranulomatous anterior iritis headache and photophobia anterior chamber anterior chamber inflammation MEDICAL_TRANSCRIPTION,Description Pars plana vitrectomy membrane peel 23 gauge right eye Medical Specialty Ophthalmology Sample Name Vitrectomy 2 Transcription PREOPERATIVE DIAGNOSES Epiretinal membrane right eye CME right eye POSTOPERATIVE DIAGNOSES Epiretinal membrane right eye CME right eye PROCEDURES Pars plana vitrectomy membrane peel 23 gauge right eye PREOPERATIVE FINDINGS The patient had epiretinal membrane causing cystoid macular edema Options were discussed with the patient stressing that the visual outcome was guarded Especially since this membrane was of chronic duration there is no guarantee of visual outcome DESCRIPTION OF PROCEDURE The patient was wheeled to the OR table Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified Preparation was made for 23 gauge vitrectomy using the trocar inferotemporal cannula was placed 3 5 mm from the limbus and verified The fluid was run Then superior sclerotomies were created using the trocars and 3 5 mm from the limbus at 10 o clock and 2 o clock Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps ILM forceps the membrane was peeled off in its entirety There were no complications DVT precautions were in place I as attending was present in the entire case Keywords ophthalmology epiretinal membrane pars plana vitrectomy membrane peel macular edema cystoid eye retrobulbar epiretinal vitrectomy membrane MEDICAL_TRANSCRIPTION,Description Vitrectomy opening A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Medical Specialty Ophthalmology Sample Name Vitrectomy Opening Transcription VITRECTOMY OPENING The patient was brought to the operating room and appropriately identified General anesthesia was induced by the anesthesiologist The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants Hemostasis was maintained with wet field cautery Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant A 5 0 nylon suture was passed through partial thickness sclera on either side of this mark The MVR blade was used to make a sclerotomy between the preplaced sutures An 8 0 nylon suture was then preplaced for a later sclerotomy closure The infusion cannula was inspected and found to be in good working order The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants Keywords ophthalmology westcott scissors inferotemporal quadrants conjunctival peritomy sclerotomy vitrectomy supranasal supratemporal cannula inferotemporalNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Scleral buckle opening under local anesthesia Medical Specialty Ophthalmology Sample Name Scleral Buckle Opening Local Anesthesia Transcription PROCEDURE IN DETAIL After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table After intravenous sedation was administered a retrobulbar block consisting of 2 Xylocaine with 0 75 Marcaine and Wydase was administered to the right eye without difficulty The patient s right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a 360 degree conjunctival peritomy was performed at the limbus The 4 rectus muscles were looped and isolated using 2 0 silk suture The retinal periphery was then inspected via indirect ophthalmoscopy Keywords ophthalmology retinal periphery ophthalmoscopy scleral buckle operating anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Short flap trabeculectomy with lysis of conjunctival scarring tenonectomy peripheral iridectomy paracentesis watertight conjunctival closure and 0 5 mg mL mitomycin x2 minutes left eye Uncontrolled open angle glaucoma and conjunctival scarring left eye Medical Specialty Ophthalmology Sample Name Trabeculectomy Tenonectomy Transcription PREOPERATIVE DIAGNOSES 1 Uncontrolled open angle glaucoma left eye 2 Conjunctival scarring left eye POSTOPERATIVE DIAGNOSES 1 Uncontrolled open angle glaucoma left eye 2 Conjunctival scarring left eye PROCEDURES Short flap trabeculectomy with lysis of conjunctival scarring tenonectomy peripheral iridectomy paracentesis watertight conjunctival closure and 0 5 mg mL mitomycin x2 minutes left eye ANESTHESIA Retrobulbar block with monitored anesthesia care COMPLICATIONS None ESTIMATED BLOOD LOSS Negligible DESCRIPTION OF PROCEDURE The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines In the preoperative area the patient received pilocarpine drops The patient received IV propofol and once somnolent from this a retrobulbar block was administered consisting of 2 Xylocaine plain Approximately 3 mL were given The operative eye then underwent a Betadine prep with respect to the face lids lashes and eye During the draping process care was taken to isolate the lashes A screw type speculum was inserted to maintain patency of lids A 6 0 Vicryl suture was placed through the superior cornea and the eye was reflected downward to expose the superior conjunctiva A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea All Tenons were removed from the overlying sclera and the area was treated with wet field cautery to achieve hemostasis A 2 mm x 3 mm scleral flap was then outlined with a Micro Sharp blade This was approximately one half scleral depth in thickness A crescent blade was then used to dissect forward the clear cornea Hemostasis was again achieved with wet field cautery A Weck Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes The site was then profusely irrigated with balanced salt solution A paracentesis wound was made temporarily and then the Micro Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed A Kelly Descemet punch was then inserted and a trabeculectomy was performed Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0 12 forceps The iris was then repositioned into the eye and the anterior chamber was inflated with BSS The scleral flap was sutured in place with two 10 0 nylon sutures with knots trimmed rotated and buried The overlying conjunctiva was then closed with a running 8 0 Vicryl suture on a BV needle BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage Antibiotic and steroid drops were placed in the eye as was homatropine 5 The antibiotic consisted of Vigamox and the steroid was Econopred Plus A patch and shield were placed over the eye after the drape was removed The patient was taken to the recovery room in good condition She will be seen in followup in the office tomorrow Keywords ophthalmology uncontrolled open angle glaucoma open angle conjunctival scarring trabeculectomy tenonectomy iridectomy paracentesis watertight conjunctival closure conjunctival scarring eye glaucoma cornea scleral MEDICAL_TRANSCRIPTION,Description Tube Shunt Ahmed valve model S2 implant with pericardial reinforcement Sample Template Medical Specialty Ophthalmology Sample Name Tube Shunt Ahmed Valve Implant Transcription PREOPERATIVE DIAGNOSIS Open angle glaucoma OX POSTOPERATIVE DIAGNOSIS Open angle glaucoma OX PROCEDURE Ahmed valve model S2 implant with pericardial reinforcement XXX eye INDICATIONS This is a XX year old wo man with glaucoma in the OX eye uncontrolled by maximum tolerated medical therapy PROCEDURE The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding infection reoperation retinal detachment diplopia ptosis loss of vision and loss of the eye corneal hemorrhage hypotony elevated pressure worsening of glaucoma and corneal edema Informed consent was obtained Patient received several sets of drops in his her XXX eye including Ocuflox and Ocular S He was taken to the operating room where monitored anesthetic care was initiated Retrobulbar anesthesia was then administered to the XXX eye using a 50 50 mixture of 2 plain lidocaine and 0 05 Marcaine The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion A speculum was placed on the eyelids and microscope was brought into position A 7 0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva At this point smooth forceps and Westcott scissors were used to create a 100 degree superotemporal conjunctival peritomy approximately 2 mm posterior to the superotemporal limbus This was then dissected anteriorly to the limbus edge and then posteriorly Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure At this point we primed the Ahmed valve with a 27 gauge cannula using BSS and it was noted to be patent We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly We then measured with calipers so that it was positioned 9 mm posterior to the limbus The Ahmed valve was then tacked down with 8 0 nylon suture through both fenestrations We then applied light cautery to the superotemporal episcleral bed We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon We then used a 23 gauge needle and entered the superotemporal sclera approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea We then trimmed the tube beveled up in a 30 degree fashion with Vannas scissors and introduced the tube through the 23 gauge tract into the anterior chamber so that approximately 2 3 mm of tube was extending into the anterior chamber We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens away from the cornea and away from the iris We then tacked down the tubes to the sclera with 8 0 Vicryl suture in a figure of eight fashion The pericardium was soaked in gentamicin We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with 8 0 nylon suture At this point we then re approximated the conjunctiva to its original position and we closed it with an 8 0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites We then removed the traction suture At the end of the case the pupil was round the chamber was deep the tube appeared to be well positioned The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate The speculum was removed Ocuflox and Maxitrol ointment were placed over the eye Then an eye patch and shield were placed over the eye The patient was awakened and taken to the recovery room in stable condition Keywords ophthalmology tube shunt ahmed valve healon maxitrol ointment ocuflox open angle anterior chamber bleeding conjunctival peritomy cornea corneal edema corneal hemorrhage diplopia elevated pressure glaucoma hypotony infection loss of the eye loss of vision ophthalmic fashion ptosis reoperation retinal detachment sclera superotemporal worsening of glaucoma ahmed valve model superotemporal limbus eye ahmed implant bss valve limbus MEDICAL_TRANSCRIPTION,Description Scleral buckle opening The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma Medical Specialty Ophthalmology Sample Name Scleral Buckle Opening Transcription SCLERAL BUCKLE OPENING The patient was brought to the operating room and appropriately identified General anesthesia was induced by the anesthesiologist The patient was prepped and draped in the usual sterile fashion A lid speculum was used to provide exposure to the right eye A 360 degree limbal conjunctival peritomy was created with Westcott scissors Curved tenotomy scissors were used to enter each of the intermuscular quadrants The inferior rectus muscle was isolated with a muscle hook freed of its Tenon s attachment and tied with a 2 0 silk suture The 3 other rectus muscles were isolated in a similar fashion The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma Keywords ophthalmology tenotomy scleral quadrants scleral thinning scleral buckle staphylomaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Trabeculectomy with mitomycin C Sample Template Medical Specialty Ophthalmology Sample Name Trabeculectomy Transcription PREOPERATIVE DIAGNOSIS Open angle glaucoma OX POSTOPERATIVE DIAGNOSIS Open angle glaucoma OX PROCEDURE Trabeculectomy with mitomycin C XXX eye 0 3 c per mg times three minutes INDICATIONS This is a XX year old wo man with glaucoma in the OX eye uncontrolled by maximum tolerated medical therapy PROCEDURE The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding infection reoperation retinal detachment diplopia ptosis loss of vision and loss of the eye corneal hemorrhage hypotony elevated pressure worsening of glaucoma and corneal edema Informed consent was obtained Patient received several sets of drops in his her XXX eye including Ocuflox Ocular and pilocarpine S He was taken to the operating room where monitored anesthetic care was initiated Retrobulbar anesthesia was then administered to the XXX eye using a 50 50 mixture of 2 plain lidocaine and 0 05 Marcaine The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position A Lieberman lid speculum was used to provide exposure Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap Residual episcleral vessels were cauterized with Eraser tip cautery Sponges soaked in mitomycin C 0 3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock Sponges were removed and area was copiously irrigated with balanced salt solution A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap This was dissected anteriorly with a crescent blade to clear cornea A temporal paracentesis was then made Scleral flap was lifted and a Super blade was used to enter the anterior chamber A Kelly Descemet punch was used to remove a block of limbal tissue DeWecker scissors were used to perform a surgical iridectomy The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea A scleral flap was then re approximated back on the bed One end of the scleral flap was closed with a 10 0 nylon suture in interrupted fashion and the knot was buried The other end of the scleral flap was closed with 10 0 nylon suture in interrupted fashion and the knot was buried The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber Therefore it was felt that another 10 0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber Conjunctiva was then re approximated to the limbus and closed with 9 0 Vicryl suture on a TG needle at each of the peritomy ends Then a horizontal mattress style 9 0 Vicryl suture was placed at the center of the conjunctival peritomy The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck cel sponge The anterior chamber was inflated and there was noted that the superior bleb was well formed At the end of the case the pupil was round the chamber was formed and the pressure was felt to be adequate Speculum and drapes were carefully removed Ocuflox and Maxitrol ointment were placed over the eye Atropine was also placed over the eye Then an eye patch and eye shield were placed over the eye The patient was taken to the recovery room in good condition There were no complications Keywords ophthalmology trabeculectomy kelly descemet punch maxitrol ointment open angle glaucoma tg needle bleeding corneal edema corneal hemorrhage hypotony diplopia elevated pressure glaucoma infection iridectomy loss of the eye loss of vision mitomycin c ptosis reoperation retinal detachment temporal paracentesis worsening of glaucoma balanced salt solution anterior chamber scleral flap eye angle mitomycin conjunctival chamber flap MEDICAL_TRANSCRIPTION,Description Scleral Buckle opening under general anesthesia Medical Specialty Ophthalmology Sample Name Scleral Buckle Opening General Anesthesia Transcription PROCEDURE IN DETAIL After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty The patient s right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun A wire lid speculum was inserted into the right eye and a 360 degree conjunctival peritomy was performed at the limbus The 4 rectus muscles were looped and isolated using 2 0 silk suture The retinal periphery was then inspected via indirect ophthalmoscopy Keywords ophthalmology retinal periphery conjunctival peritomy ophthalmoscopy scleral buckle operating anesthesiaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Repair of ruptured globe involving posterior sclera Sample Template Medical Specialty Ophthalmology Sample Name Ruptured Globe Repair Posterior Sclera Transcription PREOPERATIVE DIAGNOSIS Ruptured globe OX POSTOPERATIVE DIAGNOSIS Ruptured globe OX PROCEDURE Repair of ruptured globe OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was placed to provide exposure Upon examination and dissection of the conjunctiva superiorly a scleral rupture was found The rupture extended approximately 15 mm in length superior to the cornea approximately 2 mm from the limbus in a horizontal fashion There was also a rupture at the limbus near the middle of this laceration causing the anterior chamber to be flat There was a large blood clot filling the anterior chamber An attempt was made to wash out the anterior chamber with BSS on a cannula The BSS was injected through the limbal rupture which communicated with the anterior chamber The blood clot did not move It was extremely adherent to the iris At that time the rupture that involved the limbus from approximately 10 30 until 12 o clock was closed using 1 suture of 10 0 nylon The scleral laceration was then closed using 10 interrupted sutures with 9 0 Vicryl At that time the anterior chamber was formed and appeared to be fairly deep The wounds were checked and found to be watertight The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7 0 Vicryl sutures 2 nasally and 2 temporally All suture knots were buried Gentamicin 0 5 cc was injected subconjunctivally Then the speculum was removed The drapes were removed Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye An eye patch and shield were placed over the eye The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition Keywords ophthalmology ruptured globe ancef bss maxitrol ointment ocuflox anterior chamber bleeding conjunctiva infection limbus loss of the eye loss of vision re operation scleral laceration scleral rupture wire lid speculum repair of ruptured globe ruptured anterior chamber globe MEDICAL_TRANSCRIPTION,Description Ruptured globe with full thickness corneal laceration repair Sample Template Medical Specialty Ophthalmology Sample Name Ruptured Globe Repair Cornea Transcription PREOPERATIVE DIAGNOSIS Ruptured globe with full thickness corneal laceration OX POSTOPERATIVE DIAGNOSIS Ruptured globe with full thickness corneal laceration OX PROCEDURE Ruptured globe with full thickness corneal laceration repair OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe with full thickness corneal laceration of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection astigmatism cataract re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was placed to provide exposure and 0 12 forceps and a Superblade were used to create a paracentesis at approximately 11 o clock Viscoat was injected through the paracentesis to fill the anterior chamber The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound More Viscoat was injected to deepen the anterior chamber A 10 0 nylon suture was used to place four sutures to close the corneal laceration BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound A fifth 10 0 nylon suture was then placed The wound was packed and found to be watertight The sutures were rotated the wound was again checked and found to be watertight A small amount of Viscoat was again injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue Several drops were placed in the XXX eye including Ocuflox Pred Forte Timolol 0 5 Alphagan and Trusopt An eye patch and shield were taped over the XXX eye The patient was awakened from general anesthesia S he was taken to the recovery area in good condition There were no complications Keywords ophthalmology ruptured globe alphagan bss ocuflox pred forte superblade timolol viscoat cannula anterior chamber astigmatism bleeding cataract corneal laceration full thickness corneal laceration infection laceration repair loss of the eye loss of vision paracentesis re operation wire lid speculum viscoat corneal laceration MEDICAL_TRANSCRIPTION,Description Repair of ruptured globe with repositing of uveal tissue Sample Template Medical Specialty Ophthalmology Sample Name Ruptured Globe Repair Sclera and Limbus Transcription PREOPERATIVE DIAGNOSIS Ruptured globe with uveal prolapse OX POSTOPERATIVE DIAGNOSIS Ruptured globe with uveal prolapse OX PROCEDURE Repair of ruptured globe with repositing of uveal tissue OX ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with a ruptured globe of the XXX eye PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient received IV antibiotics including Ancef and Levaeuin prior to surgery The patient was brought to the operating room and placud in the supine position where s he wad prepped and draped in the routine fashion A wire lid speculum was carefully placed to provide exposure A two armed 7 mm scleral laceration was seen in the supranasal quadrant The laceration involved the sclera and the limbus in this area There was a small amount of iris tissue prolapsed in the wound The Westcott scissors and 0 12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber The anterior chamber remained formed and the iris tissue easily resumed its normal position The pupil appeared round An 8 0 nylon suture was used to close the scleral portion of the laceration Three sutures were placed using the 8 0 nylon suture Then 9 0 nylon suture was used to close the limbal portion of the wound After the wound appeared closed a Superblade was used to create a paracentesis at approximately 2 o clock BSS was injected through the paracentesis to fill the anterior chamber The wound was checked and found to be watertight No leaks were observed An 8 0 Vicryl suture was used to reposition the conjunctiva and close the wound Three 8 0 Vicryl sutures were placed in the conjunctiva All scleral sutures were completely covered The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment The lid speculum was carefully removed The drapes were carefully removed Sterile saline was used to clean around the XXX eye as well as the rest of the face The area was carefully dried and an eye patch and shield were taped over the XXX eye The patient was awakened from general anesthesia without difficulty S he was taken to the recovery area in good condition There were no complications Keywords ophthalmology ruptured globe bss subconjunctival bleeding conjunctiva eye patch infection limbus loss of the eye loss of vision re operation scleral laceration supranasal quadrant uveal prolapse wire lid speculum iris tissue anterior chamber laceration iris chamber ruptured globe eye MEDICAL_TRANSCRIPTION,Description Small office note on premature retina and vitreous Medical Specialty Ophthalmology Sample Name Premature retina and vitreous Transcription OCULAR FINDINGS Anterior chamber space Cornea iris lens and pupils all unremarkable on gross examination in each eye Ocular adnexal spaces appear very good in each eye Cyclomydril x2 was used to dilate the pupil in each eye Medial spaces are clear and the periphery is still hazy in each eye Ocular disc space normal size and shape with a pink color with clear margin in each eye Macular spaces are normal in appearance for the age in each eye Posterior pole No dilated blood vessels seen in each eye Periphery The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye IMPRESSION Premature retina and vitreous each eye PLAN Recheck in two weeks Keywords ophthalmology eye ocular premature retina pupils periphery premature vitreous retina eye MEDICAL_TRANSCRIPTION,Description Repair of one half full thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant Medical Specialty Ophthalmology Sample Name Repair of Canthal Lid Defect Transcription PREOPERATIVE DIAGNOSIS Status post Mohs resection epithelial skin malignancy left lower lid left lateral canthus and left upper lid POSTOPERATIVE DIAGNOSIS Status post Mohs resection epithelial skin malignancy left lower lid left lateral canthus and left upper lid PROCEDURES 1 Repair of one half full thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid 2 Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant ASSISTANT None ANESTHESIA Attended local by Strickland and Associates COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in supine position Dressing was removed from the left eye which revealed the defect as noted above After systemic administration of alfentanil local anesthetic was infiltrated into the left upper lid left lateral canthus and left lower eyelid The patient was prepped and draped in the usual ophthalmic fashion Protective scleral shell was placed in the left eye A 4 0 silk traction sutures placed through the upper eyelid margin The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3 1 2 4 mm from the lid margin the full width of the eyelid Relaxing incisions were made both medially and laterally and Mueller s muscle was subsequently dissected free from the superior tarsal border The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6 0 Vicryl sutures and one 4 0 Vicryl suture The protective scleral shell was removed from the eye The medial aspect of the eyelid was advanced temporally The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6 0 Vicryl sutures The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7 0 Vicryl suture The upper eyelid wound was present It was advanced to the advanced tarsoconjunctival pedicle temporally The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6 0 Vicryl suture it was then secured to the lateral orbital rim with two interrupted 6 0 Vicryl sutures Skin muscle flap was then elevated was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7 0 Vicryl sutures Burrows triangle was removed as was necessary to create smooth wound closure which was closed with interrupted 7 0 Vicryl suture Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6 0 Vicryl suture to the periosteum overlying the lateral orbital rim The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7 0 Vicryl followed by wound closure temporally with interrupted 7 0 Vicryl suture with removal of a burrow s triangle as was necessary to create smooth wound closure Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure The patient tolerated the procedure well and left the operating room in excellent condition There were no apparent complications Keywords ophthalmology mohs resection epithelial skin lid left lateral canthus lateral canthal defect tarsoconjunctival pedicle flap lateral canthal tendon skin muscle flap interrupted vicryl sutures canthal defect mohs resection lid defect pedicle flap canthal tendon lateral canthus upper eyelid lateral orbital eyelid vicryl sutures repair eye canthal defect tarsoconjunctival pedicle MEDICAL_TRANSCRIPTION,Description Macular edema right eye Insertion of radioactive plaque right eye with lateral canthotomy The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5 0 Dacron The placement was confirmed with indirect ophthalmoscopy Medical Specialty Ophthalmology Sample Name Radioactive Plaque Insertion Transcription PREOPERATIVE DIAGNOSIS Macular edema right eye POSTOPERATIVE DIAGNOSIS Macular edema right eye TITLE OF OPERATION Insertion of radioactive plaque right eye with lateral canthotomy OPERATIVE PROCEDURE IN DETAIL The patient was prepped and draped in the usual manner for a local eye procedure Initially a 5 cc retrobulbar injection of 2 Xylocaine was done Then a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus A 2 0 silk traction suture was placed around the insertion of the lateral rectus muscle and with gentle traction the temporal one half of the globe was exposed The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5 0 Dacron The placement was confirmed with indirect ophthalmoscopy Next the eye was irrigated with Neosporin and the conjunctiva was closed with 6 0 plain catgut The intraocular pressure was found to be within normal limits An eye patch was applied and the patient was sent to the Recovery Room in good condition A lateral canthotomy had been done Keywords ophthalmology canthotomy ophthalmoscopy radioactive plaque scleral surface macular edema lateral canthotomy macular MEDICAL_TRANSCRIPTION,Description Bilateral rectus recession with the microscopic control 8 mm both eyes Medical Specialty Ophthalmology Sample Name Rectus Recession Transcription PREOPERATIVE DIAGNOSIS Congenital bilateral esotropia 42 prism diopters PROCEDURE Bilateral rectus recession with the microscopic control 8 mm both eyes POSTOPERATIVE DIAGNOSIS Congenital bilateral esotropia 42 prism diopters COMPLICATIONS None PROCEDURE IN DETAIL The patient was taken to the Surgery Room and placed in the supine position The general anesthesia was achieved with intubation with no problems Both eyes were prepped and draped in usual manner The attention was turned the right eye and a hole was made in the drape and a self retaining eye speculum was placed ensuring eyelash in the eye drape The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem The eyeball rotated medially and upwards by holding the limbus at 7 o clock position Inferior fornix conjunctival incision was made and Tenons capsule buttonholed The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook The Tenons capsule was buttonholed The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle __________ extension of the muscle was excised The 7 0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders The muscle was disinserted from original insertion The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion The suture was pulled tied and cut The muscle was in good position The conjunctiva was closed with 7 0 Vicryl suture in running fashion The suture was pulled tied and cut The eye speculum was taken out Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion The suture was pulled tied and cut The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition To be seen in the office in 1 week Keywords ophthalmology congenital bilateral esotropia esotropia tenons capsule rectus muscle bilateral rectus recession rectus recession eye speculum muscle hook eyes muscle rectus MEDICAL_TRANSCRIPTION,Description Cervical facial rhytidectomy Quadrilateral blepharoplasty Autologous fat injection to the upper lip donor site abdomen Medical Specialty Ophthalmology Sample Name Rhytidectomy Blepharoplasty Transcription PREOPERATIVE DIAGNOSIS Ageing face POSTOPERATIVE DIAGNOSIS Ageing face OPERATIVE PROCEDURE 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip OPERATIONS PERFORMED 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip donor site abdomen INDICATION This is a 62 year old female for the above planned procedure She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative PROCEDURE The patient was brought to the operative room under satisfaction and she was placed supine on the OR table Administered general endotracheal anesthesia followed by sterile prep and drape at the patient s face and abdomen This included the neck accordingly Two platysmal sling application and operating headlight were utilized Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery The first procedure was performed was that of a quadrilateral blepharoplasty Markers were applied to both upper lids in symmetrical fashion The skin was excised from the right upper lid first followed by appropriate muscle resection Minimal fat removed from the medial upper portion of the eyelid Hemostasis was controlled with the quadrilateral tip needle closure with a running 7 0 nylon suture Attention was then turned to the lower lid A classic skin muscle flap was created accordingly Fat was resected from the middle medial and lateral quadrant The fat was allowed to open drain the arcus marginalis for appropriate contour Hemostasis was controlled with the pinpoint cautery accordingly Skin was redraped with a conservative amount resected Running closure with 7 0 nylon was accomplished without difficulty The exact same procedure was repeated on the left upper and lower lid After completion of this portion of the procedure the lag lid was again placed in the eyes Eye mass was likewise clamped Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure The right face was first operated It was injected with a 0 25 Marcaine 1 200 000 adrenaline A submental incision was created followed by suction lipectomy and very minimal amounts of in 3 mm and 2 mm suction cannula She had minimal subcutaneous extra fat as noted Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post occipital hairline The flap was elevated without difficulty with various facelift scissors Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4 cm incision Rectus plication in the midline with a running 4 0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation cutting and cautery The submental incision was closed with a running 7 0 nylon over 5 0 Monocryl Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication The left side of face was first closed followed by interrupted SMAS plication utilizing 4 0 wide Mersilene The skin was draped appropriately and appropriate tissue was resected A 7 mm 9 0 French drain was utilized accordingly prior to closure of the skin with interrupted 4 0 Monocryl in the post occipital region followed by running 5 0 nylon in the postauricular surface Preauricular interrupted 5 0 Monocryl was followed by running 7 0 nylon The hairline temporal incision was closed with running 5 0 nylon The exact same closure was accomplished on the right side of the face with a same size 7 mm French drain The patient s dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3 inch Ace The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly Approximately 2 5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure The incision site was closed with 7 0 nylon The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position The patient will be admitted for overnight short stay through the cosmetic package procedure She will be discharged in the morning Estimated blood loss was less than 75 cc No complications noted and the patient tolerated the procedure well Keywords ophthalmology ageing face adaptic polysporin ointment autologous fat injection bovie cautery kerlix wrap smas plication arcus marginalis blepharoplasty facelift platysmal sling quadrilateral rhytidectomy right upper lid cervical facial rhytidectomy pinpoint cautery facial rhytidectomy quadrilateral blepharoplasty running nylon autologous MEDICAL_TRANSCRIPTION,Description Radioactive plaque macular edema Removal of radioactive plaque right eye with lateral canthotomy A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus A 2 0 traction suture was passed around the insertion of the lateral rectus and the temporal one half of the globe was exposed Medical Specialty Ophthalmology Sample Name Radioactive Plaque Removal Transcription PREOPERATIVE DIAGNOSIS Radioactive plaque macular edema POSTOPERATIVE DIAGNOSIS Radioactive plaque macular edema TITLE OF OPERATION Removal of radioactive plaque right eye with lateral canthotomy OPERATIVE PROCEDURE IN DETAIL The patient was prepped and draped in the usual manner for a local eye procedure Then a retrobulbar injection of 2 Xylocaine was performed A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus A 2 0 traction suture was passed around the insertion of the lateral rectus and the temporal one half of the globe was exposed Next the plaque was identified and the two scleral sutures were removed The plaque was gently extracted and the conjunctiva was re sutured with 6 0 catgut following removal of the traction suture The fundus was inspected with direct ophthalmoscopy An eye patch was applied following Neosporin solution irrigation The patient was sent to the recovery room in good condition A lateral canthotomy had been done Keywords ophthalmology conjunctiva eye patch ophthalmoscopy radioactive plaque traction suture eye radioactive plaque MEDICAL_TRANSCRIPTION,Description Phacoemulsification of cataract extraocular lens implant in left eye Medical Specialty Ophthalmology Sample Name Phacoemulsification of Cataract 1 Transcription PREOPERATIVE DIAGNOSES 1 Senile nuclear cataract left eye 2 Senile cortical cataract left eye POSTOPERATIVE DIAGNOSES 1 Senile nuclear cataract left eye 2 Senile cortical cataract left eye PROCEDURES Phacoemulsification of cataract extraocular lens implant in left eye LENS IMPLANT USED Alcon model SN60WF power of 22 5 diopters PHACOEMULSIFICATION TIME 1 minute 41 seconds at 44 4 power INDICATIONS FOR PROCEDURE This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20 40 The patient complains of difficulties with glare in performing activities of daily living INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery All questions from the patient were answered after the surgical procedure was explained in detail The risks of the procedure as explained to the patient include but are not limited to pain infection bleeding loss of vision retinal detachment need for further surgery loss of lens nucleus double vision etc Alternative of the procedure is to do nothing or seek a second opinion Informed consent for this procedure was obtained from the patient OPERATIVE TECHNIQUE The patient was brought to the holding area Previously an intravenous infusion was begun at a keep vein open rate After adequate sedation by the anesthesia department under monitored anesthesia care conditions a peribulbar and retrobulbar block was given around the operative eye A total of 10 mL mixture with a 70 30 mixture of 2 Xylocaine without epinephrine and 0 75 bupivacaine without epinephrine An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted Vital sign monitors were detached from the patient The patient was moved to the operative suite and the same monitors were reattached The periocular area was cleansed dried prepped and draped in the usual sterile manner for ocular surgery The speculum was set into place and the operative microscope was brought over the eye The eye was examined Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea Then a pocket incision was created without entering the anterior chamber of the eye Two peripheral paracentesis ports were created on each side of the initial incision site Viscoelastic was used to deepen the anterior chamber of the eye A 2 65 mm keratome was then used to complete the corneal valve incision A cystitome was bent and created using a tuberculin syringe needle It was placed in the anterior chamber of the eye A continuous curvilinear capsulorrhexis was begun It was completed using O Gawa Utrata forceps A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus The lens nucleus was noted to be freely mobile in the bag The phacoemulsification tip was placed into the anterior chamber of the eye The lens nucleus was phacoemulsified and aspirated in a divide and conquer technique All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports The posterior capsule remained intact throughout the entire procedure Provisc was used to deepen the anterior chamber of the eye A crescent blade was used to expand the internal aspect of the wound The lens was taken from its container and inspected No defects were found The lens power selected was compared with the surgery worksheet from Dr X s office The lens was placed in an inserter under Provisc It was placed through the wound into the capsular bag and extruded gently from the inserter It was noted to be adequately centered in the capsular bag using a Sinskey hook The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique The eye was noted to be inflated without overinflation The wounds were tested for leaks none were found Five drops dilute Betadine solution was placed over the eye The eye was irrigated The speculum was removed The drapes were removed The periocular area was cleaned and dried Maxitrol ophthalmic ointment was placed into the interpalpebral space A semi pressure patch and shield was placed over the eye The patient was taken to the floor in stable and satisfactory condition was given detailed written instructions and asked to follow up with Dr X tomorrow morning in the office Keywords ophthalmology senile nuclear cataract senile phacoemulsification phacoemulsification of cataract lens implant lens nucleus anterior chamber lens alcon eye cataract MEDICAL_TRANSCRIPTION,Description Sample post dilation patient instructions Medical Specialty Ophthalmology Sample Name Post Dilation Instructions Transcription The effects of eye dilation drops will gradually decrease It typically takes TWO to SIX HOURS for the effects to wear off During this time reading may be more difficult and sensitivity to light may increase For a short time wearing sunglasses may help Keywords ophthalmology dilation drops eye dilation sunglasses blindness eye examinations dilation eyesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens insertion Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 6 Transcription PROCEDURE Phacoemulsification with posterior chamber intraocular lens insertion INTRAOCULAR LENS Allergan Medical Optics model S140MB XXX diopter chamber lens PHACO TIME Not known ANESTHESIA Retrobulbar block with local minimal anesthesia care COMPLICATIONS None ESTIMATED BLOOD LOSS None DESCRIPTION OF PROCEDURE While the patient was in the holding area the operative eye was dilated with four sets of drops The drops consisted of Cyclogyl 1 Acular and Neo Synephrine 2 5 Additionally a peripheral IV was established by the anesthesia team Once the eye was dilated the patient was wheeled to the operating suite Inside the operating suite central monitoring lines were established Through the peripheral IV the patient received intravenous sedation consisting of Propofol and once somnolent from this retrobulbar block was administered consisting of 2 cc s of 2 Xylocaine plain with 150 units of Wydase The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained Digital pressure was applied for approximately five minutes The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery A Betadine prep was carried out of the face lids and eye During the draping process care was taken to isolate the lashes A wire lid speculum was inserted to maintain patency of the lids With benefit of the operating microscope a diamond blade was used to place a groove temporally A paracentesis wound was also placed temporally using the same blade Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2 8 mm diamond keratome was used to enter the anterior chamber through the previously placed groove The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty The capsular remnant was withdrawn from the eye using long angled McPherson forceps Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed The lens was noted to rotate freely within the capsular bag The phaco instrument was then inserted into the eye using the Kelman tip The lens nucleus was grooved and broken into two halves One of the halves was in turn broken into quarters Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification Attention was then turned toward the remaining half of the nucleus and this in turn was removed as well with the splitting maneuver Once the nucleus had been removed from the eye the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections Once the cortical material had been completely removed a diamond dusted cannula was inserted into the eye and the posterior capsule was polished Viscoelastic was again instilled into the capsular bag as well as the anterior chamber The wound was enlarged slightly using the diamond keratome The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps Once inside the eye the lens was unfolded into the capsular bag in a single maneuver It was noted to be centered nicely The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine Next Miostat was instilled into the operative eye and the wound was checked for water tightness It was found to be such After removing the drapes and speculum TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye The patient tolerated the procedure extremely well and was taken to the recovery area in good condition The patient is scheduled to be seen in follow up in the office tomorrow but should any complications arise this evening the patient is to contact me immediately Keywords ophthalmology diopter intraocular lens insertio phacoemulsification posterior chamber diamond keratome anterior chamber capsular bag intraocular lens intraocular allergan eye capsular chamber lens MEDICAL_TRANSCRIPTION,Description Phacoemulsification of cataract and posterior chamber lens implant right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 4 Transcription OPERATION PERFORMED Phacoemulsification of cataract and posterior chamber lens implant right eye ANESTHESIA Retrobulbar nerve block right eye DESCRIPTION OF OPERATION The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon Once anesthesia was achieved the right eye was prepped with Betadine rinsed with saline and draped in a sterile fashion A lid speculum was placed and 4 0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe A fornix based conjunctival flap was prepared superiorly from 10 to 12 o clock and episcleral vessels were cauterized using a wet field A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o clock position A lamellar dissection was carried anteriorly to clear cornea using a crescent knife A stab incision was applied with a Superblade at the 2 o clock position at the limbus The chamber was also entered through the lamellar groove using a 3 mm keratome in a beveled fashion Viscoat was injected into the chamber and an anterior capsulorrhexis performed Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side port incision A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants Each quadrant was emulsified under burst power within the capsular bag The epinuclear bowl was manipulated with vacuum flipped into the iris plane and emulsified under pulse power I A was used to aspirate cortex from the capsular bag A scratcher was used to polish the capsule and Viscoat was injected inflating the capsular bag and chamber The wound was enlarged with a shortcut blade to 5 5 mm The intraocular lens was examined found to be adequate irrigated with balanced salt and inserted into the capsular bag The lens centralized nicely and Viscoat was removed using the I A Balanced salt was injected through the side port incision The wound was tested found to be secure and a single 10 0 nylon suture was applied to the wound with the knot buried within the sclera The conjunctiva was pulled over the suture and Ancef 50 mg and Decadron 4 mg were injected sub Tenon in the inferonasal and inferotemporal quadrants Maxitrol ointment was applied topically followed by an eye pad and shield The patient tolerated the procedure and was taken from the operating room in good condition Keywords ophthalmology retrobulbar nerve block posterior chamber lens implant phacoemulsification of cataract lens implantation capsular bag cataract phacoemulsification nucleus capsular lens eye MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens implant in the right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 7 Transcription TITLE OF OPERATION Phacoemulsification with posterior chamber intraocular lens implant in the right eye INDICATION FOR SURGERY The patient is a 27 year old male who sustained an open globe injury as a child He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye PREOP DIAGNOSIS 1 History of open globe to the right eye 2 History of retinal detachment status post repair in the right eye 3 Silicone oil in anterior chamber 4 Dense silicone oil cataract in the right eye obscuring the view of the posterior pole POSTOP DIAGNOSIS 1 History of open globe to the right eye 2 History of retinal detachment status post repair in the right eye 3 Silicone oil in anterior chamber 4 Dense silicone oil cataract in the right eye obscuring the view of the posterior pole ANESTHESIA General PROS DEV IMPLANT ABC Laboratories posterior chamber intraocular lens 21 0 diopters serial number 123456 NARRATIVE Informed consent was obtained All questions were answered The patient was brought to preoperative holding area where the operative right eye was marked He was brought to the operating room and placed in the supine position EKG leads were placed General anesthesia was induced by the anesthesia service A time out was called to confirm the procedure and operative eye The right operative eye was disinfected and draped in a standard fashion for eye surgery A lid speculum was placed The vitreoretinal team placed the infusion cannula after performing a peritomy At this point in the case the patient was turned over to the cornea service with Mrs Jun A paracentesis was made at the approximately 3 o clock position Healon was placed into the anterior chamber The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108 degree axis This incision was then shelved anteriorly and used to enter the anterior chamber The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome Hydrodissection was performed The lens nucleus was removed using phacoemulsification and irrigation and aspiration Lens cortex also was removed using irrigation and aspiration Viscoelastic was placed to inflate the capsular remnant The diamond knife was used to enlarge the phaco incision Intraocular lens was selected from preoperative calculations placed in the injector system and inserted into the capsule without difficulty The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber This was done without difficulty The anterior chamber was secured and watertight at the end of the procedure Intraocular pressure was satisfactory The patient tolerated the procedure well and then was turned over to the retina service in good condition They will dictate a separate note Keywords ophthalmology phacoemulsification intraocular lens implant posterior chamber chamber eye intraocular lens MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification of cataract with posterior chamber intraocular lens right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Of Cataract 2 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Phacoemulsification of cataract with posterior chamber intraocular lens right eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE IN DETAIL The patient was identified The operative eye was treated with tetracaine 1 topically in the preoperative holding area The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery Attention was turned to the left right eye The lashes were tapped using Steri Strips to prevent blinking A lid speculum was placed to prevent lid closure Anesthesia was verified Then a 3 5 mm groove was created with a diamond blade temporarily This was beveled with a crescent blade and the anterior chamber was entered with a 3 2 mm keratome in the iris plane A 1 nonpreserved lidocaine was injected intracamerally and followed with Viscoat A paracentesis was made A round capsulorrhexis was performed The anterior capsular flap was removed Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique The irrigating aspirating machine was used to clear residual cortex The Provisc was instilled An SN60WS diopter intraocular lens was inserted into the capsular bag and the position was verified The viscoelastic was removed Intraocular lens remained well centered The incision was hydrated and the anterior chamber pressure was checked with tactile pressure and found to be normal The anterior chamber remained deep and there was no wound leak The patient tolerated the procedure well The eye was dressed with Maxitrol ointment A tight patch and Fox shield were placed The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain Keywords ophthalmology cataract posterior chamber intraocular lens hydrodelineation phacoemulsification of cataract phacoemulsification lens anterior chamber eye intraocular MEDICAL_TRANSCRIPTION,Description Right phacoemulsification of cataract with intraocular lens implantation Cataract right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification of Cataract Transcription PREOPERATIVE DIAGNOSIS ES Cataract right eye POSTOPERATIVE DIAGNOSIS ES Cataract right eye PROCEDURE Right phacoemulsification of cataract with intraocular lens implantation DESCRIPTION OF THE OPERATION Under topical anesthesia with monitored anesthesia care the patient was prepped draped and positioned under the operating microscope A lid speculum was applied to the right eye and a stab incision into the anterior chamber was done close to the limbus at about the 1 o clock position with a Superblade and Xylocaine 1 preservative free 0 25 mL was injected into the anterior chamber which was then followed by Healon to deepen the anterior chamber Using a keratome another stab incision was done close to the limbus at about the 9 o clock position and with the Utrata forceps anterior capsulorrhexis was performed and the torn anterior capsule was totally removed Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS The tip of the phaco unit was introduced into the anterior chamber and anterior sculpting of the nucleus was performed until about more than two thirds of the nucleus was removed Using the phaco tip and the Drysdale hook the nucleus was broken up into 4 pieces and then phacoemulsified The phaco tip was then exchanged for the aspiration irrigation tip and cortical materials were aspirated Posterior capsule was polished with a curette polisher and Healon was injected into the capsular bag Using the Monarch intraocular lens inserter the posterior chamber intraocular lens model SN60WF power 19 50 was placed into the inserter after applying some Healon and the tip of the inserter was gently introduced through the cornea tunnel wound into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument Intraocular lens was then rotated about half a turn with a collar button hook Healon was removed with the aspiration irrigation tip and balanced salt solution was injected through the side port to deepen the anterior chamber It was found that there was no leakage of fluid through the cornea tunnel wound For this reason no suture was applied Vigamox Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield The patient tolerated the procedure well There were no complications Keywords ophthalmology cataract implantation intraocular intraocular lens lens implantation phacoemulsification capsular bag capsule intraocular lens implantation cornea tunnel wound phacoemulsification of cataract cornea tunnel anterior chamber anesthesia cornea lens chamber MEDICAL_TRANSCRIPTION,Description Phacoemulsification with IOL right eye Cataract right eye A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o clock position through which 2 preservative free Xylocaine was injected followed by Viscoat Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 5 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye OPERATION PERFORMED Phacoemulsification with IOL right eye ANESTHESIA Topical with MAC COMPLICATIONS None ESTIMATED BLOOD LOSS None PROCEDURE IN DETAIL After appropriate consent was obtained the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o clock position through which 2 preservative free Xylocaine was injected followed by Viscoat A 2 75 mm keratome then made a stab incision at the 2 o clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata BSS on blunt cannula hydrodissector and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I A Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I A which then removed all remaining cortex as well as viscoelastic material BSS on blunt cannula hydrated all wounds which were noted to be free of leak and lid speculum was removed Under microscope the anterior chamber being soft and well formed Pred Forte Vigamox and Iopidine were placed in the eye A shield was placed over the eye The patient was followed to recovery where he was noted to be in good condition Keywords ophthalmology lid speculum lens iol viscoat posterior capsule cataract speculum incision phacoemulsification MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens placement right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 3 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Phacoemulsification with intraocular lens placement right eye ANESTHESIA Monitored anesthesia care ESTIMATED BLOOD LOSS None COMPLICATIONS None SPECIMENS None PROCEDURE IN DETAIL The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye The patient had the risks and benefits of surgery discussed After discussion the patient decided to proceed and the consent was signed On the day of surgery the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed Following this the patient was sterilely prepped and draped in the usual fashion After this a lid speculum was placed preservative free lidocaine drops were placed and the SuperSharp blade was used to make an anterior chamber paracentesis Preservative free lidocaine was instilled into the anterior chamber and then Viscoat was instilled into the eye The 3 0 diamond keratome was then used to make a clear corneal temporal incision Following this the cystotome was used to make a continuous tear type capsulotomy After this BSS was used to hydrodissect and hydrodelineate the lens The phacoemulsification unit was used to remove the cataract The I A unit was used to remove the residual cortical material Following this Provisc was used to inflate the bag The lens a model SA60AT of ABCD diopters serial 1234 was inserted into the bag and rotated into position using the Lester pusher After this the residual Provisc was removed Michol was instilled and then the corneal wound was hydrated with BSS and the wound was found to be watertight The lid speculum was removed Acular and Vigamox drops were placed The patient tolerated the procedure well without complications and will be followed up in the office tomorrow Keywords ophthalmology capsulotomy diopters intraocular lens placement lid speculum anterior chamber phacoemulsification lens cataract intraocular MEDICAL_TRANSCRIPTION,Description Phacoemulsification with intraocular lens placement A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 2 Transcription PROCEDURE PERFORMED Phacoemulsification with intraocular lens placement ANESTHESIA TYPE Topical COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo Synephrine eye drops Topical anesthetic drops were applied to the eye just prior to entering the operating room The eye was then prepped with a 5 Betadine solution injected in the usual sterile fashion A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade Lidocaine 1 preservative free 0 1 cc was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber A 2 8 mm keratome was used to create a self sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap The Utrata forceps were used to complete a continuous tear capsulorrhexis and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula Phacoemulsification in a quartering and cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit The capsular bag was re expanded with viscoelastic and then the wound was opened to a 3 4 mm size to accommodate the intraocular lens insertion using an additional keratome blade The lens was folded inserted into the capsular bag and then unfolded The trailing haptic was tucked underneath the anterior capsular rim The lens was shown to center very well The viscoelastic was removed with the irrigation and aspiration unit and one 10 0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction The wound was shown to be watertight Therefore TobraDex ointment was applied to the eye an eye pad loosely applied and a Fox shield taped firmly in place over the eye The patient tolerated the procedure well and left the operating room in good condition Keywords ophthalmology keratome phacoemulsification cortex tobradex intraocular lens aspiration unit topical chamber viscoelastic corneal capsular lens intraocular eye MEDICAL_TRANSCRIPTION,Description Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation Cataract right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction 4 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation ME 30 AC 25 0 diopter lens was used COMPLICATIONS None ANESTHESIA Local 2 peribulbar lidocaine PROCEDURE NOTE Right eye was prepped and draped in the normal sterile fashion Lid speculum placed in his right eye Paracentesis made supratemporally Viscoat injected into the anterior chamber A 2 8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed Nuclear material removed via phacoemulsification Residual cortex removed via irrigation and aspiration The posterior capsule was clear and intact Capsular bag was then filled with Provisc solution The wound was enlarged to 3 5 mm with the keratoma The lens was folded in place into the capsular bag Residual Provisc was irrigated from the eye The wound was secured with one 10 0 nylon suture The lid speculum was removed One drop of 5 povidone iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment He had a patch placed on it The patient was transported to the recovery room in stable condition Keywords ophthalmology provisc intraocular lens implantation intraocular lens lens implantation lid speculum capsular bag cataract extraction phacoemulsification cataract intraocular MEDICAL_TRANSCRIPTION,Description Visually significant cataract left eye Phacoemulsification cataract extraction with intraocular lens implantation left eye The patient was found to have a visually significant cataract and after discussion of the risks benefits and alternatives to surgery she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction 1 Transcription PREOPERATIVE DIAGNOSIS Visually significant cataract left eye POSTOPERATIVE DIAGNOSIS Visually significant cataract left eye ANESTHESIA Topical MAC PROCEDURE Phacoemulsification cataract extraction with intraocular lens implantation left eye Alcon AcrySof SN60AT 23 0 D serial COMPLICATIONS None INDICATIONS FOR SURGERY The patient is a 74 year old woman with complaints of painless progressive loss of vision in her left eye She was found to have a visually significant cataract and after discussion of the risks benefits and alternatives to surgery she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision PROCEDURE IN DETAIL The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart They were transported to the operative suite accompanied by the anesthesia service where appropriate cardiopulmonary monitoring was established MAC anesthesia was achieved which was followed by topical anesthesia using 1 preservative free tetracaine eye drops The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed Two stab incision paracenteses were made in the cornea using the MVR blade and the anterior chamber was irrigated with 1 preservative free lidocaine for intracameral anesthesia The anterior chamber was filled with viscoelastic and a shelved temporal clear corneal incision was made using the diamond groove knife and steel keratome A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent needle cystotome The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution BSS on a Chang cannula until it rotated freely The phacoemulsification handpiece was introduced into the anterior chamber and the lens nucleus was sculpted into 2 halves Each half was further subdivided with chopping and removed with phacoemulsification The remaining cortical material was removed with the irrigation and aspiration I A handpiece The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty The remaining viscoelastic was removed with the I A handpiece and the anterior chamber was filled to an appropriate intraocular pressure with BSS The corneal wounds were hydrated and verified to be water tight Antibiotic ointment was placed followed by a patch and shield The patient was transported to the PACU in good stable condition There were no complications Followup is scheduled for tomorrow morning in the eye clinic A single interrupted 10 0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case Keywords ophthalmology intraocular lens implantation eye intraocular lens lens implantation cataract extraction cataract intraocular viscoelastic handpiece implantation surgery chamber phacoemulsification extraction visually anterior lens MEDICAL_TRANSCRIPTION,Description Cataract nuclear sclerotic right eye Phacoemulsification with intraocular lens implantation right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation Transcription PREOPERATIVE DIAGNOSIS Cataract nuclear sclerotic right eye POSTOPERATIVE DIAGNOSIS Cataract nuclear sclerotic right eye OPERATIVE PROCEDURES Phacoemulsification with intraocular lens implantation right eye ANESTHESIA Topical tetracaine intracameral lidocaine monitored anesthesia care IOL AMO Model SI40 NB power diopters INDICATIONS FOR SURGERY This patient has been experiencing difficulty with eyesight regarding activities in their daily life There has been a progressive and gradual decline in the visual acuity By examination this was found to be related to cataracts The risks benefits and alternatives including observation or spectacles were discussed in detail The patient accepted these risks and elected to proceed with cataract surgery All questions were answered and informed consent was obtained Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals risks and alternatives involved as well as the postoperative instructions A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery To minimize and decrease the chance of bacterial infection the patient was started on a course of antibiotic drops for two days prior to surgery DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified The pupil was dilated per protocol The patient was taken to the operating room and placed in a comfortable supine position The operative table was placed in Trendelenburg head up tilt to decrease orbital congestion and posterior vitreous pressure The patient was prepped and draped in the usual ophthalmic sterile fashion The lids and periorbita were prepped with full strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins The conjunctival cul de sac was also prepped in dilute Betadine solution The fornices were also prepped The drape was done meticulously to ensure complete eyelash inclusion An eyelid speculum was placed to separate the eyelids A paracentesis site was made Intracameral preservative free lidocaine was injected Amvisc Plus was then used to stabilize the anterior chamber A 3 mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location A 25 gauge pre bent cystotome was used to begin a capsulorrhexis The capsular flap was removed A 27 gauge blunt cannula was used for hydrodissection The lens was able to be freely rotated within the capsular bag Divide and conquer technique was used for phacoemulsification After four sculpted grooves were made a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment Each of the four nuclear quadrants was phacoemulsified Aspiration was used to remove remaining cortex with the I A handpiece Viscoelastic was used to re inflate the capsular bag The intraocular lens was injected into the capsular bag The lens was then dialed into position The lens was well centered and stable Viscoelastic was aspirated BSS was used to re inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration A Weck Cel sponge was used to check both incision sites for leaks and none were identified The incision sites remained well approximated and dry with a well formed anterior chamber and well centered intraocular lens The eyelid speculum was removed and the patient was cleaned free of Betadine Zymar and Pred Forte drops were applied A firm eye shield was taped over the operative eye The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well Discharge instructions regarding activity restrictions eye drop use eye shield patch wearing and driving restrictions were discussed All questions were answered The discharge instructions were also reviewed with the patient by the discharging nurse The patient was comfortable and was discharged with followup in 24 hours Keywords ophthalmology nuclear sclerotic diopters viscoelastic capsulorrhexis amvisc plus lens implantation intraocular lens intraocular topical cataract phacoemulsification lens MEDICAL_TRANSCRIPTION,Description Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction Transcription DIAGNOSIS Nuclear sclerotic and cortical cataract right eye OPERATION Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation right eye PROCEDURE The patient was taken to the operating room and placed on the table in the supine position Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff Local anesthesia was obtained using 2 lidocaine 0 75 Marcaine 0 5 cc Wydase with 6 cc of this solution used in a paribulbar injection followed by ten minutes of digital massage The patient was then prepped and draped in the usual sterile fashion for eye surgery With the Zeiss operating microscopy in position a lid speculum was inserted and a 4 0 black silk bridal suture placed in the superior rectus muscle With Westcott scissors a fornix based conjunctival flap was made The surgical limbus was identified and hemostasis obtained with wet field cautery With a 57 Beaver blade a corneoscleral groove was made and shelved into clear cornea A stab incision was made at 2 o clock with a 15 degree blade With a 3 0 mm keratome the shelved groove was attended into the anterior chamber Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous tear technique Hydrodissection was performed with Balanced Salt Solution Phacoemulsification was performed in a two headed nuclear fracture technique The remaining cortical material was removed with irrigation and aspiration handpiece The posterior capsule remained intact and vacuumed with minimal suction The posterior chamber intraocular lens was obtained It was inspected irrigated inserted into the posterior chamber without difficulty Inspection revealed the intraocular lens to be in good position with intact capsule and well approximated wound There was no aqueous leak even with digital pressure The conjunctiva was pulled back into position with wet field cautery A subconjunctival injection with 20 mg Gatamycine and 0 5 cc Celestone was given Tobradex ointment was instilled into the eye which was patched and shielded appropriately after removing the lid speculum and bridle suture The patient tolerated the procedure well and was sent to the recovery room in good condition to be followed in attending physician office the next day Keywords ophthalmology extracapsular cataract extraction phacoemulsification nuclear sclerotic cortical cataract extraction with intraocular lens cataract extraction intraocular lens intraocular extracapsular implantation conjunctival cataract chamberNOTE MEDICAL_TRANSCRIPTION,Description Visually significant nuclear sclerotic cataract right eye Phacoemulsification with posterior chamber intraocular lens implantation right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Lens Implantation 1 Transcription PREOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye POSTOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye OPERATIVE PROCEDURES Phacoemulsification with posterior chamber intraocular lens implantation right eye ANESTHESIA Monitored anesthesia care with retrobulbar block consisting of 2 lidocaine in an equal mixture with 0 75 Marcaine and Amphadase INDICATIONS FOR SURGERY This patient has been experiencing difficulty with eyesight regarding activities of daily living There has been a progressive and gradual decline in the visual acuity The cataract was believed related to her decline in vision The risks benefits and alternatives including with observation or spectacles were discussed in detail The risks as explained included but are not limited to pain bleeding infection decreased or loss of vision loss of eye retinal detachment requiring further surgery and possible consultation out of town swelling of the back part of the eye retina need for prolonged eye drop use or injections instability of the lens and loss of corneal clarity necessitating long term drop use or further surgery The possibility of needing intraocular lens exchange or incorrect lens power was discussed Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed It was explained that some or all of these complications might arise at the time of or months to years after surgery The patient had a good understanding of the risks with the proposed elective eye surgery The patient accepted these risks and elected to proceed with cataract surgery All questions were answered and informed consent was signed and placed in the chart DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified The pupil was dilated per protocol The patient was taken to the operating room and placed in the supine position After intravenous sedation the retrobulbar block was injected followed by several minutes of digital massage No signs of orbital tenseness or retrobulbar hemorrhage were present The patient was prepped and draped in the usual ophthalmic sterile fashion An eyelid speculum was used to separate the eyelids A crescent blade was used to make a clear corneal temporally located incision A 1 mm Dual Bevel blade was used to make a paracentesis site The anterior chamber was filled with viscoelastic Viscoat The crescent blade was then used to make an approximate 2 mm long clear corneal tunnel through the temporal incision A 2 85 mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision A 25 gauge pre bent cystotome used to begin a capsulorrhexis The capsulorrhexis was completed with the Utrata forceps A 27 guage needle was used for hydrodissection and three full and complete fluid waves were noted The lens was able to be freely rotated within the capsular bag Divide and conquer ultrasound was used for phacoemulsification After four sculpted grooves were made a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment Each of the four nuclear quadrants was phacoemulsified Aspiration was used to remove all remaining cortex Viscoelastic was used to re inflate the capsular bag An AMO model SI40NB posterior chamber intraocular lens with power diopters and serial number was injected into the capsular bag The trailing haptic was placed with the Sinskey hook The lens was made well centered and stable Viscoelastic was aspirated BSS was used to re inflate the anterior chamber to an adequate estimated intraocular pressure A Weck Cel sponge was used to check both incision sites for leaks and none were identified The incision sites remained well approximated and dry with a well formed anterior chamber and eccentric posterior chamber intraocular lens The eyelid speculum was removed and the patient was cleaned free of Betadine Vigamox and Econopred drops were applied A soft eye patch followed by a firm eye shield was taped over the operative eye The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well Discharge instructions regarding activity restrictions eye drop use eye shield patch wearing and driving restrictions were discussed All questions were answered The discharge instructions were also reviewed with the patient by the discharging nurse The patient was comfortable and was discharged with followup in 24 hours Complications none Keywords ophthalmology retrobulbar block posterior chamber intraocular lens nuclear sclerotic cataract cataract lens implantation posterior chamber anterior chamber intraocular lens lens eye intraocular anesthesia phacoemulsification retrobulbar MEDICAL_TRANSCRIPTION,Description Nuclear sclerotic cataract right eye Kelman phacoemulsification with posterior chamber intraocular lens right eye Medical Specialty Ophthalmology Sample Name Phacoemulsification Kelman Transcription PREOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye POSTOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye OPERATIVE PROCEDURES Kelman phacoemulsification with posterior chamber intraocular lens right eye ANESTHESIA Topical COMPLICATIONS None INDICATION This is a 40 year old male who has been noticing problems with blurry vision They were found to have a visually significant cataract The risks benefits and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the operating room A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion A paracentesis was created at o clock The anterior chamber was filled with Viscoat A clear corneal incision was made at o clock with the 3 mm diamond blade A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps The lens was hydrodissected with a syringe filled with 2 Xylocaine and found to rotate freely within the capsular bag The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion The residual cortex was removed with the irrigation aspiration handpiece The capsular bag was filled with Provisc and a model SI40 15 0 diopter posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well The residual Provisc was removed with the irrigation aspiration handpiece The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution The wounds were found to be free from leak Zymar and Pred Forte were instilled postoperatively The eye was covered with the shield The patient tolerated the procedure well and there were no complications He will follow up with us in one day Keywords ophthalmology nuclear sclerotic cataract intraocular lens cataract kelman phacoemulsification sclerotic cataract posterior chamber capsular bag eye anesthesia phacoemulsification MEDICAL_TRANSCRIPTION,Description Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation An Alcon MA30BA lens was used A lid speculum was placed into the right eye Paracentesis was made at the infratemporal quadrant Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction 5 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye PROCEDURE PERFORMED Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation An Alcon MA30BA lens was used diopters ANESTHESIA Topical 4 lidocaine with 1 nonpreserved intracameral lidocaine COMPLICATIONS None PROCEDURE Prior to surgery the patient was counseled as to the risks benefits and alternatives of the procedure with risks including but not limited to bleeding infection loss of vision loss of the eye need for a second surgery retinal detachment and retinal swelling The patient understood the risks clearly and wished to proceed The patient was brought into the operating suite after being given dilating drops Topical 4 lidocaine drops were used The patient was prepped and draped in the normal sterile fashion A lid speculum was placed into the right eye Paracentesis was made at the infratemporal quadrant This was followed by 1 nonpreservative lidocaine into the anterior chamber roughly 250 microliters This was exchanged for Viscoat solution Next a crescent blade was used to create a partial thickness linear groove at the temporal limbus This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps Balanced salt solution was used to hydrodissect the nucleus Nuclear material was removed via phacoemulsification with divide and conquer technique The residual cortex was removed via irrigation and aspiration The capsular bag was then filled with Provisc solution The wound was slightly enlarged The lens was folded and inserted into the capsular bag Residual Provisc solution was irrigated out of the eye The wound was stromally hydrated and noted to be completely self sealing At the end of the case the posterior capsule was intact The lens was well centered in the capsular bag The anterior chamber was deep The wound was self sealed and subconjunctival injections of Ancef dexamethasone and lidocaine were given inferiorly Maxitrol ointment was placed into the eye The eye was patched with a shield The patient was transported to the recovery room in stable condition to follow up the following morning Keywords ophthalmology alcon phacoemulsification cataract extraction cataract intraocular lens implantation anterior chamber provisc solution capsular bag topical intraocular MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens insertion right eye A wire lid speculum was inserted to keep the eye open and the eye rotated downward Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction 3 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye ANESTHESIA Retrobulbar block COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the operating room where retrobulbar anesthesia was induced The patient was then prepped and draped using standard procedure A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0 12 The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome The chamber was then filled with viscoelastic and a continuous tear capsulorrhexis performed The phacoemulsification was then instilled in the eye and a linear incision made in the lens The lens was then cracked with a McPherson forceps and the remaining lens material removed with the phacoemulsification tip The remaining cortex was removed with an I A The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome The folding posterior chamber lens was then inserted in the capsular bag and rotated into position The remaining viscoelastic was removed from the eye with the I A The wound was checked for watertightness and found to be watertight Tobramycin drops were instilled in the eye and a shield placed over it The patient tolerated the procedure well Keywords ophthalmology tobramycin limbal lid speculum intraocular lens capsular bag eye phacoemulsification lens intraocular MEDICAL_TRANSCRIPTION,Description Cataract right eye Phacoemulsification with intraocular lens insertion right eye The patient was then prepped and draped using standard procedure An additional drop of tetracaine was instilled in the eye and then a lid speculum was inserted Medical Specialty Ophthalmology Sample Name Phacoemulsification Cataract Extraction 2 Transcription PREOPERATIVE DIAGNOSIS Cataract right eye POSTOPERATIVE DIAGNOSIS Cataract right eye TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the operating room where tetracaine drops were instilled in the eye The patient was then prepped and draped using standard procedure An additional drop of tetracaine was instilled in the eye and then a lid speculum was inserted The eye was rotated downward and a crescent blade used to make an incision at the limbus This was then dissected forward approximately 1 mm and then a keratome was used to enter the anterior chamber The anterior chamber was filled with 1 preservative free lidocaine and the lidocaine was then replaced with Provisc A cystotome was used to make a continuous tear capsulorrhexis and then the capsular flap was removed with the Utrata forceps The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco This was aided by cracking the lens nucleus with McPherson forceps The remaining cortex was removed from the eye with the I A The capsular bag was then polished with the I A on capsular bag The bag was inflated using viscoelastic and then the wound extended slightly with a keratome A folding posterior chamber lens was inserted and rotated into position using McPherson forceps The I A was then placed in the eye again and the remaining viscoelastic removed The wound was checked for watertightness and found to be watertight TobraDex drops were instilled in the eye and a shield was placed over it The patient tolerated the procedure well and was brought to recovery in good condition Keywords ophthalmology tetracaine intraocular lens lid speculum mcpherson forceps capsular bag eye phacoemulsification cataract lens intraocular MEDICAL_TRANSCRIPTION,Description Ophthalmology followup visit note Medical Specialty Ophthalmology Sample Name Ophthalmology Progress Note 2 Transcription A fluorescein angiogram was ordered at today s visit to rule out macular edema We have asked her to return in one to two weeks time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress A copy of the angiogram is enclosed for your records Keywords ophthalmology visual acuities 78 diopter lens extraocular muscle movement afferent angiogram applanation detachment dilated fundus examination fluorescein hemorrhages intraocular intraocular lenses left eye posterior chamber pupillary retinopathy right eye slit lamp lensesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Phacoemulsification with posterior chamber intraocular lens Sample Template Medical Specialty Ophthalmology Sample Name Phacoemulsification Transcription PREOPERATIVE DIAGNOSIS Senile cataract OX POSTOPERATIVE DIAGNOSIS Senile cataract OX PROCEDURE Phacoemulsification with posterior chamber intraocular lens OX model SN60AT for Acrysof natural lens XXX diopters INDICATIONS This is a XX year old wo man with decreased vision OX PROCEDURE The risks and benefits of cataract surgery were discussed at length with the patient including bleeding infection retinal detachment re operation diplopia ptosis loss of vision and loss of the eye Informed consent was obtained On the day of surgery s he received several sets of drops in the XXX eye including 2 5 phenylephrine 1 Mydriacyl 1 Cyclogyl Ocuflox and Acular S he was taken to the operating room and sedated via IV sedation 2 lidocaine jelly was placed in the XXX eye or retrobulbar anesthesia was performed using a 50 50 mixture of 2 lidocaine and 0 75 marcaine The XXX eye was prepped using a 10 Betadine solution S he was covered in sterile drapes leaving only the XXX eye exposed A Lieberman lid speculum was placed to provide exposure The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 or 11 depending upon side and handedness and assuming superior incision o clock Then 1 lidocaine was injected through the paracentesis After the nonpreserved lidocaine was injected Viscoat was injected through the paracentesis to fill the anterior chamber The Thornton fixation ring and a 2 75 mm keratome blade were used to create a two step full thickness clear corneal incision superiorly The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule BSS on a hydrodissection cannula was used to perform gentle hydrodissection Phacoemulsification was then performed to remove the nucleus I A was performed to remove the remaining cortical material Provisc was injected to fill the capsular bag and anterior chamber A XXX diopter SN60AT for Acrysof natural lens intraocular lens was injected into the capsular bag The Kuglen hook was used to rotate it into proper position in the capsular bag I A was performed to remove the remaining Viscoelastic material from the eye BSS on the 30 gauge cannula was used to hydrate the wound The wounds were checked and found to be watertight The lid speculum and drapes were carefully removed Several drops of Ocuflox were placed in the XXX eye The eye was covered with an eye shield The patient was taken to the recovery area in a good condition There were no complications Keywords ophthalmology phacoemulsification acrysof acrysof natural lens acular kuglen hook ocuflox provisc sn60at senile cataract thornton fixation ring bleeding capsular bag decreased vision diopters diplopia infection loss of the eye loss of vision ptosis retinal detachment lid speculum thornton fixation anterior chamber intraocular lens intraocular chamber lidocaine MEDICAL_TRANSCRIPTION,Description Woman with a history of macular degeneration PDT therapy Some vision therapy Complete refractive work up Medical Specialty Ophthalmology Sample Name Optometry Letter Transcription RE Sample Patient Dear Dr Sample Sample Patient was seen at the Vision Rehabilitation Institute on Month DD YYYY She is an 87 year old woman with a history of macular degeneration who admits to having PDT therapy within the last year She would like to get started with some vision therapy so that she may be able to perform her everyday household chores as well as reading small print At this time she uses a small handheld magnifier which is providing her with only limited help A complete refractive work up was performed today in which we found a mild change in her distance correction which allowed her the ability to see 20 70 in the right eye and 20 200 in the left eye With a pair of 4 reading glasses she was able to read 0 5M print quite nicely I have loaned her a pair of 4 reading glasses at this time and we have started her with fine detailed reading She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her I think that she is an excellent candidate for low vision help I am sure that we can be of great help to her in the near future Thank you for allowing us to share in the care of your patient With best regards Sample Doctor O D Keywords ophthalmology optometry letter optometry letter pdt therapy distance correction macular degeneration reading glasses vision therapy complete refractive macular degeneration MEDICAL_TRANSCRIPTION,Description Patient being referred for evaluation of glaucoma Medical Specialty Ophthalmology Sample Name Ophthalmology Letter 2 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your kind referral for patient ABC Mr ABC is being referred for evaluation of glaucoma The patient states he has no visual complaints On examination the patient s visual acuity is 20 20 bilaterally The patient s visual fields are full to confrontation Extraocular muscles are intact There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally On slit lamp examination the patient has a normal anterior segment with 1 nuclear sclerosis On dilated examination the patient has a cup to disc ratio in the right eye of 0 4 Macula vessels and periphery were within normal limits On the left eye the patient has a cup to disc ratio of 0 3 and macula vessels and periphery are also within normal limits On gonioscopy the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees In conclusion my initial impression is that Mr ABC does not have glaucoma He has fairly symmetric and small cup to disc ratios OU His intraocular pressures were within normal limits in our office today I discussed at length with him the alternatives of observation versus continued work up and testing He seemed to understand very well and went with my recommendation to continue observation for now We will take fundus photos of his optic nerves for future comparison but I think given the lack of any strong findings suspicious for glaucoma we will defer further testing at this time Should you have any specific questions or any other information that you think that I may not have included in this evaluation please feel free to contact me I have recommended him to follow up with you for continued examination continued check ups and should you find any other abnormal findings I would be happy to address those again Again thank you for your referral of Mr ABC Sincerely Keywords ophthalmology cup to disc ratio referred for evaluation cup to disc disc ratio macula vessels pressures eye macula vessels visual cup disc glaucoma examination intact MEDICAL_TRANSCRIPTION,Description Patient referred for narrow angles and possible associated glaucoma Medical Specialty Ophthalmology Sample Name Ophthalmology Letter 3 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear XYZ Thank you very much for your kind referral of Mrs ABC who you referred to me for narrow angles and possible associated glaucoma I examined Mrs ABC initially on MM DD YYYY At that time she expressed a chief concern of occasional pain around her eye but denied any flashing lights floaters halos or true brow ache She reports a family history of glaucoma in her mother but is unsure of the specific kind Her past ocular history has been fairly unremarkable As you know she has a history of non insulin dependent diabetes She is unaware of her last hemoglobin A1c levels but reports a blood sugar of 158 taken on the morning of her appointment with me She is followed by Dr X here locally Upon examination her visual acuity measured 20 20 1 in either eye with her glasses Presenting intraocular pressures were14 mmHg in either eye at 2 03 p m Pupillary reactions confrontational visual fields and ocular motility were normal The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye but the angle deepened with gonio compression suggesting appositional and not synechial closure I deferred the dilated portion of the exam on that day We proceeded with peripheral iridectomies and following this upon her most recent visit on MM DD YYYY I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent I note that she has an increased CD ratio measuring 0 65 in the right eye and 0 7 in the left and although her FDT visual fields and GDX testing were normal at your office she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes Therefore I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past In summary Mrs ABC has a history of narrow angles not successfully treated with laser PIs Her intraocular pressures have remained stable I will continue to monitor her closely Thank you very much once again for allowing me to have shared in her care If I can provide any additional information or be of further service do let me know Sincerely Keywords ophthalmology intraocular pressures narrow angles visual fields angles intraocular pressures anterior chambers gonioscopy glaucoma narrow visual eye MEDICAL_TRANSCRIPTION,Description The patient was referred for evaluation of cataracts bilaterally Medical Specialty Ophthalmology Sample Name Ophthalmology Letter 1 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your referral of patient ABC The patient was referred for evaluation of cataracts bilaterally On examination the patient was seeing 20 40 in her right eye and 20 50 in the left eye Extraocular muscles were intact visual fields were full to confrontation OU and applanations are 12 mmHg bilaterally There is no relative afferent pupillary defect On slit lamp examination lids and lashes were within normal limits The conj is quiet The cornea shows 1 guttata bilaterally The AC is deep and quiet and irises are within normal limits bilaterally There is a dense 3 to 4 nuclear sclerotic cataract in each eye On dilated fundus examination cup to disc ratio is 0 1 OU The vitreous macula vessels and periphery all appear within normal limits Impression It appears that Ms ABC visual decline is caused by bilateral cataracts She would benefit from having removed The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly I will keep you up to date of her progress and any new findings as we perform her surgery in each eye Again thank you for your kind referral of this kind lady and I will be in touch with you Sincerely Keywords ophthalmology extraocular applanations slit lamp visual field visual guttata surgery cataracts eye MEDICAL_TRANSCRIPTION,Description The patient is being referred for evaluation of diabetic retinopathy Medical Specialty Ophthalmology Sample Name Ophthalmology Letter 4 Transcription XYZ M D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your kind referral for patient ABC The patient is being referred for evaluation of diabetic retinopathy The patient was just diagnosed with diabetes however he does not have any serious visual complaints at this time On examination the patient is seeing 20 40 OD pinholing to 20 20 The vision in the left eye is 20 20 uncorrected Applanation pressures are normal at 17 mmHg bilaterally Visual fields are full to count fingers OU and there is no relative afferent pupillary defect Slit lamp examination was within normal limits other than trace to 1 nuclear sclerosis OU On dilated examination the patient shows a normal cup to disc ratio that is symmetric bilaterally The macula vessels and periphery are also within normal limits In conclusion Mr ABC does not show any evidence of diabetic retinopathy at this time We recommended him to have his eyes dilated once a year I have advised him to follow up with you for his regular check ups Again thank you for your kind referral of Mr ABC and we should check on him once a year at this time Sincerely Keywords ophthalmology pupillary defect cup to disc ratio cup to disc evaluation of diabetic retinopathy referred for evaluation diabetic retinopathy visual dilated retinopathy examination diabetic MEDICAL_TRANSCRIPTION,Description Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty A concurrent vitrectomy and endolaser was performed by the vitreoretinal team Medical Specialty Ophthalmology Sample Name Intraocular Lens Implant Transcription TITLE OF OPERATION 1 Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty 2 A concurrent vitrectomy and endolaser was performed by the vitreoretinal team INDICATION FOR SURGERY The patient is a 62 year old white male who underwent cataract surgery in 09 06 This was complicated by posterior capsule rupture An intraocular lens implant was not attempted He developed corneal edema and a preretinal hemorrhage He is aware of the risks benefits and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye vitrectomy endolaser and penetrating keratoplasty PREOP DIAGNOSIS 1 Preretinal hemorrhage 2 Diabetic retinopathy 3 Aphakia 4 Corneal edema POSTOP DIAGNOSIS 1 Preretinal hemorrhage 2 Diabetic retinopathy 3 Aphakia 4 Corneal edema ANESTHESIA General SPECIMEN 1 Donor corneal swab sent to Microbiology 2 Donor corneal scar rim sent to Eye Pathology 3 The patient s cornea sent to Eye Pathology PROS DEV IMPLANT ABC Laboratories 16 0 diopter posterior chamber intraocular lens serial number 123456 NARRATIVE Informed consent was obtained and all questions were answered The patient was brought to the preoperative holding area where the operative left eye was marked He was brought to the operating room and placed in the supine position EKG leads were placed General anesthesia was induced The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye A lid speculum was placed The posterior segment infusion was placed by the vitreoretinal service Peritomy was performed at the 3 and 9 o clock limbal positions A large Flieringa ring was then sutured to the conjunctival surface using 8 0 silk sutures tied in an interrupted fashion The cornea was then measured and was found to accommodate a 7 5 mm trephine The center of the cornea was marked The keratoprosthesis was identified A 7 5 mm trephine blade was then used to incise the anterior corneal surface This was done after a paracentesis was placed at the 1 o clock position and viscoelastic was used to dissect peripheral anterior synechiae Once the synechiae were freed the above mentioned trephination of the anterior cornea was performed Corneoscleral scissors were then used to excise completely the central cornea The keratoprosthesis was placed in position and was sutured with six interrupted 8 0 silk sutures This was done without difficulty At this point the case was turned over to the vitreoretinal team which will dictate under a separate note At the conclusion of the vitreoretinal procedure the patient was brought under the care of the cornea service The 9 0 Prolene sutures double armed were then placed on each lens haptic loop The keratoprosthesis was removed Prior to this removal scleral flaps were made partial thickness at the 3 o clock and 9 o clock positions underneath the peritomies Wet field cautery also was performed to achieve hemostasis The leading hepatic sutures were then passed through the bed of the scleral flap These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic The trailing hepatic was then placed into the posterior segment of the eye as well The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn These were tied securely into position with the IOL nicely centered At this point the donor cornea punched at 8 25 mm was then brought into the field This was secured with four cardinal sutures The corneal button was then sutured in place using a 16 bite 10 0 nylon running suture The knot was secured and buried after adequate tension was adjusted The corneal graft was watertight Attention was then turned back to the IOL sutures which were locked into position The ends were trimmed The flaps were secured with single 10 0 nylon sutures to the apex and the knots were buried At this point the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition having tolerated the procedure well No complications were noted The attending surgeon Dr X performed the entire procedure No complications of the procedure were noted The intraocular lens was selected from preoperative calculations No qualified resident was available to assist Keywords ophthalmology vitrectomy endolaser keratoplasty intraocular lens implant preretinal hemorrhage scleral flaps intraocular keratoprosthesis chamber implant scleral vitreoretinal lens sutures eye MEDICAL_TRANSCRIPTION,Description Bilateral nasolacrimal probing Tearing eyelash encrustation with probable tear duct obstruction bilateral Distal nasolacrimal duct stenosis with obstruction left and right eye Medical Specialty Ophthalmology Sample Name Nasolacrimal Probing Transcription PREOPERATIVE DIAGNOSES Tearing eyelash encrustation with probable tear duct obstruction bilateral POSTOPERATIVE DIAGNOSES 1 Distal nasolacrimal duct stenosis with obstruction left eye 2 Distal nasolacrimal duct stenosis with obstruction right eye OPERATIVE PROCEDURE Bilateral nasolacrimal probing ANESTHESIA Monitored anesthesia care along with mask sedation INDICATIONS FOR SURGERY This young infant is a 19 month old who has had persistent tearing and mild eyelash encrustation of each eye for many months Conservative measures at home have failed to completely resolve the symptoms He has been placed on previous antibiotics treatment for presumed conjunctivitis Please refer to clinic note for more details Conservative measures at home have failed to resolve the symptoms A nasolacrimal probing was offered as an elective procedure Procedure as well as inherent risks expected outcomes benefits and alternatives including continued observation were discussed with his mother prior to scheduling surgery Again a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure The risks as explained included but were not limited to temporary bleeding persistent symptoms recurrence need for further procedure possible need for future stent placement or repeat probing and anesthesia risk were all discussed Also a rare possibility of errant passage of the nasolacrimal probe was discussed Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome result from surgery No guarantees were offered Informed consent was signed and placed on the chart DESCRIPTION OF PROCEDURE The patient was identified and the procedure was verified Procedure as well as inherent risks were again discussed with parents prior to the procedure After anesthesia was induced in the operating room tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono Pen The pressure on the right was 17 mmHg and on the left was 16 mmHg A punctal dilator was then used to dilate the left superior puncta A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally The probe was advanced until a firm stop of the lacrimal bone was felt The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve There was also some mild stenosis distally but not felt significant The probe was used to navigate through this mild resistance A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency Both probes were removed The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system Patency was confirmed The left upper lid was everted and inspected and was found to be normal Attention was then turned to the right side where the similar procedure through the right superior puncta was performed A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe Again on this side a size 0 Bowman probe was unable to be placed initially to the superior puncta The probe was used to navigate the superior puncta canaliculus and then the probe was rotated superomedially and the probe was advanced Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt The mild resistance was over come at the approximate location of the valve Metal on metal feel confirmed patency through the right naris with a second metal probe At the completion of the procedure all probes were removed Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well Postoperative instructions were provided to the parents by me and the discharging nurse I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily Technique explained and demonstrated Erythromycin ointment to both eyes twice daily for three days Follow up was arranged and he may call with any further questions or concerns Keywords ophthalmology tearing eyelash encrustation tear duct obstruction nasolacrimal duct stenosis nasolacrimal bowman probe distal nasolacrimal duct nasolacrimal probing nasolacrimal duct superior puncta probe obstruction eyelash duct punctal MEDICAL_TRANSCRIPTION,Description Ophthalmology followup visit note Medical Specialty Ophthalmology Sample Name Ophthalmology Progress Note 1 Transcription She is stable at this time and does not require any intervention at today s visit I have asked her to return in six months for a followup dilated examination but would be happy to see her sooner should you or she notice any changes in her vision Keywords ophthalmology visual acuities extraocular muscle intraocular pressure pupils afferent applanation binocular dilated fundus left eye lens movements ophthalmoscope pigmentary retina retinal right eye acuitiesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Repair of upper lid canalicular laceration Sample Template Medical Specialty Ophthalmology Sample Name Lid Laceration Repair Transcription PREOPERATIVE DIAGNOSES 1 XXX upper lid laceration 2 XXX upper lid canalicular laceration POSTOPERATIVE DIAGNOSES 1 XXX upper lid laceration 2 XXX upper lid canalicular laceration PROCEDURES 1 Repair of XXX upper lid laceration 2 Repair of XXX upper lid canalicular laceration ANESTHESIA General SPECIMENS None COMPLICATIONS None INDICATIONS This is a XX year old wo man with XXX eye upper eyelid laceration involving the canaliculus PROCEDURE The risks and benefits of eye surgery were discussed at length with the patient including bleeding infection re operation loss of vision and loss of the eye Informed consent was obtained The patient was brought to the operating room and placed in the supine position where s he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery once the appropriate cardiac and respiratory monitoring was placed on him her and once general endotracheal anesthetic had been administered The patient then had the wound freshened up with Westcott scissors and cotton tip applications Hemostasis was achieved with a high temp disposable cautery Once this had been done the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene The proximal end was then found and this was intubated with the same tubing system Then two 6 0 Vicryl sutures were used to reapproximate the medial canthal tendon Once this had been done the skin was reapproximated with interrupted 6 0 Vicryl sutures and interrupted 6 0 plain gut sutures To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater and the tube was cut short The patient s nose was suctioned of blood and s he was awakened from general endotracheal anesthesia and did well S he left the operating room in good condition Keywords ophthalmology laceration monoka tube westcott scissors bleeding canalicular laceration canthal tendon cotton tip infection lid lid canalicular system lid laceration loss of the eye loss of vision ophthalmic plastic reconstructive surgery re operation upper lid lid laceration repair laceration repair lid canalicular canalicular MEDICAL_TRANSCRIPTION,Description Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position Medical Specialty Ophthalmology Sample Name Electronystagmogram Transcription PROCEDURE This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear FINDINGS Gaze testing did not reveal any evidence of nystagmus Saccadic movements did not reveal any evidence of dysmetria or overshoot Sinusoidal tracking was performed well for the patient s age Optokinetic nystagmus testing was performed poorly due to the patient s difficulty in following the commands Therefore adequate OKNs were not achieved The Dix Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus which was converted to a right beating nystagmus when she sat up again The patient complained of severe dizziness in this position There was no clear cut decremental response with repetition In the head hanging left position no significant nystagmus was identified Positional testing in the supine head hanging head right head left right lateral decubitus and left lateral decubitus positions did not reveal any evidence of nystagmus Caloric stimulation revealed a calculated unilateral weakness of 7 0 on the right normal 20 and left beating directional preponderance of 6 0 normal 20 30 IMPRESSION Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position No other significant nystagmus was noted There was no evidence of clear cut caloric stimulation abnormality This study would be most consistent with a right vestibular dysfunction Keywords ophthalmology silver chloride biopotential electrodes inferior orbital margins lateral canthi vestibular dysfunction prominent nystagmus head hanging electronystagmogram eyes nystagmus MEDICAL_TRANSCRIPTION,Description Endoscopic subperiosteal midface lift using the endotine midface suspension device Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad Medical Specialty Ophthalmology Sample Name Midface Lift Blepharoplasty Transcription PREOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident POSTOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident PROCEDURES 1 Endoscopic subperiosteal midface lift using the endotine midface suspension device 2 Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 28 year old country and western performer who was involved in a motor vehicle accident over a year ago Since that time she is felt to have facial asymmetry which is apparent in publicity photographs for her record promotions She had requested a procedure to bring about further facial asymmetry She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient s requesting cosmetic surgery and was felt to be a psychiatrically good candidate She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left Preoperative workup including CT scan failed to show any skeletal trauma The patient was counseled with regard to the risks benefits alternatives and complications of the postsurgical procedure including but not limited to bleeding infection unacceptable cosmetic appearance numbness of the face change in sensation of the face facial nerve paralysis need for further surgery need for revision hair loss etc and informed consent was obtained PROCEDURE The patient was taken to the operating room placed in supine position after having been marked in the upright position while awake General endotracheal anesthesia was induced with a 6 endotracheal tube All appropriate measures were taken to preserve the vocal cords in a professional singer Local anesthesia consisting of 5 6th 1 lidocaine with 1 100 000 units of epinephrine in 1 6th 0 25 Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia The upper eyelids were injected with 1 cc of 1 Xylocaine with 1 100 000 units of epinephrine Adequate time for vasoconstriction and anesthesia was allowed to be obtained The patient was prepped and draped in the usual sterile fashion A 4 0 silk suture was placed in the right lower lid For traction it was brought anteriorly The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe A Q Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation which was present The inferior oblique muscle was identified preserved and protected throughout the procedure The transconjunctival incision was then closed with buried knots of 6 0 fast absorbing gut Contralateral side was treated in similar fashion with like results and throughout the procedure Lacri Lube was in the eyes in order to maintain hydration Attention was next turned to the midface where a temporal incision was made parallel to the nasojugal folds Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia A 30 degree endoscope was used to visualize the fat pads so that we knew we are in the proper plane Subperiosteal dissection was carried out over the zygomatic arch and Whitnall s tubercle and the temporal dissection was completed Next bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall s tubercle The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle It was bipolar electrocauteried and the tunnel was further dissected free and opened The endotine 4 5 soft tissue suspension device was then inserted through the temporal incision brought down into the subperiosteal midface plane of dissection The guard was removed and the suspension spikes were engaged into the soft tissues The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally The endotine device was then secured to the true temporal fascia with three sutures of 3 0 PDS suture Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained The gingivobuccal sulcus incisions were closed with interrupted 4 0 chromic and the scalp incision was closed with staples The sterile dressing was applied The patient was awakened in the operating room and taken to the recovery room in good condition Keywords ophthalmology cosmetic surgery jaeger lid plate lacri lube q tip blepharoplasty conjunctiva facial asymmetry fat pad lower lid midface lift regional field block temporal fascia temporal fossa vasoconstriction true temporal fascia gingivobuccal sulcus gingivobuccal MEDICAL_TRANSCRIPTION,Description Clear corneal temporal incision no stitches A lid speculum was placed in the fissure of the right eye Medical Specialty Ophthalmology Sample Name Clear Corneal Temporal Incision Transcription CLEAR CORNEAL TEMPORAL INCISION NO STITCHES DESCRIPTION OF OPERATION Under satisfactory local anesthesia the patient was appropriately prepped and draped A lid speculum was placed in the fissure of the right eye The secondary incision was then made through clear cornea using 1 mm diamond keratome at surgeon s 7 30 position and the anterior chamber re formed using viscoelastic The primary incision was then made using a 3 mm diamond keratome at the surgeon s 5 o clock position and additional viscoelastic injected into the anterior chamber as needed The capsulorrhexis was then performed in a standard circular tear fashion The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag The residual cortex was then aspirated from the bag and the bag re expanded using viscoelastic The posterior chamber intraocular lens was then inspected irrigated coated with Healon and folded and then placed into the capsular bag under direct visualization The lens was noted to center well The residual viscoelastic was then removed from the eye and the eye re formed using balanced salt solution The eye was then checked and found to be watertight therefore no suture was used The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment A shield was applied and the patient returned to the recovery room in good condition Keywords ophthalmology clear corneal temporal incision intraocular lens corneal temporal incision lid speculum incision temporal chamber corneal viscoelastic eyeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description One week history of decreased vision in the left eye Past ocular history includes cataract extraction with lens implants in both eyes Medical Specialty Ophthalmology Sample Name Decreased Vision Consult Transcription She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003 She also has a history of glaucoma diagnosed in 1990 and macular degeneration She has been followed in her home country and is here visiting family She had the above mentioned observation and was brought in on an urgent basis today Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism Her medications include V optic 0 5 eye drops to both eyes twice a day and pilocarpine 2 OU three times a day She took both the drops this morning She also takes Eltroxin which is for hypothyroidism Plendil for blood pressure and pravastatin She is allergic to Cosopt She has a family history of blindness in her brother as well as glaucoma and hypertension Her visual acuity today at distance without correction are 20 25 in the right and count fingers at 3 feet in the left eye Manifest refraction showed no improvement in either eye The intraocular pressures by applanation were 7 on the right and 18 in the left eye Gonioscopy showed grade 4 open angles in both eyes Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes The lids were normal OU She has mild dry eye OU The corneas are clear OU The anterior chamber is deep and quiet OU Irides appear normal The lenses show well centered posterior chamber intraocular lenses OU Dilated fundus exam shows clear vitreous OU The optic nerves are normal in size They both appear to have mild pallor The optic cups in both eyes are shallow The cup to disc ratio in the right eye is not overtly large would estimated 0 5 to 0 6 however she does have very thin rim tissue inferotemporally in the right eye In the left eye the glaucoma appears to be more advanced to the larger cup to disc ratio and a thinner rim tissue The macula on the right shows drusen with focal areas of RPE atrophy I do not see any evidence of neovascularization such as subretinal fluid lipid or hemorrhage She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye In the left eye she has also several high risk drusen but no evidence of neovascularization The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild I do not see any dense or focal areas of frank RPE atrophy or hypertrophy The peripheral retinas are attached in both eyes Ms ABC has pseudophakia OU which is stable and she is doing well in this regard She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye The intraocular pressure in the mid to high teens in the left eye is probably high for her She has allergic reaction to Cosopt I will recommend starting Xalatan OS nightly I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan Regarding the macular degeneration she has had high risk changes in both eyes The vision in the right eye is good but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye Keywords ophthalmology cataract extraction lens implants decreased vision macular degeneration intraocular pressures rpe atrophy eye degeneration glaucoma macular vision MEDICAL_TRANSCRIPTION,Description Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid Medical Specialty Ophthalmology Sample Name Eyelid Squamous Cell Carcinoma Excision Transcription PREOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma POSTOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma PROCEDURE PERFORMED Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Local with sedation INDICATION The patient is a 65 year old male with a large squamous cell carcinoma on his right upper eyelid which had previous radiation DESCRIPTION OF PROCEDURE The patient was taken to the operating room laid supine administered intravenous sedation and prepped and draped in a sterile fashion He was anesthetized with a combination of 2 lidocaine and 0 5 Marcaine with Epinephrine on both upper eyelids The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact Following complete resection the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate The specimen was sent to pathology which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma Meticulous hemostasis was obtained with Bovie cautery and a full thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid The left upper eyelid incision was closed with 6 0 fast absorbing gut interrupted sutures and the skin graft was sutured in place with 6 0 fast absorbing gut interrupted sutures An eye patch was placed on the right side and the patient tolerated the procedure well and was taken to PACU in good condition Keywords ophthalmology frozen section full thickness skin grafting squamous cell carcinoma eyelid orbicularis MEDICAL_TRANSCRIPTION,Description Cataract to right eye Cataract extraction with intraocular lens implant of the right eye anterior vitrectomy of the right eye Medical Specialty Ophthalmology Sample Name Cataract Extraction Vitrectomy Transcription PREOPERATIVE DIAGNOSIS Cataract to right eye POSTOPERATIVE DIAGNOSIS Cataract to right eye PROCEDURE PERFORMED Cataract extraction with intraocular lens implant of the right eye anterior vitrectomy of the right eye LENS IMPLANT USED See below COMPLICATIONS Posterior capsular hole vitreous prolapse ANESTHESIA Topical PROCEDURE IN DETAIL The patient was identified in the preoperative holding area before being escorted back to the operating room suite Hemodynamic monitoring was begun Time out was called and the patient eye operated upon and lens implant intended were verbally verified Three drops of tetracaine were applied to the operative eye The patient was then prepped and draped in usual sterile fashion for intraocular surgery A lid speculum was placed Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife The anterior chamber was irrigated with a dilute 0 25 solution of non preserved lidocaine and filled with Viscoat The clear corneal temporal incision was fashioned The anterior chamber was entered by introducing a keratome The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco chop technique Following removal of the last nuclear quadrant there was noted to be a posterior capsular hole nasally This area was tamponaded with Healon The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area The sulcus area of the lens was then inflated using Healon and a V9002 16 0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus There was noted to be good support Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat Gentle bimanual irrigation aspiration was performed to remove remaining viscoelastic agents anteriorly The pupil was noted to constrict symmetrically Wounds were checked with Weck cels and found to be free of vitreous BSS was used to re inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12 All corneal wounds were then hydrated checked and found to be watertight and free of vitreous A single 10 0 nylon suture was placed temporarily as prophylaxis and the knot buried Lid speculum was removed TobraDex ointment light patch and a Soft Shield were applied The patient was taken to the recovery room awake and comfortable We will follow up in the morning for postoperative check He will not be given Diamox due to his sulfa allergy The intraoperative course was discussed with both he and his wife Keywords ophthalmology intraocular lens implant lid speculum cataract extraction anterior vitrectomy anterior chamber eye intraocular extraction hemodynamic implant vitrectomy vitreous cataract lens MEDICAL_TRANSCRIPTION,Description A sample note on Conjunctivitis Pink Eye Medical Specialty Ophthalmology Sample Name Conjunctivitis Transcription CONJUNCTIVITIS better known as Pink Eye is an infection of the inside of your eyelid It is usually caused by allergies bacteria viruses or chemicals WHAT ARE THE SIGNS AND SYMPTOMS 1 Red irritated eye 2 Some burning and or scratchy feeling 3 There may be a purulent pus or a mucous type discharge HOW IS IT TREATED It depends on what caused the Pink Eye It may or may not need medication for treatment If medication is given follow the directions on the label TO PREVENT THE SPREAD OF THE INFECTION 1 Wash hands thoroughly before you use the medicine in your eyes After using the medicine in your eyes Every time you touch your eyes or face 2 Wash any clothing touched by infected eyes Clothes Towels Pillowcases 3 Do not share make up If the infection is caused by bacteria or a virus you must throw away your used make up and buy new make up 4 Do not touch the infected eye because the infection will spread to the good eye IMPORTANT 5 Pink Eye Spreads Very Easily Keywords ophthalmology eyelid infected eyes pink eye conjunctivitis eyes infection eye MEDICAL_TRANSCRIPTION,Description Normal cataract surgery Medical Specialty Ophthalmology Sample Name Cataract Surgery Transcription NORMAL CATARACT SURGERY PROCEDURE DETAILS The patient was taken to the operating room where the Rand Stein anesthesia protocol was followed using alfentanil and Brevital Topical tetracaine drops were applied The operative eye was prepped and draped in the usual sterile fashion A lid speculum was inserted Under the Zeiss operating microscope a lateral clear corneal approach was utilized A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic A 3 mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome A 5 to 5 5 mm anterior capsulorrhexis was created The nucleus was hydrodissected and hydrodelineated and was freely movable in the capsular bag The nucleus was then phacoemulsified using a quadrantic divide and conquer technique Following the deep groove formation the lens was split bimanually and the resultant quadrants and epicortex removed under high vacuum burst mode phacoemulsification Peripheral cortex was removed with the irrigation and aspiration handpiece The posterior capsule was polished The capsular bag was expanded with viscoelastic The implant was inspected under the microscope and found to be free of defects The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag The trailing haptic was positioned with the cartridge system Residual viscoelastic was removed from the anterior chamber and from behind the implant The corneal wound was hydrated with balanced salt solution The anterior chamber was fully re formed through the side port incision The wound was inspected and found to be watertight The intraocular pressure was adjusted as necessary The lid speculum was removed Topical Timoptic drops Eserine and Dexacidin ointment were applied The eye was shielded The patient appeared to tolerate the procedure well and left the operating room in stable condition Followup appointment is with Dr X on the first postoperative day Keywords ophthalmology zeiss peripheral cortex phacoemulsified hydrodissected rand stein lid speculum anterior chamber capsular bag cataract viscoelasticNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description She is sent for evaluation of ocular manifestations of systemic connective tissue disorders Denies any eye problems and history includes myopia with astigmatism Medical Specialty Ophthalmology Sample Name Connective Tissue Disorder Transcription Her past medical history includes a presumed diagnosis of connective tissue disorder She has otherwise good health She underwent a shoulder ligament repair for joint laxity She does not take any eye medications and she takes Seasonale systemically She is allergic to penicillin The visual acuity today distance with her current prescription was 20 30 on the right and 20 20 on the left eye Over refraction on the right eye showed 0 50 sphere with acuity of 20 20 OD She is wearing 3 75 1 50 x 060 on the right and 2 50 0 25 x 140 OS Intraocular pressures are 13 OU and by applanation Confrontation visual fields extraocular movement and pupils are normal in both eyes Gonioscopy showed normal anterior segment angle morphology in both eyes She does have some fine iris strength crossing the angle but the angle is otherwise open 360 degrees in both eyes The lids were normal in both eyes Conjunctivae were quite OU Cornea were clear in both eyes The anterior chamber is deep and quiet OU She has clear lenses which are in good position OU Dilated fundus exam shows moderately optically clear vitreous OU The optic nerves are normal in size The cup to disc ratios were approximately 0 4 OU The nerve fiber layers are excellent OU The macula vessels and periphery were normal in both eyes No evidence of peripheral retinal degeneration is present in either eye Ms ABC has optically clear vitreous She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes She does have moderate myopia however This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur Otherwise I can see her in 1 to 2 years Keywords ophthalmology systemic connective tissue disorder stickler syndrome anterior chamber angles retinal degeneration connective tissue disorder vitreous degeneration detachment myopia optically astigmatism eyes MEDICAL_TRANSCRIPTION,Description Patient follows up for cataract extraction with lens implant 2 weeks ago Recovering well from her cataract operation in the right eye with residual corneal swelling which should resolve in the next 2 to 3 weeks Medical Specialty Ophthalmology Sample Name Cataract Extraction Followup Transcription Her past medical history includes insulin requiring diabetes mellitus for the past 28 years She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease She is scheduled to see a gastroenterologist in the near future She is taking Econopred 8 times a day to the right eye and Nevanac OD three times a day She is allergic to penicillin The visual acuity today was 20 50 pinholing no improvement in the right eye In the left eye the visual acuity was 20 80 pinholing no improvement The intraocular pressure was 14 OD and 9 OS Anterior segment exam shows normal lids OU The conjunctiva is quiet in the right eye In the left eye she has an area of sectoral scleral hyperemia superonasally in the left eye The cornea on the right eye shows a paracentral area of mild corneal edema In the left eye cornea is clear Anterior chamber in the right eye shows trace cell In the left eye the anterior chamber is deep and quiet She has a posterior chamber intraocular lens well centered and in sulcus of the left eye The lens in the left eye shows 3 nuclear sclerosis Vitreous is clear in both eyes The optic nerves appear healthy in color and normal in size with cup to disc ratio of approximately 0 48 The maculae are flat in both eyes The retinal periphery is flat in both eyes Ms ABC is recovering well from her cataract operation in the right eye with residual corneal swelling which should resolve in the next 2 to 3 weeks She will continue her current drops In the left eye she has an area of what appears to be sectoral scleritis I did a comprehensive review of systems today and she reports no changes in her pulmonary dermatologic neurologic gastroenterologic or musculoskeletal systems She is however being evaluated for inflammatory bowel disease The mild scleritis in the left eye may be a manifestation of this We will notify her gastroenterologist of this possibility of scleritis and will start Ms ABC on a course of indomethacin 25 mg by mouth two times a day I will see her again in one week She will check with her primary physician prior to starting the Indocin Keywords ophthalmology visual acuity photophobia lens implant cataract extraction eye cataract cornealNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification A peribulbar block was given to the eye using 8 cc of a mixture of 0 5 Marcaine without epinephrine mixed with Wydase plus one half of 2 lidocaine without epinephrine Medical Specialty Ophthalmology Sample Name Cataract Extraction 1 Transcription PROCEDURE PERFORMED Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification ANESTHESIA Peribulbar COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo Synephrine drops A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg A peribulbar block was given to the eye using 8 cc of a mixture of 0 5 Marcaine without epinephrine mixed with Wydase plus one half of 2 lidocaine without epinephrine The Honan balloon was then re placed over the eye for an additional 10 minutes at 20 mmHg The eye was prepped with a Betadine solution and draped in the usual sterile fashion A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15 degree blade followed by instillation of 0 1 cc of preservative free lidocaine 1 into the anterior chamber followed by viscoelastic A 2 8 mm keratome was used to create a self sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap The Utrata forceps were used to complete a continuous tear capsulorrhexis and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula Phacoemulsification in a quartering and cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit Gentle vacuuming of the central posterior capsule was performed The capsular bag was re expanded with viscoelastic and then the wound was opened to a 3 4 mm size with an additional keratome to allow insertion of the intraocular lens The intraocular lens was folded inserted into the capsular bag and then un folded The trailing haptic was tucked underneath the anterior capsular rim The lens was shown to center very well Therefore the viscoelastic was removed with the irrigation and aspiration unit and one 10 0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction The wound was shown to be watertight Therefore TobraDex ointment was applied to the eye an eye pad loosely applied and a Fox shield taped firmly in place The patient tolerated the procedure well and left the operating room in good condition Keywords ophthalmology phacoemulsification hydrodissection peribulbar block irrigation and aspiration honan balloon anterior chamber anterior capsular aspiration unit capsular bag cataract extraction intraocular lens cataract extraction peribulbar lidocaine viscoelastic chamber epinephrine anterior capsular lens intraocular eye MEDICAL_TRANSCRIPTION,Description A sample note on Cataract Medical Specialty Ophthalmology Sample Name Cataract Transcription CATARACT is the loss of transparency of the lens of the eye It often appears like a window that is fogged with steam WHAT CAUSES CATARACT FORMATION Aging the most common cause Family history Steroid use Injury to the eye Diabetes Previous eye surgery Long term exposure to sunlight HOW DO I KNOW IF I HAVE A CATARACT The best way for early detection is regular eye examinations by your medical eye doctor There are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina If these other problems exist cataract removal may not result in the return or improvement of vision Your eye doctor can tell you how much improvement in vision is likely DOES IT TAKE A LONG TIME FOR A CATARACT TO FORM Cataract development varies greatly between patients and is affected by the cause of the cataract Generally cataracts progress gradually over many years Some people especially diabetics and younger patients may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop WHAT IS THE TREATMENT FOR CATARACTS The only way to remove a cataract is surgery If the symptoms are not restricting your activity a change of glasses may alleviate the symptoms at this time No medications exercise optical devices or dietary supplements have been shown to stop the progression or prevent cataracts It is important to provide protection from excessive sunlight Making sure that the sunglasses you wear screen out ultraviolet UV light rays or your regular eyeglasses are coated with a clear anti UV coating will help prevent or slow the progression of cataracts HOW DO I KNOW IF I NEED SURGERY Surgery is considered when your vision is interfering with your daily activities It is important to evaluate if you can see to do your job and drive safely Can you read and watch TV in comfort Are you able to cook do your shopping and yard work or take your medications without difficulty Depending on how you feel your vision is affecting your daily life you and your eye doctor will decide together when it is the appropriate time to do surgery WHAT IS INVOLVED WITH CATARACT SURGERY This surgery is generally performed under local anesthesia on an outpatient basis With the assistance of a microscope the cloudy lens is removed and replaced with a permanent intraocular lens implant Right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones You will need to take eye drops as directed by your eye doctor Follow up visits are necessary to make sure the surgical site is healing without problems This procedure is performed on over 1 4 million people each year in the United States alone 95 without complications With this highly successful procedure 90 of the time vision improves unless a problem also exists with the cornea retina or optic nerve As with any surgery a good result cannot be guaranteed Keywords ophthalmology transparency eye sunlight optic nerve eye doctor cataract retina lens vision surgery MEDICAL_TRANSCRIPTION,Description Hairline biplanar temporal browlift quadrilateral blepharoplasty canthopexy cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy Medical Specialty Ophthalmology Sample Name Browlift Blepharoplasty Rhytidectomy Transcription PREOPERATIVE DIAGNOSES 1 Eyebrow ptosis 2 Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid 3 Cervical facial aging with submental lipodystrophy OPERATION 1 Hairline biplanar temporal browlift 2 Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid 3 Cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy ASSISTANT None ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in a supine position and prepped with general endotracheal anesthesia Local infiltration anesthesia with 1 Xylocaine and 1 100 000 epinephrine was infiltrated in upper and lower eyelids Markings were made and fusiform ellipse of skin was resected from the upper eyelid The lower limb of the fusiform ellipse was at the superior palpebral fold A 9 mm of upper eyelid skin was resected at the widest portion of the lips which extended from medial canthal area to the lateral orbital rim This was performed bilaterally and symmetrically and the skin was removed Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket An incision was made over the superior orbital rim Subperiosteal dissection was performed over the forehead The dissection proceeded medially The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized Hemostasis was achieved with electrocautery in this fashion A 4 cm incision was made and the forehead at the hairline subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid The incision was made in the lower lid just beneath the lashline Subcutaneous dissection was performed over the pretarsal and preseptal muscle Dissection was then proceeded down to the inferior orbital rim The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum which was separated from the inferior orbital rim The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5 0 Vicryl on a P2 needle The upper eyelid incision was closed with a running subcuticular 6 0 Prolene suture bilaterally The forehead was then elevated and the nonhairbearing forehead skin was resected 1 5 cm wide raising the tail of the eyebrow The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided A lateral canthopexy was performed with 5 0 Prolene suture on a C1 double arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides Closure was performed with interrupted 6 0 silk suture for the lower lid The eyebrow hairline brow lift was closed with interrupted 4 0 PDS suture deep subcutaneous tissue and dermis and the skin closed with a running 5 0 Prolene suture Attention then was directed to the cervical facial rhytidectomy and purse string SMAS elevation with submental lipectomy Incisions were made in preauricular area postauricular area mastoid and occipital area Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline Submental lipectomy was performed through the incision in the submental crease Fat was directly removed from the fascia Hemostasis was achieved with electrocautery A SMAS elevation was performed with a purse string suture of 2 0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia This was performed bilaterally and symmetrically Hemostasis was achieved with electrocautery The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed The skin of the cheek and neck were resected which was redundant after the posteriorly and superiorly in the neck and transversely in the cheek Closure was performed with interrupted 3 0 and 4 0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5 0 Prolene suture Drains were placed prior to final closure A 7 mm flat Jackson Pratt was then secured with 3 0 silk suture Dressing consisting of fluffs and Kerlix and a 4 inch Ace were applied to support mildly compressive dressing Scleral eye protectors were removed Maxitrol eye ointment was placed followed by Swiss therapy eye pads The patient tolerated the procedure well and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings TED hose two Jackson Pratt drains and an IV Keywords ophthalmology eyebrow ptosis dermatochalasia hairline jackson pratt swiss therapy arcus marginalis blepharoplasty browlift canthopexy fat transposition inferior orbital rim lipectomy lipodystrophy lower eyelid purse string rhytidectomy string smas elevation suborbicularis oculi frontalis muscle pds suture smas elevation submental lipectomy upper eyelid subperiosteal dissection lower lid prolene suture lower eyelids orbital rim lower eyelids sutured subcutaneous eyebrow orbital MEDICAL_TRANSCRIPTION,Description Cataract extraction with lens implantation right eye The lens was inspected and found to be free of defects folded and easily inserted into the capsular bag and unfolded Medical Specialty Ophthalmology Sample Name Cataract Extraction Transcription PROCEDURE PERFORMED Cataract extraction with lens implantation right eye DESCRIPTION OF PROCEDURE The patient was brought to the operating room The patient was identified and the correct operative site was also identified A retrobulbar block using 5 ml of 2 lidocaine without epinephrine was done after adequate anesthetic was assured and the eye was massaged to reduce risk of bleeding The patient was prepped and draped in the usual fashion A lid speculum was applied A groove incision at the 12 o clock position was made with a 5700 blade This was beveled anteriorly in a lamellar fashion using the crescent knife Then the anterior chamber was entered with a slit knife The chamber was deepened with Viscoat Then a paracentesis at the 3 o clock position was created using a super sharp blade A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps Hydrodissection was employed using BSS on a blunt 27 gauge needle The phaco tip was then introduced into the eye and the eye was divided into 4 grooves Then a second instrument was used a Sinskey hook to crack these grooves and the individual quadrants were brought into the central zone and phacoemulsified I A proceeded without difficulty using the irrigation aspiration cannula The capsule was felt to be clear and intact The capsular bag was then expanded with ProVisc The internal corneal wound was increased using the slit knife The lens was inspected and found to be free of defects folded and easily inserted into the capsular bag and unfolded A corneal light shield was then used as the wound was sutured with a figure of eight 10 0 nylon suture Then the Viscoat was removed using I A and the suture drawn up and tied The 0 2 ml of gentamicin was injected subconjunctivally Maxitrol ointment was instilled into the conjunctival sac The eye was covered with a double patch and shield and the patient was discharged Keywords ophthalmology lens implantation anterior chamber lid speculum eye sinskey hook cataract extraction capsular bag cataract capsular knife lens MEDICAL_TRANSCRIPTION,Description Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens left eye Medical Specialty Ophthalmology Sample Name Cataract Extraction 2 Transcription PREOPERATIVE DIAGNOSIS Cataract left eye POSTOPERATIVE DIAGNOSIS Cataract left eye PROCEDURE PERFORMED Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens left eye ANESTHESIA Topical COMPLICATIONS None PROCEDURE After the induction of topical anesthesia with 4 Xylocaine drops the left eye was prepped and draped in the usual fashion A speculum was inserted and the microscope was moved into position A 3 2 mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o clock position and 0 1 cc of 1 Xylocaine without preservative was instilled into the anterior chamber It was then filled with viscoelastic A stab incision was made into the anterior chamber at the limbus at 5 o clock position with a microblade A cystitome was used to make a capsulotomy and the capsulorrhexis forceps were used to complete a circular capsulorrhexis The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26 gauge cannula and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision The irrigation aspiration handpiece was used to systematically aspirate cortex 360 degrees The posterior capsule was vacuumed it was clear and intact The capsular bag and the anterior chamber were filled with viscoelastic A model MA30AC lens power 21 5 diopters serial number 864414 095 was folded grasped with the lens insertion forceps and inserted into the capsular bag The trailing loop was placed inside the bag The viscoelastic was removed with the irrigation aspiration handpiece The lens centered well A single 10 0 nylon suture was placed to close the wound It was checked and ascertained to be watertight Decadron 0 25 cc 0 25 cc of antibiotic and 0 25 cc of Xylocaine were injected subconjunctivally Dexacidin ointment was placed in the eye and the procedure was terminated The procedure was well tolerated by the patient who was returned to the recovery room in good condition Keywords ophthalmology anterior chamber keratome limbus intraocular lens cataract extraction extracapsular phacoemulsification capsular cataract chamber intraocular MEDICAL_TRANSCRIPTION,Description Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging Medical Specialty Ophthalmology Sample Name Blepharoplasty Quad Transcription PREOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging POSTOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging PROCEDURE Quad blepharoplasty ANESTHESIA General ESTIMATED BLOOD LOSS Minimal CONDITION The patient did well PROCEDURE The patient had marks and measurements prior to surgery Additional marks and measurements were made at the time of surgery these were again checked At this point the area was injected with 0 5 lidocaine with 1 200 000 epinephrine Appropriate time waited for the anesthetic and epinephrine effect Beginning on the left upper lid the skin excision was completed The muscle was opened herniated adipose tissue pad in the middle and medial aspect was brought forward cross clamped excised cauterized and allowed to retract The eyes were kept irrigated and protected throughout the procedure Attention was turned to the opposite side Procedure was carried out in the similar manner At the completion the wounds were then closed with a running 6 0 Prolene skin adhesives and Steri Strips Attention was turned to the right lower lid A lash line incision was made A skin flap was elevated and the muscle was opened Large herniated adipose tissue pads were present in each of the three compartments They were individually elevated cross clamped excised cauterized and allowed to retract At the completion a gentle tension was placed on the facial skin and several millimeters of the skin excised Attention was turned to he opposite side The procedure was carried out as just described The contralateral side was reexamined and irrigated Hemostasis was good and it was closed with a running 6 0 Prolene The opposite side was closed in a similar manner Skin adhesives and Steri Strips were applied The eyes were again irrigated and cool Swiss Eye compresses applied At the completion of the case the patient was extubated in the operating room breathing on her own doing well and transferred in good condition from operating room to recovering room Keywords ophthalmology blepharochalasia lower lid swiss eye compresses adipose tissue pad bagging blepharoplasty lash line incision quad blepharoplasty MEDICAL_TRANSCRIPTION,Description The patient seeks evaluation for a second opinion concerning cataract extraction Medical Specialty Ophthalmology Sample Name Cataract Second Opinion Transcription SUBJECTIVE The patient seeks evaluation for a second opinion concerning cataract extraction She tells me cataract extraction has been recommended in each eye however she is nervous to have surgery Past ocular surgery history is significant for neurovascular age related macular degeneration She states she has had laser four times to the macula on the right and two times to the left she sees Dr X for this OBJECTIVE On examination visual acuity with correction measures 20 400 OU Manifest refraction does not improve this There is no afferent pupillary defect Visual fields are grossly full to hand motions Intraocular pressure measures 17 mm in each eye Slit lamp examination is significant for clear corneas OU There is early nuclear sclerosis in both eyes There is a sheet like 1 2 posterior subcapsular cataract on the left Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes ASSESSMENT PLAN Advanced neurovascular age related macular degeneration OU this is ultimately visually limiting Cataracts are present in both eyes I doubt cataract removal will help increase visual acuity however I did discuss with the patient especially in the left cataract surgery will help Dr X better visualize the macula for future laser treatment so that her current vision can be maintained This information was conveyed with the use of a translator Keywords ophthalmology advanced neurovascular age related macular degeneration neurovascular age macular degeneration visual acuity cataract extraction neurovascular degeneration visual eyes macular cataract MEDICAL_TRANSCRIPTION,Description Blepharoplasty with direct brow repair Medical Specialty Ophthalmology Sample Name Blepharoplasty Direct Brow Repair Transcription PREOPERATIVE DX Dermatochalasis mechanical ptosis brow ptosis POSTOPERATIVE DX Same PROCEDURE Upper lid blepharoplasty and direct brow lift ANESTHESIA Local with sedation INDICATIONS FOR SURGERY In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction Visual field testing showed superior hemifield loss on the right and superior hemifield loss on the left These field losses resolved with upper eyelid taping which simulates the expected surgical correction Photodocumentation also showed the upper eyelids resting on the upper eyelashes as well as a decrease in the effective superior marginal reflex distance The risks benefits limitations alternatives and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation DESCRIPTION OF PROCEDURE On the day of surgery the surgical site and procedure were verified by the physician with the patient An informed consent was signed and witnessed EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia Two drops of topical proparacaine eye drops were placed on the ocular surface The skin was cleaned with alcohol prep pads The patient received 3 to 4 mL of 2 Lidocaine with epinephrine and 0 5 Marcaine mixture to each upper lid 5 to 6 mL of local were also given to the brow region along the entire length Pressure was applied over each site for 5 minutes The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side The contour of the outline was created to provide a greater temporal lift Care was taken to preserve a natural contour to the brow shape consistent with the patient s desired features Using a 15 blade the initial incision was placed just inside the superior most row of brow hairs in parallel with the follicle growth orientation The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line The dimensions of the redundant tissue measured horizontally and vertically The redundant tissue was removed sharply with Westcott scissors Hemostasis was maintained with hand held cautery and or electrocautery The closure was carried out in multiple layers The deepest muscular subcutaneous tissue was closed with 4 0 transparent nylon in a horizontal mattress fashion The intermediate layer was closed with 5 0 Vicryl similarly The skin was closed with 6 0 nylon in a running lock fashion Iced saline gauze pads were placed over the incision sites This completed the brow repair portion of the case Using a surgical marking pen a vertical line was drawn from the superior punctum to the eyebrow An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow These lines served as the relative boundary for the horizontal length of the blepharoplasty incision The desired amount of redundant tissue to be excised was carefully pinched together with 0 5 forceps This tissue was outlined with a surgical marking pen Care was taken to avoid excessive skin removal near the brow region A surgical ruler was used to ensure symmetry The skin and superficial orbicularis were incised with a 15 blade on the first upper lid This layer was removed with Westcott scissors Hemostasis was achieved with high temp hand held pen cautery The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified amount of central preaponeurotic fat was removed with cautery amount of nasal fat pad was removed in the same fashion Care was taken to not disturb the levator aponeurosis A symmetric amount of fat was removed from each side Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6 0 nylon Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface Saline gauze and cold packs were placed over the upper lids The patient was taken from the surgical suite in good condition DISCHARGE In the recovery area the results of surgery were discussed with the patient and their family Specific instructions to resume all p o oral medications including anticoagulants antiplatelets were given Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member Instructions on antibiotic ointment use were reviewed The incision sites were checked prior to release The patient was released to home with a driver after vital signs were deemed stable Keywords ophthalmology dermatochalasis erythromycin ophthalmic saline gauze blepharoplasty brow ptosis cold packs direct brow lift follicle growth hemifield loss marginal reflex mechanical ptosis ocular surface superficial orbicularis visual field surgical marking pen direct brow redundant tissue incision sites incision brow ptosis surgical MEDICAL_TRANSCRIPTION,Description Blepharoplasty procedure Medical Specialty Ophthalmology Sample Name Blepharoplasty Transcription BLEPHAROPLASTY The patient was prepped and draped The upper lid skin was marked out in a lazy S fashion and the redundant skin marked out with a Green forceps Then the upper lids were injected with 2 Xylocaine and 1 100 000 epinephrine and 1 mL of Wydase per 20 mL of solution The upper lid skin was then excised within the markings Gentle pressure was placed on the upper eyelids and the fat in each of the compartments was teased out using a scissor and cotton applicator and then the fat was cross clamped cut and the clamp cauterized This was done in the all compartments of the middle and medial compartments of the upper eyelid and then the skin sutured with interrupted 6 0 nylon sutures The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin This created a significant crisp supratarsal fold The upper lid skin was closed in this fashion and then attention was turned to the lower lid An incision was made under the lash line and slightly onto the lateral canthus The 15 blade was used to delineate the plane in the lateral portion of the incision and then using a scissor the skin was cut at the marking Then the skin muscle flap was elevated with sharp dissection The fat was located and using a scissor the three eyelid compartments were opened Fat was teased out cross clamped the fat removed and then the clamp cauterized Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze and then the excess skin removed The suture line was sutured with interrupted 6 0 silk sutures Once this was done the procedure was finished The patient left the OR in satisfactory condition The patient was given 50 mg of Demerol IM with 25 mg of Phenergan Keywords ophthalmology blepharoplasty green forceps wydase applicator canthus lash line lazy s lazy s fashion muscle flap periorbital muscle prepped and draped supratarsal fold upper lid upward gaze upper lid skin eyelidsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft Medical Specialty Ophthalmology Sample Name BCCa Excision Lower Lid Transcription PREOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid POSTOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid TITLE OF OPERATION Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft PROCEDURE The patient was brought into the operating room and prepped and draped in usual fashion Xylocaine 2 with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid A frontal nerve block was also given on the right upper lid The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect The area was marked with a marking pen with margins of 3 to 4 mm and a 15 Bard Parker blade was used to make an incision at the nasal and temporal margins of the lesion The incision was carried inferiorly and using a Steven scissors the normal skin muscle and conjunctiva was excised inferiorly The specimen was then marked and sent to pathology for frozen section Bleeding was controlled with a wet field cautery and the right upper lid was everted and an incision was made 3 mm above the lid margin with the Bard Parker blade in the entire length of the upper lid The incision reached the orbicularis and Steven scissors were used to separate the tarsus from the underlying orbicularis Vertical cuts were made nasally and temporally and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly It was placed into the defect in the lower lid and sutured with multiple interrupted 6 0 Vicryl sutures nasally temporally and inferiorly The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region The defect was closed with interrupted 5 0 Prolene sutures and the preauricular graft was sutured in place with multiple interrupted 6 0 silk sutures The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied The patient tolerated the procedure well and was sent to recovery room in good condition Keywords ophthalmology basal cell carcinoma cryotherapy steven scissors conjunctiva conjunctival flap frontal nerve block frozen section lower lid orbicularis skin graft nasal and temporal margins dorsal conjunctival flap upper lid basal carcinoma preauricular incision conjunctival MEDICAL_TRANSCRIPTION,Description Lower lid blepharoplasty Medical Specialty Ophthalmology Sample Name Blepharoplasty Lower Lid Transcription An orbital block was done An infraorbital block was also performed with a 25 gauge needle A skin muscle flap was elevated by sharp dissection down to the orbital rim area The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade teasing the periorbital fat out cross clamping the fat and removing the fat with a scissor over the clamp The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade The remaining fat was left to fall back into the orbit This was done in three compartments the middle medial and lateral compartments Fat was removed from all three compartments Then with the mouth open and the eyes in upward gaze the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6 0 silk sutures Bleeding was minimal The patient tolerated the procedure well Keywords ophthalmology lower lid wydase blepharoplasty infraorbital block muscle flap orbital rim area orbital septum periorbital fat subciliary incision upward gaze orbital clampingNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Repair of entropion left upper lid with excision of anterior lamella and cryotherapy Repairs of blepharon entropion right lower lid with mucous membrane graft Medical Specialty Ophthalmology Sample Name Blepharon Entropion Repair Transcription PREOPERATIVE DIAGNOSES 1 Entropion left upper lid 2 Entropion and some blepharon right lower lid TITLE OF OPERATION 1 Repair of entropion left upper lid with excision of anterior lamella and cryotherapy 2 Repairs of blepharon entropion right lower lid with mucous membrane graft PROCEDURE IN DETAIL The patient was brought to the operating room and prepped and draped in the usual fashion The left upper lid and right lower lid were all infiltrated with 2 Xylocaine with Epinephrine The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0 5 mm in thickness The graft was placed in saline and a 4 x 4 was placed over the lower lid Attention was then drawn to the left upper lid and the operating microscope was found to place An incision was made in the gray line nasally in the area of trichiasis and entropion and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised Bleeding was controlled with the wet field cautery and the cryoprobe was then used with a temperature of 8 degree centigrade in the freeze thaw refreeze technique to treat the bed of the excised area Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade Some of the blepharon were dissected from the globe and bleeding was controlled with the wet field cautery An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6 0 chromic catgut suture anteriorly and posteriorly The graft was in good position and everything was satisfactory at the end of procedure Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied No patch was applied to the left eye The patient tolerated the procedure well and was sent to recovery room in good condition Keywords ophthalmology entropion blepharon catgut suture cryoprobe cryotherapy freeze thaw refreeze lamella lid lower lid tarsal plate trichiasis upper lid mucous membrane graft anterior lamella mucous membrane membrane MEDICAL_TRANSCRIPTION,Description Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis Medical Specialty Ophthalmology Sample Name Bilateral Upper Lid Blepharoplasty Transcription PREOPERATIVE DIAGNOSIS Bilateral upper eyelid dermatochalasis POSTOPERATIVE DIAGNOSIS Same PROCEDURE Bilateral upper lid blepharoplasty CPT 15822 ANESTHESIA Lidocaine with 1 100 000 epinephrine DESCRIPTION OF PROCEDURE This 65 year old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction The procedure alternatives risks and limitations in this individual case have been very carefully discussed with the patient All questions have been thoroughly answered and the patient understands the surgery indicated She has requested this corrective repair be undertaken and a consent was signed The patient was brought into the operating room and placed in the supine position on the operating table An intravenous line was started and sedation and sedation anesthesia was administered IV after preoperative p o sedation The patient was monitored for cardiac rate blood pressure and oxygen saturation continuously The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured and the incisions were marked for fusiform excision with a marking pen The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally The upper eyelid areas were bilaterally injected with 1 Lidocaine with 1 100 000 Epinephrine for anesthesia and vasoconstriction The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally The face was prepped and draped in the usual sterile manner After waiting a period of approximately ten minutes for adequate vasoconstriction the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection Hemostasis was obtained with a bipolar cautery A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right The defect in the orbital septum was identified and herniated orbital fat was exposed The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit A similar procedure was performed exposing herniated portion of the nasal pocket Great care was taken to obtain perfect hemostasis with this maneuver A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion Careful hemostasis had been obtained on the upper lid areas The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7 0 blue Prolene sutures At the end of the operation the patient s vision and extraocular muscle movements were checked and found to be intact There was no diplopia no ptosis no ectropion Wounds were reexamined for hemostasis and no hematomas were noted Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally The procedures were completed without complication and tolerated well The patient left the operating room in satisfactory condition A follow up appointment was scheduled routine post op medications prescribed and post op instructions given to the responsible party The patient was released to return home in satisfactory condition Keywords ophthalmology bilateral upper eyelid dermatochalasis blepharoplasty upper lid bilateral upper lid eyelid bilateral upper lid blepharoplasty upper lid blepharoplasty eyelid dermatochalasis lid blepharoplasty orbital septum upper eyelid anesthesia dermatochalasis hemostasis MEDICAL_TRANSCRIPTION,Description The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8 0 nylon sutures The knots were trimmed Medical Specialty Ophthalmology Sample Name Ahmed Shunt Placement Transcription PROCEDURE IN DETAIL While in the holding area the patient received a peripheral IV from the nursing staff In addition pilocarpine 1 was placed into the operative eye two times separated by 10 minutes The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines Through the IV the patient received IV sedation in the form of propofol and once somnolent from this a retrobulbar block was administrated consisting of 2 Xylocaine plain Approximately 3 mL were administered The patient then underwent a Betadine prep with respect to the face lens lashes and eye During the draping process care was taken to isolate the lashes A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva Approximately 8 to 10 mm posterior to limbus the conjunctiva was incised and dissected forward to the limbus Blunt dissection was carried out in the superotemporal quadrant Next a 2 x 3 mm scleral flap was outlined that was one half scleral depth in thickness This flap was cut forward to clear cornea using a crescent blade The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8 0 nylon sutures The knots were trimmed The tube was then cut to an appropriate length to enter the anterior chamber The anterior chamber was then entered after a paracentesis wound had been made temporally A trabeculectomy was done and then the tube was threaded through the trabeculectomy site The tube was sutured in place with a multi wrapped 8 0 nylon suture The scleral flap was then sutured in place with two 10 0 nylon sutures The knots were trimmed rotated and buried A scleral patch was then placed of an appropriate size over the two It was sutured in place with interrupted 8 0 nylon sutures The knots were trimmed The overlying conjunctiva was then closed with a running 8 0 Vicryl suture with a BV needle The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft A good flow was established with irrigation into the anterior chamber Homatropine Econopred and Vigamox drops were placed into the eye A patch and shield were placed over the eye after removing the draping and the speculum The patient tolerated the procedure well He was taken to the recovery in good condition He will be seen in followup in the office tomorrow Keywords ophthalmology cornea ahmed shunt nylon sutures trabeculectomy conjunctiva chamberNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient was originally hospitalized secondary to dizziness and disequilibrium Extensive workup during her first hospitalization was all negative but a prominent feature was her very blunted affect and real anhedonia Medical Specialty Office Notes Sample Name Telemetry Monitoring Transcription DIAGNOSES PROBLEMS 1 Orthostatic hypotension 2 Bradycardia 3 Diabetes 4 Status post renal transplant secondary polycystic kidney disease in 1995 5 Hypertension 6 History of basal cell ganglia cerebrovascular event in 2004 with left residual 7 History of renal osteodystrophy 8 Iron deficiency anemia 9 Cataract status post cataract surgery 10 Chronic left lower extremity pain 11 Hyperlipidemia 12 Status post hysterectomy secondary to uterine fibroids PROCEDURES Telemetry monitoring HISTORY FINDINGS HOSPITAL COURSE The patient was originally hospitalized on 04 26 07 secondary to dizziness and disequilibrium Extensive workup during her first hospitalization was all negative but a prominent feature was her very blunted affect and real anhedonia She was transferred briefly to Psychiatry however on the second day in Psychiatry she became very orthostatic and was transferred acutely back to the medicine She briefly was on Cymbalta however this was discontinued when she was transferred back She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued She was able to maintain her pressures then was able to ambulate without difficulty We had wanted to pursue workup for possible causes for autonomic dysfunction however the patient was not interested in remaining in the hospital anymore and left really against our recommendations DISCHARGE MEDICATIONS 1 CellCept 500 mg twice a daily 2 Cyclosporine 25 mg in the morning and 15 mg in the evening 3 Prednisone 5 mg once daily 4 Hydralazine 10 mg four times a day 5 Pantoprazole 40 mg once daily 6 Glipizide 5 mg every morning 7 Aspirin 81 mg once daily FOLLOWUP CARE The patient is to follow up with Dr X in about 1 week s time Keywords office notes orthostatic hypotension bradycardia basal cell ganglia cerebrovascular event renal osteodystrophy dizziness disequilibrium telemetry monitoring MEDICAL_TRANSCRIPTION,Description Small office note on premature retina and vitreous Medical Specialty Office Notes Sample Name Premature retina and vitreous Transcription OCULAR FINDINGS Anterior chamber space Cornea iris lens and pupils all unremarkable on gross examination in each eye Ocular adnexal spaces appear very good in each eye Cyclomydril x2 was used to dilate the pupil in each eye Medial spaces are clear and the periphery is still hazy in each eye Ocular disc space normal size and shape with a pink color with clear margin in each eye Macular spaces are normal in appearance for the age in each eye Posterior pole No dilated blood vessels seen in each eye Periphery The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye IMPRESSION Premature retina and vitreous each eye PLAN Recheck in two weeks Keywords office notes eye ocular premature retina pupils periphery premature vitreous retina eye MEDICAL_TRANSCRIPTION,Description Right hand laceration x3 repaired Medical Specialty Office Notes Sample Name Right Hand Laceration Transcription HISTORY The patient is a 19 year old male who was involved in a fight approximately an hour prior to his ED presentation He punched a guy few times on the face might be the mouth and then punched a drinking glass breaking it and lacerating his right hand He has three lacerations on his right hand His wound was cleaned out thoroughly with tap water and one of the navy corpsman tried to use Superglue and gauze to repair it However it continues to bleed and he is here for evaluation PAST MEDICATION HISTORY Significant for asthma and acne CURRENT MEDICATIONS Accutane and takes no other medications TETANUS STATUS Up to date SOCIAL HISTORY He is a nonsmoker He has been drinking alcohol today but has no history of alcohol or drug abuse REVIEW OF SYSTEMS Otherwise well No febrile illness No motor or sensory complaints of any sort or paresthesias in the hand PHYSICAL EXAM GENERAL He is in no apparent distress He is alert and oriented x3 Mental status is clear and appropriate VITALS SIGNS Temperature is 98 3 heart rate 100 respirations 18 blood pressure 161 98 oxygen saturation 99 on room air by pulse oximetry which is normal EXTREMITIES Right hand he has three lacerations all over the MCP joint of his right hand irregular shaped over the fifth MCP and then over the fourth and third half wound similarly the lacerations All total approximately 4 cm in length I see no foreign bodies just capillary refills less than 2 seconds Radial pulses intact There is full range of motion with no gross deformities No significant amount of edema associated with these in the dorsum of the hand STUDIES X rays shows no open fracture or bony abnormality EMERGENCY DEPARTMENT COURSE The patient was anesthetized with 1 Xylocaine Wounds were thoroughly irrigated with tap water with at least 2 liters They were repaired with simple sutures of 4 0 Ethilon total of 17 sutures 16 of which were simple one is a horizontal mattress The patient was given Augmentin 875 mg p o due to the possibility of human bite wound ASSESSMENT RIGHT HAND LACERATIONS SIMPLE X3 REPAIRED AS DESCRIBED NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY PLAN The patient will be given Augmentin 875 mg 1 p o b i d for 7 days He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane He will take 1 p o every 6 hours or as needed 12 He will follow up for suture removal in 8 days Should he develop any signs of infection he will come immediately here for reevaluation He is discharged in stable condition Keywords office notes accutane hand laceration laceration hand MEDICAL_TRANSCRIPTION,Description Underwent tonsillectomy and adenoidectomy two weeks ago Medical Specialty Office Notes Sample Name Status Post T A Transcription SUBJECTIVE A 6 year old boy who underwent tonsillectomy and adenoidectomy two weeks ago Also I cleaned out his maxillary sinuses Symptoms included loud snoring at night sinus infections throat infections not sleeping well and fatigue The surgery went well and I had planned for him to stay overnight but Mom reminds me that by about 8 p m the night nurse gotten him to take fluids well and we let him go home then that evening He finished up his Augmentin by a day or two later he was off the Lortab Mom has not noticed any unusual voice change No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce He has not had any nasal discharge or ever had any bleeding He seems to be breathing better OBJECTIVE Exam looks good The pharynx is well healed Tongue mobility is normal Voice sounds clear Nasal passages reveal no discharge or crusting RECOMMENDATION I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth It is okay to chew gum and it is okay to eat crunchy foods such as potato chips The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis and there were no atypical findings on the laboratories I am glad he has healed up well There are no other restrictions or limitations I told Mom I had written to Dr XYZ to let her know of the findings The child will continue his regular followup visits with his family doctor and I told Mom I would be happy to see him anytime if needed He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure Keywords office notes tonsillectomy and adenoidectomy tonsillectomy adenoidectomy maxillary nasal sinuses MEDICAL_TRANSCRIPTION,Description Left shoulder injury A 41 year old male presenting for initial evaluation of his left shoulder Medical Specialty Office Notes Sample Name Shoulder Contusion Transcription CHIEF COMPLAINT Keywords office notes shoulder injury two views shoulder contusion MEDICAL_TRANSCRIPTION,Description Sample post dilation patient instructions Medical Specialty Office Notes Sample Name Post Dilation Instructions Transcription The effects of eye dilation drops will gradually decrease It typically takes TWO to SIX HOURS for the effects to wear off During this time reading may be more difficult and sensitivity to light may increase For a short time wearing sunglasses may help Keywords office notes dilation drops eye dilation sunglasses blindness eye examinations dilation eyesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago Medical Specialty Office Notes Sample Name Status Post Tympanoplasty Transcription The right eardrum is intact showing a successful tympanoplasty I cleaned a little wax from the external meatus The right eardrum might be very slightly red but not obviously infected The left eardrum not the surgical ear has a definite infection with a reddened bulging drum but no perforation or granulation tissue Also some wax at the external meatus I cleaned with a Q tip with peroxide The patient has no medical allergies Since he recently had a course of Omnicef we chose to put him on Augmentin I checked and we did not have samples so I phoned in a two week course of Augmentin 400 mg chewable twice daily with food at Walgreens I looked at this throat which looks clear The nose only has a little clear mucinous secretions If there is any ear drainage please use the Floxin drops I asked Mom to have the family doctor or Dad or me check the ears again in about two weeks from now to be sure there is no residual infection I plan to see the patient again later this spring Keywords office notes tympanoplasty surgery traumatic perforation external meatus wax external perforation eardrum meatus tympanoplasty earNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Normal review of systems template No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter Medical Specialty Office Notes Sample Name Normal ROS Template 3 Transcription HEENT No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter RESPIRATORY No shortness of breath wheezing dyspnea pulmonary disease tuberculosis or past pneumonias CARDIOVASCULAR No history of palpitations irregular rhythm chest pain hypertension hyperlipidemia diaphoresis congestive heart failure heart catheterization stress test or recent cardiac tests GASTROINTESTINAL No history of rectal bleeding appetite change abdominal pain hiatal hernia ulcer jaundice change in bowel habits or liver problems and no history of inflammatory bowel problems GENITOURINARY No dysuria hematuria frequency incontinence or colic NERVOUS SYSTEM No gait problems strokes numbness or muscle weakness PSYCHIATRIC No history of emotional lability depression or sleep disturbances ONCOLOGIC No history of any cancer change in moles or rashes No history of weight loss The patient has a good energy level ALLERGIC LYMPH No history of systemic allergy abnormal lymph nodes or swelling MUSCULOSKELETAL No fractures motor weakness arthritis or other joint pains Keywords office notes review of systems tinnitus sinusitis sore mouth hoarseness goiter heart appetite bowel weakness loss swelling MEDICAL_TRANSCRIPTION,Description Negative for any nausea vomiting fevers chills or weight loss Medical Specialty Office Notes Sample Name Normal ROS Template 4 Transcription GENERAL Negative for any nausea vomiting fevers chills or weight loss NEUROLOGIC Negative for any blurry vision blind spots double vision facial asymmetry dysphagia dysarthria hemiparesis hemisensory deficits vertigo ataxia HEENT Negative for any head trauma neck trauma neck stiffness photophobia phonophobia sinusitis rhinitis CARDIAC Negative for any chest pain dyspnea on exertion paroxysmal nocturnal dyspnea peripheral edema PULMONARY Negative for any shortness of breath wheezing COPD or TB exposure GASTROINTESTINAL Negative for any abdominal pain nausea vomiting bright red blood per rectum melena GENITOURINARY Negative for any dysuria hematuria incontinence INTEGUMENTARY Negative for any rashes cuts insect bites RHEUMATOLOGIC Negative for any joint pains photosensitive rashes history of vasculitis or kidney problems HEMATOLOGIC Negative for any abnormal bruising frequent infections or bleeding Keywords office notes review of systems trauma neck dyspnea rashes nausea vomiting MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty Office Notes Sample Name Normal ROS Template 5 Transcription REVIEW OF SYSTEMS GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs No history of OB GYN problems MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords office notes respiratory gastrointestinal integumentary hematopoietic night sweats negative allergies negative weakness neurologic throat weakness MEDICAL_TRANSCRIPTION,Description The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints Medical Specialty Office Notes Sample Name Ortho Office Visit Transcription Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature Motor strength was 5 5 on the MRC scale Reflexes were 2 and symmetrical Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally Palpable trigger points were noted on today s evaluation She is suffering from ongoing myofascitis Her treatment plan will consist of a series of trigger point injections which were performed today She tolerated the procedure well I have asked her to ice the region intermittently for 15 minutes off and on x 3 She will be followed in four weeks time for repeat trigger point injections if indicated Keywords office notes back pain trigger point injections paraspinal musculature lumbar paraspinal musculature palpable injections evaluation triggerNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing Medical Specialty Office Notes Sample Name Normal ROS Template 1 Transcription REVIEW OF SYSTEMS There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing There is no chest pain shortness of breath paroxysmal nocturnal dyspnea or chest pain with exertion There is no shortness of breath and no cough or hemoptysis No melena nausea vomiting dysphagia abdominal pain diarrhea constipation or blood in the stools No dysuria hematuria or excessive urination No muscle weakness or tenderness No new numbness or tingling No arthralgias or arthritis There are no rashes No excessive fatigability loss of motor skills or sensation No changes in hair texture change in skin color excessive or decreased appetite No swollen lymph nodes or night sweats No headaches The rest of the review of systems is negative Keywords office notes weight loss fevers chills sweats melena nausea vomiting dysphagia abdominal pain diarrhea constipation itching throat neck fullness painful swallowing breath loss neckNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Most commonly used phrases in physical exam Medical Specialty Office Notes Sample Name Normal Physical Exam Template 7 Transcription EYES The conjunctivae are clear The lids are normal appearing without evidence of chalazion or hordeolum The pupils are round and reactive The irides are without any obvious lesions noted Funduscopic examination shows sharp disk margins There are no exudates or hemorrhages noted The vessels are normal appearing EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing NECK The neck is nontender and supple The trachea is midline The thyroid is without any evidence of thyromegaly No obvious adenopathy is noted to the neck RESPIRATORY The patient has normal respiratory effort There is normal lung excursion Percussion of the chest is without any obvious dullness There is no tactile fremitus or egophony noted There is no tenderness to the chest wall or ribs There are no obvious abnormalities The lungs are clear to auscultation There are no wheezes rales or rhonchi heard There are no obvious rubs noted CARDIOVASCULAR There is a normal PMI on palpation I do not hear any obvious abnormal sounds There are no obvious murmurs There are no rubs or gallops noted The carotid arteries are without bruit No obvious thrill is palpated There is no evidence of enlarged abdominal aorta to palpation There is no abdominal mass to suggest enlargement of the aorta Good strong femoral pulses are palpated The pedal pulses are intact There is no obvious edema noted to the extremities There is no evidence of any varicosities or phlebitis noted GASTROINTESTINAL The abdomen is soft Bowel sounds are present in all quadrants There are no obvious masses There is no organomegaly and no liver or spleen is palpable No obvious hernia is noted The perineum and anus are normal in appearance There is good sphincter tone and no obvious hemorrhoids are noted There are no masses On digital examination there is no evidence of any tenderness to the rectal vault no lesions are noted Stool is brown and guaiac negative GENITOURINARY FEMALE The external genitalia is normal appearing with no obvious lesions no evidence of any unusual rash The vagina is normal in appearance with normal appearing mucosa The urethra is without any obvious lesions or discharge The cervix is normal in color with no obvious cervical discharge There are no obvious cervical lesions noted The uterus is nontender and small and there is no evidence of any adnexal masses or tenderness The bladder is nontender to palpation It is not enlarged GENITOURINARY MALE Normal scrotal contents are noted The testes are descended and nontender There are no masses and no swelling to the epididymis noted The penis is without any lesions There is no urethral discharge Digital examination of the prostate reveals a nontender non nodular prostate BREASTS The breasts are normal in appearance There is no puckering noted There is no evidence of any nipple discharge There are no obvious masses palpable There is no axillary adenopathy The skin is normal appearing over the breasts LYMPHATICS There is no evidence of any adenopathy to the anterior cervical chain There is no evidence of submandibular nodes noted There are no supraclavicular nodes palpable The axillae are without any abnormal nodes No inguinal adenopathy is palpable No obvious epitrochlear nodes are noted MUSCULOSKELETAL EXTREMITIES The patient has normal gait and station The patient has normal muscle strength and tone to all extremities There is no obvious evidence of any muscle atrophy The joints are all stable There is no evidence of any subluxation or laxity to any of the joints There is no evidence of any dislocation There is good range of motion of all extremities without any pain or tenderness to the joints or extremities There is no evidence of any contractures or crepitus There is no evidence of any joint effusions No obvious evidence of erythema overlying any of the joints is noted There is good range of motion at all joints There are normal appearing digits There are no obvious lesions to any of the nails or nail beds SKIN There is no obvious evidence of any rash There are no petechiae pallor or cyanosis noted There are no unusual nodules or masses palpable NEUROLOGIC The cranial nerves II XII are tested and are intact Deep tendon reflexes are symmetrical bilaterally The toes are downgoing with normal Babinskis Sensation to light touch is intact and symmetrical Cerebellar testing reveals normal finger nose heel shin Normal gait No ataxia PSYCHIATRIC The patient is oriented to person place and time The patient is also oriented to situation Mood and affect are appropriate for the present situation The patient can remember 3 objects after 3 minutes without any difficulties Remote memory appears to be intact The patient seems to have normal judgment and insight into the situation Keywords office notes ears nose mouth neck respiratory cardiovascular eyes gastrointestinal genitourinary breasts lymphatics musculoskeletal extremities skin neurologic psychiatric normal appearing physical exam examination MEDICAL_TRANSCRIPTION,Description Normal Physical Exam Template Well developed well nourished alert in no acute distress Medical Specialty Office Notes Sample Name Normal Physical Exam Template 5 Transcription GENERAL Well developed well nourished alert in no acute distress GCS 50 nontoxic VITAL SIGNS Blood pressure pulse respirations temperature degrees F Pulse oximetry HEENT Eyes Lids and conjunctiva No lesions Pupils equal round reactive to light and accommodation Irises symmetrical undilated Funduscopic exam reveals no hemorrhages or discopathy Ears Nose Mouth and throat External ears without lesions Nares patent Septum midline Tympanic membranes without erythema bulging or retraction Canals without lesion Hearing is grossly intact Lips teeth gums palate without lesion Posterior oropharynx No erythema No tonsillar enlargement crypt formation or abscess NECK Supple and symmetric No masses Thyroid midline non enlarged No JVD Neck is nontender Full range of motion without pain RESPIRATORY Good respiratory effort Clear to auscultation Clear to percussion Chest Symmetrical rise and fall Symmetrical expansion No egophony or tactile fremitus CARDIOVASCULAR Regular rate and rhythm No murmur gallops clicks heaves or rub Cardiac palpation within normal limits Pulses equal at carotid Femoral and pedal pulses No peripheral edema GASTROINTESTINAL No tenderness or mass No hepatosplenomegaly No hernia Bowel sounds equal times four quadrants Abdomen is nondistended No rebound guarding rigidity or ecchymosis MUSCULOSKELETAL Normal gait and station No pathology to digits or nails Extremities move times four No tenderness or effusion Range of motion adequate Strength and tone equal bilaterally stable BACK Nontender on midline Full range of motion with flexion extension and sidebending SKIN Inspection within normal limits Well hydrated No diaphoresis No obvious wound LYMPH Cervical lymph nodes No lymphadenopathy NEUROLOGICAL Cranial nerves II XII grossly intact DTRs symmetric 2 out of 4 bilateral upper and lower extremity elbow patella and ankle Motor strength 4 4 bilateral upper and lower extremity Straight leg raise is negative bilaterally PSYCHIATRIC Judgment and insight adequate Alert and oriented times three Memory and mood within normal limits No delusions hallucinations No suicidal or homicidal ideation Keywords office notes respiratory abdomen normal physical exam pulses tenderness strength lymph extremity midline range motion lesions symmetrical MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty Office Notes Sample Name Normal ROS Template 2 Transcription GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords office notes nose and throat cardiovascular integumentary negative weakness neurologic throat psychiatric weakness MEDICAL_TRANSCRIPTION,Description An example normal physical exam Medical Specialty Office Notes Sample Name Normal Physical Exam Template 1 Transcription GENERAL Vital signs and temperature as documented in nursing notes The patient appears stated age and is adequately developed EYES Pupils are equal round reactive to light and accommodation Lids and conjunctivae reveal no gross abnormality ENT Hearing appears adequate No obvious asymmetry or deformity of the ears and nose NECK Trachea midline Symmetric with no obvious deformity or mass no thyromegaly evident RESPIRATORY The patient has normal and symmetric respiratory effort Lungs are clear to auscultation CARDIOVASCULAR S1 S2 without significant murmur ABDOMEN Abdomen is flat soft nontender Bowel sounds are active No masses or pulsations present EXTREMITIES Extremities reveal no remarkable dependent edema or varicosities MUSCULOSKELETAL The patient is ambulatory with normal and symmetric gait There is adequate range of motion without significant pain or deformity SKIN Essentially clear with no significant rash or lesions Adequate skin turgor NEUROLOGICAL No acute focal neurologic changes PSYCHIATRIC Mental status judgment and affect are grossly intact and normal for age Keywords office notes vital signs equal round reactive normal physical exam physical exam MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normocephalic Negative lesions negative masses Medical Specialty Office Notes Sample Name Normal Physical Exam Template 4 Transcription GENERAL XXX VITAL SIGNS Blood pressure XXX pulse XXX temperature XXX respirations XXX Height XXX weight XXX HEAD Normocephalic Negative lesions negative masses EYES PERLA EOMI Sclerae clear Negative icterus negative conjunctivitis ENT Negative nasal hemorrhages negative nasal obstructions negative nasal exudates Negative ear obstructions negative exudates Negative inflammation in external auditory canals Negative throat inflammation or masses SKIN Negative rashes negative masses negative ulcers No tattoos NECK Negative palpable lymphadenopathy negative palpable thyromegaly negative bruits HEART Regular rate and rhythm Negative rubs negative gallops negative murmurs LUNGS Clear to auscultation Negative rales negative rhonchi negative wheezing ABDOMEN Soft nontender adequate bowel sounds Negative palpable masses negative hepatosplenomegaly negative abdominal bruits EXTREMITIES Negative inflammation negative tenderness negative swelling negative edema negative cyanosis negative clubbing Pulses adequate bilaterally MUSCULOSKELETAL Negative muscle atrophy negative masses Strength adequate bilaterally Negative movement restriction negative joint crepitus negative deformity NEUROLOGIC Cranial nerves I through XII intact Negative gait disturbance Balance and coordination intact Negative Romberg negative Babinski DTRs equal bilaterally GENITOURINARY Deferred Keywords MEDICAL_TRANSCRIPTION,Description Normal review of systems template The patient denies fever fatigue weakness weight gain or weight loss Medical Specialty Office Notes Sample Name Normal ROS Template Transcription REVIEW OF SYSTEMS GENERAL CONSTITUTIONAL The patient denies fever fatigue weakness weight gain or weight loss HEAD EYES EARS NOSE AND THROAT Eyes The patient denies pain redness loss of vision double or blurred vision flashing lights or spots dryness the feeling that something is in the eye and denies wearing glasses Ears nose mouth and throat The patient denies ringing in the ears loss of hearing nosebleeds loss of sense of smell dry sinuses sinusitis post nasal drip sore tongue bleeding gums sores in the mouth loss of sense of taste dry mouth dentures or removable dental work frequent sore throats hoarseness or constant feeling of a need to clear the throat when nothing is there waking up with acid or bitter fluid in the mouth or throat food sticking in throat when swallows or painful swallowing CARDIOVASCULAR The patient denies chest pain irregular heartbeats sudden changes in heartbeat or palpitation shortness of breath difficulty breathing at night swollen legs or feet heart murmurs high blood pressure cramps in his legs with walking pain in his feet or toes at night or varicose veins RESPIRATORY The patient denies chronic dry cough coughing up blood coughing up mucus waking at night coughing or choking repeated pneumonias wheezing or night sweats GASTROINTESTINAL The patient denies decreased appetite nausea vomiting vomiting blood or coffee ground material heartburn regurgitation frequent belching stomach pain relieved by food yellow jaundice diarrhea constipation gas blood in the stools black tarry stools or hemorrhoids GENITOURINARY The patient denies difficult urination pain or burning with urination blood in the urine cloudy or smoky urine frequent need to urinate urgency needing to urinate frequently at night inability to hold the urine discharge from the penis kidney stones rash or ulcers sexual difficulties impotence or prostate trouble no sexually transmitted diseases MUSCULOSKELETAL The patient denies arm buttock thigh or calf cramps No joint or muscle pain No muscle weakness or tenderness No joint swelling neck pain back pain or major orthopedic injuries SKIN AND BREASTS The patient denies easy bruising skin redness skin rash hives sensitivity to sun exposure tightness nodules or bumps hair loss color changes in the hands or feet with cold breast lump breast pain or nipple discharge NEUROLOGIC The patient denies headache dizziness fainting muscle spasm loss of consciousness sensitivity or pain in the hands and feet or memory loss PSYCHIATRIC The patient denies depression with thoughts of suicide voices in head telling to do things and has not been seen for psychiatric counseling or treatment ENDOCRINE The patient denies intolerance to hot or cold temperature flushing fingernail changes increased thirst increased salt intake or decreased sexual desire HEMATOLOGIC LYMPHATIC The patient denies anemia bleeding tendency or clotting tendency ALLERGIC IMMUNOLOGIC The patient denies rhinitis asthma skin sensitivity latex allergies or sensitivity Keywords office notes cardiovascular ears eyes gastrointestinal head nose respiratory review of systems denies fever blood tongue loss MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normal appearance for chronological age does not appear chronically ill Medical Specialty Office Notes Sample Name Normal Physical Exam Template 6 Transcription VITAL SIGNS Reveal a blood pressure of temperature of respirations and pulse of CONSTITUTIONAL Normal appearance for chronological age does not appear chronically ill HEENT The pupils are equal and reactive Funduscopic examination is normal Posterior pharynx is normal Tympanic membranes are clear NECK Trachea is midline Thyroid is normal The neck is supple Negative nodes RESPIRATORY Lungs are clear to auscultation bilaterally The patient has a normal respiratory rate no signs of consolidation and no egophony There are no retractions or secondary muscle use Good bilateral breath sounds are noted CARDIOVASCULAR No jugular venous distention or carotid bruits No increase in heart size to percussion There is no murmur Normal S1 and S2 sounds are noted without gallop ABDOMEN Soft to palpation in all four quadrants There is no organomegaly and no rebound tenderness Bowel sounds are normal Obturator and psoas signs are negative GENITOURINARY No bladder tenderness negative flank pain MUSCULOSKELETAL Extremities are normal with good motor tone and strength normal reflexes and normal joint strength and sensation NEUROLOGIC Normal Glasgow Coma Scale Cranial nerves II through XII appear grossly intact Normal motor and cerebellar tests Reflexes are normal HEME LYMPH No abnormal lymph nodes no signs of bleeding skin purpura petechiae or hemorrhage PSYCHIATRIC Normal with no overt depression or suicidal ideations Keywords office notes jugular venous distention flank bladder normal physical exam neck nodes respiratory tenderness motor strength reflexes sounds MEDICAL_TRANSCRIPTION,Description An example of a physical exam Medical Specialty Office Notes Sample Name Normal Physical Exam Template Transcription GENERAL Alert well developed in no acute distress MENTAL STATUS Judgment and insight appropriate for age Oriented to time place and person No recent loss of memory Affect appropriate for age EYES Pupils are equal and reactive to light No hemorrhages or exudates Extraocular muscles intact EAR NOSE AND THROAT Oropharynx clean mucous membranes moist Ears and nose without masses lesions or deformities Tympanic membranes clear bilaterally Trachea midline No lymph node swelling or tenderness RESPIRATORY Clear to auscultation and percussion No wheezing rales or rhonchi CARDIOVASCULAR Heart sounds normal No thrills Regular rate and rhythm no murmurs rubs or gallops GASTROINTESTINAL Abdomen soft nondistended No pulsatile mass no flank tenderness or suprapubic tenderness No hepatosplenomegaly NEUROLOGIC Cranial nerves II XII grossly intact No focal neurological deficits Deep tendon reflexes 2 bilaterally Babinski negative Moves all extremities spontaneously Sensation intact bilaterally SKIN No rashes or lesions No petechia No purpura Good turgor No edema MUSCULOSKELETAL No cyanosis or clubbing No gross deformities Capable of free range of motion without pain or crepitation No laxity instability or dislocation BONE No misalignment asymmetry defect tenderness or effusion Capable of from of joint above and below bone MUSCLE No crepitation defect tenderness masses or swellings No loss of muscle tone or strength LYMPHATIC Palpation of neck reveals no swelling or tenderness of neck nodes Palpation of groin reveals no swelling or tenderness of groin nodes Keywords office notes mental status ear nose and throat abdomen soft nondistended cranial nerves ii xii grossly intact physical exam MEDICAL_TRANSCRIPTION,Description Normal physical exam template Well developed well nourished in no acute distress Medical Specialty Office Notes Sample Name Normal Physical Exam Template 3 Transcription PHYSICAL EXAMINATION GENERAL APPEARANCE Well developed well nourished in no acute distress VITAL SIGNS SKIN Inspection of the skin reveals no rashes ulcerations or petechiae HEENT The sclerae were anicteric and conjunctivae were pink and moist Extraocular movements were intact and pupils were equal round and reactive to light with normal accommodation External inspection of the ears and nose showed no scars lesions or masses Lips teeth and gums showed normal mucosa The oral mucosa hard and soft palate tongue and posterior pharynx were normal NECK Supple and symmetric There was no thyroid enlargement and no tenderness or masses were felt CHEST Normal AP diameter and normal contour without any kyphoscoliosis LUNGS Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs CARDIOVASCULAR There was a regular rate and rhythm without any murmurs gallops rubs The carotid pulses were normal and 2 bilaterally without bruits Peripheral pulses were 2 and symmetric ABDOMEN Soft and nontender with normal bowel sounds The liver span was approximately 5 6 cm in the right midclavicular line by percussion The liver edge was nontender The spleen was not palpable There were no inguinal or umbilical hernias noted No ascites was noted RECTAL Normal perineal exam Sphincter tone was normal There was no external hemorrhoids or rectal masses Stool Hemoccult was negative The prostate was normal size without any nodules appreciated men only LYMPH NODES No lymphadenopathy was appreciated in the neck axillae or groin MUSCULOSKELETAL Gait was normal There was no tenderness or effusions noted Muscle strength and tone were normal EXTREMITIES No cyanosis clubbing or edema NEUROLOGIC Alert and oriented x 3 Normal affect Gait was normal Normal deep tendon reflexes with no pathological reflexes Sensation to touch was normal Keywords MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male ROS Medical Specialty Office Notes Sample Name Normal Male ROS Template 1 Transcription REVIEW OF SYSTEMS CONSTITUTIONAL Patient denies fevers chills sweats and weight changes EYES Patient denies any visual symptoms EARS NOSE AND THROAT No difficulties with hearing No symptoms of rhinitis or sore throat CARDIOVASCULAR Patient denies chest pains palpitations orthopnea and paroxysmal nocturnal dyspnea RESPIRATORY No dyspnea on exertion no wheezing or cough GI No nausea vomiting diarrhea constipation abdominal pain hematochezia or melena GU No urinary hesitancy or dribbling No nocturia or urinary frequency No abnormal urethral discharge MUSCULOSKELETAL No myalgias or arthralgias NEUROLOGIC No chronic headaches no seizures Patient denies numbness tingling or weakness PSYCHIATRIC Patient denies problems with mood disturbance No problems with anxiety ENDOCRINE No excessive urination or excessive thirst DERMATOLOGIC Patient denies any rashes or skin changes Keywords office notes review of systems normal male ros normal male male ros male ros throat urinary MEDICAL_TRANSCRIPTION,Description Normal newborn infant physical exam A well developed infant in no acute respiratory distress Medical Specialty Office Notes Sample Name Normal Newborn Infant Physical Exam Transcription GENERAL A well developed infant in no acute respiratory distress VITAL SIGNS Initial temperature was XX pulse XX respirations XX Weight XX grams length XX cm head circumference XX cm HEENT Head is normocephalic with anterior fontanelle open soft and non bulging Eyes Red reflex elicited bilaterally TMs occluded with vernix and not well visualized Nose and throat are patent without palatal defect NECK Supple without clavicular fracture LUNGS Clear to auscultation HEART Regular rate without murmur click or gallop present Pulses are 2 4 for brachial and femoral ABDOMEN Soft with bowel sounds present No masses or organomegaly GENITALIA Normal EXTREMITIES Without evidence of hip defects NEUROLOGIC The infant has good Moro grasp and suck reflexes SKIN Warm and dry without evidence of rash Keywords office notes fontanelle normocephalic newborn infant physical exam acute respiratory newborn respiratory distress head infant MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Office Notes Sample Name Normal Male Exam Template 1 Transcription MALE PHYSICAL EXAMINATION HEENT Pupils equal round and reactive to light and accommodation Extraocular movements are intact Sclerae are anicteric TMs are clear bilaterally Oropharynx is clear without erythema or exudate NECK Supple without lymphadenopathy or thyromegaly Carotids are silent There is no jugular venous distention CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm without S3 S4 No murmurs or rubs are appreciated ABDOMEN Soft nontender nondistended with positive bowel sounds No masses hepatomegaly or splenomegaly are appreciated GU Normal circumcised male No discharge or hernias No testicular masses RECTAL EXAM Normal rectal tone Prostate is smooth and not enlarged Stool is Hemoccult negative EXTREMITIES Reveal no clubbing cyanosis or edema Peripheral pulses are 2 and equal bilaterally in all four extremities JOINT EXAM Reveals no tenosynovitis NEUROLOGIC Cranial nerves II through XII are grossly intact Motor strength is 5 5 and equal in all four extremities Deep tendon reflexes are 2 4 and equal bilaterally Patient is alert and oriented times 3 PSYCHIATRIC Grossly normal DERMATOLOGIC No lesions or rashes Keywords office notes male exam physical exam normal normal male physical male sclerae extremities intact oropharynx MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Office Notes Sample Name Normal Male Exam Template 2 Transcription MALE PHYSICAL EXAMINATION Eye Eyelids normal color no edema Conjunctivae with no erythema foreign body or lacerations Sclerae normal white color no jaundice Cornea clear without lesions Pupils equally responsive to light Iris normal color no lesions Anterior chamber clear Lacrimal ducts normal Fundi clear Ear External ear has no erythema edema or lesions Ear canal unobstructed without edema discharge or lesions Tympanic membranes clear with normal light reflex No middle ear effusions Nose External nose symmetrical No skin lesions Nares open and free of lesions Turbinates normal color size and shape Mucus clear No internal lesions Throat No erythema or exudates Buccal mucosa clear Lips normal color without lesions Tongue normal shape and color without lesion Hard and soft palate normal color without lesions Teeth show no remarkable features No adenopathy Tonsils normal shape and size Uvula normal shape and color Neck Skin has no lesions Neck symmetrical No adenopathy thyromegaly or masses Normal range of motion nontender Trachea midline Chest Symmetrical Clear to auscultation bilaterally No wheezing rales or rhonchi Chest nontender Normal lung excursion No accessory muscle use Cardiovascular Heart has regular rate and rhythm with no S3 or S4 Heart rate is normal Abdominal Soft nontender nondistended bowel sounds present No hepatomegaly splenomegaly masses or bruits Genital Penis normal shape without lesions Testicles normal shape and contour without tenderness Epididymides normal shape and contour without tenderness Rectum normal tone to sphincter Prostate normal shape and contour without nodules Stool hemoccult negative No external hemorrhoids No skin lesions Musculoskeletal Normal strength all muscle groups Normal range of motion all joints No joint effusions Joints normal shape and contour No muscle masses Foot No erythema No edema Normal range of motion all joints in the foot Nontender No pain with inversion eversion plantar or dorsiflexion Ankle Anterior and posterior drawer test negative No pain with inversion eversion dorsiflexion or plantar flexion Collateral ligaments intact No joint effusion erythema edema crepitus ecchymosis or tenderness Knee Normal range of motion No joint effusion erythema nontender Anterior and posterior drawer tests negative Lachman s test negative Collateral ligaments intact Bursas nontender without edema Wrist Normal range of motion No edema or effusion nontender Negative Tinel and Phalen tests Normal strength all muscle groups Elbow Normal range of motion No joint effusion or erythema Normal strength all muscle groups Nontender Olecranon bursa flat and nontender no edema Normal supination and pronation of forearm No crepitus Hip Negative swinging test Trochanteric bursa nontender Normal range of motion Normal strength all muscle groups No pain with eversion and inversion No crepitus Normal gait Psychiatric Alert and oriented times four No delusions or hallucinations no loose associations no flight of ideas no tangentiality Affect is appropriate No psychomotor slowing or agitation Eye contact is appropriate Keywords office notes male exam normal physical exam normal range of motion male physical nontender lesions dorsiflexion sclerae contour muscle erythema joints edema shape MEDICAL_TRANSCRIPTION,Description Sample template for a normal male multisystem exam Medical Specialty Office Notes Sample Name Normal Male Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The scrotal elements were normal The testes were without discrete mass The penis showed no lesion no discharge LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords office notes within normal limits conjunctiva eyes ears nose throat male multisystem heart respiratory auscultation extremities oropharynx neck tongue MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Office Notes Sample Name Normal Male Exam Template 4 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions lids lashes brows or conjunctivae noted Funduscopic examination unremarkable No papilledema glaucoma or cataracts Ears Normal set and shape with normal hearing and normal TMs Nose and Sinus Unremarkable Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without carotid bruit JVD or significant cervical adenopathy Trachea is midline without stridor shift or subcutaneous emphysema Thyroid is palpable nontender not enlarged and free of nodularity CHEST Lungs bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI is nondisplaced Chest wall is unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS Normal male breast tissue ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and intraabdominal bruit on auscultation EXTERNAL GENITALIA Normal for age Normal penis with bilaterally descended testes that are normal in size shape and contour and without evidence of hernia or hydrocele RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool and normal sized prostate that is free of nodularity or tenderness No rectal masses palpated EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords office notes digital palpation hemoccult negative heent palpation breasts male tenderness tongue MEDICAL_TRANSCRIPTION,Description Normal female review of systems template Negative for fever weight change fatigue or aching Medical Specialty Office Notes Sample Name Normal Female ROS Template Transcription CONSTITUTIONAL Normal negative for fever weight change fatigue or aching HEENT Eyes normal Negative for glasses cataracts glaucoma retinopathy irritation or visual field defects Ears normal Negative for hearing or balance problems Nose normal Negative for runny nose sinus problems or nosebleeds Mouth normal Negative for dental problems dentures or bleeding gums Throat normal Negative for hoarseness difficulty swallowing or sore throat CARDIOVASCULAR Normal Negative for angina previous MI irregular heartbeat heart murmurs bad heart valves palpitations swelling of feet high blood pressure orthopnea paroxysmal nocturnal dyspnea or history of stress test arteriogram or pacemaker implantation PULMONARY Normal Negative for cough sputum shortness of breath wheezing asthma or emphysema GASTROINTESTINAL Normal Negative for pain vomiting heartburn peptic ulcer disease change in stool rectal pain hernia hepatitis gallbladder disease hemorrhoids or bleeding GENITOURINARY Normal female OR male Negative for incontinence UTI dysuria hematuria vaginal discharge abnormal bleeding breast lumps nipple discharge skin or nipple changes sexually transmitted diseases incontinence yeast infections or itching SKIN Normal Negative for rashes keratoses skin cancers or acne MUSCULOSKELETAL Normal Negative for back pain joint pain joint swelling arthritis joint deformity problems with ambulation stiffness osteoporosis or injuries NEUROLOGIC Normal Negative for blackouts headaches seizures stroke or dizziness PSYCHIATRIC Normal Negative for anxiety depression or phobias ENDOCRINE Normal Negative for diabetes thyroid or problems with cholesterol or hormones HEMATOLOGIC LYMPHATIC Normal Negative for anemia swollen glands or blood disorders IMMUNOLOGIC Negative Negative for steroids chemotherapy or cancer VASCULAR Normal Negative for varicose veins blood clots atherosclerosis or leg ulcers Keywords office notes cough sputum shortness of breath fever weight fatigue aching nose throat swelling disease incontinence bleeding heartbeat blood joint MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty Office Notes Sample Name Normal ENT Exam 1 Transcription EARS NOSE MOUTH AND THROAT EARS NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis There are no signs of acute trauma The nose is normal to palpation and inspection externally without evidence of acute trauma Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion inflammation or swelling The tympanic membranes are without disruption or infection Hearing intact bilaterally to normal level speech Nasal mucosa septum and turbinate examination reveals normal mucous membranes without disruption or inflammation The septum is without acute traumatic lesions or disruption The turbinates are without abnormal swelling There is no unusual rhinorrhea or bleeding LIPS TEETH GUMS The lips are without infection mass lesion or traumatic lesions The teeth are intact without obvious signs of infection The gingivae are normal to palpation and inspection OROPHARYNX The oral mucosa is normal The salivary glands are without swelling The hard and soft palates are intact The tongue is without masses or swelling with normal movement The tonsils are without inflammation The posterior pharynx is without mass lesion with good patent oropharyngeal airway Keywords office notes oral mucosa lips hearing auditory canals tympanic membranes traumatic lesions mouth throat trauma nose membranes inflammation infection swelling MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty Office Notes Sample Name Normal ENT Exam Transcription EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing Keywords office notes erythema tympanic mouth throat ears mucosa noseNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Normal child physical exam template Medical Specialty Office Notes Sample Name Normal Child Exam Template Transcription CHILD PHYSICAL EXAMINATION VITAL SIGNS Birth weight is grams length occipitofrontal circumference Character of cry was lusty GENERAL APPEARANCE Well BREATHING Unlabored SKIN Clear No cyanosis pallor or icterus Subcutaneous tissue is ample HEAD Normal Fontanelles are soft and flat Sutures are opposed EYES Normal with red reflex x2 EARS Patent Normal pinnae canals TMs NOSE Patent nares MOUTH No cleft THROAT Clear NECK No masses CHEST Normal clavicles LUNGS Clear bilaterally HEART Regular rate and rhythm without murmur ABDOMEN Soft flat No hepatosplenomegaly The cord is three vessel GENITALIA Normal genitalia with testes descended bilaterally ANUS Patent SPINE Straight and without deformity EXTREMITIES Equal movements MUSCLE TONE Good REFLEXES Moro grasp and suck are normal HIPS No click or clunk Keywords office notes child physical examination physical genitalia child MEDICAL_TRANSCRIPTION,Description Patient with juvenile myoclonic epilepsy and recent generalized tonic clonic seizure Medical Specialty Office Notes Sample Name Myoclonic Epilepsy Transcription DIAGNOSES 1 Juvenile myoclonic epilepsy 2 Recent generalized tonic clonic seizure MEDICATIONS 1 Lamictal 250 mg b i d 2 Depo Provera INTERIM HISTORY The patient returns for followup Since last consultation she has tolerated Lamictal well but she has had a recurrence of her myoclonic jerking She has not had a generalized seizure She is very concerned that this will occur Most of the myoclonus is in the mornings Recent EEG did show polyspike and slow wave complexes bilaterally more prominent on the left She states that she has been very compliant with the medications and is getting a good amount of sleep She continues to drive Social history and review of systems are discussed above and documented on the chart PHYSICAL EXAMINATION Vital signs are normal Pupils are equal and reactive to light Extraocular movements are intact There is no nystagmus Visual fields are full Demeanor is normal Facial sensation and symmetry is normal No myoclonic jerks noted during this examination No myoclonic jerks provoked by tapping on her upper extremity muscles Negative orbit Deep tendon reflexes are 2 and symmetric Gait is normal Tandem gait is normal Romberg negative IMPRESSION AND PLAN Recurrence of early morning myoclonus despite high levels of Lamictal She is tolerating the medication well and has not had a generalized tonic clonic seizure She is concerned that this is a precursor for another generalized seizure She states that she is compliant with her medications and has had a normal sleep wake cycle Looking back through her notes she initially responded very well to Keppra but did have a breakthrough seizure on Keppra This was thought secondary to severe insomnia when her baby was very young Because she tolerated the medication well and it was at least partially affective I have recommended adding Keppra 500 mg b i d Side effect profile of this medication was discussed with the patient I will see in followup in three months Keywords office notes generalized tonic clonic seizure juvenile myoclonic epilepsy tonic clonic seizure myoclonic epilepsy tonic clonic juvenile myoclonus epilepsy myoclonic seizure MEDICAL_TRANSCRIPTION,Description Persistent left hip pain Left hip avascular necrosis Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing Medical Specialty Office Notes Sample Name Hip Pain Transcription CHIEF COMPLAINT Keywords office notes hip pain radiculopathy degenerative changes avascular necrosis hip resurfacing arthrodesis hip replacement avn MEDICAL_TRANSCRIPTION,Description An example template for a routine normal female physical exam Medical Specialty Office Notes Sample Name Normal Female Exam Template 2 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI nondisplaced Chest wall unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS In the seated and supine position unremarkable ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and no intraabdominal bruit auscultated EXTERNAL GENITALIA Normal for age RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords office notes heent general appearance hepatosplenomegaly mass tenderness rebound rigidity pulse bruit adenopathy chest percussion inspection palpation signs tongue MEDICAL_TRANSCRIPTION,Description Sample template for a normal female multisystem exam Medical Specialty Office Notes Sample Name Normal Female Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema BREASTS Breast inspection showed them to be symmetrical with no nipple discharge Palpation of the breasts and axilla revealed no obvious mass that I could appreciate GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The external genitalia appeared to be normal The pelvic exam revealed no adnexal masses The uterus appeared to be normal in size and there was no cervical motion tenderness LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords MEDICAL_TRANSCRIPTION,Description Nephrology office visit for followup of microscopic hematuria Medical Specialty Office Notes Sample Name Nephrology Office Visit 1 Transcription HISTORY OF PRESENT ILLNESS The patient is a 78 year old woman here because of recently discovered microscopic hematuria History of present illness occurs in the setting of a recent check up which demonstrated red cells and red cell casts on a routine evaluation The patient has no new joint pains however she does have a history of chronic degenerative joint disease She does not use nonsteroidal agents She has had no gross hematuria and she has had no hemoptysis REVIEW OF SYSTEMS No chest pain or shortness of breath no problem with revision The patient has had decreased hearing for many years She has no abdominal pain or nausea or vomiting She has no anemia She has noticed no swelling She has no history of seizures PAST MEDICAL HISTORY Significant for hypertension and hyperlipidemia There is no history of heart attack or stroke She has had bilateral simple mastectomies done 35 years ago She has also had one third of her lung removed for carcinoma probably an adeno CA related to a pneumonia She also had hysterectomy in the past SOCIAL HISTORY She is a widow She does not smoke MEDICATIONS 1 Dyazide one a day 2 Pravachol 80 mg a day in the evening 3 Vitamin E once a day 4 One baby aspirin per day FAMILY HISTORY Unremarkable PHYSICAL EXAMINATION She looks younger than her stated age of 78 years She was hard of hearing but could read my lips Respirations were 16 She was afebrile Pulse was about 90 and regular Her gait was normal Blood pressure is 140 70 in her left arm seated HEENT She had arcus cornealis The pupils were equal The sclerae were not icteric The conjunctivae were pink NECK The thyroid is not palpated No nodes were palpated in the neck CHEST Clear to auscultation She had no sacral edema CARDIAC Regular but she was tachycardic at the rate of about 90 She had no diastolic murmur ABDOMEN Soft and nontender I did not palpate the liver EXTREMITIES She had no appreciable edema She had no digital clubbing She had no cyanosis She had changes of the degenerative joint disease in her fingers She had good pedal pulses She had no twitching or myoclonic jerks LABORATORY DATA The urine I saw 1 2 red cells per high power fields She had no protein She did have many squamous cells The patient has creatinine of 1 mg percent and no proteinuria It seems unlikely that she has glomerular disease however we cannot explain the red cells in the urine PLAN To obtain a routine sonogram I would also repeat a routine urinalysis to check for blood again I have ordered a C3 and C4 and if the repeat urine shows red cells I will recommend a cystoscopy with a retrograde pyelogram Keywords office notes nephrology creatinine cystoscopy glomerular high power fields hyperlipidemia hypertension microscopic hematuria proteinuria pyelogram red cell retrograde sonogram urinalysis red cells hematuria MEDICAL_TRANSCRIPTION,Description Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20 25 Medical Specialty Office Notes Sample Name Gen Med Office Note 1 Transcription HISTORY OF PRESENT ILLNESS The patient is a 43 year old male who was recently discharged from our care on the 1 13 06 when he presented for shortness of breath He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20 25 The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure During his hospital stay he was commenced on metoprolol for rate control and given that he had atrial fibrillation he was also started on warfarin which his INR has been followed up by the Homeless Clinic For his congestive cardiac failure he was restarted on Digoxin and lisinopril For his hyperthyroidism we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy He was restarted on PTU and discharged from the hospital on this medication While in the hospital it was also noted that he abused cigarettes and cocaine and we advised strongly against this given the condition of his heart It was also noted that he had elevated liver function tests which an ultrasound was normal but his hepatitis panel was pending Since his discharge his hepatitis panel has come back normal for hepatitis A B and C Since discharge the patient has complained of shortness of breath mainly at night when lying flat but otherwise he states he has been well and compliant with his medication MEDICATIONS Digoxin 250 mcg daily lisinopril 5 mg daily metoprolol 50 mg twice daily PTU propylthiouracil 300 mg orally four times a day warfarin variable dose based on INR PHYSICAL EXAMINATION VITAL SIGNS He was afebrile today Blood pressure 114 98 Pulse 92 but irregular Respiratory rate 25 HEENT Obvious exophthalmus but no obvious lid lag today NECK There was no thyroid mass palpable CHEST Clear except for occasional bibasilar crackles CARDIOVASCULAR Heart sounds were dual but irregular with no additional sounds ABDOMEN Soft nontender nondistended EXTREMITIES Mild 1 peripheral edema in both legs PLAN The patient has also been attending the Homeless Clinic since discharge from the hospital where he has been receiving quality care and they have been looking after every aspect of his health including his hyperthyroidism It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic at which time he should attend endocrine review with Dr Huffman for further treatment of his hyperthyroidism Regarding his atrial fibrillation he is moderately rate controlled with metoprolol 50 mg b i d His rate in clinic today was 92 He could benefit from increasing his metoprolol dose however in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure Regarding his congestive cardiac failure he currently appears stable with some variation in his weight He states he has been taking his wife s Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema We should consider adding him on a low dose furosemide tablet to be taken either daily or when his weight is above his target range A Digoxin level has not been repeated since discharge and we feel that this should be followed up We have also increased his lisinopril to 5 mg daily but the patient did not receive his script upon departing our clinic Regarding his elevated liver function tests we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel but yet the liver function tests should be followed up Keywords office notes congestive cardiac failure ejection fraction atrial fibrillation congestive cardiac cardiac failure office lisinopril metoprolol hepatitis fibrillation hyperthyroidism atrial cardiac congestive MEDICAL_TRANSCRIPTION,Description Patient complains of constipation Has not had BM for two days Medical Specialty Office Notes Sample Name Constipation 1 Transcription Patient was informed by Dr ABC that he does not need sleep study as per patient PHYSICAL EXAMINATION General Pleasant brighter Vital signs 117 78 12 56 Abdomen Soft nontender Bowel sounds normal ASSESSMENT AND PLAN 1 Constipation Milk of Magnesia 30 mL daily p r n Dulcolax suppository twice a week p r n 2 CAD angina See cardiologist this afternoon Call me if constipation not resolved by a m consider a Fleet enema then as discussed Keywords office notes constipation bm milk of magnesia suppository dulcolax fleet enema MEDICAL_TRANSCRIPTION,Description The patient with continued problems with her headaches Medical Specialty Office Notes Sample Name Headache Office Visit Transcription She also had EMG nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy moderate right ulnar neuropathy bilateral mild to moderate carpal tunnel and diabetic neuropathy She was referred to Dr XYZ and will be seeing him on August 8 2006 She was also never referred to the endocrine clinic to deal with her poor diabetes control Her last hemoglobin A1c was 10 PAST MEDICAL HISTORY Diabetes hypertension elevated lipids status post CVA and diabetic retinopathy MEDICATIONS Glyburide Avandia metformin lisinopril Lipitor aspirin metoprolol and Zonegran PHYSICAL EXAMINATION Blood pressure was 140 70 heart rate was 76 respiratory rate was 18 and weight was 226 pounds On general exam she has an area of tenderness on palpation in the left parietal region of her scalp Neurological exam is detailed on our H P form Her neurological exam is within normal limits IMPRESSION AND PLAN For her headaches we are going to titrate Zonegran up to 200 mg q h s to try to maximize the Zonegran therapy If this is not effective when she comes back on August 7 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica We also discussed with Ms Hawkins the possibility of nerve block injection however at this point she is not interested She will be seeing Dr XYZ for her neuropathies We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult Keywords office notes nerve conduction studies emg zonegran therapy ulnar neuropathy endocrine clinic diabetes control neurological exam headache zonegran MEDICAL_TRANSCRIPTION,Description Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain Medical Specialty Office Notes Sample Name Chest Pain Office Note Transcription DISCHARGE DIAGNOSES 1 Chest pain The patient ruled out for myocardial infarction on serial troponins Result of nuclear stress test is pending 2 Elevated liver enzymes etiology uncertain for an outpatient followup 3 Acid reflux disease TEST DONE Nuclear stress test results of which are pending HOSPITAL COURSE This 32 year old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain O2 saturation at 94 with both atypical and typical features of ischemia The patient ruled out for myocardial infarction with serial troponins Nuclear stress test has been done results of which are pending The patient is stable to be discharged pending the results of nuclear stress test and cardiologist s recommendations He will follow up with cardiologist Dr X in two weeks and with his primary physician in two to four weeks Discharge medications will depend on results of nuclear stress test Keywords office notes chest pain serial troponins premature coronary artery disease coronary artery disease nuclear stress test stress test MEDICAL_TRANSCRIPTION,Description Induction of vaginal delivery of viable male Apgars 8 and 9 Term pregnancy and oossible rupture of membranes prolonged Medical Specialty Office Notes Sample Name Induction of Vaginal Delivery Transcription DIAGNOSES 1 Term pregnancy 2 Possible rupture of membranes prolonged PROCEDURE Induction of vaginal delivery of viable male Apgars 8 and 9 HOSPITAL COURSE The patient is a 20 year old female gravida 4 para 0 who presented to the office She had small amount of leaking since last night On exam she was positive Nitrazine no ferning was noted On ultrasound her AFI was about 4 7 cm Because of a variable cervix oligohydramnios and possible ruptured membranes we recommended induction She was brought to the hospital and begun on Pitocin Once she was in her regular pattern we ruptured her bag of water fluid was clear She went rapidly to completion over the next hour and a half She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation Upon delivery of the head the anterior and posterior arms were delivered and remainder of the baby without complications The baby was vigorous moving all extremities The cord was clamped and cut The baby was handed off to mom with nurse present Apgars were 8 and 9 Placenta was delivered spontaneously intact Three vessel cord with no retained placenta Estimated blood loss was about 150 mL There were no tears Keywords office notes induction of vaginal delivery vaginal delivery viable male pregnancy placenta vaginal membranes apgars MEDICAL_TRANSCRIPTION,Description Cardiology office visit sample note Medical Specialty Office Notes Sample Name Cardiology Office Visit 2 Transcription HISTORY OF PRESENT ILLNESS This 57 year old black female was seen in my office on Month DD YYYY for further evaluation and management of hypertension Patient has severe backache secondary to disc herniation Patient has seen an orthopedic doctor and is scheduled for surgery Patient also came to my office for surgical clearance Patient had cardiac cath approximately four years ago which was essentially normal Patient is documented to have morbid obesity and obstructive sleep apnea syndrome Patient does not use a CPAP mask Her exercise tolerance is eight to ten feet for shortness of breath Patient also has two pillow orthopnea She has intermittent pedal edema PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 135 70 Respirations 18 per minute Heart rate 70 beats per minute Weight 258 pounds HEENT Head normocephalic Eyes no evidence of anemia or jaundice Oral hygiene is good NECK Supple JVP is flat Carotid upstroke is good LUNGS Clear CARDIOVASCULAR There is no murmur or gallop heard over the precordium ABDOMEN Soft There is no hepatosplenomegaly EXTREMITIES The patient has no pedal edema MEDICATIONS 1 BuSpar 50 mg daily 2 Diovan 320 12 5 daily 3 Lotrel 10 20 daily 4 Zetia 10 mg daily 5 Ambien 10 mg at bedtime 6 Fosamax 70 mg weekly DIAGNOSES 1 Controlled hypertension 2 Morbid obesity 3 Osteoarthritis 4 Obstructive sleep apnea syndrome 5 Normal coronary arteriogram 6 Severe backache PLAN 1 Echocardiogram stress test 2 Routine blood tests 3 Sleep apnea study 4 Patient will be seen again in my office in two weeks Keywords MEDICAL_TRANSCRIPTION,Description Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only Medical Specialty Office Notes Sample Name Abnormal Stress Test Transcription HISTORY OF PRESENT ILLNESS Mr ABC is a 60 year old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only He required 3 sublingual nitroglycerin in total please see also admission history and physical for full details The patient underwent cardiac catheterization with myself today which showed mild to moderate left main distal disease of 30 moderate proximal LAD with a severe mid LAD lesion of 99 and a mid left circumflex lesion of 80 with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA I discussed these results with the patient and he had been relating to me that he was having rest anginal symptoms as well as nocturnal anginal symptoms and especially given the severity of the mid left anterior descending lesion with a markedly abnormal stress test I felt he was best suited for transfer for PCI I discussed the case with Dr X at Medical Center who has kindly accepted the patient in transfer CONDITION ON TRANSFER Stable but guarded The patient is pain free at this time MEDICATIONS ON TRANSFER 1 Aspirin 325 mg once a day 2 Metoprolol 50 mg once a day but we have had to hold it because of relative bradycardia which he apparently has a history of 3 Nexium 40 mg once a day 4 Zocor 40 mg once a day and there is a fasting lipid profile pending at the time of this dictation I see that his LDL was 136 on May 3 2002 5 Plavix 600 mg p o x1 which I am giving him tonight Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation GERD arthritis DISPOSITION The patient and his wife have requested and are agreeable with transfer to Medical Center and we are enclosing the CD ROM of his images Keywords office notes standard bruce nitroglycerin abnormal stress test st depressions anginal symptoms stress test lad anginal stress MEDICAL_TRANSCRIPTION,Description Vacuum assisted vaginal delivery of a third degree midline laceration and right vaginal side wall laceration and repair of the third degree midline laceration lasting for 25 minutes Medical Specialty Obstetrics Gynecology Sample Name Vaginal Delivery Vacuum Assisted Transcription PREOPERATIVE DIAGNOSES 1 A 40 weeks 6 days intrauterine pregnancy 2 History of positive serology for HSV with no evidence of active lesions 3 Non reassuring fetal heart tones POST OPERATIVE DIAGNOSES 1 A 40 weeks 6 days intrauterine pregnancy 2 History of positive serology for HSV with no evidence of active lesions 3 Non reassuring fetal heart tones PROCEDURES 1 Vacuum assisted vaginal delivery of a third degree midline laceration and right vaginal side wall laceration 2 Repair of the third degree midline laceration lasting for 25 minutes ANESTHESIA Local ESTIMATED BLOOD LOSS 300 mL COMPLICATIONS None FINDINGS 1 Live male infant with Apgars of 9 and 9 2 Placenta delivered spontaneously intact with a three vessel cord DISPOSITION The patient and baby remain in the LDR in stable condition SUMMARY This is a 36 year old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix When she was admitted her cervix was 2 5 cm dilated with 80 effacement The baby had a 2 station She had no regular contractions Fetal heart tones were 120s and reactive She was started on Pitocin for labor induction and labored quite rapidly She had spontaneous rupture of membranes with a clear fluid She had planned on an epidural however she had sudden rapid cervical change and was unable to get the epidural With the rapid cervical change and descent of fetal head there were some variable decelerations The baby was at a 1 station when the patient began pushing I had her push to get the baby to a 2 station During pushing the fetal heart tones were in the 80s and did not recover in between contractions Because of this I recommended a vacuum delivery for the baby The patient agreed The baby s head was confirmed to be in the right occiput anterior presentation The perineum was injected with 1 lidocaine The bladder was drained The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally With the patient s next contraction the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby s head to a 3 station The contraction ended The vacuum was released and the fetal heart tones remained in the at this time 90s to 100s With the patient s next contraction the vacuum was reapplied and the baby s head was delivered to a 4 station A modified Ritgen maneuver was used to stabilize the fetal head The vacuum was deflated and removed The baby s head then delivered atraumatically There was no nuchal cord The baby s anterior shoulder delivered after a less than 30 second delay No additional maneuvers were required to deliver the anterior shoulder The posterior shoulder and remainder of the body delivered easily The baby s mouth and nose were bulb suctioned The cord was clamped x2 and cut The infant was handed to the respiratory therapist Pitocin was added to the patient s IV fluids The placenta delivered spontaneously was intact and had a three vessel cord A vaginal inspection revealed a third degree midline laceration as well as a right vaginal side wall laceration The right side wall laceration was repaired with 3 0 Vicryl suture in a running fashion with local anesthesia The third degree laceration was also repaired with 3 0 Vicryl sutures Local anesthesia was used The capsule was visible but did not appear to be injured at all It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with 3 0 Vicryl in the typical fashion The patient tolerated the procedure very well She remains in the LDR with the baby The baby is vigorous crying and moving all extremities He will go to the new born nursery when ready The total time for repair of the laceration was 25 minutes Keywords obstetrics gynecology intrauterine pregnancy non reassuring fetal heart tones vacuum assisted vaginal delivery vaginal side wall laceration fetal heart tones vaginal delivery vacuum assisted laceration intrauterine tones contractions MEDICAL_TRANSCRIPTION,Description The patient needs refills on her Xanax Medical Specialty Office Notes Sample Name Consult Smoking Cessation Transcription CHIEF COMPLAINT I need refills HISTORY OF PRESENT ILLNESS The patient presents today stating that she needs refills on her Xanax and she would also like to get something to help her quit smoking She is a new patient today She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain She states that she is under the care of a cancer specialist however she just recently moved back to this area and is trying to find a doctor a little closer than his office She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try OBJECTIVE Well developed and well nourished She does not appear to be in any acute distress Cardiovascular Regular rhythm No murmurs gallops or rubs Capillary refill less than 3 seconds Peripheral pulses are 2 bilaterally Respiratory Her lungs are clear to auscultation bilaterally with good effort No tenderness to palpation over chest wall Musculoskeletal She has full range of motion of all four extremities No tenderness to palpation over long bones Skin Warm and dry No rashes or lesions Neuro Alert and oriented x3 Cranial nerves II XII are grossly intact No focal deficits PLAN I did refill her medications I have requested that she have her primary doctor forward her records to me I have discussed Chantix and its use and success rate She was given a prescription as well as a coupon She is to watch for any worsening signs or symptoms She verbalized understanding of discharge instructions and prescriptions I would like to see her back to proceed with her preventive health measures Keywords office notes quit smoking chantix mesothelioma smoking xanax refills MEDICAL_TRANSCRIPTION,Description A 21 year old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office Medical Specialty Obstetrics Gynecology Sample Name Vacuum D C Transcription PREOPERATIVE DIAGNOSIS Blighted ovum severe cramping POSTOPERATIVE DIAGNOSIS Blighted ovum severe cramping OPERATION PERFORMED Vacuum D C DRAINS None ANESTHESIA General HISTORY This 21 year old white female gravida 1 para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office Due to the severe cramping a decision to undergo vacuum D C was made At the time of the procedure moderate amount of tissue was obtained PROCEDURE The patient was taken to the operating room and placed in a supine position at which time a general form of anesthesia was administered by the anesthesia department The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion A weighted vaginal speculum was placed in the posterior vaginal vault Anterior lip of the cervix was grasped with single tooth tenaculum and the cervix was dilated to approximately 8 mm straight Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction Methargen 0 2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure Once the procedure was completed the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed The patient was repositioned to supine position and taken to recovery room in stable condition Keywords obstetrics gynecology pitocin single tooth tenaculum vaginal vault vacuum d c blighted ovum speculum tenaculum curetting blighted cramping MEDICAL_TRANSCRIPTION,Description Laparoscopic assisted vaginal hysterectomy Abnormal uterine bleeding Uterine fibroids Medical Specialty Obstetrics Gynecology Sample Name Vaginal Hysterectomy Laparoscopic Assisted Transcription PREOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Uterine fibroids POSTOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Uterine fibroids OPERATION PERFORMED Laparoscopic assisted vaginal hysterectomy ANESTHESIA General endotracheal anesthesia DESCRIPTION OF PROCEDURE After adequate general endotracheal anesthesia the patient was placed in dorsal lithotomy position prepped and draped in the usual manner for a laparoscopic procedure A speculum was placed into the vagina A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix The uterus was sounded to 10 5 cm A 10 RUMI cannula was utilized and attached for uterine manipulation The single tooth tenaculum and speculum were removed from the vagina At this time the infraumbilical area was injected with 0 25 Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity Aspiration was negative therefore the abdomen was insufflated with carbon dioxide After adequate insufflation Veress needle was removed and an 11 mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity Through the trocar sheath the laparoscope was inserted and adequate visualization of the pelvic structures was noted At this time the suprapubic area was injected with 0 25 Marcaine with epinephrine A 5 mm skin incision was made and a 5 mm trocar was introduced into the abdominal cavity for instrumentation Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular The fallopian tubes have been previously interrupted surgically The ovaries appeared normal bilaterally The cul de sac was clean without evidence of endometriosis scarring or adhesions The ureters were noted to be deep in the pelvis At this time the right cornu was grasped and the right fallopian tube uteroovarian ligament and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery The uterine artery was identified It was doubly coagulated with bipolar electrocautery and transected A similar procedure was carried out on the left with the left uterine cornu identified The left fallopian tube uteroovarian ligament and round ligaments were doubly coagulated with bipolar electrocautery and transected The remainder of the cardinal ligament uterine vessels anterior and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery The uterine artery was identified It was doubly coagulated with bipolar electrocautery and transected The anterior leaf of the broad ligament was then dissected to the midline bilaterally establishing a bladder flap with a combination of blunt and sharp dissection At this time attention was made to the vaginal hysterectomy The laparoscope was removed and attention was made to the vaginal hysterectomy The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum A circumferential injection with 0 25 Marcaine with epinephrine was made at the cervicovaginal portio A circumferential incision was then made at the cervicovaginal portio The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty The right uterosacral ligament was clamped transected and ligated with 0 Vicryl sutures The left uterosacral ligament was clamped transected and ligated with 0 Vicryl suture The parametrial tissue was then clamped bilaterally transected and ligated with 0 Vicryl suture bilaterally The uterus was then removed and passed off the operative field Laparotomy pack was placed into the pelvis The pedicles were evaluated There was no bleeding noted therefore the laparotomy pack was removed The uterosacral ligaments were suture fixated into the vaginal cuff angles with 0 Vicryl sutures The vaginal cuff was then closed in a running fashion with 0 Vicryl suture Hemostasis was noted throughout At this time the laparoscope was reinserted into the abdomen The abdomen was reinsufflated Evaluation revealed no further bleeding Irrigation with sterile water was performed and again no bleeding was noted The suprapubic trocar sheath was then removed under laparoscopic visualization The laparoscope was removed The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed The skin incisions were closed with 4 0 Vicryl in subcuticular fashion Neosporin and Band Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition Estimated blood loss was approximately 100 mL There were no complications The instrument sponge and needle counts were correct Keywords obstetrics gynecology abnormal uterine bleeding laparoscopic assisted vaginal hysterectomy uterine fibroids bipolar electrocautery vaginal hysterectomy vicryl sutures tooth uterine uterosacral laparoscope electrocautery hysterectomy laparoscopic coagulated vaginal ligament transected MEDICAL_TRANSCRIPTION,Description Pregnant female with nausea vomiting and diarrhea OB ultrasound less than 14 weeks transvaginal Medical Specialty Obstetrics Gynecology Sample Name Ultrasound OB 8 Transcription REASON FOR EXAM Pregnant female with nausea vomiting and diarrhea FINDINGS The uterus measures 8 6 x 4 4 x 5 4 cm and contains a gestational sac with double decidual sac sign A yolk sac is visualized What appears to represent a crown rump length measures 3 3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09 28 09 Please note however that no fetal heart tones are seen However fetal heart tones would be expected at this age The right ovary measures 3 1 x 1 6 x 2 3 cm The left ovary measures 3 3 x 1 9 x 3 5 cm No free fluid is detected IMPRESSION Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09 28 09 A live intrauterine pregnancy however could not be confirmed as a sonographic fetal heart rate would be expected at this time A close interval followup in correlation with beta hCG is necessary as findings may represent an inevitable abortion Keywords obstetrics gynecology intrauterine pregnancy estimated date of delivery nausea vomiting fetal heart tones ovary measures fetal heart ultrasound ob ovary pregnancy sac fetal intrauterine MEDICAL_TRANSCRIPTION,Description The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Medical Specialty Obstetrics Gynecology Sample Name Uterine Papillary Serous Carcinoma Transcription HISTORY OF PRESENT ILLNESS The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Her last cycle of chemotherapy was finished on 01 18 08 and she complains about some numbness in her right upper extremity This has not gotten worse recently and there is no numbness in her toes She denies any tingling or burning REVIEW OF SYSTEMS Negative for any fever chills nausea vomiting headache chest pain shortness of breath abdominal pain constipation diarrhea melena hematochezia or dysuria The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head PHYSICAL EXAMINATION VITAL SIGNS Temperature 35 6 blood pressure 143 83 pulse 65 respirations 18 and weight 66 5 kg GENERAL She is a middle aged white female not in any distress HEENT No lymphadenopathy or mucositis CARDIOVASCULAR Regular rate and rhythm LUNGS Clear to auscultation bilaterally EXTREMITIES No cyanosis clubbing or edema NEUROLOGICAL No focal deficits noted PELVIC Normal appearing external genitalia Vaginal vault with no masses or bleeding LABORATORY DATA None today RADIOLOGIC DATA CT of the chest abdomen and pelvis from 01 28 08 revealed status post total abdominal hysterectomy bilateral salpingo oophorectomy with an unremarkable vaginal cuff No local or distant metastasis Right probably chronic gonadal vein thrombosis ASSESSMENT This is a 67 year old white female with history of uterine papillary serous carcinoma status post total abdominal hysterectomy and bilateral salpingo oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy She is doing well with no evidence of disease clinically or radiologically PLAN 1 Plan to follow her every 3 months and CT scans every 6 months for the first 2 years 2 The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated 3 The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now 4 The patient was advised about doing Kegel exercises for urinary incontinence and we will address this issue again during next clinic visit if it is persistent Keywords obstetrics gynecology chemotherapy uterine papillary serous carcinoma oophorectomy carboplatin taxol abdominal uterine papillary carcinoma MEDICAL_TRANSCRIPTION,Description Exam under anesthesia with uterine suction curettage A 10 1 2 week pregnancy spontaneous incomplete abortion Medical Specialty Obstetrics Gynecology Sample Name Uterine Suction Curettage Transcription PREOPERATIVE DIAGNOSIS A 10 1 2 week pregnancy spontaneous incomplete abortion POSTOPERATIVE DIAGNOSIS A 10 1 2 week pregnancy spontaneous incomplete abortion PROCEDURE Exam under anesthesia with uterine suction curettage ANESTHESIA Spinal ESTIMATED BLOOD LOSS Less than 10 cc COMPLICATIONS None DRAINS None CONDITION Stable INDICATIONS The patient is a 29 year old gravida 5 para 1 0 3 1 with an LMP at 12 18 05 The patient was estimated to be approximately 10 1 2 weeks so long in her pregnancy She began to have heavy vaginal bleeding and intense lower pelvic cramping She was seen in the emergency room where she was found to be hemodynamically stable On pelvic exam her cervix was noted to be 1 to 2 cm dilated and approximately 90 effaced There were bulging membranes protruding through the dilated cervix These symptoms were consistent with the patient s prior experience of spontaneous miscarriages These findings were reviewed with her and options for treatment discussed She elected to proceed with an exam under anesthesia with uterine suction curettage The risks and benefits of the surgery were discussed with her and knowing these she gave informed consent PROCEDURE The patient was taken to the operating room where she was placed in the seated position A spinal anesthetic was successfully administered She was then moved to a dorsal lithotomy position She was prepped and draped in the usual fashion for the procedure After adequate spinal level was confirmed a bimanual exam was again performed This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size The previously noted cervical exam was confirmed The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution This solution was then removed approximately 10 minutes later with dry sterile gauze sponge The anterior cervical lip was then attached with a ring clamp The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied The tissue dislodged revealing fluid mixed with blood as well as an apparent 10 week fetus The placental tissue was then gently tractioned out as well A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity With the vacuum tubing applied in rotary motion a moderate amount of tissue consistent with products of conception was evacuated The sharp curette was then utilized to probe the endometrial surface A small amount of additional tissue was then felt in the posterior uterine wall This was curetted free A second pass was then made with a vacuum curette Again the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered A final pass was then made with a suction curette The ring clamp was then removed from the anterior cervical lip There was only a small amount of bleeding following the curettage The weighted speculum was then removed as well The bimanual exam was repeated and good involution was noted The patient was taken down from the dorsal lithotomy position She was transferred to the recovery room in stable condition The sponge and instrument count was performed and found to be correct The specimen of products of conception and 10 week fetus were submitted to Pathology for further evaluation The estimated blood loss for the procedure is less than 10 mL Keywords obstetrics gynecology spontaneous incomplete abortion uterine suction curettage fetus anterior cervical lip spontaneous incomplete abortion bimanual exam ring clamp suction curettage uterine curettage suction MEDICAL_TRANSCRIPTION,Description A 34 year old female with no fetal heart motion noted on office scan Medical Specialty Obstetrics Gynecology Sample Name Ultrasound OB 2 Transcription FINDINGS By dates the patient is 8 weeks 2 days There is a gestational sac within the endometrial cavity measuring 2 1cm consistent with 6 weeks 4 days There is a fetal pole measuring 7mm consistent with 6 weeks 4 days There was no fetal heart motion on Doppler or on color Doppler There is no fluid within the endometrial cavity There is a 2 8 x 1 2cm right adnexal cyst IMPRESSION Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days By dates the patient is 8 weeks 2 days A preliminary report was called by the ultrasound technologist to the referring physician Keywords obstetrics gynecology fetal heart motion gestational sac endometrial cavity fetal pole fetal heart heart motion gestational fetal MEDICAL_TRANSCRIPTION,Description Ultrasound a 22 year old pregnant female Medical Specialty Obstetrics Gynecology Sample Name Ultrasound OB 6 Transcription GENERAL EVALUATION Fetal Cardiac Activity Normal at 140 BPM Fetal Position Variable Placenta Posterior without evidence of placenta previa Uterus Normal Cervix Keywords obstetrics gynecology pregnant female fetal anatomy pregnant placenta gestational ultrasound fetal MEDICAL_TRANSCRIPTION,Description OB Ultrasound A 29 year old female requests for size and date of pregnancy Medical Specialty Obstetrics Gynecology Sample Name Ultrasound OB 1 Transcription EXAM OB Ultrasound HISTORY A 29 year old female requests for size and date of pregnancy FINDINGS A single live intrauterine gestation in the cephalic presentation fetal heart rate is measured 147 beats per minute Placenta is located posteriorly grade 0 without previa Cervical length is 4 2 cm There is normal amniotic fluid index of 12 2 cm There is a 4 chamber heart There is spontaneous body limb motion The stomach bladder kidneys cerebral ventricles heel spine extremities and umbilical cord are unremarkable BIOMETRIC DATA BPD 7 77 cm 31 weeks 1 day HC 28 26 cm 31 weeks 1 day AC 26 63 cm 30 weeks 5 days FL 6 06 cm 31 weeks 4 days Composite sonographic age 30 weeks 6 days plus minus 17 days ESTIMATED DATE OF DELIVERY Month DD YYYY Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces IMPRESSION Single live intrauterine gestation without complications as described Keywords obstetrics gynecology ultrasound ac bpd cervical length estimated date of delivery fl hc placenta single live amniotic fluid bladder cephalic cephalic presentation cerebral ventricles extremities fetal heart rate fetal weight gestation heel intrauterine kidneys pregnancy previa spine stomach umbilical cord live intrauterine intrauterine gestation MEDICAL_TRANSCRIPTION,Description Transvaginal ultrasound to evaluate pelvic pain Medical Specialty Obstetrics Gynecology Sample Name Ultrasound Transvaginal Transcription EXAM Transvaginal ultrasound HISTORY Pelvic pain FINDINGS The right ovary measures 1 6 x 3 4 x 2 0 cm There are several simple appearing probable follicular cysts There is no abnormal flow to suggest torsion on the right Left ovary is enlarged demonstrating a 6 0 x 3 5 x 3 7 cm complex cystic mass of uncertain etiology This could represent a large hemorrhagic cyst versus abscess There is no evidence for left ovarian torsion There is a small amount of fluid in the cul de sac likely physiologic The uterus measures 7 7 x 5 0 cm The endometrial echo is normal at 6 mm IMPRESSION 1 No evidence for torsion 2 Large complex cystic left ovarian mass as described This could represent a large hemorrhagic cyst however an abscess neoplasm cannot be excluded Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature Keywords obstetrics gynecology ultrasound pelvic pain transvaginal cul de sac cystic mass echo endometrial flow follicular cysts hemorrhagic cyst laparoscopic neoplasm ovarian ovary uterus transvaginal ultrasound complex cystic torsion MEDICAL_TRANSCRIPTION,Description Ultrasound of pelvis menorrhagia Medical Specialty Obstetrics Gynecology Sample Name Ultrasound Pelvis Transcription EXAM Ultrasound of pelvis HISTORY Menorrhagia FINDINGS Uterus is enlarged measuring 11 0 x 7 5 x 11 0 cm It appears to be completely replaced by multiple ill defined fibroids The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids The right ovary measures 3 9 x 1 9 x 2 3 cm The left ovary is not seen No complex cystic adnexal masses are identified IMPRESSION Essential replacement of the uterus by fibroids It is difficult to measure given their heterogenous and diffuse nature MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization Keywords obstetrics gynecology pelvis mri menorrhagia ultrasound adnexa echo complex endometrial fibroids ovary uterine fibroid uterus ultrasound of pelvis MEDICAL_TRANSCRIPTION,Description Desires permanent sterilization Laparoscopic tubal ligation Falope ring method Normal appearing uterus and adnexa bilaterally Medical Specialty Obstetrics Gynecology Sample Name Tubal Ligation Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Desires permanent sterilization POSTOPERATIVE DIAGNOSIS Desires permanent sterilization PROCEDURE Laparoscopic tubal ligation Falope ring method ANESTHESIA General ESTIMATED BLOOD LOSS 10 mL COMPLICATIONS None INDICATIONS FOR SURGERY A 35 year old female P4 0 0 4 who desires permanent sterilization The risks of bleeding infection damage to other organs and subsequent ectopic pregnancy was explained Informed consent was obtained OPERATIVE FINDINGS Normal appearing uterus and adnexa bilaterally DESCRIPTION OF PROCEDURE After administration of general anesthesia the patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion The speculum was placed in the vagina the cervix was grasped with the tenaculum and a uterine manipulator inserted This area was then draped off the remainder of the operative field A 5 mm incision was made umbilically after injecting 0 25 Marcaine 2 mL A Veress needle was inserted to confirm an opening pressure of 2 mmHg Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity The Veress needle was removed and a 5 mm port placed Position was confirmed using a laparoscope A second port was placed under direct visualization 3 fingerbreadths suprapubically 7 mm in diameter after 2 mL of 0 25 Marcaine was injected This was done under direct visualization The pelvic cavity was examined with the findings as noted above The Falope rings were then applied to each tube bilaterally Good segments were noted to be ligated The accessory port was removed The abdomen was deflated The laparoscope and sheath was removed The skin edges were approximated with 5 0 Monocryl suture in subcuticular fashion The instruments were removed from the vagina The patient was returned to the supine position recalled from anesthesia and transferred to the recovery room in satisfactory condition Sponge and needle counts correct at the conclusion of the case Estimated blood loss was minimal Keywords obstetrics gynecology tenaculum uterine manipulator veress needle tubal ligation permanent sterilization uterus adnexa cavity laparoscope laparoscopic needle sterilization MEDICAL_TRANSCRIPTION,Description Ultrasound OB followup for fetal growth Medical Specialty Obstetrics Gynecology Sample Name Ultrasound OB Transcription REASON FOR EXAM Followup for fetal growth INTERPRETATION Real time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented FETAL BIOMETRY BPD 8 3 cm 33 weeks 4 days HC 30 2 cm 33 weeks 4 days AC 27 9 cm 32 weeks 0 days FL 6 4 cm 33 weeks 1 day The head to abdomen circumference ratio is normal at 1 08 and the femur length to abdomen circumference ratio is normal at 23 0 Estimated fetal weight is 2 001 grams The amniotic fluid volume appears normal and the calculated index is normal for the age at 13 7 cm A detailed fetal anatomic exam was not performed at this setting this being a limited exam for growth The placenta is posterofundal and grade 2 IMPRESSION Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks 5 days plus or minus 17 days giving and estimated date of confinement of 8 04 05 There has been normal progression of fetal growth compared to the two prior exams of 2 11 05 and 4 04 05 The examination of 4 04 05 questioned an echogenic focus within the left ventricle The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle Keywords obstetrics gynecology amniotic fluid volume placenta posterofundal intrauterine pregnancy followup for fetal growth ultrasound ob cephalic presentation abdomen circumference circumference ratio echogenic focus fetal growth fetal MEDICAL_TRANSCRIPTION,Description Laparoscopic bilateral tubal ligation with Falope rings Medical Specialty Obstetrics Gynecology Sample Name Tubal Ligation Transcription DIAGNOSIS Multiparous female desires permanent sterilization NAME OF OPERATION Laparoscopic bilateral tubal ligation with Falope rings ANESTHESIA General ET tube COMPLICATIONS None FINDINGS Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid PROCEDURE The patient was taken to the operating room and placed on the table in the supine position After adequate general anesthesia was obtained she was placed in the lithotomy position and examined She was found to have an anteverted uterus and no adnexal mass She was prepped and draped in the usual fashion The Foley catheter was placed A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix An infraumbilical incision was made with the knife A Veress needle was inserted into the abdomen Intraperitoneal location was verified with approximately 10 cc of sterile solution A pneumoperitoneum was created The Veress needle was then removed and a trocar was inserted directly without difficulty Intraperitoneal location was verified visually with the laparoscope There was no evidence of any intra abdominal trauma Each fallopian tube was elevated with a Falope ring applicator and a Falope ring was placed on each tube with a 1 cm to 1 5 cm portion of the tube above the Falope ring The pneumoperitoneum was evacuated and the trocar was removed under direct visualization An attempt was made to close the fascia with a figure of eight suture However this was felt to be more subcutaneous The skin was closed in a subcuticular fashion and the patient was taken to the recovery room awake with vital signs stable Keywords obstetrics gynecology sterilization laparoscopic bilateral tubal ligation with falope rings falope ring applicator laparoscopic bilateral tubal ligation bilateral tubal ligation veress needle tubal ligation falope rings anesthesia tubal ligation falope MEDICAL_TRANSCRIPTION,Description Laparoscopic tubal fulguration Medical Specialty Obstetrics Gynecology Sample Name Tubal Fulguration Laparoscopic Transcription A 1 cm infraumbilical skin incision was made Through this a Veress needle was inserted into the abdominal cavity The abdomen was filled with approximately 2 liters of CO2 gas The Veress needle was withdrawn A trocar sleeve was placed through the incision into the abdominal cavity The trocar was withdrawn and replaced with the laparoscope A 1 cm suprapubic skin incision was made Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope The trocar was withdrawn and replaced with a probe The patient was placed in Trendelenburg position and the bowel was pushed out of the pelvis Upon visualization of the pelvis organs the uterus fallopian tubes and ovaries were all normal The probe was withdrawn and replaced with the bipolar cautery instrument The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus Electrical current was applied to the tube at this point and fulgurated The tube was then regrasped just distal to this and refulgurated It was then regrasped just distal to the lateral point and refulgurated again The same procedure was then carried out on the opposite tube The bipolar cautery instrument was withdrawn and replaced with the probe The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes The upper abdomen was visualized and the liver surface was normal The gas was allowed to escape from the abdomen and the instruments were removed The skin incisions were repaired The instruments were removed from the vagina There were no complications to the procedure Blood loss was minimal The patient went to the postanesthesia recovery room in stable condition Keywords obstetrics gynecology tubal fulguration cohen cannula laparoscopic trendelenburg position veress needle abdominal cavity bipolar cautery dorsal lithotomy fallopian tubes fimbriated ends fulgurated laparoscope uterus distal trocar tubesNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Postpartum tubal ligation and removal of upper abdominal skin wall mass Medical Specialty Obstetrics Gynecology Sample Name Tubal Ligation Postpartum Transcription PREOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass POSTOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass OPERATION PERFORMED Postpartum tubal ligation and removal of upper abdominal skin wall mass ESTIMATED BLOOD LOSS Less than 5 mL DRAINS None ANESTHESIA Spinal INDICATION This is a 35 year old white female gravida 6 para 3 0 3 3 who is status post delivery on 09 18 2007 The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level PROCEDURE IN DETAIL The patient was taken to the operating room placed in a seated position with spinal form of anesthesia administered by anesthesia department The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed The fascia grasped with two Kocher s and then sharply incised and then peritoneum was entered with use of blunt dissection Two Army Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock s and followed to the fimbriated end A modified Pomeroy technique was completed with double tying of with 0 chromic then upper portion was sharply incised and the cut fallopian tube edges were then cauterized Adequate hemostasis was noted This tube was placed back in its anatomic position The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side and upper portion was then sharply incised and the cut edges re cauterized with adequate hemostasis and this was placed back in its anatomic position The peritoneum as well as fascia was reapproximated with 0 Vicryl The subcutaneous tissues reapproximated with 3 0 Vicryl and skin edges reapproximated with 4 0 Vicryl as well in a subcuticular stitch Pressure dressings were applied Marcaine 10 mL was used prior to making an incision Sterile dressing was applied The large mole like lesion was grasped with Allis It was approximately 1 cm x 0 5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4 0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied Instrument count needle count and sponge counts were all correct and the patient was taken to recovery room in stable condition Keywords obstetrics gynecology sterilization fallopian tube tubal ligation postpartum MEDICAL_TRANSCRIPTION,Description Postoperative day 1 total abdominal hysterectomy Normal postoperative course Medical Specialty Obstetrics Gynecology Sample Name Total Abdominal Hysterectomy Followup Transcription POSTOPERATIVE DAY 1 TOTAL ABDOMINAL HYSTERECTOMY SUBJECTIVE The patient is alert and oriented x3 and sitting up in bed The patient has been ambulating without difficulty The patient is still NPO The patient denies any new symptomatology from 6 10 2009 The patient has complaints of incisional tenderness The patient was given a full explanation about her clinical condition and all her questions were answered OBJECTIVE VITAL SIGNS Afebrile now Other vital signs are stable GU Urinating through Foley catheter ABDOMEN Soft negative rebound EXTREMITIES Without Homans nontender BACK Without CVA tenderness GENITALIA Vagina slight spotting Wound dry and intact ASSESSMENT Normal postoperative course PLAN 1 Follow clinically 2 Continue present therapy 3 Ambulate with nursing assistance only Keywords obstetrics gynecology postoperative course total abdominal hysterectomy postoperative MEDICAL_TRANSCRIPTION,Description Laparoscopic tubal sterilization tubal coagulation Medical Specialty Obstetrics Gynecology Sample Name Tubal Sterilization Coagulation Transcription PROCEDURE Laparoscopic tubal sterilization tubal coagulation PREOPERATIVE DIAGNOSIS Request tubal coagulation POSTOPERATIVE DIAGNOSIS Request tubal coagulation PROCEDURE Under general anesthesia the patient was prepped and draped in the usual manner Manipulating probe placed on the cervix changed gloves Small cervical stab incision was made Veress needle was inserted without problem A 3 L of carbon dioxide was insufflated The incision was enlarged A 5 mm trocar placed through the incision without problem Laparoscope placed through the trocar Pelvic contents visualized A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline Under direct vision the trocar was placed in the abdominal cavity Uterus tubes and ovaries were all normal There were no pelvic adhesions no evidence of endometriosis Uterus was anteverted and the right adnexa was placed on a stretch The tube was grasped 1 cm from the cornual region care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation The tube was grasped again and the procedure was repeated for a separate coagulation so that 1 5 cm of the tube was coagulated The structure was confirmed to be tube by looking at fimbriated end The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it Under traction the amp meter was grasped 3 more times so that a total of 1 5 cm of tube was coagulated again Tube was confirmed by fimbriated end Gas was lend out of the abdomen Both punctures repaired with 4 0 Vicryl and punctures were injected with 0 5 Marcaine 10 mL The patient went to the recovery room in good condition Keywords obstetrics gynecology cervix cervical stab incision laparoscopic tubal sterilization tubal sterilization tubal coagulation sterilization laparoscopic endometriosis MEDICAL_TRANSCRIPTION,Description True cut needle biopsy of the breast This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin Medical Specialty Obstetrics Gynecology Sample Name True Cut Needle Biopsy Breast Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the left breast POSTOPERATIVE DIAGNOSIS Carcinoma of the left breast PROCEDURE PERFORMED True cut needle biopsy of the breast GROSS FINDINGS This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin At this time a true cut needle biopsy was performed PROCEDURE The patient was taken to operating room is laid in the supine position sterilely prepped and draped in the usual fashion The area over the left breast was infiltrated with 1 1 mixture of 0 25 Marcaine and 1 Xylocaine Using a 18 gauge automatic true cut needle core biopsy five biopsies were taken of the left breast in core fashion Hemostasis was controlled with pressure The patient tolerated the procedure well pending the results of biopsy Keywords obstetrics gynecology carcinoma true cut needle biopsy nipple discharge dimpling puckering breast MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy Severe menometrorrhagia unresponsive to medical therapy anemia and symptomatic fibroid uterus Medical Specialty Obstetrics Gynecology Sample Name Total Abdominal Hysterectomy 1 Transcription PREOPERATIVE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Anemia 3 Symptomatic fibroid uterus POSTOPERATIVE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Anemia 3 Symptomatic fibroid uterus PROCEDURE Total abdominal hysterectomy ANESTHESIA General ESTIMATED BLOOD LOSS 150 mL COMPLICATIONS None FINDING Large fibroid uterus PROCEDURE IN DETAIL The patient was prepped and draped in the usual sterile fashion for an abdominal procedure A scalpel was used to make a Pfannenstiel skin incision which was carried down sharply through the subcutaneous tissue to the fascia The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel The O Connor O Sullivan instrument was then placed without difficulty The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty Hemostasis was noted at this point of the procedure The bladder flap was then developed free from the uterus without difficulty Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using 1 chromic suture ligature in an interrupted fashion on the left and right side This was done without difficulty The uterine fundus was then separated from the uterine cervix without difficulty This specimen was sent to pathology for identification The cervix was then developed with careful dissection Jorgenson scissors were then used to remove the cervix from the vaginal cuff This was sent to pathology for identification Hemostasis was noted at this point of the procedure A 1 chromic suture ligature was then used in running fashion at the angles and along the cuff Hemostasis was again noted Figure of eight sutures were then used in an interrupted fashion to close the cuff Hemostasis was again noted The entire pelvis was washed Hemostasis was noted The peritoneum was then closed using 2 0 chromic suture ligature in running pursestring fashion The rectus abdominis muscles were approximated using 1 chromic suture ligature in an interrupted fashion The fascia was closed using 0 Vicryl in interlocking running fashion Foundation sutures were then placed in an interrupted fashion for further closing the fascia The skin was closed with staple gun Sponge and needle counts were noted to be correct x2 at the end of the procedure Instrument count was noted to be correct x2 at the end of the procedure Hemostasis was noted at each level of closure The patient tolerated the procedure well and went to recovery room in good condition Keywords obstetrics gynecology menometrorrhagia fibroid uterus total abdominal hysterectomy rectus abdominis muscles fibroid uterus suture ligature therapy hemostasis anemia abdominal MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy Enlarged fibroid uterus pelvic pain and pelvic endometriosis On laparotomy the uterus did have multiple pedunculated fibroids Medical Specialty Obstetrics Gynecology Sample Name Total Abdominal Hysterectomy 2 Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Pelvic pain POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Pelvic pain 3 Pelvic endometriosis PROCEDURE PERFORMED Total abdominal hysterectomy ANESTHESIA General endotracheal and spinal with Astramorph COMPLICATIONS None ESTIMATED BLOOD LOSS 200 cc FLUIDS 2400 cc of crystalloids URINE OUTPUT 100 cc of clear urine INDICATIONS This is a 40 year old female gravida 0 with a history of longstanding enlarged fibroid uterus On ultrasound the uterus measured 14 cm x 6 5 cm x 7 8 cm She had received two dosage of Lupron to help shrink the fibroid Her most recent Pap smear was normal FINDINGS On a manual exam the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated On laparotomy the uterus did have multiple pedunculated fibroids the largest being approximately 7 cm The bilateral tubes and ovaries appeared normal There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament PROCEDURE After consent was obtained the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife The fascia was incised in midline and the incision extended laterally using Mayo scissors The superior aspect of the fascial incision was grasped with Kocher clamps tented up and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors Attention was then turned to the inferior aspect of the incision which in a similar fashion was grasped with Kocher clamps tented up and dissected off the underlying rectus muscles The rectus muscles were separated in the midline and the peritoneum was identified grasped with hemostat and entered sharply with Metzenbaum scissors This incision was extended superiorly and inferiorly with good visualization of the bladder The uterus was then brought up out of the incision The bowel adhesions were carefully taken down using Metzenbaum scissors Good hemostasis was noted at this point The self retaining retractor was then placed The bladder blade was placed The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension The uterus was then grasped with a Lahey clamp and brought up out of the incision The left round ligament was identified and grasped with Allis clamp and tented up A hemostat was passed in the avascular area beneath the round ligament A suture 0 Vicryl was used to suture ligate the round ligament Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament An avascular area of the broad ligament was then identified and entered bluntly The suture of 0 Vicryl was then used to suture ligate the left uterovarian ligament Two straight Ochsner s were placed across the uterovarian ligament proximal to the previous suture The ligament was then transected and suture ligated with 0 Vicryl Attention was then turned to the right round ligament which in a similar fashion was tented up with an Allis clamp An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with 0 Vicryl Two straight Ochsner s were placed across the ligament proximal to previous suture This was then transected and suture ligated again with 0 Vicryl The left uterine peritoneum was then identified and grasped with Allis clamps The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors This incision was extended across the anterior portion of the uterus and the bladder flap was taken down It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray Tec The Ray Tec was left in place at this point to ensure that the bladder was below the level of the cervix The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner s Each were then transected and suture ligated with 0 Vicryl A curved Ochsner was then placed on either side of the cervix The tissue was transected using a long knife and suture ligated with 0 Vicryl Incidentally prior to taking down the round ligaments a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie The cervix was then grasped with a Lahey clamp The cervicovaginal fascia was then taken down first using the long handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix A double pointed scissors were used to enter the vaginal vault below the level of the cervix A straight Ochsner was placed on the vaginal vault The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue The vaginal cuff was then reapproximated with 0 Vicryl in a running locked fashion and the pelvis was copiously irrigated There was a small area of bleeding noted on the underside of the bladder The bladder was tented up using an Allis clamp and a figure of eight suture of 3 0 Vicryl was placed with excellent hemostasis noted at this point The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down A figure of eight suture of 0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament The round ligament was too short It would be a maximal amount of stretch to incorporate therefore only the left round ligament was incorporated into the vaginal cuff The bilateral adnexal areas were then re peritonealized with 3 0 Vicryl in a running fashion The bladder flap was reapproximated to the vaginal cuff using one interrupted suture The pelvis was again irrigated at this point with excellent hemostasis noted Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder There was no spillage of blue fluid into the abdomen The fluid again was allowed to drain All sponges were then removed and the bowel was allowed to return to its anatomical position The peritoneum was then reapproximated with 0 Vicryl in a running fashion The fascia was reapproximated also with 0 Vicryl in a running fashion The skin was then closed with staples A previously placed Betadine soaked Ray Tec was removed from the patient s vagina and sponge stick was used to assess any bleeding in the vaginal vault There was no appreciable bleeding The patient tolerated the procedure well Sponge lap and needle counts were correct x2 The patient was taken to the recovery room in satisfactory condition She will be followed immediately postoperatively within the hospital Keywords obstetrics gynecology pelvic pain pelvic endometriosis astramorph total abdominal hysterectomy enlarged fibroid metzenbaum scissors vaginal cuff scissors vaginal uterus ligament hysterectomy endometriosis pedunculated fibroids infundibulopelvic uterovarian abdominal laparotomy peritoneum MEDICAL_TRANSCRIPTION,Description The patient comes for three week postpartum checkup complaining of allergies Medical Specialty Obstetrics Gynecology Sample Name Three Week Postpartum Checkup Transcription CHIEF COMPLAINT The patient comes for three week postpartum checkup complaining of allergies HISTORY OF PRESENT ILLNESS She is doing well postpartum She has had no headache She is breastfeeding and feels like her milk is adequate She has not had much bleeding She is using about a mini pad twice a day not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish She has not yet had sexual intercourse She does complain that she has had a little pain with the bowel movement and every now and then she notices a little bright red bleeding She has not been particularly constipated but her husband says she is not eating her vegetables like she should Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes runny nose sneezing and kind of a pressure sensation in her ears MEDICATIONS Prenatal vitamins ALLERGIES She thinks to Benadryl FAMILY HISTORY Mother is 50 and healthy Dad is 40 and healthy Half sister age 34 is healthy She has a sister who is age 10 who has some yeast infections PHYSICAL EXAMINATION VITALS Weight 124 pounds Blood pressure 96 54 Pulse 72 Respirations 16 LMP 10 18 03 Age 39 HEENT Head is normocephalic Eyes EOMs intact PERRLA Conjunctiva clear Fundi Discs flat cups normal No AV nicking hemorrhage or exudate Ears TMs intact Mouth No lesion Throat No inflammation She has allergic rhinitis with clear nasal drainage clear watery discharge from the eyes Abdomen Soft No masses Pelvic Uterus is involuting Rectal She has one external hemorrhoid which has inflamed Stool is guaiac negative and using anoscope no other lesions are identified ASSESSMENT PLAN Satisfactory three week postpartum course seasonal allergies We will try Patanol eyedrops and Allegra 60 mg twice a day She was cautioned about the possibility that this may alter her milk supply She is to drink extra fluids and call if she has problems with that We will try ProctoFoam HC For the hemorrhoids also increase the fiber in her diet That prescription was written as well as one for Allegra and Patanol She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy which is their ultimate plan for birth control and she anticipates that happening fairly soon She will call and return if she continues to have problems with allergies Meantime rechecking in three weeks for her final six week postpartum checkup Keywords obstetrics gynecology checkup allergies postpartum complaining of allergies seasonal allergies postpartum checkup MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy and bilateral salpingo oophorectomy Medical Specialty Obstetrics Gynecology Sample Name TAH BSO Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Dysmenorrhea 3 Dyspareunia 4 Endometriosis 5 Enlarged uterus 6 Menorrhagia POSTOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Dysmenorrhea 3 Dyspareunia 4 Endometriosis 5 Enlarged uterus 6 Menorrhagia PROCEDURE Total abdominal hysterectomy and bilateral salpingo oophorectomy ESTIMATED BLOOD LOSS Less than 100 mL DRAINS Foley ANESTHESIA General This 28 year old white female who presented to undergo TAH BSO secondary to chronic pelvic pain and a diagnosis of endometriosis At the time of the procedure once entering into the abdominal cavity there was no gross evidence of abnormalities of the uterus ovaries or fallopian tube All endometriosis had been identified laparoscopically from a previous surgery At the time of the surgery all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed in supine position at which time general form of anesthesia was administered by the anesthesia department The patient was then prepped and draped in the usual fashion for a low transverse incision Approximately two fingerbreadths above the pubic symphysis a first knife was used to make a low transverse incision This was extended down to the level of the fascia The fascia was nicked in the center and extended in a transverse fashion The edges of the fascia were grasped with Kocher Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique The abdominal rectus muscle was divided in the midline and extended in a vertical fashion Perineum was entered at the high point and extended in a vertical fashion as well An O Connor O Sullivan retractor was put in place on either side A bladder blade was put in place as well Uterus was grasped with a double tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade The bladder flap was released with Metzenbaum scissors and then dissected away caudally EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip Two Heaney were placed on either side of the uterus at the level of cardinal ligaments These were sharply incised and both pedicles were tied off with 1 Vicryl suture Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact From there the corners of the vaginal cuff were reinforced with figure of eight stitches Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re approximate the edges with a second layer used to reinforce the first Bladder flap was created with the use of 3 0 Vicryl and Gelfoam was placed underneath The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips The entire area was then re peritonized and copious amounts of saline were used to irrigate the pelvic cavity Once this was completed Gelfoam was placed into the cul de sac and the O Connor O Sullivan retractor was removed as well as all the wet lap pack Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2 0 Vicryl was used to re approximate the peritoneum as well as abdominal rectus muscle The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re approximate the fascia with overlapping in the center The subcutaneous tissue was irrigated Cautery was used to create adequate hemostasis and 3 0 Vicryl was used to re approximate the tissue and the skin edges were re approximated with sterile staples Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood The patient was taken to recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords obstetrics gynecology tah bso total abdominal hysterectomy bilateral salpingo oophorectomy hysterectomy pelvic pai dysmenorrhea dyspareunia endometriosis uterus menorrhagia betadine soaked sponge bladder flap vaginal vault abdominal fascia rectus MEDICAL_TRANSCRIPTION,Description Suction dilation and curettage for incomplete abortion On bimanual exam the patient has approximately 15 week anteverted mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina There was a large amount of tissue obtained on the procedure Medical Specialty Obstetrics Gynecology Sample Name Suction Dilation Curettage 1 Transcription PREOPERATIVE DIAGNOSIS Incomplete abortion POSTOPERATIVE DIAGNOSIS Incomplete abortion PROCEDURE PERFORMED Suction dilation and curettage ANESTHESIA General and nonendotracheal by Dr X ESTIMATED BLOOD LOSS Less than 200 cc SPECIMENS Endometrial curettings DRAINS None FINDINGS On bimanual exam the patient has approximately 15 week anteverted mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina There was a large amount of tissue obtained on the procedure PROCEDURE The patient was taken to the operating room where a general anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion Once the anesthetic was found to be adequate a bimanual exam was performed under anesthetic Next a weighted speculum was placed in the vagina The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm no cervical dilation was needed A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed Two passes were made with the suction curettage Next a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed which revealed a good uterine cry on all sides of the uterus After the procedure the vulsellum tenaculum was removed The cervix was seemed to be hemostatic The weighted speculum was removed The patient was given 0 25 mg of Methergine IM approximately half way through the procedure After the procedure a second bimanual exam was performed and the patient s uterus had significantly decreased in size It is now approximately eight to ten week size The patient was taken from the operating room in stable condition after she was cleaned She will be discharged on today She was given Methergine Motrin and doxycycline for her postoperative care She will follow up in one week in the office Keywords obstetrics gynecology uterus anteverted dorsal lithotomy position weighted speculum mobile uterus vulsellum tenaculum bimanual exam vagina tenaculum dilation bimanual cervix suction curettage MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH left salpingo oophorectomy lysis of interloop bowel adhesions Chronic pelvic pain endometriosis prior right salpingo oophorectomy history of intrauterine device perforation and exploratory surgery Medical Specialty Obstetrics Gynecology Sample Name TAH Salpingo oophorectomy Lysis of Adhesions Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic pain 2 Endometriosis 3 Prior right salpingo oophorectomy 4 History of intrauterine device perforation and exploratory surgery POSTOPERATIVE DIAGNOSES 1 Endometriosis 2 Interloop bowel adhesions PROCEDURE PERFORMED 1 Total abdominal hysterectomy TAH 2 Left salpingo oophorectomy 3 Lysis of interloop bowel adhesions ANESTHESIA General ESTIMATED BLOOD LOSS 400 cc FLUIDS 2300 cc of lactated Ringers as well as lactated Ringers for intraoperative irrigation URINE 500 cc of clear urine output INTRAOPERATIVE FINDINGS The vulva and perineum are without lesions On bimanual exam the uterus was enlarged movable and anteverted The intraabdominal findings revealed normal liver margin kidneys and stomach upon palpation The uterus was found to be normal in size with evidence of endometriosis on the uterus The right ovary and fallopian tube were absent The left fallopian tube and ovary appeared normal with evidence of a small functional cyst There was evidence of left adnexal adhesion to the pelvic side wall which was filmy unable to be bluntly dissected There were multiple interloop bowel adhesions that were filmy in nature noted The appendix was absent There did appear to be old suture in a portion of the bowel most likely from a prior procedure INDICATIONS This patient is a 45 year old African American gravida7 para3 0 0 3 who is here for definitive treatment of chronic pelvic pain with a history of endometriosis She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo oophorectomy She has tried Lupron and did stop secondary to the side effects PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the Operating Suite and placed under general anesthesia She was then prepped and draped in the sterile fashion and placed in the dorsal supine position An indwelling Foley catheter was placed With the skin knife an incision was made removing the old cicatrix A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder At this point the intraabdominal cavity was manually explored and the above findings were noted A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field The bowel was then packed with moist laparotomy sponges Prior to this the filmy adhesions leftover were taken down At this point the left round ligament was identified grasped with two hemostats transected and suture ligated with 0 Vicryl At this point the broad ligament was dissected down and the lost portion of the bladder flap was created The posterior aspect of the peritoneum was also dissected At this point the infundibulopelvic ligament was isolated and three tie of 0 Vicryl was used to isolate the pedicle Two hemostats were then placed across the pedicle and this was transected with the scalpel This was then suture ligated in Heaney fashion The right round ligament was then identified and in the similar fashion two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament This was then ligated with three tie of 0 Vicryl Also incorporated in this was the remnant from the previous right salpingo oophorectomy At this point the bladder flap was further created with sharp dissection as well as the moist Ray Tech to push the bladder down off the anterior portion of the cervix The left uterine artery was then skeletonized and a straight Heaney was placed In a similar fashion the contralateral uterine artery was skeletonized and straight Heaney clamp was placed These ligaments bilaterally were transected and suture ligated in a left Heaney stitch At this point curved Masterson was used to incorporate the cardinal ligament complex thus was transected and suture ligated Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated Prior to ligating the uterine arteries the uterosacral arteries were tagged bilaterally with 0 Vicryl At this point the roticulator was placed across the vaginal cuff and snug underneath the entire cervix The roticulator was then clamped and removed and the staple line was in place This was found to be hemostatic A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally At this point McCall culdoplasty was performed with an 0 Vicryl incorporating each uterosacral as well as the posterior peritoneum There did appear to be good support on palpation Prior to this the specimen was handed off and sent to pathology At this point there did appear to be small amount of oozing at the right peritoneum Hemostasis was obtained using a 0 Vicryl in two single stitches Good hemostasis was then obtained on the cuff as well as the pedicles Copious irrigation was performed at this point with lactate Ringers The round ligaments were then incorporated into the cuff bilaterally Again copious amount of irrigation was performed and good hemostasis was obtained At this point the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally At this point the bowel packing as well as moist Ray Tech was removed and while re approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel Good hemostasis was obtained of these sites as well The sigmoid colon was then returned to its anatomic position and the omentum as well The rectus muscle was then reapproximated with two interrupted sutures of 2 0 Vicryl The fascia was then reapproximated with 0 Vicryl in a running fashion from lateral to medial meeting in the midline The Scarpa s fascia was then closed with 3 0 plain in a running suture The skin was then re approximated with 4 0 undyed Vicryl in a subcuticular closure This was dressed with an Op Site The patient tolerated the procedure well The sponge lap and needle were correct x2 After the procedure the patient was extubated and brought out of general anesthesia She will go to the floor where she will be followed postoperatively in the hospital Keywords obstetrics gynecology chronic pelvic pain endometriosis intrauterine device exploratory abdominal hysterectomy tah total abdominal hysterectomy lysis of interloop bowel adhesions salpingo oophorectomy bowel ligament adhesions interloop hemostasis uterus salpingo oophorectomy MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH with bilateral salpingooophorectomy and uterosacral ligament vault suspension Cervical intraepithelial neoplasia grade III postconization Recurrent dysplasia Uterine procidentia grade II III Mild vaginal vault prolapse Medical Specialty Obstetrics Gynecology Sample Name TAH Salpingooophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Cervical intraepithelial neoplasia grade III status post conization with poor margins 2 Recurrent dysplasia 3 Unable to follow in office 4 Uterine procidentia grade II III POSTOPERATIVE DIAGNOSES 1 Cervical intraepithelial neoplasia grade III postconization 2 Poor margins 3 Recurrent dysplasia 4 Uterine procidentia grade II III 5 Mild vaginal vault prolapse PROCEDURES PERFORMED 1 Total abdominal hysterectomy TAH with bilateral salpingooophorectomy 2 Uterosacral ligament vault suspension ANESTHESIA General and spinal with Astramorph for postoperative pain ESTIMATED BLOOD LOSS Less than 100 cc FLUIDS 2400 cc URINE 200 cc of clear urine output INDICATIONS This patient is a 57 year old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins FINDINGS On bimanual examination the uterus was found to be small There were no adnexal masses appreciated Intraabdominal findings revealed a small uterus approximately 2 cm in size The ovaries were atrophic consistent with menopause The liver margins and stomach were palpated and found to be normal PROCEDURE IN DETAIL After informed consent was obtained the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control She was then placed in the dorsal lithotomy position and administered general anesthesia She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder At this point the patient was evaluated for a possible vaginal hysterectomy She was nulliparous and the pelvis was narrow After the anesthesia was administered the patient was repeatedly stooling and therefore because of these two reasons the decision was made to do an abdominal hysterectomy After the patient was prepped and draped a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis The second scalpel was used to dissect out to the underlying layer of fascia The fascia was incised in the midline and extended laterally using the Mayo scissors The superior aspect of the rectus fascia was grasped with Ochsners tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors In a similar fashion the inferior portion of the rectus fascia was tented up dissected off bluntly as well as with Mayo scissors The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder At this point the above findings were noted and the GYN Balfour retractor was placed Moist laparotomy sponges were used to pack the bowel out of the operative field The bladder blade and the extension for the retractor were then placed An Allis was used on the uterus for retraction The round ligaments were then identified clamped with two hemostats and transected and then suture ligated The anterior portion of the broad ligament was dissected along vesicouterine resection The bladder was then dissected off the anterior cervix and vagina without difficulty The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats transected and suture ligated with 0 Vicryl suture The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with 0 Vicryl Good hemostasis was assured The cardinal ligaments on both sides were clamped using a curved hemostat transected and suture ligated with 0 Vicryl Good hemostasis was obtained Two hemostats were then placed just under the cervix meeting in the midline The uterus and cervix were then _______ off using a scalpel This was handed and sent to Pathology for evaluation Using 0 Vicryl suture the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament A baseball stitch was then used to close the cuff to the midline The same was done to the left vaginal cuff angle which was affixed to the ipsilateral and cardinal ligaments The baseball stitch was used to close the cuff to the midline The hemostats were removed and the cuff was closed and good hemostasis was noted The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a 0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff The pelvis was then copiously irrigated with warm normal saline Good support and hemostasis was noted The bowel packing was then removed and the GYN Balfour retractor was moved The peritoneum was then repaired with 0 Vicryl in a running fashion The fascia was then closed using 0 Vicryl in a running fashion marking the first stitch and first last stitch in a lateral to medial fashion The skin was then closed with 4 0 undyed Vicryl in a subcuticular closure and an Op Site was placed over this The patient was then brought out of general anesthesia and extubated The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She will follow up postoperatively as an inpatient Keywords obstetrics gynecology cervical intraepithelial neoplasia vaginal vault prolapse uterosacral ligament vault suspension total abdominal hysterectomy bilateral salpingooophorectomy abdominal hysterectomy uterosacral ligament recurrent dysplasia uterine procidentia suture ligated abdominal intraepithelial tah salpingooophorectomy hysterectomy ligament hemostats vaginal MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH with a right salpingo oophorectomy Medical Specialty Obstetrics Gynecology Sample Name TAH Salpingo oophorectomy 1 Transcription PREOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation POSTOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation PROCEDURE PERFORMED Total abdominal hysterectomy TAH with a right salpingo oophorectomy COMPLICATIONS None ESTIMATED BLOOD LOSS 250 cc FLUIDS 1500 cc of crystalloids URINE 125 cc of clear urine at the end of the procedure FINDINGS On exam under anesthesia an obese female with an enlarged fibroid uterus freely movable on the pelvis Operative findings demonstrated the same with normal appearing tubes bilaterally The right ovary contained a right ovarian cyst The left ovary appeared to be within normal limits The peritoneal surfaces were noted to be within normal limits The bowel was also noted to be within normal limits INDICATIONS FOR THIS PROCEDURE The patient is a 44 year old female who had an endometrial ablation done in May which showed submucosal fibroids She had history of anemia and has been on iron therapy She started having bleeding three weeks ago with intermittent bouts of flooding She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy The uterus cervix and right tube and ovary was sent to pathology for review PROCEDURE After informed consent was obtained all questions were answered to the patient s satisfaction in layman s term She was taken to the operating room where a general anesthesia was obtained without any difficulty She was examined under anesthesia with noted findings above She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia With the second knife the fascia was excised in the midline and extended laterally with the Mayo scissors The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly Attention was then turned to the inferior aspect of the fascial incision which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly The rectus muscle was then separated in the midline the peritoneum was identified entered bluntly and digitally Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder The GYN Balfour was then placed A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges Attention was then turned to the round ligaments bilaterally which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the O tie was passed through and then tied down Then the round ligament was transected and suture ligated and noted to be hemostatic The round ligaments were then skeletonized to create a window in the broad ligament The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a 0 Vicryl in a Heaney stitch fashion It was noted to be hemostatic Attention was then turned to the left side in which the uterovarian vessel was isolated and then tied with an O tie and then doubly clamped with straight Ochsner clamps transected and suture ligated with a 0 Vicryl in a Heaney stitch fashion and noted to be hemostatic The vesicouterine peritoneum was then identified tented up with Allis clamps and then the bladder flap was created sharply with a Russian and Metzenbaum scissors Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray Tec sponge down to the level of the cervix The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic In the similar fashion the broad ligament down to the level of the caudal ligament the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated and noted to be hemostatic The second Lahey clamp was then placed on the cervix The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable The cuff was then outlined The vaginal cuff was grasped with a Ochsner clamp and then the cervix uterus and the right tube and ovary were transected using the Jorgenson scissors The cuff outlined with Ochsner clamps The cuff was then painted with a Betadine soaked Ray Tec sponge and the sponge was placed over the vagina The vaginal cuff was then closed with a 0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles A long Allis was then used to grasp the mid portion of the cuff and a 0 Vicryl figure of eight stitch was placed in the mid portion of the cuff and tied down At this time the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff and then tied down to bring the cuff close and together Then the right round ligament was pulled into the cuff and tied down with the 0 Vicryl that was used as a figure of eight stitch in the middle of the cuff The left round ligament was too small to reach the cuff The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic The peritoneum was then re peritonealized with a 3 0 Vicryl in a running fashion The GYN Balfour and all packing sponges were removed from the abdomen Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic The ______ was placed back into the hollow of the sacrum The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a 3 0 Vicryl in a running fashion and then the fascia was closed with 0 Vicryl in a running fashion The skin was closed with staples and dressing applied The patient was then examined at the end of the procedure The Betadine soaked sponge was removed from the vagina The cuff was noted to be intact without bleeding and the patient tolerated the procedure well Sponge lap and needle counts were correct x2 and she was taken to the recovery in stable condition The patient will be followed throughout her hospital stay Keywords obstetrics gynecology tah salpingo oophorectomy total abdominal hysterectomy abnormal uterine bleeding endometrial ablatio ochsner clamps round ligaments clamps ligaments cuff salpingo oophorectomy hysterectomy uterine ablation tubes abdominal anesthesia MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH Severe menometrorrhagia unresponsive to medical therapy severe anemia and symptomatic fibroid uterus Medical Specialty Obstetrics Gynecology Sample Name TAH Discharge Summary Transcription ADMISSION DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Symptomatic fibroid uterus DISCHARGE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Symptomatic fibroid uterus 4 Extensive adenomyosis by pathological report OPERATION PERFORMED On 6 10 2009 total abdominal hysterectomy TAH COMPLICATIONS None BLOOD TRANSFUSIONS None INFECTIONS None SIGNIFICANT LAB AND X RAY On admission hemoglobin and hematocrit was 10 5 and 32 8 respectively On discharge hemoglobin and hematocrit 7 9 and 25 2 HOSPITAL COURSE AND TREATMENT The patient was admitted to the surgical suite and taken to the operating room on 6 10 2009 where a total abdominal hysterectomy TAH with low intraoperative complication was performed The patient tolerated all procedures well On the 1st postoperative day the patient was afebrile and all vital signs were stable On the 3rd postoperative day the patient was ambulating with difficulty and tolerating clear liquid diet On the 4th postoperative day the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness On the 5th postoperative day the patient was afebrile Vital signs were stable The patient was tolerating a diet and ambulating without difficulty The patient was desirous of going home The patient denied any abdominal pain or flank pain The patient had minimal incisional wound tenderness The patient was desirous of going home and was discharged home DISCHARGE CONDITION Stable DISCHARGE INSTRUCTIONS Regular diet bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks pelvic rest for 6 weeks Motrin 600 mg tablets 1 tablet p o q 8h p r n pain Colace 100 mg tablets 1 tablet p o daily p r n constipation and ferrous sulfate 60 mg tablets 1 tablet p o daily and multiple vitamin 1 tablet p o daily The patient is to return on Wednesday 6 17 2009 for removal of staples The patient was given a full explanation of her clinical condition The patient was given full and complete postoperative and discharge instructions All her questions were answered Keywords obstetrics gynecology adenomyosis total abdominal hysterectomy fibroid uterus postoperative day hemoglobin hematocrit therapy menometrorrhagia anemia fibroid uterus tah hysterectomy abdominal MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH and left salpingo oophorectomy Hypermenorrhea uterine fibroids pelvic pain left adnexal mass and pelvic adhesions Medical Specialty Obstetrics Gynecology Sample Name TAH Salpingo oophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Uterine fibroids 3 Pelvic pain 4 Left adnexal mass 5 Pelvic adhesions POSTOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Uterine fibroids 3 Pelvic pain 4 Left adnexal mass 5 Pelvic adhesions PROCEDURE PERFORMED 1 Total abdominal hysterectomy TAH 2 Left salpingo oophorectomy ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 cc INDICATIONS The patient is a 47 year old Caucasian female with complaints of hypermenorrhea and pelvic pain noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003 The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment FINDINGS AT THE TIME OF SURGERY Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass On laparotomy the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass The bowel omentum and appendix had a normal appearance PROCEDURE The patient was taken to the operative suite where anesthesia was found to be adequate She was then prepared and draped in normal sterile fashion A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel The fascia was then incised in the midline The fascial incision was then extended laterally with Mayo scissors The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors Attention was then turned to the inferior aspect of this incision which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors The rectus muscle was then separated in the midline The peritoneum was identified tented up with hemostats and entered sharply with Metzenbaum scissors The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder The uterus and left adnexa were then palpated and brought out into the surgical field The fundus of the uterus was grasped with a Lahey clamp The GYN Balfour retractor was placed The bladder blade was placed The bowel was packed away with moist laparotomy sponges and the extension through GYN Balfour retractor was placed At this time the patient s anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass Attention was first turned to the right round ligament which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat It was then suture ligated with 0 Vicryl suture transected with the broad ligament being skeletonized on both sides Next the right ________ was isolated bluntly as the patient had a previous RSO This was then suture ligated with 0 Vicryl suture doubly clamped with Kocher clamps transected and suture ligated with 0 Vicryl suture with a Heaney stitch Attention was then turned to the left round ligament which was tented up with the Babcock Small window was made beneath it and the broad ligament with hemostat was then suture ligated with 0 Vicryl suture transected and skeletonized with the aid of Metzenbaums The left infundibulopelvic ligament was then bluntly isolated It was then suture ligated with 0 Vicryl suture doubly clamped with Kocher clamps and transected and suture ligated with 0 Vicryl suture with a Heaney stitch The bladder flap was then placed on tension with Allis clamps It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians It was then gently pushed off of lower uterine segment with the aid of a moist Ray Tec The uterine arteries were then skeletonized bilaterally They were then clamped with straight Kocher clamps transected and suture ligated with 0 Vicryl suture The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps These were then transected and suture ligated with 0 Vicryl suture The lower uterine segment was then grasped with Lahey clamps at which time the cervix was already visible It was then entered with the last transection The cervix was grasped with a single toothed tenaculum and the uterus cervix and left adnexa were amputated off the vagina with the aid of Jorgenson scissors The angles of the vaginal cuff were then grasped with Kocher clamps A Betadine soaked Ray Tec was then pushed into the vagina and the vaginal cuff was closed with 0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament at which time the suction tip was changed and copious suction irrigation was performed Good hemostasis was appreciated A figure of eight suture in the center of the vaginal cuff was placed with 0 Vicryl This was tagged for later use The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of 0 Vicryl suture The round ligaments were then pulled into the vaginal cuff using the figure of eight suture placed in the center of the vaginal cuff and these were tied in place The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated The peritoneal surfaces were then reapproximated with the aid of 3 0 Vicryl suture in a running fashion The GYN Balfour retractor and bladder blade were then removed The bowel was then packed Again copious suction irrigation was performed with hemostasis appreciated The peritoneum was then reapproximated with 2 0 Vicryl suture in a running fashion The fascia was then reapproximated with 0 Vicryl suture in a running fashion The Scarpa s fascia was then reapproximated with 3 0 plain gut in a running fashion and the skin was closed with 4 0 undyed Vicryl in a subcuticular fashion Steri Strips were placed At the end of the procedure the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally The patient tolerated the procedure well and was taken to Recovery in stable condition Sponge lap and needle counts were correct x2 Specimens include uterus cervix left fallopian tube and ovary Keywords MEDICAL_TRANSCRIPTION,Description Spontaneous vaginal delivery Male infant cephalic presentation ROA Apgars 2 and 7 Weight 8 pounds and 1 ounce Intact placenta Three vessel cord Third degree midline tear Medical Specialty Obstetrics Gynecology Sample Name Spontaneous Vaginal Delivery 1 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 plus weeks gestation 2 Gestational hypertension 3 Thick meconium 4 Failed vacuum attempted delivery POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 plus weeks gestation 2 Gestational hypertension 3 Thick meconium 4 Failed vacuum attempted delivery OPERATION PERFORMED Spontaneous vaginal delivery ANESTHESIA Epidural was placed x2 ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS Thick meconium Severe variables Apgars were 2 and 7 Respiratory therapy and ICN nurse at delivery Baby went to Newborn Nursery FINDINGS Male infant cephalic presentation ROA Apgars 2 and 7 Weight 8 pounds and 1 ounce Intact placenta Three vessel cord Third degree midline tear DESCRIPTION OF OPERATION The patient was admitted this morning for induction of labor secondary to elevated blood pressure especially for the last three weeks She was already 3 cm dilated She had artificial rupture of membranes Pitocin was started and she actually went to complete dilation While pushing there was sudden onset of thick meconium and she was having some severe variables and several late decelerations When she was complete 2 vacuum attempted delivery three pop offs were done The vacuum was then no longer used after the three pop offs The patient pushed for a little bit longer and had a delivery ROA of a male infant cephalic over a third degree midline tear Secondary to the thick meconium DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery Baby was delivered floppy Cord was clamped x2 and cut and the baby was handed off to awaiting ICN nurse and respiratory therapist Delivery of intact placenta and three vessel cord Third degree midline tear was repaired with Vicryl without any complications Baby initially did well and went to Newborn Nursery where they are observing him a little bit longer there Again mother and baby are both doing well Mother will go to Postpartum and baby is already in Newborn Nursery Keywords obstetrics gynecology thick meconium cephalic presentation intrauterine pregnancy gestational hypertension spontaneous vaginal delivery delivery vaginal placenta newborn meconium apgars MEDICAL_TRANSCRIPTION,Description Laparoscopic right salpingooophorectomy Right pelvic pain and ovarian mass Right ovarian cyst with ovarian torsion Medical Specialty Obstetrics Gynecology Sample Name Salpingooophorectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSES 1 Right pelvic pain 2 Right ovarian mass POSTOPERATIVE DIAGNOSES 1 Right pelvic pain 2 Right ovarian mass 3 8 cm x 10 cm right ovarian cyst with ovarian torsion PROCEDURE PERFORMED Laparoscopic right salpingooophorectomy ANESTHESIA General with endotracheal tube COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc TUBES None DRAINS None PATHOLOGY The right tube and ovary sent to pathology for review FINDINGS On exam under anesthesia a normal appearing vulva and vagina and normally palpated cervix a uterus that was normal size and a large right adnexal mass Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice Otherwise the uterus left tube and ovary bowel liver margins appendix and gallbladder were noted all to be within normal limits There was no noted blood in the pelvis INDICATIONS FOR THIS PROCEDURE The patient is a 26 year old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night which has been increasing in intensity The pain persisted despite multiple pain medications given in the Emergency Room The patient reports positive nausea and vomiting There was no vaginal bleeding or discharge There was no fevers or chills Her cultures done in the Emergency Room were pending The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst questionable hemorrhagic The uterus and left ovary were within normal limits There was a positive flow noted to bilateral ovaries on ultrasound Therefore it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy PROCEDURE After informed consent was obtained and all questions were answered to the patient s satisfaction in layman s terms she was taken to the operating room where general anesthesia was obtained without any difficulty She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above She was prepped and draped in the usual sterile fashion A weighted speculum was placed in the patient s vagina with excellent visualization of the cervix The cervix was grasped at 12 o clock position with a single toothed tenaculum and pulled into the operative field The uterus was then sounded to approximately 3 5 inches and then a uterine elevator was placed The vulsellum tenaculum was removed The weighted speculum was removed Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp The CO2 was then turned on with unoccluded flow and excellent pressures This was continued till a normal symmetrical pneumoperitoneum was obtained Then a 11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope Laparoscopic findings are as noted above A suprapubic incision was made with the knife and then a 12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization Then a grasper was used to untorse the ovary Then a 12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system The right tube and ovary were amputated and noted to be hemostatic The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag The ovary was too large to fit completely into the bag Therefore a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag There was approximately 200 cc of fluid aspirated from the cyst This was a clear yellow fluid Then the bag was closed and the ovary was removed from the suprapubic port The suprapubic port did have to be extended somewhat to allow for the removal of the ovary The trocar and sleeve were then placed back into the port The abdomen was copiously irrigated with warm normal saline using the Nezhat Dorsey suction irrigator and the incision site was noted to be hemostatic The pelvis was clear and clean Pictures were obtained The suprapubic port was then removed under direct visualization and then using a 0 vicyrl and UR6 Two figure of eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed Therefore the peritoneal surface was noted to be hemostatic Therefore the camera was removed All instruments were removed The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank 12 port and the infraumbilical port and these were removed The infraumbilical port was examined and noted to have a small fascial defect which was repaired with 0 Vicryl and UR6 The right flank area was palpated and there was no facial defect noted The skin was then closed with 4 0 undyed Vicryl in subcuticular fashion Dressings were changed The weighted speculum was removed from the patient s cervix The cervix noted to be hemostatic The patient tolerated the procedure well Sponge lap and needle counts were correct x2 and the patient was taken to the Recovery in stable condition Keywords MEDICAL_TRANSCRIPTION,Description Repeat cesarean section and bilateral tubal ligation Medical Specialty Obstetrics Gynecology Sample Name Repeat C section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 weeks 2 History of previous cesarean section x2 The patient desires a repeat section 3 Chronic hypertension 4 Undesired future fertility The patient desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 39 weeks 2 History of previous cesarean section x2 The patient desires a repeat section 3 Chronic hypertension 4 Undesired future fertility The patient desires permanent sterilization PROCEDURE PERFORMED Repeat cesarean section and bilateral tubal ligation ANESTHESIA Spinal ESTIMATED BLOOD LOSS 800 mL COMPLICATIONS None FINDINGS Male infant in cephalic presentation with anteflexed head Apgars were 2 at 1 minute and 9 at 5 minutes 9 at 10 minutes and weight 7 pounds 8 ounces Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 31 year old gravida 5 para 4 female who presented to repeat cesarean section at term The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section additionally she desires permanent fertilization The procedure was described to the patient in detail including possible risks of bleeding infection injury to surrounding organs and the possible need for further surgery and informed consent was obtained PROCEDURE NOTE The patient was taken to the operating room where spinal anesthesia was administered without difficulty The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to elevate the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors Attention was then turned to the inferior aspect of the fascial incision which in similar fashion was grasped with Kocher clamps elevated and the underlying rectus muscles were dissected off bluntly and using the Bovie The rectus muscles were dissected in the midline The peritoneum was identified and entered using Metzenbaum scissors this incision was extended superiorly and inferiorly with good visualization of the bladder The bladder blade was inserted The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors This incision was extended laterally and the bladder flap was created digitally The bladder blade was reinserted The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction Clear fluid was noted The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant s head without the Kelly The nose and mouth were bulb suctioned The cord was clamped and cut The infant was subsequently handed to the awaiting nursery nurse The placenta was delivered spontaneously intact with a three vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic sutures Hemostasis was visualized Attention was turned to the right fallopian tube which was grasped with Babcock clamp using a modified Pomeroy method a 2 cm of segment of tube ligated x2 transected and specimen was sent to pathology Attention was then turned to the left fallopian tube which was grasped with Babcock clamp again using a modified Pomeroy method a 2 cm segment of tube was ligated x2 and transected Hemostasis was visualized bilaterally The uterus was returned to the abdomen both fallopian tubes were visualized and were noted to be hemostatic The uterine incision was reexamined and it was noted to be hemostatic The pelvis was copiously irrigated The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was closed with 0 Vicryl suture the subcutaneous layer was closed with 3 0 plain gut and the skin was closed with staples Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords obstetrics gynecology bilateral tubal ligation permanent sterilization undesired future fertility repeat cesarean section intrauterine pregnancy mayo scissors kocher clamps metzenbaum scissors fallopian tube babcock clamp pomeroy method rectus muscles cesarean section intrauterine cesarean MEDICAL_TRANSCRIPTION,Description Radical vulvectomy complete bilateral inguinal lymphadenectomy superficial and deep Medical Specialty Obstetrics Gynecology Sample Name Radical Vulvectomy Transcription PREOPERATIVE DIAGNOSIS Clinical stage III squamous cell carcinoma of the vulva POSTOPERATIVE DIAGNOSIS Clinical stage III squamous cell carcinoma of the vulva OPERATION PERFORMED Radical vulvectomy complete bilateral inguinal lymphadenectomy superficial and deep ANESTHESIA General endotracheal tube SPECIMENS Radical vulvectomy right and left superficial and deep inguinal lymph nodes INDICATIONS FOR PROCEDURE The patient recently presented with a new vaginal nodule Biopsy was obtained and revealed squamous carcinoma The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3 Nx Mx on clinical examination Of note past history is significant for pelvic radiation for cervical cancer many years previously FINDINGS The examination under anesthesia revealed a 1 5 cm nodule of disease extending slightly above the hymeneal ring There was no palpable lymphadenopathy in either inguinal node region There were no other nodules ulcerations or other lesions At the completion of the procedure there was no clinical evidence of residual disease PROCEDURE The patient was brought to the Operating Room with an IV in place She was placed in the low anterior lithotomy position after adequate anesthesia had been induced Examination under anesthesia was performed with findings as noted after which she was prepped and draped The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament Camper s fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial The cribriform fascia was isolated and dissected with preservation of the femoral nerve The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments The medial lymph node bundle was isolated and Cloquet s node was clamped divided and ligated bilaterally The saphenous vessels were identified and preserved bilaterally The inferior margin of the specimen was ligated divided and removed Inguinal node sites were irrigated and excellent hemostasis was noted Jackson Pratt drains were placed and Camper s fascia was approximated with simple interrupted stitches The skin was closed with running subcuticular stitches using 4 0 Monocryl suture Attention was turned to the radical vulvectomy specimen A marking pen was used to outline the margins of resection allowing 15 20 mm of margin on the inferior lateral and anterior margins The medial margin extended into the vagina and was approximately 5 8 mm The skin was incised and underlying adipose tissue was divided with electrocautery Vascular bundles were isolated divided and ligated After removal of the specimen additional margin was obtained from the right vaginal side wall adjacent to the tumor site Margins were submitted on the right posterior middle and anterior vaginal side walls After removal of the vaginal margins the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2 0 Vicryl suture The skin was closed with interrupted horizontal mattress stitches using 3 0 Vicryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords obstetrics gynecology squamous cell carcinoma vulvectomy radical vulvectomy bilateral inguinal lymphadenectomy hymeneal ring camper s fascia carcinoma of the vulva inguinal lymphadenectomy lymph nodes inguinal vulva squamous carcinoma radical lymphadenectomy fascia vaginal nodes MEDICAL_TRANSCRIPTION,Description Sterilization candidate Cervical dilatation and laparoscopic bilateral partial salpingectomy A 30 year old female gravida 4 para 3 0 1 3 who desires permanent sterilization Medical Specialty Obstetrics Gynecology Sample Name Salpingectomy Cervical Dilatation Transcription PREOPERATIVE DIAGNOSIS Sterilization candidate POSTOPERATIVE DIAGNOSIS Sterilization candidate PROCEDURE PERFORMED 1 Cervical dilatation 2 Laparoscopic bilateral partial salpingectomy ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc SPECIMEN Portions of bilateral fallopian tubes INDICATIONS This is a 30 year old female gravida 4 para 3 0 1 3 who desires permanent sterilization FINDINGS On bimanual exam the uterus is small anteverted and freely mobile There are no adnexal masses appreciated On laparoscopic exam the uterus bilateral tubes and ovaries appeared normal The liver margin and bowel appeared normal PROCEDURE After consent was obtained the patient was taken to the operating room where general anesthetic was administered The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion A sterile speculum was placed in the patient s vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterus was then sounded to 7 cm The cervix was serially dilated with Hank dilators A 20 Hank dilator was left in place The sterile speculum was then removed Gloves were changed Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient s previous scar The Veress needle was placed and gas was turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted Two 5 mm step trocars were placed one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus The Endoloop was placed through the left sided port A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper A knuckle of tube was brought up with the grasper and a 0 Vicryl Endoloop synched down across this knuckle of tube The suture was then cut using the endoscopic shears The portion of tube that was tied off was removed using a Harmonic scalpel This was then removed from the abdomen and sent to Pathology The right tube was then identified and in a similar fashion the grasper was placed through the loop of the 0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop The loop was then synched down The Endoshears were used to cut the suture The Harmonic scalpel was then used to remove that portion of tube The portion of the tube that was removed from the abdomen was sent to Pathology Both tubes were examined and found to have excellent hemostasis All instruments were then removed The 5 mm ports were removed with good hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar was removed The fascia of the infraumbilical incision was reapproximated with an interrupted suture of 3 0 Vicryl The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of Marcaine was injected at the incision site The vulsellum tenaculum and cervical dilator were then removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of the procedure The patient was taken to the recovery room in satisfactory condition She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks Keywords obstetrics gynecology cervical dilatation partial salpingectomy permanent sterilization vulsellum tenaculum hank dilators infraumbilical incision vicryl endoloop salpingectomy dilatation hemostasis cervical laparoscopic endoloop sterilization MEDICAL_TRANSCRIPTION,Description Spontaneous vaginal delivery Term pregnancy at 40 and 3 7th weeks On evaluation of triage she was noted to be contracting approximately every five minutes and did have discomfort with her contractions Medical Specialty Obstetrics Gynecology Sample Name Spontaneous Vaginal Delivery Transcription PREOPERATIVE DIAGNOSIS Term pregnancy at 40 and 3 7th weeks PROCEDURE PERFORMED Spontaneous vaginal delivery HISTORY OF PRESENT ILLNESS The patient is a 36 year old African American female who is a G 2 P 2 0 0 2 with an EDC of 08 30 2003 She is blood type AB ve with antibody screen negative and is also rubella immune VDRL nonreactive hepatitis B surface antigen negative and HIV nonreactive She does have a history of sickle cell trait She presented to Labor and Delivery Triage at 40 and 3 7th weeks gestation with complaint of contractions every ten minutes She also stated that she has lost her mucous plug She did have fetal movement noted no leak of fluid did have some spotting On evaluation of triage she was noted to be contracting approximately every five minutes and did have discomfort with her contractions She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated 70 effaced and 3 station This was a change from her last office exam at which she was 1 cm to 2 cm dilated PROCEDURE DETAILS The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained After her membranes were ruptured contractions did increase to every two to three minutes as well as the intensity increased She was given Nubain for discomfort with good result She had a spontaneous vaginal delivery of a live born female at 11 37 with meconium stained fluid as noted from ROA position After controlled delivery of the head tight nuchal cord was noted which was quickly double clamped and cut and the shoulders and body were delivered without difficulty The infant was taken to the awaiting pediatrician Weight was 2870 gm length was 51 cm The Apgars were 6 at 1 minute and 9 at 5 minutes There was initial neonatal depression which was treated by positive pressure ventilation and the administration of Narcan Spontaneous delivery of an intact placenta with a three vessel cord was noted at 11 45 On examination there were no noted perineal abrasions or lacerations On vaginal exam there were no noted cervical or vaginal sidewall lacerations Estimated blood loss was less than 250 cc Mother and infant are in recovery doing well at this time Keywords obstetrics gynecology roa position arom labor and delivery spontaneous vaginal delivery term pregnancy contracting meconium lacerations pregnancy contractions vaginal MEDICAL_TRANSCRIPTION,Description Modified radical mastectomy An elliptical incision was made to incorporate the nipple areolar complex and the previous biopsy site The skin incision was carried down to the subcutaneous fat but no further Medical Specialty Obstetrics Gynecology Sample Name Radical Mastectomy 1 Transcription PROCEDURE PERFORMED Modified radical mastectomy ANESTHESIA General endotracheal tube PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury An elliptical incision was made to incorporate the nipple areolar complex and the previous biopsy site The skin incision was carried down to the subcutaneous fat but no further Using traction and counter traction the upper flap was dissected from the chest wall medially to the sternal border superiorly to the clavicle laterally to the anterior border of the latissimus dorsi muscle and superolaterally to the insertion of the pectoralis major muscle The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2 0 Vicryl The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely Once the lateral border of the pectoralis major muscle was identified the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist The axilla was then cleared of its contents by sharp dissection Small vessels entering the axillary vein were clipped and divided The axilla was cleared down to the chest wall and dissection was continued laterally to the subscapular vein The long thoracic nerve was cleared identified lying against the chest and was carefully preserved The long thoracic nerve represented the posterior most aspect of the dissection As the axillary contents were dissected in the posterolateral axilla the thoracodorsal nerve was identified and carefully preserved The dissection continued caudally until the entire specimen was freed and delivered from the operative field Copious water lavage was used to remove any debris and hemostasis was obtained with Bovie electrocautery Two Jackson Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major These were secured to the skin using 2 0 silk which was Roman sandaled around the drain The skin incision was approximated with skin staples A dressing was applied The drains were placed on grenade suction All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords obstetrics gynecology latissimus dorsi muscle pectoralis major muscle pectoralis fascia axillary vein thoracic nerve radical mastectomy pectoralis major axillary incision mastectomy fascia muscle pectoralis MEDICAL_TRANSCRIPTION,Description Invasive carcinoma of left breast Left modified radical mastectomy Medical Specialty Obstetrics Gynecology Sample Name Radical Mastectomy Transcription PREOPERATIVE DIAGNOSIS Invasive carcinoma of left breast POSTOPERATIVE DIAGNOSIS Invasive carcinoma of left breast OPERATION PERFORMED Left modified radical mastectomy ANESTHESIA General endotracheal INDICATION FOR THE PROCEDURE The patient is a 52 year old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast The patient was elected to have a left modified radical mastectomy she was not interested in a partial mastectomy She is aware of the risks and complications of surgery and wished to proceed DESCRIPTION OF PROCEDURE The patient was taken to the operating room She underwent general endotracheal anesthetic The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well The patient s left anterior chest wall neck axilla and left arm were prepped and draped in the usual sterile manner The recent biopsy site was located in the upper and outer quadrant of left breast The plain incision was marked along the skin Tissues and the flaps were injected with 0 25 Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site The flaps were raised superiorly and just below the clavicle medially to the sternum laterally towards the latissimus dorsi rectus abdominus fascia Following this the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle The dissection was started medially and extended laterally towards the left axilla The breast was removed and then the axillary contents were dissected out Left axillary vein and artery were identified and preserved as well as the lung _____ The patient had several clinically palpable lymph nodes they were removed with the axillary dissection Care was taken to avoid injury to any of the above mentioned neurovascular structures After the tissues were irrigated we made sure there were no signs of bleeding Hemostasis had been achieved with Hemoclips Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps The subcu was then approximated with interrupted 4 0 Vicryl sutures and skin with clips The drains were sutured to the chest wall with 3 0 nylon sutures Dressing was applied and the procedure was completed The patient went to the recovery room in stable condition Keywords obstetrics gynecology invasive carcinoma chest wall neck axilla modified radical mastectomy radical mastectomy invasive carcinoma mastectomy MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy radical hysterectomy bilateral ovarian transposition pelvic and obturator lymphadenectomy Medical Specialty Obstetrics Gynecology Sample Name Radical Hysterectomy Transcription PREOPERATIVE DIAGNOSIS Cervical adenocarcinoma stage I POSTOPERATIVE DIAGNOSIS Cervical adenocarcinoma stage I OPERATION PERFORMED Exploratory laparotomy radical hysterectomy bilateral ovarian transposition pelvic and obturator lymphadenectomy ANESTHESIA General endotracheal tube SPECIMENS Uterus with attached parametrium and upper vagina right and left pelvic and obturator lymph nodes INDICATIONS FOR PROCEDURE The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended FINDINGS During the examination under anesthesia the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments During the exploratory laparotomy there was no evidence of disease extension into the broad ligament or bladder flap There was no evidence of intraperitoneal spread or lymphadenopathy OPERATIVE PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthetic was administered after which she was examined under anesthesia The vagina was then prepped and a Foley catheter was placed She was prepped and draped A Pfannenstiel incision was made three centimeters above the symphysis pubis The peritoneum was entered and the abdomen was explored with findings as noted The Bookwalter retractor was placed and bowel was packed Clamps were placed on the broad ligament for traction The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments The round ligaments were isolated divided and ligated The peritoneum overlying the vesicouterine fold was incised and the bladder was mobilized using sharp dissection The pararectal and paravesical spaces were opened and the broad ligament was palpated with no evidence of suspicious findings or disease extension The utero ovarian ligaments were then isolated divided and doubly ligated Tubes and ovaries were mobilized The ureters were dissected free from the medial leaf of the peritoneum When the crossover of the uterine artery was reached and the artery was isolated at its origin divided and ligated The uterine artery pedicle was dissected anteriorly over the ureter The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated This was continued until the insertion point of the ureter into the bladder trigone The peritoneum across the cul de sac was divided and the rectovaginal space was opened Clamps were placed on the uterosacral ligaments at their point of origin Tissues were divided and suture ligated Clamps were placed on the paravaginal tissues which were then divided and suture ligated The vagina was then clamped and divided at the junction between the middle and upper third The vaginal vault was closed with interrupted figure of eight stitches Excellent hemostasis was noted Retractors were repositioned in the retroperitoneum for the lymphadenectomy The borders of dissection included the bifurcation of the common iliac artery superiorly the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly the psoas muscle laterally and the anterior division of the hypogastric artery medially The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection Ligaclips were applied where necessary After removal of the lymph node specimens the pelvis was irrigated The ovaries were transposed above the pelvic brim using running stitches Packs and retractors were removed and peritoneum was closed with a running stitch Subcutaneous tissues were irrigated and fascia was closed with a running mass stitch using delayed absorbable suture Subcutaneous adipose was irrigated and Scarpa s fascia was closed with a running stitch Skin was closed with a running subcuticular stitch Final sponge needle and instrument counts were correct at the completion of the procedure The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords obstetrics gynecology cervical adenocarcinoma radical hysterectomy exploratory laparotomy bilateral ovarian transposition lymphadenectomy parametrium cervix pelvic and obturator lymphadenectomy pelvic and obturator obturator lymphadenectomy laparotomy ovarian adenocarcinoma radical hysterectomy pelvic obturator peritoneum nodes ligaments MEDICAL_TRANSCRIPTION,Description Missed abortion Suction dilation and curettage Medical Specialty Obstetrics Gynecology Sample Name Suction Dilation Curettage Transcription PREOPERATIVE DIAGNOSIS Missed abortion POSTOPERATIVE DIAGNOSIS Missed abortion PROCEDURE PERFORMED Suction dilation and curettage ANESTHESIA Spinal ESTIMATED BLOOD LOSS 50 mL COMPLICATIONS None FINDINGS Products of conception consistent with a 6 week intrauterine pregnancy INDICATIONS The patient is a 28 year old gravida 4 para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today A workup done in the emergency room revealed a beta quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown rump length consistent with a 6 week and 2 day pregnancy No heart tones were visible On examination in the emergency room a moderate amount of bleeding was noted Additionally the cervix was noted to be 1 cm dilated These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient After discussion of these options the patient opted for a suction dilation and curettage The patient was described to the patient in detail including risks of infection bleeding injury to surrounding organs including risk of perforation Informed consent was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where spinal anesthesia was administered without difficulty The patient was prepped and draped in usual sterile fashion in lithotomy position A weighted speculum was placed The anterior lip of the cervix was grasped with a single tooth tenaculum At this time a 7 mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus Following removal of the products of conception a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted At this time the suction curette was advanced one additional time to suction any remaining products All instruments were removed Hemostasis was visualized The patient was stable at the completion of the procedure Sponge lap and instrument counts were correct Keywords obstetrics gynecology missed abortion intrauterine pregnancy dilation curettage suction intrauterine MEDICAL_TRANSCRIPTION,Description Pelvic laparotomy lysis of pelvic adhesions and left salpingooophorectomy with insertion of Pain Buster Pain Management System Medical Specialty Obstetrics Gynecology Sample Name Pelvic Laparotomy Transcription PREOPERATIVE DIAGNOSIS Large left adnexal mass 8 cm in diameter POSTOPERATIVE DIAGNOSIS Pelvic adhesions 6 cm ovarian cyst PROCEDURES PERFORMED 1 Pelvic laparotomy 2 Lysis of pelvic adhesions 3 Left salpingooophorectomy with insertion of Pain Buster Pain Management System by Dr X GROSS FINDINGS There was a transabdominal mass palpable in the lower left quadrant An ultrasound suggestive with a mass of 8 cm did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment the ovarian neoplasm persisted and did not decreased in size PROCEDURE Under general anesthesia the patient was placed in lithotomy position prepped and draped A low transverse incision was made down to and through to the rectus sheath The rectus sheath was put laterally The inferior epigastric arteries were identified bilaterally doubly clamped and tied with 0 Vicryl sutures The rectus muscle was then split transversally and the peritoneum was split transversally as well The left adnexal mass was identified and large bowel was attached to the mass and Dr Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament The infundibulopelvic ligament was isolated entered via blunt dissection A 0 Vicryl suture was put into place doubly clamped with curved Heaney clamps cut with curved Mayo scissors and 0 Vicryl fixation suture put into place Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then 0 Vicryl suture was put into place Pathology was called to evaluate the mass for potential malignancy and the pathology s verbal report at the time of surgery was that this was a benign lesion Irrigation was used Minimal blood loss at the time of surgery was noted Sigmoid colon was inspected in place in physiologic position of the cul de sac as well as small bowel omentum Instrument needle and sponge counts were called for and found to be correct The peritoneum was closed with 0 Vicryl continuous running locking suture The rectus sheath was closed with 0 Vicryl continuous running locking suture A DonJoy Pain Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples Final instrument needle counts were called for and found to be correct The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition Keywords obstetrics gynecology lysis of pelvic adhesions salpingooophorectomy pain buster pain management system adnexal mass pelvic laparotomy pelvic adhesions rectus sheath vicryl sutures adhesions pelvic MEDICAL_TRANSCRIPTION,Description Consultation for an ASCUS Pap smear Medical Specialty Obstetrics Gynecology Sample Name OB GYN Consultation 3 Transcription Pap smear in November 2006 showed atypical squamous cells of undetermined significance She has a history of an abnormal Pap smear At that time she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia She underwent a cone biopsy that per her report was negative for any pathology She had no vulvar treatment at that time Since that time she has had normal Pap smears She denies abnormal vaginal bleeding discharge or pain She uses Yaz for birth control She reports one sexual partner since 1994 and she is a nonsmoker She states that she has a tendency to have yeast infections and bacterial vaginosis She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr B She also has a history of chlamydia when she was in college PAST MEDICAL HX Depression PAST SURGICAL HX None MEDICATIONS Lexapro 10 mg a day and Yaz ALLERGIES NO KNOWN DRUG ALLERGIES OB HX Normal spontaneous vaginal delivery at term in 2001 and 2004 Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces FAMILY HX Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use He currently has metastatic melanoma mother with hypertension and depression father with alcoholism SOCIAL HX She is a public relations consultant She is a nonsmoker drinks infrequent alcohol and does not use drugs She enjoys horseback riding and teaches jumping PE VITALS Height 5 feet 6 inches Weight 139 lb BMI 22 4 Blood Pressure 102 58 GENERAL She is well developed and well nourished with normal habitus and no deformities She is alert and oriented to time place and person and her mood and affect is normal NECK Without thyromegaly or lymphadenopathy LUNGS Clear to auscultation bilaterally HEART Regular rate and rhythm without murmurs BREASTS Deferred ABDOMEN Soft nontender and nondistended There is no organomegaly or lymphadenopathy PELVIC Normal external female genitalia Vulva vagina and urethra within normal limits Cervix is status post cone biopsy however the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance GC and chlamydia cultures as well as a repeat Pap smear were done Colposcopy is then performed without and with acetic acid This shows an entirely normal transformation zone so no biopsies are taken An endocervical curettage is then performed with Cytobrush and curette and sent to pathology Colposcopy of the vulva is then performed again with acetic acid There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter There are absolutely no abnormal vessels within this area The vulvar colposcopy is completely within normal limits A P ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup We will check the results of the Pap smear in addition we have ordered DNA testing for high risk HPV We will check the results of the ECC She will return in two weeks for test results If these are normal she will need two normal Pap smears six months apart and I think followup colposcopy for the vulvar changes Keywords obstetrics gynecology lmp ascus pap smear abnormal pap smear atypical bacterial vaginosis chlamydia cone biopsy infection interstitial cystitis intraepithelial mammogram neoplasia perirectal condyloma squamous vaginal bleeding vulvar yeast infection pap smears pap ob gyn colposcopy smear MEDICAL_TRANSCRIPTION,Description Specimen labeled right ovarian cyst is received fresh for frozen section Medical Specialty Obstetrics Gynecology Sample Name Pathology Ovarian Cyst Transcription GROSS DESCRIPTION Specimen labeled right ovarian cyst is received fresh for frozen section It consists of a smooth walled clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid Both surfaces of the wall are pink tan smooth and grossly unremarkable No firm or thick areas or papillary structures are noted on the cyst wall externally or internally After removal the fluid the cyst weight 68 grams The fluid is transparent and slightly mucoid A frozen section is submitted DIAGNOSIS Benign cystic ovary Keywords obstetrics gynecology right ovarian cyst specimen ovarian cyst frozen section ovarian frozen sectionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Nonpalpable neoplasm right breast Needle localized wide excision of nonpalpable neoplasm right breast Medical Specialty Obstetrics Gynecology Sample Name Needle Localized Excision Breast Neoplasm Transcription PREOPERATIVE DIAGNOSIS Nonpalpable neoplasm right breast POSTOPERATIVE DIAGNOSIS Deferred for Pathology PROCEDURE PERFORMED Needle localized wide excision of nonpalpable neoplasm right breast SPECIMEN Mammography GROSS FINDINGS This 53 year old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast After excision of neoplasm there was a separate 1 x 2 cm nodule palpated within the cavity This too was excised OPERATIVE PROCEDURE The patient was taken to the operating room placed in supine position in the operating table Intravenous sedation was administered by the Anesthesia Department The Kopans wire was trimmed to an appropriate length The patient was sterilely prepped and draped in the usual manner Local anesthetic consisting of 1 lidocaine and 0 5 Marcaine was injected into the proposed line of incision A curvilinear circumareolar incision was then made with a 15 scalpel blade close to the wire The wire was stabilized and brought to protrude through the incision Skin flaps were then generated with electrocautery A generous core tissue was grasped with Allis forceps and excised with electrocautery Prior to complete excision the superior margin was marked with a 2 0 Vicryl suture which was tied and cut short The lateral margin was marked with a 2 0 Vicryl suture which was tied and cut along The posterior margin was marked with a 2 0 Polydek suture which was tied and cut The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm On palpation of the cavity there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen Hemostasis was obtained with electrocautery Good hemostasis was obtained The incision was closed in two layers The first layer consisting of a subcuticular inverted interrupted sutures of 4 0 undyed Vicryl The second layer consisted of Steri Strips on the epidermis A pressure dressing of fluff 4x4s ABDs and Elastic bandage was applied The patient tolerated the surgery well Keywords obstetrics gynecology neoplasm needle localized wide excision needle localized nonpalpable neoplasm needle incision electrocautery excision breast MEDICAL_TRANSCRIPTION,Description Female referred for evaluation of an abnormal colposcopy low grade Pap with suspicious high grade features Medical Specialty Obstetrics Gynecology Sample Name OB GYN Consultation 1 Transcription PAST MEDICAL HX Significant for asthma pneumonia and depression PAST SURGICAL HX None MEDICATIONS Prozac 20 mg q d She desires to be on the NuvaRing ALLERGIES Lactose intolerance SOCIAL HX She denies smoking or alcohol or drug use PE VITALS Stable Weight 114 lb Height 5 feet 2 inches GENERAL Well developed well nourished female in no apparent distress HEENT Within normal limits NECK Supple without thyromegaly HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Soft and nontender There is no rebound or guarding No palpable masses and no peritoneal signs EXTREMITIES Within normal limits SKIN Warm and dry GU External genitalia is without lesion Vaginal is clean without discharge Cervix appears normal however a colposcopy was performed using acetic acid which showed a thick acetowhite ring around the cervical os and extending into the canal BIMANUAL Reveals significant cervical motion tenderness and fundal tenderness She had no tenderness in her adnexa There are no palpable masses A Although unlikely based on the patient s exam and pain I have to consider subclinical pelvic inflammatory disease GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr A A LEEP is a reasonable approach even in this 16 year old P We will schedule LEEP in the near future Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low grade lesions as well as high grade lesions Now we have her given her first shot Keywords obstetrics gynecology gravida ecc external genitalia hpv leep pap acetowhite biopsies blood with urination cervical os colposcopy intraepithelial right lower quadrant squamous suspicious vaginal discharge low grade pap low grade MEDICAL_TRANSCRIPTION,Description Consultation because of irregular periods and ovarian cyst Medical Specialty Obstetrics Gynecology Sample Name OB GYN Consultation 2 Transcription She started her periods at age 13 She is complaining of a three month history of lower abdominal pain for which she has been to the emergency room twice She describes the pain as bilateral intermittent and non radiating It decreases slightly when she eats and increases with activity She states the pain when it comes can last for half a day It is not associated with movement but occasionally the pain was so bad that it was associated with vomiting She has tried LactAid which initially helped but then the pain returned She has tried changing her diet and Pepcid AC She was seen at XYZ where blood work was done At that time she had a normal white count and a normal H H She was given muscle relaxants which did not work Approximately two weeks ago she was seen in the emergency room at XYZ where a pelvic ultrasound was done This showed a 1 9 x 1 4 cm cyst on the right with no free fluid The left ovary and uterus appeared normal Two days later the pain resolved and she has not had a recurrence She denies constipation and diarrhea She has had some hot flashes but has not taken her temperature In addition she states that her periods have been very irregular coming between four and six weeks They are associated with cramping which she is not happy about She has never had a pelvic exam She states she is not sexually active and declined having her mother leave the room so she was not questioned regarding this without her mother present She is very interested in not having pain with her periods and if this was a cyst that caused her pain she is interested in starting birth control pills to prevent this from happening again PAST MEDICAL HX Pneumonia in 2002 depression diagnosed in 2005 and seizures as an infant PAST SURGICAL HX Plastic surgery on her ear after a dog bite in 1997 MEDICATIONS Zoloft 50 mg a day and LactAid ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HX She enjoys cooking and scrapbooking She does have a boyfriend again she states she is not sexually active She also states that she exercises regularly does not smoke cigarettes use drugs or drink alcohol FAMILY HX Significant for her maternal grandfather with adult onset diabetes a maternal grandmother with hypertension mother with depression and a father who died of colon cancer at 32 years of age She also has a paternal great grandfather who was diagnosed with colon cancer PE VITALS Height 5 feet 5 inches Weight 190 lb Blood Pressure 120 88 GENERAL She is well developed well nourished with normal habitus and no deformities NECK Without thyromegaly or lymphadenopathy LUNGS Clear to auscultation bilaterally HEART Regular rate and rhythm without murmurs ABDOMEN Soft nontender and nondistended There is no organomegaly or lymphadenopathy PELVIC Deferred A P Abdominal pain unclear etiology I expressed my doubt that her pain was secondary to this 1 9 cm ovarian cyst given the fact that there was no free fluid surrounding this However given that she has irregular periods and they are painful for her I think it is reasonable to start her on a low dose birth control pill She has no personal or familial contraindications to start this She was given a prescription for Lo Ovral dispensed 30 with refill x 4 She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns If she should have the recurrence of her pain I have advised her to call Keywords obstetrics gynecology irregular periods lactaid abdominal pain birth control pills cyst ovarian cyst ovaries ovary pelvic exam sexually active uterus lymphadenopathy pelvic irregular periods MEDICAL_TRANSCRIPTION,Description Bilateral breast MRI with without IV contrast Medical Specialty Obstetrics Gynecology Sample Name MRI Breast 1 Transcription FINDINGS There are post biopsy changes seen in the retroareolar region middle third aspect of the left breast at the post biopsy site There is abnormal enhancement seen in this location compatible with patient s history of malignancy There is increased enhancement seen in the inferior aspect of the left breast at the 6 00 o clock N 5 5 cm position measuring 1 2 cm Further work up with ultrasound is indicated There are other multiple benign appearing enhancing masses seen in both the right and left breasts None of the remaining masses appear worrisome for malignancy based upon MRI criteria IMPRESSION BIRADS CATEGORY M 5 There is a malignant appearing area of enhancement in the left breast which does correspond to the patient s history of recent diagnosis of malignancy She has been scheduled to see a surgeon as well as Medical Oncologist Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6 00 o clock N 5 5 cm position for further evaluation of the mass At that same time ultrasonography of the remaining masses should also be performed Please note however that the remaining masses have primarily benign features based upon MRI criteria However further evaluation with ultrasound should be performed Keywords obstetrics gynecology breast cancer bilateral breast mri bilateral breast iv contrast contrast ultrasound ultrasonography malignancy mri benign masses breast MEDICAL_TRANSCRIPTION,Description Repeat low transverse cesarean section and bilateral tubal ligation BTL Intrauterine pregnancy at term with previous cesarean section Desires permanent sterilization Macrosomia Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section BTL Transcription PREOPERATIVE DIAGNOSIS Intrauterine pregnancy at term with previous cesarean section SECONDARY DIAGNOSES 1 Desires permanent sterilization 2 Macrosomia POSTOPERATIVE DIAGNOSES 1 Desires permanent sterilization 2 Macrosomia 3 Status post repeat low transverse cesarean and bilateral tubal ligation PROCEDURES 1 Repeat low transverse cesarean section 2 Bilateral tubal ligation BTL ANESTHESIA Spinal FINDINGS A viable female infant weighing 7 pounds 10 ounces assigned Apgars of 9 and 9 There was normal pelvic anatomy normal tubes The placenta was normal in appearance with a three vessel cord DESCRIPTION OF PROCEDURE Patient was brought to the operating room with an IV running and a Foley catheter in place satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip The abdomen was prepped and draped in a sterile fashion A Pfannenstiel incision was made and carried sharply down to the level of fascia The fascia was incised transversely The fascia was dissected away from the underlying rectus muscles With sharp and blunt dissection rectus muscles were divided in midline The perineum was entered bluntly The incision was carried vertically with scissors Transverse incision was made across the bladder peritoneum The bladder was dissected away from the underlying lower uterine segment Bladder retractor was placed to protect the bladder The lower uterine segment was entered sharply with a scalpel Incision was carried transversely with bandage scissors Clear amniotic fluids were encountered The infant was out of the pelvis and was in oblique vertex presentation The head was brought down into the incision and delivered easily as were the shoulders and body The mouth and oropharynx were suctioned vigorously The cord was clamped and cut The infant was passed off to the waiting pediatrician in satisfactory condition Cord bloods were taken Placenta was delivered spontaneously and found to be intact Uterus was explored and found to be empty Uterus was delivered through the abdominal incision and massaged vigorously Intravenous Pitocin was administered T clamps were placed about the margins of the uterine incision which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis Secondary running locking stitch was placed for extra strength to the wound At this point attention was diverted to the patient s tubes a Babcock clamp grasped the isthmic portion of each tube and approximately 1 cm knuckle on either side was tied off with two lengths of 0 plain catgut Intervening knuckle was excised and passed off the field The proximal end of the tubal mucosa was cauterized Cul de sac and gutters were suctioned vigorously The uterus was returned to its proper anatomic position in the abdomen The fascia was closed with a simple running stitch of 0 PDS The skin was closed with running subcuticular of 4 0 Monocryl Uterus was expressed of its contents Patient was brought to the recovery room in satisfactory condition There were no complications There was 600 cc of blood loss All sponge needle and instrument counts were reported to be correct SPECIMEN Tubal segments DRAIN Foley catheter draining clear yellow urine Keywords obstetrics gynecology placenta low transverse cesarean section bilateral tubal ligation permanent sterilization cesarean section intrauterine btl sterilization macrosomia uterine MEDICAL_TRANSCRIPTION,Description Lysis of pelvic adhesions The patient had an 8 cm left ovarian mass The mass was palpable on physical examination and was tender She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy Medical Specialty Obstetrics Gynecology Sample Name Lysis of Pelvic Adhesions Transcription PREOPERATIVE DIAGNOSIS Multiple pelvic adhesions POSTOPERATIVE DIAGNOSIS Multiple pelvic adhesions PROCEDURE PERFORMED Lysis of pelvic adhesions ANESTHESIA General with local SPECIMEN None COMPLICATIONS None HISTORY The patient is a 32 year old female who had an 8 cm left ovarian mass which was evaluated by Dr X She had a ultrasound which demonstrated the same The mass was palpable on physical examination and was tender She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy During the surgery there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon These adhesions were taken down sharply with Metzenbaum scissors PROCEDURE A pelvic laparotomy had been performed by Dr X Upon exploration of the abdomen multiple pelvic adhesions were noted as previously stated A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst The ureter had been identified and isolated prior to the adhesiolysis There was no evidence of bleeding The remainder of the case was performed by Dr X and this will be found in a separate operative report Keywords obstetrics gynecology lysis of pelvic adhesions pelvic adhesions pelvic adhesions salpingooophorectomy lysis laparotomy sigmoid colon mass ovarian MEDICAL_TRANSCRIPTION,Description Primary low transverse cervical cesarean section Intrauterine pregnancy of 39 weeks Herpes simplex virus positive by history hepatitis C positive by history with low elevation of transaminases cephalopelvic disproportion asynclitism postpartum macrosomia and delivery of viable 9 lb female neonate Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 9 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy of 39 weeks 2 Herpes simplex virus positive by history 3 Hepatitis C positive by history with low elevation of transaminases 4 Cephalopelvic disproportion 5 Asynclitism 6 Postpartum macrosomia POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy of 39 weeks 2 Herpes simplex virus positive by history 3 Hepatitis C positive by history with low elevation of transaminases 4 Cephalopelvic disproportion 5 Asynclitism 6 Postpartum macrosomia 7 Delivery of viable 9 lb female neonate PROCEDURE PERFORMED Primary low transverse cervical cesarean section COMPLICATIONS None ESTIMATED BLOOD LOSS About 600 cc Baby is doing well The patient s uterus is intact bladder is intact HISTORY The patient is an approximately 25 year old Caucasian female with gravida 4 para 1 0 2 1 The patient s last menstrual period was in December of 2002 with a foreseeable due date on 09 16 03 confirmed by ultrasound The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases The patient had been seen through our office for prenatal care The patient is on Valtrex The patient was found to be 3 cm about 40 0 to 9 engaged Bag of waters was ruptured She was on Pitocin She was contracting appropriately for a couple of hours or so with appropriate ________ There was no cervical change noted Most probably because there was a sink vertex and that the head was too large to descend into the pelvis The patient was advised of this and we recommended cesarean section She agreed We discussed the surgery foreseeable risks and complications alternative treatment the procedure itself and recovery in layman s terms The patient s questions were answered I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire PROCEDURE The patient was then taken back to operative suite She was given anesthetic and sterilely prepped and draped Pfannenstiel incision was used A second knife was used to carry the incision down to the anterior rectus fascia Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature The rectus muscles were separated The patient s peritoneum tented up towards the umbilicus and we entered the abdominal cavity There was a very thin lower uterine segment There seemed to be quite a large baby The patient had a small nick in the uterus Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity clear amniotic fluid was obtained A blunt low transverse cervical incision was made Following this we placed a ________ on the very large fetal head The head was delivered following which we were able to deliver a large baby girl 9 lb good at tone and cry The patient then underwent removal of the placenta after the cord blood and ABG were taken The patient s uterus was examined There appeared to be no retained products The patient s uterine incision was reapproximated and sutured with 0 Vicryl in a running non interlocking fashion the second imbricating over the first The patient s uterus was hemostatic Bladder flap was reapproximated with 0 Vicryl The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures The patient had three interrupted sutures of this The fascia was reapproximated with two stitches of 0 Vicryl going from each apex towards the midline The Scarpa s fascia was reapproximated with 0 gut There was noted no fascial defects and the skin was closed with 0 Vicryl Prior to closing the abdominal cavity the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact The patient was hemostatic All counts were correct and the patient tolerated the procedure well We will see her back in recovery Keywords obstetrics gynecology intrauterine pregnancy herpes simplex virus hepatitis c cephalopelvic disproportion asynclitism postpartum macrosomia low transverse cervical cesarean section rectus fascia cesarean section intrauterine transaminases herpes uterus fascia MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization Intrauterine pregnancy at 35 1 7 Rh isoimmunization Suspected fetal anemia Desires permanent sterilization Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 8 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 35 1 7 2 Rh isoimmunization 3 Suspected fetal anemia 4 Desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 35 1 7 2 Rh isoimmunization 3 Suspected fetal anemia 4 Desires permanent sterilization OPERATION PERFORMED Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization ANESTHESIA Spinal anesthesia COMPLICATIONS None ESTIMATED BLOOD LOSS 500 mL INTRAOPERATIVE FLUIDS 1000 mL crystalloids URINE OUTPUT 300 mL clear urine at the end of procedure SPECIMENS Cord gases hematocrit on cord blood placenta and bilateral tubal segments INTRAOPERATIVE FINDINGS Male infant vertex position very bright yellow amniotic fluid Apgars 7 and 8 at 1 and 5 minutes respectively Weight pending at this time His name is Kasson as well as umbilical cord and placenta stained yellow Otherwise normal appearing uterus and bilateral tubes and ovaries DESCRIPTION OF OPERATION After informed consent was obtained the patient was taken to the operating room where spinal anesthesia was obtained by Dr X without difficulties The patient was placed in supine position with leftward tilt Fetal heart tones were checked and were 140s and she was prepped and draped in a normal sterile fashion At this time a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery The fascia was nicked sharply in the midline The fascial incision was extended laterally with Mayo scissors The inferior aspect of the fascial incision was grasped with Kocher x2 elevated and rectus muscles dissected sharply with the use of Mayo scissors Attention was then turned to the superior aspect of the fascial incision Fascia was grasped elevated and rectus muscles dissected off sharply The rectus muscles were separated in the midline bluntly The peritoneum was identified grasped and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder Bladder blade was inserted Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U shaped fashion with the scalpel Uterine incision was extended laterally and manually Membranes were ruptured and bright yellow clear amniotic fluid was noted Infant s head was in a floating position able to flex the head push against the incision and then easily brought it to the field vertex Nares and mouth were suctioned with bulb suction Remainder of the infant was delivered atraumatically The infant was very pale upon delivery Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team An 8 cm segment of the tube was doubly clamped and transected Cord gases were obtained Cord was then cleansed laid on a clean laparotomy sponge and cord blood was drawn for hematocrit measurements At this time it was noted that the cord was significantly yellow stained as well as the placenta At this time the placenta was delivered via gentle traction on the cord and exterior uterine massage Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1 0 chromic in a running locked fashion Two areas of oozing were noted and separate figure of eight sutures were placed to obtain hemostasis At this time the uterine incision was hemostatic The bladder was examined and found to be well below the level of the incision repair Tubes and ovaries were examined and found to be normal The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp Mesosalpinx was divided with electrocautery and a 4 cm segment of tube was doubly tied and transected with a 3 cm segment of tube removed Hemostasis was noted Then attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp Mesosalpinx was incised and 3 4 cm tube doubly tied transected and excised and excellent hemostasis was noted Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen Gutters were cleared off all clots and debris Lower uterine segments were again re inspected and found to be hemostatic Sites of tubal sterilization were also visualized and were hemostatic At this time the peritoneum was grasped with Kelly clamps x3 and closed with running 3 0 Vicryl suture Copious irrigation was used Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline At this time the fascia was closed using 0 Vicryl in a running fashion Manual palpation confirms thorough and adequate closure of the fascial layer Copious irrigation was again used Hemostasis noted and skin was closed with staples The patient tolerated the procedure well Sponge lap needle and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia The patient will be followed for her severe right upper quadrant pain post delivery If she continues to have pain may need a surgical consult for gallbladder and or angiogram for evaluation of right kidney and questionable venous plexus This all will be relayed to Dr Y her primary obstetrician who was on call starting this morning at 7 a m through the weekend Keywords obstetrics gynecology intrauterine pregnancy rh isoimmunization primary low transverse cesarean section bilateral tubal sterilization pfannenstiel skin incision fascial incision uterine incision fetal anemia permanent sterilization rectus muscles incision tubes cord MEDICAL_TRANSCRIPTION,Description Primary low transverse C section Postdates pregnancy failure to progress meconium stained amniotic fluid Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 4 Transcription PREOPERATIVE DIAGNOSES 1 Postdates pregnancy 2 Failure to progress 3 Meconium stained amniotic fluid POSTOPERATIVE DIAGNOSES 1 Postdates pregnancy 2 Failure to progress 3 Meconium stained amniotic fluid OPERATION Primary low transverse C section ANESTHESIA Epidural DESCRIPTION OF OPERATION The patient was taken to the operating room and under epidural anesthesia she was prepped and draped in the usual manner Anesthesia was tested and found to be adequate Incision was made Pfannenstiel approximately 1 5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty the fascia being incised laterally Bleeders were bovied Rectus muscles were separated from the overlying fascia with blunt and sharp dissection Muscles were separated in the midline Peritoneum was entered sharply and incision was carried out laterally in each direction Bladder blade was placed and bladder flap developed with blunt and sharp dissection A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction Allis was placed in the incision and an uncomplicated extraction of a 7 pound 4 ounce Apgar 9 female was accomplished and given to the pediatric service in attendance Infant was carefully suctioned after delivery of the head and body Cord blood was collected _______ and endometrial cavity was wiped free of membranes and clots Lower segment incision was inspected There were some extensive adhesions on the left side and a figure of eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present Cul de sac was suctioned free of blood and clots and irrigated Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated Lower segment incision was again inspected and found to be hemostatic The abdominal wall was then closed in layers 2 0 chromic on the peritoneum 0 Maxon on the fascia 3 0 plain on the subcutaneous and staples on the skin Hemostasis was present between all layers The area was gently irrigated across the peritoneum and fascial layers There were no intraoperative complications except blood loss The patient was taken to the recovery room in satisfactory condition Keywords obstetrics gynecology pregnancy meconium stained amniotic fluid low transverse c section amniotic fluid meconium peritoneum blood chromic fascial amniotic incision MEDICAL_TRANSCRIPTION,Description Primary low transverse cervical cesarean section Intrauterine pregnancy at 38 weeks and malpresentation A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively weighing 3030 g No nuchal cord No meconium Normal uterus fallopian tubes and ovaries Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 5 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 38 weeks 2 Malpresentation POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 38 weeks 2 Malpresentation 3 Delivery of a viable male neonate PROCEDURE PERFORMED Primary low transverse cervical cesarean section ANESTHESIA Spinal with Astramorph ESTIMATED BLOOD LOSS 300 cc URINE OUTPUT 80 cc of clear urine FLUIDS 2000 cc of crystalloids COMPLICATIONS None FINDINGS A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively weighing 3030 g No nuchal cord No meconium Normal uterus fallopian tubes and ovaries INDICATIONS This patient is a 21 year old gravida 3 para 1 0 1 1 Caucasian female who presented to Labor and Delivery in labor Her cervix did make some cervical chains She did progress to 75 and 2 however there was a raised lobular area palpated on the fetal head However on exam unable to delineate the facial structures but definite fetal malpresentation The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring The contraction pattern was inadequate It was discussed with the patient s family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended All the questions were answered PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt Prior to this the spinal anesthesia was administered The patient was then prepped and draped A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel The fascia was then incised in the midline and extended laterally using Mayo scissors The superior aspect of the rectus fascia was then grasped with Ochsners tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors The superior portion and inferior portion of the rectus fascia was identified tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors The rectus muscle was then separated in the midline The peritoneum was then identified tented up with hemostats and entered sharply with Metzenbaum scissors The peritoneum was then gently stretched The vesicouterine peritoneum was then identified tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors The uterus was entered with the second scalpel and large transverse incision This was then extended in upward and lateral fashion bluntly The infant was then delivered atraumatically The nose and mouth were suctioned The cord was then clamped and cut The infant was handed off to the awaiting pediatrician The placenta was then manually extracted The uterus was exteriorized and cleared of all clots and debris The uterine incision was then repaired using 0 chromic in a running fashion marking a U stitch A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis The uterus was then returned to the anatomical position The abdomen and the gutters were cleared of all clots Again the incision was found to be hemostatic The rectus muscle was then reapproximated with 2 0 Vicryl in a single interrupted stitch The rectus fascia was then repaired with 0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion This was palpated and the patient was found to be without defect and intact The skin was then closed with staples The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She will be followed up as an inpatient with Dr X Keywords obstetrics gynecology low transverse cervical cesarean section cesarean section pregnancy neonate metzenbaum scissors intrauterine pregnancy rectus fascia rectus muscle intrauterine peritoneum malpresentation transverse astramorph MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section via Pfannenstiel incision Pregnancy at 40 weeks failure to progress premature prolonged rupture of membranes group B strep colonization and delivery of viable male neonate Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 6 Transcription PREOPERATIVE DIAGNOSES 1 Pregnancy at 40 weeks 2 Failure to progress 3 Premature prolonged rupture of membranes 4 Group B strep colonization POSTOPERATIVE DIAGNOSIS 1 Pregnancy at 40 weeks 2 Failure to progress 3 Premature prolonged rupture of membranes 4 Group B strep colonization 5 Delivery of viable male neonate PROCEDURE PERFORMED Primary low transverse cesarean section via Pfannenstiel incision ANESTHESIA Spinal ESTIMATED BLOOD LOSS 1000 cc FLUID REPLACEMENT 2700 cc crystalloid URINE 500 cc clear yellow urine in the Foley catheter INTRAOPERATIVE FINDINGS Normal appearing uterus tubes and ovaries A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively Infant weight equaled to 4140 gm with clear amniotic fluid The umbilical cord was wrapped around the leg tightly x1 Infant was in a vertex right occiput anterior position INDICATIONS FOR PROCEDURE The patient is a 19 year old G1 P0 at 41 and 1 7th weeks intrauterine pregnancy She presented at mid night on 08 22 03 complaining of spontaneous rupture of membranes which was confirmed in Labor and Delivery The patient had a positive group beta strep colonization culture and was started on penicillin The patient was also started on Pitocin protocol at that time The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor IUPC was placed without difficulty and contractions appeared to be regular however they were inadequate amount of the daily units The patient was given a rest from the Pitocin She walked and had a short shower The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions Maximum cervical dilation was 5 cm 80 effaced negative 2 station and cephalic position At the time of C section the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation as there was suspected macrosomia on ultrasound Options were discussed with the patient and family and it was determined that we will take her for C section today Consent was signed All questions were answered with Dr X present PROCEDURE The patient was taken to the operative suite where a spinal anesthetic was placed She was placed in the dorsal supine position with left upward tilt She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel The fascia was incised in the midline and extended laterally using curved Mayo scissors The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle The rectus muscle was separated in the midline bluntly The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors The peritoneum was then bluntly stretched The bladder blade was placed The vesicouterine peritoneum was identified tented up with Allis and entered sharply with Metzenbaum scissors The incision was extended laterally and the bladder flap created digitally The bladder blade was then reinserted in the lower uterine segment A low transverse uterine incision was made with a second scalpel The uterine incision was extended laterally bluntly The bladder blade was removed and the infant s head was delivered with the assistance of a vacuum Infant s nose and mouth were bulb suctioned and the body was delivered atraumatically There was of note an umbilical cord around the leg tightly x1 Cord was clamped and cut Infant was handed to the waiting pediatrician Cord gas was sent for pH as well as blood typing The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris The uterine incision was grasped circumferentially with Alfred clamps and closed with 0 Chromic in a running locked fashion A second layer of imbricating stitch was performed using 0 Chromic suture to obtain excellent hemostasis The uterus was returned to the abdomen The gutters were cleared of all clots and debris The rectus muscle was loosely approximated with 0 Vicryl suture in a single interrupted fashion The fascia was reapproximated with 0 Vicryl suture in a running fashion The subcutaneous Scarpa s fascia was then closed with 2 0 plain gut The skin was then closed with staples The incision was dressed with sterile dressing and bandage Blood clots were evacuated from the vagina The patient tolerated the procedure well The sponge lap and needle counts were correct x2 The mother was taken to the recovery room in stable and satisfactory condition Keywords obstetrics gynecology c section cesarean section low transverse pregnancy rupture of membranes cervical dilation kocher clamps metzenbaum scissors vicryl suture pfannenstiel incision uterine incision rectus muscles incision transverse colonization rectus muscles bladder uterine section fascia MEDICAL_TRANSCRIPTION,Description A repeat low transverse cervical cesarean section Lysis of adhesions Dissection of the bladder of the anterior abdominal wall and away from the fascia and the patient also underwent a bilateral tubal occlusion via Hulka clips Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 10 Transcription PREOPERATIVE DIAGNOSES 1 36th and 4 7th week intrauterine growth rate 2 Charcot Marie Tooth disease 3 Previous amniocentesis showing positive fetal lung maturity family planning complete 4 Previous spinal fusion 5 Two previous C sections The patient refuses trial labor The patient is with regular contractions dilated to 3 possibly an early labor contractions are getting more and more painful POSTOPERATIVE DIAGNOSES 1 36th and 4 7th week intrauterine growth rate 2 Charcot Marie Tooth disease 3 Previous amniocentesis showing positive fetal lung maturity family planning complete 4 Previous spinal effusion 5 Two previous C section The patient refuses trial labor The patient is with regular contractions dilated to 3 possibly an early labor contractions are getting more and more painful 6 Adhesions of bladder 7 Poor fascia quality 8 Delivery of a viable female neonate PROCEDURE PERFORMED 1 A repeat low transverse cervical cesarean section 2 Lysis of adhesions 3 Dissection of the bladder of the anterior abdominal wall and away from the fascia 4 The patient also underwent a bilateral tubal occlusion via Hulka clips COMPLICATIONS None BLOOD LOSS 600 cc HISTORY AND INDICATIONS Indigo Carmine dye bladder test in which the bladder was filled showed that there was no defects in the bladder of the uterus The uterus appeared to be intact This patient is a 26 year old Caucasian female The patient is well known to the OB GYN clinic The patient had two previous C sections She appears to be in probably early labor She had an amniocentesis early today She is contracting regularly about every three minutes The contractions are painful and getting much more so since the amniocentesis The patient had fetal lung maturity noted The patient also has probable IUGR as none of her babies have been over 4 lb The patient s baby appears to be somewhat small The patient suffers from Charcot Marie Tooth disease which has left her wheelchair bound The patient has had a spinal fusion however family planning is definitely complete per the patient The patient refuses trial labor The patient and I discussed the consent She understands the foreseeable risks and complications alternative treatment of the procedure itself and recovery Her questions were answered The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure which would result in either an intrauterine or ectopic pregnancy The patient understands this and would like to try our best PROCEDURE The patient was taken back to the operative suite She was given general anesthetic by Department of Anesthesiology Once again in layman s terms the patient understands the risks The patient had the informed consent reviewed and understood The patient has had a Pfannenstiel incision which was slightly bent towards the right side favoring the right side The patient had the first knife went through this incision The second knife was used to go to the level of fascia The fascia was very thin ruddy in appearance and with abundant scar tissue The fascia was incised Following this we were able to see the peritoneum There was really no obvious rectus abdominal muscles noted They were very weak atrophic and thin The patient has the peritoneum tented up We entered the abdominal cavity The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia The bladder flap was then entered into the uterus as well There are some bladder adhesions We removed these adhesions and we removed the bladder of the fascia We dissected the bladder of the lower segment We made a small nick on the lower segment We were able to utilize the blunt end of the knife to enter into the uterine cavity The baby was in occiput transverse position with the ear being cocked at such a position as well The patient s baby was delivered without difficulty It was a 4 lb and 10 oz baby girl who vigorously cried well There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection The patient s placenta was delivered There was no retained placenta The uterine incision was closed with two layers of 0 Vicryl the second layer imbricating over the first The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized Then we ligated this as there was bleeding and oozing The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc The 400 cc was instilled The bladder appears to be intact The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment There was some oozing around the area of the bladder We placed an Avitene there The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx The patient has two clips on each side There was excellent tubal occlusion and placement The uterus was placed back into the abdominal cavity We rechecked again The tubal placement was excellent It did not involve the round ligaments uterosacral ligaments the uteroovarian ligaments and the tube into the mesosalpinx The patient then underwent further examination Hemostasis appeared to be good The fascia was reapproximated with short running intervals of 0 Vicryl across the fascia We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible The Scarpa s fascia was reapproximated with 0 gut The skin was reapproximated then as well via subcutaneous closure The patient s sponge and needle counts found to be correct Uterus appeared to be normal prior to closure Bladder appeared to be normal The patient s blood loss is 600 cc Keywords obstetrics gynecology intrauterine growth rate charcot marie tooth disease amniocentesis c sections trial labor low transverse cervical cesarean section lysis of adhesions dissection bladder abdominal wall fascia hulka clips bilateral tubal occlusion intrauterine transverse uterus abdominal MEDICAL_TRANSCRIPTION,Description Primary low segment cesarean section Medical Specialty Obstetrics Gynecology Sample Name Low Segment C Section Transcription PREOPERATIVE DIAGNOSIS Pregnancy at 42 weeks nonreassuring fetal testing and failed induction POSTOPERATIVE DIAGNOSIS Pregnancy at 42 weeks nonreassuring fetal testing and failed induction PROCEDURE Primary low segment cesarean section The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia Bleeding points were snapped and coagulated along the way The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles These were divided in the midline revealing the peritoneum which was opened vertically The uterus was in mid position The bladder flap was incised elliptically and reflected caudad A low transverse hysterotomy incision was then constructed and extended bluntly Amniotomy revealed clear amniotic fluid A live born vigorous male infant was then delivered from the right occiput transverse position The infant breathed and cried spontaneously The nares and pharynx were suctioned The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team Cord blood samples were obtained The placenta was manually removed and the uterus was eventrated for closure The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two layer technique using 0 Vicryl suture with the second layer imbricating the first Hemostasis was completed with an additional figure of eight suture of 0 Vicryl The cornual sac and gutters were irrigated The uterus was returned to the abdominal cavity The adnexa were inspected and were normal The abdomen was then closed in layers Fascia was closed with running 0 Vicryl sutures subcutaneous tissue with running 3 0 plain Catgut and skin with 3 0 Monocryl subcuticular suture and Steri Strips Blood loss was estimated at 700 mL All counts were correct The patient tolerated the procedure well and left the operating room in excellent condition Keywords obstetrics gynecology nonreassuring fetal testing anterior rectus fascia pennington clamps fetal testing low segment induction suture MEDICAL_TRANSCRIPTION,Description Repeat low transverse C section lysis of omental adhesions lysis of uterine adhesions with repair of uterine defect and bilateral tubal ligation Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 3 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 33 weeks twin gestation 2 Active preterm labor 3 Advanced dilation 4 Multiparity 5 Requested sterilization POSTOPERATIVE DIAGNOSIS 1 Intrauterine pregnancy at 33 weeks twin gestation 2 Active preterm labor 3 Advanced dilation 4 Multiparity 5 Requested sterilization 6 Delivery of a viable female A weighing 4 pounds 7 ounces Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces Apgars 6 and 7 at 1 and 5 minutes respectively 7 Uterine adhesions and omentum adhesions OPERATION PERFORMED Repeat low transverse C section lysis of omental adhesions lysis of uterine adhesions with repair of uterine defect and bilateral tubal ligation ANESTHESIA General ESTIMATED BLOOD LOSS 500 mL DRAINS Foley This is a 25 year old white female gravida 3 para 2 0 0 2 with twin gestation at 33 weeks and previous C section The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm The decision for C section was made PROCEDURE The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision The patient was then given general anesthesia and once this was completed first knife was used to make a low transverse incision extending down to the level of the fascia The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically The abdominal rectus muscle was divided in the center and extended in a vertical fashion Peritoneum was entered at a high point and extended in a vertical fashion as well The bladder blade was put in place The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus The first fetus was vertex The fluid was clear The head was delivered followed by the remaining portion of the body The cord was doubly clamped and cut The newborn handed off to waiting pediatrician and nursery personnel The second fluid was ruptured It was the clear fluid as well The presenting part was brought down to be vertex The head was delivered followed by the rest of the body and the cord was doubly clamped and cut and newborn handed off to waiting pediatrician in addition of the nursery personnel Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B Once this was completed the placenta was delivered and handed off for further inspection by Pathology At this time it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection Then there were multiple omental adhesions on the surface of the uterus itself This needed to be released as well as on the abdominal wall and then the uterus could be externalized The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re approximate the uterine incision with the second layer used to imbricate the first The bladder flap was re approximated with 3 0 Vicryl and Gelfoam underneath The right fallopian tube was grasped with a Babcock it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized The same technique was completed on the left side with the knuckle portion cut off and cauterized as well The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis Interceed was placed over this area as well The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position The gutters were wiped clean of any remaining blood The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re approximate abdominal rectus muscles as well as the peritoneal edges The abdominal rectus muscle was irrigated The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center The subcutaneous tissue was irrigated Cautery was used to create adequate hemostasis and 3 0 Vicryl was used to re approximate the subcutaneous tissue Skin edges were re approximated with sterile staples Sterile dressing was applied Uterus was evacuated of any remaining blood vaginally The patient was taken to the recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords obstetrics gynecology intrauterine pregnancy gestation preterm labor omentum adhesions low transverse c section uterine adhesions intrauterine adhesions abdominal uterus uterine MEDICAL_TRANSCRIPTION,Description Primary low transverse cesarean section Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Arrest of dilation POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Arrest of dilation PROCEDURE PERFORMED Primary low transverse cesarean section ANESTHESIA Epidural ESTIMATED BLOOD LOSS 1000 mL COMPLICATIONS None FINDINGS Female infant in cephalic presentation OP position weight 9 pounds 8 ounces Apgars were 9 at 1 minute and 9 at 5 minutes Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 20 year old gravida 1 para 0 female who presented to labor and delivery in early active labor at 40 and 6 7 weeks gestation The patient progressed to 8 cm at which time Pitocin was started She subsequently progressed to 9 cm but despite adequate contractions arrested dilation at 9 cm A decision was made to proceed with a primary low transverse cesarean section The procedure was described to the patient in detail including possible risks of bleeding infection injury to surrounding organs and possible need for further surgery Informed consent was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where epidural anesthesia was found to be adequate The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left ward tilt A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to elevate the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors Attention was then turned to the inferior aspect of the fascial incision which in similar fashion was grasped with Kocher clamps elevated and the underlying rectus muscles were dissected off bluntly and using Mayo scissors The rectus muscles were dissected in the midline The peritoneum was bluntly dissected entered and extended superiorly and inferiorly with good visualization of the bladder The bladder blade was inserted The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors This incision was extended laterally and the bladder flap was created digitally The bladder blade was reinserted The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction Clear fluid was noted The infant was subsequently delivered atraumatically The nose and mouth were bulb suctioned The cord was clamped and cut The infant was subsequently handed to the awaiting nursery nurse Next cord blood was obtained per the patient s request for cord blood donation which took several minutes to perform Subsequent to the collection of this blood the placenta was removed spontaneously intact with a 3 vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic suture Hemostasis was visualized The uterus was returned to the abdomen The pelvis was copiously irrigated The uterine incision was reexamined and was noted to be hemostatic The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was closed with 0 Vicryl the subcutaneous layer was closed with 3 0 plain gut and the skin was closed with staples Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords obstetrics gynecology intrauterine pregnancy at term arrest of dilation cephalic presentation low transverse cesarean section cesarean section rectus muscles intrauterine MEDICAL_TRANSCRIPTION,Description Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 2 Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate 2 Protein S low 3 Oligohydramnios POSTOPERATIVE 1 Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate 2 Protein S low 3 Oligohydramnios 4 Delivery of a viable female weight 5 pound 14 ounces Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7 314 OPERATION PERFORMED Low transverse C section ESTIMATED BLOOD LOSS 500 mL DRAINS Foley ANESTHESIA Spinal with Duramorph HISTORY OF PRESENT ILLNESS This is a 21 year old white female gravida 1 para 0 who had presented to the hospital at 37 3 7 weeks for induction The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration Due to the IUGR as well a decision for a C section was made PROCEDURE The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department The patient was then repositioned prepped and draped in a slight left lateral tilt Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis This was extended down to the level of the fascia The fascia was nicked in the center and extended in transverse fashion Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique The abdominal rectus muscle was divided in the center extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus Presenting part was vertex the head was delivered followed by the remaining portion of the body The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel Cord pH blood and cord blood was obtained The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0 chromic and a continuous locking stitch with a second layer used to imbricate the first The bladder flap was re peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2 0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum This area was then irrigated Cautery was used for adequate hemostasis corners of the fascia grasped with hemostats and continuous locking stitch of 1 Vicryl was started at both corners and overlapped in the center Subcutaneous tissue was irrigated with saline and reapproximated with 3 0 Vicryl Skin edges reapproximated with sterile staples Sterile dressing was applied The uterus was evacuated of any remaining clots vaginally The patient was taken to recovery room in stable condition Instrument count needle count and sponge counts were all correct Keywords obstetrics gynecology apgars low transverse c section fetal heart rate bladder blade intrauterine pregnancy intrauterine MEDICAL_TRANSCRIPTION,Description LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh Medical Specialty Obstetrics Gynecology Sample Name LEEP Transcription DIAGNOSIS 1 Broad based endocervical poly 2 Broad based pigmented raised nevus right thigh OPERATION 1 LEEP procedure of endocervical polyp 2 Electrical excision of pigmented mole of inner right thigh FINDINGS There was a 1 5 x 1 5 cm broad based pigmented nevus on the inner thigh that was excised with a wire loop Also there was a butt based 1 cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal PROCEDURE With the patient in the supine position general anesthesia was administered The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion An insulated posterior weighted retractor was put in Using the LEEP tenaculum we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting 30 coagulation The endocervical polyp on the posterior lip of the cervix was excised Then changing from a 50 of coagulation and 5 cutting the base of the polyp was electrocoagulated which controlled all the bleeding The wire loop was attached and the pigmented raised nevus on the inner thigh was excised with the wire loop Cautery of the base was done and then it was closed with figure of eight 3 0 Vicryl sutures A band aid was applied over this Rechecking the cervix no bleeding was noted The patient was laid flat on the table awakened and moved to the recovery room bed and sent to the recovery room in satisfactory condition Keywords obstetrics gynecology endocervical polyp pigmented mole polyp leep tenaculum leep cervix endocervical pigmented MEDICAL_TRANSCRIPTION,Description Carbon dioxide laser photo ablation due to recurrent dysplasia of vulva Medical Specialty Obstetrics Gynecology Sample Name Laser of Vulva Transcription PREOPERATIVE DIAGNOSIS Recurrent dysplasia of vulva POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Carbon dioxide laser photo ablation ANESTHESIA General laryngeal mask INDICATIONS FOR PROCEDURE The patient has a past history of recurrent vulvar dysplasia She has had multiple prior procedures for treatment She was counseled to undergo laser photo ablation FINDINGS Examination under anesthesia revealed several slightly raised and pigmented lesions predominantly on the left labia and perianal regions After staining with acetic acid several additional areas of acetowhite epithelium were seen on both sides and in the perianal region PROCEDURE The patient was brought to the operating room with an IV in place Anesthetic was administered after which she was placed in the lithotomy position Examination under anesthesia was performed after which she was prepped and draped Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid Setting was 25 watts using a 6 mm pattern size with the silk touch hand piece in the paint mode Excellent hemostasis was noted and Bacitracin was applied prophylactically The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords obstetrics gynecology laser of vulva recurrent dysplasia carbon dioxide laser photo ablation recurrent dysplasia of vulva dysplasia of vulva carbon dioxide laser photo ablation carbon dysplasia laser ablation MEDICAL_TRANSCRIPTION,Description Primary cesarean section by low transverse incision Term pregnancy nonreassuring fetal heart tracing Medical Specialty Obstetrics Gynecology Sample Name Low Transverse C Section 1 Transcription PREOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing POSTOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing OPERATION Primary cesarean section by low transverse incision ANESTHESIA Epidural ESTIMATED BLOOD LOSS 450 mL COMPLICATIONS None CONDITION Stable DRAINS Foley catheter INDICATIONS The patient is a 39 year old G4 para 0 0 3 0 with an EDC of 03 08 2009 The patient began having prodromal symptoms 2 to 3 days prior to presentation She was seen on 03 09 2007 and a nonstress test was performed This revealed some spontaneous variable appearing decelerations She was given IV hydration A biophysical profile was obtained which provided a score of 0 8 with only a 1 cm fluid pocket found Therefore she was admitted for further fetal monitoring and evaluation She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated She was having somewhat irregular contractions but with stronger contractions continued to have decelerations to 50 to 60 beats per minute Due to these findings a scalp electrode was placed as well as an IUPC for an amnioinfusion This relieved the decelerations somewhat However over a period of time with strong contractions she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations Due to this finding it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery These findings were reviewed with the patient and recommendation was made for cesarean section delivery The risks and benefits of this surgery were reviewed and knowing these facts the patient gave informed consent PROCEDURE The patient was taken to the operating room where her epidural anesthesia was reinforced She was prepped and draped in the usual fashion for the procedure After adequate epidural level was confirmed the scalp was utilized to make a transverse incision in the patient s lower abdominal wall This incision was carried down to the level of the fascia which was also transversely incised After adequate hemostasis the fascia was bluntly and sharply separated up from the underlying rectus muscle The rectus muscle was separated in midline exposing the peritoneum The peritoneum was carefully grasped and elevated with hemostats It was entered in an up and down fashion with Metzenbaum scissors The bladder blade was placed in the lower pole of the incision to protect the bladder The uterus was palpated and inspected A thin lower uterine segment was noted The vertex presentation was confirmed The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall Clear fluid was noted upon entering into the amniotic space At 05 27 a term viable female infant was delivered up through the incision She had spontaneous respirations She was given bulb suctioning for clear fluid Her cord was clamped and cut and she was delivered off the field to Dr X who was attending The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes Her birth weight was found to be 5 pounds and 5 ounces The placenta was manually extracted from the endometrial cavity A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis The uterus was delivered up into the operative field The endometrial cavity was swiped clean with a moist laparotomy pad The uterine incision was then closed in a two layered fashion with 0 Vicryl suture the first layer interlocking and the second layer imbricating Two additional stitches of 3 0 Vicryl suture were utilized for hemostasis The uterine incision was noted to be hemostatic upon closure The uterus was rotated forward normal tubes and ovaries were noted on both sides The uterus was then returned to its normal position of the abdominal cavity The sponge and instrument count was performed for the first time at this point and found to be correct The pelvis and anterior uterine space was then irrigated with saline solution It was suctioned dry A final check of the uterine incision confirmed hemostasis The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture The subcutaneous tissue was then exposed and the fascia closed with two running lengths of 0 Vicryl suture beginning in lateral margins and overlapping the midline The subcutaneous tissue was then irrigated and inspected No active bleeding was noted It was closed with a running length of 3 0 plain catgut suture The skin was then approximated with surgical steel staples The incision was infiltrated with a 0 5 solution of Marcaine local anesthetic The incision was cleansed and sterilely dressed The patient was transferred to the recovery room in stable condition The estimated blood loss through the procedure was 450 mL The sponge and instrument counts were performed two more times during closure and found to be correct each time Keywords obstetrics gynecology low transverse incision edc para amnioinfusion nonreassuring fetal heart tracing primary cesarean section fetal heart tracing low transverse term pregnancy fetal heart heart tracing rectus muscle uterine incision vicryl suture incision transverse fetal suture uterine MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and drainage of cyst Medical Specialty Obstetrics Gynecology Sample Name Laparoscopy Drainage of Cyst Transcription PREOPERATIVE DIAGNOSIS Ovarian cyst persistent POSTOPERATIVE DIAGNOSIS Ovarian cyst ANESTHESIA General NAME OF OPERATION Diagnostic laparoscopy and drainage of cyst PROCEDURE The patient was taken to the operating room prepped and draped in the usual manner and adequate anesthesia was induced An infraumbilical incision was made and Veress needle placed without difficulty Gas was entered into the abdomen at two liters The laparoscope was entered and the abdomen was visualized The second puncture site was made and the second trocar placed without difficulty The cyst was noted on the left a 3 cm ovarian cyst This was needled and a hole cut in it with the scissors Hemostasis was intact Instruments were removed The patient was awakened and taken to the recovery room in good condition Keywords obstetrics gynecology ovarian cyst infraumbilical incision drainage of cyst diagnostic laparoscopy laparoscopy drainage ovarian MEDICAL_TRANSCRIPTION,Description Laparoscopy with left salpingo oophorectomy Left adnexal mass ovarian lesion The labia and perineum were within normal limits The hymen was found to be intact Laparoscopic findings revealed a 4 cm left adnexal mass which appeared fluid filled Medical Specialty Obstetrics Gynecology Sample Name Laparoscopy Salpingo oophorectomy Transcription PREOPERATIVE DIAGNOSIS Left adnexal mass POSTOPERATIVE DIAGNOSIS Left ovarian lesion PROCEDURE PERFORMED Laparoscopy with left salpingo oophorectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than 50 cc COMPLICATIONS None FINDINGS The labia and perineum were within normal limits The hymen was found to be intact Laparoscopic findings revealed a 4 cm left adnexal mass which appeared fluid filled There were a few calcifications on the surface of the mass The right ovary and fallopian tube appeared normal There was no evidence of endometriosis The uterus appeared normal in size There were no pelvic adhesions noted INDICATIONS The patient is a 55 year old gravida 0 para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5 3 cm She does complain of minimal discomfort Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen PROCEDURE IN DETAIL After informed consent was obtained the patient was taken back to the Operative Suite prepped and draped and placed in the dorsal lithotomy position A 1 cm skin incision was made in the infraumbilical vault While tenting up the abdominal wall the Veress needle was inserted without difficulty and the abdomen was insufflated This was done using appropriate flow and volume of CO2 The 11 step trocar was then placed without difficulty The above findings were confirmed A 12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization Two additional ports were placed one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall Both 12 step ports were done under direct visualization Using a grasper the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision The skin was extended around this incision and the fascia was extended using the Mayo scissors The specimen was removed intact in the Endocatch bag through this site Prior to desufflation of the abdomen the site where the left adnexa was removed was visualized to be hemostatic All the port sites were hemostatic as well The fascia of the suprapubic incision was then repaired using a running 0 Vicryl stitch on a UR6 needle The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion The remaining incisions were also closed with 4 0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated Steri Strips were placed on each of the incisions The patient tolerated the procedure well Sponge lap and needle count were x2 She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her Keywords obstetrics gynecology salpingo oophorectomy ovarian lesion adnexal mass salpingo oophorectomy abdominal wall intact adnexal laparoscopy mass MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy and right salpingectomy Medical Specialty Obstetrics Gynecology Sample Name Laparotomy Salpingectomy Transcription PREOPERATIVE DIAGNOSES 1 Right ectopic pregnancy 2 Severe abdominal pain 3 Tachycardia POSTOPERATIVE DIAGNOSES 1 Right ectopic pregnancy 2 Severe abdominal pain 3 Tachycardia PROCEDURE PERFORMED Exploratory laparotomy and right salpingectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 200 mL COMPLICATIONS None FINDINGS Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity Normal appearing ovaries bilaterally normal appearing left fallopian tube and normal appearing uterus INDICATIONS The patient is a 23 year old gravida P2 P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08 08 and treated appropriately and adequately with methotrexate Evaluation in the emergency room reveals a second right ectopic pregnancy Her beta quant was found to be approximately 13 000 The ultrasound showed right adnexal mass with crown rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy The procedure was discussed with the patient in detail including risks of bleeding infection injury to surrounding organs and possible need for further surgery Informed consult was obtained prior to proceeding with the procedure PROCEDURE NOTE The patient was taken to the operating room where general anesthesia was administered without difficulty The patient was prepped and draped in the usual sterile fashion A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie The fascia was incised in the midline and extended laterally using Mayo scissors Kocher clamps were used to grasp the superior aspect of the fascial incision which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors attention was then turned to the inferior aspect which was grasped with Kocher clamps elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors The rectus muscles were dissected in the midline The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder At this time the blood found in the abdomen was suctioned The bowel was packed with moist laparotomy sponge The right ectopic pregnancy was identified The fallopian tube was clamped x2 excised and ligated x2 using 0 Vicryl suture Hemostasis was visualized At this time the left tube and ovary were examined and were found to be normal in appearance The pelvis was cleared off clots and was copiously irrigated The fallopian tube was reexamined and it was noted to be hemostatic At this time the laparotomy sponges were removed The rectus muscles were reapproximated using 3 0 Vicryl The fascia was reapproximated with 0 Vicryl sutures The subcutaneous layer was closed with 3 0 plain gut The skin was closed with 4 0 Monocryl Sponge lap and instrument counts were correct x2 The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords obstetrics gynecology ectopic pregnancy salpingectomy exploratory laparotomy fallopian tube mayo scissors rectus muscles MEDICAL_TRANSCRIPTION,Description Attempted laparoscopy open laparoscopy and fulguration of endometrial implant Chronic pelvic pain probably secondary to endometriosis Medical Specialty Obstetrics Gynecology Sample Name Laparoscopy 3 Transcription PREOPERATIVE DIAGNOSIS Chronic pelvic pain probably secondary to endometriosis POSTOPERATIVE DIAGNOSIS Mild pelvic endometriosis PROCEDURE 1 Attempted laparoscopy 2 Open laparoscopy 3 Fulguration of endometrial implant ANESTHESIA General endotracheal BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS The patient is a 21 year old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone containing birth control pills either cyclically or daily as well as progestational medication only who had a negative GI workup recently including colonoscopy and desired definitive operative evaluation and diagnosis prior to initiation of a 6 month course of Depo Lupron PROCEDURE After an adequate plane of general anesthesia had been obtained the patient was placed in a dorsal lithotomy position She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery Bimanual examination revealed a mid position normal sized uterus with benign adnexal area In the high lithotomy position a weighted speculum was placed into the posterior vaginal wall The anterior lip of the cervix was grasped with a single tooth tenaculum A Hulka tenaculum was placed transcervically The other instruments were removed A Foley catheter was placed transurethrally to drain the bladder intraoperatively In the low lithotomy position and in steep Trendelenburg attention was turned to the infraumbilical region Here a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum The needle was removed the incision minimally enlarged and the 5 trocar and cannula were placed The trocar was removed and the scope placed confirming a preperitoneal insufflation The space was drained off the insufflated gas and 2 more attempts were made which failed due to the patient s adiposity Attention was turned back to the vaginal area where in the high lithotomy position attempts were made at a posterior vaginal apical insertion The Hulka tenaculum was removed the posterior lip of the cervix grasped with a single tooth tenaculum and the long Allis clamp used to grasp the posterior fornix on which was placed traction The first short and subsequently 15 cm Veress needles were attempted to be placed but after several passes no good pneumoperitoneum could be established via this route also It was elected not to do a transcervical intentional uterine perforation but to return to the umbilical area The 15 cm Veress needle was inserted several times but again a pneumo was preperitoneal Finally an open laparoscopic approach was undertaken The skin incision was expanded with a knife blade Blunt dissection was used to carry the dissection down to the fascia This was grasped with Kocher clamps entered sharply and opened transversely Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff Dissection continued between the rectus muscle and finally the anterior peritoneum was reached grasped elevated and entered At this juncture the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created a 10 scope was placed confirming the intraperitoneal positioning Under direct visualization a suprapubic 5 mm cannula and manipulative probe were placed Clockwise inspection of the pelvis revealed a benign vesicouterine pouch normal uterus and fundus normal right tube and ovary In the cul de sac there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting The left tube and ovary were normal There were no adhesions There was no evidence of acute pelvic inflammatory disease The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated Pictures were taken for confirmation both before and after the burn The carbon chars were irrigated and aspirated The smoke plume was removed without difficulty Approximately 50 mL of irrigant was left in the pelvis Due to the difficulty in placing and maintaining the Hasson cannula no attempts were made to view the upper abdominal quadrant specifically the liver and gallbladder The suprapubic cannula was removed under direct visualization the pneumo released the scope removed the stay sutures cut and the Hasson cannula removed The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site Finally the skin incisions were approximated with 3 0 Dexon subcuticularly They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies The vaginal instruments were removed All counts were correct The patient tolerated the procedure well and was taken to the recovery room in stable condition Keywords obstetrics gynecology endometriosis fulguration endometrial single tooth tenaculum endometrial implant hulka tenaculum veress needle hasson cannula pneumoperitoneum laparoscopy cannula MEDICAL_TRANSCRIPTION,Description Laparoscopy with ablation of endometriosis Allen Masters window in the upper left portion of the cul de sac bronze lesions of endometriosis in the central portion of the cul de sac as well as both the left uterosacral ligament flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul de sac Medical Specialty Obstetrics Gynecology Sample Name Laparoscopy 4 Transcription PROCEDURE Laparoscopy with ablation of endometriosis DIAGNOSIS Endometriosis ANESTHESIA General ESTIMATED BLOOD LOSS None FINDINGS Allen Masters window in the upper left portion of the cul de sac bronze lesions of endometriosis in the central portion of the cul de sac as well as both the left uterosacral ligament flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul de sac Normal tubes and ovaries normal gallbladder smooth liver edge PROCEDURE The patient was taken to the operating room and placed under general anesthesia She was put in the dorsal lithotomy position and the perineum and abdomen were prepped and draped in a sterile manner Subumbilical area was injected with Marcaine and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated Scalpel was used to make a subumbilical incision through which a 5 mm trocar was placed Laparoscope was inserted through the cannula and the pelvis was visualized Under direct visualization two 5 mm trocars were placed in the right and left suprapubic midline Incision sites were transilluminated and injected with Marcaine prior to cutting Hulka manipulator was placed on the cervix Pelvis was inspected and blood tinged fluid was aspirated from the cul de sac The beginnings of an Allen Masters window in the left side of the cul de sac were visualized along with bronze lesions of endometriosis Some more lesions were noted above the left uterosacral ligament Flame lesions were noted above the right uterosacral ligament Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube There was a somewhat leathery appearance to the ovaries The lesions of endometriosis were ablated with the argon beam coagulator as was a region of the Allen Masters window Pelvis was irrigated and all operative sites were hemostatic No other abnormalities were visualized and all instruments were moved under direct visualization Approximately 200 mL of fluid remained in the abdominal cavity All counts were correct and the skin incisions were closed with 2 0 Vicryl after all CO2 was allowed to escape The patient was taken to the recovery in stable condition Keywords obstetrics gynecology ablation of endometriosis allen masters window uterosacral ligament endometriosis cul de sac laparoscopy lesions ablation MEDICAL_TRANSCRIPTION,Description Laparotomy and myomectomy Enlarged fibroid uterus and blood loss anemia On bimanual exam the patient has an enlarged approximately 14 week sized uterus that is freely mobile and anteverted with no adnexal masses Surgically the patient has an enlarged fibroid uterus with a large fundal anterior fibroids Medical Specialty Obstetrics Gynecology Sample Name Laparotomy Myomectomy Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Blood loss anemia PROCEDURE PERFORMED 1 Laparotomy 2 Myomectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than a 100 cc URINE OUTPUT 110 cc clear at the end of the procedure FLUIDS 500 cc during the procedure SPECIMENS Four uterine fibroids DRAINS Foley catheter to gravity COMPLICATIONS None FINDINGS On bimanual exam the patient has an enlarged approximately 14 week sized uterus that is freely mobile and anteverted with no adnexal masses Surgically the patient has an enlarged fibroid uterus with a large fundal anterior fibroids which is approximately 6 cm and several small submucosal fibroids within the endometrium Both ovaries and tubes appeared within normal limits PROCEDURE The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position After the general anesthetic was found to be adequate a Pfannenstiel skin incision was made with the first knife This was carried through the underlying layer of fascia with a second knife The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors The superior aspect of the fascial incision was then grasped with Ochsner clamps tented up and dissected off the underlying layer of rectus muscle bluntly It was then dissected in the middle with the Mayo scissors The inferior aspect of this incision was addressed in a similar manner The rectus muscles were separated in the midline bluntly The peritoneum was identified with hemostat clamps tented up and entered sharply with the Metzenbaum scissors The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly Next the uterus was grasped bluntly and removed from the abdomen The fundal fibroid was identified It was then injected with vasopressin 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels 15 cc was injected Next the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen The edges of the myometrium was grasped with Allis clamps tented up and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger The fibroid was easily and bluntly dissected out It was also grasped with Lahey clamp to prevent traction Once the blunt dissection of the large fibroid was complete it was handed off to the scrub nurse The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed At this point several smaller fibroids were noticed along the endometrial surface of the uterus Three of these were removed just by bluntly grasping with the Lahey clamp and twisting all three of these were approximately 1 cm to 2 cm in size These were also handed to the scrub tech Next the uterine incision was then closed with first two interrupted layers of 0 chromic in an interrupted figure of eight fashion and then with a 0 Vicryl in a running baseball stitch The uterus was seen to be completely hemostatic after closure Next a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed Next the greater omentum was replaced over the uterus The rectus muscles were then reapproximated with a single interrupted suture of 0 Vicryl in the midline Then the fascia was closed with 0 Vicryl in a running fashion Next the Scarpa s fascia was closed with 3 0 plain gut in a running fashion and the skin was closed with 4 0 undyed Vicryl in a running subcuticular fashion The incision was then dressed with 0 5 inch Steri Strips and bandaged appropriately After the patient was cleaned she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital Keywords obstetrics gynecology enlarged fibroid uterus blood loss anemia laparotomy myomectomy metzenbaum scissors uterus fibroid rectus fascia scissors fashion clamps enlarged incision bluntly MEDICAL_TRANSCRIPTION,Description Pelvic pain pelvic endometriosis and pelvic adhesions Laparoscopy Harmonic scalpel ablation of endometriosis lysis of adhesions and cervical dilation Laparoscopically the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa Medical Specialty Obstetrics Gynecology Sample Name Laparoscopy Transcription PREOPERATIVE DIAGNOSIS Pelvic pain POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Pelvic endometriosis 3 Pelvic adhesions PROCEDURE PERFORMED 1 Laparoscopy 2 Harmonic scalpel ablation of endometriosis 3 Lysis of adhesions 4 Cervical dilation ANESTHESIA General SPECIMEN Peritoneal biopsy ESTIMATED BLOOD LOSS Scant COMPLICATIONS None FINDINGS On bimanual exam the patient has a small anteverted and freely mobile uterus with no adnexal masses Laparoscopically the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa There are adhesions involving the right ovary to the anterior abdominal wall and the bowel There are also adhesions from the omentum to the anterior abdominal wall near the liver The uterus and ovaries appear within normal limits other than the adhesions The left fallopian tube grossly appeared within normal limits The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized There was a large area of endometriosis approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul de sac There was also vesicular appearing endometriosis lesion in the posterior cul de sac PROCEDURE The patient was taken in the operating room and generalized anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion After exam under anesthetic weighted speculum was placed in the vagina The anterior lip of the cervix was grasped with vulsellum tenaculum The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank then the uterine manipulator was inserted and attached to the anterior lip of the cervix At this point the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife The superior aspect of the umbilicus was grasped with a towel clamp The abdomen was tented up and a Veress needle inserted through this incision When the Veress needle was felt to be in place deep position was checked by placing saline in the needle This was seen to freely drop in the abdomen so it was connected to CO2 gas Again this was started at the lowest setting was seen to flow freely so it was advanced to the high setting The abdomen was then insufflated to an adequate distention Once an adequate distention was reached the CO2 gas was disconnected The Veress needle was removed and a size 11 step trocar was placed Next the laparoscope was inserted through this port The medial port was connected to CO2 gas Next a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis Through this a Veress needle was inserted followed by size 5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size 5 trocar was also placed Next a grasper was placed through the suprapubic port This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions Bowel was carefully examined afterwards and no injuries or bleeding were seen Next the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty There was a small amount of bleeding from the anterior abdominal wall peritoneum This was ablated with the Harmonic scalpel The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul de sac Both of these areas were seen to be hemostatic Next a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul de sac This was sent to pathology Next the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed It was seen to be completely hemostatic Next the two size 5 ports were removed under direct visualization The camera was removed The abdomen was desufflated The size 11 introducer was replaced and the 11 port was removed Next all the ports were closed with 4 0 undyed Vicryl in a subcuticular interrupted fashion The incisions were dressed with Steri Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow up in one week in the clinic for pathology results and to have a postoperative check Keywords obstetrics gynecology pelvic pain endometriosis pelvic adhesions laparoscopy scalpel ablation lysis of adhesions cervical dilation peritoneal biopsy harmonic scalpel adhesions harmonic scalpel abdominal pelvic abdomen anterior MEDICAL_TRANSCRIPTION,Description Dilatation and curettage D C and Laparoscopic ablation of endometrial implants Pelvic pain hypermenorrhea and mild pelvic endometriosis Medical Specialty Obstetrics Gynecology Sample Name Laparoscopic Ablation of Eendometrial Implants Transcription PREOPERATIVE DIAGNOSES 1 Pelvic pain 2 Hypermenorrhea POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Hypermenorrhea 3 Mild pelvic endometriosis PROCEDURE PERFORMED 1 Dilatation and curettage D C 2 Laparoscopic ablation of endometrial implants ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 50 cc SPECIMEN Endometrial curettings INDICATIONS This is a 26 year old female with a history of approximately one year of heavy painful menses She did complain of some dyspareunia and wants a definitive diagnosis FINDINGS On bimanual exam the uterus is small and anteverted with mildly decreased mobility on the left side There are no adnexal masses appreciated On laparoscopic exam the uterus is normal appearing but slightly compressible The bilateral tubes and ovaries appear normal There is evidence of endometriosis on the left pelvic sidewall in the posterior cul de sac There was no endometriosis in the right pelvic sidewall or along the bladder flap There were some adhesions on the right abdominal sidewall from the previous appendectomy The liver margin gallbladder and bowel appeared normal The uterus was sounded to 9 cm PROCEDURE After consent was obtained the patient was taken to the operating room and general anesthetic was administered The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion Sterile speculum was placed in the patient s vagina The anterior lip of the cervix was grasped with vulsellum tenaculum The uterus was sounded to 9 cm The cervix was then serially dilated with Hank dilators A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium The moderate amount of tissue that was obtained was sent to Pathology The 20 Hank dilator was then replaced and the sterile speculum was removed Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made The Veress needle was placed into this incision and the gas was turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate The 11 mm trocar was then placed through this incision and a camera was placed with the above findings noted A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul de sac was removed to allow better visualization of the posterior cul de sac The lesions in the posterior cul de sac were then ablated using the Harmonic scalpel All instruments were then removed The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar was removed The skin was closed with 4 0 undyed Vicryl in subcuticular fashion Approximately 10 cc of 0 25 Marcaine was placed in the incision sites The dilator and vulsellum tenaculum were removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of procedure The patient was taken to the recovery room in satisfactory condition She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives Keywords obstetrics gynecology pelvic pain hypermenorrhea endometriosis dilatation and curettage d c endometrial implants ablation cul de sac vulsellum tenaculum hank dilators laparoscopic ablation bierman needle pelvic MEDICAL_TRANSCRIPTION,Description Laparoscopic supracervical hysterectomy A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management Medical Specialty Obstetrics Gynecology Sample Name Laparoscopic Supracervical Hysterectomy Transcription PREOPERATIVE DIAGNOSIS 1 Dysmenorrhea 2 Menorrhagia POSTOPERATIVE DIAGNOSIS 1 Dysmenorrhea 2 Menorrhagia PROCEDURE Laparoscopic supracervical hysterectomy ESTIMATED BLOOD LOSS 30 cc COMPLICATIONS None INDICATIONS FOR SURGERY A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management Please see clinic notes Risks of bleeding infection damage to other organs have been explained Informed consent was obtained OPERATIVE FINDINGS Slightly enlarged but otherwise normal appearing uterus Normal appearing adnexa bilaterally OPERATIVE PROCEDURE IN DETAIL After administration of general anesthesia the patient was placed in dorsal lithotomy position prepped and draped in the usual sterile fashion Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field A 5 mm incision was made umbilically after injecting 0 25 Marcaine 0 25 Marcaine was injected in all the incisional sites Veress needle was inserted position confirmed using the saline drop method After confirming an opening pressure of 4 mmHg of CO2 gas approximately four liters was insufflated in the abdominal cavity Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side All these were placed under direct visualization Pelvic cavity was examined with findings as noted above The left utero ovarian ligament was grasped and cauterized using the Gyrus Part of the superior aspect of the broad ligament was then cauterized as well Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment The remainder of the broad and cardinal ligament was then cauterized and excised A similar procedure was performed on the right side The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament After assuring that the bladder was well out of the way of the operative field bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments The area was irrigated extensively and cautery used to assure hemostasis A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination Hemostasis was again confirmed under low pressure Using Carter Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5 0 Monocryl suture Instruments removed from vagina Patient returned to supine position recalled from general anesthesia and transferred to recovery in satisfactory condition Sponge and needle counts correct at the conclusion of the case Estimated blood loss was 30 cc There were no complications Keywords obstetrics gynecology adnexa uterus laparoscopic supracervical hysterectomy veress needle bladder flap cardinal ligament uterine cauterized dysmenorrhea menorrhagia MEDICAL_TRANSCRIPTION,Description Total laparoscopic hysterectomy with laparoscopic staging including paraaortic lymphadenectomy bilateral pelvic and obturator lymphadenectomy and washings Medical Specialty Obstetrics Gynecology Sample Name Laparoscopic Hysterectomy Transcription PREOPERATIVE DIAGNOSIS Endometrial carcinoma POSTOPERATIVE DIAGNOSIS Endometrial carcinoma PROCEDURE PERFORMED Total laparoscopic hysterectomy with laparoscopic staging including paraaortic lymphadenectomy bilateral pelvic and obturator lymphadenectomy and washings ANESTHESIA General endotracheal tube SPECIMENS Pelvic washings for cytology uterus with attached right tube and ovary pelvic and paraaortic lymph node dissection obturator lymph node dissection INDICATIONS FOR PROCEDURE The patient was recently found to have a grade II endometrial cancer She was counseled to undergo laparoscopic staging FINDINGS During the laparoscopy the uterus was noted to be upper limits of normal size with a normal appearing right fallopian tubes and ovaries No ascites was present On assessment of the upper abdomen the stomach diaphragm liver gallbladder spleen omentum and peritoneal surfaces of the bowel were all unremarkable in appearance PROCEDURE The patient was brought into the operating room with an intravenous line in placed and anesthetic was administered She was placed in a low anterior lithotomy position using Allen stirrups The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon The laparoscopic port sites were anesthetized with intradermal injection of 0 25 Marcaine There were five ports placed including a 3 mm left subcostal port a 10 mm umbilical port a 10 mm suprapubic port and 5 mm right and left lower quadrant ports The Veress needle was placed through a small incision at the base of the umbilicus and a pneumoperitoneum was insufflated without difficulty The 3 mm port was then placed in the left subcostal position without difficulty and a 3 mm scope was placed There were no adhesions underlying the previous vertical midline scar The 10 mm port was placed in the umbilicus and the laparoscope was inserted Remaining ports were placed under direct laparoscopic guidance Washings were obtained from the pelvis and the abdomen was explored with the laparoscope with findings as noted Attention was then turned to lymphadenectomy An incision in the retroperitoneum was made over the right common iliac artery extending up the aorta to the retroperitoneal duodenum The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached Pedicles were sealed and divided with bipolar cutting forceps Excellent hemostasis was noted Boundaries of dissection included the ureters laterally common ileac arteries at uterine crossover inferiorly and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps The retroperitoneal space was then opened and the lymph nodes were dissected with boundaries of dissection being the bifurcation of the common iliac artery superiorly psoas muscle laterally inguinal ligament inferiorly and the anterior division of the hypogastric artery medially The posterior boundary was the obturator nerve which was carefully identified and preserved bilaterally The left common iliac lymph node was elevated and removed using the same technique Attention was then turned to the laparoscopic hysterectomy The right infundibulopelvic ligament was divided using the bipolar cutting forceps The mesovarium was skeletonized A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps and the peritoneum on the vesicouterine fold was incised to mobilize the bladder Once the Koh colpotomy ring was skeletonized and in position the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring The vagina was transected using a monopolar hook or bipolar spatula resulting in separation of the uterus and attached tubes and ovaries The uterus tubes and ovaries were then delivered through the vagina and the pneumo occluder balloon was reinserted to maintain pneumoperitoneum The vaginal vault was closed with interrupted figure of eight stitches of 0 Vicryl using the Endo Stitch device The abdomen was irrigated and excellent hemostasis was noted The insufflation pressure was reduced and no evidence of bleeding was seen The suprapubic port was then removed and the fascia was closed with a Carter Thomason device and 0 Vicryl suture The remaining ports were removed under direct laparoscopic guidance and the pneumoperitoneum was released The umbilical port was removed using laparoscopic guidance The umbilical fascia was closed with an interrupted figure of eight stitch using 2 0 Vicryl The skin was closed with interrupted subcuticular stitches using 4 0 Monocryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was awakened and taken to the post anesthesia care unit in stable condition Keywords obstetrics gynecology endometrial carcinoma laparoscopic hysterectomy total laparoscopic hysterectomy laparoscopic staging lymphadenectomy pelvic obturator lymph node dissection direct laparoscopic guidance tubes and ovaries bipolar cutting forceps node dissection koh colpotomy iliac artery infundibulopelvic ligament laparoscopic guidance retroperitoneal duodenum lymph node laparoscopic hysterectomy endometrial pneumoperitoneum washings vaginal retroperitoneal forceps bipolar MEDICAL_TRANSCRIPTION,Description Exam under anesthesia Removal of intrauterine clots Postpartum hemorrhage Medical Specialty Obstetrics Gynecology Sample Name Intrauterine Clots Removal Transcription PREOPERATIVE DIAGNOSIS Postpartum hemorrhage POSTOPERATIVE DIAGNOSIS Postpartum hemorrhage PROCEDURE Exam under anesthesia Removal of intrauterine clots ANESTHESIA Conscious sedation ESTIMATED BLOOD LOSS Approximately 200 mL during the procedure but at least 500 mL prior to that and probably more like 1500 mL prior to that COMPLICATIONS None INDICATIONS AND CONCERNS This is a 19 year old G1 P1 female status post vaginal delivery who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery I was called for persistent bleeding and passing large clots I examined the patient and found her to have at least 500 mL of clots in her uterus She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her I did advise her that I would recommend they came under anesthesia and dilation and curettage Risks and benefits of this procedure were discussed with Misty all of her questions were adequately answered and informed consent was obtained PROCEDURE The patient was taken to the operating room where satisfactory conscious sedation was performed She was placed in the dorsal lithotomy position prepped and draped in the usual fashion Bimanual exam revealed moderate amount of clot in the uterus I was able to remove most of the clots with my hands and an attempt at short curettage was performed but because of contraction of the uterus this was unable to be adequately performed I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found At this point the procedure was terminated Bleeding at this time was minimal Preop H H were 8 3 and 24 2 The patient tolerated the procedure well and was taken to the recovery room in good condition Keywords obstetrics gynecology uterus intrauterine clots postpartum hemorrhage intrauterine curettage hemorrhage bleeding postpartum clots MEDICAL_TRANSCRIPTION,Description Intrauterine pregnancy at term with previous cesarean Desired sterilization Status post repeat low transverse cesarean and bilateral tubal ligation Medical Specialty Obstetrics Gynecology Sample Name Intrauterine Pregnancy Discharge Summary Transcription ADMITTING DIAGNOSIS Intrauterine pregnancy at term with previous cesarean SECONDARY DIAGNOSIS Desired sterilization DISCHARGE DIAGNOSES 1 Intrauterine pregnancy at term with previous cesarean 2 Desired sterilization 3 Status post repeat low transverse cesarean and bilateral tubal ligation HISTORY The patient is a 35 year old gravida 2 para 1 0 0 1 with intrauterine pregnancy on 08 30 09 Pregnancy was uncomplicated She opted for a scheduled elective C section and sterilization without any trial of labor All routine screening labs were normal and she underwent a high resolution ultrasound during pregnancy PAST MEDICAL HISTORY Significant for postpartum depression after her last baby as well as a cesarean ALLERGIES SHE HAS SEASONAL ALLERGIES MEDICATIONS She is taking vitamins and iron PHYSICAL EXAMINATION GENERAL An alert gravid woman in no distress ABDOMEN Gravid nontender non irritable with an infant in the vertex presentation Estimated fetal weight was greater than 10 pounds HOSPITAL COURSE On the first hospital day the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9 There was normal placenta normal pelvic anatomy There was 600 cc estimated blood loss Patient recovered uneventfully from her anesthesia and surgery She was able to ambulate and void She tolerated regular diet She passed flatus She was breast feeding Postoperative hematocrit was 31 On the second postoperative day the patient was discharged home in satisfactory condition DISCHARGE MEDICATIONS Motrin and Percocet for pain Paxil for postpartum depression She was instructed to do no lifting straining or driving to put nothing in the vagina and to see me in two weeks or with signs of severe pain heavy bleeding fever or other problems Keywords obstetrics gynecology cesarean bilateral tubal ligation low transverse cesarean intrauterine gravida sterilization pregnancy MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C hysteroscopy and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid Thickened endometrium and tamoxifen therapy adnexal cyst endometrial polyp and right ovarian cyst Medical Specialty Obstetrics Gynecology Sample Name Hysteroscopy Laproscopy with Salpingooophorectomy Transcription PREOPERATIVE DIAGNOSES 1 Thickened endometrium and tamoxifen therapy 2 Adnexal cyst POSTOPERATIVE DIAGNOSES 1 Thickened endometrium and tamoxifen therapy 2 Adnexal cyst 3 Endometrial polyp 4 Right ovarian cyst PROCEDURE PERFORMED 1 Dilation and curettage D C 2 Hysteroscopy 3 Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid ANESTHESIA General ESTIMATED BLOOD LOSS Less than 20 cc COMPLICATIONS None INDICATIONS This patient is a 44 year old gravida 2 para 1 1 1 2 female who was diagnosed with breast cancer in December of 2002 She has subsequently been on tamoxifen Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst The above procedures were therefore performed FINDINGS On bimanual exam the uterus was found to be slightly enlarged and anteverted The external genitalia was normal Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium Laparoscopic findings revealed a normal appearing uterus and normal left ovary There was no evidence of endometriosis on the ovaries bilaterally the ovarian fossa the cul de sac or the vesicouterine peritoneum There was a cyst on the right ovary which appeared simple in nature The cyst was aspirated and the fluid was blood tinged Therefore the decision to perform oophorectomy was made The liver margins appeared normal and there were no pelvic or abdominal adhesions noted The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite prepped and draped and placed in the dorsal lithotomy position Her bladder was drained with a red Robinson catheter A bimanual exam was performed which revealed the above findings A weighted speculum was then placed in the posterior vaginal vault in the 12 o clock position and the cervix was grasped with vulsellum tenaculum The cervix was then sounded in the anteverted position to 10 cm The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10 The hysteroscope was then inserted and the above findings were noted A sharp curette was then introduced and the 4 cm polyp was removed The hysteroscope was then reinserted and the polyp was found to be completely removed at this point The polyp was sent to Pathology for evaluation The uterine elevator was then placed as a means to manipulate the uterus The weighted speculum was removed Gloves were changed Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made While tenting up the abdominal wall the Veress needle was inserted without difficulty Using a sterile saline drop test appropriate placement was confirmed The abdomen was then insufflated with appropriate volume inflow of CO2 The 11 step trocar was placed without difficulty The above findings were then visualized A 5 mm port was placed 2 cm above the pubic symphysis This was done under direct visualization and the grasper was inserted through this port for better visualization A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament Prior to this the cyst was aspirated using 60 cc syringe on a needle Approximately 20 cc of blood tinged fluid was obtained After the ovary and fallopian tube were completely transected this was placed in an EndoCatch bag and removed through the lateral port site The incision was found to be hemostatic The area was suction irrigated After adequate inspection the port sites were removed from the patient s abdomen and the abdomen was desufflated The infraumbilical port site and laparoscope were also removed The incisions were then repaired with 4 0 undyed Vicryl and dressed with Steri Strips 10 cc of 0 25 Marcaine was then injected locally The patient tolerated the procedure well The sponge lap and needle counts were correct x2 She will be followed up on an outpatient basis Keywords obstetrics gynecology adnexal cyst endometrial ovarian cyst dilation and curettage d c hysteroscopy laparoscopy salpingooophorectomy aspiration of cyst fluid thickened endometrium tamoxifen therapy abdominal wall cyst ovarian endometrium MEDICAL_TRANSCRIPTION,Description Induction of vaginal delivery of viable male Apgars 8 and 9 Term pregnancy and oossible rupture of membranes prolonged Medical Specialty Obstetrics Gynecology Sample Name Induction of Vaginal Delivery Transcription DIAGNOSES 1 Term pregnancy 2 Possible rupture of membranes prolonged PROCEDURE Induction of vaginal delivery of viable male Apgars 8 and 9 HOSPITAL COURSE The patient is a 20 year old female gravida 4 para 0 who presented to the office She had small amount of leaking since last night On exam she was positive Nitrazine no ferning was noted On ultrasound her AFI was about 4 7 cm Because of a variable cervix oligohydramnios and possible ruptured membranes we recommended induction She was brought to the hospital and begun on Pitocin Once she was in her regular pattern we ruptured her bag of water fluid was clear She went rapidly to completion over the next hour and a half She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation Upon delivery of the head the anterior and posterior arms were delivered and remainder of the baby without complications The baby was vigorous moving all extremities The cord was clamped and cut The baby was handed off to mom with nurse present Apgars were 8 and 9 Placenta was delivered spontaneously intact Three vessel cord with no retained placenta Estimated blood loss was about 150 mL There were no tears Keywords obstetrics gynecology induction of vaginal delivery vaginal delivery viable male pregnancy placenta vaginal membranes apgars MEDICAL_TRANSCRIPTION,Description Hysteroscopy Essure tubal occlusion and ThermaChoice endometrial ablation Medical Specialty Obstetrics Gynecology Sample Name Hysteroscopy Endometrial Ablation Transcription PREOPERATIVE DX 1 Menorrhagia 2 Desires permanent sterilization POSTOPERATIVE DX 1 Menorrhagia 2 Desires permanent sterilization OPERATIVE PROCEDURE Hysteroscopy Essure tubal occlusion and ThermaChoice endometrial ablation ANESTHESIA General with paracervical block ESTIMATED BLOOD LOSS Minimal FLUIDS On hysteroscopy 100 ml deficit of lactated Ringer s via IV 850 ml of lactated Ringer s COMPLICATIONS None PATHOLOGY None DISPOSITION Stable to recovery room FINDINGS A nulliparous cervix without lesions Uterine cavity sounding to 10 cm normal appearing tubal ostia bilaterally fluffy endometrium normal appearing cavity without obvious polyps or fibroids PROCEDURE The patient was taken to the operating room where general anesthesia was found to be adequate She was prepped and draped in the usual sterile fashion A speculum was placed into the vagina The anterior lip of the cervix was grasped with a single tooth tenaculum and a paracervical block was performed using 20 ml of 0 50 lidocaine with 1 200 000 of epinephrine The cervical vaginal junction at the 4 o clock position was injected and 5 ml was instilled The block was performed at 8 o clock as well with 5 ml at 10 and 2 o clock The lidocaine was injected into the cervix The cervix was minimally dilated with 17 Hanks dilator The 5 mm 30 degree hysteroscope was then inserted under direct visualization using lactated Ringer s as a distention medium The uterine cavity was viewed and the above normal findings were noted The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia The coil was advanced and easily placed and the device withdrawn There were three coils into the uterine cavity after removal of the insertion device The device was removed and reloaded The advice was to advance under direct visualization and the tip was inserted into the left ostia This passed easily and the device was inserted It was removed easily and three coils again were into the uterine cavity The hysteroscope was then removed and the ThermaChoice ablation was performed The uterus was then sounded to 9 5 to 10 cm The ThermaChoice balloon was primed and pressure was drawn to a negative 150 The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W The pressure was brought up to 170 and the cycle was initiated A full cycle of eight minutes was performed At no time there was a significant loss of pressure from the catheter balloon After the cycle was complete the balloon was deflated and withdrawn The tenaculum was withdrawn No bleeding was noted The patient was then awakened transferred and taken to the recovery room in satisfactory condition Keywords obstetrics gynecology menorrhagia essure hysteroscopy thermachoice uterine cavity endometrial ablation endometrium fibroids fluffy lactated ringer nulliparous paracervical block permanent sterilization polyps tubal occlusion tubal ostia lactated ringer s ablation uterine MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy right and left pelvic lymphadenectomy common iliac lymphadenectomy and endometrial cancer staging procedure Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy TAH BSO Transcription PREOPERATIVE DIAGNOSIS Endometrial cancer POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy right and left pelvic lymphadenectomy common iliac lymphadenectomy and endometrial cancer staging procedure ANESTHESIA General endotracheal tube SPECIMENS Pelvic washings for cytology uterus with attached tubes and ovaries right and left pelvic lymph nodes para aortic nodes INDICATIONS FOR PROCEDURE The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy She was counseled to undergo staging laparotomy FINDINGS Examination under anesthesia revealed a small uterus with no nodularity During the laparotomy the uterus was small mobile and did not show any evidence of extrauterine spread of disease Other abdominal viscera including the diaphragm liver spleen omentum small and large bowel and peritoneal surfaces were palpably normal There was no evidence of residual neoplasm after removal of the uterus The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthesia was induced after which she was examined prepped and draped A vertical midline incision was made and fascia was divided The peritoneum was entered without difficulty and washings were obtained The abdomen was explored with findings as noted A Bookwalter retractor was placed and bowel was packed Clamps were placed on the broad ligament for traction The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament The round ligaments were isolated divided and ligated The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder Retroperitoneal spaces were then opened allowing exposure of pelvic vessels and ureters The infundibulopelvic ligaments were isolated divided and doubly ligated The uterine artery pedicles were skeletonized clamped divided and suture ligated Additional pedicles were developed on each side of the cervix after which tissue was divided and suture ligated When the base of the cervix was reached the vagina was cross clamped and divided allowing removal of the uterus with attached tubes and ovaries Angle stitches of o Vicryl were placed incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure of eight stitches The pelvis was irrigated and excellent hemostasis was noted Retractors were repositioned to allow exposure for lymphadenectomy Metzenbaum scissors were used to incise lymphatic tissues Borders of the pelvic node dissection included the common iliac bifurcation superiorly the psoas muscle laterally the cross over of the deep circumflex iliac vein over the external iliac artery inferiorly and the anterior division of the hypogastric artery medially The posterior border of dissection was the obturator nerve which was carefully identified and preserved bilaterally Ligaclips were applied where necessary After the lymphadenectomy was performed bilaterally excellent hemostasis was noted Retractors were again repositioned to allow exposure of para aortic nodes Lymph node tissue was mobilized Ligaclips were applied and the tissue was excised The pelvis was again irrigated and excellent hemostasis was noted The bowel was run and no evidence of disease was seen All packs and retractors were removed and the abdominal wall was closed using a running Smead Jones closure with 1 permanent monofilament suture Subcutaneous tissues were irrigated and a Jackson Pratt drain was placed Scarpa s fascia was closed with a running stitch and skin was closed with a running subcuticular stitch The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition Keywords obstetrics gynecology tah bso lymphadenectomy endometrial total abdominal hysterectomy bilateral salpingo oophorectomy tubes and ovaries salpingo oophorectomy lymph nodes endometrial cancer abdominal hysterectomy oophorectomy hemostasis retractors washings laparotomy ligated pelvic uterus nodes MEDICAL_TRANSCRIPTION,Description Pelvic tumor cystocele rectocele and uterine fibroid Total abdominal hysterectomy bilateral salpingooophorectomy repair of bladder laceration appendectomy Marshall Marchetti Krantz cystourethropexy and posterior colpoperineoplasty She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy BSO Appendectomy Transcription 1 Pelvic tumor 2 Cystocele 3 Rectocele POSTOPERATIVE DIAGNOSES 1 Degenerated joint 2 Uterine fibroid 3 Cystocele 4 Rectocele PROCEDURE PERFORMED 1 Total abdominal hysterectomy 2 Bilateral salpingooophorectomy 3 Repair of bladder laceration 4 Appendectomy 5 Marshall Marchetti Krantz cystourethropexy 6 Posterior colpoperineoplasty GROSS FINDINGS The patient had a history of a rapidly growing mass on the abdomen extending from the pelvis over the past two to three months She had a recent D C and laparoscopy and enlarged mass was noted and could not be determined if it was from the ovary or the uterus Curettings were negative for malignancy The patient did have a large cystocele and rectocele and a collapsed anterior and posterior vaginal wall Upon laparotomy there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five month pregnancy The ovaries appeared to be within normal limits There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation and during dissection a laceration inadvertently occurred and it was immediately recognized No other pathology noted from the abdominal cavity or adhesions The upper right quadrant of the abdomen compatible with a previous gallbladder surgery The appendix is in its normal anatomic position The ileum was within normal limits with no Meckel s diverticulum seen and no other gross pathology evident There was no evidence of metastasis or tumors in the left lobe of the liver Upon frozen section diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy OPERATIVE PROCEDURE The patient was taken to the Operating Room prepped and draped in the low lithotomy position under general anesthesia A midline incision was made around the umbilicus down to the lower abdomen With a 10 Bard Parker blade knife the incision was carried down through the fascia The fascia was incised in the midline muscle fibers were splint in the midline the peritoneum was grasped with hemostats and with a 10 Bard Parker blade after incision was made with Mayo scissors A Balfour retractor was placed into the wound This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care The infundibular ligament on the right side was isolated and ligated with 0 Vicryl suture brought to an avascular area doubly clamped and divided from the ovary and the ligament again re ligated with 0 Vicryl suture The right round ligament was ligated with 0 Vicryl suture brought to an avascular space within the broad ligament and divided from the uterus The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do and during dissection the bladder was inadvertently entered After this was immediately recognized the bladder flap was wiped away from the anterior surface of the uterus The bladder was then repaired with a running locking stitch 0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two layer closure of 0 Vicryl suture After removing the uterus the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors and the straight Ochsner was placed by 0 Vicryl suture thus controlling the uterine blood supply The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps divided from the uterus with 10 Bard Parker blade knife and a curved Ochsner was placed by 0 Vicryl suture The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using 10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors A single toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors The vaginal cuff was then closed using a running 0 Vicryl suture in locking stitch incorporating all layers of the vagina the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect The round ligaments were approximated to the vaginal cuff with 0 Vicryl suture and the bladder flap approximated to the round ligaments with 000 Vicryl suture The ______ was re peritonealized with 000 Vicryl suture and then the cecum brought into the incision The pelvis was irrigated with approximately 500 cc of water The appendix was grasped with Babcock forceps The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors The curved hemostats were placed with 00 Vicryl suture The base of the appendix was ligated with 0 plain gut suture doubly clamped and divided from the distal appendix with 10 Bard Parker blade knife and the base inverted with a pursestring suture with 00 Vicryl No bleeding was noted Sponge instrument and needle counts were found to be correct All packs and retractors were removed The peritoneum muscle fascia was closed in single layer closure using running looped 1 PDS but prior to closure a Marshall Marchetti Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted 0 Vicryl suture Following this the abdominal wall was closed as previously described and the skin was closed using skin staples Attention was then turned to the vagina where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa and flaps were created bilaterally In this fashion the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted 0 Vicryl suture Excess vaginal mucosa was excised and the vaginal mucosa closed with running 00 Vicryl suture The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted 00 Vicryl suture The skin was closed with a running 000 plain gut subcuticular stitch The vaginal vault was packed with a Betadine soaked Kling gauze sponge Sterile dressing was applied The patient was sent to recovery room in stable condition Keywords obstetrics gynecology marshall marchetti krantz cystourethropexy pelvic tumor cystocele rectocele uterine fibroid hysterectomy salpingooophorectomy bladder laceration appendectomy colpoperineoplasty marshall marchetti krantz cystourethropexy bard parker blade knife vicryl suture vaginal mucosa uterus vaginal uterine mucosa scissors ligament bladder MEDICAL_TRANSCRIPTION,Description Total vaginal hysterectomy Microinvasive carcinoma of the cervix Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy Discharge Summary 2 Transcription ADMISSION DIAGNOSIS Microinvasive carcinoma of the cervix DISCHARGE DIAGNOSIS Microinvasive carcinoma of the cervix PROCEDURE PERFORMED Total vaginal hysterectomy HISTORY OF PRESENT ILLNESS The patient is a 36 year old white female gravida 7 para 5 last period mid March status post tubal ligation She had an abnormal Pap smear in the 80s which she failed to followup on until this year Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02 12 2007 also showing microinvasive carcinoma with a 1 mm invasion She has elected definitive therapy with a total vaginal hysterectomy She is aware of the future need of Pap smears PAST MEDICAL HISTORY Past history is significant for seven pregnancies five term deliveries and significant past history of tobacco use PHYSICAL EXAMINATION Physical exam is within normal limits with a taut normal size uterus and a small cervix status post cone biopsy LABORATORY DATA AND DIAGNOSTIC STUDIES Chest x ray was clear Discharge hemoglobin 10 8 HOSPITAL COURSE She was taken to the operating room on 04 02 2007 where a total vaginal hysterectomy was performed under general anesthesia There was an incidental cystotomy at the time of the creation of the bladder flap This was repaired intraoperatively without difficulty Postoperative she did very well Bowel and bladder function returned quickly She is ambulating well and tolerating a regular diet Routine postoperative instructions given and understood Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time DISCHARGE MEDICATIONS Vicodin Motrin and Macrodantin at bedtime for urinary tract infection suppression DISCHARGE CONDITION Good Final pathology report was free of residual disease Keywords obstetrics gynecology pap smear total vaginal hysterectomy hysterectomy microinvasive carcinoma cervix MEDICAL_TRANSCRIPTION,Description Wide Local Excision of the Vulva Radical anterior hemivulvectomy Posterior skinning vulvectomy Medical Specialty Obstetrics Gynecology Sample Name Hemivulvectomy Transcription PREOPERATIVE DIAGNOSIS Recurrent vulvar melanoma POSTOPERATIVE DIAGNOSIS Recurrent vulvar melanoma OPERATION PERFORMED Radical anterior hemivulvectomy Posterior skinning vulvectomy SPECIMENS Radical anterior hemivulvectomy posterior skinning vulvectomy INDICATIONS FOR PROCEDURE The patient has a history of vulvar melanoma first diagnosed in November of 1995 She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris Biopsy obtained by The patient confirmed recurrence In addition biopsies on the posterior labia left side demonstrated melanoma in situ FINDINGS During the examination under anesthesia the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris No other obvious lesions were seen The room was darkened and a Woods lamp was used to inspect the epithelium A marking pen was used to outline all pigmented areas which included several patches on both the right and left labia PROCEDURE The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen The radical anterior hemivulvectomy was designed so that a 1 5 2 0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum After removal of the radical anterior portion the skin on the posterior labia and perineal body was mobilized Skin was incised with a scalpel and electrocautery was used to undermine After removal of the specimen the wounds were closed primarily with subcutaneous interrupted stitches of 3 0 Vicryl suture The final sponge needle and instrument counts were correct at the completion of the procedure The patient was then taken to the Post Anesthesia Care Unit in stable condition Keywords obstetrics gynecology vulvar melanoma wide local excision radical anterior hemivulvectomy posterior skinning vulvectomy vulvectomy hemivulvectomy melanoma woods lamp recurrent vulvar melanoma anterior hemivulvectomy vulvar labia radical skinning MEDICAL_TRANSCRIPTION,Description Laparoscopic supracervical hysterectomy Menorrhagia and dysmenorrhea Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy Laparoscopic Supracervical Transcription PREOPERATIVE DIAGNOSES Menorrhagia and dysmenorrhea POSTOPERATIVE DIAGNOSES Menorrhagia and dysmenorrhea PROCEDURE Laparoscopic supracervical hysterectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 100 mL FINDINGS An 8 10 cm anteverted uterus right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid a normal appearing left ovary and normal appearing tubes bilaterally SPECIMENS Uterine fragments COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty The patient was placed in dorsal lithotomy position Examination under anesthesia revealed an anteverted uterus and no adnexal masses The patient was prepped and draped in normal sterile fashion A Foley catheter was placed in the patient s bladder The patient s cervix was visualized with speculum A single tooth tenaculum was placed on the anterior lip of the cervix A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated The tenaculum and speculum were then removed from the vagina Attention was then turned to the patient s abdomen where a small infraumbilical incision was made with scalpel Veress needle was placed through this incision and the patient s abdomen was inflated to a pressure of 15 mmHg Veress needle was removed and then 5 mm trocar was placed through the umbilical incision Laparoscope was placed through this incision and the patient s abdominal contents were visualized A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5 mm trocar was placed through this incision on direct visualization for laparoscope A trocar incision was made in the right lower quadrant A 10 mm trocar was placed through this incision under direct visualization with the laparoscope A ___ trocar incision was made in the left lower quadrant and a 2nd 10 mm trocar was placed through this incision under direct visualization with the laparoscope The patient s abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe The Gyrus cautery was used to cauterize and cut the right and left round ligaments The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment The right uteroovarian ligament was cauterized and cut using the Gyrus The uterine vessels were then bluntly dissected The Gyrus was then used to cauterize the right uterine vessels Gyrus was then used on the left side to cauterize and cut the left round ligament The anterior leaf of the broad ligament on the left side was bluntly dissected cauterized and cut Using the Gyrus the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected The left uterine vessels were then cauterized and cut using the Gyrus At this point as the uterine vessels had been cauterized on both sides the uterine body exhibited blanching At this point the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels The HUMI manipulator was removed prior to amputation of the uterine body After the uterine body was detached from the cervical stump morcellation of the uterine body was performed using the uterine morcellator The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision Once all fragments of the uterus were removed from the abdominal cavity the pelvis was irrigated The Harmonic scalpel was used to cauterize the remaining endocervical canal The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles The Harmonic scalpel was then used to incise the right ovarian simple cyst The right ovarian cyst was then drained yielding straw colored fluid The site of right ovarian cystotomy was noted to be hemostatic The pelvis was again inspected and noted to be hemostatic The ureters were identified on both sides and noted to be intact throughout the visualized course All instruments were then removed from the patient s abdomen and the abdomen was deflated The fascial defects at the 10 mm trocar sites were closed using figure of 8 sutures of 0 Vicryl and skin incisions were closed with a 4 0 Vicryl in subcuticular fashion The cervix was then visualized with the speculum Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks All instruments were removed from the patient s vagina and the patient was placed in normal supine position Sponge lap needle and instrument counts were correct x2 The patient was awoken from anesthesia and then transferred to the recovery room in stable condition Keywords obstetrics gynecology supracervical hysterectomy incision uterine uteroovarian hysterectomy supracervical menorrhagia dysmenorrhea cervical laparoscopic laparoscope cervix ligaments trocar MEDICAL_TRANSCRIPTION,Description The patient underwent a total vaginal hysterectomy Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy Discharge Summary Transcription ADMISSION DIAGNOSES 1 Menorrhagia 2 Uterus enlargement 3 Pelvic pain DISCHARGE DIAGNOSIS Status post vaginal hysterectomy COMPLICATIONS None BRIEF HISTORY OF PRESENT ILLNESS This is a 36 year old gravida 3 para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period She also had symptoms of back pain dysmenorrhea and dysuria The symptoms had been worsening over time The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination PROCEDURE The patient underwent a total vaginal hysterectomy HOSPITAL COURSE The patient was admitted on 09 04 2007 to undergo total vaginal hysterectomy The procedure preceded as planned without complication Uterus was sent for pathologic analysis The patient was monitored in the hospital 2 days postoperatively She recovered quite well and vitals remained stable Laboratory studies H H were followed and appeared stable on 09 05 2007 with hemoglobin of 11 2 and hematocrit of 31 8 The patient was ready for discharge on Monday morning of 09 06 2007 LABORATORY FINDINGS Please see chart for full studies during admission DISPOSITION The patient was discharged to home in stable condition She was instructed to follow up in the office postoperatively Keywords obstetrics gynecology menorrhagia uterus enlargement pelvic pain total vaginal hysterectomy vaginal hysterectomy uterus vaginal hysterectomy MEDICAL_TRANSCRIPTION,Description Total vaginal hysterectomy Menometrorrhagia dysmenorrhea and small uterine fibroids Medical Specialty Obstetrics Gynecology Sample Name Hysterectomy Discharge Summary 1 Transcription ADMISSION DIAGNOSES 1 Menometrorrhagia 2 Dysmenorrhea 3 Small uterine fibroids DISCHARGE DIAGNOSES 1 Menorrhagia 2 Dysmenorrhea 3 Small uterine fibroids OPERATION PERFORMED Total vaginal hysterectomy BRIEF HISTORY AND PHYSICAL The patient is a 42 year old white female gravida 3 para 2 with two prior vaginal deliveries She is having increasing menometrorrhagia and dysmenorrhea Ultrasound shows a small uterine fibroid She has failed oral contraceptives and surgical therapy is planned PAST HISTORY Significant for reflux SURGICAL HISTORY Tubal ligation PHYSICAL EXAMINATION A top normal sized uterus with normal adnexa LABORATORY VALUES Her discharge hemoglobin is 12 4 HOSPITAL COURSE She was taken to the operating room on 11 05 07 where a total vaginal hysterectomy was performed under general anesthesia Postoperatively she has done well Bowel and bladder function have returned normally She is ambulating well tolerating a regular diet Routine postoperative instructions given and said follow up will be in four weeks in the office DISCHARGE MEDICATIONS Preoperative meds plus Vicodin for pain DISCHARGE CONDITION Good Keywords obstetrics gynecology dysmenorrhea uterine fibroids vaginal total vaginal hysterectomy menometrorrhagia uterine fibroids MEDICAL_TRANSCRIPTION,Description Mammogram bilateral full field digital mammography FFDM patient with positive history of breast cancer Medical Specialty Obstetrics Gynecology Sample Name Full Field Digital Mammogram FFDM 2 Transcription EXAM Screening full field digital mammogram HISTORY Screening examination of a 58 year old female who currently denies complaints Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy The patient s sister was also diagnosed with breast cancer at the age of 59 TECHNIQUE Standard digital mammographic imaging was performed The examination was performed with iCAD Second Look Version 7 2 COMPARISON Most recently obtained __________ FINDINGS The right breast is again smaller than the left There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously dense fibroglandular tissue There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes A few benign appearing microcalcifications are present No dominant malignant appearing mass lesion developing area of architectural distortion or suspicious appearing cluster of microcalcifications are identified The skin is stable No enlarged axillary lymph node is seen IMPRESSION 1 No significant interval changes are seen No mammographic evidence of malignancy is identified 2 Annual screening mammography is recommended or sooner if clinical symptoms warrant BIRADS Classification 2 Benign MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD Second Look Software Version 7 2 was utilized Keywords obstetrics gynecology digital mammography full field digital mammogram ffdm second look version field digital mammogram digital mammogram breast cancer mammographic icad microcalcifications mammogram screening digital mammography breast MEDICAL_TRANSCRIPTION,Description Bilateral Screening Mammogram Full Field Digital Mammography FFDM Benign Findings Medical Specialty Obstetrics Gynecology Sample Name Full Field Digital Mammogram FFDM 1 Transcription EXAM Digital screening mammogram HISTORY 51 year old female presents for screening mammography Patient denies personal history of breast cancer Breast cancer was reported in her maternal aunt TECHNIQUE Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm dd yy Comparison is made with the previous performed on mm dd yy iCAD Second Look proprietary software was utilized FINDINGS The breasts demonstrate a mixture of adipose and fibroglandular elements Composition appears similar Multiple tiny punctate benign appearing calcifications are visualized bilaterally No dominant mass areas of architecture distortion or malignant type calcifications are seen Skin overlying both breasts is unremarkable IMPRESSION Stable and benign mammographic findings Continued yearly mammographic screening is recommended BIRADS Classification 2 Benign MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD SecondLook Software Version 7 2 was utilized Keywords obstetrics gynecology mediolateral craniocaudal fibroglandular bilateral screening mammogram breast cancer screening mammogram mammographic mammogram breasts screening mammography MEDICAL_TRANSCRIPTION,Description External cephalic version A 39 week intrauterine pregnancy with complete breech presentation Medical Specialty Obstetrics Gynecology Sample Name External Cephalic Version Transcription PREOPERATIVE DIAGNOSIS A 39 week intrauterine pregnancy with complete breech presentation POSTOPERATIVE DIAGNOSIS A 39 week intrauterine pregnancy in vertex presentation status post successful external cephalic version PROCEDURE External cephalic version COMPLICATIONS None PROCEDURE IN DETAIL The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained The patient was noted to have irregular contractions She was given 1 dose of subcutaneous terbutaline which resolved her contraction A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation There was noted to be adequate fluid Using manual pressure the breech was manipulated in a forward roll fashion until a vertex presentation was obtained Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring Following successful external cephalic version the patient was placed on continuous external fetal monitoring She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version She did not have regular contractions and therefore she was felt to be stable for discharge to home She was given appropriate labor instructions Keywords obstetrics gynecology intrauterine pregnancy vertex presentation complete breech presentation external cephalic version fetal contractions pregnancy breech intrauterine MEDICAL_TRANSCRIPTION,Description Fractional dilatation and curettage Medical Specialty Obstetrics Gynecology Sample Name Dilatation Curettage D C Transcription PREOPERATIVE DIAGNOSIS Postmenopausal bleeding POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Fractional dilatation and curettage SPECIMENS Endocervical curettings endometrial curettings INDICATIONS FOR PROCEDURE The patient recently presented with postmenopausal bleeding An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os FINDINGS Examination under anesthesia revealed a retroverted retroflexed uterus with fundal diameter of 6 5 cm The uterine cavity was smooth upon curettage Curettings were fairly copious Sounding depth was 8 cm PROCEDURE The patient was brought to the Operating Room with an IV in place The patient was given a general anesthetic and was placed in the lithotomy position Examination under anesthesia was completed with findings as noted She was prepped and draped and a speculum was placed into the vagina Tenaculum was placed on the cervix The endocervical canal was curetted using a Kevorkian curette and the sound was used to measure the overall depth of the uterus The endocervical canal was dilated without difficulty to a size 16 French dilator A small sharp curette was passed into the uterine cavity and curettings were obtained After completion of the curettage polyp forceps were passed into the uterine cavity No additional tissue was obtained Upon completion of the dilatation and curettage minimum blood loss was noted The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition Keywords obstetrics gynecology postmenopausal bleeding endometrial fractional dilatation fractional dilatation and curettage endocervical dilatation and curettage endocervical canal uterine cavity curetted dilatation curettings curettage MEDICAL_TRANSCRIPTION,Description Stage IIIC endometrial cancer Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 Medical Specialty Obstetrics Gynecology Sample Name Endometrial Cancer Followup Transcription CHIEF COMPLAINT 1 Stage IIIC endometrial cancer 2 Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane HISTORY OF PRESENT ILLNESS The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 In March 2010 she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus CT scan of the abdomen on 03 22 2010 showed an enlarged uterus thickening of the endometrium and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis On 04 01 2010 she had a robotic modified radical hysterectomy with bilateral salpingo oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy The pathology was positive for grade III endometrial adenocarcinoma 9 5 cm in size with 2 cm of invasion Four of 30 lymph nodes were positive for disease The left ovary was positive for metastatic disease Postsurgical PET CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup Of note we had sent off genetic testing which was denied back in June I have been trying to get this testing completed CURRENT MEDICATIONS Synthroid q d ferrous sulfate 325 mg b i d multivitamin q d Ativan 0 5 mg q 4 hours p r n nausea and insomnia gabapentin one tablet at bedtime ALLERGIES Keywords obstetrics gynecology adjuvant adjuvant chemotherapy cisplatin adriamycin abraxane endometrial cancer lymphadenectomy chemotherapy endometrial disease MEDICAL_TRANSCRIPTION,Description A 31 year old white female admitted to the hospital with pelvic pain and vaginal bleeding Right ruptured ectopic pregnancy with hemoperitoneum Anemia secondary to blood loss Medical Specialty Obstetrics Gynecology Sample Name Ectopic Pregnancy Discharge Summary Transcription HISTORY OF PRESENT ILLNESS This is the case of a 31 year old white female admitted to the hospital with pelvic pain and vaginal bleeding The patient had a positive hCG with a negative sonogram and hCG titer of about 18 000 HOSPITAL COURSE The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion to rule out ectopic pregnancy or rupture of corpus luteal cyst The patient was kept in observation for 24 hours The sonogram stated there was no gestational sac but there was a small mass within the uterus that could represent a gestational sac The patient was admitted to the hospital A repeat hCG titer done on the same day came back as 15 000 but then the following day it came back as 18 000 The diagnosis of a possible ruptured ectopic pregnancy was established The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy The right salpingectomy was performed with no complications The patient received 2 units of red packed cells On admission her hemoglobin was 12 9 then in the afternoon it dropped to 8 1 and the following morning it was 7 9 Again based on these findings the severe abdominal pain we made the diagnosis of ectopic and it was proved or confirmed at surgery The hospital course was uneventful There was no fever reported The abdomen was soft She had a normal bowel movement The patient was dismissed on 09 09 2007 to be followed in my office in 4 days FINAL DIAGNOSES 1 Right ruptured ectopic pregnancy with hemoperitoneum 2 Anemia secondary to blood loss PLAN The patient will be dismissed on pain medication and iron therapy Keywords obstetrics gynecology anemia blood loss ruptured ectopic pregnancy gestational sac ectopic pregnancy hemoperitoneum gestational ruptured pregnancy ectopic MEDICAL_TRANSCRIPTION,Description Dilation and evacuation 12 week incomplete miscarriage The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os this was teased out and then a D E was performed yielding significant amount of central tissue Medical Specialty Obstetrics Gynecology Sample Name Dilation Evacuation Transcription PREOPERATIVE DIAGNOSIS 12 week incomplete miscarriage POSTOPERATIVE DIAGNOSIS 12 week incomplete miscarriage OPERATION PERFORMED Dilation and evacuation ANESTHESIA General OPERATIVE FINDINGS The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os this was teased out and then a D E was performed yielding significant amount of central tissue The fetus of 12 week had been delivered previously by Dr X in the ER ESTIMATED BLOOD LOSS Less than 100 mL COMPLICATIONS None SPONGE AND NEEDLE COUNT Correct DESCRIPTION OF OPERATION The patient was taken to the operating room placed in the operating table in supine position After adequate anesthesia the patient was placed in dorsal lithotomy position The vagina was prepped The patient was then draped A speculum was placed in the vagina Previously mentioned products of conception were teased out with a ring forceps The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10 mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12 week pregnancy A sharp curettage then was performed and followed by two repeat suction curettages The procedure was then terminated and the equipment removed from the vagina as well as the speculum The patient tolerated the procedure well Blood type is Rh negative We will see the patient back in my office in 2 weeks Keywords obstetrics gynecology incomplete miscarriage dilation evacuation vagina protruding protruding speculum miscarriage forceps curettages vagina MEDICAL_TRANSCRIPTION,Description Emergency cesarean section Medical Specialty Obstetrics Gynecology Sample Name Emergency C section Transcription PREOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Nonreassuring fetal heart tones with a prolonged deceleration POSTOPERATIVE DIAGNOSES 1 Intrauterine pregnancy at term 2 Nonreassuring fetal heart tones with a prolonged deceleration PROCEDURE PERFORMED Emergency cesarean section ANESTHESIA General and endotracheal as well as local anesthesia ESTIMATED BLOOD LOSS 800 mL COMPLICATIONS None FINDINGS Female infant in cephalic presentation in OP position Normal uterus tubes and ovaries are noted Weight was 6 pounds and 3 ounces Apgars were 6 at 1 minute and 7 at 5 minutes and 9 at 10 minutes Normal uterus tubes and ovaries were noted INDICATIONS The patient is a 21 year old Gravida 1 para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a m on the day of delivery The patient was admitted and cervix was found to be 1 cm dilated Pitocin augmentation of labor was started The patient was admitted by her primary obstetrician Dr Salisbury and was managed through the day by him at approximately 5 p m at change of shift care was assumed by me At this time the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline good variability was noted as well as accelerations variable deceleration despite position change was occurring with almost every contraction but was lasting for 60 to 90 seconds at the longest Vaginal exam was done Cervix was noted to be 4 cm dilated At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations At 19 20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section Clock in the operating room is noted to be 2 minutes faster then the time on trace view The OR delivery time was 19 36 Delivery of this infant was performed in 14 minutes from the onset of the deceleration Upon arrival to the operating room while prepping the patient for surgery and awaiting the arrival of the anesthesiologist heart tones were noted to be in 60s and slowly came up to the 80s Following the transfer of the patient to the operating room bed and prep of the abdomen the decision was made to begin the surgery under local anesthesia 2 lidocaine was obtained for this purpose PROCEDURE NOTE The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt 2 lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2 lidocaine As the incision site was being injected the anesthesiologist arrived The procedure was started prior to the patient being put under general anesthesia A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique The rectus muscles were separated in midline The peritoneum was bluntly dissected The bladder blade was inserted The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction The infant was subsequently delivered Immediately following delivery of the infant The infant was noted to be crying with good tones The cord was clammed and cut The infant was subsequently transferred or handed to the nursery nurse The placenta was delivered manually intact with a three vessel cord noted The uterus was exteriorized and cleared of all clots and debris The uterine incision was repaired in 2 layers using 0 chromic sutures Hemostasis was visualized The uterus was returned to the abdomen The pelvis was copiously irrigated The rectus muscles were reapproximated in the midline using 3 0 Vicryl The fascia was reapproximated with 0 Vicryl suture The subcutaneous layer was closed with 2 0 plain gut The skin was closed in the subcuticular stitch using 4 0 Monocryl Steri strips were applied Sponge laps and instrument counts were correct The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition Keywords obstetrics gynecology intrauterine pregnancy at term prolonged deceleration apgars emergency cesarean section fetal heart tones intrauterine MEDICAL_TRANSCRIPTION,Description The patient is a 39 year old gravida 3 para 2 who is now at 20 weeks and 2 days gestation This pregnancy is a twin gestation The patient presents for her fetal anatomical survey Medical Specialty Obstetrics Gynecology Sample Name Fetal Anatomical Survey Transcription PAST MEDICAL HISTORY The patient denies any significant past medical history PAST SURGICAL HISTORY The patient denies any significant surgical history MEDICATIONS The patient takes no medications ALLERGIES No known drug allergies SOCIAL HISTORY She denies use of cigarettes alcohol or drugs FAMILY HISTORY No family history of birth defects mental retardation or any psychiatric history DETAILS I performed a transabdominal ultrasound today using a 4 MHz transducer There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins The fetal biometry of twin A is as follows The biparietal diameter is 4 9 cm consistent with 20 weeks and 5 days head circumference 17 6 cm consistent with 20 weeks and 1 day the abdominal circumference is 15 0 cm consistent with 20 weeks and 2 days and femur length is 3 1 cm consistent with 19 weeks and 5 days and the humeral length is 3 0 cm consistent with 20 weeks and 0 day The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g The following structures are seen as normal on the fetal anatomical survey the shape of the fetal head the choroid plexuses the cerebellum nuchal fold thickness the fetal spine and fetal face the four chamber view of the fetal heart the outflow tracts of the fetal heart the stomach the kidneys and cord insertion site the bladder the extremities the genitalia the cord which appeared to have three vessels and the placenta Limited in views of baby A with a nasolabial region The following is the fetal biometry for twin B The biparietal diameter is 4 7 cm consistent with 20 weeks and 2 days head circumference 17 5 cm consistent with 20 weeks and 0 day the abdominal circumference is 15 5 cm consistent with 20 weeks and 5 days the femur length is 3 3 cm consistent with 20 weeks and 3 days and the humeral length is 3 1 cm consistent with 20 weeks and 2 days the average gestational age by ultrasound is 22 weeks and 2 days and the estimated fetal weight is 384 g The following structures were seen as normal on the fetal anatomical survey The shape of the fetal head the choroid plexuses the cerebellum nuchal fold thickness the fetal spine and fetal face the four chamber view of the fetal heart the outflow tracts of the fetal heart the stomach the kidneys and cord insertion site the bladder the extremities the genitalia the cord which appeared to have three vessels and the placenta Limited on today s ultrasound the views of nasolabial region In summary this is a twin gestation which may well be monochorionic at 20 weeks and 1 day There is like gender and a single placenta One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today I sat with the patient and her husband and discussed alternative findings and the complications We focused our discussion today on the association of twin pregnancy with preterm delivery We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks gestation while the average twin delivery occurs at 35 weeks gestation We discussed the fact that 15 of twins deliver prior to 32 weeks gestation These are the twins which we have the most concern regarding the long term prospects of prematurity We discussed several etiologies of preterm delivery including preterm labor incompetent cervix premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth We discussed the need for frequent office visits to screen for preeclampsia We also discussed treatment options such as cervical cerclage bedrest tocolytic medications and antenatal steroids I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well being In closing I do want to thank you very much for involving me in the care of your delightful patient I did review all of the above findings and recommendations with the patient today at the time of her visit Please do not hesitate to contact me if I could be of any further help to you Total visit time 40 minutes Keywords obstetrics gynecology vaginal delivery transducer transabdominal ultrasound placenta amniotic fluid fetal anatomical survey preterm delivery twin gestation gestation infant fetal anatomical delivery ultrasound MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy Extensive lysis of adhesions Right salpingo oophorectomy Pelvic mass suspected right ovarian cyst Medical Specialty Obstetrics Gynecology Sample Name Exploratory Laparotomy 2 Transcription PREOPERATIVE DIAGNOSES 1 Pelvic mass 2 Suspected right ovarian cyst POSTOPERATIVE DIAGNOSES 1 Pelvic mass 2 Suspected right ovarian cyst PROCEDURES 1 Exploratory laparotomy 2 Extensive lysis of adhesions 3 Right salpingo oophorectomy ANESTHESIA General ESTIMATED BLOOD LOSS 200 mL SPECIMENS Right tube and ovary COMPLICATIONS None FINDINGS Extensive adhesive disease with the omentum and bowel walling of the entire pelvis which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst tube and ovary in order to remove them The large and small bowels were completely enveloping a large right ovarian cystic mass Normal anatomy was difficult to see due to adhesions Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid Cyst wall tube and ovary were stripped away from the bowel Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube There was excellent postoperative hemostasis PROCEDURE The patient was taken to the operating room where general anesthesia was achieved without difficulty She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient s prior incision Incision was carried down carefully until the peritoneal cavity was reached Care was taken upon entry of the peritoneum to avoid injury of underlying structures At this point the extensive adhesive disease was noted again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery The omentum was carefully stripped away from the patient s right side developing a window This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum A large mass of bowel was noted to be adherent to itself causing a quite tortuous course Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis Excellent hemostasis was noted The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment the cyst was ruptured Large amount of turbid fluid was noted and was evacuated The cyst wall was then carefully placed under tension and stripped away from the patient s small and large bowel Once the bowel was freed the remnants of round ligament was identified elevated and the peritoneum was incised opening the retroperitoneal space The retroperitoneal space was opened following the line of the ovarian vessels which were identified and elevated and a window made inferior to the ovarian vessels but superior to the course of the ureter This pedicle was doubly clamped transected and tied with a free tie of 2 0 Vicryl A suture ligature of 0 Vicryl was used to obtain hemostasis Excellent hemostasis was noted at this pedicle The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary which was still densely adherent to the peritoneum Care was taken at the side of the remnant of the uterine vessels However a laceration of the uterine vessels did occur which was clamped with a right angle clamp and carefully sutured ligated with excellent hemostasis noted Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed The opposite tube and ovary were identified were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal It was then left in situ Hemostasis was achieved in the pelvis with the use of electrocautery The abdomen and pelvis were copiously irrigated with warm saline solution The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle and the ovarian vessel pedicle The areas of the bowel had previously been dissected and due to adhesive disease it was carefully inspected and excellent hemostasis was noted All instruments and packs removed from the patient s abdomen The abdomen was closed with a running mattress closure of 0 PDS beginning at the superior aspect of the incision and extending inferiorly Excellent closure of the incision was noted The subcutaneous tissues were then copiously irrigated Hemostasis was achieved with the use of cautery Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of 0 plain gut suture The skin was closed with staples Incision was sterilely clean and dressed The patient was awakened from general anesthesia and taken to the recovery room in stable condition All counts were noted correct times three Keywords obstetrics gynecology pelvic mass ovarian cyst exploratory laparotomy lysis of adhesions salpingo oophorectomy cyst bowel adhesions uterine abdomen pelvis ovary peritoneum ovarian hemostasis MEDICAL_TRANSCRIPTION,Description Diagnostic Mammogram and ultrasound of the breast Medical Specialty Obstetrics Gynecology Sample Name Diagnostic Mammogram Transcription EXAM Bilateral diagnostic mammogram and right breast ultrasound History of palpable abnormality at 10 o clock in the right breast Family history of a sister with breast cancer at age 43 TECHNIQUE CC and MLO views of both breasts were obtained Spot compression views of the palpable area were also obtained Right breast ultrasound was performed Comparison is made with mm dd yy FINDINGS The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue No new mass or architectural distortion is evident Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged There is no suspicious cluster of microcalcifications Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass IMPRESSION 1 Stable mammographic appearance from mm dd yy 2 No sonographic evidence of a mass at 10 o clock in the right breast to correspond to the palpable abnormality The need for further assessment of a palpable abnormality should be determined clinically BIRADS Classification 2 Benign Keywords obstetrics gynecology diagnostic mammogram diagnostic mammogram ultrasound palpable MEDICAL_TRANSCRIPTION,Description She required augmentation with Pitocin to achieve a good active phase She achieved complete cervical dilation Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 9 Transcription DELIVERY NOTE This G1 P0 with EDC 12 23 08 presented with SROM about 7 30 this morning Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho Exam upon arrival 2 to 3 cm 100 effaced 1 station and by report pool of fluid was positive for Nitrazine and positive ferning She required augmentation with Pitocin to achieve a good active phase She achieved complete cervical dilation at 1900 At this time a bulging bag was noted which ruptured and thick meconium was present At 1937 hours she delivered a viable male infant left occiput anterior Mouth and nares suctioned well with a DeLee on the perineum No nuchal cord present Shoulders and body followed easily Infant re suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance Apgars 9 and 9 Pitocin 15 units infused via pump protocol Placenta followed complete and intact with fundal massage and general traction on the cord Three vessels are noted She sustained a bilateral periurethral lax on the left side this extended down to the labia minora became a second degree in the inferior portion and did have some significant bleeding in this area Therefore this was repaired with 3 0 Vicryl after 1 lidocaine infiltrated approximately 5 mL The remainder of the lacerations was not at all bleeding and no other lacerations present Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots however as the Pitocin infused and massage continued this improved significantly EBL was about 500 mL Bleeding appears much better however Cytotec 400 mcg was placed per rectum apparently prophylactically Mom and baby currently doing very well Keywords obstetrics gynecology augmentation with pitocin delivery cervical dilation perineum lacerations pitocin infantNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Her cervix on admission was not ripe so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon she was having frequent contractions and fetal heart tracing was reassuring At a later time Pitocin was started Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 8 Transcription DELIVERY NOTE The patient is a very pleasant 22 year old primigravida with prenatal care with both Dr X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital The patient was admitted to labor and delivery on Tuesday December 22 2008 at 5 30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital Her cervix on admission was not ripe so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon she was having frequent contractions and fetal heart tracing was reassuring At a later time Pitocin was started The next day at about 9 o clock in the morning I checked her cervix and performed artifical rupture of membranes which did reveal Meconium stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started The patient did have labor epidural which worked well It should be noted that the patient s recent vaginal culture for group B strep did come back negative for group B strep The patient went on to have a normal spontaneous vaginal delivery of a live term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1 5 ounces at birth The intensive care nursery staff was present because of the presence of Meconium stained amniotic fluid DeLee suctioning was performed at the perineum A second degree midline episiotomy was repaired in layers in the usual fashion using 3 0 Vicryl The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm ESTIMATED BLOOD LOSS Approximately 300 mL Keywords obstetrics gynecology amniotic fluid contractions pitocin meconium cervix labor vaginal delivery intravaginallyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy Acute pelvic inflammatory disease and periappendicitis The patient appears to have a significant pain requiring surgical evaluation It did not appear that the pain was pelvic in nature but more higher up in the abdomen more towards the appendix Medical Specialty Obstetrics Gynecology Sample Name Diagnostic Laparoscopy 1 Transcription PREOPERATIVE DIAGNOSIS Acute abdominal pain rule out appendicitis versus other POSTOPERATIVE DIAGNOSIS Acute pelvic inflammatory disease and periappendicitis PROCEDURE PERFORMED Diagnostic laparoscopy COMPLICATIONS None CULTURES Intra abdominally are done HISTORY The patient is a 31 year old African American female patient who complains of sudden onset of pain and has seen in the Emergency Room The pain has started in the umbilical area and radiated to McBurney s point The patient appears to have a significant pain requiring surgical evaluation It did not appear that the pain was pelvic in nature but more higher up in the abdomen more towards the appendix The patient was seen by Dr Y at my request in the ER with me in attendance We went over the case He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed The patient on ultrasound had a 0 9 cm ovarian cyst on the right side The patient s cyst was not completely simple and they are concerns over the possibility of an abnormality The patient states that she has had chlamydia in the past but it was not a pelvic infection more vaginal infection The patient has had hospitalization for this The patient therefore signed informed in layman s terms with her understanding that perceivable risks and complications the alternative treatment the procedure itself and recovery All questions were answered PROCEDURE The patient was seen in the Emergency Room In the Emergency Room there is really no apparent vaginal discharge No odor or cervical motion tenderness Negative bladder sweep Adnexa were without abnormalities In the OR we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10 week size The patient had no adnexal fullness The patient then underwent an insertion of a uterine manipulator and Dr X was in the case at that time and he started the laparoscopic process i e inserting the laparoscope We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus The both fallopian tubes were seen There did not appear to be hydrosalpinx The ovaries were seen The left showed some adhesions into the ovarian fossa The cul de sac had a banded adhesions The patient on the right adnexa had a hemorrhagic ovarian cyst where the cyst was only about a centimeter enlarged The ovary did not appear to have pus in it but there was pus over the area of the bladder flap The patient s bowel was otherwise unremarkable The liver contained evidence of Fitz Hugh Curtis syndrome and prior PID The appendix was somewhat adherent into the retrocecal area and to the mid quadrant abdominal sidewall on the right The case was then turned over to Dr Y who was in the room at that time and Dr X had left The patient s case was turned over to him Dr Y was performed an appendectomy following which cultures and copious irrigation Dr Y was then closed the case The patient was placed on antibiotics We await the results of the cultures and as well further ______ therapy PRIMARY DIAGNOSES 1 Periappendicitis 2 Pelvic inflammatory disease 3 Chronic adhesive disease Keywords obstetrics gynecology periappendicitis pelvic inflammatory disease chronic adhesive disease abdominal pain appendicitis diagnostic laparoscopy laparoscopy pelvic MEDICAL_TRANSCRIPTION,Description The patient is a 22 year old woman with a possible ruptured ectopic pregnancy Medical Specialty Obstetrics Gynecology Sample Name Diagnostic Laparoscopy Transcription TITLE OF OPERATION Diagnostic laparoscopy INDICATION FOR SURGERY The patient is a 22 year old woman with a possible ruptured ectopic pregnancy PREOP DIAGNOSIS Possible ruptured ectopic pregnancy POSTOP DIAGNOSIS No evidence of ectopic pregnancy or ruptured ectopic pregnancy ANESTHESIA General endotracheal SPECIMEN Peritoneal fluid EBL Minimal FLUIDS 900 cubic centimeters crystalloids URINE OUTPUT 400 cubic centimeters FINDINGS Adhesed left ovary with dilated left fallopian tube tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary perihepatic lesions consistent with history of PID approximately 1 200 cubic centimeters of more serous than sanguineous fluid No evidence of ectopic pregnancy COMPLICATIONS None PROCEDURE After obtaining informed consent the patient was taken to the operating room where general endotracheal anesthesia was administered She was examined under anesthesia An 8 10 cm anteverted uterus was noted The patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy Attention was then turned to the patient s abdomen where a 5 mm incision was made in the inferior umbilicus The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water No peritoneum was obtained without difficulty using 4 liters of CO2 gas The 5 mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope The above noted findings were visualized A 5 mm skin incision was made approximately one third of the way from the ASI to the umbilicus at McBurney s point Under direct visualization the trocar and sleeve were advanced without difficulty A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep The peritoneal fluid was aspirated and sent for culture and wash and cytology The abdomen and pelvis were surveyed with the above noted findings No active bleeding was noted No evidence of ectopic pregnancy was noted The instruments were removed from the abdomen under good visualization with good hemostasis noted The sponge on a sponge stick was removed from the vagina The patient tolerated the procedure well and was taken to the recovery room in stable condition The attending Dr X was present and scrubbed for the entire procedure Keywords obstetrics gynecology peritoneal fluid sanguineous fluid ruptured ectopic pregnancy diagnostic laparoscopy intrauterine pregnancy ectopic pregnancy trocar ruptured ectopic tortuous pregnancy MEDICAL_TRANSCRIPTION,Description The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes She was found to be positive for Nitrazine pull and fern At that time she was not actually contracting Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 7 Transcription DELIVERY NOTE The patient is a 29 year old gravida 6 para 2 1 2 3 who has had an estimated date of delivery at 01 05 2009 The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12 26 2008 She was found to be positive for Nitrazine pull and fern At that time she was not actually contracting She was Group B Streptococcus positive however was 5 cm dilated The patient was started on Group B Streptococcus prophylaxis with ampicillin She received a total of three doses throughout her labor Her pregnancy was complicated by scanty prenatal care She would frequently miss visits At 37 weeks she claims that she had a suspicious bump on her left labia There was apparently no fluid or blistering of the lesion Therefore it was not cultured by the provider however the patient was sent for serum HSV antibody levels which she tested positive for both HSV1 and HSV2 I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr X who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery The patient requested an epidural anesthetic which she received with very good relief She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions She delivered a viable female infant on 12 27 2008 at 0626 hours delivering over an intact perineum The baby delivered in the occiput anterior position The baby was delivered to the mother s abdomen where she was warm dry and stimulated The umbilical cord was doubly clamped and then cut The baby s Apgars were 8 and 9 The placenta was delivered spontaneously intact There was a three vessel cord with normal insertion The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol The perineum was inspected and was found to be fully intact Estimated blood loss was approximately 400 mL The patient s blood type is A She is rubella immune and as previously mentioned GBS positive and she received three doses of ampicillin Keywords obstetrics gynecology nitrazine pull and fern rupture of membranes spontaneous membranes nitrazine streptococcus pitocin perineum hsv laborNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Her pregnancy is complicated by preterm contractions She was on bedrest since her 34th week She was admitted here and labor was confirmed with rupture of membranes Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 6 Transcription DELIVERY NOTE This is an 18 year old G2 P0 at 35 4 7th weeks by a stated EDC of 01 21 09 The patient is a patient of Dr X s Her pregnancy is complicated by preterm contractions She was on bedrest since her 34th week She also has a history of tobacco abuse with asthma She was admitted here and labor was confirmed with rupture of membranes She was initially 5 70 1 Her bag was ruptured IUPC was placed She received an epidural for pain control and Pitocin augmentation was performed She progressed for several hours to complete and to push then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation Delivery of the head was manual assisted The shoulders and the rest of body then followed without difficulty Baby was bulb suctioned had a vigorous cry Cord was clamped twice and cut and the infant was handed to the awaiting nursing team Placenta then delivered spontaneously and intact was noted to have a three vessel cord The inspection of the perineum revealed it to be intact There was a hymenal remnant skin tag that was protruding from the vaginal introitus I discussed this with the patient She opted to have it removed This was performed and I put a single interrupted suture 3 0 Vicryl for hemostasis Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair Overall EBL is 300 mL Mom and baby are currently doing well Cord gases are being sent due to prematurity Keywords obstetrics gynecology preterm rupture of membranes preterm contractions contractions pregnancy deliveryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Artificial rupture of membrane was performed for clear fluid She did receive epidural anesthesia She progressed to complete and pushing Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 5 Transcription DELIVERY NOTE This is a 30 year old G7 P5 female at 39 4 7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away She was admitted and started on Pitocin Her cervix is 3 cm 50 effaced and 2 station Artificial rupture of membrane was performed for clear fluid She did receive epidural anesthesia She progressed to complete and pushing She pushed to approximately one contraction and delivered a live born female infant at 1524 hours Apgars were 8 at 1 minute and 9 at 5 minutes Placenta was delivered intact with three vessel cord The cervix was visualized No lacerations were noted Perineum remained intact Estimated blood loss is 300 mL Complications were none Mother and baby remained in the birthing room in good condition Keywords obstetrics gynecology perineum placenta rupture of membrane artificial rupture cervix delivery inductionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description She progressed in labor throughout the day Finally getting the complete and began pushing Pushed for about an hour and a half when she was starting to crown Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 4 Transcription DELIVERY NOTE The patient came in around 0330 hours in the morning on this date 12 30 08 in early labor and from a closed cervix very posterior yesterday she was 3 cm dilated Membranes ruptured this morning by me with some meconium An IUPC was placed Some Pitocin was started because the contractions were very weak She progressed in labor throughout the day Finally getting the complete at around 1530 hours and began pushing Pushed for about an hour and a half when she was starting to crown The Foley was already removed at some point during the pushing The epidural was turned down by the anesthesiologist because she was totally numb She pushed well and brought the head drown crowning at which time I arrived and setting her up delivery with prepping and draping She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed With delivery of the head I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance Exam revealed a good second degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact although I cannot see good fascia around the sphincter anteriorly The placenta separated with some bleeding seen and was assisted expressed and completely intact Uterus firmed up well with IV pit Repair of the tear with 2 0 Vicryl stitches and a 3 0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural Once this was complete mom and baby doing well Baby was a female infant Apgars 8 and 9 Keywords obstetrics gynecology iupc meconium pitocin epidural rectum sphincter labor perineum pushed deliveryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Delivery was via spontaneous vaginal delivery Nuchal cord x1 were tight and reduced Infant was DeLee suctioned at perineum Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 3 Transcription DELIVERY NOTE On 12 23 08 at 0235 hours a 23 year old G1 P0 white female GBS negative under epidural anesthesia delivered a viable female infant with Apgar scores of 7 and 9 Points taken of for muscle tone and skin color Weight and length are unknown at this time Delivery was via spontaneous vaginal delivery Nuchal cord x1 were tight and reduced Infant was DeLee suctioned at perineum Cord clamped and cut and infant handed to the awaiting nurse in attendance Cord blood sent for analysis intact Meconium stained placenta with three vessel cord was delivered spontaneously at 0243 hours A 15 units of Pitocin was started after delivery of the placenta Uterus cervix and vagina were explored and a mediolateral episiotomy was repaired with a 3 0 Vicryl in a normal fashion Estimated blood loss was approximately 400 mL The patient was taken to the recovery room in stable condition Infant was taken to Newborn Nursery in stable condition The patient tolerated the procedure well The only intrapartum event that occurred was thick meconium Otherwise there were no other complications The patient tolerated the procedure well Keywords obstetrics gynecology nuchal cord spontaneous nuchal delee delivered meconium placenta vaginal perineum delivery infantNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise Fetal position is right occiput anterior Medical Specialty Obstetrics Gynecology Sample Name Delivery Note Transcription HISTORY This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest unfortunately felt decreased fetal movement yesterday 12 29 08 presented to the hospital for evaluation on the evening of 12 29 08 At approximately 2030 hours and on admission no cardiac activity was noted by my on call partner Dr X This was confirmed by Dr Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks gestation SUMMARY She was admitted She was 3 cm dilated on admission She desired induction of labor Therefore Pitocin was started Epidural was placed for labor pain She did have a temperature of 100 7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy She remained febrile approximately 100 3 She then progressed On my initial exam at approximately 0730 hours she was 3 to 4 cm dilated She had reported previously some mucous discharge with no ruptured membranes Upon my exam no membranes were noted Attempted artificial rupture of membranes was performed No fluid noted and there was no fluid discharge noted all the way until the time of delivery Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor She progressed well and completely dilated pushed approximately three times and proceeded with delivery DELIVERY NOTE Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise Fetal position is right occiput anterior COMPLICATIONS Again intrauterine fetal demise Placenta delivery spontaneous Condition was intact with a three vessel cord Lacerations she had a small right periurethral laceration as well as a small second degree midline laceration These were both repaired postdelivery with 4 0 Vicryl on an SH and a 3 0 Vicryl on a CT 1 respectively Estimated blood loss was 200 mL Infant is a male infant appears grossly morphologically normal Apgars were 0 and 0 Weight pending at this time NARRATIVE OF DELIVERY I was called This patient was completely dilated I arrived She pushed for three contractions She was very comfortable She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant There was a tight nuchal cord x1 that was reduced after delivery of the fetus Cord was doubly clamped The infant was transferred to a bassinet cleaned by the nursing staff en route The placenta delivered spontaneously was carefully examined found to be intact No signs of abruption No signs of abnormal placentation or abnormal cord insertion The cord was examined and a three vessel cord was confirmed At this time IV Pitocin and bimanual massage Fundus firm as above with minimal postpartum bleeding The vagina and perineum were carefully inspected A small right periurethral laceration was noted was repaired with a 4 0 Vicryl on an SH needle followed by a small second degree midline laceration was repaired in a normal running fashion with a 3 0 Vicryl suture At this time the repair is intact She is hemostatic All instruments and sponges were removed from the vagina and the procedure was ended Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time We have called pastor in to baptize the baby as well as calling social work They are deciding on a burial versus cremation have decided against autopsy at this time She will be transferred to postpartum for her recovery She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders Keywords obstetrics gynecology decreased fetal movement labor pain preterm labor delivery note vaginal delivery fetal position fetal demise intrauterine delivery spontaneous dilated lacerations cord fetal MEDICAL_TRANSCRIPTION,Description Pitocin was started quickly to allow for delivery as quickly as possible Baby was delivered with a single maternal pushing effort with retraction by the forceps Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 2 Transcription Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete and then as she began to push there were additional decelerations of the baby s heart rate which were suspicions of cord around the neck These were variable decelerations occurring late in the contraction phase The baby was in a 2 at a 3 station in an occiput anterior position and so a low forceps delivery was performed with Tucker forceps using gentle traction and the baby was delivered with a single maternal pushing effort with retraction by the forceps The baby was a little bit depressed at birth because of the cord around the neck and the cord had to be cut before the baby was delivered because of the tension but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes The female infant seemed to weigh about 7 5 pounds but has not been officially weighed yet Cord gases were sent and the placenta was sent to Pathology The cervix the placenta and the rectum all seemed to be intact The second degree episiotomy was repaired with 2 O and 3 0 Vicryl Blood loss was about 400 mL Because of the hole in the dura plan is to keep the patient horizontal through the day and a Foley catheter is left in place She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter The baby s father was present for the delivery as was one of the patient s sisters All are relieved and pleased with the good outcome Keywords obstetrics gynecology labor delivery pitocin tucker forceps apnea cerebrospinal fluid contraction epidural episiotomy fetal heart tones baby was delivered baby s heart rate heart rate catheter placenta cordNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient had ultrasound done on admission that showed gestational age of 38 2 7 weeks The patient progressed to a normal spontaneous vaginal delivery over an intact perineum Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 10 Transcription DELIVERY NOTE This is a 30 year old G6 P5 0 0 5 with unknown LMP and no prenatal care who came in complaining of contractions and active labor The patient had ultrasound done on admission that showed gestational age of 38 2 7 weeks The patient progressed to a normal spontaneous vaginal delivery over an intact perineum Rupture of membranes occurred on 12 25 08 at 2008 hours via artificial rupture of membranes No meconium was noted Infant was delivered on 12 25 08 at 2154 hours Two doses of ampicillin was given prior to rupture of membranes GBS status unknown Intrapartum events no prenatal care The patient had epidural for anesthesia No observed abnormalities were noted on initial newborn exam Apgar scores were 9 and 9 at one and five minutes respectively There was a nuchal cord x1 nonreducible which was cut with two clamps and scissors prior to delivery of body of child Placenta was delivered spontaneously and was normal and intact There was a three vessel cord Baby was bulb suctioned and then sent to newborn nursery Mother and baby were in stable condition EBL was approximately 500 mL NSVD with postpartum hemorrhage No active bleeding was noted upon deliverance of the placenta Dr X attended the delivery with second year resident Dr X Upon deliverance of the placenta the uterus was massaged and there was good tone Pitocin was started following deliverance of the placenta Baby delivered vertex from OA position Mother following delivery had a temperature of 100 7 denied any specific complaints and was stable following delivery Keywords obstetrics gynecology spontaneous vaginal delivery rupture of membranes gestational age vaginal delivery intact perineum prenatal care gestational placentaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Complex right lower quadrant mass with possible ectopic pregnancy Right ruptured tubal pregnancy and pelvic adhesions Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy Medical Specialty Obstetrics Gynecology Sample Name D C Tubal Pregnancy Removal Transcription PREOPERATIVE DIAGNOSIS Complex right lower quadrant mass with possible ectopic pregnancy POSTOPERATIVE DIAGNOSES 1 Right ruptured tubal pregnancy 2 Pelvic adhesions PROCEDURE PERFORMED 1 Dilatation and curettage 2 Laparoscopy with removal of tubal pregnancy and right partial salpingectomy ANESTHESIA General ESTIMATED BLOOD LOSS Less than 100 cc COMPLICATIONS None INDICATIONS The patient is a 25 year old African American female gravida 7 para 1 0 5 1 with two prior spontaneous abortions with three terminations who presents with pelvic pain She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900 Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy FINDINGS On bimanual exam the uterus was approximately 10 weeks in size mobile and anteverted There were no adnexal masses appreciated although there was some fullness in the right lower quadrant The cervical os appeared parous Laparoscopic findings revealed a right ectopic pregnancy which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary There were some pelvic adhesions in the right abdominal wall as well The left fallopian tube and ovary and uterus appeared normal There was no evidence of endometriosis There was a small amount of blood in the posterior cul de sac PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite prepped and draped placed under general anesthesia and placed in the dorsal lithotomy position The bimanual exam was performed which revealed the above findings A weighted speculum was placed in the patient s posterior vaginal vault and the 12 o clock position of the cervix was grasped with the vulsellum tenaculum The cervix was then serially dilated using Hank dilators up to a 10 A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue The tissue was sent to pathology for evaluation The uterine elevator was then placed in the patient s cervix Gloves were changed The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made While tenting up the abdominal wall the Veress needle was placed without difficulty The abdomen was then insufflated with appropriate volume and flow of CO2 The 11 step trocar was then placed without difficulty in abdominal wall The placement was confirmed with a laparoscope It was then decided to put a 5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents The above findings were then noted Because the tubal pregnancy was adherent to the ovary an additional port was placed in the right lateral aspect of the patient s abdomen A 12 step trocar port was placed under direct visualization Using a grasper Nezhat Dorsey suction irrigator the mass was hydro dissected off of the right ovary and further shelled away with graspers This was removed with the gallbladder grasper through the right lateral port site There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached Partial salpingectomy was therefore performed This was done using the LigaSure The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected Good hemostasis was obtained in all of the right adnexal structures The pelvis was then copiously suction irrigated The area again was then visualized and again found to be hemostatic The instruments were then removed from the patient s abdomen under direct visualization The abdomen was then desufflated and the 11 step trocar was removed The incisions were then repaired with 4 0 undyed Vicryl and dressed with Steri Strips The uterine elevator was removed from the patient s vagina The patient tolerated the procedure well The sponge lap and needle count were correct x2 She will follow up postoperatively as an outpatient Keywords obstetrics gynecology lower quadrant mass tubal pregnancy pelvic adhesions laparoscopy salpingectomy ectopic pregnancy abdominal wall pregnancy MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C laparoscopy right salpingectomy lysis of adhesions and evacuation of hemoperitoneum Pelvic pain ectopic pregnancy and hemoperitoneum Medical Specialty Obstetrics Gynecology Sample Name D C Laparoscopy Salpingectomy Transcription PREOPERATIVE DIAGNOSES 1 Pelvic pain 2 Ectopic pregnancy POSTOPERATIVE DIAGNOSES 1 Pelvic pain 2 Ectopic pregnancy 3 Hemoperitoneum PROCEDURES PERFORMED 1 Dilation and curettage D C 2 Laparoscopy 3 Right salpingectomy 4 Lysis of adhesions 5 Evacuation of hemoperitoneum ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Scant from the operation however there was approximately 2 liters of clotted and old blood in the abdomen SPECIMENS Endometrial curettings and right fallopian tube COMPLICATIONS None FINDINGS On bimanual exam the patient has a small anteverted uterus it is freely mobile No adnexal masses however were appreciated on the bimanual exam Laparoscopically the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus There were also adhesions to the left fallopian tube and the right fallopian tube There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood There was some questionable gestational tissue ________ on the left sacrospinous ligament There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube PROCEDURE After an informed consent was obtained the patient was taken to the operating room and the general anesthetic was administered She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion Once the anesthetic was found to be adequate a bimanual exam was performed under anesthetic A weighted speculum was then placed in the vagina The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum The cervix was then serially dilated with Hank dilators to a size 20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology At this point the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed Next attention was then turned to the abdomen The surgeons all are removed the dirty gloves in the previous portion of the case Next a 2 cm incision was made immediately inferior to umbilicus The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision Next a syringe was used to inject normal saline into the Veress needle The normal saline was seen to drop freely so a Veress needle was connected to the CO2 gas which was started at its lowest setting The gas was seen to flow freely with normal resistance so the CO2 gas was advanced to a higher setting The abdomen was insufflated to an adequate distension Once an adequate distention was reached the CO2 gas was disconnected The Veress needle was removed and a size 11 step trocar was placed The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted Next a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera A Veress needle and a step sheath were inserted through this incision Next the Veress needle was removed and a size 5 trocar was inserted under direct visualization Next a size 5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion A size 12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes Next the Dorsey suction irrigator was used to copiously irrigate the abdomen Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen Once the majority of blood was cleaned from the abdomen the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with 12 port Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy An EndoCatch bag was then placed to the size 12 port and this was used to remove the right fallopian tube and ectopic pregnancy This was then sent to the pathology Next the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic The abdomen was further irrigated The liver was examined and appeared to be within normal limits At this point the two size 5 ports and a size 12 port were removed under direct visualization The camera was then removed The CO2 gas was disconnected and the abdomen was desufflated The introducer was then replaced in a size 11 port and the whole port and introducer was removed as a single unit All laparoscopic incisions were closed with a 4 0 undyed Vicryl in a subcuticular interrupted fashion They were then steri stripped and bandaged appropriately At the end of the procedure the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition The patient tolerated the procedure well Sponge lap and needle counts were correct x2 She was discharged home with a postoperative hemoglobin of 8 9 She was given iron 325 mg to be taken twice a day for five months and Darvocet N 100 mg to be taken every four to six hours for pain She will follow up within a week in the OB resident clinic Keywords obstetrics gynecology pelvic pain ectopic pregnancy hemoperitoneum d c dilation laparoscopy curettage salpingectomy lysis of adhesions bimanual exam veress needle fallopian tube umbilicus cervix ectopic pregnancy abdomen tube MEDICAL_TRANSCRIPTION,Description Spontaneous controlled sterile vaginal delivery performed without episiotomy Medical Specialty Obstetrics Gynecology Sample Name Delivery Note 1 Transcription The patient presented in the early morning hours of February 12 2007 with contractions The patient was found to be in false versus early labor and managed as an outpatient The patient returned to labor and delivery approximately 12 hours later with regular painful contractions There was minimal cervical dilation but 80 effacement by nurse examination The patient was admitted Expected management was utilized initially Stadol was used for analgesia Examination did not reveal vulvar lesions Epidural was administered Membranes ruptured spontaneously Cervical dilation progressed Acceleration deceleration complexes were seen Overall fetal heart tones remained reassuring during the progress of labor The patient was allowed to labor down during second stage Early decelerations were seen as well as acceleration deceleration complexes Overall fetal heart tones were reassuring Good maternal pushing effort produced progressive descent Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck There was no loop or coil of cord Infant was vigorous female sex Oropharynx was aggressively aspirated Cord blood was obtained Placenta delivered spontaneously Following delivery uterus was explored without findings of significant tissue Examination of the cervix did not reveal lacerations Upper vaginal lacerations were not seen Multiple first degree lacerations were present Specific locations included the vestibula at 5 o clock left labia minora with short extension up the left sulcus right anterior labia minora at the vestibule and midline of the vestibule All mucosal lacerations were reapproximated with interrupted simple sutures of 4 0 Vicryl with the knots being buried Post approximation examination of the rectum showed smooth intact mucosa Blood loss with the delivery was 400 mL Plans for postpartum care include routine postpartum orders Nursing personnel will be notified of Gilbert s syndrome Keywords obstetrics gynecology delivery gilbert s syndrome membranes cervical dilation contractions labia minora labor labor and delivery trimester uterus vaginal delivery vaginal lacerations vulvar fetal heart tones fetal heart heart tones postpartum vaginal fetal lacerationsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Enlarged fibroid uterus infertility pelvic pain and probable bilateral tubal occlusion Dilatation and curettage and laparoscopy and injection of indigo carmine dye Medical Specialty Obstetrics Gynecology Sample Name D C Laparoscopy Transcription PREOPERATIVE DIAGNOSES 1 Hypermenorrhea 2 Pelvic pain 3 Infertility POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Infertility 3 Pelvic pain 4 Probable bilateral tubal occlusion PROCEDURE PERFORMED 1 Dilatation and curettage 2 Laparoscopy 3 Injection of indigo carmine dye GROSS FINDINGS The uterus was anteverted firm enlarged irregular and mobile The cervix is nulliparous without lesions Adnexal examination was negative for masses PROCEDURE The patient was placed in the lithotomy position properly prepared and draped in sterile manner After bimanual examination the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum Uterus sounded to a depth of 10 5 cm Endocervical canal was progressively dilated with Hanks dilators to 20 French A medium sized sharp curet was used to obtain a moderated amount of tissue upon curettage which was taken from all uterine quadrants and sent to the pathologist for analysis A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted The laparoscope was then inserted through the trocar with visualization of the pelvic contents In steep Trendelenburg position the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria The ovaries also appeared normal bilaterally The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still Both fallopian tubes apparently were blocked The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum The patient tolerated the procedure well Instruments were removed from the vaginal vault and the abdomen Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two 4 0 undyed Vicryl sutures Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition Keywords obstetrics gynecology dilatation and curettage laparoscopy pelvic pain infertility enlarged fibroid uterus tubal occlusion indigo carmine dye fibroid uterus uterus infertility peritoneal cavity fallopian tubes indigo carmine endocervical uterine pelvic curettage uterus MEDICAL_TRANSCRIPTION,Description Enlarged fibroid uterus hypermenorrhea and secondary anemia Dilatation and curettage and hysteroscopy Medical Specialty Obstetrics Gynecology Sample Name D C Hysteroscopy Transcription PREOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Hypermenorrhea POSTOPERATIVE DIAGNOSES 1 Enlarged fibroid uterus 2 Hypermenorrhea 3 Secondary anemia PROCEDURE PERFORMED 1 Dilatation and curettage 2 Hysteroscopy GROSS FINDINGS Uterus was anteverted greatly enlarged irregular and firm The cervix is patulous and nulliparous without lesions Adnexal examination was negative for masses PROCEDURE The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia After bimanual examination the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum The uterus was sounded to a depth of 11 cm The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a 10 Hegar The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera The endometrial cavity was distended with fluids and the cavity visualized Multiple irregular areas of fibroid degeneration were noted throughout the cavity The coronal areas were visualized bilaterally with corresponding tubal ostia A moderate amount of proliferative appearing endometrium was noted There were no direct intraluminal lesions seen The patient tolerated the procedure well Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity A large sharp curet was then used to obtain a moderate amount of tissue which was the sent to pathologist for analysis The instrument was removed from the vaginal vault The patient was sent to recovery area in satisfactory postoperative condition Keywords obstetrics gynecology dilatation and curettage hysteroscopy anemia enlarged fibroid uterus endometrial cavity hypermenorrhea fibroid uterus MEDICAL_TRANSCRIPTION,Description Hysteroscopy dilatation and curettage D C and myomectomy Severe menometrorrhagia unresponsive to medical therapy severe anemia and fibroid uterus Medical Specialty Obstetrics Gynecology Sample Name D C Discharge Summary Transcription ADMISSION DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Fibroid uterus DISCHARGE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Fibroid uterus OPERATIONS PERFORMED 1 Hysteroscopy 2 Dilatation and curettage D C 3 Myomectomy COMPLICATIONS Large endometrial cavity fibroid requiring careful dissection and excision BLOOD TRANSFUSIONS Two units of packed red blood cells INFECTION None SIGNIFICANT LAB AND X RAY Posttransfusion of the 2nd unit showed her hematocrit of 25 hemoglobin of 8 3 HOSPITAL COURSE AND TREATMENT The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage D C was performed Hysteroscopy revealed a large endometrial cavity fibroid Careful shaving and excision of this fibroid was performed with removal of the fibroid Hemostasis was noted completely at the end of this procedure Postoperatively the patient has done well The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss The patient is now ambulating without difficulty and tolerating her diet The patient desires to go home The patient is discharged to home DISCHARGE CONDITION Stable DISCHARGE INSTRUCTIONS Regular diet bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks pelvic rest for 6 weeks Vicodin tablets 1 tablet p o q 4 6 h p r n pain multiple vitamin 1 tab p o daily ferrous sulfate tablets 1 tablet p o daily Ambulate with assistance at home only The patient is to return to see Dr X p r n plus Tuesday 6 16 2009 for further followup care The patient was given full and complete postop and discharge instructions All her questions were answered Keywords obstetrics gynecology d c fibroid uterus myomectomy dilatation curettage menometrorrhagia uterus hysteroscopy fibroid MEDICAL_TRANSCRIPTION,Description D C and hysteroscopy Abnormal uterine bleeding enlarged fibroid uterus hypermenorrhea intermenstrual spotting and thickened endometrium per ultrasound of a 2 cm lining MEDICAL_TRANSCRIPTION,Description Abdominal pain CT examination of the abdomen and pelvis with intravenous contrast Medical Specialty Obstetrics Gynecology Sample Name CT Abdomen Pelvis OB GYN Transcription EXAM CT examination of the abdomen and pelvis with intravenous contrast INDICATIONS Abdominal pain TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue 300 contrast administration Oral contrast was not administered There was no comparison of studies FINDINGS CT PELVIS Within the pelvis the uterus demonstrates a thickened appearing endometrium There is also a 4 4 x 2 5 x 3 4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology There is also a 2 5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid Several smaller fibroids were also suspected The ovaries are unremarkable in appearance There is no free pelvic fluid or adenopathy CT ABDOMEN The appendix has normal appearance in the right lower quadrant There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis The small and large bowels are otherwise unremarkable The stomach is grossly unremarkable There is no abdominal or retroperitoneal adenopathy There are no adrenal masses The kidneys liver gallbladder and pancreas are in unremarkable appearance The spleen contains several small calcified granulomas but no evidence of masses It is normal in size The lung bases are clear bilaterally The osseous structures are unremarkable other than mild facet degenerative changes at L4 L5 and L5 S1 IMPRESSION 1 Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4 4 x 2 5 x 3 4 cm 2 Multiple uterine fibroids 3 Prominent endometrium 4 Followup pelvic ultrasound is recommended Keywords obstetrics gynecology ovaries pelvic fluid adenopathy uterine segment cervix hypodense mass ct examination fibroids pelvic ct pelvis isovue abdomen MEDICAL_TRANSCRIPTION,Description Laparoscopic assisted vaginal hysterectomy bilateral salpingo oophorectomy culdoplasty and cystoscopy Chronic pelvic inflammatory disease pelvic adhesions pelvic pain fibroid uterus and enterocele Medical Specialty Obstetrics Gynecology Sample Name Culdoplasty Vaginal Hysterectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic pelvic inflammatory disease 2 Pelvic adhesions 3 Pelvic pain 4 Fibroid uterus 5 Enterocele POSTOPERATIVE DIAGNOSES 1 Chronic pelvic inflammatory disease 2 Pelvic adhesions 3 Pelvic pain 4 Fibroid uterus 5 Enterocele PROCEDURE PERFORMED 1 Laparoscopic assisted vaginal hysterectomy bilateral salpingo oophorectomy 2 McCall s culdoplasty 3 Cystoscopy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 350 cc INDICATIONS The patient is a 45 year old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation uncontrolled with Anaprox DS also with complaints of dyspareunia On laparoscopy in May of 2003 PID adenomyosis and uterine fibroids were demonstrated The patient desires definitive treatment FINDINGS AT THE TIME OF SURGERY Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities On laparoscopic examination the uterus was quite soft and boggy consistent with the uterine adenomyosis There was also evidence of fibroid change in the right fundal aspect of the uterus There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes There were filmy adhesions to the right pelvic side wall as well as left pelvic side wall PROCEDURE The patient taken to the operative suite where anesthesia was found to be adequate She was then prepared and draped in the normal sterile fashion A Foley catheter was initially placed and was noted to be draining clear to yellow urine A weighted speculum was placed in the patient s vagina The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterus sounded to 7 cm and the cervix was then progressively dilated A 20 Hank dilator which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator At this time after the gloves were changed attention was then turned to the patient s abdomen A small approximately 1 cm infraumbilical incision was made with the scalpel A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures A 10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope On entrance into the patient s abdomen and pelvis survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance At this time under transillumination in the left anterior axillary line a second incision was made with a scalpel and through this site a 12 mm step trocar was inserted under direct visualization by the laparoscope A third incision was made in the right anterior axillary line under transillumination and through this site a second 12 mm step trocar was placed under direct visualization by the laparoscope Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a 5 mm step trocar was inserted through this site The uterus was elevated and deviated to the patient s right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper The Endo GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament transecting and stapling at the same time Attention was then turned to the right adnexa The uterus was brought over to the patient s left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper An Endo GIA was used to transect and staple this vasculature and down passed to the level of round ligament At this time there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic In addition on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted At this time the uterus was dropped and the vesicouterine peritoneum was grasped with graspers The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure At this time copious suction irrigation was performed and the operative sites were found to be hemostatic The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure The weighted speculum was placed into the patient s vagina At this time the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o clock position to 3 o clock position The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly Next using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly At this time two curved Heaney clamps were placed across the uterine artery on the right This was then transected and suture ligated with 0 Vicryl suture The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with 0 Vicryl suture Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps transected and suture ligated with 0 Vicryl suture This second clamp was then advanced to capture the vasculature and the cardinal ligament complex This was again transected and suture ligated with 0 Vicryl suture Next the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff Next the uterus ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology At this time the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure Next the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of 0 Chromic beginning at the 9 o clock position over to the 3 o clock position Next the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly The angles of the vaginal cuff were then closed with 0 Chromic suture figure of eight stitch with care taken to incorporate the anterior vaginal mucosa the anterior peritoneum and the previously closed posterior vaginal mucosa and the posterior peritoneum Two additional sutures medially were placed and these were tagged and not tied in place A 0 Vicryl suture on a UR6 needle was used to perform the McCall s culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized This was then tied in place and the remainder of the vaginal cuff was closed with 0 Chromic suture with figure of eight stitches At this time the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re insufflated and the patient was placed in Trendelenburg The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time The bladder was then drained and the Foley catheter was replaced and after gloves changed attention was turned to the abdomen with the laparoscopic instruments removed from the patient s abdomen The skin incisions were closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of 0 25 Marcaine in total were injected at incision site for additional analgesia The Steri Strips were placed The patient tolerated the procedure well and taken to recovery in stable condition Sponge lap and needle counts were correct x2 The specimens include the uterus cervix bilateral ovaries and fallopian tubes The patient will have her Foley catheter maintained for approximately 7 to 10 days Keywords obstetrics gynecology pelvic inflammatory disease pelvic adhesions pelvic pain fibroid uterus enterocele salpingo oophorectomy mccall s culdoplasty cystoscopy laparoscopic assisted vaginal hysterectomy foley catheter vaginal mucosa vaginal cuff bladder ligament clamps suture pelvic uterus vaginal inflammatory laparoscopic MEDICAL_TRANSCRIPTION,Description Dilation and curettage D C and hysteroscopy A female presents 7 months status post spontaneous vaginal delivery has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp Medical Specialty Obstetrics Gynecology Sample Name D C Hysteroscopy 1 Transcription PREOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Status post spontaneous vaginal delivery POSTOPERATIVE DIAGNOSES 1 Abnormal uterine bleeding 2 Status post spontaneous vaginal delivery PROCEDURE PERFORMED 1 Dilation and curettage D C 2 Hysteroscopy ANESTHESIA IV sedation with paracervical block ESTIMATED BLOOD LOSS Less than 10 cc INDICATIONS This is a 17 year old African American female that presents 7 months status post spontaneous vaginal delivery without complications at that time The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp PROCEDURE The patient was consented and seen in the preoperative suite She was taken to the operative suite placed in a dorsal lithotomy position and placed under IV sedation She was prepped and draped in the normal sterile fashion Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine A bimanual exam was done was performed by Dr X and Dr Z The uterus was found to be anteverted mobile fully involuted to a pre pregnancy stage The cervix and vagina were grossly normal with no obvious masses or deformities A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum The uterus was sounded to 8 cm The cervix was sterilely dilated with Hank dilator and then Hagar dilator At the time of blunt dilation it was noticed that the dilator passed posteriorly with greater ease than it had previously The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus Under direct visualization the ostia were within normal limits The endometrial lining was hyperplastic however there was no evidence of retained products or endometrial polyps The hyperplastic tissue did not appear to have calcification or other abnormalities There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation however this area was hemostatic no evidence of bowel involvement and was approximately 1 x 1 cm in nature The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul de sac There was a normal consistency of the cervix and the normal step off The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum The cervix was found to be hemostatic The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room The patient will be sent home once stable from anesthesia She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings The patient is sent home on Tylenol 3 prescription as she is allergic to Motrin The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks The patient is also instructed to contact us if she has any problems with further bleeding fevers or difficulty with urination Keywords obstetrics gynecology dilation and curettage hysteroscopy abnormal uterine bleeding spontaneous vaginal delivery endometrial curettings vaginal delivery uterine bleeding endometrial d c cervix vaginal uterine delivery MEDICAL_TRANSCRIPTION,Description Cervical cone biopsy dilatation curettage Medical Specialty Obstetrics Gynecology Sample Name Cone Biopsy Transcription PREOPERATIVE DIAGNOSIS Cervical carcinoma in situ POSTOPERATIVE DIAGNOSIS Cervical carcinoma in situ OPERATION PERFORMED Cervical cone biopsy dilatation curettage SPECIMENS Cone biopsy endocervical curettings endometrial curettings INDICATIONS FOR PROCEDURE The patient recently presented with a Pap smear showing probable adenocarcinoma in situ The patient was advised to have cone biopsy to fully assess endocervical glands FINDINGS During the examination under anesthesia the vulva vagina and cervix were grossly unremarkable The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted PROCEDURE The patient was brought to the Operating Room with an IV in place Anesthetic was administered and she was placed in the lithotomy position The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction Angle stitches of 0 Vicryl sutures were placed at 3 o clock and 9 o clock in the lateral vagina fornices The cervix was stained with Lugol s iodine solution After the cervix was stained a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os The specimen was removed intact after which the uterine cavity was sounded to a depth of 8 cm A Kevorkian curette was used to obtain endocervical curettings The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture Upon completion of the suture placement the endocervical canal was sounded to assure patency A prophylactic application of Monsel s solution completed the procedure The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition Final sponge needle and instrument counts were Keywords obstetrics gynecology cervical carcinoma in situ cervical cone biopsy endometrial curettings endocervical endometrial dilatation curettage carcinoma in situ cone biopsy dilatation curettage carcinoma vicryl curettings vagina sutures cervix cervical cone biopsy MEDICAL_TRANSCRIPTION,Description Colpocleisis and rectocele repair Medical Specialty Obstetrics Gynecology Sample Name Colpocleisis Transcription PREOPERATIVE DIAGNOSES Vault prolapse and rectocele POSTOPERATIVE DIAGNOSES Vault prolapse and rectocele OPERATION Colpocleisis and rectocele repair ANESTHESIA Spinal ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid BRIEF HISTORY OF THE PATIENT This is an 85 year old female who presented to us with a vaginal mass On physical exam the patient was found to have grade 3 rectocele and poor apical support and history of hysterectomy The patient had good anterior support at the bladder Options were discussed such as watchful waiting pessary repair with and without mesh and closing of the vagina colpocleisis were discussed Risk of anesthesia bleeding infection pain MI DVT PE morbidity and mortality of the procedure were discussed Risk of infection and abscess formation were discussed The patient understood all the risks and benefits and wanted to proceed with the procedure Risk of retention and incontinence were discussed Consent was obtained through the family members DETAILS OF THE OR The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient had a Foley catheter placed The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support A 1 lidocaine with epinephrine was applied for posterior hydrodissection which was very difficult to do due to the significant scarring of the posterior part Attempts were made to lift the vaginal mucosa off of the rectum which was very very difficult to do at this point due to the patient s overall poor medical condition in terms of poor mobility and significant scarring Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis Oral consent was obtained from the family and her surgery was preceded The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors Using 0 Vicryl 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus The vaginal mucosa was pretty much completely closed off all the way up to the introitus Indigo carmine was given Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings There was no injury to the bladder or kinking of the ureteral openings The bladder was normal Rectal exam was normal at the end of the colpocleisis repair There was good hemostasis At the end of the procedure Foley was removed and the patient was brought to recovery in a stable condition Keywords obstetrics gynecology vault prolapse rectocele repair rectocele vaginal mass metzenbaum scissors ureteral openings vaginal mucosa colpocleisis vaginal infection MEDICAL_TRANSCRIPTION,Description Repeat low transverse cesarean section bilateral tubal ligation BTL extensive anterior abdominal wall uterine bladder adhesiolysis Term pregnancy and desires permanent sterilization Medical Specialty Obstetrics Gynecology Sample Name Cesarean Section BTL Transcription PREOPERATIVE DIAGNOSES 1 Term pregnancy 2 Desires permanent sterilization POSTOPERATIVE DIAGNOSES 1 Term pregnancy 2 Desires permanent sterilization PROCEDURE 1 Repeat low transverse cesarean section 2 Bilateral tubal ligation 3 Extensive anterior abdominal wall uterine bladder adhesiolysis ANESTHESIA Spinal epidural with good effect FINDINGS Delivered vigorous male infant from cephalic presentation Apgars 9 9 Birth weight 6 pounds 14 ounces Infant suctioned with a bulb upon delivery of the head and body Cord clamped and cut and infant passed to pediatric team present Complete placenta manually extracted intact with three vessel cord Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision In addition the bladder was involved in adhesion mass complex A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries Bilateral tubal ligation performed without difficulty via Parkland technique ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS None URINE OUTPUT Per anesthesia records Urine cleared postoperatively IV FLUIDS Per anesthesia records The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs OPERATIVE TECHNIQUE The patient was placed in a supine position after spinal epidural anesthesia She was prepped and draped in the usual manner for repeat cesarean section A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife This incision was extended laterally with Mayo scissors Dense fibromuscular layer was encountered from the patient s previous surgeries Upon entry incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision Fascia was previously separated superiorly and inferiorly from the muscular layer A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall Inferiorly difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall These adhesions likewise were surgically transacted via sharp blunt and electrocautery dissection This was successfully done without anterior entry into the bladder Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus The uterus was then incised using a sharp knife and low transverse incision This was extended with bandage scissors The infant was delivered easily from a cephalic presentation Bulb suction was done following delivery of the head and body The cord clamped and cut and the infant passed to pediatric team present Cord segment and cord blood was obtained Complete placenta manually extracted intact with three vessel cord Vigorous male infant Apgars 9 9 weight 6 pounds 14 ounces Complete placenta with three vessels retrieved Uterus was exteriorized from the abdominal cavity Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining Pennington clamps placed at the uterine incision angles and the inferior incision lip A 1 chromic suture closed the uterus in running continuous interlocking closure Good hemostasis upon completion of the closure Laparotomy pads placed in the posterior cul de sac to remove any blood or clots The uterus was returned to the abdominal cavity after using 1 chromic suture to close the anterior uterine incision that was partial thickness through the serosal end of the muscular layer at midline adhesion This was closed with chromic suture in a running continuous interlocking closure with good hemostasis Attention was then focused on the bilateral tubal ligation Babcock clamp placed in the mid fallopian tube and elevated Cautery was used to make a window in the avascular segment of the mesosalpinx Proximal and distal 1 chromic suture ligation with mid fallopian tube transection performed The ligated proximal and distal stumps were then cauterized with Bovie cautery This tubal ligation procedure was done in a bilateral fashion Upon completion of tubal ligation uterus was returned to the abdominal cavity Left and right gutters examined and found to be clean and dry Evaluation of the low uterine segment incision revealed continued hemostasis Oozing was encountered in the inferior bladder of dissection and 2 0 chromic suture in running continuous fashion partial thickness of the bladder to control the oozing at this site was successfully done Interceed was then placed on the low uterine incision and the low anterior uterine aspect The midline rectus including peritoneum was re approximated with simple interrupted chromic sutures Irrigation of the muscular layer with good hemostasis noted The fascia was closed with 1 Vicryl in a running continuous closure Subcutaneous tissue was irrigated additional hemostasis with Bovie cautery The skin was closed with staples Keywords obstetrics gynecology term pregnancy sterilization low transverse cesarean section bilateral tubal ligation adhesiolysis anterior uterus abdominal cavity cesarean section chromic suture tubal ligation adhesions uterus abdominal infant anterior cesarean hemostasis chromic uterine MEDICAL_TRANSCRIPTION,Description Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress Primary low transverse cesarean section Medical Specialty Obstetrics Gynecology Sample Name Cholestasis Of Pregnancy Transcription FINAL DIAGNOSES Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress PROCEDURE Included primary low transverse cesarean section SUMMARY This 32 year old gravida 2 was induced for cholestasis of pregnancy at 38 1 2 weeks The patient underwent a 2 day induction On the second day the patient continued to progress all the way to the point of 9 5 cm at which point she failed to progress During the hour or two of evaluation at 9 5 cm the patient was also noted to have some fetal tachycardia and an occasional late deceleration Secondary to these factors the patient was brought to the operative suite for primary low transverse cesarean section which she underwent without significant complication There was a slightly enlarged blood loss at approximately 1200 mL and postoperatively the patient was noted to have a very mild tachycardia coupled with 100 3 degrees Fahrenheit temperature right at delivery It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay The patient received 72 hours of antibiotics with there never being a temperature above 100 3 degrees Fahrenheit The maternal tachycardia resolved within a day The patient did well throughout the 3 day stay progressing to full diet regular bowel movements normal urination patterns The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20 It should be noted however that this was actually an expected result with the initial hematocrit of 32 preoperatively Therefore there was anemia but not an unexplained anemia PHYSICAL EXAMINATION ON DISCHARGE Includes the stable vital signs afebrile state An alert and oriented patient who is desirous at discharge Full range of motion all extremities fully ambulatory Pulse is regular and strong Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus The incision is beautiful and soft and nontender There is scant lochia and there is minimal edema LABORATORY STUDIES Include hematocrit of 27 and the last liver function tests was within normal limits 48 hours prior to discharge FOLLOWUP For the patient includes pelvic rest regular diet Follow up with me in 1 to 2 weeks Motrin 800 mg p o q 8h p r n cramps Tylenol No 3 one p o q 4h p r n pain prenatal vitamin one p o daily and topical triple antibiotic to incision b i d to q i d Keywords obstetrics gynecology delivered pregnancy fetal intolerance induction pelvic rest low transverse cesarean section cholestasis of pregnancy cesarean section pregnancy fetal tachycardia cholestasis MEDICAL_TRANSCRIPTION,Description Excision of left breast mass The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin Medical Specialty Obstetrics Gynecology Sample Name Breast Mass Excision 2 Transcription PREOPERATIVE DIAGNOSIS Breast mass left POSTOPERATIVE DIAGNOSIS Breast mass left PROCEDURE Excision of left breast mass OPERATION After obtaining an informed consent the patient was taken to the operating room where he underwent general endotracheal anesthesia The time out process was followed Preoperative antibiotic was given The patient was prepped and draped in the usual fashion The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia The whole of specimen including the skin the mass and surrounding subcutaneous tissue and fascia were excised en bloc Hemostasis was achieved with the cautery The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl A small pressure dressing was applied Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition Keywords obstetrics gynecology breast mass excision freely mobile breast mass endotracheal fascia specimen MEDICAL_TRANSCRIPTION,Description Breast radiation therapy followup note Left breast adenocarcinoma stage T3 N1b M0 stage IIIA Medical Specialty Obstetrics Gynecology Sample Name Breast Radiation Therapy Followup Transcription DIAGNOSIS Left breast adenocarcinoma stage T3 N1b M0 stage IIIA She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes CURRENT MEDICATIONS 1 Glucosamine complex 2 Toprol XL 3 Alprazolam 4 Hydrochlorothiazide 5 Dyazide 6 Centrum Dr X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck She previously received a total of 46 8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area As such I feel that we could safely re treat the lower neck Her weight has increased to 189 5 from 185 2 She does complain of some coughing and fatigue PHYSICAL EXAMINATION NECK On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present RESPIRATORY Good air entry bilaterally Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected No lumps bumps or evidence of disease involving the right breast is present ABDOMEN Normal bowel sounds no hepatomegaly No tenderness on deep palpation She has just started her last cycle of chemotherapy today and she wishes to visit her daughter in Brooklyn New York After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time I look forward to keeping you informed of her progress Thank you for having allowed me to participate in her care Keywords obstetrics gynecology carboplatin taxol radiation therapy breast adenocarcinoma beam radiotherapy chest wall radiotherapy supraclavicular lymphadenopathy adenocarcinoma breast MEDICAL_TRANSCRIPTION,Description Left breast mass and hypertrophic scar of the left breast Excision of left breast mass and revision of scar The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site Medical Specialty Obstetrics Gynecology Sample Name Breast Mass Excision 1 Transcription PREOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast POSTOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast PROCEDURE PERFORMED Excision of left breast mass and revision of scar ANESTHESIA Local with sedation SPECIMEN Scar with left breast mass DISPOSITION The patient tolerated the procedure well and transferred to the recover room in stable condition BRIEF HISTORY The patient is an 18 year old female who presented to Dr X s office The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site The patient also has a hypertrophic scar Thus the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass INTRAOPERATIVE FINDINGS A hypertrophic scar was found and removed The cicatrix was removed in its entirety and once opening the wound the area of tissue where the palpable mass was was excised as well and sent to the lab PROCEDURE After informed consent risks and benefits of the procedure were explained to the patient and the patient s family the patient was brought to the operating suite prepped and draped in the normal sterile fashion Elliptical incision was made over the previous cicatrix The total length of the incision was 5 5 cm Removing the cicatrix in its entirety with a 15 blade Bard Parker scalpel after anesthetizing with local solution with 0 25 Marcaine Next the area of tissue just inferior to the palpable mass where the palpable was removed with electro Bovie cautery Hemostasis was maintained Attention was next made to approximating the deep dermal layers An interrupted 4 0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges Steri Strips as well as bacitracin and sterile dressings were applied The patient tolerated the procedure well and was transferred to recovery in stable condition Keywords obstetrics gynecology hypertrophic scar palpable mass fibrocystic scar fibrocystic disease breast mass breast cicatrix excision biopsy hypertrophic palpable MEDICAL_TRANSCRIPTION,Description Ultrasound BPP Advanced maternal age and hypertension Medical Specialty Obstetrics Gynecology Sample Name Biophysical Profile 1 Transcription HISTORY Advanced maternal age and hypertension FINDINGS There is a single live intrauterine pregnancy with a vertex lie posterior placenta and adequate amniotic fluid The amniotic fluid index is 23 2 cm Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03 28 08 Based on fetal measurements obtained today estimated fetal weight is 3249 plus or minus 396 g 7 pounds 3 ounces plus or minus 14 ounces which places the fetus in the 66th percentile for the estimated gestational age Fetal heart motion at a rate of 156 beats per minute is documented The cord Doppler ratio is normal at 2 2 The biophysical profile score assessing fetal breathing movement gross body movement fetal tone and qualitative amniotic fluid volume is 8 8 IMPRESSION 1 Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03 28 08 2 Biophysical profile BPP score 8 8 Keywords obstetrics gynecology ultrasound bpp maternal age intrauterine pregnancy biophysical profile amniotic fluid gestational age amniotic gestational fetal MEDICAL_TRANSCRIPTION,Description Bilateral Mammogram abnormal additional views requested Medical Specialty Obstetrics Gynecology Sample Name Bilateral Mammogram Transcription EXAM Mammographic screening FFDM HISTORY 40 year old female who is on oral contraceptive pills She has no present symptomatic complaints No prior history of breast surgery nor family history of breast CA TECHNIQUE Standard CC and MLO views of the breasts COMPARISON This is the patient s baseline study FINDINGS The breasts are composed of moderately to significantly dense fibroglandular tissue The overlying skin is unremarkable There are a tiny cluster of calcifications in the right breast near the central position associated with 11 30 on a clock There are benign appearing calcifications in both breasts as well as unremarkable axillary lymph nodes There are no spiculated masses or architectural distortion IMPRESSION Tiny cluster of calcifications at the 11 30 position of the right breast Recommend additional views spot magnification in the MLO and CC views of the right breast BIRADS Classification 0 Incomplete MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD Second Look Software Version 7 2 was utilized Keywords obstetrics gynecology ffdm mammographic screening tiny cluster of calcifications bilateral mammogram additional views bilateral mammogram cluster breasts calcifications mammography MEDICAL_TRANSCRIPTION,Description A complex closure and debridement of wound The patient is a 26 year old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant just below the costal margin that was lanced by General Surgery and resolved however it continued to drain Medical Specialty Neurosurgery Sample Name Wound Closure Debridement Hydrocephalus Transcription TITLE OF OPERATION A complex closure and debridement of wound INDICATION FOR SURGERY The patient is a 26 year old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant just below the costal margin that was lanced by General Surgery and resolved however it continued to drain There is no evidence of fevers CRP was normal Shunt CT were all normal The thought was he has insidious fistula versus tract where recommendation was for excision of this tract PREOP DIAGNOSIS Possible cerebrospinal fluid versus wound fistula POSTOP DIAGNOSIS Possible cerebrospinal fluid versus wound fistula PROCEDURE DETAIL The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway positioned supine and the right side was prepped and draped in the usual sterile fashion Next working on the fistula this was elliptically excised Once this was excised this was followed down to the fistulous tract which was completely removed There was no CSF drainage The catheter was visualized although not adequately properly Once this was excised it was irrigated and then closed in multiple layers using 3 0 Vicryl for the deep layers and 4 0 Caprosyn and Indermil with a dry sterile dressing applied The patient was reversed extubated and transferred to the recovery room in stable condition Multiple cultures were sent as well as the tracts sent to Pathology All sponge and needle counts were correct Keywords neurosurgery debridement of wound shunt costal margin cerebrospinal fluid cerebrospinal closure debridement hydrocephalus surgery draining fistula wound MEDICAL_TRANSCRIPTION,Description Placement of right new ventriculoperitoneal VP shunts Strata valve and to removal of right frontal Ommaya reservoir Medical Specialty Neurosurgery Sample Name VP Shunt Placement Transcription TITLE OF OPERATION Placement of right new ventriculoperitoneal VP shunts Strata valve and to removal of right frontal Ommaya reservoir INDICATION FOR SURGERY The patient is a 2 month old infant born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt PREOP DIAGNOSIS Hydrocephalus POSTOP DIAGNOSIS Hydrocephalus PROCEDURE DETAIL The patient was brought to the operating room underwent induction of general endotracheal airway positioned supine head turned towards left The right side prepped and draped in the usual sterile fashion Next using a 15 blade scalpel two incisions were made one in the parietooccipital region and The second just lateral to the umbilicus Once this was clear the Bactiseal catheter was then tunneled This was connected to a Strata valve The Strata valve was programmed to a setting of 1 01 and this was ensured The small burr hole was then created The area was then coagulated Once this was completed new Bactiseal catheter was then inserted It was connected to the Strata valve There was good distal flow The distal end was then inserted into the peritoneal region via trocar Once this was insured all the wounds were irrigated copiously and closed with 3 0 Vicryl and 4 0 Caprosyn as well as Indermil glue The right frontal incision was then opened The Ommaya reservoir identified and removed The wound was then also closed with an inverted 3 0 Vicryl and 4 0 Caprosyn Once all the wounds were completed dry sterile dressings were applied The patient was then transported back to the ICU in stable condition intubated Blood loss minimal All sponge and needle counts were correct Keywords neurosurgery ommaya reservoir frontal strata valve intraventricular hemorrhage vp shunt ventriculoperitoneal hydrocephalus MEDICAL_TRANSCRIPTION,Description Endoscopic third ventriculostomy Medical Specialty Neurosurgery Sample Name Ventriculostomy Transcription PREOPERATIVE DIAGNOSIS Aqueductal stenosis POSTOPERATIVE DIAGNOSIS Aqueductal stenosis TITLE OF PROCEDURE Endoscopic third ventriculostomy ANESTHESIA General endotracheal tube anesthesia DEVICES Bactiseal ventricular catheter with an Aesculap burr hole port SKIN PREPARATION ChloraPrep COMPLICATIONS None SPECIMENS CSF for routine studies INDICATIONS FOR OPERATION Triventricular hydrocephalus most consistent with aqueductal stenosis The patient having a long history of some intermittent headaches macrocephaly OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in supine position with the head neutral The right frontal area was shaven and then the head was prepped and draped in a standard routine manner The area of the proposed scalp incision was infiltrated with 0 25 Marcaine with 1 200 000 epinephrine A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture Two Weitlaner were used to hold the scalp open A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated Neuropen was introduced directly through the parenchyma into the ventricular system which was quite large and dilated CSF was collected for routine studies We saw the total absence of __________ consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle I could bend the ventricular catheter and look back and see the aqueduct which was quite stenotic with a little bit of chorioplexus near its opening The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________ various motions We went through the membrane of Liliequist We could see the basilar artery and the clivus and there was no significant bleeding from the edges The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2 0 Ethibond suture The wound was irrigated out with bacitracin and closed using 3 0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri Strips The patient tolerated the procedure well Keywords neurosurgery aqueductal stenosis ventriculostomy triventricular hydrocephalus neuropen endoscopic third ventriculostomy endotracheal tube anesthesia burr hole port aqueductal MEDICAL_TRANSCRIPTION,Description Diagnostic mammogram full field digital ultrasound of the breast and mammotome core biopsy of the left breast Medical Specialty Obstetrics Gynecology Sample Name Breast Ultrasound Biopsy Transcription EXAM Bilateral diagnostic mammogram left breast ultrasound and biopsy HISTORY 30 year old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder The patient has a family history of breast cancer within her mother at age 58 Patient denies personal history of breast cancer TECHNIQUE AND FINDINGS Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm dd yy An additional lateromedial projection of the right breast was obtained The breasts demonstrate heterogeneously dense fibroglandular tissue Within the upper outer aspect of the left breast there is evidence of a circumscribed density measuring approximately 1 cm x 0 7 cm in diameter No additional dominant mass areas of architectural distortion or malignant type calcifications are seen Multiple additional benign appearing calcifications are visualized bilaterally Skin overlying both breasts is unremarkable Bilateral breast ultrasound was subsequently performed which demonstrated an ovoid mass measuring approximately 0 5 x 0 5 x 0 4 cm in diameter located within the anteromedial aspect of the left shoulder This mass demonstrates isoechoic echotexture to the adjacent muscle with no evidence of internal color flow This may represent benign fibrous tissue or a lipoma Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o clock position measuring 0 7 x 0 7 x 0 8 cm in diameter At this time the lesion was determined to be amenable by ultrasound guided core biopsy The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o clock position of the left breast Informed consent was obtained The lesion was re localized under ultrasound guidance The left breast was prepped and draped in the usual sterile fashion 2 lidocaine was administered locally for anesthesia Additional lidocaine with epinephrine was administered around the distal aspect of the lesion A small skin nick was made Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides The lateral to medial approach was performed with an 11 gauge Mammotome device The device was advanced under ultrasound guidance with the superior aspect of the lesion placed within the aperture Two core biopsies were obtained The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion consistent with a rapidly expanding hematoma Arterial blood was visualized exiting the access site A biopsy clip was attempted to be placed however could not be performed secondary to the active hemorrhage Therefore the Mammotome was removed and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved Postprocedural imaging of the 2 o clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1 9 x 4 4 x 1 3 cm in diameter The left breast was re cleansed with a ChloraPrep and a pressure bandage and ice packing were applied to the left breast The patient was observed in the ultrasound department for the following 30 minutes without complaints The patient was subsequently discharged with information and instructions on utilizing the ice bandage The obtained specimens were sent to pathology for further analysis IMPRESSION 1 A mixed solid and cystic lesion at the 2 o clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument and multiple core biopsies were obtained Transient arterial hemorrhage was noted at the biopsy site resulting in a localized 4 cm hematoma Pressure was applied until hemostasis was achieved The patient was monitored for approximately 30 minutes after the procedure and was ultimately discharged in good condition The core biopsies were submitted to pathology for further analysis 2 Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow and likely represents fibrotic changes or a lipoma 3 Suspicious mammographic findings The circumscribed density measuring approximately 8 mm at the 2 o clock position of the left breast was subsequently biopsied Further pathologic analysis is pending BIRADS Classification 4 Suspicious findings MAMMOGRAPHY INFORMATION 1 A certain percentage of cancers probably 10 to 15 will not be identified by mammography 2 Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present 3 These images were obtained with FDA approved digital mammography equipment and iCAD SecondLook Software Version 7 2 was utilized Keywords obstetrics gynecology mammotome core biopsy diagnostic mammogram breast cancer bilateral breasts circumscribed density ovoid mass breast ultrasound core biopsy lesion biopsy breast hematoma mammotome mammography ultrasound MEDICAL_TRANSCRIPTION,Description Abdominosacrocolpopexy enterocele repair cystoscopy and lysis of adhesions Medical Specialty Obstetrics Gynecology Sample Name Abdominosacrocolpopexy Transcription PREOPERATIVE DIAGNOSES 1 Vault prolapse 2 Enterocele PREOPERATIVE DIAGNOSES 1 Vault prolapse 2 Enterocele OPERATIONS 1 Abdominosacrocolpopexy 2 Enterocele repair 3 Cystoscopy 4 Lysis of adhesions ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL SPECIMEN None BRIEF HISTORY The patient is a 53 year old female with history of hysterectomy presented with vaginal vault prolapse The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse Options such as watchful waiting pessary abdominal surgery robotic sacrocolpopexy versus open sacrocolpopexy were discussed The patient already had multiple abdominal scars Risk of open surgery was little bit higher for the patient After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy Risks of anesthesia bleeding infection pain MI DVT PE mesh erogenic exposure complications with mesh were discussed The patient understood the risks of recurrence etc and wanted to proceed with the procedure The patient was told to perform no heavy lifting for 3 months etc The patient was bowel prepped preoperative antibiotics were given DETAILS OF THE OPERATION The patient was brought to the OR anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A Pfannenstiel low abdominal incision was done at the old incision site The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle The muscle was split in the middle and peritoneum was entered using sharp mets There was no injury to the bowel upon entry There were significant adhesions which were unleashed All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released similarly colon was mobilized There was minimal space everything was packed Bookwalter placed then over the sacral bone The middle of the sacral bone was identified The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened The ligament over the sacral or sacral __________ was easily identified 0 Ethibond stitches were placed x3 A 1 cm x 5 cm mesh was cut out This was a Prolene soft mesh which was tied at the sacral ligament The bladder was clearly off the vault area which was exposed in the raw surface 0 Ethibond stitches were placed x3 The mesh was attached The apex was clearly up enterocele sac was closed using 4 0 Vicryl without much difficulty The ureter was not involved at all in this process The peritoneum was closed over the mesh Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel Prior to closure antibiotic irrigation was done using Ancef solution The mesh has been exposed in antibiotic solution prior to the usage After a through irrigation with L and half of antibiotic solution All the solution was removed Good hemostasis was obtained All the packing was removed Count was correct Rectus abdominus muscle was brought together using 4 0 Vicryl The fascia was closed using loop 1 PDS in running fascia from both sides and was tied in the middle Subcutaneous tissue was closed using 4 0 Vicryl and the skin was closed using 4 0 Monocryl in subcuticular fashion Cystoscopy was done at the end of the procedure Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure Cystoscopy was done and indigo carmine has been given There was good efflux of indigo carmine in both of the ureteral opening There was no injury to the rectum or the bladder The bladder appeared completely normal The rectal exam was done at the end of the procedure after the cystoscopy After the cysto was done the scope was withdrawn Foley was placed back The patient was brought to recovery in the stable condition Keywords obstetrics gynecology enterocele repair cystoscopy lysis of adhesions enterocele ethibond stitches indigo carmine vault prolapse sacrocolpopexy peritoneum abdominosacrocolpopexy MEDICAL_TRANSCRIPTION,Description Placement of left ventriculostomy via twist drill Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure Medical Specialty Neurosurgery Sample Name Ventriculostomy Placement Transcription PROCEDURE Placement of left ventriculostomy via twist drill PREOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure POSTOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure INDICATIONS FOR PROCEDURE The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage His condition is felt to be critical In a desperate attempt to relieve increased intracranial pressure we have proposed placing a ventriculostomy I have discussed this with patient s wife who agrees and asked that we proceed emergently After a sterile prep drape and shaving of the hair over the left frontal area this area is infiltrated with local anesthetic Subsequently a 1 cm incision was made over Kocher s point Hemostasis was obtained Then a twist drill was made over this area Bones strips were irrigated away The dura was perforated with a spinal needle A Camino monitor was connected and zeroed This was then passed into the left lateral ventricle on the first pass Excellent aggressive very bloody CSF under pressure was noted This stopped slowed and some clots were noted This was irrigated and then CSF continued Initial opening pressures were 30 but soon arose to 80 or a 100 The patient tolerated the procedure well The wound was stitched shut and the ventricular drain was then connected to a drainage bag Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding Keywords neurosurgery intraventricular hemorrhage hydrocephalus intracranial pressure camino monitor twist drill ventriculostomy hemorrhage intracranial pressure intraventricular MEDICAL_TRANSCRIPTION,Description Burr hole and insertion of external ventricular drain catheter Medical Specialty Neurosurgery Sample Name Ventricular Drain Catheter Insertion Transcription PREOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury POSTOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury PROCEDURE Burr hole and insertion of external ventricular drain catheter ANESTHESIA Just bedside sedation PROCEDURE Scalp was clipped He was prepped with ChloraPrep and Betadine Incisions are infiltrated with 1 Xylocaine with epinephrine 1 200000 He did receive antibiotics post procedure He was draped in a sterile manner Incision made just to the right of the right mid pupillary line 10 cm behind the nasion A self retaining retractor was placed Burr hole was drilled with the cranial twist drill The dura was punctured with a twist drill A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle The pressure was initially high The CSF was clear and colorless The CSF drainage rapidly tapered off because of the brain swelling With two tries the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound the depth of catheter is 7 cm from the outer table of the skull There was intermittent drainage of CSF after that The catheter was secured to the scalp with 2 0 silk suture and the incision was closed with Ethilon suture The patient tolerated the procedure well No complications Sponge and needle counts were correct Blood loss is minimal None replaced Keywords neurosurgery intracranial pressure cerebral edema external ventricular drain catheter ventricular drain catheter brain injury burr hole ventricular brain catheter MEDICAL_TRANSCRIPTION,Description BPP of Gravida 1 para 0 at 33 weeks 5 days by early dating The patient is developing gestational diabetes Medical Specialty Obstetrics Gynecology Sample Name Biophysical Profile Transcription CLINICAL HISTORY Gravida 1 para 0 at 33 weeks 5 days by early dating The patient is developing gestational diabetes Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation The placenta was posterior in position There was normal fetal breathing movement gross body movement and fetal tone and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18 2 cm The following measurements were obtained Biparietal diameter 8 54 cm head circumference 30 96 cm abdominal circumference 29 17 cm and femoral length 6 58 cm These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation CONCLUSION Normal biophysical profile BPP with a score of 8 out of possible 8 The fetus is size appropriate for gestation Keywords obstetrics gynecology biophysical profile gestational diabetes amniotic fluid bpp gravida para diabetes fetus fetalNOTE MEDICAL_TRANSCRIPTION,Description Desires permanent sterilization Laparoscopic bilateral tubal occlusion with Hulka clips Medical Specialty Obstetrics Gynecology Sample Name Bilateral Tubal Occlusion Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Desires permanent sterilization POSTOPERATIVE DIAGNOSIS Desires permanent sterilization PROCEDURE PERFORMED Laparoscopic bilateral tubal occlusion with Hulka clips ANESTHESIA General ESTIMATED BLOOD LOSS Less than 20 cc COMPLICATIONS None FINDINGS On bimanual exam the uterus was found to be anteverted at approximately six weeks in size There were no adnexal masses appreciated The vulva and perineum appeared normal Laparoscopic findings revealed normal appearing uterus fallopian tubes bilaterally as well as ovaries bilaterally There was a functional cyst on the left ovary There was filmy adhesion in the left pelvic sidewall There were two clear lesions consistent with endometriosis one was on the right fallopian tube and the other one was in the cul de sac The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis The liver was visualized and appeared normal The spleen was also visualized INDICATIONS This patient is a 34 year old gravida 4 para 4 0 0 4 Caucasian female who desires permanent sterilization She recently had a spontaneous vaginal delivery in June and her family planning is complete PROCEDURE IN DETAIL After informed consent was obtained in layman s terms the patient was taken back to the operating suite and placed under general anesthesia She was then prepped and draped and placed in the dorsal lithotomy position A bimanual exam was performed and the above findings were noted Prior to beginning the procedure her bladder was drained with a red Robinson catheter A weighted speculum was placed in the patient s posterior vagina and the 12 o clock position of the cervix was grasped with a single toothed tenaculum The cervix was dilated so that the uterine elevator could be placed Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips a 1 cm infraumbilical skin incision was made The Veress needle was then inserted and using sterile saline ______ the pelvic cavity The abdomen was then insufflated with appropriate volume and flow of CO2 The 11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization a 7 mm bladed trocar was placed without difficulty Using the Hulka clip applicator the left fallopian tube was identified followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube A second Hulka clip was then placed across the entire diameter just proximal to this There was good hemostasis at the fallopian tube The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle A second Hulka clip was placed just distal to this again across the entire diameter Good hemostasis was obtained At this point the abdomen was desufflated and after it was desufflated the suprapubic port site was visualized and found to be hemostatic The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed The umbilical incision was then closed with two interrupted 4 0 undyed Vicryl The suprapubic incision was then closed with Steri Strips The uterine elevator was removed and the single toothed tenaculum site was found to be hemostatic The patient tolerated that procedure well The sponge lap and needle counts were correct x2 She will follow up postoperatively for followup care Keywords obstetrics gynecology laparoscopic bilateral tubal occlusion bilateral tubal occlusion hulka clips fallopian tubes anesthesia laparoscope endometriosis laparoscopic sterilization fallopian tubes clips MEDICAL_TRANSCRIPTION,Description Chronic venous hypertension with painful varicosities lower extremities bilaterally Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions bilaterally Medical Specialty Neurosurgery Sample Name Vein Stripping Transcription PREOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally POSTOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally PROCEDURES 1 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions right leg 2 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions left leg PROCEDURE DETAIL After obtaining the informed consent the patient was taken to the operating room where she underwent a general endotracheal anesthesia A time out process was followed and antibiotics were given Then both legs were prepped and draped in the usual fashion with the patient was in the supine position An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided Then an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities Then a vein stripper was passed from the right calf up to the groin and the greater saphenous vein which was divided was stripped without any difficultly Several minutes of compression was used for hemostasis Then the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do Then in the left thigh a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side Also an incision was made in the level of the knee and the saphenous vein was isolated there The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis Then a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient s position would allow us Then all incisions were closed in layers with Vicryl and staples Then the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg The stab phlebectomies were performed with a hook and they were very satisfactory Hemostasis achieved with compression and then staples were applied to the skin Then the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix fluffs and Ace bandages Estimated blood loss probably was about 150 mL The patient tolerated the procedure well and was sent to recovery room in satisfactory condition The patient is to be observed so a decision will be made whether she needs to stay overnight or be able to go home Keywords neurosurgery chronic venous hypertension varicosities stab phlebectomies greater saphenous vein stripping lower extremities vein stripping saphenous vein vein incisions hemostasis stripping branches phlebectomies thigh calf saphenous MEDICAL_TRANSCRIPTION,Description Excision of right breast mass Right breast mass with atypical proliferative cells on fine needle aspiration Medical Specialty Obstetrics Gynecology Sample Name Breast Mass Excision Transcription PREOPERATIVE DIAGNOSIS Right breast mass with atypical proliferative cells on fine needle aspiration POSTOPERATIVE DIAGNOSIS Benign breast mass ANESTHESIA General NAME OF OPERATION Excision of right breast mass PROCEDURE With the patient in the supine position the right breast was prepped and draped in a sterile fashion A curvilinear incision was made directly over the mass in the upper outer quadrant of the right breast Dissection was carried out around a firm mass which was dissected with surrounding margins of breast tissue Hemostasis was obtained using electrocautery Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma but appeared benign The breast tissues were approximated using 4 0 Vicryl The skin was closed using 5 0 Vicryl running subcuticular stitches A sterile bandage was applied The patient tolerated the procedure well Keywords obstetrics gynecology atypical proliferative cells fine needle aspiration proliferative cells breast mass breast needle aspiration fibroadenoma excision proliferative mass MEDICAL_TRANSCRIPTION,Description Subcutaneous ulnar nerve transposition A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Medical Specialty Neurosurgery Sample Name Ulnar Nerve Transposition Transcription PROCEDURE Subcutaneous ulnar nerve transposition PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected Osborne s fascia was released an ulnar neurolysis performed and the ulnar nerve was mobilized Six cm of the medial intermuscular septum was excised and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly The subcutaneous plane just superficial to the flexor pronator mass was developed Meticulous hemostasis was maintained with bipolar electrocautery The nerve was transposed anteriorly superficial to the flexor pronator mass Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve A semicircular medially based flap of flexor pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating The subcutaneous tissue and skin were closed with simple interrupted sutures Marcaine with epinephrine was injected into the wound The elbow was dressed and splinted The patient was awakened and sent to the recovery room in good condition having tolerated the procedure well Keywords neurosurgery neurolysis ulnar periosteal flexor pronator mass ulnar nerve transposition medial intermuscular septum nerve transposition intermuscular septum flexor pronator ulnar nerve nerve MEDICAL_TRANSCRIPTION,Description Bilateral temporal artery biopsy Rule out temporal arteritis Medical Specialty Neurosurgery Sample Name Temporal Artery Biopsy Transcription PREOPERATIVE DIAGNOSIS Rule out temporal arteritis POSTOPERATIVE DIAGNOSIS Rule out temporal arteritis PROCEDURE Bilateral temporal artery biopsy ANESTHESIA Local anesthesia 1 Xylocaine with epinephrine INDICATIONS I was consulted by Dr X for this patient with bilateral temporal headaches to rule out temporal arteritis I explained fully the procedure to the patient PROCEDURE Both sides were done exactly the same way After 1 Xylocaine infiltration a 2 to 3 cm incision was made over the temporal artery The temporal artery was identified and was grossly normal on both sides Proximal and distal were ligated with both of 3 0 silk suture and Hemoccult The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm They were sent as separate specimens right and left labeled The wound was then closed with interrupted 3 0 Monocryl subcuticular sutures and Dermabond She tolerated the procedure well Keywords neurosurgery headaches bilateral temporal artery temporal artery biopsy temporal arteritis temporal artery temporal biopsy arteritis MEDICAL_TRANSCRIPTION,Description Headaches question of temporal arteritis Bilateral temporal artery biopsies Medical Specialty Neurosurgery Sample Name Temporal Artery Biopsy 1 Transcription PREOPERATIVE DIAGNOSIS Headaches question of temporal arteritis POSTOPERATIVE DIAGNOSIS Headaches question of temporal arteritis PROCEDURE Bilateral temporal artery biopsies DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion Xylocaine 1 was utilized and then an incision was made in front of the right ear and deepened anteriorly The temporal artery was found and exposed in an extension of about 2 cm The artery was proximally and distally ligated with 6 0 Prolene and also a side branch and a sample was sent for pathology Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl Then the patient was turned and her left temporal area was prepped and draped in the usual fashion A similar procedure was performed with 1 Xylocaine and exposed her temporal artery which was excised in an extent to about 2 cm This was also proximally and distally ligated with 6 0 Prolene and also side branch Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl Dressings were applied to both areas The patient tolerated the procedure well Estimated blood loss was negligible and the patient went back to Same Day Surgery for recovery Keywords neurosurgery temporal arteritis temporal artery temporal artery biopsies hemostasis subcuticular headaches arteritis MEDICAL_TRANSCRIPTION,Description Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty Medical Specialty Neurosurgery Sample Name Suboccipital Craniectomy Transcription TITLE OF OPERATION Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty INDICATION FOR SURGERY The patient with a large 3 5 cm acoustic neuroma The patient is having surgery for resection There was significant cerebellar peduncle compression The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex The case took 12 hours This was more difficult and took longer than the usual acoustic neuroma PREOP DIAGNOSIS Right acoustic neuroma POSTOP DIAGNOSIS Right acoustic neuroma PROCEDURE The patient was brought to the operating room General anesthesia was induced in the usual fashion After appropriate lines were placed the patient was placed in Mayfield 3 point head fixation hold into a right park bench position to expose the right suboccipital area A time out was settled with nursing and anesthesia and the head was shaved prescrubbed with chlorhexidine prepped and draped in the usual fashion The incision was made and cautery was used to expose the suboccipital bone Once the suboccipital bone was exposed under the foramen magnum the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus The dura was then opened in a cruciate fashion the cisterna magna was drained which nicely relaxed the cerebellum The dura leaves were held back with the 4 0 Nurolon The microscope was then brought into the field and under the microscope the cerebellar hemisphere was elevated Laterally the arachnoid was very thick This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa Initially two retractors were used one on the tentorium and one inferiorly The arachnoid was taken down off the tumor There were multiple blood vessels on the surface which were bipolared The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum however as the tumor was able to be debulked the edge began to be mobilized The redundant capsule was bipolared and cut out to get further access to the center of the tumor Working inferiorly and then superiorly the tumor was taken down off the tentorium as well as out the 9th 10th or 11th nerve complex It was very difficult to identify the 7th nerve complex The brainstem was identified above the complex Similarly inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain Attention was then taken to try identify the 7th nerve complex There were multitude of veins including the lateral pontine vein which were coming right into this area The lateral pontine vein was maintained Microscissors and bipolar were used to develop the plain and then working inferiorly the 7th nerve was identified coming off the brainstem A number 1 and number 2 microinstruments were then used to began to develop the plane This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve Cavitron was used to debulk the lesion and then further dissection was carried out The nerve stimulated beautifully at the brainstem level throughout this The tumor continued to be mobilized off the lateral pontine vein until it was completely off The Cavitron was used to debulk the lesion out back laterally towards the area of the porus The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus At this point the capsule was so redundant it was felt to isolate the nerve in the porus There was minimal bulk remaining intracranially All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem Dr X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus I then scrubbed back into case once Dr X had completed removing this portion of the tumor There was no tumor remaining at this point I placed some Norian in the porus to seal any air cells although there were no palpated An intradural space was then irrigated thoroughly There was no bleeding The nerve was attempted to be stimulated at the brainstem level but it did not stimulate at this time The dura was then closed with 4 0 Nurolons in interrupted fashion A muscle plug was used over one area Duragen was laid and strips over the suture line followed by Hemaseel Gelfoam was set over this and then a titanium cranioplasty was carried out The wound was then irrigated thoroughly O Vicryls were used to close the deep muscle and fascia 3 0 Vicryl for subcutaneous tissue and 3 0 nylon on the skin The patient was extubated and taken to the ICU in stable condition Keywords neurosurgery suboccipital craniectomy microscope cranioplasty acoustic neuroma cerebellar peduncle nerve complex brainstem nurolon cavitron kerrison leksell lateral pontine vein suboccipital craniectomy nerve tumor MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of right temporal bone middle ear space Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 Medical Specialty Neurosurgery Sample Name Skull Base Reconstruction Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space PROCEDURE Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was brought into the operating room placed on the table in supine position General endotracheal anesthesia was obtained in the usual fashion The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen The neck was prepped as well After this was performed I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle After this was performed I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible The condyle was skeletonized so that it could be easily seen The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared The neck contents to the hyoid were dissected out The hypoglossal nerve vagus nerve and spinal accessory nerve were dissected towards the jugular foramen The neck contents were removed as a separate specimen The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis A large posterior facial vein was identified and likewise clipped for later use I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus dissecting or exposing the dura to the level of the jugular bulb It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion Once this was dissected out Dr X entered the procedure for completion of the resection with the craniotomy For details please see his operative note After Dr X had completed the resection I then harvested the rectus free flap A skin paddle was drawn out next to the umbilicus about 4 x 4 cm The skin paddle was incised with the Bovie and down to the anterior rectus sheath Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin The skin paddle was then sutured to the fascia and muscle with interrupted 3 0 Vicryl The anterior rectus sheath was then reflected off the rectus muscle which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction The vascular pedicle could be seen entering the muscle in usual fashion The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel The wound was then packed with saline impregnated sponges The rectus muscle with attached skin paddle was then transferred into the neck The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9 0 Ethilon with standard microvascular technique Ischemia time was less than 10 minutes Likewise the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9 0 Ethilon as well There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case The wound was irrigated with copious amounts of saline The eustachian tube was obstructed with bone wax The muscle was then laid into position with the skin paddle underneath the conchal bowl I removed most the skin of the conchal bowl de epithelializing and leaving the fat in place The wound was closed in layers overlying the muscle which was secured superiorly to the muscle overlying the temporal skull The subcutaneous tissues were closed with interrupted 3 0 Vicryl The skin was closed with skin staples There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself The skin paddle was closed with interrupted 4 0 Prolene to the edges of the conchal bowl The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with 1 Prolene with the more running suture taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors The subcutaneous tissues were closed with interrupted 2 0 Vicryl and skin was closed with skin staples The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened The patient was then transferred to the PACU in stable condition with spontaneous respirations having tolerated the procedure well Keywords neurosurgery rectus abdominis myocutaneous skull base defect squamous cell carcinoma skull base squamous cell rectus sheath abdominis muscle rectus sheath MEDICAL_TRANSCRIPTION,Description Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new Medical Specialty Neurosurgery Sample Name Shunt Revision 2 Transcription PREOPERATIVE DIAGNOSIS Shunt malfunction POSTOPERATIVE DIAGNOSIS Partial proximal obstruction patent distal system TITLE OF OPERATION Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new SPECIMENS None COMPLICATIONS None ANESTHESIA General SKIN PREPARATION Chloraprep INDICATIONS FOR OPERATION Headaches irritability slight increase in ventricle size Preoperatively patient improved with Diamox BRIEF NARRATIVE OF OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in the supine position with the head rotated towards the left The right frontal area and right retroauricular area was shaved and then the head neck chest and abdomen were prepped and draped out in the routine manner The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter right over the sleeve on top of it and when that was entered the CSF poured out around the ventricular catheter The ventricular catheter was then disconnected from the reservoir and endoscopically explored We saw it was blocked up proximally The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter I was able to free up the ventricular catheter and endoscopically inserted a new Bactiseal ventricular catheter The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle It irrigated out well There was minimal amount of bleeding but not significant The distal catheter system was tested There was good distal run off Therefore a linear skin incision was made in the retroauricular area Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1 5 shunt assist was brought through the subgaleal tissue connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve All connections were secured with 2 0 Ethibond sutures Careful attention was made to make sure that the ProGAV was in the right orientation The wounds were irrigated out with Bacitracin closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin followed by Mastisol and Steri Strips The patient tolerated the procedure well He was awakened extubated and taken to recovery room in satisfactory condition Keywords neurosurgery chloraprep distal shunt revision colorado needle tip colorado needle progav valve shunt revision ventricular catheter catheter shunt ventricular MEDICAL_TRANSCRIPTION,Description Anterior spine fusion from T11 L3 Posterior spine fusion from T3 L5 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft Medical Specialty Neurosurgery Sample Name Spine Fusion Transcription PREOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis POSTOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis PROCEDURES 1 Anterior spine fusion from T11 L3 2 Posterior spine fusion from T3 L5 3 Posterior spine segmental instrumentation from T3 L5 placement of morcellized autograft and allograft ESTIMATED BLOOD LOSS 500 mL FINDINGS The patient was found to have a severe scoliosis This was found to be moderately corrected Hardware was found to be in good positions on AP and lateral projections using fluoroscopy INDICATIONS The patient has a history of severe neurogenic scoliosis He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression Risks and benefits were discussed at length with the family over many visits They wished to proceed PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position General anesthesia was induced without incident He was given a weight adjusted dose of antibiotics Appropriate lines were then placed He had a neuromonitoring performed as well He was then initially placed in the lateral decubitus position with his left side down and right side up An oblique incision was then made over the flank overlying the 10th rib Underlying soft tissues were incised down at the skin incision The rib was then identified and subperiosteal dissection was performed The rib was then removed and used for autograft placement later The underlying pleura was then split longitudinally This allowed for entry into the pleural space The lung was then packed superiorly with wet lap The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine Once the spine was achieved subperiosteal dissection was performed over the visualized vertebral bodies This required cauterization of the segmental vessels Once the subperiosteal dissection was performed to the posterior and anterior extents possible the diskectomies were performed These were performed from T11 L3 This was over 5 levels Disks and endplates were then removed Once this was performed morcellized rib autograft was placed into the spaces The table had been previously bent to allow for easier access of the spine This was then straightened to allow for compression and some correction of the curvature The diaphragm was then repaired as was the pleura overlying the thoracic cavity The ribs were held together with 1 Vicryl sutures Muscle layers were then repaired using a running 2 0 PDS sutures and the skin was closed using running inverted 2 0 PDS suture as well Skin was closed as needed with running 4 0 Monocryl This was dressed with Xeroform dry sterile dressings and tape The patient was then rotated into a prone position The spine was prepped and draped in a standard fashion Longitudinal incision was made from T2 L5 The underlying soft tissues were incised down at the skin incision Electrocautery was then used to maintain hemostasis The spinous processes were then identified and the overlying apophyses were split This allowed for subperiosteal dissection over the spinous processes lamina facet joints and transverse processes Once this was completed the C arm was brought in which allowed for easy placement of screws in the lumbar spine These were placed at L4 and L5 The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum This was done using a rongeur as well as a Kerrison rongeur Spinous processes were then harvested for morcellized autograft Once all the interspaces were prepared Songer wires were then passed These were placed from L3 T3 Once the wires were placed a unit rod was then positioned This was secured initially at the screws distally on both the left and right side The wires were then tightened in sequence from the superior extent to the inferior extent first on the left sided spine where I was operating and then on the right side spine This allowed for excellent correction of the scoliotic curvature Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin This was done using pulsed lavage The wound was then closed in layers The deep fascia was closed using running 1 PDS suture subcutaneous tissue was closed using running inverted 2 0 PDS suture the skin was closed using 4 0 Monocryl as needed The wound was then dressed with Steri Strips Xeroform dry sterile dressings and tape The patient was awakened from anesthesia and taken to the intensive care unit in stable condition All instrument sponge and needle counts were correct at the end of the case The patient will be managed in the ICU and then on the floor as indicated Keywords neurosurgery anterior spine fusion posterior spine fusion spine segmental instrumentation dry sterile dressings autograft and allograft pds sutures spinous processes spine fusion spine instrumentation morcellized allograft fusion autograft MEDICAL_TRANSCRIPTION,Description Thoracic right sided discectomy at T8 T9 The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 Medical Specialty Neurosurgery Sample Name Thoracic Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8 T9 OPERATION PERFORMED Thoracic right sided discectomy at T8 T9 BRIEF HISTORY AND INDICATION FOR OPERATION The patient is a 53 year old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8 T9 She has failed conservative measures and sought operative intervention for relief of her symptoms For details of workup please see the dictated operative report DESCRIPTION OF OPERATION Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected Second check was made prior to prepping and draping Following this we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8 T9 level We then made an approach through a midline incision and came out over the pars We dissected down carefully to identify the pars We then went on the outside of the pars and identified the foramen and then we took another series of x rays to confirm the T8 T9 level We did this under live fluoroscopy We confirmed T8 T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars The pars was then drilled out We identified the disc even further and found the disc herniation material that was under the spinal cord We then took a combination of small pituitaries and removed the disc material without difficulty Once we had disc material out we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further Once we had done that we inspected up by the nerve root found some more disc material there and removed that as well We could trace the nerve root out freely and easily We made sure there was no evidence of further disc material We used an Epstein curette and placed a nerve hook under the nerve root The Epstein curette removed some more disc material Once we had done this we were satisfied with the decompression We irrigated the wound copiously to make sure there is no further disc material and then ready for closure We did place some steroid over the nerve root and readied for closure Hemostasis was meticulous The wound was closed with 1 Vicryl suture for the fascial layer 2 Vicryl suture for the skin and Monocryl and Steri Strips applied Dressing was applied The patient was awoken from anesthesia and taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 150 mL COMPLICATIONS None DISPOSITION To PACU in stable condition having tolerated the procedure well to mobilize routinely when she is comfortable to go to her home Keywords neurosurgery thoracic right sided discectomy herniated nucleus pulposus discectomy thoracic herniated MEDICAL_TRANSCRIPTION,Description Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma Medical Specialty Neurosurgery Sample Name Pterional Craniotomy Transcription PREOPERATIVE DIAGNOSIS Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm POSTOPERATIVE DIAGNOSIS Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm OPERATION Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma ANESTHESIA Endotracheal ESTIMATED BLOOD LOSS 250 mL REPLACEMENTS 3 units of packed cells DRAINS None COMPLICATIONS None PROCEDURE With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest turned 45 degrees to the patient s left and a small roll placed under her right shoulder and hip the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient s zygoma Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture attached with rubber bands and Allis clamps The bone flap which had not been fixed in place was removed An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool B1 attached to the Midas Rex instrumentation Further bone removal was accomplished with Leksell rongeur and hemostasis controlled with the use of bone wax At this point a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex The sylvian fissure was then dissected with the dissection description being dictated by Dr X Following successful splitting of the sylvian fissure to its apparent midplate attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of what appeared to be an aneurysm could be visualized Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm this was felt to be able to be handled with bipolar coagulation which was done and the vessel then cut with microscissors and the aneurysm removed in toto Attention was next turned to the apparent nidus of the arteriovenous malformation which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr X With removal of the arteriovenous malformation attention was then turned to the previous frontal cortical incision which was the site of partial decompression of the patient s intracerebral hematoma on the day of her admission Self retaining retractors were placed within this cortical incision and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation Following removal of additional hematoma the bed of the hematoma site was lined with Surgicel Irrigation revealed no further active bleeding and it was felt that at this time both the arteriovenous malformation associated aneurysm and intracerebral hematoma had been sequentially dealt with The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges the freeze dried fascia which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2 holed plate and 3 mm screws and the portable minidriver With this return of the inferior plate accomplished it was possible to reposition the bone flaps into their initial configuration and attachments were secured anterior and posterior with somewhat longer 2 holed plates and 3 mm screws to the frontal and posterior temporal parietal region The wound was then closed It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap The wound was then closed by approximating the temporalis muscle with 2 0 Vicryl suture the fascia was closed with 2 0 Vicryl suture and the galea was closed with 2 0 interrupted suture and the skin approximated with staples The patient appeared to tolerate the procedure well without complications Keywords neurosurgery hemorrhage arteriovenous malformation aneurysm pterional craniotomy bone flap bipolar coagulation arteriovenous pterional malformation hematoma intracerebral MEDICAL_TRANSCRIPTION,Description Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus Medical Specialty Neurosurgery Sample Name Pituitary Adenomectomy Transcription PREOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma POSTOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma OPERATION PERFORMED Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus harvesting of dermal fascia abdominal fat graft placement of abdominal fat graft into sella turcica reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm repair of nasal septal deviation using the operating microscope and microdissection technique and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion INDICATIONS FOR PROCEDURE This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor which is known to be an invasive pituitary adenoma He did not return for followup or radiotherapy as instructed and the tumor has regrown For this reason he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible The high risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him Many risks including CSF leak and blindness were discussed in detail After clear understanding of all the same he elected to proceed ahead with surgery PROCEDURE The patient was placed on the operating table and after adequate induction of general anesthesia he was placed in the left lateral decubitus position Care was taken to pad all pressure points appropriately The back was prepped and draped in usual sterile manner A 14 gauge Tuohy needle was introduced into the lumbar subarachnoid space Clear and colorless CSF issued forth A catheter was inserted to a distance of 40 cm and the needle was removed The catheter was then connected to a closed drainage system for aspiration and infusion This no touch technique is now a standard of care for treatment of patients with large invasive adenomas Via injections through the lumbar drain one increases intracranial pressure and produces gentle migration of the tumor This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus The patient was then placed supine and the 3 point headrest was affixed He was placed in the semi sitting position with the head turned to the right and a roll placed under the left shoulder Care was taken to pad all pressure points appropriately The fluoroscope C arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection The metallic arm was then connected to the table for the use of the endoscope The oropharynx nasopharynx and abdominal areas were then prepped and draped in the usual sterile manner A transverse incision was made in the abdominal region and several large pieces of fat were harvested for later use Hemostasis was obtained The wound was carefully closed in layers I then advanced a 0 degree endoscope up the left nostril The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium Needle Bovie electrocautery was used to clear mucosa away from the ostium The perpendicular plate of the ethmoid had already been separated from the sphenoid I entered into the sphenoid There was a tremendous amount of dense fibrous scar tissue present and I slowly and carefully worked through all this I identified a previous sellar opening and widely opened the bone which had largely regrown out to the cavernous sinus laterally on the left which was very well exposed and the cavernous sinus on the right which I exposed the very medial portion of The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present The operating microscope was then utilized Working under magnification I used hypophysectomy placed in the nostril The dura was then carefully opened in the midline and I immediately encountered tissue consistent with pituitary adenoma A frozen section was obtained which confirmed this diagnosis without malignant features Slowly and meticulously I worked to remove the tumor I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free The tumor was moderately vascular and very fibrotic Slowly and carefully I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right There appeared to be cavernous sinus invasion on the left It was consistent with what we saw on the MRI imaging The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter A large amount of this was removed There was a CSF leak as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free Under high magnification I actually worked up into this cavity and performed a very radical excision of tumor While there may be a small amount of tumor remaining it appeared that a radical excision had been created with decompression of the optic apparatus In fact I reinserted the endoscope and could see the optic chiasm well I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression Attention was therefore turned to closure The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained I asked Anesthesiology to perform a Valsalva maneuver and there was no evidence of bleeding Attention was turned to closure and reconstruction I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air Using a polypropylene insert I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm DuraSeal was placed over this and the sphenoid sinus was carefully packed with fat and DuraSeal I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation The middle turbinates were then restored to their anatomic position There was no significant intranasal bleeding and for this reason an open nasal packing was required Sterile dressings were applied and the operation was terminated The patient tolerated the procedure well and left to the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisting of tumor Keywords MEDICAL_TRANSCRIPTION,Description Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end Medical Specialty Neurosurgery Sample Name Shunt Revision 3 Transcription PREOPERATIVE DIAGNOSIS Blocked ventriculoperitoneal shunt POSTOPERATIVE DIAGNOSIS Blocked ventriculoperitoneal shunt PROCEDURE Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end ANESTHESIA General HISTORY The patient is nonverbal He is almost 3 years old He presented with 2 months of irritability vomiting and increasing seizures CT scan was not conclusive but shuntogram shows no flow through the shunt DESCRIPTION OF PROCEDURE After induction of general anesthesia the patient was placed supine on the operating room table with his head turned to the left Scalp was clipped He was prepped on the head neck chest and abdomen with ChloraPrep Incisions were infiltrated with 0 5 Xylocaine with epinephrine 1 200 000 He received oxacillin He was then reprepped and draped in a sterile manner The frontal incision was reopened and extended along the valve Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts I separated the ventricular catheter from the valve and this was a medium pressure small contour Medtronic valve There was some flow from the ventricular catheter but not as much as I would expect I removed the right angled clip with a curette and then pulled out the ventricular catheter and there was gushing of CSF under high pressure So I do believe that the catheter was obstructed although inspection of the old catheter holes did not show any specific obstructions A new Codman BACTISEAL catheter was placed through the same hole I replaced it several times because I wanted to be sure it was in the cavity It entered easily and there was still just intermittent flow of CSF The catheter irrigated very well and seemed to be patent I tested the distal system with an irrigation filled feeding tube and there was excellent flow through the distal valve and catheter So I did not think it was necessary to replace those at this time The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve The valve connection was secured to the pericranium with a 2 0 Ethibond suture The wound was irrigated with bacitracin irrigation The shunt pumped and refilled well The wound was then closed with 4 0 Vicryl interrupted galeal suture and Steri Strips on the skin It was uncertain whether this will correct the problem or not but we will continue to evaluate If his abdominal pressure is too high then he may need a different valve This will be determined over time but at this time the shunt seemed to empty and refill easily The patient tolerated the procedure well No complications Sponge and needle counts were correct Blood loss was minimal None replaced Keywords neurosurgery bactiseal bactiseal catheter codman bactiseal blocked ventriculoperitoneal shunt ventriculoperitoneal shunt revision ventricular catheter shunt revision ventriculoperitoneal shunt catheter ventriculoperitoneal ventricular shunt MEDICAL_TRANSCRIPTION,Description Endoscopic proximal shunt revision Medical Specialty Neurosurgery Sample Name Shunt Revision 1 Transcription PREOPERATIVE DIAGNOSIS Shunt malfunction The patient with a ventriculoatrial shunt POSTOPERATIVE DIAGNOSIS Shunt malfunction The patient with a ventriculoatrial shunt ANESTHESIA General endotracheal tube anesthesia INDICATIONS FOR OPERATION Headaches fluid accumulating along shunt tract FINDINGS Partial proximal shunt obstruction TITLE OF OPERATION Endoscopic proximal shunt revision SPECIMENS None COMPLICATIONS None DEVICES Portnoy ventricular catheter OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner The old right frontal scalp incision was reopened in a curvilinear manner and the Bactiseal ventricular catheter was identified as it went into the right frontal horn The distal end of the VA shunt was flushed and tested with heparinized saline found to be patent and it was then clamped Endoscopically the proximal end was explored and we found debris within the lumen and then we were able to freely move the catheter around We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract which were going into the catheter consistent with partial proximal obstruction A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before but would take a gentle curve going into the right lateral ventricle It flushed in quite well was left at about 6 5 cm to 7 cm and connected to the existing straight connector and secured with 2 0 Ethibond sutures The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3 0 Vicryl for the galea and a 4 0 running Monocryl for the scalp followed by Mastisol and Steri Strips The patient was awakened and extubated having tolerated the procedure well without complications It should be noted that the when we were irrigating through the ventricular catheter fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest Keywords neurosurgery ventriculoatrial shunt endoscopic proximal shunt revision endoscopic proximal shunt portnoy ventricular catheter shunt malfunction shunt revision ventricular catheter shunt endoscopic ventricular proximal catheter MEDICAL_TRANSCRIPTION,Description Application of PMT large halo crown and vest Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion Medical Specialty Neurosurgery Sample Name PMT Halo Crown Vest Transcription PREOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion POSTOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion and potentially unstable cervical spine OPERATIVE PROCEDURE Application of PMT large halo crown and vest ESTIMATED BLOOD LOSS None ANESTHESIA Local conscious sedation with Morphine and Versed COMPLICATIONS None Post fixation x rays nonalignment no new changes Post fixation neurologic examination normal CLINICAL HISTORY The patient is a 41 year old female who presented to me with severe cervical spondylosis and myelopathy She was referred to me by Dr X The patient underwent a complicated anterior cervical discectomy 2 level corpectomy spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate Surgery had gone well and the patient has done well in the last 2 days She is neurologically improved and is moving all four extremities No airway issues It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller She was consented for the procedure and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest The patient had this procedure done at the bedside in the SICU room 1 I used a combination of some morphine 1 mg and Versed 2 mg for this procedure I also used local anesthetic with 1 Xylocaine and epinephrine a total of 15 to 20 cc PROCEDURE DETAILS The patient s head was positioned on some towels the retroauricular region was shaved and the forehead and the posterolateral periauricular regions were prepped with Betadine A large PMT crown was brought in and fixed to the skull with pins under local anesthetic Excellent fixation achieved It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae I then put the vest on by sitting the patient up stabilizing her neck The vest was brought in from the front as well and connected Head was tilted appropriately slightly extended and in the midline All connections were secured and pins were torqued and tightened During the procedure the patient did fine with no significant pain Post procedure she is neurologically intact and she remained intact throughout X rays of the cervical spine AP lateral and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes The patient will be subjected to a CT scan to further define the alignment and barring any problems she will be ambulating with the halo on The patient will undergo pin site care as per protocol and likely she will go in the next 2 to 3 days Her prognosis indeed is excellent and she is already about 90 or so better from her surgery She is also on a short course of Decadron which we will wean off in due course The matter was discussed with the patient and the patient s family Keywords neurosurgery cervical spondylosis anterior cervical discectomy corpectomy decompression fusion pmt crown vest pmt halo cervical MEDICAL_TRANSCRIPTION,Description Bilateral endoscopic proximal shunt revision and a distal shunt revision Medical Specialty Neurosurgery Sample Name Shunt Revision Transcription TITLE OF OPERATION Bilateral endoscopic proximal shunt revision and a distal shunt revision INDICATIONS FOR OPERATION Headaches full subtemporal site PREOPERATIVE DIAGNOSIS Slit ventricle syndrome POSTOPERATIVE DIAGNOSIS Slit ventricle syndrome FINDINGS Coaptation of ventricles against proximal end of ventricular catheter ANESTHESIA General endotracheal tube anesthesia DEVICES A Codman Hakim programmable valve with Portnoy ventricular catheter a 0 20 proGAV valve with a shunt assist of 20 cm dual right angled connector and a flushing reservoir BRIEF NARRATIVE OF OPERATIVE PROCEDURE After satisfactory general endotracheal tube anesthesia was administered the patient was positioned on the operating table in the prone position with the head held on a soft foam padding The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0 25 Marcaine with 1 200 000 epinephrine after routine prepping and draping Both U shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir which might have been leading to the coaptation of the ventricles The patient also had a right subtemporal depression which was full preoperatively The entire old apparatus was dissected out We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted They were both inspected No definite debris were seen After removing the ventricular catheters the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter On the right side we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location The old valve was dissected out and the proGAV valve with a 2 0 shunt assist was inserted and secured with a 2 0 Ethibond suture The proGAV valve was then connected to a Bactiseal distal tubing which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir All connections secured with 2 0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve which was set to an opening pressure of 8 and the other one being the Bactiseal tubing which was going towards the flushing reservoir All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin followed by Mastisol and Steri Strips The patient tolerated the procedure well without complications CSF was not sent off Keywords neurosurgery codman hakim portnoy slit ventricle syndrome shunt revision bilateral endoscopic proximal shunt coaptation of the ventricles portnoy ventricular catheter ventricular catheter progav valve flushing reservoir bactiseal tubing shunt ventricular bactiseal MEDICAL_TRANSCRIPTION,Description Placement of Scott cannula right lateral ventricle Medical Specialty Neurosurgery Sample Name Scott Cannula Transcription PROCEDURE Placement of Scott cannula right lateral ventricle DESCRIPTION OF THE OPERATION The right side of the head was shaved and the area was then prepped using Betadine prep Following an injection with Xylocaine with epinephrine a small 1 5 cm linear incision was made paralleling the midline lateral to the midline at the region of the coronal suture A twist drill was made with the hand drill through the dura A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF The Scott cannula was secured to the skin using 3 0 silk sutures This will be connected to external drainage set at 10 cm of water Keywords neurosurgery coronal suture twist drill lateral ventricle csf placement of scott cannula scott cannula scott cannulaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Leukemic meningitis Right frontal side inlet Ommaya reservoir The patient is a 49 year old gentleman with leukemia and meningeal involvement who was undergoing intrathecal chemotherapy Medical Specialty Neurosurgery Sample Name Ommaya reservoir Transcription TITLE OF OPERATION Right frontal side inlet Ommaya reservoir INDICATION FOR SURGERY The patient is a 49 year old gentleman with leukemia and meningeal involvement who was undergoing intrathecal chemotherapy Recommendation was for an Ommaya reservoir Risks and benefits have been explained They agreed to proceed PREOP DIAGNOSIS Leukemic meningitis POSTOP DIAGNOSIS Leukemic meningitis PROCEDURE DETAIL The patient was brought to the operating room underwent induction of laryngeal mask airway positioned supine on a horseshoe headrest The right frontal region was prepped and draped in the usual sterile fashion Next a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line Once this was completed a burr hole was then created with a high speed burr The dura was then coagulated and opened The Ommaya reservoir catheter was inserted up to 6 5 cm There was good flow This was connected to the side inlet flat bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision This was then cut and __________ It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies Wound was then irrigated copiously with __________ irrigation closed using 3 0 Vicryl for the deep layers and 4 0 Caprosyn for the skin The connection was made with a 3 0 silk suture and was a right angle intermediate to hold the catheter in place Keywords neurosurgery caprosyn leukemic meningitis ommaya reservoir leukemia meningeal intrathecal chemotherapy leukemic meningitis ommaya MEDICAL_TRANSCRIPTION,Description Transnasal transsphenoidal approach in resection of pituitary tumor The patient is a 17 year old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor Medical Specialty Neurosurgery Sample Name Pituitary Tumor Resection Transcription TITLE OF OPERATION Transnasal transsphenoidal approach in resection of pituitary tumor INDICATION FOR SURGERY The patient is a 17 year old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor She was started on Dostinex with increasing dosages The most recent MRI demonstrated an increased growth with hemorrhage This was then discontinued Most recent prolactin was at 70 although normalized the recommendation was surgical resection given the size of the sellar lesion All the risks benefits and alternatives were explained in great detail via translator PREOP DIAGNOSIS Pituitary tumor POSTOP DIAGNOSIS Pituitary tumor PROCEDURE DETAIL The patient brought to the operating room positioned on the horseshoe headrest in a neutral position supine The fluoroscope was then positioned The approach will be dictated by Dr X Once the operating microscope and the endoscope were then used to approach it through transnasal this was complicated and complex secondary to the drilling within the sinus Once this was ensured the tumor was identified separated from the pituitary gland it was isolated and then removed It appeared to be hemorrhagic and a necrotic pituitary several sections were sent Once this was ensured and completed and hemostasis obtained the wound was irrigated There might have been a small CSF leak with Valsalva so the recommendation was for a reconstruction Dr X will dictate The fat graft was harvested from the left lower quadrant and closed primarily this was soaked in fat and used to close the closure All sponge and needle counts were correct The patient was extubated and transported to the recovery room in stable condition Blood loss was minimal Keywords neurosurgery transnasal transsphenoidal approach resection pituitary tumor transsphenoidal transnasal prolactin tumor pituitary MEDICAL_TRANSCRIPTION,Description Botulinum toxin injection bilateral rectus femoris medial hamstrings and gastrocnemius soleus muscles phenol neurolysis of bilateral obturator nerves application of bilateral short leg fiberglass casts Medical Specialty Neurosurgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 3 Transcription PROCEDURE CODES 64640 times two 64614 time two 95873 times two 29405 times two PREOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 POSTOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s mom The patient was brought to minor procedures and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation Approximately 4 mL of 5 phenol was injected in this location bilaterally Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 50 units was injected in the rectus femoris bilaterally 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL After injections were performed bilateral short leg fiberglass casts were applied The patient tolerated the procedure well and no complications were encountered Keywords neurosurgery botulinum toxin injection bilateral toxin injection bilateral rectus neurolysis of bilateral obturator short leg fiberglass casts muscles phenol neurolysis botulinum toxin injection gastrocnemius soleus muscles short leg fiberglass femoris medial cerebral palsy active emg emg stimulation phenol neurolysis toxin injection rectus femoris gastrocnemius soleus soleus muscles obturator nerves leg fiberglass fiberglass casts botulinum toxin hamstrings gastrocnemius obturator nerves fiberglass casts muscles botulinum phenol bilateral injection toxin MEDICAL_TRANSCRIPTION,Description Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection Medical Specialty Neurosurgery Sample Name Neuroplasty Transcription PREOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment POSTOPERATIVE DIAGNOSES 1 Recurrent intractable low back and left lower extremity pain with history of L4 L5 discectomy 2 Epidural fibrosis with nerve root entrapment OPERATION PERFORMED Left L4 L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection ANESTHESIA Local IV sedation COMPLICATIONS None SUMMARY The patient in the operating room status post transforaminal epidurogram see operative note for further details Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen 375 units of Wydase was injected through each needle After two minutes 3 5 cc of 0 5 Marcaine and 80 mg of Depo Medrol was injected through each needle These needles were removed and the patient was discharged in stable condition Keywords neurosurgery nerve root decompression discectomy epidural fibrosis nerve root entrapment transforaminal neuroplasty neural foramen nerve root foramen neuroplasty transforaminal needle epidural MEDICAL_TRANSCRIPTION,Description Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles Medical Specialty Neurosurgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 2 Transcription PROCEDURES PERFORMED Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles PROCEDURE CODES 64640 times one 64614 times two 95873 times two PREOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 POSTOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient She was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse Approximately 6 mL of 5 phenol was injected in this location At all sites of phenol injections injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords neurosurgery femoris and vastus medialis intermedius and right pectoralis rectus femoris and vastus vastus medialis intermedius botulinum toxin injection medialis intermedius major muscles cerebral palsy active emg emg stimulation phenol neurolysis toxin injection obturator nerve rectus femoris pectoralis major botulinum toxin pectoralis botulinum phenol injection toxin MEDICAL_TRANSCRIPTION,Description Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation Medical Specialty Neurosurgery Sample Name Lumbar Re exploration Transcription PREOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation POSTOPERATIVE DIAGNOSIS Recurrent degenerative spondylolisthesis and stenosis at L4 5 and L5 S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation PROCEDURE Lumbar re exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4 5 and L5 S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4 5 and L5 S1 followed by placement of the pedicle screw fixation devices at L3 L4 L5 and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1 2 and then at L3 L4 L4 L5 and L5 S1 bilaterally DESCRIPTION OF PROCEDURE This is a 68 year old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2 She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area There was no evidence of infection on the imaging or with her laboratory studies In addition she developed a pretty profound stenosis at L4 L5 and L5 S1 that appeared to be recurrent as well She now presents for revision of her hardware extension of fusion and decompression The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia She was placed on the operative table in the prone position Back was prepared with Betadine iodine and alcohol We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it After these were removed it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase We then dressed the L4 L5 and L5 S1 levels which were profoundly stenotic This was a combination of scar and overgrown bone She had previously undergone bilateral hemilaminectomies at L4 5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels After completing this we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels We used 10 x 32 mm spacers at both L4 L5 and L5 S1 This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4 L5 and S1 tightened the pedicle screws in L3 This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level Once we placed the plate onto the screws and locked them in position we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4 L5 and L5 S1 and L3 L4 again the goal being to create a dorsal fusion and enhance the interbody fusion as well The wound was then irrigated copiously with bacitracin solution and then we closed in layers using 1 Vicryl in muscle and fascia 3 0 in subcutaneous tissue and approximated staples in the skin Prior to closing the skin we confirmed correct sponge and needle count We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies The Cell Saver blood was recycled and she was given two units of packed red blood cells as well I was present for and performed the entire procedure myself or supervised Keywords neurosurgery degenerative spondylolisthesis spondylolisthesis stenosis lumbar re exploration internal fixation plate hemilaminectomy diskectomy synthetic spacers pedicle screws fusion lumbar pedicle fixation hardware MEDICAL_TRANSCRIPTION,Description Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors Medical Specialty Neurosurgery Sample Name Phenol Neurolysis Botulinum Toxin Injection 1 Transcription PROCEDURES PERFORMED Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors PROCEDURE CODES 64640 times three 64614 times four 95873 times four PREOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 POSTOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s brother The patient was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation Approximately 7 mL was injected on the right side and 5 mL on the left side At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation Approximately 5 mL of 5 phenol was injected in this location Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified using active EMG stimulation Approximately 150 units was injected in the knee extensors bilaterally 100 units in the left pectoralis major and 50 units in the left wrist flexors Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords neurosurgery spastic quadriparesis emg stimulation emg botulinum toxin injection traumatic brain brain injury phenol neurolysis toxin injection musculocutaneous nerve obturator nerves pectoralis major wrist flexors knee extensors active emg botulinum toxin toxin injection stimulus neurolysis musculocutaneous extensors botulinum phenol MEDICAL_TRANSCRIPTION,Description Repair of nerve and tendon right ring finger and exploration of digital laceration Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger Medical Specialty Neurosurgery Sample Name Nerve Tendon Repair Finger Transcription PREOPERATIVE DIAGNOSIS Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury POSTOPERATIVE DIAGNOSES 1 Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis 2 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger PROCEDURE PERFORMED 1 Repair of nerve and tendon right ring finger 2 Exploration of digital laceration ANESTHESIA General ESTIMATED BLOOD LOSS Less than 10 cc TOTAL TOURNIQUET TIME 57 minutes COMPLICATIONS None DISPOSITION To PACU in stable condition BRIEF HISTORY OF PRESENT ILLNESS This is a 13 year old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger GROSS OPERATIVE FINDINGS After wound exploration it was found there was a 100 laceration to the ulnar digital neurovascular bundle The FDS had a partial ulnar slip laceration and the FDP had a 25 transverse laceration as well The radial neurovascular bundle was found to be completely intact OPERATIVE PROCEDURE The patient was taken to the operating room and placed in the supine position All bony prominences were adequately padded Tourniquet was placed on the right upper extremity after being packed with Webril but not inflated at this time The right upper extremity was prepped and draped in the usual sterile fashion The hand was inspected Palmar surface revealed approximally 0 5 cm laceration at the base of the right ring finger at the base of proximal phalanx which was approximated with nylon suture The sutures were removed and the wound was explored It was found that the ulnar digital neurovascular bundle was 100 transected The radial neurovascular bundle on the right ring finger was found to be completely intact We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25 laceration in a transverse fashion to the FDP We copiously irrigated the wound Repair was undertaken of the FDS with 3 0 undyed Ethibond suture The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact Attention during our repair at the flexor tendon the A1 pulley was incised for better visualization as well as better tendon excursion after repair Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury The digital nerve was dissected proximally and distally to likely visualize the nerve The nerve was then approximated using microvascular technique with 8 0 nylon suture The hands were well approximated The nerve was not under undue tension The wound was then copiously irrigated and the skin was closed with 4 0 nylon interrupted horizontal mattress alternating with simple suture Sterile dressing was placed and a dorsal extension Box splint was placed The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition Overall prognosis is good Keywords neurosurgery laceration flexor tendon volar laceration digital laceration ulnar slip flexor digitorum neurovascular bundle nerve injury ring finger neurovascular fds bundle tendon repair flexor digital ulnar MEDICAL_TRANSCRIPTION,Description Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots Right L4 S1 posterolateral fusion with local bone graft Left L4 through S1 segmental pedicle screw instrumentation Preparation harvesting of local bone graft Medical Specialty Neurosurgery Sample Name Laminotomy Facetectomy Foraminotomy Transcription PREOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis POSTOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis OPERATION PERFORMED 1 Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots 2 Right L4 L5 and right L5 S1 laminotomies medial facetectomies and foraminotomies decompression of right L5 and S1 nerve roots 3 Right L4 S1 posterolateral fusion with local bone graft 4 Left L4 through S1 segmental pedicle screw instrumentation 5 Preparation harvesting of local bone graft ANESTHESIA General endotracheal PREPARATION Povidone iodine INDICATION This is a gentleman with right sided lumbosacral radiculopathy MRI disclosed and lateral recess stenosis at the L4 5 L5 S1 foraminal narrowing in L4 and L5 roots The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain The patient understood major risks and complications such as death and paralysis seemingly rare main concern is a 10 to 15 of failure rate to respond to surgery for which further surgery may or may not be indicated small risk of wound infection spinal fluid leak The patient is understanding and agreed to proceed and signed the consent PROCEDURE The patient was brought to the operating room peripheral venous lines were placed General anesthesia was induced The patient was intubated Foley catheter was in place The patient laid prone onto the OSI table using 6 post pressure points were carefully padded the back was shaved sterilely prepped and draped A previous incision was infiltrated with local and incised with a scalpel The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4 L5 in the sacral ala Laminotomies were then performed at L4 L5 and L5 S1 in a similar fashion using Midas Rex drill with AM8 bit inferior portion of lamina below and superior portion of lamina above and the medial facet was drilled down to the thin shelf of bone The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison bone was harvested throughout to be used for bone grafting The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies L4 L5 roots were extensively decompressed Pars interarticularis were maintained Using angled 2 mm Kerrisons hypertrophied ligamentum flavum the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise Pedicle screws were placed L4 L5 and S1 on the right side Initial hole began with Midas Rex drill deepened with a gear shift and with 4 5 mm tap palpating with pedicle probe It showed no penetration outside the pedicle vertebral body At L4 L5 5 5 x 45 mm screws were placed and at S1 5 5 x 40 mm screw was placed Good bone purchase was obtained Gelfoam was placed over the roots laterally corticated transverse processes lateral facet joints were prepared small infuse sponge was placed posterolaterally on the right side then the local bone graft from L4 to S1 Traction was applied between the L4 L5 L5 S1 screws locking notes were tightened out heads were rotated fractured off about 2 3 mm traction were applied at each side further opening the foramen for the exiting roots Prior to placement of BMP the wound was irrigated with antibiotic irrigation Medium Hemovac drain was placed in the depth of wound brought out through a separate stab incision Deep fascia was closed with 1 Vicryl subcutaneous fascia with 1 Vicryl and subcuticular with 2 0 Vicryl Skin was stapled The drain was sutured in place with 2 0 Vicryl and connected to closed drain system The patient was laid supine on the bed extubated and taken to recovery room in satisfactory condition The patient tolerated the procedure well without apparent complication Final sponge and needle counts are correct Estimated blood loss 600 mL The patient received 200 mL of cell saver blood back Keywords neurosurgery lumbosacral radiculopathy lumbar spondylolysis laminotomies medial facetectomies foraminotomies decompression nerve roots fusion bone graft segmental pedicle screw transverse processes bone facetectomies transpedicular graft pedicle MEDICAL_TRANSCRIPTION,Description Microscopic assisted lumbar laminotomy with discectomy at L5 S1 on the left Herniated nucleus pulposus of L5 S1 on the left MEDICAL_TRANSCRIPTION,Description L1 laminotomy microdissection retrieval of foreign body retained lumbar spinal catheter attempted insertion of new external lumbar drain and fluoroscopy Medical Specialty Neurosurgery Sample Name Laminotomy Microdissection Transcription PREOPERATIVE DIAGNOSES 1 Fractured and retained lumbar subarachnoid spinal catheter 2 Pseudotumor cerebri benign intracranial hypertension PROCEDURES 1 L1 laminotomy 2 Microdissection 3 Retrieval of foreign body retained lumbar spinal catheter 4 Attempted insertion of new external lumbar drain 5 Fluoroscopy ANESTHESIA General HISTORY The patient had a lumbar subarachnoid drain placed yesterday All went well with the surgery The catheter stopped draining and on pulling back the catheter it fractured and CT scan showed that the remaining fragment is deep to the lamina The patient continues to have right eye blindness and headaches presumably from the pseudotumor cerebri DESCRIPTION OF PROCEDURE After induction of general anesthesia the patient was placed prone on the operating room table resting on chest rolls Her face was resting in a pink foam headrest Extreme care was taken positioning her because she weighs 92 kg There was a lot of extra padding for her limbs and her limbs were positioned comfortably The arms were not hyperextended Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance A Foley catheter was in place She received IV Cipro 400 mg because she is allergic to most antibiotics Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space The patient was then prepped and draped in a sterile manner A 7 cm incision was made over the L1 lamina The incision was carried down through the fascia all the way down to the spinous processes A self retaining McCullough retractor was placed The laminae were quite deep The microscope was brought in and using the Midas Rex drill with the AM 8 bit and removing some of the spinous process of L1 L2 with double action rongeurs the laminotomy was then done using the drill and great care was taken and using a 2 mm rongeur the last layer of lamina was removed exposing the epidural fat and dura The opening in the bone was 1 5 x 1 5 cm Occasionally bipolar cautery was used for bleeding of epidural veins but this cautery was kept to a minimum Under high magnification the dura was opened with an 11 blade and microscissors At first there was a linear incision vertically to the left of midline and I then needed to make a horizontal incision more towards the right The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus Microdissection under high magnification did not expose the catheter The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps The wound was irrigated with bacitracin irrigation At this point I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle Dr Y also tried Despite using the fluoroscope and our best attempts we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned It will be done at a later date I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location Under high magnification the dura was closed with 6 0 PDS interrupted sutures After the dura was closed a piece of Gelfoam was placed over the dura The paraspinous muscles were closed with 0 Vicryl interrupted sutures The subcutaneous fascia was also closed with 0 Vicryl interrupted suture The subcutaneous layer was closed with 2 0 Vicryl interrupted suture and the skin with 4 0 Vicryl Rapide The 4 0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room The patient tolerated procedure well No complications Sponge and needle counts correct Blood loss minimal none replaced This procedure took 5 hours This case was also extremely difficult due to patient s size and the difficulty of locating the catheter deep to the cauda equina Keywords neurosurgery laminotomy microdissection lumbar spinal catheter external lumbar drain fluoroscopy lumbar subarachnoid spinal catheter intracranial hypertension vicryl interrupted sutures lumbar catheter MEDICAL_TRANSCRIPTION,Description Lumbar puncture A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained Medical Specialty Neurosurgery Sample Name Lumbar Puncture 2 Transcription PROCEDURE PERFORMED Lumbar puncture The procedure benefits risks including possible risks of infection were explained to the patient and his father who is signing the consent form Alternatives were explained They agreed to proceed with the lumbar puncture Permit was signed and is on the chart The indication was to rule out toxoplasmosis or any other CNS infection DESCRIPTION The area was prepped and draped in a sterile fashion Lidocaine 1 of 5 mL was applied to the L3 L4 spinal space after the area had been prepped with Betadine three times A 20 gauge spinal needle was then inserted into the L3 L4 space Attempt was successful on the first try and several mLs of clear colorless CSF were obtained The spinal needle was then withdrawn and the area cleaned and dried and a Band Aid applied to the clean dry area COMPLICATIONS None The patient was resting comfortably and tolerated the procedure well ESTIMATED BLOOD LOSS None DISPOSITION The patient was resting comfortably with nonlabored breathing and the incision was clean dry and intact Labs and cultures were sent for the usual in addition to some extra tests that had been ordered The opening pressure was 292 the closing pressure was 190 Keywords neurosurgery spinal needle lumbar puncture lumbar gauge csf MEDICAL_TRANSCRIPTION,Description Lumbar puncture with moderate sedation Medical Specialty Neurosurgery Sample Name Lumbar Puncture 1 Transcription PROCEDURE Lumbar puncture with moderate sedation INDICATION The patient is a 2 year 2 month old little girl who presented to the hospital with severe anemia hemoglobin 5 8 elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test She was transfused with packed red blood cells Her hemolysis seemed to slow down She also on presentation had indications of urinary tract infection with urinalysis significant for 2 leukocytes positive nitrites 3 protein 3 blood 25 to 100 white cells 10 to 25 bacteria 10 to 25 epithelial cells on clean catch specimen Culture subsequently grew out no organisms however the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital She had a blood culture which was also negative She was empirically started on presentation with the cefotaxime intravenously Her white count on presentation was significantly elevated at 20 800 subsequently increased to 24 7 and then decreased to 16 6 while on antibiotics After antibiotics were discontinued she increased over the next 2 days to an elevated white count of 31 000 with significant bandemia metamyelocytes and myelocytes present She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI I discussed with The patient s parents prior to the procedure the lumbar puncture and moderate sedation procedures The risks benefits alternatives complications including but not limited to bleeding infection respiratory depression Questions were answered to their satisfaction They would like to proceed PROCEDURE IN DETAIL After time out procedure was obtained the child was given appropriate monitoring equipment including appropriate vital signs were obtained She was then given Versed 1 mg intravenously by myself She subsequently became sleepy the respiratory monitors end tidal cardiopulmonary and pulse oximetry were applied She was then given 20 mcg of fentanyl intravenously by myself She was placed in the left lateral decubitus position Dr X cleansed the patient s back in a normal sterile fashion with Betadine solution She inserted a 22 gauge x 1 5 inch spinal needle in the patient s L3 L4 interspace that was carefully identified under my direct supervision Clear fluid was not obtained initially needle was withdrawn intact The patient was slightly repositioned by the nurse and Dr X reinserted the needle in the L3 L4 interspace position the needle was able to obtain clear fluid approximately 3 mL was obtained The stylette was replaced and the needle was withdrawn intact and bandage was applied Betadine solution was cleansed from the patient s back During the procedure there were no untoward complications the end tidal CO2 pulse oximetry and other vitals remained stable Of note EMLA cream had also been applied prior procedure this was removed prior to cleansing of the back Fluid will be sent for a routine cell count Gram stain culture protein and glucose DISPOSITION The child returned to room on the medical floor in satisfactory condition Keywords neurosurgery moderate sedation lumbar puncture needle lumbar MEDICAL_TRANSCRIPTION,Description Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques and repair of CSF fistula microtechniques L5 S1 application of DuraSeal Lumbar stenosis and cerebrospinal fluid fistula Medical Specialty Neurosurgery Sample Name Lumbar Laminectomy Transcription PREOPERATIVE DIAGNOSIS Lumbar stenosis POSTOPERATIVE DIAGNOSES Lumbar stenosis and cerebrospinal fluid fistula TITLE OF THE OPERATION 1 Lumbar laminectomy for decompression with foraminotomies L3 L4 L4 L5 L5 S1 microtechniques 2 Repair of CSF fistula microtechniques L5 S1 application of DuraSeal INDICATIONS The patient is an 82 year old woman who has about a four month history now of urinary incontinence and numbness in her legs and hands and difficulty ambulating She was evaluated with an MRI scan which showed a very high grade stenosis in her lumbar spine and subsequent evaluation included a myelogram which demonstrated cervical stenosis at C4 C5 C5 C6 and C6 C7 as well as a complete block of the contrast at L4 L5 and no contrast at L5 S1 either and stenosis at L3 L4 and all the way up but worse at L3 L4 L4 L5 and L5 S1 Yesterday she underwent an anterior cervical discectomy and fusions C4 C5 C5 C6 C6 C7 and had some improvement of her symptoms and increased strength even in the recovery room She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation though she has been cardioverted She and her son understand the nature indications and risks of the surgery and agreed to go ahead PROCEDURE The patient was brought from the Neuro ICU to the operating room where general endotracheal anesthesia was obtained She was rolled in a prone position on the Wilson frame The back was prepared in the usual manner with Betadine soak followed by Betadine paint Markings were applied Sterile drapes were applied Using the usual anatomical landmarks linear midline incision was made presumed over L4 L5 and L5 S1 Sharp dissection was carried down into subcutaneous tissue then Bovie electrocautery was used to isolate the spinous processes A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5 S1 The incision was extended rostrally and deep Gelpi s were inserted to expose the spinous processes and lamina of L3 L4 L5 and S1 Using the Leksell rongeur the spinous processes of L4 and L5 were removed completely and the caudal part of L3 A high speed drill was then used to thin the caudal lamina of L3 all of the lamina of L4 and of L5 Then using various Kerrison punches I proceeded to perform a laminectomy Removing the L5 lamina there was a dural band attached to the ligamentum flavum and this caused about a 3 mm tear in the dura There was CSF leak The lamina removal was continued ligamentum flavum was removed to expose all the dura Then using 4 0 Nurolon suture a running locking suture was used to close the approximate 3 mm long dural fistula There was no CSF leak with Valsalva I then continued the laminectomy removing all of the lamina of L5 and of L4 removing the ligamentum flavum between L3 L4 L4 L5 and L5 S1 Foraminotomies were accomplished bilaterally The caudal aspect of the lamina of L3 also was removed The dura came up quite nicely I explored out along the L4 L5 and S1 nerve roots after completing the foraminotomies the roots were quite free Further more the thecal sac came up quite nicely In order to ensure no CSF leak we would follow the patient out of the operating room The dural closure was covered with a small piece of fat This was all then covered with DuraSeal glue Gelfoam was placed on top of this then the muscle was closed with interrupted 0 Ethibond The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion Scarpa s fascia was closed with a running 0 Vicryl and finally the skin was closed with a running locking 3 0 nylon The wound was blocked with 0 5 plain Marcaine ESTIMATED BLOOD LOSS Estimated blood loss for the case was about 100 mL SPONGE AND NEEDLE COUNTS Correct FINDINGS A very tight high grade stenosis at L3 L4 L4 L5 and L5 S1 There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis The patient tolerated the procedure well with stable vitals throughout Keywords neurosurgery microtechniques fistula duraseal foraminotomies lumbar stenosis cerebrospinal lumbar laminectomy ligamentum flavum csf laminectomy lamina MEDICAL_TRANSCRIPTION,Description Injection for myelogram and microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain Medical Specialty Neurosurgery Sample Name Lumbar Laminectomy Discectomy Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus L5 S1 on the left with severe weakness and intractable pain PROCEDURE PERFORMED 1 Injection for myelogram 2 Microscopic assisted lumbar laminectomy with discectomy at L5 S1 on the left on 08 28 03 BLOOD LOSS Approximately 25 cc ANESTHESIA General POSITION Prone on the Jackson table INTRAOPERATIVE FINDINGS Extruded nucleus pulposus at the level of L5 S1 HISTORY This is a 34 year old male with history of back pain with radiation into the left leg in the S1 nerve root distribution The patient was lifting at work on 08 27 03 and felt immediate sharp pain from his back down to the left lower extremity He denied any previous history of back pain or back surgeries Because of his intractable pain as well as severe weakness in the S1 nerve root distribution the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on After an informed consent was obtained all risks as well as complications were discussed with the patient PROCEDURE DETAIL He was wheeled back to Operating Room 5 at ABCD General Hospital on 08 28 03 After a general anesthetic was administered a Foley catheter was inserted The patient was then turned prone on the Jackson table All of his bony prominences were well padded At this time a myelogram was then performed After the lumbar spine was prepped a 20 gauge needle was then used to perform a myelogram The needle was localized to the level of L3 L4 region Once inserted into the thecal sac we immediately got cerebrospinal fluid through the spinal needle At this time approximately 10 cc of Conray injected into the thecal sac The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast The myelogram did reveal that there was some space occupying lesion most likely disc at the level of L5 S1 on the left There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C arm fluoroscopy At this point the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy A long spinal needle was then inserted into region of surgery on the right The surgery was going to be on the left Once the spinal needle was inserted a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5 S1 nerve root region At this time an approximately 2 cm skin incision was made over the lumbar region dissected down to the deep lumbar fascia At this time a Weitlaner was inserted Bovie cautery was used to obtain hemostasis We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left hand side At this time a Taylor retractor was then inserted and held there for retraction Suction as well as Bovie cautery was used to obtain hemostasis At this time a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression Once the laminotomy was performed a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots Once the ligamentum flavum was removed we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root which was compressive We removed the extruded disc with further freeing up of the S1 nerve root A nerve root retractor was then placed Identification of disc space was then performed A 15 blade was then inserted and small a key hole into the disc space was then performed with a 15 blade A small pituitary was then inserted within the disc space and more disc material was freed and removed The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc Once this was performed we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free At this time copious irrigation was used to irrigate the wound We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur At this time a small piece of Gelfoam was then used to cover the exposed nerve root We did not have any dural leaks during this case 1 0 Vicryl was then used to approximate the deep lumbar fascia 2 0 Vicryl was used to approximate the superficial lumbar fascia and 4 0 running Vicryl for the subcutaneous skin Sterile dressings were then applied The patient was then carefully slipped over into the supine position extubated and transferred to Recovery in stable condition At this time we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level Keywords neurosurgery microscopic assisted lumbar laminectomy discectomy nerve root lumbar laminectomy herniated nucleus thecal sac spinal needle nucleus pulposus disc space root nerve weakness lumbar laminectomy nucleus pulposus myelogram MEDICAL_TRANSCRIPTION,Description Left sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull Medical Specialty Neurosurgery Sample Name Hemicraniectomy Transcription TITLE OF OPERATION Left sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure INDICATION FOR SURGERY The patient is a patient well known to my service She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull I took her to the operating a few days ago for a large right sided hemicraniectomy to save her life I spoke with the family the mom especially about the risks benefits and alternatives of this procedure most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes I discussed with them that this was a life saving procedure and the family agreed to proceed with surgery as a level 1 We went to the operating room at that time and we did a very large right sided hemicraniectomy The patient was put in the intensive care unit We had placed also at that time a left sided intracranial pressure monitor both which we took out a few days ago Over the last few days the patient began to slowly deteriorate little bit on her clinical examination that is she was at first localizing briskly with the right side and that began to be less brisk We obtained a CT scan at this point and we noted that she had a fair amount of swelling in the left hemisphere with about 1 5 cm of midline shift At this point once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left sided very large hemicraniectomy with this __________ this was once again a life saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side PROCEDURE IN DETAIL The patient was taken to the operating room She was already intubated and under general anesthesia The head was put in a 3 pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right hand side down and the left hand side up since on the right hand side she did not have a bone flap which complicated matters a little bit so we had to use a 3 pin Mayfield headholder The patient tolerated this well We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery so we incorporated this incision into the new incision and to be able to open the skin on the left side we did a T shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin We connected this Prior to this we brought in all surgical instrumentation under sterile and standard conditions We opened the skin as in opening a book and then we also did a myocutaneous flap We brought in the muscle with it We had a very good exposure of the skull We identified all the important landmarks including the zygoma inferiorly the superior sagittal suture as well as posteriorly and anteriorly We had very good landmarks so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly a very large decompression of the left side At this point we opened the dura and the dura as soon as it was opened there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly All this was irrigated thoroughly Once we made sure we had absolutely great hemostasis without any complications we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely We had absolutely good hemostasis We put a piece of Gelfoam over the brain We had opened the dura in a cruciate fashion and the brain clearly bulging out despite of the fact that it was in the dependent position I went ahead and irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place This running nylon we put in place in order not to put any absorbables although I put a few 0 popoffs just to approximate the skin nicely Once we had done this irrigated thoroughly once again the skin We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit The EBL was about 200 cubic centimeters Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct No complications The patient went back to the intensive care unit Keywords neurosurgery large hemicraniectomy intracranial pressure multiple fractures skull traumatic brain injury mayfield headholder injury hemicraniectomyNOTE MEDICAL_TRANSCRIPTION,Description Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Medical Specialty Neurosurgery Sample Name Laminectomy Discectomy Facetectomy Transcription TITLE OF OPERATION Revision laminectomy L5 S1 discectomy L5 S1 right medial facetectomy preparation of disk space and arthrodesis with interbody graft with BMP INDICATIONS FOR SURGERY Please refer to medical record but in short the patient is a 43 year old male known to me status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain failed conservative therapy Risks and benefits of surgery were explained in detail including risk of bleeding infection stroke heart attack paralysis need for further surgery hardware failure persistent symptoms and death This list was inclusive but not exclusive An informed consent was obtained after all patient s questions were answered PREOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly POSTOPERATIVE DIAGNOSIS Severe lumbar spondylosis L5 S1 collapsed disk space hypermobility and herniated disk posteriorly ANESTHESIA General anesthesia and endotracheal tube intubation DISPOSITION The patient to PACU with stable vital signs PROCEDURE IN DETAIL The patient was taken to the operating room After adequate general anesthesia with endotracheal tube intubation was obtained the patient was placed prone on the Jackson table Lumbar spine was shaved prepped and draped in the usual sterile fashion An incision was carried out from L4 to S1 Hemostasis was obtained with bipolar and Bovie cauterization A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4 L5 and sacrum At this time laminectomy was carried out of L5 S1 Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space At this time the disk was entered with a 15 blade and bipolar The disk was entered with straight up and down biting pituitaries curettes and the high speed drill and we were able to takedown calcified herniated disk We were able to reestablish the disk space it was very difficult required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal very carefully holding the spinal canal out of harm s way as well as the exiting nerve root Once this was done we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic At this time Dr X will dictate the posterolateral fusion pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound There were no complications Keywords neurosurgery revision laminectomy discectomy facetectomy arthrodesis lumbar spondylosis hypermobility collapsed disk space medial facetectomy interbody graft herniated disk interbody laminectomy disk therapy lumbar herniated space MEDICAL_TRANSCRIPTION,Description Right frontotemporoparietal craniotomy evacuation of acute subdural hematoma Acute subdural hematoma right with herniation syndrome Medical Specialty Neurosurgery Sample Name Frontotemporoparietal Craniotomy Transcription PREOPERATIVE DIAGNOSES Acute subdural hematoma right with herniation syndrome POSTOPERATIVE DIAGNOSES Acute subdural hematoma right with herniation syndrome OPERATION PERFORMED Right frontotemporoparietal craniotomy evacuation of acute subdural hematoma ANESTHESIA General endotracheal PREPARATION Povidone INDICATION This is an 83 year old male with herniation syndrome with large subdural hematoma 100 This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery DESCRIPTION OF PROCEDURE The patient was brought to the operating room intubated The patient previously was given fresh frozen plasma plus recombinant activated factor VII The patient had a roll placed on his right shoulder head was maintained three point fixation with a Mayfield headholder The right side of the head was shaved thoroughly prepped and draped a large scalp incision was marked infiltrated with local and incised with a scalpel Raney clips were applied to the scalp margins hemostasis temporalis muscle and fascia pericranium opened and aligned with incision flap was reflected anteriorly Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator then using Midas Rex drill with a B1 foot plate a free flap was turned The dura was opened in a cruciate fashion acute subdural hematoma was evacuated There was a small arterial bleeder in the anterior parietal region which was controlled with bipolar electrocautery Using suction and biopsy forceps acute clot was resected from the frontotemporoparietal and occipital poles subdural space was irrigated no further bleeders were encountered Dura was closed with 4 0 Nurolon A subdural Camino ICP catheter was placed in the subdural space Bone flaps secured in place with neuro clips with 5 mm screws central pack up suture was placed dural tack up sutures were placed using 4 0 Nurolon prior to placement of the bone flap The wound was irrigated with saline temporalis muscle and fascia closed with 2 0 Vicryl subgaleal Hemovac was placed galea was closed with 2 0 Vicryl and scalp with staples ICP monitor and the Hemovac were sutured in place with 2 0 Vicryl The patient was taken out of the head holder a sterile dressing placed The head was wrapped The patient was taken directly to ICU still intubated in guarded condition Brain was nicely soft and pulsatile At the termination of the procedure no significant contusion of the brain was identified Final sponge and needle counts are correct Estimated blood loss 400 cc Keywords neurosurgery subdural hematoma craniotomy herniation subdural temporalis frontotemporoparietal hematoma MEDICAL_TRANSCRIPTION,Description Complete laminectomy L4 and facetectomy L3 L4 level A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level Posterior spinal instrumentation L4 to S1 using Synthes Pangea System Posterior spinal fusion L4 to S1 Insertion of morselized autograft L4 to S1 Medical Specialty Neurosurgery Sample Name Laminectomy Facetectomy Transcription PREOPERATIVE DIAGNOSIS Dural tear postoperative laminectomy L4 L5 POSTOPERATIVE DIAGNOSES 1 Dural tear postoperative laminectomy L4 L5 2 Laterolisthesis L4 L5 3 Spinal instability L4 L5 OPERATIONS PERFORMED 1 Complete laminectomy L4 2 Complete laminectomy plus facetectomy L3 L4 level 3 A dural repair right sided on the lateral sheath subarticular recess at the L4 pedicle level 4 Posterior spinal instrumentation L4 to S1 using Synthes Pangea System 5 Posterior spinal fusion L4 to S1 6 Insertion of morselized autograft L4 to S1 ANESTHESIA General ESTIMATED BLOOD LOSS 500 mL COMPLICATIONS None DRAINS Hemovac x1 DISPOSITION Vital signs stable taken to the recovery room in a satisfactory condition extubated INDICATIONS FOR OPERATION The patient is a 48 year old gentleman who has had a prior decompression several weeks ago He presented several days later with headaches as well as a draining wound He was subsequently taken back for a dural repair For the last 10 to 11 days he has been okay except for the last two days he has had increasing headaches has nausea vomiting as well as positional migraines He has fullness in the back of his wound The patient s risks and benefits have been conferred him due to the fact that he does have persistent spinal leak The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively PROCEDURE IN DETAIL After appropriate consent was obtained from the patient the patient was wheeled back to the operating theater room 7 The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties The patient was given intraoperative antibiotics The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion Initially a midline incision was made from the cephalad to caudad level Full thickness skin flaps were developed It was seen immediately that there was large amount of copious fluid emanating from the wound clear like fluid which was the cerebrospinal fluid Cultures were taken aerobic anaerobic AFB fungal Once this was done the paraspinal muscles were affected from the posterior elements It was seen that there were no facet complexes on the right side at L4 L5 and L5 S1 It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4 5 level from the listhesis Once this was done however the fluid emanating from the dura could not be seen appropriately Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left Complete laminectomy at L3 was done Once this was done within the subarticular recess on the right side at the L4 pedicle level a rent in the dura was seen Once this was appropriately cleaned the dural edges were approximated using a running 6 0 Prolene suture A Valsalva confirmed no significant lead after the repair was made There was a significant laterolisthesis at L4 L5 and due to the fact that there were no facet complexes at L5 S1 and L4 L5 on the right side as well as there was a significant concavity on the right L4 L5 disk space which was demonstrated from intraoperative x rays and compared to preoperative x rays it was decided from an instrumentation The lateral pedicle screws were placed at L4 L5 and S1 using the standard technique of Magerl After this the standard starting point was made Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall Once this was done this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall The screws were subsequently placed Tricortical purchase was obtained at S1 ________ appropriate size screws Precontoured titanium rod was then appropriately planned and placed between the screws at L4 L5 and S1 This was done on the right side first The screw was torqued at S1 appropriately and subsequently at L5 Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4 Neutral compression distraction was obtained on the left side Screws were torqued at L4 L5 and S1 appropriately Good placement was seen both in AP and lateral planes using fluoroscopy Laterolisthesis corrected appropriately at L4 and L5 Posterior spinal fusion was completed by decorticating the posterior elements at L4 L5 and the sacral ala with a curette Once good bleeding subchondral bone was appreciated the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix This was placed in the posterior lateral gutters DuraGen was then placed over the dural repair and after this fibrin glue was placed appropriately Deep retractors then removed from the confines of the wound Fascia was closed using interrupted Prolene running suture 1 Once this was done suprafascial drain was placed appropriately Subcutaneous tissues were opposed using a 2 0 Prolene suture The dermal edges were approximated using staples Wound was dressed sterilely using bacitracin ointment Xeroform 4 x 4 s and tape The drain was connected appropriately The patient was rolled on stretcher in usual supine position extubated uneventfully and taken back to the recovery room in a satisfactory stable condition No complications arose Keywords MEDICAL_TRANSCRIPTION,Description Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root Medical Specialty Neurosurgery Sample Name Hemilaminotomy Foraminotomy Transcription PRE AND POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy at C5 C6 OPERATION Left C5 6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root After informed consent was obtained from the patient he was taken to the OR After general anesthesia had been induced Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted At this point the patient s was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position The patient s posterior cervical area was then prepped and draped in the usual sterile fashion At this time the patient s incision site was infiltrated with 1 percent Lidocaine with epinephrine A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes which could be palpated After dissection down to a spinous process using Bovie cautery a clamp was placed on this spinous processes and cross table lateral x ray was taken This showed the spinous process to be at the C4 level Therefore further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified After the muscle was dissected off the lamina laterally on the left side self retaining retractors were placed and after hemostasis was achieved a Penfield probe was placed in the interspace presumed to be C5 6 and another cross table lateral x ray of the C spine was taken This film confirmed our position at C5 6 and therefore the operating microscope was brought onto the field at this time At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur However progress was limited because of thickness of the bone Therefore at this time the Midas Rex drill the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area After the bone had been thinned out further bone was removed using the Kerrison rongeur At this point the nerve root was visually inspected and observed to be decompressed However there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery After hemostasis was achieved the surgical site was copiously irrigated with Bacitracin Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches The subcutaneous layer was then reapproximated using 000 Dexon The skin was reapproximated using a running 000 nylon Sterile dressings were applied The patient was then extubated in the OR and transferred to the Recovery room in stable condition ESTIMATED BLOOD LOSS minimal Keywords neurosurgery foraminotomy with medial facetectomy facetectomy for microscopic decompression decompression of nerve root hemilaminotomy and foraminotomy decompression of nerve microscopic decompression medial facetectomy kerrison rongeur nerve root spinous processes facetectomy kerrison hemilaminotomy foraminotomy MEDICAL_TRANSCRIPTION,Description CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Medical Specialty Neurosurgery Sample Name Frameless Stereotactic Radiosurgery Transcription PREOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation POSTOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation PROCEDURE PERFORMED CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Please note no qualified resident was available to assist in the procedure INDICATION The patient is a 30 year old male with a right occipital AVM He was referred for stereotactic radiosurgery The risks of the radiosurgical treatment were discussed with the patient including but not limited to failure to completely obliterate the AVM need for additional therapy radiation injury radiation necrosis headaches seizures visual loss or other neurologic deficits The patient understands these risks and would like to proceed PROCEDURE IN DETAIL The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment He was placed on the treatment table The Aquaplast mask was constructed Initial imaging was obtained by the CyberKnife system The patient was then transported over to the CT scanner at Stanford Under the supervision of Dr X 125 mL of Omnipaque 250 contrast was administered Dr X then supervised the acquisition of 1 2 mm contiguous axial CT slices These images were uploaded over the hospital network to the treatment planning computer and the patient was discharged home Treatment plan was then performed by me I outlined the tumor volume Inverse treatment planning was used to generate the treatment plan for this patient This resulted in a total dose of 20 Gy delivered to 84 isodose line using a 12 5 mm collimator The maximum dose within this center of treatment volume was 23 81 Gy The volume treated was 2 972 mL and the treated lesion dimensions were 1 9 x 2 7 x 1 6 cm The volume treated at the reference dose was 98 The coverage isodose line was 79 The conformality index was 1 74 and modified conformality index was 1 55 The treatment plan was reviewed by me and Dr Y of Radiation Oncology and the treatment plan was approved On the morning of May 14 2004 the patient arrived at the Outpatient CyberKnife Suite He was placed on the treatment table The Aquaplast mask was applied Initial imaging was used to bring the patient into optimal position The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin He tolerated the procedure well He was given 8 mg of Decadron for prophylaxis and discharged home Followup will consist of an MRI scan in 6 months The patient will return to our clinic once that study is completed I was present and participated in the entire procedure on this patient consisting of CT guided frameless stereotactic radiosurgery for the right occipital AVM Dr X was present during the entire procedure and will be dictating his own operative note Keywords neurosurgery ct guided occipital cyberknife frameless stereotactic radiosurgery occipital arteriovenous malformation conformality index arteriovenous malformation malformation avm arteriovenous MEDICAL_TRANSCRIPTION,Description Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System Medical Specialty Neurosurgery Sample Name Decompressive Laminectomy Transcription PREOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression POSTOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression OPERATION PERFORMED Decompressive laminectomy at T12 with bilateral facetectomies decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click X System using 6 5 mm diameter x 40 mm length T11 screws and L1 screws 7 mm diameter x 45 mm length ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 400 mL replaced 2 units of packed cells Preoperative hemoglobin was less than 10 DRAINS None COMPLICATIONS None DESCRIPTION OF PROCEDURE With the patient prepped and draped in a routine fashion in the prone position on laminae support an x ray was taken and demonstrated a needle at the T12 L1 interspace An incision was made over the posterior spinous process of T10 T11 T12 L1 and L2 A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10 T11 T12 L1 and L2 An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent Initially on the patient s left side pedicle screws were placed in T11 and L1 The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle Placement confirmed with biplanar coaxial fluoroscopy The awl was in appropriate location and using a pedicle finder under fluoroscopic control the pedicle was probed to the mid portion of the body of T11 A 40 mm Click X screw 6 5 mm diameter with rod holder was then threaded into the T11 vertebral body Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra articular process was located using an AM 8 dissecting tool AM attachment to the Midas Rex instrumentation The area was decorticated an awl was placed and under fluoroscopic biplanar imaging noted to be at the pedicle in L1 Using a pedicle probe the pedicle was then probed to the mid body of L1 and a 7 mm diameter 45 mm in length Click X Synthes screw with rod holder was placed in the L1 vertebral body At this point an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient s ventral canal on the right side Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12 At this point a laminectomy was performed using 45 degree Kerrison rongeur both 2 mm and 4 mm and Leksell rongeur There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11 T12 interlaminar space Additionally there was marked instability of the facets bilaterally at T12 and L1 These facets were removed with 45 degree Kerrison rongeur and Leksell rongeur Bony compression both superiorly and laterally from fractured bony elements was removed with 45 degree Kerrison rongeur until the thecal sac was completely decompressed The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors and these nerve roots were noted to be completely free Hemostasis was controlled with bipolar coagulation At this point a Frazier dissector could be passed superiorly inferiorly medially and laterally to the T11 T12 nerve roots bilaterally and the thecal sac was noted to be decompressed both superiorly and inferiorly and noted to be quite pulsatile A 4 Penfield was then used to probe the floor of the spinal canal and no significant ventral compression remained on the thecal sac Copious antibiotic irrigation was used and at this point on the patient s right side pedicle screws were placed at T11 and L1 using the technique described for a left sided pedicle screw placement The anatomic landmarks being the transverse process at T11 the inferior articulating facet and the lateral aspect of the superior articular facet for T11 and at L1 the transverse process the junction of the intra articular process and the facet joint With the screws placed on the left side the elongated rod was removed from the patient s right side along with the locking caps which had been placed It was felt that distraction was not necessary A 75 mm rod could be placed on the patient s left side with reattachment of the locking screw heads with the rod cap locker in place however it was necessary to cut a longer rod for the patient s right side with the screws slightly greater distance apart ultimately settling on a 90 mm rod The locking caps were placed on the right side and after all 4 locking caps were placed the locking cap screws were tied to the cold weld Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11 T12 or T12 L1 with excellent positioning of the rods and screws A crosslink approximately 60 mm in width was then placed between the right and left rods and all 4 screws were tightened It should be noted that prior to the placement of the rods the patient s autologous bone which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11 T12 and L1 with AM 8 dissecting tool AM attachment as well as the lateral aspects of the facet joints This was done bilaterally prior to placement of the rods Following placement of the rods as noted above allograft bone chips were packed in addition on top of the patient s own allograft in these posterolateral gutters Gelfoam was used to cover the thecal sac and at this point the wound was closed by approximating the deep muscle with 0 Vicryl suture The fascia was closed with interrupted 0 Vicryl suture subcutaneous layer was closed with 2 0 Vicryl suture subcuticular layer was closed with 2 0 inverted interrupted Vicryl suture and the skin approximated with staples The patient appeared to tolerate the procedure well without complications Keywords neurosurgery facetectomies decompression posterolateral fusion synthes click x system decompressive laminectomy leksell rongeur kerrison rongeur transverse processes thecal sac nerve roots pedicle screws spinous process pedicle process screws rods laminectomy decompressive spinous MEDICAL_TRANSCRIPTION,Description Evacuation of epidural hematoma and insertion of epidural drain Epidural hematoma cervical spine Status post cervical laminectomy C3 through C7 postop day 10 Central cord syndrome and acute quadriplegia Medical Specialty Neurosurgery Sample Name Epidural Hematoma Evacuation Transcription PREOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia POSTOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia PROCEDURE PERFORMED 1 Evacuation of epidural hematoma 2 Insertion of epidural drain ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 200 cc HISTORY This is a 64 year old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction She was then transferred to Beaumont Hospital at which point she developed a sternal abscess The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren Michigan at which point she developed a second what was termed minor myocardial infarction The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later brings us to the month of August at which time she was at home ambulating with a walker or a cane and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI which showed record signal change The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery but objectively there was not much improvement Approximately 10 days after the surgery brings us to today s date the health officer was notified of the patient s labored breathing When she examined the patient she also noted that the patient was unable to move her extremities She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma On clinical examination there was swelling in the posterior aspect of the neck The patient has no active movement in the upper and lower extremity muscle groups Reflexes are absent in the upper and lower extremities Long track signs are absent Sensory level is at the C4 dermatome Rectal tone is absent I discussed the findings with the patient and also the daughter We discussed the possibility of this is permanent quadriplegia but at this time the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery OPERATIVE PROCEDURE The patient was taken to OR 1 at ABCD General Hospital on a gurney Department of Anesthesia administered fiberoptic intubation and general anesthetic A Foley catheter was placed in the bladder The patient was log rolled in a prone position on the Jackson table Bony prominences were well padded The patient s head was placed in the prone view anesthesia head holder At this point the wound was examined closely and there was hematoma at the caudal pole of the wound Next the patient was prepped and draped in the usual sterile fashion The previous skin incision was reopened At this point hematoma properly exits from the wound All sutures were removed and the epidural spaces were encountered at this time The self retaining retractors were placed in the depth of the wound Consolidated hematoma was now removed from the wound Next the epidural space was encountered There was no additional hematoma in the epidural space or on the thecal sac A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well Next the wound was irrigated copiously with one liter of saline using a syringe The walls of the wound were explored There was no active bleeding Retractors were removed at this time and even without pressure on the musculature there was no active bleeding A 19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space Fascia was reapproximated with 1 Vicryl sutures subcutaneous tissue with 3 0 Vicryl sutures Steri Strips covered the incision and dressing was then applied over the incision The patient was then log rolled in the supine position on the hospital gurney She remained intubated for airway precautions and transferred to the recovery room in stable condition Once in the recovery room she was alert She was following simple commands and using her head to nod but she did not have any active movement of her upper or lower extremities Prognosis for this patient is guarded Keywords neurosurgery epidural hematoma cervical spine cervical laminectomy central cord syndrome acute quadriplegia insertion of epidural drain epidural drain epidural space hematoma epidural cervical laminectomy quadriplegia MEDICAL_TRANSCRIPTION,Description Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor Medical Specialty Neurosurgery Sample Name Cystic Suprasellar Tumor Resection Transcription TITLE OF OPERATION Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor INDICATION FOR SURGERY She is a 3 year old girl who is known to have a head injury and CT in 2005 was normal presented with headache All endocrine labs were normal Surgery was recommended PREOP DIAGNOSIS Cystic suprasellar tumor POSTOP DIAGNOSIS Cystic suprasellar tumor PROCEDURE DETAIL The patient was brought to operating room underwent smooth induction of general endotracheal anesthesia head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended The patient was then prepped and draped in the usual sterile fashion With the assistance of fluoro and mapping the localization the right nostril was infiltrated Dr X will dictate the procedure of the approach Once the dura was visualized there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling Once the operating microscope was in the field at this point the drilling was completed The dura was opened in cruciate fashion revealing normal pituitary which was displaced and the cystic tumor This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down Once this was completed there was no evidence of any bleeding The endoscope was then used to remove any residual fragments __________ with the arachnoid Once this was completely ensured small piece of Duragel was placed and the closure will be dictated by Dr X She was reversed extubated and transported to the ICU in stable condition Blood loss minimal All sponge needle counts were correct Keywords neurosurgery microsurgical transnasal resection cystic suprasellar tumor transnasal resection endoscopic transnasal microsurgical suprasellar cystic tumor MEDICAL_TRANSCRIPTION,Description Left temporal craniotomy and removal of brain tumor Medical Specialty Neurosurgery Sample Name Craniotomy Temporal Transcription PREOPERATIVE DIAGNOSIS Brain tumor left temporal lobe POSTOPERATIVE DIAGNOSIS Brain tumor left temporal lobe glioblastoma multiforme OPERATIVE PROCEDURE 1 Left temporal craniotomy 2 Removal of brain tumor OPERATING MICROSCOPE Stealth PROCEDURE The patient was placed in the supine position shoulder roll and the head was turned to the right side The entire left scalp was prepped and draped in the usual fashion after having being placed in 2 point skeletal fixation Next we made an inverted U fashion base over the asterion over temporoparietal area of the skull A free flap was elevated after the scalp that was reflected using the burr hole and craniotome The bone flap was placed aside and soaked in the bacitracin solution The dura was then opened in an inverted U fashion Using the Stealth we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle We head through the vein of Labbe and we made great care to preserve this We saw where the tumor almost made to the surface Here we made a small corticectomy using the Stealth for guidance We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid This was submitted to pathology We biopsied this very abnormal tissue and submitted it to pathology They gave us a frozen section diagnosis of glioblastoma multiforme With the operating microscope and Greenwood bipolar forceps we then systematically debulked this tumor It was very vascular and we really continued to remove this tumor until all visible tumors was removed We appeared to get two gliotic planes circumferentially We could see it through the ventricle After removing all visible tumor grossly we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4 0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal The bone flap was then replaced and sutured with the Lorenz titanium plate system The muscle fascia galea was closed with interrupted 2 0 Vicryl sutures Skin staples were used for skin closure The blood loss of the operation was about 200 cc There were no complications of the surgery per se The needle count sponge count and the cottonoid count were correct COMMENT Operating microscope was quite helpful in this as we could use the light as well as the magnification to help us delineate the brain tumor gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic looking tumor of the brain Keywords neurosurgery temporal lobe brain tumor lorenz titanium plate burr hole cortex corticectomy craniotome craniotomy frozen section glioblastoma multiforme temporal craniotomy temporoparietal ventricle white matter tumor temporal brain MEDICAL_TRANSCRIPTION,Description Biparietal craniotomy insertion of left lateral ventriculostomy right suboccipital craniectomy and excision of tumor Medical Specialty Neurosurgery Sample Name Craniotomy Biparietal Transcription PREOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm POSTOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm TITLE OF THE OPERATION 1 Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer 2 Insertion of left lateral ventriculostomy under Stealth stereotactic guidance 3 Right suboccipital craniectomy and excision of tumor 4 Microtechniques for all the above 5 Stealth stereotactic guidance for all of the above and intraoperative ultrasound INDICATIONS The patient is a 48 year old woman with a diagnosis of breast cancer made five years ago A year ago she was diagnosed with cranial metastases and underwent whole brain radiation She recently has deteriorated such that she came to my office unable to ambulate in a wheelchair Metastatic workup does reveal multiple bone metastases but no spinal cord compression She had a consult with Radiation Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery but the lesions greater than 3 cm needed to be removed Consequently this operation is performed PROCEDURE IN DETAIL The patient underwent a planning MRI scan with Stealth protocol She was brought to the operating room with fiducial still on her scalp General endotracheal anesthesia was obtained She was placed on the Mayfield head holder and rolled into the prone position She was well padded secured and so forth The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint This was done only of course after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system Sterile drapes were applied and the accuracy of the system was confirmed A biparietal incision was performed A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation A biparietal craniotomy was carried out carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system The dura was opened and reflected back to the midline An inner hemispheric approach was used to reach the very large metastatic tumor This was very delicate removing the tumor and the co surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor The tumor was wrapped around and included the choroidal vessels At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region Bleeding was quite vigorous in some of the arteries and finally however was completely controlled Complete removal of the tumor was confirmed by intraoperative ultrasound Once the tumor had been removed and meticulous hemostasis was obtained this wound was left opened and attention was turned to the right suboccipital area A linear incision was made just lateral to the greater occipital nerve Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull A burr hole was placed down low using a craniotome A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor and this was draining CSF relieving pressure in the posterior fossa Upon opening the craniotomy in the parietal occipital region the brain was noted to be extremely tight thus necessitating placement of the ventriculostomy At the posterior fossa a corticectomy was accomplished and the tumor was countered directly The tumor as the one above was removed both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator A gross total excision of this tumor was obtained as well I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle however this was just over the lower cranial nerves and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss this lesion was left alone and to be radiated and that it is less than 3 cm in diameter Meticulous hemostasis was obtained for this wound as well The posterior fossa wound was then closed in layers The dura was closed with interrupted and running mattress of 4 0 Nurolon The dura was watertight and it was covered with blue glue Gelfoam was placed over the dural closure Then the muscle and fascia were closed in individual layers using 0 Ethibond Subcutaneous was closed with interrupted inverted 2 0 and 0 Vicryl and the skin was closed with running locking 3 0 Nylon For the cranial incision the ventriculostomy was brought out through a separate stab wound The bone flap was brought on to the field The dura was closed with running and interrupted 4 0 Nurolon At the beginning of the case dural tack ups had been made and these were still in place The sinuses both the transverse sinus and sagittal sinus were covered with thrombin soaked Gelfoam to take care of any small bleeding areas in the sinuses Once the dura was closed the bone flap was returned to the wound and held in place with the Lorenz microplates The wound was then closed in layers The galea was closed with multiple sutures of interrupted 2 0 Vicryl The skin was closed with a running locking 3 0 Nylon Estimated blood loss for the case was more than 1 L The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid Nevertheless her vitals remained stable throughout the case and we hopefully helped her survival and her long term neurologic status for this really nice lady Keywords neurosurgery metastatic lesion biparietal mayfield head holder microtechniques stealth craniotomy excision fiducial infratentorial parietooccipital stereotactic suboccipital subtentorial ventriculostomy lesions to the brain removal of the tumor parietal occipital region running locking nylon biparietal craniotomy posterior fossa tumor brain dura lesions MEDICAL_TRANSCRIPTION,Description Left retrosigmoid craniotomy and excision of acoustic neuroma Medical Specialty Neurosurgery Sample Name Craniotomy Retrosigmoid Transcription PREOPERATIVE DIAGNOSIS Left acoustic neuroma POSTOPERATIVE DIAGNOSIS Left acoustic neuroma PROCEDURE PERFORMED Left retrosigmoid craniotomy and excision of acoustic neuroma ANESTHESIA General OPERATIVE FINDINGS This patient had a 3 cm acoustic neuroma The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve The facial nerve was stimulated at the brainstem at 0 05 milliamperes at the conclusion of the dissections PROCEDURE IN DETAIL Following induction of adequate general anesthetic the patient was positioned for surgery She was placed in a lateral position and her head was maintained with Mayfield pins The left periauricular area was shaved prepped and draped in the sterile fashion Transdermal electrodes for continuous facial nerve EMG monitoring were placed and no response was verified The proposed incision was injected with 1 Xylocaine with epinephrine Next T shaped incision was made approximately 5 cm behind the postauricular crease The incision was undermined at the level of temporalis fascia and the portion of the fascia was harvested for further use Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax Bergen retractors were used to maintain exposure Using a cutting bur with continuous suction and irrigation of craniotomy was performed The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly From these structures approximately 4 x 4 cm a window of bone was removed Bone shavings were collected during the dissection and placed in Siloxane suspension for later use The bone flap was also left at the site for further use Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base Bone wax was used to occlude air cells lateral to the sigmoid sinus There was extensively aerated temporal bone At this point Dr Trask entered the case in order to open the dura and expose the tumor The cerebellum was retracted away from the tumor and the retractor was placed to help maintain exposure Once initial exposure was completed attention was directed to the posterior aspect of the temporal bone The dura was excised from around the porous acusticus extending posteriorly along the bone Then using diamond burs the internal auditory canal was dissected out The bone was removed laterally for distance of approximately 8 mm There was considerable aeration around the internal auditory canal as well The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult Therefore Dr Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor With dissection he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem The eighth nerve was identified and transected Tumor debulking allowed for retraction of the tumor capsule away from the brainstem The facial nerve was difficult to identify at the brainstem as well It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve Attention was then redirected to the internal auditory canal where this portion of the tumor was removed The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus At this point plane of dissection was again indistinct The tumor had been released from the porous and could be rotated The tumor was further debulked and thinned but could not crucially visualize the nerve on the anterior face of the tumor The nerve could be stimulated but was quite splayed over the anterior face Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve both proximally and distally However the cerebellopontine angle portion of the nerve was not usually delineated However the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness It was released from the brainstem ventrally The tumor was then cauterized with bipolar electrocautery The facial nerve was stimulated at the brainstem and stimulated easily at 0 05 milliamperes Overall the remaining tumor volume would be of small percentage of the original volume At this point Dr Trask re inspected the posterior fossa to ensure complete hemostasis The air cells around the internal auditory canal were packed off with muscle and bone wax A piece of fascia was then laid over the bone defect Next the dura was closed with DuraGen and DuraSeal The bone flap and bone were then placed in the bone defect Postauricular musculature was then reapproximated using interrupted 3 0 Vicryl sutures The skin was also closed using interrupted subdermal 3 0 Vicryl sutures Running 4 0 nylon suture was placed at the skin levels Sterile mastoid dressing was then placed The patient tolerated the procedure well and was transported to the PACU in a stable condition All counts were correct at the conclusion of the procedure ESTIMATED BLOOD LOSS 100 mL Keywords neurosurgery neuroma bergen retractors emissary veins mayfield pins acoustic acoustic neuroma cerebellopontine craniotomy facial nerve periauricular retrosigmoid retrosigmoid craniotomy internal auditory canal porous acusticus sigmoid sinus auditory canal bone brainstem nerve postauricular tumor MEDICAL_TRANSCRIPTION,Description Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA Medical Specialty Neurosurgery Sample Name Craniotomy Occipital Transcription PREOPERATIVE DIAGNOSIS Brain tumors multiple POSTOPERATIVE DIAGNOSES Brain tumors multiple adenocarcinoma and metastasis from breast PROCEDURE Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA PROCEDURE The patient was placed in the prone position after general endotracheal anesthesia was administered The scalp was prepped and draped in the usual fashion The CUSA was brought in to supplement the use of operating microscope as well as the stealth which was used to localize the tumor Following this we then made a transverse linear incision the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor The bone flap was elevated The ultrasound was then used The ultrasound showed the tumors directly I believe are in the interhemispheric fissure We noticed that the dura was quite tense despite that the patient had slight hyperventilation We gave 4 ounce of mannitol the brain became more pulsatile We then used the stealth to perform a ventriculostomy Once this was done the brain began to pulsate nicely We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus After having done this we then used operating microscope and slight self retaining retraction was used We obtained access to the tumor We biopsied this and submitted it This was returned as a malignant brain tumor metastatic tumor adenocarcinoma compatible with breast cancer Following this we then debulked this tumor using CUSA and then removed it in total After gross total removal of this tumor the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery The next step was after removal of this tumor closure of the wound a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates The tumors self extend into the ventricle and after we had removed the tumor we could see our ventricular catheter in the occipital horn of the ventricle This being the case we left this ventricular catheter in brought it out through a separate incision and connected to sterile drainage The next step was to close the wound after reapproximating the bone flap The galea was closed with 2 0 Vicryl and the skin was closed with interrupted 3 0 nylon sutures inverted with mattress sutures The sterile dressings were applied to the scalp The patient returned to the recovery room in satisfactory condition Hemodynamically remained stable throughout the operation Once again we performed occipital craniotomy total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy The tumor was removed using the combination of CUSA ultrasound stealth guided ventriculostomy and the patient will have a second operation today we will perform a selective craniectomy to remove another large tumor in the posterior fossa Keywords neurosurgery brain tumor cusa occipital adenocarcinoma bone flap craniotomy malignant metastatic scalp galea transverse linear incision ventriculostomy occipital craniotomy tumor stealth brain MEDICAL_TRANSCRIPTION,Description Right frontal craniotomy with resection of right medial frontal brain tumor Stereotactic image guided neuronavigation and microdissection and micro magnification for resection of brain tumor Medical Specialty Neurosurgery Sample Name Craniotomy Neuronavigation Transcription PROCEDURES 1 Right frontal craniotomy with resection of right medial frontal brain tumor 2 Stereotactic image guided neuronavigation for resection of tumor 3 Microdissection and micro magnification for resection of brain tumor ANESTHESIA General via endotracheal tube INDICATIONS FOR THE PROCEDURE The patient is a 71 year old female with a history of left sided weakness and headaches She has a previous history of non small cell carcinoma of the lung treated 2 years ago An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor After informed consent was obtained the patient was brought to the operating room for surgery PREOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift POSTOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift probable metastatic lung carcinoma DESCRIPTION OF THE PROCEDURE The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube She was positioned on the operating room table in the Sugita frame with the head secured Using the preoperative image guided MRI we carefully registered the fiducials and then obtained the stereotactic image guided localization to guide us towards the tumor We marked external landmarks Then we shaved the head over the right medial frontal area This area was then sterilely prepped and draped Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted A horseshoe shaped flap was based on the right and then brought across to the midline This was opened and hemostasis obtained using Raney clips The skin flap was retracted medially Two burr holes were made and were carefully connected One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap Hemostasis was obtained Using the neuronavigation we identified where the tumor was The dura was then opened based on a horseshoe flap based on the medial sinus We retracted this medially and carefully identified the brain The brain surface was discolored and obviously irritated consistent with the tumor We used the stereotactic neuronavigation to identify the tumor margins Then we used a bipolar to coagulate a thin layer of brain over the tumor Subsequently we entered the tumor The tumor itself was extremely hard Specimens were taken and send for frozen section analysis which showed probable metastatic carcinoma We then carefully dissected around the tumor margins Using the microscope we then brought microscopic magnification and dissection into the case We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly medially inferiorly and laterally Then using the Cavitron we cored out the central part of the tumor Then we collapsed the tumor on itself and removed it entirely In this fashion microdissection and magnification resection of the tumor was carried out We resected the entire tumor Neuronavigation was used to confirm that no further tumor residual was remained Hemostasis was obtained using bipolar coagulation and Gelfoam We also lined the cavity with Surgicel The cavity was nicely dry and excellent hemostasis was obtained The dura was closed using multiple interrupted 4 0 Nurolon sutures in a watertight fashion Surgicel was placed over the dural closure The bone flap was repositioned and held in place using CranioFIX cranial fixators The galea was re approximated and the skin was closed with staples The wound was dressed The patient was returned to the intensive care unit She was awake and moving extremities well No apparent complications were noted Needle and sponge counts were listed as correct at the end of the procedure Estimated intraoperative blood loss was approximately 150 mL and none was replaced Keywords neurosurgery stereotactic image guided neuronavigation micro magnification resection of brain tumor frontal craniotomy mass effect brain shift stereotactic image brain tumor brain tumor craniotomy endotracheal carcinoma neuronavigation microdissection MEDICAL_TRANSCRIPTION,Description Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain Medical Specialty Neurosurgery Sample Name Craniotomy Burr Hole Transcription PREOPERATIVE DIAGNOSIS Right chronic subdural hematoma POSTOPERATIVE DIAGNOSIS Right chronic subdural hematoma TYPE OF OPERATION Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS 100 cc OPERATIVE PROCEDURE In preoperative identification the patient was taken to the operating room and placed in supine position Following induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery Table was turned The right shoulder roll was placed The head was turned to the left and rested on a doughnut The scalp was shaved and then prepped and draped in usual sterile fashion Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss The parietal boss incision was opened It was about an inch and a half in length It was carried down to the skull Self retaining retractor was placed A bur hole was now fashioned with the perforator This was widened with a 2 mm Kerrison punch The dura was now coagulated with bipolar electrocautery It was opened in a cruciate type fashion The dural edges were coagulated back to the bony edges There was egress of a large amount of liquid Under pressure we irrigated for quite sometime until irrigation was returning mostly clear A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision It was secured with a 3 0 nylon suture The area was closed with interrupted inverted 2 0 Vicryl sutures The skin was closed with staples Sterile dressing was applied The patient was subsequently returned back to anesthesia He was extubated in the operating room and transported to PACU in satisfactory condition Keywords neurosurgery hematoma burr hole craniotomy frontotemporal frontotemporal craniotomy subdural subdural drain subdural hematoma subdural space MEDICAL_TRANSCRIPTION,Description Acute left subdural hematoma Left frontal temporal craniotomy for evacuation of acute subdural hematoma CT imaging reveals an acute left subdural hematoma which is hemispheric Medical Specialty Neurosurgery Sample Name Craniotomy Frontotemporal 1 Transcription PREOPERATIVE DIAGNOSIS Acute left subdural hematoma POSTOPERATIVE DIAGNOSIS Acute left subdural hematoma PROCEDURE Left frontal temporal craniotomy for evacuation of acute subdural hematoma DESCRIPTION OF PROCEDURE This is a 76 year old man who has a history of acute leukemia He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury His CT imaging reveals an acute left subdural hematoma which is hemispheric The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy The images were brought up on the electronic imaging and confirmed that this was a left sided condition He was fixed in a three point headrest His scalp was shaved and prepared with Betadine iodine and alcohol We made a small curved incision over the temporal parietal frontal region The scalp was reflected A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created After completing the bur hole flap the dura was opened and a gelatinous mass of subdural was peeled away from the brain The brain actually looked relatively relaxed and after removal of the hematoma the brain sort of slowly came back up We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline After we felt that we had an adequate decompression the dura was reapproximated and we filled the subdural space with saline We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates The scalp was reapproximated and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment Given that this actual skin looked good with apparent removal of about 80 of the subdural we elected to take patient to the Intensive Care Unit for further management I was present for the entire procedure and supervised this I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain Keywords neurosurgery subdural hematoma temporal craniotomy craniotomy subdural space bur hole subdural hematoma MEDICAL_TRANSCRIPTION,Description Bilateral orbital frontal zygomatic craniotomy skull base approach bilateral orbital advancement with C shaped osteotomies down to the inferior orbital rim with bilateral orbital advancement with bone grafts bilateral forehead reconstruction with autologous graft Medical Specialty Neurosurgery Sample Name Craniotomy Frontal Zygomatic Transcription PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly PROCEDURES 1 Bilateral orbital frontal zygomatic craniotomy skull base approach 2 Bilateral orbital advancement with C shaped osteotomies down to the inferior orbital rim with bilateral orbital advancement with bone grafts 3 Bilateral forehead reconstruction with autologous graft 4 Advancement of the temporalis muscle bilaterally 5 Barrel stave osteotomies of the parietal bones ANESTHESIA General PROCEDURE After induction of general anesthesia the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut Scalp was clipped He was prepped with ChloraPrep Incision was infiltrated with 0 5 Xylocaine with epinephrine 1 200 000 and he received antibiotics and he was then reprepped and draped in a sterile manner A bicoronal zigzag incision was made and Raney clips used for hemostasis Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly These were subgaleal flaps Bipolar and Bovie cautery were used for hemostasis The craniectomy was outlined with methylene blue The pericranium was incised exposing the bone along the outline of the craniotomy Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture One was just above the nasion and the other was near the bregma Also bilateral pterional bur holes were drilled There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes The dura was separated with a 4 Penfield dissector and then the craniotomies were fashioned or cut I should say with the Midas Rex drill using the V5 bit and the footplate attachment the bilateral craniotomies were cut and then the midline piece was elevated separately Great care was taken when removing the bone from the midline Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled The wound was irrigated with bacitracin irrigation The next step was to perform the orbital osteotomies with careful protection of the orbital contents Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally This was a very thick and vertically oriented orbital roof on each side Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet Bone wax was used for hemostasis It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit This was done with the Midas Rex drill using B5 bit Also the marked ridge just above the nasion was burred down with the Midas Rex drill The osteotomies were also carried down through the zygoma At this point with a gentle rocking motion and sustained pressure using the osteotomes it was then possible to carefully advance the orbital rims bilaterally first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally Dr X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim This created a shelf for the notched bone graft to lean against basically anteriorly The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly The left medial orbital rim greenstick fractured a bit but the bone graft appeared to stay in place Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with 3 0 Vicryl suture This helped fill in the indentation left by the orbital advancement at the temporal region Also I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel stave osteotomies in the parietal bones and then greenstick fractured these barrel staves outward to create a more normal contour of the bone slightly posteriorly At this point Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure The wound was then irrigated with bacitracin irrigation Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma At this point the reconstruction looked good The advancement was about 1 cm and we were pleased with the results The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with 4 0 and some 3 0 Vicryl interrupted suture and 5 0 mild chromic on the skin The patient tolerated procedure well No complications Sponge and needle counts were correct Again blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma Keywords neurosurgery metopic synostosis trigonocephaly bilateral orbital frontal zygomatic craniotomy skull base approach orbital advancement c shaped osteotomies forehead reconstruction temporalis muscle midas rex drill frontal zygomatic sagittal sinus orbital roof orbital rim bone grafts forehead bone orbital craniotomy osteotomies MEDICAL_TRANSCRIPTION,Description Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques Medical Specialty Neurosurgery Sample Name Craniotomy Frontotemporal Transcription PREOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma POSTOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma TITLE OF THE OPERATION Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques ASSISTANT None INDICATIONS The patient is a 75 year old man with a 6 week history of decline following a head injury He was rendered unconscious by the head injury He underwent an extensive syncopal workup in Mississippi This workup was negative The patient does indeed have a heart pacemaker The patient was admitted to ABCD three days ago and yesterday underwent a CT scan which showed a large appearance of subdural hematoma There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity The patient and the family understood the nature indications and risk of the surgery and agreed to go ahead DESCRIPTION OF PROCEDURE The patient was brought to the operating room where general and endotracheal anesthesia was obtained The head was turned over to the left side and was supported on a cushion There was a roll beneath the right shoulder The right calvarium was shaved and prepared in the usual manner with Betadine soaked scrub followed by Betadine paint Markings were applied Sterile drapes were applied A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia Weitlaner retractors were inserted A single bur hole was placed underneath the temporalis muscle I placed the craniotomy a bit low in order to have better cosmesis A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm The bone was set aside The dura was clearly discolored and very tense The dura was opened in a cruciate fashion with a 15 blade There was immediate flow of a thin motor oil fluid under high pressure Literally the fluid shot out several inches with the first nick in the membranous cavity The dura was reflected back and biopsy of the membranes was taken and sent for permanent section The margins of the membrane were coagulated The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none The dura was then closed in a watertight fashion using running locking 4 0 Nurolon Tack up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system The wound was irrigated thoroughly once more and was closed in layers Muscle fascia and galea were closed in separate layers with interrupted inverted 2 0 Vicryl Finally the skin was closed with running locking 3 0 nylon Estimated blood loss for the case was less than 30 mL Sponge and needle counts were correct FINDINGS Chronic subdural hematoma with multiple septations and thickened subdural membrane I might add that the arachnoid was not violated at all during this procedure Also it was noted that there was no subarachnoid blood but only subdural blood Keywords neurosurgery frontotemporal weitlaner calvarium cookie cutter type craniotomy dura frontotemporal craniotomy galea hematoma subdural subdural hematoma syncopal temporalis subacute subdural hematoma temporalis muscle MEDICAL_TRANSCRIPTION,Description Frontal craniotomy for placement of deep brain stimulator electrode Microelectrode recording of deep brain structures Intraoperative programming and assessment of device Medical Specialty Neurosurgery Sample Name Brain Stimulator Electrode Transcription PREOPERATIVE DIAGNOSIS Tremor dystonic form POSTOPERATIVE DIAGNOSIS Tremor dystonic form COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 mL ANESTHESIA MAC monitored anesthesia care with local anesthesia TITLE OF PROCEDURES 1 Left frontal craniotomy for placement of deep brain stimulator electrode 2 Right frontal craniotomy for placement of deep brain stimulator electrode 3 Microelectrode recording of deep brain structures 4 Stereotactic volumetric CT scan of head for target coordinate determination 5 Intraoperative programming and assessment of device INDICATIONS The patient is a 61 year old woman with a history of dystonic tremor The movements have been refractory to aggressive medical measures felt to be candidate for deep brain stimulation The procedure is discussed below I have discussed with the patient in great deal the risks benefits and alternatives She fully accepted and consented to the procedure PROCEDURE IN DETAIL The patient was brought to the holding area and to the operating room in stable condition She was placed on the operating table in seated position Her head was shaved Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50 50 mixture of 0 5 Marcaine and 2 lidocaine in all planes IV antibiotics were administered as was the sedation She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken The images were then transported to the surgery planned work station where a 3 D reconstruction was performed and the target coordinates were then chosen Target coordinates chosen were 20 mm to the left of the AC PC midpoint 3 mm anterior to the AC PC midpoint and 4 mm below the AC PC midpoint Each coordinate was then transported to the operating room as Leksell coordinates The patient was then placed on the operating table in a seated position once again Foley catheter was placed and she was secured to the table using the Mayfield unit At this point then the patient s right frontal and left parietal bossings were cleaned shaved and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes Sterile drapes placed around the perimeter of the field This same scalp region was then anesthetized with same local anesthetic mixture A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings Bur holes were created on either side of the midline just behind the coronal suture Hemostasis was controlled using bipolar and Bovie and self retaining retractors had been placed in the field Using the drill then two small grooves were cut in the frontal bone with a 5 mm cutting burs and Stryker drill The bur holes were then curetted free the dura cauterized and then opened in a cruciate manner on both sides with a 11 blade The cortical surface was then nicked with a 11 blade on both sides as well The Leksell arc with right sided coordinate was dialed in was then secured to the frame Microelectrode drive was secured to the arc Microelectrode recording was then performed The signatures of the cells were recognized Microelectrode unit was removed Deep brain stimulating electrode holding unit was mounted The DBS electrode was then loaded into target and intraoperative programming and testing was performed Using the screener box and standard parameters the patient experienced some relief of symptoms on her left side This electrode was secured in position using bur hole ring and cap system Attention was then turned to the left side where left sided coordinates were dialed into the system The microelectrode unit was then remounted Microelectrode recording was then undertaken After multiple passes the microelectrode unit was removed Deep brain stimulator electrode holding unit was mounted at the desired trajectory The DBS electrode was loaded into target and intraoperative programming and testing was performed once again using the screener box Using standard parameters the patient experienced similar results on her right side This electrode was secured using bur hole ring and cap system The arc was then removed A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel We then closed the electrode replaced subgaleally Copious amounts of Betadine irrigation were used Hemostasis was controlled using the bipolar only Closure was instituted using 3 0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples Sterile dressings were applied The Leksell arc was then removed She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition All needle sponge cottonoid and blade counts were correct x2 as verified by the nurses Keywords neurosurgery dystonic ac pc ct scan dbs electrode intraoperative programming microelectrode stereotactic tremor brain stimulator craniotomy device dystonic tremor electrode frontal screener box target coordinate volumetric deep brain stimulator electrode brain stimulator electrode volumetric ct stimulator brain MEDICAL_TRANSCRIPTION,Description Right sided craniotomy for evacuation of a right frontal intracranial hemorrhage Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull based brain tumor Medical Specialty Neurosurgery Sample Name Craniotomy Transcription TITLE OF OPERATION Right sided craniotomy for evacuation of a right frontal intracranial hemorrhage INDICATION FOR SURGERY The patient is very well known to our service In brief the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull based brain tumor He was taken to the operating room for the orbitozygomatic approach Intraoperatively everything went well without any complications The brain at the end of the procedure was absolutely intact but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan developed a second seizure He was given Ativan for this and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe what appeared to be a hemorrhagic conversion of potential venous infarct I had a long discussion immediately with Dr X and Dr Y We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component It worried me and I think that we needed to go ahead and take him to the operating room immediately The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure The original plan was to do first a right sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma PREOP DIAGNOSIS Pituitary tumor with a large intracranial component status post resection and now development of an intracranial hemorrhage POSTOP DIAGNOSIS Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach ANESTHESIA General PROCEDURE IN DETAIL The patient was taken to the operating room In the supine position his head was put in a horseshoe without any complications The patient tolerated this very well and the prior incision was immediately opened The surgery had taken place a few hours prior to this the original orbitozygomatic approach At this point this was a life saving procedure We went ahead opened the old incision after everything was sterilely prepped and all the surgical instrumentation was brought into place We went ahead and opened the incision and took out the pterional bone flap without any complications We immediately opened the dura expeditiously and the brain was moderately under some pressure but not really bulging out So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead and over the next few hours very meticulously began to evacuate these clots without any complication whatsoever We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications and we had a very nice resection The brain was very relaxed We had a very good resection of the actual blood clot and the brain was very relaxed We irrigated thoroughly We identified the ventricles We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure All this was done very well and then we lined the cavity with Surgicel and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle and then after this everything was good We went ahead and closed back the actual dura back We had done a pericranial flap This was also put back in place and the dura was closed with 4 0 Surgilons We reconstructed everything The frontal sinus was reconstructed thoroughly without any complications We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place and went ahead and put the bone flap back and reconstructed very nicely once again with self tapping self drilling screws low profile plates Once everything was confirmed to be in place we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop offs and the skin with staples without any complications In summary the procedure was going back to the operating room for evacuation of a right sided intracranial hemorrhage most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications So everything was stable Estimated blood loss was about 100 cubic centimeters The sponges and needle counts were correct No specimens were sent to pathology DISPOSITION The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation Keywords neurosurgery orbitozygomatic intracranial brain tumor intraparenchymal hematoma orbitozygomatic approach frontal lobe intracranial hemorrhage pituitary tumor craniotomy hemorrhage MEDICAL_TRANSCRIPTION,Description Bilateral carotid cerebral angiogram and right femoral popliteal angiogram Medical Specialty Neurosurgery Sample Name Bilateral Carotid Cerebral Angiogram Transcription PREOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease POSTOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease OPERATIONS PERFORMED 1 Bilateral carotid cerebral angiogram 2 Right femoral popliteal angiogram FINDINGS The right carotid cerebral system was selectively catheterized and visualized The right internal carotid artery was found to be very tortuous with kinking in its cervical portions but no focal stenosis was noted Likewise the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery The left carotid cerebral system was selectively catheterized and visualized The cervical portion of the left internal carotid artery showed a 30 to 40 stenosis with small ulcer crater present The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery Visualization of the right lower extremity showed no significant disease PROCEDURE With the patient in supine position under local anesthesia plus intravenous sedation the groin areas were prepped and draped in a sterile fashion The common femoral artery was punctured in a routine retrograde fashion and a 5 French introducer sheath was advanced under fluoroscopic guidance A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above Following completion of the above the catheter and introducer sheath were removed Heparin had been initially given which was reversed with protamine Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and sandbag compression The patient tolerated the procedure well throughout Keywords neurosurgery femoral popliteal angiogram carotid cerebral angiogram internal carotid artery carotid artery angiogram carotid cerebral artery MEDICAL_TRANSCRIPTION,Description Anterior cranial vault reconstruction with fronto orbital bar advancement Medical Specialty Neurosurgery Sample Name Cranial Vault Reconstruction Transcription INDICATION FOR OPERATION Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly PREOPERATIVE DIAGNOSIS Syndromic craniosynostosis POSTOPERATIVE DIAGNOSIS Syndromic craniosynostosis TITLE OF OPERATION Anterior cranial vault reconstruction with fronto orbital bar advancement SPECIMENS None DRAINS One subgaleal drain exiting from the left posterior aspect of wound DESCRIPTION OF PROCEDURE After satisfactory general endotracheal tube anesthesia was started the patient was placed on the operating table in supine position with the head held on a horseshoe shaped headrest and the head was prepped and draped down the routine manner Here the proposed scalp incision was infiltrated with 1 Xylocaine and then a zigzag scalp incision was made from one ear to the other ear posterior to the coronal suture Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion Using a craniotome several bur holes were made two on the either side of the midline posteriorly and then two posterolaterally The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right going paramedian along the superior sagittal sinus in the midline and then curving over the fronto orbital bar We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right which was abnormal The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs On the right the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof The orbital rim was then dissected out and then using the saw and chisels we were able to make the releasing cuts to free up the orbital rims zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate It was then replaced and advanced and then relaxing barrel staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position The bone flaps were then reapproximated using absorbable plates and screws as well as 2 0 Vicryl to secure back into place Some of the places were also secured in the midline posteriorly as well as off to the right where the bony defects were in place The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum The wounds were irrigated out A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast absorbing gut for the skin followed by sterile dressings The patient tolerated the procedure well and did receive blood transfusions Keywords neurosurgery coronal synostosis syndromic craniosynostosis craniosynostosis plagiocephaly fronto orbital bar cranial vault reconstruction cranial vault orbital bar orbital cranial MEDICAL_TRANSCRIPTION,Description Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate Severe low back pain Medical Specialty Neurosurgery Sample Name Anterior Lumbar Fusion Transcription PREOPERATIVE DIAGNOSIS Severe low back pain POSTOPERATIVE DIAGNOSIS Severe low back pain OPERATIONS PERFORMED Anterior lumbar fusion L4 L5 L5 S1 PEEK vertebral spacer structural autograft from L5 vertebral body BMP and anterior plate ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 50 mL DRAINS None COMPLICATIONS None PATHOLOGICAL FINDINGS Dr X made the approach and once we were at the L5 S1 disk space we removed the disk and we placed a 13 mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body This was filled with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug At L4 L5 we used a 13 mm PEEK vertebral spacer with structural autograft and BMP and then we placed a two level 87 mm Integra sacral plate with 28 x 6 mm screws two each at L4 and L5 and 36 x 6 mm screws at S1 OPERATION IN DETAIL The patient was placed under general endotracheal anesthesia The abdomen was prepped and draped in the usual fashion Dr X made the approach and once the L5 S1 disk space was identified we incised this with a knife and then removed a large core of bone taking rotating cutters I was able to remove additional disk space and score the vertebral bodies The rest of the disk removal was done with the curette scraping the endplates I tried various sized spacers and at this point we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20 mm Chronos VerteFill tricalcium phosphate plug Half of this was used to fill the spacer at L5 S1 BMP was placed in the spacer as well and then it was tapped into place We then moved the vessels over the opposite way approaching the L4 L5 disk space laterally and the disk was removed in a similar fashion and we also used a 13 mm PEEK vertebral spacer but this is the variety that we could put in from one side This was filled with bone and BMP as well Once this was done we were able to place an 87 mm Integra sacral plate down over the three vertebral bodies and place these screws Following this bleeding points were controlled and Dr X proceeded with the closure of the abdomen SUMMARY This is a 51 year old man who reports 15 year history of low back pain and intermittent bilateral leg pain and achiness He has tried multiple conservative treatments including physical therapy epidural steroid injections etc MRI scan shows a very degenerated disk at L5 S1 less so at L3 L4 and L4 L5 A discogram was positive with the lower 3 levels but he has pain which starts below the iliac crest and I feel that the L3 L4 disk is probably that symptomatic An anterior lumbar interbody fusion was suggested Procedure risks and complications were explained Keywords neurosurgery peek vertebral spacer autograft anterior lumbar fusion lumbar fusion vertebral body vertebral spacer vertebral spacer anterior lumbar fusion MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion C5 C6 utilizing Bengal cage Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Interbody Fusion 3 Transcription PREOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 POSTOPERATIVE DIAGNOSES 1 Spondylosis with cervical stenosis C5 C6 greater than C4 C5 C6 C7 721 0 723 0 2 Neck pain with left radiculopathy progressive 723 1 723 4 3 Headaches progressive 784 0 PROCEDURES 1 Anterior cervical discectomy at C5 C6 for neural decompression 63075 2 Anterior interbody fusion C5 C6 22554 utilizing Bengal cage 22851 3 Anterior cervical instrumentation at C5 C6 for stabilization by Uniplate construction at C5 C6 22845 with intraoperative x ray x2 SERVICE Neurosurgery ANESTHESIA Keywords neurosurgery spondylosis neck pain headaches decompression uniplate anterior cervical discectomy neural decompression cervical stenosis prevertebral space antibiotic solution cervical discectomy interbody fusion bengal cage interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description Bifrontal cranioplasty cranial defect greater than 10 cm in diameter in the frontal region Medical Specialty Neurosurgery Sample Name Bifrontal Cranioplasty Transcription PREOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region POSTOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region PROCEDURE Bifrontal cranioplasty ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS Nil INDICATIONS FOR PROCEDURE The patient is a 66 year old gentleman who has a history of prior chondrosarcoma that he had multiple resections for The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty After discussing the risks benefits and alternatives of surgery the decision was made to proceed with operative intervention in the form of a cranioplasty He had previously undergone a CT scan Premanufactured cranioplasty made for him that was sterile and ready to implant DESCRIPTION OF PROCEDURE After induction of adequate general endotracheal anesthesia an appropriate time out was performed We identified the patient the location of surgery the appropriate surgical procedure and the appropriate implant He was given intravenous antibiotics with ceftriaxone vancomycin and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis The scalp was prepped and draped in the usual sterile fashion A previous incision was reopened and the scalp flap was reflected forward We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap We freed up the bony edges circumferentially but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base We did explore laterally and saw a little bit of the mesh on the lateral orbit Once we had the bony edges explored we took the performed plate and secured it in a place with titanium plates and screws We had achieved good hemostasis The wound was closed in multiple layers in usual fashion over a Blake drain At the end of the procedure all sponge and needle counts were correct A sterile dressing was applied to the incision The patient was transported to the recovery room in good condition after having tolerated the procedure well I was personally present and scrubbed and performed supervised all key portions Keywords neurosurgery cranial defect frontal region bifrontal cranioplasty cranioplasty chondrosarcoma scalp flap bony edges bone flap bifrontal cranial endotracheal frontal MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 9 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 PROCEDURE Anterior cervical discectomy fusion C5 C6 followed by instrumentation C5 C6 with titanium dynamic plating system Aesculap Operating microscope was used for both illumination and magnification FIRST ASSISTANT Nurse practitioner PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion for anterior discectomy and fusion An incision was made midline to the anterior body of the sternocleidomastoid at C5 C6 level The skin subcutaneous tissue and platysma muscle was divided exposing the carotid sheath which was retracted laterally Trachea and esophagus were retracted medially After placing the self retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x rays we then proceeded with the discectomy We then cleaned out the disc at C5 C6 after incising the annulus fibrosis We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes and the next step was to clean out the disc space totally With this having been done we then turned our attention with the operating microscope to the osteophytes We drilled off the vertebral osteophytes at C5 C6 as well as the uncovertebral osteophytes This was removed along with the posterior longitudinal ligament After we had done this the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion We observed that there was a ____________ in the posterior longitudinal ligament There was a free fragment disc which had broken through the posterior longitudinal ligament just to the right of midline The next step was to obtain the bone from the back bone using cortical cancellous graft 10 mm in size after we had estimated the size That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor After we had tapped in the bone plug we then removed the distraction and the bone plug was fitting nicely We then use the Aesculap cervical titanium instrumentation with the 16 mm screws After securing the C5 C6 disc with four screws and titanium plate x rays showed good alignment of the spine good placement of the bone graft and after x rays showed excellent position of the bone graft and instrumentation we then placed in a Jackson Pratt drain in the prevertebral space brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and skin was closed with Steri Strips Blood loss during the operation was less than 10 mL No complications of the surgery Needle count sponge count and cottonoid count were correct Keywords neurosurgery aesculap titanium dynamic plating system anterior cervical discectomy herniated nucleus pulposus cervical discectomy operating microscope longitudinal ligament discectomy anterior instrumentation cervical titanium MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5 C6 utilizing Bengal cage Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Interbody Fusion 2 Transcription PREOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 POSTOPERATIVE DIAGNOSES 1 Large herniated nucleus pulposus C5 C6 with myelopathy 722 21 2 Cervical spondylosis 3 Cervical stenosis C5 C6 secondary to above 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 with spinal cord and spinal canal decompression 63075 2 Anterior interbody fusion at C5 C6 22554 utilizing Bengal cage 22851 3 Anterior instrumentation for stabilization by Uniplate construction C5 C6 22845 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected only in a subplatysmal manner bluntly and with only blunt dissection at the prevertebral space where a localizing intraoperative x ray was obtained once self retaining retractors were placed along the mesial edge of a cauterized longus colli muscle to protect surrounding tissues throughout the remainder of the case A prominent anterior osteophyte at C5 C6 was then localized compared to preoperative studies in the usual fashion intraoperatively and the osteophyte was excised with a rongeur and bony fragments saved This allowed for an annulotomy which was carried out with a 11 blade and discectomy removed with straight disc forceps portions of the disc which were sent to Pathology for a permanent section Residual osteophytes and disc fragments were removed with 1 and 2 mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace a sign of a decompressed status At no time during the case was evidence of CSF leakage and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation Once the decompression was inspected with a double ball dissector and all found to be completely decompressed and the dura bulged at the interspace and pulsated then a Bengal cage was filled with the patient s own bone elements and fusion putty and countersunk into position and was quite tightly applied Further stability was added nonetheless with an appropriate size Uniplate which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner The wound was inspected and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was Steri Stripped for reinforcement and a sterile dressing was applied incorporating a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner Once the sterile dressing was applied the patient was taken from the operating room to the recovery area having left in stable condition At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords neurosurgery herniated nucleus pulposus myelopathy cervical spondylosis cervical stenosis anterior instrumentation uniplate decompression anterior cervical discectomy spinal cord spinal canal sterile dressing interbody fusion bengal cage interbody cervical anterior discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy and moderate stenosis C5 6 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion Discharge Summary Transcription FINAL DIAGNOSES 1 Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy 2 Moderate stenosis C5 6 OPERATION On 06 25 07 anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray This is a 60 year old white male who was in the office on 05 01 07 because of neck pain with left radiculopathy and tension headaches In the last year or so he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right He has some neck pain at times and has seen Dr X for an epidural steroid injection which was very helpful More recently he saw Dr Y and went through some physical therapy without much relief Cervical MRI scan was obtained and revealed a large right sided disc herniation at C4 5 with significant midline herniations at C5 6 and a large left HNP at C6 7 In view of the multiple levels of pathology I was not confident that anything short of surgical intervention would give him significant relief The procedure and its risk were fully discussed and he decided to proceed with the operation HOSPITAL COURSE Following admission the procedure was carried out without difficulty Blood loss was about 125 cc Postop x ray showed good alignment and positioning of the cages plate and screws After surgery he was able to slowly increase his activity level with assistance from physical therapy He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck He also had some nausea with the PCA He had a low grade fever to 100 2 and was started on incentive spirometry Over the next 12 hours his fever resolved and he was able to start getting up and around much more easily By 06 27 07 he was ready to go home He has been counseled regarding wound care and has received a neck sheet for instruction He will be seen in two weeks for wound check and for a followup evaluation x rays in about six weeks He has prescriptions for Lortab 7 5 mg and Robaxin 750 mg He is to call if there are any problems Keywords neurosurgery slimlock herniated nucleuses pulposus anterior cervical discectomy bengal cages anterior herniated cervical radiculopathy discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression and anterior interbody fusion at C5 C6 and C6 C7 utilizing Bengal cages x2 Anterior instrumentation by Uniplate construction C5 C6 and C7 with intraoperative x ray x2 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 5 Transcription PREOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 POSTOPERATIVE DIAGNOSES 1 Cervical spondylosis C5 C6 greater than C6 C7 721 0 2 Neck pain progressive 723 1 with right greater than left radiculopathy 723 4 surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C5 C6 and C6 C7 for neural decompression 63075 63076 2 Anterior interbody fusion at C5 C6 and C6 C7 22554 22585 utilizing Bengal cages x2 22851 3 Anterior instrumentation by Uniplate construction C5 C6 and C7 22845 with intraoperative x ray x2 ANESTHESIA General OPERATIONS The patient was brought to the operating room and placed in the supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then with only blunt dissection the prevertebral space was encountered and localizing intraoperative x ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self retaining retractors for exposure of tissues Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5 C6 and then at C6 C7 with rongeur allowing for an annulotomy with an 11 blade through collapsed disc space at C5 6 and even more collapsed at C6 C7 Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels sending to Pathology in a routine fashion as disc specimen This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6 C7 removing large osteophytes and process residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well This allowed for the bulging into the interspace of the dura sign of decompressed status and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam Once hemostasis well achieved Bengal cage was filled with the patient s own bone elements of appropriate size and this was countersunk into position and quite tightly applied it at first C5 C6 then secondly at C6 C7 These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size The appropriate size screws and post placement x ray showed well aligned elements and removal of osteophytes etc The wound was again irrigated with antibiotic solution inspected and finally closed in a multiple layered closure by approximation of platysma with interrupted 3 0 Vicryl and the skin with subcuticular stitch of 4 0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin and later incorporated itself into sterile bandage Once the bandage was placed the patient was taken extubated from the operating room to the Recovery area having in stable but guarded condition At the conclusion of the case all instrument needle and sponge counts were accurate and correct There were no intraoperative complications of any type Keywords neurosurgery cervical spondylosis anterior cervical discectomy anterior instrumentation annulotomy kerrison rongeurs surgifoam vertebral space uniplate construction bengal cages neural decompression anterior cervical cervical discectomy interbody anterior cervical discectomy MEDICAL_TRANSCRIPTION,Description C4 C5 C5 C6 anterior cervical discectomy and fusion The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 7 Transcription PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PREOPERATIVE DIAGNOSIS C4 C5 C5 C6 stenosis PROCEDURE C4 C5 C5 C6 anterior cervical discectomy and fusion COMPLICATIONS None ANESTHESIA General INDICATIONS OF PROCEDURE The patient is a 62 year old female who presents with neck pain as well as upper extremity symptoms Her MRI showed stenosis at portion of C4 to C6 I discussed the procedure as well as risks and complications She wishes to proceed with surgery Risks will include but are not limited to infection hemorrhage spinal fluid leak worsened neurologic deficit recurrent stenosis requiring further surgery difficulty with fusion requiring further surgery long term hoarseness of voice difficulty swallowing medical anesthesia risk PROCEDURE The patient was taken to the operating room on 10 02 2007 She was intubated for anesthesia TEDS and boots as well as Foley catheter were placed She was placed in a supine position with her neck in neutral position Appropriate pads were also used The area was prepped and draped in usual sterile fashion Preoperative localization was taken _____ not changed Incision was made on the right side in transverse fashion over C5 vertebral body level This was made with a 10 blade knife and further taken down with pickups and scissors The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine Intraoperative x ray was taken Longus colli muscles were retracted laterally Caspar retractors were used Intraoperative x ray was taken I first turned by attention at C5 C6 interspace This was opened with 15 blade knife Disc material was taken out using pituitary as well as Kerrison rongeur Anterior aspects were taken down End plates were arthrodesed using curettes This was done under distraction Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur Bilateral foraminotomies were done At this point I felt that there was a good decompression The foramen appeared to be opened Medtronic cage was then encountered and sent few millimeters This was packed with demineralized bone matrix The distraction was then taken down The cage appeared to be strong This procedure was then repeated at C4 C5 A 42 mm AcuFix plate was then placed between C4 and C6 This was carefully screwed and locked The instrumentation appeared to be strong Intraoperative x ray was taken Irrigation was used Hemostasis was achieved The platysmas was closed with 3 0 Vicryl stitches The subcutaneous was closed with 4 0 Vicryl stitches The skin was closed with Steri strips The area was clean and dry and dressed with Telfa and Tegaderm Soft cervical collar was placed for the patient She was extubated per anesthesia and brought to the recovery in stable condition Keywords neurosurgery anterior cervical discectomy fusion infection hemorrhage spinal fluid leak anesthesia foley catheter teds anterior cervical cervical discectomy anterior cervical discectomy stenosis MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4 C5 C5 C6 and C6 C7 utilizing Bengal cages times three Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Interbody Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 greater than C6 C7 and C4 C5 with left radiculopathy 2 Cervical stenosis with cord compression C5 C6 723 0 with surgical findings confirmed PROCEDURES 1 Anterior cervical discectomy at C4 C5 C5 C6 and C6 C7 for neural decompression 63075 63076 63076 2 Anterior interbody fusion at C4 C5 C5 C6 and C6 C7 22554 22585 22585 utilizing Bengal cages times three 22851 3 Anterior instrumentation for stabilization by Slim LOC plate C4 C5 C6 and C7 22846 with intraoperative x ray times two ANESTHESIA General SERVICE Neurosurgery OPERATION The patient was brought into the operating room placed in a supine position where general anesthesia was administered Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma which was dissected in a subplatysmal manner and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border and self retaining retractors were placed to reveal the anterior osteophytic spaces Large osteophytes were excised with a rongeur at C4 5 C5 C6 and C6 C7 revealing a collapsed disc space and a 11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4 C5 then at C5 C6 then at C6 C7 sending specimen for permanent section to Pathology in a routine and separate manner Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament which was removed in a similar piecemeal fashion with 1 and 2 mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes widely laterally bilaterally at each interspace with one at C4 C5 more right sided The most prominent osteophyte and compression was at C5 C6 followed by C6 C7 and C4 C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels once the ligaments were proximally removed as well and similarly a sign of a decompressed status The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away Appropriate size Bengal cages were filled with the patient s own bone elements and countersunk into position filled along with fusion putty and once these were quite tightly applied and checked further stability was added by the placement of a Slim LOC plate of appropriate size with appropriate size screws and a post placement x ray showed well aligned elements The wound was irrigated with antibiotic solution again and inspected and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3 0 Vicryl and the skin with a subcuticular stitch of 4 0 Vicryl and this was sterilely dressed and incorporated a Penrose drain which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion At the conclusion of the case all instruments needle and sponge counts were accurate and correct and there were no intraoperative complications of any type Keywords neurosurgery herniated nucleus pulposus radiculopathy cervical stenosis anterior instrumentation stabilization slim loc neural decompression anterior cervical discectomy cord compression interbody fusion bengal cages interbody compression anterior fusion decompression discectomy cervical MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus C5 C6 with spinal stenosis Anterior cervical discectomy with fusion C5 C6 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 2 Transcription PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5 C6 with spinal stenosis PROCEDURE Anterior cervical discectomy with fusion C5 C6 PROCEDURE IN DETAIL The patient was placed in supine position The neck was prepped and draped in the usual fashion An incision was made from midline to the anterior border of the sternocleidomastoid in the right side Skin and subcutaneous tissue were divided sharply Trachea and esophagus were retracted medially Carotid sheath was retracted laterally Longus colli muscles were dissected away from the vertebral bodies of C5 C6 We confirmed our position by taking intraoperative x rays We then used the operating microscope and cleaned out the disk completely We then sized the interspace and then tapped in a 7 mm cortical cancellous graft We then used the DePuy Dynamic plate with 14 mm screws Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed in layers using 2 0 Vicryl for muscle and fascia The blood loss was less than 10 20 mL No complication Needle count sponge count and cottonoid count was correct Keywords neurosurgery carotid sheath jackson pratt drain anterior cervical discectomy herniated nucleus pulposus cervical discectomy herniated nucleus nucleus pulposus spinal stenosis discectomy fusion herniated nucleus pulposus spinal stenosis anterior MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy allograft fusion and anterior plating Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 8 Transcription PROCEDURES PERFORMED C5 C6 anterior cervical discectomy allograft fusion and anterior plating ESTIMATED BLOOD LOSS 10 mL CLINICAL NOTE This is a 57 year old gentleman with refractory neck pain with single level degeneration of the cervical spine and there was also some arm pain We decided go ahead with anterior cervical discectomy at C5 C6 and fusion The risks of lack of pain relief paralysis hoarse voice nerve injuries and infection were explained and the patient agreed to proceed DESCRIPTION OF PROCEDURE The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut He had tape placed over the shoulders during intraoperative x rays and his elbows were well padded The tape was placed and his arms were well padded He was prepped and draped in a sterile fashion A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle We then dissected sharply medial to carotid artery which we palpated to the prevertebral region We placed Caspar retractors for medial and lateral exposure over the C5 C6 disc space which we confirmed with the lateral cervical spine x ray including 18 gauge needle in the disc space We then marked the disc space We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space We then under magnification removed all the disc material we could possibly see down to bleeding bone and both the endplates We took down posterior longitudinal ligament as well We incised the 6 mm cornerstone bone We placed a 6 mm parallel medium bone nicely into the disc space We then sized a 23 mm plate We inserted the screws nicely above and below We tightened down the lock nuts We irrigated the wound We assured hemostasis using bone wax prior to placing the plate We then assured hemostasis once again We reapproximated the platysma using 3 0 Vicryl in a simple interrupted fashion The subcutaneous level was closed using 3 0 Vicryl in a simple buried fashion The skin was closed with 3 0 Monocryl in a running subcuticular stitch Steri Strips were applied Dry sterile dressing with Telfa was applied over this We obtained an intraoperative x ray to confirm the proper level and good position of both plates and screw construct on the lateral x ray and the patient was transferred to the recovery room moving all four extremities with stable vital signs I was present as a primary surgeon throughout the entire case Keywords neurosurgery allograft fusion anterior cervical discectomy neck pain cervical spine discectomy fusion sternocleidomastoid muscle assured hemostasis anterior cervical cervical discectomy disc space cervical anterior allograft MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression of spinal cord Anterior cervical fusion Anterior cervical instrumentation Insertion of intervertebral device Use of operating microscope Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 6 Transcription PREOPERATIVE DIAGNOSIS Symptomatic disk herniation C7 T1 FINAL DIAGNOSIS Symptomatic disk herniation C7 T1 PROCEDURES PERFORMED 1 Anterior cervical discectomy with decompression of spinal cord C7 T1 2 Anterior cervical fusion C7 T1 3 Anterior cervical instrumentation anterior C7 T1 4 Insertion of intervertebral device C7 T1 5 Use of operating microscope ANESTHESIOLOGY General endotracheal ESTIMATED BLOOD LOSS A 30 mL PROCEDURE IN DETAIL The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service He was placed in the supine position on an OR table His arms were carefully taped down He was sterilely prepped and draped in the usual fashion A 4 cm incision was made obliquely over the left side of his neck Subcutaneous tissue was dissected down to the level of the platysma The platysma was incised using electrocautery Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle This allowed us to get right down on to the anterior cervical spine Blunt dissection was done to sweep off the longus colli We isolated the C7 T1 interspace An x ray was taken to verify we were indeed at the C7 T1 interspace Shadow Line retractor was placed as well as Caspar pins This provided very very good access to the C7 T1 disk At this point the operating microscope was brought into the decompression A thorough and aggressive C7 T1 discectomy was done using a succession of curettes pituitary rongeur 4 mm cutting bur and a 2 Kerrison rongeur At the end of the discectomy the cartilaginous endplates were carefully removed using 4 mm cutting burr The posterior longitudinal ligament was carefully resected using 2 Kerrison rongeur Left sided C8 foraminotomy was accomplished using nerve hook and a 2 mm Kerrison rongeur At the end of the decompression there was no further compression on the left C8 nerve root A Synthes cortical cancellous ____________ bone was placed in the interspace Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed two in the body of C7 and two in the body of T1 An x ray was taken It showed good placement of the plate and screws A deep drain was placed The platysma layer was closed in running fashion using 1 Vicryl Subcutaneous tissue was closed in an interrupted fashion using 2 0 Vicryl Skin was closed in a running fashion using 4 0 Monocryl Steri Strips and dressings were applied All counts were correct There were no complications Keywords neurosurgery disk herniation cervical discectomy decompression spinal cord anterior cervical fusion anterior cervical discectomy kerrison rongeur anterior cervical instrumentation cervical anterior platysma kerrison fashion interspace rongeur discectomy herniation MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws Cervical spondylosis and herniated nucleus pulposus of C4 C5 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Arthrodesis 2 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 POSTOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4 C5 TITLE OF OPERATION Anterior cervical discectomy C4 C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with Synthes Vector plate and screws ESTIMATED BLOOD LOSS Less than 100 mL OPERATIVE PROCEDURE IN DETAIL After identification the patient was taken to the operating room and placed in supine position Following the induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position A preoperative x ray was obtained to identify the operative level and neck position An incision was marked at the C4 C5 level on the right side The incision was opened with 10 blade knife Dissection was carried down through subcutaneous tissues using Bovie electrocautery The platysma muscle was divided with the cautery and mobilized rostrally and caudally The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia This was opened with scissors and dissected rostrally and caudally with the peanut dissectors The operative level was confirmed with an intraoperative x ray The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5 Self retaining retractor was placed in submuscular position and distraction pins were placed in the vertebral bodies of C4 and C5 and distraction was instituted We then incise the annulus of C4 C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes Operating microscope was draped and brought into play Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch There was a transligamentous disc herniation which was removed during this process We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent Cord was seen to be pulsating freely behind the dura There appeared to be no complications and the decompression appeared adequate We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body An 8 mm lordotic trial was used and appeared perfect We then used a corticocancellous 8 mm lordotic graft This was tapped into position Distraction was released appeared to be in excellent position We then positioned an 18 mm Vector plate over the inner space Intraoperative x ray was obtained with the stay screw in place plates appeared to be in excellent position We then use a 14 mm self tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion All of the screws locked to the plate and this was confirmed on visual inspection Intraoperative x ray was again obtained Construct appeared satisfactory Attention was then directed to closure The wound was copiously irrigated All of the self retaining retractors were removed Bleeding points were controlled with bone wax and bipolar electrocautery The platysma layer was now closed with interrupted 3 0 Vicryl sutures The skin was closed with running 3 0 Vicryl subcuticular stitch Steri Strips were applied A sterile bandage was applied All sponge needle and cottonoid counts were reported as correct The patient tolerated the procedure well He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition Keywords neurosurgery synthes vector plate lordotic acf spacer corticocancellous arthrodesis anterior cervical discectomy herniated nucleus pulposus anterior cervical spacer screws discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure Cervical spondylotic myelopathy with cord compression and cervical spondylosis Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion Transcription PREOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis POSTOPERATIVE DIAGNOSES Cervical spondylotic myelopathy with cord compression and cervical spondylosis In addition to this he had a large herniated disk at C3 C4 in the midline PROCEDURE Anterior cervical discectomy fusion C3 C4 and C4 C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure PROCEDURE IN DETAIL The patient placed in the supine position the neck was prepped and draped in the usual fashion Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4 Skin subcutaneous tissue and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4 C5 It appeared that the C5 C6 disk area had fused spontaneously We then confirmed that position by taking intraoperative x rays and then proceeded to do discectomy and fusion at C3 C4 C4 C5 After placing distraction screws and self retaining retractors with the teeth beneath the bellies of the longus colli muscles we then meticulously removed the disk at C3 C4 C4 C5 using the combination of angled strip pituitary rongeurs and curettes after we had incised the anulus fibrosus with 15 blade Next step was to totally decompress the spinal cord using the operating microscope and high speed cutting followed by the diamond drill with constant irrigation We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments This was then removed with 2 mm Kerrison rongeur After we removed the posterior longitudinal ligament we could see the dura pulsating nicely We did foraminotomies at C3 C4 as well as C4 C5 as well After having totally decompressed both the cord as well as the nerve roots of C3 C4 C4 C5 we proceeded to the next step which was a fusion We sized two 8 mm cortical cancellous grafts and after distracting the bone at C3 C4 C4 C5 we gently tapped the grafts into place The distraction was removed and the grafts were now within We went to the next step for the procedure which was the instrumentation and stabilization of the fused area We then placed a titanium ABC plate from C3 C5 secured it with 16 mm titanium screws X rays showed good position of the screws end plate The next step was to place Jackson Pratt drain to the vertebral fascia Meticulous hemostasis was obtained The wound was closed in layers using 2 0 Vicryl for the subcutaneous tissue Steri Strips were used for skin closure Blood loss less than about 200 mL No complications of the surgery Needle counts sponge count and cottonoid count was correct Keywords neurosurgery titanium plates fixation bone black bone procedure anterior cervical discectomy titanium plates cervical discectomy spondylotic myelopathy cord compression cervical spondylosis foraminotomies cervical anterior MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusion C2 C3 C3 C4 Removal of old instrumentation C4 C5 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Fusion 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C2 C3 2 Spinal stenosis C3 C4 PROCEDURES 1 Anterior cervical discectomy C3 C4 C2 C3 2 Anterior cervical fusion C2 C3 C3 C4 3 Removal of old instrumentation C4 C5 4 Fusion C3 C4 and C2 C3 with instrumentation using ABC plates PROCEDURE IN DETAIL The patient was placed in the supine position The neck was prepped and draped in the usual fashion for anterior cervical discectomy A high incision was made to allow access to C2 C3 Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially This exposed the vertebral bodies of C2 C3 and C4 C5 which was bridged by a plate We placed in self retaining retractors With the tooth beneath the blades the longus colli muscles were dissected away from the vertebral bodies of C2 C3 C4 and C5 After having done this we used the all purpose instrumentation to remove the instrumentation at C4 C5 we could see that fusion at C4 C5 was solid We next proceeded with the discectomy at C2 C3 and C3 C4 with disc removal In a similar fashion using a curette to clean up the disc space and the space was fairly widened as well as drilling up the vertebral joints using high speed cutting followed by diamond drill bit It was obvious that the C3 C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis With the operating microscope however we had good visualization of these nerve roots and we were able to ___________ both at C2 C3 and C3 C4 We then placed the ABC 55 mm plate from C2 down to C4 These were secured with 16 mm titanium screws after excellent purchase We took an x ray which showed excellent position of the plate the screws and the graft themselves The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson Pratt drain was placed in the prevertebral space and brought out through a separate incision The wound was closed with 2 0 Vicryl for subcutaneous tissues and Steri Strips used to close the skin Blood loss was about 50 mL No complication of the surgery Needle count sponge count cottonoid count was correct The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb At the time of surgery he had total collapse of the C2 C3 and C4 disc with osteophyte formation At both levels he has high grade spinal stenosis at these levels especially foramen stenosis causing the compression neck pain headaches and arm and shoulder pain He does have degenerative changes at C5 C6 C6 C7 C7 T1 however they do not appear to be symptomatic although x rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form Keywords neurosurgery abc plates osteophyte cervical discectomy cervical fusion herniated nucleus pulposus anterior cervical discectomy nucleus pulposus vertebral bodies osteophyte formation spinal stenosis cervical discectomy anterior instrumentation vertebral stenosis fusion MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy with decompression anterior cervical fusion anterior cervical instrumentation and Allograft C5 C6 Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Decompression 1 Transcription PREOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 POSTOPERATIVE DIAGNOSES 1 Herniated disc C5 C6 2 Cervical spondylosis C5 C6 PROCEDURES 1 Anterior cervical discectomy with decompression C5 C6 2 Anterior cervical fusion C5 C6 3 Anterior cervical instrumentation C5 C6 4 Allograft C5 C6 ANESTHESIA General endotracheal COMPLICATIONS None PATIENT STATUS Taken to recovery room in stable condition INDICATIONS The patient is a 36 year old female who has had severe recalcitrant right upper extremity pain numbness tingling shoulder pain axial neck pain and headaches for many months Nonoperative measures failed to relieve her symptoms and surgical intervention was requested We discussed reasonable risks benefits and alternatives of various treatment options Continuation of nonoperative care versus the risks associated with surgery were discussed She understood the risks including bleeding nerve vessel damage infection hoarseness dysphagia adjacent segment degeneration continued worsening pain failed fusion and potential need for further surgery Despite these risks she felt that current symptoms will be best managed operatively SUMMARY OF SURGERY IN DETAIL Following informed consent and preoperative administration of antibiotics the patient was brought to the operating suite General anesthetic was administered The patient was placed in the supine position All prominences and neurovascular structures were well accommodated The patient was noted to have pulse in this position Preoperative x rays revealed appropriate levels for skin incision Ten pound inline traction was placed via Gardner Wells tongs and shoulder roll was placed The patient was then prepped and draped in sterile fashion Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease Subcutaneous tissue was dissected down to the level of the omohyoid which was transected Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally This was taken down to the prevertebral fascia which was bluntly split Intraoperative x ray was taken to ensure proper levels Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli thus placing no new traction on the surrounding vital structures Inferior spondylosis was removed with high speed bur A scalpel and curette was used to remove the disc Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally Disc herniation was removed from the right posterolateral aspect of the interspace High speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura No further evidence of compression was identified Hemostasis was achieved with thrombin soaked Gelfoam Interspace was then distracted with Caspar pin distractions set gently Interspace was then gently retracted with the Caspar pin distraction set An 8 mm allograft was deemed in appropriate fit This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit The graft was stable to pull out forces Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14 mm self drilling screws Plate and screws were then locked to the plate Final x rays revealed proper positioning of the plate excellent distraction in the disc space and apposition of the endplates and allograft Wounds were copiously irrigated with normal saline Omohyoid was approximated with 3 0 Vicryl Running 3 0 Vicryl was used to close the platysma Subcuticular Monocryl and Steri Strips were used to close the skin A deep drain was placed prior to wound closure The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition There were no intraoperative complications All needle and sponge counts were correct Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal Keywords neurosurgery cervical spondylosis cervical fusion decompression instrumentation anterior cervical discectomy anterior cervical herniated disc cervical discectomy anterior cervical fusion allograft discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy arthrodesis partial corpectomy Machine bone allograft placement of anterior cervical plate with a Zephyr MEDICAL_TRANSCRIPTION,Description Arthrodesis anterior interbody technique anterior cervical discectomy anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws implantation of machine bone implant Disc herniation with right arm radiculopathy Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy Arthrodesis 1 Transcription PREOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy POSTOPERATIVE DIAGNOSES C5 C6 disc herniation with right arm radiculopathy PROCEDURE 1 C5 C6 arthrodesis anterior interbody technique 2 C5 C6 anterior cervical discectomy 3 C5 C6 anterior instrumentation with a 23 mm Mystique plate and the 13 mm screws 4 Implantation of machine bone implant 5 Microsurgical technique ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 100 mL BACKGROUND INFORMATION AND SURGICAL INDICATIONS The patient is a 45 year old right handed gentleman who presented with neck and right arm radicular pain The pain has become more and more severe It runs to the thumb and index finger of the right hand and it is accompanied by numbness If he tilts his neck backwards the pain shoots down the arm If he is working with the computer it is very difficult to use his mouse He tried conservative measures and failed to respond so he sought out surgery Surgery was discussed with him in detail A C5 C6 anterior cervical discectomy and fusion was recommended He understood and wished to proceed with surgery Thus he was brought in same day for surgery on 07 03 2007 DESCRIPTION OF PROCEDURE He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR There general endotracheal anesthesia was induced He was positioned on the OR table with an IV bag between the scapulae The neck was slightly extended and taped into position A metal arch was placed across the neck and intraoperative x ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle The incision was extended through skin subcutaneous fat and platysma Hemostasis was assured with Bovie cautery The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6 C7 disk based on x rays and then around the C5 C6 disk space An intraoperative x ray confirmed C5 C6 disk space had been localized and then the self retained distraction system was inserted to maintain exposure A 15 blade knife was used to incise the C5 C6 disk and remove disk material and distraction pins were inserted into C5 C6 and distraction placed across the disk space The operating microscope was then brought into the field and used throughout the case except for the closure Various pituitaries 15 blade knife and curette were used to evacuate the disk as best as possible Then the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina A small amount of disk material was found at the right neural foramen After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure the wound was thoroughly irrigated A spacing mechanism was intact into the disk space and it was determined that a 7 spacer was appropriate So a 7 machine bone implant was taken and tapped into disk space and slightly counter sunk The wound was thoroughly irrigated and inspected for hemostasis A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5 C6 to hold the bone into position and the wound was once again irrigated The patient was valsalved There was no further bleeding seen and intraoperative x ray confirmed a good position near the bone plate and screws and the wound was enclosed in layers The 3 0 Vicryl was used to approximate platysma and 3 0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin The wound was cleaned Mastisol was placed on the skin and Steri strips were used to approximate skin margins Sterile dressing was placed on the patient s neck He was extubated in the OR and transported to the recovery room in stable condition There were no complications Keywords neurosurgery herniation radiculopathy interbody mystique bone implant anterior cervical discectomy neural foramina mystique plate disc herniation arm radiculopathy cervical discectomy disk space disk cervical anterior wound discectomy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy at C5 6 and placement of artificial disk replacement Right C5 C6 herniated nucleus pulposus Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy 2 Transcription ADMITTING DIAGNOSIS Right C5 C6 herniated nucleus pulposus PRIMARY OPERATIVE PROCEDURE Anterior cervical discectomy at C5 6 and placement of artificial disk replacement SUMMARY This is a pleasant 43 year old woman who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs She underwent another MRI and significant degenerative disease at C5 6 with a central and right sided herniation was noted Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery She was interested in participating in the artificial disk replacement study and was entered into that study She was randomly picked for the artificial disk and underwent the above named procedure on 08 27 2007 She has done well postoperatively with a sensation of right arm pain and numbness in her fingers She will have x rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well She will follow up with Dr X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x rays with ring prior to the appointment She will contact our office prior to her appointment if she has problems Prescriptions were written for Flexeril 10 mg 1 p o t i d p r n 50 with 1 refill and Lortab 7 5 500 mg 1 to 2 q 6 h p r n 60 with 1 refill Keywords neurosurgery herniated nucleus pulposus anterior cervical discectomy artificial disk replacement cervical discectomy nucleusNOTE MEDICAL_TRANSCRIPTION,Description C5 C6 anterior cervical discectomy bone bank allograft and anterior cervical plate Left cervical radiculopathy Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy 4 Transcription PREOPERATIVE DIAGNOSIS Left cervical radiculopathy POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy PROCEDURES PERFORMED 1 C5 C6 anterior cervical discectomy 2 Bone bank allograft 3 Anterior cervical plate TUBES AND DRAINS LEFT IN PLACE None COMPLICATIONS None SPECIMEN SENT TO PATHOLOGY None ANESTHESIA General endotracheal INDICATIONS This is a middle aged man who presented to me with left arm pain He had multiple levels of disease but clinically it was C6 radiculopathy We tested him in the office and he had weakness referable to that nerve The procedure was done at that level DESCRIPTION OF PROCEDURE The patient was taken to the operating room at which time an intravenous line was placed General endotracheal anesthesia was obtained He was positioned supine in the operative area and the right neck was prepared An incision was made and carried down to the ventral spine on the right in the usual manner An x ray confirmed our location We were impressed by the degenerative change and the osteophyte overgrowth As we had excepted the back of the disk space was largely closed off by osteophytes We patiently drilled through them to the posterior ligament We went through that until we saw the dura We carefully went to the patient s symptomatic left side The C6 foramen was narrowed by uncovertebral joint overgrowth The foramen was open widely An allograft was placed An anterior Steffee plate was placed Closure was commenced The wound was closed in layers with Steri Strips on the skin A dressing was applied It should be noted that the above operation was done also with microscopic magnification and illumination Keywords neurosurgery cervical radiculopathy anterior cervical discectomy bank allograft cervical discectomy anterior cervical foramen discectomy allograft radiculopathy MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy two levels and C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy 3 Transcription PREOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain POSTOPERATIVE DIAGNOSES Cervical disk protrusions at C5 C6 and C6 C7 cervical radiculopathy and cervical pain PROCEDURES C5 C6 and C6 C7 anterior cervical discectomy two levels C5 C6 and C6 C7 allograft fusions A C5 C7 anterior cervical plate fixation Sofamor Danek titanium window plate intraoperative fluoroscopy used and intraoperative microscopy used Intraoperative SSEP and EMG monitoring used ANESTHESIA General endotracheal COMPLICATIONS None INDICATION FOR THE PROCEDURE This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain numbness weakness with MRI showing significant disk protrusions with the associate complexes at C5 C6 and C6 C7 with associated cervical radiculopathy After failure of conservative treatment this patient elected to undergo surgery DESCRIPTION OF PROCEDURE The patient was brought to the OR and after adequate general endotracheal anesthesia she was placed supine on the OR table with the head of the bed about 10 degrees A shoulder roll was placed and the head supported on a donut support The cervical region was prepped and draped in the standard fashion A transverse cervical incision was made from the midline which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle In a transverse fashion the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done Then the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia which was gently dissected and released superiorly and inferiorly Spinal needles were placed into the displaced C5 C6 and C6 C7 to confirm these disk levels using lateral fluoroscopy Following this monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5 C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly A 15 scalpel was used to do a discectomy at C5 C6 from endplate to endplate and uncovertebral joint On the uncovertebral joint a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect This was done under the microscope A high speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the 15 scalpel and then Kerrison punches 1 mm and then 2 mm were used to decompress further disk calcified material at the C5 C6 level This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen Then at the C6 C7 level in a similar fashion 15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate to endplate using a 15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate and then high speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released Then using the Kerrison punches we used 1 mm and 2 mm to remove disk calcified material which was extending more posteriorly to the left and the right This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots With this done the wound was irrigated Hemostasis was ensured with bipolar coagulation Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6 mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5 C6 and C6 C7 discectomy sites Then the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate Danek windows titanium plates was then taken and sized and placed A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5 two in the vertebral body of C6 and two in the vertebral body of C7 The holes were then drilled and after this self tapping screws were placed into the vertebral body of C5 C6 and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5 C6 and C7 With this done operative fluoroscopy was used to check good alignment of the graft screw and plate and then the wound was irrigated Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down A 10 round Jackson Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site Then the platysma was approximated using 2 0 Vicryl inverted interrupted stitches and the skin closed with 4 0 Vicryl running subcuticular stitch Steri Strips and sterile dressings were applied The patient remained hemodynamically stable throughout the procedure Throughout the procedure the microscope had been used for the disk decompression and high speed drilling In addition intraoperative SSEP EMG monitoring and motor evoked potentials remained stable throughout the procedure The patient remained stable throughout the procedure Keywords neurosurgery cervical disk protrusions cervical radiculopathy cervical pain cervical plate fixation sofamor danek titanium window plate anterior cervical discectomy vertebral body vertebral disk intraoperative anterior decompression fluoroscopy radiculopathy discectomy cervical MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy removal of herniated disc and osteophytes bilateral C4 nerve root decompression harvesting of bone for autologous vertebral bodies for creation of arthrodesis grafting of fibular allograft bone for creation of arthrodesis creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies and placement of anterior spinal instrumentation using the operating microscope and microdissection technique Medical Specialty Neurosurgery Sample Name Anterior Cervical Discectomy 1 Transcription PREOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression POSTOPERATIVE DIAGNOSIS Cervical spondylosis at C3 C4 with cervical radiculopathy and spinal cord compression OPERATION PERFORMED 1 Anterior cervical discectomy of C3 C4 2 Removal of herniated disc and osteophytes 3 Bilateral C4 nerve root decompression 4 Harvesting of bone for autologous vertebral bodies for creation of arthrodesis 5 Grafting of fibular allograft bone for creation of arthrodesis 6 Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies 7 Placement of anterior spinal instrumentation using the operating microscope and microdissection technique INDICATIONS FOR PROCEDURE This 62 year old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain Conservative therapy has failed to improve the problem Imaging studies showed severe spondylosis of C3 C4 with neuroforaminal narrowing and spinal cord compression A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives He clearly understood it and had no further questions and requested that I proceed PROCEDURE IN DETAIL The patient was placed on the operating room table and was intubated using a fiberoptic technique The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses The neck was carefully prepped and draped in the usual sterile manner A transverse incision was made on a skin crease on the left side of the neck Dissection was carried down through the platysmal musculature and the anterior spine was exposed The medial borders of the longus colli muscles were dissected free from their attachments to the spine A needle was placed and it was believed to be at the C3 C4 interspace and an x ray properly localized this space Castoff self retaining pins were placed into the body of the C3 and C4 Self retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles The annulus was incised and a discectomy was performed Quite a bit of overhanging osteophytes were identified and removed As I worked back to the posterior lips of the vertebral body the operating microscope was utilized There was severe overgrowth of spondylitic spurs A high speed diamond bur was used to slowly drill these spurs away I reached the posterior longitudinal ligament and opened it and exposed the underlying dura Slowly and carefully I worked out towards the C3 C4 foramen The dura was extremely thin and I could see through it in several areas I removed the bony compression in the foramen and identified soft tissue and veins overlying the root All of these were not stripped away for fear of tearing this very tissue paper thin dura However radical decompression was achieved removing all the bony compression in the foramen out to the pedicle and into the foramen An 8 mm of the root was exposed although I left the veins over the root intact The microscope was angled to the left side where a similar procedure was performed Once the decompression was achieved a high speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration Bone thus from the drilling was preserved for use for the arthrodesis Attention was turned to creation of the arthrodesis As I had drilled quite a bit into the bodies I selected a large 12 mm graft and distracted the space maximally Under distraction the graft was placed and fit well An x ray showed good graft placement Attention was turned to spinal instrumentation A Synthes Short Stature plate was used with four 3 mm screws Holes were drilled with all four screws were placed with pretty good purchase Next the locking screws were then applied An x ray was obtained which showed good placement of graft plate and screws The upper screws were near the upper endplate of C3 The C3 vertebral body that remained was narrow after drilling off the spurs Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate Attention was turned to closure A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin The wound was then carefully closed in layers Sterile dressings were applied along with a rigid Philadelphia collar The operation was then terminated The patient tolerated the procedure well and left for the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisted of bone and soft tissue as well as C3 C4 disc material Keywords neurosurgery herniated osteophytes nerve root decompression harvesting autologous vertebral arthrodesis anterior technique anterior cervical discectomy spinal cord compression fibular allograft bone creation of arthrodesis cervical discectomy spinal instrumentation cord compression vertebral body vertebral bodies spinal cord bone instrumentation cervical anterior grafting spinal discectomy allograft MEDICAL_TRANSCRIPTION,Description Herniated nucleus pulposus Anterior cervical decompression anterior spine instrumentation anterior cervical spine fusion and application of machined allograft Medical Specialty Neurosurgery Sample Name Anterior Cervical Decompression Transcription PREOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 POSTOPERATIVE DIAGNOSES 1 Herniated nucleus pulposus C5 C6 2 Herniated nucleus pulposus C6 C7 PROCEDURE PERFORMED 1 Anterior cervical decompression C5 C6 2 Anterior cervical decompression C6 C7 3 Anterior spine instrumentation 4 Anterior cervical spine fusion C5 C6 5 Anterior cervical spine fusion C6 C7 6 Application of machined allograft at C5 C6 7 Application of machined allograft at C6 C7 8 Allograft structural at C5 C6 9 Allograft structural at C6 C7 ANESTHESIA General PREOPERATIVE NOTE This patient is a 47 year old male with chief complaint of severe neck pain and left upper extremity numbness and weakness Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5 C6 and C6 C7 on the left The patient has failed epidural steroid injections Risks and benefits of the above procedure were discussed with the patient including bleeding infection muscle loss nerve damage paralysis and death OPERATIVE REPORT The patient was taken to the OR and placed in the supine position After general endotracheal anesthesia was obtained the patient s neck was sterilely prepped and draped in the usual fashion A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body It was taken down through the subcutaneous tissues exposing the platysmus muscle The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine An 18 gauge needle was placed in the C5 C6 interspace and the intraoperative x ray confirmed that this was the appropriate level Next the longus colli muscles were resected laterally on both the right and left side and then a complete anterior cervical discectomy was performed The disk was very degenerated and brown in color There was an acute disk herniation through posterior longitudinal ligament The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed Approximately 5 mm of the nerve root on both the right and left side was visualized A ball ended probe could be passed up the foramen Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates of C5 and C6 were prepared using a high speed burr and a 6 mm lordotic machined allograft was malleted into place There was good bony apposition both proximally and distally Next attention was placed at the C6 C7 level Again the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6 C7 was performed The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left The posterior longitudinal ligament was removed A bilateral foraminotomy was performed Approximately 5 mm of the C7 nerve root was visualized on both sides A micro nerve hook was able to be passed up the foramen easily Bleeding was controlled with bipolar electrocautery and Surgiflo The end plates at C6 C7 were then prepared using a high speed burr and then a 7 mm machined lordotic allograft was malleted into place There was good bony apposition both proximally and distally Next a 44 mm Blackstone low profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws Intraoperative x ray confirmed appropriate positioning of the plate and the graft The wound was then copiously irrigated with normal saline and bacitracin There was no active bleeding upon closure of the wound A small drain was placed deep The platysmal muscle was closed with 3 0 Vicryl The skin was closed with 4 0 Monocryl Mastisol and Steri Strips were applied The patient was monitored throughout the procedure with free running EMGs and SSEPs and there were no untoward events The patient was awoken and taken to the recovery room in satisfactory condition Keywords neurosurgery herniated nucleus pulposus anterior cervical decompression spine fusion cervical spine allograft anterior cervical spine anterior cervical MEDICAL_TRANSCRIPTION,Description EEG during wakefulness and light sleep is abnormal with independent positive sharp wave activity seen in both frontotemporal head regions more predominant in the right frontotemporal region Medical Specialty Neurology Sample Name Video EEG 3 Transcription PROCEDURE EEG during wakefulness demonstrates background activity consisting of moderate amplitude beta activity seen bilaterally The EEG background is symmetric Independent small positive sharp wave activity is seen in the frontotemporal regions bilaterally with sharp slow wave discharges seen more predominantly in the right frontotemporal head region No clinical signs of involuntary movements are noted during synchronous video monitoring Recording time is 22 minutes and 22 seconds There is attenuation of the background faster activity during drowsiness and some light sleep is recorded No sustained epileptogenic activity is evident but the independent bilateral sharp wave activity is seen intermittently Photic stimulation induced a bilaterally symmetric photic driving response IMPRESSION EEG during wakefulness and light sleep is abnormal with independent positive sharp wave activity seen in both frontotemporal head regions more predominant in the right frontotemporal region The EEG findings are consistent with potentially epileptogenic process Clinical correlation is warranted Keywords neurology epileptogenic wakefulness eeg frontotemporal activityNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A pleasant gentleman with a history of Wilson s disease who has been treated with penicillamine Medical Specialty Neurology Sample Name Wilson s Disease Letter Transcription Doctor s Address Dear Doctor This letter is an introduction to my patient A who you will be seeing in the near future He is a pleasant gentleman with a history of Wilson s disease It has been treated with penicillamine He was diagnosed with this at age 14 He was on his way to South Carolina for a trip when he developed shortness of breath palpitations and chest discomfort He went to the closest hospital that they were near in Randolph North Carolina and he was found to be in atrial fibrillation with rapid rate He was admitted there and observed He converted to normal sinus rhythm spontaneously and so he required no further interventions He was started on Lopressor which he has tolerated well An echocardiogram was performed which revealed mild to moderate left atrial enlargement Normal ejection fraction No other significant valvular abnormality He reported to physicians there that he had cirrhosis related to his Wilson s disease Therefore hepatologist was consulted There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease therefore he was placed on aspirin 325 mg once a day In discussion with Mr A and review of his chart that I have available it is unclear as to the status of his liver disease however he has never had a liver biopsy so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control He is in normal sinus rhythm as of my evaluation of him on 06 12 2008 He is tolerating his metoprolol and aspirin without any difficulty I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes I appreciate your input regarding this friendly gentleman His current medicines include penicillamine 250 mg p o four times a day metoprolol 12 5 mg twice a day and aspirin 325 mg a day If you have any questions regarding his care please feel free to call me to discuss his case Otherwise I will look forward to hearing back from you regarding his evaluation Thank you as always for your care of our patient Keywords neurology atrial enlargement wilson s disease penicillamine MEDICAL_TRANSCRIPTION,Description This is a 43 year old female with a history of events concerning for seizures Video EEG monitoring is performed to capture events and or identify etiology Medical Specialty Neurology Sample Name Video EEG Transcription TIME SEEN 0734 hours and 1034 hours TOTAL RECORDING TIME 27 hours 4 minutes PATIENT HISTORY This is a 43 year old female with a history of events concerning for seizures Video EEG monitoring is performed to capture events and or identify etiology VIDEO EEG DIAGNOSES 1 AWAKE Normal 2 SLEEP No activation 3 CLINICAL EVENTS None DESCRIPTION Approximately 27 hours of continuous 21 channel digital video EEG monitoring was performed The waking background is unchanged from that previously reported Hyperventilation produced no changes in the resting record Photic stimulation failed to elicit a well developed photic driving response Approximately five and half hours of spontaneous intermittent sleep was obtained Sleep spindles were present and symmetric The patient had no clinical events during the recording CLINICAL INTERPRETATION This is normal video EEG monitoring for a patient of this age No interictal epileptiform activity was identified The patient had no clinical events during the recording Clinical correlation is required Keywords neurology electroencephalography eeg monitoring video eeg seizures eeg MEDICAL_TRANSCRIPTION,Description The patient has a history of epilepsy and has also had non epileptic events in the past Video EEG monitoring is performed to assess whether it is epileptic seizures or non epileptic events Medical Specialty Neurology Sample Name Video EEG 1 Transcription DATE OF EXAMINATION Start 12 29 2008 at 1859 hours End 12 30 2008 at 0728 hours TOTAL RECORDING TIME 12 hours 29 minutes PATIENT HISTORY This is a 46 year old female with a history of events concerning for seizures The patient has a history of epilepsy and has also had non epileptic events in the past Video EEG monitoring is performed to assess whether it is epileptic seizures or non epileptic events VIDEO EEG DIAGNOSES 1 Awake Normal 2 Sleep Activation of a single left temporal spike seen maximally at T3 3 Clinical events None DESCRIPTION Approximately 12 hours of continuous 21 channel digital video EEG monitoring was performed During the waking state there is a 9 Hz dominant posterior rhythm The background of the record consists primarily of alpha frequency activity At times during the waking portion of the record there appears to be excessive faster frequency activity No activation procedures were performed Approximately four hours of intermittent sleep was obtained A single left temporal T3 spike is seen in sleep Vertex waves and sleep spindles were present and symmetric The patient had no clinical events during the recording CLINICAL INTERPRETATION This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep The patient had no clinical events during the recording period Clinical correlation is required Keywords neurology non epileptic events temporal spike eeg monitoring video eeg epilepsy frequency eeg epileptic MEDICAL_TRANSCRIPTION,Description EEG during wakefulness drowsiness and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity Medical Specialty Neurology Sample Name Video EEG 2 Transcription IMPRESSION EEG during wakefulness drowsiness and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity Keywords neurology ekg artifact video monitoring wakefulness drowsiness eegNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Chronic venous hypertension with painful varicosities lower extremities bilaterally Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions bilaterally Medical Specialty Neurology Sample Name Vein Stripping Transcription PREOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally POSTOPERATIVE DIAGNOSIS Chronic venous hypertension with painful varicosities lower extremities bilaterally PROCEDURES 1 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions right leg 2 Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions left leg PROCEDURE DETAIL After obtaining the informed consent the patient was taken to the operating room where she underwent a general endotracheal anesthesia A time out process was followed and antibiotics were given Then both legs were prepped and draped in the usual fashion with the patient was in the supine position An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided Then an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities Then a vein stripper was passed from the right calf up to the groin and the greater saphenous vein which was divided was stripped without any difficultly Several minutes of compression was used for hemostasis Then the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do Then in the left thigh a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side Also an incision was made in the level of the knee and the saphenous vein was isolated there The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis Then a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient s position would allow us Then all incisions were closed in layers with Vicryl and staples Then the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg The stab phlebectomies were performed with a hook and they were very satisfactory Hemostasis achieved with compression and then staples were applied to the skin Then the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix fluffs and Ace bandages Estimated blood loss probably was about 150 mL The patient tolerated the procedure well and was sent to recovery room in satisfactory condition The patient is to be observed so a decision will be made whether she needs to stay overnight or be able to go home Keywords neurology chronic venous hypertension varicosities stab phlebectomies greater saphenous vein stripping lower extremities vein stripping saphenous vein vein incisions hemostasis stripping branches phlebectomies thigh calf saphenous MEDICAL_TRANSCRIPTION,Description Placement of left ventriculostomy via twist drill Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure Medical Specialty Neurology Sample Name Ventriculostomy Placement Transcription PROCEDURE Placement of left ventriculostomy via twist drill PREOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure POSTOPERATIVE DIAGNOSIS Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure INDICATIONS FOR PROCEDURE The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage His condition is felt to be critical In a desperate attempt to relieve increased intracranial pressure we have proposed placing a ventriculostomy I have discussed this with patient s wife who agrees and asked that we proceed emergently After a sterile prep drape and shaving of the hair over the left frontal area this area is infiltrated with local anesthetic Subsequently a 1 cm incision was made over Kocher s point Hemostasis was obtained Then a twist drill was made over this area Bones strips were irrigated away The dura was perforated with a spinal needle A Camino monitor was connected and zeroed This was then passed into the left lateral ventricle on the first pass Excellent aggressive very bloody CSF under pressure was noted This stopped slowed and some clots were noted This was irrigated and then CSF continued Initial opening pressures were 30 but soon arose to 80 or a 100 The patient tolerated the procedure well The wound was stitched shut and the ventricular drain was then connected to a drainage bag Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding Keywords neurology intraventricular hemorrhage hydrocephalus intracranial pressure camino monitor twist drill ventriculostomy hemorrhage intracranial pressure intraventricular MEDICAL_TRANSCRIPTION,Description Subcutaneous ulnar nerve transposition A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Medical Specialty Neurology Sample Name Ulnar Nerve Transposition Transcription PROCEDURE Subcutaneous ulnar nerve transposition PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg A curvilinear incision was made over the medial elbow starting proximally at the medial intermuscular septum curving posterior to the medial epicondyle then curving anteriorly along the path of the ulnar nerve Dissection was carried down to the ulnar nerve Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected Osborne s fascia was released an ulnar neurolysis performed and the ulnar nerve was mobilized Six cm of the medial intermuscular septum was excised and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly The subcutaneous plane just superficial to the flexor pronator mass was developed Meticulous hemostasis was maintained with bipolar electrocautery The nerve was transposed anteriorly superficial to the flexor pronator mass Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve A semicircular medially based flap of flexor pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating The subcutaneous tissue and skin were closed with simple interrupted sutures Marcaine with epinephrine was injected into the wound The elbow was dressed and splinted The patient was awakened and sent to the recovery room in good condition having tolerated the procedure well Keywords neurology neurolysis ulnar periosteal flexor pronator mass ulnar nerve transposition medial intermuscular septum nerve transposition intermuscular septum flexor pronator ulnar nerve nerve MEDICAL_TRANSCRIPTION,Description Headaches question of temporal arteritis Bilateral temporal artery biopsies Medical Specialty Neurology Sample Name Temporal Artery Biopsy 1 Transcription PREOPERATIVE DIAGNOSIS Headaches question of temporal arteritis POSTOPERATIVE DIAGNOSIS Headaches question of temporal arteritis PROCEDURE Bilateral temporal artery biopsies DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion Xylocaine 1 was utilized and then an incision was made in front of the right ear and deepened anteriorly The temporal artery was found and exposed in an extension of about 2 cm The artery was proximally and distally ligated with 6 0 Prolene and also a side branch and a sample was sent for pathology Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl Then the patient was turned and her left temporal area was prepped and draped in the usual fashion A similar procedure was performed with 1 Xylocaine and exposed her temporal artery which was excised in an extent to about 2 cm This was also proximally and distally ligated with 6 0 Prolene and also side branch Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl Dressings were applied to both areas The patient tolerated the procedure well Estimated blood loss was negligible and the patient went back to Same Day Surgery for recovery Keywords neurology temporal arteritis temporal artery temporal artery biopsies hemostasis subcuticular headaches arteritis MEDICAL_TRANSCRIPTION,Description Bilateral temporal artery biopsy Rule out temporal arteritis Medical Specialty Neurology Sample Name Temporal Artery Biopsy Transcription PREOPERATIVE DIAGNOSIS Rule out temporal arteritis POSTOPERATIVE DIAGNOSIS Rule out temporal arteritis PROCEDURE Bilateral temporal artery biopsy ANESTHESIA Local anesthesia 1 Xylocaine with epinephrine INDICATIONS I was consulted by Dr X for this patient with bilateral temporal headaches to rule out temporal arteritis I explained fully the procedure to the patient PROCEDURE Both sides were done exactly the same way After 1 Xylocaine infiltration a 2 to 3 cm incision was made over the temporal artery The temporal artery was identified and was grossly normal on both sides Proximal and distal were ligated with both of 3 0 silk suture and Hemoccult The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm They were sent as separate specimens right and left labeled The wound was then closed with interrupted 3 0 Monocryl subcuticular sutures and Dermabond She tolerated the procedure well Keywords neurology headaches bilateral temporal artery temporal artery biopsy temporal arteritis temporal artery temporal biopsy arteritis MEDICAL_TRANSCRIPTION,Description A 92 year old female had a transient episode of slurred speech and numbness of her left cheek for a few hours Medical Specialty Neurology Sample Name TIA Cosult Transcription REASON FOR CONSULTATION This 92 year old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours However the chart indicates that she had recurrent TIAs x3 yesterday each lasting about 5 minutes with facial drooping and some mental confusion She had also complained of blurred vision for several days She was brought to the emergency room last night where she was noted to have a left carotid bruit and was felt to have recurrent TIAs CURRENT MEDICATIONS The patient is on Lanoxin amoxicillin Hydergine Cardizem Lasix Micro K and a salt free diet SOCIAL HISTORY She does not smoke or drink alcohol FINDINGS Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone probably representing the benign osteochondroma seen on previous studies CBC was normal aside from a hemoglobin of 11 2 ECG showed atrial fibrillation BUN was 22 creatinine normal CPK normal glucose normal electrolytes normal PHYSICAL EXAMINATION On examination the patient is noted to be alert and fully oriented She has some impairment of recent memory She is not dysphasic or apraxic Speech is normal and clear The head is noted to be normocephalic Neck is supple Carotid pulses are full bilaterally with left carotid bruit Neurologic exam shows cranial nerve function II through XII to be intact save for some slight flattening of the left nasolabial fold Motor examination shows no drift of the outstretched arms There is no tremor or past pointing Finger to nose and heel to shin performed well bilaterally Motor showed intact neuromuscular tone strength and coordination in all limbs Reflexes 1 and symmetrical with bilateral plantar flexion absent jaw jerk no snout Sensory exam is intact to pinprick touch vibration position temperature and graphesthesia IMPRESSION Neurological examination is normal aside from mild impairment of recent memory slight flattening of the left nasolabial fold and left carotid bruit She also has atrial fibrillation apparently chronic In view of her age and the fact that she is in chronic atrial fibrillation I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs RECOMMENDATIONS I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated in which case you might consider it best to do an angiography and consider endarterectomy In view of her age I would be reluctant to recommend Coumadin anticoagulation I will be happy to follow the patient with you Keywords neurology atrial fibrillation carotid bruit slurred speech numbness calcified mass lesion neurological examination tias carotid benign MEDICAL_TRANSCRIPTION,Description Evaluation of possible tethered cord She underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age Medical Specialty Neurology Sample Name Tethered Cord Evaluation Transcription REASON FOR VISIT The patient referred by Dr X for evaluation of her possible tethered cord HISTORY OF PRESENT ILLNESS Briefly she is a 14 year old right handed female who is in 9th grade who underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age The last surgery was in 03 95 She did well however in the past several months has had some leg pain in both legs out laterally worsening at night and requiring Advil Motrin as well as Tylenol PM Denies any new bowel or bladder dysfunction or increased sensory loss She had some patchy sensory loss from L4 to S1 MEDICATIONS Singulair for occasional asthma FINDINGS She is awake alert and oriented x 3 Pupils equal and reactive EOMs are full Motor is 5 out of 5 She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus There is no evidence of clonus There is diminished sensation from L4 to S1 having proprioception ASSESSMENT AND PLAN Possible tethered cord I had a thorough discussion with the patient and her parents I have recommended a repeat MRI scan The prescription was given today MRI of the lumbar spine was just completed I would like to see her back in clinic We did discuss the possible symptoms of this tethering Keywords neurology tethering lipomyomeningocele repair sensory loss tethered cord mri cord lipomyomeningocele MEDICAL_TRANSCRIPTION,Description Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty Medical Specialty Neurology Sample Name Suboccipital Craniectomy Transcription TITLE OF OPERATION Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty INDICATION FOR SURGERY The patient with a large 3 5 cm acoustic neuroma The patient is having surgery for resection There was significant cerebellar peduncle compression The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex The case took 12 hours This was more difficult and took longer than the usual acoustic neuroma PREOP DIAGNOSIS Right acoustic neuroma POSTOP DIAGNOSIS Right acoustic neuroma PROCEDURE The patient was brought to the operating room General anesthesia was induced in the usual fashion After appropriate lines were placed the patient was placed in Mayfield 3 point head fixation hold into a right park bench position to expose the right suboccipital area A time out was settled with nursing and anesthesia and the head was shaved prescrubbed with chlorhexidine prepped and draped in the usual fashion The incision was made and cautery was used to expose the suboccipital bone Once the suboccipital bone was exposed under the foramen magnum the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus The dura was then opened in a cruciate fashion the cisterna magna was drained which nicely relaxed the cerebellum The dura leaves were held back with the 4 0 Nurolon The microscope was then brought into the field and under the microscope the cerebellar hemisphere was elevated Laterally the arachnoid was very thick This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa Initially two retractors were used one on the tentorium and one inferiorly The arachnoid was taken down off the tumor There were multiple blood vessels on the surface which were bipolared The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum however as the tumor was able to be debulked the edge began to be mobilized The redundant capsule was bipolared and cut out to get further access to the center of the tumor Working inferiorly and then superiorly the tumor was taken down off the tentorium as well as out the 9th 10th or 11th nerve complex It was very difficult to identify the 7th nerve complex The brainstem was identified above the complex Similarly inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain Attention was then taken to try identify the 7th nerve complex There were multitude of veins including the lateral pontine vein which were coming right into this area The lateral pontine vein was maintained Microscissors and bipolar were used to develop the plain and then working inferiorly the 7th nerve was identified coming off the brainstem A number 1 and number 2 microinstruments were then used to began to develop the plane This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve Cavitron was used to debulk the lesion and then further dissection was carried out The nerve stimulated beautifully at the brainstem level throughout this The tumor continued to be mobilized off the lateral pontine vein until it was completely off The Cavitron was used to debulk the lesion out back laterally towards the area of the porus The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus At this point the capsule was so redundant it was felt to isolate the nerve in the porus There was minimal bulk remaining intracranially All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem Dr X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus I then scrubbed back into case once Dr X had completed removing this portion of the tumor There was no tumor remaining at this point I placed some Norian in the porus to seal any air cells although there were no palpated An intradural space was then irrigated thoroughly There was no bleeding The nerve was attempted to be stimulated at the brainstem level but it did not stimulate at this time The dura was then closed with 4 0 Nurolons in interrupted fashion A muscle plug was used over one area Duragen was laid and strips over the suture line followed by Hemaseel Gelfoam was set over this and then a titanium cranioplasty was carried out The wound was then irrigated thoroughly O Vicryls were used to close the deep muscle and fascia 3 0 Vicryl for subcutaneous tissue and 3 0 nylon on the skin The patient was extubated and taken to the ICU in stable condition Keywords neurology suboccipital craniectomy microscope cranioplasty acoustic neuroma cerebellar peduncle nerve complex brainstem nurolon cavitron kerrison leksell lateral pontine vein suboccipital craniectomy nerve tumor MEDICAL_TRANSCRIPTION,Description MRI demonstrated right contrast enhancing temporal mass Medical Specialty Neurology Sample Name SOAP Temporal Mass Transcription SUBJECTIVE The patient is a 55 year old African American male that was last seen in clinic on 07 29 2008 with diagnosis of new onset seizures and an MRI scan which demonstrated right contrast enhancing temporal mass Given the characteristics of this mass and his new onset seizures it is significantly concerning for a high grade glioma OBJECTIVE The patient is alert and oriented times three GCS of 15 Cranial nerves II to XII are grossly intact Motor exam demonstrates 5 5 strength in all four extremities Sensation is intact to light touch pain temperature and proprioception Cerebellar exam is intact Gait is normal and tandem on heels and toes Speech is appropriate Judgment is intact Pupils are equal and reactive to light ASSESSMENT AND PLAN The patient is a 55 year old African American male with a new diagnosis of rim enhancing right temporal mass Given the characteristics of the MRI scan it is highly likely that he demonstrates high grade glioma and concerning for glioblastoma multiforme We have discussed in length the possible benefits of biopsy surgical resection medical management as well as chemotherapy radiation treatments and doing nothing Given the high probability that the mass represents a high grade glioma the patient after weighing the risks and the benefits of surgery has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high grade glioma The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor He agrees that he will be n p o after mid night on Wednesday night He is sent for preoperative assessment with the Anesthesiology tomorrow morning He has undergone vocational rehab assessment Keywords neurology new onset seizures temporal mass cerebellar exam glioma temporal massNOTE MEDICAL_TRANSCRIPTION,Description Numbness and tingling in the right upper extremity intermittent and related to the positioning of the wrist Carpal tunnel syndrome suspected Medical Specialty Neurology Sample Name SOAP Numbness Tingling Transcription SUBJECTIVE This patient presents to the office today because of some problems with her right hand It has been going tingling and getting numb periodically over several weeks She just recently moved her keyboard down at work She is hoping that will help She is worried about carpal tunnel She does a lot of repetitive type activities It is worse at night If she sleeps on it a certain way she will wake up and it will be tingling then she can usually shake out the tingling but nonetheless it is very bothersome for her It involves mostly the middle finger although she says it also involves the first and second digits on the right hand She has some pain in her thumb as well She thinks that could be arthritis OBJECTIVE Weight 213 2 pounds blood pressure 142 84 pulse 92 respirations 16 General The patient is nontoxic and in no acute distress Musculoskeletal The right hand was examined It appears to be within normal limits and the appearance is similar to the left hand She has good and equal grip strength noted bilaterally She has negative Tinel s bilaterally She has a positive Phalen s test The fingers on the right hand are neurovascularly intact with a normal capillary refill ASSESSMENT Numbness and tingling in the right upper extremity intermittent and related to the positioning of the wrist I suspect carpal tunnel syndrome PLAN The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock up wrist splint We are going to try this for two weeks and if the condition is still present then we are going to proceed with EMG test at that time She is going to let me know While she is here I am going to also get her the blood test she needs for her diabetes I am noting that her blood pressure is elevated but improved from the last visit I also noticed that she has lost a lot of weight She is working on diet and exercise and she is doing a great job Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve Keywords neurology tinel s phalen s positioning of the wrist numbness and tingling carpal tunnel syndrome carpal tunnel numbness tingling MEDICAL_TRANSCRIPTION,Description Sleep study patient with symptoms of obstructive sleep apnea with snoring Medical Specialty Neurology Sample Name Sleep Study Interpretation Transcription PROCEDURE Sleep study CLINICAL INFORMATION This patient is a 56 year old gentleman who had symptoms of obstructive sleep apnea with snoring hypertension The test was done 01 24 06 The patient weighed 191 pounds five feet seven inches tall SLEEP QUESTIONNAIRE According to the patient s own estimate the patient took about 15 minutes to fall asleep slept for six and a half hours did have some dreams Did not wake up and the sleep was less refreshing He was sleepy in the morning STUDY PROTOCOL An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph After the scalp was prepared Ag AgCl electrodes were applied to the scalp according to the International 10 20 System EEG was monitored from C4 A1 C3 A2 O2 A1 and O2 A1 EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively Nasal and oral airflow were monitored using a triple port Thermistor Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt Blood oxygen saturation was continuously monitored by pulse oximetry Heart rate and rhythm were monitored by surface electrocardiography Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs Body position and snoring level were also monitored TECHNICAL QUALITY OF STUDY Good ELECTROPHYSIOLOGIC MEASUREMENTS Total recording time 406 minutes total sleep time 365 minutes sleep latency 25 5 minutes REM latency 49 minutes _____ 90 sleep latency measured 86 _____ period was obtained The patient spent 10 of the time awake in bed Stage I 3 8 Stage II 50 5 Stage III 14 Stage REM 21 7 The patient had relatively good sleep architecture except for excessive waking RESPIRATORY MEASUREMENTS Total apnea hypopnea 75 age index 12 3 per hour REM age index 15 per hour Total arousal 101 arousal index 15 6 per hour Oxygen desaturation was down to 88 Longest event 35 second hypopnea with an FiO2 of 94 Total limb movements 92 PRM index 15 1 per hour PRM arousal index 8 9 per hour ELECTROCARDIOGRAPHIC OBSERVATIONS Heart rate while asleep 60 to 64 per minute while awake 70 to 78 per minute CONCLUSIONS Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea hypopnea index RECOMMENDATIONS AXIS B Overnight polysomnography AXIS C Hypertension The patient should return for nasal CPAP titration Sleep apnea if not treated may lead to chronic hypertension which may have cardiovascular consequences Excessive daytime sleepiness dysfunction and memory loss may also occur Keywords neurology sleep study obstructive sleep apnea snoring hypertension polysomnogram compumedics polysomnograph ag agcl electrodes triple port thermistor rem latency polysomnography cpap titration sleep latency apnea sleep obstructive index MEDICAL_TRANSCRIPTION,Description HCT SAH Contusion Skull fracture Medical Specialty Neurology Sample Name SAH Contusion Skull Fracture Transcription CC Headache HX This 51 y o RHM was moving furniture several days prior to presentation when he struck his head vertex against a door panel He then stepped back and struck his back on a trailer hitch There was no associated LOC but he felt dazed He complained a HA since the accident The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting He has been lying in bed most of the time since the accident He also complained of transient left lower extremity weakness The night before admission he went to his bedroom and his girlfriend heard a loud noise She found him on the floor unable to speak or move his left side well He was taken to a local ER In the ER experienced a spell in which he stared to the right for approximately one minute During this time he was unable to speak and did not seem to comprehend verbal questions This resolved ER staff noted decreased left sided movement and a left Babinski sign He was given valium 5 mg and DPH 1 0g A HCT was performed and he was transferred to UIHC PMH DM Coronary Artery Disease Left femoral neuropathy of unknown etiology Multiple head trauma in past falls fights MEDS unknown oral med for DM SHX 10 pack year h o Tobacco use quit 2 years ago 6 pack beer week No h o illicit drug use FHX unknown EXAM 70BPM BP144 83 16RPM 36 0C MS Alert and oriented to person place time Fluent speech CN left lower facial weakness with right gaze preference Pupils 3 3 decreasing to 2 2 on exposure to light Optic disks flat MOTOR decreased spontaneous movement of left sided extremities 5 4 strength in both upper and lower extremities Normal muscle tone and bulk SENSORY withdrew equally to noxious stimulation in all four extremities GAIT STATION COORDINATION not tested The general physical exam was unremarkable During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward and his right hand twitched The entire spell lasted one minute During the episode he was verbally unresponsive He appeared groggy and lethargic after the event HCT without contrast 11 18 92 right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma as well as some adjacent subarachnoid blood and brain contusion LABS CBC GS PT PTT were all WNL COURSE The patient was diagnosed with a right frontal SAH contusion and post traumatic seizures DPH was continued and he was given a Librium taper for possible alcoholic withdrawal A neurosurgical consult was obtained He did not receive surgical intervention and was discharged 12 1 92 Neuropsychological testing on 11 25 92 revealed poor orientation to time or place and poor attention Anterograde verbal and visual memory was severely impaired Speech became mildly dysarthric when fatigued Defective word finding Difficulty copying 2 of 3 three dimensional figures Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits Keywords neurology sah contusion skull fracture headache post traumatic seizures lower extremity weakness loud noise hct weakness skull hematoma fracture MEDICAL_TRANSCRIPTION,Description Diagnosis of benign rolandic epilepsy Medical Specialty Neurology Sample Name Rolandic Epilepsy Transcription City State Dear Dr Y I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr Z His last visit was in June 2006 and he carries a diagnosis of benign rolandic epilepsy To review his birth was unremarkable He is a second child born to a G3 P1 to 2 female He has had normal development and is a bright child in 7th grade He began having seizures however at 9 years of age It is manifested typically as generalized tonic clonic seizures upon awakening or falling into sleep He also had smaller spells with more focal convulsion and facial twitching His EEGs have shown a pattern consistent with benign rolandic epilepsy central temporal sharp waves both of the right and left hemisphere Most recent EEG in May 2006 shows the same abnormalities ABC initially was placed on Tegretol but developed symptoms of toxicity hallucinations on this medication he was switched to Trileptal He has done very well taking 300 mg twice a day without any further seizures His last event was the day of his last EEG when he was sleep deprived and was off medication That was a convulsion lasting 5 minutes He has done well otherwise Parents deny that he has any problems with concentration He has not had any behavior issues He is an active child and participates in sports and some motocross activities He has one older sibling and he lives with his parents Father manages Turkey farm with foster farms Mother is an 8th grade teacher Family history is positive for a 3rd cousin who has seizures but the specific seizure type is not known There is no other relevant family history Review of systems is positive for right heel swelling and tenderness to palpation This is perhaps due to sports injury He has not sprained his ankle and does not have any specific acute injury around the time that this was noted He does also have some discomfort in the knees and ankles in the general sense with activities He has no rashes or any numbness weakness or loss of skills He has no respiratory or cardiovascular complaints He has no nausea vomiting diarrhea or abdominal complaints Past medical history is otherwise unremarkable Other workup includes CT scan and MRI scan of the brain which are both normal PHYSICAL EXAMINATION GENERAL The patient is a well nourished well hydrated male in no acute distress VITAL SIGNS His weight today is 80 6 pounds Height is 58 1 4 inches Blood pressure 113 66 Head circumference 36 3 cm HEENT Atraumatic normocephalic Oropharynx shows no lesions NECK Supple without adenopathy CHEST Clear auscultation CARDIOVASCULAR Regular rate and rhythm No murmurs ABDOMEN Benign without organomegaly EXTREMITIES No clubbing cyanosis or edema NEUROLOGIC The patient is alert and oriented His cognitive skills appear normal for his age His speech is fluent and goal directed He follows instructions well His cranial nerves reveal his pupils equal round and reactive to light Extraocular movements are intact Visual fields are full Disks are sharp bilaterally Face moves symmetrically with normal sensation Palate elevates midline Tongue protrudes midline Hearing is intact bilaterally Motor exam reveals normal strength and tone Sensation intact to light touch and vibration His gait is nonataxic with normal heel toe and tandem Finger to nose finger nose finger rapid altering movements are normal Deep tendon reflexes are 2 and symmetric IMPRESSION This is an 11 year old male with benign rolandic epilepsy who is followed over the past 2 years in our clinic Most recent electroencephalogram still shows abnormalities but it has not been done since May 2006 The plan at this time is to repeat his electroencephalogram follow his electroencephalogram annually until it reveres to normal At that time he will be tapered off of medication I anticipate at some point in the near future within about a year or so he will actually be taken off medication For now I will continue on Trileptal 300 mg twice a day which is a low starting dose for him There is no indication that his dose needs to be increased Family understands the plan We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months Parents will contact us after the electroencephalogram is done so they can get the results Thank you very much for allowing me to access ABC for further management Keywords neurology tonic clonic seizures benign rolandic epilepsy rolandic epilepsy epilepsy seizures electroencephalogram MEDICAL_TRANSCRIPTION,Description Reflex sympathetic dystrophy of both lower extremities Medical Specialty Neurology Sample Name Reflex Sympathetic Dystrophy Letter Transcription Doctor s Address Dear Doctor This letter serves as a reintroduction of my patient A who will be seeing you on Thursday 06 12 2008 As you know he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg He has been through Wound Clinic to try to help heal this but was intolerant of compression dressings and was unable to get satisfactory healing of this He has been seen by Dr X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain He was seen by Dr Y at Orthopedic Associates for review of this However in my discussion with Dr Z and his evaluation of Mr A it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg and concerns of worsening of his RST symptoms on his left leg if he would have an amputation Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test Dr Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr A s pain He has been to Cleveland Clinic for implantable stimulator which was unsuccessful at dramatically improving his pain He currently is taking methadone up to eight tablets four times a day morphine up to 100 mg three times a day and Dilaudid two tablets by mouth every two hours to help reduce his pain He also is currently taking Neurontin 1600 mg three times a day Effexor XR 250 mg once a day Cytomel 25 mcg once a day Seroquel 100 mg p o q day levothyroxine 300 mcg p o q day Prinivil 20 mg p o q day and Mevacor 40 mg p o q day I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation Dr Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion He has been evaluated by Dr X for rehab concerns to determine He agrees that a less aggressive form of therapy may be most appropriate I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation If you have any questions regarding his care please feel free to call me at my office Otherwise I look forward to hearing back from you shortly after your evaluation Please feel free to call me if it is possible or if you have any questions about anything Keywords neurology rsd reflex sympathetic dystrophy orthopedic oxygenationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Followup left sided rotator cuff tear and cervical spinal stenosis Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis Medical Specialty Neurology Sample Name Rotator Cuff Tear Transcription REASON FOR VISIT Followup left sided rotator cuff tear and cervical spinal stenosis HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy I had last seen her on 06 21 07 At that time she had been referred to me Dr X and Dr Y for evaluation of her left sided C6 radiculopathy She also had a significant rotator cuff tear and is currently being evaluated for left sided rotator cuff repair surgery I believe on approximately 07 20 07 At our last visit I only had a report of her prior cervical spine MRI I did not have any recent images I referred her for cervical spine MRI and she returns today She states that her symptoms are unchanged She continues to have significant left sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr Y She also has a second component of pain which radiates down the left arm in a C6 distribution to the level of the wrist She has some associated minimal weakness described in detail in our prior office note No significant right upper extremity symptoms No bowel bladder dysfunction No difficulty with ambulation FINDINGS On examination she has 4 plus over 5 strength in the left biceps and triceps muscle groups 4 out of 5 left deltoid 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities Light touch sensation is minimally decreased in the left C6 distribution otherwise intact Biceps and brachioradialis reflexes are 1 plus Hoffmann sign normal bilaterally Motor strength is 5 out of 5 in all muscle groups in lower extremities Hawkins and Neer impingement signs are positive at the left shoulder An EMG study performed on 06 08 07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity Cervical spine MRI dated 06 28 07 is reviewed It is relatively limited study due to artifact He does demonstrate evidence of minimal to moderate stenosis at the C5 C6 level but without evidence of cord impingement or cord signal change There appears to be left paracentral disc herniation at the C5 C6 level although axial T2 weighted images are quite limited ASSESSMENT AND PLAN Ms ABC s history physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain which is due to a combination of left sided rotator cuff tear and moderate cervical spinal stenosis I agree with the plan to go ahead and continue with rotator cuff surgery With regard to the radiculopathy I believe this can be treated non operatively to begin with I am referring her for consideration of cervical epidural steroid injections The improvement in her pain may help her recover better from the shoulder surgery I will see her back in followup in 3 months at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine I will also be in touch with Dr Y to let him know this information prior to the surgery in several weeks Keywords neurology upper extremity radiculopathy rotator cuff repair cervical spinal stenosis rotator cuff tear physical examination cuff impingement stenosis extremity surgery tear shoulder rotator cervical MEDICAL_TRANSCRIPTION,Description Botulinum toxin injection bilateral rectus femoris medial hamstrings and gastrocnemius soleus muscles phenol neurolysis of bilateral obturator nerves application of bilateral short leg fiberglass casts Medical Specialty Neurology Sample Name Phenol Neurolysis Botulinum Toxin Injection 3 Transcription PROCEDURE CODES 64640 times two 64614 time two 95873 times two 29405 times two PREOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 POSTOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s mom The patient was brought to minor procedures and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation Approximately 4 mL of 5 phenol was injected in this location bilaterally Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 50 units was injected in the rectus femoris bilaterally 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL After injections were performed bilateral short leg fiberglass casts were applied The patient tolerated the procedure well and no complications were encountered Keywords neurology botulinum toxin injection bilateral toxin injection bilateral rectus neurolysis of bilateral obturator short leg fiberglass casts muscles phenol neurolysis botulinum toxin injection gastrocnemius soleus muscles short leg fiberglass femoris medial cerebral palsy active emg emg stimulation phenol neurolysis toxin injection rectus femoris gastrocnemius soleus soleus muscles obturator nerves leg fiberglass fiberglass casts botulinum toxin hamstrings gastrocnemius obturator nerves fiberglass casts muscles botulinum phenol bilateral injection toxin MEDICAL_TRANSCRIPTION,Description Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus Medical Specialty Neurology Sample Name Pituitary Adenomectomy Transcription PREOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma POSTOPERATIVE DIAGNOSIS Large and invasive recurrent pituitary adenoma OPERATION PERFORMED Endoscopic assisted transsphenoidal exploration and radical excision of pituitary adenoma endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus harvesting of dermal fascia abdominal fat graft placement of abdominal fat graft into sella turcica reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm repair of nasal septal deviation using the operating microscope and microdissection technique and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion INDICATIONS FOR PROCEDURE This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor which is known to be an invasive pituitary adenoma He did not return for followup or radiotherapy as instructed and the tumor has regrown For this reason he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible The high risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him Many risks including CSF leak and blindness were discussed in detail After clear understanding of all the same he elected to proceed ahead with surgery PROCEDURE The patient was placed on the operating table and after adequate induction of general anesthesia he was placed in the left lateral decubitus position Care was taken to pad all pressure points appropriately The back was prepped and draped in usual sterile manner A 14 gauge Tuohy needle was introduced into the lumbar subarachnoid space Clear and colorless CSF issued forth A catheter was inserted to a distance of 40 cm and the needle was removed The catheter was then connected to a closed drainage system for aspiration and infusion This no touch technique is now a standard of care for treatment of patients with large invasive adenomas Via injections through the lumbar drain one increases intracranial pressure and produces gentle migration of the tumor This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus The patient was then placed supine and the 3 point headrest was affixed He was placed in the semi sitting position with the head turned to the right and a roll placed under the left shoulder Care was taken to pad all pressure points appropriately The fluoroscope C arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection The metallic arm was then connected to the table for the use of the endoscope The oropharynx nasopharynx and abdominal areas were then prepped and draped in the usual sterile manner A transverse incision was made in the abdominal region and several large pieces of fat were harvested for later use Hemostasis was obtained The wound was carefully closed in layers I then advanced a 0 degree endoscope up the left nostril The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium Needle Bovie electrocautery was used to clear mucosa away from the ostium The perpendicular plate of the ethmoid had already been separated from the sphenoid I entered into the sphenoid There was a tremendous amount of dense fibrous scar tissue present and I slowly and carefully worked through all this I identified a previous sellar opening and widely opened the bone which had largely regrown out to the cavernous sinus laterally on the left which was very well exposed and the cavernous sinus on the right which I exposed the very medial portion of The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present The operating microscope was then utilized Working under magnification I used hypophysectomy placed in the nostril The dura was then carefully opened in the midline and I immediately encountered tissue consistent with pituitary adenoma A frozen section was obtained which confirmed this diagnosis without malignant features Slowly and meticulously I worked to remove the tumor I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free The tumor was moderately vascular and very fibrotic Slowly and carefully I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right There appeared to be cavernous sinus invasion on the left It was consistent with what we saw on the MRI imaging The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter A large amount of this was removed There was a CSF leak as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free Under high magnification I actually worked up into this cavity and performed a very radical excision of tumor While there may be a small amount of tumor remaining it appeared that a radical excision had been created with decompression of the optic apparatus In fact I reinserted the endoscope and could see the optic chiasm well I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression Attention was therefore turned to closure The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained I asked Anesthesiology to perform a Valsalva maneuver and there was no evidence of bleeding Attention was turned to closure and reconstruction I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air Using a polypropylene insert I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm DuraSeal was placed over this and the sphenoid sinus was carefully packed with fat and DuraSeal I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation The middle turbinates were then restored to their anatomic position There was no significant intranasal bleeding and for this reason an open nasal packing was required Sterile dressings were applied and the operation was terminated The patient tolerated the procedure well and left to the recovery room in excellent condition The sponge and needle counts were reported as correct and there were no intraoperative complications Specimens were sent to Pathology consisting of tumor Keywords MEDICAL_TRANSCRIPTION,Description Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles Medical Specialty Neurology Sample Name Phenol Neurolysis Botulinum Toxin Injection 2 Transcription PROCEDURES PERFORMED Phenol neurolysis right obturator nerve botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles PROCEDURE CODES 64640 times one 64614 times two 95873 times two PREOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 POSTOPERATIVE DIAGNOSIS Spastic right hemiparetic cerebral palsy 343 1 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient She was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse Approximately 6 mL of 5 phenol was injected in this location At all sites of phenol injections injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified with active EMG stimulation Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords neurology femoris and vastus medialis intermedius and right pectoralis rectus femoris and vastus vastus medialis intermedius botulinum toxin injection medialis intermedius major muscles cerebral palsy active emg emg stimulation phenol neurolysis toxin injection obturator nerve rectus femoris pectoralis major botulinum toxin pectoralis botulinum phenol injection toxin MEDICAL_TRANSCRIPTION,Description Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1 2 years Medical Specialty Neurology Sample Name Suspected Seizure Activity Transcription XYZ Street City State Dear Dr CD Thank you for seeing Mr XYZ a pleasant 19 year old male who has seen you in 2005 for suspected seizure activity He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1 2 years He is requesting to come off the Dilantin at this point Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use His physical exam neurologically is normal at this time His Dilantin level is slightly low at 12 5 I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time I understand this will probably entail repeating his EEG and so please coordinate this through Health Center I await your response and whether we should continue this medication If you require any laboratory we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling Keywords neurology eeg suspected seizure activity seizure activity seizure episode seizure dilantinNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient with pseudotumor cerebri without papilledema comes in because of new onset of headaches Medical Specialty Neurology Sample Name Pseudotumor Cerebri Transcription REASON FOR VISIT The patient is a 38 year old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches She comes to clinic by herself HISTORY OF PRESENT ILLNESS Dr X has cared for her since 2002 She has a Codman Hakim shunt set at 90 mmH2O She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr Y for medical management of her chronic headaches We also recommended that the patient see a psychiatrist regarding her depression which she stated that she would followup with that herself Today the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04 18 08 She states that since that time her headaches have been bad They woke her up at night She has not been able to sleep She has not had a good sleep cycle since that time She states that the pain is constant and is worse with coughing straining and sneezing as well as on standing up She states that they feel a little bit better when lying down Medication shave not helped her She has tried taking Imitrex as well as Motrin 800 mg twice a day but she states it has not provided much relief The pain is generalized but also noted to be quite intense in the frontal region of her head She also reports ringing in the ears and states that she just does not feel well She reports no nausea at this time She also states that she has been experiencing intermittent blurry vision and dimming lights as well She tells me that she has an appointment with Dr Y tomorrow She reports no other complaints at this time MAJOR FINDINGS On examination today this is a pleasant 38 year old woman who comes back from the clinic waiting area without difficulty She is well developed well nourished and kempt Vital Signs Blood pressure 153 86 pulse 63 and respiratory rate 16 Cranial Nerves Intact for extraocular movements Facial movement hearing head turning tongue and palate movements are all intact I did not know any papilledema on exam bilaterally I examined her shut site which is clean dry and intact She did have a small 3 mm to 4 mm round scab which was noted farther down from her shunt reservoir It looks like there is a little bit of dry blood there ASSESSMENT The patient appears to have had worsening headaches since shunt adjustment back after an MRI PROBLEMS DIAGNOSES 1 Pseudotumor cerebri without papilledema 2 Migraine headaches PROCEDURES I programmed her shunt to 90 mmH2O PLAN It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x ray However the picture of the x ray was not the most desirable picture Thus I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x ray to confirm the setting at 90 In addition she told me that she is scheduled to see Dr Y tomorrow so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient Keywords neurology migraine headaches pseudotumor cerebri without papilledema onset of headaches blurry vision shunt adjustment pseudotumor cerebri headaches pseudotumor cerebri papilledema MEDICAL_TRANSCRIPTION,Description Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors Medical Specialty Neurology Sample Name Phenol Neurolysis Botulinum Toxin Injection 1 Transcription PROCEDURES PERFORMED Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves Botulinum toxin injection left pectoralis major left wrist flexors and bilateral knee extensors PROCEDURE CODES 64640 times three 64614 times four 95873 times four PREOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 POSTOPERATIVE DIAGNOSIS Spastic quadriparesis secondary to traumatic brain injury 907 0 ANESTHESIA MAC COMPLICATIONS None DESCRIPTION OF TECHNIQUE Informed consent was obtained from the patient s brother The patient was brought to the minor procedure area and sedated per their protocol The patient was positioned lying supine Skin overlying all areas injected was prepped with chlorhexidine The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation Approximately 7 mL was injected on the right side and 5 mL on the left side At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation Approximately 5 mL of 5 phenol was injected in this location Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus Negative drawback for blood was done prior to each injection of phenol Muscles injected with botulinum toxin were identified using active EMG stimulation Approximately 150 units was injected in the knee extensors bilaterally 100 units in the left pectoralis major and 50 units in the left wrist flexors Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL The patient tolerated the procedure well and no complications were encountered Keywords neurology spastic quadriparesis emg stimulation emg botulinum toxin injection traumatic brain brain injury phenol neurolysis toxin injection musculocutaneous nerve obturator nerves pectoralis major wrist flexors knee extensors active emg botulinum toxin toxin injection stimulus neurolysis musculocutaneous extensors botulinum phenol MEDICAL_TRANSCRIPTION,Description MRI L Spine Bilateral lower extremity numbness Medical Specialty Neurology Sample Name Normal L Spine MRI Transcription CC Bilateral lower extremity numbness HX 21 y o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11 5 96 The symptoms became maximal over a 12 24 hour period and have not changed since The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space He denied bowel bladder problems or weakness or numbness elsewhere Hot showers may improve his symptoms He has suffered no recent flu like illness Past medical and family histories are unremarkable He was on no medications EXAM Unremarkable except for mild distal vibratory sensation loss in the toes R L LAB CBC Gen Screen TSH FT4 SPE ANA were all WNL MRI L SPINE Normal COURSE Normal exam and diminished symptoms at following visit 4 23 93 Keywords neurology bilateral lower extremity numbness mri l spine bilateral lower extremity lower extremity numbness bilateral spine mri extremities numbness MEDICAL_TRANSCRIPTION,Description Cervical lumbosacral thoracic spine flexion and extension to evaluate back and neck pain Medical Specialty Neurology Sample Name Radiologic Exam Spine Transcription EXAM Cervical lumbosacral thoracic spine flexion and extension HISTORY Back and neck pain CERVICAL SPINE FINDINGS AP lateral with flexion and extension and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable Keywords neurology radiologic exam ap back cervical oblique views alignment disc space extension fixation flexion foramina intervertebral lateral views lumbosacral neck neck pain oblique odontoid view pain physiologic projections spine subluxation thoracic flexion and extension thoracic spine vertebral MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of right temporal bone middle ear space Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 Medical Specialty Neurology Sample Name Skull Base Reconstruction Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma of right temporal bone middle ear space PROCEDURE Right temporal bone resection rectus abdominis myocutaneous free flap for reconstruction of skull base defect right selective neck dissection zones 2 and 3 ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was brought into the operating room placed on the table in supine position General endotracheal anesthesia was obtained in the usual fashion The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen The neck was prepped as well After this was performed I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle After this was performed I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible The condyle was skeletonized so that it could be easily seen The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared The neck contents to the hyoid were dissected out The hypoglossal nerve vagus nerve and spinal accessory nerve were dissected towards the jugular foramen The neck contents were removed as a separate specimen The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis A large posterior facial vein was identified and likewise clipped for later use I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus dissecting or exposing the dura to the level of the jugular bulb It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion Once this was dissected out Dr X entered the procedure for completion of the resection with the craniotomy For details please see his operative note After Dr X had completed the resection I then harvested the rectus free flap A skin paddle was drawn out next to the umbilicus about 4 x 4 cm The skin paddle was incised with the Bovie and down to the anterior rectus sheath Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin The skin paddle was then sutured to the fascia and muscle with interrupted 3 0 Vicryl The anterior rectus sheath was then reflected off the rectus muscle which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction The vascular pedicle could be seen entering the muscle in usual fashion The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel The wound was then packed with saline impregnated sponges The rectus muscle with attached skin paddle was then transferred into the neck The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9 0 Ethilon with standard microvascular technique Ischemia time was less than 10 minutes Likewise the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9 0 Ethilon as well There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case The wound was irrigated with copious amounts of saline The eustachian tube was obstructed with bone wax The muscle was then laid into position with the skin paddle underneath the conchal bowl I removed most the skin of the conchal bowl de epithelializing and leaving the fat in place The wound was closed in layers overlying the muscle which was secured superiorly to the muscle overlying the temporal skull The subcutaneous tissues were closed with interrupted 3 0 Vicryl The skin was closed with skin staples There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself The skin paddle was closed with interrupted 4 0 Prolene to the edges of the conchal bowl The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with 1 Prolene with the more running suture taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors The subcutaneous tissues were closed with interrupted 2 0 Vicryl and skin was closed with skin staples The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened The patient was then transferred to the PACU in stable condition with spontaneous respirations having tolerated the procedure well Keywords neurology rectus abdominis myocutaneous skull base defect squamous cell carcinoma skull base squamous cell rectus sheath abdominis muscle rectus sheath MEDICAL_TRANSCRIPTION,Description Contusion of the frontal lobe of the brain closed head injury and history of fall and headache probably secondary to contusion Medical Specialty Neurology Sample Name Neurology Discharge Summary Transcription PRELIMINARY DIAGNOSES 1 Contusion of the frontal lobe of the brain 2 Closed head injury and history of fall 3 Headache probably secondary to contusion FINAL DIAGNOSES 1 Contusion of the orbital surface of the frontal lobes bilaterally 2 Closed head injury 3 History of fall COURSE IN THE HOSPITAL This is a 29 year old male who fell at home He was seen in the emergency room due to headache CT of the brain revealed contusion of the frontal lobe near the falx The patient did not have any focal signs He was admitted to ABCD Neurology consultation was obtained Neuro checks were done The patient continued to remain stable although he had some frontal headache He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure The patient remained clinically stable and his headache resolved He was discharged home on 11 6 2008 PLAN Discharge the patient to home ACTIVITY As tolerated The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p o q 6 h p r n headache The patient has been advised to follow up with me as well as the neurologist in about 1 week Keywords neurology interhemispheric frontal lobe head injury brain contusion MEDICAL_TRANSCRIPTION,Description Sample for Neuropsychological Evaluation Medical Specialty Neurology Sample Name Neuropsychological Evaluation 1 Transcription REASON FOR EVALUATION The patient is a 37 year old white single male admitted to the hospital through the emergency room I had seen him the day before in my office and recommended him to go into the hospital He had just come from a trip to Taho in Nevada and he became homicidal while there He started having thoughts about killing his mother He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him HISTORY OF PRESENT ILLNESS This is a patient that has been suffering from a chronic psychotic condition now for a number of years He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too The patient has not used any drugs since age 25 However he has continued having intense and frequent psychotic bouts I have seen him now for approximately one year He has been quite refractory to treatment We tried different types of combination of medications which have included Clozaril Risperdal lithium and Depakote with partial response and usually temporary The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days The dosages that we have used have been very high He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level However he has not responded He has delusions of antichrist He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals He has paranoid delusions He also gets homicidal like prior to this admission PAST PSYCHIATRIC HISTORY As mentioned before this patient has been psychotic off and on for about 20 years now He has had years in which he did better on Clozaril and also his other medications With typical anti psychotics he has done well at times but he eventually gets another psychotic bout PAST MEDICAL HISTORY He has a history of obesity and also of diabetes mellitus However most recently he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa The patient has chronic bronchitis He smokes cigarettes constantly up to 60 a day DRUG HISTORY He stopped using drugs when he was 25 He has got a lapse but he was more than 10 years and he has been clean ever since then As mentioned before he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis PSYCHOSOCIAL STATUS The patient lives with his mother and has been staying with her for a few years now We have talked to her She is very supportive His only sister is also very supportive of him He has lived in the ABCD houses in the past He has done poorly in some of them MENTAL STATUS EXAMINATION The patient appeared alert oriented to time place and person His affect is flat He talked about auditory hallucinations which are equivocal in nature He is not homicidal in the hospital as he was when he was at home His voice and speech are normal He believes in telepathy His memory appears intact and his intelligence is calculated as average INITIAL DIAGNOSES AXIS I Schizophrenia AXIS II Deferred AXIS III History of diabetes mellitus obesity and chronic bronchitis AXIS IV Moderate AXIS V GAF of 35 on admission INITIAL TREATMENT AND PLAN Since the patient has been on high dosages of medications we will give him a holiday and a structured environment We will put him on benzodiazepines and make a decision anti psychotic later We will make sure that he is safe and that he addresses his medical needs well Keywords neurology neuropsychological gaf schizophrenia anti psychotic chronic psychotic condition delusions hallucination homicidal marijuana psychological psychotic smokes cigarettes smoking neuropsychological evaluation clozaril bronchitis axis MEDICAL_TRANSCRIPTION,Description Neurologic examination sample Medical Specialty Neurology Sample Name Neurologic Examination Transcription NEUROLOGICAL EXAMINATION At present the patient is awake alert and fully oriented There is no evidence of cognitive or language dysfunction Cranial nerves Visual fields are full Funduscopic examination is normal Extraocular movements full Pupils equal round react to light There is no evidence of nystagmus noted Fifth nerve function is normal There is no facial asymmetry noted Lower cranial nerves are normal Manual motor testing reveals good tone and bulk throughout There is no evidence of pronator drift or decreased fine finger movements Muscle strength is 5 5 throughout Deep tendon reflexes are 2 throughout with downgoing toes Sensory examination is intact to all modalities including stereognosis graphesthesia TESTING OF STATION AND GAIT The patient is able to walk toe heel and tandem walk Finger to nose and heel to shin moves are normal Romberg sign negative I appreciate no carotid bruits or cardiac murmurs Noncontrast CT scan of the head shows no evidence of acute infarction hemorrhage or extra axial collection Keywords neurology station motor testing nerve function neurologic examination cranial nerves cranial extraocular movementsNOTE MEDICAL_TRANSCRIPTION,Description The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness Medical Specialty Neurology Sample Name Neuropsychological Evaluation 5 Transcription PROBLEMS AND ISSUES 1 Headaches nausea and dizziness consistent with a diagnosis of vestibular migraine recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment 2 Some degree of peripheral neuropathy consistent with diabetic neuropathy encouraged her to watch her diet and exercise daily HISTORY OF PRESENT ILLNESS The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness I obtained and documented a full history and physical examination I reviewed the new patient questionnaire which she completed prior to her arrival today I also reviewed the results of tests which she had brought with her Briefly she is a 60 year old woman initially from Ukraine who had headaches since age 25 She recalls that in 1996 when her husband died her headaches became more frequent They were pulsating She was given papaverine which was successful in reducing the severity of her symptoms After six months of taking papaverine she no longer had any headaches In 2004 her headaches returned She also noted that she had zig zag lines in her vision Sometimes she would not see things in her peripheral visions She had photophobia and dizziness which was mostly lightheadedness On one occasion she almost had a syncope Again she has started taking Russian medications which did help her The dizziness and headaches have become more frequent and now occur on average once to twice per week They last two hours since she takes papaverine which stops the symptoms within 30 minutes PAST MEDICAL HISTORY Her past medical history is significant for injury to her left shoulder gastroesophageal reflux disorder diabetes anxiety and osteoporosis MEDICATIONS Her medications include hydrochlorothiazide lisinopril glipizide metformin vitamin D Centrum multivitamin tablets Actos lorazepam as needed Vytorin and Celexa ALLERGIES She has no known drug allergies FAMILY HISTORY There is family history of migraine and diabetes in her siblings SOCIAL HISTORY She drinks alcohol occasionally REVIEW OF SYSTEMS Her review of systems was significant for headaches pain in her left shoulder sleeping problems and gastroesophageal reflex symptoms Remainder of her full 14 point review of system was unremarkable PHYSICAL EXAMINATION On examination the patient was pleasant She was able to speak English fairly well Her blood pressure was 130 84 Heart rate was 80 Respiratory rate was 16 Her weight was 188 pounds Her pain score was 0 10 Her general exam was completely unremarkable Her neurological examination showed subtle weakness in her left arm due to discomfort and pain She had reduced vibration sensation in her left ankle and to some degree in her right foot There was no ataxia She was able to walk normally Reflexes were 2 throughout She had had a CT scan with constant which per Dr X s was unremarkable She reports that she had a brain MRI two years ago which was also unremarkable IMPRESSION AND PLAN The patient is a delightful 60 year old chemist from Ukraine who has had episodes of headaches with nausea photophobia and dizziness since her 20s She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms Her diagnosis is consistent with vestibular migraine I do not see evidence of multiple sclerosis Ménière s disease or benign paroxysmal positional vertigo I talked to her in detail about the importance of following a migraine diet I gave her instructions including a list of foods times which worsen migraine I reviewed this information for more than half the clinic visit I would like to start her on amitriptyline at a dose of 10 mg at time She will take Motrin at a dose of 800 mg as needed for her severe headaches She will make a diary of her migraine symptoms so that we can find any triggering food items which worsen her symptoms I encouraged her to walk daily in order to improve her fitness which helps to reduce migraine symptoms Keywords neurology nausea dizziness migraine peripheral neuropathy diabetic neuropathy neuropathy positional vertigo photophobia and dizziness neurology consultation tunnel vision vestibular migraine migraine symptoms headaches photophobia ataxia MEDICAL_TRANSCRIPTION,Description Neurologic consultation was requested to evaluate her seizure medication and lethargy Medical Specialty Neurology Sample Name Neurologic Consultation Transcription REASON FOR CONSULTATION Neurologic consultation was requested by Dr X to evaluate her seizure medication and lethargy HISTORY OF PRESENT ILLNESS The patient is well known to me She has symptomatic partial epilepsy secondary to a static encephalopathy cerebral palsy and shunted hydrocephalus related to prematurity She also has a history of factor V Leiden deficiency She was last seen at neurology clinic on 11 16 2007 At that time instructions were given to mom to maximize her Trileptal dose if seizures continue She did well on 2 mL twice a day without any sedation This past Friday she had a 25 minute seizure reportedly This consisted of eye deviation unresponsiveness and posturing Diastat was used and which mom perceived was effective Her Trileptal dose was increased to 3 mL b i d yesterday According to mom since her shunt revision on 12 18 2007 she has been sleepier than normal She appeared to be stable until this past Monday about six days ago she became more lethargic and had episodes of vomiting and low grade fevers According to mom she had stopped vomiting since her hospitalization Reportedly she was given a medication in the emergency room She still is lethargic will not wake up spontaneously When she does awaken however she is appropriate and interacts with them She is able to eat well however her overall p o intake has been diminished She has also been less feisty as her usual sounds She has been seizure free since her admission LABORATORY DATA Pertinent labs obtained here showed the following CRP is less than 0 3 CMP normal and CBC within normal limits CSF cultures so far is negative Dr Limon s note refers to a CSF white blood cell count of 2 1 RBC glucose of 55 and protein of 64 There are no imaging studies in the computer I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr X who indicated that there was no evidence of shunt malfunction or infection CURRENT MEDICATIONS Trileptal 180 mg b i d lorazepam 1 mg p r n acetaminophen and azithromycin PHYSICAL EXAMINATION GENERAL The patient was asleep but easily aroused There was a brief period of drowsiness which she had some jerky limb movements but not seizures She eventually started crying and became agitated She made attempts to sit by bending her neck forward Fully awake she sucks her bottle eagerly HEENT She was obviously visually impaired Pupils were 3 mm sluggishly reactive to light EXTREMITIES Bilateral lower extremity spasticity was noted There was increased flexor tone in the right upper extremity IV was noted on the left hand ASSESSMENT Seizure breakthrough due to intercurrent febrile illness Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded I concur with Dr X s recommendations I do not recommend any changes in Trileptal for now I will be available while she remains hospitalized Keywords neurology lethargy encephalopathy cerebral palsy shunted hydrocephalus seizure breakthrough shunt malfunction neurologic consultation neurologic seizure trileptal MEDICAL_TRANSCRIPTION,Description Neurologic consultation was requested to assess and assist with seizure medication Medical Specialty Neurology Sample Name Neurologic Consultation 3 Transcription HISTORY Neurologic consultation was requested to assess and assist with her seizure medication The patient is a 3 year 3 months old girl with refractory epilepsy She had been previously followed by XYZ but has been under the care of the UCSF epilepsy program and recently by Dr Y I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom The patient had seizure breakthrough in August 2007 which requires inpatient admission Thanksgiving and then after that time had seizures every other day up to date early December She remained seizure free until 12 25 2007 when she had a breakthrough seizure at home treated with Diastat She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home Mom documented 103 temperature at home In the ER this was 101 to 102 degrees Fahrenheit I reviewed the ER notes At 0754 hours she was having intermittent generalized tonic clonic seizures despite receiving a total of 1 5 mg of lorazepam x5 UCSF fellow was contacted She was given additional fosphenytoin and had a total dose of 15 mg kg administered Vital weight was 27 Seizures apparently had stopped The valproic acid level obtained at 0835 hours was 79 According to mom her last dose was at 6 p m and she did not receive her morning dose Other labs slightly showed leukocytosis with white blood cell count 21 000 and normal CMP Previous workup here showed an EEG on 2005 which showed a left posterior focus MRI on June 2007 and January 2005 were within normal limits Mom describes the following seizure types 1 Eye blinking with unresponsiveness 2 Staring off to one side 3 Focal motor activity in one arm and recently generalized tonic seizure She also said that she was supposed to see Dr Y this Friday but had postponed it to some subsequent time when results of genetic testing would be available She was being to physicians care as Dr Z had previously being following her last UCSF She had failed most of the first and second line anti epileptic drugs These include Keppra Lamictal Trileptal phenytoin and phenobarbital These are elicited to allergies but she has not had any true allergic reactions to these Actually it has resulted in an allergic reaction resulting in rash and hypotension She also had been treated with Clobazam Her best control is with her current regimen of valproic acid and Tranxene Other attempts to taper Topamax but this resulted increased seizures She also has oligohidrosis during this summertime CURRENT MEDICATIONS Include Diastat 20 mg Topamax 25 mg b i d which is 3 3 per kilo per day Tranxene 15 mg b i d Depakote 125 mg t i d which is 25 per kilo per day PHYSICAL EXAMINATION VITAL SIGNS Weight 15 kg GENERAL The patient was awake she appeared sedated and postictal NECK Supple NEUROLOGICAL She had a few brief myoclonic jerks of her legs during drowsiness but otherwise no overt seizure no seizure activity nor involuntary movements were observed She was able to follow commands such as when I request that she gave mom a kiss She acknowledged her doll Left fundus is sharp She resisted the rest of the exam There was no obvious lateralized findings ASSESSMENT Status epilepticus resolved Triggered by a febrile illness possibly viral Refractory remote symptomatic partial epilepsy IMPRESSION I discussed the maximizing Depakote to mom and she concurred I recommend increasing her maintenance dose to one in the morning one in the day and two at bedtime For today she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p o Dr X agreed with the changes and orders were written for this She can continue her current doses of Topamax and Tranxene This can be given by NG if needed Topamax can be potentially increased to 25 mg in the morning and 50 mg at night I will be available as needed during the rest of her hospitalization Mom will call contact Dr Y an update him about the recent changes Keywords neurology eye blinking status epilepticus seizure medication valproic acid allergic reactions neurologic consultation seizure neurologic seizures MEDICAL_TRANSCRIPTION,Description Patient with juvenile myoclonic epilepsy and recent generalized tonic clonic seizure Medical Specialty Neurology Sample Name Myoclonic Epilepsy Transcription DIAGNOSES 1 Juvenile myoclonic epilepsy 2 Recent generalized tonic clonic seizure MEDICATIONS 1 Lamictal 250 mg b i d 2 Depo Provera INTERIM HISTORY The patient returns for followup Since last consultation she has tolerated Lamictal well but she has had a recurrence of her myoclonic jerking She has not had a generalized seizure She is very concerned that this will occur Most of the myoclonus is in the mornings Recent EEG did show polyspike and slow wave complexes bilaterally more prominent on the left She states that she has been very compliant with the medications and is getting a good amount of sleep She continues to drive Social history and review of systems are discussed above and documented on the chart PHYSICAL EXAMINATION Vital signs are normal Pupils are equal and reactive to light Extraocular movements are intact There is no nystagmus Visual fields are full Demeanor is normal Facial sensation and symmetry is normal No myoclonic jerks noted during this examination No myoclonic jerks provoked by tapping on her upper extremity muscles Negative orbit Deep tendon reflexes are 2 and symmetric Gait is normal Tandem gait is normal Romberg negative IMPRESSION AND PLAN Recurrence of early morning myoclonus despite high levels of Lamictal She is tolerating the medication well and has not had a generalized tonic clonic seizure She is concerned that this is a precursor for another generalized seizure She states that she is compliant with her medications and has had a normal sleep wake cycle Looking back through her notes she initially responded very well to Keppra but did have a breakthrough seizure on Keppra This was thought secondary to severe insomnia when her baby was very young Because she tolerated the medication well and it was at least partially affective I have recommended adding Keppra 500 mg b i d Side effect profile of this medication was discussed with the patient I will see in followup in three months Keywords neurology generalized tonic clonic seizure juvenile myoclonic epilepsy tonic clonic seizure myoclonic epilepsy tonic clonic juvenile myoclonus epilepsy myoclonic seizure MEDICAL_TRANSCRIPTION,Description Neurologic consultation and follow up Medical Specialty Neurology Sample Name Neurologic Consultation 1 Transcription SOCIAL HISTORY FAMILY HISTORY AND PAST MEDICAL HISTORY Reviewed There are no changes otherwise REVIEW OF SYSTEMS Fatigue pain difficulty with sleep mood fluctuations low stamina mild urgency frequency and hesitancy preponderance of lack of stamina preponderance of pain particularly in the left shoulder EXAMINATION The patient is alert and oriented Extraocular movements are full The face is symmetric The uvula is midline Speech has normal prosody Today there is much less guarding of the left shoulder In the lower extremities iliopsoas quadriceps femoris and tibialis anterior are full The gait is narrow based and noncircumductive Rapid alternating movements are slightly off bilaterally The gait does not have significant slapping characteristics Sensory examination is largely unremarkable Heart lungs and abdomen are within normal limits IMPRESSION Mr ABC is doing about the same We discussed the issue of adherence to Copaxone In order to facilitate this I would like him to take Copaxone every other day but on a regular rhythm His wife continues to inject him He has not been able to start himself on the injections Greater than 50 of this 40 minute appointment was devoted to counseling Keywords neurology neurologic consultation stamina preponderance neurologic consultation copaxone MEDICAL_TRANSCRIPTION,Description Patient with stable expressive aphasia and decreased vision Medical Specialty Neurology Sample Name Multiple Meningiomas Transcription CC Stable expressive aphasia and decreased vision HX This 72y o woman was diagnosed with a left sphenoid wing meningioma on 6 3 80 She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital nuchal headaches One month prior to that presentation she developed leftward head turning and 3 days prior to presentation had an episode of severe dysphasia A HCT done locally revealed a homogenously enhancing lesion of the left sphenoid wing Skull X rays showed deviation of the pineal to the right She was transferred to UIHC and was noted to have a normal neurologic exam per Neurosurgery note Angiography demonstrated a highly vascular left temporal sphenoid wing tumor She under went left temporal craniotomy and complete resection of the tumor which on pathologic analysis was consistent with a meningioma The left sphenoid wing meningioma recurred and was excised 9 25 84 There was regrowth of this tumor seen on HCT 1985 A 6 88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma HCT in 1989 revealed left temporal sphenoid left tentorial and new left frontal lesions On 2 14 91 she presented with increasing lethargy and difficulty concentrating A 2 14 91 HCT revealed increased size and surrounding edema of the left frontal meningioma The left frontal and temporal meningiomas were excised on 2 25 91 These tumors all recurred and a left parietal lesion developed She underwent resection of the left frontal meningioma on 11 21 91 due to right sided weakness and expressive aphasia The weakness partially resolved and though the speech improved following resection it did not return to normal In May 1992 she experienced 3 tonic clonic type seizures all of which began with a Jacksonian march up the RLE then RUE before generalizing Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased On 12 7 92 she underwent a left fronto temporo parieto occipital craniotomy and excision of five meningiomas Postoperatively she developed worsened right sided weakness and expressive aphasia The weakness and aphasia improved by 3 93 but never returned to normal Keywords neurology sphenoid wing meningioma sphenoid wing expressive aphasia meningiomas aphasia sphenoidNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description MRI T spine and CXR Aortic Dissection Medical Specialty Neurology Sample Name MRI T Spine Transcription CC BLE weakness HX This 82y o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia He was in his usual state of health until 5 30PM on 4 6 95 when he developed sudden pressure like epigastric discomfort associated with bilateral lower extremity weakness SOB lightheadedness and diaphoresis He knelt down to the floor and went to sleep The Emergency Medical Service was alert and arrived within minutes at which time he was easily aroused though unable to move or feel his lower extremities No associated upper extremity or bulbar dysfunction was noted He was taken to a local hospital where an INR was found to be 9 1 He was given vitamin K 15mg and transferred to UIHC to rule out spinal epidural hemorrhage An MRI scan of the T spine was obtained and the preliminary reading was normal The Neurology service was then asked to evaluate the patient MEDS Coumadin 2mg qd Digoxin 0 25mg qd Prazosin 2mg qd PMH 1 HTN 2 A Fib on coumadin 3 Peripheral vascular disease s p left Femoral popliteal bypass 8 94 and graft thrombosis thrombolisis 9 94 4 Adenocarcinoma of the prostate s p TURP 1992 FHX unremarkable SHX Farmer Married no Tobacco ETOH illicit drug use EXAM BP165 60 HR86 RR18 34 2C SAO2 98 on room air MS A O to person place time In no acute distress Lucid CN unremarkable MOTOR 5 5 strength in BUE Flaccid paraplegia in BLE Sensory T6 sensory level to LT PP bilaterally Decreased vibratory sense in BLE in a stocking distribution distally Coord Intact FNF and RAM in BUE Unable to do HKS Station no pronator drift Gait not done Reflexes 2 2 BUE Absent in BLE plantar responses were flexor bilaterally Rectal decreased rectal tone GEN EXAM No carotid bruitts Lungs bibasilar crackles CV Irregular rate and rhythm with soft diastolic murmur at the left sternal border Abdomen flat soft non tender without bruitt or pulsatile mass Distal pulses were strong in all extremities COURSE Hgb 12 6 Hct 40 WBC 11 7 Plt 154k INR 7 6 PTT 50 CK 41 the GS was normal EKG showed A Fib at 75BPM with competing junctional pacemaker essentially unchanged from 9 12 94 It was suspected that the patient sustained an anterior cervico thoracic spinal cord infarction with resultant paraplegia and T6 sensory level A CXR was done in the ER prior to admission This revealed cardiomegaly and a widened mediastinum He returned from the x ray suite and suddenly became unresponsive and went into cardiopulmonary arrest Resuscitative measures failed Pericardiocentesis was unremarkable Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma The dissection was seen in retrospect on the MRI T spine Keywords neurology mri a o aortic dissection cxr irregular rate and rhythm mri scan neurology service t spine carotid bruitts epidural hemorrhage mediastinum paraplegia person place stocking distribution time weakness mri t spine sensory level spine MEDICAL_TRANSCRIPTION,Description The thoracic spine was examined in the AP lateral and swimmer s projections Medical Specialty Neurology Sample Name MRI T Spine 1 Transcription EXAM Thoracic Spine REASON FOR EXAM Injury INTERPRETATION The thoracic spine was examined in the AP lateral and swimmer s projections There is mild chronic appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies A mild amount of anterior osteophytic lipping is seen involving the thoracic spine There is a suggestion of generalized osteoporosis The intervertebral disc spaces appear generally well preserved The pedicles appear intact IMPRESSION 1 Mild chronic appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies 2 Mild degenerative changes of the thoracic spine 3 Osteoporosis Keywords neurology thoracic spine swimmer s projections osteoporosis osteophytic lipping anterior wedging vertebral bodies thoracic spine MEDICAL_TRANSCRIPTION,Description MRI of lumbar spine without contrast to evaluate chronic back pain Medical Specialty Neurology Sample Name MRI of Lumbar Spine w o Contrast Transcription EXAM MRI of lumbar spine without contrast HISTORY A 24 year old female with chronic back pain TECHNIQUE Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting FINDINGS The visualized cord is normal in signal intensity and morphology with conus terminating in proper position Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture contusion compression deformity or marrow replacement process There are no paraspinal masses Disc heights signal and vertebral body heights are maintained throughout the lumbar spine L5 S1 Central canal neural foramina are patent L4 L5 Central canal neural foramina are patent L3 L4 Central canal neural foramen is patent L2 L3 Central canal neural foramina are patent L1 L2 Central canal neural foramina are patent The visualized abdominal aorta is normal in caliber Incidental note has been made of multiple left sided ovarian probable physiologic follicular cysts IMPRESSION No acute disease in the lumbar spine Keywords neurology mri central canal noncontrast abdominal aorta axial back pain contrast follicular cysts images lumbar spine morphology neural foramina sagittal signal intensity without contrast mri of lumbar spine mri of lumbar lumbar foramina neural patent spine MEDICAL_TRANSCRIPTION,Description MRI of the Cervical Thoracic and Lumbar Spine Medical Specialty Neurology Sample Name MRI Spine Transcription INTERPRETATION MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal At C4 C5 there were minimal uncovertebral osteophytes with mild associated right foraminal compromise At C5 C6 there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac but no cord deformity or foraminal compromise At C6 C7 there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina MRI of the thoracic spine showed normal vertebral body height and alignment There was evidence of disc generation especially anteriorly at the T5 T6 level There was no significant central canal or foraminal compromise Thoracic cord normal in signal morphology MRI of the lumbar spine showed normal vertebral body height and alignment There is disc desiccation at L4 L5 and L5 S1 with no significant central canal or foraminal stenosis at L1 L2 L2 L3 and L3 L4 There was a right paracentral disc protrusion at L4 L5 narrowing of the right lateral recess The transversing nerve root on the right was impinged at that level The right foramen was mildly compromised There was also a central disc protrusion seen at the L5 S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise IMPRESSION Overall impression was mild degenerative changes present in the cervical thoracic and lumbar spine without high grade central canal or foraminal narrowing There was narrowing of the right lateral recess at L4 L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion This was also seen on a prior study Keywords neurology cervical spine mri cervical thoracic lumbar transversing nerve root vertebral body height vertebral body disc protrusion foraminal compromise central foraminal disc spineNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description MRI L spine History of progressive lower extremity weakness right frontal glioblastoma with lumbar subarachnoid seeding Medical Specialty Neurology Sample Name MRI L Spine Subarachnoid Seeding Transcription CC Progressive lower extremity weakness HX This 52y o RHF had a h o right frontal glioblastoma multiforme GBM diagnosed by brain biopsy partial resection on 1 15 1991 She had been healthy until 1 6 91 when she experienced a generalized tonic clonic type seizure during the night She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture There was minimal associated edema and no mass effect Following extirpation of the tumor mass she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions In 11 91 she received BCNU and Procarbazine chemotherapy protocols This was followed by four courses of 5FU Carboplatin 3 92 6 92 9 92 10 92 chemotherapy On 10 12 92 she presented for her 4th course of 5FU Carboplatin and complained of non radiating dull low back pain and proximal lower extremity weakness but was still able to ambulate She denied any bowel bladder difficulty PMH s p oral surgery for wisdom tooth extraction FHX SHX 1 2 ppd cigarettes rare ETOH use Father died of renal CA MEDS Decadron 12mg day EXAM Vitals unremarkable MS Unremarkable Motor 5 5 BUE LE 4 5 prox 5 5 distal to hips Normal tone and muscle bulk Sensory No deficits appreciated Coord Unremarkable Station No mention in record of being tested Gait Mild difficulty climbing stairs Reflexes 1 1 throughout and symmetric Plantar responses were down going bilaterally INITIAL IMPRESSION Steroid myopathy Though there was enough of a suspicion of drop metastasis that an MRI of the L spine was obtained COURSE The MRI L spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris suggestive of subarachnoid seeding of tumor No focal mass or cord compression was visualized CSF examination revealed 19RBC 22WBC 17 Lymphocytes and 5 histiocytes Glucose 56 Protein 150 Cytology negative The patient was discharged home on 10 17 92 but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months She was last seen on 3 3 93 and showed signs of worsening weakness left hemiplegia R L as her tumor grew and spread She then entered a hospice Keywords neurology glioblastoma multiforme gbm steroid myopathy hemiplegia progressive lower extremity weakness mri l spine lower extremity weakness frontal glioblastoma subarachnoid seeding lower extremity glioblastoma subarachnoid spine mri lower weakness MEDICAL_TRANSCRIPTION,Description MRI L S Spine for Cauda Equina Syndrome secondary to L3 4 disc herniation Low Back Pain LBP with associated BLE weakness Medical Specialty Neurology Sample Name MRI L S Spine Cauda Equina Syndrome Transcription CC Low Back Pain LBP with associated BLE weakness HX This 75y o RHM presented with a 10 day h o progressively worsening LBP The LBP started on 12 3 95 began radiating down the RLE on 12 6 95 then down the LLE on 12 9 95 By 12 10 95 he found it difficult to walk On 12 11 95 he drove himself to his local physician but no diagnosis was rendered He was given some NSAID and drove home By the time he got home he had great difficulty walking due to LBP and weakness in BLE but managed to feed his pets and himself On 12 12 95 he went to see a local orthopedist but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain He also had had BLE numbness since 12 11 95 He was evaluated locally and an L S Spine CT scan and L S Spine X rays were negative He was then referred to UIHC MEDS SLNTC Coumadin 4mg qd Propranolol Procardia XL Altace Zaroxolyn PMH 1 MI 11 9 78 2 Cholecystectomy 3 TURP for BPH 1980 s 4 HTN 5 Amaurosis Fugax OD 8 95 Mayo Clinic evaluation TEE but Carotid Doppler but non surgical so placed on Coumadin FHX Father died age 59 of valvular heart disease Mother died of DM Brother had CABG 8 95 SHX retired school teacher 0 5 1 0 pack cigarettes per day for 60 years EXAM BP130 56 HR68 RR16 Afebrile MS A O to person place time Speech fluent without dysarthria Lucid Appeared uncomfortable CN Unremarkable MOTOR 5 5 strength in BUE Lower extremity strength Hip flexors extensors 4 4 Hip abductors 3 3 Hip adductors 5 5 Knee flexors extensors 4 4 Ankle flexion 4 4 Tibialis Anterior 2 2 Peronei 3 3 Mild atrophy in 4 extremities Questionable fasciculations in BLE Spasms illicited on striking quadriceps with reflex hammer percussion myotonia No rigidity and essential normal muscle tone on passive motion SENSORY Decreased vibratory sense in stocking distribution from toes to knees in BLE worse on right No sensory level PP LT TEMP testing unremarkable COORD Normal FNF RAM Slowed HKS due to weakness Station No pronator drift Romberg testing not done Gait Unable to stand Reflexes 2 2 BUE 1 trace patellae 0 0 Achilles Plantar responses were flexor bilaterally Abdominal reflex was present in all four quadrants Anal reflex was illicited from all four quadrants No jaw jerk or palmomental reflexes illicited Rectal normal rectal tone guaiac negative stool GEN EXAM Bilateral Carotid Bruits No lymphadenopathy right inguinal hernia rhonchi and inspiratory wheeze in both lung fields COURSE WBC 11 6 Hgb 13 4 Hct 38 Plt 295 ESR 40 normal 0 14 CRP 1 4 normal 0 4 INR 1 5 PTT 35 normal Creatinine 2 1 CK 346 EKG normal The differential diagnosis included Amyotrophy Polymyositis Epidural hematoma Disc Herniation and Guillain Barre syndrome An MRI of the lumbar spine was obtained 12 13 95 This revealed an L3 4 disc herniation extending inferiorly and behind the L4 vertebral body This disc was located more on the right than on the left compromised the right neural foramen and narrowed the spinal canal The patient underwent a L3 4 laminectomy and diskectomy and subsequently improved He was never seen in follow up at UIHC Keywords neurology ble weakness carotid doppler disc herniation guillain barre syndrome amyotrophy polymyositis epidural hematoma mri l s spine cauda equina syndrome flexors extensors cauda equina herniation cauda equina extensors reflexes mri hip flexors weakness MEDICAL_TRANSCRIPTION,Description MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57 year old Medical Specialty Neurology Sample Name MRI of Brain w o Contrast Transcription EXAM MRI of the brain without contrast HISTORY Daily headaches for 6 months in a 57 year old TECHNIQUE Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting FINDINGS The brain is normal in signal intensity and morphology for age There are no extraaxial fluid collections There is no hydrocephalus midline shift Posterior fossa 7th and 8th nerve complexes and intraorbital contents are within normal limits The normal vascular flow volumes are maintained The paranasal sinuses are clear Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct IMPRESSION Normal MRI brain Specifically no findings to explain the patient s headaches are identified Keywords neurology mri diffusion posterior fossa axial brain contrast extraaxial flow fluid collections headaches hydrocephalus intraorbital morphology paranasal sagittal sinuses vascular weighting without contrast mri of the brain noncontrast MEDICAL_TRANSCRIPTION,Description MRI Head W WO Contrast Medical Specialty Neurology Sample Name MRI Head Transcription EXAM MRI Head W WO Contrast REASON FOR EXAM Dyspnea COMPARISON None TECHNIQUE MRI of the head performed without and with 12 ml of IV gadolinium Magnevist INTERPRETATION There are no abnormal unexpected foci of contrast enhancement There are no diffusion weighted signal abnormalities There are minimal predominantly periventricular deep white matter patchy foci of FLAIR T2 signal hyperintensity the rest of the brain parenchyma appearing unremarkable in signal The ventricles and sulci are prominent but proportionate Per T2 weighted sequence there is no hyperdense vascularity There are no calvarial signal abnormalities There is no significant mastoid air cell fluid No significant sinus mucosal disease per MRI IMPRESSION 1 No abnormal unexpected foci of contrast enhancement specifically no evidence for metastases or masses 2 No evidence for acute infarction 3 Mild scattered patchy chronic small vessel ischemic disease changes 4 Diffuse cortical volume loss consistent with patient s age 5 Preliminary report was issued at the time of dictation Keywords neurology dyspnea mri of the head foci of contrast patchy foci white matter w wo contrast mri head mri MEDICAL_TRANSCRIPTION,Description MRI head without contrast Medical Specialty Neurology Sample Name MRI Head 1 Transcription EXAM MRI head without contrast REASON FOR EXAM Severe headaches INTERPRETATION Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla Correlation is made with the head CT of 4 18 05 On the diffusion sequence there is no significant bright signal to indicate acute infarction There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease There is mild chronic ischemic change involving the pons bilaterally slightly greater on the right and when correlating with the recent scan there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy There is an old moderate sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution No abnormal mass effect is identified There are no findings to suggest active hydrocephalus No abnormal extra axial collection is identified There is normal flow void demonstrated in the major vascular systems The sagittal sequence demonstrates no Chiari malformation The region of the pituitary optic chiasm grossly appears normal The mastoids and paranasal sinuses are clear IMPRESSION 1 No definite acute findings identified involving the brain 2 There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes There is an old moderate sized infarct of the superior portion of the right cerebellar hemisphere 3 Moderate to moderately advanced atrophy Keywords neurology severe headaches chiari malformation cerebral ischemic change mri head without contrast cerebellar hemisphere superior portion mri head cerebellar infarction ischemic MEDICAL_TRANSCRIPTION,Description MRI C spine C4 5 Transverse Myelitis Medical Specialty Neurology Sample Name MRI C spine Transcription CC Left hemibody numbness HX This 44y o RHF awoke on 7 29 93 with left hemibody numbness without tingling weakness ataxia visual or mental status change She had no progression of her symptoms until 7 7 93 when she notices her right hand was stiff and clumsy She coincidentally began listing to the right when walking She denied any recent colds flu like illness or history of multiple sclerosis She denied symptoms of Lhermitte s or Uhthoff s phenomena MEDS none PMH 1 Bronchitis twice in past year last 2 months ago FHX Father with HTN and h o strokes at ages 45 and 80 now 82 years old Mother has DM and is age 80 SHX Denies Tobacco ETOH illicit drug use EXAM BP112 76 HR52 RR16 36 8C MS unremarkable CN unremarkable Motor 5 5 strength throughout except for slowing of right hand fine motor movement There was mildly increased muscle tone in the RUE and RLE Sensory decreased PP below T2 level on left and some dysesthesias below L1 on the left Coord positive rebound in RUE Station Gait unremarkable Reflexes 3 3 throughout all four extremities Plantar responses were flexor bilaterally Rectal exam not done Gen exam reportedly normal COURSE GS CBC PT PTT ESR Serum SSA SSB dsDNA B12 were all normal MRI C spine 7 145 93 showed an area of decreased T1 and increased T2 signal at the C4 6 levels within the right lateral spinal cord The lesion appeared intramedullary and eccentric and peripherally enhanced with gadolinium Lumbar puncture 7 16 93 revealed the following CSF analysis results RBC 0 WBC 1 lymphocyte Protein 28mg dl Glucose 62mg dl CSF Albumin 16 normal 14 20 Serum Albumin 4520 normal 3150 4500 CSF IgG 4 1mg dl normal 0 6 2 CSF IgG total CSF protein 15 normal 1 14 CSF IgG index 1 1 normal 0 0 7 Oligoclonal bands were present She was discharged home The patient claimed her symptoms resolved within one month She did not return for a scheduled follow up MRI C spine Keywords neurology mri c spine c spine lhermitte s myelitis transverse myelitis uhthoff s ataxia clumsy hemibody numbness mental status numbness tingling weakness mri c spine hemibody mri spine csf MEDICAL_TRANSCRIPTION,Description MRI Brain Subacute right thalamic infarct Medical Specialty Neurology Sample Name MRI Brain Thalamic Infarct Transcription CC Left hemiplegia HX A 58 y o RHF awoke at 1 00AM on 10 23 92 with left hemiplegia and dysarthria which cleared within 15 minutes She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable She was admitted locally She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour She was placed on IV Heparin following the 3rd episode and was transferred to UIHC She had not been taking ASA PMH 1 HTN 2 Psoriasis SHX denied ETOH Tobacco illicit drug use FHX Unknown MEDS Heparin only EXAM BP160 90 HR145 supine BP105 35 HR128 light headed standing RR12 T37 7C MS Dysarthria only Lucid thought process CN left lower facial weakness only Motor mild left hemiparesis with normal muscle bulk Mildly increased left sided muscle tone Sensory unremarkable Coordination impaired secondary to weakness on left Otherwise unremarkable Station left pronator drift Romberg testing not done Gait not tested Reflexes symmetric 2 throughout Gen Exam CV Tachycardic without murmur COURSE The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures She was immediately placed in a reverse Trendelenburg position and given IV fluids Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms PT PTT GS CBC ABG were unremarkable EKG revealed sinus tachycardia with rate dependent junctional changes CXR unremarkable MRI Brain was obtained and showed an evolving right thalamic lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images Over the ensuing days of admission she had significant fluctuations of her BP 200mmHG to 140mmHG systolic Her symptoms worsened with falls in BP Her BP was initially controlled with esmolol or labetalol Renal Ultrasound abdominal pelvic CT renal function scan serum and urine osmolality urine catecholamines metanephrine studies were unremarkable Carotid doppler study revealed 0 15 BICA stenosis and antegrade vertebral artery flow bilaterally Transthoracic echocardiogram was unremarkable Cerebral angiogram was performed to r o vasculitis This revealed narrowing of the M1 segment of the right MCA This was thought secondary to atherosclerosis and not vasculitis She was discharged on ASA Procardia XL and Labetalol Keywords neurology mri brain ct brain heparin dysarthria hemiplegia infarct neurological exam thalamic thalamic infarct mri brain MEDICAL_TRANSCRIPTION,Description MRI C spine to evaluate right shoulder pain C5 6 disk herniation Medical Specialty Neurology Sample Name MRI C Spine C5 6 Disk Herniation Transcription CC Right shoulder pain HX This 46 y o RHF presented with a 4 month history of right neck and shoulder stiffness and pain The symptoms progressively worsened over the 4 month course 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain The later was described as a throbbing pain She also experienced numbness in both lower extremities and pain in the coccygeal region The pains worsened at night and impaired sleep She denied any visual change bowel or bladder difficulties and symptoms involving the LUE She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck Lhermitte s phenomena She denied any history of neck back head trauma She had been taking Naprosyn with little relief PMH 1 Catamenial Headaches 2 Allergy to Macrodantin SHX FHX Smokes 2ppd cigarettes EXAM Vital signs were unremarkable CN unremarkable Motor full strength throughout Normal tone and muscle bulk Sensory No deficits on LT PP VIB TEMP PROP testing Coord Gait Station Unremarkable Reflexes 2 2 in BUE except 2 at left biceps 1 1 BLE except an absent right ankle reflex Plantar responses were flexor bilaterally Rectal exam normal tone IMPRESSION C spine lesion COURSE MRI C spine revealed a central C5 6 disk herniation with compression of the spinal cord at that level EMG NCV showed normal NCV but 1 sharps and fibrillations in the right biceps C5 6 brachioradialis C5 6 triceps C7 8 and teres major and 2 sharps and fibrillations in the right pronator terres There was increased insertional activity in all muscles tested on the right side The findings were consistent with a C6 7 radiculopathy The patient subsequently underwent C5 6 laminectomy and her symptoms resolved Keywords neurology shoulder pain stiffness numbness lhermitte s phenomena c spine lesion disk herniation mri c spine reflexes biceps mri disk shoulder spine herniation MEDICAL_TRANSCRIPTION,Description MRI report Cervical Spine Chiropractic Specific Medical Specialty Neurology Sample Name MRI Cervical Spine Chiropractic Specific Transcription FINDINGS Normal foramen magnum Normal brainstem cervical cord junction There is no tonsillar ectopia Normal clivus and craniovertebral junction Normal anterior atlantoaxial articulation C2 3 There is disc desiccation but no loss of disc space height disc displacement endplate spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina C3 4 There is disc desiccation with a posterior central disc herniation of the protrusion type The small posterior central disc protrusion measures 3 x 6mm AP x transverse in size and is producing ventral thecal sac flattening CSF remains present surrounding the cord The residual AP diameter of the central canal measures 9mm There is minimal right sided uncovertebral joint arthrosis but no substantial foraminal compromise C4 5 There is disc desiccation slight loss of disc space height with a right posterior lateral pre foraminal disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis The disc osteophyte complex measures approximately 5mm in its AP dimension There is minimal posterior annular bulging measuring approximately 2mm The AP diameter of the central canal has been narrowed to 9mm CSF remains present surrounding the cord There is probable radicular impingement upon the exiting right C5 nerve root C5 6 There is disc desiccation moderate loss of disc space height with a posterior central disc herniation of the protrusion type The disc protrusion measures approximately 3 x 8mm AP x transverse in size There is ventral thecal sac flattening with effacement of the circumferential CSF cleft The residual AP diameter of the central canal has been narrowed to 7mm Findings indicate a loss of the functional reserve of the central canal but there is no cord edema There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise C6 7 There is disc desiccation mild loss of disc space height with 2mm of posterior annular bulging There is bilateral uncovertebral and apophyseal joint arthrosis left greater than right with probable radicular impingement upon the bilateral exiting C7 nerve roots C7 T1 T1 2 There is disc desiccation with no disc displacement Normal central canal and intervertebral neural foramina T3 4 There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord IMPRESSION Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above C3 4 posterior central disc herniation of the protrusion type but no cord impingement C4 5 right posterior lateral disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root C5 6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal C6 7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots T3 4 degenerative disc disease with posterior annular bulging Keywords neurology exiting c nerve roots loss of disc space posterior central disc herniation herniation of the protrusion uncovertebral and apophyseal joint intervertebral neural foramina ventral thecal sac thecal sac flattening disc osteophyte complex disc space height central disc herniation apophyseal joint arthrosis posterior annular bulging degenerative disc disease posterior central disc csf cleft osteophyte complex radicular impingement disc disease central disc annular bulging disc desiccation joint arthrosis central canal cervical degenerative csf foraminal bulging impingement protrusion uncovertebral arthrosis canal MEDICAL_TRANSCRIPTION,Description MRI Cervical Spine without contrast Medical Specialty Neurology Sample Name MRI Cervical Spine 2 Transcription EXAM MRI SPINAL CORD CERVICAL WITHOUT CONTRAST CLINICAL Right arm pain numbness and tingling FINDINGS Vertebral alignment and bone marrow signal characteristics are unremarkable The C2 3 and C3 4 disk levels appear unremarkable At C4 5 broad based disk osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour A discrete cord signal abnormality is not identified There may also be some narrowing of the neuroforamina at this level At C5 6 central disk osteophyte contacts and mildly impresses on the ventral cord contour Distinct neuroforaminal narrowing is not evident At C6 7 mild diffuse disk osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface Distinct cord compression is not evident There may be mild narrowing of the neuroforamina at his level A specific abnormality is not identified at the C7 T1 level IMPRESSION Disk osteophyte at C4 5 through C6 7 with contact and may mildly indent the ventral cord contour at these levels Some possible neuroforaminal narrowing is also noted at levels as stated above Keywords neurology mri cervical spine ventral cord contour cervical spine spinal cord cord contour ventral cord mri narrowing ventral cord MEDICAL_TRANSCRIPTION,Description MRI Brain MRI C T spine Multiple hemangioblastoma in Von Hippel Lindau Disease Medical Specialty Neurology Sample Name MRI Brain and C T Spine Transcription CC Weakness HX This 30 y o RHM was in good health until 7 93 when he began experiencing RUE weakness and neck pain He was initially treated by a chiropractor and after an unspecified length of time developed atrophy and contractures of his right hand He then went to a local neurosurgeon and a cervical spine CT scan 9 25 92 revealed an intramedullary lesion at C2 3 and an extramedullary lesion at C6 7 He underwent a C6 T1 laminectomy with exploration and decompression of the spinal cord His clinical condition improved over a 3 month post operative period and then progressively worsened He developed left sided paresthesia and upper extremity weakness right worse than left He then developed ataxia nausea vomiting and hyperreflexia On 8 31 93 MRI C spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa On 9 1 93 he underwent suboccipital craniotomy with tumor excision decompression and biopsy which was consistent with hemangioblastoma His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9 93 through 1 19 94 He was evaluated in the NeuroOncology clinic on 10 26 95 for consideration of chemotherapy He complained of progressive proximal weakness of all four extremities and dysphagia He had difficulty putting on his shirt and raising his arms and he had been having increasing difficulty with manual dexterity e g unable to feed himself with utensils He had difficulty going down stairs but could climb stairs He had no bowel or bladder incontinence or retention MEDS none PMH see above FHX Father with Von Hippel Lindau Disease SHX retired truck driver smokes 1 3 packs of cigarettes per day but denied alcohol use He is divorced and has two sons who are healthy He lives with his mother ROS noncontributory EXAM Vital signs were unremarkable MS A O to person place and time Speech fluent and without dysarthria Thought process lucid and appropriate CN unremarkable exept for 4 4 strength of the trapezeii No retinal hemangioblastoma were seen MOTOR 4 4 strength in proximal and distal upper extremities There is diffuse atrophy and claw hands bilaterally He is unable to manipulate hads to any great extent 4 4 strength throughout BLE There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities SENSORY There was a right T3 and left T8 cord levels to PP on the posterior thorax Decreased LT in throughout the 4 extremities COORD difficult to assess due to weakness Station BUE pronator drift Gait stands without assistance but can only manage to walk a few steps Spastic gait Reflexes Hyperreflexic on left 3 and Hyporeflexic on right 1 Babinski signs were present bilaterally Gen exam unremarkable COURSE 9 8 95 GS normal By 11 14 95 he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies MRI Brain 2 19 96 revealed several lesions hemangioblastoma in the cerebellum and brain stem There were postoperative changes and a cyst in the medulla On 10 25 96 he presented with a 1 5 week h o numbness in BLE from the mid thighs to his toes and worsening BLE weakness He developed decubitus ulcers on his buttocks He also had had intermittent urinary retention for month chronic SOB and dysphagia He had been sitting all day long as he could not move well and had no daytime assistance His exam findings were consistent with his complaints He had had no episodes of diaphoresis headache or elevated blood pressures An MRI of the C T spine 10 26 96 revealed a prominent cervicothoracic syrinx extending down to T10 There was evidence of prior cervical laminectomy of C6 T1 with expansion of the cord in the thecalsac at that region Multiple intradural extra spinal nodular lesions hyperintense on T2 isointense on T1 enhanced gadolinium were seen in the cervical spine and cisterna magna The largest of which measures 1 1 x 1 0 x 2 0cm There are also several large ring enhancing lesions in cerebellum The lesions were felt to be consistent with hemangioblastoma No surgical or medical intervention was initiated Visiting nursing was provided He has since been followed by his local physician Keywords MEDICAL_TRANSCRIPTION,Description MRI cervical spine Medical Specialty Neurology Sample Name MRI Cervical Spine 1 Transcription EXAM MRI CERVICAL SPINE CLINICAL A57 year old male Received for outside consultation is an MRI examination performed on 11 28 2005 FINDINGS Normal brainstem cervical cord junction Normal cisterna magna with no tonsillar ectopia Normal clivus with a normal craniovertebral junction Normal anterior atlantoaxial articulation C2 3 Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina with no cord or radicular impingement C3 4 There is disc desiccation with minimal annular bulging The residual AP diameter of the central canal measures approximately 10mm CSF remains present surrounding the cord C4 5 There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema There is minimal uncovertebral joint arthrosis C5 6 There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm AP x transverse The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement C6 7 There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft There is a left posterolateral disc osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root C7 T1 T1 2 Minimal disc desiccation with no disc displacement or endplate spondylosis IMPRESSION Multilevel degenerative disc disease as described above C4 5 borderline central canal stenosis with mild bilateral foraminal compromise C5 6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion C6 7 degenerative disc disease and endplate spondylosis with a left posterolateral disc osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis Normal cervical cord Keywords neurology borderline central canal stenosis mri cervical spine borderline central canal central canal stenosis degenerative disc annular bulging ap diameter endplate spondylosis borderline central canal stenosis disc desiccation central canal cervical disc spondylosis stenosis cord canal MEDICAL_TRANSCRIPTION,Description MRI Brain Left Basal Ganglia Posterior temporal lobe and Left cerebellar lacunar infarctions with Wernickes Aphasia Medical Specialty Neurology Sample Name MRI Brain Wernicke aphasia Transcription CC Difficulty with speech HX This 72 y o RHM awoke early on 8 14 95 to prepare to play golf He felt fine However at 6 00AM on 8 14 95 he began speaking abnormally His wife described his speech as word salad and complete gibberish She immediately took him to a local hospital Enroute he was initially able to understand what was spoken to him By the time he arrived at the hospital at 6 45AM he was unable to follow commands His speech was reportedly unintelligible the majority of the time and some of the health care workers thought he was speaking a foreign language There were no other symptoms or signs He had no prior history of cerebrovascular disease Blood pressure 130 70 and Pulse 82 upon admission to the local hospital on 8 14 95 Evaluation at the local hospital included 1 HCT scan revealed an old left putaminal hypodensity but no acute changes or evidence of hemorrhage 2 Carotid Duplex scan showed ICA stenosis of 40 bilaterally He was placed on heparin and transferred to UIHC on 8 16 95 In addition he had noted memory and word finding difficulty for 2 months prior to presentation He had undergone a gastrectomy 16 years prior for peptic ulcer disease His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation He and his wife felt that this resulted in improvement of his language and cognitive skills MEDS Heparin IV Vitamin B12 injection q week Lopressor Folate MVI PMH 1 Hypothyroidism reportedly resolved 2 Gastrectomy 3 Vitamin B12 deficiency FHX Mother died of MI age 70 Father died of prostate cancer age 80 Bother died of CAD and prostate cancer age 74 SHX Married 3 children who are alive and well Semi retired Attorney Denied h o tobacco ETOH illicit drug use EXAM BP 110 70 HR 50 RR 14 Afebrile MS A O to person and place but not time Oral comprehension was poor beyond the simplest of conversational phrases Speech was fluent but consisted largely of word salad When asked how he was he replied abadeedleedlebadle Repetition was defective especially with long phrases On rare occasions he uttered short comments appropriately Speech was marred by semantic and phonemic paraphasias He named colors and described most actions well although he described a faucet dripping as a faucet drop He called red reed Reading comprehension was better than aural comprehension He demonstrated excellent written calculations Spoken calculations were accurate except when the calculations became more complex For example he said that ten percent of 100 was equal to 1 200 CN Pupils 2 3 decreasing to 1 1 on exposure to light VFFTC There were no field cuts or evidence of visual neglect EOM were intact Face moved symmetrically The rest of the CN exam was unremarkable MOTOR Full strength throughout with normal muscle tone and bulk There was no evidence of drift SENSORY unremarkable COORD unremarkable Station unremarkable Gait mild difficulty with TW Reflexes 2 2 in BUE 2 2 patellae 1 1 Achilles Plantar responses were flexor on the left and equivocal on the right Gen Exam unremarkable COURSE Lab data on admission Glucose 97 BUN 20 Na 134 K 4 0 Cr 1 3 Chloride 98 CO2 24 PT 11 PTT 42 WBC 12 0 normal differential Hgb 11 4 Hct 36 Plt 203k UA normal TSH 6 0 FT4 0 88 Vit B12 876 Folate 19 1 He was admitted and continued on heparin MRI scan 8 16 95 revealed increased signal on T2 weighted images in Wernicke s area in the left temporal region Transthoracic echocardiogram on 8 17 95 was unremarkable Transesophageal echocardiogram on 8 18 95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve LAE 4 8cm and spontaneous echo contrast in the left atrium were noted There was no evidence of intracardiac shunt or clot Carotid duplex scan on 8 16 95 revealed 0 15 BICA stenosis with anterograde vertebral artery flow bilaterally Neuropsychologic testing revealed a Wernicke s aphasia The impression was that the patient had had a cardioembolic stroke involving a lower division branch of the left MCA He was subsequently placed on warfarin Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge 8 21 95 He has had no further stroke like episodes up until his last follow up visit in 1997 Keywords neurology mri brain difficulty with speech left basal ganglia posterior temporal lobe wernicke s area wernickes aphasia cerebellar infarctions lacunar word finding difficulty carotid duplex scan aphasia wernicke s mri brain MEDICAL_TRANSCRIPTION,Description MRI Brain T spine Demyelinating disease Medical Specialty Neurology Sample Name MRI Brain T spine Demyelinating disease Transcription CC Sensory loss HX 25y o RHF began experiencing pruritus in the RUE above the elbow and in the right scapular region on 10 23 92 In addition she had paresthesias in the proximal BLE and toes of the right foot Her symptoms resolved the following day On 10 25 92 she awoke in the morning and her legs felt asleep with decreased sensation The sensory loss gradually progressed rostrally to the mid chest She felt unsteady on her feet and had difficulty ambulating In addition she also began to experience pain in the right scapular region She denied any heat or cold intolerance fatigue weight loss MEDS None PMH Unremarkable FHX GF with CAD otherwise unremarkable SHX Married unemployed 2 children Patient was born and raised in Iowa Denied any h o Tobacco ETOH illicit drug use EXAM BP121 66 HR77 RR14 36 5C MS A O to person place and time Speech normal with logical lucid thought process CN mild optic disk pallor OS No RAPD EOM full and smooth No INO The rest of the CN exam was unremarkable MOTOR Full strength throughout all extremities except for 5 4 hip extensors Normal muscle tone and bulk Sensory Decreased PP LT below T4 5 on the left side down to the feet Decreased PP LT VIB in BLE left worse than right Allodynic in RUE Coord Intact FNF HKS and RAM bilaterally Station No pronator drift Romberg s test not documented Gait Unsteady wide based Able to TT and HW Poor TW Reflexes 3 3 BUE Hoffman s signs were present bilaterally 4 4 patellae 3 3 Achilles with 3 4 beat nonsustained clonus Plantar responses were extensor on the right and flexor on the left Gen Exam Unremarkable COURSE CBC GS PT PTT ESR FT4 TSH ANA Vit B12 Folate VDRL and Urinalysis were normal MRI T spine 10 27 92 was unremarkable MRI Brain 10 28 92 revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum periventricular region brachium pontis and right pons The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis 10 28 92 Lumbar puncture revealed the following CSF results RBC 1 WBC 9 8 lymphocytes 1 histiocyte Glucose 55mg dl Protein 46mg dl normal 15 45 CSF IgG 7 5mg dl normal 0 0 6 2 CSF IgG index 1 3 normal 0 0 0 7 agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample Beta 2 microglobulin was unremarkable An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing Visual and Brainstem Auditory evoked potentials were normal HTLV 1 titers were negative CSF cultures and cytology were negative She was not treated with medications as her symptoms were primarily sensory and non debilitating and she was discharged home She returned on 11 7 92 as her symptoms of RUE dysesthesia lower extremity paresthesia and weakness all worsened On 11 6 92 she developed slow slurred speech and had marked difficulty expressing her thoughts She also began having difficulty emptying her bladder Her 11 7 92 exam was notable for normal vital signs lying motionless with eyes open and nodding and rhythmically blinking every few minutes She was oriented to place and time of day but not to season day of the week and she did not know who she was She had a leftward gaze preference and right lower facial weakness Her RLE was spastic with sustained ankle clonus There was dysesthetic sensory perception in the RUE Jaw jerk and glabellar sign were present MRI brain 11 7 92 revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale The right peritrigonal region is more prominent than on prior study The left centrum semiovale lesion has less enhancement than previously Multiple other white matter lesions are demonstrated on the right side in the posterior limb of the internal capsule the anterior periventricular white matter optic radiations and cerebellum The peritrigonal lesions on both sides have increased in size since the 10 92 MRI The findings were felt more consistent with demyelinating disease and less likely glioma Post viral encephalitis Rapidly progressive demyelinating disease and tumor were in the differential diagnosis Lumbar Puncture 11 8 92 revealed RBC 2 WBC 12 12 lymphocytes Glucose 57 Protein 51 elevated cytology and cultures were negative HIV 1 titer was negative Urine drug screen negative A stereotactic brain biopsy of the right parieto occipital region was consistent with demyelinating disease She was treated with Decadron 6mg IV qhours and Cytoxan 0 75gm m2 1 25gm On 12 3 92 she has a focal motor seizure with rhythmic jerking of the LUE loss of consciousness and rightward eye deviation EEG revealed diffuse slowing with frequent right sided sharp discharges She was placed on Dilantin She became depressed Keywords neurology sensory loss lumbar puncture peritrigonal region centrum semiovale mri brain white matter demyelinating disease csf demyelinating mri brain MEDICAL_TRANSCRIPTION,Description MRI brain Cerebral Angiogram CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes Medical Specialty Neurology Sample Name MRI Brain Cerebral Angiogram Transcription CC Difficulty with word finding HX This 27y o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2 19 96 She denied any associated dysphagia diplopia numbness or weakness of her extremities She went to sleep with her symptoms on 2 19 96 and awoke with them on 2 20 96 She also awoke with a headache HA and mild neck stiffness She took a shower and her HA and neck stiffness resolved Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech That evening she began to experience numbness and weakness in the lower right face She felt like there was a rubber band wrapped around her tongue For 3 weeks prior to presentation she experienced transient episodes of a boomerang shaped field cut in the left eye The episodes were not associated with any other symptoms One week prior to presentation she went to a local ER for menorrhagia She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months Local evaluation included an unremarkable carotid duplex scan However a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion An MRI brain scan on 2 20 96 revealed nonspecific white matter changes in the right periventricular region EEG reportedly showed diffuse slowing CRP was reportedly too high to calibrate MEDS Ortho Novum 7 7 7 started 2 3 96 and ASA started 2 20 96 PMH 1 ventral hernia repair 10 years ago 2 mild concussion suffered during a MVA without loss of consciousness 5 93 3 Anxiety disorder 4 One childbirth FHX She did not know her father and was not in contact with her mother SHX Lives with boyfriend Smokes one pack of cigarettes every three days and has done so for 10 years Consumes 6 bottles of beers one day a week Unemployed and formerly worked at an herbicide plant EXAM BP150 79 HR77 RR22 37 4C MS A O to person place and time Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors Comprehension naming and reading were intact She was able to repeat though her repetition was occasionally marked by phonemic paraphasic errors She had no difficulty with calculation CN VFFTC Pupils 5 5 decreasing to 3 3 EOM intact No papilledema or hemorrhages seen on fundoscopy No RAPD or INO There was right lower facial weakness Facial sensation was intact bilaterally The rest of the CN exam was unremarkable MOTOR 5 5 strength throughout with normal muscle bulk and tone Sensory No deficits Coord Station Gait unremarkable Reflexes 2 2 throughout Plantar responses were flexor bilaterally Gen Exam unremarkable COURSE CRP 1 2 elevated ESR 10 RF 20 ANA 1 40 ANCA 1 40 TSH 2 0 FT4 1 73 Anticardiolipin antibody IgM 10 8GPL units normal 10 9 Anticardiolipin antibody IgG 14 8GPL normal 22 9 SSA and SSB were normal Urine beta hCG pregnancy and drug screen were negative EKG CXR and UA were negative MRI brain 2 21 96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere In addition there were subtle T2 signal changes in the right frontal right parietal and left parietal regions as seen previously on her local MRI can In addition special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia She underwent Cerebral Angiography on 2 22 96 This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe These changes corresponded to the areas of ischemic changes seen on MRI There was also segmental narrowing of the caliber of the vessels in the circle of Willis There was a small aneurysm at the origin of the LPCA There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments The study was highly suggestive of vasculitis 2 23 96 Neuro ophthalmology evaluation revealed no evidence of retinal vasculitic change Neuropsychologic testing the same day revealed slight impairment of complex attention only She was started on Prednisone 60mg qd and Tagamet 400mg qhs On 2 26 96 she underwent a right frontal brain biopsy Pathologic evaluation revealed evidence of focal necrosis stroke infarct but no evidence of vasculitis Immediately following the brain biopsy while still in the recovery room she experienced sudden onset right hemiparesis and transcortical motor type aphasia Initial HCT was unremarkable An EEG was consistent with a focal lesion in the left hemisphere However a 2 28 96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus This was felt consistent with vasculitis She began q2month cycles of Cytoxan 1 575mg IV on 2 29 96 She became pregnant after her 4th cycle of Cytoxan despite warnings to the contrary After extensive discussions with OB GYN it was recommended she abort the pregnancy She underwent neuropsychologic testing which revealed no significant cognitive deficits She later agreed to the abortion She has undergone 9 cycles of Cytoxan one cycle every 2 months as of 4 97 She had complained of one episode of paresthesias of the LUE in 1 97 MRI then showed no new signs ischemia Keywords MEDICAL_TRANSCRIPTION,Description MRI Brain Thrombus in torcula of venous sinuses Medical Specialty Neurology Sample Name MRI Brain Thrombus Transcription CC Motor vehicle bicycle collision HX A 5 y o boy admitted 10 17 92 He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth He was intubated and ventilated in the field and then transferred to UIHC PMH FHX SHX unremarkable MEDS none EXAM BP 127 91 HR69 RR30 MS unconscious and intubated Glasgow coma scale 4 CN Pupils 6 6 fixed Corneal reflex trace OD absent OS Gag present on manipulation of endotracheal tube MOTOR SENSORY bilateral decorticate posturing to noxious stimulation chest Reflexes bilaterally Laceration of mid forehead exposing calvarium COURSE Emergent Brain CT scan revealed Displaced fracture of left calvarium Left frontoparietal intraparenchymal hemorrhage Right ventricular collection of blood Right cerebral intraparenchymal hemorrhage Significant mass effect with deviation of the midline structures to right The left ventricle was compressed with obliteration of the suprasellar cistern Air within the soft tissues in the left infra temporal region C spine XR Abdominal Chest CT were unremarkable Patient was taken to the OR emergently and underwent bifrontal craniotomy evacuation of a small epidural and subdural hematomas and duraplasty He was given mannitol enroute to the OR and hyperventilated during and after the procedure Postoperatively he continued to manifest decerebrate posturing On 11 16 92 he underwent VP shunting with little subsequent change in his neurological status On 11 23 92 he underwent tracheostomy On 12 11 92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy By the time of discharge 1 14 93 he tracked relatively well OD but had a CN3 palsy OS He had relatively severe extensor rigidity in all extremities R L His tracheotomy was closed prior to discharge A 11 16 92 Brain MRI demonstrated infarction in the upper brain stem particularly in the Pons left cerebellum right basil ganglia and thalamus He was initially treated for seizure prophylaxis with DPH but developed neutropenia so it was discontinued He developed seizures within several months of discharge and was placed on VPA Depakene This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol 10 8 93 Brain MRI one year after MVA revealed interval appearance of hydrocephalus abnormal increased T2 signal in the medulla right pons both basal ganglia right frontal and left occipital regions a small mid brain and a right subdural fluid collection These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion and signs of a previous right subdural hematoma He was last seen 10 30 96 in the pediatric neurology clinic age 9 years He was averaging 2 3 seizures per day characterized by extension of BUE with tremor and audible cry or laughter on Tegretol and Diazepam In addition he experiences 24 48hour periods of startle response myoclonic movement of the shoulders with or without stimulation every 6 weeks He had limited communication skills sparse speech On exam he had disconjugate gaze dilated fixed left pupil spastic quadriplegia Keywords neurology mri brain brain mri thrombus intraparenchymal hemorrhage motor vehicle prophylaxis sinuses torcula venous sinuses venous brain thrombus bilateral decorticate decorticate posturing subdural hematomas subdural mri brain torcula MEDICAL_TRANSCRIPTION,Description MRI Brain and Brainstem Falling Multiple System Atrophy Medical Specialty Neurology Sample Name MRI Brain and Brainstem Transcription CC Falling HX This 67y o RHF was diagnosed with Parkinson s Disease in 9 1 95 by a local physician For one year prior to the diagnosis the patient experienced staggering gait falls and episodes of lightheadedness She also noticed that she was slowly losing her voice and that her handwriting was becoming smaller and smaller Two months prior to diagnosis she began experienced bradykinesia but denied any tremor She noted no improvement on Sinemet which was started in 9 95 At the time of presentation 2 13 96 she continued to have problems with coordination and staggering gait She felt weak in the morning and worse as the day progressed She denied any fever chills nausea vomiting HA change in vision seizures or stroke like events or problems with upper extremity coordination MEDS Sinemet CR 25 100 1tab TID Lopressor 25mg qhs Vitamin E 1tab TID Premarin 1 25mg qd Synthroid 0 75mg qd Oxybutynin 2 5mg has isocyamine 0 125mg qd PMH 1 Hysterectomy 1965 2 Appendectomy 1950 s 3 Left CTR 1975 and Right CTR 1978 4 Right oophorectomy 1949 for tumor 5 Bladder repair 1980 for unknown reason 6 Hypothyroidism dx 4 94 7 HTN since 1973 FHX Father died of MI age 80 Mother died of MI age73 Brother died of Brain tumor age 9 SHX Retired employee of Champion Automotive Co Denies use of TOB ETOH Illicit drugs EXAM BP supine 182 113 HR supine 94 BP standing 161 91 HR standing 79 RR16 36 4C MS A O to person place and time Speech fluent and without dysarthria No comment regarding hypophonia CN Pupils 5 5 decreasing to 2 2 on exposure to light Disks flat Remainder of CN exam unremarkable Motor 5 5 strength throughout NO tremor noted at rest or elicited upon movement or distraction Sensory Unremarkable PP VIB testing Coord Did not show sign of dysmetria dyssynergia or dysdiadochokinesia There was mild decrement on finger tapping and clasping unclasping hands right worse than left Gait Slow gait with difficulty turning on point Difficulty initiating gait There was reduced BUE swing on walking right worse than left Station 3 4step retropulsion Reflexes 2 2 and symmetric throughout BUE and patellae 1 1 Achilles Plantar responses were flexor Gen Exam Inremarkable HEENT unremarkable COURSE The patient continued Sinemet CR 25 100 1tab TID and was told to monitor orthostatic BP at home The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia She was seen again on 5 28 96 and reported no improvement in her condition In addition she complained of worsening lightheadedness upon standing and had an episode 1 week prior to 5 28 96 in which she was at her kitchen table and became unable to move There were no involuntary movements or alteration in sensorium mental status During the episode she recalled wanting to turn but could not Two weeks prior to 5 28 96 she had an episode of orthostatic syncope in which she struck her head during a fall She discontinued Sinemet 5 days prior to 5 28 96 and felt better She felt she was moving slower and that her micrographia had worsened She had had recent difficulty rolling over in bed and has occasional falls when turning She denied hypophonia dysphagia or diplopia On EXAM BP supine 153 110 with HR 88 BP standing 110 80 with HR 96 Myerson s sign and mild hypomimia but no hypophonia There was normal blinking and EOM Motor strength was full throughout No resting tremor but mild postural tremor present No rigidity noted Mild decrement on finger tapping noted Reflexes were symmetric No Babinski signs and no clonus Gait was short stepped with mild anteroflexed posture She was unable to turn on point 3 4 step Retropulsion noted The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy Drager syndrome It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20 30 degrees at night Indomethacin was suggested to improve BP in future Keywords neurology myerson s sign falling dysautonomia mri brain and brainstem brain and brainstem mri brain sinemet cr mri brainstem ctr tumor retropulsion parkinsonism brain lightheadedness hypophonia standing sinemet MEDICAL_TRANSCRIPTION,Description MRI Brain Pilocytic Astrocytoma in thalamus and caudate Medical Specialty Neurology Sample Name MRI Brain Pilocytic Astrocytoma Transcription CC Headache HX The patient is an 8y o RHM with a 2 year history of early morning headaches 3 00 6 00AM intermittently relieved by vomiting only He had been evaluated 2 years ago and an EEG was normal then but no brain imaging was performed His headaches progressively worsened especially in the past two months prior to this presentation For 2 weeks prior to his 1 25 93 evaluation at UIHC he would awake screaming His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and Vermox was prescribed and arrangements were made for a neurologic evaluation On the evening of 1 24 93 the patient awoke screaming and began to vomit This was followed by a 10 min period of tonic clonic type movements and postictal lethargy He was taken to a local ER and a brain CT revealed an intracranial mass He was given Decadron and Phenytoin and transferred to UIHC for further evaluation MEDS noted above PMH 1 Born at 37 5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother Pregnancy complicated by vaginal bleeding at 7 months Met developmental milestones without difficulty 2 Frequent otitis media now resolved 3 Immunizations were up to date FHX non contributory SHX lives with biologic father and mother No siblings In 3rd grade mainstream and maintaining good marks in schools EXAM BP121 57mmHg HR103 RR16 36 9C MS Sleepy but cooperative CN EOM full and smooth Advanced papilledema OU VFFTC Pupils 4 4 decreasing to 2 2 Right lower facial weakness Tongue midline upon protrusion Corneal reflexes intact bilaterally Motor 5 5 strength Slightly increased muscle on right side Sensory No deficit to PP VIB noted Coord normal FNF HKS and RAM bilaterally Station Mild truncal ataxia Tends to fall backward Reflexes BUE 2 2 Patellar 3 3 Ankles 3 3 with 6 beats of nonsustained clonus bilaterally Gen exam unremarkable COURSE The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs Brain MRI 1 26 93 revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images There were areas of cystic formation at its periphery The mass appeared to enhance on post gadolinium images there was associated white matter edema and compression of the left lateral ventricle and midline shift to the right There was no sign of uncal herniation He underwent bilateral VP shunting on 1 26 93 and then subtotal resection left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum on 1 28 93 He then received 5040cGy of radiation therapy in 28 fractions completed on 3 25 93 A 3 20 95 neuropsychological evaluation revealed low average intellect on the WISC III There were also signs of memory attention reading and spelling deficits and mild right sided motor incoordination and mood variability He remained in mainstream classes at school but his physical and cognitive performance began to deteriorate in 4 95 Neurosurgical evaluation in 4 95 noted increased right hemiplegia and right homonymous hemianopia MRI revealed tumor progression and he was subsequently placed on Carboplatin VP 16 CG 9933 protocol chemotherapy regimen A He was last seen on 4 96 and was having difficulty in the 6th grade he was also undergoing physical therapy for his right hemiplegia Keywords neurology mri brain pilocytic astrocytoma caudate thalamus headache astrocytoma hemiplegia pilocytic mri MEDICAL_TRANSCRIPTION,Description Right pontine pyramidal tract infarct Medical Specialty Neurology Sample Name MRI Brain Pontine Stroke Transcription CC Left sided weakness HX 74 y o RHF awoke from a nap at 11 00 AM on 11 22 92 and felt weak on her left side She required support on that side to ambulate In addition she felt spoke as though she was drunk Nevertheless she was able to comprehend what was being spoken around her Her difficulty with speech completely resolved by 12 00 noon She was brought to UIHC ETC at 8 30AM on 11 23 92 for evaluation MEDS none ALLERGIES ASA PCN both cause rash PMH 1 HTN 2 COPD 3 h o hepatitis unknown type 4 Macular degeneration SHX Widowed lives alone Denied ETOH Tobacco illicit drug use FHX unremarkable EXAM BP191 89 HR68 RR16 37 2C MS A O to person place and time Speech fluent without dysarthria Intact naming comprehension and repetition CN Central scotoma OS old Mild upper lid ptosis OD old per picture Lower left facial weakness Motor Mild Left hemiparesis 4 to 5 strength throughout affected side No mention of muscle tone in chart Sensory unremarkable Coord impaired FNF and HKS movement secondary to weakness Station Left pronator drift No Romberg sign seen Gait Left hemiparetic gait with decreased LUE swing Reflexes 3 3 biceps and triceps 3 3 patellae 2 3 ankles with 3 4beats of non sustained ankle clonus on left Plantars Left babinski sign and flexor on right General Exam 2 6 SEM at left sternal border COURSE GS CBC PT PTT CK ESR were within normal limits ABC 7 4 46 63 on room air EKG showed a sinus rhythm with right bundle branch block MRI brain 11 23 95 revealed a right pontine pyramidal tract infarction She was treated with Ticlopidine 250mg bid On 11 26 92 her left hemiparesis worsened A HCT 11 27 92 was unremarkable The patient was treated with IV Heparin This was discontinued the following day when her strength returned to that noted on 11 23 95 On 11 27 92 she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies Carotid duplex showed 0 15 bilateral ICA stenosis and antegrade vertebral artery flow bilaterally Transthoracic echocardiogram revealed aortic insufficiency only Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation aortic valvular fibrosis There was calcification and possible thrombus seen in the descending aorta Cardiology did not feel the later was an indication for anticoagulation She was discharged home on Isordil 20 tid Metoprolol 25mg q12hours and Ticlid 250mg bid Keywords neurology mri brain pontine stroke difficulty with speech hemiparesis pontine pyramidal tract infarct weakness mri brain pyramidal echocardiogram pontine infarct MEDICAL_TRANSCRIPTION,Description A middle aged male with increasing memory loss and history of Lyme disease Medical Specialty Neurology Sample Name MRI Brain Lyme Disease Transcription FINDINGS There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica This mass lesions measures approximately 16 x 18 x 18mm craniocaudal x AP x mediolateral in size Keywords neurology increasing memory loss intrasellar mass lesion memory loss sella turcica cavernous sinus sphenoid sinus ct imaging white matter retention cyst maxillary antrum lyme disease mass lesion disease cavernous cortical mass lesion MEDICAL_TRANSCRIPTION,Description MRI Brain Progressive Multifocal Leukoencephalopathy PML occurring in an immunosuppressed patient with polymyositis Medical Specialty Neurology Sample Name MRI Brain Leukoencephalopathy Transcription CC Progressive left visual field loss HX This 46y o RHF with polymyositis since 1988 presented with complaint of visual field loss since 12 94 The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia She began experiencing stiffness numbness tingling and incoordination of her left hand 6 weeks prior to this admission These symptoms were initially attributed to carpal tunnel syndrome MRI scan of the brain done locally on 6 23 95 revealed increased periventricular white matter signal on T2 images particularly in the left temporo occipital and right parietal lobes There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images There was gyral enhancement near the right Sylvian fissure Cerebral angiogram on 7 19 95 done locally was unremarkable Lumbar puncture on 7 19 95 was unremarkable She complained of frequent holocranial throbbing headaches for the past 6 months the HA s are associated with photophobia phonophobia and nausea but no vomiting She has also been experiencing chills and night sweats for the past 2 3 weeks She denies weight loss but acknowledged decreased appetite and increased generalized fatigue for the past 3 4 months She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness She has been on immunosuppressive drugs since 1988 including Prednisone Prednisone and methotrexate Cyclosporin Imuran Cytoxan and Plaquenil At present she in ambulatory with use of walker Her last CK 3 125 and ESR 16 on 6 28 95 MEDS Prednisone 20mg qd Cytoxan 75mg qd Zantac 150mg bid Vasotec 10mg bid Premarin 0 625 qd Provera 2 5mg qd CaCO3 500mg bid Vit D 50 000units qweek Vit E qd MVI 1 tab qd PMH 1 polymyositis diagnosed in 1988 by muscle biopsy 2 hypertension 3 lichen planus 4 Lower extremity deep venous thrombosis one year ago placed on Coumadin and this resulted in postmenopausal bleeding FHX Mother is alive and has a h o HTN and stroke Father died in motor vehicle accident at age 40 years SHX Married 3 children who are healthy She denied any Tobacco ETOH Illicit drug use EXAM BP160 74 HR95 RR12 35 8C Wt 86 4kg Ht 5 6 MS A O to person place and time Speech was normal Mood euthymic with appropriate affect CN Pupils 4 4 decreasing to 2 2 on exposure to light No RAPD noted Optic Disk were flat EOM testing unremarkable Confrontational visual field testing revealed a left homonymous hemianopsia The rest of the CN exam was unremarkable MOTOR Upper extremities 5 5 proximally 5 4 elbow wrist hand Lower extremities 4 4 proximally and 5 5 and below knees SENSORY unremarkable COORD Dyssynergia of LUE FNF movement Slowed finger tapping on left HNS movements were normal bilaterally Station LUE drift and fix on arm roll No Romberg sign elicited Gait Waddling gait but could TT and stand on both heels She had difficulty with tandem walking but did not fall to any particular side Reflexes 2 2 brachioradialis and biceps 2 2 triceps 1 1 patellae 1 1 Achilles Plantar responses were flexor on the right and withdrawal response on the left GEN EXAM No rashes II VI systolic ejection murmur at the left sternal border COURSE Electrolytes PT PTT Urinalysis and CXR were normal ESR 38 normal 20 CRP1 4 normal 0 4 CK 2 917 LDH 356 AST 67 MRI Brain 8 8 95 revealed slight improvement of the abnormal white matter changes seen on previous outside MRI In addition new sphenoid sinus disease suggestive of sinusitis was seen She underwent stereotactic biopsy of the right parietal region on 8 10 95 which on H E and LFB stained sections revealed multiple discrete areas of demyelination containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic ground glass nuclei enlarged astrocytes and sparse perivascular lymphocytic infiltrates In situ hybridization performed on block A2 at the university of Pittsburgh is positive for JC virus The ultrastructural studies demonstrated no viral particles She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable She had a seizure in 12 95 and was placed on Dilantin Her neurologic deficits worsened slightly but reached a plateau by 10 96 as indicated by a 4 14 97 Neurology clinic visit note 1 22 96 MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres worse on the right side There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto occipital regions There was progression of abnormal signal in the Basal Ganglia worse on the right and new involvement of the brainstem Keywords neurology mri brain pml progressive multifocal leukoencephalopathy polymyositis visual field loss leukoencephalopathy lower extremity field loss white matter visual field signal brain mri MEDICAL_TRANSCRIPTION,Description Progressive loss of color vision OD Medical Specialty Neurology Sample Name Meningioma Transcription CC Progressive loss of color vision OD HX 58 y o female presents with a one year history of progressive loss of color vision In the past two months she has developed blurred vision and a central scotoma OD There are no symptoms of photopsias diplopia headache or eye pain There are no other complaints There have been mild fluctuations of her symptoms but her vision has never returned to its baseline prior to symptom onset one year ago EXAM Visual acuity with correction 20 25 1 OD 20 20 1 OS Pupils were 3 5mm OU There was a 0 8 log unit RAPD OD Intraocular pressures were 25 and 24 OD and OS respectively and there was an increase to 27 on upgaze OD but no increase on upgaze OS Optic disk pallor was evident OD but not OS Additionally there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye Foveal flicker fusion occurred at a frequency of 21 9 OD and 30 7 OS Color plate testing scores 6 14 OD and 10 14 OS Goldman visual field examination showed an enlarged and deepened blind spot with an infero temporal defect especially in the smaller diopters IMPRESSION ON 2 6 89 Optic neuropathy atrophy OD rule out mass lesion affecting optic nerve Particular attention was paid to the area of the optic canal cavernous sinus and sphenoid sinus BRAIN CT W CONTRAST 2 13 89 Enhancing calcified lesion in the posterior aspect of the right optic nerve probable meningioma MRI ORBITS W AND W OUT GADOLINIUM CONTRAST 4 26 89 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD The mass is just proximal to the orbital apex There is relatively homogeneous enhancement of the mass The findings are most consistent with meningioma MRI 1995 Mild enlargement of tumor with possible slight extension into the right cavernous sinus COURSE Resection and biopsy were deferred due to risk of blindness and suspicion that the tumor was a slow growing meningioma 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam There was greater red color desaturation of the temporal field OD Visual acuity had decreased from 20 20 to 20 64 OD All other deficits seen on her initial exam remained stable or slightly worsened By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection Keywords neurology goldman visual field examination loss of color vision visual field examination visual acuity cavernous sinus color vision visual field optic nerve meningioma MEDICAL_TRANSCRIPTION,Description A middle aged female with memory loss Medical Specialty Neurology Sample Name MRI Brain Memory Loss Transcription FINDINGS There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces There is confluent white matter hyperintensity in a bi hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra axial or extraaxial mass lesions There is a cavum velum interpositum normal variant There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space Normal basal ganglia and thalami Normal internal and external capsules Normal midbrain There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease There are areas of T2 hyperintensity involving the bilateral brachium pontis left greater than right with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology Interval reassessment of this lesion is recommended There is a remote lacunar infarction of the right cerebellar hemisphere Normal left cerebellar hemisphere and vermis There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery Normal flow within the carotid arteries and circle of Willis Normal calvarium central skull base and temporal bones There is no demonstrated calvarium metastases IMPRESSION Severe generalized cerebral atrophy Extensive chronic white matter ischemic changes in a bi hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation Interval reassessment of this lesion is recommended Remote lacunar infarction in the right cerebellar hemisphere Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or lacunar infarction No demonstrated calvarial metastases Keywords neurology white matter ischemic remote lacunar infarction memory loss matter ischemic remote lacunar cerebellar hemisphere lacunar infarction brachium pontis white matter basilar calvarium ischemic enhancement cerebellar hemispheres hyperintensity infarction brachium MEDICAL_TRANSCRIPTION,Description MRI Brain Ventriculomegaly of the lateral 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus unencapsulated in a non immune suppressed HIV negative individual Medical Specialty Neurology Sample Name MRI Brain Cryptococcus Transcription CC Headache HX This 37y o LHM was seen one month prior to this presentation for HA nausea and vomiting Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home These symptoms had been recurrent since onset At presentation he complained of mild blurred vision OU difficulty concentrating and HA which worsened upon sitting up The headaches were especially noticeable in the early morning He described them as non throbbing headaches They begin in the bifrontal region and radiate posteriorly They occurred up to 6 times day The HA improved with lying down or dropping the head down between the knees towards the floor The headaches were associated with blurred vision nausea vomiting photophobia and phonophobia He denied any scotomata or positive visual phenomena He denies any weakness numbness tingling dysarthria or diplopia His weight has fluctuated from 163 to 148 over the past 3 months and at present he weighs 154 His appetite has been especially poor in the past month MEDS Sulfasalazine qid Tylenol 650mg q4hours PMH 1 Ulcerative Colitis dx 1989 2 HTN 3 occasional HAs since the early 1980s which are different in character and much less severe than his current HAs They were not associated with nausea vomiting photophobia phonophobia or difficulty thinking FHX MGF with h o stroke Mother and Father were healthy No h o of migraine in family SHX Single Works as a newpaper printing press worker Denies tobacco ETOH or illicit drug use but admits he was a heavy drinker until the last 1970s when he quit EXAM BP159 92 HR 48 sitting BP126 70 HR48 supine RR14 36 2C MS A O to person place and time Speech clear Appears uncomfortable but acts appropriately and cooperatively No difficulty with short and long term memory CN Grad 2 3 papilledema OS Grade 1 papilledema 2 o clock OD Pupils 4 4 decreasing to 2 2 on exposure to light Bilateral horizontal sustained nystagmus on right and leftward gaze Bilateral vertical sustained nystagmus on up and downward gaze Face symmetric with full movement and PP sensation Tongue midline with full ROM Gag and SCM were intact bilaterally Motor Full strength throughout with normal muscle bulk and tone Sensory Unremarkable Coord Mild dysynergia on FNF movements in BUE HNS and RAM were unremarkable Station Unsteady with and without eyes open on Romberg test No drift in any particular direction Gait Wide based ataxic and to some degree magnetic and apraxic Gen Exam Unremarkable COURSE Urinalysis revealed 1 2RBC 2 3WBC and bacteria were noted Repeat Urinalysis was negative the next day PT PTT CXR and GS were normal CBC revealed 10 4WBC with 7 1Granulocytes HCT 10 18 95 revealed hydrocephalus MRI 10 18 95 revealed ventriculomegaly of the lateral 3rd and 4th ventricles There was enhancement of the meninges about the prepontine cisterna and internal auditory canals and enhancement of a scar or inflammed lining of the foramen of Magendie These changes were felt suggestive of bacterial or granulomatous meningitis The patient underwent ventriculostomy on 10 19 94 CSF taken on 10 19 94 via V P shunt insertion revealed 22 WBC 21 lymphocytes 1 monocyte 380 RBC Glucose 58 Protein 29 GS negative Cultures bacterial fungal AFB negative Cryptococcal Antigen and India Ink were negative Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg dl Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions VDRL and HIV testing was unremarkable 10 27 94 and 10 31 94 CSF cultures taken from the cervical region eventually grew non encapsulated crytococcus neoformans The patient was treated with amphotericin and showed some improvement However scarring had probably occurred by then and the V P shunt was left in place Keywords neurology ventriculomegaly foramen of magendie mri brain blurred vision headache brain ventricles cryptococcus foramen csf MEDICAL_TRANSCRIPTION,Description Problems with seizures hemiparesis has been to the hospital developed C diff and is in the nursing home currently Medical Specialty Neurology Sample Name Malignant Meningioma Consult Transcription REASON FOR VISIT This is a new patient evaluation for Mr A There is a malignant meningioma He is referred by Dr X HISTORY OF PRESENT ILLNESS He said he has had two surgeries in 07 06 followed by radiation and then again in 08 07 He then had a problem with seizures hemiparesis has been to the hospital developed C diff and is in the nursing home currently He is unable to stand at the moment He is unable to care for himself I reviewed the information that was sent down with him from the nursing home which includes his medical history MEDICATIONS Keppra 1500 twice a day and Decadron 6 mg four times a day His other medicines include oxycodone an aspirin a day Prilosec Dilantin 300 a day and Flagyl FINDINGS On examination he is lying on the stretcher He has oxygen on and has periods of spontaneous hyperventilation He is unable to lift his right arm or right leg He has an expressive dysphasia and confusion I reviewed the imaging studies from summer from the beginning of 10 07 end of 10 07 as well as the current MRI he had last week This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema This is a malignant meningioma by diagnosis ASSESSMENT PLAN In summary Mr A has significant disability and is not independent currently I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor Given that there are not good therapies and chemotherapy would be the option at the moment and he certainly is not in a condition where chemotherapy would be given I believe that surgery would not be in his best interest I discussed this both with him although it is not clear to me how much he understood as well as his family Keywords neurology seizures hemiparesis tumor seizures hemiparesis malignant meningioma chemotherapy malignant meningioma aspirin MEDICAL_TRANSCRIPTION,Description MRI Brain to evaluate sudden onset blindness Basilar bilateral thalamic strokes Medical Specialty Neurology Sample Name MRI Brain Bilateral Thalamic Strokes Transcription CC Sudden onset blindness HX This 58 y o RHF was in her usual healthy state until 4 00PM 1 8 93 when she suddenly became blind Tongue numbness and slurred speech occurred simultaneously with the loss of vision The vision transiently improved to severe blurring enroute to a local ER but worsened again once there While being evaluated she became unresponsive even to deep noxious stimuli She was transferred to UIHC for further evaluation Upon arrival at UIHC her signs and symptoms were present but markedly improved PMH 1 Hysterectomy many years previous 2 Herniorrhaphy in past 3 DJD relieved with NSAIDs FHX SHX Married x 27yrs Husband denied Tobacco ETOH illicit drug use for her Unremarkable FHx MEDS none EXAM Vitals 36 9C HR 93 BP 151 93 RR 22 98 O2Sat MS somnolent but arousable to verbal stimulation minimal speech followed simple commands on occasion CN Blinked to threat from all directions EOM appeared full Pupils 2 2 decreasing to 1 1 Corneas Winced to PP in all areas of Face Gag Tongue midline Oculocephalic reflex intact Motor UE 4 5 proximally Full strength in all other areas Normal tone and muscle bulk Sensory Withdrew to PP in all extremities Gait ND Reflexes 2 2 throughout UE 3 3 patella 2 2 ankles Plantar responses were flexor bilaterally Gen exam unremarkable COURSE MRI Brain revealed bilateral thalamic strokes Transthoracic echocardiogram TTE showed an intraatrial septal aneurysm with right to left shunt Transesophageal echocardiogram TEE revealed the same No intracardiac thrombus was found Lower extremity dopplers were unremarkable Carotid duplex revealed 0 15 bilateral ICA stenosis Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU diminished up and down gaze Neuropsychologic assessment 1 12 15 93 revealed severe impairment of anterograde verbal and visual memory including acquisition and delayed recall and recognition Speech was effortful and hypophonic with very defective verbal associative fluency Reading comprehension was somewhat preserved though she complained that despite the ability to see type clearly she could not make sense of words There was impairment of 2 D constructional praxis A follow up Neuropsychology evaluation in 7 93 revealed little improvement Laboratory studies TSH FT4 CRP ESR GS PT PTT were unremarkable Total serum cholesterol 195 Triglycerides 57 HDL 43 LDL 141 She was placed on ASA and discharged1 19 93 She was last seen on 5 2 95 and was speaking fluently and lucidly She continued to have mild decreased vertical eye movements Coordination and strength testing were fairly unremarkable She continues to take ASA 325 mg qd Keywords neurology blindness mri transthoracic echocardiogram transesophageal echocardiogram tsh ft4 crp esr gs pt ptt bilateral thalamic strokes sudden onset blindness mri brain thalamic strokes brain thalamic strokes MEDICAL_TRANSCRIPTION,Description MRI Brain Olfactory groove meningioma Medical Specialty Neurology Sample Name MRI Brain Meningioma Olfactory Transcription CC Progressive visual loss HX 76 y o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation He continues to be anosmic but has also recently noted decreased vision OD He denies any headaches weakness numbness weight loss or nasal discharge MEDS none PMH 1 Diabetes Mellitus dx 1 year ago 2 Benign Prostatic Hypertrophy s p TURP 3 Right shoulder surgery DJD FHX noncontributory SHX Denies history of Tobacco ETOH illicit drug use EXAM BP132 66 HR78 RR16 36 0C MS A O to person place and time No other specifics given in Neurosurgery Otolaryngology Neuro ophthalmology notes CN Visual acuity has declined from 20 40 to 20 400 OD 20 30 OS No RAPD EOM was full and smooth and without nystagmus Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS OD worse with a normal periphery Intraocular pressures were 15 14 OD OS There was moderate pallor of the disc OD Facial sensation was decreased on the right side V1 distribution Motor Sensory Coord Station Gait were all unremarkable Reflexes 2 2 and symmetric throughout Plantars were flexor bilaterally Gen Exam unremarkable COURSE MRI Brain 10 7 92 revealed a large 6x5x6cm slightly heterogeneous mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove The mass extends approximately 3 6cm superior to the planum into both frontal regions with edema in both frontal lobes The mass extends 2 5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses It also extends into the superomedial aspect of the right maxillary sinus There is probable partial encasement of both internal carotid arteries just above the siphon The optic nerves are difficult to visualize but there is also probable encasement of these structures as well The mass enhances significantly with gadolinium contrast These finds are consistent with Meningioma The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma Postoperatively he lost visual acuity OS but this gradually returned to baseline His 9 6 96 neuro ophthalmology evaluation revealed visual acuity of 20 25 3 OD and 20 80 2 OS His visual fields continued to abnormal but improved and stable when compared to 10 92 His anosmia never resolved Keywords neurology mri brain olfactory groove headaches meningioma nasal discharge numbness visual loss weakness weight loss visual acuity mri brain isointense sinuses visual MEDICAL_TRANSCRIPTION,Description Patient with sudden onset dizziness and RUE clumsiness Giant Left MCA Aneurysm Medical Specialty Neurology Sample Name MCA Aneurysm Transcription HX This 46y o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness The symptoms resolved within 10 min He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness RUE dysfunction and expressive aphasia could not get the words out His wife took him to his local MD and on the way there his symptoms resolved His aphasia recurred at his physician s office and a CT scan of the brain revealed a left temporal mass He was transferred to UIHC PMH HTN for many years MEDS Vasotec and Dyazide SHX FHX ETOH abuse quit 92 30pk yr Cigarettes quit 92 EXAM BP158 92 HR91 RR16 MS Speech fluent without dysarthria CN no deficits noted Motor no weakness or abnormal tone noted Sensory no deficits noted Coord normal Station no drift Gait ND Reflexes 3 throughout Plantars down going bilaterally Gen exam unremarkable STUDIES WBC14 3K Na 132 Cl 94 CO2 22 Glucose 129 CT Brain without contrast Calcified 2 5 x 2 5cm mass arising from left sylvian fissure temporal lobe MRI Brain 8 31 92 right temporo parietal mass with mixed signal on T1 and T2 images It has a peripheral dark rim on T1 and T2 with surrounding edema This suggests a component of methemoglobin and hemosiderin within it Slight peripheral enhancement was identified There are two smaller foci of enhancement in the posterior parietal lobe on the right There is nonspecific white matter foci within the pons and right thalamus Impression right temporoparietal hemorrhage suggesting aneurysm or mass The two smaller foci may suggest metastasis The white matter changes probably reflect microvascular disease 3 Vessel cerebroangiogram 8 31 92 Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm COURSE The aneurysm was felt to be inoperable and he was discharged home on Dilantin ASA and Diltiazem Keywords neurology mca aneurysm rue clumsiness white matter aneurysm mca dizziness aphasia matter clumsiness brain peripheral MEDICAL_TRANSCRIPTION,Description A 21 month old male presented for delayed motor development jaw quivering and lazy eye Medical Specialty Neurology Sample Name Lobar Holoprosencephaly Transcription CC Delayed motor development HX This 21 month old male presented for delayed motor development jaw quivering and lazy eye He was an 8 pound 10 ounce product of a full term uncomplicated pregnancy labor spontaneous vaginal delivery to a G3P3 married white female mother There had been no known toxic intrauterine exposures He had no serious illnesses or hospitalizations since birth He sat independently at 7 months stood at 11 months crawled at 16 months but did not cruise until 18 months He currently cannot walk and easily falls His gait is reportedly marked by left intoeing His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself throw and transfer objects easily He knows greater than 20 words and speaks two word phrases No seizures or unusual behavior were reported except for quivering movement of his jaw This has occurred since birth In addition the parents have noted transient left exotropia PMH As above FHX Many family members with lazy eye No other neurologic diseases declared 9 and 5 year old sisters who are healthy SHX lives with parents and sisters EXAM BP83 67 HR122 36 4C Head circumference 48 0cm Weight 12 68kg 70 Height 86 0cm 70 MS fairly cooperative CN Minimal transient esotropia OS Tremulous quivering of jaw increased with crying No obvious papilledema though difficult to evaluate due to patient movement Motor sat independently with normal posture and no truncal ataxia symmetric and normal strength and muscle bulk throughout Sensory withdrew to vibration Coordination unremarkable in BUE Station no truncal ataxia Gait On attempting to walk his right foot rotated laterally at almost 70degrees Both lower extremities could rotate outward to 90degrees There was marked passive eversion at the ankles as well Reflexes 2 2 throughout Musculoskeletal pes planovalgus bilaterally COURSE CK normal The parents decided to forego an MRI in 8 90 The patient returned 12 11 92 at age 4 years He was ambulatory and able to run awkwardly His general health had been good but he showed signs developmental delay Formal evaluation had tested his IQ at 87 at age 3 5 years He was weakest on tasks requiring visual motor integration and fine motor and visual discrimination skills He was 6 months delayed in cognitive development at that time On exam age 4 years he displayed mild right ankle laxity on eversion and inversion but normal gait The rest of the neurological exam was normal Head circumference was 49 5cm 50 and height and weight were in the 90th percentile Fragile X analysis and karyotyping were unremarkable Keywords neurology delayed motor development jaw quivering head circumference truncal ataxia delayed motor motor development lazy eye jaw quivering delayed intrauterine MEDICAL_TRANSCRIPTION,Description Lumbar puncture with moderate sedation Medical Specialty Neurology Sample Name Lumbar Puncture 1 Transcription PROCEDURE Lumbar puncture with moderate sedation INDICATION The patient is a 2 year 2 month old little girl who presented to the hospital with severe anemia hemoglobin 5 8 elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test She was transfused with packed red blood cells Her hemolysis seemed to slow down She also on presentation had indications of urinary tract infection with urinalysis significant for 2 leukocytes positive nitrites 3 protein 3 blood 25 to 100 white cells 10 to 25 bacteria 10 to 25 epithelial cells on clean catch specimen Culture subsequently grew out no organisms however the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital She had a blood culture which was also negative She was empirically started on presentation with the cefotaxime intravenously Her white count on presentation was significantly elevated at 20 800 subsequently increased to 24 7 and then decreased to 16 6 while on antibiotics After antibiotics were discontinued she increased over the next 2 days to an elevated white count of 31 000 with significant bandemia metamyelocytes and myelocytes present She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI I discussed with The patient s parents prior to the procedure the lumbar puncture and moderate sedation procedures The risks benefits alternatives complications including but not limited to bleeding infection respiratory depression Questions were answered to their satisfaction They would like to proceed PROCEDURE IN DETAIL After time out procedure was obtained the child was given appropriate monitoring equipment including appropriate vital signs were obtained She was then given Versed 1 mg intravenously by myself She subsequently became sleepy the respiratory monitors end tidal cardiopulmonary and pulse oximetry were applied She was then given 20 mcg of fentanyl intravenously by myself She was placed in the left lateral decubitus position Dr X cleansed the patient s back in a normal sterile fashion with Betadine solution She inserted a 22 gauge x 1 5 inch spinal needle in the patient s L3 L4 interspace that was carefully identified under my direct supervision Clear fluid was not obtained initially needle was withdrawn intact The patient was slightly repositioned by the nurse and Dr X reinserted the needle in the L3 L4 interspace position the needle was able to obtain clear fluid approximately 3 mL was obtained The stylette was replaced and the needle was withdrawn intact and bandage was applied Betadine solution was cleansed from the patient s back During the procedure there were no untoward complications the end tidal CO2 pulse oximetry and other vitals remained stable Of note EMLA cream had also been applied prior procedure this was removed prior to cleansing of the back Fluid will be sent for a routine cell count Gram stain culture protein and glucose DISPOSITION The child returned to room on the medical floor in satisfactory condition Keywords neurology moderate sedation lumbar puncture needle lumbar MEDICAL_TRANSCRIPTION,Description Patient with a 1 year history of progressive anterograde amnesia Medical Specialty Neurology Sample Name Limbic Encephalitis Transcription CC Rapidly progressive amnesia HX This 63 y o RHM presented with a 1 year history of progressive anterograde amnesia On presentation he could not remember anything from one minute to the next He also had some retrograde memory loss in that he could not remember the names of his grandchildren but had generally preserved intellect language personality and calculating ability He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally There was no mass affect The areas mildly enhanced with gadolinium PMH 1 CAD MI x 2 1978 and 1979 2 PVD s p aortic endarterectomy 3 1991 3 HTN 4 Bilateral inguinal hernia repair FHX SHX Mother died of a stroke at age 58 Father had CAD and HTN The patient quit smoking in 1991 but was a heavy smoker 2 3ppd for many years He had been a feed salesman all of his adult life ROS Unremarkable No history of cancer EXAM BP 136 75 HR 73 RR12 T36 6 MS Alert but disoriented to person place time He could not remember his birthdate and continually asked the interviewer what year it was He could not remember when he married retired or his grandchildren s names He scored 18 30 on the Follutein s MMSE with severe deficits in orientation and memory He had moderate difficulty naming He repeated normally and had no constructional apraxia Judgement remained good CN unremarkable Motor Full strength throughout with normal muscle tone and bulk Sensory Intact to LT PP PROP Coordination unremarkable Station No pronator drift truncal ataxia or Romberg sign Gait unremarkable Reflexes 3 throughout with downgoing plantar responses bilaterally Gen Exam unremarkable STUDIES MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally with mild enhancement on the gadolinium scans MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor EEG was normal awake and asleep Antineuronal antibody screening was unremarkable CSF studies were unremarkable and included varicella zoster herpes zoster HIV and HTLV testing and cytology The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes but no organism or etiology was concluded TFT B12 VDRL ESR CRP ANA SPEP and Folate studies were unremarkable Neuropsychologic testing revealed severe anterograde memory verbal and visual loss and less severe retrograde memory loss Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally IMPRESSION Limbic encephalitis secondary to cancer of unknown origin He was last seen 7 26 96 MMSE 20 30 and category fluency 20 Disinhibited affect Mild right grasp reflex The clinical course was benign and non progressive and unusual for such a diagnosis though not unheard of Keywords neurology mri brain progressive anterograde amnesia retrograde memory loss limbic encephalitis anterograde amnesia memory loss limbic encephalitis amnesia anterograde memory MEDICAL_TRANSCRIPTION,Description Lumbar discogram L2 3 L3 4 L4 5 and L5 S1 Low back pain Medical Specialty Neurology Sample Name Lumbar Discogram Transcription PREOPERATIVE DIAGNOSIS Low back pain POSTOPERATIVE DIAGNOSIS Low back pain PROCEDURE PERFORMED 1 Lumbar discogram L2 3 2 Lumbar discogram L3 4 3 Lumbar discogram L4 5 4 Lumbar discogram L5 S1 ANESTHESIA IV sedation PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed prone onto a radiolucent table The C arm was brought into the operative field and AP left right oblique and lateral fluoroscopic images of the L1 2 through L5 S1 levels were obtained We then proceeded to prepare the low back with a Betadine solution and draped sterile Using an oblique approach to the spine the L5 S1 level was addressed using an oblique projection angled C arm in order to allow for perpendicular penetration of the disc space A metallic marker was then placed laterally and a needle entrance point was determined A skin wheal was raised with 1 Xylocaine and an 18 gauge needle was advanced up to the level of the disc space using AP oblique and lateral fluoroscopic projections A second needle 22 gauge 6 inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections was placed into the center of the nucleus We then proceeded to perform a similar placement of needles at the L4 5 L3 4 and L2 3 levels A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting we then proceeded to inject the disc spaces sequentially Keywords neurology back pain c arm fluoroscopic projections disc space lumbar discogram fluoroscopic needle MEDICAL_TRANSCRIPTION,Description The patient comes in today because of feeling lightheaded and difficulty keeping his balance Medical Specialty Neurology Sample Name Lightheadedness Transcription HISTORY OF PRESENT ILLNESS The patient comes in today because of feeling lightheaded and difficulty keeping his balance He denies this as a spinning sensation that he had had in the past with vertigo He just describes as feeling very lightheaded It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position It tends to ease when he sits down again but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over Lorazepam did not help this sensation His blood pressure has been up lately and his dose of metoprolol was increased They feel these symptoms have gotten worse since metoprolol was increased PAST MEDICAL HISTORY Detailed on our H P form Positive for elevated cholesterol diabetes glaucoma cataracts hypertension heart disease vertigo stroke in May of 2005 congestive heart failure CABG and cataract removed right eye CURRENT MEDICATIONS Detailed on the H P form PHYSICAL EXAMINATION His blood pressure sitting down was 180 80 with a pulse rate of 56 Standing up blood pressure was 160 80 with a pulse rate of 56 His general exam and neurological exam were detailed on our H P form Pertinent positives on his neurological exam were decreased sensation in his left face and left arm and leg IMPRESSION AND PLAN This lightheaded he exquisitely denies vertigo the vertigo that he has had in the past He states this is more of a lightheaded type feeling He did have a mild blood pressure drop here in the office We are also concerned that bradycardia might be contributing to his feeling of lightheadedness We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling We will schedule him for the Holter monitor and refer him back to his cardiologist Keywords neurology lightheaded feeling feeling lightheaded pulse rate neurological exam holter monitor blood pressure balance vertigo lightheadedness MEDICAL_TRANSCRIPTION,Description Headache improved Intracranial aneurysm Medical Specialty Neurology Sample Name Intracranial aneurysm ER Visit Transcription CHIEF COMPLAINT Headache HPI This is a 24 year old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan He was discharged home with a follow up to neurosurgery on the 14th Apparently an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery He has had headaches since the 13th and complains now of some worsening of his pain He denies photophobia fever vomiting and weakness of the arms or legs PMH As above MEDS Vicodin ALLERGIES None PHYSICAL EXAM BP 180 110 Pulse 65 RR 18 Temp 97 5 Mr P is awake and alert in no apparent distress HEENT Pupils equal round reactive to light oropharynx moist sclera clear Neck Supple no meningismus Lungs Clear Heart Regular rate and rhythm no murmur gallop or rub Abdomen Benign Neuro Awake and alert motor strength normal no numbness normal gait DTRs normal Cranial nerves normal COURSE IN THE ED Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass no blood and no hydrocephalus I recommended an LP but he prefers not to have this done He received morphine for pain and his headache improved I ve recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram He left the ED against my advice IMPRESSION Headache improved Intracranial aneurysm PLAN The patient will return tomorrow am for his angiogram Keywords neurology angiogram mass ct scan intracranial aneurysm headache aneurysm intracranial MEDICAL_TRANSCRIPTION,Description Right shoulder impingement syndrome right suprascapular neuropathy Medical Specialty Neurology Sample Name Impairment Rating Transcription CHIEF COMPLAINT Right shoulder pain HISTORY The patient is a pleasant 31 year old right handed white female who injured her shoulder while transferring a patient back on 01 01 02 She formerly worked for Veteran s Home as a CNA She has had a long drawn out course of treatment for this shoulder She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002 She had ongoing pain and was evaluated by Dr X who felt that she had a possible brachial plexopathy He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms He then referred her to ABCD who did EMG testing demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12 18 03 She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr X She comes to me for impairment rating She has no chronic health problems otherwise fevers chills or general malaise She is not working She is right hand dominant She denies any prior history of injury to her shoulder PAST MEDICAL HISTORY Negative aside from above FAMILY HISTORY Noncontributory SOCIAL HISTORY Please see above REVIEW OF SYSTEMS Negative aside from above PHYSICAL EXAMINATION A pleasant age appropriate woman moderately overweight in no apparent distress Normal gait and station normal posture normal strength tone sensation and deep tendon reflexes with the exception of 4 5 strength in the supraspinatus musculature on the right She has decreased motion in the right shoulder as follows She has 160 degrees of flexion 155 degrees of abduction 35 degrees of extension 25 degrees of adduction 45 degrees of internal rotation and 90 degrees of external rotation She has a positive impingement sign on the right ASSESSMENT Right shoulder impingement syndrome right suprascapular neuropathy DISCUSSION With a reasonable degree of medical certainty she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment Fifth Edition The reason for this impairment is the incident of 01 01 02 For her suprascapular neuropathy she is rated as a grade IV motor deficit which I rate as a 13 motor deficit This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16 which produces a 2 impairment of the upper extremity when the two values are multiplied together 2 impairment of the upper extremity For her lack of motion in the shoulder she also has additional impairment on the right She has a 1 impairment of the upper extremity due to lack of shoulder flexion She has a 1 impairment of the upper extremity due to lack of shoulder abduction She has a 1 impairment of the upper extremity due to lack of shoulder adduction She has a 1 impairment of the upper extremity due to lack of shoulder extension There is no impairment for findings in shoulder external rotation She has a 3 impairment of the upper extremity due to lack of shoulder internal rotation Thus the impairment due to lack of motion in her shoulder is a 6 impairment of the upper extremity This combines with the 2 impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8 impairment of the upper extremity which in turn is a 5 impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment Fifth Edition stated with a reasonable degree of medical certainty Keywords neurology ama guide evaluation of permanent impairment impairment rating permanent impairment suprascapular nerve suprascapular neuropathy injured extremity shoulder impairment neuropathy suprascapular MEDICAL_TRANSCRIPTION,Description Woman with adult hydrocephalus routine evaluation Medical Specialty Neurology Sample Name Hydrocephalus Transcription REASON FOR VISIT Ms ABC is a 67 year old woman with adult hydrocephalus who returns to clinic for a routine evaluation She comes to clinic by herself HISTORY OF PRESENT ILLNESS She has been followed for her hydrocephalus since 2002 She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007 She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time however we decided to leave her shunt setting at 1 0 We wanted her to followup with Dr XYZ regarding the MRI of the cervical spine Today she tells me that with respect to her bladder last week she had some episodes of urinary frequency however this week she is not experiencing the same type of episodes She reports no urgency incontinence and feels that she completely empties her bladder when she goes She does experience some leakage with coughing She wears the pad on a daily basis She does not think that her bladder has changed much since we saw her last With respect to her thinking and memory she reports no problems at this time She reports no headaches at this time With respect to her walking and balance she says that it feels worse In the beginning of May she had a coughing spell and at that time she developed buttock pain which travels down the legs She states that her leg often feel like elastic and she experiences a tingling radiculopathy She says that this tingling is constant and at times painful She feels that she is walking slower for this reason She does not use the cane at this time Most of the time she is able to walk over uneven surfaces She is able to walk up and down stairs and has no trouble getting in and out of a car MEDICATIONS Rhinocort 32 mg two sprays a day Singulair 10 mg once a day Xyzal 5 mg in the morning Spiriva once a day Advair twice a day Prevacid 30 mg twice a day Os Cal 500 mg once a day multivitamin once a day and aspirin 81 mg a day MAJOR FINDINGS On exam today this is a pleasant 67 year old woman who comes back from the clinic waiting area with little difficulty She is well developed well nourished and kempt The shunt site is clean dry and intact and confirmed at a setting of 1 0 Mental Status Assessed and appears intact for orientation recent and remote memory attention span concentration language and fund of knowledge Her Mini Mental Status exam score was 26 30 when attention was tested with calculations and 30 30 when attention was tested with spelling Cranial Nerves Extraocular movements are somewhat inhibited She does not display any nystagmus at this time Facial movement hearing head turning tongue and palate movement are all intact Gait Assessed using the Tinetti assessment tool which showed a balance score of 13 16 and a gait score of 11 12 for a total score of 24 28 ASSESSMENT Ms ABC has been experiencing difficulty with walking over the past several months PROBLEMS DIAGNOSES 1 Hydrocephalus 2 Cervical stenosis and retrolisthesis 3 Neuropathy in the legs PLAN Before we recommend anything more we would like to get a hold of the notes from Dr XYZ to try to come up with a concrete plan as to what we can do next for Ms ABC We believe that her walking is most likely not being effected by the hydrocephalus We would like to see her back in clinic in two and a half months or so We also talked to her about having her obtain cane training so that she knows how to properly use her cane which she states she does have one I suggested that she use the cane at her on discretion Keywords neurology cervical stenosis retrolisthesis neuropathy cervical corpectomy adult hydrocephalus cervical hydrocephalus MEDICAL_TRANSCRIPTION,Description Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization Medical Specialty Neurology Sample Name Iliopsoas Hematoma 2 Transcription CC RLE weakness HX This 42y o RHM was found 2 27 95 slumped over the steering wheel of the Fed Ex truck he was driving He was cyanotic and pulseless according to witnesses EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine lidocaine bretylium and electrically defibrillated and intubated in the field Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks defibrillation at 360 joules per shock epinephrine and lidocaine This had no effect He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation He was then taken emergently to cardiac catherization and was found to have normal coronary arteries He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin His blood pressure gradually improved and his balloon pump was discontinued on 5 5 95 Recovery was complicated by acute renal failure and liver failure Initail CK 13 780 the CKMB fraction was normal at 0 8 On 3 10 95 the patient experienced CP and underwent cardiac catherization This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis Subsequent CK 1381 and CKMB 5 4 elevated The patient was amnestic to the event and for 10 days following the event He was transferred to UIHC for cardiac electrophysiology study MEDS Nifedipine ASA Amiodarone Capoten Isordil Tylenol Darvocet prn Reglan prn Coumadin KCL SLNTG prn CaCO3 Valium prn Nubain prn PMH hypercholesterolemia FHX Father alive age 69 with h o TIAs Mother died age 62 and had CHF A Fib CAD Maternal Grandfather died of an MI and had h o SVT Maternal Grandmother had h o SVT SHX Married 7 children driver for Fed Ex Denied tobacco ETOH illicit drug use EXAM BP112 74 HR64 RR16 Afebrile MS A O to person place and time Euthymic with appropriate affect CN unremarkable Motor Hip flexion 3 5 Hip extension 5 5 Knee flexion5 5 Knee extension 2 5 Plantar flexion extension inversion and eversion 5 5 There was full strength thoughout BUE Sensory decreased PP Vib LT TEMP about anterior aspect of thigh and leg in a femoral nerve distribution Coord poor and slowed HKS on right due to weakness Station no drift or Romberg sign Gait difficulty bearing weight on RLE Reflexes 1 1 throughout BUE 0 2 patellae 2 2 archilles Plantar responses were flexor bilaterally COURSE MRI Pelvis 3 28 95 revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma An intra osseous lipoma was incidentally notice in the right sacrum Neuropsychologic assessment showed moderately compromised anterograde verbal memory and temporal orientation and retrograde recall were below expectations These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history He underwent implantation of a Medtronic internal cardiac difibrillator His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation He suffered mild to moderate permanent RLE weakness especially involving the quadriceps His femoral nerve compression had been present to long to warrant decompression EMG NCV studies revealed severe axonal degeneration Keywords neurology cardiac electrophysiology study iliopsoas hematoma rle weakness balloon pump femoral nerve cardiac catherization hematoma iliopsoas catherization epinephrine fibrillation cardiac MEDICAL_TRANSCRIPTION,Description Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation Medical Specialty Neurology Sample Name Laminectomy Foraminotomy Followup Transcription REASON FOR VISIT Followup status post L4 L5 laminectomy and bilateral foraminotomies and L4 L5 posterior spinal fusion with instrumentation HISTORY OF PRESENT ILLNESS Ms ABC returns today for followup status post L4 L5 laminectomy and bilateral foraminotomies and posterior spinal fusion on 06 08 07 Preoperatively her symptoms those of left lower extremity are radicular pain She had not improved immediately postoperatively She had a medial breech of a right L4 pedicle screw We took her back to the operating room same night and reinserted the screw Postoperatively her pain had improved I had last seen her on 06 28 07 at which time she was doing well She had symptoms of what she thought was restless leg syndrome at that time She has been put on ReQuip for this She returned I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative She states that she had recurrent left lower extremity pain which was similar to the pain she had preoperatively but in a different distribution further down the leg Thus I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation She states that overall she is improved compared to preoperatively She is ambulating better than she was preoperatively The pain is not as severe as it was preoperatively The right leg pain is improved The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side She denies any significant low back pain No right lower extremity symptoms No infectious symptoms whatsoever No fever chills chest pain shortness of breath No drainage from the wound No difficulties with the incision FINDINGS On examination Ms ABC is a pleasant well developed well nourished female in no apparent distress Alert and oriented x 3 Normocephalic atraumatic Respirations are normal and nonlabored Afebrile to touch Left tibialis anterior strength is 3 out of 5 extensor hallucis strength is 2 out of 5 Gastroc soleus strength is 3 to 4 out of 5 This has all been changed compared to preoperatively Motor strength is otherwise 4 plus out of 5 Light touch sensation decreased along the medial aspect of the left foot Straight leg raise test normal bilaterally The incision is well healed There is no fluctuance or fullness with the incision whatsoever No drainage Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws Lumbar spine MRI performed on 07 03 07 is also reviewed It demonstrates evidence of adequate decompression at L4 and L5 There is a moderate size subcutaneous fluid collection seen which does not appear compressive and may be compatible with normal postoperative fluid collection especially given the fact that she had a revision surgery performed ASSESSMENT AND PLAN Ms ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies and posterior spinal fusion with instrumentation on 07 08 07 The case is significant for merely misdirected right L4 pedicle screw which was reoriented with subsequent resolution of symptoms I am uncertain with regard to the etiology of the symptoms However it does appear that the radiographs demonstrate appropriate positioning of the instrumentation no hardware shift and the MRI demonstrates only a postoperative suprafascial fluid collection I do not see any indication for another surgery at this time I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection My recommendation at this time is that the patient is to continue with mobilization I have reassured her that her spine appears stable at this time She is happy with this I would like her to continue ambulating as much as possible She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested I have also her referred to Mrs Khan at Physical Medicine and Rehabilitation for continued aggressive management I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve She knows that if she has any difficulties she may follow up with me sooner Keywords neurology spinal fusion restless leg syndrome posterior spinal fusion pedicle screw lumbar spine bilateral foraminotomies fluid collection foraminotomy instrumentation laminectomy screw spine MEDICAL_TRANSCRIPTION,Description Intractable epilepsy here for video EEG Medical Specialty Neurology Sample Name Intractable Epilepsy Transcription CHIEF COMPLAINT Intractable epilepsy here for video EEG HISTORY OF PRESENT ILLNESS The patient is a 9 year old male who has history of global developmental delay and infantile spasms Ultimately imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum showing a pattern of cerebral dysgenesis He has had severe global developmental delay and is nonverbal He can follow objects with his eyes but has no ability to interact with his environment to any great degree He has noted if any purposeful use of the hands He has abnormal movements constantly which are more choreiform and dystonic He has spastic quadriparesis which is variable at times The patient is unable to sit or stand and receives all his nutrition via G tube The patient began having seizures in infancy presenting as infantile spasms I began seeing him at 20 months of age At that point he had undergone workup in Seattle Washington and then was seeing Dr X child neurologist in Mexico who started Vigabatrin for infantile spasms The patient had benefit from this medication and was doing well at that time with regard to that seizure type He initially was on phenobarbital which failed to give him benefit He continued on phenobarbital however for a long period time thereafter The patient then began having more tonic seizures after his episodic spasms had subsided and failed several medication trials including valproic acid Topamax and Zonegran at least briefly Upon starting Lamictal he began to have benefit and then actually had 1 year seizure freedom before having an isolated seizure or 2 Over the next 6 months to a year he only had few further seizures and was doing well in a general sense It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg kg day These events manifest as tonic spells with eye deviation and posturing Mother reports flexion of the upper extremities extension with lower extremities During that time he is not able to cry or say any sounds These events last from seconds to minutes and occur at least multiple times per week There are times where he has none for a few days and other times where he has multiple days in a row with events He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout He may vomit after these episodes then seems to calm down It is unclear whether this is a seizure or whether the patient is still responsive MEDICATIONS The patient s medications include Lamictal for a total of 200 mg twice a day It is a 150 mg tablet and 25 mg tablets He is on Zonegran using 25 mg capsules 2 capsules twice daily and baclofen 10 mg three times day He has other medications including the Xopenex and Atrovent REVIEW OF SYSTEMS At this time is negative any fevers nausea vomiting diarrhea abdominal complaints rashes arthritis or arthralgias No respiratory or cardiovascular complaints He has no change in his skills at this point FAMILY HISTORY Noncontributory PHYSICAL EXAMINATION GENERAL The patient is a slender male who is microcephalic He has EEG electrodes in place and is on the video EEG at that time HEENT His oropharynx shows no lesions NECK Supple without adenopathy CHEST Clear to auscultation CARDIOVASCULAR Regular rate and rhythm No murmurs ABDOMEN Benign with G tube in place EXTREMITIES Reveal no clubbing cyanosis or edema NEUROLOGICAL The patient is alert and has bilateral esotropia He is able to fix and follow objects briefly He is unable to reach for objects He exhibits constant choreiform movements when excited These are more prominent in the upper extremities and lower extremities He has some dystonic posture with flexion of the wrist and fingers bilaterally He also has plantar flexion at the ankles bilaterally His cranial nerves reveal that his pupils are equal round and reactive to light Extraocular movements are intact other than bilateral esotropia His face moves symmetrically Palate elevates in midline Hearing appears intact bilaterally Motor exam reveals dystonic and variable tone overall there is mild in spasticity both upper and lower extremities as described above He has clonus at the ankles bilaterally and some valgus contracture of the ankles His sensation is intact to light touch bilaterally Deep tendon reflexes are 2 to 3 bilaterally IMPRESSION PLAN This is a 9 year old male with congenital brain malformation and intractable epilepsy He has microcephaly as well as dystonic cerebral palsy He had a re emergence of seizures which are difficult to classify although some sound like tonic episodes and others are more concerning for non epileptic phenomenon such as discomfort He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types He will remain hospitalized for probably at least 48 hours to 72 hours He could be discharged sooner if multiple events are captured His medications we will continue his current dose of Zonegran and Lamictal for now Both of these medications are very long acting discontinuing them while in the hospital may simply result in severe seizures after discharge Keywords neurology brain malformation congenital intractable epilepsy global developmental delay video eeg seizures intractable eeg MEDICAL_TRANSCRIPTION,Description The patient with continued problems with her headaches Medical Specialty Neurology Sample Name Headache Office Visit Transcription She also had EMG nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy moderate right ulnar neuropathy bilateral mild to moderate carpal tunnel and diabetic neuropathy She was referred to Dr XYZ and will be seeing him on August 8 2006 She was also never referred to the endocrine clinic to deal with her poor diabetes control Her last hemoglobin A1c was 10 PAST MEDICAL HISTORY Diabetes hypertension elevated lipids status post CVA and diabetic retinopathy MEDICATIONS Glyburide Avandia metformin lisinopril Lipitor aspirin metoprolol and Zonegran PHYSICAL EXAMINATION Blood pressure was 140 70 heart rate was 76 respiratory rate was 18 and weight was 226 pounds On general exam she has an area of tenderness on palpation in the left parietal region of her scalp Neurological exam is detailed on our H P form Her neurological exam is within normal limits IMPRESSION AND PLAN For her headaches we are going to titrate Zonegran up to 200 mg q h s to try to maximize the Zonegran therapy If this is not effective when she comes back on August 7 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica We also discussed with Ms Hawkins the possibility of nerve block injection however at this point she is not interested She will be seeing Dr XYZ for her neuropathies We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult Keywords neurology nerve conduction studies emg zonegran therapy ulnar neuropathy endocrine clinic diabetes control neurological exam headache zonegran MEDICAL_TRANSCRIPTION,Description Closed head injury with evidence of axonal injury vs vascular injury to the left substantia nigra right subdural hematoma and possible subarachnoid hemorrhage vascular ischemic injury in the right occipital lobe right basal ganglia caudate nucleus right frontal lobe and right temporal lobe contusion Medical Specialty Neurology Sample Name Head Trauma Transcription CC Depressed mental status HX 29y o female fell down a flight of stairs on 2 20 95 striking the right side of her head She then walked over to and lay down on a living room couch She was found there the next morning by her boyfriend poorly responsive and amidst a coffee ground like emesis She was taken to a local ER and HCT revealed a right supraorbital fracture right SDH and left SAH Spine X rays revealed a T12 vertebral body fracture There were retinal hemorrhages OU She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic neurosurgical care MEDS on transfer Dilantin Zantac Proventil MDI Tylenol PMH 1 pyelonephritis 2 multiple STD s 3 Polysubstance Abuse ETOH MJ Amphetamine 4 G5P4 FHX unknown SHX polysubstance abuse smoked 1 pack per day for 15years EXAM BP127 97 HR83 RR25 37 2C MS Minimal to no spontaneous speech Unresponsive to verbal commands Lethargic and somnolent Groaned yes inappropriately CN Pupils 4 4 decreasing to 2 2 on exposure to light VFFTT Retinal hemorrhages OU EOM difficult to assess Facial movement appeared symmetric Tongue midline Corneal and gag responses were intact MOTOR no spontaneous movement withdrew extremities to noxious stimulation e g deep nail bed pressure Sensory withdrew to noxious stimuli Coord Station Gait not tested Reflexes 2 2 BUE 2 2 BLE Babinski signs were present bilaterally HEENT Periorbital and upper lid ecchymoses about the right eye Scleral hemorrhage OD GEN EXAM mild bruising of the extremities COURSE 2 27 95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage 2 28 95 brain MRI revealed 1 a small right sided SDH 2 Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic vascular injury 3 abnormal signal within the right basal ganglia caudate nucleus consistent with ischemia 4 abnormal signal in the uncal portion of the right frontal lobe consistent with contusion 5 small parenchymal hemorrhage in the inferior anterior right temporal lobe and 6 opacification of the right maxillary sinus EEG 2 28 95 was abnormal with occasional sharp transients in the left temporal region and irregular more or less continuous right greater than left delta slow waves and decreased background activity in the right hemisphere the findings were consistent with focal pathology on the right seizure tendency in the left temporal region and bilateral cerebral dysfunction By the time of discharge 4 17 95 she was verbalizing one or two words and required assistance with feeding and ambulation She could not function independently Keywords neurology closed head injury axonal injury vascular injury substantia nigra subdural hematoma subarachnoid hemorrhage vascular ischemic injury occipital lobe retinal hemorrhages temporal region axonal hemorrhages hemorrhage MEDICAL_TRANSCRIPTION,Description Headache Right frontal lobe glioma Medical Specialty Neurology Sample Name Glioma 2 Transcription CC Headache HX 37 y o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours The headachese were dull to throbbing in character She was initially treated with Parafon forte for tension type headaches but the pain did not resolve She subsequently underwent HCT in early 12 90 which revealed a right frontal mass lesion PMH 1 s p tonsillectomy 2 s p elective abortion FHX Mother with breast CA MA with bone cancer AODM both sides of family SHX Denied tobacco or illicit drug use Rarely consumes ETOH Married with 2 teenage children EXAM VItal signs unremarkable MS Alert and oriented to person place time Lucid thought process per NSG note CN unremarkable Motor full strength with normal muscle bulk and tone Sensory unremarkable Coordination unremarkable Station Gait unremarkable Reflexes unremarkable Gen Exam unremarkable COURSE MRI Brain large solid and cystic right frontal lobe mass with a large amount of surrounding edema There is apparent tumor extension into the corpus callosum across the midline Tumor extension is also suggested in the anterior limb of the interanl capsule on the right There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle The MRI findings are most consistent with glioblastoma The patient underwent right frontal lobectomy The pathological diagnosis was xanthomatous astrocytoma The literature at the time was not clear as to optimal treatment protocol People have survived as long as 25 years after diagnosis with this type of tumor XRT was deferred until 11 91 when an MRI and PET Scan suggested extension of the tumor She then received 5580 cGy of XRT in divided segments She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement She was treated with BCNU chemotherapy protocol in 1992 Keywords neurology frontal lobe tumor extension glioma headache lobectomy astrocytoma MEDICAL_TRANSCRIPTION,Description Sellar HCT Pituitary mass Medical Specialty Neurology Sample Name HCT Pituitary Mass Transcription CC HA and vision loss HX 71 y o RHM developed a cataclysmic headache on 11 5 92 associated with a violent sneeze The headache lasted 3 4 days On 11 7 92 he had acute pain and loss of vision in the left eye Over the following day his left pupil enlarged and his left upper eyelid began to droop He was seen locally and a brain CT showed no sign of bleeding but a tortuous left middle cerebral artery was visualized The patient was transferred to UIHC 11 12 92 FHX HTN stroke coronary artery disease melanoma SHX Quit smoking 15 years ago MEDS Lanoxin Capoten Lasix KCL ASA Voltaren Alupent MDI PMH CHF Atrial Fibrillation Obesity Anemia Duodenal Ulcer Spinal AVM resection 1986 with residual T9 sensory level hyperreflexia and bilateral babinski signs COPD EXAM 35 5C BP 140 91 P86 RR20 Alert and oriented to person place and time CN No light perception OS Pupils 3 7 decreasing to 2 7 on exposure to light i e fixed dilated pupil OS Upon neutral gaze the left eye deviated laterally and inferiorly There was complete ptosis OS On downward gaze their was intorsion OS The left eye could not move superiorly medially or effectively downward but could move laterally EOM were full OD The rest of the CN exam was unremarkable Motor Coordination Station and Gait testing were unremarkable Sensory exam revealed decreased pinprick and light touch below T9 old Muscle stretch reflexes were increased 3 3 in both lower extremities and there were bilateral babinski signs old The upper extremity reflexes were symmetrical 2 2 Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally The rest of the general exam was unremarkable LAB CBC PT PTT General Screen were unremarkable except for a BUN 21mg DL CSF protein 88mg DL glucose 58mg DL RBC 2800 mm3 WBC 1 mm3 ANA RF TSH FT4 were WNL IMPRESSION CN3 palsy and loss of vision Differential diagnosis temporal arteritis aneurysm intracranial mass COURSE The outside Brain CT revealed a tortuous left MCA A four vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA There was no evidence of aneursym Transesophageal Echocardiogram revealed atrial enlargement only Neuroopthalmologic evaluation revealed Loss of color vision and visual acuity OS RAPD OS bilateral optic disk pallor OS OD CN3 palsy and bilateral temporal field loss OS OD ESR CRP MRI were recommended to rule out temporal arteritis and intracranial mass ESR 29mm Hr CRP 4 3mg DL high The patient was placed on prednisone Temporal artery biopsy showed no evidence of vasculitis MRI scan could not be obtained due to patient weight Sellar CT was done instead coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass In retrospect sellar enlargement could be seen on the angiogram X rays Differential consideration was given to cystic pituitary adenoma noncalcified craniopharyngioma or Rathke s cleft cyst with solid component The patient refused surgery He was seen in Neuroopthalmology Clinic 2 18 93 and was found to have mild recovery of vision OS and improved visual fields Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil OS on adduction downgaze and upgaze The upper eyelid OS elevated on adduction and down gaze OS EOM movements were otherwise full and there was no evidence of ptosis In retrospect he was felt to have suffered pituitary apoplexy in 11 92 Keywords neurology sellar hct htn pituitary aneurysm brain ct cataclysmic coronary artery disease headache intracranial mass loss of vision mass melanoma palsy sneeze stroke temporal arteritis vision loss bilateral babinski signs sellar enlargement pituitary mass temporal vision MEDICAL_TRANSCRIPTION,Description HCT for memory loss and for calcification of basal ganglia globus pallidi Medical Specialty Neurology Sample Name HCT Calcification of Basal Ganglia Transcription CC Memory loss HX This 77 y o RHF presented with a one year history of progressive memory loss Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8 15AM Sunday morning That Sunday she went to pick up her sister at her sister s home and when her sister was not there because the sister had gone to pick up the patient the patient left She later called the sister and asked her if she sister had overslept During her UIHC evaluation she denied she knew anything about the incident No other complaints were brought forth by the patients family PMH Unremarkable MEDS None FHX Father died of an MI Mother had DM type II SHX Denies ETOH illicit drug Tobacco use ROS Unremarkable EXAM Afebrile 80BPM BP 158 98 16RPM Alert and oriented to person place time Euthymic 29 30 on Folstein s MMSE with deficit on drawing Recalled 2 6 objects at five minutes and could not recite a list of 6 objects in 6 trials Digit span was five forward and three backward CN mild right lower facial droop only MOTOR Full strength throughout SENSORY No deficits to PP Vib Prop LT Temp COORD Poor RAM in LUE only GAIT NB and ambulated without difficulty STATION No drift or Romberg sign REFLEXES 3 bilaterally with flexor plantar responses There were no frontal release signs LABS CMB General Screen FT4 TSH VDRL were all WNL NEUROPSYCHOLOGICAL EVALUATION 12 7 92 Verbal associative fluency was defective Verbal memory including acquisition and delayed recall and recognition was severely impaired Visual memory including immediate and delayed recall was also severely impaired Visuoperceptual discrimination was mildly impaired as was 2 D constructional praxis HCT 12 7 92 Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient s age Calcification is seen in both globus pallidi and this was felt to be a normal variant Keywords neurology memory loss romberg sign hct cerebral atrophy calcification of basal ganglia basal ganglia globus pallidi basal ganglia globus pallidi calcification MEDICAL_TRANSCRIPTION,Description CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Medical Specialty Neurology Sample Name Frameless Stereotactic Radiosurgery Transcription PREOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation POSTOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation PROCEDURE PERFORMED CT guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking Please note no qualified resident was available to assist in the procedure INDICATION The patient is a 30 year old male with a right occipital AVM He was referred for stereotactic radiosurgery The risks of the radiosurgical treatment were discussed with the patient including but not limited to failure to completely obliterate the AVM need for additional therapy radiation injury radiation necrosis headaches seizures visual loss or other neurologic deficits The patient understands these risks and would like to proceed PROCEDURE IN DETAIL The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment He was placed on the treatment table The Aquaplast mask was constructed Initial imaging was obtained by the CyberKnife system The patient was then transported over to the CT scanner at Stanford Under the supervision of Dr X 125 mL of Omnipaque 250 contrast was administered Dr X then supervised the acquisition of 1 2 mm contiguous axial CT slices These images were uploaded over the hospital network to the treatment planning computer and the patient was discharged home Treatment plan was then performed by me I outlined the tumor volume Inverse treatment planning was used to generate the treatment plan for this patient This resulted in a total dose of 20 Gy delivered to 84 isodose line using a 12 5 mm collimator The maximum dose within this center of treatment volume was 23 81 Gy The volume treated was 2 972 mL and the treated lesion dimensions were 1 9 x 2 7 x 1 6 cm The volume treated at the reference dose was 98 The coverage isodose line was 79 The conformality index was 1 74 and modified conformality index was 1 55 The treatment plan was reviewed by me and Dr Y of Radiation Oncology and the treatment plan was approved On the morning of May 14 2004 the patient arrived at the Outpatient CyberKnife Suite He was placed on the treatment table The Aquaplast mask was applied Initial imaging was used to bring the patient into optimal position The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin He tolerated the procedure well He was given 8 mg of Decadron for prophylaxis and discharged home Followup will consist of an MRI scan in 6 months The patient will return to our clinic once that study is completed I was present and participated in the entire procedure on this patient consisting of CT guided frameless stereotactic radiosurgery for the right occipital AVM Dr X was present during the entire procedure and will be dictating his own operative note Keywords neurology ct guided occipital cyberknife frameless stereotactic radiosurgery occipital arteriovenous malformation conformality index arteriovenous malformation malformation avm arteriovenous MEDICAL_TRANSCRIPTION,Description This 62 year old white female has essential tremor and mild torticollis Tremor not bothersome for most activities of daily living but she does have a great difficulty writing which is totally illegible Medical Specialty Neurology Sample Name Essential Tremor Torticollis Transcription REASON FOR CONSULT Essential tremor and torticollis HISTORY OF PRESENT ILLNESS This is a 62 year old right handed now left handed white female with tremor since 5th grade She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam She thinks that her clonazepam is helping her a lot especially with anxiety and stress and this makes the tremor better She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day to day activity Since around 6 to 7 years she has had a head tremor which is mainly no no and occasional voice tremor also Additionally the patient has been diagnosed with migraine headaches without aura which are far and few apart She also has some stress incontinence Last MRI brain was done in 2001 reportedly normal CURRENT MEDICATIONS 1 Klonopin 0 5 mg twice a day 2 Primidone 100 mg b i d 3 Propranolol long acting 80 mg once in the morning PAST MEDICAL HISTORY Essential tremor cervical dystonia endometriosis migraine headaches without aura left ear sensorineural deafness and basal cell carcinoma resection on the nose PAST SURGICAL HISTORY L5 S1 lumbar laminectomy in 1975 exploratory laparotomy in 1967 tonsillectomy and adenoidectomy and anal fissure surgery in 1975 FAMILY HISTORY Both parents have ET and hypertension Maternal cousin with lupus SOCIAL HISTORY Denies any smoking or alcohol She is married since 44 years has 3 children She used to work as a labor and delivery nurse up until early 2001 when she retired REVIEW OF SYSTEMS No fever chills nausea or vomiting No visual complaints She complains of hearing decreased on the left No chest pain or shortness of breath No constipation She does give a history of urge incontinence No rashes No depressive symptoms PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 131 72 pulse is 50 and weight is 71 3 kg HEENT PERRLA EOMI CARDIOVASCULAR S1 and S2 normal Regular rate and rhythm She does have a rash over the right ankle with a prior basal cell carcinoma was resected NEUROLOGIC Alert and oriented x4 Speech shows a voice tremor occasionally Language is intact Cranial nerves II through XII intact Motor examination showed 5 5 power in all extremities with minimal increased tone Sensory examination was intact to light touch Reflexes were brisk bilaterally but they were equal and both toes were downgoing Her coordination showed minimal intentional component to bilateral finger to nose Gait was intact Lot of swing on Romberg s The patient did have a tremor both upper extremities right more than left She did have a head tremor which was no no variety and she had a minimal torticollis with her head twisted to the left ASSESSMENT AND PLAN This 62 year old white female has essential tremor and mild torticollis Tremor not bothersome for most activities of daily living but she does have a great difficulty writing which is totally illegible The patient did not wish to change any of her medication doses at this point We will go ahead and check MRI brain and we will get the films later We will see her back in 3 months Also the patient declined any possible Botox for the mild torticollis she has at this point Keywords neurology clonazepam difficulty writing head tremor voice tremor migraine headaches mri brain essential tremor torticollis carcinoma MEDICAL_TRANSCRIPTION,Description Fall with questionable associated loss of consciousness Left parietal epidural hematoma Medical Specialty Neurology Sample Name Epidural Hematoma Transcription CC Fall with questionable associated loss of consciousness HX This 81 y o RHM fell down 20 steps on the evening of admission 1 10 93 while attempting to put his boots on at the top of the staircase He was evaluated locally and was amnestic to the event at the time of examination A HCT scan was obtained and he was transferred to UIHC Neurosurgery MEDS Lasix 40mg qd Zantac 150mg qd Lanoxin 0 125mg qd Capoten 2 5mg bid Salsalate 750mg tid ASA 325mg qd Ginsana Ginseng 100mg bid PMH 1 Atrial fibrillation 2 Right hemisphere stroke 11 22 88 with associated left hemiparesis and amaurosis fugax This was followed by a RCEA 12 1 88 for 98 stenosis The stroke symptoms signs resolved 3 DJD 4 Right TKR 2 3 years ago 5 venous stasis with no h o DVT 6 former participant in NASCET 7 TURP for BPH No known allergies FHX Father died of an MI at unknown age Mother died of complications of a dental procedure He has one daughter who is healthy SHX Married Part time farmer Denied tobacco ETOH illicit drug use EXAM BP157 86 HR100 and irregular RR20 36 7C 100 SaO2 MS A O to person place time Speech fluent and without dysarthria CN Pupils 3 3 decreasing to 2 2 on exposure to light EOM intact VFFTC Optic disks were flat Face was symmetric with symmetric movement The remainder of the CN exam was unremarkable Motor 5 5 strength throughout with normal muscle tone and bulk Sensory unremarkable Coord unremarkable Station Gait not mentioned in chart Reflexes symmetric Plantar responses were flexor bilaterally Gen Exam CV IRRR without murmur Lungs CTA Abdomen NT ND NBS HEENT abrasion over the right forehead Extremity distal right leg edema erythema just above the ankle tender to touch COURSE 1 10 93 outside HCT was reviewed It revealed a left parietal epidural hematoma GS PT PTT UA and CBC were unremarkable RLE XR revealed a fracture of the right lateral malleolus for which he was casted Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH Keywords neurology loss of consciousness parietal epidural hematoma parietal epidural epidural hematoma consciousness epidural hematoma MEDICAL_TRANSCRIPTION,Description Evacuation of epidural hematoma and insertion of epidural drain Epidural hematoma cervical spine Status post cervical laminectomy C3 through C7 postop day 10 Central cord syndrome and acute quadriplegia Medical Specialty Neurology Sample Name Epidural Hematoma Evacuation Transcription PREOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia POSTOPERATIVE DIAGNOSES 1 Epidural hematoma cervical spine 2 Status post cervical laminectomy C3 through C7 postop day 10 3 Central cord syndrome 4 Acute quadriplegia PROCEDURE PERFORMED 1 Evacuation of epidural hematoma 2 Insertion of epidural drain ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 200 cc HISTORY This is a 64 year old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction She was then transferred to Beaumont Hospital at which point she developed a sternal abscess The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren Michigan at which point she developed a second what was termed minor myocardial infarction The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later brings us to the month of August at which time she was at home ambulating with a walker or a cane and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI which showed record signal change The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery but objectively there was not much improvement Approximately 10 days after the surgery brings us to today s date the health officer was notified of the patient s labored breathing When she examined the patient she also noted that the patient was unable to move her extremities She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma On clinical examination there was swelling in the posterior aspect of the neck The patient has no active movement in the upper and lower extremity muscle groups Reflexes are absent in the upper and lower extremities Long track signs are absent Sensory level is at the C4 dermatome Rectal tone is absent I discussed the findings with the patient and also the daughter We discussed the possibility of this is permanent quadriplegia but at this time the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery OPERATIVE PROCEDURE The patient was taken to OR 1 at ABCD General Hospital on a gurney Department of Anesthesia administered fiberoptic intubation and general anesthetic A Foley catheter was placed in the bladder The patient was log rolled in a prone position on the Jackson table Bony prominences were well padded The patient s head was placed in the prone view anesthesia head holder At this point the wound was examined closely and there was hematoma at the caudal pole of the wound Next the patient was prepped and draped in the usual sterile fashion The previous skin incision was reopened At this point hematoma properly exits from the wound All sutures were removed and the epidural spaces were encountered at this time The self retaining retractors were placed in the depth of the wound Consolidated hematoma was now removed from the wound Next the epidural space was encountered There was no additional hematoma in the epidural space or on the thecal sac A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well Next the wound was irrigated copiously with one liter of saline using a syringe The walls of the wound were explored There was no active bleeding Retractors were removed at this time and even without pressure on the musculature there was no active bleeding A 19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space Fascia was reapproximated with 1 Vicryl sutures subcutaneous tissue with 3 0 Vicryl sutures Steri Strips covered the incision and dressing was then applied over the incision The patient was then log rolled in the supine position on the hospital gurney She remained intubated for airway precautions and transferred to the recovery room in stable condition Once in the recovery room she was alert She was following simple commands and using her head to nod but she did not have any active movement of her upper or lower extremities Prognosis for this patient is guarded Keywords neurology epidural hematoma cervical spine cervical laminectomy central cord syndrome acute quadriplegia insertion of epidural drain epidural drain epidural space hematoma epidural cervical laminectomy quadriplegia MEDICAL_TRANSCRIPTION,Description Fall loss of consciousness Medical Specialty Neurology Sample Name Epidural Fluid Collection Transcription CC Fall loss of consciousness HX This 44y o male fell 15 20feet from a construction site scaffold landing on his head on a cement sidewalk He was transported directly from the scene approximately one mile east of UIHC The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage but upon evaluation in the ER was found to be in his esophagus and was immediately replaced into the trachea Replacement of the ET tube required succinylcholine The patient remained in a C collar during the procedure Once in the ER the patient had a 15min period of bradycardia MEDS none prior to accident PMH No significant chronic or recent illness s p left knee arthroplasty h o hand fractures FHX Unremarkable SHX Married Rare cigarette use Occasional Marijuana use Social ETOH use per wife EXAM BP156 79 HR 74 RR Ambu Bag ventilation via ET tube 34 7C 72 100 O2Sat MS Unresponsive to verbal stimulation No spontaneous verbalization CN Does not open close eyes to command or spontaneously Pupils 9 7 and nonreactive Corneas Gag Oculocephalic and Oculovestibular reflexes not performed Motor minimal spontaneous movement of the 4 extremities Sensory withdraws LUE and BLE to noxious stimulation Coord Station Gait Not tested Reflexes 1 2 and symmetric throughout Babinski signs were present bilaterally HEENT severe facial injury with brain parenchyma and blood from the right nostril Severe soft tissue swelling about side of head Gen Exam CV RRR without murmur Lungs CTA Abdomen distended after ET tube misplacement COURSE HCT upon arrival 10 29 92 revealed Extensive parenchymal contusions in right fronto parietal area Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle Considerable mass effect is exerted upon the right lateral ventricle near totally obliterating its contour Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area There are extensive fractures of the following two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone as well as the greater wing of the sphenoid Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right Extensive comminution of the right half of the frontal bone and marked displacement is seen Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells The medial and lateral walls of the maxillary sinus are fractured and minimally displaced as well as the medial wall of the left maxillary sinus The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly Portable chest c spine and abdominal XRays were unremarkable but limited studies Abdominal CT was unremarkable Hgb 10 4g dl Hct29 WBC17 4k mm3 Plt 190K ABG 7 28 48 46 on admission Glucose 131 The patient was hyperventilated Mannitol was administered 1g kg and the patient was given a Dilantin loading dose He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures The patient remained in a persistent vegetative state at UIHC and upon the request of this wife his feeding tube was discontinued He later expired Keywords neurology loss of consciousness soft tissue swelling medial wall maxillary sinus sphenoid collection tube bone MEDICAL_TRANSCRIPTION,Description EMG Nerve Conduction Study showing sensory motor length dependent neuropathy consistent with diabetes severe left ulnar neuropathy and moderate to severe left median neuropathy Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 4 Transcription NERVE CONDUCTION STUDIES Bilateral ulnar sensory responses are absent Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude The left radial sensory response is normal and robust Left sural response is absent Left median motor distal latency is prolonged with attenuated evoked response amplitude Conduction velocity across the forearm is mildly slowed Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow Conduction velocities across the forearm and across the elbow are prolonged Conduction velocity proximal to the elbow is normal The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist There is mild diminution of response around the elbow Conduction velocity slows across the elbow The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head F waves are prolonged NEEDLE EMG Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle It revealed spontaneous activity in lower cervical paraspinals left abductor pollicis brevis and first dorsal interosseous muscles There were signs of chronic reinnervation in triceps extensor digitorum communis flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A sensory motor length dependent neuropathy consistent with diabetes 2 A severe left ulnar neuropathy This is probably at the elbow although definitive localization cannot be made 3 Moderate to severe left median neuropathy This is also probably at the carpal tunnel although definitive localization cannot be made 4 Right ulnar neuropathy at the elbow mild 5 Right median neuropathy at the wrist consistent with carpal tunnel syndrome moderate 6 A left C8 radiculopathy double crush syndrome 7 There is no evidence for thoracic radiculitis The patient has made very good response with respect to his abdominal pain since starting Neurontin He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch He is still scheduled for MRI of C spine and T spine I will see him in followup after the above scans Keywords neurology emg nerve conduction study nerve conduction studies needle emg electrical study neuropathy ulnar neuropathy median neuropathy severely attenuated evoked response normal evoked response amplitude attenuated evoked response amplitude median motor distal latency motor distal latency abductor pollicis pollicis brevis dorsal interosseous carpal tunnel conduction emg nerve needle MEDICAL_TRANSCRIPTION,Description A woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities Abnormal electrodiagnostic study Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 8 Transcription REFERRING DIAGNOSIS Motor neuron disease PERTINENT HISTORY AND EXAMINATION Briefly the patient is an 83 year old woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities SUMMARY The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity The right ulnar sensory amplitude was reduced with slowing of the conduction velocity The right radial sensory amplitude was reduced with slowing of the conduction velocity The right sural and left sural sensory responses were absent The right median motor response showed a prolonged distal latency across the wrist with proximal slowing The distal amplitude was very reduced and there was a reduction with proximal stimulation The right ulnar motor amplitude was borderline normal with slowing of the conduction velocity across the elbow The right common peroneal motor response showed a decreased amplitude when recorded from the EDB with mild slowing of the proximal conduction velocity across the knee The right tibial motor response showed a reduced amplitude with prolongation of the distal latency The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing The left tibial motor response showed a decreased amplitude with a borderline normal distal latency The minimum F wave latencies were normal with the exception of a mild prolongation of the ulnar F wave latency and the tibial F wave latency as indicated above With repetitive nerve stimulation there was no significant decrement noted in either the right nasalis or the right trapezius muscles Concentric needle EMG studies were performed in the right lower extremity right upper extremity thoracic paraspinals and in the tongue There was evidence of increased insertional activity in the right tibialis anterior muscle with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue In addition there was evidence of increased amplitude long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above INTERPRETATION Abnormal electrodiagnostic study There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow Even despite the patient s age the decrease in sensory responses is concerning and makes it difficult to be certain about the diagnosis of motor neuron disease However the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease The patient will return for further evaluation Keywords neurology electrodiagnostic study electrodiagnostic edb latency nerve conduction study emg motor neuron disease distal latency motor response motor amplitude conduction MEDICAL_TRANSCRIPTION,Description The patient is status post C3 C4 anterior cervical discectomy and fusion Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 5 Transcription She has an extensive past medical history of rheumatoid arthritis fibromyalgia hypertension hypercholesterolemia and irritable bowel syndrome She has also had bilateral carpal tunnel release On examination normal range of movement of C spine She has full strength in upper and lower extremities Normal straight leg raising Reflexes are 2 and symmetric throughout No Babinski She has numbness to light touch in her right big toe NERVE CONDUCTION STUDIES The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude Bilateral tibial motor nerves could not be obtained technical The remaining nerves tested revealed normal distal latencies evoked response amplitudes conduction velocities F waves and H reflexes NEEDLE EMG Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI It revealed 2 spontaneous activity in the right APB and FDI and 1 spontaneous activity in lower cervical paraspinals lower and middle lumbosacral paraspinals right extensor digitorum communis muscle and right pronator teres There was evidence of chronic denervation in the right first dorsal interosseous pronator teres abductor pollicis brevis and left first dorsal interosseous IMPRESSION This electrical study is abnormal It reveals the following 1 An active right C8 T1 radiculopathy Electrical abnormalities are moderate 2 An active right C6 C7 radiculopathy Electrical abnormalities are mild 3 Evidence of chronic left C8 T1 denervation No active denervation 4 Mild right lumbosacral radiculopathies This could not be further localized because of normal EMG testing in the lower extremity muscles 5 There is evidence of mild sensory carpal tunnel on the right she has had previous carpal tunnel release Results were discussed with the patient It appears that she has failed conservative therapy and I have recommended to her that she return to Dr X for his assessment for possible surgery to her C spine She will continue with conservative therapy for the mild lumbosacral radiculopathies Keywords neurology emg nerve conduction study needle emg paraspinal muscles radiculopathy electrical abnormalities carpal tunnel release evoked response lumbosacral radiculopathies conservative therapy carpal tunnel conduction emg nerve MEDICAL_TRANSCRIPTION,Description Patient had movor vehicle accirdent and may have had a brief loss of consciousness Shortly thereafter she had some blurred vision Since that time she has had right low neck pain and left low back pain Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 7 Transcription HISTORY The patient is a 34 year old right handed female who states her symptoms first started after a motor vehicle accident in September 2005 She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision which lasted about a week and then resolved Since that time she has had right low neck pain and left low back pain She has been extensively worked up and treated for this MRI of the C T spine and LS spine has been normal She has improved significantly but still complains of pain In June of this year she had different symptoms which she feels are unrelated She had some chest pain and feeling of tightness in the left arm and leg and face By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg Symptoms lasted for about two days and then resolved However since that time she has had intermittent numbness in the left hand and leg The face numbness has completely resolved Symptoms are mild She denies any previous similar episodes She denies associated dizziness vision changes incoordination weakness change in gait or change in bowel or bladder function There is no associated headache Brief examination reveals normal motor examination with no pronator drift and no incoordination Normal gait Cranial nerves are intact Sensory examination reveals normal facial sensation She has normal and symmetrical light touch temperature and pinprick in the upper extremities In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot In this area she has normal light touch and pinprick She describes it as a strange unusual sensation NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the left arm and leg NEEDLE EMG Needle EMG was performed in the left leg lumbosacral paraspinal right tibialis anterior and right upper thoracic paraspinal muscles using a disposable concentric needle It revealed normal insertional activity no spontaneous activity and normal motor unit action potential form in all muscles tested IMPRESSION This electrical study is normal There is no evidence for peripheral neuropathy entrapment neuropathy plexopathy or lumbosacral radiculopathy EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident This was normal Based on her history of sudden onset of left face arm and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year Symptoms are now very mild but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms Once she has the test done she will phone me and further management will be based on the results Keywords neurology nerve conduction studies motor sensory distal latencies evoked response conduction velocities needle emg loss of consciousness motor vehicle accident thoracic paraspinal needle paraspinal conduction MEDICAL_TRANSCRIPTION,Description Electroencephalographic findings and interpretation Medical Specialty Neurology Sample Name Electroencephalography Transcription HISTORY This is a digital EEG performed on a 75 year old male with seizures BACKGROUND ACTIVITY The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region This rhythm is also accompanied by some beta activity which occurs infrequently There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson s Part of the EEG is obscured by the muscle contraction artifact There are also left temporal sharps occurring infrequently during the tracing At one point of time there was some slowing occurring in the right frontal head region ACTIVATION PROCEDURES Photic stimulation was performed and did not show any significant abnormality SLEEP PATTERNS No sleep architecture was observed during this tracing IMPRESSION This awake alert drowsy EEG is abnormal due to the presence of slowing in the right frontal head region due to the presence of sharps arising in the left temporal head region and due to the tremors The slowing can be consistent with underlying structural abnormalities so a stroke subdural hematoma etc should be ruled out The tremor probably represents a Parkinson s tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities so clinical correlation is recommended Keywords neurology electroencephalography eeg hz rhythm parkinson s tremor photic stimulation frontal head region temporal head region muscle contractions seizures parkinson s temporal MEDICAL_TRANSCRIPTION,Description A right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident with no specific injury at that time Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 3 Transcription HISTORY The patient is a 56 year old right handed female with longstanding intermittent right low back pain who was involved in a motor vehicle accident in September of 2005 At that time she did not notice any specific injury Five days later she started getting abnormal right low back pain At this time it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf Symptoms are worse when sitting for any length of time such as driving a motor vehicle Mild symptoms when walking for long periods of time Relieved by standing and lying down She denies any left leg symptoms or right leg weakness No change in bowel or bladder function Symptoms have slowly progressed She has had Medrol Dosepak and analgesics which have not been very effective She underwent a spinal epidural injection which was effective for the first few hours but she had recurrence of the pain by the next day This was done four and a half weeks ago On examination lower extremities strength is full and symmetric Straight leg raising is normal OBJECTIVE Sensory examination is normal to all modalities Full range of movement of lumbosacral spine Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint Deep tendon reflexes are 2 and symmetric at the knees 2 at the left ankle and 1 at the right ankle NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in the lower extremities Right tibial H reflex is slightly prolonged when compared to the left tibial H reflex NEEDLE EMG Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle There were signs of chronic denervation in right tibialis anterior peroneus longus gastrocnemius medialis and left gastrocnemius medialis muscles IMPRESSION This electrical study is abnormal It reveals the following 1 A mild right L5 versus S1 radiculopathy 2 Left S1 nerve root irritation There is no evidence of active radiculopathy 3 There is no evidence of plexopathy myopathy or peripheral neuropathy MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5 S1 neuroforaminal stenosis slightly worse on the right Results were discussed with the patient and her daughter I would recommend further course of spinal epidural injections with Dr XYZ If she has no response then surgery will need to be considered She agrees with this approach and will followup with you in the near future Keywords neurology emg nerve conduction study radiculopathy peripheral neuropathy nerve root irritation motor vehicle accident lumbosacral paraspinal muscles spinal epidural lumbosacral spine peroneus longus gastrocnemius medialis lower extremities emg nerve conduction needle MEDICAL_TRANSCRIPTION,Description Patient with a past medical history of a left L5 S1 lumbar microdiskectomy with complete resolution of left leg symptoms Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 6 Transcription HISTORY The patient is a 46 year old right handed gentleman with a past medical history of a left L5 S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms who now presents with a four month history of gradual onset of right sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle Symptoms are worsened by any activity and relieved by rest He also feels that when the pain is very severe he has some subtle right leg weakness No left leg symptoms No bowel or bladder changes On brief examination full strength in both lower extremities No sensory abnormalities Deep tendon reflexes are 2 and symmetric at the patellas and absent at both ankles Positive straight leg raising on the right MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5 S1 encroaching upon the right exiting S1 nerve root NERVE CONDUCTION STUDIES Motor and sensory distal latencies evoked response amplitudes and conduction velocities are normal in the lower extremities The right common peroneal F wave is minimally prolonged The right tibial H reflex is absent NEEDLE EMG Needle EMG was performed on the right leg left gastrocnemius medialis muscle and right lumbosacral paraspinal muscles using a disposable concentric needle It revealed spontaneous activity in the right gastrocnemius medialis gluteus maximus and lower lumbosacral paraspinal muscles There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles IMPRESSION This electrical study is abnormal It reveals an acute right S1 radiculopathy There is no evidence for peripheral neuropathy or left or right L5 radiculopathy Results were discussed with the patient and he is scheduled to follow up with Dr X in the near future Keywords neurology microdiskectomy needle emg nerve conduction studies lumbosacral paraspinal muscles lumbar microdiskectomy lower extremities lumbosacral paraspinal paraspinal muscles gluteus maximus leg symptoms gastrocnemius medialis emg nerve conduction lumbosacral needle gastrocnemius medialis muscles MEDICAL_TRANSCRIPTION,Description A 21 channel digital electroencephalogram was performed on a patient in the awake state Medical Specialty Neurology Sample Name Electroencephalogram 4 Transcription PROCEDURE A 21 channel digital electroencephalogram was performed on a patient in the awake state Per the technician s notes the patient is taking Depakene The recording consists of symmetric 9 Hz alpha activity Throughout the recording repetitive episodes of bursts of 3 per second spike and wave activity are noted The episodes last from approximately1 to 7 seconds The episodes are exacerbated by hyperventilation IMPRESSION Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation This activity could represent true petit mal epilepsy Clinical correlation is suggested Keywords neurology alpha activity wave activity hyperventilation electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient with longstanding bilateral arm pain which is predominantly in the medial aspect of arms and hands as well as left hand numbness worse at night and after doing repetitive work with left hand Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 1 Transcription HISTORY The patient is a 52 year old right handed female with longstanding bilateral arm pain which is predominantly in the medial aspect of her arms and hands as well as left hand numbness worse at night and after doing repetitive work with her left hand She denies any weakness No significant neck pain change in bowel or bladder symptoms change in gait or similar symptoms in the past She is on Lyrica for the pain which has been somewhat successful Examination reveals positive Phalen s test on the left Remainder of her neurological examination is normal NERVE CONDUCTION STUDIES The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity The left median sensory distal latency is prolonged with an attenuated evoked response amplitude The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude The right median motor distal latency and evoked response amplitude is normal Left ulnar motor and sensory and left radial sensory responses are normal Left median F wave is normal NEEDLE EMG Needle EMG was performed on the left arm right first dorsal interosseous muscle and bilateral cervical paraspinal muscles It revealed spontaneous activity in the left abductor pollicis brevis muscle There is increased insertional activity in the right first dorsal interosseous muscle Both interosseous muscles showed signs of reinnervation Left extensor digitorum communis muscle showed evidence of reduced recruitment Cervical paraspinal muscles were normal IMPRESSION This electrical study is abnormal It reveals the following A left median neuropathy at the wrist consistent with carpal tunnel syndrome Electrical abnormalities are moderate to mild bilateral C8 radiculopathies This may be an incidental finding I have recommended MRI of the spine without contrast and report will be sent to Dr XYZ She will follow up with Dr XYZ with respect to treatment of the above conditions Keywords neurology nerve conduction study emg neuropathy median motor distal latency median sensory distal latency attenuated evoked response amplitude emg nerve conduction study sensory distal latency attenuated evoked response dorsal interosseous muscle cervical paraspinal muscles emg nerve conduction conduction study median motor needle emg distal latency evoked response emg nerve bilateral evoked conduction MEDICAL_TRANSCRIPTION,Description Electroencephalogram EEG This is an 18 channel recording obtained using the standard scalp and referential electrodes observing the 10 20 international system Medical Specialty Neurology Sample Name Electroencephalogram 2 Transcription REPORT This is an 18 channel recording obtained using the standard scalp and referential electrodes observing the 10 20 international system The patient was reported to be cooperative and was awake throughout the recording CLINICAL NOTE This is a 51 year old male who is being evaluated for dizziness Spontaneous activity is fairly well organized characterized by low to medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region Eye opening caused a bilateral symmetrical block on the first run In addition to the above description movement of muscle and other artifacts are seen On subsequent run no additional findings were seen During subsequent run again no additional findings were seen Hyperventilation was omitted Photic stimulation was performed but no clear cut photic driving was seen EKG was monitored during this recording and it showed normal sinus rhythm when monitored IMPRESSION This record is essentially within normal limits Clinical correlation is recommended Keywords neurology referential electrodes scalp hyperventilation photic stimulation electroencephalogram MEDICAL_TRANSCRIPTION,Description Electroencephalogram EEG Photic stimulation reveals no important changes Essentially normal Medical Specialty Neurology Sample Name Electroencephalogram 1 Transcription REPORT The electroencephalogram shows background activity at about 9 10 cycle second bilaterally Little activity in the beta range is noted Waves of 4 7 cycle second of low amplitude were occasionally noted Abundant movements and technical artifacts are noted throughout this tracing Hyperventilation was not performed Photic stimulation reveals no important changes CLINICAL INTERPRETATION The electroencephalogram is essentially normal Keywords neurology beta range hyperventilation photic stimulation electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A ight handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg Medical Specialty Neurology Sample Name EMG Nerve Conduction Study 2 Transcription HISTORY The patient is a 78 year old right handed inpatient with longstanding history of cervical spinal stenosis status post decompression opioid dependence who has had longstanding low back pain radiating into the right leg She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain which radiates down into her buttocks and down to posterior aspect of her thigh into her knee This has required large amounts of opioid analgesics to control She has been basically bedridden because of this She was brought into hospital for further investigations PHYSICAL EXAMINATION On examination she has positive straight leg rising on the right with severe shooting radicular type pain with right leg movement Difficult to assess individual muscles but strength is largely intact Sensory examination is symmetric Deep tendon reflexes reveal hyporeflexia in both patellae which probably represents a cervical myelopathy from prior cord compression She has slightly decreased right versus left ankle reflexes The Babinski s are positive On nerve conduction studies motor and sensory distal latencies evoked response amplitudes conduction velocities and F waves are normal in lower extremities NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles There is evidence of denervation in right gastrocnemius medialis muscle IMPRESSION This electrical study is abnormal It reveals the following 1 Inactive right S1 L5 radiculopathy 2 There is no evidence of left lower extremity radiculopathy peripheral neuropathy or entrapment neuropathy Results were discussed with the patient and she is scheduled for imaging studies in the next day Keywords neurology needle emg radiculopathy electrical study emg nerve conduction study cervical spinal stenosis lumbosacral paraspinal muscles gastrocnemius medialis muscles spinal stenosis post decompression lumbosacral paraspinal paraspinal muscles gastrocnemius medialis medialis muscles decompression emg nerve conduction cervical spinal needle muscles MEDICAL_TRANSCRIPTION,Description Normal awake and drowsy stage I sleep EEG for patient s age Medical Specialty Neurology Sample Name Electroencephalogram Transcription DESCRIPTION OF RECORD This tracing was obtained utilizing 27 paste on gold plated surface disc electrodes placed according to the International 10 20 system Electrode impedances were measured and reported at less than 5 kilo ohms each FINDINGS In general the background rhythms are bilaterally symmetrical During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well modulated 9 10 Hz alpha activity best seen posteriorly The alpha activity attenuates with eye opening During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity There is no evidence of focal slowing or paroxysmal activity IMPRESSION Normal awake and drowsy stage I sleep EEG for patient s age Keywords neurology gold plated surface disc electrodes paroxysmal activity eeg drowsy stage sleep eeg stage sleep electrodes awake moderate activity MEDICAL_TRANSCRIPTION,Description Abnormal electroencephalogram revealing generalized poorly organized slowing with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally somewhat more prevalent on the right Medical Specialty Neurology Sample Name Electroencephalogram 3 Transcription IMPRESSION Abnormal electroencephalogram revealing generalized poorly organized slowing with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally somewhat more prevalent on the right Clinical correlation is suggested Keywords neurology sleep vertex activity muscle artifact sharp wave activity electroencephalogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description History of numbness in both big toes and up the lateral aspect of both calves She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness Medical Specialty Neurology Sample Name EMG Nerve Conduction Study Transcription HISTORY The patient is a 52 year old female with a past medical history of diet controlled diabetes diffuse arthritis plantar fasciitis and muscle cramps who presents with a few month history of numbness in both big toes and up the lateral aspect of both calves Symptoms worsened considerable about a month ago This normally occurs after being on her feet for any length of time She was started on amitriptyline and this has significantly improved her symptoms She is almost asymptomatic at present She dose complain of longstanding low back pain but no pain that radiates from her back into her legs She has had no associated weakness On brief examination straight leg raising is normal The patient is obese There is mild decreased vibration and light touch in distal lower extremities Strength is full and symmetric Deep tendon reflexes at the knees are 2 and symmetric and absent at the ankles NERVE CONDUCTION STUDIES Bilateral sural sensory responses are absent Bilateral superficial sensory responses are present but mildly reduced The right radial sensory response is normal The right common peroneal and tibial motor responses are normal Bilateral H reflexes are absent NEEDLE EMG Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle Lumbar paraspinals were attempted but were too painful to get a good assessment IMPRESSION This electrical study is abnormal It reveals the following 1 A very mild purely sensory length dependent peripheral neuropathy 2 Mild bilateral L5 nerve root irritation There is no evidence of active radiculopathy Based on the patient s history and exam her new symptoms are consistent with mild bilateral L5 radiculopathies Symptoms have almost completely resolved over the last month since starting Elavil I would recommend MRI of the lumbosacral spine if symptoms return With respect to the mild neuropathy this is probably related to her mild glucose intolerance early diabetes However I would recommend a workup for other causes to include the following Fasting blood sugar HbA1c ESR RPR TSH B12 serum protein electrophoresis and Lyme titer Keywords neurology nerve conduction studies needle emg numbness tibialis posterior muscle sensory responses muscle tibialis toes MEDICAL_TRANSCRIPTION,Description Possible cerebrovascular accident The EEG was obtained using 21 electrodes placed in scalp to scalp and scalp to vertex montages Medical Specialty Neurology Sample Name EEG Transcription DIAGNOSIS Possible cerebrovascular accident DESCRIPTION The EEG was obtained using 21 electrodes placed in scalp to scalp and scalp to vertex montages The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7 8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session Transient periods of drowsiness occurred naturally producing irregular 5 7 cycle per second activity mostly over the anterior regions Hyperventilation was not performed No epileptiform activity or any definite lateralizing findings were seen IMPRESSION Mildly abnormal study The findings are suggestive of a generalized cerebral disorder Due to the abundant amount of movement artifacts any lateralizing findings if any cannot be well appreciated Clinical correlation is recommended Keywords neurology scalp to scalp scalp to vertex montages electrodes amplitude epileptiform activity cerebrovascular accident eegNOTE MEDICAL_TRANSCRIPTION,Description This is a 95 5 hour continuous video EEG monitoring study Medical Specialty Neurology Sample Name EEG Monitoring Study Transcription TECHNICAL SUMMARY The patient was recorded from 2 15 p m on 08 21 06 through 1 55 p m on 08 25 06 The patient was recorded digitally using the 10 20 system of electrode placement Additional temporal electrodes and single channels of EOG and EKG were also recorded The patient s medications valproic acid Zonegran and Keppra were weaned progressively throughout the study The occipital dominant rhythm is 10 to 10 5 Hz and well regulated Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally HYPERVENTILATION There are no significant changes with 4 minutes of adequate overbreathing PHOTIC STIMULATION There are no significant changes with various frequencies of flickering light SLEEP There are no focal or lateralizing features and no abnormal waveforms INDUCED EVENT On the final day of study a placebo induction procedure was performed to induce a clinical event The patient was informed that we would be doing prolonged photic stimulation and hyperventilation which might induce a seizure At 1 38 p m the patient was instructed to begin hyperventilation Approximately four minutes later photic stimulation with random frequencies of flickering light was initiated Approximately 8 minutes into the procedure the patient became unresponsive to verbal questioning Approximately 1 minute later she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed She persisted with the shaking and some side to side movements of her head for approximately 1 minute before abruptly stopping Approximately 30 seconds later she became slowly responsive initially only uttering a few words and able to say her name When asked what had just occurred she replied that she was asleep and did not remember any event When later asked she did admit that this was consistent with the seizures she is experiencing at home EEG There are no significant changes to the character of the background EEG activity present in the minutes preceding during or following this event Of note while her eyes were closed and she was non responsive there is a well regulated occipital dominant rhythm present IMPRESSION The findings of this patient s 95 5 hour continuous video EEG monitoring study are within the range of normal variation No epileptiform activity is present One clinical event was induced with hyperventilation and photic stimulation The clinical features of this event are described in the technical summary above There was no epileptiform activity associated with this event This finding is consistent with a non epileptic pseudoseizure Keywords neurology video eeg monitoring study eog ekg abnormal waveforms photic stimulation hyperventilation eeg monitoring study eeg monitoring monitoring study eeg monitoring MEDICAL_TRANSCRIPTION,Description Diagnostic cerebral angiogram and transcatheter infusion of papaverine Medical Specialty Neurology Sample Name Diagnostic Cerebral Angiogram Transcription EXAM 1 Diagnostic cerebral angiogram 2 Transcatheter infusion of papaverine ANESTHESIA General anesthesia FLUORO TIME 19 5 minutes CONTRAST Visipaque 270 100 mL INDICATIONS FOR PROCEDURE The patient is a 13 year old boy who had clipping for a left ICA bifurcation aneurysm He was referred for a routine postop check angiogram He is doing fine clinically All questions were answered risks explained informed consent taken and patient was brought to angio suite TECHNIQUE After informed consent was taken patient was brought to angio suite both groin sites were prepped and draped in sterile manner Patient was placed under general anesthesia for entire duration of the procedure Groin access was obtained with a stiff micropuncture wire and a 4 French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush A 4 French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections The images showed spasm of the left internal carotid artery and the left A1 it was thought planned to infused papaverine into the ICA and the left A1 After that the diagnostic catheter was taken up into the distal internal carotid artery SL 10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery Post papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1 The catheter was then removed from the patient pressure was held for 10 minutes leading to hemostasis Patient was then transferred back to the ICU in the Children s Hospital where he was extubated without any deficits INTERPRETATION OF IMAGES 1 LEFT COMMON INTERNAL CAROTID ARTERY INJECTIONS The left internal carotid artery is of normal caliber In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1 There is poor filling of the A2 through left internal carotid artery injection There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution 2 RIGHT INTERNAL CAROTID ARTERY INJECTION The right internal carotid artery is of normal caliber There is opacification of the right ophthalmic and the posterior communicating artery The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery Right MCA along with the distal branches are filling normally Capillary filling and venous drainage are normal 3 POST PAPAVERINE INJECTION The post papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm IMPRESSION 1 Well clipped left ICA bifurcation aneurysm 2 Moderately severe spasm of the internal carotid artery and left A1 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels Keywords neurology transcatheter infusion of papaverine internal carotid artery heparinized saline flush diagnostic cerebral angiogram ica bifurcation aneurysm anterior cerebral artery carotid artery internal carotid saline flush venous drainage papaverine injection ica bifurcation bifurcation aneurysm anterior cerebral cerebral artery artery injections infusion carotid artery angiogram diagnostic ica aneurysm cerebral papaverine MEDICAL_TRANSCRIPTION,Description Patient with episode of lightheadedness and suddenly experienced vertigo Medical Specialty Neurology Sample Name Dural AVM Transcription CC Vertigo HX This 61y o RHF experienced a 2 3 minute episode of lightheadedness while driving home from the dentist in 5 92 In 11 92 while eating breakfast she suddenly experienced vertigo This was immediately followed by nausea and several episodes of vomiting The vertigo lasted 2 3minutes She retired to her room for a 2 hour nap after vomiting When she awoke the symptoms had resolved On 1 13 93 she had an episode of right arm numbness lasting 4 5hours There was no associated weakness HA dysarthria dysphagia visual change vertigo or lightheadedness OUTSIDE RECORDS 12 16 92 Carotid Doppler RICA 30 40 LICA 10 20 12 4 92 brain MRI revealed a right cerebellar hypodensity consistent with infarct MEDS Zantac 150mg bid Proventil MDI bid Azmacort MDI bid Doxycycline 100mg bid Premarin 0 625mg qd Provera 2 5mg qd ASA 325mg qd PMH 1 MDD off antidepressants since 6 92 2 asthma 3 allergic rhinitis 4 chronic sinusitis 5 s p Caldwell Luc 1978 and nasal polypectomy 6 GERD 7 h o elevated TSH 8 hypercholesterolemia 287 on 11 20 93 9 h o heme positive stool BE 11 24 92 and UGI 11 25 92 negative FHX Father died of a thoracic aortic aneurysm age 71 Mother died of stroke age 81 SHX Married One son deceased Salesperson Denied tobacco ETOH illicit drug use EXAM BP RUE 132 72 LUE 136 76 HR67 RR16 Afebrile 59 2kg MS A O to person place time Speech fluent and without dysarthria Thought lucid CN unremarkable Motor 5 5 strength throughout with normal muscle bulk and tone Sensory No deficits appreciated Coord unremarkable Station no pronator drift truncal ataxia or Romberg sign Gait not done Reflexes 2 2 throughout BUE and at patellae 1 1 at Achilles Plantar responses were flexor bilaterally Gen Exam Obese COURSE CBC GS PT PTT UA were unremarkable The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke She was placed on Ticlid 250mg bid HCT 1 15 93 low density focus in the right medial and posterior cerebellar hemisphere MRI and MRA 1 18 93 revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation e g cavernous angioma An abnormal vascular blush was seen on the MRA This area appeared to be supplied by one of the external carotid arteries which one is was not specified this finding maybe suggestive of a vascular malformation 1 20 93 Cerebral Angiogram The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition The vascular blush seen on MRA was no visualized on angiography The patient was discharged home on 1 25 93 Keywords neurology avm episode of lightheadedness vascular malformation cavernous angioma vascular blush cerebellar hemisphere malformation cavernous angioma angiography lightheadedness hemisphere vertigo cerebellar MEDICAL_TRANSCRIPTION,Description CT Brain unshunted hydrocephalus Dandy Walker Malformation Medical Specialty Neurology Sample Name Dandy Walker Malformation Transcription CC Seizure D O HX 29 y o male with cerebral palsy non shunted hydrocephalus spastic quadriplegia mental retardation bilateral sensory neural hearing loss severe neurogenic scoliosis and multiple contractures of the 4 extremities neurogenic bowel and bladder incontinence and a history of seizures He was seen for evaluation of seizures which first began at age 27 years two years before presentation His typical episodes consist of facial twitching side not specified unresponsive pupils and moaning The episodes last approximately 1 2 minutes in duration and are followed by post ictal fatigue He was placed on DPH but there was no record of an EEG prior to presentation He had had no seizure events in over 1 year prior to presentation while on DPH 100mg O 200mg He also complained of headaches for the past 10 years BIRTH HX Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother Birth weight 7 10oz No instrumentation required Labor 11hours Light gas anesthesia given Apgars unknown Mother reportedly had the flu in the 7th or 8th month of gestation Patient discharged 5 days post partum Development spoke first words between 1 and 2 years of age Rolled side to side at age 2 but did not walk Fed self with hands at age 2 years Never toilet trained PMH 1 Hydrocephalus manifested by macrocephaly by age 2 3 months Head circumference 50 5cm at 4 months of age wide sutures and bulging fontanels Underwent ventriculogram age 4 months which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle The cortex of the cerebral hemisphere was less than 1cm in thickness especially in the occipital regions where only a thin rim of tissue was left Neurosurgical intervention was not attempted and the patient deemed inoperable at the time By 31 months of age the patients head circumference was 68cm at which point the head size arrested Other problems mentioned above SHX institutionalized at age 18 years FHX unremarkable EXAM Vitals unknown MS awake with occasional use of intelligible but inappropriately used words CN Rightward beating nystagmus increase on leftward gaze Right gaze preference Corneal responses were intact bilaterally Fundoscopic exam not noted Motor spastic quadriparesis moves RUE more than other extremities Sensory withdrew to PP in 4 extremities Coord ND Station ND Gait ND wheel chair bound Reflexes RUE 2 LUE 3 RLE 4 with sustained cross adductor clonus in the right quadriceps LLE 3 Other Macrocephaly measurement not given Scoliosis Rest of general exam unremarkable except for numerous abdominal scars COURSE EEG 8 26 92 Abnormal with diffuse slowing and depressed background left worse than right and poorly formed background activity at 5 7hz Right posterior sharp transients and rhythmic delta theta bursts from the right temporal region The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin Keywords neurology seizure dandy walker malformation eeg macrocephaly bilateral sensory neural hearing loss hydrocephalus hythmic delta theta bursts mental retardation neurogenic bowel and bladder incontinence severe neurogenic scoliosis spastic quadriplegia unshunted hydrocephalus dandy walker malformation dandy walker head circumference presentation gestation headaches incontinence MEDICAL_TRANSCRIPTION,Description Cerebrovascular accident CVA with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule Acute bronchitis with reactive airway disease Medical Specialty Neurology Sample Name CVA Discharge Summary Transcription DIAGNOSES ON ADMISSION 1 Cerebrovascular accident CVA with right arm weakness 2 Bronchitis 3 Atherosclerotic cardiovascular disease 4 Hyperlipidemia 5 Thrombocytopenia DIAGNOSES ON DISCHARGE 1 Cerebrovascular accident with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule 3 Acute bronchitis with reactive airway disease 4 Thrombocytopenia most likely due to old coronary infarct anterior aspect of the right external capsule 5 Atherosclerotic cardiovascular disease 6 Hyperlipidemia HOSPITAL COURSE The patient was admitted to the emergency room Plavix was started in addition to baby aspirin He was kept on oral Zithromax for his cough He was given Xopenex treatment because of his respiratory distress Carotid ultrasound was reviewed and revealed a 50 to 69 obstruction of left internal carotid Dr X saw him in consultation and recommended CT angiogram This showed no significant obstructive lesion other than what was known on the ultrasound Head MRI was done and revealed the above findings The patient was begun on PT and improved By discharge he had much improved strength in his right arm He had no further progressions His cough improved with oral Zithromax and nebulizer treatments His platelets also improved as well By discharge his platelets was up to 107 000 His H H was stable at 41 7 and 14 6 and his white count was 4300 with a normal differential Chest x ray revealed a mild elevated right hemidiaphragm but no infiltrate Last chemistry panel on December 5 2003 sodium 137 potassium 4 0 chloride 106 CO2 23 glucose 88 BUN 17 creatinine 0 7 calcium was 9 1 PT INR on admission was 1 03 PTT 34 7 At the time of discharge the patient s cough was much improved His right arm weakness has much improved His lung examination has just occasional rhonchi He was changed to a metered dose inhaler with albuterol He is being discharged home An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57 moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation He will follow up in my office in 1 week He is to start PT and OT as an outpatient He is to avoid driving his car He is to notify if further symptoms He has 2 more doses of Zithromax at home he will complete His prognosis is good Keywords neurology subacute infarct atherosclerotic cardiovascular disease cerebrovascular accident coronary infarct external capsule cva cerebrovascular mri bronchitis cardiovascular xopenex atherosclerotic accident MEDICAL_TRANSCRIPTION,Description a pleasant 62 year old male with cerebral palsy Medical Specialty Neurology Sample Name Discharge Summary Cerebral Palsy Transcription DISCHARGE DIAGNOSES 1 Bilateral lower extremity cellulitis secondary to bilateral tinea pedis 2 Prostatic hypertrophy with bladder outlet obstruction 3 Cerebral palsy DISCHARGE INSTRUCTIONS The patient would be discharged on his usual Valium 10 20 mg at bedtime for spasticity Flomax 0 4 mg daily cefazolin 500 mg q i d and Lotrimin cream between toes b i d for an additional two weeks He will be followed in the office HISTORY OF PRESENT ILLNESS This is a pleasant 62 year old male with cerebral palsy The patient was recently admitted to Hospital with lower extremity cellulitis This resolved however recurred in both legs Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis PAST MEDICAL FAMILY SOCIAL HISTORY As per the admission record REVIEW OF SYSTEMS As per the admission record PHYSICAL EXAMINATION As per the admission record LABORATORY STUDIES At the time of admission his white blood cell count was 8200 with a normal differential hemoglobin 13 6 hematocrit 40 6 with normal indices and platelet count was 250 000 Comprehensive metabolic profile was unremarkable except for a nonfasting blood sugar of 137 lactic acid was 0 8 Urine demonstrated 4 9 red blood cells per high powered field with 2 bacteria Blood culture and wound cultures were unremarkable Chest x ray was unremarkable HOSPITAL COURSE The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin On this regimen his lower extremity edema and erythema resolved quite rapidly Because of urinary frequency a bladder scan was done suggesting about 600 cc of residual urine A Foley catheter was inserted and was productive of approximately 500 cc of urine The patient was prescribed Flomax 0 4 mg daily 24 hours later the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours At the time of this dictation the patient was ambulating minimally however not sufficiently to resume independent living Keywords neurology bilateral lower extremity cellulitis cerebral palsy ambulating bilateral tinea pedis lower extremity cellulitis cerebral palsy discharge MEDICAL_TRANSCRIPTION,Description Brain CT with contrast Abnormal Gyriform enhancing lesion stroke in the left parietal region not seen on non contrast HCTs Medical Specialty Neurology Sample Name CT Scan of Brain with Contrast Transcription CC Confusion HX A 71 y o RHM with a history of two strokes one in 11 90 and one in 11 91 had been in a stable state of health until 12 31 92 when he became confused and displayed left sided weakness and difficulty speaking The symptoms resolved within hours and recurred the following day He was then evaluated locally and HCT revealed an old right parietal stroke Carotid duplex scan revealed a high grade stenosis of the RICA Cerebral Angiogram revealed 90 RICA and 50 LICA stenosis He was then transferred to UIHC Vascular Surgery for carotid endarterectomy His confusion persisted and he was evaluated by Neurology on 1 8 93 and transferred to Neurology on 1 11 93 PMH 1 cholecystectomy 2 inguinal herniorrhaphies bilaterally 3 ETOH abuse 3 10 beers day 4 Right parietal stroke 10 87 with residual left hemiparesis Leg worse than arm 5 2nd stoke in distant past of unspecified type MEDS None on admission FHX Alzheimer s disease and stroke on paternal side of family SHX 50 pack yr cigarette use ROS no weight loss poor appetite selective eater EXAM BP137 70 HR81 RR13 O2Sat 95 Afebrile MS Oriented to city and month but did not know date or hospital Naming and verbal comprehension were intact He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2 3 objects in two minutes but both with assistance only Incorrectly spelled world backward as dlow CN unremarkable except neglects left visual field to double simultaneous stimulation Motor Deltoids 4 4 biceps 5 4 triceps 5 4 grip 4 4 HF4 4 HE 4 4 Hamstrings 5 5 AE 5 5 AF 5 5 Sensory intact PP LT Vib Coord dysdiadochokinesis on RAM bilaterally Station dyssynergic RUE on FNF movement Gait ND Reflexes 2 2 throughout BUE and at patellae Absent at ankles Right plantar was flexor and Left plantar was equivocal COURSE CBC revealed normal Hgb Hct Plt and WBC but Mean corpuscular volume was large at 103FL normal 82 98 Urinalysis revealed 20 WBC GS TSH FT4 VDRL ANA and RF were unremarkable He was treated for a UTI with amoxacillin Vitamin B12 level was reduced at 139pg ml normal 232 1137 Schillings test was inconclusive dure to inability to complete a 24 hour urine collection He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days then qMonth He was also placed on Thiamine 100mg qd Folate 1mg qd and ASA 325mg qd His ESR and CRP were elevated on admission but fell as his UTI was treated EEG showed diffuse slowing and focal slowing in the theta delta range in the right temporal area HCT with contrast on 1 19 93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct and an old right parietal hypodensity infarct His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency He was lost to follow up and did not undergo carotid endarterectomy Keywords neurology ct scan abnormal gyriform enhancing lesion brain ct ct with contrast carotid duplex scan confusion hct difficulty speaking left sided weakness non contrast hct parietal region stroke theta delta with contrast gyriform enhancing lesion gyriform enhancing enhancing lesion parietal stroke carotid endarterectomy ct scan gyriform endarterectomy contrast hcts brain parietal MEDICAL_TRANSCRIPTION,Description CT Scan of brain without contrast Medical Specialty Neurology Sample Name CT Scan of Brain w o Contrast Transcription REASON FOR EXAMINATION Face asleep COMPARISON EXAMINATION None TECHNIQUE Multiple axial images were obtained of the brain 5 mm sections were acquired 2 5 mm sections were acquired without injection of intravenous contrast Reformatted sagittal and coronal images were obtained DISCUSSION No acute intracranial abnormalities appreciated No evidence for hydrocephalus midline shift space occupying lesions or abnormal fluid collections No cortical based abnormalities appreciated The sinuses are clear No acute bony abnormalities identified Preliminary report given to emergency room at conclusion of exam by Dr Xyz IMPRESSION No acute intracranial abnormalities appreciated Keywords neurology ct scan multiple axial images asleep brain coronal coronal images hydrocephalus intracranial intravenous contrast sagittal without contrast ct scan contrast abnormalities MEDICAL_TRANSCRIPTION,Description CT of Lumbar Spine without Contrast Patient with history of back pain after a fall Medical Specialty Neurology Sample Name CT of Lumbar Spine w o Contrast Transcription EXAM Lumbar spine CT without contrast HISTORY Back pain after a fall TECHNIQUE Noncontrast axial images were acquired through the lumbar spine Coronal and sagittal reconstruction views were also obtained FINDINGS There is no evidence for acute fracture or subluxation There is no spondylolysis or spondylolisthesis The central canal and neuroforamen are grossly patent at all levels There are no abnormal paraspinal masses There is no wedge compression deformity There is intervertebral disk space narrowing to a mild degree at L2 3 and L4 5 Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta which is not dilated There was incompletely visualized probable simple left renal cyst exophytic at the lower pole IMPRESSION 1 No evidence for acute fracture or subluxation 2 Mild degenerative changes 3 Probable left simple renal cyst Keywords neurology lumbar spine back pain ct coronal atherosclerotic axial images central canal compression deformity degenerative disk space fracture intervertebral neuroforamen sagittal spondylolisthesis spondylolysis subluxation wedge without contrast contrast spine lumbar noncontrast MEDICAL_TRANSCRIPTION,Description CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Neurology Sample Name CT Head Facial Bones Cervical Spine Transcription EXAM CT head without contrast CT facial bones without contrast and CT cervical spine without contrast REASON FOR EXAM A 68 year old status post fall with multifocal pain COMPARISONS None TECHNIQUE Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast Additional high resolution sagittal and or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures INTERPRETATIONS HEAD There is mild generalized atrophy Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes There are subtle areas of increased attenuation seen within the frontal lobes bilaterally Given the patient s clinical presentation these likely represent small hemorrhagic contusions Other differential considerations include cortical calcifications which are less likely The brain parenchyma is otherwise normal in attenuation without evidence of mass midline shift hydrocephalus extra axial fluid or acute infarction The visualized paranasal sinuses and mastoid air cells are clear The bony calvarium and skull base are unremarkable FACIAL BONES The osseous structures about the face are grossly intact without acute fracture or dislocation The orbits and extra ocular muscles are within normal limits There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses The remaining visualized paranasal sinuses and mastoid air cells are clear Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture CERVICAL SPINE There is mild generalized osteopenia There are diffuse multilevel degenerative changes identified extending from C4 C7 with disk space narrowing sclerosis and marginal osteophyte formation The remaining cervical vertebral body heights are maintained without acute fracture dislocation or spondylolisthesis The central canal is grossly patent The pedicles and posterior elements appear intact with multifocal facet degenerative changes There is no prevertebral or paravertebral soft tissue masses identified The atlanto dens interval and dens are maintained IMPRESSION 1 Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions There is no associated shift or mass effect at this time Less likely this finding could be secondary to cortical calcifications The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated 2 Atrophy and chronic small vessel ischemic changes in the brain 3 Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture 4 Osteopenia and multilevel degenerative changes in the cervical spine as described above 5 Findings were discussed with Dr X from the emergency department at the time of interpretation Keywords neurology sagittal coronal soft tissue swelling paranasal sinuses mastoid air acute fracture maxillary sinuses tissue swelling underlying fracture multilevel degenerative ct head soft tissue facial bones cervical spine ct facial bones spine cervical MEDICAL_TRANSCRIPTION,Description This is a middle aged female with two month history of low back pain and leg pain Medical Specialty Neurology Sample Name CT Lumbar Spine 2 Transcription FINDINGS Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes Preliminary scout film demonstrates anterior end plate spondylosis at T11 12 and T12 L1 L1 2 There is normal disc height anterior end plate spondylosis very minimal vacuum change with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints image 4 L2 3 There is mild decreased disc height anterior end plate spondylosis circumferential disc protrusion measuring 4 6mm AP and right extraforaminal osteophyte disc complex There is mild non compressive right neural foraminal narrowing minimal facet arthrosis normal central canal and left neural foramen image 13 L3 4 There is normal disc height anterior end plate spondylosis and circumferential non compressive annular disc bulging The disc bulging flattens the ventral thecal sac and there is minimal non compressive right neural foraminal narrowing minimal to mild facet arthrosis with vacuum change on the right normal central canal and left neural foramen image 25 L4 5 Keywords neurology anterior end plate spondylosis compressive right neural foraminal compressive annular disc bulging anterior end plate annular disc bulging normal central canal plate spondylosis central canal vacuum change disc bulging neural foraminal facet arthrosis anterior spondylosis neural lumbar disc bulging foraminal arthrosis facet MEDICAL_TRANSCRIPTION,Description Noncontrast CT scan of the lumbar spine Left lower extremity muscle spasm Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested Medical Specialty Neurology Sample Name CT Lumbar Spine Transcription EXAM Noncontrast CT scan of the lumbar spine REASON FOR EXAM Left lower extremity muscle spasm COMPARISONS None FINDINGS Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis as requested No abnormal paraspinal masses are identified There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally There is marked intervertebral disk space narrowing at the L5 S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes Posterior disk osteophyte complex is present most marked in the left paracentral to lateral region extending into the lateral recess on the left This most likely will affect the S1 nerve root on the left There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly There is mild neural foraminal stenosis present Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root There is facet sclerosis bilaterally Mild lateral recess stenosis just on the right there is prominent anterior spondylosis At the L4 5 level mild bilateral facet arthrosis is present There is broad based posterior annular disk bulging or protrusion which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally No moderate or high grade central canal or neural foraminal stenosis is identified At the L3 4 level anterior spondylosis is present There are endplate degenerative changes with mild posterior annular disk bulging but no evidence of moderate or high grade central canal or neural foraminal stenosis At the L2 3 level there is mild bilateral ligamentum flavum hypertrophy Mild posterior annular disk bulging is present without evidence of moderate or high grade central canal or neural foraminal stenosis At the T12 L1 and L1 2 levels there is no evidence of herniated disk protrusion central canal or neural foraminal stenosis There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation No bony destructive changes or acute fractures are identified CONCLUSIONS 1 Advanced degenerative disk disease at the L5 S1 level 2 Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5 S1 level laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis 3 Mild bilateral neural foraminal stenosis at the L5 S1 level 4 Posterior disk bulging at the L2 3 L3 4 and L4 5 levels without evidence of moderate or high grade central canal stenosis 5 Facet arthrosis to the lower lumbar spine 6 Arteriosclerotic vascular disease Keywords neurology noncontrast ct scan lower extremity muscle spasm neural foraminal stenosis lumbar spine spine disk lumbar ct intervertebral canal foraminal noncontrast stenosis MEDICAL_TRANSCRIPTION,Description This is a middle aged female with low back pain radiating down the left leg and foot for one and a half years Medical Specialty Neurology Sample Name CT Lumbar Spine 1 Transcription FINDINGS High resolution computerized tomography was performed from T12 L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed COMPARISON Previous MRI examination 10 13 2004 There is minimal curvature of the lumbar spine convex to the left T12 L1 L1 2 L2 3 There is normal disc height with no posterior annular disc bulging or protrusion Normal central canal intervertebral neural foramina and facet joints L3 4 There is normal disc height and non compressive circumferential annular disc bulging eccentrically greater to the left Normal central canal and facet joints image 255 L4 5 There is normal disc height circumferential annular disc bulging left L5 hemilaminectomy and posterior central right paramedian broad based disc protrusion measuring 4mm AP contouring the rightward aspect of the thecal sac Orthopedic hardware is noted posteriorly at the L5 level Normal central canal facet joints and intervertebral neural foramina image 58 L5 S1 There is minimal decreased disc height postsurgical change with intervertebral disc spacer posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position The orthopedic hardware creates mild streak artifact which mildly degrades images There is a laminectomy defect spondylolisthesis with 3 5mm of anterolisthesis of L5 posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root There is fusion of the facet joints normal central canal and right neural foramen image 69 70 135 There is no bony destructive change noted There is no perivertebral soft tissue abnormality There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery IMPRESSION Minimal curvature of the lumbar spine convex to the left L3 4 posterior non compressive annular disc bulging eccentrically greater to the left L4 5 circumferential annular disc bulging non compressive central right paramedian disc protrusion left L5 laminectomy L5 S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position intervertebral disc spacer spondylolisthesis laminectomy defect posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement Minimal to mild arteriosclerotic vascular calcifications Keywords neurology posterior annular disc circumferential annular disc normal central canal annular disc bulging lumbar spine posterior annular facet joints annular disc disc bulging tomography disc lumbar orthopedic postsurgical spine annular bulging MEDICAL_TRANSCRIPTION,Description Left arm and hand numbness CT head without contrast Noncontrast axial CT images of the head were obtained with 5 mm slice thickness Medical Specialty Neurology Sample Name CT Head 3 Transcription REASON FOR EXAM Left arm and hand numbness TECHNIQUE Noncontrast axial CT images of the head were obtained with 5 mm slice thickness FINDINGS There is an approximately 5 mm shift of the midline towards the right side Significant low attenuation is seen throughout the white matter of the right frontal parietal and temporal lobes There is loss of the cortical sulci on the right side These findings are compatible with edema Within the right parietal lobe a 1 8 cm rounded hyperintense mass is seen No hydrocephalus is evident The calvarium is intact The visualized paranasal sinuses are clear IMPRESSION A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal parietal and temporal lobes A 1 8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density A postcontrast MRI is required for further characterization of this mass Gradient echo imaging should be obtained Keywords neurology numbness head ct images frontal parietal temporal axial ct images parietal and temporal ct head slice thickness white matter frontal parietal temporal lobes parietal lobe edema intact noncontrast mass ct lobes arm MEDICAL_TRANSCRIPTION,Description The patient is a 79 year old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan The patient s subdural effusions are still noticeable but they are improving Medical Specialty Neurology Sample Name CT Head 2 Transcription REASON FOR CT SCAN The patient is a 79 year old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16 2008 I changed the shunt setting from 1 5 to 2 0 on February 12 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving CT scan from 03 11 2008 demonstrates frontal horn span at the level of foramen of Munro of 2 6 cm The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm There is a single shunt which enters on the right occipital side and ends in the left lateral ventricle He has symmetric bilateral subdurals that are less than 1 cm in breadth each which is a reduction from the report from January 16 2008 which states that he had a subdural hygroma maximum size 1 3 cm on the right and 1 1 cm on the left ASSESSMENT The patient s subdural effusions are still noticeable but they are improving at the setting of 2 0 PLAN I would like to see the patient with a new head CT in about three months at which time we can decide whether 2 0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting Keywords neurology ct scan subdural adult hydrocephalus bilateral effusions shunt setting subdural effusions hydrocephalus ventricular scan ct MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast and CT cervical spine without contrast Noncontrast axial CT images of the head were obtained Medical Specialty Neurology Sample Name CT Head and C Spine Transcription CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the head were obtained FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved There is no calvarial fracture The visualized paranasal sinuses and mastoid air cells are clear IMPRESSION Negative for acute intracranial disease CT CERVICAL SPINE TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained Sagittal and coronal images were obtained FINDINGS Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms No fracture or subluxation is seen Anterior and posterior osteophyte formation is seen at C5 C6 No abnormal anterior cervical soft tissue swelling is seen No spinal compression is noted The atlanto dens interval is normal There is a large retention cyst versus polyp within the right maxillary sinus IMPRESSION 1 Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms 2 Degenerative disk and joint disease at C5 C6 3 Retention cyst versus polyp of the right maxillary sinus Keywords neurology muscle spasms cervical lordosis intracranial hemorrhage motor vehicle collision axial ct images ct head ct anterior cyst polyp maxillary contrast intracranial sinuses spine axial head cervical noncontrast MEDICAL_TRANSCRIPTION,Description CT head without contrast Assaulted positive loss of consciousness rule out bleed CT examination of the head was performed without intravenous contrast administration Medical Specialty Neurology Sample Name CT Head 4 Transcription EXAM CT head without contrast INDICATIONS Assaulted positive loss of consciousness rule out bleed TECHNIQUE CT examination of the head was performed without intravenous contrast administration There are no comparison studies FINDINGS There are no abnormal extraaxial fluid collections There is no midline shift or mass effect Ventricular system demonstrates no dilatation There is no evidence of acute intracranial hemorrhage The calvarium is intact There is a laceration in the left parietal region of the scalp without underlying calvarial fractures The mastoid air cells are clear IMPRESSION No acute intracranial process Keywords neurology extraaxial fluid intracranial hemorrhage parietal region scalp loss of consciousness ct examination ct head intracranial intravenous contrast MEDICAL_TRANSCRIPTION,Description CT cervical spine for trauma CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Medical Specialty Neurology Sample Name CT C Spine 2 Transcription EXAM CT cervical spine C spine for trauma FINDINGS CT examination of the cervical spine was performed without contrast Coronal and sagittal reformats were obtained for better anatomical localization Cervical vertebral body height alignment and interspacing are maintained There is no evidence of fractures or destructive osseous lesions There are no significant degenerative endplate or facet changes No significant osseous central canal or foraminal narrowing is present IMPRESSION Negative cervical spine Keywords neurology c spine anatomical degenerative endplate ct examination cervical spine coronal ct spine cervicalNOTE MEDICAL_TRANSCRIPTION,Description Common CT Head template Medical Specialty Neurology Sample Name CT Head Transcription TECHNIQUE Sequential axial CT images were obtained from the vertex to the skull base without contrast FINDINGS There is mild generalized atrophy Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes The brain parenchyma is otherwise normal in attenuation with no evidence of mass hemorrhage midline shift hydrocephalus extra axial fluid or acute infarction The visualized paranasal sinuses and mastoid air cells are clear The bony calvarium and skull base are within normal limits IMPRESSION No acute abnormalities Keywords neurology decreased attenuation skull base sequential axial ct images bony calvarium extra axial fluid ct head attenuationNOTE MEDICAL_TRANSCRIPTION,Description Noncontrast CT head due to seizure disorder Medical Specialty Neurology Sample Name CT Head 1 Transcription EXAM CT head REASON FOR EXAM Seizure disorder TECHNIQUE Noncontrast CT head FINDINGS There is no evidence of an acute intracranial hemorrhage or infarction There is no midline shift intracranial mass or mass effect There is no extra axial fluid collection or hydrocephalus Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening IMPRESSION No acute process in the brain Keywords neurology mass effect extra axial fluid hydrocephalus midline shift intracranial mass paranasal sinuses mastoid air cells frontal sinus mucosal thickening seizure disorder ct head seizure sinuses ct head noncontrast MEDICAL_TRANSCRIPTION,Description Axial images through the cervical spine with coronal and sagittal reconstructions Medical Specialty Neurology Sample Name CT C Spine 1 Transcription EXAM CT cervical spine REASON FOR EXAM MVA feeling sleepy headache shoulder and rib pain TECHNIQUE Axial images through the cervical spine with coronal and sagittal reconstructions FINDINGS There is reversal of the normal cervical curvature at the vertebral body heights The intervertebral disk spaces are otherwise maintained There is no prevertebral soft tissue swelling The facets are aligned The tip of the clivus and occiput appear intact On the coronal reconstructed sequence there is satisfactory alignment of C1 on C2 no evidence of a base of dens fracture The included portions of the first and second ribs are intact There is no evidence of a posterior element fracture Included portions of the mastoid air cells appear clear There is no CT evidence of a moderate or high grade stenosis IMPRESSION No acute process cervical spine Keywords neurology c spine axial images sagittal reconstructions cervical spine sagittal fracture coronal spine axial cervical ct MEDICAL_TRANSCRIPTION,Description HCT Subdural hemorrhage Medical Specialty Neurology Sample Name CT Brain Subdural Hemorrhage Transcription CC Difficulty with speech HX This 84 y o RHF presented with sudden onset word finding and word phonation difficulties She had an episode of transient aphasia in 2 92 during which she had difficulty with writing written and verbal comprehension and exhibited numerous semantic and phonemic paraphasic errors of speech These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation Workup at that time revealed a right to left shunt on trans thoracic echocardiogram Carotid doppler studies showed 0 15 BICA stenosis and a LICA aneurysm mentioned above Brain CT was unremarkable She was placed on ASA after the 2 92 event In 5 92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only This was not felt to be a contusion nevertheless she was placed on Dilantin seizure prophylaxis Her left arm was casted and she returned home 5 hours prior to presentation today the patient began having difficulty finding words and putting them into speech She was able to comprehend speech This continued for an hour then partially resolved for one hour then returned then waxed and waned There was no reported weakness numbness incontinence seizure like activity incoordination HA nausea vomiting or lightheadedness MEDS ASA DPH Tenormin Premarin HCTZ PMH 1 transient fluent aphasia 2 92 which resolved 2 bilateral carotid endarterectomies 1986 3 HTN 4 distal left internal carotid artery aneurysm EXAM BP 168 70 Pulse 82 RR 16 35 8F MS A O x 3 Difficulty following commands Speech fluent and without dysarthria There were occasional phonemic paraphasic errors CN Unremarkable Motor 5 5 throughout except for 4 right wrist extension and right knee flexion Sensory unremarkable Coordination mild left finger nose finger dysynergia and dysmetria Gait mildly unsteady tandem walk Station no Romberg sign Reflexes slightly more brisk at the left patella than on the right Plantar responses were flexor bilaterally The remainder of the neurologic exam and the general physical exam were unremarkable LABS CBC WNL Gen Screen WNL PT PTT WNL DPH 26 2mcg ml CXR WNL EKG LBBB HCT revealed a left subdural hematoma COURSE Patient was taken to surgery and the subdural hematoma was evacuated Her mental status language skills improved dramatically The DPH dosage was adjusted appropriately Keywords neurology ct brain ct difficulty with speech hct subdural hemorrhage hemorrhage phonation difficulties subdural transient fluent aphasia phonemic paraphasic errors hematoma carotid speech MEDICAL_TRANSCRIPTION,Description CT Brain Midbrain hemangioma Medical Specialty Neurology Sample Name CT Brain Hemangioma Transcription CC Horizontal diplopia HX This 67 y oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic The diplopia began acutely and continued intermittently for one year During this time he was twice evaluated for myasthenia gravis details of evaluation not known and was told he probably did not have this disease He received no treatment and the diplopia spontaneously resolved He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia The diplopia continues to occur daily and intermittently and lasts for only a few minutes in duration It resolves when he covers one eye It is worse when looking at distant objects and objects off to either side of midline There are no other symptoms associated with the diplopia PMH 1 4Vessel CABG and pacemaker placement 4 84 2 Hypercholesterolemia 3 Bipolar Affective D O FHX HTN Colon CA and a daughter with unknown type of dystonia SHX Denied Tobacco ETOH illicit drug use ROS no recent weight loss fever chills night sweats CP SOB He occasionally experiences bilateral lower extremity cramping claudication after walking for prolonged periods MEDS Lithium 300mg bid Accupril 20mg bid Cellufresh Ophthalmologic Tears ASA 325mg qd EXAM BP216 108 HR72 RR14 Wt81 6kg T36 6C MS unremarkable CN horizontal binocular diplopia on lateral gaze in both directions No other CN deficits noted Motor 5 5 full strength throughout with normal muscle bulk and tone Sensory unremarkable Coord mild ataxia of RAM left right Station no pronator drift or Romberg sign Gait unremarkable Reflexes 2 2 symmetric throughout Plantars bilateral dorsiflexion STUDIES COURSE Gen Screen unremarkable Brain CT revealed 1 0 x 1 5 cm area of calcific density within the medial two thirds of the left cerebral peduncle This shows no mass effect but demonstrates mild contrast enhancement There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease The midbrain findings are most suggestive of a hemangioma though another consideration would be a low grade astrocytoma this would likely show less enhancement Metastatic lesions could show calcification but one would expect to see some degree of edema The long standing clinical history suggest the former i e hemangioma No surgical or neuroradiologic intervention was done and the patient was simply followed He was lost to follow up in 1993 Keywords neurology hemangioma brain ct ct brain binocular diplopia calcific density diplopia horizontal binocular diplopia myasthenia gravis horizontal binocular midbrain binocular ct horizontal MEDICAL_TRANSCRIPTION,Description Common CT C Spine template Medical Specialty Neurology Sample Name CT C Spine Transcription TECHNIQUE Sequential axial CT images were obtained through the cervical spine without contrast Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures FINDINGS The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture dislocation or spondylolisthesis The vertebral body heights and disc spaces are maintained The central canal is patent The pedicles and posterior elements are intact The paravertebral soft tissues are within normal limits The atlanto dens interval and the dens are intact The visualized lung apices are clear IMPRESSION No acute abnormalities Keywords neurology sequential axial ct images atlanto dens interval dens ct c spine cervical spineNOTE MEDICAL_TRANSCRIPTION,Description CT of Brain Subacute SDH Medical Specialty Neurology Sample Name CT Brain Subdural hematoma Transcription CC Progressive unsteadiness following head trauma HX A7 7 y o male fell as he was getting out of bed and struck his head 4 weeks prior to admission He then began to experience progressive unsteadiness and gait instability for several days after the fall He was then evaluated at a local ER and prescribed meclizine This did not improve his symptoms and over the past one week prior to admission began to develop left facial LUE LLE weakness He was seen by a local MD on the 12 8 92 and underwent and MRI Brain scan This showed a right subdural mass He was then transferred to UIHC for further evaluation PMH 1 cardiac arrhythmia 2 HTN 3 excision of lip lesion 1 yr ago SHX FHX Unremarkable No h o ETOH abuse MEDS Meclizine Procardia XL EXAM Afebrile BP132 74 HR72 RR16 MS A O x 3 Speech fluent Comprehension naming repetition were intact CN Left lower facial weakness only MOTOR Left hemiparesis 4 5 throughout Sensory intact PP TEMP LT PROP VIB Coordination ND Station left pronator drift Gait left hemiparesis evident by decreased LUE swing and LLE drag Reflexes 2 3 in UE 2 2 LE Right plantar downgoing Left plantar equivocal Gen Exam unremarkable COURSE Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto occipital regions on the right There was effacement of the right lateral ventricle and a 0 5 cm leftward midline shift He underwent a HCT on admission 12 8 92 which showed a right subdural hematoma He then underwent emergent evacuation of this hematoma He was discharged home 6 days after surgery Keywords neurology ct brain mri sdh subdural hematoma gait instability head trauma hematoma subacute subdural weakness hemiparesis MEDICAL_TRANSCRIPTION,Description Stroke in distribution of recurrent artery of Huebner left Medical Specialty Neurology Sample Name CT Brain Stroke Transcription CC Falls HX This 51y o RHF fell four times on 1 3 93 because her legs suddenly gave out She subsequently noticed weakness involving the right leg and often required the assistance of her arms to move it During some of these episodes she appeared mildly pale and felt generally weak her husband would give her 3 teaspoons of sugar and she would appear to improve thought not completely During one episode she held her RUE in an odd fisted posture She denied any other focal weakness sensory change dysarthria diplopia dysphagia or alteration of consciousness She did not seek medical attention despite her weakness Then last night 1 4 93 she fell again and because her weakness did not subsequently improve she came to UIHC for evaluation on 1 5 93 MEDS Micronase 5mg qd HCTZ quit ASA 6 months ago tired of taking it PMH 1 DM type 2 dx 6 months ago 2 HTN 3 DJD 4 s p Vitrectomy and retinal traction OU for retinal detachment 7 92 5 s p Cholecystemomy 1968 6 Cataract implant OU 1992 7 s p C section FHX Grand Aunt stroke MG CAD Mother CAD died MI age 63 Father with unknown CA Sisters HTN No DM in relatives SHX Married lives with husband 4 children alive and well Denied tobacco ETOH illicit drug use ROS intermittent diarrhea for 20 years EXAM BP164 82 HR64 RR18 36 0C MS A O to person place time Speech fluent and without dysarthria Intact naming comprehension reading CN Pupils 4 5 irregular 4 0 irregular and virtually fixed Optic disks flat EOM intact VFFTC Right lower facial weakness The rest of the CN exam was unremarkable Motor 5 5 BUE with some question of breakaway LE HF and HE 4 5 KF5 5 AF and AE 5 5 Normal muscle bulk and tone Sensory intact PP VIB PROP LT T graphesthesia Coord slowed FNF and HKS worse on right Station no pronator drift or Romberg sign Gait Unsteady wide based gait Unable to heel walk on right Reflexes 2 2 throughout Slightly more brisk on right Plantar responses were downgoing bilaterally HEENT N0 Carotid or cranial bruits Gen Exam unremarkable COURSE CBC GS including glucose PT PTT EKG CXR on admission 1 5 93 were unremarkable HCT 1 5 93 revealed a hypodensity in the left caudate consistent with ischemic change Carotid Duplex 0 15 RICA 16 49 LICA antegrade vertebral artery flow bilaterally Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function No valvular abnormalities or thrombus were seen The patient s history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness Keywords MEDICAL_TRANSCRIPTION,Description CT Brain Subarachnoid hemorrhage Medical Specialty Neurology Sample Name CT Brain SAH Transcription CC Headache HX This 16 y o RHF was in good health until 11 00PM the evening of 11 27 87 when she suddenly awoke from sleep with severe headache Her parents described her as holding her head between her hands She had no prior history of severe headaches 30 minutes later she felt nauseated and vomited The vomiting continued every 30 minutes and she developed neck stiffness At 2 00AM on 11 28 97 she got up to go to the bathroom and collapsed in her mother s arms Her mother noted she appeared weak on the left side Shortly after this she experienced fecal and urinary incontinence She was taken to a local ER and transferred to UIHC PMH FHX SHX completely unremarkable FHx Has boyfriend and is sexually active Denied drug ETOH Tobacco use MEDS Oral Contraceptive pill QD EXAM BP152 82 HR74 RR16 T36 9C MS Somnolent and difficult to keep awake Prefer to lie on right side because of neck pain stiffness Answers appropriately though when questioned CN No papilledema noted Pupils 4 4 decreasing to 2 2 EOM Intact Face left facial weakness The rest of the CN exam was unremarkable Motor Upper extremities 5 3 with left pronator drift Lower extremities 5 4 with LLE weakness evident throughout Coordination left sided weakness evident Station left pronator drift Gait left hemiparesis Reflexes 2 2 throughout No clonus Plantars were flexor bilaterally Gen Exam unremarkable COURSE The patient underwent emergent CT Brain This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region She then underwent a 4 vessel cerebral angiogram This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus This suggested straight sinus thromboses MRI Brain was then done this was unremarkable and did not show sign of central venous thrombosis CBC Blood Cx ESR PT PTT GS CSF Cx ANA were negative Lumbar puncture on 12 1 87 revealed an opening pressure of 55cmH20 RBC18550 WBC25 18neutrophils 7lymphocytes Protein25mg dl Glucose47mg dl Cx negative The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use She recovered well but returned to Neurology at age 32 for episodic blurred vision and lightheadedness EEG was compatible with seizure tendency right greater than left theta bursts from the mid temporal regions and she was recommended an anticonvulsant which she refused Keywords neurology ct brain sah cerebral angiogram blurred vision lightheadedness central venous thrombosis subarachnoid hemorrhage pronator drift venous thrombosis ct brain subarachnoid hemorrhage pronator venous thrombosis weakness MEDICAL_TRANSCRIPTION,Description CT Brain to evaluate episodic mental status change RUE numbness chorea and calcification of Basal Ganglia globus pallidi Medical Specialty Neurology Sample Name CT Brain Calcification of Basal Ganglia Transcription CC Episodic mental status change and RUE numbness and chorea found on exam HX This 78y o RHM was referred for an episode of unusual behavior and RUE numbness In 9 91 he experienced near loss of consciousness generalized weakness headache and vomiting Evaluation at that time revealed an serum glucose of 500mg dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms Since then he became progressively more forgetful and at the time of evaluation 1 17 93 had lost his ability to perform his job repairing lawn mowers His wife had taken over the family finances He had also been stumbling when ambulating for 2 months prior to presentation He was noted to be occasionally confused upon awakening for last several months On 1 15 93 he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason There had been no change in sleep appetite or complaint of depression In addition for two months prior to presentation he had been experiencing 10 15minute episodes of RUE numbness There was no face or lower extremity involvement During the last year he had developed unusual movements of his extremities MEDS NPH Humulin 12U qAM and 6U qPM Advil prn PMH 1 Traumatic amputation of the 4th and 5th digits of his left hand 2 Hospitalized for an unknown nervous condition in the 1940 s SHX FHX Retired small engine mechanic who worked in a poorly ventilated shop Married with 13 children No history of ETOH Tobacco or illicit drug use Father had tremors following a stroke Brother died of brain aneurysm No history of depression suicide or Huntington s disease in family ROS no history of CAD Renal or liver disease SOB Chest pain fevers chills night sweats or weight loss No report of sign of bleeding EXAM BP138 63 HR65 RR15 36 1C MS Alert and oriented to self season but not date year or place Latent verbal responses and direction following Intact naming but able to repeat only simple but not complex phrases Slowed speech with mild difficulty with word finding 2 3 recall at one minute and 0 3 at 3 minutes Knew the last 3 presidents 14 27 on MMSE unable to spell world backwards Unable to read write for complaint of inability to see without glasses CN II XII appeared grossly intact EOM were full and smooth and without unusual saccadic pursuits OKN intact Choreiform movements of the tongue were noted Motor 5 5 strength throughout with Guggenheim type resistance there were choreiform type movements of all extremities bilaterally No motor impersistence noted Sensory unreliable Cord normal FNF HKS and RAM bilaterally Station No Romberg sign Gait unsteady and wide based Reflexes BUE 2 2 Patellar 2 2 Ankles Trace Trace Plantars were flexor bilaterally Gen Exam 2 6 Systolic ejection murmur in aortic area COURSE No family history of Huntington s disease could be elicited from relatives Brain CT 1 18 93 bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact Carotid duplex 1 18 93 RICA 0 15 LICA 16 49 stenosis and normal vertebral artery flow bilaterally Transthoracic Echocardiogram TTE 1 18 93 revealed severe aortic fibrosis or valvular calcification with severe aortic stenosis in the face of normal LV function Cardiology felt the patient the patient had asymptomatic aortic stenosis EEG 1 20 93 showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant MRI Brain 1 22 93 multiple focal and more confluent areas of increased T2 signal in the periventricular white matter more prominent on the left in addition there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres and age related atrophy incidentally there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses Impression diffuse bilateral age related ischemic change age related atrophy and maxillary sinus disease There were no masses or areas of abnormal enhancement TSH FT4 Vit B12 VDRL Urine drug and heavy metal screens were unremarkable CSF 1 19 93 glucose 102 serum glucose 162mg dL Protein 45mg dL RBC O WBC O Cultures negative SPEP negative However serum and CSF beta2 microglobulin levels were elevated at 2 5 and 3 1mg L respectively Hematology felt these may have been false positives CBC 1 17 93 Hgb 10 4g dL low HCT 31 low RBC 3 34mil mm3 low WBC 5 8K mm3 Plt 201K mm3 Retic 30 1K mm3 normal Serum Iron 35mcg dL low TIBC 201mcg dL low FeSat 17 low CRP 0 1mg dL normal ESR 83mm hr high Bone Marrow Bx normal with adequate iron stores Hematology felt the finding were compatible with anemia of chronic disease Neuropsychologic evaluation on 1 17 93 revealed significant impairments in multiple realms of cognitive function visuospatial reasoning verbal and visual memory visual confrontational naming impaired arrhythmatic dysfluent speech marked by use of phrases no longer than 5 words frequent word finding difficulty and semantic paraphasic errors most severe for expressive language attention and memory The pattern of findings reveals an atypical aphasia suggestive of left temporo parietal dysfunction The patient was discharged1 22 93 on ASA 325mg qd He was given a diagnosis of senile chorea and dementia unspecified type 6 18 93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia Keywords neurology episodic mental status change huntington s disease brain ct transthoracic echocardiogram carotid duplex mental status change ct brain basal ganglia mental status globus pallidi aortic stenosis maxillary sinuses rue numbness basal ganglia globus pallidi therapy chorea ct rue brain MEDICAL_TRANSCRIPTION,Description CT brain post craniectomy RMCA stroke and SBE Medical Specialty Neurology Sample Name CT Brain Transcription CC Left sided weakness HX This 28y o RHM was admitted to a local hospital on 6 30 95 for a 7 day history of fevers chills diaphoresis anorexia urinary frequency myalgias and generalized weakness He denied foreign travel IV drug abuse homosexuality recent dental work or open wound Blood and urine cultures were positive for Staphylococcus Aureus oxacillin sensitive He was place on appropriate antibiotic therapy according to sensitivity A 7 3 95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation Later that day he developed left sided weakness and severe dysarthria and aphasia HCT on 7 3 95 revealed mild attenuated signal in the right hemisphere On 7 4 95 he developed first degree AV block and was transferred to UIHC MEDS Nafcillin 2gm IV q4hrs Rifampin 600mg q12hrs Gentamicin 130mg q12hrs PMH 1 Heart murmur dx age 5 years FHX Unremarkable SHX Employed cook Denied ETOH Tobacco illicit drug use EXAM BP 123 54 HR 117 RR 16 37 0C MS Somnolent and arousable only by shaking and repetitive verbal commands He could follow simple commands only He nodded appropriately to questioning most of the time Dysarthric speech with sparse verbal output CN Pupils 3 3 decreasing to 2 2 on exposure to light Conjugate gaze preference toward the right Right hemianopia by visual threat testing Optic discs flat and no retinal hemorrhages or Roth spots were seen Left lower facial weakness Tongue deviated to the left Weak gag response bilaterally Weak left corneal response MOTOR Dense left flaccid hemiplegia SENSORY Less responsive to PP on left COORD Unable to test Station and Gait Not tested Reflexes 2 3 throughout more brisk on the left side Left ankle clonus and a Left Babinski sign were present GEN EXAM Holosystolic murmur heard throughout the precordium Janeway lesions were present in the feet and hands No Osler s nodes were seen COURSE 7 6 95 HCT showed a large RMCA stroke with mass shift His neurologic exam worsened and he was intubated hyperventilated and given IV Mannitol He then underwent emergent left craniectomy and duraplasty He tolerated the procedure well and his brain was allowed to swell He then underwent mitral valve replacement on 7 11 95 with a St Judes valve His post operative recovery was complicated by pneumonia pericardial effusion and dysphagia He required temporary PEG placement for feeding The 7 27 95 8 6 95 and 10 18 96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke His 10 18 96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop His proximal LLE strength was rated at a 4 His LUE was plegic He had a seizure 6 days prior to his 10 18 96 evaluation This began as a Jacksonian march of shaking in the LUE then involved the LLE There was no LOC or tongue biting He did have urinary incontinence He was placed on DPH His speech was dysarthric but fluent He appeared bright alert and oriented in all spheres Keywords neurology ct brain rmca anorexia chills craniectomy diaphoresis fevers myalgias stroke urinary frequency echocardiogram holosystolic murmur pneumonia pericardial effusion tongue biting sided weakness mitral valve rmca stroke ct hct weakness MEDICAL_TRANSCRIPTION,Description CT Brain Suprasellar aneurysm pre and post bleed Medical Specialty Neurology Sample Name CT Brain Aneurysm Transcription CC Decreasing visual acuity HX This 62 y o RHF presented locally with a 2 month history of progressive loss of visual acuity OD She had a 2 year history of progressive loss of visual acuity OS and is now blind in that eye She denied any other symptomatology Denied HA PMH 1 depression 2 Blind OS MEDS None SHX FHX unremarkable for cancer CAD aneurysm MS stroke No h o Tobacco or ETOH use EXAM T36 0 BP121 85 HR 94 RR16 MS Alert and oriented to person place and time Speech fluent and unremarkable CN Pale optic disks OU Visual acuity 20 70 OD and able to detect only shadow of hand movement OS Pupils were pharmacologically dilated earlier The rest of the CN exam was unremarkable MOTOR 5 5 throughout with normal bulk and tone Sensory no deficits to LT PP VIB PROP Coord FNF RAM HKS intact bilaterally Station No pronator drift Gait ND Reflexes 3 3 BUE 2 2 BLE Plantar responses were flexor bilaterally Gen Exam unremarkable No carotid cranial bruits COURSE CT Brain showed large enhancing 4 x 4 x 3 cm suprasellar sellar mass without surrounding edema Differential dx included craniopharyngioma pituitary adenoma and aneurysm MRI Brain findings were consistent with an aneurysm The patient underwent 3 vessel cerebral angiogram on 12 29 92 This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis Emergent HCT showed no evidence of hemorrhage or sign of infarct Emergent carotid duplex showed no significant stenosis or clot The patient was left with an expressive aphasia and right hemiparesis SPECT scans were obtained on 1 7 93 and 2 24 93 They revealed hypoperfusion in the distribution of the left MCA and decreased left basal ganglia perfusion which may represent in part a mass effect from the LICA aneurysm She was discharged home and returned and underwent placement of a Selverstone Clamp on 3 9 93 The clamp was gradually and finally closed by 3 14 93 She did well and returned home On 3 20 93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia A HCT then showed SAH around her aneurysm which had thrombosed She was place on Nimodipine Her clinical status improved then on 3 25 93 she rapidly deteriorated over a 2 hour period to the point of lethargy complete expressive aphasia and right hemiplegia An emergent HCT demonstrated a left ACA and left MCA infarction She required intubation and worsened as cerebral edema developed She was pronounced brain dead Her organs were donated for transplant Keywords neurology ct brain hct mri brain suprasellar suprasellar aneurysm aneurysm cerebral angiogram craniopharyngioma internal carotid artery loss of visual acuity pituitary adenoma suprasellar sellar mass visual acuity expressive aphasia cerebral ct hemiparesis aphasia brain MEDICAL_TRANSCRIPTION,Description Acute left subdural hematoma Left frontal temporal craniotomy for evacuation of acute subdural hematoma CT imaging reveals an acute left subdural hematoma which is hemispheric Medical Specialty Neurology Sample Name Craniotomy Frontotemporal 1 Transcription PREOPERATIVE DIAGNOSIS Acute left subdural hematoma POSTOPERATIVE DIAGNOSIS Acute left subdural hematoma PROCEDURE Left frontal temporal craniotomy for evacuation of acute subdural hematoma DESCRIPTION OF PROCEDURE This is a 76 year old man who has a history of acute leukemia He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury His CT imaging reveals an acute left subdural hematoma which is hemispheric The patient was brought to the operating room placed under satisfactory general endotracheal anesthesia He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy The images were brought up on the electronic imaging and confirmed that this was a left sided condition He was fixed in a three point headrest His scalp was shaved and prepared with Betadine iodine and alcohol We made a small curved incision over the temporal parietal frontal region The scalp was reflected A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created After completing the bur hole flap the dura was opened and a gelatinous mass of subdural was peeled away from the brain The brain actually looked relatively relaxed and after removal of the hematoma the brain sort of slowly came back up We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline After we felt that we had an adequate decompression the dura was reapproximated and we filled the subdural space with saline We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates The scalp was reapproximated and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment Given that this actual skin looked good with apparent removal of about 80 of the subdural we elected to take patient to the Intensive Care Unit for further management I was present for the entire procedure and supervised this I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain Keywords neurology subdural hematoma temporal craniotomy craniotomy subdural space bur hole subdural hematoma MEDICAL_TRANSCRIPTION,Description Heidenhain variant of Creutzfeldt Jakob Disease CJD Medical Specialty Neurology Sample Name Creutzfeldt Jakob Disease Transcription CC Progressive memory and cognitive decline HX This 73 y o RHF presented on 1 12 95 with progressive memory and cognitive decline since 11 94 Her difficulties were first noted by family the week prior to Thanksgiving when they were taking her to Vail Colorado to play Murder She Wrote at family gathering Unbeknownst to the patient was the fact that she had been chosen to be the assassin Prior to boarding the airplane her children hid a toy gun in her carry on luggage As the patient walked through security the alarm went off and within seconds she was surrounded searched and interrogated She and her family eventually made their flight but she seemed unusually flustered and disoriented by the event In prior times they would have expected her to have brushed off the incident with a chuckle While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing Murder She Wrote She needed assistance to complete the game The family noted no slurring of speech difficulty with vision or focal weakness at the time She returned to work at a local florist shop the Monday following Thanksgiving and by her own report had difficulty carrying out her usual tasks of flower arranging and operating the cash register She quit working the next day and never went back Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist Serum VDRL TFTs GS B12 Folate CBC CXR and MRI of the Brain were all reportedly unremarkable The working diagnosis was Dementia of the Alzheimer s Type One to two weeks prior to her 1 12 95 presentation she became repeatedly lost in her own home In addition she and especially her family noticed increased difficulty with word finding attention and calculation Furthermore she began expressing emotional lability unusual for her She also tended to veer toward the right when walking and often did not recognize the location of people talking to her MEDS None PMH Unremarkable FHX Father and mother died in their 80 s of old age There was no history of dementing illness stroke HTN DM or other neurological disease in her family She has 5 children who were alive and well SHX She attained a High School education and had been widowed for over 30 years She lived alone for 15 years until to 12 94 when her daughters began sharing the task of caring for her She had no history of tobacco alcohol or illicit drug use EXAM Vitals signs were within normal limits MS A O to person place and time At times she seemed in absence She scored 20 30 on MMSE and had difficulty with concentration calculation visuospatial construction Her penmanship was not normal and appeared child like according to her daughters She had difficulty writing a sentence and spoke in a halting fashion she appeared to have difficulty finding words In addition while attempting to write she had difficulty finding the right margin of the page CN Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia The rest of the CN exam was unremarkable Motor 5 5 strength throughout with normal muscle tone and bulk Sensory extinguishing of RUE sensation on double simultaneous stimulation and at times she appeared to show sign of RUE neglect There were no unusual spontaneous movements noted Coord unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field Station No sign of Romberg or pronator drift There was no truncal ataxia Gait decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target Reflexes 2 2 and symmetric throughout all four extremities Plantar responses were equivocal bilaterally COURSE CBC GS PT PTT ESR UA CRP TSH FT4 and EKG were unremarkable CSF analysis revealed 38 RBC 0 WBC Protein 36 glucose 76 The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal occipital regions Repeat MRI at UIHC revealed the same plus increased signal on T2 weighted images in the left frontal region as well CXR transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable A 1 23 95 left frontal brain biopsy revealed spongiform changes without sign of focal necrosis vasculitis or inflammatory changes The working diagnosis became Creutzfeldt Jakob Disease Heidenhaim variant The patient died on 2 15 95 Brain tissue was sent to the University of California at San Francisco Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus frontal cortex hypothalamus globus pallidus putamen insula amygdala hippocampus cerebellum and medulla This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus Hydrolytic autoclaving technique was used with PrP specific antibodies to identify the presence of protease resistant PrP CJD The patient s brain tissue was strongly positive for PrP CJD Keywords MEDICAL_TRANSCRIPTION,Description Right frontal craniotomy with resection of right medial frontal brain tumor Stereotactic image guided neuronavigation and microdissection and micro magnification for resection of brain tumor Medical Specialty Neurology Sample Name Craniotomy Neuronavigation Transcription PROCEDURES 1 Right frontal craniotomy with resection of right medial frontal brain tumor 2 Stereotactic image guided neuronavigation for resection of tumor 3 Microdissection and micro magnification for resection of brain tumor ANESTHESIA General via endotracheal tube INDICATIONS FOR THE PROCEDURE The patient is a 71 year old female with a history of left sided weakness and headaches She has a previous history of non small cell carcinoma of the lung treated 2 years ago An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor After informed consent was obtained the patient was brought to the operating room for surgery PREOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift POSTOPERATIVE DIAGNOSES Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift probable metastatic lung carcinoma DESCRIPTION OF THE PROCEDURE The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube She was positioned on the operating room table in the Sugita frame with the head secured Using the preoperative image guided MRI we carefully registered the fiducials and then obtained the stereotactic image guided localization to guide us towards the tumor We marked external landmarks Then we shaved the head over the right medial frontal area This area was then sterilely prepped and draped Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted A horseshoe shaped flap was based on the right and then brought across to the midline This was opened and hemostasis obtained using Raney clips The skin flap was retracted medially Two burr holes were made and were carefully connected One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap Hemostasis was obtained Using the neuronavigation we identified where the tumor was The dura was then opened based on a horseshoe flap based on the medial sinus We retracted this medially and carefully identified the brain The brain surface was discolored and obviously irritated consistent with the tumor We used the stereotactic neuronavigation to identify the tumor margins Then we used a bipolar to coagulate a thin layer of brain over the tumor Subsequently we entered the tumor The tumor itself was extremely hard Specimens were taken and send for frozen section analysis which showed probable metastatic carcinoma We then carefully dissected around the tumor margins Using the microscope we then brought microscopic magnification and dissection into the case We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly medially inferiorly and laterally Then using the Cavitron we cored out the central part of the tumor Then we collapsed the tumor on itself and removed it entirely In this fashion microdissection and magnification resection of the tumor was carried out We resected the entire tumor Neuronavigation was used to confirm that no further tumor residual was remained Hemostasis was obtained using bipolar coagulation and Gelfoam We also lined the cavity with Surgicel The cavity was nicely dry and excellent hemostasis was obtained The dura was closed using multiple interrupted 4 0 Nurolon sutures in a watertight fashion Surgicel was placed over the dural closure The bone flap was repositioned and held in place using CranioFIX cranial fixators The galea was re approximated and the skin was closed with staples The wound was dressed The patient was returned to the intensive care unit She was awake and moving extremities well No apparent complications were noted Needle and sponge counts were listed as correct at the end of the procedure Estimated intraoperative blood loss was approximately 150 mL and none was replaced Keywords neurology stereotactic image guided neuronavigation micro magnification resection of brain tumor frontal craniotomy mass effect brain shift stereotactic image brain tumor brain tumor craniotomy endotracheal carcinoma neuronavigation microdissection MEDICAL_TRANSCRIPTION,Description Left temporal craniotomy and removal of brain tumor Medical Specialty Neurology Sample Name Craniotomy Temporal Transcription PREOPERATIVE DIAGNOSIS Brain tumor left temporal lobe POSTOPERATIVE DIAGNOSIS Brain tumor left temporal lobe glioblastoma multiforme OPERATIVE PROCEDURE 1 Left temporal craniotomy 2 Removal of brain tumor OPERATING MICROSCOPE Stealth PROCEDURE The patient was placed in the supine position shoulder roll and the head was turned to the right side The entire left scalp was prepped and draped in the usual fashion after having being placed in 2 point skeletal fixation Next we made an inverted U fashion base over the asterion over temporoparietal area of the skull A free flap was elevated after the scalp that was reflected using the burr hole and craniotome The bone flap was placed aside and soaked in the bacitracin solution The dura was then opened in an inverted U fashion Using the Stealth we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle We head through the vein of Labbe and we made great care to preserve this We saw where the tumor almost made to the surface Here we made a small corticectomy using the Stealth for guidance We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid This was submitted to pathology We biopsied this very abnormal tissue and submitted it to pathology They gave us a frozen section diagnosis of glioblastoma multiforme With the operating microscope and Greenwood bipolar forceps we then systematically debulked this tumor It was very vascular and we really continued to remove this tumor until all visible tumors was removed We appeared to get two gliotic planes circumferentially We could see it through the ventricle After removing all visible tumor grossly we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4 0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal The bone flap was then replaced and sutured with the Lorenz titanium plate system The muscle fascia galea was closed with interrupted 2 0 Vicryl sutures Skin staples were used for skin closure The blood loss of the operation was about 200 cc There were no complications of the surgery per se The needle count sponge count and the cottonoid count were correct COMMENT Operating microscope was quite helpful in this as we could use the light as well as the magnification to help us delineate the brain tumor gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic looking tumor of the brain Keywords neurology temporal lobe brain tumor lorenz titanium plate burr hole cortex corticectomy craniotome craniotomy frozen section glioblastoma multiforme temporal craniotomy temporoparietal ventricle white matter tumor temporal brain MEDICAL_TRANSCRIPTION,Description Left retrosigmoid craniotomy and excision of acoustic neuroma Medical Specialty Neurology Sample Name Craniotomy Retrosigmoid Transcription PREOPERATIVE DIAGNOSIS Left acoustic neuroma POSTOPERATIVE DIAGNOSIS Left acoustic neuroma PROCEDURE PERFORMED Left retrosigmoid craniotomy and excision of acoustic neuroma ANESTHESIA General OPERATIVE FINDINGS This patient had a 3 cm acoustic neuroma The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve The facial nerve was stimulated at the brainstem at 0 05 milliamperes at the conclusion of the dissections PROCEDURE IN DETAIL Following induction of adequate general anesthetic the patient was positioned for surgery She was placed in a lateral position and her head was maintained with Mayfield pins The left periauricular area was shaved prepped and draped in the sterile fashion Transdermal electrodes for continuous facial nerve EMG monitoring were placed and no response was verified The proposed incision was injected with 1 Xylocaine with epinephrine Next T shaped incision was made approximately 5 cm behind the postauricular crease The incision was undermined at the level of temporalis fascia and the portion of the fascia was harvested for further use Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax Bergen retractors were used to maintain exposure Using a cutting bur with continuous suction and irrigation of craniotomy was performed The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly From these structures approximately 4 x 4 cm a window of bone was removed Bone shavings were collected during the dissection and placed in Siloxane suspension for later use The bone flap was also left at the site for further use Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base Bone wax was used to occlude air cells lateral to the sigmoid sinus There was extensively aerated temporal bone At this point Dr Trask entered the case in order to open the dura and expose the tumor The cerebellum was retracted away from the tumor and the retractor was placed to help maintain exposure Once initial exposure was completed attention was directed to the posterior aspect of the temporal bone The dura was excised from around the porous acusticus extending posteriorly along the bone Then using diamond burs the internal auditory canal was dissected out The bone was removed laterally for distance of approximately 8 mm There was considerable aeration around the internal auditory canal as well The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult Therefore Dr Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor With dissection he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem The eighth nerve was identified and transected Tumor debulking allowed for retraction of the tumor capsule away from the brainstem The facial nerve was difficult to identify at the brainstem as well It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve Attention was then redirected to the internal auditory canal where this portion of the tumor was removed The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus At this point plane of dissection was again indistinct The tumor had been released from the porous and could be rotated The tumor was further debulked and thinned but could not crucially visualize the nerve on the anterior face of the tumor The nerve could be stimulated but was quite splayed over the anterior face Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve both proximally and distally However the cerebellopontine angle portion of the nerve was not usually delineated However the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness It was released from the brainstem ventrally The tumor was then cauterized with bipolar electrocautery The facial nerve was stimulated at the brainstem and stimulated easily at 0 05 milliamperes Overall the remaining tumor volume would be of small percentage of the original volume At this point Dr Trask re inspected the posterior fossa to ensure complete hemostasis The air cells around the internal auditory canal were packed off with muscle and bone wax A piece of fascia was then laid over the bone defect Next the dura was closed with DuraGen and DuraSeal The bone flap and bone were then placed in the bone defect Postauricular musculature was then reapproximated using interrupted 3 0 Vicryl sutures The skin was also closed using interrupted subdermal 3 0 Vicryl sutures Running 4 0 nylon suture was placed at the skin levels Sterile mastoid dressing was then placed The patient tolerated the procedure well and was transported to the PACU in a stable condition All counts were correct at the conclusion of the procedure ESTIMATED BLOOD LOSS 100 mL Keywords neurology neuroma bergen retractors emissary veins mayfield pins acoustic acoustic neuroma cerebellopontine craniotomy facial nerve periauricular retrosigmoid retrosigmoid craniotomy internal auditory canal porous acusticus sigmoid sinus auditory canal bone brainstem nerve postauricular tumor MEDICAL_TRANSCRIPTION,Description Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA Medical Specialty Neurology Sample Name Craniotomy Occipital Transcription PREOPERATIVE DIAGNOSIS Brain tumors multiple POSTOPERATIVE DIAGNOSES Brain tumors multiple adenocarcinoma and metastasis from breast PROCEDURE Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA PROCEDURE The patient was placed in the prone position after general endotracheal anesthesia was administered The scalp was prepped and draped in the usual fashion The CUSA was brought in to supplement the use of operating microscope as well as the stealth which was used to localize the tumor Following this we then made a transverse linear incision the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor The bone flap was elevated The ultrasound was then used The ultrasound showed the tumors directly I believe are in the interhemispheric fissure We noticed that the dura was quite tense despite that the patient had slight hyperventilation We gave 4 ounce of mannitol the brain became more pulsatile We then used the stealth to perform a ventriculostomy Once this was done the brain began to pulsate nicely We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus After having done this we then used operating microscope and slight self retaining retraction was used We obtained access to the tumor We biopsied this and submitted it This was returned as a malignant brain tumor metastatic tumor adenocarcinoma compatible with breast cancer Following this we then debulked this tumor using CUSA and then removed it in total After gross total removal of this tumor the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery The next step was after removal of this tumor closure of the wound a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates The tumors self extend into the ventricle and after we had removed the tumor we could see our ventricular catheter in the occipital horn of the ventricle This being the case we left this ventricular catheter in brought it out through a separate incision and connected to sterile drainage The next step was to close the wound after reapproximating the bone flap The galea was closed with 2 0 Vicryl and the skin was closed with interrupted 3 0 nylon sutures inverted with mattress sutures The sterile dressings were applied to the scalp The patient returned to the recovery room in satisfactory condition Hemodynamically remained stable throughout the operation Once again we performed occipital craniotomy total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy The tumor was removed using the combination of CUSA ultrasound stealth guided ventriculostomy and the patient will have a second operation today we will perform a selective craniectomy to remove another large tumor in the posterior fossa Keywords neurology brain tumor cusa occipital adenocarcinoma bone flap craniotomy malignant metastatic scalp galea transverse linear incision ventriculostomy occipital craniotomy tumor stealth brain MEDICAL_TRANSCRIPTION,Description Postoperative visit for craniopharyngioma with residual disease According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved Medical Specialty Neurology Sample Name Craniopharyngioma Postop Transcription REASON FOR VISIT Postoperative visit for craniopharyngioma HISTORY OF PRESENT ILLNESS Briefly a 16 year old right handed boy who is in eleventh grade who presents with some blurred vision and visual acuity difficulties was found to have a suprasellar tumor He was brought to the operating room on 01 04 07 underwent a transsphenoidal resection of tumor Histology returned as craniopharyngioma There is some residual disease however the visual apparatus was decompressed According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved MEDICATIONS Synthroid 100 mcg per day FINDINGS On exam he is awake alert and oriented x 3 Pupils are equal and reactive EOMs are full His visual acuity is 20 25 in the right improved from 20 200 and the left is 20 200 improved from 20 400 He has a bitemporal hemianopsia which is significantly improved and wider His motor is 5 out of 5 There are no focal motor or sensory deficits The abdominal incision is well healed There is no evidence of erythema or collection The lumbar drain was also well healed The postoperative MRI demonstrates small residual disease Histology returned as craniopharyngioma ASSESSMENT Postoperative visit for craniopharyngioma with residual disease PLANS I have recommended that he call I discussed the options with our radiation oncologist Dr X They will schedule the appointment to see him In addition he probably will need an MRI prior to any treatment to follow the residual disease Keywords neurology visual acuity blurred vision tinnitus headaches residual disease tumor histology craniopharyngioma MEDICAL_TRANSCRIPTION,Description Cerebral palsy worsening seizures A pleasant 43 year old female with past medical history of CP since birth seizure disorder complex partial seizure with secondary generalization and on top of generalized epilepsy hypertension dyslipidemia and obesity Medical Specialty Neurology Sample Name Consult Seizures 1 Transcription CHIEF COMPLAINT Worsening seizures HISTORY OF PRESENT ILLNESS A pleasant 43 year old female with past medical history of CP since birth seizure disorder complex partial seizure with secondary generalization and on top of generalized epilepsy hypertension dyslipidemia and obesity The patient stated she was in her normal state of well being when she was experiencing having frequent seizures She lives in assisted living She has been falling more frequently The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this There was no head trauma but apparently she was doing that many times and there was no responsiveness The patient has no memory of the event She is now back to her baseline She states her seizures are worse in the setting of stress but it is not clear to her why this has occurred She is on Carbatrol 300 mg b i d and she has been very compliant and without any problems The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome PAST MEDICAL HISTORY Include dyslipidemia and hypertension FAMILY HISTORY Positive for stroke and sleep apnea SOCIAL HISTORY No smoking or drinking No drugs MEDICATIONS AT HOME Include Avapro lisinopril and dyslipidemia medication she does not remember REVIEW OF SYSTEMS The patient does complain of gasping for air witnessed apneas and dry mouth in the morning The patient also has excessive daytime sleepiness with EDS of 16 PHYSICAL EXAMINATION VITAL SIGNS Last blood pressure 130 85 respirations 20 and pulse 70 GENERAL Normal NEUROLOGICAL As follows Right handed female normal orientation normal recollection to 3 objects The patient has underlying MR Speech no aphasia no dysarthria Cranial nerves funduscopic intact without papilledema Pupils are equal round and reactive to light Extraocular movements intact No nystagmus Her mood is intact Symmetric face sensation Symmetric smile and forehead Intact hearing Symmetric palate elevation Symmetric shoulder shrug and tongue midline Motor 5 5 proximal and distal The patient does have limp on the right lower extremity Her Babinski is hyperactive on the left lower extremity upgoing toes on the left Sensory the patient does have sharp soft touch vibration intact and symmetric The patient has trouble with ambulation She does have ataxia and uses a walker to ambulate There is no bradykinesia Romberg is positive to the left Cerebellar finger nose finger is intact Rapid alternating movements are intact Upper airway examination the patient has a Friedman tongue position with 4 oropharyngeal crowding Neck more than 16 to 17 inches BMI elevated above 33 Head and neck circumference very high IMPRESSION 1 Cerebral palsy worsening seizures 2 Hypertension 3 Dyslipidemia 4 Obstructive sleep apnea 5 Obesity RECOMMENDATIONS 1 Admission to the EMU drop her Carbatrol 200 b i d monitor for any epileptiform activity Initial time of admission is 3 nights and 3 days 2 Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated Continue her other medications 3 Consult Dr X for hypertension internal medicine management 4 I will follow this patient per EMU protocol Keywords MEDICAL_TRANSCRIPTION,Description Biparietal craniotomy insertion of left lateral ventriculostomy right suboccipital craniectomy and excision of tumor Medical Specialty Neurology Sample Name Craniotomy Biparietal Transcription PREOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm POSTOPERATIVE DIAGNOSES Multiple metastatic lesions to the brain a subtentorial lesion on the left greater than 3 cm and an infratentorial lesion on the right greater than 3 cm TITLE OF THE OPERATION 1 Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer 2 Insertion of left lateral ventriculostomy under Stealth stereotactic guidance 3 Right suboccipital craniectomy and excision of tumor 4 Microtechniques for all the above 5 Stealth stereotactic guidance for all of the above and intraoperative ultrasound INDICATIONS The patient is a 48 year old woman with a diagnosis of breast cancer made five years ago A year ago she was diagnosed with cranial metastases and underwent whole brain radiation She recently has deteriorated such that she came to my office unable to ambulate in a wheelchair Metastatic workup does reveal multiple bone metastases but no spinal cord compression She had a consult with Radiation Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery but the lesions greater than 3 cm needed to be removed Consequently this operation is performed PROCEDURE IN DETAIL The patient underwent a planning MRI scan with Stealth protocol She was brought to the operating room with fiducial still on her scalp General endotracheal anesthesia was obtained She was placed on the Mayfield head holder and rolled into the prone position She was well padded secured and so forth The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint This was done only of course after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system Sterile drapes were applied and the accuracy of the system was confirmed A biparietal incision was performed A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation A biparietal craniotomy was carried out carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system The dura was opened and reflected back to the midline An inner hemispheric approach was used to reach the very large metastatic tumor This was very delicate removing the tumor and the co surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor The tumor was wrapped around and included the choroidal vessels At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region Bleeding was quite vigorous in some of the arteries and finally however was completely controlled Complete removal of the tumor was confirmed by intraoperative ultrasound Once the tumor had been removed and meticulous hemostasis was obtained this wound was left opened and attention was turned to the right suboccipital area A linear incision was made just lateral to the greater occipital nerve Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull A burr hole was placed down low using a craniotome A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor and this was draining CSF relieving pressure in the posterior fossa Upon opening the craniotomy in the parietal occipital region the brain was noted to be extremely tight thus necessitating placement of the ventriculostomy At the posterior fossa a corticectomy was accomplished and the tumor was countered directly The tumor as the one above was removed both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator A gross total excision of this tumor was obtained as well I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle however this was just over the lower cranial nerves and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss this lesion was left alone and to be radiated and that it is less than 3 cm in diameter Meticulous hemostasis was obtained for this wound as well The posterior fossa wound was then closed in layers The dura was closed with interrupted and running mattress of 4 0 Nurolon The dura was watertight and it was covered with blue glue Gelfoam was placed over the dural closure Then the muscle and fascia were closed in individual layers using 0 Ethibond Subcutaneous was closed with interrupted inverted 2 0 and 0 Vicryl and the skin was closed with running locking 3 0 Nylon For the cranial incision the ventriculostomy was brought out through a separate stab wound The bone flap was brought on to the field The dura was closed with running and interrupted 4 0 Nurolon At the beginning of the case dural tack ups had been made and these were still in place The sinuses both the transverse sinus and sagittal sinus were covered with thrombin soaked Gelfoam to take care of any small bleeding areas in the sinuses Once the dura was closed the bone flap was returned to the wound and held in place with the Lorenz microplates The wound was then closed in layers The galea was closed with multiple sutures of interrupted 2 0 Vicryl The skin was closed with a running locking 3 0 Nylon Estimated blood loss for the case was more than 1 L The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid Nevertheless her vitals remained stable throughout the case and we hopefully helped her survival and her long term neurologic status for this really nice lady Keywords neurology metastatic lesion biparietal mayfield head holder microtechniques stealth craniotomy excision fiducial infratentorial parietooccipital stereotactic suboccipital subtentorial ventriculostomy lesions to the brain removal of the tumor parietal occipital region running locking nylon biparietal craniotomy posterior fossa tumor brain dura lesions MEDICAL_TRANSCRIPTION,Description Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques Medical Specialty Neurology Sample Name Craniotomy Frontotemporal Transcription PREOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma POSTOPERATIVE DIAGNOSIS Right frontotemporal chronic subacute subdural hematoma TITLE OF THE OPERATION Right frontotemporal craniotomy and evacuation of hematoma biopsy of membranes microtechniques ASSISTANT None INDICATIONS The patient is a 75 year old man with a 6 week history of decline following a head injury He was rendered unconscious by the head injury He underwent an extensive syncopal workup in Mississippi This workup was negative The patient does indeed have a heart pacemaker The patient was admitted to ABCD three days ago and yesterday underwent a CT scan which showed a large appearance of subdural hematoma There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity The patient and the family understood the nature indications and risk of the surgery and agreed to go ahead DESCRIPTION OF PROCEDURE The patient was brought to the operating room where general and endotracheal anesthesia was obtained The head was turned over to the left side and was supported on a cushion There was a roll beneath the right shoulder The right calvarium was shaved and prepared in the usual manner with Betadine soaked scrub followed by Betadine paint Markings were applied Sterile drapes were applied A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia Weitlaner retractors were inserted A single bur hole was placed underneath the temporalis muscle I placed the craniotomy a bit low in order to have better cosmesis A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm The bone was set aside The dura was clearly discolored and very tense The dura was opened in a cruciate fashion with a 15 blade There was immediate flow of a thin motor oil fluid under high pressure Literally the fluid shot out several inches with the first nick in the membranous cavity The dura was reflected back and biopsy of the membranes was taken and sent for permanent section The margins of the membrane were coagulated The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none The dura was then closed in a watertight fashion using running locking 4 0 Nurolon Tack up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system The wound was irrigated thoroughly once more and was closed in layers Muscle fascia and galea were closed in separate layers with interrupted inverted 2 0 Vicryl Finally the skin was closed with running locking 3 0 nylon Estimated blood loss for the case was less than 30 mL Sponge and needle counts were correct FINDINGS Chronic subdural hematoma with multiple septations and thickened subdural membrane I might add that the arachnoid was not violated at all during this procedure Also it was noted that there was no subarachnoid blood but only subdural blood Keywords neurology frontotemporal weitlaner calvarium cookie cutter type craniotomy dura frontotemporal craniotomy galea hematoma subdural subdural hematoma syncopal temporalis subacute subdural hematoma temporalis muscle MEDICAL_TRANSCRIPTION,Description Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain Medical Specialty Neurology Sample Name Craniotomy Burr Hole Transcription PREOPERATIVE DIAGNOSIS Right chronic subdural hematoma POSTOPERATIVE DIAGNOSIS Right chronic subdural hematoma TYPE OF OPERATION Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS 100 cc OPERATIVE PROCEDURE In preoperative identification the patient was taken to the operating room and placed in supine position Following induction of satisfactory general endotracheal anesthesia the patient was prepared for surgery Table was turned The right shoulder roll was placed The head was turned to the left and rested on a doughnut The scalp was shaved and then prepped and draped in usual sterile fashion Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss The parietal boss incision was opened It was about an inch and a half in length It was carried down to the skull Self retaining retractor was placed A bur hole was now fashioned with the perforator This was widened with a 2 mm Kerrison punch The dura was now coagulated with bipolar electrocautery It was opened in a cruciate type fashion The dural edges were coagulated back to the bony edges There was egress of a large amount of liquid Under pressure we irrigated for quite sometime until irrigation was returning mostly clear A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision It was secured with a 3 0 nylon suture The area was closed with interrupted inverted 2 0 Vicryl sutures The skin was closed with staples Sterile dressing was applied The patient was subsequently returned back to anesthesia He was extubated in the operating room and transported to PACU in satisfactory condition Keywords neurology hematoma burr hole craniotomy frontotemporal frontotemporal craniotomy subdural subdural drain subdural hematoma subdural space MEDICAL_TRANSCRIPTION,Description Patient with a history of mesothelioma and likely mild dementia most likely Alzheimer type Medical Specialty Neurology Sample Name Consult Alzheimer disease Transcription The patient states that she has been doing fairly well at home She balances her own checkbook She does not do her own taxes but she has never done so in the past She states that she has no problems with cooking meals getting her own meals and she is still currently driving She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren She is unfortunately living alone and although she seems to miss her grandchildren and is estranged from her son she denies any symptoms of frank depression There is unfortunately no one available to us to corroborate how well she is doing at home She lives alone and takes care of herself and does not communicate very much with her brother and sister She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren She denied any sort of personality change paranoid ideas or hallucinations She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it When these headaches are very severe she goes to the emergency room to get a single shot She is unclear if this is some sort of a migraine medication or just a primary pain medication She takes Fiorinal for these headaches and she states that this helps greatly She denies visual or migraine symptoms REVIEW OF SYSTEMS Negative for any sort of focal neurologic deficits such as weakness numbness visual changes dysarthria diplopia or dysphagia She also denies any sort of movement disorders tremors rigidities or clonus Her personal opinion is that some of her memory problems may be due to simply to her age and or nervousness She is unclear as if her memory is any worse than anyone else in her age group PAST MEDICAL HISTORY Significant for mesothelioma which was diagnosed seemingly more than 20 to 25 years ago The patient was not sure of exactly when it was diagnosed This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations The mesothelioma is in her abdomen She does not know of any history of having lung mesothelioma She states that she has never gotten chemotherapy or radiation for her mesothelioma Furthermore she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable She does have a history of three car accidents that she says were all rear enders where she was hit while essentially in a stopped position These have all occurred over the past five years She also has a diagnosis of dementing illness possibly Alzheimer disease from her previous neurology consultation This diagnosis was given in March 2006 MEDICATIONS Fiorinal p r n aspirin unclear if baby or full sized Premarin unclear of the dose ALLERGIES NONE SOCIAL HISTORY Significant for her being without a companion at this point She was born in Munich Germany She immigrated to of America in 1957 after her family had to move to Eastern Germany which was under Russian occupation at that time She is divorced She used to work as a secretary and later worked as a clerical worker at IBM She stopped working more than 20 years ago due to complications from her mesothelioma She denies any significant tobacco alcohol or illicit drugs She is bilingual speaking German and English She has known English from before her teens She has the equivalent of a high school education in Germany She has one brother and one sister both of whom are healthy and she does not spend much time communicating with them She has one son who lives in Santa Cruz He has grandchildren She is trying to contact with her grandchildren FAMILY HISTORY Significant for lung liver and prostate cancer Her mother died in her 80s of old age but it appears that she may have had a mild dementing illness at that time Whatever that dementing illness was appears to have started mostly in her 80s per the patient No one else appears to have Alzheimer disease including her brother and sister PHYSICAL EXAMINATION Her blood pressure is 152 92 pulse 80 and weight 80 7 kg She is alert and well nourished in no apparent distress She occasionally fumbles with questions of orientation missing the day and the date She also did not know the name of the hospital she thought it was O Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in She lost three points for recall Even with prompting she could not remember the objects that she was given to remember Her Mini Mental Score was 22 30 There were no naming problems or problems with repetition There were also no signs of dysarthria Her pupils were bilaterally reactive to light and accommodation Her extraocular movements were intact Her visual fields were full to confrontation Her sensations of her face arm and leg were normal There were no signs of neglect with double simultaneous stimulation Tongue was midline Her palate was symmetric Her face was symmetric as well Strength was approximately 5 5 She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain Her reflexes were symmetric and 2 except for her toes which were 1 to trace Her plantar reflexes were mute Her sensation was normal for pain temperature and vibration There were no signs of ataxia on finger to nose and there was no dysdiadochokinesia Gait was narrow and she could toe walk briefly and heel walk without difficulty SUMMARY Ms A is a pleasant 72 year old right handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia most likely Alzheimer type We tactfully discussed the patient s diagnosis with her and she felt reassured We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept so we wrote her another prescription for Aricept The patient herself seemed very concerned about the stigma of the disease but our lengthy discussion expressed genuine understanding as to why her outpatient physician had reported her to DMV It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment She will follow up with us in the next six months and will call us if she has any problems with the Aricept She was written for Aricept to start at 5 mg for three weeks and if she has no side effects which typically are GI side effects then she can go up to 10 mg a day We also reviewed with Ms A the findings for outpatient MRI which showed some mild atrophy per report and also that her metabolic workup which included an RPR TSH and B12 were all within normal limits Keywords neurology neurology consultation dementing illness alzheimer disease dementia alzheimer mesothelioma MEDICAL_TRANSCRIPTION,Description Patient with a history of right upper pons and right cerebral peduncle infarction Medical Specialty Neurology Sample Name Consult Cerebral Peduncle Infarction Transcription FAMILY HISTORY AND SOCIAL HISTORY Reviewed and remained unchanged MEDICATIONS List remained unchanged including Plavix aspirin levothyroxine lisinopril hydrochlorothiazide Lasix insulin and simvastatin ALLERGIES She has no known drug allergies FALL RISK ASSESSMENT Completed and there was no history of falls REVIEW OF SYSTEMS Full review of systems again was pertinent for shortness of breath lack of energy diabetes hypothyroidism weakness numbness and joint pain Rest of them was negative PHYSICAL EXAMINATION Vital Signs Today blood pressure was 170 66 heart rate was 66 respiratory rate was 16 she weighed 254 pounds as stated and temperature was 98 0 General She was a pleasant person in no acute distress HEENT Normocephalic and atraumatic No dry mouth No palpable cervical lymph nodes Her conjunctivae and sclerae were clear NEUROLOGICAL EXAMINATION Remained unchanged Mental Status Normal Cranial Nerves Mild decrease in the left nasolabial fold Motor There was mild increased tone in the left upper extremity Deltoids showed 5 5 The rest showed full strength Hip flexion again was 5 5 on the left The rest showed full strength Reflexes Reflexes were hypoactive and symmetrical Gait She was mildly abnormal No ataxia noted Wide based ambulated with a cane IMPRESSION Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis has been clinically stable with mild improvement She is planned for surgical intervention for the internal carotid artery RECOMMENDATIONS At this time again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes She will continue to follow with endocrinology for diabetes and thyroid problems I have recommended a strict control of her blood sugar optimizing cholesterol and blood pressure control regular exercise and healthy diet and I have discussed with Ms A and her daughter to give us a call for post surgical recovery I will see her back in about four months or sooner if needed Keywords neurology internal carotid artery cerebral peduncle infarction carotid artery blood pressure upper pons infarction cerebral peduncle MEDICAL_TRANSCRIPTION,Description The patient had several episodes where she felt like her face was going to twitch which she could suppress it with grimacing movements of her mouth and face Medical Specialty Neurology Sample Name Consult Facial Twitching Transcription REASON FOR REFERRAL Facial twitching HISTORY OF PRESENT ILLNESS The patient had several episodes where she felt like her face was going to twitch which she could suppress it with grimacing movements of her mouth and face She reports she is still having right posterior head pressure like sensations approximately one time per week These still are characterized by a tingling pressure like sensation that often has a feeling as though water is running down on her hair This has also decreased in frequency occurring approximately one time per week and seems to respond to over the counter analgesics such as Aleve Lastly during conversation today she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non stimulating environments or in front of the television She states that she feels fatigued all the time and does not get good sleep She describes it as insomnia but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9 00 a m each morning and sleeps no more than five to six hours ever but usually five hours Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom She thinks she may snore but she is not sure She does not recall any events of awakening and gasping for breath PAST MEDICAL HISTORY Please see my earlier notes in chart FAMILY HISTORY Please see my earlier notes in chart SOCIAL HISTORY Please see my earlier notes in charts REVIEW OF SYSTEMS Today she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood poor sleep and possible snoring otherwise the 10 system review is negative PHYSICAL EXAMINATION General Examination Unremarkable mainly for mild to moderate obesity with a weight of 258 pounds Otherwise general examination is unremarkable NEUROLOGICAL EXAMINATION As before is nonfocal Please see note in chart for details PERTINENT FINDINGS Since the last evaluation she has had an MRI performed which was largely unremarkable except for a 1 2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal which does not enhance The nature of this lesion is unclear Certainly this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences LABS She was supposed to have Lyme titers and thyroid tests as well as fasting glucose which were not done however in light of her improvement these may not need to be performed at this time IMPRESSION 1 Left facial twitching appears to be improving Most likely this is a peripheral nerve injury related to her abscess as previously described In light of her negative MRI and clinical improvement we discussed options and elected to just observe for now 2 Posterior pressure like headache also appears to be improving The etiology is unclear but as it responds nicely to nonsteroidal antiinflammatories and is decreasing no further evaluation is needed 3 Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9 00 a m with insufficient sleep There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study For the time being sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10 00 a m or 10 30 to get a full night sleep She is on vacation next week and is going to try to see if this will help We also discussed as before weight loss and exercise which could be helpful 4 Right clivus and petrous lesion of unknown etiology We will repeat the MRI at four months to see for interval change 5 The patient voiced understanding of these plans and will be following up with me in five months Keywords neurology grimacing headache clivus and petrous facial twitching sleep facial twitching MEDICAL_TRANSCRIPTION,Description Chest CT Thymoma and history of ocular myasthenia gravis Medical Specialty Neurology Sample Name Chest CT Myasthenia Gravis Transcription CC Intermittent binocular horizontal vertical and torsional diplopia HX 70y o RHM referred by Neuro ophthalmology for evaluation of neuromuscular disease In 7 91 he began experiencing intermittent binocular horizontal vertical and torsional diplopia which was worse and frequent at the end of the day and was eliminated when closing one either eye An MRI Brain scan at that time was unremarkable He was seen at UIHC Strabismus Clinic in 5 93 for these symptoms On exam he was found to have intermittent right hypertropia in primary gaze and consistent diplopia in downward and rightward gaze This was felt to possibly represent Grave s disease Thyroid function studies were unremarkable but orbital echography suggested Graves orbitopathy The patient was then seen in the Neuro ophthalmology clinic on 12 23 92 His exam remained unchanged He underwent Tensilon testing which was unremarkable On 1 13 93 he was seen again in Neuro ophthalmology His exam remained relatively unchanged and repeat Tensilon testing was unremarkable He then underwent a partial superior rectus resection OD with only mild improvement of his diplopia During his 8 27 96 Neuro ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid His diplopia subsequently improved but did not resolve The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid At present he denied any fatigue on repetitive movement He denied dysphagia SOB dysarthria facial weakness fevers chills night sweats weight loss or muscle atrophy MEDS Viokase Probenecid Mestinon 30mg tid PMH 1 Gastric ulcer 30 years ago 2 Cholecystectomy 3 Pancreatic insufficiency 4 Gout 5 Diplopia FHX Mother died age 89 of old age Father died age 89 of stroke Brother age 74 with CAD Sister died age 30 of cancer SHX Retired insurance salesman and denies history of tobacco or illicit drug us He has no h o ETOH abuse and does not drink at present EXAM BP 155 104 HR 92 RR 12 Temp 34 6C WT 76 2kg MS Unremarkable Normal speech with no dysarthria CN Right hypertropia worse on rightward gaze and less on leftward gaze Minimal to no ptosis OD No ptosis OS VFFTC No complaint of diplopia The rest of the CN exam was unremarkable MOTOR 5 5 strength throughout with normal muscle bulk and tone SENSORY No deficits appreciated on PP VIB LT PROP TEMP testing Coordination Station Gait Unremarkable Reflexes 2 2 throughout Plantar responses were flexor on the right and withdrawal on the left HEENT and GEN EXAM Unremarkable COURSE EMG NCV 9 26 96 Repetitive stimulation studies of the median facial and spinal accessory nerves showed no evidence of decrement at baseline and at intervals up to 3 minutes following exercise The patient had been off Mestinon for 8 hours prior to testing Chest CT with contrast 9 26 96 revealed a 4x2 5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch This was highly suggestive of a thymoma There were diffuse emphysematous disease with scarring in the lung bases A few nodules suggestive of granulomas and few calcified perihilar lymph nodes He underwent thoracotomy and resection of the mass Pathologic analysis was consistent with a thymoma lymphocyte predominant type with capsular and pleural invasion and extension to the phrenic nerve resection margin Acetylcholine Receptor binding antibody titer 12 8nmol L normal 0 7 Acetylcholine receptor blocking antibody 10 normal Acetylcholine receptor modulating antibody 42 normal 19 Striated muscle antibody 1 320 normal 1 10 Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma He was subsequently treated with XRT and continued to complain of fatigue at his 4 18 97 Oncology visit Keywords neurology diplopia neuromuscular disease muscle antibody titers chest ct intermittent binocular rightward gaze striated muscle myasthenia gravis intermittent torsional binocular myasthenia chest thymoma ophthalmology antibody MEDICAL_TRANSCRIPTION,Description Cervical spondylosis and kyphotic deformity She had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Medical Specialty Neurology Sample Name Cervical Spondylosis Neuro Consult Transcription REASON FOR NEUROLOGICAL CONSULTATION Cervical spondylosis and kyphotic deformity The patient was seen in conjunction with medical resident Dr X I personally obtained the history performed examination and generated the impression and plan HISTORY OF PRESENT ILLNESS The patient is a 45 year old African American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain This has subsequently resolved She started vigorous workouts in November 2005 In March of this year she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician By her report she had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Symptoms progressed to sensory symptoms of her knees elbows and left middle toe She then started getting sensory sensations in the left hand and arm She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg Symptoms have been mildly progressive She is unaware of any trigger other than the vigorous workouts as mentioned above She has no associated bowel or bladder symptoms No particular position relieves her symptoms Workup has included two MRIs of the C spine which were personally reviewed and are discussed below She saw you for consultation and the possibility of surgical decompression was raised At this time she is somewhat reluctant to go through any surgical procedure PAST MEDICAL HISTORY 1 Ocular migraines 2 Myomectomy 3 Infertility 4 Hyperglycemia 5 Asthma 6 Hypercholesterolemia MEDICATIONS Lipitor Pulmicort Allegra Xopenex Patanol Duac topical gel Loprox cream and Rhinocort ALLERGIES Penicillin and aspirin Family history social history and review of systems are discussed above as well as documented in the new patient information sheet Of note she does not drink or smoke She is married with two adopted children She is a paralegal specialist She used to exercise vigorously but of late has been advised to stop exercising and is currently only walking REVIEW OF SYSTEMS She does complain of mild blurred vision but these have occurred before and seem associated with headaches PHYSICAL EXAMINATION On examination blood pressure 138 82 pulse 90 respiratory rate 14 and weight 176 5 pounds Pain scale is 0 A full general and neurological examination was personally performed and is documented on the chart Of note she has a normal general examination Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk She has mild postural tremor in both arms She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities Motor examination reveals no weakness to individual muscle testing but on gait she does have a very subtle left hemiparesis She has hyperreflexia in her lower extremities worse on the left Babinski s are downgoing PERTINENT DATA MRI of the brain from 05 02 06 and MRI of the C spine from 05 02 06 and 07 25 06 were personally reviewed MRI of the brain is broadly within normal limits MRI of the C spine reveals large central disc herniation at C6 C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema There is also a fairly large disc at C3 C4 with cord deformity and partial effacement of the subarachnoid space I do not appreciate any cord edema at this level IMPRESSION AND PLAN The patient is a 45 year old female with cervical spondylosis with a large C6 C7 herniated disc with mild cord compression and signal change at that level She has a small disc at C3 C4 with less severe and only subtle cord compression History and examination are consistent with signs of a myelopathy Results were discussed with the patient and her mother I am concerned about progressive symptoms Although she only has subtle symptoms now we made her aware that with progression of this process she may have paralysis If she is involved in any type of trauma to the neck such as motor vehicle accident she could have an acute paralysis I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem I have recommended that she wear a hard collar while driving The results of my consultation were discussed with you telephonically Keywords neurology kyphotic cervical radiculopathy myelopathy kyphotic deformity cord compression cervical spondylosis toe spondylosis cord MEDICAL_TRANSCRIPTION,Description Diagnosis of bulbar cerebral palsy and hypotonia Medical Specialty Neurology Sample Name Cerebral Palsy Letter Transcription Doctor s Address Dear Doctor This letter serves as an introduction to my patient A who will be seeing you in the near future He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia He has been treated by Dr X through the pediatric neurology clinic He saw Dr X recently and she noted that he was having difficulty with mouth breathing which was contributing to some of his speech problems She also noted and confirmed that he has significant tonsillar hypertrophy The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech Therefore I ask for your opinion on this matter For his chronic allergic rhinitis symptoms he is currently on Flonase two sprays to each nostril once a day He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms He does have an allergy to penicillin I appreciate your input on his care If you have any questions regarding please feel free to call me through my office Otherwise I look forward to hearing back from you regarding his evaluation Keywords neurology peech swallowing breathing bulbar cerebral palsy mouth breathing cerebral palsy hypotoniaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram Lateral medullary syndrome secondary to left vertebral artery dissection Medical Specialty Neurology Sample Name Cerebral Angiogram Lateral Medullary Syndrome Transcription CC Falling to left HX 26y oRHF fell and struck her head on the ice 3 5 weeks prior to presentation There was no associated loss of consciousness She noted a dull headache and severe sharp pain behind her left ear 8 days ago The pain lasted 1 2 minutes in duration The next morning she experienced difficulty walking and consistently fell to the left In addition the left side of her face had become numb and she began choking on food Family noted her pupils had become unequal in size She was seen locally and felt to be depressed and admitted to a psychiatric facility She was subsequently transferred to UIHC following evaluation by a local ophthalmologist MEDS Prozac and Ativan both recently started at the psychiatric facility PMH 1 Right esotropia and hyperopia since age 1year 2 Recurrent UTI FHX Unremarkable SHX Divorced Lives with children No spontaneous abortions Denied ETOH Tobacco Illicit Drug use EXAM BP 138 110 HR 85 RR 16 Temp 37 2C MS A O to person place time Speech fluent and without dysarthria Intact naming comprehension repetition CN Pupils 4 2 decreasing to 3 1 on exposure to light Optic Disks flat VFFTC Esotropia OD otherwise EOM full Horizontal nystagmus on leftward gaze Decreased corneal reflex OS Decreased PP TEMP sensation on left side of face Light touch testing normal Decreased gag response on left Uvula deviates to right The rest of the CN exam was unremarkable Motor 5 5 strength throughout with normal muscle bulk and tone Sensory Decreased PP and TEMP on right side of body PROP VIB intact Coord Difficulty with FNF HKS RAM on left Normal on right side Station No pronator drift Romberg test not noted Gait unsteady with tendency to fall to left Reflexes 3 3 throughout BUE and Patellae 2 2 Achilles Plantar responses were flexor bilaterally Gen Exam Obese In no acute distress Otherwise unremarkable HEENT No carotid vertebral cranial bruits COURSE PT PTT GS CBC TSH FT4 and Cholesterol screen were all within normal limits HCT on admission was negative MRI Brain done locally 2 2 93 was reviewed and a left lateral medullary stroke was appreciated The patient underwent a cerebral angiogram on 2 3 93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery There is severe irregular narrowing of the horizontal portion above the posterior arch of C1 The findings were felt consistent with a left vertebral artery dissection Neuro opthalmology confirmed a left Horner s pupil by clinical exam and history Cookie swallow study was unremarkable The Patient was placed on Heparin then converted to Coumadin The PT on discharge was 17 She remained on Coumadin for 3 months and then was switched to ASA for 1 year An Otolaryngologic evaluation on 10 96 noted true left vocal cord paralysis with full glottic closure A prosthesis was made and no surgical invention was done Keywords neurology horner s pupil mri brain otolaryngologic cerebral angiogram cerebral angiogram lateral medullary syndrome vertebral artery angiogram syndrome falling narrowing medullary vertebral cerebral MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms Medical Specialty Neurology Sample Name Cerebral Angiogram MRA Transcription CC Transient visual field loss HX This 58 y o RHF had a 2 yr h o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations She was evaluated by a local physician several days prior to this presentation 1 7 91 for clumsiness of her right hand and falling HCT and MRI brain revealed bilateral posterior clinoid masses MEDS Colace Quinidine Synthroid Lasix Lanoxin KCL Elavil Tenormin PMH 1 Obesity 2 VBG 1990 3 A Fib 4 HTN 5 Hypothyroidism 6 Hypercholesterolemia 7 Briquet s syndrome h o of hysterical paralysis 8 CLL dx 1989 in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil prednisone chemotherapy 10 95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil prednisone 1 10 96 she received 3000cGy to right parotid mass 9 SNHL FHX Father died MI age 61 SHX Denied Tobacco ETOH illicit drug use EXAM Vitals were unremarkable The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face diffusely about the left upper and lower face per neurosurgery notes The neuro ophthalmologic exam was unremarkable per Neuro ophthalmology COURSE She underwent Cerebral Angiography on 1 8 91 This revealed a 15x17x20mm LICA paraclinoid ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid ophthalmic artery aneurysm On 1 16 91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped She has complained of headaches since Keywords neurology visual field loss transient visual field cerebral angiography ophthalmic paraclinoid aneurysm paraclinoid ophthalmic cavernous frontotemporal craniotomy exam was unremarkable artery aneurysms mra visual parotid cerebral artery neurologic aneurysms angiogram MEDICAL_TRANSCRIPTION,Description Cerebral Angiogram Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery Medical Specialty Neurology Sample Name Cerebral Angiogram Left ICA PCA Aneurysm Transcription CC Fluctuating level of consciousness HX 59y o male experienced a pop in his head on 10 10 92 while showering in Cheyenne Wyoming He was visiting his son at the time He was found unconscious on the shower floor 1 5 hours later His son then drove him Back to Iowa Since then he has had recurrent headaches and fluctuating level of consciousness according to his wife He presented at local hospital this AM 10 13 92 A HCT there demonstrated a subarachnoid hemorrhage He was then transferred to UIHC MEDS none PMH 1 Right hip and clavicle fractures many years ago 2 All of his teeth have been removed FHX Not noted SHX Cigar smoker Truck driver EXAM BP 193 73 HR 71 RR 21 Temp 37 2C MS A O to person place and time No note regarding speech or thought process CN Subhyaloid hemorrhages OU Pupils 4 4 decreasing to 2 2 on exposure to light Face symmetric Tongue midline Gag response difficult to elicit Corneal responses not noted MOTOR 5 5 strength throughout Sensory Intact PP VIB Reflexes 2 2 throughout Plantars were flexor bilaterally Gen Exam unremarkable COURSE The patient underwent Cerebral Angiography on 10 13 92 This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery The patient subsequently underwent clipping of this aneurysm He recovery was complicated severe vasospasm and bacterial meningitis HCT on 10 19 92 revealed multiple low density areas in the left hemisphere in the LACA LPCA watershed left fronto parietal area and left thalamic region He was left with residual right hemiparesis urinary incontinence some unspecified degree of mental dysfunction He was last seen 2 26 93 in Neurosurgery clinic and had stable deficits Keywords neurology consciousness level of consciousness hct subhyaloid hemorrhages cerebral angiography carotid artery communication artery laca lpca fluctuating level of consciousness internal carotid artery lobulated aneurysm lobulated supraclinoid cerebral aneurysm artery angiogram MEDICAL_TRANSCRIPTION,Description Bilateral carotid cerebral angiogram and right femoral popliteal angiogram Medical Specialty Neurology Sample Name Bilateral Carotid Cerebral Angiogram Transcription PREOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease POSTOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease OPERATIONS PERFORMED 1 Bilateral carotid cerebral angiogram 2 Right femoral popliteal angiogram FINDINGS The right carotid cerebral system was selectively catheterized and visualized The right internal carotid artery was found to be very tortuous with kinking in its cervical portions but no focal stenosis was noted Likewise the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery The left carotid cerebral system was selectively catheterized and visualized The cervical portion of the left internal carotid artery showed a 30 to 40 stenosis with small ulcer crater present The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery Visualization of the right lower extremity showed no significant disease PROCEDURE With the patient in supine position under local anesthesia plus intravenous sedation the groin areas were prepped and draped in a sterile fashion The common femoral artery was punctured in a routine retrograde fashion and a 5 French introducer sheath was advanced under fluoroscopic guidance A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above Following completion of the above the catheter and introducer sheath were removed Heparin had been initially given which was reversed with protamine Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and sandbag compression The patient tolerated the procedure well throughout Keywords neurology femoral popliteal angiogram carotid cerebral angiogram internal carotid artery carotid artery angiogram carotid cerebral artery MEDICAL_TRANSCRIPTION,Description Bilateral carotid ultrasound Medical Specialty Neurology Sample Name Carotid Ultrasound Transcription EXAM Bilateral carotid ultrasound REASON FOR EXAM Headache TECHNIQUE Color grayscale and Doppler analysis is employed FINDINGS On the grayscale images the right common carotid artery demonstrates patency with mild intimal thickening only At the level of the carotid bifurcation there is heterogeneous hard plaque present but without grayscale evidence of greater than 50 stenosis Right common carotid waveform is normal with a peak systolic velocity of 0 474 m second and an end diastolic velocity of 0 131 m second The right ECA is patent as well with the velocity measurement 0 910 m second The right internal carotid artery at the bifurcation demonstrates plaque formation but no evidence of greater than 50 stenosis Proximal peak systolic velocity in the internal carotid artery is 0 463 m second with proximal end diastolic velocity of 0 170 The mid internal carotid peak systolic velocity is 0 564 m second and mid ICA end diastolic velocity is 0 199 m second Right ICA distal PSV 0 580 m second right ICA distal EDV 0 204 m second Vertebral flow is antegrade on the right at 0 469 m second On the left the common carotid artery demonstrates intimal thickening but is otherwise patent At the level of the bifurcation however there is more pronounced plaque formation with approximately 50 stenosis by the grayscale analysis See the velocity measurements below Left carotid ECA measurement 0 938 m second Left common carotid PSV 0 686 m second and left common carotid end diastolic velocity 0 137 m second Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50 stenosis This should be further assessed with CTA for more precise measurement The left proximal ICA PSV 0 955 m second left proximal ICA EDV 0 287 m second There is spectral broadening in the proximal aspect of the carotid waveform The left carotid ICA mid PSV 0 895 left carotid ICA mid EDV 0 278 with also spectral broadening present The left distal ICA PSV 0 561 left distal ICA EDV 0 206 again the spectral broadening present Vertebral flow is antegrade at 0 468 m second IMPRESSION The study demonstrates bilateral hard plaque at the bifurcation left greater than right There is at least 50 stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment Keywords neurology doppler analysis headache edv ica eca psv distal ica edv hard plaque bilateral carotid ultrasound peak systolic velocity internal carotid artery plaque formation carotid ultrasound carotid artery carotid stenosis proximal artery velocity MEDICAL_TRANSCRIPTION,Description Brain CT and MRI suprasellar mass pituitary adenoma Medical Specialty Neurology Sample Name Brain MRI Pituitary Adenoma Transcription CC Orthostatic lightheadedness HX This 76 y o male complained of several months of generalized weakness and malaise and a two week history of progressively worsening orthostatic dizziness The dizziness worsened when moving into upright positions In addition he complained of intermittent throbbing holocranial headaches which did not worsen with positional change for the past several weeks He had lost 40 pounds over the past year and denied any recent fever SOB cough vomiting diarrhea hemoptysis melena hematochezia bright red blood per rectum polyuria night sweats visual changes or syncopal episodes He had a 100 pack year history of tobacco use and continued to smoke 1 to 2 packs per day He has a history of sinusitis EXAM BP 98 80 mmHg and pulse 64 BPM supine BP 70 palpable mmHG and pulse 84BPM standing RR 12 Afebrile Appeared fatigued CN unremarkable Motor and Sensory exam unremarkable Coord Slowed but otherwise unremarkable movements Reflexes 2 2 and symmetric throughout all 4 extremities Plantar responses were flexor bilaterally The rest of the neurologic and general physical exam was unremarkable LAB Na 121 meq L K 4 2 meq L Cl 90 meq L CO2 20meq L BUN 12mg DL CR 1 0mg DL Glucose 99mg DL ESR 30mm hr CBC WNL with nl WBC differential Urinalysis SG 1 016 and otherwise WNL TSH 2 8 IU ML FT4 0 9ng DL Urine Osmolality 246 MOSM Kg low Urine Na 35 meq L COURSE The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved but returned within 24 48hrs Further laboratory studies revealed Aldosterone serum 2ng DL low 30 minute Cortrosyn Stimulation test pre 6 9ug DL borderline low post 18 5ug DL normal stimulation rise Prolactin 15 5ng ML no baseline given FSH and LH were within normal limits for males Testosterone 33ng DL wnl Sinus XR series done for history of headache showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids There was also an abnormal calcification seen in the middle of the sellar region A left maxillary sinus opacity with air fluid level was seen Goldman visual field testing was unremarkable Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma He was treated with Fludrocortisone 0 05 mg BID and within 24hrs despite discontinuation of IV fluids remained hemodynamically stable and free of symptoms of orthostatic hypotension His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing 1 1997 though he has developed dementia felt secondary to cerebrovascular disease stroke TIA Keywords neurology brain ct goldman mri orthostatic adenoma generalized weakness hypotension lightheadedness malaise pituitary sinus opacity suprasellar mass brain ct and mri orthostatic hypotension pituitary adenoma brain sinusitis sellar MEDICAL_TRANSCRIPTION,Description Frontal craniotomy for placement of deep brain stimulator electrode Microelectrode recording of deep brain structures Intraoperative programming and assessment of device Medical Specialty Neurology Sample Name Brain Stimulator Electrode Transcription PREOPERATIVE DIAGNOSIS Tremor dystonic form POSTOPERATIVE DIAGNOSIS Tremor dystonic form COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 100 mL ANESTHESIA MAC monitored anesthesia care with local anesthesia TITLE OF PROCEDURES 1 Left frontal craniotomy for placement of deep brain stimulator electrode 2 Right frontal craniotomy for placement of deep brain stimulator electrode 3 Microelectrode recording of deep brain structures 4 Stereotactic volumetric CT scan of head for target coordinate determination 5 Intraoperative programming and assessment of device INDICATIONS The patient is a 61 year old woman with a history of dystonic tremor The movements have been refractory to aggressive medical measures felt to be candidate for deep brain stimulation The procedure is discussed below I have discussed with the patient in great deal the risks benefits and alternatives She fully accepted and consented to the procedure PROCEDURE IN DETAIL The patient was brought to the holding area and to the operating room in stable condition She was placed on the operating table in seated position Her head was shaved Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50 50 mixture of 0 5 Marcaine and 2 lidocaine in all planes IV antibiotics were administered as was the sedation She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken The images were then transported to the surgery planned work station where a 3 D reconstruction was performed and the target coordinates were then chosen Target coordinates chosen were 20 mm to the left of the AC PC midpoint 3 mm anterior to the AC PC midpoint and 4 mm below the AC PC midpoint Each coordinate was then transported to the operating room as Leksell coordinates The patient was then placed on the operating table in a seated position once again Foley catheter was placed and she was secured to the table using the Mayfield unit At this point then the patient s right frontal and left parietal bossings were cleaned shaved and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes Sterile drapes placed around the perimeter of the field This same scalp region was then anesthetized with same local anesthetic mixture A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings Bur holes were created on either side of the midline just behind the coronal suture Hemostasis was controlled using bipolar and Bovie and self retaining retractors had been placed in the field Using the drill then two small grooves were cut in the frontal bone with a 5 mm cutting burs and Stryker drill The bur holes were then curetted free the dura cauterized and then opened in a cruciate manner on both sides with a 11 blade The cortical surface was then nicked with a 11 blade on both sides as well The Leksell arc with right sided coordinate was dialed in was then secured to the frame Microelectrode drive was secured to the arc Microelectrode recording was then performed The signatures of the cells were recognized Microelectrode unit was removed Deep brain stimulating electrode holding unit was mounted The DBS electrode was then loaded into target and intraoperative programming and testing was performed Using the screener box and standard parameters the patient experienced some relief of symptoms on her left side This electrode was secured in position using bur hole ring and cap system Attention was then turned to the left side where left sided coordinates were dialed into the system The microelectrode unit was then remounted Microelectrode recording was then undertaken After multiple passes the microelectrode unit was removed Deep brain stimulator electrode holding unit was mounted at the desired trajectory The DBS electrode was loaded into target and intraoperative programming and testing was performed once again using the screener box Using standard parameters the patient experienced similar results on her right side This electrode was secured using bur hole ring and cap system The arc was then removed A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel We then closed the electrode replaced subgaleally Copious amounts of Betadine irrigation were used Hemostasis was controlled using the bipolar only Closure was instituted using 3 0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples Sterile dressings were applied The Leksell arc was then removed She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition All needle sponge cottonoid and blade counts were correct x2 as verified by the nurses Keywords neurology dystonic ac pc ct scan dbs electrode intraoperative programming microelectrode stereotactic tremor brain stimulator craniotomy device dystonic tremor electrode frontal screener box target coordinate volumetric deep brain stimulator electrode brain stimulator electrode volumetric ct stimulator brain MEDICAL_TRANSCRIPTION,Description MRI Arteriovenous malformation with hemorrhage Medical Specialty Neurology Sample Name AVM with Hemorrhage Transcription CC Headache HX 63 y o RHF first seen by Neurology on 9 14 71 for complaint of episodic vertigo During that evaluation she described a several year history of migraine headaches She experienced her first episode of vertigo in 1969 The vertigo clockwise typically began suddenly after lying down and was not associated with nausea vomiting headache The vertigo had not been consistently associated with positional change and could last hours to days On 3 15 71 after 5 day bout of vertigo right ear ache and difficulty ambulating secondary to the vertigo she sought medical attention and underwent an audiogram which reportedly showed a 20 decline in low tone acuity AD She complained of associated tinnitus which she described as a whistle In addition her symptoms appeared to worsen with changes in head position i e looking up or down The symptoms gradually resolved and she did well until 8 71 when she experienced a 19 day episode of vertigo tinnitus and intermittent headaches She was seen 9 14 71 in Neurology and admitted for evaluation Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region The AVM was primarily fed by the right MCA Otolaryngologic evaluation concluded that she probably also suffered from Meniere s disease On 10 14 74 she underwent a 21 day admission for SAH secondary to right parietal AVM On 11 23 91 she was admitted for left sided weakness LUE LLE headache and transient visual change Neurological exam confirmed left sided weakness and dysesthesia of the LUE only Brain CT confirmed a 3 x 4 cm left parietal hemorrhage She underwent unsuccessful embolization Neuroradiology had planned to do 3 separate embolizations but during the first via the left MCA they were unable to cannulate many of the AVM vessels and abandoned the procedure She recovered with residual left hemisensory loss In 12 92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention In 1 93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix AZ Keywords neurology arteriovenous malformation avm brain ct cerebral angiogram headache audiogram carotid bruits difficulty ambulating hemorrhage interventricular hemorrhage migraine tinnitus vertigo visual change weakness episode of vertigo evaluation MEDICAL_TRANSCRIPTION,Description MRI for Arnold Chiari II with syrinx Medical Specialty Neurology Sample Name Arnold Chiari II with Syrinx Transcription CC Right sided numbness HX 28 y o male presented with a 3 month history of progressive right sided numbness now anesthetic to pain In addition he experienced worsening balance and episodes of aspiration while eating PMH 1 Born prematurely and weighed 3 2oz 2 Multiple episodes of aspiration pneumonia as an infant and child 3 ASD repair age 14 4 Left ptosis repair age 11 5 Scoliosis 6 Gait abnormality 7 Poor pharyngeal reflexes SHX FHX Mainstream high school education no mental retardation ambulatory works at cardboard shop for the disabled EXAM Short stature Head tilt to right CN Left ptosis decreased left nasolabial fold decreased gag reflex bilaterally Motor Full strength Sensory Marked hypesthesia on entire right side Coord Slowed RAM on left Station No drift Gait ND Reflexes 3 throughout Babinski signs bilaterally 8 beat ankle clonus on right and 3 beat ankle clonus on left MRI Arnold Chiari II with syrinx Severe basilar invagination marked compression of ventral pontomedullary junction downward descension of cerebellar tonsils and vermis COURSE Patient underwent transpalatal pharyngeal ventral decompression of pons medulla with resection of clivus odontoid and tracheostomy placement on 9 29 92 Halo vest and ring were removed 6 18 93 6 months later his Philadelphia collar was removed He was last seen 4 8 94 and he had mildly spastic gait with good strength and hyperreflexia throughout His gag response had returned and he was eating without difficulty Sensation had returned to his extremities Keywords neurology right sided numbness arnold chiari ii with syrinx cerebellar tonsils vermis philadelphia collar arnold chiari ii ankle clonus mri numbness chiari syrinx gait reflexes arnold MEDICAL_TRANSCRIPTION,Description A 75 year old female comes in with concerns of having a stroke Medical Specialty Neurology Sample Name Bell s Palsy Transcription SUBJECTIVE The patient is a 75 year old female who comes in today with concerns of having a stroke She states she feels like she has something in her throat She started with some dizziness this morning and some left hand and left jaw numbness She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr XYZ for that who gave her some Antivert She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face as well as the left side of her neck She said she had an earache a day or so ago She has not had any cold symptoms ALLERGIES Demerol and codeine MEDICATIONS Lotensin Lopid metoprolol and Darvocet REVIEW OF SYSTEMS The patient says that she feels little bit nauseated at times She denies chest pain or shortness of breath and again feels like she has something in her throat She has been able to swallow liquids okay She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth She does say that she occasionally has numbness in her left hand prior to today PHYSICAL EXAMINATION General She is awake and alert no acute distress Vital Signs Blood pressure 175 86 Temperature She is afebrile Pulse 78 Respiratory rate 20 O2 sat 93 on room air HEENT Her TMs are normal bilaterally Posterior pharynx is unremarkable It should be noted that her uvula did not deviate and neither did her tongue When she smiles though she has some drooping of the left side of her face as well as some mild nasolabial fold flattening Neck Without adenopathy or thyromegaly Carotids pulses are brisk without bruits Lungs Clear to auscultation Heart Regular rate and rhythm without murmur Extremities Her muscle strength is symmetrical and intact bilaterally DTRs are 2 4 bilaterally and muscle strength is intact in the upper extremities She has a positive Tinel s sign on her left wrist Neurological I also took monofilament and she could sense it easily when testing her sensation on her face ASSESSMENT Bell s Palsy PLAN We did get an EKG showed some ST segment changes anterolaterally The only EKG I have here is from 1998 and she actually had bypass in 1999 but there certainly does not appear to be anything acute on his EKG I assured her that it does not look like she has a stroke If she wants to prevent a stroke obviously quitting her smoking would help It should be noted she also takes Synthroid and Zocor We are going to give her Valtrex 1 g t i d for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face she needs to come back but I will not start her on steroids at this time which she agreed with Keywords neurology stroke bell s palsy st segment changes ekg dizziness numbness dizzy muscle strength palsy bell s MEDICAL_TRANSCRIPTION,Description MRI Right temporal lobe astrocytoma Medical Specialty Neurology Sample Name Astrocytoma Transcription CC Episodic confusion HX This 65 y o RHM reportedly suffered a stroke on 1 17 92 He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode The stroke was reportedly verified on MRI scan dated 1 17 92 He was subsequently placed on ASA and DPH He admitted that there had been short periods 1 2 days duration since then during which he had forgotten to take his DPH However even when he had been taking his DPH regularly he continued to experience the spells mentioned above He denied any associated tonic clonic movement incontinence tongue biting HA visual change SOB palpitation weakness or numbness The episodes of confusion and memory loss last 1 2 minutes in duration and have been occurring 2 3 times per week PMH Bilateral Hearing Loss of unknown etiology S P bilateral ear surgery many years ago MEDS DPH and ASA SHX FHX 2 4 Beers day 1 2 packs of cigarettes per day EXAM BP 111 68 P 68BPM 36 8C Alert and Oriented to person place and time 30 30 on mini mental status test Speech fluent and without dysarthria CN Left superior quandranopia only Motor 5 5 strength throughout Sensory unremarkable except for mild decreased vibration sense in feet Coordination unremarkable Gait and station testing were unremarkable He was able to tandem walk without difficulty Reflexes 2 and symmetric throughout Flexor plantar responses bilaterally LAB Gen Screen CBC PT PTT all WNL DPH 4 6mcg ml Review of outside MRI Brain done 1 17 92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus The area did not enhance with gadolinium contrast CXR 8 31 92 5 x 6 mm spiculated opacity in apex right lung EEG 8 24 92 normal awake and asleep MRI Brain with without contrast 8 31 92 Decreased T1 and increased T2 signal in the right temporal lobe The lesion increased in size and enhances more greatly when compared to the 1 17 92 MRI exam There is also edema surrounding the affected area and associated mass effect NEUROPSYCHOLOGICAL TESTING Low average digit symbol substitution mildly impaired verbal learning and severely defective delayed recall There was relative preservation of other cognitive functions The findings were consistent with left mesiotemporal dysfunction COURSE Patient underwent right temporal lobectomy on 9 16 92 following initial treatment with Decadron Pathologic analysis was consistent with a Grade 2 astrocytoma GFAP staining positive Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed Keywords neurology confusion gfap gfap staining mri scan astrocytoma hippocampus memory loss palpitation signal stroke temporal lobe tongue biting tonic clonic movement weakness increased t signal mri brain mri temporal MEDICAL_TRANSCRIPTION,Description Patient seen in Neuro Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma Medical Specialty Neurology Sample Name Anaplastic Astrocytoma Letter Transcription XYZ RE ABC MEDICAL RECORD 123 Dear Dr XYZ I saw ABC back in Neuro Oncology Clinic today He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma Within the last several days he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective Despite repeatedly emphasizing this however the patient still is worried about potential long term side effects from treatment that frankly seem unwarranted at this particular time After seeing you in clinic he and his friend again wanted to discuss possible changes in the chemotherapy regimen They came in with a list of eight possible agents that they would like to be administered within the next two weeks They then wanted another MRI to be performed and they were hoping that with the use of this type of approach they might be able to induce another remission from which he can once again be spared radiation From my view I noticed a man whose language has deteriorated in the week since I last saw him This is very worrisome Today for the first time I felt that there was a definite right facial droop as well Therefore there is no doubt that he is becoming symptomatic from his growing tumor It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future Emphasizing this once again in addition to recommending steroids I once again tried to convince him to undergo radiation Despite an hour this again amazingly was not possible It is not that he does not want treatment however Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised we compromised and elected to go back to Temodar in a low dose daily type regimen We would plan on giving 75 mg sq m everyday for 21 days out of 28 days In addition we will stop thalidomide 100 mg day If he tolerates this for one week we then agree that we would institute another one of the medications that he listed for us At this stage we are thinking of using Accutane at that point While I am very uncomfortable with this type of approach I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval In the spirit of compromise he again consented to be evaluated by radiation and this time seemed more resigned to the fact that it was going to happen sooner than later I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term I will keep you apprised of followups If you have any questions or if I could be of any further assistance feel free to contact me Sincerely Keywords neurology neuro oncology anaplastic astrocytoma anaplastic oncology radiation astrocytoma MEDICAL_TRANSCRIPTION,Description CT Brain arachnoid cyst Arachnoid cyst diagnosed by CT brain Medical Specialty Neurology Sample Name Arachnoid Cyst Transcription CC Seizures HX The patient was initially evaluated at UIHC at 7 years of age He had been well until 7 months prior to evaluation when he started having spells which were described as dizzy spells lasting from several seconds to one minute in duration They occurred quite infrequently and he was able to resume activity immediately following the episodes The spell became more frequent and prolonged and by the time of initial evaluation were occurring 2 3 times per day and lasting 2 3 minutes in duration In addition in the 3 months prior to evaluation the right upper extremity would become tonic and flexed during the episodes and he began to experience post ictal fatigue BIRTH HX 32 weeks gestation to a G4 mother and weighed 4 11oz He was placed in an incubator for 3 weeks He was jaundiced but there was no report that he required treatment PMH Single febrile convulsion lasting 3 hours at age 2 years MEDS none EXAM Appears healthy and in no acute distress Unremarkable general and neurologic exam Impression Psychomotor seizures Studies Skull X Rays were unremarkable EEG showed minimal spike activity during hyperventilation as well as random sharp delta activity over the left temporal area in drowsiness and sleep This record also showed moderate amplitude asymmetry left greater than right over the frontal central and temporal areas which is a peculiar finding COURSE The patient was initially treated with Phenobarbital then Dilantin was added early 1970 s then Depakene was added early 1980 s due to poor seizure control An EEG on 8 22 66 showed Left mid temporal spike focus with surrounding slow abnormality especially posterior to the anterior temporal areas sparing the parasagittal region In addition the right lateral anterior hemisphere voltage is relatively depressed this suggests two separate areas of cerebral pathology He underwent his first HCT scan in Sioux City in 1981 and this revealed an right temporal arachnoid cyst The patient had behavioral problems throughout elementary junior high high school He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted He was placed on numerous antiepileptic medication combinations including Tegretol Dilantin Phenobarbital Depakote Acetazolamide and Mysoline Despite this he averaged 2 3 spells a month He was last seen 6 19 95 and was taking Dilantin and Tegretol His typical spells were described as sudden in onset and without aura He frequently becomes tonic or undergoes tonic clonic movement and falls with associated loss of consciousness He usually has rapid recovery and can return to work in 20 minutes He works at a Turkey packing plant Serial HCT scans showed growth in the arachnoid cyst until 1991 when growth arrest appeared to have occurred Keywords neurology arachnoid cyst hct scan seizures serial hct scans dizzy spells drowsiness hyperventilation loss of consciousness moderate amplitude asymmetry temporal area tonic clonic movement phenobarbital dilantin cyst temporal arachnoid MEDICAL_TRANSCRIPTION,Description Bilateral renal ultrasound Medical Specialty Nephrology Sample Name Renal Ultrasound 1 Transcription EXAM Bilateral renal ultrasound CLINICAL INDICATION UTI TECHNIQUE Transverse and longitudinal sonograms of the kidneys were obtained FINDINGS The right kidney is of normal size and echotexture and measures 5 7 x 2 2 x 3 8 cm The left kidney is of normal size and echotexture and measures 6 2 x 2 8 x 3 0 cm There is no evidence for HYDRONEPHROSIS or PERINEPHRIC fluid collections The bladder is of normal size and contour The bladder contains approximately 13 mL of urine after recent voiding This is a small postvoid residual IMPRESSION Normal renal ultrasound Small postvoid residual Keywords nephrology bilateral renal ultrasound postvoid residual renal ultrasound residual kidneys renal ultrasound MEDICAL_TRANSCRIPTION,Description Right shockwave lithotripsy cystoscopy and stent removal x2 Medical Specialty Nephrology Sample Name Shockwave Lithotripsy Transcription PREOPERATIVE DIAGNOSIS Right renal stone POSTOPERATIVE DIAGNOSIS Right renal stone PROCEDURE Right shockwave lithotripsy cystoscopy and stent removal x2 ANESTHESIA LMA ESTIMATED BLOOD LOSS Minimal The patient was given antibiotics preoperatively HISTORY This is a 47 year old male who presented with right renal stone and right UPJ stone The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney The plan was for shockwave lithotripsy The patient had duplicated system on the right side Risk of anesthesia bleeding infection pain MI DVT PE was discussed Options such as watchful waiting passing the stone on its own and shockwave lithotripsy were discussed The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily Consent was obtained DETAILS OF THE OPERATION The patient was brought to the OR Anesthesia was applied The patient was placed in the supine position Using Dornier lithotriptor total of 2500 shocks were applied Energy levels were slowly started at O2 increased up to 7 gradually the stone seem to have broken into smaller pieces as the number of shocks went up The shocks were started at 60 per minute and slowly increased up to 90 per minute The patient s heart rate and blood pressure were stable throughout the entire procedure After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion and cystoscopy was done Using graspers the stent was grasped x2 and pulled out both stents were removed The patient tolerated the procedure well The patient was brought to recovery in stable condition The plan was for the patient to follow up with us and plan for KUB in about two to three months Keywords nephrology renal stone stent removal upj stone shockwave lithotripsy cystoscopy stent renal shocks upj shockwave lithotripsy stone MEDICAL_TRANSCRIPTION,Description AP abdomen and ultrasound of kidney Medical Specialty Nephrology Sample Name Ultrasound Kidney Transcription EXAM AP abdomen and ultrasound of kidney HISTORY Ureteral stricture AP ABDOMEN FINDINGS Comparison is made to study from Month DD YYYY There is a left lower quadrant ostomy There are no dilated bowel loops suggesting obstruction There is a double J right ureteral stent which appears in place There are several pelvic calcifications which are likely vascular No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters Overall findings are stable versus most recent exam IMPRESSION Properly positioned double J right ureteral stent No evidence for calcified renal or ureteral stones ULTRASOUND KIDNEYS FINDINGS The right kidney is normal in cortical echogenicity of solid mass stone hydronephrosis measuring 9 0 x 2 9 x 4 3 cm There is a right renal ureteral stent identified There is no perinephric fluid collection The left kidney demonstrates moderate to severe hydronephrosis No stone or solid masses seen The cortex is normal The bladder is decompressed IMPRESSION 1 Left sided hydronephrosis 2 No visible renal or ureteral calculi 3 Right ureteral stent Keywords nephrology ureteral stricture ap abdomen bowel loops calcified calculi double j echogenicity hydronephrosis kidney left lower quadrant obstruction ostomy perinephric renal solid mass stent ultrasound ureteral stent ureteral stones ureters ureteral MEDICAL_TRANSCRIPTION,Description Ultrasound kidneys renal for renal failure neurogenic bladder status post cystectomy Medical Specialty Nephrology Sample Name Renal Ultrasound Transcription EXAM Renal ultrasound HISTORY Renal failure neurogenic bladder status post cystectomy TECHNIQUE Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes COMPARISON Most recently obtained mm dd yy FINDINGS The right kidney measures 12 x 5 2 x 4 6 cm and the left kidney measures 12 2 x 6 2 x 4 4 cm The imaged portions of the kidneys fail to demonstrate evidence of mass hydronephrosis or calculus There is no evidence of cortical thinning Incidentally there is a rounded low attenuation mass within the inferior aspect of the right lobe of the liver measuring 2 1 x 1 5 x 1 9 cm which has suggestion of some peripheral blood flow IMPRESSION 1 No evidence of hydronephrosis 2 Mass within the right lobe of the liver The patient apparently has a severe iodine allergy Further evaluation with MRI is recommended 3 The results of this examination were given to XXX in Dr XXX office on mm dd yy at XXX Keywords nephrology lobe of the liver status post cystectomy renal ultrasound renal failure neurogenic bladder bladder status neurogenic bladder cystectomy hydronephrosis lobe liver ultrasound mass renal kidneys renal MEDICAL_TRANSCRIPTION,Description MRI brain PET scan Dementia of Alzheimer type with primary parietooccipital involvement Medical Specialty Neurology Sample Name Alzheimer Disease Transcription CC Memory difficulty HX This 64 y o RHM had had difficulty remembering names phone numbers and events for 12 months prior to presentation on 2 28 95 This had been called to his attention by the clerical staff at his parish he was a Catholic priest He had had no professional or social faux pas or mishaps due to his memory He could not tell whether his problem was becoming worse so he brought himself to the Neurology clinic on his own referral MEDS None PMH 1 appendectomy 2 tonsillectomy 3 childhood pneumonia 4 allergy to sulfa drugs FHX Both parents experienced memory problems in their ninth decades but not earlier 5 siblings have had no memory trouble There are no neurological illnesses in his family SHX Catholic priest Denied Tobacco ETOH illicit drug use EXAM BP131 74 HR78 RR12 36 9C Wt 77kg Ht 178cm MS A O to person place and time 29 30 on MMSE 2 3 recall at 5 minutes 2 10 word recall at 10 minutes Unable to remember the name of the President Clinton 23words 60 sec on Category fluency testing normal Mild visual constructive deficit The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted COURSE TSH 5 1 T4 7 9 RPR non reactive Neuropsychological evaluation 3 6 95 revealed 1 well preserved intellectual functioning and orientation 2 significant deficits in verbal and visual memory proper naming category fluency and working memory 3 performances which were below expectations on tests of speed of reading visual scanning visual construction and clock drawing 4 limited insight into the scope and magnitude of cognitive dysfunction The findings indicated multiple areas of cerebral dysfunction With the exception of the patient s report of minimal occupational dysfunction which may reflect poor insight the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer s disease MRI brain 3 6 95 showed mild generalized atrophy more severe in the occipital parietal regions In 4 96 his performance on repeat neuropsychological evaluation was relatively stable His verbal learning and delayed recognition were within normal limits whereas delayed recall was moderately severely impaired Immediate and delayed visual memory were slightly below expectations Temporal orientation and expressive language skills were below expectation especially in word retrieval These findings were suggestive of particular but not exclusive involvement of the temporal lobes On 9 30 96 he was evaluated for a 5 minute spell of visual loss OU The episode occurred on Friday 9 27 96 in the morning while sitting at his desk doing paperwork He suddenly felt that his gaze was pulled toward a pile of letters then a curtain came down over both visual fields like everything was in the shade During the episode he felt fully alert and aware of his surroundings He concurrently heard a grating sound in his head After the episode he made several phone calls during which he reportedly sounded confused and perseverated about opening a bank account He then drove to visit his sister in Muscatine Iowa without accident He was reportedly normal when he reached her house He was able to perform Mass over the weekend without any difficulty Neurologic examination 9 30 96 was notable for 1 category fluency score of 18items 60 sec 2 VFFTC and EOM were intact There was no RAPD INO loss of visual acuity Glucose 178 elevated ESR Lipid profile GS CBC with differential Carotid duplex scan EKG and EEG were all normal MRI brain 9 30 96 was unchanged from previous 3 6 95 On 1 3 97 he had a 30 second spell of lightheadedness without vertigo but with balance difficulty after picking up a box of books The episode was felt due to orthostatic changes 1 8 97 neuropsychological evaluation was stable and his MMSE score was 25 30 with deficits in visual construction orientation and 2 3 recall at 1 minute Category fluency score 23 items 60 sec Neurologic exam was notable for graphesthesia in the left hand In 2 97 he had episodes of anxiety marked fluctuations in job performance and resigned his pastoral position His neurologic exam was unchanged An FDG PET scan on 2 14 97 revealed decreased uptake in the right posterior temporal parietal and lateral occipital regions Keywords neurology dementia a o to person alzheimer s disease alzheimer s type mmse mmse score mri brain memory difficulty neuropsychological balance difficulty category fluency faux pas minimal occupational dysfunction parieto occipital progressive dementia syndrome visual acuity visual loss visual memory pet scan neuropsychological evaluation alzheimer s neurological memory MEDICAL_TRANSCRIPTION,Description Right ureteropelvic junction obstruction Robotic assisted pyeloplasty anterograde right ureteral stent placement transposition of anterior crossing vessels on the right and nephrolithotomy Medical Specialty Nephrology Sample Name Pyeloplasty Robotic Transcription PROCEDURES 1 Robotic assisted pyeloplasty 2 Anterograde right ureteral stent placement 3 Transposition of anterior crossing vessels on the right 4 Nephrolithotomy DIAGNOSIS Right ureteropelvic junction obstruction DRAINS 1 Jackson Pratt drain times one from the right flank 2 Foley catheter times one ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None SPECIMENS 1 Renal pelvis 2 Kidney stones INDICATIONS The patient is a 30 year old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries Up on consideration of various modalities and therapy the patient decided to undergo surgical therapy PROCEDURE IN DETAIL The patient was verified by armband and the procedure being robotic assisted right pyeloplasty with nephrolithotomy was verified and the procedure was carried out After institution of general endotracheal anesthesia and intravenous preoperative antibiotics the patient was positioned into the right flank position with his right flank elevated Great care was taken to pad all pressure points and a right arm hanger was used The patient was flexed slightly and a kidney rest was used Sequential compression devices were also placed Next the patient was prepped and draped in normal sterile fashion with povidone iodine Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test A low pressure high flow pneumoperitoneum was adequately obtained using CO2 gas Next a 12 mm camera port was placed near the umbilicus The camera was inserted and no bowel injury was seen Next under direct vision flanking 8 mm camera ports a 12 mm assist port a 5 mm liver retraction port and 5 mm assist port were placed The robot was docked and the instruments passed through respective checks Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially Next the right lateral duodenum was cauterized for further access to the right retroperitoneum At this point the right kidney was in clear view and the fascia was entered Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole These arteries were dissected carefully and vessel loops were applied Next a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out The pyelotomy was extended so that the renal collecting system could be directly inspected Sequentially each major calyx was inspected under direct vision and irrigated A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient At this point we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis The proximal ureter was spatulated using cold scissors Next redundant renal pelvis was excised using cold scissors and sent for permanent section We then identified the most inferior dependent portion of the renal pelvis and placed a heel stitch at this for ureteral renal pelvis anastomosis in a semi running fashion 3 0 Monocryl sutures were used to re anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis Next remainder of the pyelotomy was closed to itself also using 2 0 Monocryl sutures Before final stitches were placed a 6x28 ureteral stent was placed anterograde This was accomplished by placing the stents over a guidewire placing the guidewire under direct vision anterograde through the ureter This was done until the proximal end was in the renal pelvis the guidewire was removed and good proximal curl was verified by direct vision Then the pyelotomy was completely closed again with 2 0 Monocryl sutures Next attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis Good pulsation was verified by direct vision proximal and distal to these pexy sutures Next Gerota s fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum Hemostasis appeared excellent at this point There was no obvious urine extravasation At this time the procedure was terminated The robot was undocked Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion Then all skin port sites were closed with 4 0 Monocryl in a subcuticular fashion and Dermabond and band aids were applied over this Also notably a Jackson Pratt drain was placed in the area of the right kidney and additional right flank stab incision The patient tolerated the procedure well and no immediate perioperative complication was noted DISPOSITION The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery Keywords nephrology pyeloplasty ureteral stent placement nephrolithotomy ureteropelvic junction obstruction jackson pratt drain foley catheter renal pelvis kidney stones monocryl sutures pelvis renal ureteropelvic sutures MEDICAL_TRANSCRIPTION,Description Cadaveric renal transplant to right pelvis endstage renal disease Medical Specialty Nephrology Sample Name Renal Transplant Cadaveric Transcription HISTORY OF PRESENT ILLNESS The patient is a 50 year old African American female with past medical history significant for hypertension and endstage renal disease on hemodialysis secondary to endstage renal disease last hemodialysis was on June 22 2007 The patient presents with no complaints for cadaveric renal transplant After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys the patient was deemed appropriate for operative intervention and transplantation of kidney PREOPERATIVE DIAGNOSIS Endstage renal disease POSTOPERATIVE DIAGNOSIS Endstage renal disease PROCEDURE Cadaveric renal transplant to right pelvis ESTIMATED BLOOD LOSS 400 mL FLUIDS One liter of normal saline and one liter of 5 of albumin ANESTHESIA General endotracheal SPECIMEN None DRAIN None COMPLICATIONS None The patient tolerated the procedure without any complication PROCEDURE IN DETAIL The patient was brought to the operating room prepped and draped in sterile fashion After adequate anesthesia was achieved a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1 5 cm medial of the ASIS down to the suprapubic space After this was taken down with a 10 blade electrocautery was used to take down tissue down to the layer of the subcutaneous fat Camper s and Scarpa s were dissected with electrocautery Hemostasis was achieved throughout the tissue plains with electrocautery The external oblique aponeurosis was identified with musculature and was entered with electrocautery Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia Additionally the rectus sheath was entered in a linear fashion After these planes were entered using electrocautery the retroperitoneum was dissected free from the transversalis fascia using blunt dissection After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery Upon entering through the transversalis fascia the epigastric vessels were identified and doubly ligated and tied with 0 silk ties After the ligation of the epigastric vessels the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane This was done without any complication and without entering the peritoneum grossly The round ligament was identified and doubly ligated at this time with 0 silk ties as well The dissection continued down now to layer of the alveolar tissue covering the right iliac artery This alveolar tissue was cleared using blunt dissection as well as electrocautery After the external iliac artery was identified it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture The right iliac vein was then identified and this was cleared again using electrocautery and blunt dissection After the right iliac vein was identified and cleared off all the alveolar tissue it was circumferentially cleared as well An additional perforating branch was noted at the inferior pole of the right iliac vein This was tied with a 0 silk tie and secured Hemostasis was achieved at this time and the tie had adequate control The dissection continued down and identified all other vital structures in this area Careful preservation of all vital structures was carried out throughout the dissection At this time Satinsky clamp was placed over the right iliac vein This was then opened using a 11 blade approximately 1 cm in length The heparinized saline was placed and irrigated throughout the inside of the vein and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked The renal vein was then elevated and identified in this area A 5 0 double ended Prolene stitch was used to secure the renal vein both superiorly and inferiorly and after appropriately being secured with 5 0 Prolene these were tied down and secured The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5 0 Prolene securing both superior and inferior poles After such time the 5 0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again After this was done and the artery was secured the Satinsky clamp was removed and a bulldog placed over The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow At this time all Satinsky clamps were removed and all bulldog clamps were removed The dissection then continued down to the layer of the bladder at which time the bladder was identified Appropriate area on the dome the bladder was identified for entry This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion Before this was done 0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length At this time a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well Subsequently the superior and inferior pole stitches with 5 0 Prolene were used to secure the ureter to the bladder This was then run mucosa to mucosa in a circumferential manner until secured in both superior and inferior poles once again Good flow was noted from the ureter at the time of operation Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself At this time an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again This was inspected and noted for proper control Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects At this time the anastomoses were all inspected hemostasis was achieved and good closure of the anastomosis was noted at this time The kidney was then placed back into its new position in the right pelvic fossa and the area was once again inspected for hemostasis which was achieved A 1 0 Prolene stitch was then used for mass closure of the external internal and transversalis fascias and musculature in a running fashion from superior to inferior This was secured and knots were dumped Subsequently the area was then checked and inspected for hemostasis which was achieved with electrocautery and the skin was closed with 4 0 running Monocryl The patient tolerated procedure well without evidence of complication transferred to the Dunn ICU where he was noted to be stable Dr A was present and scrubbed through the entire procedure Keywords nephrology endstage renal disease ethibond satinsky clamp aponeurosis cadaveric cross match curvilinear incision hemodialysis iliac vein pelvic fossa peritoneum recipient renal transplant transplant transversalis fascia superior and inferior poles endstage renal renal disease vein electrocautery bladder renal intervention MEDICAL_TRANSCRIPTION,Description Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit hypertension mild renal insufficiency and anemia which has been present chronically over the past year Medical Specialty Nephrology Sample Name Pyelonephritis Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pyelonephritis 2 History of uterine cancer and ileal conduit urinary diversion 3 Hypertension 4 Renal insufficiency 5 Anemia DISCHARGE DIAGNOSES 1 Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit 2 Hypertension 3 Mild renal insufficiency 4 Anemia which has been present chronically over the past year HOSPITAL COURSE The patient was admitted with suspected pyelonephritis Renal was consulted It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr X Her symptoms responded to IV antibiotics and she remained clinically stable Klebsiella was isolated in this urine which was sensitive to Bactrim and she was discharged on p o Bactrim She was scheduled on 08 07 2007 for further surgery She is to follow up with Dr Y in 7 10 days She also complained of right knee pain and the right knee showed no sign of effusion She was exquisitely tender to touch of the patellar tendon It was thought that this did not represent intraarticular process She was advised to use ibuprofen over the counter two to three tabs t i d Keywords nephrology uterine cancer renal insufficiency pyelonephritis mucous plugging ileal conduit MEDICAL_TRANSCRIPTION,Description Nephrology office visit for followup of microscopic hematuria Medical Specialty Nephrology Sample Name Nephrology Office Visit 1 Transcription HISTORY OF PRESENT ILLNESS The patient is a 78 year old woman here because of recently discovered microscopic hematuria History of present illness occurs in the setting of a recent check up which demonstrated red cells and red cell casts on a routine evaluation The patient has no new joint pains however she does have a history of chronic degenerative joint disease She does not use nonsteroidal agents She has had no gross hematuria and she has had no hemoptysis REVIEW OF SYSTEMS No chest pain or shortness of breath no problem with revision The patient has had decreased hearing for many years She has no abdominal pain or nausea or vomiting She has no anemia She has noticed no swelling She has no history of seizures PAST MEDICAL HISTORY Significant for hypertension and hyperlipidemia There is no history of heart attack or stroke She has had bilateral simple mastectomies done 35 years ago She has also had one third of her lung removed for carcinoma probably an adeno CA related to a pneumonia She also had hysterectomy in the past SOCIAL HISTORY She is a widow She does not smoke MEDICATIONS 1 Dyazide one a day 2 Pravachol 80 mg a day in the evening 3 Vitamin E once a day 4 One baby aspirin per day FAMILY HISTORY Unremarkable PHYSICAL EXAMINATION She looks younger than her stated age of 78 years She was hard of hearing but could read my lips Respirations were 16 She was afebrile Pulse was about 90 and regular Her gait was normal Blood pressure is 140 70 in her left arm seated HEENT She had arcus cornealis The pupils were equal The sclerae were not icteric The conjunctivae were pink NECK The thyroid is not palpated No nodes were palpated in the neck CHEST Clear to auscultation She had no sacral edema CARDIAC Regular but she was tachycardic at the rate of about 90 She had no diastolic murmur ABDOMEN Soft and nontender I did not palpate the liver EXTREMITIES She had no appreciable edema She had no digital clubbing She had no cyanosis She had changes of the degenerative joint disease in her fingers She had good pedal pulses She had no twitching or myoclonic jerks LABORATORY DATA The urine I saw 1 2 red cells per high power fields She had no protein She did have many squamous cells The patient has creatinine of 1 mg percent and no proteinuria It seems unlikely that she has glomerular disease however we cannot explain the red cells in the urine PLAN To obtain a routine sonogram I would also repeat a routine urinalysis to check for blood again I have ordered a C3 and C4 and if the repeat urine shows red cells I will recommend a cystoscopy with a retrograde pyelogram Keywords nephrology creatinine cystoscopy glomerular high power fields hyperlipidemia hypertension microscopic hematuria proteinuria pyelogram red cell retrograde sonogram urinalysis red cells hematuria MEDICAL_TRANSCRIPTION,Description The patient is admitted with a diagnosis of acute on chronic renal insufficiency Medical Specialty Nephrology Sample Name Nephrology Consultation 4 Transcription HISTORY The patient is a 61 year old male patient I was asked to evaluate this patient because of the elevated blood urea and creatinine The patient has ascites pleural effusion hematuria history of coronary artery disease pulmonary nodules history of congestive heart failure status post AICD The patient has a history of exposure to asbestos in the past history of diabetes mellitus of 15 years duration hypertension and peripheral vascular disease The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall The patient has been having increasing distention of the abdomen and frequent nosebleeds PAST MEDICAL HISTORY As above PAST SURGICAL HISTORY The patient had a pacemaker placed ALLERGIES NKDA REVIEW OF SYSTEMS Showed no history of fever no chills no weight loss No history of sore throat No history of any ascites No history of nausea vomiting or diarrhea No black stools No history of any rash No back pain No leg pain No neuropsychiatric problems FAMILY HISTORY History of hypertension diabetes present SOCIAL HISTORY He is a nonsmoker nonalcoholic and not a drug user PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 124 66 heart rate around 68 per minute and temperature 96 4 HEENT The patient is atraumatic and normocephalic Pupils are equal and reactive to light Extraocular muscles are intact NECK Supple No JVD and no thyromegaly HEART S1 and S2 heard No murmurs or extra sounds ABDOMEN Distention of the abdomen present EXTREMITIES No pedal edema LABORATORY His lab investigation showed WBC of 6 2 H H is 11 and 34 PT PTT and INR is normal Urinalysis showed 2 protein and 3 blood and 5 to 10 rbc s Potassium is 5 3 BUN of 39 and creatinine of 1 9 Liver function test ALT was 12 AST 15 albumin 3 TSH of 4 8 and T3 of 1 33 IMPRESSION AND PLAN The patient is admitted with a diagnosis of acute on chronic renal insufficiency rule out hepatorenal insufficiency could be secondary to congestive heart failure cardiac cirrhosis rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis The patient has hematuria could be secondary to benign prostatic hypertrophy rule out malignancy We will do urine for cytology We will do a renal ultrasound and 24 hour urine collection for protein creatinine creatinine clearance immunofixation serum electrophoresis serum uric acid serum iron TIBC and serum ferritin levels We will send a PSA level and if needed may be a urology consult Keywords nephrology mesothelioma ascites pleural effusion hematuria history of coronary artery disease pulmonary nodules congestive heart failure aicd hepatorenal insufficiency pulmonary nodule diabetic nephropathy chronic renal insufficiency nodules serum insufficiency MEDICAL_TRANSCRIPTION,Description A 14 year old young lady is in the renal failure and in need of dialysis Medical Specialty Nephrology Sample Name Peritoneal Dialysis Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Renal failure POSTOPERATIVE DIAGNOSIS Renal failure OPERATION PERFORMED Insertion of peritoneal dialysis catheter ANESTHESIA General INDICATIONS This 14 year old young lady is in the renal failure and in need of dialysis She had had a previous PD catheter placed but it became infected and had to be removed She therefore comes back to the operating room for a new PD catheter OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in the usual manner A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection The fascia was divided and the posterior fascia and peritoneum were identified A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed which could easily be brought up through the incision A PD catheter was then placed into the pelvis over a guidewire At this point the peritoneum and posterior fascia was closed around the catheter The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return The skin was closed with 5 0 subcuticular Monocryl Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition Keywords nephrology pd catheter catheter omentum peritoneal dialysis catheter peritoneal dialysis renal failure peritoneal dialysis renal MEDICAL_TRANSCRIPTION,Description Patient with end stage renal disease secondary to hypertension a reasonable candidate for a kidney transplantation Medical Specialty Nephrology Sample Name Nephrology Consultation 3 Transcription PAST MEDICAL SURGICAL HISTORY Briefly his past medical history is significant for hypertension of more than 5 years asthma and he has been on Advair and albuterol He was diagnosed with renal disease in 02 2008 and has since been on hemodialysis since 02 2008 His past surgical history is only significant for left AV fistula on the wrist done in 04 2008 He still has urine output He has no history of blood transfusion PERSONAL AND SOCIAL HISTORY He is a nonsmoker He denies any alcohol No illicit drugs He used to work as the custodian at the nursing home but now on disability since 03 2008 He is married with 2 sons ages 5 and 17 years old FAMILY HISTORY No similar illness in the family except for hypertension in his one sister and his mom who died at 61 years old of congestive heart failure His father is 67 years old currently alive with asthma He also has one sister who has hypertension The rest of the 6 siblings are alive and well ALLERGIES No known drug allergies MEDICATIONS Singulair 10 mg once daily Cardizem 365 mg once daily Coreg 25 mg once daily hydralazine 100 mg three times a day Lanoxin 0 125 mg once daily Crestor 10 mg once daily lisinopril 10 mg once daily Phoslo 3 tablets with meals and Advair 250 mg inhaler b i d REVIEW OF SYSTEMS Significant only for asthma No history of chest pain normal MI He has hypertension He occasionally will develop colds especially with weather changes GI Negative GU Still making urine about 1 3 times per day Musculoskeletal Negative Skin He complains of dry skin Neurologic Negative Psychiatry Negative Endocrine Negative Hematology Negative PHYSICAL EXAMINATION A pleasant 41 year old African American male who stands 5 feet 6 inches and weighs about 193 pounds HEENT Anicteric sclera pink conjunctiva no cervical lymphadenopathy Chest Equal chest expansion Clear breath sounds Heart Distinct heart sounds regular rhythm with no murmur Abdomen Soft nontender flabby no organomegaly Extremities Poor peripheral pulses No cyanosis and no edema ASSESSMENT AND PLAN This is a 49 year old African American male who was diagnosed with end stage renal disease secondary to hypertension He is on hemodialysis since 02 2008 Overall I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma Other than that I think that he is a reasonable candidate for transplant I would like to thank you for allowing me to participate in the care of your patient Please feel free to contact me if there are any questions regarding his case Keywords nephrology kidney transplantation pretransplant transplant clinic renal disease secondary kidney hemodialysis renal asthma transplantation hypertension MEDICAL_TRANSCRIPTION,Description Transplant nephrectomy after rejection of renal transplant Medical Specialty Nephrology Sample Name Nephrectomy Transplant Transcription PREOPERATIVE DIAGNOSIS Rejection of renal transplant POSTOPERATIVE DIAGNOSIS Rejection of renal transplant OPERATIVE PROCEDURE Transplant nephrectomy DESCRIPTION OF PROCEDURE The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously but the ureter was wide open and there was no evidence of obstruction Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested With the patient in the supine position the previously placed nephrostomy tube was removed The patient then after adequate prepping and draping and placing of a small roll under the right hip underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space During the course of dissection the iliac artery and vein were identified as was the native ureter and the patient s ilioinguinal nerve all these were preserved The individual vessels in the kidney were identified ligated and incised and the kidney was removed The ureter was encountered during the course of resection but was not ligated The patient s retroperitoneal space was irrigated with antibiotic solution and 19 Blake drain was placed into the retroperitoneal space and the patient returned to the recovery room in good condition ESTIMATED BLOOD LOSS 900 mL Keywords nephrology renal transplant blake drain rejection iliac artery ilioinguinal immunosuppression kidney function nephrectomy nephrostomy tube retroperitoneal space toxic ureter vein transplant renal retroperitoneal kidney MEDICAL_TRANSCRIPTION,Description Patient with a diagnosis of pancreatitis developed hypotension and possible sepsis and respiratory as well as renal failure Medical Specialty Nephrology Sample Name Nephrology Consultation 2 Transcription HISTORY The patient was in the intensive care unit setting he was intubated and sedated The patient is a 55 year old patient who was admitted secondary to a diagnosis of pancreatitis developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output His creatinine has gone from 2 1 to 4 2 overnight and the patient also developed florid acidosis and hypokalemia Nephrology input has been requested for management of acute renal failure and acidosis PAST MEDICAL HISTORY 1 Pancreatitis 2 Poison ivy The patient has recently been on oral steroids 3 Hypertension MEDICATIONS Include Ambien prednisone and blood pressure medication which is not documented in the record at the moment INPATIENT MEDICATIONS Include Protonix IV half normal saline at 125 mL an hour D5W with 3 ounces of bicarbonate at 150 mL an hour The patient was initially on dopamine which has now been discontinued The patient remains on Levophed and Invanz 1 g IV q 24 h PHYSICAL EXAMINATION Vitals emergency room presentation the blood pressure was 82 45 His blood pressure in the ICU had dipped down into the 60s systolic most recent blood pressure is 108 67 and he has been maintained on 100 FiO2 The patient has had minimal urine output since admission HEENT the patient is intubated at the moment Neck examination no overt lymph node enlargement No jugular venous distention Lungs examination is benign in terms of crackles The patient has some harsh breath sounds secondary to being intubated CVS S1 and S2 are fairly regular at the moment There is no pericardial rub Abdominal examination obese but benign Extremity examination reveals no lower extremity edema CNS the patient is intubated and sedated LABORATORY DATA Blood work sodium 152 potassium 2 7 bicarbonate 13 BUN 36 and creatinine 4 2 The patient s BUN and creatinine yesterday were 23 and 2 1 respectively H H of 17 7 and 51 6 white cell count of 8 4 from earlier on this morning The patient s liver function tests are all out of whack and his alkaline phosphatase is 226 ALT is 539 CK 1103 INR 1 66 and ammonia level of 55 Latest ABGs show a pH of 7 04 bicarbonate of 10 7 pCO2 of 40 3 and pO2 of 120 7 ASSESSMENT 1 Acute renal failure which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension but the patient is at the moment on 100 FiO2 He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis The patient also has significant acidosis and his creatinine has increased from 2 1 to 4 2 overnight Given the fact that he would need dialytic support for his electrolyte derangements and for volume control I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability 2 Hypotension which is significant and is related to his sepsis Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment 3 Acidosis which is again secondary to his renal failure The patient was administered intravenous bicarbonate as mentioned above Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements 4 Pancreatitis which has been managed by his gastroenterologist 5 Sepsis the patient is on broad spectrum antibiotic therapy 6 Hypercalcemia The patient has been given calcium chloride We will need to watch for rebound hypercalcemia 7 Hypoalbuminemia 8 Hypokalemia which has been repleted RECOMMENDATIONS Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration Keywords nephrology intubated consultation hypercalcemia hypoalbuminemia iv fluid acidosis creatinine hemodiafiltration hypokalemia hypotension intravenous pancreatitis renal failure respiratory urine output continuous venovenous hemodiafiltration electrolyte derangements conventional hemodialysis continuous venovenous venovenous hemodiafiltration blood pressure venovenous bicarbonate sepsis MEDICAL_TRANSCRIPTION,Description Septic from nephrolithiasis Nephrolithiasis status post lithotripsy and stent placed in the left ureter urinary incontinence recent sepsis Medical Specialty Nephrology Sample Name Nephrolithiasis Progress Note Transcription SUBJECTIVE The patient returns today for a followup She was recently in the hospital and was found to be septic from nephrolithiasis This was all treated She did require a stent in the left ureter Dr XYZ took care of this She had a stone which was treated with lithotripsy She is now back here for followup I had written out all of her medications with their dose and schedule on a progress sheet I had given her instructions regarding follow up here and follow with Dr F Unfortunately that piece of paper was lost Somehow between the hospital and home she lost it and has not been able to find it She has no followup appointment with Dr F The day after she was dismissed her nephew called me stating that the prescriptions were lost instructions were lost etc Later she apparently found the prescriptions and they were filled She tells me she is taking the antibiotic which I believe was Levaquin and she has one more to take She had no clue as to seeing Dr XYZ again She says she is still not feeling very well and feels somewhat sick like She has no clue as to still having a ureteral stent I explained this to she and her husband again today ALLERGIES Sulfa CURRENT MEDICATIONS As I have given are Levaquin Prinivil 20 mg a day Bumex 0 5 mg a day Levsinex 0 375 mg a day cimetidine 400 mg a day potassium chloride 8 mEq a day and atenolol 25 mg a day REVIEW OF SYSTEMS She says she is voiding okay She denies fever chills or sweats OBJECTIVE General She was able to get up on the table by herself although she is quite unstable Vital Signs Blood pressure was okay at about 120 70 by me Neck Supple Lungs Clear Heart Regular rate and rhythm Abdomen Soft Extremities There is no edema IMPRESSION 1 Hypertension controlled 2 Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr F 3 Urinary incontinence 4 Recent sepsis PLAN 1 I discussed at length with she and her husband again the need to get into at least an assisted living apartment 2 I gave her instructions in writing to stop by Dr F s office on the way out today to get an appointment for followup regarding her stent 3 See me back here in two months 4 I made no changes in her medications Keywords nephrology nephrolithiasis septic lithotripsy nephrolithiasis status post lithotripsy septic from nephrolithiasis urinary incontinence incontinence atenolol stent medications MEDICAL_TRANSCRIPTION,Description Laparoscopic right radical nephrectomy due to right renal mass Medical Specialty Nephrology Sample Name Nephrectomy Radical Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOP DIAGNOSIS Right renal mass PROCEDURE PERFORMED Laparoscopic right radical nephrectomy ESTIMATED BLOOD LOSS 100 mL X RAYS None SPECIMENS Right radical nephrectomy specimen COMPLICATIONS None ANESTHESIA General endotracheal DRAINS 16 French Foley catheter per urethra BRIEF HISTORY The patient is a 71 year old woman recently diagnosed with 6 5 cm right upper pole renal mass This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma I discussed a variety of options with her and she opted to proceed with a laparoscopic right radical nephrectomy All questions were answered and she wished to proceed with surgery as planned PROCEDURE IN DETAIL After acquisition of appropriate written and informed consent and administration of perioperative antibiotics the patient was taken to the operating room and placed supine on the operating table Note that sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia After institution of adequate general anesthetic via the endotracheal route she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest All pressure points were carefully padded and she was securely taped to the table to prevent shifting during the procedure Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16 French Foley catheter per urethra to gravity drainage The abdomen was insufflated in the right outer quadrant Note that the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident We then placed a 10 12 Visiport trocar approximately 7 cm lateral to the umbilicus Once this had entered into the peritoneal cavity without incident the remaining trocars were all placed Under direct laparoscopic visualization we placed three additional trocars an 11 mm screw type trocar in the umbilicus a 6 mm screw type trocar in the upper midline approximately 7 cm above the umbilicus and 10 12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar There were some adhesions of omentum to the underside of that scar and these were taken down sharply using laparoscopic scissors We began nephrectomy procedure by reflecting the right colon by incising the white line of Toldt This exposed the retroperitoneum on the right side The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only We then identified the ureter and gonadal vein in the retroperitoneum The gonadal vein was left down along the vena cava and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum Sequential packets of tissue were taken using primarily the LigaSure Atlas device Once we got to the renal hilum it became apparent that this patient had two sets of renal arteries and veins We proceeded then and skeletonized the structures into four individual packets We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland The adrenal was spared during this procedure There was no contiguous connection between the renal mass and a right adrenal gland This plane of dissection was taken down primarily using the LigaSure device We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring Once this was completed the kidney was free except for its attachment to the ureter and lateral attachments The lateral attachments of the kidney were taken down using the LigaSure Atlas device and then the ureter was doubly clipped and transected The kidney was then freed within the retroperitoneum A 50 mm EndoCatch bag was introduced through the lower most trocar site and the kidney was placed into this bag for subsequent extraction We extended the lower most trocar site approximately 6 cm to facilitate extraction The kidney was removed and passed off the table as a specimen for pathology This was bivalved by pathology and we reviewed the specimen Keywords nephrology renal mass carter thomason endocatch bag foley catheter gi stapler laparoscopic ligasure toldt laparoscopic scissors nephrectomy radical nephrectomy screw type trocar umbilicus upper pole urethra carter thomason closure device laparoscopic right radical nephrectomy carter thomason closure carter thomason renal hilum kidney abdomen endotracheal radical oncocytoma renal MEDICAL_TRANSCRIPTION,Description Right radical nephrectomy and assisted laparoscopic approach Medical Specialty Nephrology Sample Name Nephrectomy Radical Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOPERATIVE DIAGNOSIS Right renal mass PROCEDURE Right radical nephrectomy and assisted laparoscopic approach ANESTHESIA General PROCEDURE IN DETAIL The patient underwent general anesthesia with endotracheal intubation An orogastric was placed and a Foley catheter placed He was placed in a modified flank position with the hips rotated to 45 degrees Pillow was used to prevent any pressure points He was widely shaved prepped and draped A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus The incision was made through the premarked site through the skin and subcutaneous tissue The aponeurosis of the external oblique was incised in the direction of its fibers Muscle splitting incision was made in the internal oblique and transversus abdominis The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring Then abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions Once this had been completed the scope was placed in the usual port and dissection begun by taking down the white line of Toldt so that the colon could be retracted medially This exposed the duodenum which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava Next attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down so that the psoas muscle was exposed The attachments lateral to the kidney was taken down so that the kidney could be flipped anteriorly and medially and this helped in exposing the renal artery The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device After the arteries had been divided the renal vein was divided again using a stapling device The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler and the specimen was removed Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland which was controlled with Surgicel Next the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion The estimated blood loss was negligible There were no complications The patient tolerated the procedure well and left the operating room in satisfactory condition Keywords nephrology renal mass foley catheter gerota fascia muscle splitting incision pneumo sleeve endotracheal laparoscopic nephrectomy orogastric renal fossa right lower quadrant trocar umbilicus vena cava renal pneumo radical MEDICAL_TRANSCRIPTION,Description Laparoscopic right partial nephrectomy due to right renal mass Medical Specialty Nephrology Sample Name Nephrectomy Partial Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Right renal mass POSTOPERATIVE DIAGNOSIS Right renal mass PROCEDURE PERFORMED Laparoscopic right partial nephrectomy ESTIMATED BLOOD LOSS 250 mL X RAYS None SPECIMENS Included right renal mass as well as biopsies from the base of the resection ANESTHESIA General endotracheal COMPLICATIONS None DRAINS Included a JP drain in the right flank as well as a 16 French Foley catheter per urethra BRIEF HISTORY The patient is a 60 year old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter I had a long discussion with him concerning variety of options We talked in particular about extirpated versus ablative surgery Based on his young age and excellent state of health decision was made at this point to proceed to a right partial nephrectomy laparoscopically All questions were answered and he wished to proceed with surgery as planned Note that the patient does have a positive family history of renal cell carcinoma PROCEDURE IN DETAIL After acquisition of proper informed consent and administration of perioperative antibiotics the patient was taken to the operating room and placed supine on the operating table After institution of adequate general anesthetic via endotracheal rod he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest All pressure points were carefully padded and he was securely taped to the table Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia His abdomen was then prepped and draped in a standard surgical fashion Note that a 16 French Foley catheter was in place per urethra as well as an orogastric tube The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident We then placed a Visiport 10 x 12 trocar in the right lateral abdomen With the trocar in place we were able to place the remaining trocars under direct laparoscopic visualization We placed three additional trocars An 11 mm screw type trocar at the umbilicus a 6 screw type trocar 7 cm in the midline above the umbilicus and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline The procedure was begun by reflecting the right colon by incising the white line of Toldt The colon was reflected medially and the retroperitoneum was exposed on that side This was a fairly superficial lesion so decision was made in advance to potentially not perform vascular clamping however I did feel it important to get high level control prior to proceeding to the partial With the colon reflected the duodenum was identified and it was reflected medially under Kocher maneuver The ureter and gonadal vein were identified on the right side and elevated The space between the ureter and the gonadal vein was then developed and the gonadal vein was dropped elevating only the ureter and carrying this plane dissection up towards the renal hilum Once we got up to the renal hilum we were able to skeletonize the renal hilar vessels partially and in particular we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device With the kidney free and the hilum prepared the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma and using this approach we were able to identify the 2 cm right renal mass located in the lower pole laterally A cap of fat was left overlying this mass Based on the position of the mass we performed intraoperative laparoscopic ultrasound which showed the mass to be somewhat deeper than initially anticipated Based on this finding I decided to go ahead and clamp the renal hilum during resection A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure and he also received Lasix prior to clamping the renal hilum With the renal hilum clamped we did resect the tumor using cold scissors There was somewhat more bleeding than would be expected based on the hilar clamping however we were able to successfully resect this lesion We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section With the tumor resected the base of the resection was then cauterized using the Argon beam coagulator and several bleeding vessels were oversewn using figure of eight 3 0 Vicryl sutures with lap ties for tensioning We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure We then released the vascular clamp Total clamp time was 11 minutes There was minimal bleeding and occlusion of this maneuver and after unclamping the kidney the kidney pinked up appropriately and appeared well perfused after removal of the clamp We then replaced the kidney within its Gerota envelope and closed that with 3 0 Vicryl using lap ties for tensioning A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2 0 nylon The specimen was placed into a 10 mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm It was evaluated on the table and passed off the table for Pathology to evaluate They stated that the tumor was close to the margin but there appeared to be 1 2 mm normal parenchyma around the tumor In addition the frozen section biopsies from the base of the resection were negative for renal cell carcinoma Based on these findings the lower most trocar site was closed using a running 0 Vicryl suture in the fascia We then re insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis Any bleeding points were controlled primarily using bipolar cautery or hemoclips The area was copiously irrigated with normal saline The colon was then replaced into its normal anatomic position The mesentry was evaluated There were no defects noted We closed the 10 x 12 lateral most trocar site using a Carter Thompson closure device with 0 Vicryl All trocars were removed under direct visualization and the abdomen was desufflated prior to removal of the last trocar The skin incisions were irrigated with normal saline and infiltrated with 0 25 Marcaine and the skin was closed using a running 4 0 Monocryl in subcuticular fashion Benzoin and Steri Strips were placed The patient was returned in supine position and awoken from general anesthetic without incident He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring At the end of the case sponge instrument and needle counts were correct I was scrubbed and present throughout the entire case Keywords nephrology renal mass foley catheter gerota fascia jp drain kocher maneuver laparoscopic ligasure device satinsky clamp toldt bulldogs nephrectomy renal parenchyma resection urethra vicryl sutures partial nephrectomy gonadal vein renal hilum satinsky renal kidney hilum foley endotracheal MEDICAL_TRANSCRIPTION,Description Left partial nephrectomy due to left renal mass Medical Specialty Nephrology Sample Name Nephrectomy Partial Transcription PREOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter POSTOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter OPERATION PERFORMED Left partial nephrectomy ANESTHESIA General with epidural COMPLICATIONS None ESTIMATED BLOOD LOSS About 350 mL REPLACEMENT Crystalloid and Cell Savers from the case INDICATIONS FOR SURGERY This is a 64 year old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy Due to the peripheral nature of the tumor located in the mid to lower pole laterally he has elected to undergo a partial nephrectomy Potential complications include but are not limited to 1 Infection 2 Bleeding 3 Postoperative pain 4 Herniation from the incision PROCEDURE IN DETAIL Epidural anesthesia was administered in the holding area after which the patient was transferred into the operating room General endotracheal anesthesia was administered after which the patient was positioned in the flank standard position A left flank incision was made over the area of the twelfth rib The subcutaneous space was opened by using the Bovie The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered Once the retroperitoneum had been entered the incision was extended until the peritoneal envelope could be identified The peritoneum was swept medially The Finochietto retractor was then placed for exposure The kidney was readily identified and was mobilized from outside Gerota s fascia The ureter was dissected out easily and was separated with a vessel loop The superior aspect of the kidney was mobilized from the superior attachment The pedicle of the left kidney was completely dissected revealing the vein and the artery The artery was a single artery and was dissected easily by using a right angle clamp A vessel loop was placed around the renal artery The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney The Gerota s fascia overlying that portion of the kidney was opened in the area circumferential to the tumor Once the renal capsule had been identified the capsule was scored using a Bovie about 0 5 cm lateral to the border of the tumor Bulldog clamp was then placed on the renal artery The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex This was performed by using the blunted end of the scalpel The tumor was removed easily The argon beam coagulation device was then utilized to coagulate the base of the resection The visible larger bleeding vessels were oversewn by using 4 0 Vicryl suture The edges of the kidney were then reapproximated by using 2 0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through Two horizontal mattress sutures were placed and were tied down The Gerota s fascia was then also closed by using 2 0 Vicryl suture The area of the kidney at the base was covered with Surgicel prior to tying the sutures The bulldog clamp was removed and perfect hemostasis was evident There was no evidence of violation into the calyceal system A 19 French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision The drain was anchored by using silk sutures The flank fascial layers were closed in three separate layers in the more medial aspect The lateral posterior aspect was closed in two separate layers using Vicryl sutures The skin was finally reapproximated by using metallic clips The patient tolerated the procedure well Keywords nephrology renal mass bovie finochietto retractor gerota s fascia herniation bulldog clamp needle biopsy nephrectomy partial nephrectomy renal cell carcinoma retroperitoneum vicryl suture gerota s kidney partial renal sutures vicryl MEDICAL_TRANSCRIPTION,Description Status post cadaveric kidney transplant with stable function Medical Specialty Nephrology Sample Name Kidney Transplant Followup Transcription REASON FOR VISIT Kidney transplant HISTORY OF PRESENT ILLNESS The patient is a 52 year old gentleman with ESRD secondary to hypertension status post kidney transplant in February 2006 He had to back down on his WelChol because of increased backache He actually increased his Pravachol and is tolerating this with minimal problems He comes in for followup ALLERGIES Aspirin and Altace caused cough Lipitor and Pravachol at higher doses caused myalgias Zetia caused myalgias MEDICATIONS Gengraf 125 50 mg daily CellCept 500 mg q i d acyclovir 800 mg q i d DexFol daily ferrous sulfate Mondays Wednesdays and Fridays metoprolol 50 mg b i d vitamin C daily baby aspirin 81 mg daily Bactrim Single Strength daily Cozaar 50 mg daily WelChol 625 mg daily and Pravachol 10 mg daily PAST MEDICAL HISTORY 1 ESRD secondary to hypertension 2 Cadaveric kidney in February 2006 3 Gunshot wound in Southeast Asia 4 Hyperlipidemia REVIEW OF SYSTEMS Cardiovascular No chest pain dyspnea on exertion orthopnea PND or edema GU No hematuria foamy urine pyuria frequency or dysuria He has occasional tingling over his graft but this is not bothering him today PHYSICAL EXAMINATION VITAL SIGNS Pulse 82 Blood pressure is 108 64 Weight is 64 5 kg GENERAL He is in no apparent distress HEART Regular rate and rhythm No murmurs rubs or gallops LUNGS Clear bilaterally ABDOMEN Soft nontender and nondistended Multiple scars Right lower quadrant graft is unremarkable EXTREMITIES No edema LABORATORY DATA Labs dated 07 11 06 hematocrit 34 8 sodium 137 magnesium 1 9 potassium 4 9 chloride 102 CO2 25 BUN is 37 creatinine is 1 3 calcium 10 1 phosphorus 3 7 and albumin 4 4 LFTs unremarkable Cholesterol 221 triglycerides 104 HDL 42 LDL 158 and cyclosporine 163 IMPRESSION 1 Status post cadaveric kidney transplant with stable function 2 Hypertension under excellent control 3 Hyperlipidemia not at goal He simply is not tolerating higher doses of medications PLAN 1 We will add over the counter fish oil b i d 2 Continue all current medications 3 Recheck labs today including urinalysis 4 He will see transplant in two weeks and me in four weeks We will plan to send urine for decoy cells on his next visit Keywords nephrology esrd secondary to hypertension status post cadaveric kidney transplant transplant with stable function cadaveric kidney transplant secondary to hypertension stable function cadaveric kidney kidney transplant esrd hyperlipidemia edema cadaveric welchol orthopnea kidney transplant MEDICAL_TRANSCRIPTION,Description Right hand assisted laparoscopic cryoablation of renal lesions x2 Lysis of adhesions and renal biopsy Medical Specialty Nephrology Sample Name Laparoscopic Cryoablation Transcription PREOPERATIVE DIAGNOSIS Bilateral renal mass POSTOPERATIVE DIAGNOSIS Bilateral renal mass OPERATION Right hand assisted laparoscopic cryoablation of renal lesions x2 Lysis of adhesions and renal biopsy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 100 Ml FLUIDS Crystalloid The patient was bowel prepped and was given preoperative antibiotics BRIEF HISTORY The patient is a 73 year old male who presented to us with a referral from Dr X s office with bilateral renal mass and renal insufficiency The patient s baseline creatinine was around 1 6 to 1 7 The patient was found to have a 3 to 4 cm exophytic right renal mass 1 cm renal mass inferior to that and about 2 cm left renal mass Since the patient had bilateral renal disease and the patient had renal insufficiency the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy one kidney at a time The patient understood all his options had done some research on cryotherapy and wanted to proceed with the procedure The patient had a renal biopsy done which showed a possibility of an oncocytoma which also would indicate that if this is not truly a cancerous lesion but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney Risk of anesthesia bleeding infection pain hernia bowel obstruction ileus injury to bowel postoperative bleeding etc were discussed The patient understood the risk of delayed bleeding the needing for nephrectomy renal failure renal insufficiency etc and wanted to proceed with the procedure DETAILS OF THE OR The patient was brought to the OR Anesthesia was applied The patient was given preoperative antibiotics The patient was bowel prepped The patient was placed in right side up left side down semiflank with kidney rest up All the pressure points are very well padded using foam and towels The left knee was bent and the right knee was straight There was no tension on any of the joints All pressure points were well padded The patient was taped to the table using 2 inch wide tape all the way around A Foley catheter and OG tube were in place prior to prepping and draping the patient A periumbilical incision measuring about 6 cm was made The incision was carried through the subcutaneous tissue through the fascia using sharp dissection The peritoneum was open Abdomen was entered There were some adhesions on the right side of the abdomen which were released using metz Two 12 mm ports were placed in the anteroaxillary line and one in the midclavicular line A gel porter was placed Pneumoperitoneum was obtained All ports were placed under direct vision and the right colon was reflected medially Duodenum was cauterized Minimal dissection was done on the hilum and the Gerota s was opened laterally and the renal masses were clearly visualized all the way around Pictures were taken Superficial biopsies were taken of 2 renal lesions using 3 different probes The 2 lesions were frozen The 2 probes were 2 4 mm and the other one was 3 1 mm in diameter So the R3 8 and R2 4 long probes were used Freezing thawing two cycles were done The temperatures were 131 137 150 and the freezing time was 5 and 10 minutes each and passive sign was done The exact times or exact temperatures are on the chart There was a nice ice ball with each freezing and with passive sign The probes were removed The probes were placed directly percutaneously through the skin into the renal lesions After freezing thawing the probes were removed and to seal with Surgicel were placed Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding From the time the probes were removed until the time the laparoscope was removed was total of 30 minutes So the masses were visualized for a total of 30 minutes without any pneumoperitoneum Pneumoperitoneum was obtained again Fibrin glue was placed over it just for precautionary measure There was about a total of 100 mL of blood loss overall with the entire procedure Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ The kidney was kept in the left hand at all times Careful attention was drawn to make sure that the probe was deep enough at least 3 5 to 4 cm in to get the medial aspect of the tumors frozen The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions At the end of the procedure after freezing thawing and putting the fibrin glue Surgicel and EndoSeal the colon was reflected medially Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel Lap count was correct Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions No deeper biopsies were done to minimize the risk of bleeding The 12 mm ports were closed using 0 Vicryl and the middle incision The hand port incision was closed using looped 1 PDS from both sides and was tied in the middle Please note that the pneumoperitoneum was closed using 0 Vicryl in running fashion After closing the abdomen 4 0 Monocryl was used to close the skin and Dermabond was applied The patient was brought to recovery in a stable condition Keywords nephrology hand assisted laparoscopic cryoablation laparoscopic cryoablation bilateral renal mass fibrin glue laparoscopic cryoablation renal insufficiency renal lesions renal biopsy renal mass insufficiency renal freezing thawing lesions MEDICAL_TRANSCRIPTION,Description Left laparoscopic hand assisted nephrectomy Medical Specialty Nephrology Sample Name Nephrectomy Transcription PREOPERATIVE DIAGNOSIS Left renal mass left renal bleed POSTOPERATIVE DIAGNOSIS Left renal mass left renal bleed PROCEDURE PERFORMED Left laparoscopic hand assisted nephrectomy ANESTHESIA General endotracheal EBL 100 mL The patient had a triple lumen catheter A line placed BRIEF HISTORY The patient is a 54 year old female with history of diabetic nephropathy diabetes hypertension left BKA who presented with abdominal pain with left renal bleed The patient was found to have a complex mass in the upper pole and the lower pole of the kidney MRI and CAT scan showed questionable renal mass which could be malignant Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy At this point the patient was unable to go home The patient continually complained of pain The patient required about 3 to 4 units of blood transfusions prior The patient initially came in with hemoglobin less than 5 The hemoglobin prior to surgery was 10 Risks of anesthesia bleeding infection pain MI DVT PE respiratory failure morbidity and mortality of the procedure due to her low ejection fraction were discussed Cardiac clearance was obtained The patient was high risk family and the patient knew about the risk The recommendation from the pulmonologist cardiologist and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention The patient and family understood all the risks and benefits in order to proceed with the surgery DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient had A line triple lumen catheter The patient was placed in left side up right side down oblique position All the pressure points were well padded The right fistula was carefully padded completely around it Axilla was protected The fistula was checked throughout the procedure to ensure that it was stable The arms ankles knees and joints were all padded with foam The patient was taped to the table using 2 inch wide tape OG and a Foley catheter were in place A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply There were some adhesions where the omentum was into the umbilical hernia which was completely stuck The omentum was released out of that just so we could obtain pneumoperitoneum Pneumoperitoneum was obtained after using GelPort Two 12 mm ports were placed in the left anterior axillary line and mid clavicular line The colon was reflected medially Kidney was dissected laterally behind and inferiorly There was large hematoma visualized with significant amount of old blood which was irrigated out Dissection was carried superiorly and the spleen was reflected medially The spleen and colon were all intact at the end of the procedure They were stable all throughout Using endovascular GIA stapler all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve Hemostasis was obtained The renal vein and the renal artery were stapled and there was excellent hemostasis The dissection was carried lateral to the adrenal and medial to the right kidney The adrenal was preserved The entire kidney was removed through the hand port Irrigation was performed There was excellent hemostasis at the end of the nephrectomy Fibrin glue and Surgicel were applied just in case the patient had delayed DIC The colon was placed back and 12 mm ports were closed under direct palpation using 0 Vicryl The fascia was closed using loop 1 PDS in a running fashion and was tied in the middle Please note that prior to the fascial closure the peritoneum was closed using 0 Vicryl in running fashion The subcuticular tissue was brought together using 4 0 Vicryl The skin was closed using 4 0 Monocryl Dermabond was applied The patient was brought to the recovery in a stable condition Keywords nephrology laparoscopic nephrectomy laparoscopic hand assisted nephrectomy triple lumen catheter lumen catheter running fashion renal mass renal bleed dissection hemostasis kidney renal MEDICAL_TRANSCRIPTION,Description Laparoscopic lysis of adhesions attempted laparoscopic pyeloplasty and open laparoscopic pyeloplasty Right ureteropelvic junction obstruction severe intraabdominal adhesions and retroperitoneal fibrosis Medical Specialty Nephrology Sample Name Laparoscopic Pyeloplasty Transcription PREOPERATIVE DIAGNOSIS Right ureteropelvic junction obstruction POSTOPERATIVE DIAGNOSES 1 Right ureteropelvic junction obstruction 2 Severe intraabdominal adhesions 3 Retroperitoneal fibrosis PROCEDURES PERFORMED 1 Laparoscopic lysis of adhesions 2 Attempted laparoscopic pyeloplasty 3 Open laparoscopic pyeloplasty ANESTHESIA General INDICATION FOR PROCEDURE This is a 62 year old female with a history of right ureteropelvic junction obstruction with chronic indwelling double J ureteral stent The patient presents for laparoscopic pyeloplasty PROCEDURE After informed consent was obtained the patient was taken to the operative suite and administered general anesthetic The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient s positioning for bowel retraction Hassan technique was performed for the initial trocar placement in the periumbilical region Abdominal insufflation was performed There were significant adhesions noted A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two and half hours also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus an additional 5 mm port in the right upper quadrant subcostal and midclavicular After adhesions were taken down the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially The kidney was able to be palpated within Gerota s fascia The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction The renal pelvis was also identified and dissected free There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open An incision was made from the right upper quadrant port extending towards the midline This was carried down through the subcutaneous tissue anterior fascia muscle layers posterior fascia and peritoneum A Bookwalter retractor was placed The renal pelvis and the ureter were again identified Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery The tissue was sent down to Pathology for analysis Please note that upon entering the abdomen all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue At this point the indwelling double J ureteral stent was removed At this time the ureter was spatulated laterally and at the apex of this spatulation a 4 0 Vicryl suture was placed This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated The back wall of the ureteropelvic anastomosis was then approximated with running 4 0 Vicryl suture At this point a double J stent was placed with a guidewire down into the bladder The anterior wall of the uteropelvic anastomosis was then closed again with a 4 0 running Vicryl suture Renal sinus fat was then placed around the anastomosis and sutured in place Please note in the inferior pole of the kidney there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue This was repaired with horizontal mattress sutures 2 0 Vicryl FloSeal was placed over this and the renal capsule was placed over this A good hemostasis was noted A 10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis The initial trocar incision was closed with 0 Vicryl suture The abdominal incision was also then closed with running 0 Vicryl suture incorporating all layers of muscle and fascia The Scarpa s fascia was then closed with interrupted 3 0 Vicryl suture The skin edges were then closed with staples Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator We placed the patient on IV antibiotics and pain medications We will obtain KUB and x rays for stent placement Further recommendations to follow Keywords nephrology retroperitoneal fibrosis pyeloplasty laparoscopic lysis of adhesions ureteropelvic junction obstruction laparoscopic pyeloplasty ureteropelvic junction junction ureteropelvic intraabdominal adhesions MEDICAL_TRANSCRIPTION,Description Insertion of left femoral circle C catheter indwelling catheter Chronic renal failure The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm A Cath was situated Medical Specialty Nephrology Sample Name Indwelling Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Chronic renal failure POSTOPERATIVE DIAGNOSIS Chronic renal failure PROCEDURE PERFORMED Insertion of left femoral circle C catheter ANESTHESIA 1 lidocaine ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None HISTORY The patient is a 36 year old African American male presented to ABCD General Hospital on 08 30 2003 for evaluation of elevated temperature He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm A Cath was situated He did require a short term of Levophed for hypotension He is felt to have an infected dialysis catheter which was removed He was planned to undergo replacement of his Perm A Cath dialysis catheter however this was not possible He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long term indwelling catheter can be established for dialysis He was explained the risks benefits and complications of the procedure previously He gave us informed consent to proceed OPERATIVE PROCEDURE The patient was placed in the supine position The left inguinal region was shaved His left groin was then prepped and draped in normal sterile fashion with Betadine solution Utilizing 1 lidocaine the skin and subcutaneous tissue were anesthetized with 1 lidocaine Under direct aspiration technique the left femoral vein was cannulated Next utilizing an 18 gauge Cook needle the left femoral vein was cannulated Sutures were removed nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter The needle was then removed Utilizing 11 blade scalpel a small skin incision was made adjacent to the catheter Utilizing a 10 French dilator the skin subcutaneous tissue and left femoral vein were dilated over the Seldinger guidewire Dilator was removed and a preflushed circle C 8 inch catheter was inserted over the Seldinger guidewire The guidewire was retracted out from the blue distal port and grasped The catheter was then placed in the left femoral vessel _______ This catheter was then fixed to the skin with 3 0 silk suture A mesenteric dressing was then placed over the catheter site The patient tolerated the procedure well He was turned to the upright position without difficulty He will undergo dialysis today per Nephrology Keywords nephrology chronic renal failure femoral circle c catheter indwelling catheter catheter insertion seldinger guidewire indwelling femoral dialysis MEDICAL_TRANSCRIPTION,Description Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein End stage renal disease with failing AV dialysis fistula Medical Specialty Nephrology Sample Name Hemodialysis Fistula Construction Transcription PREOPERATIVE DIAGNOSIS End stage renal disease with failing AV dialysis fistula POSTOPERATIVE DIAGNOSIS End stage renal disease with failing AV dialysis fistula PROCEDURE Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein ANESTHESIA Endotracheal DESCRIPTION OF OPERATIVE PROCEDURE General endotracheal anesthesia was initiated without difficulty The right arm axilla and chest wall were prepped and draped in sterile fashion Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent The draining veins are the deep brachial veins The primary vein was carefully dissected out and small tributaries clamped divided and ligated with 3 0 Vicryl suture A nice length of vein was obtained to the distal one third of the arm This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein which remains patent through a small collateral vein A transverse skin incision was made over the superior aspect of the old fistula vein This vein was carefully dissected out and encircled with vascular tapes The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula The patient was sensible was then systemically heparinized The existing fistula vein was clamped proximally and distally incised longitudinally for about a centimeter The brachial vein end was spatulated Subsequently a branchial vein to arterialized fistula vein anastomosis was then constructed using running 6 0 Prolene suture in routine fashion After the completion of the anastomosis the fistula vein was forebled and the branchial vein backbled The anastomosis was completed A nice thrill could be palpated over the outflow brachial vein Hemostasis was noted A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with 3 0 nylon suture The wounds were then closed using interrupted 4 0 Vicryl and deep subcutaneous tissue ___ staples closed the skin Sterile dressings were applied The patient was then x ray d and taken to Recovery in satisfactory condition Estimated blood loss 50 mL drains 8 mm Blake Operative complication none apparent final sponge needle and instrument counts reported as correct Keywords nephrology end stage renal disease av dialysis fistula brachial vein upper arm hemodialysis fistula fistula vein hemodialysis av dialysis anastomosis brachial MEDICAL_TRANSCRIPTION,Description Acute on chronic renal failure and uremia Insertion of a right internal jugular vein hemodialysis catheter Medical Specialty Nephrology Sample Name Internal Jugular Vein Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Acute on chronic renal failure 2 Uremia POSTOPERATIVE DIAGNOSES 1 Acute on chronic renal failure 2 Uremia PROCEDURE PERFORMED Insertion of a right internal jugular vein hemodialysis catheter ANESTHESIA 1 local lidocaine BLOOD LOSS Less than 5 cc COMPLICATIONS None HISTORY The patient is a 74 year old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time He is slightly short of breath with mild difficulty in breathing A pre procedure x ray was obtained which showed no pneumothorax He did have a significant right pleural effusion and a mild left pleural effusion We decided to insert the catheter on the right side PROCEDURE The patient was prepped and draped in the usual sterile fashion 1 lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein Using the same anesthetic needle the right internal jugular vein was used to cannulate with good venous blood return The tract was noted The needle was removed and a second 18 gauge thin walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty The needle was removed and an 11 blade was used to make a small skin incision provided skin and vein dilators were used The circle C 8 inch hemodialysis catheter was then inserted over the guidewire without difficulty The guidewire was removed Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty The ports were flushed with injectable normal saline secondary to the patient going for dialysis today Thus he will not need heparinization of the lines Again he tolerated the procedure well A postoperative x ray would be obtained to check catheter placement and rule out pneumothorax Keywords nephrology uremia internal jugular vein hemodialysis catheter pneumothorax jugular vein dialysis chronic renal failure internal jugular vein pleural effusion hemodialysis catheter renal failure cannulate guidewire insertion jugular catheter hemodialysis vein MEDICAL_TRANSCRIPTION,Description Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore Tex graft Chronic renal failure and thrombosed left forearm arteriovenous Gore Tex bridge fistula Medical Specialty Nephrology Sample Name Fogarty Thrombectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula POSTOPERATIVE DIAGNOSIS 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula PROCEDURE PERFORMED 1 Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula 2 Revision of distal anastomosis with 7 mm interposition Gore Tex graft ANESTHESIA General with controlled ventillation GROSS FINDINGS The patient is a 58 year old black male with chronic renal failure He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality OPERATIVE PROCEDURE The patient was taken to the OR suite placed in supine position General anesthetic was administered Left arm was prepped and draped in appropriate manner A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop Transverse graftotomy was created A 4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow A fistulogram was performed and the above findings were noted In a retrograde fashion the proximal anastomosis was patent There was no narrowing within the forearm graft Both veins were flushed with heparinized saline and controlled with a vascular clamp A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia Utilizing both blunt and sharp dissection the brachial vein as well as distal anastomosis was isolated The distal anastomosis amputated off the fistula and oversewn with continuous running 6 0 Prolene suture tied upon itself The vein was controlled with vascular clamps Longitudinal venotomy created along the anteromedial wall A 7 mm graft was brought on to the field and this was cut to shape and size This was sewed to the graft in an end to side fashion with U clips anchoring the graft at the heel and toe with interrupted 6 0 Prolene sutures Good backflow bleeding was confirmed The vein flushed with heparinized saline and graft was controlled with vascular clamp The end of the insertion graft was cut to shape in length and sutured to the graft in an end to end fashion with continuous running 6 0 Prolene suture Good backflow bleeding was confirmed The graftotomy was then closed with interrupted 6 0 Prolene suture Flow through the fistula was permitted a good flow passed The wound was copiously irrigated with antibiotic solution Sponge needles instrument counts were correct All surgical sites were inspected Good hemostasis was noted The incision was closed in layers with absorbable sutures Sterile dressing was applied The patient tolerated the procedure well and returned to the recovery room in apparent stable condition Keywords nephrology chronic renal failure thrombosed gore tex bridge fistula arteriovenous fogarty thrombectomy anastomosis gore tex bridge fogarty thrombectomy prolene suture renal failure distal anastomosis bridge fistula interposition renal prolene MEDICAL_TRANSCRIPTION,Description Urine leaked around the ostomy site for his right sided nephrostomy tube The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure Medical Specialty Nephrology Sample Name Leaking Nephrostomy Tube Transcription CHIEF COMPLAINT Leaking nephrostomy tube HISTORY OF PRESENT ILLNESS This 61 year old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube The leaking began this a m The patient denies any pain does not have fever and has no other problems or complaints The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure The patient states he feels like his usual self and has no other problems or concerns The patient denies any fever or chills No nausea or vomiting No flank pain no abdominal pain no chest pain no shortness of breath no swelling to the legs REVIEW OF SYSTEMS Review of systems otherwise negative and noncontributory PAST MEDICAL HISTORY Metastatic prostate cancer anemia hypertension MEDICATIONS Medication reconciliation sheet has been reviewed on the nurses note ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a nonsmoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 7 oral blood pressure 150 85 pulse is 91 respirations 16 oxygen saturation 97 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed appears to be healthy calm comfortable no acute distress looks well HEENT Eyes are normal with clear sclerae and cornea NECK Supple full range of motion CARDIOVASCULAR Heart has regular rate and rhythm without murmur rub or gallop Peripheral pulses are 2 No dependent edema RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender nondistended No rebound or guarding Normal benign abdominal exam MUSCULOSKELETAL The patient has nontender back and flank No abnormalities noted to the back other than the bilateral nephrostomy tubes The nephrostomy tube left has no abnormalities no sign of infection No leaking of urine nontender nephrostomy tube on the right has a damp dressing which has a small amount of urine soaked into it There is no obvious active leak from the ostomy site No sign of infection No erythema swelling or tenderness The collection bag is full of clear urine The patient has no abnormalities on his legs SKIN No rashes or lesions No sign of infection NEUROLOGIC Motor and sensory are intact to the extremities The patient has normal ambulation normal speech PSYCHIATRIC Alert and oriented x4 Normal mood and affect HEMATOLOGIC AND LYMPHATIC No bleeding or bruising EMERGENCY DEPARTMENT COURSE Reviewed the patient s admission record from one month ago when he was admitted for the placement of the nephrostomy tubes both Dr X and Dr Y have been consulted and both had recommended nephrostomy tubes there was not the name mentioned as to who placed the nephrostomy tubes There was no consultation dictated for this and no name was mentioned in the discharge summary paged Dr X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes Dr A responded to the page and recommended __________ off a BMP and discussing it with Dr B the radiologist as he recalled that this was the physician who placed the nephrostomy tubes paged Dr X and received a call back from Dr X Dr X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a m tomorrow This was discussed with the patient and instructions to return to the hospital at 10 a m to have this tube changed out by Dr X was explained and understood DIAGNOSES 1 WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE 2 PROSTATE CANCER METASTATIC 3 URETERAL OBSTRUCTION The patient on discharge is stable and dispositioned to home PLAN We will have the patient return to the hospital tomorrow at 10 a m for the replacement of his right nephrostomy tube by Dr X The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns Keywords nephrology nephrostomy site ureteral obstruction leaking nephrostomy tube acute renal failure bilateral nephrostomy ureteral obstructions nephrostomy tube tube nephrostomy ureteral prostate leaking urine tubes MEDICAL_TRANSCRIPTION,Description Patient with left renal cell carcinoma left renal cyst had robotic Assisted laparoscopic left renal cyst decortication and cystoscopy Medical Specialty Nephrology Sample Name Discharge Summary Nephrology Transcription ADMITTING DIAGNOSES Left renal cell carcinoma left renal cyst DISCHARGE DIAGNOSIS Left renal cell carcinoma left renal cyst SECONDARY DIAGNOSES 1 Chronic obstructive pulmonary disease 2 Coronary artery disease PROCEDURES Robotic Assisted laparoscopic left renal cyst decortication and cystoscopy HISTORY OF PRESENT ILLNESS Mr ABC is a 70 year old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts He has undergone MRI of the abdomen on June 18 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma Of note there are no other enhancing solid masses seen on this MRI After discussion of multiple management strategies with the patient including 1 Left partial nephrectomy 2 Left radical nephrectomy 3 Left renal cyst decortication The patient is likely to undergo the latter procedure HOSPITAL COURSE The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy Intraoperatively approximately four enlarged renal cysts and six smaller renal cysts were initially removed The contents were aspirated and careful dissection of the cyst wall was performed Multiple specimens of the cyst wall were sent for pathology Approximately one liter of cystic fluid was drained during the procedure The renal bed was inspected for hemostasis which appear to be adequate There were no complications with the procedure Single JP drain was left in place Additionally the patient underwent flexible cystoscopy which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra Furthermore no gross lesions were encountered in the bladder The patient left OR with transfer to the PACU and subsequently to the hospital floor The patient s postoperative course was relatively uneventful His diet and activity were gradually advanced without complication On postoperative day 2 he was passing flatus and has had bowel movements His Jackson Pratt drain was discontinued on postoperative day 3 that being the day of discharge His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly At the time of discharge he was afebrile His vital signs indicated hemodynamic stability and he had no evidence of infection The patient was instructed to follow up with Dr XYZ on 8 12 2008 at 1 50 p m and was given prescription for pain medications as well as laxative DISPOSITION To home DISCHARGE CONDITION Good MEDICATIONS Please see attached medication list INSTRUCTIONS The patient was instructed to contact Dr XYZ s office for fever greater than 101 5 intractable pain nausea vomiting or any other concerns FOLLOWUP The patient will follow up with Dr XYZ for a postoperative check on 08 12 2008 at 1 50 p m and he was made aware of this appointment Keywords nephrology decortication cystoscopy pain nausea vomiting renal cyst decortication renal cell carcinoma robotic assisted renal cyst renal robotic laparoscopic nephrectomy cysts cell carcinoma discharge MEDICAL_TRANSCRIPTION,Description The patient is being discharged for continued hemodialysis and rehab Medical Specialty Nephrology Sample Name Discharge Summary Hemodialysis Transcription DISCHARGE DIAGNOSES 1 End stage renal disease on hemodialysis 2 History of T9 vertebral fracture 3 Diskitis 4 Thrombocytopenia 5 Congestive heart failure with ejection fraction of approximately 30 6 Diabetes type 2 7 Protein malnourishment 8 History of anemia HISTORY AND HOSPITAL COURSE The patient is a 77 year old white male who presented to Hospital of Bossier on April 14 2008 The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy which was the cause of need for continued hospitalization He also needed to continue with dialysis and he needed to improve his rehabilitation The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles He did have some bouts of issues with constipation on and off throughout his hospitalization but this seemed to come under control with more aggressive management The patient had remained afebrile He did also have a bout with some episodic confusion problems which appeared to be more of a sundowner type of a problem but this too cleared with his stay here at Promise On the day of discharge on May 9 2008 the patient was in good spirits was very clear and lucid He denied any complaints of pain He did have some trouble with sleep at night at times but I think this was mainly tied into the fact that he sleeps a lot during the day The patient has increased his appetite some and has been eating some His vital signs remain stable His blood pressure on discharge was 126 63 heart rate is 80 respiratory rate of 20 and temperature was 98 3 PPD was negative An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise The patient and his family understood our plan and agreed with it He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him He did not have any acute questions as to where he was going and what the next step of his care would be but we did discuss this at length prior to date of discharge Keywords nephrology end stage renal disease thrombocytopenia anemia hospitalization hemodialysis and rehab hemodialysis MEDICAL_TRANSCRIPTION,Description Cystourethroscopy right retrograde pyelogram right ureteral pyeloscopy right renal biopsy and right double J 4 5 x 26 mm ureteral stent placement Right renal mass and ureteropelvic junction obstruction and hematuria Medical Specialty Nephrology Sample Name Cystourethroscopy Retrograde Pyelogram 1 Transcription PREOPERATIVE DIAGNOSES 1 Right renal mass 2 Hematuria POSTOPERATIVE DIAGNOSES 1 Right renal mass 2 Right ureteropelvic junction obstruction PROCEDURES PERFORMED 1 Cystourethroscopy 2 Right retrograde pyelogram 3 Right ureteral pyeloscopy 4 Right renal biopsy 5 Right double J 4 5 x 26 mm ureteral stent placement ANESTHESIA Sedation SPECIMEN Urine for cytology and culture sensitivity right renal pelvis urine for cytology and right upper pole biopsies INDICATION The patient is a 74 year old male who was initially seen in the office with hematuria He was then brought to the hospital for other medical problems and found to still have hematuria He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation PROCEDURE After consent was obtained the patient was brought to the operating room and placed in the supine position He was given IV sedation and placed in dorsal lithotomy position He was then prepped and draped in the standard fashion A 21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder The patient was noted to have mildly enlarged prostate however it was non obstructing Upon visualization of the bladder the patient was noted to have some tuberculation to the bladder There were no masses or any other abnormalities noted other than the tuberculation Attention was then turned to the right ureteral orifice and an open end of the catheter was then passed into the right ureteral orifice A retrograde pyelogram was performed Upon visualization there was no visualization of the upper collecting system on the right side At this point a guidewire was then passed through the open end of the ureteral catheter and the catheter was removed The bladder was drained and the cystoscope was removed The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction The wire was then again passed through the flexible scope and the flexible scope was removed A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system Upon visualization of the collecting system of the upper portion there was noted to be papillary mass within the collecting system The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass Once this was done the wire was left in place and the ureteroscope was removed The cystoscope was then placed back into the bladder and a 26 x 4 5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis The stent was noted to be clear within the right renal pelvis as well as in the bladder The bladder was drained and the cystoscope was removed The patient tolerated the procedure well He will be transferred to the recovery room and back to his room It has been discussed with his primary physician that the patient will likely need a nephrectomy He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday Keywords nephrology renal mass hematuria ureteropelvic junction obstruction cystourethroscopy retrograde pyelogram ureteral pyeloscopy renal biopsy double j ureteral stent placement ureteropelvic junction flexible scope papillary mass ureteral stent renal pelvis ureteral orifice amplatz wire retrograde pyelogram ureteral cystoscope ureteroscope renal bladder MEDICAL_TRANSCRIPTION,Description Cystourethroscopy bilateral retrograde pyelogram and transurethral resection of bladder tumor of 1 5 cm in size Recurrent bladder tumor and history of bladder carcinoma Medical Specialty Nephrology Sample Name Cystourethroscopy Retrograde Pyelogram Transcription PREOPERATIVE DIAGNOSES 1 Recurrent bladder tumor 2 History of bladder carcinoma POSTOPERATIVE DIAGNOSIS Keywords nephrology recurrent bladder tumor bladder carcinoma bilateral retrograde pyelogram transurethral resection of bladder tumor lateral wall bladder tumor transurethral resection retrograde pyelogram tumor bladder cystourethroscopy pyelogram MEDICAL_TRANSCRIPTION,Description Common Excretory Urogram IVP template Medical Specialty Nephrology Sample Name Excretory Urogram IVP Transcription There is normal and symmetrical filling of the caliceal system Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects The postvoid films demonstrate normal emptying of the collecting system including the urinary bladder IMPRESSION Negative intravenous urogram Keywords nephrology intravenous urogram caliceal system urinary bladder excretory urogram collecting systems ivp urogram intravenousNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder Medical Specialty Nephrology Sample Name Cystopyelogram 1 Transcription PREOPERATIVE DIAGNOSIS Gross hematuria POSTOPERATIVE DIAGNOSIS Gross hematuria OPERATIONS Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder ANESTHESIA Spinal FINDINGS Significant amount of bladder clots measuring about 150 to 200 mL two cupful of clots were removed There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side The right ureteral opening was difficult to visualize the left one was normal BRIEF HISTORY The patient is a 78 year old male with history of gross hematuria and recurrent UTIs The patient had hematuria Cystoscopy revealed atypical biopsy The patient came in again with gross hematuria The first biopsy was done about a month ago The patient was to come back and have repeat biopsies done but before that came into the hospital with gross hematuria The options of watchful waiting removal of the clots and biopsies were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed Morbidity and mortality of the procedure were discussed Consent was obtained from the daughter in law who has the power of attorney in Florida DESCRIPTION OF PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in the dorsal lithotomy position The patient was prepped and draped in the usual sterile fashion The patient had been off of the Coumadin for about 4 days and INR had been reversed The patient has significant amount of clot upon entering the bladder There was a tight bladder neck contracture The prostate was not enlarged Using ACMI 24 French sheath using Ellick irrigation about 2 cupful of clots were removed It took about half an hour to just remove the clots After removing the clots using 24 French cutting loop resectoscope tumor on the left upper wall near the dome or near the 2 o clock position was resected This was lateral to the left ureteral opening The base was coagulated for hemostasis Same thing was done at 10 o clock on the right side where there was some tumor that was visualized The back wall and the rest of the bladder appeared normal Using 8 French cone tip catheter left sided pyelogram was normal The right sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots The contrast did go up to what appeared to be the right ureteral opening but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening A little bit of contrast went out but the force was not made just to avoid any secondary stricture formation The patient did have CT with contrast which showed that the kidneys were normal At this time a 24 three way irrigation was started The patient was brought to Recovery room in stable condition Keywords nephrology clot evacuation transurethral resection bladder tumor bladder neck gross hematuria bladder cystopyelogram hematuria clots MEDICAL_TRANSCRIPTION,Description Right hydronephrosis right flank pain atypical dysplastic urine cytology extrarenal pelvis on the right no evidence of obstruction or ureteral bladder lesions Cystoscopy bilateral retrograde ureteropyelograms right ureteral barbotage for urine cytology and right ureterorenoscopy Medical Specialty Nephrology Sample Name Cystoscopy Ureteropyelogram Ureteral Barbotage Transcription PREOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology POSTOPERATIVE DIAGNOSES 1 Right hydronephrosis 2 Right flank pain 3 Atypical dysplastic urine cytology 4 Extrarenal pelvis on the right 5 No evidence of obstruction or ureteral bladder lesions PROCEDURE PERFORMED 1 Cystoscopy 2 Bilateral retrograde ureteropyelograms 3 Right ureteral barbotage for urine cytology 4 Right ureterorenoscopy diagnostic ANESTHESIA Spinal SPECIMEN TO PATHOLOGY Urine and saline wash barbotage from right ureter through the ureteral catheter ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE This is a 70 year old female who reports progressive intermittent right flank pain associated with significant discomfort and disability She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone She has some ureteral thickening in her distal right ureter She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia associated karyotypic profile She was brought to the operating room for further evaluation and treatment DESCRIPTION OF OPERATION After preoperative counseling the patient was taken to the operating room and administered a spinal anesthesia She was placed in the lithotomy position prepped and draped in the usual sterile fashion The 21 French cystoscope was inserted per urethra into the bladder The bladder was inspected and found to be without evidence of intravesical tumors stones or mucosal abnormalities The right ureteral orifice was visualized and cannulated with an open ended ureteral catheter This was gently advanced to the mid ureter Urine was collected for cytology Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter An 0 038 guidewire was then passed up through the open ended ureteral catheter The open ended ureteral catheter and cystoscope were removed and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis Using direct vision and fluoroscopy to confirm location the entire renal pelvis and calyces were inspected The renal pelvis demonstrated an extrarenal pelvis but no evidence of obstruction at the renal UPJ level There were no intrapelvic or calyceal stones The ureter demonstrated no significant mucosal abnormalities no visible tumors and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate The ureteroscope was then removed The cystoscope was reinserted Once again retrograde injection of contrast through an open ended ureteral catheter was undertaken in the right ureter and collecting system No evidence of extravasation or significant change in anatomy was visualized The left ureteral orifice was then visualized and cannulated with an open ended ureteral catheter and retrograde injection of contrast demonstrated a normal left ureter and collecting system The cystoscope was removed Foley catheter was inserted The patient was placed in the supine position and transferred to the recovery room in satisfactory condition Keywords nephrology hydronephrosis ureteropyelogram ureterorenoscopy flank pain renal pelvis urine cytology ureteral cystoscopy barbotage cystoscope retrograde urine MEDICAL_TRANSCRIPTION,Description Right lower pole renal stone and possibly infected stent Cysto stent removal Medical Specialty Nephrology Sample Name Cysto Stent Removal Transcription PREOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent POSTOPERATIVE DIAGNOSIS Right lower pole renal stone and possibly infected stent OPERATION Cysto stent removal ANESTHESIA Local MAC ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid MEDICATIONS The patient was on vancomycin and Levaquin was given x1 dose The patient was on vancomycin for the last 5 days BRIEF HISTORY The patient is a 53 year old female who presented with Enterococcus urosepsis CT scan showed a lower pole stone with a stent in place The stent was placed about 2 months ago but when patient came in with a possibly UPJ stone with fevers of unknown etiology The patient had a stent placed at that time due to the fevers thinking that this was an urospetic stone There was some pus that came out The patient was cultured actually it was negative at that time The patient subsequently was found to have lower extremity DVT and then was started on Coumadin The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE The repeat films were taken which showed the stone had migrated into the pole The stent was intact The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin Cipro and Levaquin where treatment was little bit more complicated Due to drug interaction the patient was admitted for IV antibiotic treatment The thinking was that either the stone or the stent is infected since the stone is pretty small in size the stent is very likely possibility that it could have been infected and now it needs to be removed Since the stone is not obstructing there is no reason to replace the stent at this time We are unable to do the ureteroscopy or the shock wave lithotripsy when the patient is fully anticoagulated So the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin which would be probably about 4 months down the road Plan is to get rid of the stent and improve patient s urinary symptoms and to get rid of the infection and we will worry about the stone at later point DETAILS OF THE OR Consent had been obtained from the patient Risks benefits and options were discussed Risk of anesthesia bleeding infection pain MI DVT and PE were discussed The patient understood all the risks and benefits of removing the stent and wanted to proceed The patient was brought to the OR The patient was placed in dorsal lithotomy position The patient was given some IV pain meds The patient had received vancomycin and Levaquin preop Cystoscopy was performed using graspers The stent was removed without difficulty Plan was for repeat cultures and continuation of the IV antibiotics Keywords nephrology infected stent cysto stent removal cysto stent renal stone lower pole infected stone stent cysto MEDICAL_TRANSCRIPTION,Description Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached Medical Specialty Nephrology Sample Name Cystopyelogram Transcription PREOPERATIVE DIAGNOSIS Left distal ureteral stone POSTOPERATIVE DIAGNOSIS Left distal ureteral stone PROCEDURE PERFORMED Cystopyelogram left ureteroscopy laser lithotripsy stone basket extraction stent exchange with a string attached ANESTHESIA LMA EBL Minimal FLUIDS Crystalloid The patient was given antibiotics 1 g of Ancef and the patient was on oral antibiotics at home BRIEF HISTORY The patient is a 61 year old female with history of recurrent uroseptic stones The patient had stones x2 1 was already removed second one came down had recurrent episode of sepsis stent was placed Options were given such as watchful waiting laser lithotripsy shockwave lithotripsy etc Risks of anesthesia bleeding infection pain need for stent and removal of the stent were discussed The patient understood and wanted to proceed with the procedure DETAILS OF THE PROCEDURE The patient was brought to the OR Anesthesia was applied The patient was placed in dorsal lithotomy position The patient was prepped and draped in usual sterile fashion A 0 035 glidewire was placed in the left system Using graspers left sided stent was removed A semirigid ureteroscopy was done A stone was visualized in the mid to upper ureter Using laser the stone was broken into 5 to 6 small pieces Using basket extraction all the pieces were removed Ureteroscopy all the way up to the UPJ was done which was negative There were no further stones Using pyelograms the rest of the system appeared normal The entire ureter on the left side was open and patent There were no further stones Due to the edema and the surgery plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours Over the 0 035 glidewire a 26 double J stent was placed There was a nice curl in the kidney and one in the bladder The patient tolerated the procedure well Please note that the string was kept in place and the patient was to remove the stent the next day The patient s family was instructed how to do so The patient had antibiotics and pain medications at home The patient was brought to recovery room in a stable condition Keywords nephrology laser lithotripsy shockwave lithotripsy double j stent distal ureteral stone ureteral stone basket extraction cystopyelogram laser lithotripsy stones string ureteroscopy stone stent MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain with swelling at the site of the ileostomy CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 9 Transcription CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain with swelling at the site of the ileostomy TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas adrenal glands and kidneys are unremarkable Punctate calcifications in the gallbladder lumen likely represent a gallstone CT PELVIS Postsurgical changes of a left lower quadrant ileostomy are again seen There is no evidence for an obstruction A partial colectomy and diverting ileostomy is seen within the right lower quadrant The previously seen 3 4 cm subcutaneous fluid collection has resolved Within the left lower quadrant a 3 4 cm x 2 5 cm loculated fluid collection has not significantly changed This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded No obstruction is seen The appendix is not clearly visualized The urinary bladder is unremarkable IMPRESSION 1 Resolution of the previously seen subcutaneous fluid collection 2 Left pelvic 3 4 cm fluid collection has not significantly changed in size or appearance These findings may be due to a pelvic abscess 3 Right lower quadrant ileostomy has not significantly changed 4 Cholelithiasis Keywords nephrology axial ct images isovue 300 ct pelvis ct abdomen fluid collection abdomen obstruction subcutaneous abscess pelvic fluid collection pelvis ileostomy ct isovue MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain nausea diarrhea and recent colonic resection CT abdomen with and without contrast and CT pelvis with contrast Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 8 Transcription CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain nausea diarrhea and recent colonic resection in 11 08 TECHNIQUE Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 FINDINGS The liver is normal in size and attenuation The gallbladder is normal The spleen is normal in size and attenuation The adrenal glands and pancreas are unremarkable The kidneys are normal in size and attenuation No hydronephrosis is detected Free fluid is seen within the right upper quadrant within the lower pelvis A markedly thickened loop of distal small bowel is seen This segment measures at least 10 cm long No definite pneumatosis is appreciated No free air is apparent at this time Inflammatory changes around this loop of bowel Mild distention of adjacent small bowel loops measuring up to 3 5 cm is evident No complete obstruction is suspected as there is contrast material within the colon Postsurgical changes compatible with the partial colectomy are noted Postsurgical changes of the anterior abdominal wall are seen Mild thickening of the urinary bladder wall is seen IMPRESSION 1 Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis An inflammatory process such as infection or ischemia must be considered Close interval followup is necessary 2 Thickening of the urinary bladder wall is nonspecific and may be due to under distention However evaluation for cystitis is advised Keywords nephrology abdominal pain nausea diarrhea colonic resection axial ct images ct abdomen isovue inflammatory urinary bladder abdominal colonic wall thickening axial bowel contrast attenuation pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description Noncontrast CT abdomen and pelvis per renal stone protocol Medical Specialty Nephrology Sample Name CT KUB Transcription EXAM CT KUB REASON FOR EXAM Flank pain TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol Correlation is made with the prior examination dated 01 16 09 FINDINGS There is no intrarenal stone or obstruction bilaterally There is no hydronephrosis ureteral dilatation There are calcifications about the pelvis including one in the left upper pelvis but these are stable from the prior study and there is no upstream ureteral dilatation the findings therefore are favored to represent phleboliths The bladder is nearly completely decompressed There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction The appendix is normal There is no evidence for a pericolonic inflammatory process or small bowel obstruction Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths There is no pelvic free fluid or adenopathy Lung bases appear clear Given the lack of contrast liver spleen adrenal glands and the pancreas appear grossly unremarkable The gallbladder has been resected There is no abdominal free fluid or pathologic adenopathy IMPRESSION 1 No renal stone or evidence of obstruction Stable appearing pelvic calcifications likely indicate phleboliths 2 Normal appendix Keywords nephrology pericolonic inflammatory process phleboliths renal stone protocol ct kub ct abdomen ureteral dilatation free fluid renal stone noncontrast kub adenopathy abdomen ct renal stone obstruction pelvis MEDICAL_TRANSCRIPTION,Description CT guided needle placement CT guided biopsy of right renal mass and embolization of biopsy tract with gelfoam Medical Specialty Nephrology Sample Name CT Guided Biopsy Kidney Transcription REASON FOR EXAM This 60 year old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr X PROCEDURE The procedure risks and possible complications including but not limited to severe hemorrhage which could result in emergent surgery were explained to the patient The patient understood All questions were answered and informed consent was obtained With the patient in the prone position noncontrasted CT localization images were obtained through the kidney Conscious sedation was utilized with the patient being monitored The patient was administered divided dose of Versed and fentanyl intravenously Following sterile preparation and local anesthesia to the posterior aspect of the right flank an 18 gauge co axial Temno type needle was directed into the inferior pole right renal mass from the posterior oblique approach Two biopsy specimens were obtained and placed in 10 formalin solution CT documented needle placement Following the biopsy there was active bleeding through the stylet as well as a small hematoma about the inferior aspect of the right kidney posteriorly I placed several torpedo pledgets of Gelfoam through the co axial sheath into the site of bleeding The bleeding stopped The co axial sheath was then removed Bandage was applied Hemostasis was obtained The patient was placed in the supine position Postbiopsy CT images were then obtained The patient s hematoma appeared stable The patient was without complaints of pain or discomfort The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged as stable The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr Fieldstone for the results and follow up care FINDINGS Initial noncontrasted CT localization images reveals the presence of an approximately 2 1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass There are small droplets of air within the hematoma No hydronephrosis is identified CONCLUSION 1 Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10 formalin solution 2 Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets Keywords nephrology embolization ct localization gelfoam pledgets ct guided needle placement ct guided biopsy needle placement renal mass ct guided inferior pole ct biopsy hematoma kidney mass MEDICAL_TRANSCRIPTION,Description Residual stone status post right percutaneous nephrolithotomy attempted second look nephrolithotomy cysto with insertion of 6 French variable length double J stent Medical Specialty Nephrology Sample Name Cysto Double J Stent Insersion Transcription PREOPERATIVE DIAGNOSIS Residual stone status post right percutaneous nephrolithotomy POSTOPERATIVE DIAGNOSES Residual stone status post right percutaneous nephrolithotomy attempted second look nephrolithotomy cysto with insertion of 6 French variable length double J stent ANESTHESIA General via endotracheal tube BLOOD LOSS Minimal DRAINS 16 French Foley 6 French variable length double J stent INTRAOPERATIVE COMPLICATIONS Unable to re access the collecting system DESCRIPTION OF PROCEDURE The patient was brought to the operating room and laid supine General anesthesia was accomplished A 16 French Foley was placed using aseptic technique The patient was then placed on the operating table prone His right flank was prepped and draped in a sterile fashion At this point contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed The 5 French Pollack catheter was used to pass a 0 38 super stiff Amplatz wire The wire would not go down the ureter Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track both with rigid dilator and the balloon dilator and access could not be obtained After multiple attempts access was lost At this point the tubes were left out of the kidney and sterile dressings were applied The patient was then placed on another operating table supine His genitalia were prepped and draped after removing his Foley catheter Flexible cystoscopy was performed and the right orifice identified which was edematous and erythematous The wire was passed up to kidney and a 5 French Pollack catheter was then passed over to after the removing the scope The wire was removed Contrast injection with good placement in the collecting system The wire was replaced The Pollack catheter removed and 6 French variable length double J stent was inserted using fluoroscopic guidance The wire was removed leaving the double J stent in good position _______ 16 French Foley was reinserted and connected to close drains Procedure was terminated at this point and had been well tolerated The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well Keywords nephrology residual stone percutaneous cobra catheters amplatz double j stent pollack catheter cysto catheter nephrolithotomy stent french MEDICAL_TRANSCRIPTION,Description Lower quadrant pain with nausea vomiting and diarrhea CT abdomen without contrast and CT pelvis without contrast Noncontrast axial CT images of the abdomen and pelvis are obtained Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 7 Transcription REASON FOR EXAM Lower quadrant pain with nausea vomiting and diarrhea TECHNIQUE Noncontrast axial CT images of the abdomen and pelvis are obtained FINDINGS Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material Gallstones are seen within the gallbladder lumen No abnormal pericholecystic fluid is seen The liver is normal in size and attenuation The spleen is normal in size and attenuation A 2 2 x 1 8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas No pancreatic ductal dilatation is seen There is no abnormal adjacent stranding No suspected pancreatitis is seen The kidneys show no stone formation or hydronephrosis The large and small bowels are normal in course and caliber There is no evidence for obstruction The appendix appears within normal limits In the pelvis the urinary bladder is unremarkable There is a 4 2 cm cystic lesion of the right adnexal region No free fluid free air or lymphadenopathy is detected There is left basilar atelectasis IMPRESSION 1 A 2 2 cm low attenuation lesion is seen at the pancreatic tail This is felt to be originating from the pancreas a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised Additionally when the patient s creatinine improves a contrast enhanced study utilizing pancreatic protocol is needed Alternatively an MRI may be obtained 2 Cholelithiasis 3 Left basilar atelectasis 4 A 4 2 cm cystic lesion of the right adnexa correlation with pelvic ultrasound is advised Keywords nephrology ct abdomen ct pelvis neoplasm lesion attenuation hydronephrosis stone formation ct images cystic lesion abdomen cystic pancreatic ct pelvis intravenous noncontrast MEDICAL_TRANSCRIPTION,Description Noncontrast CT abdomen and pelvis per renal stone protocol Medical Specialty Nephrology Sample Name CT Stone Protocol Transcription EXAM CT stone protocol REASON FOR EXAM History of stones rule out stones TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol FINDINGS Correlation is made with a prior examination dated 01 20 09 Again identified are small intrarenal stones bilaterally These are unchanged There is no hydronephrosis or significant ureteral dilatation There is no stone along the expected course of the ureters or within the bladder There is a calcification in the low left pelvis not in line with ureter this finding is stable and is compatible with a phlebolith There is no asymmetric renal enlargement or perinephric stranding The appendix is normal There is no evidence of a pericolonic inflammatory process or small bowel obstruction Scans through the pelvis disclose no free fluid or adenopathy Lung bases aside from very mild dependent atelectasis appear clear Given the lack of contrast liver spleen adrenal glands and the pancreas are grossly unremarkable The gallbladder is present There is no abdominal free fluid or pathologic adenopathy IMPRESSION 1 Bilateral intrarenal stones no obstruction 2 Normal appendix Keywords nephrology noncontrast ct abdomen and pelvis renal stone protocol renal stone intrarenal stones stone protocol ureteral adenopathy renal ct protocol pelvis intrarenal stone abdomen noncontrast MEDICAL_TRANSCRIPTION,Description CT abdomen and pelvis without contrast stone protocol reconstruction Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 4 Transcription EXAM CT abdomen and pelvis without contrast stone protocol reconstruction REASON FOR EXAM Flank pain TECHNIQUE Noncontrast CT abdomen and pelvis with coronal reconstructions FINDINGS There is no intrarenal stone bilaterally However there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right The right renal pelvis is not dilated There is no stone along the course of the ureter I cannot exclude the possibility of recent stone passage although the findings are ultimately technically indeterminate and clinical correlation is advised There is no obvious solid appearing mass given the lack of contrast Scans of the pelvis disclose no evidence of stone within the decompressed bladder No pelvic free fluid or adenopathy There are few scattered diverticula There is a moderate amount of stool throughout the colon There are scattered diverticula but no CT evidence of acute diverticulitis The appendix is normal There are mild bibasilar atelectatic changes Given the lack of contrast visualized portions of the liver spleen adrenal glands and the pancreas are grossly unremarkable The gallbladder is present There is no abdominal free fluid or pathologic adenopathy There are degenerative changes of the lumbar spine IMPRESSION 1 Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding There is no stone identified along the course of the left ureter or in the bladder Could this patient be status post recent stone passage Clinical correlation is advised 2 Diverticulosis 3 Moderate amount of stool throughout the colon 4 Normal appendix Keywords nephrology coronal reconstructions stone protocol renal pelvic dilatation proximal ureteral dilatation ct abdomen and pelvis stone protocol reconstruction abdomen and pelvis perinephric stranding free fluid scattered diverticula renal dilatation contrast ureteral ct abdomen pelvis stone noncontrast MEDICAL_TRANSCRIPTION,Description Motor vehicle collision CT head without contrast CT facial bones without contrast and CT cervical spine without contrast Medical Specialty Nephrology Sample Name CT Head Facial Bones Cervical Spine 1 Transcription CT HEAD WITHOUT CONTRAST CT FACIAL BONES WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision CT HEAD TECHNIQUE Noncontrast axial CT images of the head were obtained without contrast FINDINGS There is no acute intracranial hemorrhage mass effect midline shift or extra axial fluid collection The ventricles and cortical sulci are normal in shape and configuration The gray white matter junctions are well preserved No calvarial fracture is seen IMPRESSION Negative for acute intracranial disease CT FACIAL BONES WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions FINDINGS There is no facial bone fracture The maxilla and mandible are intact The visualized paranasal sinuses are clear The temporomandibular joints are intact The nasal bone is intact The orbits are intact The extra ocular muscles and orbital nerves are normal The orbital globes are normal IMPRESSION No evidence for a facial bone fracture CT CERVICAL SPINE WITHOUT CONTRAST TECHNIQUE Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions FINDINGS There is a normal lordosis of the cervical spine no fracture or subluxation is seen The vertebral body heights are normal The intervertebral disk spaces are well preserved The atlanto dens interval is normal No abnormal anterior cervical soft tissue swelling is seen There is no spinal compression deformity IMPRESSION Negative for a facial bone fracture Keywords nephrology intracranial disease motor vehicle collision orbital nerves extra ocular muscles cervical spine ct cervical spine ct facial bones ct head axial ct images facial bone fracture facial bones ct noncontrast intracranial axial spine fracture cervical contrast facial bones MEDICAL_TRANSCRIPTION,Description Right sided abdominal pain with nausea and fever CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 6 Transcription REASON FOR EXAM Right sided abdominal pain with nausea and fever TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas gallbladder adrenal glands and kidney are unremarkable CT PELVIS Within the right lower quadrant the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant Findings are compatible with acute appendicitis The large and small bowels are normal in course and caliber without obstruction The urinary bladder is normal The uterus appears unremarkable Mild free fluid is seen in the lower pelvis No destructive osseous lesions are seen The visualized lung bases are clear IMPRESSION Acute appendicitis Keywords nephrology adrenal glands appendicitis gallbladder kidney liver pancreas spleen acute appendicitis ct pelvis ct abdomen abdominal contrast fluid abdomen inflammatory pelvis ct MEDICAL_TRANSCRIPTION,Description CT of the abdomen and pelvis without contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 3 Transcription EXAM CT of the abdomen and pelvis without contrast HISTORY Lower abdominal pain FINDINGS Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis There is a 1 6 cm nodular density at the left posterior sulcus Noncontrast technique limits evaluation of the solid abdominal organs Cardiomegaly and atherosclerotic calcifications are seen Hepatomegaly is observed There is calcification within the right lobe of the liver likely related to granulomatous changes Subtle irregularity of the liver contour is noted suggestive of cirrhosis There is splenomegaly seen There are two low attenuation lesions seen in the posterior aspect of the spleen which are incompletely characterized that may represent splenic cyst The pancreas appears atrophic There is a left renal nodule seen which measures 1 9 cm with a Hounsfield unit density of approximately 29 which is indeterminate There is mild bilateral perinephric stranding There is an 8 mm fat density lesion in the anterior inner polar region of the left kidney compatible in appearance with angiomyolipoma There is a 1 cm low attenuation lesion in the upper pole of the right kidney likely representing a cyst but incompletely characterized on this examination Bilateral ureters appear normal in caliber along their visualized course The bladder is partially distended with urine but otherwise unremarkable Postsurgical changes of hysterectomy are noted There are pelvic phlebolith seen There is a calcified soft tissue density lesion in the right pelvis which may represent an ovary with calcification as it appears continuous with the right gonadal vein Scattered colonic diverticula are observed The appendix is within normal limits The small bowel is unremarkable There is an anterior abdominal wall hernia noted containing herniated mesenteric fat The hernia neck measures approximately 2 7 cm There is stranding of the fat within the hernia sac There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis Degenerative changes of the spine are observed IMPRESSION 1 Anterior abdominal wall hernia with mesenteric fat containing stranding suggestive of incarcerated fat 2 Nodule in the left lower lobe recommend follow up in 3 months 3 Indeterminate left adrenal nodule could be further assessed with dedicated adrenal protocol CT or MRI 4 Hepatomegaly with changes suggestive of cirrhosis There is also splenomegaly observed 5 Low attenuation lesions in the spleen may represent cyst that are incompletely characterized on this examination 6 Fat density lesion in the left kidney likely represents angiomyolipoma 7 Fat density soft tissue lesion in the region of the right adnexa this contains calcifications and may represent an ovary or possibly dermoid cyst Keywords nephrology abdominal pain cardiomegaly atherosclerotic calcifications hepatomegaly perinephric stranding low attenuation lesions abdominal calcifications lesions abdomen MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan Medical Specialty Nephrology Sample Name CT Scan of Abdomen Pelvis with Contrast Transcription EXAM CT scan of the abdomen and pelvis with contrast REASON FOR EXAM Abdominal pain COMPARISON EXAM None TECHNIQUE Multiple axial images of the abdomen and pelvis were obtained 5 mm slices were acquired after injection of 125 cc of Omnipaque IV In addition oral ReadiCAT was given Reformatted sagittal and coronal images were obtained DISCUSSION There are numerous subcentimeter nodules seen within the lung bases The largest measures up to 6 mm No hiatal hernia is identified Consider chest CT for further evaluation of the pulmonary nodules The liver gallbladder pancreas spleen adrenal glands and kidneys are within normal limits No dilated loops of bowel There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat In addition there is soft tissue stranding seen of the lower pelvis In addition the uterus is not identified Correlate with history of recent surgery There is no free fluid or lymphadenopathy seen within the abdomen or pelvis The bladder is within normal limits for technique No acute bony abnormalities appreciated No suspicious osteoblastic or osteolytic lesions IMPRESSION 1 Postoperative changes seen within the pelvis without appreciable evidence for free fluid 2 Numerous subcentimeter nodules seen within the lung bases Consider chest CT for further characterization Keywords nephrology ct scan abdominal pain multiple axial images abdomen and pelvis adrenal glands chest ct coronal gallbladder kidneys liver lymphadenopathy nodules osteoblastic osteolytic pancreas sagittal spleen with contrast free fluid ct abdomen pelvis MEDICAL_TRANSCRIPTION,Description CT abdomen without contrast and pelvis without contrast reconstruction Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 5 Transcription EXAM CT abdomen without contrast and pelvis without contrast reconstruction REASON FOR EXAM Right lower quadrant pain rule out appendicitis TECHNIQUE Noncontrast CT abdomen and pelvis An intravenous line could not be obtained for the use of intravenous contrast material FINDINGS The appendix is normal There is a moderate amount of stool throughout the colon There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process Examination of the extreme lung bases appear clear no pleural effusions The visualized portions of the liver spleen adrenal glands and pancreas appear normal given the lack of contrast There is a small hiatal hernia There is no intrarenal stone or evidence of obstruction bilaterally There is a questionable vague region of low density in the left anterior mid pole region this may indicate a tiny cyst but it is not well seen given the lack of contrast This can be correlated with a followup ultrasound if necessary The gallbladder has been resected There is no abdominal free fluid or pathologic adenopathy There is abdominal atherosclerosis without evidence of an aneurysm Dedicated scans of the pelvis disclosed phleboliths but no free fluid or adenopathy There are surgical clips present There is a tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection IMPRESSION 1 Normal appendix 2 Moderate stool throughout the colon 3 No intrarenal stones 4 Tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection The report was faxed upon dictation Keywords nephrology reconstruction appendicitis urinary tract infection ct abdomen abdomen ct pelvis contrast noncontrast MEDICAL_TRANSCRIPTION,Description Abnormal liver enzymes and diarrhea CT pelvis with contrast and ct abdomen with and without contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 11 Transcription EXAM CT pelvis with contrast and ct abdomen with and without contrast INDICATIONS Abnormal liver enzymes and diarrhea TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration Pre contrast images through the abdomen were also obtained COMPARISON There were no comparison studies FINDINGS The lung bases are clear The liver demonstrates mild intrahepatic biliary ductal dilatation These findings may be secondary to the patient s post cholecystectomy state The pancreas spleen adrenal glands and kidneys are unremarkable There is a 13 mm peripheral enhancing fluid collection in the anterior pararenal space of uncertain etiology There are numerous nonspecific retroperitoneal and mesenteric lymph nodes These may be reactive however an early neoplastic process would be difficult to totally exclude There is a right inguinal hernia containing a loop of small bowel This may produce a partial obstruction as there is mild fluid distention of several small bowel loops particularly in the right lower quadrant The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine The urinary bladder is unremarkable The uterus is not visualized IMPRESSION 1 Right inguinal hernia containing small bowel Partial obstruction is suspected 2 Nonspecific retroperitoneal and mesenteric lymph nodes 3 Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology 4 Diverticulosis without evidence of diverticulitis 5 Status post cholecystectomy with mild intrahepatic biliary ductal dilatation 6 Osteopenia and degenerative changes of the spine and pelvis Keywords nephrology pre contrast images contrast biliary ductal dilatation pancreas spleen adrenal glands kidneys mesenteric lymph nodes fluid collection inguinal hernia ct abdomen hernia diverticulosis diverticulitis osteopenia degenerative spine bowel pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis without and with intravenous contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 2 Transcription EXAM CT scan of the abdomen and pelvis without and with intravenous contrast CLINICAL INDICATION Left lower quadrant abdominal pain COMPARISON None FINDINGS CT scan of the abdomen and pelvis was performed without and with intravenous contrast Total of 100 mL of Isovue was administered intravenously Oral contrast was also administered The lung bases are clear The liver is enlarged and decreased in attenuation There are no focal liver masses There is no intra or extrahepatic ductal dilatation The gallbladder is slightly distended The adrenal glands pancreas spleen and left kidney are normal A 12 mm simple cyst is present in the inferior pole of the right kidney There is no hydronephrosis or hydroureter The appendix is normal There are multiple diverticula in the rectosigmoid There is evidence of focal wall thickening in the sigmoid colon image 69 with adjacent fat stranding in association with a diverticulum These findings are consistent with diverticulitis No pneumoperitoneum is identified There is no ascites or focal fluid collection The aorta is normal in contour and caliber There is no adenopathy Degenerative changes are present in the lumbar spine IMPRESSION Findings consistent with diverticulitis Please see report above Keywords nephrology extrahepatic ductal dilatation gallbladder glands pancreas spleen kidney adrenal abdomen and pelvis ct scan intravenous abdomen MEDICAL_TRANSCRIPTION,Description CT Abdomen Pelvis W WO Contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis Transcription EXAM CT Abdomen Pelvis W WO Contrast REASON FOR EXAM Status post aortobiiliac graft repair TECHNIQUE 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement No oral or rectal contrast was utilized Comparison is made with the prior CT abdomen and pelvis dated 10 20 05 There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3 7 cm transversely x 3 4 AP Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips The size of the native aneurysm component at this level is stable at 5 5 cm in diameter with mural thrombus surrounding the enhancing endolumen There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak Further distally there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either No exoluminal leakage is identified at any level There is no retroperitoneal hematoma present The findings are unchanged from the prior exam The liver spleen pancreas adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present There is advanced atrophy of the left kidney No hydronephrosis is present No acute findings are identified elsewhere in the abdomen The lung bases are clear Concerning the remainder of the pelvis no acute pathology is identified There is prominent streak artifact from the left total hip replacement There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis The bladder grossly appears normal A hysterectomy has been performed IMPRESSION 1 No complications identified regarding endoluminal aortoiliac graft repair as described The findings are stable compared to the study of 10 20 04 2 Stable mild aneurysm of aortic aneurysm centered roughly at renal artery level 3 No other acute findings noted 4 Advanced left renal atrophy Keywords nephrology aortobiiliac graft repair renal atrophy ct abdomen pelvis w wo contrast aortic aneurysm renal artery mural thrombus endoluminal leak ct abdomen ct contrast pelvis abdomen MEDICAL_TRANSCRIPTION,Description Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT abdomen without contrast and CT pelvis without contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 10 Transcription CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST REASON FOR EXAM Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT ABDOMEN There is no evidence for a retroperitoneal hematoma The liver spleen adrenal glands and pancreas are unremarkable Within the superior pole of the left kidney there is a 3 9 cm cystic lesion A 3 3 cm cystic lesion is also seen within the inferior pole of the left kidney No calcifications are noted The kidneys are small bilaterally CT PELVIS Evaluation of the bladder is limited due to the presence of a Foley catheter the bladder is nondistended The large and small bowels are normal in course and caliber There is no obstruction Bibasilar pleural effusions are noted IMPRESSION 1 No evidence for retroperitoneal bleed 2 There are two left sided cystic lesions within the kidney correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam 3 The kidneys are small in size bilaterally 4 Bibasilar pleural effusions Keywords nephrology cystic lesion superior pole kidney ct pelvis ct abdomen retroperitoneal hematoma lesion kidneys bladder bibasilar pleural effusions lesions pelvis hematoma retroperitoneal cystic ct abdomen MEDICAL_TRANSCRIPTION,Description CT Abdomen and Pelvis with contrast Medical Specialty Nephrology Sample Name CT Abdomen Pelvis 1 Transcription EXAM CT Abdomen and Pelvis with contrast REASON FOR EXAM Nausea vomiting diarrhea for one day Fever Right upper quadrant pain for one day COMPARISON None TECHNIQUE CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement CT ABDOMEN Lung bases are clear The liver gallbladder spleen pancreas and bilateral adrenal kidneys are unremarkable The aorta is normal in caliber There is no retroperitoneal lymphadenopathy CT PELVIS The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change Per CT the colon and small bowel are unremarkable The bladder is distended No free fluid air Visualized osseous structures demonstrate no definite evidence for acute fracture malalignment or dislocation IMPRESSION 1 Unremarkable exam specifically no evidence for acute appendicitis 2 No acute nephro ureterolithiasis 3 No secondary evidence for acute cholecystitis Results were communicated to the ER at the time of dictation Keywords nephrology liver gallbladder spleen pancreas adrenal kidneys lymphadenopathy abdomen and pelvis contrast ct MEDICAL_TRANSCRIPTION,Description Chronic kidney disease stage IV secondary to polycystic kidney disease Hypertension which is finally better controlled Metabolic bone disease and anemia Medical Specialty Nephrology Sample Name Chronic Kidney Disease Followup Transcription HISTORY OF PRESENT ILLNESS This is a followup for this 69 year old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease His creatinine has ranged between 4 and 4 5 over the past 6 months since I have been following him I have been trying to get him educated about end stage kidney disease and we have been unsuccessful in getting him into classes On his last visit I really stressed the importance of him taking his medications adequately and not missing some of the doses and he returns today with much better blood pressure control He has also brought a machine at home and states his blood pressure readings have been better He has not gone to the transplant orientation class yet and has not been to dialysis education yet and both of these I have discussed with him in the past He also needs followup for his elevated PSA in the past which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant REVIEW OF SYSTEMS Really negative He continues to feel well He denies any problems with shortness of breath chest pain swelling in his legs nausea or vomiting and his appetite remains good CURRENT MEDICATIONS 1 Vytorin 10 40 mg one a day 2 Rocaltrol 0 25 micrograms a day 3 Carvedilol 12 5 mg twice a day 4 Cozaar 50 mg twice a day 5 Lasix 40 mg a day PHYSICAL EXAMINATION VITAL SIGNS On exam his blood pressure is 140 57 pulse 58 current weight is 67 1 kg and again his blood pressure is markedly improved over his previous readings GENERAL He is a thin African American gentleman in no distress LUNGS Clear CARDIOVASCULAR Regular rate and rhythm Normal S1 and S2 I did not appreciate a murmur ABDOMEN Soft He has a very soft systolic murmur at the left lower sternal border No rubs or gallops EXTREMITIES No significant edema LABORATORY DATA Today indicates that his creatinine is 4 5 and stable ionized calcium 8 5 intact PTH 458 and hemoglobin stable at 10 9 He is not on EPO yet His UA has been negative IMPRESSION 1 Chronic kidney disease stage IV secondary to polycystic kidney disease His estimated GFR is 16 mL per minute He has no uremic symptoms 2 Hypertension which is finally better controlled 3 Metabolic bone disease 4 Anemia RECOMMENDATION He needs a number of things done in terms of followup and education I gave him more information again about dialysis education and transplant and instructed him he needs to go to these classes I also gave him websites that he can get on to find out more information I have not made any changes in his medications He is getting blood work done prior to his next visit with me I will check a PSA on him but he needs to get back into see urology as his last PSA that I see was 37 and this was from 02 05 He will see me back in about 4 to 6 weeks Keywords nephrology metabolic bone disease anemia polycystic kidney disease chronic kidney disease blood pressure transplant metabolic kidney MEDICAL_TRANSCRIPTION,Description Marked right hydronephrosis without hydruria Medical Specialty Nephrology Sample Name Consult Hydronephrosis Transcription CHIEF COMPLAINT Right hydronephrosis HISTORY OF PRESENT ILLNESS The patient is a 56 year old female who has a history of uterine cancer breast cancer mesothelioma She is scheduled to undergo mastectomy in two weeks In September 1999 she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation Again she is scheduled for mastectomy in two weeks She underwent a recent PET scan for Dr X which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney There was no dilation of the right ureter noted Urinalysis today is microscopically negative PAST MEDICAL HISTORY Uterine cancer mesothelioma breast cancer diabetes hypertension PAST SURGICAL HISTORY Lumpectomy hysterectomy MEDICATIONS Diovan HCT 80 12 5 mg daily metformin 500 mg daily ALLERGIES None FAMILY HISTORY Noncontributory SOCIAL HISTORY She is retired Does not smoke or drink REVIEW OF SYSTEMS I have reviewed his review of systems sheet and it is on the chart PHYSICAL EXAMINATION Please see the physical exam sheet I completed Abdomen is soft nontender nondistended no palpable masses no CVA tenderness IMPRESSION AND PLAN Marked right hydronephrosis without hydruria She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005 I will try to obtain the report to see if the right kidney was evaluated at that time She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed She will call us back to schedule the x rays She understands the great importance and getting back in touch with us to schedule these x rays due to the possibility that it may be somehow related to the cancer There is also a question of a stone present in the kidney She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests Keywords nephrology hydruria hydronephrosis review of systems uterine cancer breast cancer mesothelioma mastectomy kidney cancer MEDICAL_TRANSCRIPTION,Description Left forearm arteriovenous fistula between cephalic vein and radial artery Medical Specialty Nephrology Sample Name AV Fistula 5 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease hypertension diabetes need for chronic arteriovenous access 2 Ischemic cardiomyopathy ejection fraction 20 POSTOPERATIVE DIAGNOSES 1 End stage renal disease hypertension diabetes need for chronic arteriovenous access 2 Ischemic cardiomyopathy ejection fraction 20 OPERATION Left forearm arteriovenous fistula between cephalic vein and radial artery INDICATION FOR SURGERY This is a patient referred by Dr Michael Campbell He is a 44 year old African American who has end stage renal disease and also ischemic cardiomyopathy This morning he received coronary angiogram by Dr A which was reportedly normal after which he was brought to the operating room for an AV fistula All the advantages disadvantages risks and benefits of the procedure were explained to him for which he had consented ANESTHESIA Monitored anesthesia care DESCRIPTION OF PROCEDURE The patient was identified brought to the operating room placed supine and IV sedation given This was done under monitored anesthesia care He was prepped and draped in the usual sterile fashion He received local infiltration of 0 25 Marcaine with epinephrine in the region of the proposed incision Incision was about 2 5 cm long between the cephalic vein and the distal part of the forearm and the radial artery Incision was deepened down through the subcutaneous fascia The vein was identified dissected for a good length and then the artery was identified and dissected Heparin 5000 units was given The artery clamped proximally and distally opened up in the middle It was found to have Monckeberg s arteriosclerosis of a moderate intensity The vein was of good caliber and size The vein was clipped distally fashioned to size and shape and arteriotomy created in the distal radial artery and end to side anastomosis was performed using 7 0 Prolene and bled prior to tying it down Thrill was immediately felt and heard The incision was closed in two layers and sterile dressing applied Keywords nephrology end stage renal disease av fistula marcaine with epinephrine monckeberg s monitored anesthesia care angiogram arteriosclerosis arteriovenous fistula cephalic vein ischemic cardiomyopathy radial artery subcutaneous fascia arteriovenous forearm ischemic MEDICAL_TRANSCRIPTION,Description Creation of autologous right brachiobasilic arteriovenous fistula first stage Medical Specialty Nephrology Sample Name AV Fistula 4 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease 2 Left subclavian vein occlusion 3 Status post chronic tracheostomy 4 Status post coronary artery bypass grafting 5 Right subclavian vein stenosis POSTOPERATIVE DIAGNOSES 1 End stage renal disease 2 Left subclavian vein occlusion 3 Status post chronic tracheostomy 4 Status post coronary artery bypass grafting 5 Right subclavian vein stenosis OPERATIVE PROCEDURE Creation of autologous right brachiobasilic arteriovenous fistula first stage INDICATIONS FOR THE PROCEDURE This patient has a known left subclavian vein occlusion The right subclavian vein has an estimated 50 stenosis The patient has a catheter traversed in the right innominate vein The right basilic vein was judged to be suitable for usage on vein mapping OPERATIVE FINDINGS The basilic vein was of an adequate size but somewhat sclerotic A first stage autologous right brachiobasilic arteriovenous fistula was created A grade 2 was felt at completion OPERATIVE PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the operating room The patient was placed in the supine position The patient received regional nerve block The patient also received intravenous sedation The right arm was prepped and draped in the usual sterile fashion We used ultrasound to locate the basilic vein at the cubital fossa A small transverse incision was made slightly above the basilic vein The basilic vein was identified and immobilized The basilic vein was of a good size but somewhat sclerotic The underlying fascia was incised and the brachial artery was identified and immobilized The brachial artery was normal We then divided the basilic vein distally The distal end was ligated using silk suture The brachial artery was clamped proximally and distally A small longitudinal arteriotomy was made in the brachial artery We did not give heparin The end of the basilic vein was then sewn end to side to the brachial artery using a running 7 0 Prolene suture Just prior to completion of the anastomosis it was flushed and anastomosis was completed Flow was then established A grade 2 was felt in the outflow basilic fistula Hemostasis was secured The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4 0 Monocryl subcuticular suture for the skin A sterile dry dressing was applied The patient tolerated the procedure well There were no operative complications The sponge instrument and needle counts were correct at the end of the case I was present and participated in all aspects of the procedure The patient was transferred to the recovery room in satisfactory condition Keywords nephrology end stage renal disease left subclavian vein occlusion arteriovenous fistula artery bypass grafting autologous basilic vein brachial artery brachiobasilic clamped fistula sclerotic subclavian vein subclavian vein stenosis tracheostomy brachiobasilic arteriovenous fistula subclavian vein occlusion vein occlusion subclavian basilic artery MEDICAL_TRANSCRIPTION,Description Acute renal failure probable renal vein thrombosis hypercoagulable state and deep venous thromboses with pulmonary embolism Medical Specialty Nephrology Sample Name Azotemia Consult Transcription REASON FOR CONSULTATION Azotemia HISTORY OF PRESENT ILLNESS The patient is a 36 year old gentleman admitted to the hospital because he passed out at home Over the past week he has been noticing increasing shortness of breath He also started having some abdominal pain however he continued about his regular activity until the other day when he passed out at home His wife called paramedics and he was brought to the emergency room The patient has had a workup at this time which shows bilateral pulmonary infarcts He has been started on heparin and we are asked to see him because of increasing BUN and creatinine The patient has no past history of any renal problems He feels that he has been in good health until this current episode His appetite has been good He denies swelling in his feet or ankles He denies chest pain He denies any problems with bowel habits He denies any unexplained weight loss He denies any recent change in bowel habits or recent change in urinary habits PHYSICAL EXAMINATION GENERAL A gentleman seen who appears his stated age VITAL SIGNS Blood pressure is 130 70 CHEST Chest expands equally bilaterally Breath sounds are heard bilaterally HEART Had a regular rhythm no gallops or rubs ABDOMEN Obese There is no organomegaly There are no bruits There is no peripheral edema He has good pulse in all 4 extremities He has good muscle mass LABORATORY DATA The patient s current chemistries include a hemoglobin of 14 8 white count of 16 3 his sodium 133 potassium 5 1 chloride 104 CO2 of 19 a BUN of 26 and a creatinine of 3 5 On admission to the hospital his creatinine on 6 27 2009 was 0 9 The patient has had several studies including a CAT scan of his abdomen which shows poor perfusion to his right kidney IMPRESSION 1 Acute renal failure probable renal vein thrombosis 2 Hypercoagulable state 3 Deep venous thromboses with pulmonary embolism DISCUSSION We are presented with a 36 year old gentleman who has been in good health until this current event He most likely has a hypercoagulable state and has bilateral pulmonary emboli Most likely the patient has also had emboli to his renal veins and it is causing renal vein thrombosis Interestingly the urine protein was obtained which is not that elevated and I would suspect that it would have been higher Unfortunately the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem The patient s urine output is about 30 to 40 mL per hour Several chemistries have been ordered A triple renal scan has been ordered I reviewed all of this with the patient and his wife Hopefully under his current anticoagulation there will be some resolution of his renal vein thrombosis If not and his renal failure progresses we are looking at dialytic intervention Both he and his wife were aware of this Thank you very much for asking to see this acutely ill gentleman in consultation with you Keywords nephrology urine output deep venous thromboses renal failure pulmonary embolism renal azotemia hypercoagulable vein thrombosis pulmonary MEDICAL_TRANSCRIPTION,Description Right basilic vein transposition End stage renal disease with need for a long term hemodialysis access Excellent flow through fistula following the procedure Medical Specialty Nephrology Sample Name Basilic Vein Transposition Transcription PREOPERATIVE DIAGNOSIS End stage renal disease with need for a long term hemodialysis access POSTOPERATIVE DIAGNOSIS End stage renal disease with need for a long term hemodialysis access PROCEDURE Right basilic vein transposition ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None FINDINGS Excellent flow through fistula following the procedure STATEMENT OF MEDICAL NECESSITY The patient is a 68 year old black female who recently underwent a brachiobasilic AV fistula but without transposition She has good flow excellent physical exam and now is ready for superficialization of the basilic vein After discussing the risks and benefits of the procedure with the patient preoperatively the patient voiced understanding and signed informed consent PROCEDURE IN DETAIL The patient was taken to the operating room placed supine on the operating table After adequate general endotracheal anesthesia was obtained the right arm was circumferentially prepped and draped in a standard sterile fashion A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein There was noted to be excellent flow through the vein A pocket was then created just lateral to the incision in the subcutaneous tissue The vein was then placed into this pocket securing with multiple interrupted 3 0 Vicryl sutures The bed of dissection of the basilic vein was then treated with fibrin sealant The subcutaneous tissue was then reapproximated with 3 0 Vicryl sutures in interrupted fashion The skin was closed using 4 0 Monocryl suture for a subcuticular stitch Dermabond was applied to the incision Again there was noted to be good palpable thrill throughout the superficialized vein The patient was then awakened and taken to the recovery room in stable condition Keywords nephrology end stage renal disease hemodialysis av fistula brachiobasilic basilic vein transposition hemodialysis access vein basilic MEDICAL_TRANSCRIPTION,Description Creation of AV fistula left wrist in the anatomic snuffbox Medical Specialty Nephrology Sample Name AV Fistula 3 Transcription TITLE OF PROCEDURE Creation of AV fistula left wrist in the anatomic snuffbox PREOPERATIVE DIAGNOSIS End stage renal disease need for chronic access POSTOPERATIVE DIAGNOSIS End stage renal disease need for chronic access INDICATION OF THE PROCEDURE This 74 year old lady was referred by Dr P for placement of an AV fistula She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein She undergoes dialysis on Monday Wednesday and Friday at DaVita in Alameda and is under the care of Dr P She underwent coronary bypass surgery in 2000 and her cardiologist is Dr T She lives with her husband and she also has a son at home and she is a very active lady She is right handed The plan was to place an AV fistula at the left wrist The risks and benefits were fully explained to her She elected to proceed as planned PROCEDURE IN DETAIL In the operating room under monitored anesthesia care with intravenous sedation she was prepped and draped surgically Lidocaine 1 was used for local anesthesia in the anatomic snuffbox at the left wrist The cephalic vein was exposed The superficial branch of the radial artery was carefully protected and the radial artery was exposed There was moderate calcification of the radial artery The patient was heparinized and end to side anastomosis was performed between the cephalic vein and radial artery using a 7 0 Prolene suture There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion The wound was closed using absorbable suture and she was transferred to Recovery There were no complications Keywords nephrology av fistula end stage renal disease permcath chronic access jugular vein monitored anesthesia monitored anesthesia care prepped and draped snuffbox superficial branch creation of av fistula cephalic vein radial artery radial artery fistula MEDICAL_TRANSCRIPTION,Description Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula Medical Specialty Nephrology Sample Name AV Fistula 1 Transcription PREOPERATIVE DIAGNOSIS End stage renal disease POSTOPERATIVE DIAGNOSIS End stage renal disease PROCEDURE Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula ANESTHESIA General DESCRIPTION OF PROCEDURE The patient was taken to the operating room where after induction of general anesthetic the patient s arm was prepped and draped in a sterile fashion The IV catheter was inserted into the vein on the lower surface of the left forearm Venogram was performed which demonstrated adequate appearance of the cephalic vein above the elbow Through a transverse incision the cephalic vein and brachial artery were both exposed at the antecubital fossa The cephalic vein was divided and the proximal end was anastomosed to the artery in an end to side fashion with a running 6 0 Prolene suture The clamps were removed establishing flow through the fistula Hemostasis was obtained The wound was closed in layers with PDS sutures Sterile dressing was applied The patient was taken to recovery room in stable condition Keywords nephrology end stage renal disease prolene suture venogram antecubital fossa arteriovenous arteriovenous fistula brachiocephalic arteriovenous fistula cephalic vein fistula prepped and draped brachiocephalic cephalic vein MEDICAL_TRANSCRIPTION,Description He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally Medical Specialty Letters Sample Name Pediatric Urology Letter Transcription XYZ M D Suite 123 ABC Avenue City STATE 12345 RE XXXX XXXX MR 0000000 Dear Dr XYZ XXXX was seen in followup in the Pediatric Urology Clinic I appreciate you speaking with me while he was in clinic He continues to have abdominal pain and he had a diuretic renal scan which indicates no evidence of obstruction and good differential function bilaterally When I examined him he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region however on actual physical examination he seems to complain of pain through his entire right side His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration They also feel that since he has been on Detrol his pain levels have been somewhat worse and so I have given them the option of stopping the Detrol initially I think he should stay on MiraLax for management of his bowels I would also suggest that he be referred to Pediatric Gastroenterology for evaluation If they do not find any abnormalities from a gastrointestinal perspective then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain Thank you for following XXXX along with us in Pediatric Urology Clinic If you have any questions please feel free to contact me Sincerely yours Keywords letters differential function diuretic renal scan abdominal pain renal scan pediatric urology MEDICAL_TRANSCRIPTION,Description Vasectomy 10 years ago failed Azoospermic Reversal two years ago Interested in sperm harvesting and cryopreservation Medical Specialty Letters Sample Name Urology Letter Transcription Sample Address RE Sample Patient Wife s name Sample Name Dear Sample Doctor Mr Sample Patient was seen on Month DD YYYY describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan He has remained azoospermic postoperatively The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife Apparently several attempts at induction have been tried and due to some anatomic abnormality they have been unsuccessful At the time that he left the office he was asking for cryopreservation At the time of sperm harvesting I recently received a phone call suggesting that he does not want to do this at all unless his wife s ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately At his initial request Month DD YYYY was picked as the date for scheduled harvesting although this may change if you require fresh specimen Thank you very much for the opportunity to have seen him Sample Doctor M D Keywords letters urology letter urology letter azoospermic cryopreservation specimen harvest sperm harvesting vasectomy vasectomy reversal fresh specimen reversal sperm MEDICAL_TRANSCRIPTION,Description Diagnosis of benign rolandic epilepsy Medical Specialty Letters Sample Name Rolandic Epilepsy Transcription City State Dear Dr Y I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr Z His last visit was in June 2006 and he carries a diagnosis of benign rolandic epilepsy To review his birth was unremarkable He is a second child born to a G3 P1 to 2 female He has had normal development and is a bright child in 7th grade He began having seizures however at 9 years of age It is manifested typically as generalized tonic clonic seizures upon awakening or falling into sleep He also had smaller spells with more focal convulsion and facial twitching His EEGs have shown a pattern consistent with benign rolandic epilepsy central temporal sharp waves both of the right and left hemisphere Most recent EEG in May 2006 shows the same abnormalities ABC initially was placed on Tegretol but developed symptoms of toxicity hallucinations on this medication he was switched to Trileptal He has done very well taking 300 mg twice a day without any further seizures His last event was the day of his last EEG when he was sleep deprived and was off medication That was a convulsion lasting 5 minutes He has done well otherwise Parents deny that he has any problems with concentration He has not had any behavior issues He is an active child and participates in sports and some motocross activities He has one older sibling and he lives with his parents Father manages Turkey farm with foster farms Mother is an 8th grade teacher Family history is positive for a 3rd cousin who has seizures but the specific seizure type is not known There is no other relevant family history Review of systems is positive for right heel swelling and tenderness to palpation This is perhaps due to sports injury He has not sprained his ankle and does not have any specific acute injury around the time that this was noted He does also have some discomfort in the knees and ankles in the general sense with activities He has no rashes or any numbness weakness or loss of skills He has no respiratory or cardiovascular complaints He has no nausea vomiting diarrhea or abdominal complaints Past medical history is otherwise unremarkable Other workup includes CT scan and MRI scan of the brain which are both normal PHYSICAL EXAMINATION GENERAL The patient is a well nourished well hydrated male in no acute distress VITAL SIGNS His weight today is 80 6 pounds Height is 58 1 4 inches Blood pressure 113 66 Head circumference 36 3 cm HEENT Atraumatic normocephalic Oropharynx shows no lesions NECK Supple without adenopathy CHEST Clear auscultation CARDIOVASCULAR Regular rate and rhythm No murmurs ABDOMEN Benign without organomegaly EXTREMITIES No clubbing cyanosis or edema NEUROLOGIC The patient is alert and oriented His cognitive skills appear normal for his age His speech is fluent and goal directed He follows instructions well His cranial nerves reveal his pupils equal round and reactive to light Extraocular movements are intact Visual fields are full Disks are sharp bilaterally Face moves symmetrically with normal sensation Palate elevates midline Tongue protrudes midline Hearing is intact bilaterally Motor exam reveals normal strength and tone Sensation intact to light touch and vibration His gait is nonataxic with normal heel toe and tandem Finger to nose finger nose finger rapid altering movements are normal Deep tendon reflexes are 2 and symmetric IMPRESSION This is an 11 year old male with benign rolandic epilepsy who is followed over the past 2 years in our clinic Most recent electroencephalogram still shows abnormalities but it has not been done since May 2006 The plan at this time is to repeat his electroencephalogram follow his electroencephalogram annually until it reveres to normal At that time he will be tapered off of medication I anticipate at some point in the near future within about a year or so he will actually be taken off medication For now I will continue on Trileptal 300 mg twice a day which is a low starting dose for him There is no indication that his dose needs to be increased Family understands the plan We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months Parents will contact us after the electroencephalogram is done so they can get the results Thank you very much for allowing me to access ABC for further management Keywords letters tonic clonic seizures benign rolandic epilepsy rolandic epilepsy epilepsy seizures electroencephalogram MEDICAL_TRANSCRIPTION,Description A pleasant gentleman with a history of Wilson s disease who has been treated with penicillamine Medical Specialty Letters Sample Name Wilson s Disease Letter Transcription Doctor s Address Dear Doctor This letter is an introduction to my patient A who you will be seeing in the near future He is a pleasant gentleman with a history of Wilson s disease It has been treated with penicillamine He was diagnosed with this at age 14 He was on his way to South Carolina for a trip when he developed shortness of breath palpitations and chest discomfort He went to the closest hospital that they were near in Randolph North Carolina and he was found to be in atrial fibrillation with rapid rate He was admitted there and observed He converted to normal sinus rhythm spontaneously and so he required no further interventions He was started on Lopressor which he has tolerated well An echocardiogram was performed which revealed mild to moderate left atrial enlargement Normal ejection fraction No other significant valvular abnormality He reported to physicians there that he had cirrhosis related to his Wilson s disease Therefore hepatologist was consulted There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease therefore he was placed on aspirin 325 mg once a day In discussion with Mr A and review of his chart that I have available it is unclear as to the status of his liver disease however he has never had a liver biopsy so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control He is in normal sinus rhythm as of my evaluation of him on 06 12 2008 He is tolerating his metoprolol and aspirin without any difficulty I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes I appreciate your input regarding this friendly gentleman His current medicines include penicillamine 250 mg p o four times a day metoprolol 12 5 mg twice a day and aspirin 325 mg a day If you have any questions regarding his care please feel free to call me to discuss his case Otherwise I will look forward to hearing back from you regarding his evaluation Thank you as always for your care of our patient Keywords letters atrial enlargement wilson s disease penicillamine MEDICAL_TRANSCRIPTION,Description Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1 2 years Medical Specialty Letters Sample Name Suspected Seizure Activity Transcription XYZ Street City State Dear Dr CD Thank you for seeing Mr XYZ a pleasant 19 year old male who has seen you in 2005 for suspected seizure activity He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1 2 years He is requesting to come off the Dilantin at this point Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use His physical exam neurologically is normal at this time His Dilantin level is slightly low at 12 5 I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time I understand this will probably entail repeating his EEG and so please coordinate this through Health Center I await your response and whether we should continue this medication If you require any laboratory we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling Keywords letters eeg suspected seizure activity seizure activity seizure episode seizure dilantinNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Reflex sympathetic dystrophy of both lower extremities Medical Specialty Letters Sample Name Reflex Sympathetic Dystrophy Letter Transcription Doctor s Address Dear Doctor This letter serves as a reintroduction of my patient A who will be seeing you on Thursday 06 12 2008 As you know he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg He has been through Wound Clinic to try to help heal this but was intolerant of compression dressings and was unable to get satisfactory healing of this He has been seen by Dr X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain He was seen by Dr Y at Orthopedic Associates for review of this However in my discussion with Dr Z and his evaluation of Mr A it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg and concerns of worsening of his RST symptoms on his left leg if he would have an amputation Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test Dr Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr A s pain He has been to Cleveland Clinic for implantable stimulator which was unsuccessful at dramatically improving his pain He currently is taking methadone up to eight tablets four times a day morphine up to 100 mg three times a day and Dilaudid two tablets by mouth every two hours to help reduce his pain He also is currently taking Neurontin 1600 mg three times a day Effexor XR 250 mg once a day Cytomel 25 mcg once a day Seroquel 100 mg p o q day levothyroxine 300 mcg p o q day Prinivil 20 mg p o q day and Mevacor 40 mg p o q day I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation Dr Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion He has been evaluated by Dr X for rehab concerns to determine He agrees that a less aggressive form of therapy may be most appropriate I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation If you have any questions regarding his care please feel free to call me at my office Otherwise I look forward to hearing back from you shortly after your evaluation Please feel free to call me if it is possible or if you have any questions about anything Keywords letters rsd reflex sympathetic dystrophy orthopedic oxygenationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Creation of right brachiocephalic arteriovenous fistula Medical Specialty Nephrology Sample Name AV Fistula 2 Transcription PREOPERATIVE DIAGNOSES 1 End stage renal disease 2 Diabetes POSTOPERATIVE DIAGNOSES 1 End stage renal disease 2 Diabetes OPERATIVE PROCEDURE Creation of right brachiocephalic arteriovenous fistula INDICATIONS FOR THE PROCEDURE This patient has end stage renal disease Although the patient is right handed preoperative vein mapping demonstrated much better vein in the right arm Hence a right brachiocephalic fistula is being planned OPERATIVE FINDINGS The right cephalic vein at the elbow is chosen to be suitable It is slightly sporadic but of an adequate size An end to side right brachiocephalic arteriovenous fistula was created At completion there was a great thrill OPERATIVE PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the operating room The patient was placed in the supine position The patient received a regional nerve block The patient also received intravenous sedation The right arm was prepped and draped in the usual sterile fashion We made a small transverse incision in the right cubital fossa The cephalic vein was identified and mobilized The fascia was incised and the brachial artery was also identified and mobilized The brachial artery was free off significant disease A good pulse was noted The cephalic vein was mobilized proximally and distally The brachial artery was mobilized proximally and distally We did not give heparin The brachial artery was then clamped proximally and distally The cephalic vein was also clamped proximally and distally Longitudinal arteriotomy was made in brachial artery and a longitudinal venotomy was made in the cephalic vein We then sewn the vein to the artery in a side to side fashion using a running 7 0 Prolene suture Just prior to completion of the anastomosis it was flushed and the anastomosis was then completed A great thrill was noted We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it This surrounded the anastomosis as an end to side functionally A great thrill remained in the fistula Hemostasis was secured We then closed the wound using interrupted PDS sutures for the fascia and a running 4 0 Monocryl subcuticular suture for the skin Sterile dry dressing was applied The patient tolerated the procedure well There were no operative complications The sponge instrument and needle counts were correct at the end of the case I was present and participated in all aspects of the procedure The patient was then transferred to the recovery room in satisfactory condition A great thrill was felt in the fistula completion There was also a palpable radial pulse distally Keywords nephrology end stage renal disease prolene suture brachial artery brachiocephalic brachiocephalic arteriovenous fistula cephalic vein fistula general anesthetic prepped and draped proximally and distally renal disease av cephalic artery vein MEDICAL_TRANSCRIPTION,Description The patient is being referred for evaluation of diabetic retinopathy Medical Specialty Letters Sample Name Ophthalmology Letter 4 Transcription XYZ M D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your kind referral for patient ABC The patient is being referred for evaluation of diabetic retinopathy The patient was just diagnosed with diabetes however he does not have any serious visual complaints at this time On examination the patient is seeing 20 40 OD pinholing to 20 20 The vision in the left eye is 20 20 uncorrected Applanation pressures are normal at 17 mmHg bilaterally Visual fields are full to count fingers OU and there is no relative afferent pupillary defect Slit lamp examination was within normal limits other than trace to 1 nuclear sclerosis OU On dilated examination the patient shows a normal cup to disc ratio that is symmetric bilaterally The macula vessels and periphery are also within normal limits In conclusion Mr ABC does not show any evidence of diabetic retinopathy at this time We recommended him to have his eyes dilated once a year I have advised him to follow up with you for his regular check ups Again thank you for your kind referral of Mr ABC and we should check on him once a year at this time Sincerely Keywords letters pupillary defect cup to disc ratio cup to disc evaluation of diabetic retinopathy referred for evaluation diabetic retinopathy visual dilated retinopathy examination diabetic MEDICAL_TRANSCRIPTION,Description Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness paraesthesia and tingling in both arms Medical Specialty Letters Sample Name Ortho Letter 2 Transcription XYZ D C 60 Evergreen Place Suite 902 East Orange NJ 07018 Re Keywords letters paraspinal musculature palpable trigger points trigger point injections lumbar region paraspinal musculature injections trigger MEDICAL_TRANSCRIPTION,Description Woman with a history of macular degeneration PDT therapy Some vision therapy Complete refractive work up Medical Specialty Letters Sample Name Optometry Letter Transcription RE Sample Patient Dear Dr Sample Sample Patient was seen at the Vision Rehabilitation Institute on Month DD YYYY She is an 87 year old woman with a history of macular degeneration who admits to having PDT therapy within the last year She would like to get started with some vision therapy so that she may be able to perform her everyday household chores as well as reading small print At this time she uses a small handheld magnifier which is providing her with only limited help A complete refractive work up was performed today in which we found a mild change in her distance correction which allowed her the ability to see 20 70 in the right eye and 20 200 in the left eye With a pair of 4 reading glasses she was able to read 0 5M print quite nicely I have loaned her a pair of 4 reading glasses at this time and we have started her with fine detailed reading She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her I think that she is an excellent candidate for low vision help I am sure that we can be of great help to her in the near future Thank you for allowing us to share in the care of your patient With best regards Sample Doctor O D Keywords letters optometry letter optometry letter pdt therapy distance correction macular degeneration reading glasses vision therapy complete refractive macular degeneration MEDICAL_TRANSCRIPTION,Description Patient being referred for evaluation of glaucoma Medical Specialty Letters Sample Name Ophthalmology Letter 2 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your kind referral for patient ABC Mr ABC is being referred for evaluation of glaucoma The patient states he has no visual complaints On examination the patient s visual acuity is 20 20 bilaterally The patient s visual fields are full to confrontation Extraocular muscles are intact There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally On slit lamp examination the patient has a normal anterior segment with 1 nuclear sclerosis On dilated examination the patient has a cup to disc ratio in the right eye of 0 4 Macula vessels and periphery were within normal limits On the left eye the patient has a cup to disc ratio of 0 3 and macula vessels and periphery are also within normal limits On gonioscopy the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees In conclusion my initial impression is that Mr ABC does not have glaucoma He has fairly symmetric and small cup to disc ratios OU His intraocular pressures were within normal limits in our office today I discussed at length with him the alternatives of observation versus continued work up and testing He seemed to understand very well and went with my recommendation to continue observation for now We will take fundus photos of his optic nerves for future comparison but I think given the lack of any strong findings suspicious for glaucoma we will defer further testing at this time Should you have any specific questions or any other information that you think that I may not have included in this evaluation please feel free to contact me I have recommended him to follow up with you for continued examination continued check ups and should you find any other abnormal findings I would be happy to address those again Again thank you for your referral of Mr ABC Sincerely Keywords letters cup to disc ratio referred for evaluation cup to disc disc ratio macula vessels ophthalmology pressures eye macula vessels visual cup disc glaucoma examination intact MEDICAL_TRANSCRIPTION,Description 9 month old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing cough and shortness of breath over the last several months Medical Specialty Letters Sample Name Pediatric Letter Transcription Sample Address RE Sample Patient Dear Doctor We had the pleasure of seeing Abc and his mother in the clinic today As you certainly know he is now a 9 month old male product of a twin gestation complicated by some very mild prematurity He has been having problems with wheezing cough and shortness of breath over the last several months You and your partners have treated him aggressively with inhaled steroids and bronchodilator Despite this however he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course Although there is no smoke exposure there is a significant family history with both Abc s father and uncle having problems with asthma as well as his older sister The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father s house On exam today Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy We spent the majority of our 45 minute just reviewing basic principles of asthma management and I believe that Abc s mother is fairly well versed in this I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1 5 milligrams 0 5 milliliters on alternate days I have encouraged his mother to contact our office so that we can answer questions if necessary by phone Thanks so much for allowing us to be involved in his care Sincerely Keywords letters gestation bronchodilator childhood childhood asthma cough father healthy letter mother pediatric prematurity shortness of breath sister wheezing wheezing cough asthma MEDICAL_TRANSCRIPTION,Description The patient was referred for evaluation of cataracts bilaterally Medical Specialty Letters Sample Name Ophthalmology Letter 1 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear Dr XYZ Thank you for your referral of patient ABC The patient was referred for evaluation of cataracts bilaterally On examination the patient was seeing 20 40 in her right eye and 20 50 in the left eye Extraocular muscles were intact visual fields were full to confrontation OU and applanations are 12 mmHg bilaterally There is no relative afferent pupillary defect On slit lamp examination lids and lashes were within normal limits The conj is quiet The cornea shows 1 guttata bilaterally The AC is deep and quiet and irises are within normal limits bilaterally There is a dense 3 to 4 nuclear sclerotic cataract in each eye On dilated fundus examination cup to disc ratio is 0 1 OU The vitreous macula vessels and periphery all appear within normal limits Impression It appears that Ms ABC visual decline is caused by bilateral cataracts She would benefit from having removed The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly I will keep you up to date of her progress and any new findings as we perform her surgery in each eye Again thank you for your kind referral of this kind lady and I will be in touch with you Sincerely Keywords letters extraocular applanations slit lamp visual field ophthalmology visual guttata surgery cataracts eye MEDICAL_TRANSCRIPTION,Description A 19 year old right handed male injured in a motor vehicle accident Medical Specialty Letters Sample Name Ortho Letter 1 Transcription XYZ D C Re ABC Dear Dr XYZ I had the pleasure of seeing your patient ABC today MM DD YYYY in consultation He is an unfortunate 19 year old right handed male who was injured in a motor vehicle accident on MM DD YYYY where he was the driver of an automobile which was struck on the front passenger s side The patient sustained impact injuries to his neck and lower back There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures He was taken to Hospital x rays were taken apparently which were negative and he was released At the present time he complains of neck and lower back pain radiating into his right arm and right leg with weakness numbness paraesthesia and tingling in his right arm and right leg He has had no difficulty with bowel or bladder function He does experience intermittent headaches associated with his neck pain with no other associated symptoms PAST HEALTH He was injured in a prior motor vehicle accident on MM DD YYYY At the time of his most recent injuries he was completely symptom free and under no active therapy There is no history of hypertension diabetes heart disease neurological disorders ulcers or tuberculosis SOCIAL HISTORY He denies tobacco or alcohol consumption ALLERGIES No known drug allergies CURRENT MEDICATIONS None FAMILY HISTORY Otherwise noncontributory FUNCTIONAL INQUIRY Otherwise noncontributory REVIEW OF DIAGNOSTIC STUDIES Includes an MRI scan of the cervical spine dated MM DD YYYY which showed evidence for disc bulging at the C6 C7 level MRI scan of the lumbar spine on MM DD YYYY showed evidence of a disc herniation at the L1 L2 level as well as a disc protrusion at the L2 L3 level with disc herniations at the L3 L4 and L4 L5 level and disc protrusion at the L5 S1 level PHYSICAL EXAMINATION Reveals an alert and oriented male with normal language function Vital Signs Blood pressure was 105 68 in the left arm sitting Heart rate was 70 and regular Height was 5 feet 8 inches Weight was 182 pounds Cranial nerve evaluation was unremarkable Pupils were equal and reactive Funduscopic evaluation was clear There was no evidence for nystagmus There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree with tenderness and spasm in the paraspinal musculature Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left Motor strength was 5 5 on the MRC scale Reflexes were 2 symmetrical and active No pathological responses were noted Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity Cerebellar function was normal There was normal station and gait Chest and cardiovascular evaluations were unremarkable Heart sounds were normal There were no extra sounds or murmurs Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature CLINICAL IMPRESSION Reveals a 19 year old male suffering from a posttraumatic cervical and lumbar radiculopathy secondary to traumatic injuries sustained in a motor vehicle accident on MM DD YYYY In view of the persistent radicular complaints associated with the weakness numbness paraesthesia and tingling as well as the objective sensory loss noted on today s evaluation as well as the non specific nature of the radiculopathy I have scheduled him for an EMG study on his right upper and right lower extremity in two week s time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms Palpable trigger points were noted on today s evaluation He is suffering from ongoing myofascitis His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks time I have encouraged him to continue with his ongoing treatment program under your care and supervision I will be following him in two weeks time Once again thank you kindly for allowing me to participate in this patient s care and management Yours sincerely Keywords letters numbness paraesthesia and tingling paraesthesia and tingling cervical and lumbar motor vehicle accident mri scan disc protrusion paraspinal musculature letter musculature radiculopathy nerve trigger vehicle accident cervical lumbar evaluation disc ortho MEDICAL_TRANSCRIPTION,Description Patient referred for narrow angles and possible associated glaucoma Medical Specialty Letters Sample Name Ophthalmology Letter 3 Transcription XYZ O D RE ABC DOB MM DD YYYY Dear XYZ Thank you very much for your kind referral of Mrs ABC who you referred to me for narrow angles and possible associated glaucoma I examined Mrs ABC initially on MM DD YYYY At that time she expressed a chief concern of occasional pain around her eye but denied any flashing lights floaters halos or true brow ache She reports a family history of glaucoma in her mother but is unsure of the specific kind Her past ocular history has been fairly unremarkable As you know she has a history of non insulin dependent diabetes She is unaware of her last hemoglobin A1c levels but reports a blood sugar of 158 taken on the morning of her appointment with me She is followed by Dr X here locally Upon examination her visual acuity measured 20 20 1 in either eye with her glasses Presenting intraocular pressures were14 mmHg in either eye at 2 03 p m Pupillary reactions confrontational visual fields and ocular motility were normal The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye but the angle deepened with gonio compression suggesting appositional and not synechial closure I deferred the dilated portion of the exam on that day We proceeded with peripheral iridectomies and following this upon her most recent visit on MM DD YYYY I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent I note that she has an increased CD ratio measuring 0 65 in the right eye and 0 7 in the left and although her FDT visual fields and GDX testing were normal at your office she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes Therefore I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past In summary Mrs ABC has a history of narrow angles not successfully treated with laser PIs Her intraocular pressures have remained stable I will continue to monitor her closely Thank you very much once again for allowing me to have shared in her care If I can provide any additional information or be of further service do let me know Sincerely Keywords letters intraocular pressures narrow angles visual fields angles ophthalmology intraocular pressures anterior chambers gonioscopy glaucoma narrow visual eye MEDICAL_TRANSCRIPTION,Description Diagnosis of bulbar cerebral palsy and hypotonia Medical Specialty Letters Sample Name Cerebral Palsy Letter Transcription Doctor s Address Dear Doctor This letter serves as an introduction to my patient A who will be seeing you in the near future He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia He has been treated by Dr X through the pediatric neurology clinic He saw Dr X recently and she noted that he was having difficulty with mouth breathing which was contributing to some of his speech problems She also noted and confirmed that he has significant tonsillar hypertrophy The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech Therefore I ask for your opinion on this matter For his chronic allergic rhinitis symptoms he is currently on Flonase two sprays to each nostril once a day He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms He does have an allergy to penicillin I appreciate your input on his care If you have any questions regarding please feel free to call me through my office Otherwise I look forward to hearing back from you regarding his evaluation Keywords letters peech swallowing breathing bulbar cerebral palsy mouth breathing cerebral palsy hypotoniaNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Letter on evaluation regarding extraction of mandibular left second molar tooth 18 Medical Specialty Letters Sample Name Letter Dentistry Transcription XYZ S RE ABC Dear Dr XYZ On your kind referral I had the pleasure of meeting and consulting with ABC on MM DD YYYY for evaluation regarding extraction of his mandibular left second molar tooth 18 This previously root canaled tooth now failed is scheduled for removal As per your request I agree that placement of an implant in the 20 and 19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area I have given Mr ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process We will plan to place two Straumann implants as per our normal protocol one each in the 19 and 20 positions with the 19 implant being a wide neck larger diameter implant I will plan on providing the prosthetic abutments the lab analogue and temporary healing cap at the end of the four month integration period If you have any additional suggestions or concerns please give me a call Best regards Keywords letters molar tooth extraction mandibular straumann wide neck placement positions prosthetic implant tooth MEDICAL_TRANSCRIPTION,Description Follow up update on patient with left carotid angioplasty and stent placement Medical Specialty Letters Sample Name Cardiology Letter Transcription Please accept this letter of follow up on patient xxx xxx He is now three months out from a left carotid angioplasty and stent placement He was a part of a CapSure trial He has done quite well with no neurologic or cardiac event in the three months of follow up He had a follow up ultrasound performed today that shows the stent to be patent with no evidence of significant recurrence Sincerely XYZ MD Keywords letters capsure cardiac event ultrasound carotid angioplasty stent placement letter angioplastyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Male with a history of therapy controlled hypertension borderline diabetes and obesity Risk factors for coronary heart disease Medical Specialty Letters Sample Name Cardiovascular Letter Transcription Dear Sample Doctor Thank you for referring Mr Sample Patient for cardiac evaluation This is a 67 year old obese male who has a history of therapy controlled hypertension borderline diabetes and obesity He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance Specifically no chest discomfort of any kind no dyspnea on exertion unless extreme exertion is performed no orthopnea or PND He is known to have a mother with coronary heart disease He has never been a smoker He has never had a syncopal episode MI or CVA He had his gallbladder removed No bleeding tendencies No history of DVT or pulmonary embolism The patient is retired rarely consumes alcohol and consumes coffee moderately He apparently has a sleep disorder according to his wife not in the office the patient snores and stops breathing during sleep He is allergic to codeine and aspirin angioedema Physical exam revealed a middle aged man weighing 283 pounds for a height of 5 feet 11 inches His heart rate was 98 beats per minute and regular His blood pressure was 140 80 mmHg in the right arm in a sitting position and 150 80 mmHg in a standing position He is in no distress Venous pressure is normal Carotid pulsations are normal without bruits The lungs are clear Cardiac exam was normal The abdomen was obese and organomegaly was not palpated There were no pulsatile masses or bruits The femoral pulses were 3 in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3 in character There was no peripheral edema He had a chemistry profile which suggests diabetes mellitus with a fasting blood sugar of 136 mg dl Renal function was normal His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL His sodium was a little bit increased His A1c hemoglobin was increased He had a spirometry which was reported as normal He had a resting electrocardiogram on December 20 2002 which was also normal He had a treadmill Cardiolite which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90 of the predicted maximum heart rate There were no symptoms or ischemia by EKG There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging In summary we have a 67 year old gentleman with risk factors for coronary heart disease I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity hypertension possible insulin resistance and some degree of fasting hyperglycemia as well as slight triglyceride elevation He denies any symptoms of coronary heart disease but he probably has some degree of coronary atherosclerosis possibly affecting the inferior wall by functional testings In view of the absence of symptoms medical therapy is indicated at the present time with very aggressive risk factor modification I explained and discussed extensively with the patient the benefits of regular exercise and a walking program was given to the patient He also should start aggressively losing weight I have requested additional testing today which will include an apolipoprotein B LPa lipoprotein as well as homocystine and cardio CRP to further assess his risk of atherosclerosis In terms of medication I have changed his verapamil for a long acting beta blocker he should continue on an ACE inhibitor and his Plavix The patient is allergic to aspirin I also will probably start him on a statin if any of the studies that I have recommended come back abnormal and furthermore if he is confirmed to have diabetes Along this line perhaps we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes which I believe he should This however I will leave entirely up to you to decide If indeed he is considered to be a diabetic a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general and coronary artery disease in particular I do not find an indication at this point in time to proceed with any further testing such as coronary angiography in the absence of symptoms If you have any further questions please do not hesitate to let me know Thank you once again for this kind referral Sincerely Sample Doctor M D Keywords letters cardiovascular letter angioedema beta blocker cardiac evaluation chest discomfort coronary heart disease hypertension metabolic syndrome therapy controlled hypertension truncal obesity controlled hypertension borderline diabetes risk factors heart disease intolerance therapy heart atherosclerosis diabetes coronary aspirin MEDICAL_TRANSCRIPTION,Description Patient seen in Neuro Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma Medical Specialty Letters Sample Name Anaplastic Astrocytoma Letter Transcription XYZ RE ABC MEDICAL RECORD 123 Dear Dr XYZ I saw ABC back in Neuro Oncology Clinic today He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma Within the last several days he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective Despite repeatedly emphasizing this however the patient still is worried about potential long term side effects from treatment that frankly seem unwarranted at this particular time After seeing you in clinic he and his friend again wanted to discuss possible changes in the chemotherapy regimen They came in with a list of eight possible agents that they would like to be administered within the next two weeks They then wanted another MRI to be performed and they were hoping that with the use of this type of approach they might be able to induce another remission from which he can once again be spared radiation From my view I noticed a man whose language has deteriorated in the week since I last saw him This is very worrisome Today for the first time I felt that there was a definite right facial droop as well Therefore there is no doubt that he is becoming symptomatic from his growing tumor It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future Emphasizing this once again in addition to recommending steroids I once again tried to convince him to undergo radiation Despite an hour this again amazingly was not possible It is not that he does not want treatment however Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised we compromised and elected to go back to Temodar in a low dose daily type regimen We would plan on giving 75 mg sq m everyday for 21 days out of 28 days In addition we will stop thalidomide 100 mg day If he tolerates this for one week we then agree that we would institute another one of the medications that he listed for us At this stage we are thinking of using Accutane at that point While I am very uncomfortable with this type of approach I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval In the spirit of compromise he again consented to be evaluated by radiation and this time seemed more resigned to the fact that it was going to happen sooner than later I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term I will keep you apprised of followups If you have any questions or if I could be of any further assistance feel free to contact me Sincerely Keywords letters neuro oncology anaplastic astrocytoma anaplastic oncology radiation astrocytoma MEDICAL_TRANSCRIPTION,Description Letter to the patient to let him know about his abnormal cholesterol test results Medical Specialty Letters Sample Name Abnormal Cholesterol Result Letter Transcription ABNORMAL CHOLESTEROL RESULT LETTER Recently you had a cholesterol test done The cholesterol levels were abnormal These are usually associated with increased risk for stroke and heart attack I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best step I would like you to make an appointment if you are interested in treatment for this There are several treatment options available at this time Diet is one of the options although there is limited reduction in total cholesterol and LDL cholesterol with dieting Most of the time under strict diet patients can achieve a 15 reduction in cholesterol If your cholesterol levels are moderate to severely elevated usually diet is not the first line of therapy If you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia Most of the time cholesterol that is elevated is from your genetic background and is independent of diet New research shows that treatment of high cholesterol can decrease your risk of developing Alzheimer s disease Again I am recommending at least we discuss medical treatment for hypercholesterolemia Please consider calling for a followup appointment concerning your cholesterol levels If you should have any further questions please do not hesitate to contact me I am enclosing a copy of your lab results for your review Keywords letters letter ldl abnormal cholesterol cholesterol level cholesterol test heart attack hypercholesterolemia increased risk lab results stroke total cholesterol abnormal cholesterol result abnormal cholesterol cholesterol levels levels treatment dietNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Specimen Lung left lower lobe resection Sarcomatoid carcinoma with areas of pleomorphic giant cell carcinoma and spindle cell carcinoma The tumor closely approaches the pleural surface but does not invade the pleura Medical Specialty Lab Medicine Pathology Sample Name Immunohistochemical Study Transcription CLINICAL HISTORY Patient is a 37 year old female with a history of colectomy for adenoma During her preop evaluation it was noted that she had a lesion on her chest x ray CT scan of the chest confirmed a left lower mass SPECIMEN Lung left lower lobe resection IMMUNOHISTOCHEMICAL STUDIES Tumor cells show no reactivity with cytokeratin AE1 AE3 No significant reactivity with CAM5 2 and no reactivity with cytokeratin 20 are seen Tumor cells show partial reactivity with cytokeratin 7 PAS with diastase demonstrates no convincing intracytoplasmic mucin No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody No significant reactivity is demonstrated with melanoma marker HMB 45 or Melan A Tumor cell nuclei spindle cell and pleomorphic giant cell carcinoma components show nuclear reactivity with thyroid transcription factor marker TTF 1 The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic giant cell carcinoma and spindle cell carcinoma components FINAL DIAGNOSIS Histologic Tumor Type Sarcomatoid carcinoma with areas of pleomorphic giant cell carcinoma and spindle cell carcinoma Tumor Size 2 7 x 2 0 x 1 4 cm Visceral Pleura Involvement The tumor closely approaches the pleural surface but does not invade the pleura Vascular Invasion Present Margins Bronchial resection margins and vascular margins are free of tumor Lymph Nodes Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes Pathologic Stage pT1N1MX Keywords lab medicine pathology cytokeratin 20 hmb 45 melanoma spindle cell carcinoma tumor cells carcinoma immunohistochemical lung cytokeratin sarcomatoid spindle pleural cell tumor MEDICAL_TRANSCRIPTION,Description Prostate adenocarcinoma and erectile dysfunction Pathology report Medical Specialty Lab Medicine Pathology Sample Name Pathology Prostate Transcription SPECIMENS 1 Pelvis right pelvic obturator node 2 Pelvis left pelvic obturator node 3 Prostate POST OPERATIVE DIAGNOSIS Adenocarcinoma of prostate erectile dysfunction DIAGNOSTIC OPINION 1 Adenocarcinoma Gleason score 9 with tumor extension to periprostatic tissue margin involvement and tumor invasion to seminal vesicle prostate 2 No evidence of metastatic carcinoma right pelvic obturator lymph node 3 Metastatic adenocarcinoma left obturator lymph node see description CLINICAL HISTORY None listed GROSS DESCRIPTION Specimen 1 labeled right pelvic obturator lymph nodes consists of two portions of adipose tissue measuring 2 5 x 1x 0 8 cm and 2 5 x 1x 0 5 cm There are two lymph nodes measuring 1 x 0 7 cm and 0 5 x 0 5 cm The entire specimen is cut into several portions and totally embedded Specimen 2 labeled left pelvic obturation lymph nodes consists of an adipose tissue measuring 4 x 2 x 1 cm There are two lymph nodes measuring 1 3 x 0 8 cm and 1 x 0 6 cm The entire specimen is cut into 1 cm The entire specimen is cut into several portions and totally embedded Specimen 3 labeled prostate consists of a prostate It measures 5 x 4 5 x 4 cm The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration External surface also shows tumor induration especially in right side External surface is stained with green ink The cut surface shows diffuse tumor induration especially in right side The tumor appears to extend to excision margin Multiple representative sections are made MICROSCOPIC DESCRIPTION Section 1 reveals lymph node There is no evidence of metastatic carcinoma Section 2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node Section 3 reveals adenocarcinoma of prostate Gleason s score 9 5 4 The tumor shows extension to periprostatic tissue as well as margin involvement Seminal vesicle attached to prostate tissue shows tumor invasion Dr XXX reviewed the above case His opinion agrees with the above diagnosis SUMMARY A Adenocarcinoma of prostate Gleason s score 9 with both lobe involvement and seminal vesicle involvement T3b B There is lymph node metastasis N1 C Distant metastasis cannot be assessed MX D Excision margin is positive and there is tumor extension to periprostatic tissue Keywords lab medicine pathology pelvic obturator node erectile dysfunction seminal vesicle prostate lymph node specimen section adenocarcinoma of prostate pelvic obturator tumor lymph node specimens adenocarcinoma MEDICAL_TRANSCRIPTION,Description Specimen labeled right ovarian cyst is received fresh for frozen section Medical Specialty Lab Medicine Pathology Sample Name Pathology Ovarian Cyst Transcription GROSS DESCRIPTION Specimen labeled right ovarian cyst is received fresh for frozen section It consists of a smooth walled clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid Both surfaces of the wall are pink tan smooth and grossly unremarkable No firm or thick areas or papillary structures are noted on the cyst wall externally or internally After removal the fluid the cyst weight 68 grams The fluid is transparent and slightly mucoid A frozen section is submitted DIAGNOSIS Benign cystic ovary Keywords lab medicine pathology right ovarian cyst specimen ovarian cyst frozen section ovarian frozen sectionNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Probable right upper lobe lung adenocarcinoma Specimen is received fresh for frozen section labeled with the patient s identification and Right upper lobe lung Medical Specialty Lab Medicine Pathology Sample Name Lung adenocarcinoma Path Report Transcription CLINICAL HISTORY Probable right upper lobe lung adenocarcinoma SPECIMEN Lung right upper lobe resection GROSS DESCRIPTION Specimen is received fresh for frozen section labeled with the patient s identification and Right upper lobe lung It consists of one lobectomy specimen measuring 16 1 x 10 6 x 4 5 cm The specimen is covered by a smooth pink tan and gray pleural surface which is largely unremarkable Sectioning reveals a round ill defined firm tan gray mucoid mass This mass measures 3 6 x 3 3 x 2 7 cm and is located 3 7 cm from the closest surgical margin and 3 9 cm from the hilum There is no necrosis or hemorrhage evident The tumor grossly appears to abut but not invade through the visceral pleura and the overlying pleura is puckered FINAL DIAGNOSIS Right lung upper lobe lobectomy Bronchioloalveolar carcinoma mucinous type COMMENT Right upper lobe lobectomy Tumor type Bronchioloalveolar carcinoma mucinous type Histologic grade Well differentiated Tumor size greatest diameter 3 6 cm Blood lymphatic vessel invasion Absent Perineural invasion Absent Bronchial margin Negative Vascular margin Negative Inked surgical margin Negative Visceral pleura Not involved In situ carcinoma Absent Non neoplastic lung Emphysema Hilar lymph nodes Number of positive lymph nodes 0 Total number of lymph nodes 1 P53 immunohistochemical stain is negative in the tumor Keywords lab medicine pathology bronchioloalveolar carcinoma mucinous mucoid mass lymph nodes upper lobe visceral bronchioloalveolar carcinoma lymph pleural margin tumor adenocarcinoma specimen lobe lung MEDICAL_TRANSCRIPTION,Description Specimen labeled sesamoid bone left foot Medical Specialty Lab Medicine Pathology Sample Name Pathology Sesamoid Bone Transcription GROSS DESCRIPTION Specimen labeled sesamoid bone left foot is received in formalin and consists of three irregular fragments of grey brown hard bony tissue admixed with multiple fragments of brown tan rubbery fibrocollagenous soft tissue altogether measuring 3 1 x 1 5 x 0 9 cm The specimen is entirely submitted after decalcification DIAGNOSIS Acute Osteomyelitis with foci of marrow fibrosis Focal acute and chronic inflammation of fascia and soft tissue Arteriosclerosis severely occlusive Keywords lab medicine pathology marrow fibrosis osteomyelitis arteriosclerosis inflammation of fascia specimen fragmentsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The right upper lobe wedge biopsy shows a poorly differentiated non small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy Medical Specialty Lab Medicine Pathology Sample Name Lung Biopsy Pathology Report 1 Transcription GROSS DESCRIPTION A Received fresh labeled with patient s name designated right upper lobe wedge is an 8 0 x 3 5 x 3 0 cm wedge of lung which has an 11 5 cm staple line There is a 0 8 x 0 7 x 0 5 cm sessile tumor with surrounding pleural puckering B Received fresh labeled with patient s name designated lymph node is a 1 7 cm possible lymph node with anthracotic pigment C Received fresh labeled with patient s name designated right upper lobe is a 16 0 x 14 5 x 6 0 cm lobe of lung The lung is inflated with formalin There is a 12 0 cm staple line on the lateral surface inked blue There is a 1 3 x 1 1 x 0 8 cm subpleural firm ill defined mass 2 2 cm from the bronchial margin and 1 5 cm from the previously described staple line The overlying pleura is puckered D Received fresh labeled with patient s name designated 4 lymph nodes is a 2 0 x 2 0 x 2 0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue E Received fresh labeled with patient s name designated subcarinal lymph node is a 2 0 x 1 7 x 0 8 cm aggregate of lymphoid material with anthracotic pigment FINAL DIAGNOSIS A Right upper lobe wedge lung biopsy Poorly differentiated non small cell carcinoma Tumor Size 0 8 cm Arterial large vessel invasion Not seen Small vessel lymphatic invasion Not seen Pleural invasion Not identified Margins of excision Negative for malignancy B Biopsy 10R lymph node Anthracotically pigmented lymphoid tissue negative for malignancy C Right upper lobe lung Moderately differentiated non small cell carcinoma adenocarcinoma Tumor Size 1 3 cm Arterial large vessel invasion Present Small vessel lymphatic invasion Not seen Pleural invasion Not identified Margins of excision Negative for malignancy D Biopsy 4R lymph nodes Lymphoid tissue negative for malignancy E Biopsy subcarinal lymph node Lymphoid tissue negative for malignancy COMMENTS Pathologic examination reveals two separate tumors in the right upper lobe They appear histologically distinct suggesting they are separate primary tumors pT1 The right upper lobe wedge biopsy part A shows a poorly differentiated non small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy The right upper lobe carcinoma identified in the resection part C is a moderately differentiated adenocarcinoma with obvious gland formation Keywords lab medicine pathology lung biopsy wedge lobe pathologic lymph node node lymphoid malignancy lung lymph biopsy MEDICAL_TRANSCRIPTION,Description Lung wedge biopsy right lower lobe and resection right upper lobe Lymph node biopsy level 2 and 4 and biopsy level 7 subcarinal PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe which were also identified by CT scan Medical Specialty Lab Medicine Pathology Sample Name Lung Biopsy Pathology Report Transcription CLINICAL HISTORY A 48 year old smoker found to have a right upper lobe mass on chest x ray and is being evaluated for chest pain PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe which were also identified by CT scan The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter The patient was referred for surgical treatment SPECIMEN A Lung wedge biopsy right lower lobe B Lung resection right upper lobe C Lymph node biopsy level 2 and 4 D Lymph node biopsy level 7 subcarinal FINAL DIAGNOSIS A Wedge biopsy of right lower lobe showing Adenocarcinoma Grade 2 Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin B Right upper lobe lung resection showing Adenocarcinoma grade 2 measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin Two 2 hilar lymph nodes with no metastatic tumor C Lymph node biopsy at level 2 and 4 showing seven 7 lymph nodes with anthracosis and no metastatic tumor D Lymph node biopsy level 7 subcarinal showing 5 lymph nodes with anthracosis and no metastatic tumor COMMENT The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor there is isolated nests of tumor cells within the air spaces Furthermore immunoperoxidase stain for Ck 7 CK 20 and TTF are performed on both the right lower and right upper lobe nodule The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe Keywords lab medicine pathology pet scan wedge biopsy morphology lung wedge biopsy lymph node biopsy lymph node lower lobe tumor biopsy lobe lung mass lymph node MEDICAL_TRANSCRIPTION,Description Is it BNP or BMP Medical Specialty Lab Medicine Pathology Sample Name BNP v s BMP Transcription BNP brain natriuretic peptide or B type natriuretic peptide is a substance produced in the heart ventricles when there is excessive strain to the heart muscles A blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure where the heart is unable to pump sufficient amount of blood required by the body s needs When a person has a heart failure such as MI BNP is secreted so immensely that it sits well above the measurable range Values above 100 signal a problematic situation and those above 500 a highly demanding state Note that a person with a remote history of heart problems may not have BNP levels elevated but it is used as a measure of acute events On the other hand BMP or basic metabolic panel is not a single test but a group of 8 tests glucose calcium sodium potassium bicarbonate chloride BUN creatinine Any test that has the word panel in it is not a single test so cannot have a single value With this logic in mind if a doctor uses phrases like BNP BMP is elevated negative positive is greater than less than etc and then a single value it may not be BMP You can also take the hint from the file whether the patient presented to the hospital with an acute coronary event Likewise if he says multiple values for this test this must be BMP Keywords lab medicine pathology brain natriuretic peptide b type natriuretic peptide basic metabolic panel glucose calcium sodium potassium bicarbonate chloride bun creatinine natriuretic peptide bmp bnp MEDICAL_TRANSCRIPTION,Description Right shoulder impingement syndrome right suprascapular neuropathy Medical Specialty IME QME Work Comp etc Sample Name Impairment Rating Transcription CHIEF COMPLAINT Right shoulder pain HISTORY The patient is a pleasant 31 year old right handed white female who injured her shoulder while transferring a patient back on 01 01 02 She formerly worked for Veteran s Home as a CNA She has had a long drawn out course of treatment for this shoulder She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002 She had ongoing pain and was evaluated by Dr X who felt that she had a possible brachial plexopathy He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms He then referred her to ABCD who did EMG testing demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12 18 03 She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr X She comes to me for impairment rating She has no chronic health problems otherwise fevers chills or general malaise She is not working She is right hand dominant She denies any prior history of injury to her shoulder PAST MEDICAL HISTORY Negative aside from above FAMILY HISTORY Noncontributory SOCIAL HISTORY Please see above REVIEW OF SYSTEMS Negative aside from above PHYSICAL EXAMINATION A pleasant age appropriate woman moderately overweight in no apparent distress Normal gait and station normal posture normal strength tone sensation and deep tendon reflexes with the exception of 4 5 strength in the supraspinatus musculature on the right She has decreased motion in the right shoulder as follows She has 160 degrees of flexion 155 degrees of abduction 35 degrees of extension 25 degrees of adduction 45 degrees of internal rotation and 90 degrees of external rotation She has a positive impingement sign on the right ASSESSMENT Right shoulder impingement syndrome right suprascapular neuropathy DISCUSSION With a reasonable degree of medical certainty she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment Fifth Edition The reason for this impairment is the incident of 01 01 02 For her suprascapular neuropathy she is rated as a grade IV motor deficit which I rate as a 13 motor deficit This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16 which produces a 2 impairment of the upper extremity when the two values are multiplied together 2 impairment of the upper extremity For her lack of motion in the shoulder she also has additional impairment on the right She has a 1 impairment of the upper extremity due to lack of shoulder flexion She has a 1 impairment of the upper extremity due to lack of shoulder abduction She has a 1 impairment of the upper extremity due to lack of shoulder adduction She has a 1 impairment of the upper extremity due to lack of shoulder extension There is no impairment for findings in shoulder external rotation She has a 3 impairment of the upper extremity due to lack of shoulder internal rotation Thus the impairment due to lack of motion in her shoulder is a 6 impairment of the upper extremity This combines with the 2 impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8 impairment of the upper extremity which in turn is a 5 impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment Fifth Edition stated with a reasonable degree of medical certainty Keywords ime qme work comp etc ama guide evaluation of permanent impairment impairment rating permanent impairment suprascapular nerve suprascapular neuropathy injured extremity shoulder impairment neuropathy suprascapular MEDICAL_TRANSCRIPTION,Description Patient presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus Medical Specialty IME QME Work Comp etc Sample Name Major Depressive Disorder IME Consult Transcription IDENTIFYING DATA Mr T is a 45 year old white male CHIEF COMPLAINT Mr T presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus His confidence and self esteem are significantly low He stated he has excessive somnolence his energy level is extremely low motivation is low and he has a lack for personal interests He has had suicidal ideation but this is currently in remission Furthermore he continues to have hopeless thoughts and crying spells Mr T stated these symptoms appeared approximately two months ago HISTORY OF PRESENT ILLNESS On March 25 2003 Mr T was fired from his job secondary to an event at which he stated he was first being harassed by another employee This other employee had confronted Mr T with a very aggressive verbal style where this employee had placed his face directly in front of Mr T was spitting on him and called him bitch Mr T then retaliated and went to hit the other employee Due to this event Mr T was fired It should be noted that Mr T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to deal with it There are no other apparent stressors in Mr T s life at this time or in recent months Mr T stated that work was his entire life and he based his entire identity on his work ethic It should be noted that Mr T was a process engineer for Plum Industries for the past 14 years PAST PSYCHIATRIC HISTORY There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr T s family physician Dr B at which point Mr T was placed on Lexapro with an unknown dose at this time Mr T is currently seeing Dr J for psychotherapy where he has been in treatment since April 2003 PAST PSYCHIATRIC REVIEW OF SYSTEMS Mr T denied any history throughout his childhood adolescence and early adulthood for depressive anxiety or psychotic disorders He denied any suicide attempts or profound suicidal or homicidal ideation Mr T furthermore stated that his family psychiatric history is unremarkable SUBSTANCE ABUSE HISTORY Mr T stated he used alcohol following his divorce in 1993 but has not used it for the last two years No other substance abuse was noted LEGAL HISTORY Currently charges are pending over the above described incident MEDICAL HISTORY Mr T denied any hospitalizations surgeries or current medications use for any heart disease lung disease liver disease kidney disease gastrointestinal disease neurological disease closed head injury endocrine disease infectious blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia PERSONAL AND SOCIAL HISTORY Mr T was born in Dwyne Missouri with no complications associated with his birth Originally he was raised by both parents but they separated at an early age When he was about seven years old he was raised by his mother and stepfather He did not sustain a relationship with his biological father from that time on He stated his parents moved a lot and because this many times he was picked on in his new environments Mr T stated he was at times a rebellious teenager but he denied any significant inability to socialize and denied any learning disabilities or the need for special education Mr T stated his stepfather was somewhat verbally abusive and that he committed suicide when Mr T was 18 years old He graduated from high school and began work at Dana Corporation for two to three years after which he worked as an energy auditor for a gas company He then became a homemaker while his wife worked for Chrysler for approximately two years Mr T was married for eleven years and divorced in 1993 He has a son who is currently 20 years old After being a home maker Mr T worked for his mother in a restaurant and moved on from there to work for Borg Warner corporation for one to two years before beginning at Plum Industries where he worked for 14 years and worked his way up to lead engineer Mental Status Exam Mr T presented with a hyper vigilant appearance his eye contact was appropriate to the interview and his motor behavior was tense At times he showed some involuntary movements that would be more akin to a resting tremor There was no psychomotor retardation but there was some mild psychomotor excitement His speech was clear concise but pressured His attitude was overly negative and his mood was significant for moderate depression anxiety anhedonia and loneliness and mild evidence of anger There was no evidence of euphoria or diurnal mood variation His affective expression was restricted range but there was no evidence of lability At times his affective tone and facial expressions were inappropriate to the interview There was no evidence of auditory visual olfactory gustatory tactile or visceral hallucinations There was no evidence of illusions depersonalizations or derealizations Mr T presented with a sequential and goal directed stream of thought There was no evidence of incoherence irrelevance evasiveness circumstantiality loose associations or concrete thinking There was no evidence of delusions however there was some ambivalence guilt and self derogatory thoughts There was evidence of concreteness for similarities and proverbs His intelligence was average His concentration was mildly impaired and there was no evidence of distractibility He was oriented to time place person and situation There was no evidence of clouded consciousness or dissociation His memory was intact for immediate recent and remote events He presented with poor appetite easily fatigued and decreased libidinal drive as well as excessive somnolence There was a moderate preoccupation with his physical health pertaining to his headaches His judgment was poor for finances family relations social relations employment and at this time he had no future plans Mr T s insight is somewhat moderate as he is aware of his contribution to the problem His motivation for getting well is good as he accepts offered treatment complies with recommended treatment and seeks effective treatments He has a well developed empathy for others and capacity for affection There was no evidence of entitlement egocentricity controllingness intimidation or manipulation His credibility seemed good There was no evidence for potential self injury suicide or violence The reliability and completeness of information was very good and there were no barriers to communication The information gathered was based on the patient s self report and objective testing and observation His attitude toward the examiner was neutral and his attitude toward the examination process was neutral There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings and there was no lack of cooperation with the evaluation or poor compliance with treatment and no evidence of antisocial personality disorder IMPRESSIONS Major Depressive Disorder single episode RECOMMENDATIONS AND PLAN I recommend Mr T continue with psychopharmacologic care as well as psychotherapy At this time the excessive amount of psychiatric symptoms would impede Mr T from seeking employment Furthermore it appears that the primary precipitating event had occurred on March 25 2003 when Mr T was fired from his job after being harassed for over a year As Mr T placed his entire identity and sense of survival on his work this was a deafening blow to his psychological functioning Furthermore it only appears logical that this would precipitate a major depressive episode Keywords ime qme work comp etc muscle tremor headaches excessive nervousness poor concentration independent medical evaluation psychopharmacologic poor ability to focus major depressive disorder tremor depressive psychiatric MEDICAL_TRANSCRIPTION,Description Hospice visit for 77 year old gentleman with advanced colon cancer Medical Specialty Hospice Palliative Care Sample Name Hospice Visit Colon Cancer Transcription HISTORY OF PRESENT ILLNESS History as provided primarily by the patient s daughter as well as the referring physician revealed an approximately two year history of colon cancer initially diagnosed when the patient presented with a swelling in his groin Approximately one month ago he presented with abdominal pain and presented to the hospital with transverse colon obstruction He had a diverting colostomy performed approximately one month ago Approximately two weeks ago he was admitted to hospital with infection of this with chronically swollen lower extremities and is home now for approximately one week He was deemed not to be a candidate for chemotherapy or radiation on the basis of extensive disease as well as a longstanding history of cirrhosis with esophageal varices Additional history includes an enlarged heart and chronic lower extremity edema associated with trauma from his time as an army infantryman in Korea many decades ago The patient is alert and lives alone although the daughter Ruby is in from out of town for several weeks to care for him He denies any particular problems with the exception of itch and a site of leakage around his ostomy site His appetite is notably improved since discharge from hospital and both he and his daughter believe he has gained a few pounds of weight His stooling is regular There is no fever Of greatest concern to his daughter is a possibility that his colostomy might be reversible and at the recommendation of some of the physicians at the referring hospital he was to have had a PET scan to assess whether the ostomy is reversible for various reasons primarily insurance The PET scan has not been done and the family is quite concerned about a potential surgical intervention The patient denies anxiety or depression and there is no history of same He was married for over 50 years and now widowed for nearly 10 He is a stepfather to five children and he has seven of his own all in all raising 12 children His daughters Ruby and Camilla are most involved with the patient s care The patient is retired worked in supermarkets for many years when he is very proud of his time as an infantryman in Korea He did sustain an injury to the right eye during his service He has lots of children grandchildren and great grandchildren and seems to derive great pleasure from them He denies spiritual or religious distress As to advanced directives the patient appears not to have any significant advanced directives written or oral Family apparently is working on a plan MEDICATIONS Medications include Toprol 12 5 mg twice daily Lasix 20 mg daily ranitidine 75 mg daily potassium 20 mEq daily Benadryl 25 50 mg at the hour of sleep as needed not typically taken and a prescription in the house for Keflex 500 mg q i d for red legs has not yet begun PHYSICAL EXAMINATION Examination reveals am alert pale but thin gentleman with evident wasting He is seated and walks without assistance His blood pressure is 135 75 Pulse is 80 Respiratory rate is 14 He is afebrile Head is without icterus Pupils are equal and round He has a red dry tongue without leaking mucosal lesions There is no jugular venous distention The chest has increased AP diameter with good air entry bilaterally There is a systolic ejection murmur heard over the entire precordium The rate is regular The abdomen he has a right sided colostomy with a prolapsed bowel There is an area of approximately 5 cm x 8 cm of erythema adjacent to the ostomy The skin is intact The bowel sounds are active There is no tenderness in the abdomen and no palpable masses Extremities show chronic lymphedema The right lower extremity has an 8 cm x 10 cm patch over the anterior shin that is darkened but not red and not warm The distal pulses are intact Rectal exam shows no external nor internal hemorrhoids No mass is felt and no blood on the gloved finger Neurologically he is alert He is oriented times three His speech is clear His mood appears to be good His short term memory is intact There is no focal neurological deficit ASSESSMENT A 77 year old gentleman with apparent widespread intra abdominal spread of rectal cancer Status post bowel obstruction Comorbid cirrhosis with esophageal varices No history of bleeding The patient has had significant clinical and functional decline and I expect that his prognosis would be measured in weeks to months The patient lives alone and is currently being very well cared for his daughter from out of town She will be leaving in a few weeks There is another in town daughter however she works and has a large family PLAN I will communicate with the patient s referring physician to ascertain what clinical course and data is available A moisture barrier will be applied to his peri ostomy wound today and we would reassess within 24 hours It would be appropriate for a family meeting to be scheduled to review the family and the patient s understanding of his clinical condition and to begin to address an appropriate plan of care for the patient s inevitable decline I spoke with Dr Abc who informed me that family has in their possession a disc with the CAT scan results We will try to ask radiologic colleagues when we obtain the disc to give us a formal reading so that we might better understand the patient s clinical condition and better inform family of his clinical status Keywords hospice palliative care hospice cat scan results hospice nurse pet scan abdominal pain admitted to hospital cirrhosis colon cancer colon obstruction esophageal varices longstanding moisture barrier referring physician health colon cancer MEDICAL_TRANSCRIPTION,Description Back injury with RLE radicular symptoms The patient is a 52 year old male who is here for independent medical evaluation Medical Specialty IME QME Work Comp etc Sample Name Back Injury IME Transcription PAST MEDICAL CONDITION None ALLERGIES None CURRENT MEDICATION Zyrtec and hydrocodone 7 5 mg one every 4 to 6 hours p r n for pain CHIEF COMPLAINT Back injury with RLE radicular symptoms HISTORY OF PRESENT ILLNESS The patient is a 52 year old male who is here for independent medical evaluation The patient states that he works for ABC ABC as a temporary worker He worked for ABCD too The patient s main job was loading and unloading furniture and appliances for the home The patient was approximately there for about two and a half weeks Date of injury occurred back in October The patient stating that he had history of previous back problems ongoing however he states that on this particular day back in October he was unloading an 18 wheeler at ABC and he was bending down picking up boxes to unload and load Unfortunately at this particular event the patient had sharp pain in his lower back Soon afterwards he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee This became progressively worse He also states that some of his radiating pain went down to his left leg as well He noticed increase in buttock spasm and also noticed spasm in his buttocks He initially saw Dr Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch I believe The patient states that after this treatment his symptoms still persisted At this point the patient later on was referred to Dr XYZ through the workmen s comp and he was initially evaluated back in April After the evaluation the patient was sent for MRI was provided with pain medications such as short acting opioids He was put on restricted duty The MRI essentially came back negative but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr XYZ in June with maximum medical improvement Unfortunately the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr XYZ again and at this point the patient was provided with further medication management and sent for Pain Clinic referral The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr ABC without any significant relief The patient also was sent for EMG and nerve conduction study which was performed by Dr ABCD and the MRI EMG and nerve conduction study came back essentially negative for radiculopathy which was performed by Dr ABCD The patient states that he continues to have pain with extended sitting he has radiating symptoms down to his lower extremity on the right side of his leg increase in pain with stooping He has difficulty sleeping at nighttime because of increase in pain Ultimately the patient was returned back to work in June and deemed with maximum medical improvement back in June The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg worse than the left side The patient also went to see Dr X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long term relief in his overall radicular symptoms PHYSICAL EXAMINATION The patient was examined with the gown on Lumbar flexion was moderately decreased Extension was normal Side bending to the right was decreased Side bending to the left was within normal limits Rotation and extension to the right side was causing increasing pain Extension and side bending to the left was within normal limits without significant pain on the left side While seated straight leg was negative on the LLE at 90 and also negative on the RLE at 90 There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position In supine position straight leg was negative in the LLE and also negative on the RLE Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits Deep tendon reflex at the patella was 2 4 bilaterally but there was a decrease in reflex in the Achilles tendon 1 4 on the right side and essentially 2 4 on the left side Medial hamstring reflex was 2 4 on both hamstrings as well On prone position there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area right side was worse than the left side Increase in pain at deep palpatory examination in midline of the L5 and S1 level MEDICAL RECORD REVIEW I had the opportunity to review Dr XYZ s medical records Also reviewed Dr ABC procedural note which was the epidural steroid injection block that was performed in December Also reviewed Dr X s medical record notes and an EMG and nerve study that was performed by Dr ABCD which was essentially normal The MRI of the lumbar spine that was performed back in April which showed no evidence of herniated disc DIAGNOSIS Residual from low back injury with right lumbar radicular symptomatology EVALUATION RECOMMENDATION The patient has an impairment based on AMA Guides Fifth Edition and it is permanent The patient appears to have re aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18 wheel truck Essentially there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left The patient also has increase in back pain with lumbar flexion and rotational movement to the right side With these ongoing symptoms the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function Therefore the patient is assigned 8 impairment of the whole person We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide Using page 384 table 15 3 the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury In this particular section it states that the patient s clinical history and examination findings are compatible with specific injury and finding may include significant muscle guarding or spasm observed at the time of examination a symmetric loss of range of motion or non verifiable radicular complaints define his complaints of radicular pain without objective findings no alteration of the structural integrity and no significant radiculopathy The patient also has decrease in activities of daily living therefore the patient is assigned at the higher impairment rating of 8 WPI In the future the patient should avoid prolonged walking standing stooping squatting hip bending climbing excessive flexion extension and rotation of his back His one time weight limit should be determined by work trial although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology the patient also should be monitored closely for specific dependency to short acting opioids in the near future by specialist who could monitor and closely follow his overall pain management The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future Keywords ime qme work comp etc rle radicular symptoms independent medical evaluation injury lle deep tendon reflex emg mri lumbar radicular symptomatology MEDICAL_TRANSCRIPTION,Description Initial visit for a 95 year old gentleman with a Hospice diagnosis of CHF Medical Specialty Hospice Palliative Care Sample Name Hospice Visit CHF Transcription HISTORY This is an initial visit for this 95 year old gentleman with a Hospice diagnosis of CHF He was referred to us by Dr ABC who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20 25 The patient was seen in the office approximately three days ago with a clinical diagnosis of bronchitis The FES as well as the daughter report that he has had significant clinical and functional decline over the last two to three weeks He is no longer ambulatory His appetite is significantly decreased and he had significant unmeasured weight loss He is notably more weak He is unable to perform any of the activities of daily living and he is increasingly somnolent with poor sleep at night The patient says that he is ready to die that he is after all 95 years old and is aware that his clinical and functional status has been declining He worked as a chef for almost seven decades and retired approximately two years ago He denies pain He admits to some cough but he believes the cough is improved on the current antibiotic He does note that he sleeps poorly and unable to indicate a cause for that difficulty in sleeping He reports that he recently made a trip to California where he said goodbye to his children that live there The patient reports that his goals of care are to stay at home He has never been hospitalized with the exception of some surgery on his back in Houston Texas decades ago that he has no interest in going to a hospital and that he would be happy to sign a DNR form and that he would like no heroics performed in the event that his heart or breathing stops He denies anxiety or depression and feels that his life has been quite full and quite successful and that when time comes he is ready to go MEDICATIONS His medications include Avelox 400 mg He is on day four of a seven day dose He is on Coreg 3 125 mg a day lisinopril 5 mg a day Coumadin 2 5 mg a day digoxin 0 125 mg every other day Lasix 80 mg twice daily Inspra twice daily and he is on a transdermal nitro patch 12 hours on and 12 hours off He takes Tylenol extra strength every four to six hours for bilateral shoulder pain typically one to two doses a day PHYSICAL EXAMINATION Exam reveals a cachectic somnolent gentleman who appears to be comfortable His blood pressure is 90 60 His heart rate is 80 and irregular His respiratory rate is 14 Head reveals marked temporal wasting He is anicteric The pupils are equal and round There is jugular venous distention noted approximately 2 3 cm above the notch Chest shows good air entry bilaterally with scattered rhonchi No audible wheezing His heart sounds are irregular and there is a musical systolic ejection murmur radiating to the axilla The abdomen is soft with a large midline well healed surgical scar The bowel sounds are normoactive There is no tenderness or palpable organomegaly He has 2 edema of his lower extremities with some weeping of the right lower extremity and no evidence of infection Neurologically while somnolent easily aroused and speech is quite clear He identities the date as October of 2008 but is otherwise oriented His short term memory is quite poor His insight is also poor He appears to be somewhat sad There are mild regular tremors right hand worse than left but there is otherwise no focal neurological deficit A phone conversation with his daughter Xyz his health care proxy ensued His daughter is very concerned with his clinical decline and is raising the question of whether he would benefit from hospitalization She reports that her mother died after a many year course with heart failure and had upwards of three dozen hospitalizations At each hospitalization she seem to derive benefit and wondered if her dad would drive equal benefit from hospitalizations She is aware that he is unwilling to be hospitalized and I believe hopefully that the Hospice team might persuade him She also reports that he has been talking about dying for nearly five years ASSESSMENT A 95 year old gentleman with endstage CHF with recent significant clinical and functional decline The patient appears to have relatively little in the way of symptoms although perhaps some sleep hygiene might be of help While today the patient appears to be very calm and sedated the history is one of significant emotional lability Family is having great difficulty accepting the terminality of the patient s circumstances PLAN A DNR was placed in the house after the above noted conversation was had I believe the patient might benefit from low dose hypnotic and 7 5 mg of Restoril was ordered Reassessment of the patient s condition is warranted A family meeting will be offered to review the circumstances of the patient s condition in hopes that family might better accept his wishes and to develop a plan of care for this gentleman Keywords hospice palliative care hospice chf dnr dnr was placed hospice team air entry appetite bronchitis cardiomyopathy clinical diagnosis ejection fraction functional decline hospitalization hospitalized initial visit plan of care somnolent weight loss MEDICAL_TRANSCRIPTION,Description First degree and second degree burns right arm secondary to hot oil spill Workers Compensation industrial injury Medical Specialty IME QME Work Comp etc Sample Name Burn Consult Transcription CHIEF COMPLAINT Burn right arm HISTORY OF PRESENT ILLNESS This is a Workers Compensation injury This patient a 41 year old male was at a coffee shop where he works as a cook and hot oil splashed onto his arm burning from the elbow to the wrist on the medial aspect He has had it cooled and presents with his friend to the Emergency Department for care PAST MEDICAL HISTORY Noncontributory MEDICATIONS None ALLERGIES None PHYSICAL EXAMINATION GENERAL Well developed well nourished 21 year old male adult who is appropriate and cooperative His only injury is to the right upper extremity There are first and second degree burns on the right forearm ranging from the elbow to the wrist Second degree areas with blistering are scattered through the medial aspect of the forearm There is no circumferential burn and I see no areas of deeper burn The patient moves his hands well Pulses are good Circulation to the hand is fine FINAL DIAGNOSIS 1 First degree and second degree burns right arm secondary to hot oil spill 2 Workers Compensation industrial injury TREATMENT The wound is cooled and cleansed with soaking in antiseptic solution The patient was ordered Demerol 50 mg IM for pain but he refused and did not want pain medication A burn dressing is applied with Neosporin ointment The patient is given Tylenol No 3 tabs 4 to take home with him and take one or two every four hours p r n for pain He is to return tomorrow for a dressing change Tetanus immunization is up to date Preprinted instructions are given Workers Compensation first report and work status report are completed DISPOSITION Home Keywords ime qme work comp etc burn workers compensation industrial injury workers compensation degree MEDICAL_TRANSCRIPTION,Description Hospice care for a 55 year old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs Medical Specialty Hospice Palliative Care Sample Name Hospice Visit CA of Cervix Transcription HISTORY OF PRESENT ILLNESS The patient is a 55 year old woman with carcinoma of the cervix metastatic to retroperitoneum lung which was diagnosed approximately two years ago There is a nodule in her lung which was treated by excision in February of 2007 on the right side She had spread to her kidney She had right sided nephrectomy and left sided nephrostomy She also had invasion of the bladder Currently all of her urine comes out through the renal nephrostomy She complains of burning vaginal pain as well as chronic discharge which has improved slightly recently She is not able to engage in intercourse because of the pain and bleeding She also has pain with bowel movements as well as painful urgency The pain is at least 3 4 10 and is partially relieved with methadone rescues and interferes with her ability to sleep at night as she feels exhausted and tired She has some nausea and diminished appetite No hallucinations She is anxious frequently and this is helped with clonazepam which she has taken chronically for her anxiety disorder and recently started Zyprexa She has occasional shortness of breath which used to be helped with oxygen in the hospital PAST MEDICAL HISTORY Peptic ulcer disease hypertension REVIEW OF SYSTEMS She has constipation with hard bowel movements MEDICATIONS Norvasc 10 mg daily isosorbide 60 mg every 24 hours olanzapine at 2 5 5 mg in bedtime clonazepam 1 mg every eight hours Sorbitol 30 cc twice a day Senna S two tabs daily methadone 60 mg every eight hours and 30 mg every four hours p r n pain ALLERGIES She has no known allergies SOCIAL HISTORY The patient lives with her common law husband and her daughter Code Status DNR Religion Catholic She has a past history of heroin use and was enrolled in MMTP program for 12 hours She reports feeling discouraged from her symptoms and pain PHYSICAL EXAMINATION Blood pressure 120 80 pulse 80 and respirations 14 General Appearance Mildly obese woman PERRLA 3 mm Oral mucosa moist without lesions Lungs Clear Heart RRR without murmurs Abdomen Somewhat distended but soft and nontender There is firmness found in the low abdomen bilaterally There is erythema in the intertriginous area and vulva as well as some serous discharge from the vagina Neurological Exam Cranial nerves II through XII are grossly intact There is normal tone Power is 5 5 DTRs nonreactive Sensation intact to fine touch Mental Status The patient is alert fully oriented normal speech and thought process Normal affect ASSESSMENT AND PLAN 1 Carcinoma of the cervix metastatic to the retroperitoneum bladder and lung with irritable obstruction and gradual decline in the performance status Given this her prognosis is likely to be limited to six months and she will benefit from home hospice care 2 Pain which is a combination of somatic nociceptive pain due to the retroperitoneal invasion as well as a neuropathic component from pelvic and nerve involvement by the surgery as well as radiation therapy and disease itself We are going to increase methadone to 70 mg every eight hours and continue 30 mg for breakthrough We will add pregabalin 50 mg three times a day and titrate the dose up as needed 3 Nausea and poor appetite We will start Megace 200 mg daily 4 Shortness of breath We will provide oxygen p r n 5 Candidal infection We will start clotrimazole 1 cream b i d 6 Constipation We will advance the bowel regimen to Sorbitol 30 cc three times a day and Senna S three tabs twice a day 7 Psychosocial The patient is getting discouraged We will provide supportive counseling Length of the encounter was 80 minutes more than half spent on exchange of information Thank you for the opportunity to participate in the care for this patient Keywords hospice palliative care hospice carcinoma of the cervix code status length of the encounter mmtp program normal affect shortness of breath bladder decline exchange of information hospice care irritable obstruction lung nephrectomy nephrostomy performance status poor appetite prognosis is likely to be limited to retroperitoneum carcinoma metastatic cervix lungs MEDICAL_TRANSCRIPTION,Description Hospice care for a 41 year old man with the AIDS complicated with recent cryptococcal infection disseminated MAC and Kaposi s sarcoma Medical Specialty Hospice Palliative Care Sample Name Hospice Visit AIDS Transcription HISTORY OF PRESENT ILLNESS The patient is a 41 year old man with the AIDS complicated with recent cryptococcal infection disseminated MAC and Kaposi s sarcoma His viral load in July of 2007 was 254 000 and CD4 count was 7 He was recently admitted for debility and possible pneumonia He was started on antiretroviral therapy as well as Cipro and Flagyl and was also found to have pleural effusion on the right His history is also significant for pancreatitis and transient renal failure during last hospitalization He became frustrated since he was not getting better and discontinued all antibiotics When taken home yesterday he had symptoms consistent with a partial bowel obstruction He was vomiting and had no bowel movements for a few days Last night was able to have a bowel movement and has not vomited since then He was able to take small amounts of food He now has persistent cough productive of clear sputum and some shortness of breath He also complains of pain at his KS lesions on the right leg and left thigh especially when touched although that pain is incidental and not present when he is simply lying down He has overall weakness PAST MEDICAL HISTORY Unremarkable MEDICATIONS Acetaminophen 650 mg q 6h p r n fever which he has not been using Motrin 400 mg q 6h p r n pain which has not helped His pain and dexamethasone with guaifenesin 5 10 mL q 4h p r n cough ALLERGIES He has no known allergies SOCIAL HISTORY The patient is now staying with his mother He is the youngest of six children Code Status DNR His brother is the health care proxy PHYSICAL EXAMINATION Blood pressure 140 80 pulse 120 and respirations 28 Temperature 103 9 General Appearance Ill looking young man diaphoretic PERRLA 3 mm Oral mucosa moist without lesions Lungs Diminished breath sounds in the right middle lower lobe Heart RRR without murmurs Abdomen Distended with soft and nontender Diminished bowel sounds Extremities Without cyanosis or edema There is a large Kaposi s sarcoma on the right medial leg and left medial proximal thigh which is somewhat tender Neurological Exam Cranial nerves II through XII are grossly intact There is normal tone Power is 4 5 DTRs nonreactive Normal fine touch Mental Status The patient is somnolent but arousable Withdrawn affect Normal speech and though process ASSESSMENT AND PLAN 1 AIDS complicated with multiple opportunistic infections with poor performance status which suggested a limited prognosis of less than six months He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments 2 Pain which is somatic nociceptive from KS lesions The patient has not tolerated morphine in the past We will start oxycodone 5 mg q 2h as needed 3 Cough We will use oxycodone with the same indication as well 4 Fever We encouraged him to use Tylenol as needed 5 Insomnia We will use lorazepam 0 25 0 5 mg at bedtime as needed 6 Psychosocial We discussed his coping with the diagnosis He is fully aware of his limited prognosis Supportive counseling was provided to his mother Length of the encounter was one hour more than half spent on exchange of information Keywords hospice palliative care hospice aids cd4 count code status dnr kaposi s sarcoma length of the encounter cryptococcal infection exchange of information health care proxy home hospice home hospice care hospice care hospitalization viral load bowel infection MEDICAL_TRANSCRIPTION,Description Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support Medical Specialty Hospice Palliative Care Sample Name Care Conference With Family Transcription REASON FOR FOLLOWUP Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support HISTORY OF PRESENT ILLNESS This is a 65 year old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA 125 and a complex mass located in the ovary As the patient was showing signs of improvement with some speech and ability to follow commands decision was made to continue to pursue an aggressive level of care treat her dysphagia hypertension debilitation and this was being done However last night the patient had apparently catastrophic event around 2 40 in the morning Rapid response was called and the patient was intubated started on pressure support and given CPR This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care The patient was seen and examined she was intubated and sedated Limbs were cool Cardiovascular exam revealed tachycardia Lungs had coarse breath sounds Abdomen was soft Extremities were cool to the touch Pupils were 6 to 2 mm doll s eyes were not intact They were not responsive to light Based on discussion with all family members involved including both sons daughter and daughter in law a decision was made to proceed with terminal wean and comfort care measures All pressure support was discontinued The patient was started on intravenous morphine and respiratory was requested to remove the ET tube Monitors were turned off and the patient was made as comfortable as possible Family is at the bedside at this time The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month this is a very reasonable and appropriate approach given the patient s failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities Total time spent at the bedside today in critical care services medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes Keywords hospice palliative care full code status terminal wean comfort care cpr advanced cardiac life support care conference family bedsideNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient with immune thrombocytopenia Medical Specialty Hematology Oncology Sample Name Thrombocytopenia SOAP Note Transcription SUBJECTIVE I am following the patient today for immune thrombocytopenia Her platelets fell to 10 on 01 09 07 and shortly after learning of that result I increased her prednisone to 60 mg a day Repeat on 01 16 07 revealed platelets up at 43 No bleeding problems have been noted I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day The patient had been on 20 mg every other day at least for a while and her platelets hovered at least above 20 or so PHYSICAL EXAMINATION Vitals As in chart The patient is alert pleasant and cooperative She is in no apparent distress The petechial areas on her legs have resolved ASSESSMENT AND PLAN Patient with improvement of her platelet count on burst of prednisone We will decrease her prednisone to 40 mg for 3 days then go down to 20 mg a day Basically thereafter over time I may try to sneak it back a little bit further She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D We will arrange to have a CBC drawn weekly Keywords hematology oncology platelets platelet count thrombocytopenia prednisone MEDICAL_TRANSCRIPTION,Description True cut needle biopsy of the breast This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin Medical Specialty Hematology Oncology Sample Name True Cut Needle Biopsy Breast Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the left breast POSTOPERATIVE DIAGNOSIS Carcinoma of the left breast PROCEDURE PERFORMED True cut needle biopsy of the breast GROSS FINDINGS This 65 year old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge On exam she has a noticeable carcinoma of the left breast with dimpling puckering and erosion through the skin At this time a true cut needle biopsy was performed PROCEDURE The patient was taken to operating room is laid in the supine position sterilely prepped and draped in the usual fashion The area over the left breast was infiltrated with 1 1 mixture of 0 25 Marcaine and 1 Xylocaine Using a 18 gauge automatic true cut needle core biopsy five biopsies were taken of the left breast in core fashion Hemostasis was controlled with pressure The patient tolerated the procedure well pending the results of biopsy Keywords hematology oncology carcinoma true cut needle biopsy nipple discharge dimpling puckering breast MEDICAL_TRANSCRIPTION,Description Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion Right lateral base of tongue lesion probable cancer Medical Specialty Hematology Oncology Sample Name Tongue Lesion Biopsy Transcription PREOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer POSTOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer PROCEDURE PERFORMED Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion ANESTHESIA General FINDINGS An ulceration in the right lateral base of tongue region This was completely excised ESTIMATED BLOOD LOSS Less than 5 mL FLUIDS Crystalloid only COMPLICATIONS None DRAINS None CONDITION Stable PROCEDURE The patient placed supine in position under general anesthesia First a Sweetheart gag was placed in the patient s mouth and the mouth was elevated The lesion in the tongue could be seen Then it was injected with 1 lidocaine and 1 100 00 epinephrine After 5 minutes of waiting then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total Suction cautery was used for hemostasis Then 3 simple interrupted 4 0 Vicryl sutures were used to close the wound and procedure was then terminated at that time Keywords hematology oncology excisional biopsy tongue lesion mouth biopsy MEDICAL_TRANSCRIPTION,Description The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Medical Specialty Hematology Oncology Sample Name Uterine Papillary Serous Carcinoma Transcription HISTORY OF PRESENT ILLNESS The patient is a 67 year old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol is here today for followup Her last cycle of chemotherapy was finished on 01 18 08 and she complains about some numbness in her right upper extremity This has not gotten worse recently and there is no numbness in her toes She denies any tingling or burning REVIEW OF SYSTEMS Negative for any fever chills nausea vomiting headache chest pain shortness of breath abdominal pain constipation diarrhea melena hematochezia or dysuria The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head PHYSICAL EXAMINATION VITAL SIGNS Temperature 35 6 blood pressure 143 83 pulse 65 respirations 18 and weight 66 5 kg GENERAL She is a middle aged white female not in any distress HEENT No lymphadenopathy or mucositis CARDIOVASCULAR Regular rate and rhythm LUNGS Clear to auscultation bilaterally EXTREMITIES No cyanosis clubbing or edema NEUROLOGICAL No focal deficits noted PELVIC Normal appearing external genitalia Vaginal vault with no masses or bleeding LABORATORY DATA None today RADIOLOGIC DATA CT of the chest abdomen and pelvis from 01 28 08 revealed status post total abdominal hysterectomy bilateral salpingo oophorectomy with an unremarkable vaginal cuff No local or distant metastasis Right probably chronic gonadal vein thrombosis ASSESSMENT This is a 67 year old white female with history of uterine papillary serous carcinoma status post total abdominal hysterectomy and bilateral salpingo oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy She is doing well with no evidence of disease clinically or radiologically PLAN 1 Plan to follow her every 3 months and CT scans every 6 months for the first 2 years 2 The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated 3 The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now 4 The patient was advised about doing Kegel exercises for urinary incontinence and we will address this issue again during next clinic visit if it is persistent Keywords hematology oncology chemotherapy uterine papillary serous carcinoma oophorectomy carboplatin taxol abdominal uterine papillary carcinoma MEDICAL_TRANSCRIPTION,Description Newly diagnosed T cell lymphoma The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago Medical Specialty Hematology Oncology Sample Name T Cell Lymphoma Consult Transcription CHIEF COMPLAINT Newly diagnosed T cell lymphoma HISTORY OF PRESENT ILLNESS The patient is a very pleasant 40 year old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago He was originally treated with antibiotics as a possible tooth abscess Prior to this event in March of 2010 he was treated for strep throat The pain at that time was on the right side About a month ago he started having night sweats The patient reports feeling hot when he went to bed he fall asleep and would wake up soaked All these symptoms were preceded by overwhelming fatigue and exhaustion He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home With the fatigue he has had some mild chest pain and shortness of breath and has also noted a decrease in his appetite although he reports his weight has been stable He also reports occasional headaches with some stabbing and pain in his feet and legs He also complains of some left groin pain PAST MEDICAL HISTORY Significant for HIV diagnosed in 2000 He also had mononucleosis at that time The patient reports being on anti hepatitis viral therapy period that was very intense He took the meds for about six months he reports stopping and prior to 2002 at one point during his treatment he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells He reports no other history of transfusions He has history of spontaneous pneumothorax The first episode was 1989 on his right lung In 1990 he had a slow collapse of the left lung He reports no other history of pneumothoraces In 2003 he had shingles He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy FAMILY HISTORY Notable for his mother who is currently battling non small cell lung cancer She is a nonsmoker His sister is Epstein Barr virus positive The patient s mother also reports that she is Epstein Barr virus positive His maternal grandfather died from complications from melanoma His mother also has diabetes SOCIAL HISTORY The patient is single He currently lives with his mother in house for several both in New York and here in Colorado His mother moved out to Colorado eight years ago and he has been out here for seven years He currently is self employed and does antiquing He has also worked as nurses aide and worked in group home for the state of New York for the developmentally delayed He is homosexual currently not sexually active He does have smoking history as about a thirteen and a half pack year history of smoking currently smoking about a quarter of a pack per day He does not use alcohol or illicit drugs REVIEW OF SYSTEMS As mentioned above his weight has been fairly stable Although he suffered from obesity as a young teenager but through a period of anorexia but his weight has been stable now for about 20 years He has had night sweats chest pain and is also suffering from some depression as well as overwhelming fatigue stabbing short lived headaches and occasional shortness of breath He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck He has had fevers as well The rest of his review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology t cell lymphoma submandibular tooth abscess strep throat submandibular region lymphoma neck MEDICAL_TRANSCRIPTION,Description Excision of mass left second toe and distal Symes amputation left hallux with excisional biopsy Mass left second toe Tumor Left hallux bone invasion of the distal phalanx Medical Specialty Hematology Oncology Sample Name Symes Amputation Hallux Transcription PREOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux bone invasion of the distal phalanx POSTOPERATIVE DIAGNOSES 1 Mass left second toe 2 Tumor 3 Left hallux with bone invasion of the distal phalanx PROCEDURE PERFORMED 1 Excision of mass left second toe 2 Distal Syme s amputation left hallux with excisional biopsy HISTORY This 47 year old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size The patient also has history of shave biopsy in the past The patient does state that he desires surgical excision at this time PROCEDURE IN DETAIL An IV was instituted by the Department of Anesthesia in the preoperative holding area The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff After adequate sedation by the Department of Anesthesia a total of 6 cc mixed with 1 lidocaine plain with 0 5 Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe The foot was then prepped and draped in the usual sterile orthopedic fashion The foot was elevated from the operating table and exsanguinated with an Esmarch bandage Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses The foot was lowered to the operating table The stockinet was reflected and the foot was cleansed with wet and dry sponge A distal Syme s incision was planned over the distal aspect of the left hallux The incision was performed with a 10 blade and deepened with 15 down to the level of bone The dorsal skin flap was removed and dissected in toto off of the distal phalanx There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx The tissue was sent to Pathology where Dr Green stated that a frozen sample would be of less use for examining for cancer Dr Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen At this time a sagittal saw was then used to resect all ends of bone of the distal phalanx The area was inspected for any remaining suspicious tissues Any suspicious tissue was removed The area was then flushed with copious amounts of sterile saline The skin was then reapproximated with 4 0 nylon with a combination of simple and vertical mattress sutures Attention was then directed to the left second toe There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe A linear incision was made just medial to the tissue mass The mass was then dissected from the overlying skin and off of the underlying capsule This tissue mass was hard round and pearly gray in appearance It does not invade into any other surrounding tissues The area was then flushed with copious amounts of sterile saline and the skin was closed with 4 0 nylon Dressings consisted of Owen silk soaked in Betadine 4x4s Kling Kerlix and an Ace wrap The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot The patient tolerated the above procedure and anesthesia well without complications The patient was transported to PACU with vital signs stable and vascular status intact The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr Bonnani in his office as directed The patient will be contacted immediately pending the results of pathology Cultures obtained in the case were aerobic and anaerobic gram stain Silver stain and a CBC Keywords hematology oncology distal phalanx mass tumor hallux bone phalanx symes amputation excisional biopsy distal amputation invasion toe symes incision flushed excision tissue hallux MEDICAL_TRANSCRIPTION,Description Posttransplant lymphoproliferative disorder chronic renal insufficiency squamous cell carcinoma of the skin anemia secondary to chronic renal insufficiency and chemotherapy and hypertension The patient is here for followup visit and chemotherapy Medical Specialty Hematology Oncology Sample Name Posttransplant Lymphoproliferative Disorder Transcription CHIEF COMPLAINT The patient is here for followup visit and chemotherapy DIAGNOSES 1 Posttransplant lymphoproliferative disorder 2 Chronic renal insufficiency 3 Squamous cell carcinoma of the skin 4 Anemia secondary to chronic renal insufficiency and chemotherapy 5 Hypertension HISTORY OF PRESENT ILLNESS A 51 year old white male diagnosed with PTLD in latter half of 2007 He presented with symptoms of increasing adenopathy abdominal pain weight loss and anorexia He did not seek medical attention immediately He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin which showed diagnosis of large cell lymphoma He was discussed at the hematopathology conference Chemotherapy with rituximab plus cyclophosphamide daunorubicin vincristine and prednisone was started First cycle of chemotherapy was complicated by sepsis despite growth factor support He also appeared to have become disoriented either secondary to sepsis or steroid therapy The patient has received 5 cycles of chemotherapy to date He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well His therapy has been interrupted for infection related to squamous cell cancer skin surgery as well as complaints of chest infection The patient is here for the sixth and final cycle of chemotherapy He states he feels well He denies any nausea vomiting cough shortness of breath chest pain or fatigue He denies any tingling or numbness in his fingers Review of systems is otherwise entirely negative Performance status on the ECOG scale is 1 PHYSICAL EXAMINATION VITAL SIGNS He is afebrile Blood pressure 161 80 pulse 65 weight 71 5 kg which is essentially unchanged from his prior visit There is mild pallor noted There is no icterus adenopathy or petechiae noted CHEST Clear to auscultation CARDIOVASCULAR S1 and S2 normal with regular rate and rhythm Systolic flow murmur is best heard in the pulmonary area ABDOMEN Soft and nontender with no organomegaly Renal transplant is noted in the right lower quadrant with a scar present EXTREMITIES Reveal no edema LABORATORY DATA CBC from today shows white count of 9 6 with a normal differential ANC of 7400 hemoglobin 8 9 hematocrit 26 5 with an MCV of 109 and platelet count of 220 000 ASSESSMENT AND PLAN 1 Diffuse large B cell lymphoma following transplantation The patient is to receive his sixth and final cycle of chemotherapy today PET scan has been ordered to be done within 2 weeks He will see me back for the visit in 3 weeks with CBC CMP and LDH 2 Chronic renal insufficiency 3 Anemia secondary to chronic renal failure and chemotherapy He is to continue on his regimen of growth factor support 4 Hypertension This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled His CMP is pending from today 5 Squamous cell carcinoma of the skin The scalp is well healed He still has an open wound on the right posterior aspect of his trunk This has no active drainage but it is yet to heal This probably will heal by secondary intention once chemotherapy is finished Prescription for prednisone as part of his chemotherapy has been given to him Keywords hematology oncology anemia chemotherapy posttransplant lymphoproliferative disorder squamous cell carcinoma chronic renal insufficiency renal insufficiency adenopathy lymphoproliferative MEDICAL_TRANSCRIPTION,Description Prostate Brachytherapy Prostate I 125 Implantation Medical Specialty Hematology Oncology Sample Name Prostate Brachytherapy Transcription PROSTATE BRACHYTHERAPY PROSTATE I 125 IMPLANTATION This patient will be treated to the prostate with ultrasound guided I 125 seed implantation The original consultation and treatment planning will be separately performed At the time of the implantation special coordination will be required Stepping ultrasound will be performed and utilized in the pre planning process Some discrepancies are frequently identified based on the positioning edema and or change in the tumor since the pre planning process Re assessment is required at the time of surgery evaluating the pre plan and comparing to the stepping ultrasound Modifications will be made in real time to add or subtract needles and seeds as required This may be integrated with the loading of the seeds performed by the brachytherapist as well as coordinated with the urologist dosimetrist or physicist The brachytherapy must be customized to fit the individual s tumor and prostate Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder Keywords hematology oncology i 125 implantation tumor prostate prostate brachytherapy implantationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Radical resection of tumor of the scalp excision of tumor from the skull with debridement of the superficial cortex with diamond bur and advancement flap closure Medical Specialty Hematology Oncology Sample Name Resection of Tumor of Scalp Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma of the scalp POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Radical resection of tumor of the scalp CPT 11643 Excision of tumor from the skull with debridement of the superficial cortex with diamond bur Advancement flap closure with total undermined area 18 centimeters by 16 centimeters CPT 14300 ANESTHESIA General endotracheal anesthesia INDICATIONS This is an 81 year old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy positive for skin malignancy specifically squamous call carcinoma This appears to be affixed to the underlying scalp PLAN Radical resection with frozen sections to clear margins thereafter with planned reconstruction CONSENT I have discussed with the patient the possible risks of bleeding infection renal problems scar formation injury to muscle nerves and possible need for additional surgery with possible recurrence of the patient s carcinoma with review of detailed informed consent with the patient who understood and wished to proceed FINDINGS The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull The final periosteal margin which centrally appeared was positive for carcinoma The final margins peripherally were all negative DESCRIPTION OF PROCEDURE IN DETAIL The patient was taken to the operating room and there was placed supine on the operating room table General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint Thereafter the local anesthesia was injected into the area around the tumor A type excision was planned down to the periosteum A supraperiosteal radical resection was performed It was obvious that there was tumor at the deep margin involving the periosteum The edges were marked along the four quadrants at the 12 o clock 3 o clock 6 o clock and the 9 o clock positions and these were sent for frozen section evaluation Frozen section revealed positive margins at one end of the resection Therefore an additional circumferential resection was performed and the final margins were all negative Following completion the deep periosteal margin was resected The circumferential periosteal margins were noted to be negative however centrally there was a small area which showed tumor eroding into the superficial cortex of the skull Therefore the Midas Rex drill was utilized to resect approximately 1 2 mm of the superficial cortex of the bone at the area where the positive margin was located Healthy bone was obtained however it did not enter the diploic or marrow containing bone in the area Therefore no bong margin was taken However at the end of the procedure it did not appear that the residual bone had any residual changes consistent with carcinoma Following completion of the bony resection the area was irrigated with copious amounts of saline Thereafter advancement flaps were created both on the left and the right side of the scalp with the total undermined area being approximately 18cm by 16cm The galea was incised in multiple areas to provide for additional mobilization of the tissue The tissue was closed under tension with 3 0 Vicryl suture deep in the galea and surgical staples superficially The patient was awakened from anesthetic was extubated and was taken to the recovery room in stable condition DISPOSITION The patient was discharged to home with antibiotics and analgesics to follow up in approximately one week NOTE The final margins of both periosteal as well as skin were negative circumferentially around the tumor The only positive margin was deep which was a periosteal margin and bone underlying it was partially resected as was indicated above Keywords hematology oncology squamous cell carcinoma of the scalp squamous cell carcinoma radical resection margin midas rex drill radical resection of tumor resection of tumor endotracheal anesthesia superficial cortex margins periosteum skull cortex periosteal scalp resection tumor MEDICAL_TRANSCRIPTION,Description Invasive carcinoma of left breast Left modified radical mastectomy Medical Specialty Hematology Oncology Sample Name Radical Mastectomy Transcription PREOPERATIVE DIAGNOSIS Invasive carcinoma of left breast POSTOPERATIVE DIAGNOSIS Invasive carcinoma of left breast OPERATION PERFORMED Left modified radical mastectomy ANESTHESIA General endotracheal INDICATION FOR THE PROCEDURE The patient is a 52 year old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast The patient was elected to have a left modified radical mastectomy she was not interested in a partial mastectomy She is aware of the risks and complications of surgery and wished to proceed DESCRIPTION OF PROCEDURE The patient was taken to the operating room She underwent general endotracheal anesthetic The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well The patient s left anterior chest wall neck axilla and left arm were prepped and draped in the usual sterile manner The recent biopsy site was located in the upper and outer quadrant of left breast The plain incision was marked along the skin Tissues and the flaps were injected with 0 25 Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site The flaps were raised superiorly and just below the clavicle medially to the sternum laterally towards the latissimus dorsi rectus abdominus fascia Following this the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle The dissection was started medially and extended laterally towards the left axilla The breast was removed and then the axillary contents were dissected out Left axillary vein and artery were identified and preserved as well as the lung _____ The patient had several clinically palpable lymph nodes they were removed with the axillary dissection Care was taken to avoid injury to any of the above mentioned neurovascular structures After the tissues were irrigated we made sure there were no signs of bleeding Hemostasis had been achieved with Hemoclips Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps The subcu was then approximated with interrupted 4 0 Vicryl sutures and skin with clips The drains were sutured to the chest wall with 3 0 nylon sutures Dressing was applied and the procedure was completed The patient went to the recovery room in stable condition Keywords hematology oncology invasive carcinoma chest wall neck axilla modified radical mastectomy radical mastectomy invasive carcinoma mastectomy MEDICAL_TRANSCRIPTION,Description Excision of right superior parathyroid adenoma seen on sestamibi parathyroid scan and an ultrasound Medical Specialty Hematology Oncology Sample Name Parathyroid Adenoma Excision Transcription PREOPERATIVE DIAGNOSIS Right superior parathyroid adenoma POSTOPERATIVE DIAGNOSIS Right superior parathyroid adenoma PROCEDURE Excision of right superior parathyroid adenoma ANESTHESIA Local with 1 Xylocaine and anesthesia standby with sedation CLINICAL HISTORY This 80 year old woman has had some mild dementia She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations She was found to be hypercalcemic Intact PTH was mildly elevated A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma FINDINGS AND PROCEDURE The patient was placed on the operating table in the supine position A time out was taken so that the anesthesia personnel nursing personnel surgical team and patient could confirm the patient s identity operative site and operative plan The electronic medical record was reviewed as was the ultrasound The patient was sedated A small roll was placed behind the shoulders to moderately hyperextend the neck The head was supported in a foam head cradle The neck and chest were prepped with chlorhexidine and isolated with sterile drapes After infiltration with 1 Xylocaine with epinephrine along the planned incision a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin subcutaneous tissue and platysma The larger anterior neck veins were divided between 4 0 silk ligatures Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection The sternohyoid muscles were separated in the midline and the right sternohyoid muscle was retracted laterally The right sternothyroid muscle was divided transversely with the cautery The right middle thyroid vein was divided between 4 0 silk ligatures The right thyroid lobe was rotated leftward Posterior to the mid portion of the left thyroid lobe a right superior parathyroid adenoma of moderate size was identified This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed It was sent for weight and frozen section It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma Prior to the procedure a peripheral blood sample had been obtained and placed in a purple top tube labeled pre excision It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma However we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts and therefore we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH The neck was irrigated with saline and hemostasis found to be satisfactory The sternohyoid muscles were reapproximated with interrupted 4 0 Vicryl The platysma was closed with interrupted 4 0 Vicryl and the skin was closed with subcuticular 5 0 Monocryl and Dermabond The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well Keywords hematology oncology parathyroid adenoma superior parathyroid adenoma excision sestamibi parathyroid scan sestamibi parathyroid parathyroid scan sternohyoid muscles superior parathyroid parathyroid sestamibi platysma adenoma ultrasound sternohyoid thyroid muscles MEDICAL_TRANSCRIPTION,Description Followup for polycythemia vera with secondary myelofibrosis JAK 2 positive myeloproliferative disorder He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy Medical Specialty Hematology Oncology Sample Name Polycythemia Vera Followup Transcription DIAGNOSIS Polycythemia vera with secondary myelofibrosis REASON FOR VISIT Followup of the above condition CHIEF COMPLAINT Left shin pain HISTORY OF PRESENT ILLNESS A 55 year old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis Diagnosis was made some time in 2005 2006 Initially he underwent phlebotomy He subsequently transferred his care here In the past he has been on hydroxyurea and interferon but did not tolerate both of them He is JAK 2 positive He does not have any siblings for a match related transplant He was seen for consideration of a MUD transplant but was deemed not to be a candidate because of the social support as well as his reasonably good health At our institution the patient received a trial of lenalidomide and prednisone for a short period He did well with the combination Subsequently he developed intolerance to lenalidomide He complained of severe fatigue and diarrhea This was subsequently stopped The patient reports some injury to his left leg last week His left leg apparently was swollen He took steroids for about 3 days and stopped Left leg swelling has disappeared The patient denies any other complaints at this point in time He admits to smoking marijuana He says this gives him a great appetite and he has actually gained some weight Performance status in the ECOG scale is 1 PHYSICAL EXAMINATION VITAL SIGNS He is afebrile Blood pressure 144 85 pulse 86 weight 61 8 kg and respiratory rate 18 per minute GENERAL He is in no acute distress HEENT There is no pallor icterus or cervical adenopathy that is noted Oral cavity is normal to exam CHEST Clear to auscultation CARDIOVASCULAR S1 and S2 normal with regular rate and rhythm ABDOMEN Soft and nontender with no hepatomegaly Spleen is palpable 4 fingerbreadths below the left costal margin There is no guarding tenderness rebound or rigidity noted Bowel sounds are present EXTREMITIES Reveal no edema Palpation of the left tibia revealed some mild tenderness However I do not palpate any bony abnormalities There is no history of deep venous thrombosis LABORATORY DATA CBC from today is significant for a white count of 41 900 with an absolute neutrophil count of 34 400 hemoglobin 14 8 with an MCV of 56 7 and platelet count 235 000 ASSESSMENT AND PLAN 1 JAK 2 positive myeloproliferative disorder The patient has failed pretty much all available options He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy I have e mailed Dr X to see whether he will be a candidate for the LBH trial Hopefully we can get a JAK 2 inhibitor trial quickly on board 2 I am concerned about the risk of thrombosis with his elevated white count He is on aspirin prophylaxis The patient has been told to call me with any complaints 3 Left shin pain I have ordered x rays of the left tibia and knee today The patient will return to the clinic in 3 weeks He is to call me in the interim for any problems Keywords hematology oncology jak 2 positive myeloproliferative disorder secondary myelofibrosis mud transplant ecog scale myeloproliferative disorder radioactive phosphorus jak positive polycythemia vera thrombosis myelofibrosis MEDICAL_TRANSCRIPTION,Description Left breast cancer Nuclear medicine lymphatic scan A 16 hour left anterior oblique imaging was performed with and without shielding of the original injection site Medical Specialty Hematology Oncology Sample Name Nuclear Medicine Lymphatic Scan Transcription EXAM Nuclear medicine lymphatic scan REASON FOR EXAM Left breast cancer TECHNIQUE 1 0 mCi of Technetium 99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations A 16 hour left anterior oblique imaging was performed with and without shielding of the original injection site FINDINGS There are two small foci of increased activity in the left axilla This is consistent with the sentinel lymph node No other areas of activity are visualized outside of the injection site and two axillary lymph nodes IMPRESSION Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node Keywords hematology oncology technetium 99m mci biopsy breast cancer nuclear medicine lymphatic scan lymph node nuclear breast MEDICAL_TRANSCRIPTION,Description Polycythemia rubra vera The patient is an 83 year old female with a history of polycythemia vera She comes in to clinic today for followup She has not required phlebotomies for several months Medical Specialty Hematology Oncology Sample Name Polycythemia Rubra Vera Transcription CHIEF COMPLAINT Polycythemia rubra vera HISTORY OF PRESENT ILLNESS The patient is an 83 year old female with a history of polycythemia vera She comes in to clinic today for followup She has not required phlebotomies for several months The patient comes to clinic unaccompanied CURRENT MEDICATIONS Levothyroxine 200 mcg q d Nexium 40 mg q d Celebrex 200 mg q d vitamin D3 2000 IU q d aspirin 81 mg q d selenium 200 mg q d Aricept 10 mg q d Skelaxin 800 mg q d ropinirole 1 mg q d vitamin E 1000 IU q d vitamin C 500 mg q d flaxseed oil 100 mg daily fish oil 100 units q d Vicodin q h s and stool softener q d ALLERGIES Penicillin REVIEW OF SYSTEMS The patient s chief complaint is her weight She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key She has questions as to whether or not there would be any contra indications to her going on the diet Otherwise she feels great She had family reunion in Iowa once in four days out there She continues to volunteer Hospital and is walking and enjoying her summer She denies any fevers chills or night sweats She has some mild constipation problem but has had under control The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology polycythemia rubra vera phlebotomy hematocrit polycythemia MEDICAL_TRANSCRIPTION,Description Pilonidal cyst with abscess formation Excision of infected pilonidal cyst Medical Specialty Hematology Oncology Sample Name Pilonidal Cyst Excision Transcription PREOPERATIVE DIAGNOSIS Pilonidal cyst with abscess formation POSTOPERATIVE DIAGNOSIS Pilonidal cyst with abscess formation OPERATION Excision of infected pilonidal cyst PROCEDURE After obtaining informed consent the patient underwent a spinal anesthetic and was placed in the prone position in the operating room A time out process was followed Antibiotics were given and then the patient was prepped and draped in the usual fashion It appeared to me that the abscess had drained somewhat during the night as it was much smaller than I was anticipating An elliptical excision of all infected tissues down to the coccyx was performed Hemostasis was achieved with a cautery The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing The patient was sent to recovery room in satisfactory condition Estimated blood loss was minimal The patient tolerated the procedure well Keywords hematology oncology hemostasis excision pilonidal cyst cyst abscess infected MEDICAL_TRANSCRIPTION,Description Left neck dissection Metastatic papillary cancer left neck The patient had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection Medical Specialty Hematology Oncology Sample Name Neck Dissection Transcription PREOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck POSTOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck OPERATION PERFORMED Left neck dissection ANESTHESIA General endotracheal INDICATIONS The patient is a very nice gentleman who has had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound which are suspicious for recurrent cancer Left neck dissection is indicated DESCRIPTION OF OPERATION The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered the table was then turned A shoulder roll placed under the shoulders and the face was placed in an extended fashion The left neck chest and face were prepped with Betadine and draped in a sterile fashion A hockey stick skin incision was performed extending a previous incision line superiorly towards the mastoid cortex through skin subcutaneous tissue and platysma with Bovie electrocautery on cut mode Subplatysmal superior and inferior flaps were raised The dissection was left lateral neck dissection encompassing zones 1 2A 2B 3 and the superior portion of 4 The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles stripped from the carotid artery the X cranial nerve the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr X in the paratracheal region The submandibular gland was removed as well The X XI and XII cranial nerves were preserved The internal jugular vein and carotid artery were preserved as well Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure There were two obviously positive nodes in this neck dissection One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2 A 10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2 0 silk ligature The wound was closed in layers using a 3 0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples A fluff and Kling pressure dressing was then applied The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords hematology oncology metastatic papillary cancer thyroidectomy thyroid cancer papillary cell type dissection neck metastatic paratracheal papillary cancer MEDICAL_TRANSCRIPTION,Description Nonpalpable neoplasm right breast Needle localized wide excision of nonpalpable neoplasm right breast Medical Specialty Hematology Oncology Sample Name Needle Localized Excision Breast Neoplasm Transcription PREOPERATIVE DIAGNOSIS Nonpalpable neoplasm right breast POSTOPERATIVE DIAGNOSIS Deferred for Pathology PROCEDURE PERFORMED Needle localized wide excision of nonpalpable neoplasm right breast SPECIMEN Mammography GROSS FINDINGS This 53 year old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast After excision of neoplasm there was a separate 1 x 2 cm nodule palpated within the cavity This too was excised OPERATIVE PROCEDURE The patient was taken to the operating room placed in supine position in the operating table Intravenous sedation was administered by the Anesthesia Department The Kopans wire was trimmed to an appropriate length The patient was sterilely prepped and draped in the usual manner Local anesthetic consisting of 1 lidocaine and 0 5 Marcaine was injected into the proposed line of incision A curvilinear circumareolar incision was then made with a 15 scalpel blade close to the wire The wire was stabilized and brought to protrude through the incision Skin flaps were then generated with electrocautery A generous core tissue was grasped with Allis forceps and excised with electrocautery Prior to complete excision the superior margin was marked with a 2 0 Vicryl suture which was tied and cut short The lateral margin was marked with a 2 0 Vicryl suture which was tied and cut along The posterior margin was marked with a 2 0 Polydek suture which was tied and cut The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm On palpation of the cavity there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen Hemostasis was obtained with electrocautery Good hemostasis was obtained The incision was closed in two layers The first layer consisting of a subcuticular inverted interrupted sutures of 4 0 undyed Vicryl The second layer consisted of Steri Strips on the epidermis A pressure dressing of fluff 4x4s ABDs and Elastic bandage was applied The patient tolerated the surgery well Keywords hematology oncology neoplasm needle localized wide excision needle localized nonpalpable neoplasm needle incision electrocautery excision breast MEDICAL_TRANSCRIPTION,Description Discharge summary of a patient presenting with a large mass aborted through the cervix Medical Specialty Hematology Oncology Sample Name Mullerian Adenosarcoma Transcription PRINCIPAL DIAGNOSIS Mullerian adenosarcoma HISTORY OF PRESENT ILLNESS The patient is a 56 year old presenting with a large mass aborted through the cervix PHYSICAL EXAM CHEST Clear There is no heart murmur ABDOMEN Nontender PELVIC There is a large mass in the vagina HOSPITAL COURSE The patient went to surgery on the day of admission The postoperative course was marked by fever and ileus The patient regained bowel function She was discharged on the morning of the seventh postoperative day OPERATIONS July 25 2006 Total abdominal hysterectomy bilateral salpingo oophorectomy DISCHARGE CONDITION Stable PLAN The patient will remain at rest initially with progressive ambulation thereafter She will avoid lifting driving stairs or intercourse She will call me for fevers drainage bleeding or pain Family history social history and psychosocial needs per the social worker The patient will follow up in my office in one week PATHOLOGY Mullerian adenosarcoma MEDICATIONS Percocet 5 40 one q 3 h p r n pain Keywords hematology oncology cervix fevers drainage bleeding mullerian adenosarcoma mullerian adenosarcoma MEDICAL_TRANSCRIPTION,Description Biopsy proven mesothelioma Placement of Port A Cath left subclavian vein with fluoroscopy Medical Specialty Hematology Oncology Sample Name Mesothelioma Port A Cath Insertion Transcription PREOPERATIVE DIAGNOSIS Mesothelioma POSTOPERATIVE DIAGNOSIS Mesothelioma OPERATIVE PROCEDURE Placement of Port A Cath left subclavian vein with fluoroscopy ASSISTANT None ANESTHESIA General endotracheal COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient is a 74 year old gentleman who underwent right thoracoscopy and was found to have biopsy proven mesothelioma He was brought to the operating room now for Port A Cath placement for chemotherapy After informed consent was obtained with the patient the patient was taken to the operating room placed in supine position After induction of general endotracheal anesthesia routine prep and drape of the left chest left subclavian vein was cannulated with 18 gauze needle and guidewire was inserted Needle was removed Small incision was made large enough to harbor the port Dilator and introducers were then placed over the guidewire Guidewire and dilator were removed and a Port A Cath was introduced in the subclavian vein through the introducers Introducers were peeled away without difficulty He measured with fluoroscopy and cut to the appropriate length The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium It was then connected to the hub of the port Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall Wounds were then closed Needle count sponge count and instrument counts were all correct Keywords hematology oncology biopsy proven mesothelioma placement of port a cath port a cath subclavian vein fluoroscopy mesothelioma MEDICAL_TRANSCRIPTION,Description Rhabdomyosarcoma of the left orbit Left subclavian vein MediPort placement Needs chemotherapy Medical Specialty Hematology Oncology Sample Name MediPort Placement Transcription PREOPERATIVE DIAGNOSIS Rhabdomyosarcoma of the left orbit POSTOPERATIVE DIAGNOSIS Rhabdomyosarcoma of the left orbit PROCEDURE Left subclavian vein MediPort placement 7 5 French single lumen INDICATIONS FOR PROCEDURE This patient is a 16 year old girl with newly diagnosed rhabdomyosarcoma of the left orbit The patient is being taken to the operating room for MediPort placement She needs chemotherapy DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s neck chest and shoulders were prepped and draped in usual sterile fashion An incision was made on the left shoulder area The left subclavian vein was cannulated The wire was passed which was in good position under fluoro using Seldinger Technique Near wire incision site made a pocket above the fascia and sutured in a size 7 5 French single lumen MediPort into the pocket in 4 places using 3 0 Nurolon I then sized the catheter under fluoro and placed introducer and dilator over the wire removed the wire and dilator placed the catheter through the introducer and removed the introducer The line tip was in good position under fluoro It withdrew and flushed well I then closed the incision using 4 0 Vicryl 5 0 Monocryl for the skin and dressed with Steri Strips Accessed the ports with a 1 inch 20 gauge Huber needle and it withdrew and flushed well with final heparin flush We secured this with Tegaderm The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology Keywords hematology oncology rhabdomyosarcoma of the left orbit single lumen subclavian vein mediport placement chemotherapy rhabdomyosarcoma mediport MEDICAL_TRANSCRIPTION,Description Right nodular malignant mesothelioma Medical Specialty Hematology Oncology Sample Name Mesothelioma Thoracotomy Lobectomy Transcription PREOPERATIVE DIAGNOSIS Right mesothelioma POSTOPERATIVE DIAGNOSIS Right lung mass invading diaphragm and liver FINDINGS Right lower lobe lung mass invading diaphragm and liver PROCEDURES 1 Right thoracotomy 2 Right lower lobectomy with en bloc resection of diaphragm and portion of liver SPECIMENS Right lower lobectomy with en bloc resection of diaphragm and portion of liver BLOOD LOSS 600 mL FLUIDS Crystalloid 2 7 L and 1 unit packed red blood cells ANESTHESIA Double lumen endotracheal tube CONDITION Stable extubated to PACU PROCEDURE IN DETAIL Briefly this is a gentleman who was diagnosed with a B cell lymphoma and then subsequently on workup noted to have a right sided mass seeming to arise from the right diaphragm He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma Thus he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm He was explained the risks benefits and alternatives to this procedure He wished to proceed so he was brought to the operating room An epidural catheter was placed He was put in a supine position where SCDs and Foley catheter were placed He was put under general endotracheal anesthesia with a double lumen endotracheal tube He was given preoperative antibiotics then he was placed in the left decubitus position and the area was prepped and draped in the usual fashion A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument the chest was entered Upon entering the chest the chest wall retractor was inserted and the cavity inspected It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm He also had some marked lymphadenopathy With these findings which were thought at that time to be more consistent with a bronchogenic carcinoma we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection Thus we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2 0 ties Once we had clearly delineated the arterial anatomy we were able to pass a right angle around the artery going to the superior segment This was ligated in continuity with an additional stick tie in the proximal portion of 3 0 silk This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe This was also ligated in continuity and actually doubly ligated Care was taken to preserve the artery to the right and middle lobe We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein The superior pulmonary vein was visualized as well The right angle was passed around the inferior pulmonary vein and this was ligated in continuity with 2 0 silk and a 3 0 stick tie Upon division of this portion the specimen site had some bleeding which was eventually controlled using several 3 0 silk sutures The bronchial anatomy was defined Next we identified the bronchus going to the right lower lobe as well as the right middle lobe A TA 30 4 8 stapler was then closed The lung insufflated The right middle lobe and right upper lobe were noted to inflate well The stapler was fired and the bronchus was cut with a 10 blade We then turned our attention to the diaphragm There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor and we bovied around this with at least 1 cm margin Upon going through the diaphragm it became clear that the tumor was also involving the dome of the liver so after going around the diaphragm in its entirety we proceeded to wedge out the portion of liver that was involved It seemed that it would be a mucoid shallow portion The Bovie was set to high cautery The capsule was entered and then using Bovie cautery we wedged out the remaining portion of the tumor with a margin of normal liver It did leave quite a shallow defect in the liver Hemostasis was achieved with Bovie cautery and gentle pressure The specimen was then taken off the table and sent to Pathology for permanent The area was inspected for hemostasis A 10 flat JP was placed in the abdomen at the portion of the wedge resection and 0 Prolene was used to close the diaphragmatic defect which was under very little tension A single 32 straight chest tube was also placed The lung was seen to expand We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe Hemostasis was observed at the end of the case The chest tube was irrigated with sterile water and there was no air leak observed from the bronchial stump The chest was then closed with Vicryl at the level of the intercostal muscles staying above the ribs The 2 0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer and 4 0 Monocryl was used to close the skin The patient was then brought to supine position extubated and brought to the recovery room in stable condition Dr X was present for the entirety of the procedure which was a right thoracotomy right lower lobectomy with en bloc resection of diaphragm and a portion of liver Keywords hematology oncology double lumen endotracheal en bloc resection malignant mesothelioma lung mass endotracheal tube chest tube bovie cautery en bloc diaphragm lobectomy mesothelioma thoracotomy MEDICAL_TRANSCRIPTION,Description Malignant mass of the left neck squamous cell carcinoma Left neck mass biopsy and selective surgical neck dissection left Medical Specialty Hematology Oncology Sample Name Neck Mass Biopsy Transcription PREOPERATIVE DIAGNOSIS Malignant mass of the left neck POSTOPERATIVE DIAGNOSIS Malignant mass of the left neck squamous cell carcinoma PROCEDURES 1 Left neck mass biopsy 2 Selective surgical neck dissection left DESCRIPTION OF PROCEDURE After obtaining an informed the patient was taken to the operating room where a time out process was followed Preoperative antibiotic was given and Dr X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room Finally a 5 5 French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation Then the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation The neck was prepped and draped in the usual fashion I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap Then I performed an extensive anesthetic block of the area Then an incision was made along the area marked for development of the flap but in a very limited extent just to expose the cervical mass The cervical mass which was about 4 cm in diameter and very firm and rubbery was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck A wedge sample was sent to Pathology for frozen section At the same time we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen Therefore a larger sample was sent to Pathology and at that particular time the fresh frozen was reported as having squamous elements This was not totally clear in my mind and therefore I proceeded to excise the full mass which luckily was not attached to any structures except in the very deep surface There there were some attachments to branches of the external carotid artery which had to be suture ligated At any rate the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma With that information in hand we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap which basically involved a reverse U shape on the left neck This worked out quite nicely The external jugular vein was out of the way so initially we did not deal with it We proceeded to tackle the area III and extended into II A When we excised the mass the upper end was in intimate relationship with the parotid gland which was relatively large in this patient but it looked normal otherwise Also I felt that the submaxillary gland was enlarged At any rate we decided to clean up the areas III and IV and a few nodes from II A that were removed and then we went into the posterior triangle where we identified the spinal accessory nerve which we protected actually did not even dissect close to it The same nerve had been already identified anterior to the internal jugular vein very proximally behind the digastric and the sternocleidomastoid muscle At any rate there were large nodes in the posterior triangle in areas V A and V B which were excised and sent to Pathology for examination Also there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen Hemostasis was revised and found to be adequate The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap The flap was replaced in its position A soft Jackson Pratt catheter was left in the area and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin I would like to mention that also the facial vein was excised and the external jugular vein was ligated It was in very lateral location and it was on the site of the drain so we ligated that but did not excise it A pressure dressing was applied The patient tolerated the procedure well Estimated blood loss was no more than 100 mL The patient was extubated in the operating room and sent for recovery Keywords hematology oncology neck mass biopsy surgical neck dissection internal jugular vein external jugular vein squamous cell carcinoma neck mass malignant mass neck dissection mass neck wedge vein MEDICAL_TRANSCRIPTION,Description Right pleural effusion and suspected malignant mesothelioma Medical Specialty Hematology Oncology Sample Name Mesothelioma Pleural Biopsy Transcription PREOPERATIVE DIAGNOSIS Right pleural effusion and suspected malignant mesothelioma POSTOPERATIVE DIAGNOSIS Right pleural effusion suspected malignant mesothelioma PROCEDURE Right VATS pleurodesis and pleural biopsy ANESTHESIA General double lumen endotracheal DESCRIPTION OF FINDINGS Right pleural effusion firm nodules diffuse scattered throughout the right pleura and diaphragmatic surface SPECIMEN Pleural biopsies for pathology and microbiology ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid 1 2 L and 1 9 L of pleural effusion drained INDICATIONS Briefly this is a 66 year old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma Upon transfer he had a right pleural effusion demonstrated on x ray as well as some shortness of breath and dyspnea on exertion The risks benefits and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed PROCEDURE IN DETAIL After informed consent was obtained the patient was brought to the operating room and placed in supine position A double lumen endotracheal tube was placed SCDs were also placed and he was given preoperative Kefzol The patient was then brought into the right side up left decubitus position and the area was prepped and draped in the usual fashion A needle was inserted in the axillary line to determine position of the effusion At this time a 10 mm port was placed using the knife and Bovie cautery The effusion was drained by placing a sucker into this port site Upon feeling the surface of the pleura there were multiple firm nodules An additional anterior port was then placed in similar fashion The effusion was then drained with a sucker Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura Of note feeling the diaphragmatic surface it appeared that it was quite nodular but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease This will be worked up with further imaging study later in his hospitalization After the effusion had been drained 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc The lungs were then inflated and noted to inflate well A 32 curved chest tube chest tube was placed and secured with nylon The other port site was closed at the level of the fascia with 2 0 Vicryl and then 4 0 Monocryl for the skin The patient was then brought in the supine position and extubated and brought to recovery room in stable condition Dr X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies The counts were correct x2 at the end of the case Keywords hematology oncology double lumen endotracheal pleural surface chest tube pleural biopsy malignant mesothelioma vats pleurodesis pleural biopsies pleural effusion pleural vats pleurodesis mesothelioma MEDICAL_TRANSCRIPTION,Description Extensive stage small cell lung cancer Chemotherapy with carboplatin and etoposide Left scapular pain status post CT scan of the thorax Medical Specialty Hematology Oncology Sample Name Lung Cancer Followup Transcription CHIEF COMPLAINT 1 Extensive stage small cell lung cancer 2 Chemotherapy with carboplatin and etoposide 3 Left scapular pain status post CT scan of the thorax HISTORY OF PRESENT ILLNESS The patient is a 67 year old female with extensive stage small cell lung cancer She is currently receiving treatment with carboplatin and etoposide She completed her fifth cycle on 08 12 10 She has had ongoing back pain and was sent for a CT scan of the thorax She comes into clinic today accompanied by her daughters to review the results CURRENT MEDICATIONS Levothyroxine 88 mcg daily Soriatane 25 mg daily Timoptic 0 5 solution b i d Vicodin 5 500 mg one to two tablets q 6 hours p r n ALLERGIES No known drug allergies REVIEW OF SYSTEMS The patient continues to have back pain some time she also take two pain pill She received platelet transfusion the other day and reported mild fever She denies any chills night sweats chest pain or shortness of breath The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology small cell lung cancer carboplatin etoposide pet ct pleural base base mass extensive stage ct scan lung cancer lung cancer MEDICAL_TRANSCRIPTION,Description Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism subdural hematoma pancytopenia and pneumonia Medical Specialty Hematology Oncology Sample Name Leiomyosarcoma Transcription ADMITTING DIAGNOSES 1 Leiomyosarcoma 2 History of pulmonary embolism 3 History of subdural hematoma 4 Pancytopenia 5 History of pneumonia PROCEDURES DURING HOSPITALIZATION 1 Cycle six of CIVI CAD Cytoxan Adriamycin and DTIC from 07 22 2008 to 07 29 2008 2 CTA chest PE study showing no evidence for pulmonary embolism 3 Head CT showing no evidence of acute intracranial abnormalities 4 Sinus CT normal mini CT of the paranasal sinuses HISTORY OF PRESENT ILLNESS Ms ABC is a pleasant 66 year old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007 The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon MRI showed inflammation and was thought to be secondary to rheumatoid arthritis The mass increased in size She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma margins were impossible to assess but were likely positive She was evaluated by Dr X and Dr Y and a decision was made to proceed with preoperative chemotherapy She began treatment with CIVI CAD in December 2007 Her course was complicated by pulmonary embolus pneumonia and subdural hematoma while on anticoagulation She eventually underwent surgical resection on May 1 2008 with small area of residual disease but otherwise clear margins HOSPITAL COURSE 1 Leiomyosarcoma the patient was admitted to Hem Onco B Service under attending Dr XYZ for cycle six of continuous IV infusion Cytoxan Adriamycin and DTIC which she tolerated well 2 History of pulmonary embolism Upon admission the patient reported an approximate two week history of dyspnea on exertion and some mild chest pain She underwent a CTA which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day She had no further complaints throughout the hospitalization with any shortness of breath or chest pain 3 History of subdural hematoma also on admission the patient noted some mild intermittent headaches that were fleeting in nature several a day that would resolve on their own Her headaches were not responding to pain medication and so on 07 24 2008 we obtained a head CT that showed no evidence of acute intracranial abnormalities The patient also had a history of sinusitis and so a sinus CT scan was obtained which was normal 4 Pancytopenia On admission the patient s white blood count was 3 4 hemoglobin 11 3 platelet count 82 and ANC of 2400 The patient s counts were followed throughout admission She did not require transfusion of red blood cells or platelets however on 07 26 2008 her ANC did dip to 900 and she was placed on neutropenic diet At discharge her ANC is back up to 1100 and she is taken off neutropenic diet Her white blood cell count at discharge was 1 4 and her hemoglobin was 11 2 with a platelet count of 140 5 History of pneumonia During admission the patient did not exhibit any signs or symptoms of pneumonia DISPOSITION Home in stable condition DIET Regular and less neutropenic ACTIVITY Resume same activity FOLLOWUP The patient will have lab work at Dr XYZ on 08 05 2008 and she will also return to the cancer center on 08 12 2008 at 10 20 a m The patient is also advised to monitor for any fevers greater than 100 5 and should she have any further problems in the meantime to please call in to be seen sooner Keywords hematology oncology leiomyosarcoma embolism hematoma pneumonia acute intracranial abnormalities white blood platelet count blood cells neutropenic diet subdural hematoma pulmonary embolism intracranial pancytopenia neutropenic subdural pulmonary MEDICAL_TRANSCRIPTION,Description Left axillary lymph node excisional biopsy Left axillary adenopathy Medical Specialty Hematology Oncology Sample Name Lymph Node Excisional Biopsy Transcription PREOPERATIVE DIAGNOSIS Left axillary adenopathy POSTOPERATIVE DIAGNOSIS Left axillary adenopathy PROCEDURE Left axillary lymph node excisional biopsy ANESTHESIA LMA INDICATIONS Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only Note she refused her CMF adjuvant therapy and this was for a triple negative infiltrating ductal carcinoma of the breast Patient has been following with Dr Diener and Dr Wilmot I believe that genetic counseling had been recommended to her and obviously the CMF was recommended but she declined both She presented to the office with left axillary adenopathy in view of the high risk nature of her lesion I recommended that she have this lymph node removed The procedure purpose risk expected benefits potential complications alternative forms of therapy were discussed with her and she was agreeable to surgery TECHNIQUE Patient was identified then taken into the operating room where after induction of appropriate anesthesia her left chest neck axilla and arm were prepped with Betadine solution draped in a sterile fashion An incision was made at the hairline carried down by sharp dissection through the clavipectoral fascia I was able to easily palpate the lymph node and grasp it with a figure of eight 2 0 silk suture and by sharp dissection was carried to hemoclip all attached structures The lymph node was excised in its entirety The wound was irrigated The lymph node sent to pathology The wound was then closed Hemostasis was assured and the patient was taken to recovery room in stable condition Keywords hematology oncology axillary lymph node excisional biopsy sharp dissection excisional biopsy lymph node axillary excisional biopsy MEDICAL_TRANSCRIPTION,Description Iron deficiency anemia She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis Medical Specialty Hematology Oncology Sample Name Iron deficiency anemia Transcription CHIEF COMPLAINT Iron deficiency anemia HISTORY OF PRESENT ILLNESS This is a very pleasant 19 year old woman who was recently hospitalized with iron deficiency anemia She was seen in consultation by Dr X She underwent a bone marrow biopsy on 07 21 10 which showed a normal cellular marrow with trilineage hematopoiesis On 07 22 10 her hemoglobin was 6 5 and therefore she was transfused 2 units of packed red blood cells Her iron levels were 5 and her percent transferrin was 2 There was no evidence of hemolysis Of note she had a baby 5 months ago however she does not describe excessive bleeding at the time of birth She currently has an IUD so she is not menstruating She was discharged from the hospital on iron supplements She denies any fevers chills or night sweats No lymphadenopathy No nausea or vomiting No change in bowel or bladder habits She specifically denies melena or hematochezia CURRENT MEDICATIONS Iron supplements and Levaquin ALLERGIES Penicillin REVIEW OF SYSTEMS As per the HPI otherwise negative PAST MEDICAL HISTORY She is status post birth of a baby girl 5 months ago She is G1 P1 She is currently using an IUD for contraception SOCIAL HISTORY She has no tobacco use She has rare alcohol use No illicit drug use FAMILY HISTORY Her maternal grandmother had stomach cancer There is no history of hematologic malignancies PHYSICAL EXAM GEN Keywords hematology oncology trilineage hematopoiesis cellular marrow bone marrow biopsy iron deficiency anemia bone marrow anemia hemoglobin lymphadenopathy deficiency tobacco MEDICAL_TRANSCRIPTION,Description A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy Medical Specialty Hematology Oncology Sample Name Intraperitoneal Mesothelioma Transcription REASON FOR ADMISSION Intraperitoneal chemotherapy HISTORY A very pleasant 63 year old hypertensive nondiabetic African American female with a history of peritoneal mesothelioma The patient has received prior intravenous chemotherapy Due to some increasing renal insufficiency and difficulties with hydration it was elected to change her to intraperitoneal therapy She had her first course with intraperitoneal cisplatin which was very difficultly tolerated by her Therefore on the last hospitalization for IP chemo she was switched to Taxol The patient since her last visit has done relatively well She had no acute problems and has basically only chronic difficulties She has had some decrease in her appetite although her weight has been stable She has had no fever chills or sweats Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease She had a recent CT scan of the chest and abdomen The report showed the following findings In the chest there was a small hiatal hernia and a calcification in the region of the mitral valve There was one mildly enlarged mediastinal lymph node Several areas of ground glass opacity were noted in the lower lungs which were subtle and nonspecific No pulmonary masses were noted In the abdomen there were no abnormalities of the liver pancreas spleen and left adrenal gland On the right adrenal gland a 17 x 13 mm right adrenal adenoma was noted There were some bilateral renal masses present which were not optimally evaluated due to noncontrast study A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst It was unchanged from February and measured 9 mm There was again minimal left pelvic iliac _______ with right and left peritoneal catheters noted and were unremarkable Mesenteric nodes were seen which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them There was a conglomerate omental mass which had decreased in volume when compared to previous study now measuring 8 4 x 1 6 cm In the pelvis there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter No suspicious osseous lesions were noted CURRENT MEDICATIONS Norco 10 per 325 one to two p o q 4h p r n pain atenolol 50 mg p o b i d Levoxyl 75 mcg p o daily Phenergan 25 mg p o q 4 6h p r n nausea lorazepam 0 5 mg every 8 hours as needed for anxiety Ventolin HFA 2 puffs q 6h p r n Plavix 75 mg p o daily Norvasc 10 mg p o daily Cymbalta 60 mg p o daily and Restoril 30 mg at bedtime as needed for sleep ALLERGIES THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS AND SHE HAD DIFFICULTY TOLERATING ATIVAN PHYSICAL EXAMINATION VITAL SIGNS The patient s height is 165 cm weight is 77 kg BSA is 1 8 sq m The vital signs reveal blood pressure to be 158 75 heart rate 61 per minute with a regular sinus rhythm temperature of 96 6 degrees respiratory rate 18 with an SpO2 of 100 on room air GENERAL She is normally developed well nourished very cooperative oriented to person place and time and in no distress at this time She is anicteric HEENT EOM is full Pupils are equal round reactive to light and accommodation Disc margins are unremarkable as are the ocular fields Mouth and pharynx within normal limits The TMs are glistening bilaterally External auditory canals are unremarkable NECK Supple nontender without adenopathy Trachea is midline There are no bruits nor is there jugular venous distention CHEST Clear to percussion and auscultation bilaterally HEART Regular rate and rhythm without murmur gallop or rub BREASTS Unremarkable ABDOMEN Slightly protuberant Bowel tones are present and normal She has no palpable mass and there is no hepatosplenomegaly EXTREMITIES Within normal limits NEUROLOGICAL Nonfocal DIAGNOSTIC IMPRESSION 1 Intraperitoneal mesothelioma partial remission as noted by CT scan of the abdomen 2 Presumed left lower pole kidney hemorrhagic cyst 3 History of hypertension 4 Type 1 bipolar disease PLAN The patient will have appropriate laboratory studies done A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney Interventional radiology will access for ports in the abdomen She will receive chemotherapy intraperitoneally The plan will be to use intraperitoneal Taxol Keywords hematology oncology chemo taxol intraperitoneal mesothelioma peritoneal mesothelioma intravenous chemotherapy adrenal gland hemorrhagic cyst peritoneal intraperitoneal hemorrhagic mesothelioma chemotherapy MEDICAL_TRANSCRIPTION,Description Intensity modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices Medical Specialty Hematology Oncology Sample Name Intensity Modulated Radiation Therapy Transcription INTENSITY MODULATED RADIATION THERAPY Intensity modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices The treatment planning process requires at least 4 hours of physician time The technology is appropriate in this patient s case due to the fact that the target volume is adjacent to significant radiosensitive structures Sequential CT scans are obtained and transferred to the treatment planning software Extensive analysis occurs The target volumes including margins for uncertainty patient movement and occult tumor extension are selected In addition organs at risk are outlined Doses are selected both for targets as well as for organs at risk Associated dose constraints are placed Inverse treatment planning is then performed in conjunction with the physics staff These are reviewed by the physician and ultimately performed only following approval by the physician Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease while minimizing exposure to organs at risk This is performed in hopes of minimizing associated complications The physician delineates the treatment type number of fractions and total volume During the time of treatment there is extensive physician intervention monitoring the patient set up and tolerance In addition specific QA is performed by the physics staff under the physician s direction In view of the above the special procedure code 77470 is deemed appropriate Keywords hematology oncology multiple beam arrangements intensity modulated radiation therapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Hyperfractionation This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy Medical Specialty Hematology Oncology Sample Name Hyperfractionation Transcription HYPERFRACTIONATION This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy The radiotherapy will be given in a hyperfractionated fraction decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing previously irradiated or poorly oxygenated tumors The dose per fraction and the total dose are calculated by me and this is individualized for each patient according to radiobiologic principles During the hyperfractionated radiotherapy the chance of severe acute side effects is increased so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly Keywords hematology oncology irradiated oxygenated tumors malignancy radiobiologic hyperfractionation hyperfractionated radiotherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Intensity modulated radiation therapy simulation note The patient will receive intensity modulated radiation therapy in order to deliver high dose treatment to sensitive structures Medical Specialty Hematology Oncology Sample Name Intensity Modulated Radiation Therapy Simulation Transcription INTENSITY MODULATED RADIATION THERAPY SIMULATION The patient will receive intensity modulated radiation therapy in order to deliver high dose treatment to sensitive structures The target volume is adjacent to significant radiosensitive structures Initially the preliminary isocenter is set on a fluoroscopically based simulation unit The patient is appropriately immobilized using a customized immobilization device Preliminary simulation films are obtained and approved by me The patient is marked and transferred to the CT scanner Sequential images are obtained and transferred electronically to the treatment planning software Extensive analysis then occurs The target volume including margins for uncertainty patient movement and occult tumor extension are selected In addition organs at risk are outlined Appropriate doses are selected both for the target as well as constraints for organs at risk Inverse treatment planning is performed by the physics staff under my supervision These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance Keywords hematology oncology target volume intensity modulated radiation therapy simulationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description HDR Brachytherapy Medical Specialty Hematology Oncology Sample Name HDR Brachytherapy Transcription HDR BRACHYTHERAPY The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified Simulation films were obtained documenting its positioning The 3 dimensional treatment planning process was accomplished utilizing the CT derived data A treatment plan was selected utilizing sequential dwell positions within a single catheter The patient was taken to the treatment area The patient was appropriately positioned and the position of the intracavitary device was checked Catheter length measurements were taken Appropriate measurements of the probe dimensions and assembly were also performed The applicator was attached to the HDR after loader device The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication The brachytherapy source was appropriately removed back to the brachytherapy safe within the device Radiation screening was performed with the Geiger Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate Following completion of the procedure the intracavitary device was removed without difficulty The patient was in no apparent distress and was discharged home Keywords hematology oncology geiger muller treatment planning hdr brachytherapy intracavitary applicator brachytherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Stage IIIC endometrial cancer Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 Medical Specialty Hematology Oncology Sample Name Endometrial Cancer Followup Transcription CHIEF COMPLAINT 1 Stage IIIC endometrial cancer 2 Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane HISTORY OF PRESENT ILLNESS The patient is a 47 year old female who was noted to have abnormal vaginal bleeding in the fall of 2009 In March 2010 she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus CT scan of the abdomen on 03 22 2010 showed an enlarged uterus thickening of the endometrium and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis On 04 01 2010 she had a robotic modified radical hysterectomy with bilateral salpingo oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy The pathology was positive for grade III endometrial adenocarcinoma 9 5 cm in size with 2 cm of invasion Four of 30 lymph nodes were positive for disease The left ovary was positive for metastatic disease Postsurgical PET CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup Of note we had sent off genetic testing which was denied back in June I have been trying to get this testing completed CURRENT MEDICATIONS Synthroid q d ferrous sulfate 325 mg b i d multivitamin q d Ativan 0 5 mg q 4 hours p r n nausea and insomnia gabapentin one tablet at bedtime ALLERGIES Keywords hematology oncology adjuvant adjuvant chemotherapy cisplatin adriamycin abraxane endometrial cancer lymphadenectomy chemotherapy endometrial disease MEDICAL_TRANSCRIPTION,Description Re excision of squamous cell carcinoma site right hand Medical Specialty Hematology Oncology Sample Name Excision of Squamous Cell Carcinoma Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised NAME OF OPERATION Re excision of squamous cell carcinoma site right hand ANESTHESIA Local with monitored anesthesia care INDICATIONS Patient 72 status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb The deep margin was positive Other margins were clear He was brought back for re excision PROCEDURE The patient was brought to the operating room and placed in the supine position He was given intravenous sedation The right hand was prepped and draped in the usual sterile fashion Three cubic centimeters of 1 Xylocaine mixed 50 50 with 0 5 Marcaine with epinephrine was instilled with local anesthetic around the site of the excision and the site of the cancer was re excised with an elliptical incision down to the extensor tendon sheath The tissue was passed off the field as a specimen The wound was irrigated with warm normal saline Hemostasis was assured with the electrocautery The wound was closed with running 3 0 nylon without complication The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied Keywords hematology oncology monitored anesthesia care elliptical incision squamous cell carcinoma site squamous cell carcinoma squamous cell excision squamous carcinoma MEDICAL_TRANSCRIPTION,Description Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid Medical Specialty Hematology Oncology Sample Name Eyelid Squamous Cell Carcinoma Excision Transcription PREOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma POSTOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma PROCEDURE PERFORMED Excision of right upper eyelid squamous cell carcinoma with frozen section and full thickness skin grafting from the opposite eyelid COMPLICATIONS None BLOOD LOSS Minimal ANESTHESIA Local with sedation INDICATION The patient is a 65 year old male with a large squamous cell carcinoma on his right upper eyelid which had previous radiation DESCRIPTION OF PROCEDURE The patient was taken to the operating room laid supine administered intravenous sedation and prepped and draped in a sterile fashion He was anesthetized with a combination of 2 lidocaine and 0 5 Marcaine with Epinephrine on both upper eyelids The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact Following complete resection the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate The specimen was sent to pathology which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma Meticulous hemostasis was obtained with Bovie cautery and a full thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid The left upper eyelid incision was closed with 6 0 fast absorbing gut interrupted sutures and the skin graft was sutured in place with 6 0 fast absorbing gut interrupted sutures An eye patch was placed on the right side and the patient tolerated the procedure well and was taken to PACU in good condition Keywords hematology oncology frozen section full thickness skin grafting squamous cell carcinoma eyelid orbicularis MEDICAL_TRANSCRIPTION,Description A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma Medical Specialty Hematology Oncology Sample Name Discharge Summary Mesothelioma Transcription PREOPERATIVE DIAGNOSIS Right pleural mass POSTOPERATIVE DIAGNOSIS Mesothelioma PROCEDURES PERFORMED 1 Flexible bronchoscopy 2 Mediastinoscopy 3 Right thoracotomy 4 Parietal pleural biopsy CONSULTS Consults obtained during this hospitalization included 1 Radiation Oncology 2 Pulmonary Medicine 3 Medical Oncology 4 Cancer Center Team consult 5 Massage therapy consult HOSPITAL COURSE The patient s hospital course was unremarkable Her pain was well controlled with an epidural that was placed by Anesthesia At the time of discharge the patient was ambulatory She was discharged with home oxygen available She was discharged with albuterol nebulizer treatments treatments were to be q i d She was discharged with a prescription for Vicodin for pain control She is to follow up with Dr X in the office in one week with a chest x ray She is instructed not to lift push or pull anything greater than 10 pounds She is instructed not to drive until after she sees us in the office and is off her pain medications Keywords hematology oncology flexible bronchoscopy mediastinoscopy right thoracotomy pleural biopsy pleural mass mesothelioma oncology MEDICAL_TRANSCRIPTION,Description Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation Medical Specialty Hematology Oncology Sample Name Disseminated Intravascular Coagulation Transcription DIAGNOSES 1 Disseminated intravascular coagulation 2 Streptococcal pneumonia with sepsis CHIEF COMPLAINT Unobtainable as the patient is intubated for respiratory failure CURRENT HISTORY OF PRESENT ILLNESS This is a 20 year old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation At this time she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time prothrombin time low fibrinogen and elevated D dimer At this time I am being consulted for further evaluation and recommendations for treatment The nurses report that she has actually improved clinically over the last 24 hours Bleeding has been a problem however it seems to have been abrogated at this time with factor replacement as well as platelet infusion There is no prior history of coagulopathy PAST MEDICAL HISTORY Otherwise nondescript as is the past surgical history SOCIAL HISTORY There were possible illicit drugs Her family is present and I have discussed her case with her mother and sister FAMILY HISTORY Otherwise noncontributory REVIEW OF SYSTEMS Not otherwise pertinent PHYSICAL EXAMINATION GENERAL She is a sedated young black female in no acute distress lying in bed intubated VITAL SIGNS She has a rate of 67 blood pressure of 100 60 and the respiratory rate per the ventilator approximately 14 to 16 HEENT Her sclerae showed conjunctival hemorrhage There are no petechiae Her nasal vestibules are clear Oropharynx has ET tube in place NECK No jugular venous pressure distention CHEST Coarse breath sounds bilaterally HEART Regular rate and rhythm ABDOMEN Soft and nontender with good bowel sounds There was some oozing around the site of her central line EXTREMITIES No clubbing cyanosis or edema There is no evidence of compromise arterial blood flow at the digits or of her hands or feet LABORATORY STUDIES The DIC parameters with a platelet count of approximately 50 000 INR of 2 4 normal PTT at this time fibrinogen of 200 and a D dimer of 13 IMPRESSION PLAN At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease My recommendation for the patient is to continue factor replacement as you are It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time There is no indication at this point for Xigris However if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen normalization of her coagulation times I would consider low dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions I will repeat her laboratory studies in the morning and give more recommendations at that time Keywords hematology oncology intravascular coagulation pneumonia thromboplastin time prothrombin time disseminated intravascular coagulation streptococcal pneumonia intravascular coagulation infusion coagulopathy fibrinogen respiratory oropharynx sepsis disseminated MEDICAL_TRANSCRIPTION,Description Concomitant chemoradiotherapy for curative intent patients Medical Specialty Hematology Oncology Sample Name Concomitant Chemoradiotherapy Transcription CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer The chemotherapy is given in addition to the radiotherapy not only to act as a cytotoxic agent on its own but also to potentiate and enhance the effect of radiotherapy on tumor cells It has been shown in the literature that this will maximize the chance of control During the course of the treatment the patient s therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held This combined treatment usually produces greater side effects than either treatment alone and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects In accordance this requires more frequency consultation and coordination with the medical oncologist Therefore this becomes a very time intensive treatment and justifies CPT Code 77470 Keywords hematology oncology tumor cells concomitant chemoradiotherapy chemotherapy radiotherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Postoperative visit for craniopharyngioma with residual disease According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved Medical Specialty Hematology Oncology Sample Name Craniopharyngioma Postop Transcription REASON FOR VISIT Postoperative visit for craniopharyngioma HISTORY OF PRESENT ILLNESS Briefly a 16 year old right handed boy who is in eleventh grade who presents with some blurred vision and visual acuity difficulties was found to have a suprasellar tumor He was brought to the operating room on 01 04 07 underwent a transsphenoidal resection of tumor Histology returned as craniopharyngioma There is some residual disease however the visual apparatus was decompressed According to him he is doing well back at school without any difficulties He has some occasional headaches and tinnitus but his vision is much improved MEDICATIONS Synthroid 100 mcg per day FINDINGS On exam he is awake alert and oriented x 3 Pupils are equal and reactive EOMs are full His visual acuity is 20 25 in the right improved from 20 200 and the left is 20 200 improved from 20 400 He has a bitemporal hemianopsia which is significantly improved and wider His motor is 5 out of 5 There are no focal motor or sensory deficits The abdominal incision is well healed There is no evidence of erythema or collection The lumbar drain was also well healed The postoperative MRI demonstrates small residual disease Histology returned as craniopharyngioma ASSESSMENT Postoperative visit for craniopharyngioma with residual disease PLANS I have recommended that he call I discussed the options with our radiation oncologist Dr X They will schedule the appointment to see him In addition he probably will need an MRI prior to any treatment to follow the residual disease Keywords hematology oncology visual acuity blurred vision tinnitus headaches residual disease tumor histology craniopharyngioma MEDICAL_TRANSCRIPTION,Description Conformal simulation with coplanar beams This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated Medical Specialty Hematology Oncology Sample Name Conformal Simulation Transcription CONFORMAL SIMULATION WITH COPLANAR BEAMS This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated It allows us to highly focus the beam of radiation and shape the beam to the target volume delivering a homogenous dosage through it while sparing the surrounding more radiosensitive normal tissues This will allow us to give the optimum chance of tumor control while minimizing the acute and long term side effects A conformal simulation is a simulation which involves extended physician therapist and dosimetrist time and effort The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized One then approximates the field sizes and arrangements gantry angles collimator angles and number of fields Radiographs are taken and these fields are marked on the patient s skin The patient is then transferred to the diagnostic facility and placed on a flat CT scan table Scans are then performed through the targeted area The CT scans are evaluated by the radiation oncologist and the tumor volume target volume and critical structures are outlined on each slice of the CT scan The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures This volume is then reconstructed in 3 dimensional space Utilizing the beam s eye view features the appropriate blocks are designed Multiplane computerized dosimetry is performed throughout the volume Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan each individual slice is then reviewed by the physician The beam s eye view block design and appropriate volumes are also printed and reviewed by the physician Once these are approved Cerrobend blocks will be custom fabricated If significant changes are made in the field arrangements from the original simulation the patient is brought back to the simulator where the computer designed fields are re simulated Keywords hematology oncology coplanar beams ct scan target volume conformal simulation beamsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient is a 57 year old female with invasive ductal carcinoma of the left breast T1c Nx M0 left breast carcinoma Medical Specialty Hematology Oncology Sample Name Consult Breast Cancer 1 Transcription CHIEF COMPLAINT Left breast cancer HISTORY The patient is a 57 year old female who I initially saw in the office on 12 27 07 as a referral from the Tomball Breast Center On 12 21 07 the patient underwent image guided needle core biopsy of a 1 5 cm lesion at the 7 o clock position of the left breast inferomedial The biopsy returned showing infiltrating ductal carcinoma high histologic grade The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging She prior to that area denied any complaints She had no nipple discharge No trauma history She has had been on no estrogen supplementation She has had no other personal history of breast cancer Her family history is positive for her mother having breast cancer at age 48 The patient has had no children and no pregnancies She denies any change in the right breast Subsequent to the office visit and tissue diagnosis of breast cancer she has had medical oncology consultation with Dr X and radiation oncology consultation with Dr Y I have discussed the case with Dr X and Dr Y who are both in agreement with proceeding with surgery prior to adjuvant therapy The patient s metastatic workup has otherwise been negative with MRI scan and CT scanning The MRI scan showed some close involvement possibly involving the left pectoralis muscle although thought to also possibly represent biopsy artifact CT scan of the neck chest and abdomen is negative for metastatic disease PAST MEDICAL HISTORY Previous surgery is history of benign breast biopsy in 1972 laparotomy in 1981 1982 and 1984 right oophorectomy in 1984 and ganglion cyst removal of the hand in 1987 MEDICATIONS She is currently on omeprazole for reflux and indigestion ALLERGIES SHE HAS NO KNOWN DRUG ALLERGIES REVIEW OF SYSTEMS Negative for any recent febrile illnesses chest pains or shortness of breath Positive for restless leg syndrome Negative for any unexplained weight loss and no change in bowel or bladder habits FAMILY HISTORY Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure SOCIAL HISTORY The patient works as a school teacher and teaching high school PHYSICAL EXAMINATION GENERAL The patient is a white female alert and oriented x 3 appears her stated age of 57 HEENT Head is atraumatic and normocephalic Sclerae are anicteric NECK Supple CHEST Clear HEART Regular rate and rhythm BREASTS Exam reveals an approximately 1 5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o clock position which clinically is not fixed to the underlying pectoralis muscle There are no nipple retractions No skin dimpling There is some at the time of the office visit ecchymosis from recent biopsy There is no axillary adenopathy The remainder of the left breast is without abnormality The right breast is without abnormality The axillary areas are negative for adenopathy bilaterally ABDOMEN Soft nontender without masses No gross organomegaly No CVA or flank tenderness EXTREMITIES Grossly neurovascularly intact IMPRESSION The patient is a 57 year old female with invasive ductal carcinoma of the left breast T1c Nx M0 left breast carcinoma RECOMMENDATIONS I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient The procedure and risks of the surgery were explained to include but not limited to extra bleeding infection unsightly scar formation the possibility of local recurrence the possibility of left upper extremity lymphedema was explained Local numbness paresthesias or chronic pain was explained The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers She was certainly encouraged to obtain further surgical medical opinions prior to proceeding I believe the patient has given full informed consent and desires to proceed with the above Keywords MEDICAL_TRANSCRIPTION,Description Genetic counseling for a strong family history of colon polyps She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps Medical Specialty Hematology Oncology Sample Name Colon Polyps Genetic Counseling Transcription REASON FOR CONSULT Genetic counseling HISTORY OF PRESENT ILLNESS The patient is a very pleasant 61 year old female with a strong family history of colon polyps The patient reports her first polyps noted at the age of 50 She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps She does have an identical twice who is the one of the 11 who has never had a history of polyps She also has history of several malignancies in the family Her father died of a brain tumor at the age of 81 There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement Her sister died at the age of 65 breast cancer She has two maternal aunts with history of lung cancer both of whom were smoker Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer There is no other cancer history PAST MEDICAL HISTORY Significant for asthma CURRENT MEDICATIONS Include Serevent two puffs daily and Nasonex two sprays daily ALLERGIES Include penicillin She is also allergic seafood crab and mobster SOCIAL HISTORY The patient is married She was born and raised in South Dakota She moved to Colorado 37 years ago She attended collage at the Colorado University She is certified public account She does not smoke She drinks socially REVIEW OF SYSTEMS The patient denies any dark stool or blood in her stool She has had occasional night sweats and shortness of breath and cough associated with her asthma She also complains of some acid reflux as well as anxiety She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology family history strong family history precancerous polyps brain tumor lung cancer genetic counseling colon polyps polyps MEDICAL_TRANSCRIPTION,Description Routine colorectal cancer screening He occasionally gets some loose stools Medical Specialty Hematology Oncology Sample Name Colon Cancer Screening Transcription HISTORY AND REASON FOR CONSULTATION For evaluation of this patient for colon cancer screening HISTORY OF PRESENT ILLNESS Mr A is a 53 year old gentleman who was referred for colon cancer screening The patient said that he occasionally gets some loose stools Other than that there are no other medical problems PAST MEDICAL HISTORY The patient does not have any serious medical problems at all He denies any hypertension diabetes or any other problems He does not take any medications PAST SURGICAL HISTORY Surgery for deviated nasal septum in 1996 ALLERGIES No known drug allergies SOCIAL HISTORY Does not smoke but drinks occasionally for the last five years FAMILY HISTORY There is no history of any colon cancer in the family REVIEW OF SYSTEMS Denies any significant diarrhea Sometimes he gets some loose stools Occasionally there is some constipation Stools caliber has not changed There is no blood in stool or mucus in stool No weight loss Appetite is good No nausea vomiting or difficulty in swallowing Has occasional heartburn PHYSICAL EXAMINATION The patient is alert and oriented x3 Vital signs Weight is 214 pounds Blood pressure is 111 70 Pulse is 69 per minute Respiratory rate is 18 HEENT Negative Neck Supple There is no thyromegaly Cardiovascular Both heart sounds are heard Rhythm is regular No murmur Lungs Clear to percussion and auscultation Abdomen Soft and nontender No masses felt Bowel sounds are heard Extremities Free of any edema IMPRESSION Routine colorectal cancer screening RECOMMENDATIONS Colonoscopy I have explained the procedure of colonoscopy with benefits and risks in particular the risk of perforation hemorrhage and infection The patient agreed for it We will proceed with it I also explained to the patient about conscious sedation He agreed for conscious sedation Keywords hematology oncology colon cancer screening loose stools colorectal colonoscopy MEDICAL_TRANSCRIPTION,Description Breast radiation therapy followup note Left breast adenocarcinoma stage T3 N1b M0 stage IIIA Medical Specialty Hematology Oncology Sample Name Breast Radiation Therapy Followup Transcription DIAGNOSIS Left breast adenocarcinoma stage T3 N1b M0 stage IIIA She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes CURRENT MEDICATIONS 1 Glucosamine complex 2 Toprol XL 3 Alprazolam 4 Hydrochlorothiazide 5 Dyazide 6 Centrum Dr X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck She previously received a total of 46 8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area As such I feel that we could safely re treat the lower neck Her weight has increased to 189 5 from 185 2 She does complain of some coughing and fatigue PHYSICAL EXAMINATION NECK On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present RESPIRATORY Good air entry bilaterally Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected No lumps bumps or evidence of disease involving the right breast is present ABDOMEN Normal bowel sounds no hepatomegaly No tenderness on deep palpation She has just started her last cycle of chemotherapy today and she wishes to visit her daughter in Brooklyn New York After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time I look forward to keeping you informed of her progress Thank you for having allowed me to participate in her care Keywords hematology oncology carboplatin taxol radiation therapy breast adenocarcinoma beam radiotherapy chest wall radiotherapy supraclavicular lymphadenopathy adenocarcinoma breast MEDICAL_TRANSCRIPTION,Description Excision of left breast mass The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin Medical Specialty Hematology Oncology Sample Name Breast Mass Excision 2 Transcription PREOPERATIVE DIAGNOSIS Breast mass left POSTOPERATIVE DIAGNOSIS Breast mass left PROCEDURE Excision of left breast mass OPERATION After obtaining an informed consent the patient was taken to the operating room where he underwent general endotracheal anesthesia The time out process was followed Preoperative antibiotic was given The patient was prepped and draped in the usual fashion The mass was identified adjacent to the left nipple It was freely mobile and it did not seem to hold the skin An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia The whole of specimen including the skin the mass and surrounding subcutaneous tissue and fascia were excised en bloc Hemostasis was achieved with the cautery The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl A small pressure dressing was applied Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition Keywords hematology oncology breast mass excision freely mobile breast mass endotracheal fascia specimen MEDICAL_TRANSCRIPTION,Description T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation Medical Specialty Hematology Oncology Sample Name Cancer of the nasopharynx Transcription DIAGNOSIS T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation completed June 2006 status post 2 cycles carboplatin 5 FU given as adjuvant therapy completed September 2006 hearing loss related to chemotherapy and radiation xerostomia history of left upper extremity deep venous thrombosis PERFORMANCE STATUS 0 INTERVAL HISTORY In the interim since his last visit he has done quite well He is working He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics Overall when he compares his strength to six or eight months ago he notes that he feels much stronger He has no complaints other than mild xerostomia and treatment related hearing loss PHYSICAL EXAMINATION Vital Signs Height 65 inches weight 150 pulse 76 blood pressure 112 74 temperature 95 4 respirations 18 HEENT Extraocular muscles intact Sclerae not icteric Oral cavity free of exudate or ulceration Dry mouth noted Lymph No palpable adenopathy in cervical supraclavicular or axillary areas Lungs Clear Cardiac Rhythm regular Abdomen Soft nondistended Neither liver spleen nor other masses palpable Lower Extremities Without edema Neurologic Awake alert ambulatory oriented cognitively intact I reviewed the CT images and report of the study done on May 1 This showed no evidence of metabolically active malignancy Most recent laboratory studies were performed last September and the TSH was normal I have asked him to repeat the TSH at the one year anniversary He is on no current medications In summary this 57 year old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy He has made a good recovery We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up We will see him in six months time with a PET CT He returns to the general care and direction of Dr ABC Keywords hematology oncology radiation therapy with cycles cancer of the nasopharynx status post radiation cisplatin with radiation radiation therapy hearing loss hearing cisplatin xerostomia cancer radiation nasopharynx MEDICAL_TRANSCRIPTION,Description Excision of right breast mass Right breast mass with atypical proliferative cells on fine needle aspiration Medical Specialty Hematology Oncology Sample Name Breast Mass Excision Transcription PREOPERATIVE DIAGNOSIS Right breast mass with atypical proliferative cells on fine needle aspiration POSTOPERATIVE DIAGNOSIS Benign breast mass ANESTHESIA General NAME OF OPERATION Excision of right breast mass PROCEDURE With the patient in the supine position the right breast was prepped and draped in a sterile fashion A curvilinear incision was made directly over the mass in the upper outer quadrant of the right breast Dissection was carried out around a firm mass which was dissected with surrounding margins of breast tissue Hemostasis was obtained using electrocautery Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma but appeared benign The breast tissues were approximated using 4 0 Vicryl The skin was closed using 5 0 Vicryl running subcuticular stitches A sterile bandage was applied The patient tolerated the procedure well Keywords hematology oncology atypical proliferative cells fine needle aspiration proliferative cells breast mass breast needle aspiration fibroadenoma excision proliferative mass MEDICAL_TRANSCRIPTION,Description Newly diagnosed cholangiocarcinoma The patient is noted to have an increase in her liver function tests on routine blood work Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Medical Specialty Hematology Oncology Sample Name Cholangiocarcinoma Consult Transcription REASON FOR CONSULTATION Newly diagnosed cholangiocarcinoma HISTORY OF PRESENT ILLNESS The patient is a very pleasant 77 year old female who is noted to have an increase in her liver function tests on routine blood work in December 2009 Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Common bile duct was noted to be 10 mm in size on that ultrasound She then underwent a CT scan of the abdomen in July 2010 which showed intrahepatic ductal dilatation with the common bile duct size being 12 7 mm She then underwent an MRI MRCP which was notable for stricture of the distal common bile duct She was then referred to gastroenterology and underwent an ERCP On August 24 2010 she underwent the endoscopic retrograde cholangiopancreatography She was noted to have a stricturing mass of the mid to proximal common bile duct consistent with cholangiocarcinoma A temporary biliary stent was placed across the biliary stricture Blood work was obtained during the hospitalization She was also noted to have an elevated CA99 She comes in to clinic today for initial Medical Oncology consultation After she sees me this morning she has a follow up consultation with a surgeon PAST MEDICAL HISTORY Significant for hypertension and hyperlipidemia In July she had eye surgery on her left eye for a muscle repair Other surgeries include left ankle surgery for a fractured ankle in 2000 CURRENT MEDICATIONS Diovan 80 12 5 mg daily Lipitor 10 mg daily Lutein 20 mg daily folic acid 0 8 mg daily and multivitamin daily ALLERGIES No known drug allergies FAMILY HISTORY Notable for heart disease She had three brothers that died of complications from open heart surgery Her parents and brothers all had hypertension Her younger brother died at the age of 18 of infection from a butcher s shop He was cutting Argentinean beef and contracted an infection and died within 24 hours She has one brother that is living who has angina and a sister who is 84 with dementia She has two adult sons who are in good health SOCIAL HISTORY The patient has been married to her second husband for the past ten years Her first husband died in 1995 She does not have a smoking history and does not drink alcohol REVIEW OF SYSTEMS The patient reports a change in her bowels ever since she had the stent placed She has noted some weight loss but she notes that that is due to not eating very well She has had some mild fatigue but prior to her diagnosis she had absolutely no symptoms As mentioned above she was noted to have abnormal alkaline phosphatase and total bilirubin AST and ALT which prompted the followup She has had some difficulty with her vision that has improved with her recent surgical procedure She denies any fevers chills night sweats She has had loose stools The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords MEDICAL_TRANSCRIPTION,Description Left breast mass and hypertrophic scar of the left breast Excision of left breast mass and revision of scar The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site Medical Specialty Hematology Oncology Sample Name Breast Mass Excision 1 Transcription PREOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast POSTOPERATIVE DIAGNOSES 1 Left breast mass 2 Hypertrophic scar of the left breast PROCEDURE PERFORMED Excision of left breast mass and revision of scar ANESTHESIA Local with sedation SPECIMEN Scar with left breast mass DISPOSITION The patient tolerated the procedure well and transferred to the recover room in stable condition BRIEF HISTORY The patient is an 18 year old female who presented to Dr X s office The patient is status post left breast biopsy which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site The patient also has a hypertrophic scar Thus the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass INTRAOPERATIVE FINDINGS A hypertrophic scar was found and removed The cicatrix was removed in its entirety and once opening the wound the area of tissue where the palpable mass was was excised as well and sent to the lab PROCEDURE After informed consent risks and benefits of the procedure were explained to the patient and the patient s family the patient was brought to the operating suite prepped and draped in the normal sterile fashion Elliptical incision was made over the previous cicatrix The total length of the incision was 5 5 cm Removing the cicatrix in its entirety with a 15 blade Bard Parker scalpel after anesthetizing with local solution with 0 25 Marcaine Next the area of tissue just inferior to the palpable mass where the palpable was removed with electro Bovie cautery Hemostasis was maintained Attention was next made to approximating the deep dermal layers An interrupted 4 0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges Steri Strips as well as bacitracin and sterile dressings were applied The patient tolerated the procedure well and was transferred to recovery in stable condition Keywords hematology oncology hypertrophic scar palpable mass fibrocystic scar fibrocystic disease breast mass breast cicatrix excision biopsy hypertrophic palpable MEDICAL_TRANSCRIPTION,Description A nurse with a history of breast cancer enrolled is clinical trial C40502 Her previous treatments included Zometa Faslodex and Aromasin She was found to have disease progression first noted by rising tumor markers Medical Specialty Hematology Oncology Sample Name Breast Cancer Followup Transcription CHIEF COMPLAINT 1 Metastatic breast cancer 2 Enrolled is clinical trial C40502 3 Sinus pain HISTORY OF PRESENT ILLNESS She is a very pleasant 59 year old nurse with a history of breast cancer She was initially diagnosed in June 1994 Her previous treatments included Zometa Faslodex and Aromasin She was found to have disease progression first noted by rising tumor markers PET CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU C40502 She was randomized to the ixabepilone plus Avastin She experienced dose limiting toxicity with the fourth cycle The Ixempra was skipped on day 1 and day 8 She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy Early in the month she had concerned about possible perforated septum She was seen by ENT urgently She was found to have nasal septum intact She comes into clinic today for day eight Ixempra CURRENT MEDICATIONS Zometa monthly calcium with Vitamin D q d multivitamin q d Ambien 5 mg q h s Pepcid AC 20 mg q d Effexor 112 mg q d Lyrica 100 mg at bedtime Tylenol p r n Ultram p r n Mucinex one to two tablets b i d Neosporin applied to the nasal mucosa b i d nasal rinse daily ALLERGIES Compazine REVIEW OF SYSTEMS The patient is comfort in knowing that she does not have a septal perforation She has progressive neuropathy and decreased sensation in her fingertips She makes many errors when keyboarding I would rate her neuropathy as grade 2 She continues to have headaches respond to Ultram which she takes as needed She occasionally reports pain in her right upper quadrant as well as right sternum He denies any fevers chills or night sweats Her diarrhea has finally resolved and her bowels are back to normal The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology zometa faslodex aromasin dose limiting toxicity metastatic breast cancer perforated septum nasal septum clinical trial breast cancer disease metastatic breast cancer MEDICAL_TRANSCRIPTION,Description Excisional biopsy of right cervical lymph node Medical Specialty Hematology Oncology Sample Name Biopsy Cervical Lymph Node Transcription PREOPERATIVE DIAGNOSIS Cervical lymphadenopathy POSTOPERATIVE DIAGNOSIS Cervical lymphadenopathy PROCEDURE Excisional biopsy of right cervical lymph node ANESTHESIA General endotracheal anesthesia SPECIMEN Right cervical lymph node EBL 10 cc COMPLICATIONS None FINDINGS Enlarged level 2 lymph node was identified and removed and sent for pathologic examination FLUIDS Please see anesthesia report URINE OUTPUT None recorded during the case INDICATIONS FOR PROCEDURE This is a 43 year old female with a several year history of persistent cervical lymphadenopathy She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic After risks and benefits of surgery were discussed with the patient an informed consent was obtained She was scheduled for an excisional biopsy of the right cervical lymph node PROCEDURE IN DETAIL The patient was taken to the operating room and placed in the supine position She was anesthetized with general endotracheal anesthesia The neck was then prepped and draped in the sterile fashion Again noted on palpation there was an enlarged level 2 cervical lymph node A 3 cm horizontal incision was made over this lymph node Dissection was carried down until the sternocleidomastoid muscle was identified The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation The area was then explored for any other enlarged lymph nodes None were identified and hemostasis was achieved with electrocautery A quarter inch Penrose drain was placed in the wound The wound was then irrigated and closed with 3 0 interrupted Vicryl sutures for a deep closure followed by a running 4 0 Prolene subcuticular suture Mastisol and Steri Strip were placed over the incision and sterile bandage was applied The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition She will return to the office tomorrow in followup to have the Penrose drain removed Keywords hematology oncology lymphadenopathy excisional biopsy fna mastisol penrose drain cervical cervical lymph node endotracheal anesthesia lymph node sternocleidomastoid cervical lymph lymph anesthesia MEDICAL_TRANSCRIPTION,Description Excision of nasal tip basal carcinoma previous positive biopsy Medical Specialty Hematology Oncology Sample Name BCCa Excision Nasal Tip Transcription PREOPERATIVE DIAGNOSIS Basal cell carcinoma nasal tip previous positive biopsy POSTOPERATIVE DIAGNOSIS Basal cell carcinoma nasal tip previous positive biopsy OPERATION PERFORMED Excision of nasal tip basal carcinoma Total area of excision approximately 1 cm to 12 mm frozen section x2 final margins clear INDICATION A 66 year old female for excision of nasal basal cell carcinoma This area is to be excised accordingly and closed We had multiple discussions regarding types of closure SUMMARY The patient was brought to the OR in satisfactory condition and placed supine on the OR table Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision The area was injected after sterile prep and drape with Marcaine 0 25 with 1 200 000 adrenaline The specimen was sent to pathology Margins were still positive at the inferior 6 o clock margin and this was resubmitted accordingly Final margins were clear Closure consisted of undermining circumferentially Advancement closure with dog ear removal distally and proximally was accomplished without difficulty Closure with interrupted 5 0 Monocryl running 7 0 nylon followed by Xeroform gauze light pressure dressing and Steri Strips The patient is discharged on minocycline and Darvocet N 100 NOTE The 2 6 mm loupe magnification was utilized throughout the procedure No complications noted with excellent and all clear margins at the termination An advancement closure technique was utilized Keywords hematology oncology basal cell carcinoma closure steri strips xeroform gauze excision light pressure dressing loupe magnification nasal tip basal carcinoma basal cell cell carcinoma biopsy basal carcinoma nasal MEDICAL_TRANSCRIPTION,Description The patient was admitted for symptoms that sounded like postictal state CT showed edema and slight midline shift MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery Medical Specialty Hematology Oncology Sample Name Brain Tumor Consult Transcription REASON FOR CONSULTATION I was asked by Dr X to see the patient in regard to his likely recurrent brain tumor HISTORY OF PRESENT ILLNESS The patient was admitted for symptoms that sounded like postictal state He was initially taken to Hospital CT showed edema and slight midline shift and therefore he was transferred here He has been seen by Hospitalists Service He has not had a recurrent seizure Electroencephalogram shows slowing MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery There is inhomogeneous uptake consistent with potential necrosis He also has had a SPECT image of his brain consistent with neoplasm suggesting relatively high grade neoplasm The patient was diagnosed with a brain tumor in 1999 All details are still not available to us He underwent a biopsy by Dr Y One of the notes suggested that this was a glioma likely an oligodendroglioma pending a second opinion at Clinic That is not available on the chart as I dictate After discussion of treatment issues with radiation therapist and Dr Z medical oncologist the decision was made to treat him primarily with radiation alone He tolerated that reasonably well His wife says it s been several years since he had a scan His behavior had not been changed until it changed as noted earlier in this summary PAST MEDICAL HISTORY He has had a lumbar fusion I believe he s had heart disease Mental status changes are either due to the tumor or other psychiatric problems SOCIAL HISTORY He is living with his wife next door to one of his children He has been disabled since 2001 due to the back problems REVIEW OF SYSTEMS No headaches or vision issues Ongoing heart problems without complaints No weakness numbness or tingling except that related to his chronic neck pain No history of endocrine problems He has nocturia and urinary frequency PHYSICAL EXAMINATION Blood pressure 146 91 pulse 76 Normal conjunctivae Ears nose throat normal Neck is supple Chest clear Heart tones normal Abdomen soft Positive bowel sounds No hepatosplenomegaly No adenopathy in the neck supraclavicular or axillary regions Neurologically alert Cranial nerves are intact Strength is 5 5 throughout LABORATORY WORK White blood count 10 4 hemoglobin 16 platelets not noted Sodium 137 calcium 9 1 IMPRESSION AND PLAN Likely recurrent low grade tumor possibly evolved to a higher grade given the MRI and SPECT findings Dr X s note suggests discussing the situation in the tumor board on Wednesday He is stable enough The pause in his care would not jeopardize his current status It would be helpful to get old films and pathology from Abbott Northwestern However he likely will need a re biopsy as he is highly suspicious for recurrent tumor and radiation necrosis Optimizing his treatment would probably be helped by knowing his current grade of tumor Keywords hematology oncology spect electroencephalogram middle cerebral artery brain tumor inhomogeneous frontotemporal neoplasm recurrent MEDICAL_TRANSCRIPTION,Description Excision basal cell carcinoma right medial canthus with frozen section and reconstruction of defect with glabellar rotation flap Medical Specialty Hematology Oncology Sample Name BCCa Excision Canthus Transcription PREOPERATIVE DIAGNOSIS Basal cell carcinoma 0 8 cm diameter right medial canthus POSTOPERATIVE DIAGNOSIS Basal cell carcinoma 0 8 cm diameter right medial canthus OPERATION Excision basal cell carcinoma 0 8 cm diameter right medial canthus with frozen section and reconstruction of defect 1 2 cm diameter with glabellar rotation flap ANESTHESIA Monitored anesthesia care JUSTIFICATION The patient is an 80 year old white female with a biopsy proven basal cell carcinoma of the right medial canthus She was scheduled for elective excision with frozen section under local anesthesia as an outpatient PROCEDURE With an intravenous infusing and under suitable premedication the patient was placed supine on the operative table The face was prepped with pHisoHex draped The right medial canthal region and the glabellar region were anesthetized with 1 Xylocaine with 1 100 000 epinephrine Under loupe magnification the lesion was excised with 2 mm margins oriented with sutures and submitted for frozen section pathology The report was basal cell carcinoma with all margins free of tumor Hemostasis was controlled with the Bovie Excised lesion diameter was 1 2 cm The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin The flap was elevated with a scalpel and Bovie rotated into the defect without tension to the defect with scissors and inset in layer with interrupted 5 0 Vicryl for the dermis and running 5 0 Prolene for the skin Donor site was closed in V Y fashion with similar suture technique The wounds were dressed with bacitracin ointment The patient was returned to the recovery room in satisfactory condition She tolerated the procedure satisfactorily and then no complications Blood loss was essentially nil Keywords hematology oncology basal cell carcinoma excision bacitracin canthal region canthus frozen section glabellar glabellar region loupe magnification phisohex rotation flap loupe excision basal cell carcinoma medial canthus basal cell cell carcinoma basal cell carcinoma MEDICAL_TRANSCRIPTION,Description Right axillary adenopathy thrombocytopenia and hepatosplenomegaly Right axillary lymph node biopsy Medical Specialty Hematology Oncology Sample Name Biopsy Axillary Lymph Node Transcription PREOPERATIVE DIAGNOSES 1 Right axillary adenopathy 2 Thrombocytopenia 3 Hepatosplenomegaly POSTOPERATIVE DIAGNOSES 1 Right axillary adenopathy 2 Thrombocytopenia 3 Hepatosplenomegaly PROCEDURE PERFORMED Right axillary lymph node biopsy ANESTHESIA Local with sedation COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to the recovery room in stable condition BRIEF HISTORY The patient is a 37 year old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly The working diagnosis is lymphoma however the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis Thus the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery INTRAOPERATIVE FINDINGS The patient was found to have a large right axillary lymphadenopathy one of the lymph node was sent down as a fresh specimen PROCEDURE After informed written consent risks and benefits of this procedure were explained to the patient The patient was brought to the operating suite prepped and draped in a normal sterile fashion Multiple lymph nodes were palpated in the right axilla however the most inferior node was to be removed First the skin was anesthetized with 1 lidocaine solution Next using a 15 blade scalpel an incision was made approximately 4 cm in length transversally in the inferior axilla Next using electro Bovie cautery maintaining hemostasis dissection was carried down to the lymph node The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab Several hemostats were used suture ligated with 3 0 Vicryl suture and hemostasis was maintained Next the deep dermal layers were approximated with 3 0 Vicryl suture After the wound has been copiously irrigated the skin was closed with running subcuticular 4 0 undyed Vicryl suture and the pathology is pending The patient did tolerated the procedure well Steri Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition Keywords hematology oncology hepatosplenomegaly thrombocytopenia axillary adenopathy axillary lymph node biopsy axillary lymph node lymph node biopsy lymph node lymph node axillary adenopathy hemostasis suture biopsy MEDICAL_TRANSCRIPTION,Description Discharge summary of a patient with a BRCA 2 mutation Medical Specialty Hematology Oncology Sample Name BRCA 2 mutation Transcription DISCHARGE DIAGNOSES BRCA 2 mutation HISTORY OF PRESENT ILLNESS The patient is a 59 year old with a BRCA 2 mutation Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27 PHYSICAL EXAMINATION The chest was clear The abdomen was nontender Pelvic examination shows no masses No heart murmur HOSPITAL COURSE The patient underwent surgery on the day of admission In the postoperative course she was afebrile and unremarkable The patient regained bowel function and was discharged on the morning of the fourth postoperative day OPERATIONS AND PROCEDURES Total abdominal hysterectomy bilateral salpingo oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25 2006 PATHOLOGY A 105 gram uterus without dysplasia or cancer CONDITION ON DISCHARGE Stable PLAN The patient will remain at rest initially with progressive ambulation after She will avoid lifting driving or intercourse She will call me if any fevers drainage bleeding or pain Follow up in my office in four weeks Family history social history psychosocial needs per the social worker DISCHARGE MEDICATIONS Percocet 5 40 one every 3 hours p r n pain Keywords hematology oncology brca 2 mutation brca 2 mutation breast cancer brca mutation breast postoperative peritoneum brca discharge cancer MEDICAL_TRANSCRIPTION,Description Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft Medical Specialty Hematology Oncology Sample Name BCCa Excision Lower Lid Transcription PREOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid POSTOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid TITLE OF OPERATION Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft PROCEDURE The patient was brought into the operating room and prepped and draped in usual fashion Xylocaine 2 with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid A frontal nerve block was also given on the right upper lid The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect The area was marked with a marking pen with margins of 3 to 4 mm and a 15 Bard Parker blade was used to make an incision at the nasal and temporal margins of the lesion The incision was carried inferiorly and using a Steven scissors the normal skin muscle and conjunctiva was excised inferiorly The specimen was then marked and sent to pathology for frozen section Bleeding was controlled with a wet field cautery and the right upper lid was everted and an incision was made 3 mm above the lid margin with the Bard Parker blade in the entire length of the upper lid The incision reached the orbicularis and Steven scissors were used to separate the tarsus from the underlying orbicularis Vertical cuts were made nasally and temporally and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly It was placed into the defect in the lower lid and sutured with multiple interrupted 6 0 Vicryl sutures nasally temporally and inferiorly The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region The defect was closed with interrupted 5 0 Prolene sutures and the preauricular graft was sutured in place with multiple interrupted 6 0 silk sutures The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied The patient tolerated the procedure well and was sent to recovery room in good condition Keywords hematology oncology basal cell carcinoma cryotherapy steven scissors conjunctiva conjunctival flap frontal nerve block frozen section lower lid orbicularis skin graft nasal and temporal margins dorsal conjunctival flap upper lid basal carcinoma preauricular incision conjunctival MEDICAL_TRANSCRIPTION,Description Patient seen in Neuro Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma Medical Specialty Hematology Oncology Sample Name Anaplastic Astrocytoma Letter Transcription XYZ RE ABC MEDICAL RECORD 123 Dear Dr XYZ I saw ABC back in Neuro Oncology Clinic today He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma Within the last several days he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective Despite repeatedly emphasizing this however the patient still is worried about potential long term side effects from treatment that frankly seem unwarranted at this particular time After seeing you in clinic he and his friend again wanted to discuss possible changes in the chemotherapy regimen They came in with a list of eight possible agents that they would like to be administered within the next two weeks They then wanted another MRI to be performed and they were hoping that with the use of this type of approach they might be able to induce another remission from which he can once again be spared radiation From my view I noticed a man whose language has deteriorated in the week since I last saw him This is very worrisome Today for the first time I felt that there was a definite right facial droop as well Therefore there is no doubt that he is becoming symptomatic from his growing tumor It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future Emphasizing this once again in addition to recommending steroids I once again tried to convince him to undergo radiation Despite an hour this again amazingly was not possible It is not that he does not want treatment however Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised we compromised and elected to go back to Temodar in a low dose daily type regimen We would plan on giving 75 mg sq m everyday for 21 days out of 28 days In addition we will stop thalidomide 100 mg day If he tolerates this for one week we then agree that we would institute another one of the medications that he listed for us At this stage we are thinking of using Accutane at that point While I am very uncomfortable with this type of approach I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval In the spirit of compromise he again consented to be evaluated by radiation and this time seemed more resigned to the fact that it was going to happen sooner than later I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term I will keep you apprised of followups If you have any questions or if I could be of any further assistance feel free to contact me Sincerely Keywords hematology oncology neuro oncology anaplastic astrocytoma anaplastic oncology radiation astrocytoma MEDICAL_TRANSCRIPTION,Description Chronic lymphocytic leukemia CLL autoimmune hemolytic anemia and oral ulcer The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis Medical Specialty Hematology Oncology Sample Name Anemia Leukemia Followup Transcription CHIEF COMPLAINT 1 Chronic lymphocytic leukemia CLL 2 Autoimmune hemolytic anemia 3 Oral ulcer HISTORY OF PRESENT ILLNESS The patient is a 72 year old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008 He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day He comes in to clinic today for follow up and complete blood count At his last office visit we discontinued this prophylactic antivirals and antibacterial CURRENT MEDICATIONS Prilosec 20 mg b i d levothyroxine 50 mcg q d Lopressor 75 mg q d vitamin C 500 mg q d multivitamin q d simvastatin 20 mg q d and prednisone 5 mg q o d ALLERGIES Vicodin REVIEW OF SYSTEMS The patient reports ulcer on his tongue and his lip He has been off of Valtrex for five days He is having some difficulty with his night vision with his left eye He has a known cataract He denies any fevers chills or night sweats He continues to have headaches The rest of his review of systems is negative PHYSICAL EXAM VITALS Keywords hematology oncology oral ulcer leukemia anemia hemolysis blood count chronic lymphocytic leukemia autoimmune hemolytic anemia hemolytic cll lymphocytic autoimmune MEDICAL_TRANSCRIPTION,Description Left axillary dissection with incision and drainage of left axillary mass Right axillary mass excision and incision and drainage Bilateral axillary masses rule out recurrent Hodgkin s disease Medical Specialty Hematology Oncology Sample Name Axillary Dissection Mass Excision Transcription PREOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease POSTOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease PROCEDURE PERFORMED 1 Left axillary dissection with incision and drainage of left axillary mass 2 Right axillary mass excision and incision and drainage ANESTHESIA LMA SPECIMENS Left axillary mass with nodes and right axillary mass ESTIMATED BLOOD LOSS Less than 30 cc INDICATION This 56 year old male presents to surgical office with history of bilateral axillary masses Upon evaluation it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter The patient had been continued on antibiotics preoperatively The patient with history of Hodgkin s lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time Consent for possible recurrence of Hodgkin s lymphoma warranted exploration and excision of these masses The patient was explained the risks and benefits of the procedure and informed consent was obtained GROSS FINDINGS Upon dissection of the left axillary mass the mass was removed in toto and noted to have a cavity within it consistent with an abscess No loose structures were identified and sent for frozen section which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma however the confirmed pathology report is pending at this time The right axillary mass was excised without difficulty without requiring full axillary dissection PROCEDURE The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete A 10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis Identification of the axillary anatomy was made and care was made to avoid injury to nerve vessel or musculature Once this mass was removed in toto lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture Upon revaluation of the incisional site it was noted to be hemostatic Warm lap sponge was then left in place at this site Next attention was turned to the right axilla where a 10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with 3 0 Vicryl suture followed by 4 0 Vicryl running subcuticular stitch Steri Strips were applied Attention was returned back left axilla which upon re exploration was noted to be hemostatic and a 7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision This was placed within the incision site ________ drainage of the axillary potential space Approximation of the deep dermal tissues were then done with 3 0 Vicryl in an interrupted technique followed by 4 0 Vicryl with running subcuticular technique Steri Strips and sterile dressings were applied JP bulb was then placed to suction and sterile dressings were applied to both axilla The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1 2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise Keywords hematology oncology incision and drainage axillary mass excision axillary dissection hodgkin s disease axillary mass mass incision axillary MEDICAL_TRANSCRIPTION,Description Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair Patient with a 5 5 cm diameter nonfunctioning mass in his right adrenal Medical Specialty Hematology Oncology Sample Name Adrenalectomy Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia POSTOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia OPERATION PERFORMED Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair ANESTHESIA General CLINICAL NOTE This is a 52 year old inmate with a 5 5 cm diameter nonfunctioning mass in his right adrenal Procedure was explained including risks of infection bleeding possibility of transfusion possibility of further treatments being required Alternative of fully laparoscopic are open surgery or watching the lesion DESCRIPTION OF OPERATION In the right flank up position table was flexed He had a Foley catheter in place Incision was made from just above the umbilicus about 5 5 cm in diameter The umbilical hernia was taken down An 11 mm trocar was placed in the midline superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin A liver retractor was placed to this The colon was reflected medially by incising the white line of Toldt The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly The vena cava was identified The main renal vein was identified Coming superior to the main renal vein staying right on the vena cava all small vessels were clipped and then divided Coming along the superior pole of the kidney the tumor was dissected free from top of the kidney with clips and Bovie The harmonic scalpel was utilized superiorly and laterally Posterior attachments were divided between clips and once the whole adrenal was mobilized the adrenal vein and one large adrenal artery were noted doubly clipped and divided Specimen was placed in a collection bag removed intact Hemostasis was excellent The umbilical hernia had been completely taken down The edges were freshened up Vicryl 1 was utilized to close the incision and 2 0 Vicryl was used to close the fascia of the trocar Skin closed with clips He tolerated the procedure well All sponge and instrument counts were correct Estimated blood loss less than 100 mL The patient was awakened extubated and returned to recovery room in satisfactory condition Keywords hematology oncology adrenalectomy laparoscopic hand assisted umbilical hernia repair vena cava renal vein hernia repair laparoscopic umbilical hernia MEDICAL_TRANSCRIPTION,Description This 68 year old man presents to the emergency department for three days of cough claims that he has brought up some green and grayish sputum He says he does not feel short of breath He denies any fever or chills Medical Specialty General Medicine Sample Name Viral Syndrome ER Visit Transcription SUBJECTIVE This 68 year old man presents to the emergency department for three days of cough claims that he has brought up some green and grayish sputum He says he does not feel short of breath He denies any fever or chills REVIEW OF SYSTEMS HEENT Denies any severe headache or sore throat CHEST No true pain GI No nausea vomiting or diarrhea PAST HISTORY He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation He also lists some other medications I do have his medications list He is on Pacerone Zaroxolyn albuterol inhaler Neurontin Lasix and several other medicines Those are the predominant medicines He is not a diabetic The past history otherwise he has had smoking history but he quit several years ago and denies any COPD or emphysema No one else in the family is sick PHYSICAL EXAMINATION GENERAL The patient appears comfortable He did not appear to be in any respiratory distress He was alert I heard him cough once during the entire encounter He did not bring up any sputum at that time VITAL SIGNS His temperature is 98 pulse 71 respiratory rate 18 blood pressure 122 57 and pulse ox is 95 on room air HEENT Throat was normal RESPIRATORY He was breathing normally There was clear and equal breath sounds He was speaking in full sentences There was no accessory muscle use HEART Sounded regular SKIN Normal color warm and dry NEUROLOGIC Neurologically he was alert IMPRESSION Viral syndrome which we have been seeing in many cases throughout the week The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature normal pulse normal respiratory rate and near normal oxygen The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding The patient understands this I then asked him if the cough was annoying him he said it was I offered him a cough syrup which he agreed to take The patient was then discharged with Tussionex Pennkinetic a hydrocodone time release cough syrup I told to check in three days if the symptoms were not getting better The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later His wife calls me very angry that I did not give him antibiotics I explained her exactly what I explained to him that they were not indicative at this time and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection DIAGNOSIS Viral respiratory illness Keywords general medicine sputum short of breath fever chills copd emphysema viral respiratory illness green and grayish sputum viral syndrome respiratory rate cough syrup cough antibiotics inhaler MEDICAL_TRANSCRIPTION,Description Sore throat Upper respiratory infection Medical Specialty General Medicine Sample Name URI SOAP Transcription SUBJECTIVE Mom brings patient in today because of sore throat starting last night Eyes have been very puffy He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday He has had low grade fever and just felt very run down appearing very tired He is still eating and drinking well and his voice has been hoarse but no coughing No shortness of breath vomiting diarrhea or abdominal pain PAST MEDICAL HISTORY Unremarkable There is no history of allergies He does have some history of some episodes of high blood pressure and his weight is up about 14 pounds from the last year FAMILY HISTORY Noncontributory No one else at home is sick OBJECTIVE General A 13 year old male appearing tired but in no acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally gray in color Good light reflex Oropharynx pink and moist No erythema or exudate Some drainage is seen in the posterior pharynx Nares Swollen red No drainage seen No sinus tenderness Eyes are clear Chest Respirations are regular and nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry and pink moist mucous membranes No rash LABORATORY Strep test is negative Strep culture is negative RADIOLOGY Water s View of the sinuses is negative for any sinusitis or acute infection ASSESSMENT Upper respiratory infection PLAN At this point just treat symptomatically I gave him some samples of Levall for the congestion and as an expectorant Push fluids and rest May use ibuprofen or Tylenol for discomfort Keywords general medicine soap uri upper respiratory infection water s view congestion light reflex sore throat respiratory strep infection MEDICAL_TRANSCRIPTION,Description Patient with morbid obesity Medical Specialty General Medicine Sample Name Weight Loss Evaluation Transcription REASON FOR VISIT Weight loss evaluation HISTORY OF PRESENT ILLNESS Keywords general medicine medifast obesity weight loss morbid obesity weight loss evaluation weight MEDICAL_TRANSCRIPTION,Description 3 Dimensional Simulation This patient is undergoing 3 dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures Medical Specialty Hematology Oncology Sample Name 3 Dimensional Simulation Transcription 3 DIMENSIONAL SIMULATION This patient is undergoing 3 dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures This optimizes the chance of controlling tumor while diminishing the acute and long term side effects With conformal 3 dimensional simulation there is extended physician therapist and dosimetrist effort and time expended The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized Preliminary filed sizes and arrangements including gantry angles collimator angles and number of fields are conceived Radiographs are taken and these films are approved by the physician Appropriate marks are placed on the patient s skin or on the immobilization device The patient is transferred to the diagnostic facility and placed on a flat CT scan table Scans are performed through the targeted area The scans are evaluated by the radiation oncologist and the tumor volume target volume and critical structures are outlined on the CT images The dosimetrist then evaluates the slices in the treatment planning computer with appropriately marked structures This volume is reconstructed in a virtual 3 dimensional space utilizing the beam s eye view features Appropriate blocks are designed Multiplane computerized dosimetry is performed throughout the volume Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan the individual slices are then reviewed by the physician The beam s eye view block design and appropriate volumes are also printed and reviewed by the physician Once these are approved physical blocks or multi leaf collimator equivalents will be devised If significant changes are made in the field arrangements from the original simulation the patient is brought back to the simulator where computer designed fields are re simulated In view of the extensive effort and time expenditure required this procedure justifies the special procedure code 77470 Keywords hematology oncology 3 dimensional simulation planned radiation therapy ct scan ct images beam s eye view field arrangements normal structures therapy dimensional simulationNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days Medical Specialty General Medicine Sample Name Toothache ER Visit Transcription CHIEF COMPLAINT Toothache HISTORY OF PRESENT ILLNESS This is a 29 year old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled Complains of new tooth pain The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments he has to be on standby appointments only The patient denies any other problems or complaints The patient denies any recent illness or injuries The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness No recent weight change HEENT No headache no neck pain the toothache pain for the past three days as previously mentioned There is no throat swelling no sore throat no difficulty swallowing solids or liquids The patient denies any rhinorrhea No sinus congestion pressure or pain no ear pain no hearing change no eye pain or vision change CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath or cough GASTROINTESTINAL No abdominal pain No nausea or vomiting GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No focal weakness or numbness Normal speech HEMATOLOGIC LYMPHATIC No lymph node swelling has been noted PAST MEDICAL HISTORY Chronic knee pain CURRENT MEDICATIONS OxyContin and Vicodin ALLERGIES PENICILLIN AND CODEINE SOCIAL HISTORY The patient is still a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 9 oral blood pressure is 146 83 pulse is 74 respirations 16 oxygen saturation 98 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed The patient is a little overweight but otherwise appears to be healthy The patient is calm comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Eyes are normal with clear conjunctiva and cornea bilaterally There is no icterus injection or discharge Pupils are 3 mm and equally round and reactive to light bilaterally There is no absence of light sensitivity or photophobia Extraocular motions are intact bilaterally Ears are normal bilaterally without any sign of infection There is no erythema swelling of canals Tympanic membranes are intact without any erythema bulging or fluid levels or bubbles behind it Nose is normal without rhinorrhea or audible congestion There is no tenderness over the sinuses NECK Supple nontender and full range of motion There is no meningismus No cervical lymphadenopathy No JVD Mouth and oropharynx shows multiple denture and multiple dental caries The patient has tenderness to tooth 12 as well as tooth 21 The patient has normal gums There is no erythema or swelling There is no purulent or other discharge noted There is no fluctuance or suggestion of abscess There are no new dental fractures The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling The buccal membranes are normal Mucous membranes are moist The floor of the mouth is normal without any abscess suggestion of Ludwig s syndrome CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally without shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to back arms and legs The patient has normal use of his extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact to the extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No cervical lymphadenopathy is palpated EMERGENCY DEPARTMENT COURSE The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction DIAGNOSES 1 ODONTALGIA 2 MULTIPLE DENTAL CARIES CONDITION UPON DISPOSITION Stable DISPOSITION To home PLAN The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes The patient was requested to have reevaluation within two days The patient was given a prescription for Percocet and clindamycin The patient was given drug precautions for the use of these medicines The patient was offered discharge instructions on toothache but states that he already has it He declined the instructions The patient was asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern Keywords general medicine odontalgi multiple dental caries dentist dental disease extensive dental disease teeth pulled lower teeth cervical lymphadenopathy dental caries toothache erythema swelling teeth dental MEDICAL_TRANSCRIPTION,Description Patient with immune thrombocytopenia Medical Specialty General Medicine Sample Name Thrombocytopenia SOAP Note Transcription SUBJECTIVE I am following the patient today for immune thrombocytopenia Her platelets fell to 10 on 01 09 07 and shortly after learning of that result I increased her prednisone to 60 mg a day Repeat on 01 16 07 revealed platelets up at 43 No bleeding problems have been noted I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day The patient had been on 20 mg every other day at least for a while and her platelets hovered at least above 20 or so PHYSICAL EXAMINATION Vitals As in chart The patient is alert pleasant and cooperative She is in no apparent distress The petechial areas on her legs have resolved ASSESSMENT AND PLAN Patient with improvement of her platelet count on burst of prednisone We will decrease her prednisone to 40 mg for 3 days then go down to 20 mg a day Basically thereafter over time I may try to sneak it back a little bit further She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D We will arrange to have a CBC drawn weekly Keywords general medicine platelets platelet count thrombocytopenia prednisone MEDICAL_TRANSCRIPTION,Description The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission Medical Specialty General Medicine Sample Name Shortness Of Breath Progress Note Transcription She was evaluated this a m and was without any significant clinical change Her white count has been improving and down to 12 000 A chest x ray obtained today showed some bilateral infiltrates but no acute cardiopulmonary change There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia She has been on Zosyn for the infection Throughout her hospitalization we have been trying to adjust her pain medications She states that the methadone did not work for her She was immune to oxycodone She had been on tramadol before and was placed back on that There was some question that this may have been causing some dizziness She also was on clonazepam and alprazolam for the underlying bipolar disorder Apparently her husband was in this afternoon He had a box of her pain medications It is unclear whether she took a bunch of these or precisely what happened I was contacted that she was less responsive She periodically has some difficulty to arouse due to pain medications which she has been requesting repeatedly though at times does not appear to have objective signs of ongoing pain The nurse found her and was unable to arouse her at this point There was a concern that she had taken some medications from home She was given Narcan and appeared to come around some Breathing remained somewhat labored and she had some diffuse scattered rhonchi which certainly changed from this a m Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity With O2 via mask oxygenation was stable at 90 to 95 after initial hypoxia was noted A chest x ray was obtained at this time An ECG was obtained which shows a sinus tachycardia noted to have ischemic abnormalities In light of the acute decompensation she was then transferred to the ICU We will continue the IV Zosyn Respiratory protocol with respiratory management Continue alprazolam p r n but avoid if she appears sedated We will attempt to avoid additional pain medications but we will continue with the Dilaudid for time being I suspect she will need something to control her bipolar disorder Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission At this juncture she does not appear to need an intubation Pending chest x ray she may require additional IV furosemide Keywords general medicine shortness of breath pulmonary medicine bipolar disorder icuNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Chronic snoring in children Medical Specialty General Medicine Sample Name Snoring Transcription CHRONIC SNORING Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome Both conditions may lead to sleep fragmentation and or intermittent oxygen desaturation both of which have significant health implications including poor sleep quality and stress on the cardiovascular system Symptoms like daytime somnolence fatigue hyperactivity behavior difficulty i e ADHD and decreased school performance have been reported with these conditions In addition the most severe cases may be associated with right ventricular hypertrophy pulmonary and or systemic hypertension and even cor pulmonale In this patient the risks for a sleep disordered breathing include obesity and the tonsillar hypertrophy It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed Keywords general medicine snoring chronic snoring behavior difficulty fatigue hyperactivity obstructive sleep apnea oxygen oxygen desaturation polysomnogram poor sleep quality right ventricular hypertrophy school performance sleep fragmentation somnolence systemic hypertension upper airway upper airway resistant syndrome snoring chronic hypertrophy sleepNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description He got addicted to drugs He decided it would be a good idea to get away from the bad crowd and come up and live with his mom Medical Specialty General Medicine Sample Name SOAP Substance Abuse Transcription SUBJECTIVE This patient presents to the office today with his mom for checkup He used to live in the city He used to go to college down in the city He got addicted to drugs He decided it would be a good idea to get away from the bad crowd and come up and live with his mom He has a history of doing heroin He was injecting into his vein He was seeing a physician in the city They were prescribing methadone for some time He says that did help He was on 10 mg of methadone He was on it for three to four months He tried to wean down on the methadone a couple of different times but failed He has been intermittently using heroin He says one of the big problems is that he lives in a household full of drug users and he could not get away from it All that changed now that he is living with his mom The last time he did heroin was about seven to eight days ago He has not had any methadone in about a week either He is coming in today specifically requesting methadone He also admits to being depressed He is sad a lot and down He does not have much energy He does not have the enthusiasm He denies any suicidal or homicidal ideations at the present time I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms His past medical history is significant for no medical problems Surgical history he voluntarily donated his left kidney Family and social history were reviewed per the nursing notes His allergies are no known drug allergies Medications he takes no medications regularly OBJECTIVE His weight is 164 pounds blood pressure 108 60 pulse 88 respirations 16 and temperature was not taken General He is nontoxic and in no acute distress Psychiatric Alert and oriented times 3 Skin I examined his upper extremities He showed me his injection sites I can see marks but they seem to be healing up nicely I do not see any evidence of cellulitis There is no evidence of necrotizing fasciitis ASSESSMENT Substance abuse PLAN I had a long talk with the patient and his mom I am not prescribing him any narcotics or controlled substances I am not in the practice of trading one addiction for another It has been one week without any sort of drugs at all I do not think he needs weaning I think right now it is mostly psychological although there still could be some residual physical addiction However once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time I do believe that his depression needs to be treated I gave him fluoxetine 20 mg one tablet daily I discussed the side effects in detail I did also warn him that all antidepressant medications carry an increased risk of suicide If he should start to feel any of these symptoms he should call 911 or go to the emergency room immediately If he has any problems or side effects he was also directed to call me here at the office After hours he can go to the emergency room or call 911 I am going to see him back in three weeks for the depression I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group We are unable to make a referral for him to do that He has to call on his own He has no insurance However I think fluoxetine is very affordable He can get it for 4 per month at Wal Mart His mom is going to keep an eye on him as well He is going to be staying there It sounds like he is looking for a job Keywords general medicine addicted to drugs substance abuse abuse heroin methadone MEDICAL_TRANSCRIPTION,Description Followup of moderate to severe sleep apnea The patient returns today to review his response to CPAP Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction Medical Specialty General Medicine Sample Name Sleep Apnea Transcription REASON FOR VISIT Mr ABC is a 30 year old man who returns in followup of his still moderate to severe sleep apnea He returns today to review his response to CPAP HISTORY OF PRESENT ILLNESS The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner He was found to have moderate to severe sleep apnea predominantly hypopnea was treated with nasal CPAP at 10 cm H2O nasal pressure He has been on CPAP now for several months and returns for followup to review his response to treatment The patient reports that the CPAP has limited his snoring at night Occasionally his bed partner wakes him in the middle of the night when the mask comes off and reminds him to replace the mask The patient estimates that he uses the CPAP approximately 5 to 7 nights per week and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night The patient s sleep pattern consists of going to bed between 11 00 and 11 30 at night and awakening between 6 to 7 a m on weekdays On weekends he might sleep until 8 to 9 a m On Saturday night he might go to bed approximately mid night As noted the patient is not snoring on CPAP He denies much tossing and turning and does not awaken with the sheets in disarray He awakens feeling relatively refreshed In the past few months the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures He continues to work at Smith Barney in downtown Baltimore He generally works from 8 to 8 30 a m until approximately 5 to 5 30 p m He is involved in training purpose to how to sell managed funds and accounts The patient reports no change in daytime stamina He has no difficulty staying awake during the daytime or evening hours The past medical history is notable for allergic rhinitis MEDICATIONS He is maintained on Flonase and denies much in the way of nasal symptoms ALLERGIES Molds FINDINGS Vital signs Blood pressure 126 75 pulse 67 respiratory rate 16 weight 172 pounds height 5 feet 9 inches temperature 98 4 degrees and SaO2 is 99 on room air at rest The patient has adenoidal facies as noted previously Laboratories The patient forgot to bring his smart card in for downloading today ASSESSMENT Moderate to severe sleep apnea I have recommended the patient continue CPAP indefinitely He will be sending me his smart card for downloading to determine his CPAP usage pattern In addition he will continue efforts to maintain his weight at current levels or below Should he succeed in reducing further we might consider re running a sleep study to determine whether he still requires a CPAP PLANS In the meantime if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction He will be returning for routine followup in 6 months Keywords general medicine daytime stamina fiberoptic ent exam moderate to severe smart card sleep apnea cpap apnea sleep MEDICAL_TRANSCRIPTION,Description Right hand laceration x3 repaired Medical Specialty General Medicine Sample Name Right Hand Laceration Transcription HISTORY The patient is a 19 year old male who was involved in a fight approximately an hour prior to his ED presentation He punched a guy few times on the face might be the mouth and then punched a drinking glass breaking it and lacerating his right hand He has three lacerations on his right hand His wound was cleaned out thoroughly with tap water and one of the navy corpsman tried to use Superglue and gauze to repair it However it continues to bleed and he is here for evaluation PAST MEDICATION HISTORY Significant for asthma and acne CURRENT MEDICATIONS Accutane and takes no other medications TETANUS STATUS Up to date SOCIAL HISTORY He is a nonsmoker He has been drinking alcohol today but has no history of alcohol or drug abuse REVIEW OF SYSTEMS Otherwise well No febrile illness No motor or sensory complaints of any sort or paresthesias in the hand PHYSICAL EXAM GENERAL He is in no apparent distress He is alert and oriented x3 Mental status is clear and appropriate VITALS SIGNS Temperature is 98 3 heart rate 100 respirations 18 blood pressure 161 98 oxygen saturation 99 on room air by pulse oximetry which is normal EXTREMITIES Right hand he has three lacerations all over the MCP joint of his right hand irregular shaped over the fifth MCP and then over the fourth and third half wound similarly the lacerations All total approximately 4 cm in length I see no foreign bodies just capillary refills less than 2 seconds Radial pulses intact There is full range of motion with no gross deformities No significant amount of edema associated with these in the dorsum of the hand STUDIES X rays shows no open fracture or bony abnormality EMERGENCY DEPARTMENT COURSE The patient was anesthetized with 1 Xylocaine Wounds were thoroughly irrigated with tap water with at least 2 liters They were repaired with simple sutures of 4 0 Ethilon total of 17 sutures 16 of which were simple one is a horizontal mattress The patient was given Augmentin 875 mg p o due to the possibility of human bite wound ASSESSMENT RIGHT HAND LACERATIONS SIMPLE X3 REPAIRED AS DESCRIBED NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY PLAN The patient will be given Augmentin 875 mg 1 p o b i d for 7 days He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane He will take 1 p o every 6 hours or as needed 12 He will follow up for suture removal in 8 days Should he develop any signs of infection he will come immediately here for reevaluation He is discharged in stable condition Keywords general medicine accutane hand laceration laceration hand MEDICAL_TRANSCRIPTION,Description Request for consultation to evaluate stomatitis possibly methotrexate related Medical Specialty General Medicine Sample Name Request For Consultation Transcription REASON FOR CONSULTATION Please evaluate stomatitis possibly methotrexate related HISTORY OF PRESENT ILLNESS The patient is a very pleasant 57 year old white female a native of Cuba being seen for evaluation and treatment of sores in her mouth that she has had for the last 10 12 days The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments but over the past ten years she has been treated with methotrexate quite successfully Her dosage has varied somewhere between 20 and 25 mg per week About the beginning of this year her dosage was decreased from 25 mg to 20 mg but because of the flare of the rheumatoid arthritis it was increased to 22 5 mg per week She has had no problems with methotrexate as far as she knows She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth About two weeks ago just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection She does not remember the name of the antibiotic Although she claims she remembers taking this type of medication in the past without any problems She was on that medication three pills a day for three to four days She notes no other problems with her skin She remembers no allergic reactions to medication She has no previous history of fever blisters PHYSICAL EXAMINATION Reveals superficial erosions along the lips particularly the lower lips The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva Her posterior pharynx was difficult to visualize but I saw no erosions on the areas today There did however appear to be one small erosion on the soft palate Examination of the rest of her skin revealed no areas of dermatitis or blistering There were some macular hyperpigmentation on the right arm where she has had a previous burn plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries IMPRESSION Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems Methotrexate may produce an erosive stomatitis and enteritis after such a use The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed She has had no diarrhea today however She has noted no blood in her stools and has had no episodes of nausea or vomiting I am not as familiar with the NSAID causing an erosive stomatitis I understand that it can cause gastrointestinal upset but given the choice between the two I would think the methotrexate is the most likely etiology for the stomatitis RECOMMENDED THERAPY I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients skin problem However in my experience this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate for an extended period of time because the medication is stored within the liver and in fatty tissue Topically I have prescribed Lidex gel which I find works extremely well in stomatitis conditions It can be applied t i d Thank you very much for allowing me to share in the care of this pleasant patient I will follow her with you as needed Keywords general medicine stomatitis nsaid blistering blisters buccal mucosa dermatitis erosive stomatitis gastrointestinal methotrexate mouth rheumatoid arthritis stomatitis conditions superficial erosions upper respiratory infection illness medication MEDICAL_TRANSCRIPTION,Description Symptomatic thyroid goiter Total thyroidectomy Medical Specialty General Medicine Sample Name Post Thyroidectomy Discharge Summary Transcription ADMISSION DIAGNOSIS Symptomatic thyroid goiter DISCHARGE DIAGNOSIS Symptomatic thyroid goiter PROCEDURE PERFORMED DURING THIS HOSPITALIZATION Total thyroidectomy INDICATIONS FOR THE SURGERY Briefly the patient is a 71 year old female referred with increasingly symptomatic large nodular thyroid goiter She presented now after informed consent for the above procedure understanding the inherent risks and complications and risk benefit ratio HOSPITAL COURSE The patient underwent total thyroidectomy on 09 22 08 which she tolerated very well and remained stable in the postoperative period On postoperative day 1 she was tolerating her diet began on thyroid hormone replacement and remained afebrile with stable vital signs She required intravenous narcotics for pain control She was judged stable for discharge home on 09 25 08 tolerating a diet well having no fever stable vital signs and good pain control The wound was clean and dry The drain was removed She was instructed to follow up in the surgical office within one week after discharge She was given prescription for Vicodin for pain and Synthroid thyroid hormone and otherwise the appropriate wound care instructions per my routine wound care sheet Keywords general medicine nodular symptomatic thyroid goiter thyroidectomy goiter MEDICAL_TRANSCRIPTION,Description Refractory hypertension much improved history of cardiac arrhythmia and history of pacemaker secondary to AV block history of GI bleed and history of depression Medical Specialty General Medicine Sample Name Refractory Hypertension Followup Transcription PROBLEM LIST 1 Refractory hypertension much improved 2 History of cardiac arrhythmia and history of pacemaker secondary to AV block 3 History of GI bleed in 1995 4 History of depression HISTORY OF PRESENT ILLNESS This is a return visit to the renal clinic for this patient She is an 85 year old woman with history as noted above Her last visit was approximately four months ago Since that time the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously She is not reporting any untoward side effect She is not having weakness dizziness lightheadedness nausea vomiting constipation diarrhea abdominal pain chest pain shortness of breath or difficulty breathing She has no orthopnea Her exercise capacity is about the same The only problem she has is musculoskeletal and that pain in the right buttock she thinks originating from her spine No history of extremity pain CURRENT MEDICATIONS 1 Triamterene hydrochlorothiazide 37 5 25 mg 2 Norvasc 10 mg daily 3 Atenolol 50 mg a day 4 Atacand 32 mg a day 5 Cardura 4 mg a day PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 2 pulse 47 respirations 16 and blood pressure 157 56 THORAX Revealed lungs that are clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 I could not hear murmur today ABDOMEN Above plane but nontender EXTREMITIES Revealed no edema ASSESSMENT This is a return visit for this patient who has refractory hypertension This seems to be doing very well given her current blood pressure reading at least much improved from what she had been previously We had discussed with her in the past beginning to see an internist at the senior center She apparently had an appointment scheduled and it was missed We are going to reschedule that today given her overall state of well being and the fact that she has no evidence of GFR that is greater than 60 PLAN The plan will be for her to follow up at the senior center for her routine health care and should the need arise for further management of blood pressure a referral back to us In the meantime we will discharge her from our practice Should there be confusion or difficulty getting in the senior center we can always see her back in followup Keywords general medicine cardiac arrhythmia av block refractory hypertension blood pressure pacemaker atenolol arrhythmia MEDICAL_TRANSCRIPTION,Description Pressure decubitus right hip Medical Specialty General Medicine Sample Name Pressure decubitus Transcription CHIEF COMPLAINT Pressure decubitus right hip HISTORY OF PRESENT ILLNESS This is a 30 year old female patient presenting with the above chief complaint She has a history of having had a similar problem last year which resolved in about three treatments She appears to have residual from spina bifida thus spending most of her time in a wheelchair She relates recently she has been spending up to 16 hours a day in a wheelchair She has developed a pressure decubitus on her right trochanter ischial area of several weeks duration She is now presenting for evaluation and management of same Denies any chills or fever any other symptoms PAST MEDICAL HISTORY Back closure for spina bifida hysterectomy breast reduction and a shunt SOCIAL HISTORY She denies the use of alcohol illicits or tobacco MEDICATIONS Pravachol Dilantin Toprol and Macrobid ALLERGIES SULFA AND LATEX REVIEW OF SYSTEMS Other than the above aforementioned the remaining ROS is unremarkable PHYSICAL EXAMINATION GENERAL A pleasant female with deformity of back HEENT Head is normocephalic Oral mucosa and dentition appear to be normal CHEST Breath sounds equal and present bilateral CVS Sinus GI Obese nontender no hepatosplenomegaly EXTREMITIES Deformity of lower extremities secondary to spina bifida SKIN She has a full thickness pressure decubitus involving the right hip which is 2 x 6 4 x 0 3 moderate amount of serous material appears to have good granulation tissue PLAN Daily applications of Acticoat pressure relief at least getting out of the chair for half of the time at least eight hours out of the chair and we will see her in one week DIAGNOSIS Sequelae of spina bifida pressure decubitus of right hip area Keywords general medicine pressure decubitus acticoat sequelae breast reduction decubitus hysterectomy ischial area pressure spina bifida trochanter wheelchair bifida MEDICAL_TRANSCRIPTION,Description Atypical pneumonia hypoxia rheumatoid arthritis and suspected mild stress induced adrenal insufficiency This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission Medical Specialty General Medicine Sample Name Pneumonia Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pneumonia failed outpatient treatment 2 Hypoxia 3 Rheumatoid arthritis DISCHARGE DIAGNOSES 1 Atypical pneumonia suspected viral 2 Hypoxia 3 Rheumatoid arthritis 4 Suspected mild stress induced adrenal insufficiency HOSPITAL COURSE This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission She was seen on multiple occasions at Urgent Care and in her physician s office Initial x ray showed some mild diffuse patchy infiltrates She was first started on Avelox but had a reaction switched to Augmentin which caused loose stools and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin Her O2 saturations drifted downward They were less than 88 when active at rest varied between 88 and 92 Decision was made because of failed outpatient treatment of pneumonia Her medical history is significant for rheumatoid arthritis She is on 20 mg of methotrexate every week as well as Remicade every eight weeks Her last dose of Remicade was in the month of June Hospital course was relatively unremarkable CT scan was performed and no specific focal pathology was seen Dr X pulmonologist was consulted He also was uncertain as to the exact etiology but viral etiology was most highly suspected Because of her loose stools C difficile toxin was ordered although that is pending at the time of discharge She was continued on Rocephin IV and azithromycin Her fever broke 18 hours prior to discharge and O2 saturations improved as did her overall strength and clinical status She was instructed to finish azithromycin She has two pills left at home She is to follow up with Dr X in two to three days Because she is on chronic prednisone therapy it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia She is to continue the increased dose of prednisone at 20 mg up from 5 mg per day We will consult her rheumatologist as to whether to continue her methotrexate which we held this past Friday Methotrexate is known on some occasions to cause pneumonitis Keywords general medicine adrenal insufficiency hypoxia cough fevers weakness chills atypical pneumonia loose stools rheumatoid arthritis azithromycin arthritis pneumonia MEDICAL_TRANSCRIPTION,Description Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit hypertension mild renal insufficiency and anemia which has been present chronically over the past year Medical Specialty General Medicine Sample Name Pyelonephritis Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pyelonephritis 2 History of uterine cancer and ileal conduit urinary diversion 3 Hypertension 4 Renal insufficiency 5 Anemia DISCHARGE DIAGNOSES 1 Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit 2 Hypertension 3 Mild renal insufficiency 4 Anemia which has been present chronically over the past year HOSPITAL COURSE The patient was admitted with suspected pyelonephritis Renal was consulted It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr X Her symptoms responded to IV antibiotics and she remained clinically stable Klebsiella was isolated in this urine which was sensitive to Bactrim and she was discharged on p o Bactrim She was scheduled on 08 07 2007 for further surgery She is to follow up with Dr Y in 7 10 days She also complained of right knee pain and the right knee showed no sign of effusion She was exquisitely tender to touch of the patellar tendon It was thought that this did not represent intraarticular process She was advised to use ibuprofen over the counter two to three tabs t i d Keywords general medicine uterine cancer renal insufficiency pyelonephritis mucous plugging ileal conduit MEDICAL_TRANSCRIPTION,Description Patient in emergency room due to high potassium value Medical Specialty General Medicine Sample Name Patient with High Potassium Transcription CHIEF COMPLAINT My potassium is high HISTORY OF PRESENT ILLNESS A 47 year old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue Labs drawn there revealed a potassium of 7 0 and he was told to come here for further evaluation At time of his assessment in the emergency room he noted general malaise and fatigue for eight months Over this same time period he had subjective fevers and chills night sweats and a twenty pound weight loss He described anorexia with occasional nausea and vomiting of non bilious material along with a feeling of light headedness that occurred shortly after standing from a sitting or lying position He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2 3 blocks where before he had been able to jog 2 3 miles He also noted that over the past year his left testicle had been getting progressively more swollen and painful He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement Over the last several months there had been chronic drainage of yellowish material from this testicle He denied trauma to this area He denied diarrhea or constipation changes in his urinary habits rashes or skin changes arthritis arthralgias abdominal pain headache or visual changes PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Mone MEDICATIONS Occasional acetaminophen ALLERGIES NKDA SOCIAL HISTORY He drank a 6 pack of beer per day for the past 30 years He smoked a pack and a half of cigarettes per day for the past 35 years He was currently unemployed but had worked as a mechanic and as a carpet layer in the past He had been briefly incarcerated 5 years prior to admission He denied intravenous drug use or unprotected sexual exposures FAMILY HISTORY There was a history of coronary artery disease and diabetes mellitus in the family PHYSICAL EXAM VITAL SIGNS Temp 98 6 F Respirations 16 minute Lying down Blood pressure 109 70 pulse 70 minute Sitting Blood pressure 78 65 pulse 79 minute Standing Blood pressure 83 70 pulse 95 minute GENERAL well developed well nourished no acute distress HEENT Normocephalic atraumatic Sclerae anicteric Oropharynx with hyperpigmented patches on the mucosa of the palate No oral thrush No lymphadenopathy No jugular venous distension No thyromegaly Neck supple LUNGS Decreased intensity of breath sounds throughout without adventitious sounds No dullness to percussion or changes in fremitus CARDIOVASCULAR Regular rate and rhythm No murmurs gallops or rubs Normal intensity of heart sounds Normal peripheral pulses ABDOMEN Soft non tender non distended Positive bowel sounds No organomegaly RECTAL Normal sphincter tone No masses Normal prostate Guaiac negative stool GENITOURINARY Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect Right testicle normal EXTREMITIES Marked clubbing noted in fingers and toes No cyanosis or edema No rash or arthritis LYMPHATICS 1 x 1 cm mobile firm non tender lymph node noted in left inguinal region Otherwise no other palpable lymphadenopathy CHEST X RAY Ill defined reticular densities in both apices No pleural effusions Cardiomediastinal silhouette within normal range CHEST CT SCAN Multiple bilateral apical nodules masses Largest 3 2 x 1 6 cm in left apex Several of these masses demonstrate spiculation There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions There is a subcarinal node that demonstrates calcifications ABDOMINAL CT SCAN Multiple hypodense lesions are noted throughout the liver The right adrenal gland is full measuring 1 0 x 2 3 cm Otherwise the spleen pancreas left adrenal and kidneys are free of gross mass No significant lymphadenopathy or abnormal fluid collections are seen TESTICULAR ULTRASOUND There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis There is a large septated hydrocele on the left The right epididymis and testis is normal HOSPITAL COURSE The above mentioned studies were obtained Further laboratory tests and a diagnostic procedure were performed Keywords general medicine potassium is high chest x ray chest ct scan abdominal ct scan testicular ultrasound lymph node ct scan blood pressure abdominal multiple subcarinal epididymis potassium lymphadenopathy MEDICAL_TRANSCRIPTION,Description Obesity hypoventilation syndrome A 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study Medical Specialty General Medicine Sample Name Obesity Hypoventilation Syndrome Transcription HISTORY OF PRESENT ILLNESS This is a 61 year old woman with a history of polyarteritis nodosa mononeuritis multiplex involving the lower extremities and severe sleep apnea returns in followup following an overnight sleep study on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep She returns today to review results of an inpatient study performed approximately two weeks ago In the meantime the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex She also takes Lasix for lower extremity edema The patient reports that she generally initiates sleep on CPAP but rips her mask off tosses and turns throughout the night and has terrible quality sleep MEDICATIONS Current medications are as previously noted Changes include reduction in prednisone from 9 to 6 mg by mouth every morning She continues to take Ativan 1 mg every six hours as needed She takes imipramine 425 mg at bedtime Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation 45 to 75 mg by mouth every 8 hours as needed FINDINGS Vital signs Blood pressure 153 81 pulse 90 respiratory rate 20 weight 311 8 pounds up 10 pounds from earlier this month height 5 feet 6 inches temperature 98 4 degrees SaO2 is 88 on room air at rest Chest is clear Extremities show lower extremity pretibial edema with erythema LABORATORIES An arterial blood gas on room air showed a pH of 7 38 PCO2 of 52 and PO2 of 57 CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used She used it for greater than 4 hours per night on 67 of night surveyed Her estimated apnea hypopnea index was 3 per hour Her average leak flow was 67 liters per minute The patient s overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy She slept for a total sleep time of 257 minutes out of 272 minutes in bed sleep efficiency approximately 90 Sleep stage distribution was relatively normal with 2 stage I 72 stage II 24 stage III IV and 2 stage REM sleep There were no periodic limb movements during sleep There was evidence of a severe predominantly central sleep apnea during non REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour Oxyhemoglobin saturations during non REM sleep fluctuated from the baseline of 92 to an average low of 82 During REM sleep the baseline oxyhemoglobin saturation was 87 decreased to 81 with sleep disordered breathing episodes Of note the sleep study was performed on CPAP at 10 5 cm of H2O with oxygen at 8 liters per minute ASSESSMENT 1 Obesity hypoventilation syndrome The patient has evidence of a well compensated respiratory acidosis which is probably primarily related to severe obesity In addition there may be contribution from large doses of opiates and standing doses of gabapentin 2 Severe central sleep apnea on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute The breathing pattern is that of cluster or Biot s breathing throughout sleep The primary etiology is probably opiate use with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation and worsen desaturations during apneic episodes 3 Mononeuritis multiplex with pain requiring significant substantial doses of analgesia 4 Hypoxemia primarily due to obesity hypoventilation and presumably basilar atelectasis and a combination of V Q mismatch and shunt on that basis PLANS My overall impression is that we should treat this patient s sleep disruption with measures to decrease central sleep apnea during sleep These will include 1 Decrease in evening doses of MS Contin 2 Modest weight loss of approximately 10 to 20 pounds and 3 Instituting Automated Servo Ventilation via nasal mask With regard to latter the patient will be returning for a trial of ASV to examine its effect on sleep disordered breathing patterns In addition the patient will benefit from modest diuresis with improvement of oxygenation as well as nocturnal desaturation and oxygen requirements I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time She was instructed to take between one and two K Tab with her evening dose of Lasix 10 to 20 mEq In addition we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation Further workup for hypoxemia may include high resolution CT scanning if evidence for significant pulmonary restriction and or reductions in diffusion capacity is evident on pulmonary function testing Keywords general medicine polyarteritis nodosa obesity hypoventilation syndrome pulmonary function obesity hypoventilation mononeuritis multiplex sleep apnea sleep study rem sleep ativan sleep hypoventilation obesity MEDICAL_TRANSCRIPTION,Description A 47 year old white female presents with concern about possible spider bite to the left side of her neck Medical Specialty General Medicine Sample Name Possible Spider Bite Transcription SUBJECTIVE This 47 year old white female presents with concern about possible spider bite to the left side of her neck She is not aware of any specific injury She noticed a little tenderness and redness on her left posterior shoulder about two days ago It seems to be getting a little bit larger in size and she saw some red streaks extending up her neck She has had no fever The area is very minimally tender but not particularly so CURRENT MEDICATIONS Generic Maxzide Climara patch multivitamin Tums Claritin and vitamin C ALLERGIES No known medicine allergies OBJECTIVE Vital Signs Weight is 150 pounds Blood pressure 122 82 Extremities Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter In the center is a tiny mark which could certainly be an insect or spider bite There is no eschar there but just a tiny marking There are a couple of erythematous streaks extending towards the neck ASSESSMENT Possible insect bite with lymphangitis PLAN 1 Duricef 1 g daily for seven days 2 Cold packs to the area 3 Discussed symptoms that were suggestive of the worsening in which case she would need to call me 4 Incidentally she has noticed a little bit of dryness and redness on her eyelids particularly the upper ones and the lower lateral areas I suspect she has a mild contact dermatitis and suggested hydrocortisone 1 cream to be applied sparingly at bedtime only Keywords general medicine spider bite injury tenderness redness insect bite lymphangitis streaks spider neck bite MEDICAL_TRANSCRIPTION,Description This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain Medical Specialty General Medicine Sample Name Pain from Hernia ER Consult Transcription HISTORY OF PRESENT ILLNESS This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain At the time of my exam he states that his left lower extremity pain has improved considerably He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably He does have a history of multiple medical problems including atrial fibrillation he is on Coumadin which is currently subtherapeutic multiple CVAs in the past peripheral vascular disease and congestive heart failure He has multiple chronic history of previous ischemia of his large bowel in the past PHYSICAL EXAM VITAL SIGNS Currently his temperature is 98 2 pulse is 95 and blood pressure is 138 98 HEENT Unremarkable LUNGS Clear CARDIOVASCULAR An irregular rhythm ABDOMEN Soft EXTREMITIES His upper extremities are well perfused He has palpable radial and femoral pulses He does not have any palpable pedal pulses in either right or left lower extremity He does have reasonable capillary refill in both feet He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool but it is relatively warm Apparently this was lot worst few hours ago He describes significant pain and pallor which he feels has improved and certainly clinically at this point does not appear to be as significant IMPRESSION AND PLAN This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease essentially related to spasm versus a small clot which may have been lysed to some extent He currently has a viable extremity and viable foot but certainly has significant making compromised flow It is unclear to me whether this is chronic or acute and whether he is a candidate for any type of intervention He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime Given his potential history of recent lower GI bleeding he has been evaluated by GI to see whether or not he is a candidate for heparinization We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate Again at this point he has no pain relatively rapid capillary refill and relatively normal motor function suggesting a viable extremity We will follow him along closely Keywords general medicine blood in stool nausea capillary refill angiogram hernia extremity MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty General Medicine Sample Name Normal ROS Template 5 Transcription REVIEW OF SYSTEMS GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs No history of OB GYN problems MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords general medicine respiratory gastrointestinal integumentary hematopoietic night sweats negative allergies negative weakness neurologic throat weakness MEDICAL_TRANSCRIPTION,Description Negative for any nausea vomiting fevers chills or weight loss Medical Specialty General Medicine Sample Name Normal ROS Template 4 Transcription GENERAL Negative for any nausea vomiting fevers chills or weight loss NEUROLOGIC Negative for any blurry vision blind spots double vision facial asymmetry dysphagia dysarthria hemiparesis hemisensory deficits vertigo ataxia HEENT Negative for any head trauma neck trauma neck stiffness photophobia phonophobia sinusitis rhinitis CARDIAC Negative for any chest pain dyspnea on exertion paroxysmal nocturnal dyspnea peripheral edema PULMONARY Negative for any shortness of breath wheezing COPD or TB exposure GASTROINTESTINAL Negative for any abdominal pain nausea vomiting bright red blood per rectum melena GENITOURINARY Negative for any dysuria hematuria incontinence INTEGUMENTARY Negative for any rashes cuts insect bites RHEUMATOLOGIC Negative for any joint pains photosensitive rashes history of vasculitis or kidney problems HEMATOLOGIC Negative for any abnormal bruising frequent infections or bleeding Keywords general medicine review of systems trauma neck dyspnea rashes nausea vomiting MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normal appearance for chronological age does not appear chronically ill Medical Specialty General Medicine Sample Name Normal Physical Exam Template 6 Transcription VITAL SIGNS Reveal a blood pressure of temperature of respirations and pulse of CONSTITUTIONAL Normal appearance for chronological age does not appear chronically ill HEENT The pupils are equal and reactive Funduscopic examination is normal Posterior pharynx is normal Tympanic membranes are clear NECK Trachea is midline Thyroid is normal The neck is supple Negative nodes RESPIRATORY Lungs are clear to auscultation bilaterally The patient has a normal respiratory rate no signs of consolidation and no egophony There are no retractions or secondary muscle use Good bilateral breath sounds are noted CARDIOVASCULAR No jugular venous distention or carotid bruits No increase in heart size to percussion There is no murmur Normal S1 and S2 sounds are noted without gallop ABDOMEN Soft to palpation in all four quadrants There is no organomegaly and no rebound tenderness Bowel sounds are normal Obturator and psoas signs are negative GENITOURINARY No bladder tenderness negative flank pain MUSCULOSKELETAL Extremities are normal with good motor tone and strength normal reflexes and normal joint strength and sensation NEUROLOGIC Normal Glasgow Coma Scale Cranial nerves II through XII appear grossly intact Normal motor and cerebellar tests Reflexes are normal HEME LYMPH No abnormal lymph nodes no signs of bleeding skin purpura petechiae or hemorrhage PSYCHIATRIC Normal with no overt depression or suicidal ideations Keywords general medicine jugular venous distention flank bladder normal physical exam neck nodes respiratory tenderness motor strength reflexes sounds MEDICAL_TRANSCRIPTION,Description Normal review of systems template No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter Medical Specialty General Medicine Sample Name Normal ROS Template 3 Transcription HEENT No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter RESPIRATORY No shortness of breath wheezing dyspnea pulmonary disease tuberculosis or past pneumonias CARDIOVASCULAR No history of palpitations irregular rhythm chest pain hypertension hyperlipidemia diaphoresis congestive heart failure heart catheterization stress test or recent cardiac tests GASTROINTESTINAL No history of rectal bleeding appetite change abdominal pain hiatal hernia ulcer jaundice change in bowel habits or liver problems and no history of inflammatory bowel problems GENITOURINARY No dysuria hematuria frequency incontinence or colic NERVOUS SYSTEM No gait problems strokes numbness or muscle weakness PSYCHIATRIC No history of emotional lability depression or sleep disturbances ONCOLOGIC No history of any cancer change in moles or rashes No history of weight loss The patient has a good energy level ALLERGIC LYMPH No history of systemic allergy abnormal lymph nodes or swelling MUSCULOSKELETAL No fractures motor weakness arthritis or other joint pains Keywords general medicine review of systems tinnitus sinusitis sore mouth hoarseness goiter heart appetite bowel weakness loss swelling MEDICAL_TRANSCRIPTION,Description Most commonly used phrases in physical exam Medical Specialty General Medicine Sample Name Normal Physical Exam Template 7 Transcription EYES The conjunctivae are clear The lids are normal appearing without evidence of chalazion or hordeolum The pupils are round and reactive The irides are without any obvious lesions noted Funduscopic examination shows sharp disk margins There are no exudates or hemorrhages noted The vessels are normal appearing EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing NECK The neck is nontender and supple The trachea is midline The thyroid is without any evidence of thyromegaly No obvious adenopathy is noted to the neck RESPIRATORY The patient has normal respiratory effort There is normal lung excursion Percussion of the chest is without any obvious dullness There is no tactile fremitus or egophony noted There is no tenderness to the chest wall or ribs There are no obvious abnormalities The lungs are clear to auscultation There are no wheezes rales or rhonchi heard There are no obvious rubs noted CARDIOVASCULAR There is a normal PMI on palpation I do not hear any obvious abnormal sounds There are no obvious murmurs There are no rubs or gallops noted The carotid arteries are without bruit No obvious thrill is palpated There is no evidence of enlarged abdominal aorta to palpation There is no abdominal mass to suggest enlargement of the aorta Good strong femoral pulses are palpated The pedal pulses are intact There is no obvious edema noted to the extremities There is no evidence of any varicosities or phlebitis noted GASTROINTESTINAL The abdomen is soft Bowel sounds are present in all quadrants There are no obvious masses There is no organomegaly and no liver or spleen is palpable No obvious hernia is noted The perineum and anus are normal in appearance There is good sphincter tone and no obvious hemorrhoids are noted There are no masses On digital examination there is no evidence of any tenderness to the rectal vault no lesions are noted Stool is brown and guaiac negative GENITOURINARY FEMALE The external genitalia is normal appearing with no obvious lesions no evidence of any unusual rash The vagina is normal in appearance with normal appearing mucosa The urethra is without any obvious lesions or discharge The cervix is normal in color with no obvious cervical discharge There are no obvious cervical lesions noted The uterus is nontender and small and there is no evidence of any adnexal masses or tenderness The bladder is nontender to palpation It is not enlarged GENITOURINARY MALE Normal scrotal contents are noted The testes are descended and nontender There are no masses and no swelling to the epididymis noted The penis is without any lesions There is no urethral discharge Digital examination of the prostate reveals a nontender non nodular prostate BREASTS The breasts are normal in appearance There is no puckering noted There is no evidence of any nipple discharge There are no obvious masses palpable There is no axillary adenopathy The skin is normal appearing over the breasts LYMPHATICS There is no evidence of any adenopathy to the anterior cervical chain There is no evidence of submandibular nodes noted There are no supraclavicular nodes palpable The axillae are without any abnormal nodes No inguinal adenopathy is palpable No obvious epitrochlear nodes are noted MUSCULOSKELETAL EXTREMITIES The patient has normal gait and station The patient has normal muscle strength and tone to all extremities There is no obvious evidence of any muscle atrophy The joints are all stable There is no evidence of any subluxation or laxity to any of the joints There is no evidence of any dislocation There is good range of motion of all extremities without any pain or tenderness to the joints or extremities There is no evidence of any contractures or crepitus There is no evidence of any joint effusions No obvious evidence of erythema overlying any of the joints is noted There is good range of motion at all joints There are normal appearing digits There are no obvious lesions to any of the nails or nail beds SKIN There is no obvious evidence of any rash There are no petechiae pallor or cyanosis noted There are no unusual nodules or masses palpable NEUROLOGIC The cranial nerves II XII are tested and are intact Deep tendon reflexes are symmetrical bilaterally The toes are downgoing with normal Babinskis Sensation to light touch is intact and symmetrical Cerebellar testing reveals normal finger nose heel shin Normal gait No ataxia PSYCHIATRIC The patient is oriented to person place and time The patient is also oriented to situation Mood and affect are appropriate for the present situation The patient can remember 3 objects after 3 minutes without any difficulties Remote memory appears to be intact The patient seems to have normal judgment and insight into the situation Keywords general medicine ears nose mouth neck respiratory cardiovascular eyes gastrointestinal genitourinary breasts lymphatics musculoskeletal extremities skin neurologic psychiatric normal appearing physical exam examination MEDICAL_TRANSCRIPTION,Description Normal review of systems template The patient denies fever fatigue weakness weight gain or weight loss Medical Specialty General Medicine Sample Name Normal ROS Template Transcription REVIEW OF SYSTEMS GENERAL CONSTITUTIONAL The patient denies fever fatigue weakness weight gain or weight loss HEAD EYES EARS NOSE AND THROAT Eyes The patient denies pain redness loss of vision double or blurred vision flashing lights or spots dryness the feeling that something is in the eye and denies wearing glasses Ears nose mouth and throat The patient denies ringing in the ears loss of hearing nosebleeds loss of sense of smell dry sinuses sinusitis post nasal drip sore tongue bleeding gums sores in the mouth loss of sense of taste dry mouth dentures or removable dental work frequent sore throats hoarseness or constant feeling of a need to clear the throat when nothing is there waking up with acid or bitter fluid in the mouth or throat food sticking in throat when swallows or painful swallowing CARDIOVASCULAR The patient denies chest pain irregular heartbeats sudden changes in heartbeat or palpitation shortness of breath difficulty breathing at night swollen legs or feet heart murmurs high blood pressure cramps in his legs with walking pain in his feet or toes at night or varicose veins RESPIRATORY The patient denies chronic dry cough coughing up blood coughing up mucus waking at night coughing or choking repeated pneumonias wheezing or night sweats GASTROINTESTINAL The patient denies decreased appetite nausea vomiting vomiting blood or coffee ground material heartburn regurgitation frequent belching stomach pain relieved by food yellow jaundice diarrhea constipation gas blood in the stools black tarry stools or hemorrhoids GENITOURINARY The patient denies difficult urination pain or burning with urination blood in the urine cloudy or smoky urine frequent need to urinate urgency needing to urinate frequently at night inability to hold the urine discharge from the penis kidney stones rash or ulcers sexual difficulties impotence or prostate trouble no sexually transmitted diseases MUSCULOSKELETAL The patient denies arm buttock thigh or calf cramps No joint or muscle pain No muscle weakness or tenderness No joint swelling neck pain back pain or major orthopedic injuries SKIN AND BREASTS The patient denies easy bruising skin redness skin rash hives sensitivity to sun exposure tightness nodules or bumps hair loss color changes in the hands or feet with cold breast lump breast pain or nipple discharge NEUROLOGIC The patient denies headache dizziness fainting muscle spasm loss of consciousness sensitivity or pain in the hands and feet or memory loss PSYCHIATRIC The patient denies depression with thoughts of suicide voices in head telling to do things and has not been seen for psychiatric counseling or treatment ENDOCRINE The patient denies intolerance to hot or cold temperature flushing fingernail changes increased thirst increased salt intake or decreased sexual desire HEMATOLOGIC LYMPHATIC The patient denies anemia bleeding tendency or clotting tendency ALLERGIC IMMUNOLOGIC The patient denies rhinitis asthma skin sensitivity latex allergies or sensitivity Keywords general medicine cardiovascular ears eyes gastrointestinal head nose respiratory review of systems denies fever blood tongue loss MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normocephalic Negative lesions negative masses Medical Specialty General Medicine Sample Name Normal Physical Exam Template 4 Transcription GENERAL XXX VITAL SIGNS Blood pressure XXX pulse XXX temperature XXX respirations XXX Height XXX weight XXX HEAD Normocephalic Negative lesions negative masses EYES PERLA EOMI Sclerae clear Negative icterus negative conjunctivitis ENT Negative nasal hemorrhages negative nasal obstructions negative nasal exudates Negative ear obstructions negative exudates Negative inflammation in external auditory canals Negative throat inflammation or masses SKIN Negative rashes negative masses negative ulcers No tattoos NECK Negative palpable lymphadenopathy negative palpable thyromegaly negative bruits HEART Regular rate and rhythm Negative rubs negative gallops negative murmurs LUNGS Clear to auscultation Negative rales negative rhonchi negative wheezing ABDOMEN Soft nontender adequate bowel sounds Negative palpable masses negative hepatosplenomegaly negative abdominal bruits EXTREMITIES Negative inflammation negative tenderness negative swelling negative edema negative cyanosis negative clubbing Pulses adequate bilaterally MUSCULOSKELETAL Negative muscle atrophy negative masses Strength adequate bilaterally Negative movement restriction negative joint crepitus negative deformity NEUROLOGIC Cranial nerves I through XII intact Negative gait disturbance Balance and coordination intact Negative Romberg negative Babinski DTRs equal bilaterally GENITOURINARY Deferred Keywords MEDICAL_TRANSCRIPTION,Description Normal physical exam template Well developed well nourished in no acute distress Medical Specialty General Medicine Sample Name Normal Physical Exam Template 3 Transcription PHYSICAL EXAMINATION GENERAL APPEARANCE Well developed well nourished in no acute distress VITAL SIGNS SKIN Inspection of the skin reveals no rashes ulcerations or petechiae HEENT The sclerae were anicteric and conjunctivae were pink and moist Extraocular movements were intact and pupils were equal round and reactive to light with normal accommodation External inspection of the ears and nose showed no scars lesions or masses Lips teeth and gums showed normal mucosa The oral mucosa hard and soft palate tongue and posterior pharynx were normal NECK Supple and symmetric There was no thyroid enlargement and no tenderness or masses were felt CHEST Normal AP diameter and normal contour without any kyphoscoliosis LUNGS Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs CARDIOVASCULAR There was a regular rate and rhythm without any murmurs gallops rubs The carotid pulses were normal and 2 bilaterally without bruits Peripheral pulses were 2 and symmetric ABDOMEN Soft and nontender with normal bowel sounds The liver span was approximately 5 6 cm in the right midclavicular line by percussion The liver edge was nontender The spleen was not palpable There were no inguinal or umbilical hernias noted No ascites was noted RECTAL Normal perineal exam Sphincter tone was normal There was no external hemorrhoids or rectal masses Stool Hemoccult was negative The prostate was normal size without any nodules appreciated men only LYMPH NODES No lymphadenopathy was appreciated in the neck axillae or groin MUSCULOSKELETAL Gait was normal There was no tenderness or effusions noted Muscle strength and tone were normal EXTREMITIES No cyanosis clubbing or edema NEUROLOGIC Alert and oriented x 3 Normal affect Gait was normal Normal deep tendon reflexes with no pathological reflexes Sensation to touch was normal Keywords MEDICAL_TRANSCRIPTION,Description There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing Medical Specialty General Medicine Sample Name Normal ROS Template 1 Transcription REVIEW OF SYSTEMS There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing There is no chest pain shortness of breath paroxysmal nocturnal dyspnea or chest pain with exertion There is no shortness of breath and no cough or hemoptysis No melena nausea vomiting dysphagia abdominal pain diarrhea constipation or blood in the stools No dysuria hematuria or excessive urination No muscle weakness or tenderness No new numbness or tingling No arthralgias or arthritis There are no rashes No excessive fatigability loss of motor skills or sensation No changes in hair texture change in skin color excessive or decreased appetite No swollen lymph nodes or night sweats No headaches The rest of the review of systems is negative Keywords general medicine weight loss fevers chills sweats melena nausea vomiting dysphagia abdominal pain diarrhea constipation itching throat neck fullness painful swallowing breath loss neckNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty General Medicine Sample Name Normal ROS Template 2 Transcription GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords general medicine nose and throat cardiovascular integumentary negative weakness neurologic throat psychiatric weakness MEDICAL_TRANSCRIPTION,Description Normal newborn infant physical exam A well developed infant in no acute respiratory distress Medical Specialty General Medicine Sample Name Normal Newborn Infant Physical Exam Transcription GENERAL A well developed infant in no acute respiratory distress VITAL SIGNS Initial temperature was XX pulse XX respirations XX Weight XX grams length XX cm head circumference XX cm HEENT Head is normocephalic with anterior fontanelle open soft and non bulging Eyes Red reflex elicited bilaterally TMs occluded with vernix and not well visualized Nose and throat are patent without palatal defect NECK Supple without clavicular fracture LUNGS Clear to auscultation HEART Regular rate without murmur click or gallop present Pulses are 2 4 for brachial and femoral ABDOMEN Soft with bowel sounds present No masses or organomegaly GENITALIA Normal EXTREMITIES Without evidence of hip defects NEUROLOGIC The infant has good Moro grasp and suck reflexes SKIN Warm and dry without evidence of rash Keywords general medicine fontanelle normocephalic newborn infant physical exam acute respiratory newborn respiratory distress head infant MEDICAL_TRANSCRIPTION,Description An example normal physical exam Medical Specialty General Medicine Sample Name Normal Physical Exam Template 1 Transcription GENERAL Vital signs and temperature as documented in nursing notes The patient appears stated age and is adequately developed EYES Pupils are equal round reactive to light and accommodation Lids and conjunctivae reveal no gross abnormality ENT Hearing appears adequate No obvious asymmetry or deformity of the ears and nose NECK Trachea midline Symmetric with no obvious deformity or mass no thyromegaly evident RESPIRATORY The patient has normal and symmetric respiratory effort Lungs are clear to auscultation CARDIOVASCULAR S1 S2 without significant murmur ABDOMEN Abdomen is flat soft nontender Bowel sounds are active No masses or pulsations present EXTREMITIES Extremities reveal no remarkable dependent edema or varicosities MUSCULOSKELETAL The patient is ambulatory with normal and symmetric gait There is adequate range of motion without significant pain or deformity SKIN Essentially clear with no significant rash or lesions Adequate skin turgor NEUROLOGICAL No acute focal neurologic changes PSYCHIATRIC Mental status judgment and affect are grossly intact and normal for age Keywords general medicine vital signs equal round reactive normal physical exam physical exam MEDICAL_TRANSCRIPTION,Description An example of a physical exam Medical Specialty General Medicine Sample Name Normal Physical Exam Template Transcription GENERAL Alert well developed in no acute distress MENTAL STATUS Judgment and insight appropriate for age Oriented to time place and person No recent loss of memory Affect appropriate for age EYES Pupils are equal and reactive to light No hemorrhages or exudates Extraocular muscles intact EAR NOSE AND THROAT Oropharynx clean mucous membranes moist Ears and nose without masses lesions or deformities Tympanic membranes clear bilaterally Trachea midline No lymph node swelling or tenderness RESPIRATORY Clear to auscultation and percussion No wheezing rales or rhonchi CARDIOVASCULAR Heart sounds normal No thrills Regular rate and rhythm no murmurs rubs or gallops GASTROINTESTINAL Abdomen soft nondistended No pulsatile mass no flank tenderness or suprapubic tenderness No hepatosplenomegaly NEUROLOGIC Cranial nerves II XII grossly intact No focal neurological deficits Deep tendon reflexes 2 bilaterally Babinski negative Moves all extremities spontaneously Sensation intact bilaterally SKIN No rashes or lesions No petechia No purpura Good turgor No edema MUSCULOSKELETAL No cyanosis or clubbing No gross deformities Capable of free range of motion without pain or crepitation No laxity instability or dislocation BONE No misalignment asymmetry defect tenderness or effusion Capable of from of joint above and below bone MUSCLE No crepitation defect tenderness masses or swellings No loss of muscle tone or strength LYMPHATIC Palpation of neck reveals no swelling or tenderness of neck nodes Palpation of groin reveals no swelling or tenderness of groin nodes Keywords general medicine mental status ear nose and throat abdomen soft nondistended cranial nerves ii xii grossly intact physical exam MEDICAL_TRANSCRIPTION,Description Normal Physical Exam Template Well developed well nourished alert in no acute distress Medical Specialty General Medicine Sample Name Normal Physical Exam Template 5 Transcription GENERAL Well developed well nourished alert in no acute distress GCS 50 nontoxic VITAL SIGNS Blood pressure pulse respirations temperature degrees F Pulse oximetry HEENT Eyes Lids and conjunctiva No lesions Pupils equal round reactive to light and accommodation Irises symmetrical undilated Funduscopic exam reveals no hemorrhages or discopathy Ears Nose Mouth and throat External ears without lesions Nares patent Septum midline Tympanic membranes without erythema bulging or retraction Canals without lesion Hearing is grossly intact Lips teeth gums palate without lesion Posterior oropharynx No erythema No tonsillar enlargement crypt formation or abscess NECK Supple and symmetric No masses Thyroid midline non enlarged No JVD Neck is nontender Full range of motion without pain RESPIRATORY Good respiratory effort Clear to auscultation Clear to percussion Chest Symmetrical rise and fall Symmetrical expansion No egophony or tactile fremitus CARDIOVASCULAR Regular rate and rhythm No murmur gallops clicks heaves or rub Cardiac palpation within normal limits Pulses equal at carotid Femoral and pedal pulses No peripheral edema GASTROINTESTINAL No tenderness or mass No hepatosplenomegaly No hernia Bowel sounds equal times four quadrants Abdomen is nondistended No rebound guarding rigidity or ecchymosis MUSCULOSKELETAL Normal gait and station No pathology to digits or nails Extremities move times four No tenderness or effusion Range of motion adequate Strength and tone equal bilaterally stable BACK Nontender on midline Full range of motion with flexion extension and sidebending SKIN Inspection within normal limits Well hydrated No diaphoresis No obvious wound LYMPH Cervical lymph nodes No lymphadenopathy NEUROLOGICAL Cranial nerves II XII grossly intact DTRs symmetric 2 out of 4 bilateral upper and lower extremity elbow patella and ankle Motor strength 4 4 bilateral upper and lower extremity Straight leg raise is negative bilaterally PSYCHIATRIC Judgment and insight adequate Alert and oriented times three Memory and mood within normal limits No delusions hallucinations No suicidal or homicidal ideation Keywords general medicine respiratory abdomen normal physical exam pulses tenderness strength lymph extremity midline range motion lesions symmetrical MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male ROS Medical Specialty General Medicine Sample Name Normal Male ROS Template 1 Transcription REVIEW OF SYSTEMS CONSTITUTIONAL Patient denies fevers chills sweats and weight changes EYES Patient denies any visual symptoms EARS NOSE AND THROAT No difficulties with hearing No symptoms of rhinitis or sore throat CARDIOVASCULAR Patient denies chest pains palpitations orthopnea and paroxysmal nocturnal dyspnea RESPIRATORY No dyspnea on exertion no wheezing or cough GI No nausea vomiting diarrhea constipation abdominal pain hematochezia or melena GU No urinary hesitancy or dribbling No nocturia or urinary frequency No abnormal urethral discharge MUSCULOSKELETAL No myalgias or arthralgias NEUROLOGIC No chronic headaches no seizures Patient denies numbness tingling or weakness PSYCHIATRIC Patient denies problems with mood disturbance No problems with anxiety ENDOCRINE No excessive urination or excessive thirst DERMATOLOGIC Patient denies any rashes or skin changes Keywords general medicine review of systems normal male ros normal male male ros male ros throat urinary MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty General Medicine Sample Name Normal Male Exam Template 1 Transcription MALE PHYSICAL EXAMINATION HEENT Pupils equal round and reactive to light and accommodation Extraocular movements are intact Sclerae are anicteric TMs are clear bilaterally Oropharynx is clear without erythema or exudate NECK Supple without lymphadenopathy or thyromegaly Carotids are silent There is no jugular venous distention CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm without S3 S4 No murmurs or rubs are appreciated ABDOMEN Soft nontender nondistended with positive bowel sounds No masses hepatomegaly or splenomegaly are appreciated GU Normal circumcised male No discharge or hernias No testicular masses RECTAL EXAM Normal rectal tone Prostate is smooth and not enlarged Stool is Hemoccult negative EXTREMITIES Reveal no clubbing cyanosis or edema Peripheral pulses are 2 and equal bilaterally in all four extremities JOINT EXAM Reveals no tenosynovitis NEUROLOGIC Cranial nerves II through XII are grossly intact Motor strength is 5 5 and equal in all four extremities Deep tendon reflexes are 2 4 and equal bilaterally Patient is alert and oriented times 3 PSYCHIATRIC Grossly normal DERMATOLOGIC No lesions or rashes Keywords general medicine male exam physical exam normal normal male physical male sclerae extremities intact oropharynx MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty General Medicine Sample Name Normal Male Exam Template 2 Transcription MALE PHYSICAL EXAMINATION Eye Eyelids normal color no edema Conjunctivae with no erythema foreign body or lacerations Sclerae normal white color no jaundice Cornea clear without lesions Pupils equally responsive to light Iris normal color no lesions Anterior chamber clear Lacrimal ducts normal Fundi clear Ear External ear has no erythema edema or lesions Ear canal unobstructed without edema discharge or lesions Tympanic membranes clear with normal light reflex No middle ear effusions Nose External nose symmetrical No skin lesions Nares open and free of lesions Turbinates normal color size and shape Mucus clear No internal lesions Throat No erythema or exudates Buccal mucosa clear Lips normal color without lesions Tongue normal shape and color without lesion Hard and soft palate normal color without lesions Teeth show no remarkable features No adenopathy Tonsils normal shape and size Uvula normal shape and color Neck Skin has no lesions Neck symmetrical No adenopathy thyromegaly or masses Normal range of motion nontender Trachea midline Chest Symmetrical Clear to auscultation bilaterally No wheezing rales or rhonchi Chest nontender Normal lung excursion No accessory muscle use Cardiovascular Heart has regular rate and rhythm with no S3 or S4 Heart rate is normal Abdominal Soft nontender nondistended bowel sounds present No hepatomegaly splenomegaly masses or bruits Genital Penis normal shape without lesions Testicles normal shape and contour without tenderness Epididymides normal shape and contour without tenderness Rectum normal tone to sphincter Prostate normal shape and contour without nodules Stool hemoccult negative No external hemorrhoids No skin lesions Musculoskeletal Normal strength all muscle groups Normal range of motion all joints No joint effusions Joints normal shape and contour No muscle masses Foot No erythema No edema Normal range of motion all joints in the foot Nontender No pain with inversion eversion plantar or dorsiflexion Ankle Anterior and posterior drawer test negative No pain with inversion eversion dorsiflexion or plantar flexion Collateral ligaments intact No joint effusion erythema edema crepitus ecchymosis or tenderness Knee Normal range of motion No joint effusion erythema nontender Anterior and posterior drawer tests negative Lachman s test negative Collateral ligaments intact Bursas nontender without edema Wrist Normal range of motion No edema or effusion nontender Negative Tinel and Phalen tests Normal strength all muscle groups Elbow Normal range of motion No joint effusion or erythema Normal strength all muscle groups Nontender Olecranon bursa flat and nontender no edema Normal supination and pronation of forearm No crepitus Hip Negative swinging test Trochanteric bursa nontender Normal range of motion Normal strength all muscle groups No pain with eversion and inversion No crepitus Normal gait Psychiatric Alert and oriented times four No delusions or hallucinations no loose associations no flight of ideas no tangentiality Affect is appropriate No psychomotor slowing or agitation Eye contact is appropriate Keywords general medicine male exam normal physical exam normal range of motion male physical nontender lesions dorsiflexion sclerae contour muscle erythema joints edema shape MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty General Medicine Sample Name Normal Male Exam Template 4 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions lids lashes brows or conjunctivae noted Funduscopic examination unremarkable No papilledema glaucoma or cataracts Ears Normal set and shape with normal hearing and normal TMs Nose and Sinus Unremarkable Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without carotid bruit JVD or significant cervical adenopathy Trachea is midline without stridor shift or subcutaneous emphysema Thyroid is palpable nontender not enlarged and free of nodularity CHEST Lungs bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI is nondisplaced Chest wall is unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS Normal male breast tissue ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and intraabdominal bruit on auscultation EXTERNAL GENITALIA Normal for age Normal penis with bilaterally descended testes that are normal in size shape and contour and without evidence of hernia or hydrocele RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool and normal sized prostate that is free of nodularity or tenderness No rectal masses palpated EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords general medicine digital palpation hemoccult negative heent palpation breasts male tenderness tongue MEDICAL_TRANSCRIPTION,Description Sample template for a normal male multisystem exam Medical Specialty General Medicine Sample Name Normal Male Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The scrotal elements were normal The testes were without discrete mass The penis showed no lesion no discharge LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords general medicine within normal limits conjunctiva eyes ears nose throat male multisystem heart respiratory auscultation extremities oropharynx neck tongue MEDICAL_TRANSCRIPTION,Description Normal child physical exam template Medical Specialty General Medicine Sample Name Normal Child Exam Template Transcription CHILD PHYSICAL EXAMINATION VITAL SIGNS Birth weight is grams length occipitofrontal circumference Character of cry was lusty GENERAL APPEARANCE Well BREATHING Unlabored SKIN Clear No cyanosis pallor or icterus Subcutaneous tissue is ample HEAD Normal Fontanelles are soft and flat Sutures are opposed EYES Normal with red reflex x2 EARS Patent Normal pinnae canals TMs NOSE Patent nares MOUTH No cleft THROAT Clear NECK No masses CHEST Normal clavicles LUNGS Clear bilaterally HEART Regular rate and rhythm without murmur ABDOMEN Soft flat No hepatosplenomegaly The cord is three vessel GENITALIA Normal genitalia with testes descended bilaterally ANUS Patent SPINE Straight and without deformity EXTREMITIES Equal movements MUSCLE TONE Good REFLEXES Moro grasp and suck are normal HIPS No click or clunk Keywords general medicine child physical examination physical genitalia child MEDICAL_TRANSCRIPTION,Description Sample template for a normal female multisystem exam Medical Specialty General Medicine Sample Name Normal Female Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema BREASTS Breast inspection showed them to be symmetrical with no nipple discharge Palpation of the breasts and axilla revealed no obvious mass that I could appreciate GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The external genitalia appeared to be normal The pelvic exam revealed no adnexal masses The uterus appeared to be normal in size and there was no cervical motion tenderness LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty General Medicine Sample Name Normal ENT Exam 1 Transcription EARS NOSE MOUTH AND THROAT EARS NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis There are no signs of acute trauma The nose is normal to palpation and inspection externally without evidence of acute trauma Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion inflammation or swelling The tympanic membranes are without disruption or infection Hearing intact bilaterally to normal level speech Nasal mucosa septum and turbinate examination reveals normal mucous membranes without disruption or inflammation The septum is without acute traumatic lesions or disruption The turbinates are without abnormal swelling There is no unusual rhinorrhea or bleeding LIPS TEETH GUMS The lips are without infection mass lesion or traumatic lesions The teeth are intact without obvious signs of infection The gingivae are normal to palpation and inspection OROPHARYNX The oral mucosa is normal The salivary glands are without swelling The hard and soft palates are intact The tongue is without masses or swelling with normal movement The tonsils are without inflammation The posterior pharynx is without mass lesion with good patent oropharyngeal airway Keywords general medicine oral mucosa lips hearing auditory canals tympanic membranes traumatic lesions mouth throat trauma nose membranes inflammation infection swelling MEDICAL_TRANSCRIPTION,Description She is a 28 year old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood tinged vomit starting approximately worse over the past couple of days This is patient s fourth trip to the emergency room and second trip for admission Medical Specialty General Medicine Sample Name Nausea Vomiting ER Visit Transcription HISTORY OF PRESENT ILLNESS She is a 28 year old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood tinged vomit starting approximately worse over the past couple of days This is patient s fourth trip to the emergency room and second trip for admission PAST MEDICAL HISTORY Nonsignificant PAST SURGICAL HISTORY None SOCIAL HISTORY No alcohol drugs or tobacco PAST OBSTETRICAL HISTORY This is her first pregnancy PAST GYNECOLOGICAL HISTORY Not pertinent While in the emergency room the patient was found to have slight low sodium potassium slightly elevated and her ALT of 93 AST of 35 total bilirubin is 1 2 Her urine was 3 ketones 2 protein and 1 esterase and rbc too numerous to count with moderate amount of bacteria H and H stable at 14 1 and 48 7 She was then admitted after giving some Phenergan and Zofran IV As started on IV given hydration as well as given a dose of Rocephin to treat bladder infection She was admitted overnight nausea and vomiting resolved to only one episode of vomiting after receiving Maalox tolerated fluids as well as p o food Followup chemistry was obtained for AST ALT and we will plan for discharge if lab variables resolve ASSESSMENT AND PLAN 1 This is a 28 year old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup 2 Slightly elevated ALT questionable likely due to the nausea and vomiting We will recheck for followup Keywords general medicine iv hydration elevated alt emergency nausea vomiting MEDICAL_TRANSCRIPTION,Description Normal female review of systems template Negative for fever weight change fatigue or aching Medical Specialty General Medicine Sample Name Normal Female ROS Template Transcription CONSTITUTIONAL Normal negative for fever weight change fatigue or aching HEENT Eyes normal Negative for glasses cataracts glaucoma retinopathy irritation or visual field defects Ears normal Negative for hearing or balance problems Nose normal Negative for runny nose sinus problems or nosebleeds Mouth normal Negative for dental problems dentures or bleeding gums Throat normal Negative for hoarseness difficulty swallowing or sore throat CARDIOVASCULAR Normal Negative for angina previous MI irregular heartbeat heart murmurs bad heart valves palpitations swelling of feet high blood pressure orthopnea paroxysmal nocturnal dyspnea or history of stress test arteriogram or pacemaker implantation PULMONARY Normal Negative for cough sputum shortness of breath wheezing asthma or emphysema GASTROINTESTINAL Normal Negative for pain vomiting heartburn peptic ulcer disease change in stool rectal pain hernia hepatitis gallbladder disease hemorrhoids or bleeding GENITOURINARY Normal female OR male Negative for incontinence UTI dysuria hematuria vaginal discharge abnormal bleeding breast lumps nipple discharge skin or nipple changes sexually transmitted diseases incontinence yeast infections or itching SKIN Normal Negative for rashes keratoses skin cancers or acne MUSCULOSKELETAL Normal Negative for back pain joint pain joint swelling arthritis joint deformity problems with ambulation stiffness osteoporosis or injuries NEUROLOGIC Normal Negative for blackouts headaches seizures stroke or dizziness PSYCHIATRIC Normal Negative for anxiety depression or phobias ENDOCRINE Normal Negative for diabetes thyroid or problems with cholesterol or hormones HEMATOLOGIC LYMPHATIC Normal Negative for anemia swollen glands or blood disorders IMMUNOLOGIC Negative Negative for steroids chemotherapy or cancer VASCULAR Normal Negative for varicose veins blood clots atherosclerosis or leg ulcers Keywords general medicine cough sputum shortness of breath fever weight fatigue aching nose throat swelling disease incontinence bleeding heartbeat blood joint MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty General Medicine Sample Name Normal ENT Exam Transcription EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing Keywords general medicine erythema tympanic mouth throat ears mucosa noseNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description An example template for a routine normal female physical exam Medical Specialty General Medicine Sample Name Normal Female Exam Template 2 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI nondisplaced Chest wall unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS In the seated and supine position unremarkable ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and no intraabdominal bruit auscultated EXTERNAL GENITALIA Normal for age RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords general medicine heent general appearance hepatosplenomegaly mass tenderness rebound rigidity pulse bruit adenopathy chest percussion inspection palpation signs tongue MEDICAL_TRANSCRIPTION,Description Patient started out having toothache now radiating into his jaw and towards his left ear Ellis type II dental fracture Medical Specialty General Medicine Sample Name Jaw Pain ER Visit Transcription CHIEF COMPLAINT Jaw pain HISTORY OF PRESENT ILLNESS This is a 58 year old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments but has not seen a dentist since this new toothache began The patient denies any facial swelling No headache No swelling to the throat No sore throat No difficulty swallowing liquids or solids No neck pain No lymph node swelling The patient denies any fever or chills Denies any other problems or complaints REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness HEENT No headache No neck pain No eye pain or vision change No rhinorrhea No sinus congestion pressure or pain No sore throat No throat swelling The patient does have the toothache on the left lower side that radiates towards his left ear as previously described The patient does not have ear pain or hearing change No pressure in the ear CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath GASTROINTESTINAL No nausea or vomiting No abdominal pain MUSCULOSKELETAL No back pain SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No speech change HEMATOLOGIC LYMPHATIC No lymph node swelling PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None CURRENT MEDICATIONS None ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient smokes marijuana The patient does not smoke cigarettes PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 2 oral blood pressure is 168 84 pulse is 87 respirations 16 and oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed The patient appears to be healthy The patient is calm comfortable in no acute distress looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctivae bilaterally Nose normal without rhinorrhea or audible congestion There is no tenderness over the sinuses Ears are normal without any sign of infection No erythema or swelling of the canals Tympanic membranes are intact and normal without any erythema bulging air fluid levels or bubbles behind it MOUTH The patient has a dental fracture at tooth 18 The patient states that the fracture is a couple of months old The patient does not have any obvious dental caries The gums are normal without any erythema swelling or evidence of infection There is no fluctuance or suggestion of abscess There is slight tenderness of the tooth 18 The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling Mucous membranes are moist Floor of the mouth is normal without any tenderness or swelling No suggestion of abscess There is no pre or post auricular lymphadenopathy either NECK Supple Nontender Full range of motion No meningismus No cervical lymphadenopathy No JVD No carotid artery or vertebral artery bruits CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally No shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to the back arms or legs The patient has normal use of the extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect No evidence of clinical intoxification HEMATOLOGIC LYMPHATIC No lymphadenitis is palpated DIAGNOSES 1 ACUTE LEFT JAW PAIN 2 18 DENTAL FRACTURE WHICH IS AN ELLIS TYPE II FRACTURE 3 ELEVATED BLOOD PRESSURE CONDITION UPON DISPOSITION Stable DISPOSITION Home PLAN We will have the patient follow up with his dentist Dr X in three to five days for reevaluation The patient was encouraged to take Motrin 400 mg q 6h as needed for pain The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain He was given precautions for drowsiness and driving with the use of this medication The patient was also given a prescription for pen V The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition develop any other problems or symptoms of concern Keywords general medicine jaw pain dental appointment ellis type ii fracture ellis type dental fracture toothache tenderness pressure erythema MEDICAL_TRANSCRIPTION,Description Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Medical Specialty General Medicine Sample Name Melena ICU Followup Transcription HISTORY Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient Over the last 24 hours the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value He also underwent EGD earlier today with Dr X I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding Dr X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough now producing yellow brown sputum with increasing frequency but he has had no further episodes of melena since transfer to the ICU He is also complaining of some laryngitis and some pharyngitis but is denying any abdominal complaints nausea or diarrhea PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 100 54 heart rate 80 and temperature 98 8 Is and Os negative fluid balance of 1 4 liters in the last 24 hours GENERAL This is a somnolent 68 year old male who arouses to voice wakes up seems to have good appetite has continuing cough Pallor is improved EYES Conjunctivae are now pink ENT Oropharynx is clear CARDIOVASCULAR Reveals distant heart tones with regular rate and rhythm LUNGS Have coarse breath sounds with wheezes rhonchi and soft crackles in the bases ABDOMEN Soft and nontender with no organomegaly appreciated EXTREMITIES Showed no clubbing cyanosis or edema Capillary refill time is now normal in the fingertips NEUROLOGICAL Cranial nerves II through XII are grossly intact with no focal neurological deficits LABORATORY DATA Laboratories drawn at 1449 today WBC 10 hemoglobin and hematocrit 11 5 and 33 1 and platelets 288 000 This is up from 8 6 and 24 7 Platelets are stable Sodium is 134 potassium 4 0 chloride 101 bicarb 26 BUN 19 creatinine 1 0 glucose 73 calcium 8 4 INR 0 96 iron 13 saturations 4 TIBC 312 TSH 0 74 CEA elevated at 8 6 ferritin 27 5 and occult blood positive EGD final results pending per Dr X s note and conversation with me earlier ulcerative esophagitis without signs of active bleeding at this time IMPRESSION PLAN 1 Melena secondary to ulcerative esophagitis We will continue to monitor the patient overnight to ensure there is no further bleeding If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation 2 Chronic obstructive pulmonary disease exacerbation The patient is doing well taking PO We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments We will add guaifenesin and N acetyl cysteine in a hope to mobilize some of his secretions This does appear to be improving His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications 3 Elevated CEA The patient will need colonoscopy on an outpatient basis He has refused this today We would like to encourage him to do so Of note the patient when he came in was on bloodless protocol but with urging did accept the transfusion Similarly I am hoping that with proper counseling the patient will consent to further examination with colonoscopy given his guaiac positive status elevated CEA and risk factors 4 Anemia normochromic normocytic with low total iron binding capacity This appears to be anemia of chronic disease However this is likely some iron deficiency superimposed on top of this given his recent bleeding with consider iron vitamin C folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding Total critical care time spent today discussing the case with Dr X examining the patient reviewing laboratory trends adjusting medications and counseling the patient in excess is 35 minutes Keywords general medicine anemia gi bleeding hemoglobin ulcerative esophagitis obstructive pulmonary disease icu followup infection obstructive pulmonary egd melena bleeding MEDICAL_TRANSCRIPTION,Description Local reaction secondary to insect sting Patient was stung by a bee on his right hand left hand and right knee at approximately noon today Medical Specialty General Medicine Sample Name Insect Sting Transcription HISTORY OF PRESENT ILLNESS Patient is a 76 year old white male who presents with his wife stating that he was stung by a bee on his right hand left hand and right knee at approximately noon today He did not note any immediate reaction Since that time he has noted some increasing redness and swelling to his left hand but he denies any generalized symptoms such as itching hives or shortness of breath He denies any sensation of tongue swelling or difficulty swallowing The patient states he was stung approximately one month ago without any serious reaction He did windup taking Benadryl at that time He has not taken anything today for his symptoms but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day ALLERGIES HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS HEADACHE MORPHINE NAUSEA AND VOMITING AND TORADOL ULCER SOCIAL HISTORY Patient is married and is a nonsmoker and lives with his wife who is here with him Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp and vital signs are all within normal limits GENERAL In general the patient is an elderly white male who is sitting on the stretcher in no acute distress HEENT Head is normocephalic and atraumatic The face shows no edema The tongue is not swollen and the airway is widely patent NECK No stridor HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes EXTREMITIES Upper extremities there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals There was some slight edema of the fourth digit on which he still is wearing his wedding band The right hand shows no reaction The right knee is not swollen either The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube I was able to remove his wedding band without any difficulty Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting I did explain to him that his swelling and redness may progress over the next few days ASSESSMENT Local reaction secondary to insect sting PLAN The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone I did explain that the swelling may worsen over the next two to three days it may produce a large local reaction but that anti histamines were still the mainstay of therapy for such a reaction If he is not improved in the next four days follow up with his PCP for a re exam Keywords general medicine stung by a bee local reaction insect sting reaction insect bee knee edema sting swelling hand MEDICAL_TRANSCRIPTION,Description This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms Medical Specialty General Medicine Sample Name Itchy Rash ER Visit Transcription CHIEF COMPLAINT Itchy rash HISTORY OF PRESENT ILLNESS This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms No facial swelling No tongue or lip swelling No shortness of breath wheezing or other associated symptoms He cannot think of anything that could have triggered this off There have been no changes in his foods medications or other exposures as far as he knows He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day PAST MEDICAL HISTORY Negative for chronic medical problems No local physician Has had previous back surgery and appendectomy otherwise generally healthy REVIEW OF SYSTEMS As mentioned denies any oropharyngeal swelling No lip or tongue swelling No wheezing or shortness of breath No headache No nausea Notes itchy rash especially on his torso and upper arms SOCIAL HISTORY The patient is accompanied with his wife FAMILY HISTORY Negative MEDICATIONS None ALLERGIES TORADOL MORPHINE PENICILLIN AND AMPICILLIN PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile He is slightly tachycardic 105 but stable blood pressure and respiratory rate GENERAL The patient is in no distress Sitting quietly on the gurney HEENT Unremarkable His oral mucosa is moist and well hydrated Lips and tongue look normal Posterior pharynx is clear NECK Supple His trachea is midline There is no stridor LUNGS Very clear with good breath sounds in all fields There is no wheezing Good air movement in all lung fields CARDIAC Without murmur Slight tachycardia ABDOMEN Soft nontender SKIN Notable for a confluence erythematous blanching rash on the torso as well as more of a blotchy papular macular rash on the upper arms He noted some on his buttocks as well Remaining of the exam is unremarkable ED COURSE The patient was treated with epinephrine 1 1000 0 3 mL subcutaneously along with 50 mg of Benadryl intramuscularly After about 15 20 minutes he states that itching started to feel better The rash has started to fade a little bit and feeling a lot more comfortable IMPRESSION ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS ASSESSMENT AND PLAN The patient has what looks to be some type of allergic reaction although the underlying cause is difficult to assess He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off In the meantime I think he can be managed with some antihistamine over the counter He is responding already to Benadryl and the epinephrine that we gave him here He is told that if he develops any respiratory complaints shortness of breath wheezing or tongue or lip swelling he will return immediately for evaluation He is discharged in stable condition Keywords general medicine urticaria pruritus lip swelling allergic reaction itchy rash torso swelling itchy rash MEDICAL_TRANSCRIPTION,Description Hypothermia Rule out sepsis was negative as blood cultures sputum cultures and urine cultures were negative Organic brain syndrome Seizure disorder Adrenal insufficiency Hypothyroidism Anemia of chronic disease Medical Specialty General Medicine Sample Name Hypothermia Discharge Summary Transcription DIAGNOSIS AT ADMISSION Hypothermia DIAGNOSES ON DISCHARGE 1 Hypothermia 2 Rule out sepsis was negative as blood cultures sputum cultures and urine cultures were negative 3 Organic brain syndrome 4 Seizure disorder 5 Adrenal insufficiency 6 Hypothyroidism 7 Anemia of chronic disease HOSPITAL COURSE The patient was admitted through the emergency room He was admitted to the Intensive Care Unit He was rewarmed and had blood sputum and urine cultures done He was placed on IV Rocephin His usual medications of Dilantin and Depakene were given The patient s hypertension was treated with fluid boluses The patient was empirically placed on Synthroid and hydrocortisone by Dr X Blood work consisted of a chemistry panel that was unremarkable except for decreased proteins H H was stable at 33 3 10 9 and platelets of 80 000 White blood cell counts were normal differential was normal TSH was 3 41 Free T4 was 0 9 Dr X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement A cortisol level was obtained prior to administration of hydrocortisone This was 10 9 and that was not a fasting level Dr X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef The patient was eventually changed to prednisone 2 5 mg b i d in addition to his Florinef 0 1 mg on Monday Wednesday and Friday The patient was started back on his tube feeds He tolerated these poorly with residuals Reglan was increased to 10 mg q 6 h and erythromycin is being added The patient s temperature has been stable in the 94 to 95 range Other vital signs have been stable His urine output has been diminished An external jugular line was placed in the Intensive Care Unit The patient s legal guardian Janet Sanchez in Albuquerque has requested he be transported there As per several physicians in Albuquerque and Dr Y an internist we will accept him once we have a nursing home available to him He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque His prognosis is poor Keywords general medicine sepsis organic brain syndrome seizure disorder anemia of chronic disease adrenal insufficiency blood cultures MEDICAL_TRANSCRIPTION,Description Sample male exam and review of systems Medical Specialty General Medicine Sample Name Male Exam ROS Transcription GENERAL REVIEW OF SYSTEMS General No fevers chills or sweats No weight loss or weight gain Cardiovascular No exertional chest pain orthopnea PND or pedal edema No palpitations Neurologic No paresis paresthesias or syncope Eyes No double vision or blurred vision Ears No tinnitus or decreased auditory acuity ENT No allergy symptoms such as rhinorrhea or sneezing GI No indigestion heartburn or diarrhea No blood in the stools or black stools No change in bowel habits GU No dysuria hematuria or pyuria No polyuria or nocturia Denies slow urinary stream Psych No symptoms of depression or anxiety Pulmonary No wheezing cough or sputum production Skin No skin lesions or nonhealing lesions Musculoskeletal No joint pain bone pain or back pain No erythema at the joints Endocrine No heat or cold intolerance No polydipsia Hematologic No easy bruising or easy bleeding No swollen lymph nodes PHYSICAL EXAM Vital Blood pressure today was heart rate respiratory rate Ears TMs intact bilaterally Throat is clear without hyperemia Mouth Mucous membranes normal Tongue normal Neck Supple carotids 2 bilaterally without bruits no lymphadenopathy or thyromegaly Chest Clear to auscultation no dullness to percussion Heart Revealed a regular rhythm normal S1 and S2 No murmurs clicks or gallops Abdomen Soft to palpation without guarding or rebound No masses or hepatosplenomegaly palpable Bowel sounds are normoactive Extremities bilaterally symmetrical Peripheral pulses 2 in all extremities No pedal edema Neurologic examination Essentially intact including cranial nerves II through XII intact bilaterally Deep tendon reflexes 2 and symmetrical Genitalia Bilaterally descended testes without tenderness or masses No hernias palpable Rectal examination revealed normal sphincter tone no rectal mass Prostate was Stool was Hemoccult negative Keywords general medicine male exam cardiovascular ent ears endocrine extremities genitalia hemoccult musculoskeletal pulmonary auditory acuity blurred vision heart rate nocturia pedal edema percussion polydipsia rectal mass regular rhythm respiratory rate review of systems swollen lymph nodes tinnitus intact bilaterally masses MEDICAL_TRANSCRIPTION,Description Chief complaint of chest pain previously diagnosed with hyperthyroidism Medical Specialty General Medicine Sample Name Hyperthyroidism Following Pregnancy Transcription HISTORY Patient is a 21 year old white woman who presented with a chief complaint of chest pain She had been previously diagnosed with hyperthyroidism Upon admission she had complaints of constant left sided chest pain that radiated to her left arm She had been experiencing palpitations and tachycardia She had no diaphoresis no nausea vomiting or dyspnea She had a significant TSH of 0 004 and a free T4 of 19 3 Normal ranges for TSH and free T4 are 0 5 4 7 µIU mL and 0 8 1 8 ng dL respectively Her symptoms started four months into her pregnancy as tremors hot flashes agitation and emotional inconsistency She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards She complained of sweating but has experienced no diarrhea and no change in appetite She was given isosorbide mononitrate and IV steroids in the ER FAMILY HISTORY Diabetes Hypertension Father had a Coronary Artery Bypass Graph CABG at age 34 SOCIAL HISTORY She had a baby five months ago She smokes a half pack a day She denies alcohol and drug use MEDICATIONS Citalopram 10mg once daily for depression low dose tramadol PRN pain PHYSICAL EXAMINATION Temperature 98 4 Pulse 123 Respiratory Rate 16 Blood Pressure 143 74 HEENT She has exophthalmos and could not close her lids completely Cardiovascular tachycardia Neurologic She had mild hyperreflexiveness LAB All labs within normal limits with the exception of Sodium 133 Creatinine 0 2 TSH 0 004 Free T4 19 3 EKG showed sinus tachycardia with a rate of 122 Urine pregnancy test was negative HOSPITAL COURSE After admission she was given propranolol at 40mg daily and continued on telemetry On the 2nd day of treatment the patient still complained of chest pain EKG again showed tachycardia Propranolol was increased from 40mg daily to 60mg twice daily A I 123 thyroid uptake scan demonstrated an increased thyroid uptake of 90 at 4 hours and 94 at 24 hours The normal range for 4 hour uptake is 5 15 and 15 25 for 24 hour uptake Endocrine consult recommended radioactive I 131 for treatment of Graves disease Two days later she received 15 5mCi of I 131 She was to return home after the iodine treatment She was instructed to avoid contact with her baby for the next week and to cease breast feeding ASSESSMENT PLAN 1 Treatment of hyperthyroidism Patient underwent radioactive iodine 131 ablation therapy 2 Management of cardiac symptoms stemming from hyperthyroidism Patient was discharged on propranolol 60mg one tablet twice daily 3 Monitor patient for complications of I 131 therapy such as hypothyroidism She should return to Endocrine Clinic in six weeks to have thyroid function tests performed Long term follow up includes thyroid function tests at 6 12 month intervals 4 Prevention of pregnancy for one year post I 131 therapy Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive taken one tablet daily 5 Monitor ocular health Patient was given methylcellulose ophthalmic one drop in each eye daily She should follow up in 6 weeks with the Ophthalmology clinic 6 Management of depression Patient will be continued on citalopram 10 mg Keywords general medicine hyperthyroidism diabetes hypertension hospital course thyroid function tachycardia pregnancy MEDICAL_TRANSCRIPTION,Description Human immunodeficiency virus disease with stable control on Atripla Resolving left gluteal abscess completing Flagyl Diabetes mellitus currently on oral therapy Hypertension depression and chronic musculoskeletal pain of unclear etiology Medical Specialty General Medicine Sample Name HIV Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 41 year old white male with a history of HIV disease His last CD4 count was 425 viral load was less than 50 in 08 07 He was recently hospitalized for left gluteal abscess for which he underwent I D and he has newly diagnosed diabetes mellitus He also has a history of hypertension and hypertriglyceridemia He had been having increased urination and thirst He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess The endocrine team apparently felt that insulin might be best for this patient but because of financial issues elected to place him on Glucophage and glyburide The patient reports that he has been taking the medication He is in general feeling better He says that his gluteal abscess is improving and he will be following up with Surgery today CURRENT MEDICATIONS 1 Gabapentin 600 mg at night 2 Metformin 1000 mg twice a day 3 Glipizide 5 mg a day 4 Flagyl 500 mg four times a day 5 Flexeril 10 mg twice a day 6 Paroxetine 20 mg a day 7 Atripla one at night 8 Clonazepam 1 mg twice a day 9 Blood pressure medicine name unknown REVIEW OF SYSTEMS He otherwise has a negative review of systems PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 6 blood pressure 145 90 pulse 123 respirations 20 and weight is 89 9 kg 198 pounds HEENT Unremarkable except for some submandibular lymph nodes His fundi are benign NECK Supple LUNGS Clear to auscultation and percussion CARDIAC Reveals regular rate and rhythm without murmur rub or gallop ABDOMEN Soft and nontender without organomegaly or mass EXTREMITIES Show no cyanosis clubbing or edema GU Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions IMPRESSION 1 Human immunodeficiency virus disease with stable control on Atripla 2 Resolving left gluteal abscess completing Flagyl 3 Diabetes mellitus currently on oral therapy 4 Hypertension 5 Depression 6 Chronic musculoskeletal pain of unclear etiology PLAN The patient will continue his current medications He will have laboratory studies done in 3 to 4 weeks and we will see him a few weeks thereafter He has been encouraged to keep his appointment with his psychologist Keywords general medicine human immunodeficiency virus disease diabetes mellitus atripla hiv depression musculoskeletal diabetes hypertension MEDICAL_TRANSCRIPTION,Description Nonischemic cardiomyopathy branch vessel coronary artery disease congestive heart failure NYHA Class III history of nonsustained ventricular tachycardia hypertension and hepatitis C Medical Specialty General Medicine Sample Name Hypertension Cardiomyopathy Transcription PROBLEMS LIST 1 Nonischemic cardiomyopathy 2 Branch vessel coronary artery disease 3 Congestive heart failure NYHA Class III 4 History of nonsustained ventricular tachycardia 5 Hypertension 6 Hepatitis C INTERVAL HISTORY The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications However he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest He has history of orthopnea and PND He has gained a few pounds of weight but denied to have any palpitation presyncope or syncope REVIEW OF SYSTEMS Positive for right upper quadrant pain He has occasional nausea but no vomiting His appetite has decreased No joint pain TIA seizure or syncope Other review of systems is unremarkable I reviewed his past medical history past surgical history and family history SOCIAL HISTORY He has quit smoking but unfortunately was positive for cocaine during last hospital stay in 01 08 ALLERGIES He has no known drug allergies MEDICATIONS I reviewed his medication list in the chart He states he is compliant but he was not taking the revised dose of medications as per discharge orders and prescription PHYSICAL EXAMINATION VITAL SIGNS Pulse 91 per minute and regular blood pressure 151 102 in the right arm and 152 104 in the left arm weight 172 pounds which is about 6 pounds more than last visit in 11 07 HEENT Atraumatic and normocephalic No pallor icterus or cyanosis NECK Supple Jugular venous distention 5 cm above the clavicle present No thyromegaly LUNGS Clear to auscultation No rales or rhonchi Pulse ox was 98 on room air CVS S1 and S2 present S3 and S4 present ABDOMEN Soft and nontender Liver is palpable 5 cm below the right subcostal margin EXTREMITIES No clubbing or cyanosis A 1 edema present ASSESSMENT AND PLAN The patient has hypertension nonischemic cardiomyopathy and branch vessel coronary artery disease Clinically he is in NYHA Class III He has some volume overload and was not unfortunately taking Lasix as prescribed I have advised him to take Lasix 40 mg p o b i d I also increased the dose of hydralazine from 75 mg t i d to 100 mg t i d I advised him to continue to take Toprol and lisinopril I have also added Aldactone 25 mg p o daily for survival advantage I reinforced the idea of not using cocaine He states that it was a mistake may be somebody mixed in his drink but he has not intentionally taken any cocaine I encouraged him to find a primary care provider He will come for a BMP check in one week I asked him to check his blood pressure and weight I discussed medication changes and gave him an updated list I have asked him to see a gastroenterologist for hepatitis C At this point his Medicaid is pending He has no insurance and finds hard to find a primary care provider I will see him in one month He will have his fasting lipid profile AST and ALT checked in one week Keywords general medicine congestive heart failure hypertension cardiomyopathy coronary artery disease ventricular tachycardia nonischemic cardiomyopathy branch vessel nyha class nonischemic tachycardia orthopnea MEDICAL_TRANSCRIPTION,Description An 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation Medical Specialty General Medicine Sample Name Hypertension Consult Transcription HISTORY OF PRESENT ILLNESS The patient is an 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall Basically the patient states that yesterday she fell and she is not certain about the circumstances on her driveway and on her left side hit a rock When she came to the emergency room she was found to have a rapid atrial tachyarrhythmia and was put on Cardizem with reportedly heart rate in the 50s so that was stopped Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker An ECG this morning showing normal sinus rhythm with frequent APCs Her potassium at that time was 3 1 She does recall having palpitations because of the pain after the fall but she states she is not having them since and has not had them prior She denies any chest pain nor shortness of breath prior to or since the fall She states clearly she can walk and she would be able to climb 2 flights of stairs without problems PAST CARDIAC HISTORY She is followed by Dr X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure On 05 12 08 preserved left and right ventricular systolic function aortic sclerosis with apparent mild aortic stenosis and bi atrial enlargement She has previously had a Persantine Myoview nuclear rest stress test scan completed at ABCD Medical Center in 07 06 that was negative She has had significant mitral valve regurgitation in the past being moderate but on the most recent echocardiogram on 05 12 08 that was not felt to be significant She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker She does have a history of significant hypertension in the past She has had dizzy spells and denies clearly any true syncope She has had bradycardia in the past from beta blocker therapy MEDICATIONS ON ADMISSION 1 Multivitamin p o daily 2 Aspirin 325 mg once a day 3 Lisinopril 40 mg once a day 4 Felodipine 10 mg once a day 5 Klor Con 20 mEq p o b i d 6 Omeprazole 20 mg p o daily presumably for GERD 7 MiraLax 17 g p o daily 8 Lasix 20 mg p o daily ALLERGIES PENICILLIN IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST FAMILY HISTORY She states her brother died of an MI suddenly in his 50s SOCIAL HISTORY She does not smoke cigarettes abuse alcohol nor use any illicit drugs She is retired from Morse Chain and delivering newspapers She is widowed She lives alone but has family members who live either on her property or adjacent to it REVIEW OF SYSTEMS She denies a history of stroke cancer vomiting of blood coughing up blood bright red blood per rectum bleeding stomach ulcers She does not recall renal calculi nor cholelithiasis denies asthma emphysema pneumonia tuberculosis sleep apnea home oxygen use She does note occasional peripheral edema She is not aware of prior history of MI She denies diabetes She does have a history of GERD She notes feeling depressed at times because of living alone She denies rheumatologic conditions including psoriasis or lupus Remainder of review of systems is negative times 15 except as described above PHYSICAL EXAM Height 5 feet 0 inches weight 123 pounds temperature 99 2 degrees Fahrenheit blood pressure has ranged from 160 87 with pulses recorded at being 144 and currently ranges 101 53 to 147 71 pulse 64 respiratory rate 20 O2 saturation 97 On general exam she is a pleasant elderly woman who is hard of hearing but is alert and interactive HEENT Shows cranium is normocephalic and atraumatic She has moist mucosal membranes Neck veins were not distended There are no carotid bruits Lungs Clear to auscultation anteriorly without wheezes She is relatively immobile because of her left hip fracture Cardiac Exam S1 S2 regular rate frequent ectopic beats 2 6 systolic ejection murmur preserved aortic component of the second heart sound There is also a soft holosystolic murmur heard There is no rub or gallop PMI is nondisplaced Abdomen is soft and nondistended Bowel sounds present Extremities without significant clubbing cyanosis and there is trivial to 1 peripheral edema Pulses appear grossly intact Affect is appropriate Visible skin warm and perfused She is not able to move because of left hip fracture easily in bed DIAGNOSTIC STUDIES LAB DATA Pertinent labs include chest x ray with radiology report pending but shows only a calcified aortic knob No clear pulmonary vascular congestion Sodium 140 potassium 3 7 it was 3 1 on admission chloride 106 bicarbonate 27 BUN 17 creatinine 0 9 glucose 150 magnesium was 2 on 07 13 06 Troponin was 0 03 followed by 0 18 INR is 0 93 white blood cell count 10 2 hematocrit 36 platelet count 115 000 EKGs are reviewed Initial EKG done on 08 19 08 at 1832 shows MAT heart rate of 104 beats per minute no ischemic changes She had a followup EKG done at 20 37 on 08 19 08 which shows wandering atrial pacemaker and some lateral T wave changes not significantly changed from prior Followup EKG done this morning shows normal sinus rhythm with frequent APCs IMPRESSION She is an 84 year old female with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery Telemetry now reviewed shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia which has been corrected There has been no atrial fibrillation documented I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath She actually describes feeling good exercise capacity prior to this fall Given favorable risk to benefit ratio for needed left hip surgery I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil which has been started which should help control the multifocal atrial tachycardia which she had and would watch for heart rate with that Continued optimization of electrolytes The patient cannot take beta blockers as previously Toprol reportedly caused shortness of breath although there was some report that it caused bradycardia so we would watch her heart rate on the verapamil The patient is aware of the cardiac risks certainly it is moderate and wishes to proceed with needed surgery I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr X after discharge Regarding her mild thrombocytopenia I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease management of left hip fracture as per orthopedist Keywords general medicine hypokalemia shortness of breath atrial tachycardia sinus rhythm hip fracture atrial tachycardia rhythm apcs cardiac regurgitation aortic hypertension pulmonary MEDICAL_TRANSCRIPTION,Description The patient with continued problems with her headaches Medical Specialty General Medicine Sample Name Headache Office Visit Transcription She also had EMG nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy moderate right ulnar neuropathy bilateral mild to moderate carpal tunnel and diabetic neuropathy She was referred to Dr XYZ and will be seeing him on August 8 2006 She was also never referred to the endocrine clinic to deal with her poor diabetes control Her last hemoglobin A1c was 10 PAST MEDICAL HISTORY Diabetes hypertension elevated lipids status post CVA and diabetic retinopathy MEDICATIONS Glyburide Avandia metformin lisinopril Lipitor aspirin metoprolol and Zonegran PHYSICAL EXAMINATION Blood pressure was 140 70 heart rate was 76 respiratory rate was 18 and weight was 226 pounds On general exam she has an area of tenderness on palpation in the left parietal region of her scalp Neurological exam is detailed on our H P form Her neurological exam is within normal limits IMPRESSION AND PLAN For her headaches we are going to titrate Zonegran up to 200 mg q h s to try to maximize the Zonegran therapy If this is not effective when she comes back on August 7 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica We also discussed with Ms Hawkins the possibility of nerve block injection however at this point she is not interested She will be seeing Dr XYZ for her neuropathies We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult Keywords general medicine nerve conduction studies emg zonegran therapy ulnar neuropathy endocrine clinic diabetes control neurological exam headache zonegran MEDICAL_TRANSCRIPTION,Description Upper respiratory tract infection persistent Tinea pedis Wart on the finger Hyperlipidemia Tobacco abuse Medical Specialty General Medicine Sample Name Gen Med SOAP 9 Transcription SUBJECTIVE This patient presents to the office today for a checkup He has several things to go over and discuss First he is sick He has been sick for a month intermittently but over the last couple of weeks it is worse He is having a lot of yellow phlegm when he coughs It feels likes it is in his chest He has been taking Allegra D intermittently but he is almost out and he needs a refill The second problem his foot continues to breakout It seems like it was getting a lot better and now it is bad again He was diagnosed with tinea pedis previously but he is about out of the Nizoral cream I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence He works in the flint and it is really hot where he works and it has been quite humid lately The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger He is interested in getting that frozen today Apparently he tells me I froze a previous wart on him in the past and it went away Next he is interested in getting some blood test done He specifically mentions the blood test for his prostate which I informed him is called the PSA He is 50 years old now He will also be getting his cholesterol checked again because he has a history of high cholesterol He made a big difference in his cholesterol by quitting smoking but unfortunately after taking his social history today he tells me that he is back to smoking He says it is difficult to quit He tells me he did quit chewing tobacco I told him to keep trying to quit smoking REVIEW OF SYSTEMS General With this illness he has had no problems with fever HEENT Some runny nose more runny nose than congestion Respiratory Denies shortness of breath Skin He has a peeling skin on the bottom of his feet mostly the right foot that he is talking about today At times it is itchy OBJECTIVE His weight is 238 4 pounds blood pressure 128 74 temperature 97 8 pulse 80 and respirations 16 General exam The patient is nontoxic and in no acute distress Ears Tympanic membranes pearly gray bilaterally Mouth No erythema ulcers vesicles or exudate noted Neck is supple No lymphadenopathy Lungs Clear to auscultation No rales rhonchi or wheezing Cardiac Regular rate and rhythm without murmur Extremities No edema cyanosis or clubbing Skin exam I checked out the bottom of his right foot He has peeling skin visible consistent with tinea pedis On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart The size of this wart is approximately 3 mm in diameter ASSESSMENT 1 Upper respiratory tract infection persistent 2 Tinea pedis 3 Wart on the finger 4 Hyperlipidemia 5 Tobacco abuse PLAN The patient is getting a refill on Allegra D I am giving him a refill on the Nizoral 2 cream that he should use to the foot area twice a day I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work His wart has been present for some time now and he would like to get it frozen I offered him the liquid nitrogen treatment and he did agree to it I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart He tolerated the procedure very well I froze it once and I allowed for a 3 mm freeze zone I gave him verbal wound care instructions after the procedure Lastly when he is fasting I am going to send him to the lab with a slip which I gave him today for a basic metabolic profile CBC fasting lipid profile and a screening PSA test Lastly for the upper respiratory tract infection I am giving him amoxicillin 500 mg three times a day for 10 days Keywords general medicine hyperlipidemia allegra d upper respiratory tract infection tinea pedis wart tobacco abuse blood test runny nose peeling skin tinea pedis abuse infection wart MEDICAL_TRANSCRIPTION,Description Migraine headache The patient was seen in the urgent care Medical Specialty General Medicine Sample Name Headache Urgent Care Visit Transcription CC Headache HPI This is a 15 year old girl presenting with occipital headache for the last six hours She denies trauma She has been intermittently nauseated but has not vomited and has some photophobia Denies fever or change in vision She has no past history of headaches PMH None MEDICATIONS Tylenol for pain ALLERGIES None FAMILY HISTORY Grandmother died of cerebral aneurysm ROS Negative PHYSICAL EXAM Vital Signs BP 102 60 P 70 RR 20 T 98 2 HEENT Throat is clear nasopharynx clear TMs clear there is no lymphadenopathy no tenderness to palpations sinuses nontender Neck Supple without meningismus Chest Lungs clear heart regular without murmur COURSE IN THE ED The patient was seen in the urgent care and examined At this time her photophobia and nausea make migraine highly likely She is well appearing and we ll try Tylenol with codeine for her pain One day off school and follow up with her primary doctor IMPRESSION Migraine headache PLAN See above Keywords general medicine photophobia nausea migraine headache tylenol migraine headache MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Patient with shoulder bursitis pharyngitis attention deficit disorder Medical Specialty General Medicine Sample Name Gen Med SOAP 5 Transcription S The patient is here today with his mom for several complaints Number one he has been having issues with his right shoulder Approximately 10 days ago he fell slipping on ice did not hit his head but fell straight on his shoulder He has been having issues ever since He is having difficulties raising his arm over his head He does have some intermittent numbness in his fingers at night He is not taking any anti inflammatories or pain relievers He is also complaining of a sore throat He did have some exposure to Strep and he has a long history of strep throat Denies any fevers rashes nausea vomiting diarrhea and constipation He is also being seen for ADHD by Dr B Adderall and Zoloft He takes these once a day He does notice when he does not take his medication He is doing well in school He is socializing well He is maintaining his weight and tolerating the medications However he is having issues with anger control He realizes when he has anger outbursts that it is a problem His mom is concerned He actually was willing to go to counseling and was wondering if there was anything available for him at this time PAST MEDICAL SURGICAL SOCIAL HISTORY Reviewed and unchanged O VSS In general patient is A Ox3 NAD Heart RRR Lungs CTA HEENT Unremarkable He does have 2 tonsils no erythema or exudate noted except for some postnasal drip Musculoskeletal Limited in range of motion active on the right He stops at about 95 degrees No muscle weakness Neurovascularly intact Negative biceps tenderness Psych No suicidal homicidal ideations Answering questions appropriately No hallucinations Keywords general medicine adhd attention deficit disorde pharyngitis anger control anti inflammatories bursitis diarrhea fevers nausea numbness rashes shoulder strep throat vomiting attention deficit deficit disorder anti inflammatories soap anger intermittent MEDICAL_TRANSCRIPTION,Description Patient today with multiple issues Medical Specialty General Medicine Sample Name Gen Med SOAP 8 Transcription SUBJECTIVE I am following the patient today for multiple issues He once again developed gross hematuria which was unprovoked His Coumadin has been held The patient has known BPH and is on Flomax He is being treated with Coumadin because of atrial fibrillation and stroke This is the second time he has had significant gross hematuria this month He also fell about a week ago and is complaining of buttock pain and leg pain We did get x rays of hips knees and ankles Clearly he has significant degenerative disease in all these areas No fractures noted however He felt that the pain is pretty severe and particularly worse in the morning His sinuses are bothering him He wonders about getting some nasal saline spray We talked about Coumadin stroke risk etc in the setting of atrial fibrillation PHYSICAL EXAMINATION Vitals As in chart The patient is alert pleasant and cooperative He is not in any apparent distress He is comfortable in a seated position I did not examine him further today ASSESSMENT AND PLAN 1 Hematuria Coumadin needs to be stopped so we will evaluate what is going on which is probably just some BPH We will also obtain a repeat UA as he did describe to me some dysuria However I do not think this would account for the gross hematuria He will be started on an aspirin 81 mg p o daily 2 For the pain we will try him on Lortab He will get a Lortab everyday in the morning 5 500 prior to getting out of bed and then he will have the option of having a few more throughout the day if he requires it 3 We will see about getting him set up with massage therapy and or physical therapy as well for his back pain 4 For his sinuses we will arrange for him to have saline nasal spray at the bedside for p r n use Keywords general medicine multiple issues atrial fibrillation gross hematuria multiple bph fibrillation hematuria MEDICAL_TRANSCRIPTION,Description Patient with several medical problems mouth being sore cough right shoulder pain and neck pain Medical Specialty General Medicine Sample Name Gen Med SOAP 6 Transcription SUBJECTIVE The patient is in with several medical problems He complains his mouth being sore since last week and also some trouble with my eyes He states that they feel funny but he is seeing okay He denies any more diarrhea or abdominal pain Bowels are working okay He denies nausea or diarrhea Eating is okay He is emptying his bladder okay He denies dysuria His back is hurting worse He complains of right shoulder pain and neck pain over the last week but denies any injury He reports that his cough is about the same CURRENT MEDICATIONS Metronidazole 250 mg q i d Lortab 5 500 b i d Allegra 180 mg daily Levothroid 100 mcg daily Lasix 20 mg daily Flomax 0 4 mg at h s aspirin 81 mg daily Celexa 40 mg daily verapamil SR 180 mg one and a half tablet daily Zetia 10 mg daily Feosol b i d ALLERGIES Lamisil Equagesic Bactrim Dilatrate cyclobenzaprine OBJECTIVE General He is a well developed well nourished elderly male in no acute distress Vital Signs His age is 66 Temperature 97 7 Blood pressure 134 80 Pulse 88 Weight 201 pounds HEENT Head was normocephalic Examination of the throat reveals it to be clear He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis Neck Supple without adenopathy or thyromegaly Lungs Clear Heart Regular rate and rhythm Extremities He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder Back has limited range of motion He is nontender to his back Deep tendon reflexes are 2 bilaterally in lower extremities Straight leg raising is positive for back pain on the right side at 90 degrees Abdomen Soft nontender without hepatosplenomegaly or mass He has normal bowel sounds ASSESSMENT 1 Clostridium difficile enteritis improved 2 Right shoulder pain 3 Chronic low back pain 4 Yeast thrush 5 Coronary artery disease 6 Urinary retention which is doing better PLAN I put him on Diflucan 200 mg daily for seven days We will have him stop his metronidazole little earlier at his request He can drop it down to t i d until Friday of this week and then finish Friday s dose and then stop the metronidazole and that will be more than a 10 day course I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr XYZ p r n for his eye discomfort and his left eye pterygium which is noted on exam minimal redness is noted to the conjunctiva on the left side but no mattering was seen Recheck with me in two to three weeks Keywords general medicine clostridium difficile enteritis coronary artery disease urinary retention yeast thrush cough neck pain several medical problems shoulder pain range of motion soap metronidazole shoulder neck MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Medical Specialty General Medicine Sample Name Gen Med SOAP 3 Transcription S XYZ is in today not feeling well for the last three days She is a bit sick with bodyaches She is coughing She has a sore throat especially when she coughs Her cough is productive of green colored sputum She has had some chills No vomiting No diarrhea She is sleeping okay She does not feel like she needs anything for the cough She did call in yesterday and got a refill of her Keflex She took two Keflex this morning and she is feeling a little bit better now She is tearful just tired of feeling ran down O Vital signs as per chart Respirations 15 Exam Nontoxic No acute distress Alert and oriented HEENT TMs are clear bilaterally without erythema or bulging Clear external canals Clear tympanic Conjunctivae are clear Clear nasal mucosa Clear oropharynx with moist mucous membranes NECK is soft and supple without lymphadenopathy LUNGS are coarse with no severe rhonchi or wheezes HEART is regular rate and rhythm without murmur ABDOMEN is soft and nontender Chest x ray reveals no obvious consolidation or infiltrates We will send the x ray for over read Influenza test is negative Rapid strep screen is negative A Bronchitis URI P 1 Motrin as needed for fever and discomfort 2 Push fluids 3 Continue on the Keflex 4 Follow up with Dr ABC if symptoms persist or worsen otherwise as needed Keywords general medicine bodyaches alert and oriented no acute distress soap diarrhea lymphadenopathy regular rate and rhythm rhonchi soft and nontender supple vomiting wheezes coughing keflex oriented MEDICAL_TRANSCRIPTION,Description General Medicine SOAP note Medical Specialty General Medicine Sample Name Gen Med SOAP 4 Transcription S ABC is in today for a followup of her atrial fibrillation They have misplaced the Cardizem She is not on this and her heart rate is up just a little bit today She does complain of feeling dizziness some vertigo some lightheadedness and has attributed this to the Coumadin therapy She is very adamant that she wants to stop the Coumadin She is tired of blood draws We have had a difficult time getting her regulated No chest pains No shortness of breath She is moving around a little bit better Her arm does not hurt her Her back pain is improving as well O Vital signs as per chart Respirations 15 Exam Nontoxic No acute distress Alert and oriented HEENT TMs are clear bilaterally without erythema or bulging Clear external canals Clear tympanic Conjunctivae are clear Clear nasal mucosa Clear oropharynx with moist mucous membranes NECK is soft and supple LUNGS are clear to auscultation HEART is irregularly irregular mildly tachycardic ABDOMEN is soft and nontender EXTREMITIES No cyanosis no clubbing no edema EKG shows atrial fibrillation with a heart rate of 104 A 1 Keywords general medicine soap alert and oriented no acute distress no cyanosis atrial fibrillation blood draw dizziness irregularly irregular lightheadedness no clubbing no edema shortness of breath soft and nontender vertigo heart fibrillation coumadin atrial MEDICAL_TRANSCRIPTION,Description The patient has recently had an admission for pneumonia with positive blood count She returned after vomiting and a probable seizure Medical Specialty General Medicine Sample Name Gen Med SOAP 11 Transcription SUBJECTIVE The patient has recently had an admission for pneumonia with positive blood count She was treated with IV antibiotics and p o antibiotics she improved on that She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102 She was found to have strep She was treated with penicillin and sent home She returned about 8 o clock after vomiting and a probable seizure Temperature was 104 5 she was lethargic after that She had an LP which was unremarkable She had blood cultures which have not grown anything The CSF has not grown anything at this point PHYSICAL EXAMINATION She is alert recovering from anesthesia Head eyes ears nose and throat are unremarkable Chest is clear to auscultation and percussion Abdomen is soft Extremities are unremarkable LAB STUDIES White count in the emergency room was 9 8 with a slight shift CSF glucose was 68 protein was 16 and there were no cells The Gram stain was unremarkable ASSESSMENT I feel that this patient has a febrile seizure PLAN My plan is to readmit the patient to control her temperature and assess her white count I am going to observe her overnight Keywords general medicine antibiotics febrile seizure temperature blood count white count pneumonia seizure MEDICAL_TRANSCRIPTION,Description Patient with NIDDM hypertension CAD status post CABG hyperlipidemia etc Medical Specialty General Medicine Sample Name Gen Med SOAP 2 Transcription SUBJECTIVE Overall she has been doing well Her blood sugars have usually been less than or equal to 135 by home glucose monitoring Her fasting blood sugar today is 120 by our Accu Chek She is exercising three times per week Review of systems is otherwise unremarkable OBJECTIVE Her blood pressure is 110 60 Other vitals are stable HEENT Unremarkable Neck Unremarkable Lungs Clear Heart Regular Abdomen Unchanged Extremities Unchanged Neurologic Unchanged ASSESSMENT 1 NIDDM with improved control 2 Hypertension 3 Coronary artery disease status post coronary artery bypass graft 4 Degenerative arthritis 5 Hyperlipidemia 6 Hyperuricemia 7 Renal azotemia 8 Anemia 9 Fibroglandular breasts PLAN We will get follow up labs today We will continue with current medications and treatment We will arrange for a follow up mammogram as recommended by the radiologist in six months which will be approximately Month DD YYYY The patient is advised to proceed with previous recommendations She is to follow up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow up as directed Keywords general medicine accu chek heent unremarkable hyperlipidemia hypertension lungs clear niddm neck unremarkable progress note soap coronary artery bypass graft follow up labs glucose monitoring coronary artery MEDICAL_TRANSCRIPTION,Description Multiple problems including left leg swelling history of leukocytosis joint pain left shoulder low back pain obesity frequency with urination and tobacco abuse Medical Specialty General Medicine Sample Name Gen Med Progress Note 9 Transcription SUBJECTIVE The patient is a 44 year old white female who is here today with multiple problems The biggest concern she has today is her that left leg has been swollen It is swollen for three years to some extent but worse for the past two to three months It gets better in the morning when she is up but then through the day it begins to swell again Lately it is staying bigger and she somewhat uncomfortable with it being so large The right leg also swells but not nearly like the left leg The other problem she had was she has had pain in her shoulder and back These occurred about a year ago but the pain in her left shoulder is of most concern to her She feels like the low back pain is just a result of a poor mattress She does not remember hurting her shoulder but she said gradually she has lost some mobility It is hard time to get her hands behind her back or behind her head She has lost strength in the left shoulder As far as the blood count goes she had an elevated white count In April of 2005 Dr XYZ had asked Dr XYZ to see her because of the persistent leukocytosis however Dr XYZ felt that this was not a problem for the patient and asked her to just return here for follow up She also complains of a lot of frequency with urination and nocturia times two to three She has gained weight she thinks about 12 pounds since March She now weighs 284 Fortunately her blood pressure is staying stable She takes atenolol 12 5 mg per day and takes Lasix on a p r n basis but does not like to take it because it causes her to urinate so much She denies chest pain but she does feel like she is becoming gradually more short of breath She works for the city of Wichita as bus dispatcher so she does sit a lot and just really does not move around much Towards the end of the day her leg was really swollen I reviewed her lab work Other than the blood count her lab work has been pretty normal but she does need to have a cholesterol check OBJECTIVE General The patient is a very pleasant 44 year old white female quite obese Vital Signs Blood pressure 122 70 Temperature 98 6 HEENT Head Normocephalic Ears TMs intact Eyes Pupils round and equal Nose Mucosa normal Throat Mucosa normal Lungs Clear Heart Regular rate and rhythm Abdomen Soft and obese Extremities A lot of fluid in both legs but especially the left leg is really swollen At least 2 pedal edema The right leg just has a trace of edema She has pain in her low back with range of motion She has a lot of pain in her left shoulder with range of motion It is hard for her to get her hand behind her back She cannot get it up behind her head She has pain in the anterior left shoulder in that area ASSESSMENT 1 Multiple problems including left leg swelling 2 History of leukocytosis 3 Joint pain involving the left shoulder probably impingement syndrome 4 Low back pain chronic with obesity 5 Obesity 6 Frequency with urination 7 Tobacco abuse PLAN 1 I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel We will start her on Detrol 0 4 mg one daily and also started on Mobic 15 mg per day 2 Elevate her leg as much as possible and wear support hose if possible Keep her foot up during the day We will see her back in two weeks We will have the results of the Doppler the lab work and see how she is doing with the Detrol and the joint pain If her shoulder pain is not any better we probably should refer her on over to orthopedist We did do x rays of her shoulder today that did not show anything remarkable See her in two weeks or p r n Keywords general medicine leg swelling leukocytosis joint pain left shoulder low back pain obesity frequency with urination tobacco abuse multiple problems blood count blood pressure leg shoulder tobacco swelling weight MEDICAL_TRANSCRIPTION,Description The patient has NG tube in place for decompression Medical Specialty General Medicine Sample Name Gen Med SOAP 10 Transcription SUBJECTIVE The patient has NG tube in place for decompression She says she is feeling a bit better PHYSICAL EXAMINATION VITAL SIGNS She is afebrile Pulse is 58 and blood pressure is 110 56 SKIN There is good skin turgor GENERAL She is not in acute distress CHEST Clear to auscultation There is good air movement bilaterally CARDIOVASCULAR First and second sounds are heard No murmurs appreciated ABDOMEN Less distended Bowel sounds are absent EXTREMITIES She has 3 pedal swelling NEUROLOGICAL The patient is alert and oriented x3 Examination is nonfocal LABORATORY DATA White count is down from 20 000 to 12 5 hemoglobin is 12 hematocrit 37 and platelets 199 000 Glucose is 157 BUN 14 creatinine 0 6 sodium is 131 potassium is 4 0 and CO2 is 31 ASSESSMENT AND PLAN 1 Small bowel obstruction paralytic ileus rule out obstipation Continue with less aggressive decompression Follow surgeon s recommendation 2 Pulmonary fibrosis status post biopsy Manage as per pulmonologist 3 Leukocytosis improving Continue current antibiotics 4 Bilateral pedal swelling Ultrasound of the lower extremity negative for DVT 5 Hyponatremia improving 6 DVT prophylaxis 7 GI prophylaxis Keywords general medicine small bowel obstruction paralytic ileus decompression ng tube pedal swelling prophylaxis MEDICAL_TRANSCRIPTION,Description Short term followup Hypertension depression osteoporosis and osteoarthritis Medical Specialty General Medicine Sample Name Gen Med Progress Note 8 Transcription SUBJECTIVE The patient is an 89 year old lady She actually turns 90 later this month seen today for a short term followup Actually the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended She apparently did not feel well with the higher dose so she just went back to her previous dose of 1 mg daily She thinks she also has an element of office hypertension Also since she is on Mavik plus verapamil she could switch over to the combined drug Tarka However when we gave her samples of that she thought they were too big for her to swallow Basically she is just back on her previous blood pressure regimen However her blood pressure seems to be better today Her daughter says that they do check it periodically and it is similar to today s reading Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade We did do a C spine and right shoulder x ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder but this does not seem to cause her any problems She has some vague stomach problems although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve She takes Tylenol p r n which seems to be enough for her She does not think she has any acid reflux symptoms or heartburn She does take Tums t i d and also Mylanta at night She has had dentures for many many years and just recently I guess in the last few months although she was somewhat vague on this she has had some sores in her mouth They do heal up but then she will get another one She also thinks since she has been on the Lexapro she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor They do think the Lexapro has helped to some extent ALLERGIES None MEDICATION Verapamil 240 mg a day Mavik 1 mg a day Lipitor 10 mg one and half daily vitamins daily Ocuvite daily Tums t i d Tylenol 2 3 daily p r n and Mylanta at night REVIEW OF SYSTEMS Mostly otherwise as above OBJECTIVE General She is a pleasant elderly lady She is in no acute distress accompanied by daughter Vital signs Blood pressure 128 82 Pulse 68 Weight 143 pounds HEENT No acute changes Atraumatic normocephalic On mouth exam she does have dentures She removed her upper denture I really do not see any sores at all Her mouth exam was unremarkable Neck No adenopathy tenderness JVD bruits or mass Lungs Clear Heart Regular rate and rhythm Extremities No significant edema Reasonable pulses No clubbing or cyanosis may be just a minimal tremor in head and hands but it is very subtle and hardly noticeable No other focal or neurological deficits grossly IMPRESSION 1 Hypertension better reading today 2 Right arm symptoms resolved 3 Depression probably somewhat improved with Lexapro and she will just continue that She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it 4 Perhaps a very subtle tremor I will just watch that 5 Osteoporosis 6 Osteoarthritis PLAN I think I will just watch everything for now I would continue the Lexapro we gave her more samples plus a prescription for the 20 mg that she can cut in half I offered to see her for again short term followup However they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner She might get a flu shot here in the next few weeks Daughter mentioned here today that she thinks her mom is doing pretty well especially given that she is turning 90 here later this month and I would tend to agree with that Keywords general medicine osteoporosis osteoarthritis hypertension depression short term followup blood pressure progress blood pressure dose MEDICAL_TRANSCRIPTION,Description Palpitations possibly related to anxiety Fatigue Loose stools with some green color and also some nausea Medical Specialty General Medicine Sample Name Gen Med SOAP Transcription SUBJECTIVE This patient presents to the office today because he has not been feeling well He was in for a complete physical on 05 02 2008 According to the chart the patient gives a history of feeling bad for about two weeks At first he thought it was stress and anxiety and then he became worried it was something else He says he is having a lot of palpitations He gets a fluttering feeling in his chest He has been very tired over two weeks as well His job has been really getting to him He has been feeling nervous and anxious It seems like when he is feeling stressed he has more palpitations sometimes they cause chest pain These symptoms are not triggered by exertion He had similar symptoms about 9 or 10 years ago At that time he went through a full workup Everything ended up being negative and they gave him something that he took for his nerves and he says that helped Unfortunately he does not remember what it was Also over the last three days he has had some intestinal problems He has had some intermittent nausea and his stools have been loose He has been having some really funny green color to his bowel movements There has been no blood in the stool He is not having any abdominal pain just some nausea He does not have much of an appetite He is a nonsmoker OBJECTIVE His weight today is 168 4 pounds blood pressure 142 76 temperature 97 7 pulse 68 and respirations 16 General exam The patient is nontoxic and in no acute distress There is no labored breathing Psychiatric He is alert and oriented times 3 Ears Tympanic membranes pearly gray bilaterally Mouth No erythema ulcers vesicles or exudate noted Eyes Pupils equal round and reactive to light bilaterally Neck is supple No lymphadenopathy Lungs Clear to auscultation No rales rhonchi or wheezing Cardiac Regular rate and rhythm without murmur Extremities No edema cyanosis or clubbing ASSESSMENT 1 Palpitations possibly related to anxiety 2 Fatigue 3 Loose stools with some green color and also some nausea There has been no vomiting possibly a touch of gastroenteritis going on here PLAN The patient admits he has been putting this off now for about two weeks He says his work is definitely contributing to some of his symptoms and he feels stressed He is leaving for a vacation very soon Unfortunately he is actually leaving Wednesday for XYZ which puts us into a bit of a bind in terms of doing testing on him My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis A 12 lead EKG was performed on him in the office today This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted which is definitely a good news I am going to send him to the lab from our office to get the following tests done Comprehensive metabolic profile CBC urinalysis with reflex to culture and we will also get a chest X ray Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital We were able to squeeze him in His appointment is at 8 15 in the morning He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck I am not going to be here so he is going to see Dr X Dr X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ Certainly if something comes up we may need to postpone his trip We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago In the meantime I have given him Ativan 0 5 mg one tablet two to three times a day as needed for anxiety I talked about Ativan how it works I talked about the side effects I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck I took him off of work today and tomorrow so he could rest Keywords general medicine palpitations nausea loose stools fatigue related to anxiety stress test anxiety MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty General Medicine Sample Name Gen Med SOAP 1 Transcription SUBJECTIVE Keywords general medicine progress note clear to auscultation s1 s2 s3 s4 blood pressure clubbing cyanosis peripheral edema rubs tenderness abdomen pressure soap blood MEDICAL_TRANSCRIPTION,Description Patient with a three day history of emesis and a four day history of diarrhea Medical Specialty General Medicine Sample Name Gen Med Progress Note 7 Transcription SUBJECTIVE The patient is a 7 year old male who comes in today with a three day history of emesis and a four day history of diarrhea Apparently his brother had similar symptoms They had eaten some chicken and then ate some more of it the next day and I could not quite understand what the problem was because there is a little bit of language barrier although dad was trying very hard to explain to me what had happened But any way after he and his brother got done eating with chicken they both felt bad and have continued to feel bad The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days He has not had any emesis today He has urinated this morning His parents are both concerned because he had a fever of 103 last night Also he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis He has been drinking Pedialyte Gatorade white grape juice and 7Up otherwise he has not been eating anything MEDICATIONS None ALLERGIES He has no known drug allergies REVIEW OF SYSTEMS Negative as far as sore throat earache or cough PHYSICAL EXAMINATION General He is awake and alert no acute distress Vital Signs Blood pressure 106 75 Temperature 99 Pulse 112 Weight is 54 pounds HEENT His TMs are normal bilaterally Posterior pharynx is unremarkable Neck Without adenopathy or thyromegaly Lungs Clear to auscultation Heart Regular rate and rhythm without murmur Abdomen Benign Skin Turgor is intact His capillary refill is less than 3 seconds LABORATORY White blood cell count is 5 3 with 69 segs 15 lymphs and 13 monos His platelet count on his CBC is 215 ASSESSMENT Viral gastroenteritis PLAN The parents did point out to me a rash that he had on his buttock There were some small almost pinpoint erythematous patches of papules that have a scab on them I did not see any evidence of petechiae Therefore I just reassured them that this is a viral gastroenteritis I recommended that they stop giving him juice and just go with the Gatorade and water He is to stay away from milk products until his diarrhea and stomach upset have calmed down We talked about BRAT diet and slowly advancing his diet as he tolerates They have used some Kaopectate which did not really help with the diarrhea Otherwise follow up as needed Keywords general medicine diarrhea emesis history of gastroenteritis viral brat diet progress note MEDICAL_TRANSCRIPTION,Description A 3 year old male brought in by his mother with concerns about his eating a very particular eater not eating very much in general Medical Specialty General Medicine Sample Name Gen Med Progress Note 6 Transcription SUBJECTIVE This 3 year old male is brought by his mother with concerns about his eating He has become a very particular eater and not eating very much in general However her primary concern was he was vomiting sometimes after particular foods They had noted that when he would eat raw carrots within 5 to 10 minutes he would complain that his stomach hurt and then vomit After this occurred several times they stopped giving him carrots Last week he ate some celery and the same thing happened They had not given him any of that since He eats other foods without any apparent pain or vomiting Bowel movements are normal He does have a history of reactive airway disease intermittently He is not diagnosed with intrinsic asthma at this time and takes no medication regularly CURRENT MEDICATIONS He is on no medications ALLERGIES He has no known medicine allergies OBJECTIVE Vital Signs Weight 31 5 pounds which is an increase of 2 5 pounds since May Temperature is 97 1 He certainly appears in no distress He is quite interested in looking at his books Neck Supple without adenopathy Lungs Clear Cardiac Regular rate and rhythm without murmurs Abdomen Soft without organomegaly masses or tenderness ASSESSMENT Report of vomiting and abdominal pain after eating raw carrots and celery Etiology of this is unknown PLAN I talked with mother about this Certainly it does not suggest any kind of an allergic reaction nor obstruction At this time they will simply avoid those foods In the future they may certainly try those again and see how he tolerates those I did encourage a wide variety of fruits and vegetables in his diet as a general principle If worsening symptoms she is welcome to contact me again for reevaluation Keywords general medicine eating foods vomiting reactive airway disease raw carrots carrots MEDICAL_TRANSCRIPTION,Description The patient is in complaining of headaches and dizzy spells Medical Specialty General Medicine Sample Name Gen Med Progress Note 4 Transcription SUBJECTIVE The patient is in complaining of headaches and dizzy spells as well as a new little rash on the medial right calf She describes her dizziness as both vertigo and lightheadedness She does not have a headache at present but has some intermittent headaches neck pains and generalized myalgias She has noticed a few more bruises on her legs No fever or chills with slight cough She has had more chest pains but not at present She does have a little bit of nausea but no vomiting or diarrhea She complains of some left shoulder tenderness and discomfort She reports her blood sugar today after lunch was 155 CURRENT MEDICATIONS She is currently on her nystatin ointment to her lips q i d p r n She is still using a triamcinolone 0 1 cream t i d to her left wrist rash and her Bactroban ointment t i d p r n to her bug bites on her legs Her other meds remain as per the dictation of 07 30 2004 with the exception of her Klonopin dose being 4 mg in a m and 6 mg at h s instead of what the psychiatrist had recommended which should be 6 mg and 8 mg ALLERGIES Sulfa erythromycin Macrodantin and tramadol OBJECTIVE General She is a well developed well nourished obese female in no acute distress Vital Signs Her age is 55 Temperature 98 2 Blood pressure 110 70 Pulse 72 Weight 174 pounds HEENT Head was normocephalic Throat Clear TMs clear Neck Supple without adenopathy Lungs Clear Heart Regular rate and rhythm without murmur Abdomen Soft nontender without hepatosplenomegaly or mass Extremities Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted Her shoulders have full range of motion She has minimal tenderness to the left shoulder anteriorly Skin There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin ASSESSMENT 1 Headaches 2 Dizziness 3 Atypical chest pains 4 Chronic renal failure 5 Type II diabetes 6 Myalgias 7 Severe anxiety affect is still quite anxious PLAN I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended which should be 6 mg in the a m and 8 mg in the p m I sent her to lab for CPK due to her myalgias and pro time for monitoring her Coumadin Recheck in one week I think her dizziness is multifactorial and due to enlarged part of her anxiety I do note that she does have a few new bruises on her extremities which is likely due to her Coumadin Keywords general medicine headaches and dizzy spells chest pains shoulder progress headaches MEDICAL_TRANSCRIPTION,Description Rhabdomyolysis acute on chronic renal failure anemia leukocytosis elevated liver enzyme hypertension elevated cardiac enzyme obesity Medical Specialty General Medicine Sample Name Gen Med Progress Note 12 Transcription SUBJECTIVE The patient was seen and examined He feels much better today improved weakness and decreased muscular pain No other complaints PHYSICAL EXAMINATION GENERAL Not in acute distress awake alert and oriented x3 VITAL SIGNS Blood pressure 147 68 heart rate 82 respiratory rate 20 temperature 97 7 O2 saturation 99 on 3 L HEENT NC T PERRLA EOMI NECK Supple HEART Regular rate and rhythm RESPIRATORY Clear bilateral ABDOMEN Soft and nontender EXTREMITIES No edema Pulses present bilateral LABORATORY DATA Total CK coming down 70 142 from 25 573 total CK is 200 troponin is 2 3 from 1 9 yesterday BNP blood sugar 93 BUN of 55 7 creatinine 2 7 sodium 137 potassium 3 9 chloride 108 and CO2 of 22 Liver function test AST 704 ALT 298 alkaline phosphatase 67 total bilirubin 0 3 CBC WBC count 9 1 hemoglobin 9 9 hematocrit 29 2 and platelet count 204 Blood cultures are still pending Ultrasound of abdomen negative abdomen both kidneys were echogenic cortices suggesting chronic medical renal disease Doppler of lower extremities negative for DVT ASSESSMENT AND PLAN 1 Rhabdomyolysis most likely secondary to statins gemfibrozil discontinue it on admission Continue IV fluids We will monitor 2 Acute on chronic renal failure We will follow up with Nephrology recommendation 3 Anemia drop in hemoglobin most likely hemodilutional Repeat CBC in a m 4 Leukocytosis improving 5 Elevated liver enzyme most likely secondary to rhabdomyolysis The patient denies any abdominal pain and ultrasound is unremarkable 6 Hypertension Blood pressure controlled 7 Elevated cardiac enzyme follow up with Cardiology recommendation 8 Obesity 9 Deep venous thrombosis prophylaxis Continue Lovenox 40 mg subcu daily Keywords general medicine rhabdomyolysis acute on chronic renal failure anemia leukocytosis elevated liver enzyme hypertension elevated cardiac enzyme obesity cardiac enzyme blood pressure MEDICAL_TRANSCRIPTION,Description 5 month recheck on type II diabetes mellitus as well as hypertension Medical Specialty General Medicine Sample Name Gen Med Progress Note 11 Transcription SUBJECTIVE The patient is a 66 year old female who presents to the clinic today for a five month recheck on her type II diabetes mellitus as well as hypertension While here she had a couple of other issues as well She stated that she has been having some right shoulder pain She denies any injury but certain range of motion does cause it to hurt No weakness numbness or tingling As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100 She has not been checking any two hours after meals Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her No other issues or concerns Upon review of her chart it did show that she had a benign breast biopsy done back on 06 11 04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well ALLERGIES None MEDICATIONS She is on Hyzaar 50 12 5 one half p o daily coated aspirin daily lovastatin 40 mg one half tab p o daily multivitamin daily metformin 500 mg one tab p o b i d however she has been skipping her second dose during the day SOCIAL HISTORY She is a nonsmoker REVIEW OF SYSTEMS As noted above OBJECTIVE Vital Signs Temperature 98 2 Pulse 64 Respirations 16 Blood pressure 110 56 Weight 169 General Alert and oriented x 3 No acute distress noted Neck No lymphadenopathy thyromegaly JVD or bruits Lungs Clear to auscultation Heart Regular rate and rhythm without murmur or gallops present Breasts Exam performed with a female nurse present The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery There is no axillary adenopathy or tenderness Breasts appear to be symmetric There was no nipple discharge or retraction No breast tissue retraction noted in either the sitting or the supine position Upon palpation there were no palpable lumps or bumps and no palpable discharge Musculoskeletal She did have full range of motion of her shoulders She did have tenderness upon palpation over the right bicipital tendon There is no swelling crepitus or discoloration noted MEDICAL DECISION MAKING Most recent hemoglobin A1c was 5 6 back in October 2004 Most recent lipid checks were obtained back in July 2004 We have not had this checked since that time ASSESSMENT 1 Type II diabetes mellitus 2 Hypertension 3 Right shoulder pain 4 Hyperlipidemia PLAN 1 She is going to go to lab to obtain a hemoglobin A1c BMP lipids CPK liver enzymes and quantitative microalbumin 2 We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst 3 I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week 4 She is going to follow up in the clinic in three months for a complete comprehensive examination If any questions concerns or problems arise between now and then she should let us know Keywords MEDICAL_TRANSCRIPTION,Description Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20 25 Medical Specialty General Medicine Sample Name Gen Med Office Note 1 Transcription HISTORY OF PRESENT ILLNESS The patient is a 43 year old male who was recently discharged from our care on the 1 13 06 when he presented for shortness of breath He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20 25 The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure During his hospital stay he was commenced on metoprolol for rate control and given that he had atrial fibrillation he was also started on warfarin which his INR has been followed up by the Homeless Clinic For his congestive cardiac failure he was restarted on Digoxin and lisinopril For his hyperthyroidism we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy He was restarted on PTU and discharged from the hospital on this medication While in the hospital it was also noted that he abused cigarettes and cocaine and we advised strongly against this given the condition of his heart It was also noted that he had elevated liver function tests which an ultrasound was normal but his hepatitis panel was pending Since his discharge his hepatitis panel has come back normal for hepatitis A B and C Since discharge the patient has complained of shortness of breath mainly at night when lying flat but otherwise he states he has been well and compliant with his medication MEDICATIONS Digoxin 250 mcg daily lisinopril 5 mg daily metoprolol 50 mg twice daily PTU propylthiouracil 300 mg orally four times a day warfarin variable dose based on INR PHYSICAL EXAMINATION VITAL SIGNS He was afebrile today Blood pressure 114 98 Pulse 92 but irregular Respiratory rate 25 HEENT Obvious exophthalmus but no obvious lid lag today NECK There was no thyroid mass palpable CHEST Clear except for occasional bibasilar crackles CARDIOVASCULAR Heart sounds were dual but irregular with no additional sounds ABDOMEN Soft nontender nondistended EXTREMITIES Mild 1 peripheral edema in both legs PLAN The patient has also been attending the Homeless Clinic since discharge from the hospital where he has been receiving quality care and they have been looking after every aspect of his health including his hyperthyroidism It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic at which time he should attend endocrine review with Dr Huffman for further treatment of his hyperthyroidism Regarding his atrial fibrillation he is moderately rate controlled with metoprolol 50 mg b i d His rate in clinic today was 92 He could benefit from increasing his metoprolol dose however in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure Regarding his congestive cardiac failure he currently appears stable with some variation in his weight He states he has been taking his wife s Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema We should consider adding him on a low dose furosemide tablet to be taken either daily or when his weight is above his target range A Digoxin level has not been repeated since discharge and we feel that this should be followed up We have also increased his lisinopril to 5 mg daily but the patient did not receive his script upon departing our clinic Regarding his elevated liver function tests we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel but yet the liver function tests should be followed up Keywords general medicine congestive cardiac failure ejection fraction atrial fibrillation congestive cardiac cardiac failure office lisinopril metoprolol hepatitis fibrillation hyperthyroidism atrial cardiac congestive MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty General Medicine Sample Name Gen Med Progress Note 2 Transcription CHIEF COMPLAINT Followup on hypertension and hypercholesterolemia SUBJECTIVE This is a 78 year old male who recently had his right knee replaced and also back surgery about a year and a half ago He has done well with that He does most of the things that he wants to do He travels at every chance he has and he just got back from a cruise He denies any type of chest pain heaviness tightness pressure shortness of breath with stairs only cough or palpitations He sees Dr Ferguson He is known to have Crohn s and he takes care of that for him He sees Dr Roszhart for his prostate check He is a nonsmoker and denies swelling in his ankles MEDICATIONS Refer to chart ALLERGIES Refer to chart PHYSICAL EXAMINATION Vitals Wt 172 lbs up 2 lbs B P 150 60 T 96 4 P 72 and regular General A 78 year old male who does not appear to be in any acute distress Glasses Good dentition CV Distant S1 S2 without murmur or gallop No carotid bruits P 2 all around Lungs Diminished with increased AP diameter Abdomen Soft bowel sounds active x 4 quadrants No tenderness no distention no masses or organomegaly noted Extremities Well healed surgical scar on the right knee No edema Hand grasps are strong and equal Back Surgical scar on the lower back Neuro Intact A O Moves all four with no focal motor or sensory deficits IMPRESSION 1 Hypertension 2 Hypercholesterolemia 3 Osteoarthritis 4 Fatigue PLAN We will check a BMP lipid liver profile CPK and CBC Refill his medications x 3 months I gave him a copy of Partners in Prevention Increase his Altace to 5 mg day for better blood pressure control Diet exercise and weight loss and we will see him back in three months and p r n Keywords general medicine progress note fatigue osteoarthritis back surgery chest pain cough heaviness hypercholesterolemia hypertension palpitations pressure shortness of breath tightness surgical scar progress MEDICAL_TRANSCRIPTION,Description The patient states that he feels sick and weak Medical Specialty General Medicine Sample Name Gen Med Progress Note Transcription SUBJECTIVE The patient states that he feels sick and weak PHYSICAL EXAMINATION VITAL SIGNS Highest temperature recorded over the past 24 hours was 101 1 and current temperature is 99 2 GENERAL The patient looks tired HEENT Oral mucosa is dry CHEST Clear to auscultation He states that he has a mild cough not productive CARDIOVASCULAR First and second heart sounds were heard No murmur was appreciated ABDOMEN Soft and nontender Bowel sounds are positive Murphy s sign is negative EXTREMITIES There is no swelling NEURO The patient is alert and oriented x 3 Examination is nonfocal LABORATORY DATA White count is normal at 6 8 hemoglobin is 15 8 and platelets 257 000 Glucose is in the low 100s Comprehensive metabolic panel is unremarkable UA is negative for infection ASSESSMENT AND PLAN 1 Fever of undetermined origin probably viral since white count is normal Would continue current antibiotics empirically 2 Dehydration Hydrate the patient 3 Prostatic hypertrophy Urologist Dr X 4 DVT prophylaxis with subcutaneous heparin Keywords general medicine fever dehydration prophylaxis white count is normal white count sick weak temperature MEDICAL_TRANSCRIPTION,Description Sample progress note Gen Med Medical Specialty General Medicine Sample Name Gen Med Progress Note 1 Transcription CHIEF COMPLAINT Followup on diabetes mellitus status post cerebrovascular accident SUBJECTIVE This is a 70 year old male who has no particular complaints other than he has just discomfort on his right side We have done EMG studies He has noticed it since his stroke about five years ago He has been to see a neurologist We have tried different medications and it just does not seem to help He checks his blood sugars at home two to three times a day He kind of adjusts his own insulin himself Re evaluation of symptoms is essentially negative He has a past history of heavy tobacco and alcohol usage MEDICATIONS Refer to chart ALLERGIES Refer to chart PHYSICAL EXAMINATION Vitals Wt 118 lbs B P 108 72 T 96 5 P 80 and regular General A 70 year old male who does not appear to be in acute distress but does look older than his stated age He has some missing dentition Skin Dry and flaky CV Heart tones are okay adequate carotid pulsations He has 2 pedal pulse on the left and 1 on the right Lungs Diminished but clear Abdomen Scaphoid Rectal His prostate check was normal per Dr Gill Neuro Sensation with monofilament testing is better on the left than it is on the right IMPRESSION 1 Diabetes mellitus 2 Neuropathy 3 Status post cerebrovascular accident PLAN Refill his medications x 3 months We will check an A1c and BMP I have talked to him several times about a colonoscopy which he has refused and so we have been doing stools for occult blood We will check a PSA Continue with yearly eye exams foot exams Accu Cheks and we will see him in three months and p r n Keywords general medicine diabetes mellitus neuropathy genernal medicine post cerebrovascular accident progerss note post cerebrovascular cerebrovascular accident accident cerebrovascular neurologist insulin MEDICAL_TRANSCRIPTION,Description Sepsis due to urinary tract infection Medical Specialty General Medicine Sample Name Gen Med Progress Note 13 Transcription SUBJECTIVE The patient states she is feeling a bit better OBJECTIVE VITAL SIGNS Temperature is 95 4 Highest temperature recorded over the past 24 hours is 102 1 CHEST Examination of the chest is clear to auscultation CARDIOVASCULAR First and second heart sounds were heard No murmurs appreciated ABDOMEN Benign Right renal angle is tender Bowel sounds are positive EXTREMITIES There is no swelling NEUROLOGIC The patient is alert and oriented x3 Examination is nonfocal LABORATORY DATA White count is down from 35 000 to 15 5 Hemoglobin is 9 5 hematocrit is 30 and platelets are 269 000 BUN is down to 22 creatinine is within normal limits ASSESSMENT AND PLAN 1 Sepsis due to urinary tract infection Urine culture shows Escherichia coli resistant to Levaquin We changed to doripenem 2 Urinary tract infection we will treat with doripenem change Foley catheter 3 Hypotension Resolved continue intravenous fluids 4 Ischemic cardiomyopathy No evidence of decompensation we with monitor 5 Diabetes type 2 Uncontrolled Continue insulin sliding scale 6 Recent pulmonary embolism INR is above therapeutic range Coumadin is on hold we will monitor 7 History of coronary artery disease Troponin indeterminate Cardiologist intends no further workup Continue medical treatment Most likely troponin is secondary to impaired clearance Keywords general medicine sepsis escherichia coli urinary tract infection doripenem troponin urinary infection MEDICAL_TRANSCRIPTION,Description Comprehensive Evaluation Generalized anxiety and hypertension both under fair control Medical Specialty General Medicine Sample Name Gen Med Consult 8 Transcription SUBJECTIVE The patient comes in today for a comprehensive evaluation She is well known to me I have seen her in the past multiple times PAST MEDICAL HISTORY SOCIAL HISTORY FAMILY HISTORY Noted and reviewed today They are on the health care flow sheet She has significant anxiety which has been under fair control recently She has a lot of stress associated with a son that has some challenges There is a family history of hypertension and strokes CURRENT MEDICATIONS Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned REVIEW OF SYSTEMS Significant for occasional tiredness This is intermittent and currently not severe She is concerned about the possibly of glucose abnormalities such diabetes We will check a glucose lipid profile and a Hemoccult test also and a mammogram Her review of systems is otherwise negative PHYSICAL EXAMINATION VITAL SIGNS As above GENERAL The patient is alert oriented in no acute distress HEENT PERRLA EOMI TMs clear bilaterally Nose and throat clear NECK Supple without adenopathy or thyromegaly Carotid pulses palpably normal without bruit CHEST No chest wall tenderness BREAST EXAM No asymmetry skin changes dominant masses nipple discharge or axillary adenopathy HEART Regular rate and rhythm without murmur clicks or rubs LUNGS Clear to auscultation and percussion ABDOMEN Soft nontender bowel sounds normoactive No masses or organomegaly GU External genitalia without lesions BUS normal Vulva and vagina show just mild atrophy without any lesions Her cervix and uterus are within normal limits Ovaries are not really palpable No pelvic masses are appreciated RECTAL Negative BREASTS No significant abnormalities EXTREMITIES Without clubbing cyanosis or edema Pulses within normal limits NEUROLOGIC Cranial nerves II XII intact Strength sensation coordination and reflexes all within normal limits SKIN Noted to be normal No subcutaneous masses noted LYMPH SYSTEM No lymphadenopathy ASSESSMENT Generalized anxiety and hypertension both under fair control PLAN We will not make any changes in her medications I will have her check a lipid profile as mentioned and I will call her with that Screening mammogram will be undertaken She declined a sigmoidoscopy at this time I look forward to seeing her back in a year and as needed Keywords MEDICAL_TRANSCRIPTION,Description Comprehensive Evaluation Diabetes hypertension irritable bowel syndrome and insomnia Medical Specialty General Medicine Sample Name Gen Med Consult 9 Transcription SUBJECTIVE The patient is well known to me He comes in today for a comprehensive evaluation Really again he borders on health crises with high blood pressure diabetes and obesity He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made specifically the lack of exercise the obesity the poor eating habits etc He knows better and has been through some diabetes training In fact interestingly enough with his current medications which include the Lantus at 30 units along with Actos glyburide and metformin he achieved ideal blood sugar control back in August 2004 Since that time he has gone off of his regimen of appropriate eating and has had sugars that are running on average too high at about 178 over the last 14 days He has had elevated blood pressure His other concerns include allergic symptoms He has had irritable bowel syndrome with some cramping He has had some rectal bleeding in recent days Also once he wakes up he has significant difficulty in getting back to sleep He has had no rectal pain just the bleeding associated with that MEDICATIONS ALLERGIES As above PAST MEDICAL SURGICAL HISTORY Reviewed and updated see Health Summary Form for details FAMILY AND SOCIAL HISTORY Reviewed and updated see Health Summary Form for details REVIEW OF SYSTEMS Constitutional Eyes ENT Mouth Cardiovascular Respiratory GI GU Musculoskeletal Skin Breasts Neurologic Psychiatric Endocrine Heme Lymph Allergies Immune all negative with the following exceptions None PHYSICAL EXAMINATION VITAL SIGNS As above GENERAL The patient is alert oriented well developed obese male who is in no acute distress HEENT PERRLA EOMI TMs clear bilaterally Nose and throat clear NECK Supple without adenopathy or thyromegaly Carotid pulses palpably normal without bruit CHEST No chest wall tenderness or breast enlargement HEART Regular rate and rhythm without murmur clicks or rubs LUNGS Clear to auscultation and percussion ABDOMEN Significantly obese without any discernible organomegaly GU Normal male genitalia without testicular abnormalities inguinal adenopathy or hernia RECTAL Smooth nonenlarged prostate with just some irritation around the rectum itself No hemorrhoids are noted EXTREMITIES Some slow healing over the tibia Without clubbing cyanosis or edema Peripheral pulses within normal limits NEUROLOGIC Cranial nerves II XII intact Strength sensation coordination and reflexes all within normal limits SKIN Noted to be normal No subcutaneous masses noted LYMPH SYSTEM No lymphadenopathy noted BACK He has pain in his back in general ASSESSMENT PLAN 1 Diabetes and hypertension both under less than appropriate control In fact we discussed increasing the Lantus He appears genuine in his desire to embark on a substantial weight lowering regime and is going to do that through dietary control He knows what needs to be done with the absence of carbohydrates and especially simple sugar He will also check a hemoglobin A1c lipid profile urine for microalbuminuria and a chem profile I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range He has allergic rhinitis for which Zyrtec can be used 2 He has irritable bowel syndrome We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened For the bleeding I would like to obtain a sigmoidoscopy It is bright red blood 3 For his insomnia I found there is very little in the way of medications that are going to fix that however I have encouraged him in good sleep hygiene I will look forward to seeing him back in a month I will call him with the results of his lab His medications were made out We will use some Elocon cream for his seborrheic dermatitis of the face Zyrtec and Flonase for his allergic rhinitis Keywords MEDICAL_TRANSCRIPTION,Description The patient had temperature of 104 degrees F It has been spiking ever since and she has had left sacroiliac type hip pain She does have degenerative disk disease of her lumbar spine but no hip pathology She has swollen inguinal nodes bilaterally Medical Specialty General Medicine Sample Name Gen Med Consult 47 Transcription HISTORY OF PRESENT ILLNESS This is a 76 year old female that was admitted with fever chills and left pelvic pain The patient was well visiting in ABC with her daughter that evening She had pain in her left posterior pelvic and low back region They came back to XYZ the following day By the time they got here she was in severe pain and had fever They came straight to the emergency room She was admitted She had temperature of 104 degrees F It has been spiking ever since and she has had left sacroiliac type hip pain Multiple blood studies have been done including cultures febrile agglutinins etc She has had run a higher blood glucose to the normal and she has been on sliding scale insulin She was not known previously to be a diabetic All x rays have not been helpful as far as to determine the etiology of her discomfort MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process She does have degenerative disk disease of her lumbar spine but no hip pathology She has swollen inguinal nodes bilaterally PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS She was not known to be a diabetic until this admission She had been hypertensive She has been on medications and has been controlled She has not had hyperlipidemia She has had no thyroid problems There has been no asthma bronchitis TB emphysema or pneumonia No tuberculosis She has had no breast tumors She has had no chest pain or cardiac problems She has had gallbladder surgery She has not had any gastritis or ulcers She has had no kidney disease She has had a hysterectomy She has had 9 pregnancies and 8 living children She had A P repair She had a sacral abscess after a spinal It sounds to me like she had a pilonidal cyst which took about 3 operations to heal There have been fractures and no significant arthritis She has been quite active at her ranch in Mexico She raises goats and cattle She drives a tractor and in short has been very active PHYSICAL EXAMINATION She is a short female alert She is shivering She has ice in her axilla and behind her neck She is febrile to 101 degrees F She is alert Her complaint is that of hip pain in the posterior sacroiliac joint area She moves both her upper extremities well She can move her right leg well She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint She cannot stand sit or turn without severe pain She has normal knee reflexes No ankle reflexes She has bounding tibial pulses No sensory deficit She says she knows when she has to void She has a healed scar in the upper sacral region There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back PLAN My plan is to do a triple phase bone scan I am suspecting an infection possibly in the left sacroiliac joint It is probably some type of bacterium the etiology of which is undetermined She has had a normal white count despite her fever There has been a history of brucellosis in the past but her titers at this time are negative Continue medication which included antibiotics and also the Motrin and Darvocet Keywords general medicine inflammatory degenerative fever lumbar spine sacroiliac joint inguinal sacroiliac hip MEDICAL_TRANSCRIPTION,Description Anxiety alcohol abuse and chest pain This is a 40 year old male with digoxin toxicity secondary to likely intentional digoxin overuse Now he has had significant block with EKG changes as stated Medical Specialty General Medicine Sample Name Gen Med Consult 52 Transcription CHIEF COMPLAINT Anxiety alcohol abuse and chest pain HISTORY OF PRESENT ILLNESS This is a pleasant 40 year old male with multiple medical problems basically came to the hospital yesterday complaining of chest pain The patient states that he complained of this chest pain which is reproducible pleuritic in both chest radiating to the left back and the jaw complaining of some cough nausea questionable shortness of breath The patient describes the pain as aching sharp and alleviated with pain medications not alleviated with any nitrates Aggravated by breathing coughing and palpation over the area The pain was 9 10 in the emergency room and he was given some pain medications in the ER and was basically admitted Labs were drawn which were essentially potassium was about 5 7 and digoxin level was drawn which was about greater than 5 The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together The patient has a history prior digoxin overdose of the same nature MEDICATIONS Digoxin 0 25 mg metoprolol 50 mg Naprosyn 500 mg metformin 500 mg lovastatin 40 mg Klor Con 20 mEq Advair Diskus questionable Coreg PAST MEDICAL HISTORY MI in the past and atrial fibrillation he said that he has had one stent put in but he is not sure The last cardiologist he saw was Dr X and his primary doctor is Dr Y SOCIAL HISTORY History of alcohol use in the past He is basically requesting for more and more pain medications He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid His pain is tolerable PHYSICAL EXAMINATION VITAL SIGNS Stable GENERAL Alert and oriented x3 no apparent distress HEENT Extraocular muscles are intact CVS S1 S2 heard CHEST Clear to auscultation bilaterally ABDOMEN Soft and nontender EXTREMITIES No edema or clubbing NEURO Grossly intact Tender to palpate over the left chest no obvious erythema or redness or abnormal exam is found EKG basically shows atrial fibrillation rate controlled nonspecific ST changes ASSESSMENT AND PLAN 1 This is a 40 year old male with digoxin toxicity secondary to likely intentional digoxin overuse Now he has had significant block with EKG changes as stated Continue to follow the patient clinically at this time The patient has been admitted to ICU and will be changed to DOU 2 Chronic chest pain with a history of myocardial infarction in the past has been ruled out with negative cardiac enzymes The patient likely has opioid dependence and requesting more and more pain medications He is also bargaining for pain medications with me The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred We will try to verify his pain medications from his primary doctor and his pharmacy The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past Keywords general medicine anxiety alcohol abuse chest pain digoxin toxicity digoxin overuse atrial fibrillation opioid dependence toxicity dilaudid MEDICAL_TRANSCRIPTION,Description Patient with swelling of lips and dysphagia and Arthritis Medical Specialty General Medicine Sample Name Gen Med Consult 5 Transcription CHIEF COMPLAINT Swelling of lips causing difficulty swallowing HISTORY OF PRESENT ILLNESS This patient is a 57 year old white Cuban woman with a long history of rheumatoid arthritis She has received methotrexate on a weekly basis as an outpatient for many years Approximately two weeks ago she developed a respiratory infection for which she received antibiotics She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago She showed some initial improvement but over the last 3 5 days has had malaise a low grade fever and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate She has rather diffuse pain involving both large and small joints MEDICATIONS Prednisone 7 5 mg p o q d Premarin 0 125 mg p o q d and Dolobid 1000 mg p o q d recently discontinued because of questionable allergic reaction HCTZ 25 mg p o q o d Oral calcium supplements In the past she has been on penicillin azathioprine and hydroxychloroquine but she has not had Azulfidine cyclophosphamide or chlorambucil ALLERGIES None by history FAMILY SOCIAL HISTORY Noncontributory PHYSICAL EXAMINATION This is a chronically ill appearing female alert oriented and cooperative She moves with great difficulty because of fatigue and malaise Vital signs Blood pressure 107 80 heart rate 100 and regular respirations 22 HEENT Normocephalic No scalp lesions Dry eyes with conjuctival injections Mild exophthalmos Dry nasal mucosa Marked cracking and bleeding of her lips with erosion of the mucosa She has a large ulceration of the mucosa at the bite margin on the left She has some scattered ulcerations on her hard and soft palette Tonsils not enlarged No visible exudate She has difficulty opening her mouth because of pain SKIN She has some mild ecchymoses on her skin and some erythema she has patches but no obvious skin breakdown She has some fissuring in the buttocks crease PULMONARY Clear to percussion in auscultation CARDIOVASCULAR No murmurs or gallops noted ABDOMEN Protuberant no organomegaly and positive bowel sounds NEUROLOGIC EXAM Cranial nerves II through XII are grossly intact Diffuse hyporeflexia MUSCULOSKELATAL Erosive destructive changes in the elbows wrist and hands consistent with rheumatoid arthritis She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1 I feel no pulse distally in either leg PROBLEMS 1 Swelling of lips and dysphagia with questionable early Stevens Johnson syndrome 2 Rheumatoid Arthritis class 3 stage 4 3 Flare of arthritis after discontinuing methotrexate 4 Osteoporosis with compression fracture 5 Mild dehydration 6 Nephrolithiasis PLAN Patient is admitted for IV hydration and treatment of oral ulcerations We will obtain a dermatology consult IV leucovorin will be started and the patient will be put on high dose corticosteroids Keywords general medicine swelling iv hydration osteoporosis swelling of lips allergic reaction arthritis difficulty swallowing leucovorin low grade fever methotrexate respiratory infection rheumatoid arthritis flare of arthritis rheumatoid mucosa dysphagia MEDICAL_TRANSCRIPTION,Description A 69 year old female with past history of type II diabetes atherosclerotic heart disease hypertension carotid stenosis Medical Specialty General Medicine Sample Name Gen Med Consult 43 Transcription HISTORY A 69 year old female with past history of type II diabetes atherosclerotic heart disease hypertension carotid stenosis The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital The patient subsequently developed CVA She also developed thrombosis of the right arm which ultimately required right hand amputation She was stabilized and eventually transferred to HealthSouth for further management PHYSICAL EXAMINATION Vital Signs Pulse of 90 and blood pressure 150 70 Heart Sounds were heard grade 2 6 systolic murmur at the precordium Chest Clinically clear Abdomen Some suprapubic tenderness Evidence of right lower arm amputation The patient was started on Prevacid 30 mg daily levothyroxine 75 mcg a day Toprol 25 mg twice a day Zofran 4 mg q 6 h Coumadin dose at 5 mg and was adjusted She was given a pain control using Vicodin and Percocet amiodarone 200 mg a day Lexapro 20 mg a day Plavix 75 mg a day fenofibrate 145 mg Lasix 20 mg IV twice a day Lantus 50 units at bedtime and Humalog 10 units a c and sliding scale insulin coverage Wound care to the right heel was supervised by Dr X The patient initially was fed through NG tube which was eventually discontinued Physical therapy was ordered The patient continued to do well She was progressively ambulated Her meds were continuously adjusted The patient s insulin was eventually changed from Lantus to Levemir 25 units twice a day Dr Y also followed the patient closely for left heel ulcer LABORATORY DATA The latest cultures from left heel are pending Her electrolytes revealed sodium of 135 and potassium of 3 2 Her potassium was switched to K Dur 40 mEq twice a day Her blood chemistries are otherwise closely monitored INRs were obtained and were therapeutic Throughout her hospitalization multiple cultures were also obtained Urine cultures grew Klebsiella She was treated with appropriate antibiotics Her detailed blood work is as in the chart Detailed radiological studies are as in the chart The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation FINAL DIAGNOSES 1 Atherosclerotic heart disease status post coronary artery bypass graft 2 Valvular heart disease status post aortic valve replacement 3 Right arm arterial thrombosis status post amputation right lower arm 4 Hypothyroidism 5 Uncontrolled diabetes mellitus type 2 6 Urinary tract infection 7 Hypokalemia 8 Heparin induced thrombocytopenia 9 Peripheral vascular occlusive disease 10 Paroxysmal atrial fibrillation 11 Hyperlipidemia 12 Depression 13 Carotid stenosis Keywords general medicine arterial thrombosis valvular heart disease atherosclerotic heart disease type ii diabetes hypertension carotid stenosis heart disease diabetes carotid stenosis bypass amputation heart atherosclerotic MEDICAL_TRANSCRIPTION,Description Backache stomachache and dysuria for the last two days Urinary dysuria left flank pain pharyngitis Medical Specialty General Medicine Sample Name Gen Med Consult 41 Transcription SUBJECTIVE The patient complains of backache stomachache and dysuria for the last two days Fever just started today and cough She has history of kidney stones less than a year ago and had a urinary tract infection at that time Her back started hurting last night PAST MEDICAL HISTORY She denies sexual activities since two years ago Her last menstrual period was 06 01 2004 Her periods have been irregular She started menarche at 10 years of age and she is still irregular and it runs in Mom s side of the family Mom and maternal aunt have had total hysterectomies She also is diagnosed with abnormal valve has to be on SBE prophylaxis sees Dr XYZ Allen She avoids decongestants She is limited on her activity secondary to her heart condition MEDICATION Cylert ALLERGIES No known drug allergies OBJECTIVE Vital Signs Blood pressure is 124 72 Temperature 99 2 Respirations 20 unlabored Weight 137 pounds HEENT Normocephalic Conjunctivae noninjected No mattering noted Her TMs are bilaterally clear nonerythematous Throat clear good mucous membrane moisture but she did have erythema and edema at her posterior soft palate Neck Supple Increased lymphadenopathy noted in the submandibular nodes but no axillary nodes and no hepatosplenomegaly Respiratory Clear No wheezes no crackles no tachypnea and no retractions Cardiovascular Regular rate and rhythm S1 and S2 normal no murmur Abdomen Soft No organomegaly She did have exquisite tenderness to palpation of the left upper quadrant and flank area but the spleen was not palpable She has no suprapubic tenderness Extremities She has good range of motion of upper and lower extremities Good ambulation Her UA was positive for 2 leukocyte esterase positive nitrites 1 protein 2 ketones 4 blood greater than 50 white blood cells 10 20 rbc s and 1 bacteria Culture and sensitivity is pending Her Strep test is negative Culture is pending ASSESSMENT 1 Urinary dysuria 2 Left flank pain 3 Pharyngitis PLAN A 1 g of Rocephin IM was given Call Dr B s office tomorrow morning incase a second IM dose is needed If not then she will fill a prescription for Omnicef 300 mg capsule 1 p o b i d for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug Push fluids Await strep culture report Follow up with Dr XYZ if no better or symptoms worsen Keywords general medicine backache stomachache dysuria cylert urinary dysuria pharyngitis culture and sensitivity tenderness urinary infection MEDICAL_TRANSCRIPTION,Description Patient with intermittent episodes of severe nausea and abdominal pain Medical Specialty General Medicine Sample Name Gen Med Consult 29 Transcription CHIEF COMPLAINT This is a previously healthy 45 year old gentleman For the past 3 years he has had some intermittent episodes of severe nausea and abdominal pain On the morning of this admission he had the onset of severe pain with nausea and vomiting and was seen in the emergency department where Dr XYZ noted an incarcerated umbilical hernia He was able to reduce this with relief of pain He is now being admitted for definitive repair PAST MEDICAL HISTORY Significant only for hemorrhoidectomy He does have a history of depression and hypertension MEDICATIONS His only medications are Ziac and Remeron ALLERGIES No allergies FAMILY HISTORY Negative for cancer SOCIAL HISTORY He is single He has 2 children He drinks 4 8 beers per night and smokes half a pack per day for 30 years He was born in Salt Lake City He works in an electronic assembly for Harmony Music He has no history of hepatitis or blood transfusions PHYSICAL EXAMINATION GENERAL Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department HEENT No scleral icterus NECK No cervical supraclavicular or axillary adenopathy LUNGS Clear HEART Regular No murmurs or gallops ABDOMEN As noted obese with mildly visible bulging in the umbilicus at the superior position With gentle traction we were able to feel both herniated contents which when reduced reveals an approximately 2 cm palpable defect in the umbilicus DIAGNOSTIC STUDIES Normal sinus rhythm on EKG prolonged QT Chest x ray was negative The abdominal x rays were read as being negative His electrolytes were normal Creatinine was 0 9 White count was 6 5 hematocrit was 48 and platelet count was 307 ASSESSMENT AND PLAN Otherwise previously healthy gentleman who presents with an incarcerated umbilical hernia now for repair with mesh Keywords general medicine sinus rhythm ekg prolonged qt platelet count hematocrit umbilical hernia emergency department healthy incarcerated intermittent MEDICAL_TRANSCRIPTION,Description Nausea vomiting diarrhea and fever Medical Specialty General Medicine Sample Name Gen Med Consult 27 Transcription CHIEF COMPLAINT Nausea vomiting diarrhea and fever HISTORY OF PRESENT ILLNESS This patient is a 76 year old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia She has developed worsening confusion fever and intractable diarrhea She was brought to the emergency department for evaluation Diagnostic studies in the emergency department included a CBC which revealed a white blood cell count of 23 500 and a low potassium level of 2 6 She was admitted to the hospital for treatment of profound hypokalemia dehydration intractable diarrhea and febrile illness PAST MEDICAL HISTORY Recent history of pneumonia urosepsis dementia amputation osteoporosis and hypothyroidism MEDICATIONS Synthroid clindamycin ceftriaxone Remeron Actonel Zanaflex and hydrocodone SOCIAL HISTORY The patient has been residing at South Valley Care Center REVIEW OF SYSTEMS The patient is unable answer review of systems PHYSICAL EXAMINATION GENERAL This is a very elderly cachectic woman lying in bed in no acute distress HEENT Examination is normocephalic and atraumatic The pupils are equal round and reactive to light and accommodation The extraocular movements are full NECK Supple with full range of motion and no masses LUNGS There are decreased breath sounds at the bases bilaterally CARDIOVASCULAR Regular rate and rhythm with normal S1 and S2 and no S3 or S4 ABDOMEN Soft and nontender with no hepatosplenomegaly EXTREMITIES No clubbing cyanosis or edema NEUROLOGIC The patient moves all extremities but does not communicate DIAGNOSTIC STUDIES The CBC shows a white blood cell count of 23 500 hemoglobin 13 0 hematocrit 36 3 and platelets 287 000 The basic chemistry panel is remarkable for potassium 2 6 calcium 7 5 and albumin 2 3 IMPRESSION PLAN 1 Elevated white count This patient is admitted to the hospital for treatment of a febrile illness There is concern that she has a progression of pneumonia She may have aspirated She has been treated with ceftriaxone and clindamycin I will follow her oxygen saturation and chest x ray closely She is allergic to penicillin Therefore clindamycin is the appropriate antibiotic for possible aspiration 2 Intractable diarrhea The patient has been experiencing intractable diarrhea I am concerned about Clostridium difficile infection with possible pseudomembranous colitis I will send her stool for Clostridium difficile toxin assay I will consider treating with metronidazole 3 Hypokalemia The patient s profound hypokalemia is likely secondary to her diarrhea I will treat her with supplemental potassium 4 DNR status I have ad a discussion with the patient s daughter who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy Keywords MEDICAL_TRANSCRIPTION,Description A 2 year old little girl with stuffiness congestion and nasal drainage Allergic rhinitis Medical Specialty General Medicine Sample Name Gen Med Consult 21 Transcription SUBJECTIVE The patient is a 2 year old little girl who comes in with concerns about stuffiness congestion and nasal drainage She does take Zyrtec on a fairly regular basis Mom is having some allergy trouble herself right now She does not know her colors She knows some of her shapes She speaks in sentences She is not showing much interest in the potty She is in the 80th percentile for height and weight and still over 95th percentile for head circumference Mom has no other concerns ALLERGIES Eggs and peanuts OBJECTIVE General Alert very talkative little girl HEENT TMs clear and mobile Eyes PERRL Fundi benign Pharynx clear Mouth moist Nasal mucosa is pale with clear discharge Neck Supple without adenopathy Heart Regular rate and rhythm without murmur Lungs Clear No tachypnea wheezing rales or retractions Abdomen Soft and nontender without mass or organomegaly GU Normal female genitalia Tanner stage I Extremities No clubbing cyanosis or edema Pulses 2 and equal Hips Intact Neurological Normal DTRs are 2 Gait was normal Skin Warm and dry No rashes noted ASSESSMENT Allergic rhinitis Otherwise healthy 2 year old young lady PLAN In addition to her Zyrtec I put her on Nasonex spray one spray each nostril daily If this works for her certainly she can do it through the ragweed season Otherwise she is doing well I talked about ways to improve her potty training She is a very good eater I will see her yearly or p r n Unfortunately she is not able to get the flu shot due to her egg allergy Keywords general medicine allergic rhinitis nasal drainage stuffiness congestion drainage MEDICAL_TRANSCRIPTION,Description The patient brought in by EMS with a complaint of a decreased level of consciousness Medical Specialty General Medicine Sample Name Gen Med Consult 28 Transcription HISTORY OF PRESENT ILLNESS The patient is an 85 year old male who was brought in by EMS with a complaint of a decreased level of consciousness The patient apparently lives with his wife and was found to have a decreased status since the last one day The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse When the Adult Protective Services actually went to the patient s house he was found to be having decreased consciousness for a whole day by his wife Actually the night before he fell off his wheelchair and had lacerations on the face As per his wife she states that the patient was given an entire mg of Xanax rather than 0 125 mg of Xanax and that is why he has had decreased mental status since then The patient s wife is not able to give a history The patient has not been getting Sinemet and his other home medications in the last 2 days PAST MEDICAL HISTORY Parkinson disease MEDICATIONS Requip Neurontin Sinemet Ambien and Xanax ALLERGIES No known drug allergies SOCIAL HISTORY The patient lives with his wife PHYSICAL EXAMINATION GENERAL Keywords general medicine level of consciousness parkinson disease altered mental status dehydration elderly abuse decreased level of consciousness ems parkinson consciousness xanax sinemet decreased MEDICAL_TRANSCRIPTION,Description A 12 year old young man with sinus congestion Medical Specialty General Medicine Sample Name Gen Med Consult 22 Transcription SUBJECTIVE This is a 12 year old young man who comes in with about 10 days worth of sinus congestion He does have significant allergies including ragweed The drainage has been clear He had a little bit of a headache yesterday He has had no fever No one else is ill at home currently CURRENT MEDICATIONS Advair and Allegra He has been taking these regularly He is not sure the Allegra is working for him anymore He does think though better than Claritin PHYSICAL EXAM General Alert young man in no distress HEENT TMs clear and mobile Pharynx clear Mouth moist Nasal mucosa pale with clear discharge Neck Supple without adenopathy Heart Regular rate and rhythm without murmur Lungs Lungs clear no tachypnea wheezing rales or retractions Abdomen Soft nontender without masses or splenomegaly ASSESSMENT I think this is still his allergic rhinitis rather than a sinus infection PLAN Change to Zyrtec 10 mg samples were given He is not using nasal spray but he has some at home He should restart this Continue to watch his peak flows to make sure his asthma does not come under poor control Call if any further problems Keywords general medicine allergic rhinitis sinus infection sinus congestion congestion sinus MEDICAL_TRANSCRIPTION,Description Patient in with mom for possible ear infection Medical Specialty General Medicine Sample Name Gen Med Consult 23 Transcription SUBJECTIVE Mom brings the patient in today for possible ear infection He is complaining of left ear pain today He was treated on 04 14 2004 with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today He has not had any fever but the congestion has continued to be very thick and purulent It has never really resolved He has a loose productive sounding cough but not consistently and not keeping him up at night No wheezing or shortness of breath PAST MEDICAL HISTORY He has had some wheezing in the past but nothing recently FAMILY HISTORY All siblings are on antibiotics for ear infections and URIs OBJECTIVE General The patient is a 5 year old male Alert and cooperative No acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally have distorted light reflexes but no erythema Gray in color Oropharynx pink and moist with a lot of postnasal discharge Nares are swollen and red Thick purulent drainage Eyes are a little puffy Chest Respirations regular nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry pink Moist mucus membranes No rash ASSESSMENT Ongoing purulent rhinitis Probable sinusitis and serous otitis PLAN Change to Omnicef two teaspoons daily for 10 days Frequent saline in the nose Also there was some redness around the nares with a little bit of yellow crusting It appeared to be the start of impetigo so hold off on the Rhinocort for a few days and then restart Use a little Neosporin for now Keywords general medicine ear infection productive sounding cough purulent rhinitis serous otitis sinusitis wheezing ear amoxicillin MEDICAL_TRANSCRIPTION,Description An 18 month old white male here with his mother for complaint of intermittent fever for the past five days Allergic rhinitis fever history sinusitis resolved and teething Medical Specialty General Medicine Sample Name Gen Med Consult 17 Transcription CHIEF COMPLAINT Fever HISTORY OF PRESENT ILLNESS This is an 18 month old white male here with his mother for complaint of intermittent fever for the past five days Mother states he just completed Amoxil several days ago for a sinus infection Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum Mother states that his temperature usually elevates at night Two days his temperature was 102 6 Mother has not taken it since and in fact she states today he seems much better He is cutting an eye tooth that causes him to be drooling and sometimes fussy He has had no vomiting or diarrhea There has been no coughing Nose secretions are usually discolored in the morning but clear throughout the rest of the day Appetite is fine PHYSICAL EXAMINATION General He is alert in no distress Vital Signs Afebrile HEENT Normocephalic atraumatic Pupils equal round and react to light TMs are clear bilaterally Nares patent Clear secretions present Oropharynx is clear Neck Supple Lungs Clear to auscultation Heart Regular no murmur Abdomen Soft Positive bowel sounds No masses No hepatosplenomegaly Skin Normal turgor ASSESSMENT 1 Allergic rhinitis 2 Fever history 3 Sinusitis resolved 4 Teething PLAN Mother has been advised to continue Zyrtec as directed daily Supportive care as needed Reassurance given and he is to return to the office as scheduled Keywords general medicine sinusitis fever intermittent fever allergic rhinitis fever history teething MEDICAL_TRANSCRIPTION,Description 2 year old female who comes in for just rechecking her weight her breathing status and her diet Medical Specialty General Medicine Sample Name Gen Med Consult 19 Transcription SUBJECTIVE This is a 2 year old female who comes in for just rechecking her weight her breathing status and her diet The patient is in foster care has a long history of the prematurity born at 22 weeks She has chronic lung disease is on ventilator but doing sprints has been doing very well is up to 4 1 2 hours sprints twice daily and may go up 15 minutes every three days or so which she has been tolerating fairly well as long as they kind of get her distracted towards the end otherwise she does get sort of tachypneic She is on 2 1 2 liters of oxygen and does require that Her diet has been fluctuating They have been trying to figure out what works best with her She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her They have been doing more pureed foods and that seems to loosen her up so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure She was hospitalized a couple of weeks back for the distension she had in the abdomen Dr XYZ has been working with her G tube increasing her Mic key button size but also doing some silver nitrate applications and he is going to evaluate her again next week but they are happy with the way her G tube site is looking She also has been seen Dr Eisenbaum just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation CURRENT MEDICATIONS Flagyl vitamins Zyrtec albuterol and some Colace ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY As mentioned she is in foster care Foster mom is actually going to be out of town for a week the 19th through the 23rd so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient Biological Mom and Grandma do visit on Thursdays for about an hour REVIEW OF SYSTEMS The patient has been eating fairly well sleeping well doing well with her sprints A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI PHYSICAL EXAMINATION Vital Signs She is 28 pounds 8 ounces today 33 1 2 inches tall She is on 2 1 2 liters but she is not the vent currently she is doing her sprints and her respiratory rate is around 40 HEENT Sclerae and conjunctivae are clear TMs are clear Nares are patent Oropharynx is clear Trach site is clear of any signs of infection Chest Coarse She has got little bit of wheezing going on but she is moving air fairly well Abdomen Positive bowel sounds and soft The G tube site looks fairly clean today and healthy No signs of infection Her tone is good Capillary refill is less than three seconds ASSESSMENT A 2 year old with chronic lung disease doing the sprints some bowel difficulties also just weight gain issues because of the high energy expenditure with the sprints that she is doing PLAN At this point is to continue with the Isomil and pureed baby foods a little bit of Pediasure They are going to see Dr XYZ towards the end of this month and follow up with Dr Eisenbaum I would like to see her in approximately six weeks again but we do need to keep a close check on her weight and call if there are problems beforehand She is just doing wonderful progression on her development Each time I see her I am very impressed that relayed to foster mom Approximately 25 minutes spent with the patient most of it counseling Keywords general medicine chronic lung disease signs of infection breathing status foster mom foster care pediasure MEDICAL_TRANSCRIPTION,Description 11 year old female History of congestion possibly enlarged adenoids Medical Specialty General Medicine Sample Name Gen Med Consult 20 Transcription SUBJECTIVE This is an 11 year old female who comes in for two different things 1 She was seen by the allergist No allergies present so she stopped her Allegra but she is still real congested and does a lot of snorting They do not notice a lot of snoring at night though but she seems to be always like that 2 On her right great toe she has got some redness and erythema Her skin is kind of peeling a little bit but it has been like that for about a week and a half now PAST MEDICAL HISTORY Otherwise reviewed and noted CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY Everyone else is healthy at home REVIEW OF SYSTEMS She has been having the redness of her right great toe but also just a chronic nasal congestion and fullness Review of systems is otherwise negative PHYSICAL EXAMINATION General Well developed female in no acute distress afebrile HEENT Sclerae and conjunctivae clear Extraocular muscles intact TMs clear Nares patent A little bit of swelling of the turbinates on the left Oropharynx is essentially clear Mucous membranes are moist Neck No lymphadenopathy Chest Clear Abdomen Positive bowel sounds and soft Dermatologic She has got redness along the lateral portion of her right great toe but no bleeding or oozing Some dryness of her skin Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short ASSESSMENT 1 History of congestion possibly enlarged adenoids or just her anatomy 2 Ingrown toenail but slowly resolving on its own PLAN 1 For the congestion we will have ENT evaluate Appointment has been made with Dr XYZ for in a couple of days 2 I told her just Neosporin for her toe letting the toenail grow out longer Call if there are problems Keywords general medicine enlarged adenoids adenoids oropharynx congestion toenails toe MEDICAL_TRANSCRIPTION,Description Short term memory loss probable situational and anxiety stress issues Medical Specialty General Medicine Sample Name Gen Med Consult 16 Transcription CHIEF COMPLAINT Here with a concern of possibly issues of short term memory loss She is under exceeding amount of stress over the last 5 to 10 years She has been a widow over the last 11 years Her husband died in an MVA from a drunk driver accident She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services She does have an MBA in business Currently she works at T Mobile Customer Service and there is quite a bit of technical knowledge deadlines and stress related to that job as well She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills protocols customer service issues etc She describes the job is very demanding and high stress She denies any history of weakness lethargy or dizziness No history of stroke CURRENT MEDICATIONS Vioxx 25 mg daily HCTZ 25 mg one half tablet daily Zoloft 100 mg daily Zyrtec 10 mg daily ALLERGIES TO MEDICATIONS Naprosyn SOCIAL HISTORY FAMILY HISTORY PAST MEDICAL HISTORY AND SURGICAL HISTORY She has had hypertension very well controlled and history of elevated triglycerides She has otherwise been generally healthy Nonsmoker Please see notes dated 06 28 2004 REVIEW OF SYSTEMS Review of systems is otherwise negative PHYSICAL EXAMINATION Vital Signs Age 60 Weight 192 pounds Blood pressure 134 80 Temperature 97 8 degrees General A very pleasant 60 year old white female in no acute distress Alert ambulatory and nonlethargic HEENT PERRLA EOMs are intact TMs are clear bilaterally Throat is clear Neck Supple No cervical adenopathy Lungs Clear without wheezes or rales Heart Regular rate and rhythm Abdomen Soft nontender to palpation Extremities Moving all extremities well IMPRESSION 1 Short term memory loss probable situational 2 Anxiety stress issues PLAN Thirty minute face to face appointment in counseling with the patient At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn The current job she is at does sound extremely stressful and demanding I think her stress reactions to these as far as feeling frustrated are within normal limits We did complete a mini mental state exam including clock drawing sentence writing signature etc She does score a maximum score of 30 30 and all other tasks were completed without difficulty or any hesitation I did spend quite a bit of time reassuring her as well She is currently on Zoloft 100 mg which I think is an appropriate dose We will have her continue on that She did verbalize understanding and that she actually felt better after our discussion concerning these issues At some point in time however I would possibly recommend job change if this one would persist as far as the stress levels She is going to think about that Keywords general medicine short term memory loss anxiety short term memory loss memory loss stress issues situational memory stress MEDICAL_TRANSCRIPTION,Description 1 year old male who comes in with a cough and congestion Clinical sinusitis and secondary cough Medical Specialty General Medicine Sample Name Gen Med Consult 18 Transcription SUBJECTIVE This is a 1 year old male who comes in with a cough and congestion for the past two to three weeks Started off as a congestion but then he started coughing about a week ago Cough has gotten worsen Mother was also worried He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that but his breathing has not gotten worse since that happened He is not running any fevers PAST MEDICAL HISTORY Otherwise reviewed Fairly healthy CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY The sister is in today with clinical sinusitis Mother and father have been healthy REVIEW OF SYSTEMS He has been congested for about three weeks ago Coughing now but no fevers No vomiting Review of systems is otherwise negative PHYSICAL EXAMINATION General Well developed male in no acute distress afebrile Vital Signs Weight 22 pounds 6 ounces HEENT Sclerae and conjunctivae are clear Extraocular muscles are intact TMs are clear Nares are very congested Oropharynx has drainage in the back of the throat Mucous membranes are moist Mild erythema though Neck Some shotty lymphadenopathy Full range of motion Supple Chest Clear No crackles No wheezes Cardiovascular Regular rate and rhythm Normal S1 S2 Abdomen Positive bowel sounds and soft Dermatologic Clear Tone is good Capillary refill less than 3 seconds RADIOLOGY Chest x ray No foreign body noted as well No signs of pneumonia ASSESSMENT Clinical sinusitis and secondary cough PLAN Amoxicillin a teaspoon twice daily for 10 days Plenty of fluids Tylenol and Motrin p r n as well as oral decongestant and if coughing is not improving Keywords general medicine congestion cough sinusitis and secondary cough cough and congestion secondary cough clinical sinusitis male sinusitis MEDICAL_TRANSCRIPTION,Description Return to work Fit for duty evaluation Medical Specialty General Medicine Sample Name Gen Med Consult 1 Transcription HISTORY OF PRESENT ILLNESS This is the initial clinic visit for a 29 year old man who is seen for new onset of right shoulder pain He states that this began approximately one week ago when he was lifting stacks of cardboard The motion that he describes is essentially picking up a stack of cardboard at his waist level twisting to the right and delivering it at approximately waist level Sometimes he has to throw the stacks a little bit as well He states he felt a popping sensation on 06 30 04 Since that time he has had persistent shoulder pain with lifting activities He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder He has no upper extremity REVIEW OF SYSTEMS Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies He denies any chronic cardiac pulmonary GI GU neurologic musculoskeletal endocrine abnormalities MEDICATIONS Claritin for allergic rhinitis ALLERGIES None PHYSICAL EXAMINATION Blood pressure 120 90 respirations 10 pulse 72 temperature 97 2 He is sitting upright alert and oriented and in no acute distress Skin is warm and dry Gross neurologic examination is normal ENT examination reveals normal oropharynx nasopharynx and tympanic membranes Neck Full range of motion with no adenopathy or thyromegaly Cardiovascular Regular rate and rhythm Lungs Clear Abdomen Soft Keywords general medicine return to work consult fit for duty cleared for work muscular paresthesias shoulder shoulder pain strain waist x rays waist level neurologic abnormalities impingement examination MEDICAL_TRANSCRIPTION,Description Foreign body of the left fifth fingernail wooden splinter He attempted to remove it with tweezers at home but was unsuccessful He is requesting we attempt to remove this for him Medical Specialty General Medicine Sample Name Foreign Body Fingernail Transcription HISTORY OF PRESENT ILLNESS Patient is a 72 year old white male complaining of a wooden splinter lodged beneath his left fifth fingernail sustained at 4 p m yesterday He attempted to remove it with tweezers at home but was unsuccessful He is requesting we attempt to remove this for him The patient believes it has been over 10 years since his last tetanus shot but states he has been allergic to previous immunizations primarily with horse serum Consequently he has declined to update his tetanus immunization MEDICATIONS He is currently on several medications a list of which is attached to the chart and was reviewed He is not on any blood thinners ALLERGIES HE IS ALLERGIC ONLY TO TETANUS SERUM SOCIAL HISTORY Patient is married and is a nonsmoker and lives with his wife Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp and vital signs are all within normal limits GENERAL The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress EXTREMITIES Exam of the left fifth finger shows a 5 to 6 mm splinter lodged beneath the medial aspect of the nail plate It does not protrude beyond the end of the nail plate There is no active bleeding There is no edema or erythema of the digit tip Flexion and extension of the DIP joint is intact The remainder of the hand is unremarkable TREATMENT I did attempt to grasp the end of the splinter with splinter forceps but it is brittle and continues to break off In order to better grasp the splinter will require penetration beneath the nail plate which the patient cannot tolerate due to pain Consequently the base of the digit tip was prepped with Betadine and just distal to the DIP joint a digital block was applied with 1 lidocaine with complete analgesia of the digit tip I was able to grasp the splinter and remove this No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage ASSESSMENT Foreign body of the left fifth fingernail wooden splinter PLAN Patient was urged to clean the area b i d with soap and water and to dress with bacitracin and a Band Aid If he notes increasing redness pain or swelling he was urged to return for re evaluation Keywords general medicine horse serum wooden splinter foreign body nail plate grasp fingernail splinter MEDICAL_TRANSCRIPTION,Description Questionable foreign body right nose Belly and back pain Mild constipation Medical Specialty General Medicine Sample Name Foreign Body Right Nose Transcription CHIEF COMPLAINT Questionable foreign body right nose Belly and back pain SUBJECTIVE Mr ABC is a 2 year old boy who is brought in by parents stating that the child keeps complaining of belly and back pain This does not seem to be slowing him down They have not noticed any change in his urine or bowels They have not noted him to have any fevers or chills or any other illness They state he is otherwise acting normally He is eating and drinking well He has not had any other acute complaints although they have noted a foul odor coming from his nose Apparently he was seen here a few weeks ago for a foreign body in the right nose which was apparently a piece of cotton this was removed and placed on antibiotics His nose got better and then started to become malodorous again Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there Otherwise he has not had any runny nose earache no sore throat He has not had any cough congestion He has been acting normally Eating and drinking okay No other significant complaints He has not had any pain with bowel movement or urination nor have they noted him to be more frequently urinating then again he is still on a diaper PAST MEDICAL HISTORY Otherwise negative ALLERGIES No allergies MEDICATIONS No medications other than recent amoxicillin SOCIAL HISTORY Parents do smoke around the house PHYSICAL EXAMINATION VITAL SIGNS Stable He is afebrile GENERAL This is a well nourished well developed 2 year old little boy who is appearing very healthy normal for his stated age pleasant cooperative in no acute distress looks very healthy afebrile and nontoxic in appearance HEENT TMs canals are normal Left naris normal Right naris there is some foul odor as well as questionable purulent drainage Examination of the nose there was a foreign body noted which was the appearance of a cotton ball in the right nose that was obviously infected and malodorous This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual There was some erythema No other purulent drainage noted There was some bloody drainage This was suctioned and all mucous membranes were visualized and are negative NECK Without lymphadenopathy No other findings HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN His abdomen is entirely benign soft nontender nondistended Bowel sounds active No organomegaly or mass noted BACK Without any findings Diaper area normal GU No rash or infections Skin is intact ED COURSE He also had a P Bag placed but did not have any urine Therefore a straight catheter was done which was done with ease without complication and there was no leukocytes noted within the urine There was a little bit of blood from catheterization but otherwise normal urine X ray noted some stool within the vault Child is acting normally He is jumping up and down on the bed without any significant findings ASSESSMENT 1 Infected foreign body right naris 2 Mild constipation PLAN As far as the abdominal pain is concerned they are to observe for any changes Return if worse follow up with the primary care physician The right nose I will place the child on amoxicillin 125 per 5 mL 1 teaspoon t i d Return as needed and observe for more foreign bodies I suspect the child had placed this cotton ball in his nose again after the first episode Keywords MEDICAL_TRANSCRIPTION,Description Complaint of mood swings and tearfulness Medical Specialty General Medicine Sample Name Gen Med Consult 15 Transcription HISTORY OF PRESENT ILLNESS A 50 year old female comes to the clinic with complaint of mood swings and tearfulness This has been problematic over the last several months and is just worsening to the point where it is impairing her work Her boss asks her if she was actually on drugs in which she said no She stated may be she needed to be meaning taking some medications The patient had been prescribed Wellbutrin in the past and responded well to it however at that time it was prescribed for obsessive compulsive type disorder relating to overeating and therefore her insurance would not cover the medication She has not been on any other antidepressants in the past She is not having any suicidal ideation but is having difficulty concentrating rapid mood swings with tearfulness and insomnia She denies any hot flashes or night sweats She underwent TAH with BSO in December of 2003 FAMILY HISTORY Benign breast lump in her mother however her paternal grandmother had breast cancer The patient denies any palpitations urinary incontinence hair loss or other concerns She was recently treated for sinusitis ALLERGIES She is allergic to Sulfa CURRENT MEDICATIONS Recently finished Minocin and Duraphen II DM PHYSICAL EXAMINATION General A well developed and well nourished female conscious alert oriented times three in no acute distress Mood is dysthymic Affect is tearful Skin Without rash Eyes PERRLA Conjunctivae are clear Neck Supple with adenopathy or thyromegaly Lungs Clear Heart Regular rate and rhythm without murmur ASSESSMENT 1 Postsurgical menopause 2 Mood swings PLAN I spent about 30 minutes with the patient discussing treatment options I do believe that her moods would greatly benefit from hormone replacement therapy however she is reluctant to do this because of family history of breast cancer We will try starting her back on Wellbutrin XL 150 mg daily She may increase to 300 mg daily after three to seven days Samples provided initially If she is not obtaining adequate relief from medication alone we will then suggest that we explore the use of hormone replacement therapy I also recommended increasing her exercise We will also obtain some screening lab work including CBC UA TSH chemistry panel and lipid profile Follow up here in two weeks or sooner if any other problems She is needing her annual breast exam as well Keywords general medicine tearfulness mood swings menopause postsurgical menopause mood swings and tearfulness hormone replacement therapy breast cancer wellbutrin MEDICAL_TRANSCRIPTION,Description Left flank pain ureteral stone Medical Specialty General Medicine Sample Name Flank Pain Consult 1 Transcription REASON FOR CONSULTATION Left flank pain ureteral stone BRIEF HISTORY The patient is a 76 year old female who was referred to us from Dr X for left flank pain The patient was found to have a left ureteral stone measuring about 1 3 cm in size per the patient s history The patient has had pain in the abdomen and across the back for the last four to five days The patient has some nausea and vomiting The patient wants something done for the stone The patient denies any hematuria dysuria burning or pain The patient denies any fevers PAST MEDICAL HISTORY Negative PAST SURGICAL HISTORY Years ago she had surgery that she does not recall MEDICATIONS None ALLERGIES None REVIEW OF SYSTEMS Denies any seizure disorder chest pain denies any shortness of breath denies any dysuria burning or pain denies any nausea or vomiting at this time The patient does have a history of nausea and vomiting but is doing better PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile Vitals are stable HEART Regular rate and rhythm ABDOMEN Soft left sided flank pain and left lower abdominal pain The rest of the exam is benign LABORATORY DATA White count of 7 8 hemoglobin 13 8 and platelets 234 000 The patient s creatinine is 0 92 ASSESSMENT 1 Left flank pain 2 Left ureteral stone 3 Nausea and vomiting PLAN Plan for laser lithotripsy tomorrow Options such as watchful waiting laser lithotripsy and shockwave lithotripsy were discussed The patient has a pretty enlarged stone Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed The patient understood that the success of the surgery may be or may not be 100 that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting The patient understood all the risk benefits of the procedure and wanted to proceed Need for stent was also discussed with the patient The patient will be scheduled for surgery tomorrow Plan for continuation of the antibiotics obtain urinalysis and culture and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow Keywords general medicine flank pain ureteral stone shockwave lithotripsy shockwave nausea vomiting lithotripsy ureteral stone MEDICAL_TRANSCRIPTION,Description Left flank pain and unable to urinate Medical Specialty General Medicine Sample Name Flank Pain Consult Transcription CHIEF COMPLAINT Left flank pain and unable to urinate HISTORY The patient is a 46 year old female who presented to the emergency room with left flank pain and difficulty urinating Details are in the history and physical She does have a vague history of a bruised left kidney in a motor vehicle accident She feels much better today I was consulted by Dr X MEDICATIONS Ritalin 50 a day ALLERGIES To penicillin PAST MEDICAL HISTORY ADHD SOCIAL HISTORY No smoking alcohol or drug abuse PHYSICAL EXAMINATION She is awake alert and quite comfortable Abdomen is benign She points to her left flank where she was feeling the pain DIAGNOSTIC DATA Her CAT scan showed a focal ileus in left upper quadrant but no thickening no obstruction no free air normal appendix and no kidney stones LABORATORY WORK Showed white count 6200 hematocrit 44 7 Liver function tests and amylase were normal Urinalysis 3 bacteria IMPRESSION 1 Left flank pain question etiology 2 No evidence of surgical pathology 3 Rule out urinary tract infection PLAN 1 No further intervention from my point of view 2 Agree with discharge and followup as an outpatient Further intervention will depend on how she does clinically She fully understood and agreed Keywords general medicine flank pain unable to urinate urinary tract infection flank MEDICAL_TRANSCRIPTION,Description Sample female review of systems Medical Specialty General Medicine Sample Name Female ROS Transcription FEMALE REVIEW OF SYSTEMS Constitutional Patient denies fevers chills sweats and weight changes Eyes Patient denies any visual symptoms Ears Nose and Throat No difficulties with hearing No symptoms of rhinitis or sore throat Cardiovascular Patient denies chest pains palpitations orthopnea and paroxysmal nocturnal dyspnea Respiratory No dyspnea on exertion no wheezing or cough GI No nausea vomiting diarrhea constipation abdominal pain hematochezia or melena GU No dysuria frequency or incontinence No difficulties with vaginal discharge Musculoskeletal No myalgias or arthralgias Breasts Patient performs self breast examinations and has noticed no abnormalities or nipple discharge Neurologic No chronic headaches no seizures Patient denies numbness tingling or weakness Psychiatric Patient denies problems with mood disturbance No problems with anxiety Endocrine No excessive urination or excessive thirst Dermatologic Patient denies any rashes or skin changes Keywords general medicine constitutional breasts cardiovascular dermatologic endocrine female review of systems musculoskeletal neurologic psychiatric review of systems respiratory abdominal pain chest pains constipation diarrhea hematochezia melena nausea nipple discharge numbness orthopnea palpitations paroxysmal nocturnal dyspnea rashes tingling vomiting weakness wheezing nose systems MEDICAL_TRANSCRIPTION,Description Sample female physical exam Medical Specialty General Medicine Sample Name Female Physical Exam 1 Transcription FEMALE PHYSICAL EXAMINATION Eye Eyelids normal color no edema Conjunctivae with no erythema foreign body or lacerations Sclerae normal white color no jaundice Cornea clear without lesions Pupils equally responsive to light Iris normal color no lesions Anterior chamber clear Lacrimal ducts normal Fundi clear Ear External ear has no erythema edema or lesions Ear canal unobstructed without edema discharge or lesions Tympanic membranes clear with normal light reflex No middle ear effusions Nose External nose symmetrical No skin lesions Nares open and free of lesions Turbinates normal color size and shape Mucus clear No internal lesions Throat No erythema or exudates Buccal mucosa clear Lips normal color without lesions Tongue normal shape and color without lesion Hard and soft palate normal color without lesions Teeth show no remarkable features No adenopathy Tonsils normal shape and size Uvula normal shape and color Neck Skin has no lesions Neck symmetrical No adenopathy thyromegaly or masses Normal range of motion nontender Trachea midline Chest Symmetrical Clear to auscultation bilaterally No wheezing rales or rhonchi Chest nontender Normal lung excursion No accessory muscle use Cardiovascular Heart has regular rate and rhythm with no S3 or S4 Heart rate is normal Abdominal Soft nontender nondistended bowel sounds present No hepatomegaly splenomegaly masses or bruits Genital Labia majora normal shape without erythema or lesions Labia minora normal shape without erythema or lesions Clitoris normal shape and contour Vaginal mucosa normal color without lesions No significant discharge Cervix normal shape and parity without lesions Ovaries normal shape and contour No pelvic masses Uterus normal shape and contour No external hemorrhoids Musculoskeletal Normal strength all muscle groups Normal range of motion all joints No joint effusions Joints normal shape and contour No muscle masses Foot No erythema No edema Normal range of motion all joints in the foot Nontender No pain with inversion eversion plantar or dorsiflexion Ankle Anterior and posterior drawer test negative No pain with inversion eversion dorsiflexion or plantar flexion Collateral ligaments intact No joint effusion erythema edema crepitus ecchymosis or tenderness Knee Normal range of motion No joint effusion erythema nontender Anterior and posterior drawer tests negative Lachman s test negative Collateral ligaments intact Bursas nontender without edema Wrist Normal range of motion No edema or effusion nontender Negative Tinel and Phalen tests Normal strength all muscle groups Elbow Normal range of motion No joint effusion or erythema Normal strength all muscle groups Nontender Olecranon bursa flat and nontender no edema Normal supination and pronation of forearm No crepitus Hip Negative swinging test Trochanteric bursa nontender Normal range of motion Normal strength all muscle groups No pain with eversion and inversion No crepitus Normal gait Psychiatric Alert and oriented times four No delusions or hallucinations no loose associations no flight of ideas no tangentiality Affect is appropriate No psychomotor slowing or agitation Eye contact is appropriate Keywords general medicine physical examination abdominal anterior chamber cardiovascular chest ear ear canal eye eyelids female female physical examination labia majora labia minora nares neck symmetrical vaginal mucosa crepitus ecchymosis edema erythema joint effusion normal range of motion shape and contour normal strength joint effusions normal color nontender lesions effusions muscle joints MEDICAL_TRANSCRIPTION,Description Sample female exam and review of systems Medical Specialty General Medicine Sample Name Female Exam ROS Transcription GENERAL REVIEW OF SYSTEMS General No fevers chills or sweats No weight loss or weight gain Cardiovascular No exertional chest pain orthopnea PND or pedal edema No palpitations Neurologic No paresis paresthesias or syncope Eyes No double vision or blurred vision Ears No tinnitus or decreased auditory acuity ENT No allergy symptoms such as rhinorrhea or sneezing GI No indigestion heartburn or diarrhea No blood in the stools or black stools No change in bowel habits GU No dysuria hematuria or pyuria No polyuria or nocturia Denies slow urinary stream Psych No symptoms of depression or anxiety Pulmonary No wheezing cough or sputum production Skin No skin lesions or nonhealing lesions Musculoskeletal No joint pain bone pain or back pain No erythema at the joints Endocrine No heat or cold intolerance No polydipsia Hematologic No easy bruising or easy bleeding No swollen lymph nodes PHYSICAL EXAM Vitals Blood pressure today was heart rate respiratory rate Ears TMs intact bilaterally Throat is clear without hyperemia Mouth Mucous membranes normal Tongue normal Neck Supple carotids 2 bilaterally without bruits no lymphadenopathy or thyromegaly Chest Clear to auscultation no dullness to percussion Heart Revealed a regular rhythm normal S1 and S2 No murmurs clicks or gallops Abdomen Soft to palpation without guarding or rebound No masses or hepatosplenomegaly palpable Bowel sounds are normoactive Extremities Bilaterally symmetrical Peripheral pulses 2 in all extremities No pedal edema Neurologic examination Essentially intact including cranial nerves II through XII intact bilaterally Deep tendon reflexes 2 and symmetrical Breasts Bilaterally symmetrical without tenderness masses No axillary tenderness or masses Pelvic examination Revealed normal external genitalia Pap smear obtained without difficulty Bimanual examination revealed no pelvic tenderness or masses No uterine enlargement Rectal examination revealed normal sphincter tone no rectal masses Stool is Hemoccult negative Keywords general medicine female exam extremities hemoccult musculoskeletal neurologic examination pelvic examination back pain bone pain chills cough cranial nerves ii through xii fevers heart rate joint pain paresis paresthesias polydipsia regular rhythm weight gain wheezing examination revealed pelvic rectal heartburn symmetrical tenderness indigestion masses MEDICAL_TRANSCRIPTION,Description Sample female physical exam Medical Specialty General Medicine Sample Name Female Physical Exam 2 Transcription FEMALE PHYSICAL EXAMINATION HEENT Pupils equal round and reactive to light and accommodation Extraocular movements are intact Sclerae are anicteric TMs are clear bilaterally Oropharynx is clear without erythema or exudate Neck Supple without lymphadenopathy or thyromegaly Carotids are silent There is no jugular venous distention Chest Clear to auscultation bilaterally Cardiovascular Regular rate and rhythm without S3 S4 No murmurs or rubs are appreciated Peripheral pulses are 2 and equal bilaterally in all four extremities Abdomen Soft nontender nondistended with positive bowel sounds No masses hepatomegaly or splenomegaly are appreciated GU Reveals normal female external genitalia Speculum exam reveals vaginal mucosa to be pink and rugous Cervix appears normal Bimanual exam reveals uterus to be within normal limits Adnexa are normal without masses appreciated There is no cervical motion tenderness Rectal Exam Normal rectal tone No masses are appreciated Hemoccult is negative Extremities Reveal no clubbing cyanosis or edema Joint Exam Reveals no tenosynovitis Integumentary Normal breast tissue without lumps or masses There are no skin changes over the breasts Axillae are free of masses Neurologic Cranial nerves II through XII are grossly intact Motor strength is 5 5 and equal in all four extremities Deep tendon reflexes are 2 4 and equal bilaterally Patient is alert and oriented times 3 Psychiatric Grossly normal Dermatologic No lesions or rashes Keywords general medicine female physical examination bimanual exam heent hemoccult ii through xii breast tissue cardiovascular dermatologic external genitalia integumentary joint exam lymphadenopathy neck neurologic physical examination rectal exam skin changes speculum exam female physical extremities masses oropharynx MEDICAL_TRANSCRIPTION,Description Fifth disease with sinusitis Medical Specialty General Medicine Sample Name Fifth Disease SOAP Transcription SUBJECTIVE Grandfather brings the patient in today because of headaches mostly in her face She is feeling pressure there with a lot of sniffles Last night she complained of sore throat and a loose cough Over the last three days she has had a rash on her face back and arms A lot of fifth disease at school She says it itches and they have been doing some Benadryl for this She has not had any wheezing lately and is not taking any ongoing medications for her asthma PAST MEDICAL HISTORY Asthma and allergies FAMILY HISTORY Sister is dizzy but no other acute illnesses OBJECTIVE General The patient is an 11 year old female Alert and cooperative No acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally gray in color and good light reflex Oropharynx is pink and moist No erythema or exudates She has postnasal discharge Nares are swollen and red Purulent discharge in the posterior turbinates Both maxillary sinuses are tender She has some mild tenderness in the left frontal sinus Eyes are puffy and she has dark circles Chest Respirations are regular and nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry and pink Moist mucous membranes Red lacey rash from the wrists to the elbows both sides It is very faint on the lower back and she has reddened cheeks as well ASSESSMENT Fifth disease with sinusitis PLAN Omnicef 300 mg daily for 10 days May use some Zyrtec for the itching Samples are given Keywords general medicine fifth disease soap asthma headaches sinusitis sore throat oropharynx MEDICAL_TRANSCRIPTION,Description A 46 year old white male with Down s syndrome presents for followup of hypothyroidism as well as onychomycosis Medical Specialty General Medicine Sample Name Down s syndrome Transcription SUBJECTIVE This 46 year old white male with Down s syndrome presents with his mother for followup of hypothyroidism as well as onychomycosis He has finished six weeks of Lamisil without any problems He is due to have an ALT check today At his appointment in April I also found that he was hypothyroid with elevated TSH He was started on Levothroid 0 1 mg and has been taking that daily We will recheck a TSH today as well His mother notes that although he does not like to take the medications he is taking it with encouragement His only other medications are some eyedrops for his cornea OBJECTIVE Weight was 149 pounds which is up 2 pounds Blood pressure was 120 80 Pulse is 80 and regular Neck Supple without adenopathy No thyromegaly or nodules were palpable Cardiac Regular rate and rhythm without murmurs Skin Examination of the toenails showed really no change yet They are still quite thickened and yellowed ASSESSMENT 1 Down s syndrome 2 Onychomycosis 3 Hypothyroidism PLAN 1 Recheck ALT and TSH today and call results 2 Lamisil 250 mg 30 one p o daily with one refill They will complete the next eight weeks of therapy as long as the ALT is normal I again reviewed the symptoms of liver dysfunction 3 Continue Levothroid 0 1 mg daily unless dosage need to be adjusted based on the TSH Keywords general medicine down s syndrome hypothyroidism onychomycosis hypothyroid tsh down s MEDICAL_TRANSCRIPTION,Description Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets Medical Specialty General Medicine Sample Name Ecstasy Ingestion ER Visit Transcription CHIEF COMPLAINT I took Ecstasy HISTORY OF PRESENT ILLNESS This is a 17 year old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody nonbilious emesis Mother called the EMS service when the patient vomited On arrival here the patient states that she no longer has any nausea and that she feels just fine The patient states she feels wired but has no other problems or complaints The patient denies any pain The patient does not have any auditory of visual hallucinations The patient denies any depression or suicidal ideation The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself The patient denies any homicidal ideation The patient denies any recent illness or recent injuries The mother states that the daughter appears to be back to her usual self now REVIEW OF SYSTEMS CONSTITUTIONAL No recent illness No fever or chills HEENT No headache No neck pain No vision change or hearing change No eye or ear pain No rhinorrhea No sore throat CARDIOVASCULAR No chest pain No palpitations or racing heart RESPIRATIONS No shortness of breath No cough GASTROINTESTINAL One episode of nonbloody nonbilious emesis this morning without any nausea since then The patient denies any abdominal pain No change in bowel movements GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No dizziness syncope or near syncope PSYCHIATRIC The patient denies any depression suicidal ideation homicidal ideation auditory hallucinations or visual hallucinations ENDOCRINE No heat or cold intolerance PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Appendectomy when she was 9 years old CURRENT MEDICATIONS Birth control pills ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient denies smoking cigarettes The patient does drink alcohol and also uses illicit drugs PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 8 oral blood pressure 140 86 pulse is 79 respirations 16 oxygen saturation 100 on room air and is interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctiva bilaterally The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally No evidence of light sensitivity or photophobia Extraocular motions are intact bilaterally Nose is normal without rhinorrhea or audible congestion Ears are normal without any sign of infection Mouth and oropharynx are normal without any signs of infection Mucous membranes are moist NECK Supple and nontender Full range of motion There is no JVD CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop Peripheral pulses are 3 and bounding RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender normal and benign MUSCULOSKELETAL No abnormalities noted in back arms or legs The patient is normal use of her extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact in all extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 The patient does not have any smell of alcohol and does not exhibit any clinical intoxication The patient is quite pleasant fully cooperative HEMATOLOGIC LYMPHATIC NO lymphadenitis is noted No bruising is noted DIAGNOSES 1 ECSTASY INGESTION 2 ALCOHOL INGESTION 3 VOMITING SECONDARY TO STIMULANT ABUSE CONDITION UPON DISPOSITION Stable disposition to home with her mother PLAN I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation The patient was advised to stop drinking alcohol and taking Ecstasy as this is not only in the interest of her health but was also illegal The patient is asked to return to the emergency room should she have any worsening of her condition develop any other problems or symptoms of concern Keywords general medicine nonbilious emesis hallucinations visual auditory ecstasy ingestion suicidal ideation homicidal ideation ingestion infection alcohol ecstasy MEDICAL_TRANSCRIPTION,Description Patient running to catch a taxi and stumbled fell and struck his face on the sidewalk Medical Specialty General Medicine Sample Name Fall Laceration Transcription CC Fall and laceration HPI Mr B is a 42 year old man who was running to catch a taxi when he stumbled fell and struck his face on the sidewalk He denies loss of consciousness but says he was dazed for a while after it happened He complains of pain over the chin and right forehead where he has abrasions He denies neck pain back pain extremity pain or pain in the abdomen PMH Hypertension MEDS None ROS As above Otherwise negative PHYSICAL EXAM This is a gentleman in full C spine precautions on a backboard brought by EMS He is in no apparent distress Vital Signs BP 165 95 HR 80 RR 12 Temp 98 4 SpO2 95 HEENT No palpable step offs there is blood over the right fronto parietal area where there is a small 1cm laceration and surrounding abrasion Also 2 cm laceration over the base of the chin without communication to the oro pharynx No other trauma noted No septal hematoma No other facial bony tenderness Neck Nontender Chest Breathing comfortably equal breath sounds Heart Regular rhythm Abd Benign Ext No tenderness or deformity pulses are equal throughout good cap refill Neuro Awake and alert slight slurring of speech and cognitive slowing consistent with alcohol moves all extremities cranial nerves normal COURSE IN THE ED Patient arrived and was placed on monitors An IV had been placed in the field and labs were drawn X rays of the C spine show no fracture and I ve removed the C collar The lacerations were explored and no foreign body found They were irrigated and closed with simple interrupted sutures Labs showed normal CBC Chem 7 and U A except there was moderate protein in the urine The blood alcohol returned at 0 146 A banana bag is ordered and his care will be turned over to Dr G for further evaluation and care Keywords general medicine loss of consciousness laceration fall course in the ed placed on monitors fell and struck abrasions MEDICAL_TRANSCRIPTION,Description Patient in ER with upper respiratory infection Medical Specialty General Medicine Sample Name ER Report URI Transcription HISTORY OF PRESENT ILLNESS The patient is a two and a half month old male who has been sick for the past three to four days His mother has described congested sounds with cough and decreased appetite He has had no fever He has had no rhinorrhea Nobody else at home is currently ill He has no cigarette smoke exposure She brought him to the emergency room this morning after a bad coughing spell He did not have any apnea during this episode PAST MEDICAL HISTORY Unremarkable He has had his two month immunizations PHYSICAL EXAMINATION VITAL SIGNS Temperature 99 1 oxygen saturations 98 respirations by the nurse at 64 however at my examination was much slower and regular in the 40s GENERAL Sleeping easily aroused smiling and in no distress HEENT Soft anterior fontanelle TMs are normal Moist mucous membranes LUNGS Equal and clear CHEST Without retraction HEART Regular in rate and rhythm without murmur ABDOMEN Benign DIAGNOSTIC STUDIES Chest x ray ordered by ER physician is unremarkable but to me also ASSESSMENT Upper respiratory infection TREATMENT Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares Smaller but more frequent feeds Discuss proper sleeping position Recheck if there is any fever or if he is no better in the next three days Keywords general medicine er uri emergency room upper respiratory infection respiratory sick fever chest MEDICAL_TRANSCRIPTION,Description Left elbow pain Fracture of the humerus spiral Possible nerve injuries to the radial and median nerve possibly neurapraxia Medical Specialty General Medicine Sample Name Elbow Pain Consult Transcription CHIEF COMPLAINT Left elbow pain HISTORY OF PRESENT ILLNESS This 17 year old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow causing sudden pain He also has pain in his left ankle but he is able to walk normally He has had previous pain in his left knee He denies any passing out any neck pain at this time even though he did get hit in the head He has no chest or abdominal pain Apparently no knives or guns were involved PAST MEDICAL HISTORY He has had toe problems and left knee pain in the past REVIEW OF SYSTEMS No coughing sputum production dyspnea or chest pain No vomiting or abdominal pain No visual changes No neurologic deficits other than some numbness in his left hand SOCIAL HISTORY He is in Juvenile Hall for about 25 more days He is a nonsmoker ALLERGIES MORPHINE CURRENT MEDICATIONS Abilify PHYSICAL EXAMINATION VITAL SIGNS Stable HEENT PERRLA EOMI Conjunctivae anicteric Skull is normocephalic He is not complaining of bruising HEENT TMs and canals are normal There is no Battle sign NECK Supple He has good range of motion Spinal processes are normal to palpation LUNGS Clear CARDIAC Regular rate No murmurs or rubs EXTREMITIES Left elbow is tender He does not wish to move it at all Shoulder and clavicle are within normal limits Wrist is normal to inspection He does have some pain to palpation Hand has good capillary refill He seems to have decreased sensation in all three dermatomes He has moderately good abduction of all fingers He has moderate opponens strength with his thumb He has very good extension of all of his fingers with good strength We did an x ray of his elbow He has a spiral fracture of the distal one third of the humerus about 13 cm in length The proximal part looks like it is in good position The distal part has about 6 mm of displacement There is no significant angulation The joint itself appears to be intact The fracture line ends where it appears above the joint I do not see any extra blood in the joint I do not see any anterior or posterior Siegert sign I spoke with Dr X He suggests we go ahead and splint him up and he will follow the patient up At this point it does not seem like there needs to be any surgical revision The chance of a compartment syndrome seems very low at this time Using 4 inch Ortho Glass and two assistants we applied a posterior splint to immobilize his fingers hand and wrist all the way up to his elbow to well above the elbow He had much better comfort once this was applied There was good color to his fingers and again much better comfort Once that was on I took some 5 inch Ortho Glass and put in extra reinforcement around the elbow so he would not be moving it straightening it or breaking the fiberglass We then gave him a sling We gave him 2 Vicodin p o and 4 to go Gave him a prescription for 15 more and warned him to take it only at nighttime and use Tylenol or Motrin and ice in the daytime I gave him the name and telephone number of Dr X whom they can follow up with They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems DIAGNOSES 1 Fracture of the humerus spiral 2 Possible nerve injuries to the radial and median nerve possibly neurapraxia 3 Psychiatric disorder unspecified DISPOSITION The patient will follow up as mentioned above They can return here anytime as needed Keywords MEDICAL_TRANSCRIPTION,Description A white male veteran with multiple comorbidities who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital Medical Specialty General Medicine Sample Name Discharge Summary 6 Transcription DISCHARGE DATE MM DD YYYY HISTORY OF PRESENT ILLNESS Mr ABC is a 60 year old white male veteran with multiple comorbidities who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital He underwent a resection there He was to be admitted to the Day Hospital for cystectomy He was seen in Urology Clinic and Radiology Clinic on MM DD YYYY HOSPITAL COURSE Mr ABC presented to the Day Hospital in anticipation for Urology surgery On evaluation EKG echocardiogram was abnormal a Cardiology consult was obtained A cardiac adenosine stress MRI was then proceeded same was positive for inducible ischemia mild to moderate inferolateral subendocardial infarction with peri infarct ischemia In addition inducible ischemia seen in the inferior lateral septum Mr ABC underwent a left heart catheterization which revealed two vessel coronary artery disease The RCA proximal was 95 stenosed and the distal 80 stenosed The mid LAD was 85 stenosed and the distal LAD was 85 stenosed There was four Multi Link Vision bare metal stents placed to decrease all four lesions to 0 Following intervention Mr ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr XYZ Mr ABC had a noncomplicated post intervention hospital course He was stable for discharge home on MM DD YYYY with instructions to take Plavix daily for one month and Urology is aware of the same DISCHARGE EXAM VITAL SIGNS Temperature 97 4 heart rate 68 respirations 18 blood pressure 133 70 HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Obese soft nontender Lower abdomen tender when touched due to bladder cancer RIGHT GROIN Dry and intact no bruit no ecchymosis no hematoma Distal pulses are intact DISCHARGE LABS CBC White count 5 4 hemoglobin 10 3 hematocrit 30 platelet count 132 hemoglobin A1c 9 1 BMP Sodium 142 potassium 4 4 BUN 13 creatinine 1 1 glucose 211 Lipid profile Cholesterol 157 triglycerides 146 HDL 22 LDL 106 PROCEDURES 1 On MM DD YYYY cardiac MRI adenosine stress 2 On MM DD YYYY left heart catheterization coronary angiogram left ventriculogram coronary angioplasty with four Multi Link Vision bare metal stents two placed to the LAD in two placed to the RCA DISCHARGE INSTRUCTIONS Mr ABC is discharged home He should follow a low fat low salt low cholesterol and heart healthy diabetic diet He should follow post coronary artery intervention restrictions He should not lift greater than 10 pounds for seven days He should not drive for two days He should not immerse in water for two weeks Groin site care reviewed with patient prior to being discharged home He should check groin for bleeding edema and signs of infection Mr ABC is to see his primary care physician within one to two weeks return to Dr XYZ s clinic in four to six weeks appointment card to be mailed him He is to follow up with Urology in their clinic on MM DD YYYY at 10 o clock and then to scheduled CT scan at that time DISCHARGE DIAGNOSES 1 Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD 2 Bladder cancer 3 Diabetes 4 Dyslipidemia 5 Hypertension 6 Carotid artery stenosis status post right carotid endarterectomy in 2004 7 Multiple resections of the bladder tumor 8 Distant history of appendectomy 9 Distant history of ankle surgery Keywords general medicine coronary artery disease heart catheterization artery disease bare metal metal stents artery intervention bladder cancer coronary artery veteran surgery cardiac inducible catheterization ischemia cancer urology stenosed bladder heart artery coronary MEDICAL_TRANSCRIPTION,Description A female with the past medical history of Ewing sarcoma iron deficiency anemia hypertension and obesity Medical Specialty General Medicine Sample Name Discharge Summary 5 Transcription DATE OF ADMISSION MM DD YYYY DATE OF DISCHARGE MM DD YYYY REFERRING PHYSICIAN AB CD M D ATTENDING PHYSICIAN AT DISCHARGE X Y M D ADMITTING DIAGNOSES 1 Ewing sarcoma 2 Anemia 3 Hypertension 4 Hyperkalemia PROCEDURES DURING HOSPITALIZATION Cycle seven Ifosfamide mesna and VP 16 chemotherapy HISTORY OF PRESENT ILLNESS Ms XXX is a pleasant 37 year old African American female with the past medical history of Ewing sarcoma iron deficiency anemia hypertension and obesity She presented initially with a left frontal orbital swelling to Dr XYZ on MM DD YYYY A biopsy revealed small round cells and repeat biopsy on MM DD YYYY also showed round cells consistent with Ewing sarcoma genetic analysis indicated a T1122 translocation MRI on MM DD YYYY showed a 4 cm soft tissue mass without bony destruction CT showed similar result The patient received her first cycle of chemotherapy on MM DD YYYY On MM DD YYYY she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy She had her last course of chemotherapy on MM DD YYYY followed by radiation treatment to the ethmoid sinuses on MM DD YYYY HOSPITAL COURSE 1 Ewing sarcoma she presented for cycle seven of VP 16 ifosfamide and mesna infusions which she tolerated well throughout the admission 2 She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission Keywords general medicine iron deficiency anemia hypertension and obesity iron deficiency urine anemia hypertension chemotherapy discharge ewing sarcoma MEDICAL_TRANSCRIPTION,Description Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation Medical Specialty General Medicine Sample Name Disseminated Intravascular Coagulation Transcription DIAGNOSES 1 Disseminated intravascular coagulation 2 Streptococcal pneumonia with sepsis CHIEF COMPLAINT Unobtainable as the patient is intubated for respiratory failure CURRENT HISTORY OF PRESENT ILLNESS This is a 20 year old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation At this time she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time prothrombin time low fibrinogen and elevated D dimer At this time I am being consulted for further evaluation and recommendations for treatment The nurses report that she has actually improved clinically over the last 24 hours Bleeding has been a problem however it seems to have been abrogated at this time with factor replacement as well as platelet infusion There is no prior history of coagulopathy PAST MEDICAL HISTORY Otherwise nondescript as is the past surgical history SOCIAL HISTORY There were possible illicit drugs Her family is present and I have discussed her case with her mother and sister FAMILY HISTORY Otherwise noncontributory REVIEW OF SYSTEMS Not otherwise pertinent PHYSICAL EXAMINATION GENERAL She is a sedated young black female in no acute distress lying in bed intubated VITAL SIGNS She has a rate of 67 blood pressure of 100 60 and the respiratory rate per the ventilator approximately 14 to 16 HEENT Her sclerae showed conjunctival hemorrhage There are no petechiae Her nasal vestibules are clear Oropharynx has ET tube in place NECK No jugular venous pressure distention CHEST Coarse breath sounds bilaterally HEART Regular rate and rhythm ABDOMEN Soft and nontender with good bowel sounds There was some oozing around the site of her central line EXTREMITIES No clubbing cyanosis or edema There is no evidence of compromise arterial blood flow at the digits or of her hands or feet LABORATORY STUDIES The DIC parameters with a platelet count of approximately 50 000 INR of 2 4 normal PTT at this time fibrinogen of 200 and a D dimer of 13 IMPRESSION PLAN At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease My recommendation for the patient is to continue factor replacement as you are It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time There is no indication at this point for Xigris However if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen normalization of her coagulation times I would consider low dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions I will repeat her laboratory studies in the morning and give more recommendations at that time Keywords general medicine intravascular coagulation pneumonia thromboplastin time prothrombin time disseminated intravascular coagulation streptococcal pneumonia intravascular coagulation infusion coagulopathy fibrinogen respiratory oropharynx sepsis disseminated MEDICAL_TRANSCRIPTION,Description Patient with fever of unknown origin Medical Specialty General Medicine Sample Name Discharge Summary 7 Transcription REASON FOR ADMISSION Fever of unknown origin HISTORY OF PRESENT ILLNESS The patient is a 39 year old woman with polymyositis dermatomyositis on methotrexate once a week The patient has also been on high dose prednisone for an urticarial rash The patient was admitted because of persistent high fevers without a clear cut source of infection She had been having temperatures of up to 103 for 8 10 days She had been seen at Alta View Emergency Department a week prior to admission A workup there including chest x ray blood cultures and a transthoracic echocardiogram had all remained nondiagnostic and were normal Her chest x ray on that occasion was normal After the patient was seen in the office on August 10 she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital Studies done at Cottonwood CT scan of the chest abdomen and pelvis Results CT chest showed mild bibasilar pleural based interstitial changes These were localized to mid and lower lung zones The process was not diffuse There was no ground glass change CT abdomen and pelvis was normal Infectious disease consultation was obtained Dr XYZ saw the patient He ordered serologies for CMV including a CMV blood PCR Next serologies for EBV Legionella Chlamydia Mycoplasma Coccidioides and cryptococcal antigen and a PPD The CMV serology came back positive for IgM The IgG was negative The CMV blood PCR was positive as well Other serologies and her PPD stayed negative Blood cultures stayed negative In view of the positive CMV PCR and the changes in her CAT scan the patient was taken for a bronchoscopy BAL and transbronchial biopsies were performed The transbronchial biopsies did not show any evidence of pneumocystis fungal infection AFB There was some nonspecific interstitial fibrosis which was minimal I spoke with the pathologist Dr XYZ and immunopathology was done to look for CMV The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection The patient was started on ganciclovir once her CMV serologies had come back positive No other antibiotic therapy was prescribed Next the patient s methotrexate was held A chest x ray prior to discharge showed some bibasilar disease showing interstitial infiltrates The patient was given ibuprofen and acetaminophen during her hospitalization and her fever resolved with these measures On the BAL fluid cell count the patient only had 5 WBCs and 5 RBCs on the differential It showed 43 neutrophils 45 lymphocytes Discussions were held with Dr XYZ Dr XYZ her rheumatologist and with pathology DISCHARGE DIAGNOSES 1 Disseminated CMV infection with possible CMV pneumonitis 2 Polymyositis on immunosuppressive therapy methotrexate and prednisone DISCHARGE MEDICATIONS 1 The patient is going to go on ganciclovir 275 mg IV q 12 h for approximately 3 weeks 2 Advair 100 50 1 puff b i d 3 Ibuprofen p r n and Tylenol p r n for fever and will continue her folic acid 4 The patient will not restart for methotrexate for now She is supposed to follow up with me on August 22 2007 at 1 45 p m She is also supposed to see Dr XYZ in 2 weeks and Dr XYZ in 2 3 weeks She also has an appointment to see an ophthalmologist in about 10 days time This was a prolonged discharge more than 30 minutes were spent on discharging this patient Keywords general medicine fever of unknown origin blood cultures transbronchial biopsies infection cmv admission illness interstitial fever serologies chest nondiagnostic methotrexate MEDICAL_TRANSCRIPTION,Description Patient with increased shortness of breath of one day duration Medical Specialty General Medicine Sample Name Discharge Summary 3 Transcription DISCHARGE DIAGNOSES 1 Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure 2 Chronic atrial fibrillation with prior ablation done on Coumadin treatment 3 Mitral stenosis 4 Remote history of lung cancer with prior resection of the left upper lobe 5 Anxiety and depression HISTORY OF PRESENT ILLNESS Details are present in the dictated report BRIEF HOSPITAL COURSE The patient is a 71 year old lady who came in with increased shortness of breath of one day duration She denied history of chest pain or fevers or cough with purulent sputum at that time She was empirically treated with a course of antibiotics of Avelox for ten days She also received steroids prednisolone 60 mg and breathing treatments with albuterol Ipratropium and her bronchodilator therapy was also optimized with theophylline She continued to receive Coumadin for her chronic atrial fibrillation Her heart rate was controlled and was maintained in the 60s 70s On the third day of admission she developed worsening respiratory failure with fatigue and hence was required to be intubated and ventilated She was put on mechanical ventilation from 1 29 to 2 6 06 She was extubated on 2 6 and put on BI PAP The pressures were gradually increased from 10 and 5 to 15 of BI PAP and 5 of E PAP with FIO2 of 35 at the time of transfer to Kindred Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy DISCHARGE MEDICATIONS Prednisolone 60 mg orally once daily albuterol 2 5 mg nebulized every 4 hours Atrovent Respules to be nebulized every 6 hours Pulmicort 500 micrograms nebulized twice every 8 hours Coumadin 5 mg orally once daily magnesium oxide 200 mg orally once daily TRANSFER INSTRUCTIONS The patient is to be strictly kept on bi level PAP of 15 I PAP E PAP of 5 cm and FIO2 of 35 for most of the times during the day She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90 92 at meal times only and that is to be limited to 1 2 hours every meal On admission her potassium had risen slightly to 5 5 and hence her ACE inhibitor had to be discontinued We may restart it again at a later date once her blood pressure control is better if required Keywords general medicine chronic obstructive pulmonary disease hypercapnic respiratory failure atrial fibrillation chronic atrial fibrillation increased shortness of breath shortness of breath increased shortness coumadin atrial MEDICAL_TRANSCRIPTION,Description A white female with a history of fevers Medical Specialty General Medicine Sample Name Discharge Summary 8 Transcription DISCHARGE DIAGNOSES 1 Gram negative rod bacteremia final identification and susceptibilities still pending 2 History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade 3 History of urinary tract infections of pyelonephritis OPERATIONS PERFORMED Chest x ray July 24 2007 that was normal Transesophageal echocardiogram July 27 2007 that was normal No evidence of vegetations CT scan of the abdomen and pelvis July 27 2007 that revealed multiple small cysts in the liver the largest measuring 9 mm There were 2 3 additional tiny cysts in the right lobe The remainder of the CT scan was normal HISTORY OF PRESENT ILLNESS Briefly the patient is a 26 year old white female with a history of fevers For further details of the admission please see the previously dictated history and physical HOSPITAL COURSE Gram negative rod bacteremia The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever septicemia and Osler nodes on her fingers The patient had a transthoracic echocardiogram as an outpatient which was equivocal but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations The microbiology laboratory stated that the Gram negative rod appeared to be anaerobic thus raising the possibility of organisms like bacteroides The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade We did a CT scan of the abdomen and pelvis which only showed some benign appearing cysts in the liver There was nothing remarkable as far as her kidneys ureters or bladder were concerned I spoke with Dr XYZ of infectious diseases and Dr XYZ asked me to talk to the patient about any contact with animals given the fact that we have had a recent outbreak of tularemia here in Utah Much to my surprise the patient told me that she had multiple pet rats at home which she was constantly in contact with I ordered tularemia and leptospirosis serologies on the advice of Dr XYZ and as of the day after discharge the results of the microbiology still are not back yet The patient however appeared to be responding well to levofloxacin I gave her a 2 week course of 750 mg a day of levofloxacin and I have instructed her to follow up with Dr XYZ in the meantime Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return A thought of ours was to add doxycycline but again the patient clinically appeared to be responding to the levofloxacin In addition I told the patient that it would be my recommendation to get rid of the rats I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection I told her very clearly that she should indeed get rid of the animals The patient seemed reluctant to do so at first but I believe with some coercion from her family that she finally came to the realization that this was a recommendation worth following DISPOSITION DISCHARGE INSTRUCTIONS Activity is as tolerated Diet is as tolerated MEDICATIONS Levaquin 750 mg daily x14 days Followup is with Dr XYZ of infectious diseases I gave the patient the phone number to call on Monday for an appointment Additional followup is also with Dr XYZ her primary care physician Please note that 40 minutes was spent in the discharge Keywords general medicine abdomen and pelvis gram negative rod congenital genitourinary genitourinary abnormalities transesophageal echocardiogram infectious diseases leptospirosis serologies gram negative ct scan identification infections levofloxacin additional discharge MEDICAL_TRANSCRIPTION,Description The patient underwent a scalp skin biopsy with pathology specimen obtained At the time of discharge the patient had improved Medical Specialty General Medicine Sample Name Discharge Summary 17 Transcription FINAL DIAGNOSIS REASON FOR ADMISSION 1 Acute right lobar pneumonia 2 Hypoxemia and hypotension secondary to acute right lobar pneumonia 3 Electrolyte abnormality with hyponatremia and hypokalemia corrected 4 Elevated liver function tests etiology undetermined 5 The patient has a history of moderate to severe dementia Alzheimer s type 6 Anemia secondary to current illness and possible iron deficiency 7 Darkened mole on the scalp status post skin biopsy pending pathology report OPERATION AND PROCEDURE The patient underwent a scalp skin biopsy with pathology specimen obtained on 6 11 2009 Dr X performed the procedure thoracentesis on 6 12 2009 both diagnostic and therapeutic Dr Y s results pending DISPOSITION The patient discharged to long term acute facility under the care of Dr Z CONDITION ON DISCHARGE Clinically improved however requiring acute care CURRENT MEDICATIONS Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily HOSPITAL SUMMARY This is one of several admissions for this 68 year old female who over the initial 48 hours preceding admission had a complaint of low grade fever confusion dizziness and a nonproductive cough Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x ray revealed evolving right lobar infiltrate She was started on antibiotics Infectious Disease was consulted She was initially begun on vancomycin Blood sputum and urine cultures were obtained the results of which were negative for infection She was switched to IV Levaquin and received IV Flagyl for possible C diff colitis as well as possible cholecystitis During her hospital stay she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning Her systolic blood pressure was 60 70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour She was seen in consultation by Dr Y who monitored her fluid and pulmonary treatment Due to some elevated liver function tests she was seen in consultation by Dr X An ultrasound was negative however she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder A HIDA scan was performed and revealed no evidence of gallbladder dysfunction Liver functions were monitored throughout her stay and while elevated did reduce to approximately 1 5 times normal value She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics Over her week stay the patient was moderately hypoxemic with room air pulse oximetry of 90 She was placed on incentive spirometry and over the succeeding days she did have improved pulmonary function LABORATORY TESTS Initially revealed a white count of 13 000 however approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay Blood cultures were negative at 5 days Sputum culture was negative Urine culture was negative and thoracentesis culture negative at 24 hours The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support as no evidence of GI bleeding was obtained Her most recent blood work on 6 14 2009 revealed a white count of 7000 and hemoglobin of 12 1 with a hematocrit of 36 8 Her PT and PTT were normal Occult blood studies were negative for occult blood Hepatitis B antigen was negative Hepatitis A antibody IgM was negative Hepatitis B core IgM negative and hepatitis C core antibody was negative At the time of discharge on 6 14 2009 sodium was 135 potassium was 3 7 calcium was 8 0 her ALT was 109 AST was 70 direct bilirubin was 0 2 LDH was 219 serum iron was 7 total iron unbound 183 and ferritin level was 267 At the time of discharge the patient had improved She complained of some back discomfort and lumbosacral back x ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr Z Keywords general medicine pneumonia hypoxemia hypotension electrolyte abnormality anemia scalp skin biopsy liver function tests lobar pneumonia infectious disease skin biopsy white count cultures MEDICAL_TRANSCRIPTION,Description Upper respiratory illness with apnea possible pertussis a one plus month old female with respiratory symptoms for approximately a week prior to admission This involved cough post tussive emesis and questionable fever Medical Specialty General Medicine Sample Name Discharge Summary 16 Transcription ADMISSION DIAGNOSIS Upper respiratory illness with apnea possible pertussis DISCHARGE DIAGNOSIS Upper respiratory illness with apnea possible pertussis COMPLICATIONS None OPERATIONS None BRIEF HISTORY AND PHYSICAL This is a one plus month old female with respiratory symptoms for approximately a week prior to admission This involved cough post tussive emesis questionable fever but only 99 7 Their usual doctor prescribed amoxicillin over the phone The coughing persisted and worsened She went to the ER where sats were normal at baseline but dropped into the 80s with coughing spells They did witness some apnea They gave some Rocephin did some labs and the patient was transferred to hospital PHYSICAL EXAMINATION On admission GENERAL Well developed well nourished baby in no apparent distress HEENT There was some nasal discharge Remainder of the HEENT was normal LUNG Had few rhonchi No retractions No significant coughing or apnea during the admission physical ABDOMEN Benign EXTREMITIES Were without any cyanosis SIGNIFICANT LABS AND X RAYS She had a CBC done Garberville which showed a white count of 12 4 with a differential of 10 segs 82 lymphs 8 monos hemoglobin of 15 hematocrit 42 platelets 296 000 and a normal BMP An x ray was done and I do not have an official interpretation but to the admitting physician Dr X it showed no significant infiltrate Well at hospital she had a rapid influenza swab done which was negative She had a rapid RSV done which is still not in the chart but I believe I was told that it was negative She also had a pertussis PCR swab done and a pertussis culture done neither of which has result in the chart I do know that the pertussis culture proved to be negative CONSULTATION Public Health Department was notified of a case of suspected pertussis HOSPITAL COURSE The baby was afebrile Required no oxygen in the hospital Actually fed reasonably well Did have one episode of coughing with slight emesis Appeared basically quite well between episodes Had no apnea witnessed and after overnight observation the parents were anxious to go home The patient was started on Zithromax in the hospital CONDITION AND TREATMENT The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week INSTRUCTIONS TO PATIENT Include usual diet and to follow up within a week but certainly sooner if the coughing is worse and there is cyanosis or apnea again Keywords general medicine emesis cough upper respiratory illness respiratory illness apnea pertussis MEDICAL_TRANSCRIPTION,Description Gastroenteritis and autism She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved Medical Specialty General Medicine Sample Name Discharge Summary 15 Transcription FINAL DIAGNOSES 1 Gastroenteritis 2 Autism DIET ON DISCHARGE Regular for age MEDICATIONS ON DISCHARGE Adderall and clonidine for attention deficit hyperactivity disorder ACTIVITY ON DISCHARGE As tolerated DISPOSITION ON DISCHARGE Follow up with Dr X in ABC Office in 1 to 2 weeks HISTORY OF PRESENT ILLNESS This 10 and 4 12 year old Caucasian female has autism and is enrolled at ABC School and she takes Adderall and clonidine for her hyperactivity She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved She developed vomiting 3 days prior to admission but did not have diarrhea She voided on the day of admission When she presented to the office her weight was 124 pounds which was approximately 10 pounds below previous weights and even had a weight of 151 5 pounds 05 30 2007 and weight of 137 5 pounds 09 11 2007 with mother giving no good explanation as to why she had lost all this weight She was admitted because of the persistent vomiting but there was concern about the weight loss Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder LABORATORY DATA Laboratory data included sedimentation rate of 12 magnesium level of 2 2 TSH of 2 63 with normal being 0 34 to 5 60 free T4 of 1 68 with normal being 0 58 to 1 64 Chest x ray and abdominal films were unremarkable Hemoglobin 14 5 hematocrit 43 5 platelet count 400 000 white blood count 11 800 Urinalysis was negative for ketones Specific gravity 1 023 and negative for protein Sodium 137 potassium 3 4 chloride 103 CO2 20 BUN 21 creatinine 0 9 and anion gap 14 glucose 90 total protein 8 1 albumin 4 5 calcium 8 8 bilirubin 1 5 AST 26 ALT 16 alkaline phosphatase 118 Thyroid peroxidase antibody studies are pending HOSPITAL COURSE The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated On the second hospital day mother was comfortable taking her to home Mother did not have a good explanation for the weight loss In the hospital her weight was 124 pounds her height 58 inches temperature 98 0 degree F pulse 123 respirations 18 blood pressure 148 94 Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission She seem quite happy and in no distress at the time of discharge We will follow up in the office and try to further evaluate her for the unexplained weight loss She has been taking the Adderall for at least a year and the mother does not think the Adderall is the cause of the weight loss The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient Keywords general medicine gastroenteritis autism constipation hyperactivity blood pressure weight loss adderall MEDICAL_TRANSCRIPTION,Description Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis Medical Specialty General Medicine Sample Name Discharge Summary 11 Transcription ADMISSION DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus and hypertension DISCHARGE DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis PROCEDURE Laparoscopic cholecystectomy SERVICE Surgery HISTORY OF PRESENT ILLNESS Ms ABC is a 57 year old woman She suffers from morbid obesity She also has diabetes and obstructive sleep apnea She was evaluated in the Bariatric Surgical Center for placement of a band During her workup she was noted to have evidence of cholelithiasis It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band The patient was scheduled to undergo her procedure on 12 31 09 however at blood glucose check the patient was noted to be hyperglycemic her sugar was 438 She was admitted to the hospital for treatment of her hyperglycemia HOSPITAL COURSE Ms ABC was admitted to the hospital She was seen by Dr A He put her on an insulin drip Her sugars slowly did come down to normal down to between 115 and 134 On the next day she was then taken to the operating room where she underwent her laparoscopic cholecystectomy She was noted to be a difficult intubation for the procedure There were some indications of chronic cholecystitis a little bit of edema mild edema and adhesions of omentum around the gallbladder She underwent the procedure She tolerated without difficulty She was recovered in the Postoperative Care Unit and then returned to the floor Her blood sugar postprocedure was noted to be 233 She was started back on a sliding scale insulin She continued to do well and was felt to be stable for discharge following the procedure DISCHARGE INSTRUCTIONS To return to the Medifast diet To continue with her blood glucose She needs to follow up with Dr B and she will see me next week on Friday We will determine if we will proceed with her lap band at that time She may shower She needs to keep her wounds clean and dry No heavy lifting No driving on narcotic pain medicines She needs to continue with her CPAP machine and continue to monitor her sugars Keywords general medicine medifast hyperglycemia laparoscopic cholecystectomy medifast diet cholecystitis cholelithiasis diabetes mellitus hypertension morbid obesity obstructive sleep apnea sleep apnea diabetes MEDICAL_TRANSCRIPTION,Description The patient is a 60 year old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea nausea inability to eat Medical Specialty General Medicine Sample Name Discharge Summary 14 Transcription HISTORY OF PRESENT ILLNESS The patient is a 60 year old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea nausea inability to eat She had an EGD and colonoscopy with Dr ABC a few days prior to this admission Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis Biopsies were done The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg PAST MEDICAL HISTORY Extensive and well documented in prior charts PHYSICAL EXAMINATION Abdomen was diffusely tender Lungs clear Blood pressure 129 69 on admission At the time of admission she had just a trace of bilateral lower edema LABORATORY STUDIES White count 6 7 hemoglobin 13 hematocrit 39 3 Potassium of 3 2 on 08 15 2007 HOSPITAL COURSE Dr ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema This was done and did not really show what the cecum on the barium enema There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon She did have some enemas She had persistent nausea headache neck pain throughout this hospitalization Finally she did improve enough to the point where she could be discharged home DISCHARGE DIAGNOSIS Nausea and abdominal pain of uncertain etiology SECONDARY DIAGNOSIS Migraine headache COMPLICATIONS None DISCHARGE CONDITION Guarded DISCHARGE PLAN Follow up with me in the office in 5 to 7 days to resume all pre admission medications Diet and activity as tolerated Keywords general medicine diarrhea nausea inability to eat egd colonoscopy biopsies barium enema cecum barium admission MEDICAL_TRANSCRIPTION,Description Patient today with ongoing issues with diabetic control Medical Specialty General Medicine Sample Name Diabetes Mellitus SOAP Note 2 Transcription SUBJECTIVE I am asked to see the patient today with ongoing issues around her diabetic control We have been fairly aggressively downwardly adjusting her insulins both the Lantus insulin which we had been giving at night as well as her sliding scale Humalog insulin prior to meals Despite frequent decreases in her insulin regimen she continues to have somewhat low blood glucoses most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units which is a considerable change What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin The staff reports to me that her appetite is good and that she is eating as well as ever I talked to Anna today She feels a little fatigued Otherwise she is doing well PHYSICAL EXAMINATION Vitals as in the chart The patient is a pleasant and cooperative She is in no apparent distress ASSESSMENT AND PLAN Diabetes still with some problematic low blood glucoses most notably in the morning To address this situation I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning She will get 55 units in the morning I am also decreasing once again her Humalog sliding scale insulin prior to meals I will review the blood glucoses again next week Keywords general medicine diabetic control insulin prior to meals low blood glucoses sliding scale lantus insulin diabetes mellitus lantus glucoses MEDICAL_TRANSCRIPTION,Description A gentleman with a long history of heroin abuse trying to get off the heroin last use shortly prior to arrival including cocaine The patient does have a history of alcohol abuse but mostly he is concerned about the heroin abuse Medical Specialty General Medicine Sample Name Detox from Heroin Transcription CHIEF COMPLAINT Detox from heroin HISTORY OF PRESENT ILLNESS This is a 52 year old gentleman with a long history of heroin abuse who keeps relapsing presents once again trying to get off the heroin last use shortly prior to arrival including cocaine The patient does have a history of alcohol abuse but mostly he is concerned about the heroin abuse PAST MEDICAL HISTORY Remarkable for chronic pain He has had multiple stab wounds gunshot wounds and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain He has previously been followed by ABC but has not seen him for several years REVIEW OF SYSTEMS The patient states that he did use heroin as well as cocaine earlier today and feels under the influence Denies any headache or visual complaints No hallucinations No chest pain shortness of breath abdominal pain or back pain Denies any abscesses SOCIAL HISTORY The patient is a smoker Admits to heroin use alcohol abuse as well Also admits today using cocaine FAMILY HISTORY Noncontributory MEDICATIONS He has previously been on analgesics and pain medications chronically Apparently he just recently got out of prison He has previously also been on Klonopin and lithium He was previously on codeine for this pain ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile He is markedly hypertensive 175 104 and pulse 117 probably due to the cocaine onboard His respiratory rate is normal at 18 GENERAL The patient is a little jittery but lucid alert and oriented to person place time and situation HEENT Unremarkable Pupils are actually moderately dilated about 4 to 5 mm but reactive Extraoculars are intact His oropharynx is clear NECK Supple His trachea is midline LUNGS Clear He has good breath sounds and no wheezing No rales or rhonchi Good air movement and no cough CARDIAC Without murmur ABDOMEN Soft and nontender He has multiple track marks multiple tattoos but no abscesses NEUROLOGIC Nonfocal IMPRESSION MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN ASSESSMENT AND PLAN At this time I think the patient can be followed up at XYZ I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy I do not think he needs any further workup at this time He is discharged otherwise in stable condition Keywords general medicine phenergan detox from heroin alcohol abuse heroin abuse detox heroin alcohol cocaine abuse MEDICAL_TRANSCRIPTION,Description Patient had a piece of glass fall on to his right foot A 4 mm laceration Acute foot pain now resolved The patient was given discharge instructions on wound care Medical Specialty General Medicine Sample Name Cut on Foot ER Visit Transcription CHIEF COMPLAINT Cut on foot HISTORY OF PRESENT ILLNESS This is a 32 year old male who had a piece of glass fall on to his right foot today The patient was concerned because of the amount of bleeding that occurred with it The bleeding has been stopped and the patient does not have any pain The patient has normal use of his foot there is no numbness or weakness the patient is able to ambulate well without any discomfort The patient denies any injuries to any other portion of his body He has not had any recent illness The patient has no other problems or complaints PAST MEDICAL HISTORY Asthma CURRENT MEDICATION Albuterol ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 8 oral blood pressure 132 86 pulse is 76 and respirations 16 Oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed the patient appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear conjunctiva and cornea bilaterally NECK Supple with full range of motion CARDIOVASCULAR Peripheral pulse is 2 to the right foot Capillary refills less than two seconds to all the digits of the right foot RESPIRATIONS No shortness of breath MUSCULOSKELETAL The patient has a 4 mm partial thickness laceration to the top of the right foot and about the area of the mid foot There is no palpable foreign body no foreign body is visualized There is no active bleeding there is no exposed deeper tissues and certainly no exposed tendons bone muscle nerves or vessels It appears that the laceration may have nicked a small varicose vein which would have accounted for the heavier than usual bleeding that currently occurred at home The patient does not have any tenderness to the foot The patient has full range of motion to all the joints all the toes as well as the ankles The patient ambulates well without any difficulty or discomfort There are no other injuries noted to the rest of the body SKIN The 4 mm partial thickness laceration to the right foot as previously described No other injuries are noted NEUROLOGIC Motor is 5 5 to all the muscle groups of the right lower extremity Sensory is intact to light touch to all the dermatomes of the right foot The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No active bleeding is occurring at this time No evidence of bruising is noted to the body EMERGENCY DEPARTMENT COURSE The patient had antibiotic ointment and a bandage applied to his foot DIAGNOSES 1 A 4 MM LACERATION TO THE RIGHT FOOT 2 ACUTE RIGHT FOOT PAIN NOW RESOLVED CONDITION UPON DISPOSITION Stable DISPOSITION To home The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on Keywords general medicine foot pain cut on foot piece of glass foreign body active bleeding foot injuries atraumatic laceration bleeding body MEDICAL_TRANSCRIPTION,Description Patient with a past medical history of hypertension for 15 years Medical Specialty General Medicine Sample Name Consult Hypertension Transcription HISTORY OF PRESENT ILLNESS The patient is a 74 year old white woman who has a past medical history of hypertension for 15 years history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases who presented for evaluation of recent worsening of the hypertension According to the patient she had stable blood pressure for the past 12 15 years on 10 mg of lisinopril In August of 2007 she was treated with doxorubicin and as well as Procrit and her blood pressure started to go up to over 200s Her lisinopril was increased to 40 mg daily She was also given metoprolol and HCTZ two weeks ago after she visited the emergency room with increased systolic blood pressure Denies any physical complaints at the present time Denies having any renal problems in the past PAST MEDICAL HISTORY As above plus history of anemia treated with Procrit No smoking or alcohol use and lives alone FAMILY HISTORY Unremarkable PRESENT MEDICATIONS As above REVIEW OF SYSTEMS Cardiovascular No chest pain No palpitations Pulmonary No shortness of breath cough or wheezing Gastrointestinal No nausea vomiting or diarrhea GU No nocturia Denies having gross hematuria Salt intake is minimal Neurological Unremarkable except for history of old CVA PHYSICAL EXAMINATION Blood pressure today is 182 78 Examination of the head is unremarkable Neck is supple with no JVD Lungs are clear There is no abdominal bruit Extremities 1 edema bilaterally LABORATORY DATA Urinalysis done in the office shows 1 proteinuria same is shown by urinalysis done at Hospital The creatinine is 0 8 Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis IMPRESSION AND PLAN Accelerated hypertension No clear cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA I could only blame Procrit initiation as well as possible fluid retention as a cause of the patient s accelerated hypertension She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension At this point I would not pursue a diagnosis of renal artery stenosis Since she is maxed out on lisinopril and her pulse is 60 I would not increase beta blocker or ACE inhibitor I will continue HCTZ at 24 mg daily The patient was also given a sample of Tekturna which would hopefully improve her systolic blood pressure The patient was told to be stick with her salt intake She will report to me in 10 days with the result of her blood pressure She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna Keywords general medicine hypertension ace inhibitor accelerated hypertension hctz mra of the renal arteries procrit sma7 anemia beta blocker doxorubicin hemiparesis history of cva hyperkalemia no abdominal bruit uterine cancer renal artery stenosis artery stenosis blood pressure blood pressure renal MEDICAL_TRANSCRIPTION,Description The patient needs refills on her Xanax Medical Specialty General Medicine Sample Name Consult Smoking Cessation Transcription CHIEF COMPLAINT I need refills HISTORY OF PRESENT ILLNESS The patient presents today stating that she needs refills on her Xanax and she would also like to get something to help her quit smoking She is a new patient today She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain She states that she is under the care of a cancer specialist however she just recently moved back to this area and is trying to find a doctor a little closer than his office She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try OBJECTIVE Well developed and well nourished She does not appear to be in any acute distress Cardiovascular Regular rhythm No murmurs gallops or rubs Capillary refill less than 3 seconds Peripheral pulses are 2 bilaterally Respiratory Her lungs are clear to auscultation bilaterally with good effort No tenderness to palpation over chest wall Musculoskeletal She has full range of motion of all four extremities No tenderness to palpation over long bones Skin Warm and dry No rashes or lesions Neuro Alert and oriented x3 Cranial nerves II XII are grossly intact No focal deficits PLAN I did refill her medications I have requested that she have her primary doctor forward her records to me I have discussed Chantix and its use and success rate She was given a prescription as well as a coupon She is to watch for any worsening signs or symptoms She verbalized understanding of discharge instructions and prescriptions I would like to see her back to proceed with her preventive health measures Keywords general medicine quit smoking chantix mesothelioma smoking xanax refills MEDICAL_TRANSCRIPTION,Description Followup diabetes mellitus type 1 Medical Specialty General Medicine Sample Name Diabetes Mellitus SOAP Note 1 Transcription CHIEF COMPLAINT Followup diabetes mellitus type 1 SUBJECTIVE Patient is a 34 year old male with significant diabetic neuropathy He has been off on insurance for over a year Has been using NPH and Regular insulin to maintain his blood sugars States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago Reports that his blood sugar dropped too low which caused the accident Since this point in time he has been unwilling to let his blood sugars fall within a normal range for fear of hypoglycemia Also reports that he regulates his blood sugars with how he feels rarely checking his blood sugar with a glucometer Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time Reports that he had some indications of kidney damage when first diagnosed His urine microalbumin today is 100 His last hemoglobin A1C drawn at the end of December is 11 9 Reports that at one point he was on Lantus which worked well and he did not worry about his blood sugars dropping too low While using Lantus he was able to get his hemoglobin A1C down to 7 His last CMP shows an elevated alkaline phosphatase level of 168 He denies alcohol or drug use and is a non smoker Reports he quit drinking 3 years ago I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today Patient also has a history of gastroparesis and impotence Patient requests Nexium and Viagra neither of which are covered under the Health Plan Patient reports that he was in a scooter accident one week ago fell off his scooter hit his head Was not wearing a helmet Reports that he did not go to the emergency room and had a headache for several days after this incident Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room Patient did not comply Reports that the headache has resolved Denies any dizziness nausea vomiting or other neurological abnormalities PHYSICAL EXAMINATION WD WN Slender 34 year old white male VITAL SIGNS Blood sugar 145 blood pressure 120 88 heart rate 104 respirations 16 Microalbumin 100 SKIN There appears to be 2 skin lacerations on the left parietal region of the scalp each approximately 1 inch long No signs of infection Wound is closed with new granulation tissue Appears to be healing well HEENT Normocephalic PERRLA EOMI TMs pearly gray with landmarks present Nares patent Throat with no redness or swelling Nontender sinuses NECK Supple Full ROM No LAD CARDIAC Keywords general medicine diabetes mellitus nph regular insulin sggt diabetic neuropathy dizziness followup glucometer hypoglycemia microalbumin nausea neurological vomiting mellitus type blood sugars blood diabetes mellitus sugars MEDICAL_TRANSCRIPTION,Description Acute on chronic COPD exacerbation and community acquired pneumonia both resolving However she may need home O2 for a short period of time Medical Specialty General Medicine Sample Name COPD Pneumonia SOAP Transcription SUBJECTIVE Review of the medical record shows that the patient is a 97 year old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation The patient does have a longstanding history of COPD However she does not use oxygen at her independent assisted living home Yesterday she had made improvement since being here at the hospital She needed oxygen She was tested for home O2 and qualified for it yesterday also Her lungs were very tight She did have wheezes bilaterally and rhonchi on the right side mostly She appeared to be a bit weak and although she was requesting to be discharged home she did not appear to be fit for it Overnight the patient needed to use the rest room She stated that she needed to urinate She awoke decided not to call for assistance She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker She attempted to walk to the rest room on her own She sustained a fall She stated that she just felt weak She bumped her knee and her elbow She had femur x rays knee x rays also There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side This morning she denied any headache back pain or neck pain She complained mostly of right anterior knee pain for which she had some bruising and swelling OBJECTIVE VITAL SIGNS The patient s max temperature over the past 24 hours was 36 5 her blood pressure is 148 77 her pulse is 87 to 106 She is 95 on 2 L via nasal cannula HEART Regular rate and rhythm without murmur gallop or rub LUNGS Reveal no expiratory wheezing throughout She does have some rhonchi on the right mid base She did have a productive cough this morning and she is coughing green purulent sputum finally ABDOMEN Soft and nontender Her bowel sounds x4 are normoactive NEUROLOGIC She is alert and oriented x3 Her pupils are equal and reactive She has got a good head and facial muscle strength Her tongue is midline She has got clear speech Her extraocular motions are intact Her spine is nontender on palpation from neck to lumbar spine She has good range of motion with regard to her shoulders elbows wrists and fingers Her grip strengths are equal bilaterally Both elbows are strong from extension to flexion Her hip flexors and extenders are also strong and equal bilaterally Extension and flexion of the knee bilaterally and ankles also are strong Palpation of her right knee reveals no crepitus She does have suprapatellar inflammation with some ecchymosis and swelling She has got good joint range of motion however SKIN She did have a skin tear involving her right forearm lateral which is approximately 2 to 2 5 inches in length and is at this time currently Steri Stripped and wrapped with Coban and is not actively bleeding ASSESSMENT 1 Acute on chronic COPD exacerbation 2 Community acquired pneumonia both resolving However she may need home O2 for a short period of time 3 Generalized weakness and deconditioning secondary to the above Also sustained a fall secondary to instability and not using her walker or calling for assistance The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed PLAN 1 I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i e walker Myself and one of her daughter s spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living 2 We will obtain an orthopedic consult secondary to her fall to evaluate her x rays and function Keywords general medicine community acquired pneumonia copd exacerbation home o2 acute on chronic pneumonia exacerbation copd MEDICAL_TRANSCRIPTION,Description Followup evaluation and management of chronic medical conditions Congestive heart failure stable on current regimen Diabetes type II A1c improved with increased doses of NPH insulin Hyperlipidemia chronic renal insufficiency and arthritis Medical Specialty General Medicine Sample Name Chronic Medical Conditions Followup Transcription REASON FOR VISIT Followup evaluation and management of chronic medical conditions HISTORY OF PRESENT ILLNESS The patient has been doing quite well since he was last seen He comes in today with his daughter He has had no symptoms of CAD or CHF He had followup with Dr X and she thought he was doing quite well as well He has had no symptoms of hyperglycemia or hypoglycemia He has had no falls His right knee does pain him at times and he is using occasional doses of Tylenol for that He wonders whether he could use a knee brace to help him with that issue as well His spirits are good He has had no incontinence His memory is clear as is his thinking MEDICATIONS 1 Bumex 2 mg daily 2 Aspirin 81 mg daily 3 Lisinopril 40 mg daily 4 NPH insulin 65 units in the morning and 25 units in the evening 5 Zocor 80 mg daily 6 Toprol XL 200 mg daily 7 Protonix 40 mg daily 8 Chondroitin glucosamine no longer using MAJOR FINDINGS Weight 240 blood pressure by nurse 160 80 by me 140 78 pulse 91 and regular and O2 saturation 94 He is afebrile JVP is normal without HJR CTAP RRR S1 and S2 Aortic murmur unchanged Abdomen Soft NT without HSM normal BS Extremities No edema on today s examination Awake alert attentive able to get up on to the examination table under his own power Able to get up out of a chair with normal get up and go Bilateral OA changes of the knee Creatinine 1 7 which was down from 2 3 A1c 7 6 down from 8 5 Total cholesterol 192 HDL 37 and triglycerides 487 ASSESSMENTS 1 Congestive heart failure stable on current regimen Continue 2 Diabetes type II A1c improved with increased doses of NPH insulin Doing self blood glucose monitoring with values in the morning between 100 and 130 Continue current regimen Recheck A1c on return 3 Hyperlipidemia at last visit he had 3 protein in his urine TSH was normal We will get a 24 hour urine to rule out nephrosis as the cause of his hypertriglyceridemia In the interim both Dr X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia Specifically we were considering TriCor fenofibrate Given his problems with high CPK values in the past for now we have decided not to engage in that strategy We will leave open for the future Check fasting lipid panel today 4 Chronic renal insufficiency improved with reduction in dose of Bumex over time 5 Arthritis stable I told the patient he could use Extra Strength Tylenol up to 4 grams a day but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day He states he will inch that up slowly With regard to a brace he stated he used one in the past and that did not help very much I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease For now he will continue with his cane and walker 6 Health maintenance flu vaccination today PLANS Followup in 3 months by phone sooner as needed Keywords general medicine congestive heart failure diabetes hyperlipidemia chronic renal insufficiency arthritis chronic medical conditions heart MEDICAL_TRANSCRIPTION,Description Multiple extensive subcutaneous abscesses right thigh Massive open wound right thigh status post right excision of multiple subcutaneous abscesses right thigh Medical Specialty General Medicine Sample Name Chronic Abscesses Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Multiple extensive subcutaneous abscesses right thigh 2 Massive open wound right thigh status post right excision of multiple subcutaneous abscesses right thigh PROCEDURES PERFORMED 1 On 03 05 08 by Dr X was massive debridement of soft tissue right lateral thigh and hip 2 Soft tissue debridement on 03 16 08 of right thigh and hip by Dr X 3 Split thickness skin graft to right thigh and right hip massive open wound on 04 01 08 by Dr Y REASON FOR ADMISSION The patient is a 62 year old male with a history of drug use He had a history of injection of heroin into his bilateral thighs Unfortunately he developed chronic abscesses open wounds on his bilateral thighs much worse on his right than his left Decision was made to do a radical excision and then it is followed by reconstruction HOSPITAL COURSE The patient was admitted on 03 05 08 by Dr X He was taken to the operating room He underwent a massive resection of multiple subcutaneous abscesses heroin remnants which left massive huge open wounds to his right thigh and hip This led to a prolonged hospital course The patient initially was treated with local wound care He was treated with broad spectrum antibiotics He ended up growing out different species of Clostridium Infectious Disease consult was obtained from Dr Z He assisted in further antibiotic coverage throughout the rest of his hospitalization The patient also had significant hypoalbuminemia decreased nutrition Given his large wounds he did end up getting a feeding tube placement and prior to grafting he received significant feeding tube supplementation to help achieve adequate nutrition for healing The patient had this superior area what appeared to be further necrotic infected soft tissue He went back to the OR on 03 16 08 and further resection done by Dr X After this his wound appeared to be free of infection He is treated with a wound VAC He slowly but progressively had significant progress in his wound I went from a very poor looking wound to a red granulated wound throughout its majority He was thought ready for skin grafting Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity These were negative He was treated with SCDs to help decrease his risk On 04 01 08 the patient was taken to the operating room was thought to have an adequate ________ grafting He underwent skin grafting to his right thigh and hip massive open wound Donor sites were truncated Postoperatively the patient ended up with a vast majority of skin graft taking To unable to take he was kept on IV antibiotics strict bed rest and limited range of motion of his hip He is continued on VAC dressing Graft progressively improved with this therapy Had another ultrasound which was negative for DVT The patient was mobilized up out of his bed Infectious Disease recommendations were obtained Plan was to complete additional 10 days of antibiotics at discharge This will be oral antibiotics I would monitor his left side which has significantly decreased inflammation and irritation or infection given the antibiotic coverage So decision was not made to excise this but instead monitor By 04 11 08 his graft looked good It was pink and filling in He looked stable for discharge The patient was discharged to home DISCHARGE INSTRUCTIONS Discharge to home CONDITION Stable Antibiotic Augmentin XR script was written He is okay to shower Donor site and graft site dressing instruction orders were given for Home Health and the patient His followup was arranged with Dr X and myself Keywords general medicine multiple extensive subcutaneous abscesses open wound subcutaneous abscesses multiple subcutaneous abscesses skin grafting thigh wound abscesses wounds subcutaneous antibiotics MEDICAL_TRANSCRIPTION,Description Complex open wound right lower extremity complicated by a methicillin resistant staphylococcus aureus cellulitis The patient is a 52 year old male who has had a very complex course secondary to a right lower extremity complex open wound Medical Specialty General Medicine Sample Name Cellulitis Discharge Summary Transcription DISCHARGE DIAGNOSIS Complex open wound right lower extremity complicated by a methicillin resistant staphylococcus aureus cellulitis ADDITIONAL DISCHARGE DIAGNOSES 1 Chronic pain 2 Tobacco use 3 History of hepatitis C REASON FOR ADMISSION The patient is a 52 year old male who has had a very complex course secondary to a right lower extremity complex open wound He has had prolonged hospitalizations because of this problem He was recently discharged when he was noted to develop as an outpatient swollen red tender leg Examination in the emergency room revealed significant concern for significant cellulitis Decision was made to admit him to the hospital HOSPITAL COURSE The patient was admitted on 03 26 08 and was started on IV antibiotics elevation was also counseled to minimizing the cigarette smoking The patient had edema of his bilateral lower extremities The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C Hospital consult was obtained This included an ultrasound of his abdomen which showed just mild cirrhosis His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well The patient eventually grew MRSA in a moderate amount He was treated with IV vancomycin Local wound care and elevation The patient had slow progress He was started on compression and by 04 03 08 his leg got much improved minimal redness and swelling was down with compression The patient was thought safe to discharge home DISCHARGE INSTRUCTIONS The patient was discharged on doxycycline 100 mg p o b i d x10 days He was also given prescription for Percocet and OxyContin picked up at my office He is instructed to do daily wound care and also wrap his leg with an Ace wrap Followup was arranged in a couple of weeks DISCHARGE CONDITION Stable Keywords general medicine chronic pain methicillin resistant staphylococcus aureus cellulitis complex open wound staphylococcus aureus wound care cellulitis wound hepatitis MEDICAL_TRANSCRIPTION,Description First degree and second degree burns right arm secondary to hot oil spill Workers Compensation industrial injury Medical Specialty General Medicine Sample Name Burn Consult Transcription CHIEF COMPLAINT Burn right arm HISTORY OF PRESENT ILLNESS This is a Workers Compensation injury This patient a 41 year old male was at a coffee shop where he works as a cook and hot oil splashed onto his arm burning from the elbow to the wrist on the medial aspect He has had it cooled and presents with his friend to the Emergency Department for care PAST MEDICAL HISTORY Noncontributory MEDICATIONS None ALLERGIES None PHYSICAL EXAMINATION GENERAL Well developed well nourished 21 year old male adult who is appropriate and cooperative His only injury is to the right upper extremity There are first and second degree burns on the right forearm ranging from the elbow to the wrist Second degree areas with blistering are scattered through the medial aspect of the forearm There is no circumferential burn and I see no areas of deeper burn The patient moves his hands well Pulses are good Circulation to the hand is fine FINAL DIAGNOSIS 1 First degree and second degree burns right arm secondary to hot oil spill 2 Workers Compensation industrial injury TREATMENT The wound is cooled and cleansed with soaking in antiseptic solution The patient was ordered Demerol 50 mg IM for pain but he refused and did not want pain medication A burn dressing is applied with Neosporin ointment The patient is given Tylenol No 3 tabs 4 to take home with him and take one or two every four hours p r n for pain He is to return tomorrow for a dressing change Tetanus immunization is up to date Preprinted instructions are given Workers Compensation first report and work status report are completed DISPOSITION Home Keywords general medicine burn workers compensation industrial injury workers compensation degree MEDICAL_TRANSCRIPTION,Description Left buttock abscess status post incision and drainage Recommended some local wound care Medical Specialty General Medicine Sample Name Buttock Abscess Transcription CHIEF COMPLAINT Buttock abscess HISTORY OF PRESENT ILLNESS This patient is a 24 year old African American female who presented to the hospital with buttock pain She started off with a little pimple on the buttock She was soaking it at home without any improvement She came to the hospital on the first The patient underwent incision and drainage in the emergency department She was admitted to the hospitalist service with elevated blood sugars She has had positive blood cultures Surgery is consulted today for evaluation PAST MEDICAL HISTORY Diabetes type II poorly controlled high cholesterol PAST SURGICAL HISTORY C section and D C ALLERGIES NO KNOWN DRUG ALLERGIES MEDICATIONS Insulin metformin Glucotrol and Lipitor FAMILY HISTORY Diabetes hypertension stroke Parkinson disease and heart disease REVIEW OF SYSTEMS Significant for pain in the buttock Otherwise negative PHYSICAL EXAMINATION GENERAL This is an overweight African American female not in any distress VITAL SIGNS She has been afebrile since admission Vital signs have been stable Blood sugars have been in the 200 range HEENT Normal to inspection NECK No bruits or adenopathy LUNGS Clear to auscultation CV Regular rate and rhythm ABDOMEN Protuberant soft and nontender EXTREMITIES No clubbing cyanosis or edema RECTAL EXAM The patient has a drained abscess on the buttock cheek There is some serosanguineous drainage There is no longer any purulent drainage The wound appears relatively clean I do not see a lot of erythema ASSESSMENT AND PLAN Left buttock abscess status post incision and drainage I do not believe surgical intervention is warranted I have recommended some local wound care Please see orders for details Keywords general medicine buttock pain pimple incision and drainage local wound care blood sugars diabetes buttock abscess MEDICAL_TRANSCRIPTION,Description Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support Medical Specialty General Medicine Sample Name Care Conference With Family Transcription REASON FOR FOLLOWUP Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support HISTORY OF PRESENT ILLNESS This is a 65 year old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA 125 and a complex mass located in the ovary As the patient was showing signs of improvement with some speech and ability to follow commands decision was made to continue to pursue an aggressive level of care treat her dysphagia hypertension debilitation and this was being done However last night the patient had apparently catastrophic event around 2 40 in the morning Rapid response was called and the patient was intubated started on pressure support and given CPR This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care The patient was seen and examined she was intubated and sedated Limbs were cool Cardiovascular exam revealed tachycardia Lungs had coarse breath sounds Abdomen was soft Extremities were cool to the touch Pupils were 6 to 2 mm doll s eyes were not intact They were not responsive to light Based on discussion with all family members involved including both sons daughter and daughter in law a decision was made to proceed with terminal wean and comfort care measures All pressure support was discontinued The patient was started on intravenous morphine and respiratory was requested to remove the ET tube Monitors were turned off and the patient was made as comfortable as possible Family is at the bedside at this time The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month this is a very reasonable and appropriate approach given the patient s failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities Total time spent at the bedside today in critical care services medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes Keywords general medicine full code status terminal wean comfort care cpr advanced cardiac life support care conference family bedsideNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Atrial fibrillation with rapid ventricular response Wolff Parkinson White Syndrome recent aortic valve replacement with bioprosthetic Medtronic valve and hyperlipidemia Medical Specialty General Medicine Sample Name Atrial Fibrillation SOAP Transcription SUBJECTIVE The patient states that she feels better She is on IV amiodarone the dosage pattern is appropriate for ventricular tachycardia Researching the available records I find only an EMS verbal statement that tachycardia of wide complex was seen There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm The patient states that for a week she has been home postoperative from aortic valve replacement on 12 01 08 at ABC Medical Center The aortic stenosis was secondary to a congenital bicuspid valve by her description She states that her shortness of breath with exertion has been stable but has yet to improve from its preoperative condition She has not had any decline in her postoperative period of her tolerance to exertion The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days Last night she had a prolonged episode for which she contacted EMS Her medications at home had been uninterrupted and without change from those listed being Toprol XL 100 mg q a m Dyazide 25 37 5 mg Nexium 40 mg all taken once a day She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively She states that she has been taking her aspirin at 325 mg q a m She remains on Zyrtec 10 mg q a m Her only allergy is listed to latex OBJECTIVE VITAL SIGNS Temperature 36 1 heart rate 60 respirations 14 room air saturation 98 and blood pressure 108 60 The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC GENERAL She is alert and in no apparent distress HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are clear bilaterally to auscultation The incision is well healed and without evidence of significant cellulitis HEART Shows a regular rate and rhythm without murmur gallop heave click thrill or rub There is an occasional extra beat noted which corresponds to a premature atrial contraction on the monitor ABDOMEN Soft and benign without hepatosplenomegaly rebound rigidity or guarding EXTREMITIES Show no evidence of DVT acute arthritis cellulitis or pedal edema NEUROLOGIC Nonfocal without lateralizing findings for cranial or peripheral nervous systems strength sensation and cerebellar function Gait and station were not tested MENTAL STATUS Shows the patient to be alert coherent with full capacity for decision making BACK Negative to inspection or percussion LABORATORY DATA Shows from 12 15 08 2100 hemoglobin 11 6 white count 12 9 and platelets 126 000 INR 1 0 Electrolytes are normal with exception potassium 3 3 GFR is decreased at 50 with creatinine of 1 1 Glucose was 119 Magnesium was 2 3 Phosphorus 3 8 Calcium was slightly low at 7 8 The patient has had ionized calcium checked at Munson that was normal at 4 5 prior to her discharge Troponin is negative x2 from 2100 and repeat at 07 32 This morning her BNP was 163 at admission Her admission chest x ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion Her current EKG tracing from 05 42 shows a sinus bradycardia with Wolff Parkinson White Pattern a rate of 58 beats per minute and a corrected QT interval of 557 milliseconds Her PR interval was 0 12 We received a call from Munson Medical Center that a bed had been arranged for the patient I contacted Dr Varner and we reviewed the patient s managed to this point All combined impression is that the patient was likely to not have had actual ventricular tachycardia This is based on her EP study from October showing her to be non inducible In addition she had a cardiac catheterization that showed no evidence of coronary artery disease What is most likely that the patient has postoperative atrial fibrillation Her WPW may have degenerated into a ventricular tachycardia but this is unlikely At this point we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period I will recheck her potassium magnesium calcium and phosphorus at this point and make adjustments if indicated Dr Varner will be making arrangements for an outpatient Holter monitor and further followup post discharge IMPRESSION 1 Atrial fibrillation with rapid ventricular response 2 Wolff Parkinson White Syndrome 3 Recent aortic valve replacement with bioprosthetic Medtronic valve 4 Hyperlipidemia Keywords general medicine ventricular tachycardia wolff parkinson white syndrome ventricular response medtronic valve wolff parkinson white syndrome aortic valve replacement atrial fibrillation atrial aortic tachycardia fibrillation ventricular valve medtronic MEDICAL_TRANSCRIPTION,Description A lady was admitted to the hospital with chest pain and respiratory insufficiency She has chronic lung disease with bronchospastic angina Medical Specialty General Medicine Sample Name Chest Pain Respiratory Insufficiency Transcription We discovered new T wave abnormalities on her EKG There was of course a four vessel bypass surgery in 2001 We did a coronary angiogram This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease She may continue in the future to have angina and she will have nitroglycerin available for that if needed Her blood pressure has been elevated and so instead of metoprolol we have started her on Coreg 6 25 mg b i d This should be increased up to 25 mg b i d as preferred antihypertensive in this lady s case She also is on an ACE inhibitor So her discharge meds are as follows 1 Coreg 6 25 mg b i d 2 Simvastatin 40 mg nightly 3 Lisinopril 5 mg b i d 4 Protonix 40 mg a m 5 Aspirin 160 mg a day 6 Lasix 20 mg b i d 7 Spiriva puff daily 8 Albuterol p r n q i d 9 Advair 500 50 puff b i d 10 Xopenex q i d and p r n I will see her in a month to six weeks She is to follow up with Dr X before that Keywords general medicine chest pain respiratory insufficiency chronic lung disease bronchospastic angina insufficiency chest angina respiratory bronchospastic MEDICAL_TRANSCRIPTION,Description Patient status post gastric bypass surgery developed nausea and right upper quadrant pain Medical Specialty General Medicine Sample Name Admission History Physical Nausea Transcription CHIEF COMPLAINT Nausea PRESENT ILLNESS The patient is a 28 year old who is status post gastric bypass surgery nearly one year ago He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7 00 8 00 when he developed nausea and right upper quadrant pain which apparently wrapped around toward his right side and back He feels like he was on it but has not done so He has overall malaise and a low grade temperature of 100 3 He denies any prior similar or lesser symptoms His last normal bowel movement was yesterday He denies any outright chills or blood per rectum PAST MEDICAL HISTORY Significant for hypertension and morbid obesity now resolved PAST SURGICAL HISTORY Gastric bypass surgery in December 2007 MEDICATIONS Multivitamins and calcium ALLERGIES None known FAMILY HISTORY Positive for diabetes mellitus in his father who is now deceased SOCIAL HISTORY He denies tobacco or alcohol He has what sounds like a data entry computer job REVIEW OF SYSTEMS Otherwise negative PHYSICAL EXAMINATION His temperature is 100 3 blood pressure 129 59 respirations 16 heart rate 84 He is drowsy but easily arousable and appropriate with conversation He is oriented to person place and situation He is normocephalic atraumatic His sclerae are anicteric His mucous membranes are somewhat tacky His neck is supple and symmetric His respirations are unlabored and clear He has a regular rate and rhythm His abdomen is soft He has diffuse right upper quadrant tenderness worse focally but no rebound or guarding He otherwise has no organomegaly masses or abdominal hernias evident His extremities are symmetrical with no edema His posterior tibial pulses are palpable and symmetric He is grossly nonfocal neurologically STUDIES His white blood cell count is 8 4 with 79 segs His hematocrit is 41 His electrolytes are normal His bilirubin is 2 8 His AST 349 ALT 186 alk phos 138 and lipase is normal at 239 ASSESSMENT Choledocholithiasis cholecystitis PLAN He will be admitted and placed on IV antibiotics We will get an ultrasound this morning He will need his gallbladder out probably with intraoperative cholangiogram Hopefully the stone will pass this way Due to his anatomy an ERCP would prove quite difficult if not impossible unless laparoscopic assisted Dr X will see him later this morning and discuss the plan further The patient understands Keywords general medicine gastric bypass surgery nausea choledocholithiasis cholecystitis ercp gastric bypass bypass surgery MEDICAL_TRANSCRIPTION,Description Comprehensive annual health maintenance examination dyslipidemia tinnitus in left ear and hemorrhoids Medical Specialty General Medicine Sample Name Annual Health Maintenance Exam Transcription HISTORY OF PRESENT ILLNESS This 59 year old white male is seen for comprehensive annual health maintenance examination on 02 19 08 although this patient is in excellent overall health Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change dyslipidemia well controlled with niacin history of hemorrhoids with occasional external bleeding although no problems in the last 6 months and also history of concha bullosa of the left nostril followed by ENT associated with slight septal deviation There are no other medical problems He has no symptoms at this time and remains in excellent health PAST MEDICAL HISTORY Otherwise noncontributory There is no operation serious illness or injury other than as noted above ALLERGIES There are no known allergies FAMILY HISTORY Father died of an MI at age 67 with COPD and was a heavy smoker His mother is 88 living and well status post lung cancer resection Two brothers living and well One sister died at age 20 months of pneumonia SOCIAL HISTORY The patient is married Wife is living and well He jogs or does Cross Country track 5 times a week and weight training twice weekly No smoking or significant alcohol intake He is a physician in allergy immunology REVIEW OF SYSTEMS Otherwise noncontributory He has no gastrointestinal cardiopulmonary genitourinary or musculoskeletal symptomatology No symptoms other than as described above PHYSICAL EXAMINATION GENERAL He appears alert oriented and in no acute distress with excellent cognitive function VITAL SIGNS His height is 6 feet 2 inches weight is 181 2 blood pressure is 126 80 in the right arm 122 78 in the left arm pulse rate is 68 and regular and respirations are 16 SKIN Warm and dry There is no pallor cyanosis or icterus HEENT Tympanic membranes benign The pharynx is benign Nasal mucosa is intact Pupils are round regular and equal reacting equally to light and accommodation EOM intact Fundi reveal flat discs with clear margins Normal vasculature No hemorrhages exudates or microaneurysms No thyroid enlargement There is no lymphadenopathy LUNGS Clear to percussion and auscultation Normal sinus rhythm No premature beat murmur S3 or S4 Heart sounds are of good quality and intensity The carotids femorals dorsalis pedis and posterior tibial pulsations are brisk equal and active bilaterally ABDOMEN Benign without guarding rigidity tenderness mass or organomegaly NEUROLOGIC Grossly intact EXTREMITIES Normal GU Genitalia normal There are no inguinal hernias There are mild hemorrhoids in the anal canal The prostate is small if any normal to mildly enlarged with discrete margins symmetrical without significant palpable abnormality There is no rectal mass The stool is Hemoccult negative IMPRESSION 1 Comprehensive annual health maintenance examination 2 Dyslipidemia 3 Tinnitus left ear 4 Hemorrhoids PLAN At this time continue niacin 1000 mg in the morning 500 mg at noon and 1000 mg in the evening aspirin 81 mg daily multivitamins vitamin E 400 units daily and vitamin C 500 mg daily Consider adding lycopene selenium and flaxseed to his regimen All appropriate labs will be obtained today Followup fasting lipid profile and ALT in 6 months Keywords general medicine tinnitus dyslipidemia annual health maintenance health hemorrhoids benign MEDICAL_TRANSCRIPTION,Description Possible exposure to ant bait She is not exhibiting any symptoms and parents were explained that if she develops any vomiting she should be brought back for reevaluation Medical Specialty General Medicine Sample Name Ant Bait Exposure ER Visit Transcription CHIEF COMPLAINT Possible exposure to ant bait HISTORY OF PRESENT ILLNESS This is a 14 month old child who apparently was near the sink got into the childproof cabinet and pulled out ant bait that had Borax in it It had 11 mL of this fluid in it She spilled it on her had it on her hands Parents were not sure whether she ingested any of it So they brought her in for evaluation They did not note any symptoms of any type PAST MEDICAL HISTORY Negative Generally very healthy REVIEW OF SYSTEMS The child has not been having any coughing gagging vomiting or other symptoms Acting perfectly normal Family mostly noted that she had spilled it on the ground around her had it on her hands and on her clothes They did not witness that she ingested any but did not see anything her mouth MEDICATIONS None ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile Stable vital signs and normal pulse oximetry GENERAL The child is very active cheerful youngster in no distress whatsoever HEENT Unremarkable Oral mucosa is clear moist and well hydrated I do not see any evidence of any sort of liquid on the face Her clothing did have the substance on the clothes but I did not see any evidence of anything on her torso Apparently she had some on her hands that has been wiped off EMERGENCY DEPARTMENT COURSE I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested which should does not appear likely to be the case IMPRESSION Exposure to ant bait PLAN At this point it is fairly unlikely that this child ingested any significant amount if at all which seems unlikely She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting she should be brought back for reevaluation So the patient is discharged in stable condition Keywords general medicine borax vomiting exposure to ant bait ant bait exposure symptoms MEDICAL_TRANSCRIPTION,Description This is a pleasant 50 year old female who has undergone an APR secondary to refractory ulcerative colitis Overall her quality of life has significantly improved since she had her APR She is functioning well with her ileostomy Medical Specialty Gastroenterology Sample Name Wound Check Status Post APR Transcription HISTORY OF PRESENT ILLNESS Ms Connor is a 50 year old female who returns to clinic for a wound check The patient underwent an APR secondary to refractory ulcerative colitis Subsequently she developed a wound infection which has since healed On our most recent visit to our clinic she has her perineal stitches removed and presents today for followup of her perineal wound She describes no drainage or erythema from her bottom She is having good ostomy output She does not describe any fevers chills nausea or vomiting The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy She has been taking Percocet for this pain and it does work She has since run out has been trying extra strength Tylenol which will occasionally help this intermittent pain She is requesting additional pain medications for this occasional abdominal pain which she still experiences PHYSICAL EXAMINATION Temperature 95 8 pulse 68 blood pressure 132 73 and weight 159 pounds This is a pleasant female in no acute distress The patient s abdomen is soft nontender nondistended with a well healed midline scar There is an ileostomy in the right hemiabdomen which is pink patent productive and protuberant There are no signs of masses or hernias over the patient s abdomen ASSESSMENT AND PLAN This is a pleasant 50 year old female who has undergone an APR secondary to refractory ulcerative colitis Overall her quality of life has significantly improved since she had her APR She is functioning well with her ileostomy She did have concerns or questions about her diet and we discussed the BRAT diet which consisted of foods that would slow down the digestive tract such as bananas rice toast cheese and peanut butter I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less I have counseled her on refraining from soft drinks and fruit drinks I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy She also had questions about her occasional abdominal pain I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain The patient then brought up some right hand and arm numbness which has been there postsurgically and was thought to be from positioning during surgery This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping I told her that I felt that this would continue to improve as it has done over the past two months since her surgery I told her to continue doing hand exercises as she has been doing and this seems to be working for her Overall I think she has healed from her surgery and is doing very well Again her quality of life is significantly improved She is happy with her performance We will see her back in six months just for a general routine checkup and see how she is doing at that time Keywords gastroenterology perineal wound wound infection wound wound check ulcerative colitis apr ileostomyNOTE MEDICAL_TRANSCRIPTION,Description Upper endoscopy with foreign body removal Penny in proximal esophagus Medical Specialty Gastroenterology Sample Name Upper Endoscopy Foreign Body Removal Transcription PROCEDURE Upper endoscopy with foreign body removal PREOPERATIVE DIAGNOSIS ES Esophageal foreign body POSTOPERATIVE DIAGNOSIS ES Penny in proximal esophagus ESTIMATED BLOOD LOSS None COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the pediatric endoscopy suite After appropriate sedation by the anesthesia staff and intubation an upper endoscope was inserted into the mouth over the tongue into the esophagus at which time the foreign body was encountered It was grasped with a coin removal forcep and removed with an endoscope At that time the endoscope was reinserted advanced to the level of the stomach and stomach was evaluated and was normal The esophagus was normal with the exception of some mild erythema where the coin had been sitting There were no erosions The stomach was decompressed of air and fluid The scope was removed without difficulty SUMMARY The patient underwent endoscopic removal of esophageal foreign body PLAN To discharge home follow up as needed Keywords gastroenterology upper endoscopy endoscopy endoscopy suite esophagus foreign body foreign body removal esophageal foreign body stomach MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery Medical Specialty Gastroenterology Sample Name Umbilical Hernia Repair 1 Transcription PROCEDURE PERFORMED Umbilical hernia repair PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table The patient was sedated and an adequate local anesthetic was administered using 1 lidocaine without epinephrine The patient was prepped and draped in the usual sterile manner A standard curvilinear umbilical incision was made and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery The sac was cleared of overlying adherent tissue and the fascial defect was delineated The fascia was cleared of any adherent tissue for a distance of 1 5 cm from the defect The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures The umbilicus was then re formed using 4 0 Vicryl to tack the umbilical skin to the fascia The wound was then irrigated using sterile saline and hemostasis was obtained using Bovie electrocautery The skin was approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords gastroenterology fascial defect umbilical hernia repair curvilinear umbilical hernia sac metzenbaum scissors umbilical hernia bovie electrocautery electrocautery hernia incision umbilical MEDICAL_TRANSCRIPTION,Description Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets Medical Specialty General Medicine Sample Name Accidental Celesta Ingestion ER Visit Transcription HISTORY OF PRESENT ILLNESS Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated The patient was alert and did not vomit during the transport to the emergency room Mom left the patient and his little one year old brother in the room by themselves and she went outside of the house for a couple of minutes and when came back she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor The patient said that the pills didn t taste good so it is presumed that the patient actually ingested at least two and a half tablets of Celesta 40 mg per tablet PAST MEDICAL HISTORY Baby was born premature and he required hospitalization but was not on mechanical ventilation He doesn t have any hospitalizations after the new born No surgeries IMMUNIZATIONS Up to date ALLERGIES NOT KNOWN DRUG ALLERGIES PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 2 Celsius pulse 112 respirations 24 blood pressure 104 67 weight 15 kilograms GENERAL Alert in no acute distress SKIN No rashes HEENT Head Normocephalic atraumatic Eyes EOMI PERRL Nasal mucosa clear Throat and tonsils normal No erythema no exudates NECK Supple no lymphadenopathy no masses LUNGS Clear to auscultation bilateral HEART Regular rhythm and rate without murmur Normal S1 S2 ABDOMEN Soft nondistended nontender present bowel sounds no hepatosplenomegaly no masses EXTREMITIES Warm Capillary refill brisk Deep tendon reflexes present bilaterally NEUROLOGICAL Alert Cranial nerves II through XII intact No focal exam Normal gait RADIOGRAPHIC DATA Patient has had an EKG done at the admission and it was within normal limits for the age EMERGENCY ROOM COURSE Patient was under observation for 6 hours in the emergency room He had two more EKGs during observation in the emergency room and they were all normal His vital signs were monitored every hour and were within normal limits There was no vomiting no diarrhea during observation Patient did not receive any medication or has had any other lab work besides the EKG ASSESSMENT AND PLAN Three years old male with accidental ingestion of Celesta Discharged home with parents with a followup in the morning with his primary care physician Keywords general medicine accidental ingestion of celesta celesta tablets ingestion MEDICAL_TRANSCRIPTION,Description Viral gastroenteritis Patient complaining of the onset of nausea and vomiting after she drank lots of red wine She denies any sore throat or cough She states no one else at home has been ill Medical Specialty Gastroenterology Sample Name Viral Gastroenteritis Transcription HISTORY OF PRESENT ILLNESS Patient is a 40 year old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p m last night after she states she drank lots of red wine She states after vomiting she felt fine through the night but woke with more nausea and vomiting and diaphoresis She states she has vomited approximately 20 times today and has also had some slight diarrhea She denies any sore throat or cough She states no one else at home has been ill She has not taken anything for her symptoms MEDICATIONS Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies ALLERGIES SHE HAS NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is married and is a nonsmoker and lives with her husband who is here with her REVIEW OF SYSTEMS Patient denies any fever or cough She notes no blood in her vomitus or stool The remainder of her review of systems is discussed and all are negative Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp is 37 6 Other vital signs are all within normal limits GENERAL Patient is a healthy appearing middle aged white female who is lying on the stretcher and appears only mildly ill HEENT Head is normocephalic and atraumatic Pharynx shows no erythema tonsillar edema or exudate NECK No enlarged anterior or posterior cervical lymph nodes There is no meningismus HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes ABDOMEN Active bowel sounds Soft without any focal tenderness on palpation There are no masses guarding or rebound noted SKIN No rash EXTREMITIES No cyanosis clubbing or edema LABORATORY DATA CBC shows a white count of 12 9 with an elevation in the neutrophil count on differential Hematocrit is 33 8 but the indices are normochromic and normocytic BMP is remarkable for a random glucose of 147 All other values are unremarkable LFTs are normal Serum alcohol is less than 5 TREATMENT Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea She was given two capsules of Imodium with some apple juice which she was able to keep down The patient did feel well enough to be discharged home ASSESSMENT Viral gastroenteritis PLAN Rx for Compazine 10 mg tabs dispense five sig one p o q 8h p r n for any recurrent nausea She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet Imodium for any diarrhea but no dairy products until the diarrhea has gone for at least 24 hours If she is unimproved in the next two days she was urged to follow up with her PCP back home Keywords gastroenterology nausea vomiting viral gastroenteritis wine gastroenteritis ill MEDICAL_TRANSCRIPTION,Description Upper endoscopy with removal of food impaction Medical Specialty Gastroenterology Sample Name Upper Endoscopy Transcription PROCEDURE Upper endoscopy with removal of food impaction HISTORY OF PRESENT ILLNESS A 92 year old lady with history of dysphagia on and off for two years She comes in this morning with complaints of inability to swallow anything including her saliva This started almost a day earlier She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything She is on Coumadin and her INR is 2 5 OPERATIVE NOTE Informed consent was obtained from patient The risks of aspiration bleeding perforation infection and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed Daughter was also informed about the procedure and risks Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus There was a meat bolus in the distal esophagus This was visualized after clearing the liquid material and small particles of what appeared to be carrots The patient however was not tolerating the conscious sedation Hence Dr X was consulted and we continued the procedure with propofol sedation The scope was reintroduced into the esophagus after propofol sedation Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net Then a snare was used to cut the meat bolus into pieces as it was very soft Small pieces were grabbed with the snare and pulled out Thereafter the residual soft meat bolus was passed into the stomach along with the scope which was passed between the bolus and the esophageal wall carefully The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy No active bleeding was seen There was a distal esophageal stricture which caused slight resistance to the passage of the scope into the stomach As this area was extremely inflamed a dilatation was not attempted IMPRESSION Distal esophageal stricture with food impaction Treated as described above RECOMMENDATIONS IV Protonix 40 mg q 12h Clear liquid diet for 24 hours If the patient is stable thereafter she may take soft pureed diet only until next endoscopy which will be scheduled in three to four weeks She should take Prevacid SoluTab 30 mg b i d on discharge Keywords gastroenterology dysphagia removal of food impaction distal esophagus stomach distal esophageal esophageal stricture upper endoscopy food impaction endoscopy aspiration sedation bolus impaction esophagus MEDICAL_TRANSCRIPTION,Description Insertion of a triple lumen central line through the right subclavian vein by the percutaneous technique This lady has a bowel obstruction She was being fed through a central line which as per the patient was just put yesterday and this slipped out Medical Specialty Gastroenterology Sample Name Ttriple Lumen Central Line Transcription PREOPERATIVE DIAGNOSES 1 Bowel obstruction 2 Central line fell off POSTOPERATIVE DIAGNOSES 1 Bowel obstruction 2 Central line fell off PROCEDURE Insertion of a triple lumen central line through the right subclavian vein by the percutaneous technique PROCEDURE DETAIL This lady has a bowel obstruction She was being fed through a central line which as per the patient was just put yesterday and this slipped out At the patient s bedside after obtaining an informed consent the patient s right deltopectoral area was prepped and draped in the usual fashion Xylocaine 1 was infiltrated and with the patient in Trendelenburg position she had her right subclavian vein percutaneously cannulated without any difficulty A Seldinger technique was used and a triple lumen catheter was inserted There was a good flow through all three ports which were irrigated with saline prior to connection to the IV solutions The catheter was affixed to the skin with sutures and then a dressing was applied The postprocedure chest x ray revealed that there were no complications to the procedure and that the catheter was in good place Keywords gastroenterology central line triple lumen central line subclavian vein bowel obstruction lumen percutaneous bowel obstruction MEDICAL_TRANSCRIPTION,Description Ultrasound Abdomen elevated liver function tests Medical Specialty Gastroenterology Sample Name Ultrasound Abdomen 1 Transcription EXAM Ultrasound Abdomen REASON FOR EXAM Elevated liver function tests INTERPRETATION The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration The gallbladder is surgically absent There is no fluid collection in the cholecystectomy bed There is dilatation of the common bile duct up to 1 cm There is also dilatation of the pancreatic duct that measures up to 3 mm There is caliectasis in the right kidney The bladder is significantly distended measuring 937 cc in volume The caliectasis in the right kidney may be secondary to back pressure from the distended bladder The aorta is normal in caliber IMPRESSION 1 Dilated common duct as well as pancreatic duct as described Given the dilatation of these two ducts ERCP versus MRCP is recommended to exclude obstructing mass The findings could reflect changes of cholecystectomy 2 Significantly distended bladder with probably resultant caliectasis in the right kidney Clinical correlation recommended Keywords gastroenterology aorta dilated common duct mrcp ercp elevated liver function tests pancreatic duct distended bladder ultrasound abdomen cholecystectomy ultrasound abdomen liver dilatation caliectasis kidney bladder duct MEDICAL_TRANSCRIPTION,Description Ultrasound abdomen complete Medical Specialty Gastroenterology Sample Name Ultrasound Abdomen Transcription EXAM Ultrasound abdomen complete HISTORY 38 year old male admitted from the emergency room 04 18 2009 decreased mental status and right upper lobe pneumonia The patient has diffuse abdominal pain There is a history of AIDS TECHNIQUE An ultrasound examination of the abdomen was performed FINDINGS The liver has normal echogenicity The liver is normal sized The gallbladder has a normal appearance without gallstones or sludge There is no gallbladder wall thickening or pericholecystic fluid The common bile duct has a normal caliber at 4 6 mm The pancreas is mostly obscured by gas A small portion of the head of pancreas is visualized which has a normal appearance The aorta has a normal caliber The aorta is smooth walled No abnormalities are seen of the inferior vena cava The right kidney measures 10 8 cm in length and the left kidney 10 5 cm No masses cysts calculi or hydronephrosis is seen There is normal renal cortical echogenicity The spleen is somewhat prominent with a maximum diameter of 11 2 cm There is no ascites The urinary bladder is distended with urine and shows normal wall thickness without masses The prostate is normal sized with normal echogenicity IMPRESSION 1 Spleen size at the upper limits of normal 2 Except for small portions of pancreatic head the pancreas could not be visualized because of bowel gas The visualized portion of the head had a normal appearance 3 The gallbladder has a normal appearance without gallstones There are no renal calculi Keywords gastroenterology echogenicity gallbladder ultrasound abdomen complete ultrasound abdomen abdomen liver gallstones kidney calculi renal spleen pancreas ultrasound MEDICAL_TRANSCRIPTION,Description Left thoracotomy with drainage of pleural fluid collection esophageal exploration and repair of esophageal perforation diagnostic laparoscopy and gastrostomy and radiographic gastrostomy tube study with gastric contrast interpretation Medical Specialty Gastroenterology Sample Name Thoracotomy Esophageal Exploration Transcription PREOPERATIVE DIAGNOSIS Esophageal rupture POSTOPERATIVE DIAGNOSIS Esophageal rupture OPERATION PERFORMED 1 Left thoracotomy with drainage of pleural fluid collection 2 Esophageal exploration and repair of esophageal perforation 3 Diagnostic laparoscopy and gastrostomy 4 Radiographic gastrostomy tube study with gastric contrast interpretation ANESTHESIA General anesthesia INDICATIONS OF THE PROCEDURE The patient is a 47 year old male with a history of chronic esophageal stricture who is admitted with food sticking and retching He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy DETAILS OF THE PROCEDURE After an extensive informed consent discussion process the patient was brought to the operating room He was placed in a supine position on the operating table After induction of general anesthesia and placement of a double lumen endotracheal tube he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll Left chest was prepped and draped in a usual sterile fashion After administration of intravenous antibiotics a left thoracotomy incision was made dissection was carried down to the subcutaneous tissues muscle layers down to the fifth interspace The left lung was deflated and the pleural cavity entered The Finochietto retractor was used to help provide exposure The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed Immediately encountered was left pleural fluid including some purulent fluid Cultures of this were sampled and sent for microbiology analysis The left pleural space was then copiously irrigated A careful expiration demonstrated that the rupture appeared to be sealed There was crepitus within the mediastinal cavity The mediastinum was opened and explored and the esophagus was explored The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area The area was copiously irrigated this provided nice coverage and repair After final irrigation and inspection two chest tubes were placed including a 36 French right angled tube at the diaphragm and a posterior straight 36 French These were secured at the left axillary line region at the skin level with 0 silk The intercostal sutures were used to close the chest wall with a 2 Vicryl sutures Muscle layers were closed with running 1 Vicryl sutures The wound was irrigated and the skin was closed with skin staples The patient was then turned and placed in a supine position A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed A Veress needle was carefully inserted into the abdomen pneumoperitoneum was established in the usual fashion a bladeless 5 mm separator trocar was introduced The laparoscope was introduced A single additional left sided separator trocar was introduced It was not possible to safely pass a nasogastric or orogastric tube pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance The stomach however did have some air insufflation and we were able to place our T fasteners through the anterior abdominal wall and through the anterior gastric wall safely The skin incision was made and the gastric lumen was then accessed with the Seldinger technique Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire 18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated We confirmed that we were in the gastric lumen and the balloon was pulled up creating apposition of the gastric wall and the anterior abdominal wall The T fasteners were all crimped and secured into position As was in the plan the gastrostomy was secured to the skin and into the tube Sterile dressing was applied Aspiration demonstrated gastric content Gastrostomy tube study with interpretation Radiographic gastrostomy tube study with gastric contrast with Keywords gastroenterology esophageal rupture thoracotomy drainage of pleural fluid esophageal perforation esophageal exploration laparoscopy gastrostomy pleural fluid diagnostic laparoscopy radiographic gastrostomy gastric lumen gastrostomy tube gastric contrast gastric interpretation abdominal pleural lumen esophageal tube MEDICAL_TRANSCRIPTION,Description Umbilical hernia repair template The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia Medical Specialty Gastroenterology Sample Name Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSIS Umbilical hernia POSTOPERATIVE DIAGNOSIS Umbilical hernia PROCEDURE PERFORMED Repair of umbilical hernia ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was prepped and draped in the sterile fashion An infraumbilical incision was formed and taken down to the fascia The umbilical hernia carefully reduced back into the cavity and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia and then the wounds were infiltrated with 0 25 Marcaine The skin was reattached to the fascia with 2 0 Vicryls The skin was approximated with 2 0 Vicryl subcutaneous and then 4 0 Monocryl subcuticular stitches dressed with Steri Strips and 4 x 4 s Patient was extubated and taken to the recovery area in stable condition Keywords gastroenterology marcaine steri strips mattress sutures umbilical hernia repair umbilical hernia MEDICAL_TRANSCRIPTION,Description Closure of gastrostomy placed due to feeding difficulties Medical Specialty Gastroenterology Sample Name Surgical Closure of Gastrostomy Transcription PREOPERATIVE DIAGNOSIS Gastrostomy gastrocutaneous fistula POSTOPERATIVE DIAGNOSIS Gastrostomy gastrocutaneous fistula OPERATION PERFORMED Surgical closure of gastrostomy ANESTHESIA General INDICATIONS This 1 year old child had a gastrostomy placed due to feeding difficulties Since then he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy The tube was therefore removed but the tract has not shown signs of spontaneous closure He therefore comes to the operating room today for surgical closure of his gastrostomy OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in the usual manner An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection The tract and the stomach were freed Stay sutures were then placed on either side of the tract The tract was amputated The intervening stomach was then closed with interrupted 4 0 Lembert Nurolon sutures The fascia was then closed over the stomach using 3 0 Vicryl sutures The skin was closed with 5 0 subcuticular Monocryl A dressing was applied and the child was awakened and taken to the recovery room in satisfactory condition Keywords gastroenterology gastrocutaneous fistula nurolon closure of gastrostomy feeding difficulties surgical closure gastrostomy MEDICAL_TRANSCRIPTION,Description Open Stamm gastrotomy tube lysis of adhesions and closure of incidental colotomy Medical Specialty Gastroenterology Sample Name Stamm Gastrostomy Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 Squamous cell carcinoma of the head and neck 2 Ethanol and alcohol abuse POSTOPERATIVE DIAGNOSES 1 Squamous cell carcinoma of the head and neck 2 Ethanol and alcohol abuse PROCEDURE 1 Failed percutaneous endoscopic gastrostomy tube placement 2 Open Stamm gastrotomy tube 3 Lysis of adhesions 4 Closure of incidental colotomy ANESTHESIA General endotracheal anesthesia IV FLUIDS Crystalloid 1400 ml ESTIMATED BLOOD LOSS Thirty ml DRAINS Gastrostomy tube was placed to Foley SPECIMENS None FINDINGS Stomach located high in the peritoneal cavity Multiple adhesions around the stomach to the diaphragm and liver HISTORY The patient is a 59 year old black male who is indigent an ethanol and tobacco abuse He presented initially to the emergency room with throat and bleeding Following evaluation by ENT and biopsy it was determined to be squamous cell carcinoma of the right tonsil and soft palate The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth The malignancy was not obstructing Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy DESCRIPTION OF PROCEDURE The patient was placed in the supine position and general endotracheal anesthesia was induced Preoperatively 1 gram of Ancef was given The abdomen was prepped and draped in the usual sterile fashion After anesthesia was achieved an endoscope was placed down into the stomach and no abnormalities were noted The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall With the room darkened and intensity turned up on the endoscope a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy A 21 gauge 1 1 2 inch needle was initially placed at the margin of the light reflex and this was done twice Both times it was not visualized on the endoscopy At this point repositioning was made and again what was felt to be adequate light reflex was obtained and the 14 gauge angio catheter was placed Again after two attempts we were unable to visualize the needle in the stomach endoscopically At this point decision was made to convert the procedure to an open Stamm gastrostomy OPEN STAMM GASTROSTOMY A short upper midline incision was made and deepened through the subcutaneous tissues Hemostasis was achieved with electrocautery The linea alba was identified and incised and the peritoneal cavity was entered The abdomen was explored Adhesions were lysed with electrocautery under direct vision The stomach was identified and a location on the anterior wall near the greater curvature was selected After lysis of adhesions was confirmed we sufficiently moved the original chosen site without tension A pursestring suture of 3 0 silk was placed on the interior surface of the stomach and a second 3 0 pursestring silk stitch was placed exterior to that pursestring suture An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four 2 0 silk sutures in such a manner as to prevent leakage or torsion The catheter was then secured to the skin with two 2 0 silk sutures Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field Prior to the initiation of the gastrotomy the bowel was run and at that time there was noted to be one incidental colotomy This was oversewn with three 4 0 silk Lembert sutures At the completion of the operation the fascia was closed with 1 interrupted Vicryl suture and the skin was closed with staples The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition Keywords MEDICAL_TRANSCRIPTION,Description She is a 79 year old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago The patient has required conversion to an open procedure due to difficult anatomy Her postoperative course has been lengthened due to a prolonged ileus which resolved with tetracycline and Reglan The patient is starting to improve gain more strength She is tolerating her regular diet Medical Specialty Gastroenterology Sample Name SOAP Cholecystitis Transcription SUBJECTIVE She is a 79 year old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago The patient has required conversion to an open procedure due to difficult anatomy Her postoperative course has been lengthened due to a prolonged ileus which resolved with tetracycline and Reglan The patient is starting to improve gain more strength She is tolerating her regular diet PHYSICAL EXAMINATION VITAL SIGNS Today her temperature is 98 4 heart rate 84 respirations 20 and BP is 140 72 LUNGS Clear to auscultation No wheezes rales or rhonchi HEART Regular rhythm and rate ABDOMEN Soft less tender LABORATORY DATA Her white count continues to come down Today it is 11 6 H H of 8 8 and 26 4 platelets 359 000 We have ordered type and cross for 2 units of packed red blood cells If it drops below 25 she will receive a transfusion Her electrolytes today show a glucose of 107 sodium 137 potassium 4 0 chloride 103 2 bicarbonate 29 7 Her AST is 43 ALT is 223 her alkaline phosphatase is 214 and her bilirubin is less than 0 10 ASSESSMENT AND PLAN She had a bowel movement today and is continuing to improve I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count Keywords gastroenterology laparoscopic cholecystectomy anatomy acute cholecystitis prolonged ileus white count cholecystitis MEDICAL_TRANSCRIPTION,Description Sigmoidoscopy performed for evaluation of anemia gastrointestinal Bleeding Medical Specialty Gastroenterology Sample Name Sigmoidoscopy 1 Transcription PROCEDURE Sigmoidoscopy INDICATIONS Performed for evaluation of anemia gastrointestinal Bleeding MEDICATIONS Fentanyl Sublazine 0 1 mg IV Versed midazolam 1 mg IV BIOPSIES No BRUSHINGS PROCEDURE A history and physical examination were performed The procedure indications potential complications bleeding perforation infection adverse medication reaction and alternative available were explained to the patient who appeared to understand and indicated this Opportunity for questions was provided and informed consent obtained After placing the patient in the left lateral decubitus position the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm Careful inspection was made as the sigmoidoscope was withdrawn The quality of the prep was good The procedure was stopped due to patient discomfort The patient otherwise tolerated the procedure well There were no complications FINDINGS Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries Retroflexed examination of the rectum revealed small hemorrhoids External hemorrhoids were found Other than the findings noted above the visualized colonic segments were normal IMPRESSION Internal hemorrhoids External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries Unsuccessful Sigmoidoscopy Otherwise Normal Sigmoidoscopy to 25 cm External hemorrhoids were found Keywords gastroenterology gastrointestinal bleeding gastrointestinal sigmoidoscope rectum anemia bleeding sigmoidoscopy hemorrhoids MEDICAL_TRANSCRIPTION,Description Ultrasound Guided Paracentesis for Ascites Medical Specialty Gastroenterology Sample Name Paracentesis Ultrasound Guided Transcription EXAM Ultrasound guided paracentesis HISTORY Ascites TECHNIQUE AND FINDINGS Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained Ultrasound demonstrates free fluid in the abdomen The area of interest was localized with ultrasonography The region was sterilely prepped and draped in the usual manner Local anesthetic was administered A 5 French Yueh catheter needle combination was taken Upon crossing into the peritoneal space and aspiration of fluid the catheter was advanced out over the needle A total of approximately 5500 mL of serous fluid was obtained The catheter was then removed The patient tolerated the procedure well with no immediate postprocedure complications IMPRESSION Ultrasound guided paracentesis as above Keywords gastroenterology yueh catheter aspiration of fluid ultrasound guided paracentesis ultrasound guided needle catheter paracentesis ultrasound ascites MEDICAL_TRANSCRIPTION,Description Bleeding after transanal excision five days ago Exam under anesthesia with control of bleeding via cautery The patient is a 42 year old gentleman who is five days out from transanal excision of a benign anterior base lesion He presents today with diarrhea and bleeding Medical Specialty Gastroenterology Sample Name Postop Transanal Excision Transcription PREOPERATIVE DIAGNOSIS Bleeding after transanal excision five days ago POSTOPERATIVE DIAGNOSIS Bleeding after transanal excision five days ago PROCEDURE Exam under anesthesia with control of bleeding via cautery ANESTHESIA General endotracheal INDICATION The patient is a 42 year old gentleman who is five days out from transanal excision of a benign anterior base lesion He presents today with diarrhea and bleeding Digital exam reveals bright red blood on the finger He is for exam under anesthesia and control of hemorrhage at this time FINDINGS There was an ulcer where most of the polypoid lesion had been excised before In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa There were a few discrete sites of mild oozing which were treated with cautery and 1 suture No other obvious bleeding was seen TECHNIQUE The patient was taken to the operating room and placed on the operative table in supine position After adequate general anesthesia was induced the patient was then placed in modified prone position His buttocks were taped prepped and draped in a sterile fashion The anterior rectal wall was exposed using a Parks anal retractor The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well This was controlled with a 3 0 Monocryl figure of eight suture At the completion there was no bleeding no oozing it was completely dry and we removed our retractor and the patient was then turned and extubated and taken to the recovery room in stable condition Keywords gastroenterology diarrhea anterior base lesion polypoid lesion transanal excision transanal anesthesia bleeding MEDICAL_TRANSCRIPTION,Description Percutaneous endoscopic gastrostomy tube Protein calorie malnutrition The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores After discussion with the patient and the son they agreed to place a PEG tube for nutritional supplementation Medical Specialty Gastroenterology Sample Name PEG Tube Transcription PREOPERATIVE DIAGNOSIS Protein calorie malnutrition POSTOPERATIVE DIAGNOSIS Protein calorie malnutrition PROCEDURE PERFORMED Percutaneous endoscopic gastrostomy PEG tube ANESTHESIA Conscious sedation per Anesthesia SPECIMEN None COMPLICATIONS None HISTORY The patient is a 73 year old male who was admitted to the hospital with some mentation changes He was unable to sustain enough caloric intake and had markedly decreased albumin stores After discussion with the patient and the son they agreed to place a PEG tube for nutritional supplementation PROCEDURE After informed consent was obtained the patient was brought to the endoscopy suite He was placed in the supine position and was given IV sedation by the Anesthesia Department An EGD was performed from above by Dr X The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization The needle was removed and a guidewire was inserted through the sheath The guidewire was grasped from above with a snare by the endoscopist It was removed completely and the Ponsky PEG tube was secured to the guidewire The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall There was no evidence of bleeding Photos were taken The Bolster was placed on the PEG site A complete dictation for the EGD will be done separately by Dr X The patient tolerated the procedure well and was transferred to recovery room in stable condition He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal Keywords gastroenterology percutaneous endoscopic gastrostomy tube protein calorie malnutrition peg tube malnutrition nutritional MEDICAL_TRANSCRIPTION,Description Paracentesis A large abdominal mass which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room Medical Specialty Gastroenterology Sample Name Paracentesis Transcription PREOPERATIVE DIAGNOSIS Abdominal mass POSTOPERATIVE DIAGNOSIS Abdominal mass PROCEDURE Paracentesis DESCRIPTION OF PROCEDURE This 64 year old female has stage II endometrial carcinoma which had been resected before and treated with chemotherapy and radiation At the present time the patient is under radiation treatment Two weeks ago or so she developed a large abdominal mass which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days The cytology of the fluid was negative and the culture was also negative Eventually the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis The CAT scan showed accumulation of the fluid and the mass almost achieving 80 of the previous size Therefore I called the patient home and she came to the emergency department where the service was provided At that time I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion Unfortunately the catheter was open I did not have a drainage system at that time So I withdrew directly with a syringe 700 mL of clear fluid The system was connected to the draining bag and the patient was instructed to keep a log and how to use equipment She was given an appointment to see me in the office next Monday which is three days from now Keywords gastroenterology abdominal mass clear fluid cat scan pigtail catheter paracentesis MEDICAL_TRANSCRIPTION,Description Acute acalculous cholecystitis Open cholecystectomy The patient s gallbladder had some patchy and necrosis areas There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder Medical Specialty Gastroenterology Sample Name Open Cholecystectomy Transcription PREOPERATIVE DIAGNOSIS Acute acalculous cholecystitis POSTOPERATIVE DIAGNOSIS Acute hemorrhagic cholecystitis PROCEDURE PERFORMED Open cholecystectomy ANESTHESIA Epidural with local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition SPECIMEN Gallbladder BRIEF HISTORY The patient is a 73 year old female who presented to ABCD General Hospital on 07 23 2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture The patient subsequently went to the operating room on 07 25 2003 for a right hip hemiarthroplasty per the Orthopedics Department Subsequently the patient was doing well postoperatively however the patient does have severe O2 and steroid dependent COPD and at an extreme risk for any procedure The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08 07 2003 for surgical evaluation for upper abdominal pain During the evaluation the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08 08 03 the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder The patient did well postdrainage The patient s laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp However once the tube was removed the patient re obstructed with recurrent symptoms and a second tube was needed to be placed this was done on 08 16 2003 A HIDA scan had been performed which showed no cystic duct obstruction A tube cholecystogram was performed which showed no cystic or common duct obstruction There was abnormal appearance of the gallbladder however the pathway was patent Thus after failure of two nonoperative management therapies extensive discussions were made with the family and the patient s only option was to undergo a cholecystectomy Initial thoughts were to do a laparoscopic cholecystectomy however with the patient s severe COPD and risk for ventilator management the options were an epidural and an open cholecystectomy under local was made and to be performed INTRAOPERATIVE FINDINGS The patient s gallbladder had some patchy and necrosis areas There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder The patient also had no plane between the gallbladder and the liver bed OPERATIVE PROCEDURE After informed written consent risks and benefits of the procedure were explained to the patient and discussed with the patient s family The patient was brought to the operating room after an epidural was performed per anesthesia Local anesthesia was given with 1 lidocaine A paramedian incision was made approximately 5 cm in length with a 15 blade scalpel Next hemostasis was obtained using electro Bovie cautery Dissection was carried down transrectus in the midline to the posterior rectus fascia which was grasped with hemostats and entered with a 10 blade scalpel Next Metzenbaum scissors were used to extend the incision and the abdomen was entered The gallbladder was immediately visualized and brought up into view grasped with two ring clamps elevating the biliary tree into view Dissection with a ______ was made to identify the cystic artery and cystic duct which were both easily identified The cystic artery was clipped two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors The cystic duct was identified A silk tie 3 0 silk was placed one distal and one proximal with 3 0 silk and then cutting in between with a Metzenbaum scissors The gallbladder was then removed from the liver bed using electro Bovie cautery A plane was created The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel The gallbladder was then removed as specimen sent to pathology for frozen sections for diagnosis of which the hemorrhagic cholecystitis was diagnosed on frozen sections Permanent sections are still pending The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen The peritoneum as well as posterior rectus fascia was approximated with a running 0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure of eight 0 Vicryl sutures Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition Keywords gastroenterology open cholecystectomy hemorrhagic gallbladder serosal liver bed acute acalculous acalculous cholecystitis cystic duct bovie cautery rectus fascia metzenbaum scissors fascia cholecystitis cholecystectomy cystic MEDICAL_TRANSCRIPTION,Description Nissen fundoplication A 2 cm midline incision was made at the junction of the upper two thirds and lower one third between the umbilicus and the xiphoid process Medical Specialty Gastroenterology Sample Name Nissen Fundoplication Transcription PROCEDURE PERFORMED Nissen fundoplication DESCRIPTION OF PROCEDURE After informed consent was obtained detailing the risks of infection bleeding esophageal perforation and death the patient was brought to the operative suite and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was then placed in a modified lithotomy position taking great care to pad all extremities TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis Antibiotics were given for prophylaxis against surgical infection A 52 French bougie was placed in the proximal esophagus by Anesthesia above the cardioesophageal junction A 2 cm midline incision was made at the junction of the upper two thirds and lower one third between the umbilicus and the xiphoid process The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adaptor in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg A 30 degree laparoscope was inserted through this port and used to guide the remaining trocars The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer s line spreading the subcutaneous tissue with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 4 other 10 11 mm trocars were placed Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line at a right supraumbilical position another at the left upper quadrant at the midclavicular line at a left supraumbilical position 1 under the right costal margin in the anterior axillary line and another laterally under the left costal margin on the anterior axillary line All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position The triangular ligament was taken down sharply and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula The gastrohepatic ligament was then identified and incised in an avascular plane The dissection was carried anteromedially onto the phrenoesophageal membrane The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice This incision was extended to the right to allow identification of the right crus Then along the inner side of the crus the right esophageal wall was freed by dissecting the cleavage plane The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus The pars flaccida of the lesser omentum was opened preserving the hepatic branches of the vagus nerve This allowed free access to the crura left and right and the right posterior aspect of the esophagus and the posterior vagus nerve Attention was next turned to the left anterolateral aspect of the esophagus At its left border the left crus was identified The dissection plane between it and the left aspect of the esophagus was freed The gastrophrenic ligament was incised beginning the mobilization of the gastric pouch By dissecting the intramediastinal portion of the esophagus we elongated the intra abdominal segment of the esophagus and reduced the hiatal hernia The next step consisted of mobilization of the gastric pouch This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen away from the gastroepiploic arcade The esophagus was lifted by a Babcock inserted through the left upper quadrant port Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus A one half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus The retroesophageal channel was enlarged to allow easy passage of the antireflux valve The 52 French bougie was then carefully lowered into the proximal stomach and the hiatal orifice was repaired Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice The last part of the operation consisted of the passage and fixation of the antireflux valve With anterior retraction on the esophagus using the Penrose drain a Babcock was passed behind the esophagus from right to left It was used to grab the gastric pouch to the left of the esophagus and to pull it behind forming the wrap The 52 French bougie was used to calibrate the external ring Marcaine 0 5 was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control The skin incision was approximated with skin staples A dressing was then applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently taken to the recovery room in good and stable condition Keywords gastroenterology umbilicus insufflation phrenoesophageal membrane nissen fundoplication gastric pouch esophagus penrose antireflux nissen fundoplication trocars ligament MEDICAL_TRANSCRIPTION,Description The patient has had abdominal pain associated with a 30 pound weight loss and then developed jaundice He had epigastric pain and was admitted to the hospital A thin slice CT scan was performed which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases Medical Specialty Gastroenterology Sample Name Pancreatic Mass Discharge Summary Transcription HISTORY OF PRESENT ILLNESS The patient is a 48 year old man who has had abdominal pain since October of last year associated with a 30 pound weight loss and then developed jaundice He had epigastric pain and was admitted to the hospital A thin slice CT scan was performed which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases The patient additionally had a questionable pseudocyst in the tail of the pancreas The patient underwent ERCP on 04 04 2007 with placement of a stent This revealed a strictured pancreatic duct as well as strictured bile duct A 10 french x 9 cm stent was placed with good drainage The next morning the patient felt quite a bit more comfortable He additionally had a modest drop in his bilirubin and other liver tests Of note the patient has been having quite a bit of nausea during his admission This responded to Zofran It did not initially respond well to Phenergan though after stent placement he was significantly more comfortable and had less nausea and in fact had better response to the Phenergan itself At the time of discharge the patient s white count was 9 4 hemoglobin 10 8 hematocrit 32 with a MCV of 79 platelet count of 585 000 His sodium was 132 potassium 4 1 chloride 95 CO2 27 BUN of 8 with a creatinine of 0 3 His bilirubin was 17 1 alk phos 273 AST 104 ALT 136 total protein 7 8 and albumin of 3 8 He was tolerating a regular diet The patient had been on oral hypoglycemics as an outpatient but in hospital he was simply managed with an insulin sliding scale The patient will be transferred back to Pelican Bay under the care of Dr X at the infirmary He will be further managed for his diabetes there The patient will additionally undergo potential end of life meetings I discussed the potentials of chemotherapy with patient Certainly there are modest benefits which can be obtained with chemotherapy in metastatic pancreatic cancer though at some cost with morbidity The patient will consider this and will discuss this further with Dr X DISCHARGE MEDICATIONS 1 Phenergan 25 mg q 6 p r n 2 Duragesic patch 100 mcg q 3 d 3 Benadryl 25 50 mg p o q i d for pruritus 4 Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary 5 The patient had initially been on enalapril here His hypertension will be managed by Dr X as well PLAN The patient should return for repeat ERCP if there are signs of stent occlusion such as fever increased bilirubin worsening pain In the meantime he will be kept on a regular diet and activity per Dr X Keywords gastroenterology abdominal pain lymph nodes weight loss pancreatic mass chemotherapy abdominal bilirubin phenergan stent drainage MEDICAL_TRANSCRIPTION,Description Patient seen initially with epigastric and right upper quadrant abdominal pain nausea dizziness and bloating Medical Specialty Gastroenterology Sample Name Progress Note Liver Cirrhosis Transcription HISTORY OF PRESENT ILLNESS The patient is a 55 year old Hispanic male who was seen initially in the office February 15 2006 with epigastric and right upper quadrant abdominal pain nausea dizziness and bloating The patient at that time stated that he had established diagnosis of liver cirrhosis Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before Dr X in Las Cruces and his primary care physician in Silver City and unfortunately we did not get any information from anybody Also the patient had admission in Gila Medical Center with epigastric pain diarrhea and confusion He spent 3 days in the hospital He was followed by Dr X and unfortunately we also do not have the information of what was wrong with the patient From the patient s report he was diagnosed with some kind of viral infection At the time of admission he had a lot of epigastric pain nausea vomiting fever and chills PHYSICAL EXAMINATION VITAL SIGNS Weight 107 height 6 feet 1 inch blood pressure 128 67 heart rate 74 saturation 98 pain is 3 10 with localization of the pain in the epigastric area HEENT PERRLA EOM intact Oropharynx is clear of lesions NECK Supple No lymphadenopathy No thyromegaly LUNGS Clear to auscultation and percussion bilateral CARDIOVASCULAR Regular rate and rhythm No murmurs rubs or gallops ABDOMEN Not tender not distended Splenomegaly about 4 cm under the costal margin No hepatomegaly Bowel sounds present MUSCULOSKELETAL No cyanosis no clubbing no pitting edema NEUROLOGIC Nonfocal No asterixis No costovertebral tenderness PSYCHE The patient is oriented x4 alert and cooperative LABORATORY DATA We were able to collect lab results from Medical Center we got only CMP from the hospital which showed glucose level 79 BUN 9 creatinine 0 6 sodium 136 potassium 3 5 chloride 104 CO2 23 7 calcium 7 3 total protein 5 9 albumin 2 5 total bilirubin 5 63 His AST 56 ALT 37 alkaline phosphatase 165 and his ammonia level was 53 We do not have any other results back No hepatitis panels No alpha fetoprotein level The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive but we do not have this result despite calling medical records in the hospital to release this information ASSESSMENT AND PLAN The patient is a 55 year old with established diagnosis of liver cirrhosis unknown cause 1 Epigastric pain The patient had chronic pain syndrome he had multiple back surgeries and he has taken opiate for a prolonged period of time In the office twice the patient did not have any abdominal pain on physical exam His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously He probably requires increased level of pain control with increased dose of opiates which should be addressed with his primary care physician 2 End stage liver disease Of course we need to find out the cause of the liver cirrhosis We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before We do not have any information of any type of investigation in the past Again patient was seen by gastroenterologist already in Las Cruces Dr X The patient was advised to contact Dr X by himself to convince him to send available information because we already send release information form signed by the patient without any result It will be not reasonable to repeat unnecessary tests in that point in time We are waiting for the hepatitis panel and alpha fetoprotein level We will also need to get information about ultrasound which was done in Gila Medical Center but obviously no tumor was found on this exam of the liver We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B Until now we do not know exactly what the cause of the patient s end stage liver disease is and my differential diagnosis probably is hepatitis C The patient denied any excessive alcohol intake but I could not preclude alcohol related liver cirrhosis also We will need to look for nuclear antibody if it is not done before PSC is extremely unlikely but possible Wilson disease also possible diagnosis but again we first have to figure out if these tests were done for the patient or not Alpha1 antitrypsin deficiency will be extremely unlikely because the patient has no lung problem On his end stage liver disease we already know that he had low platelet count splenomegaly We know that his bilirubin is elevated and albumin is very low I suspect that at the time of admission to the hospital the patient presented with encephalopathy We do not know if INR was checked to look for coagulopathy The patient had an EGD in 2005 as well as colonoscopy in Silver City We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that At this point in time I recommended the patient to continue to take lactulose 50 mL 3 times daily The patient tolerated it well no diarrhea at this point in time I also recommended for him to contact his primary care physician for increased dose of opiates for him As a primary prophylaxis of GI bleeding in patient with end stage liver disease we will try to use Inderal The patient got a prescription for 10 mg pills He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25 from 75 to probably 60 58 The patient was educated how to use Inderal and he was explained why we decided to use this medication The patient will hold this medication if he is orthostatic or bradycardic Again the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above We also discussed nutrition issues The patient was provided information that his protein intake is supposed to be about 25 g per day He was advised not to over eat protein and advised not to starve He also was advised to stay away from alcohol His next visit is in 2 weeks with all results available Keywords gastroenterology abdominal pain nausea dizziness liver disease epigastric pain liver cirrhosis liver abdominal cirrhosis epigastric hepatitis MEDICAL_TRANSCRIPTION,Description Percutaneous liver biopsy With the patient lying in the supine position and the right hand underneath the head an area of maximal dullness was identified in the mid axillary location by percussion Medical Specialty Gastroenterology Sample Name Liver Biopsy Transcription TITLE OF PROCEDURE Percutaneous liver biopsy ANALGESIA 2 Lidocaine ALLERGIES The patient denied any allergy to iodine lidocaine or codeine PROCEDURE IN DETAIL The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today The patient was told of complications which might occur consisting of bleeding bile peritonitis bowel perforation pneumothorax or death The risks and benefits of the procedure were understood and the patient signed the consent form freely With the patient lying in the supine position and the right hand underneath the head an area of maximal dullness was identified in the mid axillary location by percussion The area was prepped and cleaned with povidone iodine following which the skin subcutaneous tissue and serosal surfaces were infiltrated with 2 lidocaine down to the capsule of the liver Next a small incision was made with a Bard Parker 11 scalpel A 16 gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration Liver cores measuring cm were obtained and will be sent to Pathology for routine histologic study POST PROCEDURE COURSE AND DISPOSITION The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication Normal activities can be resumed tomorrow The patient is to contact me if severe abdominal or chest pain fever melena light headedness or any unusual symptoms develop An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made COMPLICATIONS None RECOMMENDATIONS Prior to discharge hepatitis A and B vaccines will be recommended Risks and benefits for vaccination have been addressed and the patient will consider this option Keywords gastroenterology bile peritonitis bowel perforation pneumothorax klatskin needle mid axillary liver biopsy percutaneous lidocaine biopsy liver MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and laparoscopic appendectomy Right lower quadrant abdominal pain rule out acute appendicitis Medical Specialty Gastroenterology Sample Name Laparoscopy Laparoscopic Appendectomy Transcription PREOPERATIVE DIAGNOSIS Right lower quadrant abdominal pain rule out acute appendicitis POSTOPERATIVE DIAGNOSIS Acute suppurative appendicitis PROCEDURE PERFORMED 1 Diagnostic laparoscopy 2 Laparoscopic appendectomy ANESTHESIA General endotracheal and injectable 1 lidocaine and 0 25 Marcaine ESTIMATED BLOOD LOSS Minimal SPECIMEN Appendix COMPLICATIONS None BRIEF HISTORY This is a 37 year old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain which progressed throughout its course starting approximately 12 hours prior to presentation She admits to some nausea associated with it There have been no fevers chills and or genitourinary symptoms The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant She had a leukocytosis of 12 8 She did undergo a CT of the abdomen and pelvis which was non diagnostic for an acute appendicitis Given the severity of her abdominal examination and her persistence of her symptoms we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy The risks benefits complications of the procedure she gave us informed consent to proceed OPERATIVE FINDINGS Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it it was slightly enlarged The left ovary revealed some follicular cysts There was no evidence of adnexal masses and or torsion of the fallopian tubes The uterus revealed no evidence of mass and or fibroid tumors The remainder of the abdomen was unremarkable OPERATIVE PROCEDURE The patient was brought to the operative suite placed in the supine position The abdomen was prepped and draped in the normal sterile fashion with Betadine solution The patient underwent general endotracheal anesthesia The patient also received a preoperative dose of Ancef 1 gram IV After adequate sedation was achieved a 10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg Once the abdomen was sufficiently insufflated a 10 mm bladed trocar was inserted into the abdomen without difficulty A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored Next a 5 mm port was inserted in the midclavicular line of the right upper quadrant region This was inserted under direct visualization Finally a suprapubic 12 mm portal was created This was performed with 10 blade scalpel to create a transverse incision A bladed trocar was inserted into the suprapubic region This was done again under direct visualization Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly Utilizing a endovascular stapling device the appendix was transected and doubly stapled with this device Next the mesoappendix was doubly stapled and transected with the endovascular stapling device The staple line was visualized and there was no evidence of bleeding The abdomen was fully irrigated with copious amounts of normal saline The abdomen was then aspirated There was no evidence of bleeding All ports were removed under direct visualization No evidence of bleeding from the port sites The infraumbilical and suprapubic ports were then closed The fascias were then closed with 0 Vicryl suture on a UR6 needle Once the fascias were closed all incisions were closed with 4 0 undyed Vicryl The areas were cleaned Steri Strips were placed across the wound Sterile dressing was applied The patient tolerated the procedure well She was extubated following the procedure returned to Postanesthesia Care Unit in stable condition She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course Keywords gastroenterology lower quadrant diagnostic laparoscopy acute appendicitis laparoscopic appendectomy abdomen appendectomy laparoscopy appendix suprapubic MEDICAL_TRANSCRIPTION,Description Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Medical Specialty Gastroenterology Sample Name Melena ICU Followup Transcription HISTORY Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient Over the last 24 hours the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value He also underwent EGD earlier today with Dr X I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding Dr X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough now producing yellow brown sputum with increasing frequency but he has had no further episodes of melena since transfer to the ICU He is also complaining of some laryngitis and some pharyngitis but is denying any abdominal complaints nausea or diarrhea PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 100 54 heart rate 80 and temperature 98 8 Is and Os negative fluid balance of 1 4 liters in the last 24 hours GENERAL This is a somnolent 68 year old male who arouses to voice wakes up seems to have good appetite has continuing cough Pallor is improved EYES Conjunctivae are now pink ENT Oropharynx is clear CARDIOVASCULAR Reveals distant heart tones with regular rate and rhythm LUNGS Have coarse breath sounds with wheezes rhonchi and soft crackles in the bases ABDOMEN Soft and nontender with no organomegaly appreciated EXTREMITIES Showed no clubbing cyanosis or edema Capillary refill time is now normal in the fingertips NEUROLOGICAL Cranial nerves II through XII are grossly intact with no focal neurological deficits LABORATORY DATA Laboratories drawn at 1449 today WBC 10 hemoglobin and hematocrit 11 5 and 33 1 and platelets 288 000 This is up from 8 6 and 24 7 Platelets are stable Sodium is 134 potassium 4 0 chloride 101 bicarb 26 BUN 19 creatinine 1 0 glucose 73 calcium 8 4 INR 0 96 iron 13 saturations 4 TIBC 312 TSH 0 74 CEA elevated at 8 6 ferritin 27 5 and occult blood positive EGD final results pending per Dr X s note and conversation with me earlier ulcerative esophagitis without signs of active bleeding at this time IMPRESSION PLAN 1 Melena secondary to ulcerative esophagitis We will continue to monitor the patient overnight to ensure there is no further bleeding If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation 2 Chronic obstructive pulmonary disease exacerbation The patient is doing well taking PO We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments We will add guaifenesin and N acetyl cysteine in a hope to mobilize some of his secretions This does appear to be improving His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications 3 Elevated CEA The patient will need colonoscopy on an outpatient basis He has refused this today We would like to encourage him to do so Of note the patient when he came in was on bloodless protocol but with urging did accept the transfusion Similarly I am hoping that with proper counseling the patient will consent to further examination with colonoscopy given his guaiac positive status elevated CEA and risk factors 4 Anemia normochromic normocytic with low total iron binding capacity This appears to be anemia of chronic disease However this is likely some iron deficiency superimposed on top of this given his recent bleeding with consider iron vitamin C folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding Total critical care time spent today discussing the case with Dr X examining the patient reviewing laboratory trends adjusting medications and counseling the patient in excess is 35 minutes Keywords gastroenterology anemia gi bleeding hemoglobin ulcerative esophagitis obstructive pulmonary disease icu followup infection obstructive pulmonary egd melena bleeding MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy Medical Specialty Gastroenterology Sample Name Laparoscopic Gastric Bypass 1 Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic Roux en Y gastric bypass antecolic antegastric with 25 mm EEA anastamosis esophagogastroduodenoscopy ANESTHESIA General with endotracheal intubation INDICATIONS FOR PROCEDURE This is a 50 year old male who has been overweight for many years and has tried multiple different weight loss diets and programs The patient has now begun to have comorbidities related to the obesity The patient has attended our bariatric seminar and met with our dietician and psychologist The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form PROCEDURE IN DETAIL The risks and benefits were explained to the patient Consent was obtained The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation A Foley catheter was placed for bladder decompression All pressure points were carefully padded and sequential compression devices were placed on the legs The abdomen was prepped and draped in standard sterile surgical fashion Marcaine was injected into the umbilicus Keywords gastroenterology morbid obesity roux en y gastric bypass antecolic antegastric anastamosis esophagogastroduodenoscopy eea surgidac sutures roux limb port stapler laparoscopic intubation MEDICAL_TRANSCRIPTION,Description Diagnostic laparoscopy and rigid sigmoidoscopy Acute pain fever postoperatively hemostatic uterine perforation no bowel or vascular trauma Medical Specialty Gastroenterology Sample Name Laparoscopy Sigmoidoscopy Transcription PREOPERATIVE DIAGNOSES 1 Acute pain 2 Fever postoperatively POSTOPERATIVE DIAGNOSIS 1 Acute pain 2 Fever postoperatively 3 Hemostatic uterine perforation 4 No bowel or vascular trauma PROCEDURE PERFORMED 1 Diagnostic laparoscopy 2 Rigid sigmoidoscopy by Dr X ANESTHESIA General endotracheal COMPLICATIONS None ESTIMATED BLOOD LOSS Scant SPECIMEN None INDICATIONS This is a 17 year old African American female gravida 1 para 1 and had a hysteroscopy and dilation curettage on 09 05 03 The patient presented later that evening after having increasing abdominal pain fever and chills at home with a temperature up to 101 2 The patient denied any nausea vomiting or diarrhea She does complain of some frequent urination Her vaginal bleeding is minimal FINDINGS On bimanual exam the uterus is approximately 6 week size anteverted and freely mobile with no adnexal masses appreciated On laparoscopic exam there is a small hemostatic perforation noted on the left posterior aspect of the uterus There is approximately 40 cc of serosanguineous fluid in the posterior cul de sac The bilateral tubes and ovaries appeared normal There is no evidence of endometriosis in the posterior cul de sac or along the bladder flap There is no evidence of injury to the bowel or pelvic sidewall The liver margin gallbladder and remainder of the bowel including the appendix appeared normal PROCEDURE After consent was obtained the patient was taken to the Operating Room where general anesthetic was administered The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion A sterile speculum was placed in the patient s vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum The uterine manipulator was then placed into the patient s cervix and the vulsellum tenaculum and sterile speculum were removed Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made Veress needle was placed through this incision and the gas turned on When good flow and low abdominal pressures were noted the gas was turned up and the abdomen was allowed to insufflate A 11 mm trocar was then placed through this incision The camera was placed with the above findings noted A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs The serosanguineous fluid of the cul de sac was aspirated and the pelvis was copiously irrigated with sterile saline At this point Dr X was consulted He performed a rigid sigmoidoscopy please see his dictation for further details There does not appear to be any evidence of colonic injury The saline in the pelvis was then suctioned out using Nezhat Dorsey All instruments were removed The 5 mm trocar was removed under direct visualization with excellent hemostasis noted The camera was removed and the abdomen was allowed to desufflate The 11 mm trocar introducer was replaced and the trocar removed The skin was then closed with 4 0 undyed Vicryl in a subcuticular fashion Approximately 10 cc of 0 25 Marcaine was injected into the incision sites for postoperative pain relief Steri Strips were then placed across the incision The uterine manipulator was then removed from the patient s cervix with excellent hemostasis noted The patient tolerated the procedure well Sponge lap and needle counts were correct at the end of the procedure The patient was taken to the recovery room in satisfactory condition She will be followed immediately postoperatively within the hospital and started on IV antibiotics Keywords gastroenterology uterine perforation vascular bowel diagnostic laparoscopy vulsellum tenaculum uterine manipulator excellent hemostasis rigid sigmoidoscopy laparoscopy sigmoidoscopy postoperatively trocar MEDICAL_TRANSCRIPTION,Description Laparoscopy laparotomy cholecystectomy with operative cholangiogram choledocholithotomy with operative choledochoscopy and T tube drainage of the common bile duct Medical Specialty Gastroenterology Sample Name Laparoscopy Laparotomy Cholecystectomy Transcription PREOPERATIVE DIAGNOSES Cholelithiasis cholecystitis and recurrent biliary colic POSTOPERATIVE DIAGNOSES Severe cholecystitis cholelithiasis choledocholithiasis and morbid obesity PROCEDURES PERFORMED Laparoscopy laparotomy cholecystectomy with operative cholangiogram choledocholithotomy with operative choledochoscopy and T tube drainage of the common bile duct ANESTHESIA General INDICATIONS This is a 63 year old white male patient with multiple medical problems including hypertension diabetes end stage renal disease coronary artery disease and the patient is on hemodialysis who has had recurrent episodes of epigastric right upper quadrant pain The patient was found to have cholelithiasis on last admission He was being worked up for this including cardiac clearance However in the interim he returned again with another episode of same pain The patient had a HIDA scan done yesterday which shows nonvisualization of the gallbladder consistent with cystic duct obstruction Because of these laparoscopic cholecystectomy was advised with cholangiogram Possibility of open laparotomy and open procedure was also explained to the patient The procedure indications risks and alternatives were discussed with the patient in detail and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was put in supine position on the operating table under satisfactory general anesthesia The entire abdomen was prepped and draped A small transverse incision was made about 2 1 2 inches above the umbilicus in the midline under local anesthesia The patient has a rather long torso Fascia was opened vertically and stay sutures were placed in the fascia Peritoneal cavity was carefully entered Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2 Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area The patient was placed in reverse Trendelenburg and rotated to the left An 11 mm trocar was placed in the subxiphoid space and two 5 mm in the right subcostal region Slowly the dissection was carried out in the right subhepatic area Initially I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver Then some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection inflammation The visualization was extremely difficult because of the patient s obesity and a lot of fat intra abdominally although his abdominal wall is not that thick After evaluating this for a little while we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy The trocars were removed A right subcostal incision was made and peritoneal cavity was entered A Bookwalter retractor was put in place The dissection was then carried out on the undersurface of the liver Eventually the gallbladder was identified which was markedly scarred down and shrunk and appeared to have palpable stone in it Dissection was further carried down to what was felt to be the common bile duct which appeared to be somewhat larger than normal about a centimeter in size The duodenum was kocherized The gallbladder was partly intrahepatic Because of this I decided not to dig it out of the liver bed causing further bleeding and problem The inferior wall of the gallbladder was opened and two large stones one was about 3 cm long and another one about 1 5 x 2 cm long were taken out of the gallbladder It was difficult to tell where the cystic duct was Eventually after probing near the neck of the gallbladder I did find the cystic duct which was relatively very short Intraoperative cystic duct cholangiogram was done using C arm fluoroscopy This showed a rounded density at the lower end of the bile duct consistent with the stone At this time a decision was made to proceed with common duct exploration The common duct was opened between stay sutures of 4 0 Vicryl and immediately essentially clear bile came out After some pressing over the head of the pancreas through a kocherized maneuver the stone did fall into the opening in the common bile duct So it was about a 1 cm size stone which was removed Following this a 10 French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously No further stones were obtained The catheter went easily into the duodenum through the ampulla of Vater At this point a choledochoscope was inserted and proximally I did not see any evidence of any common duct stones or proximally into the biliary tree However a stone was found distally still floating around This was removed with stone forceps The bile ducts were irrigated again No further stones were removed A 16 French T tube was then placed into the bile duct and the bile duct was repaired around the T tube using 4 0 Vicryl interrupted sutures obtaining watertight closure A completion T tube cholangiogram was done at this time which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct although externally I was unable to see anything or palpate anything in this area Because of this the T tube was removed and I passed the choledochoscope proximally again and I was unable to see any evidence of any lesion or any stone in this area I felt at this time this was most likely an impression from the outside which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct The bile duct lumen was widely open T tube was again replaced into the bile duct and closed again and a completion T tube cholangiogram appeared to be more satisfactory at this time The cystic duct opening through which I had done earlier a cystic duct cholangiogram this was closed with a figure of eight suture of 2 0 Vicryl and this was actually done earlier and completion cholangiogram did not show any leak from this area The remaining gallbladder bed which was left in situ was cauterized both for hemostasis and to burn off the mucosal lining Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution Hemostasis was good A 10 mm Jackson Pratt drain was left in the foramen of Winslow and brought out through the lateral 5 mm port site The T tube was brought out through the middle 5 mm port site which was just above the incision Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and 1 Novafil running suture for the fascia Subcutaneous tissue was closed with 3 0 Vicryl running sutures in two layers Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0 25 Marcaine with epinephrine for postoperative pain control The umbilical incision was closed with 0 Vicryl figure of eight sutures for the fascia 2 0 Vicryl for the subcutaneous tissues and staples for the skin Sterile dressing was applied and the patient transferred to recovery room in stable condition Keywords gastroenterology cholelithiasis cholecystitis biliary colic choledocholithiasis laparoscopy laparotomy cholecystectomy cholangiogram choledocholithotomy choledochoscopy t tube drainage cystic duct cholangiogram common bile duct peritoneal cavity gallbladder MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with cholangiogram Acute gangrenous cholecystitis with cholelithiasis The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy Cholangiogram Transcription PREOPERATIVE DIAGNOSIS Acute cholecystitis POSTOPERATIVE DIAGNOSIS Acute gangrenous cholecystitis with cholelithiasis OPERATION PERFORMED Laparoscopic cholecystectomy with cholangiogram FINDINGS The patient had essentially a dead gallbladder with stones and positive wide bile pus coming from the gallbladder COMPLICATIONS None EBL Scant SPECIMEN REMOVED Gallbladder with stones DESCRIPTION OF PROCEDURE The patient was prepped and draped in the usual sterile fashion under general anesthesia A curvilinear incision was made below the umbilicus Through this incision the camera port was able to be placed into the peritoneal cavity under direct visualization Once this complete insufflation was begun Once insufflation was adequate additional ports were placed in the epigastrium as well as right upper quadrant Once all four ports were placed the right upper quadrant was then explored The patient had significant adhesions of omentum and colon to the liver the gallbladder constituting definitely an acute cholecystitis This was taken down using Bovie cautery to free up visualization of the gallbladder The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall Adhesions were further taken down between the omentum the colon and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area Once the adhesions were fully removed the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction At this point due to the patient s gallbladder being very necrotic it was deemed that the patient should have a drain placed The cystic duct and cystic artery were serially clipped and transected The gallbladder was removed from the gallbladder fossa removing the entire gallbladder Adequate hemostasis with Bovie cautery was achieved The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3 0 nylon suture Next the right upper quadrant was copiously irrigated out using the suction irrigator Once this was complete the additional ports were able to be removed The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure of 8 fashion All skin incisions were injected using Marcaine 1 4 percent plain The skin was reapproximated further using 4 0 Monocryl sutures in a subcuticular technique The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition Keywords gastroenterology acute cholecystitis cholangiogram cholelithiasis cholecystitis gallbladder gangrenous cholecystitis bovie cautery cystic duct laparoscopic cholecystectomy laparoscopic cholecystectomy cystic duct MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with attempted intraoperative cholangiogram A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy Cholangiogram 1 Transcription PROCEDURE PERFORMED Laparoscopic cholecystectomy with attempted intraoperative cholangiogram PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adapter in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer s lines spreading the subcutaneous tissues with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 3 other trocars were placed The first was a 10 11 mm trocar in the upper midline position The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder A laparoscopic dissector was then placed through the upper midline cannula fitted with a reducer and the structures within the triangle of Calot were meticulously dissected free A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder The gallbladder was then grasped through the upper midline cannula and a fine tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips Several attempts at passing the cholangiocatheter into the ductotomy were made Despite numerous attempts at several angles the cholangiocatheter could not be inserted into the cystic duct After several such attempts and due to the fact that the anatomy was clear we aborted any further attempts at cholangiography The distal cystic duct was doubly clipped The duct was divided between the clips The clips were carefully placed to avoid occluding the juncture with the common bile duct The port sites were injected with 0 5 Marcaine The cystic artery was found medially and slightly posteriorly to the cystic duct It was carefully dissected free from its surrounding tissues A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally The artery was divided between the clips The port sites were injected with 0 5 Marcaine After the cystic duct and artery were transected the gallbladder was dissected from the liver bed using Bovie electrocautery Prior to complete dissection of the gallbladder from the liver the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none After the complete detachment of the gallbladder from the liver the video laparoscope was removed and placed through the upper 10 11 mm cannula The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula As the gallbladder was pulled through the umbilical fascial defect the entire sheath and forceps were removed from the abdomen The neck of the gallbladder was then secured with a Kocher clamp and the gallbladder was removed from the abdomen Following gallbladder removal the remaining carbon dioxide was expelled from the abdomen Both midline fascial defects were then approximated using 0 Vicryl suture All skin incisions were approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied Dressings were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords gastroenterology intraoperative cholangiogram cystic artery laparoscopic cholecystectomy cystic duct gallbladder tonsil cholecystectomy cholangiogram abdomen laparoscopic cannula MEDICAL_TRANSCRIPTION,Description Morbid obesity Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful Medical Specialty Gastroenterology Sample Name Laparoscopic Gastric Bypass Transcription PREOPERATIVE DIAGNOSIS Morbid obesity POSTOPERATIVE DIAGNOSIS Morbid obesity PROCEDURE Laparoscopic antecolic antegastric Roux en Y gastric bypass with EEA anastomosis ANESTHESIA General with endotracheal intubation INDICATION FOR PROCEDURE This is a 30 year old female who has been overweight for many years She has tried many different diets but is unsuccessful She has been to our Bariatric Surgery Seminar received some handouts and signed the consent The risks and benefits of the procedure have been explained to the patient PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table All pressure points were carefully padded She was given general anesthesia with endotracheal intubation SCD stockings were placed on both legs Foley catheter was placed for bladder decompression The abdomen was then prepped and draped in standard sterile surgical fashion Marcaine was then injected through umbilicus A small incision was made A Veress needle was introduced into the abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg A 12 mm VersaStep port was placed through the umbilicus I then placed a 5 mm port just anterior to the midaxillary line and just subcostal on the right side I placed another 5 mm port in the midclavicular line just subcostal on the right side a few centimeters below and medial to that I placed a 12 mm VersaStep port On the left side just anterior to the midaxillary line and just subcostal I placed a 5 mm port A few centimeters below and medial to that I placed a 15 mm port I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device I then ran the distal bowel down approximately 100 cm and at 100 cm I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb and I passed a 45 white load stapler and fired a stapler creating a side to side anastomosis I reapproximated the edges of the defect I lifted it up and stapled across it with another white load stapler I then closed the mesenteric defect with interrupted Surgidac sutures I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic I then put the patient in reverse Trendelenburg I placed a liver retractor identified and dissected the angle of His I then dissected on the lesser curve approximately 2 5 cm below the gastroesophageal junction and got into a lesser space I fired transversely across the stomach with a 45 blue load stapler I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His thereby creating my gastric pouch I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil I pulled the anvil into place and I then opened up my 15 mm port site and passed my EEA stapler I passed that in the end of my Roux limb and had the spike come out antimesenteric I joined the spike with the anvil and fired a stapler creating an end to side anastomosis then divided across the redundant portion of my Roux limb with a white load GI stapler and removed it with an Endocatch bag I put some additional 2 0 Vicryl sutures in the anastomosis for further security I then placed a bowel clamp across the bowel I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch I distended gastric pouch with air There was no air leak seen I could pass the scope easily through the anastomosis There was no bleeding seen through the scope We closed the 15 mm port site with interrupted 0 Vicryl suture utilizing Carter Thomason I copiously irrigated out that incision with about 2 L of saline I then closed the skin of all incisions with running Monocryl Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well without any complications Keywords gastroenterology gastric bypass eea anastomosis roux en y antegastric antecolic morbid obesity roux limb gastric pouch intubation laparoscopic bypass roux endotracheal anastomosis gastric MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 9 Transcription PROCEDURE PERFORMED Laparoscopic cholecystectomy PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A 2 cm infraumbilical midline incision was made The fascia was then cleared of subcutaneous tissue using a tonsil clamp A 1 2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia and then tied to the special 12 mm Hasson trocar fitted with a funnel shaped adapter in order to occlude the fascial opening Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer s lines spreading the subcutaneous tissues with a tonsil clamp and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar A total of 3 other trocars were placed The first was a 10 11 mm trocar in the upper midline position The second was a 5 mm trocar placed in the anterior iliac spine The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars All of the trocars were placed without difficulty The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder A laparoscopic dissector was then placed through the upper midline cannula fitted with a reducer and the structures within the triangle of Calot were meticulously dissected free A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally The duct was divided between the clips The clips were carefully placed to avoid occluding the juncture with the common bile duct The cystic artery was found medially and slightly posterior to the cystic duct It was carefully dissected free from its surrounding tissues A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally The artery was divided between the clips The 2 midline port sites were injected with 5 Marcaine After the complete detachment of the gallbladder from the liver the video laparoscope was removed and placed through the upper 10 11 mm cannula The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula As the gallbladder was pulled through the umbilical fascial defect the entire sheath and forceps were removed from the abdomen The neck of the gallbladder was removed from the abdomen Following gallbladder removal the remaining carbon dioxide was expelled from the abdomen Both midline fascial defects were then approximated using 0 Vicryl suture All skin incisions were approximated with 4 0 Vicryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied Dressings were applied All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords gastroenterology langer s lines laparoscope cystic duct cystic artery laparoscopic cholecystectomy midline cannula infraumbilical tonsil cholecystectomy fascia abdomen trocars cannula laparoscopic gallbladder MEDICAL_TRANSCRIPTION,Description Symptomatic cholelithiasis Laparoscopic cholecystectomy and appendectomy CPT 47563 44970 The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis Laparoscopic cholecystectomy and appendectomy were recommended to her Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy Appendectomy Transcription PREOPERATIVE DIAGNOSIS Symptomatic cholelithiasis POSTOPERATIVE DIAGNOSIS Symptomatic cholelithiasis PROCEDURE Laparoscopic cholecystectomy and appendectomy CPT 47563 44970 ANESTHESIA General endotracheal INDICATIONS This is an 18 year old girl with sickle cell anemia who has had symptomatic cholelithiasis She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis Laparoscopic cholecystectomy and appendectomy were recommended to her The procedure was explained in detail including the risks of bleeding infection biliary injury retained common duct stones After answering her questions she wished to proceed and gave informed consent DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine on the operating table She was positively identified and the correct surgical site and procedure reviewed After successful administration of general endotracheal anesthesia the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped The infraumbilical skin was infiltrated with 0 25 bupivacaine with epinephrine and horizontal incision created The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg A 12 mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity Upper abdominal anatomy was normal Pelvic laparoscopy revealed bilaterally closed internal inguinal rings Additional trocars were placed under direct vision including a 5 mm reusable in the right lateral _____ There was a 12 mm expandable disposable in the right upper quadrant and a 5 mm reusable in the subxiphoid region Using these the gallbladder was grasped and retraced cephalad Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction A small ductotomy was created Reddick cholangiogram catheter was then placed within the duct and the balloon inflated Continuous fluoroscopy was used to instill contrast material This showed normal common bile duct which entered the duodenum without obstruction There was no evidence of common bile duct stones The cholangiogram catheter was removed The duct was doubly clipped and divided The artery was divided and cauterized The gallbladder was taken out of the gallbladder fossa It was then placed in Endocatch bag and left in the abdomen Attention was then paid to the appendix The appendix was identified and window was made in the mesoappendix at the base This was amputated with an Endo GIA stapler The mesoappendix was divided with an Endo GIA vascular stapler This was placed in another Endocatch bag The abdomen was then irrigated Hemostasis was satisfactory Both the appendix and gallbladder were removed and sent for pathology All trocars were removed The 12 mm port sites were closed with 2 0 PDS figure of eight fascial sutures The umbilical skin was reapproximated with interrupted 5 0 Vicryl Rapide The remaining skin incisions were closed with 5 0 Monocryl subcuticular suture The skin was cleaned Mastisol Steri Strips and band aids were applied The patient was awakened extubated in the operating room transferred to the recovery room in stable condition Keywords gastroenterology endo gia endocatch bag symptomatic cholelithiasis laparoscopic cholecystectomy appendectomy cholangiogram mesoappendix abdomen appendix cholelithiasis endotracheal laparoscopic cholecystectomy gallbladder duct MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis cholelithiasis and liver cyst Laparoscopic cholecystectomy and excision of liver cyst Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy Liver Cyst Excision Transcription PREOPERATIVE DIAGNOSES 1 Chronic cholecystitis 2 Cholelithiasis POSTOPERATIVE DIAGNOSES 1 Chronic cholecystitis 2 Cholelithiasis 3 Liver cyst PROCEDURES PERFORMED 1 Laparoscopic cholecystectomy 2 Excision of liver cyst ANESTHESIA General endotracheal and injectable 0 25 Marcaine with 1 lidocaine SPECIMENS Include 1 Gallbladder 2 Liver cyst ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None OPERATIVE FINDINGS Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder Additionally there was a notable liver cyst The remainder of the abdomen remained free of any adhesions BRIEF HISTORY This is a 66 year old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy The patient complained of intractable nausea vomiting and abdominal bloating after eating fatty foods She had had multiple attacks in the past of these complaints She was discovered to have had right upper quadrant pain on examination Additionally she had an ultrasound performed on 08 04 2003 which revealed cholelithiasis The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms She was explained the risks benefits and complications of the procedure and she gave informed consent to proceed OPERATIVE PROCEDURE The patient was brought to the operative suite and placed in the supine position The patient received preoperative antibiotics with Kefzol The abdomen was prepped and draped in the normal sterile fashion with Betadine solution The patient did undergo general endotracheal anesthesia Once the adequate sedation was achieved a supraumbilical transverse incision was created with a 10 blade scalpel Utilizing a Veress needle the Veress needle was inserted intra abdominally and was hooked to the CO2 insufflation The abdomen was insufflated to 15 mmHg After adequate insufflation was achieved the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder Decision to proceed with laparoscopic cystectomy was decided A subxiphoid transverse incision was created with a 10 blade scalpel and utilizing a bladed 12 mm trocar the trocar was inserted under direct visualization into the abdomen Two 5 mm ports were placed one at the midclavicular line 2 cm below the costal margin and a second at the axillary line one hand length approximately below the costal margin All ports were inserted with bladed 5 mm trocar then under direct visualization After all trocars were inserted the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder Adhesions adjacent were taken down with a Maryland dissector Once this was performed the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly This helped to better delineate the cystic duct as well as the cystic artery Utilizing Maryland dissector careful dissection of the cystic duct and cystic artery were created posteriorly behind each one Utilizing Endoclips clips were placed on the cystic duct and cystic artery one proximal to the gallbladder and two distally Utilizing endoscissors the cystic duct and cystic artery were ligated Next utilizing electrocautery the gallbladder was carefully dissected off the liver bed Electrocautery was used to stop any bleeding encountered along the way The gallbladder was punctured during dissection and cleared biliary contents did drained into the abdomen No evidence of stones were visualized Once the gallbladder was completely excised from the liver bed an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port This was sent off as an specimen a gallstone was identified within the gallbladder Next utilizing copious amounts of irrigation the abdomen was irrigated A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver This was also taken and sent off as specimen The abdomen was then copiously irrigated until clear irrigation was identified All laparoscopic ports were removed under direct visualization The abdomen was de insufflated Utilizing 0 Vicryl suture the abdominal fascia was approximated with a figure of eight suture in the supraumbilical and subxiphoid region All incisions were then closed with 4 0 undyed Vicryl Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures The areas were cleaned and dried Steri Strips were placed On the incisions sterile dressing was applied The patient tolerated the procedure well She was extubated following procedure She is seen to tolerate the procedure well and she will follow up with Dr X within one week for a follow up evaluation Keywords gastroenterology excision of liver cyst gallbladder omentum cystic artery gallstone laparoscopic cholecystectomy cystic duct liver cyst liver abdomen electrocautery cholelithiasis cholecystectomy adhesions laparoscopic cyst cystic MEDICAL_TRANSCRIPTION,Description Biliary colic Laparoscopic cholecystectomy Laparoscopic examination showed no injury from entry Marcaine was then injected just subxiphoid and a 5 mm port was placed under direct visualization for the laparoscope Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 5 Transcription PREOPERATIVE DIAGNOSIS Biliary colic Keywords gastroenterology veress needle gallbladder laparoscope laparoscopic examination endotracheal intubation laparoscopic cholecystectomy biliary colic abdomen cholecystectomy endotracheal umbilicus laparoscopic MEDICAL_TRANSCRIPTION,Description Acute cholecystitis Laparoscopic cholecystectomy The abdominal area was prepped and draped in the usual sterile fashion A small skin incision was made below the umbilicus It was carried down in the transverse direction on the side of her old incision It was carried down to the fascia Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 4 Transcription PREOPERATIVE DIAGNOSIS Acute cholecystitis POSTOPERATIVE DIAGNOSIS Acute cholecystitis PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General ESTIMATED BLOOD LOSS Zero COMPLICATIONS None PROCEDURE The patient was taken to the operating room and after obtaining adequate general anesthesia the patient was placed in the supine position The abdominal area was prepped and draped in the usual sterile fashion A small skin incision was made below the umbilicus It was carried down in the transverse direction on the side of her old incision It was carried down to the fascia An open pneumoperitoneum was created with Hasson technique Three additional ports were placed in the usual fashion The gallbladder was found to be acutely inflamed distended and with some necrotic areas It was carefully retracted from the isthmus and the cystic structure was then carefully identified dissected and divided between double clips The gallbladder was then taken down from the gallbladder fossa with electrocautery There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones The fascia had to be opened The gallbladder had to be opened and the stones had to be extracted carefully When it was completed I went back to the abdomen and achieved complete hemostasis The ports were then removed under direct vision with the scope The fascia of the umbilical wound was closed with a figure of eight 0 Vicryl All the incisions were injected with 0 25 Marcaine closed with 4 0 Monocryl Steri Strips and sterile dressing The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition Keywords gastroenterology laparoscopic cholecystectomy cholecystitis gallbladder fossa laparoscopic cholecystectomy acute cholecystitis gallbladder MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis Laparoscopic cholecystectomy Patient with increasingly severe more frequent right upper quadrant abdominal pain more after meals had a positive ultrasound for significant biliary sludge Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 8 Transcription PREOPERATIVE DIAGNOSIS Chronic cholecystitis POSTOPERATIVE DIAGNOSIS Chronic cholecystitis PROCEDURE PERFORMED Laparoscopic cholecystectomy BLOOD LOSS Minimal ANESTHESIA General endotracheal anesthesia COMPLICATIONS None CONDITION Stable DRAINS None DISPOSITION To recovery room and to home FLUIDS Crystalloid FINDINGS Consistent with chronic cholecystitis Final pathology is pending INDICATIONS FOR THE PROCEDURE Briefly the patient is a 38 year old male referred with increasingly severe more frequent right upper quadrant abdominal pain more after meals had a positive ultrasound for significant biliary sludge He presented now after informed consent for the above procedure PROCEDURE IN DETAIL The patient was identified in the preanesthesia area then taken to the operating room placed in the supine position on the operating table and induced under general endotracheal anesthesia The patient was correctly positioned padded at all pressure points had antiembolic TED hose and Flowtrons in the lower extremities The anterior abdomen was then prepared and draped in a sterile fashion Preemptive local anesthetic was infiltrated with 1 lidocaine and 0 5 ropivacaine The initial incision was made sharply at the umbilicus with a 15 scalpel blade and carried down through deeper tissues with Bovie cautery down to the midline fascia with a 15 scalpel blade The blunt tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg The epigastric and right subcostal trocars were placed under direct vision The right upper quadrant was well visualized The gallbladder was noted to be significantly distended with surrounding dense adhesions The fundus of the gallbladder was grasped and retracted anteriorly and superiorly and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet nose Bovie dissector and the blunt Kittner peanut dissector Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right angle clamp The cystic duct was clipped x3 and then divided The cystic artery was dissected out in like fashion clipped x3 and then divided The gallbladder was then taken off the liver bed in a retrograde fashion using the hook tip Bovie cautery with good hemostasis Prior to removal of the gallbladder all irrigation fluid was clear No active bleeding or oozing was seen All clips were noted to be secured and intact and in place The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology The camera was placed back once again into the abdominal cavity through the umbilical port and all areas remained clean and dry and the trocar was removed under direct visualization The insufflation was allowed to escape The umbilical fascia was closed using interrupted 1 Vicryl sutures Finally the skin was closed in a layered subcuticular fashion with interrupted 3 0 and 4 0 Monocryl Sterile dressings were applied The patient tolerated the procedure well Keywords gastroenterology abdomen bovie cautery endotracheal anesthesia laparoscopic cholecystectomy cystic duct chronic cholecystitis abdominal laparoscopic cholecystectomy cholecystitis gallbladder MEDICAL_TRANSCRIPTION,Description Cholecystitis and cholelithiasis Laparoscopic cholecystectomy and intraoperative cholangiogram The patient received 1 gm of IV Ancef intravenously piggyback The abdomen was prepared and draped in routine sterile fashion Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 7 Transcription PREOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis POSTOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis TITLE OF PROCEDURE 1 Laparoscopic cholecystectomy 2 Intraoperative cholangiogram ANESTHESIA General PROCEDURE IN DETAIL The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic The patient received 1 gm of IV Ancef intravenously piggyback The abdomen was prepared and draped in routine sterile fashion A 1 cm incision was made at the umbilicus and a Veress needle was inserted Saline test was performed Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg The Veress needle was removed A 10 to 11 mm cannula was inserted Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it It was largely mobile The liver had a normal appearance as did the peritoneal cavity A 5 mm cannula was inserted in the right upper quadrant anterior axillary line A second 5 mm cannula was inserted in the subcostal space A 10 to 11 mm cannula was inserted into the upper midline The gallbladder was reflected in a cephalad direction The gallbladder was punctured with the aspirating needle and under C arm fluoroscopy was filled with contrast filling the intra and extrahepatic biliary trees which appeared normal Extra contrast was aspirated and the aspirating needle was removed The ampulla was grasped with a second grasper opening the triangle of Calot The cystic duct was dissected and exposed at its junction with the ampulla was controlled with a hemoclip digitally controlled with two clips and divided This was done while the common duct was in full visualization The cystic artery was similarly controlled and divided The gallbladder was dissected from its bed and separated from the liver brought to the outside through the upper midline cannula and removed The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution There was oozing and bleeding from the lateral 5 mm cannula site but this stopped spontaneously with removal of the cannula The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear Hemostasis was excellent CO2 was evacuated and the camera removed The umbilical fascia was closed with 2 0 Vicryl the subcu with 3 0 Vicryl and the skin was closed with 4 0 nylon Sterile dressings were applied Sponge and needle counts were correct Keywords gastroenterology cholangiogram cholecystitis cholelithiasis ancef endotracheal umbilicus veress needle c arm fluoroscopy intraoperative cholangiogram laparoscopic cholecystectomy laparoscopic cholecystectomy gallbladder cannula MEDICAL_TRANSCRIPTION,Description Cholelithiasis possible choledocholithiasis Laparoscopic cholecystectomy and intraoperative cholangiogram A small incision was made in the umbilicus and a Veress needle was introduced into the abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed into the umbilicus Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 6 Transcription PREOPERATIVE DIAGNOSIS Cholelithiasis possible choledocholithiasis Keywords gastroenterology choledocholithiasis cholangiogram co2 insufflation umbilicus common bile duct bile duct laparoscopic cholecystectomy cystic duct intraoperative laparoscopic cholecystectomy cholelithiasis endotracheal gallbladder cystic duct MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Biliary colic and biliary dyskinesia The patient had a workup for her gallbladder which showed evidence of biliary dyskinesia Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 10 Transcription PREOPERATIVE DIAGNOSIS Biliary colic and biliary dyskinesia POSTOPERATIVE DIAGNOSIS Biliary colic and biliary dyskinesia PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General endotracheal COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition BRIEF HISTORY This patient is a 42 year old female who presented to Dr X s office with complaints of upper abdominal and back pain which was sudden onset for couple of weeks The patient is also diabetic The patient had a workup for her gallbladder which showed evidence of biliary dyskinesia The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia INTRAOPERATIVE FINDINGS The patient s abdomen was explored There was no evidence of any peritoneal studding or masses The abdomen was otherwise within normal limits The gallbladder was easily visualized There was an intrahepatic gallbladder There was no evidence of any inflammatory change PROCEDURE After informed written consent the risks and benefits of the procedure were explained to the patient The patient was brought into the operating suite After general endotracheal intubation the patient was prepped and draped in normal sterile fashion Next an infraumbilical incision was made with a 10 scalpel The skin was elevated with towel clips and a Veress needle was inserted The abdomen was then insufflated to 15 mmHg of pressure The Veress needle was removed and a 10 blade trocar was inserted without difficulty The laparoscope was then inserted through this 10 port and the abdomen was explored There was no evidence of any peritoneal studding The peritoneum was smooth The gallbladder was intrahepatic somewhat No evidence of any inflammatory change There were no other abnormalities noted in the abdomen Next attention was made to placing the epigastric 10 port which again was placed under direct visualization without difficulty The two 5 ports were placed one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization The gallbladder was then grasped out at its fundus elevated to patient s left shoulder Using a curved dissector the cystic duct was identified and freed up circumferentially Next an Endoclip was used to distal and proximal to the gallbladder Endoshears were used in between to transect the cystic duct The cystic artery was transected in similar fashion Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip It was done without difficulty The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology Hemostasis was maintained using electrobovie cautery The liver bed was then copiously irrigated and aspirated All the fluid and air was then aspirated and then all ports were removed under direct visualization The two 10 ports were then closed in the fascia with 0 Vicryl and a UR6 needle The skin was closed with a running subcuticular 4 0 undyed Vicryl 0 25 Marcaine was injected and Steri Strips and sterile dressings were applied The patient tolerated the procedure well and was transferred to Recovery in stable condition Keywords gastroenterology electrobovie cautery laparoscopic cholecystectomy biliary colic biliary dyskinesia biliary laparoscopic cholecystectomy colic abdomen dyskinesia gallbladder MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 1 Transcription PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table General endotracheal anesthesia was induced The patient was then prepped and draped in the usual sterile fashion An 11 blade scalpel was used to make a small infraumbilical skin incision in the midline The fascia was elevated between two Ochsner clamps and then incised A figure of eight stitch of 2 0 Vicryl was placed through the fascial edges The 11 mm port without the trocar engaged was then placed into the abdomen A pneumoperitoneum was established After an adequate pneumoperitoneum had been established the laparoscope was inserted Three additional ports were placed all under direct vision An 11 mm port was placed in the epigastric area Two 5 mm ports were placed in the right upper quadrant The patient was placed in reverse Trendelenburg position and slightly rotated to the left The fundus of the gallbladder was retracted superiorly and laterally The infundibulum was retracted inferiorly and laterally Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder The triangle of Calot was carefully opened up The cystic duct was identified heading up into the base of the gallbladder The cystic artery was also identified within the triangle of Calot After the triangle of Calot had been carefully dissected a clip was then placed high up on the cystic duct near its junction with the gallbladder The cystic artery was clipped twice proximally and once distally Scissors were then introduced and used to make a small ductotomy in the cystic duct and the cystic artery was divided An intraoperative cholangiogram was obtained This revealed good flow through the cystic duct and into the common bile duct There was good flow into the duodenum without any filling defects The hepatic radicals were clearly visualized The cholangiocatheter was removed and two clips were then placed distal to the ductotomy on the cystic duct The cystic duct was then divided using scissors The gallbladder was then removed up away from the liver bed using electrocautery The gallbladder was easily removed through the epigastric port site The liver bed was then irrigated and suctioned All dissection areas were inspected They were hemostatic There was not any bile leakage All clips were in place The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry All ports were then removed under direct vision The abdominal cavity was allowed to deflate The fascia at the epigastric port site was closed with a stitch of 2 0 Vicryl The fascia at the umbilical port was closed by tying the previously placed stitch All skin incisions were then closed with subcuticular sutures of 4 0 Monocryl and 0 25 Marcaine with epinephrine was infiltrated into all port sites The patient tolerated the procedure well The patient is currently being aroused from general endotracheal anesthesia I was present during the entire case Keywords gastroenterology laparoscopic calot ochsner clamps additional ports cholangiogram cholecystectomy cystic duct duodenum epigastric fascia gallbladder infraumbilical skin incision infundibulum pneumoperitoneum triangle of calot laparoscopic cholecystectomy liver bed epigastric port port site cystic artery triangle port duct cysticNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Appendicitis Laparoscopic appendectomy CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed through his umbilicus Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy 3 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE Laparoscopic appendectomy ANESTHESIA General with endotracheal intubation PROCEDURE IN DETAIL The patient was taken to the operating room and placed supine on the operating room table General anesthesia was administered with endotracheal intubation His abdomen was prepped and draped in a standard sterile surgical fashion A Foley catheter was placed for bladder decompression Marcaine was injected into his umbilicus A small incision was made A Veress needle was introduced in his abdomen CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12 mm VersaStep port was placed through his umbilicus A 5 mm port was then placed just to the right side of the umbilicus Another 5 mm port was placed just suprapubic in the midline Upon inspection of the cecum I was able find an inflamed and indurated appendix I was able to clear the mesentery at the base of the appendix between the appendix and the cecum I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery and thereby divided the mesentery and freed the appendix I put the appendix in an Endocatch bag and removed it through the umbilicus I irrigated out the abdomen I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter Thomason and closed the skin of all incisions with a running Monocryl Sponge instrument and needle counts were correct at the end of the case The patient tolerated the procedure well without any complications Keywords gastroenterology foley catheter co2 insufflation endotracheal intubation laparoscopic appendectomy appendectomy intubation cecum laparoscopic appendicitis endotracheal abdomen mesentery umbilicus appendix MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 2 Transcription PREOPERATIVE DIAGNOSIS 1 Cholelithiasis 2 Chronic cholecystitis POSTOPERATIVE DIAGNOSIS 1 Cholelithiasis 2 Chronic cholecystitis NAME OF OPERATION Laparoscopic cholecystectomy ANESTHESIA General FINDINGS The gallbladder was thickened and showed evidence of chronic cholecystitis There was a great deal of inflammatory reaction around the cystic duct The cystic duct was slightly larger There was a stone impacted in the cystic duct with the gallbladder The gallbladder contained numerous stones which were small With the stone impacted in the cystic duct it was felt that probably none were within the common duct Other than rather marked obesity no other significant findings were noted on limited exploration of the abdomen PROCEDURE Under general anesthesia after routine prepping and draping the abdomen was insufflated with the Veress needle and the standard four trocars were inserted uneventfully Inspection was made for any entry problems and none were encountered After limited exploration the gallbladder was then retracted superiorly and laterally and the cystic duct was dissected out This was done with some difficulty due to the fibrosis around the cystic duct but care was taken to avoid injury to the duct and to the common duct In this manner the cystic duct and cystic artery were dissected out Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct The cystic duct and cystic artery were then doubly clipped and divided taking care to avoid injury to the common duct The gallbladder was then dissected free from the gallbladder bed Again the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding The gallbladder was extracted through the operating trocar site and the trocar was reinserted Inspection was made of the gallbladder bed One or two bleeding areas were fulgurated and bleeding was well controlled Keywords gastroenterology cholelithiasis chronic inflammatory reaction cystic artery laparoscopic cholecystectomy common duct chronic cholecystitis gallbladder bed cystic duct cystic gallbladder duct inflammatory MEDICAL_TRANSCRIPTION,Description Standard Laparoscopic Cholecystectomy Operative Note Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy Transcription The patient s abdomen was prepped and draped in the usual sterile fashion A subumbilical skin incision was made The Veress needle was inserted and the patient s abdominal cavity was insufflated with moderate pressure all times A subumbilical trocar was inserted The camera was inserted in the panoramic view The abdomen demonstrated some inflammation around the gallbladder A 10 mm midepigastric trocar was inserted A 2 mm and 5 mm trocars were inserted The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge Using the dissector the cystic duct was identified and double Hemoclips were invited well away from the cystic common duct junction The cystic artery was identified and double Hemoclips applied The gallbladder was taken down from the liver bed using Endoshears and electrocautery Hemostasis was obtained The gallbladder was removed from the midepigastric trocar site without difficulty The trocars were removed and the skin incisions were reapproximated using 4 0 Monocryl Steri Strips and sterile dressing were placed The patient tolerated the procedure well and was taken to the recovery room in stable condition Keywords gastroenterology gallbladder laparoscopic cholecystectomy midepigastric trocar double hemoclips laparoscopic cholecystectomy midepigastric trocars hemoclips trocarNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Acute appendicitis with perforation Laparoscopic appendectomy A CT scan of abdomen showed evidence of appendicitis with perforation Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy 4 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis with perforation POSTOPERATIVE DIAGNOSIS Acute appendicitis with perforation ANESTHESIA General PROCEDURE Laparoscopic appendectomy INDICATIONS FOR PROCEDURE The patient is a 4 year old little boy who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia high fever and signs of peritonitis A CT scan of his abdomen showed evidence of appendicitis with perforation He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process He required several boluses of fluid for tachycardia and evidence of dehydration I met with Carlos parents and talked to them about the diagnosis of appendicis and surgical risks benefits and alternative treatment options All their questions have been answered and they agree with the surgical plan OPERATIVE FINDINGS The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well DESCRIPTION OF PROCEDURE The patient came to the operating room and had an uneventful induction of general anesthesia A Foley catheter was placed for decompression and his abdomen was prepared and draped in a standard fashion A 0 25 Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion We conducted our surgical timeout and reiterated all of Carlos unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure A 1 cm vertical infraumbilical incision was made and an open technique was used to place a 12 mm Step trocar through the umbilical fascia CO2 was insufflated to a pressure of 15 mmHg and then two additional 5 mm working ports were placed in areas that had been previously anesthetized There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum After these were gently separated we began to identify the appendix In the __________ due to the large amount of small bowel dilatation and distension I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix The base of the appendix was then ligated with 2 0 PDS Endoloops and the appendix was amputated and withdrawn through the umbilical port I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system When this was complete the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible The umbilical fascia was closed with figure of eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5 0 Monocryl and Steri Strips The patient tolerated the operation well He was awakened and taken to the recovery room in satisfactory condition His blood loss was less than 10 mL and he received only crystalloid fluid during the procedure Keywords gastroenterology adhesions peritoneum purulent debris umbilical fascia peritoneal cavity laparoscopic appendectomy appendectomy constipation purulent debris umbilical appendix abdomen laparoscopic perforation appendicitis MEDICAL_TRANSCRIPTION,Description Chronic cholecystitis without cholelithiasis Medical Specialty Gastroenterology Sample Name Laparoscopic Cholecystectomy 3 Transcription PREOPERATIVE DIAGNOSIS Chronic cholecystitis without cholelithiasis POSTOPERATIVE DIAGNOSIS Chronic cholecystitis without cholelithiasis PROCEDURE Laparoscopic cholecystectomy BRIEF DESCRIPTION The patient was brought to the operating room and anesthesia was induced The abdomen was prepped and draped and ports were placed The gallbladder was grasped and retracted The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak The ports were removed under direct vision with good hemostasis The Hasson was removed The abdomen was desufflated The gallbladder in its endo catch bag was removed The ports were closed The patient tolerated the procedure well Please see full hospital dictation Keywords gastroenterology chronic cholecystitis without cholelithiasis laparoscopic cholecystectomy cystic duct cystic artery endo catch chronic cholecystitis laparoscopic cholecystectomy abdomen cholecystitis cholelithiasis gallbladder cystic MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy The patient is a 42 year old female who presented with right lower quadrant pain She was evaluated and found to have a CT evidence of appendicitis Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy 5 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General endotracheal INDICATION FOR OPERATION The patient is a 42 year old female who presented with right lower quadrant pain She was evaluated and found to have a CT evidence of appendicitis She was subsequently consented for a laparoscopic appendectomy DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the operating room placed supine on the table The abdomen was prepared and draped in usual sterile fashion After the induction of satisfactory general endotracheal anesthesia supraumbilical incision was made A Veress needle was inserted Abdomen was insufflated to 15 mmHg A 5 mm port and camera placed The abdomen was visually explored There were no obvious abnormalities A 15 mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two Blunt dissection was used to isolate the appendix Appendix was separated from surrounding structures A window was created between the appendix and the mesoappendix GIA stapler was tossed across it and fired Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler Appendix was placed in an Endobag and removed from the patient Right lower quadrant was copiously irrigated All irrigation fluids were removed Hemostasis was verified The 15 mm port was removed and the port site closed with 0 Vicryl in the Endoclose device All other ports were irrigated infiltrated with 0 25 Marcaine and closed with 4 0 Vicryl subcuticular sutures Steri Strips and sterile dressings were applied Overall the patient tolerated this well was awakened and returned to recovery in good condition Keywords gastroenterology gia stapler laparoscopic appendectomy appendectomy endotracheal mesoappendix laparoscopic appendicitis appendix MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Acute cholecystitis status post laparoscopic cholecystectomy end stage renal disease on hemodialysis hyperlipidemia hypertension congestive heart failure skin lymphoma 5 years ago and hypothyroidism Medical Specialty Gastroenterology Sample Name Lap Chole Discharge Summary Transcription PROCEDURE Laparoscopic cholecystectomy DISCHARGE DIAGNOSES 1 Acute cholecystitis 2 Status post laparoscopic cholecystectomy 3 End stage renal disease on hemodialysis 4 Hyperlipidemia 5 Hypertension 6 Congestive heart failure 7 Skin lymphoma 5 years ago 8 Hypothyroidism HOSPITAL COURSE This is a 78 year old female with past medical condition includes hypertension end stage renal disease hyperlipidemia hypothyroidism and skin lymphoma who had a left AV fistula done about 3 days ago by Dr X and the patient went later on home but started having epigastric pain and right upper quadrant pain and mid abdominal pain some nauseated feeling and then she could not handle the pain so came to the emergency room brought by the family The patient s initial assessment the patient s vital signs were stable showed temperature 97 9 pulse was 106 and blood pressure was 156 85 EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm There is sludge in the gallbladder wall versus a stone in the gallbladder wall Thickening of the gallbladder wall with positive Murphy sign She has a history of cholecystitis Urine shows positive glucose but negative for nitrite and creatinine was 7 1 sodium 131 potassium was 5 2 and lipase and amylase were normal So the patient admitted to the Med Surg floor initially and the patient was started on IV fluid as well as low dose IV antibiotic and 2 D echocardiogram and EKG also was ordered The patient also had history of CHF in the past and recently had some workup done The patient does not remember initially Surgical consult also requested and blood culture and urine culture also ordered The same day the patient was seen by Dr Y and the patient should need cholecystectomy but the patient also needs dialysis and also needs to be cleared by the cardiologist so the patient later on seen by Dr Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy The patient also seen by nephrologist and underwent dialysis The patient s white count went down 6 1 afebrile On postop day 1 the patient started eating and also walking The patient also had chronic bronchitis The patient was later on feeling fine discussed with surgery The patient was then able to discharge to home and follow with the surgeon in about 3 5 days Discharged home with Synthroid 0 5 mg 1 tablet p o daily Plavix 75 mg p o daily folic acid 1 mg p o daily Diovan 80 mg p o daily Renagel 2 tablets 800 mg p o twice a day Lasix 40 mg p o 2 tablets twice a day lovastatin 20 mg p o daily Coreg 3 125 mg p o twice a day nebulizer therapy every 3 hours as needed also Phenergan 25 mg p o q 8 hours for nausea and vomiting Pepcid 20 mg p o daily Vicodin 1 tablet p o q 6 hours p r n as needed and Levaquin 250 mg p o every other day for the next 5 days The patient also had Premarin that she was taking advised to discontinue because of increased risk of heart disease and stroke explained to the patient Discharged home Keywords gastroenterology end stage renal disease lymphoma cholecystitis congestive heart failure skin lymphoma gallbladder wall laparoscopic cholecystectomy MEDICAL_TRANSCRIPTION,Description Ruptured appendicitis Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Ruptured appendicitis PROCEDURE Laparoscopic appendectomy INDICATIONS FOR PROCEDURE This patient is a 4 year old boy with less than 24 hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers The patient has elevated white count on exam and CT scan consistent with acute appendicitis DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general endotracheal anesthesia The patient s abdomen was prepped and draped in usual sterile fashion A periumbilical incision was made The fascia was incised Peritoneal cavity entered bluntly A 10 mm trocar and scope was passed Peritoneal cavity was insufflated Five mm ports placed in left lower and hypogastric areas On visualization of the right lower quadrant appendix was visualized stuck against the right anterior abdominal wall there is obvious site of perforation and leakage of content and pus We proceeded to take the mesoappendix down to the base and once the base was free we placed GIA stapler across the base fired the stapler removed the appendix through the periumbilical port site We irrigated and suctioned out the right lower and pelvic areas We then removed the ports under direct visualization closed the periumbilical port site fascia with 0 Vicryl all skin incisions with 5 0 Monocryl and dressed with Steri Strips The patient was extubated in the operating table and taken back to recovery room The patient tolerated the procedure well Keywords gastroenterology ruptured appendicitis acute appendicitis laparoscopic appendectomy laparoscopic ruptured abdominal peritoneal periumbilical appendicitis appendectomy MEDICAL_TRANSCRIPTION,Description Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft Medical Specialty Gastroenterology Sample Name Juxtarenal Abdominal Aortic Aneurysm Repair Transcription PREOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm POSTOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm ANESTHESIA General endotracheal anesthesia OPERATIVE TIME Three hours ANESTHESIA TIME Four hours DESCRIPTION OF PROCEDURE After thorough preoperative evaluation the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A line general endotracheal anesthesia was induced A Foley catheter was placed and a right internal jugular central line was placed The chest abdomen both groin and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered A sterile Omni Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed With the exception of the vascular findings to be described there were no apparent intra abdominal abnormalities The transverse colon retracted superiorly The small bowel was wrapped in moist green towel and retracted in the right upper quadrant The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries The mid left renal artery was likewise identified The perirenal aorta was prepared for clamp superior to the inferior left renal artery During this portion of the dissection the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis The distal dissection was then completed exposing each common iliac artery The arteries were suitable for control The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time The aneurysm was repaired First the common carotid arteries were controlled with atraumatic clamps The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed There was a high grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site The vessel was controlled with a microvascular clamp Two pairs of lumbar arteries were oversewn with 2 0 silk A 14 mm Hemashield tube graft was selected and sewn end to end fashion to the proximal aorta using a semi continuous 3 0 Prolene suture At the completion of anastomosis three patch stitches of 3 0 Prolene were required for hemostasis The graft was cut to appropriate length and sewn end to end at the iliac bifurcation using semi continuous 3 0 Prolene suture Prior to completion of this anastomosis the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation The distal anastomosis was competent without leak The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous The colon was normal in appearance and this vessel was oversewn using 2 0 silk The aneurysm sac was then closed about the grafts snuggly using 3 0 PDS in a vest over pants fashion The posterior peritoneum was reapproximated using running 3 0 PDS The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location The midline fascia was then reapproximated using running 1 PDS suture The subcutaneous tissues were irrigated with bacitracin and kanamycin solution The skin edges coapted using surgical staples At the conclusion of the case sponge and needle counts were correct and a sterile occlusive compressive dressing was applied Keywords gastroenterology inferior left renal artery semi continuous prolene suture juxtarenal abdominal aortic aneurysm inferior mesenteric artery continuous prolene suture abdominal aortic aneurysm hemashield tube inferior mesenteric renal artery aortic aneurysm aneurysm iliac endarterectomy viscera hemashield abdomen prolene arteries juxtarenal graft aortic endotracheal renal artery MEDICAL_TRANSCRIPTION,Description Appendicitis Laparoscopic appendectomy Infraumbilical incision was performed and taken down to the fascia The fascia was incised The peritoneal cavity was carefully entered Two other ports were placed in the right and left lower quadrants Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy 2 Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL The patient was prepped and draped in sterile fashion Infraumbilical incision was performed and taken down to the fascia The fascia was incised The peritoneal cavity was carefully entered Two other ports were placed in the right and left lower quadrants The appendix was readily identified and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag All hemostasis was further reconfirmed No leakage of enteral contents was noted All trocars were removed under direct visualization The umbilical fascia was closed with interrupted 0 Vicryl sutures The skin was closed with 4 0 Monocryl subcuticular stitch and dressed with Steri Strips and 4 x 4 s The patient was extubated and taken to the recovery area in stable condition The patient tolerated the procedure well Keywords gastroenterology mesoappendix endocatch laparoscopic appendectomy appendix umbilical laparoscopic appendectomy appendicitis fascia infraumbilical MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute appendicitis Medical Specialty Gastroenterology Sample Name Laparoscopic Appendectomy Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis OPERATIVE PROCEDURE Laparoscopic appendectomy INTRAOPERATIVE FINDINGS Include inflamed non perforated appendix OPERATIVE NOTE The patient was seen by me in the preoperative holding area The risks of the procedure were explained She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery General anesthesia was carried out without difficulty and a Foley catheter was inserted The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion A 5 mm blunt port was inserted infra umbilically at the level of the umbilicus under direct vision of a 5 mm 0 degree laparoscope Once we were inside the abdominal cavity CO2 was instilled to attain an adequate pneumoperitoneum A left lower quadrant 5 mm port was placed under direct vision and a 12 mm port in the suprapubic region The 5 mm scope was introduced at the umbilical port and the appendix was easily visualized The base of the cecum was acutely inflamed but not perforated I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty I reloaded with a red vascular cartridge came across the mesoappendix without difficulty I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty I reinserted the suprapubic port and irrigated out the right lower quadrant until dry One final inspection revealed no bleeding from the staple line We then removed all ports under direct vision and there was no bleeding from the abdominal trocar sites The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0 Vicryl suture The skin incision was injected with 0 25 Marcaine and closed with 4 0 Monocryl suture Steri strips and sterile dressings were applied No complications Minimal blood loss Specimen is the appendix Brought to the recovery room in stable condition Keywords gastroenterology appendix endobag laparoscopic appendectomy acute appendicitis appendectomy umbilically abdominal pneumoperitoneum laparoscopic appendicitis suprapubic mesoappendix MEDICAL_TRANSCRIPTION,Description Pneumatosis coli in the cecum Possible ischemic cecum with possible metastatic disease bilateral hydronephrosis on atrial fibrillation aspiration pneumonia chronic alcohol abuse acute renal failure COPD anemia with gastric ulcer Medical Specialty Gastroenterology Sample Name Ischemic Cecum Consult Transcription REASON FOR CONSULTATION Pneumatosis coli in the cecum HISTORY OF PRESENT ILLNESS The patient is an 87 year old gentleman who was admitted on 10 27 07 with weakness and tiredness with aspiration pneumonia The patient is very difficult to obtain information from however he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort In addition this hospitalization he has undergone an upper endoscopy which found a small ulcer after dropping his hematocrit and becoming anemic He had a CT scan on Friday 11 02 07 which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions which could be metastatic disease versus cysts In discussions with the patient he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain PAST MEDICAL HISTORY Obtained from the medical chart Chronic obstructive pulmonary disease history of pneumonia and aspiration pneumonia osteoporosis alcoholism microcytic anemia MEDICATIONS Per his current medical chart ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient had a long history of smoking but quit many years ago He does have chronic alcohol use PHYSICAL EXAMINATION GENERAL A very thin white male who is dyspneic and having difficulty breathing at the moment VITAL SIGNS Afebrile Heart rate in the 100s to 120s at times with atrial fibrillation Respiratory rate is 17 20 Blood pressure 130s 150s 60s 70s NECK Soft and supple full range of motion HEART Regular ABDOMEN Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information He does appear to have tenderness but does not have rebound and does not have peritoneal signs DIAGNOSTICS A CT scan done on 11 02 07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel ASSESSMENT Possible ischemic cecum with possible metastatic disease bilateral hydronephrosis on atrial fibrillation aspiration pneumonia chronic alcohol abuse acute renal failure COPD anemia with gastric ulcer PLAN The patient appears to have pneumatosis from a CT scan 2 days ago Nothing was done about it at that time as the patient appeared to not be symptomatic but he continues to have nausea and vomiting with abdominal pain but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time The patient has frequent desaturations secondary to his aspiration pneumonia and any surgical procedure or any surgical intervention would certainly require intubation which would then necessitate long term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state So we will look at the CT scan and make decisions based on the findings as far as that is concerned Keywords gastroenterology ischemic cecum metastatic disease bilateral hydronephrosis chronic alcohol abuse acute renal failure copd anemia gastric ulcer pneumatosis coli cecum aspiration pneumonia aspiration ischemic atrial metastatic hydronephrosis fibrillation pneumatosis pneumonia MEDICAL_TRANSCRIPTION,Description Debridement left ischial ulcer Medical Specialty Gastroenterology Sample Name Ischial Ulcer Debridement Transcription PREOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida POSTOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida PROCEDURE PERFORMED Debridement left ischial ulcer ANESTHESIA Local MAC INDICATIONS This is a 27 year old white male patient with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic The patient has a nonhealing decubitus ulcer in the left ischial region which is quite deep It appears to be right down to the bone MRI shows findings suggestive of osteomyelitis The patient is being brought to operating room for debridement of this ulcer Procedure indication and risks were explained to the patient Consent obtained PROCEDURE IN DETAIL The patient was put in right lateral position and left buttock and ischial region was prepped and draped Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base The ulcer does not appear to be going into the bone itself as there was a covering on the bone which appears to be quite healthy normal and bone itself appeared solid I did not rongeur the bone The deeper portion of the excised tissue was also sent for tissue cultures Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix Sterile dressing was applied The patient transferred to recovery room in stable condition Keywords gastroenterology debridement ischial ulcer ischial region osteomyelitis paraplegia spina bifida decubitus ulcer MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy lysis of adhesions and right hemicolectomy Right colon cancer ascites and adhesions Medical Specialty Gastroenterology Sample Name Hemicolectomy Transcription PREOPERATIVE DIAGNOSIS Right colon tumor POSTOPERATIVE DIAGNOSES 1 Right colon cancer 2 Ascites 3 Adhesions PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Lysis of adhesions 3 Right hemicolectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 200 cc URINE OUTPUT 200 cc CRYSTALLOIDS GIVEN 2700 cc INDICATIONS FOR THIS PROCEDURE The patient is a 53 year old African American female who presented with near obstructing lesion at the hepatic flexure The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma The patient was NG decompressed preoperatively and was prepared for surgery The need for removal of the colon cancer was explained at length The patient was agreeable to proceed with the surgery and signed preoperatively informed consent PROCEDURE The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively She was given triple antibiotics IV Due to her near obstructive symptoms a formal ________ was not performed The abdomen was prepped and draped in the usual sterile fashion A midline laparotomy incision was made with a 10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia Once divided the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline Extensive fluid was seen upon entering the abdomen ascites fluid which was clear straw colored and this was sampled for cytology Next the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure colonic mass which was adherent to the surrounding tissues With mobilization of the colon along the line of Toldt down to the right gutter the entire ileocecal region up to the transverse colon was mobilized into the field Next a window was made 5 inches from the ileocecal valve and a GIA 75 was fired across the ileum Next a second GIA device was fired across the proximal transverse colon just sparring the middle colic artery The dissection was then carried down along the mesentry down to the root of the mesentry Several lymph nodes were sampled carefully and small radiopaque clips were applied along the base of the mesentry The mesentry vessels are hemostated and tied with 0 Vicryl suture sequentially ligated in between Once this specimen was submitted to pathology the wound was inspected There was no evidence of bleeding from any of the suture sites Next a side by side anastomosis was performed between the transverse colon and the terminal ileum A third GIA 75 was fired side by side and GIA 55 was used to close the anastomosis A patent anastomosis was palpated The anastomosis was then protected with a 2 0 Vicryl 0 muscular suture Next the mesenteric root was closed with a running 0 Vicryl suture to prevent any chance of internal hernia The suture sites were inspected and there was no evidence of leakage Next the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction Next the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression Keywords gastroenterology colon tumor ascites adhesions lysis of adhesions exploratory laparotomy colon cancer transverse colon hemicolectomy laparotomy MEDICAL_TRANSCRIPTION,Description Right upper quadrant pain Nuclear medicine hepatobiliary scan Radiopharmaceutical 6 9 mCi of Technetium 99m Choletec Medical Specialty Gastroenterology Sample Name Hepatobiliary Scan Transcription NUCLEAR MEDICINE HEPATOBILIARY SCAN REASON FOR EXAM Right upper quadrant pain COMPARISONS CT of the abdomen dated 02 13 09 and ultrasound of the abdomen dated 02 13 09 Radiopharmaceutical 6 9 mCi of Technetium 99m Choletec FINDINGS Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time There is normal accumulation within the gallbladder After the injection of 2 1 mcg of intravenous cholecystic _______ the gallbladder ejection fraction at 30 minutes was calculated to be 32 normal is greater than 35 The patient experienced 2 10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea IMPRESSION 1 Negative for acute cholecystitis or cystic duct obstruction 2 Gallbladder ejection fraction just under the lower limits of normal at 32 that can be seen with very mild chronic cholecystitis Keywords gastroenterology radiopharmaceutical gallbladder ejection fraction nuclear medicine hepatobiliary hepatobiliary scan quadrant nuclear technetium choletec ejection fraction cholecystitis scan abdomen injection gallbladder hepatobiliary medicine MEDICAL_TRANSCRIPTION,Description Gastrostomy a 6 week old with feeding disorder and Down syndrome Medical Specialty Gastroenterology Sample Name Gastrostomy Transcription PREOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease POSTOPERATIVE DIAGNOSES 1 Feeding disorder 2 Down syndrome 3 Congenital heart disease OPERATION PERFORMED Gastrostomy ANESTHESIA General INDICATIONS This 6 week old female infant had been transferred to Children s Hospital because of Down syndrome and congenital heart disease She has not been able to feed well and in fact has to now be NG tube fed Her swallowing mechanism does not appear to be very functional and therefore it was felt that in order to aid in her home care that she would be better served with a gastrostomy OPERATIVE PROCEDURE After the induction of general anesthetic the abdomen was prepped and draped in usual manner Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection The muscle was divided and the peritoneal cavity entered The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field The site for gastrostomy was selected and a pursestring suture of 4 0 Nurolon placed in the gastric wall A 14 French 0 8 cm Mic Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube Following this the stomach was returned to the abdominal cavity and the posterior fascia was closed using a 4 0 Nurolon affixing the stomach to the posterior fascia The anterior fascia was then closed with 3 0 Vicryl subcutaneous tissue with the same and the skin closed with 5 0 subcuticular Monocryl The balloon was inflated to the full 5 mL A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition Keywords gastroenterology feeding disorder down syndrome congenital heart disease mic key tubeless nurolon subcutaneous tissue fascia syndrome stomach gastrostomy MEDICAL_TRANSCRIPTION,Description GI Consultation due to rectal bleeding positive celiac sprue panel Medical Specialty Gastroenterology Sample Name GI Consultation 1 Transcription PROBLEM Rectal bleeding positive celiac sprue panel HISTORY The patient is a 19 year old Irish Greek female who ever since elementary school has noted diarrhea constipation cramping nausea vomiting bloating belching abdominal discomfort change in bowel habits She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody She has been on a gluten free diet for approximately one week now and her symptoms are remarkably improved She actually has none of these symptoms since starting her gluten free diet She has noted intermittent rectal bleeding with constipation on the toilet tissue She feels remarkably better after starting a gluten free diet ALLERGIES No known drug allergies OPERATIONS She is status post a tonsillectomy as well as ear tubes ILLNESSES Questionable kidney stone MEDICATIONS None HABITS No tobacco No ethanol SOCIAL HISTORY She lives by herself She currently works in a dental office FAMILY HISTORY Notable for a mother who is in good health a father who has joint problems and questionable celiac disease as well She has two sisters and one brother One sister interestingly has inflammatory arthritis REVIEW OF SYSTEMS Notable for fever fatigue blurred vision rash and itching her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten free diet She also notes headaches anxiety heat and cold intolerance excessive thirst and urination Please see symptoms summary sheet dated April 18 2005 PHYSICAL EXAMINATION GENERAL She is a well developed pleasant 19 female She has a blood pressure of 120 80 a pulse of 70 she weighs 170 pounds She has anicteric sclerae Pink conjunctivae PERRLA ENT MMM NECK Supple LUNGS Clear to auscultation Keywords gastroenterology bleeding abdominal discomfort belching bloating bowel celiac sprue change in bowel habits constipation cramping diarrhea gluten free nausea rectal vomiting inflammatory arthritis rectal bleeding gi inflammatory sprue celiac gluten diet MEDICAL_TRANSCRIPTION,Description Gastroscopy Dysphagia and globus No evidence of inflammation or narrowing to explain her symptoms Medical Specialty Gastroenterology Sample Name Gastroscopy 2 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSIS Dysphagia and globus POSTOPERATIVE DIAGNOSIS Normal MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach and then through the gastrojejunal anastomosis into the efferent jejunal loop The preparation was good and all surfaces were well seen The hypopharynx was normal with no evidence of inflammation The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux damage or Barrett s Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food The gastrojejunal anastomosis was patent measuring about 12 mm with no inflammation or ulceration Beyond this there was a side to side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation The scope was withdrawn and the patient was sent to recovery room She tolerated the procedure well FINAL DIAGNOSES 1 Normal post gastric bypass anatomy 2 No evidence of inflammation or narrowing to explain her symptoms Keywords gastroenterology olympus gastroscope gastric pouch gastrojejunal anastomosis dysphagia globus esophagus mucosa gastric gastroscopy gastrojejunal inflammation MEDICAL_TRANSCRIPTION,Description Dysphagia possible stricture Retained gastric contents forming a partial bezoar suggestive of gastroparesis Medical Specialty Gastroenterology Sample Name Gastroscopy 1 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSES Dysphagia possible stricture POSTOPERATIVE DIAGNOSIS Gastroparesis MEDICATION MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus stomach and duodenum The hypopharynx was normal The esophagus had a normal upper esophageal sphincter normal contour throughout and a normal gastroesophageal junction viewed at 39 cm from the incisors There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair There was no sign of reflux esophagitis On entering the gastric lumen a large bezoar of undigested food was seen occupying much of the gastric fundus and body It had 2 to 3 mm diameter This was broken up using a scope into smaller pieces There was no retained gastric liquid The antrum appeared normal and the pylorus was patent The scope passed easily into the duodenum which was normal through the second portion On withdrawal of the scope additional views of the cardia were obtained and there was no evidence of any tumor or narrowing The scope was withdrawn The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Normal postoperative hernia repair 2 Retained gastric contents forming a partial bezoar suggestive of gastroparesis 3 Otherwise normal upper endoscopy to the descending duodenum RECOMMENDATIONS 1 Continue proton pump inhibitors 2 Use Reglan 10 mg three to four times a day Keywords gastroenterology MEDICAL_TRANSCRIPTION,Description Gastroscopy A short segment Barrett esophagus hiatal hernia and incidental fundic gland polyps in the gastric body otherwise normal upper endoscopy to the transverse duodenum Medical Specialty Gastroenterology Sample Name Gastroscopy 3 Transcription PROCEDURE Gastroscopy PREOPERATIVE DIAGNOSIS Gastroesophageal reflux disease POSTOPERATIVE DIAGNOSIS Barrett esophagus MEDICATIONS MAC PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenum to the transverse duodenum The preparation was excellent and all surfaces were well seen The hypopharynx appeared normal The esophagus had a normal contour and normal mucosa throughout its distance but at the distal end there was a moderate sized hiatal hernia noted The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors Above the GE junction there were three fingers of columnar epithelium extending cephalad to a distance of about 2 cm This appears to be consistent with Barrett esophagus Multiple biopsies were taken from numerous areas in this region There was no active ulceration or inflammation and no stricture The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus The gastric body had normal mucosa throughout Numerous small fundic gland polyps were noted measuring 3 to 5 mm in size with an entirely benign appearance Biopsies were taken from the antrum to rule out Helicobacter pylori A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions The scope was passed through the pylorus which was patent and normal The mucosa throughout the duodenum in the first second and third portions was entirely normal The scope was withdrawn and the patient was sent to the recovery room He tolerated the procedure well FINAL DIAGNOSES 1 A short segment Barrett esophagus 2 Hiatal hernia 3 Incidental fundic gland polyps in the gastric body 4 Otherwise normal upper endoscopy to the transverse duodenum RECOMMENDATIONS 1 Follow up biopsy report 2 Continue PPI therapy 3 Follow up with Dr X as needed 4 Surveillance endoscopy for Barrett in 3 years if pathology confirms this diagnosis Keywords gastroenterology olympus gastroscope barrett gastroesophageal reflux disease transverse duodenum barrett esophagus hiatal hernia gastroscopy endoscopy hiatal duodenum esophagus hernia MEDICAL_TRANSCRIPTION,Description Followup of laparoscopic fundoplication and gastrostomy Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access Medical Specialty Gastroenterology Sample Name Fundoplication Gastrostomy Followup Transcription REASON FOR VISIT Followup of laparoscopic fundoplication and gastrostomy HISTORY OF PRESENT ILLNESS The patient is a delightful baby girl who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty Dr X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber The patient had a laparoscopic fundoplication and gastrostomy on 10 05 2007 She has done well since that time She has had some episodes of retching intermittently and these seemed to be unpredictable She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved The patient currently takes about 1 ounce to 1 5 ounce of her feedings by mouth and the rest is given by G tube She seems otherwise happy and is not having an excessive amount of stools Her parents have not noted any significant problems with the gastrostomy site The patient s exam today is excellent Her belly is soft and nontender All of her laparoscopic trocar sites are healing with a normal amount of induration but there is no evidence of hernia or infection We removed The patient s gastrostomy button today and showed her parents how to reinsert one without difficulty The site of the gastrostomy is excellent There is not even a hint of granulation tissue or erythema and I am very happy with the overall appearance IMPRESSION The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy Hopefully the exquisite control of acid reflux by fundoplication will help her airway heal and if she does well allow decannulation in the future If she does require laryngotracheoplasty the protection from acid reflux will be important to healing of that procedure as well PLAN The patient will follow up as needed for problems related to gastrostomy We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future Keywords gastroenterology decannulation enteral feeding feeding access laparoscopic fundoplication gastrostomy airway laryngotracheoplasty laparoscopic fundoplication MEDICAL_TRANSCRIPTION,Description Acute gastroenteritis resolved Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology Medical Specialty Gastroenterology Sample Name Gastroenteritis Discharge Summary Transcription ADMITTING DIAGNOSES 1 Acute gastroenteritis 2 Nausea 3 Vomiting 4 Diarrhea 5 Gastrointestinal bleed 6 Dehydration DISCHARGE DIAGNOSES 1 Acute gastroenteritis resolved 2 Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology BRIEF H P AND HOSPITAL COURSE This patient is a 56 year old male a patient of Dr X with 25 pack year history also a history of diabetes type 2 dyslipidemia hypertension hemorrhoids chronic obstructive pulmonary disease and a left lower lobe calcified granuloma that apparently is stable at this time This patient presented with periumbilical abdominal pain with nausea vomiting and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse The patient was admitted into the ER and had trop x1 done which was negative and ECG showed to be of normal sinus rhythm Lab findings initially presented with a hemoglobin of 13 1 hematocrit of 38 6 with no elevation of white count Upon discharge his hemoglobin and hematocrit stayed at 10 9 and 31 3 and he was still having stool guaiac positive blood and a stool study was done which showed few white blood cells negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs The patient s nausea vomiting and diarrhea did resolve during his hospital course Was placed on IV fluids initially and on hospital day 2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly and the patient was able to tolerate p o well The patient also denied any abdominal pain upon day of discharge The patient was also started on prednisone as per GI recommendations He was started on 60 mg p o Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well PLAN The plan is to discharge the patient home He can resume his home medications of Prandin Actos Lipitor Glucophage Benicar and Advair We will also start him on a tapered dose of prednisone for 4 weeks We will start him on 15 mg p o for seven days Then week 2 we will start him on 40 mg for 1 week Then week 3 we will start him on 30 mg for 1 week and then 20 mg for 1 week and then finally we will stop He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations Keywords gastroenterology nausea vomiting diarrhea gastrointestinal bleed mesentery hemoglobin hematocrit gastrointestinal periumbilical gastroenteritis hemorrhoids MEDICAL_TRANSCRIPTION,Description Pediatric Gastroenterology History of gagging Medical Specialty Gastroenterology Sample Name Gagging 3 year old Transcription HISTORY OF PRESENT ILLNESS This is a 3 year old female patient who was admitted today with a history of gagging She was doing well until about 2 days ago when she developed gagging No vomiting No fever She has history of constipation She normally passes stool every two days after giving an enema No rectal bleeding She was brought to the Hospital with some loose stool She was found to be dehydrated She was given IV fluid bolus but then she started bleeding from G tube site There was some fresh blood coming out of the G tube site She was transferred to PICU She is hypertensive Intensivist Dr X requested me to come and look at her and do upper endoscopy to find the site of bleeding PAST MEDICAL HISTORY PEHO syndrome infantile spasm right above knee amputation developmental delay G tube fundoplication PAST SURGICAL HISTORY G tube fundoplication on 05 25 2007 Right above knee amputation ALLERGIES None DIET She is NPO now but at home she is on PediaSure 4 ounces 3 times a day through G tube 12 ounces of water per day MEDICATIONS Albuterol Pulmicort MiraLax 17 g once a week carnitine phenobarbital Depakene and Reglan FAMILY HISTORY Positive for cancer PAST LABORATORY EVALUATION On 12 27 2007 WBC 9 3 hemoglobin 7 6 hematocrit 22 1 platelet 132 000 KUB showed large stool with dilated small and large bowel loops Sodium 140 potassium 4 4 chloride 89 CO2 21 BUN 61 creatinine 2 AST 92 increased ALT 62 increased albumin 5 3 total bilirubin 0 1 Earlier this morning she had hemoglobin of 14 5 hematocrit 41 3 platelets 491 000 PT 58 increased INR 6 6 increased PTT 75 9 increased PHYSICAL EXAMINATION VITAL SIGNS Temperature 99 degrees Fahrenheit pulse 142 per minute respirations 34 per minute weight 8 6 kg GENERAL She is intubated HEENT Atraumatic She is intubated LUNGS Good air entry bilaterally No rales or wheezing ABDOMEN Distended Decreased bowel sounds GENITALIA Grossly normal female CNS She is sedated IMPRESSION A 3 year old female patient with history of passage of blood through G tube site with coagulopathy She has a history of G tube fundoplication developmental delay PEHO syndrome which is progressive encephalopathy optic atrophy PLAN Plan is to give vitamin K FFP blood transfusion Consider upper endoscopy Procedure and informed consent discussed with the family Keywords gastroenterology g tube peho syndrome tube site gagging constipation endoscopy peho hemoglobin hematocrit intubated bleeding blood fundoplication tube MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy due to rectal bleeding Medical Specialty Gastroenterology Sample Name Flex Sig 1 Transcription INDICATION Rectal bleeding PREMEDICATION See procedure nurse NCS form PROCEDURE Keywords gastroenterology rectal bleeding digital rectal exam pentax video anal verge angiodysplasia colonic mucosa diverticula endoscope flexible flexible sigmoidoscopy hemorrhoids masses polyps rectum sigmoidoscopy sphincter tone internal hemorrhoids bleeding rectal MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon Medical Specialty Gastroenterology Sample Name Flex Sig 2 Transcription PROCEDURE IN DETAIL Following a barium enema prep and lidocaine ointment to the rectal vault perirectal inspection and rectal exam were normal The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon Withdrawal notes an otherwise normal descending rectosigmoid and rectum Retroflexion noted no abnormality of the internal ring No hemorrhoids were noted Withdrawal from the patient terminated the procedure Keywords gastroenterology flexible sigmoidoscopy flex sig colonoscope olympus video colonoscope rectumNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Gastrointestinal bleed source undetermined but possibly due to internal hemorrhoids Poor prep with friable internal hemorrhoids but no gross lesions no source of bleed Medical Specialty Gastroenterology Sample Name Gastrointestinal Bleed Discharge Summary Transcription DIAGNOSIS ON ADMISSION Gastrointestinal bleed DIAGNOSES ON DISCHARGE 1 Gastrointestinal bleed source undetermined but possibly due to internal hemorrhoids 2 Atherosclerotic cardiovascular disease 3 Hypothyroidism PROCEDURE Colonoscopy FINDINGS Poor prep with friable internal hemorrhoids but no gross lesions no source of bleed HOSPITAL COURSE The patient was admitted to the emergency room by Dr X He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood Dr Y Miller saw him in consultation and recommended a colonoscopy A bowel prep was done H Hs were stable His most recent H H was 38 6 13 2 that was this morning His H H at admission was 41 14 3 The patient had the bowel prep that revealed no significant bleeding His vital signs are stable He is continuing on his usual medications of Imdur metoprolol and Synthroid His Plavix is discontinued He is given IV Protonix I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec The patient s PT INR was 1 03 PTT 25 8 Chemistry panel was unremarkable The patient was given a regular diet after his colonoscopy today He tolerated it well and is being discharged home He will be followed closely as an outpatient He will continue his Pepcid 40 mg at night Imdur Synthroid and metoprolol as prior to admission He will hold his Plavix for now They will call me for further dark stools and will avoid Pepto Bismol They will follow up in the office on Thursday Keywords gastroenterology atherosclerotic cardiovascular disease colonoscopy gross lesions bowel prep gastrointestinal bleed internal hemorrhoids hemorrhoids gastrointestinal prep MEDICAL_TRANSCRIPTION,Description Esophagitis minor stricture at the gastroesophageal junction hiatal hernia Otherwise normal upper endoscopy to the transverse duodenum Medical Specialty Gastroenterology Sample Name Gastroscopy Transcription PREOPERATIVE DIAGNOSES Dysphagia and esophageal spasm POSTOPERATIVE DIAGNOSES Esophagitis and esophageal stricture PROCEDURE Gastroscopy MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenum to the third portion of the duodenum The hypopharynx was normal and the upper esophageal sphincter was unremarkable The esophageal contour was normal with the gastroesophageal junction located at 38 cm from the incisors At this point there were several linear erosions and a sense of stricturing at 38 cm Below this there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors The mucosa within the hernia was normal The gastric lumen was normal with normal mucosa throughout The pylorus was patent permitting passage of the scope into the duodenum which was normal through the third portion During withdrawal of the scope additional views were obtained of the cardia confirming the presence of a small hiatal hernia It was decided to attempt dilation of the strictured area so an 18 mm TTS balloon was placed across the stricture and inflated to the recommended diameter When the balloon was fully inflated the lumen appeared to be larger than 18 mm diameter suggesting that the stricture was in fact not a significant one No stretching of the mucosa took place The balloon was deflated and the scope was withdrawn The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Esophagitis 2 Minor stricture at the gastroesophageal junction 3 Hiatal hernia 4 Otherwise normal upper endoscopy to the transverse duodenum RECOMMENDATIONS Continue proton pump inhibitor therapy Keywords gastroenterology duodenum esophagus gastroscope stomach upper endoscopy transverse duodenum gastroesophageal junction hiatal hernia gastroscopy endoscopy esophagitis gastroesophageal hiatal esophageal hernia MEDICAL_TRANSCRIPTION,Description Flexible sigmoidoscopy Sigmoid and left colon diverticulosis otherwise normal flexible sigmoidoscopy to the proximal descending colon Medical Specialty Gastroenterology Sample Name Flex Sig 3 Transcription PROCEDURE Flexible sigmoidoscopy PREOPERATIVE DIAGNOSIS Rectal bleeding POSTOPERATIVE DIAGNOSIS Diverticulosis MEDICATIONS None DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm reaching the proximal descending colon At this point stool occupied the lumen preventing further passage The colon distal to this was well cleaned out and easily visualized The mucosa was normal throughout the regions examined Numerous diverticula were seen There was no blood or old blood or active bleeding A retroflexed view of the anorectal junction showed no hemorrhoids He tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Sigmoid and left colon diverticulosis 2 Otherwise normal flexible sigmoidoscopy to the proximal descending colon 3 The bleeding was most likely from a diverticulum given the self limited but moderately severe quantity that he described RECOMMENDATIONS 1 Follow up with Dr X as needed 2 If there is further bleeding a full colonoscopy is recommended Keywords gastroenterology olympus gastroscope rectal bleeding flexible sigmoidoscopy colon diverticulosis descending colon diverticulosis hemorrhoids flexible sigmoidoscopy colon MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy release of small bowel obstruction and repair of periumbilical hernia Acute small bowel obstruction and incarcerated umbilical Hernia Medical Specialty Gastroenterology Sample Name Exploratory Laparotomy Hernia Repair Transcription PREOPERATIVE DIAGNOSIS 1 Acute bowel obstruction 2 Umbilical hernia POSTOPERATIVE DIAGNOSIS 1 Acute small bowel obstruction 2 Incarcerated umbilical Hernia PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Release of small bowel obstruction 3 Repair of periumbilical hernia ANESTHESIA General with endotracheal intubation COMPLICATIONS None DISPOSITION The patient tolerated the procedure well and was transferred to recovery in stable condition SPECIMEN Hernia sac HISTORY The patient is a 98 year old female who presents from nursing home extended care facility with an incarcerated umbilical hernia intractable nausea and vomiting and a bowel obstruction Upon seeing the patient and discussing in extent with the family it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery INTRAOPERATIVE FINDINGS The patient was found to have an incarcerated umbilical hernia There was a loop of small bowel incarcerated within the hernia sac It showed signs of ecchymosis however no signs of any ischemia or necrosis It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities PROCEDURE After informed written consent risks and benefits of the procedure were explained to the patient and the patient s family The patient was brought to the operating suite After general endotracheal intubation prepped and draped in normal sterile fashion A midline incision was made around the umbilical hernia defect with a 10 blade scalpel Dissection was then carried down to the fascia Using a sharp dissection an incision was made above the defect superior to the defect entering the fascia The abdomen was entered under direct visualization The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic however no signs of ischemia were noted or necrosis The remaining of the fascia was then extended using Metzenbaum scissors The hernia sac was removed using Mayo scissors and sent off as specimen Next the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities The small bowel was then milked down removing all the fluid The bowel was decompressed distal to the obstruction Once returning the abdominal contents to the abdomen attention was next made in closing the abdomen and using 1 Vicryl suture in the figure of eight fashion the fascia was closed The umbilicus was then reapproximated to its anatomical position with a 1 Vicryl suture A 3 0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin Sterile dressings were applied The patient tolerated the procedure well and was transferred to recovery in stable condition Keywords gastroenterology endotracheal intubation acute bowel obstruction umbilical hernia exploratory laparotomy release of small bowel obstruction repair of periumbilical hernia incarcerated umbilical hernia incarcerated bowel hernia exploratory laparotomy abdomen umbilical obstruction MEDICAL_TRANSCRIPTION,Description Flexible Sigmoidoscopy Medical Specialty Gastroenterology Sample Name Flex Sig Transcription MEDICATIONS None DESCRIPTION OF THE PROCEDURE After informed consent was obtained the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of cm to the proximal descending colon and then slowly withdrawn The mucosa appeared normal Retroflex examination of the rectum was normal Keywords gastroenterology flexible sigmoidoscopy flex sig olympus video colonoscope colonoscopeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy low anterior colon resection flexible colonoscopy and transverse loop colostomy and JP placement Colovesical fistula and intraperitoneal abscess Medical Specialty Gastroenterology Sample Name Exploratory Laparotomy Colon Resection Transcription PREOPERATIVE DIAGNOSIS Colovesical fistula POSTOPERATIVE DIAGNOSES 1 Colovesical fistula 2 Intraperitoneal abscess PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Low anterior colon resection 3 Flexible colonoscopy 4 Transverse loop colostomy and JP placement ANESTHESIA General HISTORY This 74 year old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra The patient had retrograde cystogram which revealed colovesical fistula Recommendation for a surgery was made The patient was explained the risks and benefits as well as the two sons and the daughter They understood that the patient can even die from this procedure All the three procedures were explained without a colostomy with Hartmann s colostomy and with a transverse loop colostomy and out of the three procedures the patient s requested to have the loop colostomy and stated that the Hartmann s colostomy leaving the anastomosis with the risk of leaking PROCEDURE DETAILS The patient was taken to the operating room prepped and draped in the sterile fashion and was given general anesthetic An incision was performed in the midline below the umbilicus to the pubis with a 10 blade Bard Parker Electrocautery was used for hemostasis down to the fascia The fascia was grasped with Ochsner s and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery Once within the peritoneum adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall At this point immediately a small bowel was retracted cephalad The patient was taken to a slightly Trendelenburg position and the descending colon was seen The white line of Toldt was opened all the way down to the area of inflammation At this point meticulous dissection was carried to separate the small bowel from the attachment to the abscess When the small bowel was completely freed of abscess bulk of the bladder was seen anteriorly to the uterus The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized At this point the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum At this point decision to place a moist towel and retract old intestine superiorly as well as to place first self retaining retractor in the abdominal cavity with a bladder blade was placed Immediately a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA 55 balloon Roticulator was fired The specimen was cut with 10 blade Bard Parker and sent it to Pathology Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis A pursestring device was fired The staple line was cut The dilators were used using 25 and 29 then _________ 29 EEA was placed and the suture was tied At this point attention was directed down to the rectal stump where dilators 25 and 29 were passed from the anus into the rectum and then the 29 Ethicon GIA was introduced The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul de sac as well as the uterine was present in this patient Immediately the EEA was connected with a mushroom It was tied fired and a Doyen was placed above the anastomosis approximately four inches Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient s anus insufflating air No air was seen evolving from the staple line All fluid was removed and pictures of the staple line were taken The scope was removed at this point The case was passed to Dr X for repair of the vesicle fistula Dr X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon After this was performed copious amount of irrigation was used again More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area The incision was performed in the right upper quadrant This incision was performed with cutting in the cautery down into the fascia splitting the muscle and then the Penrose was passed under transverse colon and was grasped on pulling the transverse colon at the level of the skin The wire was passed under the transverse colon It was left in place Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis At this point immediately yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied Electrocautery for hemostasis and the subcutaneous tissue Copious amount of irrigation was used The skin was approximated with staples At this point immediately the wound was covered with a moist towel and decision to mature the loop colostomy was made The colostomy was opened longitudinally and then matured with interrupted 3 0 Vicryl suture through the skin edge One it was completely matured immediately the index finger was probed proximally and distally and both loops were completely opened As previously mentioned the Penrose was removed and the Bard was secured with a 3 0 nylon suture The JP was secured with 3 0 nylon suture as well At this point dressings were applied The patient tolerated the procedure well The stent from the left ureter was removed and the Foley was left in place The patient did tolerate the procedure well and will be followed up during the hospitalization Keywords gastroenterology intraperitoneal abscess colovesical fistula low anterior colon resection flexible colonoscopy transverse loop colostomy jp placement exploratory laparotomy colon resection descending colon transverse colon colostomy colon laparotomy aparotomy fistula MEDICAL_TRANSCRIPTION,Description Leaking anastomosis from esophagogastrectomy Exploratory laparotomy and drainage of intra abdominal abscesses with control of leakage Medical Specialty Gastroenterology Sample Name Exploratory Laparotomy Transcription PREOPERATIVE DIAGNOSIS Leaking anastomosis from esophagogastrectomy POSTOPERATIVE DIAGNOSIS Leaking anastomosis from esophagogastrectomy PROCEDURE Exploratory laparotomy and drainage of intra abdominal abscesses with control of leakage COMPLICATIONS None ANESTHESIA General oroendotracheal intubation PROCEDURE After adequate general anesthesia was administered the patient s abdomen was prepped and draped aseptically Sutures and staples were removed The abdomen was opened The were some very early stage adhesions that were easy to separate Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon This was retracted caudally to expose the stomach There were a number of adhesions to the stomach These were carefully dissected to expose initially the closure over the gastrotomy site Initially this looked like this was leaking but it was actually found to be intact The pyloroplasty was identified and also found to be intact with no evidence of leakage Further dissection up toward the hiatus revealed an abscess collection This was sent for culture and sensitivity and was aspirated and lavaged Cavity tracked up toward the hiatus Stomach itself appeared viable there was no necrotic sections Upper apex of the stomach was felt to be viable also I did not pull the stomach and esophagus down into the abdomen from the mediastinum but placed a sucker up into the mediastinum where additional turbid fluid was identified Carefully placed a 10 mm flat Jackson Pratt drain into the mediastinum through the hiatus to control this area of leakage Two additional Jackson Pratt drains were placed essentially through the gastrohepatic omentum This was the area that most of the drainage had collected in As I had previously discussed with Dr Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair Once the drains were secured they were brought out through the anterior abdominal wall and secured with 3 0 silk sutures and secured to bulb suction The midline fascia was then closed using running 2 Prolene sutures bolstered with retention sutures Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples Dry gauze dressing was placed The patient tolerated the procedure well there were no complications Keywords gastroenterology drainage oroendotracheal intubation intra abdominal abdominal abscesses jackson pratt exploratory laparotomy anastomosis esophagogastrectomy mediastinum abdomen stomach MEDICAL_TRANSCRIPTION,Description Esophageal foreign body US penny Esophagoscopy with foreign body removal The patient had a penny lodged in the proximal esophagus in the typical location Medical Specialty Gastroenterology Sample Name Esophagoscopy Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Esophageal foreign body POSTOPERATIVE DIAGNOSIS Esophageal foreign body US penny PROCEDURE Esophagoscopy with foreign body removal ANESTHESIA General INDICATIONS The patient is a 17 month old baby girl with biliary atresia who had a delayed diagnosis and a late attempted Kasai portoenterostomy which failed The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD The patient is fed by mouth and also with nasogastric enteral feeding supplements She has had an __________ cough and relatively disinterested in oral intake for the past month She was recently in the GI Clinic and an x ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted Based on the history it is quite possible this coin has been there close to a month She is brought to the operating room now for attempted removal I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time Hopefully there will be no coin migration or significant irrigation that would require prolonged hospitalization OPERATIVE FINDINGS The patient had a penny lodged in the proximal esophagus in the typical location There was no evidence of external migration and surrounding irritation was noted but did not appear to be excessive The coin actually came out with relative ease after which endoscopically identified DESCRIPTION OF OPERATION The patient came to the operating room and had induction of general anesthesia She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications After her endotracheal tube was placed and securely taped to the left side of her mouth I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism A rigid esophagoscope was then inserted into the proximal esophagus and the scope was gradually advanced with the lumen directly in frontal view This was facilitated by the nasoenteric feeding tube that was in place which I followed carefully until the edge of the coin could be seen At this location there was quite a bit of surrounding mucosal inflammation but the coin edge could be clearly seen and was secured with the coin grasping forceps I then withdrew the scope forceps and the coin as one unit and it was easily retrieved The patient tolerated the procedure well There were no intraoperative complications There was only one single coin noted and she was awakened and taken to the recovery room in good condition Keywords gastroenterology portoenterostomy foreign body removal proximal esophagus coin esophagoscopy esophageal esophagus MEDICAL_TRANSCRIPTION,Description Esophagoscopy with removal of foreign body Esophageal foreign body no associated comorbidities are noted Medical Specialty Gastroenterology Sample Name Esophagoscopy Foreign Body Removal 1 Transcription PRIMARY DIAGNOSIS Esophageal foreign body no associated comorbidities are noted PROCEDURE Esophagoscopy with removal of foreign body CPT CODE 43215 PRINCIPAL DIAGNOSIS Esophageal foreign body ICD 9 code 935 1 DESCRIPTION OF PROCEDURE Under general anesthesia flexible EGD was performed Esophagus was visualized The quarter was visualized at the aortic knob was removed with grasper Estimated blood loss 0 Intravenous fluids during time of procedure 100 mL No tissues No complications The patient tolerated the procedure well Dr X Pipkin attending pediatric surgeon was present throughout the entire procedure The patient was transferred from OR to PACU in stable condition Keywords gastroenterology esophagus foreign body esophagoscopy esophageal MEDICAL_TRANSCRIPTION,Description Exploratory laparotomy lysis of adhesions and removal reversal of Hartmann s colostomy flexible sigmoidoscopy and cystoscopy with left ureteral stent Medical Specialty Gastroenterology Sample Name Exploratory Laparotomy 1 Transcription PREOPERATIVE DIAGNOSIS History of perforated sigmoid diverticuli with Hartmann s procedure POSTOPERATIVE DIAGNOSES 1 History of perforated sigmoid diverticuli with Hartmann s procedure 2 Massive adhesions PROCEDURE PERFORMED 1 Exploratory laparotomy 2 Lysis of adhesions and removal 3 Reversal of Hartmann s colostomy 4 Flexible sigmoidoscopy 5 Cystoscopy with left ureteral stent ANESTHESIA General HISTORY This is a 55 year old gentleman who had a previous perforated diverticula Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann s colostomy PROCEDURE The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion A cystoscope was introduced into the patient s urethra and to the bladder Immediately no evidence of cystitis was seen and the scope was introduced superiorly measuring the bladder and immediately a 5 French ____ was introduced within the left urethra The cystoscope was removed a Foley was placed and wide connection was placed attaching the left ureteral stent and Foley At this point immediately the patient was re prepped and draped and immediately after the ostomy was closed with a 2 0 Vicryl suture immediately at this point the abdominal wall was opened with a 10 blade Bard Parker down with electrocautery for complete hemostasis through the midline The incision scar was cephalad due to the severe adhesions in the midline Once the abdomen was entered in the epigastric area then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall Once the small bowel was completely free from the anterior abdominal wall at this point the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall Immediately at this point the bowel was dropped within the abdominal cavity and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis At this point the rectal stump where two previous sutures with Prolene were seen were brought with hemostats The rectal stump was free in a 360 degree fashion and immediately at this point a decision to perform the anastomosis was made First a self retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point immediately the rectal stump was well visualized no evidence of bleeding was seen and the towels were placed along the edges of the abdominal wound Immediately the pursestring device was fired approximately 1 inch from the skin and on the descending colon this was fired The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating 25 and 29 mushroom tip from the T8 Ethicon was placed within the colon and then 9 0 suture was tied Immediately from the anus the dilator 25 and 29 was introduced dilating the rectum The 29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it The EEA was then fired Once it was fired and was removed the pelvis was filled with fluid Immediately both doughnuts were ____ from the anastomosis A Doyen was placed in both the anastomosis Colonoscope was introduced No bubble or air was seen coming from the anastomosis There was no evidence of bleeding Pictures of the anastomosis were taken The scope then was removed from the patient s rectum Copious amount of irrigation was used within the peritoneal cavity Immediately at this point all complete sponge and instrument count was performed First the ostomy site was closed with interrupted figure of eight 0 Vicryl suture The peritoneum was closed with running 2 0 Vicryl suture Then the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle Subq tissue was copiously irrigated and the staples on the skin The iodoform packing was placed within the old ostomy site and then the staples on the skin as well The patient did tolerate the procedure well and will be followed during the hospitalization The left ureteral stent was removed at the end of the procedure _____ were performed Lysis of adhesions were performed Reversal of colostomy and EEA anastomosis 29 Ethicon Keywords gastroenterology reversal of hartmann s colostomy flexible sigmoidoscopy cystoscopy ureteral stent lysis of adhesions exploratory laparotomy hartmann s colostomy abdominal wall immediately adhesions colostomy sigmoidoscopy bowel anastomosis abdominal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsies Gastroesophageal reflux disease chronic dyspepsia alkaline reflux gastritis gastroparesis probable Billroth II anastomosis and status post Whipple s pancreaticoduodenectomy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy with Biopsies Transcription PREOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Chronic dyspepsia POSTOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Chronic dyspepsia 3 Alkaline reflux gastritis 4 Gastroparesis 5 Probable Billroth II anastomosis 6 Status post Whipple s pancreaticoduodenectomy PROCEDURE PERFORMED Esophagogastroduodenoscopy with biopsies INDICATIONS FOR PROCEDURE This is a 55 year old African American female who had undergone Whipple s procedure approximately five to six years ago for a benign pancreatic mass The patient has pancreatic insufficiency and is already on replacement She is currently using Nexium She has continued postprandial dyspepsia and reflux symptoms To evaluate this the patient was boarded for EGD The patient gave informed consent for the procedure GROSS FINDINGS At the time of EGD the patient was found to have alkaline reflux gastritis There was no evidence of distal esophagitis Gastroparesis was seen as there was retained fluid in the small intestine The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy Biopsies were taken and further recommendations will follow PROCEDURE The patient was taken to the Endoscopy Suite The heart and lungs examination were unremarkable The vital signs were monitored and found to be stable throughout the procedure The patient s oropharynx was anesthetized with Cetacaine spray She was placed in left lateral position The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx GE junction was in normal position There was no evidence of any hiatal hernia There was no evidence of distal esophagitis The gastric remnant was entered It was noted to be inflamed with alkaline reflux gastritis The anastomosis was open and patent The small intestine was entered There was retained fluid material in the stomach and small intestine and _______ gastroparesis Biopsies were performed Insufflated air was removed with withdrawal of the scope The patient s diet will be adjusted to postgastrectomy type diet Biopsies performed Diet will be reviewed The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis Reglan will also be added Further recommendations will follow Keywords gastroenterology gastroesophageal reflux disease chronic dyspepsia alkaline reflux gastritis gastroparesis whipple s pancreaticoduodenectomy billroth ii anastomosis gastroesophageal reflux alkaline reflux reflux gastritis gif esophagogastroduodenoscopy dyspepsia gastritis anastomosis pancreaticoduodenectomy biopsies alkaline reflux MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with photo Insertion of a percutaneous endoscopic gastrostomy tube Neuromuscular dysphagia Protein calorie malnutrition Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy Gastrostomy Tube Insertion Transcription PREOPERATIVE DIAGNOSES 1 Neuromuscular dysphagia 2 Protein calorie malnutrition POSTOPERATIVE DIAGNOSES 1 Neuromuscular dysphagia 2 Protein calorie malnutrition PROCEDURES PERFORMED 1 Esophagogastroduodenoscopy with photo 2 Insertion of a percutaneous endoscopic gastrostomy tube ANESTHESIA IV sedation and local COMPLICATIONS None DISPOSITION The patient tolerated the procedure well without difficulty BRIEF HISTORY The patient is a 50 year old African American male who presented to ABCD General Hospital on 08 18 2003 secondary to right hemiparesis from a CVA The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator dependency with respiratory failure The patient also had neuromuscular dysfunction After extended period of time per the patient s family request and requested by the ICU staff decision to place a feeding tube was decided and scheduled for today INTRAOPERATIVE FINDINGS The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules PROCEDURE After informed written consent the risks and benefits of the procedure were explained to the patient and the patient s family First the EGD was to be performed The Olympus endoscope was inserted through the mouth oropharynx and into the esophagus Esophagitis was noted The scope was then passed through the esophagus into the stomach The cardia fundus body and antrum of the stomach were visualized There was evidence of gastritis The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus Next attention was made to transilluminating the anterior abdominal wall for the PEG placement The skin was then anesthetized with 1 lidocaine The finder needle was then inserted under direct visualization The catheter was then grasped via the endoscope and the wire was pulled back up through the patient s mouth The Ponsky PEG tube was attached to the wire A skin nick was made with a 11 blade scalpel The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position The endoscope was then replaced confirming position Photograph was taken The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well We will begin tube feeds later this afternoon Keywords gastroenterology neuromuscular dysphagia protein calorie malnutrition esophagogastroduodenoscopy endoscopic gastrostomy percutaneous gastrostomy tube percutaneous endoscopic gastrostomy tube protein calorie malnutrition abdominal wall dysphagia stomach abdominal neuromuscular tube MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with pseudo and esophageal biopsy Hiatal hernia and reflux esophagitis The patient is a 52 year old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy with Biopsies 2 Transcription PREOPERATIVE DIAGNOSIS Refractory dyspepsia POSTOPERATIVE DIAGNOSIS 1 Hiatal hernia 2 Reflux esophagitis PROCEDURE PERFORMED Esophagogastroduodenoscopy with pseudo and esophageal biopsy ANESTHESIA Conscious sedation with Demerol and Versed SPECIMEN Esophageal biopsy COMPLICATIONS None HISTORY The patient is a 52 year old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough She has been on multiple medical regimens and continues with dyspeptic symptoms PROCEDURE After proper informed consent was obtained the patient was brought to the endoscopy suite She was placed in the left lateral position and was given IV Demerol and Versed for sedation When adequate level of sedation achieved the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated At the GE junction a hiatal hernia was present There were mild inflammatory changes consistent with reflux esophagitis The scope was then passed into the stomach It was insufflated and the scope was coursed along the greater curvature to the antrum The pylorus was patent There was evidence of bile reflux in the antrum The duodenal bulb and sweep were examined and were without evidence of mass ulceration or inflammation The scope was then brought back into the antrum A retroflexion was attempted multiple times however the patient was having difficulty holding the air and adequate retroflexion view was not visualized The gastroscope was then slowly withdrawn There were no other abnormalities noted in the fundus or body Once again at the GE junction esophageal biopsy was taken The scope was then completely withdrawn The patient tolerated the procedure and was transferred to the recovery room in stable condition She will return to the General Medical Floor We will continue b i d proton pump inhibitor therapy as well as dietary restrictions She should also attempt significant weight loss Keywords gastroenterology refractory dyspepsia hiatal hernia reflux esophagitis esophagogastroduodenoscopy esophageal pseudo esophageal biopsy ge junction hiatal hernia esophagitis antrum gerd MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement Malnutrition and dysphagia with two antral polyps and large hiatal hernia Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 9 Transcription PREOPERATIVE DIAGNOSES Malnutrition and dysphagia POSTOPERATIVE DIAGNOSES Malnutrition and dysphagia with two antral polyps and large hiatal hernia PROCEDURES Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement ANESTHESIA IV sedation 1 Xylocaine locally CONDITION Stable OPERATIVE NOTE IN DETAIL After risk of operation was explained to this patient s family consent was obtained for surgery The patient was brought to the GI lab There she was placed in partial left lateral decubitus position She was given IV sedation by Anesthesia Her abdomen was prepped with alcohol and then Betadine Flexible gastroscope was passed down the esophagus through the stomach into the duodenum No lesions were noted in the duodenum There appeared to be a few polyps in the antral area two in the antrum Actually one appeared to be almost covering the pylorus The scope was withdrawn back into the antrum On retroflexion we could see a large hiatal hernia No other lesions were noted Biopsy was taken of one of the polyps The scope was left in position Anterior abdominal wall was prepped with Betadine 1 Xylocaine was injected in the left epigastric area A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall into the stomach followed by a thread was grasped with a snare using the gastroscope brought out through the patient s mouth Tied to the gastrostomy tube which was then pulled down and up through the anterior abdominal wall It was held in position with a dressing and a stent A connector was applied to the cut gastrostomy tube held in place with a 2 0 silk ligature The patient tolerated the procedure well She was returned to the floor in stable condition Keywords gastroenterology antral polyps gastrostomy endoscopic gastrostomy hiatal hernia abdominal wall gastrostomy tube esophagogastroduodenoscopy malnutrition dysphagia abdominal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with gastric biopsies Antral erythema 2 cm polypoid pyloric channel tissue questionable inflammatory polyp which was biopsied duodenal erythema and erosion Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy with Biopsies 1 Transcription PROCEDURE Esophagogastroduodenoscopy with gastric biopsies INDICATION Abdominal pain FINDINGS Antral erythema 2 cm polypoid pyloric channel tissue questionable inflammatory polyp which was biopsied duodenal erythema and erosion MEDICATIONS Fentanyl 200 mcg and versed 6 mg SCOPE GIF Q180 PROCEDURE DETAIL Following the preprocedure patient assessment the procedure goals risks including bleeding perforation and side effects of medications and alternatives were reviewed Questions were answered Pause preprocedure was performed Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty The esophagus appeared to have normal motility and mucosa Regular Z line was located at 44 cm from incisors No erosion or ulceration No esophagitis Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus There was pyloric channel and antral erythema but no visible erosion or ulceration There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp This was biopsied and was placed separately in bottle 2 Random gastric biopsies from antrum incisura and body were obtained and placed in separate jar bottle 1 No active ulceration was found Upon entering the duodenal bulb there was extensive erythema and mild erosions less than 3 mm in length in first portion of duodenum duodenal bulb and junction of first and second part of the duodenum Postbulbar duodenum looked normal The patient was assessed upon completion of the procedure Okay to discharge once criteria met Follow up with primary care physician I met with patient afterward and discussed with him avoiding any nonsteroidal anti inflammatory medication Await biopsy results Keywords gastroenterology gastric biopsies duodenal erythema inflammatory polyp pyloric channel tissue pyloric channel esophagogastroduodenoscopy pyloric duodenal duodenum polypoid MEDICAL_TRANSCRIPTION,Description Positive peptic ulcer disease Gastritis Esophagogastroduodenoscopy with photography and biopsy The patient had a history of peptic ulcer disease epigastric abdominal pain x2 months being evaluated at this time for ulcer disease Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 7 Transcription PREOPERATIVE DIAGNOSIS Positive peptic ulcer disease POSTOPERATIVE DIAGNOSIS Gastritis PROCEDURE PERFORMED Esophagogastroduodenoscopy with photography and biopsy GROSS FINDINGS The patient had a history of peptic ulcer disease epigastric abdominal pain x2 months being evaluated at this time for ulcer disease Upon endoscopy gastroesophageal junction was at 40 cm no esophageal tumor varices strictures masses or no reflux esophagitis was noted Examination of the stomach reveals mild inflammation of the antrum of the stomach no ulcers erosions tumors or masses The profundus and the cardia of the stomach were unremarkable The pylorus was concentric The duodenal bulb and sweep with no inflammation tumors or masses OPERATIVE PROCEDURE The patient taken to the Endoscopy Suite prepped and draped in the left lateral decubitus position She was given IV sedation using Demerol and Versed Olympus videoscope was inserted in the hypopharynx upon deglutition passed into the esophagus Using air insufflation the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep The above gross findings noted The panendoscope was withdrawn back from the stomach deflected upon itself The lesser curve fundus and cardiac were well visualized Upon examination of these areas panendoscope was returned to midline Photographs and biopsies were obtained of the antrum of the stomach Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel Photographs and biopsies were obtained as appropriate The patient is sent to recovery room in stable condition Keywords gastroenterology antrum esophageal tumor varices strictures masses duodenal bulb peptic ulcer duodenal esophagus esophagogastroduodenoscopy panendoscope peptic inflammation ulcer disease stomach MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 4 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy INDICATIONS FOR PROCEDURE A 17 year old with history of 40 pound weight loss abdominal pain status post appendectomy with recurrent abscess formation and drainage Currently he has a fistula from his anterior abdominal wall out It does not appear to connect to the gastrointestinal tract but merely connect from the ventral surface of the rectus muscles out the abdominal wall CT scans show thickened terminal ileum which suggest that we are dealing with Crohn s disease Endoscopy is being done to evaluate for Crohn s disease MEDICATIONS General anesthesia INSTRUMENT Olympus GIF 160 and PCF 160 COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 5 mL FINDINGS With the patient in the supine position intubated under general anesthesia The endoscope was inserted without difficulty into the hypopharynx The scope was advanced down the esophagus which had normal mucosal coloration and vascular pattern Lower esophageal sphincter was located at 40 cm from the central incisors It appeared normal and appeared to function normally The endoscope was advanced into the stomach which was distended with excess air Rugal folds were flattened completely There were multiple superficial erosions scattered throughout the fundus body and antral portions consistent with Crohn s involvement of the stomach The endoscope was advanced through normal appearing pyloric valve into the first second and third portion of the duodenum which had normal mucosal coloration and fold pattern Biopsies were obtained x2 in the second portion of the duodenum antrum body and distal esophagus at 37 cm from the central incisors for histology Two additional biopsies were obtained in the antrum for CLO testing Excess air was evacuated from the stomach The scope was removed from the patient who tolerated that part of the procedure well The patient was turned and scope was changed for colonoscopy Prior to colonoscopy it was noted that there was a perianal fistula at 7 o clock The colonoscope was then inserted into the anal verge The colonic clean out was excellent The scope was advanced without difficulty to the cecum The cecal area had multiple ulcers with exudate The ileocecal valve was markedly distorted Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending transverse descending sigmoid and rectum The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon Biopsies were obtained in the cecum at 65 cm transverse colon 50 cm rectosigmoid 20 cm and rectum at 5 cm No fistulas were noted in the colon Excess air was evacuated from the colon The scope was removed The patient tolerated the procedure well and was taken to recovery in satisfactory condition IMPRESSION Normal esophagus and duodenum There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve All these findings are consistent with Crohn s disease PLAN Begin prednisone 30 mg p o daily Await PPD results and chest x ray results as well as cocci serology results If these are normal then we would recommend Remicade 5 mg kg IV infusion We would start Modulon 50 mL h for 20 hours to reverse the malnutrition state of this boy Check CMP and phosphate every Monday Wednesday and Friday for receding syndrome noted by following potassium and phosphate We will discuss with Dr X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy If he has no stricture formation in the small bowel we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn s in the small intestine that we cannot visualize with endoscopy Keywords gastroenterology olympus gif 160 pcf 160 endoscopy crohn s disease aphthous ulcers esophagogastroduodenoscopy endoscope esophagus duodenum mucosal stomach biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 6 Transcription PROCEDURE IN DETAIL Following premedication with Vistaril 50 mg and Atropine 0 4 mg IM the patient received Versed 5 0 mg intravenously after Cetacaine spray to the posterior palate The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum The upper mid and lower portions of the esophagus the lesser and greater curves of the stomach anterior and posterior walls body and antrum pylorus duodenal bulb and duodenum were all normal No evidence of friability ulceration or tumor mass was encountered The instrument was withdrawn to the antrum and biopsies taken for CLO testing and then the instrument removed Keywords gastroenterology cetacaine pylorus antrum duodenum upper esophagus esophagogastroduodenoscopy descending esophagusNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 3 Transcription PROCEDURES Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy REASON FOR PROCEDURE Child with abdominal pain and rectal bleeding Rule out inflammatory bowel disease allergic enterocolitis rectal polyps and rectal vascular malformations CONSENT History and physical examination was performed The procedure indications alternatives available and complications i e bleeding perforation infection adverse medication reaction the possible need for blood transfusion and surgery should a complication occur were discussed with the parents who understood and indicated this Opportunity for questions was provided and informed consent was obtained MEDICATION General anesthesia INSTRUMENT Olympus GIF 160 COMPLICATIONS None FINDINGS With the patient in the supine position and intubated the endoscope was inserted without difficulty into the hypopharynx The esophageal mucosa and vascular pattern appeared normal The lower esophageal sphincter was located at 25 cm from the central incisors It appeared normal A Z line was identified within the lower esophageal sphincter The endoscope was advanced into the stomach which distended with excess air Rugal folds flattened completely Gastric mucosa appeared normal throughout No hiatal hernia was noted Pyloric valve appeared normal The endoscope was advanced into the first second and third portions of duodenum which had normal mucosa coloration and fold pattern Biopsies were obtained x2 in the second portion of duodenum antrum and distal esophagus at 22 cm from the central incisors for histology Additional 2 biopsies were obtained for CLO testing in the antrum Excess air was evacuated from the stomach The scope was removed from the patient who tolerated that part of procedure well The patient was turned and the scope was advanced with some difficulty to the terminal ileum The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile appearing polyp was noted Biopsies were obtained x2 in the terminal ileum cecum ascending colon transverse colon descending colon sigmoid and rectum Then the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2 second bursts x3 The polyp was severed There was no bleeding at the stalk after removal of the polyp head The polyp head was removed by suction Excess air was evacuated from the colon The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition Estimated blood loss approximately 5 mL IMPRESSION Normal esophagus stomach duodenum and colon as well as terminal ileum except for a 1 x 1 cm rectal polyp which was removed successfully by polypectomy snare PLAN Histologic evaluation and CLO testing I will contact the parents next week with biopsy results and further management plans will be discussed at that time Keywords gastroenterology esophagus stomach duodenum rectal polyp polypectomy snare olympus gif 160 endoscope was advanced clo testing polyp head terminal ileum polypectomy biopsies esophagogastroduodenoscopy ileum mucosa colonoscopy MEDICAL_TRANSCRIPTION,Description Chronic abdominal pain and heme positive stool antral gastritis and duodenal polyp Esophagogastroduodenoscopy with photos and antral biopsy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 8 Transcription PREOPERATIVE DIAGNOSIS Chronic abdominal pain and heme positive stool POSTOPERATIVE DIAGNOSES 1 Antral gastritis 2 Duodenal polyp PROCEDURE PERFORMED Esophagogastroduodenoscopy with photos and antral biopsy ANESTHESIA Demerol and Versed DESCRIPTION OF PROCEDURE Consent was obtained after all risks and benefits were described The patient was brought back into the Endoscopy Suite The aforementioned anesthesia was given Once the patient was properly anesthetized bite block was placed in the patient s mouth Then the patient was given the aforementioned anesthesia Once he was properly anesthetized the endoscope was placed in the patient s mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach The air was insufflated down The scope was passed down to the level of the antrum where there was some evidence of gastritis seen The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen The scope was pulled back into the stomach in order to flex upon itself and straightened out Biopsies were taken for CLO and histology of the antrum The scope was pulled back The junction was visualized No other masses or lesions were seen The scope was removed The patient tolerated the procedure well We will recommend the patient be on some type of a H2 blocker Further recommendations to follow Keywords gastroenterology endoscopy gastritis clo histology antrum heme positive stool esophagogastroduodenoscopy duodenal polyp antral MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy The Olympus video panendoscope was advanced under direct vision into the esophagus The esophagus was normal in appearance and configuration The gastroesophageal junction was normal Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 5 Transcription MEDICATIONS 1 Versed intravenously 2 Demerol intravenously DESCRIPTION OF THE PROCEDURE After informed consent the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx The patient was sedated with the above medications The Olympus video panendoscope was advanced under direct vision into the esophagus The esophagus was normal in appearance and configuration The gastroesophageal junction was normal The scope was advanced into the stomach where the fundic pool was aspirated and the stomach was insufflated with air The gastric mucosa appeared normal The pylorus was normal The scope was advanced through the pylorus into the duodenal bulb which was normal then into the second part of the duodenum which was normal as well The scope was pulled back into the stomach Retroflexed view showed a normal incisura lesser curvature cardia and fundus The scope was straightened out the air removed and the scope withdrawn The patient tolerated the procedure well There were no apparent complications Keywords gastroenterology duodenal bulb gastric mucosa olympus video video panendoscope gastroesophageal junction esophagogastroduodenoscopy gastroesophageal pylorus stomach esophagus scopeNOTE MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy photography and biopsy Gastroesophageal reflux disease hiatal hernia and enterogastritis Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 12 Transcription PREOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Hiatal hernia POSTOPERATIVE DIAGNOSES 1 Gastroesophageal reflux disease 2 Hiatal hernia 3 Enterogastritis PROCEDURE PERFORMED Esophagogastroduodenoscopy photography and biopsy GROSS FINDINGS The patient has a history of epigastric abdominal pain persistent in nature She has a history of severe gastroesophageal reflux disease takes Pepcid frequently She has had a history of hiatal hernia She is being evaluated at this time for disease process She does not have much response from Protonix Upon endoscopy the gastroesophageal junction is approximately 40 cm There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia There is no advancement of the gastric mucosa up into the lower one third of the esophagus However there appeared to be inflammation as stated previously in the gastroesophageal junction There was some mild inflammation at the antrum of the stomach The fundus of the stomach was within normal limits The cardia showed some laxity to the lower esophageal sphincter The pylorus is concentric The duodenal bulb and sweep are within normal limits No ulcers or erosions OPERATIVE PROCEDURE The patient is taken to the Endoscopy Suite prepped and draped in the left lateral decubitus position The patient was given IV sedation using Demerol and Versed Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus Using air insufflation panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted Panendoscope was slowly withdrawn carefully examining the lumen of the bowel Photographs were taken with the pathology present Biopsy was obtained of the antrum of the stomach and also CLO test The biopsy is also obtained of the gastroesophageal junction at 12 3 6 and 9 o clock positions to rule out occult Barrett s esophagitis Air was aspirated from the stomach and the panendoscope was removed The patient sent to recovery room in stable condition Keywords gastroenterology biopsy gastroesophageal reflux gastroesophageal reflux disease duodenal bulb gastroesophageal junction hiatal hernia enterogastritis endoscopy esophagogastroduodenoscopy gastroesophageal MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 2 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy REASON FOR PROCEDURE The child with history of irritability and diarrhea with gastroesophageal reflux Rule out reflux esophagitis allergic enteritis and ulcer disease as well as celiac disease He has been on Prevacid 7 5 mg p o b i d with suboptimal control of this irritability Consent history and physical examinations were performed The procedure indications alternatives available and complications i e bleeding perforation infection adverse medication reactions possible need for blood transfusion and surgery associated complication occur were discussed with the mother who understood and indicated this Opportunity for questions was provided and informed consent was obtained MEDICATIONS General anesthesia INSTRUMENT Olympus GIF XQ 160 COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 5 mL FINDINGS With the patient in the supine position intubated under general anesthesia the endoscope was inserted without difficulty into the hypopharynx The proximal mid and distal esophagus had normal mucosal coloration and vascular pattern Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors A Z line was identified within the lower esophageal sphincter The endoscope was advanced into the stomach which was distended with excess air The rugal folds flattened completely The gastric mucosa was entirely normal No hiatal hernia was seen and the pyloric valve appeared normal The endoscope was advanced into first second and third portion of the duodenum which had normal mucosal coloration and fold pattern Ampule of Vater was identified and found to be normal Biopsies were obtained x2 in the second portion of duodenum antrum and distal esophagus at 22 cm from the central incisors for histology Additional two antral biopsies were obtained for CLO testing Excess air was evacuated from the stomach The scope was removed from the patient who tolerated the procedure well The patient was taken to recovery room in satisfactory condition IMPRESSION Normal esophagus stomach and duodenum PLAN Histologic evaluation and CLO testing Continue Prevacid 7 5 mg p o b i d I will contact the parents next week with biopsy results and further management plans will be discussed at that time Keywords gastroenterology olympus gif xq 160 diarrhea gastroesophageal esophagitis reflux clo testing esophagogastroduodenoscopy with biopsy endoscope esophagus stomach duodenum esophagogastroduodenoscopy MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy performed in the emergency department Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 13 Transcription PROCEDURE PERFORMED Esophagogastroduodenoscopy performed in the emergency department INDICATION Melena acute upper GI bleed anemia and history of cirrhosis and varices FINAL IMPRESSION 1 Scope passage massive liquid in stomach with some fresh blood near the fundus unable to identify source due to gastric contents 2 Endoscopy following erythromycin demonstrated grade I esophageal varices No stigmata of active bleeding Small amount of fresh blood within the hiatal hernia No definite source of bleeding seen PLAN 1 Repeat EGD tomorrow morning following aggressive resuscitation and transfusion 2 Proton pump inhibitor drip 3 Octreotide drip 4 ICU bed PROCEDURE DETAILS Prior to the procedure physical exam was stable During the procedure vital signs remained within normal limits Prior to sedation informed consent was obtained Risks benefits and alternatives including but not limited to risk of bleeding infection perforation adverse reaction to medication failure to identify pathology pancreatitis and death explained to the patient and his wife who accepted all risks The patient was prepped in the left lateral position IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin Scope tip of the Olympus gastroscope was passed into the esophagus Proximal middle and distal thirds of the esophagus were well visualized There was fresh blood in the esophagus which was washed thoroughly but no source was seen No evidence of varices was seen The stomach was entered The stomach was filled with very large clot and fresh blood and liquid which could not be suctioned due to the clot burden There was a small amount of bright red blood near the fundus but a source could not be identified due to the clot burden Because of this the gastroscope was withdrawn The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later the scope was repassed On the second look the esophagus was cleared The liquid gastric contents were cleared There was still a moderate amount of clot burden in the stomach but no active bleeding was seen There was a small grade I esophageal varices but no stigmata of bleed There was also a small amount of fresh blood within the hiatal hernia but no source of bleeding was identified The patient was hemodynamically stable therefore a decision was made for a second look in the morning The scope was withdrawn and air was suctioned The patient tolerated the procedure well and was sent to recovery without immediate complications Keywords gastroenterology gi bleed anemia cirrhosis stomach fundus hiatal hernia esophagogastroduodenoscopy erythromycin varices esophagus MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with bile aspirate Recurrent right upper quadrant pain with failure of antacid medical therapy Normal esophageal gastroduodenoscopy Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 11 Transcription PREOPERATIVE DIAGNOSIS Recurrent right upper quadrant pain with failure of antacid medical therapy POSTOPERATIVE DIAGNOSIS Normal esophageal gastroduodenoscopy PROCEDURE PERFORMED Esophagogastroduodenoscopy with bile aspirate ANESTHESIA IV Demerol and Versed in titrated fashion INDICATIONS This 41 year old female presents to surgical office with history of recurrent right upper quadrant abdominal pain Despite antacid therapy the patient s pain has continued Additional findings were concerning with possibility of a biliary etiology The patient was explained the risks and benefits of an EGD as well as a Meltzer Lyon test where upon bile aspiration was performed The patient agreed to the procedure and informed consent was obtained GROSS FINDINGS No evidence of neoplasia mucosal change or ulcer on examination Aspiration of the bile was done after the administration of 3 mcg of Kinevac PROCEDURE DETAILS The patient was placed in the supine position After appropriate anesthesia was obtained an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum Prior to this 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile At this time the patient as well complained of epigastric discomfort and nausea This pain was similar to her previous pain Bile was aspirated with a trap to enable the collection of the fluid This fluid was then sent to lab for evaluation for crystals Next photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________ gastroscope was retracted The gastroesophageal junction was noted at 20 cm No other evidence of disease was appreciated here Retraction of the gastroscope backed through the esophagus off the oropharynx removed from the patient The patient tolerated the procedure well We will await evaluation of bile aspirate Keywords gastroenterology bile aspirate esophageal gastroduodenoscopy kinevac oropharynx esophagogastroduodenoscopy gastroscope MEDICAL_TRANSCRIPTION,Description Ivor Lewis esophagogastrectomy feeding jejunostomy placement of two right sided 28 French chest tubes and right thoracotomy Medical Specialty Gastroenterology Sample Name Esophagogastrectomy Jejunostomy Chest Tubes Transcription OPERATION 1 Ivor Lewis esophagogastrectomy 2 Feeding jejunostomy 3 Placement of two right sided 28 French chest tubes 4 Right thoracotomy ANESTHESIA General endotracheal anesthesia with a dual lumen tube OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Prior to administration of general anesthesia the patient had an epidural anesthesia placed In addition he had a dual lumen endotracheal tube placed The patient was placed in the supine position to begin the procedure His abdomen and chest were prepped and draped in the standard surgical fashion After applying sterile dressings a 10 blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus Dissection was carried down through the linea using Bovie electrocautery The abdomen was opened Next a Balfour retractor was positioned as well as a mechanical retractor Next our attention was turned to freeing up the stomach In an attempt to do so we identified the right gastroepiploic artery and arcade We incised the omentum and retracted it off the stomach and gastroepiploic arcade The omentum was divided using suture ligature with 2 0 silk We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2 0 silk Next we turned our attention to performing a Kocher maneuver This was done and the stomach was freed up We took down the falciform ligament as well as the caudate attachment to the diaphragm We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest We also did a portion of the esophageal dissection from the abdomen into the chest area The esophagus and the esophageal hiatus were identified in the abdomen We next turned our attention to the left gastric artery The left gastric artery was identified at the base of the stomach We first took the left gastric vein by ligating and dividing it using 0 silk ties The left gastric artery was next taken using suture ligature with silk ties followed by 2 0 stick tie reinforcement At this point the stomach was freely mobile We then turned our attention to performing our jejunostomy feeding tube A 2 0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz We then used Bovie electrocautery to open the jejunum at this site We placed a 16 French red rubber catheter through this site We tied down in place We then used 3 0 silk sutures to perform a Witzel Next the loop of jejunum was tacked up to the abdominal wall using 2 0 silk ties After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately we turned our attention to closing the abdomen This was done with 1 Prolene We put in a 2nd layer of 2 0 Vicryl The skin was closed with 4 0 Monocryl Next we turned our attention to performing the thoracic portion of the procedure The patient was placed in the left lateral decubitus position The right chest was prepped and draped appropriately We then used a 10 blade scalpel to make an incision in a posterolateral non muscle sparing fashion Dissection was carried down to the level of the ribs with Bovie electrocautery Next the ribs were counted and the 5th interspace was entered The lung was deflated We placed standard chest retractors Next we incised the peritoneum over the esophagus We dissected the esophagus to just above the azygos vein The azygos vein in fact was taken with 0 silk ligatures and reinforced with 2 0 stick ties As mentioned we dissected the esophagus both proximally and distally down to the level of the hiatus After doing this we backed our NG tube out to above the level where we planned to perform our pursestring We used an automatic pursestring and applied We then transected the proximal portion of the stomach with Metzenbaum scissors We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus The pursestring was then tied down without difficulty Next we tabularized our stomach using a 80 GIA stapler After doing so we chose a portion of the stomach more distally and opened it using Bovie electrocautery We placed our EEA stapler through it and then punched out through the gastric wall We connected our anvil to the EEA stapler This was then secured appropriately We checked to make sure that there was appropriate muscle apposition We then fired the stapler We obtained 2 complete rings 1 of the esophagus and 1 of the stomach which were sent for pathology We also sent the gastroesophageal specimen for pathology Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins We then turned our attention to closing the gastrostomy opening This was closed with 2 0 Vicryl in a running fashion We then buttressed this with serosal 3 0 Vicryl interrupted sutures We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it Next we placed two 28 French chest tubes 1 anteriorly and 1 posteriorly taking care not to place it near the anastomosis We then closed the chest with 2 Vicryl in an interrupted figure of eight fashion The lung was brought up We closed the muscle layers with 0 Vicryl followed by 0 Vicryl then we closed the subcutaneous layer with 2 0 Vicryl and the skin with 4 0 Monocryl Sterile dressing was applied The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition Keywords gastroenterology ivor lewis esophagogastrectomy jejunostomy thoracotomy dual lumen tube chest tubes bovie electrocautery chest endotracheal electrocautery abdomen gastric esophagus tubes vicryl stomach MEDICAL_TRANSCRIPTION,Description Endoscopic retrograde cholangiopancreatography ERCP with brush cytology and biopsy Medical Specialty Gastroenterology Sample Name ERCP Transcription PROCEDURE Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy INDICATION FOR THE PROCEDURE Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis with a recent upper endoscopy showing an abnormal appearing ampulla MEDICATIONS General anesthesia The risks of the procedure were made aware to the patient and consisted of medication reaction bleeding perforation aspiration and post ERCP pancreatitis DESCRIPTION OF PROCEDURE After informed consent and appropriate sedation the duodenoscope was inserted into the oropharynx down the esophagus and into the stomach The scope was then advanced through the pylorus to the ampulla The ampulla had a markedly abnormal appearance as it was enlarged and very prominent It extended outward with an almost polypoid shape It had what appeared to be adenomatous appearing mucosa on the tip There also was ulceration noted on the tip of this ampulla The biliary and pancreatic orifices were identified This was located not at the tip of the ampulla but rather more towards the base Cannulation was performed with a Wilson Cooke TriTome sphincterotome with easy cannulation of the biliary tree The common bile duct was mildly dilated measuring approximately 12 mm The intrahepatic ducts were minimally dilated There were no filling defects identified There was felt to be a possible stricture within the distal common bile duct but this likely represented an anatomic variant given the abnormal shape of the ampulla The patient has no evidence of obstruction based on lab work and clinically Nevertheless it was decided to proceed with brush cytology of this segment This was done without any complications There was adequate drainage of the biliary tree noted throughout the procedure Multiple efforts were made to access the pancreatic ductal anatomy however because of the shape of the ampulla this was unsuccessful Efforts were made to proceed in a long scope position but still were unsuccessful Next biopsies were obtained of the ampulla away from the biliary orifice Four biopsies were taken There was some minor oozing which had ceased by the end of the procedure The stomach was then decompressed and the endoscope was withdrawn FINDINGS 1 Abnormal papilla with bulging polypoid appearance and looks adenomatous with ulceration on the tip biopsies taken 2 Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture although I think this is likely an anatomic variant brush cytology obtained 3 Unable to access the pancreatic duct RECOMMENDATIONS 1 NPO except ice chips today 2 Will proceed with MRCP to better delineate pancreatic ductal anatomy 3 Follow up biopsies and cytology Keywords gastroenterology endoscopic retrograde cholangiopancreatography biopsy brush cytology cholangiopancreatography pancreatitis endoscopy duodenoscope wilson cooke tritome ampulla common bile duct ercp endoscopic biliary pancreatic duct biopsies cytology MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy a 1 year 10 month old with a history of dysphagia to solids Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 1 Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy PREOPERATIVE DIAGNOSIS A 1 year 10 month old with a history of dysphagia to solids The procedure was done to rule out organic disease POSTOPERATIVE DIAGNOSES Loose lower esophageal sphincter and duodenal ulcers CONSENT The consent is signed MEDICATIONS The procedure was done under general anesthesia given by Dr Marino Fernandez COMPLICATIONS None PROCEDURE IN DETAIL A history and physical examination were performed and the procedure indications potential complications including bleeding perforation the need for surgery infection adverse medical reaction risks benefits and alternatives available were explained to the parents who stated good understanding and consented to go ahead with the procedure The opportunity for questions was provided and informed consent was obtained Once the consent was obtained the patient was sedated with IV medications and intubated by Dr Fernandez and placed in the supine position Then the tip of the XP 160 videoscope was introduced into the oropharynx and under direct visualization we could advance the endoscope into the upper mid and lower esophagus We did not find any strictures in the upper esophagus but the patient had the lower esophageal sphincter totally loose Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus and then into the first portion of the duodenum We noticed that the patient had several ulcers in the first portion of the duodenum Then the tip of the endoscope was advanced down into the second portion of the duodenum one biopsy was taken there and then the tip of the endoscope was brought back to the first portion and two biopsies were taken there Then the tip of the endoscope was brought back to the antrum where two biopsies were taken and one biopsy for CLOtest By retroflexed view at the level of the body of the stomach I could see that the patient had the lower esophageal sphincter loose Finally the endoscope was unflexed and was brought back to the lower esophagus where two biopsies were taken At the end air was suctioned from the stomach and the endoscope was removed out of the patient s mouth The patient tolerated the procedure well with no complications FINAL IMPRESSION 1 Duodenal ulcers 2 Loose lower esophageal sphincter PLAN 1 To start omeprazole 20 mg a day 2 To review the biopsies 3 To return the patient back to clinic in 1 to 2 weeks Keywords gastroenterology esophagogastroduodenoscopy esophageal biopsies endoscope MEDICAL_TRANSCRIPTION,Description The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm 2 5 cm right common iliac artery aneurysm Medical Specialty Gastroenterology Sample Name Endovascular Abdominal Aortic Aneurysm Repair Transcription PREOPERATIVE DIAGNOSIS Abdominal aortic aneurysm POSTOPERATIVE DIAGNOSIS Abdominal aortic aneurysm OPERATION PERFORMED Endovascular abdominal aortic aneurysm repair FINDINGS The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm 2 5 cm right common iliac artery aneurysm A Gore exclusive device was used 3 pieces were used to effect the repair We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm The right hypogastric artery had been previously coiled off Left common femoral artery was used for the _____ side We had small type 2 leak right underneath the take off the renal arteries this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery which commonly come off in this area It was felt that this would seal after reversal of the anticoagulation given sufficient time PROCEDURE With the patient supine position under general anesthesia the abdomen and lower extremities were prepped and draped in a sterile fashion Bilateral groin incisions were made and the common femoral arteries were dissected out bilaterally The patient was then heparinized The 7 French sheaths were then placed retrograde bilaterally A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side The calibrated aortogram was the done We marked the renal arteries aortic bifurcation and bifurcation common iliac arteries We then preceded placement of the main trunk by replacing the 7 French sheath in the left groin area with 18 french sheath and then deployed the trunk body just below the take off renal arteries Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery As noted above we then had to place an iliac extension down in the external iliac artery to exclude the right common iliac artery and resume completely Following completion of the above all arteries were ballooned appropriately A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries The area was ballooned aggressively It was felt that this would dissolve as discussed above Following completion of the above all wire sheaths etc were removed from both groin areas Both femoral arteries were repaired by primary suture technique Flow was then reestablished to the lower extremities and protamine was given to reverse the heparin Both surgical sites were then irrigated thoroughly Meticulous hemostasis was achieved Both wounds were then closed in a routine layered fashion Sterile antibiotic dressings were applied Sponge and needle counts were reported as correct The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition Keywords gastroenterology gore common iliac artery aneurysm abdominal aortic aneurysm repair abdominal aortic aneurysm common iliac aortic aneurysm iliac artery artery aneurysm iliac abdominal aortic arteries MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy and snare polypectomy Iron deficiency anemia Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy Transcription PROCEDURE Esophagogastroduodenoscopy with biopsy and snare polypectomy INDICATION FOR THE PROCEDURE Iron deficiency anemia MEDICATIONS MAC The risks of the procedure were made aware to the patient and consisted of medication reaction bleeding perforation and aspiration PROCEDURE After informed consent and appropriate sedation the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum The duodenal mucosa was completely normal The pylorus was normal In the stomach there was evidence of diffuse atrophic appearing nodular gastritis Multiple biopsies were obtained There also was a 1 5 cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum There was mild ulceration on the tip of this polyp It was decided to remove the polyp via snare polypectomy Retroflexion was performed and this revealed a small hiatal hernia in the distal esophagus The Z line was identified and was unremarkable The esophageal mucosa was normal FINDINGS 1 Hiatal hernia 2 Diffuse nodular and atrophic appearing gastritis biopsies taken 3 A 1 5 cm polyp with ulceration along the greater curvature removed RECOMMENDATIONS 1 Follow up biopsies 2 Continue PPI 3 Hold Lovenox for 5 days 4 Place SCDs Keywords gastroenterology esophagogastroduodenoscopy iron deficiency iron deficiency anemia anemia biopsy endoscope esophageal mucosa esophagus hiatal hernia polypectomy snare polypectomy esophagogastroduodenoscopy with biopsy iron deficiency anemia MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with antral biopsies for H pylori x2 with biopsy forceps Nausea and vomiting and upper abdominal pain Medical Specialty Gastroenterology Sample Name Esophagogastroduodenoscopy 10 Transcription PREOPERATIVE DIAGNOSIS Nausea and vomiting and upper abdominal pain POST PROCEDURE DIAGNOSIS Normal upper endoscopy OPERATION Esophagogastroduodenoscopy with antral biopsies for H pylori x2 with biopsy forceps ANESTHESIA IV sedation 50 mg Demerol 8 mg of Versed PROCEDURE The patient was taken to the endoscopy suite After adequate IV sedation with the above medications hurricane was sprayed in the mouth as well as in the esophagus A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus stomach and pylorus The first second and third portions of the duodenum were normal The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H pylori The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone The scope was then removed throughout the esophagus which was normal The patient tolerated the procedure well The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal although previous ultrasounds several years ago showed a gallstone Keywords gastroenterology h pylori forceps antral biopsies ge junction esophagogastroduodenoscopy pylori esophagus antral MEDICAL_TRANSCRIPTION,Description Upper endoscopy with biopsy The patient admitted for coffee ground emesis which has been going on for the past several days An endoscopy is being done to evaluate for source of upper GI bleeding Medical Specialty Gastroenterology Sample Name Endoscopy With Biopsy Transcription PROCEDURE Upper endoscopy with biopsy PROCEDURE INDICATION This is a 44 year old man who was admitted for coffee ground emesis which has been going on for the past several days An endoscopy is being done to evaluate for source of upper GI bleeding Informed consent was obtained Outlining the risks benefits and alternatives of the procedure included but not to risks of bleeding infection perforation the patient agreed for the procedure MEDICATIONS Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient s pressures and vital signs PROCEDURE IN DETAIL The patient was placed in the left lateral decubitus position Medications were given After adequate sedation was achieved the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum Keywords gastroenterology coffee ground emesis gi bleeding upper endoscopy iv push esophagus duodenum mucosa stomach endoscopy biopsy MEDICAL_TRANSCRIPTION,Description Intermittent rectal bleeding with abdominal pain Medical Specialty Gastroenterology Sample Name Endoscopy 4 Transcription PROCEDURE Endoscopy CLINICAL INDICATIONS Intermittent rectal bleeding with abdominal pain ANESTHESIA Fentanyl 100 mcg and 5 mg of IV Versed PROCEDURE The patient was taken to the GI lab and placed in the left lateral supine position Continuous pulse oximetry and blood pressure monitoring were in place After informed consent was obtained the video endoscope was inserted over the dorsum of the tongue without difficulty With swallowing the scope was advanced down the esophagus into the body of the stomach The scope was further advanced down to the antrum and through the pylorus into the duodenum which was visualized into its second portion It appeared free of stricture neoplasm or ulceration Samples were obtained from the antrum and prepyloric area to check for Helicobacter rapid urease and additional samples were sent to pathology Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia The scope was then slowly removed The distal esophagus appeared benign with a normal appearing gastroesophageal sphincter and no esophagitis The remaining portion of the esophagus was normal IMPRESSION Abdominal pain Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia RECOMMENDATIONS Await results of CLO testing and biopsies Return to clinic with Dr Spencer in 2 weeks for further discussion Keywords gastroenterology duodenum stomach hiatal hernia endoscopy antrum hiatal hernia gastroesophageal scope esophagus abdominal MEDICAL_TRANSCRIPTION,Description Epigastric herniorrhaphy Epigastric hernia Medical Specialty Gastroenterology Sample Name Epigastric Herniorrhaphy Transcription PREOPERATIVE DIAGNOSIS Epigastric hernia POSTOPERATIVE DIAGNOSIS Epigastric hernia OPERATIONS Epigastric herniorrhaphy ANESTHESIA General inhalation PROCEDURE Following attainment of satisfactory anesthesia the patient s abdomen was prepped with Hibiclens and draped sterilely The hernia mass had been marked preoperatively This area was anesthetized with a mixture of Marcaine and Xylocaine A transverse incision was made over the hernia and dissection carried down to the entrapped fat Sharp dissection was carried around the fat down to the fascial edge The preperitoneal fat could not be reduced therefore it is trimmed away and the small fascial defect then closed with interrupted 0 Ethibond sutures The fascial edges were injected with the local anesthetic mixture Subcutaneous tissues were then closed with interrupted 4 0 Vicryl and skin edges closed with running subcuticular 4 0 Vicryl Steri Strips and a sterile dressing were applied to complete the closure The patient was then awakened and taken to the PACU in satisfactory condition ESTIMATED BLOOD LOSS 10 mL SPONGE AND NEEDLE COUNT Reported as correct COMPLICATIONS None Keywords gastroenterology hibiclens epigastric herniorrhaphy epigastric hernia herniorrhaphy MEDICAL_TRANSCRIPTION,Description Normal upper GI endoscopy Medical Specialty Gastroenterology Sample Name Endoscopy Template Transcription INDICATIONS Dysphagia PREMEDICATION Topical Cetacaine spray and Versed IV PROCEDURE The scope was passed into the esophagus under direct vision The esophageal mucosa was all unremarkable There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis The scope was passed on down into the stomach The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present The scope was then withdrawn IMPRESSION Normal upper GI endoscopy without any evidence of anatomical narrowing Keywords gastroenterology dysphagia cetacaine spray esophagus esophageal mucosa duodenum scope was passed upper gi gi endoscopy gi endoscopy scope MEDICAL_TRANSCRIPTION,Description Patient with dysphagia Medical Specialty Gastroenterology Sample Name Endoscopy 3 Transcription PROCEDURES PERFORMED Endoscopy INDICATIONS Dysphagia POSTOPERATIVE DIAGNOSIS Esophageal ring and active reflux esophagitis PROCEDURE Informed consent was obtained prior to the procedure from the parents and patient The oral cavity is sprayed with lidocaine spray A bite block is placed Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments The GIF 160 diagnostic gastroscope used The patient was alert during the procedure The esophagus was intubated under direct visualization The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one third of the esophagus noted The stomach was unremarkable Retroflexed exam unremarkable Duodenum not intubated in order to minimize the time spent during the procedure The patient was alert although not combative A balloon was then inserted across the GE junction 15 mm to 18 mm and inflated to 3 4 7 and 7 ATM and left inflated at 18 mm for 45 seconds The balloon was then deflated The patient became uncomfortable and a good size adequate distal esophageal tear was noted The scope and balloon were then withdrawn The patient left in good condition IMPRESSION Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild PLAN I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed This has been discussed with the parents He was sent home with a prescription for omeprazole Keywords gastroenterology active reflux esophagitis ge junction distal esophageal active reflux reflux esophagitis dysphagia esophagus scope ge junction endoscopy esophageal reflux esophagitis distal balloon MEDICAL_TRANSCRIPTION,Description EGD with photos and biopsies This is a 75 year old female who presents with difficulty swallowing occasional choking and odynophagia She has a previous history of hiatal hernia She was on Prevacid currently Medical Specialty Gastroenterology Sample Name EGD With Photos Biopsies Transcription 1 Odynophagia 2 Dysphagia 3 Gastroesophageal reflux disease rule out stricture POSTOPERATIVE DIAGNOSES 1 Antral gastritis 2 Hiatal hernia PROCEDURE PERFORMED EGD with photos and biopsies GROSS FINDINGS This is a 75 year old female who presents with difficulty swallowing occasional choking and odynophagia She has a previous history of hiatal hernia She was on Prevacid currently At this time an EGD was performed to rule out stricture At the time of EGD there was noted some antral gastritis and hiatal hernia There are no strictures tumors masses or varices present OPERATIVE PROCEDURE The patient was taken to the Endoscopy Suite in the lateral decubitus position She was given sedation by the Department Of Anesthesia Once adequate sedation was reached the Olympus gastroscope was inserted into oropharynx With air insufflation entered through the proximal esophagus to the GE junction The esophagus was without evidence of tumors masses ulcerations esophagitis strictures or varices There was a hiatal hernia present The scope was passed through the hiatal hernia into the body of the stomach In the distal antrum there was some erythema with patchy erythematous changes with small superficial erosions Multiple biopsies were obtained The scope was passed through the pylorus into the duodenal bulb and duodenal suite they appeared within normal limits The scope was pulled back from the stomach retroflexed upon itself _____ fundus and GE junction As stated multiple biopsies were obtained The scope was then slowly withdrawn The patient tolerated the procedure well and sent to recovery room in satisfactory condition Keywords gastroenterology odynophagia dysphagia gastroesophageal reflux disease antral gastritis hiatal hernia difficulty swallowing esophagus stomach duodenal egd biopsies hiatal hernia MEDICAL_TRANSCRIPTION,Description Upper gastrointestinal endoscopy Medical Specialty Gastroenterology Sample Name Endoscopy Transcription PREOPERATIVE DIAGNOSIS Anemia PROCEDURE Upper gastrointestinal endoscopy POSTOPERATIVE DIAGNOSES 1 Severe duodenitis 2 Gastroesophageal junction small ulceration seen 3 No major bleeding seen in the stomach PROCEDURE IN DETAIL The patient was put in left lateral position Olympus scope was inserted from the mouth under direct visualization advanced to the upper part of the stomach upper part of esophagus middle of esophagus GE junction and some intermittent bleeding was seen at the GE junction Advanced into the upper part of the stomach into the antrum The duodenum showed extreme duodenitis and the scope was then brought back Retroflexion was performed which was normal Scope was then brought back slowly Duodenitis was seen and a little bit of ulceration seen at GE junction FINDING Severe duodenitis may be some source of bleeding from there but no active bleeding at this time Keywords gastroenterology upper gastrointestinal endoscopy ge junction gastrointestinal esophagus endoscopy stomach duodenitis bleeding MEDICAL_TRANSCRIPTION,Description EGD with dilation for dysphagia Medical Specialty Gastroenterology Sample Name EGD with Dilation Transcription INDICATION Keywords gastroenterology egd hurricaine spray olympus endoscope savary wire cricopharyngeus decubitus dilator duodenum dysphagia esophagus hiatal hernia peptic pylorus stomach tortuosity egd with dilation tortuous scope hiatal hernia MEDICAL_TRANSCRIPTION,Description Patient admitted because of recurrent nausea and vomiting with displacement of the GEJ feeding tube Medical Specialty Gastroenterology Sample Name EGD with Biopsy 1 Transcription PROCEDURE PERFORMED EGD with biopsy INDICATION Mrs ABC is a pleasant 45 year old female with a history of severe diabetic gastroparesis who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago She was admitted because of recurrent nausea and vomiting with displacement of the GEJ feeding tube A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach The endoscopy is done to confirm this and remove it as well as determine if there are any other causes to account for her symptoms Physical examination done prior to the procedure was unremarkable apart from upper abdominal tenderness MEDICATIONS Fentanyl 25 mcg Versed 2 mg 2 lidocaine spray to the pharynx INSTRUMENT GIF 160 PROCEDURE REPORT Informed consent was obtained from Mrs ABC s sister after the risks and benefits of the procedure were carefully explained which included but were not limited to bleeding infection perforation and allergic reaction to the medications Consent was not obtained from Mrs Morales due to her recent narcotic administration Conscious sedation was achieved with the patient lying in the left lateral decubitus position The endoscope was then passed through the mouth into the esophagus the stomach where retroflexion was performed and it was advanced into the second portion of the duodenum FINDINGS 1 ESOPHAGUS There was evidence of grade C esophagitis with multiple white based ulcers seen from the distal to the proximal esophagus at 12 cm in length Multiple biopsies were obtained from this region and placed in jar 1 2 STOMACH Small hiatal hernia was noted within the cardia of the stomach There was an indentation scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach The remainder of the stomach examination was normal There was no feeding tube remnant seen within the stomach 3 DUODENUM This was normal COMPLICATIONS None ASSESSMENT 1 Grade C esophagitis seen within the distal mid and proximal esophagus 2 Small hiatal hernia 3 Evidence of scarring at the site of the previous feeding tube as well as suture line material seen in the body and antrum of the stomach PLAN Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube Keywords gastroenterology recurrent nausea and vomiting egd with biopsy nausea and vomiting gastrojejunal feeding tube feeding tube remnant recurrent nausea gej feeding gastrojejunal feeding proximal esophagus hiatal hernia feeding tube egd biopsy nausea vomiting gej gastrojejunal duodenum esophagitis multiple distal biopsies hiatal hernia antrum esophagus feeding tube stomach MEDICAL_TRANSCRIPTION,Description Melena and solitary erosion over a fold at the GE junction gastric side Medical Specialty Gastroenterology Sample Name Endoscopy 2 Transcription PREOPERATIVE DIAGNOSIS Melena POSTOPERATIVE DIAGNOSIS Solitary erosion over a fold at the GE junction gastric side PREMEDICATIONS Versed 5 mg IV REPORTED PROCEDURE The Olympus gastroscope was used The scope was placed in the upper esophagus under direct visit The esophageal mucosa was entirely normal There was no evidence of erosions or ulceration There was no evidence of varices The body and antrum of the stomach were normal They pylorus duodenum bulb and descending duodenum are normal There was no blood present within the stomach The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach When this was done a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold The lesion was not bleeding If this fold were in any other location of the stomach I would consider the fold but at this location one would have to consider that this would be an isolated gastric varix As such the erosion may be more significant There was no bleeding Obviously no manipulation of the lesion was undertaken The scope was then straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Solitary erosion overlying a prominent fold at the gastroesophageal junction gastric side may simply be an erosion or may be an erosion over a varix 2 Otherwise unremarkable endoscopy no evidence of a bleeding lesion of the stomach PLAN 1 Liver profile today 2 Being Nexium 40 mg a day 3 Scheduled colonoscopy for next week Keywords gastroenterology ge junction melena olympus gastroscope solitary erosion descending duodenum esophageal mucosa esophagus gastric side pylorus duodenum bulb stomach liver profile colonoscopy ge junction gastric junction gastric endoscopy duodenum scope solitary junction gastric erosion MEDICAL_TRANSCRIPTION,Description Common description of EGD Medical Specialty Gastroenterology Sample Name EGD Template 3 Transcription without difficulty into the upper GI tract The anatomy and mucosa of the esophagus gastroesophageal junction stomach pylorus and small bowel were all carefully inspected All structures were visually normal in appearance Biopsies of the distal duodenum gastric antrum and distal esophagus were taken and sent for pathological evaluation The endoscope and insufflated air were slowly removed from the upper GI tract A repeat look at the structures involved again showed no visible abnormalities except for the biopsy sites The patient tolerated the procedure with excellent comfort and stable vital signs After a recovery period in the Endoscopy Suite the patient is discharged to continue recovering in the family s care at home The family knows to follow up with me today if there are concerns about the patient s recovery from the procedure They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made Keywords gastroenterology gastric antrum distal duodenum distal esophagus esophagus duodenum clo test upper gi tract upper gi gi tract egd endoscope gi tract structures distal biopsyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy with biopsy Patient has had biliary colic type symptoms for the past 3 1 2 weeks characterized by severe pain and brought on by eating greasy foods Medical Specialty Gastroenterology Sample Name EGD with Biopsy 2 Transcription TYPE OF PROCEDURE Esophagogastroduodenoscopy with biopsy PREOPERATIVE DIAGNOSIS Abdominal pain POSTOPERATIVE DIAGNOSIS Normal endoscopy PREMEDICATION Fentanyl 125 mcg IV Versed 8 mg IV INDICATIONS This healthy 28 year old woman has had biliary colic type symptoms for the past 3 1 2 weeks characterized by severe pain and brought on by eating greasy foods She has had similar episodes couple of years ago and was told at one point that she had gallstones but after her pregnancy a repeat ultrasound was done and apparently was normal and nothing was done at that time She was evaluated in the emergency department recently when she developed this recurrent pain and laboratory studies were unrevealing Ultrasound was normal and a HIDA scan was done which showed a low normal ejection fraction of 40 and moderate reproduction of her pain Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy PROCEDURE The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication IMPRESSION Normal endoscopy PLAN Refer to a general surgeon for consideration of cholecystectomy Keywords gastroenterology hida scan endoscopy gallstones olympus esophagogastroduodenoscopy with biopsy biliary colic colic type greasy foods normal endoscopy esophagogastroduodenoscopy biliary colic greasy foods cholecystectomy biopsy MEDICAL_TRANSCRIPTION,Description EGD with PEG tube placement using Russell technique Protein calorie malnutrition intractable nausea vomiting and dysphagia and enterogastritis Medical Specialty Gastroenterology Sample Name EGD PEG Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 protein calorie malnutrition 2 Intractable nausea vomiting and dysphagia POSTOPERATIVE DIAGNOSES 1 Protein calorie malnutrition 2 Intractable nausea vomiting and dysphagia 3 Enterogastritis PROCEDURE PERFORMED EGD with PEG tube placement using Russell technique ANESTHESIA IV sedation with 1 lidocaine for local ESTIMATED BLOOD LOSS None COMPLICATIONS None BRIEF HISTORY This is a 44 year old African American female who is well known to this service She has been hospitalized multiple times for intractable nausea and vomiting and dehydration She states that her decreased p o intake has been progressively worsening She was admitted to the service of Dr Lang and was evaluated by Dr Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube PROCEDURE After risks complications and benefits were explained to the patient and informed consent was obtained the patient was taken to the operating room She was placed in the supine position The area was prepped and draped in the sterile fashion After adequate IV sedation was obtained by anesthesia esophagogastroduodenoscopy was performed The esophagus stomach and duodenum were visualized without difficulty There was no gross evidence of any malignancy There was some enterogastritis which was noted upon exam The appropriate location was noted on the anterior wall of the stomach This area was localized externally with 1 lidocaine Large gauge needle was used to enter the lumen of the stomach under visualization A guide wire was then passed again under visualization and the needle was subsequently removed A scalpel was used to make a small incision next to the guidewire and ensuring that the underlying fascia was nicked as well A dilator with break away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break away sheath and visualized within the lumen of the stomach The balloon was then insufflated and the break away sheath was then pulled away Proper placement of the tube was ensured through visualization with a scope The tube was then sutured into place using nylon suture Appropriate sterile dressing was applied DISPOSITION The patient was transferred to the recovery in a stable condition She was subsequently returned to her room on the General Medical Floor Previous orders will be resumed We will instruct the Nursing that the PEG tube can be used at 5 p m this evening for medications if necessary and bolus feedings Keywords gastroenterology protein calorie malnutrition nausea vomiting peg tube placement russell technique peg tube egd protein dysphagia malnutrition enterogastritis MEDICAL_TRANSCRIPTION,Description Common description of EGD Medical Specialty Gastroenterology Sample Name EGD Template 2 Transcription The patient was placed in the left lateral decubitus position medicated with the above medications to achieve and maintain a conscious sedation Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation The Olympus single channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum FINDINGS ESOPHAGUS Proximal and mid esophagus were without abnormalities STOMACH Insufflated and retroflexed visualization of the gastric cavity revealed DUODENUM Normal Keywords gastroenterology gastric cavity lateral decubitus position endoscope olympus egd visualization cavity duodenum esophagusNOTE MEDICAL_TRANSCRIPTION,Description Upper endoscopy patient with dysphagia Medical Specialty Gastroenterology Sample Name Endoscopy 1 Transcription PROCEDURE Upper endoscopy PREOPERATIVE DIAGNOSIS Dysphagia POSTOPERATIVE DIAGNOSIS 1 GERD biopsied 2 Distal esophageal reflux induced stricture dilated to 18 mm 3 Otherwise normal upper endoscopy MEDICATIONS Fentanyl 125 mcg and Versed 7 mg slow IV push INDICATIONS This is a 50 year old white male with dysphagia which has improved recently with Aciphex FINDINGS The patient was placed in the left lateral decubitus position and the above medications were administered The oropharynx was sprayed with Cetacaine The endoscope was passed under direct visualization into the esophagus The squamocolumnar junction was irregular and edematous Biopsies were obtained for histology There was a mild ring at the LES which was dilated with a 15 to 18 mm balloon with no resultant mucosal trauma The entire gastric mucosa was normal including a retroflexed view of the fundus The entire duodenal mucosa was normal to the second portion The patient tolerated the procedure well without complication IMPRESSION 1 Gastroesophageal reflux disease biopsied 2 Distal esophageal reflux induced stricture dilated to 18 mm 3 Otherwise normal upper endoscopy PLAN I will await the results of the biopsies The patient was told to continue maintenance Aciphex and anti reflux precautions He will follow up with me on a p r n basis Keywords gastroenterology lateral decubitus position gastroesophageal reflux disease gerd normal upper endoscopy mucosa was normal esophageal reflux stricture dilated upper endoscopy distal esophageal aciphex biopsies dysphagia endoscopy reflux MEDICAL_TRANSCRIPTION,Description Esophagogastroduodenoscopy patient with dysphagia Medical Specialty Gastroenterology Sample Name EGD 2 Transcription PROCEDURES PERFORMED Esophagogastroduodenoscopy PREPROCEDURE DIAGNOSIS Dysphagia POSTPROCEDURE DIAGNOSIS Active reflux esophagitis distal esophageal stricture ring due to reflux esophagitis dilated with balloon to 18 mm PROCEDURE Informed consent was obtained prior to the procedure with special attention to benefits risks alternatives Risks explained as bleeding infection bowel perforation aspiration pneumonia or reaction to the medications Vital signs were monitored by blood pressure heart rate and oxygen saturation Supplemental O2 given Specifics of the procedure discussed The procedure was discussed with father and mother as the patient is mentally challenged He has no complaints of dysphagia usually for solids better with liquids worsening over the last 6 months although there is an emergency department report from last year He went to the emergency department yesterday with beef jerky All of this reviewed The patient is currently on Cortef Synthroid Tegretol Norvasc lisinopril DDAVP He is being managed for extensive past history due to an astrocytoma brain surgery hypothyroidism endocrine insufficiency He has not yet undergone significant workup He has not yet had an endoscopy or barium study performed He is developmentally delayed due to the surgery panhypopituitarism His family history is significant for his father being of mine also having reflux issues without true heartburn but distal esophageal stricture The patient does not smoke does not drink He is living with his parents Since his emergency department visitation yesterday no significant complaints Large male no acute distress Vital signs monitored in the endoscopy suite Lungs clear Cardiac exam showed regular rhythm Abdomen obese but soft Extremity exam showed large hands He was a Mallampati score A ASA classification type 2 The procedure discussed with the patient the patient s mother Risks benefits and alternatives discussed Potential alternatives for dysphagia such as motility disorder given his brain surgery given the possibility of achalasia and similar discussed The potential need for a barium swallow modified barium swallow and similar discussed All questions answered At this point the patient will undergo endoscopy for evaluation of dysphagia with potential benefit of the possibility to dilate him should there be a stricture He may have reflux symptoms without complaining of heartburn He may benefit from a trial of PPI All of this reviewed All questions answered Keywords gastroenterology distal esophageal stricture reflux esophagitis distal esophageal esophageal stricture barium swallow esophagogastroduodenoscopy esophagitis esophageal heartburn stricture endoscopy reflux dysphagia MEDICAL_TRANSCRIPTION,Description EGD and colonoscopy Blood loss anemia normal colon with no evidence of bleeding hiatal hernia fundal gastritis with polyps and antral mass Medical Specialty Gastroenterology Sample Name EGD Colonoscopy Transcription PREOPERATIVE DIAGNOSIS Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Normal colon with no evidence of bleeding 2 Hiatal hernia 3 Fundal gastritis with polyps 4 Antral mass ANESTHESIA Conscious sedation with Demerol and Versed SPECIMEN Antrum and fundal polyps HISTORY The patient is a 66 year old African American female who presented to ABCD Hospital with mental status changes She has been anemic as well with no gross evidence of blood loss She has had a decreased appetite with weight loss greater than 20 lb over the past few months After discussion with the patient and her daughter she was scheduled for EGD and colonoscopy for evaluation PROCEDURE After informed consent was obtained the patient was brought to the endoscopy suite She was placed in the left lateral position and was given IV Demerol and Versed for sedation When adequate level of sedation was achieved a digital rectal exam was performed which demonstrated no masses and no hemorrhoids The colonoscope was inserted into the rectum and air was insufflated The scope was coursed through the rectum and sigmoid colon descending colon transverse colon ascending colon to the level of the cecum There were no polyps masses diverticuli or areas of inflammation The scope was then slowly withdrawn carefully examining all walls Air was aspirated Once in the rectum the scope was retroflexed There was no evidence of perianal disease No source of the anemia was identified Attention was then taken for performing an EGD The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx The esophagus was easily intubated and traversed There were no abnormalities of the esophagus The stomach was entered and was insufflated The scope was coursed along the greater curvature towards the antrum Adjacent to the pylorus towards the anterior surface was a mass like lesion with a central _______ It was not clear if this represents a healing ulcer or neoplasm Several biopsies were taken The mass was soft The pylorus was then entered The duodenal bulb and sweep were examined There was no evidence of mass ulceration or bleeding The scope was then brought back into the antrum and was retroflexed In the fundus and body there was evidence of streaking and inflammation There were also several small sessile polyps which were removed with biopsy forceps Biopsy was also taken for CLO A hiatal hernia was present as well Air was aspirated The scope was slowly withdrawn The GE junction was unremarkable The scope was fully withdrawn The patient tolerated the procedure well and was transferred to recovery room in stable condition She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes We will await the biopsy reports and further recommendations will follow Keywords gastroenterology esophagus gastroscope hypopharynx rectum fundal gastritis antral mass hiatal hernia egd hernia polyps colonoscopy MEDICAL_TRANSCRIPTION,Description Problems with dysphagia to solids and had food impacted in the lower esophagus Upper endoscopy to evaluate the esophagus Medical Specialty Gastroenterology Sample Name EGD 1 Transcription HISTORY OF PRESENT ILLNESS Briefly this is a 17 year old male who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved to look for any stricture that may need to be dilated or any other mucosal abnormality PROCEDURE PERFORMED EGD PREP Cetacaine spray 100 mcg of fentanyl IV and 5 mg of Versed IV FINDINGS The tip of the endoscope was introduced into the esophagus and the entire length of the esophagus was dotted with numerous white punctate lesions suggestive of eosinophilic esophagitis There were come concentric rings present There was no erosion or flame hemorrhage but there was some friability in the distal esophagus Biopsies throughout the entire length of the esophagus from 25 40 cm were obtained to look for eosinophilic esophagitis There was no stricture or Barrett mucosa The bony and the antrum of the stomach are normal without any acute peptic lesions Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia There were no acute lesions and no evidence of ulcer tumor or polyp The pylorus was easily entered and the first second and third portions of the duodenum are normal Adverse reactions None FINAL IMPRESSION Esophageal changes suggestive of eosinophilic esophagitis Biopsies throughout the length of the esophagus were obtained for microscopic analysis There was no evidence of stricture Barrett or other abnormalities in the upper GI tract Keywords gastroenterology length of the esophagus food impacted lower esophagus upper endoscopy entire length eosinophilic esophagitis egd dysphagia solids impacted endoscopy mucosal endoscope biopsies barrett stomach stricture eosinophilic esophagitis esophagus MEDICAL_TRANSCRIPTION,Description Patient with complaint of symptomatic cholelithiasis Medical Specialty Gastroenterology Sample Name Discharge Summary Cholelithiasis Transcription ADMISSION DIAGNOSIS Symptomatic cholelithiasis DISCHARGE DIAGNOSIS Symptomatic cholelithiasis SERVICE Surgery CONSULTS None HISTORY OF PRESENT ILLNESS Ms ABC is a 27 year old woman who apparently presented with complaint of symptomatic cholelithiasis She was afebrile She was taken by Dr X to the operating room HOSPITAL COURSE The patient underwent a procedure She tolerated without difficulty She had her pain controlled with p o pain medicine She was afebrile She is tolerating liquid diet It was felt that the patient is stable for discharge She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs We will check a UA and urine culture prior to discharge I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over the counter for constipation and we will send her home with Percocet for pain Her labs were within normal limits She did have an elevated white blood cell count but I believe this is just leukemoid reaction but she is afebrile and if she does have UTI may also be related Her labs in terms of her bilirubin were within normal limits Her LFTs were slightly elevated I do believe this is related to the cautery used on the liver bed They were 51 and 83 for the AST and ALT respectively I feel that she looks good for discharge DISCHARGE INSTRUCTIONS Clear liquid diet x48 hours and she can return to her Medifast she may shower She needs to keep her wound clean and dry She is not to engage in any heavy lifting greater than 10 pounds x2 weeks No driving for 1 to 2 weeks She must be able to stop in an emergency and be off narcotic meds no strenuous activity but she needs to maintain mobility She can resume her medications per med rec sheets DISCHARGE MEDICATIONS As previously mentioned FOLLOWUP We will follow up on both urinalysis and cultures She is instructed to follow up with Dr X in 2 weeks She needs to call for any shortness of breath temperature greater than 101 5 chest pain intractable nausea vomiting and abdominal pain any redness swelling or foul smelling drainage from her wounds Keywords gastroenterology medifast liquid diet symptomatic cholelithiasis symptomatic cholelithiasis discharge MEDICAL_TRANSCRIPTION,Description Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux Medical Specialty Gastroenterology Sample Name Discharge Summary 10 Transcription ADMITTING DIAGNOSES Hiatal hernia gastroesophageal reflux disease reflux DISCHARGE DIAGNOSES Hiatal hernia gastroesophageal reflux disease reflux SECONDARY DIAGNOSIS Postoperative ileus PROCEDURES DONE Hiatal hernia repair and Nissen fundoplication revision BRIEF HISTORY The patient is an 18 year old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux Approximately one year ago he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia Over the past year this has caused him an increasing number of problems including chest pain when he eats and shortness of breath after large meals He is also having reflux symptoms again He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication HOSPITAL COURSE Mr A was admitted to the adolescent floor by Brenner Children s Hospital after his procedure He was stable at that time He did complain of some nausea However he did not have any vomiting at that time He had an NG tube in and was n p o He also had a PCA for pain management as well as Toradol On postoperative day 1 he complained of not being able to urinate so a Foley catheter was placed Over the next several days his hospital course proceeded as follows He continued to complain of some nausea however he did not ever have any vomiting Eventually the Foley catheter was discontinued and he had excellent urine output without any complications He ambulated frequently He remained n p o for three days He also had the NG tube in during that time On postoperative day 4 he began to have some flatus and the NG tube was discontinued He was advanced to a liquid diet and tolerated this without any complications At this time he was still using the PCA for pain control However he was using it much less frequently than on days 1 and 2 postoperatively After tolerating the full liquid diet without any complications he was advanced to a soft diet and his pain medications were transitioned to p o medications rather than the PCA The PCA was discontinued He tolerated the soft diet without any complications and continued to have flatus frequently On postoperative day 6 it was determined that he was stable for discharge to home as he was taking p o without any complications His pain was well controlled with p o pain medications He was passing gas frequently had excellent urine output and was ambulating frequently without any issues DISCHARGE CONDITION Stable DISPOSITION Discharged to home DISCHARGE INSTRUCTIONS The patient was discharged to home with instructions for maintaining a soft diet It was also recommended that he does not drink any soda postoperatively He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting He will be able to attend school when it starts in a few weeks However he is not going to be able to play football in the near future He was given prescription for pain medication upon discharge He is instructed to contact Pediatric Surgery if he has any fevers any nausea and vomiting any chest pain any constipation or any other concerns Keywords gastroenterology MEDICAL_TRANSCRIPTION,Description Modified Barium swallow Deglutition Study for Dysphagia with possible aspiration Medical Specialty Gastroenterology Sample Name Deglutition Study Modified Barium swallow Transcription EXAM Modified barium swallow SYMPTOM Dysphagia with possible aspiration FINDINGS A cookie deglutition study was performed The patient was examined in the direct lateral position Patient was challenged with thin liquids thick liquid semisolids and solids Persistently demonstrable is the presence of penetration with thin liquids This is not evident with thick liquids semisolids or solids There is weakness in the oral phase of deglutition Subglottic region appears normal There is no evidence of aspiration demonstrated IMPRESSION Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition Keywords gastroenterology aspiration deglutition study thin liquids thick liquid semisolids solids modified barium swallow barium swallow dysphagia deglutition MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan Medical Specialty Gastroenterology Sample Name CT Scan of Abdomen Pelvis with Contrast Transcription EXAM CT scan of the abdomen and pelvis with contrast REASON FOR EXAM Abdominal pain COMPARISON EXAM None TECHNIQUE Multiple axial images of the abdomen and pelvis were obtained 5 mm slices were acquired after injection of 125 cc of Omnipaque IV In addition oral ReadiCAT was given Reformatted sagittal and coronal images were obtained DISCUSSION There are numerous subcentimeter nodules seen within the lung bases The largest measures up to 6 mm No hiatal hernia is identified Consider chest CT for further evaluation of the pulmonary nodules The liver gallbladder pancreas spleen adrenal glands and kidneys are within normal limits No dilated loops of bowel There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat In addition there is soft tissue stranding seen of the lower pelvis In addition the uterus is not identified Correlate with history of recent surgery There is no free fluid or lymphadenopathy seen within the abdomen or pelvis The bladder is within normal limits for technique No acute bony abnormalities appreciated No suspicious osteoblastic or osteolytic lesions IMPRESSION 1 Postoperative changes seen within the pelvis without appreciable evidence for free fluid 2 Numerous subcentimeter nodules seen within the lung bases Consider chest CT for further characterization Keywords gastroenterology ct scan abdominal pain multiple axial images abdomen and pelvis adrenal glands chest ct coronal gallbladder kidneys liver lymphadenopathy nodules osteoblastic osteolytic pancreas sagittal spleen with contrast free fluid ct abdomen pelvis MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain nausea diarrhea and recent colonic resection CT abdomen with and without contrast and CT pelvis with contrast Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 8 Transcription CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain nausea diarrhea and recent colonic resection in 11 08 TECHNIQUE Axial CT images of the abdomen were obtained without contrast Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue 300 FINDINGS The liver is normal in size and attenuation The gallbladder is normal The spleen is normal in size and attenuation The adrenal glands and pancreas are unremarkable The kidneys are normal in size and attenuation No hydronephrosis is detected Free fluid is seen within the right upper quadrant within the lower pelvis A markedly thickened loop of distal small bowel is seen This segment measures at least 10 cm long No definite pneumatosis is appreciated No free air is apparent at this time Inflammatory changes around this loop of bowel Mild distention of adjacent small bowel loops measuring up to 3 5 cm is evident No complete obstruction is suspected as there is contrast material within the colon Postsurgical changes compatible with the partial colectomy are noted Postsurgical changes of the anterior abdominal wall are seen Mild thickening of the urinary bladder wall is seen IMPRESSION 1 Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis An inflammatory process such as infection or ischemia must be considered Close interval followup is necessary 2 Thickening of the urinary bladder wall is nonspecific and may be due to under distention However evaluation for cystitis is advised Keywords gastroenterology abdominal pain nausea diarrhea colonic resection axial ct images ct abdomen isovue inflammatory urinary bladder abdominal colonic wall thickening axial bowel contrast attenuation pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description Generalized abdominal pain with swelling at the site of the ileostomy CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 9 Transcription CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain with swelling at the site of the ileostomy TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas adrenal glands and kidneys are unremarkable Punctate calcifications in the gallbladder lumen likely represent a gallstone CT PELVIS Postsurgical changes of a left lower quadrant ileostomy are again seen There is no evidence for an obstruction A partial colectomy and diverting ileostomy is seen within the right lower quadrant The previously seen 3 4 cm subcutaneous fluid collection has resolved Within the left lower quadrant a 3 4 cm x 2 5 cm loculated fluid collection has not significantly changed This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded No obstruction is seen The appendix is not clearly visualized The urinary bladder is unremarkable IMPRESSION 1 Resolution of the previously seen subcutaneous fluid collection 2 Left pelvic 3 4 cm fluid collection has not significantly changed in size or appearance These findings may be due to a pelvic abscess 3 Right lower quadrant ileostomy has not significantly changed 4 Cholelithiasis Keywords gastroenterology axial ct images isovue 300 ct pelvis ct abdomen fluid collection abdomen obstruction subcutaneous abscess pelvic fluid collection pelvis ileostomy ct isovue MEDICAL_TRANSCRIPTION,Description Abdominal pain CT examination of the abdomen and pelvis with intravenous contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis OB GYN Transcription EXAM CT examination of the abdomen and pelvis with intravenous contrast INDICATIONS Abdominal pain TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue 300 contrast administration Oral contrast was not administered There was no comparison of studies FINDINGS CT PELVIS Within the pelvis the uterus demonstrates a thickened appearing endometrium There is also a 4 4 x 2 5 x 3 4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology There is also a 2 5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid Several smaller fibroids were also suspected The ovaries are unremarkable in appearance There is no free pelvic fluid or adenopathy CT ABDOMEN The appendix has normal appearance in the right lower quadrant There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis The small and large bowels are otherwise unremarkable The stomach is grossly unremarkable There is no abdominal or retroperitoneal adenopathy There are no adrenal masses The kidneys liver gallbladder and pancreas are in unremarkable appearance The spleen contains several small calcified granulomas but no evidence of masses It is normal in size The lung bases are clear bilaterally The osseous structures are unremarkable other than mild facet degenerative changes at L4 L5 and L5 S1 IMPRESSION 1 Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4 4 x 2 5 x 3 4 cm 2 Multiple uterine fibroids 3 Prominent endometrium 4 Followup pelvic ultrasound is recommended Keywords gastroenterology ovaries pelvic fluid adenopathy uterine segment cervix hypodense mass ct examination fibroids pelvic ct pelvis isovue abdomen MEDICAL_TRANSCRIPTION,Description Lower quadrant pain with nausea vomiting and diarrhea CT abdomen without contrast and CT pelvis without contrast Noncontrast axial CT images of the abdomen and pelvis are obtained Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 7 Transcription REASON FOR EXAM Lower quadrant pain with nausea vomiting and diarrhea TECHNIQUE Noncontrast axial CT images of the abdomen and pelvis are obtained FINDINGS Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material Gallstones are seen within the gallbladder lumen No abnormal pericholecystic fluid is seen The liver is normal in size and attenuation The spleen is normal in size and attenuation A 2 2 x 1 8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas No pancreatic ductal dilatation is seen There is no abnormal adjacent stranding No suspected pancreatitis is seen The kidneys show no stone formation or hydronephrosis The large and small bowels are normal in course and caliber There is no evidence for obstruction The appendix appears within normal limits In the pelvis the urinary bladder is unremarkable There is a 4 2 cm cystic lesion of the right adnexal region No free fluid free air or lymphadenopathy is detected There is left basilar atelectasis IMPRESSION 1 A 2 2 cm low attenuation lesion is seen at the pancreatic tail This is felt to be originating from the pancreas a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised Additionally when the patient s creatinine improves a contrast enhanced study utilizing pancreatic protocol is needed Alternatively an MRI may be obtained 2 Cholelithiasis 3 Left basilar atelectasis 4 A 4 2 cm cystic lesion of the right adnexa correlation with pelvic ultrasound is advised Keywords gastroenterology ct abdomen ct pelvis neoplasm lesion attenuation hydronephrosis stone formation ct images cystic lesion abdomen cystic pancreatic ct pelvis intravenous noncontrast MEDICAL_TRANSCRIPTION,Description Right sided abdominal pain with nausea and fever CT abdomen with contrast and CT pelvis with contrast Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 6 Transcription REASON FOR EXAM Right sided abdominal pain with nausea and fever TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue 300 CT ABDOMEN The liver spleen pancreas gallbladder adrenal glands and kidney are unremarkable CT PELVIS Within the right lower quadrant the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant Findings are compatible with acute appendicitis The large and small bowels are normal in course and caliber without obstruction The urinary bladder is normal The uterus appears unremarkable Mild free fluid is seen in the lower pelvis No destructive osseous lesions are seen The visualized lung bases are clear IMPRESSION Acute appendicitis Keywords gastroenterology adrenal glands appendicitis gallbladder kidney liver pancreas spleen acute appendicitis ct pelvis ct abdomen abdominal contrast fluid abdomen inflammatory pelvis ct MEDICAL_TRANSCRIPTION,Description CT abdomen without contrast and pelvis without contrast reconstruction Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 5 Transcription EXAM CT abdomen without contrast and pelvis without contrast reconstruction REASON FOR EXAM Right lower quadrant pain rule out appendicitis TECHNIQUE Noncontrast CT abdomen and pelvis An intravenous line could not be obtained for the use of intravenous contrast material FINDINGS The appendix is normal There is a moderate amount of stool throughout the colon There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process Examination of the extreme lung bases appear clear no pleural effusions The visualized portions of the liver spleen adrenal glands and pancreas appear normal given the lack of contrast There is a small hiatal hernia There is no intrarenal stone or evidence of obstruction bilaterally There is a questionable vague region of low density in the left anterior mid pole region this may indicate a tiny cyst but it is not well seen given the lack of contrast This can be correlated with a followup ultrasound if necessary The gallbladder has been resected There is no abdominal free fluid or pathologic adenopathy There is abdominal atherosclerosis without evidence of an aneurysm Dedicated scans of the pelvis disclosed phleboliths but no free fluid or adenopathy There are surgical clips present There is a tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection IMPRESSION 1 Normal appendix 2 Moderate stool throughout the colon 3 No intrarenal stones 4 Tiny airdrop within the bladder If this patient has not had a recent catheterization correlate for signs and symptoms of urinary tract infection The report was faxed upon dictation Keywords gastroenterology reconstruction appendicitis urinary tract infection ct abdomen abdomen ct pelvis contrast noncontrast MEDICAL_TRANSCRIPTION,Description CT abdomen and pelvis without contrast stone protocol reconstruction Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 4 Transcription EXAM CT abdomen and pelvis without contrast stone protocol reconstruction REASON FOR EXAM Flank pain TECHNIQUE Noncontrast CT abdomen and pelvis with coronal reconstructions FINDINGS There is no intrarenal stone bilaterally However there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right The right renal pelvis is not dilated There is no stone along the course of the ureter I cannot exclude the possibility of recent stone passage although the findings are ultimately technically indeterminate and clinical correlation is advised There is no obvious solid appearing mass given the lack of contrast Scans of the pelvis disclose no evidence of stone within the decompressed bladder No pelvic free fluid or adenopathy There are few scattered diverticula There is a moderate amount of stool throughout the colon There are scattered diverticula but no CT evidence of acute diverticulitis The appendix is normal There are mild bibasilar atelectatic changes Given the lack of contrast visualized portions of the liver spleen adrenal glands and the pancreas are grossly unremarkable The gallbladder is present There is no abdominal free fluid or pathologic adenopathy There are degenerative changes of the lumbar spine IMPRESSION 1 Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding There is no stone identified along the course of the left ureter or in the bladder Could this patient be status post recent stone passage Clinical correlation is advised 2 Diverticulosis 3 Moderate amount of stool throughout the colon 4 Normal appendix Keywords gastroenterology coronal reconstructions stone protocol renal pelvic dilatation proximal ureteral dilatation ct abdomen and pelvis stone protocol reconstruction abdomen and pelvis perinephric stranding free fluid scattered diverticula renal dilatation contrast ureteral ct abdomen pelvis stone noncontrast MEDICAL_TRANSCRIPTION,Description CT of the abdomen and pelvis without contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 3 Transcription EXAM CT of the abdomen and pelvis without contrast HISTORY Lower abdominal pain FINDINGS Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis There is a 1 6 cm nodular density at the left posterior sulcus Noncontrast technique limits evaluation of the solid abdominal organs Cardiomegaly and atherosclerotic calcifications are seen Hepatomegaly is observed There is calcification within the right lobe of the liver likely related to granulomatous changes Subtle irregularity of the liver contour is noted suggestive of cirrhosis There is splenomegaly seen There are two low attenuation lesions seen in the posterior aspect of the spleen which are incompletely characterized that may represent splenic cyst The pancreas appears atrophic There is a left renal nodule seen which measures 1 9 cm with a Hounsfield unit density of approximately 29 which is indeterminate There is mild bilateral perinephric stranding There is an 8 mm fat density lesion in the anterior inner polar region of the left kidney compatible in appearance with angiomyolipoma There is a 1 cm low attenuation lesion in the upper pole of the right kidney likely representing a cyst but incompletely characterized on this examination Bilateral ureters appear normal in caliber along their visualized course The bladder is partially distended with urine but otherwise unremarkable Postsurgical changes of hysterectomy are noted There are pelvic phlebolith seen There is a calcified soft tissue density lesion in the right pelvis which may represent an ovary with calcification as it appears continuous with the right gonadal vein Scattered colonic diverticula are observed The appendix is within normal limits The small bowel is unremarkable There is an anterior abdominal wall hernia noted containing herniated mesenteric fat The hernia neck measures approximately 2 7 cm There is stranding of the fat within the hernia sac There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis Degenerative changes of the spine are observed IMPRESSION 1 Anterior abdominal wall hernia with mesenteric fat containing stranding suggestive of incarcerated fat 2 Nodule in the left lower lobe recommend follow up in 3 months 3 Indeterminate left adrenal nodule could be further assessed with dedicated adrenal protocol CT or MRI 4 Hepatomegaly with changes suggestive of cirrhosis There is also splenomegaly observed 5 Low attenuation lesions in the spleen may represent cyst that are incompletely characterized on this examination 6 Fat density lesion in the left kidney likely represents angiomyolipoma 7 Fat density soft tissue lesion in the region of the right adnexa this contains calcifications and may represent an ovary or possibly dermoid cyst Keywords gastroenterology abdominal pain cardiomegaly atherosclerotic calcifications hepatomegaly perinephric stranding low attenuation lesions abdominal calcifications lesions abdomen MEDICAL_TRANSCRIPTION,Description CT Abdomen Pelvis W WO Contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis Transcription EXAM CT Abdomen Pelvis W WO Contrast REASON FOR EXAM Status post aortobiiliac graft repair TECHNIQUE 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement No oral or rectal contrast was utilized Comparison is made with the prior CT abdomen and pelvis dated 10 20 05 There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3 7 cm transversely x 3 4 AP Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips The size of the native aneurysm component at this level is stable at 5 5 cm in diameter with mural thrombus surrounding the enhancing endolumen There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak Further distally there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either No exoluminal leakage is identified at any level There is no retroperitoneal hematoma present The findings are unchanged from the prior exam The liver spleen pancreas adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present There is advanced atrophy of the left kidney No hydronephrosis is present No acute findings are identified elsewhere in the abdomen The lung bases are clear Concerning the remainder of the pelvis no acute pathology is identified There is prominent streak artifact from the left total hip replacement There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis The bladder grossly appears normal A hysterectomy has been performed IMPRESSION 1 No complications identified regarding endoluminal aortoiliac graft repair as described The findings are stable compared to the study of 10 20 04 2 Stable mild aneurysm of aortic aneurysm centered roughly at renal artery level 3 No other acute findings noted 4 Advanced left renal atrophy Keywords gastroenterology aortobiiliac graft repair renal atrophy ct abdomen pelvis w wo contrast aortic aneurysm renal artery mural thrombus endoluminal leak ct abdomen ct contrast pelvis abdomen MEDICAL_TRANSCRIPTION,Description Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks Medical Specialty Gastroenterology Sample Name Consult Rectal Bleeding Transcription PRESENT ILLNESS The patient is a very pleasant 69 year old Caucasian male whom we are asked to see primarily because of a family history of colon cancer but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks The patient states that he had his first colonoscopy 6 years ago and it was negative His mother was diagnosed with colon cancer probably in her 50s but she died of cancer of the esophagus at age 86 The patient does have hemorrhoidal bleed about once a week Otherwise he denies any change in bowel habits abdominal pain or weight loss He gets heartburn mainly with certain food such as raw onions and he has had it for years It will typically occur every couple of weeks He has had no dysphagia He has never had an upper endoscopy MEDICAL HISTORY Remarkable for hypertension adult onset diabetes mellitus hyperlipidemia and restless legs syndrome SURGICAL HISTORY Appendectomy as a child and cholecystectomy in 2003 MEDICATIONS His medications are lisinopril 40 mg daily hydrochlorothiazide 25 mg daily metformin 1000 mg twice a day Januvia 100 mg daily clonazepam 10 mg at bedtime for restless legs syndrome Crestor 10 mg nightly and Flomax 0 4 mg daily ALLERGIES No known drug allergies SOCIAL HISTORY The patient is retired He is married He had 4 children He quite smoking 25 years ago after a 35 year history of smoking He does not drink alcohol FAMILY HISTORY Mother had colon cancer in her 50s esophageal cancer in her 80s Her mother smoked and drank Father got a mesothelioma at age 65 There is a brother of 65 with hypertension REVIEW OF SYSTEMS He has had prostatitis with benign prostatic hypertrophy He has some increased urinary frequency from a history of prostatitis He has the heartburn which is diet dependent and the frequent rectal bleeding He also has restless legs syndrome at night No cardio or pulmonary complaints No weight loss PHYSICAL EXAMINATION Reveals a well developed well nourished man in no acute distress BP 112 70 Pulse 80 and regular Respirations non labored Height 5 feet 7 1 2 inches Weight 209 pounds HEENT exam Sclerae are anicteric Pupils equal conjunctivae clear No gross oropharyngeal lesions Neck is supple without lymphadenopathy thyromegaly or JVD Lungs are clear to percussion and auscultation Heart sounds are regular without murmur gallop or rub The abdomen is soft and nontender There are no masses There is no hepatosplenomegaly The bowel sounds are normal Rectal examination Deferred Extremities have no clubbing cyanosis or edema Skin is warm and dry The patient is alert and oriented with a pleasant affect and no gross motor deficits IMPRESSION 1 Family history of colon cancer 2 Rectal bleeding 3 Heartburn and a family history of esophageal cancer PLAN I agree with the indications for repeat colonoscopy which should be done at least every 5 years Also discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett s esophagus If he does not have it now then it should not be a significant risk in the future The indications and benefits of EGD colonoscopy and IRC were discussed The risks including sedation bleeding infection and perforation were discussed The importance of a good bowel prep so as to minimize missing any lesions was discussed His questions were answered and informed consent obtained It was a pleasure to care for this nice patient Keywords gastroenterology heartburn family history of esophageal cancer repeat colonoscopy colonoscopy egd irc barrett s esophagus restless legs syndrome esophageal cancer rectal bleeding colon cancer rectal bleeding cancer MEDICAL_TRANSCRIPTION,Description Patient comes for discussion of a screening colonoscopy Medical Specialty Gastroenterology Sample Name Consult Screening Colonoscopy Transcription HISTORY A is a 55 year old who I know well because I have been taking care of her husband She comes for discussion of a screening colonoscopy Her last colonoscopy was in 2002 and at that time she was told it was essentially normal Nonetheless she has a strong family history of colon cancer and it has been almost four to five years so she wants to have a repeat colonoscopy I told her that the interval was appropriate and that it made sense to do so She denies any significant weight change that she cannot explain She has had no hematochezia She denies any melena She says she has had no real change in her bowel habit but occasionally does have thin stools PAST MEDICAL HISTORY On today s visit we reviewed her entire health history Surgically she has had a stomach operation for ulcer disease back in 1974 she says She does not know exactly what was done It was done at a hospital in California which she says no longer exists This makes it difficult to find out exactly what she had done She also had her gallbladder and appendix taken out in the 1970s at the same hospital Medically she has no significant problems and no true medical illnesses She does suffer from some mild gastroparesis she says MEDICATIONS Reglan 10 mg once a day ALLERGIES She denies any allergies to medications but is sensitive to medications that cause her to have ulcers she says SOCIAL HISTORY She still smokes one pack of cigarettes a day She was counseled to quit She occasionally uses alcohol She has never used illicit drugs She is married is a housewife and has four children FAMILY HISTORY Positive for diabetes and cancer REVIEW OF SYSTEMS Essentially as mentioned above PHYSICAL EXAMINATION GENERAL A is a healthy appearing female in no apparent distress VITAL SIGNS Her vital signs reveal a weight of 164 pounds blood pressure 140 90 temperature of 97 6 degrees F HEENT No cervical bruits thyromegaly or masses She has no lymphadenopathy in the head and neck supraclavicular or axillary spaces bilaterally LUNGS Clear to auscultation bilaterally with no wheezes rubs or rhonchi HEART Regular rate and rhythm without murmur rub or gallop ABDOMEN Soft nontender nondistended EXTREMITIES No cyanosis clubbing or edema with good pulses in the radial arteries bilaterally NEURO No focal deficits is intact to soft touch in all four ASSESSMENT AND RECOMMENDATIONS In light of her history and physical clearly the patient would be well served with an upper and lower endoscopy We do not know what the anatomy is and if she did have an antrectomy she needs to be checked for marginal ulcers She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well I discussed the risks benefits and alternatives to upper and lower endoscopy and these include over sedation perforation and dehydration and she wants to proceed We will schedule her for an upper and lower endoscopy at her convenience Keywords gastroenterology screening colonoscopy colonoscopy hematochezia screening endoscopy MEDICAL_TRANSCRIPTION,Description Abnormal liver enzymes and diarrhea CT pelvis with contrast and ct abdomen with and without contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 11 Transcription EXAM CT pelvis with contrast and ct abdomen with and without contrast INDICATIONS Abnormal liver enzymes and diarrhea TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration Pre contrast images through the abdomen were also obtained COMPARISON There were no comparison studies FINDINGS The lung bases are clear The liver demonstrates mild intrahepatic biliary ductal dilatation These findings may be secondary to the patient s post cholecystectomy state The pancreas spleen adrenal glands and kidneys are unremarkable There is a 13 mm peripheral enhancing fluid collection in the anterior pararenal space of uncertain etiology There are numerous nonspecific retroperitoneal and mesenteric lymph nodes These may be reactive however an early neoplastic process would be difficult to totally exclude There is a right inguinal hernia containing a loop of small bowel This may produce a partial obstruction as there is mild fluid distention of several small bowel loops particularly in the right lower quadrant The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine The urinary bladder is unremarkable The uterus is not visualized IMPRESSION 1 Right inguinal hernia containing small bowel Partial obstruction is suspected 2 Nonspecific retroperitoneal and mesenteric lymph nodes 3 Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology 4 Diverticulosis without evidence of diverticulitis 5 Status post cholecystectomy with mild intrahepatic biliary ductal dilatation 6 Osteopenia and degenerative changes of the spine and pelvis Keywords gastroenterology pre contrast images contrast biliary ductal dilatation pancreas spleen adrenal glands kidneys mesenteric lymph nodes fluid collection inguinal hernia ct abdomen hernia diverticulosis diverticulitis osteopenia degenerative spine bowel pelvis ct abdomen MEDICAL_TRANSCRIPTION,Description A 50 year old female whose 51 year old sister has a history of multiple colon polyps which may slightly increase her risk for colon cancer in the future Medical Specialty Gastroenterology Sample Name Consult Multiple Colon Polyps Transcription HISTORY OF PRESENT ILLNESS See chart attached MEDICATIONS Tramadol 50 mg every 4 to 6 hours p r n hydrocodone 7 5 mg 500 mg every 6 hours p r n zolpidem 10 mg at bedtime triamterene 37 5 mg atenolol 50 mg vitamin D TriCor 145 mg simvastatin 20 mg ibuprofen 600 mg t i d and Lyrica 75 mg FAMILY HISTORY Mother is age 78 with history of mesothelioma Father is alive but unknown medical history as they have been estranged She has a 51 year old sister with history of multiple colon polyps She has 2 brothers 1 of whom has schizophrenia but she knows very little about their medical history To the best of her knowledge there are no family members with stomach cancer or colon cancer SOCIAL HISTORY She was born in Houston Texas and moved to Florida about 3 years ago She is divorced She has worked as a travel agent She has 2 sons ages 24 and 26 both of whom are alive and well She smokes a half a pack of cigarettes per day for more than 35 years She does not consume alcohol REVIEW OF SYSTEMS As per the form filled out in our office today is positive for hypertension weakness in arms and legs arthritis pneumonia ankle swelling getting full quickly after eating loss of appetite weight loss which is stated as fluctuating up and down 4 pounds trouble swallowing heartburn indigestion belching nausea diarrhea constipation change in bowel habits change in consistency rectal bleeding hemorrhoids abdominal discomfort and cramping associated with constipation hepatitis A or infectious hepatitis in the past and smoking and alcohol as previously stated Otherwise review of systems is negative for strokes paralysis gout cataracts glaucoma respiratory difficulties tuberculosis chest pain heart disease kidney stones hematuria rheumatic fever scarlet fever cancer diabetes thyroid disease seizure disorder blood transfusions anemia jaundice or pruritus PHYSICAL EXAMINATION Weight 152 pounds Height is 5 feet 3 inches Blood pressure 136 80 Pulse 68 In general She is a well developed and well nourished female who ambulates with the assistance of a cane Neurologically nonfocal Awake alert and oriented x 3 HEENT Head normocephalic atraumatic Sclerae anicteric Conjunctivae are pink Mouth is moist without any obvious oral lesions Neck is supple There is no submandibular submaxillary axillary supraclavicular or epitrochlear adenopathy appreciable Lungs are clear to auscultation bilaterally Heart Regular rate and rhythm without obvious gallops or murmurs Abdomen is soft nontender with good bowel sounds No organomegaly or masses are appreciable Extremities are without clubbing cyanosis and or edema Skin is warm and dry Rectal was deferred and will be done at the time of the colonoscopy IMPRESSION 1 A 50 year old female whose 51 year old sister has a history of multiple colon polyps which may slightly increase her risk for colon cancer in the future 2 Reports of recurrent bright red blood per rectum mostly on the toilet paper over the past year Bleeding most likely consistent with internal hemorrhoids however she needs further evaluation for colon polyps or colon cancer 3 Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation She is on multiple medications including narcotics and may have developed narcotic bowel syndrome 4 A long history of pyrosis dyspepsia nausea and belching for many years relieved by antacids She may likely have underlying gastroesophageal reflux disease 5 A 1 year history of some early satiety and fluctuations in her weight up and down 4 pounds She may also have some GI dysmotility including gastroparesis 6 Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine If this bone spur is pressing anteriorly it could certainly cause recurrent symptoms of dysphagia Differential also includes peptic stricture or Schatzki s ring and even remotely the possibility of an esophageal malignancy 7 A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology She may have some reaction to her multiple medications including her statin drugs which can cause mild elevations in transaminases She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C PLAN 1 We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases She will likely have the lab tests repeated in the future and if they remain persistently elevated we will be happy to see her in the future for further evaluation if her primary care physician would like 2 Discussed reflux precautions and gave literature for further review 3 Schedule an upper endoscopy with possible esophageal dilatation as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids Both procedures were explained in detail including risks and complications such as adverse reaction to medication as well as respiratory embarrassment infection bleeding perforation and possibility of missing a small polyp or tumor 4 Alternatives including upper GI series flexible sigmoidoscopy barium enema and CT colonography were discussed however the patient agrees to proceed with the plan as outlined above 5 Due to her sister s history of colon polyps she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination Keywords gastroenterology mesothelioma risk for colon cancer constipation diarrhea multiple colon polyps colon cancer colon polyps colon cancer polyps MEDICAL_TRANSCRIPTION,Description Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT abdomen without contrast and CT pelvis without contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 10 Transcription CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST REASON FOR EXAM Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin CT ABDOMEN There is no evidence for a retroperitoneal hematoma The liver spleen adrenal glands and pancreas are unremarkable Within the superior pole of the left kidney there is a 3 9 cm cystic lesion A 3 3 cm cystic lesion is also seen within the inferior pole of the left kidney No calcifications are noted The kidneys are small bilaterally CT PELVIS Evaluation of the bladder is limited due to the presence of a Foley catheter the bladder is nondistended The large and small bowels are normal in course and caliber There is no obstruction Bibasilar pleural effusions are noted IMPRESSION 1 No evidence for retroperitoneal bleed 2 There are two left sided cystic lesions within the kidney correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam 3 The kidneys are small in size bilaterally 4 Bibasilar pleural effusions Keywords gastroenterology cystic lesion superior pole kidney ct pelvis ct abdomen retroperitoneal hematoma lesion kidneys bladder bibasilar pleural effusions lesions pelvis hematoma retroperitoneal cystic ct abdomen MEDICAL_TRANSCRIPTION,Description CT scan of the abdomen and pelvis without and with intravenous contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 2 Transcription EXAM CT scan of the abdomen and pelvis without and with intravenous contrast CLINICAL INDICATION Left lower quadrant abdominal pain COMPARISON None FINDINGS CT scan of the abdomen and pelvis was performed without and with intravenous contrast Total of 100 mL of Isovue was administered intravenously Oral contrast was also administered The lung bases are clear The liver is enlarged and decreased in attenuation There are no focal liver masses There is no intra or extrahepatic ductal dilatation The gallbladder is slightly distended The adrenal glands pancreas spleen and left kidney are normal A 12 mm simple cyst is present in the inferior pole of the right kidney There is no hydronephrosis or hydroureter The appendix is normal There are multiple diverticula in the rectosigmoid There is evidence of focal wall thickening in the sigmoid colon image 69 with adjacent fat stranding in association with a diverticulum These findings are consistent with diverticulitis No pneumoperitoneum is identified There is no ascites or focal fluid collection The aorta is normal in contour and caliber There is no adenopathy Degenerative changes are present in the lumbar spine IMPRESSION Findings consistent with diverticulitis Please see report above Keywords gastroenterology extrahepatic ductal dilatation gallbladder glands pancreas spleen kidney adrenal abdomen and pelvis ct scan intravenous abdomen MEDICAL_TRANSCRIPTION,Description CT Abdomen and Pelvis with contrast Medical Specialty Gastroenterology Sample Name CT Abdomen Pelvis 1 Transcription EXAM CT Abdomen and Pelvis with contrast REASON FOR EXAM Nausea vomiting diarrhea for one day Fever Right upper quadrant pain for one day COMPARISON None TECHNIQUE CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement CT ABDOMEN Lung bases are clear The liver gallbladder spleen pancreas and bilateral adrenal kidneys are unremarkable The aorta is normal in caliber There is no retroperitoneal lymphadenopathy CT PELVIS The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change Per CT the colon and small bowel are unremarkable The bladder is distended No free fluid air Visualized osseous structures demonstrate no definite evidence for acute fracture malalignment or dislocation IMPRESSION 1 Unremarkable exam specifically no evidence for acute appendicitis 2 No acute nephro ureterolithiasis 3 No secondary evidence for acute cholecystitis Results were communicated to the ER at the time of dictation Keywords gastroenterology liver gallbladder spleen pancreas adrenal kidneys lymphadenopathy abdomen and pelvis contrast ct MEDICAL_TRANSCRIPTION,Description Patient with mid epigastric abdominal pain Sonogram revealed gallstones Medical Specialty Gastroenterology Sample Name Consult Laparoscopic Cholecystectomy Transcription PAST MEDICAL HISTORY Significant for arthritis in her knee anxiety depression high insulin levels gallstone attacks and PCOS PAST SURGICAL HISTORY None SOCIAL HISTORY Currently employed She is married She is in sales She does not smoke She drinks wine a few drinks a month CURRENT MEDICATIONS She is on Carafate and Prilosec She was on metformin but she stopped it because of her abdominal pains ALLERGIES She is allergic to PENICILLIN REVIEW OF SYSTEMS Negative for heart lungs GI GU cardiac or neurologic Denies specifically asthma allergies high blood pressure high cholesterol diabetes chronic lung disease ulcers headache seizures epilepsy strokes thyroid disorder tuberculosis bleeding clotting disorder gallbladder disease positive liver disease kidney disease cancer heart disease and heart attack PHYSICAL EXAMINATION She is afebrile Vital Signs are stable HEENT EOMI PERRLA Neck is soft and supple Lungs clear to auscultation She is mildly tender in the abdomen in the right upper quadrant No rebound Abdomen is otherwise soft Positive bowel sounds Extremities are nonedematous Ultrasound reveals gallstones no inflammation common bile duct in 4 mm IMPRESSION PLAN I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding infection deep venous thrombosis pulmonary embolism cystic leak duct leak possible need for ERCP and possible need for further surgery among other potential complications She understands and we will proceed with the surgery in the near future Keywords gastroenterology laparoscopic cholecystectomy mid epigastric epigastric abdominal potential complications laparoscopic cholecystectomy epigastric abdomen surgery gallstones disease abdominal MEDICAL_TRANSCRIPTION,Description Patient complains of constipation Has not had BM for two days Medical Specialty Gastroenterology Sample Name Constipation 1 Transcription Patient was informed by Dr ABC that he does not need sleep study as per patient PHYSICAL EXAMINATION General Pleasant brighter Vital signs 117 78 12 56 Abdomen Soft nontender Bowel sounds normal ASSESSMENT AND PLAN 1 Constipation Milk of Magnesia 30 mL daily p r n Dulcolax suppository twice a week p r n 2 CAD angina See cardiologist this afternoon Call me if constipation not resolved by a m consider a Fleet enema then as discussed Keywords gastroenterology constipation bm milk of magnesia suppository dulcolax fleet enema MEDICAL_TRANSCRIPTION,Description Colonoscopy with photos The patient is an 85 year old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia She underwent an EGD and attempted colonoscopy however due to a very poor prep only a flexible sigmoidoscopy was performed at that time A coloscopy is now being performed for completion Medical Specialty Gastroenterology Sample Name Colonoscopy With Photos Transcription PREOPERATIVE DIAGNOSIS Blood loss anemia POSTOPERATIVE DIAGNOSES 1 Diverticulosis coli 2 Internal hemorrhoids 3 Poor prep PROCEDURE PERFORMED Colonoscopy with photos ANESTHESIA Conscious sedation per Anesthesia SPECIMENS None HISTORY The patient is an 85 year old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia She underwent an EGD and attempted colonoscopy however due to a very poor prep only a flexible sigmoidoscopy was performed at that time A coloscopy is now being performed for completion PROCEDURE After proper informed consent was obtained the patient was brought to the Endoscopy Suite She was placed in the left lateral position and was given sedation by the Anesthesia Department A digital rectal exam was performed and there was no evidence of mass The colonoscope was then inserted into the rectum There was some solid stool encountered The scope was maneuvered around this There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon The scope was then passed through the transverse colon and ascending colon to the cecum No masses or polyps were noted Visualization of the portions of the colon was however somewhat limited There were scattered diverticuli noted in the sigmoid The scope was slowly withdrawn carefully examining all walls Once in the rectum the scope was retroflexed and nonsurgical internal hemorrhoids were noted The scope was then completely withdrawn The patient tolerated the procedure well and was transferred to recovery room in stable condition She will be placed on a high fiber diet and Colace and we will continue to monitor her hemoglobin Keywords gastroenterology blood loss anemia diverticulosis coli internal hemorrhoids poor prep colonoscopy sigmoidoscopy hemoglobin coloscopy colonoscopy with photos attempted colonoscopy flexible sigmoidoscopy photos anemia scope MEDICAL_TRANSCRIPTION,Description Colonoscopy with random biopsies and culture Medical Specialty Gastroenterology Sample Name Colonoscopy with Biopsy 4 Transcription PREOPERATIVE DIAGNOSIS Antibiotic associated diarrhea POSTOPERATIVE DIAGNOSIS Antibiotic associated diarrhea OPERATION PERFORMED Colonoscopy with random biopsies and culture INDICATIONS The patient is a 50 year old woman who underwent hemorrhoidectomy approximately one year ago She has been having difficulty since that time with intermittent diarrhea and abdominal pain She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes She presents today for screening colonoscopy based on the same OPERATIVE COURSE The risks and benefits of colonoscopy were explained to the patient in detail She provided her consent The morning of the operation the patient was transported from the preoperative holding area to the endoscopy suite She was placed in the left lateral decubitus position In divided doses she was given 7 mg of Versed and 125 mcg of fentanyl A digital rectal examination was performed after which time the scope was intubated from the anus to the level of the hepatic flexure This was intubated fairly easily however the patient was clearly in some discomfort and was shouting out despite the amount of anesthesia she was provided In truth the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure While more medication could have been given the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse In addition she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk For this reason the procedure was aborted at the level of the hepatic flexure She was noted to have some pools of stool This was suctioned and sent to pathology for C difficile ova and parasites and fecal leukocytes Additionally random biopsies were performed of the colon itself It is unfortunate we were unable to complete this procedure as I would have liked to have taken biopsies of the terminal ileum However given the degree of discomfort she had again coupled with the relative ease of the procedure itself I am very suspicious of irritable bowel syndrome The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition where it is anticipated she will be discharged to home PLAN She needs to follow up with me in approximately 2 weeks time both to follow up with her biopsies and cultures She has been given a prescription for VSL3 a probiotic to assist with reculturing the rectum She may also benefit from an antispasmodic and or anxiolytic Lastly it should be noted that when she next undergoes endoscopic procedure propofol would be indicated Keywords gastroenterology colonoscopy with random biopsies hepatic flexure topical culture antibiotic hepatic flexure diarrhea biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description The patient with a recent change in bowel function and hematochezia Medical Specialty Gastroenterology Sample Name Colonoscopy with Biopsy 1 Transcription PREPROCEDURE DIAGNOSIS Change in bowel function POSTPROCEDURE DIAGNOSIS Proctosigmoiditis PROCEDURE PERFORMED Colonoscopy with biopsy ANESTHESIA IV sedation POSTPROCEDURE CONDITION Stable INDICATIONS The patient is a 33 year old with a recent change in bowel function and hematochezia He is here for colonoscopy He understands the risks and wishes to proceed PROCEDURE The patient was brought to the endoscopy suite where he was placed in left lateral Sims position underwent IV sedation Digital rectal examination was performed which showed no masses and a boggy prostate The colonoscope was placed in the rectum and advanced under direct vision to the cecum In the rectum and sigmoid there were ulcerations edema mucosal abnormalities and loss of vascular pattern consistent with proctosigmoiditis Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis RECOMMENDATIONS Follow up with me in 2 weeks and we will begin Canasa suppositories Keywords gastroenterology change in bowel function iv sedation bowel function proctosigmoiditis sedation rectum bowel function colonoscopy hematochezia MEDICAL_TRANSCRIPTION,Description Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon Medical Specialty Gastroenterology Sample Name Colonoscopy with Biopsy 3 Transcription PREPROCEDURE DIAGNOSIS Abdominal pain diarrhea and fever POSTPROCEDURE DIAGNOSIS Pending pathology PROCEDURES PERFORMED Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon Keywords gastroenterology colonoscopy with multiple biopsies length of the colon diarrhea and fever terminal ileum cecum multiple biopsies ileum cecum cecum hepatic hepatic flexure terminal ileum sigmoid colon colonoscopy diarrhea cecum hepatic flexure inflammation biopsies terminal ileum sigmoid scope MEDICAL_TRANSCRIPTION,Description Common description of colonoscopy Medical Specialty Gastroenterology Sample Name Colonoscopy Template 4 Transcription A colonoscope was then passed through the rectum all the way toward the cecum which was identified by the presence of the appendiceal orifice and ileocecal valve This was done without difficulty and the bowel preparation was good The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed COMPLICATIONS None Keywords gastroenterology cecum colonoscope bleeding infection perforation allergic reaction ileocecal valve informed allergic ileocecal valve colonoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Small internal hemorrhoids and Ileal colonic anastomosis Medical Specialty Gastroenterology Sample Name Colonoscopy with Biopsy 2 Transcription PROCEDURE PERFORMED Colonoscopy and biopsy INDICATIONS The patient is a 50 year old female who has had a history of a nonspecific colitis who was admitted 3 months ago at Hospital because of severe right sided abdominal pains was found to have multiple ulcers within the right colon and was then readmitted approximately 2 weeks later because of a cecal volvulus and had a right hemicolectomy Since then she has had persistent right abdominal pains as well as diarrhea with up to 2 4 bowel movements per day She has had problems with recurrent seizures and has been seen by Dr XYZ who started her recently on methadone MEDICATIONS Fentanyl 200 mcg Versed 10 mg Phenergan 25 mg intravenously given throughout the procedure INSTRUMENT PCF 160L PROCEDURE REPORT Informed consent was obtained from the patient after the risks and benefits of the procedure were carefully explained which included but were not limited to bleeding infection perforation and allergic reaction to the medications as well as the possibility of missing polyps within the colon A colonoscope was then passed through the rectum all the way toward the ileal colonic anastomosis seen within the proximal transverse colon The distal ileum was examined which was normal in appearance Random biopsies were obtained from the ileum and placed in jar 1 Random biopsies were obtained from the normal appearing colon and placed in jar 2 Small internal hemorrhoids were noted within the rectum on retroflexion COMPLICATIONS None ASSESSMENT 1 Small internal hemorrhoids 2 Ileal colonic anastomosis seen in the proximal transverse colon 3 Otherwise normal colonoscopy and ileum examination PLAN Followup results of biopsies If the biopsies are unremarkable the patient may benefit from a trial of tricyclic antidepressants if it s okay with Dr XYZ for treatment of her chronic abdominal pains Keywords gastroenterology proximal transverse transverse colon internal hemorrhoids colonic anastomosis biopsy rectum transverse hemorrhoids colonic anastomosis abdominal ileum biopsies colonoscopy MEDICAL_TRANSCRIPTION,Description A woman referred for colonoscopy secondary to heme positive stools Procedure done to rule out generalized diverticular change colitis and neoplasia Medical Specialty Gastroenterology Sample Name Colonoscopy with Biopsy Transcription INDICATIONS FOR PROCEDURE A 79 year old Filipino woman referred for colonoscopy secondary to heme positive stools Procedure done to rule out generalized diverticular change colitis and neoplasia DESCRIPTION OF PROCEDURE The patient was explained the procedure in detail possible complications including infection perforation adverse reaction of medication and bleeding Informed consent was signed by the patient With the patient in left decubitus position had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol using Olympus video colonoscope under direct visualization was advanced to the cecum Photodocumentation of appendiceal orifice and the ileocecal valve obtained Cecum was slightly obscured with stool but the colon itself was adequately prepped There was no evidence of overt colitis telangiectasia or overt neoplasia There was moderately severe diverticular change which was present throughout the colon and photodocumented The rectal mucosa was normal and retroflexed with mild internal hemorrhoids The patient tolerated the procedure well without any complications IMPRESSION 1 Colonoscopy to the cecum with adequate preparation 2 Long tortuous spastic colon 3 Moderately severe diverticular changes present throughout 4 Mild internal hemorrhoids RECOMMENDATIONS 1 Clear liquid diet today 2 Follow up with primary care physician as scheduled from time to time 3 Increase fiber in diet strongly consider fiber supplementation Keywords gastroenterology olympus video colonoscope advanced to the cecum heme positive stools diverticular change colitis colonoscopy to the cecum spastic colon colonoscopy with biopsy liver disease biopsy hepatitis chronic liver disease mucosa polyp rectal colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy conscious sedation and snare polypectomy Medical Specialty Gastroenterology Sample Name Colonoscopy Polypectomy 2 Transcription PREPROCEDURE DIAGNOSIS Colon cancer screening POSTPROCEDURE DIAGNOSIS Colon polyps diverticulosis hemorrhoids PROCEDURE PERFORMED Colonoscopy conscious sedation and snare polypectomy INDICATIONS The patient is a 63 year old male who has myelodysplastic syndrome who was referred for colonoscopy He has had previous colonoscopy There is no family history of bleeding no current problems with his bowels On examination he has internal hemorrhoids His prostate is enlarged and increased somewhat in firmness He has scattered diverticular disease of a moderate degree and he has two polyps one 1 cm in the mid ascending colon and one in the left transverse colon which is also 1 cm These were removed with snare polypectomy technique I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding PROCEDURE After explaining the operative procedure the risks and potential complications of bleeding and perforation the patient was given 175 mcg fentanyl and 8 mg Versed intravenously for conscious sedation Blood pressure 115 60 pulse 98 respiration 18 and saturation 92 A rectal examination was done and then the colonoscope was inserted through the anorectum rectosigmoid descending transverse and ascending colon to the ileocecal valve The scope was withdrawn to the mid ascending colon where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current then retrieved through the suction port The scope was withdrawn into the left transverse colon where the second polyp was identified It was encircled with a snare and removed with a mixture of cutting and coagulating current and then removed through the suction port as well The scope was then gradually withdrawn the remaining distance and removed The patient tolerated the procedure well Keywords gastroenterology colon polyps diverticulosis hemorrhoids cutting and coagulating transverse colon snare polypectomy ascending colon colonoscopy polyps bowels coagulating sedation scope ascending snare polypectomy MEDICAL_TRANSCRIPTION,Description Total colonoscopy and polypectomy Medical Specialty Gastroenterology Sample Name Colonoscopy Polypectomy 1 Transcription PREOPERATIVE DIAGNOSIS History of colitis POSTOPERATIVE DIAGNOSIS Small left colon polyp PROCEDURE PERFORMED Total colonoscopy and polypectomy ANESTHESIA IV Versed 8 mg and 175 mcg of IV fentanyl CLINICAL HISTORY This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding He has been admitted to the hospital now for colonoscopy and polyp surveillance PROCEDURE The patient was prepped and draped in a left lateral decubitus position The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV directed monitor through the area of the rectum sigmoid colon left colon transverse colon right colon and cecum He had an excellent prep He had a 2 3 mm polyp in the left colon that was removed with a jumbo biopsy forceps He tolerated the procedure well There was no other evidence of any cancer growth tumor colitis or problems throughout the entire colon His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since Representative pictures were taken throughout the entire exam There was no other evidence any problems On withdrawal of the scope the same findings were noted FINAL IMPRESSION Small left colon polyp in a patient with intermittent colitis like symptoms and bleeding Keywords gastroenterology anus lateral decubitus position colon colonoscopy and polypectomy total colonoscopy colon polyp colonoscopy bleeding colitis polypectomy intermittent MEDICAL_TRANSCRIPTION,Description Total colonoscopy with biopsy and snare polypectomy Medical Specialty Gastroenterology Sample Name Colonoscopy Polypectomy 3 Transcription PREOPERATIVE DIAGNOSIS Alternating hard and soft stools POSTOPERATIVE DIAGNOSIS Sigmoid diverticulosis Sessile polyp of the sigmoid colon Pedunculated polyp of the sigmoid colon PROCEDURE Total colonoscopy with biopsy and snare polypectomy PREP 4 4 DIFFICULTY 1 4 PREMEDICATION AND SEDATION Fentanyl 100 midazolam 5 INDICATION FOR PROCEDURE A 64 year old male who has developed alternating hard and soft stools He has one bowel movement a day FINDINGS There is extensive sigmoid diverticulosis without evidence of inflammation or bleeding There was a small sessile polyp in the sigmoid colon and a larger pedunculated polyp in the sigmoid colon both appeared adenomatous DESCRIPTION OF PROCEDURE Preoperative counseling including an explicit discussion of the risk and treatment of perforation was provided Preoperative physical examination was performed Informed consent was obtained The patient was placed in the left lateral decubitus position Premedications were given slowly by intravenous push Rectal examination was performed which was normal The scope was introduced and passed with minimal difficulty to the cecum This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice The scope was slowly withdrawn the mucosa carefully visualized It was normal in its entirety until reaching the sigmoid colon Sigmoid colon had extensive diverticular disease small mouth without inflammation or bleeding In addition there was a small sessile polyp which was cold biopsied and recovered and approximately an 8 mm pedunculated polyp A snare was placed on the stalk of the polyp and divided with electrocautery The polyp was recovered and sent for pathologic examination Examination of the stalk showed good hemostasis The scope was slowly withdrawn and the remainder of the examination was normal ASSESSMENT Diverticular disease A diverticular disease handout was given to the patient s wife and a high fiber diet was recommended In addition 2 polyps one of which is assuredly an adenoma Patient needs a repeat colonoscopy in 3 years Keywords gastroenterology total colonoscopy with biopsy colonoscopy with biopsy total colonoscopy snare polypectomy sigmoid diverticulosis sessile polyp pedunculated polyp diverticular disease sigmoid colon colonoscopy polypectomy biopsy diverticulosis inflammation adenomatous sessile sigmoid MEDICAL_TRANSCRIPTION,Description Patient with active flare of Inflammatory Bowel Disease not responsive to conventional therapy including sulfasalazine cortisone local therapy Medical Specialty Gastroenterology Sample Name Colonoscopy 8 Transcription PROCEDURES PERFORMED Colonoscopy INDICATIONS Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease not responsive to conventional therapy including sulfasalazine cortisone local therapy PROCEDURE Informed consent was obtained prior to the procedure with special attention to benefits risks alternatives Risks explained as bleeding infection bowel perforation aspiration pneumonia or reaction to the medications Vital signs were monitored by blood pressure heart rate and oxygen saturation Supplemental O2 given Specifics discussed Preprocedure physical exam performed Stable vital signs Lungs clear Cardiac exam showed regular rhythm Abdomen soft Her past history her past workup her past visitation with me for Inflammatory Bowel Disease well responsive to sulfasalazine reviewed She currently has a flare and is not responding therefore likely may require steroid taper At the same token her symptoms are mild She has rectal bleeding essentially only some rusty stools There is not significant diarrhea just some lower stools No significant pain Therefore it is possible that we are just dealing with a hemorrhoidal bleed therefore colonoscopy now needed Past history reviewed Specifics of workup need for followup and similar discussed All questions answered A normal digital rectal examination was performed The PCF 160 AL was inserted into the anus and advanced to the cecum without difficulty as identified by the ileocecal valve cecal stump and appendical orifice All mucosal aspects thoroughly inspected including a retroflexed examination Withdrawal time was greater than six minutes Unfortunately the terminal ileum could not be intubated despite multiple attempts Findings were those of a normal cecum right colon transverse colon descending colon A small cecal polyp was noted this was biopsy removed placed in bottle 1 Random biopsies from the cecum obtained bottle 2 random biopsies from the transverse colon obtained as well as descending colon obtained bottle 3 There was an area of inflammation in the proximal sigmoid colon which was biopsied placed in bottle 4 There was an area of relative sparing with normal sigmoid lining placed in bottle 5 randomly biopsied and then inflammation again in the distal sigmoid colon and rectum biopsied bottle 6 suggesting that we may be dealing with Crohn disease given the relative sparing of the sigmoid colon and junk lesion Retroflexed showed hemorrhoidal disease Scope was then withdrawn patient left in good condition IMPRESSION Active flare of Inflammatory Bowel Disease question of Crohn disease PLAN I will have the patient follow up with me will follow up on histology follow up on the polyps She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job If not she may be started on immune suppressive medication such as azathioprine or similar All of this has been reviewed with the patient All questions answered Keywords gastroenterology sulfasalazine cortisone local therapy inflammatory bowel disease cortisone local local therapy crohn disease sigmoid colon bowel disease colonoscopy inflammatory rectal sulfasalazine cecum sigmoid bowel disease MEDICAL_TRANSCRIPTION,Description Colonoscopy Diarrhea suspected irritable bowel Medical Specialty Gastroenterology Sample Name Colonoscopy 4 Transcription PREOPERATIVE DIAGNOSIS Diarrhea suspected irritable bowel POSTOPERATIVE DIAGNOSIS Normal colonoscopy PREMEDICATIONS Versed 5 mg Demerol 75 mg IV REPORTED PROCEDURE The rectal exam revealed no external lesions The prostate was normal in size and consistency The colonoscope was inserted into the cecum with ease The cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon sigmoid colon and rectum were normal The scope was retroflexed in the rectum and no abnormality was seen so the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION Normal colonoscopy no evidence of inflammatory disease polyp or other neoplasm These findings are certainly consistent with irritable bowel syndrome Keywords gastroenterology diarrhea ascending colon cecum colonoscope colonoscopy descending colon hepatic flexure inflammatory disease irritable bowel syndrome irritable bowel polyp rectal exam rectum sigmoid colon splenic flexure transverse colon normal colonoscopy irritable bowel flexure irritable bowel MEDICAL_TRANSCRIPTION,Description Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies Hematochezia refractory dyspepsia colonic polyps at 35 cm and 15 cm diverticulosis coli and acute and chronic gastritis MEDICAL_TRANSCRIPTION,Description Patient with history of polyps Medical Specialty Gastroenterology Sample Name Colonoscopy 9 Transcription PREOPERATIVE DIAGNOSIS Prior history of polyps POSTOPERATIVE DIAGNOSIS Small polyps no evidence of residual or recurrent polyp in the cecum PREMEDICATIONS Versed 5 mg Demerol 100 mg IV REPORTED PROCEDURE The rectal chamber revealed no external lesions Prostate was normal in size and consistency The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum The position of the scope within the cecum was verified by identification of the ileocecal valve Navigation was difficult because it seemed that the cecum took an upward turn at its final turn but the examination was completed The cecum was extensively studied and no lesion was seen There was not even a scar representing the prior polyp I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago and I saw no lesion at all The scope was then slowly withdrawn In the mid transverse colon was a small submucosal lesion which appeared to be a lipoma It was freely mobile and very small with normal overlying mucosa There was a similar lesion in the descending colon Both of these appeared to be lipomatous so no attempt was made to remove them There were diverticula present in the sigmoid colon In addition there were two polyps in the sigmoid colon both of which were resected using electrocautery There was no bleeding The scope was then withdrawn The rectum was normal When the scope was retroflexed in the rectum two very small polyps were noted just at the anorectal margin and so these were obliterated using the electrocautery snare There was no specimen and there was no bleeding The scope was then straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Small polyps sigmoid colon resected them 2 Diverticulosis sigmoid colon 3 Small rectal polyps obliterated them 4 Submucosal lesions consistent with lipomata as described 5 No evidence of residual or recurrent neoplasm in the cecum Keywords gastroenterology ileocecal valve sigmoid colon polyps ileocecal submucosal electrocautery bleeding rectum rectal sigmoid cecum scope colonoscopy MEDICAL_TRANSCRIPTION,Description Patient with history of adenomas and irregular bowel habits Medical Specialty Gastroenterology Sample Name Colonoscopy 7 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSIS Follow up adenomas POSTOPERATIVE DIAGNOSES 1 Two colon polyps removed 2 Small internal hemorrhoids 3 Otherwise normal examination of cecum MEDICATIONS Fentanyl 150 mcg and Versed 7 mg slow IV push INDICATIONS This is a 60 year old white female with a history of adenomas She does have irregular bowel habits FINDINGS The patient was placed in the left lateral decubitus position and the above medications were administered The colonoscope was advanced to the cecum as identified by the ileocecal valve appendiceal orifice and blind pouch The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made including a retroflexed view of the rectum There was a 4 mm descending colon polyp which was removed with jumbo forceps and sent for histology in bottle one There was a 10 mm pale flat polyp in the distal rectum which was removed with jumbo forceps and sent for histology in bottle 2 There were small internal hemorrhoids The remainder of the examination was normal to the cecum The patient tolerated the procedure well without complication IMPRESSION 1 Two colon polyps removed 2 Small internal hemorrhoids 3 Otherwise normal examination to cecum PLAN I will await the results of the colon polyp histology The patient was told the importance of daily fiber Keywords gastroenterology colon polyps internal hemorrhoids rectum irregular bowel habits colon polyps removed irregular bowel bowel habits polyps removed bowel habits colonoscope hemorrhoids cecum forceps polyps colonoscopy adenomas MEDICAL_TRANSCRIPTION,Description Colonoscopy to evaluate prior history of neoplastic polyps Medical Specialty Gastroenterology Sample Name Colonoscopy 3 Transcription PREOPERATIVE DIAGNOSIS Prior history of neoplastic polyps POSTOPERATIVE DIAGNOSIS Small rectal polyps removed and fulgurated PREMEDICATIONS Prior to the colonoscopy the patient complained of a sever headache and she was concerned that she might become ill I asked the nurse to give her 25 mg of Demerol IV Following the IV Demerol she had a nausea reaction She was then given 25 mg of Phenergan IV Following this her headache and nausea completely resolved She was then given a total of 7 5 mg of Versed with adequate sedation Rectal exam revealed no external lesions Digital exam revealed no mass REPORTED PROCEDURE The P160 colonoscope was used The scope was placed in the rectal ampulla and advanced to the cecum Navigation through the sigmoid colon was difficult Beginning at 30 cm was a very tight bend With gentle maneuvering the scope passed through and then entered the cecum The cecum ascending colon hepatic flexure transverse colon splenic flexure and descending colon were normal The sigmoid colon was likewise normal There were five very small punctate polyps in the rectum One was resected using the electrocautery snare and the other four were ablated using the snare and cautery There was no specimen because the polyps were so small The scope was retroflexed in the rectum and no further abnormality was seen so the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Five small polyps as described all fulgurated 2 Otherwise unremarkable colonoscopy Keywords gastroenterology colonoscopy demerol phenergan rectal exam versed ascending colon cecum colonoscope descending colon fulgurated hepatic flexure neoplastic polyps punctate rectal ampulla splenic flexure transverse colon scope MEDICAL_TRANSCRIPTION,Description Colonoscopy to screen for colon cancer Medical Specialty Gastroenterology Sample Name Colonoscopy 6 Transcription INDICATIONS This is a 55 year old female who is having a colonoscopy to screen for colon cancer There is no family history of colon cancer and there has been no blood in the stool PROCEDURE PERFORMED Colonoscopy PREP Fentanyl 100 mcg IV and 3 mg Versed IV PROCEDURE The tip of the endoscope was introduced into the rectum Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions The rest of the colon through to the cecum was well visualized The cecal strap ileocecal valve and light reflex in the right lower quadrant were all identified There was no evidence of tumor polyp mass ulceration or other focus of inflammation Adverse reactions none IMPRESSION Normal colonic mucosa through to the cecum There was no evidence of tumor or polyp Keywords gastroenterology versed iv colon tumor polyp mass ulceration focus of inflammation tip of the endoscope evidence of tumor colon cancer endoscope cecum cancer colonoscopy MEDICAL_TRANSCRIPTION,Description Screening colonoscopy Tiny polyps If adenomatous repeat exam in five years Medical Specialty Gastroenterology Sample Name Colonoscopy 20 Transcription PREOPERATIVE DIAGNOSIS Screening POSTOPERATIVE DIAGNOSIS Tiny Polyps PROCEDURE PERFORMED Colonoscopy PROCEDURE The procedure indications and risks were explained to the patient who understood and agreed He was sedated with Versed 3 mg Demerol 25 mg during the examination A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner s finger into the rectum It was passed to the level of the cecum The ileocecal valve was identified as was the appendiceal orifice Slowly withdrawal through the colon revealed a small polyp in the transverse colon This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps In addition there was a 2 mm polyp versus lymphoid aggregate in the descending colon This was also removed using the cold biopsy forceps Further detail failed to reveal any other lesions with the exception of small hemorrhoids IMPRESSION Tiny polyps PLAN If adenomatous repeat exam in five years Otherwise repeat exam in 10 years Keywords gastroenterology pentax video colonoscope biopsy forceps tiny polyps polyps adenomatous colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy and biopsies epinephrine sclerotherapy hot biopsy cautery and snare polypectomy Colon cancer screening Family history of colon polyps Medical Specialty Gastroenterology Sample Name Colonoscopy 21 Transcription OPERATIVE PROCEDURES Colonoscopy and biopsies epinephrine sclerotherapy hot biopsy cautery and snare polypectomy PREOPERATIVE DIAGNOSES 1 Colon cancer screening 2 Family history of colon polyps POSTOPERATIVE DIAGNOSES 1 Multiple colon polyps 5 2 Diverticulosis sigmoid colon 3 Internal hemorrhoids ENDOSCOPE USED EC3870LK BIOPSIES Biopsies taken from all polyps Hot biopsy got applied to one Epinephrine sclerotherapy and snare polypectomy applied to four polyps ANESTHESIA Fentanyl 75 mcg Versed 6 mg and glucagon 1 5 units IV push in divided doses Also given epinephrine 1 20 000 total of 3 mL The patient tolerated the procedure well PROCEDURE The patient was placed in left lateral decubitus after appropriate sedation Digital rectal examination was done which was normal Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine Pedunculated polyp next to it was hard to see and there was a lot of peristalsis The scope then was advanced through rest of the transverse colon to ascending colon and cecum Terminal ileum was briefly reviewed appeared normal and so did cecum after copious amount of fecal material was irrigated out Ascending colon was unremarkable At hepatic flexure may be proximal transverse colon there was a sessile polyp about 1 2 cm x 1 cm that was removed in the same manner with a biopsy taken base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue which could be seen In transverse colon on withdrawal and relaxation with epinephrine an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy Then in the transverse colon additional larger polyp about 1 3 cm x 1 2 cm was removed in piecemeal fashion again with epinephrine sclerotherapy and snare polypectomy Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy The rest of the splenic flexure and descending colon were unremarkable Diverticulosis was again seen with almost constant spasm despite of glucagon Sigmoid colon did somewhat hinder the inspection of that area Rectum retroflexion posterior anal canal showed internal hemorrhoids moderate to large Excess of air insufflated was removed The endoscope was withdrawn PLAN Await biopsy report Pending biopsy report recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient s polyps Keywords gastroenterology colon cancer colon polyps snare polypectomy cautery epinephrine sclerotherapy transverse colon polypectomy colonoscopy sigmoid endoscope sclerotherapy epinephrine biopsy MEDICAL_TRANSCRIPTION,Description Mild to moderate diverticulosis She was referred for a screening colonoscopy There is no family history of colon cancer No evidence of polyps or malignancy Medical Specialty Gastroenterology Sample Name Colonoscopy 22 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES The patient is a 56 year old female She was referred for a screening colonoscopy The patient has bowel movements every other day There is no blood in the stool no abdominal pain She has hypertension dyslipidemia and gastroesophageal reflux disease She has had cesarean section twice in the past Physical examination is unremarkable There is no family history of colon cancer POSTOPERATIVE DIAGNOSIS Diverticulosis PROCEDURE IN DETAIL Procedure and possible complications were explained to the patient Ample opportunity was provided to her to ask questions Informed consent was obtained She was placed in left lateral position Inspection of perianal area was normal Digital exam of the rectum was normal Video Olympus colonoscope was introduced into the rectum The sigmoid colon is very tortuous The instrument was advanced to the cecum after placing the patient in a supine position The patient was well prepared and a good examination was possible The cecum was identified by the ileocecal valve and the appendiceal orifice Images were taken The instrument was then gradually withdrawn while examining the colon again in a circumferential manner Few diverticula were encountered in the sigmoid and descending colon Retroflex view of the rectum was unremarkable No polyps or malignancy was identified After obtaining images the air was suctioned Instrument was withdrawn from the patient The patient tolerated the procedure well There were no complications SUMMARY OF FINDINGS Colonoscopy was performed to cecum and demonstrates the following 1 Mild to moderate diverticulosis 2 RECOMMENDATION 1 The patient was provided information on diverticulosis including dietary advice 2 She was advised repeat colonoscopy after 10 years Keywords gastroenterology screening colonoscopy colon cancer colonoscopy polyps malignancy sigmoid rectum cecum diverticulosis MEDICAL_TRANSCRIPTION,Description Colonoscopy with terminal ileum examination Iron deficiency anemia Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty Medical Specialty Gastroenterology Sample Name Colonoscopy 19 Transcription INDICATION Iron deficiency anemia PROCEDURE Colonoscopy with terminal ileum examination POSTOPERATIVE DIAGNOSIS Normal examination WITHDRAWAL TIME 15 minutes SCOPE CF H180AL MEDICATIONS Fentanyl 100 mcg and versed 10 mg PROCEDURE DETAIL Following the preprocedure patient assessment the procedure goals risks including bleeding perforation missed polyp rate as well as side effects of medications and alternatives were reviewed Questions were answered Pause preprocedure was performed Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty The ileocecal valve looked normal Preparation was fair allowing examination of 85 of mucosa after washing and cleaning with tap water through the scope The terminal ileum was intubated through the ileocecal valve for a 5 cm extent Terminal ileum mucosa looked normal Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum No polyp no diverticulum and no bleeding source was identified The patient was assessed upon completion of the procedure Okay to discharge once criteria met RECOMMENDATIONS Follow up with primary care physician Keywords gastroenterology polyp endoscope mucosa iron deficiency anemia ileocecal valve terminal ileum colonoscopy anemia rectum ileum MEDICAL_TRANSCRIPTION,Description Universal diverticulosis and nonsurgical internal hemorrhoids Total colonoscopy with photos The patient is a 62 year old white male who presents to the office with a history of colon polyps and need for recheck Medical Specialty Gastroenterology Sample Name Colonoscopy 17 Transcription PREOPERATIVE DIAGNOSIS Colon polyps POSTOPERATIVE DIAGNOSES 1 Universal diverticulosis 2 Nonsurgical internal hemorrhoids PROCEDURE PERFORMED Total colonoscopy with photos ANESTHESIA Demerol 100 mg IV with Versed 3 mg IV SPECIMENS None ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE The patient is a 62 year old white male who presents to the office with a history of colon polyps and need for recheck PROCEDURE Informed consent was obtained All risks and benefits of the procedure were explained and all questions were answered The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained Upon appropriate anesthesia a digital rectal exam was performed which showed no masses The colonoscope was then placed into the anus and the air was insufflated The scope was then advanced under direct vision into the rectum rectosigmoid colon descending colon transverse colon ascending colon until it reached the cecum Upon entering the sigmoid colon and throughout the rest of the colon there was noted diverticulosis After reaching the cecum the scope was fully withdrawn visualizing all walls again noting universal diverticulosis Upon reaching the rectum the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids The scope was then subsequently removed The patient tolerated the procedure well and there were no complications Keywords gastroenterology endoscopy rectum rectosigmoid colon descending colon transverse colon ascending colon total colonoscopy colon polyps colonoscopy cecum polyps diverticulosis hemorrhoids MEDICAL_TRANSCRIPTION,Description Possible inflammatory bowel disease Polyp of the sigmoid colon Total colonoscopy with photography and polypectomy Medical Specialty Gastroenterology Sample Name Colonoscopy 18 Transcription PREOPERATIVE DIAGNOSIS Possible inflammatory bowel disease POSTOPERATIVE DIAGNOSIS Polyp of the sigmoid colon PROCEDURE PERFORMED Total colonoscopy with photography and polypectomy GROSS FINDINGS The patient had a history of ischiorectal abscess He has been evaluated now for inflammatory bowel disease Upon endoscopy the colon prep was good We were able to reach the cecum without difficulty There are no diverticluli inflammatory bowel disease strictures or obstructing lesions There was a pedunculated polyp approximately 4 5 cm in size located in the sigmoid colon at approximately 35 cm This large polyp was removed using the snare technique OPERATIVE PROCEDURE The patient was taken to the endoscopy suite prepped and draped in left lateral decubitus position IV sedation was given by Anesthesia Department The Olympus videoscope was inserted into anus Using air insufflation the colonoscope was advanced through the anus to the rectum sigmoid colon descending colon transverse colon ascending colon and cecum the above gross findings were noted The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel When the polyp again was visualized the snare was passed around the polyp It required at least two to three passes of the snare to remove the polyp in its totality There was a large stalk on the polyp ________ the polyp had been removed down to the junction of the polyp in the stalk which appeared to be cauterized and no residual adenomatous tissue was present No bleeding was identified The colonoscope was then removed and patient was sent to recovery room in stable condition Keywords gastroenterology polypectomy inflammatory bowel disease sigmoid colon rectum descending colon transverse colon ascending colon cecum total colonoscopy bowel disease inflammatory polyp colonoscopy colonoscope bowel MEDICAL_TRANSCRIPTION,Description Colonoscopy History of colon polyps and partial colon resection right colon Mild diverticulosis of the sigmoid colon Hemorrhoids Medical Specialty Gastroenterology Sample Name Colonoscopy 14 Transcription PREPROCEDURE DIAGNOSIS History of colon polyps and partial colon resection right colon POSTPROCEDURE DIAGNOSES 1 Normal operative site 2 Mild diverticulosis of the sigmoid colon 3 Hemorrhoids PROCEDURE Total colonoscopy PROCEDURE IN DETAIL The patient is a 60 year old of Dr ABC s being evaluated for the above The patient also apparently had an x ray done at the Hospital and it showed a dark spot and because of this a colonoscopy was felt to be needed She was prepped the night before and on the morning of the test with oral Fleet s brought to the second floor and sedated with a total of 50 mg of Demerol and 3 75 mg of Versed IV push Digital rectal exam was done unremarkable At that point the Pentax video colonoscope was inserted The rectal vault appeared normal The sigmoid showed diverticula throughout mild to moderate in nature The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized The scope was passed a short distance up the ileum which appeared normal The scope was then withdrawn through the transverse descending sigmoid and rectal vault area The scope was then retroflexed and anal verge visualized showed some hemorrhoids The scope was then removed The patient tolerated the procedure well RECOMMENDATIONS Repeat colonoscopy in three years Keywords gastroenterology partial colon resection diverticulosis colon polyps rectal vault colonoscopy polyps hemorrhoids sigmoid MEDICAL_TRANSCRIPTION,Description Colonoscopy in a patient with prior history of anemia and abdominal bloating Medical Specialty Gastroenterology Sample Name Colonoscopy 2 Transcription PREOPERATIVE DIAGNOSES Prior history of anemia abdominal bloating POSTOPERATIVE DIAGNOSIS External hemorrhoids otherwise unremarkable colonoscopy PREMEDICATIONS Versed 5 mg Demerol 50 mg IV REPORT OF PROCEDURE Digital rectal exam revealed external hemorrhoids The colonoscope was inserted into the rectal ampulla and advanced to the cecum The position of the scope within the cecum was verified by identification of the appendiceal orifice The cecum the ascending colon hepatic flexure transverse colon splenic flexure descending colon and rectum were normal The scope was retroflexed in the rectum and no abnormality was seen So the scope was straightened withdrawn and the procedure terminated ENDOSCOPIC IMPRESSION 1 Normal colonoscopy 2 External hemorrhoids Keywords gastroenterology colonoscopy digital rectal exam abdominal anemia ascending colon bloating cecum colonoscope descending colon hemorrhoids hepatic flexure rectal ampulla rectum splenic flexure transverse colon external hemorrhoids scope MEDICAL_TRANSCRIPTION,Description Colonoscopy Rectal bleeding and perirectal abscess Normal colonoscopy to the terminal ileum Opening in the skin at the external anal verge consistent with drainage from a perianal abscess with no palpable abscess at this time and with no evidence of fistulous connection to the bowel lumen Medical Specialty Gastroenterology Sample Name Colonoscopy 16 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES Rectal bleeding and perirectal abscess POSTOPERATIVE DIAGNOSIS Perianal abscess MEDICATIONS MAC DESCRIPTION OF PROCEDURE The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum The preparation was excellent and all surfaces were well seen The mucosa throughout the colon and in the terminal ileum was normal with no evidence of colitis Special attention was paid to the rectum including retroflexed views of the distal rectum and the anorectal junction There was no evidence of either inflammation or a fistulous opening The scope was withdrawn A careful exam of the anal canal and perianal area demonstrated a jagged 8 mm opening at the anorectal junction posteriorly 12 o clock position Some purulent material could be expressed through the opening There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material Specifically the posterior wall of the distal rectum and anal canal were soft and unremarkable In addition scars were noted in the perianal area The first was a small dimpled scar 1 cm from the anal verge in the 11 o clock position The second was a dimpled scar about 5 cm from the anal verge on the left buttock s cheek There were no other abnormalities noted The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Normal colonoscopy to the terminal ileum 2 Opening in the skin at the external anal verge consistent with drainage from a perianal abscess with no palpable abscess at this time and with no evidence of fistulous connection to the bowel lumen RECOMMENDATIONS 1 Continue antibiotics 2 Followup with Dr X 3 If drainage persists consider surgical drainage Keywords gastroenterology olympus colonoscope rectal bleeding perianal abscess terminal ileum anal verge anorectal fistulous ileum verge rectum anal perianal colonoscopy abscess MEDICAL_TRANSCRIPTION,Description History of polyps Total colonoscopy and photography Normal colonoscopy left colonic diverticular disease 3 benign prostatic hypertrophy Medical Specialty Gastroenterology Sample Name Colonoscopy 13 Transcription PREOPERATIVE DIAGNOSIS History of polyps POSTOPERATIVE DIAGNOSES 1 Normal colonoscopy left colonic diverticular disease 2 3 benign prostatic hypertrophy PROCEDURE PERFORMED Total colonoscopy and photography GROSS FINDINGS This is a 74 year old white male here for recheck colonoscopy for a history of polyps After signed informed consent blood pressure monitoring EKG monitoring and pulse oximetry monitoring he was brought to the Endoscopic Suite He was given 100 mg of Demerol 3 mg of Versed IV push slowly Digital examination revealed a large prostate for which he is following up with his urologist No nodules 3 BPH Anorectal canal was within normal limits No stricture tumor or ulcer The Olympus CF 20L video endoscope was inserted per anus The anorectal canal was visualized was normal The sigmoid descending splenic and transverse showed scattered diverticula The hepatic ascending cecum and ileocecal valve was visualized and was normal The colonoscope was removed The air was aspirated The patient was discharged with high fiber diverticular diet Recheck colonoscopy three years Keywords gastroenterology digital examination benign prostatic hypertrophy anorectal canal diverticular disease photography anorectal colonoscopy MEDICAL_TRANSCRIPTION,Description Colonoscopy Change in bowel habits and rectal prolapse Normal colonic mucosa to the cecum Medical Specialty Gastroenterology Sample Name Colonoscopy 15 Transcription PROCEDURE Colonoscopy PREOPERATIVE DIAGNOSES Change in bowel habits and rectal prolapse POSTOPERATIVE DIAGNOSIS Normal colonoscopy PROCEDURE The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice The preparation was poor but mucosa was visible after lavage and suction Small lesions might have been missed in certain places but no large lesions are likely to have been missed The mucosa was normal was visualized In particular there was no mucosal abnormality in the rectum and distal sigmoid which is reported to be prolapsing Biopsies were taken from the rectal wall to look for microscopic changes The anal sphincter was considerably relaxed with no tone and a gaping opening The patient tolerated the procedure well and was sent to recovery room FINAL DIAGNOSIS Normal colonic mucosa to the cecum No contraindications to consideration of a repair of the prolapse Keywords gastroenterology olympus colonoscope bowel habits colonic mucosa colonic rectum rectal cecum mucosa colonoscopy MEDICAL_TRANSCRIPTION,Description Routine colorectal cancer screening He occasionally gets some loose stools Medical Specialty Gastroenterology Sample Name Colon Cancer Screening Transcription HISTORY AND REASON FOR CONSULTATION For evaluation of this patient for colon cancer screening HISTORY OF PRESENT ILLNESS Mr A is a 53 year old gentleman who was referred for colon cancer screening The patient said that he occasionally gets some loose stools Other than that there are no other medical problems PAST MEDICAL HISTORY The patient does not have any serious medical problems at all He denies any hypertension diabetes or any other problems He does not take any medications PAST SURGICAL HISTORY Surgery for deviated nasal septum in 1996 ALLERGIES No known drug allergies SOCIAL HISTORY Does not smoke but drinks occasionally for the last five years FAMILY HISTORY There is no history of any colon cancer in the family REVIEW OF SYSTEMS Denies any significant diarrhea Sometimes he gets some loose stools Occasionally there is some constipation Stools caliber has not changed There is no blood in stool or mucus in stool No weight loss Appetite is good No nausea vomiting or difficulty in swallowing Has occasional heartburn PHYSICAL EXAMINATION The patient is alert and oriented x3 Vital signs Weight is 214 pounds Blood pressure is 111 70 Pulse is 69 per minute Respiratory rate is 18 HEENT Negative Neck Supple There is no thyromegaly Cardiovascular Both heart sounds are heard Rhythm is regular No murmur Lungs Clear to percussion and auscultation Abdomen Soft and nontender No masses felt Bowel sounds are heard Extremities Free of any edema IMPRESSION Routine colorectal cancer screening RECOMMENDATIONS Colonoscopy I have explained the procedure of colonoscopy with benefits and risks in particular the risk of perforation hemorrhage and infection The patient agreed for it We will proceed with it I also explained to the patient about conscious sedation He agreed for conscious sedation Keywords gastroenterology colon cancer screening loose stools colorectal colonoscopy MEDICAL_TRANSCRIPTION,Description Colon cancer screening and family history of polyps Sigmoid diverticulosis and internal hemorrhoids Medical Specialty Gastroenterology Sample Name Colonoscopy 10 Transcription PREOPERATIVE DIAGNOSES Colon cancer screening and family history of polyps POSTOPERATIVE DIAGNOSIS Colonic polyps PROCEDURE Colonoscopy ANESTHESIA MAC DESCRIPTION OF PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum The preparation was excellent and all surfaces were well seen The mucosa was normal throughout the colon and in the terminal ileum Two polyps were identified and were removed The first was a 7 mm sessile lesion in the mid transverse colon at 110 cm removed with the snare without cautery and retrieved The second was a small 4 mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved No other lesions were identified Numerous diverticula were found in the sigmoid colon A retroflex through the anorectal junction showed moderate internal hemorrhoids The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Sigmoid diverticulosis 2 Colonic polyps in the transverse colon and sigmoid colon benign appearance removed 3 Internal hemorrhoids 4 Otherwise normal colonoscopy to the terminal ileum RECOMMENDATIONS 1 Follow up biopsy report 2 Follow up with Dr X as needed 3 Screening colonoscopy in 5 years Keywords gastroenterology MEDICAL_TRANSCRIPTION,Description Colonoscopy The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum Medical Specialty Gastroenterology Sample Name Colonoscopy 12 Transcription PROCEDURE IN DETAIL Following instructions and completion of an oral colonoscopy prep the patient having been properly informed of with signature consenting to total colonoscopy and indicated procedures the patient received premedications of Vistaril 50 mg Atropine 0 4 mg IM and then intravenous medications of Demerol 50 mg and Versed 5 mg IV Perirectal inspection was normal The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum No abnormalities were seen of the terminal ileum the ileocecal valve cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon rectosigmoid and rectum Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure Keywords gastroenterology ileocecal valve cecum ascending colon hepatic flexure transverse colon splenic flexure descending colon rectosigmoid rectum terminal ileum olympus video colonoscope flexure colonoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Colonoscopy The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon descending colon around the splenic flexure into the transverse colon around the hepatic flexure down the ascending colon into the cecum Medical Specialty Gastroenterology Sample Name Colonoscopy 11 Transcription MEDICATIONS 1 Versed intravenously 2 Demerol intravenously DESCRIPTION OF THE PROCEDURE After informed consent was obtained the patient was placed in the left lateral decubitus position and sedated with the above medications The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon descending colon around the splenic flexure into the transverse colon around the hepatic flexure down the ascending colon into the cecum The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve The colonoscope was then advanced through the ileocecal valve into the terminal ileum which was normal on examination The scope was then pulled back into the cecum and then slowly withdrawn The mucosa was examined in detail The mucosa was entirely normal Upon reaching the rectum retroflex examination of the rectum was normal The scope was then straightened out the air removed and the scope withdrawn The patient tolerated the procedure well There were no apparent complications Keywords gastroenterology olympus scope sigmoid colon descending colon splenic flexure transverse colon hepatic flexure ascending colon ileocecal valve ileocecal mucosa rectum colonoscope flexure cecum colonoscopyNOTE MEDICAL_TRANSCRIPTION,Description Still having diarrhea decreased appetite Medical Specialty Gastroenterology Sample Name Clostridium Difficile Colitis Followup Transcription SUBJECTIVE The patient seen and examined feels better today Still having diarrhea decreased appetite Good urine output 600 mL since 7 o clock in the morning Afebrile PHYSICAL EXAMINATION GENERAL Nonacute distress awake alert and oriented x3 VITAL SIGNS Blood pressure 102 64 heart rate of 89 respiratory rate of 12 temperature 96 8 and O2 saturation 94 on room air HEENT PERRLA EOMI NECK Supple CARDIOVASCULAR Regular rate and rhythm RESPIRATORY Clear to auscultation bilaterally ABDOMEN Bowel sounds are positive soft and nontender EXTREMITIES No edema Pulses present bilaterally LABORATORY DATA CBC WBC count today down 10 9 from 17 3 yesterday 26 9 on admission hemoglobin 10 2 hematocrit 31 3 and platelet count 370 000 BMP BUN of 28 3 from 32 2 creatinine 1 8 from 1 89 from 2 7 Calcium of 8 2 Sodium 139 potassium 3 9 chloride 108 and CO2 of 22 Liver function test is unremarkable Stool positive for Clostridium difficile Blood culture was 131 O2 saturation result is pending ASSESSMENT AND PLAN 1 Most likely secondary to Clostridium difficile colitis and urinary tract infection improving The patient hemodynamically stable leukocytosis improved and today he is afebrile 2 Acute renal failure secondary to dehydration BUN and creatinine improving 3 Clostridium difficile colitis Continue Flagyl evaluation Dr X in a m 4 Urinary tract infection continue Levaquin for last during culture 5 Leucocytosis improving 6 Minimal elevated cardiac enzyme on admission Followup with Cardiology recommendations 7 Possible pneumonia continue vancomycin and Levaquin 8 The patient may be transferred to telemetry Keywords gastroenterology decreased appetite acute renal failure urinary tract infection leucocytosis clostridium difficile colitis MEDICAL_TRANSCRIPTION,Description Colonoscopy due to rectal bleeding constipation abnormal CT scan rule out inflammatory bowel disease Medical Specialty Gastroenterology Sample Name Colonoscopy 1 Transcription INDICATION Rectal bleeding constipation abnormal CT scan rule out inflammatory bowel disease PREMEDICATION See procedure nurse NCS form PROCEDURE Keywords gastroenterology bleeding ct scan digital rectal exam pentax video rectal cecal strap cecum colonic mucosa colonoscope colonoscopy constipation hemorrhoids ileocecal valve inflammatory bowel disease lateral position bowel disease internal hemorrhoids inflammatory MEDICAL_TRANSCRIPTION,Description Genetic counseling for a strong family history of colon polyps She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps Medical Specialty Gastroenterology Sample Name Colon Polyps Genetic Counseling Transcription REASON FOR CONSULT Genetic counseling HISTORY OF PRESENT ILLNESS The patient is a very pleasant 61 year old female with a strong family history of colon polyps The patient reports her first polyps noted at the age of 50 She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps She does have an identical twice who is the one of the 11 who has never had a history of polyps She also has history of several malignancies in the family Her father died of a brain tumor at the age of 81 There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement Her sister died at the age of 65 breast cancer She has two maternal aunts with history of lung cancer both of whom were smoker Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer There is no other cancer history PAST MEDICAL HISTORY Significant for asthma CURRENT MEDICATIONS Include Serevent two puffs daily and Nasonex two sprays daily ALLERGIES Include penicillin She is also allergic seafood crab and mobster SOCIAL HISTORY The patient is married She was born and raised in South Dakota She moved to Colorado 37 years ago She attended collage at the Colorado University She is certified public account She does not smoke She drinks socially REVIEW OF SYSTEMS The patient denies any dark stool or blood in her stool She has had occasional night sweats and shortness of breath and cough associated with her asthma She also complains of some acid reflux as well as anxiety She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords gastroenterology family history strong family history precancerous polyps brain tumor lung cancer genetic counseling colon polyps polyps MEDICAL_TRANSCRIPTION,Description Iron deficiency anemia Diverticulosis in the sigmoid Medical Specialty Gastroenterology Sample Name Colonoscopy Transcription PREOPERATIVE DIAGNOSIS Iron deficiency anemia POSTOPERATIVE DIAGNOSIS Diverticulosis PROCEDURE Colonoscopy MEDICATIONS MAC PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice Preparation was good although there was some residual material in the cecum that was difficult to clear completely The mucosa was normal throughout the colon No polyps or other lesions were identified and no blood was noted Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation A retroflex view of the anorectal junction showed no hemorrhoids The patient tolerated the procedure well and was sent to the recovery room FINAL DIAGNOSES 1 Diverticulosis in the sigmoid 2 Otherwise normal colonoscopy to the cecum RECOMMENDATIONS 1 Follow up with Dr X as needed 2 Screening colonoscopy in 2 years 3 Additional evaluation for other causes of anemia may be appropriate Keywords gastroenterology olympus colonoscope iron deficiency anemia diverticulosis sigmoid cecum anemia colonoscopy MEDICAL_TRANSCRIPTION,Description Placement of cholecystostomy tube under ultrasound guidance Acute acalculous cholecystitis Medical Specialty Gastroenterology Sample Name Cholecystostomy Tube Placement Transcription PREOPERATIVE DIAGNOSIS Acute acalculous cholecystitis POSTOPERATIVE DIAGNOSIS Acute acalculous cholecystitis PROCEDURE Placement of cholecystostomy tube under ultrasound guidance ANESTHESIA Xylocaine 1 With Epinephrine INDICATIONS Patient is a pleasant 75 year old gentleman who is about one week status post an acute MI who also has acute cholecystitis Because it is not safe to take him to the operating room for general anesthetic I recommended he undergo the above named procedure Procedure purpose risks expected benefits potential complications and alternative forms of therapy were discussed with him and he was agreeable to surgery TECHNIQUE Patient was identified then taken to the Radiology suite where the area of interest was identified using ultrasound and prepped with Betadine solution draped in sterile fashion After infiltration with 1 Xylocaine and after multiple attempts the gallbladder was finally cannulated by Dr Kindred using the Cook 18 French needle The guidewire was then placed and via Seldinger technique a 10 French pigtail catheter was placed within the gallbladder secured using the Cook catheter method and dressings were applied and patient was taken to recovery room in stable condition Keywords gastroenterology under ultrasound guidance cholecystostomy tube acalculous cholecystitis catheter cholecystostomy ultrasound acalculous cholecystitis MEDICAL_TRANSCRIPTION,Description Cholecystitis with choledocholithiasis Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction Medical Specialty Gastroenterology Sample Name Cholecystitis Discharge Summary Transcription REASON FOR ADMISSION Cholecystitis with choledocholithiasis DISCHARGE DIAGNOSES Cholecystitis choledocholithiasis ADDITIONAL DIAGNOSES 1 Status post roux en y gastric bypass converted to an open procedure in 01 07 2 Laparoscopic paraventral hernia in 11 07 3 History of sleep apnea with reversal after 100 pound weight loss 4 Morbid obesity with bmi of 39 4 PRINCIPAL PROCEDURE Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction HOSPITAL COURSE The patient is a 33 year old female admitted with elevated bilirubin and probable common bile duct stone She was admitted through the emergency room with abdominal pain elevated bilirubin and gallstones on ultrasound with a dilated common bile duct She subsequently went for a HIDA scan to rule out cholecystitis Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage She was taken to the operating room that night for laparoscopic cholecystectomy We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone The patient had undergone a Roux en Y gastric bypass but could not receive an ERCP and stone extraction therefore common bile duct exploration was performed and a stone was extracted This necessitated conversion to an open operation She was transferred to the medical surgical unit postoperatively She had a significant amount of incisional pain following morning but no nausea A Jackson Pratt drain which was left in place in two places showed serosanguineous fluid White blood cell count was down to 7500 and bilirubin decreased to 2 1 Next morning she was started on a liquid diet Foley catheter was discontinued There was no evidence of bile leak from the drains She was advanced to a regular diet on postoperative day 3 which was 12 09 07 The following morning she was tolerating regular diet Her bowels had begun to function and she was afebrile with her pain control with oral pain medications Jackson Pratt drain was discontinued from the wound The remaining Jackson Pratt drain was left adjacent to her cystic duct Following morning her laboratory studies were better Her bilirubin was down to normal and white blood cell count was normal with an H H of 9 and 26 3 Jackson Pratt drain was discontinued and she was discharged home Followup was in 3 days for staple removal She was given iron 325 mg p o t i d and Lortab elixir 15 cc p o q 4 h p r n for pain Keywords gastroenterology laparoscopy common bile duct exploration laparoscopic cholecystectomy bile duct choledocholithiasis cholecystectomy cholecystitis laparoscopic hernia MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy with cholangiogram Medical Specialty Gastroenterology Sample Name Cholecystectomy Cholangiogram Transcription PREOPERATIVE DIAGNOSES 1 Cholelithiasis 2 Acute cholecystitis POSTOPERATIVE DIAGNOSES 1 Acute on chronic cholecystitis 2 Cholelithiasis PROCEDURE PERFORMED Laparoscopic cholecystectomy with cholangiogram ANESTHESIA General INDICATIONS This is a 38 year old diabetic Hispanic female patient with ongoing recurrent episodes of right upper quadrant pain associated with nausea Ultrasound revealed cholelithiasis The patient also had somewhat thickened gallbladder wall The patient was admitted through emergency room last night with acute onset right upper quadrant pain Clinically it was felt the patient had acute cholecystitis Laparoscopic cholecystectomy with cholangiogram was advised Procedure indication risk and alternative were discussed with the patient in detail preoperatively and informed consent was obtained DESCRIPTION OF PROCEDURE The patient was put in supine position on the operating table under satisfactory general anesthesia and abdomen was prepped and draped A small transverse incision was made just above the umbilicus under local anesthesia Fascia was opened vertically Stay sutures were placed in the fascia Peritoneal cavity was carefully entered Hasson cannula was inserted and peritoneal cavity was insufflated with CO2 Laparoscopic camera was inserted and the patient was placed in reverse Trendelenburg rotated to the left A 11 mm trocar was placed in the subxiphoid space and two 5 mm in the right subcostal region Examination at this time showed no free fluid no acute inflammatory changes Liver was grossly normal Gallbladder was noted to be thickened Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema consistent with acute cholecystitis The fundus of the gallbladder was retracted superiorly and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated It was clipped distally and using C arm fluoroscopy intraoperative cystic duct cholangiogram was done which was interpreted as normal There was slight dilatation noted at the junction of the right and left hepatic duct but no filling defects or any other pathology was noted It was presumed that this was probably a congenital anomaly The cystic duct was clipped twice proximally and divided beyond the clips Cystic artery was identified isolated clipped twice proximally once distally and divided The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port Specimen was sent for histopathology Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution Hemostasis was good Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2 Umbilical area fascia was closed with 0 Vicryl figure of eight sutures required extra sutures to close the fascial defect Some difficulty was encountered closing the fascia initially because of the patient s significant amount of subcutaneous fat In the end the repair appears to be quite satisfactory Rest of the incisions closed with 3 0 Vicryl for the subcutaneous tissues and staples for the skin Sterile dressing was applied The patient transferred to recovery room in stable condition Keywords gastroenterology cholelithiasis acute cholecystitis laparoscopic cholecystectomy cholangiogram laparoscopic cholecystectomy gallbladder MEDICAL_TRANSCRIPTION,Description Laparoscopic resection of cecal polyp Local anesthetic was infiltrated into the right upper quadrant where a small incision was made Blunt dissection was carried down to the fascia which was grasped with Kocher clamps Medical Specialty Gastroenterology Sample Name Cecal Polyp Resection Transcription PREOPERATIVE DIAGNOSIS Cecal polyp POSTOPERATIVE DIAGNOSIS Cecal polyp PROCEDURE Laparoscopic resection of cecal polyp COMPLICATIONS None ANESTHESIA General oral endotracheal intubation PROCEDURE After adequate general anesthesia was administered the patient s abdomen was prepped and draped aseptically Local anesthetic was infiltrated into the right upper quadrant where a small incision was made Blunt dissection was carried down to the fascia which was grasped with Kocher clamps A bladed 11 mm port was inserted without difficulty Pneumoperitoneum was obtained using C02 Under direct vision 2 additional non bladed 11 mm trocars were placed one in the left lower quadrant and one in the right lower quadrant There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice The appendix was somewhat retrocecal in position but otherwise looked normal The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye There was enough however in the wall to identify the location of the polyp The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely The specimen was then removed through the 12 mm port and examined on the back table The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon This new staple line was then opened on the back table and examined There was some residual polypoid material noted but the margins this time appeared to be clear The peritoneal cavity was then lavaged with antibiotic solution There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery The trocars were removed under direct vision No bleeding was noted The bladed trocar site was closed using a figure of eight O Vicryl suture All skin incisions were closed with running 4 0 Monocryl subcuticular sutures Mastisol and Steri Strips were placed followed by sterile Tegaderm dressing The patient tolerated the procedure well without any complications Keywords gastroenterology polyp laparoscopic resection blunt dissection kocher clamps ileocecal valve gia stapler peritoneal cavity cecal polyp infiltrated anesthetic MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Gallstone pancreatitis Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially Medical Specialty Gastroenterology Sample Name Cholecystectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Gallstone pancreatitis POSTOPERATIVE DIAGNOSIS Gallstone pancreatitis PROCEDURE PERFORMED Laparoscopic cholecystectomy ANESTHESIA General endotracheal and local injectable Marcaine ESTIMATED BLOOD LOSS Minimal SPECIMEN Gallbladder COMPLICATIONS None OPERATIVE FINDINGS Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially These dense adhesions were associated with chronic inflammatory edematous changes The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified clipped with two clips proximally and one distally The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver There was no evidence of adhesions from the abdominal wall to the liver The remainder of the abdomen was unremarkable BRIEF HISTORY This is a 17 year old African American female who presented to ABCD General Hospital on 08 20 2003 with complaints of intractable right upper quadrant abdominal pain She had been asked to follow up and scheduled for surgery previously Her pain had now been intractable associated with anorexia She was noted on physical examination to be afebrile however she was having severe right upper quadrant pain with examination as well as a Murphy s sign and voluntary guarding with examination Her transaminases were markedly elevated She also developed pancreatitis secondary to gallstones Her common bile duct was dilated to 1 cm with no evidence of wall thickening but evidence of cholelithiasis She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis Following this she was scheduled for operative laparoscopic cholecystectomy Her parents were explained the risks benefits and complications of the procedure She gave us informed consent to proceed with surgery OPERATIVE PROCEDURE The patient brought to the operative suite and placed in the supine position Preoperatively the patient received IV antibiotics of Ancef sequential compression devices and subcutaneous heparin The abdomen was prepped and draped in the normal sterile fashion with Betadine solution Utilizing a 15 blade scalpel a transverse infraumbilical incision was created Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp the Veress needle was inserted without difficulty Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty The abdomen was then insufflated to 15 mmHg with carbon dioxide Once the abdomen was sufficiently insufflated a 10 mm bladed trocar was inserted into the abdomen without difficulty Video laparoscope was inserted and the above notable findings were identified in the operative findings The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed A 15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament Next two 5 mm trocars were inserted under direct visualization one in the midclavicular and one in the anterior midaxillary line These were inserted without difficulty The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder Utilizing Endoshears scissor a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions Next the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place Next the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor Once the clips were noted to be in place utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery The abdomen was then irrigated with copious amounts of normal saline The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port There was noted to be gallstones within the gallbladder Once the abdomen was re insufflated after removing the gallbladder and copious irrigation was performed all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall Utilizing 0 Vicryl suture a figure of eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia A 4 0 Vicryl suture was used to approximate all incisions The incisions were then injected with local injectable 0 25 Marcaine All ports were then cleaned dry Steri Strips were placed across and sterile pressure dressings were placed on top of this The patient tolerated the entire procedure well She was transferred to the Postanesthesia Care Unit in stable condition She will be followed closely in the postoperative course in General Medical Floor Keywords gastroenterology gallstone gallbladder pancreatitis anterior abdominal wall video laparoscope laparoscopic cholecystectomy omental adhesions veress needle cystic duct injectable adhesions cholecystectomy laparoscopic abdomen MEDICAL_TRANSCRIPTION,Description Newly diagnosed cholangiocarcinoma The patient is noted to have an increase in her liver function tests on routine blood work Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Medical Specialty Gastroenterology Sample Name Cholangiocarcinoma Consult Transcription REASON FOR CONSULTATION Newly diagnosed cholangiocarcinoma HISTORY OF PRESENT ILLNESS The patient is a very pleasant 77 year old female who is noted to have an increase in her liver function tests on routine blood work in December 2009 Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Common bile duct was noted to be 10 mm in size on that ultrasound She then underwent a CT scan of the abdomen in July 2010 which showed intrahepatic ductal dilatation with the common bile duct size being 12 7 mm She then underwent an MRI MRCP which was notable for stricture of the distal common bile duct She was then referred to gastroenterology and underwent an ERCP On August 24 2010 she underwent the endoscopic retrograde cholangiopancreatography She was noted to have a stricturing mass of the mid to proximal common bile duct consistent with cholangiocarcinoma A temporary biliary stent was placed across the biliary stricture Blood work was obtained during the hospitalization She was also noted to have an elevated CA99 She comes in to clinic today for initial Medical Oncology consultation After she sees me this morning she has a follow up consultation with a surgeon PAST MEDICAL HISTORY Significant for hypertension and hyperlipidemia In July she had eye surgery on her left eye for a muscle repair Other surgeries include left ankle surgery for a fractured ankle in 2000 CURRENT MEDICATIONS Diovan 80 12 5 mg daily Lipitor 10 mg daily Lutein 20 mg daily folic acid 0 8 mg daily and multivitamin daily ALLERGIES No known drug allergies FAMILY HISTORY Notable for heart disease She had three brothers that died of complications from open heart surgery Her parents and brothers all had hypertension Her younger brother died at the age of 18 of infection from a butcher s shop He was cutting Argentinean beef and contracted an infection and died within 24 hours She has one brother that is living who has angina and a sister who is 84 with dementia She has two adult sons who are in good health SOCIAL HISTORY The patient has been married to her second husband for the past ten years Her first husband died in 1995 She does not have a smoking history and does not drink alcohol REVIEW OF SYSTEMS The patient reports a change in her bowels ever since she had the stent placed She has noted some weight loss but she notes that that is due to not eating very well She has had some mild fatigue but prior to her diagnosis she had absolutely no symptoms As mentioned above she was noted to have abnormal alkaline phosphatase and total bilirubin AST and ALT which prompted the followup She has had some difficulty with her vision that has improved with her recent surgical procedure She denies any fevers chills night sweats She has had loose stools The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords MEDICAL_TRANSCRIPTION,Description Open cholecystectomy attempted laparoscopic cholecystectomy Medical Specialty Gastroenterology Sample Name Cholecystectomy Open Transcription PREOPERATIVE DIAGNOSIS ES 1 Cholelithiasis 2 Cholecystitis POSTOPERATIVE DIAGNOSIS ES 1 Acute perforated gangrenous cholecystitis 2 Cholelithiasis PROCEDURE 1 Attempted laparoscopic cholecystectomy 2 Open cholecystectomy ANESTHESIA General endotracheal anesthesia COUNTS Correct COMPLICATIONS None apparent ESTIMATED BLOOD LOSS 275 mL SPECIMENS 1 Gallbladder 2 Lymph node DRAINS One 19 French round Blake DESCRIPTION OF THE OPERATION After consent was obtained and the patient was properly identified the patient was transported to the operating room and after induction of general endotracheal anesthesia the patient was prepped and draped in a normal sterile fashion After infiltration with local a vertical incision was made at the umbilicus and utilizing graspers the underlying fascia was incised and was divided sharply Dissecting further the peritoneal cavity was entered Once this done a Hasson trocar was secured with 1 Vicryl and the abdomen was insufflated without difficulty A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space A second trocar was placed in the standard fashion in the subxiphoid area this was a 10 12 mm non bladed trocar Once this was done a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin this was a 5 mm port placed it was non bladed and placed in the usual fashion under direct visualization without difficulty A grasper was used to mobilize free the omentum which was acutely friable and after a significant time consuming effort was made to mobilize the omentum it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open The trocars were removed and a right subcostal incision was made incorporating the 10 12 subxiphoid port The subcutaneous space was divided with electrocautery as well as the muscles and fascia The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space Then utilizing a right angle and electrocautery the omentum was freed from the gallbladder An ensuing retrograde cholecystectomy was performed in which electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa this was done down to the infundibulum After meticulous dissection the cystic artery was identified and it was ligated between 3 0 silks Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified was skeletonized and a 3 0 stick tie was placed on the proximal portion of it After it was divided the gallbladder was freed from the field Once this was done the liver bed was inspected for hemostasis and this was achieved with electrocautery Copious irrigation was also used A 19 French Blake drain was placed in Morrison s pouch lateral to the gallbladder fossa and was secured in place with 2 0 nylon this was a 19 French round Blake Once this was done the umbilical port was closed with 1 Vicryl in an interrupted fashion and then the wound was closed in two layers with 1 Vicryl in an interrupted fashion The skin was closed with and absorbable stitch The patient was then awakened from anesthesia extubated and transported to the recovery room in stable condition Keywords gastroenterology cholelithiasis cholecystitis gangrenous cholecystectomy laparoscopic gallbladder blake omentum hasson electrocautery gallbladder fossa endotracheal subhepatic french MEDICAL_TRANSCRIPTION,Description Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety The patient complained of globus sensation high in her throat particularly with solid foods and with pills She denied history of coughing and chocking with meals Medical Specialty Gastroenterology Sample Name Barium Swallow Study Evaluation Transcription HISTORY The patient is a 71 year old female who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety The patient complained of globus sensation high in her throat particularly with solid foods and with pills She denied history of coughing and chocking with meals The patient s complete medical history is unknown to me at this time The patient was cooperative and compliant throughout this evaluation STUDY Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr X The patient was seated upright at a 90 degree angle in a video imaging chair To evaluate her swallowing function and safety she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids teaspoon x3 cup sip x4 thickened liquid cup sip x3 puree consistency teaspoon x3 and solid consistency 1 4 cracker x1 The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation ORAL STAGE The patient had no difficulty with bolus control and transport No spillage out lips The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation We were not able to clear out the residual with alternating cup sips and thin liquid PHARYNGEAL STAGE No aspiration or penetration occurred during this evaluation The patient s hyolaryngeal elevation and anterior movements are within the functional limits Epiglottic inversion is within functional limits She had no residual or pooling in the pharynx after the swallow CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus DIAGNOSTIC IMPRESSION The patient had no aspiration or penetration occurred during this evaluation She does appear to have a diverticulum in the area between her right faucial pillars Additional evaluation is needed by an ENT physician PLAN Based on this evaluation the following is recommended 1 The patient s diet should consist regular consistency food with thin liquids She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux 2 The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately Thank you for the opportunity to be required the patient s medical care She is not in need of skilled speech therapy and is discharged from my services Keywords gastroenterology globus sensation oral stage pharyngeal stage cervical esophageal stage consistency otolaryngologist barium swallow study evaluation faucial pillars swallow study solid foods evaluation liquid barium oral swallow foods MEDICAL_TRANSCRIPTION,Description The patient is a 76 year old male with previous history of dysphagia status post stroke A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration Medical Specialty Gastroenterology Sample Name Barium Swallow Study Evaluation 1 Transcription HISTORY The patient is a 76 year old male with previous history of dysphagia status post stroke The patient stated that he was at Hospital secondary to his stroke where he had his initial modified barium swallow study The patient stated that the results of that modified revealed aspiration with thin liquids only He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration STUDY Modified barium swallow study was performed in the radiology suite in cooperation with Dr X The patient was seated upright and in a video imaging chair throughout this assessment To evaluate the patient s swallowing function and safety he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids teaspoon x3 cup sip x3 nectar thick liquid teaspoon x2 cup sip x3 pureed consistency teaspoon x3 solid consistency 1 4 cracker x1 FINDINGS ORAL STAGE The patient had no spillage out lips Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity The patient has reduced lingual retraction contributing to vallecula pooling after the swallow Trace premature spillage was noted with thin liquids during this assessment PHARYNGEAL STAGE Aspiration noted on cup sips of thin liquid Trace to mild penetration with teaspoon amounts of thin liquid during and after the swallow The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule The patient has incomplete laryngeal closure which allowed the aspiration and penetration with thin liquids The patient had no aspiration or penetration occur with nectar thick liquid puree and solid food The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling Mild to moderate pooling in the vallecula after the swallow with liquids and puree this residual did decrease with the solid feed presentation The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus DIAGNOSTIC IMPRESSION Mild aspiration with cup sips of thin liquid penetration during and after the swallow with teaspoon amounts of thin liquid No aspiration or penetration occurred with thick liquid pureed or solid food during this assessment PROGNOSTIC IMPRESSION With a modified diet the patient s potential for swallowing safety is good PLAN Based on this evaluation the following is recommended 1 The patient should be on a regular diet with nectar thick liquids to help prevent aspiration and penetration 2 The patient should have unthickened water in between meals to help decrease his risk of dehydration 3 The patient should complete good oral care two times a day to decrease bacterial growth in mouth 4 The patient should be seated at a 90 degree angle when eating and drinking as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux Thank you for the opportunity to evaluate the patient I look forward to working with him in the outpatient setting to improve his swallowing function and safety Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re education as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety Keywords gastroenterology oral stage pharyngeal stage cervical esophageal stage nectar thick liquids aspiration modified barium swallow barium swallow study dysphagia status cup sips barium swallow swallow teaspoon barium swallowing MEDICAL_TRANSCRIPTION,Description Barium enema history of encopresis and constipation Medical Specialty Gastroenterology Sample Name Barium Enema Transcription EXAM Barium enema CLINICAL HISTORY A 4 year old male with a history of encopresis and constipation TECHNIQUE A single frontal scout radiograph of the abdomen was performed A rectal tube was inserted in usual sterile fashion and retrograde instillation of barium contrast was followed via spot fluoroscopic images A post evacuation overhead radiograph of the abdomen was performed FINDINGS The scout radiograph demonstrates a nonobstructive gastrointestinal pattern There are no suspicious calcifications seen or evidence of gross free intraperitoneal air The visualized lung bases and osseous structures are within normal limits The rectum and colon is of normal caliber throughout its course There is no evidence of obstruction as contrast is seen to flow without difficulty into the right colon and cecum A small amount of contrast is seen to opacify small bowel loops on the post evacuation image There is also opacification of a normal appearing appendix documented IMPRESSION Normal barium enema Keywords gastroenterology encopresis and constipation scout radiograph post evacuation barium enema encopresis constipation evacuation colon radiograph contrast enema barium MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy and peritoneal toilet and photos Pelvic inflammatory disease and periappendicitis Medical Specialty Gastroenterology Sample Name Appendectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSES 1 Pelvic inflammatory disease 2 Periappendicitis PROCEDURE PERFORMED 1 Laparoscopic appendectomy 2 Peritoneal toilet and photos ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 10 cc INDICATIONS FOR PROCEDURE The patient is a 31 year old African American female who presented with right lower quadrant abdominal pain presented with acute appendicitis She also had mild leukocytosis with bright blood cell count of 12 000 The necessity for diagnostic laparoscopy was explained and possible appendectomy The patient is agreeable to proceed and signed preoperatively informed consent PROCEDURE The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department The preoperative Foley antibiotics and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a 10 blade scalpel with anterior and superior traction on the abdominal wall A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation At this point the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view With the aid of a laparoscope the pelvis was visualized The ovaries are brought in views and photos are taken There is evidence of a purulence in the cul de sac and ________ with a right ovarian hemorrhagic cyst Attention was then turned on the right lower quadrant The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears Attention was turned to the suprapubic area The 12 mm port was introduced under direct visualization and the mesoappendix was identified A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line Next ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline Next attention was turned to the right upper quadrant There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz Hugh Curtis syndrome also a prior pelvic inflammatory disease All free fluid is aspirated and patient s all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology Once the ports are removed the pneumoperitoneum is allowed to escape for patient s postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with 0 Vicryl suture on a UR 6 needle Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and 4 0 Vicryl subcuticular closure is performed with undyed Vicryl Steri Strips are applied along with sterile dressings The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad spectrum IV antibiotics in the General Medical Floor Routine postoperative care will be continued on this patient Keywords gastroenterology acute appendicitis periappendicitis peritoneal toilet pelvic inflammatory disease abdominal wall direct visualization toilet appendectomy mesoappendix laparoscopic port inflammatory MEDICAL_TRANSCRIPTION,Description Hematemesis in a patient with longstanding diabetes Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis Mallory Weiss tear successful BICAP cautery Medical Specialty Gastroenterology Sample Name BICAP Cautery Transcription PREOPERATIVE DIAGNOSIS Hematemesis in a patient with longstanding diabetes POSTOPERATIVE DIAGNOSIS Mallory Weiss tear submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis PROCEDURE The procedure indications explained and he understood and agreed He was sedated with Versed 3 Demerol 25 and topical Hurricane spray to the oropharynx A bite block was placed The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision Esophagus revealed distal ulcerations Additionally the patient had a Mallory Weiss tear This was subjected to bicap cautery with good ablation The stomach was entered which revealed areas of submucosal hemorrhage consistent with trauma from vomiting There were no ulcerations or erosions in the stomach The duodenum was entered which was unremarkable The instrument was then removed The patient tolerated the procedure well with no complications IMPRESSION Mallory Weiss tear successful BICAP cautery We will keep the patient on proton pump inhibitors The patient will remain on antiemetics and be started on a clear liquid diet Keywords gastroenterology mallory weiss tear submucosal hemorrhage esophagitis vomiting bicap cautery mallory weiss diabetes esophagus submucosal hemorrhage trauma hematemesis MEDICAL_TRANSCRIPTION,Description Appendicitis nonperforated Appendectomy A transverse right lower quadrant incision was made directly over the point of maximal tenderness Medical Specialty Gastroenterology Sample Name Appendectomy Transcription PREOPERATIVE DIAGNOSIS Appendicitis POSTOPERATIVE DIAGNOSIS Appendicitis nonperforated PROCEDURE PERFORMED Appendectomy ANESTHESIA General endotracheal PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine on the operating table General endotracheal anesthesia was induced without incident The patient was prepped and draped in the usual sterile manner A transverse right lower quadrant incision was made directly over the point of maximal tenderness Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia The fascia of the external oblique was incised in the direction of the fibers and the muscle was spread with a clamp The internal oblique fascia was similarly incised and its muscular fibers were similarly spread The transversus abdominis muscle transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident Upon entering the peritoneal cavity the peritoneal fluid was noted to be clean The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound After the appendix was fully visualized the mesentery was divided between Kelly clamps and ligated with 2 0 Vicryl ties The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix The base was ligated with 2 0 Vicryl tie over the crushed area and the appendix amputated along the clamp The stump of the appendix was cauterized and the cecum was returned to the abdomen The peritoneum was irrigated with warm sterile saline The mesoappendix and cecum were examined for hemostasis which was present The wound was closed in layers using 2 0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers The skin incision was approximated with 4 0 Monocryl in a subcuticular fashion The skin was prepped with benzoin and Steri Strips were applied A dressing was placed on the wound All surgical counts were reported as correct Having tolerated the procedure well the patient was subsequently extubated and taken to the recovery room in good and stable condition Keywords gastroenterology peritoneal cavity peritoneal fluid abdominal cavity abdominis muscle transversalis fascia peritoneum internal oblique fascia vicryl ties appendectomy appendicitis appendix MEDICAL_TRANSCRIPTION,Description Acute appendicitis gangrenous Appendectomy Medical Specialty Gastroenterology Sample Name Appendectomy 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis gangrenous PROCEDURE Appendectomy DESCRIPTION OF PROCEDURE The patient was taken to the operating room under urgent conditions After having obtained an informed consent he was placed in the operating room and under anesthesia Followed by a time out process his abdominal wall was prepped and draped in the usual fashion Antibiotics had been given prior to incision A McBurney incision was performed and it carried out through the peritoneal cavity Immediately there was purulent material seen in the area Samples were taken for culture and sensitivity of aerobic and anaerobic sets The appendix was markedly swollen particularly in its distal three fourth where the distal appendix showed an abscess formation and devitalization of the wall There was quite a bit of local peritonitis The mesoappendix was clamped divided and ligated and then the appendix was ligated and divided and the stump buried with a pursestring suture of Vicryl and then a Z stitch The area was abundantly irrigated with normal saline and also the pelvis The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond The patient tolerated the procedure well Estimated blood loss was minimal and the patient was sent to the recovery room for recovery in satisfactory condition Keywords gastroenterology mcburney incision abdominal small bowel acute appendicitis appendectomy gangrenous appendix MEDICAL_TRANSCRIPTION,Description Medical Specialty Gastroenterology Sample Name Barium Swallow Study Speech Evaluation 1 Transcription SUBJECTIVE The patient is a 60 year old female who complained of coughing during meals Her outpatient evaluation revealed a mild to moderate cognitive linguistic deficit which was completed approximately 2 months ago The patient had a history of hypertension and TIA stroke The patient denied history of heartburn and or gastroesophageal reflux disorder A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration OBJECTIVE Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr ABC The patient was seated upright in a video imaging chair throughout this assessment To evaluate the patient s swallowing function and safety she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid teaspoon x2 cup sip x2 nectar thick liquid teaspoon x2 cup sip x2 puree consistency teaspoon x2 and solid food consistency 1 4 cracker x1 ASSESSMENT ORAL STAGE Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid Decreased tongue base retraction which contributed to vallecular pooling after the swallow PHARYNGEAL STAGE No aspiration was observed during this evaluation Penetration was noted with cup sips of thin liquid only Trace residual on the valleculae and on tongue base with nectar thick puree and solid consistencies The patient s hyolaryngeal elevation and anterior movement are within functional limits Epiglottic inversion is within functional limits CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus which may be contributing to the patient s complaint of globus sensation DIAGNOSTIC IMPRESSION No aspiration was noted during this evaluation Penetration with cup sips of thin liquid The patient did cough during this evaluation but that was noted related to aspiration or penetration PROGNOSTIC IMPRESSION Based on this evaluation the prognosis for swallowing and safety is good PLAN Based on this evaluation and following recommendations are being made 1 The patient to take small bite and small sips to help decrease the risk of aspiration and penetration 2 The patient should remain upright at a 90 degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation 3 The patient should be referred to a gastroenterologist for further evaluation of her esophageal function The patient does not need any skilled speech therapy for her swallowing abilities at this time and she is discharged from my services Keywords gastroenterology gastroesophageal reflux disorder cognitive linguistic deficit tia stroke swallowing function swallow study barium swallow study globus sensation esophageal penetration MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute suppurative appendicitis A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis There was no evidence of colitis on the CAT scan Medical Specialty Gastroenterology Sample Name Appendectomy Laparoscopic 1 Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute suppurative appendicitis PROCEDURE PERFORMED Laparoscopic appendectomy ANESTHESIA General endotracheal and Marcaine 0 25 local INDICATIONS This 29 year old female presents to ABCD General Hospital Emergency Department on 08 30 2003 with history of acute abdominal pain On evaluation it was noted that the patient has clinical findings consistent with acute appendicitis However the patient with additional history of loose stools for several days prior to event Therefore a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis There was no evidence of colitis on the CAT scan With this in mind and the patient s continued pain at present the patient was explained the risks and benefits of appendectomy She agreed to procedure and informed consent was obtained GROSS FINDINGS The appendix was removed without difficulty with laparoscopic approach The appendix itself noted to have a significant inflammation about it There was no evidence of perforation of the appendix PROCEDURE DETAILS The patient was placed in supine position After appropriate anesthesia was obtained and sterile prep and drape completed a 10 blade scalpel was used to make a curvilinear infraumbilical incision Through this incision a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg The Veress needle was then removed A 10 mm trocar was then introduced through this incision into the abdomen A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation Initially bilateral ovarian cysts were appreciated however there was no evidence of acute disease on evaluation Photodocumentation was obtained A 5 mm port was then placed in the right upper quadrant This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix Next a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization Through this port the dissector was utilized to create a small window in the mesoappendix Next an EndoGIA with GI staples was utilized to fire across the base of the appendix which was done noting it to be at the base of the appendix Next staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples Two 6 X loupe wires with EndoGIA were utilized in this prior portion of the procedure Next an EndoCatch was placed through the 12 mm port and the appendix was placed within it The appendix was then removed from the 12 mm port site and taken off the surgical site The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated The base of the appendix was reevaluated and noted to be hemostatic Aspiration of warm saline irrigant then done and noted to be clear There was a small adhesion appreciated in the region of the surgical site This was taken down with blunt dissection without difficulty There was no evidence of other areas of disease Upon re exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact The instruments were removed from the patient and the port sites were then taken off under direct visualization The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with 0 Vicryl ligature x2 Marcaine 0 25 was then utilized in all three incision sites and 4 0 Vicryl suture was used to approximate the skin and all three incision sites Steri Strips and sterile dressings were applied The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics pain medications and return to diet Keywords gastroenterology abdomen pelvis laparoscopic appendectomy suppurative appendicitis veress needle acute appendicitis appendix appendectomy pneumoperitoneum laparoscopic appendicitis MEDICAL_TRANSCRIPTION,Description Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair Patient with a 5 5 cm diameter nonfunctioning mass in his right adrenal Medical Specialty Gastroenterology Sample Name Adrenalectomy Umbilical Hernia Repair Transcription PREOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia POSTOPERATIVE DIAGNOSES 1 Adrenal mass right sided 2 Umbilical hernia OPERATION PERFORMED Laparoscopic hand assisted left adrenalectomy and umbilical hernia repair ANESTHESIA General CLINICAL NOTE This is a 52 year old inmate with a 5 5 cm diameter nonfunctioning mass in his right adrenal Procedure was explained including risks of infection bleeding possibility of transfusion possibility of further treatments being required Alternative of fully laparoscopic are open surgery or watching the lesion DESCRIPTION OF OPERATION In the right flank up position table was flexed He had a Foley catheter in place Incision was made from just above the umbilicus about 5 5 cm in diameter The umbilical hernia was taken down An 11 mm trocar was placed in the midline superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin A liver retractor was placed to this The colon was reflected medially by incising the white line of Toldt The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly The vena cava was identified The main renal vein was identified Coming superior to the main renal vein staying right on the vena cava all small vessels were clipped and then divided Coming along the superior pole of the kidney the tumor was dissected free from top of the kidney with clips and Bovie The harmonic scalpel was utilized superiorly and laterally Posterior attachments were divided between clips and once the whole adrenal was mobilized the adrenal vein and one large adrenal artery were noted doubly clipped and divided Specimen was placed in a collection bag removed intact Hemostasis was excellent The umbilical hernia had been completely taken down The edges were freshened up Vicryl 1 was utilized to close the incision and 2 0 Vicryl was used to close the fascia of the trocar Skin closed with clips He tolerated the procedure well All sponge and instrument counts were correct Estimated blood loss less than 100 mL The patient was awakened extubated and returned to recovery room in satisfactory condition Keywords gastroenterology adrenalectomy laparoscopic hand assisted umbilical hernia repair vena cava renal vein hernia repair laparoscopic umbilical hernia MEDICAL_TRANSCRIPTION,Description Excision of abscess removal of foreign body Repair of incisional hernia Recurrent re infected sebaceous cyst of abdomen Abscess secondary to retained foreign body and incisional hernia Medical Specialty Gastroenterology Sample Name Abscess Excision Transcription PREOPERATIVE DIAGNOSIS Recurrent re infected sebaceous cyst of abdomen POSTOPERATIVE DIAGNOSES 1 Abscess secondary to retained foreign body 2 Incisional hernia PROCEDURES 1 Excision of abscess removal of foreign body 2 Repair of incisional hernia ANESTHESIA LMA INDICATIONS Patient is a pleasant 37 year old gentleman who has had multiple procedures including a laparotomy related to trauma The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision which he says gets larger and then it drains internally causing him to be quite ill He presented to my office and I recommended that he undergo exploration of this area and removal The procedure purpose risks expected benefits potential complications and alternative forms of therapy were discussed with him and he was agreeable to surgery FINDINGS The patient was found upon excision of the cyst that it contained a large Prolene suture which is multiply knotted as it always is beneath this was a very small incisional hernia the hernia cavity which contained omentum the hernia was easily repaired DESCRIPTION OF PROCEDURE The patient was identified then taken into the operating room where after induction of an LMA anesthetic his abdomen was prepped with Betadine solution and draped in sterile fashion The puncta of the wound lesion was infiltrated with methylene blue and peroxide The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors the cyst was excised down to its base In doing so we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia The cyst was removed in its entirety divided from the omentum using a Metzenbaum and tying with 2 0 silk ties The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures The wound was then irrigated and closed with 3 0 Vicryl subcutaneous and 4 0 Vicryl subcuticular and Steri Strips Patient tolerated the procedure well Dressings were applied and he was taken to recovery room in stable condition Keywords gastroenterology sebaceous cyst prolene suture incisional hernia incisional abscess hernia abdomen omentum excision cyst MEDICAL_TRANSCRIPTION,Description Patient status post gastric bypass surgery developed nausea and right upper quadrant pain Medical Specialty Gastroenterology Sample Name Admission History Physical Nausea Transcription CHIEF COMPLAINT Nausea PRESENT ILLNESS The patient is a 28 year old who is status post gastric bypass surgery nearly one year ago He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7 00 8 00 when he developed nausea and right upper quadrant pain which apparently wrapped around toward his right side and back He feels like he was on it but has not done so He has overall malaise and a low grade temperature of 100 3 He denies any prior similar or lesser symptoms His last normal bowel movement was yesterday He denies any outright chills or blood per rectum PAST MEDICAL HISTORY Significant for hypertension and morbid obesity now resolved PAST SURGICAL HISTORY Gastric bypass surgery in December 2007 MEDICATIONS Multivitamins and calcium ALLERGIES None known FAMILY HISTORY Positive for diabetes mellitus in his father who is now deceased SOCIAL HISTORY He denies tobacco or alcohol He has what sounds like a data entry computer job REVIEW OF SYSTEMS Otherwise negative PHYSICAL EXAMINATION His temperature is 100 3 blood pressure 129 59 respirations 16 heart rate 84 He is drowsy but easily arousable and appropriate with conversation He is oriented to person place and situation He is normocephalic atraumatic His sclerae are anicteric His mucous membranes are somewhat tacky His neck is supple and symmetric His respirations are unlabored and clear He has a regular rate and rhythm His abdomen is soft He has diffuse right upper quadrant tenderness worse focally but no rebound or guarding He otherwise has no organomegaly masses or abdominal hernias evident His extremities are symmetrical with no edema His posterior tibial pulses are palpable and symmetric He is grossly nonfocal neurologically STUDIES His white blood cell count is 8 4 with 79 segs His hematocrit is 41 His electrolytes are normal His bilirubin is 2 8 His AST 349 ALT 186 alk phos 138 and lipase is normal at 239 ASSESSMENT Choledocholithiasis cholecystitis PLAN He will be admitted and placed on IV antibiotics We will get an ultrasound this morning He will need his gallbladder out probably with intraoperative cholangiogram Hopefully the stone will pass this way Due to his anatomy an ERCP would prove quite difficult if not impossible unless laparoscopic assisted Dr X will see him later this morning and discuss the plan further The patient understands Keywords gastroenterology gastric bypass surgery nausea choledocholithiasis cholecystitis ercp gastric bypass bypass surgery MEDICAL_TRANSCRIPTION,Description Laparoscopic appendectomy Acute appendicitis Medical Specialty Gastroenterology Sample Name Appendectomy Laparoscopic Transcription PREOPERATIVE DIAGNOSIS Acute appendicitis POSTOPERATIVE DIAGNOSIS Acute appendicitis PROCEDURE Laparoscopic appendectomy ANESTHESIA General endotracheal INDICATIONS Patient is a pleasant 31 year old gentleman who presented to the hospital with acute onset of right lower quadrant pain History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan I evaluated the patient in the emergency room and recommended that he undergo the above named procedure The procedure purpose risks expected benefits potential complications alternative forms of therapy were discussed with him and he was agreeable with surgery FINDINGS Patient was found to have acute appendicitis with an inflamed appendix which was edematous but essentially no suppuration TECHNIQUE The patient was identified and then taken into the operating room where after induction of general endotracheal anesthesia the abdomen was prepped with Betadine solution and draped in sterile fashion An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia which was grasped with an Allis clamp and two stay sutures of 2 0 Vicryl were placed on either side of the midline The fascia was tented and incised and the peritoneum entered by blunt finger dissection A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained Patient was placed in the Trendelenburg position rotated to his left whereupon under direct vision the 12 mm midline as well as 5 mm midclavicular and anterior axillary ports were placed The appendix was easily visualized grasped with a Babcock s A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum The mesoappendix was divided using the Endo GIA with vascular staples The appendix was placed within an Endo bag and delivered from the abdominal cavity The intra abdominal cavity was irrigated Hemostasis was assured within the mesentery and at the base of the cecum All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution The infraumbilical defect was closed with a figure of eight 0 Vicryl suture The remaining wounds were irrigated and then everything was closed subcuticular with 4 0 Vicryl suture and Steri Strips Patient tolerated the procedure well dressings were applied and he was taken to recovery room in stable condition Keywords gastroenterology endo gia babcock s laparoscopic appendectomy direct vision abdominal cavity acute appendicitis appendectomy hemostasis laparoscopic infraumbilical appendix appendicitis endotracheal MEDICAL_TRANSCRIPTION,Description The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness Symptoms are not accompanied by tinnitus or deafness Medical Specialty ENT Otolaryngology Sample Name Vertigo Consult 1 Transcription Patient had a normal MRI and normal neurological examination on August 24 2010 Assessment for peripheral vestibular function follows Most clinical tests were completed with difficulty and poor cooperation OTOSCOPY showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne ROMBERG TEST maintained postural stability with difficulty Frenzel glasses examination no spontaneous end gaze nystagmus DIX HALLPIKE showed no positional nystagmus excluding benign paroxysmal positional vertigo HEAD SHAKING AND VESTIBULOCULAR REFLEX HALMAGYI TEST were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction IMPRESSION Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing PLAN Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises in addition to supportive medical treatment in the form of betahistine 24 mg twice a day Keywords ent otolaryngology tinnitus deafness imbalance nystagmus hypofunction electronystagmography vertigo vestibular MEDICAL_TRANSCRIPTION,Description Incision and drainage I D of abdominal abscess excisional debridement of nonviable and viable skin subcutaneous tissue and muscle then removal of foreign body Medical Specialty Gastroenterology Sample Name Abdominal Abscess I D Transcription PREOPERATIVE DIAGNOSIS Abdominal wall abscess POSTOPERATIVE DIAGNOSIS Abdominal wall abscess PROCEDURE Incision and drainage I D of abdominal abscess excisional debridement of nonviable and viable skin subcutaneous tissue and muscle then removal of foreign body ANESTHESIA LMA INDICATIONS Patient is a pleasant 60 year old gentleman who initially had a sigmoid colectomy for diverticular abscess subsequently had a dehiscence with evisceration Came in approximately 36 hours ago with pain across his lower abdomen CT scan demonstrated presence of an abscess beneath the incision I recommended to the patient he undergo the above named procedure Procedure purpose risks expected benefits potential complications alternatives forms of therapy were discussed with him and he was agreeable to surgery FINDINGS The patient was found to have an abscess that went down to the level of the fascia The anterior layer of the fascia was fibrinous and some portions necrotic This was excisionally debrided using the Bovie cautery and there were multiple pieces of suture within the wound and these were removed as well TECHNIQUE Patient was identified then taken into the operating room where after induction of appropriate anesthesia his abdomen was prepped with Betadine solution and draped in a sterile fashion The wound opening where it was draining was explored using a curette The extent of the wound marked with a marking pen and using the Bovie cautery the abscess was opened and drained I then noted that there was a significant amount of undermining These margins were marked with a marking pen excised with Bovie cautery the curette was used to remove the necrotic fascia The wound was irrigated cultures sent prior to irrigation and after achievement of excellent hemostasis the wound was packed with antibiotic soaked gauze A dressing was applied The finished wound size was 9 0 x 5 3 x 5 2 cm in size Patient tolerated the procedure well Dressing was applied and he was taken to recovery room in stable condition Keywords gastroenterology excisional debridement subcutaneous tissue abdominal wall abscess foreign body abdominal abscess bovie cautery abdominal i d wound incision abscess MEDICAL_TRANSCRIPTION,Description Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak Diffuse intestinal and mesenteric lymphangiectasia Medical Specialty Gastroenterology Sample Name Abdominal Exploration Transcription PREOPERATIVE DIAGNOSES 1 Congenital chylous ascites and chylothorax 2 Rule out infradiaphragmatic lymphatic leak POSTOPERATIVE DIAGNOSES Diffuse intestinal and mesenteric lymphangiectasia ANESTHESIA General INDICATION The patient is an unfortunate 6 month old baby boy who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition but he had repeated chylothoraces Last week Dr X took the patient to the operating room in hopes that with thoracotomy a thoracic duct leak could be found which would be successfully closed surgically However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen Dr X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole This was closed and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease We met with his parents and talked to them about this and he is here today for that attempt OPERATIVE FINDINGS The patient s abdomen was relatively soft minimally distended Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum the cecum and the portion of the ascending colon It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery There was about one quarter to one third of the jejunum that did not appear to be grossly involved but I did not think that resection of three quarters of the patient s small bowel would be viable surgical option Instead we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that The lymphatic abnormality was extensive They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery They were small aneurysm like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well No other major retroperitoneal structure or correctable structure was identified Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well DESCRIPTION OF OPERATION The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow We conducted a surgical time out and reiterated all of the patient s important identifying information and confirmed the operative plan as described above Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia As the peritoneal cavity was entered we divided the umbilical vein ligamentum teres remnant between Vicryl ties and we were able to readily identify a large amount of chylous ascites that had been previously described The bowel was eviscerated and then with careful inspection we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient s chylous ascites The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected but did not appear that resection of 75 of the small intestine and colon would be a satisfactory tradeoff for The patient but would likely render him with significant short bowel and nutritional and metabolic problems Furthermore it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option We suctioned free all of the chylous accumulations replaced the intestines to their peritoneal cavity and then closed the patient s abdominal incision with 4 0 PDS on the posterior sheath and 3 0 PDS on the anterior rectus sheath Subcuticular 5 0 Monocryl and Steri Strips were used for skin closure The patient tolerated the procedure well He lost minimal blood but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time Keywords gastroenterology intestinal mesenteric lymphangiectasia ascites chylothorax lymphatic leak infradiaphragmatic abdominal exploration congenital chylous mesenteric lymphangiectasia peritoneal cavity chylous abdominal congenital abdomen lymphatic MEDICAL_TRANSCRIPTION,Description Uvulopalatopharyngoplasty and tonsillectomy The patient with a history of obstructive sleep apnea who has been using CPAP however he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea Medical Specialty ENT Otolaryngology Sample Name Uvulopalatopharyngoplasty Tonsillectomy Transcription PREOPERATIVE DIAGNOSIS Obstructive sleep apnea POSTOPERATIVE DIAGNOSIS Obstructive sleep apnea PROCEDURE PERFORMED 1 Tonsillectomy 2 Uvulopalatopharyngoplasty ANESTHESIA General endotracheal tube BLOOD LOSS Approximately 50 cc INDICATIONS The patient is a 41 year old gentleman with a history of obstructive sleep apnea who has been using CPAP however he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea PROCEDURE After all risks benefits and alternatives have been discussed with the patient informed consent was obtained The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole The needle tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar Once the tonsillar pillar was identified and the superior pole was released the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly dissecting the tonsil free from all fascial attachments Once the tonsil was delivered from the oral cavity hemostasis was obtained within the tonsillar fossa utilizing suction cautery Attention was then directed over to the left tonsil in which a similar procedure was performed Once all bleeding was controlled the mucosa of both the hard and soft palate was anesthetized with a mixture of 1 lidocaine and 1 50000 epinephrine solution Now attention was directed to the posterior pillars A hemostat was used to clamp the posterior pillar which was then taken down with Metzenbaum scissors The posterior pillar was then approximated to the anterior pillar with the use of 3 0 PDS suture so as to create a box shaped soft palate Now the uvula was reflected onto the soft palate and 12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula The mucosa was dissected off with the use of Potts scissors Now the uvula was reflected onto the soft palate and sutured down in place with use of 3 0 PDS suture approximated with deep muscle layers Now the mucosa of the soft palate and the uvula were approximated with interrupted 3 0 PDS sutures Finally 4 0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula which had been reflected onto the soft palate A final 3 0 PDS suture was used to further approximate the anterior and posterior tonsil pillars Final inspection did not reveal any further bleeding The mouth was then irrigated with saline and suctioned At this point the procedure was complete He was awakened and taken to recovery room in stable condition He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management Of note IV Decadron was administered during the procedure Keywords ent otolaryngology endotracheal metzenbaum soft palate obstructive sleep apnea tonsillectomy uvulopalatopharyngoplasty obstructive mucosa uvula palate MEDICAL_TRANSCRIPTION,Description Bilateral tympanostomy with myringotomy tube placement The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy Medical Specialty ENT Otolaryngology Sample Name Tympanostomy Myringotomy Tube Placement Transcription PREOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss POSTOPERATIVE DIAGNOSES 1 Chronic otitis media with effusion 2 Conductive hearing loss PROCEDURE PERFORMED Bilateral tympanostomy with myringotomy tube placement _______ split tube 1 0 mm ANESTHESIA Total IV general mask airway ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 1 year old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy After risks complications consequences and questions were addressed with the family a written consent was obtained for the procedure PROCEDURE The patient was brought to the operative suite by Anesthesia The patient was placed on the operating table in supine position After this the patient was then placed under general mask airway and the patient s head was then turned to the left The Zeiss operative microscope and medium sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to 5 suction After this the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a 5 suction demonstrating dry contents A _____ split tube 1 0 mm was then placed in the myringotomy incision utilizing a alligator forcep Cortisporin Otic drops were placed followed by cotton balls Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed The external auditory canal was removed off of its cerumen with a 5 suction which led to the direct visualization of the tympanic membrane The tympanic membrane appeared with no signs of retraction pockets cholesteatoma or air fluid levels A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1 0 mm was then placed with an alligator forcep After this the patient had Cortisporin Otic drops followed by cotton balls placed The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears Keywords ent otolaryngology chronic otitis media with effusion conductive hearing loss bilateral tympanostomy myringotomy tube placement cortisporin otic drops otitis media tympanostomy tympanic membrane otitis media effusion conductive hearing ear tube myringotomy MEDICAL_TRANSCRIPTION,Description The patient s main complaint is vertigo The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment Medical Specialty ENT Otolaryngology Sample Name Vertigo Consult Transcription Assessment for peripheral vestibular function follows OTOSCOPY showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne ROMBERG TEST maintained postural stability FRENZEL GLASSES EXAMINATION no spontaneous end gaze nystagmus HEAD SHAKING No provocation nystagmus DIX HALLPIKE showed no positional nystagmus excluding benign paroxysmal positional vertigo VESTIBULOCULAR REFLEX HALMAGYI TEST showed corrective saccades giving the impression of decompensated vestibular hypofunction IMPRESSION The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid PLAN Planned for electronystagmography to document the degree of vestibular hypofunction Keywords ent otolaryngology electronystagmography hearing impairment imbalance tinnitus hypofunction nystagmus vestibular vertigo MEDICAL_TRANSCRIPTION,Description Adenotonsillar hypertrophy and chronic otitis media Tympanostomy and tube placement and adenoidectomy Medical Specialty ENT Otolaryngology Sample Name Tympanostomy Transcription PREOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media POSTOPERATIVE DIAGNOSIS Adenotonsillar hypertrophy and chronic otitis media PROCEDURE PERFORMED 1 Tympanostomy and tube placement 2 Adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room prepped and draped in the usual fashion After induction of general endotracheal anesthesia the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction Attention was directed to the nasopharynx With the Bovie set at 50 coag and the suction Bovie tip on the suction hose the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior The McIvor was relaxed and attention was then directed to the ears The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris An anteroinferior quadrant tympanostomy incision was made Fluid was suctioned from the middle ear space and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle Cortisporin ear drops were instilled into the canal and a cotton ball was placed in the external meatus By a similar procedure the opposite tympanostomy and tube placement were accomplished The patient tolerated the procedure well and left the operating room in good condition Keywords ent otolaryngology robinson catheters palate tongue tympanostomy adenoidectomy chronic otitis media oral cavity adenotonsillar hypertrophy tube placement hypertrophy nasopharynx adenotonsillar MEDICAL_TRANSCRIPTION,Description Viral upper respiratory infection URI with sinus and eustachian congestion Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain Medical Specialty ENT Otolaryngology Sample Name URI Eustachian Congestion Transcription HISTORY OF PRESENT ILLNESS Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain She has had a dry cough and a fever as high as 100 but this has not been since the first day She denies any vomiting or diarrhea She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe but she does not think that this has helped FAMILY HISTORY The patient s younger sister has recently had respiratory infection complicated by pneumonia and otitis media REVIEW OF SYSTEMS The patient does note some pressure in her sinuses She denies any skin rash SOCIAL HISTORY Patient lives with her mother who is here with her Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp is 38 1 pulse is elevated at 101 other vital signs are all within normal limits Room air oximetry is 100 GENERAL Patient is a healthy appearing white female adolescent who is sitting on the stretcher and appears only mildly ill HEENT Head is normocephalic atraumatic Pharynx shows no erythema tonsillar edema or exudate Both TMs are easily visualized and are clear with good light reflex and no erythema Sinuses do show some mild tenderness to percussion NECK No meningismus or enlarged anterior posterior cervical lymph nodes HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes SKIN No rash ASSESSMENT Viral upper respiratory infection URI with sinus and eustachian congestion PLAN I did educate the patient about her problem and urged her to switch to Advil Cold Sinus for the next three to five days for better control of her sinus and eustachian discomfort I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses If she is unimproved in five days follow up with her PCP for re exam Keywords ent otolaryngology upper respiratory infection eustachian congestion erythema uri nasal cough eustachian respiratory sinus congestion infection tonsillar MEDICAL_TRANSCRIPTION,Description Tonsillectomy uvulopalatopharyngoplasty and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy and Septoplasty Transcription PREOPERATIVE DIAGNOSIS Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate POSTOPERATIVE DIAGNOSIS Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum OPERATION Tonsillectomy uvulopalatopharyngoplasty and septoplasty ANESTHESIA General anesthetics HISTORY This is a 51 year old gentleman here with his wife She confirms the history of loud snoring at night with witnessed apnea The result of the sleep study was reviewed This showed moderate sleep apnea with significant desaturation The patient was unable to tolerate treatment with CPAP At the office we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate A tortuous appearance of the septum also was observed This morning I talked to the patient and his wife about the findings I reviewed the CT images He has no history of sinus infections and does not recall a history of nasal trauma We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway Depending on the findings of surgery I explained that I might remove that bone spur that we are seeing within the nasal passage I will get the best look at it when he is asleep We discussed recovery as well He visited with Dr XYZ about the anesthetic produce PROCEDURE General tracheal anesthetic was administered by Dr XYZ and Mr Radke Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose A Crowe Davis mouth gag was placed The tonsils were very large and touched the uvula The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars Also there was a cryptic appearance of the tonsils but there was no acute redness or exudate Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present A very crowded pharynx was appreciated The tonsils were first removed using electrodissection technique Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut The tonsil fossae were injected with 0 25 Marcaine with 1 200 000 epinephrine There already was more room in the pharynx but the posterior pharyngeal wall was still obscured by the soft palate and uvula The uvula was grasped with the Alice clamp I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate We switched over from the Bayonet cautery to the blunt needle tip electrocautery The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar This incision was then deepened with the electrocautery on a cutting current The uvular artery just to the right of the midline was controlled with the suction electrocautery The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology The tonsil fossae were injected with 0 25 Marcaine with 1 200 000 epinephrine The soft palate was also injected with 0 25 Marcaine with 1 200 000 epinephrine The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3 0 chromic catgut sutures A much improved appearance of the oropharynx with a greatly improved airway was appreciated A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed I removed the cottonoids from both nostrils Speculum exam showed the inferior turbinates were large the septum was tortuous and it angulated to the right and then sharply bent back to the left The septum was injected with 0 25 Marcaine with 1 200 000 epinephrine using a separate syringe and needle A 15 blade was used to make a left cheilion incision Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator When we reached the deflected portion of the vomer this was separated from the septal cartilage with a Freer elevator The right sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome the deflected portion of the septal bone from the vomer was resected This tissue also was sent as a separate specimen to pathology The intraseptal space was irrigated with saline and suctioned The nasal septal mucosal flaps were then sutured together with a quilting suture of 4 0 plain catgut I observed no evidence of purulent secretion or polyp formation within the nostrils The inferior turbinates were then both outfractured using a knife handle and now there was a much more patent nasal airway on both sides There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose No packing was used in the nostrils Polysporin ointment was introduced into both nostrils The mouth gag was reintroduced and the pack removed from the nasopharynx The nose and throat were irrigated with saline and suctioned An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed Sponge and needle count were reported correct The mouth gag having been withdrawn the patient was then awakened and returned to recovery room in a satisfactory condition He tolerated the operation excellently Estimated blood loss was about 15 20 cc In the recovery room I observed that he was moving air well and I spoke with his wife about the findings of surgery Keywords ent otolaryngology obstructive sleep apnea syndrome afrin drops bayonet cautery cpap cottle elevator crowe davis freer elevator obstructive sleep apnea tonsillectomy hypertrophy mouth gag nasal nasal passage nasal septum nasopharynx nostrils palate pharynx septal cartilage septoplasty sleep apnea soft palate tonsils uvula uvulopalatopharyngoplasty hypertrophy of tonsils anterior tonsillar pillars soft palate incision palate incision tonsillar pillars incision MEDICAL_TRANSCRIPTION,Description Tracheostomy and thyroid isthmusectomy Ventilator dependent respiratory failure and multiple strokes Medical Specialty ENT Otolaryngology Sample Name Tracheostomy Thyroid Isthmusectomy Transcription PREOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes POSTOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes PROCEDURES PERFORMED 1 Tracheostomy 2 Thyroid isthmusectomy ANESTHESIA General endotracheal tube BLOOD LOSS Minimal less than 25 cc INDICATIONS The patient is a 50 year old gentleman who presented to the Emergency Department who had had multiple massive strokes He had required ventilator assistance and was transported to the ICU setting Because of the numerous deficits from the stroke he is expected to have a prolonged ventilatory course and he will be requiring long term care PROCEDURE After all risks benefits and alternatives were discussed with multiple family members in detail informed consent was obtained The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt tip marker The skin was then anesthetized with a mixture of 1 lidocaine and 1 100 000 epinephrine solution The patient was prepped and draped in usual fashion The surgeons were gowned and gloved A vertical skin incision was then made with a 15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage Blunt dissection was then carried down until the fascia overlying the strap muscles were identified At this point the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery Once the strap muscles have been identified palpation was performed to identify any arterial aberration A high riding innominate was not identified At this point it was recognized that the thyroid gland was overlying the trachea could not be mobilized Therefore dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland which was then doubly clamped and ligated with Bovie cautery Suture ligation with 3 0 Vicryl was then performed on the thyroid gland in a double interlocking fashion This cleared a significant portion of the trachea The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery Now a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea The second tracheal ring was identified The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based At this point the anesthetist was appropriately alerted to deflate the endotracheal tube cuff The airway was entered and inferior to the base window was created The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified At this point a 8 Shiley tracheostomy tube was inserted freely into the tracheal lumen The balloon was inflated and the ventilator was attached He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist Now all surgical retractors were removed The baseplate of the tracheostomy tube was sutured to the patient s skin with 2 0 nylon suture The tube was further secured around the patient s neck with IV tubing Finally a drain sponge was placed At this point procedure was felt to be complete The patient was returned to the ICU setting in stable condition where a chest x ray is pending Keywords ent otolaryngology ventilator dependent respiratory failure multiple strokes thyroid thyroid isthmusectomy ventilator dependent respiratory failure strap muscles thyroid gland endotracheal tube cricoid cartilage bovie cautery tracheostomy ventilator strokes cartilage tracheal isthmusectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy 3 Transcription PREOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis POSTOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis SURGICAL PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal technique SURGICAL FINDINGS A 4 4 cryptic and hypertrophic tonsils with 2 3 hypertrophic adenoid pads INDICATIONS We were requested to evaluate the patient for complaints of enlarged tonsils which cause difficulty swallowing recurrent pharyngitis and sleep induced respiratory disturbance She was evaluated and scheduled for an elective procedure DESCRIPTION OF SURGERY The patient was brought to the operative suite and placed supine on the operating room table General anesthetic was administered Once appropriate anesthetic findings were achieved the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy He was placed in semi Rose ___ position and a Crowe Davis type mouth gag was introduced into the oropharynx Under an operating headlight the oropharynx was clearly visualized The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique was removed from its fossa This followed placing the patient in a suspension position using a McIvor type mouth gag and a red rubber Robinson catheter via the right naris Once the right tonsil was removed the left tonsil was removed in a similar manner once again using a needle point Bovie dissection at 20 watts With the tonsils removed it was possible to visualize the adenoid pads The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique The adenoid pad was greater than 2 4 and hypertrophic It was removed with successive passes of electrocautery suction The tonsillar fossa was then once again hemostased with suction cautery injected with 0 5 ropivacaine with 1 100 000 adrenal solution and then closed with 2 0 Monocryl on an SH needle The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period The patient s oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine and she was recovered from her general endotracheal anesthetic She was extubated and left the operating room in good condition to the postoperative recovery room area Estimated blood loss was minimal There were no complications Specimens produced were right and left tonsils The adenoid pad was ablated with electrocautery Keywords ent otolaryngology obstructive adenotonsillar hypertrophy pharyngitis tonsillectomy adenoidectomy uvula obstructive adenotonsillar hypertrophy hypertrophic fossa tonsils oropharynx electrocautery pads MEDICAL_TRANSCRIPTION,Description Left canal wall down tympanomastoidectomy with ossicular chain reconstruction microdissection NIM facial nerve monitoring for three hours Medical Specialty ENT Otolaryngology Sample Name Tympanomastoidectomy Transcription PREOPERATIVE DIAGNOSIS Left canal cholesteatoma POSTOPERATIVE DIAGNOSIS Left canal cholesteatoma OPERATIVE PROCEDURE 1 Left canal wall down tympanomastoidectomy with ossicular chain reconstruction 2 Microdissection 3 NIM facial nerve monitoring for three hours COMPLICATIONS None FINDINGS There is an extremely large canal cholesteatoma which eroded most of the posterior and superior canal wall There was a significant amount of myringosclerosis and tympanosclerosis There is some mild erosion of the lenticular process of the incus The facial nerve was normal We removed the incus removed the head of the malleus and placed a titanium PORP from the stapes capitulum to a cartilage graft PROCEDURE The patient was taken to the operating room placed under general anesthetic and intubated without difficulty The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure There was no abnormal activity during this case We inspected the ear canal identified the huge defect which was completely filled with cerumen Through the ear canal we removed as much as we could and then infiltrated the canal and postauricular area with 1 100 000 of epinephrine We prepped and draped the ear in a sterile fashion We reopened the previously used postauricular incision and dissected down the mastoid cortex We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone A 6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out We went all the way to the mastoid antrum We finished a complete mastoidectomy with identification of the tegmen sigmoid sinus We removed the lateral aspect of the mastoid tip We lowered the facial ridge The incudostapedial joint was already membranous in nature we went ahead and used the joint knife and removed the incus We separated the incus from the stapes and then removed it We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity There was no cholesteatoma within the middle ear space but there was roughly 40 surface area perforation The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic this was removed There was also a large focus of tympanosclerosis between the stapes crura which was impinging the ability of the stapes to move We carefully dissected this out This did seem to improve the mobility of the stapes somewhat At this point there was a near total perforation There was only a minimal amount of anterior remnant of the drum left We tried to go ahead and harvest the temporalis fascia but there was really only wisps of this fascia in place He had already had a previous tympanoplasty but even outside the areas where the graft was taken the temporalis muscle was quite atrophied and lumpy and I suspect this was due to his chronic disease and long history of corticosteroid usage We harvested a few pieces as best as we could We went ahead and did a meatoplasty by making a canal incision in the 6 o clock and 12 o clock positions We excised cartilage posteriorly and inferiorly to enlarge the meatus This cartilage was thin and used for cartilage tympanoplasty We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it We did cut a titanium PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants We placed a layer of Gelfoam lateral to the graft closed the postauricular incision in layers and put 2 Merocel packs in the ear Glasscock dressing was applied The patient was awakened from anesthesia and taken to the recovery room in stable condition He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week Keywords ent otolaryngology cholesteatoma gelfoam glasscock dressing microdissection nim canal canal wall cerumen facial nerve incus myringosclerosis ossicular chain reconstruction titanium porp tympanomastoidectomy tympanosclerosis facial nerve monitoring ear canal cartilage ear MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy Chronic adenotonsillitis The patient is a 9 year old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy 5 Transcription POSTOPERATIVE DIAGNOSIS Chronic adenotonsillitis PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal tube ESTIMATED BLOOD LOSS Minimum less than 5 cc SPECIMENS Right and left tonsils 2 adenoid pad 1 There was no adenoid specimen COMPLICATIONS None HISTORY The patient is a 9 year old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years PROCEDURE Informed consent was properly obtained from the patient s parents and the patient was taken to the operating room 3 and was placed in a supine position He was placed under general endotracheal tube anesthesia by the Department of Anesthesia The bed was then rolled away from Department of Anesthesia A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap The McIvor mouth gag was carefully positioned into the patient s mouth with attention to avoid the teeth The retractor was then opened and the oropharynx was visualized The adenoid pad was then visualized with a laryngeal mirror The adenoids appeared to be 1 and non obstructing There was no evidence of submucosal cleft palate palpable There was no evidence of bifid uvula A curved Allis clamp was then used to grasp the superior pole of the right tonsil The tonsil was then retracted inferiorly and medially Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection The tonsil was then dissected out within this plane using a Bovie Tonsillar sponge was re applied to the tonsillar fossa Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa Attention was then directed to the left tonsil The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection The tonsil was then dissected out within this plane using the Bovie Next complete hemostasis was achieved within the tonsillar fossae using suction cautery After adequate hemostasis was obtained attention was directed towards the adenoid pad The adenoid pad was again visualized and appeared 1 and was non obstructing Decision was made to use suction cautery to cauterize the adenoids Using a laryngeal mirror under direct visualization the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates After cauterization was complete the nasopharynx was again visualized and tonsillar sponge was applied Adequate hemostasis was achieved The tonsillar fossae were again visualized and no evidence of bleeding was evident The throat pack was removed from the oropharynx and the oropharynx was suctioned There was no evidence of any further bleeding A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx The suction catheter was also used to suction up the stomach Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively DISPOSITION The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition Keywords ent otolaryngology chronic adenotonsillitis tonsillectomy adenoidectomy adenoid tonsils tonsillar fossa tonsillar fossae suction cautery adenotonsillitis oropharynx hemostasis cautery suction tonsillar MEDICAL_TRANSCRIPTION,Description Tonsillectomy Chronic tonsillitis Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy 1 Transcription PREOPERATIVE DIAGNOSIS Chronic tonsillitis POSTOPERATIVE DIAGNOSIS Chronic tonsillitis PROCEDURE Tonsillectomy DESCRIPTION OF PROCEDURE Under general orotracheal anesthesia a Crowe Davis mouth gag was inserted and suspended Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0 25 plain A catheter was inserted in the nose and brought out from mouth The throat was irrigated with saline There was no further bleeding The patient was awakened and extubated and moved to the recovery room in satisfactory condition Keywords ent otolaryngology crowe davis mouth gag chronic tonsillitis tonsillitis anesthesia tonsillectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy and Left superficial nasal cauterization Recurrent tonsillitis Deeply cryptic hypertrophic tonsils with numerous tonsillolith Residual adenoid hypertrophy and recurrent epistaxis Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy 4 Transcription PREOPERATIVE DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis POSTOPERATIVE DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis FINAL DIAGNOSES 1 Recurrent tonsillitis 2 Deeply cryptic hypertrophic tonsils with numerous tonsillolith 3 Residual adenoid hypertrophy and recurrent epistaxis OPERATION PERFORMED 1 Tonsillectomy and adenoidectomy 2 Left superficial nasal cauterization DESCRIPTION OF OPERATION The patient was brought to the operating room Endotracheal intubation carried out by Dr X The McIvor mouth gag was inserted and gently suspended Afrin was instilled in both sides of the nose and allowed to take effect for a period of time The hypertrophic tonsils were then removed by the suction and snare Deeply cryptic changes as expected were evident Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive They were shaved back flushed with prevertebral fascia with curette Hemostasis established with packing followed by electrocautery In light of his history of recurring nosebleeds both sides of the nose were carefully inspected A nasal endoscope was used to identify the plexus of bleeding which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device The bleeding was admittedly a bit of a annoyance An additional control was established by infiltrating slowly with a 1 Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself No additional bleeding was then evident The oropharynx was reinspected clots removed the patient was extubated taken to the recovery room in stable condition Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops Office recheck anticipated if stable and doing well in three to four weeks Keywords ent otolaryngology tonsillitis cryptic hypertrophic tonsils tonsillolith nasal cauterization adenoid hypertrophy hypertrophic tonsils adenoidectomy nasal cauterization hypertrophy epistaxis tonsils hypertrophic intubation tonsillectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy adenoidectomy Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy 2 Transcription PREOPERATIVE DIAGNOSIS Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy POSTOPERATIVE DIAGNOSIS Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy OPERATION PERFORMED Tonsillectomy adenoidectomy ANESTHESIA General endotracheal FINDINGS The tonsils were 3 enlarged and cryptic DESCRIPTION OF OPERATION Under general anesthesia with an endotracheal tube the patient was placed in supine position A mouth gag was inserted and suspended from Mayo stand Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate The adenoid area was inspected The adenoids were small The left tonsil was grasped with a tonsil tenaculum The tonsil was removed with the Gold laser The apposite tonsil was removed in a similar manner Hemostasis was secured with electrocautery Both tonsillar fossae were injected with 0 25 Marcaine with adrenaline The patient tolerated the procedure well and left the operating room in good condition Keywords ent otolaryngology tonsil gold laser adenoids chronic tonsillitis adenoid hypertrophy tonsillectomy adenoidectomy endotracheal tonsillitis symptomatic hypertrophy MEDICAL_TRANSCRIPTION,Description Tonsillectomy and adenoidectomy McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy 1 Transcription PROCEDURE PERFORMED Tonsillectomy and adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia The McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction The nasopharynx was inspected with a laryngeal mirror The adenoid tissue was fulgurated with the suction Bovie set at 35 The catheters and the dental gauze roll were then removed The anterior tonsillar pillars were infiltrated with 0 5 Marcaine and epinephrine Using the radiofrequency wand the tonsils were ablated bilaterally If bleeding occurred it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9 The tonsillectomy was completed The nasopharynx and nasal passages were suctioned free of debris and the procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords ent otolaryngology tongue nasal passage palate mcivor mouth gag gauze roll nasopharynx tonsillectomy adenoidectomy MEDICAL_TRANSCRIPTION,Description Tonsillectomy Tonsillitis McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Transcription PREOPERATIVE DIAGNOSIS Tonsillitis POSTOPERATIVE DIAGNOSIS Tonsillitis PROCEDURE PERFORMED Tonsillectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion After induction of general endotracheal anesthesia the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction The nasopharynx was inspected with the laryngeal mirror Attention was then directed to the right tonsil The anterior tonsillar pillar was infiltrated with 1 5 cc of 1 Xylocaine with 1 100 000 epinephrine as was the left tonsillar pillar The right tonsil was grasped with the tenaculum and retracted out of its fossa The anterior tonsillar pillar was incised with the 12 knife blade The plica semilunaris was incised with the Metzenbaum scissors Using the Metzenbaum scissors and the Fisher knife the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described By a similar procedure the opposite tonsillectomy was performed and the fossa was packed Attention was re directed to the right tonsil The pack was removed and bleeding was controlled with the suction Bovie unit Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs The catheters were then removed The nasal passages and oropharynx were suctioned free of debris The procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords ent otolaryngology tongue palate mcivor mouth gag anterior tonsillar metzenbaum scissors oral cavity tonsillar pillar tonsillectomy metzenbaum tonsillitis pillar tonsillar fossa MEDICAL_TRANSCRIPTION,Description Tonsillectomy adenoidectomy and removal of foreign body rock from right ear Medical Specialty ENT Otolaryngology Sample Name Tonsillectomy Adenoidectomy Transcription PREOPERATIVE DIAGNOSES Hypertrophy of tonsils and adenoids and also foreign body of right ear POSTOPERATIVE DIAGNOSES Hypertrophy of tonsils and adenoids and also foreign body of right ear OPERATIONS Tonsillectomy adenoidectomy and removal of foreign body rock from right ear ANESTHESIA General HISTORY The patient is 5 1 2 years old She is here this morning with her Mom She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well At the office we saw the tonsils were very big There was a rock in the right ear and it was very deep in the canal near the drum We will remove the foreign body under the same anesthetic PROCEDURE Natalie was placed under general anesthetic by the orotracheal route of administration under Dr XYZ and Ms B I looked into the left ear under the microscope took out a little wax and observed a normal eardrum On the right side I took out some impacted wax and removed the rock with a large suction It was actually resting on the surface of the drum but had not scarred or damaged the drum The drum was intact with no evidence of middle ear fluid The microscope was set aside Afrin drops were placed in both nostrils The neck was gently extended and the Crowe Davis mouth gag inserted The tonsils and adenoids were very large The uvula was intact Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx Tonsillectomy accomplished by sharp and blunt dissection Hemostasis achieved with electrocautery and the tonsils beds injected with 0 25 Marcaine with 1 200 000 epinephrine Sutures of zero plain catgut next were used to re approximate the posterior to the anterior tonsillar pillars suturing these down to the tonsillar beds Sponge is removed from the nasopharynx The suction electrocautery was used for pinpoint hemostasis on the adenoid bed We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices The nose and throat were then irrigated with saline and suctioned Excellent hemostasis was observed An orogastric tube was placed The stomach found to be empty The tube was removed as was the mouth gag Sponge and needle count were reported correct The child was then awakened and prepared for her to return to the recovery room She tolerated the operation excellently Keywords ent otolaryngology tonsillectomy afrin drops crowe davis hypertrophy adenoid bed adenoidectomy adenoids canal catgut dissection drum ear foreign body middle ear mouth gag nasopharynx orotracheal suction electrocautery throat tonsils uvula wax tonsils and adenoids MEDICAL_TRANSCRIPTION,Description The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago Medical Specialty ENT Otolaryngology Sample Name Status Post Tympanoplasty Transcription The right eardrum is intact showing a successful tympanoplasty I cleaned a little wax from the external meatus The right eardrum might be very slightly red but not obviously infected The left eardrum not the surgical ear has a definite infection with a reddened bulging drum but no perforation or granulation tissue Also some wax at the external meatus I cleaned with a Q tip with peroxide The patient has no medical allergies Since he recently had a course of Omnicef we chose to put him on Augmentin I checked and we did not have samples so I phoned in a two week course of Augmentin 400 mg chewable twice daily with food at Walgreens I looked at this throat which looks clear The nose only has a little clear mucinous secretions If there is any ear drainage please use the Floxin drops I asked Mom to have the family doctor or Dad or me check the ears again in about two weeks from now to be sure there is no residual infection I plan to see the patient again later this spring Keywords ent otolaryngology tympanoplasty surgery traumatic perforation external meatus wax external perforation eardrum meatus tympanoplasty earNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Right argon laser assisted stapedectomy Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis Medical Specialty ENT Otolaryngology Sample Name Stapedectomy Argon Lasor Assisted Transcription PREOPERATIVE DIAGNOSIS Bilateral progressive conductive hearing losses with probable otosclerosis POSTOPERATIVE DIAGNOSIS Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis OPERATION PERFORMED Right argon laser assisted stapedectomy DESCRIPTION OF OPERATION The patient was brought to the operating room Endotracheal intubation carried out by Dr X The patient s right ear was carefully prepped and then draped in the usual sterile fashion Slow infiltration of the external canal accomplished with 1 Xylocaine with epinephrine The earlobe was also infiltrated with the same solution A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5 0 nylon This could later be removed in bishop A reinspection of the ear canal was accomplished A 65 Beaver blade was used to make incision both at 12 o clock and at 6 o clock Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation Elevation was carried down to the fibrous annulus An annulus elevator was used to complete the elevation beneath the annular ligament The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain Palpation of the malleus revealed good mobility of both it and incus but no movement of the stapes was identified Palpation with a fine curved needle on the stapes itself revealed no movement A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well The self retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation A small bit of additional footplate was removed with a right angle hook to accommodate the 0 6 mm piston The measuring device was used and a 4 25 mm slim shaft wire Teflon piston chosen It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate The hook was placed over the incus and measurement appeared to be appropriate A downbiting crimper was then used to complete the attachment of the prosthesis to the incus Prosthesis is once again checked for location and centering and appeared to be in ideal position Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph A small pledget of fat was also placed on the top of the incudo prosthesis junction The mobility appeared excellent The flap was placed back in its normal anatomic position The external canal packed with small pledgets of Gelfoam and antibiotic ointment She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop Sutures will be out in a week and a recheck in Reno in four to five weeks from now Keywords ent otolaryngology bilateral progressive conductive hearing loss argon laser assisted conductive hearing losses intubation argon stapedectomy otosclerosis canal earlobe prosthesis pledgets laser MEDICAL_TRANSCRIPTION,Description Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung Medical Specialty ENT Otolaryngology Sample Name Thoracoscopy Thoracotomy Transcription PREOPERATIVE DIAGNOSES Empyema of the left chest and consolidation of the left lung POSTOPERATIVE DIAGNOSES Empyema of the left chest consolidation of the left lung lung abscesses of the left upper lobe and left lower lobe OPERATIVE PROCEDURE Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung ANESTHESIA General FINDINGS The patient has a complex history which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax There was also noted to be some mild infiltrates of the right lung The patient had a 30 year history of cigarette smoking A chest tube was placed at the other hospital which produced some brownish fluid that had foul odor actually what was thought to be a fecal like odor Then an abdominal CT scan was done which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT The patient was started on antibiotics and was then taken to the operating room where there was to be a thoracoscopy performed The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions but there was bloody mucous in the left main stem bronchus and this was suctioned out This was suctioned out with the addition of the use of saline in the bronchus Following the bronchoscopy a double lumen tube was placed but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day The patient was transferred for continued evaluation and treatment Today the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted These were suctioned but it was enough to produce a temporary obstruction of the left mainstem bronchus Eventually the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that The chest tube tract which was about in the sixth or seventh intercostal space but it was not possible to dissect enough down to get a acceptable visualization through this tract A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout Remarkably the surface of the lower lobe laterally was not completely covered with a fibrotic line but it was more the line anterior and posterior and more of it over the left upper lobe There were many pockets of purulent material which had a gray white appearance to it There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time There seemed to be an abscess that was about 3 cm in dimension all the lateral basilar segment of the lower lobe near the area where the chest tube was placed Many cultures were taken from several areas The most remarkable finding was a large cavity which was probably about 11 cm in dimension containing grayish pus and also caseous like material it was thought to be perhaps necrotic lung tissue perhaps a deposit related to tuberculosis in the cavity The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm PROCEDURE AND TECHNIQUE With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this Therefore the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved but it was clear that we would be unable to complete the procedure by thoracoscopy Therefore posterolateral thoracotomy incision was made entering the pleural space and what is probably the sixth intercostal space Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense Suture ligatures of Prolene were required When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity which appeared to be from pulmonary veins and these were sutured with a tissue pledget of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14 French Foley catheter was passed into the area of the tear and the balloon was inflated which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed The patch was sutured onto the pulmonary artery tear A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity Also on the pulmonary artery repair some material was used and also thrombin Gelfoam and Surgicel After reasonably good hemostasis was established pleural cavity was irrigated with saline As mentioned biopsies were taken from multiple sites on the pleura and on the edge and on the lung Then two 24 Blake chest tubes were placed one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex These were later connected to water seal suction at 40 cm of water with negative pressure Good hemostasis was observed Sponge count was reported as being correct Intercostal nerve blocks at probably the fifth sixth and seventh intercostal nerves was carried out Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib Metallic clip was passed through the rib to facilitate passage of an intracostal suture but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table so that pericostal sutures were used with 1 Vicryl The chest wall was closed with running 1 Vicryl and then 2 0 Vicryl subcutaneous and staples on the skin The chest tubes were connected to water seal drainage with 40 cm of water negative pressure Sterile dressings were applied The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition Keywords ent otolaryngology empyema biopsies bronchus declaudication endothoracic hydropneumothorax left lower lobe left lung left upper lobe mainstem pleura thoracoscopy thoracotomy thoracotomy with declaudication declaudication and drainage double lumen tube sixth intercostal space lung abscesses pleural cavity intercostal space upper lobe double lumen chest tube cavity tube chest lung pulmonary pleural intercostal MEDICAL_TRANSCRIPTION,Description Underwent tonsillectomy and adenoidectomy two weeks ago Medical Specialty ENT Otolaryngology Sample Name Status Post T A Transcription SUBJECTIVE A 6 year old boy who underwent tonsillectomy and adenoidectomy two weeks ago Also I cleaned out his maxillary sinuses Symptoms included loud snoring at night sinus infections throat infections not sleeping well and fatigue The surgery went well and I had planned for him to stay overnight but Mom reminds me that by about 8 p m the night nurse gotten him to take fluids well and we let him go home then that evening He finished up his Augmentin by a day or two later he was off the Lortab Mom has not noticed any unusual voice change No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce He has not had any nasal discharge or ever had any bleeding He seems to be breathing better OBJECTIVE Exam looks good The pharynx is well healed Tongue mobility is normal Voice sounds clear Nasal passages reveal no discharge or crusting RECOMMENDATION I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth It is okay to chew gum and it is okay to eat crunchy foods such as potato chips The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis and there were no atypical findings on the laboratories I am glad he has healed up well There are no other restrictions or limitations I told Mom I had written to Dr XYZ to let her know of the findings The child will continue his regular followup visits with his family doctor and I told Mom I would be happy to see him anytime if needed He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure Keywords ent otolaryngology tonsillectomy and adenoidectomy tonsillectomy adenoidectomy maxillary nasal sinuses MEDICAL_TRANSCRIPTION,Description Functional endoscopic sinus surgery excision of nasopharyngeal mass via endoscopic technique and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure Medical Specialty ENT Otolaryngology Sample Name Sinus Surgery Endoscopic Transcription PREOPERATIVE DIAGNOSES 1 Nasopharyngeal mass 2 Right upper lid skin lesion POSTOPERATIVE DIAGNOSES 1 Nasopharyngeal tube mass 2 Right upper lid skin lesion PROCEDURES PERFORMED 1 Functional endoscopic sinus surgery 2 Excision of nasopharyngeal mass via endoscopic technique 3 Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 30 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 51 year old Caucasian female with a history of a nasopharyngeal mass discovered with patient s chief complaint of nasal congestion and chronic ear disease The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months It appears to be growing in size and is irregularly bordered After risks complications consequences and questions were addressed to the patient a written consent was obtained for the procedure PROCEDURE The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position After this the patient was turned to 90 degrees by the Department of Anesthesia The right upper eyelid skin lesion was injected with 1 lidocaine with epinephrine 1 100 000 approximately 1 cc total After this the patient s bilateral nasal passages were then packed with cocaine soaked cottonoids of 10 solution of 4 cc total The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade After this the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors After this the ________ was then hemostatically controlled with monopolar cauterization The patient s skin was then reapproximated with a running 6 0 Prolene suture A Mastisol along with a single Steri Strip was in place followed Maxitrol ointment Attention then was drawn to the nasopharynx The cocaine soaked cottonoids were removed from the nasal passages bilaterally and zero degree otoscope was placed all the way to the patient s nasopharynx The patient had a severely deviated nasal septum more so to the right than the left There appeared to be a spur on the left inferior aspect and also on the right posterior aspect The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking It was then localized with 1 lidocaine with epinephrine 1 100 000 of approximately 3 cc total After this the lesion was then removed on the right side with the XPS blade The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely This area was taken down with the XPS blade Prior to taking down this lesion with the XPS multiple biopsies were taken with a straight biter After this a cocaine soaked cottonoid was placed back in the patient s left nasal passage region and the nasopharynx and the attention was then drawn to the right side The zero degree otoscope was placed in the patient s right nasal passage and all the way to the nasopharynx Again the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius After this the patient was then hemostatically controlled with suctioned Bovie cauterization A FloSeal was then placed followed by bilateral Merocels and bacitracin coated ointment The patient s Meroceles were then tied together to the patient s forehead and the patient was then turned back to the Anesthesia The patient was extubated in the operating room and was transferred to the recovery room in stable condition The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week The patient will be sent home with a prescription for Keflex 500 mg one p o b i d and Tylenol 3 one to two p o q 4 6h pain 30 Keywords ent otolaryngology nasopharyngeal tube mass lymphoid tissue torus tubarius sinus surgery nasal passages nasopharyngeal mass skin lesion lesion nasopharynx endoscopic nasopharyngeal MEDICAL_TRANSCRIPTION,Description A sample note on serous otitis media Medical Specialty ENT Otolaryngology Sample Name SOM Serous Otitis Media Transcription Because children need hearing to learn speech hearing loss from fluid in the middle ear can result in speech delay Children begin to speak some words by 18 months Children with fluid in both ears can show significant delay in their use of language In addition young children learn to pronounce words by hearing them spoken When there is a hearing loss even a mild one the spoken words of parents and siblings are distorted to the child with fluid in the ears Identification of fluid in the middle ear is important not only to prevent future speech problems but to avoid permanent damage to the eardrum and the middle ear Most children will have at least one ear infection before the age of four With treatment the ear infections clear up promptly Without the follow up visit fluid may still be present even though the child has no complaints or symptoms Therefore it is essential that ear infections be rechecked after initial treatment Usually the presence of fluid results in a mild conductive hearing loss This could be as much as 30 hearing loss overall After the specialist confirms that fluid is present behind both eardrums further medical treatment is often advised This may consist of additional antibiotics decongestants and in some cases nasal sprays If fluid has been present for over 12 weeks surgical drainage of the fluid is often indicated The decision to perform surgery should be based on the response to medical treatment the degree of hearing loss and the appearance of the eardum itself under the surgical microscope Surgery which drains fluid involves a small incision in the eardrum so that the fluid can be gently removed and a tube can be inserted The procedure medically termed a myringotomy and tubes or tympanostomy and tube BMT if Bilateral or PET Pressure Equalizing Tubes is performed on children under general anesthesia Keywords ent otolaryngology tube bmt pet pressure equalizing tubes serous otitis media eustachian tube ear infections otitis media middle ear hearing loss ear children fluid drain eustachian otitis media eardrum infections middle loss hearingNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Revision septoplasty repair of internal nasal valve collapse using auricular cartilage repair of bilateral external nasal valve collapse using auricular cartilage harvest of right auricular cartilage Medical Specialty ENT Otolaryngology Sample Name Septoplasty Transcription PREOPERATIVE DIAGNOSES 1 Nasal septal deviation 2 Bilateral internal nasal valve collapse 3 Bilateral external nasal valve collapse POSTOPERATIVE DIAGNOSES 1 Nasal septal deviation 2 Bilateral internal nasal valve collapse 3 Bilateral external nasal valve collapse PROCEDURES 1 Revision septoplasty 2 Repair of internal nasal valve collapse using auricular cartilage 3 Repair of bilateral external nasal valve collapse using auricular cartilage 4 Harvest of right auricular cartilage ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS Approximately 20 mL IV FLUIDS Include a liter of crystalloid fluid URINE OUTPUT None FINDINGS Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor There is also evidence of bilateral internal as well as external nasal valve collapse INDICATIONS The patient is a pleasant 49 year old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine Therefore for repair of the above mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum the risks and benefits of the procedure were discussed with him included but not limited to bleeding infection septal perforation need for further surgeries external deformity and he desired to proceed with surgery DESCRIPTION OF THE PROCEDURE IN DETAIL The patient was taken to the operating room and laid supine upon the OR table After the induction of general endotracheal anesthesia the nose was decongested using Afrin soaked pledgets followed by the injection of lidocaine with 1 100 000 epinephrine in the submucoperichondrial planes bilaterally Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor The caudal septum appeared to be now in adequate position There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place Following the evaluation of the nose a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side Very carefully the mucoperichondrial flaps were elevated over this and it was excised using an osteotome taking care to preserve the 1 5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine Very carefully the bony cartilaginous junction was identified and a small piece of the bone where the spur was was carefully removed Following this it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures Therefore attention was turned to harvesting the right sided auricular cartilage which was done after the region had adequately been prepped and draped in a sterile fashion Postauricular incision using a 15 blade the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times This was very carefully harvested This area had been injected previously with 1 lidocaine and 1 100 000 epinephrine Following this the cartilage was removed It was placed in saline noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity The spreader grafts were sutured in place using submucoperichondrial pockets After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery These were secured in place in the pockets using a 5 0 PDS suture in a mattress fashion in two places Following this attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin Subsequently the alar rim grafts were placed and extended all the way to the piriform aperture This was sutured in place using a 5 0 self absorbing gut suture The lower lateral cartilage has had some inherent asymmetry This may have been related to his previous surgery with some asymmetry of the dome however this was left in place as he did not desire any changes in the tip region and there was adequate support An endodermal suture was placed just to reenforce the region using a 5 0 PDS suture Following all this the area was closed using a mattress 4 0 plain gut on a Keith needle followed by the application of 5 0 fast absorbing gut to close the hemitransfixion incision Very carefully the skin and subcutaneous tissue envelopes were reflected The curvilinear incision was closed using a Vicryl followed by interrupted 6 0 Prolene sutures The marginal incisions were then closed using 5 0 fast absorbing gut Doyle splints were placed and secured down using a nylon suture They had ointment also placed on them Following this nasopharynx was suctioned There were no further abnormalities noted and everything appeared to be in nice position Therefore an external splint was placed after the application of Steri Strips The patient tolerated the procedure well He was awakened in the operating room He was extubated and taken to the recovery room in stable condition Keywords ent otolaryngology nasal septal deviation nasal septal auricular cartilage nasal nasal obstruction nasal valve septoplasty submucoperichondrial upper airway internal nasal valve external nasal valve hemitransfixion incision revision septoplasty septal spur valve collapse auricular cartilage collapse septum valve MEDICAL_TRANSCRIPTION,Description Septoplasty with partial inferior middle turbinectomy with KTP laser sinus endoscopy with maxillary antrostomies removal of tissue with septoplasty and partial ethmoidectomy bilaterally Medical Specialty ENT Otolaryngology Sample Name Septoplasty Turbinectomy Transcription OPERATIVE DIAGNOSES Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates OPERATIONS PERFORMED Septoplasty with partial inferior middle turbinectomy with KTP laser sinus endoscopy with maxillary antrostomies removal of tissue with septoplasty and partial ethmoidectomy bilaterally OPERATION The patient was taken to the operating room After adequate anesthesia via endotracheal intubation the nose was prepped with Afrin nasal spray After this was done 1 Xylocaine with 100 000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium After this the sinus endoscope at 25 degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate A 45 degree forceps then used to open up the maxillary sinus There was some prominent tissue and just superior to this the anterior ethmoid was opened The 45 degree forceps was then used to open the maxillary sinus ostium This was enlarged with backbiting rongeur After this was done the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa After this was done attention was then turned to the right nasal cavity staying laterally to the middle turbinate There was noted to have prominence in the anterior ethmoidal area This was then opened with 45 degree forceps This mucosa was then removed from the anterior area The maxillary sinus ostium was then opened with 45 degree forceps Tissue was removed from this area This was sent as right maxillary mucosa After this the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus Protecting the eyes with wet gauze and using KTP laser at 10 watts the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction After this was completed a septoplasty was performed The incision was made with a 15 blade Bard Parker knife The flap was then elevated overlying the spur that was protruding into the right nasal cavity This was excised with a 15 blade Bard Parker knife The tissue was then laid back in position After this was laid back in position the nasal cavity was irrigated with saline solution suctioned well as well as the oropharynx Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3 0 nylon The patient was then awakened and taken to recovery room in good condition Keywords ent otolaryngology sinusitis ktp laser septoplasty deviated endoscopy ethmoidectomy hypertrophied maxillary nasal obstruction nasal septum sinus turbinates turbinectomy partial ethmoidectomy parker knife sinus ostium nasal cavity maxillary sinus ktp mucosa cavity forceps antrostomies ostium nasal MEDICAL_TRANSCRIPTION,Description Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis Medical Specialty ENT Otolaryngology Sample Name Progress Note Supraglottitis Transcription HISTORY A 59 year old male presents in followup after being evaluated and treated as an in patient by Dr X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis admitted on 05 23 2008 discharged on 05 24 2008 Please refer to chart for history and physical and review of systems and medical record PROCEDURES PERFORMED Fiberoptic laryngoscopy identifying about 30 positive Muller maneuver No supraglottic edema 2 4 tonsils with small tonsil cyst mid tonsil left IMPRESSION 1 Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis 2 Possible obstructive sleep apnea however the patient describes no known history of this phenomenon 3 Hypercholesterolemia 4 History of anxiety 5 History of coronary artery disease 6 Hypertension RECOMMENDATIONS Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr X Cultures are still pending and follow up with Dr X in the next few weeks for re evaluation I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this but we will leave this open for him to talk with Dr X on his followup and he will pay more attention on his sleep pattern Keywords ent otolaryngology acute supraglottic edema obstructive sleep apnea acute supraglottitis airway obstruction parapharyngeal cellulitis peritonsillar cellulitis supraglottic edema supraglottitis tonsils cellulitis MEDICAL_TRANSCRIPTION,Description Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity Medical Specialty ENT Otolaryngology Sample Name Revision Rhinoplasty Transcription PREOPERATIVE DIAGNOSIS Nasal deformity status post rhinoplasty POSTOPERATIVE DIAGNOSIS Same PROCEDURE Revision rhinoplasty CPT 30450 Left conchal cartilage harvest CPT 21235 ANESTHESIA General INDICATIONS FOR THE PROCEDURE This patient is an otherwise healthy male who had a previous nasal fracture During his healing perioperatively he did sustain a hockey puck to the nose resulting in a saddle nose deformity with septal hematoma The patient healed status post rhinoplasty as a result but was left with a persistent saddle nose dorsal defect The patient was consented for the above stated procedure The risks benefits and alternatives were discussed DESCRIPTION OF PROCEDURE The patient was prepped and draped in the usual sterile fashion The patient did have approximately 12 mL of Lidocaine with epinephrine 1 with 1 100 000 infiltrated into the nasal soft tissues In addition to this cocaine pledgets were placed to assist with hemostasis At this point attention was turned to the left ear Approximately 3 mL of 1 Lidocaine with 1 100 000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb Betadine was utilized for preparation A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane I then completed this along the posterior aspect of the conchal cartilage was transected in the concha cavum and concha cymba both were harvested These were placed aside in saline Hemostasis was obtained with bipolar electrocauterization Bovie electrocauterization was also employed as needed The entire length of the wound was then closed with 5 0 plain running locking suture The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2 0 Prolene suture Antibiotic ointment was applied generously Next attention was turned to opening and lifting the soft tissues of the nose A typical external columella inverted V gull wing incision was placed on the columella and trailed into a marginal incision The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums Soft tissues were elevated over the lower lateral cartilages upper lateral cartilages onto the nasal dorsum At this point attention was turned to osteotomies and examination of the external cartilages The patient did have very broad lower lateral cartilages leading to a bulbous tip The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect Having completed this the patient had medial and lateral osteotomies performed with a 2 mm osteotome These were done transmucosally after elevating the tract using a Cottle elevator Direct hemostasis pressure was applied to assist with bruising Next attention was turned to tip mechanisms The patient had a series of double dome sutures placed into the nasal tip Then 5 0 Dexon was employed for intradomal suturing 5 0 clear Prolene was used for interdomal suturing Having completed this a 5 0 clear Prolene alar spanning suture was employed to narrow the superior tip area Next attention was turned to dorsal augmentation A Gore Tex small implant had been selected previously incised This was taken to the back table and carved under sterile conditions The patient then had the implant placed into the super tip area to assist with support of the nasal dorsum It was placed into a precise pocket and remained in the midline Next attention was turned to performing a columella strut The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage This was fixed into position utilizing a 5 0 Dexon suture Having completed placement of all augmentation grafts the patient was examined for hemostasis The external columella inverted gull wing incision along the nasal tip was closed with a series of interrupted everting 6 0 black nylon sutures The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5 0 plain interrupted sutures At the termination of the case the ear was inspected and the position of the conchal cartilage harvest was hemostatic There was no evidence of hematoma and the patient had a series of brown Steri Strips and Aquaplast cast placed over the nasal dorsum The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well The patient was transferred to the PACU in stable condition He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore Tex implant area He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest Keywords ent otolaryngology nasal deformity rhinoplasty conchal cartilage harvest conchal bulb conchal submucoperichondrial gull wing incision gore tex gull wing incision lower lateral cartilages revision rhinoplasty nasal dorsum cartilage harvest conchal cartilage cartilage nasal deformity hemostasis columella harvest cartilages MEDICAL_TRANSCRIPTION,Description Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma left nasal cavity Medical Specialty ENT Otolaryngology Sample Name Rhinectomy Nasal Endoscopy Transcription PREOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity OPERATIONS PERFORMED 1 Nasal endoscopy 2 Partial rhinectomy ANESTHESIA General endotracheal INDICATIONS This is an 81 year old gentleman who underwent septorhinoplasty many years ago He also has a history of a skin lesion which was removed from the nasal ala many years ago the details of which he does not recall He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip He was evaluated by Dr A who performed the septorhinoplasty and underwent an intranasal biopsy which showed histologic evidence of invasive squamous cell carcinoma The preoperative examination shows induration of the nasal tip without significant erythema There is focal tenderness just cephalad to the alar crease There is no lesion either externally or intranasally PROCEDURE AND FINDINGS The patient was taken to the operating room and placed in supine position Following induction of adequate general endotracheal anesthesia the left nose was decongested with Afrin He was prepped and draped in standard fashion The left nasal cavity was examined by anterior rhinoscopy The septum was midline There was slight asymmetry of the nares No lesion was seen within the nasal cavity either in the area of the intercartilaginous area which was biopsied by Dr A the septum the lateral nasal wall and the floor The 0 degree nasal endoscope was then used to examine the nasal cavity more completely No lesion was detectable A left intercartilaginous incision was made with a 15 blade since this was the area of previous biopsy by Dr A The submucosal tissue was thickened diffusely but there was no identifiable distinct or circumscribed lesion present Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section A diagnosis of diffuse invasive squamous cell carcinoma was rendered An alar incision was made with a 15 blade and the full thickness incision was completed with the electrocautery The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins Additional soft tissue was then taken from all margins tagging them for the pathologist The inferior margins were noted to be clear on the next frozen section report but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone Additional soft tissue was taken in these regions along the superior margin The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology Once all margins had been cleared histologically additional soft tissue was taken from the entire wound A 5 mm chisel was used to take down the inferior aspect of the nasal bone and the medial most aspect of the maxilla This was all submitted to pathology for routine permanent examination Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6 0 nylon suture to provide a barrier and moisture The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well Sponge and needle counts were correct Keywords ent otolaryngology nasal cavity joseph elevator squamous cell carcinoma endoscopy intranasally maxilla nasal ala nasal tip rhinectomy septorhinoplasty nasal endoscopy lateral cartilage frozen section additional soft squamous cell cell carcinoma nasal cartilage squamous carcinoma cavity tissue MEDICAL_TRANSCRIPTION,Description Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus transconjunctival exploration of orbital floor open reduction of nasal septum and nasal pyramid fracture with osteotomy Medical Specialty ENT Otolaryngology Sample Name Sinus Fractures Repairs Transcription PREOPERATIVE DIAGNOSES 1 Depressed anterior table frontal sinus fracture on the right side 2 Right nasoorbital ethmoid fracture 3 Right orbital blowout fracture with entrapped periorbita 4 Nasal septal and nasal pyramid fracture with nasal airway obstruction POSTOPERATIVE DIAGNOSES 1 Depressed anterior table frontal sinus fracture on the right side 2 Right nasoorbital ethmoid fracture 3 Right orbital blowout fracture with entrapped periorbita 4 Nasal septal and nasal pyramid fracture with nasal airway obstruction OPERATION 1 Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus 2 Transconjunctival exploration of right orbital floor with release of entrapped periorbita 3 Open reduction of nasal septum and nasal pyramid fracture with osteotomy ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in the supine position Under affects of general endotracheal anesthesia head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion A gull wing incision was drawn over the forehead scalp Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to but not including the pericranium An inferiorly based forehead flap was then elevated to the superior orbital rim The depression of the anterior table of the frontal sinus was noted An incision was made more posterior creating an inferiorly based pericranial flap The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap These allowed exposure of the medial orbital wall on the right side The displaced fractures of the right medial orbital wall were repositioned through coronal approach Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall The anterior table fracture was satisfactorily reduced Multiple 1 3 mm screws and plate fixation were utilized to recontour the anterior forehead A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall A sinus seeker was utilized and passed into the nasofrontal duct without difficulty It was felt that the frontal sinus obliteration would not be necessary At this point the pericranial flap was folded in a fan folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead At this point the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies which were made medially laterally and percutaneous transverse osteotomy of the nasal bone on the right side There is significant depression of the nasal bone on the left side A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily There is a high septal deviation which would not allow complete correction of the deviation It was felt that this would best be left for a later date Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally Local infiltration anesthesia 1 Xylocaine with 1 100 000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor Hemostasis was achieved with electrocautery There was entrapped periorbita which was released to the fractures which were repositioned but not fixed in position The forced ductions were performed which demonstrated release of the periorbit satisfactorily The conjunctival incision was closed with an interrupted simple 6 0 plain gut suture The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum The coronal incision was closed with interrupted 3 0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples Nose was dressed with Steri Strips Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3 0 Prolene suture and the nose packed with two Kennedy Merocel sponges A supportive mildly compressive dressing with fluffs Kerlix and 4 inch Ace were applied The patient tolerated the procedure well and was returned to recovery room in satisfactory condition Keywords ent otolaryngology frontal sinus nasal septal transconjunctival anterior table ethmoid ethmoid fracture gull wing incision nasal airway obstruction nasal pyramid nasoorbital osteotomy phisohex periorbita depressed anterior table nasal pyramid fracture sinus fractures inferior orbital pyramid fracture entrapped periorbita orbital fractures nasal frontal forehead sinus MEDICAL_TRANSCRIPTION,Description Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose Medical Specialty ENT Otolaryngology Sample Name Rhinoplasty Transcription PREOPERATIVE DIAGNOSES 1 Nasal obstruction secondary to deviated nasal septum 2 Bilateral turbinate hypertrophy PROCEDURE Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 26 year old white female with longstanding nasal obstruction She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose From her functional standpoint she has severe left sided nasal septal deviation with compensatory inferior turbinate hypertrophy From the aesthetic standpoint the nose is over projected lacks rotation and has a large dorsal hump First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump rotate the tip of the nose and de project the nasal tip I explained to her the risks benefits alternatives and complications for postsurgical procedure She had her questions asked and answered and requested that we proceed with surgery as outlined above PROCEDURE DETAILS The patient was taken to the operating room and placed in supine position The appropriate level of general endotracheal anesthesia was induced The face head and neck were sterilely prepped and draped The nose was anesthetized and vasoconstricted in the usual fashion Procedure began with a left hemitransfixion incision which was brought down into the left intercartilaginous incision Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane Intact bilateral septomucoperichondrial flaps were elevated and a severe left sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed Anterior and inferior one third of each inferior turbinate was clamped cut and resected The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm The bony hump of the nose was lowered with a straight osteotome by 4 mm Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip The caudal septum was shortened by 2 mm in an angle in order to enhance rotation Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of 3 0 chromic The upper lateral cartilages were rejoined to the dorsal septum with a 4 0 plain gut suture No middle valves or bone grafts were necessary Intact mucoperichondrial flaps were closed with 4 0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room taken to the recovery room in good condition Keywords ent otolaryngology nasal obstruction cosmetic dorsal hump endotracheal tube hemitransfixion incision hypertrophy intercartilaginous intercartilaginous incision nasal septum nasal tip septomucoperichondrial submucoperichondrial subperiosteal turbinate vomerine spur nasal septal nasal rhinoplasty septum MEDICAL_TRANSCRIPTION,Description Patient with suspected nasal obstruction possible sleep apnea Medical Specialty ENT Otolaryngology Sample Name Recurrent nasal obstruction Transcription CHIEF COMPLAINT Recurrent nasal obstruction HISTORY OF PRESENT ILLNESS The patient is a 5 year old male who was last evaluated by Dr F approximately one year ago for suspected nasal obstruction possible sleep apnea Dr F s assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis All of his symptoms had resolved when he had seen Dr F so no surgical plan was made and no further followup was needed However the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes Again the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature It sounds like he is snoring loudly and does have some nasal obstruction at nighttime He also is sniffing a lot through his nose He has been tried on some nasal steroids but they only use this on a p r n basis about one or two days every month and we are unsure if that has even helped at all probably not The child is not having any problems with his ears including ear infections or hearing He is also not having any problems with strep throat PAST MEDICAL HISTORY Eczema PAST SURGICAL HISTORY None MEDICATIONS None ALLERGIES No known drug allergies FAMILY HISTORY No family history of bleeding diathesis or anesthesia difficulties PHYSICAL EXAMINATION VITAL SIGNS Weight 43 pounds height 37 inches temperature 97 4 pulse 65 and blood pressure 104 48 GENERAL The patient is a well nourished male in no acute distress Listening to his voice today in the clinic he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation NOSE Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea EARS The patient tympanic membranes are clear and intact bilaterally There is no middle ear effusion ORAL CAVITY The patient has 2 tonsils bilaterally There are clearly nonobstructive His uvula is midline NECK No lymphadenopathy appreciated ASSESSMENT AND PLAN This is a 5 year old male who presents for repeat evaluation of a possible nasal obstruction questionable sleep apnea Again the mother gives a confusing sleep history but it does not really sound like he is having apneic events They deny any actual gasping events It sounds like true obstructive events He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately I have given them prescription for Nasacort Aqua one spray to each nostril twice a day I instructed them on correct way to use this and the importance to use it on a daily basis They may not see any benefit for several weeks I would like to evaluate him in six weeks to see how we are progressing If he continues to have problems I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child He may also need an allergy evaluation at that point if he continues to have problems However I would like to be fairly conservative in this child Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen I did instruct her call us if it worsens we may even need to pursue a sleep study just to settle that issue once and for all We will see him back in six weeks Keywords ent otolaryngology recurrent nasal obstruction allergic rhinitis apneic events sleep apnea nasal obstruction nasal apnea allergic obstruction sleep MEDICAL_TRANSCRIPTION,Description An example of normal ENT exam Medical Specialty ENT Otolaryngology Sample Name Sample Normal Exam ENT Transcription NASAL EXAM The nose is grossly in the midline with no evidence of fractures or dislocations The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates There is no pus or polyps in the nose on anterior rhinoscopy The airway appears adequate No external valve prolapses are observed THROAT EXAM The oral cavity is clear The tongue is clear with no lesions noted and with good symmetrical movement The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection Palate is clear The tonsils are not prominent No overt neoplasms in the mouth are noted Lips are clear The voice is adequate no deficits or hoarseness The saliva is clear EARS Canals are clear Eardrums are clear moving on insufflation and swallowing No discharge is noted in the canals Hearing appears adequate in normal tonal conversations NECK EXAM Neck is supple with no palpable masses No lymphadenopathy The thyroid gland is not palpable The trachea is in the midline The parotid and submaxillary glands are not enlarged are symmetrical and are not tender The neck movement is adequate GROSS NEUROLOGICAL EXAM Cranial nerves II XII are intact Extraocular movements are full with no restrictions Patient is alert and responsive EYE EXAM Sclerae are clear Conjunctivae are clear Pupils respond symmetrically to light Extraocular movements are complete and full Keywords ent otolaryngology ent exam boggy mucosa inferior turbinates nasal septum nose oral cavity rhinoscopy submaxillary ducts tongue neck submaxillary parotid parotid and submaxillary extraocular movements ent nasal MEDICAL_TRANSCRIPTION,Description This patient is one day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia She has had an uneventful postoperative night Medical Specialty ENT Otolaryngology Sample Name Postop Parathyroid Exploration Parathyroidectomy Transcription SUMMARY This patient is one day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia She has had an uneventful postoperative night She put out 1175 mL of urine since surgery Her incision looks good IV site and extremities are unremarkable LABORATORY DATA Her calcium level was 7 5 this morning She has been on three Tums orally b i d and I am increasing three Tums orally q i d before meals and at bedtime PLAN I will heparin lock her IV advance her diet and ambulate her I have asked her to increase her prednisone when she goes home She will double her regular dose for the next five days I will advance her diet I will continue to monitor her calcium levels throughout the day If they stabilize I am hopeful that she will be ready for discharge either later today or tomorrow She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p r n pain dispensed 240 mL with one refill Her final calcium dosage will be determined prior to discharge I will plan to see her back in the office on the 12 30 08 and she has been instructed to call or return sooner for any problems Keywords ent otolaryngology parathyroid hyperplasia parathyroid exploration pth hyperplasia parathyroidectomy parathyroidNOTE MEDICAL_TRANSCRIPTION,Description Fever otitis media and possible sepsis Medical Specialty ENT Otolaryngology Sample Name Otitis Media Discharge Summary Transcription ADMITTING DIAGNOSES 1 Fever 2 Otitis media 3 Possible sepsis HISTORY OF PRESENT ILLNESS The patient is a 10 month old male who was seen in the office 1 day prior to admission He has had a 2 day history of fever that has gone up to as high as 103 6 degrees F He has also had intermittent cough nasal congestion and rhinorrhea and no history of rashes He has been taking Tylenol and Advil to help decrease the fevers but the fever has continued to rise He was noted to have some increased workup of breathing and parents returned to the office on the day of admission PAST MEDICAL HISTORY Significant for being born at 33 weeks gestation with a birth weight of 5 pounds and 1 ounce PHYSICAL EXAMINATION On exam he was moderately ill appearing and lethargic HEENT Atraumatic normocephalic Pupils are equal round and reactive to light Tympanic membranes were red and yellow and opaque bilaterally Nares were patent Oropharynx was slightly moist and pink Neck was soft and supple without masses Heart is regular rate and rhythm without murmurs Lungs showed increased workup of breathing moderate tachypnea No rales rhonchi or wheezes were noted Abdomen Soft nontender nondistended Active bowel sounds Neurologic exam showed good muscle strength normal tone Cranial nerves II through XII are grossly intact LABORATORY FINDINGS He had electrolytes BUN and creatinine and glucose all of which were within normal limits White blood cell count was 8 6 with 61 neutrophils 21 lymphocytes 17 monocytes suggestive of a viral infection Urinalysis was completely unremarkable Chest x ray showed a suboptimal inspiration but no evidence of an acute process in the chest HOSPITAL COURSE The patient was admitted to the hospital and allowed a clear liquid diet Activity is as tolerates CBC with differential blood culture electrolytes BUN and creatinine glucose UA and urine culture all were ordered Chest x ray was ordered as well with 2 views to evaluate for a possible pneumonia Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94 Gave D5 and quarter of normal saline at 45 mL per hour which was just slightly above maintenance rate to help with hydration He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis and I will add Tylenol and ibuprofen as needed for fevers Overnight he did have his oxygen saturations drop and went into oxygen overnight His lungs remained clear but because of the need for O2 we instituted albuterol aerosols every 6 hours to help maintain good lung function The nurses were instructed to attempt to wean O2 if possible and advance the diet He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient He did well the following evening with no further oxygen requirement He continued to spike fevers but last fever was around 13 45 on the previous day At the time of exam he had 100 oxygen saturations on room air with temperature of 99 3 degrees F with clear lungs He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning CONDITION OF THE PATIENT AT DISCHARGE He was at 100 oxygen saturations on room air with no further dips at night He has become afebrile and was having no further increased work of breathing DISCHARGE DIAGNOSES 1 Bilateral otitis media 2 Fever PLAN Recommended discharge No restrictions in diet or activity He was continued Omnicef 125 mg 5 mL one teaspoon p o once daily and instructed to follow up with Dr X his primary doctor on the following Tuesday Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy Keywords ent otolaryngology sepsis cough nasal congestion rhinorrhea oxygen saturations otitis media otitis breathing lungs oropharynx fever MEDICAL_TRANSCRIPTION,Description The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures as well as open reduction nasal fracture He is on his eighth hospital day Medical Specialty ENT Otolaryngology Sample Name ORIF Facial Fractures Followup Transcription Mr ABC was transferred to room 123 this afternoon We discussed this with the nurses and it was of course cleared by Dr X The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures as well as open reduction nasal fracture He is on his eighth hospital day The patient had nasal packing in place which was removed this evening This will make it much easier for him to swallow This will facilitate p o fluids and IMF diet Examination of the face revealed some decreased swelling today He had good occlusion with intact intermaxillary fixation His tracheotomy tube is in place It is a size 8 Shiley nonfenestrated He is being suctioned comfortably The patient is in need of something for sleep in the evening so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed Tomorrow we will go ahead and change his trach to a noncuffed or a fenestrated tube so he may communicate and again this will facilitate his swallowing Hopefully we can decannulate the tracheotomy tube in the next few days Overall I believe this patient is doing well and we will look forward to being able to transfer him to the prison infirmary Keywords ent otolaryngology fenestrated tube nasal fracture facial fractures orif tracheotomy tube fractures MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty ENT Otolaryngology Sample Name Normal ENT Exam Transcription EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing Keywords ent otolaryngology erythema tympanic mouth throat ears mucosa noseNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A sample note on otitis media Medical Specialty ENT Otolaryngology Sample Name Otitis Media Transcription OTITIS MEDIA is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other The ear infection itself is not contagious but the respiratory infection preceding it is transmittable Otitis media is most often seen in infants and young children There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes nasal allergy drainage blocking the sinuses or eustachian tubes enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture Many factors can increase the risk of an ear infection like recent upper respiratory tract illness crowded living conditions family history of ear infections day care smoking in household altitude changes cold weather and genetic factors SIGNS AND SYMPTOMS Irritability Ear pain fullness hearing loss Infants may pull on ear Fever Vomiting Discharge from ear Diarrhea TREATMENT Diagnosis is by physical exam and otoscopic exam Sometimes fluid from the ear is cultured Pain relievers like acetaminophen Tylenol Infant pain relievers are available Decongestant to relieve symptoms of upper respiratory tract infection Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin Finish ALL antibiotics as prescribed Do not stop the medication even if symptoms subside Avoid swimming until infection goes away Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids Surgery to remove adenoids if they are enlarged Reduce activity until symptoms subside Call doctor s office if symptoms do not improve within 2 days of treatment and for convulsion fever ear swelling dizziness twitching facial muscles and severe headache Keywords ent otolaryngology ear ear infection otitis media sinuses drainage ear pain fullness hearing loss ear swelling fever bacterial infection eustachian tubes infection eardrum respiratory otitis media eustachian tubes MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty ENT Otolaryngology Sample Name Normal ENT Exam 1 Transcription EARS NOSE MOUTH AND THROAT EARS NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis There are no signs of acute trauma The nose is normal to palpation and inspection externally without evidence of acute trauma Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion inflammation or swelling The tympanic membranes are without disruption or infection Hearing intact bilaterally to normal level speech Nasal mucosa septum and turbinate examination reveals normal mucous membranes without disruption or inflammation The septum is without acute traumatic lesions or disruption The turbinates are without abnormal swelling There is no unusual rhinorrhea or bleeding LIPS TEETH GUMS The lips are without infection mass lesion or traumatic lesions The teeth are intact without obvious signs of infection The gingivae are normal to palpation and inspection OROPHARYNX The oral mucosa is normal The salivary glands are without swelling The hard and soft palates are intact The tongue is without masses or swelling with normal movement The tonsils are without inflammation The posterior pharynx is without mass lesion with good patent oropharyngeal airway Keywords ent otolaryngology oral mucosa lips hearing auditory canals tympanic membranes traumatic lesions mouth throat trauma nose membranes inflammation infection swelling MEDICAL_TRANSCRIPTION,Description Left neck dissection Metastatic papillary cancer left neck The patient had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection Medical Specialty ENT Otolaryngology Sample Name Neck Dissection Transcription PREOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck POSTOPERATIVE DIAGNOSIS Metastatic papillary cancer left neck OPERATION PERFORMED Left neck dissection ANESTHESIA General endotracheal INDICATIONS The patient is a very nice gentleman who has had thyroid cancer papillary cell type removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound which are suspicious for recurrent cancer Left neck dissection is indicated DESCRIPTION OF OPERATION The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered the table was then turned A shoulder roll placed under the shoulders and the face was placed in an extended fashion The left neck chest and face were prepped with Betadine and draped in a sterile fashion A hockey stick skin incision was performed extending a previous incision line superiorly towards the mastoid cortex through skin subcutaneous tissue and platysma with Bovie electrocautery on cut mode Subplatysmal superior and inferior flaps were raised The dissection was left lateral neck dissection encompassing zones 1 2A 2B 3 and the superior portion of 4 The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles stripped from the carotid artery the X cranial nerve the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr X in the paratracheal region The submandibular gland was removed as well The X XI and XII cranial nerves were preserved The internal jugular vein and carotid artery were preserved as well Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure There were two obviously positive nodes in this neck dissection One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2 A 10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2 0 silk ligature The wound was closed in layers using a 3 0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples A fluff and Kling pressure dressing was then applied The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords ent otolaryngology metastatic papillary cancer thyroidectomy thyroid cancer papillary cell type dissection neck metastatic paratracheal papillary cancer MEDICAL_TRANSCRIPTION,Description Nasal septoplasty bilateral submucous resection of the inferior turbinates and tonsillectomy and resection of soft palate Nasal septal deviation with bilateral inferior turbinate hypertrophy Tonsillitis with hypertrophy Edema to the uvula and soft palate Medical Specialty ENT Otolaryngology Sample Name Nasal Septoplasty Tonsillectomy Transcription PREOPERATIVE DIAGNOSES 1 Nasal septal deviation with bilateral inferior turbinate hypertrophy 2 Tonsillitis with hypertrophy 3 Edema to the uvula and soft palate POSTOPERATIVE DIAGNOSES 1 Nasal septal deviation with bilateral inferior turbinate hypertrophy 2 Tonsillitis with hypertrophy 3 Edema to the uvula and soft palate OPERATION PERFORMED 1 Nasal septoplasty 2 Bilateral submucous resection of the inferior turbinates 3 Tonsillectomy and resection of soft palate ANESTHESIA General endotracheal INDICATIONS Chris is a very nice 38 year old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis He also has developed tremendous edema to his posterior palate and uvula which is causing choking Correction of these mechanical abnormalities is indicated DESCRIPTION OF OPERATION The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1 lidocaine with 1 100 000 epinephrine using approximately 10 mL Afrin soaked pledgets were placed in the nasal cavity bilaterally The face was prepped with pHisoHex and draped in a sterile fashion A hemitransfixion incision was performed on the left with a 15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator Anterior to the septal deflection the septal cartilage was incised and an opposite sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps and a large inferior septal spur was removed with a V chisel Once the septum was reduced in the midline the hemitransfixion incision was closed with a 4 0 Vicryl in an interrupted fashion The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope Hemostasis was acquired by using suction electrocautery The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3 0 nylon suture The table was then turned A shoulder roll placed under the shoulders and the face was draped in a clean fashion A McIvor mouth gag was applied The tongue was retracted and the McIvor was gently suspended from the Mayo stand The left tonsil was grasped with a curved Allis forceps retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion The right tonsil was grasped in a similar fashion retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion The inferior middle and superior pole vessels were further cauterized with suction electrocautery The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3 0 Vicryl in a figure of eight interrupted fashion Copious saline irrigation of the oral cavity was then performed There was no further identifiable bleeding at the termination of the procedure The estimated blood loss was less than 10 mL The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords ent otolaryngology nasal septal deviation turbinate hypertrophy nasal septoplasty submucous resection resection of soft palate tonsillectomy bilateral inferior turbinate bovie electrocautery nasal septal inferior turbinates turbinates nasal tonsillitis electrocautery hypertrophy MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies with insertion of Santa Barbara T tube Medical Specialty ENT Otolaryngology Sample Name Myringotomy Tube Insertion 2 Transcription PREOPERATIVE DIAGNOSES Tympanic membrane atelectasis and chronic eustachian tube dysfunction POSTOPERATIVE DIAGNOSES Tympanic membrane atelectasis and chronic eustachian tube dysfunction OPERATIVE PROCEDURE Bilateral myringotomies with insertion of Santa Barbara T tube ANESTHESIA General mask FINDINGS The patient is an 8 year old white female with chronic eustachian tube dysfunction and TM atelectasis was taken to the operating room for tubes At the time of surgery she has had an extruding right Santa Barbara T tube and severe left TM atelectasis with retraction There was a scant amount of fluid in both middle ear clefts DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in supine position and general mask anesthesia was established The right ear was draped in normal sterile fashion Cerumen was removed from the external canal The extruding Santa Barbara T tube was identified and atraumatically removed A fresh Santa Barbara T tube was atraumatically inserted and Ciloxan drops applied The attention was then directed to the left side where severe TM atelectasis was identified With a mask anesthetic the eardrum elevated A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated A Santa Barbara T tube was then inserted without difficulty and 5 drops Ciloxan solution applied Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition Keywords ent otolaryngology tympanic membrane cerumen ciloxan santa barbara t tube tm atelectasis atelectasis eardrum eustachian tube eustachian tube dysfunction middle ear middle ear fluid myringotomies atelectasis and chronic eustachian santa barbara t tube myringotomies with insertion chronic eustachian tube barbara t tube santa barbara insertion tube tympanic MEDICAL_TRANSCRIPTION,Description Nasal septal reconstruction bilateral submucous resection of the inferior turbinates and bilateral outfracture of the inferior turbinates Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy Medical Specialty ENT Otolaryngology Sample Name Nasal Septal Reconstruction Transcription PREOPERATIVE DIAGNOSES 1 Chronic nasal obstruction secondary to deviated nasal septum 2 Inferior turbinate hypertrophy POSTOPERATIVE DIAGNOSES 1 Chronic nasal obstruction secondary to deviated nasal septum 2 Inferior turbinate hypertrophy PROCEDURE PERFORMED 1 Nasal septal reconstruction 2 Bilateral submucous resection of the inferior turbinates 3 Bilateral outfracture of the inferior turbinates ANESTHESIA General endotracheal tube BLOOD LOSS Minimal less than 25 cc INDICATIONS The patient is a 51 year old female with a history of chronic nasal obstruction On physical examination she was derived to have a severely deviated septum with an S shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction PROCEDURE After all risks benefits and alternatives have been discussed with the patient in detail informed consent was obtained The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away Nasal pledgets saturated with 4 cc of 10 cocaine solution were inserted into the nasal cavities These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1 lidocaine with 1 100000 epinephrine solution The nasal pledgets were then reinserted as the patient was prepped in the usual fashion The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0 25 Marcaine solution The nasal vestibules were then cleansed with a pHisoHex solution A 15 blade scalpel was then used to make an incision along the length of the caudal septum The mucoperichondrial junction was then identified with the aid of cotton tipped applicator as well as the stitch scissor Once the plane was identified the mucosal flap on the left side of the septum was elevated with the aid of a Cottle At this point it should be mentioned that the patient s septum was significantly deviated with a large S shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity Again the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur At this point the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur Again the mucosal flap was elevated in the right nasal septum Now Knight scissors were used to remove the ascending portion of the nasal cartilage which was then removed with a Takahashi forceps A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel Once all ascending cartilage has been removed inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient s symptoms Therefore the turbinates were again localized and a 15 blade scalpel was used to make a vertical incision dissected down to the chondral bone The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone Once the submucosal tissue had been resected an outfracture procedure was performed so as to fully open the nasal passages Inspection revealed very patent and nonobstructive nasal passages Now the caudal incision was reapproximated with 4 0 chromic suture Finally a 4 0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion Finally Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident Keywords ent otolaryngology chronic nasal obstruction nasal septum inferior turbinate hypertrophy nasal septal reconstruction submucous resection inferior turbinates outfracture nasal septal nasal pledgets nasal cavity nasal obstruction turbinate hypertrophy mucosal flap septal septum turbinates nasal cavity chronic hypertrophy obstruction mucosal MEDICAL_TRANSCRIPTION,Description Right middle ear exploration with a Goldenberg TORP reconstruction Medical Specialty ENT Otolaryngology Sample Name Middle Ear Exploration Transcription PREOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss POSTOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss PROCEDURE PERFORMED Right middle ear exploration with a Goldenberg TORP reconstruction ANESTHESIA General ESTIMATED BLOOD LOSS Less than 5 cc COMPLICATIONS None DESCRIPTION OF FINDINGS The patient consented to revision surgery because of the profound hearing loss in her right ear It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate She had reports of stapes fixation as well as otosclerosis on her CT scan At surgery she was found to have a mobile malleus handle but her stapes was fixed by otosclerosis There was no incus There was no specific round window niche There was a very minute crevice however exploration of this area did not reveal a niche to a round window membrane The patient had a type of TORP prosthesis which had tilted off the footplate anteriorly underneath the malleus handle DESCRIPTION OF THE PROCEDURE The patient was brought to the operative room and placed in supine position The right face ear and neck prepped with alcohol solution The right ear was draped in the sterile field External auditory canal was injected with 1 Xylocaine with 1 50 000 epinephrine A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o clock to the 7 o clock position Meatal skin was elevated middle ear was entered This exposure included the oval window round window areas There was a good cartilage graft in place and incorporated into the posterior superior of the drum The previous prosthesis was found out of position as it had tilted out of position anteriorly and there was no contact with the footplate The prosthesis was removed without difficulty The patient s stapes had an arch but the was atrophied Malleus handle was mobile The footplate was fixed Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion however upon inspection of the round window area there was found to be no definable round window niche no round window membrane The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation She is not considered to be a reconstruction candidate under the current circumstances No attempt was made to remove bone from the round window area A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate The fit was secure and supported with Gelfoam in the middle ear The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex The incision was closed with 4 0 Vicryl and individual 5 0 nylon to the skin and a sterile dressing was applied Keywords ent otolaryngology conductive hearing loss goldenberg meatal skin torp torp reconstruction ear ear exploration handle malleus otosclerosis sensorineural stapedectomy tympanomeatal middle ear exploration hearing loss malleus handle middle ear middle MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies and insertion of Shepard grommet draining tubes Medical Specialty ENT Otolaryngology Sample Name Myringotomy Tube Insertion 1 Transcription PREOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media POSTOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media OPERATION PERFORMED 1 Bilateral myringotomies 2 Insertion of Shepard grommet draining tubes ANESTHESIA General by mask ESTIMATED BLOOD LOSS Less than 1 mL COMPLICATIONS None FINDINGS The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same At this point in time he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed but no active acute infection at this point in time PROCEDURE With the patient under adequate general anesthesia with the mask delivery of anesthesia he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides Bilateral inferior radial myringotomies were performed first on the right and then on the left Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side Floxin drops were then instilled bilaterally to decrease any clotting within the tubes and then cotton ball was placed in the external meatus bilaterally At this point the patient was awakened and returned to the recovery room satisfactory with no difficulty encountered Keywords ent otolaryngology serous otitis media floxin drops shepard grommet cerumen cotton ball middle ear mucoid myringotomies tubes shepard grommet draining tubes serous otitis shepard grommet insertion MEDICAL_TRANSCRIPTION,Description Microsuspension direct laryngoscopy with biopsy Fullness in right base of the tongue and chronic right ear otalgia Medical Specialty ENT Otolaryngology Sample Name Microsuspension Direct Laryngoscopy Biopsy Transcription PREOPERATIVE DIAGNOSES 1 Fullness in right base of the tongue 2 Chronic right ear otalgia POSTOPERATIVE DIAGNOSIS Pending pathology PROCEDURE PERFORMED Microsuspension direct laryngoscopy with biopsy ANESTHESIA General INDICATION This is a 50 year old female who presents to the office with a chief complaint of ear pain on the right side Exact etiology of her ear pain had not been identified A fiberoptic examination had been performed in the office Upon examination she was noted to have fullness in the right base of her tongue She was counseled on the risks benefits and alternatives to surgery and consented to such PROCEDURE After informed consent was obtained the patient was brought to the Operative Suite where she was placed in supine position General endotracheal tube intubation was delivered by the Department of Anesthesia The patient was rotated 90 degrees away where a shoulder roll was placed A tooth guard was then placed to protect the upper dentition The Dedo laryngoscope was then inserted into the oral cavity It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view At this point it was advanced underneath the epiglottis until the vocal cords were seen At this point it was suspended via the Lewy suspension arm from the Mayo stand At this point the Zeiss microscope with a 400 mm lens was brought into the surgical field Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities It should be mentioned that the right vocal cord did appear to be slightly more hyperemic however there were no mucosal abnormalities identified This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle At this point the scope was desuspended and the microscope was removed The scope was withdrawn through the vallecular region Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable Biopsies were obtained with straight biting cup forceps Once hemostasis was achieved the scope was advanced into the piriform sinuses Again in the right piriform sinus there was noted to be studding along the right lateral wall of the piriform sinus Again biopsies were performed and once hemostasis was achieved the scope was further withdrawn down the lateral pharyngeal wall There were no mucosal abnormalities identified within the oropharynx The scope was then completely removed and a bimanual examination was performed No neck masses were identified At this point the procedure was complete The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident Keywords ent otolaryngology microsuspension laryngoscopy otalgia ear pain fiberoptic dedo laryngoscope epiglottis direct laryngoscopy piriform sinuses tongue microscope mucosal abnormalities fullness ear scope MEDICAL_TRANSCRIPTION,Description Open reduction nasal fracture with nasal septoplasty Medical Specialty ENT Otolaryngology Sample Name Nasal Septoplasty Transcription PREOPERATIVE DIAGNOSES Nasal fracture and deviated nasal septum with obstruction POSTOPERATIVE DIAGNOSES Nasal fracture and deviated nasal septum with obstruction OPERATION Open reduction nasal fracture with nasal septoplasty ANESTHESIA General HISTORY This 16 year old male fractured his nose playing basketball He has a left nasal obstruction and depressed left nasal bone DESCRIPTION OF PROCEDURE The patient was given general endotracheal anesthesia and monitored with pulse oximetry EKG and CO2 monitors The face was prepped with Betadine soap and solution and draped in a sterile fashion Nasal mucosa was decongested using Afrin pledgets as well as 1 Xylocaine 1 100 000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum lateral osteotomy sites Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve Further up the cartilaginous septum was displaced to the left of the maxillary crest There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate There was a large deep groove horizontally on the right side corresponding to the left maxillary crest A left hemitransfixion incision was made Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels which was rather difficult at the area of the vomerine spur which was very sharp and touching the inferior turbinate The caudal cartilaginous septum which was lying crosswise was separated from the main cartilage leaving approximately 1 cm strut The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area The caudal cartilaginous strut was sutured to the columella with interrupted 4 0 chromic catgut suture to bring it into the midline Further back the cartilaginous septum anterior to the ethmoid plate was deviated to the left side so it was freed from the maxillary crest nasal dorsum from the ethmoid plate and was sutured in the midline with a transfixion 4 0 plain catgut sutures Further posteriorly the ethmoid plate was deviated to the left side and portion of it was removed with Jansen Middleton punch forceps The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage This area was freed from the perichondrium on both sides The maxillary crest was removed with a gouge Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline Thus the deviated septum was corrected Left hemitransfixion incisions were closed with interrupted 4 0 chromic catgut sutures The septum was also filtered with 4 0 plain catgut sutures By valve septal splints were tied to the septum bilaterally with a transfixion 5 0 nylon suture Next the nasal bone suture deviated to the left side were corrected The right nasal bone was depressed and left nasal bone was wide Therefore the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline Steri Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment Approximate blood loss was 10 to 20 mL Keywords ent otolaryngology nasal fracture deviated nasal septum nasal septoplasty nasal bones ethmoid plate cartilaginous septum nasal bone maxillary crest septum nasal fracture maxillary cartilaginous crest MEDICAL_TRANSCRIPTION,Description Suspension microlaryngoscopy rigid bronchoscopy dilation of tracheal stenosis Medical Specialty ENT Otolaryngology Sample Name Microlaryngoscopy Transcription PREOPERATIVE DIAGNOSIS Airway obstruction secondary to laryngeal subglottic stenosis POSTOPERATIVE DIAGNOSIS Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis OPERATION PERFORMED Suspension microlaryngoscopy rigid bronchoscopy dilation of tracheal stenosis INDICATIONS FOR SURGERY The patient is a 56 year old white female with a history of relapsing polychondritis which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway She currently is trach dependent for her airway because of glottic and subglottic stenosis but she is having no significant problems breathing and talking around her trach tube and came for further evaluation Endoscopic reevaluation of her tube and nature of the proposed procedure done Risk and complications of bleeding infection alteration of with speech or swallowing failure to improve her airway and loss of voice Cardiorespiratory anesthetic results were discussed in length The patient states she understood and wished to proceed DESCRIPTION OF OPERATION The patient was taken to the operating room and placed in the supine position Under adequate general endotracheal anesthesia the patient s 5 metal tracheostomy tube was removed and a 5 laser safe endotracheal tube was inserted The patient was then prepared for endoscopy The Kantor laryngoscope was then inserted Oral cavity hypopharynx larynx and nasal cavity showed good dentition with good tongue buccal cavity and mucosa without lesions Larynx was then short epiglottis Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords This appeared to be stable and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild to moderate subglottic stenosis otherwise this appeared to be stable However distally the level of the trach site examined with the microscope and 0 and 30 degree telescopes The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube The laryngoscope was removed and a 5 x 30 pediatric rigid bronchoscope was then passed The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out Mid and distal trachea were widely patent Trachea and mainstem bronchi were patent without obvious disease The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant This was further dilated and following which was removed and a new 5 metal tracheostomy tube inserted The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition Keywords ent otolaryngology airway obstruction oral cavity bronchoscopy buccal cavity hypopharynx laryngeal larynx microlaryngoscopy nasal cavity polychondritis subglottic tracheal stenosis tracheostomy tube scar tissue subglottic stenosis tracheal airway cavity tube scarring stenosis MEDICAL_TRANSCRIPTION,Description Suspected mastoiditis ruled out right acute otitis media and severe ear pain resolving The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis Medical Specialty ENT Otolaryngology Sample Name Mastoiditis Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Suspected mastoiditis ruled out 2 Right acute otitis media 3 Severe ear pain resolving HISTORY OF PRESENT ILLNESS The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis The child has had very severe ear pain and blood draining from the right ear The child had a temperature maximum of 101 4 in the ER The patient was admitted and started on IV Unasyn which he tolerated well and required Morphine and Vicodin for pain control In the first 12 hours after admission the patient s pain decreased and also swelling of his cervical area decreased The patient was evaluated by Dr X from the ENT while in house After reviewing the CT scan it was felt that the CT scan was not consistent with mastoiditis The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge At the time of discharge his pain is markedly decreased about 2 10 and swelling in the area has improved The patient is also able to take p o well DISCHARGE PHYSICAL EXAMINATION GENERAL The patient is alert in no respiratory distress VITAL SIGNS His temperature is 97 6 heart rate 83 blood pressure 105 57 respiratory rate 16 on room air HEENT Right ear shows no redness The area behind his ear is nontender There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly NECK Supple CHEST Clear breath sounds CARDIAC Normal S1 S2 without murmur ABDOMEN Soft There is no hepatosplenomegaly or tenderness SKIN Warm and well perfused DISCHARGE WEIGHT 38 7 kg DISCHARGE CONDITION Good DISCHARGE DIET Regular as tolerated DISCHARGE MEDICATIONS 1 Ciprodex Otic Solution in the right ear twice daily 2 Augmentin 500 mg three times daily x10 days FOLLOW UP 1 Dr Y in one week ENT 2 The primary care physician in 2 to 3 days TIME SPENT Approximate discharge time is 28 minutes Keywords MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies insertion of PE tubes and pharyngeal anesthesia Medical Specialty ENT Otolaryngology Sample Name Myringotomy Tube Insertion Transcription PREOPERATIVE DIAGNOSES Chronic otitis media with effusion conductive hearing loss and recurrent acute otitis media POSTOPERATIVE DIAGNOSES Chronic otitis media with effusion conductive hearing loss and recurrent acute otitis media OPERATION Bilateral myringotomies insertion of PE tubes and pharyngeal anesthesia ANESTHESIA General via facemask ESTIMATED BLOOD LOSS None COMPLICATIONS None INDICATIONS The patient is a one year old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy PROCEDURE The patient was brought to the operating room was placed in supine position General anesthesia was begun via face mask technique Once an adequate level of anesthesia was obtained the operating microscope was brought positioned and visualized the right ear canal A small amount of wax was removed with a loop A 4 mm operating speculum was then introduced An anteroinferior quadrant radial myringotomy was then performed A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft Reuter bobbin PE tube was then inserted followed by Floxin otic drops and a cotton ball in the external meatus Head was then turned to the opposite side where similar procedure was performed Once again the middle ear cleft had a mucoid effusion A tube was inserted to an anteroinferior quadrant radial myringotomy Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs Keywords ent otolaryngology bilateral myringotomies insertion of pe tubes chronic otitis media conductive hearing loss recurrent acute otitis media reuter bobbin radial myringotomy ear cleft pe tubes middle ear otitis media effusion otitis media ear anesthesia MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis Medical Specialty ENT Otolaryngology Sample Name Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis POSTOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis OPERATION PREFORMED Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis INDICATIONS FOR THE SURGERY The patient is a 76 year old white female with a history of subglottic upper tracheal stenosis She has had undergone multiple previous endoscopic procedures in the past last procedure was in January 2007 She returns with some increasing shortness of breath and dyspnea on exertion Endoscopic reevaluation is offered to her The patient has been considering laryngotracheal reconstruction however due to a recent death in the family she has postponed this but she has been having increasing symptoms An endoscopic treatment was offered to her Nature of the proposed procedure including risks and complications involving bleeding infection alteration of voice speech or swallowing hoarseness changing permanently recurrence of stenosis despite a surgical intervention airway obstruction necessitating a tracheostomy now or in the future cardiorespiratory and anesthetic risks were all discussed in length The patient states she understood and wished to proceed DESCRIPTION OF THE OPERATION The patient was taken to the operating room placed on table in supine position Following adequate general anesthesia the patient was prepared for endoscopy The top sliding laryngoscope was then inserted in the oral cavity pharynx and larynx examined In the oral cavity she had good dentition Tongue and buccal cavity mucosa were without ulcers masses or lesions The oropharynx was clear The larynx was then manually suspended Epiglottis area epiglottic folds false cords true vocal folds with some mild edema but otherwise without ulcers masses or lesions and the supraglottic and glottic airway were widely patent The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds At the base of the subglottis there was a narrowing and in the upper trachea restenosis had occurred Moderate amount of mucoid secretions these were suctioned following which the area of stenosis was dilated Remainder of the bronchi was then examined The mid and distal trachea were widely patent Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers lesions or evidence of scarring The scope was pulled back and removed and following this a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out Once this had been completed dramatic improvement in the subglottic upper tracheal airway accomplished Instrumentation was removed and a 6 endotracheal tube uncuffed was placed to allow smooth emerge from anesthesia The patient tolerated the procedure well without complication Keywords ent otolaryngology stenosis epiglottis subglottic bronchoscope bronchoscopy endoscopic laryngoscopy laryngotracheal reconstruction larynx oral cavity pharynx tracheal true vocal folds vocal upper tracheal stenosis subglottic upper tracheal subglottic upper upper tracheal airway cavity patent MEDICAL_TRANSCRIPTION,Description Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma Medical Specialty ENT Otolaryngology Sample Name I D Auricular Hematoma Transcription PREOPERATIVE DIAGNOSIS Recurrent severe right auricular hematoma POSTOPERATIVE DIAGNOSIS Recurrent severe right auricular hematoma TITLE OF PROCEDURE Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 2 mL COMPLICATIONS None FINDINGS Approximately 5 mL of serosanguineous drainage PROCEDURE The patient underwent an incision and drainage procedure with stay suture placement on 05 28 2008 by me and also by Dr X on 05 23 2008 for a large near 100 auricular hematoma She presents for suture removal however there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr X It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters Consent was obtained The patient is aware that the complications with this ear area severe and auricular deformity is inevitable however quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation The area was prepped in the usual manner localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted A through and through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression She tolerated this procedure very well Keywords ent otolaryngology bolster dressing placement antihelix fold incision and drainage bolster dressing auricular hematoma auricular hematoma incision drainage MEDICAL_TRANSCRIPTION,Description Flexible nasal laryngoscopy Foreign body left vallecula at the base of the tongue Airway is patent and stable Medical Specialty ENT Otolaryngology Sample Name Flexible Nasal Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Oropharyngeal foreign body POSTOPERATIVE DIAGNOSES 1 Foreign body left vallecula at the base of the tongue 2 Airway is patent and stable PROCEDURE PERFORMED Flexible nasal laryngoscopy ANESTHESIA ______ with viscous lidocaine nasal spray INDICATIONS The patient is a 39 year old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken The patient felt that he had ingested a chicken bone tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body PROCEDURE After verbal informed consent was obtained the patient was placed in the upright position The fiberoptic nasal laryngoscope was inserted in the patient s right naris and then the left naris There was visualized some bilateral caudal spurring of the septum The turbinates were within normal limits There was some posterior nasoseptal deviation to the left The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity The nasal mucous membranes were pink and moist There was no evidence of mass ulceration lesion or obstruction The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally There was evidence of some mild erythema in the right fossa Rosenmüller There was no evidence of mass lesion or ulceration in this area however The eustachian tubes were patent without obstruction The scope was further advanced to the level of the oropharynx where the base of the tongue vallecula and epiglottis were visualized There was evidence of a 1 5 cm left vallecular white foreign body The rest of the oropharynx was without abnormality The epiglottis was within normal limits and was noted to be omega in shape There was no edema or erythema to the epiglottis The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords There was no evidence of erythema or edema of the posterior commissure arytenoid cartilage or superior surface of the vocal cords The laryngeal surface of the epiglottis was within normal limits There was no evidence of mass lesion or nodularity of the vocal cords The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam The glottic aperture was completely patent with inspiration The anterior commissure epiglottic folds false vocal cords and piriform sinuses were all within normal limits The scope was then removed without difficulty The patient tolerated the procedure well and remained in stable condition FINDINGS 1 A 1 5 cm white foreign body consistent with a chicken bone at the left vallecular region There is no evidence of supraglottic or piriform sinuses foreign body 2 Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller No mass is appreciated at this time PLAN The patient is to go to the operating room for direct laryngoscopy microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a m Airway precautions were instituted The patient currently remained in stable condition Keywords ent otolaryngology oropharyngeal foreign body flexible nasal laryngoscopy nasal spray foreign body tongue laryngoscopy erythema epiglottis nasal oropharyngeal MEDICAL_TRANSCRIPTION,Description Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping Hoarseness bilateral true vocal cord lesions and leukoplakia Medical Specialty ENT Otolaryngology Sample Name Laryngoscopy Vocal Cord Biopsy Transcription PREOPERATIVE DIAGNOSES 1 Hoarseness 2 Bilateral true vocal cord lesions 3 Leukoplakia POSTOPERATIVE DIAGNOSES 1 Hoarseness 2 Bilateral true vocal cord lesions 3 Leukoplakia PROCEDURE PERFORMED Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 33 year old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office Discussed risks complications and consequences of a surgical biopsy of the left true vocal cord and consent was obtained PROCEDURE The patient was brought to operative suite by anesthesia placed on the operating table in supine position After this the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg After this a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient s oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx The patient s larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one third up to the anterior third The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region The patient s anterior commissure appeared to be clear The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord Once the true vocal cord was retracted laterally there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one third aspect The patient s subglottic region was very edematous and with redundant mucosal tissue The areas of leukoplakia appeared to be cobblestoned in appearance irregularly bordered and very hard to the touch The left true vocal cord was then first addressed was stripped from posteriorly to anteriorly utilizing a 45 laryngeal forceps After this the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis The specimen was passed off the field and was sent to Pathology for evaluation Hemostasis was maintained on the left side Prior to taking this biopsy the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand The Zeiss operating microscope was then brought into view to directly visualize the vocal cords The biopsies were taken under direct visualization utilizing the Zeiss operating microscope After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed the scope was then pulled more cephalad and the piriform sinuses valecula and base of the tongue were all directly visualized which appeared normal except for the left base of tongue appeared to be full This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions A bimanual examination was then performed which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions There were no signs of any palpable cervical lymphadenopathy The tooth guard was removed and the patient was then turned back to anesthesia The patient did receive intraoperatively 10 mg of Decadron The patient tolerated the procedure well and was extubated in the operating room The patient was transferred to recovery room in stable condition and tolerated the procedure well The patient will be sent home with prescriptions for Medrol DOSEPAK Tylenol with Codeine Elixir and amoxicillin 250 mg per 5 cc Keywords ent otolaryngology direct laryngoscopy zeiss operating microscope vocal cord lesions vocal cord cord vocal microscopic laryngoscopy hoarseness biopsy leukoplakia MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of the larynx Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy Medical Specialty ENT Otolaryngology Sample Name Laryngectomy Thyroid Lobectomy Transcription TITLE OF OPERATION Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy INDICATION FOR SURGERY A 58 year old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06 07 Subsequently biopsy confirmed tumor persistence in the right glottic region Risks benefits and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks benefits and alternatives He was accompanied by his wife and daughter Risks included but were not limited to anesthesia bleeding infection injury of the nerves including lower lip weakness tongue weakness tongue numbness shoulder weakness need for physical therapy possibility of total laryngectomy possibility of inability to speak or swallow difficulty eating wound care issues failure to heal need for additional treatment and the patient understood all of these issues and they wished to proceed PREOP DIAGNOSIS Squamous cell carcinoma of the larynx POSTOP DIAGNOSIS Squamous cell carcinoma of the larynx PROCEDURE DETAIL After identifying the patient the patient was placed supine on the operating room table After the establishment of the general anesthesia via oral endotracheal intubation the patient had his eyes protected with Tegaderm A 6 endotracheal tube was placed initially Direct laryngoscopy was performed with a Lindholm laryngoscope A 0 degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis Subsequently a decision was then made to go ahead and perform the surgical intervention A hemi apron incision was employed and 1 lidocaine with 1 100 000 epinephrine was injected A shoulder roll was applied after the patient was prepped and draped in a sterile fashion Subsequently a hemi apron incision was performed Subplatysmal flaps were raised at the hyoid bone into the clavicle Attention was then turned to the right side where a level 2 3 4 neck dissection was performed Submandibular fascia was appreciated inferiorly along the submandibular gland this was incised allowing for identification of the digastric muscle Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified Level 2A contents were then dissected off the floor of the neck including levels 3 and 4 Preservation of the phrenic nerve was obtained by identification and subsequently cross clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4 The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve Levels 2 3 4 neck dissection specimens were then labeled appropriately attached with staples and sent for histopathological evaluation Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed Subsequently the strap muscles were separated in the midline The trachea was identified in the midline The thyroid isthmus was plicated using the Harmonic scalpel and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage Once this was performed sinuses were mobilized from the thyroid cartilage both on the right and left side respectively The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular Attention was then turned to performing a cricothyrotomy Upon performing this it was obvious that there was tumor just above the level of the cricothyrotomy incision A 7 anode tube was then placed in this area and secured Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis Subsequently the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage and the thyroid cartilage was then intentionally fractured along the anterior spine It was evident that this tumor had extended more than 1 cm into the subglottic region Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly though it was evident that the cricoid cartilage was invaded Frozen section biopsy then confirmed this finding as read by Dr X of Surgical Pathology In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage the patient s case was then converted into a total laryngectomy Subsequently the trachea was transected at the level 3 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3 0 vertical mattress sutures for the skin A W plasty was also performed to allow for enlargement of the stoma Attention was then turned to identifying the common parting wall of the trachea and the esophagus Attention was then turned to resecting the hyoid bone The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism The wound was copiously irrigated Subsequently a tracheoesophageal puncture site was performed using a right angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect Once this was performed a running 3 0 canal stitch was used to close the pharynx Subsequently interrupted 4 0 chromic stitches were then used as reinforcement line from superior to inferior and fibrin glue was applied Two 10 JP drains were placed on the right side and one on the left side and secured appropriately with 3 0 nylon The wound was then closed using interrupted 3 0 Vicryl for the platysma and staples for the skin The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later Keywords ent otolaryngology laryngectomy neck dissection tracheoesophageal cricopharyngeal myotomy thyroid lobectomy squamous cell carcinoma larynx thyroid cartilage cricoid cartilage total laryngectomy thyroid cartilage MEDICAL_TRANSCRIPTION,Description Functional endoscopic sinus surgery bilateral maxillary antrostomy bilateral total ethmoidectomy bilateral nasal polypectomy and right middle turbinate reduction Medical Specialty ENT Otolaryngology Sample Name Ethmoidectomy Nasal Polypectomy Transcription PROCEDURES PERFORMED 1 Functional endoscopic sinus surgery 2 Bilateral maxillary antrostomy 3 Bilateral total ethmoidectomy 4 Bilateral nasal polypectomy 5 Right middle turbinate reduction ANESTHESIA General endotracheal tube BLOOD LOSS Approximately 50 cc INDICATION This is a 48 year old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally PROCEDURE After all risks benefits and alternatives have been discussed with the patient in detail informed consent was obtained The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10 cocaine solution were inserted into the nasal cavity The nasal septum as well as the turbinates were then localized with a mixture of 1 lidocaine with 1 100 000 epinephrine solution The patient was then prepped and draped in the usual fashion Attention was directed first to the left nasal cavity A zero degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate There was also polypoid disease present within the left middle meatus Nasopharynx was visualized with a patent eustachian tube At this point the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate The ostium to the sphenoid sinus was visualized and was not entered At this point the left middle turbinate was localized and then medialized with the use of a freer elevator A ball tip probe was then used to localize the openings for the natural maxillary ostium Side biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider The opening of the maxillary sinus was visualized The posterior fontanelle was taken down with the use of straight line forceps It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident The maxillary sinus ostia was then suctioned with Olive tip suction and maxillary wash was performed The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient s eyes for any vibration All polypoid tissue was collected in the microdebrider and sent as a surgical specimen Once all polypoid tissue has been removed the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes Attention was then directed to the right nasal cavity Again a sinus endoscope was inserted Inspection revealed a grossly hypertrophied turbinate It was felt that this enlarged and polypoid turbinate was contributing the patient s symptoms Therefore the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate which was then resected with use of side biting scissors as well the Takahashi forceps Sinus endoscope was then inserted all the way down through the nasopharynx Again the eustachian tube was visualized without any obstructing lesions or masses Upon retraction there was again polypoid tissue noted within the ethmoid sinuses The ball tip probe was again used to locate the right maxillary ostium The side biting forceps was used further take down the uncinate process The maxillary ostium was then widened with use of a XPS microdebrider A maxillary sinus wash was then performed Now the attention was directed to the ethmoid air cells It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient s eye Once all polypoid tissue have been removed some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner Once all bleeding has been controlled all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room At this point the procedure was felt to be complete The patient was awakened and taken to the recovery room without incident Keywords ent otolaryngology endoscopic sinus surgery maxillary antrostomy ethmoidectomy nasal polypectomy turbinate reduction sinus surgery sinus endoscope maxillary sinus nasal cavity polypoid tissue sinus maxillary turbinate polypoid nasal total ostium microdebrider MEDICAL_TRANSCRIPTION,Description Incompetent glottis Fat harvesting from the upper thigh micro laryngoscopy fat injection thyroplasty Medical Specialty ENT Otolaryngology Sample Name Fat Harvesting Transcription PREOPERATIVE DIAGNOSIS Incompetent glottis POSTOPERATIVE DIAGNOSIS Incompetent glottis OPERATION PERFORMED 1 Fat harvesting from the upper thigh 2 Micro laryngoscopy 3 Fat injection thyroplasty FINDINGS AND PROCEDURE With the patient in the supine position under adequate general endotracheal anesthesia the operative area was prepped and draped in a routine fashion A 1 cm incision was made in the upper thigh and approximately 5 cc of fat was liposuctioned from the subcutaneous space After this had been accomplished the wound was closed with an interrupted subcuticular suture of 4 0 chromic and a light compression dressing was applied Next the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin After this had been accomplished it was placed in a 3 cc BD syringe and thence into the Stasney fat injector device Next a Dedo laryngoscope was used to visualize the larynx and approximately cc of fat was injected into the right TA muscle and cc of fat into the left TA muscle The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition Estimated blood loss was negligible Keywords ent otolaryngology dedo laryngoscope physiosol micro laryngoscopy fat injection fat harvesting incompetent glottis laryngoscopy thyroplasty glottis thigh MEDICAL_TRANSCRIPTION,Description Fiberoptic nasolaryngoscopy Dysphagia with no signs of piriform sinus pooling or aspiration Right parapharyngeal lesion likely thyroid cartilage nonhemorrhagic Medical Specialty ENT Otolaryngology Sample Name Fiberoptic Nasolaryngoscopy Transcription PREOPERATIVE DIAGNOSES 1 Dysphagia 2 Right parapharyngeal hemorrhagic lesion POSTOPERATIVE DIAGNOSES 1 Dysphagia with no signs of piriform sinus pooling or aspiration 2 No parapharyngeal hemorrhagic lesion noted 3 Right parapharyngeal lesion likely thyroid cartilage nonhemorrhagic PROCEDURE PERFORMED Fiberoptic nasolaryngoscopy ANESTHESIA None COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 93 year old Caucasian male who was admitted to ABCD General Hospital on 08 07 2003 secondary to ischemic ulcer on the right foot ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08 17 03 with a fiberoptic nasolaryngoscopy a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation The patient subsequently resolved with his dysphagia and workup of Speech was obtained which showed no aspiration no pooling minimal premature spillage with solids but good protection of the airway This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior PROCEDURE DETAILS The patient was brought in the semi Fowler s position a fiberoptic nasal laryngoscope was then passed into the patient s right nasal passage all the way to the nasopharynx The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx and down to the hypopharynx The patient s oro and nasopharynx all appeared normal with no signs of any gross lesions edema or ecchymosis Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx There were no signs of any obstruction The epiglottis piriform sinuses vallecula and base of tongue all appeared normal with no signs of any gross lesions The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions The scope was then pulled out and the patient tolerated the procedure well At this time we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion Keywords ent otolaryngology parapharyngeal dysphagia sinus pooling piriform nasolaryngoscopy fiberoptic laryngoscope nasopharynx oropharynx fiberoptic nasolaryngoscopy hemorrhagic lesion aspiration cartilage hypopharynx lesion MEDICAL_TRANSCRIPTION,Description Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy Medical Specialty ENT Otolaryngology Sample Name ENT Consult 1 Transcription CHIEF COMPLAINT Chronic otitis media adenoid hypertrophy HISTORY OF PRESENT ILLNESS The patient is a 2 1 2 year old with a history of persistent bouts of otitis media superimposed upon persistent middle ear effusions He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes ALLERGIES None MEDICATIONS Antibiotics p r n FAMILY HISTORY Diabetes heart disease hearing loss allergy and cancer MEDICAL HISTORY Unremarkable SURGICAL HISTORY None SOCIAL HISTORY Some minor second hand tobacco exposure There are no pets in the home PHYSICAL EXAMINATION Ears are well retracted immobile Tympanic membranes with effusions present bilaterally No severe congestions thick mucoid secretions no airflow Oral cavity Oropharynx 2 to 3 tonsils No exudates Floor of mouth and tongue are normal Larynx and pharynx not examined Neck No nodes masses or thyromegaly Lungs Reveal rare rhonchi otherwise clear Cardiac exam Regular rate and rhythm No murmurs Abdomen Soft nontender Positive bowel sounds Neurologic exam Nonfocal IMPRESSION Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy PLAN The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes Keywords ent otolaryngology chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy pe tubes otitis media with effusion adenoidectomy and bilateral myringotomy eustachian tube dysfunction insertion of pe chronic otitis media bilateral myringotomy otitis media adenoidectomy myringotomy adenoid hypertrophy otitis media MEDICAL_TRANSCRIPTION,Description Left ear cartilage graft repair of nasal vestibular stenosis using an ear cartilage graft cosmetic rhinoplasty left inferior turbinectomy Medical Specialty ENT Otolaryngology Sample Name Ear Cartilage Graft Transcription PREOPERATIVE DIAGNOSES 1 Posttraumatic nasal deformity 2 Nasal obstruction 3 Nasal valve collapse 4 Request for cosmetic change with excellent appearance of nose POSTOPERATIVE DIAGNOSES 1 Posttraumatic nasal deformity 2 Nasal obstruction 3 Nasal valve collapse 4 Request for cosmetic change with excellent appearance of nose OPERATIVE PROCEDURES 1 Left ear cartilage graft 2 Repair of nasal vestibular stenosis using an ear cartilage graft 3 Cosmetic rhinoplasty 4 Left inferior turbinectomy ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair We discussed with the patient the indications risks benefits alternatives and complications of the proposed surgical procedure she had her questions asked and answered Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager The patient had questions asked and answered Informed consent was obtained PROCEDURE IN DETAIL The patient was taken to the operating room and placed in supine position The appropriate level of general endotracheal anesthesia was induced The patient was converted to the lounge chair position and the nose was anesthetized and vasoconstricted in the usual fashion Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum The septal angle was approached and submucoperichondrial flaps were elevated Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered The upper laterals were divided and medial and lateral osteotomies were carried out Inadequate septal cartilage was noted to be present for use as spreader graft therefore left postauricular incision was made and the conchal bowl cartilage graft was harvested and it was closed with 3 0 running locking chromic with a sterile cotton ball pressure dressing applied Ear cartilage graft was then placed to put two spreader grafts on the left and one the right The two on the left extended all the way up to the caudal tip the one on the right just primarily the medial wall It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum The upper lateral cartilage was noted to be of the same width and length in size Yet the left lower cartilage was scarred and adherent to the upper lateral cartilage The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages A middle crus stitch was used to unite the domes and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height The spreader brought an excellent aesthetic appearance to the nose We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height Mucoperichondrial flaps were closed with 4 0 plain gut suture The skin was closed with 5 0 chromic and 6 0 fast absorbing gut Doyle splints were placed on each side of nasal septum and secured with 3 0 nylon and a Denver splint was applied The patient was awakened in the operating room and taken to the recovery room in good condition Keywords ent otolaryngology nasal deformity nasal obstruction nasal valve cartilage cartilaginous crural graft nasal fracture postauricular rhinoplasty septal cartilage submucoperichondrial turbinectomy vestibular ear cartilage graft posttraumatic nasal deformity vestibular stenosis ear cartilage cartilage graft cartilages caudal nasal nose obstruction repair stenosis MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy and bronchoscopy Medical Specialty ENT Otolaryngology Sample Name Direct Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic stenosis POSTOPERATIVE DIAGNOSIS Subglottic stenosis OPERATIVE PROCEDURES Direct laryngoscopy and bronchoscopy ANESTHESIA General inhalation DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operative table General inhalational anesthesia was administered through the patient s tracheotomy tube The small Parsons laryngoscope was inserted and the 2 9 mm telescope was used to inspect the airway There was an estimated 60 70 circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds The stoma showed some suprastomal fibroma The remaining tracheobronchial passages were clear The patient s 3 5 neonatal tracheostomy tube was repositioned and secured with Velcro ties Bleeding was negligible There were no untoward complications The patient tolerated the procedure well and was transferred to recovery room in stable condition Keywords ent otolaryngology laryngoscopy and bronchoscopy direct laryngoscopy subglottic stenosis bronchoscopy laryngoscopy subglottic stenosis MEDICAL_TRANSCRIPTION,Description Right ear examination under anesthesia Right tympanic membrane perforation along with chronic otitis media Medical Specialty ENT Otolaryngology Sample Name Ear Examination Transcription PREOPERATIVE DIAGNOSIS Right tympanic membrane perforation POSTOPERATIVE DIAGNOSIS Right tympanic membrane perforation along with chronic otitis media PROCEDURE Right ear examination under anesthesia INDICATIONS The patient is a 15 year old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss Exam in the office revealed a posterior superior right marginal tympanic perforation Risks and benefits of surgery including risk of bleeding general anesthesia hearing loss as well as recurrent perforation were discussed with the mother The mother wished to proceed with surgery FINDINGS The patient was brought to the room placed in supine position given general endotracheal anesthesia The postauricular crease was then injected with 1 Xylocaine with 1 200 000 epinephrine along with external meatus An area of the scalp was shaved above the ear and then also 1 Xylocaine with 1 200 000 epinephrine injected a total of 4 mL local anesthetic was used The ear was then prepped and draped in the usual sterile fashion The microscope was then brought into view and examining the marginal perforation the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum The granulation tissue was debrided as much as possible Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible The middle ear space was filled with Floxin drops The patient woke up anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge was correct Estimated blood loss minimal Keywords ent otolaryngology chronic otitis media middle ear space tympanic membrane perforation otitis media hearing loss middle ear ear space ear examination membrane perforation tympanic membrane anesthesia membrane tympanic ear perforation MEDICAL_TRANSCRIPTION,Description Right ear pain with drainage otitis media and otorrhea Medical Specialty ENT Otolaryngology Sample Name Ear Pain Drainage Transcription CHIEF COMPLAINT Right ear pain with drainage HISTORY OF PRESENT ILLNESS This is a 12 year old white male here with his mother for complaints of his right ear hurting Mother states he has been complaining for several days A couple of days ago she noticed drainage from the right ear The patient states it has been draining for several days and it has a foul smell to it He has had some low grade fever The patient was seen in the office about a week ago with complaints of a sore throat headache and fever The patient was evaluated for Strep throat which was negative and just had been doing supportive care He did have a recent airplane ride a couple of weeks ago also There has been no cough shortness of breath or wheezing No vomiting or diarrhea PHYSICAL EXAM General He is alert in no distress Vital Signs Temperature 99 1 degrees HEENT Normocephalic atraumatic Pupils equal round and react to light The left TM is clear The right TM is poorly visualized secondary to purulent secretions in the right ear canal There is no erythema of the ear canals Nares is patent Oropharynx is clear The patient does wear braces Neck Supple Lungs Clear to auscultation Heart Regular No murmur ASSESSMENT 1 Right otitis media 2 Right otorrhea PLAN Ceftin 250 mg by mouth twice a day for 10 days Ciprodex four drops to the right ear twice a day The patient is to return to the office in two weeks for followup Keywords ent otolaryngology drainage ear hurting ear pain otitis media otorrhea ear pain with drainage otitis media ear MEDICAL_TRANSCRIPTION,Description Common CT Neck template Medical Specialty ENT Otolaryngology Sample Name CT Neck Transcription TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast FINDINGS Scans through the base of the brain are unremarkable The oropharynx and nasopharynx are within normal limits The airway is patent The epiglottis and epiglottic folds are normal The thyroid submandibular and parotid glands enhance homogenously The vascular and osseous structures in the neck are intact There is no lymphadenopathy The visualized lung apices are clear IMPRESSION No acute abnormalities Keywords ent otolaryngology sequential axial ct images optiray parotid glands epiglottic folds epiglottis base of the brain ct neckNOTE MEDICAL_TRANSCRIPTION,Description Repair of left ear laceration deformity Y V plasty 2 cm Repair of right ear laceration deformity complex repair 2 cm Medical Specialty ENT Otolaryngology Sample Name Ear Laceration Repair Transcription PREOPERATIVE DIAGNOSIS Bilateral ear laceration deformities POSTOPERATIVE DIAGNOSIS Bilateral ear laceration deformities PROCEDURE 1 Repair of left ear laceration deformity Y V plasty 2 cm 2 Repair of right ear laceration deformity complex repair 2 cm ANESTHESIA 1 Xylocaine 1 100 000 epinephrine local BRIEF CLINICAL NOTE This patient was brought to the operating room today for the above procedure OPERATIVE NOTE The patient was laid in supine position adequately anesthetized with the above anesthesia sterilely prepped and draped The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared The marsupialized epithelialized tracts were pared to raw tissue They were pared in a fashion to create a Y V plasty with de epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge The 5 0 chromic sutures were used to approximate anteriorly posteriorly and anterior centrifugal edge in the Y V plasty fashion to decrease the risk of notching Bacitracin Band Aid was placed Next attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly posteriorly to create raw edges This was not taken through the edge of the lobe to decrease the risk of notch deformity The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog ear deformity toward the edge The 5 0 chromic sutures were used in interrupted fashion for this The patient tolerated the procedure well Band Aid and bacitracin were placed She left the operating room in stable condition Keywords ent otolaryngology bilateral ear laceration dog ear deformity ear laceration deformity band aid laceration deformity ear laceration laceration deformity ear repair MEDICAL_TRANSCRIPTION,Description The patient is a 40 year old female with a past medical history of repair of deviated septum with complication of a septal perforation At this time the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis Medical Specialty ENT Otolaryngology Sample Name Deviated Septum Repair Followup Transcription CHIEF COMPLAINT Septal irritation HISTORY OF PRESENT ILLNESS The patient is a 39 year old African American female status post repair of septal deviation but unfortunately ultimately ended with a large septal perforation The patient has been using saline nasal wash 2 3 times daily however she states that she still has discomfort in her nose with a stretching like pressure She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose She has no other complaints at this time PHYSICAL EXAM GENERAL This is a pleasant African American female resting in the examination room chair in no apparent distress ENT External auditory canals are clear Tympanic membrane shows no perforation is intact NOSE The patient has a slightly deviated right septum Septum has a large perforation in the anterior 2 3rd of the septum This appears to be well healed There is no sign of crusting in the nose ORAL CAVITY No lesions or sores Tonsils show no exudate or erythema NECK No cervical lymphadenopathy VITAL SIGNS Temperature 98 degrees Fahrenheit pulse 77 respirations 18 blood pressure 130 73 ASSESSMENT AND PLAN The patient is a 40 year old female with a past medical history of repair of deviated septum with complication of a septal perforation At this time the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis At this time I counseled the patient on the risks and benefits of surgery She will consider surgery but at this time would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting which she will apply with the edge of a Q tip We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash we will consider setting the patient for surgery at that time Keywords ent otolaryngology saline nasal wash deviated septum saline nasal septal perforation nose septum septal perforation MEDICAL_TRANSCRIPTION,Description CT maxillofacial for trauma CT examination of the maxillofacial bones was performed without contrast Coronal reconstructions were obtained for better anatomical localization Medical Specialty ENT Otolaryngology Sample Name CT Maxillofacial Transcription EXAM CT maxillofacial for trauma FINDINGS CT examination of the maxillofacial bones was performed without contrast Coronal reconstructions were obtained for better anatomical localization There is normal appearance to the orbital rims The ethmoid sphenoid and frontal sinuses are clear There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally The nasal bones appear intact The zygomatic arches are intact The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes The mandible and maxilla are intact There is soft tissue swelling seen involving the right cheek IMPRESSION 1 Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally 2 Mild soft tissue swelling about the right cheek Keywords ent otolaryngology ethmoid sphenoid frontal sinuses mandible maxilla ct examination maxillofacial bones mucosal thickening maxillary sinuses ct maxillofacial MEDICAL_TRANSCRIPTION,Description Postoperative hemorrhage Examination under anesthesia with control of right parapharyngeal space hemorrhage The patient is a 35 year old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy Medical Specialty ENT Otolaryngology Sample Name Control of Parapharyngeal Hemorrhage Transcription PREOPERATIVE DIAGNOSIS Postoperative hemorrhage POSTOPERATIVE DIAGNOSIS Postoperative hemorrhage SURGICAL PROCEDURE Examination under anesthesia with control of right parapharyngeal space hemorrhage ANESTHESIA General endotracheal technique SURGICAL FINDINGS Right lower pole bleeder cauterized with electrocautery with good hemostasis INDICATIONS FOR SURGERY The patient is a 35 year old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy Previously in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty However in the PACU after a coughing spell she began bleeding from the right oropharynx and was taken back to the operative suite for control of hemorrhage DESCRIPTION OF SURGERY The patient was placed supine on the operating room table and general anesthetic was administered once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage A Crowe Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa this area was cauterized with suction cautery and irrigated There was no other bleeding noted The patient was repositioned and the mouth gag the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined There was a small amount of oozing noted in the right tonsillar bed and this was cauterized with suction cautery No other bleeding was noted and the patient was recovered from general anesthetic She was extubated and left the operating room in good condition to postoperative recovery room area Prior to extubation the patient s tonsillar fossa were injected with a 6 mL of 0 25 Marcaine with 1 100 000 adrenalin solution to facilitate postoperative analgesia and hemostasis Keywords ent otolaryngology obstructive adenotonsillar hypertrophy tonsillar fossa suction cautery postoperative hemorrhage parapharyngeal space anesthesia oropharynx parapharyngeal tonsillectomy hemorrhage MEDICAL_TRANSCRIPTION,Description A 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth Medical Specialty ENT Otolaryngology Sample Name Chronic Otitis Media Transcription CHIEF COMPLAINT Chronic otitis media HISTORY OF PRESENT ILLNESS This is a 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth There is also associated chronic nasal congestion There had been no bouts of spontaneous tympanic membrane perforation but there had been elevations of temperature up to 102 during the acute infection He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia ALLERGIES None MEDICATIONS None FAMILY HISTORY Noncontributory MEDICAL HISTORY Mild reflux PREVIOUS SURGERIES None SOCIAL HISTORY The patient is not in daycare There are no pets in the home There is no secondhand tobacco exposure PHYSICAL EXAMINATION Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present Left ear is still little bit black Nose moderate inferior turbinate hypertrophy No polyps or purulence Oral cavity oropharynx 2 tonsils No exudates Neck no nodes masses or thyromegaly Lungs are clear to A P Cardiac exam regular rate and rhythm No murmurs Abdomen is soft and nontender Positive bowel sounds IMPRESSION Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media and wax accumulation PLAN The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia Keywords ent otolaryngology chronic nasal congestion tympanic membrane perforation chronic otitis media tube insertion facemask anesthesia otitis media otitis media MEDICAL_TRANSCRIPTION,Description Cauterization of epistaxis left nasal septum Fiberoptic nasal laryngoscopy Atrophic dry nasal mucosa Epistaxis Atrophic laryngeal changes secondary to inhaled steroid use Medical Specialty ENT Otolaryngology Sample Name Cauterization Epistaxis Transcription PREOPERATIVE DIAGNOSIS Epistaxis and chronic dysphonia POSTOPERATIVE DIAGNOSES 1 Atrophic dry nasal mucosa 2 Epistaxis 3 Atrophic laryngeal changes secondary to inhaled steroid use PROCEDURE PERFORMED 1 Cauterization of epistaxis left nasal septum 2 Fiberoptic nasal laryngoscopy ANESTHESIA Neo Synephrine with lidocaine nasal spray FINDINGS 1 Atrophic dry cracked nasal mucosa 2 Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation INDICATIONS The patient is a 37 year old African American female who was admitted to ABCD General Hospital with a left wrist abscess The patient was taken to the operating room for incision and drainage Postoperatively the patient was placed on nasal cannula oxygen and developed subsequent epistaxis Upon evaluating the patient the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery The patient does report of having endotracheal tube intubation during anesthesia The patient also gives a history of inhaled steroid use for her asthma The patient was extubated after surgery without difficulty but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia PROCEDURE DETAILS After the procedure was described the patient was placed in the seated position The fiberoptic nasal laryngoscope was then inserted into the patient s left naris The nasal mucosal membranes were dry and atrophic throughout There was no evidence of any mass lesions The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity There was no evidence of mass ulceration lesion or obstruction The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic dry supraglottic and glottic changes There was no evidence of any local mass lesion nodule or ulcerations There was no evidence of any erythema Upon phonation the vocal cords approximated completely and upon inspiration the true vocal cords were abducted in a normal fashion and was symmetric The airway was stable and patent throughout the entire examination The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx The eustachian tube was completely visualized and was patent without obstruction The scope was then further removed without difficulty The patient tolerated the procedure well and remained in stable condition RECOMMENDATIONS AND PLAN The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris At this time we were unable to discontinue the patient s inhaled steroids that she is using for her asthma If this becomes possible in the future this may provide her some relief of her chronic dysphonia The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems Keywords ent otolaryngology laryngeal inhaled steroid use dry nasal mucosa fiberoptic nasal laryngoscopy nasal mucosa atrophic cauterization mucosa supraglottic laryngoscope fiberoptic dysphonia lesions epistaxis MEDICAL_TRANSCRIPTION,Description Repair of bilateral cleft of the palate with vomer flaps Medical Specialty ENT Otolaryngology Sample Name Cleft Repair Transcription PREOPERATIVE DIAGNOSES Bilateral cleft lip and bilateral cleft of the palate POSTOPERATIVE DIAGNOSES Bilateral cleft lip and bilateral cleft of the palate PROCEDURE PERFORMED Repair of bilateral cleft of the palate with vomer flaps ESTIMATED BLOOD LOSS 40 mL COMPLICATIONS None ANESTHESIA General endotracheal anesthesia CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE Stable extubated and transferred to the recovery room in stable condition INDICATIONS FOR PROCEDURE The patient is a 10 month old baby with a history of a bilateral cleft of the lip and palate The patient has undergone cleft lip repair and she is here today for her cleft palate operation We have discussed with the mother the nature of the procedure risks and benefits the risks included but not limited to the risk of bleeding infection dehiscence scarring the need for future revision surgeries We will proceed with surgery DETAILS OF THE PROCEDURE The patient was taken into the operating room placed in the supine position and general anesthetic was administered A prophylactic dose of antibiotics was given The patient proceeded to have bilateral PE tube placement by Dr X from Ear Nose and Throat Surgery After he was done with his procedure the head of the bed was turned 90 degrees The patient was positioned with a shoulder roll and doughnut A Dingman retractor was placed The operative area was infiltrated with lidocaine with epinephrine 1 200 000 a total of 3 mL and then I proceeded with the prepping and draping The patient was prepped and draped I proceeded to do the palate repair The nature of the palate repair was done in the same way on the both sides I will describe one side The other side was done exactly in the same manner The 2 hemiuvulas are placed holding from a single hook and infiltrated with lidocaine with epinephrine 1 200 000 triangle in the nasal mucosa was previously marked This triangle of nasal mucosa was removed and excised This was done on both uvulas Then an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa A 1 mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better Once the incision was done up to the level of the hard palate the muscle was dissected off the surrounding tissue 2 mm from the nasal and the oral mucosa Then I proceeded to place an incision at the alveolopalatal junction with the help of 15 blade The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap Then the flap was lifted up with the help of a freer and then the remaining of the incision medially was completed Hemostasis was achieved with help of electrocautery and Surgicel The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator The greater auricular foramen was exposed and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially This procedure was done on both sides in the same manner and then __________ dissection was done including dissection of the hard palate from the nasal mucosa it was evident that the nasal mucosa would not reach medially to be placed together At this point the decision was made to proceed with vomer flaps The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book The incision was done with a 15C blade The vomer flaps were dissected and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate This was approximated on both sides with 5 0 chromic running and interrupted stitches and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5 0 chromic and a 4 0 chromic Then 2 stitches of 4 0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side on the other side and then coming back on the mucosa to evert the edges of the soft palate The remaining part of the soft palate was placed together with 4 0 Vicryl and 4 0 chromic interrupted stitches The throat pack was removed The palate was cleaned The Dingman retractor was removed and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2 0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm The patient tolerated the procedure without complications BSS is applied to the eye after removing the Tegaderm I was present and participated in all aspects of the procedure The sponge needle and instrument count were completed at the end of the procedure The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition Keywords ent otolaryngology bilateral cleft cleft lip oral mucosa hard palate soft palate vomer flaps mucoperiosteal flap nasal mucosa flaps cleft mucosa palate mucoperiosteal bilateral nasal MEDICAL_TRANSCRIPTION,Description Bilateral myringotomy and tube placement tonsillectomy and adenoidectomy Medical Specialty ENT Otolaryngology Sample Name BMT T A Transcription PREOPERATIVE DIAGNOSES Chronic otitis media and tonsillar adenoid hypertrophy POSTOPERATIVE DIAGNOSES Chronic otitis media and tonsillar adenoid hypertrophy PROCEDURES Bilateral myringotomy and tube placement tonsillectomy and adenoidectomy INDICATIONS FOR PROCEDURE The patient is a 3 1 2 year old child with history of recurrent otitis media as well as snoring and chronic mouth breathing Risks and benefits of surgery including risk of bleeding general anesthesia tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents FINDINGS The patient was brought to the operating room placed in supine position given general endotracheal anesthesia The left ear was then draped in a clean fashion Under microscopic visualization the ear canal was cleaned of the wax Myringotomy incision was made in the anterior inferior quadrant There was no fluid in the middle ear space A Micron Bobbin tube was easily placed Floxin drops were placed in the ear The same was performed on the right side with similar findings The patient was then turned to be placed in Rose position The patient draped in clean fashion A small McIvor mouth gag was used to hold open the oral cavity The soft palate was palpated There was no submucous cleft felt Using a 1 1 mixture of 1 Xylocaine with 1 100 000 epinephrine and 0 25 Marcaine both tonsillar pillars and the fossae injected with approximately 7 mL total Using a curved Allis the right tonsil was grasped and pulled medially Tonsil was dissected off the tonsillar fossa using a Coblator The left tonsil was removed in the similar fashion Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting The soft palate was then retracted using red rubber catheter Under mirror visualization the patient was found to have enlarged adenoids The adenoids were removed using the Coblator Hemostasis was also achieved using the Coblator on coagulation setting The rubber catheter was then removed Reexamining the oropharynx small bleeding points were cauterized with the Coblator Stomach contents were then aspirated with saline sump The patient was woken up from anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge correct Estimated blood loss minimal Keywords ent otolaryngology bilateral myringotomy tube placement tonsillectomy adenoidectomy micron bobbin myringotomy and tube tonsillectomy and adenoidectomy chronic otitis media tonsillar adenoid tonsillar fossa rubber catheter otitis media adenoids myringotomy otitis media tonsillar coblator MEDICAL_TRANSCRIPTION,Description Cleft soft palate Repair of cleft soft palate and excise accessory ear tag right ear Medical Specialty ENT Otolaryngology Sample Name Cleft Repair Soft Palate Transcription PREOPERATIVE DIAGNOSIS Cleft soft palate POSTOPERATIVE DIAGNOSIS Cleft soft palate PROCEDURES 1 Repair of cleft soft palate CPT 42200 2 Excise accessory ear tag right ear ANESTHESIA General DESCRIPTION OF PROCEDURE The patient was placed supine on the operating room table After anesthesia was administered time out was taken to ensure correct patient procedure and site The face was prepped and draped in a sterile fashion The right ear tag was examined first This was a small piece of skin and cartilaginous material protruding just from the tragus The lesion was excised and injected with 0 25 bupivacaine with epinephrine and then excised using an elliptical style incision Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus After this was done the wound was cauterized and then closed using interrupted 5 0 Monocryl Attention was then turned towards the palate The Dingman mouthgag was inserted and the palate was injected with 0 25 bupivacaine with epinephrine After giving this 5 minutes to take effect the palate was incised along its margins The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline The Z plasties were then designed so there would be opposing Z plasties from the nasal mucosa compared to the oral mucosa The nasal mucosa was sutured first using interrupted 4 0 Vicryl Next the muscle was reapproximated using interrupted 4 0 Vicryl with an attempt to overlap the muscle in the midline In addition the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate Following this the oral layer of mucosa was repaired using an opposing Z plasty compared to the nasal layer This was also sutured in place using interrupted 4 0 Vicryl The anterior and posterior open edges of the palatal were sewn together The patient tolerated the procedure well Suction of blood and mucus performed at the end of the case The patient tolerated the procedure well IMMEDIATE COMPLICATIONS None DISPOSITION In satisfactory condition to recovery Keywords ent otolaryngology repair tragus oral mucosa nasal mucosa ear tag soft palate palate cleft soft MEDICAL_TRANSCRIPTION,Description Bilateral myringotomy tubes and adenoidectomy Medical Specialty ENT Otolaryngology Sample Name BMT Adenoidectomy Transcription PREOPERATIVE DIAGNOSIS Chronic otitis media POSTOPERATIVE DIAGNOSIS Chronic otitis media PROCEDURE PERFORMED Bilateral myringotomy tubes and adenoidectomy INDICATIONS FOR PROCEDURE The patient is an 8 year old child with history of recurrent otitis media The patient has had previous tube placement Tubes have since plugged and are no more functioning The patient has had recent recurrent otitis media Risks and benefits in terms of bleeding anesthesia and tympanic membrane perforation were discussed with the mother Mother wished to proceed with the surgery PROCEDURE IN DETAIL The patient was brought to the room placed supine The patient was given general endotracheal anesthesia Starting on the left ear under microscopic visualization the ear was cleaned of wax A Bobbin tube was found stuck to the tympanic membrane This was removed After removing the tube the patient was found to have microperforation through which serous fluid was draining A fresh myringotomy was made in the anterior inferior quadrant More serous fluid was aspirated from middle ear space The new Bobbin tube was easily placed Floxin drops were placed in the ear In the right ear again under microscopic visualization the ear was cleaned the tube was removed off tympanic membrane There was no perforation seen however there was some granulation tissue on the surface of tympanic membrane A fresh myringotomy incision was made in the anterior inferior quadrant More serous fluid was drained out of middle ear space The tube was easily placed and Floxin drops were placed in the ear This completes tube portion of the surgery The patient was then turned and placed in the Rose position Shoulder roll was placed for neck extension Using a small McIvor mouth gag mouth was held open Using a rubber catheter the soft palate was retracted Under mirror visualization the nasopharynx was examined The patient was found to have minimal adenoidal tissue This was removed using a suction Bovie The patient was then awakened from anesthesia extubated and brought to recovery room in stable condition There were no intraoperative complications Needle and sponge count correct Estimated blood loss none Keywords ent otolaryngology chronic otitis media bilateral myringotomy tubes adenoidectomy myringotomy tubes and adenoidectomy middle ear space bilateral myringotomy bobbin tube fresh myringotomy serous fluid otitis media tympanic membrane tubes myringotomy otitis media membrane MEDICAL_TRANSCRIPTION,Description T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation Medical Specialty ENT Otolaryngology Sample Name Cancer of the nasopharynx Transcription DIAGNOSIS T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation completed June 2006 status post 2 cycles carboplatin 5 FU given as adjuvant therapy completed September 2006 hearing loss related to chemotherapy and radiation xerostomia history of left upper extremity deep venous thrombosis PERFORMANCE STATUS 0 INTERVAL HISTORY In the interim since his last visit he has done quite well He is working He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics Overall when he compares his strength to six or eight months ago he notes that he feels much stronger He has no complaints other than mild xerostomia and treatment related hearing loss PHYSICAL EXAMINATION Vital Signs Height 65 inches weight 150 pulse 76 blood pressure 112 74 temperature 95 4 respirations 18 HEENT Extraocular muscles intact Sclerae not icteric Oral cavity free of exudate or ulceration Dry mouth noted Lymph No palpable adenopathy in cervical supraclavicular or axillary areas Lungs Clear Cardiac Rhythm regular Abdomen Soft nondistended Neither liver spleen nor other masses palpable Lower Extremities Without edema Neurologic Awake alert ambulatory oriented cognitively intact I reviewed the CT images and report of the study done on May 1 This showed no evidence of metabolically active malignancy Most recent laboratory studies were performed last September and the TSH was normal I have asked him to repeat the TSH at the one year anniversary He is on no current medications In summary this 57 year old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy He has made a good recovery We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up We will see him in six months time with a PET CT He returns to the general care and direction of Dr ABC Keywords ent otolaryngology radiation therapy with cycles cancer of the nasopharynx status post radiation cisplatin with radiation radiation therapy hearing loss hearing cisplatin xerostomia cancer radiation nasopharynx MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies placement of ventilating tubes nasal endoscopy and adenoidectomy Medical Specialty ENT Otolaryngology Sample Name Bilateral Myringotomies Transcription PREOPERATIVE DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy POSTOPERATIVE DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy FINAL DIAGNOSES 1 Recurrent acute otitis media bilateral middle ear effusions 2 Chronic rhinitis 3 Recurrent adenoiditis with adenoid hypertrophy 4 Acute and chronic adenoiditis OPERATIONS PERFORMED 1 Bilateral myringotomies 2 Placement of ventilating tubes 3 Nasal endoscopy 4 Adenoidectomy DESCRIPTION OF OPERATIONS The patient was brought to the operating room endotracheal intubation carried out by Dr X Both sides of the patient s nose were then sprayed with Afrin Ears were inspected then with the operating microscope The anterior inferior quadrant myringotomy incisions were performed Then a modest amount of serous and a trace of mucoid material encountered that was evacuated The middle ear mucosa looked remarkably clean Armstrong tubes were inserted Ciprodex drops were instilled Ciprodex will be planned for two postoperative days as well Nasal endoscopy was carried out and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products The adenoids were shaved back flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts and representative cultures were taken Additional adenoid tissue was shaved backwards with the RADenoid shaver Electrocautery was used to establish hemostasis and repeat nasal endoscopy accomplished The patient still had residual evidence of inter choanal adenoid tissue and video photos were taken That remaining material was resected guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx Electrocautery again used to establish hemostasis Bleeding was trivial Extensive irrigation accomplished No additional bleeding was evident The patient was awakened extubated taken to the recovery room in a stable condition Discharge anticipated later in the day on Augmentin 400 mg twice daily Lortab or Tylenol p r n for pain Office recheck would be anticipated if stable and doing well in approximately two weeks Parents were instructed to call however regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic Keywords ent otolaryngology bilateral middle ear effusions recurrent acute otitis media chronic rhinitis recurrent adenoiditis with adenoid hypertrophy adenoiditis bilateral myringotomies ventilating tubes nasal endoscopy adenoidectomy adenoid hypertrophy myringotomies otitis media hypertrophy endoscopy intubation nasal MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy Adenotonsillitis with hypertrophy The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms Adenotonsillectomy is indicated Medical Specialty ENT Otolaryngology Sample Name Adenotonsillectomy 2 Transcription POSTOPERATIVE DIAGNOSIS Adenotonsillitis with hypertrophy OPERATION PERFORMED Adenotonsillectomy ANESTHESIA General endotracheal INDICATIONS The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms Adenotonsillectomy is indicated DESCRIPTION OF PROCEDURE The patient was placed on the operating room table in the supine position After adequate general endotracheal anesthesia was administered table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion A McIvor mouth gag was applied The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly The adenoids were removed with suction electrocautery under mere visualization The left tonsil was grasped with a curved Allis forceps retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion The inferior middle and superior pole vessels were further cauterized with suction electrocautery Copious saline irrigation of the oral cavity was then performed There was no further identifiable bleeding at the termination of the procedure The estimated blood loss was less than 10 mL The patient was extubated in the operating room brought to the recovery room in satisfactory condition There were no intraoperative complications Keywords ent otolaryngology hypertrophy adenotonsillitis tonsillar pillar bovie electrocautery adenotonsillectomyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral Myringotomy with placement of PE tubes Medical Specialty ENT Otolaryngology Sample Name Bilateral Myringotomies 2 Transcription PREOPERATIVE DIAGNOSES Bilateral chronic otitis media POSTOPERATIVE DIAGNOSES Bilateral chronic otitis media ANESTHESIA General mask NAME OF OPERATION Bilateral Myringotomy with placement of PE tubes PROCEDURE The patient was taken to the operating room and placed in the supine position After adequate general inhalation anesthesia was obtained the operating microscope with brought in for full use throughout the case First the left and then the right tympanic membrane was approached An anterior inferior radial incision was made in the left tympanic membrane Suction revealed a substantial amount of mucopurulent drainage A Sheehy pressure equalization tube was placed in the myringotomy site Floxin drops were added The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage The patient tolerated the procedure well and returned to the recovery room awake and in stable condition Keywords ent otolaryngology placement of pe tubes bilateral chronic otitis media chronic otitis media bilateral myringotomy pe tubes chronic otitis otitis media tympanic membrane mucopurulent drainage tympanic membrane mucopurulent myringotomy tubes MEDICAL_TRANSCRIPTION,Description A sample note on bilateral myringotomy tubes Medical Specialty ENT Otolaryngology Sample Name BMT Bilateral Myringotomy Tubes Transcription Parents often ask why the fluid cannot be drained without inserting a tube The need for the tube insertion is because the eardrum incision generally heals very rapidly within a few days which is not long enough for the swollen membranes in the middle ear to return to normal As soon as the eardrum heals fluid will reaccumulate Tubes were first introduced because of this very problem There are many types of tubes but all tubes serve the same function They keep the eardrum open allow air to enter the middle ear space and permit fluid in the middle ear to drain Most tubes will gradually be rejected by the ear and work their way out of the eardrum As they come out the eardrum seals behind the tube Tubes will last four to six months in the eardrum before they come out Occasionally the eardrum does not heal completely when the tube comes out The majority of children treated with tubes do not require further surgery They may have ear infections in the future but most will clear up with medical treatment Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection Children tend to outgrow this cycle by age 7 or 8 In an ear nose and throat specialty practice this group comprises 10 to 15 of all children who have required tubes Occasionally the physician has to physically remove the tube from the ear drum Keywords ent otolaryngology eardrum myringotomy tubes bilateral myringotomy tubes myringotomy tubes ear infections middle ear fluid childrenNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Adenoidectomy Adenoid hypertrophy The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied Medical Specialty ENT Otolaryngology Sample Name Adenoidectomy 1 Transcription PREOPERATIVE DIAGNOSIS Adenoid hypertrophy POSTOPERATIVE DIAGNOSIS Adenoid hypertrophy PROCEDURE PERFORMED Adenoidectomy ANESTHESIA General endotracheal DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied Two 12 French red rubber Robinson catheters were placed 1 in each nasal passage and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction The nasopharynx was inspected with the laryngeal mirror Serial passages of the curettes were utilized to remove the nasopharyngeal tissue following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0 25 Neo Synephrine and tannic acid powder Attention was then redirected to the oropharynx The McIvor was reopened packs removed and the bleeding was controlled with the suction Bovie unit The catheters were removed and the nasal passages and oropharynx were suctioned free of debris The McIvor was then removed and the procedure was terminated The patient tolerated the procedure well and left the operating room in good condition Keywords ent otolaryngology palate nasal passage mcivor mouth gag oral cavity nasal nasopharynx oropharynx hypertrophy oral cavity mcivor tongue adenoidectomy MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy Recurrent tonsillitis The adenoid bed was examined and was moderately hypertrophied Adenoid curettes were used to remove this tissue and packs placed Medical Specialty ENT Otolaryngology Sample Name Adenotonsillectomy 1 Transcription PREOPERATIVE DIAGNOSIS Recurrent tonsillitis POSTOPERATIVE DIAGNOSIS Recurrent tonsillitis PROCEDURE Adenotonsillectomy COMPLICATIONS None PROCEDURE DETAILS The patient was brought to the operating room and under general endotracheal anesthesia in supine position the table turned and a McIvor mouthgag placed The adenoid bed was examined and was moderately hypertrophied Adenoid curettes were used to remove this tissue and packs placed Next the right tonsil was grasped with a curved Allis and using the gold laser the anterior tonsillar pillar incised and with this laser dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed A similar procedure was performed on the contralateral tonsil Following meticulous hemostasis saline was used to irrigate and no further bleeding noted The patient was then allowed to awaken and was brought to the recovery room in stable condition Keywords ent otolaryngology curved allis tonsillitis hypertrophied curettes tonsillar adenoid adenotonsillectomy MEDICAL_TRANSCRIPTION,Description Adenotonsillectomy primary patient under age 12 Medical Specialty ENT Otolaryngology Sample Name Adenotonsillectomy Transcription PREOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis POSTOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis OPERATIVE PROCEDURE Adenotonsillectomy primary patient under age 12 ANESTHESIA General endotracheal anesthesia PROCEDURE IN DETAIL This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron She was placed supine on the operating room table General endotracheal anesthesia was induced without difficulty In the holding area her allergies were reviewed It is unclear whether she is actually allergic to penicillin Codeine caused her to be excitable but she did not actually have an allergic reaction to codeine She might be allergic to BACTRIM and SULFA After positioning a small shoulder roll and draping sterilely McIvor mouthgag 3 blade was inserted and suspended from the Mayo stand There was no bifid uvula or submucous cleft She had 3 cryptic tonsils with significant debris in the tonsillar crypts Injection at each peritonsillar area with 0 25 with Marcaine with 1 200 000 Epinephrine approximately 1 5 mL total volume The left superior tonsillar pole was then grasped with curved Allis forceps _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7 3 Mouthgag was released reopened no bleeding was seen The right tonsil was then removed in the same fashion The mouthgag released reopened and no bleeding was seen Small red rubber catheter in the nasal passage was used to retract the soft palate She had mild to moderate adenoidal tissue residual It was removed with Coblation Evac Xtra gently curved Wand on 9 5 Red rubber catheter was then removed Mouthgag was again released reopened no bleeding was seen Orogastric suction carried out with only scant clear stomach contents Mouthgag was then removed Teeth and lips were inspected and were in their preoperative condition The patient then awakened extubated and taken to recovery room in good condition TOTAL BLOOD LOSS FROM TONSILLECTOMY Less than 2 mL TOTAL BLOOD LOSS FROM ADENOIDECTOMY Less than 2 mL COMPLICATIONS No intraoperative events or complications occurred PLAN Family will be counseled postoperatively Postoperatively the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days Lortab Elixir for pain _______ and promethazine if needed for nausea and vomiting Keywords ent otolaryngology hypertrophic adenotonsillitis adenotonsillitis endotracheal anesthesia coblation evac xtra wand lortab elixir red rubber catheter total blood loss adenotonsillectomy forceps mouthgag MEDICAL_TRANSCRIPTION,Description Adenoidectomy procedure Medical Specialty ENT Otolaryngology Sample Name Adenoidectomy Transcription ADENOIDECTOMY PROCEDURE The patient was brought into the operating room suite anesthesia administered via endotracheal tube Following this the patient was draped in standard fashion The Crowe Davis mouth gag was inserted in the oral cavity The palate and tonsils were inspected the palate was suspended with a red rubber catheter passed through the right nostril Following this the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer The adenoid pad was removed without difficulty The nasopharynx was packed Following this the nasopharynx was unpacked several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated The Crowe Davis was released The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery Keywords ent otolaryngology adenoidectomy crowe davis adenoid pad electrocautery endotracheal tube gently coagulated mouth gag nasopharynx oral cavity red rubber catheter vomer palate tonsilsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral myringotomies with Armstrong grommet tubes Adenoidectomy and Tonsillectomy Medical Specialty ENT Otolaryngology Sample Name Bilateral Myringotomies 1 Transcription PREOPERATIVE DIAGNOSES OM chronic serous simple or unspecified Adenoid hyperplasia Hypertrophy of tonsils POSTOPERATIVE DIAGNOSIS Same as preoperative diagnosis OPERATION Bilateral myringotomies with Armstrong grommet tubes Adenoidectomy and Tonsillectomy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DRAINS None CONSENT The procedure benefits and risks were discussed in detail preoperatively The parentsagreed to proceed after all questions were answered TECHNIQUE The patient was brought to the operating room and placed in the supine position After general mask anesthesia was adequately obtained the right external auditory canal was cleaned out under the microscope Serous fluid was aspirated from the middle ear space An Armstrong grommet tube was placed down through the incision and rotated into place The opposite ear was then cleaned out under the microscope Serous fluid was aspirated from the middle ear space An Armstrong grommet tube was placed down through the incision and rotated into place Cortisporin suspension was placed in both ear canals Then the patient was intubated A Crowe Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate The adenoid fossa was visualized with the mirror The adenoids were removed using the microdebrider Two adenoid packs were placed The packs were removed one by one Using mirror and suction bovie adequate hemostasis was achieved The tonsils were quite large and cryptic The tenaculum was placed on the superior pole of the right tonsil Cheesy material came out from the crypts The tonsils were retracted medially The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar and the plane was developed between the tonsil and the musculature The tonsil was completely dissected out of this plane preserving both the anterior and posterior tonsillar pillars All bleeders were cauterized as they were encountered The tenaculum was then placed on the superior pole of the left tonsil Cheesy material came out from the crypts The tonsils were retracted medially The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar and the plane was developed between the tonsil and the musculature The tonsil was completely dissected out of this plane preserving both the anterior and posterior tonsillar pillars All bleeders were cauterized as they were encountered Both tonsil beds were then re cauterized paying particular attention to the inferior and superior poles The stomach was evacuated with the nasogastric tube The patient was then awakened in the operating room extubated and taken to the recovery room in satisfactory condition Keywords ent otolaryngology adenoid hyperplasia om adenoidectomy tonsillectomy auditory canal serous fluid crowe davis mouth gag tonsils adenoidectomy and tonsillectomy armstrong grommet tubes bovie electrocautery tonsillar pillar bilateral myringotomies armstrong tubes grommet tonsillar bilateral myringotomies tenaculum MEDICAL_TRANSCRIPTION,Description Left thyroid mass Left total thyroid lumpectomy The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan which demonstrated a hot nodule on the left anterior pole Medical Specialty Endocrinology Sample Name Total Thyroid Lumpectomy Transcription PREOPERATIVE DIAGNOSIS Left thyroid mass POSTOPERATIVE DIAGNOSIS Left thyroid mass PROCEDURE PERFORMED Left total thyroid lumpectomy ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Less than 50 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 76 year old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan which demonstrated a hot nodule on the left anterior pole The patient was then discussed the risks complications and consequences of a surgical procedure and a written consent was obtained PROCEDURE The patient is brought to the operative suite by Anesthesia The patient was placed on the operative table in supine position After this the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll After this the skin incision was marked approximately two fingerbreadths above the sternal notch It was then localized with 1 lidocaine with epinephrine 1 1000 approximately 7 cc total After this the patient was then prepped and draped in the usual sterile fashion and a 10 blade was then utilized to make a skin incision The subcutaneous tissue was then bluntly dissected utilizing a Ray Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions After this the midline was then identified and grasped on either side with a DeBakey forceps The raphe was noted and Bovie cauterization was utilized to cut down into this region The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle It was separated on the left side from the patient s sternothyroid muscle After this the sternothyroid muscle was identified grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners After this the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself It was freed from the thyroid gland and reflected laterally and posteriorly The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally After this the patient s thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter As the gland was rotated more anteriorly the recurrent laryngeal nerve on the left side was identified and further dissection along Berry s ligament on the medial aspect was performed The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected After this the gland was easily rotated anteriorly with further dissection carried up to the superior pole The superior pole was exposed with the help of a Richardson and Army Navy retractors with cross clamping and tying of the superior laryngeal artery and vein Further the small bleeding vessels were identified and bipolared and cut with the Metzenbaum scissors The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea Berry s ligament was finally freed and the gland was cross clamped on the opposing thyroid isthmus with a mosquito After this the gland was cut with a Metzenbaum scissors and tied with a 3 0 undyed Vicryl tie The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization Surgicel was then cut in small strips and three replaced in the lateral part of the neck The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses The strap muscles were then reapproximated with 3 0 Vicryl on a SH followed by reapproximation of the subcutaneous tissue with 4 0 Vicryl followed by reapproximation of the skin by running subcuticular 5 0 Prolene and a 6 0 fast absorbing gut Mastisol Steri Strips and bacitracin were placed followed by a sterile 4 x 4 dressing The patient was then turned back to Anesthesia extubated in the operating room and transferred to Recovery in stable condition The patient tolerated the procedure well and will be admitted to hospital for 23 hour observation and will be followed up in one week afterwards Keywords endocrinology thyroid lumpectomy thyroid uptake scan thyroid mass nodule total thyroid lumpectomy parathyroid glands berry s ligament metzenbaum scissors thyroid gland thyroid mass gland thyroid total MEDICAL_TRANSCRIPTION,Description Adenoidectomy and tonsillectomy and lingual frenulectomy Chronic adenotonsillitis and ankyloglossia Medical Specialty ENT Otolaryngology Sample Name Adenoidectomy Tonsillectomy Lingual Frenulectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic adenotonsillitis 2 Ankyloglossia POSTOPERATIVE DIAGNOSES 1 Chronic adenotonsillitis 2 Ankyloglossia PROCEDURE PERFORMED 1 Adenoidectomy and tonsillectomy 2 Lingual frenulectomy ANESTHESIA General endotracheal FINDINGS SPECIMEN Tonsil and adenoid tissue COMPLICATIONS None CONDITION The patient is stable and tolerated the procedure well and sent to PACU HISTORY OF PRESENT ILLNESS This is a 3 year old child with a history of adenotonsillitis PROCEDURE The patient was prepped and draped in the usual sterile fashion A curved hemostat was used to grasp the lingual frenulum The stat was removed and Metzenbaum scissors were used to free the lingual frenulum Cautery was used to allow hemostasis The patient was then turned McIvor mouth gag was inserted Tonsils and adenoids were exposed The patient s right tonsil was first grasped with a curved hemostat Needle tip cautery was used to free the superior pole of tonsil The tonsil was then grasped in medial superior aspect with a straight hemostat The tonsil fascia planes were identified with Bovie dissection along the plane The tonsil was freed from anterior pillar and posterior pillar Amputation occurred along the same plane as the patient s tongue Suction cautery was then used to allow for hemostasis The patient s adenoids were then viewed with an adenoid mirror An adenoid curet was used to remove the patient s adenoid tissue Specimen sent Suction cautery was used to allow for hemostasis Superior pole of left tonsil was then grasped with a curved hemostat Superior pole was freed using needle tip Bovie dissection Beginning with 15 desiccate after superior pole was free Bovie was switched to 15 fulgurate and the tonsil was stripped from anterior and posterior pillars The tonsil was then amputated at the same plane as tongue base Hemostasis was achieved with using suction cautery Mouth gag was removed Dual position and occlusion were tested The patient was extubated and tolerated the procedure well and sent back to PACU Keywords ent otolaryngology adenotonsillitis ankyloglossia adenoidectomy tonsillectomy frenulectomy tonsil adenoid tissue metzenbaum scissors lingual frenulectomy chronic adenotonsillitis curved hemostat suction cautery hemostat hemostasis lingual cautery MEDICAL_TRANSCRIPTION,Description Tracheostomy and thyroid isthmusectomy Ventilator dependent respiratory failure and multiple strokes Medical Specialty Endocrinology Sample Name Tracheostomy Thyroid Isthmusectomy Transcription PREOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes POSTOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Multiple strokes PROCEDURES PERFORMED 1 Tracheostomy 2 Thyroid isthmusectomy ANESTHESIA General endotracheal tube BLOOD LOSS Minimal less than 25 cc INDICATIONS The patient is a 50 year old gentleman who presented to the Emergency Department who had had multiple massive strokes He had required ventilator assistance and was transported to the ICU setting Because of the numerous deficits from the stroke he is expected to have a prolonged ventilatory course and he will be requiring long term care PROCEDURE After all risks benefits and alternatives were discussed with multiple family members in detail informed consent was obtained The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt tip marker The skin was then anesthetized with a mixture of 1 lidocaine and 1 100 000 epinephrine solution The patient was prepped and draped in usual fashion The surgeons were gowned and gloved A vertical skin incision was then made with a 15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage Blunt dissection was then carried down until the fascia overlying the strap muscles were identified At this point the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery Once the strap muscles have been identified palpation was performed to identify any arterial aberration A high riding innominate was not identified At this point it was recognized that the thyroid gland was overlying the trachea could not be mobilized Therefore dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland which was then doubly clamped and ligated with Bovie cautery Suture ligation with 3 0 Vicryl was then performed on the thyroid gland in a double interlocking fashion This cleared a significant portion of the trachea The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery Now a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea The second tracheal ring was identified The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based At this point the anesthetist was appropriately alerted to deflate the endotracheal tube cuff The airway was entered and inferior to the base window was created The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified At this point a 8 Shiley tracheostomy tube was inserted freely into the tracheal lumen The balloon was inflated and the ventilator was attached He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist Now all surgical retractors were removed The baseplate of the tracheostomy tube was sutured to the patient s skin with 2 0 nylon suture The tube was further secured around the patient s neck with IV tubing Finally a drain sponge was placed At this point procedure was felt to be complete The patient was returned to the ICU setting in stable condition where a chest x ray is pending Keywords endocrinology ventilator dependent respiratory failure multiple strokes thyroid thyroid isthmusectomy ventilator dependent respiratory failure strap muscles thyroid gland endotracheal tube cricoid cartilage bovie cautery tracheostomy ventilator strokes cartilage tracheal isthmusectomy MEDICAL_TRANSCRIPTION,Description Total thyroidectomy with removal of substernal extension on the left Thyroid goiter with substernal extension on the left Medical Specialty Endocrinology Sample Name Total Thyroidectomy Transcription PREOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left POSTOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left PROCEDURE PERFORMED Total thyroidectomy with removal of substernal extension on the left THIRD ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 200 cc COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 54 year old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine The patient subsequently then had a CT scan which demonstrated a very large thyroid gland especially on the left side with substernal extension down to the level of the aortic arch The patient was then immediately set up for surgery After risks complications consequences and questions were addressed with the patient a written consent was obtained PROCEDURE The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed After this the patient then had the area marked initially The preoperative setting was then localized with 1 lidocaine and epinephrine 1 100 000 approximately 10 cc total After this the patient was then prepped and draped in the usual sterile fashion A 15 Bard Parker was then utilized to make a skin incision horizontally approximately 5 cm on either side from midline After this a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle There appeared to be a natural dehiscence of the platysma in the midline A sub platysmal dissection was then performed in the superior inferior and lateral directions with the help of a bear claw Metzenbaum scissors and DeBakey forceps Any bleeding was controlled with monopolar cauterization After this the two anterior large jugular veins were noted and resected laterally The patient s trachea appeared to be slightly deviated to the right with identification finally of the midline raphe off midline to the right This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors After this was dissected the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland After this attention was then drawn to the left gland where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly After this the superior and inferior parathyroid glands were noted The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly After this the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors After this the thyroid gland was further freed down to the level of the Berry s ligament inferiorly and the dissection was carried once again more superiorly The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry s ligament tissue from the gland with the bipolar cauterization and the fine stat Finally attention was then drawn back to the patient s right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry s ligament The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with 2 0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally The Berry s ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization After this Surgicel was then placed in the bilateral neck regions and a 10 Jackson Pratt drain was then placed within the left neck region with some extension over to the right neck region This was brought out through the inferior skin incision and secured to the skin with a 2 0 nylon suture The strap muscles were then reapproximated with a running 3 0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a 4 0 undyed Vicryl The skin was then reapproximated with a 5 0 Prolene subcuticular along with a 6 0 fast over the top After this Mastisol Steri Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain The patient was then turned back to Anesthesia extubated in the operating room and transferred to Recovery in stable condition The patient tolerated the procedure well and remained stable throughout Keywords endocrinology thyroid goiter goiter thyroid total thyroidectomy berry s ligament dissection gland thyroidectomy anesthesia berry s ligament cauterization extension substernal MEDICAL_TRANSCRIPTION,Description Total thyroidectomy The patient is a female with a history of Graves disease Suppression was attempted however unsuccessful She presents today with her thyroid goiter Medical Specialty Endocrinology Sample Name Thyroidectomy 1 Transcription PREOPERATIVE DIAGNOSIS Thyroid goiter POSTOPERATIVE DIAGNOSIS Thyroid goiter PROCEDURE PERFORMED Total thyroidectomy ANESTHESIA 1 General endotracheal anesthesia 2 9 cc of 1 lidocaine with 1 100 000 epinephrine COMPLICATIONS None PATHOLOGY Thyroid INDICATIONS The patient is a female with a history of Graves disease Suppression was attempted however unsuccessful She presents today with her thyroid goiter A thyroidectomy was indicated at this time secondary to the patient s chronic condition Indications alternatives risks consequences benefits and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail She agreed to proceed A full informed consent was obtained PROCEDURE The patient presented to ABCD General Hospital on 09 04 2003 with the history was reviewed and physical examinations was evaluated The patient was brought by the Department of Anesthesiology brought back to surgical suite and given IV access and general endotracheal anesthesia A 9 cc of 1 lidocaine with 1 100 000 of epinephrine was infiltrated into the area of pre demarcated above the suprasternal notch Time is allowed for full hemostasis to be achieved The patient was then prepped and draped in the normal sterile fashion A 10 blade was then utilized to make an incision in the pre demarcated and anesthetized area Unipolar electrocautery was utilized for hemostasis Finger dissection was carried out in the superior and inferior planes Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior medial and lateral directions using hemostat Metzenbaum and blunt dissection The strap muscles were identified The midline raphe was not easily identifiable at this time An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid Sternohyoid and sternothyroid muscles were identified and separated on the patient s right side and then subsequently on the left side It was noted at this time that the thyroid lobule on the right side is a bi lobule Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid force in the lateral direction This was carried down to the inferior and superior areas The superior pole of the right lobule was then identified A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature This was carried out until the superior pole was identified Careful attention was made to avoid nerve injury in this area Dissection was then carried down again bluntly separating the inferior and superior lobes The bilobed right thyroid was then retracted medially The recurrent laryngeal nerve was then identified and tracked to its insertion The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid When it was completed this lobule was then removed from Berry s ligament There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation Attention was then diverted to the patient s left side In a similar fashion the sternohyoid and sternothyroid muscles were already separated Army Navy as well as femoral retractors were utilized to lateralize the appropriate musculature The middle thyroid vein was identified Blunt dissection was carried out laterally to superiorly once again A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly Once again a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis Once again a careful attention was made not to injure the nerve in this area The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects The inferior aspect was then identified The inferior thyroid artery and vein were then identified and ligated The left thyroid was then medialized and the recurrent laryngeal nerve has been identified A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible The thyroid was then removed from the Berry s ligament and it was then sent to Pathology for further evaluation Evaluation of the visceral space did not reveal any bleeding at this time This was irrigated and pinpoint areas were bipolored as necessary Surgicel was then placed bilaterally The strap muscles as well as the appropriate fascial attachments were then approximated with a 3 0 Vicryl suture in the midline The platysma was identified and approximated with a 4 0 Vicryl suture and the subdermal plane was approximated with a 4 0 Vicryl suture A running suture consisting of 5 0 Prolene suture was then placed and fast absorbing 6 0 was then placed in a running fashion Steri Strips Tincoban bacitracin and a pressure gauze was then placed The patient was then admitted for further evaluation and supportive care The patient tolerated the procedure well The patient was transferred to Postanesthesia Care Unit in stable condition Keywords endocrinology thyroid goiter graves disease thyroidectomy total thyroidectomy dissection superior kitner MEDICAL_TRANSCRIPTION,Description Total thyroidectomy for goiter Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration Medical Specialty Endocrinology Sample Name Thyroidectomy Transcription TITLE OF OPERATION Total thyroidectomy for goiter INDICATION FOR SURGERY This is a 41 year old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery Risks benefits alternatives of the procedures were discussed in great detail with the patient Risks include but were not limited to anesthesia bleeding infection injury to nerve vocal fold paralysis hoarseness low calcium need for calcium supplementation tumor recurrence need for additional treatment need for thyroid medication cosmetic deformity and other The patient understood all these issues and they wished to proceed PREOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration POSTOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration ANESTHESIA General endotracheal PROCEDURE DETAIL After identifying the patient the patient was placed supine in a operating room table After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube The eyes were then tacked with Tegaderm The Nerve Integrity monitoring system endotracheal tube was confirmed to be working adequately Essentially a 7 cm incision was employed in the lower skin crease of the neck A 1 lidocaine with 1 100 000 epinephrine were given Shoulder roll was applied The patient prepped and draped in a sterile fashion A 15 blade was used to make the incision Subplatysmal flaps were raised to the thyroid notch and sternal respectively The strap muscles were separated in the midline As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side The sternothyroid muscle was transected horizontally Similar procedure was performed on the right side Attention was then turned to identify the trachea in the midline Veins in this area and the pretracheal region were ligated with a harmonic scalpel Subsequently attention was turned to dissecting the capsule off of the left thyroid lobe Again this was very firm in nature The superior thyroid pole was dissected in the superior third artery vein and the individual vessels were ligated with a harmonic scalpel The inferior and superior parathyroid glands were protected Recurrent laryngeal nerve was identified in the tracheoesophageal groove This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch This was followed superiorly The level of cricothyroid membrane upon complete visualization of the entire nerve Berry s ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea A prominent pyramidal level was also appreciated and dissected as well Attention was then turned to the right side There was significant amount of thyroid tissue that was very firm Multiple nodules were appreciated In a similar fashion the capsule was dissected The superior and inferior parathyroid glands protected and preserved The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule Once the recurrent laryngeal nerve was identified again on this side the nerve had arborized early prior to the coursing underneath the inferior thyroid artery The anterior motor branch was then very fine almost filamentous and stimulated at 0 5 milliamps completely dissected toward the cricothyroid membrane with complete visualization A small amount of tissue was left at the Berry s ligament as the remainder of thyroid level was dissected over the trachea The entire thyroid specimen was then removed marked with a stitch upon the superior pole The wound was copiously irrigated Valsalva maneuver was given bleeding points controlled The parathyroid glands appeared to be viable Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system Attention was then turned to burying the Surgicel on the wound bed on both sides The strap muscles were reapproximated in the midline using a 3 0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated The 1 8th inch Hemovac drain was placed and secured with a 3 0 nylon The incision was then closed with interrupted 3 0 Vicryl and Indermil for the skin The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25 gauge needle The patient tolerated the procedure well was extubated in the operating room table and sent to postanesthesia care unit in a good condition Upon completion of the case fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility Keywords endocrinology total thyroidectomy goiter multinodular thyroid goiter multinodular thyroid nodules parathyroid glands thyroid goiter thyroid artery thyroidectomy MEDICAL_TRANSCRIPTION,Description Squamous cell carcinoma of the larynx Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy Medical Specialty Endocrinology Sample Name Laryngectomy Thyroid Lobectomy Transcription TITLE OF OPERATION Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy INDICATION FOR SURGERY A 58 year old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06 07 Subsequently biopsy confirmed tumor persistence in the right glottic region Risks benefits and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks benefits and alternatives He was accompanied by his wife and daughter Risks included but were not limited to anesthesia bleeding infection injury of the nerves including lower lip weakness tongue weakness tongue numbness shoulder weakness need for physical therapy possibility of total laryngectomy possibility of inability to speak or swallow difficulty eating wound care issues failure to heal need for additional treatment and the patient understood all of these issues and they wished to proceed PREOP DIAGNOSIS Squamous cell carcinoma of the larynx POSTOP DIAGNOSIS Squamous cell carcinoma of the larynx PROCEDURE DETAIL After identifying the patient the patient was placed supine on the operating room table After the establishment of the general anesthesia via oral endotracheal intubation the patient had his eyes protected with Tegaderm A 6 endotracheal tube was placed initially Direct laryngoscopy was performed with a Lindholm laryngoscope A 0 degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis Subsequently a decision was then made to go ahead and perform the surgical intervention A hemi apron incision was employed and 1 lidocaine with 1 100 000 epinephrine was injected A shoulder roll was applied after the patient was prepped and draped in a sterile fashion Subsequently a hemi apron incision was performed Subplatysmal flaps were raised at the hyoid bone into the clavicle Attention was then turned to the right side where a level 2 3 4 neck dissection was performed Submandibular fascia was appreciated inferiorly along the submandibular gland this was incised allowing for identification of the digastric muscle Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified Level 2A contents were then dissected off the floor of the neck including levels 3 and 4 Preservation of the phrenic nerve was obtained by identification and subsequently cross clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4 The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve Levels 2 3 4 neck dissection specimens were then labeled appropriately attached with staples and sent for histopathological evaluation Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed Subsequently the strap muscles were separated in the midline The trachea was identified in the midline The thyroid isthmus was plicated using the Harmonic scalpel and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage Once this was performed sinuses were mobilized from the thyroid cartilage both on the right and left side respectively The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular Attention was then turned to performing a cricothyrotomy Upon performing this it was obvious that there was tumor just above the level of the cricothyrotomy incision A 7 anode tube was then placed in this area and secured Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis Subsequently the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage and the thyroid cartilage was then intentionally fractured along the anterior spine It was evident that this tumor had extended more than 1 cm into the subglottic region Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly though it was evident that the cricoid cartilage was invaded Frozen section biopsy then confirmed this finding as read by Dr X of Surgical Pathology In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage the patient s case was then converted into a total laryngectomy Subsequently the trachea was transected at the level 3 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3 0 vertical mattress sutures for the skin A W plasty was also performed to allow for enlargement of the stoma Attention was then turned to identifying the common parting wall of the trachea and the esophagus Attention was then turned to resecting the hyoid bone The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism The wound was copiously irrigated Subsequently a tracheoesophageal puncture site was performed using a right angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect Once this was performed a running 3 0 canal stitch was used to close the pharynx Subsequently interrupted 4 0 chromic stitches were then used as reinforcement line from superior to inferior and fibrin glue was applied Two 10 JP drains were placed on the right side and one on the left side and secured appropriately with 3 0 nylon The wound was then closed using interrupted 3 0 Vicryl for the platysma and staples for the skin The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later Keywords endocrinology laryngectomy neck dissection tracheoesophageal cricopharyngeal myotomy thyroid lobectomy squamous cell carcinoma larynx thyroid cartilage cricoid cartilage total laryngectomy thyroid cartilage MEDICAL_TRANSCRIPTION,Description Chief complaint of chest pain previously diagnosed with hyperthyroidism Medical Specialty Endocrinology Sample Name Hyperthyroidism Following Pregnancy Transcription HISTORY Patient is a 21 year old white woman who presented with a chief complaint of chest pain She had been previously diagnosed with hyperthyroidism Upon admission she had complaints of constant left sided chest pain that radiated to her left arm She had been experiencing palpitations and tachycardia She had no diaphoresis no nausea vomiting or dyspnea She had a significant TSH of 0 004 and a free T4 of 19 3 Normal ranges for TSH and free T4 are 0 5 4 7 µIU mL and 0 8 1 8 ng dL respectively Her symptoms started four months into her pregnancy as tremors hot flashes agitation and emotional inconsistency She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards She complained of sweating but has experienced no diarrhea and no change in appetite She was given isosorbide mononitrate and IV steroids in the ER FAMILY HISTORY Diabetes Hypertension Father had a Coronary Artery Bypass Graph CABG at age 34 SOCIAL HISTORY She had a baby five months ago She smokes a half pack a day She denies alcohol and drug use MEDICATIONS Citalopram 10mg once daily for depression low dose tramadol PRN pain PHYSICAL EXAMINATION Temperature 98 4 Pulse 123 Respiratory Rate 16 Blood Pressure 143 74 HEENT She has exophthalmos and could not close her lids completely Cardiovascular tachycardia Neurologic She had mild hyperreflexiveness LAB All labs within normal limits with the exception of Sodium 133 Creatinine 0 2 TSH 0 004 Free T4 19 3 EKG showed sinus tachycardia with a rate of 122 Urine pregnancy test was negative HOSPITAL COURSE After admission she was given propranolol at 40mg daily and continued on telemetry On the 2nd day of treatment the patient still complained of chest pain EKG again showed tachycardia Propranolol was increased from 40mg daily to 60mg twice daily A I 123 thyroid uptake scan demonstrated an increased thyroid uptake of 90 at 4 hours and 94 at 24 hours The normal range for 4 hour uptake is 5 15 and 15 25 for 24 hour uptake Endocrine consult recommended radioactive I 131 for treatment of Graves disease Two days later she received 15 5mCi of I 131 She was to return home after the iodine treatment She was instructed to avoid contact with her baby for the next week and to cease breast feeding ASSESSMENT PLAN 1 Treatment of hyperthyroidism Patient underwent radioactive iodine 131 ablation therapy 2 Management of cardiac symptoms stemming from hyperthyroidism Patient was discharged on propranolol 60mg one tablet twice daily 3 Monitor patient for complications of I 131 therapy such as hypothyroidism She should return to Endocrine Clinic in six weeks to have thyroid function tests performed Long term follow up includes thyroid function tests at 6 12 month intervals 4 Prevention of pregnancy for one year post I 131 therapy Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive taken one tablet daily 5 Monitor ocular health Patient was given methylcellulose ophthalmic one drop in each eye daily She should follow up in 6 weeks with the Ophthalmology clinic 6 Management of depression Patient will be continued on citalopram 10 mg Keywords endocrinology hyperthyroidism diabetes hypertension hospital course thyroid function tachycardia pregnancy MEDICAL_TRANSCRIPTION,Description Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin Medical Specialty Endocrinology Sample Name Diabetes Mellitus Followup Transcription PROBLEM LIST 1 Type 1 diabetes mellitus insulin pump 2 Hypertension 3 Hyperlipidemia HISTORY OF PRESENT ILLNESS The patient is a 39 year old woman returns for followup management of type 1 diabetes mellitus Her last visit was approximately 4 months ago Since that time the patient states her health had been good and her glycemic control had been good however within the past 2 weeks she had a pump malfunction had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks She is not reporting any severe hypoglycemic events but is having some difficulty with hyperglycemia both fasting and postprandial She is not reporting polyuria polydipsia or polyphagia She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well She is working on a full time basis and so eats on the run a lot probably eats more than she should and not making the best choices little time for physical activity She is keeping up with all her other appointments and has recently had a good eye examination She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144 CURRENT MEDICATIONS 1 Zoloft 50 mg p o once daily 2 Lisinopril 40 mg once daily 3 Symlin 60 micrograms not taking at this point 4 Folic acid 2 by mouth every day 5 NovoLog insulin via insulin pump about 90 units of insulin per day REVIEW OF SYSTEMS She denies fever chills sweats nausea vomiting diarrhea constipation abdominal pain chest pain shortness of breath difficulty breathing dyspnea on exertion or change in exercise tolerance She is not having painful urination or blood in the urine She is not reporting polyuria polydipsia or polyphagia PHYSICAL EXAMINATION GENERAL Today showed a very pleasant well nourished woman in no acute distress VITAL SIGNS Temperature not taken pulse 98 respirations 20 blood pressure 148 89 and weight 91 19 kg THORAX Revealed lungs clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 no S4 auscultated ABDOMEN Nontender EXTREMITIES Showed no clubbing cyanosis or edema SKIN Intact and do not appear atrophic Deep tendon reflexes were 2 4 without a delayed relaxation phase LABORATORY DATA Dated 10 05 08 showed a total cholesterol of 223 triglyceride 140 HDL 54 and LDL 144 The hemoglobin A1c was 6 4 and the spot urine for microalbumin was 9 2 micrograms of protein 1 mg of creatinine Sodium 136 potassium 4 5 chloride 102 CO2 30 mEq BUN 11 mg dL creatinine 0 6 mg estimated GFR greater than 60 blood sugar 118 calcium 9 4 and her LFTs were unremarkable TSH is 1 07 and free T4 is 0 81 ASSESSMENT AND PLAN 1 This is a return visit to the endocrine clinic for the patient a 39 year old woman with history as noted above Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin Basal rate is as follows 12 a m 1 5 02 30 a m 1 75 and 6 a m 1 5 Her correction factor is 19 Her carb insulin ratio is 6 Her active insulin time is 5 and her targets are at 12 a m 110 and 6 a m to midnight is 100 We made adjustments to her pump and the plan will be to see her back in approximately 2 months 2 Hyperlipidemia The patient is not taking statin therefore we will prescribe Lipitor 20 mg one p o once daily Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now 3 We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well Keywords endocrinology endocrine clinic insulin pump diabetes mellitus insulin glycemic fasting polyuria polydipsia polyphagia diabetes MEDICAL_TRANSCRIPTION,Description The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1 3rd region Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy Medical Specialty Endocrinology Sample Name Post Hemithyroidectomy Transcription PREOPERATIVE DIAGNOSES Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy POSTOPERATIVE DIAGNOSES Papillary carcinoma of the follicular variant of the thyroid in the right lobe status post right hemithyroidectomy PROCEDURE The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1 3rd region FINDINGS Normal appearing thyroid gland with a possible lump in the inferior aspect there was a parathyroid gland that by frozen section _________ was not thyroid it was reimplanted to the left lower sternocleidomastoid region ESTIMATED BLOOD LOSS Approximately 10 mL FLUIDS Crystalloid only COMPLICATIONS None DRAINS Rubber band drain in the neck CONDITION Stable PROCEDURE The patient placed supine under general anesthesia First a shoulder roll was placed 1 lidocaine and 1 100 000 epinephrine was injected into the old scar natural skin fold and Betadine prep Sterile dressing was placed The laryngeal monitoring was noted to be working fine Then an incision was made in this area in a curvilinear fashion through the old scar taken through the fat and the platysma level The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid the thyroid gland was then found Then using bipolar cautery and a Coblation dissector the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally the thyroid gland was released then came into the Berry ligaments The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels which were crossed with the Harmonic scalpel and removed No bleeding was seen There was a small nick in the external jugular vein that was tied with a 4 0 Vicryl suture ligature After this was completed on examining the specimen there appeared to be a lobule on it and it was sent off as possibly parathyroid therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature After this was completed no bleeding was seen The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4 0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5 0 nylon was used to close the skin and Mastisol and Steri Strips were placed along the skin edges and then on awakening both laryngeal nerves were working normally Procedure was then terminated at that time Keywords endocrinology thyroid rubber band drain berry ligaments papillary carcinoma follicular variant strap muscles thyroid gland sternocleidomastoid parathyroid hemithyroidectomy MEDICAL_TRANSCRIPTION,Description Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field Medical Specialty Endocrinology Sample Name Metastatic Lymphadenopathy Thyroid Tissue Removal Transcription TITLE OF OPERATION Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field INDICATION FOR SURGERY The patient is a 37 year old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04 07 with final pathology revealing extrafocal extrathyroidal extension and extranodal extension in the soft tissues of his medullary thyroid cancer The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease Fine needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer Risks benefits and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed The risks included but not limited to anesthesia bleeding infection injury to nerve lip tongue shoulder weakness tongue numbness droopy eyelid tumor comes back need for additional treatment diaphragm weakness pneumothorax need for chest tube others The patient understood all these issues and did wish to proceed PROCEDURE DETAIL After identifying the patient the patient was placed supine on the operating room table The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube The eyes were protected with Tegaderm The patient was rotated to 180 degrees towards the operating surgeon The Foley catheter was placed into the bladder with good return of urine Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip The incision then was planned around the old scar to be excised A 1 lidocaine with 1 to 100 000 epinephrine was injected A shoulder roll was applied The incision was made the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly Attention was then turned to performing the level 1 dissection on the left Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric The submandibular gland was appreciated and retracted laterally The mylohyoid muscle appreciated The lingual nerve was appreciated and the submandibular ganglion was ligated The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis The marginal mandibular nerve stimulated at the completion of this portion of the procedure Attention was then turned to incising the fascia along the clavicle on the left side Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified The brachial plexus and phrenic nerve were identified The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels Attention was then turned to the central neck The strap muscles were appreciated in the midline There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed Attention was then turned to identify the carotid artery and the internal jugular vein on the left side This was traced inferiorly internal jugular vein to the brachiocephalic vein Palpation deep to this area into the mediastinum and up against the trachea revealed a 1 5 cm lymph node mass Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis Attention was then turned to the right neck dissection A posterior flap on the right was raised to the anterior border of the trapezius The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly Attention was then turned to identifying the submandibular gland A digastric tunnel was performed back to the sternocleidomastoid muscle The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated The omohyoid muscle was retracted inferiorly Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle Subsequently the internal jugular vein was identified The external jugular vein ligated about 1 cm above the clavicle Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex Dissection along the floor of the neck then was performed to allow for mobilization The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly The cervical rootlets were transected after the contribution so the phrenic nerve all the way superiorly to the skull base The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein The wound was copiously irrigated Valsalva maneuver was given No bleeding points identified The wound was then prepared for closure Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3 0 nylon The wound was closed with interrupted 3 0 Vicryl for platysma subsequently a 4 0 running Biosyn for the skin and Indermil The patient tolerated the procedure well was extubated on the operating room table and sent to the postanesthesia care unit in good condition Keywords endocrinology lymphadenopathy thyroid infraclavicular fossa lymph nodes dissection pretracheal internal jugular vein infraclavicular lymphadenopathy metastatic lymphadenopathy mandibular nerve vein nodes neck nerve muscle jugularNOTE MEDICAL_TRANSCRIPTION,Description Patient today with ongoing issues with diabetic control Medical Specialty Endocrinology Sample Name Diabetes Mellitus SOAP Note 2 Transcription SUBJECTIVE I am asked to see the patient today with ongoing issues around her diabetic control We have been fairly aggressively downwardly adjusting her insulins both the Lantus insulin which we had been giving at night as well as her sliding scale Humalog insulin prior to meals Despite frequent decreases in her insulin regimen she continues to have somewhat low blood glucoses most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units which is a considerable change What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin The staff reports to me that her appetite is good and that she is eating as well as ever I talked to Anna today She feels a little fatigued Otherwise she is doing well PHYSICAL EXAMINATION Vitals as in the chart The patient is a pleasant and cooperative She is in no apparent distress ASSESSMENT AND PLAN Diabetes still with some problematic low blood glucoses most notably in the morning To address this situation I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning She will get 55 units in the morning I am also decreasing once again her Humalog sliding scale insulin prior to meals I will review the blood glucoses again next week Keywords endocrinology diabetic control insulin prior to meals low blood glucoses sliding scale lantus insulin diabetes mellitus lantus glucoses MEDICAL_TRANSCRIPTION,Description Left axillary dissection with incision and drainage of left axillary mass Right axillary mass excision and incision and drainage Bilateral axillary masses rule out recurrent Hodgkin s disease Medical Specialty Endocrinology Sample Name Axillary Dissection Mass Excision Transcription PREOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease POSTOPERATIVE DIAGNOSIS Bilateral axillary masses rule out recurrent Hodgkin s disease PROCEDURE PERFORMED 1 Left axillary dissection with incision and drainage of left axillary mass 2 Right axillary mass excision and incision and drainage ANESTHESIA LMA SPECIMENS Left axillary mass with nodes and right axillary mass ESTIMATED BLOOD LOSS Less than 30 cc INDICATION This 56 year old male presents to surgical office with history of bilateral axillary masses Upon evaluation it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter The patient had been continued on antibiotics preoperatively The patient with history of Hodgkin s lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time Consent for possible recurrence of Hodgkin s lymphoma warranted exploration and excision of these masses The patient was explained the risks and benefits of the procedure and informed consent was obtained GROSS FINDINGS Upon dissection of the left axillary mass the mass was removed in toto and noted to have a cavity within it consistent with an abscess No loose structures were identified and sent for frozen section which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma however the confirmed pathology report is pending at this time The right axillary mass was excised without difficulty without requiring full axillary dissection PROCEDURE The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete A 10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis Identification of the axillary anatomy was made and care was made to avoid injury to nerve vessel or musculature Once this mass was removed in toto lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture Upon revaluation of the incisional site it was noted to be hemostatic Warm lap sponge was then left in place at this site Next attention was turned to the right axilla where a 10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with 3 0 Vicryl suture followed by 4 0 Vicryl running subcuticular stitch Steri Strips were applied Attention was returned back left axilla which upon re exploration was noted to be hemostatic and a 7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision This was placed within the incision site ________ drainage of the axillary potential space Approximation of the deep dermal tissues were then done with 3 0 Vicryl in an interrupted technique followed by 4 0 Vicryl with running subcuticular technique Steri Strips and sterile dressings were applied JP bulb was then placed to suction and sterile dressings were applied to both axilla The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1 2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise Keywords endocrinology incision and drainage axillary mass excision axillary dissection hodgkin s disease axillary mass mass incision axillary MEDICAL_TRANSCRIPTION,Description Urgent cardiac catheterization with coronary angiogram Medical Specialty Emergency Room Reports Sample Name Urgent Cardiac Cath Transcription PROCEDURE Urgent cardiac catheterization with coronary angiogram PROCEDURE IN DETAIL The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest The right groin was prepped and draped in usual manner Under 2 lidocaine anesthesia the right femoral artery was entered A 6 French sheath was placed The patient was already on anticoagulation Selective coronary angiograms were then performed using a left and a 3DRC catheter The catheters were reviewed The catheters were then removed and an Angio Seal was placed There was some hematoma at the cath site RESULTS 1 The left main was free of disease 2 The left anterior descending and its branches were free of disease 3 The circumflex was free of disease 4 The right coronary artery was free of disease There was no gradient across the aortic valve IMPRESSION Normal coronary angiogram Keywords emergency room reports cardiac catheterization coronary angiogram angiogram MEDICAL_TRANSCRIPTION,Description Followup diabetes mellitus type 1 Medical Specialty Endocrinology Sample Name Diabetes Mellitus SOAP Note 1 Transcription CHIEF COMPLAINT Followup diabetes mellitus type 1 SUBJECTIVE Patient is a 34 year old male with significant diabetic neuropathy He has been off on insurance for over a year Has been using NPH and Regular insulin to maintain his blood sugars States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago Reports that his blood sugar dropped too low which caused the accident Since this point in time he has been unwilling to let his blood sugars fall within a normal range for fear of hypoglycemia Also reports that he regulates his blood sugars with how he feels rarely checking his blood sugar with a glucometer Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time Reports that he had some indications of kidney damage when first diagnosed His urine microalbumin today is 100 His last hemoglobin A1C drawn at the end of December is 11 9 Reports that at one point he was on Lantus which worked well and he did not worry about his blood sugars dropping too low While using Lantus he was able to get his hemoglobin A1C down to 7 His last CMP shows an elevated alkaline phosphatase level of 168 He denies alcohol or drug use and is a non smoker Reports he quit drinking 3 years ago I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today Patient also has a history of gastroparesis and impotence Patient requests Nexium and Viagra neither of which are covered under the Health Plan Patient reports that he was in a scooter accident one week ago fell off his scooter hit his head Was not wearing a helmet Reports that he did not go to the emergency room and had a headache for several days after this incident Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room Patient did not comply Reports that the headache has resolved Denies any dizziness nausea vomiting or other neurological abnormalities PHYSICAL EXAMINATION WD WN Slender 34 year old white male VITAL SIGNS Blood sugar 145 blood pressure 120 88 heart rate 104 respirations 16 Microalbumin 100 SKIN There appears to be 2 skin lacerations on the left parietal region of the scalp each approximately 1 inch long No signs of infection Wound is closed with new granulation tissue Appears to be healing well HEENT Normocephalic PERRLA EOMI TMs pearly gray with landmarks present Nares patent Throat with no redness or swelling Nontender sinuses NECK Supple Full ROM No LAD CARDIAC Keywords endocrinology diabetes mellitus nph regular insulin sggt diabetic neuropathy dizziness followup glucometer hypoglycemia microalbumin nausea neurological vomiting mellitus type blood sugars blood diabetes mellitus sugars MEDICAL_TRANSCRIPTION,Description This 68 year old man presents to the emergency department for three days of cough claims that he has brought up some green and grayish sputum He says he does not feel short of breath He denies any fever or chills Medical Specialty Emergency Room Reports Sample Name Viral Syndrome ER Visit Transcription SUBJECTIVE This 68 year old man presents to the emergency department for three days of cough claims that he has brought up some green and grayish sputum He says he does not feel short of breath He denies any fever or chills REVIEW OF SYSTEMS HEENT Denies any severe headache or sore throat CHEST No true pain GI No nausea vomiting or diarrhea PAST HISTORY He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation He also lists some other medications I do have his medications list He is on Pacerone Zaroxolyn albuterol inhaler Neurontin Lasix and several other medicines Those are the predominant medicines He is not a diabetic The past history otherwise he has had smoking history but he quit several years ago and denies any COPD or emphysema No one else in the family is sick PHYSICAL EXAMINATION GENERAL The patient appears comfortable He did not appear to be in any respiratory distress He was alert I heard him cough once during the entire encounter He did not bring up any sputum at that time VITAL SIGNS His temperature is 98 pulse 71 respiratory rate 18 blood pressure 122 57 and pulse ox is 95 on room air HEENT Throat was normal RESPIRATORY He was breathing normally There was clear and equal breath sounds He was speaking in full sentences There was no accessory muscle use HEART Sounded regular SKIN Normal color warm and dry NEUROLOGIC Neurologically he was alert IMPRESSION Viral syndrome which we have been seeing in many cases throughout the week The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature normal pulse normal respiratory rate and near normal oxygen The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding The patient understands this I then asked him if the cough was annoying him he said it was I offered him a cough syrup which he agreed to take The patient was then discharged with Tussionex Pennkinetic a hydrocodone time release cough syrup I told to check in three days if the symptoms were not getting better The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later His wife calls me very angry that I did not give him antibiotics I explained her exactly what I explained to him that they were not indicative at this time and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection DIAGNOSIS Viral respiratory illness Keywords emergency room reports sputum short of breath fever chills copd emphysema viral respiratory illness green and grayish sputum viral syndrome respiratory rate cough syrup cough antibiotics inhaler MEDICAL_TRANSCRIPTION,Description Completion thyroidectomy with limited right paratracheal node dissection Medical Specialty Endocrinology Sample Name Completion Thyroidectomy Transcription TITLE OF OPERATION Completion thyroidectomy with limited right paratracheal node dissection INDICATION FOR SURGERY A 49 year old woman with a history of a left dominant nodule in her thyroid gland who subsequently underwent left thyroid lobectomy and isthmusectomy was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus Consideration given to completion thyroidectomy Risks benefits and alternatives of this procedure was discussed with the patient in great detail Risks included but were not limited to anesthesia bleeding infection injury to nerves including vocal fold paralysis hoarseness low calcium scar cosmetic deformity need for thyroid hormone replacement and also need for further management The patient understood all of this and then wished to proceed PREOP DIAGNOSIS Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen POSTOP DIAGNOSIS Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen PROCEDURE DETAIL After identifying the patient the patient was placed supine in the operating room table After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube the eyes were protected with Tegaderm Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured The previous skin incision for a thyroidectomy was then planned then incorporated into an ellipse The patient was prepped and draped in a sterile fashion Subsequently the ellipse around the previous incision was deformed The scar was then excised Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side There was some dense fibrosis and inflammation surrounding the right thyroid lobe Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly then preserved Of note is that there were multiple lymph nodes in the paratracheal region on the right side These lymph nodes were carefully dissected away from the recurrent laryngeal nerve trachea and the carotid artery and sent as a separate specimen labeled right paratracheal lymph nodes The wound was copiously irrigated Valsalva maneuver was given Surgicel was placed in the wound bed Strap muscles were reapproximated in the midline with 3 0 Vicryl and incision was then closed with interrupted 3 0 Vicryl and Indermil for the skin The patient was extubated in the operating room table sent to the postanesthesia care unit in good condition Keywords endocrinology multifocal thyroid carcinoma thyroid lobectomy thyroid papillary thyroid lobe isthmus completion thyroidectomy thyroidectomy paratracheal lobectomy MEDICAL_TRANSCRIPTION,Description Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days Medical Specialty Emergency Room Reports Sample Name Toothache ER Visit Transcription CHIEF COMPLAINT Toothache HISTORY OF PRESENT ILLNESS This is a 29 year old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled Complains of new tooth pain The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments he has to be on standby appointments only The patient denies any other problems or complaints The patient denies any recent illness or injuries The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness No recent weight change HEENT No headache no neck pain the toothache pain for the past three days as previously mentioned There is no throat swelling no sore throat no difficulty swallowing solids or liquids The patient denies any rhinorrhea No sinus congestion pressure or pain no ear pain no hearing change no eye pain or vision change CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath or cough GASTROINTESTINAL No abdominal pain No nausea or vomiting GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No focal weakness or numbness Normal speech HEMATOLOGIC LYMPHATIC No lymph node swelling has been noted PAST MEDICAL HISTORY Chronic knee pain CURRENT MEDICATIONS OxyContin and Vicodin ALLERGIES PENICILLIN AND CODEINE SOCIAL HISTORY The patient is still a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 9 oral blood pressure is 146 83 pulse is 74 respirations 16 oxygen saturation 98 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed The patient is a little overweight but otherwise appears to be healthy The patient is calm comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Eyes are normal with clear conjunctiva and cornea bilaterally There is no icterus injection or discharge Pupils are 3 mm and equally round and reactive to light bilaterally There is no absence of light sensitivity or photophobia Extraocular motions are intact bilaterally Ears are normal bilaterally without any sign of infection There is no erythema swelling of canals Tympanic membranes are intact without any erythema bulging or fluid levels or bubbles behind it Nose is normal without rhinorrhea or audible congestion There is no tenderness over the sinuses NECK Supple nontender and full range of motion There is no meningismus No cervical lymphadenopathy No JVD Mouth and oropharynx shows multiple denture and multiple dental caries The patient has tenderness to tooth 12 as well as tooth 21 The patient has normal gums There is no erythema or swelling There is no purulent or other discharge noted There is no fluctuance or suggestion of abscess There are no new dental fractures The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling The buccal membranes are normal Mucous membranes are moist The floor of the mouth is normal without any abscess suggestion of Ludwig s syndrome CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally without shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to back arms and legs The patient has normal use of his extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact to the extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No cervical lymphadenopathy is palpated EMERGENCY DEPARTMENT COURSE The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction DIAGNOSES 1 ODONTALGIA 2 MULTIPLE DENTAL CARIES CONDITION UPON DISPOSITION Stable DISPOSITION To home PLAN The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes The patient was requested to have reevaluation within two days The patient was given a prescription for Percocet and clindamycin The patient was given drug precautions for the use of these medicines The patient was offered discharge instructions on toothache but states that he already has it He declined the instructions The patient was asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern Keywords emergency room reports odontalgi multiple dental caries dentist dental disease extensive dental disease teeth pulled lower teeth cervical lymphadenopathy dental caries toothache erythema swelling teeth dental MEDICAL_TRANSCRIPTION,Description The patient had a syncopal episode last night She did not have any residual deficit She had a headache at that time She denies chest pains or palpitations Medical Specialty Emergency Room Reports Sample Name Syncope ER Visit 1 Transcription REASON FOR VISIT Syncope HISTORY The patient is a 75 year old lady who had a syncopal episode last night She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up the cereal was on the floor She did not have any residual deficit She had a headache at that time She denies chest pains or palpitations PAST MEDICAL HISTORY Arthritis first episode of high blood pressure today She had a normal stress test two years ago MEDICATIONS Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150 70 SOCIAL HISTORY She does not smoke and she does not drink She lives with her daughter PHYSICAL EXAMINATION GENERAL Lady in no distress VITAL SIGNS Blood pressure 172 91 came down to 139 75 heart rate 91 and respirations 20 Afebrile HEENT Head is normal NECK Supple LUNGS Clear to auscultation and percussion HEART No S3 no S4 and no murmurs ABDOMEN Soft EXTREMITIES Lower extremities no edema DIAGNOSTIC DATA Her EKG shows sinus rhythm with nondiagnostic Q waves in the inferior leads ASSESSMENT Syncope PLAN She had a CT scan of the brain that was negative today The blood pressure is high We will start Maxzide We will do an outpatient Holter and carotid Doppler study She has had an echocardiogram along with the stress test before and it was normal We will do an outpatient followup Keywords emergency room reports residual deficit headache ct scan syncopal episode stress test blood pressure syncope MEDICAL_TRANSCRIPTION,Description Return visit to the endocrine clinic for acquired hypothyroidism papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992 and diabetes mellitus Medical Specialty Endocrinology Sample Name Acquired Hypothyroidism Followup Transcription PROBLEM LIST 1 Acquired hypothyroidism 2 Papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992 3 Diabetes mellitus 4 Insomnia with sleep apnea HISTORY OF PRESENT ILLNESS This is a return visit to the endocrine clinic for the patient with history as noted above She is 45 years old Her last visit was about 6 months ago Since that time the patient states her health has remained unchanged Currently primary complaint is one of fatigue that she feels throughout the day She states however she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day In terms of her thyroid issues the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism She is not reporting temperature intolerance palpitations muscle weakness tremors nausea vomiting constipation hyperdefecation or diarrhea Her weight has been stable She is not reporting proximal muscle weakness CURRENT MEDICATIONS 1 Levothyroxine 125 micrograms p o once daily 2 CPAP 3 Glucotrol 4 Avandamet 5 Synthroid 6 Byetta injected twice daily REVIEW OF SYSTEMS As stated in the HPI She is not reporting polyuria polydipsia or polyphagia She is not reporting fevers chills sweats visual acuity changes nausea vomiting constipation or diarrhea She is not having any lightheadedness weakness chest pain shortness of breath difficulty breathing orthopnea or dyspnea on exertion PHYSICAL EXAMINATION GENERAL She is an overweight very pleasant woman in no acute distress VITAL SIGNS Temperature 96 9 pulse 85 respirations not counted blood pressure 135 65 and weight 85 7 kg NECK Reveals well healed surgical scar in the anteroinferior aspect of the neck There is no palpable thyroid tissue noted on this examination today There is no lymphadenopathy THORAX Reveals lungs that are clear PA and lateral without adventitious sounds CARDIOVASCULAR Demonstrated regular rate and rhythm S1 and S2 without murmur No S3 no S4 is auscultated EXTREMITIES Deep tendon reflexes 2 4 without a delayed relaxation phase No fine resting tremor of the outstretched upper extremity SKIN HAIR AND NAILS All are unremarkable LABORATORY DATABASE Lab data on 08 29 07 showed the following Thyroglobulin quantitative less than 0 5 and thyroglobulin antibody less than 20 free T4 1 35 and TSH suppressed at 0 121 ASSESSMENT AND PLAN This is a 45 year old woman with history as noted above 1 Acquired hypothyroidism status post total thyroidectomy for papillary carcinoma in 1992 2 Plan to continue following thyroglobulin levels 3 Plan to obtain a free T4 TSH and thyroglobulin levels today 4 Have the patient call the clinic next week for followup and continued management of her hypothyroid state 5 Plan today is to repeat her thyroid function studies This case was discussed with Dr X and the recommendation We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0 41 or less Therefore labs have been drawn We plan to see the patient back in approximately 6 months or sooner A repeat body scan will not been done the one in 03 06 was negative Keywords endocrinology thyroid function studies thyroid gland diabetes mellitus papillary carcinoma total thyroidectomy acquired hypothyroidism carcinoma thyroidectomy thyroglobulin hypothyroidism MEDICAL_TRANSCRIPTION,Description This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain Medical Specialty Emergency Room Reports Sample Name Pain from Hernia ER Consult Transcription HISTORY OF PRESENT ILLNESS This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain At the time of my exam he states that his left lower extremity pain has improved considerably He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably He does have a history of multiple medical problems including atrial fibrillation he is on Coumadin which is currently subtherapeutic multiple CVAs in the past peripheral vascular disease and congestive heart failure He has multiple chronic history of previous ischemia of his large bowel in the past PHYSICAL EXAM VITAL SIGNS Currently his temperature is 98 2 pulse is 95 and blood pressure is 138 98 HEENT Unremarkable LUNGS Clear CARDIOVASCULAR An irregular rhythm ABDOMEN Soft EXTREMITIES His upper extremities are well perfused He has palpable radial and femoral pulses He does not have any palpable pedal pulses in either right or left lower extremity He does have reasonable capillary refill in both feet He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool but it is relatively warm Apparently this was lot worst few hours ago He describes significant pain and pallor which he feels has improved and certainly clinically at this point does not appear to be as significant IMPRESSION AND PLAN This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease essentially related to spasm versus a small clot which may have been lysed to some extent He currently has a viable extremity and viable foot but certainly has significant making compromised flow It is unclear to me whether this is chronic or acute and whether he is a candidate for any type of intervention He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime Given his potential history of recent lower GI bleeding he has been evaluated by GI to see whether or not he is a candidate for heparinization We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate Again at this point he has no pain relatively rapid capillary refill and relatively normal motor function suggesting a viable extremity We will follow him along closely Keywords emergency room reports blood in stool nausea capillary refill angiogram hernia extremity MEDICAL_TRANSCRIPTION,Description She is a 28 year old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood tinged vomit starting approximately worse over the past couple of days This is patient s fourth trip to the emergency room and second trip for admission Medical Specialty Emergency Room Reports Sample Name Nausea Vomiting ER Visit Transcription HISTORY OF PRESENT ILLNESS She is a 28 year old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood tinged vomit starting approximately worse over the past couple of days This is patient s fourth trip to the emergency room and second trip for admission PAST MEDICAL HISTORY Nonsignificant PAST SURGICAL HISTORY None SOCIAL HISTORY No alcohol drugs or tobacco PAST OBSTETRICAL HISTORY This is her first pregnancy PAST GYNECOLOGICAL HISTORY Not pertinent While in the emergency room the patient was found to have slight low sodium potassium slightly elevated and her ALT of 93 AST of 35 total bilirubin is 1 2 Her urine was 3 ketones 2 protein and 1 esterase and rbc too numerous to count with moderate amount of bacteria H and H stable at 14 1 and 48 7 She was then admitted after giving some Phenergan and Zofran IV As started on IV given hydration as well as given a dose of Rocephin to treat bladder infection She was admitted overnight nausea and vomiting resolved to only one episode of vomiting after receiving Maalox tolerated fluids as well as p o food Followup chemistry was obtained for AST ALT and we will plan for discharge if lab variables resolve ASSESSMENT AND PLAN 1 This is a 28 year old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup 2 Slightly elevated ALT questionable likely due to the nausea and vomiting We will recheck for followup Keywords emergency room reports iv hydration elevated alt emergency nausea vomiting MEDICAL_TRANSCRIPTION,Description Patient started out having toothache now radiating into his jaw and towards his left ear Ellis type II dental fracture Medical Specialty Emergency Room Reports Sample Name Jaw Pain ER Visit Transcription CHIEF COMPLAINT Jaw pain HISTORY OF PRESENT ILLNESS This is a 58 year old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments but has not seen a dentist since this new toothache began The patient denies any facial swelling No headache No swelling to the throat No sore throat No difficulty swallowing liquids or solids No neck pain No lymph node swelling The patient denies any fever or chills Denies any other problems or complaints REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness HEENT No headache No neck pain No eye pain or vision change No rhinorrhea No sinus congestion pressure or pain No sore throat No throat swelling The patient does have the toothache on the left lower side that radiates towards his left ear as previously described The patient does not have ear pain or hearing change No pressure in the ear CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath GASTROINTESTINAL No nausea or vomiting No abdominal pain MUSCULOSKELETAL No back pain SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No speech change HEMATOLOGIC LYMPHATIC No lymph node swelling PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None CURRENT MEDICATIONS None ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient smokes marijuana The patient does not smoke cigarettes PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 2 oral blood pressure is 168 84 pulse is 87 respirations 16 and oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed The patient appears to be healthy The patient is calm comfortable in no acute distress looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctivae bilaterally Nose normal without rhinorrhea or audible congestion There is no tenderness over the sinuses Ears are normal without any sign of infection No erythema or swelling of the canals Tympanic membranes are intact and normal without any erythema bulging air fluid levels or bubbles behind it MOUTH The patient has a dental fracture at tooth 18 The patient states that the fracture is a couple of months old The patient does not have any obvious dental caries The gums are normal without any erythema swelling or evidence of infection There is no fluctuance or suggestion of abscess There is slight tenderness of the tooth 18 The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling Mucous membranes are moist Floor of the mouth is normal without any tenderness or swelling No suggestion of abscess There is no pre or post auricular lymphadenopathy either NECK Supple Nontender Full range of motion No meningismus No cervical lymphadenopathy No JVD No carotid artery or vertebral artery bruits CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally No shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to the back arms or legs The patient has normal use of the extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect No evidence of clinical intoxification HEMATOLOGIC LYMPHATIC No lymphadenitis is palpated DIAGNOSES 1 ACUTE LEFT JAW PAIN 2 18 DENTAL FRACTURE WHICH IS AN ELLIS TYPE II FRACTURE 3 ELEVATED BLOOD PRESSURE CONDITION UPON DISPOSITION Stable DISPOSITION Home PLAN We will have the patient follow up with his dentist Dr X in three to five days for reevaluation The patient was encouraged to take Motrin 400 mg q 6h as needed for pain The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain He was given precautions for drowsiness and driving with the use of this medication The patient was also given a prescription for pen V The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition develop any other problems or symptoms of concern Keywords emergency room reports jaw pain dental appointment ellis type ii fracture ellis type dental fracture toothache tenderness pressure erythema MEDICAL_TRANSCRIPTION,Description Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Medical Specialty Emergency Room Reports Sample Name Melena ICU Followup Transcription HISTORY Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8 status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr X of Gastroenterology confirming diagnosis of ulcerative esophagitis also for continuing chronic obstructive pulmonary disease exacerbation with productive cough infection and shortness of breath Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient Over the last 24 hours the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value He also underwent EGD earlier today with Dr X I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding Dr X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough now producing yellow brown sputum with increasing frequency but he has had no further episodes of melena since transfer to the ICU He is also complaining of some laryngitis and some pharyngitis but is denying any abdominal complaints nausea or diarrhea PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 100 54 heart rate 80 and temperature 98 8 Is and Os negative fluid balance of 1 4 liters in the last 24 hours GENERAL This is a somnolent 68 year old male who arouses to voice wakes up seems to have good appetite has continuing cough Pallor is improved EYES Conjunctivae are now pink ENT Oropharynx is clear CARDIOVASCULAR Reveals distant heart tones with regular rate and rhythm LUNGS Have coarse breath sounds with wheezes rhonchi and soft crackles in the bases ABDOMEN Soft and nontender with no organomegaly appreciated EXTREMITIES Showed no clubbing cyanosis or edema Capillary refill time is now normal in the fingertips NEUROLOGICAL Cranial nerves II through XII are grossly intact with no focal neurological deficits LABORATORY DATA Laboratories drawn at 1449 today WBC 10 hemoglobin and hematocrit 11 5 and 33 1 and platelets 288 000 This is up from 8 6 and 24 7 Platelets are stable Sodium is 134 potassium 4 0 chloride 101 bicarb 26 BUN 19 creatinine 1 0 glucose 73 calcium 8 4 INR 0 96 iron 13 saturations 4 TIBC 312 TSH 0 74 CEA elevated at 8 6 ferritin 27 5 and occult blood positive EGD final results pending per Dr X s note and conversation with me earlier ulcerative esophagitis without signs of active bleeding at this time IMPRESSION PLAN 1 Melena secondary to ulcerative esophagitis We will continue to monitor the patient overnight to ensure there is no further bleeding If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation 2 Chronic obstructive pulmonary disease exacerbation The patient is doing well taking PO We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments We will add guaifenesin and N acetyl cysteine in a hope to mobilize some of his secretions This does appear to be improving His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications 3 Elevated CEA The patient will need colonoscopy on an outpatient basis He has refused this today We would like to encourage him to do so Of note the patient when he came in was on bloodless protocol but with urging did accept the transfusion Similarly I am hoping that with proper counseling the patient will consent to further examination with colonoscopy given his guaiac positive status elevated CEA and risk factors 4 Anemia normochromic normocytic with low total iron binding capacity This appears to be anemia of chronic disease However this is likely some iron deficiency superimposed on top of this given his recent bleeding with consider iron vitamin C folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding Total critical care time spent today discussing the case with Dr X examining the patient reviewing laboratory trends adjusting medications and counseling the patient in excess is 35 minutes Keywords emergency room reports anemia gi bleeding hemoglobin ulcerative esophagitis obstructive pulmonary disease icu followup infection obstructive pulmonary egd melena bleeding MEDICAL_TRANSCRIPTION,Description Patient presents to the Emergency Department with complaint of a bleeding bump on his penis Medical Specialty Emergency Room Reports Sample Name Penile Mass Emergency Visit Transcription CHIEF COMPLAINT Bloody bump on penis HISTORY OF PRESENT ILLNESS This is a 29 year old African American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis The patient states that he has had a large bump on the end of his penis for approximately a year and a half He states that it has never bled before It has never caused him any pain or has never been itchy The patient states that he is sexually active but has been monogamous with the same person for the past 13 years He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice The patient does state that last night he was trying to get some meaning that he was engaging in sexual intercourse at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis The patient said that there is a large amount of blood from this injury This happened last night but he was embarrassed to come to the Emergency Department yesterday when it was bleeding The patient has been able to get the bleeding to stop but the large bump is still located on the end of his penis and he is concerned that it will rip off and does want it removed The patient denies any drainage or discharge from his penis He denies fevers or chills recently He also denies nausea or vomiting The patient has not had any discharge from his penis He has not had any other skin lesions on his penis that are new to him He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years The patient has never had these checked out He denies fevers chills or night sweats He denies unintentional weight gain or loss He denies any other bumps rashes or lesions throughout the skin on his body PAST MEDICAL HISTORY No significant medical problems PAST SURGICAL HISTORY Surgery for excision of a bullet after being shot in the back SOCIAL HABITS The patient denies illicit drug usage He occasionally smokes tobacco and drinks alcohol MEDICATIONS None ALLERGIES No known medical allergies PHYSICAL EXAMINATION GENERAL This is an African American male who appears his stated age of 29 years He is well nourished well developed in no acute distress The patient is pleasant He is sitting on a Emergency Department gurney VITAL SIGNS Temperature 98 4 degrees Fahrenheit blood pressure of 139 78 pulse of 83 respiratory rate of 18 and pulse oximetry of 98 on room air HEART Regular rate and rhythm Clear S1 S2 No murmur rub or gallop is appreciated LUNGS Clear to auscultation bilaterally No wheezes rales or rhonchi ABDOMEN Soft nontender nondistended and positive bowel sounds throughout GENITOURINARY The patient s external genitalia is markedly abnormal There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus This pedunculated mass is approximately 1 5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well There are no open lesions at this point There is a small tear of the skin where the mass attaches to the glans near the urethral meatus Bleeding is currently stanch and there is no sign of secondary infection at this time Bilateral testicles are descended and normal without pain or mass bilaterally There is no inguinal adenopathy EXTREMITIES No edema SKIN Warm dry and intact No rash or lesion DIAGNOSTIC STUDIES Non emergency department courses It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass ASSESSMENT AND PLAN Penile mass The patient does have a large pedunculated penile mass He will be referred to the urologist who is on call today The patient will need this mass excised and biopsied The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER Keywords emergency room reports bump on penis bleeding bump glans urethral meatus penile mass emergency department penis penile pedunculated bump mass MEDICAL_TRANSCRIPTION,Description Suspected mastoiditis ruled out right acute otitis media and severe ear pain resolving The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis Medical Specialty Emergency Room Reports Sample Name Mastoiditis Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Suspected mastoiditis ruled out 2 Right acute otitis media 3 Severe ear pain resolving HISTORY OF PRESENT ILLNESS The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis The child has had very severe ear pain and blood draining from the right ear The child had a temperature maximum of 101 4 in the ER The patient was admitted and started on IV Unasyn which he tolerated well and required Morphine and Vicodin for pain control In the first 12 hours after admission the patient s pain decreased and also swelling of his cervical area decreased The patient was evaluated by Dr X from the ENT while in house After reviewing the CT scan it was felt that the CT scan was not consistent with mastoiditis The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge At the time of discharge his pain is markedly decreased about 2 10 and swelling in the area has improved The patient is also able to take p o well DISCHARGE PHYSICAL EXAMINATION GENERAL The patient is alert in no respiratory distress VITAL SIGNS His temperature is 97 6 heart rate 83 blood pressure 105 57 respiratory rate 16 on room air HEENT Right ear shows no redness The area behind his ear is nontender There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly NECK Supple CHEST Clear breath sounds CARDIAC Normal S1 S2 without murmur ABDOMEN Soft There is no hepatosplenomegaly or tenderness SKIN Warm and well perfused DISCHARGE WEIGHT 38 7 kg DISCHARGE CONDITION Good DISCHARGE DIET Regular as tolerated DISCHARGE MEDICATIONS 1 Ciprodex Otic Solution in the right ear twice daily 2 Augmentin 500 mg three times daily x10 days FOLLOW UP 1 Dr Y in one week ENT 2 The primary care physician in 2 to 3 days TIME SPENT Approximate discharge time is 28 minutes Keywords MEDICAL_TRANSCRIPTION,Description This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms Medical Specialty Emergency Room Reports Sample Name Itchy Rash ER Visit Transcription CHIEF COMPLAINT Itchy rash HISTORY OF PRESENT ILLNESS This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms No facial swelling No tongue or lip swelling No shortness of breath wheezing or other associated symptoms He cannot think of anything that could have triggered this off There have been no changes in his foods medications or other exposures as far as he knows He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day PAST MEDICAL HISTORY Negative for chronic medical problems No local physician Has had previous back surgery and appendectomy otherwise generally healthy REVIEW OF SYSTEMS As mentioned denies any oropharyngeal swelling No lip or tongue swelling No wheezing or shortness of breath No headache No nausea Notes itchy rash especially on his torso and upper arms SOCIAL HISTORY The patient is accompanied with his wife FAMILY HISTORY Negative MEDICATIONS None ALLERGIES TORADOL MORPHINE PENICILLIN AND AMPICILLIN PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile He is slightly tachycardic 105 but stable blood pressure and respiratory rate GENERAL The patient is in no distress Sitting quietly on the gurney HEENT Unremarkable His oral mucosa is moist and well hydrated Lips and tongue look normal Posterior pharynx is clear NECK Supple His trachea is midline There is no stridor LUNGS Very clear with good breath sounds in all fields There is no wheezing Good air movement in all lung fields CARDIAC Without murmur Slight tachycardia ABDOMEN Soft nontender SKIN Notable for a confluence erythematous blanching rash on the torso as well as more of a blotchy papular macular rash on the upper arms He noted some on his buttocks as well Remaining of the exam is unremarkable ED COURSE The patient was treated with epinephrine 1 1000 0 3 mL subcutaneously along with 50 mg of Benadryl intramuscularly After about 15 20 minutes he states that itching started to feel better The rash has started to fade a little bit and feeling a lot more comfortable IMPRESSION ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS ASSESSMENT AND PLAN The patient has what looks to be some type of allergic reaction although the underlying cause is difficult to assess He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off In the meantime I think he can be managed with some antihistamine over the counter He is responding already to Benadryl and the epinephrine that we gave him here He is told that if he develops any respiratory complaints shortness of breath wheezing or tongue or lip swelling he will return immediately for evaluation He is discharged in stable condition Keywords emergency room reports urticaria pruritus lip swelling allergic reaction itchy rash torso swelling itchy rash MEDICAL_TRANSCRIPTION,Description Urine leaked around the ostomy site for his right sided nephrostomy tube The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure Medical Specialty Emergency Room Reports Sample Name Leaking Nephrostomy Tube Transcription CHIEF COMPLAINT Leaking nephrostomy tube HISTORY OF PRESENT ILLNESS This 61 year old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube The leaking began this a m The patient denies any pain does not have fever and has no other problems or complaints The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure The patient states he feels like his usual self and has no other problems or concerns The patient denies any fever or chills No nausea or vomiting No flank pain no abdominal pain no chest pain no shortness of breath no swelling to the legs REVIEW OF SYSTEMS Review of systems otherwise negative and noncontributory PAST MEDICAL HISTORY Metastatic prostate cancer anemia hypertension MEDICATIONS Medication reconciliation sheet has been reviewed on the nurses note ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a nonsmoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 7 oral blood pressure 150 85 pulse is 91 respirations 16 oxygen saturation 97 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed appears to be healthy calm comfortable no acute distress looks well HEENT Eyes are normal with clear sclerae and cornea NECK Supple full range of motion CARDIOVASCULAR Heart has regular rate and rhythm without murmur rub or gallop Peripheral pulses are 2 No dependent edema RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender nondistended No rebound or guarding Normal benign abdominal exam MUSCULOSKELETAL The patient has nontender back and flank No abnormalities noted to the back other than the bilateral nephrostomy tubes The nephrostomy tube left has no abnormalities no sign of infection No leaking of urine nontender nephrostomy tube on the right has a damp dressing which has a small amount of urine soaked into it There is no obvious active leak from the ostomy site No sign of infection No erythema swelling or tenderness The collection bag is full of clear urine The patient has no abnormalities on his legs SKIN No rashes or lesions No sign of infection NEUROLOGIC Motor and sensory are intact to the extremities The patient has normal ambulation normal speech PSYCHIATRIC Alert and oriented x4 Normal mood and affect HEMATOLOGIC AND LYMPHATIC No bleeding or bruising EMERGENCY DEPARTMENT COURSE Reviewed the patient s admission record from one month ago when he was admitted for the placement of the nephrostomy tubes both Dr X and Dr Y have been consulted and both had recommended nephrostomy tubes there was not the name mentioned as to who placed the nephrostomy tubes There was no consultation dictated for this and no name was mentioned in the discharge summary paged Dr X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes Dr A responded to the page and recommended __________ off a BMP and discussing it with Dr B the radiologist as he recalled that this was the physician who placed the nephrostomy tubes paged Dr X and received a call back from Dr X Dr X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a m tomorrow This was discussed with the patient and instructions to return to the hospital at 10 a m to have this tube changed out by Dr X was explained and understood DIAGNOSES 1 WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE 2 PROSTATE CANCER METASTATIC 3 URETERAL OBSTRUCTION The patient on discharge is stable and dispositioned to home PLAN We will have the patient return to the hospital tomorrow at 10 a m for the replacement of his right nephrostomy tube by Dr X The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns Keywords emergency room reports nephrostomy site ureteral obstruction leaking nephrostomy tube acute renal failure bilateral nephrostomy ureteral obstructions nephrostomy tube tube nephrostomy ureteral prostate leaking urine tubes MEDICAL_TRANSCRIPTION,Description Headache improved Intracranial aneurysm Medical Specialty Emergency Room Reports Sample Name Intracranial aneurysm ER Visit Transcription CHIEF COMPLAINT Headache HPI This is a 24 year old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan He was discharged home with a follow up to neurosurgery on the 14th Apparently an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery He has had headaches since the 13th and complains now of some worsening of his pain He denies photophobia fever vomiting and weakness of the arms or legs PMH As above MEDS Vicodin ALLERGIES None PHYSICAL EXAM BP 180 110 Pulse 65 RR 18 Temp 97 5 Mr P is awake and alert in no apparent distress HEENT Pupils equal round reactive to light oropharynx moist sclera clear Neck Supple no meningismus Lungs Clear Heart Regular rate and rhythm no murmur gallop or rub Abdomen Benign Neuro Awake and alert motor strength normal no numbness normal gait DTRs normal Cranial nerves normal COURSE IN THE ED Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass no blood and no hydrocephalus I recommended an LP but he prefers not to have this done He received morphine for pain and his headache improved I ve recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram He left the ED against my advice IMPRESSION Headache improved Intracranial aneurysm PLAN The patient will return tomorrow am for his angiogram Keywords emergency room reports angiogram mass ct scan intracranial aneurysm headache aneurysm intracranial MEDICAL_TRANSCRIPTION,Description An 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation Medical Specialty Emergency Room Reports Sample Name Hypertension Consult Transcription HISTORY OF PRESENT ILLNESS The patient is an 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall Basically the patient states that yesterday she fell and she is not certain about the circumstances on her driveway and on her left side hit a rock When she came to the emergency room she was found to have a rapid atrial tachyarrhythmia and was put on Cardizem with reportedly heart rate in the 50s so that was stopped Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker An ECG this morning showing normal sinus rhythm with frequent APCs Her potassium at that time was 3 1 She does recall having palpitations because of the pain after the fall but she states she is not having them since and has not had them prior She denies any chest pain nor shortness of breath prior to or since the fall She states clearly she can walk and she would be able to climb 2 flights of stairs without problems PAST CARDIAC HISTORY She is followed by Dr X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure On 05 12 08 preserved left and right ventricular systolic function aortic sclerosis with apparent mild aortic stenosis and bi atrial enlargement She has previously had a Persantine Myoview nuclear rest stress test scan completed at ABCD Medical Center in 07 06 that was negative She has had significant mitral valve regurgitation in the past being moderate but on the most recent echocardiogram on 05 12 08 that was not felt to be significant She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker She does have a history of significant hypertension in the past She has had dizzy spells and denies clearly any true syncope She has had bradycardia in the past from beta blocker therapy MEDICATIONS ON ADMISSION 1 Multivitamin p o daily 2 Aspirin 325 mg once a day 3 Lisinopril 40 mg once a day 4 Felodipine 10 mg once a day 5 Klor Con 20 mEq p o b i d 6 Omeprazole 20 mg p o daily presumably for GERD 7 MiraLax 17 g p o daily 8 Lasix 20 mg p o daily ALLERGIES PENICILLIN IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST FAMILY HISTORY She states her brother died of an MI suddenly in his 50s SOCIAL HISTORY She does not smoke cigarettes abuse alcohol nor use any illicit drugs She is retired from Morse Chain and delivering newspapers She is widowed She lives alone but has family members who live either on her property or adjacent to it REVIEW OF SYSTEMS She denies a history of stroke cancer vomiting of blood coughing up blood bright red blood per rectum bleeding stomach ulcers She does not recall renal calculi nor cholelithiasis denies asthma emphysema pneumonia tuberculosis sleep apnea home oxygen use She does note occasional peripheral edema She is not aware of prior history of MI She denies diabetes She does have a history of GERD She notes feeling depressed at times because of living alone She denies rheumatologic conditions including psoriasis or lupus Remainder of review of systems is negative times 15 except as described above PHYSICAL EXAM Height 5 feet 0 inches weight 123 pounds temperature 99 2 degrees Fahrenheit blood pressure has ranged from 160 87 with pulses recorded at being 144 and currently ranges 101 53 to 147 71 pulse 64 respiratory rate 20 O2 saturation 97 On general exam she is a pleasant elderly woman who is hard of hearing but is alert and interactive HEENT Shows cranium is normocephalic and atraumatic She has moist mucosal membranes Neck veins were not distended There are no carotid bruits Lungs Clear to auscultation anteriorly without wheezes She is relatively immobile because of her left hip fracture Cardiac Exam S1 S2 regular rate frequent ectopic beats 2 6 systolic ejection murmur preserved aortic component of the second heart sound There is also a soft holosystolic murmur heard There is no rub or gallop PMI is nondisplaced Abdomen is soft and nondistended Bowel sounds present Extremities without significant clubbing cyanosis and there is trivial to 1 peripheral edema Pulses appear grossly intact Affect is appropriate Visible skin warm and perfused She is not able to move because of left hip fracture easily in bed DIAGNOSTIC STUDIES LAB DATA Pertinent labs include chest x ray with radiology report pending but shows only a calcified aortic knob No clear pulmonary vascular congestion Sodium 140 potassium 3 7 it was 3 1 on admission chloride 106 bicarbonate 27 BUN 17 creatinine 0 9 glucose 150 magnesium was 2 on 07 13 06 Troponin was 0 03 followed by 0 18 INR is 0 93 white blood cell count 10 2 hematocrit 36 platelet count 115 000 EKGs are reviewed Initial EKG done on 08 19 08 at 1832 shows MAT heart rate of 104 beats per minute no ischemic changes She had a followup EKG done at 20 37 on 08 19 08 which shows wandering atrial pacemaker and some lateral T wave changes not significantly changed from prior Followup EKG done this morning shows normal sinus rhythm with frequent APCs IMPRESSION She is an 84 year old female with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery Telemetry now reviewed shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia which has been corrected There has been no atrial fibrillation documented I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath She actually describes feeling good exercise capacity prior to this fall Given favorable risk to benefit ratio for needed left hip surgery I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil which has been started which should help control the multifocal atrial tachycardia which she had and would watch for heart rate with that Continued optimization of electrolytes The patient cannot take beta blockers as previously Toprol reportedly caused shortness of breath although there was some report that it caused bradycardia so we would watch her heart rate on the verapamil The patient is aware of the cardiac risks certainly it is moderate and wishes to proceed with needed surgery I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr X after discharge Regarding her mild thrombocytopenia I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease management of left hip fracture as per orthopedist Keywords emergency room reports hypokalemia shortness of breath atrial tachycardia sinus rhythm hip fracture atrial tachycardia rhythm apcs cardiac regurgitation aortic hypertension pulmonary MEDICAL_TRANSCRIPTION,Description Left hip fracture The patient is a 53 year old female with probable pathological fracture of the left proximal femur Medical Specialty Emergency Room Reports Sample Name Hip Fracture ER Consult Transcription REASON FOR CONSULTATION Left hip fracture HISTORY OF PRESENT ILLNESS The patient is a pleasant 53 year old female with a known history of sciatica apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight History was obtained from the patient As per the history she reported that she has been having back pain with left leg pain since past 4 weeks She has been using a walker for ambulation due to disabling pain in her left thigh and lower back She was seen by her primary care physician and was scheduled to go for MRI yesterday However she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall Since then she was unable to ambulate The patient called paramedics and was brought to the emergency room She denied any history of fall She reported that she stepped the wrong way causing the pain to become worse She is complaining of severe pain in her lower extremity and back pain Denies any tingling or numbness Denies any neurological symptoms Denies any bowel or bladder incontinence X rays were obtained which were remarkable for left hip fracture Orthopedic consultation was called for further evaluation and management On further interview with the patient it is noted that she has a history of malignant melanoma which was diagnosed approximately 4 to 5 years ago She underwent surgery at that time and subsequently she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3 2008 PAST MEDICAL HISTORY Sciatica and melanoma PAST SURGICAL HISTORY As discussed above surgery for melanoma and hysterectomy ALLERGIES NONE SOCIAL HISTORY Denies any tobacco or alcohol use She is divorced with 2 children She lives with her son PHYSICAL EXAMINATION GENERAL The patient is well developed well nourished in mild distress secondary to left lower extremity and back pain MUSCULOSKELETAL Examination of the left lower extremity there is presence of apparent shortening and external rotation deformity Tenderness to palpation is present Leg rolling is positive for severe pain in the left proximal hip Further examination of the spine is incomplete secondary to severe leg pain She is unable to perform a straight leg raising EHL EDL 5 5 2 pulses are present distally Calf is soft and nontender Homans sign is negative Sensation to light touch is intact IMAGING AP view of the hip is reviewed Only 1 limited view is obtained This is a poor quality x ray with a lot of soft tissue shadow This x ray is significant for basicervical type femoral neck fracture Lesser trochanter is intact This is a high intertrochanteric fracture basicervical There is presence of lytic lesion around the femoral neck which is not well delineated on this particular x ray We need to order repeat x rays including AP pelvis femur and knee LABS Have been reviewed ASSESSMENT The patient is a 53 year old female with probable pathological fracture of the left proximal femur DISCUSSION AND PLAN Nature and course of the diagnosis has been discussed with the patient Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma this appears to be a pathological fracture of the left proximal hip At the present time I would recommend obtaining a bone scan and repeat x rays which will include AP pelvis femur hip including knee She denies any pain elsewhere She does have a past history of back pain and sciatica but at the present time this appears to be a metastatic bone lesion with pathological fracture I have discussed the case with Dr X and recommended oncology consultation With the above fracture and presentation she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty cemented type Indication risk and benefits of left hip hemiarthroplasty has been discussed with the patient which includes but not limited to bleeding infection nerve injury blood vessel injury dislocation early and late persistent pain leg length discrepancy myositis ossificans intraoperative fracture prosthetic fracture need for conversion to total hip replacement surgery revision surgery DVT pulmonary embolism risk of anesthesia need for blood transfusion and cardiac arrest She understands above and is willing to undergo further procedure The goal and the functional outcome have been explained Further plan will be discussed with her once we obtain the bone scan and the radiographic studies We will also await for the oncology feedback and clearance Thank you very much for allowing me to participate in the care of this patient I will continue to follow up Keywords emergency room reports calcar proximal femur pathological fracture hip fracture hemiarthroplasty melanoma MEDICAL_TRANSCRIPTION,Description Migraine headache The patient was seen in the urgent care Medical Specialty Emergency Room Reports Sample Name Headache Urgent Care Visit Transcription CC Headache HPI This is a 15 year old girl presenting with occipital headache for the last six hours She denies trauma She has been intermittently nauseated but has not vomited and has some photophobia Denies fever or change in vision She has no past history of headaches PMH None MEDICATIONS Tylenol for pain ALLERGIES None FAMILY HISTORY Grandmother died of cerebral aneurysm ROS Negative PHYSICAL EXAM Vital Signs BP 102 60 P 70 RR 20 T 98 2 HEENT Throat is clear nasopharynx clear TMs clear there is no lymphadenopathy no tenderness to palpations sinuses nontender Neck Supple without meningismus Chest Lungs clear heart regular without murmur COURSE IN THE ED The patient was seen in the urgent care and examined At this time her photophobia and nausea make migraine highly likely She is well appearing and we ll try Tylenol with codeine for her pain One day off school and follow up with her primary doctor IMPRESSION Migraine headache PLAN See above Keywords emergency room reports photophobia nausea migraine headache tylenol migraine headache MEDICAL_TRANSCRIPTION,Description 4 day old with hyperbilirubinemia and heart murmur Medical Specialty Emergency Room Reports Sample Name Hyperbilirubinemia 4 day old Transcription HISTORY The patient is a 4 day old being transferred here because of hyperbilirubinemia and some hypoxia Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic but her oxygen came up with minimal supplemental oxygen She was also noted to have periodic breathing The patient is breast and bottle fed and has been feeding well There has been no diarrhea or vomiting Voiding well Bowels have been regular According to the report from referring facility because the patient had periodic breathing and was hypoxic it was thought the patient was septic and she was given a dose of IM ampicillin The patient was born at 37 weeks gestation to gravida 3 para 3 female by repeat C section Birth weight was 8 pounds 6 ounces and the mother s antenatal other than was normal except for placenta previa The patient s mother apparently went into labor and then underwent a cesarean section FAMILY HISTORY Positive for asthma and diabetes and there is no exposure to second hand smoke PHYSICAL EXAMINATION VITAL SIGNS The patient has a temperature of 36 8 rectally pulse of 148 per minute respirations 50 per minute oxygen saturation is 96 on room air but did go down to 90 and the patient was given 1 liter by nasal cannula GENERAL The patient is icteric well hydrated Does have periodic breathing Color is pink and also icterus is noted scleral and skin HEENT Normal NECK Supple CHEST Clear HEART Regular with a soft 3 6 murmur Femorals are well palpable Cap refill is immediate ABDOMEN Soft small umbilical hernia is noted which is reducible EXTERNAL GENITALIA Those of a female child SKIN Color icteric Nonspecific rash on the body which is sparse The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area EXTREMITIES The patient moves all extremities well Has a normal tone and a good suck EMERGENCY DEPARTMENT COURSE It was indicated to the parents that I would be repeating labs and also catheterize urine specimen Parents were made aware of the fact that child did have a murmur I spoke to Dr X who suggested doing an EKG which was normal and since the patient will be admitted for hyperbilirubinemia an echo could be done in the morning The case was discussed with Dr Y and he will be admitting this child for hyperbilirubinemia CBC done showed a white count of 15 700 hemoglobin 18 gm hematocrit 50 6 platelets 245 000 10 bands 44 segs 34 lymphs and 8 monos Chemistries done showed sodium of 142 mEq L potassium 4 5 mEq L chloride 104 mEq L CO2 28 mmol L glucose 75 mg BUN 8 mg creatinine 0 7 mg and calcium 8 0 mg Total bilirubin was 25 4 mg all of which was unconjugated CRP was 0 3 mg Blood culture was drawn Catheterized urine specimen was normal Parents were kept abreast of what was going on all the time and the need for admission Phototherapy was instituted in the ER almost after the baby got to the emergency room IMPRESSION Hyperbilirubinemia and heart murmur DIFFERENTIAL DIAGNOSES Considered breast milk jaundice ABO incompatibility galactosemia and ventricular septal defect Keywords emergency room reports hypoxia periodic breathing heart murmur urine specimen yellow bilirubin heart murmur hyperbilirubinemia MEDICAL_TRANSCRIPTION,Description Patient in ER with upper respiratory infection Medical Specialty Emergency Room Reports Sample Name ER Report URI Transcription HISTORY OF PRESENT ILLNESS The patient is a two and a half month old male who has been sick for the past three to four days His mother has described congested sounds with cough and decreased appetite He has had no fever He has had no rhinorrhea Nobody else at home is currently ill He has no cigarette smoke exposure She brought him to the emergency room this morning after a bad coughing spell He did not have any apnea during this episode PAST MEDICAL HISTORY Unremarkable He has had his two month immunizations PHYSICAL EXAMINATION VITAL SIGNS Temperature 99 1 oxygen saturations 98 respirations by the nurse at 64 however at my examination was much slower and regular in the 40s GENERAL Sleeping easily aroused smiling and in no distress HEENT Soft anterior fontanelle TMs are normal Moist mucous membranes LUNGS Equal and clear CHEST Without retraction HEART Regular in rate and rhythm without murmur ABDOMEN Benign DIAGNOSTIC STUDIES Chest x ray ordered by ER physician is unremarkable but to me also ASSESSMENT Upper respiratory infection TREATMENT Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares Smaller but more frequent feeds Discuss proper sleeping position Recheck if there is any fever or if he is no better in the next three days Keywords emergency room reports er uri emergency room upper respiratory infection respiratory sick fever chest MEDICAL_TRANSCRIPTION,Description Patient running to catch a taxi and stumbled fell and struck his face on the sidewalk Medical Specialty Emergency Room Reports Sample Name Fall Laceration Transcription CC Fall and laceration HPI Mr B is a 42 year old man who was running to catch a taxi when he stumbled fell and struck his face on the sidewalk He denies loss of consciousness but says he was dazed for a while after it happened He complains of pain over the chin and right forehead where he has abrasions He denies neck pain back pain extremity pain or pain in the abdomen PMH Hypertension MEDS None ROS As above Otherwise negative PHYSICAL EXAM This is a gentleman in full C spine precautions on a backboard brought by EMS He is in no apparent distress Vital Signs BP 165 95 HR 80 RR 12 Temp 98 4 SpO2 95 HEENT No palpable step offs there is blood over the right fronto parietal area where there is a small 1cm laceration and surrounding abrasion Also 2 cm laceration over the base of the chin without communication to the oro pharynx No other trauma noted No septal hematoma No other facial bony tenderness Neck Nontender Chest Breathing comfortably equal breath sounds Heart Regular rhythm Abd Benign Ext No tenderness or deformity pulses are equal throughout good cap refill Neuro Awake and alert slight slurring of speech and cognitive slowing consistent with alcohol moves all extremities cranial nerves normal COURSE IN THE ED Patient arrived and was placed on monitors An IV had been placed in the field and labs were drawn X rays of the C spine show no fracture and I ve removed the C collar The lacerations were explored and no foreign body found They were irrigated and closed with simple interrupted sutures Labs showed normal CBC Chem 7 and U A except there was moderate protein in the urine The blood alcohol returned at 0 146 A banana bag is ordered and his care will be turned over to Dr G for further evaluation and care Keywords emergency room reports loss of consciousness laceration fall course in the ed placed on monitors fell and struck abrasions MEDICAL_TRANSCRIPTION,Description Emergent fiberoptic bronchoscopy with lavage Status post multiple trauma motor vehicle accident Acute respiratory failure Acute respiratory distress ventilator asynchrony Hypoxemia Complete atelectasis of left lung Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system Medical Specialty Emergency Room Reports Sample Name Fiberoptic Bronchoscopy with Lavage Transcription PREOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung POSTOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung 6 Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system PROCEDURE PERFORMED Emergent fiberoptic plus bronchoscopy with lavage LOCATION OF PROCEDURE ICU Room 164 ANESTHESIA SEDATION Propofol drip Brevital 75 mg morphine 5 mg and Versed 8 mg HISTORY The patient is a 44 year old male who was admitted to ABCD Hospital on 09 04 03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions requiring ventilatory assistance The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation Chest x ray as noted above revealed complete atelectasis of the left lung The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy PROCEDURE DETAIL A bronchoscope was inserted through the oroendotracheal tube which was partially obstructed with blood clots These were lavaged with several aliquots of normal saline until cleared The bronchoscope required removal because the tissue clots were obstructing the bronchoscope The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina The endotracheal tube was noted to be in good position The bronchoscope was advanced through the distal trachea There was a white tissue completely obstructing the left main stem at the carina The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes There was diffuse mucus impactions tissue as well as intermittent clots There was no evidence of any active bleeding noted Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system There is no plugging or obstruction of the right bronchial system The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified approximately 4 cm above the main carina The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure Throughout the procedure pulse oximetry was greater than 95 throughout There is no hemodynamic instability or variability noted during the procedure Postprocedure chest x ray is pending at this time Keywords emergency room reports multiple trauma motor vehicle accident acute respiratory failure acute respiratory distress ventilator asynchrony hypoxemia atelectasis bronchoscopy lavage fiberoptic bronchoscopy endotracheal tube acute respiratory asynchrony bronchoscope fiberoptic endotracheal bronchial ventilatory tube respiratory MEDICAL_TRANSCRIPTION,Description Questionable foreign body right nose Belly and back pain Mild constipation Medical Specialty Emergency Room Reports Sample Name Foreign Body Right Nose Transcription CHIEF COMPLAINT Questionable foreign body right nose Belly and back pain SUBJECTIVE Mr ABC is a 2 year old boy who is brought in by parents stating that the child keeps complaining of belly and back pain This does not seem to be slowing him down They have not noticed any change in his urine or bowels They have not noted him to have any fevers or chills or any other illness They state he is otherwise acting normally He is eating and drinking well He has not had any other acute complaints although they have noted a foul odor coming from his nose Apparently he was seen here a few weeks ago for a foreign body in the right nose which was apparently a piece of cotton this was removed and placed on antibiotics His nose got better and then started to become malodorous again Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there Otherwise he has not had any runny nose earache no sore throat He has not had any cough congestion He has been acting normally Eating and drinking okay No other significant complaints He has not had any pain with bowel movement or urination nor have they noted him to be more frequently urinating then again he is still on a diaper PAST MEDICAL HISTORY Otherwise negative ALLERGIES No allergies MEDICATIONS No medications other than recent amoxicillin SOCIAL HISTORY Parents do smoke around the house PHYSICAL EXAMINATION VITAL SIGNS Stable He is afebrile GENERAL This is a well nourished well developed 2 year old little boy who is appearing very healthy normal for his stated age pleasant cooperative in no acute distress looks very healthy afebrile and nontoxic in appearance HEENT TMs canals are normal Left naris normal Right naris there is some foul odor as well as questionable purulent drainage Examination of the nose there was a foreign body noted which was the appearance of a cotton ball in the right nose that was obviously infected and malodorous This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual There was some erythema No other purulent drainage noted There was some bloody drainage This was suctioned and all mucous membranes were visualized and are negative NECK Without lymphadenopathy No other findings HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN His abdomen is entirely benign soft nontender nondistended Bowel sounds active No organomegaly or mass noted BACK Without any findings Diaper area normal GU No rash or infections Skin is intact ED COURSE He also had a P Bag placed but did not have any urine Therefore a straight catheter was done which was done with ease without complication and there was no leukocytes noted within the urine There was a little bit of blood from catheterization but otherwise normal urine X ray noted some stool within the vault Child is acting normally He is jumping up and down on the bed without any significant findings ASSESSMENT 1 Infected foreign body right naris 2 Mild constipation PLAN As far as the abdominal pain is concerned they are to observe for any changes Return if worse follow up with the primary care physician The right nose I will place the child on amoxicillin 125 per 5 mL 1 teaspoon t i d Return as needed and observe for more foreign bodies I suspect the child had placed this cotton ball in his nose again after the first episode Keywords MEDICAL_TRANSCRIPTION,Description Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets Medical Specialty Emergency Room Reports Sample Name Ecstasy Ingestion ER Visit Transcription CHIEF COMPLAINT I took Ecstasy HISTORY OF PRESENT ILLNESS This is a 17 year old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody nonbilious emesis Mother called the EMS service when the patient vomited On arrival here the patient states that she no longer has any nausea and that she feels just fine The patient states she feels wired but has no other problems or complaints The patient denies any pain The patient does not have any auditory of visual hallucinations The patient denies any depression or suicidal ideation The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself The patient denies any homicidal ideation The patient denies any recent illness or recent injuries The mother states that the daughter appears to be back to her usual self now REVIEW OF SYSTEMS CONSTITUTIONAL No recent illness No fever or chills HEENT No headache No neck pain No vision change or hearing change No eye or ear pain No rhinorrhea No sore throat CARDIOVASCULAR No chest pain No palpitations or racing heart RESPIRATIONS No shortness of breath No cough GASTROINTESTINAL One episode of nonbloody nonbilious emesis this morning without any nausea since then The patient denies any abdominal pain No change in bowel movements GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No dizziness syncope or near syncope PSYCHIATRIC The patient denies any depression suicidal ideation homicidal ideation auditory hallucinations or visual hallucinations ENDOCRINE No heat or cold intolerance PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Appendectomy when she was 9 years old CURRENT MEDICATIONS Birth control pills ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient denies smoking cigarettes The patient does drink alcohol and also uses illicit drugs PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 8 oral blood pressure 140 86 pulse is 79 respirations 16 oxygen saturation 100 on room air and is interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctiva bilaterally The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally No evidence of light sensitivity or photophobia Extraocular motions are intact bilaterally Nose is normal without rhinorrhea or audible congestion Ears are normal without any sign of infection Mouth and oropharynx are normal without any signs of infection Mucous membranes are moist NECK Supple and nontender Full range of motion There is no JVD CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop Peripheral pulses are 3 and bounding RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender normal and benign MUSCULOSKELETAL No abnormalities noted in back arms or legs The patient is normal use of her extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact in all extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 The patient does not have any smell of alcohol and does not exhibit any clinical intoxication The patient is quite pleasant fully cooperative HEMATOLOGIC LYMPHATIC NO lymphadenitis is noted No bruising is noted DIAGNOSES 1 ECSTASY INGESTION 2 ALCOHOL INGESTION 3 VOMITING SECONDARY TO STIMULANT ABUSE CONDITION UPON DISPOSITION Stable disposition to home with her mother PLAN I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation The patient was advised to stop drinking alcohol and taking Ecstasy as this is not only in the interest of her health but was also illegal The patient is asked to return to the emergency room should she have any worsening of her condition develop any other problems or symptoms of concern Keywords emergency room reports nonbilious emesis hallucinations visual auditory ecstasy ingestion suicidal ideation homicidal ideation ingestion infection alcohol ecstasy MEDICAL_TRANSCRIPTION,Description This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Medical Specialty Emergency Room Reports Sample Name Dental Pain Transcription CHIEF COMPLAINT Dental pain HISTORY OF PRESENT ILLNESS This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Presents now for evaluation PAST MEDICAL HISTORY Remarkable for chronic back pain neck pain from a previous cervical fusion and degenerative disc disease She has chronic pain in general and is followed by Dr X REVIEW OF SYSTEMS Otherwise unremarkable Has not noted any fever or chills However she as mentioned does note the dental discomfort with increasing swelling and pain Otherwise unremarkable except as noted CURRENT MEDICATIONS Please see list ALLERGIES IODINE FISH OIL FLEXERIL BETADINE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile has stable and normal vital signs The patient is sitting quietly on the gurney and does not look to be in significant distress but she is complaining of dental pain HEENT Unremarkable I do not see any obvious facial swelling but she is definitely tender all in the left mandible region There is no neck adenopathy Oral mucosa is moist and well hydrated Dentition looks to be in reasonable condition However she definitely is tender to percussion on the left lower first premolar I do not see any huge cavity or anything like that No real significant gingival swelling and there is no drainage noted None of the teeth are tender to percussion PROCEDURE Dental nerve block Using 0 5 Marcaine with epinephrine I performed a left inferior alveolar nerve block along with an apical nerve block which achieves good anesthesia I have then written a prescription for penicillin and Vicodin for pain IMPRESSION ACUTE DENTAL ABSCESS ASSESSMENT AND PLAN The patient needs to follow up with the dentist for definitive treatment and care She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics However outpatient followup should be adequate She is discharged in stable condition Keywords emergency room reports dental pain dental abscess dental block nerve block mandible swelling dental MEDICAL_TRANSCRIPTION,Description Chest tube insertion done by two physicians in ER spontaneous pneumothorax secondary to barometric trauma Medical Specialty Emergency Room Reports Sample Name Chest Tube Insertion in ER Transcription PREOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis POSTOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis INFORMED CONSENT Not obtained This patient is obtunded intubated and septic This is an emergent procedure with 2 physician emergency consent signed and on the chart PROCEDURE The patient s right chest was prepped and draped in sterile fashion The site of insertion was anesthetized with 1 Xylocaine and an incision was made Blunt dissection was carried out 2 intercostal spaces above the initial incision site The chest wall was opened and a 32 French chest tube was placed into the thoracic cavity after examination with the finger making sure that the thoracic cavity had been entered correctly The chest tube was placed A postoperative chest x ray is pending at this time The patient tolerated the procedure well and was taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 10 mL COMPLICATIONS None SPONGE COUNT Correct x2 Keywords emergency room reports spontaneous pneumothorax barometric trauma respiratory failure sepsis pneumonia blunt dissection chest wall thoracic cavity chest x ray chest tube insertion chest tube pneumothorax tube chest insertion MEDICAL_TRANSCRIPTION,Description Patient had a piece of glass fall on to his right foot A 4 mm laceration Acute foot pain now resolved The patient was given discharge instructions on wound care Medical Specialty Emergency Room Reports Sample Name Cut on Foot ER Visit Transcription CHIEF COMPLAINT Cut on foot HISTORY OF PRESENT ILLNESS This is a 32 year old male who had a piece of glass fall on to his right foot today The patient was concerned because of the amount of bleeding that occurred with it The bleeding has been stopped and the patient does not have any pain The patient has normal use of his foot there is no numbness or weakness the patient is able to ambulate well without any discomfort The patient denies any injuries to any other portion of his body He has not had any recent illness The patient has no other problems or complaints PAST MEDICAL HISTORY Asthma CURRENT MEDICATION Albuterol ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 8 oral blood pressure 132 86 pulse is 76 and respirations 16 Oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed the patient appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear conjunctiva and cornea bilaterally NECK Supple with full range of motion CARDIOVASCULAR Peripheral pulse is 2 to the right foot Capillary refills less than two seconds to all the digits of the right foot RESPIRATIONS No shortness of breath MUSCULOSKELETAL The patient has a 4 mm partial thickness laceration to the top of the right foot and about the area of the mid foot There is no palpable foreign body no foreign body is visualized There is no active bleeding there is no exposed deeper tissues and certainly no exposed tendons bone muscle nerves or vessels It appears that the laceration may have nicked a small varicose vein which would have accounted for the heavier than usual bleeding that currently occurred at home The patient does not have any tenderness to the foot The patient has full range of motion to all the joints all the toes as well as the ankles The patient ambulates well without any difficulty or discomfort There are no other injuries noted to the rest of the body SKIN The 4 mm partial thickness laceration to the right foot as previously described No other injuries are noted NEUROLOGIC Motor is 5 5 to all the muscle groups of the right lower extremity Sensory is intact to light touch to all the dermatomes of the right foot The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No active bleeding is occurring at this time No evidence of bruising is noted to the body EMERGENCY DEPARTMENT COURSE The patient had antibiotic ointment and a bandage applied to his foot DIAGNOSES 1 A 4 MM LACERATION TO THE RIGHT FOOT 2 ACUTE RIGHT FOOT PAIN NOW RESOLVED CONDITION UPON DISPOSITION Stable DISPOSITION To home The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on Keywords emergency room reports foot pain cut on foot piece of glass foreign body active bleeding foot injuries atraumatic laceration bleeding body MEDICAL_TRANSCRIPTION,Description Acute foot or ankle sprain possible small fracture Medical Specialty Emergency Room Reports Sample Name Ankle pain Transcription CHIEF COMPLAINT Ankle pain HISTORY OF PRESENT ILLNESS The patient is a pleasant 17 year old gentleman who was playing basketball today in gym Two hours prior to presentation he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now It hurts to move or bear weight No other injuries noted He does not think he has had injuries to his ankle in the past PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None SOCIAL HISTORY He does not drink or smoke ALLERGIES Unknown MEDICATIONS Adderall and Accutane REVIEW OF SYSTEMS As above Ten systems reviewed and are negative PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 6 pulse 70 respirations 16 blood pressure 120 63 and pulse oximetry 100 on room air GENERAL Keywords emergency room reports accutane foot or ankle sprain ankle sprain ankle sprain splint fracture MEDICAL_TRANSCRIPTION,Description The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone Medical Specialty Emergency Room Reports Sample Name Airway Compromise Foreign Body ER Visit Transcription HISTORY OF PRESENT ILLNESS The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone PAST MEDICAL HISTORY Significant for diabetes hypertension asthma cholecystectomy and total hysterectomy and cataract ALLERGIES No known drug allergies CURRENT MEDICATIONS Prevacid Humulin Diprivan Proventil Unasyn and Solu Medrol FAMILY HISTORY Noncontributory SOCIAL HISTORY Negative for illicit drugs alcohol and tobacco PHYSICAL EXAMINATION Please see the hospital chart LABORATORY DATA Please see the hospital chart HOSPITAL COURSE The patient was taken to the operating room by Dr X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated If not she would require tracheostomy The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated She was doing well with good p o s good airway good voice and desiring to be discharged home So the patient is being prepared for discharge at this point We will have Dr X evaluate her before she leaves to make sure I do not have any problem with her going home Dr Y feels she could be discharged today and will have her return to see him in a week Keywords emergency room reports diabetes hypertension asthma cholecystectomy fishbone foreign body airway compromise airway MEDICAL_TRANSCRIPTION,Description Possible exposure to ant bait She is not exhibiting any symptoms and parents were explained that if she develops any vomiting she should be brought back for reevaluation Medical Specialty Emergency Room Reports Sample Name Ant Bait Exposure ER Visit Transcription CHIEF COMPLAINT Possible exposure to ant bait HISTORY OF PRESENT ILLNESS This is a 14 month old child who apparently was near the sink got into the childproof cabinet and pulled out ant bait that had Borax in it It had 11 mL of this fluid in it She spilled it on her had it on her hands Parents were not sure whether she ingested any of it So they brought her in for evaluation They did not note any symptoms of any type PAST MEDICAL HISTORY Negative Generally very healthy REVIEW OF SYSTEMS The child has not been having any coughing gagging vomiting or other symptoms Acting perfectly normal Family mostly noted that she had spilled it on the ground around her had it on her hands and on her clothes They did not witness that she ingested any but did not see anything her mouth MEDICATIONS None ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile Stable vital signs and normal pulse oximetry GENERAL The child is very active cheerful youngster in no distress whatsoever HEENT Unremarkable Oral mucosa is clear moist and well hydrated I do not see any evidence of any sort of liquid on the face Her clothing did have the substance on the clothes but I did not see any evidence of anything on her torso Apparently she had some on her hands that has been wiped off EMERGENCY DEPARTMENT COURSE I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested which should does not appear likely to be the case IMPRESSION Exposure to ant bait PLAN At this point it is fairly unlikely that this child ingested any significant amount if at all which seems unlikely She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting she should be brought back for reevaluation So the patient is discharged in stable condition Keywords emergency room reports borax vomiting exposure to ant bait ant bait exposure symptoms MEDICAL_TRANSCRIPTION,Description A 6 year old was laying down on one side and he was crying and moaning sent from the Emergency Room with the diagnosis of intracranial bleeding Medical Specialty Emergency Room Reports Sample Name Altered Mental Status ER Visit Transcription CHIEF COMPLAINT Altered mental status HISTORY OF PRESENT ILLNESS This is a 6 year old white male who was sent from the Emergency Room with the diagnosis of intracranial bleeding The patient was found by the 8 year old sister in the bathroom He was laying down on one side and he was crying and moaning The sibling went and told the parents The parents rushed to the bathroom they found him crying and he was not moving the left side of his body He was initially alert but his alertness diminished They decided to take him to the emergency room in Hospital where a CT was done on his head which showed a 4 x 4 x 2 5 cm bleed The emergency physician called our emergency room and I decided to involve Neurosurgery Mr X the physician assistant who is on call for the Neurosurgery Services Collectively they have made arrangements with the ICU attendings to have the child transported to our emergency room For a small stop I am obtaining an MRI and then admitting to the ICU History was taken from the parents He had a history of gastroesophageal reflux disease otherwise a healthy child MEDICATIONS None ALLERGIES No known drug allergies PAST SURGICAL HISTORY He had only tympanostomy tubes placed FAMILY MEDICAL HISTORY Unremarkable PHYSICAL EXAMINATION GENERAL He was brought by our transport team While en route he was not as alert as he was He was still oriented He had to be stimulated via sternal rub to wake up and saturation went down to the 80s and he was started on nasal cannula and code 3 was initiated and he was rushed to our emergency room When I saw him he was lethargic but arousable He could recognize where he was and he could recognize also his parents well HEENT Pupils are 4 mm reactive to direct and indirect light No signs of trauma is seen on the head Throat is clear LUNGS Clear to auscultation HEART Regular rate and rhythm ABDOMEN Soft NEUROLOGIC He has left sided weakness but his cranial nerves II through XII are grossly intact EMERGENCY DEPARTMENT COURSE In the emergency room at the time when I saw him Dr Y and Dr Z were from the ICU and Anesthesia Services arrived also and they evaluated the patient with me and pretty much they took care of the patient They decided to give him a dose of IV mannitol I ordered his labs type and cross CBC is 15 6 white blood cell count hemoglobin 12 8 PT PTT were ordered due to the bleed which was seen intracerebrally They were 13 1 and 24 5 respectively Blood gas I STAT pH 7 36 pCO2 is 51 This was a venous specimen The ICU attendings decided to do a rapid sequence intubation This was done in our emergency room by Dr Y and Dr Z The patient was sent to the MRI and from where he was going to be admitted to the ICU in critical condition DIFFERENTIAL DIAGNOSES Arteriovenous malformation stroke traumatic injury IMPRESSION Intracerebral hemorrhage of uncertain etiology to be determined while inpatient TIME SPENT I spent 30 minutes critical care time with the patient excluding any procedures Keywords emergency room reports arteriovenous malformation stroke traumatic injury intracerebral hemorrhage altered mental status crying and moaning mental status intracranial bleeding icu attendings emergency intracranial neurosurgery gastroesophageal intracerebrally bleeding icu MEDICAL_TRANSCRIPTION,Description Acute episode of agitation She was complaining that she felt she might have been poisoned at her care facility Medical Specialty Emergency Room Reports Sample Name Agitation ER Visit Transcription HISTORY OF PRESENT ILLNESS This is a 91 year old female who was brought in by family Apparently she was complaining that she felt she might have been poisoned at her care facility The daughter who accompanied the patient states that she does not think anything is actually wrong but she became extremely agitated and she thinks that is the biggest problem with the patient right now The patient apparently had a little bit of dry heaves but no actual vomiting She had just finished eating dinner No one else in the facility has been ill PAST MEDICAL HISTORY Remarkable for previous abdominal surgeries She has a pacemaker She has a history of recent collarbone fracture REVIEW OF SYSTEMS Very difficult to get from the patient herself She seems to deny any significant pain or discomfort but really seems not particularly intent on letting me know what is bothering her She initially stated that everything was wrong but could not specify any specific complaints Denies chest pain back pain or abdominal pain Denies any extremity symptoms or complaints SOCIAL HISTORY The patient is a nonsmoker She is accompanied here with daughter who brought her over here They were visiting the patient when this episode occurred MEDICATIONS Please see list ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile actually has a very normal vital signs including normal pulse oximetry at 99 on room air GENERAL The patient is an elderly frail looking little lady lying on the gurney She is awake alert and not really wanted to answer most of the questions I asked her She does have a tremor with her mouth which the daughter states has been there for many years HEENT Eye exam is unremarkable Oral mucosa is still moist and well hydrated Posterior pharynx is clear NECK Supple LUNGS Actually clear with good breath sounds There are no wheezes no rales or rhonchi Good air movement CARDIAC Without murmur ABDOMEN Soft I do not elicit any tenderness There is no abdominal distention Bowel sounds are present in all quadrants SKIN Skin is without rash or petechiae There is no cyanosis EXTREMITIES No evidence of any trauma to the extremities EMERGENCY DEPARTMENT COURSE I had a long discussion with the family and they would like the patient receive something for agitation so she was given 0 5 mg of Ativan intramuscularly After about half an hour I came back to talk to the patient and the family the patient states that she feels better Family states she seems more calm They do not want to pursue any further workup at this time IMPRESSION ACUTE EPISODE OF AGITATION PLAN At this time I had reviewed the patient s records and it is not particularly enlightening as to what could have triggered off this episode The patient herself has good vital signs She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given a small quantity was given to the patient Family and daughter specifically did not want to pursue any workup at this point which at this point I think is reasonable and we will have her follow up with ABC She is discharged in stable condition Keywords emergency room reports acute episode of agitation agitation MEDICAL_TRANSCRIPTION,Description The patient was referred for outpatient skilled speech therapy secondary to right hemisphere disorder status post stroke The patient attended nine outpatient skilled speech therapy sessions Medical Specialty Discharge Summary Sample Name Speech Therapy Discharge Summary 2 Transcription The patient made some progress during therapy She accomplished two and a half out of her five short term therapy goals We did complete an oral mechanism examination and clinical swallow evaluation which showed her swallowing to be within functional limits The patient improved on her turn taking skills during conversation and she was able to listen to a narrative and recall the main idea plus five details after a three minute delay independently The patient continues to have difficulty with visual scanning in cancellation task secondary to her significant left neglect She also did not accomplish her sustained attention goal which required her to complete tasks greater than 80 accuracy for at least 15 minutes independently Thus she also continued to have difficulty with reading comprehension secondary to the significance of her left neglect The patient was initially authorized for 12 outpatient speech therapy sessions but once again she only attended 9 Her last session occurred on 01 09 09 She has not made any additional followup sessions with me for over three weeks so she is discharged from my services at this time Keywords discharge summary outpatient speech therapy swallow evaluation swallowing skilled speech therapy hemisphere disorder speech therapy speechNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets Medical Specialty Emergency Room Reports Sample Name Accidental Celesta Ingestion ER Visit Transcription HISTORY OF PRESENT ILLNESS Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated The patient was alert and did not vomit during the transport to the emergency room Mom left the patient and his little one year old brother in the room by themselves and she went outside of the house for a couple of minutes and when came back she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor The patient said that the pills didn t taste good so it is presumed that the patient actually ingested at least two and a half tablets of Celesta 40 mg per tablet PAST MEDICAL HISTORY Baby was born premature and he required hospitalization but was not on mechanical ventilation He doesn t have any hospitalizations after the new born No surgeries IMMUNIZATIONS Up to date ALLERGIES NOT KNOWN DRUG ALLERGIES PHYSICAL EXAMINATION VITAL SIGNS Temperature 36 2 Celsius pulse 112 respirations 24 blood pressure 104 67 weight 15 kilograms GENERAL Alert in no acute distress SKIN No rashes HEENT Head Normocephalic atraumatic Eyes EOMI PERRL Nasal mucosa clear Throat and tonsils normal No erythema no exudates NECK Supple no lymphadenopathy no masses LUNGS Clear to auscultation bilateral HEART Regular rhythm and rate without murmur Normal S1 S2 ABDOMEN Soft nondistended nontender present bowel sounds no hepatosplenomegaly no masses EXTREMITIES Warm Capillary refill brisk Deep tendon reflexes present bilaterally NEUROLOGICAL Alert Cranial nerves II through XII intact No focal exam Normal gait RADIOGRAPHIC DATA Patient has had an EKG done at the admission and it was within normal limits for the age EMERGENCY ROOM COURSE Patient was under observation for 6 hours in the emergency room He had two more EKGs during observation in the emergency room and they were all normal His vital signs were monitored every hour and were within normal limits There was no vomiting no diarrhea during observation Patient did not receive any medication or has had any other lab work besides the EKG ASSESSMENT AND PLAN Three years old male with accidental ingestion of Celesta Discharged home with parents with a followup in the morning with his primary care physician Keywords emergency room reports accidental ingestion of celesta celesta tablets ingestion MEDICAL_TRANSCRIPTION,Description Total abdominal hysterectomy TAH Severe menometrorrhagia unresponsive to medical therapy severe anemia and symptomatic fibroid uterus Medical Specialty Discharge Summary Sample Name TAH Discharge Summary Transcription ADMISSION DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Symptomatic fibroid uterus DISCHARGE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Symptomatic fibroid uterus 4 Extensive adenomyosis by pathological report OPERATION PERFORMED On 6 10 2009 total abdominal hysterectomy TAH COMPLICATIONS None BLOOD TRANSFUSIONS None INFECTIONS None SIGNIFICANT LAB AND X RAY On admission hemoglobin and hematocrit was 10 5 and 32 8 respectively On discharge hemoglobin and hematocrit 7 9 and 25 2 HOSPITAL COURSE AND TREATMENT The patient was admitted to the surgical suite and taken to the operating room on 6 10 2009 where a total abdominal hysterectomy TAH with low intraoperative complication was performed The patient tolerated all procedures well On the 1st postoperative day the patient was afebrile and all vital signs were stable On the 3rd postoperative day the patient was ambulating with difficulty and tolerating clear liquid diet On the 4th postoperative day the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness On the 5th postoperative day the patient was afebrile Vital signs were stable The patient was tolerating a diet and ambulating without difficulty The patient was desirous of going home The patient denied any abdominal pain or flank pain The patient had minimal incisional wound tenderness The patient was desirous of going home and was discharged home DISCHARGE CONDITION Stable DISCHARGE INSTRUCTIONS Regular diet bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks pelvic rest for 6 weeks Motrin 600 mg tablets 1 tablet p o q 8h p r n pain Colace 100 mg tablets 1 tablet p o daily p r n constipation and ferrous sulfate 60 mg tablets 1 tablet p o daily and multiple vitamin 1 tablet p o daily The patient is to return on Wednesday 6 17 2009 for removal of staples The patient was given a full explanation of her clinical condition The patient was given full and complete postoperative and discharge instructions All her questions were answered Keywords discharge summary adenomyosis total abdominal hysterectomy fibroid uterus postoperative day hemoglobin hematocrit therapy menometrorrhagia anemia fibroid uterus tah hysterectomy abdominal MEDICAL_TRANSCRIPTION,Description Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction Medical Specialty Discharge Summary Sample Name Urology Discharge Summary Transcription PROCEDURES Cystourethroscopy and transurethral resection of prostate COMPLICATIONS None ADMITTING DIAGNOSIS Difficulty voiding HISTORY This 67 year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction Physical examination revealed normal heart and lungs Abdomen was negative for abnormal findings LABORATORY DATA BUN 19 and creatinine 1 1 Blood group was A Rh positive Hemoglobin 13 Hematocrit 32 1 Prothrombin time 12 6 seconds PTT 37 1 Discharge hemoglobin 11 4 and hematocrit 33 3 Chest x ray calcified old granulomatous disease otherwise normal EKG was normal COURSE IN THE HOSPITAL The patient had a cysto and TUR of the prostate Postoperative course was uncomplicated The pathology report is pending at the time of dictation He is being discharged in satisfactory condition with a good urinary stream minimal hematuria and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet DISCHARGE DIAGNOSIS Enlarged prostate with benign bladder neck obstruction To be followed in my office in one week and by Dr ABC next available as an outpatient Keywords discharge summary tur bun cystourethroscopy difficulty voiding bladder neck obstruction creatinine cysto enlarged prostate transurethral resection of prostate urinary stream bladder neck neck obstruction prostate MEDICAL_TRANSCRIPTION,Description Syncope end stage renal disease requiring hemodialysis congestive heart failure and hypertension Medical Specialty Discharge Summary Sample Name Renal Disease Discharge Summary Transcription ADMISSION DIAGNOSES 1 Syncope 2 End stage renal disease requiring hemodialysis 3 Congestive heart failure 4 Hypertension DISCHARGE DIAGNOSES 1 Syncope 2 End stage renal disease requiring hemodialysis 3 Congestive heart failure 4 Hypertension CONDITION ON DISCHARGE Stable PROCEDURE PERFORMED None HOSPITAL COURSE The patient is a 44 year old African American male who was diagnosed with end stage renal disease requiring hemodialysis three times per week approximately four to five months ago He reports that over the past month he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes He reportedly had this even while seated and denied overt dizziness He reports this lightheadedness is made even worse when standing He has had these symptoms almost daily over the past month He does report some confusion when he awakens He reports that he loses consciousness for two to three minutes Denies any bowel or bladder loss although he reports very little urine output secondary to his end stage renal disease He denied any palpitations warmth or diaphoresis which is indicative of vasovagal syncope There were no witnesses to his syncopal episodes He also denied any clonic activity and no history of seizures In the emergency room the patient was given fluids and orthostatics were checked At that time orthostatics were negative however due to the fact that fluid had been given before it is impossible to rule out orthostatic hypotension The patient presented to the hospital on Coreg 12 5 mg b i d and lisinopril 10 mg daily secondary to his hypertension congestive heart failure with dilated cardiomyopathy and end stage renal disease Regarding his syncopal episodes he was admitted with likely orthostatic hypotension Cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily At that time the Coreg had been held secondary to hypotension Cardiology also ordered a nuclear medicine myocardial perfusion stress test Regarding the end stage renal disease Nephrology was consulted as the patient was due for hemodialysis treatment the day following admission Nephrology was able to perform dialysis on the patient and Renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame Renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the Coreg to 6 25 mg b i d They reported that the Procrit should be continued As previously indicated regarding the dilated cardiomyopathy Cardiology ordered a nuclear medicine stress test to be performed Also regarding the patient s hypertension he actually was noted to have hypotension on admission and as previously stated the Coreg was originally discontinued and then it was restarted at 6 25 mg b i d and the patient tolerated this well The patient s hospital course remained uncomplicated until September 17 2007 the day the nuclear medicine stress test was scheduled The patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low the patient proceeded to discharge himself against medical advice DISCHARGE INSTRUCTIONS MEDICATIONS The patient left AMA No specific discharge instructions and medications were given At the time of the patient leaving AMA his medications were as follows 1 Aspirin 81 mg p o daily 2 Multivitamin Nephrocaps one cap p o daily 3 Fosrenol 500 mg chewable t i d 4 Lisinopril 2 5 mg daily 6 Coreg 3 125 mg p o b i d 7 Procrit 10 000 units inject every Tuesday Thursday and Saturday 8 Heparin 5000 units q 8h subcutaneous for DVT prophylaxis Keywords discharge summary syncope congestive heart failure end stage renal disease requiring hemodialysis nuclear medicine stress test stage renal renal disease renal disease hemodialysis MEDICAL_TRANSCRIPTION,Description The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety Medical Specialty Discharge Summary Sample Name Speech Therapy Discharge Summary 1 Transcription HISTORY The patient is a 67 year old female was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety At the onset of therapy on 03 26 08 the patient was NPO with a G tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3 6 100 based on the Western Aphasia Battery Since the initial evaluation the patient has attended 60 outpatient speech therapy sessions which have focussed on her receptive communication expressive language multimodality communication skills and swallowing function and safety SHORT TERM GOALS 1 The patient met 3 out of 4 original short term therapy goals which were to complete a modified barium swallow study which she did do and which revealed no aspiration At this time the patient is eating and drinking and taking all medications by mouth however her G tube is still present The patient was instructed to talk to the primary care physician about removal of her feeding tube 2 The patient will increase accuracy of yes no responses to greater than 80 accuracy She did accomplish this goal The patient is also able to identify named objects with greater than 80 accuracy ADDITIONAL GOALS Following the completion of these goals additional goals were established Based on reevaluation the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90 accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80 accuracy independently The patient continues to have difficulty stating verbally yes or no to questions as well as accurately using head gestures and to respond to yes no questions The patient continues to have marked difficulty with her expressive language abilities She is able to write simple words to help express her basic wants and needs She has made great strides however with her receptive communication she is able to read words as well as short phrases and able to point to named objects and answer simple to moderate complex yes no questions A reevaluation completed on 12 01 08 revealed an aphasia quotient of 26 4 Once again she made significant improvement and comprehension but continues to have unintelligible speech An alternative communication device was discussed with the patient and her husband but at this time the patient does not want to utilize a communication device If in the future the patient continues to struggle with her expressive communication an alternative augmented communication device would be a benefit to her Please reconsult at that time if and when the patient is ready to use a speech generating device The patient is discharged from my services at this time due to a plateau in her progress Numerous home activities were recommended to allow her to continue to make progress at home Keywords discharge summary communication skills g tube aphasia language evaluation western aphasia battery skilled speech therapy swallowing function speech therapy therapy swallowing aspiration speech communication MEDICAL_TRANSCRIPTION,Description The patient was discharged by court as a voluntary drop by prosecution Medical Specialty Discharge Summary Sample Name Psychiatric Discharge Summary Transcription DISCHARGE DISPOSITION The patient was discharged by court as a voluntary drop by prosecution This was AMA against hospital advice DISCHARGE DIAGNOSES AXIS I Schizoaffective disorder bipolar type AXIS II Deferred AXIS III Hepatitis C AXIS IV Severe AXIS V 19 CONDITION OF PATIENT ON DISCHARGE The patient remained disorganized The patient was suffering from prolactinemia secondary to medications DISCHARGE FOLLOWUP To be arranged per the patient as the patient was discharged by court DISCHARGE MEDICATIONS A 2 week supply of the following was phoned into the patient s pharmacy Seroquel 25 mg p o nightly Zyprexa 5 mg p o b i d MENTAL STATUS AT THE TIME OF DISCHARGE Attitude was cooperative Appearance showed fair hygiene and grooming Psychomotor behavior showed restlessness No EPS or TD was noted Affect was restricted Mood remained anxious and speech was pressured Thoughts remained tangential and the patient endorsed paranoid delusions The patient denied auditory hallucinations The patient denied suicidal or homicidal ideation was oriented to person and place Overall insight into her illness remained impaired HISTORY AND HOSPITAL COURSE The patient is a 22 year old female with a history of bipolar affective disorder was initially admitted for evaluation of increasing mood lability disorganization and inappropriate behaviors The patient reportedly was asking her father to have sex with her and tried to pull down her mother s pants The patient took her clothing off was noted to be very disorganized sexually and religiously preoccupied and endorsed auditory hallucinations of voices telling her to calm herself and others The patient has a history of depression versus bipolar disorder last hospitalized in Pierce County in 2008 but without recent treatment The patient on admission interview was noted to be labile and disorganized The patient was initiated on Risperdal M Tab 2 mg p o b i d for psychosis and mood lability and also medically evaluated by Rebecca Richardson MD The patient remained labile and suspicious during her hospital stay The patient continued to be sexually preoccupied and had poor insight into her need for treatment The patient denied further auditory hallucinations The patient was treated with Seroquel for persistent mood lability and psychosis The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge The patient remained disorganized but was given a voluntary drop by prosecution against medical advice when she went to court on 01 11 2010 The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies The patient was thus discharged in symptomatic condition Keywords discharge summary schizoaffective disorder bipolar type mood lability disorganization bipolar affective disorder voluntary drop auditory hallucinations psychiatric axis MEDICAL_TRANSCRIPTION,Description Speech therapy discharge summary The patient was admitted for skilled speech therapy secondary to cognitive linguistic deficits Medical Specialty Discharge Summary Sample Name Speech Therapy Discharge Summary Transcription LONG TERM GOALS Both functional and cognitive linguistic ability to improve safety and independence at home and in the community This goal has been met based on the patient and husband reports the patient is able to complete all activities which she desires to do at home During the last reevaluation the patient had a significant progress and all cognitive domains evaluated which are attention memory executive functions language and visuospatial skill She continues to have an overall mild cognitive linguistic deficit but this is significantly improved from her initial evaluation which showed severe impairment The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued The patient and her husband both agreed with the patient s discharge Keywords discharge summary narrative memory executive function attention speech therapy visuospatial accuracy linguistic cognitive speechNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit hypertension mild renal insufficiency and anemia which has been present chronically over the past year Medical Specialty Discharge Summary Sample Name Pyelonephritis Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pyelonephritis 2 History of uterine cancer and ileal conduit urinary diversion 3 Hypertension 4 Renal insufficiency 5 Anemia DISCHARGE DIAGNOSES 1 Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit 2 Hypertension 3 Mild renal insufficiency 4 Anemia which has been present chronically over the past year HOSPITAL COURSE The patient was admitted with suspected pyelonephritis Renal was consulted It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr X Her symptoms responded to IV antibiotics and she remained clinically stable Klebsiella was isolated in this urine which was sensitive to Bactrim and she was discharged on p o Bactrim She was scheduled on 08 07 2007 for further surgery She is to follow up with Dr Y in 7 10 days She also complained of right knee pain and the right knee showed no sign of effusion She was exquisitely tender to touch of the patellar tendon It was thought that this did not represent intraarticular process She was advised to use ibuprofen over the counter two to three tabs t i d Keywords discharge summary uterine cancer renal insufficiency pyelonephritis mucous plugging ileal conduit MEDICAL_TRANSCRIPTION,Description The patient has had abdominal pain associated with a 30 pound weight loss and then developed jaundice He had epigastric pain and was admitted to the hospital A thin slice CT scan was performed which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases Medical Specialty Discharge Summary Sample Name Pancreatic Mass Discharge Summary Transcription HISTORY OF PRESENT ILLNESS The patient is a 48 year old man who has had abdominal pain since October of last year associated with a 30 pound weight loss and then developed jaundice He had epigastric pain and was admitted to the hospital A thin slice CT scan was performed which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases The patient additionally had a questionable pseudocyst in the tail of the pancreas The patient underwent ERCP on 04 04 2007 with placement of a stent This revealed a strictured pancreatic duct as well as strictured bile duct A 10 french x 9 cm stent was placed with good drainage The next morning the patient felt quite a bit more comfortable He additionally had a modest drop in his bilirubin and other liver tests Of note the patient has been having quite a bit of nausea during his admission This responded to Zofran It did not initially respond well to Phenergan though after stent placement he was significantly more comfortable and had less nausea and in fact had better response to the Phenergan itself At the time of discharge the patient s white count was 9 4 hemoglobin 10 8 hematocrit 32 with a MCV of 79 platelet count of 585 000 His sodium was 132 potassium 4 1 chloride 95 CO2 27 BUN of 8 with a creatinine of 0 3 His bilirubin was 17 1 alk phos 273 AST 104 ALT 136 total protein 7 8 and albumin of 3 8 He was tolerating a regular diet The patient had been on oral hypoglycemics as an outpatient but in hospital he was simply managed with an insulin sliding scale The patient will be transferred back to Pelican Bay under the care of Dr X at the infirmary He will be further managed for his diabetes there The patient will additionally undergo potential end of life meetings I discussed the potentials of chemotherapy with patient Certainly there are modest benefits which can be obtained with chemotherapy in metastatic pancreatic cancer though at some cost with morbidity The patient will consider this and will discuss this further with Dr X DISCHARGE MEDICATIONS 1 Phenergan 25 mg q 6 p r n 2 Duragesic patch 100 mcg q 3 d 3 Benadryl 25 50 mg p o q i d for pruritus 4 Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary 5 The patient had initially been on enalapril here His hypertension will be managed by Dr X as well PLAN The patient should return for repeat ERCP if there are signs of stent occlusion such as fever increased bilirubin worsening pain In the meantime he will be kept on a regular diet and activity per Dr X Keywords discharge summary abdominal pain lymph nodes weight loss pancreatic mass chemotherapy abdominal bilirubin phenergan stent drainage MEDICAL_TRANSCRIPTION,Description Fever otitis media and possible sepsis Medical Specialty Discharge Summary Sample Name Otitis Media Discharge Summary Transcription ADMITTING DIAGNOSES 1 Fever 2 Otitis media 3 Possible sepsis HISTORY OF PRESENT ILLNESS The patient is a 10 month old male who was seen in the office 1 day prior to admission He has had a 2 day history of fever that has gone up to as high as 103 6 degrees F He has also had intermittent cough nasal congestion and rhinorrhea and no history of rashes He has been taking Tylenol and Advil to help decrease the fevers but the fever has continued to rise He was noted to have some increased workup of breathing and parents returned to the office on the day of admission PAST MEDICAL HISTORY Significant for being born at 33 weeks gestation with a birth weight of 5 pounds and 1 ounce PHYSICAL EXAMINATION On exam he was moderately ill appearing and lethargic HEENT Atraumatic normocephalic Pupils are equal round and reactive to light Tympanic membranes were red and yellow and opaque bilaterally Nares were patent Oropharynx was slightly moist and pink Neck was soft and supple without masses Heart is regular rate and rhythm without murmurs Lungs showed increased workup of breathing moderate tachypnea No rales rhonchi or wheezes were noted Abdomen Soft nontender nondistended Active bowel sounds Neurologic exam showed good muscle strength normal tone Cranial nerves II through XII are grossly intact LABORATORY FINDINGS He had electrolytes BUN and creatinine and glucose all of which were within normal limits White blood cell count was 8 6 with 61 neutrophils 21 lymphocytes 17 monocytes suggestive of a viral infection Urinalysis was completely unremarkable Chest x ray showed a suboptimal inspiration but no evidence of an acute process in the chest HOSPITAL COURSE The patient was admitted to the hospital and allowed a clear liquid diet Activity is as tolerates CBC with differential blood culture electrolytes BUN and creatinine glucose UA and urine culture all were ordered Chest x ray was ordered as well with 2 views to evaluate for a possible pneumonia Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94 Gave D5 and quarter of normal saline at 45 mL per hour which was just slightly above maintenance rate to help with hydration He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis and I will add Tylenol and ibuprofen as needed for fevers Overnight he did have his oxygen saturations drop and went into oxygen overnight His lungs remained clear but because of the need for O2 we instituted albuterol aerosols every 6 hours to help maintain good lung function The nurses were instructed to attempt to wean O2 if possible and advance the diet He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient He did well the following evening with no further oxygen requirement He continued to spike fevers but last fever was around 13 45 on the previous day At the time of exam he had 100 oxygen saturations on room air with temperature of 99 3 degrees F with clear lungs He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning CONDITION OF THE PATIENT AT DISCHARGE He was at 100 oxygen saturations on room air with no further dips at night He has become afebrile and was having no further increased work of breathing DISCHARGE DIAGNOSES 1 Bilateral otitis media 2 Fever PLAN Recommended discharge No restrictions in diet or activity He was continued Omnicef 125 mg 5 mL one teaspoon p o once daily and instructed to follow up with Dr X his primary doctor on the following Tuesday Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy Keywords discharge summary sepsis cough nasal congestion rhinorrhea oxygen saturations otitis media otitis breathing lungs oropharynx fever MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation ORIF of right Schatzker III tibial plateau fracture with partial medial meniscectomy Medical Specialty Discharge Summary Sample Name ORIF Discharge Summary Transcription ADMISSION DIAGNOSIS Right tibial plateau fracture DISCHARGE DIAGNOSES Right tibial plateau fracture and also medial meniscus tear on the right side PROCEDURES PERFORMED Open reduction and internal fixation ORIF of right Schatzker III tibial plateau fracture with partial medial meniscectomy CONSULTATIONS To rehab Dr X and to Internal Medicine for management of multiple medical problems including hypothyroid diabetes mellitus type 2 bronchitis and congestive heart failure HOSPITAL COURSE The patient was admitted and consented for operation and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence The patient seemed to be recovering well The patient spent the next several days on the floor nonweightbearing with CPM machine in place developed a brief period of dyspnea which seems to have resolved and may have been a combination of bronchitis thick secretions and fluid overload The patient was given nebulizer treatment and Lasix increased the same to resolve the problem The patient was comfortable stabilized breathing well On day 12 was transferred to ABCD DISCHARGE INSTRUCTIONS The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy DIET Regular ACTIVITY AND LIMITATIONS Nonweightbearing to the right lower extremity The patient is to continue CPM machine while in bed along with antiembolic stockings The patient will require nursing physical therapy occupational therapy and social work consults DISCHARGE MEDICATIONS Resume home medications but increase Lasix to 80 mg every morning Lovenox 30 mg subcu daily x2 weeks Vicodin 5 500 mg one to two every four to six hours p r n pain Combivent nebulizer every four hours while awake for difficulty breathing Zithromax one week 250 mg daily and guaifenesin long acting one twice a day b i d FOLLOWUP Follow up with Dr Y in 7 to 10 days in office CONDITION ON DISCHARGE Stable Keywords discharge summary open reduction internal fixation schatzker iii tibial plateau fracture meniscectomy tibial plateau fracture orif schatzker fixation reduction tibial fracture plateau MEDICAL_TRANSCRIPTION,Description Contusion of the frontal lobe of the brain closed head injury and history of fall and headache probably secondary to contusion Medical Specialty Discharge Summary Sample Name Neurology Discharge Summary Transcription PRELIMINARY DIAGNOSES 1 Contusion of the frontal lobe of the brain 2 Closed head injury and history of fall 3 Headache probably secondary to contusion FINAL DIAGNOSES 1 Contusion of the orbital surface of the frontal lobes bilaterally 2 Closed head injury 3 History of fall COURSE IN THE HOSPITAL This is a 29 year old male who fell at home He was seen in the emergency room due to headache CT of the brain revealed contusion of the frontal lobe near the falx The patient did not have any focal signs He was admitted to ABCD Neurology consultation was obtained Neuro checks were done The patient continued to remain stable although he had some frontal headache He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure The patient remained clinically stable and his headache resolved He was discharged home on 11 6 2008 PLAN Discharge the patient to home ACTIVITY As tolerated The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p o q 6 h p r n headache The patient has been advised to follow up with me as well as the neurologist in about 1 week Keywords discharge summary interhemispheric frontal lobe head injury brain contusion MEDICAL_TRANSCRIPTION,Description Occupational therapy discharge summary Traumatic brain injury cervical musculoskeletal strain Medical Specialty Discharge Summary Sample Name Occupational Therapy Discharge Summary Transcription DIAGNOSES Traumatic brain injury cervical musculoskeletal strain DISCHARGE SUMMARY The patient was seen for evaluation on 12 11 06 followed by 2 treatment sessions Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion strength and coordination functional mobility training self care training cognitive retraining caregiver instruction and home exercise program Goals were not achieved as the patient was admitted to inpatient rehabilitation center RECOMMENDATIONS Discharged from OT this date as the patient has been admitted to Inpatient Rehabilitation Center Thank you for this referral Keywords discharge summary musculoskeletal strain occupational therapy traumatic brain cervical musculoskeletal rehabilitation MEDICAL_TRANSCRIPTION,Description Atypical pneumonia hypoxia rheumatoid arthritis and suspected mild stress induced adrenal insufficiency This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission Medical Specialty Discharge Summary Sample Name Pneumonia Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pneumonia failed outpatient treatment 2 Hypoxia 3 Rheumatoid arthritis DISCHARGE DIAGNOSES 1 Atypical pneumonia suspected viral 2 Hypoxia 3 Rheumatoid arthritis 4 Suspected mild stress induced adrenal insufficiency HOSPITAL COURSE This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission She was seen on multiple occasions at Urgent Care and in her physician s office Initial x ray showed some mild diffuse patchy infiltrates She was first started on Avelox but had a reaction switched to Augmentin which caused loose stools and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin Her O2 saturations drifted downward They were less than 88 when active at rest varied between 88 and 92 Decision was made because of failed outpatient treatment of pneumonia Her medical history is significant for rheumatoid arthritis She is on 20 mg of methotrexate every week as well as Remicade every eight weeks Her last dose of Remicade was in the month of June Hospital course was relatively unremarkable CT scan was performed and no specific focal pathology was seen Dr X pulmonologist was consulted He also was uncertain as to the exact etiology but viral etiology was most highly suspected Because of her loose stools C difficile toxin was ordered although that is pending at the time of discharge She was continued on Rocephin IV and azithromycin Her fever broke 18 hours prior to discharge and O2 saturations improved as did her overall strength and clinical status She was instructed to finish azithromycin She has two pills left at home She is to follow up with Dr X in two to three days Because she is on chronic prednisone therapy it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia She is to continue the increased dose of prednisone at 20 mg up from 5 mg per day We will consult her rheumatologist as to whether to continue her methotrexate which we held this past Friday Methotrexate is known on some occasions to cause pneumonitis Keywords discharge summary adrenal insufficiency hypoxia cough fevers weakness chills atypical pneumonia loose stools rheumatoid arthritis azithromycin arthritis pneumonia MEDICAL_TRANSCRIPTION,Description Symptomatic thyroid goiter Total thyroidectomy Medical Specialty Discharge Summary Sample Name Post Thyroidectomy Discharge Summary Transcription ADMISSION DIAGNOSIS Symptomatic thyroid goiter DISCHARGE DIAGNOSIS Symptomatic thyroid goiter PROCEDURE PERFORMED DURING THIS HOSPITALIZATION Total thyroidectomy INDICATIONS FOR THE SURGERY Briefly the patient is a 71 year old female referred with increasingly symptomatic large nodular thyroid goiter She presented now after informed consent for the above procedure understanding the inherent risks and complications and risk benefit ratio HOSPITAL COURSE The patient underwent total thyroidectomy on 09 22 08 which she tolerated very well and remained stable in the postoperative period On postoperative day 1 she was tolerating her diet began on thyroid hormone replacement and remained afebrile with stable vital signs She required intravenous narcotics for pain control She was judged stable for discharge home on 09 25 08 tolerating a diet well having no fever stable vital signs and good pain control The wound was clean and dry The drain was removed She was instructed to follow up in the surgical office within one week after discharge She was given prescription for Vicodin for pain and Synthroid thyroid hormone and otherwise the appropriate wound care instructions per my routine wound care sheet Keywords discharge summary nodular symptomatic thyroid goiter thyroidectomy goiter MEDICAL_TRANSCRIPTION,Description Suspected mastoiditis ruled out right acute otitis media and severe ear pain resolving The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis Medical Specialty Discharge Summary Sample Name Mastoiditis Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Suspected mastoiditis ruled out 2 Right acute otitis media 3 Severe ear pain resolving HISTORY OF PRESENT ILLNESS The patient is an 11 year old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis The child has had very severe ear pain and blood draining from the right ear The child had a temperature maximum of 101 4 in the ER The patient was admitted and started on IV Unasyn which he tolerated well and required Morphine and Vicodin for pain control In the first 12 hours after admission the patient s pain decreased and also swelling of his cervical area decreased The patient was evaluated by Dr X from the ENT while in house After reviewing the CT scan it was felt that the CT scan was not consistent with mastoiditis The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge At the time of discharge his pain is markedly decreased about 2 10 and swelling in the area has improved The patient is also able to take p o well DISCHARGE PHYSICAL EXAMINATION GENERAL The patient is alert in no respiratory distress VITAL SIGNS His temperature is 97 6 heart rate 83 blood pressure 105 57 respiratory rate 16 on room air HEENT Right ear shows no redness The area behind his ear is nontender There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly NECK Supple CHEST Clear breath sounds CARDIAC Normal S1 S2 without murmur ABDOMEN Soft There is no hepatosplenomegaly or tenderness SKIN Warm and well perfused DISCHARGE WEIGHT 38 7 kg DISCHARGE CONDITION Good DISCHARGE DIET Regular as tolerated DISCHARGE MEDICATIONS 1 Ciprodex Otic Solution in the right ear twice daily 2 Augmentin 500 mg three times daily x10 days FOLLOW UP 1 Dr Y in one week ENT 2 The primary care physician in 2 to 3 days TIME SPENT Approximate discharge time is 28 minutes Keywords MEDICAL_TRANSCRIPTION,Description Discharge summary of a patient presenting with a large mass aborted through the cervix Medical Specialty Discharge Summary Sample Name Mullerian Adenosarcoma Transcription PRINCIPAL DIAGNOSIS Mullerian adenosarcoma HISTORY OF PRESENT ILLNESS The patient is a 56 year old presenting with a large mass aborted through the cervix PHYSICAL EXAM CHEST Clear There is no heart murmur ABDOMEN Nontender PELVIC There is a large mass in the vagina HOSPITAL COURSE The patient went to surgery on the day of admission The postoperative course was marked by fever and ileus The patient regained bowel function She was discharged on the morning of the seventh postoperative day OPERATIONS July 25 2006 Total abdominal hysterectomy bilateral salpingo oophorectomy DISCHARGE CONDITION Stable PLAN The patient will remain at rest initially with progressive ambulation thereafter She will avoid lifting driving stairs or intercourse She will call me for fevers drainage bleeding or pain Family history social history and psychosocial needs per the social worker The patient will follow up in my office in one week PATHOLOGY Mullerian adenosarcoma MEDICATIONS Percocet 5 40 one q 3 h p r n pain Keywords discharge summary cervix fevers drainage bleeding mullerian adenosarcoma mullerian adenosarcoma MEDICAL_TRANSCRIPTION,Description Respiratory distress syndrome intrauterine growth restriction thrombocytopenia hypoglycemia retinal immaturity The baby is an ex 32 weeks small for gestational age infant with birth weight 1102 Medical Specialty Discharge Summary Sample Name Neonatal Discharge Summary 1 Transcription ADMITTING DIAGNOSES Respiratory distress syndrome intrauterine growth restriction thrombocytopenia hypoglycemia retinal immaturity HISTORY OF PRESENTING ILLNESS The baby is an ex 32 weeks small for gestational age infant with birth weight 1102 Baby was born at ABCD Hospital at 1333 on 07 14 2006 Mother is a 20 year old gravida 1 para 0 female who received prenatal care Prenatal course was complicated by low amniotic fluid index and hypertension She was evaluated for evolving preeclampsia and had a C section secondary to the nonreassuring fetal status Baby delivered operatively Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children s Hospital Infant was transferred to Children s Hospital for higher level of care stayed at Children s Hospital for approximately 2 weeks and was transferred back to ABCD where he stayed until he was discharged on 08 16 2006 HOSPITAL COURSE At the time of transfer to ABCD these were the following issues FEEDING AND NUTRITION Baby was on TPN and p o feeds had been started and were advanced 1 ml q 6h Baby was tolerating p o feeds of expressed breast milk and baby began to experience some abdominal distention The p o feeds were held and IV D10 water was given Baby was started on Mylicon drops and glycerin suppositories Abdominal ultrasound showed gaseous distention without signs of obstruction OG tube was passed Baby improved after couple of days when p o feedings were restarted Baby was also given Reglan At the time of discharge baby was tolerating p o feeds well of BM fortified with 22 cal NeoSure Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams RESPIRATIONS At the time of admission baby was not having any apnea spells no bradycardia or desaturations was saturating well on room air and continued to do well on room air until the time of discharge HYPOGLYCEMIA Baby began to experience hypoglycemic episodes on 07 24 2006 Blood glucose level was as low as 46 D10 was given initially as bolus Baby continued to experience hypoglycemic episodes Diazoxide was started 5 mg kg per os every 8 hours and fingersticks were done to monitor blood glucose level The baby improved with diazoxide hypoglycemic issues resolved and then began again Diazoxide was discontinued but the hypoglycemic issues restarted The Diazoxide was restarted again Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg kg and then the diazoxide was discontinued At the time of discharge blood glucose levels were not being stable for 24 hours CARDIOVASCULAR Infant was hemodynamically stable on admission from Madera Infant has a closed PDA Infant had two cardiac echograms done The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery then the circumflex coronary artery CNS Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage The ultrasound was negative for intracranial hemorrhage INFECTIOUS DISEASE The patient had been on antibiotics during the stay at Madera At the time of admission to the ABCD the patient was not on any antibiotics and his clinically condition has remained stable HEMATOLOGY The patient is status post phototherapy at Madera and was started on iron OPHTHALMOLOGY Exam on 07 17 2006 showed immature retina The patient is to get followup exam after discharge DISCHARGE DIAGNOSIS Stable ex 32 weeks preemie DISCHARGE INSTRUCTIONS The patient has been educated on CPR measures Followup appointment has been made at Kid s Care Calcium challenge has been done The patient s parents are comfortable with feeding The patient has been discharged on NeoSure and expressed breast milk Keywords discharge summary delivered preeclampsia immaturity intrauterine prenatal coronary artery blood glucose discharge baby coronary intracranial hypoglycemia hypoglycemic infant MEDICAL_TRANSCRIPTION,Description Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism subdural hematoma pancytopenia and pneumonia Medical Specialty Discharge Summary Sample Name Leiomyosarcoma Transcription ADMITTING DIAGNOSES 1 Leiomyosarcoma 2 History of pulmonary embolism 3 History of subdural hematoma 4 Pancytopenia 5 History of pneumonia PROCEDURES DURING HOSPITALIZATION 1 Cycle six of CIVI CAD Cytoxan Adriamycin and DTIC from 07 22 2008 to 07 29 2008 2 CTA chest PE study showing no evidence for pulmonary embolism 3 Head CT showing no evidence of acute intracranial abnormalities 4 Sinus CT normal mini CT of the paranasal sinuses HISTORY OF PRESENT ILLNESS Ms ABC is a pleasant 66 year old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007 The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon MRI showed inflammation and was thought to be secondary to rheumatoid arthritis The mass increased in size She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma margins were impossible to assess but were likely positive She was evaluated by Dr X and Dr Y and a decision was made to proceed with preoperative chemotherapy She began treatment with CIVI CAD in December 2007 Her course was complicated by pulmonary embolus pneumonia and subdural hematoma while on anticoagulation She eventually underwent surgical resection on May 1 2008 with small area of residual disease but otherwise clear margins HOSPITAL COURSE 1 Leiomyosarcoma the patient was admitted to Hem Onco B Service under attending Dr XYZ for cycle six of continuous IV infusion Cytoxan Adriamycin and DTIC which she tolerated well 2 History of pulmonary embolism Upon admission the patient reported an approximate two week history of dyspnea on exertion and some mild chest pain She underwent a CTA which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day She had no further complaints throughout the hospitalization with any shortness of breath or chest pain 3 History of subdural hematoma also on admission the patient noted some mild intermittent headaches that were fleeting in nature several a day that would resolve on their own Her headaches were not responding to pain medication and so on 07 24 2008 we obtained a head CT that showed no evidence of acute intracranial abnormalities The patient also had a history of sinusitis and so a sinus CT scan was obtained which was normal 4 Pancytopenia On admission the patient s white blood count was 3 4 hemoglobin 11 3 platelet count 82 and ANC of 2400 The patient s counts were followed throughout admission She did not require transfusion of red blood cells or platelets however on 07 26 2008 her ANC did dip to 900 and she was placed on neutropenic diet At discharge her ANC is back up to 1100 and she is taken off neutropenic diet Her white blood cell count at discharge was 1 4 and her hemoglobin was 11 2 with a platelet count of 140 5 History of pneumonia During admission the patient did not exhibit any signs or symptoms of pneumonia DISPOSITION Home in stable condition DIET Regular and less neutropenic ACTIVITY Resume same activity FOLLOWUP The patient will have lab work at Dr XYZ on 08 05 2008 and she will also return to the cancer center on 08 12 2008 at 10 20 a m The patient is also advised to monitor for any fevers greater than 100 5 and should she have any further problems in the meantime to please call in to be seen sooner Keywords discharge summary leiomyosarcoma embolism hematoma pneumonia acute intracranial abnormalities white blood platelet count blood cells neutropenic diet subdural hematoma pulmonary embolism intracranial pancytopenia neutropenic subdural pulmonary MEDICAL_TRANSCRIPTION,Description Chronic laryngitis hoarseness The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties Medical Specialty Discharge Summary Sample Name Laryngitis Discharge Transcription DIAGNOSIS Chronic laryngitis hoarseness HISTORY The patient is a 68 year old male was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties The patient attended initial evaluation plus 3 outpatient speech therapy sessions which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions The patient made great progress and he came in to discuss with an appointment on 12 23 08 stating that his voice had finally returned to normal SHORT TERM GOALS 1 To be independent with relaxation and stretching exercises and Lessac Madsen Resonant Voice Therapy Protocol 2 He also met short term goal therapy 3 and he is independent with resonant voice therapy tasks 3 We did not complete his __________ ratio during his last session so I am unsure if he had met his short term goal number 2 4 To be referred for a videostroboscopy but at this time the patient is not in need of this evaluation However in the future if hoarseness returns it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy LONG TERM GOALS 1 The patient did reach his long term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty 2 The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy The patient is discharged from my services at this time with a home program to continue to promote normal voicing Keywords discharge summary vocal hygiene voice activities hoarseness skilled speech therapy chronic laryngitis voice therapy resonant voice videostroboscopy laryngitis MEDICAL_TRANSCRIPTION,Description The patient is an 1812 g baby boy born by vaginal delivery to a 32 year old gravida 3 para 2 at 34 weeks of gestation Mother had two previous C sections Medical Specialty Discharge Summary Sample Name Neonatal Discharge Summary Transcription HOSPITAL COURSE The patient is an 1812 g baby boy born by vaginal delivery to a 32 year old gravida 3 para 2 at 34 weeks of gestation Mother had two previous C sections Baby was born at 5 57 on 07 30 2006 Mother received ampicillin 2 g 4 hours prior to delivery Mother came with preterm contractions with progressive active labor in spite of the terbutaline and magnesium sulfate Baby was born with Apgar scores of 8 and 9 at delivery Fluid was cleared Nuchal cord x1 Prenatal was at ABC Valley Prenatal labs were O positive antibody negative rubella immune RPR nonreactive Baby was suctioned on perineum with good support The baby was admitted to the NICU for prematurity and to rule out sepsis Baby s cry was good Color tone and __________ mild retractions CBC CRP blood cultures were done IV fluids of D10 at a rate of 6 mL an hour Ampicillin and gentamicin were started via protocol At the time of admission the patient was stable on room air and has feeding issues Baby was fed EBM 22 and NeoSure per os Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours The patient continues on feeding issues will not suck properly was kept in the NICU and put on OG tube for a couple of days after which p o feeds were advanced Also the baby was able to suck properly and was tolerating feeds The baby was fed EBM 22 and NeoSure was added a day before discharge At the time of discharge baby was stable on room air baby was tolerated p o foods and was sucking properly was taking ad lib feeds and gaining weight ADMISSION DIAGNOSES Respiratory distress rule out sepsis and prematurity DISCHARGE DIAGNOSES Stable ex 34 week preemie Pediatrician after discharge will be Dr X DISCHARGE INSTRUCTIONS To follow up with Dr X in 2 to 3 days an appointment was made for 08 14 2006 CPR teaching was completed on 08 11 2006 to parents Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed Ad lib feeding on demand Keywords discharge summary gestation preemie prematurity sepsis neosure feeds born delivery perineum discharge MEDICAL_TRANSCRIPTION,Description Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis Medical Specialty Discharge Summary Sample Name Neck Pain Discharge Summary Transcription ADMISSION DIAGNOSES 1 Neck pain with right upper extremity radiculopathy 2 Cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis DISCHARGE DIAGNOSES 1 Neck pain with right upper extremity radiculopathy 2 Cervical spondylosis with herniated nucleus pulposus C4 C5 C5 C6 and C6 C7 with stenosis OPERATIVE PROCEDURES 1 Anterior cervical discectomy with decompression C4 C5 C5 C6 and C6 C7 2 Arthrodesis with anterior interbody fusion C4 C5 C5 C6 and C6 C7 3 Spinal instrumentation C4 through C7 4 Implant 5 Allograft COMPLICATIONS None COURSE ON ADMISSION This is the case of a very pleasant 41 year old Caucasian female who was seen in clinic as an initial consultation on 09 13 07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient s hand The patient s symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now The patient has been treated with medications which has been unrelenting The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4 C5 C5 C6 and C6 C7 The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness which was treated well with IV morphine The patient has resolution of the pain down the arm but she does have some tingling of the right thumb and right index finger The patient apparently is doing well with slight dysphagia we treated her with Decadron and we will send her home with Medrol The patient will have continued pain medication coverage with Darvocet and Flexeril The patient will follow up with me as scheduled Instructions have been given Keywords discharge summary radiculopathy cervical spondylosis neck pain anterior cervical discectomy herniated nucleus pulposus cervical anterior herniated MEDICAL_TRANSCRIPTION,Description This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR Medical Specialty Discharge Summary Sample Name Kawasaki Disease Discharge Summary Transcription ADMITTING DIAGNOSIS Kawasaki disease DISCHARGE DIAGNOSIS Kawasaki disease resolving HOSPITAL COURSE This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR When he was sent to the hospital he had a fever of 102 Subsequently the patient was evaluated and based on the criteria he was started on high dose of aspirin and IVIG Echocardiogram was also done which was negative IVIG was done x1 and between 12 hours of IVIG he spiked fever again it was repeated twice and then after second IVIG he did not spike any more fever Today his fever and his rash have completely resolved He does not have any conjunctivitis and no redness of mucous membranes He is more calm and quite and taking good p o so with a very close followup and a cardiac followup he will be sent home DISCHARGE ACTIVITIES Ad lib DISCHARGE DIET PO ad lib DISCHARGE MEDICATIONS Aspirin high dose 340 mg q 6h for 1 day and then aspirin low dose 40 mg q d for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p o once a day He will be followed by his primary doctor in 2 to 3 days Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG all the live virus vaccine and if he gets any rashes any fevers should go to primary care doctor as soon as possible Keywords discharge summary mucous membranes conjunctivitis ad lib kawasaki disease vaccine fever aspirin MEDICAL_TRANSCRIPTION,Description Total vaginal hysterectomy Microinvasive carcinoma of the cervix Medical Specialty Discharge Summary Sample Name Hysterectomy Discharge Summary 2 Transcription ADMISSION DIAGNOSIS Microinvasive carcinoma of the cervix DISCHARGE DIAGNOSIS Microinvasive carcinoma of the cervix PROCEDURE PERFORMED Total vaginal hysterectomy HISTORY OF PRESENT ILLNESS The patient is a 36 year old white female gravida 7 para 5 last period mid March status post tubal ligation She had an abnormal Pap smear in the 80s which she failed to followup on until this year Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02 12 2007 also showing microinvasive carcinoma with a 1 mm invasion She has elected definitive therapy with a total vaginal hysterectomy She is aware of the future need of Pap smears PAST MEDICAL HISTORY Past history is significant for seven pregnancies five term deliveries and significant past history of tobacco use PHYSICAL EXAMINATION Physical exam is within normal limits with a taut normal size uterus and a small cervix status post cone biopsy LABORATORY DATA AND DIAGNOSTIC STUDIES Chest x ray was clear Discharge hemoglobin 10 8 HOSPITAL COURSE She was taken to the operating room on 04 02 2007 where a total vaginal hysterectomy was performed under general anesthesia There was an incidental cystotomy at the time of the creation of the bladder flap This was repaired intraoperatively without difficulty Postoperative she did very well Bowel and bladder function returned quickly She is ambulating well and tolerating a regular diet Routine postoperative instructions given and understood Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time DISCHARGE MEDICATIONS Vicodin Motrin and Macrodantin at bedtime for urinary tract infection suppression DISCHARGE CONDITION Good Final pathology report was free of residual disease Keywords discharge summary pap smear total vaginal hysterectomy hysterectomy microinvasive carcinoma cervix MEDICAL_TRANSCRIPTION,Description Laparoscopic cholecystectomy Acute cholecystitis status post laparoscopic cholecystectomy end stage renal disease on hemodialysis hyperlipidemia hypertension congestive heart failure skin lymphoma 5 years ago and hypothyroidism Medical Specialty Discharge Summary Sample Name Lap Chole Discharge Summary Transcription PROCEDURE Laparoscopic cholecystectomy DISCHARGE DIAGNOSES 1 Acute cholecystitis 2 Status post laparoscopic cholecystectomy 3 End stage renal disease on hemodialysis 4 Hyperlipidemia 5 Hypertension 6 Congestive heart failure 7 Skin lymphoma 5 years ago 8 Hypothyroidism HOSPITAL COURSE This is a 78 year old female with past medical condition includes hypertension end stage renal disease hyperlipidemia hypothyroidism and skin lymphoma who had a left AV fistula done about 3 days ago by Dr X and the patient went later on home but started having epigastric pain and right upper quadrant pain and mid abdominal pain some nauseated feeling and then she could not handle the pain so came to the emergency room brought by the family The patient s initial assessment the patient s vital signs were stable showed temperature 97 9 pulse was 106 and blood pressure was 156 85 EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm There is sludge in the gallbladder wall versus a stone in the gallbladder wall Thickening of the gallbladder wall with positive Murphy sign She has a history of cholecystitis Urine shows positive glucose but negative for nitrite and creatinine was 7 1 sodium 131 potassium was 5 2 and lipase and amylase were normal So the patient admitted to the Med Surg floor initially and the patient was started on IV fluid as well as low dose IV antibiotic and 2 D echocardiogram and EKG also was ordered The patient also had history of CHF in the past and recently had some workup done The patient does not remember initially Surgical consult also requested and blood culture and urine culture also ordered The same day the patient was seen by Dr Y and the patient should need cholecystectomy but the patient also needs dialysis and also needs to be cleared by the cardiologist so the patient later on seen by Dr Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy The patient also seen by nephrologist and underwent dialysis The patient s white count went down 6 1 afebrile On postop day 1 the patient started eating and also walking The patient also had chronic bronchitis The patient was later on feeling fine discussed with surgery The patient was then able to discharge to home and follow with the surgeon in about 3 5 days Discharged home with Synthroid 0 5 mg 1 tablet p o daily Plavix 75 mg p o daily folic acid 1 mg p o daily Diovan 80 mg p o daily Renagel 2 tablets 800 mg p o twice a day Lasix 40 mg p o 2 tablets twice a day lovastatin 20 mg p o daily Coreg 3 125 mg p o twice a day nebulizer therapy every 3 hours as needed also Phenergan 25 mg p o q 8 hours for nausea and vomiting Pepcid 20 mg p o daily Vicodin 1 tablet p o q 6 hours p r n as needed and Levaquin 250 mg p o every other day for the next 5 days The patient also had Premarin that she was taking advised to discontinue because of increased risk of heart disease and stroke explained to the patient Discharged home Keywords discharge summary end stage renal disease lymphoma cholecystitis congestive heart failure skin lymphoma gallbladder wall laparoscopic cholecystectomy MEDICAL_TRANSCRIPTION,Description Painful right knee status post total knee arthroplasty many years ago Status post poly exchange right knee total knee arthroplasty Medical Specialty Discharge Summary Sample Name Knee Arthroplasty Discharge Summary Transcription ADMISSION DIAGNOSIS Painful right knee status post total knee arthroplasty many years ago The patient had gradual onset of worsening soreness and pain in this knee X ray showed that the poly seems to be worn out significantly in this area DISCHARGE DIAGNOSIS Status post poly exchange right knee total knee arthroplasty CONDITION ON DISCHARGE Stable PROCEDURES PERFORMED Poly exchange total knee right CONSULTATIONS Anesthesia managed femoral nerve block on the patient HOSPITAL COURSE The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components The patient recovered well after this Working with PT she was able to ambulate with minimal assistance Nerve block was removed by anesthesia The patient did well on oral pain medications The patient was discharged home She is actually going to home with her son who will be able to assist her and look after her for anything she might need The patient is comfortable with this understands the therapy regimen and is very satisfied after the procedure DISCHARGE INSTRUCTIONS AND MEDICATIONS The patient is to be discharged home to the care of the son Diet is regular Activity weight bear as tolerated right lower extremity Continue to do physical therapy exercises The patient will be discharged home on Coumadin 4 mg a day as the INR was 1 9 on discharge with twice weekly lab checks Vicodin 5 500 mg take one to two tablets p o q 4 6h Resume home medications Call the office or return to the emergency room for any concerns including increased redness swelling drainage fever or any concerns regarding operation or site of incision The patient is to follow up with Dr ABC in two weeks Keywords discharge summary painful right knee total knee arthroplasty poly exchange femoral nerve block patellar tibial poly knee arthroplasty knee arthroplasty MEDICAL_TRANSCRIPTION,Description A 66 year old female with knee osteoarthrosis who failed conservative management Medical Specialty Discharge Summary Sample Name Knee Osteoarthrosis Discharge Summary Transcription PRINCIPAL DIAGNOSIS Knee osteoarthrosis PRINCIPAL PROCEDURE Total knee arthroplasty HISTORY AND PHYSICAL A 66 year old female with knee osteoarthrosis Failed conservative management Risks and benefits of different treatment options were explained Informed consent was obtained PAST SURGICAL HISTORY Right knee surgery cosmetic surgery and carotid sinus surgery MEDICATIONS Mirapex ibuprofen and Ambien ALLERGIES QUESTIONABLE PENICILLIN ALLERGIES PHYSICAL EXAMINATION GENERAL Female who appears younger than her stated age Examination of her gait reveals she walks without assistive devices HEENT Normocephalic and atraumatic CHEST Clear to auscultation CARDIOVASCULAR Regular rate and rhythm ABDOMEN Soft EXTREMITIES Grossly neurovascularly intact HOSPITAL COURSE The patient was taken to the operating room OR on 03 15 2007 She underwent right total knee arthroplasty She tolerated this well She was taken to the recovery room After uneventful recovery room course she was brought to regular surgical floor Mechanical and chemical deep venous thrombosis DVT prophylaxis were initiated Routine postoperative antibiotics were administered Hemovac drain was discontinued on postoperative day 2 Physical therapy was initiated Continuous passive motion CPM was also initiated She was able to spontaneously void She transferred to oral pain medication Incision remained clean dry and intact during the hospital course No pain with calf squeeze She was felt to be ready for discharge home on 03 19 2007 DISPOSITION Discharged to home FOLLOW UP Follow up with Dr X in one week Prescriptions were written for Percocet and Coumadin INSTRUCTIONS Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing Keywords discharge summary total knee arthroplasty conservative management knee arthroplasty physical therapy knee osteoarthrosis arthroplasty osteoarthrosis knee MEDICAL_TRANSCRIPTION,Description Total vaginal hysterectomy Menometrorrhagia dysmenorrhea and small uterine fibroids Medical Specialty Discharge Summary Sample Name Hysterectomy Discharge Summary 1 Transcription ADMISSION DIAGNOSES 1 Menometrorrhagia 2 Dysmenorrhea 3 Small uterine fibroids DISCHARGE DIAGNOSES 1 Menorrhagia 2 Dysmenorrhea 3 Small uterine fibroids OPERATION PERFORMED Total vaginal hysterectomy BRIEF HISTORY AND PHYSICAL The patient is a 42 year old white female gravida 3 para 2 with two prior vaginal deliveries She is having increasing menometrorrhagia and dysmenorrhea Ultrasound shows a small uterine fibroid She has failed oral contraceptives and surgical therapy is planned PAST HISTORY Significant for reflux SURGICAL HISTORY Tubal ligation PHYSICAL EXAMINATION A top normal sized uterus with normal adnexa LABORATORY VALUES Her discharge hemoglobin is 12 4 HOSPITAL COURSE She was taken to the operating room on 11 05 07 where a total vaginal hysterectomy was performed under general anesthesia Postoperatively she has done well Bowel and bladder function have returned normally She is ambulating well tolerating a regular diet Routine postoperative instructions given and said follow up will be in four weeks in the office DISCHARGE MEDICATIONS Preoperative meds plus Vicodin for pain DISCHARGE CONDITION Good Keywords discharge summary dysmenorrhea uterine fibroids vaginal total vaginal hysterectomy menometrorrhagia uterine fibroids MEDICAL_TRANSCRIPTION,Description Hemiarthroplasty right hip Fracture of the right femoral neck also history of Alzheimer s dementia hypothyroidism and status post hemiarthroplasty of the hip Medical Specialty Discharge Summary Sample Name Hemiarthroplasty Discharge Summary Transcription ADMISSION DIAGNOSES Fracture of the right femoral neck also history of Alzheimer s dementia and hypothyroidism DISCHARGE DIAGNOSES Fracture of the right femoral neck also history of Alzheimer s dementia hypothyroidism and status post hemiarthroplasty of the hip PROCEDURE PERFORMED Hemiarthroplasty right hip CONSULTATIONS Medicine for management of multiple medical problems including Alzheimer s HOSPITAL COURSE The patient was admitted on 08 06 2007 after a fall with subsequent fracture of the right hip The patient was admitted to Orthopedics and consulted Medicine The patient was actually taken to the operating room consent signed by durable power of attorney taken on 08 06 2007 had right hip hemiarthroplasty recovered without incidence The patient had continued confusion and dementia which is apparently his baseline secondary to his Alzheimer s Brief elevation of white count following the surgery which did subside Studies UA and blood culture were negative The patient was stable and was discharged to Heartland CONDITION ON DISCHARGE Stable DISCHARGE INSTRUCTIONS Transfer to ABC for rehab and continued care Diabetic diet Activity ambulate as tolerated with posterior hip precautions Rehab potential fair He will need nursing Social Work PT OT and nutrition consults Resume home meds DVT prophylaxis aspirin and compression stockings Follow up Dr X in one to two weeks call 123 4567 for an appointment Keywords discharge summary femoral neck orthopedics rehab femoral neck fracture dementia hemiarthroplasty hip MEDICAL_TRANSCRIPTION,Description Intrauterine pregnancy at term with previous cesarean Desired sterilization Status post repeat low transverse cesarean and bilateral tubal ligation Medical Specialty Discharge Summary Sample Name Intrauterine Pregnancy Discharge Summary Transcription ADMITTING DIAGNOSIS Intrauterine pregnancy at term with previous cesarean SECONDARY DIAGNOSIS Desired sterilization DISCHARGE DIAGNOSES 1 Intrauterine pregnancy at term with previous cesarean 2 Desired sterilization 3 Status post repeat low transverse cesarean and bilateral tubal ligation HISTORY The patient is a 35 year old gravida 2 para 1 0 0 1 with intrauterine pregnancy on 08 30 09 Pregnancy was uncomplicated She opted for a scheduled elective C section and sterilization without any trial of labor All routine screening labs were normal and she underwent a high resolution ultrasound during pregnancy PAST MEDICAL HISTORY Significant for postpartum depression after her last baby as well as a cesarean ALLERGIES SHE HAS SEASONAL ALLERGIES MEDICATIONS She is taking vitamins and iron PHYSICAL EXAMINATION GENERAL An alert gravid woman in no distress ABDOMEN Gravid nontender non irritable with an infant in the vertex presentation Estimated fetal weight was greater than 10 pounds HOSPITAL COURSE On the first hospital day the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9 There was normal placenta normal pelvic anatomy There was 600 cc estimated blood loss Patient recovered uneventfully from her anesthesia and surgery She was able to ambulate and void She tolerated regular diet She passed flatus She was breast feeding Postoperative hematocrit was 31 On the second postoperative day the patient was discharged home in satisfactory condition DISCHARGE MEDICATIONS Motrin and Percocet for pain Paxil for postpartum depression She was instructed to do no lifting straining or driving to put nothing in the vagina and to see me in two weeks or with signs of severe pain heavy bleeding fever or other problems Keywords discharge summary cesarean bilateral tubal ligation low transverse cesarean intrauterine gravida sterilization pregnancy MEDICAL_TRANSCRIPTION,Description The patient underwent a total vaginal hysterectomy Medical Specialty Discharge Summary Sample Name Hysterectomy Discharge Summary Transcription ADMISSION DIAGNOSES 1 Menorrhagia 2 Uterus enlargement 3 Pelvic pain DISCHARGE DIAGNOSIS Status post vaginal hysterectomy COMPLICATIONS None BRIEF HISTORY OF PRESENT ILLNESS This is a 36 year old gravida 3 para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period She also had symptoms of back pain dysmenorrhea and dysuria The symptoms had been worsening over time The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination PROCEDURE The patient underwent a total vaginal hysterectomy HOSPITAL COURSE The patient was admitted on 09 04 2007 to undergo total vaginal hysterectomy The procedure preceded as planned without complication Uterus was sent for pathologic analysis The patient was monitored in the hospital 2 days postoperatively She recovered quite well and vitals remained stable Laboratory studies H H were followed and appeared stable on 09 05 2007 with hemoglobin of 11 2 and hematocrit of 31 8 The patient was ready for discharge on Monday morning of 09 06 2007 LABORATORY FINDINGS Please see chart for full studies during admission DISPOSITION The patient was discharged to home in stable condition She was instructed to follow up in the office postoperatively Keywords discharge summary menorrhagia uterus enlargement pelvic pain total vaginal hysterectomy vaginal hysterectomy uterus vaginal hysterectomy MEDICAL_TRANSCRIPTION,Description Hypothermia Rule out sepsis was negative as blood cultures sputum cultures and urine cultures were negative Organic brain syndrome Seizure disorder Adrenal insufficiency Hypothyroidism Anemia of chronic disease Medical Specialty Discharge Summary Sample Name Hypothermia Discharge Summary Transcription DIAGNOSIS AT ADMISSION Hypothermia DIAGNOSES ON DISCHARGE 1 Hypothermia 2 Rule out sepsis was negative as blood cultures sputum cultures and urine cultures were negative 3 Organic brain syndrome 4 Seizure disorder 5 Adrenal insufficiency 6 Hypothyroidism 7 Anemia of chronic disease HOSPITAL COURSE The patient was admitted through the emergency room He was admitted to the Intensive Care Unit He was rewarmed and had blood sputum and urine cultures done He was placed on IV Rocephin His usual medications of Dilantin and Depakene were given The patient s hypertension was treated with fluid boluses The patient was empirically placed on Synthroid and hydrocortisone by Dr X Blood work consisted of a chemistry panel that was unremarkable except for decreased proteins H H was stable at 33 3 10 9 and platelets of 80 000 White blood cell counts were normal differential was normal TSH was 3 41 Free T4 was 0 9 Dr X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement A cortisol level was obtained prior to administration of hydrocortisone This was 10 9 and that was not a fasting level Dr X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef The patient was eventually changed to prednisone 2 5 mg b i d in addition to his Florinef 0 1 mg on Monday Wednesday and Friday The patient was started back on his tube feeds He tolerated these poorly with residuals Reglan was increased to 10 mg q 6 h and erythromycin is being added The patient s temperature has been stable in the 94 to 95 range Other vital signs have been stable His urine output has been diminished An external jugular line was placed in the Intensive Care Unit The patient s legal guardian Janet Sanchez in Albuquerque has requested he be transported there As per several physicians in Albuquerque and Dr Y an internist we will accept him once we have a nursing home available to him He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque His prognosis is poor Keywords discharge summary sepsis organic brain syndrome seizure disorder anemia of chronic disease adrenal insufficiency blood cultures MEDICAL_TRANSCRIPTION,Description Patient discharged after laparoscopic Roux en Y gastric bypass Medical Specialty Discharge Summary Sample Name Gastric Bypass Summary Transcription FINAL DIAGNOSES 1 Morbid obesity status post laparoscopic Roux en Y gastric bypass 2 Hypertension 3 Obstructive sleep apnea on CPAP OPERATION AND PROCEDURE Laparoscopic Roux en Y gastric bypass BRIEF HOSPITAL COURSE SUMMARY This is a 30 year old male who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities Underwent standard bariatric evaluation consults diagnostics and preop Medifast induced weight loss in anticipation of elective bariatric surgery Taken to the OR via same day surgery process for elective gastric bypass tolerated well recovered in the PACU and sent to the floor for routine postoperative care There DVT prophylaxis was continued with subcu heparin early and frequent mobilization and SCDs PCA was utilized for pain control efficaciously he utilized the CPAP was monitored and had no new cardiopulmonary complaints Postop day 1 labs within normal limits able to clinically start bariatric clear liquids at 2 ounces per hour this was tolerated well He was ambulatory had no cardiopulmonary complaints no unusual fever or concerning symptoms By the second postoperative day was able to advance to four ounces per hour tolerated this well and is able to discharge in stable and improved condition today He had his drains removed today as well DISCHARGE INSTRUCTIONS Include re appointment in the office in the next week call in the interim if any significant concerning complaints Scripts left in the chart for omeprazole and Lortab Med rec sheet completed on no meds He will maintain bariatric clear liquids at home goal 64 ounces per day maintain activity at home but no heavy lifting or straining Can shower starting tomorrow drain site care and wound care reviewed He will re appoint in the office in the next week certainly call in the interim if any significant concerning complaints Keywords discharge summary medifast laparoscopic roux en y gastric bypass roux en y bariatric clear liquids gastric bypass laparoscopic gastric bariatric bypass MEDICAL_TRANSCRIPTION,Description Acute gastroenteritis resolved Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology Medical Specialty Discharge Summary Sample Name Gastroenteritis Discharge Summary Transcription ADMITTING DIAGNOSES 1 Acute gastroenteritis 2 Nausea 3 Vomiting 4 Diarrhea 5 Gastrointestinal bleed 6 Dehydration DISCHARGE DIAGNOSES 1 Acute gastroenteritis resolved 2 Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology BRIEF H P AND HOSPITAL COURSE This patient is a 56 year old male a patient of Dr X with 25 pack year history also a history of diabetes type 2 dyslipidemia hypertension hemorrhoids chronic obstructive pulmonary disease and a left lower lobe calcified granuloma that apparently is stable at this time This patient presented with periumbilical abdominal pain with nausea vomiting and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse The patient was admitted into the ER and had trop x1 done which was negative and ECG showed to be of normal sinus rhythm Lab findings initially presented with a hemoglobin of 13 1 hematocrit of 38 6 with no elevation of white count Upon discharge his hemoglobin and hematocrit stayed at 10 9 and 31 3 and he was still having stool guaiac positive blood and a stool study was done which showed few white blood cells negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs The patient s nausea vomiting and diarrhea did resolve during his hospital course Was placed on IV fluids initially and on hospital day 2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly and the patient was able to tolerate p o well The patient also denied any abdominal pain upon day of discharge The patient was also started on prednisone as per GI recommendations He was started on 60 mg p o Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well PLAN The plan is to discharge the patient home He can resume his home medications of Prandin Actos Lipitor Glucophage Benicar and Advair We will also start him on a tapered dose of prednisone for 4 weeks We will start him on 15 mg p o for seven days Then week 2 we will start him on 40 mg for 1 week Then week 3 we will start him on 30 mg for 1 week and then 20 mg for 1 week and then finally we will stop He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations Keywords discharge summary nausea vomiting diarrhea gastrointestinal bleed mesentery hemoglobin hematocrit gastrointestinal periumbilical gastroenteritis hemorrhoids MEDICAL_TRANSCRIPTION,Description Gastrointestinal bleed source undetermined but possibly due to internal hemorrhoids Poor prep with friable internal hemorrhoids but no gross lesions no source of bleed Medical Specialty Discharge Summary Sample Name Gastrointestinal Bleed Discharge Summary Transcription DIAGNOSIS ON ADMISSION Gastrointestinal bleed DIAGNOSES ON DISCHARGE 1 Gastrointestinal bleed source undetermined but possibly due to internal hemorrhoids 2 Atherosclerotic cardiovascular disease 3 Hypothyroidism PROCEDURE Colonoscopy FINDINGS Poor prep with friable internal hemorrhoids but no gross lesions no source of bleed HOSPITAL COURSE The patient was admitted to the emergency room by Dr X He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood Dr Y Miller saw him in consultation and recommended a colonoscopy A bowel prep was done H Hs were stable His most recent H H was 38 6 13 2 that was this morning His H H at admission was 41 14 3 The patient had the bowel prep that revealed no significant bleeding His vital signs are stable He is continuing on his usual medications of Imdur metoprolol and Synthroid His Plavix is discontinued He is given IV Protonix I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec The patient s PT INR was 1 03 PTT 25 8 Chemistry panel was unremarkable The patient was given a regular diet after his colonoscopy today He tolerated it well and is being discharged home He will be followed closely as an outpatient He will continue his Pepcid 40 mg at night Imdur Synthroid and metoprolol as prior to admission He will hold his Plavix for now They will call me for further dark stools and will avoid Pepto Bismol They will follow up in the office on Thursday Keywords discharge summary atherosclerotic cardiovascular disease colonoscopy gross lesions bowel prep gastrointestinal bleed internal hemorrhoids hemorrhoids gastrointestinal prep MEDICAL_TRANSCRIPTION,Description A 31 year old white female admitted to the hospital with pelvic pain and vaginal bleeding Right ruptured ectopic pregnancy with hemoperitoneum Anemia secondary to blood loss Medical Specialty Discharge Summary Sample Name Ectopic Pregnancy Discharge Summary Transcription HISTORY OF PRESENT ILLNESS This is the case of a 31 year old white female admitted to the hospital with pelvic pain and vaginal bleeding The patient had a positive hCG with a negative sonogram and hCG titer of about 18 000 HOSPITAL COURSE The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion to rule out ectopic pregnancy or rupture of corpus luteal cyst The patient was kept in observation for 24 hours The sonogram stated there was no gestational sac but there was a small mass within the uterus that could represent a gestational sac The patient was admitted to the hospital A repeat hCG titer done on the same day came back as 15 000 but then the following day it came back as 18 000 The diagnosis of a possible ruptured ectopic pregnancy was established The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy The right salpingectomy was performed with no complications The patient received 2 units of red packed cells On admission her hemoglobin was 12 9 then in the afternoon it dropped to 8 1 and the following morning it was 7 9 Again based on these findings the severe abdominal pain we made the diagnosis of ectopic and it was proved or confirmed at surgery The hospital course was uneventful There was no fever reported The abdomen was soft She had a normal bowel movement The patient was dismissed on 09 09 2007 to be followed in my office in 4 days FINAL DIAGNOSES 1 Right ruptured ectopic pregnancy with hemoperitoneum 2 Anemia secondary to blood loss PLAN The patient will be dismissed on pain medication and iron therapy Keywords discharge summary anemia blood loss ruptured ectopic pregnancy gestational sac ectopic pregnancy hemoperitoneum gestational ruptured pregnancy ectopic MEDICAL_TRANSCRIPTION,Description Discharge Summary of a patient with hematuria benign prostatic hyperplasia complex renal cyst versus renal cell carcinoma and osteoarthritis Medical Specialty Discharge Summary Sample Name Discharge Summary Urology Transcription ADMITTING DIAGNOSES 1 Hematuria 2 Benign prostatic hyperplasia 3 Osteoarthritis DISCHARGE DIAGNOSES 1 Hematuria resolved 2 Benign prostatic hyperplasia 3 Complex renal cyst versus renal cell carcinoma or other tumor 4 Osteoarthritis HOSPITAL COURSE This is a 77 year old African American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission He stated that he never had blood in his urine before however he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago He was admitted to a regular bed Dr G of Urology was consulted for evaluation of his hematuria During the workup for this he had a CT of the abdomen and pelvis with and without contrast with early and late phase imaging for evaluation of the kidneys and collecting system At that time he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended He had an ultrasound done of the cyst which showed a 2 1 x 2 7 cm mass arising from the right kidney which again did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor so an MRI was scheduled on the day of discharge for further evaluation of this The report was not back at discharge The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular and he was diagnosed with nonprostatic hyperplasia His urine slowly cleared He tolerated a regular diet with no difficulties in his activities of daily living and his Foley was removed on the day of discharge He was started on ciprofloxacin Colace and Lasix after the transurethral resection and continued these for a short course He is asked to continue the Colace as an outpatient for stool softening for comfort DISCHARGE MEDICATIONS Colace 100 mg 1 b i d DISCHARGE FOLLOWUP PLANNING The patient is to follow up with his primary care physician at ABCD Dr B or Dr J the patient is unsure of which in the next couple weeks He is to follow up with Dr G of Urology in the next week by phone in regards to the patient s MRI and plans for a laparoscopic partial renal resection biopsy This is scheduled for the week after discharge potentially by Dr G and the patient will discuss the exact time later this week The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output Keywords discharge summary bph benign prostatic hyperplasia hematuria osteoarthritis clots cystoscopy gross hematuria kidney renal cell carcinoma renal cyst simple cyst prostatic hyperplasia transurethral resection discharge summary urology transurethral prostate prostatic hyperplasia gross benign renal cyst MEDICAL_TRANSCRIPTION,Description The patient was admitted after undergoing a drawn out process with a small bowel obstruction Medical Specialty Discharge Summary Sample Name Discharge Summary Respiratory Failure Transcription DISCHARGE DIAGNOSIS 1 Respiratory failure improved 2 Hypotension resolved 3 Anemia of chronic disease stable 4 Anasarca improving 5 Protein malnourishment improving 6 End stage liver disease HISTORY AND HOSPITAL COURSE The patient was admitted after undergoing a drawn out process with a small bowel obstruction His bowel function started to improve He was on TPN prior to coming to Hospital He has remained on TPN throughout his time here but his appetite and his p o intake have improved some The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine At one point we were unsuccessful at weaning him off the dopamine but after approximately 11 days he finally started to tolerate weaning parameters was successfully removed from dopamine and has maintained his blood pressure without difficulty The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left sided pneumonia This has been treated successfully with Zyvox and Levaquin and Diflucan He seems to be currently doing much better He is only using BiPAP in the evening As stated above he is eating better He had some evidence of redness and exquisite swelling around his genital and lower abdominal region This may be mainly dependent edema versus anasarca The patient has been diuresed aggressively over the last 4 to 5 days and this seems to have made some improvement in his swelling This morning the patient denies any acute distress He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation He will be discharged to Garden Court skilled nursing facility DISCHARGE MEDICATIONS INSTRUCTIONS He is going to be going with Protonix 40 mg daily metoclopramide 10 mg every 6 hours Zyvox 600 mg daily for 5 days Diflucan 150 mg p o daily for 3 days Bumex 2 mg p o daily Megace 400 mg p o b i d Ensure 1 can t i d with meals and MiraLax 17 gm p o daily The patient is going to require physical therapy to help with assistance in strength training He is also going to need respiratory care to work with his BiPAP His initial settings are at a rate of 20 pressure support of 12 PEEP of 6 FIO2 of 40 The patient will need a sleep study which the nursing home will be able to set up PHYSICAL EXAMINATION VITAL SIGNS On the day of discharge heart rate 99 respiratory rate 20 blood pressure 102 59 temperature 98 2 O2 sat 97 GENERAL A well developed white male who appears in no apparent distress HEENT Unremarkable CARDIOVASCULAR Positive S1 S2 without murmur rubs or gallops LUNGS Clear to auscultation bilaterally without wheezes or crackles ABDOMEN Positive for bowel sounds Soft nondistended He does have some generalized redness around his abdominal region and groin This does appear improved compared to presentation last week The swelling in this area also appears improved EXTREMITIES Show no clubbing or cyanosis He does have some lower extremity edema 2 distal pedal pulses are present NEUROLOGIC The patient is alert and oriented to person and place He is alert and aware of surroundings We have not had any difficulties with confusion here lately MUSCULOSKELETAL The patient moves all extremities without difficulty He is just weak in general LABORATORY DATA Lab work done today shows the following White count 4 2 hemoglobin 10 2 hematocrit 30 6 and platelet count 184 000 Electrolytes show sodium 139 potassium 4 1 chloride 98 CO2 26 glucose 79 BUN 56 and creatinine 1 4 Calcium 8 8 phosphorus is a little high at 5 5 magnesium 2 2 albumin 3 9 PLAN Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning Hopefully long term planning will be discharge home He has a history of end stage liver disease with cirrhosis which may make him a candidate for hospice upon discharge The family initially wanted to bring the patient home but he is too weak and requires too much assistance to adequately consider this option at this time Keywords discharge summary respiratory failure hypotension anemia anasarca end stage liver disease drawn out process bowel obstruction blood pressure dopamine discharge MEDICAL_TRANSCRIPTION,Description Patient with left renal cell carcinoma left renal cyst had robotic Assisted laparoscopic left renal cyst decortication and cystoscopy Medical Specialty Discharge Summary Sample Name Discharge Summary Nephrology Transcription ADMITTING DIAGNOSES Left renal cell carcinoma left renal cyst DISCHARGE DIAGNOSIS Left renal cell carcinoma left renal cyst SECONDARY DIAGNOSES 1 Chronic obstructive pulmonary disease 2 Coronary artery disease PROCEDURES Robotic Assisted laparoscopic left renal cyst decortication and cystoscopy HISTORY OF PRESENT ILLNESS Mr ABC is a 70 year old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts He has undergone MRI of the abdomen on June 18 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma Of note there are no other enhancing solid masses seen on this MRI After discussion of multiple management strategies with the patient including 1 Left partial nephrectomy 2 Left radical nephrectomy 3 Left renal cyst decortication The patient is likely to undergo the latter procedure HOSPITAL COURSE The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy Intraoperatively approximately four enlarged renal cysts and six smaller renal cysts were initially removed The contents were aspirated and careful dissection of the cyst wall was performed Multiple specimens of the cyst wall were sent for pathology Approximately one liter of cystic fluid was drained during the procedure The renal bed was inspected for hemostasis which appear to be adequate There were no complications with the procedure Single JP drain was left in place Additionally the patient underwent flexible cystoscopy which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra Furthermore no gross lesions were encountered in the bladder The patient left OR with transfer to the PACU and subsequently to the hospital floor The patient s postoperative course was relatively uneventful His diet and activity were gradually advanced without complication On postoperative day 2 he was passing flatus and has had bowel movements His Jackson Pratt drain was discontinued on postoperative day 3 that being the day of discharge His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly At the time of discharge he was afebrile His vital signs indicated hemodynamic stability and he had no evidence of infection The patient was instructed to follow up with Dr XYZ on 8 12 2008 at 1 50 p m and was given prescription for pain medications as well as laxative DISPOSITION To home DISCHARGE CONDITION Good MEDICATIONS Please see attached medication list INSTRUCTIONS The patient was instructed to contact Dr XYZ s office for fever greater than 101 5 intractable pain nausea vomiting or any other concerns FOLLOWUP The patient will follow up with Dr XYZ for a postoperative check on 08 12 2008 at 1 50 p m and he was made aware of this appointment Keywords discharge summary decortication cystoscopy pain nausea vomiting renal cyst decortication renal cell carcinoma robotic assisted renal cyst renal robotic laparoscopic nephrectomy cysts cell carcinoma discharge MEDICAL_TRANSCRIPTION,Description The patient is being discharged for continued hemodialysis and rehab Medical Specialty Discharge Summary Sample Name Discharge Summary Hemodialysis Transcription DISCHARGE DIAGNOSES 1 End stage renal disease on hemodialysis 2 History of T9 vertebral fracture 3 Diskitis 4 Thrombocytopenia 5 Congestive heart failure with ejection fraction of approximately 30 6 Diabetes type 2 7 Protein malnourishment 8 History of anemia HISTORY AND HOSPITAL COURSE The patient is a 77 year old white male who presented to Hospital of Bossier on April 14 2008 The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy which was the cause of need for continued hospitalization He also needed to continue with dialysis and he needed to improve his rehabilitation The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles He did have some bouts of issues with constipation on and off throughout his hospitalization but this seemed to come under control with more aggressive management The patient had remained afebrile He did also have a bout with some episodic confusion problems which appeared to be more of a sundowner type of a problem but this too cleared with his stay here at Promise On the day of discharge on May 9 2008 the patient was in good spirits was very clear and lucid He denied any complaints of pain He did have some trouble with sleep at night at times but I think this was mainly tied into the fact that he sleeps a lot during the day The patient has increased his appetite some and has been eating some His vital signs remain stable His blood pressure on discharge was 126 63 heart rate is 80 respiratory rate of 20 and temperature was 98 3 PPD was negative An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise The patient and his family understood our plan and agreed with it He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him He did not have any acute questions as to where he was going and what the next step of his care would be but we did discuss this at length prior to date of discharge Keywords discharge summary end stage renal disease thrombocytopenia anemia hospitalization hemodialysis and rehab hemodialysis MEDICAL_TRANSCRIPTION,Description Trauma ATV accident resulting in left open humerus fracture Medical Specialty Discharge Summary Sample Name Discharge Summary ATV Accident Transcription ADMITTING DIAGNOSIS Trauma ATV accident resulting in left open humerus fracture DISCHARGE DIAGNOSIS Trauma ATV accident resulting in left open humerus fracture SECONDARY DIAGNOSIS None HISTORY OF PRESENT ILLNESS For complete details please see dictated history and physical by Dr X dated July 23 2008 Briefly the patient is a 10 year old male who presented to the Hospital Emergency Department following an ATV accident He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters The patient denies any loss of consciousness He was not amnestic to the event He was taken by family members to the Iredell County Hospital where he was initially evaluated Due to the extent of his injuries he was immediately transferred to Hospital Emergency Department for further evaluation HOSPITAL COURSE Upon arrival in the Hospital Emergency Department he was noted to have an open left humerus fracture No other apparent injuries This was confirmed with radiographic imaging showing that the chest and pelvis x rays were negative for any acute injury and that the cervical spine x ray was negative for fracture malalignment The left upper extremity x ray did demonstrate an open left distal humerus fracture The orthopedic surgery team was then consulted and upon their evaluation the patient was taken emergently to the operating room for surgical repair of his left humerus fracture In the operating room the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture In the operating room his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures Throughout the duration of the procedure the patient had a palpable distal radial pulse The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture A wound VAC was then placed over the wound at the conclusion of the procedure The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring His diet was advanced and his pain was controlled with pain medication The day following his surgery the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C collar was removed at that point Once his C spine had been cleared and the absence of a closed head injury was confirmed The patient was then transferred from the Intensive Care Unit to the General Floor bed His clinical status continued to improve and on July 26 2008 he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound He again tolerated this procedure well on his return to the General Pediatrics Floor Throughout his stay there was concern for compartment syndrome due to the nature and extent of his injuries However frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity Moreover the patient had no complaints of paresthesia There was no demonstration of pallor or pain on passive motion There was good capillary refill to the digits of the left hand By the date of the discharge the patient was on a full pediatric select diet and was tolerating this well He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies He was afebrile and his vital signs were stable and once cleared by Orthopedics he was deemed appropriate for discharge PROCEDURES DURING THIS HOSPITALIZATION 1 Irrigation and debridement of open type 3 subcondylar left distal humerus fracture July 23 2008 2 Open reduction and internal fixation of the left supracondylar humerus fracture July 23 2008 3 Negative pressure wound dressing July 23 2008 4 Irrigation and debridement of left elbow fracture July 26 2008 5 CT of the brain without contrast July 24 2008 DISPOSITION Home with parents INVASIVE LINES None DISCHARGE INSTRUCTIONS The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities move furniture lift heavy objects or use his left upper extremity He was asked to followup with return appointment in one week to see Dr Y in Orthopedics Additionally he was told to call his pediatrician if he develops any fevers pain loss of sensation loss of pulse or discoloration of his fingers or paleness to his hand Keywords discharge summary humerus fracture trauma irrigation and debridement atv accident upper extremity humerus fracture orthopedic MEDICAL_TRANSCRIPTION,Description Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success Medical Specialty Discharge Summary Sample Name Discharge Summary Gastric Bypass Transcription ADMISSION DIAGNOSIS Morbid obesity BMI is 51 DISCHARGE DIAGNOSIS Morbid obesity BMI is 51 PROCEDURE Laparoscopic gastric bypass SERVICE Surgery CONSULT Anesthesia and pain HISTORY OF PRESENT ILLNESS Ms A is a 27 year old woman who suffered from morbid obesity for many years She has made multiple attempts at nonsurgical weight loss without success She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate She underwent her procedure HOSPITAL COURSE Ms A underwent her procedure She tolerated without difficulty She was admitted to the floor post procedure Her postoperative course has been unremarkable On postoperative day 1 she was hemodynamically stable afebrile normal labs and she was started on a clear liquid diet which she has tolerated without difficulty She has ambulated and had no complaints Today on postoperative day 2 the patient continues to do well Pain controlled with p o pain medicine ambulating without difficulty tolerating a liquid diet At this point it is felt that she is stable for discharge Her drain was discontinued DISCHARGE INSTRUCTIONS Liquid diet x1 week then advance to pureed and soft as tolerated No heavy lifting greater than 10 pounds x4 weeks The patient is instructed to not engage in any strenuous activity but maintain mobility No driving for 1 to 2 weeks She must be able to stop in an emergency and be off narcotic pain medicine She may shower She needs to keep her wounds clean and dry She needs to follow up in my office in 1 week for postoperative evaluation She is instructed to call for any problems of shortness of breath chest pain calf pain temperature greater than 101 5 any redness swelling or foul smelling drainage from her wounds intractable nausea vomiting and abdominal pain She is instructed just to resume her discharge medications DISCHARGE MEDICATIONS She was given a scripts for Lortab Elixir Flexeril ursodiol and Colace Keywords discharge summary laparoscopic gastric bypass gastric bypass morbid obesity liquid diet bmi discharge MEDICAL_TRANSCRIPTION,Description A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma Medical Specialty Discharge Summary Sample Name Discharge Summary Mesothelioma Transcription PREOPERATIVE DIAGNOSIS Right pleural mass POSTOPERATIVE DIAGNOSIS Mesothelioma PROCEDURES PERFORMED 1 Flexible bronchoscopy 2 Mediastinoscopy 3 Right thoracotomy 4 Parietal pleural biopsy CONSULTS Consults obtained during this hospitalization included 1 Radiation Oncology 2 Pulmonary Medicine 3 Medical Oncology 4 Cancer Center Team consult 5 Massage therapy consult HOSPITAL COURSE The patient s hospital course was unremarkable Her pain was well controlled with an epidural that was placed by Anesthesia At the time of discharge the patient was ambulatory She was discharged with home oxygen available She was discharged with albuterol nebulizer treatments treatments were to be q i d She was discharged with a prescription for Vicodin for pain control She is to follow up with Dr X in the office in one week with a chest x ray She is instructed not to lift push or pull anything greater than 10 pounds She is instructed not to drive until after she sees us in the office and is off her pain medications Keywords discharge summary flexible bronchoscopy mediastinoscopy right thoracotomy pleural biopsy pleural mass mesothelioma oncology MEDICAL_TRANSCRIPTION,Description Patient with fever of unknown origin Medical Specialty Discharge Summary Sample Name Discharge Summary 7 Transcription REASON FOR ADMISSION Fever of unknown origin HISTORY OF PRESENT ILLNESS The patient is a 39 year old woman with polymyositis dermatomyositis on methotrexate once a week The patient has also been on high dose prednisone for an urticarial rash The patient was admitted because of persistent high fevers without a clear cut source of infection She had been having temperatures of up to 103 for 8 10 days She had been seen at Alta View Emergency Department a week prior to admission A workup there including chest x ray blood cultures and a transthoracic echocardiogram had all remained nondiagnostic and were normal Her chest x ray on that occasion was normal After the patient was seen in the office on August 10 she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital Studies done at Cottonwood CT scan of the chest abdomen and pelvis Results CT chest showed mild bibasilar pleural based interstitial changes These were localized to mid and lower lung zones The process was not diffuse There was no ground glass change CT abdomen and pelvis was normal Infectious disease consultation was obtained Dr XYZ saw the patient He ordered serologies for CMV including a CMV blood PCR Next serologies for EBV Legionella Chlamydia Mycoplasma Coccidioides and cryptococcal antigen and a PPD The CMV serology came back positive for IgM The IgG was negative The CMV blood PCR was positive as well Other serologies and her PPD stayed negative Blood cultures stayed negative In view of the positive CMV PCR and the changes in her CAT scan the patient was taken for a bronchoscopy BAL and transbronchial biopsies were performed The transbronchial biopsies did not show any evidence of pneumocystis fungal infection AFB There was some nonspecific interstitial fibrosis which was minimal I spoke with the pathologist Dr XYZ and immunopathology was done to look for CMV The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection The patient was started on ganciclovir once her CMV serologies had come back positive No other antibiotic therapy was prescribed Next the patient s methotrexate was held A chest x ray prior to discharge showed some bibasilar disease showing interstitial infiltrates The patient was given ibuprofen and acetaminophen during her hospitalization and her fever resolved with these measures On the BAL fluid cell count the patient only had 5 WBCs and 5 RBCs on the differential It showed 43 neutrophils 45 lymphocytes Discussions were held with Dr XYZ Dr XYZ her rheumatologist and with pathology DISCHARGE DIAGNOSES 1 Disseminated CMV infection with possible CMV pneumonitis 2 Polymyositis on immunosuppressive therapy methotrexate and prednisone DISCHARGE MEDICATIONS 1 The patient is going to go on ganciclovir 275 mg IV q 12 h for approximately 3 weeks 2 Advair 100 50 1 puff b i d 3 Ibuprofen p r n and Tylenol p r n for fever and will continue her folic acid 4 The patient will not restart for methotrexate for now She is supposed to follow up with me on August 22 2007 at 1 45 p m She is also supposed to see Dr XYZ in 2 weeks and Dr XYZ in 2 3 weeks She also has an appointment to see an ophthalmologist in about 10 days time This was a prolonged discharge more than 30 minutes were spent on discharging this patient Keywords discharge summary fever of unknown origin blood cultures transbronchial biopsies infection cmv admission illness interstitial fever serologies chest nondiagnostic methotrexate MEDICAL_TRANSCRIPTION,Description Patient with complaint of symptomatic cholelithiasis Medical Specialty Discharge Summary Sample Name Discharge Summary Cholelithiasis Transcription ADMISSION DIAGNOSIS Symptomatic cholelithiasis DISCHARGE DIAGNOSIS Symptomatic cholelithiasis SERVICE Surgery CONSULTS None HISTORY OF PRESENT ILLNESS Ms ABC is a 27 year old woman who apparently presented with complaint of symptomatic cholelithiasis She was afebrile She was taken by Dr X to the operating room HOSPITAL COURSE The patient underwent a procedure She tolerated without difficulty She had her pain controlled with p o pain medicine She was afebrile She is tolerating liquid diet It was felt that the patient is stable for discharge She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs We will check a UA and urine culture prior to discharge I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over the counter for constipation and we will send her home with Percocet for pain Her labs were within normal limits She did have an elevated white blood cell count but I believe this is just leukemoid reaction but she is afebrile and if she does have UTI may also be related Her labs in terms of her bilirubin were within normal limits Her LFTs were slightly elevated I do believe this is related to the cautery used on the liver bed They were 51 and 83 for the AST and ALT respectively I feel that she looks good for discharge DISCHARGE INSTRUCTIONS Clear liquid diet x48 hours and she can return to her Medifast she may shower She needs to keep her wound clean and dry She is not to engage in any heavy lifting greater than 10 pounds x2 weeks No driving for 1 to 2 weeks She must be able to stop in an emergency and be off narcotic meds no strenuous activity but she needs to maintain mobility She can resume her medications per med rec sheets DISCHARGE MEDICATIONS As previously mentioned FOLLOWUP We will follow up on both urinalysis and cultures She is instructed to follow up with Dr X in 2 weeks She needs to call for any shortness of breath temperature greater than 101 5 chest pain intractable nausea vomiting and abdominal pain any redness swelling or foul smelling drainage from her wounds Keywords discharge summary medifast liquid diet symptomatic cholelithiasis symptomatic cholelithiasis discharge MEDICAL_TRANSCRIPTION,Description A white female with a history of fevers Medical Specialty Discharge Summary Sample Name Discharge Summary 8 Transcription DISCHARGE DIAGNOSES 1 Gram negative rod bacteremia final identification and susceptibilities still pending 2 History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade 3 History of urinary tract infections of pyelonephritis OPERATIONS PERFORMED Chest x ray July 24 2007 that was normal Transesophageal echocardiogram July 27 2007 that was normal No evidence of vegetations CT scan of the abdomen and pelvis July 27 2007 that revealed multiple small cysts in the liver the largest measuring 9 mm There were 2 3 additional tiny cysts in the right lobe The remainder of the CT scan was normal HISTORY OF PRESENT ILLNESS Briefly the patient is a 26 year old white female with a history of fevers For further details of the admission please see the previously dictated history and physical HOSPITAL COURSE Gram negative rod bacteremia The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever septicemia and Osler nodes on her fingers The patient had a transthoracic echocardiogram as an outpatient which was equivocal but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations The microbiology laboratory stated that the Gram negative rod appeared to be anaerobic thus raising the possibility of organisms like bacteroides The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade We did a CT scan of the abdomen and pelvis which only showed some benign appearing cysts in the liver There was nothing remarkable as far as her kidneys ureters or bladder were concerned I spoke with Dr XYZ of infectious diseases and Dr XYZ asked me to talk to the patient about any contact with animals given the fact that we have had a recent outbreak of tularemia here in Utah Much to my surprise the patient told me that she had multiple pet rats at home which she was constantly in contact with I ordered tularemia and leptospirosis serologies on the advice of Dr XYZ and as of the day after discharge the results of the microbiology still are not back yet The patient however appeared to be responding well to levofloxacin I gave her a 2 week course of 750 mg a day of levofloxacin and I have instructed her to follow up with Dr XYZ in the meantime Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return A thought of ours was to add doxycycline but again the patient clinically appeared to be responding to the levofloxacin In addition I told the patient that it would be my recommendation to get rid of the rats I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection I told her very clearly that she should indeed get rid of the animals The patient seemed reluctant to do so at first but I believe with some coercion from her family that she finally came to the realization that this was a recommendation worth following DISPOSITION DISCHARGE INSTRUCTIONS Activity is as tolerated Diet is as tolerated MEDICATIONS Levaquin 750 mg daily x14 days Followup is with Dr XYZ of infectious diseases I gave the patient the phone number to call on Monday for an appointment Additional followup is also with Dr XYZ her primary care physician Please note that 40 minutes was spent in the discharge Keywords discharge summary abdomen and pelvis gram negative rod congenital genitourinary genitourinary abnormalities transesophageal echocardiogram infectious diseases leptospirosis serologies gram negative ct scan identification infections levofloxacin additional discharge MEDICAL_TRANSCRIPTION,Description a pleasant 62 year old male with cerebral palsy Medical Specialty Discharge Summary Sample Name Discharge Summary Cerebral Palsy Transcription DISCHARGE DIAGNOSES 1 Bilateral lower extremity cellulitis secondary to bilateral tinea pedis 2 Prostatic hypertrophy with bladder outlet obstruction 3 Cerebral palsy DISCHARGE INSTRUCTIONS The patient would be discharged on his usual Valium 10 20 mg at bedtime for spasticity Flomax 0 4 mg daily cefazolin 500 mg q i d and Lotrimin cream between toes b i d for an additional two weeks He will be followed in the office HISTORY OF PRESENT ILLNESS This is a pleasant 62 year old male with cerebral palsy The patient was recently admitted to Hospital with lower extremity cellulitis This resolved however recurred in both legs Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis PAST MEDICAL FAMILY SOCIAL HISTORY As per the admission record REVIEW OF SYSTEMS As per the admission record PHYSICAL EXAMINATION As per the admission record LABORATORY STUDIES At the time of admission his white blood cell count was 8200 with a normal differential hemoglobin 13 6 hematocrit 40 6 with normal indices and platelet count was 250 000 Comprehensive metabolic profile was unremarkable except for a nonfasting blood sugar of 137 lactic acid was 0 8 Urine demonstrated 4 9 red blood cells per high powered field with 2 bacteria Blood culture and wound cultures were unremarkable Chest x ray was unremarkable HOSPITAL COURSE The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin On this regimen his lower extremity edema and erythema resolved quite rapidly Because of urinary frequency a bladder scan was done suggesting about 600 cc of residual urine A Foley catheter was inserted and was productive of approximately 500 cc of urine The patient was prescribed Flomax 0 4 mg daily 24 hours later the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours At the time of this dictation the patient was ambulating minimally however not sufficiently to resume independent living Keywords discharge summary bilateral lower extremity cellulitis cerebral palsy ambulating bilateral tinea pedis lower extremity cellulitis cerebral palsy discharge MEDICAL_TRANSCRIPTION,Description A white male veteran with multiple comorbidities who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital Medical Specialty Discharge Summary Sample Name Discharge Summary 6 Transcription DISCHARGE DATE MM DD YYYY HISTORY OF PRESENT ILLNESS Mr ABC is a 60 year old white male veteran with multiple comorbidities who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital He underwent a resection there He was to be admitted to the Day Hospital for cystectomy He was seen in Urology Clinic and Radiology Clinic on MM DD YYYY HOSPITAL COURSE Mr ABC presented to the Day Hospital in anticipation for Urology surgery On evaluation EKG echocardiogram was abnormal a Cardiology consult was obtained A cardiac adenosine stress MRI was then proceeded same was positive for inducible ischemia mild to moderate inferolateral subendocardial infarction with peri infarct ischemia In addition inducible ischemia seen in the inferior lateral septum Mr ABC underwent a left heart catheterization which revealed two vessel coronary artery disease The RCA proximal was 95 stenosed and the distal 80 stenosed The mid LAD was 85 stenosed and the distal LAD was 85 stenosed There was four Multi Link Vision bare metal stents placed to decrease all four lesions to 0 Following intervention Mr ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr XYZ Mr ABC had a noncomplicated post intervention hospital course He was stable for discharge home on MM DD YYYY with instructions to take Plavix daily for one month and Urology is aware of the same DISCHARGE EXAM VITAL SIGNS Temperature 97 4 heart rate 68 respirations 18 blood pressure 133 70 HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Obese soft nontender Lower abdomen tender when touched due to bladder cancer RIGHT GROIN Dry and intact no bruit no ecchymosis no hematoma Distal pulses are intact DISCHARGE LABS CBC White count 5 4 hemoglobin 10 3 hematocrit 30 platelet count 132 hemoglobin A1c 9 1 BMP Sodium 142 potassium 4 4 BUN 13 creatinine 1 1 glucose 211 Lipid profile Cholesterol 157 triglycerides 146 HDL 22 LDL 106 PROCEDURES 1 On MM DD YYYY cardiac MRI adenosine stress 2 On MM DD YYYY left heart catheterization coronary angiogram left ventriculogram coronary angioplasty with four Multi Link Vision bare metal stents two placed to the LAD in two placed to the RCA DISCHARGE INSTRUCTIONS Mr ABC is discharged home He should follow a low fat low salt low cholesterol and heart healthy diabetic diet He should follow post coronary artery intervention restrictions He should not lift greater than 10 pounds for seven days He should not drive for two days He should not immerse in water for two weeks Groin site care reviewed with patient prior to being discharged home He should check groin for bleeding edema and signs of infection Mr ABC is to see his primary care physician within one to two weeks return to Dr XYZ s clinic in four to six weeks appointment card to be mailed him He is to follow up with Urology in their clinic on MM DD YYYY at 10 o clock and then to scheduled CT scan at that time DISCHARGE DIAGNOSES 1 Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD 2 Bladder cancer 3 Diabetes 4 Dyslipidemia 5 Hypertension 6 Carotid artery stenosis status post right carotid endarterectomy in 2004 7 Multiple resections of the bladder tumor 8 Distant history of appendectomy 9 Distant history of ankle surgery Keywords discharge summary coronary artery disease heart catheterization artery disease bare metal metal stents artery intervention bladder cancer coronary artery veteran surgery cardiac inducible catheterization ischemia cancer urology stenosed bladder heart artery coronary MEDICAL_TRANSCRIPTION,Description Patient with increased shortness of breath of one day duration Medical Specialty Discharge Summary Sample Name Discharge Summary 3 Transcription DISCHARGE DIAGNOSES 1 Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure 2 Chronic atrial fibrillation with prior ablation done on Coumadin treatment 3 Mitral stenosis 4 Remote history of lung cancer with prior resection of the left upper lobe 5 Anxiety and depression HISTORY OF PRESENT ILLNESS Details are present in the dictated report BRIEF HOSPITAL COURSE The patient is a 71 year old lady who came in with increased shortness of breath of one day duration She denied history of chest pain or fevers or cough with purulent sputum at that time She was empirically treated with a course of antibiotics of Avelox for ten days She also received steroids prednisolone 60 mg and breathing treatments with albuterol Ipratropium and her bronchodilator therapy was also optimized with theophylline She continued to receive Coumadin for her chronic atrial fibrillation Her heart rate was controlled and was maintained in the 60s 70s On the third day of admission she developed worsening respiratory failure with fatigue and hence was required to be intubated and ventilated She was put on mechanical ventilation from 1 29 to 2 6 06 She was extubated on 2 6 and put on BI PAP The pressures were gradually increased from 10 and 5 to 15 of BI PAP and 5 of E PAP with FIO2 of 35 at the time of transfer to Kindred Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy DISCHARGE MEDICATIONS Prednisolone 60 mg orally once daily albuterol 2 5 mg nebulized every 4 hours Atrovent Respules to be nebulized every 6 hours Pulmicort 500 micrograms nebulized twice every 8 hours Coumadin 5 mg orally once daily magnesium oxide 200 mg orally once daily TRANSFER INSTRUCTIONS The patient is to be strictly kept on bi level PAP of 15 I PAP E PAP of 5 cm and FIO2 of 35 for most of the times during the day She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90 92 at meal times only and that is to be limited to 1 2 hours every meal On admission her potassium had risen slightly to 5 5 and hence her ACE inhibitor had to be discontinued We may restart it again at a later date once her blood pressure control is better if required Keywords discharge summary chronic obstructive pulmonary disease hypercapnic respiratory failure atrial fibrillation chronic atrial fibrillation increased shortness of breath shortness of breath increased shortness coumadin atrial MEDICAL_TRANSCRIPTION,Description The patient underwent a scalp skin biopsy with pathology specimen obtained At the time of discharge the patient had improved Medical Specialty Discharge Summary Sample Name Discharge Summary 17 Transcription FINAL DIAGNOSIS REASON FOR ADMISSION 1 Acute right lobar pneumonia 2 Hypoxemia and hypotension secondary to acute right lobar pneumonia 3 Electrolyte abnormality with hyponatremia and hypokalemia corrected 4 Elevated liver function tests etiology undetermined 5 The patient has a history of moderate to severe dementia Alzheimer s type 6 Anemia secondary to current illness and possible iron deficiency 7 Darkened mole on the scalp status post skin biopsy pending pathology report OPERATION AND PROCEDURE The patient underwent a scalp skin biopsy with pathology specimen obtained on 6 11 2009 Dr X performed the procedure thoracentesis on 6 12 2009 both diagnostic and therapeutic Dr Y s results pending DISPOSITION The patient discharged to long term acute facility under the care of Dr Z CONDITION ON DISCHARGE Clinically improved however requiring acute care CURRENT MEDICATIONS Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily HOSPITAL SUMMARY This is one of several admissions for this 68 year old female who over the initial 48 hours preceding admission had a complaint of low grade fever confusion dizziness and a nonproductive cough Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x ray revealed evolving right lobar infiltrate She was started on antibiotics Infectious Disease was consulted She was initially begun on vancomycin Blood sputum and urine cultures were obtained the results of which were negative for infection She was switched to IV Levaquin and received IV Flagyl for possible C diff colitis as well as possible cholecystitis During her hospital stay she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning Her systolic blood pressure was 60 70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour She was seen in consultation by Dr Y who monitored her fluid and pulmonary treatment Due to some elevated liver function tests she was seen in consultation by Dr X An ultrasound was negative however she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder A HIDA scan was performed and revealed no evidence of gallbladder dysfunction Liver functions were monitored throughout her stay and while elevated did reduce to approximately 1 5 times normal value She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics Over her week stay the patient was moderately hypoxemic with room air pulse oximetry of 90 She was placed on incentive spirometry and over the succeeding days she did have improved pulmonary function LABORATORY TESTS Initially revealed a white count of 13 000 however approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay Blood cultures were negative at 5 days Sputum culture was negative Urine culture was negative and thoracentesis culture negative at 24 hours The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support as no evidence of GI bleeding was obtained Her most recent blood work on 6 14 2009 revealed a white count of 7000 and hemoglobin of 12 1 with a hematocrit of 36 8 Her PT and PTT were normal Occult blood studies were negative for occult blood Hepatitis B antigen was negative Hepatitis A antibody IgM was negative Hepatitis B core IgM negative and hepatitis C core antibody was negative At the time of discharge on 6 14 2009 sodium was 135 potassium was 3 7 calcium was 8 0 her ALT was 109 AST was 70 direct bilirubin was 0 2 LDH was 219 serum iron was 7 total iron unbound 183 and ferritin level was 267 At the time of discharge the patient had improved She complained of some back discomfort and lumbosacral back x ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr Z Keywords discharge summary pneumonia hypoxemia hypotension electrolyte abnormality anemia scalp skin biopsy liver function tests lobar pneumonia infectious disease skin biopsy white count cultures MEDICAL_TRANSCRIPTION,Description A female with the past medical history of Ewing sarcoma iron deficiency anemia hypertension and obesity Medical Specialty Discharge Summary Sample Name Discharge Summary 5 Transcription DATE OF ADMISSION MM DD YYYY DATE OF DISCHARGE MM DD YYYY REFERRING PHYSICIAN AB CD M D ATTENDING PHYSICIAN AT DISCHARGE X Y M D ADMITTING DIAGNOSES 1 Ewing sarcoma 2 Anemia 3 Hypertension 4 Hyperkalemia PROCEDURES DURING HOSPITALIZATION Cycle seven Ifosfamide mesna and VP 16 chemotherapy HISTORY OF PRESENT ILLNESS Ms XXX is a pleasant 37 year old African American female with the past medical history of Ewing sarcoma iron deficiency anemia hypertension and obesity She presented initially with a left frontal orbital swelling to Dr XYZ on MM DD YYYY A biopsy revealed small round cells and repeat biopsy on MM DD YYYY also showed round cells consistent with Ewing sarcoma genetic analysis indicated a T1122 translocation MRI on MM DD YYYY showed a 4 cm soft tissue mass without bony destruction CT showed similar result The patient received her first cycle of chemotherapy on MM DD YYYY On MM DD YYYY she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy She had her last course of chemotherapy on MM DD YYYY followed by radiation treatment to the ethmoid sinuses on MM DD YYYY HOSPITAL COURSE 1 Ewing sarcoma she presented for cycle seven of VP 16 ifosfamide and mesna infusions which she tolerated well throughout the admission 2 She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission Keywords discharge summary iron deficiency anemia hypertension and obesity iron deficiency urine anemia hypertension chemotherapy discharge ewing sarcoma MEDICAL_TRANSCRIPTION,Description Gastroenteritis and autism She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved Medical Specialty Discharge Summary Sample Name Discharge Summary 15 Transcription FINAL DIAGNOSES 1 Gastroenteritis 2 Autism DIET ON DISCHARGE Regular for age MEDICATIONS ON DISCHARGE Adderall and clonidine for attention deficit hyperactivity disorder ACTIVITY ON DISCHARGE As tolerated DISPOSITION ON DISCHARGE Follow up with Dr X in ABC Office in 1 to 2 weeks HISTORY OF PRESENT ILLNESS This 10 and 4 12 year old Caucasian female has autism and is enrolled at ABC School and she takes Adderall and clonidine for her hyperactivity She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved She developed vomiting 3 days prior to admission but did not have diarrhea She voided on the day of admission When she presented to the office her weight was 124 pounds which was approximately 10 pounds below previous weights and even had a weight of 151 5 pounds 05 30 2007 and weight of 137 5 pounds 09 11 2007 with mother giving no good explanation as to why she had lost all this weight She was admitted because of the persistent vomiting but there was concern about the weight loss Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder LABORATORY DATA Laboratory data included sedimentation rate of 12 magnesium level of 2 2 TSH of 2 63 with normal being 0 34 to 5 60 free T4 of 1 68 with normal being 0 58 to 1 64 Chest x ray and abdominal films were unremarkable Hemoglobin 14 5 hematocrit 43 5 platelet count 400 000 white blood count 11 800 Urinalysis was negative for ketones Specific gravity 1 023 and negative for protein Sodium 137 potassium 3 4 chloride 103 CO2 20 BUN 21 creatinine 0 9 and anion gap 14 glucose 90 total protein 8 1 albumin 4 5 calcium 8 8 bilirubin 1 5 AST 26 ALT 16 alkaline phosphatase 118 Thyroid peroxidase antibody studies are pending HOSPITAL COURSE The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated On the second hospital day mother was comfortable taking her to home Mother did not have a good explanation for the weight loss In the hospital her weight was 124 pounds her height 58 inches temperature 98 0 degree F pulse 123 respirations 18 blood pressure 148 94 Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission She seem quite happy and in no distress at the time of discharge We will follow up in the office and try to further evaluate her for the unexplained weight loss She has been taking the Adderall for at least a year and the mother does not think the Adderall is the cause of the weight loss The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient Keywords discharge summary gastroenteritis autism constipation hyperactivity blood pressure weight loss adderall MEDICAL_TRANSCRIPTION,Description Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis Medical Specialty Discharge Summary Sample Name Discharge Summary 11 Transcription ADMISSION DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus and hypertension DISCHARGE DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis PROCEDURE Laparoscopic cholecystectomy SERVICE Surgery HISTORY OF PRESENT ILLNESS Ms ABC is a 57 year old woman She suffers from morbid obesity She also has diabetes and obstructive sleep apnea She was evaluated in the Bariatric Surgical Center for placement of a band During her workup she was noted to have evidence of cholelithiasis It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band The patient was scheduled to undergo her procedure on 12 31 09 however at blood glucose check the patient was noted to be hyperglycemic her sugar was 438 She was admitted to the hospital for treatment of her hyperglycemia HOSPITAL COURSE Ms ABC was admitted to the hospital She was seen by Dr A He put her on an insulin drip Her sugars slowly did come down to normal down to between 115 and 134 On the next day she was then taken to the operating room where she underwent her laparoscopic cholecystectomy She was noted to be a difficult intubation for the procedure There were some indications of chronic cholecystitis a little bit of edema mild edema and adhesions of omentum around the gallbladder She underwent the procedure She tolerated without difficulty She was recovered in the Postoperative Care Unit and then returned to the floor Her blood sugar postprocedure was noted to be 233 She was started back on a sliding scale insulin She continued to do well and was felt to be stable for discharge following the procedure DISCHARGE INSTRUCTIONS To return to the Medifast diet To continue with her blood glucose She needs to follow up with Dr B and she will see me next week on Friday We will determine if we will proceed with her lap band at that time She may shower She needs to keep her wounds clean and dry No heavy lifting No driving on narcotic pain medicines She needs to continue with her CPAP machine and continue to monitor her sugars Keywords discharge summary medifast hyperglycemia laparoscopic cholecystectomy medifast diet cholecystitis cholelithiasis diabetes mellitus hypertension morbid obesity obstructive sleep apnea sleep apnea diabetes MEDICAL_TRANSCRIPTION,Description Cardiac arrest severe congestive heart failure acute on chronic respiratory failure osteoporosis and depression Medical Specialty Discharge Summary Sample Name Death Summary 2 Transcription FINAL DIAGNOSES 1 Cardiac arrest 2 Severe congestive heart failure 3 Acute on chronic respiratory failure 4 Osteoporosis 5 Depression HISTORY OF PRESENT ILLNESS This 92 year old lady with history of depression and chronic low back pain osteoporosis and congestive heart failure was diagnosed having pneumonia approximately for at least 10 days prior to admission In the ER she was given oral antibiotics She also saw me few days before admission coming for a followup She was doing fairly well She was thought to have congestive heart failure and she was advised to continue with her diuretics For the last few days the patient started to have anorexia she did not eat well and she did not drink well Her family could not take care of her So she was brought to the emergency room where she was found to have rapid heart rate with a sinus tachycardia around 112 to 130s The ________ was found to be dry She was given 1 L of IV fluids and she was subsequently admitted in the hospital for further management COURSE IN THE HOSPITAL The patient stayed in the telemetry The patient had significant shortness of breath secondary to congestive heart failure with bilateral basilar crackles She was continued on IV antibiotics and general IV hydration was started initially because of low blood pressure and low perfusion status On subsequently improved and stopped and Lasix was started Dr X cardiologist was also placed The patient s family wanted her to be a DNR and DNI They were allowing us to treat her aggressively medically for pneumonia and congestive heart failure However the patient became extremely weak mostly unresponsive At this time the patient s family wanted a Hospice consult which was requested By the time the Hospice could evaluate her the patient s condition got deteriorated she went into more bradycardiac and hypertension and subsequently expired Please see the hospital notes for complete details Keywords discharge summary bradycardiac hypertension hospice congestive heart failure cardiac arrest respiratory failure MEDICAL_TRANSCRIPTION,Description The patient is a 60 year old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea nausea inability to eat Medical Specialty Discharge Summary Sample Name Discharge Summary 14 Transcription HISTORY OF PRESENT ILLNESS The patient is a 60 year old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea nausea inability to eat She had an EGD and colonoscopy with Dr ABC a few days prior to this admission Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis Biopsies were done The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg PAST MEDICAL HISTORY Extensive and well documented in prior charts PHYSICAL EXAMINATION Abdomen was diffusely tender Lungs clear Blood pressure 129 69 on admission At the time of admission she had just a trace of bilateral lower edema LABORATORY STUDIES White count 6 7 hemoglobin 13 hematocrit 39 3 Potassium of 3 2 on 08 15 2007 HOSPITAL COURSE Dr ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema This was done and did not really show what the cecum on the barium enema There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon She did have some enemas She had persistent nausea headache neck pain throughout this hospitalization Finally she did improve enough to the point where she could be discharged home DISCHARGE DIAGNOSIS Nausea and abdominal pain of uncertain etiology SECONDARY DIAGNOSIS Migraine headache COMPLICATIONS None DISCHARGE CONDITION Guarded DISCHARGE PLAN Follow up with me in the office in 5 to 7 days to resume all pre admission medications Diet and activity as tolerated Keywords discharge summary diarrhea nausea inability to eat egd colonoscopy biopsies barium enema cecum barium admission MEDICAL_TRANSCRIPTION,Description Death summary of patient with advanced non small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis Medical Specialty Discharge Summary Sample Name Death Summary 1 Transcription DISCHARGE DIAGNOSES 1 Advanced non small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis 2 Respiratory failure secondary to above 3 Likely postobstructive pneumonia 4 Gastrointestinal bleed 5 Thrombocytopenia 6 Acute renal failure 7 Hyponatremia 8 Hypercalcemia likely secondary to paraneoplastic syndrome from the non small cell lung CA possible metastases to the bones 9 Leukemoid reaction likely secondary to malignancy 10 Elevated liver function tests HOSPITAL COURSE This is a 53 year old African American male patient of Dr X who was admitted through the emergency room He has been having some right hip pain and cough The patient had a CT scan of the chest which revealed a left pleural effusion extensive mediastinal mass left hilar adenopathy causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein and the multiple nodules on the right side of his chest These were all consistent with metastatic disease He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion The patient had severe shortness of breath chest pain a left sided chest tube was inserted and pleural effusion was positive for malignant cells The history of right hip pain could be secondary to metastatic disease The patient underwent bronchoscopy which is positive for non small cell lung CA The patient was seen by various consultants The patient underwent respiratory failure requiring intubation mechanical ventilatory support He was extubated but had to be re intubated because of respiratory failure Had a long discussion with the patient s wife and other family members The patient was seen by Dr Y The patient was not in a condition to undergo any kind of chemotherapy being on the ventilator The patient progressively got deteriorated The patient s family requested for DNR withdrawal of the life support The patient was extubated and he was pronounced expired on 08 21 08 at 01 40 hours I appreciate all consultants input Keywords discharge summary dnr pronounced expired extubated death summary lung carcinoma pleural effusion MEDICAL_TRANSCRIPTION,Description Upper respiratory illness with apnea possible pertussis a one plus month old female with respiratory symptoms for approximately a week prior to admission This involved cough post tussive emesis and questionable fever Medical Specialty Discharge Summary Sample Name Discharge Summary 16 Transcription ADMISSION DIAGNOSIS Upper respiratory illness with apnea possible pertussis DISCHARGE DIAGNOSIS Upper respiratory illness with apnea possible pertussis COMPLICATIONS None OPERATIONS None BRIEF HISTORY AND PHYSICAL This is a one plus month old female with respiratory symptoms for approximately a week prior to admission This involved cough post tussive emesis questionable fever but only 99 7 Their usual doctor prescribed amoxicillin over the phone The coughing persisted and worsened She went to the ER where sats were normal at baseline but dropped into the 80s with coughing spells They did witness some apnea They gave some Rocephin did some labs and the patient was transferred to hospital PHYSICAL EXAMINATION On admission GENERAL Well developed well nourished baby in no apparent distress HEENT There was some nasal discharge Remainder of the HEENT was normal LUNG Had few rhonchi No retractions No significant coughing or apnea during the admission physical ABDOMEN Benign EXTREMITIES Were without any cyanosis SIGNIFICANT LABS AND X RAYS She had a CBC done Garberville which showed a white count of 12 4 with a differential of 10 segs 82 lymphs 8 monos hemoglobin of 15 hematocrit 42 platelets 296 000 and a normal BMP An x ray was done and I do not have an official interpretation but to the admitting physician Dr X it showed no significant infiltrate Well at hospital she had a rapid influenza swab done which was negative She had a rapid RSV done which is still not in the chart but I believe I was told that it was negative She also had a pertussis PCR swab done and a pertussis culture done neither of which has result in the chart I do know that the pertussis culture proved to be negative CONSULTATION Public Health Department was notified of a case of suspected pertussis HOSPITAL COURSE The baby was afebrile Required no oxygen in the hospital Actually fed reasonably well Did have one episode of coughing with slight emesis Appeared basically quite well between episodes Had no apnea witnessed and after overnight observation the parents were anxious to go home The patient was started on Zithromax in the hospital CONDITION AND TREATMENT The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week INSTRUCTIONS TO PATIENT Include usual diet and to follow up within a week but certainly sooner if the coughing is worse and there is cyanosis or apnea again Keywords discharge summary emesis cough upper respiratory illness respiratory illness apnea pertussis MEDICAL_TRANSCRIPTION,Description Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux Medical Specialty Discharge Summary Sample Name Discharge Summary 10 Transcription ADMITTING DIAGNOSES Hiatal hernia gastroesophageal reflux disease reflux DISCHARGE DIAGNOSES Hiatal hernia gastroesophageal reflux disease reflux SECONDARY DIAGNOSIS Postoperative ileus PROCEDURES DONE Hiatal hernia repair and Nissen fundoplication revision BRIEF HISTORY The patient is an 18 year old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux Approximately one year ago he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia Over the past year this has caused him an increasing number of problems including chest pain when he eats and shortness of breath after large meals He is also having reflux symptoms again He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication HOSPITAL COURSE Mr A was admitted to the adolescent floor by Brenner Children s Hospital after his procedure He was stable at that time He did complain of some nausea However he did not have any vomiting at that time He had an NG tube in and was n p o He also had a PCA for pain management as well as Toradol On postoperative day 1 he complained of not being able to urinate so a Foley catheter was placed Over the next several days his hospital course proceeded as follows He continued to complain of some nausea however he did not ever have any vomiting Eventually the Foley catheter was discontinued and he had excellent urine output without any complications He ambulated frequently He remained n p o for three days He also had the NG tube in during that time On postoperative day 4 he began to have some flatus and the NG tube was discontinued He was advanced to a liquid diet and tolerated this without any complications At this time he was still using the PCA for pain control However he was using it much less frequently than on days 1 and 2 postoperatively After tolerating the full liquid diet without any complications he was advanced to a soft diet and his pain medications were transitioned to p o medications rather than the PCA The PCA was discontinued He tolerated the soft diet without any complications and continued to have flatus frequently On postoperative day 6 it was determined that he was stable for discharge to home as he was taking p o without any complications His pain was well controlled with p o pain medications He was passing gas frequently had excellent urine output and was ambulating frequently without any issues DISCHARGE CONDITION Stable DISPOSITION Discharged to home DISCHARGE INSTRUCTIONS The patient was discharged to home with instructions for maintaining a soft diet It was also recommended that he does not drink any soda postoperatively He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting He will be able to attend school when it starts in a few weeks However he is not going to be able to play football in the near future He was given prescription for pain medication upon discharge He is instructed to contact Pediatric Surgery if he has any fevers any nausea and vomiting any chest pain any constipation or any other concerns Keywords discharge summary MEDICAL_TRANSCRIPTION,Description Cerebrovascular accident CVA with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule Acute bronchitis with reactive airway disease Medical Specialty Discharge Summary Sample Name CVA Discharge Summary Transcription DIAGNOSES ON ADMISSION 1 Cerebrovascular accident CVA with right arm weakness 2 Bronchitis 3 Atherosclerotic cardiovascular disease 4 Hyperlipidemia 5 Thrombocytopenia DIAGNOSES ON DISCHARGE 1 Cerebrovascular accident with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule 3 Acute bronchitis with reactive airway disease 4 Thrombocytopenia most likely due to old coronary infarct anterior aspect of the right external capsule 5 Atherosclerotic cardiovascular disease 6 Hyperlipidemia HOSPITAL COURSE The patient was admitted to the emergency room Plavix was started in addition to baby aspirin He was kept on oral Zithromax for his cough He was given Xopenex treatment because of his respiratory distress Carotid ultrasound was reviewed and revealed a 50 to 69 obstruction of left internal carotid Dr X saw him in consultation and recommended CT angiogram This showed no significant obstructive lesion other than what was known on the ultrasound Head MRI was done and revealed the above findings The patient was begun on PT and improved By discharge he had much improved strength in his right arm He had no further progressions His cough improved with oral Zithromax and nebulizer treatments His platelets also improved as well By discharge his platelets was up to 107 000 His H H was stable at 41 7 and 14 6 and his white count was 4300 with a normal differential Chest x ray revealed a mild elevated right hemidiaphragm but no infiltrate Last chemistry panel on December 5 2003 sodium 137 potassium 4 0 chloride 106 CO2 23 glucose 88 BUN 17 creatinine 0 7 calcium was 9 1 PT INR on admission was 1 03 PTT 34 7 At the time of discharge the patient s cough was much improved His right arm weakness has much improved His lung examination has just occasional rhonchi He was changed to a metered dose inhaler with albuterol He is being discharged home An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57 moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation He will follow up in my office in 1 week He is to start PT and OT as an outpatient He is to avoid driving his car He is to notify if further symptoms He has 2 more doses of Zithromax at home he will complete His prognosis is good Keywords discharge summary subacute infarct atherosclerotic cardiovascular disease cerebrovascular accident coronary infarct external capsule cva cerebrovascular mri bronchitis cardiovascular xopenex atherosclerotic accident MEDICAL_TRANSCRIPTION,Description Death summary of an 80 year old patient with a history of COPD Medical Specialty Discharge Summary Sample Name Death Summary Transcription CAUSE OF DEATH 1 Acute respiratory failure 2 Chronic obstructive pulmonary disease exacerbation SECONDARY DIAGNOSES 1 Acute respiratory failure probably worsened by aspiration 2 Acute on chronic renal failure 3 Non Q wave myocardial infarction 4 Bilateral lung masses 5 Occlusive carotid disease 6 Hypertension 7 Peripheral vascular disease HOSPITAL COURSE This 80 year old patient with a history of COPD had had recurrent admissions over the past few months The patient was admitted again on 12 15 08 after he had been discharged the previous day Came in with acute on chronic respiratory failure with CO2 of 57 The patient was in rapid atrial fibrillation RVR with a rapid ventricular response of 160 beats per minute The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation The patient s heart rate was controlled with IV Cardizem Troponin was consistent with non Q wave MI The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease Echocardiogram showed normal ejection fraction normal left and right side but stage 3 restrictive physiology There was also prosthetic aortic valve The patient was admitted to Intensive Care Unit and was intubated Pulmonary was managed by Critical Care Dr X The patient was successfully extubated Was tapered from IV steroids and put on p o steroids The patient s renal function has stabilized with a creatinine of between 2 1 and 2 3 There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient s renal status Wife decided catheterization should be canceled and the patient managed conservatively The patient was transferred to the telemetry floor While in telemetry floor the patient s renal function started deteriorating went up from 2 08 to 2 67 in two days The patient had nausea and vomiting Was unable to tolerate p o Was put on cautious hydration The patient went into acute respiratory distress Intubation showed the patient had aspirated He was in acute respiratory failure with bronchospasms and exacerbation of COPD X ray of chest did not show any infiltrate but showed dilatation of the stomach The patient was transferred to the Intensive Care Unit because of acute respiratory failure was intubated by Critical Care Dr X The patient was put on the vent Overnight the patient s condition did not improve Continued to be severely hypoxic The patient expired on the morning of 12 24 08 from acute respiratory failure Keywords discharge summary myocardial infarction intensive care unit acute respiratory failure death summary atrial fibrillation renal function telemetry floor respiratory failure death chronic exacerbation infarction respiratory MEDICAL_TRANSCRIPTION,Description Cognitive linguistic impairment secondary to stroke The patient was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits Medical Specialty Discharge Summary Sample Name Cognitive Linguistic Impairment Discharge Transcription DIAGNOSIS Cognitive linguistic impairment secondary to stroke NUMBER OF SESSIONS COMPLETED 5 HOSPITAL COURSE The patient is a 73 year old female who was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits Based on the initial evaluation completed 12 29 08 the patient had mild difficulty with generative naming and auditory comprehension and recall The patient s skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities At this time the patient has accomplished all 5 of her short term therapy goals She is able to complete functional mass tasks with 100 accuracy independently She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently She is able to state 15 items in a broad category within a minute and a half independently The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100 accuracy independently The patient also met her long term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home The patient is no longer in need of skilled speech therapy and is discharged from my services She did quite well in therapy and also agreed with this discharge Keywords discharge summary stroke linguistic deficits speech therapy skilled speech therapy linguistic impairment cognitive linguistic cognitive linguistic MEDICAL_TRANSCRIPTION,Description Patient had some cold symptoms was treated as bronchitis with antibiotics Medical Specialty Discharge Summary Sample Name Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Acute respiratory failure resolved 2 Severe bronchitis leading to acute respiratory failure improving 3 Acute on chronic renal failure improved 4 Severe hypertension improved 5 Diastolic dysfunction X ray on discharge did not show any congestion and pro BNP is normal SECONDARY DIAGNOSES 1 Hyperlipidemia 2 Recent evaluation and treatment including cardiac catheterization which did not show any coronary artery disease 3 Remote history of carcinoma of the breast 4 Remote history of right nephrectomy 5 Allergic rhinitis HOSPITAL COURSE This 83 year old patient had some cold symptoms was treated as bronchitis with antibiotics Not long after the patient returned from Mexico the patient started having progressive shortness of breath came to the emergency room with severe bilateral wheezing and crepitations X rays however did not show any congestion or infiltrates and pro BNP was within normal limits The patient however was hypoxic and required 4L nasal cannula She was admitted to the Intensive Care Unit The patient improved remarkably over the night on IV steroids and empirical IV Lasix Initial swab was positive for MRSA colonization Discussed with infectious disease Dr X and it was decided no treatment was required for de colonization The patient s breathing has improved There is no wheezing or crepitations and O2 saturation is 91 on room air The patient is yet to go for exercise oximetry Her main complaint is nasal congestion and she is now on steroid nasal spray The patient was seen by Cardiology Dr Z who advised continuation of beta blockers for diastolic dysfunction The patient has been weaned off IV steroids and is currently on oral steroids which she will be on for seven days DISPOSITION The patient has been discharged home DISCHARGE MEDICATIONS 1 Metoprolol 25 mg p o b i d 2 Simvastatin 20 mg p o daily NEW MEDICATIONS 1 Prednisone 20 mg p o daily for seven days 2 Flonase nasal spray daily for 30 days Results for oximetry pending to evaluate the patient for need for home oxygen FOLLOW UP The patient will follow up with Pulmonology Dr Y in one week s time and with cardiologist Dr X in two to three weeks time Keywords discharge summary acute respiratory failure bronchitis acute on chronic renal failure severe hypertension diastolic dysfunction cold symptoms iv steroids nasal spray nasal steroids MEDICAL_TRANSCRIPTION,Description Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress Primary low transverse cesarean section Medical Specialty Discharge Summary Sample Name Cholestasis Of Pregnancy Transcription FINAL DIAGNOSES Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress PROCEDURE Included primary low transverse cesarean section SUMMARY This 32 year old gravida 2 was induced for cholestasis of pregnancy at 38 1 2 weeks The patient underwent a 2 day induction On the second day the patient continued to progress all the way to the point of 9 5 cm at which point she failed to progress During the hour or two of evaluation at 9 5 cm the patient was also noted to have some fetal tachycardia and an occasional late deceleration Secondary to these factors the patient was brought to the operative suite for primary low transverse cesarean section which she underwent without significant complication There was a slightly enlarged blood loss at approximately 1200 mL and postoperatively the patient was noted to have a very mild tachycardia coupled with 100 3 degrees Fahrenheit temperature right at delivery It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay The patient received 72 hours of antibiotics with there never being a temperature above 100 3 degrees Fahrenheit The maternal tachycardia resolved within a day The patient did well throughout the 3 day stay progressing to full diet regular bowel movements normal urination patterns The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20 It should be noted however that this was actually an expected result with the initial hematocrit of 32 preoperatively Therefore there was anemia but not an unexplained anemia PHYSICAL EXAMINATION ON DISCHARGE Includes the stable vital signs afebrile state An alert and oriented patient who is desirous at discharge Full range of motion all extremities fully ambulatory Pulse is regular and strong Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus The incision is beautiful and soft and nontender There is scant lochia and there is minimal edema LABORATORY STUDIES Include hematocrit of 27 and the last liver function tests was within normal limits 48 hours prior to discharge FOLLOWUP For the patient includes pelvic rest regular diet Follow up with me in 1 to 2 weeks Motrin 800 mg p o q 8h p r n cramps Tylenol No 3 one p o q 4h p r n pain prenatal vitamin one p o daily and topical triple antibiotic to incision b i d to q i d Keywords discharge summary delivered pregnancy fetal intolerance induction pelvic rest low transverse cesarean section cholestasis of pregnancy cesarean section pregnancy fetal tachycardia cholestasis MEDICAL_TRANSCRIPTION,Description Cholecystitis with choledocholithiasis Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction Medical Specialty Discharge Summary Sample Name Cholecystitis Discharge Summary Transcription REASON FOR ADMISSION Cholecystitis with choledocholithiasis DISCHARGE DIAGNOSES Cholecystitis choledocholithiasis ADDITIONAL DIAGNOSES 1 Status post roux en y gastric bypass converted to an open procedure in 01 07 2 Laparoscopic paraventral hernia in 11 07 3 History of sleep apnea with reversal after 100 pound weight loss 4 Morbid obesity with bmi of 39 4 PRINCIPAL PROCEDURE Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction HOSPITAL COURSE The patient is a 33 year old female admitted with elevated bilirubin and probable common bile duct stone She was admitted through the emergency room with abdominal pain elevated bilirubin and gallstones on ultrasound with a dilated common bile duct She subsequently went for a HIDA scan to rule out cholecystitis Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage She was taken to the operating room that night for laparoscopic cholecystectomy We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone The patient had undergone a Roux en Y gastric bypass but could not receive an ERCP and stone extraction therefore common bile duct exploration was performed and a stone was extracted This necessitated conversion to an open operation She was transferred to the medical surgical unit postoperatively She had a significant amount of incisional pain following morning but no nausea A Jackson Pratt drain which was left in place in two places showed serosanguineous fluid White blood cell count was down to 7500 and bilirubin decreased to 2 1 Next morning she was started on a liquid diet Foley catheter was discontinued There was no evidence of bile leak from the drains She was advanced to a regular diet on postoperative day 3 which was 12 09 07 The following morning she was tolerating regular diet Her bowels had begun to function and she was afebrile with her pain control with oral pain medications Jackson Pratt drain was discontinued from the wound The remaining Jackson Pratt drain was left adjacent to her cystic duct Following morning her laboratory studies were better Her bilirubin was down to normal and white blood cell count was normal with an H H of 9 and 26 3 Jackson Pratt drain was discontinued and she was discharged home Followup was in 3 days for staple removal She was given iron 325 mg p o t i d and Lortab elixir 15 cc p o q 4 h p r n for pain Keywords discharge summary laparoscopy common bile duct exploration laparoscopic cholecystectomy bile duct choledocholithiasis cholecystectomy cholecystitis laparoscopic hernia MEDICAL_TRANSCRIPTION,Description A 67 year old male with COPD and history of bronchospasm who presents with a 3 day history of increased cough respiratory secretions wheezings and shortness of breath Medical Specialty Discharge Summary Sample Name COPD Discharge Summary Transcription HISTORY OF PRESENT ILLNESS A 67 year old male with COPD and history of bronchospasm who presents with a 3 day history of increased cough respiratory secretions wheezings and shortness of breath He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis superimposed upon longstanding COPD Unfortunately over the past few months he has returned to pipe smoking At the time of admission he denied fever diaphoresis nausea chest pain or other systemic symptoms PAST MEDICAL HISTORY Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy COPD as described above history of hypertension and history of elevated cholesterol PHYSICAL EXAMINATION Heart tones regular with an easily audible mechanical click Breath sounds are greatly diminished with rales and rhonchi over all lung fields LABORATORY STUDIES Sodium 139 potassium 4 5 BUN 42 and creatinine 1 7 Hemoglobin 10 7 and hematocrit 31 7 HOSPITAL COURSE He was started on intravenous antibiotics vigorous respiratory therapy intravenous Solu Medrol The patient improved on this regimen Chest x ray did not show any CHF The cortisone was tapered The patient s oxygenation improved and he was able to be discharged home DISCHARGE DIAGNOSES Chronic obstructive pulmonary disease and acute asthmatic bronchitis COMPLICATIONS None DISCHARGE CONDITION Guarded DISCHARGE PLAN Prednisone 20 mg 3 times a day for 2 days 2 times a day for 5 days and then one daily Keflex 500 mg 3 times a day and to resume his other preadmission medication can be given a pneumococcal vaccination before discharge To follow up with me in the office in 4 5 days Keywords discharge summary increased cough respiratory secretions wheezings shortness of breath acute asthmatic bronchitis asthmatic bronchitis respiratory breath asthmatic copd MEDICAL_TRANSCRIPTION,Description Hysteroscopy dilatation and curettage D C and myomectomy Severe menometrorrhagia unresponsive to medical therapy severe anemia and fibroid uterus Medical Specialty Discharge Summary Sample Name D C Discharge Summary Transcription ADMISSION DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Fibroid uterus DISCHARGE DIAGNOSES 1 Severe menometrorrhagia unresponsive to medical therapy 2 Severe anemia 3 Fibroid uterus OPERATIONS PERFORMED 1 Hysteroscopy 2 Dilatation and curettage D C 3 Myomectomy COMPLICATIONS Large endometrial cavity fibroid requiring careful dissection and excision BLOOD TRANSFUSIONS Two units of packed red blood cells INFECTION None SIGNIFICANT LAB AND X RAY Posttransfusion of the 2nd unit showed her hematocrit of 25 hemoglobin of 8 3 HOSPITAL COURSE AND TREATMENT The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage D C was performed Hysteroscopy revealed a large endometrial cavity fibroid Careful shaving and excision of this fibroid was performed with removal of the fibroid Hemostasis was noted completely at the end of this procedure Postoperatively the patient has done well The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss The patient is now ambulating without difficulty and tolerating her diet The patient desires to go home The patient is discharged to home DISCHARGE CONDITION Stable DISCHARGE INSTRUCTIONS Regular diet bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks pelvic rest for 6 weeks Vicodin tablets 1 tablet p o q 4 6 h p r n pain multiple vitamin 1 tab p o daily ferrous sulfate tablets 1 tablet p o daily Ambulate with assistance at home only The patient is to return to see Dr X p r n plus Tuesday 6 16 2009 for further followup care The patient was given full and complete postop and discharge instructions All her questions were answered Keywords discharge summary d c fibroid uterus myomectomy dilatation curettage menometrorrhagia uterus hysteroscopy fibroid MEDICAL_TRANSCRIPTION,Description Chronic obstructive pulmonary disease COPD exacerbation and acute bronchitis Medical Specialty Discharge Summary Sample Name COPD Bronchitis Discharge Summary Transcription DIAGNOSIS AT ADMISSION Chronic obstructive pulmonary disease COPD exacerbation and acute bronchitis DIAGNOSES AT DISCHARGE 1 Chronic obstructive pulmonary disease exacerbation and acute bronchitis 2 Congestive heart failure 3 Atherosclerotic cardiovascular disease 4 Mild senile type dementia 5 Hypothyroidism 6 Chronic oxygen dependent 7 Do not resuscitate do not intubate HOSPITAL COURSE The patient was admitted from the office by Dr X She was placed on the usual medications that included Synthroid 0 05 mg a day enalapril 5 mg a day Imdur 30 mg a day Lanoxin 0 125 mg a day aspirin 81 mg a day albuterol and Atrovent nebulizers q 4 h potassium chloride 10 mEq 2 tablets per day Lasix 40 mg a day Humibid L A 600 mg b i d She was placed on oral Levaquin after a load of 500 mg and 250 mg a day She was given oxygen encouraged to eat and suctioned as needed Laboratory data included a urinalysis that had 0 2 WBCs per high power field and urine culture was negative blood cultures x2 were negative TSH was 1 7 and chem 7 sodium 134 potassium 4 4 chloride 93 CO2 34 glucose 105 BUN 17 creatinine 0 9 and calcium 9 1 Digoxin was 1 3 White blood cell count was 6100 with a normal differential H H 37 4 12 1 platelets 335 000 Chest x ray was thought to have prominent interstitial lung changes without acute infiltrate There is a question if there is mild fluid overload The patient improved with the above regimen By discharge her lungs fell back to her baseline She had no significant shortness of breath Her O2 saturations were stable Her vital signs were stable She is discharged home to follow up with me in a week and a half Her daughter has been spoken to by phone and she will notify me if she worsens or has problems PROGNOSIS Guarded Keywords discharge summary chronic obstructive pulmonary disease exacerbation chronic obstructive pulmonary disease pulmonary copd discharge bronchitis MEDICAL_TRANSCRIPTION,Description Congestive heart failure CHF with left pleural effusion Anemia of chronic disease Medical Specialty Discharge Summary Sample Name CHF Pleural Effusion Discharge Summary Transcription DIAGNOSIS AT ADMISSION Congestive heart failure CHF with left pleural effusion DIAGNOSES AT DISCHARGE 1 Congestive heart failure CHF with pleural effusion 2 Hypertension 3 Prostate cancer 4 Leukocytosis 5 Anemia of chronic disease HOSPITAL COURSE The patient was admitted to the emergency room by Dr X He has diuresed with IV Lasix He was placed on Prinivil aspirin oxybutynin docusate and Klor Con Chest x rays were followed He did have free flowing fluid in his left chest Radiology consultation was obtained for thoracentesis The patient was seen by Dr Y An echocardiogram was done This revealed an ejection fraction of 60 with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3 An adenosine sestamibi was done in March 2000 with a small fixed apical defect but no ischemia Cardiac enzymes were negative Dr Y recommended a beta blocker with an ACE inhibitor therefore the lisinopril was discontinued The patient felt much better after the thoracentesis I do not have the details of this i e the volumes No fluid was sent for routine studies LABORATORY AT DISCHARGE Sodium 134 potassium 4 2 chloride 99 CO2 26 glucose 182 BUN 17 and creatinine 1 0 Glucose was elevated because of several doses of Solu Medrol given to him because of bronchospams Magnesium was 1 8 calcium was 8 1 Liver enzymes were unremarkable Cardiac enzymes were normal as mentioned PT INR is 1 02 PTT 31 3 white blood cell count 15 000 with a left shift This was presumed due to the corticosteroids H H was 32 3 11 3 and platelets 352 000 and MCV was 99 The patient s O2 saturations on room air were normal Vital signs were stable DISCHARGE MEDICATIONS He is being discharged home on Lasix 40 mg daily potassium chloride 10 mEq daily atenolol 25 mg daily aspirin 5 grains daily Ditropan 5 mg b i d and Colace 100 mg b i d FOLLOWUP He will be followed in my office in 1 week He is to notify if recurrent fever or chills PROGNOSIS Guarded Keywords discharge summary prostate cancer anemia of chronic disease congestive heart failure pleural effusion thoracentesis chf anemia MEDICAL_TRANSCRIPTION,Description Multiple extensive subcutaneous abscesses right thigh Massive open wound right thigh status post right excision of multiple subcutaneous abscesses right thigh Medical Specialty Discharge Summary Sample Name Chronic Abscesses Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Multiple extensive subcutaneous abscesses right thigh 2 Massive open wound right thigh status post right excision of multiple subcutaneous abscesses right thigh PROCEDURES PERFORMED 1 On 03 05 08 by Dr X was massive debridement of soft tissue right lateral thigh and hip 2 Soft tissue debridement on 03 16 08 of right thigh and hip by Dr X 3 Split thickness skin graft to right thigh and right hip massive open wound on 04 01 08 by Dr Y REASON FOR ADMISSION The patient is a 62 year old male with a history of drug use He had a history of injection of heroin into his bilateral thighs Unfortunately he developed chronic abscesses open wounds on his bilateral thighs much worse on his right than his left Decision was made to do a radical excision and then it is followed by reconstruction HOSPITAL COURSE The patient was admitted on 03 05 08 by Dr X He was taken to the operating room He underwent a massive resection of multiple subcutaneous abscesses heroin remnants which left massive huge open wounds to his right thigh and hip This led to a prolonged hospital course The patient initially was treated with local wound care He was treated with broad spectrum antibiotics He ended up growing out different species of Clostridium Infectious Disease consult was obtained from Dr Z He assisted in further antibiotic coverage throughout the rest of his hospitalization The patient also had significant hypoalbuminemia decreased nutrition Given his large wounds he did end up getting a feeding tube placement and prior to grafting he received significant feeding tube supplementation to help achieve adequate nutrition for healing The patient had this superior area what appeared to be further necrotic infected soft tissue He went back to the OR on 03 16 08 and further resection done by Dr X After this his wound appeared to be free of infection He is treated with a wound VAC He slowly but progressively had significant progress in his wound I went from a very poor looking wound to a red granulated wound throughout its majority He was thought ready for skin grafting Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity These were negative He was treated with SCDs to help decrease his risk On 04 01 08 the patient was taken to the operating room was thought to have an adequate ________ grafting He underwent skin grafting to his right thigh and hip massive open wound Donor sites were truncated Postoperatively the patient ended up with a vast majority of skin graft taking To unable to take he was kept on IV antibiotics strict bed rest and limited range of motion of his hip He is continued on VAC dressing Graft progressively improved with this therapy Had another ultrasound which was negative for DVT The patient was mobilized up out of his bed Infectious Disease recommendations were obtained Plan was to complete additional 10 days of antibiotics at discharge This will be oral antibiotics I would monitor his left side which has significantly decreased inflammation and irritation or infection given the antibiotic coverage So decision was not made to excise this but instead monitor By 04 11 08 his graft looked good It was pink and filling in He looked stable for discharge The patient was discharged to home DISCHARGE INSTRUCTIONS Discharge to home CONDITION Stable Antibiotic Augmentin XR script was written He is okay to shower Donor site and graft site dressing instruction orders were given for Home Health and the patient His followup was arranged with Dr X and myself Keywords discharge summary multiple extensive subcutaneous abscesses open wound subcutaneous abscesses multiple subcutaneous abscesses skin grafting thigh wound abscesses wounds subcutaneous antibiotics MEDICAL_TRANSCRIPTION,Description A 49 year old man with respiratory distress history of coronary artery disease with prior myocardial infarctions and recently admitted with pneumonia and respiratory failure Medical Specialty Discharge Summary Sample Name Cardio Pulmo Discharge Summary Transcription ADMISSION DIAGNOSIS 1 Respiratory arrest 2 End stage chronic obstructive pulmonary disease 3 Coronary artery disease 4 History of hypertension DISCHARGE DIAGNOSIS 1 Status post respiratory arrest 2 Chronic obstructive pulmonary disease 3 Congestive heart failure 4 History of coronary artery disease 5 History of hypertension SUMMARY The patient is a 49 year old man who was admitted to the hospital in respiratory distress and had to be intubated shortly after admission to the emergency room The patient s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999 The patient has recently been admitted to the hospital with pneumonia and respiratory failure The patient has been smoking up until three to four months previously On the day of admission the patient had the sudden onset of severe dyspnea and called an ambulance The patient denied any gradual increase in wheezing any increase in cough any increase in chest pain any increase in sputum prior to the onset of his sudden dyspnea ADMISSION PHYSICAL EXAMINATION GENERAL Showed a well developed slightly obese man who was in extremis NECK Supple with no jugular venous distension HEART Showed tachycardia without murmurs or gallops PULMONARY Status showed decreased breath sounds but no clear cut rales or wheezes EXTREMITIES Free of edema HOSPITAL COURSE The patient was admitted to the Special Care Unit and intubated He received intravenous antibiotic therapy with Levaquin He received intravenous diuretic therapy He received hand held bronchodilator therapy The patient also was given intravenous steroid therapy with Solu Medrol The patient s course was one of gradual improvement and after approximately three days the patient was extubated He continued to be quite dyspneic with wheezes as well as basilar rales After pulmonary consultation was obtained the pulmonary consultant felt that the patient s overall clinical picture suggested that he had a significant element of congestive heart failure With this the patient was placed on increased doses of Lisinopril and Digoxin with improvement of his respiratory status On the day of discharge the patient had minimal basilar rales his chest also showed minimal expiratory wheezes he had no edema his heart rate was regular his abdomen was soft and his neck veins were not distended It was therefore felt that the patient was stable for further management on an outpatient basis DIAGNOSTIC DATA The patient s admission laboratory data was notable for his initial blood gas which showed a pH of 7 02 with a pCO2 of 118 and a pO2 of 103 The patient s electrocardiogram showed nonspecific ST T wave changes The patent s CBC showed a white count of 24 000 with 56 neutrophils and 3 bands DISPOSITION The patient was discharged home DISCHARGE INSTRUCTIONS His diet was to be a 2 grams sodium 1800 calorie ADA diet His medications were to be Prednisone 20 mg twice per day Theo 24 400 mg per day Furosemide 40 mg 1 1 2 tabs p o per day Acetazolamide 250 mg one p o per day Lisinopril 20 mg one p o twice per day Digoxin 0 125 mg one p o q d nitroglycerin paste 1 inch h s K Dur 60 mEq p o b i d He was also to use a Ventolin inhaler every four hours as needed and Azmacort four puffs twice per day He was asked to return for follow up with Dr X in one to two weeks Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge Keywords discharge summary ada diet congestive heart failure coronary artery disease respiratory arrest chest pain chronic obstructive pulmonary disease emergency room hypertension sputum wheezing respiratory distress myocardial infarctions respiratory failure pulmonary disease basilar rales heart failure infarctions heart wheezes coronary pulmonary discharge respiratory MEDICAL_TRANSCRIPTION,Description Complex open wound right lower extremity complicated by a methicillin resistant staphylococcus aureus cellulitis The patient is a 52 year old male who has had a very complex course secondary to a right lower extremity complex open wound Medical Specialty Discharge Summary Sample Name Cellulitis Discharge Summary Transcription DISCHARGE DIAGNOSIS Complex open wound right lower extremity complicated by a methicillin resistant staphylococcus aureus cellulitis ADDITIONAL DISCHARGE DIAGNOSES 1 Chronic pain 2 Tobacco use 3 History of hepatitis C REASON FOR ADMISSION The patient is a 52 year old male who has had a very complex course secondary to a right lower extremity complex open wound He has had prolonged hospitalizations because of this problem He was recently discharged when he was noted to develop as an outpatient swollen red tender leg Examination in the emergency room revealed significant concern for significant cellulitis Decision was made to admit him to the hospital HOSPITAL COURSE The patient was admitted on 03 26 08 and was started on IV antibiotics elevation was also counseled to minimizing the cigarette smoking The patient had edema of his bilateral lower extremities The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C Hospital consult was obtained This included an ultrasound of his abdomen which showed just mild cirrhosis His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well The patient eventually grew MRSA in a moderate amount He was treated with IV vancomycin Local wound care and elevation The patient had slow progress He was started on compression and by 04 03 08 his leg got much improved minimal redness and swelling was down with compression The patient was thought safe to discharge home DISCHARGE INSTRUCTIONS The patient was discharged on doxycycline 100 mg p o b i d x10 days He was also given prescription for Percocet and OxyContin picked up at my office He is instructed to do daily wound care and also wrap his leg with an Ace wrap Followup was arranged in a couple of weeks DISCHARGE CONDITION Stable Keywords discharge summary chronic pain methicillin resistant staphylococcus aureus cellulitis complex open wound staphylococcus aureus wound care cellulitis wound hepatitis MEDICAL_TRANSCRIPTION,Description Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy Chronic pain syndrome Medical Specialty Discharge Summary Sample Name Back Leg Pain Discharge Summary Transcription ADMISSION DIAGNOSIS Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy SECONDARY DIAGNOSIS Chronic pain syndrome PRINCIPAL PROCEDURE L5 Gill procedure with interbody and posterolateral 360 degrees circumferential arthrodesis using cages bone graft recombinant bone morphogenic protein and pedicle fixation This was performed by Dr X on 01 08 08 BRIEF HISTORY OF HOSPITAL COURSE The patient is a man with a history of longstanding back buttock and bilateral leg pain He was evaluated and found to have bilateral pars defects at L5 S1 with spondylolysis and instability He was admitted and underwent an uncomplicated surgical procedure as noted above In the postoperative period he was up and ambulatory He was taking p o fluids and diet well He was afebrile His wounds were healing well Subsequently the patient was discharged home DISCHARGE MEDICATIONS Discharge medications included his usual preoperative pain medication as well as other medications FOLLOWUP At this time the patient will follow up with me in the office in six weeks time The patient understands discharge plans and is in agreement with the discharge plan He will follow up as noted Keywords discharge summary chronic pain syndrome spinal instability pars defects radiculopathy spondylolysis leg MEDICAL_TRANSCRIPTION,Description A lady was admitted to the hospital with chest pain and respiratory insufficiency She has chronic lung disease with bronchospastic angina Medical Specialty Discharge Summary Sample Name Chest Pain Respiratory Insufficiency Transcription We discovered new T wave abnormalities on her EKG There was of course a four vessel bypass surgery in 2001 We did a coronary angiogram This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease She may continue in the future to have angina and she will have nitroglycerin available for that if needed Her blood pressure has been elevated and so instead of metoprolol we have started her on Coreg 6 25 mg b i d This should be increased up to 25 mg b i d as preferred antihypertensive in this lady s case She also is on an ACE inhibitor So her discharge meds are as follows 1 Coreg 6 25 mg b i d 2 Simvastatin 40 mg nightly 3 Lisinopril 5 mg b i d 4 Protonix 40 mg a m 5 Aspirin 160 mg a day 6 Lasix 20 mg b i d 7 Spiriva puff daily 8 Albuterol p r n q i d 9 Advair 500 50 puff b i d 10 Xopenex q i d and p r n I will see her in a month to six weeks She is to follow up with Dr X before that Keywords discharge summary chest pain respiratory insufficiency chronic lung disease bronchospastic angina insufficiency chest angina respiratory bronchospastic MEDICAL_TRANSCRIPTION,Description Bronchiolitis respiratory syncytial virus positive improved and stable Innocent heart murmur stable Medical Specialty Discharge Summary Sample Name Bronchiolitis Discharge Summary Transcription DIAGNOSES 1 Bronchiolitis respiratory syncytial virus positive improved and stable 2 Innocent heart murmur stable HOSPITAL COURSE The patient was admitted for an acute onset of congestion She was checked for RSV which was positive and admitted to the hospital for acute bronchiolitis She has always been stable on room air however because of her age and her early diagnosis she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness She was treated per pathway orders However on the second day of admission the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission There was a heart murmur that was heard that sounded innocent but yet there was no chest x ray that was obtained We did obtain a chest x ray which did show a slight perihilar infiltrate in the right upper lobe However the rest of the lungs were normal and the heart was also normal There were no complications during her hospitalization and she continued to be stable and eating better On day 2 of the admission it was decided she was okay to go home Mother was advised regarding signs and symptoms of increased respiratory distress which includes tachypnea increased retractions grunting nasal flaring etc and she was very comfortable looking for this During her hospitalization albuterol MDI was given to the patient and more for mom to learn outpatient care The patient did receive a couple of doses but she did not have any significant respiratory distress and she was discharged in improved condition DISCHARGE PHYSICAL EXAMINATION VITAL SIGNS She is afebrile Vital signs were stable within normal limits on room air GENERAL She is sleeping and in no acute distress HEENT Her anterior fontanelle was soft and flat She does have some upper airway congestion CARDIOVASCULAR Regular rate and rhythm with a 2 3 6 systolic murmur that radiates to bilateral axilla and the back EXTREMITIES Her femoral pulses were 2 and her extremities were warm and well perfused with good capillary refill LUNGS Her lungs did show some slight coarseness but good air movement with equal breath sounds She does not have any wheezes at this time but she does have a few scattered crackles at bilateral bases She did not have any respiratory distress while she was asleep ABDOMEN Normal bowel sounds Soft and nondistended GENITOURINARY She is Tanner I female DISCHARGE WEIGHT Her weight at discharge 3 346 kg which is up 6 grams from admission DISCHARGE INSTRUCTIONS ACTIVITY No one should smoke near The patient She should also avoid all other exposures to smoke such as from fireplaces and barbecues She is to avoid contact with other infants since she is sick and they are to limit travel There should be frequent hand washings DIET Regular diet Continue breast feeding as much as possible and encourage oral intake MEDICATIONS She will be sent home on albuterol MDI to be used as needed for cough wheezes or dyspnea ADDITIONAL INSTRUCTIONS Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing if she stops breathing or she decides that she does not want to eat Keywords discharge summary bronchiolitis respiratory syncytial virus bulb suctioning innocent heart murmur chest x ray syncytial virus heart murmur respiratory distress lungs MEDICAL_TRANSCRIPTION,Description Discharge summary of a patient with a BRCA 2 mutation Medical Specialty Discharge Summary Sample Name BRCA 2 mutation Transcription DISCHARGE DIAGNOSES BRCA 2 mutation HISTORY OF PRESENT ILLNESS The patient is a 59 year old with a BRCA 2 mutation Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27 PHYSICAL EXAMINATION The chest was clear The abdomen was nontender Pelvic examination shows no masses No heart murmur HOSPITAL COURSE The patient underwent surgery on the day of admission In the postoperative course she was afebrile and unremarkable The patient regained bowel function and was discharged on the morning of the fourth postoperative day OPERATIONS AND PROCEDURES Total abdominal hysterectomy bilateral salpingo oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25 2006 PATHOLOGY A 105 gram uterus without dysplasia or cancer CONDITION ON DISCHARGE Stable PLAN The patient will remain at rest initially with progressive ambulation after She will avoid lifting driving or intercourse She will call me if any fevers drainage bleeding or pain Follow up in my office in four weeks Family history social history psychosocial needs per the social worker DISCHARGE MEDICATIONS Percocet 5 40 one every 3 hours p r n pain Keywords discharge summary brca 2 mutation brca 2 mutation breast cancer brca mutation breast postoperative peritoneum brca discharge cancer MEDICAL_TRANSCRIPTION,Description Counting calorie points exercising pretty regularly seems to be doing well Medical Specialty Diets and Nutritions Sample Name Dietary Consult 4 Transcription SUBJECTIVE The patient is keeping a food journal that she brought in She is counting calorie points which ranged 26 to 30 per day She is exercising pretty regularly She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia The patient requests information on diabetic exchanges She said she is feeling better since she has lost weight OBJECTIVE Vital Signs The patient s weight today is 209 pounds which is down 22 pounds since I last saw her on 06 07 2004 I praised her weight loss and her regular exercising I looked at her food journal I praised her record keeping I gave her a list of the diabetic exchanges and explained them I also gave her a food dairy sheet so that she could record exchanges I encouraged her to continue ASSESSMENT The patient seems happy with her progress and she seems to be doing well She needs to continue PLAN Followup is on a p r n basis She is always welcome to call or return Keywords diets and nutritions overeaters anonymous diabetic exchanges exercising pretty regularly food journal diabetic exercising exchanges regularly MEDICAL_TRANSCRIPTION,Description Dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction Medical Specialty Diets and Nutritions Sample Name Dietary Consult Weight Reduction Transcription SUBJECTIVE This is a 56 year old female who comes in for a dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction The patient states that her husband has been diagnosed with high blood cholesterol as well She wants some support with some dietary recommendations to assist both of them in healthier eating The two of them live alone now and she is used to cooking for large portions She is having a hard time adjusting to preparing food for the two of them She would like to do less food preparation in fact She is starting a new job this week OBJECTIVE Her reported height is 5 feet 4 inches Today s weight was 170 pounds BMI is approximately 29 A diet history was obtained I instructed the patient on a 1200 calorie meal plan emphasizing low saturated fat sources with moderate amounts of sodium as well Information on fast food eating was supplied and additional information on low fat eating was also supplied ASSESSMENT The patient s basal energy expenditure is estimated at 1361 calories a day Her total calorie requirement for weight maintenance is estimated at 1759 calories a day Her diet history reflects that she is making some very healthy food choices on a regular basis She does emphasize a lot of fruits and vegetables trying to get a fruit or a vegetable or both at most meals She also is emphasizing lower fat selections Her physical activity level is moderate at this time She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long term basis for weight reduction We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well We discussed menu selection as well as food preparation techniques The patient appears to have been influenced by the current low carb high protein craze and had really limited her food selections based on that I was able to give her some more room for variety including some moderate portions of potatoes pasta and even on occasion breading her meat as long as she prepares it in a low fat fashion which was discussed PLAN Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week This translates into a 1200 calorie meal plan I encouraged the patient to keep food records in order to better track calories consumed I recommended low fat selections and especially those that are lower in saturated fats Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well This was a one hour consultation I provided my name and number should additional needs arise Keywords diets and nutritions hyperlipidemia hypertension gastroesophageal reflux disease weight reduction dietary recommendations healthier eating meal plan dietary consultation low fat physical activity weight gastroesophageal dietary calories food MEDICAL_TRANSCRIPTION,Description Dietary consultation for gestational diabetes Medical Specialty Diets and Nutritions Sample Name Dietary Consult Gestational Diabetes Transcription SUBJECTIVE This is a 38 year old female who comes for dietary consultation for gestational diabetes Patient reports that she is scared to eat because of its impact on her blood sugars She is actually trying not to eat while she is working third shift at Wal Mart Historically however she likes to eat out with a high frequency She enjoys eating rice as part of her meals She is complaining of feeling fatigued and tired all the time because she works from 10 p m to 7 a m at Wal Mart and has young children at home She sleeps two to four hours at a time throughout the day She has been testing for ketones first thing in the morning when she gets home from work OBJECTIVE Today s weight 155 5 pounds Weight from 10 07 04 was 156 7 pounds A diet history was obtained Blood sugar records for the last three days reveal the following fasting blood sugars 83 84 87 77 two hour postprandial breakfast 116 107 97 pre lunch 85 108 77 two hour postprandial lunch 86 131 100 pre supper 78 91 100 two hour postprandial supper 125 121 161 bedtime 104 90 and 88 I instructed the patient on dietary guidelines for gestational diabetes The Lily Guide for Meal Planning was provided and reviewed Additional information on gestational diabetes was applied A sample 2000 calorie meal plan was provided with a carbohydrate budget established ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1336 calories a day Her total calorie requirements including a physical activity factor as well as additional calories for pregnancy totals to 2036 calories per day Her diet history reveals that she has somewhat irregular eating patterns In the last 24 hours when she was working at Wal Mart she ate at 5 a m but did not eat anything prior to that since starting work at 10 p m We discussed the need for small frequent eating We identified carbohydrate as the food source that contributes to the blood glucose response We identified carbohydrate sources in the food supply recognizing that they are all good for her The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars In regard to use of her traditional foods of rice I pulled out a one third cup measuring cup to identify a 15 gram equivalent of rice We discussed the need for moderating the portion of carbohydrates consumed at one given time Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake Her weight loss was discouraged Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time PLAN The meal plan provided has a carbohydrate content that represents 40 percent of a 2000 calorie meal plan The meal plan was devised to distribute her carbohydrates more evenly throughout the day The meal plan was meant to reflect an example for her eating while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time The meal plan is as follows breakfast 2 carbohydrate servings snack 1 carbohydrate serving lunch 2 3 carbohydrate servings snack 1 carbohydrate serving dinner 2 3 carbohydrate servings bedtime snack 1 2 carbohydrate servings Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep Encouraged adequate rest Also recommend adequate calories to sustain weight gain of one half to one pound per week If the meal plan reflected does not support slow gradual weight gain then we will need to add more foods accordingly This was a one hour consultation I provided my name and number should additional needs arise Keywords diets and nutritions blood sugars fatigued total calorie carbohydrate content consultation for gestational diabetes dietary consultation weight gain gestational diabetes carbohydrate servings meal planning meals weight carbohydrate dietary servings planning MEDICAL_TRANSCRIPTION,Description Dietary consultation for diabetes during pregnancy Medical Specialty Diets and Nutritions Sample Name Dietary Consult Diabetes 1 Transcription SUBJECTIVE This is a 28 year old female who comes for dietary consultation for diabetes during pregnancy Patient reports that she had gestational diabetes with her first pregnancy She did use insulin at that time as well She does not fully understand what ketones are She walks her daughter to school and back home each day which takes 20 minutes each way She is not a big milk drinker but she does try to drink some OBJECTIVE Weight is 238 3 pounds Weight from last week s visit was 238 9 pounds Prepregnancy weight is reported at 235 pounds Height is 62 3 4 inches Prepregnancy BMI is approximately 42 1 2 Insulin schedule is NovoLog 70 30 20 units in the morning and 13 units at supper time Blood sugar records for the last week reveal the following Fasting blood sugars ranging from 92 to 104 with an average of 97 two hour postprandial breakfast readings ranging from 172 to 196 with an average of 181 two hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two hour postprandial dinner readings ranging from 109 to 121 with an average of 116 Overall average is 140 A diet history was obtained Expected date of confinement is May 1 2005 Instructed the patient on dietary guidelines for gestational diabetes A 2300 meal plan was provided and reviewed The Lily Guide for Meal Planning was provided and reviewed ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day Her total calorie requirements including physical activity factors as well as additional calories for pregnancy totals 2367 calories a day Her diet history reveals that she is eating three meals a day and three snacks The snacks were just added last week following presence of ketones in her urine We identified carbohydrate sources in the food supply recognizing that they are the foods that raise blood sugar the most We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1 2 a pound a week through the duration of the pregnancy We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars While a sample meal plan was provided reflecting the patient s carbohydrate budget I emphasized the need for her to eat according to her appetite but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates PLAN Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45 of the calories from carbohydrate Breakfast Three carbohydrate servings Morning snack One carbohydrate serving Lunch Four carbohydrate servings Afternoon snack One carbohydrate serving Supper Four carbohydrate servings Bedtime snack One carbohydrate serving Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy Recommend patient include a fruit or a vegetable with most of her meals Also recommend including solid protein with each meal as well as with the bedtime snack Charlie Athene reviewed blood sugars at this consultation as well and made the following insulin adjustment Morning 70 30 will increase from 20 units up to 24 units and evening 70 30 we will increase from 13 units up to 16 units Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two hour postprandial Provided my name and number should there be additional dietary questions Keywords diets and nutritions diabetes during pregnancy diabetes insulin gestational diabetes adjusted for obesity calorie requirements dietary consultation carbohydrate postprandial meal calories dietary pregnancy servings snacks MEDICAL_TRANSCRIPTION,Description Anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy and moderate stenosis C5 6 Medical Specialty Discharge Summary Sample Name Anterior Cervical Discectomy Fusion Discharge Summary Transcription FINAL DIAGNOSES 1 Herniated nucleuses pulposus C5 6 greater than C6 7 left greater than C4 5 right with left radiculopathy 2 Moderate stenosis C5 6 OPERATION On 06 25 07 anterior cervical discectomy and fusions C4 5 C5 6 C6 7 using Bengal cages and Slimlock plate C4 to C7 intraoperative x ray This is a 60 year old white male who was in the office on 05 01 07 because of neck pain with left radiculopathy and tension headaches In the last year or so he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right He has some neck pain at times and has seen Dr X for an epidural steroid injection which was very helpful More recently he saw Dr Y and went through some physical therapy without much relief Cervical MRI scan was obtained and revealed a large right sided disc herniation at C4 5 with significant midline herniations at C5 6 and a large left HNP at C6 7 In view of the multiple levels of pathology I was not confident that anything short of surgical intervention would give him significant relief The procedure and its risk were fully discussed and he decided to proceed with the operation HOSPITAL COURSE Following admission the procedure was carried out without difficulty Blood loss was about 125 cc Postop x ray showed good alignment and positioning of the cages plate and screws After surgery he was able to slowly increase his activity level with assistance from physical therapy He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck He also had some nausea with the PCA He had a low grade fever to 100 2 and was started on incentive spirometry Over the next 12 hours his fever resolved and he was able to start getting up and around much more easily By 06 27 07 he was ready to go home He has been counseled regarding wound care and has received a neck sheet for instruction He will be seen in two weeks for wound check and for a followup evaluation x rays in about six weeks He has prescriptions for Lortab 7 5 mg and Robaxin 750 mg He is to call if there are any problems Keywords discharge summary slimlock herniated nucleuses pulposus anterior cervical discectomy bengal cages anterior herniated cervical radiculopathy discectomy MEDICAL_TRANSCRIPTION,Description Followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome Medical Specialty Diets and Nutritions Sample Name Dietary Consult Hyperlipidemia Transcription SUBJECTIVE This is a followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome The patient reports that she has worked hard for a number of weeks following the meal plan prescribed but felt like she was gaining weight and not losing weight on it She is not sure that she was following it accurately She is trying to walk 1 1 2 to 2 miles every other day but is increasing her time in the garden and doing other yard work as well Once she started experiencing some weight gain she went back to her old South Beach Diet and felt like she was able to take some of that weight off However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low fat eating OBJECTIVE Weight is 275 pounds Food records were reviewed ASSESSMENT The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago I did carefully review her food records and evaluated calories consumed While she was carefully tracking the volume of protein and carbohydrates she was getting some excess calories from the fatty proteins selected Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates While this still is not as much carbohydrate as I would normally recommend I am certainly willing to work with her on how she feels her body best handles weight reduction We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time PLAN A new 1500 calorie meal plan was developed based on 35 of the calories coming from protein 40 of the calories from carbohydrate and 25 of the calories from fat This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack This also translates in to 2 ounces of protein at breakfast 6 ounces at lunch 2 ounces in the afternoon snack 6 ounces at supper and 2 ounces in the evening snack We have eliminated the morning snack The patient will now track the grams of fat in her meats as well as added fats Her goal for total fats over the course of the day is no more than 42 grams of fat per day This was a half hour consultation We will plan to see the patient back in one month for support Keywords diets and nutritions hyperlipidemia hypertension metabolic syndrome meal food records south beach diet dietary consultation meal plan carbohydrates snack dietary calories weight MEDICAL_TRANSCRIPTION,Description Elevated cholesterol and is on medication to lower it Medical Specialty Diets and Nutritions Sample Name Dietary Consult 1 Transcription SUBJECTIVE His brother although he is a vegetarian has elevated cholesterol and he is on medication to lower it The patient started improving his diet when he received the letter explaining his lipids are elevated He is consuming less cappuccino quiche crescents candy from vending machines etc He has started packing his lunch three to four times per week instead of eating out so much He is exercising six to seven days per week by swimming biking running lifting weights one and a half to two and a half hours each time He is in training for a triathlon He says he is already losing weight due to his efforts OBJECTIVE Height 6 foot 2 inches Weight 204 pounds on 03 07 05 Ideal body weight 190 pounds plus or minus ten percent He is 107 percent standard of midpoint ideal body weight BMI 26 189 A 48 year old male Lab on 03 15 05 Cholesterol 251 LDL 166 VLDL 17 HDL 68 Triglycerides 87 I explained to the patient the dietary guidelines to help improve his lipids I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2 300 calories since he is interested in losing weight I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read I encouraged him to continue as he is doing ASSESSMENT Basal energy expenditure 1960 x 1 44 activity factor is approximately 2 800 calories His 24 hour recall shows he is making many positive changes already to lower his fat and cholesterol intake He needs to continue as he is doing He verbalized understanding and seemed receptive PLAN The patient plans to recheck his lipids through Dr XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet Keywords diets and nutritions vegetarian lipids cholesterol intake elevated cholesterol losing weight body weight dietary cholesterol MEDICAL_TRANSCRIPTION,Description Incision and drainage first metatarsal head left foot with culture and sensitivity Medical Specialty Discharge Summary Sample Name Abscess with Cellulitis Discharge Summary Transcription ADMITTING DIAGNOSIS Abscess with cellulitis left foot DISCHARGE DIAGNOSIS Status post I D left foot PROCEDURES Incision and drainage first metatarsal head left foot with culture and sensitivity HISTORY OF PRESENT ILLNESS The patient presented to Dr X s office on 06 14 07 complaining of a painful left foot The patient had been treated conservatively in office for approximately 5 days but symptoms progressed with the need of incision and drainage being decided MEDICATIONS Ancef IV ALLERGIES ACCUTANE SOCIAL HISTORY Denies smoking or drinking PHYSICAL EXAMINATION Palpable pedal pulses noted bilaterally Capillary refill time less than 3 seconds digits 1 through 5 bilateral Skin supple and intact with positive hair growth Epicritic sensation intact bilateral Muscle strength 5 5 dorsiflexors plantar flexors invertors evertors Left foot with erythema edema positive tenderness noted left forefoot area LABORATORY White blood cell count never was abnormal The remaining within normal limits X ray is negative for osteomyelitis On 06 14 07 the patient was taken to the OR for incision and drainage of left foot abscess The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q 12h after surgery and later changed Ancef 2 g IV every 8 hours Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06 19 07 in excellent condition DISCHARGE MEDICATIONS Lorcet 10 650 mg dispense 24 tablets one tablet to be taken by mouth q 6h as needed for pain The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics DISCHARGE INSTRUCTIONS Included keeping the foot elevated with long periods of rest The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation The patient to keep dressing dry and intact left foot The patient to contact Dr X for all followup care if any problems arise The patient was given written and oral instruction about wound care before discharge Prior to discharge the patient was noted to be afebrile All vitals were stable The patient s questions were answered and the patient was discharged in apparent satisfactory condition Followup care was given via Dr X office Keywords discharge summary accutane metatarsal head left foot abscess with cellulitis culture and sensitivity incision and drainage metatarsal head foot cellulitis ancef abscess incision drainage MEDICAL_TRANSCRIPTION,Description Dietary consult for a 79 year old African American female diagnosed with type 2 diabetes in 1983 Medical Specialty Diets and Nutritions Sample Name Dietary Consult Diabetes 2 Transcription SUBJECTIVE The patient is a 79 year old African American female with a self reported height of 5 foot 3 inches and weight of 197 pounds She was diagnosed with type 2 diabetes in 1983 She is not allergic to any medicines DIABETES MEDICATIONS Her diabetes medications include Humulin insulin 70 30 44 units at breakfast and 22 units at supper Also metformin 500 mg at supper OTHER MEDICATIONS Other medications include verapamil Benicar Toprol clonidine and hydrochlorothiazide ASSESSMENT The patient and her daughter completed both days of diabetes education in a group setting Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician Fasting blood sugars are 127 80 and 80 Two hour postprandial breakfast reading was 105 two hour postprandial lunch reading was 88 and two hour postprandial dinner reading was 73 and 63 Her diet was excellent Seven hours of counseling about diabetes mellitus was provided on this date Blood glucose values obtained at 10 a m were 84 and at 2 30 p m were 109 Assessment of her knowledge is completed at the end of the counseling session She demonstrated increased knowledge in all areas and had no further questions She also completed an evaluation of the class The patient s feet were examined during the education session She had flat feet bilaterally Skin color was pink temperature warm Pedal pulses 2 Her right second and third toes lay on each other Also the same on her left foot However there was no skin breakdown She had large bunions medial aspect of the ball of both feet She had positive sensitivity to most areas of her feet however she had negative sensitivity to the medial and lateral aspect of the balls of her left foot During the education session she set behavioral goals for self care First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels Second goal is to eat a well balanced meal at 1200 calories in order to lose one half pound of weight per week and improve her blood glucose control Third goal is to exercise by walking for 15 to 30 minutes a day three to five days a week to increase her blood glucose control Her success in achieving these goals will be followed in three months by a letter from the diabetes education class RECOMMENDATIONS Since she is doing so well with her diet changes her blood sugars have been within normal limits and sometimes on the low side especially considering the fact that she has low blood sugar unawareness She is to followup with Dr XYZ for possible reduction in her insulin doses Keywords diets and nutritions dietary consult diabetes education glucose control blood sugars blood glucose dietary diabetes MEDICAL_TRANSCRIPTION,Description The patient is brought in by an assistant with some of his food diary sheets Medical Specialty Diets and Nutritions Sample Name Dietary Consult 3 Transcription SUBJECTIVE The patient is brought in by an assistant with some of his food diary sheets They wonder if the patient needs to lose anymore weight OBJECTIVE The patient s weight today is 186 1 2 pounds which is down 1 1 2 pounds in the past month He has lost a total of 34 1 2 pounds I praised this I went over his food diary and praised all of his positive food choices reported especially his use of sugar free Kool Aid sugar free pudding and diet pop I encouraged him to continue all of that as well as his regular physical activity ASSESSMENT The patient is losing weight at an acceptable rate He needs to continue keeping a food diary and his regular physical activity PLAN The patient plans to see Dr XYZ at the end of May 2005 I recommended that they ask Dr XYZ what weight he would like for the patient to be at Follow up will be with me June 13 2005 Keywords diets and nutritions weight kool aid food diary sheets diary sheets physical activity food diary dietary sheets diary food MEDICAL_TRANSCRIPTION,Description The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity Medical Specialty Diets and Nutritions Sample Name Dietary Consult 2 Transcription SUBJECTIVE The patient s assistant brings in her food diary sheets The patient says she stays active by walking at the mall OBJECTIVE Weight today is 201 pounds which is down 3 pounds in the past month She has lost a total of 24 pounds I praised this and encouraged her to continue I went over her food diary I praised her three meal pattern and all of her positive food choices especially the use of sugar free Kool Aid sugar free Jell O sugar free lemonade diet pop as well as the variety of foods she is using in her three meal pattern I encouraged her to continue all of this ASSESSMENT The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity She needs to continue all this PLAN Followup is set for 06 13 05 to check the patient s weight her food diary and answer any questions Keywords diets and nutritions food diary sheets active balanced diet three meal pattern weight loss sugar free food diary dietary weight meal diary sheets food MEDICAL_TRANSCRIPTION,Description Skin biopsy scalp mole Darkened mole status post punch biopsy scalp lesion Rule out malignant melanoma with pulmonary metastasis Medical Specialty Dermatology Sample Name Scalp Mole Skin Biopsy Transcription PROCEDURE Skin biopsy scalp mole INDICATION A 66 year old female with pulmonary pneumonia effusion rule out metastatic melanoma to lung PROCEDURE NOTE The patient s scalp hair was removed with 1 K Y jelly 2 Betadine prep locally 3 A 1 lidocaine with epinephrine local instilled 4 A 3 mm punch biopsy used to obtain biopsy specimen which was sent to the lab To control bleeding two 4 0 P3 nylon sutures were applied antibiotic ointment on the wound Hemostasis was controlled The patient tolerated the procedure IMPRESSION Darkened mole status post punch biopsy scalp lesion rule out malignant melanoma with pulmonary metastasis PLAN The patient will have sutures removed in 10 days Keywords dermatology k y jelly darkened mole scalp mole skin biopsy punch biopsy melanoma MEDICAL_TRANSCRIPTION,Description Punch biopsy of right upper chest skin lesion Medical Specialty Dermatology Sample Name Punch Biopsy 1 Transcription PROCEDURE Punch biopsy of right upper chest skin lesion ESTIMATED BLOOD LOSS Minimal FLUIDS Minimal COMPLICATIONS None PROCEDURE The area around the lesion was anesthetized after she gave consent for her procedure Punch biopsy including some portion of lesion and normal tissue was performed Hemostasis was completed with pressure holding The biopsy site was approximated with non dissolvable suture The area was hemostatic All counts were correct and there were no complications The patient tolerated the procedure well She will see us back in approximately five days Keywords dermatology punch biopsy skin lesion MEDICAL_TRANSCRIPTION,Description Dietary consultation for carbohydrate counting for type I diabetes Medical Specialty Diets and Nutritions Sample Name Carbohydrate Counting Transcription SUBJECTIVE This is a 62 year old female who comes for dietary consultation for carbohydrate counting for type I diabetes The patient reports that she was hospitalized over the weekend for DKA She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477 She gave herself in smaller increments a total of 70 extra units of her Humalog Ten of those units were injectable the others were in the forms of pump Her blood sugar was over 600 when she went to the hospital later that day She is here at this consultation complaining of not feeling well still because she has a cold She realizes that this is likely because her immune system was so minimized in the hospital OBJECTIVE Current insulin doses on her insulin pump are boluses set at 5 units at breakfast 6 units at lunch and 11 units at supper Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30 5 units per 24 hours A diet history was obtained I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg dl was also recommended The Lilly guide for meal planning was provided and reviewed Additional carbohydrate counting book was provided ASSESSMENT The patient was taught an insulin to carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago which she does not recall It is based on the 500 rule which suggests this ratio We did identify carbohydrate sources in the food supply recognizing 15 g equivalents We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources She does seem to have a pattern of fixing blood sugars later in the day after they are elevated We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals With this in mind she was recommended to follow with three servings or 45 g of carbohydrate at breakfast three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately PLAN Recommend the patient use 1 unit of insulin for every 10 g carbohydrate load consumed Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day This was a one hour consultation Provided my name and number should additional needs arise Keywords diets and nutritions insulin pump carbohydrate load immune system dietary consultation carbohydrate ratio blood sugars carbohydrate counting carbohydrate dietary blood counting insulin MEDICAL_TRANSCRIPTION,Description Maculopapular rash in kind of a linear pattern over arms legs and chest area which are consistent with a poison ivy or a poison oak Medical Specialty Dermatology Sample Name Poison Ivy SOAP Transcription SUBJECTIVE He is a 24 year old male who said that he had gotten into some poison ivy this weekend while he was fishing He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it he said that the last time he was here he got a steroid injection by Dr Blackman it looked like it was Depo Medrol 80 mg He said that it worked fairly well although it seemed to still take awhile to get rid of it He has been using over the counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest legs arms and back OBJECTIVE Vitals Temperature is 99 2 His weight is 207 pounds Skin Examination reveals a raised maculopapular rash in kind of a linear pattern over his arms legs and chest area which are consistent with a poison ivy or a poison oak ASSESSMENT AND PLAN Poison ivy Plan would be Solu Medrol 125 mg IM X 1 Continue over the counter Benadryl or Rx allergy medicine that he was given the last time he was here which is a one a day allergy medicine he can not exactly remember what it is which would also be fine rather than the over the counter Benadryl if he would like to use that instead Keywords dermatology poison ivy steroid injection depo medrol maculopapular rash poison oak maculopapular chest ivy poison MEDICAL_TRANSCRIPTION,Description The skin biopsy was performed on the right ankle and right thigh The patient was consented for skin biopsy The complications instructions as to how the procedure will be performed and postoperative instructions were given to the patient Medical Specialty Dermatology Sample Name Skin Biopsy Transcription PROCEDURE The site was cleaned with antiseptic A local anesthetic 2 lidocaine was given at each site A 3 mm punch biopsy was performed in the left calf and left thigh above the knee The site was then checked for bleeding Once hemostasis was achieved a local antibiotic was placed and the site was bandaged The patient was not on any anticoagulant medications There were also no other medications which would affect the ability to conduct the skin biopsy The patient was further instructed to keep the site completely dry for the next 24 hours after which a new Band Aid and antibiotic ointment should be applied to the area They were further instructed to avoid getting the site dirty or infected The patient completed the procedure without any complications and was discharged home The biopsy will be sent for analysis The patient will follow up with Dr X within the next two weeks to review her results Keywords dermatology antiseptic local anesthetic hemostasis punch biopsy band aid skin biopsyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Mohs Micrographic Surgery for basal cell CA at medial right inferior helix Medical Specialty Dermatology Sample Name Mohs Micrographic Surgery 2 Transcription PREOP DIAGNOSIS Basal Cell CA POSTOP DIAGNOSIS Basal Cell CA LOCATION Medial right inferior helix PREOP SIZE 1 4 x 1 cm POSTOP SIZE 2 7 x 2 cm INDICATION Poorly defined borders COMPLICATIONS None HEMOSTASIS Electrodessication PLANNED RECONSTRUCTION Wedge resection advancement flap DESCRIPTION OF PROCEDURE Prior to each surgical stage the surgical site was tested for anesthesia and reanesthetized as needed after which it was prepped and draped in a sterile fashion The clinically apparent tumor was carefully defined and debulked prior to the first stage determining the extent of the surgical excision With each stage a thin layer of tumor laden tissue was excised with a narrow margin of normal appearing skin using the Mohs fresh tissue technique A map was prepared to correspond to the area of skin from which it was excised The tissue was prepared for the cryostat and sectioned Each section was coded cut and stained for microscopic examination The entire base and margins of the excised piece of tissue were examined by the surgeon Areas noted to be positive on the previous stage if applicable were removed with the Mohs technique and processed for analysis No tumor was identified after the final stage of microscopically controlled surgery The patient tolerated the procedure well without any complication After discussion with the patient regarding the various options the best closure option for each defect was selected for optimal functional and cosmetic results Keywords dermatology medial right inferior helix wedge resection advancement flap tumor laden tissue mohs fresh tissue technique mohs technique mohs micrographic surgery basal cell ca micrographic surgery basal cell micrographic helix basal cell ca mohs tissue stage MEDICAL_TRANSCRIPTION,Description Mohs Micrographic Surgery for basal cell CA at mid parietal scalp Medical Specialty Dermatology Sample Name Mohs Micrographic Surgery 1 Transcription PREOP DIAGNOSIS Basal Cell CA POSTOP DIAGNOSIS Basal Cell CA LOCATION Mid parietal scalp PREOP SIZE 1 5 x 2 9 cm POSTOP SIZE 2 7 x 2 9 cm INDICATION Poorly defined borders COMPLICATIONS None HEMOSTASIS Electrodessication PLANNED RECONSTRUCTION Simple Linear Closure DESCRIPTION OF PROCEDURE Prior to each surgical stage the surgical site was tested for anesthesia and reanesthetized as needed after which it was prepped and draped in a sterile fashion The clinically apparent tumor was carefully defined and debulked prior to the first stage determining the extent of the surgical excision With each stage a thin layer of tumor laden tissue was excised with a narrow margin of normal appearing skin using the Mohs fresh tissue technique A map was prepared to correspond to the area of skin from which it was excised The tissue was prepared for the cryostat and sectioned Each section was coded cut and stained for microscopic examination The entire base and margins of the excised piece of tissue were examined by the surgeon Areas noted to be positive on the previous stage if applicable were removed with the Mohs technique and processed for analysis No tumor was identified after the final stage of microscopically controlled surgery The patient tolerated the procedure well without any complication After discussion with the patient regarding the various options the best closure option for each defect was selected for optimal functional and cosmetic results Keywords dermatology basal cell ca basal cell mohs technique mohs tumor laden tissue mohs fresh tissue technique mohs micrographic surgery micrographic surgery parietal scalp micrographic basal cell ca surgical tumor tissue stage MEDICAL_TRANSCRIPTION,Description Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm Medical Specialty Dermatology Sample Name Wasp Sting SOAP Transcription SUBJECTIVE He is a 29 year old white male who is a patient of Dr XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm He says that he has been stung by wasps before and had similar reactions He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past He has had a lot of swelling but no anaphylaxis type reactions in the past no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past no racing heart beat or anxiety feeling just a lot of localized swelling where the sting occurs OBJECTIVE Vitals His temperature is 98 4 Respiratory rate is 18 Weight is 250 pounds Extremities Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm extending up to the elbow He says that it is really not painful or anything like that It is really not all that red and no signs of infection at this time ASSESSMENT Wasp sting to the right wrist area PLAN 1 Solu Medrol 125 mg IM X 1 2 Over the counter Benadryl ice and elevation of that extremity 3 Follow up with Dr XYZ if any further evaluation is needed Keywords dermatology yellow jacket wasp wasp sting swelling solu medrol lot of swelling stung sting wasp MEDICAL_TRANSCRIPTION,Description Worrisome skin lesion A punch biopsy of the worrisome skin lesion was obtained Lesion was removed Medical Specialty Dermatology Sample Name Punch Biopsy 2 Transcription PREOPERATIVE DIAGNOSIS Worrisome skin lesion left hand POSTPROCEDURE DIAGNOSIS Worrisome skin lesion left hand PROCEDURE The patient gave informed consent for his procedure After informed consent was obtained attention was turned toward the area of interest which was prepped and draped in the usual sterile fashion Local anesthetic medication was infiltrated around and into the area of interest There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included The predominant portion of the biopsy was of the lesion itself Lesion was removed Attention was turned toward the area Pressure was held and the area was hemostatic The skin and the area were closed with 5 0 nylon suture All counts were correct The procedure was closed A sterile dressing was applied There were no complications The patient had no neurovascular deficits etc after this minor punch biopsy procedure Keywords dermatology skin lesion squamous cell carcinoma punch biopsy MEDICAL_TRANSCRIPTION,Description Patient comes in for initial evaluation of a hyperesthesia on his right abdomen Medical Specialty Dermatology Sample Name Hyperesthesia Transcription SUBJECTIVE This 49 year old white male established patient in dermatology last seen in the office on 08 02 2002 comes in today for initial evaluation of a hyperesthesia on his right abdomen then on his left abdomen then on his left medial thigh It cleared for awhile This has been an intermittent problem Now it is back again on his right lower abdomen At first it was thought that he may have early zoster This started six weeks before the holidays and is still going on more so in the past eight days on his abdomen and right hip area He has had no treatment on this there are no skin changes at all The patient bathes everyday but tries to use little soap The patient is married He works as an airplane mechanic FAMILY SOCIAL AND ALLERGY HISTORY The patient has sinus and CVA He is a nonsmoker No known drug allergies CURRENT MEDICATIONS Lipitor aspirin folic acid PHYSICAL EXAMINATION The patient is well developed appears stated age Overall health is good He does have psoriasis with some psoriatic arthritis and his skin looks normal today On his trunk he does have the hyperesthesia As you touch him he winces IMPRESSION Hyperesthesia question etiology TREATMENT 1 Discussed condition and treatment with the patient 2 Discontinue hot soapy water to these areas 3 Increase moisturizing cream and lotion 4 I referred him to Dr ABC or Dr XYZ for neurology evaluation We did not see anything on skin today Return p r n flare Keywords dermatology abdomen hyperesthesia soapy water moisturizing cream initial evaluation MEDICAL_TRANSCRIPTION,Description Incision and drainage I D of buttock abscess Medical Specialty Dermatology Sample Name I D Buttock Abscess Transcription PRINCIPAL DIAGNOSIS Buttock abscess ICD code 682 5 PROCEDURE PERFORMED Incision and drainage I D of buttock abscess CPT CODE 10061 DESCRIPTION OF PROCEDURE Under general anesthesia skin was prepped and draped in usual fashion Two incisions were made along the right buttock approximately 5 mm diameter Purulent material was drained and irrigated with copious amounts of saline flush A Penrose drain was placed Penrose drain was ultimately sutured forming a circular drain The patient s drain will be kept in place for a period of 1 week and to be taken as an outpatient basis Anesthesia general endotracheal anesthesia Estimated blood loss approximately 5 mL Intravenous fluids 100 mL Tissue collected Purulent material from buttock abscess sent for usual cultures and chemistries Culture and sensitivity Gram stain A single Penrose drain was placed and left in the patient Dr X attending surgeon was present throughout the entire procedure Keywords dermatology incision and drainage purulent material penrose drain buttock abscess i d drainage MEDICAL_TRANSCRIPTION,Description A 60 total body surface area flame burns status post multiple prior excisions and staged graftings Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra not grafted on the back Medical Specialty Dermatology Sample Name Epidermal Autograft Transcription PREOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings POSTOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings PROCEDURES PERFORMED 1 Epidermal autograft on Integra to the back 3520 cm2 2 Application of allograft to areas of the lost Integra not grafted on the back 970 cm2 ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 50 cc BLOOD PRODUCTS RECEIVED One unit of packed red blood cells COMPLICATIONS None INDICATIONS The patient is a 26 year old male who sustained a 60 total body surface area flame burn involving the head face neck chest abdomen back bilateral upper extremities hands and bilateral lower extremities He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites the extent they will provide coverage OPERATIVE FINDINGS 1 Variable take of Integra particularly centrally and inferiorly on the back A fair amount of lost Integra over the upper back and shoulders 2 No evidence of infection 3 Healthy viable wound beds prior to grafting PROCEDURE IN DETAIL The patient was brought to the operating room and positioned supine General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed He was then repositioned prone and perioperative IV antibiotics were administered He was prepped and draped in the usual sterile manner All staples were removed from the Integra and the adherent areas of Silastic were removed The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution Hemostasis of the wound bed was ensured using epinephrine soaked Telfa pads Following dermal tumescence of the buttocks epidermal autografts were harvested 8 one thousandths of an inch using the air Zimmer dermatome These grafts were passed to the back table where they were meshed 3 1 The donor sites were hemostased using epinephrine soaked Telfa and lap pads Once all the grafts were meshed we brought them back up onto the field positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment We were happy with the lie of the grafts and they were stapled into place The grafts were then overlaid with Conformant 2 which was also stapled into place Utilizing all of his buttocks skin we did not have enough to cover his entire back so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment Allograft was thawed and meshed 1 1 It was then brought up onto the field trimmed to fit and stapled into place over the wound Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied Donor sites on his buttocks were dressed in Acticoat and secured with staples He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications He was transported to PACU in stable condition Keywords dermatology flame burns body surface area epidermal autograft autograft integra integra engraftment wound grafts epidermal allograft MEDICAL_TRANSCRIPTION,Description This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms Medical Specialty Dermatology Sample Name Itchy Rash ER Visit Transcription CHIEF COMPLAINT Itchy rash HISTORY OF PRESENT ILLNESS This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms No facial swelling No tongue or lip swelling No shortness of breath wheezing or other associated symptoms He cannot think of anything that could have triggered this off There have been no changes in his foods medications or other exposures as far as he knows He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day PAST MEDICAL HISTORY Negative for chronic medical problems No local physician Has had previous back surgery and appendectomy otherwise generally healthy REVIEW OF SYSTEMS As mentioned denies any oropharyngeal swelling No lip or tongue swelling No wheezing or shortness of breath No headache No nausea Notes itchy rash especially on his torso and upper arms SOCIAL HISTORY The patient is accompanied with his wife FAMILY HISTORY Negative MEDICATIONS None ALLERGIES TORADOL MORPHINE PENICILLIN AND AMPICILLIN PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile He is slightly tachycardic 105 but stable blood pressure and respiratory rate GENERAL The patient is in no distress Sitting quietly on the gurney HEENT Unremarkable His oral mucosa is moist and well hydrated Lips and tongue look normal Posterior pharynx is clear NECK Supple His trachea is midline There is no stridor LUNGS Very clear with good breath sounds in all fields There is no wheezing Good air movement in all lung fields CARDIAC Without murmur Slight tachycardia ABDOMEN Soft nontender SKIN Notable for a confluence erythematous blanching rash on the torso as well as more of a blotchy papular macular rash on the upper arms He noted some on his buttocks as well Remaining of the exam is unremarkable ED COURSE The patient was treated with epinephrine 1 1000 0 3 mL subcutaneously along with 50 mg of Benadryl intramuscularly After about 15 20 minutes he states that itching started to feel better The rash has started to fade a little bit and feeling a lot more comfortable IMPRESSION ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS ASSESSMENT AND PLAN The patient has what looks to be some type of allergic reaction although the underlying cause is difficult to assess He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off In the meantime I think he can be managed with some antihistamine over the counter He is responding already to Benadryl and the epinephrine that we gave him here He is told that if he develops any respiratory complaints shortness of breath wheezing or tongue or lip swelling he will return immediately for evaluation He is discharged in stable condition Keywords dermatology urticaria pruritus lip swelling allergic reaction itchy rash torso swelling itchy rash MEDICAL_TRANSCRIPTION,Description Evaluation and recommendations regarding facial rhytids Medical Specialty Dermatology Sample Name Facial Rhytids Transcription HISTORY This 57 year old female who presented today for evaluation and recommendations regarding facial rhytids In summary the patient is a healthy 57 year old female nonsmoker with no history of skin disease who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds RECOMMENDATIONS I do believe a facelift procedure would be of maximum effect for the patient s areas of concern and a quick lift type procedure certainly would address these issues I went over risks and benefits with the patient along with the preoperative and postoperative care and risks include but are not limited to bleeding infection discharge scar formation need for further surgery facial nerve injury numbness asymmetry of face problems with hypertrophic scarring problems with dissatisfaction with anticipated results and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center Keywords dermatology quick lift hypertrophic scarring facial rhytids mid face region nasolabial folds liftNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two layer closure Shave excision of the right nasal ala skin neoplasm Medical Specialty Dermatology Sample Name Excision Skin Neoplasm Transcription PREOPERATIVE DIAGNOSES 1 Enlarging nevus of the left upper cheek 2 Enlarging nevus 0 5 x 1 cm left lower cheek 3 Enlarging superficial nevus 0 5 x 1 cm right nasal ala TITLE OF PROCEDURES 1 Excision of left upper cheek skin neoplasm 0 5 x 1 cm with two layer closure 2 Excision of the left lower cheek skin neoplasm 0 5 x 1 cm with a two layer plastic closure 3 Shave excision of the right nasal ala 0 5 x 1 cm skin neoplasm ANESTHESIA Local I used a total of 5 mL of 1 lidocaine with 1 100 000 epinephrine ESTIMATED BLOOD LOSS Less than 10 mL COMPLICATIONS None PROCEDURE The patient was evaluated preop and noted to be in stable condition Chart and informed consent were all reviewed preop All risks benefits and alternatives regarding the procedure have been reviewed in detail with the patient Risks including but not limited to bleeding infection scarring recurrence of the lesion need for further procedures have been all reviewed Each of these lesions appears to be benign nevi however they have been increasing in size The lesions involving the left upper and lower cheek appear to be deep These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision Each of these lesions was marked The skin was cleaned with a sterile alcohol swab Local anesthetic was infiltrated Sterile prep and drape were then performed Began first excision of the left upper cheek skin lesion This was excised with the 15 blade full thickness Once it was removed in its entirety undermining was performed and the wound was closed with 5 0 myochromic for the deep subcutaneous 5 0 nylon interrupted for the skin The lesion of the lower cheek was removed in a similar manner Again it was excised with a 15 blade with two layer plastic closure Both these lesions appear to be fairly deep nevi The right nasal ala nevus was superficially shaved using the radiofrequency wave unit Each of these lesions was sent as separate specimens The patient was discharged from my office in stable condition He had minimal blood loss The patient tolerated the procedure very well Postop care instructions were reviewed in detail We have scheduled a recheck in one week and we will make further recommendations at that time Keywords dermatology enlarging nevus nevus skin neoplasm nasal ala cheek skin neoplasm shave excision superficial lesions neoplasm excision cheek MEDICAL_TRANSCRIPTION,Description Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm Medical Specialty Dermatology Sample Name Excision Keratotic Neoplasm Transcription PREOPERATIVE DIAGNOSES 1 Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm 2 Enlarging keratotic neoplasm of the left nasolabial fold measuring 0 5 x 0 5 cm 3 Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm POSTOPERATIVE DIAGNOSES 1 Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm 2 Enlarging keratotic neoplasm of the left nasolabial fold measuring 0 5 x 0 5 cm 3 Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm TITLE OF PROCEDURES 1 Excision of the left temple keratotic neoplasm final defect 1 8 x 1 5 cm with two layer plastic closure 2 Excision of the left nasolabial fold defect 0 5 x 0 5 cm with single layer closure 3 Excision of the right temple keratotic neoplasm final defect measuring 1 5 x 1 5 cm with two layer plastic closure ANESTHESIA Local using 3 mL of 1 lidocaine with 1 100 000 epinephrine ESTIMATED BLOOD LOSS Less than 30 mL COMPLICATIONS None PROCEDURE The patient was evaluated preoperatively and noted to be in stable condition Informed consent was obtained from the patient All risks benefits and alternatives regarding the surgery have been reviewed in detail with the patient This includes risks of bleeding infection scarring recurrence of lesion need for further procedures etc Each of the areas was cleaned with a sterile alcohol swab Planned excision site was marked with a marking pen Local anesthetic was infiltrated Sterile prep and drape were then performed We began first with excision of the left temple followed by the left nasolabial and right temple lesions The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm However it is somewhat deeper than the standard seborrheic keratosis The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region Once this was removed wide undermining was performed and the wound was closed in a two layer fashion using 5 0 myochromic for the deep subcutaneous and 5 0 nylon for the skin Excision of left cheek was a keratotic nevus It was excised with a defect 0 5 x 0 5 cm It was closed in a single layer fashion 5 0 nylon The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension Once it was excised full thickness the defect measure 1 5 x 1 5 cm Wide undermine was performed and it was closed in a two layer fashion using 5 0 myochromic for the deep subcutaneous 5 0 nylon that was used to close skin Sterile dressing was applied afterwards The patient was discharged in stable condition Postop care instructions reviewed in detail She is scheduled with me in one week and we will make further recommendations at that time Keywords dermatology keratotic lesion keratotic neoplasm seborrheic keratotic neoplasm seborrheic keratotic neoplasm nasolabial two layer plastic closure nasolabial fold excision MEDICAL_TRANSCRIPTION,Description Hand dermatitis Medical Specialty Dermatology Sample Name Dermatitis SOAP Transcription SUBJECTIVE This is a 29 year old Vietnamese female established patient of dermatology last seen in our office on 07 13 04 She comes in today as a referral from ABC D O for a reevaluation of her hand eczema I have treated her with Aristocort cream Cetaphil cream increased moisturizing cream and lotion and wash her hands in Cetaphil cleansing lotion She comes in today for reevaluation because she is flaring Her hands are very dry they are cracked she has been washing with soap She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin She has been wearing some gloves also apparently The patient is single She is unemployed FAMILY SOCIAL AND ALLERGY HISTORY The patient has asthma sinus hives and history of psoriasis No known drug allergies MEDICATIONS The patient is a nonsmoker No bad sunburns or blood pressure problems in the past CURRENT MEDICATIONS Claritin and Zyrtec p r n PHYSICAL EXAMINATION The patient has very dry cracked hands bilaterally IMPRESSION Hand dermatitis TREATMENT 1 Discussed further treatment with the patient and her interpreter 2 Apply Aristocort ointment 0 1 and equal part of Polysporin ointment t i d and p r n itch 3 Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion 4 Keflex 500 mg b i d times two weeks with one refill Return in one month if not better otherwise on a p r n basis and send Dr XYZ a letter on this office visit Keywords dermatology cetaphil cleansing lotion hand dermatitis aristocort wash ointment hand lotion dermatitis MEDICAL_TRANSCRIPTION,Description Excisional biopsy of actinic keratosis and skin nevus two layer and one layer plastic closures Medical Specialty Dermatology Sample Name Biopsy Actinic Keratosis Transcription PREOPERATIVE DIAGNOSES 1 Left chest actinic keratosis 2 cm 2 Left medial chest actinic keratosis 1 cm 3 Left shoulder actinic keratosis 1 cm POSTOPERATIVE DIAGNOSES 1 Left chest actinic keratosis 2 cm 2 Left medial chest actinic keratosis 1 cm 3 Left shoulder actinic keratosis 1 cm TITLE OF PROCEDURES 1 Excisional biopsy of left chest 2 cm actinic keratosis 2 Two layer plastic closure 3 Excisional biopsy of left chest medial actinic keratosis 1 cm with one layer plastic closure 4 Excisional biopsy of left should skin nevus 1 cm one layer plastic closure ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 6 mL ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None PROCEDURE All areas were prepped draped and localized in the usual manner Afterwards elliptical incisions were placed with a 15 blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions After all were removed they were closed with one layer technique for the shoulder and medial lesion and the larger left chest lesion was closed with two layer closure using Monocryl 5 0 for subcuticular closure and 5 0 nylon for skin closure She tolerated this procedure very well and postoperative care instructions were provided She will follow up next week for suture removal Of note she had an episode of hemoptysis which could not be explained prompting an emergency room visit and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made Keywords dermatology two layer plastic closure one layer plastic closure skin nevus actinic keratosis plastic closures keratosis actinic biopsy forceps layer closures chest MEDICAL_TRANSCRIPTION,Description Temporal cheek neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek neck and jowl lipotosis and facial rhytides Medical Specialty Dermatology Sample Name Cheek Neck Facelift Transcription PREOPERATIVE DIAGNOSIS Facial and neck skin ptosis Cheek neck and jowl lipotosis Facial rhytides POSTOPERATIVE DIAGNOSIS Same PROCEDURE Temporal cheek neck facelift CPT 15825 Submental suction assisted lipectomy CPT 15876 ANESTHESIA General DESCRIPTION OF PROCEDURE This patient is a 65 year old female who has progressive aging changes of the face and neck The patient demonstrates the deformities described above and has requested surgical correction The procedure risks limitations and alternatives in this individual case have been very carefully discussed with the patient The patient has consented to surgery The patient was brought into the operating room and placed in the supine position on the operating table An intravenous line was started and anesthesia was maintained throughout the case The patient was monitored for cardiac blood pressure and oxygen saturation continuously The hair was prepared and secured with rubber bands and micropore tape along the incision line A marking pen had been used to outline the area of the incisions which included the preauricular area to the level of the tragus the post tragal region the post auricular region and into the hairline In addition the incision was marked in the temporal area in the event of a temporal lift then across the coronal scalp for the forehead lift The incision was marked in the submental crease for the submental lipectomy and liposuction The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline The areas to be operated on were injected with 1 Lidocaine containing 1 100 000 Epinephrine This provided local anesthesia and vasoconstriction The total of Lidocaine used throughout the procedure was maintained at no more than 500mg SUBMENTAL SUCTION ASSISTED LIPECTOMY The incision was made as previously outlined in the submental crease in a transverse direction through the skin and subcutaneous tissue and hemostasis was obtained with bipolar cautery A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly The tunnels were enlarged with a 6mm flat liposuction cannula Then with the Wells Johnson liposuction machine 27 29 inches of underwater mercury suction was accomplished in all tunnels Care was taken not to turn the opening of the suction cannula up to the dermis but it was rotated in and out taking a symmetrical amount of fat from each area A similar procedure was performed with the 4 mm cannula cleaning the area Bilateral areas were palpated for symmetry and any remaining fat was then suctioned directly A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle A plication stitch of 3 0 Vicryl was placed When a satisfactory visible result had been accomplished from the liposuction the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion 5 0 plain catgut was used for closure in a running interlocking fashion The wound was cleaned at the end dried and Mastisol applied Then tan micropore tape was placed for support to the entire area FACE LIFT After waiting approximately 10 15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal A gentle curve was then made and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region A preauricular incision was carried into the natural crease superior to the tragus curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin The incision was made in the temporal area beveling parallel with the hair follicles The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim At the superior level of the zygoma and at the level of the sideburn dissection was brought more superficially in order to avoid the nerves and vessels in the areas specifically the frontalis branch of the facial nerve The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8 10cm in the neck region When the areas of dissection had been connected carefully hemostasis was obtained and all areas inspected At no point were muscle fibers or major vessels or nerves encountered in the dissection The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM The SMAS flap was then advanced posteriorly and superiorly The SMAS was split at the level of the earlobe and the inferior portion was sutured to the mastoid periosteum The excess SMAS was trimmed and excised from the portion anterior to the auricle The SMAS was then imbricated with 2 0 Surgidak interrupted sutures The area was then inspected for any bleeding points and careful hemostasis obtained The flaps were then rotated and advanced posteriorly and then superiorly and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2 0 Tycron suture The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period Skin closure was accomplished in the hairbearing areas with 5 0 Nylon in the preauricular tuft and 4 0 Nylon interrupted in the post auricular area The pre auricular area was closed first with 5 0 Dexon at the ear lobules and 6 0 Nylon at the lobules and 5 0 plain catgut in a running interlocking fashion 5 0 Plain catgut was used in the post auricular area as well leaving ample room for serosanguinous drainage into the dressing The post tragal incisin was closed with interrupted and running interlocking 5 0 plain catgut The exact similar procedure was repeated on the left side At the end of this procedure all flaps were inspected for adequate capillary filling or any evidence of hematoma formation Any small amount of fluid was expressed post auricularly A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines ABD padding over 4X4 gauze was used to cover the pre and post auricular areas This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non constricting but secured fashion The entire dressing complex was secured with a pre formed elastic stretch wrap device All branches of the facial nerve were checked and appeared to be functioning normally The procedures were completed without complication and tolerated well The patient left the operating room in satisfactory condition A follow up appointment was scheduled routine post op medications prescribed and post op instructions given to the responsible party The patient was released to home in satisfactory condition Keywords dermatology neck skin ptosis lipotosis rhytides facelift submental suction assisted lipectomy pre and post auricular cheek neck facelift auricular region neck facelift cheek neck post auricular auricular incision postoperative cheek submental dissection neck MEDICAL_TRANSCRIPTION,Description First degree and second degree burns right arm secondary to hot oil spill Workers Compensation industrial injury Medical Specialty Dermatology Sample Name Burn Consult Transcription CHIEF COMPLAINT Burn right arm HISTORY OF PRESENT ILLNESS This is a Workers Compensation injury This patient a 41 year old male was at a coffee shop where he works as a cook and hot oil splashed onto his arm burning from the elbow to the wrist on the medial aspect He has had it cooled and presents with his friend to the Emergency Department for care PAST MEDICAL HISTORY Noncontributory MEDICATIONS None ALLERGIES None PHYSICAL EXAMINATION GENERAL Well developed well nourished 21 year old male adult who is appropriate and cooperative His only injury is to the right upper extremity There are first and second degree burns on the right forearm ranging from the elbow to the wrist Second degree areas with blistering are scattered through the medial aspect of the forearm There is no circumferential burn and I see no areas of deeper burn The patient moves his hands well Pulses are good Circulation to the hand is fine FINAL DIAGNOSIS 1 First degree and second degree burns right arm secondary to hot oil spill 2 Workers Compensation industrial injury TREATMENT The wound is cooled and cleansed with soaking in antiseptic solution The patient was ordered Demerol 50 mg IM for pain but he refused and did not want pain medication A burn dressing is applied with Neosporin ointment The patient is given Tylenol No 3 tabs 4 to take home with him and take one or two every four hours p r n for pain He is to return tomorrow for a dressing change Tetanus immunization is up to date Preprinted instructions are given Workers Compensation first report and work status report are completed DISPOSITION Home Keywords dermatology burn workers compensation industrial injury workers compensation degree MEDICAL_TRANSCRIPTION,Description 1 year black female for initial evaluation of a lifelong history of atopic eczema Medical Specialty Dermatology Sample Name Atopic Eczema Transcription SUBJECTIVE This 1 year black female new patient in dermatology sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema The patient s mom is from Tanzania The patient has been treated with Elidel cream b i d for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson s Baby Oil on her The patient is a well developed baby Appears stated age Overall health is good FAMILY SOCIAL AND ALLERGY HISTORY The patient has eczema and a positive atopic family history No psoriasis No known drug allergies CURRENT MEDICATIONS None PHYSICAL EXAMINATION The patient has eczematous changes today on her face trunk and extremities IMPRESSION Atopic eczema TREATMENT 1 Discussed condition and treatment with Mom 2 Continue bathing twice a week 3 Discontinue hot soapy water 4 Discontinue Elidel for now 5 Add Aristocort cream 0 25 Polysporin ointment Aquaphor b i d and p r n itch We will see her in one month if not better otherwise on a p r n basis Send a letter to ABC Practice program Keywords dermatology elidel cream johnson s baby oil polysporin ointment atopic eczema eczema eczematous hot soapy water atopic elidel MEDICAL_TRANSCRIPTION,Description Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days Medical Specialty Dentistry Sample Name Toothache ER Visit Transcription CHIEF COMPLAINT Toothache HISTORY OF PRESENT ILLNESS This is a 29 year old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled Complains of new tooth pain The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments he has to be on standby appointments only The patient denies any other problems or complaints The patient denies any recent illness or injuries The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness No recent weight change HEENT No headache no neck pain the toothache pain for the past three days as previously mentioned There is no throat swelling no sore throat no difficulty swallowing solids or liquids The patient denies any rhinorrhea No sinus congestion pressure or pain no ear pain no hearing change no eye pain or vision change CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath or cough GASTROINTESTINAL No abdominal pain No nausea or vomiting GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No focal weakness or numbness Normal speech HEMATOLOGIC LYMPHATIC No lymph node swelling has been noted PAST MEDICAL HISTORY Chronic knee pain CURRENT MEDICATIONS OxyContin and Vicodin ALLERGIES PENICILLIN AND CODEINE SOCIAL HISTORY The patient is still a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 9 oral blood pressure is 146 83 pulse is 74 respirations 16 oxygen saturation 98 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed The patient is a little overweight but otherwise appears to be healthy The patient is calm comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Eyes are normal with clear conjunctiva and cornea bilaterally There is no icterus injection or discharge Pupils are 3 mm and equally round and reactive to light bilaterally There is no absence of light sensitivity or photophobia Extraocular motions are intact bilaterally Ears are normal bilaterally without any sign of infection There is no erythema swelling of canals Tympanic membranes are intact without any erythema bulging or fluid levels or bubbles behind it Nose is normal without rhinorrhea or audible congestion There is no tenderness over the sinuses NECK Supple nontender and full range of motion There is no meningismus No cervical lymphadenopathy No JVD Mouth and oropharynx shows multiple denture and multiple dental caries The patient has tenderness to tooth 12 as well as tooth 21 The patient has normal gums There is no erythema or swelling There is no purulent or other discharge noted There is no fluctuance or suggestion of abscess There are no new dental fractures The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling The buccal membranes are normal Mucous membranes are moist The floor of the mouth is normal without any abscess suggestion of Ludwig s syndrome CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally without shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to back arms and legs The patient has normal use of his extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact to the extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No cervical lymphadenopathy is palpated EMERGENCY DEPARTMENT COURSE The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction DIAGNOSES 1 ODONTALGIA 2 MULTIPLE DENTAL CARIES CONDITION UPON DISPOSITION Stable DISPOSITION To home PLAN The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes The patient was requested to have reevaluation within two days The patient was given a prescription for Percocet and clindamycin The patient was given drug precautions for the use of these medicines The patient was offered discharge instructions on toothache but states that he already has it He declined the instructions The patient was asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern Keywords dentistry odontalgi multiple dental caries dentist dental disease extensive dental disease teeth pulled lower teeth cervical lymphadenopathy dental caries toothache erythema swelling teeth dental MEDICAL_TRANSCRIPTION,Description Cauterization of peri and intra anal condylomas Extensive perianal and intra anal condyloma which are likely represent condyloma acuminata Medical Specialty Dermatology Sample Name Condyloma Cauterization Transcription PREOPERATIVE DIAGNOSIS Extensive perianal and intra anal condyloma POSTOPERATIVE DIAGNOSIS Extensive perianal and intra anal condyloma PROCEDURE PERFORMED Cauterization of peri and intra anal condylomas ANESTHESIA IV sedation and local SPECIMEN Multiple condylomas were sent to pathology ESTIMATED BLOOD LOSS 10 cc BRIEF HISTORY This is a 22 year old female who presented to the office complaining of condylomas she had noted in her anal region She has noticed approximately three to four weeks ago She denies any pain but does state that there is some itching No other symptoms associated GROSS FINDINGS We found multiple extensive perianal and intra anal condylomas which are likely represent condyloma acuminata PROCEDURE After risks benefits and complications were explained to the patient and a verbal consent was obtained the patient was taken to the operating room After the area was prepped and draped a local anesthesia was achieved with Marcaine Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure The condylomas were removed 350 degrees from the perianal and intra anal regions After all visible condylomas were removed the area was again washed with acetic acid solution Any residual condylomas were then cauterized at this time The area was then examined again for any residual bleeding and there was none DISPOSITION The patient was taken to Recovery in stable condition She will be sent home with prescriptions for a topical lidocaine and Vicodin She will be instructed to do sitz bath b i d and post bowel movement She will follow up in the office next week Keywords dermatology intra anal perianal acuminata cauterization condyloma anal MEDICAL_TRANSCRIPTION,Description Left buttock abscess status post incision and drainage Recommended some local wound care Medical Specialty Dermatology Sample Name Buttock Abscess Transcription CHIEF COMPLAINT Buttock abscess HISTORY OF PRESENT ILLNESS This patient is a 24 year old African American female who presented to the hospital with buttock pain She started off with a little pimple on the buttock She was soaking it at home without any improvement She came to the hospital on the first The patient underwent incision and drainage in the emergency department She was admitted to the hospitalist service with elevated blood sugars She has had positive blood cultures Surgery is consulted today for evaluation PAST MEDICAL HISTORY Diabetes type II poorly controlled high cholesterol PAST SURGICAL HISTORY C section and D C ALLERGIES NO KNOWN DRUG ALLERGIES MEDICATIONS Insulin metformin Glucotrol and Lipitor FAMILY HISTORY Diabetes hypertension stroke Parkinson disease and heart disease REVIEW OF SYSTEMS Significant for pain in the buttock Otherwise negative PHYSICAL EXAMINATION GENERAL This is an overweight African American female not in any distress VITAL SIGNS She has been afebrile since admission Vital signs have been stable Blood sugars have been in the 200 range HEENT Normal to inspection NECK No bruits or adenopathy LUNGS Clear to auscultation CV Regular rate and rhythm ABDOMEN Protuberant soft and nontender EXTREMITIES No clubbing cyanosis or edema RECTAL EXAM The patient has a drained abscess on the buttock cheek There is some serosanguineous drainage There is no longer any purulent drainage The wound appears relatively clean I do not see a lot of erythema ASSESSMENT AND PLAN Left buttock abscess status post incision and drainage I do not believe surgical intervention is warranted I have recommended some local wound care Please see orders for details Keywords dermatology buttock pain pimple incision and drainage local wound care blood sugars diabetes buttock abscess MEDICAL_TRANSCRIPTION,Description Extraction of teeth 2 and 19 and incision and drainage I D of intraoral and extraoral of left mandibular dental abscess Medical Specialty Dentistry Sample Name Teeth Extraction I D 1 Transcription PREOPERATIVE DIAGNOSES Carious teeth 2 and 19 and left mandibular dental abscess POSTOPERATIVE DIAGNOSES Carious teeth 2 and 19 and left mandibular dental abscess PROCEDURES Extraction of teeth 2 and 19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess ANESTHESIA General oral endotracheal COMPLICATIONS None DRAINS Penrose 0 25 inch intraoral and vestibule and extraoral CONDITION Stable to PACU DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure In addition the extraoral area on the left neck was prepped with Betadine and draped accordingly Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant total of 3 4 mL of lidocaine 2 with 1 100 000 epinephrine and Marcaine 1 7 mL of 0 5 with 1 200 000 epinephrine An incision was made with 15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible No purulent drainage was obtained The 0 25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3 0 silk suture Moving to the intraoral area periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth 19 The area did not drain any purulent material The carious tooth 19 was then extracted by elevator and forceps extraction After the tooth was removed the 0 25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3 0 silk suture The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth 2 was then extracted by routine elevator and forceps extraction After the extraction the throat pack was removed An orogastric tube was then placed by Dr X and stomach contents were suctioned The pharynx was then suctioned with the Yankauer suction The patient was awakened extubated and taken to the PACU in stable condition Keywords dentistry yankauer suction orogastric tube carious teeth penrose drain forceps extraction dental abscess incision elevator mandibular dental abscess teeth intraoral extraction drainage MEDICAL_TRANSCRIPTION,Description Extraction of teeth Incision and drainage I D of left mandibular vestibular abscess adjacent to teeth 18 and 19 Medical Specialty Dentistry Sample Name Teeth Extraction I D Transcription PREOPERATIVE DIAGNOSES 1 Carious teeth 2 5 12 15 18 19 and 31 2 Left mandibular vestibular abscess POSTOPERATIVE DIAGNOSES 1 Carious teeth 2 5 12 15 18 19 and 31 2 Left mandibular vestibular abscess PROCEDURE 1 Extraction of teeth 2 5 12 15 18 19 31 2 Incision and drainage I D of left mandibular vestibular abscess adjacent to teeth 18 and 19 ANESTHESIA General nasotracheal COMPLICATIONS None DRAIN Quarter inch Penrose drain place in left mandibular vestibule adjacent to teeth 18 and 19 secured with 3 0 silk suture CONDITION The patient was taken to the PACU in stable condition INDICATION Patient is a 32 year old female who was admitted yesterday 03 04 10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess DESCRIPTION OF PROCEDURE Patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route patient was prepped and draped in the usual fashion for an intraoral procedure A gauze throat pack was placed and local anesthetic was administered in all four quadrants a total of 6 8 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of Marcaine 0 5 with 1 200 000 epinephrine The area in the left vestibular area adjacent to the teeth 18 and 19 was aspirated with 5 cc syringe with an 18 guage needle and approximately 1 mL of purulent material was aspirated This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab An incision was then made in the left mandibular vestibule adjacent to teeth 18 and 19 The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained Penrose drain was then placed using a curved hemostat The drain was secured with 3 0 silk suture The extraction of the teeth was then begun on the left side removing teeth 12 15 18 and 19 with forceps extraction then moving to the right side teeth 2 5 and 31 were removed with forceps extraction uneventfully After completion of the procedure the throat pack was removed the pharynx was suctioned The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube The nasogastric tube was then removed Patient was then extubated and taken to the PACU in stable condition Keywords dentistry mandibular vestibular abscess throat pack purulent material forceps extraction nasogastric tube carious teeth incision teeth nasogastric carious extraction MEDICAL_TRANSCRIPTION,Description Acne with folliculitis Medical Specialty Dermatology Sample Name Acne SOAP Transcription SUBJECTIVE The patient is a 49 year old white female established patient to Dermatology last seen in the office on 08 10 2004 She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest stomach neck and back On examination this is a flaring of her acne with small folliculitis lesions The patient has been taking amoxicillin 500 mg b i d and using Tazorac cream 0 1 and her face is doing well but she has been out of her medicine now for three days also She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products etc The patient is married She is a secretary FAMILY SOCIAL AND ALLERGY HISTORY She has hay fever eczema sinus and hives She has no melanoma or skin cancers or psoriasis Her mother had oral cancer The patient is a nonsmoker No blood tests Had some sunburn in the past She is on benzoyl peroxide and Daypro CURRENT MEDICATIONS Lexapro Effexor Ditropan aspirin vitamins PHYSICAL EXAMINATION The patient is well developed appears stated age Overall health is good She has a couple of acne lesions one on her face and neck but there are a lot of small folliculitis like lesions on her abdomen chest and back IMPRESSION Acne with folliculitis TREATMENT 1 Discussed condition and treatment with the patient 2 Continue the amoxicillin 500 mg two at bedtime 3 Add Septra DS every morning with extra water 4 Continue the Tazorac cream 0 1 it is okay to use on back and chest also 5 Referred to ABC clinic for an aesthetic consult Return in two months for followup evaluation of her acne Keywords dermatology acne with folliculitis tazorac cream acne tazorac cream folliculitis MEDICAL_TRANSCRIPTION,Description Removal of cystic lesion removal of teeth modified Le Fort I osteotomy MEDICAL_TRANSCRIPTION,Description Extraction of tooth T and incision and drainage I D of right buccal space infection Right buccal space infection and abscess tooth T Medical Specialty Dentistry Sample Name Teeth Extraction I D 2 Transcription PREOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth T POSTOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth T PROCEDURE Extraction of tooth T and incision and drainage I D of right buccal space infection ANESTHESIA General oral endotracheal tube COMPLICATIONS None SPECIMENS Aerobic and anaerobic cultures were sent IV FLUID 150 mL ESTIMATED BLOOD LOSS 10 mL PROCEDURE The patient was brought to the operating room placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route the patient was prepped and draped in the usual fashion for an intraoral procedure Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located The abscess cavity was aspirated using a 5 mL syringe with an 18 gauge needle Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing The area in the buccal vestibule was then opened with approximately 1 cm incision Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity A small amount of additional purulence was drained from it approximately 1 mL and at this point tooth T was extracted by forceps extraction Periosteal elevator was used to explore the area near the extraction site This was continuous with abscess cavity so the abscess cavity was allowed to drain into the extraction site No drain was placed Upon completion of the procedure the throat pack was removed The pharynx was suctioned The stomach was also suctioned and the patient was then awakened extubated and taken to the recovery room in stable condition Keywords dentistry buccal space incision and drainage throat pack extraction site tooth i d drainage infection cavity extraction incision buccal abscess MEDICAL_TRANSCRIPTION,Description Acne from continually washing area frequent phone use so the receiver rubs on face and oral contraceptive use Acne Vulgaris Medical Specialty Dermatology Sample Name Acne Vulgaris H P Transcription CHIEF COMPLAINT 1 1 This 19 year old female presents today complaining of acne from continually washing area frequent phone use so the receiver rubs on face and oral contraceptive use Location She indicates the problem location is the chin right temple and left temple locally Severity Severity of condition is worsening Menses Onset 13 years old Interval 22 27 days Duration 4 6 days Flow light Complications none ALLERGIES Patient admits allergies to penicillin resulting in difficulty breathing MEDICATION HISTORY Patient is currently taking Alesse 28 20 mcg 0 10 mg tablet usage started on 08 07 2001 medication was prescribed by Obstetrician Gynecologist A PAST MEDICAL HISTORY Female Reproductive Hx birth control pill use Childhood Illnesses chickenpox measles PAST SURGICAL HISTORY No previous surgeries FAMILY HISTORY Patient admits a family history of anxiety stress disorder associated with mother SOCIAL HISTORY Patient admits caffeine use She consumes 3 5 servings per day Patient admits alcohol use Drinking is described as social Patient admits good diet habits Patient admits exercising regularly Patient denies STD history REVIEW OF SYSTEMS Integumentary periodic reddening of face acne problems Allergic Immunologic allergic or immunologic symptoms Constitutional Symptoms constitutional symptoms such as fever headache nausea dizziness PHYSICAL EXAM Patient is a 19 year old female who appears pleasant in no apparent distress her given age well developed well nourished and with good attention to hygiene and body habitus Skin Examination of scalp shows no abnormalities Hair growth and distribution is normal Inspection of skin outside of affected area reveals no abnormalities Palpation of skin shows no abnormalities Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis chromidrosis or bromhidrosis Face shows keratotic papule IMPRESSION Acne vulgaris PLAN Recommended treatment is antibiotic therapy Patient received extensive counseling about acne She understands acne treatment is usually long term Return to clinic in 4 week s PATIENT INSTRUCTIONS Patient received literature regarding acne vulgaris Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion PRESCRIPTIONS Tetracycline Dosage 250 mg capsule Sig BID Dispense 60 Refills 0 Allow Generic Yes Keywords MEDICAL_TRANSCRIPTION,Description Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 Open reduction internal fixation ORIF of bilateral mandible fractures with multiple approaches CPT code 21470 and surgical extraction of teeth 17 CPT code 41899 Medical Specialty Dentistry Sample Name ORIF Mandible Fracture Transcription PREOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 POSTOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802 35 and open symphysis of mandible 802 36 PROCEDURE Open reduction internal fixation ORIF of bilateral mandible fractures with multiple approaches CPT code 21470 and surgical extraction of teeth 17 CPT code 41899 ANESTHESIA General anesthesia via nasal endotracheal intubation FLUIDS 1800 mL of LR ESTIMATED BLOOD LOSS 150 mL HARDWARE A 2 3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2 0 reconstruction plate on the left angle SPECIMEN None COMPLICATIONS None CONDITION The patient was extubated to the PACU breathing spontaneously in excellent good condition INDICATIONS FOR THE PROCEDURE The patient is a 55 year old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder He was worked up by the emergency department His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage Oral maxillary facial surgery was consulted to manage the mandible fracture After review of the CT and examination it was determined that the patient would benefit from open reduction internal fixation of bilateral mandible fractures Risks benefits and alternative to treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was brought to the operating room 2 at Hospital He was laid in supine position on the operating room table ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics The patient was prepped and draped in the usual oral maxillofacial surgery fashion The surgeon approached the operating room table in a sterile fashion Approximately 10 mL of 1 lidocaine with 1 100 000 epinephrine was injected into oral vestibule in a nerve block fashion Erich arch bars were adapted to the maxilla and mandible secured in the posterior teeth with 24 gauge surgical steel wire and 26 gauge surgical steel wire in the anterior This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth The patient was manipulated up into maximum intercuspation He has a malocclusion with severe bruxism and so wear facets were lined up This was secured with 26 gauge surgical steel wire Attention was then directed to the symphysis extraorally Approximately 5 mL of 1 lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible After waiting appropriate time for local anesthesia using a 15 blade a skin and platysma incision was made Then using a series of blunt and sharp dissections the dissection was carried to the inferior border of the mandible The periosteum was incised and reflected with the periosteal elevator The fracture was noted and it was displaced Manipulation of the segments and checking with the occlusion intraorally the fracture was aligned This was secured with 7 hole 2 3 titanium locking reconstruction plate with bicortical screws The wound was then packed with moist Ray Tec and attention was directed intraorally to the left angle fracture Approximately 5 mL of 1 lidocaine with 1 100 000 epinephrine was injected into the left vestibule After waiting appropriate time for local anesthesia to take effect using Bovie electrocautery a sagittal split incision was made and the fracture was identified It was noted that the fracture went through tooth 17 and this needed to be extracted Taking a round bur a buckle trough was made and the tooth was elevated and removed both distal and mesial roots The fracture was then reduced and lateral superior border plate 2 0 4 whole with monocortical screws was placed The fracture was noted to be well reduced The wound was then irrigated with copious amount of sterile water The patient was released for excellent intercuspation He was then manipulated up into the occlusion easily Wound was then closed with running 3 0 chromic gut suture Attention was then directed extraorally This was irrigated with copious amount of sterile water and closed in a layer fashion with 3 0 Vicryl 4 0 Vicryl and 5 0 Prolene on skin Attention was then again directed into the mouth The throat pack was removed and orogastric tube was placed and stomach content was evacuated The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions At this point the procedure was then determined to be over The patient was extubated and breathing spontaneously transported to the PACU in excellent condition Keywords dentistry mandible endotracheal leibinger pacu oral maxillary facial surgery maxillofacial buckle round bur lidocaine with epinephrine surgical steel wire bilateral mandible fractures mandible fracture orif symphysis fracture MEDICAL_TRANSCRIPTION,Description Open reduction and internal fixation of left atrophic mandibular fracture removal of failed dental implant from the left mandible The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture Medical Specialty Dentistry Sample Name ORIF Mandibular Fracture Dental Implant Removal Transcription PREOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant POSTOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant PROCEDURE PERFORMED Open reduction and internal fixation ORIF of left atrophic mandibular fracture removal of failed dental implant from the left mandible ANESTHESIA General nasotracheal ESTIMATED BLOOD LOSS 125 mL FLUIDS GIVEN 1 L of crystalloids SPECIMEN Soft tissue from the fracture site sent for histologic diagnosis CULTURES Also sent for Gram stain aerobic and anaerobic culture and sensitivity INDICATIONS FOR THE PROCEDURE The patient is a 79 year old male who fell in his hometown following an episode of syncope He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above mentioned fracture He was admitted to hospital in Harleton Texas where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass His mandible fracture was not noted initially The patient also has a history of prostate cancer and a renal cell carcinoma The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending The patient later saw a local oral surgeon He diagnosed his mandible fracture and advised him to seek treatment in Houston He presented to my office for evaluation on January 18 2010 and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant which had been placed approximately 15 years ago The patient had significant discomfort and could eat foods and drink fluids with difficulty Due to the nature of his fracture and the complex medical history he was sent to the hospital for admission and following cardiac clearance he was scheduled for surgery today PROCEDURE IN DETAIL The patient was taken to the operating room and placed in a supine position Following a nasal intubation and induction of general anesthesia the surgeon then scrubbed gowned and gloved in the normal sterile fashion The patient was then prepped and draped in a manner consistent with sterile procedures A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region approximately 1 5 cm medial to the inferior border of the mandible A 1 mL of lidocaine 1 with 1 100 000 epinephrine was then infiltrated along the incision and then a 15 blade was used to incise through the skin and subcutaneous tissue A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible Electrocautery as well as 4 0 silk ties were used for hemostasis A 15 blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11 hole Synthes reconstruction plate was then used to stand on the fracture site Since there was an area of weakness in the right parasymphysis region in the location of another dental implant the bone plate was extended posterior to that site When the plate was adapted to the mandible it was then secured to the bone with 9 screws each being 2 mm in diameter and each screw was placed bicortically All the screws were also locking screws Following placement of the screws there was felt to be excellent stability of the fracture so the wound was irrigated with a copious amount of normal saline The incision was closed in multiple layers with 4 0 Vicryl in the muscular and subcutaneous layers and 5 0 nylon in the skin A sterile dressing was then placed over the incision The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs Estimated blood loss is 125 mL Keywords dentistry atrophic mandibular fracture dental implant open reduction and internal fixation orif mandibular fracture mandible atrophic mandibular dental implant MEDICAL_TRANSCRIPTION,Description Left facial cellulitis and possible odontogenic abscess Attempted incision and drainage I D of odontogenic abscess Medical Specialty Dentistry Sample Name Odontogenic Abscess I D Transcription PREOPERATIVE DIAGNOSES 1 Left facial cellulitis 2 Possible odontogenic abscess of the 18 19 and 20 POSTOPERATIVE DIAGNOSES 1 Left facial cellulitis 2 Possible odontogenic abscess of the 18 19 and 20 PROCEDURE PERFORMED Attempted incision and drainage I D of odontogenic abscess ANESTHESIA 1 lidocaine plain approximately 5 cc total COMPLICATIONS The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA The attempted FNA was without any purulent aspirate although limited in the area of attempted examination INDICATIONS FOR THE PROCEDURE The patient is a 39 year old Caucasian female who was admitted to ABCD General Hospital on 08 21 03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology The patient states that this was started approximately 24 hours ago The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain The patient admits to poor dental hygiene Denies any recent or dental abscesses in the past The patient is a substance abuser does admit to smoking cocaine approximately three days ago The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted After risks complications consequences and questions were discussed with the patient a written consent was obtained for an I D of a possible odontogenic abscess ________ on the CT scan PROCEDURE The patient was brought in upright and supine position Approximately 5 cc of 1 lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side This was done at the base of 18 19 and 20 teeth After this the patient did have approximately 2 more mg of morphine given through the IV for pain control After this the 18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of 18 tooth and 19 with one stick placed There were no signs of any purulent drainage although at this time the patient became very irate and noncompliant and refusing further examination The patient understood consequences of her actions Does state that she does not care at this time and just wants to be left alone At this time the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q 6h along with pain control utilizing Toradol morphine and Vicodin The patient will also be started on Peridex oral rinse of 10 cc p o swish and spit t i d and a K pad to the left face Keywords dentistry odontogenic facial cellulitis incision and drainage fna buccogingival odontogenic abscess abscess drainage i d cellulitis MEDICAL_TRANSCRIPTION,Description Letter on evaluation regarding extraction of mandibular left second molar tooth 18 Medical Specialty Dentistry Sample Name Letter Dentistry Transcription XYZ S RE ABC Dear Dr XYZ On your kind referral I had the pleasure of meeting and consulting with ABC on MM DD YYYY for evaluation regarding extraction of his mandibular left second molar tooth 18 This previously root canaled tooth now failed is scheduled for removal As per your request I agree that placement of an implant in the 20 and 19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area I have given Mr ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process We will plan to place two Straumann implants as per our normal protocol one each in the 19 and 20 positions with the 19 implant being a wide neck larger diameter implant I will plan on providing the prosthetic abutments the lab analogue and temporary healing cap at the end of the four month integration period If you have any additional suggestions or concerns please give me a call Best regards Keywords dentistry molar tooth extraction mandibular straumann wide neck placement positions prosthetic implant tooth MEDICAL_TRANSCRIPTION,Description Autologous iliac crest bone graft to maxilla and mandible under general anesthetic Maxillary atrophy severe mandibular atrophy acquired facial deformity and masticatory dysfunction Medical Specialty Dentistry Sample Name Iliac Crest Bone Graft Maxilla Mandible Transcription PREOPERATIVE DIAGNOSES 1 Maxillary atrophy 2 Severe mandibular atrophy 3 Acquired facial deformity 4 Masticatory dysfunction POSTOPERATIVE DIAGNOSES 1 Maxillary atrophy 2 Severe mandibular atrophy 3 Acquired facial deformity 4 Masticatory dysfunction PROCEDURE PERFORMED Autologous iliac crest bone graft to maxilla and mandible under general anesthetic Dr X and company accompanied the patient to OR 6 at 7 30 a m Nasal trachea intubation was performed per routine The bilateral iliac crest harvest was first performed by Dr X and company under separate OR report Once the bone was harvested surgical templets were used to recontour initially the maxillary graft and the mandibular graft Then CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft Subsequent to the harvest of the bilateral ilium the intraoral region was scrubbed per routine Surgical team scrubbed and gowned in usual fashion and the patient was draped Xylocaine 1 1 100 000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa A primary incision was made in the maxilla starting on the patient s left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion Release incisions were made in the posterior region of the maxilla A full thickness periosteal reflexion first exposed the palatal region The contents of the neurovascular canal from the greater palatine foramina were identified The hard palate was directly observed The facial tissues were then reflected exposing the lateral aspect of the maxilla the zygomatic arch the infraorbital nerve artery and vein the lateral piriform rim the inferior piriform rim and the remaining issue of the nasal spine Similar features were reflected on the contralateral side The area was re contoured with rongeurs The block of bone which was formed and harvested from the left ilium was then placed and found to be stable A surgical mallet then compressed this bone further into the region A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla Particulate bone was then placed around the remaining block of bone A piece of AlloDerm mixed with Croften and patient s platelet rich plasma which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded the tissues were approximated for primary closure without tension using interrupted and continuous sutures 3 0 Gore Tex Attention was brought then to the mandible 1 Xylocaine 1 100 000 epinephrine was infiltrated in the labial mucosa 5 cc were given A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body The anterior body was found to be approximately 3 mm in height A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible A similar procedure was done on the contralateral side The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1 6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self tapping 2 mm diameter titanium screws The block of bone was further re contoured in situ Particulate bone was then injected into the posterior tunnels bilaterally A piece of AlloDerm was placed over those particulate segments The tissues were approximated for primary closure using 3 0 Gore Tex suture both interrupted and horizontal mattress in form The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap The estimated blood loss in the harvest of the hip was 100 cc The estimated blood loss in the intraoral procedure was 220 cc Total blood loss for the procedure 320 cc The fluid administered 300 cc The urine out 180 All sponges were counted encountered for as were sutures The patient was taken to Recovery at approximately 12 o clock noon Keywords dentistry autologous iliac crest bone graft to mandible mandibular atrophy maxillary atrophy facial deformity masticatory dysfunction iliac crest bone graft mental foramina iliac crest bone autologous maxillary mandibular maxilla MEDICAL_TRANSCRIPTION,Description Excisional biopsy of skin nevus and two layer plastic closure Trichloroacetic acid treatment to left lateral nasal skin 2 5 cm to treat actinic keratosis Medical Specialty Dermatology Sample Name Biopsy Skin Nevus Transcription PREOPERATIVE DIAGNOSES 1 Left back skin nevus 2 cm 2 Right mid back skin nevus 1 cm 3 Right shoulder skin nevus 2 5 cm 4 Actinic keratosis left lateral nasal skin 2 5 cm POSTOPERATIVE DIAGNOSES 1 Left back skin nevus 2 cm 2 Right mid back skin nevus 1 cm 3 Right shoulder skin nevus 2 5 cm 4 Actinic keratosis left lateral nasal skin 2 5 cm PATHOLOGY Pending TITLE OF PROCEDURES 1 Excisional biopsy of left back skin nevus 2 cm two layer plastic closure 2 Excisional biopsy of mid back skin nevus 1 cm one layer plastic closure 3 Excisional biopsy of right shoulder skin nevus 2 5 cm one layer plastic closure 4 Trichloroacetic acid treatment to left lateral nasal skin 2 5 cm to treat actinic keratosis ANESTHESIA Xylocaine 1 with 1 100 000 dilution of epinephrine totaling 8 mL BLOOD LOSS Minimal COMPLICATIONS None PROCEDURE Consent was obtained The areas were prepped and draped and localized in the usual manner First attention was drawn to the left back An elliptical incision was made with a 15 blade scalpel The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse After dissection the skin was undermined Radiofrequency cautery was used for hemostasis and using a 5 0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4 0 nylon interrupted suture Next attention was drawn to the mid back The skin was incised with a vertical elliptical incision with a 15 blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors Afterwards the skin was approximated using 4 0 nylon interrupted sutures Next attention was drawn to the shoulder lesion It was previously marked and a 15 blade scalpel was used to make an elliptical incision into the skin Next the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis Next subcuticular plain was closed with 5 0 undyed Vicryl interrupted suture Skin was closed with 4 0 nylon suture interrupted Lastly trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed Please refer to separate operative report for details The patient tolerated this procedure very well and we will follow up next week for postoperative re evaluation or sooner if there are any problems Keywords dermatology mid back skin nevus actinic keratosis trichloroacetic acid treatment bishop forceps skin nevus plastic closure curved iris iris scissors nasal skin nevus biopsy nasal forceps MEDICAL_TRANSCRIPTION,Description Right buccal and canine s base infection from necrotic teeth ICD9 CODE 528 3 Incision and drainage of multiple facial spaces CPT Code 40801 Surgical removal of the following teeth The teeth numbers 1 2 3 4 and 5 CPT code 41899 and dental code 7210 Medical Specialty Dentistry Sample Name Surgical Removal of Teeth Transcription PREOPERATIVE DIAGNOSIS Right buccal and canine s base infection from necrotic teeth ICD9 CODE 528 3 POSTOPERATIVE DIAGNOSIS Right buccal and canine s base infection from necrotic teeth ICD9 Code 528 3 PROCEDURE Incision and drainage of multiple facial spaces CPT Code 40801 Surgical removal of the following teeth The teeth numbers 1 2 3 4 and 5 CPT code 41899 and dental code 7210 SPECIMENS Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab DRAINS A 1 5 inch Penrose drain placed in the right buccal and canine space ESTIMATED BLOOD LOSS 40 Ml FLUID 700 mL of crystalloid COMPLICATIONS None CONDITION The patient was extubated breathing spontaneously to the PACU in good condition INDICATION FOR PROCEDURE The patient is a 41 year old that has a recent history of toothache and tooth pain She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse The patient was admitted to the hospital on Monday for IV antibiotics Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia Risks benefits and alternatives of treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was taken to the operating room and laid on the operating room table on supine fashion ASA monitors were attached as stated General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics The patient was prepped and draped in usual oromaxillary facial surgery fashion An 18 gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space This pus was then cultured and sent to micro lab for cultures and sensitivities Approximately 7 mL of 1 lidocaine with 1 1000 epinephrine was injected in the maxillary vestibule and palate After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case Mouth rinse was then poured into the oral cavity The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction Using a 15 blade a clavicular incision from tooth 5 back to 1 with tuberosity release was performed A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space It was noted on exam that the tooth 1 was fractured off to the gum line with gross decay Tooth 2 3 4 and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth 2 and 3 and some mobility on teeth 4 and 5 It was decided that teeth 1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed Using a rongeur both buccal bone and the tooth 1 2 3 4 and 5 were surgically removed The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed This site was then irrigated with copious amounts of sterile water There was still noted to be induration in the buccal mucosa so 15 blade was used anterior to Stensen duct A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed A little to no pus was received Using a half inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2 0 Ethilon suture Remainder of the flap was left open to drain Further examination of the floor of mouth was soft The lateral pharynx was nonindurated or swollen At this point the throat pack was removed and OG tube was placed and the stomach contents were evacuated The procedure was then determined to be over The patient was extubated breathing spontaneously and transferred to the PACU in excellent condition Keywords dentistry cultures buccal teeth canine pacu teeth extractions oromaxillary facial facial surgery buccal space throat pack buccal mucosa surgical removal canine s base necrotic teeth cpt code infection oral surgery mucosa anesthesia facial pus toothache MEDICAL_TRANSCRIPTION,Description Patient started out having toothache now radiating into his jaw and towards his left ear Ellis type II dental fracture Medical Specialty Dentistry Sample Name Jaw Pain ER Visit Transcription CHIEF COMPLAINT Jaw pain HISTORY OF PRESENT ILLNESS This is a 58 year old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments but has not seen a dentist since this new toothache began The patient denies any facial swelling No headache No swelling to the throat No sore throat No difficulty swallowing liquids or solids No neck pain No lymph node swelling The patient denies any fever or chills Denies any other problems or complaints REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness HEENT No headache No neck pain No eye pain or vision change No rhinorrhea No sinus congestion pressure or pain No sore throat No throat swelling The patient does have the toothache on the left lower side that radiates towards his left ear as previously described The patient does not have ear pain or hearing change No pressure in the ear CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath GASTROINTESTINAL No nausea or vomiting No abdominal pain MUSCULOSKELETAL No back pain SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No speech change HEMATOLOGIC LYMPHATIC No lymph node swelling PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None CURRENT MEDICATIONS None ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient smokes marijuana The patient does not smoke cigarettes PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 2 oral blood pressure is 168 84 pulse is 87 respirations 16 and oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed The patient appears to be healthy The patient is calm comfortable in no acute distress looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctivae bilaterally Nose normal without rhinorrhea or audible congestion There is no tenderness over the sinuses Ears are normal without any sign of infection No erythema or swelling of the canals Tympanic membranes are intact and normal without any erythema bulging air fluid levels or bubbles behind it MOUTH The patient has a dental fracture at tooth 18 The patient states that the fracture is a couple of months old The patient does not have any obvious dental caries The gums are normal without any erythema swelling or evidence of infection There is no fluctuance or suggestion of abscess There is slight tenderness of the tooth 18 The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling Mucous membranes are moist Floor of the mouth is normal without any tenderness or swelling No suggestion of abscess There is no pre or post auricular lymphadenopathy either NECK Supple Nontender Full range of motion No meningismus No cervical lymphadenopathy No JVD No carotid artery or vertebral artery bruits CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally No shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to the back arms or legs The patient has normal use of the extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect No evidence of clinical intoxification HEMATOLOGIC LYMPHATIC No lymphadenitis is palpated DIAGNOSES 1 ACUTE LEFT JAW PAIN 2 18 DENTAL FRACTURE WHICH IS AN ELLIS TYPE II FRACTURE 3 ELEVATED BLOOD PRESSURE CONDITION UPON DISPOSITION Stable DISPOSITION Home PLAN We will have the patient follow up with his dentist Dr X in three to five days for reevaluation The patient was encouraged to take Motrin 400 mg q 6h as needed for pain The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain He was given precautions for drowsiness and driving with the use of this medication The patient was also given a prescription for pen V The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition develop any other problems or symptoms of concern Keywords dentistry jaw pain dental appointment ellis type ii fracture ellis type dental fracture toothache tenderness pressure erythema MEDICAL_TRANSCRIPTION,Description Full mouth dental rehabilitation in the operative room under general anesthesia Medical Specialty Dentistry Sample Name Full Mouth Dental Rehabilitation 2 Transcription OPERATION PERFORMED Full mouth dental rehabilitation in the operative room under general anesthesia PREOPERATIVE DIAGNOSIS Severe dental caries POSTOPERATIVE DIAGNOSES 1 Severe dental caries 2 Non restorable teeth COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY 43 minutes BRIEF HISTORY The patient was first seen by me on 04 26 2007 She had a history of open heart surgery at 11 months of age She presented with severe anterior caries with most likely dental extractions needed Due to her young age I felt that she would be best served in the safety of the hospital operating room After consultation with the mother she agreed to have her treated in the safety of the hospital operating room at Children s Hospital OPERATIVE PREPARATION This child was brought to Hospital Day Surgery and is accompanied by her mother There I met with them and discussed the needs of the child types of restorations to be performed the risks and benefits of the treatment as well as the options and alternatives of the treatment After all their questions and concerns were addressed I gave the informed consent to proceed with the treatment The patient s history and physical examination was reviewed Once she was cleared by Anesthesia and the child was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with a nasal endotracheal tube and the tube was stabilized The head was wrapped and the eyes were taped shut for protection An angiocatheter was placed in the left hand and an IV was started The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath A moist continuous throat pack was placed beyond the tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative clinical photographs were taken Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography After the radiographs were taken the lead shield was removed Prophylaxis was then performed using prophy cup and fluoridated prophy paste The teeth were then rinsed well and the patient s oral cavity was suctioned clean Clinical and radiographic examinations followed and areas of decay were noted During the restorative phase these areas of decay were entered into and removed Entry was made to the level of the dental enamel junction and beyond as necessary to remove it Final caries was removed and was confirmed upon reaching hard firm sounding dentin Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement Non restorable primary teeth would be extracted Upon conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were then taken The continuous gauze throat pack was removed with continuous suction with visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene All primary teeth were present Dental caries were present on the following teeth Tooth D E F and G caries on all surfaces teeth J lingual caries The remainder of her teeth and soft tissues were within normal limits The following restorations and procedures were performed Tooth D E F and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam CONCLUSION The mother was informed of the completion of the procedure She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care They will contact to my office in the event of immediate postoperative complications After full recovery she was discharged from the recovery room in the care of her mother Keywords dentistry full mouth dental rehabilitation dental rehabilitation full mouth dental caries non restorable teeth dental extractions throat pack oral cavity restorative phase primary teeth dental anesthesia mouth rehabilitation prophylaxis oral amalgam tooth MEDICAL_TRANSCRIPTION,Description Incision and drainage of right buccal space abscess and teeth extraction Medical Specialty Dentistry Sample Name I D Buccal Space Abscess Transcription PREOPERATIVE DIAGNOSES 1 Right buccal space abscess cellulitis 2 Nonrestorable caries teeth 1 29 and 32 POSTOPERATIVE DIAGNOSES 1 Right buccal space abscess cellulitis 2 Nonrestorable caries teeth 1 29 and 32 PROCEDURE 1 Incision and drainage of right buccal space abscess 2 Extraction of teeth 1 29 and 32 ANESTHESIA GETA EBL 20 mL IV FLUIDS 900 mL URINE OUTPUT Not measured COMPLICATIONS None SPECIMENS 1 Aerobic culture was sent from the right buccal space abscess cellulitis 2 Anaerobic culture from the same space was also obtained PROCEDURE IN DETAIL The patient was identified in the appropriate holding area and transported to 13 The patient was intubated by anesthesia orotracheally using a 7 ET tube The patient was induced in effective sleep using a propofol and gas inhalation anesthetics Following intubation the patient s mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack At that point approximately 5 mL of 2 lidocaine with 1 20 000 epinephrine was injected for a right inferior alveolar block as well as local infiltration in the right long buccal nerve area as well as the right cheek area Local infiltration also was done near the tooth 32 At this point a periosteal elevator was used to loosen up the gingival tissue of the teeth 1 29 and 32 and all 3 teeth were extracted using simple extraction using elevators and forceps In addition the previous Penrose drain was removed by removing the suture and the incision that was used for I D on the previous day was extended laterally A hemostat was used to puncture through to the right buccal space Approximately 2 5 to 3 mL of purulence was drained and that was used for Gram stain and culture as mentioned above Following copious irrigation of the area following the extraction and following the incision and drainage 2 quarter inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space At this point copious irrigation was done again the throat pack was removed and the procedure was ended Note that the patient was extubated without incident Dr B was present for all critical aspects of patient care Keywords dentistry abscess 7 et tube aerobic culture anaerobic culture extraction of teeth geta alveolar block buccal space caries cellulitis copious irrigation extraction teeth nonrestorable caries teeth buccal space abscess nonrestorable caries caries teeth throat pack buccal MEDICAL_TRANSCRIPTION,Description Closed reduction of mandible fractures with Erich arch bars and elastic fixation Left angle and right body mandible fractures Medical Specialty Dentistry Sample Name Mandible Fractures Closed Reduction Transcription HISTORY OF PRESENT ILLNESS The patient is a 22 year old male who sustained a mandible fracture and was seen in the emergency department at Hospital He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures PREOPERATIVE DIAGNOSES Left angle and right body mandible fractures POSTOPERATIVE DIAGNOSES Left angle and right body mandible fractures PROCEDURE Closed reduction of mandible fractures with Erich arch bars and elastic fixation ANESTHESIA General nasotracheal COMPLICATIONS None CONDITION Stable to PACU DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route the patient was prepped and draped in the usual fashion for placement of arch bars Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25 gauge circumdental wires After the placement of the arch bars the occlusion was checked and found to be satisfactory and stable The throat pack was then removed An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point the procedure was terminated and the patient was then awakened extubated and taken to the PACU in stable condition Keywords dentistry closed reduction of mandible fractures erich arch bars elastic fixation throat pack arch bars arch erich mandible fractures MEDICAL_TRANSCRIPTION,Description Full mouth dental rehabilitation in the operating room under general anesthesia Medical Specialty Dentistry Sample Name Full Mouth Dental Rehabilitation 1 Transcription OPERATION PERFORMED Full mouth dental rehabilitation in the operating room under general anesthesia PREOPERATIVE DIAGNOSES 1 Severe dental caries 2 Hemophilia POSTOPERATIVE DIAGNOSES 1 Severe dental caries 2 Hemophilia 3 Nonrestorable teeth COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY 1 hour and 22 minutes BRIEF HISTORY The patient was first seen by me on 08 23 2007 who is 4 year old with hemophilia who received infusion on Tuesdays and Thursdays and he has a MediPort Mom reported history of high fever after surgery and he has one seizure previously He has history of trauma to his front teeth and physician put him on antibiotics He was only cooperative for having me do a visual examination on his anterior teeth Visual examination revealed severe dental caries and dental abscess from tooth E and his maxillary anterior teeth needed to be extracted Due to his young age and hemophilia I felt that he would be best served to be taken to the hospital operating room OTHER PREPARATION The child was brought to the Hospital Day Surgery accompanied by his mother There I met with her and discussed the needs of the child types of restoration to be performed and the risks and benefits of the treatment as well as the options and alternatives of the treatment After all her questions and concerns were addressed she gave her informed consent to proceed with treatment The patient s history and physical examination was reviewed He was given factor for appropriately for his hemophilia prior to being taken back to the operating room Once he was cleared by Anesthesia the child was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with an oral tube and the tube was stabilized The head was wrapped and IV was started The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath A moist continuous throat pack was placed beyond tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative clinical photographs were taken Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph After the radiographs were taken the lead shield was removed Prophylaxis was then performed using a prophy cup and fluoridated prophy paste The patient s teeth were rinsed well The patient s oral cavity was suctioned clean Clinical and radiographic examination followed and areas of decay were noted During the restorative phase these areas of decay were incidentally removed Entry was made to the level of the dental enamel junction and beyond as necessary to remove it Final caries removal was confirmed upon reaching hard firm and sound dentin Teeth restored with composite ___________ bonded with a one step bonding agent Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement Non restorable primary teeth would be extracted The caries were extensive and invaded the pulp tissues pulp therapy was initiated using ViscoStat and then IRM pulpotomies Teeth treated in such a manner would then be crowned with stainless steel crowns Upon conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were then taken The continuous gauze throat pack was removed with continuous suction with visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room was taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene All primary teeth were present Dental carries were present on the following teeth Tooth B OL caries tooth C M L S caries tooth B caries on all surfaces tooth E caries on all surfaces tooth F caries on all surfaces tooth T caries on all surfaces tooth H lingual and facial caries tooth I caries on all surfaces tooth L caries on all surfaces and tooth S all caries The remainder of his teeth and soft tissues were within normal limits The following restoration and procedures were performed Tooth B OL amalgam tooth C M L S composite tooth D E F and G were extracted tooth H and L and separate F composite Tooth I is stainless steel crown tooth L pulpotomy and stainless steel crown and tooth S no amalgam Sutures were also placed at extraction site D E S and G CONCLUSION The mother was informed of the completion of the procedure She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care She is to contact to myself with an event of immediate postoperative complications and after full recovery he was discharged from recovery room in the care of his mother She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control Keywords MEDICAL_TRANSCRIPTION,Description Dental restoration Dental caries Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe Medical Specialty Dentistry Sample Name Dental Restoration Transcription PREOPERATIVE DIAGNOSIS Dental caries POSTOPERATIVE DIAGNOSIS Dental caries PROCEDURE Dental restoration CLINICAL HISTORY This 2 year 10 month old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting He was referred to me for that reason to be treated under general anesthesia for his dental work Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe There are no contraindications to this procedure He is healthy His history and physical is in the chart PROCEDURE The patient was brought to the operating room at 10 15 and placed in the supine position Dr X administered the general anesthetic after which 2 bite wing and 2 periapical x rays were exposed and developed and his teeth were examined A throat pack was then placed Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite Teeth E and F had caries in the mesial and distal surfaces these carious lesions were excavated and the teeth were restored with composite Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary This was done using ferric sulfate and zinc oxide eugenol For final restorations amalgam restorations were placed involving the occlusal surfaces both teeth I and L A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11 30 There was no blood loss Keywords dentistry cavities carious lesions throat pack composite teeth occlusal surfaces dental restoration dental caries dental teeth caries MEDICAL_TRANSCRIPTION,Description Left masticator space infection secondary to necrotic tooth 17 Extraoral incision and drainage of facial space infection and extraction of necrotic tooth 17 Medical Specialty Dentistry Sample Name Extraoral I D Transcription PREOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth 17 POSTOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth 17 SURGICAL PROCEDURE Extraoral incision and drainage of facial space infection and extraction of necrotic tooth 17 FLUIDS 500 mL of crystalloid ESTIMATED BLOOD LOSS 60 mL SPECIMENS Cultures and sensitivities Aerobic and anaerobic were sent for micro studies DRAINS One 0 25 inch Penrose placed in the medial aspect of the masticator space CONDITION Good extubated breathing spontaneously to PACU INDICATIONS FOR PROCEDURE The patient is a 26 year old Caucasian male with a 2 week history of a toothache and 5 day history of increasing swelling of his left submandibular region presents to Clinic complaining of difficulty swallowing and breathing Oral surgery was consulted to evaluate the patient After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth 17 Risks benefits alternatives treatments were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was transported to operating room 4 at Clinic He was laid supine on the operating room table ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics The patient was prepped and draped in the usual oral and maxillofacial surgery fashion The surgeon approached the operating room table in sterile fashion Approximately 2 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left submandibular area in the area of the incision After waiting appropriate time for local anesthesia to take effect an 18 gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed This was sent for aerobic and anaerobic micro Using a 15 blade a 2 cm incision was made in the left submandibular region then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed The left masticator space was thoroughly explored as well as the left submandibular space and submental space Pus was drained from this site Copious amounts of sterile fluid were irrigated into the site Attention was then directed intraorally where a moistened Ray Tec sponge was placed in the posterior oropharynx to act as a throat pack Approximately 4 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left inferior alveolar nerve block Using a 15 blade a full thickness mucoperiosteal flap was developed around tooth 17 The tooth was elevated and delivered and the lingual area of tooth 17 was explored and more pus was expressed This pus was evacuated intraorally __________ suction The extraction site and the left masticator space were irrigated and it was noted that the irrigation was communicating with extraoral incision in the neck A 0 25 inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2 0 silk suture A tack stitch intraorally with 3 0 chromic suture was placed The throat pack was then removed An orogastric tube was placed and removed all other stomach contents and then removed At this point the procedure was then determined to be over The patient was extubated breathing spontaneously and transported to PACU in good condition Keywords dentistry masticator space infection extraoral incision and drainage ray tec sponge submandibular space infection necrotic tooth masticator space space drainage necrotic incision masticator tooth MEDICAL_TRANSCRIPTION,Description Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth 32 Extraction of teeth Medical Specialty Dentistry Sample Name Carious Teeth Extraction Transcription PREOPERATIVE DIAGNOSIS Carious teeth and periodontal disease affecting all remaining teeth POSTOPERATIVE DIAGNOSIS Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth 32 PROCEDURE Extraction of remaining teeth numbers 2 3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 and 32 ANESTHESIA General oral endotracheal COMPLICATIONS None CONDITION Stable to PACU PROCEDURE Patient was brought to the operating room placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia the patient was prepped and draped in the usual fashion for an intraoral procedure Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9 10 11 12 13 14 15 and 16 were removed with elevators and forceps extraction Moving to the lower quadrant on the left side tooth numbers 17 18 19 20 21 22 23 and 24 were removed with elevators and routine forceps extraction The flaps were then closed with 3 0 gut sutures and upon completion of the two quadrants on the left side the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right Teeth numbers 2 3 4 5 7 and 8 were then removed with elevators and routine forceps extraction It was noted that tooth 6 was missing could not be seen whether tooth 6 was palately impacted but the tooth was not encountered On the lower right quadrant teeth numbers 25 26 27 28 29 30 and 31 were removed with elevators and routine forceps extraction Tooth 32 was partially bony impacted but exposed so it was removed by removing bone on buccal aspect with high speed drill with a round bur Tooth was then luxated from the socket The flaps were then closed on both quadrants with 3 0 gut sutures The area was irrigated thoroughly with normal saline solution and a total of 8 5 mL of lidocaine 2 with 1 100 000 epinephrine and 3 6 mL of bupivacaine 0 5 with epinephrine 1 200 000 Upon completion of the procedure the throat pack was removed The pharynx was suctioned An oral gastric tube was passed and small amount of stomach contents were suctioned The patient was then extubated and taken to PACU in stable condition Keywords dentistry intraoral procedure partial bony impacted tooth teeth extraction forceps extraction periodontal disease carious teeth periodontal carious MEDICAL_TRANSCRIPTION,Description Dental prophylaxis under general anesthesia Medical Specialty Dentistry Sample Name Dental Prophylaxis Transcription OPERATION PERFORMED Dental prophylaxis under general anesthesia PREOPERATIVE DIAGNOSES 1 Impacted wisdom teeth 2 Moderate gingivitis POSTOPERATIVE DIAGNOSES 1 Impacted wisdom teeth 2 Moderate gingivitis COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal DURATION OF SURGERY One hour 17 minutes BRIEF HISTORY The patient was referred to me by Dr X He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him I agreed I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination This clinical and radiographic examination revealed no dental caries however she was in need of a good dental cleaning OPERATIVE PREPARATION The patient was brought to Hospital Day Surgery accompanied by her mother I met with them and discussed the needs of the child types of restoration to be performed and the risks and benefits of the treatment as well as the options and alternatives of the treatment After all their questions and concerns were addressed they gave their informed consent to proceed with the treatment The patient s history and physical examination was reviewed Once she was cleared by Anesthesia she was taken back to the operating room OPERATIVE PROCEDURE The patient was placed on the surgical table in the usual supine position with all extremities protected Anesthesia was induced by mask The patient was then intubated with a nasal endotracheal tube and the tube was stabilized The head was wrapped and the eyes were taped shut for protection An Angiocath was previously placed in preop The head and neck were draped in sterile towels and the body was covered with lead apron and sterile sheath A moist continuous throat pack was placed beyond tonsillar pillars Plastic lip and cheek retractors were then placed Preoperative digital intraoral photographs were taken No digital radiographs were taken in the operating room as I stated before I had a full set of digital radiographs taken in my office A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done She presented with moderate calculus on the buccal surfaces of her maxillary first molars and lower molars She did not require any restorative dentistry Upon the conclusion of the restorative phase the oral cavity was aspirated and found to be free of blood mucus and other debris The original treatment plan was verified with the actual treatment provided Postoperative clinical photographs were taken The continuous gauze throat pack was removed with continuous suction and visualization Topical fluoride was then placed on the teeth At the end of the procedure the child was undraped extubated and awakened in the operating room taken to the recovery room breathing spontaneously with stable vital signs FINDINGS This patient presented in her permanent dentition Her teeth 1 16 17 and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr Alexander Oral hygiene was fair There was generalized plaque and calculus throughout She did not have any caries did not require any restorative dentistry CONCLUSION Following my dental surgery the patient continued to intubated and was prepped for oral surgery procedures by Dr X and his associates There were no postop pain requirements I did not have any specific requirements for the patient or her mother and that will be handled by Dr X and their instructions on soft foods etc and pain control will be managed by them Keywords dentistry dental prophylaxis impacted wisdom teeth gingivitis wisdom teeth moderate gingivitis dental rehabilitation throat pack digital radiographs restorative dentistry impacted anesthesia restorative wisdom oral prophylaxis teeth dental MEDICAL_TRANSCRIPTION,Description Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 Removal of benign cyst and extraction of full bone impacted tooth 17 Medical Specialty Dentistry Sample Name Bone Impacted Tooth Removal Transcription PREOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 POSTOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth 17 PROCEDURE Removal of benign cyst and extraction of full bone impacted tooth 17 ANESTHESIA General anesthesia with nasal endotracheal intubation SPECIMEN Cyst and section tooth 17 ESTIMATED BLOOD LOSS 10 mL FLUIDS 1200 of Lactated Ringer s COMPLICATIONS None CONDITION The patient was extubated and transported to the PACU in good condition Breathing spontaneously INDICATION FOR PROCEDURE The patient is a 38 year old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible Preoperatively a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible it was determined that the patient would benefit from removal of the cyst and removal of tooth 17 under general anesthesia in the operating room Risks benefits and alternatives of treatment were thoroughly discussed with the patient and consent was obtained DESCRIPTION OF PROCEDURE The patient was taken to the operating room 1 at Hospital and laid in the supine fashion on the operating room table As stated general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics The patient was prepped and draped in usual oro maxillofacial surgery fashion Approximately 6 mL of 2 lidocaine with 1 100 000 epinephrine was injected in the usual nerve block fashion After waiting appropriate time for local anesthesia to take effect a moistened Ray Tec sponge was placed in the posterior pharynx Peridex mouth rinse was used to prep the oral cavity This was removed with suction Using a 15 blade a sagittal split osteotomy incision was made along the left ramus A full thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super erupted since the biopsy 6 weeks earlier Using a Hall drill a buccal osteotomy was developed the tooth was sectioned in half fractured with an elevator and delivered in two pieces Using a double ended curette the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review The area was irrigated with copious amounts of sterile water and closed with 3 0 chromic gut suture The throat pack was removed The procedure was then determined to be over and the patient was extubated breathing spontaneously and transported to the PACU in good condition Keywords dentistry dentigerous wisdom tooth extraction bone impacted tooth nasal endotracheal dentigerous cyst cyst intubation osteotomy mandible MEDICAL_TRANSCRIPTION,Description Dental restorations and extractions Dental caries He has had multiple severe carious lesions that warrant multiple extractions at this time Medical Specialty Dentistry Sample Name Dental Restorations Extractions Transcription PREOPERATIVE DIAGNOSIS Dental caries POSTOPERATIVE DIAGNOSIS Dental caries PROCEDURE Dental restorations and extractions CLINICAL HISTORY This 23 year old male is a client of the ABC Center because of his disability the nature of which is unclear to me at this time however he reportedly has several issues that qualify him as disabled He has had multiple severe carious lesions that warrant multiple extractions at this time It is also unclear to me as to how his prior or existing restorations were accomplished In any case he has been cleared for the procedure today He has his history and physical in the chart PROCEDURE The patient was brought to the operating room at 11 o clock and placed in the supine position Dr X administered the general anesthetic after which a throat pack was placed Available full mouth x rays were reviewed These x rays were taken at another location Teeth 2 4 10 12 13 15 18 20 27 and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies All of these aforementioned teeth were extracted using combinations of forceps and elevators Hemostasis in all of these sites was accomplished with direct pressure using gauze packs Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal These carious lesions and his tooth were excavated and the tooth was restored with amalgam involving these surfaces Tooth 6 had caries on the facial surface which was excavated and the tooth was restored with composite Tooth 7 had caries involving the distal surface Tooth 8 likewise had caries involving the distal surface and both of these distal lesions extended into incisal area These carious lesions were excavated and both of these teeth were restored with composite Tooth 9 had caries in a mesial surface and a buccal surface which was excavated and this tooth was restored with composite Tooth 28 caries in the mesial surface extending to the occlusal which was excavated and the tooth was restored with amalgam and tooth 30 had carries in the buccal surface which was excavated and the tooth was restored with amalgam A prophylaxis was done primarily using a rotating rubber cup and some minor scaling and the mouth was irrigated and suctioned thoroughly The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 1330 hours There was negligible blood loss Keywords dentistry extractions multiple extractions mesial surface buccal surface dental restorations dental caries distal surface composite tooth carious lesions tooth dental caries MEDICAL_TRANSCRIPTION,Description This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Medical Specialty Dentistry Sample Name Dental Pain Transcription CHIEF COMPLAINT Dental pain HISTORY OF PRESENT ILLNESS This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Presents now for evaluation PAST MEDICAL HISTORY Remarkable for chronic back pain neck pain from a previous cervical fusion and degenerative disc disease She has chronic pain in general and is followed by Dr X REVIEW OF SYSTEMS Otherwise unremarkable Has not noted any fever or chills However she as mentioned does note the dental discomfort with increasing swelling and pain Otherwise unremarkable except as noted CURRENT MEDICATIONS Please see list ALLERGIES IODINE FISH OIL FLEXERIL BETADINE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile has stable and normal vital signs The patient is sitting quietly on the gurney and does not look to be in significant distress but she is complaining of dental pain HEENT Unremarkable I do not see any obvious facial swelling but she is definitely tender all in the left mandible region There is no neck adenopathy Oral mucosa is moist and well hydrated Dentition looks to be in reasonable condition However she definitely is tender to percussion on the left lower first premolar I do not see any huge cavity or anything like that No real significant gingival swelling and there is no drainage noted None of the teeth are tender to percussion PROCEDURE Dental nerve block Using 0 5 Marcaine with epinephrine I performed a left inferior alveolar nerve block along with an apical nerve block which achieves good anesthesia I have then written a prescription for penicillin and Vicodin for pain IMPRESSION ACUTE DENTAL ABSCESS ASSESSMENT AND PLAN The patient needs to follow up with the dentist for definitive treatment and care She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics However outpatient followup should be adequate She is discharged in stable condition Keywords dentistry dental pain dental abscess dental block nerve block mandible swelling dental MEDICAL_TRANSCRIPTION,Description Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose Medical Specialty Cosmetic Plastic Surgery Sample Name Rhinoplasty Transcription PREOPERATIVE DIAGNOSES 1 Nasal obstruction secondary to deviated nasal septum 2 Bilateral turbinate hypertrophy PROCEDURE Cosmetic rhinoplasty Request for cosmetic change in the external appearance of the nose ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 26 year old white female with longstanding nasal obstruction She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose From her functional standpoint she has severe left sided nasal septal deviation with compensatory inferior turbinate hypertrophy From the aesthetic standpoint the nose is over projected lacks rotation and has a large dorsal hump First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump rotate the tip of the nose and de project the nasal tip I explained to her the risks benefits alternatives and complications for postsurgical procedure She had her questions asked and answered and requested that we proceed with surgery as outlined above PROCEDURE DETAILS The patient was taken to the operating room and placed in supine position The appropriate level of general endotracheal anesthesia was induced The face head and neck were sterilely prepped and draped The nose was anesthetized and vasoconstricted in the usual fashion Procedure began with a left hemitransfixion incision which was brought down into the left intercartilaginous incision Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane Intact bilateral septomucoperichondrial flaps were elevated and a severe left sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed Anterior and inferior one third of each inferior turbinate was clamped cut and resected The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm The bony hump of the nose was lowered with a straight osteotome by 4 mm Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip The caudal septum was shortened by 2 mm in an angle in order to enhance rotation Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of 3 0 chromic The upper lateral cartilages were rejoined to the dorsal septum with a 4 0 plain gut suture No middle valves or bone grafts were necessary Intact mucoperichondrial flaps were closed with 4 0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room taken to the recovery room in good condition Keywords cosmetic plastic surgery nasal obstruction cosmetic dorsal hump endotracheal tube hemitransfixion incision hypertrophy intercartilaginous intercartilaginous incision nasal septum nasal tip septomucoperichondrial submucoperichondrial subperiosteal turbinate vomerine spur nasal septal nasal rhinoplasty septum MEDICAL_TRANSCRIPTION,Description Bilateral open mandible fracture open left angle and open symphysis fracture Closed reduction of mandible fracture with MMF Medical Specialty Dentistry Sample Name Closed Reduction Mandible Fracture Transcription PREOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture POSTOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture PROCEDURE Closed reduction of mandible fracture with MMF ANESTHESIA General anesthesia via nasal endotracheal intubation FLUIDS 2 L of crystalloid ESTIMATED BLOOD LOSS Minimal HARDWARE None SPECIMENS None COMPLICATIONS None CONDITION The patient was extubated to PACU in good condition INDICATIONS FOR PROCEDURE The patient is a 17 year old female who is 2 days status post an altercation in which she sustained multiple blows to the face She was worked up on Friday night 2 days earlier at Hospital was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call The patient was worked up initially On initial exam it was noted that the patient had a left V3 paresthesia She had a gross malocclusion On the facial CT and panoramic x ray it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures Risks benefits and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient s mother DESCRIPTION OF PROCEDURE The patient was taken to the operating room 4 at Hospital and laid in a supine position on the operating room table Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics The patient was prepped and draped in the usual oromaxillofacial surgery fashion Surgeon approached the operating table in a sterile fashion Approximately 10 mL of 2 lidocaine with 1 100 000 epinephrine was injected into the oral vestibule in a nerve block fashion A moistened Ray Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse scrubbed with a toothbrush The Peridex was evacuated with Yankauer suction Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24 gauge surgical steel wire on the posterior teeth and 26 gauge surgical steel wire on the anterior teeth Same was done on the mandible The patient was then manipulated up in the maximum intercuspation and noted to be reproducible The throat pack was then removed The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics At this point in time the procedure was then determined to be over The patient was extubated and transferred to the PACU in good condition Keywords dentistry open symphysis fracture closed reduction mmf endotracheal pacu bilateral open mandible fracture symphysis fracture mandible fracture fracture intubation angle mandible MEDICAL_TRANSCRIPTION,Description Cervical facial rhytidectomy Quadrilateral blepharoplasty Autologous fat injection to the upper lip donor site abdomen Medical Specialty Cosmetic Plastic Surgery Sample Name Rhytidectomy Blepharoplasty Transcription PREOPERATIVE DIAGNOSIS Ageing face POSTOPERATIVE DIAGNOSIS Ageing face OPERATIVE PROCEDURE 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip OPERATIONS PERFORMED 1 Cervical facial rhytidectomy 2 Quadrilateral blepharoplasty 3 Autologous fat injection to the upper lip donor site abdomen INDICATION This is a 62 year old female for the above planned procedure She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative PROCEDURE The patient was brought to the operative room under satisfaction and she was placed supine on the OR table Administered general endotracheal anesthesia followed by sterile prep and drape at the patient s face and abdomen This included the neck accordingly Two platysmal sling application and operating headlight were utilized Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery The first procedure was performed was that of a quadrilateral blepharoplasty Markers were applied to both upper lids in symmetrical fashion The skin was excised from the right upper lid first followed by appropriate muscle resection Minimal fat removed from the medial upper portion of the eyelid Hemostasis was controlled with the quadrilateral tip needle closure with a running 7 0 nylon suture Attention was then turned to the lower lid A classic skin muscle flap was created accordingly Fat was resected from the middle medial and lateral quadrant The fat was allowed to open drain the arcus marginalis for appropriate contour Hemostasis was controlled with the pinpoint cautery accordingly Skin was redraped with a conservative amount resected Running closure with 7 0 nylon was accomplished without difficulty The exact same procedure was repeated on the left upper and lower lid After completion of this portion of the procedure the lag lid was again placed in the eyes Eye mass was likewise clamped Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure The right face was first operated It was injected with a 0 25 Marcaine 1 200 000 adrenaline A submental incision was created followed by suction lipectomy and very minimal amounts of in 3 mm and 2 mm suction cannula She had minimal subcutaneous extra fat as noted Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post occipital hairline The flap was elevated without difficulty with various facelift scissors Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4 cm incision Rectus plication in the midline with a running 4 0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation cutting and cautery The submental incision was closed with a running 7 0 nylon over 5 0 Monocryl Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication The left side of face was first closed followed by interrupted SMAS plication utilizing 4 0 wide Mersilene The skin was draped appropriately and appropriate tissue was resected A 7 mm 9 0 French drain was utilized accordingly prior to closure of the skin with interrupted 4 0 Monocryl in the post occipital region followed by running 5 0 nylon in the postauricular surface Preauricular interrupted 5 0 Monocryl was followed by running 7 0 nylon The hairline temporal incision was closed with running 5 0 nylon The exact same closure was accomplished on the right side of the face with a same size 7 mm French drain The patient s dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3 inch Ace The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly Approximately 2 5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure The incision site was closed with 7 0 nylon The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position The patient will be admitted for overnight short stay through the cosmetic package procedure She will be discharged in the morning Estimated blood loss was less than 75 cc No complications noted and the patient tolerated the procedure well Keywords cosmetic plastic surgery ageing face adaptic polysporin ointment autologous fat injection bovie cautery kerlix wrap smas plication arcus marginalis blepharoplasty facelift platysmal sling quadrilateral rhytidectomy right upper lid cervical facial rhytidectomy pinpoint cautery facial rhytidectomy quadrilateral blepharoplasty running nylon autologous MEDICAL_TRANSCRIPTION,Description Nipple areolar reconstruction utilizing a full thickness skin graft and mastopexy Medical Specialty Cosmetic Plastic Surgery Sample Name Nipple Reconstruction Transcription PREOPERATIVE DIAGNOSES 1 Surgical absence of left nipple areola with personal history of breast cancer 2 Breast asymmetry POSTOPERATIVE DIAGNOSES 1 Surgical absence of left nipple areola with personal history of breast cancer 2 Breast asymmetry PROCEDURE 1 Left nipple areolar reconstruction utilizing a full thickness skin graft from the left groin 2 Redo right mastopexy ANESTHESIA General endotracheal COMPLICATIONS None DESCRIPTION OF PROCEDURE IN DETAIL The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia the patient was placed in a frog leg position and prepped and draped in usual fashion for the above noted procedure The initial portion of the procedure was harvesting a full thickness skin graft from the left groin region This was accomplished by ellipsing out a 42 mm diameter circle of skin just below the thigh peroneal crease The defect was then closed with 3 0 Vicryl followed by 3 0 chromic suture in a running locked fashion The area was dressed with antibiotic ointment and then a Peri Pad The patient s legs were brought out frog leg back to the midline and sterile towels were placed over the opening in the drapes Surgical team s gloves were changed and then attention was turned to the planning of the left nipple flap A maltese cross pattern was employed with a 1 cm diameter nipple and a 42 mm diameter nipple areolar complex Once the maltese cross had been designed on the breast at the point where the nipple was to be placed the areas of the portion of flap were de epithelialized Then when this had been completed the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple At this point a Bovie electrocautery was used to control bleeding points and then 4 0 chromic suture was used to suture the arms of the flap together creating the nipple When this had been completed the skin graft which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft At this point the graft was sutured into position in the defect using 3 0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola At this point 4 0 chromic was used to run around the perimeter of the full thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4 0 chromic The areolar skin graft was pie crusted Then at this point the area of areola was dressed with silicone gel sheeting A silo was placed over the neonipple with 3 0 nylon through the apex of the neonipple to support the nipple in an erect position Mastisol and Steri Strips were then applied At this point attention was turned to the right breast where a 2 cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made The skin was removed from the area and then a layered closure of 3 0 Vicryl followed by 3 0 PDS in a running subcuticular fashion was carried out When this had been completed the Mastisol and Steri Strips were applied to the transverse right breast incision Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola The patient was then placed in Surgi Bra and then was taken from the operating room to the recovery room in good condition Keywords cosmetic plastic surgery nipple areola breast asymmetry general endotracheal peri pad surgi bra breast cancer frog leg position full thickness skin graft general endotracheal anesthesia mastopexy nipple areolar complex nipple areolar reconstruction nipple flap prepped and draped transverse mastopexy areolar reconstruction skin graft graft nipple areolar breast MEDICAL_TRANSCRIPTION,Description Perlane injection for the nasolabial fold Restylane injection for the glabellar fold Medical Specialty Cosmetic Plastic Surgery Sample Name Perlane Restylane Injection Transcription PREOPERATIVE DIAGNOSES 1 Nasolabial mesiolabial fold 2 Mid glabellar fold POSTOPERATIVE DIAGNOSES 1 Nasolabial mesiolabial fold 2 Mid glabellar fold TITLE OF PROCEDURES 1 Perlane injection for the nasolabial fold 2 Restylane injection for the glabellar fold ANESTHESIA Topical with Lasercaine COMPLICATIONS None PROCEDURE The patient was evaluated preop and noted to be in stable condition Chart and informed consent were all reviewed preop All risks benefits and alternatives regarding the procedure have been reviewed in detail with the patient This includes risk of bleeding infection scarring need for further procedure etc The patient did sign the informed consent form regarding the Perlane and Restylane She is aware of the potential risk of bruising The patient has had Cosmederm in the past and had had a minimal response with this Please note Lasercaine had to be applied 30 minutes prior to the procedure The excess Lasercaine was removed with a sterile alcohol swab Using the linear threading technique I injected the deep nasolabial fold We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold They were carefully massaged into good position at the end of the procedure She did have some mild erythema noted I then used approximately 0 4 mL of the Restylane for injection of the mid glabellar site She has a resting line of the mid glabella that did not respond with previous Botox injection Once this was filled the Restylane was massaged into the proper tissue plane Cold compressors were applied afterwards She is scheduled for a recheck in the next one to two weeks and we will make further recommendations at that time Post Restylane and Perlane precautions have been reviewed with the patient as well Keywords cosmetic plastic surgery lasercaine nasolabial mesiolabial fold mid glabellar fold perlane injection restylane injection nasolabial fold mesiolabial fold glabellar fold injection perlane nasolabial glabellar restylane MEDICAL_TRANSCRIPTION,Description Endoscopic subperiosteal midface lift using the endotine midface suspension device Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad Medical Specialty Cosmetic Plastic Surgery Sample Name Midface Lift Blepharoplasty Transcription PREOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident POSTOPERATIVE DIAGNOSES 1 Request for cosmetic surgery 2 Facial asymmetry following motor vehicle accident PROCEDURES 1 Endoscopic subperiosteal midface lift using the endotine midface suspension device 2 Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad ANESTHESIA General via endotracheal tube INDICATIONS FOR OPERATION The patient is a 28 year old country and western performer who was involved in a motor vehicle accident over a year ago Since that time she is felt to have facial asymmetry which is apparent in publicity photographs for her record promotions She had requested a procedure to bring about further facial asymmetry She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient s requesting cosmetic surgery and was felt to be a psychiatrically good candidate She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left Preoperative workup including CT scan failed to show any skeletal trauma The patient was counseled with regard to the risks benefits alternatives and complications of the postsurgical procedure including but not limited to bleeding infection unacceptable cosmetic appearance numbness of the face change in sensation of the face facial nerve paralysis need for further surgery need for revision hair loss etc and informed consent was obtained PROCEDURE The patient was taken to the operating room placed in supine position after having been marked in the upright position while awake General endotracheal anesthesia was induced with a 6 endotracheal tube All appropriate measures were taken to preserve the vocal cords in a professional singer Local anesthesia consisting of 5 6th 1 lidocaine with 1 100 000 units of epinephrine in 1 6th 0 25 Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia The upper eyelids were injected with 1 cc of 1 Xylocaine with 1 100 000 units of epinephrine Adequate time for vasoconstriction and anesthesia was allowed to be obtained The patient was prepped and draped in the usual sterile fashion A 4 0 silk suture was placed in the right lower lid For traction it was brought anteriorly The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe A Q Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation which was present The inferior oblique muscle was identified preserved and protected throughout the procedure The transconjunctival incision was then closed with buried knots of 6 0 fast absorbing gut Contralateral side was treated in similar fashion with like results and throughout the procedure Lacri Lube was in the eyes in order to maintain hydration Attention was next turned to the midface where a temporal incision was made parallel to the nasojugal folds Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia A 30 degree endoscope was used to visualize the fat pads so that we knew we are in the proper plane Subperiosteal dissection was carried out over the zygomatic arch and Whitnall s tubercle and the temporal dissection was completed Next bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall s tubercle The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle It was bipolar electrocauteried and the tunnel was further dissected free and opened The endotine 4 5 soft tissue suspension device was then inserted through the temporal incision brought down into the subperiosteal midface plane of dissection The guard was removed and the suspension spikes were engaged into the soft tissues The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally The endotine device was then secured to the true temporal fascia with three sutures of 3 0 PDS suture Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained The gingivobuccal sulcus incisions were closed with interrupted 4 0 chromic and the scalp incision was closed with staples The sterile dressing was applied The patient was awakened in the operating room and taken to the recovery room in good condition Keywords cosmetic plastic surgery cosmetic surgery jaeger lid plate lacri lube q tip blepharoplasty conjunctiva facial asymmetry fat pad lower lid midface lift regional field block temporal fascia temporal fossa vasoconstriction true temporal fascia gingivobuccal sulcus gingivobuccal MEDICAL_TRANSCRIPTION,Description Split thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg Medical Specialty Cosmetic Plastic Surgery Sample Name Skin Graft Transcription DIAGNOSIS Stasis ulcers of the lower extremities OPERATION Split thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg INDICATIONS This 84 year old female presented recently with large ulcers of the lower extremities These were representing on the order of 50 or more of the circumference of her lower leg They were in a distribution to be consistent with stasis ulcers They were granulating nicely and she was scheduled for surgery FINDINGS Large ulcers of lower extremities with size as described above These are irregular in shape and posterior and laterally on the lower legs There was no evidence of infection The ultimate skin grafting was quite satisfactory PROCEDURE Having obtained adequate general endotracheal anesthesia the patient was prepped from the pubis to the toes The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed Once this was accomplished the skin was harvested from the right thigh at approximately 0 013 inch This was meshed 1 1 5 and then stapled into position on the wounds The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution She was then dressed in additional Kerlix followed by Webril and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them and at the same time did not put pressure across the heels The donor site was dressed with Op Site The patient tolerated the procedure well and returned to the recovery room in satisfactory condition Keywords cosmetic plastic surgery skin graft lower extremities split thickness skin grafting skin grafting kerlix grafting extremities ulcers leg MEDICAL_TRANSCRIPTION,Description Bilateral transaxillary subpectoral mammoplasty with saline filled implants Medical Specialty Cosmetic Plastic Surgery Sample Name Mammoplasty 4 Transcription DIAGNOSIS Bilateral hypomastia NAME OF OPERATION Bilateral transaxillary subpectoral mammoplasty with saline filled implants ANESTHESIA General PROCEDURE After first obtaining a suitable level of general anesthesia with the patient in the supine position the breasts were prepped with Betadine scrub and solution Sterile towels sheets and drapes were placed in the usual fashion for surgery of the breasts Following prepping and draping the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0 5 Xylocaine with 1 200 000 units of epinephrine After a suitable hemostatic waiting period transaxillary incisions were made and dissection was carried down to the edge of the pectoralis fascia Blunt dissection was then used to form a bilateral subpectoral pocket Through the subpectoral pocket a sterile suction tip was introduced and copious irrigation with sterile saline solution was used until the irrigant was clear Following completion of irrigation 350 cc saline filled implants were introduced They were first filled with 60 cc of saline and checked for gross leakage none was evident They were over filled to 400 cc of saline each The patient was then placed in the seated position and the left breast needed 10 cc of additional fluid for symmetry Following completion of the filling of the implants and checking the breasts for symmetry the patient s wounds were closed with interrupted vertical mattress sutures of 4 0 Prolene Flexan dressings were applied followed by the patient s bra She seemed to tolerate the procedure well Keywords cosmetic plastic surgery bilateral transaxillary subpectoral mammoplasty saline filled implants subpectoral mammoplasty mammoplasty transaxillary subpectoral implants breasts saline anesthesia MEDICAL_TRANSCRIPTION,Description Bilateral augmentation mammoplasty breast implant TCA peel to lesions vein stripping Medical Specialty Cosmetic Plastic Surgery Sample Name Mammoplasty 2 Transcription PREOPERATIVE DIAGNOSES Breast hypoplasia melasma to the face and varicose veins to the posterior aspect of the right distal thigh popliteal fossa area PROCEDURES 1 Bilateral augmentation mammoplasty subglandular with a mammary gel silicone breast implant 435 cc each 2 TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area ANESTHESIA General endotracheal EBL 100 cc IV FLUIDS 2L URINE OUTPUT Per Anesthesia INDICATION FOR SURGERY The patient is a 48 year old female who was seen in clinic by Dr W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity She requested that surgical procedures to be performed for correction of these abnormalities As such complications were explained to the patient including infection bleeding poor wound healing and need for additional surgery The patient subsequently signed the consent and requested that Dr W and associates to perform the procedure TECHNIQUE The patient was brought to the operating room in supine position General anesthesia was induced and then the patient was placed on the operating table in a prone position The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion First multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed Once these varicose veins had been completely stripped and avulsed then next the wounds were then irrigated and were cleaned with wet and dry and all the incisions were closed with the use of 5 0 Monocryl buried interrupted sutures The incisions were then dressed with Mastisol Steri Strips ABDs and a TED hose Next the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position The anterior chest was then prepped and draped in a sterile fashion Next a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts Once the pectoralis muscle and fascia were identified then a surgical plane was created in a subglandular layer The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well A sizer was used to identify the appropriate size of the silicone implant to be used This was determined to be approximately 435 cc bilaterally As such two mammary gel silicone breast implants were placed in a subglandular muscle Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant the circumareolar incisions were closed in approximately 4 layered fashion closing the fascia subcutaneous tissue deep dermis and a running dermal subcuticular for final skin closure This was performed with 3 0 Monocryl and then 4 0 Monocryl for running subcuticular The incisions were then dressed with Mastisol Steri Strips and Xeroform and dressed with sample Kerlix Next our attention was paid to the face where 25 TCA solution was applied to two locations one on the left cheek and the other one on the right cheek where a hyperpigmentation melasma Several applications of the TCA peel was performed and at the end of this the frosting was noted to both spots At the end of the case needle and instrument counts were correct Dr W was present and scrubbed for the entire procedure The patient was extubated in the operating room and taken to the PACU in stable condition Keywords cosmetic plastic surgery breast hypoplasia monocryl pacu tca tca peel ted hose augmentation mammoplasty breast implant melasma poor wound healing popliteal fossa area prepped and draped silicone varicose vein vein stripping mastisol steri strips steri strips circumareolar incisions mammary gel varicose veins augmentation breast circumareolar incisions mammoplasty mastisol strips MEDICAL_TRANSCRIPTION,Description Suction assisted lipectomy lipodystrophy of the abdomen and thighs Medical Specialty Cosmetic Plastic Surgery Sample Name Lipectomy Abdomen Thighs Transcription PREOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs POSTOPERATIVE DIAGNOSIS Lipodystrophy of the abdomen and thighs OPERATION Suction assisted lipectomy ANESTHESIA General FINDINGS AND PROCEDURE With the patient under satisfactory general endotracheal anesthesia the entire abdomen flanks perineum and thighs to the knees were prepped and draped circumferentially in sterile fashion After this had been completed a 15 blade was used to make small stab wounds in the lateral hips the pubic area and upper edge of the umbilicus Through these small incisions a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen A 3 and 4 mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate which was mostly fat little fluid and blood Attention was then directed to the thighs both inner and outer A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs After this had been completed 3 and 4 mm cannulas were used to suction 650 cc from each side approximately 50 cc in the inner thigh and 600 on each lateral thigh The patient tolerated the procedure very well All of this aspirate was mostly fat with little fluid and very little blood Wounds were cleaned and steri stripped and dressing of ABD pads and was then applied The patient tolerated the procedure very well and was sent to the recovery room in good condition Keywords cosmetic plastic surgery lipodystrophy abd pads suction assisted lipectomy abdomen aspirate lipectomy perineum steri stripped thighs umbilicus abdomen and thighs abdomen thighs MEDICAL_TRANSCRIPTION,Description Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty Medical Specialty Cosmetic Plastic Surgery Sample Name Hemangioma Debulking Rhinoplasty Transcription PREOPERATIVE DIAGNOSIS Hemangioma nasal tip POSTOPERATIVE DIAGNOSIS Hemangioma nasal tip PROCEDURE PERFORMED 1 Debulking of hemangioma of the nasal tip through an open rhinoplasty approach 2 Rhinoplasty ESTIMATED BLOOD LOSS Minimal FINDINGS Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes CONDITION Condition of the patient at end of the procedure stable transferred to recovery room INDICATIONS FOR THE PROCEDURE The patient is a 2 year old female with a history of a nasal tip hemangioma The hemangioma has involved at her upper tongue There has not been any change in the last 6 months We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma They understand the nature of the incision the nature of the surgery and the possibility of future revision surgeries They understand the risk of bleeding infection dehiscence scarring need for future revision surgery and minor asymmetry They wished to proceed with surgery Because of the procedure informed consent is obtained The patient is taken to operating room and placed in the supine position General anesthetic is administrated to an oroendotracheal tube The face is prepped and draped in the usual manner The incision is designed to the lower aspect of the hemangioma which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions The area is infiltrated with lidocaine with epinephrine We waited 7 minutes for the hemostatic effect and proceeded with the incision The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa then extended laterally and upward to follow the lower lateral cartilage This is done in both sides Further incision is done A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip The hemangioma is removed and is found to be involving the medial aspects of both medial crura This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion Hemostasis is achieved with electrocautery Then we proceed to place some interdomal stitches with the help of a 6 0 clear nylon and intercrural stitches are placed and then an interdomal stitch a single one was placed The skin is redraped and the nose found to have satisfactory shape The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella Portions of skin and hemangioma are taken laterally on both sides of the columella distally The skin was closed with 6 0 mild chromic stitches including the portion at the level of the columella and rim incisions medially The remaining of the internal incisions are closed with 5 0 chromic interrupted stitches The nose is irrigated and suctioned The patient tolerated the procedure without complications I was present and participated in all aspects of the procedure Sponge and instrument count were complete at the end of the procedure Keywords cosmetic plastic surgery rhinoplasty approach debulking of hemangioma nasal domes lower lateral cartilages nasal tip columella hemangioma debulking cartilages rhinoplasty nasal MEDICAL_TRANSCRIPTION,Description Liposuction of the supraumbilical abdomen revision of right breast reconstruction excision of soft tissue fullness of the lateral abdomen and flank MEDICAL_TRANSCRIPTION,Description Bilateral reduction mammoplasty for bilateral macromastia Medical Specialty Cosmetic Plastic Surgery Sample Name Mammoplasty 1 Transcription PREOPERATIVE DIAGNOSIS Bilateral macromastia POSTOPERATIVE DIAGNOSIS Bilateral macromastia OPERATION Bilateral reduction mammoplasty ANESTHESIA General FINDINGS The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle PROCEDURE With the patient under satisfactory general endotracheal anesthesia the entire chest was prepped and draped in usual sterile fashion A previously placed mark to identify the neo nipple site was re identified and carefully measured for asymmetry and appeared to be satisfactory A keyhole wire ring was then used to outline the basic wise pattern with 6 cm lamps inferiorly This was then carefully checked for symmetry and appeared to be satisfactory All marks were then completed and lightly incised on both breasts The right breast was approached first The neo nipple site was de epithelialized superiorly and then the inferior pedicle was de epithelialized using cutting cautery After this had been completed cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately This was taken down to the prepectoral fashion dissected for short distance superiorly and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle There was very little bleeding with this procedure After this had been completed attention was directed to the lateral side and the inferior incision was made and taken down to the serratus Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket After this had been completed cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast Hemostasis was obtained with electrocautery After this had been completed cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps On the right side there was a small palpable lobule which had shown up on mammogram but nothing except some fat density was identified This site had been previously marked carefully and there were no unusual findings and the superior tissue was then sent out separately for pathology After this had been completed final hemostasis obtained and the wound was irrigated and a tagging suture placed to approximate the tissues The breast cleared and the nipple appeared good Attention was then directed to the left breast which was completed in the similar manner After this had been completed the patient was placed in a near upright position and symmetry appeared good but it was a bit poor on the lateral aspect of the right side which was little larger and some suction lipectomy was carried out in this area After completion of this 1860 grams had been removed from the right and 1505 grams was removed from the left Through separate stab wounds on the lateral aspect 10 mm flat Blake drains were brought out and sutures were then placed and irrigated The wounds were then closed with interrupted 4 0 Monocryl on the deep dermis and running intradermal 4 0 Monocryl on the skin packing sutures and staples were removed as they were approached The nipple was sutured with running intradermal 4 0 Monocryl Vascularity appeared good throughout After this had been completed all wounds were cleaned and Steri Stripped The patient tolerated the procedure well All counts were correct Estimated blood loss was less than 150 mL and she was sent to recovery room in good condition Keywords cosmetic plastic surgery macromastia estimated blood loss monocryl steri stripped dermis inferior breast mammoplasty neo nipple prepped and draped ptotic breasts recovery room in good condition reduction mammoplasty superior breast upright position bilateral macromastia incision superiorly breasts MEDICAL_TRANSCRIPTION,Description Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple areolar complex Medical Specialty Cosmetic Plastic Surgery Sample Name Mammoplasty 3 Transcription PREOPERATIVE DIAGNOSES Bilateral mammary hypertrophy with breast asymmetry right breast larger than left POSTOPERATIVE DIAGNOSES Bilateral mammary hypertrophy with breast asymmetry right breast larger than left OPERATION Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast ANESTHESIA General endotracheal anesthesia PROCEDURE IN DETAIL The patient was placed in the supine position under the effects of general endotracheal anesthesia The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion Markings were then made in the standing position preoperatively The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast A McKissock ring was utilized as a pattern It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40 degree angle Medial and lateral flaps were drawn 8 cm in length At the most medial and lateral extremity inframammary folds a line was drawn to the lower level at the medial and lateral flaps On the left side the epithelialization was performed about the 45 mm nipple areolar complex within the confines of the superior medially based dermal parenchymal pedicle Resection of the skin subcutaneous tissue and glandular tissue was performed along the inframammary fold and then cut was made medially and laterally The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle and laterally the resection was performed tangential to the chest wall skin subcutaneous tissue and glandular tissue towards the axillary tail The pedicle was thinned as well so it was 2 cm thick beneath the nipple areolar complex and they were medially 4 cm thick at its base On the right side 947 g of breast tissue was removed Hemostasis was achieved with electrocautery Identical procedure was performed on the opposite left side again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45 mm diameter nipple areolar complex Resection of the skin subcutaneous tissue and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex Hemostasis was achieved with electrocautery With pedicle on the left the breast issue on the left side was weighed at 758 g Hemostasis was achieved with cautery The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides The nipple areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple areolar complex Closure was performed with interrupted 3 0 PDS suture for deep subcutaneous tissue and dermis Skin was closed with running subcuticular 4 0 Monocryl suture A Jackson Pratt drain had been placed prior to final closure and secured with a 4 0 silk suture The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization Closure was performed with an anchor shaped closure around the nipple areolar complex vertically of inframammary folds and across the inframammary folds Dressing was applied The suture line was treated with Dermabond The patient returned to the recovery room with 2 Jackson Pratt drains 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days The patient tolerated the procedure well and returned to the recovery room in satisfactory condition Keywords cosmetic plastic surgery bilateral mammary hypertrophy duraprep general endotracheal anesthesia jackson pratt drains breast asymmetry hypertrophy inframammary folds mammary mammoplasty nipple areolar complex nipple areolar complex parenchymal pedicle prepped and draped reduction mammoplasty transposition medial and lateral based dermal dermal parenchymal parenchymal pedicle subcutaneous tissue nipple areolar inferiorly subcutaneous inframammary breast tissue MEDICAL_TRANSCRIPTION,Description Suction assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies Medical Specialty Cosmetic Plastic Surgery Sample Name Lipectomy Breast Transcription PREOPERATIVE DIAGNOSIS Mammary hypertrophy with breast ptosis POSTOPERATIVE DIAGNOSIS Mammary hypertrophy with breast ptosis OPERATION Suction assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in the supine position Under effects of general endotracheal anesthesia markings were made preoperatively for the mastopexy An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold A stab incision was made bilaterally and tumescent infiltration of anesthesia lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle 200 cc was infiltrated on each side This was followed by power assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4 mm cannula This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o clock position This would result in an elevation of the nipple areolar complex with transposition The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle Hemostasis was achieved with electrocautery After the epithelialization was performed on both sides nipple areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple areolar complex beneath the transposed nipple Closure was performed with interrupted 3 0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4 0 Monocryl suture Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing The patient tolerated the procedure well The patient was returned to recovery room in satisfactory condition Keywords cosmetic plastic surgery breast ptosis dermabond mammary hypertrophy monocryl anesthesia breast tissue endotracheal anesthesia lipectomy mastopexies mastopexy nipple nipple areolar complex suction assisted lipectomy nipple areolar complex lactated ringers nipple areolar areolar complex epithelialization areolar breast MEDICAL_TRANSCRIPTION,Description Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging Medical Specialty Cosmetic Plastic Surgery Sample Name Blepharoplasty Quad Transcription PREOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging POSTOPERATIVE DIAGNOSES 1 Blepharochalasia 2 Lower lid large primary and secondary bagging PROCEDURE Quad blepharoplasty ANESTHESIA General ESTIMATED BLOOD LOSS Minimal CONDITION The patient did well PROCEDURE The patient had marks and measurements prior to surgery Additional marks and measurements were made at the time of surgery these were again checked At this point the area was injected with 0 5 lidocaine with 1 200 000 epinephrine Appropriate time waited for the anesthetic and epinephrine effect Beginning on the left upper lid the skin excision was completed The muscle was opened herniated adipose tissue pad in the middle and medial aspect was brought forward cross clamped excised cauterized and allowed to retract The eyes were kept irrigated and protected throughout the procedure Attention was turned to the opposite side Procedure was carried out in the similar manner At the completion the wounds were then closed with a running 6 0 Prolene skin adhesives and Steri Strips Attention was turned to the right lower lid A lash line incision was made A skin flap was elevated and the muscle was opened Large herniated adipose tissue pads were present in each of the three compartments They were individually elevated cross clamped excised cauterized and allowed to retract At the completion a gentle tension was placed on the facial skin and several millimeters of the skin excised Attention was turned to he opposite side The procedure was carried out as just described The contralateral side was reexamined and irrigated Hemostasis was good and it was closed with a running 6 0 Prolene The opposite side was closed in a similar manner Skin adhesives and Steri Strips were applied The eyes were again irrigated and cool Swiss Eye compresses applied At the completion of the case the patient was extubated in the operating room breathing on her own doing well and transferred in good condition from operating room to recovering room Keywords cosmetic plastic surgery blepharochalasia lower lid swiss eye compresses adipose tissue pad bagging blepharoplasty lash line incision quad blepharoplasty MEDICAL_TRANSCRIPTION,Description Temporal cheek neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek neck and jowl lipotosis and facial rhytides Medical Specialty Cosmetic Plastic Surgery Sample Name Cheek Neck Facelift Transcription PREOPERATIVE DIAGNOSIS Facial and neck skin ptosis Cheek neck and jowl lipotosis Facial rhytides POSTOPERATIVE DIAGNOSIS Same PROCEDURE Temporal cheek neck facelift CPT 15825 Submental suction assisted lipectomy CPT 15876 ANESTHESIA General DESCRIPTION OF PROCEDURE This patient is a 65 year old female who has progressive aging changes of the face and neck The patient demonstrates the deformities described above and has requested surgical correction The procedure risks limitations and alternatives in this individual case have been very carefully discussed with the patient The patient has consented to surgery The patient was brought into the operating room and placed in the supine position on the operating table An intravenous line was started and anesthesia was maintained throughout the case The patient was monitored for cardiac blood pressure and oxygen saturation continuously The hair was prepared and secured with rubber bands and micropore tape along the incision line A marking pen had been used to outline the area of the incisions which included the preauricular area to the level of the tragus the post tragal region the post auricular region and into the hairline In addition the incision was marked in the temporal area in the event of a temporal lift then across the coronal scalp for the forehead lift The incision was marked in the submental crease for the submental lipectomy and liposuction The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline The areas to be operated on were injected with 1 Lidocaine containing 1 100 000 Epinephrine This provided local anesthesia and vasoconstriction The total of Lidocaine used throughout the procedure was maintained at no more than 500mg SUBMENTAL SUCTION ASSISTED LIPECTOMY The incision was made as previously outlined in the submental crease in a transverse direction through the skin and subcutaneous tissue and hemostasis was obtained with bipolar cautery A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible 4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly The tunnels were enlarged with a 6mm flat liposuction cannula Then with the Wells Johnson liposuction machine 27 29 inches of underwater mercury suction was accomplished in all tunnels Care was taken not to turn the opening of the suction cannula up to the dermis but it was rotated in and out taking a symmetrical amount of fat from each area A similar procedure was performed with the 4 mm cannula cleaning the area Bilateral areas were palpated for symmetry and any remaining fat was then suctioned directly A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle A plication stitch of 3 0 Vicryl was placed When a satisfactory visible result had been accomplished from the liposuction the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion 5 0 plain catgut was used for closure in a running interlocking fashion The wound was cleaned at the end dried and Mastisol applied Then tan micropore tape was placed for support to the entire area FACE LIFT After waiting approximately 10 15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal A gentle curve was then made and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region A preauricular incision was carried into the natural crease superior to the tragus curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin The incision was made in the temporal area beveling parallel with the hair follicles The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim At the superior level of the zygoma and at the level of the sideburn dissection was brought more superficially in order to avoid the nerves and vessels in the areas specifically the frontalis branch of the facial nerve The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8 10cm in the neck region When the areas of dissection had been connected carefully hemostasis was obtained and all areas inspected At no point were muscle fibers or major vessels or nerves encountered in the dissection The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM The SMAS flap was then advanced posteriorly and superiorly The SMAS was split at the level of the earlobe and the inferior portion was sutured to the mastoid periosteum The excess SMAS was trimmed and excised from the portion anterior to the auricle The SMAS was then imbricated with 2 0 Surgidak interrupted sutures The area was then inspected for any bleeding points and careful hemostasis obtained The flaps were then rotated and advanced posteriorly and then superiorly and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2 0 Tycron suture The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period Skin closure was accomplished in the hairbearing areas with 5 0 Nylon in the preauricular tuft and 4 0 Nylon interrupted in the post auricular area The pre auricular area was closed first with 5 0 Dexon at the ear lobules and 6 0 Nylon at the lobules and 5 0 plain catgut in a running interlocking fashion 5 0 Plain catgut was used in the post auricular area as well leaving ample room for serosanguinous drainage into the dressing The post tragal incisin was closed with interrupted and running interlocking 5 0 plain catgut The exact similar procedure was repeated on the left side At the end of this procedure all flaps were inspected for adequate capillary filling or any evidence of hematoma formation Any small amount of fluid was expressed post auricularly A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines ABD padding over 4X4 gauze was used to cover the pre and post auricular areas This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non constricting but secured fashion The entire dressing complex was secured with a pre formed elastic stretch wrap device All branches of the facial nerve were checked and appeared to be functioning normally The procedures were completed without complication and tolerated well The patient left the operating room in satisfactory condition A follow up appointment was scheduled routine post op medications prescribed and post op instructions given to the responsible party The patient was released to home in satisfactory condition Keywords cosmetic plastic surgery neck skin ptosis lipotosis rhytides facelift submental suction assisted lipectomy pre and post auricular cheek neck facelift auricular region neck facelift cheek neck post auricular auricular incision postoperative cheek submental dissection neck MEDICAL_TRANSCRIPTION,Description Hairline biplanar temporal browlift quadrilateral blepharoplasty canthopexy cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy Medical Specialty Cosmetic Plastic Surgery Sample Name Browlift Blepharoplasty Rhytidectomy Transcription PREOPERATIVE DIAGNOSES 1 Eyebrow ptosis 2 Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid 3 Cervical facial aging with submental lipodystrophy OPERATION 1 Hairline biplanar temporal browlift 2 Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid 3 Cervical facial rhytidectomy with purse string SMAS elevation with submental lipectomy ASSISTANT None ANESTHESIA General endotracheal anesthesia PROCEDURE The patient was placed in a supine position and prepped with general endotracheal anesthesia Local infiltration anesthesia with 1 Xylocaine and 1 100 000 epinephrine was infiltrated in upper and lower eyelids Markings were made and fusiform ellipse of skin was resected from the upper eyelid The lower limb of the fusiform ellipse was at the superior palpebral fold A 9 mm of upper eyelid skin was resected at the widest portion of the lips which extended from medial canthal area to the lateral orbital rim This was performed bilaterally and symmetrically and the skin was removed Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket An incision was made over the superior orbital rim Subperiosteal dissection was performed over the forehead The dissection proceeded medially The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized Hemostasis was achieved with electrocautery in this fashion A 4 cm incision was made and the forehead at the hairline subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid The incision was made in the lower lid just beneath the lashline Subcutaneous dissection was performed over the pretarsal and preseptal muscle Dissection was then proceeded down to the inferior orbital rim The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum which was separated from the inferior orbital rim The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5 0 Vicryl on a P2 needle The upper eyelid incision was closed with a running subcuticular 6 0 Prolene suture bilaterally The forehead was then elevated and the nonhairbearing forehead skin was resected 1 5 cm wide raising the tail of the eyebrow The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided A lateral canthopexy was performed with 5 0 Prolene suture on a C1 double arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides Closure was performed with interrupted 6 0 silk suture for the lower lid The eyebrow hairline brow lift was closed with interrupted 4 0 PDS suture deep subcutaneous tissue and dermis and the skin closed with a running 5 0 Prolene suture Attention then was directed to the cervical facial rhytidectomy and purse string SMAS elevation with submental lipectomy Incisions were made in preauricular area postauricular area mastoid and occipital area Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline Submental lipectomy was performed through the incision in the submental crease Fat was directly removed from the fascia Hemostasis was achieved with electrocautery A SMAS elevation was performed with a purse string suture of 2 0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia This was performed bilaterally and symmetrically Hemostasis was achieved with electrocautery The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed The skin of the cheek and neck were resected which was redundant after the posteriorly and superiorly in the neck and transversely in the cheek Closure was performed with interrupted 3 0 and 4 0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5 0 Prolene suture Drains were placed prior to final closure A 7 mm flat Jackson Pratt was then secured with 3 0 silk suture Dressing consisting of fluffs and Kerlix and a 4 inch Ace were applied to support mildly compressive dressing Scleral eye protectors were removed Maxitrol eye ointment was placed followed by Swiss therapy eye pads The patient tolerated the procedure well and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings TED hose two Jackson Pratt drains and an IV Keywords cosmetic plastic surgery eyebrow ptosis dermatochalasia hairline jackson pratt swiss therapy arcus marginalis blepharoplasty browlift canthopexy fat transposition inferior orbital rim lipectomy lipodystrophy lower eyelid purse string rhytidectomy string smas elevation suborbicularis oculi frontalis muscle pds suture smas elevation submental lipectomy upper eyelid subperiosteal dissection lower lid prolene suture lower eyelids orbital rim lower eyelids sutured subcutaneous eyebrow orbital MEDICAL_TRANSCRIPTION,Description A 60 total body surface area flame burns status post multiple prior excisions and staged graftings Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra not grafted on the back Medical Specialty Cosmetic Plastic Surgery Sample Name Epidermal Autograft Transcription PREOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings POSTOPERATIVE DIAGNOSIS A 60 total body surface area flame burns status post multiple prior excisions and staged graftings PROCEDURES PERFORMED 1 Epidermal autograft on Integra to the back 3520 cm2 2 Application of allograft to areas of the lost Integra not grafted on the back 970 cm2 ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 50 cc BLOOD PRODUCTS RECEIVED One unit of packed red blood cells COMPLICATIONS None INDICATIONS The patient is a 26 year old male who sustained a 60 total body surface area flame burn involving the head face neck chest abdomen back bilateral upper extremities hands and bilateral lower extremities He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites the extent they will provide coverage OPERATIVE FINDINGS 1 Variable take of Integra particularly centrally and inferiorly on the back A fair amount of lost Integra over the upper back and shoulders 2 No evidence of infection 3 Healthy viable wound beds prior to grafting PROCEDURE IN DETAIL The patient was brought to the operating room and positioned supine General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed He was then repositioned prone and perioperative IV antibiotics were administered He was prepped and draped in the usual sterile manner All staples were removed from the Integra and the adherent areas of Silastic were removed The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution Hemostasis of the wound bed was ensured using epinephrine soaked Telfa pads Following dermal tumescence of the buttocks epidermal autografts were harvested 8 one thousandths of an inch using the air Zimmer dermatome These grafts were passed to the back table where they were meshed 3 1 The donor sites were hemostased using epinephrine soaked Telfa and lap pads Once all the grafts were meshed we brought them back up onto the field positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment We were happy with the lie of the grafts and they were stapled into place The grafts were then overlaid with Conformant 2 which was also stapled into place Utilizing all of his buttocks skin we did not have enough to cover his entire back so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment Allograft was thawed and meshed 1 1 It was then brought up onto the field trimmed to fit and stapled into place over the wound Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied Donor sites on his buttocks were dressed in Acticoat and secured with staples He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications He was transported to PACU in stable condition Keywords cosmetic plastic surgery flame burns body surface area epidermal autograft autograft integra integra engraftment wound grafts epidermal allograft MEDICAL_TRANSCRIPTION,Description Capsulotomy left breast and flat advancement V to Y left breast for correction of lower pole defect breast assymetry status post previous breast surgery Medical Specialty Cosmetic Plastic Surgery Sample Name Capsulotomy Flat Advancement Left Breast Transcription PREOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery POSTOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery OPERATION Capsulotomy left breast flat advancement V to Y left breast for correction lower pole defect ANESTHESIA LMA FINDINGS AND PROCEDURE The patient is a 35 year old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast The nipple inframammary fold distance is approximately 1 5 cm shorter than the fuller right breast The patient has bilateral Mentor Smooth round moderate projection jell filled mammary prosthesis 225 cc The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance She was then brought to the operating room and after satisfactory LMA anesthesia had been induced the patient was prepped and draped in the usual manger The patient received a gram of Kefzol prior to beginning the procedure The previous inverted T scar was excised down to the underlying capsule of the breast implant The breast was carefully dissected off of the underlying capsule Care being taken to preserve the vascular supply to the skin and breast flap When the anterior portion of the breast was dissected free of the underlying capsule the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2 0 Monocryl statures Care was taken to avoid as much exposure of the implant as well as damage to the implant When the flap had been created and advanced hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50 000 units Kefzol 1 g gentamicin 80 mg and 500 cc of saline The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2 0 Biosyn This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast The remainder of the inverted T was closed with interrupted sutures of 3 and 2 0 Biosyn and the skin was closed with continuous suture of 5 0 nylon Bacitracin and a standard breast dressing were applied The anesthesia was terminated and the patient was recovered in the operating room Sponge instrument needle count reported as corrected Estimated blood loss negligible Keywords cosmetic plastic surgery capsulotomy biosyn breast breast assymetry kefzol mentor smooth breast surgeries flat advancement inframammary fold lower pole defect mammary mammary prosthesis nipple breast surgery assymetry inframammary capsule MEDICAL_TRANSCRIPTION,Description Hypomastia Patient wants breast augmentation and liposuction of her abdomen Medical Specialty Cosmetic Plastic Surgery Sample Name Breast Augmentation Consult Transcription REASON FOR VISIT This is a cosmetic consultation HISTORY OF PRESENT ILLNESS The patient is a very pleasant 34 year old white female who is a nurse in the operating room She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her She is very bright and well informed about cosmetic surgery She has recently had some neck surgery for a re fusion of her neck and is currently on methadone for chronic pain regarding this Her current desires are that she obtain a breast augmentation and liposuction of her abdomen and she came to me mostly because I offer transumbilical breast augmentation Her breasts are reportedly healthy without any significant problems Her weight is currently stable PAST MEDICAL AND SURGICAL HISTORY Negative Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02 05 and in 09 06 She has had no previous cosmetic or aesthetic surgery FAMILY HISTORY AND SOCIAL HISTORY Significant for Huntington disease in her mother and diabetes in her father Her brother has an aneurysm She does occasionally smoke and has been trying to quit recently She is currently smoking about a pack a day She drinks about once a week She is currently a registered nurse circulator and scrub technician in the operating room at Hopkins She has no children REVIEW OF SYSTEMS A 12 system review is significant for some musculoskeletal pain mostly around her neck and thoracic region She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain She has considered difficult airway due to anterior cervical disk fusion and instability Her last mammogram was in 2000 She has a size 38C breast MEDICATIONS Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed ALLERGIES None FINDINGS On exam today the patient has good posture good physique good skin tone She is tanned Her lower abdomen has some excess adiposity There is some mild laxity of the lower abdominal skin Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation There was no piercing in that region Her breasts are C shaped They are not ptotic They have good symmetry with no evidence of tubular breast deformity She has no masses or lesions noted The nipples are of appropriate size and shape for a woman of her age Her scar on her neck from her anterior cervical disk fusion is well healed Hopefully our scars would be similar to this IMPRESSION AND PLAN Hypomastia I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely This would make her fill out her clothes much better and I think transumbilical technique in her is a good option I have discussed with her the other treatment options and she does not want scars around her breasts if at all possible I think her lower abdominal skin is of good tone I think suction lipectomy in this region would bring down her size and accentuate her waist nicely I am a little concerned about the lower abdominal skin laxity and I will discuss with her further that in the near future if this continues to be a problem she may need a mini tummy tuck I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed I will try to set this up in the near future I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure Due to her neck issues we may not be able to perform her surgery but I will check with Dr X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused Keywords cosmetic plastic surgery breast augmentation and liposuction liposuction of her abdomen transumbilical breast augmentation cosmetic surgery abdominal skin breast augmentation augmentation liposuction cosmetic transumbilical breast MEDICAL_TRANSCRIPTION,Description Breast reconstruction post mastectomy A 51 year old lady for mastectomy on the right side who is interested in the possibility of breast reconstruction Medical Specialty Cosmetic Plastic Surgery Sample Name Breast Reconstruction Transcription REASON FOR CONSULTATION Breast reconstruction post mastectomy HISTORY OF PRESENT ILLNESS The patient is a 51 year old lady who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy which revealed that there was breast cancer This apparently was positive in two separate locations within the suspicious area She also underwent MRI which suggested that there was significant size to the area involved Her contralateral left breast appeared to be uninvolved She has had consultation with Dr ABC and they are currently in place to perform a right mastectomy PAST MEDICAL HISTORY Positive for hypertension which is controlled on medications She is a nonsmoker and engages in alcohol only moderately PAST SURGICAL HISTORY Surgical history includes uterine fibroids some kind of cyst excision on her foot and cataract surgery ALLERGIES None known MEDICATIONS Lipitor ramipril Lasix and potassium PHYSICAL EXAMINATION On examination the patient is a healthy looking 51 year old lady who is moderately overweight Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps There are no any significant scars on the right breast as she has only undergone needle biopsy at this point Exam also reveals abdomen where there is moderate excessive fat but what I consider a good morphology for a potential TRAM flap IMPRESSION A 51 year old lady for mastectomy on the right side who is interested in the possibility of breast reconstruction We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted but in a heavier lady with large breasts I think it virtually deemed to failure We therefore mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant In either case the contralateral breast reduction would be part of the overall plan The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed In any case she does prefer this option in order to avoid the need for an implant We discussed pros and cons of the surgery including the risks such as infection bleeding scarring hernia or bulging of the donor site seroma of the abdomen and fat necrosis or even the skin slough in the abdomen We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself PLAN The patient is definitely interested in undergoing TRAM flap reconstruction At the moment we are planning to do it as an immediate reconstruction at the time of the mastectomy For this reason I have made arrangements to do initial vascular delay procedure within the next couple of days We may cancel this if the chance of postoperative irradiation is high If this is the case I think we can do a better job on the reconstruction if we defer it The patient understands this and will proceed according to the recommendations from Dr ABC and from the oncologist Keywords cosmetic plastic surgery breast reconstruction mastectomy lump breast mammogram needle biopsy breast cancer hypertrophy tram flap latissimus dorsi MEDICAL_TRANSCRIPTION,Description Blepharoplasty procedure Medical Specialty Cosmetic Plastic Surgery Sample Name Blepharoplasty Transcription BLEPHAROPLASTY The patient was prepped and draped The upper lid skin was marked out in a lazy S fashion and the redundant skin marked out with a Green forceps Then the upper lids were injected with 2 Xylocaine and 1 100 000 epinephrine and 1 mL of Wydase per 20 mL of solution The upper lid skin was then excised within the markings Gentle pressure was placed on the upper eyelids and the fat in each of the compartments was teased out using a scissor and cotton applicator and then the fat was cross clamped cut and the clamp cauterized This was done in the all compartments of the middle and medial compartments of the upper eyelid and then the skin sutured with interrupted 6 0 nylon sutures The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin This created a significant crisp supratarsal fold The upper lid skin was closed in this fashion and then attention was turned to the lower lid An incision was made under the lash line and slightly onto the lateral canthus The 15 blade was used to delineate the plane in the lateral portion of the incision and then using a scissor the skin was cut at the marking Then the skin muscle flap was elevated with sharp dissection The fat was located and using a scissor the three eyelid compartments were opened Fat was teased out cross clamped the fat removed and then the clamp cauterized Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze and then the excess skin removed The suture line was sutured with interrupted 6 0 silk sutures Once this was done the procedure was finished The patient left the OR in satisfactory condition The patient was given 50 mg of Demerol IM with 25 mg of Phenergan Keywords cosmetic plastic surgery blepharoplasty green forceps wydase applicator canthus lash line lazy s lazy s fashion muscle flap periorbital muscle prepped and draped supratarsal fold upper lid upward gaze upper lid skin eyelidsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z osteotomies and bilateral forehead reconstruction with autologous graft Medical Specialty Cosmetic Plastic Surgery Sample Name Bilateral Orbital Frontozygomatic Craniotomy Transcription PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly PROCEDURES PERFORMED 1 Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z osteotomies 2 Bone grafts 3 Bilateral forehead reconstruction with autologous graft ANESTHESIA General endotracheal anesthesia COMPLICATIONS None CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE Stable transferred to recovery room ESTIMATED BLOOD LOSS 300 mL CRYSTALLOIDS Packed red blood cells 440 mL FFP 100 mL URINARY OUTPUT 160 mL INDICATIONS FOR PROCEDURE The patient is a 9 month old baby with a history of trigonocephaly and metopic synostosis We have discussed locations the nature of trigonocephaly s repair metopic synostosis repair with bilateral fronto orbital advancement forehead reconstruction and bone graft We have discussed risks and benefits Risks included but not limited to risk of bleeding infection dehiscence scarring need for future revision surgeries minimal possibility of death the alternatives devastating bleeding anesthesia death dehiscence infection The parents understand decide to proceed with surgery Informed consent was obtained and we proceed with surgery DESCRIPTION OF PROCEDURE The patient was taken into the operating room placed in the supine position General anesthetic was administered Prophylactic dose of antibiotic was given Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees The patient was once more positioned and padded in the usual manner The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time then the definitive prep and draping of the area was done The procedure began with an incision through the full thickness of the skin into the subcutaneous tissue down to the subgaleal plane The subgaleal plane was developed and reflected anteriorly and slightly posteriorly Hemostasis achieved with electrocautery Raney clips were applied to both flaps to prevent significant bleeding Then we proceed with craniotomy part and Dr Y proceeded with this part of the procedure I assisted her and this will be described in a different operative report Then the area corresponding to the C shaped osteotomy was marked and then we proceed in conjunction with Dr Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor The osteotomies were done with the Midas and some irrigation There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim This was done on both sides Hemostasis achieved with bone wax and electrocautery Once the osteotomies were completed __________ of the osteotomy sites allowed advancements On the left side there was a minor fracture to the superior orbital rim that was plated The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3 0 Vicryl interrupted stitches The forehead flaps were attached with the help of absorbable mesh The forehead portions were applied to the fronto orbital advancement of fronto orbital piece with the help of Synthes mesh and 3 mm screws Hemostasis was checked The flaps were retracted back into position The wound was closed with 3 0 Vicryl interrupted sutures 4 0 Vicryl interrupted stitches and 5 0 running fast absorbing gut Dressing was applied with Xeroform bacitracin and ABDs and a burn net The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition I was present and participated in all aspects of the procedure Sponge needle and instrument counts were completed at the end of the procedure Keywords cosmetic plastic surgery metopic synostosis craniotomy z osteotomies orbital advancement bone grafts frontozygomatic forehead reconstruction autologous graft bilateral orbital frontozygomatic craniotomy orbital osteotomies forehead MEDICAL_TRANSCRIPTION,Description Left upper extremity amputation This 3 year old male suffered amputation of his left upper extremity with complications of injury He presents at this time for further attempts at closure Left abdominal flap 5 x 5 cm to left forearm debridement of skin subcutaneous tissue muscle and bone closure of wounds placement of VAC negative pressure wound dressing Medical Specialty Cosmetic Plastic Surgery Sample Name Closure of Amputation Wounds Transcription PREOPERATIVE DIAGNOSIS Left upper extremity amputation POSTOPERATIVE DIAGNOSIS Left upper extremity amputation PROCEDURES 1 Left abdominal flap 5 x 5 cm to left forearm 2 Debridement of skin subcutaneous tissue muscle and bone 3 Closure of wounds simple closure approximately 8 cm 4 Placement of VAC negative pressure wound dressing INDICATIONS This 3 year old male suffered amputation of his left upper extremity with complications of injury He presents at this time for further attempts at closure OPERATIVE FINDINGS A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory DESCRIPTION OF PROCEDURE Under inhalational anesthesia he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen chest and groin He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them In this fashion simple closure was accomplished and its total length was approximately 8 cm It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis At this time once we accomplished debridement and simple closure removing skin subcutaneous tissue muscle and bone as well as closing the arm we could design our flap for the abdomen The flap was designed as a slightly greater than 1 1 ellipse of skin from just below the costal margin This was elevated at the level of the external oblique and then laid on the left forearm The donor s site was closed using interrupted 4 0 Vicryl in the deep dermis and running subcuticular 4 0 Monocryl on the skin Steri Strips were applied At this time the flap was inset using again 4 0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition Keywords cosmetic plastic surgery abdominal flap debridement skin subcutaneous tissue muscle bone closure of wounds vac vac negative upper extremity closure wounds flap extremity amputation MEDICAL_TRANSCRIPTION,Description Belly button piercing for insertion of belly button ring Medical Specialty Cosmetic Plastic Surgery Sample Name Belly Button Piercing Transcription PROCEDURE Belly button piercing for insertion of belly button ring DESCRIPTION OF PROCEDURE The patient was prepped after informed consent was given of risk of infection and foreign body reaction The area was marked by the patient and then prepped The area was injected with 2 Xylocaine 1 100 000 epinephrine Then a 14 gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the 14 gauge needle and pulled through A small ball was placed over the end of the ring This terminated the procedure The patient tolerated the procedure well Postop instructions were given regarding maintenance Patient left the office in satisfactory condition Keywords cosmetic plastic surgery belly button piercing 2 xylocaine belly button postop instructions the patient tolerated the procedure well foreign body gauge needle needle piercing ring satisfactory condition umbilical button piercing belly buttonNOTE MEDICAL_TRANSCRIPTION,Description A well child check with concern of some spitting up quite a bit Medical Specialty Consult History and Phy Sample Name Well Child Check 5 Transcription SUBJECTIVE The patient presents with Mom for a first visit to our office for a well child check with concern of some spitting up quite a bit Mom wants to make sure that this is normal The patient is nursing well every two to three hours She does have some spitting up on occasion It has happened two or three times with some curdled appearance x 1 No projectile in nature nonbilious Normal voiding and stooling pattern Growth and Development Denver II normal passing all developmental milestones per age See Denver II form in the chart PAST MEDICAL HISTORY Mom reports uncomplicated pregnancy with prenatal care provided by Dr XYZ in Wichita Kansas Delivery after induction secondary to postdate at St Joseph Hospital Infant delivered by SVD with birth weight of 6 pounds 13 ounce Length of 19 inches Did well after delivery and dismissed to home with Mom Received hepatitis B 1 prior to dismissal No other hospitalizations No surgeries No known medical allergies No medications Mom has tried Mylicon drops on occasion FAMILY HISTORY Significant for cardiovascular disease hypertension diabetes mellitus and thyroid problems in maternal and paternal grandparents Healthy Mother Father There is also history of breast colon and ovarian cancer on the maternal side of the family her grandmother who is present at visit today There is history of asthma in the patient s father SOCIAL HISTORY The patient lives at home with 23 year old mother who is a homemaker and 24 year old father John who is a supervisor at Excel The family lives in Bentley Kansas No smoking in the home Family does have one pet cat REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Weight 7 pounds 12 ounces Height 21 inches Head circumference 35 cm Temperature 97 2 degrees General Well developed well nourished cooperative alert interactive 2 week old white female in no acute distress HEENT Atraumatic normocephalic Anterior fontanel is soft and flat Pupils are equal round and reactive Sclerae clear Red reflexes present bilaterally TMs are clear bilaterally Oropharynx Mucous membranes are moist and pink Neck Supple no lymphadenopathy Chest Clear to auscultation bilaterally No wheeze or crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender nondistended Positive bowel sounds No mass nor organomegaly Genitourinary Tanner I female genitalia Femoral pulses are equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Negative Ortolani or Barlow maneuver Back Straight No scoliosis Integument Warm dry and pink without lesions Neurologic Alert Good muscle tone and strength ASSESSMENT PLAN 1 Well 2 week old white female 2 Anticipatory guidelines for growth diet development safety issues as well as immunizations and visitation schedule Gave 2 week well child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family 3 Call the office or on call physician if the patient has fever feeding problems or breathing problems Otherwise plan to recheck at 1 month of age Keywords consult history and phy well child check denver ii child check growth development denver cardiovascular maternal mother spitting father child check asthma family mom MEDICAL_TRANSCRIPTION,Description A 3 month well child check Medical Specialty Consult History and Phy Sample Name Well Child Check 6 Transcription SUBJECTIVE Patient presents with Mom and Dad for her 5 year 3 month well child check Family has not concerns stating patient has been doing well overall since last visit Taking in a well balanced diet consisting of milk and dairy products fruits vegetables proteins and grains with minimal junk food and snack food No behavioral concerns Gets along well with peers as well as adults Is excited to start kindergarten this upcoming school year Does attend daycare Normal voiding and stooling pattern No concerns with hearing or vision Sees the dentist regularly Growth and development Denver II normal passing all developmental milestones per age in areas of fine motor gross motor personal and social interaction and speech and language development See Denver II form in the chart ALLERGIES None MEDICATIONS None FAMILY SOCIAL HISTORY Unchanged since last checkup Lives at home with mother father and sibling No smoking in the home REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Vital Signs Weight 43 pounds Height 42 1 4 inches Temperature 97 7 Blood pressure 90 64 General Well developed well nourished cooperative alert and interactive 5 year 3month old white female in no acute distress HEENT Atraumatic normocephalic Pupils equal round and reactive Sclerae clear Red reflex present bilaterally Extraocular muscles intact TMs clear bilaterally Oropharynx Mucous membranes moist and pink Good dentition Neck Supple no lymphadenopathy Chest Clear to auscultation bilaterally No wheeze or crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender Nondistended Positive bowel sounds No masses or organomegaly GU Tanner I female genitalia Femoral pulses equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Back Straight No scoliosis Integument Warm dry and pink without lesions Neurological Alert Good muscle tone and strength Cranial nerves II XII grossly intact DTRs 2 4 bilaterally ASSESSMENT PLAN 1 Well 5 year 3 month old white female 2 Anticipatory guidance for growth and diet development and safety issues as well as immunizations Will receive MMR DTaP and IPV today Discussed risks and benefits as well as possible side effects and symptomatic treatment Gave 5 year well child check handout to mom Completed school pre participation physical Copy in the chart Completed vision and hearing screening Reviewed results with family 3 Follow up in one year for next well child check or as needed for acute care Keywords consult history and phy denver ii child check mom diet growth denver family development child check MEDICAL_TRANSCRIPTION,Description 1 year well child check Medical Specialty Consult History and Phy Sample Name Well Child Check 4 Transcription SUBJECTIVE The patient presents with Mom and Dad for her 1 year well child check The family has no concerns stating the patient has been doing well overall since the last visit taking in a well balanced diet consisting of formula transitioning to whole milk fruits vegetables proteins and grains Normal voiding and stooling pattern No concerns with hearing or vision Growth and development Denver II normal passing all developmental milestones per age in areas of fine motor gross motor personal and social interaction as well as speech and language development See Denver II form in the chart PAST MEDICAL HISTORY Allergies None Medications Tylenol this morning in preparation for vaccines and a multivitamin daily FAMILY SOCIAL HISTORY Unchanged since last checkup REVIEW OF SYSTEMS As per HPI otherwise negative OBJECTIVE Weight 24 pounds 1 ounce Height 30 inches Head circumference 46 5 cm Temperature afebrile General A well developed well nourished cooperative alert and interactive 1 year old white female smiling happy and drooling HEENT Atraumatic normocephalic Anterior fontanel is closed Pupils equally round and reactive Sclerae are clear Red reflex present bilaterally Extraocular muscles intact TMs are clear bilaterally Oropharynx Mucous membranes are moist and pink Good dentition Drooling and chewing with teething behavior today Neck is supple No lymphadenopathy Chest Clear to auscultation bilaterally No wheeze No crackles Good air exchange Cardiovascular Regular rate and rhythm No murmur Good pulses bilaterally Abdomen Soft nontender Nondistended Positive bowel sounds No mass No organomegaly Genitourinary Tanner I female genitalia Femoral pulses equal bilaterally No rash Extremities Full range of motion No cyanosis clubbing or edema Negative Ortolani and Barlow maneuver Back Straight No scoliosis Integument Warm dry and pink without lesions Neurological Alert Good muscle tone and strength Cranial nerves II through XII are grossly intact ASSESSMENT AND PLAN 1 Well 1 year old white female 2 Anticipatory guidance Reviewed growth diet development and safety issues as well as immunizations Will receive Pediarix and HIB today Discussed risks and benefits as well as possible side effects and symptomatic treatment Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available Gave 1 year well child checkup handout to Mom and Dad 3 Follow up for the 15 month well child check or as needed for acute care Keywords consult history and phy well child check denver ii child check checkup check child MEDICAL_TRANSCRIPTION,Description 1 month old for a healthy checkup Well child check Medical Specialty Consult History and Phy Sample Name Well Child Check 7 Transcription SUBJECTIVE This is a 1 month old who comes in for a healthy checkup Mom says things are gone very well He is kind of acting like he has got a little bit of sore throat but no fevers He is still eating well He is up to 4 ounces every feeding He has not been spitting up Voiding and stooling well PAST MEDICAL HISTORY Reviewed very healthy CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None DIETARY His formula fed on Enfamil Lipil Voiding and stooling well Growth chart reviewed with Mom DEVELOPMENTAL He is starting to track with his eyes He is smiling a little bit moving hands and feet symmetrically PHYSICAL EXAMINATION In general well developed well nourished male in no acute distress DERMATOLOGIC Without rash or lesion HEENT Head normocephalic and atraumatic Anterior fontanel soft and flat Eyes Pupils equal round and reactive to light Extraocular movements intact Red reflexes present bilaterally Does appear to have conjugate gaze Ears Tympanic membranes are pink to gray translucent neutral position normal light reflex and mobility Nares are patent pink mucosa moist Oropharynx clear with pink mucosa normal moisture NECK Supple without masses CHEST Clear to auscultation and percussion with easy respirations and no accessory muscle use CARDIOVASCULAR Regular rate and rhythm without murmurs rubs heaves or gallops ABDOMEN Soft nontender nondistended without hepatosplenomegaly GU EXAM Normal Tanner I male Testes descended bilaterally No hernias noted EXTREMITIES Pink and warm Moving all extremities well No subluxation of the hips and leg creases appear symmetric NEUROLOGIC Alert otherwise nonfocal 2 deep tendon reflexes at the knees Fixes and follows appropriately to both voice and face ASSESSMENT Well child check PLAN 1 Diet growth and safety discussed 2 Immunizations discussed and updated with hepatitis B 3 Return to clinic at two months of age Call if problems Keywords MEDICAL_TRANSCRIPTION,Description Consultation for wrist pain Medical Specialty Consult History and Phy Sample Name Wrist Pain Transcription CHIEF COMPLAINT Left wrist pain HISTORY OF PRESENT PROBLEM Keywords consult history and phy wrist pain scapholunate tenderness to palpation three views traumatic wrist injury ulnar styloid nonunion ulnar styloid wrist union soreness styloid ulnar MEDICAL_TRANSCRIPTION,Description A 9 month well child check Medical Specialty Consult History and Phy Sample Name Well Child Check 2 Transcription SUBJECTIVE This 9 month old Hispanic male comes in today for a 9 month well child check They are visiting from Texas until the end of April 2004 Mom says he has been doing well since last seen He is up to date on his immunizations per her report She notes that he has developed some bumps on his chest that have been there for about a week Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics Mom says he has been doing fine since then She has no concerns about him PAST MEDICAL HISTORY Significant for term vaginal delivery without complications MEDICATIONS None ALLERGIES None SOCIAL HISTORY Lives with parents There is no smoking in the household REVIEW OF SYSTEMS Developmentally is appropriate No fevers No other rashes No cough or congestion No vomiting or diarrhea Eating normally OBJECTIVE His weight is 16 pounds 9 ounces Height is 26 1 4 inches Head circumference is 44 75 cm Pulse is 124 Respirations are 26 Temperature is 98 1 degrees Generally this is a well developed well nourished 9 month old male who is active alert and playful in no acute distress HEENT Normocephalic atraumatic Anterior fontanel is soft and flat Tympanic membranes are clear bilaterally Conjunctivae are clear Pupils equal round and reactive to light Nares without turbinate edema Oropharynx is nonerythematous NECK Supple without lymphadenopathy thyromegaly carotid bruit or JVD CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm without murmur ABDOMEN Soft nontender nondistended normoactive bowel sounds No masses or organomegaly to palpation GU Normal male external genitalia Uncircumcised penis Bilaterally descended testes Femoral pulses 2 4 EXTREMITIES Moves all four extremities equally Minimal tibial torsion SKIN Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest ASSESSMENT PLAN 1 Well child check Is doing well Will recommend a followup well child check at 1 year of age and immunizations at that time Discussed safety issues including poisons choking hazards pet safety appropriate nutrition with Mom She is given a parenting guide handout 2 Molluscum contagiosum Described the viral etiology of these Told her they are self limited and we will continue to monitor at this time 3 Left otitis media resolved Continue to monitor We will plan on following up in three months if they are still in the area or p r n Keywords consult history and phy well child check otitis media molluscum contagiosum immunizations developed atraumatic child MEDICAL_TRANSCRIPTION,Description Well child Left lacrimal duct stenosis Medical Specialty Consult History and Phy Sample Name Well Child Check 1 Transcription CHIEF COMPLAINT Well child check HISTORY OF PRESENT ILLNESS This is a 12 month old female here with her mother for a well child check Mother states she has been doing well She is concerned about drainage from her left eye Mother states she was diagnosed with a blocked tear duct on that side shortly after birth and normally she has crusted secretions every morning She states it is worse when the child gets a cold She has been using massaging when she can remember to do so The patient is drinking whole milk without problems She is using solid foods three times a day She sleeps well without problems Her bowel movements are regular without problems She does not attend daycare DEVELOPMENTAL ASSESSMENT Social She can feed herself with fingers She is comforted by parent s touch She is able to separate and explore Fine motor She scribbles She has a pincer grasp She can drink from a cup Language She says dada She says one to two other words and she indicates her wants Gross motor She can stand alone She cruises She walks alone She stoops and recovers PHYSICAL EXAMINATION General She is alert in no distress Vital signs Weight 25th percentile Height 25th percentile Head circumference 50th percentile HEENT Normocephalic atraumatic Pupils are equal round and reactive to light Left eye with watery secretions and crusted lashes Conjunctiva is clear TMs are clear bilaterally Nares are patent Mild nasal congestion present Oropharynx is clear Neck Supple Lungs Clear to auscultation Heart Regular No murmur Abdomen Soft Positive bowel sounds No masses No hepatosplenomegaly GU Female external genitalia Extremities Symmetrical Femoral pulses are 2 bilaterally Full range of motion of all extremities Neurologic Grossly intact Skin Normal turgor Testing Hearing and vision assessments grossly normal ASSESSMENT 1 Well child 2 Left lacrimal duct stenosis PLAN MMR 1 and Varivax 1 today VIS statements given to Mother after discussion Evaluation and treatment as needed with Dr XYZ with respect to the blocked tear duct Anticipatory guidance for age She is to return to the office in three months Keywords consult history and phy well child check drainage eye lacrimal duct stenosis lacrimal duct mmr varivax vis statements tear duct lacrimal percentile mother child MEDICAL_TRANSCRIPTION,Description Patient with morbid obesity Medical Specialty Consult History and Phy Sample Name Weight Loss Evaluation Transcription REASON FOR VISIT Weight loss evaluation HISTORY OF PRESENT ILLNESS Keywords consult history and phy medifast obesity weight loss morbid obesity weight loss evaluation weight MEDICAL_TRANSCRIPTION,Description Viral gastroenteritis Patient complaining of the onset of nausea and vomiting after she drank lots of red wine She denies any sore throat or cough She states no one else at home has been ill Medical Specialty Consult History and Phy Sample Name Viral Gastroenteritis Transcription HISTORY OF PRESENT ILLNESS Patient is a 40 year old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p m last night after she states she drank lots of red wine She states after vomiting she felt fine through the night but woke with more nausea and vomiting and diaphoresis She states she has vomited approximately 20 times today and has also had some slight diarrhea She denies any sore throat or cough She states no one else at home has been ill She has not taken anything for her symptoms MEDICATIONS Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies ALLERGIES SHE HAS NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is married and is a nonsmoker and lives with her husband who is here with her REVIEW OF SYSTEMS Patient denies any fever or cough She notes no blood in her vomitus or stool The remainder of her review of systems is discussed and all are negative Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp is 37 6 Other vital signs are all within normal limits GENERAL Patient is a healthy appearing middle aged white female who is lying on the stretcher and appears only mildly ill HEENT Head is normocephalic and atraumatic Pharynx shows no erythema tonsillar edema or exudate NECK No enlarged anterior or posterior cervical lymph nodes There is no meningismus HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes ABDOMEN Active bowel sounds Soft without any focal tenderness on palpation There are no masses guarding or rebound noted SKIN No rash EXTREMITIES No cyanosis clubbing or edema LABORATORY DATA CBC shows a white count of 12 9 with an elevation in the neutrophil count on differential Hematocrit is 33 8 but the indices are normochromic and normocytic BMP is remarkable for a random glucose of 147 All other values are unremarkable LFTs are normal Serum alcohol is less than 5 TREATMENT Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea She was given two capsules of Imodium with some apple juice which she was able to keep down The patient did feel well enough to be discharged home ASSESSMENT Viral gastroenteritis PLAN Rx for Compazine 10 mg tabs dispense five sig one p o q 8h p r n for any recurrent nausea She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet Imodium for any diarrhea but no dairy products until the diarrhea has gone for at least 24 hours If she is unimproved in the next two days she was urged to follow up with her PCP back home Keywords consult history and phy nausea vomiting viral gastroenteritis wine gastroenteritis ill MEDICAL_TRANSCRIPTION,Description The patient with recurrent nongranulomatous anterior iritis and most recently pain in left eye associated with headache and photophobia Medical Specialty Consult History and Phy Sample Name Uveitis Transcription PAST MEDICAL HISTORY Significant for GERD history of iron deficiency anemia and asthma for which she takes an inhaler REVIEW OF SYSTEMS Positive for only for left knee arthritis She has no exposure to tuberculosis or syphilis she has no mouth or genital ulcers She has no skin rashes She has no connective tissue disorders PAST OCULAR HISTORY Significant for cataract and glaucoma surgery of the right eye PHYSICAL EXAMINATION On examination visual acuity measures hand motions on the right and 20 25 in the left There is an afferent pupillary defect on the right On examination there is a right hypertropia There is dense anterior chamber inflammation on the right eye with a stagnant aqueous There is either neovascularization on the iris or reactive iris vessels it is difficult to discern This seems to be complete iris synechia to the anterior lens capsule There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface The anterior chamber appears narrow On the left there is also dense inflammation at 4 cell There is 1 nuclear sclerosis Dilated fundus examination cannot be performed on the right secondary to intense inflammation On the left there is no evidence of active posterior uveitis There is some inferior vitreous debris ASSESSMENT PLAN Chronic bilateral recurrent nongranulomatous diffuse uveitis Currently there is very severe right eye inflammation and severe left eye I discussed at length with the patient that this will likely take an oral steroid to quite her down Since she has only one seeing eye I am anxious to obtain a decreased inflammation as soon as possible She has been on oral steroids in the past We also discussed considering the aggressive recurrent nature of this process it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left I anticipate we will likely start methotrexate in the near future In this acute phase I have recommended oral steroids at a dose of 60 mg a day hourly topical Pred Forte as well as atropine sulfate We will watch her closely in clinic I am sending a copy of this dictation to her primary care doctor she said she has had a negative HLA B27 rheumatoid factor and ANA in the past At this stage to be thorough I would ask Dr X to assist us in repeating her chest x ray PPD if not current and an RPR Additionally in anticipation of need for methotrexate it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C Keywords consult history and phy iritis nongranulomatous uveitis eye inflammation photophobia recurrent nongranulomatous anterior iritis headache and photophobia anterior chamber anterior chamber inflammation MEDICAL_TRANSCRIPTION,Description The patient s main complaint is vertigo The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment Medical Specialty Consult History and Phy Sample Name Vertigo Consult Transcription Assessment for peripheral vestibular function follows OTOSCOPY showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne ROMBERG TEST maintained postural stability FRENZEL GLASSES EXAMINATION no spontaneous end gaze nystagmus HEAD SHAKING No provocation nystagmus DIX HALLPIKE showed no positional nystagmus excluding benign paroxysmal positional vertigo VESTIBULOCULAR REFLEX HALMAGYI TEST showed corrective saccades giving the impression of decompensated vestibular hypofunction IMPRESSION The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid PLAN Planned for electronystagmography to document the degree of vestibular hypofunction Keywords consult history and phy electronystagmography hearing impairment imbalance tinnitus hypofunction nystagmus vestibular vertigo MEDICAL_TRANSCRIPTION,Description The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness Symptoms are not accompanied by tinnitus or deafness Medical Specialty Consult History and Phy Sample Name Vertigo Consult 1 Transcription Patient had a normal MRI and normal neurological examination on August 24 2010 Assessment for peripheral vestibular function follows Most clinical tests were completed with difficulty and poor cooperation OTOSCOPY showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne ROMBERG TEST maintained postural stability with difficulty Frenzel glasses examination no spontaneous end gaze nystagmus DIX HALLPIKE showed no positional nystagmus excluding benign paroxysmal positional vertigo HEAD SHAKING AND VESTIBULOCULAR REFLEX HALMAGYI TEST were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction IMPRESSION Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing PLAN Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises in addition to supportive medical treatment in the form of betahistine 24 mg twice a day Keywords consult history and phy tinnitus deafness imbalance nystagmus hypofunction electronystagmography vertigo vestibular MEDICAL_TRANSCRIPTION,Description Viral upper respiratory infection URI with sinus and eustachian congestion Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain Medical Specialty Consult History and Phy Sample Name URI Eustachian Congestion Transcription HISTORY OF PRESENT ILLNESS Patient is a 14 year old white female who presents with her mother complaining of a four day history of cold symptoms consisting of nasal congestion and left ear pain She has had a dry cough and a fever as high as 100 but this has not been since the first day She denies any vomiting or diarrhea She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe but she does not think that this has helped FAMILY HISTORY The patient s younger sister has recently had respiratory infection complicated by pneumonia and otitis media REVIEW OF SYSTEMS The patient does note some pressure in her sinuses She denies any skin rash SOCIAL HISTORY Patient lives with her mother who is here with her Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp is 38 1 pulse is elevated at 101 other vital signs are all within normal limits Room air oximetry is 100 GENERAL Patient is a healthy appearing white female adolescent who is sitting on the stretcher and appears only mildly ill HEENT Head is normocephalic atraumatic Pharynx shows no erythema tonsillar edema or exudate Both TMs are easily visualized and are clear with good light reflex and no erythema Sinuses do show some mild tenderness to percussion NECK No meningismus or enlarged anterior posterior cervical lymph nodes HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes SKIN No rash ASSESSMENT Viral upper respiratory infection URI with sinus and eustachian congestion PLAN I did educate the patient about her problem and urged her to switch to Advil Cold Sinus for the next three to five days for better control of her sinus and eustachian discomfort I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses If she is unimproved in five days follow up with her PCP for re exam Keywords consult history and phy upper respiratory infection eustachian congestion erythema uri nasal cough eustachian respiratory sinus congestion infection tonsillar MEDICAL_TRANSCRIPTION,Description Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days Medical Specialty Consult History and Phy Sample Name Toothache ER Visit Transcription CHIEF COMPLAINT Toothache HISTORY OF PRESENT ILLNESS This is a 29 year old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled Complains of new tooth pain The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments he has to be on standby appointments only The patient denies any other problems or complaints The patient denies any recent illness or injuries The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness No recent weight change HEENT No headache no neck pain the toothache pain for the past three days as previously mentioned There is no throat swelling no sore throat no difficulty swallowing solids or liquids The patient denies any rhinorrhea No sinus congestion pressure or pain no ear pain no hearing change no eye pain or vision change CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath or cough GASTROINTESTINAL No abdominal pain No nausea or vomiting GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No focal weakness or numbness Normal speech HEMATOLOGIC LYMPHATIC No lymph node swelling has been noted PAST MEDICAL HISTORY Chronic knee pain CURRENT MEDICATIONS OxyContin and Vicodin ALLERGIES PENICILLIN AND CODEINE SOCIAL HISTORY The patient is still a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 9 oral blood pressure is 146 83 pulse is 74 respirations 16 oxygen saturation 98 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed The patient is a little overweight but otherwise appears to be healthy The patient is calm comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Eyes are normal with clear conjunctiva and cornea bilaterally There is no icterus injection or discharge Pupils are 3 mm and equally round and reactive to light bilaterally There is no absence of light sensitivity or photophobia Extraocular motions are intact bilaterally Ears are normal bilaterally without any sign of infection There is no erythema swelling of canals Tympanic membranes are intact without any erythema bulging or fluid levels or bubbles behind it Nose is normal without rhinorrhea or audible congestion There is no tenderness over the sinuses NECK Supple nontender and full range of motion There is no meningismus No cervical lymphadenopathy No JVD Mouth and oropharynx shows multiple denture and multiple dental caries The patient has tenderness to tooth 12 as well as tooth 21 The patient has normal gums There is no erythema or swelling There is no purulent or other discharge noted There is no fluctuance or suggestion of abscess There are no new dental fractures The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling The buccal membranes are normal Mucous membranes are moist The floor of the mouth is normal without any abscess suggestion of Ludwig s syndrome CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally without shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to back arms and legs The patient has normal use of his extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact to the extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No cervical lymphadenopathy is palpated EMERGENCY DEPARTMENT COURSE The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction DIAGNOSES 1 ODONTALGIA 2 MULTIPLE DENTAL CARIES CONDITION UPON DISPOSITION Stable DISPOSITION To home PLAN The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes The patient was requested to have reevaluation within two days The patient was given a prescription for Percocet and clindamycin The patient was given drug precautions for the use of these medicines The patient was offered discharge instructions on toothache but states that he already has it He declined the instructions The patient was asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern Keywords consult history and phy odontalgi multiple dental caries dentist dental disease extensive dental disease teeth pulled lower teeth cervical lymphadenopathy dental caries toothache erythema swelling teeth dental MEDICAL_TRANSCRIPTION,Description Evaluation of possible tethered cord She underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age Medical Specialty Consult History and Phy Sample Name Tethered Cord Evaluation Transcription REASON FOR VISIT The patient referred by Dr X for evaluation of her possible tethered cord HISTORY OF PRESENT ILLNESS Briefly she is a 14 year old right handed female who is in 9th grade who underwent a lipomyomeningocele repair at 3 days of age and then again at 3 1 2 years of age The last surgery was in 03 95 She did well however in the past several months has had some leg pain in both legs out laterally worsening at night and requiring Advil Motrin as well as Tylenol PM Denies any new bowel or bladder dysfunction or increased sensory loss She had some patchy sensory loss from L4 to S1 MEDICATIONS Singulair for occasional asthma FINDINGS She is awake alert and oriented x 3 Pupils equal and reactive EOMs are full Motor is 5 out of 5 She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus There is no evidence of clonus There is diminished sensation from L4 to S1 having proprioception ASSESSMENT AND PLAN Possible tethered cord I had a thorough discussion with the patient and her parents I have recommended a repeat MRI scan The prescription was given today MRI of the lumbar spine was just completed I would like to see her back in clinic We did discuss the possible symptoms of this tethering Keywords consult history and phy tethering lipomyomeningocele repair sensory loss tethered cord mri cord lipomyomeningocele MEDICAL_TRANSCRIPTION,Description A 92 year old female had a transient episode of slurred speech and numbness of her left cheek for a few hours Medical Specialty Consult History and Phy Sample Name TIA Cosult Transcription REASON FOR CONSULTATION This 92 year old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours However the chart indicates that she had recurrent TIAs x3 yesterday each lasting about 5 minutes with facial drooping and some mental confusion She had also complained of blurred vision for several days She was brought to the emergency room last night where she was noted to have a left carotid bruit and was felt to have recurrent TIAs CURRENT MEDICATIONS The patient is on Lanoxin amoxicillin Hydergine Cardizem Lasix Micro K and a salt free diet SOCIAL HISTORY She does not smoke or drink alcohol FINDINGS Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone probably representing the benign osteochondroma seen on previous studies CBC was normal aside from a hemoglobin of 11 2 ECG showed atrial fibrillation BUN was 22 creatinine normal CPK normal glucose normal electrolytes normal PHYSICAL EXAMINATION On examination the patient is noted to be alert and fully oriented She has some impairment of recent memory She is not dysphasic or apraxic Speech is normal and clear The head is noted to be normocephalic Neck is supple Carotid pulses are full bilaterally with left carotid bruit Neurologic exam shows cranial nerve function II through XII to be intact save for some slight flattening of the left nasolabial fold Motor examination shows no drift of the outstretched arms There is no tremor or past pointing Finger to nose and heel to shin performed well bilaterally Motor showed intact neuromuscular tone strength and coordination in all limbs Reflexes 1 and symmetrical with bilateral plantar flexion absent jaw jerk no snout Sensory exam is intact to pinprick touch vibration position temperature and graphesthesia IMPRESSION Neurological examination is normal aside from mild impairment of recent memory slight flattening of the left nasolabial fold and left carotid bruit She also has atrial fibrillation apparently chronic In view of her age and the fact that she is in chronic atrial fibrillation I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs RECOMMENDATIONS I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated in which case you might consider it best to do an angiography and consider endarterectomy In view of her age I would be reluctant to recommend Coumadin anticoagulation I will be happy to follow the patient with you Keywords consult history and phy atrial fibrillation carotid bruit slurred speech numbness calcified mass lesion neurological examination tias carotid benign MEDICAL_TRANSCRIPTION,Description Newly diagnosed T cell lymphoma The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago Medical Specialty Consult History and Phy Sample Name T Cell Lymphoma Consult Transcription CHIEF COMPLAINT Newly diagnosed T cell lymphoma HISTORY OF PRESENT ILLNESS The patient is a very pleasant 40 year old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago He was originally treated with antibiotics as a possible tooth abscess Prior to this event in March of 2010 he was treated for strep throat The pain at that time was on the right side About a month ago he started having night sweats The patient reports feeling hot when he went to bed he fall asleep and would wake up soaked All these symptoms were preceded by overwhelming fatigue and exhaustion He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home With the fatigue he has had some mild chest pain and shortness of breath and has also noted a decrease in his appetite although he reports his weight has been stable He also reports occasional headaches with some stabbing and pain in his feet and legs He also complains of some left groin pain PAST MEDICAL HISTORY Significant for HIV diagnosed in 2000 He also had mononucleosis at that time The patient reports being on anti hepatitis viral therapy period that was very intense He took the meds for about six months he reports stopping and prior to 2002 at one point during his treatment he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells He reports no other history of transfusions He has history of spontaneous pneumothorax The first episode was 1989 on his right lung In 1990 he had a slow collapse of the left lung He reports no other history of pneumothoraces In 2003 he had shingles He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy FAMILY HISTORY Notable for his mother who is currently battling non small cell lung cancer She is a nonsmoker His sister is Epstein Barr virus positive The patient s mother also reports that she is Epstein Barr virus positive His maternal grandfather died from complications from melanoma His mother also has diabetes SOCIAL HISTORY The patient is single He currently lives with his mother in house for several both in New York and here in Colorado His mother moved out to Colorado eight years ago and he has been out here for seven years He currently is self employed and does antiquing He has also worked as nurses aide and worked in group home for the state of New York for the developmentally delayed He is homosexual currently not sexually active He does have smoking history as about a thirteen and a half pack year history of smoking currently smoking about a quarter of a pack per day He does not use alcohol or illicit drugs REVIEW OF SYSTEMS As mentioned above his weight has been fairly stable Although he suffered from obesity as a young teenager but through a period of anorexia but his weight has been stable now for about 20 years He has had night sweats chest pain and is also suffering from some depression as well as overwhelming fatigue stabbing short lived headaches and occasional shortness of breath He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck He has had fevers as well The rest of his review of systems is negative PHYSICAL EXAM VITALS Keywords consult history and phy t cell lymphoma submandibular tooth abscess strep throat submandibular region lymphoma neck MEDICAL_TRANSCRIPTION,Description Therapeutic recreation initial evaluation Patient is a 54 year old male admitted with diagnosis of CVA with right hemiparesis Medical Specialty Consult History and Phy Sample Name Therapeutic Recreation Initial Evaluation Transcription HISTORY Patient is a 54 year old male admitted with diagnosis of CVA with right hemiparesis Patient is currently living in ABC with his son as this was closer his to his job At discharge he will live with his spouse in a new job The home is single level with no steps Prior to admission his wife reports that he was independent with all activities He was working full time for an oil company Past medical history includes hypertension and diabetes mental status and dysphagia Ability to follow instruction rules Not able to identify cognitive status as of yet COMMUNICATION SKILLS No initiation of conversation He answered 1 yes no question PHYSICAL STATUS Fall safety Aspiration precautions Endurance Ball activities 4 to 5 minutes Restorator 25 minutes Standing and rolling type of 3 minutes LEISURE LIFESTYLE Level of participation activities involved in Reading and housework INFORMATION OBTAINED Interview observation and chart review TREATMENT PLAN Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas Patient scored 10 11 in physical domain due to decreased endurance He scored 11 11 in the cognitive and social domain Patient will attend 1 session per day focusing on Endurance activities Patient will attend 1 2 group sessions per week focusing on leisure awareness and postdischarge resources GOALS PATIENT GOALS Not able to identify but cooperative with all activities He answered yes that he enjoyed the restorator SHORT TERM GOALS ONE WEEK GOALS 1 Patient to increase tolerance for ball activities to 7 minutes 2 Patient provided to use the restorator as he enjoys and it is good for endurance LONG TERM GOALS Patient to increase standing tolerance standing leisure activities to 7 to 10 minutes Patient has concurred with the above treatment planning goals Keywords consult history and phy endurance ball activities therapeutic recreation hemiparesis tolerance recreation restorator leisure therapeutic MEDICAL_TRANSCRIPTION,Description The patient had a syncopal episode last night She did not have any residual deficit She had a headache at that time She denies chest pains or palpitations Medical Specialty Consult History and Phy Sample Name Syncope ER Visit 1 Transcription REASON FOR VISIT Syncope HISTORY The patient is a 75 year old lady who had a syncopal episode last night She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up the cereal was on the floor She did not have any residual deficit She had a headache at that time She denies chest pains or palpitations PAST MEDICAL HISTORY Arthritis first episode of high blood pressure today She had a normal stress test two years ago MEDICATIONS Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150 70 SOCIAL HISTORY She does not smoke and she does not drink She lives with her daughter PHYSICAL EXAMINATION GENERAL Lady in no distress VITAL SIGNS Blood pressure 172 91 came down to 139 75 heart rate 91 and respirations 20 Afebrile HEENT Head is normal NECK Supple LUNGS Clear to auscultation and percussion HEART No S3 no S4 and no murmurs ABDOMEN Soft EXTREMITIES Lower extremities no edema DIAGNOSTIC DATA Her EKG shows sinus rhythm with nondiagnostic Q waves in the inferior leads ASSESSMENT Syncope PLAN She had a CT scan of the brain that was negative today The blood pressure is high We will start Maxzide We will do an outpatient Holter and carotid Doppler study She has had an echocardiogram along with the stress test before and it was normal We will do an outpatient followup Keywords consult history and phy residual deficit headache ct scan syncopal episode stress test blood pressure syncope MEDICAL_TRANSCRIPTION,Description Sports physical with normal growth and development Medical Specialty Consult History and Phy Sample Name Sports Physical 1 Transcription HISTORY This child is seen for a sports physical NUTRITIONAL HISTORY She takes meats vegetables and fruits Eats well Has may be 1 to 2 cups a day of milk Her calcium intake could be better She does not drink that much pop but she likes koolaid Her stools are normal Brushes her teeth Sees a dentist DEVELOPMENTAL HISTORY She did well in school last year Hearing and vision no problems She wears corrective lenses She will be in 8th grade and involved in volleyball basketball and she will be moving to Texas She did go to Burton this last year She also plays clarinet and will be involved also in cheerleading She likes to swim in the summer time Her menarche was January 2004 It occurs every 7 weeks No particular problems at this time OTHER ACTIVITIES TV time about 2 to 3 hours a day She does not use drugs alcohol or smoke and denies sexual activity MEDICATIONS Advair 250 50 b i d Flonase b i d Allegra q d 120 mg Xopenex and albuterol p r n ALLERGIES No known drug allergies OBJECTIVE Vital Signs Blood pressure 98 60 Temperature 96 6 tympanic Weight 107 pounds which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64 1 2 inches Her body mass index is 18 1 which is 40th percentile Pulse 68 HEENT Normocephalic Fundi benign Pupils are equal and reactive to light and accommodation Conjunctivae were non injected Her pupils were equal and reactive to light and accommodation No strabismus She wears glasses Her vision was 20 20 in both eyes TMs are bilaterally clear Nonerythematous Hearing in the ears she was able to pass 40 decibel to 30 decibel With the right ear she has some problems but the left ear she passed Throat was clear Nonerythematous Good dentition Neck Supple Thyroid normal sized No increased lymphadenopathy in the submandibular nodes and no axillary nodes Respiratory Clear No wheezes and no crackles No tachypnea and no retractions Cardiovascular Regular rate and rhythm S1 and S2 normal No murmur Abdomen Soft No organomegaly and no masses No hepatosplenomegaly GU Normal female genitalia Tanner stage III in breast and pubic hair development and she was given a breast exam Negative for any masses Skin Without rash Extremities Deep tendon reflexes 2 4 bilaterally and equal Neurological Romberg negative Back No scoliosis She had good circumduction at the shoulder joints and duck walk is normal ASSESSMENT Sports physical with normal growth and development PLAN If problems continue she will need to have her hearing rechecked Hopefully in the school there will be a screening mat She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months We reviewed her immunizations for tetanus and her last acellular DPT was 11 25 1996 When she goes to Texas Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release We talked about her menarche Recommended the exam of the breast regularly Talked about other anticipatory guidance including sunscreen use of seat belts and drugs alcohol and smoking and sexual activity and avoidance at her age and to continue on her present medications She also has had problems with her ankles in the past She had no limitation here but we gave her some ankle strengthening exercise handouts while she was in the office Keywords MEDICAL_TRANSCRIPTION,Description The patient is a 4 month old who presented with supraventricular tachycardia and persistent cyanosis Medical Specialty Consult History and Phy Sample Name Supraventricular Tachycardia Consult Transcription HISTORY The patient is a 4 month old who presented today with supraventricular tachycardia and persistent cyanosis The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised Parents however did note the patient to be quite dusky since the time of her birth however were reassured by the pediatrician that this was normal The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness some irritability and rapid heart rate Parents do state that she does appear to breathe rapidly tires somewhat with the feeding with increased respiratory effort and diaphoresis The patient is exclusively breast fed and feeding approximately 2 hours Upon arrival at Children s Hospital the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement northwest axis and poor R wave progression possible right ventricular hypertrophy FAMILY HISTORY Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed REVIEW OF SYSTEMS A complete review of systems including neurologic respiratory gastrointestinal genitourinary are otherwise negative PHYSICAL EXAMINATION GENERAL Physical examination that showed a sedated acyanotic infant who is in no acute distress VITAL SIGNS Heart rate of 170 respiratory rate of 65 saturation it is nasal cannula oxygen of 74 with a prostaglandin infusion at 0 5 mcg kg minute HEENT Normocephalic with no bruit detected She had symmetric shallow breath sounds clear to auscultation She had full symmetrical pulses HEART There is normoactive precordium without a thrill There is normal S1 single loud S2 and a 2 6 continuous shunt type of murmur could be appreciated at the left upper sternal border ABDOMEN Soft Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected X RAYS Review of the chest x ray demonstrated a normal situs normal heart size and adequate pulmonary vascular markings There is a prominent thymus An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs a left superior vena cava draining into the left atrium a criss cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left sided morphologic left ventricle The left atrium drained through the tricuspid valve into a right sided morphologic right ventricle There is a large inlet ventricular septal defect as pulmonary atresia The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch There was a small vertical ductus as a sole source of pulmonary artery blood flow The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter Biventricular function is well maintained FINAL IMPRESSION The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function The saturations are now also adequate on prostaglandin E1 RECOMMENDATION My recommendation is that the patient be continued on prostaglandin E1 The patient s case was presented to the cardiothoracic surgical consultant Dr X The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention The patient will require some form of systemic to pulmonary shunt modified pelvic shunt or central shunt as a durable source of pulmonary blood flow Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age These findings and recommendations were reviewed with the parents via a Spanish interpreter Keywords consult history and phy congenital heart disease cyanotic ductal dependent pulmonary blood flow ventricular septal defect blood flow supraventricular tachycardia tachycardia ventricular supraventricular shunt heart pulmonary MEDICAL_TRANSCRIPTION,Description Status post brain tumor with removal The patient did receive skilled speech therapy while in the acute rehab which focused on higher level cognitive and linguistic skills such as attention memory mental flexibility and improvement of her executive function Medical Specialty Consult History and Phy Sample Name Speech Therapy Evaluation 1 Transcription DIAGNOSIS Status post brain tumor with removal SUBJECTIVE The patient is a 64 year old female with previous medical history of breast cancer that has metastasized to her lung liver spleen and brain status post radiation therapy The patient stated that on 10 24 08 she had a brain tumor removed with subsequent left sided weakness The patient was readmitted to ABC Hospital on 12 05 08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling The patient remained at the acute rehab at ABC until she was discharged home on 01 05 09 The patient did receive skilled speech therapy while in the acute rehab which focused on higher level cognitive and linguistic skills such as attention memory mental flexibility and improvement of her executive function The patient also complains of difficulty with word retrieval and slurring of speech The patient denies any difficulty with swallowing at this time OBJECTIVE Portions of the cognitive linguistic quick test was administered An oral mechanism exam was performed A motor speech protocol was completed The cognitive linguistic subtests of recalling personal facts symbol cancellation confrontational naming clock drawing story retelling generative naming design and memory and completion of mazes was administered The patient was 100 accurate with recalling personal facts completion of the symbol cancellation tasks and with confrontational naming She had no difficulty with the clock drawing task however she has considerable hand tremors which makes writing difficult In the storytelling task she scored within normal limits She was also within normal limits for generative naming She did have difficulty with the design memory and mazes subtests She was unable to complete the second maze during the allotted time The design generation subtest was also completed She was able to draw four unique designs and toward the end of the tasks was no longer able to recall the stated direction ORAL MECHANISM EXAMINATION The patient has mild left facial droop with decreased nasolabial fold Tongue is at midline and lingual range of motion and strength are within functional limit The patient does complain of biting her tongue on occasion but denied biting the inside of her cheeks Her AMRs are judged to be within functional limit Her rate of speech is decreased with a monotonous vocal quality The decreased rate may be a compensation for decreased word retrieval ability The patient s speech is judged to be 100 intelligible without background noise DIAGNOSTIC IMPRESSION The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility memory and executive function PLAN OF CARE Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment SHORT TERM GOALS THREE WEEKS 1 The patient will complete deductive reasoning and mental flexibility tasks with greater than 90 accuracy independently 2 The patient will complete perspective memory test with 100 accuracy using compensatory strategy 3 The patient will complete visual perceptual activities which focus on scanning flexibility and problem solving with greater than 90 accuracy with minimal cueing 4 The patient will listen to and or read a lengthy narrative and be able to recall at least 6 details after a 15 minute delay independently PATIENT S GOAL To improve functional independence and cognitive abilities LONG TERM GOAL FOUR WEEKS Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver Keywords consult history and phy linguistic skills memory mental flexibility deductive reasoning skilled speech therapy speech therapy cognitive linguistic therapy linguistic speech cognitive MEDICAL_TRANSCRIPTION,Description Global aphasia The patient is referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy status post stroke Medical Specialty Consult History and Phy Sample Name Speech Therapy Evaluation Transcription MEDICAL DIAGNOSIS Strokes SPEECH AND LANGUAGE THERAPY DIAGNOSIS Global aphasia SUBJECTIVE The patient is a 44 year old female who is referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy status post stroke The patient s sister in law was present throughout this assessment and provided all the patient s previous medical history Based on the sister in law s report the patient had a stroke on 09 19 08 The patient spent 6 weeks at XY Medical Center where she was subsequently transferred to XYZ for therapy for approximately 3 weeks ABCD brought the patient to home the Monday before Thanksgiving because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson The patient s previous medical history includes a long history of illegal drug use to include cocaine crystal methamphetamine and marijuana In March of 2008 the patient had some type of potassium issue and she was hospitalized at that time Prior to the stroke the patient was not working and ABCD reported that she believes the patient completed the ninth grade but she did not graduate from high school During the case history I did pose several questions to the patient but her response was often no She was very emotional during this evaluation and crying occurred multiple times OBJECTIVE To evaluate the patient s overall communication ability a Western Aphasia Battery was completed Also tests were not done due to time constraint and the patient s severe difficulty and emotional state Speech automatic tests were also completed to determine if the patient had any functional speech ASSESSMENT Based on the results of the Weston aphasia battery the patient s deficits most closely resemble global aphasia On the spontaneous speech subtest the patient responded no to all questions asked except for how are you today where she gave a thumbs up She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly The patient s sister in law did state that the patient wore glasses but she currently does not have them and she did not know the extent the patient s visual deficit On the auditory verbal comprehension portion of the Western Aphasia Battery the patient answered no to all yes no questions The auditory word recognition subtest the patient had 5 out of 60 responses correct With the sequential command she had 10 out of 80 corrects She was able to shut her eyes point to the window and point to the pen after directions With repetition subtest she repeated bed correctly but no other stimuli At this time the patient became very emotional and repeatedly stated I can t During the naming subtest of the Western Aphasia Battery the patient s responses contained numerous paraphasias and her speech was often unintelligible due to jargon The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech In regards to speech automatics the patient is able to count from 1 to 9 accurately however stated 7 instead of 10 at the end of the task She is not able to state the days of the week or months in the year or her name at this time She cannot identify the day on calendar and was unable to verbally state the date or month DIAGNOSTIC IMPRESSION The patient s communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication She does perseverate and is very emotional due to probable frustration Outpatient skilled speech therapy is recommended to improve the patient s functional communication skills PATIENT GOAL Her sister in law stated that they would like to improve upon the patient s speech to allow her to communicate more easily at home PLAN OF CARE Outpatient skilled speech therapy two times a week for the next 12 weeks Therapy to include aphasia treatment and home activities SHORT TERM GOALS 8 WEEKS 1 The patient will answer simple yes no questions with greater than 90 accuracy with minimal cueing 2 The patient will be able to complete speech automatic tasks with greater than 80 accuracy without models or cueing 3 The patient will be able to complete simple sentence completion and or phrase completion with greater than 80 accuracy with minimal cueing 4 The patient will be able to follow simple one step commands with greater than 80 accuracy with minimal cueing 5 The patient will be able to name 10 basic everyday objects with greater than 80 accuracy with minimal cueing SHORT TERM GOALS 12 WEEKS Functional communication abilities to allow the patient to express her basic wants and needs Keywords consult history and phy speech automatic tasks minimal cueing sentence completion western aphasia battery skilled speech therapy global aphasia speech therapy speech aphasia MEDICAL_TRANSCRIPTION,Description Consultation for right shoulder pain Medical Specialty Consult History and Phy Sample Name Shoulder Pain Consult Transcription CHIEF COMPLAINT Right shoulder pain HISTORY OF PRESENT PROBLEM Keywords consult history and phy shoulder pain history of present problem cortisone shot no numbness or tingling rhomboids scapula shoulder impingement focal findings shoulder MEDICAL_TRANSCRIPTION,Description This patient was seen in clinic for a school physical Medical Specialty Consult History and Phy Sample Name School Physical 1 Transcription SUBJECTIVE This patient was seen in clinic for a school physical NUTRITIONAL HISTORY She eats well takes meats vegetables and fruits but her calcium intake is limited She does not drink a whole lot of pop Her stools are normal Brushes her teeth sees a dentist Developmental History Hearing and vision is okay She did well in school last year She will be going to move to Texas will be going to Bowie High School She will be involved in cheerleading track volleyball and basketball She will be also playing the clarinet and will be a freshman in that school Her menarche was 06 30 2004 PAST MEDICAL HISTORY She is still on medications for asthma She has a problem with her eye lately this has been bothering her and she also has had a rash in the left leg She had been pulling weeds on 06 25 2004 and then developed a rash on 06 27 2004 Review of her immunizations her last tetanus shot was 06 17 2003 MEDICATIONS Advair 100 50 b i d Allegra 60 mg b i d Flonase q d Xopenex Intal and albuterol p r n ALLERGIES No known drug allergies OBJECTIVE Vital Signs Weight 112 pounds about 40th percentile Height 63 1 4 inches also the 40th percentile Her body mass index was 19 7 40th percentile Temperature 97 7 tympanic Pulse 80 Blood pressure 96 64 HEENT Normocephalic Fundi benign Pupils equal and reactive to light and accommodation No strabismus Her vision was 20 20 in both eyes and each with contacts Hearing She passed that test Her TMs are bilaterally clear and nonerythematous Throat was clear Good mucous membrane moisture and good dentition Neck Supple Thyroid normal sized No increased lymphadenopathy in the submandibular nodes and no axillary nodes Abdomen No hepatosplenomegaly Respiratory Clear No wheezes No crackles No tachypnea No retractions Cardiovascular Regular rate and rhythm S1 and S2 normal No murmur Abdomen Soft No organomegaly and no masses GU Normal female genitalia Tanner stage 3 breast development and pubic hair development Examination of the breasts was negative for any masses or abnormalities or discharge from her areola Extremities She has good range of motion of upper and lower extremities Deep tendon reflexes were 2 4 bilaterally and equal Romberg negative Back No scoliosis She had good circumduction at shoulder joint and her duck walk was normal SKIN She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption No honey crusting was noted on the skin She also had some mild rash on the anterior abdominal area near the panty line similar to that rash It was raised and blanch with pressure it was slightly erythematous ASSESSMENT AND PLAN 1 Sports physical 2 The patient received her first hepatitis A vaccine She will get a booster in 6 to 12 months Prescription for Atarax 10 mg tablets one to two tablets p o q 4 6h p r n and a prescription for Elocon ointment to be applied topically except for the face once a day with a refill She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician We talked about anticipatory guidance including breast exam which we have reviewed with her today seatbelt use and sunscreen We talked about avoidance of drugs and alcohol and sexual activity Continue on her present medications and if her rash is not improved and goes to the neck or the face she will need to be on PO steroid medication but presently that was held and moved to treatment with Atarax and Elocon Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing Keywords consult history and phy school physical calcium intake hearing and vision hepatitis a vaccine booster anticipatory guidance developmental percentile physical school rash MEDICAL_TRANSCRIPTION,Description A 71 year old female who I am seeing for the first time She has a history of rheumatoid arthritis for the last 6 years She is not on DMARD but as she recently had a surgery followed by a probable infection Medical Specialty Consult History and Phy Sample Name Rheumatoid Arthritis Consult Transcription HISTORY OF PRESENT ILLNESS A 71 year old female who I am seeing for the first time She has a history of rheumatoid arthritis for the last 6 years She was followed by another rheumatologist She says she has been off and on on prednisone and Arava The rheumatologist as per the patient would not want her to be on a long term medicine so he would give her prednisone and then switch to Arava and then switch her back to prednisone She says she had been on prednisone for the last 6 to 9 months She is on 5 mg a day She recently had a left BKA and there was a question of infection so it had to be debrided I was consulted to see if her prednisone is to be continued The patient denies any joint pains at the present time She says when this started she had significant joint pains and was unable to walk She had pain in the hands and feet Currently she has no pain in any of her joints REVIEW OF SYSTEMS Denies photosensitivity oral or nasal ulcer seizure psychosis and skin rashes PAST MEDICAL HISTORY Significant for hypertension peripheral vascular disease and left BKA FAMILY HISTORY Noncontributory SOCIAL HISTORY Denies tobacco alcohol or illicit drugs PHYSICAL EXAMINATION VITAL SIGNS BP 130 70 heart rate 80 and respiratory rate 14 HEENT EOMI PERRLA NECK Supple No JVD No lymphadenopathy CHEST Clear to auscultation HEART S1 and S2 No S3 no murmurs ABDOMEN Soft and nontender No organomegaly EXTREMITIES No edema NEUROLOGIC Deferred ARTICULAR She has swelling of bilateral wrists but no significant tenderness LABORATORY DATA Labs in chart was reviewed ASSESSMENT AND PLAN A 71 year old female with a history of rheumatoid arthritis on longstanding prednisone She is not on DMARD but as she recently had a surgery followed by a probable infection I will hold off on that As she has no pain I have decreased the prednisone to 2 5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow If in a couple of weeks her symptoms stay the same then I would discontinue the prednisone I would defer that to Dr X If she flares up at that point prednisone may have to be restarted with a DMARD so that eventually she could stay off the prednisone I discussed this at length with the patient and she is in full agreement with the plan I explained to her that if she is to be discharged if she wishes she could follow up with me in clinic or if she goes back to Victoria then see her rheumatologist over there Keywords consult history and phy prednisone joint pains rheumatoid arthritis arthritis dmard rheumatologist rheumatoid pains MEDICAL_TRANSCRIPTION,Description Request for consultation to evaluate stomatitis possibly methotrexate related Medical Specialty Consult History and Phy Sample Name Request For Consultation Transcription REASON FOR CONSULTATION Please evaluate stomatitis possibly methotrexate related HISTORY OF PRESENT ILLNESS The patient is a very pleasant 57 year old white female a native of Cuba being seen for evaluation and treatment of sores in her mouth that she has had for the last 10 12 days The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments but over the past ten years she has been treated with methotrexate quite successfully Her dosage has varied somewhere between 20 and 25 mg per week About the beginning of this year her dosage was decreased from 25 mg to 20 mg but because of the flare of the rheumatoid arthritis it was increased to 22 5 mg per week She has had no problems with methotrexate as far as she knows She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth About two weeks ago just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection She does not remember the name of the antibiotic Although she claims she remembers taking this type of medication in the past without any problems She was on that medication three pills a day for three to four days She notes no other problems with her skin She remembers no allergic reactions to medication She has no previous history of fever blisters PHYSICAL EXAMINATION Reveals superficial erosions along the lips particularly the lower lips The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva Her posterior pharynx was difficult to visualize but I saw no erosions on the areas today There did however appear to be one small erosion on the soft palate Examination of the rest of her skin revealed no areas of dermatitis or blistering There were some macular hyperpigmentation on the right arm where she has had a previous burn plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries IMPRESSION Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems Methotrexate may produce an erosive stomatitis and enteritis after such a use The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed She has had no diarrhea today however She has noted no blood in her stools and has had no episodes of nausea or vomiting I am not as familiar with the NSAID causing an erosive stomatitis I understand that it can cause gastrointestinal upset but given the choice between the two I would think the methotrexate is the most likely etiology for the stomatitis RECOMMENDED THERAPY I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients skin problem However in my experience this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate for an extended period of time because the medication is stored within the liver and in fatty tissue Topically I have prescribed Lidex gel which I find works extremely well in stomatitis conditions It can be applied t i d Thank you very much for allowing me to share in the care of this pleasant patient I will follow her with you as needed Keywords consult history and phy stomatitis nsaid blistering blisters buccal mucosa dermatitis erosive stomatitis gastrointestinal methotrexate mouth rheumatoid arthritis stomatitis conditions superficial erosions upper respiratory infection illness medication MEDICAL_TRANSCRIPTION,Description Patient with suspected nasal obstruction possible sleep apnea Medical Specialty Consult History and Phy Sample Name Recurrent nasal obstruction Transcription CHIEF COMPLAINT Recurrent nasal obstruction HISTORY OF PRESENT ILLNESS The patient is a 5 year old male who was last evaluated by Dr F approximately one year ago for suspected nasal obstruction possible sleep apnea Dr F s assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis All of his symptoms had resolved when he had seen Dr F so no surgical plan was made and no further followup was needed However the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes Again the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature It sounds like he is snoring loudly and does have some nasal obstruction at nighttime He also is sniffing a lot through his nose He has been tried on some nasal steroids but they only use this on a p r n basis about one or two days every month and we are unsure if that has even helped at all probably not The child is not having any problems with his ears including ear infections or hearing He is also not having any problems with strep throat PAST MEDICAL HISTORY Eczema PAST SURGICAL HISTORY None MEDICATIONS None ALLERGIES No known drug allergies FAMILY HISTORY No family history of bleeding diathesis or anesthesia difficulties PHYSICAL EXAMINATION VITAL SIGNS Weight 43 pounds height 37 inches temperature 97 4 pulse 65 and blood pressure 104 48 GENERAL The patient is a well nourished male in no acute distress Listening to his voice today in the clinic he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation NOSE Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea EARS The patient tympanic membranes are clear and intact bilaterally There is no middle ear effusion ORAL CAVITY The patient has 2 tonsils bilaterally There are clearly nonobstructive His uvula is midline NECK No lymphadenopathy appreciated ASSESSMENT AND PLAN This is a 5 year old male who presents for repeat evaluation of a possible nasal obstruction questionable sleep apnea Again the mother gives a confusing sleep history but it does not really sound like he is having apneic events They deny any actual gasping events It sounds like true obstructive events He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately I have given them prescription for Nasacort Aqua one spray to each nostril twice a day I instructed them on correct way to use this and the importance to use it on a daily basis They may not see any benefit for several weeks I would like to evaluate him in six weeks to see how we are progressing If he continues to have problems I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child He may also need an allergy evaluation at that point if he continues to have problems However I would like to be fairly conservative in this child Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen I did instruct her call us if it worsens we may even need to pursue a sleep study just to settle that issue once and for all We will see him back in six weeks Keywords consult history and phy recurrent nasal obstruction allergic rhinitis apneic events sleep apnea nasal obstruction nasal apnea allergic obstruction sleep MEDICAL_TRANSCRIPTION,Description Patient with complaints of significant coughing and wheezing Medical Specialty Consult History and Phy Sample Name Pulmonary Consultation 2 Transcription PAST MEDICAL HISTORY Unremarkable except for diabetes and atherosclerotic vascular disease ALLERGIES PENICILLIN CURRENT MEDICATIONS Include Glucovance Seroquel Flomax and Nexium PAST SURGICAL HISTORY Appendectomy and exploratory laparotomy FAMILY HISTORY Noncontributory SOCIAL HISTORY The patient is a non smoker No alcohol abuse The patient is married with no children REVIEW OF SYSTEMS Significant for an old CVA PHYSICAL EXAMINATION The patient is an elderly male alert and cooperative Blood pressure 96 60 mmHg Respirations were 20 Pulse 94 Afebrile O2 was 94 on room air HEENT Normocephalic and atraumatic Pupils are reactive Oral mucosa is grossly normal Neck is supple Lungs Decreased breath sounds Disturbed breath sounds with poor exchange Heart Regular rhythm Abdomen Soft and nontender No organomegaly or masses Extremities No cyanosis clubbing or edema LABORATORY DATA Oropharyngeal evaluation done on 11 02 2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses which clear with liquid swallow and double saliva swallow ASSESSMENT 1 Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration 2 Old CVA with left hemiparesis 3 Oropharyngeal dysphagia 4 Diabetes PLAN At the present time the patient is recommended to continue on a regular diet continue speech pathology evaluation as well as perform double swallow during meals with bolus sensation He may use Italian lemon ice during meals to help clear sinuses as well The patient will follow up with you If you need any further assistance do not hesitate to call me Keywords consult history and phy pulmonary evaluation cough wheezing congestion coughing and wheezing breath sounds oropharyngeal dysphagia pulmonary breath sounds dysphagia aspiration sinuses oropharyngeal coughing swallowing MEDICAL_TRANSCRIPTION,Description Increasing oxygen requirement Baby boy has significant pulmonary hypertension Medical Specialty Consult History and Phy Sample Name Pulmonary Hypertension Pediatric Consult Transcription INDICATION FOR CONSULTATION Increasing oxygen requirement HISTORY Baby boy XYZ is a 29 3 7 week gestation infant His mother had premature rupture of membranes on 12 20 08 She then presented to the Labor and Delivery with symptoms of flu The baby was then induced and delivered The mother had a history of premature babies in the past This baby was doing well and then we had a significant increasing oxygen requirement from room air up to 85 He is now on 60 FiO2 PHYSICAL FINDINGS GENERAL He appears to be pink well perfused and slightly jaundiced VITAL SIGNS Pulse 156 56 respiratory rate 92 sat and 59 28 mmHg blood pressure SKIN He was pink He was on the high frequency ventilator with good wiggle His echocardiogram showed normal structural anatomy He has evidence for significant pulmonary hypertension A large ductus arteriosus was seen with bidirectional shunt A foramen ovale shunt was also noted with bidirectional shunt The shunting for both the ductus and the foramen ovale was equal left to right and right to left IMPRESSION My impression is that baby boy XYZ has significant pulmonary hypertension The best therapy for this is to continue oxygen If clinically worsens he may require nitric oxide Certainly Indocin should not be used at this time He needs to have lower pulmonary artery pressures for that to be considered Thank you very much for allowing me to be involved in baby XYZ s care Keywords consult history and phy high frequency ventilator structural anatomy foramen ovale oxygen requirement hypertension pulmonary MEDICAL_TRANSCRIPTION,Description She was admitted following an overdose of citalopram and warfarin The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage Medical Specialty Consult History and Phy Sample Name Psychiatric Consult 2 Transcription HISTORY OF PRESENT ILLNESS This is a 41 year old registered nurse R N She was admitted following an overdose of citalopram and warfarin The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage She notes starting in January her husband of five years seemed to be quite withdrawn It turned out he was having an affair with one of her best friends and he subsequently moved in with this woman The patient is distressed as over the five years of their marriage she has gotten herself into considerable debt supporting him and trying to find a career that would work for him They had moved to ABCD where he had recently been employed as a restaurant manager She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her She has history of seasonal affective disorder winter depressions characterized by increased sleep increased irritability impatience and fatigue Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder In January she went on citalopram She reports since that time she has lost 40 pounds of weight has trouble sleeping at night thinks perhaps her mood got worse on the citalopram which is possible though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood PAST AND DEVELOPMENTAL HISTORY She was born in XYZ She describes the family as being somewhat dysfunctional Father was a truckdriver She is an only child She reports that she had a history of anorexia and bulimia as a teenager In her 20s she served six years in Naval Reserve She was previously married for four years She described that as an abusive relationship She had a history of being in counseling with ABC but does not think this therapist who is now by her estimate 80 years old is still in practice PHYSICAL EXAMINATION GENERAL This is an alert and cooperative woman VITAL SIGNS Temperature 98 1 pulse 60 respirations 18 blood pressure 95 54 oxygen saturation 95 and weight is 132 PSYCHIATRIC She makes good eye contact Speech is normal in rate volume grammar and vocabulary There is no thought disorder She denies being suicidal Her affect is appropriate for material being discussed She has a sense of future wants to get back to work has plans to return to counseling She appeared to have normal orientation concentration memory and judgment Medical history is notable for factor V Leiden deficiency history of pulmonary embolus restless legs syndrome She has been off her Mirapex I did encourage her to go back on the Mirapex which would likely lead to some improvement in mood by facilitating better sleep The patient at this time can contract for safety She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with LABORATORY DATA INR which is still 8 8 In 1998 she had a normal MRI Electrolytes BUN creatinine and CBC were all normal DIAGNOSES 1 Seasonal depressive disorder 2 Restless legs syndrome 3 Overdose of citalopram and warfarin RECOMMENDATIONS The patient reports she has been feeling better since discontinuing antidepressants I therefore recommend she stay off antidepressants at present If needed she can take Prozac which has been effective for her in the past and she plans to see a psychiatrist for consultation She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac this will be an appropriate agent to try as needed in the future but given the situational nature of the depression she primarily appears to need counseling Please feel free to contact me at digital pager if there is additional information I can provide Keywords consult history and phy citalopram depressive disorder overdose warfarin restless legs syndrome disorder mood MEDICAL_TRANSCRIPTION,Description Psychiatric History and Physical Patient with major depression Medical Specialty Consult History and Phy Sample Name Psych H P 1 Transcription HISTORY OF PRESENT ILLNESS This 40 year old white single man was hospitalized at XYZ Hospital in the mental health ward issues were filled up by his sister and his mother The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr Silverberg became concerned about his behavior called the family and told them to have him put in the hospital and at one point called the police because the patient was throwing cellphones and having tantrums in his office The history includes the fact that the patient is the 3rd of 4 children A brother who is approximately 8 years older sexually abused brother who is 4 years older The brother who is 8 years older lives in California and will contact the family has had minimal contact for many years That brother in California is gay The brother who is 4 years older sexually abused the patient from age 8 to 12 on a regular basis He said he told his mother several years ago but she did nothing about it The patient finished high school and with some struggle completed college at the University of Houston He has a sister who is approximately a year and half younger than he is who was sexually abused by the brothers will but only on one occasion She has been concerned about patient s behavior and was instrumental in having him committed Reportedly the patient ran away from home at the age of 12 or 13 because of the abuse but was not able to tell his family what happened He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time He states he injured his back about 10 yeas ago He told he had disk problems but never had surgery He subsequently was put on psychiatric disability for depression states he has been unable to get out of bed at times and isolates and keeps to himself He has been on a variety of different medications including Celexa 40 mg and ADD medication different times and reportedly has used amphetamines in the past although he denies it at this time He minimizes any alcohol use which appears not to be a problem but what does appear to be a problem is he isolates stays at home has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed He has never been psychiatrically hospitalized before MENTAL STATUS EXAMINATION Revealed a somewhat disheveled 40 year old man who was clearly quite depressed and somewhat shocked at his family s commitment He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother s wife what had happened The brother has a child and wife became very upset with him Normocephalic Pleasant cooperative disheveled man with about 37 to 40 thoughts were somewhat guarded His affect was anxious and depressed and he denied being suicidal although the family said that he has talked about it at times Recent past memory were intact DIAGNOSES Axis I Major depression rule out substance abuse Axis II Deferred at this time Axis III Noncontributory Axis IV Family financial and social pressures Axis V Global Assessment of Functioning 40 RECOMMENDATION The patient will be hospitalized to assess Along the issues the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree He says he has had several part time jobs but never been able to sustain employment although he would like to Keywords consult history and phy history of present illness global assessment of functioning mental status examination major depression psychiatric abuse behavior depression mental health mental health ward psychiatric disability sexually abused substance abuse health MEDICAL_TRANSCRIPTION,Description Bipolar disorder apparently stable on medications Mild organic brain syndrome presumably secondary to her chronic inhalant paint abuse Medical Specialty Consult History and Phy Sample Name Psychiatric Consult 1 Transcription HISTORY OF PRESENT ILLNESS This is a 53 year old widowed woman she lives at ABC Hotel She presented with a complaint of chest pain evaluations revealed severe aortic stenosis She has been refusing cardiac catheter and she may well need aortic valve replacement She states that she does not want heart surgery or valve replacement She has a history of bipolar disorder and has been diagnosed at times with schizophrenia She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel She denies hallucinations psychosis paranoia and suicidal ideation at this time States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature surgery does present some additional risks The patient notes that she has a long history of substance abuse primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting violation of orders to abstain from substance abuse and the longest confinement of these was 100 days The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care PAST AND DEVELOPMENTAL HISTORY She was born in XYZ She is a high school graduate from ABCD High School She did have an abusive childhood She is married four times She notes she developed depression when a number of her children died PHYSICAL EXAMINATION GENERAL This is an obese woman in bed She is somewhat restless and moving during the interview VITAL SIGNS Temperature of 97 3 pulse 70 respirations 18 blood pressure 113 68 and oxygen saturation 94 on 3 L of oxygen PSYCHIATRY Speech is normal rate volume grammar and vocabulary consistent with her educational level There is no overt thought disorder She does not appear psychotic She is not suicidal on formal testing She gives the date as Sunday 05 19 2007 when it is the 20th and 207 when it is 2007 She is oriented to place She can memorize four times repeats two at five minutes gets the other two with category hints this places short term memory in normal limits She had difficulty with serial three subtractions counting on her fingers and had difficulty naming the months in reverse order stating December November September October June July August September but recognizes this was not right and then said March April May She is able to name objects appropriately LABORATORY DATA Chest x ray showing no acute changes Carotid duplex shows no stenosis Electrolytes and liver function tests are normal TSH normal Hematocrit 31 Triglycerides 152 DIAGNOSES 1 Bipolar disorder apparently stable on medications 2 Mild organic brain syndrome presumably secondary to her chronic inhalant paint abuse 3 Aortic stenosis 4 Sleep apnea 5 Obesity 6 Anemia 7 Gastroesophageal reflux disease RECOMMENDATIONS It is my impression at present that the patient retains ability to make decisions on her own behalf Given this lady s underlying mental problems I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel While she may well need surgery and cardiac catheter she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her She clearly at this time wants to leave this hospital she normally gets her care through XYZ Health Again in summary I would consider her to retain the ability to make decisions on her own behalf Please feel free to contact me at digital pager if additional information is needed Keywords consult history and phy organic brain syndrom substance abuse bipolar disorder mental abuse MEDICAL_TRANSCRIPTION,Description Psychiatric consultation has been requested as the patient has been noncompliant with treatment leave the unit does not return when requested and it was unclear as to whether this is secondary to confusion or willful behavior Medical Specialty Consult History and Phy Sample Name Psychiatric Consult Transcription HISTORY OF PRESENT ILLNESS This is a 23 year old married man who had an onset of aplastic anemia in December underwent a bone marrow transplant in the end of March has developed very severe graft versus host reaction Psychiatric consultation has been requested as the patient has been noncompliant with treatment leave the unit does not return when requested and it was unclear as to whether this is secondary to confusion or willful behavior The patient gives a significant history of behavioral problems from late adolescence until the onset of illness states he had lot of trouble with law he was convicted of assault he was also arrested with small amount of cannabis states he served one year incarcerated in ABCD that was about two years ago Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program he was discharged from that on 05 28 2006 and states he has been clean and sober since then Prior to going to rehabilitation he was using intravenous heroin couple of times a week since age 17 which would have been over a period of about five years reports heavy use of cannabis smoking pot up to five times a day if he could He would drink up to half of a fifth of rum on a daily basis when available The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime He complained of some depressive and some anxiety symptoms but these do not appear to be out of proportion to his medical issues and for this individual the frustrations of his treatments He would have a limited support system here in Colorado He married in January and states that the marriage is not going particularly well being young sick and hospitalized has not helped his relationship with his new wife who apparently is expecting a child in July I would recommend some couples counseling as a part of their treatment here The patient was fairly drowsy during the interview and full past and developmental history was not obtained The patient s comment is that he grew up all over that his parents had separated that he lived with his mother that he dropped out of school in eleventh grade at that time was living in XYZ area because he did not like school PHYSICAL EXAMINATION GENERAL This is a cooperative man speech is soft and difficult to understand There is no thought disorder and no hallucination He denies being suicidal but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital VITAL SIGNS Temperature 97 2 pulse 117 respirations 16 blood pressure 127 74 oxygen saturation 97 and weight is 154 pounds PSYCHIATRY There is no thought disorder no paranoia no delusions and no psychotic symptoms Activities of daily living ADLs appear intact On formal testing he is oriented to place He can give a reasonable recitation of his medical history He is oriented to the year knows it is the 15th but gave the month as June instead of May He can memorize four items repeats three out of four at five minutes gives the fourth through the category which places short term memory in normal limits He can do serial three subtractions accurately can name objects appropriately LABORATORY DATA Sodium of 135 BUN of 24 and glucose 119 GGT of 355 ALT of 97 LDH of 703 and alk phos of 144 FK506 is 28 8 which is elevated tacrolimus level Hematocrit 29 and white count is 7000 DIAGNOSES AXIS I Depressive disorder secondary to the underlying medical condition of graft versus host reaction AXIS II Personality disorder not otherwise specified NOS AXIS III History of polysubstance abuse in remission RECOMMENDATIONS 1 This patient appears to retain the ability to make decisions on his own behalf I think he is mentally competent Unfortunately his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness If the patient refuses treatment he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die 2 The patient does complain of depressed mood also of anxiety We did discuss medications He appeared somewhat sedated at the time of my interview I would recommend that we try Seroquel 25 mg twice daily on an as needed basis to see if this diminishes anxiety I will have Dr X followup with him Please feel free to contact me at digital pager if additional information is needed My overall recommendation would be that the patient be on some random urine drug screening that he use cell phone if he goes off the unit to be called back up when treatments are scheduled and hopefully he will be agreeable to complying with this Keywords consult history and phy noncompliant confusion graft versus host reaction psychiatric consultation willful behavior cannabis MEDICAL_TRANSCRIPTION,Description Patient with a history of PTSD depression and substance abuse Medical Specialty Consult History and Phy Sample Name Psych Consult Psychosis Transcription IDENTIFYING DATA Psychosis HISTORY OF PRESENT ILLNESS The patient is a 28 year old Samoan female who was her grandmother s caretaker Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior She had lived with her parents and son but parents removed son from the home secondary to the patient s erratic behavior Recently she was picked up by Kent Police Department leaping on Highway 99 PAST MEDICAL HISTORY PTSD depression and substance abuse PAST SURGICAL HISTORY Unknown ALLERGIES Unknown MEDICATIONS Unknown REVIEW OF SYSTEMS Unable to obtain secondary to the patient being in seclusion OBJECTIVE Vital signs that were previously taken revealed a blood pressure of 152 86 pulse of 106 respirations of 18 and temperature is 97 6 degrees Fahrenheit General appearance HEENT and history and physical examination was unable to be obtained today as patient was put into seclusion LABORATORY DATA Laboratory reviewed reveals a BMP slightly elevated glucose at 100 2 Previous urine tox was positive for THC Urinalysis was negative but did note positive UA wbc s CBC slightly elevated leukocytosis at 12 0 normal range is 4 to 11 ASSESSMENT AND PLAN AXIS I Psychosis Inpatient Psychiatric Team to follow AXIS II Deferred AXIS III We were unable to perform physical examination on the patient today secondary to her being in seclusion Laboratory was reviewed revealing leukocytosis possibly secondary to a UTI We will wait until the patient is out of seclusion to perform examination Should she have some complaints of dysuria or any suprapubic pain then we will begin on appropriate antimicrobial therapy We will followup with the patient should any new medical issues arise Keywords consult history and phy ptsd depression psychosis psychiatric substance abuse erratic behavior behavior axis MEDICAL_TRANSCRIPTION,Description Psychiatric Consultation of patient with dementia Medical Specialty Consult History and Phy Sample Name Psych Consult Dementia Transcription REASON FOR CONSULT Dementia HISTORY OF PRESENT ILLNESS The patient is a 33 year old black female referred to the hospital by a neurologist in Tyler Texas for disorientation and illusions Symptoms started in June of 2006 when the patient complained of vision problems and disorientation The patient was seen wearing clothes inside out along with other unusual behaviors In August or September of 2006 the patient reported having a sudden onset of headaches loss of vision and talking sporadically without making any sense The patient sought treatment from an ophthalmologist We did not find any abnormality in the Behavior Center in Tyler Texas The Behavior Center referred the patient to Dr Abc a neurologist in Tyler who then referred the patient to this hospital According to the mother the patient has had no past major medical or psychiatric illnesses The patient was functioning normally before June 2006 working as accounting tech after having completed 2 years of college She reports of worsening in symptoms mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety Currently the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006 Sleeping patterns and the amount is unknown Appetite is okay PAST PSYCHIATRIC HISTORY The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler Texas where she was given Effexor She stopped taking it soon after since they worsened her eye vision and balance PAST MEDICAL HISTORY In 2001 diagnosed with Meniere disease was treated such that she could function normally in everyday activities including work No current medications Denies history of seizures strokes diabetes hypertension heart disease or head injury FAMILY MEDICAL HISTORY Father s grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient s mother Both the mother s father and father s mother had nervous breakdowns but at unknown dates SOCIAL HISTORY The patient lives with a mother who takes care of the patient s ADLs The patient completed school up to two years in college and worked as accounting tech for eight years Denies use of alcohol tobacco or illicit drugs MENTAL STATUS EXAMINATION The patient is 33 year old black female wearing clean clothes a small towel on her head and over a wheel chair with her head rested on a pillow and towel Decreased motor activity but did blink her eyes often but arrhythmically Poor eye contact Speech illogic Concentration was not able to be assessed Mood is unknown Flat and constricted affect Thought content thought process and perception could not be assessed Sensorial memory information intelligence judgment and insight could not be evaluated due to lack of communication by the patient MINI MENTAL STATUS EXAM Unable to be performed AXIS I Rapidly progressing early onset of dementia rule out dementia secondary to general medical condition rule out dementia secondary to substance abuse AXIS II Deferred AXIS III Deferred AXIS IV Deferred AXIS V 1 ASSESSMENT The patient is a 32 year old black female with rapid and early onset of dementia with no significant past medical history There is no indication as to what precipitated these symptoms as the mother is not aware of any factors and the patient is unable to communicate The patient presented with headaches vision forms and disorientation in June 2006 She currently presents with ataxia vision loss and illusions PLAN Wait for result of neurological tests Thank you very much for the consultation Keywords consult history and phy reason for consult concentration dementia mood psychiatric consultation sensorial memory affect disorientation illusions information insight intelligence judgment loss of vision motor activity neurologist thought process unusual behaviors mental status examination consultation headaches MEDICAL_TRANSCRIPTION,Description The patient with pseudotumor cerebri without papilledema comes in because of new onset of headaches Medical Specialty Consult History and Phy Sample Name Pseudotumor Cerebri Transcription REASON FOR VISIT The patient is a 38 year old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches She comes to clinic by herself HISTORY OF PRESENT ILLNESS Dr X has cared for her since 2002 She has a Codman Hakim shunt set at 90 mmH2O She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr Y for medical management of her chronic headaches We also recommended that the patient see a psychiatrist regarding her depression which she stated that she would followup with that herself Today the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04 18 08 She states that since that time her headaches have been bad They woke her up at night She has not been able to sleep She has not had a good sleep cycle since that time She states that the pain is constant and is worse with coughing straining and sneezing as well as on standing up She states that they feel a little bit better when lying down Medication shave not helped her She has tried taking Imitrex as well as Motrin 800 mg twice a day but she states it has not provided much relief The pain is generalized but also noted to be quite intense in the frontal region of her head She also reports ringing in the ears and states that she just does not feel well She reports no nausea at this time She also states that she has been experiencing intermittent blurry vision and dimming lights as well She tells me that she has an appointment with Dr Y tomorrow She reports no other complaints at this time MAJOR FINDINGS On examination today this is a pleasant 38 year old woman who comes back from the clinic waiting area without difficulty She is well developed well nourished and kempt Vital Signs Blood pressure 153 86 pulse 63 and respiratory rate 16 Cranial Nerves Intact for extraocular movements Facial movement hearing head turning tongue and palate movements are all intact I did not know any papilledema on exam bilaterally I examined her shut site which is clean dry and intact She did have a small 3 mm to 4 mm round scab which was noted farther down from her shunt reservoir It looks like there is a little bit of dry blood there ASSESSMENT The patient appears to have had worsening headaches since shunt adjustment back after an MRI PROBLEMS DIAGNOSES 1 Pseudotumor cerebri without papilledema 2 Migraine headaches PROCEDURES I programmed her shunt to 90 mmH2O PLAN It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x ray However the picture of the x ray was not the most desirable picture Thus I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x ray to confirm the setting at 90 In addition she told me that she is scheduled to see Dr Y tomorrow so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient Keywords consult history and phy migraine headaches pseudotumor cerebri without papilledema onset of headaches blurry vision shunt adjustment pseudotumor cerebri headaches pseudotumor cerebri papilledema MEDICAL_TRANSCRIPTION,Description Adenocarcinoma of the prostate Erectile dysfunction History Physical Medical Specialty Consult History and Phy Sample Name Prostate Adenocarcinoma H P Transcription HISTORY OF PRESENT ILLNESS The patient is a 62 year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes He has a PSA of 3 1 with a prostate gland size of 41 grams This was initially found on rectal examination with a nodule on the right side of the prostate showing enlargement relative to the left He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr XXX and ultimately underwent an open biopsy that was not malignant Prior to this he has also had a ProstaScint scan that was negative for any metastatic disease Again he is being admitted to undergo a radical prostatectomy the risks benefits and alternatives of which have been discussed including that of bleeding and a blood transfusion PAST MEDICAL HISTORY Coronary stenting History of high blood pressure as well He has erectile dysfunction and has been treated with Viagra MEDICATIONS Lisinopril Aspirin Zocor and Prilosec ALLERGIES Penicillin SOCIAL HISTORY He is not a smoker He does drink six beers a day REVIEW OF SYSTEMS Remarkable for his high blood pressure and drug allergies but otherwise unremarkable except for some obstructive urinary symptoms with an AUA score of 19 PHYSICAL EXAMINATION HEENT Examination unremarkable Breasts Examination deferred Chest Clear to auscultation Cardiac Regular rate and rhythm Abdomen Soft and nontender He has no hernias Genitourinary There is a normal appearing phallus prominence of the right side of prostate Extremities Examination unremarkable Neurologic Examination nonfocal IMPRESSION 1 Adenocarcinoma of the prostate 2 Erectile dysfunction PLAN The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy The risks benefits and alternatives of this have been discussed He understands and asks that I proceed ahead We also discussed bleeding and blood transfusions and the risks benefits and alternatives thereof Keywords consult history and phy gleason score gleason prostate gland prostascint retropubic prostatectomy adenocarcinoma of the prostate erectile dysfunction adenocarcinoma radical prostatectomy erectile dysfunction prostate MEDICAL_TRANSCRIPTION,Description The patient was referred due to a recent admission for pseudoseizures Medical Specialty Consult History and Phy Sample Name Pseudoseizures Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of the Hospitalist Service at Children s Hospital due to a recent admission for pseudoseizures This was a 90 minute initial intake completed on 10 19 2007 with the patient s mother I have reviewed with her the boundaries of confidentiality and the treatment consent form and she stated that she had understood these concepts PRESENTING PROBLEM It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity These were confirmed by video EEG and consist of trembling shaking and things of that nature She does have a history of focal seizures and perhaps simple seizures which were diagnosed when she was 5 years old but the seizure activity that was documented during the hospital stay is of a significant different quality I had met with them in the hospital and introduced myself and gathered some basic background information but this is a supplement to that information which is contained within this chart It was reported to me that she has been under considerable stress First of all it should be noted that the patient is developmentally delayed Although she is 17 years old she operates at about a fourth grade level Mother reported that The patient becomes stressed because she thinks that everyone is against her that she cannot do anything unless someone is there that she needs a lot of direction that she gets confused easily that she thinks that people become angry at her that she misinterprets what people are saying and thinks that they are upset It is reported the patient feels that her mother yells at her and that is mad at her often It was reported that in addition she recently has had change in her visitation with her father that she within the last 6 months has started seeing her father every other weekend after he had been discharged from prison She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him also additional stressor is at school She reports that she has no friends that she feels unwanted and picked on She gets confused easily at school worries about things and believes that the teachers become angry with her In regards to her mood mother reported that she is usually happy unless things do not go her way and then she becomes upset and says that nobody cares about her She sits in the couch she become angry does not speak Mother sends her to her room and she calms down takes a couple of deep breaths and that passes It is reported that the patient has always been this way and that is not a change in her behavior Mother did think that she did seem a little more depressed that she seems more lonely Over the last few months she has seemed a little bit more down because she does not have any friends and that she is bored Mother reported that she frequently complains of being bored but has always been this way No sleep disturbance was noted No changes in weight No suicidal ideation No deficits in energy were noted Mother did report that she does tend to worry but her worries tend to be because she gets confused does not understand what she needs to do and is quite rigid but mother did not feel that the worry was actually affecting her functioning on a daily basis DEVELOPMENTAL HISTORY The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery She was delivered at 36 weeks gestation Mother reported that she received prenatal care Difficulties during the pregnancy were denied The use of drugs alcohol tobacco during the pregnancy were denied No eating or sleeping difficulties during the perinatal period were reported Temperament was described as easy The patient is described as a cuddly baby In terms of serious injuries they were denied Serious illnesses She has been diagnosed since age 5 with seizures Mother was not able to tell me the exact kind of seizures but it would appear from I could gather that they are focal seizures and possibly simple to complex partial seizures The patient does not have a history of allergy or toileting problems She is currently taking Trileptal 450 mg b i d and she is currently taking Depakote although she is going to be weaned off the Depakote by her neurologist She is taking Prevacid and ibuprofen The neurologist that she sees is Dr Y here at Children s Hospital FAMILY BACKGROUND In terms of family background the patient lives with her mother age 38 and her mother s partner who is age 40 and with her 16 year old sister who does not have any developmental delays Mother had been married to the patient s father but they were together as a couple beginning 1990 married in 1997 separated in 2002 and divorced in 2003 he lives in the ABC area and visits them every other Saturday but there are no overnight visits The paternal grandparents are both living here in California but are separated They are 3 paternal uncles and 2 paternal aunts In terms of the maternal family maternal grandmother and grandfather are deceased Maternal grandfather deceased in 1991 due to cancer Maternal grandmother deceased in 2001 due to cancer There are 5 maternal aunts and 2 maternal uncles all who live in California She reported that the patient is particularly close to her maternal aunt whose name is Carmen Mother s partner had been married previously he has 2 children from that relationship a 23 year old and a 20 year old female who really are not part of the patient s daily life In terms of other family background it was reported that the mother s partner gets frustrated with The patient does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things The sister was described as having some resentment towards her older sister that she feels like she was just to watch out for her care for her and that sister has always wanted to follow her around and do the things that she does The biological father allegedly was in jail for a year due to drug possession Mother reported that he had a problem with methamphetamine In addition she reported there is an accusation that he had molested their niece however she stated that there was a trial and he was found to be not guilty of that She stated there was no evidence that he had ever molested the patient or her sister There had been quite a bit of chaos in the family when the mother and father were together There was a lot of arguing There were a lot of moves there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother s report The patient did observe this After the separation it was reported that there were continued difficulties that the father took the patient and her sister from school without mother s knowledge and had filed to get custody of them and actually ended up having custody of them for a month and told the patient and her sister that the mother had abandoned them Mother reported that they went to court and there was a court order giving the mother custody back after the father went to jail Mother stated that was approximately 5 years ago In terms of current mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday Wednesday s and Friday s but she does have the weekends off The patient was reported also to have a job through her school on several weeknights Mother reported that she graduated from high school had a year of college She was an average student had learning difficulties in reading No psychological or drug or alcohol history was reported by mother In terms of the biological father mother stated that he graduated from high school had a couple of years of college was a good student no learning problems or psychological problems for him were reported Mother reported that he had a history of methamphetamine use Other psychiatric history in the family was denied SOCIAL HISTORY She reported that the patient feels like she does not have any friends that she is lonely and bored really does not do much for fun Her fun consists primarily of doing crafts with mother sewing painting drawing beadwork and things like that It was reported that she really feels that she is bored and does not have much to do ACADEMIC BACKGROUND The patient is in the 11th grade at High School She has 2 regular education classes mother could not tell me what they were but the rest of her classes are special education Mother could not tell me what her IQ was although she noticed she works at about a 4th or 5th grade level Mother reported that the terminology most often used with the patient was developmental delay Her counselor s name is Mr XYZ but she reported that overall she is a good student but she does have sometimes some difficulties at school becoming upset or angry regarding the little things that she does not seem to understand It is reported that the patient feels that she has no friends at school that she is lonely and that is she does not really care for school She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p m where she stocks shelves It is reported that she does not like to go to school because she feels like nobody likes her She is not involved in any kind of clubs or groups at school Mother reported that she is also not receiving CVRC services PREVIOUS COUNSELING Mother reported that she has been in counseling before but mother could not give me any information about that who did the counseling or what it was about She does receive evidently some peer counseling at school because she gets upset and needs help in calming down DIAGNOSTIC SUMMARY AND IMPRESSION It appears that the patient best qualifies for a diagnosis of conversion disorder and information from Neurology suggests that the seizure episodes are not true seizures but appear to be pseudoseizures The patient is experiencing quite bit of stress with a lot of changes in her life also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand PLAN My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her and then to begin teaching coping skills as well as explore ways for reducing her stress DSM IV DIAGNOSES AXIS I Conversion disorder 300 11 AXIS II Diagnoses deferred AXIS III Seizure disorder AXIS IV Problems with primary support group peer problems and educational problems AXIS V Global assessment of functioning equals 60 Keywords consult history and phy conversion disorder global assessment of functioning primary support group peer problems developmental delays seizures developmentally axis pseudoseizures MEDICAL_TRANSCRIPTION,Description Consult for subcutaneous emphysema and a small right sided pneumothorax secondary to trauma Medical Specialty Consult History and Phy Sample Name Pneumothorax Subcutaneous Emphysema Transcription REASON FOR CONSULTATION Pneumothorax and subcutaneous emphysema HISTORY OF PRESENT ILLNESS The patient is a 48 year old male who was initially seen in the emergency room on Monday with complaints of scapular pain The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema a small right sided pneumothorax but no other findings The patient was admitted for observation PAST SURGICAL HISTORY Hernia repair and tonsillectomy ALLERGIES Penicillin MEDICATIONS Please see chart REVIEW OF SYSTEMS Not contributory PHYSICAL EXAMINATION GENERAL Well developed well nourished lying on hospital bed in minimal distress HEENT Normocephalic and atraumatic Pupils are equal round and reactive to light Extraocular muscles are intact NECK Supple Trachea is midline CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm ABDOMEN Soft nontender and nondistended Normoactive bowel sounds EXTREMITIES No clubbing edema or cyanosis SKIN The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday DIAGNOSTIC STUDIES As above IMPRESSION The patient is a 48 year old male with subcutaneous emphysema and a small right sided pneumothorax secondary to trauma These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend RECOMMENDATIONS At this time the CT Surgery service has been consulted and has left recommendations The patient also is awaiting bronchoscopy per the Pulmonary Service At this time there are no General Surgery issues Keywords consult history and phy trauma tracheobronchial bronchoscopy scapular pain subcutaneous emphysema pneumothorax subcutaneous emphysema MEDICAL_TRANSCRIPTION,Description The patient is a 16 month old boy who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge Medical Specialty Consult History and Phy Sample Name Penile Cellulitis Transcription CHIEF COMPLAINT Penile cellulitis status post circumcision HISTORY OF PRESENT ILLNESS The patient is a 16 month old boy who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago The mother states that on Thursday he developed fairly significant swelling scrotum was also swollen the suprapubic region was swollen and he was having a purulent discharge and a fairly significant fever to 102 to 103 He was seen at Hospital transferred to Children s Hospital for further care Since being hospitalized his cultures apparently have grown Staph but is unknown yet whether it is methicillin resistant He has been placed on clindamycin and he is now currently afebrile and with marked improvement according to the mother I was requested a consultation by Dr X because of the appearance of penis The patient has been voiding without difficulty throughout PAST MEDICAL HISTORY The patient has no known allergies He was a term delivery via vaginal delivery Surgeries he has had 2 circumcisions No other hospitalizations He has had no heart murmurs seizures asthma or bronchitis REVIEW OF SYSTEMS A 14 point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned He also had an ear infection about 1 to 2 weeks before his circumcision SOCIAL HISTORY The patient lives with both parents and no siblings There are smokers at home MEDICATIONS Clindamycin and bacitracin ointment Also Bactrim PHYSICAL EXAMINATION VITAL SIGNS Weight is 14 9 kg GENERAL The patient was sleepy but easily arousable HEAD AND NECK Grossly normal His neck and chest are without masses NARES He had some crusted nares otherwise no other discharge LUNGS Clear CARDIAC Without murmurs or gallops ABDOMEN Soft without masses or tenderness GU He has a fairly prominent suprapubic fat pad and he is quite a large child in any event however there were no signs of erythema There was some induration around the penis however there were no signs of active infection He has a buried appearance of the penis after recent circumcision with a normal appearing glans The tissue itself however was quite dull and is soft or readily retractable at this time The scrotum was normal and there was no erythema there was no tenderness Both testes were descended without hydroceles EXTREMITIES He has full range of motion of all 4 extremities SKIN Warm pink and dry NEUROLOGIC Grossly intact BACK Normal IMPRESSION PLAN The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis This is being treated but it is most likely Staph and pending sensitivities I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad I recommended that he be treated most likely with Bactrim for a 10 day course at home bacitracin or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad which makes it more likely Otherwise it is a fairly healthy appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so He has a scheduled followup appointment with his urologist and he should keep that appointment or followup sooner if there is any other problem arising Keywords consult history and phy newborn circumcision suprapubic fat pad penile cellulitis penile swelling cellulitis penis penile suprapubic circumcision MEDICAL_TRANSCRIPTION,Description A 7 year old white male started to complain of pain in his fingers elbows and neck This patient may have had reactive arthritis Medical Specialty Consult History and Phy Sample Name Pediatric Rheumatology Consult Transcription HISTORY We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic He was sent here with a chief complaint of joint pain in several joints for few months This is a 7 year old white male who has no history of systemic disease who until 2 months ago was doing well and 2 months ago he started to complain of pain in his fingers elbows and neck At this moment this is better and is almost gone but for several months he was having pain to the point that he would cry at some point He is not a complainer according to his mom and he is a very active kid There is no history of previous illness to this or had gastrointestinal problems He has problems with allergies especially seasonal allergies and he takes Claritin for it Other than that he has not had any other problem Denies any swelling except for that doctor mentioned swelling on his elbow There is no history of rash no stomach pain no diarrhea no fevers no weight loss no ulcers in his mouth except for canker sores No lymphadenopathy no eye problems and no urinary problems MEDICATIONS His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis ALLERGIES He has no allergies to any drugs BIRTH HISTORY Pregnancy and delivery with no complications He has no history of hospitalizations or surgeries FAMILY HISTORY Positive for arthritis in his grandmother No history of pediatric arthritis There is history of psoriasis in his dad SOCIAL HISTORY He lives with mom dad brother sister and everybody is healthy They live in Easton They have 4 dogs 3 cats 3 mules and no deer At school he is in second grade and he is doing PE without any limitation PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 7 pulse is 96 respiratory rate is 24 height is 118 1 cm weight is 22 1 kg and blood pressure is 61 44 GENERAL He is alert active in no distress very cooperative HEENT He has no facial rash No lymphadenopathy Oral mucosa is clear No tonsillitis His ear canals are clear and pupils are reactive to light and accommodation CHEST Clear to auscultation HEART Regular rhythm and no murmur ABDOMEN Soft nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation in any of his joints or active swelling today He has no tenderness either in any of his joints Muscle strength is 5 5 in proximal muscles LABORATORY DATA Includes an arthritis panel It has normal uric acid sedimentation rate of 2 rheumatoid factor of 6 and antinuclear antibody that is negative and C reactive protein that is 7 1 His mother stated that this was done while he was having symptoms ASSESSMENT AND PLAN This patient may have had reactive arthritis He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis I do not see any problems at this moment on his laboratories or on his physical examination This may have been related to recent episode of viral infection or infection of some sort Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints I will be glad to see him back If you have any question on further assessment and plan please do no hesitate to contact us Keywords consult history and phy rheumatology pediatric reactive arthritis psoriatic arthritis psoriasis joints swelling arthritis MEDICAL_TRANSCRIPTION,Description Pain management for post laminectomy low back syndrome and radiculopathy Medical Specialty Consult History and Phy Sample Name Pain Management Consult 1 Transcription Mr XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice For all these reasons this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient The patient was seen late because he had not filled in the patient questionnaire To summarize the history here Mr XYZ who is not very clear on events from the past sustained a work related injury some time in 1998 At that time he was driving an 18 wheeler truck The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer He experienced severe low back pain and eventually a short while later underwent a fusion of L4 L5 and L5 S1 The patient had an uneventful hospital course from the surgery which was done somewhere in Florida by a surgeon who he does not remember He was able to return to his usual occupation but then again had a second work related injury in May of 2005 At that time he was required to boat trucks to his rig and also to use a chain pulley system to raise and lower the vehicles Mr XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital He was MRI ed at that time which apparently showed a re herniation of an L5 S1 disc and then he somehow ended up in Houston where he underwent fusion by Dr W from L3 through S2 This was done on 12 15 2005 Initially he did fairly well and was able to walk and move around but then gradually the pain reappeared and he started getting severe left sided leg pain going down the lateral aspect of the left leg into his foot He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg The patient was referred to Dr A pain management specialist and Dr A has maintained him on opioid medications consisting of Norco 10 325 mg for breakthrough pain and oxycodone 30 mg t i d with Lunesta 3 mg q h s for sleep Carisoprodol 350 mg t i d and Lyrica 100 mg q daily The patient states that he is experiencing no side effects from medications and takes medications as required He has apparently been drug screened and his drug screening has been found to be normal The patient underwent an extensive behavioral evaluation on 05 22 06 by TIR Rehab Center At that time it was felt that Mr XYZ showed a degree of moderate level of depression There were no indications in the evaluation that Mr XYZ showed any addictive or noncompliant type behaviors It was felt at that time that Mr XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications Of concern to the therapist at that time was the patient s untreated and unmonitored hypertension and diabetes Mr XYZ indicated at that time they had not purchased any prescription medications or any of these health related issues because of financial limitations He still apparently is not under really good treatment for either of these conditions and on today s evaluation he actually denies that he had diabetes The impression was that the patient had axis IV diagnosis of chronic functional limitations financial loss and low losses with no axis III diagnosis This was done by Rhonda Ackerman Ph D a psychologist It was also suggested at that time that the patient should quit smoking Despite these evaluations Mr XYZ really did not get involved in psychotherapy and there was poor attendance of these visits there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke reduced mental clarity and future falls It was felt that any surgical interventions should be put on hold at that time In September of 2006 the patient was evaluated at Baylor College of Medicine in the Occupational Health Program The evaluation was done by a physician at that time whose report is clearly documented in the record Evaluation was done by Dr B At present Mr XYZ continues on with his oxycodone and Norco These were prescribed by Dr A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks The patient states that there has been no recent change in either the severity or the distribution of his pain He is unable to sleep because of pain and his activities of daily living are severely limited He spends most of his day lying on the floor watching TV and occasionally will walk a while from detailed questioning shows that his activities of daily living are practically zero The patient denies smoking at this time He denies alcohol use or aberrant drug use He obtains no pain medications from no other sources Review of MRI done on 02 10 06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4 5 and S1 nerve roots which appear to be retracted posteriorly There is a small right posterior herniation at L1 L2 PAST MEDICAL HISTORY Significant for hypertension hypercholesterolemia and non insulin dependent diabetes mellitus The patient does not know what medications he is taking for diabetes and denies any diabetes CABG in July of 2006 with no preoperative angina shortness of breath or myocardial infarction History of depression lumbar fusion surgery in 2000 left knee surgery 25 years ago SOCIAL HISTORY The patient is on disability He does not smoke He does not drink alcohol He is single He lives with a girlfriend He has minimal activities of daily living The patient cannot recollect when last a urine drug screen was done REVIEW OF SYSTEMS No fevers no headaches chest pain nausea shortness of breath or change in appetite Depressive symptoms of crying and decreased self worth have been noted in the past No neurological history of strokes epileptic seizures Genitourinary negative Gastrointestinal negative Integumentary negative Behavioral depression PHYSICAL EXAMINATION The patient is short of hearing His cognitive skills appear to be significantly impaired The patient is oriented x3 to time and place Weight 185 pounds temperature 97 5 blood pressure 137 92 pulse 61 The patient is complaining of pain of a 9 10 Musculoskeletal The patient s gait is markedly antalgic with predominant weightbearing on the left leg There is marked postural deviation to the left Because of pain the patient is unable to heel toe or tandem gait Examination of the neck and cervical spine are within normal limits Range of motion of the elbow shoulders are within normal limits No muscle spasm or abnormal muscle movements noted in the neck and upper extremities Head is normocephalic Examination of the anterior neck is within normal limits There is significant muscle wasting of the quadriceps and hamstrings on the left as well as of the calf muscles Skin is normal Hair distribution normal Skin temperature normal in both the upper and lower extremities The lumbar spine curvature is markedly flattened There is a well healed central scar extending from T12 to L1 The patient exhibits numerous positive Waddell s signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding worse on the left than the right Range of motion testing of the lumbar spine is labored in all directions It is interesting that the patient cannot flex more than 5 in the standing position but is able to sit without any problem There is a marked degree of sciatic notch tenderness on the left No abnormal muscle spasms or muscle movements were noted Patrick s test is negative bilaterally There are no provocative facetal signs in either the left or right quadrants of the lumbar area Neurological exam Cranial nerves II through XII are within normal limits Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps triceps and brachioradialis reflexes Neurological exam of the lower extremities shows a 2 right patellar reflex and 1 on the left There is no ankle clonus Babinski is negative Sensory testing shows a minimal degree of sensory loss on the right L5 distribution Muscle testing shows decreased L4 L5 on the left with extensor hallucis longus 2 5 Ankle extensors are 3 on the left and 5 on the right Dorsiflexors of the left ankle are 2 on the left and 5 on the right Straight leg raising test is positive on the left at about 35 There is no ankle clonus Hoffman s test and Tinel s test are normal in the upper extremities Respiratory Breath sounds normal Trachea is midline Cardiovascular Heart sounds normal No gallops or murmurs heard Carotid pulses present No carotid bruits Peripheral pulses are palpable Abdomen Hernia site is intact No hepatosplenomegaly No masses No areas of tenderness or guarding IMPRESSION 1 Post laminectomy low back syndrome 2 Left L5 S1 radiculopathy 3 Severe cognitive impairment with minimal for rehabilitation or return to work 4 Opioid dependence for pain control TREATMENT PLAN The patient will continue on with his medications prescribed by Dr Chang and I will see him in two weeks time and probably suggest switching over from OxyContin to methadone I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment I will get a behavioral evaluation from Mr Tom Welbeck and refer the patient for ongoing physical therapy The prognosis here for any improvement or return to work is zero Keywords consult history and phy pain management opioid dependence patrick s test behavioral evaluation cognitive impairment low back syndrome motor strength pain control physical therapy radiculopathy spinal cord stimulation activities of daily living neurological exam laminectomy hearing diabetes muscle syndrome MEDICAL_TRANSCRIPTION,Description Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints Medical Specialty Consult History and Phy Sample Name Orthopedic Consult 4 Transcription CHIEF COMPLAINT Chronic low back left buttock and leg pain HISTORY OF PRESENT ILLNESS This is a pleasant 49 year old gentleman post lumbar disc replacement from January 2005 Unfortunately the surgery and interventional procedures have not been helpful in alleviating his pain He has also tried acupuncture TENS unit physical therapy chiropractic treatment and multiple neuropathic medications including Elavil Topamax Cymbalta Neurontin and Lexapro which he discontinued either due to side effects or lack of effectiveness in decreasing his pain Most recently he has had piriformis injections which did give him a brief period of relief however he reports that the Botox procedure that was done on March 8 2006 has not given him any relief from his buttock pain He states that approximately 75 of his pain is in his buttock and leg and 25 in his back He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back He rated his pain today as 6 10 describing it is shooting sharp and aching It is increased with lifting prolonged standing or walking and squatting decreased with ice reclining and pain medication It is constant but variable in degree It continues to affect activities and sleep at night as well as mood at times He is currently not satisfied completely with his level of pain relief MEDICATIONS Kadian 30 mg b i d Zanaflex one half to one tablet p r n spasm and Advil p r n ALLERGIES No known drug allergies REVIEW OF SYSTEMS Complete multisystem review was noted and signed in the chart SOCIAL HISTORY Unchanged from prior visit PHYSICAL EXAMINATION Blood pressure 123 87 pulse 89 respirations 18 and weight 220 lbs He is a well developed obese male in no acute distress He is alert and oriented x3 and displays normal mood and affect with no evidence of acute anxiety or depression He ambulates with normal gait and has normal station He is able to heel and toe walk He denies any sensory changes ASSESSMENT PLAN This is a pleasant 49 year old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints We discussed treatment options at length and he is willing to undergo a trial of Lyrica He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation Keywords consult history and phy radiculitis myofascial acupuncture tens unit physical therapy chiropractic treatment lumbar disk replacement lumbar disk disk replacement orthopedic MEDICAL_TRANSCRIPTION,Description Low back pain lumbar degenerative disc disease lumbar spondylosis facet and sacroiliac joint syndrome lumbar spinal stenosis primarily bilateral recess intermittent lower extremity radiculopathy DJD of both knees bilateral pes anserinus bursitis and chronic pain syndrome Medical Specialty Consult History and Phy Sample Name Orthopedic Consult 1 Transcription SUBJECTIVE The patient comes back to see me today She is a pleasant 73 year old Caucasian female who had seen Dr XYZ with low back pain lumbar degenerative disc disease lumbar spondylosis facet and sacroiliac joint syndrome lumbar spinal stenosis primarily bilateral recess intermittent lower extremity radiculopathy DJD of both knees bilateral pes anserinus bursitis and chronic pain syndrome Dr XYZ had performed right and left facet and sacroiliac joint injections subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1 She was subsequently seen with some mid back pain and she had right T8 T9 and T9 T10 facet injections on 10 28 2004 She was last seen on 04 08 2005 with recurrent pain in her low back on the right Dr XYZ repeated her radiofrequency ablation on the right side from L3 S1 on 05 04 2005 The patient comes back to see me today She states that the radiofrequency ablation has helped her significantly there but she still has one spot in her low back that seems to be hurting her on the right and seems to be pointing to her right sacroiliac joint She is also complaining of pain in both knees She says that 20 years ago she had a cortisone shot in her knees which helped her significantly She has not had any x rays for quite some time She is taking some Lortab 7 5 mg tablets up to four daily which help her with her pain symptoms She is also taking Celebrex through Dr S office PAST MEDICAL HISTORY Essentially unchanged from my visit of 04 08 2005 PHYSICAL EXAMINATION General Reveals a pleasant Caucasian female Vital Signs Height is 5 feet 5 inches Weight is 183 pounds She is afebrile HEENT Benign Neck Shows functional range of movements with a negative Spurling s Musculoskeletal Examination shows degenerative joint disease of both knees with medial and lateral joint line tenderness with tenderness at both pes anserine bursa Straight leg raises are negative bilaterally Posterior tibials are palpable bilaterally Skin and Lymphatics Examination of the skin does not reveal any additional scars rashes cafe au lait spots or ulcers No significant lymphadenopathy noted Spine Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint She has no other major tenderness Spinal movements are limited but functional Neurological She is alert and oriented with appropriate mood and affect She has normal tone and coordination Reflexes are 2 and symmetrical Sensation is intact to pinprick FUNCTIONAL EXAMINATION Gait has a normal stance and swing phase with no antalgic component to it IMPRESSION 1 Low back syndrome with lumbar degenerative disc disease lumbar spinal stenosis and facet joint syndrome on the right L4 5 and L5 S1 2 Improved spinal right L3 S1 radiofrequency ablation 3 Right sacroiliac joint sprain strain symptomatic 4 Left lumbar facet joint syndrome stable 6 Right thoracic facet joint syndrome stable 7 Lumbar spinal stenosis primarily lateral recess with intermittent lower extremity radiculopathy stable 8 Degenerative disc disease of both knees symptomatic 9 Pes anserinus bursitis bilaterally symptomatic 10 Chronic pain syndrome RECOMMENDATIONS Dr XYZ and I discussed with the patient her pathology She has some symptoms in her low back on the right side at the sacroiliac joint Dr XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy She is also having pain in both knees We will plan on x rays of both knees AP and lateral and plan on seeing her back on Monday or Friday for possible intraarticular and or pes anserine bursa injections bilaterally I explained the rationale for each of these injections possible complications and she wishes to proceed In the interim she can continue on Lortab and Celebrex We will plan for the follow up following these interventions sooner if needed She voiced understanding and agreement Physical exam findings history of present illness and recommendations were performed with and in agreement with Dr Goel s findings Keywords consult history and phy low back pain lumbar degenerative disc disease lumbar spondylosis facet sacroiliac joint syndrome lumbar spinal stenosis intermittent lower extremity radiculopathy djd of both knees bilateral pes anserinus bursitis chronic pain syndrome degenerative disc disease pes anserinus bursitis pes anserine bursa sacroiliac joint joint syndrome degenerative disc lumbar spinal bilateral recess lumbar joint intermittent djd orthopedic pes spinal spondylosis sacroiliac syndrome MEDICAL_TRANSCRIPTION,Description This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain Medical Specialty Consult History and Phy Sample Name Pain from Hernia ER Consult Transcription HISTORY OF PRESENT ILLNESS This is a 53 year old man who presented to emergency room with multiple complaints including pain from his hernia some question of blood in his stool nausea and vomiting and also left lower extremity pain At the time of my exam he states that his left lower extremity pain has improved considerably He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably He does have a history of multiple medical problems including atrial fibrillation he is on Coumadin which is currently subtherapeutic multiple CVAs in the past peripheral vascular disease and congestive heart failure He has multiple chronic history of previous ischemia of his large bowel in the past PHYSICAL EXAM VITAL SIGNS Currently his temperature is 98 2 pulse is 95 and blood pressure is 138 98 HEENT Unremarkable LUNGS Clear CARDIOVASCULAR An irregular rhythm ABDOMEN Soft EXTREMITIES His upper extremities are well perfused He has palpable radial and femoral pulses He does not have any palpable pedal pulses in either right or left lower extremity He does have reasonable capillary refill in both feet He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool but it is relatively warm Apparently this was lot worst few hours ago He describes significant pain and pallor which he feels has improved and certainly clinically at this point does not appear to be as significant IMPRESSION AND PLAN This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease essentially related to spasm versus a small clot which may have been lysed to some extent He currently has a viable extremity and viable foot but certainly has significant making compromised flow It is unclear to me whether this is chronic or acute and whether he is a candidate for any type of intervention He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime Given his potential history of recent lower GI bleeding he has been evaluated by GI to see whether or not he is a candidate for heparinization We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate Again at this point he has no pain relatively rapid capillary refill and relatively normal motor function suggesting a viable extremity We will follow him along closely Keywords consult history and phy blood in stool nausea capillary refill angiogram hernia extremity MEDICAL_TRANSCRIPTION,Description A lady with symptoms consistent with possible oligoarticular arthritis of her knees Medical Specialty Consult History and Phy Sample Name Oligoarticular Arthritis 2 Transcription HISTORY A is a young lady who came here with a diagnosis of seizure disorder and history of Henoch Schonlein purpura with persistent proteinuria A was worked up for collagen vascular diseases and is here to find out the results Also was recommended to take 7 5 mg of Mobic every day for her joint pains She states that she continues with some joint pain and feeling tired all the time Mother states that also her seizure has continued without any control so far She is having some studies in the next few days She is mostly stiff on her legs neck and also on her hands The rest of the review of systems is in the chart PHYSICAL EXAMINATION VITAL SIGNS Temperature today is 99 2 degrees Fahrenheit weight is 45 9 kg blood pressure is 123 59 height is 149 5 cm and pulse is 94 HEENT She has no facial rashes no lymphadenopathy no alopecia no oral ulcerations Pupils are reactive to accommodation Funduscopic examination is within normal limits NECK No neck masses CHEST Clear to auscultation HEART Regular rhythm with no murmur ABDOMEN Soft nontender with no visceromegaly SKIN No rashes today MUSCULOSKELETAL Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities but she does have minus plus swelling of her knees with flexion contracture bilaterally on both LABORATORY DATA Laboratories were not done recently but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease but shows some evidence of decreased calcium and vitamin D levels ASSESSMENT This is a patient who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D She also has chronic proteinuria and seizure disorder My recommendation is to start her on vitamin D and calcium supplements and also increase the Mobic to 50 mg which is one of the few things she can tolerate with all the medication she is taking We are going to refer her to physical therapy and see her back in 2 months for followup The plan was discussed with A and her parents and they have no further questions Keywords consult history and phy arthralgias deficiency vitamin d collagen vascular diseases seizure disorder vascular diseases joint pains oligoarticular arthritis arthritis oligoarticular MEDICAL_TRANSCRIPTION,Description Degenerative disk disease of the right hip low back pain with lumbar scoliosis post laminectomy syndrome lumbar spinal stenosis facet and sacroiliac joint syndrome and post left hip arthroplasty Medical Specialty Consult History and Phy Sample Name Orthopedic Consult 2 Transcription SUBJECTIVE The patient comes back to see me today She is a pleasant 77 year old Caucasian female who had seen Dr XYZ with right leg pain She has a history of prior laminectomy for spinal stenosis She has seen Dr XYZ with low back pain and lumbar scoliosis post laminectomy syndrome lumbar spinal stenosis and clinical right L2 radiculopathy which is symptomatic Dr XYZ had performed two right L2 L3 transforaminal epidural injections last one in March 2005 She was subsequently seen and Dr XYZ found most of her remaining symptoms are probably coming from her right hip An x ray of the hip showed marked degenerative changes with significant progression of disease compared to 08 04 2004 study Dr XYZ had performed right intraarticular hip injection on 04 07 2005 She was last seen on 04 15 2005 At that time she had the hip injection that helped her briefly with her pain She is not sure whether or not she wants to proceed with hip replacement We recommend she start using a cane and had continued her on some pain medicines The patient comes back to see me today She continues to complain of significant pain in her right hip especially with weightbearing or with movement She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her She is taking Ultracet or other the generic it sounds like up to four times daily She states she can take this much more frequently as she still has significant pain symptoms She is using a cane to help her ambulate PAST MEDICAL HISTORY Essentially unchanged from her visit of 04 15 2005 PHYSICAL EXAMINATION General Reveals a pleasant Caucasian female Vital Signs Height is 5 feet 4 inches Weight is 149 pounds She is afebrile HEENT Benign Neck Shows functional range of movements with a negative Spurling s Musculoskeletal Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half grade weakness of her right hip adductors and right quadriceps as compared to the left Straight leg raises are negative bilaterally Posterior tibials are palpable bilaterally Skin and Lymphatics Examination of the skin does not reveal any additional scars rashes cafe au lait spots or ulcers No significant lymphadenopathy noted Spine Examination shows lumbar scoliosis with surgical scar with no major tenderness Spinal movements are limited but functional Neurological She is alert and oriented with appropriate mood and affect She has normal tone and coordination Reflexes are 2 and symmetrical Sensations are intact to pinprick FUNCTIONAL EXAMINATION Gait has a normal stance and swing phase with no antalgic component to it IMPRESSION 1 Degenerative disk disease of the right hip symptomatic 2 Low back syndrome lumbar spinal stenosis clinically right L2 radiculopathy stable 3 Low back pain with lumbar scoliosis post laminectomy syndrome stable 4 Facet and sacroiliac joint syndrome on the right stable 5 Post left hip arthroplasty 6 Chronic pain syndrome RECOMMENDATIONS The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement In the interim her Ultracet is not quite taking care of her pain I have asked her to discontinue it and we will start her on Tylenol 3 up to four times a day I have written a prescription for this for 120 tablets and two refills The patient will call for the refills when she needs them I will plan further follow up in six months sooner if needed She voiced understanding and is in agreement with this plan Physical exam findings history of present illness and recommendations were performed with and in agreement with Dr Goel s findings Keywords consult history and phy scoliosis lumbar laminectomy spinal stenosis radiculopathy chronic pain syndrome low back pain facet and sacroiliac joint degenerative disk disease sacroiliac joint syndrome lumbar spinal stenosis disk disease sacroiliac joint hip arthroplasty hip injection hip replacement lumbar scoliosis injections hip orthopedic MEDICAL_TRANSCRIPTION,Description A 17 year old male with oligoarticular arthritis of his right knee Medical Specialty Consult History and Phy Sample Name Oligoarticular Arthritis 1 Transcription HISTORY A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic A is a 17 year old male with oligoarticular arthritis of his right knee He had a joint injection back in 03 2007 and since then he has been doing relatively well He is taking Indocin only as needed even though he said he has pain regularly and he said that his knee has not changed since the beginning but he said he only takes the medicine when he has pain which is not every day but almost every day He denies any swelling more than what it was before and he denies any other joints are affected at this moment Denies any fevers or any rashes PHYSICAL EXAMINATION On physical examination his temperature is 98 6 weight is 104 6 kg which is 4 4 kg less than before 108 70 is his blood pressure weight is 91 0 kg and his pulse is 80 He is alert active and oriented in no distress He has no facial rashes no lymphadenopathy no alopecia Funduscopic examination is within normal limit He has no cataracts and symmetric pupils to light and accommodation His chest is clear to auscultation The heart has a regular rhythm with no murmur The abdomen is soft and nontender with no visceromegaly Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness Lower extremities He still has some weakness of the knees hip areas and the calf muscles He does have minus plus swelling of the right knee with a very hypermobile patella There is no limitation in his range of motion and the swelling is very minimal with some mild tenderness In terms of his laboratories they were not done today ASSESSMENT This is a 17 year old male with oligoarticular arthritis He is HLA B27 negative PLAN In terms of the plan I discussed with him what things he should be taking and the fact that since he has persistent symptoms he should be on medication every day I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints and if he does not respond to this or continue with the symptoms we may need to get an MRI We will see him back in three months He was evaluated by our physical therapist who gave him some recommendations in terms of exercise for his lower extremities Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI Today he received his flu shot Discussed this with A and his aunt and they had no further questions Keywords consult history and phy rheumatology rheumatology clinic lower extremities oligoarticular arthritis arthritis oligoarticular knee swelling MEDICAL_TRANSCRIPTION,Description Consultation for an ASCUS Pap smear Medical Specialty Consult History and Phy Sample Name OB GYN Consultation 3 Transcription Pap smear in November 2006 showed atypical squamous cells of undetermined significance She has a history of an abnormal Pap smear At that time she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia She underwent a cone biopsy that per her report was negative for any pathology She had no vulvar treatment at that time Since that time she has had normal Pap smears She denies abnormal vaginal bleeding discharge or pain She uses Yaz for birth control She reports one sexual partner since 1994 and she is a nonsmoker She states that she has a tendency to have yeast infections and bacterial vaginosis She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr B She also has a history of chlamydia when she was in college PAST MEDICAL HX Depression PAST SURGICAL HX None MEDICATIONS Lexapro 10 mg a day and Yaz ALLERGIES NO KNOWN DRUG ALLERGIES OB HX Normal spontaneous vaginal delivery at term in 2001 and 2004 Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces FAMILY HX Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use He currently has metastatic melanoma mother with hypertension and depression father with alcoholism SOCIAL HX She is a public relations consultant She is a nonsmoker drinks infrequent alcohol and does not use drugs She enjoys horseback riding and teaches jumping PE VITALS Height 5 feet 6 inches Weight 139 lb BMI 22 4 Blood Pressure 102 58 GENERAL She is well developed and well nourished with normal habitus and no deformities She is alert and oriented to time place and person and her mood and affect is normal NECK Without thyromegaly or lymphadenopathy LUNGS Clear to auscultation bilaterally HEART Regular rate and rhythm without murmurs BREASTS Deferred ABDOMEN Soft nontender and nondistended There is no organomegaly or lymphadenopathy PELVIC Normal external female genitalia Vulva vagina and urethra within normal limits Cervix is status post cone biopsy however the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance GC and chlamydia cultures as well as a repeat Pap smear were done Colposcopy is then performed without and with acetic acid This shows an entirely normal transformation zone so no biopsies are taken An endocervical curettage is then performed with Cytobrush and curette and sent to pathology Colposcopy of the vulva is then performed again with acetic acid There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter There are absolutely no abnormal vessels within this area The vulvar colposcopy is completely within normal limits A P ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup We will check the results of the Pap smear in addition we have ordered DNA testing for high risk HPV We will check the results of the ECC She will return in two weeks for test results If these are normal she will need two normal Pap smears six months apart and I think followup colposcopy for the vulvar changes Keywords consult history and phy lmp ascus pap smear abnormal pap smear atypical bacterial vaginosis chlamydia cone biopsy infection interstitial cystitis intraepithelial mammogram neoplasia perirectal condyloma squamous vaginal bleeding vulvar yeast infection pap smears pap ob gyn colposcopy smear MEDICAL_TRANSCRIPTION,Description Female referred for evaluation of an abnormal colposcopy low grade Pap with suspicious high grade features Medical Specialty Consult History and Phy Sample Name OB GYN Consultation 1 Transcription PAST MEDICAL HX Significant for asthma pneumonia and depression PAST SURGICAL HX None MEDICATIONS Prozac 20 mg q d She desires to be on the NuvaRing ALLERGIES Lactose intolerance SOCIAL HX She denies smoking or alcohol or drug use PE VITALS Stable Weight 114 lb Height 5 feet 2 inches GENERAL Well developed well nourished female in no apparent distress HEENT Within normal limits NECK Supple without thyromegaly HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Soft and nontender There is no rebound or guarding No palpable masses and no peritoneal signs EXTREMITIES Within normal limits SKIN Warm and dry GU External genitalia is without lesion Vaginal is clean without discharge Cervix appears normal however a colposcopy was performed using acetic acid which showed a thick acetowhite ring around the cervical os and extending into the canal BIMANUAL Reveals significant cervical motion tenderness and fundal tenderness She had no tenderness in her adnexa There are no palpable masses A Although unlikely based on the patient s exam and pain I have to consider subclinical pelvic inflammatory disease GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr A A LEEP is a reasonable approach even in this 16 year old P We will schedule LEEP in the near future Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low grade lesions as well as high grade lesions Now we have her given her first shot Keywords consult history and phy gravida ecc external genitalia hpv leep pap acetowhite biopsies blood with urination cervical os colposcopy intraepithelial right lower quadrant squamous suspicious vaginal discharge low grade pap low grade MEDICAL_TRANSCRIPTION,Description Normal review of systems template No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter Medical Specialty Consult History and Phy Sample Name Normal ROS Template 3 Transcription HEENT No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter RESPIRATORY No shortness of breath wheezing dyspnea pulmonary disease tuberculosis or past pneumonias CARDIOVASCULAR No history of palpitations irregular rhythm chest pain hypertension hyperlipidemia diaphoresis congestive heart failure heart catheterization stress test or recent cardiac tests GASTROINTESTINAL No history of rectal bleeding appetite change abdominal pain hiatal hernia ulcer jaundice change in bowel habits or liver problems and no history of inflammatory bowel problems GENITOURINARY No dysuria hematuria frequency incontinence or colic NERVOUS SYSTEM No gait problems strokes numbness or muscle weakness PSYCHIATRIC No history of emotional lability depression or sleep disturbances ONCOLOGIC No history of any cancer change in moles or rashes No history of weight loss The patient has a good energy level ALLERGIC LYMPH No history of systemic allergy abnormal lymph nodes or swelling MUSCULOSKELETAL No fractures motor weakness arthritis or other joint pains Keywords consult history and phy review of systems tinnitus sinusitis sore mouth hoarseness goiter heart appetite bowel weakness loss swelling MEDICAL_TRANSCRIPTION,Description Consultation because of irregular periods and ovarian cyst Medical Specialty Consult History and Phy Sample Name OB GYN Consultation 2 Transcription She started her periods at age 13 She is complaining of a three month history of lower abdominal pain for which she has been to the emergency room twice She describes the pain as bilateral intermittent and non radiating It decreases slightly when she eats and increases with activity She states the pain when it comes can last for half a day It is not associated with movement but occasionally the pain was so bad that it was associated with vomiting She has tried LactAid which initially helped but then the pain returned She has tried changing her diet and Pepcid AC She was seen at XYZ where blood work was done At that time she had a normal white count and a normal H H She was given muscle relaxants which did not work Approximately two weeks ago she was seen in the emergency room at XYZ where a pelvic ultrasound was done This showed a 1 9 x 1 4 cm cyst on the right with no free fluid The left ovary and uterus appeared normal Two days later the pain resolved and she has not had a recurrence She denies constipation and diarrhea She has had some hot flashes but has not taken her temperature In addition she states that her periods have been very irregular coming between four and six weeks They are associated with cramping which she is not happy about She has never had a pelvic exam She states she is not sexually active and declined having her mother leave the room so she was not questioned regarding this without her mother present She is very interested in not having pain with her periods and if this was a cyst that caused her pain she is interested in starting birth control pills to prevent this from happening again PAST MEDICAL HX Pneumonia in 2002 depression diagnosed in 2005 and seizures as an infant PAST SURGICAL HX Plastic surgery on her ear after a dog bite in 1997 MEDICATIONS Zoloft 50 mg a day and LactAid ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HX She enjoys cooking and scrapbooking She does have a boyfriend again she states she is not sexually active She also states that she exercises regularly does not smoke cigarettes use drugs or drink alcohol FAMILY HX Significant for her maternal grandfather with adult onset diabetes a maternal grandmother with hypertension mother with depression and a father who died of colon cancer at 32 years of age She also has a paternal great grandfather who was diagnosed with colon cancer PE VITALS Height 5 feet 5 inches Weight 190 lb Blood Pressure 120 88 GENERAL She is well developed well nourished with normal habitus and no deformities NECK Without thyromegaly or lymphadenopathy LUNGS Clear to auscultation bilaterally HEART Regular rate and rhythm without murmurs ABDOMEN Soft nontender and nondistended There is no organomegaly or lymphadenopathy PELVIC Deferred A P Abdominal pain unclear etiology I expressed my doubt that her pain was secondary to this 1 9 cm ovarian cyst given the fact that there was no free fluid surrounding this However given that she has irregular periods and they are painful for her I think it is reasonable to start her on a low dose birth control pill She has no personal or familial contraindications to start this She was given a prescription for Lo Ovral dispensed 30 with refill x 4 She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns If she should have the recurrence of her pain I have advised her to call Keywords consult history and phy irregular periods lactaid abdominal pain birth control pills cyst ovarian cyst ovaries ovary pelvic exam sexually active uterus lymphadenopathy pelvic irregular periods MEDICAL_TRANSCRIPTION,Description Negative for any nausea vomiting fevers chills or weight loss Medical Specialty Consult History and Phy Sample Name Normal ROS Template 4 Transcription GENERAL Negative for any nausea vomiting fevers chills or weight loss NEUROLOGIC Negative for any blurry vision blind spots double vision facial asymmetry dysphagia dysarthria hemiparesis hemisensory deficits vertigo ataxia HEENT Negative for any head trauma neck trauma neck stiffness photophobia phonophobia sinusitis rhinitis CARDIAC Negative for any chest pain dyspnea on exertion paroxysmal nocturnal dyspnea peripheral edema PULMONARY Negative for any shortness of breath wheezing COPD or TB exposure GASTROINTESTINAL Negative for any abdominal pain nausea vomiting bright red blood per rectum melena GENITOURINARY Negative for any dysuria hematuria incontinence INTEGUMENTARY Negative for any rashes cuts insect bites RHEUMATOLOGIC Negative for any joint pains photosensitive rashes history of vasculitis or kidney problems HEMATOLOGIC Negative for any abnormal bruising frequent infections or bleeding Keywords consult history and phy review of systems trauma neck dyspnea rashes nausea vomiting MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty Consult History and Phy Sample Name Normal ROS Template 5 Transcription REVIEW OF SYSTEMS GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs No history of OB GYN problems MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords consult history and phy respiratory gastrointestinal integumentary hematopoietic night sweats negative allergies negative weakness neurologic throat weakness MEDICAL_TRANSCRIPTION,Description There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing Medical Specialty Consult History and Phy Sample Name Normal ROS Template 1 Transcription REVIEW OF SYSTEMS There was no weight loss fevers chills sweats There is no blurring of the vision itching throat or neck pain or neck fullness There is no vertigo or hoarseness or painful swallowing There is no chest pain shortness of breath paroxysmal nocturnal dyspnea or chest pain with exertion There is no shortness of breath and no cough or hemoptysis No melena nausea vomiting dysphagia abdominal pain diarrhea constipation or blood in the stools No dysuria hematuria or excessive urination No muscle weakness or tenderness No new numbness or tingling No arthralgias or arthritis There are no rashes No excessive fatigability loss of motor skills or sensation No changes in hair texture change in skin color excessive or decreased appetite No swollen lymph nodes or night sweats No headaches The rest of the review of systems is negative Keywords consult history and phy weight loss fevers chills sweats melena nausea vomiting dysphagia abdominal pain diarrhea constipation itching throat neck fullness painful swallowing breath loss neckNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Normal review of systems template Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies Medical Specialty Consult History and Phy Sample Name Normal ROS Template 2 Transcription GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies INTEGUMENTARY Negative rash negative jaundice HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability NEUROLOGIC Negative headaches negative syncope negative seizures negative weakness negative tremor No history of strokes no history of other neurologic conditions EYES Negative visual changes negative diplopia negative scotomata negative impaired vision EARS Negative tinnitus negative vertigo negative hearing impairment NOSE AND THROAT Negative postnasal drip negative sore throat CARDIOVASCULAR Negative chest pain negative dyspnea on exertion negative palpations negative edema No history of heart attack no history of arrhythmias no history of hypertension RESPIRATORY No history of shortness of breath no history of asthma no history of chronic obstructive pulmonary disease no history of obstructive sleep apnea GASTROINTESTINAL Negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal pain GENITOURINARY Negative frequency negative urgency negative dysuria negative incontinence No history of STDs MUSCULOSKELETAL Negative myalgia negative joint pain negative stiffness negative weakness negative back pain PSYCHIATRIC See psychiatric evaluation ENDOCRINE No history of diabetes mellitus no history of thyroid problems no history of endocrinologic abnormalities Keywords consult history and phy nose and throat cardiovascular integumentary negative weakness neurologic throat psychiatric weakness MEDICAL_TRANSCRIPTION,Description Most commonly used phrases in physical exam Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 7 Transcription EYES The conjunctivae are clear The lids are normal appearing without evidence of chalazion or hordeolum The pupils are round and reactive The irides are without any obvious lesions noted Funduscopic examination shows sharp disk margins There are no exudates or hemorrhages noted The vessels are normal appearing EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing NECK The neck is nontender and supple The trachea is midline The thyroid is without any evidence of thyromegaly No obvious adenopathy is noted to the neck RESPIRATORY The patient has normal respiratory effort There is normal lung excursion Percussion of the chest is without any obvious dullness There is no tactile fremitus or egophony noted There is no tenderness to the chest wall or ribs There are no obvious abnormalities The lungs are clear to auscultation There are no wheezes rales or rhonchi heard There are no obvious rubs noted CARDIOVASCULAR There is a normal PMI on palpation I do not hear any obvious abnormal sounds There are no obvious murmurs There are no rubs or gallops noted The carotid arteries are without bruit No obvious thrill is palpated There is no evidence of enlarged abdominal aorta to palpation There is no abdominal mass to suggest enlargement of the aorta Good strong femoral pulses are palpated The pedal pulses are intact There is no obvious edema noted to the extremities There is no evidence of any varicosities or phlebitis noted GASTROINTESTINAL The abdomen is soft Bowel sounds are present in all quadrants There are no obvious masses There is no organomegaly and no liver or spleen is palpable No obvious hernia is noted The perineum and anus are normal in appearance There is good sphincter tone and no obvious hemorrhoids are noted There are no masses On digital examination there is no evidence of any tenderness to the rectal vault no lesions are noted Stool is brown and guaiac negative GENITOURINARY FEMALE The external genitalia is normal appearing with no obvious lesions no evidence of any unusual rash The vagina is normal in appearance with normal appearing mucosa The urethra is without any obvious lesions or discharge The cervix is normal in color with no obvious cervical discharge There are no obvious cervical lesions noted The uterus is nontender and small and there is no evidence of any adnexal masses or tenderness The bladder is nontender to palpation It is not enlarged GENITOURINARY MALE Normal scrotal contents are noted The testes are descended and nontender There are no masses and no swelling to the epididymis noted The penis is without any lesions There is no urethral discharge Digital examination of the prostate reveals a nontender non nodular prostate BREASTS The breasts are normal in appearance There is no puckering noted There is no evidence of any nipple discharge There are no obvious masses palpable There is no axillary adenopathy The skin is normal appearing over the breasts LYMPHATICS There is no evidence of any adenopathy to the anterior cervical chain There is no evidence of submandibular nodes noted There are no supraclavicular nodes palpable The axillae are without any abnormal nodes No inguinal adenopathy is palpable No obvious epitrochlear nodes are noted MUSCULOSKELETAL EXTREMITIES The patient has normal gait and station The patient has normal muscle strength and tone to all extremities There is no obvious evidence of any muscle atrophy The joints are all stable There is no evidence of any subluxation or laxity to any of the joints There is no evidence of any dislocation There is good range of motion of all extremities without any pain or tenderness to the joints or extremities There is no evidence of any contractures or crepitus There is no evidence of any joint effusions No obvious evidence of erythema overlying any of the joints is noted There is good range of motion at all joints There are normal appearing digits There are no obvious lesions to any of the nails or nail beds SKIN There is no obvious evidence of any rash There are no petechiae pallor or cyanosis noted There are no unusual nodules or masses palpable NEUROLOGIC The cranial nerves II XII are tested and are intact Deep tendon reflexes are symmetrical bilaterally The toes are downgoing with normal Babinskis Sensation to light touch is intact and symmetrical Cerebellar testing reveals normal finger nose heel shin Normal gait No ataxia PSYCHIATRIC The patient is oriented to person place and time The patient is also oriented to situation Mood and affect are appropriate for the present situation The patient can remember 3 objects after 3 minutes without any difficulties Remote memory appears to be intact The patient seems to have normal judgment and insight into the situation Keywords consult history and phy ears nose mouth neck respiratory cardiovascular eyes gastrointestinal genitourinary breasts lymphatics musculoskeletal extremities skin neurologic psychiatric normal appearing physical exam examination MEDICAL_TRANSCRIPTION,Description Normal review of systems template The patient denies fever fatigue weakness weight gain or weight loss Medical Specialty Consult History and Phy Sample Name Normal ROS Template Transcription REVIEW OF SYSTEMS GENERAL CONSTITUTIONAL The patient denies fever fatigue weakness weight gain or weight loss HEAD EYES EARS NOSE AND THROAT Eyes The patient denies pain redness loss of vision double or blurred vision flashing lights or spots dryness the feeling that something is in the eye and denies wearing glasses Ears nose mouth and throat The patient denies ringing in the ears loss of hearing nosebleeds loss of sense of smell dry sinuses sinusitis post nasal drip sore tongue bleeding gums sores in the mouth loss of sense of taste dry mouth dentures or removable dental work frequent sore throats hoarseness or constant feeling of a need to clear the throat when nothing is there waking up with acid or bitter fluid in the mouth or throat food sticking in throat when swallows or painful swallowing CARDIOVASCULAR The patient denies chest pain irregular heartbeats sudden changes in heartbeat or palpitation shortness of breath difficulty breathing at night swollen legs or feet heart murmurs high blood pressure cramps in his legs with walking pain in his feet or toes at night or varicose veins RESPIRATORY The patient denies chronic dry cough coughing up blood coughing up mucus waking at night coughing or choking repeated pneumonias wheezing or night sweats GASTROINTESTINAL The patient denies decreased appetite nausea vomiting vomiting blood or coffee ground material heartburn regurgitation frequent belching stomach pain relieved by food yellow jaundice diarrhea constipation gas blood in the stools black tarry stools or hemorrhoids GENITOURINARY The patient denies difficult urination pain or burning with urination blood in the urine cloudy or smoky urine frequent need to urinate urgency needing to urinate frequently at night inability to hold the urine discharge from the penis kidney stones rash or ulcers sexual difficulties impotence or prostate trouble no sexually transmitted diseases MUSCULOSKELETAL The patient denies arm buttock thigh or calf cramps No joint or muscle pain No muscle weakness or tenderness No joint swelling neck pain back pain or major orthopedic injuries SKIN AND BREASTS The patient denies easy bruising skin redness skin rash hives sensitivity to sun exposure tightness nodules or bumps hair loss color changes in the hands or feet with cold breast lump breast pain or nipple discharge NEUROLOGIC The patient denies headache dizziness fainting muscle spasm loss of consciousness sensitivity or pain in the hands and feet or memory loss PSYCHIATRIC The patient denies depression with thoughts of suicide voices in head telling to do things and has not been seen for psychiatric counseling or treatment ENDOCRINE The patient denies intolerance to hot or cold temperature flushing fingernail changes increased thirst increased salt intake or decreased sexual desire HEMATOLOGIC LYMPHATIC The patient denies anemia bleeding tendency or clotting tendency ALLERGIC IMMUNOLOGIC The patient denies rhinitis asthma skin sensitivity latex allergies or sensitivity Keywords consult history and phy cardiovascular ears eyes gastrointestinal head nose respiratory review of systems denies fever blood tongue loss MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normocephalic Negative lesions negative masses Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 4 Transcription GENERAL XXX VITAL SIGNS Blood pressure XXX pulse XXX temperature XXX respirations XXX Height XXX weight XXX HEAD Normocephalic Negative lesions negative masses EYES PERLA EOMI Sclerae clear Negative icterus negative conjunctivitis ENT Negative nasal hemorrhages negative nasal obstructions negative nasal exudates Negative ear obstructions negative exudates Negative inflammation in external auditory canals Negative throat inflammation or masses SKIN Negative rashes negative masses negative ulcers No tattoos NECK Negative palpable lymphadenopathy negative palpable thyromegaly negative bruits HEART Regular rate and rhythm Negative rubs negative gallops negative murmurs LUNGS Clear to auscultation Negative rales negative rhonchi negative wheezing ABDOMEN Soft nontender adequate bowel sounds Negative palpable masses negative hepatosplenomegaly negative abdominal bruits EXTREMITIES Negative inflammation negative tenderness negative swelling negative edema negative cyanosis negative clubbing Pulses adequate bilaterally MUSCULOSKELETAL Negative muscle atrophy negative masses Strength adequate bilaterally Negative movement restriction negative joint crepitus negative deformity NEUROLOGIC Cranial nerves I through XII intact Negative gait disturbance Balance and coordination intact Negative Romberg negative Babinski DTRs equal bilaterally GENITOURINARY Deferred Keywords MEDICAL_TRANSCRIPTION,Description Normal physical exam template Well developed well nourished in no acute distress Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 3 Transcription PHYSICAL EXAMINATION GENERAL APPEARANCE Well developed well nourished in no acute distress VITAL SIGNS SKIN Inspection of the skin reveals no rashes ulcerations or petechiae HEENT The sclerae were anicteric and conjunctivae were pink and moist Extraocular movements were intact and pupils were equal round and reactive to light with normal accommodation External inspection of the ears and nose showed no scars lesions or masses Lips teeth and gums showed normal mucosa The oral mucosa hard and soft palate tongue and posterior pharynx were normal NECK Supple and symmetric There was no thyroid enlargement and no tenderness or masses were felt CHEST Normal AP diameter and normal contour without any kyphoscoliosis LUNGS Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs CARDIOVASCULAR There was a regular rate and rhythm without any murmurs gallops rubs The carotid pulses were normal and 2 bilaterally without bruits Peripheral pulses were 2 and symmetric ABDOMEN Soft and nontender with normal bowel sounds The liver span was approximately 5 6 cm in the right midclavicular line by percussion The liver edge was nontender The spleen was not palpable There were no inguinal or umbilical hernias noted No ascites was noted RECTAL Normal perineal exam Sphincter tone was normal There was no external hemorrhoids or rectal masses Stool Hemoccult was negative The prostate was normal size without any nodules appreciated men only LYMPH NODES No lymphadenopathy was appreciated in the neck axillae or groin MUSCULOSKELETAL Gait was normal There was no tenderness or effusions noted Muscle strength and tone were normal EXTREMITIES No cyanosis clubbing or edema NEUROLOGIC Alert and oriented x 3 Normal affect Gait was normal Normal deep tendon reflexes with no pathological reflexes Sensation to touch was normal Keywords MEDICAL_TRANSCRIPTION,Description An example normal physical exam Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 1 Transcription GENERAL Vital signs and temperature as documented in nursing notes The patient appears stated age and is adequately developed EYES Pupils are equal round reactive to light and accommodation Lids and conjunctivae reveal no gross abnormality ENT Hearing appears adequate No obvious asymmetry or deformity of the ears and nose NECK Trachea midline Symmetric with no obvious deformity or mass no thyromegaly evident RESPIRATORY The patient has normal and symmetric respiratory effort Lungs are clear to auscultation CARDIOVASCULAR S1 S2 without significant murmur ABDOMEN Abdomen is flat soft nontender Bowel sounds are active No masses or pulsations present EXTREMITIES Extremities reveal no remarkable dependent edema or varicosities MUSCULOSKELETAL The patient is ambulatory with normal and symmetric gait There is adequate range of motion without significant pain or deformity SKIN Essentially clear with no significant rash or lesions Adequate skin turgor NEUROLOGICAL No acute focal neurologic changes PSYCHIATRIC Mental status judgment and affect are grossly intact and normal for age Keywords consult history and phy vital signs equal round reactive normal physical exam physical exam MEDICAL_TRANSCRIPTION,Description Normal physical exam template Normal appearance for chronological age does not appear chronically ill Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 6 Transcription VITAL SIGNS Reveal a blood pressure of temperature of respirations and pulse of CONSTITUTIONAL Normal appearance for chronological age does not appear chronically ill HEENT The pupils are equal and reactive Funduscopic examination is normal Posterior pharynx is normal Tympanic membranes are clear NECK Trachea is midline Thyroid is normal The neck is supple Negative nodes RESPIRATORY Lungs are clear to auscultation bilaterally The patient has a normal respiratory rate no signs of consolidation and no egophony There are no retractions or secondary muscle use Good bilateral breath sounds are noted CARDIOVASCULAR No jugular venous distention or carotid bruits No increase in heart size to percussion There is no murmur Normal S1 and S2 sounds are noted without gallop ABDOMEN Soft to palpation in all four quadrants There is no organomegaly and no rebound tenderness Bowel sounds are normal Obturator and psoas signs are negative GENITOURINARY No bladder tenderness negative flank pain MUSCULOSKELETAL Extremities are normal with good motor tone and strength normal reflexes and normal joint strength and sensation NEUROLOGIC Normal Glasgow Coma Scale Cranial nerves II through XII appear grossly intact Normal motor and cerebellar tests Reflexes are normal HEME LYMPH No abnormal lymph nodes no signs of bleeding skin purpura petechiae or hemorrhage PSYCHIATRIC Normal with no overt depression or suicidal ideations Keywords consult history and phy jugular venous distention flank bladder normal physical exam neck nodes respiratory tenderness motor strength reflexes sounds MEDICAL_TRANSCRIPTION,Description An example of a physical exam Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template Transcription GENERAL Alert well developed in no acute distress MENTAL STATUS Judgment and insight appropriate for age Oriented to time place and person No recent loss of memory Affect appropriate for age EYES Pupils are equal and reactive to light No hemorrhages or exudates Extraocular muscles intact EAR NOSE AND THROAT Oropharynx clean mucous membranes moist Ears and nose without masses lesions or deformities Tympanic membranes clear bilaterally Trachea midline No lymph node swelling or tenderness RESPIRATORY Clear to auscultation and percussion No wheezing rales or rhonchi CARDIOVASCULAR Heart sounds normal No thrills Regular rate and rhythm no murmurs rubs or gallops GASTROINTESTINAL Abdomen soft nondistended No pulsatile mass no flank tenderness or suprapubic tenderness No hepatosplenomegaly NEUROLOGIC Cranial nerves II XII grossly intact No focal neurological deficits Deep tendon reflexes 2 bilaterally Babinski negative Moves all extremities spontaneously Sensation intact bilaterally SKIN No rashes or lesions No petechia No purpura Good turgor No edema MUSCULOSKELETAL No cyanosis or clubbing No gross deformities Capable of free range of motion without pain or crepitation No laxity instability or dislocation BONE No misalignment asymmetry defect tenderness or effusion Capable of from of joint above and below bone MUSCLE No crepitation defect tenderness masses or swellings No loss of muscle tone or strength LYMPHATIC Palpation of neck reveals no swelling or tenderness of neck nodes Palpation of groin reveals no swelling or tenderness of groin nodes Keywords consult history and phy mental status ear nose and throat abdomen soft nondistended cranial nerves ii xii grossly intact physical exam MEDICAL_TRANSCRIPTION,Description Normal Physical Exam Template Well developed well nourished alert in no acute distress Medical Specialty Consult History and Phy Sample Name Normal Physical Exam Template 5 Transcription GENERAL Well developed well nourished alert in no acute distress GCS 50 nontoxic VITAL SIGNS Blood pressure pulse respirations temperature degrees F Pulse oximetry HEENT Eyes Lids and conjunctiva No lesions Pupils equal round reactive to light and accommodation Irises symmetrical undilated Funduscopic exam reveals no hemorrhages or discopathy Ears Nose Mouth and throat External ears without lesions Nares patent Septum midline Tympanic membranes without erythema bulging or retraction Canals without lesion Hearing is grossly intact Lips teeth gums palate without lesion Posterior oropharynx No erythema No tonsillar enlargement crypt formation or abscess NECK Supple and symmetric No masses Thyroid midline non enlarged No JVD Neck is nontender Full range of motion without pain RESPIRATORY Good respiratory effort Clear to auscultation Clear to percussion Chest Symmetrical rise and fall Symmetrical expansion No egophony or tactile fremitus CARDIOVASCULAR Regular rate and rhythm No murmur gallops clicks heaves or rub Cardiac palpation within normal limits Pulses equal at carotid Femoral and pedal pulses No peripheral edema GASTROINTESTINAL No tenderness or mass No hepatosplenomegaly No hernia Bowel sounds equal times four quadrants Abdomen is nondistended No rebound guarding rigidity or ecchymosis MUSCULOSKELETAL Normal gait and station No pathology to digits or nails Extremities move times four No tenderness or effusion Range of motion adequate Strength and tone equal bilaterally stable BACK Nontender on midline Full range of motion with flexion extension and sidebending SKIN Inspection within normal limits Well hydrated No diaphoresis No obvious wound LYMPH Cervical lymph nodes No lymphadenopathy NEUROLOGICAL Cranial nerves II XII grossly intact DTRs symmetric 2 out of 4 bilateral upper and lower extremity elbow patella and ankle Motor strength 4 4 bilateral upper and lower extremity Straight leg raise is negative bilaterally PSYCHIATRIC Judgment and insight adequate Alert and oriented times three Memory and mood within normal limits No delusions hallucinations No suicidal or homicidal ideation Keywords consult history and phy respiratory abdomen normal physical exam pulses tenderness strength lymph extremity midline range motion lesions symmetrical MEDICAL_TRANSCRIPTION,Description Normal newborn infant physical exam A well developed infant in no acute respiratory distress Medical Specialty Consult History and Phy Sample Name Normal Newborn Infant Physical Exam Transcription GENERAL A well developed infant in no acute respiratory distress VITAL SIGNS Initial temperature was XX pulse XX respirations XX Weight XX grams length XX cm head circumference XX cm HEENT Head is normocephalic with anterior fontanelle open soft and non bulging Eyes Red reflex elicited bilaterally TMs occluded with vernix and not well visualized Nose and throat are patent without palatal defect NECK Supple without clavicular fracture LUNGS Clear to auscultation HEART Regular rate without murmur click or gallop present Pulses are 2 4 for brachial and femoral ABDOMEN Soft with bowel sounds present No masses or organomegaly GENITALIA Normal EXTREMITIES Without evidence of hip defects NEUROLOGIC The infant has good Moro grasp and suck reflexes SKIN Warm and dry without evidence of rash Keywords consult history and phy fontanelle normocephalic newborn infant physical exam acute respiratory newborn respiratory distress head infant MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male ROS Medical Specialty Consult History and Phy Sample Name Normal Male ROS Template 1 Transcription REVIEW OF SYSTEMS CONSTITUTIONAL Patient denies fevers chills sweats and weight changes EYES Patient denies any visual symptoms EARS NOSE AND THROAT No difficulties with hearing No symptoms of rhinitis or sore throat CARDIOVASCULAR Patient denies chest pains palpitations orthopnea and paroxysmal nocturnal dyspnea RESPIRATORY No dyspnea on exertion no wheezing or cough GI No nausea vomiting diarrhea constipation abdominal pain hematochezia or melena GU No urinary hesitancy or dribbling No nocturia or urinary frequency No abnormal urethral discharge MUSCULOSKELETAL No myalgias or arthralgias NEUROLOGIC No chronic headaches no seizures Patient denies numbness tingling or weakness PSYCHIATRIC Patient denies problems with mood disturbance No problems with anxiety ENDOCRINE No excessive urination or excessive thirst DERMATOLOGIC Patient denies any rashes or skin changes Keywords consult history and phy review of systems normal male ros normal male male ros male ros throat urinary MEDICAL_TRANSCRIPTION,Description Normal female review of systems template Negative for fever weight change fatigue or aching Medical Specialty Consult History and Phy Sample Name Normal Female ROS Template Transcription CONSTITUTIONAL Normal negative for fever weight change fatigue or aching HEENT Eyes normal Negative for glasses cataracts glaucoma retinopathy irritation or visual field defects Ears normal Negative for hearing or balance problems Nose normal Negative for runny nose sinus problems or nosebleeds Mouth normal Negative for dental problems dentures or bleeding gums Throat normal Negative for hoarseness difficulty swallowing or sore throat CARDIOVASCULAR Normal Negative for angina previous MI irregular heartbeat heart murmurs bad heart valves palpitations swelling of feet high blood pressure orthopnea paroxysmal nocturnal dyspnea or history of stress test arteriogram or pacemaker implantation PULMONARY Normal Negative for cough sputum shortness of breath wheezing asthma or emphysema GASTROINTESTINAL Normal Negative for pain vomiting heartburn peptic ulcer disease change in stool rectal pain hernia hepatitis gallbladder disease hemorrhoids or bleeding GENITOURINARY Normal female OR male Negative for incontinence UTI dysuria hematuria vaginal discharge abnormal bleeding breast lumps nipple discharge skin or nipple changes sexually transmitted diseases incontinence yeast infections or itching SKIN Normal Negative for rashes keratoses skin cancers or acne MUSCULOSKELETAL Normal Negative for back pain joint pain joint swelling arthritis joint deformity problems with ambulation stiffness osteoporosis or injuries NEUROLOGIC Normal Negative for blackouts headaches seizures stroke or dizziness PSYCHIATRIC Normal Negative for anxiety depression or phobias ENDOCRINE Normal Negative for diabetes thyroid or problems with cholesterol or hormones HEMATOLOGIC LYMPHATIC Normal Negative for anemia swollen glands or blood disorders IMMUNOLOGIC Negative Negative for steroids chemotherapy or cancer VASCULAR Normal Negative for varicose veins blood clots atherosclerosis or leg ulcers Keywords consult history and phy cough sputum shortness of breath fever weight fatigue aching nose throat swelling disease incontinence bleeding heartbeat blood joint MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Consult History and Phy Sample Name Normal Male Exam Template 4 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions lids lashes brows or conjunctivae noted Funduscopic examination unremarkable No papilledema glaucoma or cataracts Ears Normal set and shape with normal hearing and normal TMs Nose and Sinus Unremarkable Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without carotid bruit JVD or significant cervical adenopathy Trachea is midline without stridor shift or subcutaneous emphysema Thyroid is palpable nontender not enlarged and free of nodularity CHEST Lungs bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI is nondisplaced Chest wall is unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS Normal male breast tissue ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and intraabdominal bruit on auscultation EXTERNAL GENITALIA Normal for age Normal penis with bilaterally descended testes that are normal in size shape and contour and without evidence of hernia or hydrocele RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool and normal sized prostate that is free of nodularity or tenderness No rectal masses palpated EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords consult history and phy digital palpation hemoccult negative heent palpation breasts male tenderness tongue MEDICAL_TRANSCRIPTION,Description Sample template for a normal male multisystem exam Medical Specialty Consult History and Phy Sample Name Normal Male Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The scrotal elements were normal The testes were without discrete mass The penis showed no lesion no discharge LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords consult history and phy within normal limits conjunctiva eyes ears nose throat male multisystem heart respiratory auscultation extremities oropharynx neck tongue MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty Consult History and Phy Sample Name Normal ENT Exam Transcription EARS NOSE MOUTH AND THROAT The nose is without any evidence of any deformity The ears are with normal appearing pinna Examination of the canals is normal appearing bilaterally There is no drainage or erythema noted The tympanic membranes are normal appearing with pearly color normal appearing landmarks and normal light reflex Hearing is grossly intact to finger rubbing and whisper The nasal mucosa is moist The septum is midline There is no evidence of septal hematoma The turbinates are without abnormality No obvious abnormalities to the lips The teeth are unremarkable The gingivae are without any obvious evidence of infection The oral mucosa is moist and pink There are no obvious masses to the hard or soft palate The uvula is midline The salivary glands appear unremarkable The tongue is midline The posterior pharynx is without erythema or exudate The tonsils are normal appearing Keywords consult history and phy erythema tympanic mouth throat ears mucosa noseNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description An example template for a routine normal female physical exam Medical Specialty Consult History and Phy Sample Name Normal Female Exam Template 2 Transcription VITAL SIGNS Blood pressure pulse respirations temperature GENERAL APPEARANCE Alert and in no apparent distress calm cooperative and communicative HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are bilaterally clear to auscultation and percussion HEART S1 and S2 Regular rate and rhythm without murmur heave click lift thrill rub or gallop PMI nondisplaced Chest wall unremarkable to inspection and palpation No axillary or supraclavicular adenopathy detected BREASTS In the seated and supine position unremarkable ABDOMEN No hepatosplenomegaly mass tenderness rebound rigidity or guarding No widening of the aortic impulse and no intraabdominal bruit auscultated EXTERNAL GENITALIA Normal for age RECTAL Negative to 7 cm by gloved digital palpation with Hemoccult negative stool EXTREMITIES Good distal pulse and perfusion without evidence of edema cyanosis clubbing or deep venous thrombosis Nails of the hands and feet and creases of the palms and soles are unremarkable Good active and passive range of motion of all major joints BACK Normal to inspection and percussion Negative for spinous process tenderness or CVA tenderness Negative straight leg raising Kernig and Brudzinski signs NEUROLOGIC Nonfocal for cranial and peripheral nervous systems strength sensation and cerebellar function Affect is normal Speech is clear and fluent Thought process is lucid and rational Gait and station are unremarkable SKIN Unremarkable for any premalignant or malignant condition with normal changes for age Keywords consult history and phy heent general appearance hepatosplenomegaly mass tenderness rebound rigidity pulse bruit adenopathy chest percussion inspection palpation signs tongue MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Consult History and Phy Sample Name Normal Male Exam Template 1 Transcription MALE PHYSICAL EXAMINATION HEENT Pupils equal round and reactive to light and accommodation Extraocular movements are intact Sclerae are anicteric TMs are clear bilaterally Oropharynx is clear without erythema or exudate NECK Supple without lymphadenopathy or thyromegaly Carotids are silent There is no jugular venous distention CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm without S3 S4 No murmurs or rubs are appreciated ABDOMEN Soft nontender nondistended with positive bowel sounds No masses hepatomegaly or splenomegaly are appreciated GU Normal circumcised male No discharge or hernias No testicular masses RECTAL EXAM Normal rectal tone Prostate is smooth and not enlarged Stool is Hemoccult negative EXTREMITIES Reveal no clubbing cyanosis or edema Peripheral pulses are 2 and equal bilaterally in all four extremities JOINT EXAM Reveals no tenosynovitis NEUROLOGIC Cranial nerves II through XII are grossly intact Motor strength is 5 5 and equal in all four extremities Deep tendon reflexes are 2 4 and equal bilaterally Patient is alert and oriented times 3 PSYCHIATRIC Grossly normal DERMATOLOGIC No lesions or rashes Keywords consult history and phy male exam physical exam normal normal male physical male sclerae extremities intact oropharynx MEDICAL_TRANSCRIPTION,Description An example template for a routine normal male physical exam Medical Specialty Consult History and Phy Sample Name Normal Male Exam Template 2 Transcription MALE PHYSICAL EXAMINATION Eye Eyelids normal color no edema Conjunctivae with no erythema foreign body or lacerations Sclerae normal white color no jaundice Cornea clear without lesions Pupils equally responsive to light Iris normal color no lesions Anterior chamber clear Lacrimal ducts normal Fundi clear Ear External ear has no erythema edema or lesions Ear canal unobstructed without edema discharge or lesions Tympanic membranes clear with normal light reflex No middle ear effusions Nose External nose symmetrical No skin lesions Nares open and free of lesions Turbinates normal color size and shape Mucus clear No internal lesions Throat No erythema or exudates Buccal mucosa clear Lips normal color without lesions Tongue normal shape and color without lesion Hard and soft palate normal color without lesions Teeth show no remarkable features No adenopathy Tonsils normal shape and size Uvula normal shape and color Neck Skin has no lesions Neck symmetrical No adenopathy thyromegaly or masses Normal range of motion nontender Trachea midline Chest Symmetrical Clear to auscultation bilaterally No wheezing rales or rhonchi Chest nontender Normal lung excursion No accessory muscle use Cardiovascular Heart has regular rate and rhythm with no S3 or S4 Heart rate is normal Abdominal Soft nontender nondistended bowel sounds present No hepatomegaly splenomegaly masses or bruits Genital Penis normal shape without lesions Testicles normal shape and contour without tenderness Epididymides normal shape and contour without tenderness Rectum normal tone to sphincter Prostate normal shape and contour without nodules Stool hemoccult negative No external hemorrhoids No skin lesions Musculoskeletal Normal strength all muscle groups Normal range of motion all joints No joint effusions Joints normal shape and contour No muscle masses Foot No erythema No edema Normal range of motion all joints in the foot Nontender No pain with inversion eversion plantar or dorsiflexion Ankle Anterior and posterior drawer test negative No pain with inversion eversion dorsiflexion or plantar flexion Collateral ligaments intact No joint effusion erythema edema crepitus ecchymosis or tenderness Knee Normal range of motion No joint effusion erythema nontender Anterior and posterior drawer tests negative Lachman s test negative Collateral ligaments intact Bursas nontender without edema Wrist Normal range of motion No edema or effusion nontender Negative Tinel and Phalen tests Normal strength all muscle groups Elbow Normal range of motion No joint effusion or erythema Normal strength all muscle groups Nontender Olecranon bursa flat and nontender no edema Normal supination and pronation of forearm No crepitus Hip Negative swinging test Trochanteric bursa nontender Normal range of motion Normal strength all muscle groups No pain with eversion and inversion No crepitus Normal gait Psychiatric Alert and oriented times four No delusions or hallucinations no loose associations no flight of ideas no tangentiality Affect is appropriate No psychomotor slowing or agitation Eye contact is appropriate Keywords consult history and phy male exam normal physical exam normal range of motion male physical nontender lesions dorsiflexion sclerae contour muscle erythema joints edema shape MEDICAL_TRANSCRIPTION,Description Normal child physical exam template Medical Specialty Consult History and Phy Sample Name Normal Child Exam Template Transcription CHILD PHYSICAL EXAMINATION VITAL SIGNS Birth weight is grams length occipitofrontal circumference Character of cry was lusty GENERAL APPEARANCE Well BREATHING Unlabored SKIN Clear No cyanosis pallor or icterus Subcutaneous tissue is ample HEAD Normal Fontanelles are soft and flat Sutures are opposed EYES Normal with red reflex x2 EARS Patent Normal pinnae canals TMs NOSE Patent nares MOUTH No cleft THROAT Clear NECK No masses CHEST Normal clavicles LUNGS Clear bilaterally HEART Regular rate and rhythm without murmur ABDOMEN Soft flat No hepatosplenomegaly The cord is three vessel GENITALIA Normal genitalia with testes descended bilaterally ANUS Patent SPINE Straight and without deformity EXTREMITIES Equal movements MUSCLE TONE Good REFLEXES Moro grasp and suck are normal HIPS No click or clunk Keywords consult history and phy child physical examination physical genitalia child MEDICAL_TRANSCRIPTION,Description Sample template for a normal female multisystem exam Medical Specialty Consult History and Phy Sample Name Normal Female Exam Template Transcription MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits The patient appeared alert EYES The conjunctiva was clear The pupil was equal and reactive There was no ptosis The irides appeared normal EARS NOSE AND THROAT The ears and the nose appeared normal in appearance Hearing was grossly intact The oropharynx showed that the mucosa was moist There was no lesion that I could see in the palate tongue tonsil or posterior pharynx NECK The neck was supple The thyroid gland was not enlarged by palpation RESPIRATORY The patient s respiratory effort was normal Auscultation of the lung showed it to be clear with good air movement CARDIOVASCULAR Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted The extremities showed no edema BREASTS Breast inspection showed them to be symmetrical with no nipple discharge Palpation of the breasts and axilla revealed no obvious mass that I could appreciate GASTROINTESTINAL The abdomen was soft nontender with no rebound no guarding no enlarged liver or spleen Bowel sounds were present GU The external genitalia appeared to be normal The pelvic exam revealed no adnexal masses The uterus appeared to be normal in size and there was no cervical motion tenderness LYMPHATIC There was no appreciated node that I could feel in the groin or neck area MUSCULOSKELETAL The head and neck by inspection showed no obvious deformity Again the extremities showed no obvious deformity Range of motion appeared to be normal for the upper and lower extremities SKIN Inspection of the skin and subcutaneous tissues appeared to be normal The skin was pink warm and dry to touch NEUROLOGIC Deep tendon reflexes were symmetrical at the patellar area Sensation was grossly intact by touch PSYCHIATRIC The patient was oriented to time place and person The patient s judgment and insight appeared to be normal Keywords MEDICAL_TRANSCRIPTION,Description Sample normal ear nose mouth and throat exam Medical Specialty Consult History and Phy Sample Name Normal ENT Exam 1 Transcription EARS NOSE MOUTH AND THROAT EARS NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis There are no signs of acute trauma The nose is normal to palpation and inspection externally without evidence of acute trauma Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion inflammation or swelling The tympanic membranes are without disruption or infection Hearing intact bilaterally to normal level speech Nasal mucosa septum and turbinate examination reveals normal mucous membranes without disruption or inflammation The septum is without acute traumatic lesions or disruption The turbinates are without abnormal swelling There is no unusual rhinorrhea or bleeding LIPS TEETH GUMS The lips are without infection mass lesion or traumatic lesions The teeth are intact without obvious signs of infection The gingivae are normal to palpation and inspection OROPHARYNX The oral mucosa is normal The salivary glands are without swelling The hard and soft palates are intact The tongue is without masses or swelling with normal movement The tonsils are without inflammation The posterior pharynx is without mass lesion with good patent oropharyngeal airway Keywords consult history and phy oral mucosa lips hearing auditory canals tympanic membranes traumatic lesions mouth throat trauma nose membranes inflammation infection swelling MEDICAL_TRANSCRIPTION,Description The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness Medical Specialty Consult History and Phy Sample Name Neuropsychological Evaluation 5 Transcription PROBLEMS AND ISSUES 1 Headaches nausea and dizziness consistent with a diagnosis of vestibular migraine recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment 2 Some degree of peripheral neuropathy consistent with diabetic neuropathy encouraged her to watch her diet and exercise daily HISTORY OF PRESENT ILLNESS The patient comes in for a neurology consultation regarding her difficult headaches tunnel vision and dizziness I obtained and documented a full history and physical examination I reviewed the new patient questionnaire which she completed prior to her arrival today I also reviewed the results of tests which she had brought with her Briefly she is a 60 year old woman initially from Ukraine who had headaches since age 25 She recalls that in 1996 when her husband died her headaches became more frequent They were pulsating She was given papaverine which was successful in reducing the severity of her symptoms After six months of taking papaverine she no longer had any headaches In 2004 her headaches returned She also noted that she had zig zag lines in her vision Sometimes she would not see things in her peripheral visions She had photophobia and dizziness which was mostly lightheadedness On one occasion she almost had a syncope Again she has started taking Russian medications which did help her The dizziness and headaches have become more frequent and now occur on average once to twice per week They last two hours since she takes papaverine which stops the symptoms within 30 minutes PAST MEDICAL HISTORY Her past medical history is significant for injury to her left shoulder gastroesophageal reflux disorder diabetes anxiety and osteoporosis MEDICATIONS Her medications include hydrochlorothiazide lisinopril glipizide metformin vitamin D Centrum multivitamin tablets Actos lorazepam as needed Vytorin and Celexa ALLERGIES She has no known drug allergies FAMILY HISTORY There is family history of migraine and diabetes in her siblings SOCIAL HISTORY She drinks alcohol occasionally REVIEW OF SYSTEMS Her review of systems was significant for headaches pain in her left shoulder sleeping problems and gastroesophageal reflex symptoms Remainder of her full 14 point review of system was unremarkable PHYSICAL EXAMINATION On examination the patient was pleasant She was able to speak English fairly well Her blood pressure was 130 84 Heart rate was 80 Respiratory rate was 16 Her weight was 188 pounds Her pain score was 0 10 Her general exam was completely unremarkable Her neurological examination showed subtle weakness in her left arm due to discomfort and pain She had reduced vibration sensation in her left ankle and to some degree in her right foot There was no ataxia She was able to walk normally Reflexes were 2 throughout She had had a CT scan with constant which per Dr X s was unremarkable She reports that she had a brain MRI two years ago which was also unremarkable IMPRESSION AND PLAN The patient is a delightful 60 year old chemist from Ukraine who has had episodes of headaches with nausea photophobia and dizziness since her 20s She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms Her diagnosis is consistent with vestibular migraine I do not see evidence of multiple sclerosis Ménière s disease or benign paroxysmal positional vertigo I talked to her in detail about the importance of following a migraine diet I gave her instructions including a list of foods times which worsen migraine I reviewed this information for more than half the clinic visit I would like to start her on amitriptyline at a dose of 10 mg at time She will take Motrin at a dose of 800 mg as needed for her severe headaches She will make a diary of her migraine symptoms so that we can find any triggering food items which worsen her symptoms I encouraged her to walk daily in order to improve her fitness which helps to reduce migraine symptoms Keywords consult history and phy nausea dizziness migraine peripheral neuropathy diabetic neuropathy neuropathy positional vertigo photophobia and dizziness neurology consultation tunnel vision vestibular migraine migraine symptoms headaches photophobia ataxia MEDICAL_TRANSCRIPTION,Description Neurologic examination sample Medical Specialty Consult History and Phy Sample Name Neurologic Examination Transcription NEUROLOGICAL EXAMINATION At present the patient is awake alert and fully oriented There is no evidence of cognitive or language dysfunction Cranial nerves Visual fields are full Funduscopic examination is normal Extraocular movements full Pupils equal round react to light There is no evidence of nystagmus noted Fifth nerve function is normal There is no facial asymmetry noted Lower cranial nerves are normal Manual motor testing reveals good tone and bulk throughout There is no evidence of pronator drift or decreased fine finger movements Muscle strength is 5 5 throughout Deep tendon reflexes are 2 throughout with downgoing toes Sensory examination is intact to all modalities including stereognosis graphesthesia TESTING OF STATION AND GAIT The patient is able to walk toe heel and tandem walk Finger to nose and heel to shin moves are normal Romberg sign negative I appreciate no carotid bruits or cardiac murmurs Noncontrast CT scan of the head shows no evidence of acute infarction hemorrhage or extra axial collection Keywords consult history and phy station motor testing nerve function neurologic examination cranial nerves cranial extraocular movementsNOTE MEDICAL_TRANSCRIPTION,Description Sample for Neuropsychological Evaluation Medical Specialty Consult History and Phy Sample Name Neuropsychological Evaluation 1 Transcription REASON FOR EVALUATION The patient is a 37 year old white single male admitted to the hospital through the emergency room I had seen him the day before in my office and recommended him to go into the hospital He had just come from a trip to Taho in Nevada and he became homicidal while there He started having thoughts about killing his mother He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him HISTORY OF PRESENT ILLNESS This is a patient that has been suffering from a chronic psychotic condition now for a number of years He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too The patient has not used any drugs since age 25 However he has continued having intense and frequent psychotic bouts I have seen him now for approximately one year He has been quite refractory to treatment We tried different types of combination of medications which have included Clozaril Risperdal lithium and Depakote with partial response and usually temporary The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days The dosages that we have used have been very high He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level However he has not responded He has delusions of antichrist He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals He has paranoid delusions He also gets homicidal like prior to this admission PAST PSYCHIATRIC HISTORY As mentioned before this patient has been psychotic off and on for about 20 years now He has had years in which he did better on Clozaril and also his other medications With typical anti psychotics he has done well at times but he eventually gets another psychotic bout PAST MEDICAL HISTORY He has a history of obesity and also of diabetes mellitus However most recently he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa The patient has chronic bronchitis He smokes cigarettes constantly up to 60 a day DRUG HISTORY He stopped using drugs when he was 25 He has got a lapse but he was more than 10 years and he has been clean ever since then As mentioned before he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis PSYCHOSOCIAL STATUS The patient lives with his mother and has been staying with her for a few years now We have talked to her She is very supportive His only sister is also very supportive of him He has lived in the ABCD houses in the past He has done poorly in some of them MENTAL STATUS EXAMINATION The patient appeared alert oriented to time place and person His affect is flat He talked about auditory hallucinations which are equivocal in nature He is not homicidal in the hospital as he was when he was at home His voice and speech are normal He believes in telepathy His memory appears intact and his intelligence is calculated as average INITIAL DIAGNOSES AXIS I Schizophrenia AXIS II Deferred AXIS III History of diabetes mellitus obesity and chronic bronchitis AXIS IV Moderate AXIS V GAF of 35 on admission INITIAL TREATMENT AND PLAN Since the patient has been on high dosages of medications we will give him a holiday and a structured environment We will put him on benzodiazepines and make a decision anti psychotic later We will make sure that he is safe and that he addresses his medical needs well Keywords consult history and phy neuropsychological gaf schizophrenia anti psychotic chronic psychotic condition delusions hallucination homicidal marijuana psychological psychotic smokes cigarettes smoking neuropsychological evaluation clozaril bronchitis axis MEDICAL_TRANSCRIPTION,Description Neurologic consultation and follow up Medical Specialty Consult History and Phy Sample Name Neurologic Consultation 1 Transcription SOCIAL HISTORY FAMILY HISTORY AND PAST MEDICAL HISTORY Reviewed There are no changes otherwise REVIEW OF SYSTEMS Fatigue pain difficulty with sleep mood fluctuations low stamina mild urgency frequency and hesitancy preponderance of lack of stamina preponderance of pain particularly in the left shoulder EXAMINATION The patient is alert and oriented Extraocular movements are full The face is symmetric The uvula is midline Speech has normal prosody Today there is much less guarding of the left shoulder In the lower extremities iliopsoas quadriceps femoris and tibialis anterior are full The gait is narrow based and noncircumductive Rapid alternating movements are slightly off bilaterally The gait does not have significant slapping characteristics Sensory examination is largely unremarkable Heart lungs and abdomen are within normal limits IMPRESSION Mr ABC is doing about the same We discussed the issue of adherence to Copaxone In order to facilitate this I would like him to take Copaxone every other day but on a regular rhythm His wife continues to inject him He has not been able to start himself on the injections Greater than 50 of this 40 minute appointment was devoted to counseling Keywords consult history and phy neurologic consultation stamina preponderance neurologic consultation copaxone MEDICAL_TRANSCRIPTION,Description Neurologic consultation was requested to assess and assist with seizure medication Medical Specialty Consult History and Phy Sample Name Neurologic Consultation 3 Transcription HISTORY Neurologic consultation was requested to assess and assist with her seizure medication The patient is a 3 year 3 months old girl with refractory epilepsy She had been previously followed by XYZ but has been under the care of the UCSF epilepsy program and recently by Dr Y I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom The patient had seizure breakthrough in August 2007 which requires inpatient admission Thanksgiving and then after that time had seizures every other day up to date early December She remained seizure free until 12 25 2007 when she had a breakthrough seizure at home treated with Diastat She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home Mom documented 103 temperature at home In the ER this was 101 to 102 degrees Fahrenheit I reviewed the ER notes At 0754 hours she was having intermittent generalized tonic clonic seizures despite receiving a total of 1 5 mg of lorazepam x5 UCSF fellow was contacted She was given additional fosphenytoin and had a total dose of 15 mg kg administered Vital weight was 27 Seizures apparently had stopped The valproic acid level obtained at 0835 hours was 79 According to mom her last dose was at 6 p m and she did not receive her morning dose Other labs slightly showed leukocytosis with white blood cell count 21 000 and normal CMP Previous workup here showed an EEG on 2005 which showed a left posterior focus MRI on June 2007 and January 2005 were within normal limits Mom describes the following seizure types 1 Eye blinking with unresponsiveness 2 Staring off to one side 3 Focal motor activity in one arm and recently generalized tonic seizure She also said that she was supposed to see Dr Y this Friday but had postponed it to some subsequent time when results of genetic testing would be available She was being to physicians care as Dr Z had previously being following her last UCSF She had failed most of the first and second line anti epileptic drugs These include Keppra Lamictal Trileptal phenytoin and phenobarbital These are elicited to allergies but she has not had any true allergic reactions to these Actually it has resulted in an allergic reaction resulting in rash and hypotension She also had been treated with Clobazam Her best control is with her current regimen of valproic acid and Tranxene Other attempts to taper Topamax but this resulted increased seizures She also has oligohidrosis during this summertime CURRENT MEDICATIONS Include Diastat 20 mg Topamax 25 mg b i d which is 3 3 per kilo per day Tranxene 15 mg b i d Depakote 125 mg t i d which is 25 per kilo per day PHYSICAL EXAMINATION VITAL SIGNS Weight 15 kg GENERAL The patient was awake she appeared sedated and postictal NECK Supple NEUROLOGICAL She had a few brief myoclonic jerks of her legs during drowsiness but otherwise no overt seizure no seizure activity nor involuntary movements were observed She was able to follow commands such as when I request that she gave mom a kiss She acknowledged her doll Left fundus is sharp She resisted the rest of the exam There was no obvious lateralized findings ASSESSMENT Status epilepticus resolved Triggered by a febrile illness possibly viral Refractory remote symptomatic partial epilepsy IMPRESSION I discussed the maximizing Depakote to mom and she concurred I recommend increasing her maintenance dose to one in the morning one in the day and two at bedtime For today she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p o Dr X agreed with the changes and orders were written for this She can continue her current doses of Topamax and Tranxene This can be given by NG if needed Topamax can be potentially increased to 25 mg in the morning and 50 mg at night I will be available as needed during the rest of her hospitalization Mom will call contact Dr Y an update him about the recent changes Keywords consult history and phy eye blinking status epilepticus seizure medication valproic acid allergic reactions neurologic consultation seizure neurologic seizures MEDICAL_TRANSCRIPTION,Description Neurogenic bladder in a patient catheterizing himself 3 times a day changing his catheter 3 times a week Medical Specialty Consult History and Phy Sample Name Neurogenic Bladder Consult Transcription HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr ABC s office regarding the above He has history of neurogenic bladder and on intermittent self catheterization 3 times a day However June 24 2008 he was seen in the ER and with fever weakness possible urosepsis He had a blood culture which was positive for Staphylococcus epidermidis as well as urine culture noted for same bacteria He was treated on IV antibiotics Dr XYZ also saw the patient Discharged home Not taking any antibiotics Today in the office the patient denies any dysuria gross hematuria fever chills He is catheterizing 3 times a day changing his catheter weekly Does have history of renal transplant which has been followed by Dr X and is on chronic steroids Renal ultrasound June 23 2008 was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space Creatinine July 7 2008 was 2 0 BUN 36 and patient tells me this is being followed by Dr X No interval complaints today no issues with catheterization or any gross hematuria IMPRESSION 1 Neurogenic bladder in a patient catheterizing himself 3 times a day changing his catheter 3 times a week we again reviewed the technique of catheterization and he has no issues with this 2 Recurrent urinary tract infection in a patient who has been hospitalized twice within the last few months he is on steroids for renal transplant which has most likely been overall reducing his immune system He is asymptomatic today No complaints today PLAN Following a detailed discussion with the patient we elected to proceed with intermittent self catheterization changing catheter weekly and technique has been discussed as above Based on the recent culture we will place him on Keflex nighttime prophylaxis for the next three months or so He will call if any concerns Follow up as previously scheduled in September for re assessment All questions answered The patient is seen and evaluated by myself Keywords consult history and phy neurogenic bladder catheterizing catheter urinary tract infection self catheterization intermittent self catheterization renal transplant catheterization MEDICAL_TRANSCRIPTION,Description Neurologic consultation was requested to evaluate her seizure medication and lethargy Medical Specialty Consult History and Phy Sample Name Neurologic Consultation Transcription REASON FOR CONSULTATION Neurologic consultation was requested by Dr X to evaluate her seizure medication and lethargy HISTORY OF PRESENT ILLNESS The patient is well known to me She has symptomatic partial epilepsy secondary to a static encephalopathy cerebral palsy and shunted hydrocephalus related to prematurity She also has a history of factor V Leiden deficiency She was last seen at neurology clinic on 11 16 2007 At that time instructions were given to mom to maximize her Trileptal dose if seizures continue She did well on 2 mL twice a day without any sedation This past Friday she had a 25 minute seizure reportedly This consisted of eye deviation unresponsiveness and posturing Diastat was used and which mom perceived was effective Her Trileptal dose was increased to 3 mL b i d yesterday According to mom since her shunt revision on 12 18 2007 she has been sleepier than normal She appeared to be stable until this past Monday about six days ago she became more lethargic and had episodes of vomiting and low grade fevers According to mom she had stopped vomiting since her hospitalization Reportedly she was given a medication in the emergency room She still is lethargic will not wake up spontaneously When she does awaken however she is appropriate and interacts with them She is able to eat well however her overall p o intake has been diminished She has also been less feisty as her usual sounds She has been seizure free since her admission LABORATORY DATA Pertinent labs obtained here showed the following CRP is less than 0 3 CMP normal and CBC within normal limits CSF cultures so far is negative Dr Limon s note refers to a CSF white blood cell count of 2 1 RBC glucose of 55 and protein of 64 There are no imaging studies in the computer I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr X who indicated that there was no evidence of shunt malfunction or infection CURRENT MEDICATIONS Trileptal 180 mg b i d lorazepam 1 mg p r n acetaminophen and azithromycin PHYSICAL EXAMINATION GENERAL The patient was asleep but easily aroused There was a brief period of drowsiness which she had some jerky limb movements but not seizures She eventually started crying and became agitated She made attempts to sit by bending her neck forward Fully awake she sucks her bottle eagerly HEENT She was obviously visually impaired Pupils were 3 mm sluggishly reactive to light EXTREMITIES Bilateral lower extremity spasticity was noted There was increased flexor tone in the right upper extremity IV was noted on the left hand ASSESSMENT Seizure breakthrough due to intercurrent febrile illness Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded I concur with Dr X s recommendations I do not recommend any changes in Trileptal for now I will be available while she remains hospitalized Keywords consult history and phy lethargy encephalopathy cerebral palsy shunted hydrocephalus seizure breakthrough shunt malfunction neurologic consultation neurologic seizure trileptal MEDICAL_TRANSCRIPTION,Description The patient is admitted with a diagnosis of acute on chronic renal insufficiency Medical Specialty Consult History and Phy Sample Name Nephrology Consultation 4 Transcription HISTORY The patient is a 61 year old male patient I was asked to evaluate this patient because of the elevated blood urea and creatinine The patient has ascites pleural effusion hematuria history of coronary artery disease pulmonary nodules history of congestive heart failure status post AICD The patient has a history of exposure to asbestos in the past history of diabetes mellitus of 15 years duration hypertension and peripheral vascular disease The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall The patient has been having increasing distention of the abdomen and frequent nosebleeds PAST MEDICAL HISTORY As above PAST SURGICAL HISTORY The patient had a pacemaker placed ALLERGIES NKDA REVIEW OF SYSTEMS Showed no history of fever no chills no weight loss No history of sore throat No history of any ascites No history of nausea vomiting or diarrhea No black stools No history of any rash No back pain No leg pain No neuropsychiatric problems FAMILY HISTORY History of hypertension diabetes present SOCIAL HISTORY He is a nonsmoker nonalcoholic and not a drug user PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 124 66 heart rate around 68 per minute and temperature 96 4 HEENT The patient is atraumatic and normocephalic Pupils are equal and reactive to light Extraocular muscles are intact NECK Supple No JVD and no thyromegaly HEART S1 and S2 heard No murmurs or extra sounds ABDOMEN Distention of the abdomen present EXTREMITIES No pedal edema LABORATORY His lab investigation showed WBC of 6 2 H H is 11 and 34 PT PTT and INR is normal Urinalysis showed 2 protein and 3 blood and 5 to 10 rbc s Potassium is 5 3 BUN of 39 and creatinine of 1 9 Liver function test ALT was 12 AST 15 albumin 3 TSH of 4 8 and T3 of 1 33 IMPRESSION AND PLAN The patient is admitted with a diagnosis of acute on chronic renal insufficiency rule out hepatorenal insufficiency could be secondary to congestive heart failure cardiac cirrhosis rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis The patient has hematuria could be secondary to benign prostatic hypertrophy rule out malignancy We will do urine for cytology We will do a renal ultrasound and 24 hour urine collection for protein creatinine creatinine clearance immunofixation serum electrophoresis serum uric acid serum iron TIBC and serum ferritin levels We will send a PSA level and if needed may be a urology consult Keywords consult history and phy mesothelioma ascites pleural effusion hematuria history of coronary artery disease pulmonary nodules congestive heart failure aicd hepatorenal insufficiency pulmonary nodule diabetic nephropathy chronic renal insufficiency nodules serum insufficiency MEDICAL_TRANSCRIPTION,Description Patient with end stage renal disease secondary to hypertension a reasonable candidate for a kidney transplantation Medical Specialty Consult History and Phy Sample Name Nephrology Consultation 3 Transcription PAST MEDICAL SURGICAL HISTORY Briefly his past medical history is significant for hypertension of more than 5 years asthma and he has been on Advair and albuterol He was diagnosed with renal disease in 02 2008 and has since been on hemodialysis since 02 2008 His past surgical history is only significant for left AV fistula on the wrist done in 04 2008 He still has urine output He has no history of blood transfusion PERSONAL AND SOCIAL HISTORY He is a nonsmoker He denies any alcohol No illicit drugs He used to work as the custodian at the nursing home but now on disability since 03 2008 He is married with 2 sons ages 5 and 17 years old FAMILY HISTORY No similar illness in the family except for hypertension in his one sister and his mom who died at 61 years old of congestive heart failure His father is 67 years old currently alive with asthma He also has one sister who has hypertension The rest of the 6 siblings are alive and well ALLERGIES No known drug allergies MEDICATIONS Singulair 10 mg once daily Cardizem 365 mg once daily Coreg 25 mg once daily hydralazine 100 mg three times a day Lanoxin 0 125 mg once daily Crestor 10 mg once daily lisinopril 10 mg once daily Phoslo 3 tablets with meals and Advair 250 mg inhaler b i d REVIEW OF SYSTEMS Significant only for asthma No history of chest pain normal MI He has hypertension He occasionally will develop colds especially with weather changes GI Negative GU Still making urine about 1 3 times per day Musculoskeletal Negative Skin He complains of dry skin Neurologic Negative Psychiatry Negative Endocrine Negative Hematology Negative PHYSICAL EXAMINATION A pleasant 41 year old African American male who stands 5 feet 6 inches and weighs about 193 pounds HEENT Anicteric sclera pink conjunctiva no cervical lymphadenopathy Chest Equal chest expansion Clear breath sounds Heart Distinct heart sounds regular rhythm with no murmur Abdomen Soft nontender flabby no organomegaly Extremities Poor peripheral pulses No cyanosis and no edema ASSESSMENT AND PLAN This is a 49 year old African American male who was diagnosed with end stage renal disease secondary to hypertension He is on hemodialysis since 02 2008 Overall I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma Other than that I think that he is a reasonable candidate for transplant I would like to thank you for allowing me to participate in the care of your patient Please feel free to contact me if there are any questions regarding his case Keywords consult history and phy kidney transplantation pretransplant transplant clinic renal disease secondary kidney hemodialysis renal asthma transplantation hypertension MEDICAL_TRANSCRIPTION,Description Patient with a diagnosis of pancreatitis developed hypotension and possible sepsis and respiratory as well as renal failure Medical Specialty Consult History and Phy Sample Name Nephrology Consultation 2 Transcription HISTORY The patient was in the intensive care unit setting he was intubated and sedated The patient is a 55 year old patient who was admitted secondary to a diagnosis of pancreatitis developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output His creatinine has gone from 2 1 to 4 2 overnight and the patient also developed florid acidosis and hypokalemia Nephrology input has been requested for management of acute renal failure and acidosis PAST MEDICAL HISTORY 1 Pancreatitis 2 Poison ivy The patient has recently been on oral steroids 3 Hypertension MEDICATIONS Include Ambien prednisone and blood pressure medication which is not documented in the record at the moment INPATIENT MEDICATIONS Include Protonix IV half normal saline at 125 mL an hour D5W with 3 ounces of bicarbonate at 150 mL an hour The patient was initially on dopamine which has now been discontinued The patient remains on Levophed and Invanz 1 g IV q 24 h PHYSICAL EXAMINATION Vitals emergency room presentation the blood pressure was 82 45 His blood pressure in the ICU had dipped down into the 60s systolic most recent blood pressure is 108 67 and he has been maintained on 100 FiO2 The patient has had minimal urine output since admission HEENT the patient is intubated at the moment Neck examination no overt lymph node enlargement No jugular venous distention Lungs examination is benign in terms of crackles The patient has some harsh breath sounds secondary to being intubated CVS S1 and S2 are fairly regular at the moment There is no pericardial rub Abdominal examination obese but benign Extremity examination reveals no lower extremity edema CNS the patient is intubated and sedated LABORATORY DATA Blood work sodium 152 potassium 2 7 bicarbonate 13 BUN 36 and creatinine 4 2 The patient s BUN and creatinine yesterday were 23 and 2 1 respectively H H of 17 7 and 51 6 white cell count of 8 4 from earlier on this morning The patient s liver function tests are all out of whack and his alkaline phosphatase is 226 ALT is 539 CK 1103 INR 1 66 and ammonia level of 55 Latest ABGs show a pH of 7 04 bicarbonate of 10 7 pCO2 of 40 3 and pO2 of 120 7 ASSESSMENT 1 Acute renal failure which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension but the patient is at the moment on 100 FiO2 He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis The patient also has significant acidosis and his creatinine has increased from 2 1 to 4 2 overnight Given the fact that he would need dialytic support for his electrolyte derangements and for volume control I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability 2 Hypotension which is significant and is related to his sepsis Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment 3 Acidosis which is again secondary to his renal failure The patient was administered intravenous bicarbonate as mentioned above Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements 4 Pancreatitis which has been managed by his gastroenterologist 5 Sepsis the patient is on broad spectrum antibiotic therapy 6 Hypercalcemia The patient has been given calcium chloride We will need to watch for rebound hypercalcemia 7 Hypoalbuminemia 8 Hypokalemia which has been repleted RECOMMENDATIONS Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration Keywords consult history and phy intubated consultation hypercalcemia hypoalbuminemia iv fluid nephrology acidosis creatinine hemodiafiltration hypokalemia hypotension intravenous pancreatitis renal failure respiratory urine output continuous venovenous hemodiafiltration electrolyte derangements conventional hemodialysis continuous venovenous venovenous hemodiafiltration blood pressure venovenous bicarbonate sepsis MEDICAL_TRANSCRIPTION,Description A 6 mm left intrarenal stone nonobstructing by ultrasound and IVP Medical Specialty Consult History and Phy Sample Name Microhematuria Consult Transcription HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr ABC s office regarding the above He was seen a few weeks ago for routine followup and he was noted for microhematuria Due to his history of kidney stone renal ultrasound as well as IVP was done He presents today for followup He denies any dysuria gross hematuria or flank pain issues Last stone episode was over a year ago No history of smoking Daytime frequency 3 to 4 and nocturia 1 to 2 good stream empties well with no incontinence Creatinine 1 0 on June 25 2008 UA at that time was noted for 5 9 RBCs renal ultrasound of 07 24 2008 revealed 6 mm left intrarenal stone with no hydronephrosis IVP same day revealed a calcification over the left kidney but without bilateral hydronephrosis The calcification previously noted on the ureter appears to be outside the course of the ureter Otherwise unremarkable This is discussed IMPRESSION 1 A 6 mm left intrarenal stone nonobstructing by ultrasound and IVP The patient is asymptomatic We have discussed surgical intervention versus observation He indicates that this stone is not bothersome prefers observation need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed 2 Microhematuria we discussed possible etiologies of this and the patient is agreeable to cystoscopy in the near future Urine sent for culture and sensitivity PLAN As above The patient will follow up for cystoscopy urine sent for cytology continue hydration Call if any concern The patient is seen and evaluated by myself Keywords consult history and phy intrarenal stone ivp ultrasound microhematuria hydration kidney stone renal ultrasound MEDICAL_TRANSCRIPTION,Description Patient with stable expressive aphasia and decreased vision Medical Specialty Consult History and Phy Sample Name Multiple Meningiomas Transcription CC Stable expressive aphasia and decreased vision HX This 72y o woman was diagnosed with a left sphenoid wing meningioma on 6 3 80 She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital nuchal headaches One month prior to that presentation she developed leftward head turning and 3 days prior to presentation had an episode of severe dysphasia A HCT done locally revealed a homogenously enhancing lesion of the left sphenoid wing Skull X rays showed deviation of the pineal to the right She was transferred to UIHC and was noted to have a normal neurologic exam per Neurosurgery note Angiography demonstrated a highly vascular left temporal sphenoid wing tumor She under went left temporal craniotomy and complete resection of the tumor which on pathologic analysis was consistent with a meningioma The left sphenoid wing meningioma recurred and was excised 9 25 84 There was regrowth of this tumor seen on HCT 1985 A 6 88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma HCT in 1989 revealed left temporal sphenoid left tentorial and new left frontal lesions On 2 14 91 she presented with increasing lethargy and difficulty concentrating A 2 14 91 HCT revealed increased size and surrounding edema of the left frontal meningioma The left frontal and temporal meningiomas were excised on 2 25 91 These tumors all recurred and a left parietal lesion developed She underwent resection of the left frontal meningioma on 11 21 91 due to right sided weakness and expressive aphasia The weakness partially resolved and though the speech improved following resection it did not return to normal In May 1992 she experienced 3 tonic clonic type seizures all of which began with a Jacksonian march up the RLE then RUE before generalizing Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased On 12 7 92 she underwent a left fronto temporo parieto occipital craniotomy and excision of five meningiomas Postoperatively she developed worsened right sided weakness and expressive aphasia The weakness and aphasia improved by 3 93 but never returned to normal Keywords consult history and phy sphenoid wing meningioma sphenoid wing expressive aphasia meningiomas aphasia sphenoidNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Loculated left effusion multilobar pneumonia Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency Medical Specialty Consult History and Phy Sample Name Multilobar Pneumonia Transcription REASON FOR CONSULTATION Loculated left effusion multilobar pneumonia Keywords consult history and phy neck bruits nasal cannula rhythm pneumonia chest tube fluid collection pleural effusion multilobar pneumonia pleural loculations multilobar MEDICAL_TRANSCRIPTION,Description Progressive loss of color vision OD Medical Specialty Consult History and Phy Sample Name Meningioma Transcription CC Progressive loss of color vision OD HX 58 y o female presents with a one year history of progressive loss of color vision In the past two months she has developed blurred vision and a central scotoma OD There are no symptoms of photopsias diplopia headache or eye pain There are no other complaints There have been mild fluctuations of her symptoms but her vision has never returned to its baseline prior to symptom onset one year ago EXAM Visual acuity with correction 20 25 1 OD 20 20 1 OS Pupils were 3 5mm OU There was a 0 8 log unit RAPD OD Intraocular pressures were 25 and 24 OD and OS respectively and there was an increase to 27 on upgaze OD but no increase on upgaze OS Optic disk pallor was evident OD but not OS Additionally there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye Foveal flicker fusion occurred at a frequency of 21 9 OD and 30 7 OS Color plate testing scores 6 14 OD and 10 14 OS Goldman visual field examination showed an enlarged and deepened blind spot with an infero temporal defect especially in the smaller diopters IMPRESSION ON 2 6 89 Optic neuropathy atrophy OD rule out mass lesion affecting optic nerve Particular attention was paid to the area of the optic canal cavernous sinus and sphenoid sinus BRAIN CT W CONTRAST 2 13 89 Enhancing calcified lesion in the posterior aspect of the right optic nerve probable meningioma MRI ORBITS W AND W OUT GADOLINIUM CONTRAST 4 26 89 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD The mass is just proximal to the orbital apex There is relatively homogeneous enhancement of the mass The findings are most consistent with meningioma MRI 1995 Mild enlargement of tumor with possible slight extension into the right cavernous sinus COURSE Resection and biopsy were deferred due to risk of blindness and suspicion that the tumor was a slow growing meningioma 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam There was greater red color desaturation of the temporal field OD Visual acuity had decreased from 20 20 to 20 64 OD All other deficits seen on her initial exam remained stable or slightly worsened By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection Keywords consult history and phy goldman visual field examination loss of color vision visual field examination visual acuity cavernous sinus color vision visual field optic nerve meningioma MEDICAL_TRANSCRIPTION,Description Mental status changes after a fall She sustained a concussion with postconcussive symptoms and syndrome that has resolved Medical Specialty Consult History and Phy Sample Name Mental Status Changes Consult Transcription CHIEF COMPLAINT Mental status changes after a fall HISTORY Ms ABC is a 76 year old female with Alzheimer s apparently is normally very talkative active independent but with advanced Alzheimer s Apparently she tripped backwards hitting her head on a wheelchair and had although no loss consciousness had altered mental status changes She was very confused incomprehensible speech and was not responding appropriately She was transported here stable with no significant changes She ultimately upon arrival here was unchanged in that she was not responding appropriately She would have garbled speech somewhat inappropriate at times and unable to follow commands No other history was able to be obtained All pertinent history is documented within the records Physical examination also documented in the records essentially as above PHYSICAL EXAMINATION HEENT Without any obvious signs of trauma Pupils are equal and reactive Extraocular movements are difficult to assess with her eyes closed but she will open to voice TMs canals are normal without any signs of hemotympanum Nasal mucosa and oropharynx are normal NECK Nontender full range of motion was not examined initially a collar was placed HEART Regular LUNGS Clear CHEST BACK ABDOMEN Without trauma SKIN With multiple excoriations from scratching and itching NEUROLOGIC Otherwise she has good sensation withdrawals to pain When lifting the arm she will hold them up and draw let them down slowly With movement of the legs she did straighten them back out slowly DTRs were intact and equal bilaterally Otherwise the remainder of the examination was unable to be done because of patient s non cooperation and mental status change LABORATORY DATA CT scan of the head was negative as was cervical spine She has a history of being on Coumadin Her INR is 1 92 CBC was with a white count of 3 8 50 neutrophils 8 bands CMP did note a potassium which was elevated at 5 9 troponin was normal mag is 2 5 valproic acid level 24 3 ASSESSMENT AND PLAN Ms ABC is a 76 year old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours has completely resolved It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved At this time she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation I have discussed this with her son he agrees Otherwise she has improved significantly The patient was discussed with XYZ who will admit the patient for further evaluation and treatment Keywords consult history and phy alzheimer s no loss consciousness mental status MEDICAL_TRANSCRIPTION,Description Patient presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus Medical Specialty Consult History and Phy Sample Name Major Depressive Disorder IME Consult Transcription IDENTIFYING DATA Mr T is a 45 year old white male CHIEF COMPLAINT Mr T presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus His confidence and self esteem are significantly low He stated he has excessive somnolence his energy level is extremely low motivation is low and he has a lack for personal interests He has had suicidal ideation but this is currently in remission Furthermore he continues to have hopeless thoughts and crying spells Mr T stated these symptoms appeared approximately two months ago HISTORY OF PRESENT ILLNESS On March 25 2003 Mr T was fired from his job secondary to an event at which he stated he was first being harassed by another employee This other employee had confronted Mr T with a very aggressive verbal style where this employee had placed his face directly in front of Mr T was spitting on him and called him bitch Mr T then retaliated and went to hit the other employee Due to this event Mr T was fired It should be noted that Mr T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to deal with it There are no other apparent stressors in Mr T s life at this time or in recent months Mr T stated that work was his entire life and he based his entire identity on his work ethic It should be noted that Mr T was a process engineer for Plum Industries for the past 14 years PAST PSYCHIATRIC HISTORY There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr T s family physician Dr B at which point Mr T was placed on Lexapro with an unknown dose at this time Mr T is currently seeing Dr J for psychotherapy where he has been in treatment since April 2003 PAST PSYCHIATRIC REVIEW OF SYSTEMS Mr T denied any history throughout his childhood adolescence and early adulthood for depressive anxiety or psychotic disorders He denied any suicide attempts or profound suicidal or homicidal ideation Mr T furthermore stated that his family psychiatric history is unremarkable SUBSTANCE ABUSE HISTORY Mr T stated he used alcohol following his divorce in 1993 but has not used it for the last two years No other substance abuse was noted LEGAL HISTORY Currently charges are pending over the above described incident MEDICAL HISTORY Mr T denied any hospitalizations surgeries or current medications use for any heart disease lung disease liver disease kidney disease gastrointestinal disease neurological disease closed head injury endocrine disease infectious blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia PERSONAL AND SOCIAL HISTORY Mr T was born in Dwyne Missouri with no complications associated with his birth Originally he was raised by both parents but they separated at an early age When he was about seven years old he was raised by his mother and stepfather He did not sustain a relationship with his biological father from that time on He stated his parents moved a lot and because this many times he was picked on in his new environments Mr T stated he was at times a rebellious teenager but he denied any significant inability to socialize and denied any learning disabilities or the need for special education Mr T stated his stepfather was somewhat verbally abusive and that he committed suicide when Mr T was 18 years old He graduated from high school and began work at Dana Corporation for two to three years after which he worked as an energy auditor for a gas company He then became a homemaker while his wife worked for Chrysler for approximately two years Mr T was married for eleven years and divorced in 1993 He has a son who is currently 20 years old After being a home maker Mr T worked for his mother in a restaurant and moved on from there to work for Borg Warner corporation for one to two years before beginning at Plum Industries where he worked for 14 years and worked his way up to lead engineer Mental Status Exam Mr T presented with a hyper vigilant appearance his eye contact was appropriate to the interview and his motor behavior was tense At times he showed some involuntary movements that would be more akin to a resting tremor There was no psychomotor retardation but there was some mild psychomotor excitement His speech was clear concise but pressured His attitude was overly negative and his mood was significant for moderate depression anxiety anhedonia and loneliness and mild evidence of anger There was no evidence of euphoria or diurnal mood variation His affective expression was restricted range but there was no evidence of lability At times his affective tone and facial expressions were inappropriate to the interview There was no evidence of auditory visual olfactory gustatory tactile or visceral hallucinations There was no evidence of illusions depersonalizations or derealizations Mr T presented with a sequential and goal directed stream of thought There was no evidence of incoherence irrelevance evasiveness circumstantiality loose associations or concrete thinking There was no evidence of delusions however there was some ambivalence guilt and self derogatory thoughts There was evidence of concreteness for similarities and proverbs His intelligence was average His concentration was mildly impaired and there was no evidence of distractibility He was oriented to time place person and situation There was no evidence of clouded consciousness or dissociation His memory was intact for immediate recent and remote events He presented with poor appetite easily fatigued and decreased libidinal drive as well as excessive somnolence There was a moderate preoccupation with his physical health pertaining to his headaches His judgment was poor for finances family relations social relations employment and at this time he had no future plans Mr T s insight is somewhat moderate as he is aware of his contribution to the problem His motivation for getting well is good as he accepts offered treatment complies with recommended treatment and seeks effective treatments He has a well developed empathy for others and capacity for affection There was no evidence of entitlement egocentricity controllingness intimidation or manipulation His credibility seemed good There was no evidence for potential self injury suicide or violence The reliability and completeness of information was very good and there were no barriers to communication The information gathered was based on the patient s self report and objective testing and observation His attitude toward the examiner was neutral and his attitude toward the examination process was neutral There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings and there was no lack of cooperation with the evaluation or poor compliance with treatment and no evidence of antisocial personality disorder IMPRESSIONS Major Depressive Disorder single episode RECOMMENDATIONS AND PLAN I recommend Mr T continue with psychopharmacologic care as well as psychotherapy At this time the excessive amount of psychiatric symptoms would impede Mr T from seeking employment Furthermore it appears that the primary precipitating event had occurred on March 25 2003 when Mr T was fired from his job after being harassed for over a year As Mr T placed his entire identity and sense of survival on his work this was a deafening blow to his psychological functioning Furthermore it only appears logical that this would precipitate a major depressive episode Keywords consult history and phy muscle tremor headaches excessive nervousness poor concentration independent medical evaluation psychopharmacologic poor ability to focus major depressive disorder tremor depressive psychiatric MEDICAL_TRANSCRIPTION,Description Patient with sudden onset dizziness and RUE clumsiness Giant Left MCA Aneurysm Medical Specialty Consult History and Phy Sample Name MCA Aneurysm Transcription HX This 46y o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness The symptoms resolved within 10 min He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness RUE dysfunction and expressive aphasia could not get the words out His wife took him to his local MD and on the way there his symptoms resolved His aphasia recurred at his physician s office and a CT scan of the brain revealed a left temporal mass He was transferred to UIHC PMH HTN for many years MEDS Vasotec and Dyazide SHX FHX ETOH abuse quit 92 30pk yr Cigarettes quit 92 EXAM BP158 92 HR91 RR16 MS Speech fluent without dysarthria CN no deficits noted Motor no weakness or abnormal tone noted Sensory no deficits noted Coord normal Station no drift Gait ND Reflexes 3 throughout Plantars down going bilaterally Gen exam unremarkable STUDIES WBC14 3K Na 132 Cl 94 CO2 22 Glucose 129 CT Brain without contrast Calcified 2 5 x 2 5cm mass arising from left sylvian fissure temporal lobe MRI Brain 8 31 92 right temporo parietal mass with mixed signal on T1 and T2 images It has a peripheral dark rim on T1 and T2 with surrounding edema This suggests a component of methemoglobin and hemosiderin within it Slight peripheral enhancement was identified There are two smaller foci of enhancement in the posterior parietal lobe on the right There is nonspecific white matter foci within the pons and right thalamus Impression right temporoparietal hemorrhage suggesting aneurysm or mass The two smaller foci may suggest metastasis The white matter changes probably reflect microvascular disease 3 Vessel cerebroangiogram 8 31 92 Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm COURSE The aneurysm was felt to be inoperable and he was discharged home on Dilantin ASA and Diltiazem Keywords consult history and phy mca aneurysm rue clumsiness white matter aneurysm mca dizziness aphasia matter clumsiness brain peripheral MEDICAL_TRANSCRIPTION,Description Problems with seizures hemiparesis has been to the hospital developed C diff and is in the nursing home currently Medical Specialty Consult History and Phy Sample Name Malignant Meningioma Consult Transcription REASON FOR VISIT This is a new patient evaluation for Mr A There is a malignant meningioma He is referred by Dr X HISTORY OF PRESENT ILLNESS He said he has had two surgeries in 07 06 followed by radiation and then again in 08 07 He then had a problem with seizures hemiparesis has been to the hospital developed C diff and is in the nursing home currently He is unable to stand at the moment He is unable to care for himself I reviewed the information that was sent down with him from the nursing home which includes his medical history MEDICATIONS Keppra 1500 twice a day and Decadron 6 mg four times a day His other medicines include oxycodone an aspirin a day Prilosec Dilantin 300 a day and Flagyl FINDINGS On examination he is lying on the stretcher He has oxygen on and has periods of spontaneous hyperventilation He is unable to lift his right arm or right leg He has an expressive dysphasia and confusion I reviewed the imaging studies from summer from the beginning of 10 07 end of 10 07 as well as the current MRI he had last week This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema This is a malignant meningioma by diagnosis ASSESSMENT PLAN In summary Mr A has significant disability and is not independent currently I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor Given that there are not good therapies and chemotherapy would be the option at the moment and he certainly is not in a condition where chemotherapy would be given I believe that surgery would not be in his best interest I discussed this both with him although it is not clear to me how much he understood as well as his family Keywords consult history and phy seizures hemiparesis tumor seizures hemiparesis malignant meningioma chemotherapy malignant meningioma aspirin MEDICAL_TRANSCRIPTION,Description Low back pain lumbar radiculopathy degenerative disc disease lumbar spinal stenosis history of anemia high cholesterol and hypothyroidism Medical Specialty Consult History and Phy Sample Name Lumbar Radiculopathy Consult Transcription FAMILY HISTORY Her father died from leukemia Her mother died from kidney and heart failure She has two brothers five sisters one with breast cancer two sons and a daughter She describes cancer hypertension nervous condition kidney disease high cholesterol and depression in her family SOCIAL HISTORY She is divorced She does not have support at home She denies tobacco alcohol and illicit drug use ALLERGIES Hypaque dye when she had x rays for her kidneys MEDICATIONS Prempro q d Levoxyl 75 mcg q d Lexapro 20 mg q d Fiorinal as needed currently she is taking it three times a day and aspirin as needed She also takes various supplements including multivitamin q d calcium with vitamin D b i d magnesium b i d Ester C b i d vitamin E b i d flax oil and fish oil b i d evening primrose 1000 mg b i d Quercetin 500 mg b i d Policosanol 20 mg two a day glucosamine chondroitin three a day coenzyme Q 10 30 mg two a day holy basil two a day sea vegetables two a day and very green vegetables PAST MEDICAL HISTORY Anemia high cholesterol and hypothyroidism PAST SURGICAL HISTORY In 1979 tubal ligation and three milk ducts removed In 1989 she had a breast biopsy and in 2007 a colonoscopy She is G4 P3 with no cesarean section REVIEW OF SYSTEMS HEENT For headaches and sore throat Musculoskeletal She is right handed with joint pain stiffness and decreased range of motion Cardiac For heart murmur GI Negative and noncontributory Respiratory Negative and noncontributory Urinary Negative and noncontributory Hem Onc Negative and noncontributory Vascular Negative and noncontributory Psychiatric Negative and noncontributory Genital Negative and noncontributory She denies any bowel or bladder dysfunction or loss of sensation in her genital area PHYSICAL EXAMINATION She is 5 feet 2 inches tall Current weight is 132 pounds weight one year ago was 126 pounds BP is 122 68 On physical exam patient is alert and oriented with normal mentation and appropriate speech in no acute distress General a well developed and well nourished female in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth good dentition Cranial nerves II III IV and VI vision is intact visual fields are full to confrontation EOMs full bilaterally and pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movement Cranial nerve VIII hearing intact Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cranial nerve XI strong and symmetrical shoulder shrugs against resistance Cardiac regular rate and rhythm Chest and lungs are clear bilaterally Skin is warm and dry normal turgor and texture No rashes or lesions are noted General musculoskeletal exam reveals no gross deformities fasciculations or atrophy Peripheral vascular no cyanosis clubbing or edema Examination of the low back reveals some mild paralumbar spasms She is nontender to palpation of her spinous processes SI joints and paralumbar musculature She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation Deep tendon reflexes are 2 bilateral knees and ankles No ankle clonus is elicited Babinski toes are downgoing Straight leg raising is negative bilaterally Strength on manual exam is 5 5 and equal bilateral lower extremity She is able to ambulate on her toes and her heels without any difficulty She is able to get up standing on one foot on to the toes She does have some difficulty getting up on to her heels when standing on one foot She has trouble with this on the left and right She complains of increased pain while doing this as well She also has positive Patrick FABER on the right with pain with internal and external rotation negative on the left Sensation is intact She has good accuracy to pinprick dull versus sharp FINDINGS The patient brings in lumbar spine MRI dated November 20 2007 which demonstrates degenerative disc disease throughout At L4 L5 there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged At L5 S1 in the right neuroforamina there appears to be soft tissue density just lateral and posterior to the nerve root which may cause some displacement but it is unclear This could represent a facet synovial cyst This is lateral to the facet She does not have x rays for review She has had hip and knee x rays taken but does not bring them in with her ASSESSMENT Low back pain lumbar radiculopathy degenerative disc disease lumbar spinal stenosis history of anemia high cholesterol and hypothyroidism PLAN We discussed treatment options with this patient including 1 Do nothing 2 Conservative therapies 3 Surgery She seems to have some issues with her right hip so I would like for her to fax us over the report of her hip and knee x rays We will also order some x rays of her lumbar spine as well as lower extremity EMG At this point the patient has not exhausted conservative measures and would like to start with epidural steroid injections so we will go ahead and send her out for that After she has gotten her second epidural injection she will return to the office for a followup visit to see how she is doing All questions and concerns were addressed If she should have any further questions concerns or complications she will contact our office immediately Otherwise we will see her as scheduled Case was reviewed and discussed with Dr L Keywords consult history and phy back pain hip pain low back pain x rays lumbar spinal stenosis degenerative disc disease spinal stenosis lumbar spine lumbar radiculopathy cranial nerves lumbar degenerative anemia MEDICAL_TRANSCRIPTION,Description Lumbar muscle strain and chronic back pain Patient has a history of chronic back pain dating back to an accident that he states he suffered two years ago Medical Specialty Consult History and Phy Sample Name Lower back pain Transcription HISTORY OF PRESENT ILLNESS Patient is a 50 year old white male complaining of continued lower back pain Patient has a history of chronic back pain dating back to an accident that he states he suffered two years ago He states he helped a friend unload a motorcycle from a vehicle two and a half days ago after which he felt it in his lower back The following day two days ago he states he rode to Massachusetts and Maine to pick up clients He feels that this aggravated his chronic back pain as well He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture He is being prescribed Ultram Celebrex gabapentin and amitriptyline by his PCP for his chronic back pain He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain The patient did self refer to another physician who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives particularly the medications that the patient feels that he needs Patient states he did not do this because he was feeling well at that time The patient did present to our emergency room last night at which time he saw Dr X He was given a prescription for 12 Vicodin as well as some to take home last night The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines He is on several medications the list of which is attached to the chart MEDICATIONS In addition to the aforementioned medications he is on Cymbalta pantoprazole and a multivitamin ALLERGIES HE IS ALLERGIC TO RELAFEN ITCHING SOCIAL HISTORY The patient is married and lives with his wife Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Pulse is elevated at 105 Temp and other vitals signs are all within normal limits GENERAL Patient is a middle aged white male who is sitting on the stretcher in no acute distress BACK Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine more so on the right than on the left There is a well healed upper lumbar incision from his previous L1 L2 fusion There is no erythema ecchymosis or soft tissue swelling Mobility is generally very good without obvious signs of discomfort HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes MUSCULOSKELETAL With the patient supine there is some discomfort in the lower back with bent knee flexion of both hips as well as with straight leg abduction of the left leg There is some mild discomfort on internal and external rotation of the hips as well DTRs are 1 at the knees and trace at the ankles I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication which the patient feels that he needs and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a good day I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe then on a bad day he will have nowhere else to turn I explained to him that some emergency physicians do chose to use opiates for a short term as Dr X did last night It is unclear if the patient is looking for a different opiate medication but I do not think it is wise to give him more particularly as he has not even filled the prescription that was given to him last night I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back Celebrex tramadol amitriptyline gabapentin and the Vicodin that he was given last night I did suggest that we could try a different anti inflammatory if he felt that the Celebrex is not helping The patient is agreeable to this ASSESSMENT 1 Lumbar muscle strain 2 Chronic back pain PLAN At this point in time I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible Rx for Voltaren 75 mg tabs dispensed 20 sig one p o q 12h for pain instead of Celebrex He may continue with his other medications as directed but not the methadone or Darvocet I did urge him to reschedule his pain clinic appointment as he was urged to do originally If unimproved this week he should follow up with Dr Y Keywords consult history and phy back pain lumbar muscle strain chronic back pain illness lower medications MEDICAL_TRANSCRIPTION,Description New patient consultation Low back pain degenerative disc disease spinal stenosis diabetes and history of prostate cancer status post radiation Medical Specialty Consult History and Phy Sample Name Low Back Pain Consult Transcription FAMILY HISTORY His parents are deceased He has two brothers ages 68 and 77 years old who are healthy He has siblings a brother and a sister who were twins who died at birth He has two sons 54 and 57 years old who are healthy He describes history of diabetes and heart attack in his family SOCIAL HISTORY He is married and has support at home He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week ALLERGIES Garamycin MEDICATIONS Insulin 20 to 25 units twice a day Lorazepam 0 05 mg he has a history of using this medication but most recently stopped taking it Glipizide 5 mg with each meal Advair 250 as needed aspirin q h s cod liver oil b i d Centrum AZ q d PAST MEDICAL HISTORY The patient has been diabetic for 35 years has been insulin dependent for the last 20 years He also has a history of prostate cancer which was treated by radiation He says his PSA is at 0 01 PAST SURGICAL HISTORY In 1985 he had removal of a testicle due to enlarged testicle he is not quite sure of the cause but he states it was not cancer REVIEW OF SYSTEMS Musculoskeletal He is right handed Respiratory For shortness of breath Urinary For frequent urination GI He denies any bowel or bladder dysfunction Genital He denies any loss of sensation or erectile problems HEENT Negative and noncontributory Hem Onc Negative and noncontributory Cardiac Negative and noncontributory Vascular Negative and noncontributory Psychiatric Negative and noncontributory PHYSICAL EXAMINATION He is 5 feet 10 inches tall Current weight is 204 pounds weight one year ago was 212 BP is 130 66 Pulse is 78 On physical exam the patient is alert and oriented with normal mentation and appropriate speech in no acute distress HEENT exam head is atraumatic and normocephalic Eyes sclerae are anicteric Teeth poor dentition Cranial nerves II III IV and VI vision intact visual fields full to confrontation EOMs full bilaterally and pupils are equal round and reactive to light Cranial nerves V and VII normal facial sensation and symmetrical facial movements Cranial nerve VIII hearing is intact Cranial nerves IX X and XII tongue protrudes midline and palate elevates symmetrically Cardiac regular rate a holosystolic murmur is also noted which is about grade 1 to 2 Chest and lungs are clear bilaterally Skin is warm and dry normal turgor and texture No rashes or lesions are noted Peripheral vascular no cyanosis clubbing or edema is noted General musculoskeletal exam reveals no gross deformities fasciculations or atrophy Station and gait are appropriate He ambulates well without any difficulties or assistance No antalgic or spastic gait is noted Examination of the low back reveals no paralumbar spasms He is nontender to palpation over his spinous process SI joints or paralumbar musculature Deep tendon reflexes are 2 bilaterally at the knees and 1 at the ankles No ankle clonus is elicited Babinski toes are downgoing Sensation is intact He does have some decreased sensation to pinprick dull versus sharp over the right lower extremity compared to that of the left Strength is 5 5 and equal bilateral lower extremities He is able to ambulate on his toes and his heels without any weakness noted He has negative straight leg raising bilaterally FINDINGS The patient brings in lumbar spine MRI for 11 15 2007 which demonstrates degenerative disc disease throughout At L4 L5 and L5 S1 he has severe disc space narrowing At L3 L4 he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge which caused moderate neuroforaminal narrowing At L4 L5 degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis At L5 S1 there is an annular disc bulge more to the right causing right sided neuroforaminal stenosis which is quite severe compared to that on the left ASSESSMENT Low back pain degenerative disc disease spinal stenosis diabetes and history of prostate cancer status post radiation PLAN We discussed treatment options with this patient including 1 Do nothing 2 Conservative therapies 3 Surgery The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam I did phone the patient s primary care doctor Dr O Unfortunately Dr O is out of the country and I did speak with Dr K who is covering for Dr O I informed Dr K that the patient had a new onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before so I obtained an EKG A copy was provided to the patient and the patient was referred back to his primary care physician for workup He was also released from our care at this time to a p r n basis but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications which he will receive from his primary doctor All questions and concerns were addressed If he should have any further questions concerns or complications he will contact our office immediately Otherwise we will see him p r n Warning signs and symptoms were gone over with him Case was reviewed and discussed with Dr L Keywords consult history and phy back pain ligamentum flavum hypertrophy annular disc bulge degenerative disc disease spinal stenosis cranial nerves degenerative MEDICAL_TRANSCRIPTION,Description A 21 month old male presented for delayed motor development jaw quivering and lazy eye Medical Specialty Consult History and Phy Sample Name Lobar Holoprosencephaly Transcription CC Delayed motor development HX This 21 month old male presented for delayed motor development jaw quivering and lazy eye He was an 8 pound 10 ounce product of a full term uncomplicated pregnancy labor spontaneous vaginal delivery to a G3P3 married white female mother There had been no known toxic intrauterine exposures He had no serious illnesses or hospitalizations since birth He sat independently at 7 months stood at 11 months crawled at 16 months but did not cruise until 18 months He currently cannot walk and easily falls His gait is reportedly marked by left intoeing His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself throw and transfer objects easily He knows greater than 20 words and speaks two word phrases No seizures or unusual behavior were reported except for quivering movement of his jaw This has occurred since birth In addition the parents have noted transient left exotropia PMH As above FHX Many family members with lazy eye No other neurologic diseases declared 9 and 5 year old sisters who are healthy SHX lives with parents and sisters EXAM BP83 67 HR122 36 4C Head circumference 48 0cm Weight 12 68kg 70 Height 86 0cm 70 MS fairly cooperative CN Minimal transient esotropia OS Tremulous quivering of jaw increased with crying No obvious papilledema though difficult to evaluate due to patient movement Motor sat independently with normal posture and no truncal ataxia symmetric and normal strength and muscle bulk throughout Sensory withdrew to vibration Coordination unremarkable in BUE Station no truncal ataxia Gait On attempting to walk his right foot rotated laterally at almost 70degrees Both lower extremities could rotate outward to 90degrees There was marked passive eversion at the ankles as well Reflexes 2 2 throughout Musculoskeletal pes planovalgus bilaterally COURSE CK normal The parents decided to forego an MRI in 8 90 The patient returned 12 11 92 at age 4 years He was ambulatory and able to run awkwardly His general health had been good but he showed signs developmental delay Formal evaluation had tested his IQ at 87 at age 3 5 years He was weakest on tasks requiring visual motor integration and fine motor and visual discrimination skills He was 6 months delayed in cognitive development at that time On exam age 4 years he displayed mild right ankle laxity on eversion and inversion but normal gait The rest of the neurological exam was normal Head circumference was 49 5cm 50 and height and weight were in the 90th percentile Fragile X analysis and karyotyping were unremarkable Keywords consult history and phy delayed motor development jaw quivering head circumference truncal ataxia delayed motor motor development lazy eye jaw quivering delayed intrauterine MEDICAL_TRANSCRIPTION,Description Patient with a 1 year history of progressive anterograde amnesia Medical Specialty Consult History and Phy Sample Name Limbic Encephalitis Transcription CC Rapidly progressive amnesia HX This 63 y o RHM presented with a 1 year history of progressive anterograde amnesia On presentation he could not remember anything from one minute to the next He also had some retrograde memory loss in that he could not remember the names of his grandchildren but had generally preserved intellect language personality and calculating ability He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally There was no mass affect The areas mildly enhanced with gadolinium PMH 1 CAD MI x 2 1978 and 1979 2 PVD s p aortic endarterectomy 3 1991 3 HTN 4 Bilateral inguinal hernia repair FHX SHX Mother died of a stroke at age 58 Father had CAD and HTN The patient quit smoking in 1991 but was a heavy smoker 2 3ppd for many years He had been a feed salesman all of his adult life ROS Unremarkable No history of cancer EXAM BP 136 75 HR 73 RR12 T36 6 MS Alert but disoriented to person place time He could not remember his birthdate and continually asked the interviewer what year it was He could not remember when he married retired or his grandchildren s names He scored 18 30 on the Follutein s MMSE with severe deficits in orientation and memory He had moderate difficulty naming He repeated normally and had no constructional apraxia Judgement remained good CN unremarkable Motor Full strength throughout with normal muscle tone and bulk Sensory Intact to LT PP PROP Coordination unremarkable Station No pronator drift truncal ataxia or Romberg sign Gait unremarkable Reflexes 3 throughout with downgoing plantar responses bilaterally Gen Exam unremarkable STUDIES MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally with mild enhancement on the gadolinium scans MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor EEG was normal awake and asleep Antineuronal antibody screening was unremarkable CSF studies were unremarkable and included varicella zoster herpes zoster HIV and HTLV testing and cytology The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes but no organism or etiology was concluded TFT B12 VDRL ESR CRP ANA SPEP and Folate studies were unremarkable Neuropsychologic testing revealed severe anterograde memory verbal and visual loss and less severe retrograde memory loss Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally IMPRESSION Limbic encephalitis secondary to cancer of unknown origin He was last seen 7 26 96 MMSE 20 30 and category fluency 20 Disinhibited affect Mild right grasp reflex The clinical course was benign and non progressive and unusual for such a diagnosis though not unheard of Keywords consult history and phy mri brain progressive anterograde amnesia retrograde memory loss limbic encephalitis anterograde amnesia memory loss limbic encephalitis amnesia anterograde memory MEDICAL_TRANSCRIPTION,Description The patient comes in today because of feeling lightheaded and difficulty keeping his balance Medical Specialty Consult History and Phy Sample Name Lightheadedness Transcription HISTORY OF PRESENT ILLNESS The patient comes in today because of feeling lightheaded and difficulty keeping his balance He denies this as a spinning sensation that he had had in the past with vertigo He just describes as feeling very lightheaded It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position It tends to ease when he sits down again but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over Lorazepam did not help this sensation His blood pressure has been up lately and his dose of metoprolol was increased They feel these symptoms have gotten worse since metoprolol was increased PAST MEDICAL HISTORY Detailed on our H P form Positive for elevated cholesterol diabetes glaucoma cataracts hypertension heart disease vertigo stroke in May of 2005 congestive heart failure CABG and cataract removed right eye CURRENT MEDICATIONS Detailed on the H P form PHYSICAL EXAMINATION His blood pressure sitting down was 180 80 with a pulse rate of 56 Standing up blood pressure was 160 80 with a pulse rate of 56 His general exam and neurological exam were detailed on our H P form Pertinent positives on his neurological exam were decreased sensation in his left face and left arm and leg IMPRESSION AND PLAN This lightheaded he exquisitely denies vertigo the vertigo that he has had in the past He states this is more of a lightheaded type feeling He did have a mild blood pressure drop here in the office We are also concerned that bradycardia might be contributing to his feeling of lightheadedness We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling We will schedule him for the Holter monitor and refer him back to his cardiologist Keywords consult history and phy lightheaded feeling feeling lightheaded pulse rate neurological exam holter monitor blood pressure balance vertigo lightheadedness MEDICAL_TRANSCRIPTION,Description Urine leaked around the ostomy site for his right sided nephrostomy tube The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure Medical Specialty Consult History and Phy Sample Name Leaking Nephrostomy Tube Transcription CHIEF COMPLAINT Leaking nephrostomy tube HISTORY OF PRESENT ILLNESS This 61 year old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube The leaking began this a m The patient denies any pain does not have fever and has no other problems or complaints The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure The patient states he feels like his usual self and has no other problems or concerns The patient denies any fever or chills No nausea or vomiting No flank pain no abdominal pain no chest pain no shortness of breath no swelling to the legs REVIEW OF SYSTEMS Review of systems otherwise negative and noncontributory PAST MEDICAL HISTORY Metastatic prostate cancer anemia hypertension MEDICATIONS Medication reconciliation sheet has been reviewed on the nurses note ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a nonsmoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 97 7 oral blood pressure 150 85 pulse is 91 respirations 16 oxygen saturation 97 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed appears to be healthy calm comfortable no acute distress looks well HEENT Eyes are normal with clear sclerae and cornea NECK Supple full range of motion CARDIOVASCULAR Heart has regular rate and rhythm without murmur rub or gallop Peripheral pulses are 2 No dependent edema RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender nondistended No rebound or guarding Normal benign abdominal exam MUSCULOSKELETAL The patient has nontender back and flank No abnormalities noted to the back other than the bilateral nephrostomy tubes The nephrostomy tube left has no abnormalities no sign of infection No leaking of urine nontender nephrostomy tube on the right has a damp dressing which has a small amount of urine soaked into it There is no obvious active leak from the ostomy site No sign of infection No erythema swelling or tenderness The collection bag is full of clear urine The patient has no abnormalities on his legs SKIN No rashes or lesions No sign of infection NEUROLOGIC Motor and sensory are intact to the extremities The patient has normal ambulation normal speech PSYCHIATRIC Alert and oriented x4 Normal mood and affect HEMATOLOGIC AND LYMPHATIC No bleeding or bruising EMERGENCY DEPARTMENT COURSE Reviewed the patient s admission record from one month ago when he was admitted for the placement of the nephrostomy tubes both Dr X and Dr Y have been consulted and both had recommended nephrostomy tubes there was not the name mentioned as to who placed the nephrostomy tubes There was no consultation dictated for this and no name was mentioned in the discharge summary paged Dr X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes Dr A responded to the page and recommended __________ off a BMP and discussing it with Dr B the radiologist as he recalled that this was the physician who placed the nephrostomy tubes paged Dr X and received a call back from Dr X Dr X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a m tomorrow This was discussed with the patient and instructions to return to the hospital at 10 a m to have this tube changed out by Dr X was explained and understood DIAGNOSES 1 WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE 2 PROSTATE CANCER METASTATIC 3 URETERAL OBSTRUCTION The patient on discharge is stable and dispositioned to home PLAN We will have the patient return to the hospital tomorrow at 10 a m for the replacement of his right nephrostomy tube by Dr X The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns Keywords consult history and phy nephrostomy site ureteral obstruction leaking nephrostomy tube acute renal failure bilateral nephrostomy ureteral obstructions nephrostomy tube tube nephrostomy ureteral prostate leaking urine tubes MEDICAL_TRANSCRIPTION,Description Consult for laparoscopic gastric bypass Medical Specialty Consult History and Phy Sample Name Laparoscopic Gastric Bypass Consult 1 Transcription HISTORY OF PRESENT ILLNESS I have seen ABC today He is a very pleasant gentleman who is 42 years old 344 pounds He is 5 9 He has a BMI of 51 He has been overweight for ten years since the age of 33 at his highest he was 358 pounds at his lowest 260 He is pursuing surgical attempts of weight loss to feel good get healthy and begin to exercise again He wants to be able to exercise and play volleyball Physically he is sluggish He gets tired quickly He does not go out often When he loses weight he always regains it and he gains back more than he lost His biggest weight loss is 25 pounds and it was three months before he gained it back He did six months of not drinking alcohol and not taking in many calories He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin s Diet for one month two years ago PAST MEDICAL HISTORY He has difficulty climbing stairs difficulty with airline seats tying shoes used to public seating difficulty walking high cholesterol and high blood pressure He has asthma and difficulty walking two blocks or going eight to ten steps He has sleep apnea and snoring He is a diabetic on medication He has joint pain knee pain back pain foot and ankle pain leg and foot swelling He has hemorrhoids PAST SURGICAL HISTORY Includes orthopedic or knee surgery SOCIAL HISTORY He is currently single He drinks alcohol ten to twelve drinks a week but does not drink five days a week and then will binge drink He smokes one and a half pack a day for 15 years but he has recently stopped smoking for the past two weeks FAMILY HISTORY Obesity heart disease and diabetes Family history is negative for hypertension and stroke CURRENT MEDICATIONS Include Diovan Crestor and Tricor MISCELLANEOUS EATING HISTORY He says a couple of friends of his have had heart attacks and have had died He used to drink everyday but stopped two years ago He now only drinks on weekends He is on his second week of Chantix which is a medication to come off smoking completely Eating he eats bad food He is single He eats things like bacon eggs and cheese cheeseburgers fast food eats four times a day seven in the morning at noon 9 p m and 2 a m He currently weighs 344 pounds and 5 9 His ideal body weight is 160 pounds He is 184 pounds overweight If he lost 70 of his excess body weight that would be 129 pounds and that would get him down to 215 REVIEW OF SYSTEMS Negative for head neck heart lungs GI GU orthopedic or skin He also is positive for gout He denies chest pain heart attack coronary artery disease congestive heart failure arrhythmia atrial fibrillation pacemaker pulmonary embolism or CVA He denies venous insufficiency or thrombophlebitis Denies shortness of breath COPD or emphysema Denies thyroid problems hip pain osteoarthritis rheumatoid arthritis GERD hiatal hernia peptic ulcer disease gallstones infected gallbladder pancreatitis fatty liver hepatitis rectal bleeding polyps incontinence of stool urinary stress incontinence or cancer He denies cellulitis pseudotumor cerebri meningitis or encephalitis PHYSICAL EXAMINATION He is alert and oriented x 3 Cranial nerves II XII are intact Neck is soft and supple Lungs He has positive wheezing bilaterally Heart is regular rhythm and rate His abdomen is soft Extremities He has 1 pitting edema IMPRESSION PLAN I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding infection deep venous thrombosis pulmonary embolism leakage from the gastrojejuno anastomosis jejunojejuno anastomosis and possible bowel obstruction among other potential complications He understands He wants to proceed with workup and evaluation for laparoscopic Roux en Y gastric bypass He will need to get a letter of approval from Dr XYZ He will need to see a nutritionist and mental health worker He will need an upper endoscopy by either Dr XYZ He will need to go to Dr XYZ as he previously had a sleep study We will need another sleep study He will need H pylori testing thyroid function tests LFTs glycosylated hemoglobin and fasting blood sugar After this is performed we will submit him for insurance approval Keywords consult history and phy laparoscopic gastric bypass heart attacks body weight pulmonary embolism potential complications sleep study weight loss gastric bypass anastomosis loss sleep laparoscopic gastric bypass heart pounds weight MEDICAL_TRANSCRIPTION,Description Consult for laparoscopic gastric bypass Medical Specialty Consult History and Phy Sample Name Laparoscopic Gastric Bypass Consult 2 Transcription PAST MEDICAL HISTORY He has difficulty climbing stairs difficulty with airline seats tying shoes used to public seating and lifting objects off the floor He exercises three times a week at home and does cardio He has difficulty walking two blocks or five flights of stairs Difficulty with snoring He has muscle and joint pains including knee pain back pain foot and ankle pain and swelling He has gastroesophageal reflux disease PAST SURGICAL HISTORY Includes reconstructive surgery on his right hand 13 years ago SOCIAL HISTORY He is currently single He has about ten drinks a year He had smoked significantly up until several months ago He now smokes less than three cigarettes a day FAMILY HISTORY Heart disease in both grandfathers grandmother with stroke and a grandmother with diabetes Denies obesity and hypertension in other family members CURRENT MEDICATIONS None ALLERGIES He is allergic to Penicillin MISCELLANEOUS EATING HISTORY He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester New York and he feels that we are the appropriate program He had a poor experience with the Greenwich program Eating history he is not an emotional eater Does not like sweets He likes big portions and carbohydrates He likes chicken and not steak He currently weighs 312 pounds Ideal body weight would be 170 pounds He is 142 pounds overweight If he lost 60 of his excess body weight that would be 84 pounds and he should weigh about 228 REVIEW OF SYSTEMS Negative for head neck heart lungs GI GU orthopedic and skin Specifically denies chest pain heart attack coronary artery disease congestive heart failure arrhythmia atrial fibrillation pacemaker high cholesterol pulmonary embolism high blood pressure CVA venous insufficiency thrombophlebitis asthma shortness of breath COPD emphysema sleep apnea diabetes leg and foot swelling osteoarthritis rheumatoid arthritis hiatal hernia peptic ulcer disease gallstones infected gallbladder pancreatitis fatty liver hepatitis hemorrhoids rectal bleeding polyps incontinence of stool urinary stress incontinence or cancer Denies cellulitis pseudotumor cerebri meningitis or encephalitis PHYSICAL EXAMINATION He is alert and oriented x 3 Cranial nerves II XII are intact Afebrile Vital Signs are stable Keywords consult history and phy laparoscopic gastric bypass weight loss programs gastric bypass atkin s diet weight watcher s body weight laparoscopic gastric weight loss pounds months weight laparoscopic band loss diets overweight lost MEDICAL_TRANSCRIPTION,Description The patient with an L5 compression fracture is to come to the hospital for bilateral L5 kyphoplasty The patient has a history of back and buttock pain for some time Medical Specialty Consult History and Phy Sample Name Kyphoplasty Consult Transcription HISTORY The patient is to come to the hospital for bilateral L5 kyphoplasty The patient is an 86 year old female with an L5 compression fracture The patient has a history of back and buttock pain for some time She was found to have an L5 compression fracture She was treated conservatively over several months but did not improve Unfortunately she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture but without complete healing The patient has had continued pain and at this time is felt to be a candidate for kyphoplasty She denies bowel or bladder incontinence She does complain of back pain She has been wearing a back brace and corset She does not have weakness PAST MEDICAL HISTORY The patient has a history of multiple medical problems including hypothyroidism hypertension and gallbladder difficulties PAST SURGICAL HISTORY She has had multiple previous surgeries including bowel surgery hysterectomy rectocele repair and appendectomy She also has a diagnosis of polymyalgia rheumatica CURRENT MEDICATIONS She is on multiple medications currently ALLERGIES SHE IS ALLERGIC TO CODEINE PENICILLIN AND CEPHALOSPORINS FAMILY HISTORY The patient s parents are deceased PERSONAL AND SOCIAL HISTORY The patient lives locally She is a widow She does not smoke cigarettes or use illicit drugs PHYSICAL EXAMINATION GENERAL The patient is an elderly frail white female in no distress LUNGS Clear HEART Sounds are regular ABDOMEN She has a protuberant abdomen She has tenderness to palpation in the lumbosacral area Sciatic notch tenderness is not present Straight leg raise testing evokes back pain NEUROLOGICAL She is awake alert and oriented Speech is intact Comprehension is normal Strength is intact in the upper extremities She has giveaway strength in the lower extremities Reflexes are diminished at the knees and ankles Gait is otherwise normal DATA REVIEWED Plain studies of the lumbar spine show an L5 compression fracture A CT scan has shown some healing of this fracture She has degenerative change at the L4 L5 level with a very slight spondylolisthesis at this level ASSESSMENT AND PLAN The patient is a woman with a history of longstanding back buttock and leg pain She has a documented L5 compression fracture which has not healed despite appropriate conservative treatments At this point I believe the patient is a good candidate for L5 kyphoplasty I have discussed the procedure with her and I have reviewed with her and her family risks benefits and alternatives to surgery Risks of surgery including but not limited to bleeding infection stroke paralysis death failure to improve spinal fluid leak need for further surgery cement extravasation failure to improve her pain and other potential complications have all been discussed The patient understands the issues involved She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01 18 08 Keywords consult history and phy leg pain lumbar spine l5 compression fracture compression fracture kyphoplasty buttock surgery fracture MEDICAL_TRANSCRIPTION,Description A 13 year old new patientfor evaluation of thoracic kyphosis Family history of kyphosis in a maternal aunt and grandfather She was noted by her parents to have round back posture Medical Specialty Consult History and Phy Sample Name Kyphosis Transcription REASON FOR VISIT Kyphosis HISTORY OF PRESENT ILLNESS The patient is a 13 year old new patient is here for evaluation of thoracic kyphosis The patient has a family history in a maternal aunt and grandfather of kyphosis She was noted by her parents to have round back posture They have previously seen another orthopedist who recommended observation at this time She is here for a second opinion in regards to kyphosis The patient denies any pain in her back or any numbness tingling or weakness in her upper or lower extremities No problems with her bowels or bladder PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Bilateral pinning of her ears SOCIAL HISTORY She is currently an eighth grader at Middle School and is interested in basketball She lives with both of her parents and has a 9 year old brother She had menarche beginning in September FAMILY HISTORY Of kyphosis in great grandmother and second cousin REVIEW OF SYSTEMS She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness MEDICATIONS She is currently on Zyrtec Flonase and Ceftin for an ear infection ALLERGIES No known drug allergies FINDINGS On physical exam she is alert oriented and in no acute distress standing 63 inches tall In regards to her back her skin is intact with no rashes lesions and or no dimpling or hair spots No cafe au lait spots She is not tender to palpation from her occiput to her sacrum There is no evidence of paraspinal muscle spasm On forward bending there is a mild kyphosis She is not able to touch her toes indicating her hamstring tightness She has a full 5 out of 5 in all muscle groups Her lower extremities including iliopsoas quadriceps gastroc soleus tibialis anterior and extensor hallucis longus Her sensation intact to light touch in L1 through L2 dermatomal distributions She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes X rays today included PA and lateral sclerosis series She has approximately 46 degree kyphosis ASSESSMENT Kyphosis PLANS The patient s kyphosis is quite mild While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home At this time three options were discussed with the parents including observation physical therapy and bracing At this juncture given that she has continued to grow they are Risser 0 She may benefit from continued observation with physical therapy bracing would be a more aggressive option certainly that thing would be lost with following at this time As such she was given a prescription for physical therapy for extension based strengthening exercises flexibility range of motion exercises postural training with no forward bending We will see her back in 3 months time for repeat radiographs at that time including PA and lateral standing of scoliosis series Should she show evidence of continued progression of her kyphotic deformity discussions of bracing would be held at time We will see her back in 3 months time for repeat evaluation Keywords consult history and phy thoracic kyphosis round back posture physical therapy kyphosis patientfor orthopedist MEDICAL_TRANSCRIPTION,Description This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms Medical Specialty Consult History and Phy Sample Name Itchy Rash ER Visit Transcription CHIEF COMPLAINT Itchy rash HISTORY OF PRESENT ILLNESS This 34 year old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms No facial swelling No tongue or lip swelling No shortness of breath wheezing or other associated symptoms He cannot think of anything that could have triggered this off There have been no changes in his foods medications or other exposures as far as he knows He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day PAST MEDICAL HISTORY Negative for chronic medical problems No local physician Has had previous back surgery and appendectomy otherwise generally healthy REVIEW OF SYSTEMS As mentioned denies any oropharyngeal swelling No lip or tongue swelling No wheezing or shortness of breath No headache No nausea Notes itchy rash especially on his torso and upper arms SOCIAL HISTORY The patient is accompanied with his wife FAMILY HISTORY Negative MEDICATIONS None ALLERGIES TORADOL MORPHINE PENICILLIN AND AMPICILLIN PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile He is slightly tachycardic 105 but stable blood pressure and respiratory rate GENERAL The patient is in no distress Sitting quietly on the gurney HEENT Unremarkable His oral mucosa is moist and well hydrated Lips and tongue look normal Posterior pharynx is clear NECK Supple His trachea is midline There is no stridor LUNGS Very clear with good breath sounds in all fields There is no wheezing Good air movement in all lung fields CARDIAC Without murmur Slight tachycardia ABDOMEN Soft nontender SKIN Notable for a confluence erythematous blanching rash on the torso as well as more of a blotchy papular macular rash on the upper arms He noted some on his buttocks as well Remaining of the exam is unremarkable ED COURSE The patient was treated with epinephrine 1 1000 0 3 mL subcutaneously along with 50 mg of Benadryl intramuscularly After about 15 20 minutes he states that itching started to feel better The rash has started to fade a little bit and feeling a lot more comfortable IMPRESSION ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS ASSESSMENT AND PLAN The patient has what looks to be some type of allergic reaction although the underlying cause is difficult to assess He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off In the meantime I think he can be managed with some antihistamine over the counter He is responding already to Benadryl and the epinephrine that we gave him here He is told that if he develops any respiratory complaints shortness of breath wheezing or tongue or lip swelling he will return immediately for evaluation He is discharged in stable condition Keywords consult history and phy urticaria pruritus lip swelling allergic reaction itchy rash torso swelling itchy rash MEDICAL_TRANSCRIPTION,Description Right knee injury suggestive of a recurrent anterior cruciate ligament tear possible internal derangement While playing tennis she had a non contact injury in which she injured the right knee She had immediate pain and swelling Medical Specialty Consult History and Phy Sample Name Knee Injury Transcription HISTORY OF PRESENT ILLNESS The patient is an 18 year old girl brought in by her father today for evaluation of a right knee injury She states that approximately 3 days ago while playing tennis she had a non contact injury in which she injured the right knee She had immediate pain and swelling At this time she complains of pain and instability in the knee The patient s past medical history is significant for having had an ACL injury to the knee in 2008 She underwent anterior cruciate ligament reconstruction by Dr X at that time subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently she sought attention from Dr Y who performed a revision ACL reconstruction at the end of 2008 The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury PAST MEDICAL HISTORY She claims no chronic illnesses PAST SURGICAL HISTORY She had an anterior cruciate ligament reconstruction in 03 2008 and subsequently had a revision ACL reconstruction in 12 2008 She has also had arm surgery when she was 6 years old MEDICATIONS She takes no medications on a regular basis ALLERGIES She is allergic to Keflex and has skin sensitivity to Steri Strips SOCIAL HISTORY The patient is single She is a full time student at University Uses no tobacco alcohol or illicit drugs She exercises weekly mainly tennis and swelling REVIEW OF SYSTEMS Significant for recent weight gain occasional skin rashes The remainder of her systems negative PHYSICAL EXAMINATION GENERAL The patient is 4 foot 10 inches tall weighs 110 pounds EXTREMITIES She ambulates with some difficulty with a marked limp on the right side Inspection of the knee reveals a significant effusion in the knee She has difficulty with passive range of motion of the knee secondary to pain She does have tenderness to palpation at the medial joint line and has a positive Lachman s exam NEUROVASCULAR She is neurovascularly intact IMPRESSION Right knee injury suggestive of a recurrent anterior cruciate ligament tear possible internal derangement PLAN The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft In the meantime she will continue to use ice as needed Moderate her activities and use crutches She will follow up as soon as the MRI is performed Keywords consult history and phy acl graft acl reconstruction knee anterior cruciate ligament internal derangement contact injury knee injury injury cruciate acl anterior MEDICAL_TRANSCRIPTION,Description Patient started out having toothache now radiating into his jaw and towards his left ear Ellis type II dental fracture Medical Specialty Consult History and Phy Sample Name Jaw Pain ER Visit Transcription CHIEF COMPLAINT Jaw pain HISTORY OF PRESENT ILLNESS This is a 58 year old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments but has not seen a dentist since this new toothache began The patient denies any facial swelling No headache No swelling to the throat No sore throat No difficulty swallowing liquids or solids No neck pain No lymph node swelling The patient denies any fever or chills Denies any other problems or complaints REVIEW OF SYSTEMS CONSTITUTIONAL No fever or chills No fatigue or weakness HEENT No headache No neck pain No eye pain or vision change No rhinorrhea No sinus congestion pressure or pain No sore throat No throat swelling The patient does have the toothache on the left lower side that radiates towards his left ear as previously described The patient does not have ear pain or hearing change No pressure in the ear CARDIOVASCULAR No chest pain RESPIRATIONS No shortness of breath GASTROINTESTINAL No nausea or vomiting No abdominal pain MUSCULOSKELETAL No back pain SKIN No rashes or lesions NEUROLOGIC No vision or hearing change No speech change HEMATOLOGIC LYMPHATIC No lymph node swelling PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None CURRENT MEDICATIONS None ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient smokes marijuana The patient does not smoke cigarettes PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 2 oral blood pressure is 168 84 pulse is 87 respirations 16 and oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed The patient appears to be healthy The patient is calm comfortable in no acute distress looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctivae bilaterally Nose normal without rhinorrhea or audible congestion There is no tenderness over the sinuses Ears are normal without any sign of infection No erythema or swelling of the canals Tympanic membranes are intact and normal without any erythema bulging air fluid levels or bubbles behind it MOUTH The patient has a dental fracture at tooth 18 The patient states that the fracture is a couple of months old The patient does not have any obvious dental caries The gums are normal without any erythema swelling or evidence of infection There is no fluctuance or suggestion of abscess There is slight tenderness of the tooth 18 The oropharynx is normal without any sign of infection There is no erythema exudate lesion or swelling Mucous membranes are moist Floor of the mouth is normal without any tenderness or swelling No suggestion of abscess There is no pre or post auricular lymphadenopathy either NECK Supple Nontender Full range of motion No meningismus No cervical lymphadenopathy No JVD No carotid artery or vertebral artery bruits CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop RESPIRATIONS Clear to auscultation bilaterally No shortness of breath GASTROINTESTINAL Abdomen is normal and nontender MUSCULOSKELETAL No abnormalities are noted to the back arms or legs The patient has normal use of the extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect No evidence of clinical intoxification HEMATOLOGIC LYMPHATIC No lymphadenitis is palpated DIAGNOSES 1 ACUTE LEFT JAW PAIN 2 18 DENTAL FRACTURE WHICH IS AN ELLIS TYPE II FRACTURE 3 ELEVATED BLOOD PRESSURE CONDITION UPON DISPOSITION Stable DISPOSITION Home PLAN We will have the patient follow up with his dentist Dr X in three to five days for reevaluation The patient was encouraged to take Motrin 400 mg q 6h as needed for pain The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain He was given precautions for drowsiness and driving with the use of this medication The patient was also given a prescription for pen V The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition develop any other problems or symptoms of concern Keywords consult history and phy jaw pain dental appointment ellis type ii fracture ellis type dental fracture toothache tenderness pressure erythema MEDICAL_TRANSCRIPTION,Description Pneumatosis coli in the cecum Possible ischemic cecum with possible metastatic disease bilateral hydronephrosis on atrial fibrillation aspiration pneumonia chronic alcohol abuse acute renal failure COPD anemia with gastric ulcer Medical Specialty Consult History and Phy Sample Name Ischemic Cecum Consult Transcription REASON FOR CONSULTATION Pneumatosis coli in the cecum HISTORY OF PRESENT ILLNESS The patient is an 87 year old gentleman who was admitted on 10 27 07 with weakness and tiredness with aspiration pneumonia The patient is very difficult to obtain information from however he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort In addition this hospitalization he has undergone an upper endoscopy which found a small ulcer after dropping his hematocrit and becoming anemic He had a CT scan on Friday 11 02 07 which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions which could be metastatic disease versus cysts In discussions with the patient he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain PAST MEDICAL HISTORY Obtained from the medical chart Chronic obstructive pulmonary disease history of pneumonia and aspiration pneumonia osteoporosis alcoholism microcytic anemia MEDICATIONS Per his current medical chart ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient had a long history of smoking but quit many years ago He does have chronic alcohol use PHYSICAL EXAMINATION GENERAL A very thin white male who is dyspneic and having difficulty breathing at the moment VITAL SIGNS Afebrile Heart rate in the 100s to 120s at times with atrial fibrillation Respiratory rate is 17 20 Blood pressure 130s 150s 60s 70s NECK Soft and supple full range of motion HEART Regular ABDOMEN Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information He does appear to have tenderness but does not have rebound and does not have peritoneal signs DIAGNOSTICS A CT scan done on 11 02 07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel ASSESSMENT Possible ischemic cecum with possible metastatic disease bilateral hydronephrosis on atrial fibrillation aspiration pneumonia chronic alcohol abuse acute renal failure COPD anemia with gastric ulcer PLAN The patient appears to have pneumatosis from a CT scan 2 days ago Nothing was done about it at that time as the patient appeared to not be symptomatic but he continues to have nausea and vomiting with abdominal pain but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time The patient has frequent desaturations secondary to his aspiration pneumonia and any surgical procedure or any surgical intervention would certainly require intubation which would then necessitate long term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state So we will look at the CT scan and make decisions based on the findings as far as that is concerned Keywords consult history and phy ischemic cecum metastatic disease bilateral hydronephrosis chronic alcohol abuse acute renal failure copd anemia gastric ulcer pneumatosis coli cecum aspiration pneumonia aspiration ischemic atrial metastatic hydronephrosis fibrillation pneumatosis pneumonia MEDICAL_TRANSCRIPTION,Description Intractable epilepsy here for video EEG Medical Specialty Consult History and Phy Sample Name Intractable Epilepsy Transcription CHIEF COMPLAINT Intractable epilepsy here for video EEG HISTORY OF PRESENT ILLNESS The patient is a 9 year old male who has history of global developmental delay and infantile spasms Ultimately imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum showing a pattern of cerebral dysgenesis He has had severe global developmental delay and is nonverbal He can follow objects with his eyes but has no ability to interact with his environment to any great degree He has noted if any purposeful use of the hands He has abnormal movements constantly which are more choreiform and dystonic He has spastic quadriparesis which is variable at times The patient is unable to sit or stand and receives all his nutrition via G tube The patient began having seizures in infancy presenting as infantile spasms I began seeing him at 20 months of age At that point he had undergone workup in Seattle Washington and then was seeing Dr X child neurologist in Mexico who started Vigabatrin for infantile spasms The patient had benefit from this medication and was doing well at that time with regard to that seizure type He initially was on phenobarbital which failed to give him benefit He continued on phenobarbital however for a long period time thereafter The patient then began having more tonic seizures after his episodic spasms had subsided and failed several medication trials including valproic acid Topamax and Zonegran at least briefly Upon starting Lamictal he began to have benefit and then actually had 1 year seizure freedom before having an isolated seizure or 2 Over the next 6 months to a year he only had few further seizures and was doing well in a general sense It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg kg day These events manifest as tonic spells with eye deviation and posturing Mother reports flexion of the upper extremities extension with lower extremities During that time he is not able to cry or say any sounds These events last from seconds to minutes and occur at least multiple times per week There are times where he has none for a few days and other times where he has multiple days in a row with events He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout He may vomit after these episodes then seems to calm down It is unclear whether this is a seizure or whether the patient is still responsive MEDICATIONS The patient s medications include Lamictal for a total of 200 mg twice a day It is a 150 mg tablet and 25 mg tablets He is on Zonegran using 25 mg capsules 2 capsules twice daily and baclofen 10 mg three times day He has other medications including the Xopenex and Atrovent REVIEW OF SYSTEMS At this time is negative any fevers nausea vomiting diarrhea abdominal complaints rashes arthritis or arthralgias No respiratory or cardiovascular complaints He has no change in his skills at this point FAMILY HISTORY Noncontributory PHYSICAL EXAMINATION GENERAL The patient is a slender male who is microcephalic He has EEG electrodes in place and is on the video EEG at that time HEENT His oropharynx shows no lesions NECK Supple without adenopathy CHEST Clear to auscultation CARDIOVASCULAR Regular rate and rhythm No murmurs ABDOMEN Benign with G tube in place EXTREMITIES Reveal no clubbing cyanosis or edema NEUROLOGICAL The patient is alert and has bilateral esotropia He is able to fix and follow objects briefly He is unable to reach for objects He exhibits constant choreiform movements when excited These are more prominent in the upper extremities and lower extremities He has some dystonic posture with flexion of the wrist and fingers bilaterally He also has plantar flexion at the ankles bilaterally His cranial nerves reveal that his pupils are equal round and reactive to light Extraocular movements are intact other than bilateral esotropia His face moves symmetrically Palate elevates in midline Hearing appears intact bilaterally Motor exam reveals dystonic and variable tone overall there is mild in spasticity both upper and lower extremities as described above He has clonus at the ankles bilaterally and some valgus contracture of the ankles His sensation is intact to light touch bilaterally Deep tendon reflexes are 2 to 3 bilaterally IMPRESSION PLAN This is a 9 year old male with congenital brain malformation and intractable epilepsy He has microcephaly as well as dystonic cerebral palsy He had a re emergence of seizures which are difficult to classify although some sound like tonic episodes and others are more concerning for non epileptic phenomenon such as discomfort He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types He will remain hospitalized for probably at least 48 hours to 72 hours He could be discharged sooner if multiple events are captured His medications we will continue his current dose of Zonegran and Lamictal for now Both of these medications are very long acting discontinuing them while in the hospital may simply result in severe seizures after discharge Keywords consult history and phy brain malformation congenital intractable epilepsy global developmental delay video eeg seizures intractable eeg MEDICAL_TRANSCRIPTION,Description Iron deficiency anemia She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis Medical Specialty Consult History and Phy Sample Name Iron deficiency anemia Transcription CHIEF COMPLAINT Iron deficiency anemia HISTORY OF PRESENT ILLNESS This is a very pleasant 19 year old woman who was recently hospitalized with iron deficiency anemia She was seen in consultation by Dr X She underwent a bone marrow biopsy on 07 21 10 which showed a normal cellular marrow with trilineage hematopoiesis On 07 22 10 her hemoglobin was 6 5 and therefore she was transfused 2 units of packed red blood cells Her iron levels were 5 and her percent transferrin was 2 There was no evidence of hemolysis Of note she had a baby 5 months ago however she does not describe excessive bleeding at the time of birth She currently has an IUD so she is not menstruating She was discharged from the hospital on iron supplements She denies any fevers chills or night sweats No lymphadenopathy No nausea or vomiting No change in bowel or bladder habits She specifically denies melena or hematochezia CURRENT MEDICATIONS Iron supplements and Levaquin ALLERGIES Penicillin REVIEW OF SYSTEMS As per the HPI otherwise negative PAST MEDICAL HISTORY She is status post birth of a baby girl 5 months ago She is G1 P1 She is currently using an IUD for contraception SOCIAL HISTORY She has no tobacco use She has rare alcohol use No illicit drug use FAMILY HISTORY Her maternal grandmother had stomach cancer There is no history of hematologic malignancies PHYSICAL EXAM GEN Keywords consult history and phy trilineage hematopoiesis cellular marrow bone marrow biopsy iron deficiency anemia bone marrow anemia hemoglobin lymphadenopathy deficiency tobacco MEDICAL_TRANSCRIPTION,Description Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization Medical Specialty Consult History and Phy Sample Name Iliopsoas Hematoma 2 Transcription CC RLE weakness HX This 42y o RHM was found 2 27 95 slumped over the steering wheel of the Fed Ex truck he was driving He was cyanotic and pulseless according to witnesses EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine lidocaine bretylium and electrically defibrillated and intubated in the field Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks defibrillation at 360 joules per shock epinephrine and lidocaine This had no effect He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation He was then taken emergently to cardiac catherization and was found to have normal coronary arteries He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin His blood pressure gradually improved and his balloon pump was discontinued on 5 5 95 Recovery was complicated by acute renal failure and liver failure Initail CK 13 780 the CKMB fraction was normal at 0 8 On 3 10 95 the patient experienced CP and underwent cardiac catherization This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis Subsequent CK 1381 and CKMB 5 4 elevated The patient was amnestic to the event and for 10 days following the event He was transferred to UIHC for cardiac electrophysiology study MEDS Nifedipine ASA Amiodarone Capoten Isordil Tylenol Darvocet prn Reglan prn Coumadin KCL SLNTG prn CaCO3 Valium prn Nubain prn PMH hypercholesterolemia FHX Father alive age 69 with h o TIAs Mother died age 62 and had CHF A Fib CAD Maternal Grandfather died of an MI and had h o SVT Maternal Grandmother had h o SVT SHX Married 7 children driver for Fed Ex Denied tobacco ETOH illicit drug use EXAM BP112 74 HR64 RR16 Afebrile MS A O to person place and time Euthymic with appropriate affect CN unremarkable Motor Hip flexion 3 5 Hip extension 5 5 Knee flexion5 5 Knee extension 2 5 Plantar flexion extension inversion and eversion 5 5 There was full strength thoughout BUE Sensory decreased PP Vib LT TEMP about anterior aspect of thigh and leg in a femoral nerve distribution Coord poor and slowed HKS on right due to weakness Station no drift or Romberg sign Gait difficulty bearing weight on RLE Reflexes 1 1 throughout BUE 0 2 patellae 2 2 archilles Plantar responses were flexor bilaterally COURSE MRI Pelvis 3 28 95 revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma An intra osseous lipoma was incidentally notice in the right sacrum Neuropsychologic assessment showed moderately compromised anterograde verbal memory and temporal orientation and retrograde recall were below expectations These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history He underwent implantation of a Medtronic internal cardiac difibrillator His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation He suffered mild to moderate permanent RLE weakness especially involving the quadriceps His femoral nerve compression had been present to long to warrant decompression EMG NCV studies revealed severe axonal degeneration Keywords consult history and phy cardiac electrophysiology study iliopsoas hematoma rle weakness balloon pump femoral nerve cardiac catherization hematoma iliopsoas catherization epinephrine fibrillation cardiac MEDICAL_TRANSCRIPTION,Description Right shoulder impingement syndrome right suprascapular neuropathy Medical Specialty Consult History and Phy Sample Name Impairment Rating Transcription CHIEF COMPLAINT Right shoulder pain HISTORY The patient is a pleasant 31 year old right handed white female who injured her shoulder while transferring a patient back on 01 01 02 She formerly worked for Veteran s Home as a CNA She has had a long drawn out course of treatment for this shoulder She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002 She had ongoing pain and was evaluated by Dr X who felt that she had a possible brachial plexopathy He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms He then referred her to ABCD who did EMG testing demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12 18 03 She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr X She comes to me for impairment rating She has no chronic health problems otherwise fevers chills or general malaise She is not working She is right hand dominant She denies any prior history of injury to her shoulder PAST MEDICAL HISTORY Negative aside from above FAMILY HISTORY Noncontributory SOCIAL HISTORY Please see above REVIEW OF SYSTEMS Negative aside from above PHYSICAL EXAMINATION A pleasant age appropriate woman moderately overweight in no apparent distress Normal gait and station normal posture normal strength tone sensation and deep tendon reflexes with the exception of 4 5 strength in the supraspinatus musculature on the right She has decreased motion in the right shoulder as follows She has 160 degrees of flexion 155 degrees of abduction 35 degrees of extension 25 degrees of adduction 45 degrees of internal rotation and 90 degrees of external rotation She has a positive impingement sign on the right ASSESSMENT Right shoulder impingement syndrome right suprascapular neuropathy DISCUSSION With a reasonable degree of medical certainty she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment Fifth Edition The reason for this impairment is the incident of 01 01 02 For her suprascapular neuropathy she is rated as a grade IV motor deficit which I rate as a 13 motor deficit This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16 which produces a 2 impairment of the upper extremity when the two values are multiplied together 2 impairment of the upper extremity For her lack of motion in the shoulder she also has additional impairment on the right She has a 1 impairment of the upper extremity due to lack of shoulder flexion She has a 1 impairment of the upper extremity due to lack of shoulder abduction She has a 1 impairment of the upper extremity due to lack of shoulder adduction She has a 1 impairment of the upper extremity due to lack of shoulder extension There is no impairment for findings in shoulder external rotation She has a 3 impairment of the upper extremity due to lack of shoulder internal rotation Thus the impairment due to lack of motion in her shoulder is a 6 impairment of the upper extremity This combines with the 2 impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8 impairment of the upper extremity which in turn is a 5 impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment Fifth Edition stated with a reasonable degree of medical certainty Keywords consult history and phy ama guide evaluation of permanent impairment impairment rating permanent impairment suprascapular nerve suprascapular neuropathy injured extremity shoulder impairment neuropathy suprascapular MEDICAL_TRANSCRIPTION,Description Chief complaint of chest pain previously diagnosed with hyperthyroidism Medical Specialty Consult History and Phy Sample Name Hyperthyroidism Following Pregnancy Transcription HISTORY Patient is a 21 year old white woman who presented with a chief complaint of chest pain She had been previously diagnosed with hyperthyroidism Upon admission she had complaints of constant left sided chest pain that radiated to her left arm She had been experiencing palpitations and tachycardia She had no diaphoresis no nausea vomiting or dyspnea She had a significant TSH of 0 004 and a free T4 of 19 3 Normal ranges for TSH and free T4 are 0 5 4 7 µIU mL and 0 8 1 8 ng dL respectively Her symptoms started four months into her pregnancy as tremors hot flashes agitation and emotional inconsistency She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards She complained of sweating but has experienced no diarrhea and no change in appetite She was given isosorbide mononitrate and IV steroids in the ER FAMILY HISTORY Diabetes Hypertension Father had a Coronary Artery Bypass Graph CABG at age 34 SOCIAL HISTORY She had a baby five months ago She smokes a half pack a day She denies alcohol and drug use MEDICATIONS Citalopram 10mg once daily for depression low dose tramadol PRN pain PHYSICAL EXAMINATION Temperature 98 4 Pulse 123 Respiratory Rate 16 Blood Pressure 143 74 HEENT She has exophthalmos and could not close her lids completely Cardiovascular tachycardia Neurologic She had mild hyperreflexiveness LAB All labs within normal limits with the exception of Sodium 133 Creatinine 0 2 TSH 0 004 Free T4 19 3 EKG showed sinus tachycardia with a rate of 122 Urine pregnancy test was negative HOSPITAL COURSE After admission she was given propranolol at 40mg daily and continued on telemetry On the 2nd day of treatment the patient still complained of chest pain EKG again showed tachycardia Propranolol was increased from 40mg daily to 60mg twice daily A I 123 thyroid uptake scan demonstrated an increased thyroid uptake of 90 at 4 hours and 94 at 24 hours The normal range for 4 hour uptake is 5 15 and 15 25 for 24 hour uptake Endocrine consult recommended radioactive I 131 for treatment of Graves disease Two days later she received 15 5mCi of I 131 She was to return home after the iodine treatment She was instructed to avoid contact with her baby for the next week and to cease breast feeding ASSESSMENT PLAN 1 Treatment of hyperthyroidism Patient underwent radioactive iodine 131 ablation therapy 2 Management of cardiac symptoms stemming from hyperthyroidism Patient was discharged on propranolol 60mg one tablet twice daily 3 Monitor patient for complications of I 131 therapy such as hypothyroidism She should return to Endocrine Clinic in six weeks to have thyroid function tests performed Long term follow up includes thyroid function tests at 6 12 month intervals 4 Prevention of pregnancy for one year post I 131 therapy Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive taken one tablet daily 5 Monitor ocular health Patient was given methylcellulose ophthalmic one drop in each eye daily She should follow up in 6 weeks with the Ophthalmology clinic 6 Management of depression Patient will be continued on citalopram 10 mg Keywords consult history and phy hyperthyroidism diabetes hypertension hospital course thyroid function tachycardia pregnancy MEDICAL_TRANSCRIPTION,Description Nonischemic cardiomyopathy branch vessel coronary artery disease congestive heart failure NYHA Class III history of nonsustained ventricular tachycardia hypertension and hepatitis C Medical Specialty Consult History and Phy Sample Name Hypertension Cardiomyopathy Transcription PROBLEMS LIST 1 Nonischemic cardiomyopathy 2 Branch vessel coronary artery disease 3 Congestive heart failure NYHA Class III 4 History of nonsustained ventricular tachycardia 5 Hypertension 6 Hepatitis C INTERVAL HISTORY The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications However he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest He has history of orthopnea and PND He has gained a few pounds of weight but denied to have any palpitation presyncope or syncope REVIEW OF SYSTEMS Positive for right upper quadrant pain He has occasional nausea but no vomiting His appetite has decreased No joint pain TIA seizure or syncope Other review of systems is unremarkable I reviewed his past medical history past surgical history and family history SOCIAL HISTORY He has quit smoking but unfortunately was positive for cocaine during last hospital stay in 01 08 ALLERGIES He has no known drug allergies MEDICATIONS I reviewed his medication list in the chart He states he is compliant but he was not taking the revised dose of medications as per discharge orders and prescription PHYSICAL EXAMINATION VITAL SIGNS Pulse 91 per minute and regular blood pressure 151 102 in the right arm and 152 104 in the left arm weight 172 pounds which is about 6 pounds more than last visit in 11 07 HEENT Atraumatic and normocephalic No pallor icterus or cyanosis NECK Supple Jugular venous distention 5 cm above the clavicle present No thyromegaly LUNGS Clear to auscultation No rales or rhonchi Pulse ox was 98 on room air CVS S1 and S2 present S3 and S4 present ABDOMEN Soft and nontender Liver is palpable 5 cm below the right subcostal margin EXTREMITIES No clubbing or cyanosis A 1 edema present ASSESSMENT AND PLAN The patient has hypertension nonischemic cardiomyopathy and branch vessel coronary artery disease Clinically he is in NYHA Class III He has some volume overload and was not unfortunately taking Lasix as prescribed I have advised him to take Lasix 40 mg p o b i d I also increased the dose of hydralazine from 75 mg t i d to 100 mg t i d I advised him to continue to take Toprol and lisinopril I have also added Aldactone 25 mg p o daily for survival advantage I reinforced the idea of not using cocaine He states that it was a mistake may be somebody mixed in his drink but he has not intentionally taken any cocaine I encouraged him to find a primary care provider He will come for a BMP check in one week I asked him to check his blood pressure and weight I discussed medication changes and gave him an updated list I have asked him to see a gastroenterologist for hepatitis C At this point his Medicaid is pending He has no insurance and finds hard to find a primary care provider I will see him in one month He will have his fasting lipid profile AST and ALT checked in one week Keywords consult history and phy congestive heart failure hypertension cardiomyopathy coronary artery disease ventricular tachycardia nonischemic cardiomyopathy branch vessel nyha class nonischemic tachycardia orthopnea MEDICAL_TRANSCRIPTION,Description Local reaction secondary to insect sting Patient was stung by a bee on his right hand left hand and right knee at approximately noon today Medical Specialty Consult History and Phy Sample Name Insect Sting Transcription HISTORY OF PRESENT ILLNESS Patient is a 76 year old white male who presents with his wife stating that he was stung by a bee on his right hand left hand and right knee at approximately noon today He did not note any immediate reaction Since that time he has noted some increasing redness and swelling to his left hand but he denies any generalized symptoms such as itching hives or shortness of breath He denies any sensation of tongue swelling or difficulty swallowing The patient states he was stung approximately one month ago without any serious reaction He did windup taking Benadryl at that time He has not taken anything today for his symptoms but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day ALLERGIES HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS HEADACHE MORPHINE NAUSEA AND VOMITING AND TORADOL ULCER SOCIAL HISTORY Patient is married and is a nonsmoker and lives with his wife who is here with him Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp and vital signs are all within normal limits GENERAL In general the patient is an elderly white male who is sitting on the stretcher in no acute distress HEENT Head is normocephalic and atraumatic The face shows no edema The tongue is not swollen and the airway is widely patent NECK No stridor HEART Regular rate and rhythm without murmurs rubs or gallops LUNGS Clear without rales rhonchi or wheezes EXTREMITIES Upper extremities there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals There was some slight edema of the fourth digit on which he still is wearing his wedding band The right hand shows no reaction The right knee is not swollen either The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube I was able to remove his wedding band without any difficulty Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting I did explain to him that his swelling and redness may progress over the next few days ASSESSMENT Local reaction secondary to insect sting PLAN The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone I did explain that the swelling may worsen over the next two to three days it may produce a large local reaction but that anti histamines were still the mainstay of therapy for such a reaction If he is not improved in the next four days follow up with his PCP for a re exam Keywords consult history and phy stung by a bee local reaction insect sting reaction insect bee knee edema sting swelling hand MEDICAL_TRANSCRIPTION,Description Likely molluscum contagiosum genital warts caused by HPV It is not clear where this came from but it is most likely sexually transmitted Medical Specialty Consult History and Phy Sample Name HPV Consult Transcription He has no voiding complaints and no history of sexually transmitted diseases PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Back surgery with a fusion of L5 S1 MEDICATIONS He does take occasional Percocet for his back discomfort ALLERGIES HE HAS NO ALLERGIES SOCIAL HISTORY He is a smoker He takes rare alcohol His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid He travels to anywhere for his work He is married with one son FAMILY HISTORY Negative for prostate cancer kidney cancer bladder cancer enlarged prostate or kidney disease REVIEW OF SYSTEMS Negative for tremors headaches dizzy spells numbness tingling feeling hot or cold tired or sluggishness abdominal pain nausea or vomiting indigestion heartburn fevers chills weight loss wheezing frequent cough shortness of breath chest pain varicose veins high blood pressure skin rash joint pain ear infections sore throat sinus problems hay fever blood clotting problems depressive affect or eye problems PHYSICAL EXAMINATION GENERAL The patient is afebrile His vital signs are stable He is 177 pounds 5 feet 8 inches Blood pressure 144 66 He is healthy appearing He is alert and oriented x 3 HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN Soft and nontender His penis is circumcised He has a pedunculated cauliflower like lesion on the dorsum of the penis at approximately 12 o clock It is very obvious and apparent He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber His testicles are descended bilaterally There are no masses ASSESSMENT AND PLAN This is likely molluscum contagiosum genital warts caused by HPV I did state to the patient that this is likely a viral infection that could have had a long incubation period It is not clear where this came from but it is most likely sexually transmitted He is instructed that he should use protected sex from this point on in order to try and limit the transmission Regarding the actual lesion itself I did mention that we could apply a cream of Condylox which could take up to a month to work I also offered him C02 laser therapy for the genital warts which is an outpatient procedure The patient is very interested in something quick and effective such as a CO2 laser procedure I did state that the recurrence rate is significant and somewhere as high as 20 despite enucleating these lesions The patient understood this and still wished to proceed There is minimal risk otherwise except for those inherent in laser injury and accidental injury The patient understood and wished to proceed Keywords consult history and phy sexually transmitted molluscum contagiosum genital warts hpv MEDICAL_TRANSCRIPTION,Description An 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation Medical Specialty Consult History and Phy Sample Name Hypertension Consult Transcription HISTORY OF PRESENT ILLNESS The patient is an 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall Basically the patient states that yesterday she fell and she is not certain about the circumstances on her driveway and on her left side hit a rock When she came to the emergency room she was found to have a rapid atrial tachyarrhythmia and was put on Cardizem with reportedly heart rate in the 50s so that was stopped Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker An ECG this morning showing normal sinus rhythm with frequent APCs Her potassium at that time was 3 1 She does recall having palpitations because of the pain after the fall but she states she is not having them since and has not had them prior She denies any chest pain nor shortness of breath prior to or since the fall She states clearly she can walk and she would be able to climb 2 flights of stairs without problems PAST CARDIAC HISTORY She is followed by Dr X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure On 05 12 08 preserved left and right ventricular systolic function aortic sclerosis with apparent mild aortic stenosis and bi atrial enlargement She has previously had a Persantine Myoview nuclear rest stress test scan completed at ABCD Medical Center in 07 06 that was negative She has had significant mitral valve regurgitation in the past being moderate but on the most recent echocardiogram on 05 12 08 that was not felt to be significant She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker She does have a history of significant hypertension in the past She has had dizzy spells and denies clearly any true syncope She has had bradycardia in the past from beta blocker therapy MEDICATIONS ON ADMISSION 1 Multivitamin p o daily 2 Aspirin 325 mg once a day 3 Lisinopril 40 mg once a day 4 Felodipine 10 mg once a day 5 Klor Con 20 mEq p o b i d 6 Omeprazole 20 mg p o daily presumably for GERD 7 MiraLax 17 g p o daily 8 Lasix 20 mg p o daily ALLERGIES PENICILLIN IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST FAMILY HISTORY She states her brother died of an MI suddenly in his 50s SOCIAL HISTORY She does not smoke cigarettes abuse alcohol nor use any illicit drugs She is retired from Morse Chain and delivering newspapers She is widowed She lives alone but has family members who live either on her property or adjacent to it REVIEW OF SYSTEMS She denies a history of stroke cancer vomiting of blood coughing up blood bright red blood per rectum bleeding stomach ulcers She does not recall renal calculi nor cholelithiasis denies asthma emphysema pneumonia tuberculosis sleep apnea home oxygen use She does note occasional peripheral edema She is not aware of prior history of MI She denies diabetes She does have a history of GERD She notes feeling depressed at times because of living alone She denies rheumatologic conditions including psoriasis or lupus Remainder of review of systems is negative times 15 except as described above PHYSICAL EXAM Height 5 feet 0 inches weight 123 pounds temperature 99 2 degrees Fahrenheit blood pressure has ranged from 160 87 with pulses recorded at being 144 and currently ranges 101 53 to 147 71 pulse 64 respiratory rate 20 O2 saturation 97 On general exam she is a pleasant elderly woman who is hard of hearing but is alert and interactive HEENT Shows cranium is normocephalic and atraumatic She has moist mucosal membranes Neck veins were not distended There are no carotid bruits Lungs Clear to auscultation anteriorly without wheezes She is relatively immobile because of her left hip fracture Cardiac Exam S1 S2 regular rate frequent ectopic beats 2 6 systolic ejection murmur preserved aortic component of the second heart sound There is also a soft holosystolic murmur heard There is no rub or gallop PMI is nondisplaced Abdomen is soft and nondistended Bowel sounds present Extremities without significant clubbing cyanosis and there is trivial to 1 peripheral edema Pulses appear grossly intact Affect is appropriate Visible skin warm and perfused She is not able to move because of left hip fracture easily in bed DIAGNOSTIC STUDIES LAB DATA Pertinent labs include chest x ray with radiology report pending but shows only a calcified aortic knob No clear pulmonary vascular congestion Sodium 140 potassium 3 7 it was 3 1 on admission chloride 106 bicarbonate 27 BUN 17 creatinine 0 9 glucose 150 magnesium was 2 on 07 13 06 Troponin was 0 03 followed by 0 18 INR is 0 93 white blood cell count 10 2 hematocrit 36 platelet count 115 000 EKGs are reviewed Initial EKG done on 08 19 08 at 1832 shows MAT heart rate of 104 beats per minute no ischemic changes She had a followup EKG done at 20 37 on 08 19 08 which shows wandering atrial pacemaker and some lateral T wave changes not significantly changed from prior Followup EKG done this morning shows normal sinus rhythm with frequent APCs IMPRESSION She is an 84 year old female with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery Telemetry now reviewed shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia which has been corrected There has been no atrial fibrillation documented I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath She actually describes feeling good exercise capacity prior to this fall Given favorable risk to benefit ratio for needed left hip surgery I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil which has been started which should help control the multifocal atrial tachycardia which she had and would watch for heart rate with that Continued optimization of electrolytes The patient cannot take beta blockers as previously Toprol reportedly caused shortness of breath although there was some report that it caused bradycardia so we would watch her heart rate on the verapamil The patient is aware of the cardiac risks certainly it is moderate and wishes to proceed with needed surgery I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr X after discharge Regarding her mild thrombocytopenia I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease management of left hip fracture as per orthopedist Keywords consult history and phy hypokalemia shortness of breath atrial tachycardia sinus rhythm hip fracture atrial tachycardia rhythm apcs cardiac regurgitation aortic hypertension pulmonary MEDICAL_TRANSCRIPTION,Description Patient comes in for initial evaluation of a hyperesthesia on his right abdomen Medical Specialty Consult History and Phy Sample Name Hyperesthesia Transcription SUBJECTIVE This 49 year old white male established patient in dermatology last seen in the office on 08 02 2002 comes in today for initial evaluation of a hyperesthesia on his right abdomen then on his left abdomen then on his left medial thigh It cleared for awhile This has been an intermittent problem Now it is back again on his right lower abdomen At first it was thought that he may have early zoster This started six weeks before the holidays and is still going on more so in the past eight days on his abdomen and right hip area He has had no treatment on this there are no skin changes at all The patient bathes everyday but tries to use little soap The patient is married He works as an airplane mechanic FAMILY SOCIAL AND ALLERGY HISTORY The patient has sinus and CVA He is a nonsmoker No known drug allergies CURRENT MEDICATIONS Lipitor aspirin folic acid PHYSICAL EXAMINATION The patient is well developed appears stated age Overall health is good He does have psoriasis with some psoriatic arthritis and his skin looks normal today On his trunk he does have the hyperesthesia As you touch him he winces IMPRESSION Hyperesthesia question etiology TREATMENT 1 Discussed condition and treatment with the patient 2 Discontinue hot soapy water to these areas 3 Increase moisturizing cream and lotion 4 I referred him to Dr ABC or Dr XYZ for neurology evaluation We did not see anything on skin today Return p r n flare Keywords consult history and phy dermatology abdomen hyperesthesia soapy water moisturizing cream initial evaluation MEDICAL_TRANSCRIPTION,Description Left hip fracture The patient is a 53 year old female with probable pathological fracture of the left proximal femur Medical Specialty Consult History and Phy Sample Name Hip Fracture ER Consult Transcription REASON FOR CONSULTATION Left hip fracture HISTORY OF PRESENT ILLNESS The patient is a pleasant 53 year old female with a known history of sciatica apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight History was obtained from the patient As per the history she reported that she has been having back pain with left leg pain since past 4 weeks She has been using a walker for ambulation due to disabling pain in her left thigh and lower back She was seen by her primary care physician and was scheduled to go for MRI yesterday However she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall Since then she was unable to ambulate The patient called paramedics and was brought to the emergency room She denied any history of fall She reported that she stepped the wrong way causing the pain to become worse She is complaining of severe pain in her lower extremity and back pain Denies any tingling or numbness Denies any neurological symptoms Denies any bowel or bladder incontinence X rays were obtained which were remarkable for left hip fracture Orthopedic consultation was called for further evaluation and management On further interview with the patient it is noted that she has a history of malignant melanoma which was diagnosed approximately 4 to 5 years ago She underwent surgery at that time and subsequently she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3 2008 PAST MEDICAL HISTORY Sciatica and melanoma PAST SURGICAL HISTORY As discussed above surgery for melanoma and hysterectomy ALLERGIES NONE SOCIAL HISTORY Denies any tobacco or alcohol use She is divorced with 2 children She lives with her son PHYSICAL EXAMINATION GENERAL The patient is well developed well nourished in mild distress secondary to left lower extremity and back pain MUSCULOSKELETAL Examination of the left lower extremity there is presence of apparent shortening and external rotation deformity Tenderness to palpation is present Leg rolling is positive for severe pain in the left proximal hip Further examination of the spine is incomplete secondary to severe leg pain She is unable to perform a straight leg raising EHL EDL 5 5 2 pulses are present distally Calf is soft and nontender Homans sign is negative Sensation to light touch is intact IMAGING AP view of the hip is reviewed Only 1 limited view is obtained This is a poor quality x ray with a lot of soft tissue shadow This x ray is significant for basicervical type femoral neck fracture Lesser trochanter is intact This is a high intertrochanteric fracture basicervical There is presence of lytic lesion around the femoral neck which is not well delineated on this particular x ray We need to order repeat x rays including AP pelvis femur and knee LABS Have been reviewed ASSESSMENT The patient is a 53 year old female with probable pathological fracture of the left proximal femur DISCUSSION AND PLAN Nature and course of the diagnosis has been discussed with the patient Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma this appears to be a pathological fracture of the left proximal hip At the present time I would recommend obtaining a bone scan and repeat x rays which will include AP pelvis femur hip including knee She denies any pain elsewhere She does have a past history of back pain and sciatica but at the present time this appears to be a metastatic bone lesion with pathological fracture I have discussed the case with Dr X and recommended oncology consultation With the above fracture and presentation she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty cemented type Indication risk and benefits of left hip hemiarthroplasty has been discussed with the patient which includes but not limited to bleeding infection nerve injury blood vessel injury dislocation early and late persistent pain leg length discrepancy myositis ossificans intraoperative fracture prosthetic fracture need for conversion to total hip replacement surgery revision surgery DVT pulmonary embolism risk of anesthesia need for blood transfusion and cardiac arrest She understands above and is willing to undergo further procedure The goal and the functional outcome have been explained Further plan will be discussed with her once we obtain the bone scan and the radiographic studies We will also await for the oncology feedback and clearance Thank you very much for allowing me to participate in the care of this patient I will continue to follow up Keywords consult history and phy calcar proximal femur pathological fracture hip fracture hemiarthroplasty melanoma MEDICAL_TRANSCRIPTION,Description Closed head injury with evidence of axonal injury vs vascular injury to the left substantia nigra right subdural hematoma and possible subarachnoid hemorrhage vascular ischemic injury in the right occipital lobe right basal ganglia caudate nucleus right frontal lobe and right temporal lobe contusion Medical Specialty Consult History and Phy Sample Name Head Trauma Transcription CC Depressed mental status HX 29y o female fell down a flight of stairs on 2 20 95 striking the right side of her head She then walked over to and lay down on a living room couch She was found there the next morning by her boyfriend poorly responsive and amidst a coffee ground like emesis She was taken to a local ER and HCT revealed a right supraorbital fracture right SDH and left SAH Spine X rays revealed a T12 vertebral body fracture There were retinal hemorrhages OU She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic neurosurgical care MEDS on transfer Dilantin Zantac Proventil MDI Tylenol PMH 1 pyelonephritis 2 multiple STD s 3 Polysubstance Abuse ETOH MJ Amphetamine 4 G5P4 FHX unknown SHX polysubstance abuse smoked 1 pack per day for 15years EXAM BP127 97 HR83 RR25 37 2C MS Minimal to no spontaneous speech Unresponsive to verbal commands Lethargic and somnolent Groaned yes inappropriately CN Pupils 4 4 decreasing to 2 2 on exposure to light VFFTT Retinal hemorrhages OU EOM difficult to assess Facial movement appeared symmetric Tongue midline Corneal and gag responses were intact MOTOR no spontaneous movement withdrew extremities to noxious stimulation e g deep nail bed pressure Sensory withdrew to noxious stimuli Coord Station Gait not tested Reflexes 2 2 BUE 2 2 BLE Babinski signs were present bilaterally HEENT Periorbital and upper lid ecchymoses about the right eye Scleral hemorrhage OD GEN EXAM mild bruising of the extremities COURSE 2 27 95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage 2 28 95 brain MRI revealed 1 a small right sided SDH 2 Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic vascular injury 3 abnormal signal within the right basal ganglia caudate nucleus consistent with ischemia 4 abnormal signal in the uncal portion of the right frontal lobe consistent with contusion 5 small parenchymal hemorrhage in the inferior anterior right temporal lobe and 6 opacification of the right maxillary sinus EEG 2 28 95 was abnormal with occasional sharp transients in the left temporal region and irregular more or less continuous right greater than left delta slow waves and decreased background activity in the right hemisphere the findings were consistent with focal pathology on the right seizure tendency in the left temporal region and bilateral cerebral dysfunction By the time of discharge 4 17 95 she was verbalizing one or two words and required assistance with feeding and ambulation She could not function independently Keywords consult history and phy closed head injury axonal injury vascular injury substantia nigra subdural hematoma subarachnoid hemorrhage vascular ischemic injury occipital lobe retinal hemorrhages temporal region axonal hemorrhages hemorrhage MEDICAL_TRANSCRIPTION,Description Patient presents with gross hematuria that started this morning Medical Specialty Consult History and Phy Sample Name Hematuria Consult Transcription HISTORY OF PRESENT ILLNESS This is a 77 year old male who presents with gross hematuria that started this morning The patient is a difficult historian does have a speech impediment slow to answer questions but daughter was able to answer lot of questions too He is complaining of no other pain He denies any abdominal pain Denies any bleeding anywhere else Denies any bruising He had an episode similar to this a year ago where it began the same with hematuria He was discharged after a workup in the hospital in the emergency room with Levaquin Three days later he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding His H and H was down in the 6 level He received blood transfusions He was diagnosed with a malignancy coagulopathy and sounds like was in critical condition Family actually states that they were told that he was unlikely to live through that event but he did Since then he has had no bleeding The patient has had no fever No cough No chest pain or shortness of breath No bleeding gums No blurred vision No headache No recent falls or trauma He has had no nausea or vomiting No diarrhea No blood in the stool or melena No leg or calf pain No joint pain No rashes No swollen glands He has no numbness weakness or tingling to his extremities No acute anxiety or depression PAST MEDICAL HISTORY Has prostate cancer MEDICATION He is receiving Lupron injection by Dr Y The only other medication that he takes is Tramadol SOCIAL HISTORY He does not smoke or drink PHYSICAL EXAMINATION Vital Signs Are all reviewed on triage General He is alert Answers slowly with a speech impediment but answers appropriately HEENT Pupils equal round and reactive to light Normal extraocular muscles Nonicteric sclerae Conjunctivae are not pale His oropharynx is clear His mucous membranes are moist Heart Regular rate and rhythm with no murmurs Lungs Clear Abdomen Soft nontender nondistended Normal bowel sounds No organomegaly or mass Extremities No calf tenderness erythema or warmth He has no bruises noted Neurological Cranial nerves II through XII are intact He has 5 5 strength throughout GU Normal LABORATORY DATA The patient did on urinalysis have few red blood cells His urine was also grossly red although no blood clots or gross blood was noted It was more of a red fluid He had a mild decrease in H and H at 12 1 and 34 6 His white count was normal at 7 2 His PT was elevated at 15 9 PTT elevated at 36 4 INR is 1 4 His comprehensive metabolic profile is normal except for BUN of 19 CONDITION The patient is stable at this time although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy the patient is discussed with Dr X and he is admitted for orders Also we will consult Dr Y see orders for further Keywords consult history and phy prostate cancer bleeding gross hematuria speech impediment hematuria coagulopathy blood MEDICAL_TRANSCRIPTION,Description New patient visit for right hand pain Punched the wall 3 days prior to presentation complained of ulnar sided right hand pain and was seen in the emergency room Medical Specialty Consult History and Phy Sample Name Hand Pain Consult Transcription REASON FOR VISIT New patient visit for right hand pain HISTORY OF PRESENT ILLNESS The patient is a 28 year old right hand dominant gentleman who punched the wall 3 days prior to presentation He complained of ulnar sided right hand pain and was seen in the emergency room Reportedly he had some joints in his hand pushed back and placed by somebody in emergency room Today he admits that his pain is much better Currently since that time he has been in the splint with minimal pain He has had no numbness tingling or other concerning symptoms PAST MEDICAL HISTORY Negative SOCIAL HISTORY The patient is a nonsmoker and does not use illegal drugs Occasionally drinks REVIEW OF SYSTEMS A 12 point review of systems is negative MEDICATIONS None ALLERGIES No known drug allergies FINDINGS On physical exam he has swelling and tenderness over the ulnar dorsum of his hand He has a normal cascade He has 70 degrees of MCP flexion and full IP flexion and extension He has 3 to 5 strength in his grip and intrinsics He has intact sensation to light touch in the radial ulnar and median nerve distribution Two plus radial pulse X rays taken from today were reviewed include three views of the right hand They show possible small fractures of the base of the fourth and third metacarpals Joint appears to be located A 45 degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals His injury films from 09 15 07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals ASSESSMENT Status post right third and fourth metacarpal carpometacarpal dislocations PLANS The patient was placed into a short arm cast and intrinsic plus I would like him to wear this for 2 weeks and then follow up with us At that time we will transition him to an OT splint and begin range of motion activities of the fingers and wrist We should see him back in 2 weeks time at which time he should obtain three views of the right hand and a 45 degree oblique view out of cast Keywords consult history and phy hand pain pain hand metacarpals MEDICAL_TRANSCRIPTION,Description Headache Right frontal lobe glioma Medical Specialty Consult History and Phy Sample Name Glioma 2 Transcription CC Headache HX 37 y o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours The headachese were dull to throbbing in character She was initially treated with Parafon forte for tension type headaches but the pain did not resolve She subsequently underwent HCT in early 12 90 which revealed a right frontal mass lesion PMH 1 s p tonsillectomy 2 s p elective abortion FHX Mother with breast CA MA with bone cancer AODM both sides of family SHX Denied tobacco or illicit drug use Rarely consumes ETOH Married with 2 teenage children EXAM VItal signs unremarkable MS Alert and oriented to person place time Lucid thought process per NSG note CN unremarkable Motor full strength with normal muscle bulk and tone Sensory unremarkable Coordination unremarkable Station Gait unremarkable Reflexes unremarkable Gen Exam unremarkable COURSE MRI Brain large solid and cystic right frontal lobe mass with a large amount of surrounding edema There is apparent tumor extension into the corpus callosum across the midline Tumor extension is also suggested in the anterior limb of the interanl capsule on the right There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle The MRI findings are most consistent with glioblastoma The patient underwent right frontal lobectomy The pathological diagnosis was xanthomatous astrocytoma The literature at the time was not clear as to optimal treatment protocol People have survived as long as 25 years after diagnosis with this type of tumor XRT was deferred until 11 91 when an MRI and PET Scan suggested extension of the tumor She then received 5580 cGy of XRT in divided segments She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement She was treated with BCNU chemotherapy protocol in 1992 Keywords consult history and phy frontal lobe tumor extension glioma headache lobectomy astrocytoma MEDICAL_TRANSCRIPTION,Description Comprehensive Evaluation Diabetes hypertension irritable bowel syndrome and insomnia Medical Specialty Consult History and Phy Sample Name Gen Med Consult 9 Transcription SUBJECTIVE The patient is well known to me He comes in today for a comprehensive evaluation Really again he borders on health crises with high blood pressure diabetes and obesity He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made specifically the lack of exercise the obesity the poor eating habits etc He knows better and has been through some diabetes training In fact interestingly enough with his current medications which include the Lantus at 30 units along with Actos glyburide and metformin he achieved ideal blood sugar control back in August 2004 Since that time he has gone off of his regimen of appropriate eating and has had sugars that are running on average too high at about 178 over the last 14 days He has had elevated blood pressure His other concerns include allergic symptoms He has had irritable bowel syndrome with some cramping He has had some rectal bleeding in recent days Also once he wakes up he has significant difficulty in getting back to sleep He has had no rectal pain just the bleeding associated with that MEDICATIONS ALLERGIES As above PAST MEDICAL SURGICAL HISTORY Reviewed and updated see Health Summary Form for details FAMILY AND SOCIAL HISTORY Reviewed and updated see Health Summary Form for details REVIEW OF SYSTEMS Constitutional Eyes ENT Mouth Cardiovascular Respiratory GI GU Musculoskeletal Skin Breasts Neurologic Psychiatric Endocrine Heme Lymph Allergies Immune all negative with the following exceptions None PHYSICAL EXAMINATION VITAL SIGNS As above GENERAL The patient is alert oriented well developed obese male who is in no acute distress HEENT PERRLA EOMI TMs clear bilaterally Nose and throat clear NECK Supple without adenopathy or thyromegaly Carotid pulses palpably normal without bruit CHEST No chest wall tenderness or breast enlargement HEART Regular rate and rhythm without murmur clicks or rubs LUNGS Clear to auscultation and percussion ABDOMEN Significantly obese without any discernible organomegaly GU Normal male genitalia without testicular abnormalities inguinal adenopathy or hernia RECTAL Smooth nonenlarged prostate with just some irritation around the rectum itself No hemorrhoids are noted EXTREMITIES Some slow healing over the tibia Without clubbing cyanosis or edema Peripheral pulses within normal limits NEUROLOGIC Cranial nerves II XII intact Strength sensation coordination and reflexes all within normal limits SKIN Noted to be normal No subcutaneous masses noted LYMPH SYSTEM No lymphadenopathy noted BACK He has pain in his back in general ASSESSMENT PLAN 1 Diabetes and hypertension both under less than appropriate control In fact we discussed increasing the Lantus He appears genuine in his desire to embark on a substantial weight lowering regime and is going to do that through dietary control He knows what needs to be done with the absence of carbohydrates and especially simple sugar He will also check a hemoglobin A1c lipid profile urine for microalbuminuria and a chem profile I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range He has allergic rhinitis for which Zyrtec can be used 2 He has irritable bowel syndrome We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened For the bleeding I would like to obtain a sigmoidoscopy It is bright red blood 3 For his insomnia I found there is very little in the way of medications that are going to fix that however I have encouraged him in good sleep hygiene I will look forward to seeing him back in a month I will call him with the results of his lab His medications were made out We will use some Elocon cream for his seborrheic dermatitis of the face Zyrtec and Flonase for his allergic rhinitis Keywords MEDICAL_TRANSCRIPTION,Description GI Consultation due to rectal bleeding positive celiac sprue panel Medical Specialty Consult History and Phy Sample Name GI Consultation 1 Transcription PROBLEM Rectal bleeding positive celiac sprue panel HISTORY The patient is a 19 year old Irish Greek female who ever since elementary school has noted diarrhea constipation cramping nausea vomiting bloating belching abdominal discomfort change in bowel habits She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody She has been on a gluten free diet for approximately one week now and her symptoms are remarkably improved She actually has none of these symptoms since starting her gluten free diet She has noted intermittent rectal bleeding with constipation on the toilet tissue She feels remarkably better after starting a gluten free diet ALLERGIES No known drug allergies OPERATIONS She is status post a tonsillectomy as well as ear tubes ILLNESSES Questionable kidney stone MEDICATIONS None HABITS No tobacco No ethanol SOCIAL HISTORY She lives by herself She currently works in a dental office FAMILY HISTORY Notable for a mother who is in good health a father who has joint problems and questionable celiac disease as well She has two sisters and one brother One sister interestingly has inflammatory arthritis REVIEW OF SYSTEMS Notable for fever fatigue blurred vision rash and itching her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten free diet She also notes headaches anxiety heat and cold intolerance excessive thirst and urination Please see symptoms summary sheet dated April 18 2005 PHYSICAL EXAMINATION GENERAL She is a well developed pleasant 19 female She has a blood pressure of 120 80 a pulse of 70 she weighs 170 pounds She has anicteric sclerae Pink conjunctivae PERRLA ENT MMM NECK Supple LUNGS Clear to auscultation Keywords consult history and phy bleeding abdominal discomfort belching bloating bowel celiac sprue change in bowel habits constipation cramping diarrhea gluten free nausea rectal vomiting inflammatory arthritis rectal bleeding gi inflammatory sprue celiac gluten diet MEDICAL_TRANSCRIPTION,Description Comprehensive Evaluation Generalized anxiety and hypertension both under fair control Medical Specialty Consult History and Phy Sample Name Gen Med Consult 8 Transcription SUBJECTIVE The patient comes in today for a comprehensive evaluation She is well known to me I have seen her in the past multiple times PAST MEDICAL HISTORY SOCIAL HISTORY FAMILY HISTORY Noted and reviewed today They are on the health care flow sheet She has significant anxiety which has been under fair control recently She has a lot of stress associated with a son that has some challenges There is a family history of hypertension and strokes CURRENT MEDICATIONS Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned REVIEW OF SYSTEMS Significant for occasional tiredness This is intermittent and currently not severe She is concerned about the possibly of glucose abnormalities such diabetes We will check a glucose lipid profile and a Hemoccult test also and a mammogram Her review of systems is otherwise negative PHYSICAL EXAMINATION VITAL SIGNS As above GENERAL The patient is alert oriented in no acute distress HEENT PERRLA EOMI TMs clear bilaterally Nose and throat clear NECK Supple without adenopathy or thyromegaly Carotid pulses palpably normal without bruit CHEST No chest wall tenderness BREAST EXAM No asymmetry skin changes dominant masses nipple discharge or axillary adenopathy HEART Regular rate and rhythm without murmur clicks or rubs LUNGS Clear to auscultation and percussion ABDOMEN Soft nontender bowel sounds normoactive No masses or organomegaly GU External genitalia without lesions BUS normal Vulva and vagina show just mild atrophy without any lesions Her cervix and uterus are within normal limits Ovaries are not really palpable No pelvic masses are appreciated RECTAL Negative BREASTS No significant abnormalities EXTREMITIES Without clubbing cyanosis or edema Pulses within normal limits NEUROLOGIC Cranial nerves II XII intact Strength sensation coordination and reflexes all within normal limits SKIN Noted to be normal No subcutaneous masses noted LYMPH SYSTEM No lymphadenopathy ASSESSMENT Generalized anxiety and hypertension both under fair control PLAN We will not make any changes in her medications I will have her check a lipid profile as mentioned and I will call her with that Screening mammogram will be undertaken She declined a sigmoidoscopy at this time I look forward to seeing her back in a year and as needed Keywords MEDICAL_TRANSCRIPTION,Description Patient with swelling of lips and dysphagia and Arthritis Medical Specialty Consult History and Phy Sample Name Gen Med Consult 5 Transcription CHIEF COMPLAINT Swelling of lips causing difficulty swallowing HISTORY OF PRESENT ILLNESS This patient is a 57 year old white Cuban woman with a long history of rheumatoid arthritis She has received methotrexate on a weekly basis as an outpatient for many years Approximately two weeks ago she developed a respiratory infection for which she received antibiotics She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago She showed some initial improvement but over the last 3 5 days has had malaise a low grade fever and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate She has rather diffuse pain involving both large and small joints MEDICATIONS Prednisone 7 5 mg p o q d Premarin 0 125 mg p o q d and Dolobid 1000 mg p o q d recently discontinued because of questionable allergic reaction HCTZ 25 mg p o q o d Oral calcium supplements In the past she has been on penicillin azathioprine and hydroxychloroquine but she has not had Azulfidine cyclophosphamide or chlorambucil ALLERGIES None by history FAMILY SOCIAL HISTORY Noncontributory PHYSICAL EXAMINATION This is a chronically ill appearing female alert oriented and cooperative She moves with great difficulty because of fatigue and malaise Vital signs Blood pressure 107 80 heart rate 100 and regular respirations 22 HEENT Normocephalic No scalp lesions Dry eyes with conjuctival injections Mild exophthalmos Dry nasal mucosa Marked cracking and bleeding of her lips with erosion of the mucosa She has a large ulceration of the mucosa at the bite margin on the left She has some scattered ulcerations on her hard and soft palette Tonsils not enlarged No visible exudate She has difficulty opening her mouth because of pain SKIN She has some mild ecchymoses on her skin and some erythema she has patches but no obvious skin breakdown She has some fissuring in the buttocks crease PULMONARY Clear to percussion in auscultation CARDIOVASCULAR No murmurs or gallops noted ABDOMEN Protuberant no organomegaly and positive bowel sounds NEUROLOGIC EXAM Cranial nerves II through XII are grossly intact Diffuse hyporeflexia MUSCULOSKELATAL Erosive destructive changes in the elbows wrist and hands consistent with rheumatoid arthritis She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1 I feel no pulse distally in either leg PROBLEMS 1 Swelling of lips and dysphagia with questionable early Stevens Johnson syndrome 2 Rheumatoid Arthritis class 3 stage 4 3 Flare of arthritis after discontinuing methotrexate 4 Osteoporosis with compression fracture 5 Mild dehydration 6 Nephrolithiasis PLAN Patient is admitted for IV hydration and treatment of oral ulcerations We will obtain a dermatology consult IV leucovorin will be started and the patient will be put on high dose corticosteroids Keywords consult history and phy swelling iv hydration osteoporosis swelling of lips allergic reaction arthritis difficulty swallowing leucovorin low grade fever methotrexate respiratory infection rheumatoid arthritis flare of arthritis rheumatoid mucosa dysphagia MEDICAL_TRANSCRIPTION,Description Anxiety alcohol abuse and chest pain This is a 40 year old male with digoxin toxicity secondary to likely intentional digoxin overuse Now he has had significant block with EKG changes as stated Medical Specialty Consult History and Phy Sample Name Gen Med Consult 52 Transcription CHIEF COMPLAINT Anxiety alcohol abuse and chest pain HISTORY OF PRESENT ILLNESS This is a pleasant 40 year old male with multiple medical problems basically came to the hospital yesterday complaining of chest pain The patient states that he complained of this chest pain which is reproducible pleuritic in both chest radiating to the left back and the jaw complaining of some cough nausea questionable shortness of breath The patient describes the pain as aching sharp and alleviated with pain medications not alleviated with any nitrates Aggravated by breathing coughing and palpation over the area The pain was 9 10 in the emergency room and he was given some pain medications in the ER and was basically admitted Labs were drawn which were essentially potassium was about 5 7 and digoxin level was drawn which was about greater than 5 The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together The patient has a history prior digoxin overdose of the same nature MEDICATIONS Digoxin 0 25 mg metoprolol 50 mg Naprosyn 500 mg metformin 500 mg lovastatin 40 mg Klor Con 20 mEq Advair Diskus questionable Coreg PAST MEDICAL HISTORY MI in the past and atrial fibrillation he said that he has had one stent put in but he is not sure The last cardiologist he saw was Dr X and his primary doctor is Dr Y SOCIAL HISTORY History of alcohol use in the past He is basically requesting for more and more pain medications He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid His pain is tolerable PHYSICAL EXAMINATION VITAL SIGNS Stable GENERAL Alert and oriented x3 no apparent distress HEENT Extraocular muscles are intact CVS S1 S2 heard CHEST Clear to auscultation bilaterally ABDOMEN Soft and nontender EXTREMITIES No edema or clubbing NEURO Grossly intact Tender to palpate over the left chest no obvious erythema or redness or abnormal exam is found EKG basically shows atrial fibrillation rate controlled nonspecific ST changes ASSESSMENT AND PLAN 1 This is a 40 year old male with digoxin toxicity secondary to likely intentional digoxin overuse Now he has had significant block with EKG changes as stated Continue to follow the patient clinically at this time The patient has been admitted to ICU and will be changed to DOU 2 Chronic chest pain with a history of myocardial infarction in the past has been ruled out with negative cardiac enzymes The patient likely has opioid dependence and requesting more and more pain medications He is also bargaining for pain medications with me The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred We will try to verify his pain medications from his primary doctor and his pharmacy The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past Keywords consult history and phy anxiety alcohol abuse chest pain digoxin toxicity digoxin overuse atrial fibrillation opioid dependence toxicity dilaudid MEDICAL_TRANSCRIPTION,Description The patient had temperature of 104 degrees F It has been spiking ever since and she has had left sacroiliac type hip pain She does have degenerative disk disease of her lumbar spine but no hip pathology She has swollen inguinal nodes bilaterally Medical Specialty Consult History and Phy Sample Name Gen Med Consult 47 Transcription HISTORY OF PRESENT ILLNESS This is a 76 year old female that was admitted with fever chills and left pelvic pain The patient was well visiting in ABC with her daughter that evening She had pain in her left posterior pelvic and low back region They came back to XYZ the following day By the time they got here she was in severe pain and had fever They came straight to the emergency room She was admitted She had temperature of 104 degrees F It has been spiking ever since and she has had left sacroiliac type hip pain Multiple blood studies have been done including cultures febrile agglutinins etc She has had run a higher blood glucose to the normal and she has been on sliding scale insulin She was not known previously to be a diabetic All x rays have not been helpful as far as to determine the etiology of her discomfort MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process She does have degenerative disk disease of her lumbar spine but no hip pathology She has swollen inguinal nodes bilaterally PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS She was not known to be a diabetic until this admission She had been hypertensive She has been on medications and has been controlled She has not had hyperlipidemia She has had no thyroid problems There has been no asthma bronchitis TB emphysema or pneumonia No tuberculosis She has had no breast tumors She has had no chest pain or cardiac problems She has had gallbladder surgery She has not had any gastritis or ulcers She has had no kidney disease She has had a hysterectomy She has had 9 pregnancies and 8 living children She had A P repair She had a sacral abscess after a spinal It sounds to me like she had a pilonidal cyst which took about 3 operations to heal There have been fractures and no significant arthritis She has been quite active at her ranch in Mexico She raises goats and cattle She drives a tractor and in short has been very active PHYSICAL EXAMINATION She is a short female alert She is shivering She has ice in her axilla and behind her neck She is febrile to 101 degrees F She is alert Her complaint is that of hip pain in the posterior sacroiliac joint area She moves both her upper extremities well She can move her right leg well She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint She cannot stand sit or turn without severe pain She has normal knee reflexes No ankle reflexes She has bounding tibial pulses No sensory deficit She says she knows when she has to void She has a healed scar in the upper sacral region There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back PLAN My plan is to do a triple phase bone scan I am suspecting an infection possibly in the left sacroiliac joint It is probably some type of bacterium the etiology of which is undetermined She has had a normal white count despite her fever There has been a history of brucellosis in the past but her titers at this time are negative Continue medication which included antibiotics and also the Motrin and Darvocet Keywords consult history and phy inflammatory degenerative fever lumbar spine sacroiliac joint inguinal sacroiliac hip MEDICAL_TRANSCRIPTION,Description A 69 year old female with past history of type II diabetes atherosclerotic heart disease hypertension carotid stenosis Medical Specialty Consult History and Phy Sample Name Gen Med Consult 43 Transcription HISTORY A 69 year old female with past history of type II diabetes atherosclerotic heart disease hypertension carotid stenosis The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital The patient subsequently developed CVA She also developed thrombosis of the right arm which ultimately required right hand amputation She was stabilized and eventually transferred to HealthSouth for further management PHYSICAL EXAMINATION Vital Signs Pulse of 90 and blood pressure 150 70 Heart Sounds were heard grade 2 6 systolic murmur at the precordium Chest Clinically clear Abdomen Some suprapubic tenderness Evidence of right lower arm amputation The patient was started on Prevacid 30 mg daily levothyroxine 75 mcg a day Toprol 25 mg twice a day Zofran 4 mg q 6 h Coumadin dose at 5 mg and was adjusted She was given a pain control using Vicodin and Percocet amiodarone 200 mg a day Lexapro 20 mg a day Plavix 75 mg a day fenofibrate 145 mg Lasix 20 mg IV twice a day Lantus 50 units at bedtime and Humalog 10 units a c and sliding scale insulin coverage Wound care to the right heel was supervised by Dr X The patient initially was fed through NG tube which was eventually discontinued Physical therapy was ordered The patient continued to do well She was progressively ambulated Her meds were continuously adjusted The patient s insulin was eventually changed from Lantus to Levemir 25 units twice a day Dr Y also followed the patient closely for left heel ulcer LABORATORY DATA The latest cultures from left heel are pending Her electrolytes revealed sodium of 135 and potassium of 3 2 Her potassium was switched to K Dur 40 mEq twice a day Her blood chemistries are otherwise closely monitored INRs were obtained and were therapeutic Throughout her hospitalization multiple cultures were also obtained Urine cultures grew Klebsiella She was treated with appropriate antibiotics Her detailed blood work is as in the chart Detailed radiological studies are as in the chart The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation FINAL DIAGNOSES 1 Atherosclerotic heart disease status post coronary artery bypass graft 2 Valvular heart disease status post aortic valve replacement 3 Right arm arterial thrombosis status post amputation right lower arm 4 Hypothyroidism 5 Uncontrolled diabetes mellitus type 2 6 Urinary tract infection 7 Hypokalemia 8 Heparin induced thrombocytopenia 9 Peripheral vascular occlusive disease 10 Paroxysmal atrial fibrillation 11 Hyperlipidemia 12 Depression 13 Carotid stenosis Keywords consult history and phy arterial thrombosis valvular heart disease atherosclerotic heart disease type ii diabetes hypertension carotid stenosis heart disease diabetes carotid stenosis bypass amputation heart atherosclerotic MEDICAL_TRANSCRIPTION,Description Backache stomachache and dysuria for the last two days Urinary dysuria left flank pain pharyngitis Medical Specialty Consult History and Phy Sample Name Gen Med Consult 41 Transcription SUBJECTIVE The patient complains of backache stomachache and dysuria for the last two days Fever just started today and cough She has history of kidney stones less than a year ago and had a urinary tract infection at that time Her back started hurting last night PAST MEDICAL HISTORY She denies sexual activities since two years ago Her last menstrual period was 06 01 2004 Her periods have been irregular She started menarche at 10 years of age and she is still irregular and it runs in Mom s side of the family Mom and maternal aunt have had total hysterectomies She also is diagnosed with abnormal valve has to be on SBE prophylaxis sees Dr XYZ Allen She avoids decongestants She is limited on her activity secondary to her heart condition MEDICATION Cylert ALLERGIES No known drug allergies OBJECTIVE Vital Signs Blood pressure is 124 72 Temperature 99 2 Respirations 20 unlabored Weight 137 pounds HEENT Normocephalic Conjunctivae noninjected No mattering noted Her TMs are bilaterally clear nonerythematous Throat clear good mucous membrane moisture but she did have erythema and edema at her posterior soft palate Neck Supple Increased lymphadenopathy noted in the submandibular nodes but no axillary nodes and no hepatosplenomegaly Respiratory Clear No wheezes no crackles no tachypnea and no retractions Cardiovascular Regular rate and rhythm S1 and S2 normal no murmur Abdomen Soft No organomegaly She did have exquisite tenderness to palpation of the left upper quadrant and flank area but the spleen was not palpable She has no suprapubic tenderness Extremities She has good range of motion of upper and lower extremities Good ambulation Her UA was positive for 2 leukocyte esterase positive nitrites 1 protein 2 ketones 4 blood greater than 50 white blood cells 10 20 rbc s and 1 bacteria Culture and sensitivity is pending Her Strep test is negative Culture is pending ASSESSMENT 1 Urinary dysuria 2 Left flank pain 3 Pharyngitis PLAN A 1 g of Rocephin IM was given Call Dr B s office tomorrow morning incase a second IM dose is needed If not then she will fill a prescription for Omnicef 300 mg capsule 1 p o b i d for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug Push fluids Await strep culture report Follow up with Dr XYZ if no better or symptoms worsen Keywords consult history and phy backache stomachache dysuria cylert urinary dysuria pharyngitis culture and sensitivity tenderness urinary infection MEDICAL_TRANSCRIPTION,Description A 12 year old young man with sinus congestion Medical Specialty Consult History and Phy Sample Name Gen Med Consult 22 Transcription SUBJECTIVE This is a 12 year old young man who comes in with about 10 days worth of sinus congestion He does have significant allergies including ragweed The drainage has been clear He had a little bit of a headache yesterday He has had no fever No one else is ill at home currently CURRENT MEDICATIONS Advair and Allegra He has been taking these regularly He is not sure the Allegra is working for him anymore He does think though better than Claritin PHYSICAL EXAM General Alert young man in no distress HEENT TMs clear and mobile Pharynx clear Mouth moist Nasal mucosa pale with clear discharge Neck Supple without adenopathy Heart Regular rate and rhythm without murmur Lungs Lungs clear no tachypnea wheezing rales or retractions Abdomen Soft nontender without masses or splenomegaly ASSESSMENT I think this is still his allergic rhinitis rather than a sinus infection PLAN Change to Zyrtec 10 mg samples were given He is not using nasal spray but he has some at home He should restart this Continue to watch his peak flows to make sure his asthma does not come under poor control Call if any further problems Keywords consult history and phy allergic rhinitis sinus infection sinus congestion congestion sinus MEDICAL_TRANSCRIPTION,Description Patient in with mom for possible ear infection Medical Specialty Consult History and Phy Sample Name Gen Med Consult 23 Transcription SUBJECTIVE Mom brings the patient in today for possible ear infection He is complaining of left ear pain today He was treated on 04 14 2004 with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today He has not had any fever but the congestion has continued to be very thick and purulent It has never really resolved He has a loose productive sounding cough but not consistently and not keeping him up at night No wheezing or shortness of breath PAST MEDICAL HISTORY He has had some wheezing in the past but nothing recently FAMILY HISTORY All siblings are on antibiotics for ear infections and URIs OBJECTIVE General The patient is a 5 year old male Alert and cooperative No acute distress Neck Supple without adenopathy HEENT Ear canals clear TMs bilaterally have distorted light reflexes but no erythema Gray in color Oropharynx pink and moist with a lot of postnasal discharge Nares are swollen and red Thick purulent drainage Eyes are a little puffy Chest Respirations regular nonlabored Lungs Clear to auscultation throughout Heart Regular rhythm without murmur Skin Warm dry pink Moist mucus membranes No rash ASSESSMENT Ongoing purulent rhinitis Probable sinusitis and serous otitis PLAN Change to Omnicef two teaspoons daily for 10 days Frequent saline in the nose Also there was some redness around the nares with a little bit of yellow crusting It appeared to be the start of impetigo so hold off on the Rhinocort for a few days and then restart Use a little Neosporin for now Keywords consult history and phy ear infection productive sounding cough purulent rhinitis serous otitis sinusitis wheezing ear amoxicillin MEDICAL_TRANSCRIPTION,Description The patient brought in by EMS with a complaint of a decreased level of consciousness Medical Specialty Consult History and Phy Sample Name Gen Med Consult 28 Transcription HISTORY OF PRESENT ILLNESS The patient is an 85 year old male who was brought in by EMS with a complaint of a decreased level of consciousness The patient apparently lives with his wife and was found to have a decreased status since the last one day The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse When the Adult Protective Services actually went to the patient s house he was found to be having decreased consciousness for a whole day by his wife Actually the night before he fell off his wheelchair and had lacerations on the face As per his wife she states that the patient was given an entire mg of Xanax rather than 0 125 mg of Xanax and that is why he has had decreased mental status since then The patient s wife is not able to give a history The patient has not been getting Sinemet and his other home medications in the last 2 days PAST MEDICAL HISTORY Parkinson disease MEDICATIONS Requip Neurontin Sinemet Ambien and Xanax ALLERGIES No known drug allergies SOCIAL HISTORY The patient lives with his wife PHYSICAL EXAMINATION GENERAL Keywords consult history and phy level of consciousness parkinson disease altered mental status dehydration elderly abuse decreased level of consciousness ems parkinson consciousness xanax sinemet decreased MEDICAL_TRANSCRIPTION,Description Nausea vomiting diarrhea and fever Medical Specialty Consult History and Phy Sample Name Gen Med Consult 27 Transcription CHIEF COMPLAINT Nausea vomiting diarrhea and fever HISTORY OF PRESENT ILLNESS This patient is a 76 year old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia She has developed worsening confusion fever and intractable diarrhea She was brought to the emergency department for evaluation Diagnostic studies in the emergency department included a CBC which revealed a white blood cell count of 23 500 and a low potassium level of 2 6 She was admitted to the hospital for treatment of profound hypokalemia dehydration intractable diarrhea and febrile illness PAST MEDICAL HISTORY Recent history of pneumonia urosepsis dementia amputation osteoporosis and hypothyroidism MEDICATIONS Synthroid clindamycin ceftriaxone Remeron Actonel Zanaflex and hydrocodone SOCIAL HISTORY The patient has been residing at South Valley Care Center REVIEW OF SYSTEMS The patient is unable answer review of systems PHYSICAL EXAMINATION GENERAL This is a very elderly cachectic woman lying in bed in no acute distress HEENT Examination is normocephalic and atraumatic The pupils are equal round and reactive to light and accommodation The extraocular movements are full NECK Supple with full range of motion and no masses LUNGS There are decreased breath sounds at the bases bilaterally CARDIOVASCULAR Regular rate and rhythm with normal S1 and S2 and no S3 or S4 ABDOMEN Soft and nontender with no hepatosplenomegaly EXTREMITIES No clubbing cyanosis or edema NEUROLOGIC The patient moves all extremities but does not communicate DIAGNOSTIC STUDIES The CBC shows a white blood cell count of 23 500 hemoglobin 13 0 hematocrit 36 3 and platelets 287 000 The basic chemistry panel is remarkable for potassium 2 6 calcium 7 5 and albumin 2 3 IMPRESSION PLAN 1 Elevated white count This patient is admitted to the hospital for treatment of a febrile illness There is concern that she has a progression of pneumonia She may have aspirated She has been treated with ceftriaxone and clindamycin I will follow her oxygen saturation and chest x ray closely She is allergic to penicillin Therefore clindamycin is the appropriate antibiotic for possible aspiration 2 Intractable diarrhea The patient has been experiencing intractable diarrhea I am concerned about Clostridium difficile infection with possible pseudomembranous colitis I will send her stool for Clostridium difficile toxin assay I will consider treating with metronidazole 3 Hypokalemia The patient s profound hypokalemia is likely secondary to her diarrhea I will treat her with supplemental potassium 4 DNR status I have ad a discussion with the patient s daughter who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy Keywords MEDICAL_TRANSCRIPTION,Description A 2 year old little girl with stuffiness congestion and nasal drainage Allergic rhinitis Medical Specialty Consult History and Phy Sample Name Gen Med Consult 21 Transcription SUBJECTIVE The patient is a 2 year old little girl who comes in with concerns about stuffiness congestion and nasal drainage She does take Zyrtec on a fairly regular basis Mom is having some allergy trouble herself right now She does not know her colors She knows some of her shapes She speaks in sentences She is not showing much interest in the potty She is in the 80th percentile for height and weight and still over 95th percentile for head circumference Mom has no other concerns ALLERGIES Eggs and peanuts OBJECTIVE General Alert very talkative little girl HEENT TMs clear and mobile Eyes PERRL Fundi benign Pharynx clear Mouth moist Nasal mucosa is pale with clear discharge Neck Supple without adenopathy Heart Regular rate and rhythm without murmur Lungs Clear No tachypnea wheezing rales or retractions Abdomen Soft and nontender without mass or organomegaly GU Normal female genitalia Tanner stage I Extremities No clubbing cyanosis or edema Pulses 2 and equal Hips Intact Neurological Normal DTRs are 2 Gait was normal Skin Warm and dry No rashes noted ASSESSMENT Allergic rhinitis Otherwise healthy 2 year old young lady PLAN In addition to her Zyrtec I put her on Nasonex spray one spray each nostril daily If this works for her certainly she can do it through the ragweed season Otherwise she is doing well I talked about ways to improve her potty training She is a very good eater I will see her yearly or p r n Unfortunately she is not able to get the flu shot due to her egg allergy Keywords consult history and phy allergic rhinitis nasal drainage stuffiness congestion drainage MEDICAL_TRANSCRIPTION,Description 11 year old female History of congestion possibly enlarged adenoids Medical Specialty Consult History and Phy Sample Name Gen Med Consult 20 Transcription SUBJECTIVE This is an 11 year old female who comes in for two different things 1 She was seen by the allergist No allergies present so she stopped her Allegra but she is still real congested and does a lot of snorting They do not notice a lot of snoring at night though but she seems to be always like that 2 On her right great toe she has got some redness and erythema Her skin is kind of peeling a little bit but it has been like that for about a week and a half now PAST MEDICAL HISTORY Otherwise reviewed and noted CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY Everyone else is healthy at home REVIEW OF SYSTEMS She has been having the redness of her right great toe but also just a chronic nasal congestion and fullness Review of systems is otherwise negative PHYSICAL EXAMINATION General Well developed female in no acute distress afebrile HEENT Sclerae and conjunctivae clear Extraocular muscles intact TMs clear Nares patent A little bit of swelling of the turbinates on the left Oropharynx is essentially clear Mucous membranes are moist Neck No lymphadenopathy Chest Clear Abdomen Positive bowel sounds and soft Dermatologic She has got redness along the lateral portion of her right great toe but no bleeding or oozing Some dryness of her skin Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short ASSESSMENT 1 History of congestion possibly enlarged adenoids or just her anatomy 2 Ingrown toenail but slowly resolving on its own PLAN 1 For the congestion we will have ENT evaluate Appointment has been made with Dr XYZ for in a couple of days 2 I told her just Neosporin for her toe letting the toenail grow out longer Call if there are problems Keywords consult history and phy enlarged adenoids adenoids oropharynx congestion toenails toe MEDICAL_TRANSCRIPTION,Description Patient with intermittent episodes of severe nausea and abdominal pain Medical Specialty Consult History and Phy Sample Name Gen Med Consult 29 Transcription CHIEF COMPLAINT This is a previously healthy 45 year old gentleman For the past 3 years he has had some intermittent episodes of severe nausea and abdominal pain On the morning of this admission he had the onset of severe pain with nausea and vomiting and was seen in the emergency department where Dr XYZ noted an incarcerated umbilical hernia He was able to reduce this with relief of pain He is now being admitted for definitive repair PAST MEDICAL HISTORY Significant only for hemorrhoidectomy He does have a history of depression and hypertension MEDICATIONS His only medications are Ziac and Remeron ALLERGIES No allergies FAMILY HISTORY Negative for cancer SOCIAL HISTORY He is single He has 2 children He drinks 4 8 beers per night and smokes half a pack per day for 30 years He was born in Salt Lake City He works in an electronic assembly for Harmony Music He has no history of hepatitis or blood transfusions PHYSICAL EXAMINATION GENERAL Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department HEENT No scleral icterus NECK No cervical supraclavicular or axillary adenopathy LUNGS Clear HEART Regular No murmurs or gallops ABDOMEN As noted obese with mildly visible bulging in the umbilicus at the superior position With gentle traction we were able to feel both herniated contents which when reduced reveals an approximately 2 cm palpable defect in the umbilicus DIAGNOSTIC STUDIES Normal sinus rhythm on EKG prolonged QT Chest x ray was negative The abdominal x rays were read as being negative His electrolytes were normal Creatinine was 0 9 White count was 6 5 hematocrit was 48 and platelet count was 307 ASSESSMENT AND PLAN Otherwise previously healthy gentleman who presents with an incarcerated umbilical hernia now for repair with mesh Keywords consult history and phy sinus rhythm ekg prolonged qt platelet count hematocrit umbilical hernia emergency department healthy incarcerated intermittent MEDICAL_TRANSCRIPTION,Description 1 year old male who comes in with a cough and congestion Clinical sinusitis and secondary cough Medical Specialty Consult History and Phy Sample Name Gen Med Consult 18 Transcription SUBJECTIVE This is a 1 year old male who comes in with a cough and congestion for the past two to three weeks Started off as a congestion but then he started coughing about a week ago Cough has gotten worsen Mother was also worried He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that but his breathing has not gotten worse since that happened He is not running any fevers PAST MEDICAL HISTORY Otherwise reviewed Fairly healthy CURRENT MEDICATIONS None ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY The sister is in today with clinical sinusitis Mother and father have been healthy REVIEW OF SYSTEMS He has been congested for about three weeks ago Coughing now but no fevers No vomiting Review of systems is otherwise negative PHYSICAL EXAMINATION General Well developed male in no acute distress afebrile Vital Signs Weight 22 pounds 6 ounces HEENT Sclerae and conjunctivae are clear Extraocular muscles are intact TMs are clear Nares are very congested Oropharynx has drainage in the back of the throat Mucous membranes are moist Mild erythema though Neck Some shotty lymphadenopathy Full range of motion Supple Chest Clear No crackles No wheezes Cardiovascular Regular rate and rhythm Normal S1 S2 Abdomen Positive bowel sounds and soft Dermatologic Clear Tone is good Capillary refill less than 3 seconds RADIOLOGY Chest x ray No foreign body noted as well No signs of pneumonia ASSESSMENT Clinical sinusitis and secondary cough PLAN Amoxicillin a teaspoon twice daily for 10 days Plenty of fluids Tylenol and Motrin p r n as well as oral decongestant and if coughing is not improving Keywords consult history and phy congestion cough sinusitis and secondary cough cough and congestion secondary cough clinical sinusitis male sinusitis MEDICAL_TRANSCRIPTION,Description An 18 month old white male here with his mother for complaint of intermittent fever for the past five days Allergic rhinitis fever history sinusitis resolved and teething Medical Specialty Consult History and Phy Sample Name Gen Med Consult 17 Transcription CHIEF COMPLAINT Fever HISTORY OF PRESENT ILLNESS This is an 18 month old white male here with his mother for complaint of intermittent fever for the past five days Mother states he just completed Amoxil several days ago for a sinus infection Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum Mother states that his temperature usually elevates at night Two days his temperature was 102 6 Mother has not taken it since and in fact she states today he seems much better He is cutting an eye tooth that causes him to be drooling and sometimes fussy He has had no vomiting or diarrhea There has been no coughing Nose secretions are usually discolored in the morning but clear throughout the rest of the day Appetite is fine PHYSICAL EXAMINATION General He is alert in no distress Vital Signs Afebrile HEENT Normocephalic atraumatic Pupils equal round and react to light TMs are clear bilaterally Nares patent Clear secretions present Oropharynx is clear Neck Supple Lungs Clear to auscultation Heart Regular no murmur Abdomen Soft Positive bowel sounds No masses No hepatosplenomegaly Skin Normal turgor ASSESSMENT 1 Allergic rhinitis 2 Fever history 3 Sinusitis resolved 4 Teething PLAN Mother has been advised to continue Zyrtec as directed daily Supportive care as needed Reassurance given and he is to return to the office as scheduled Keywords consult history and phy sinusitis fever intermittent fever allergic rhinitis fever history teething MEDICAL_TRANSCRIPTION,Description 2 year old female who comes in for just rechecking her weight her breathing status and her diet Medical Specialty Consult History and Phy Sample Name Gen Med Consult 19 Transcription SUBJECTIVE This is a 2 year old female who comes in for just rechecking her weight her breathing status and her diet The patient is in foster care has a long history of the prematurity born at 22 weeks She has chronic lung disease is on ventilator but doing sprints has been doing very well is up to 4 1 2 hours sprints twice daily and may go up 15 minutes every three days or so which she has been tolerating fairly well as long as they kind of get her distracted towards the end otherwise she does get sort of tachypneic She is on 2 1 2 liters of oxygen and does require that Her diet has been fluctuating They have been trying to figure out what works best with her She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her They have been doing more pureed foods and that seems to loosen her up so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure She was hospitalized a couple of weeks back for the distension she had in the abdomen Dr XYZ has been working with her G tube increasing her Mic key button size but also doing some silver nitrate applications and he is going to evaluate her again next week but they are happy with the way her G tube site is looking She also has been seen Dr Eisenbaum just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation CURRENT MEDICATIONS Flagyl vitamins Zyrtec albuterol and some Colace ALLERGIES TO MEDICINES None FAMILY SOCIAL HISTORY As mentioned she is in foster care Foster mom is actually going to be out of town for a week the 19th through the 23rd so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient Biological Mom and Grandma do visit on Thursdays for about an hour REVIEW OF SYSTEMS The patient has been eating fairly well sleeping well doing well with her sprints A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI PHYSICAL EXAMINATION Vital Signs She is 28 pounds 8 ounces today 33 1 2 inches tall She is on 2 1 2 liters but she is not the vent currently she is doing her sprints and her respiratory rate is around 40 HEENT Sclerae and conjunctivae are clear TMs are clear Nares are patent Oropharynx is clear Trach site is clear of any signs of infection Chest Coarse She has got little bit of wheezing going on but she is moving air fairly well Abdomen Positive bowel sounds and soft The G tube site looks fairly clean today and healthy No signs of infection Her tone is good Capillary refill is less than three seconds ASSESSMENT A 2 year old with chronic lung disease doing the sprints some bowel difficulties also just weight gain issues because of the high energy expenditure with the sprints that she is doing PLAN At this point is to continue with the Isomil and pureed baby foods a little bit of Pediasure They are going to see Dr XYZ towards the end of this month and follow up with Dr Eisenbaum I would like to see her in approximately six weeks again but we do need to keep a close check on her weight and call if there are problems beforehand She is just doing wonderful progression on her development Each time I see her I am very impressed that relayed to foster mom Approximately 25 minutes spent with the patient most of it counseling Keywords consult history and phy chronic lung disease signs of infection breathing status foster mom foster care pediasure MEDICAL_TRANSCRIPTION,Description Short term memory loss probable situational and anxiety stress issues Medical Specialty Consult History and Phy Sample Name Gen Med Consult 16 Transcription CHIEF COMPLAINT Here with a concern of possibly issues of short term memory loss She is under exceeding amount of stress over the last 5 to 10 years She has been a widow over the last 11 years Her husband died in an MVA from a drunk driver accident She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services She does have an MBA in business Currently she works at T Mobile Customer Service and there is quite a bit of technical knowledge deadlines and stress related to that job as well She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills protocols customer service issues etc She describes the job is very demanding and high stress She denies any history of weakness lethargy or dizziness No history of stroke CURRENT MEDICATIONS Vioxx 25 mg daily HCTZ 25 mg one half tablet daily Zoloft 100 mg daily Zyrtec 10 mg daily ALLERGIES TO MEDICATIONS Naprosyn SOCIAL HISTORY FAMILY HISTORY PAST MEDICAL HISTORY AND SURGICAL HISTORY She has had hypertension very well controlled and history of elevated triglycerides She has otherwise been generally healthy Nonsmoker Please see notes dated 06 28 2004 REVIEW OF SYSTEMS Review of systems is otherwise negative PHYSICAL EXAMINATION Vital Signs Age 60 Weight 192 pounds Blood pressure 134 80 Temperature 97 8 degrees General A very pleasant 60 year old white female in no acute distress Alert ambulatory and nonlethargic HEENT PERRLA EOMs are intact TMs are clear bilaterally Throat is clear Neck Supple No cervical adenopathy Lungs Clear without wheezes or rales Heart Regular rate and rhythm Abdomen Soft nontender to palpation Extremities Moving all extremities well IMPRESSION 1 Short term memory loss probable situational 2 Anxiety stress issues PLAN Thirty minute face to face appointment in counseling with the patient At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn The current job she is at does sound extremely stressful and demanding I think her stress reactions to these as far as feeling frustrated are within normal limits We did complete a mini mental state exam including clock drawing sentence writing signature etc She does score a maximum score of 30 30 and all other tasks were completed without difficulty or any hesitation I did spend quite a bit of time reassuring her as well She is currently on Zoloft 100 mg which I think is an appropriate dose We will have her continue on that She did verbalize understanding and that she actually felt better after our discussion concerning these issues At some point in time however I would possibly recommend job change if this one would persist as far as the stress levels She is going to think about that Keywords consult history and phy short term memory loss anxiety short term memory loss memory loss stress issues situational memory stress MEDICAL_TRANSCRIPTION,Description Complaint of mood swings and tearfulness Medical Specialty Consult History and Phy Sample Name Gen Med Consult 15 Transcription HISTORY OF PRESENT ILLNESS A 50 year old female comes to the clinic with complaint of mood swings and tearfulness This has been problematic over the last several months and is just worsening to the point where it is impairing her work Her boss asks her if she was actually on drugs in which she said no She stated may be she needed to be meaning taking some medications The patient had been prescribed Wellbutrin in the past and responded well to it however at that time it was prescribed for obsessive compulsive type disorder relating to overeating and therefore her insurance would not cover the medication She has not been on any other antidepressants in the past She is not having any suicidal ideation but is having difficulty concentrating rapid mood swings with tearfulness and insomnia She denies any hot flashes or night sweats She underwent TAH with BSO in December of 2003 FAMILY HISTORY Benign breast lump in her mother however her paternal grandmother had breast cancer The patient denies any palpitations urinary incontinence hair loss or other concerns She was recently treated for sinusitis ALLERGIES She is allergic to Sulfa CURRENT MEDICATIONS Recently finished Minocin and Duraphen II DM PHYSICAL EXAMINATION General A well developed and well nourished female conscious alert oriented times three in no acute distress Mood is dysthymic Affect is tearful Skin Without rash Eyes PERRLA Conjunctivae are clear Neck Supple with adenopathy or thyromegaly Lungs Clear Heart Regular rate and rhythm without murmur ASSESSMENT 1 Postsurgical menopause 2 Mood swings PLAN I spent about 30 minutes with the patient discussing treatment options I do believe that her moods would greatly benefit from hormone replacement therapy however she is reluctant to do this because of family history of breast cancer We will try starting her back on Wellbutrin XL 150 mg daily She may increase to 300 mg daily after three to seven days Samples provided initially If she is not obtaining adequate relief from medication alone we will then suggest that we explore the use of hormone replacement therapy I also recommended increasing her exercise We will also obtain some screening lab work including CBC UA TSH chemistry panel and lipid profile Follow up here in two weeks or sooner if any other problems She is needing her annual breast exam as well Keywords consult history and phy tearfulness mood swings menopause postsurgical menopause mood swings and tearfulness hormone replacement therapy breast cancer wellbutrin MEDICAL_TRANSCRIPTION,Description Return to work Fit for duty evaluation Medical Specialty Consult History and Phy Sample Name Gen Med Consult 1 Transcription HISTORY OF PRESENT ILLNESS This is the initial clinic visit for a 29 year old man who is seen for new onset of right shoulder pain He states that this began approximately one week ago when he was lifting stacks of cardboard The motion that he describes is essentially picking up a stack of cardboard at his waist level twisting to the right and delivering it at approximately waist level Sometimes he has to throw the stacks a little bit as well He states he felt a popping sensation on 06 30 04 Since that time he has had persistent shoulder pain with lifting activities He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder He has no upper extremity REVIEW OF SYSTEMS Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies He denies any chronic cardiac pulmonary GI GU neurologic musculoskeletal endocrine abnormalities MEDICATIONS Claritin for allergic rhinitis ALLERGIES None PHYSICAL EXAMINATION Blood pressure 120 90 respirations 10 pulse 72 temperature 97 2 He is sitting upright alert and oriented and in no acute distress Skin is warm and dry Gross neurologic examination is normal ENT examination reveals normal oropharynx nasopharynx and tympanic membranes Neck Full range of motion with no adenopathy or thyromegaly Cardiovascular Regular rate and rhythm Lungs Clear Abdomen Soft Keywords consult history and phy return to work consult fit for duty cleared for work muscular paresthesias shoulder shoulder pain strain waist x rays waist level neurologic abnormalities impingement examination MEDICAL_TRANSCRIPTION,Description Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery Medical Specialty Consult History and Phy Sample Name Gastric Bypass Discussion 3 Transcription PAST MEDICAL HISTORY Significant for hypertension The patient takes hydrochlorothiazide for this She also suffers from high cholesterol and takes Crestor She also has dry eyes and uses Restasis for this She denies liver disease kidney disease cirrhosis hepatitis diabetes mellitus thyroid disease bleeding disorders prior DVT HIV and gout She also denies cardiac disease and prior history of cancer PAST SURGICAL HISTORY Significant for tubal ligation in 1993 She had a hysterectomy done in 2000 and a gallbladder resection done in 2002 MEDICATIONS Crestor 20 mg p o daily hydrochlorothiazide 20 mg p o daily Veramist spray 27 5 mcg daily Restasis twice a day and ibuprofen two to three times a day ALLERGIES TO MEDICATIONS Bactrim which causes a rash The patient denies latex allergy SOCIAL HISTORY The patient is a life long nonsmoker She only drinks socially one to two drinks a month She is employed as a manager at the New York department of taxation She is married with four children FAMILY HISTORY Significant for type II diabetes on her mother s side as well as liver and heart failure She has one sibling that suffers from high cholesterol and high triglycerides REVIEW OF SYSTEMS Positive for hot flashes She also complains about snoring and occasional slight asthma She does complain about peripheral ankle swelling and heartburn She also gives a history of hemorrhoids and bladder infections in the past She has weight bearing joint pain as well as low back degenerating discs She denies obstructive sleep apnea kidney stones bloody bowel movements ulcerative colitis Crohn s disease dark tarry stools and melena PHYSICAL EXAMINATION On examination temperature is 97 7 pulse 84 blood pressure 126 80 respiratory rate was 20 Well nourished well developed in no distress Eye exam pupils equal round and reactive to light Extraocular motions intact Neuro exam deep tendon reflexes 1 in the lower extremities No focal neuro deficits noted Neck exam nonpalpable thyroid midline trachea no cervical lymphadenopathy no carotid bruit Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished Cardiac exam regular rate and rhythm without murmur or bruit Abdominal exam positive bowel sounds soft nontender obese nondistended abdomen No palpable tenderness No right upper quadrant tenderness No organomegaly appreciated No obvious hernias noted Lower extremity exam 1 edema noted Positive dorsalis pedis pulses ASSESSMENT The patient is a 56 year old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities The patient is interested in gastric bypass surgery The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities PLAN In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively I have recommended six weeks of Medifast for the patient to obtain a 10 preoperative weight loss Keywords consult history and phy weight watchers roux en y atkins medifast meridia south beach cabbage diets laparoscopic roux en y gastric bypass surgery rice weight loss six weeks of medifast weight loss modalities body mass index gastric bypass surgery bariatric surgery gastric bypass MEDICAL_TRANSCRIPTION,Description Patient scheduled for laparoscopic gastric bypass Medical Specialty Consult History and Phy Sample Name Gastric Bypass Discussion 2 Transcription HISTORY The patient is scheduled for laparoscopic gastric bypass The patient has been earlier seen by Dr X her physician She has been referred to us from Family Practice In short she is a 33 year old lady with a BMI of 43 otherwise healthy with unsuccessful nonsurgical methods of weight loss She was on laparoscopic gastric bypass for weight loss She meets the National Institute of Health Criteria She is very well educated and motivated and has no major medical contraindications for the procedure PHYSICAL EXAMINATION On physical examination today she weighs 216 pounds with a BMI of 43 5 pulse is 96 temperature is 97 6 blood pressure is 122 80 Lungs are clear Abdomen is soft nontender There is stigmata for morbid obesity She has cesarean section scars in the lower abdomen with no herniation DISCUSSION I had a long talk with the patient about laparoscopic gastric bypass possible open including risks benefits alternatives need for long term followup need to adhere to dietary and exercise guidelines I also explained to her complications including rare cases of death secondary to DVT PE leak peritonitis sepsis shock multisystem organ failure need for re operation including for leak or bleeding gastrostomy or jejunostomy for feeding rare case of respiratory failure requiring mechanical ventilation etc with myocardial infarction pneumonia atelectasis in the postoperative period were also discussed Short term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation marginal ulcer secondary to smoking or anti inflammatory drug intake which can progress on to perforation or bleeding small bowel obstruction secondary to internal hernia or adhesions signs and symptoms of which were discussed The patient would alert us for earlier intervention Symptomatic gallstone formation secondary to rapid weight loss were also discussed How to avoid it by taking ursodiol were also discussed Long term complications of gastric bypass including hair loss excess skin multivitamin and mineral deficiencies protein calorie malnutrition weight regain weight plateauing need for major lifestyle and exercise and habit changes avoiding pregnancy in the first two years etc were all stressed The patient understands She wants to go to surgery In preparation of surgery she will undergo very low calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities She will also see a psychologist nutritionist and exercise physiologist for a multidisciplinary effort for short and long term success for weight loss surgery I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time Keywords consult history and phy medifast laparoscopic gastric bypass short term complications long term complications gastric bypass complications of gastric bypass weight loss MEDICAL_TRANSCRIPTION,Description Pediatric Gastroenterology History of gagging Medical Specialty Consult History and Phy Sample Name Gagging 3 year old Transcription HISTORY OF PRESENT ILLNESS This is a 3 year old female patient who was admitted today with a history of gagging She was doing well until about 2 days ago when she developed gagging No vomiting No fever She has history of constipation She normally passes stool every two days after giving an enema No rectal bleeding She was brought to the Hospital with some loose stool She was found to be dehydrated She was given IV fluid bolus but then she started bleeding from G tube site There was some fresh blood coming out of the G tube site She was transferred to PICU She is hypertensive Intensivist Dr X requested me to come and look at her and do upper endoscopy to find the site of bleeding PAST MEDICAL HISTORY PEHO syndrome infantile spasm right above knee amputation developmental delay G tube fundoplication PAST SURGICAL HISTORY G tube fundoplication on 05 25 2007 Right above knee amputation ALLERGIES None DIET She is NPO now but at home she is on PediaSure 4 ounces 3 times a day through G tube 12 ounces of water per day MEDICATIONS Albuterol Pulmicort MiraLax 17 g once a week carnitine phenobarbital Depakene and Reglan FAMILY HISTORY Positive for cancer PAST LABORATORY EVALUATION On 12 27 2007 WBC 9 3 hemoglobin 7 6 hematocrit 22 1 platelet 132 000 KUB showed large stool with dilated small and large bowel loops Sodium 140 potassium 4 4 chloride 89 CO2 21 BUN 61 creatinine 2 AST 92 increased ALT 62 increased albumin 5 3 total bilirubin 0 1 Earlier this morning she had hemoglobin of 14 5 hematocrit 41 3 platelets 491 000 PT 58 increased INR 6 6 increased PTT 75 9 increased PHYSICAL EXAMINATION VITAL SIGNS Temperature 99 degrees Fahrenheit pulse 142 per minute respirations 34 per minute weight 8 6 kg GENERAL She is intubated HEENT Atraumatic She is intubated LUNGS Good air entry bilaterally No rales or wheezing ABDOMEN Distended Decreased bowel sounds GENITALIA Grossly normal female CNS She is sedated IMPRESSION A 3 year old female patient with history of passage of blood through G tube site with coagulopathy She has a history of G tube fundoplication developmental delay PEHO syndrome which is progressive encephalopathy optic atrophy PLAN Plan is to give vitamin K FFP blood transfusion Consider upper endoscopy Procedure and informed consent discussed with the family Keywords consult history and phy g tube peho syndrome tube site gagging constipation endoscopy peho hemoglobin hematocrit intubated bleeding blood fundoplication tube MEDICAL_TRANSCRIPTION,Description Foreign body of the left fifth fingernail wooden splinter He attempted to remove it with tweezers at home but was unsuccessful He is requesting we attempt to remove this for him Medical Specialty Consult History and Phy Sample Name Foreign Body Fingernail Transcription HISTORY OF PRESENT ILLNESS Patient is a 72 year old white male complaining of a wooden splinter lodged beneath his left fifth fingernail sustained at 4 p m yesterday He attempted to remove it with tweezers at home but was unsuccessful He is requesting we attempt to remove this for him The patient believes it has been over 10 years since his last tetanus shot but states he has been allergic to previous immunizations primarily with horse serum Consequently he has declined to update his tetanus immunization MEDICATIONS He is currently on several medications a list of which is attached to the chart and was reviewed He is not on any blood thinners ALLERGIES HE IS ALLERGIC ONLY TO TETANUS SERUM SOCIAL HISTORY Patient is married and is a nonsmoker and lives with his wife Nursing notes were reviewed with which I agree PHYSICAL EXAMINATION VITAL SIGNS Temp and vital signs are all within normal limits GENERAL The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress EXTREMITIES Exam of the left fifth finger shows a 5 to 6 mm splinter lodged beneath the medial aspect of the nail plate It does not protrude beyond the end of the nail plate There is no active bleeding There is no edema or erythema of the digit tip Flexion and extension of the DIP joint is intact The remainder of the hand is unremarkable TREATMENT I did attempt to grasp the end of the splinter with splinter forceps but it is brittle and continues to break off In order to better grasp the splinter will require penetration beneath the nail plate which the patient cannot tolerate due to pain Consequently the base of the digit tip was prepped with Betadine and just distal to the DIP joint a digital block was applied with 1 lidocaine with complete analgesia of the digit tip I was able to grasp the splinter and remove this No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage ASSESSMENT Foreign body of the left fifth fingernail wooden splinter PLAN Patient was urged to clean the area b i d with soap and water and to dress with bacitracin and a Band Aid If he notes increasing redness pain or swelling he was urged to return for re evaluation Keywords consult history and phy horse serum wooden splinter foreign body nail plate grasp fingernail splinter MEDICAL_TRANSCRIPTION,Description Gentleman with long standing morbid obesity resistant to nonsurgical methods of weight loss with BMI of 69 7 Medical Specialty Consult History and Phy Sample Name Gastric Bypass Discussion 1 Transcription HISTORY OF PRESENT ILLNESS In short the patient is a 55 year old gentleman with long standing morbid obesity resistant to nonsurgical methods of weight loss with BMI of 69 7 with comorbidities of hypertension atrial fibrillation hyperlipidemia possible sleep apnea and also osteoarthritis of the lower extremities He is also an ex smoker He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT PE rates and marginal ulcer problems after surgery which will be discussed later on PHYSICAL EXAMINATION On physical examination today he weighs 514 8 pounds he has gained 21 pounds since the last visit with us His pulse is 78 temperature is 97 5 blood pressure is 132 74 Lungs are clear He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size Abdomen is soft nontender No incisions No umbilical hernia no groin hernia has a large abdominal pannus No hepatosplenomegaly Lower extremities no pedal edema No calf tenderness Deep tendon reflexes are normal Lungs are clear S1 S2 is heard Regular rate and rhythm DISCUSSION I had a long talk with the patient about laparoscopic gastric bypass possible open including risks benefits alternatives need for long term followup need to adhere to dietary and exercise guidelines I also explained to him complications including rare cases of death secondary to DVT PE leak peritonitis sepsis shock multisystem organ failure need for reoperations need for endoscopy for bleeding or leak operations which could be diagnostic laparoscopy exploratory laparotomy drainage procedure gastrostomy jejunostomy for feeding bleeding requiring blood transfusion myocardial infarction pneumonia atelectasis respiratory failure requiring mechanical ventilation rarely tracheostomy rare cases of renal failure requiring dialysis etc were all discussed All these are going to be at high risk for this patient secondary to his supermorbid obese condition I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation marginal ulcer secondary to smoking or antiinflammatory drug intake which can progress on to perforation or bleeding small bowel obstruction secondary to internal hernia or adhesions signs and symptoms of which are described so the patient could alert us for earlier intervention symptomatic gallstone formation during rapid weight loss how to avoid it by taking ursodiol which will be prescribed in the postoperative period Long term complication of gastric bypass including hair loss excess skin multivitamin and mineral deficiencies protein calorie malnutrition weight regain weight plateauing psychosocial and marital issues addiction transfer etc were all discussed with the patient The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk He will be seen by cardiologist pulmonologist He will also undergo long Medifast dieting under our guidance which is a very low calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities He will also see a psychologist nutritionist and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long term success Especially for him in view of his restricted mobility supermorbid obesity status and possibility of a pulmonary hypertension secondary to sleep apnea he has been advised to have retrievable IVC filter and also will go home on Lovenox He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so All these were discussed with the patient The patient understands He wants to go to surgery All questions were answered I will see him in few weeks before the planned date of surgery Keywords consult history and phy medifast medifast dieting hypertension atrial fibrillation hyperlipidemia sleep apnea morbid obesity metabolic comorbidities weight loss supermorbid obesity gastric bypass bypass MEDICAL_TRANSCRIPTION,Description Abscess of the left foot etiology unclear at this time Possibility of foreign body Medical Specialty Consult History and Phy Sample Name Foot Infection Management Transcription REASON FOR CONSULTATION Management for infection of the left foot HISTORY The patient is a 26 year old short Caucasian male who appears in excellent health presented a week ago as he felt some pain in the ball of his left foot He noticed a small dark spot He did not remember having had any injuries to that area specifically no puncture wounds He had not been doing any outdoor works or activities No history of working outdoors has not been to the beach or to the lake has not been out of town His swelling progressed so he went to see Dr X 4 days ago The area was debrided in the office and he was placed on Keflex It was felt that may be he had a foreign body but nothing was found in the office and x ray was negative for opaque foreign bodies His foot got worse with more swelling and at this time purulent too red and was admitted to the hospital today is scheduled for surgical exploration this evening Ancef and Cipro were prescribed today He denies any fever chills red streaks lymphadenitis He had a tetanus shot in 2002 most recently He had childhood asthma He uses alcohol socially He works full time He is an electrician ALLERGIES ACCUTANE PHYSICAL EXAMINATION GENERAL Well developed well nourished adult Caucasian male in no acute distress VITAL SIGNS His weight is 190 pounds height 69 inches temperature 98 respirations 20 pulse 78 and blood pressure 143 63 O2 sat 98 on room air HEENT Mouth unremarkable NECK Supple LUNGS Clear HEART Regular rate rhythm No murmur or gallop ABDOMEN Soft and nontender EXTREMITIES Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema There is bloodied blister around it The area is tender to touch warm with a slight edema of the rest of the foot with very faint erythema There is some mild intertrigo between the fourth and fifth left toes Palpable pedal pulses Leg unremarkable No femoral or inguinal lymphadenopathy LABORATORY Labs show white cell count of 6300 hemoglobin 13 6 platelet count of _____ with 80 monos 17 eos _____ creatinine 1 3 BUN of 16 glucose 110 Calcium ferritin albumin bilirubin ALT AST alkaline phosphatase are normal PT and PTT normal and the sed rate was 35 mm per hour IMPRESSION Abscess of the left foot etiology unclear at this time Possibility of foreign body RECOMMENDATIONS PLAN He is going to be discharged in about half an hour Cultures Gram stain fungal cultures and smear to be obtained I have changed his antibiotic to vancomycin plus Maxipime He is currently on tetanus immunizations so no need for booster at this time Keywords consult history and phy accutane possibility of foreign body foot etiology foreign body infection foot abscess MEDICAL_TRANSCRIPTION,Description Consultation for left foot pain Medical Specialty Consult History and Phy Sample Name Foot pain Consultation Transcription CHIEF COMPLAINT Left foot pain HISTORY XYZ is a basketball player for University of Houston who sustained an injury the day prior They were traveling He came down on another player s foot sustaining what he describes as an inversion injury Swelling and pain onset immediately He was taped but was able to continue playing He was examined by John Houston the trainer and had tenderness around the navicular so was asked to come over and see me for evaluation He has been in a walking boot He has been taped firmly Pain with weightbearing activities He is limping a bit No significant foot injuries in the past Most of his pain is located around the dorsal aspect of the hindfoot and midfoot PHYSICAL EXAM He does have some swelling from the hindfoot out toward the midfoot His arch is maintained His motion at the ankle and subtalar joints is preserved Forefoot motion is intact He has pain with adduction and abduction across the hindfoot Most of this discomfort is laterally His motor strength is grossly intact His sensation is intact and his pulses are palpable and strong His ankle is not tender He has minimal to no tenderness over the ATFL He has no medial tenderness along the deltoid or the medial malleolus His anterior drawer is solid His external rotation stress is not painful at the ankle His tarsometatarsal joints specifically 1 2 and 3 are nontender His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus Some tenderness over the dorsolateral side of the talonavicular joint as well The medial talonavicular joint is not tender RADIOGRAPHS Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic I don t see a definite fracture The tarsometarsal joints are anatomically aligned Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified Review of an MR scan of the ankle dated 12 01 05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area Also some changes along the dorsal talonavicular joint I don t see any significant marrow edema or definitive fracture line IMPRESSION Left Chopart joint sprain PLAN I have spoken to XYZ about this Continue with ice and boot for weightbearing activities We will start him on a functional rehab program and progress him back to activities when his symptoms allow He is clear on the prolonged duration of recovery for these hindfoot type injuries Keywords consult history and phy foot pain calcaneocuboid joint dorsal aspect dorsal talonavicular joint foot injuries hindfoot midfoot rehab program walking boot weightbearing talonavicular joint dorsal talonavicular ankle foot tenderness MEDICAL_TRANSCRIPTION,Description Questionable foreign body right nose Belly and back pain Mild constipation Medical Specialty Consult History and Phy Sample Name Foreign Body Right Nose Transcription CHIEF COMPLAINT Questionable foreign body right nose Belly and back pain SUBJECTIVE Mr ABC is a 2 year old boy who is brought in by parents stating that the child keeps complaining of belly and back pain This does not seem to be slowing him down They have not noticed any change in his urine or bowels They have not noted him to have any fevers or chills or any other illness They state he is otherwise acting normally He is eating and drinking well He has not had any other acute complaints although they have noted a foul odor coming from his nose Apparently he was seen here a few weeks ago for a foreign body in the right nose which was apparently a piece of cotton this was removed and placed on antibiotics His nose got better and then started to become malodorous again Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there Otherwise he has not had any runny nose earache no sore throat He has not had any cough congestion He has been acting normally Eating and drinking okay No other significant complaints He has not had any pain with bowel movement or urination nor have they noted him to be more frequently urinating then again he is still on a diaper PAST MEDICAL HISTORY Otherwise negative ALLERGIES No allergies MEDICATIONS No medications other than recent amoxicillin SOCIAL HISTORY Parents do smoke around the house PHYSICAL EXAMINATION VITAL SIGNS Stable He is afebrile GENERAL This is a well nourished well developed 2 year old little boy who is appearing very healthy normal for his stated age pleasant cooperative in no acute distress looks very healthy afebrile and nontoxic in appearance HEENT TMs canals are normal Left naris normal Right naris there is some foul odor as well as questionable purulent drainage Examination of the nose there was a foreign body noted which was the appearance of a cotton ball in the right nose that was obviously infected and malodorous This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual There was some erythema No other purulent drainage noted There was some bloody drainage This was suctioned and all mucous membranes were visualized and are negative NECK Without lymphadenopathy No other findings HEART Regular rate and rhythm LUNGS Clear to auscultation ABDOMEN His abdomen is entirely benign soft nontender nondistended Bowel sounds active No organomegaly or mass noted BACK Without any findings Diaper area normal GU No rash or infections Skin is intact ED COURSE He also had a P Bag placed but did not have any urine Therefore a straight catheter was done which was done with ease without complication and there was no leukocytes noted within the urine There was a little bit of blood from catheterization but otherwise normal urine X ray noted some stool within the vault Child is acting normally He is jumping up and down on the bed without any significant findings ASSESSMENT 1 Infected foreign body right naris 2 Mild constipation PLAN As far as the abdominal pain is concerned they are to observe for any changes Return if worse follow up with the primary care physician The right nose I will place the child on amoxicillin 125 per 5 mL 1 teaspoon t i d Return as needed and observe for more foreign bodies I suspect the child had placed this cotton ball in his nose again after the first episode Keywords MEDICAL_TRANSCRIPTION,Description Left flank pain ureteral stone Medical Specialty Consult History and Phy Sample Name Flank Pain Consult 1 Transcription REASON FOR CONSULTATION Left flank pain ureteral stone BRIEF HISTORY The patient is a 76 year old female who was referred to us from Dr X for left flank pain The patient was found to have a left ureteral stone measuring about 1 3 cm in size per the patient s history The patient has had pain in the abdomen and across the back for the last four to five days The patient has some nausea and vomiting The patient wants something done for the stone The patient denies any hematuria dysuria burning or pain The patient denies any fevers PAST MEDICAL HISTORY Negative PAST SURGICAL HISTORY Years ago she had surgery that she does not recall MEDICATIONS None ALLERGIES None REVIEW OF SYSTEMS Denies any seizure disorder chest pain denies any shortness of breath denies any dysuria burning or pain denies any nausea or vomiting at this time The patient does have a history of nausea and vomiting but is doing better PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile Vitals are stable HEART Regular rate and rhythm ABDOMEN Soft left sided flank pain and left lower abdominal pain The rest of the exam is benign LABORATORY DATA White count of 7 8 hemoglobin 13 8 and platelets 234 000 The patient s creatinine is 0 92 ASSESSMENT 1 Left flank pain 2 Left ureteral stone 3 Nausea and vomiting PLAN Plan for laser lithotripsy tomorrow Options such as watchful waiting laser lithotripsy and shockwave lithotripsy were discussed The patient has a pretty enlarged stone Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed The patient understood that the success of the surgery may be or may not be 100 that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting The patient understood all the risk benefits of the procedure and wanted to proceed Need for stent was also discussed with the patient The patient will be scheduled for surgery tomorrow Plan for continuation of the antibiotics obtain urinalysis and culture and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow Keywords consult history and phy flank pain ureteral stone shockwave lithotripsy shockwave nausea vomiting lithotripsy ureteral stone MEDICAL_TRANSCRIPTION,Description Left flank pain and unable to urinate Medical Specialty Consult History and Phy Sample Name Flank Pain Consult Transcription CHIEF COMPLAINT Left flank pain and unable to urinate HISTORY The patient is a 46 year old female who presented to the emergency room with left flank pain and difficulty urinating Details are in the history and physical She does have a vague history of a bruised left kidney in a motor vehicle accident She feels much better today I was consulted by Dr X MEDICATIONS Ritalin 50 a day ALLERGIES To penicillin PAST MEDICAL HISTORY ADHD SOCIAL HISTORY No smoking alcohol or drug abuse PHYSICAL EXAMINATION She is awake alert and quite comfortable Abdomen is benign She points to her left flank where she was feeling the pain DIAGNOSTIC DATA Her CAT scan showed a focal ileus in left upper quadrant but no thickening no obstruction no free air normal appendix and no kidney stones LABORATORY WORK Showed white count 6200 hematocrit 44 7 Liver function tests and amylase were normal Urinalysis 3 bacteria IMPRESSION 1 Left flank pain question etiology 2 No evidence of surgical pathology 3 Rule out urinary tract infection PLAN 1 No further intervention from my point of view 2 Agree with discharge and followup as an outpatient Further intervention will depend on how she does clinically She fully understood and agreed Keywords consult history and phy flank pain unable to urinate urinary tract infection flank MEDICAL_TRANSCRIPTION,Description This 62 year old white female has essential tremor and mild torticollis Tremor not bothersome for most activities of daily living but she does have a great difficulty writing which is totally illegible Medical Specialty Consult History and Phy Sample Name Essential Tremor Torticollis Transcription REASON FOR CONSULT Essential tremor and torticollis HISTORY OF PRESENT ILLNESS This is a 62 year old right handed now left handed white female with tremor since 5th grade She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam She thinks that her clonazepam is helping her a lot especially with anxiety and stress and this makes the tremor better She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day to day activity Since around 6 to 7 years she has had a head tremor which is mainly no no and occasional voice tremor also Additionally the patient has been diagnosed with migraine headaches without aura which are far and few apart She also has some stress incontinence Last MRI brain was done in 2001 reportedly normal CURRENT MEDICATIONS 1 Klonopin 0 5 mg twice a day 2 Primidone 100 mg b i d 3 Propranolol long acting 80 mg once in the morning PAST MEDICAL HISTORY Essential tremor cervical dystonia endometriosis migraine headaches without aura left ear sensorineural deafness and basal cell carcinoma resection on the nose PAST SURGICAL HISTORY L5 S1 lumbar laminectomy in 1975 exploratory laparotomy in 1967 tonsillectomy and adenoidectomy and anal fissure surgery in 1975 FAMILY HISTORY Both parents have ET and hypertension Maternal cousin with lupus SOCIAL HISTORY Denies any smoking or alcohol She is married since 44 years has 3 children She used to work as a labor and delivery nurse up until early 2001 when she retired REVIEW OF SYSTEMS No fever chills nausea or vomiting No visual complaints She complains of hearing decreased on the left No chest pain or shortness of breath No constipation She does give a history of urge incontinence No rashes No depressive symptoms PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 131 72 pulse is 50 and weight is 71 3 kg HEENT PERRLA EOMI CARDIOVASCULAR S1 and S2 normal Regular rate and rhythm She does have a rash over the right ankle with a prior basal cell carcinoma was resected NEUROLOGIC Alert and oriented x4 Speech shows a voice tremor occasionally Language is intact Cranial nerves II through XII intact Motor examination showed 5 5 power in all extremities with minimal increased tone Sensory examination was intact to light touch Reflexes were brisk bilaterally but they were equal and both toes were downgoing Her coordination showed minimal intentional component to bilateral finger to nose Gait was intact Lot of swing on Romberg s The patient did have a tremor both upper extremities right more than left She did have a head tremor which was no no variety and she had a minimal torticollis with her head twisted to the left ASSESSMENT AND PLAN This 62 year old white female has essential tremor and mild torticollis Tremor not bothersome for most activities of daily living but she does have a great difficulty writing which is totally illegible The patient did not wish to change any of her medication doses at this point We will go ahead and check MRI brain and we will get the films later We will see her back in 3 months Also the patient declined any possible Botox for the mild torticollis she has at this point Keywords consult history and phy clonazepam difficulty writing head tremor voice tremor migraine headaches mri brain essential tremor torticollis carcinoma MEDICAL_TRANSCRIPTION,Description Fall with questionable associated loss of consciousness Left parietal epidural hematoma Medical Specialty Consult History and Phy Sample Name Epidural Hematoma Transcription CC Fall with questionable associated loss of consciousness HX This 81 y o RHM fell down 20 steps on the evening of admission 1 10 93 while attempting to put his boots on at the top of the staircase He was evaluated locally and was amnestic to the event at the time of examination A HCT scan was obtained and he was transferred to UIHC Neurosurgery MEDS Lasix 40mg qd Zantac 150mg qd Lanoxin 0 125mg qd Capoten 2 5mg bid Salsalate 750mg tid ASA 325mg qd Ginsana Ginseng 100mg bid PMH 1 Atrial fibrillation 2 Right hemisphere stroke 11 22 88 with associated left hemiparesis and amaurosis fugax This was followed by a RCEA 12 1 88 for 98 stenosis The stroke symptoms signs resolved 3 DJD 4 Right TKR 2 3 years ago 5 venous stasis with no h o DVT 6 former participant in NASCET 7 TURP for BPH No known allergies FHX Father died of an MI at unknown age Mother died of complications of a dental procedure He has one daughter who is healthy SHX Married Part time farmer Denied tobacco ETOH illicit drug use EXAM BP157 86 HR100 and irregular RR20 36 7C 100 SaO2 MS A O to person place time Speech fluent and without dysarthria CN Pupils 3 3 decreasing to 2 2 on exposure to light EOM intact VFFTC Optic disks were flat Face was symmetric with symmetric movement The remainder of the CN exam was unremarkable Motor 5 5 strength throughout with normal muscle tone and bulk Sensory unremarkable Coord unremarkable Station Gait not mentioned in chart Reflexes symmetric Plantar responses were flexor bilaterally Gen Exam CV IRRR without murmur Lungs CTA Abdomen NT ND NBS HEENT abrasion over the right forehead Extremity distal right leg edema erythema just above the ankle tender to touch COURSE 1 10 93 outside HCT was reviewed It revealed a left parietal epidural hematoma GS PT PTT UA and CBC were unremarkable RLE XR revealed a fracture of the right lateral malleolus for which he was casted Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH Keywords consult history and phy loss of consciousness parietal epidural hematoma parietal epidural epidural hematoma consciousness epidural hematoma MEDICAL_TRANSCRIPTION,Description Fall loss of consciousness Medical Specialty Consult History and Phy Sample Name Epidural Fluid Collection Transcription CC Fall loss of consciousness HX This 44y o male fell 15 20feet from a construction site scaffold landing on his head on a cement sidewalk He was transported directly from the scene approximately one mile east of UIHC The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage but upon evaluation in the ER was found to be in his esophagus and was immediately replaced into the trachea Replacement of the ET tube required succinylcholine The patient remained in a C collar during the procedure Once in the ER the patient had a 15min period of bradycardia MEDS none prior to accident PMH No significant chronic or recent illness s p left knee arthroplasty h o hand fractures FHX Unremarkable SHX Married Rare cigarette use Occasional Marijuana use Social ETOH use per wife EXAM BP156 79 HR 74 RR Ambu Bag ventilation via ET tube 34 7C 72 100 O2Sat MS Unresponsive to verbal stimulation No spontaneous verbalization CN Does not open close eyes to command or spontaneously Pupils 9 7 and nonreactive Corneas Gag Oculocephalic and Oculovestibular reflexes not performed Motor minimal spontaneous movement of the 4 extremities Sensory withdraws LUE and BLE to noxious stimulation Coord Station Gait Not tested Reflexes 1 2 and symmetric throughout Babinski signs were present bilaterally HEENT severe facial injury with brain parenchyma and blood from the right nostril Severe soft tissue swelling about side of head Gen Exam CV RRR without murmur Lungs CTA Abdomen distended after ET tube misplacement COURSE HCT upon arrival 10 29 92 revealed Extensive parenchymal contusions in right fronto parietal area Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle Considerable mass effect is exerted upon the right lateral ventricle near totally obliterating its contour Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area There are extensive fractures of the following two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone as well as the greater wing of the sphenoid Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right Extensive comminution of the right half of the frontal bone and marked displacement is seen Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells The medial and lateral walls of the maxillary sinus are fractured and minimally displaced as well as the medial wall of the left maxillary sinus The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly Portable chest c spine and abdominal XRays were unremarkable but limited studies Abdominal CT was unremarkable Hgb 10 4g dl Hct29 WBC17 4k mm3 Plt 190K ABG 7 28 48 46 on admission Glucose 131 The patient was hyperventilated Mannitol was administered 1g kg and the patient was given a Dilantin loading dose He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures The patient remained in a persistent vegetative state at UIHC and upon the request of this wife his feeding tube was discontinued He later expired Keywords consult history and phy loss of consciousness soft tissue swelling medial wall maxillary sinus sphenoid collection tube bone MEDICAL_TRANSCRIPTION,Description Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy Medical Specialty Consult History and Phy Sample Name ENT Consult 1 Transcription CHIEF COMPLAINT Chronic otitis media adenoid hypertrophy HISTORY OF PRESENT ILLNESS The patient is a 2 1 2 year old with a history of persistent bouts of otitis media superimposed upon persistent middle ear effusions He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes ALLERGIES None MEDICATIONS Antibiotics p r n FAMILY HISTORY Diabetes heart disease hearing loss allergy and cancer MEDICAL HISTORY Unremarkable SURGICAL HISTORY None SOCIAL HISTORY Some minor second hand tobacco exposure There are no pets in the home PHYSICAL EXAMINATION Ears are well retracted immobile Tympanic membranes with effusions present bilaterally No severe congestions thick mucoid secretions no airflow Oral cavity Oropharynx 2 to 3 tonsils No exudates Floor of mouth and tongue are normal Larynx and pharynx not examined Neck No nodes masses or thyromegaly Lungs Reveal rare rhonchi otherwise clear Cardiac exam Regular rate and rhythm No murmurs Abdomen Soft nontender Positive bowel sounds Neurologic exam Nonfocal IMPRESSION Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy PLAN The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes Keywords consult history and phy chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media adenoid hypertrophy pe tubes otitis media with effusion adenoidectomy and bilateral myringotomy eustachian tube dysfunction insertion of pe chronic otitis media bilateral myringotomy otitis media adenoidectomy myringotomy adenoid hypertrophy otitis media MEDICAL_TRANSCRIPTION,Description Left elbow pain Fracture of the humerus spiral Possible nerve injuries to the radial and median nerve possibly neurapraxia Medical Specialty Consult History and Phy Sample Name Elbow Pain Consult Transcription CHIEF COMPLAINT Left elbow pain HISTORY OF PRESENT ILLNESS This 17 year old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow causing sudden pain He also has pain in his left ankle but he is able to walk normally He has had previous pain in his left knee He denies any passing out any neck pain at this time even though he did get hit in the head He has no chest or abdominal pain Apparently no knives or guns were involved PAST MEDICAL HISTORY He has had toe problems and left knee pain in the past REVIEW OF SYSTEMS No coughing sputum production dyspnea or chest pain No vomiting or abdominal pain No visual changes No neurologic deficits other than some numbness in his left hand SOCIAL HISTORY He is in Juvenile Hall for about 25 more days He is a nonsmoker ALLERGIES MORPHINE CURRENT MEDICATIONS Abilify PHYSICAL EXAMINATION VITAL SIGNS Stable HEENT PERRLA EOMI Conjunctivae anicteric Skull is normocephalic He is not complaining of bruising HEENT TMs and canals are normal There is no Battle sign NECK Supple He has good range of motion Spinal processes are normal to palpation LUNGS Clear CARDIAC Regular rate No murmurs or rubs EXTREMITIES Left elbow is tender He does not wish to move it at all Shoulder and clavicle are within normal limits Wrist is normal to inspection He does have some pain to palpation Hand has good capillary refill He seems to have decreased sensation in all three dermatomes He has moderately good abduction of all fingers He has moderate opponens strength with his thumb He has very good extension of all of his fingers with good strength We did an x ray of his elbow He has a spiral fracture of the distal one third of the humerus about 13 cm in length The proximal part looks like it is in good position The distal part has about 6 mm of displacement There is no significant angulation The joint itself appears to be intact The fracture line ends where it appears above the joint I do not see any extra blood in the joint I do not see any anterior or posterior Siegert sign I spoke with Dr X He suggests we go ahead and splint him up and he will follow the patient up At this point it does not seem like there needs to be any surgical revision The chance of a compartment syndrome seems very low at this time Using 4 inch Ortho Glass and two assistants we applied a posterior splint to immobilize his fingers hand and wrist all the way up to his elbow to well above the elbow He had much better comfort once this was applied There was good color to his fingers and again much better comfort Once that was on I took some 5 inch Ortho Glass and put in extra reinforcement around the elbow so he would not be moving it straightening it or breaking the fiberglass We then gave him a sling We gave him 2 Vicodin p o and 4 to go Gave him a prescription for 15 more and warned him to take it only at nighttime and use Tylenol or Motrin and ice in the daytime I gave him the name and telephone number of Dr X whom they can follow up with They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems DIAGNOSES 1 Fracture of the humerus spiral 2 Possible nerve injuries to the radial and median nerve possibly neurapraxia 3 Psychiatric disorder unspecified DISPOSITION The patient will follow up as mentioned above They can return here anytime as needed Keywords MEDICAL_TRANSCRIPTION,Description Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets Medical Specialty Consult History and Phy Sample Name Ecstasy Ingestion ER Visit Transcription CHIEF COMPLAINT I took Ecstasy HISTORY OF PRESENT ILLNESS This is a 17 year old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight the patient ended up taking a total of six Ecstasy tablets The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody nonbilious emesis Mother called the EMS service when the patient vomited On arrival here the patient states that she no longer has any nausea and that she feels just fine The patient states she feels wired but has no other problems or complaints The patient denies any pain The patient does not have any auditory of visual hallucinations The patient denies any depression or suicidal ideation The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself The patient denies any homicidal ideation The patient denies any recent illness or recent injuries The mother states that the daughter appears to be back to her usual self now REVIEW OF SYSTEMS CONSTITUTIONAL No recent illness No fever or chills HEENT No headache No neck pain No vision change or hearing change No eye or ear pain No rhinorrhea No sore throat CARDIOVASCULAR No chest pain No palpitations or racing heart RESPIRATIONS No shortness of breath No cough GASTROINTESTINAL One episode of nonbloody nonbilious emesis this morning without any nausea since then The patient denies any abdominal pain No change in bowel movements GENITOURINARY No dysuria MUSCULOSKELETAL No back pain No muscle or joint aches SKIN No rashes or lesions NEUROLOGIC No dizziness syncope or near syncope PSYCHIATRIC The patient denies any depression suicidal ideation homicidal ideation auditory hallucinations or visual hallucinations ENDOCRINE No heat or cold intolerance PAST MEDICAL HISTORY None PAST SURGICAL HISTORY Appendectomy when she was 9 years old CURRENT MEDICATIONS Birth control pills ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient denies smoking cigarettes The patient does drink alcohol and also uses illicit drugs PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 8 oral blood pressure 140 86 pulse is 79 respirations 16 oxygen saturation 100 on room air and is interpreted as normal CONSTITUTIONAL The patient is well nourished and well developed appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear cornea and conjunctiva bilaterally The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally No evidence of light sensitivity or photophobia Extraocular motions are intact bilaterally Nose is normal without rhinorrhea or audible congestion Ears are normal without any sign of infection Mouth and oropharynx are normal without any signs of infection Mucous membranes are moist NECK Supple and nontender Full range of motion There is no JVD CARDIOVASCULAR Heart is regular rate and rhythm without murmur rub or gallop Peripheral pulses are 3 and bounding RESPIRATIONS Clear to auscultation bilaterally No shortness of breath No wheezes rales or rhonchi Good air movement bilaterally GASTROINTESTINAL Abdomen is soft nontender normal and benign MUSCULOSKELETAL No abnormalities noted in back arms or legs The patient is normal use of her extremities SKIN No rashes or lesions NEUROLOGIC Cranial nerves II through XII are intact Motor and sensory are intact in all extremities The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 The patient does not have any smell of alcohol and does not exhibit any clinical intoxication The patient is quite pleasant fully cooperative HEMATOLOGIC LYMPHATIC NO lymphadenitis is noted No bruising is noted DIAGNOSES 1 ECSTASY INGESTION 2 ALCOHOL INGESTION 3 VOMITING SECONDARY TO STIMULANT ABUSE CONDITION UPON DISPOSITION Stable disposition to home with her mother PLAN I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation The patient was advised to stop drinking alcohol and taking Ecstasy as this is not only in the interest of her health but was also illegal The patient is asked to return to the emergency room should she have any worsening of her condition develop any other problems or symptoms of concern Keywords consult history and phy nonbilious emesis hallucinations visual auditory ecstasy ingestion suicidal ideation homicidal ideation ingestion infection alcohol ecstasy MEDICAL_TRANSCRIPTION,Description Patient with episode of lightheadedness and suddenly experienced vertigo Medical Specialty Consult History and Phy Sample Name Dural AVM Transcription CC Vertigo HX This 61y o RHF experienced a 2 3 minute episode of lightheadedness while driving home from the dentist in 5 92 In 11 92 while eating breakfast she suddenly experienced vertigo This was immediately followed by nausea and several episodes of vomiting The vertigo lasted 2 3minutes She retired to her room for a 2 hour nap after vomiting When she awoke the symptoms had resolved On 1 13 93 she had an episode of right arm numbness lasting 4 5hours There was no associated weakness HA dysarthria dysphagia visual change vertigo or lightheadedness OUTSIDE RECORDS 12 16 92 Carotid Doppler RICA 30 40 LICA 10 20 12 4 92 brain MRI revealed a right cerebellar hypodensity consistent with infarct MEDS Zantac 150mg bid Proventil MDI bid Azmacort MDI bid Doxycycline 100mg bid Premarin 0 625mg qd Provera 2 5mg qd ASA 325mg qd PMH 1 MDD off antidepressants since 6 92 2 asthma 3 allergic rhinitis 4 chronic sinusitis 5 s p Caldwell Luc 1978 and nasal polypectomy 6 GERD 7 h o elevated TSH 8 hypercholesterolemia 287 on 11 20 93 9 h o heme positive stool BE 11 24 92 and UGI 11 25 92 negative FHX Father died of a thoracic aortic aneurysm age 71 Mother died of stroke age 81 SHX Married One son deceased Salesperson Denied tobacco ETOH illicit drug use EXAM BP RUE 132 72 LUE 136 76 HR67 RR16 Afebrile 59 2kg MS A O to person place time Speech fluent and without dysarthria Thought lucid CN unremarkable Motor 5 5 strength throughout with normal muscle bulk and tone Sensory No deficits appreciated Coord unremarkable Station no pronator drift truncal ataxia or Romberg sign Gait not done Reflexes 2 2 throughout BUE and at patellae 1 1 at Achilles Plantar responses were flexor bilaterally Gen Exam Obese COURSE CBC GS PT PTT UA were unremarkable The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke She was placed on Ticlid 250mg bid HCT 1 15 93 low density focus in the right medial and posterior cerebellar hemisphere MRI and MRA 1 18 93 revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation e g cavernous angioma An abnormal vascular blush was seen on the MRA This area appeared to be supplied by one of the external carotid arteries which one is was not specified this finding maybe suggestive of a vascular malformation 1 20 93 Cerebral Angiogram The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition The vascular blush seen on MRA was no visualized on angiography The patient was discharged home on 1 25 93 Keywords consult history and phy avm episode of lightheadedness vascular malformation cavernous angioma vascular blush cerebellar hemisphere malformation cavernous angioma angiography lightheadedness hemisphere vertigo cerebellar MEDICAL_TRANSCRIPTION,Description Right ear pain with drainage otitis media and otorrhea Medical Specialty Consult History and Phy Sample Name Ear Pain Drainage Transcription CHIEF COMPLAINT Right ear pain with drainage HISTORY OF PRESENT ILLNESS This is a 12 year old white male here with his mother for complaints of his right ear hurting Mother states he has been complaining for several days A couple of days ago she noticed drainage from the right ear The patient states it has been draining for several days and it has a foul smell to it He has had some low grade fever The patient was seen in the office about a week ago with complaints of a sore throat headache and fever The patient was evaluated for Strep throat which was negative and just had been doing supportive care He did have a recent airplane ride a couple of weeks ago also There has been no cough shortness of breath or wheezing No vomiting or diarrhea PHYSICAL EXAM General He is alert in no distress Vital Signs Temperature 99 1 degrees HEENT Normocephalic atraumatic Pupils equal round and react to light The left TM is clear The right TM is poorly visualized secondary to purulent secretions in the right ear canal There is no erythema of the ear canals Nares is patent Oropharynx is clear The patient does wear braces Neck Supple Lungs Clear to auscultation Heart Regular No murmur ASSESSMENT 1 Right otitis media 2 Right otorrhea PLAN Ceftin 250 mg by mouth twice a day for 10 days Ciprodex four drops to the right ear twice a day The patient is to return to the office in two weeks for followup Keywords consult history and phy drainage ear hurting ear pain otitis media otorrhea ear pain with drainage otitis media ear MEDICAL_TRANSCRIPTION,Description A 12 year old with discoid lupus on the control with optimal regimen Medical Specialty Consult History and Phy Sample Name Discoid Lupus Transcription HISTORY A is 12 year old female who comes today for follow up appointment and a CCS visit She has the diagnosis of discoid lupus and we have been following her for her conditions her treatments and also to watch her for any development of her systemic lupus A has been doing well with just Plaquenil alone and mother said that during the summer the rash gets brighter but now that it is getting darker and she is at school the rash is starting to become lighter again She has been using her cream which is hydrocortisone at night and applying it with no problems She denies any hair losses denies any decrease in appetite actually she has been gaining some weight She denies any ulcerations in her mouth eye problems or any lumps in her body She denies any fevers or any problems with the urine PHYSICAL EXAMINATION VITAL SIGNS Today temperature is 100 1 weight is 73 5 kg blood pressure is 121 61 height is 158 and pulse is 84 GENERAL She is alert active and oriented in no distress HEENT She had a head full of hair with no bald spots She has a macular rash on her cheeks bilaterally with hyperpigmented circles No scales no excoriations and no palpable erythema Oral mucosa is clear with no ulcerations NECK Soft with no masses She does have acanthosis nigricans on the base of the neck CHEST Clear to auscultation HEART Regular rhythm with no murmur ABDOMEN Soft and nontender with no visceromegaly MUSCULOSKELETAL Shows no limitation swelling or tenderness in any of her joints SKIN Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size but most of them are about 1 cm in diameter which are hyperpigmented No erythema no purpura no petechiae and no raised borders They look more like cigarette points She has this in her upper extremities especially in the forearms and also on her lower extremities on the legs but just very few lesions and very light She has some periungual erythema as well as some palmar erythema but this is minimal LABORATORY DATA Laboratories today done we have a CBC with a white blood cell count of 7 9 hemoglobin is 14 3 platelet count is 321 000 sed rate is only 11 and CMP shows no abnormalities Pending is antinuclear antibody complement level ASSESSMENT She is 12 year old with discoid lupus on the control with optimal regimen We are going to switch her to Protopic at night especially in the face Continue on Plaquenil get some laboratories and wait for the results Diet evaluation today because of the gaining weight and acanthosis nigricans and will see her back in about 3 months for follow up Future plans will be depending on whether or not she evolves into a full blown lupus I discussed the plan with her mother and they had no further questions Keywords consult history and phy lupus systemic lupus acanthosis nigricans discoid lupus extremities rash erythema discoid MEDICAL_TRANSCRIPTION,Description Dietary consultation for weight reduction secondary to diabetes Medical Specialty Consult History and Phy Sample Name Dietary Consultation 2 Transcription SUBJECTIVE This is a 54 year old female who comes for dietary consultation for weight reduction secondary to diabetes She did attend diabetes education classes at Abc Clinic She comes however wanting to really work at weight reduction She indicates that she has been on the Atkins diet for about two years and lost about ten pounds She is now following a veggie diet which she learned about in Poland originally She has been on it for three weeks and intends to follow it for another three weeks This does not allow any fruits or grains or starchy vegetables or meats She does eat nuts for protein She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet She also wants to know that if she gets skinny enough if the diabetes will go away Her problem time blood sugar wise is in the morning She states that if she eats too much in the evening that her blood sugars are always higher the next morning OBJECTIVE Weight 189 pounds Reported height 5 feet 5 inches BMI is approximately 31 1 2 Diabetes medications include metformin 500 mg daily Lab from 5 12 04 Hemoglobin A1C was 6 4 A diet history was obtained I instructed the patient on dietary guidelines for weight reduction A 1200 calorie meal plan was recommended ASSESSMENT Patient s diet history reflects that she is highly restricting carbohydrates in her food intake She does not have blood sugar records with her for me to review but we discussed strategies for improving blood sugar control in the morning This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts She is doing some physical activity two to three times a week This includes aerobic walking with weights on her arms and her ankles She is likely going to need to increase frequency in this area to help support weight reduction Her basal metabolic rate was estimated at 1415 calories a day Her total calorie requirements for weight maintenance are estimated at 1881 calories a day A 1200 calorie meal plan should support a weight loss of at least one pound a week PLAN Recommend patient increase the frequency of her walking to five days a week Encouraged a 30 minute duration Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations And lastly I encouraged caloric intake of just under 1200 calories daily Recommend keeping food records and tracking caloric intake It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage However I encouraged her to be careful not to reduce calories below 1000 calories daily She may want to consider a multivitamin as well This was a one hour consultation Keywords consult history and phy consultation atkins diet blood sugar reaction diabetes diabetes education diabetes education classes diet history dietary consultation dietary guidelines meal plan protein veggie diet weight reduction caloric intake blood sugar reduction sugar calories blood dietary weight MEDICAL_TRANSCRIPTION,Description Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation Medical Specialty Consult History and Phy Sample Name Disseminated Intravascular Coagulation Transcription DIAGNOSES 1 Disseminated intravascular coagulation 2 Streptococcal pneumonia with sepsis CHIEF COMPLAINT Unobtainable as the patient is intubated for respiratory failure CURRENT HISTORY OF PRESENT ILLNESS This is a 20 year old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation At this time she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time prothrombin time low fibrinogen and elevated D dimer At this time I am being consulted for further evaluation and recommendations for treatment The nurses report that she has actually improved clinically over the last 24 hours Bleeding has been a problem however it seems to have been abrogated at this time with factor replacement as well as platelet infusion There is no prior history of coagulopathy PAST MEDICAL HISTORY Otherwise nondescript as is the past surgical history SOCIAL HISTORY There were possible illicit drugs Her family is present and I have discussed her case with her mother and sister FAMILY HISTORY Otherwise noncontributory REVIEW OF SYSTEMS Not otherwise pertinent PHYSICAL EXAMINATION GENERAL She is a sedated young black female in no acute distress lying in bed intubated VITAL SIGNS She has a rate of 67 blood pressure of 100 60 and the respiratory rate per the ventilator approximately 14 to 16 HEENT Her sclerae showed conjunctival hemorrhage There are no petechiae Her nasal vestibules are clear Oropharynx has ET tube in place NECK No jugular venous pressure distention CHEST Coarse breath sounds bilaterally HEART Regular rate and rhythm ABDOMEN Soft and nontender with good bowel sounds There was some oozing around the site of her central line EXTREMITIES No clubbing cyanosis or edema There is no evidence of compromise arterial blood flow at the digits or of her hands or feet LABORATORY STUDIES The DIC parameters with a platelet count of approximately 50 000 INR of 2 4 normal PTT at this time fibrinogen of 200 and a D dimer of 13 IMPRESSION PLAN At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease My recommendation for the patient is to continue factor replacement as you are It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time There is no indication at this point for Xigris However if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen normalization of her coagulation times I would consider low dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions I will repeat her laboratory studies in the morning and give more recommendations at that time Keywords consult history and phy intravascular coagulation pneumonia thromboplastin time prothrombin time disseminated intravascular coagulation streptococcal pneumonia intravascular coagulation infusion coagulopathy fibrinogen respiratory oropharynx sepsis disseminated MEDICAL_TRANSCRIPTION,Description Dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction Medical Specialty Consult History and Phy Sample Name Dietary Consult Weight Reduction Transcription SUBJECTIVE This is a 56 year old female who comes in for a dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction The patient states that her husband has been diagnosed with high blood cholesterol as well She wants some support with some dietary recommendations to assist both of them in healthier eating The two of them live alone now and she is used to cooking for large portions She is having a hard time adjusting to preparing food for the two of them She would like to do less food preparation in fact She is starting a new job this week OBJECTIVE Her reported height is 5 feet 4 inches Today s weight was 170 pounds BMI is approximately 29 A diet history was obtained I instructed the patient on a 1200 calorie meal plan emphasizing low saturated fat sources with moderate amounts of sodium as well Information on fast food eating was supplied and additional information on low fat eating was also supplied ASSESSMENT The patient s basal energy expenditure is estimated at 1361 calories a day Her total calorie requirement for weight maintenance is estimated at 1759 calories a day Her diet history reflects that she is making some very healthy food choices on a regular basis She does emphasize a lot of fruits and vegetables trying to get a fruit or a vegetable or both at most meals She also is emphasizing lower fat selections Her physical activity level is moderate at this time She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long term basis for weight reduction We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well We discussed menu selection as well as food preparation techniques The patient appears to have been influenced by the current low carb high protein craze and had really limited her food selections based on that I was able to give her some more room for variety including some moderate portions of potatoes pasta and even on occasion breading her meat as long as she prepares it in a low fat fashion which was discussed PLAN Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week This translates into a 1200 calorie meal plan I encouraged the patient to keep food records in order to better track calories consumed I recommended low fat selections and especially those that are lower in saturated fats Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well This was a one hour consultation I provided my name and number should additional needs arise Keywords consult history and phy hyperlipidemia hypertension gastroesophageal reflux disease weight reduction dietary recommendations healthier eating meal plan dietary consultation low fat physical activity weight gastroesophageal dietary calories food MEDICAL_TRANSCRIPTION,Description Dietary consultation for gestational diabetes Medical Specialty Consult History and Phy Sample Name Dietary Consult Gestational Diabetes Transcription SUBJECTIVE This is a 38 year old female who comes for dietary consultation for gestational diabetes Patient reports that she is scared to eat because of its impact on her blood sugars She is actually trying not to eat while she is working third shift at Wal Mart Historically however she likes to eat out with a high frequency She enjoys eating rice as part of her meals She is complaining of feeling fatigued and tired all the time because she works from 10 p m to 7 a m at Wal Mart and has young children at home She sleeps two to four hours at a time throughout the day She has been testing for ketones first thing in the morning when she gets home from work OBJECTIVE Today s weight 155 5 pounds Weight from 10 07 04 was 156 7 pounds A diet history was obtained Blood sugar records for the last three days reveal the following fasting blood sugars 83 84 87 77 two hour postprandial breakfast 116 107 97 pre lunch 85 108 77 two hour postprandial lunch 86 131 100 pre supper 78 91 100 two hour postprandial supper 125 121 161 bedtime 104 90 and 88 I instructed the patient on dietary guidelines for gestational diabetes The Lily Guide for Meal Planning was provided and reviewed Additional information on gestational diabetes was applied A sample 2000 calorie meal plan was provided with a carbohydrate budget established ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1336 calories a day Her total calorie requirements including a physical activity factor as well as additional calories for pregnancy totals to 2036 calories per day Her diet history reveals that she has somewhat irregular eating patterns In the last 24 hours when she was working at Wal Mart she ate at 5 a m but did not eat anything prior to that since starting work at 10 p m We discussed the need for small frequent eating We identified carbohydrate as the food source that contributes to the blood glucose response We identified carbohydrate sources in the food supply recognizing that they are all good for her The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars In regard to use of her traditional foods of rice I pulled out a one third cup measuring cup to identify a 15 gram equivalent of rice We discussed the need for moderating the portion of carbohydrates consumed at one given time Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake Her weight loss was discouraged Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time PLAN The meal plan provided has a carbohydrate content that represents 40 percent of a 2000 calorie meal plan The meal plan was devised to distribute her carbohydrates more evenly throughout the day The meal plan was meant to reflect an example for her eating while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time The meal plan is as follows breakfast 2 carbohydrate servings snack 1 carbohydrate serving lunch 2 3 carbohydrate servings snack 1 carbohydrate serving dinner 2 3 carbohydrate servings bedtime snack 1 2 carbohydrate servings Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep Encouraged adequate rest Also recommend adequate calories to sustain weight gain of one half to one pound per week If the meal plan reflected does not support slow gradual weight gain then we will need to add more foods accordingly This was a one hour consultation I provided my name and number should additional needs arise Keywords consult history and phy blood sugars fatigued total calorie carbohydrate content consultation for gestational diabetes dietary consultation weight gain gestational diabetes carbohydrate servings meal planning meals weight carbohydrate dietary servings planning MEDICAL_TRANSCRIPTION,Description Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia Medical Specialty Consult History and Phy Sample Name Dietary Consultation 1 Transcription SUBJECTIVE This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia The patient reports that she has resumed food record keeping which she feels like it has given her greater control Her physical activity level has remained high Her struggle times are in the mid afternoon if she has not had enough food to eat as well as in the evening after dinner OBJECTIVE Vital Signs Weight is 189 1 2 pounds Food records were reviewed ASSESSMENT The patient has experienced a weight loss of 1 1 2 pounds in the last month She is commended for these efforts We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks We discussed the value of this and how it was very difficulty to resume it however after she suspended the record keeping We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms This will likely be around 2 30 or 3 p m for her We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking PLAN I recommended the patient routinely include an afternoon snack around 2 30 to 3 p m It will be helpful if this snack includes some protein such as nuts or low fat cheese She is also encouraged to continue with her record keeping for food choices and calorie points I also recommended she maintain her high level of physical activity Will plan to follow the patient in one month for ongoing support This was a 30 minute consultation Keywords consult history and phy dietary consultation calorie count calorie points consultation food choices food record hyperlipidemia low fat cheese many fruits and vegetables physical activity polycystic ovarian syndrome snack dietary polycystic food afternoon MEDICAL_TRANSCRIPTION,Description Followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome Medical Specialty Consult History and Phy Sample Name Dietary Consult Hyperlipidemia Transcription SUBJECTIVE This is a followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome The patient reports that she has worked hard for a number of weeks following the meal plan prescribed but felt like she was gaining weight and not losing weight on it She is not sure that she was following it accurately She is trying to walk 1 1 2 to 2 miles every other day but is increasing her time in the garden and doing other yard work as well Once she started experiencing some weight gain she went back to her old South Beach Diet and felt like she was able to take some of that weight off However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low fat eating OBJECTIVE Weight is 275 pounds Food records were reviewed ASSESSMENT The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago I did carefully review her food records and evaluated calories consumed While she was carefully tracking the volume of protein and carbohydrates she was getting some excess calories from the fatty proteins selected Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates While this still is not as much carbohydrate as I would normally recommend I am certainly willing to work with her on how she feels her body best handles weight reduction We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time PLAN A new 1500 calorie meal plan was developed based on 35 of the calories coming from protein 40 of the calories from carbohydrate and 25 of the calories from fat This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack This also translates in to 2 ounces of protein at breakfast 6 ounces at lunch 2 ounces in the afternoon snack 6 ounces at supper and 2 ounces in the evening snack We have eliminated the morning snack The patient will now track the grams of fat in her meats as well as added fats Her goal for total fats over the course of the day is no more than 42 grams of fat per day This was a half hour consultation We will plan to see the patient back in one month for support Keywords consult history and phy hyperlipidemia hypertension metabolic syndrome meal food records south beach diet dietary consultation meal plan carbohydrates snack dietary calories weight MEDICAL_TRANSCRIPTION,Description Dietary consult for a 79 year old African American female diagnosed with type 2 diabetes in 1983 Medical Specialty Consult History and Phy Sample Name Dietary Consult Diabetes 2 Transcription SUBJECTIVE The patient is a 79 year old African American female with a self reported height of 5 foot 3 inches and weight of 197 pounds She was diagnosed with type 2 diabetes in 1983 She is not allergic to any medicines DIABETES MEDICATIONS Her diabetes medications include Humulin insulin 70 30 44 units at breakfast and 22 units at supper Also metformin 500 mg at supper OTHER MEDICATIONS Other medications include verapamil Benicar Toprol clonidine and hydrochlorothiazide ASSESSMENT The patient and her daughter completed both days of diabetes education in a group setting Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician Fasting blood sugars are 127 80 and 80 Two hour postprandial breakfast reading was 105 two hour postprandial lunch reading was 88 and two hour postprandial dinner reading was 73 and 63 Her diet was excellent Seven hours of counseling about diabetes mellitus was provided on this date Blood glucose values obtained at 10 a m were 84 and at 2 30 p m were 109 Assessment of her knowledge is completed at the end of the counseling session She demonstrated increased knowledge in all areas and had no further questions She also completed an evaluation of the class The patient s feet were examined during the education session She had flat feet bilaterally Skin color was pink temperature warm Pedal pulses 2 Her right second and third toes lay on each other Also the same on her left foot However there was no skin breakdown She had large bunions medial aspect of the ball of both feet She had positive sensitivity to most areas of her feet however she had negative sensitivity to the medial and lateral aspect of the balls of her left foot During the education session she set behavioral goals for self care First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels Second goal is to eat a well balanced meal at 1200 calories in order to lose one half pound of weight per week and improve her blood glucose control Third goal is to exercise by walking for 15 to 30 minutes a day three to five days a week to increase her blood glucose control Her success in achieving these goals will be followed in three months by a letter from the diabetes education class RECOMMENDATIONS Since she is doing so well with her diet changes her blood sugars have been within normal limits and sometimes on the low side especially considering the fact that she has low blood sugar unawareness She is to followup with Dr XYZ for possible reduction in her insulin doses Keywords consult history and phy dietary consult diabetes education glucose control blood sugars blood glucose dietary diabetes MEDICAL_TRANSCRIPTION,Description The patient is brought in by an assistant with some of his food diary sheets Medical Specialty Consult History and Phy Sample Name Dietary Consult 3 Transcription SUBJECTIVE The patient is brought in by an assistant with some of his food diary sheets They wonder if the patient needs to lose anymore weight OBJECTIVE The patient s weight today is 186 1 2 pounds which is down 1 1 2 pounds in the past month He has lost a total of 34 1 2 pounds I praised this I went over his food diary and praised all of his positive food choices reported especially his use of sugar free Kool Aid sugar free pudding and diet pop I encouraged him to continue all of that as well as his regular physical activity ASSESSMENT The patient is losing weight at an acceptable rate He needs to continue keeping a food diary and his regular physical activity PLAN The patient plans to see Dr XYZ at the end of May 2005 I recommended that they ask Dr XYZ what weight he would like for the patient to be at Follow up will be with me June 13 2005 Keywords consult history and phy weight kool aid food diary sheets diary sheets physical activity food diary dietary sheets diary food MEDICAL_TRANSCRIPTION,Description The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity Medical Specialty Consult History and Phy Sample Name Dietary Consult 2 Transcription SUBJECTIVE The patient s assistant brings in her food diary sheets The patient says she stays active by walking at the mall OBJECTIVE Weight today is 201 pounds which is down 3 pounds in the past month She has lost a total of 24 pounds I praised this and encouraged her to continue I went over her food diary I praised her three meal pattern and all of her positive food choices especially the use of sugar free Kool Aid sugar free Jell O sugar free lemonade diet pop as well as the variety of foods she is using in her three meal pattern I encouraged her to continue all of this ASSESSMENT The patient has been successful with weight loss due to assistance from others in keeping a food diary picking lower calorie items her three meal pattern getting a balanced diet and all her physical activity She needs to continue all this PLAN Followup is set for 06 13 05 to check the patient s weight her food diary and answer any questions Keywords consult history and phy food diary sheets active balanced diet three meal pattern weight loss sugar free food diary dietary weight meal diary sheets food MEDICAL_TRANSCRIPTION,Description Dietary consultation for diabetes during pregnancy Medical Specialty Consult History and Phy Sample Name Dietary Consult Diabetes 1 Transcription SUBJECTIVE This is a 28 year old female who comes for dietary consultation for diabetes during pregnancy Patient reports that she had gestational diabetes with her first pregnancy She did use insulin at that time as well She does not fully understand what ketones are She walks her daughter to school and back home each day which takes 20 minutes each way She is not a big milk drinker but she does try to drink some OBJECTIVE Weight is 238 3 pounds Weight from last week s visit was 238 9 pounds Prepregnancy weight is reported at 235 pounds Height is 62 3 4 inches Prepregnancy BMI is approximately 42 1 2 Insulin schedule is NovoLog 70 30 20 units in the morning and 13 units at supper time Blood sugar records for the last week reveal the following Fasting blood sugars ranging from 92 to 104 with an average of 97 two hour postprandial breakfast readings ranging from 172 to 196 with an average of 181 two hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two hour postprandial dinner readings ranging from 109 to 121 with an average of 116 Overall average is 140 A diet history was obtained Expected date of confinement is May 1 2005 Instructed the patient on dietary guidelines for gestational diabetes A 2300 meal plan was provided and reviewed The Lily Guide for Meal Planning was provided and reviewed ASSESSMENT Patient s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day Her total calorie requirements including physical activity factors as well as additional calories for pregnancy totals 2367 calories a day Her diet history reveals that she is eating three meals a day and three snacks The snacks were just added last week following presence of ketones in her urine We identified carbohydrate sources in the food supply recognizing that they are the foods that raise blood sugar the most We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1 2 a pound a week through the duration of the pregnancy We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars While a sample meal plan was provided reflecting the patient s carbohydrate budget I emphasized the need for her to eat according to her appetite but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates PLAN Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45 of the calories from carbohydrate Breakfast Three carbohydrate servings Morning snack One carbohydrate serving Lunch Four carbohydrate servings Afternoon snack One carbohydrate serving Supper Four carbohydrate servings Bedtime snack One carbohydrate serving Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy Recommend patient include a fruit or a vegetable with most of her meals Also recommend including solid protein with each meal as well as with the bedtime snack Charlie Athene reviewed blood sugars at this consultation as well and made the following insulin adjustment Morning 70 30 will increase from 20 units up to 24 units and evening 70 30 we will increase from 13 units up to 16 units Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two hour postprandial Provided my name and number should there be additional dietary questions Keywords consult history and phy diabetes during pregnancy diabetes insulin gestational diabetes adjusted for obesity calorie requirements dietary consultation carbohydrate postprandial meal calories dietary pregnancy servings snacks MEDICAL_TRANSCRIPTION,Description One week history of decreased vision in the left eye Past ocular history includes cataract extraction with lens implants in both eyes Medical Specialty Consult History and Phy Sample Name Decreased Vision Consult Transcription She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003 She also has a history of glaucoma diagnosed in 1990 and macular degeneration She has been followed in her home country and is here visiting family She had the above mentioned observation and was brought in on an urgent basis today Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism Her medications include V optic 0 5 eye drops to both eyes twice a day and pilocarpine 2 OU three times a day She took both the drops this morning She also takes Eltroxin which is for hypothyroidism Plendil for blood pressure and pravastatin She is allergic to Cosopt She has a family history of blindness in her brother as well as glaucoma and hypertension Her visual acuity today at distance without correction are 20 25 in the right and count fingers at 3 feet in the left eye Manifest refraction showed no improvement in either eye The intraocular pressures by applanation were 7 on the right and 18 in the left eye Gonioscopy showed grade 4 open angles in both eyes Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes The lids were normal OU She has mild dry eye OU The corneas are clear OU The anterior chamber is deep and quiet OU Irides appear normal The lenses show well centered posterior chamber intraocular lenses OU Dilated fundus exam shows clear vitreous OU The optic nerves are normal in size They both appear to have mild pallor The optic cups in both eyes are shallow The cup to disc ratio in the right eye is not overtly large would estimated 0 5 to 0 6 however she does have very thin rim tissue inferotemporally in the right eye In the left eye the glaucoma appears to be more advanced to the larger cup to disc ratio and a thinner rim tissue The macula on the right shows drusen with focal areas of RPE atrophy I do not see any evidence of neovascularization such as subretinal fluid lipid or hemorrhage She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye In the left eye she has also several high risk drusen but no evidence of neovascularization The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild I do not see any dense or focal areas of frank RPE atrophy or hypertrophy The peripheral retinas are attached in both eyes Ms ABC has pseudophakia OU which is stable and she is doing well in this regard She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye The intraocular pressure in the mid to high teens in the left eye is probably high for her She has allergic reaction to Cosopt I will recommend starting Xalatan OS nightly I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan Regarding the macular degeneration she has had high risk changes in both eyes The vision in the right eye is good but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye Keywords consult history and phy cataract extraction lens implants decreased vision macular degeneration intraocular pressures rpe atrophy eye degeneration glaucoma macular vision MEDICAL_TRANSCRIPTION,Description Counting calorie points exercising pretty regularly seems to be doing well Medical Specialty Consult History and Phy Sample Name Dietary Consult 4 Transcription SUBJECTIVE The patient is keeping a food journal that she brought in She is counting calorie points which ranged 26 to 30 per day She is exercising pretty regularly She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia The patient requests information on diabetic exchanges She said she is feeling better since she has lost weight OBJECTIVE Vital Signs The patient s weight today is 209 pounds which is down 22 pounds since I last saw her on 06 07 2004 I praised her weight loss and her regular exercising I looked at her food journal I praised her record keeping I gave her a list of the diabetic exchanges and explained them I also gave her a food dairy sheet so that she could record exchanges I encouraged her to continue ASSESSMENT The patient seems happy with her progress and she seems to be doing well She needs to continue PLAN Followup is on a p r n basis She is always welcome to call or return Keywords consult history and phy overeaters anonymous diabetic exchanges exercising pretty regularly food journal diabetic exercising exchanges regularly MEDICAL_TRANSCRIPTION,Description This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Medical Specialty Consult History and Phy Sample Name Dental Pain Transcription CHIEF COMPLAINT Dental pain HISTORY OF PRESENT ILLNESS This is a 27 year old female who presents with a couple of days history of some dental pain She has had increasing swelling and pain to the left lower mandible area today Presents now for evaluation PAST MEDICAL HISTORY Remarkable for chronic back pain neck pain from a previous cervical fusion and degenerative disc disease She has chronic pain in general and is followed by Dr X REVIEW OF SYSTEMS Otherwise unremarkable Has not noted any fever or chills However she as mentioned does note the dental discomfort with increasing swelling and pain Otherwise unremarkable except as noted CURRENT MEDICATIONS Please see list ALLERGIES IODINE FISH OIL FLEXERIL BETADINE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile has stable and normal vital signs The patient is sitting quietly on the gurney and does not look to be in significant distress but she is complaining of dental pain HEENT Unremarkable I do not see any obvious facial swelling but she is definitely tender all in the left mandible region There is no neck adenopathy Oral mucosa is moist and well hydrated Dentition looks to be in reasonable condition However she definitely is tender to percussion on the left lower first premolar I do not see any huge cavity or anything like that No real significant gingival swelling and there is no drainage noted None of the teeth are tender to percussion PROCEDURE Dental nerve block Using 0 5 Marcaine with epinephrine I performed a left inferior alveolar nerve block along with an apical nerve block which achieves good anesthesia I have then written a prescription for penicillin and Vicodin for pain IMPRESSION ACUTE DENTAL ABSCESS ASSESSMENT AND PLAN The patient needs to follow up with the dentist for definitive treatment and care She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics However outpatient followup should be adequate She is discharged in stable condition Keywords consult history and phy dental pain dental abscess dental block nerve block mandible swelling dental MEDICAL_TRANSCRIPTION,Description The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder Medical Specialty Consult History and Phy Sample Name Conversion Disorder Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of Children s Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time After his discharge the patient was scheduled to see me for followup services This was a 90 minute intake that was completed on 10 10 2007 with the patient s mother I reviewed with her the treatment consent form as well as the boundaries of confidentiality and she stated that she understood these concepts PRESENTING PROBLEMS Please see the inpatient hospital progress note contained in his chart for additional background information The patient s mother reported that he continues with his conversion episodes She noted that they are occurring approximately 6 times a day They consist primarily of tremors arching his back and by her report doing some gang signs during the episode She reported that the conversion reactions had decreased after his hospitalization and he had none for 3 days but then they began picking up again From information gathered from mother it would suggest that she frequently does status checks where she asks him how he is doing and that after she began checking on him more that he began having more conversion reactions In terms of what she does when he has a conversion reaction she reported that primarily that she tries to keep him safe She puts a sheath under him because the carpeting is dirty She removes any furniture she wraps his legs together so they do not knock together she sits with him and she gives him attention and says calm down breathe and after it is over she continues to tell him to be calm and to breathe She denied that she gives them any more attention I strongly encouraged her to stop doing status checks as this likely is reinforcing the behavior I also noted that while he certainly needs to be kept safe that she does not want to give a lot of attention to this behavior and that over time we will teach him ways of coping with this independently In regards to his mood she reported that his mood is quite good She denied any sadness or irritability She denied anhedonia She reports that he is a little bit hard to get up in the morning He is going to bed at about 11 getting up at 8 or 9 No changes in weight or eating were noted No changes in concentration suicidal ideation and any suicidal history was denied She denied symptoms of anxiety although she did note that she thought he worried a little about going to school and some financial stress Other symptoms of psychopathology were denied DEVELOPMENTAL HISTORY The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery Mother reported that she did receive prenatal care The use of alcohol drugs or tobacco during the pregnancy were denied She denied that he had any feeding or sleeping problems in the perinatal period She described him as a fussy and active baby but he was described as a cuddly baby She noted that the pediatricians never expressed any concerns regarding his developmental milestones SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN Serious injures or toileting problems were denied as were a history of seizures FAMILY BACKGROUND The patient currently lives with his mother who is age 57 and with her partner who is age 40 They have been together since 1994 and he is the only father figure that the patient has even known The father was previously in a relationship that resulted in an 11 year old daughter who visits the patient s home every other weekend The patient s father s whereabouts are unknown There is no information on his family Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient and the patient has never met him As noted there is no information on the paternal side of the family In terms of the mother s side of family the maternal grandfather died in his 60s due to what mother described as hardening of the arteries and the maternal grandmother died in 2003 due to stroke There were 4 maternal aunts one of them died at age 9 months from pneumonia one of them died at 19 years old from what was described as a brain tumor and there are 3 maternal uncles In terms of family relationships it was reported that overall the patient tends to get along fairly well with his parents who reported that the patient and her partner tend to compete for mother s attention and she noted this is difficult at times She reported that the patient and her partner do not really do anything together Mother reported that there is no domestic violence in the home but there is some marital conflict and this is may be difficult for The patient as it is carried on in Spanish and he does not speak Spanish There also is some stress in the home due to the stepdaughter as there are some concerns that her mother may be involved in drugs The mother reported that she attended high school did not attend any college She denied learning problems She denied psychological problems or any drug alcohol history In terms of the biological father she reported he did not graduate from high school She did not know of learning problems psychological problems She denied that he had a drug alcohol history There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather It should be noted that the patient and his family live in a small 4 bedroom apartment where privacy is very difficult SOCIAL BACKGROUND She reported that the patient is able to make and keep friends but he enjoys lifting weights skateboarding and that he recently had an opportunity to do rock climbing he really enjoyed that I encouraged her to have him involved in physical activity as this is good for discharge the stress to encourage the weightlifting as well as the skateboarding Mother is going to check further information regarding the rock climbing that the patient had been involved in which was at it sounds like by her description as some sort of boys and girls type of club Abuse of drugs or alcohol were denied The patient was not described as being sexually active ACADEMIC BACKGROUND The patient is currently in the 10th grade At present he is on independent studies which began after his hospitalization The mother reported that the teacher who had come to school saw one of his episodes and stated that they would not want him to be attending school I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies that he needed to be returned to his normal school environment He has never had an episode at school and he needs to be back with his peers back in a regular environment where he is under normal expectations I spoke with her regarding my concerns regarding the fact that he is unsupervised during the day and we do not want this turning into one big long vacation where he is not getting his work done and he gets himself in trouble Normally he would be attending at High School The mother stated that she would contact them as well as check into possibly a 504 Plan She reported that he really does not to go back to High School He says the kids are bad however she denied that he has any history of fighting She noted that he is stressed by the school there have been some peer problems possibly some bullying I noted these need to be addressed with the school as she had not done so She stated that she would speak with a counselor She noted however that he has a history of not liking school and avoiding going to school She noted that he is somewhat behind in his work due to the hospitalization His grades traditionally are C s She denied any Special Education Services PREVIOUS COUNSELING Denied DIAGNOSTIC SUMMARY AND IMPRESSION Similar to my impression at the hospital it would appear that the patient clearly qualifies for a diagnosis of conversion disorder It appears that there are multiple stressors in the family and that the mother is reinforcing his conversion reaction I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing DSM IV DIAGNOSES AXIS I Conversion disorder 300 11 AXIS II No diagnosis V71 09 AXIS III No diagnosis AXIS IV Problems with primary support group educational problems and peer problems AXIS V Global Assessment of Functioning equals 60 Keywords consult history and phy developmental history academic background global assessment of functioning normal school environment conversion reactions conversion disorder conversion background environment peers disorder axis MEDICAL_TRANSCRIPTION,Description A gentleman with a long history of heroin abuse trying to get off the heroin last use shortly prior to arrival including cocaine The patient does have a history of alcohol abuse but mostly he is concerned about the heroin abuse Medical Specialty Consult History and Phy Sample Name Detox from Heroin Transcription CHIEF COMPLAINT Detox from heroin HISTORY OF PRESENT ILLNESS This is a 52 year old gentleman with a long history of heroin abuse who keeps relapsing presents once again trying to get off the heroin last use shortly prior to arrival including cocaine The patient does have a history of alcohol abuse but mostly he is concerned about the heroin abuse PAST MEDICAL HISTORY Remarkable for chronic pain He has had multiple stab wounds gunshot wounds and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain He has previously been followed by ABC but has not seen him for several years REVIEW OF SYSTEMS The patient states that he did use heroin as well as cocaine earlier today and feels under the influence Denies any headache or visual complaints No hallucinations No chest pain shortness of breath abdominal pain or back pain Denies any abscesses SOCIAL HISTORY The patient is a smoker Admits to heroin use alcohol abuse as well Also admits today using cocaine FAMILY HISTORY Noncontributory MEDICATIONS He has previously been on analgesics and pain medications chronically Apparently he just recently got out of prison He has previously also been on Klonopin and lithium He was previously on codeine for this pain ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile He is markedly hypertensive 175 104 and pulse 117 probably due to the cocaine onboard His respiratory rate is normal at 18 GENERAL The patient is a little jittery but lucid alert and oriented to person place time and situation HEENT Unremarkable Pupils are actually moderately dilated about 4 to 5 mm but reactive Extraoculars are intact His oropharynx is clear NECK Supple His trachea is midline LUNGS Clear He has good breath sounds and no wheezing No rales or rhonchi Good air movement and no cough CARDIAC Without murmur ABDOMEN Soft and nontender He has multiple track marks multiple tattoos but no abscesses NEUROLOGIC Nonfocal IMPRESSION MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN ASSESSMENT AND PLAN At this time I think the patient can be followed up at XYZ I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy I do not think he needs any further workup at this time He is discharged otherwise in stable condition Keywords consult history and phy phenergan detox from heroin alcohol abuse heroin abuse detox heroin alcohol cocaine abuse MEDICAL_TRANSCRIPTION,Description Elevated cholesterol and is on medication to lower it Medical Specialty Consult History and Phy Sample Name Dietary Consult 1 Transcription SUBJECTIVE His brother although he is a vegetarian has elevated cholesterol and he is on medication to lower it The patient started improving his diet when he received the letter explaining his lipids are elevated He is consuming less cappuccino quiche crescents candy from vending machines etc He has started packing his lunch three to four times per week instead of eating out so much He is exercising six to seven days per week by swimming biking running lifting weights one and a half to two and a half hours each time He is in training for a triathlon He says he is already losing weight due to his efforts OBJECTIVE Height 6 foot 2 inches Weight 204 pounds on 03 07 05 Ideal body weight 190 pounds plus or minus ten percent He is 107 percent standard of midpoint ideal body weight BMI 26 189 A 48 year old male Lab on 03 15 05 Cholesterol 251 LDL 166 VLDL 17 HDL 68 Triglycerides 87 I explained to the patient the dietary guidelines to help improve his lipids I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2 300 calories since he is interested in losing weight I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read I encouraged him to continue as he is doing ASSESSMENT Basal energy expenditure 1960 x 1 44 activity factor is approximately 2 800 calories His 24 hour recall shows he is making many positive changes already to lower his fat and cholesterol intake He needs to continue as he is doing He verbalized understanding and seemed receptive PLAN The patient plans to recheck his lipids through Dr XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet Keywords consult history and phy vegetarian lipids cholesterol intake elevated cholesterol losing weight body weight dietary cholesterol MEDICAL_TRANSCRIPTION,Description Patient had a piece of glass fall on to his right foot A 4 mm laceration Acute foot pain now resolved The patient was given discharge instructions on wound care Medical Specialty Consult History and Phy Sample Name Cut on Foot ER Visit Transcription CHIEF COMPLAINT Cut on foot HISTORY OF PRESENT ILLNESS This is a 32 year old male who had a piece of glass fall on to his right foot today The patient was concerned because of the amount of bleeding that occurred with it The bleeding has been stopped and the patient does not have any pain The patient has normal use of his foot there is no numbness or weakness the patient is able to ambulate well without any discomfort The patient denies any injuries to any other portion of his body He has not had any recent illness The patient has no other problems or complaints PAST MEDICAL HISTORY Asthma CURRENT MEDICATION Albuterol ALLERGIES NO KNOWN DRUG ALLERGIES SOCIAL HISTORY The patient is a smoker PHYSICAL EXAMINATION VITAL SIGNS Temperature 98 8 oral blood pressure 132 86 pulse is 76 and respirations 16 Oxygen saturation is 100 on room air and interpreted as normal CONSTITUTIONAL The patient is well nourished well developed the patient appears to be healthy The patient is calm and comfortable in no acute distress and looks well The patient is pleasant and cooperative HEENT Head is atraumatic normocephalic and nontender Eyes are normal with clear conjunctiva and cornea bilaterally NECK Supple with full range of motion CARDIOVASCULAR Peripheral pulse is 2 to the right foot Capillary refills less than two seconds to all the digits of the right foot RESPIRATIONS No shortness of breath MUSCULOSKELETAL The patient has a 4 mm partial thickness laceration to the top of the right foot and about the area of the mid foot There is no palpable foreign body no foreign body is visualized There is no active bleeding there is no exposed deeper tissues and certainly no exposed tendons bone muscle nerves or vessels It appears that the laceration may have nicked a small varicose vein which would have accounted for the heavier than usual bleeding that currently occurred at home The patient does not have any tenderness to the foot The patient has full range of motion to all the joints all the toes as well as the ankles The patient ambulates well without any difficulty or discomfort There are no other injuries noted to the rest of the body SKIN The 4 mm partial thickness laceration to the right foot as previously described No other injuries are noted NEUROLOGIC Motor is 5 5 to all the muscle groups of the right lower extremity Sensory is intact to light touch to all the dermatomes of the right foot The patient has normal speech and normal ambulation PSYCHIATRIC The patient is alert and oriented x4 Normal mood and affect HEMATOLOGIC LYMPHATIC No active bleeding is occurring at this time No evidence of bruising is noted to the body EMERGENCY DEPARTMENT COURSE The patient had antibiotic ointment and a bandage applied to his foot DIAGNOSES 1 A 4 MM LACERATION TO THE RIGHT FOOT 2 ACUTE RIGHT FOOT PAIN NOW RESOLVED CONDITION UPON DISPOSITION Stable DISPOSITION To home The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on Keywords consult history and phy foot pain cut on foot piece of glass foreign body active bleeding foot injuries atraumatic laceration bleeding body MEDICAL_TRANSCRIPTION,Description Cerebral palsy worsening seizures A pleasant 43 year old female with past medical history of CP since birth seizure disorder complex partial seizure with secondary generalization and on top of generalized epilepsy hypertension dyslipidemia and obesity Medical Specialty Consult History and Phy Sample Name Consult Seizures 1 Transcription CHIEF COMPLAINT Worsening seizures HISTORY OF PRESENT ILLNESS A pleasant 43 year old female with past medical history of CP since birth seizure disorder complex partial seizure with secondary generalization and on top of generalized epilepsy hypertension dyslipidemia and obesity The patient stated she was in her normal state of well being when she was experiencing having frequent seizures She lives in assisted living She has been falling more frequently The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this There was no head trauma but apparently she was doing that many times and there was no responsiveness The patient has no memory of the event She is now back to her baseline She states her seizures are worse in the setting of stress but it is not clear to her why this has occurred She is on Carbatrol 300 mg b i d and she has been very compliant and without any problems The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome PAST MEDICAL HISTORY Include dyslipidemia and hypertension FAMILY HISTORY Positive for stroke and sleep apnea SOCIAL HISTORY No smoking or drinking No drugs MEDICATIONS AT HOME Include Avapro lisinopril and dyslipidemia medication she does not remember REVIEW OF SYSTEMS The patient does complain of gasping for air witnessed apneas and dry mouth in the morning The patient also has excessive daytime sleepiness with EDS of 16 PHYSICAL EXAMINATION VITAL SIGNS Last blood pressure 130 85 respirations 20 and pulse 70 GENERAL Normal NEUROLOGICAL As follows Right handed female normal orientation normal recollection to 3 objects The patient has underlying MR Speech no aphasia no dysarthria Cranial nerves funduscopic intact without papilledema Pupils are equal round and reactive to light Extraocular movements intact No nystagmus Her mood is intact Symmetric face sensation Symmetric smile and forehead Intact hearing Symmetric palate elevation Symmetric shoulder shrug and tongue midline Motor 5 5 proximal and distal The patient does have limp on the right lower extremity Her Babinski is hyperactive on the left lower extremity upgoing toes on the left Sensory the patient does have sharp soft touch vibration intact and symmetric The patient has trouble with ambulation She does have ataxia and uses a walker to ambulate There is no bradykinesia Romberg is positive to the left Cerebellar finger nose finger is intact Rapid alternating movements are intact Upper airway examination the patient has a Friedman tongue position with 4 oropharyngeal crowding Neck more than 16 to 17 inches BMI elevated above 33 Head and neck circumference very high IMPRESSION 1 Cerebral palsy worsening seizures 2 Hypertension 3 Dyslipidemia 4 Obstructive sleep apnea 5 Obesity RECOMMENDATIONS 1 Admission to the EMU drop her Carbatrol 200 b i d monitor for any epileptiform activity Initial time of admission is 3 nights and 3 days 2 Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated Continue her other medications 3 Consult Dr X for hypertension internal medicine management 4 I will follow this patient per EMU protocol Keywords MEDICAL_TRANSCRIPTION,Description Consult for prostate cancer Medical Specialty Consult History and Phy Sample Name Consult Prostate Cancer Transcription CONSULT FOR PROSTATE CANCER The patient returned for consultation for his newly diagnosed prostate cancer The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding infection rectal injury impotence and incontinence These were discussed at length Alternative therapies including radiation therapy either radioactive seed placement conformal radiation therapy or the HDR radiation treatments were discussed with the risks of bladder bowel and rectal injury and possible impotence were discussed also There is a risk of rectal fistula Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis gynecomastia hot flashes and impotency Potency may not recover after the hormone therapy has been completed Cryosurgery was discussed with the risks of urinary retention stricture formation incontinence and impotency There is a risk of rectal fistula He would need to have a suprapubic catheter for about two weeks and may need to learn self intermittent catheterization if he cannot void adequately Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence Observation therapy was discussed with him in addition I answered all questions that were put to me and I think he understands the options that are available I spoke with the patient for over 60 minutes concerning these options Keywords consult history and phy prostate cancer cryosurgery hdr radiation prostate surgery bladder bleeding bowel consultation impotence incontinence infection prostatectomy radiation therapy radical rectal rectal fistula rectal injury prostate cancer consult cancer radiation prostateNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks Medical Specialty Consult History and Phy Sample Name Consult Rectal Bleeding Transcription PRESENT ILLNESS The patient is a very pleasant 69 year old Caucasian male whom we are asked to see primarily because of a family history of colon cancer but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks The patient states that he had his first colonoscopy 6 years ago and it was negative His mother was diagnosed with colon cancer probably in her 50s but she died of cancer of the esophagus at age 86 The patient does have hemorrhoidal bleed about once a week Otherwise he denies any change in bowel habits abdominal pain or weight loss He gets heartburn mainly with certain food such as raw onions and he has had it for years It will typically occur every couple of weeks He has had no dysphagia He has never had an upper endoscopy MEDICAL HISTORY Remarkable for hypertension adult onset diabetes mellitus hyperlipidemia and restless legs syndrome SURGICAL HISTORY Appendectomy as a child and cholecystectomy in 2003 MEDICATIONS His medications are lisinopril 40 mg daily hydrochlorothiazide 25 mg daily metformin 1000 mg twice a day Januvia 100 mg daily clonazepam 10 mg at bedtime for restless legs syndrome Crestor 10 mg nightly and Flomax 0 4 mg daily ALLERGIES No known drug allergies SOCIAL HISTORY The patient is retired He is married He had 4 children He quite smoking 25 years ago after a 35 year history of smoking He does not drink alcohol FAMILY HISTORY Mother had colon cancer in her 50s esophageal cancer in her 80s Her mother smoked and drank Father got a mesothelioma at age 65 There is a brother of 65 with hypertension REVIEW OF SYSTEMS He has had prostatitis with benign prostatic hypertrophy He has some increased urinary frequency from a history of prostatitis He has the heartburn which is diet dependent and the frequent rectal bleeding He also has restless legs syndrome at night No cardio or pulmonary complaints No weight loss PHYSICAL EXAMINATION Reveals a well developed well nourished man in no acute distress BP 112 70 Pulse 80 and regular Respirations non labored Height 5 feet 7 1 2 inches Weight 209 pounds HEENT exam Sclerae are anicteric Pupils equal conjunctivae clear No gross oropharyngeal lesions Neck is supple without lymphadenopathy thyromegaly or JVD Lungs are clear to percussion and auscultation Heart sounds are regular without murmur gallop or rub The abdomen is soft and nontender There are no masses There is no hepatosplenomegaly The bowel sounds are normal Rectal examination Deferred Extremities have no clubbing cyanosis or edema Skin is warm and dry The patient is alert and oriented with a pleasant affect and no gross motor deficits IMPRESSION 1 Family history of colon cancer 2 Rectal bleeding 3 Heartburn and a family history of esophageal cancer PLAN I agree with the indications for repeat colonoscopy which should be done at least every 5 years Also discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett s esophagus If he does not have it now then it should not be a significant risk in the future The indications and benefits of EGD colonoscopy and IRC were discussed The risks including sedation bleeding infection and perforation were discussed The importance of a good bowel prep so as to minimize missing any lesions was discussed His questions were answered and informed consent obtained It was a pleasure to care for this nice patient Keywords consult history and phy heartburn family history of esophageal cancer repeat colonoscopy colonoscopy egd irc barrett s esophagus restless legs syndrome esophageal cancer rectal bleeding colon cancer rectal bleeding cancer MEDICAL_TRANSCRIPTION,Description The patient needs refills on her Xanax Medical Specialty Consult History and Phy Sample Name Consult Smoking Cessation Transcription CHIEF COMPLAINT I need refills HISTORY OF PRESENT ILLNESS The patient presents today stating that she needs refills on her Xanax and she would also like to get something to help her quit smoking She is a new patient today She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain She states that she is under the care of a cancer specialist however she just recently moved back to this area and is trying to find a doctor a little closer than his office She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try OBJECTIVE Well developed and well nourished She does not appear to be in any acute distress Cardiovascular Regular rhythm No murmurs gallops or rubs Capillary refill less than 3 seconds Peripheral pulses are 2 bilaterally Respiratory Her lungs are clear to auscultation bilaterally with good effort No tenderness to palpation over chest wall Musculoskeletal She has full range of motion of all four extremities No tenderness to palpation over long bones Skin Warm and dry No rashes or lesions Neuro Alert and oriented x3 Cranial nerves II XII are grossly intact No focal deficits PLAN I did refill her medications I have requested that she have her primary doctor forward her records to me I have discussed Chantix and its use and success rate She was given a prescription as well as a coupon She is to watch for any worsening signs or symptoms She verbalized understanding of discharge instructions and prescriptions I would like to see her back to proceed with her preventive health measures Keywords consult history and phy quit smoking chantix mesothelioma smoking xanax refills MEDICAL_TRANSCRIPTION,Description Patient comes for discussion of a screening colonoscopy Medical Specialty Consult History and Phy Sample Name Consult Screening Colonoscopy Transcription HISTORY A is a 55 year old who I know well because I have been taking care of her husband She comes for discussion of a screening colonoscopy Her last colonoscopy was in 2002 and at that time she was told it was essentially normal Nonetheless she has a strong family history of colon cancer and it has been almost four to five years so she wants to have a repeat colonoscopy I told her that the interval was appropriate and that it made sense to do so She denies any significant weight change that she cannot explain She has had no hematochezia She denies any melena She says she has had no real change in her bowel habit but occasionally does have thin stools PAST MEDICAL HISTORY On today s visit we reviewed her entire health history Surgically she has had a stomach operation for ulcer disease back in 1974 she says She does not know exactly what was done It was done at a hospital in California which she says no longer exists This makes it difficult to find out exactly what she had done She also had her gallbladder and appendix taken out in the 1970s at the same hospital Medically she has no significant problems and no true medical illnesses She does suffer from some mild gastroparesis she says MEDICATIONS Reglan 10 mg once a day ALLERGIES She denies any allergies to medications but is sensitive to medications that cause her to have ulcers she says SOCIAL HISTORY She still smokes one pack of cigarettes a day She was counseled to quit She occasionally uses alcohol She has never used illicit drugs She is married is a housewife and has four children FAMILY HISTORY Positive for diabetes and cancer REVIEW OF SYSTEMS Essentially as mentioned above PHYSICAL EXAMINATION GENERAL A is a healthy appearing female in no apparent distress VITAL SIGNS Her vital signs reveal a weight of 164 pounds blood pressure 140 90 temperature of 97 6 degrees F HEENT No cervical bruits thyromegaly or masses She has no lymphadenopathy in the head and neck supraclavicular or axillary spaces bilaterally LUNGS Clear to auscultation bilaterally with no wheezes rubs or rhonchi HEART Regular rate and rhythm without murmur rub or gallop ABDOMEN Soft nontender nondistended EXTREMITIES No cyanosis clubbing or edema with good pulses in the radial arteries bilaterally NEURO No focal deficits is intact to soft touch in all four ASSESSMENT AND RECOMMENDATIONS In light of her history and physical clearly the patient would be well served with an upper and lower endoscopy We do not know what the anatomy is and if she did have an antrectomy she needs to be checked for marginal ulcers She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well I discussed the risks benefits and alternatives to upper and lower endoscopy and these include over sedation perforation and dehydration and she wants to proceed We will schedule her for an upper and lower endoscopy at her convenience Keywords consult history and phy screening colonoscopy colonoscopy hematochezia screening endoscopy MEDICAL_TRANSCRIPTION,Description A 50 year old female whose 51 year old sister has a history of multiple colon polyps which may slightly increase her risk for colon cancer in the future Medical Specialty Consult History and Phy Sample Name Consult Multiple Colon Polyps Transcription HISTORY OF PRESENT ILLNESS See chart attached MEDICATIONS Tramadol 50 mg every 4 to 6 hours p r n hydrocodone 7 5 mg 500 mg every 6 hours p r n zolpidem 10 mg at bedtime triamterene 37 5 mg atenolol 50 mg vitamin D TriCor 145 mg simvastatin 20 mg ibuprofen 600 mg t i d and Lyrica 75 mg FAMILY HISTORY Mother is age 78 with history of mesothelioma Father is alive but unknown medical history as they have been estranged She has a 51 year old sister with history of multiple colon polyps She has 2 brothers 1 of whom has schizophrenia but she knows very little about their medical history To the best of her knowledge there are no family members with stomach cancer or colon cancer SOCIAL HISTORY She was born in Houston Texas and moved to Florida about 3 years ago She is divorced She has worked as a travel agent She has 2 sons ages 24 and 26 both of whom are alive and well She smokes a half a pack of cigarettes per day for more than 35 years She does not consume alcohol REVIEW OF SYSTEMS As per the form filled out in our office today is positive for hypertension weakness in arms and legs arthritis pneumonia ankle swelling getting full quickly after eating loss of appetite weight loss which is stated as fluctuating up and down 4 pounds trouble swallowing heartburn indigestion belching nausea diarrhea constipation change in bowel habits change in consistency rectal bleeding hemorrhoids abdominal discomfort and cramping associated with constipation hepatitis A or infectious hepatitis in the past and smoking and alcohol as previously stated Otherwise review of systems is negative for strokes paralysis gout cataracts glaucoma respiratory difficulties tuberculosis chest pain heart disease kidney stones hematuria rheumatic fever scarlet fever cancer diabetes thyroid disease seizure disorder blood transfusions anemia jaundice or pruritus PHYSICAL EXAMINATION Weight 152 pounds Height is 5 feet 3 inches Blood pressure 136 80 Pulse 68 In general She is a well developed and well nourished female who ambulates with the assistance of a cane Neurologically nonfocal Awake alert and oriented x 3 HEENT Head normocephalic atraumatic Sclerae anicteric Conjunctivae are pink Mouth is moist without any obvious oral lesions Neck is supple There is no submandibular submaxillary axillary supraclavicular or epitrochlear adenopathy appreciable Lungs are clear to auscultation bilaterally Heart Regular rate and rhythm without obvious gallops or murmurs Abdomen is soft nontender with good bowel sounds No organomegaly or masses are appreciable Extremities are without clubbing cyanosis and or edema Skin is warm and dry Rectal was deferred and will be done at the time of the colonoscopy IMPRESSION 1 A 50 year old female whose 51 year old sister has a history of multiple colon polyps which may slightly increase her risk for colon cancer in the future 2 Reports of recurrent bright red blood per rectum mostly on the toilet paper over the past year Bleeding most likely consistent with internal hemorrhoids however she needs further evaluation for colon polyps or colon cancer 3 Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation She is on multiple medications including narcotics and may have developed narcotic bowel syndrome 4 A long history of pyrosis dyspepsia nausea and belching for many years relieved by antacids She may likely have underlying gastroesophageal reflux disease 5 A 1 year history of some early satiety and fluctuations in her weight up and down 4 pounds She may also have some GI dysmotility including gastroparesis 6 Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine If this bone spur is pressing anteriorly it could certainly cause recurrent symptoms of dysphagia Differential also includes peptic stricture or Schatzki s ring and even remotely the possibility of an esophageal malignancy 7 A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology She may have some reaction to her multiple medications including her statin drugs which can cause mild elevations in transaminases She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C PLAN 1 We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases She will likely have the lab tests repeated in the future and if they remain persistently elevated we will be happy to see her in the future for further evaluation if her primary care physician would like 2 Discussed reflux precautions and gave literature for further review 3 Schedule an upper endoscopy with possible esophageal dilatation as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids Both procedures were explained in detail including risks and complications such as adverse reaction to medication as well as respiratory embarrassment infection bleeding perforation and possibility of missing a small polyp or tumor 4 Alternatives including upper GI series flexible sigmoidoscopy barium enema and CT colonography were discussed however the patient agrees to proceed with the plan as outlined above 5 Due to her sister s history of colon polyps she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination Keywords consult history and phy mesothelioma risk for colon cancer constipation diarrhea multiple colon polyps colon cancer colon polyps colon cancer polyps MEDICAL_TRANSCRIPTION,Description The patient admitted with palpitations and presyncope Medical Specialty Consult History and Phy Sample Name Consult Palpitations Presyncope Transcription HISTORY OF PRESENT ILLNESS The patient is a charming and delightful 46 year old woman admitted with palpitations and presyncope The patient is active and a previously healthy young woman who has had nine years of occasional palpitations Symptoms occur three to four times per year and follow no identifiable pattern She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate The last two episodes the most recent of which was yesterday were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision On neither occasion did she lose consciousness Yesterday she had a modestly active morning taking a walk with her dogs and performing her normal routines While working on a computer she had a spell Palpitations persisted for a short time thereafter as outlined in the hospital s admission note prompting her to seek evaluation at the hospital She was in sinus rhythm on arrival and has been asymptomatic since No history of exogenous substance abuse alcohol abuse or caffeine abuse She does have a couple of sodas and at least one to two coffees daily She is a nonsmoker She is a mother of two There is no family history of congenital heart disease She has had no history of thoracic trauma No symptoms to suggest thyroid disease No known history of diabetes hypertension or dyslipidemia Family history is negative for ischemic heart disease Remote history is significant for an ACL repair complicated by contact urticaria from a neoprene cast No regular medications prior to admission The only allergy is the neoprene reaction outlined above PHYSICAL EXAMINATION Vital signs as charted Pupils are reactive Sclerae nonicteric Mucous membranes are moist Neck veins not distended No bruits Lungs are clear Cardiac exam is regular without murmurs gallops or rubs Abdomen is soft without guarding rebound masses or bruits Extremities well perfused No edema Strong and symmetrical distal pulses A 12 lead EKG shows sinus rhythm with normal axis and intervals No evidence of preexcitation LABORATORY STUDIES Unremarkable No evidence of myocardial injury Thyroid function is pending Two dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease IMPRESSION PLAN Episodic palpitations over a nine year period Outpatient workup would be appropriate Event recorder should be obtained and the patient can be seen again in the office upon completion of that study Suppressive medication beta blocker or Cardizem was discussed with the patient for symptomatic improvement though this would be unlikely to be a curative therapy The patient expresses a preference to avoid medical therapy if possible Thank you for this consultation We will be happy to follow her both during this hospitalization and following discharge Caffeine avoidance was discussed as well ADDENDUM During her initial evaluation a D dimer was mildly elevated to 5 CT scan showed no evidence of pulmonary embolus Lower extremity venous ultrasound is pending however in the absence of embolization to the pulmonary vasculature this would be an unlikely cause of palpitations In addition no progression over the nine year period that she has been symptomatic suggests that this is an unlikely cause Keywords consult history and phy presyncope palpitations episodic palpitations beta blocker ultrasound palpitations and presyncope sinus rhythm heart disease heart MEDICAL_TRANSCRIPTION,Description Marked right hydronephrosis without hydruria Medical Specialty Consult History and Phy Sample Name Consult Hydronephrosis Transcription CHIEF COMPLAINT Right hydronephrosis HISTORY OF PRESENT ILLNESS The patient is a 56 year old female who has a history of uterine cancer breast cancer mesothelioma She is scheduled to undergo mastectomy in two weeks In September 1999 she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation Again she is scheduled for mastectomy in two weeks She underwent a recent PET scan for Dr X which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney There was no dilation of the right ureter noted Urinalysis today is microscopically negative PAST MEDICAL HISTORY Uterine cancer mesothelioma breast cancer diabetes hypertension PAST SURGICAL HISTORY Lumpectomy hysterectomy MEDICATIONS Diovan HCT 80 12 5 mg daily metformin 500 mg daily ALLERGIES None FAMILY HISTORY Noncontributory SOCIAL HISTORY She is retired Does not smoke or drink REVIEW OF SYSTEMS I have reviewed his review of systems sheet and it is on the chart PHYSICAL EXAMINATION Please see the physical exam sheet I completed Abdomen is soft nontender nondistended no palpable masses no CVA tenderness IMPRESSION AND PLAN Marked right hydronephrosis without hydruria She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005 I will try to obtain the report to see if the right kidney was evaluated at that time She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed She will call us back to schedule the x rays She understands the great importance and getting back in touch with us to schedule these x rays due to the possibility that it may be somehow related to the cancer There is also a question of a stone present in the kidney She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests Keywords consult history and phy hydruria hydronephrosis review of systems uterine cancer breast cancer mesothelioma mastectomy kidney cancer MEDICAL_TRANSCRIPTION,Description The patient had several episodes where she felt like her face was going to twitch which she could suppress it with grimacing movements of her mouth and face Medical Specialty Consult History and Phy Sample Name Consult Facial Twitching Transcription REASON FOR REFERRAL Facial twitching HISTORY OF PRESENT ILLNESS The patient had several episodes where she felt like her face was going to twitch which she could suppress it with grimacing movements of her mouth and face She reports she is still having right posterior head pressure like sensations approximately one time per week These still are characterized by a tingling pressure like sensation that often has a feeling as though water is running down on her hair This has also decreased in frequency occurring approximately one time per week and seems to respond to over the counter analgesics such as Aleve Lastly during conversation today she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non stimulating environments or in front of the television She states that she feels fatigued all the time and does not get good sleep She describes it as insomnia but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9 00 a m each morning and sleeps no more than five to six hours ever but usually five hours Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom She thinks she may snore but she is not sure She does not recall any events of awakening and gasping for breath PAST MEDICAL HISTORY Please see my earlier notes in chart FAMILY HISTORY Please see my earlier notes in chart SOCIAL HISTORY Please see my earlier notes in charts REVIEW OF SYSTEMS Today she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood poor sleep and possible snoring otherwise the 10 system review is negative PHYSICAL EXAMINATION General Examination Unremarkable mainly for mild to moderate obesity with a weight of 258 pounds Otherwise general examination is unremarkable NEUROLOGICAL EXAMINATION As before is nonfocal Please see note in chart for details PERTINENT FINDINGS Since the last evaluation she has had an MRI performed which was largely unremarkable except for a 1 2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal which does not enhance The nature of this lesion is unclear Certainly this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences LABS She was supposed to have Lyme titers and thyroid tests as well as fasting glucose which were not done however in light of her improvement these may not need to be performed at this time IMPRESSION 1 Left facial twitching appears to be improving Most likely this is a peripheral nerve injury related to her abscess as previously described In light of her negative MRI and clinical improvement we discussed options and elected to just observe for now 2 Posterior pressure like headache also appears to be improving The etiology is unclear but as it responds nicely to nonsteroidal antiinflammatories and is decreasing no further evaluation is needed 3 Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9 00 a m with insufficient sleep There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study For the time being sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10 00 a m or 10 30 to get a full night sleep She is on vacation next week and is going to try to see if this will help We also discussed as before weight loss and exercise which could be helpful 4 Right clivus and petrous lesion of unknown etiology We will repeat the MRI at four months to see for interval change 5 The patient voiced understanding of these plans and will be following up with me in five months Keywords consult history and phy grimacing headache clivus and petrous facial twitching sleep facial twitching MEDICAL_TRANSCRIPTION,Description Patient with complaint of left knee pain Patient is obese and will be starting Medifast Diet Medical Specialty Consult History and Phy Sample Name Consult Knee Pain Transcription CHIEF COMPLAINT Left knee pain SUBJECTIVE This is a 36 year old white female who presents to the office today with a complaint of left knee pain She is approximately five days after a third Synvisc injection She states that the knee is 35 to 40 better but continues to have a constant pinching pain when she full weight bears cannot handle having her knee in flexion has decreased range of motion with extension Rates her pain in her knee as a 10 10 She does alternate ice and heat She is using Tylenol No 3 p r n and ibuprofen OTC p r n with minimal relief ALLERGIES 1 PENICILLIN 2 KEFLEX 3 BACTRIM 4 SULFA 5 ACE BANDAGES MEDICATIONS 1 Toprol 2 Xanax 3 Advair 4 Ventolin 5 Tylenol No 3 6 Advil REVIEW OF SYSTEMS Will be starting the Medifast diet has discussed this with her PCP who encouraged her to have gastric bypass but the patient would like to try this Medifast diet first Other than this denies any further problems with her eyes ears nose throat heart lungs GI GU musculoskeletal nervous system except what is noted above and below PHYSICAL EXAMINATION VITAL SIGNS Pulse 72 blood pressure 130 88 respirations 16 height 5 feet 6 5 inches GENERAL This is a 36 year old white female who is A O x3 in no apparent distress with a pleasant affect She is well developed well nourished appears her stated age EXTREMITIES Orthopedic evaluation of the left knee reveals there to be well healed portholes She does have some medial joint line swelling Negative ballottement She has significant pain to palpation of the medial joint line none of the lateral joint line She has no pain to palpation on the popliteal fossa Range of motion is approximately 5 degrees to 95 degrees of flexion It should be noted that she has extreme hyperextension on the right with 95 degrees of flexion on the right She has a click with McMurray Negative anterior posterior drawer No varus or valgus instability noted Positive patellar grind test Calf is soft and nontender Gait is stable and antalgic on the left ASSESSMENT 1 Osteochondral defect torn meniscus left knee 2 Obesity PLAN I have encouraged the patient to work on weight reduction as this will only benefit her knee I did discuss treatment options at length with the patient but I think the best plan for her would be to work on weight reduction She questions whether she needs a total knee I don t believe she needs total knee replacement She may however at some point need an arthroscopy I have encouraged her to start formal physical therapy and a home exercise program Will use ice or heat p r n I have given her refills on Tylenol No 3 Flector patch and Relafen not to be taken with any other anti inflammatory She does have some abdominal discomfort with the anti inflammatories was started on Nexium 20 mg one p o daily She will follow up in our office in four weeks If she has not gotten any relief with formal physical therapy and the above noted treatments we will discuss with Dr X whether she would benefit from another knee arthroscopy The patient shows a good understanding of this treatment plan and agrees Keywords consult history and phy medifast medifast diet obesity gastric bypass knee pain weight reduction knee MEDICAL_TRANSCRIPTION,Description Patient with mid epigastric abdominal pain Sonogram revealed gallstones Medical Specialty Consult History and Phy Sample Name Consult Laparoscopic Cholecystectomy Transcription PAST MEDICAL HISTORY Significant for arthritis in her knee anxiety depression high insulin levels gallstone attacks and PCOS PAST SURGICAL HISTORY None SOCIAL HISTORY Currently employed She is married She is in sales She does not smoke She drinks wine a few drinks a month CURRENT MEDICATIONS She is on Carafate and Prilosec She was on metformin but she stopped it because of her abdominal pains ALLERGIES She is allergic to PENICILLIN REVIEW OF SYSTEMS Negative for heart lungs GI GU cardiac or neurologic Denies specifically asthma allergies high blood pressure high cholesterol diabetes chronic lung disease ulcers headache seizures epilepsy strokes thyroid disorder tuberculosis bleeding clotting disorder gallbladder disease positive liver disease kidney disease cancer heart disease and heart attack PHYSICAL EXAMINATION She is afebrile Vital Signs are stable HEENT EOMI PERRLA Neck is soft and supple Lungs clear to auscultation She is mildly tender in the abdomen in the right upper quadrant No rebound Abdomen is otherwise soft Positive bowel sounds Extremities are nonedematous Ultrasound reveals gallstones no inflammation common bile duct in 4 mm IMPRESSION PLAN I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding infection deep venous thrombosis pulmonary embolism cystic leak duct leak possible need for ERCP and possible need for further surgery among other potential complications She understands and we will proceed with the surgery in the near future Keywords consult history and phy laparoscopic cholecystectomy mid epigastric epigastric abdominal potential complications laparoscopic cholecystectomy epigastric abdomen surgery gallstones disease abdominal MEDICAL_TRANSCRIPTION,Description Patient with a past medical history of hypertension for 15 years Medical Specialty Consult History and Phy Sample Name Consult Hypertension Transcription HISTORY OF PRESENT ILLNESS The patient is a 74 year old white woman who has a past medical history of hypertension for 15 years history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases who presented for evaluation of recent worsening of the hypertension According to the patient she had stable blood pressure for the past 12 15 years on 10 mg of lisinopril In August of 2007 she was treated with doxorubicin and as well as Procrit and her blood pressure started to go up to over 200s Her lisinopril was increased to 40 mg daily She was also given metoprolol and HCTZ two weeks ago after she visited the emergency room with increased systolic blood pressure Denies any physical complaints at the present time Denies having any renal problems in the past PAST MEDICAL HISTORY As above plus history of anemia treated with Procrit No smoking or alcohol use and lives alone FAMILY HISTORY Unremarkable PRESENT MEDICATIONS As above REVIEW OF SYSTEMS Cardiovascular No chest pain No palpitations Pulmonary No shortness of breath cough or wheezing Gastrointestinal No nausea vomiting or diarrhea GU No nocturia Denies having gross hematuria Salt intake is minimal Neurological Unremarkable except for history of old CVA PHYSICAL EXAMINATION Blood pressure today is 182 78 Examination of the head is unremarkable Neck is supple with no JVD Lungs are clear There is no abdominal bruit Extremities 1 edema bilaterally LABORATORY DATA Urinalysis done in the office shows 1 proteinuria same is shown by urinalysis done at Hospital The creatinine is 0 8 Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis IMPRESSION AND PLAN Accelerated hypertension No clear cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA I could only blame Procrit initiation as well as possible fluid retention as a cause of the patient s accelerated hypertension She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension At this point I would not pursue a diagnosis of renal artery stenosis Since she is maxed out on lisinopril and her pulse is 60 I would not increase beta blocker or ACE inhibitor I will continue HCTZ at 24 mg daily The patient was also given a sample of Tekturna which would hopefully improve her systolic blood pressure The patient was told to be stick with her salt intake She will report to me in 10 days with the result of her blood pressure She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna Keywords consult history and phy hypertension ace inhibitor accelerated hypertension hctz mra of the renal arteries procrit sma7 anemia beta blocker doxorubicin hemiparesis history of cva hyperkalemia no abdominal bruit uterine cancer renal artery stenosis artery stenosis blood pressure blood pressure renal MEDICAL_TRANSCRIPTION,Description The patient has been suffering from intractable back and leg pain Medical Specialty Consult History and Phy Sample Name Consult Back Leg Pain Transcription Her axial back pain is greatly improved but not completely eradicated There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption PAST MEDICAL HISTORY Significant for anxiety disorder PAST SURGICAL HISTORY Foot surgery abdominal surgery and knee surgery CURRENT MEDICATIONS Lipitor and Lexapro ALLERGIES She is allergic to sulfa medications SOCIAL HISTORY She is married retired Denies tobacco or ethanol use FAMILY HISTORY Father died of mesothelioma Mother gastric problems REVIEW OF SYSTEMS No recent history of night sweats fevers weight loss visual changes loss of consciousness convulsion or dysphagia Otherwise review of systems is unremarkable and a detailed history can be found in the patient s chart PHYSICAL EXAMINATION Physical exam can be found in great detail in the patient s chart ASSESSMENT AND PLAN The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome Her lumbar facet joints were denervated approximately 6 months ago The denervation procedure helped her axial back pain approximately 40 when standing With extension and rotation it helped her axial back pain approximately 70 She is now able to swing a golf club She was unable to swing a golf club due to the rotational movements before her rhizotomy She is currently playing golf Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p o b i d We will follow her up in 1 month s time Keywords consult history and phy multilevel lumbar internal disc disruption denervation procedure lumbar facet joint syndrome swing a golf lumbar internal disc internal disc disruption lumbar internal internal disc disc disruption intractable surgery disc lumbar MEDICAL_TRANSCRIPTION,Description Patient with a history of right upper pons and right cerebral peduncle infarction Medical Specialty Consult History and Phy Sample Name Consult Cerebral Peduncle Infarction Transcription FAMILY HISTORY AND SOCIAL HISTORY Reviewed and remained unchanged MEDICATIONS List remained unchanged including Plavix aspirin levothyroxine lisinopril hydrochlorothiazide Lasix insulin and simvastatin ALLERGIES She has no known drug allergies FALL RISK ASSESSMENT Completed and there was no history of falls REVIEW OF SYSTEMS Full review of systems again was pertinent for shortness of breath lack of energy diabetes hypothyroidism weakness numbness and joint pain Rest of them was negative PHYSICAL EXAMINATION Vital Signs Today blood pressure was 170 66 heart rate was 66 respiratory rate was 16 she weighed 254 pounds as stated and temperature was 98 0 General She was a pleasant person in no acute distress HEENT Normocephalic and atraumatic No dry mouth No palpable cervical lymph nodes Her conjunctivae and sclerae were clear NEUROLOGICAL EXAMINATION Remained unchanged Mental Status Normal Cranial Nerves Mild decrease in the left nasolabial fold Motor There was mild increased tone in the left upper extremity Deltoids showed 5 5 The rest showed full strength Hip flexion again was 5 5 on the left The rest showed full strength Reflexes Reflexes were hypoactive and symmetrical Gait She was mildly abnormal No ataxia noted Wide based ambulated with a cane IMPRESSION Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis has been clinically stable with mild improvement She is planned for surgical intervention for the internal carotid artery RECOMMENDATIONS At this time again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes She will continue to follow with endocrinology for diabetes and thyroid problems I have recommended a strict control of her blood sugar optimizing cholesterol and blood pressure control regular exercise and healthy diet and I have discussed with Ms A and her daughter to give us a call for post surgical recovery I will see her back in about four months or sooner if needed Keywords consult history and phy internal carotid artery cerebral peduncle infarction carotid artery blood pressure upper pons infarction cerebral peduncle MEDICAL_TRANSCRIPTION,Description The patient is a 57 year old female with invasive ductal carcinoma of the left breast T1c Nx M0 left breast carcinoma Medical Specialty Consult History and Phy Sample Name Consult Breast Cancer 1 Transcription CHIEF COMPLAINT Left breast cancer HISTORY The patient is a 57 year old female who I initially saw in the office on 12 27 07 as a referral from the Tomball Breast Center On 12 21 07 the patient underwent image guided needle core biopsy of a 1 5 cm lesion at the 7 o clock position of the left breast inferomedial The biopsy returned showing infiltrating ductal carcinoma high histologic grade The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging She prior to that area denied any complaints She had no nipple discharge No trauma history She has had been on no estrogen supplementation She has had no other personal history of breast cancer Her family history is positive for her mother having breast cancer at age 48 The patient has had no children and no pregnancies She denies any change in the right breast Subsequent to the office visit and tissue diagnosis of breast cancer she has had medical oncology consultation with Dr X and radiation oncology consultation with Dr Y I have discussed the case with Dr X and Dr Y who are both in agreement with proceeding with surgery prior to adjuvant therapy The patient s metastatic workup has otherwise been negative with MRI scan and CT scanning The MRI scan showed some close involvement possibly involving the left pectoralis muscle although thought to also possibly represent biopsy artifact CT scan of the neck chest and abdomen is negative for metastatic disease PAST MEDICAL HISTORY Previous surgery is history of benign breast biopsy in 1972 laparotomy in 1981 1982 and 1984 right oophorectomy in 1984 and ganglion cyst removal of the hand in 1987 MEDICATIONS She is currently on omeprazole for reflux and indigestion ALLERGIES SHE HAS NO KNOWN DRUG ALLERGIES REVIEW OF SYSTEMS Negative for any recent febrile illnesses chest pains or shortness of breath Positive for restless leg syndrome Negative for any unexplained weight loss and no change in bowel or bladder habits FAMILY HISTORY Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure SOCIAL HISTORY The patient works as a school teacher and teaching high school PHYSICAL EXAMINATION GENERAL The patient is a white female alert and oriented x 3 appears her stated age of 57 HEENT Head is atraumatic and normocephalic Sclerae are anicteric NECK Supple CHEST Clear HEART Regular rate and rhythm BREASTS Exam reveals an approximately 1 5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o clock position which clinically is not fixed to the underlying pectoralis muscle There are no nipple retractions No skin dimpling There is some at the time of the office visit ecchymosis from recent biopsy There is no axillary adenopathy The remainder of the left breast is without abnormality The right breast is without abnormality The axillary areas are negative for adenopathy bilaterally ABDOMEN Soft nontender without masses No gross organomegaly No CVA or flank tenderness EXTREMITIES Grossly neurovascularly intact IMPRESSION The patient is a 57 year old female with invasive ductal carcinoma of the left breast T1c Nx M0 left breast carcinoma RECOMMENDATIONS I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient The procedure and risks of the surgery were explained to include but not limited to extra bleeding infection unsightly scar formation the possibility of local recurrence the possibility of left upper extremity lymphedema was explained Local numbness paresthesias or chronic pain was explained The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers She was certainly encouraged to obtain further surgical medical opinions prior to proceeding I believe the patient has given full informed consent and desires to proceed with the above Keywords MEDICAL_TRANSCRIPTION,Description Patient with a history of mesothelioma and likely mild dementia most likely Alzheimer type Medical Specialty Consult History and Phy Sample Name Consult Alzheimer disease Transcription The patient states that she has been doing fairly well at home She balances her own checkbook She does not do her own taxes but she has never done so in the past She states that she has no problems with cooking meals getting her own meals and she is still currently driving She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren She is unfortunately living alone and although she seems to miss her grandchildren and is estranged from her son she denies any symptoms of frank depression There is unfortunately no one available to us to corroborate how well she is doing at home She lives alone and takes care of herself and does not communicate very much with her brother and sister She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren She denied any sort of personality change paranoid ideas or hallucinations She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it When these headaches are very severe she goes to the emergency room to get a single shot She is unclear if this is some sort of a migraine medication or just a primary pain medication She takes Fiorinal for these headaches and she states that this helps greatly She denies visual or migraine symptoms REVIEW OF SYSTEMS Negative for any sort of focal neurologic deficits such as weakness numbness visual changes dysarthria diplopia or dysphagia She also denies any sort of movement disorders tremors rigidities or clonus Her personal opinion is that some of her memory problems may be due to simply to her age and or nervousness She is unclear as if her memory is any worse than anyone else in her age group PAST MEDICAL HISTORY Significant for mesothelioma which was diagnosed seemingly more than 20 to 25 years ago The patient was not sure of exactly when it was diagnosed This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations The mesothelioma is in her abdomen She does not know of any history of having lung mesothelioma She states that she has never gotten chemotherapy or radiation for her mesothelioma Furthermore she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable She does have a history of three car accidents that she says were all rear enders where she was hit while essentially in a stopped position These have all occurred over the past five years She also has a diagnosis of dementing illness possibly Alzheimer disease from her previous neurology consultation This diagnosis was given in March 2006 MEDICATIONS Fiorinal p r n aspirin unclear if baby or full sized Premarin unclear of the dose ALLERGIES NONE SOCIAL HISTORY Significant for her being without a companion at this point She was born in Munich Germany She immigrated to of America in 1957 after her family had to move to Eastern Germany which was under Russian occupation at that time She is divorced She used to work as a secretary and later worked as a clerical worker at IBM She stopped working more than 20 years ago due to complications from her mesothelioma She denies any significant tobacco alcohol or illicit drugs She is bilingual speaking German and English She has known English from before her teens She has the equivalent of a high school education in Germany She has one brother and one sister both of whom are healthy and she does not spend much time communicating with them She has one son who lives in Santa Cruz He has grandchildren She is trying to contact with her grandchildren FAMILY HISTORY Significant for lung liver and prostate cancer Her mother died in her 80s of old age but it appears that she may have had a mild dementing illness at that time Whatever that dementing illness was appears to have started mostly in her 80s per the patient No one else appears to have Alzheimer disease including her brother and sister PHYSICAL EXAMINATION Her blood pressure is 152 92 pulse 80 and weight 80 7 kg She is alert and well nourished in no apparent distress She occasionally fumbles with questions of orientation missing the day and the date She also did not know the name of the hospital she thought it was O Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in She lost three points for recall Even with prompting she could not remember the objects that she was given to remember Her Mini Mental Score was 22 30 There were no naming problems or problems with repetition There were also no signs of dysarthria Her pupils were bilaterally reactive to light and accommodation Her extraocular movements were intact Her visual fields were full to confrontation Her sensations of her face arm and leg were normal There were no signs of neglect with double simultaneous stimulation Tongue was midline Her palate was symmetric Her face was symmetric as well Strength was approximately 5 5 She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain Her reflexes were symmetric and 2 except for her toes which were 1 to trace Her plantar reflexes were mute Her sensation was normal for pain temperature and vibration There were no signs of ataxia on finger to nose and there was no dysdiadochokinesia Gait was narrow and she could toe walk briefly and heel walk without difficulty SUMMARY Ms A is a pleasant 72 year old right handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia most likely Alzheimer type We tactfully discussed the patient s diagnosis with her and she felt reassured We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept so we wrote her another prescription for Aricept The patient herself seemed very concerned about the stigma of the disease but our lengthy discussion expressed genuine understanding as to why her outpatient physician had reported her to DMV It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment She will follow up with us in the next six months and will call us if she has any problems with the Aricept She was written for Aricept to start at 5 mg for three weeks and if she has no side effects which typically are GI side effects then she can go up to 10 mg a day We also reviewed with Ms A the findings for outpatient MRI which showed some mild atrophy per report and also that her metabolic workup which included an RPR TSH and B12 were all within normal limits Keywords consult history and phy neurology consultation dementing illness alzheimer disease dementia alzheimer mesothelioma MEDICAL_TRANSCRIPTION,Description She is sent for evaluation of ocular manifestations of systemic connective tissue disorders Denies any eye problems and history includes myopia with astigmatism Medical Specialty Consult History and Phy Sample Name Connective Tissue Disorder Transcription Her past medical history includes a presumed diagnosis of connective tissue disorder She has otherwise good health She underwent a shoulder ligament repair for joint laxity She does not take any eye medications and she takes Seasonale systemically She is allergic to penicillin The visual acuity today distance with her current prescription was 20 30 on the right and 20 20 on the left eye Over refraction on the right eye showed 0 50 sphere with acuity of 20 20 OD She is wearing 3 75 1 50 x 060 on the right and 2 50 0 25 x 140 OS Intraocular pressures are 13 OU and by applanation Confrontation visual fields extraocular movement and pupils are normal in both eyes Gonioscopy showed normal anterior segment angle morphology in both eyes She does have some fine iris strength crossing the angle but the angle is otherwise open 360 degrees in both eyes The lids were normal in both eyes Conjunctivae were quite OU Cornea were clear in both eyes The anterior chamber is deep and quiet OU She has clear lenses which are in good position OU Dilated fundus exam shows moderately optically clear vitreous OU The optic nerves are normal in size The cup to disc ratios were approximately 0 4 OU The nerve fiber layers are excellent OU The macula vessels and periphery were normal in both eyes No evidence of peripheral retinal degeneration is present in either eye Ms ABC has optically clear vitreous She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes She does have moderate myopia however This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur Otherwise I can see her in 1 to 2 years Keywords consult history and phy systemic connective tissue disorder stickler syndrome anterior chamber angles retinal degeneration connective tissue disorder vitreous degeneration detachment myopia optically astigmatism eyes MEDICAL_TRANSCRIPTION,Description Routine colorectal cancer screening He occasionally gets some loose stools Medical Specialty Consult History and Phy Sample Name Colon Cancer Screening Transcription HISTORY AND REASON FOR CONSULTATION For evaluation of this patient for colon cancer screening HISTORY OF PRESENT ILLNESS Mr A is a 53 year old gentleman who was referred for colon cancer screening The patient said that he occasionally gets some loose stools Other than that there are no other medical problems PAST MEDICAL HISTORY The patient does not have any serious medical problems at all He denies any hypertension diabetes or any other problems He does not take any medications PAST SURGICAL HISTORY Surgery for deviated nasal septum in 1996 ALLERGIES No known drug allergies SOCIAL HISTORY Does not smoke but drinks occasionally for the last five years FAMILY HISTORY There is no history of any colon cancer in the family REVIEW OF SYSTEMS Denies any significant diarrhea Sometimes he gets some loose stools Occasionally there is some constipation Stools caliber has not changed There is no blood in stool or mucus in stool No weight loss Appetite is good No nausea vomiting or difficulty in swallowing Has occasional heartburn PHYSICAL EXAMINATION The patient is alert and oriented x3 Vital signs Weight is 214 pounds Blood pressure is 111 70 Pulse is 69 per minute Respiratory rate is 18 HEENT Negative Neck Supple There is no thyromegaly Cardiovascular Both heart sounds are heard Rhythm is regular No murmur Lungs Clear to percussion and auscultation Abdomen Soft and nontender No masses felt Bowel sounds are heard Extremities Free of any edema IMPRESSION Routine colorectal cancer screening RECOMMENDATIONS Colonoscopy I have explained the procedure of colonoscopy with benefits and risks in particular the risk of perforation hemorrhage and infection The patient agreed for it We will proceed with it I also explained to the patient about conscious sedation He agreed for conscious sedation Keywords consult history and phy colon cancer screening loose stools colorectal colonoscopy MEDICAL_TRANSCRIPTION,Description Genetic counseling for a strong family history of colon polyps She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps Medical Specialty Consult History and Phy Sample Name Colon Polyps Genetic Counseling Transcription REASON FOR CONSULT Genetic counseling HISTORY OF PRESENT ILLNESS The patient is a very pleasant 61 year old female with a strong family history of colon polyps The patient reports her first polyps noted at the age of 50 She has had colonoscopies required every five years and every time she has polyps were found She reports that of her 11 brothers and sister 7 have had precancerous polyps She does have an identical twice who is the one of the 11 who has never had a history of polyps She also has history of several malignancies in the family Her father died of a brain tumor at the age of 81 There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement Her sister died at the age of 65 breast cancer She has two maternal aunts with history of lung cancer both of whom were smoker Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer There is no other cancer history PAST MEDICAL HISTORY Significant for asthma CURRENT MEDICATIONS Include Serevent two puffs daily and Nasonex two sprays daily ALLERGIES Include penicillin She is also allergic seafood crab and mobster SOCIAL HISTORY The patient is married She was born and raised in South Dakota She moved to Colorado 37 years ago She attended collage at the Colorado University She is certified public account She does not smoke She drinks socially REVIEW OF SYSTEMS The patient denies any dark stool or blood in her stool She has had occasional night sweats and shortness of breath and cough associated with her asthma She also complains of some acid reflux as well as anxiety She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords consult history and phy family history strong family history precancerous polyps brain tumor lung cancer genetic counseling colon polyps polyps MEDICAL_TRANSCRIPTION,Description Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress Primary low transverse cesarean section Medical Specialty Consult History and Phy Sample Name Cholestasis Of Pregnancy Transcription FINAL DIAGNOSES Delivered pregnancy cholestasis of pregnancy fetal intolerance to labor failure to progress PROCEDURE Included primary low transverse cesarean section SUMMARY This 32 year old gravida 2 was induced for cholestasis of pregnancy at 38 1 2 weeks The patient underwent a 2 day induction On the second day the patient continued to progress all the way to the point of 9 5 cm at which point she failed to progress During the hour or two of evaluation at 9 5 cm the patient was also noted to have some fetal tachycardia and an occasional late deceleration Secondary to these factors the patient was brought to the operative suite for primary low transverse cesarean section which she underwent without significant complication There was a slightly enlarged blood loss at approximately 1200 mL and postoperatively the patient was noted to have a very mild tachycardia coupled with 100 3 degrees Fahrenheit temperature right at delivery It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay The patient received 72 hours of antibiotics with there never being a temperature above 100 3 degrees Fahrenheit The maternal tachycardia resolved within a day The patient did well throughout the 3 day stay progressing to full diet regular bowel movements normal urination patterns The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20 It should be noted however that this was actually an expected result with the initial hematocrit of 32 preoperatively Therefore there was anemia but not an unexplained anemia PHYSICAL EXAMINATION ON DISCHARGE Includes the stable vital signs afebrile state An alert and oriented patient who is desirous at discharge Full range of motion all extremities fully ambulatory Pulse is regular and strong Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus The incision is beautiful and soft and nontender There is scant lochia and there is minimal edema LABORATORY STUDIES Include hematocrit of 27 and the last liver function tests was within normal limits 48 hours prior to discharge FOLLOWUP For the patient includes pelvic rest regular diet Follow up with me in 1 to 2 weeks Motrin 800 mg p o q 8h p r n cramps Tylenol No 3 one p o q 4h p r n pain prenatal vitamin one p o daily and topical triple antibiotic to incision b i d to q i d Keywords consult history and phy delivered pregnancy fetal intolerance induction pelvic rest low transverse cesarean section cholestasis of pregnancy cesarean section pregnancy fetal tachycardia cholestasis MEDICAL_TRANSCRIPTION,Description A 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth Medical Specialty Consult History and Phy Sample Name Chronic Otitis Media Transcription CHIEF COMPLAINT Chronic otitis media HISTORY OF PRESENT ILLNESS This is a 14 month old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth There is also associated chronic nasal congestion There had been no bouts of spontaneous tympanic membrane perforation but there had been elevations of temperature up to 102 during the acute infection He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia ALLERGIES None MEDICATIONS None FAMILY HISTORY Noncontributory MEDICAL HISTORY Mild reflux PREVIOUS SURGERIES None SOCIAL HISTORY The patient is not in daycare There are no pets in the home There is no secondhand tobacco exposure PHYSICAL EXAMINATION Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present Left ear is still little bit black Nose moderate inferior turbinate hypertrophy No polyps or purulence Oral cavity oropharynx 2 tonsils No exudates Neck no nodes masses or thyromegaly Lungs are clear to A P Cardiac exam regular rate and rhythm No murmurs Abdomen is soft and nontender Positive bowel sounds IMPRESSION Chronic eustachian tube dysfunction chronic otitis media with effusion recurrent acute otitis media and wax accumulation PLAN The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia Keywords consult history and phy chronic nasal congestion tympanic membrane perforation chronic otitis media tube insertion facemask anesthesia otitis media otitis media MEDICAL_TRANSCRIPTION,Description Newly diagnosed cholangiocarcinoma The patient is noted to have an increase in her liver function tests on routine blood work Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Medical Specialty Consult History and Phy Sample Name Cholangiocarcinoma Consult Transcription REASON FOR CONSULTATION Newly diagnosed cholangiocarcinoma HISTORY OF PRESENT ILLNESS The patient is a very pleasant 77 year old female who is noted to have an increase in her liver function tests on routine blood work in December 2009 Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis Common bile duct was noted to be 10 mm in size on that ultrasound She then underwent a CT scan of the abdomen in July 2010 which showed intrahepatic ductal dilatation with the common bile duct size being 12 7 mm She then underwent an MRI MRCP which was notable for stricture of the distal common bile duct She was then referred to gastroenterology and underwent an ERCP On August 24 2010 she underwent the endoscopic retrograde cholangiopancreatography She was noted to have a stricturing mass of the mid to proximal common bile duct consistent with cholangiocarcinoma A temporary biliary stent was placed across the biliary stricture Blood work was obtained during the hospitalization She was also noted to have an elevated CA99 She comes in to clinic today for initial Medical Oncology consultation After she sees me this morning she has a follow up consultation with a surgeon PAST MEDICAL HISTORY Significant for hypertension and hyperlipidemia In July she had eye surgery on her left eye for a muscle repair Other surgeries include left ankle surgery for a fractured ankle in 2000 CURRENT MEDICATIONS Diovan 80 12 5 mg daily Lipitor 10 mg daily Lutein 20 mg daily folic acid 0 8 mg daily and multivitamin daily ALLERGIES No known drug allergies FAMILY HISTORY Notable for heart disease She had three brothers that died of complications from open heart surgery Her parents and brothers all had hypertension Her younger brother died at the age of 18 of infection from a butcher s shop He was cutting Argentinean beef and contracted an infection and died within 24 hours She has one brother that is living who has angina and a sister who is 84 with dementia She has two adult sons who are in good health SOCIAL HISTORY The patient has been married to her second husband for the past ten years Her first husband died in 1995 She does not have a smoking history and does not drink alcohol REVIEW OF SYSTEMS The patient reports a change in her bowels ever since she had the stent placed She has noted some weight loss but she notes that that is due to not eating very well She has had some mild fatigue but prior to her diagnosis she had absolutely no symptoms As mentioned above she was noted to have abnormal alkaline phosphatase and total bilirubin AST and ALT which prompted the followup She has had some difficulty with her vision that has improved with her recent surgical procedure She denies any fevers chills night sweats She has had loose stools The rest of her review of systems is negative PHYSICAL EXAM VITALS Keywords MEDICAL_TRANSCRIPTION,Description Chest pain possible syncopal spells She has been having multiple cardiovascular complaints including chest pains which feel like cramps and sometimes like a dull ache which will last all day long Medical Specialty Consult History and Phy Sample Name Chest Pain Cardiac Consult Transcription REASON FOR REFERRAL Chest pain possible syncopal spells She is a very pleasant 31 year old mother of two children with ADD She was doing okay until January of 2009 when she had a partial hysterectomy Since then she just says things have changed She just does not want to go out anymore and just does not feel the same Also at the same time she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband Her 11 year old is having a lot of trouble at school and she often has to go there to take care of problems In this setting she has been having multiple cardiovascular complaints including chest pains which feel like cramps and sometimes like a dull ache which will last all day long She is also tender in the left breast area and gets numbness in her left hand She has also had three spells of falling she is not really clear on whether these are syncopal but they sound like they could be as she sees spots before her eyes Twice it happened when getting up quickly at night and another time in the grocery store She suffered no trauma She has no remote history of syncope Her weight has not changed in the past year MEDICATIONS Naprosyn which she takes up to six a day ALLERGIES Sulfa SOCIAL HISTORY She does not smoke or drink She is married with two children REVIEW OF SYSTEMS Otherwise unremarkable PEX BP 130 70 without orthostatic changes PR 72 WT 206 pounds She is a healthy young woman No JVD No carotid bruit No thyromegaly Cardiac Regular rate and rhythm There is no significant murmur gallop or rub Chest Mildly tender in the upper pectoral areas bilaterally breast exam was not performed Lungs Clear Abdomen Soft Moderately overweight Extremities No edema and good distal pulses EKG Normal sinus rhythm normal EKG ECHOCARDIOGRAM FOR SYNCOPE Essentially normal study IMPRESSION 1 Syncopal spells These do sound in fact to be syncopal I suspect it is simple orthostasis vasovagal as her EKG and echocardiogram looks good I have asked her to drink plenty of fluids and to not to get up suddenly at night I think this should take care of the problem I would not recommend further workup unless these spells continue at which time I would recommend a tilt table study 2 Chest pains Atypical for cardiac etiology undoubtedly due to musculoskeletal factors from her emotional stressors The Naprosyn is not helping that much I gave her a prescription for Flexeril and instructed her in its use not to drive after taking it RECOMMENDATIONS 1 Reassurance that her cardiac checkup looks excellent which it does 2 Drink plenty of fluids and arise slowly from bed 3 Flexeril 10 mg q 6 p r n 4 I have asked her to return should the syncopal spells continue Keywords consult history and phy chest pain syncopal echocardiogram ekg cardiac etiology syncopal spells rhythm flexeril cardiac chest MEDICAL_TRANSCRIPTION,Description Cervical spondylosis and kyphotic deformity She had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Medical Specialty Consult History and Phy Sample Name Cervical Spondylosis Neuro Consult Transcription REASON FOR NEUROLOGICAL CONSULTATION Cervical spondylosis and kyphotic deformity The patient was seen in conjunction with medical resident Dr X I personally obtained the history performed examination and generated the impression and plan HISTORY OF PRESENT ILLNESS The patient is a 45 year old African American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain This has subsequently resolved She started vigorous workouts in November 2005 In March of this year she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician By her report she had a nerve conduction study and a diagnosis of radiculopathy was made She had an MRI of lumbosacral spine which was within normal limits She then developed a tingling sensation in the right middle toe Symptoms progressed to sensory symptoms of her knees elbows and left middle toe She then started getting sensory sensations in the left hand and arm She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg Symptoms have been mildly progressive She is unaware of any trigger other than the vigorous workouts as mentioned above She has no associated bowel or bladder symptoms No particular position relieves her symptoms Workup has included two MRIs of the C spine which were personally reviewed and are discussed below She saw you for consultation and the possibility of surgical decompression was raised At this time she is somewhat reluctant to go through any surgical procedure PAST MEDICAL HISTORY 1 Ocular migraines 2 Myomectomy 3 Infertility 4 Hyperglycemia 5 Asthma 6 Hypercholesterolemia MEDICATIONS Lipitor Pulmicort Allegra Xopenex Patanol Duac topical gel Loprox cream and Rhinocort ALLERGIES Penicillin and aspirin Family history social history and review of systems are discussed above as well as documented in the new patient information sheet Of note she does not drink or smoke She is married with two adopted children She is a paralegal specialist She used to exercise vigorously but of late has been advised to stop exercising and is currently only walking REVIEW OF SYSTEMS She does complain of mild blurred vision but these have occurred before and seem associated with headaches PHYSICAL EXAMINATION On examination blood pressure 138 82 pulse 90 respiratory rate 14 and weight 176 5 pounds Pain scale is 0 A full general and neurological examination was personally performed and is documented on the chart Of note she has a normal general examination Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk She has mild postural tremor in both arms She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities Motor examination reveals no weakness to individual muscle testing but on gait she does have a very subtle left hemiparesis She has hyperreflexia in her lower extremities worse on the left Babinski s are downgoing PERTINENT DATA MRI of the brain from 05 02 06 and MRI of the C spine from 05 02 06 and 07 25 06 were personally reviewed MRI of the brain is broadly within normal limits MRI of the C spine reveals large central disc herniation at C6 C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema There is also a fairly large disc at C3 C4 with cord deformity and partial effacement of the subarachnoid space I do not appreciate any cord edema at this level IMPRESSION AND PLAN The patient is a 45 year old female with cervical spondylosis with a large C6 C7 herniated disc with mild cord compression and signal change at that level She has a small disc at C3 C4 with less severe and only subtle cord compression History and examination are consistent with signs of a myelopathy Results were discussed with the patient and her mother I am concerned about progressive symptoms Although she only has subtle symptoms now we made her aware that with progression of this process she may have paralysis If she is involved in any type of trauma to the neck such as motor vehicle accident she could have an acute paralysis I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem I have recommended that she wear a hard collar while driving The results of my consultation were discussed with you telephonically Keywords consult history and phy kyphotic cervical radiculopathy myelopathy kyphotic deformity cord compression cervical spondylosis toe spondylosis cord MEDICAL_TRANSCRIPTION,Description T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation Medical Specialty Consult History and Phy Sample Name Cancer of the nasopharynx Transcription DIAGNOSIS T1 N3 M0 cancer of the nasopharynx status post radiation therapy with 2 cycles of high dose cisplatin with radiation completed June 2006 status post 2 cycles carboplatin 5 FU given as adjuvant therapy completed September 2006 hearing loss related to chemotherapy and radiation xerostomia history of left upper extremity deep venous thrombosis PERFORMANCE STATUS 0 INTERVAL HISTORY In the interim since his last visit he has done quite well He is working He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics Overall when he compares his strength to six or eight months ago he notes that he feels much stronger He has no complaints other than mild xerostomia and treatment related hearing loss PHYSICAL EXAMINATION Vital Signs Height 65 inches weight 150 pulse 76 blood pressure 112 74 temperature 95 4 respirations 18 HEENT Extraocular muscles intact Sclerae not icteric Oral cavity free of exudate or ulceration Dry mouth noted Lymph No palpable adenopathy in cervical supraclavicular or axillary areas Lungs Clear Cardiac Rhythm regular Abdomen Soft nondistended Neither liver spleen nor other masses palpable Lower Extremities Without edema Neurologic Awake alert ambulatory oriented cognitively intact I reviewed the CT images and report of the study done on May 1 This showed no evidence of metabolically active malignancy Most recent laboratory studies were performed last September and the TSH was normal I have asked him to repeat the TSH at the one year anniversary He is on no current medications In summary this 57 year old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy He has made a good recovery We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up We will see him in six months time with a PET CT He returns to the general care and direction of Dr ABC Keywords consult history and phy radiation therapy with cycles cancer of the nasopharynx status post radiation cisplatin with radiation radiation therapy hearing loss hearing cisplatin xerostomia cancer radiation nasopharynx MEDICAL_TRANSCRIPTION,Description Dietary consultation for carbohydrate counting for type I diabetes Medical Specialty Consult History and Phy Sample Name Carbohydrate Counting Transcription SUBJECTIVE This is a 62 year old female who comes for dietary consultation for carbohydrate counting for type I diabetes The patient reports that she was hospitalized over the weekend for DKA She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477 She gave herself in smaller increments a total of 70 extra units of her Humalog Ten of those units were injectable the others were in the forms of pump Her blood sugar was over 600 when she went to the hospital later that day She is here at this consultation complaining of not feeling well still because she has a cold She realizes that this is likely because her immune system was so minimized in the hospital OBJECTIVE Current insulin doses on her insulin pump are boluses set at 5 units at breakfast 6 units at lunch and 11 units at supper Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30 5 units per 24 hours A diet history was obtained I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg dl was also recommended The Lilly guide for meal planning was provided and reviewed Additional carbohydrate counting book was provided ASSESSMENT The patient was taught an insulin to carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago which she does not recall It is based on the 500 rule which suggests this ratio We did identify carbohydrate sources in the food supply recognizing 15 g equivalents We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources She does seem to have a pattern of fixing blood sugars later in the day after they are elevated We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals With this in mind she was recommended to follow with three servings or 45 g of carbohydrate at breakfast three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately PLAN Recommend the patient use 1 unit of insulin for every 10 g carbohydrate load consumed Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day This was a one hour consultation Provided my name and number should additional needs arise Keywords consult history and phy insulin pump carbohydrate load immune system dietary consultation carbohydrate ratio blood sugars carbohydrate counting carbohydrate dietary blood counting insulin MEDICAL_TRANSCRIPTION,Description Left buttock abscess status post incision and drainage Recommended some local wound care Medical Specialty Consult History and Phy Sample Name Buttock Abscess Transcription CHIEF COMPLAINT Buttock abscess HISTORY OF PRESENT ILLNESS This patient is a 24 year old African American female who presented to the hospital with buttock pain She started off with a little pimple on the buttock She was soaking it at home without any improvement She came to the hospital on the first The patient underwent incision and drainage in the emergency department She was admitted to the hospitalist service with elevated blood sugars She has had positive blood cultures Surgery is consulted today for evaluation PAST MEDICAL HISTORY Diabetes type II poorly controlled high cholesterol PAST SURGICAL HISTORY C section and D C ALLERGIES NO KNOWN DRUG ALLERGIES MEDICATIONS Insulin metformin Glucotrol and Lipitor FAMILY HISTORY Diabetes hypertension stroke Parkinson disease and heart disease REVIEW OF SYSTEMS Significant for pain in the buttock Otherwise negative PHYSICAL EXAMINATION GENERAL This is an overweight African American female not in any distress VITAL SIGNS She has been afebrile since admission Vital signs have been stable Blood sugars have been in the 200 range HEENT Normal to inspection NECK No bruits or adenopathy LUNGS Clear to auscultation CV Regular rate and rhythm ABDOMEN Protuberant soft and nontender EXTREMITIES No clubbing cyanosis or edema RECTAL EXAM The patient has a drained abscess on the buttock cheek There is some serosanguineous drainage There is no longer any purulent drainage The wound appears relatively clean I do not see a lot of erythema ASSESSMENT AND PLAN Left buttock abscess status post incision and drainage I do not believe surgical intervention is warranted I have recommended some local wound care Please see orders for details Keywords consult history and phy buttock pain pimple incision and drainage local wound care blood sugars diabetes buttock abscess MEDICAL_TRANSCRIPTION,Description First degree and second degree burns right arm secondary to hot oil spill Workers Compensation industrial injury Medical Specialty Consult History and Phy Sample Name Burn Consult Transcription CHIEF COMPLAINT Burn right arm HISTORY OF PRESENT ILLNESS This is a Workers Compensation injury This patient a 41 year old male was at a coffee shop where he works as a cook and hot oil splashed onto his arm burning from the elbow to the wrist on the medial aspect He has had it cooled and presents with his friend to the Emergency Department for care PAST MEDICAL HISTORY Noncontributory MEDICATIONS None ALLERGIES None PHYSICAL EXAMINATION GENERAL Well developed well nourished 21 year old male adult who is appropriate and cooperative His only injury is to the right upper extremity There are first and second degree burns on the right forearm ranging from the elbow to the wrist Second degree areas with blistering are scattered through the medial aspect of the forearm There is no circumferential burn and I see no areas of deeper burn The patient moves his hands well Pulses are good Circulation to the hand is fine FINAL DIAGNOSIS 1 First degree and second degree burns right arm secondary to hot oil spill 2 Workers Compensation industrial injury TREATMENT The wound is cooled and cleansed with soaking in antiseptic solution The patient was ordered Demerol 50 mg IM for pain but he refused and did not want pain medication A burn dressing is applied with Neosporin ointment The patient is given Tylenol No 3 tabs 4 to take home with him and take one or two every four hours p r n for pain He is to return tomorrow for a dressing change Tetanus immunization is up to date Preprinted instructions are given Workers Compensation first report and work status report are completed DISPOSITION Home Keywords consult history and phy burn workers compensation industrial injury workers compensation degree MEDICAL_TRANSCRIPTION,Description The patient was admitted for symptoms that sounded like postictal state CT showed edema and slight midline shift MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery Medical Specialty Consult History and Phy Sample Name Brain Tumor Consult Transcription REASON FOR CONSULTATION I was asked by Dr X to see the patient in regard to his likely recurrent brain tumor HISTORY OF PRESENT ILLNESS The patient was admitted for symptoms that sounded like postictal state He was initially taken to Hospital CT showed edema and slight midline shift and therefore he was transferred here He has been seen by Hospitalists Service He has not had a recurrent seizure Electroencephalogram shows slowing MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery There is inhomogeneous uptake consistent with potential necrosis He also has had a SPECT image of his brain consistent with neoplasm suggesting relatively high grade neoplasm The patient was diagnosed with a brain tumor in 1999 All details are still not available to us He underwent a biopsy by Dr Y One of the notes suggested that this was a glioma likely an oligodendroglioma pending a second opinion at Clinic That is not available on the chart as I dictate After discussion of treatment issues with radiation therapist and Dr Z medical oncologist the decision was made to treat him primarily with radiation alone He tolerated that reasonably well His wife says it s been several years since he had a scan His behavior had not been changed until it changed as noted earlier in this summary PAST MEDICAL HISTORY He has had a lumbar fusion I believe he s had heart disease Mental status changes are either due to the tumor or other psychiatric problems SOCIAL HISTORY He is living with his wife next door to one of his children He has been disabled since 2001 due to the back problems REVIEW OF SYSTEMS No headaches or vision issues Ongoing heart problems without complaints No weakness numbness or tingling except that related to his chronic neck pain No history of endocrine problems He has nocturia and urinary frequency PHYSICAL EXAMINATION Blood pressure 146 91 pulse 76 Normal conjunctivae Ears nose throat normal Neck is supple Chest clear Heart tones normal Abdomen soft Positive bowel sounds No hepatosplenomegaly No adenopathy in the neck supraclavicular or axillary regions Neurologically alert Cranial nerves are intact Strength is 5 5 throughout LABORATORY WORK White blood count 10 4 hemoglobin 16 platelets not noted Sodium 137 calcium 9 1 IMPRESSION AND PLAN Likely recurrent low grade tumor possibly evolved to a higher grade given the MRI and SPECT findings Dr X s note suggests discussing the situation in the tumor board on Wednesday He is stable enough The pause in his care would not jeopardize his current status It would be helpful to get old films and pathology from Abbott Northwestern However he likely will need a re biopsy as he is highly suspicious for recurrent tumor and radiation necrosis Optimizing his treatment would probably be helped by knowing his current grade of tumor Keywords consult history and phy spect electroencephalogram middle cerebral artery brain tumor inhomogeneous frontotemporal neoplasm recurrent MEDICAL_TRANSCRIPTION,Description Breast reconstruction post mastectomy A 51 year old lady for mastectomy on the right side who is interested in the possibility of breast reconstruction Medical Specialty Consult History and Phy Sample Name Breast Reconstruction Transcription REASON FOR CONSULTATION Breast reconstruction post mastectomy HISTORY OF PRESENT ILLNESS The patient is a 51 year old lady who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy which revealed that there was breast cancer This apparently was positive in two separate locations within the suspicious area She also underwent MRI which suggested that there was significant size to the area involved Her contralateral left breast appeared to be uninvolved She has had consultation with Dr ABC and they are currently in place to perform a right mastectomy PAST MEDICAL HISTORY Positive for hypertension which is controlled on medications She is a nonsmoker and engages in alcohol only moderately PAST SURGICAL HISTORY Surgical history includes uterine fibroids some kind of cyst excision on her foot and cataract surgery ALLERGIES None known MEDICATIONS Lipitor ramipril Lasix and potassium PHYSICAL EXAMINATION On examination the patient is a healthy looking 51 year old lady who is moderately overweight Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps There are no any significant scars on the right breast as she has only undergone needle biopsy at this point Exam also reveals abdomen where there is moderate excessive fat but what I consider a good morphology for a potential TRAM flap IMPRESSION A 51 year old lady for mastectomy on the right side who is interested in the possibility of breast reconstruction We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted but in a heavier lady with large breasts I think it virtually deemed to failure We therefore mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant In either case the contralateral breast reduction would be part of the overall plan The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed In any case she does prefer this option in order to avoid the need for an implant We discussed pros and cons of the surgery including the risks such as infection bleeding scarring hernia or bulging of the donor site seroma of the abdomen and fat necrosis or even the skin slough in the abdomen We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself PLAN The patient is definitely interested in undergoing TRAM flap reconstruction At the moment we are planning to do it as an immediate reconstruction at the time of the mastectomy For this reason I have made arrangements to do initial vascular delay procedure within the next couple of days We may cancel this if the chance of postoperative irradiation is high If this is the case I think we can do a better job on the reconstruction if we defer it The patient understands this and will proceed according to the recommendations from Dr ABC and from the oncologist Keywords consult history and phy breast reconstruction mastectomy lump breast mammogram needle biopsy breast cancer hypertrophy tram flap latissimus dorsi MEDICAL_TRANSCRIPTION,Description Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet recurrent bunion deformity right forefoot pes planovalgus deformity bilateral feet Medical Specialty Consult History and Phy Sample Name Bunion Pes Planovalgus Deformity Transcription HISTORY OF PRESENT ILLNESS The patient is a 57 year old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet right greater than left The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well The patient had prior surgery performed approximately 13 years ago She states that since the time of the original surgery the deformity has slowly recurred and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete PAST MEDICAL HISTORY FAMILY HISTORY SOCIAL HISTORY REVIEW OF SYSTEMS See Patient History sheet which was reviewed with the patient and is signed in the chart Past medical history on the patient past surgical history current medications drug related allergies and social history have all been updated and reviewed and enclosed in the chart PHYSICAL EXAMINATION Physical exam reveals a pleasant 57 year old female who is 5 feet 4 inches and 150 pounds She has palpable pulses Neurologic sensation is intact Examination of the extremities shows the patient as having well healed surgical sites from her arthroplasty second digits bilaterally and prior bunionectomy There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw toe deformity of the second and third toes to the left foot and to a lesser degree the second toe to the right Gait analysis The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet X RAY INTERPRETATION X rays taken today three views to the right foot shows presence of internal K wire and wire from prior bunionectomy Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle No evidence of arthrosis in the joint is noted Significant shift to the fibular sesamoid is present ASSESSMENT 1 Recurrent bunion deformity right forefoot 2 Pes planovalgus deformity bilateral feet PLAN TREATMENT 1 Today we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal Anticipated length of healing was noted for the patient as were potential risks and complications The patient ultimately would probably require surgery on her left foot at a later date as well 2 The patient will explore her ability to get out of work for the above mentioned period of time and will be in touch with regards regarding scheduling at a later date 3 All questions were answered Keywords consult history and phy x rays pain mtp joint pes planovalgus deformity pes planovalgus bunion deformity planovalgus forefoot foot deformity bunionectomy bunion MEDICAL_TRANSCRIPTION,Description Recurrent bladder tumor The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5 cm area of papillomatosis just above the left ureteric orifice Medical Specialty Consult History and Phy Sample Name Bladder Tumor Transcription CHIEF COMPLAINT Recurrent bladder tumor HISTORY OF PRESENT ILLNESS The patient is a 79 year old woman the patient of Dr X who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5 cm area of papillomatosis just above the left ureteric orifice The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006 This was followed by bladder instillation of BCG At this time the patient denies any voiding symptoms or hematuria The patient opting for TUR and electrofulguration of the recurrent tumors ALLERGIES None known MEDICATIONS Atenolol 5 mg daily OPERATIONS Status post bilateral knee replacements and status post TUR of bladder tumors REVIEW OF SYSTEMS Other than some mild hypertension the patient is in very very good health No history of diabetes shortness of breath or chest pain PHYSICAL EXAMINATION Well developed and well nourished woman alert and oriented Her lungs are clear Heart regular sinus rhythm Back no CVA tenderness Abdomen soft and nontender No palpable masses IMPRESSION Recurrent bladder tumors PLAN The patient to have CBC chem 6 PT PTT EKG and chest x ray beforehand Keywords consult history and phy bladder neck voiding symptoms hematuria transitional cell carcinomas ureteric orifice bladder tumor bladder cystoscopy papillomatosis transitional carcinomas orifice MEDICAL_TRANSCRIPTION,Description Patient with a history of gross hematuria CT scan was performed which demonstrated no hydronephrosis or upper tract process however there was significant thickening of the left and posterior bladder wall Medical Specialty Consult History and Phy Sample Name Bladder Cancer Transcription CHIEF COMPLAINT Bladder cancer HISTORY OF PRESENT ILLNESS The patient is a 68 year old Caucasian male with a history of gross hematuria The patient presented to the emergency room near his hometown on 12 24 2007 for evaluation of this gross hematuria CT scan was performed which demonstrated no hydronephrosis or upper tract process however there was significant thickening of the left and posterior bladder wall Urology referral was initiated and the patient was sent to be evaluated by Dr X He eventually underwent a bladder biopsy on 01 18 08 which demonstrated high grade transitional cell carcinoma without any muscularis propria in the specimen Additionally the patient underwent workup for a right adrenal lesion which was noted on the initial CT scan This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement All of this workup was found to be grossly negative Secondary to the absence of muscle in the specimen the patient was taken back to the operating room on 02 27 08 by Dr X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck At that time the referring urologist determined the tumor to be too large and risky for local resection and the patient was referred to ABCD Urology for management and diagnosis The patient presents today for evaluation by Dr Y PAST MEDICAL HISTORY Includes condyloma hypertension diabetes mellitus hyperlipidemia undiagnosed COPD peripheral vascular disease and claudication The patient denies coronary artery disease PAST SURGICAL HISTORY Includes bladder biopsy on 01 18 08 without muscularis propria in the high grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2 The patient denies any bowel resection or GU injury at that time however he is unsure CURRENT MEDICATIONS 1 Metoprolol 100 mg b i d 2 Diltiazem 120 mg daily 3 Hydrocodone 10 500 mg p r n 4 Pravastatin 40 mg daily 5 Lisinopril 20 mg daily 6 Hydrochlorothiazide 25 mg daily FAMILY HISTORY Negative for any GU cancer stones or other complaints The patient states he has one uncle who died of lung cancer He denies any other family history SOCIAL HISTORY The patient smokes approximately 2 packs per day times greater than 40 years He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month He denies any drug use He is a retired liquor store owner PHYSICAL EXAMINATION GENERAL He is a well developed well nourished Caucasian male who appears slightly older than stated age VITAL SIGNS Temperature is 96 7 blood pressure is 108 57 pulse is 75 and weight of 193 8 pounds HEAD AND NECK Normocephalic atraumatic LUNGS Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung which is clear somewhat with cough HEART Regular rate and rhythm ABDOMEN Soft and nontender The liver and spleen are not palpably enlarged There is a large midline defect covered by skin of which the fascia has numerous holes poking through These small hernias are of approximately 2 cm in diameter at the largest and are nontender GU The penis is circumcised and there are no lesions plaques masses or deformities There is some tenderness to palpation near the meatus where 20 French Foley catheter is in place Testes are bilaterally descended and there are no masses or tenderness There is bilateral mild atrophy Epididymidis are grossly within normal limits bilaterally Spermatic cords are grossly within normal limits There are no palpable inguinal hernias RECTAL The prostate is mildly enlarged with a small focal firm area in the midline near the apex There is however no other focal nodules The prostate is grossly approximately 35 to 40 g and is globally firm Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault EXTREMITIES Demonstrate no cyanosis clubbing or edema There is dark red urine in the Foley bag collection LABORATORY EXAM Review of laboratory from outside facility demonstrates creatinine of 2 38 with BUN of 42 Additionally laboratory exam demonstrates a grossly normal serum cortisol ACTH potassium aldosterone level during lesion workup CT scan was reviewed from outside facility report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam There is a 3 1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted IMPRESSION Bladder cancer PLAN The patient will undergo a completion TURBT on 03 20 08 with bilateral retrograde pyelograms at the time of surgery Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr Y The patient will be scheduled for anesthesia preop The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging The patient understands these instructions and also agrees to quit smoking prior to his next visit This patient was seen in evaluation with Dr Y who agrees with the impression and plan Keywords consult history and phy retrograde pyelogram bladder biopsy muscularis propria bladder cancer gross hematuria bladder wall ct scan bladder hematuria MEDICAL_TRANSCRIPTION,Description Hypomastia Patient wants breast augmentation and liposuction of her abdomen Medical Specialty Consult History and Phy Sample Name Breast Augmentation Consult Transcription REASON FOR VISIT This is a cosmetic consultation HISTORY OF PRESENT ILLNESS The patient is a very pleasant 34 year old white female who is a nurse in the operating room She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her She is very bright and well informed about cosmetic surgery She has recently had some neck surgery for a re fusion of her neck and is currently on methadone for chronic pain regarding this Her current desires are that she obtain a breast augmentation and liposuction of her abdomen and she came to me mostly because I offer transumbilical breast augmentation Her breasts are reportedly healthy without any significant problems Her weight is currently stable PAST MEDICAL AND SURGICAL HISTORY Negative Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02 05 and in 09 06 She has had no previous cosmetic or aesthetic surgery FAMILY HISTORY AND SOCIAL HISTORY Significant for Huntington disease in her mother and diabetes in her father Her brother has an aneurysm She does occasionally smoke and has been trying to quit recently She is currently smoking about a pack a day She drinks about once a week She is currently a registered nurse circulator and scrub technician in the operating room at Hopkins She has no children REVIEW OF SYSTEMS A 12 system review is significant for some musculoskeletal pain mostly around her neck and thoracic region She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain She has considered difficult airway due to anterior cervical disk fusion and instability Her last mammogram was in 2000 She has a size 38C breast MEDICATIONS Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed ALLERGIES None FINDINGS On exam today the patient has good posture good physique good skin tone She is tanned Her lower abdomen has some excess adiposity There is some mild laxity of the lower abdominal skin Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation There was no piercing in that region Her breasts are C shaped They are not ptotic They have good symmetry with no evidence of tubular breast deformity She has no masses or lesions noted The nipples are of appropriate size and shape for a woman of her age Her scar on her neck from her anterior cervical disk fusion is well healed Hopefully our scars would be similar to this IMPRESSION AND PLAN Hypomastia I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely This would make her fill out her clothes much better and I think transumbilical technique in her is a good option I have discussed with her the other treatment options and she does not want scars around her breasts if at all possible I think her lower abdominal skin is of good tone I think suction lipectomy in this region would bring down her size and accentuate her waist nicely I am a little concerned about the lower abdominal skin laxity and I will discuss with her further that in the near future if this continues to be a problem she may need a mini tummy tuck I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed I will try to set this up in the near future I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure Due to her neck issues we may not be able to perform her surgery but I will check with Dr X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused Keywords consult history and phy breast augmentation and liposuction liposuction of her abdomen transumbilical breast augmentation cosmetic surgery abdominal skin breast augmentation augmentation liposuction cosmetic transumbilical breast MEDICAL_TRANSCRIPTION,Description Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety The patient complained of globus sensation high in her throat particularly with solid foods and with pills She denied history of coughing and chocking with meals Medical Specialty Consult History and Phy Sample Name Barium Swallow Study Evaluation Transcription HISTORY The patient is a 71 year old female who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety The patient complained of globus sensation high in her throat particularly with solid foods and with pills She denied history of coughing and chocking with meals The patient s complete medical history is unknown to me at this time The patient was cooperative and compliant throughout this evaluation STUDY Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr X The patient was seated upright at a 90 degree angle in a video imaging chair To evaluate her swallowing function and safety she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids teaspoon x3 cup sip x4 thickened liquid cup sip x3 puree consistency teaspoon x3 and solid consistency 1 4 cracker x1 The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation ORAL STAGE The patient had no difficulty with bolus control and transport No spillage out lips The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation We were not able to clear out the residual with alternating cup sips and thin liquid PHARYNGEAL STAGE No aspiration or penetration occurred during this evaluation The patient s hyolaryngeal elevation and anterior movements are within the functional limits Epiglottic inversion is within functional limits She had no residual or pooling in the pharynx after the swallow CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus DIAGNOSTIC IMPRESSION The patient had no aspiration or penetration occurred during this evaluation She does appear to have a diverticulum in the area between her right faucial pillars Additional evaluation is needed by an ENT physician PLAN Based on this evaluation the following is recommended 1 The patient s diet should consist regular consistency food with thin liquids She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux 2 The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately Thank you for the opportunity to be required the patient s medical care She is not in need of skilled speech therapy and is discharged from my services Keywords consult history and phy globus sensation oral stage pharyngeal stage cervical esophageal stage consistency otolaryngologist barium swallow study evaluation faucial pillars swallow study solid foods evaluation liquid barium oral swallow foods MEDICAL_TRANSCRIPTION,Description The patient is a 76 year old male with previous history of dysphagia status post stroke A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration Medical Specialty Consult History and Phy Sample Name Barium Swallow Study Evaluation 1 Transcription HISTORY The patient is a 76 year old male with previous history of dysphagia status post stroke The patient stated that he was at Hospital secondary to his stroke where he had his initial modified barium swallow study The patient stated that the results of that modified revealed aspiration with thin liquids only He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration STUDY Modified barium swallow study was performed in the radiology suite in cooperation with Dr X The patient was seated upright and in a video imaging chair throughout this assessment To evaluate the patient s swallowing function and safety he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids teaspoon x3 cup sip x3 nectar thick liquid teaspoon x2 cup sip x3 pureed consistency teaspoon x3 solid consistency 1 4 cracker x1 FINDINGS ORAL STAGE The patient had no spillage out lips Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity The patient has reduced lingual retraction contributing to vallecula pooling after the swallow Trace premature spillage was noted with thin liquids during this assessment PHARYNGEAL STAGE Aspiration noted on cup sips of thin liquid Trace to mild penetration with teaspoon amounts of thin liquid during and after the swallow The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule The patient has incomplete laryngeal closure which allowed the aspiration and penetration with thin liquids The patient had no aspiration or penetration occur with nectar thick liquid puree and solid food The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling Mild to moderate pooling in the vallecula after the swallow with liquids and puree this residual did decrease with the solid feed presentation The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus DIAGNOSTIC IMPRESSION Mild aspiration with cup sips of thin liquid penetration during and after the swallow with teaspoon amounts of thin liquid No aspiration or penetration occurred with thick liquid pureed or solid food during this assessment PROGNOSTIC IMPRESSION With a modified diet the patient s potential for swallowing safety is good PLAN Based on this evaluation the following is recommended 1 The patient should be on a regular diet with nectar thick liquids to help prevent aspiration and penetration 2 The patient should have unthickened water in between meals to help decrease his risk of dehydration 3 The patient should complete good oral care two times a day to decrease bacterial growth in mouth 4 The patient should be seated at a 90 degree angle when eating and drinking as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux Thank you for the opportunity to evaluate the patient I look forward to working with him in the outpatient setting to improve his swallowing function and safety Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re education as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety Keywords consult history and phy oral stage pharyngeal stage cervical esophageal stage nectar thick liquids aspiration modified barium swallow barium swallow study dysphagia status cup sips barium swallow swallow teaspoon barium swallowing MEDICAL_TRANSCRIPTION,Description Bladder instillation for chronic interstitial cystitis Medical Specialty Consult History and Phy Sample Name Bladder Instillation Transcription CHIEF COMPLAINT The patient comes for bladder instillation for chronic interstitial cystitis SUBJECTIVE The patient is crying today when she arrives in the office saying that she has a lot of discomfort These bladder instillations do not seem to be helping her She feels anxious and worried She does not think she can take any more pain She is debating whether or not to go back to Dr XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this and she fears these bladder instillations because they do not seem to help They seem to be intensifying her pain She has the extra burden of each time she comes needing to have pain medication one way or another thus then we would not allow her to drive under the influence of the pain medicine So she has to have somebody come with her and that is kind of troublesome to her We discussed this at length I did suggest that it was completely appropriate for her to decide She will terminate these if they are that uncomfortable and do not seem to be giving her any relief although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality She had Hysterectomy in the past MEDICATIONS Premarin 1 25 mg daily Elmiron 100 mg t i d Elavil 50 mg at bedtime OxyContin 10 mg three tablets three times a day Toprol XL 25 mg daily ALLERGIES Compazine and Allegra OBJECTIVE Vital Signs Weight 140 pounds Blood pressure 132 90 Pulse 102 Respirations 18 Age 27 PLAN We discussed going for another evaluation by Dr XYZ and seeking his opinion She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete The instillations give that a full trial and then he would be willing to see her back As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today s instillation which she did choose to take then she would choose to cancel Friday s appointment also that she would not feel too badly over the holiday weekend I thought that was reasonable and agreed that that would work out PROCEDURE She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine We waited about 20 minutes The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10 minute wait the bladder was instilled with DMSO Kenalog heparin and sodium bicarbonate and the catheter was removed The patient retained the solution for one hour changing position every 15 minutes and then voided to empty the bladder She seemed to tolerate it moderately well She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it If not she will cancel and will start over next week or she will see Dr Friesen Keywords consult history and phy urethra dmso bladder chronic interstitial cystitis interstitial cystitis bladder instillation instillation instillations MEDICAL_TRANSCRIPTION,Description A woman presenting to our clinic for the first time for evaluation of hip pain right greater than left of greater than 2 years duration The pain is located laterally as well as anteriorly into the groin Medical Specialty Consult History and Phy Sample Name Bilateral Hip Pain Transcription HISTORY OF PRESENT ILLNESS The patient is a 38 year old woman presenting to our clinic for the first time for evaluation of hip pain right greater than left of greater than 2 years duration The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip The pain is located laterally as well as anteriorly into the groin She states that the pain is present during activities such as walking and she does get some painful popping and clicking in the right hip She is here for evaluation for the first time She sought no previous medical attention for this PAST MEDICAL HISTORY Significant for depression and reflux disease PAST SURGICAL HISTORY Cesarean section x 2 CURRENT MEDICATIONS Listed in the chart and reviewed with the patient ALLERGIES The patient has no known drug allergies SOCIAL HISTORY The patient is married She is employed as an office manager She does smoke cigarettes one pack per day for the last 20 years She consumes alcohol 3 to 5 drinks daily She uses no illicit drugs She exercises monthly mainly walking and low impact aerobics She also likes to play softball REVIEW OF SYSTEMS Significant for occasional indigestion and nausea as well as anxiety and depression The remainder of the systems negative PHYSICAL EXAMINATION The patient is 5 foot 2 inches tall weighs 155 pounds The patient ambulates independently without an assist device with normal stance and gait Inspection of the hips reveals normal contour and appearance and good symmetry The patient is able to do an active straight leg raise against gravity and against resistance bilaterally She has no significant trochanteric tenderness She does however have some tenderness in the groin bilaterally There is no crepitus present with passive or active range of motion of the hips She is grossly neurologically intact in the bilateral lower extremities DIAGNOSTIC DATA X rays performed today in the clinic include an AP view of the pelvis and a frog leg lateral of the right hip There are no acute findings No fractures or dislocations There are minimal degenerative changes noted in the joint There is however the suggestion of an exostosis on the superior femoral neck which could be consistent with femoroacetabular impingement IMPRESSION Bilateral hip pain right worse than left possibly suggesting femoroacetabular impingement based on x rays and her clinical picture is also consistent with possible labral tear PLAN After discussing possible diagnoses with the patient I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip We will get that done as soon as possible In the meantime she is asked to moderate her activities She will follow up as soon as the MRIs are performed Keywords consult history and phy bilateral hip pain femoroacetabular impingement hip MEDICAL_TRANSCRIPTION,Description Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux en Y gastric bypass Medical Specialty Consult History and Phy Sample Name Bariatric Consult Surgical Weight Loss 4 Transcription HISTORY OF PRESENT ILLNESS Ms A is a 55 year old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux en Y gastric bypass The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers NutriSystem Jenny Craig TOPS cabbage diet grape fruit diet Slim Fast Richard Simmons as well as over the counter measures without any long term sustainable weight loss At the time of presentation to the practice she is 5 feet 6 inches tall with a weight of 285 4 pounds and a body mass index of 46 She has obesity related comorbidities which includes hypertension and hypercholesterolemia PAST MEDICAL HISTORY Significant for hypertension for which the patient takes Norvasc and Lopressor for She also suffers from high cholesterol and is on lovastatin for this She has depression for which she takes citalopram She also stated that she had a DVT in the past prior to her hysterectomy She also suffers from thyroid disease in the past though this is unclear the nature of this PAST SURGICAL HISTORY Significant for cholecystectomy in 2008 for gallstones She also had a hysterectomy in 1994 secondary to hemorrhage The patient denies any other abdominal surgeries MEDICATIONS Norvasc 10 mg p o daily Lopressor tartrate 50 mg p o b i d lovastatin 10 mg p o at bedtime citalopram 10 mg p o daily aspirin 500 mg three times a day which is currently stopped vitamin D Premarin 0 3 mg one tablet p o daily currently stopped omega 3 fatty acids and vitamin D 50 000 units q weekly ALLERGIES The patient denies allergies to medications and to latex SOCIAL HISTORY The patient is a homemaker She is married with 2 children aged 22 and 28 She is a lifelong nonsmoker and nondrinker FAMILY HISTORY Significant for high blood pressure and diabetes as well as cancer on her father side He did pass away from congestive heart failure Mother suffers from high blood pressure cancer and diabetes Her mother has passed away secondary to cancer She has two brothers one passed away from brain cancer REVIEW OF SYSTEMS Significant for ankle swelling The patient also wears glasses for vision and has dentures She does complain of shortness of breath with exertion She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain The patient denies ulcerative colitis Crohn disease bleeding diathesis liver disease or kidney disease She denies chest pain cardiac disease cancer and stroke PHYSICAL EXAMINATION The patient is a well nourished well developed female in no distress Eye Exam Pupils equal and reactive to light Extraocular motions are intact Neck Exam No cervical lymphadenopathy Midline trachea No carotid bruits Nonpalpable thyroid Neuro Exam Gross motor strength in the upper and lower extremities equal bilaterally with no focal neuro deficits noted Lung Exam Clear breath sounds without rhonchi or wheezes Cardiac Exam Regular rate and rhythm without murmur or bruits Abdominal Exam Positive bowel sounds Soft nontender obese and nondistended abdomen Lap cholecystectomy scars noted No obvious hernias No organomegaly appreciated Lower extremity Exam Edema 1 Dorsalis pedis pulses 2 ASSESSMENT The patient is a 55 year old female with a body mass index of 46 suffering from obesity related comorbidities including hypertension and hypercholesterolemia who presents to the practice for consideration of gastric bypass surgery The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity related comorbidities PLAN In preparation for surgery we will obtain the usual baseline laboratory values including baseline vitamin levels I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy Also the patient will meet with the dietitian and psychologist as per her usual routine I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10 preoperative weight loss in preparation for surgery Keywords consult history and phy jenny craig medifast nutrisystem richard simmons slim fast tops weight watchers cabbage diet grape fruit diet roux en y laparoscopic roux en y gastric bypass weight loss modalities surgical weight loss body mass index weight loss MEDICAL_TRANSCRIPTION,Description Evaluation for bariatric surgery Medical Specialty Consult History and Phy Sample Name Bariatric Consult Surgical Weight Loss 3 Transcription PAST MEDICAL HISTORY Her medical conditions driving her toward surgery include hypercholesterolemia hypertension varicose veins prior history of stroke She denies any history of cancer She does have a history of hepatitis which I will need to further investigate She complains of multiple joint pains and heavy snoring PAST SURGICAL HISTORY Includes hysterectomy in 1995 for fibroids and varicose vein removal She had one ovary removed at the time of the hysterectomy as well SOCIAL HISTORY She is a single mother of one adopted child FAMILY HISTORY There is a strong family history of heart disease and hypertension as well as diabetes on both sides of her family Her mother is alive Her father is deceased from alcohol She has five siblings MEDICATIONS As you know she takes the following medications for her diabetes insulin 70 units 6 units times four years aspirin 81 mg a day Actos 15 mg Crestor 10 mg and CellCept 500 mg two times a day ALLERGIES She has no known drug allergies PHYSICAL EXAM She is a 54 year old obese female She does not appear to have any significant residual deficits from her stroke There may be slight left arm weakness ASSESSMENT PLAN We will have her undergo routine nutritional and psychosocial assessment I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia as well as hypertension with significant weight loss She is otherwise at increased risk for future complications given her history and weight loss will be a good option We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company Keywords consult history and phy evaluation for bariatric surgery bariatric surgery varicose veins weight loss varicose veins diabetes bariatric surgical loss surgery hypertension weight MEDICAL_TRANSCRIPTION,Description Medical Specialty Consult History and Phy Sample Name Barium Swallow Study Speech Evaluation 1 Transcription SUBJECTIVE The patient is a 60 year old female who complained of coughing during meals Her outpatient evaluation revealed a mild to moderate cognitive linguistic deficit which was completed approximately 2 months ago The patient had a history of hypertension and TIA stroke The patient denied history of heartburn and or gastroesophageal reflux disorder A modified barium swallow study was ordered to objectively evaluate the patient s swallowing function and safety and to rule out aspiration OBJECTIVE Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr ABC The patient was seated upright in a video imaging chair throughout this assessment To evaluate the patient s swallowing function and safety she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid teaspoon x2 cup sip x2 nectar thick liquid teaspoon x2 cup sip x2 puree consistency teaspoon x2 and solid food consistency 1 4 cracker x1 ASSESSMENT ORAL STAGE Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid Decreased tongue base retraction which contributed to vallecular pooling after the swallow PHARYNGEAL STAGE No aspiration was observed during this evaluation Penetration was noted with cup sips of thin liquid only Trace residual on the valleculae and on tongue base with nectar thick puree and solid consistencies The patient s hyolaryngeal elevation and anterior movement are within functional limits Epiglottic inversion is within functional limits CERVICAL ESOPHAGEAL STAGE The patient s upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus which may be contributing to the patient s complaint of globus sensation DIAGNOSTIC IMPRESSION No aspiration was noted during this evaluation Penetration with cup sips of thin liquid The patient did cough during this evaluation but that was noted related to aspiration or penetration PROGNOSTIC IMPRESSION Based on this evaluation the prognosis for swallowing and safety is good PLAN Based on this evaluation and following recommendations are being made 1 The patient to take small bite and small sips to help decrease the risk of aspiration and penetration 2 The patient should remain upright at a 90 degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation 3 The patient should be referred to a gastroenterologist for further evaluation of her esophageal function The patient does not need any skilled speech therapy for her swallowing abilities at this time and she is discharged from my services Keywords consult history and phy gastroesophageal reflux disorder cognitive linguistic deficit tia stroke swallowing function swallow study barium swallow study globus sensation esophageal penetration MEDICAL_TRANSCRIPTION,Description Evaluation for elective surgical weight loss via the Lap Band as opposed to gastric bypass Medical Specialty Consult History and Phy Sample Name Bariatric Consult Surgical Weight Loss 2 Transcription PAST MEDICAL HISTORY She had a negative stress test four to five years ago She gets short of breath in walking about 30 steps She has had non insulin dependent diabetes for about eight years now She has a left knee arthritis and history of hemorrhoids PAST SURGICAL HISTORY Pertinent for laparoscopic cholecystectomy tonsillectomy left knee surgery and right breast lumpectomy PSYCHOLOGICAL HISTORY Negative except that she was rehabilitated for alcohol addiction in 1990 SOCIAL HISTORY The patient is married She is an office manager for a gravel company Her spouse is also overweight She drinks on a weekly basis and she smokes about two packs of cigarettes over a week s period of time She is doing this for about 35 years FAMILY HISTORY Diabetes and hypertension MEDICATIONS Include Colestid 1 g daily Actos 30 mg daily Amaryl 2 mg daily Soma and meloxicam for her back pain ALLERGIES She has no allergies however she does get tachycardic with caffeine Sudafed or phenylpropanolamine REVIEW OF SYSTEMS Otherwise negative PHYSICAL EXAM This is a pleasant female in no acute distress Alert and oriented x 3 HEENT Normocephalic atraumatic Extraocular muscles intact nonicteric sclerae Chest is clear Abdomen is obese soft nontender and nondistended Extremities show no edema clubbing or cyanosis ASSESSMENT PLAN This is a 51 year old female with a BMI of 43 who is interested in the Lap Band as opposed to gastric bypass ABC will be asking for a letter of medical necessity from XYZ She will also need an EKG and clearance for surgery She will also see my nutritionist and social worker and once this is completed we will submit her to her insurance company for approval Keywords consult history and phy elective surgical weight loss surgical weight loss weight loss lap band gastric bypass loss weight lap band lost gained diabetes gastric bypass overweight surgical MEDICAL_TRANSCRIPTION,Description Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap Band Medical Specialty Consult History and Phy Sample Name Bariatric Consult Surgical Weight Loss 1 Transcription PAST MEDICAL HISTORY She has a history of hypertension and shortness of breath PAST SURGICAL HISTORY Pertinent for cholecystectomy PSYCHOLOGICAL HISTORY Negative SOCIAL HISTORY She is single She drinks alcohol once a week She does not smoke FAMILY HISTORY Pertinent for obesity and hypertension MEDICATIONS Include Topamax 100 mg twice daily Zoloft 100 mg twice daily Abilify 5 mg daily Motrin 800 mg daily and a multivitamin ALLERGIES She has no known drug allergies REVIEW OF SYSTEMS Negative PHYSICAL EXAM This is a pleasant female in no acute distress Alert and oriented x 3 HEENT Normocephalic atraumatic Extraocular muscles intact nonicteric sclerae Chest is clear to auscultation bilaterally Cardiovascular is normal sinus rhythm Abdomen is obese soft nontender and nondistended Extremities show no edema clubbing or cyanosis ASSESSMENT PLAN This is a 34 year old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap Band ABC will be asking for a letter of medical necessity from Dr XYZ She will also see my nutritionist and social worker and have an upper endoscopy Once this is completed we will submit her to her insurance company for approval Keywords consult history and phy elective surgical weight loss surgical weight loss weight loss loss weight bmi surgical pounds MEDICAL_TRANSCRIPTION,Description Acute renal failure probable renal vein thrombosis hypercoagulable state and deep venous thromboses with pulmonary embolism Medical Specialty Consult History and Phy Sample Name Azotemia Consult Transcription REASON FOR CONSULTATION Azotemia HISTORY OF PRESENT ILLNESS The patient is a 36 year old gentleman admitted to the hospital because he passed out at home Over the past week he has been noticing increasing shortness of breath He also started having some abdominal pain however he continued about his regular activity until the other day when he passed out at home His wife called paramedics and he was brought to the emergency room The patient has had a workup at this time which shows bilateral pulmonary infarcts He has been started on heparin and we are asked to see him because of increasing BUN and creatinine The patient has no past history of any renal problems He feels that he has been in good health until this current episode His appetite has been good He denies swelling in his feet or ankles He denies chest pain He denies any problems with bowel habits He denies any unexplained weight loss He denies any recent change in bowel habits or recent change in urinary habits PHYSICAL EXAMINATION GENERAL A gentleman seen who appears his stated age VITAL SIGNS Blood pressure is 130 70 CHEST Chest expands equally bilaterally Breath sounds are heard bilaterally HEART Had a regular rhythm no gallops or rubs ABDOMEN Obese There is no organomegaly There are no bruits There is no peripheral edema He has good pulse in all 4 extremities He has good muscle mass LABORATORY DATA The patient s current chemistries include a hemoglobin of 14 8 white count of 16 3 his sodium 133 potassium 5 1 chloride 104 CO2 of 19 a BUN of 26 and a creatinine of 3 5 On admission to the hospital his creatinine on 6 27 2009 was 0 9 The patient has had several studies including a CAT scan of his abdomen which shows poor perfusion to his right kidney IMPRESSION 1 Acute renal failure probable renal vein thrombosis 2 Hypercoagulable state 3 Deep venous thromboses with pulmonary embolism DISCUSSION We are presented with a 36 year old gentleman who has been in good health until this current event He most likely has a hypercoagulable state and has bilateral pulmonary emboli Most likely the patient has also had emboli to his renal veins and it is causing renal vein thrombosis Interestingly the urine protein was obtained which is not that elevated and I would suspect that it would have been higher Unfortunately the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem The patient s urine output is about 30 to 40 mL per hour Several chemistries have been ordered A triple renal scan has been ordered I reviewed all of this with the patient and his wife Hopefully under his current anticoagulation there will be some resolution of his renal vein thrombosis If not and his renal failure progresses we are looking at dialytic intervention Both he and his wife were aware of this Thank you very much for asking to see this acutely ill gentleman in consultation with you Keywords consult history and phy urine output deep venous thromboses renal failure pulmonary embolism renal azotemia hypercoagulable vein thrombosis pulmonary MEDICAL_TRANSCRIPTION,Description Possible exposure to ant bait She is not exhibiting any symptoms and parents were explained that if she develops any vomiting she should be brought back for reevaluation Medical Specialty Consult History and Phy Sample Name Ant Bait Exposure ER Visit Transcription CHIEF COMPLAINT Possible exposure to ant bait HISTORY OF PRESENT ILLNESS This is a 14 month old child who apparently was near the sink got into the childproof cabinet and pulled out ant bait that had Borax in it It had 11 mL of this fluid in it She spilled it on her had it on her hands Parents were not sure whether she ingested any of it So they brought her in for evaluation They did not note any symptoms of any type PAST MEDICAL HISTORY Negative Generally very healthy REVIEW OF SYSTEMS The child has not been having any coughing gagging vomiting or other symptoms Acting perfectly normal Family mostly noted that she had spilled it on the ground around her had it on her hands and on her clothes They did not witness that she ingested any but did not see anything her mouth MEDICATIONS None ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient was afebrile Stable vital signs and normal pulse oximetry GENERAL The child is very active cheerful youngster in no distress whatsoever HEENT Unremarkable Oral mucosa is clear moist and well hydrated I do not see any evidence of any sort of liquid on the face Her clothing did have the substance on the clothes but I did not see any evidence of anything on her torso Apparently she had some on her hands that has been wiped off EMERGENCY DEPARTMENT COURSE I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested which should does not appear likely to be the case IMPRESSION Exposure to ant bait PLAN At this point it is fairly unlikely that this child ingested any significant amount if at all which seems unlikely She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting she should be brought back for reevaluation So the patient is discharged in stable condition Keywords consult history and phy borax vomiting exposure to ant bait ant bait exposure symptoms MEDICAL_TRANSCRIPTION,Description Comprehensive annual health maintenance examination dyslipidemia tinnitus in left ear and hemorrhoids Medical Specialty Consult History and Phy Sample Name Annual Health Maintenance Exam Transcription HISTORY OF PRESENT ILLNESS This 59 year old white male is seen for comprehensive annual health maintenance examination on 02 19 08 although this patient is in excellent overall health Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change dyslipidemia well controlled with niacin history of hemorrhoids with occasional external bleeding although no problems in the last 6 months and also history of concha bullosa of the left nostril followed by ENT associated with slight septal deviation There are no other medical problems He has no symptoms at this time and remains in excellent health PAST MEDICAL HISTORY Otherwise noncontributory There is no operation serious illness or injury other than as noted above ALLERGIES There are no known allergies FAMILY HISTORY Father died of an MI at age 67 with COPD and was a heavy smoker His mother is 88 living and well status post lung cancer resection Two brothers living and well One sister died at age 20 months of pneumonia SOCIAL HISTORY The patient is married Wife is living and well He jogs or does Cross Country track 5 times a week and weight training twice weekly No smoking or significant alcohol intake He is a physician in allergy immunology REVIEW OF SYSTEMS Otherwise noncontributory He has no gastrointestinal cardiopulmonary genitourinary or musculoskeletal symptomatology No symptoms other than as described above PHYSICAL EXAMINATION GENERAL He appears alert oriented and in no acute distress with excellent cognitive function VITAL SIGNS His height is 6 feet 2 inches weight is 181 2 blood pressure is 126 80 in the right arm 122 78 in the left arm pulse rate is 68 and regular and respirations are 16 SKIN Warm and dry There is no pallor cyanosis or icterus HEENT Tympanic membranes benign The pharynx is benign Nasal mucosa is intact Pupils are round regular and equal reacting equally to light and accommodation EOM intact Fundi reveal flat discs with clear margins Normal vasculature No hemorrhages exudates or microaneurysms No thyroid enlargement There is no lymphadenopathy LUNGS Clear to percussion and auscultation Normal sinus rhythm No premature beat murmur S3 or S4 Heart sounds are of good quality and intensity The carotids femorals dorsalis pedis and posterior tibial pulsations are brisk equal and active bilaterally ABDOMEN Benign without guarding rigidity tenderness mass or organomegaly NEUROLOGIC Grossly intact EXTREMITIES Normal GU Genitalia normal There are no inguinal hernias There are mild hemorrhoids in the anal canal The prostate is small if any normal to mildly enlarged with discrete margins symmetrical without significant palpable abnormality There is no rectal mass The stool is Hemoccult negative IMPRESSION 1 Comprehensive annual health maintenance examination 2 Dyslipidemia 3 Tinnitus left ear 4 Hemorrhoids PLAN At this time continue niacin 1000 mg in the morning 500 mg at noon and 1000 mg in the evening aspirin 81 mg daily multivitamins vitamin E 400 units daily and vitamin C 500 mg daily Consider adding lycopene selenium and flaxseed to his regimen All appropriate labs will be obtained today Followup fasting lipid profile and ALT in 6 months Keywords consult history and phy tinnitus dyslipidemia annual health maintenance health hemorrhoids benign MEDICAL_TRANSCRIPTION,Description The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone Medical Specialty Consult History and Phy Sample Name Airway Compromise Foreign Body ER Visit Transcription HISTORY OF PRESENT ILLNESS The patient is a 17 year old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room She was intubated and fishbone PAST MEDICAL HISTORY Significant for diabetes hypertension asthma cholecystectomy and total hysterectomy and cataract ALLERGIES No known drug allergies CURRENT MEDICATIONS Prevacid Humulin Diprivan Proventil Unasyn and Solu Medrol FAMILY HISTORY Noncontributory SOCIAL HISTORY Negative for illicit drugs alcohol and tobacco PHYSICAL EXAMINATION Please see the hospital chart LABORATORY DATA Please see the hospital chart HOSPITAL COURSE The patient was taken to the operating room by Dr X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated If not she would require tracheostomy The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated She was doing well with good p o s good airway good voice and desiring to be discharged home So the patient is being prepared for discharge at this point We will have Dr X evaluate her before she leaves to make sure I do not have any problem with her going home Dr Y feels she could be discharged today and will have her return to see him in a week Keywords consult history and phy diabetes hypertension asthma cholecystectomy fishbone foreign body airway compromise airway MEDICAL_TRANSCRIPTION,Description Acute episode of agitation She was complaining that she felt she might have been poisoned at her care facility Medical Specialty Consult History and Phy Sample Name Agitation ER Visit Transcription HISTORY OF PRESENT ILLNESS This is a 91 year old female who was brought in by family Apparently she was complaining that she felt she might have been poisoned at her care facility The daughter who accompanied the patient states that she does not think anything is actually wrong but she became extremely agitated and she thinks that is the biggest problem with the patient right now The patient apparently had a little bit of dry heaves but no actual vomiting She had just finished eating dinner No one else in the facility has been ill PAST MEDICAL HISTORY Remarkable for previous abdominal surgeries She has a pacemaker She has a history of recent collarbone fracture REVIEW OF SYSTEMS Very difficult to get from the patient herself She seems to deny any significant pain or discomfort but really seems not particularly intent on letting me know what is bothering her She initially stated that everything was wrong but could not specify any specific complaints Denies chest pain back pain or abdominal pain Denies any extremity symptoms or complaints SOCIAL HISTORY The patient is a nonsmoker She is accompanied here with daughter who brought her over here They were visiting the patient when this episode occurred MEDICATIONS Please see list ALLERGIES NONE PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile actually has a very normal vital signs including normal pulse oximetry at 99 on room air GENERAL The patient is an elderly frail looking little lady lying on the gurney She is awake alert and not really wanted to answer most of the questions I asked her She does have a tremor with her mouth which the daughter states has been there for many years HEENT Eye exam is unremarkable Oral mucosa is still moist and well hydrated Posterior pharynx is clear NECK Supple LUNGS Actually clear with good breath sounds There are no wheezes no rales or rhonchi Good air movement CARDIAC Without murmur ABDOMEN Soft I do not elicit any tenderness There is no abdominal distention Bowel sounds are present in all quadrants SKIN Skin is without rash or petechiae There is no cyanosis EXTREMITIES No evidence of any trauma to the extremities EMERGENCY DEPARTMENT COURSE I had a long discussion with the family and they would like the patient receive something for agitation so she was given 0 5 mg of Ativan intramuscularly After about half an hour I came back to talk to the patient and the family the patient states that she feels better Family states she seems more calm They do not want to pursue any further workup at this time IMPRESSION ACUTE EPISODE OF AGITATION PLAN At this time I had reviewed the patient s records and it is not particularly enlightening as to what could have triggered off this episode The patient herself has good vital signs She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given a small quantity was given to the patient Family and daughter specifically did not want to pursue any workup at this point which at this point I think is reasonable and we will have her follow up with ABC She is discharged in stable condition Keywords consult history and phy acute episode of agitation agitation MEDICAL_TRANSCRIPTION,Description Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only Medical Specialty Consult History and Phy Sample Name Abnormal Stress Test Transcription HISTORY OF PRESENT ILLNESS Mr ABC is a 60 year old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only He required 3 sublingual nitroglycerin in total please see also admission history and physical for full details The patient underwent cardiac catheterization with myself today which showed mild to moderate left main distal disease of 30 moderate proximal LAD with a severe mid LAD lesion of 99 and a mid left circumflex lesion of 80 with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA I discussed these results with the patient and he had been relating to me that he was having rest anginal symptoms as well as nocturnal anginal symptoms and especially given the severity of the mid left anterior descending lesion with a markedly abnormal stress test I felt he was best suited for transfer for PCI I discussed the case with Dr X at Medical Center who has kindly accepted the patient in transfer CONDITION ON TRANSFER Stable but guarded The patient is pain free at this time MEDICATIONS ON TRANSFER 1 Aspirin 325 mg once a day 2 Metoprolol 50 mg once a day but we have had to hold it because of relative bradycardia which he apparently has a history of 3 Nexium 40 mg once a day 4 Zocor 40 mg once a day and there is a fasting lipid profile pending at the time of this dictation I see that his LDL was 136 on May 3 2002 5 Plavix 600 mg p o x1 which I am giving him tonight Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation GERD arthritis DISPOSITION The patient and his wife have requested and are agreeable with transfer to Medical Center and we are enclosing the CD ROM of his images Keywords consult history and phy standard bruce nitroglycerin abnormal stress test st depressions anginal symptoms stress test lad anginal stress MEDICAL_TRANSCRIPTION,Description Acne from continually washing area frequent phone use so the receiver rubs on face and oral contraceptive use Acne Vulgaris Medical Specialty Consult History and Phy Sample Name Acne Vulgaris H P Transcription CHIEF COMPLAINT 1 1 This 19 year old female presents today complaining of acne from continually washing area frequent phone use so the receiver rubs on face and oral contraceptive use Location She indicates the problem location is the chin right temple and left temple locally Severity Severity of condition is worsening Menses Onset 13 years old Interval 22 27 days Duration 4 6 days Flow light Complications none ALLERGIES Patient admits allergies to penicillin resulting in difficulty breathing MEDICATION HISTORY Patient is currently taking Alesse 28 20 mcg 0 10 mg tablet usage started on 08 07 2001 medication was prescribed by Obstetrician Gynecologist A PAST MEDICAL HISTORY Female Reproductive Hx birth control pill use Childhood Illnesses chickenpox measles PAST SURGICAL HISTORY No previous surgeries FAMILY HISTORY Patient admits a family history of anxiety stress disorder associated with mother SOCIAL HISTORY Patient admits caffeine use She consumes 3 5 servings per day Patient admits alcohol use Drinking is described as social Patient admits good diet habits Patient admits exercising regularly Patient denies STD history REVIEW OF SYSTEMS Integumentary periodic reddening of face acne problems Allergic Immunologic allergic or immunologic symptoms Constitutional Symptoms constitutional symptoms such as fever headache nausea dizziness PHYSICAL EXAM Patient is a 19 year old female who appears pleasant in no apparent distress her given age well developed well nourished and with good attention to hygiene and body habitus Skin Examination of scalp shows no abnormalities Hair growth and distribution is normal Inspection of skin outside of affected area reveals no abnormalities Palpation of skin shows no abnormalities Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis chromidrosis or bromhidrosis Face shows keratotic papule IMPRESSION Acne vulgaris PLAN Recommended treatment is antibiotic therapy Patient received extensive counseling about acne She understands acne treatment is usually long term Return to clinic in 4 week s PATIENT INSTRUCTIONS Patient received literature regarding acne vulgaris Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion PRESCRIPTIONS Tetracycline Dosage 250 mg capsule Sig BID Dispense 60 Refills 0 Allow Generic Yes Keywords MEDICAL_TRANSCRIPTION,Description Patient status post gastric bypass surgery developed nausea and right upper quadrant pain Medical Specialty Consult History and Phy Sample Name Admission History Physical Nausea Transcription CHIEF COMPLAINT Nausea PRESENT ILLNESS The patient is a 28 year old who is status post gastric bypass surgery nearly one year ago He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7 00 8 00 when he developed nausea and right upper quadrant pain which apparently wrapped around toward his right side and back He feels like he was on it but has not done so He has overall malaise and a low grade temperature of 100 3 He denies any prior similar or lesser symptoms His last normal bowel movement was yesterday He denies any outright chills or blood per rectum PAST MEDICAL HISTORY Significant for hypertension and morbid obesity now resolved PAST SURGICAL HISTORY Gastric bypass surgery in December 2007 MEDICATIONS Multivitamins and calcium ALLERGIES None known FAMILY HISTORY Positive for diabetes mellitus in his father who is now deceased SOCIAL HISTORY He denies tobacco or alcohol He has what sounds like a data entry computer job REVIEW OF SYSTEMS Otherwise negative PHYSICAL EXAMINATION His temperature is 100 3 blood pressure 129 59 respirations 16 heart rate 84 He is drowsy but easily arousable and appropriate with conversation He is oriented to person place and situation He is normocephalic atraumatic His sclerae are anicteric His mucous membranes are somewhat tacky His neck is supple and symmetric His respirations are unlabored and clear He has a regular rate and rhythm His abdomen is soft He has diffuse right upper quadrant tenderness worse focally but no rebound or guarding He otherwise has no organomegaly masses or abdominal hernias evident His extremities are symmetrical with no edema His posterior tibial pulses are palpable and symmetric He is grossly nonfocal neurologically STUDIES His white blood cell count is 8 4 with 79 segs His hematocrit is 41 His electrolytes are normal His bilirubin is 2 8 His AST 349 ALT 186 alk phos 138 and lipase is normal at 239 ASSESSMENT Choledocholithiasis cholecystitis PLAN He will be admitted and placed on IV antibiotics We will get an ultrasound this morning He will need his gallbladder out probably with intraoperative cholangiogram Hopefully the stone will pass this way Due to his anatomy an ERCP would prove quite difficult if not impossible unless laparoscopic assisted Dr X will see him later this morning and discuss the plan further The patient understands Keywords consult history and phy gastric bypass surgery nausea choledocholithiasis cholecystitis ercp gastric bypass bypass surgery MEDICAL_TRANSCRIPTION,Description The patient was referred due to concerns regarding behavioral acting out as well as encopresis Medical Specialty Consult History and Phy Sample Name Adjustment Disorder Encopresis Transcription REASON FOR REFERRAL The patient was referred to me by Dr X of the Clinic due to concerns regarding behavioral acting out as well as encopresis This is a 90 minute initial intake completed on 10 03 2007 I met with the patient s mother individually for the entire session I reviewed with her the treatment consent form as well as the boundaries of confidentiality and she stated that she understood these concepts PRESENTING PROBLEMS Mother reported that her primary concern in regard to the patient had to do with his oppositionality She was more ambivalent regarding addressing the encopresis In regards to his oppositionality she reported that the onset of his oppositionality was approximately at 4 years of age that before that he had been a very compliant and happy child and that he has slowly worsened over time She noted that the oppositionality occurred approximately after his brother who has multiple medical problems was born At that time mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year She reported that in terms of the behaviors that he loses his temper frequently he argues with her that he defies her authority that she has to ask him many times to do things that she has to repeat instructions that he ignores her that he whines and this is when he is told to do something that he does not want to do She reported that he deliberately annoys other people that he can be angry and resentful She reported that he does not display these behaviors with the father nor does he display them at home but they are specific to her She reported that her response to him typically is that she repeats what she wants him to do many many times that eventually she gets upset She yells at him talks with him and tries to make him go and do what she wants him to do Mother also noted that she probably ignores some his misbehaviors She stated that the father tends to be more firm and more direct with him and that the father sometimes thinks that the mother is too easy on him In regards to symptoms of depression she denied symptoms of depression noting that he tends to only become unhappy when he has to do something that he does not want to do such as go to school or follow through on a command She denied any suicidal ideation She denied all symptoms of anxiety PTSD was denied ADHD symptoms were denied as were all other symptoms of psychopathology In regards to the encopresis she reported that he has always soiled he does so 2 to 3 times a day She reported that he is concerned about this issue He currently wears underwear and had a pull up She reported that he was seen at the Gastroenterology Department here several years ago and has more recently been seen at the Diseases Center seen by Dr Y reported that the last visit was several months ago that he is on MiraLax He does sit on the toilet may be 2 times a day although that is not consistent Mother believes that he is probably constipated or impacted again He refuses to eat any fiber In regards to what happens when he soils mother basically takes full responsibility She cleans and changes his underwear thinks of things that she has tried she mostly gets frustrated makes negative comments even though she knows that he really cannot help it She has never provided him with any sort of rewards because she feels that this is something he just needs to learn to do In regards to other issues she noted that he becomes frustrated quite easily especially around homework that when mother has to correct him or when he has had difficulty doing something that he becomes upset that he will cry and he will get angry Mother s response to him is that either she gets agitated and raises her voice tells him to stop etc Mother reported it is not only with homework but also with other tasks such as if he is trying to build with his LEGOs and things do not go well DEVELOPMENTAL BACKGROUND The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery The patient presented in a breech position Mother denied the use of drugs alcohol or tobacco during the pregnancy No sleeping or eating issues were present in the perinatal period Temperament was described as easy He was described as a cuddly baby No concerns expressed regarding his developmental milestones No serious injuries reported No hospitalizations or surgeries No allergies The patient has been encopretic for all of his life He currently is taking MiraLax FAMILY BACKGROUND The patient lives with his mother who is age 37 and is primarily a homemaker but does work approximately 48 hours a month as a beautician with his father age 35 who is a police officer and also with his younger brother who is age 3 and has significant medical problems as will be noted in a moment Mother and father have been together since 1997 married in 1999 The maternal grandmother and grandfather are living and are together and live in the Central California Coast Area There is one maternal aunt age 33 and then two adopted maternal aunt and uncle age 18 and age 13 In regards to the father s side of the family the paternal grandparents are divorced Grandfather was in Arkansas grandmother lives in Dos Palos The patient does not see his grandfather Mother stated that her relationship with her child was as described that he very much stresses her out that she wishes that he was not so defiant that she finds him to be a very stressful child to deal with In regards to the relationship with the father it was reported that the father tends to leave most of the parenting over to the mother unless she specifically asks him to do something and then he will follow through and do it He will step in and back mother up in terms of parenting tell the child not to speak to his mother that way etc Mother reported that he does spend some time with the children but not as much as mother would like him to but occasionally he will go outside and do things with them The mother reported that sometimes she has a problem in interfering with his parenting that she steps in and defends The patient It was reported that mother stated that she tries the parenting technique primarily of yelling and tried time out although her description suggests that she is not doing time out correctly as he simply gets up from his time out and she does not follow through Mother reported that she and the patient are very much alike in temperament and this has made things more difficult Mother tends to be stubborn and gets angry easily also Mother reported becoming fatigued in her parenting that she lets him get away with things sometimes because she does not want to punish him all day long sometimes ignores problems that she probably should not ignore There was reported to be jealousy between The patient and his brother B B evidently has some heart problems and feeding issues and because of that tends to get more attention in terms of his medical needs and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get and that there is some tension between the brothers They do play well together however The patient does tend to be somewhat intrusive gets in his space and then B will hit him Mother reported that she graduated from high school went to Community College and was an average student No learning problems Mother has a history of depression She has currently been taking 100 mg of Zoloft administered by her primary medical doctor She is not receiving counseling She has been on the medications for the last 5 years Her dosage has not been changed in a year She feels that she is getting more irritable and more angry I encouraged her to see a primary medical doctor Mother has no drug or alcohol history Father graduated from high school went to the Police Academy average student No learning problems no psychological problems no drug or alcohol problems are reported In terms of extended family maternal grandmother as well as maternal great grandfather have a history of depression Other psychiatric symptoms were denied in the family Mother reported that the marriage is generally okay that there is some arguing She reported that it was in the normal range ACADEMIC BACKGROUND The patient attends the Roosevelt Elementary School where he is in a regular first grade classroom with Mrs The patient This is in the Kingsburg Unified School District No behavior problems academic problems were reported He does not receive special education services SOCIAL HISTORY The patient was described as being able to make and keep friends but at this point in time there has been no teasing regarding smell from the encopresis He does have kids over to play at the house PREVIOUS COUNSELING Denied DIAGNOSTIC SUMMARY AND IMPRESSION My impression is that the patient has a long history of constipation and impaction which has been treated medically but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting increased fiber regular medication so that the problem has likely continued She also has not used any sort of rewards as a way to encourage him in the encopresis The patient clearly qualifies for a diagnosis of disruptive behavior disorder not otherwise specified and possibly oppositional defiant disorder It would appear that mother needs help in her parenting and that she tends to mostly use yelling and anger as a way and tends to repeat herself a lot and does not have a strategy for how to follow through and to deal with defiant behavior Also mother and father may not be on the same page in terms of parenting PLAN In terms of my plan I will meet with the child in the next couple of weeks I also asked the mother to bring the father in so he could be involved in the treatment also and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher DSM IV DIAGNOSES AXIS I Adjustment disorder with disturbance of conduct 309 3 Encopresis without constipation overflow incontinence 307 7 AXIS II No diagnoses V71 09 AXIS III No diagnoses AXIS IV Problems with primary support group AXIS V Global assessment of functioning equals 65 Keywords consult history and phy developmental background axis dsm iv adjustment disorder behavioral adjustment depression oppositionality encopresis MEDICAL_TRANSCRIPTION,Description Consultation for left foot pain Medical Specialty Chiropractic Sample Name Foot pain Consultation Transcription CHIEF COMPLAINT Left foot pain HISTORY XYZ is a basketball player for University of Houston who sustained an injury the day prior They were traveling He came down on another player s foot sustaining what he describes as an inversion injury Swelling and pain onset immediately He was taped but was able to continue playing He was examined by John Houston the trainer and had tenderness around the navicular so was asked to come over and see me for evaluation He has been in a walking boot He has been taped firmly Pain with weightbearing activities He is limping a bit No significant foot injuries in the past Most of his pain is located around the dorsal aspect of the hindfoot and midfoot PHYSICAL EXAM He does have some swelling from the hindfoot out toward the midfoot His arch is maintained His motion at the ankle and subtalar joints is preserved Forefoot motion is intact He has pain with adduction and abduction across the hindfoot Most of this discomfort is laterally His motor strength is grossly intact His sensation is intact and his pulses are palpable and strong His ankle is not tender He has minimal to no tenderness over the ATFL He has no medial tenderness along the deltoid or the medial malleolus His anterior drawer is solid His external rotation stress is not painful at the ankle His tarsometatarsal joints specifically 1 2 and 3 are nontender His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus Some tenderness over the dorsolateral side of the talonavicular joint as well The medial talonavicular joint is not tender RADIOGRAPHS Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic I don t see a definite fracture The tarsometarsal joints are anatomically aligned Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified Review of an MR scan of the ankle dated 12 01 05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area Also some changes along the dorsal talonavicular joint I don t see any significant marrow edema or definitive fracture line IMPRESSION Left Chopart joint sprain PLAN I have spoken to XYZ about this Continue with ice and boot for weightbearing activities We will start him on a functional rehab program and progress him back to activities when his symptoms allow He is clear on the prolonged duration of recovery for these hindfoot type injuries Keywords chiropractic foot pain calcaneocuboid joint dorsal aspect dorsal talonavicular joint foot injuries hindfoot midfoot rehab program walking boot weightbearing talonavicular joint dorsal talonavicular ankle foot tenderness MEDICAL_TRANSCRIPTION,Description Consultation for wrist pain Medical Specialty Chiropractic Sample Name Wrist Pain Transcription CHIEF COMPLAINT Left wrist pain HISTORY OF PRESENT PROBLEM Keywords chiropractic wrist pain scapholunate tenderness to palpation three views traumatic wrist injury ulnar styloid nonunion ulnar styloid wrist union soreness styloid ulnar MEDICAL_TRANSCRIPTION,Description MRI report Cervical Spine Chiropractic Specific Medical Specialty Chiropractic Sample Name MRI Cervical Spine Chiropractic Specific Transcription FINDINGS Normal foramen magnum Normal brainstem cervical cord junction There is no tonsillar ectopia Normal clivus and craniovertebral junction Normal anterior atlantoaxial articulation C2 3 There is disc desiccation but no loss of disc space height disc displacement endplate spondylosis or uncovertebral joint arthrosis Normal central canal and intervertebral neural foramina C3 4 There is disc desiccation with a posterior central disc herniation of the protrusion type The small posterior central disc protrusion measures 3 x 6mm AP x transverse in size and is producing ventral thecal sac flattening CSF remains present surrounding the cord The residual AP diameter of the central canal measures 9mm There is minimal right sided uncovertebral joint arthrosis but no substantial foraminal compromise C4 5 There is disc desiccation slight loss of disc space height with a right posterior lateral pre foraminal disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis The disc osteophyte complex measures approximately 5mm in its AP dimension There is minimal posterior annular bulging measuring approximately 2mm The AP diameter of the central canal has been narrowed to 9mm CSF remains present surrounding the cord There is probable radicular impingement upon the exiting right C5 nerve root C5 6 There is disc desiccation moderate loss of disc space height with a posterior central disc herniation of the protrusion type The disc protrusion measures approximately 3 x 8mm AP x transverse in size There is ventral thecal sac flattening with effacement of the circumferential CSF cleft The residual AP diameter of the central canal has been narrowed to 7mm Findings indicate a loss of the functional reserve of the central canal but there is no cord edema There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise C6 7 There is disc desiccation mild loss of disc space height with 2mm of posterior annular bulging There is bilateral uncovertebral and apophyseal joint arthrosis left greater than right with probable radicular impingement upon the bilateral exiting C7 nerve roots C7 T1 T1 2 There is disc desiccation with no disc displacement Normal central canal and intervertebral neural foramina T3 4 There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord IMPRESSION Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above C3 4 posterior central disc herniation of the protrusion type but no cord impingement C4 5 right posterior lateral disc osteophyte complex with right sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root C5 6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal C6 7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots T3 4 degenerative disc disease with posterior annular bulging Keywords chiropractic exiting c nerve roots loss of disc space posterior central disc herniation herniation of the protrusion uncovertebral and apophyseal joint intervertebral neural foramina ventral thecal sac thecal sac flattening disc osteophyte complex disc space height central disc herniation apophyseal joint arthrosis posterior annular bulging degenerative disc disease posterior central disc csf cleft osteophyte complex radicular impingement disc disease central disc annular bulging disc desiccation joint arthrosis central canal cervical degenerative csf foraminal bulging impingement protrusion uncovertebral arthrosis canal MEDICAL_TRANSCRIPTION,Description Pain management for post laminectomy low back syndrome and radiculopathy Medical Specialty Chiropractic Sample Name Pain Management Consult 1 Transcription Mr XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice For all these reasons this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient The patient was seen late because he had not filled in the patient questionnaire To summarize the history here Mr XYZ who is not very clear on events from the past sustained a work related injury some time in 1998 At that time he was driving an 18 wheeler truck The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer He experienced severe low back pain and eventually a short while later underwent a fusion of L4 L5 and L5 S1 The patient had an uneventful hospital course from the surgery which was done somewhere in Florida by a surgeon who he does not remember He was able to return to his usual occupation but then again had a second work related injury in May of 2005 At that time he was required to boat trucks to his rig and also to use a chain pulley system to raise and lower the vehicles Mr XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital He was MRI ed at that time which apparently showed a re herniation of an L5 S1 disc and then he somehow ended up in Houston where he underwent fusion by Dr W from L3 through S2 This was done on 12 15 2005 Initially he did fairly well and was able to walk and move around but then gradually the pain reappeared and he started getting severe left sided leg pain going down the lateral aspect of the left leg into his foot He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg The patient was referred to Dr A pain management specialist and Dr A has maintained him on opioid medications consisting of Norco 10 325 mg for breakthrough pain and oxycodone 30 mg t i d with Lunesta 3 mg q h s for sleep Carisoprodol 350 mg t i d and Lyrica 100 mg q daily The patient states that he is experiencing no side effects from medications and takes medications as required He has apparently been drug screened and his drug screening has been found to be normal The patient underwent an extensive behavioral evaluation on 05 22 06 by TIR Rehab Center At that time it was felt that Mr XYZ showed a degree of moderate level of depression There were no indications in the evaluation that Mr XYZ showed any addictive or noncompliant type behaviors It was felt at that time that Mr XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications Of concern to the therapist at that time was the patient s untreated and unmonitored hypertension and diabetes Mr XYZ indicated at that time they had not purchased any prescription medications or any of these health related issues because of financial limitations He still apparently is not under really good treatment for either of these conditions and on today s evaluation he actually denies that he had diabetes The impression was that the patient had axis IV diagnosis of chronic functional limitations financial loss and low losses with no axis III diagnosis This was done by Rhonda Ackerman Ph D a psychologist It was also suggested at that time that the patient should quit smoking Despite these evaluations Mr XYZ really did not get involved in psychotherapy and there was poor attendance of these visits there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke reduced mental clarity and future falls It was felt that any surgical interventions should be put on hold at that time In September of 2006 the patient was evaluated at Baylor College of Medicine in the Occupational Health Program The evaluation was done by a physician at that time whose report is clearly documented in the record Evaluation was done by Dr B At present Mr XYZ continues on with his oxycodone and Norco These were prescribed by Dr A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks The patient states that there has been no recent change in either the severity or the distribution of his pain He is unable to sleep because of pain and his activities of daily living are severely limited He spends most of his day lying on the floor watching TV and occasionally will walk a while from detailed questioning shows that his activities of daily living are practically zero The patient denies smoking at this time He denies alcohol use or aberrant drug use He obtains no pain medications from no other sources Review of MRI done on 02 10 06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4 5 and S1 nerve roots which appear to be retracted posteriorly There is a small right posterior herniation at L1 L2 PAST MEDICAL HISTORY Significant for hypertension hypercholesterolemia and non insulin dependent diabetes mellitus The patient does not know what medications he is taking for diabetes and denies any diabetes CABG in July of 2006 with no preoperative angina shortness of breath or myocardial infarction History of depression lumbar fusion surgery in 2000 left knee surgery 25 years ago SOCIAL HISTORY The patient is on disability He does not smoke He does not drink alcohol He is single He lives with a girlfriend He has minimal activities of daily living The patient cannot recollect when last a urine drug screen was done REVIEW OF SYSTEMS No fevers no headaches chest pain nausea shortness of breath or change in appetite Depressive symptoms of crying and decreased self worth have been noted in the past No neurological history of strokes epileptic seizures Genitourinary negative Gastrointestinal negative Integumentary negative Behavioral depression PHYSICAL EXAMINATION The patient is short of hearing His cognitive skills appear to be significantly impaired The patient is oriented x3 to time and place Weight 185 pounds temperature 97 5 blood pressure 137 92 pulse 61 The patient is complaining of pain of a 9 10 Musculoskeletal The patient s gait is markedly antalgic with predominant weightbearing on the left leg There is marked postural deviation to the left Because of pain the patient is unable to heel toe or tandem gait Examination of the neck and cervical spine are within normal limits Range of motion of the elbow shoulders are within normal limits No muscle spasm or abnormal muscle movements noted in the neck and upper extremities Head is normocephalic Examination of the anterior neck is within normal limits There is significant muscle wasting of the quadriceps and hamstrings on the left as well as of the calf muscles Skin is normal Hair distribution normal Skin temperature normal in both the upper and lower extremities The lumbar spine curvature is markedly flattened There is a well healed central scar extending from T12 to L1 The patient exhibits numerous positive Waddell s signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding worse on the left than the right Range of motion testing of the lumbar spine is labored in all directions It is interesting that the patient cannot flex more than 5 in the standing position but is able to sit without any problem There is a marked degree of sciatic notch tenderness on the left No abnormal muscle spasms or muscle movements were noted Patrick s test is negative bilaterally There are no provocative facetal signs in either the left or right quadrants of the lumbar area Neurological exam Cranial nerves II through XII are within normal limits Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps triceps and brachioradialis reflexes Neurological exam of the lower extremities shows a 2 right patellar reflex and 1 on the left There is no ankle clonus Babinski is negative Sensory testing shows a minimal degree of sensory loss on the right L5 distribution Muscle testing shows decreased L4 L5 on the left with extensor hallucis longus 2 5 Ankle extensors are 3 on the left and 5 on the right Dorsiflexors of the left ankle are 2 on the left and 5 on the right Straight leg raising test is positive on the left at about 35 There is no ankle clonus Hoffman s test and Tinel s test are normal in the upper extremities Respiratory Breath sounds normal Trachea is midline Cardiovascular Heart sounds normal No gallops or murmurs heard Carotid pulses present No carotid bruits Peripheral pulses are palpable Abdomen Hernia site is intact No hepatosplenomegaly No masses No areas of tenderness or guarding IMPRESSION 1 Post laminectomy low back syndrome 2 Left L5 S1 radiculopathy 3 Severe cognitive impairment with minimal for rehabilitation or return to work 4 Opioid dependence for pain control TREATMENT PLAN The patient will continue on with his medications prescribed by Dr Chang and I will see him in two weeks time and probably suggest switching over from OxyContin to methadone I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment I will get a behavioral evaluation from Mr Tom Welbeck and refer the patient for ongoing physical therapy The prognosis here for any improvement or return to work is zero Keywords chiropractic pain management opioid dependence patrick s test behavioral evaluation cognitive impairment low back syndrome motor strength pain control physical therapy radiculopathy spinal cord stimulation activities of daily living neurological exam laminectomy hearing diabetes muscle syndrome MEDICAL_TRANSCRIPTION,Description Insertion of a VVIR permanent pacemaker This is an 87 year old Caucasian female with critical aortic stenosis with an aortic valve area of 0 5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias Medical Specialty Cardiovascular Pulmonary Sample Name VVIR Permanent Pacemaker Insertion Transcription PROCEDURE PERFORMED Insertion of a VVIR permanent pacemaker COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal SITE Left subclavian vein access INDICATION This is an 87 year old Caucasian female with critical aortic stenosis with an aortic valve area of 0 5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore this is indicated so that we can give better control of heart rate and to maintain beta blocker therapy in the order of treatment It is overall a Class II indication for permanent pacemaker insertion PROCEDURE The risks benefits and alternative of the procedure were all discussed with the patient and the patient s family in detail at great length Overall options and precautions of the pacemaker and indications were all discussed They agreed to the pacemaker The consent was signed and placed in the chart The patient was taken to the Cardiac Catheterization Lab where she was monitored throughout the whole procedure The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion Myself and Dr Wildes spoke for approximately 8 minutes before insertion for the procedure Using a lidocaine with epinephrine the area of the left subclavian vein and left pectodeltoid region was anesthetized locally IV sedation increments and analgesics were given Using a 18 gauge needle the left subclavian vein access was cannulated without difficulty A guidewire was then passed through the Cook needle and the Cook needle was then removed The wire was secured in place with the hemostat Using a 10 and 15 scalpel blade a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia The skin was then undermined used to make a pocket for the pacemaker The guidewire was then tunneled through the pacer pocket Cordis sheath was then inserted through the guidewire The guidewire and dilator were removed ___ cordis sheath was in placed within This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy It was placed into the apex Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained the lead was then sutured in place with 1 0 silk suture to the pectoris major muscle The lead was then connected on pulse generator The pocket was then irrigated and cleansed Pulse generator and the wire was then inserted into the ____ pocket The skin was then closed with gut suture The skin was then closed with 4 0 Poly___ sutures using a subcuticular uninterrupted technique The area was then cleansed and dried Steri Strips and pressure dressing was then applied The patient tolerated the procedure well there was no complications These are the settings on the pacemaker IMPLANT DEVICE Pulse Generator Model Name Sigma model 12345 serial 123456 VENTRICLE LEAD Model 12345 the ventricular lead serial 123456 Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex BRADY PARAMETER SETTINGS ARE AS FOLLOWS Amplitude was set at 3 5 volts with a pulse of 0 4 sensitivity of 2 8 The pacing mode was set at VVIR lower rate of 60 and upper rate of 120 STIMULATION THRESHOLDS The right ventricular lead and bipolar threshold voltage is 0 6 volts 1 milliapms current 600 Ohms resistance R wave sensing 11 millivolts The patient tolerated the procedure well There was no complications The patient went to recovery in stable condition Chest x ray will be ordered She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia Thank you for allowing me to participate in her care If you have any questions or concerns please feel free to contact Keywords cardiovascular pulmonary aortic stenosis vvir permanent pacemaker permanent pacemaker insertion congestive heart failure tachybrady arrhythmias subclavian vein cordis sheath ventricular lead pulse generator permanent pacemaker insertion ventricle vvir ventricular permanent pacemaker leads MEDICAL_TRANSCRIPTION,Description Right and Left carotid ultrasound Medical Specialty Cardiovascular Pulmonary Sample Name Ultrasound Carotid 1 Transcription RIGHT 1 Mild heterogeneous plaque seen in common carotid artery 2 Moderate heterogeneous plaque seen in the bulb and internal carotid artery 3 Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70 4 Peak systolic velocity is normal in common carotid bulb and internal carotid artery 5 Peak systolic velocity is 280 cm sec in external carotid artery with moderate spectral broadening LEFT 1 Mild heterogeneous plaque seen in common carotid artery and external carotid artery 2 Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50 3 Peak systolic velocity is normal in common carotid artery and in the bulb 4 Peak systolic velocity is 128 cm sec in internal carotid artery and 156 cm sec in external carotid artery VERTEBRALS Antegrade flow seen bilaterally Keywords cardiovascular pulmonary carotid ultrasound antegrade flow peak systolic velocity bulb carotid artery homogeneous plaque plaque spectral broadening bulb and internal carotid velocity is normal common carotid artery internal carotid artery external carotid artery internal carotid external carotid peak systolic systolic velocity artery carotid ultrasound velocity heterogeneous MEDICAL_TRANSCRIPTION,Description Need for intravenous access Insertion of a right femoral triple lumen catheter he patient is also ventilator dependent respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access Medical Specialty Cardiovascular Pulmonary Sample Name Triple Lumen Catheter Insertion 1 Transcription PREOPERATIVE DIAGNOSIS Need for intravenous access POSTOPERATIVE DIAGNOSIS Need for intravenous access PROCEDURE PERFORMED Insertion of a right femoral triple lumen catheter ANESTHESIA Includes 4 cc of 1 lidocaine locally ESTIMATED BLOOD LOSS Minimum INDICATIONS The patient is an 86 year old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site The patient is also ventilator dependent respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access PROCEDURE The patient s legal guardian was talked to All questions were answered and consent was obtained The patient was sterilely prepped and draped Approximately 4 cc of 1 lidocaine was injected into the inguinal site A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30 degree angle cephalad and aspirated until a dark venous blood was aspirated A guidewire was then placed through the needle The needle was then removed The skin was ________ at the base of the wire and a dilator was placed over the wire The triple lumen catheters were then flushed with bacteriostatic saline The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times The wire was then carefully removed Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports Each port was closed off and also kept off Straight needle suture was then used to suture the triple lumen catheter down to the skin Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site The surgical site was then sterilely cleaned The patient tolerated the full procedure well There were no complications The nurse was then contacted to allow for access of the triple lumen catheter Keywords cardiovascular pulmonary intravenous access catheter femoral triple lumen catheter triple lumen catheter lumen ventilator respiratory guidewire MEDICAL_TRANSCRIPTION,Description The patient was exercised according to standard Bruce protocol for 9 minutes Medical Specialty Cardiovascular Pulmonary Sample Name Treadmill Test Transcription REASON FOR EXAMINATION Abnormal EKG FINDINGS The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85 of age predicted maximal heart rate Peak blood pressure was 132 60 The patient did not experience any chest discomfort during stress or recovery The test was terminated due to leg fatigue and achieving target heart rate Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram Technetium was injected at 5 minutes into stress IMPRESSION 1 Good exercise tolerance 2 Adequate heart rate and blood pressure response 3 This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease Keywords cardiovascular pulmonary ekg st depression maximal heart rate treadmill test bruce protocol blood pressure heart rate treadmill electrocardiogram MEDICAL_TRANSCRIPTION,Description Coronary artery bypass surgery and aortic stenosis Transthoracic echocardiogram was performed of technically limited quality Concentric hypertrophy of the left ventricle with left ventricular function Moderate mitral regurgitation Severe aortic stenosis severe Medical Specialty Cardiovascular Pulmonary Sample Name Transthoracic Echocardiography Transcription REASON FOR EXAM Coronary artery bypass surgery and aortic stenosis FINDINGS Transthoracic echocardiogram was performed of technically limited quality The left ventricle was normal in size and dimensions with normal LV function Ejection fraction was 50 to 55 Concentric hypertrophy noted with interventricular septum measuring 1 6 cm posterior wall measuring 1 2 cm Left atrium is enlarged measuring 4 42 cm Right sided chambers are normal in size and dimensions Aortic root has normal diameter Mitral and tricuspid valve reveals annular calcification Fibrocalcific valve leaflets noted with adequate excursion Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets Atrial and ventricular septum are intact Pericardium is intact without any effusion No obvious intracardiac mass or thrombi noted Doppler study reveals mild to moderate mitral regurgitation Severe aortic stenosis with peak velocity of 2 76 with calculated ejection fraction 50 to 55 with severe aortic stenosis There is also mitral stenosis IMPRESSION 1 Concentric hypertrophy of the left ventricle with left ventricular function 2 Moderate mitral regurgitation 3 Severe aortic stenosis severe RECOMMENDATIONS Transesophageal echocardiogram is clinically warranted to assess the aortic valve area Keywords cardiovascular pulmonary coronary artery bypass surgery aortic stenosis annular calcification tricuspid mitral regurgitation severe aortic stenosis concentric hypertrophy mitral regurgitation transthoracic echocardiogram hypertrophy ventricular valve stenosis aortic MEDICAL_TRANSCRIPTION,Description Bilateral carotid ultrasound to evaluate pain Medical Specialty Cardiovascular Pulmonary Sample Name Ultrasound Carotid 2 Transcription EXAM Ultrasound carotid bilateral REASON FOR EXAMINATION Pain COMPARISON None FINDINGS Bilateral common carotid arteries branches demonstrate minimal predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery There are no different colors or spectral Doppler waveform abnormalities PARAMETRIC DATA Right CCA PSV 0 72 m s Right ICA PSV is 0 595 m s Right ICA EDV 0 188 m s Right vertebral 0 517 m s Right IC CC is 0 826 Left CCA PSV 0 571 m s left ICA PSV 0 598 m s Left ICA EDV 0 192 m s Left vertebral 0 551 m s Left IC CC is 1 047 IMPRESSION 1 No evidence for clinically significant stenosis 2 Minimal predominantly soft plaquing Keywords cardiovascular pulmonary carotid cca psv doppler ic cc ica edv ica psv ultrasound arteries calcific plaquing common carotid internal carotid artery spectral stenosis waveform ultrasound carotid bilateral ultrasound carotid plaquing MEDICAL_TRANSCRIPTION,Description Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter Hyperpyrexia leukocytosis ventilator dependent respiratory failure and acute pancreatitis Medical Specialty Cardiovascular Pulmonary Sample Name Triple Lumen Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Hyperpyrexia leukocytosis 2 Ventilator dependent respiratory failure 3 Acute pancreatitis POSTOPERATIVE DIAGNOSES 1 Hyperpyrexia leukocytosis 2 Ventilator dependent respiratory failure 3 Acute pancreatitis PROCEDURE PERFORMED 1 Insertion of a right brachial artery arterial catheter 2 Insertion of a right subclavian vein triple lumen catheter ANESTHESIA Local 1 lidocaine BLOOD LOSS Less than 5 cc COMPLICATIONS None INDICATIONS The patient is a 46 year old Caucasian female admitted with severe pancreatitis She was severely dehydrated and necessitated some fluid boluses The patient became hypotensive required many fluid boluses became very anasarcic and had difficulty with breathing and became hypoxic She required intubation and has been ventilator dependent in the Intensive Care since that time The patient developed very high temperatures as well as leukocytosis Her lines required being changed PROCEDURE 1 RIGHT BRACHIAL ARTERIAL LINE The patient s right arm was prepped and draped in the usual sterile fashion There was a good brachial pulse palpated The artery was cannulated with the provided needle and the kit There was good arterial blood return noted immediately On the first stick the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery The femoral catheter was used in this case secondary to the patient s severe edema and anasarca We did not feel that the shorter catheter would provide enough length The catheter was connected to the system and flushed without difficulty A good waveform was noted The catheter was sutured into place with 3 0 silk suture and OpSite dressing was placed over this 2 RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER The patient was prepped and draped in the usual sterile fashion 1 Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle Using the anesthetic needle we checked down to the soft tissues anesthetizing as we proceeded to the angle of the clavicle this was also anesthetized Next a 18 gauge thin walled needle was used following the same track to the angle of clavicle We roughed the needle down off the clavicle and directed it towards the sternal notch There was good venous return noted immediately The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein The needle was then removed A small skin nick was made with a 11 blade scalpel and the provided dilator was used to dilate the skin soft tissue and vein Next the triple lumen catheter was inserted over the guidewire without difficulty The guidewire was removed All the ports aspirated and flushed without difficulty The catheter was sutured into place with 3 0 silk suture and a sterile OpSite dressing was also applied The patient tolerated the above procedures well A chest x ray has been ordered however it has not been completed at this time this will be checked and documented in the progress notes Keywords cardiovascular pulmonary hyperpyrexia leukocytosis ventilator dependen respiratory failure pancreatitis brachial artery arterial catheter subclavian vein triple lumen catheter catheter brachial needle MEDICAL_TRANSCRIPTION,Description Urgent cardiac catheterization with coronary angiogram Medical Specialty Cardiovascular Pulmonary Sample Name Urgent Cardiac Cath Transcription PROCEDURE Urgent cardiac catheterization with coronary angiogram PROCEDURE IN DETAIL The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest The right groin was prepped and draped in usual manner Under 2 lidocaine anesthesia the right femoral artery was entered A 6 French sheath was placed The patient was already on anticoagulation Selective coronary angiograms were then performed using a left and a 3DRC catheter The catheters were reviewed The catheters were then removed and an Angio Seal was placed There was some hematoma at the cath site RESULTS 1 The left main was free of disease 2 The left anterior descending and its branches were free of disease 3 The circumflex was free of disease 4 The right coronary artery was free of disease There was no gradient across the aortic valve IMPRESSION Normal coronary angiogram Keywords cardiovascular pulmonary cardiac catheterization coronary angiogram angiogram MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiographic examination report Aortic valve replacement Assessment of stenotic valve Evaluation for thrombus on the valve Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 3 Transcription REASON FOR EXAM Aortic valve replacement Assessment of stenotic valve Evaluation for thrombus on the valve PREOPERATIVE DIAGNOSIS Atrial valve replacement POSTOPERATIVE DIAGNOSES Moderate stenosis of aortic valve replacement Mild mitral regurgitation Normal left ventricular function PROCEDURES IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control The oropharynx anesthetized with benzocaine spray and lidocaine solution Esophageal intubation was done with no difficulty with the second attempt In a semi Fowler position the probe was passed to transthoracic views at about 40 to 42 cm Multiple pictures obtained Assessment of the peak velocity was done later The probe was pulled to the mid esophageal level Different pictures including short axis views of the aortic valve was done Extubation done with no problems and no blood on the probe The patient tolerated the procedure well with no immediate postprocedure complications INTERPRETATION The left atrium was mildly dilated No masses or thrombi were seen The left atrial appendage was free of thrombus Pulse wave interrogation showed peak velocities of 60 cm per second The left ventricle was normal in size and contractility with mild LVH EF is normal and preserved The right atrium and right ventricle were both normal in size Mitral valve showed no vegetations or prolapse There was mild to moderate regurgitation on color flow interrogation Aortic valve was well seated mechanical valve bileaflet with acoustic shadowing beyond the valve noticed No perivalvular leak was noticed There was increased velocity across the valve with peak velocity of 3 2 m sec with calculated aortic valve area by continuity equation at 1 2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves No AIC Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve Overall showed no abnormalities The tricuspid valve was structurally normal Interatrial septum appeared to be intact confirmed by color flow interrogation as well as agitated saline contrast study The aorta and aortic arch were unremarkable No dissection IMPRESSION 1 Mildly dilated left atrium 2 Mild to moderate regurgitation 3 Well seated mechanical aortic valve with peak velocity of 3 2 m sec and calculated valve area of 1 2 cm2 consistent with moderate aortic stenosis Reevaluation in two to three years with transthoracic echocardiogram will be recommended Keywords cardiovascular pulmonary aortic valve replacement stenotic valve thrombus stenosis ventricular esophageal peak velocity valve replacement aortic valve aortic transesophageal valve oropharynx atrium interrogation atrial moderate MEDICAL_TRANSCRIPTION,Description Transesophageal Echocardiogram A woman admitted to the hospital with a large right MCA CVA causing a left sided neurological deficit incidentally found to have atrial fibrillation on telemetry Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 6 Transcription HISTORY OF PRESENT ILLNESS I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr A and Neurology Please see also my cardiovascular consultation dictated separately But essentially this is a pleasant 72 year old woman admitted to the hospital with a large right MCA CVA causing a left sided neurological deficit incidentally found to have atrial fibrillation on telemetry She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult I discussed the procedure in detail with the patient as well as with her daughter who was present at the patient s bedside with the patient s verbal consent I then performed a risk benefit alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts alternatives being transthoracic echo imaging which she had already had with an inherent false negativity for this indication as well as empiric medical management which the patient was not interested in risks including but not limited to and the patient was aware this was not an all inclusive list of oversedation from conscious sedation risk of aspiration pneumonia from regurgitation of stomach contents risk of oropharyngeal esophageal oral tracheal pulmonary and or gastric perforation hemorrhage or tear The patient expressed understanding of this risk benefit alternative analysis had the opportunity to ask questions which I invited from her and her daughter all of which were answered to their self stated satisfaction The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram PROCEDURE The appropriate time out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient position physician procedure documentation there were no safety issues identified by staff nor myself She received 20 cc of viscous lidocaine for topical oral anesthetic effect She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect The multi plane probe was passed using digital guidance for several passes after an oral bite block had been put into place for protection of oral dentition This was placed into the posterior oropharynx and advanced into the esophagus then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout She was recovered as per the Medical Center conscious sedation protocol and there were no apparent complications of the procedure FINDINGS Normal left ventricular size and systolic function LVEF of 60 Mild left atrial enlargement Normal right atrial size Normal right ventricular size and systolic function No left ventricular wall motion abnormalities identified The four pulmonary veins are identified The left atrial appendage is interrogated including with Doppler and color flow and while there is good to and fro motion seen echo smoke is seen and in fact an intracardiac thrombus is identified and circumscribed at 1 83 cm in circumference at the base of the left atrial appendage No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves The mitral valve is seen There is mild mitral regurgitation with two jets No mitral stenosis Four pulmonary veins were identified without reversible pulmonary venous flow There are three cusps of the aortic valve seen No aortic stenosis There is trace aortic insufficiency There is trace pulmonic insufficiency The pulmonary artery is seen and is within normal limits There is trace to mild tricuspid regurgitation Unable to estimate PA systolic pressure accurately however on the recent transthoracic echocardiogram which I would direct the reader to on January 5 2010 RVSP was calculated at 40 mmHg on that study E wave velocity on average is 0 95 m sec with a deceleration time of 232 milliseconds The proximal aorta is within normal limits annulus 1 19 cm sinuses of Valsalva 2 54 cm ascending aorta 2 61 cm The intra atrial septum is identified as are the SVC and IVC and these are within normal limits The intra atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting including no atrial septal defect nor patent foramen ovale No pericardial effusion There is mild nonmobile descending aortic atherosclerosis seen IMPRESSION 1 Normal left ventricular size and systolic function Left ventricular ejection fraction visually estimated at 60 without regional wall motion abnormalities 2 Mild left atrial enlargement 3 Intracardiac thrombus identified at the base of the left atrial appendage 4 Mild mitral regurgitation with two jets 5 Mild nonmobile descending aortic atherosclerosis Compared to the transthoracic echocardiogram done previously other than identification of the intracardiac thrombus other findings appear quite similar These results have been discussed with Dr A of inpatient Internal Medicine service as well as the patient who was recovering from conscious sedation and her daughter with the patient s verbal consent Keywords cardiovascular pulmonary echo thrombus intracardiac cardiovascular pulmonary veins intracardiac thrombus transesophageal echocardiogram echocardiogram atrial mca cva transesophageal pulmonary ventricular aortic MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 4 Transcription PROCEDURE NOTE The patient was brought to the transesophageal echo laboratory after informed consent was obtained The patient was seen by Anesthesia for MAC anesthesia The patient s posterior pharynx was anesthetized with local Cetacaine spray The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty FINDINGS 1 Left ventricle is normal in size and function ejection fraction approximately 60 2 Right ventricle is normal in size and function 3 Left atrium and right atrium are normal in size 4 Mitral valve aortic valve tricuspid valve and pulmonic valve with no evidence of vegetation Aortic valve is only minimally thickened 5 Mild mitral regurgitation and mild tricuspid regurgitation 6 No left ventricular thrombus 7 No pericardial effusion 8 There is evidence of patent foramen ovale by contrast study The patient tolerated the procedure well and is sent to recovery in stable condition He should be n p o x4 hours then liquid then increase as tolerated Once his infection is cleared he should follow up with us with regard to followup of patent foramen ovale Keywords cardiovascular pulmonary ventricle atrium mitral valve aortic valve tricuspid valve pulmonic valve regurgitation transesophageal probe transesophageal echocardiogram posterior pharynx transesophageal valve MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram MRSA bacteremia rule out endocarditis The patient has aortic stenosis Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 5 Transcription CLINICAL INDICATIONS MRSA bacteremia rule out endocarditis The patient has aortic stenosis DESCRIPTION OF PROCEDURE The transesophageal echocardiogram was performed after getting verbal and a written consent signed Then a multiplane TEE probe was introduced into the upper esophagus mid esophagus lower esophagus and stomach and multiple views were obtained There were no complications The patient s throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl FINDINGS 1 Aortic valve is thick and calcified a severely restricted end opening and there is 0 6 x 8 mm vegetation attached to the right coronary cusp The peak velocity across the aortic valve was 4 6 m sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0 6 sq cm by planimetry 2 Mitral valve is calcified and thick No vegetation seen There is mild to moderate MR present There is mild AI present also 3 Tricuspid valve and pulmonary valve are structurally normal 4 There is a mild TR present 5 There is no clot seen in the left atrial appendage The velocity in the left atrial appendage was 0 6 m sec 6 Intraatrial septum was intact There is no clot or mass seen 7 Normal LV and RV systolic function 8 There is thick raised calcified plaque seen in the thoracic aorta and arch SUMMARY 1 There is a 0 6 x 0 8 cm vegetation present in the aortic valve with severe aortic stenosis Calculated aortic valve area was 0 6 sq cm 2 Normal LV systolic function Keywords cardiovascular pulmonary endocarditis aortic stenosis tee probe mrsa bacteremia transesophageal echocardiogram aortic echocardiogram esophagus vegetation transesophageal MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram due to vegetation and bacteremia Normal left ventricular size and function Echodensity involving the aortic valve suggestive of endocarditis and vegetation Doppler study as above most pronounced being moderate to severe aortic insufficiency Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 2 Transcription REASON FOR EXAM Vegetation and bacteremia PROCEDURE Transesophageal echocardiogram INTERPRETATION The procedure and its complications were explained to the patient in detail and formal consent was obtained The patient was brought to special procedure unit His throat was anesthetized with lidocaine spray Subsequently 2 mg of IV Versed was given for sedation The patient was positioned Probe was introduced without any difficulty The patient tolerated the procedure very well Probe was taken out No complications were noted Findings are as mentioned below FINDINGS 1 Left ventricle has normal size and dimensions with normal function Ejection fraction of 60 2 Left atrium and right sided chambers were of normal size and dimensions 3 Left atrial appendage is clean without any clot or smoke effect 4 Atrial septum is intact Bubble study was negative 5 Mitral valve is structurally normal 6 Aortic valve reveals echodensity suggestive of vegetation 7 Tricuspid valve was structurally normal 8 Doppler reveals moderate mitral regurgitation and moderate to severe aortic regurgitation 9 Aorta is benign IMPRESSION 1 Normal left ventricular size and function 2 Echodensity involving the aortic valve suggestive of endocarditis and vegetation 3 Doppler study as above most pronounced being moderate to severe aortic insufficiency Keywords cardiovascular pulmonary ventricle atrium atrial septum mitral valv aortic valve tricuspid valve doppler ventricular size transesophageal echocardiogram severe aortic bacteremia transesophageal echocardiogram echodensity vegetation valve aortic MEDICAL_TRANSCRIPTION,Description Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiography Probe Transcription INDICATIONS FOR PROCEDURE Impending open heart surgery for closure of ventricular septal defect in a 4 month old girl Procedures were done under general anesthesia The patient was already in the operating room under general anesthesia Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures PROCEDURE 1 Insertion of transesophageal echocardiography probe DESCRIPTION OF PROCEDURE 1 The probe was well lubricated and with digital manipulation was passed into the esophagus without resistance The probe was placed so that the larger diameter was in the anterior posterior position during insertion The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography At the end it was removed without trauma and there was no blood tingeing It is to be noted that approximately 30 minutes after removing the cannula I inserted a 14 French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned There was no overt bleeding PROCEDURE 2 Attempted and unsuccessful insertion of arterial venous lines DESCRIPTION OF PROCEDURE 2 Both groins were prepped and draped The patient was placed at 10 degrees head up position A Cook 4 French double lumen 8 cm catheter kit was opened Using the 21 gauge needle that comes with the kit several attempts were made to insert central venous and then an arterial line in the left groin There were several successful punctures of these vessels but I was unable to advance Seldinger wire After removal of the needles the area was compressed digitally for approximately 5 minutes There was a small hematoma that was not growing Initially the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds Using 1 lidocaine I infiltrated the vessels of the groin both medial and lateral to the vascular sheath Further observation the capillary refill and circulation of the left leg became more than adequate The O2 saturation monitor that was on the left toe functioned well throughout the procedures from the beginning to the end At the end of the procedure the circulation of the leg was intact Keywords cardiovascular pulmonary impending open heart surgery ventricular septal defect antibiotic prophylaxis cefazolin transesophageal echocardiography probe arterial venous lines groin transesophageal echocardiography echocardiography probe insertion transesophageal arterial venous groins echocardiography probe MEDICAL_TRANSCRIPTION,Description Tracheostomy change A 6 Shiley with proximal extension was changed to a 6 Shiley with proximal extension Ventilator dependent respiratory failure and laryngeal edema Medical Specialty Cardiovascular Pulmonary Sample Name Tracheostomy Change Transcription PREOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Laryngeal edema POSTOPERATIVE DIAGNOSES 1 Ventilator dependent respiratory failure 2 Laryngeal edema PROCEDURE PERFORMED Tracheostomy change A 6 Shiley with proximal extension was changed to a 6 Shiley with proximal extension INDICATIONS The patient is a 60 year old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed The patient was noted at that time to have transglottic edema Biopsies were taken At the time of surgery it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection The patient is currently postop day 6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support A decision was made to perform tracheostomy change DESCRIPTION OF PROCEDURE The patient was seen in the Intensive Care Unit The patient was placed in a supine position The neck was then extended The sutures that were previously in place in the 6 Shiley with proximal extension were removed The patient was preoxygenated to 100 After several minutes the patient was noted to have a pulse oximetry of 100 The IV tubing that was supporting the patient s trache was then cut The tracheostomy tube was then suctioned The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned With the guidewire in place and with adequate visualization a new 6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea The guidewire was then removed and the inner cannula was then placed into the tracheostomy The patient was then reconnected to the ventilator and was noted to have normal tidal volumes The patient had a tidal volume of 500 and was returning 500 cc to 510 cc The patient continued to saturate well with saturations 99 The patient appeared comfortable and her vital signs were stable A soft trache collar was then connected to the trachesotomy A drain sponge was then inserted underneath the new trache site The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes COMPLICATIONS None DISPOSITION The patient tolerated the procedure well 0 25 acetic acid soaks were ordered to the drain sponge every shift Keywords cardiovascular pulmonary shiley proximal extension ventilator dependent respiratory failure laryngeal edema tracheostomy cannula respiratory laryngeal nasogastric edema ventilator MEDICAL_TRANSCRIPTION,Description Tracheostomy with skin flaps and SCOOP procedure FastTract Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease Medical Specialty Cardiovascular Pulmonary Sample Name Tracheostomy SCOOP Procedure Transcription PREOPERATIVE DIAGNOSES 1 Oxygen dependency 2 Chronic obstructive pulmonary disease POSTOPERATIVE DIAGNOSES 1 Oxygen dependency 2 Chronic obstructive pulmonary disease PROCEDURES PERFORMED 1 Tracheostomy with skin flaps 2 SCOOP procedure FastTract ANESTHESIA Total IV anesthesia ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 55 year old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home The patient with extensive smoking history who presents after risks complications and consequences of the SCOOP FastTract procedure were explained PROCEDURE The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position After this the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg The patient s sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch The midline was also marked and 1 lidocaine with epinephrine 1 100 000 at approximately 4 cc total was then utilized to localize the neck After this the patient was then prepped and draped with Hibiclens A skin incision was then made in the midline with a 15 Bard Parker in a vertical fashion After this the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with 2 0 undyed Vicryl ties Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles The patient s sternohyoid muscle was identified and grasped on either side and the midline raphe was identified Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization After this the patient s anterior trachea was then identified and cleaned with pusher After this the cricoid cartilage along the first and second tracheal rings was identified The cricoid hook was placed and the trachea was brought more anteriorly and superiorly After this the patient s head incision was placed below the second tracheal ring with a 15 Bard Parker After this the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage After this the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap After this the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100 The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours The patient will have the stent guidewire removed with a scoop catheter 11 cm placed Keywords cardiovascular pulmonary oxygen dependency chronic obstructive pulmonary disease tracheostomy scoop procedure nasal cannula scoop procedure fasttract thyroid isthmus cricoid cartilage isthmus oxygen dependency scoop cartilages MEDICAL_TRANSCRIPTION,Description Tilt table test A patient with past medical history of syncope The patient is also complaining of dizziness Medical Specialty Cardiovascular Pulmonary Sample Name Tilt Table Test 1 Transcription INDICATIONS The patient is a 22 year old female with past medical history of syncope The patient is also complaining of dizziness She was referred here by Dr X for tilt table TECHNIQUE Risks and benefits explained to the patient Consent obtained She was lying down on her back for 20 minutes and her blood pressure was 111 75 and heart rate 89 She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120 80 Then the patient received sublingual nitroglycerin 0 4 mg The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110 50 The patient felt nauseous and felt hot at that time She did not pass out COMPLICATIONS None Tilt table was then terminated SUMMARY Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure RECOMMENDATIONS I recommend followup in the office in one week and she will need Toprol XL 12 5 mg every day if symptoms persist Keywords cardiovascular pulmonary vasovagal syncope tilt table test blood pressure heart rate dizziness MEDICAL_TRANSCRIPTION,Description Tracheotomy for patient with respiratory failure Medical Specialty Cardiovascular Pulmonary Sample Name Tracheotomy 1 Transcription PREOPERATIVE DIAGNOSIS Respiratory failure POSTOPERATIVE DIAGNOSIS Respiratory failure OPERATIVE PROCEDURE Tracheotomy ANESTHESIA General inhalational DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine on the operating table General inhalational anesthesia was administered through the patient s existing 4 0 endotracheal tube The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring The incision area was infiltrated with 1 Xylocaine with epinephrine 1 100 000 A 67 blade was used to perform the incision Electrocautery was used to remove excess fat tissue to expose the strap muscles The strap muscles were grasped and divided in the midline with a cutting electrocautery Sharp dissection was used to expose the anterior trachea and cricoid cartilage The thyroid isthmus was identified crossing just below the cricoid cartilage This was divided in the midline with electrocautery Blunt dissection was used to expose adequate cartilaginous rings A 4 0 silk was used for stay sutures to the midline of the cricoid Additional stay sutures were placed on each side of the third tracheal ring Thin DuoDerm was placed around the stoma The tracheal incision was performed with a 11 blade through the second third and fourth tracheal rings The cartilaginous edges were secured to the skin edges with interrupted 4 0 Monocryl A 4 5 PED tight to shaft cuffed Bivona tube was placed and secured with Velcro ties A flexible scope was passed through the tracheotomy tube The carina was visualized approximately 1 5 cm distal to the distal end of the tracheotomy tube Ventilation was confirmed There was good chest rise and no appreciable leak The procedure was terminated The patient was in stable condition Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition Keywords cardiovascular pulmonary bivona tube duoderm tracheotomy tube respiratory failure cricoid cartilage tracheotomy tracheal MEDICAL_TRANSCRIPTION,Description Transesophageal echocardiogram for aortic stenosis Normal left ventricular size and function Benign Doppler flow pattern Doppler study essentially benign Aorta essentially benign Atrial septum intact Study was negative Medical Specialty Cardiovascular Pulmonary Sample Name Transesophageal Echocardiogram 1 Transcription INDICATION Aortic stenosis PROCEDURE Transesophageal echocardiogram INTERPRETATION Procedure and complications explained to the patient in detail Informed consent was obtained The patient was anesthetized in the throat with lidocaine spray Subsequently 3 mg of IV Versed was given for sedation The patient was positioned and transesophageal probe was introduced without any difficulty Images were taken The patient tolerated the procedure very well without any complications Findings as mentioned below FINDINGS 1 Left ventricle is in normal size and dimension Normal function Ejection fraction of 60 2 Left atrium and right sided chambers are of normal size and dimension 3 Mitral tricuspid and pulmonic valves are structurally normal 4 Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion 5 Left atrial appendage is clean without any clot or smoke effect 6 Atrial septum intact Study was negative 7 Doppler study essentially benign 8 Aorta essentially benign 9 Aortic valve planimetry valve area average about 1 3 cm2 consistent with moderate aortic stenosis SUMMARY 1 Normal left ventricular size and function 2 Benign Doppler flow pattern 3 Aortic valve area of 1 3 cm2 planimetry Keywords cardiovascular pulmonary aortic valve ejection fraction planimetry ventricular transesophageal echocardiogram atrial septum septum intact transesophageal echocardiogram aortic stenosis doppler aortic valves MEDICAL_TRANSCRIPTION,Description Aortic stenosis Insertion of a Toronto stentless porcine valve cardiopulmonary bypass and cold cardioplegia arrest of the heart Medical Specialty Cardiovascular Pulmonary Sample Name Toronto Porcine Valve Insertion Transcription PREOPERATIVE DIAGNOSIS Aortic stenosis POSTOPERATIVE DIAGNOSIS Aortic stenosis PROCEDURES PERFORMED 1 Insertion of a mm Toronto stentless porcine valve 2 Cardiopulmonary bypass 3 Cold cardioplegia arrest of the heart ANESTHESIA General endotracheal anesthesia ESTIMATED BLOOD LOSS 300 cc INTRAVENOUS FLUIDS 1200 cc of crystalloid URINE OUTPUT 250 cc AORTIC CROSS CLAMP TIME CARDIOPULMONARY BYPASS TIME TOTAL PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the neck chest and legs were prepped and draped in the standard surgical fashion We used a 10 blade scalpel to make a midline median sternotomy incision Dissection was carried down to the left of the sternum using Bovie electrocautery The sternum was opened with a sternal saw The chest retractor was positioned Next full dose heparin was given The pericardium was opened Pericardial stay sutures were positioned After obtaining adequate ACT we prepared to place the patient on cardiopulmonary bypass A 2 0 double pursestring of Ethibond suture was placed in the ascending aorta Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine Next a 3 0 Prolene pursestring was placed in the right atrial appendage Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine A 4 0 U stitch was placed in the right atrium A retrograde cardioplegia catheter was positioned at this site Next scissors were used to dissect out the right upper pulmonary vein A 4 0 Prolene pursestring was placed in the right upper pulmonary vein Next a right angle sump was placed at this position We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery The aorta was completely encircled Next an antegrade cardioplegia needle and associated sump were placed in the ascending aorta We then prepared to cross clamp the aorta We went down on our flows and cross clamped the aorta We backed up our flows We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart The patient had some aortic insufficiency so we elected after initially arresting the heart to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit Next after obtaining complete diastolic arrest of the heart we turned our attention to exposing the aortic valve and 4 0 Tycron sutures were placed in the commissures In addition a 2 0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view Next scissors were used to excise the diseased aortic valve leaflets Care was taken to remove all the calcium from the aortic annulus We then sized up the aortic annulus which came out to be a mm stentless porcine Toronto valve We prepared the valve Next we placed our proximal suture line of interrupted 4 0 Tycron sutures for the annulus We started with our individual commissural stitches They were connected to our valve sewing ring Next we placed 5 interrupted 4 0 Tycron sutures in a subannular fashion at each commissural position After doing so we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve The valve was lowered into place and all of the sutures were tied Next we gave another round of cold blood antegrade and retrograde cardioplegia Next we sewed our distal suture line We began with the left coronary cusp of the valve We ran a 5 0 RB needle up both sides of the valve Care was taken to avoid the left coronary ostia This procedure was repeated on the right cusp of the stentless porcine valve Again care was taken to avoid any injury to the coronary ostia Lastly we sewed our non coronary cusp This was done without difficulty At this point we inspected our aortic valve There was good coaptation of the leaflets and it was noted that both the left and the right coronary ostia were open We gave another round of cold blood antegrade and retrograde cardioplegia The antegrade portion was given in a direct ostial fashion once again We now turned our attention to closing the aorta A 4 0 Prolene double row of suture was used to close the aorta in a running fashion Just prior to closing we de aired the heart and gave a warm shot of antegrade and retrograde cardioplegia At this point we removed our aortic cross clamp The heart gradually regained its electromechanical activity We placed 2 atrial and 2 ventricular pacing wires We removed our aortic vent and oversewed that site with another 4 0 Prolene on an SH needle We removed our retrograde cardioplegia catheter We oversewed that site with a 5 0 Prolene By now the heart was de aired and resumed normal electromechanical activity We began to wean the patient from cardiopulmonary bypass We then removed our venous cannula and suture ligated that site with a 2 silk We then gave full dose protamine After knowing that there was no evidence of a protamine reaction we removed the aortic cannula We buttressed that site with a 4 0 Prolene on an SH needle We placed a mediastinal chest tube and brought it out through the skin We also placed 2 Blake drains 1 in the left chest and 1 in the right chest as the patient had some bilateral pleural effusions They were brought out through the skin The sternum was closed with 7 wires in an interrupted figure of eight fashion The fascia was closed with 1 Vicryl We closed the subcu tissue with 2 0 Vicryl and the skin with 4 0 PDS Keywords cardiovascular pulmonary cardioplegia toronto stentless porcine valve tycron sutures coronary ostia porcine valve retrograde cardioplegia cardiopulmonary bypass sutures valve insertion toronto aortic stentless chest coronary porcine cardiopulmonary prolene atrial bypass heart aorta MEDICAL_TRANSCRIPTION,Description Thrombosed left forearm loop fistula graft chronic renal failure and hyperkalemia Thrombectomy of the left forearm loop graft The venous outflow was good There was stenosis in the mid venous limb of the graft Medical Specialty Cardiovascular Pulmonary Sample Name Thrombectomy Transcription PREOPERATIVE DIAGNOSES 1 Thrombosed left forearm loop fistula graft 2 Chronic renal failure 3 Hyperkalemia POSTOPERATIVE DIAGNOSES 1 Thrombosed left forearm loop fistula graft 2 Chronic renal failure 3 Hyperkalemia PROCEDURE PERFORMED Thrombectomy of the left forearm loop graft ANESTHESIA Local with sedation ESTIMATED BLOOD LOSS Less than 5 cc COMPLICATIONS None OPERATIVE FINDINGS The venous outflow was good There was stenosis in the mid venous limb of the graft INDICATIONS The patient is an 81 year old African American female who presents with an occluded left forearm loop graft She was not able to have her dialysis as routine Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery Both Surgery and Anesthesia thought this would be too risky to do Thus she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning This morning her predialysis potassium was 6 and thus she was scheduled for surgery after her dialysis PROCEDURE The patient was taken to the operative suite and prepped and draped in the usual sterile fashion A transverse incision was made at the region of the venous anastomosis of the graft Further dissection was carried down to the catheter The vein appeared to be soft and without thrombus This outflow did not appear to be significantly impaired A transverse incision was made with a 11 blade on the venous limb of the graft near the anastomosis Next a thrombectomy was done using a 4 Fogarty catheter Some of the clot and thrombus was removed from the venous limb The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis Once removing most of the clots from the venous limb prior to removing the plug dilators were passed down the venous limb also indicating the area of stenosis At this point we felt the patient would benefit from a curettage of the venous limb of the graft This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage The Fogarty balloon was then passed beyond the clot and the plug The plug was visualized and inspected This also gave a good brisk bleeding from the graft The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb Attention was directed up to its anastomosis and the vein Fogarty balloon and thrombectomy was also performed well enough into this way There was good venous back bleeding following this The area was checked for any stenosis with the dilators and none was present Next a 6 0 Prolene suture was used in a running fashion to close the graft Just prior to tying the suture the graft was allowed to flush to move any debris or air The suture was also checked at that point for augmentation which was good The suture was tied down and the wound was irrigated with antibiotic solution Next a 3 0 Vicryl was used to approximate the subcutaneous tissues and a 4 0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges Steri Strips were applied and the patient was taken to recovery in stable condition She tolerated the procedure well She will be discharged from recovery when stable She is to resume her regular dialysis schedule and present for dialysis tomorrow Keywords cardiovascular pulmonary thrombosed hyperkalemia thrombectomy forearm loop graft venous outflow chronic renal failure venous limb loop graft forearm loop limb forearm graft venous anastomosis stenosis MEDICAL_TRANSCRIPTION,Description Thromboendarterectomy of right common external and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending and reverse autogenous saphenous vein graft to the obtuse marginal posterior descending branch of the right coronary artery Medical Specialty Cardiovascular Pulmonary Sample Name Thromboendarterectomy Transcription OPERATIVE PROCEDURE 1 Thromboendarterectomy of right common external and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure 2 Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending and reverse autogenous saphenous vein graft to the obtuse marginal posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection placement of temporary pacing wires DESCRIPTION The patient was brought to the operating room placed in supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring lines were placed The chest abdomen and legs were prepped and draped in a sterile fashion The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4 0 silk and flushing with vein solution The leg was closed with running 3 0 Dexon subcu and running 4 0 Dexon subcuticular on the skin and later wrapped A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The sternum was closed A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma The deep fascia was divided The facial vein was divided between clamps and tied with 2 0 silk The common carotid artery takeoff of the external and internal carotid arteries were dissected free with care taken to identify and preserve the hypoglossal and vagus nerves The common carotid artery was double looped with umbilical tape takeoff of the external was looped with a heavy silk distal internal was double looped with a heavy silk Shunts were prepared A patch was prepared Heparin 50 mg was given IV Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery Distal internal was held with a forceps Internal carotid artery was opened with 11 blade Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond The shunt was placed and proximal and distal snares were tightened Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine feathery distal edge using eversion on the external All loose debris was removed and Dacron patch was then sutured in place with running 6 0 Prolene suture removing the shunt just prior to completing the suture line Suture line was completed and the neck was packed The pericardium was opened A pericardial cradle was created The patient was heparinized for cardiopulmonary bypass cannulated with a single aortic and single venous cannula A retrograde cardioplegia cannula was placed with a pursestring of 4 0 Prolene into the coronary sinus and secured to a Rumel tourniquet An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted The ascending aorta was cross clamped and cold blood potassium cardioplegia was given antegrade a total of 5 cc per kg This was followed sumping of the ascending aorta and retrograde cardioplegia a total of 5 cc per kg to the coronary sinus The obtuse marginal 1 coronary was identified and opened and an end to side anastomosis was then performed with running 7 0 Prolene suture The vein was cut to length Antegrade and retrograde cold blood potassium cardioplegia was given The obtuse marginal 2 was not felt to be suitable for bypass therefore the posterior descending of the right coronary was identified and opened and an end to side anastomosis was then performed with running 7 0 Prolene suture to reverse autogenous saphenous vein The vein was cut to length The mammary was clipped distally divided and spatulated for anastomosis Antegrade and retrograde cold blood potassium cardioplegia was given The anterior descending was identified and opened the mammary was then sutured to this with running 8 0 Prolene suture Warm blood potassium cardioplegia was given and the cross clamp was removed A partial occlusion clamp was placed Two aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture The partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Atrial and ventricular pacing wires were placed Ventilation was commenced The patient was fully warmed The patient was weaned from cardiopulmonary bypass and de cannulated in a routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire the linea alba with figure of eight 1 Vicryl the sternal fascia with running 1 Vicryl the subcu with running 2 0 Dexon and the skin with a running 4 0 Dexon subcuticular stitch Keywords cardiovascular pulmonary cabg thromboendarterectomy carotid artery coronary artery bypass mammary obtuse papaverine soaked running prolene suture cardiopulmonary bypass internal carotid running prolene prolene suture carotid sutured artery prolene coronary bypass veinNOTE MEDICAL_TRANSCRIPTION,Description Thrombectomy AV shunt left forearm and patch angioplasty of the venous anastomosis Thrombosed arteriovenous shunt left forearm with venous anastomotic stenosis Medical Specialty Cardiovascular Pulmonary Sample Name Thrombectomy AV Shunt Transcription PREOPERATIVE DIAGNOSIS Thrombosed arteriovenous shunt left forearm POSTOPERATIVE DIAGNOSIS Thrombosed arteriovenous shunt left forearm with venous anastomotic stenosis PROCEDURE Thrombectomy AV shunt left forearm and patch angioplasty of the venous anastomosis ANESTHESIA Local SKIN PREP Betadine DRAINS None PROCEDURE TECHNIQUE The left arm was prepped and draped Xylocaine 1 was administered and a transverse antecubital incision was made over the venous limb of the graft which was dissected out and encircled with a vessel loop The runoff vein was dissected out and encircled with the vessel loop as well A longitudinal incision was made over the venous anastomosis There was a narrowing in the area and slightly the incision was extended more proximally There was good back bleeding from the vein as well as bleeding from the more distal vein These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously A 4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established There was a narrowing in the mid portion of the venous limb of the graft which was dilated with a 5 coronary dilator The Fogarty catheter was then passed up the vein but no clot was obtained A patch PTFE material was fashioned and was sutured over the graftotomy with running 6 0 Gore Tex suture Clamps were removed and flow established A thrill was easily palpable Hemostasis was achieved and the wound was irrigated and closed with 3 0 Vicryl subcutaneous suture followed by 4 0 nylon on the skin A sterile dressing was applied The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well Sponge instrument and needle counts were reported as correct Keywords cardiovascular pulmonary angioplasty venous anastomosis patch angioplasty av shunt venous anastomosis av thrombectomy thrombosed arteriovenous vein forearm shunt MEDICAL_TRANSCRIPTION,Description Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection Intercostal nerve block for postoperative pain relief at five levels Medical Specialty Cardiovascular Pulmonary Sample Name Thoracotomy Lobectomy Transcription PREOPERATIVE DIAGNOSES 1 Non small cell carcinoma of the left upper lobe 2 History of lymphoma in remission POSTOPERATIVE DIAGNOSES 1 Non small cell carcinoma of the left upper lobe 2 History of lymphoma in remission PROCEDURE Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection Intercostal nerve block for postoperative pain relief at five levels INDICATIONS FOR THE PROCEDURE This is an 84 year old lady who was referred by Dr A for treatment of her left upper lobe carcinoma The patient has a history of lymphoma and is in remission An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma A mass in the left upper lobe was biopsied with fine needle aspiration and shown to be a primary non small cell carcinoma of the lung PET scan was otherwise negative for spread and resection was advised All the risk and benefits were fully explained to the patient and she elected to proceed as planned She was transferred to rehab for couple of weeks to buildup strength before the surgery PROCEDURE IN DETAIL In the operating room under anesthesia she was prepped and draped suitably Dr B was the staff anesthesiologist Left muscle sparing mini thoracotomy was made The serratus and latissimus muscles were not cut but moved out to the way Access to the chest was obtained through the fifth intercostal space Two Tuffier retractors of right angles provided adequate exposure The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology The parietal pleural reflexion around the hilum was now circumcised and lymph nodes were taken from station 8 and station 5 The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30 2 5 staple gun or and the smaller one were ligated with 2 0 silk The left superior pulmonary vein was transected using a TA30 2 5 staple gun and the fissure was completed using firings of an endo GIA 60 4 8 staple gun Finally the left upper lobe bronchus was transected using a TA30 4 8 staple gun Please note that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe The specimen was delivered and sent to pathology The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe Frozen section showed that the margin was negative The chest was irrigated with warm sterile water and when the left lower lobe inflated there was no air leak A single 32 French chest tube was inserted and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together A 2 Vicryl pericostal sutures were now applied The serratus and latissimus muscles retracted back in place A 19 French Blake drain placed in the subcutaneous tissues and 2 0 Vicryl used for the fat followed by 4 0 Monocryl for the skin The patient was transferred to the ICU in a stable condition Keywords cardiovascular pulmonary upper lobe intercostal nerve block non small cell carcinoma axillary lymph node endo gia latissimus lobectomy lymph node dissection lymphoma pulmonary vein serratus thoracotomy muscle sparing mini thoracotomy upper lobectomy staple gun intercostal MEDICAL_TRANSCRIPTION,Description Left thoracotomy with total pulmonary decortication and parietal pleurectomy Empyema of the chest left Medical Specialty Cardiovascular Pulmonary Sample Name Thoracotomy Pleurectomy Transcription PREOPERATIVE DIAGNOSIS Empyema of the chest left POSTOPERATIVE DIAGNOSIS Empyema of the chest left PROCEDURE Left thoracotomy with total pulmonary decortication and parietal pleurectomy PROCEDURE DETAIL After obtaining the informed consent the patient was brought to the operating room where he underwent a general endotracheal anesthetic using a double lumen endotracheal tube A time out process had been followed and preoperative antibiotics were given The patient was positioned with the left side up for a left thoracotomy The patient was prepped and draped in the usual fashion A posterolateral thoracotomy was performed It included the previous incision The chest was entered through the fifth intercostal space Actually there was a very strong and hard parietal pleura which initially did not allow us to obtain a good exposure and actually the layer was so tough that the pin of the chest retractor broke Thanks to Dr X s ingenuity we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura We aspirated an abundant amount of pus from this cavity The sample was taken for culture and sensitivity Then at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm Once we accomplished that we proceeded to remove the solid exudate that was adhered to the lung Further samples for culture and sensitivity were sent Then we were left with the trapped lung It was trapped by thickened visceral pleura This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively Finally we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened we were able to inflate both the left upper and lower lobes of the lung satisfactorily There was only one area towards the mediastinum that apparently I was not able to fill This area of course was very rigid but any surgery in the direction __________ would have caused __________ injury so I restrained from doing that Two large chest tubes were placed The cavity had been abundantly irrigated with warm saline Then the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure of eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin The chest tubes were affixed to the skin with heavy sutures of silk Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation he was able to be extubated in the operating room Estimated blood loss was about 500 mL The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition Keywords cardiovascular pulmonary total pulmonary decortication pulmonary decortication parietal pleurectomy endotracheal tube chest retractor chest tubes parietal pleura pleurectomy empyema endotracheal thoracotomy pleura chest MEDICAL_TRANSCRIPTION,Description Tilt table test Tilt table test is negative for any evidence of vasovagal orthostasis or vasodepressor syndrome Medical Specialty Cardiovascular Pulmonary Sample Name Tilt Table Test Transcription FINDINGS 1 The patient s supine blood pressure was 153 88 with heart rate of 54 beats per minute 2 There was no significant change in heart rate or blood pressure on 80 degree tilt 3 No symptoms reported during the tilt study CONCLUSION Tilt table test is negative for any evidence of vasovagal orthostasis or vasodepressor syndrome Keywords cardiovascular pulmonary blood pressure tilt table test vasovagal vasodepressor orthostasisNOTE MEDICAL_TRANSCRIPTION,Description Empyema Right thoracotomy total decortication and intraoperative bronchoscopy A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion On CT scan evaluation there is evidence of an entrapped right lower lobe with loculations Medical Specialty Cardiovascular Pulmonary Sample Name Thoracotomy Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Empyema POSTOPERATIVE DIAGNOSIS Empyema PROCEDURE PERFORMED 1 Right thoracotomy total decortication 2 Intraoperative bronchoscopy ANESTHESIA General COMPLICATIONS None ESTIMATED BLOOD LOSS 300 cc FLUIDS 2600 cc IV crystalloid URINE 300 cc intraoperatively INDICATIONS FOR PROCEDURE The patient is a 46 year old Caucasian male who was admitted to ABCD Hospital since 08 14 03 with acute diagnosis of right pleural effusion A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion On CT scan evaluation there is evidence of an entrapped right lower lobe with loculations Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent OPERATIVE PROCEDURE The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department Intraoperative bronchoscopy was performed by Dr Y and evaluation of carina left upper and lower lobes with segmental evidence of diffuse mucous thick secretions which were thoroughly lavaged with sterile saline lavage Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation The right bronchus lower middle and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses lesions or suspicious extrinsic compressions on the bronchi At this point all mucous secretions were thoroughly irrigated and aspirated until the airways were clear Bronchoscope was then removed Vital signs remained stable throughout this portion of the procedure The patient was re intubated by Anesthesia with a double lumen endotracheal tube At this point the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion At this point the right chest was prepped and draped in the usual sterile fashion The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine The first port was placed through this incision intrathoracically A bronchoscope was placed for inspection of the intrathoracic cavity Pictures were taken There is extensive fibrinous exudate noted under parietal and visceral pleura encompassing the lung surface diaphragm and the posterolateral aspect of the right thorax At this point a second port site anteriorly was placed under direct visualization With the aid of the thoracoscopic view a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid Due to the gelatinous nature of the fibrinous exudate there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped Due to the extensive nature of the disease decision was made to open the chest in a formal right thoracotomy fashion Incision was made The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi which was separated with electrocautery down to the anterior 6th rib space The chest cavity was entered with the right lung deflated per Anesthesia at our request Once the intrathoracic cavity was accessed a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe middle and the right lower lobe With the expansion of the lung and reduction of the pleural surface fibrinous extubate warm irrigation was used and the lungs allowed to re expand There was no evidence of gross leakage or bleeding at the conclusion of surgery Full lung re expansion was noted upon re inflation of the lung Two 32 French thoracostomy tubes were placed one anteriorly straight and one posteriorly on the diaphragmatic sulcus The chest tubes were secured in place with 0 silk sutures and placed on Pneumovac suction Next the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running 2 0 Vicryl suture Next subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure Steri Strips were applied along with sterile occlusive dressings The patient was awakened from anesthesia without difficulty and extubated in the operating room The chest tubes were maintained on Pleur Evac suction for full re expansion of the lung The patient was transported to the recovery with vital signs stable Stat portable chest x ray is pending The patient will be admitted to the Intensive Care Unit for close monitoring overnight Keywords cardiovascular pulmonary empyema total decortication intraoperative bronchoscopy intrathoracic cavity fibrinous exudate latissimus dorsi chest tubes pleural effusion bronchoscopy thoracostomy thoracotomy decortication anesthesia pleural MEDICAL_TRANSCRIPTION,Description Left thoracotomy with drainage of pleural fluid collection esophageal exploration and repair of esophageal perforation diagnostic laparoscopy and gastrostomy and radiographic gastrostomy tube study with gastric contrast interpretation Medical Specialty Cardiovascular Pulmonary Sample Name Thoracotomy Esophageal Exploration Transcription PREOPERATIVE DIAGNOSIS Esophageal rupture POSTOPERATIVE DIAGNOSIS Esophageal rupture OPERATION PERFORMED 1 Left thoracotomy with drainage of pleural fluid collection 2 Esophageal exploration and repair of esophageal perforation 3 Diagnostic laparoscopy and gastrostomy 4 Radiographic gastrostomy tube study with gastric contrast interpretation ANESTHESIA General anesthesia INDICATIONS OF THE PROCEDURE The patient is a 47 year old male with a history of chronic esophageal stricture who is admitted with food sticking and retching He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy DETAILS OF THE PROCEDURE After an extensive informed consent discussion process the patient was brought to the operating room He was placed in a supine position on the operating table After induction of general anesthesia and placement of a double lumen endotracheal tube he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll Left chest was prepped and draped in a usual sterile fashion After administration of intravenous antibiotics a left thoracotomy incision was made dissection was carried down to the subcutaneous tissues muscle layers down to the fifth interspace The left lung was deflated and the pleural cavity entered The Finochietto retractor was used to help provide exposure The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed Immediately encountered was left pleural fluid including some purulent fluid Cultures of this were sampled and sent for microbiology analysis The left pleural space was then copiously irrigated A careful expiration demonstrated that the rupture appeared to be sealed There was crepitus within the mediastinal cavity The mediastinum was opened and explored and the esophagus was explored The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area The area was copiously irrigated this provided nice coverage and repair After final irrigation and inspection two chest tubes were placed including a 36 French right angled tube at the diaphragm and a posterior straight 36 French These were secured at the left axillary line region at the skin level with 0 silk The intercostal sutures were used to close the chest wall with a 2 Vicryl sutures Muscle layers were closed with running 1 Vicryl sutures The wound was irrigated and the skin was closed with skin staples The patient was then turned and placed in a supine position A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed A Veress needle was carefully inserted into the abdomen pneumoperitoneum was established in the usual fashion a bladeless 5 mm separator trocar was introduced The laparoscope was introduced A single additional left sided separator trocar was introduced It was not possible to safely pass a nasogastric or orogastric tube pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance The stomach however did have some air insufflation and we were able to place our T fasteners through the anterior abdominal wall and through the anterior gastric wall safely The skin incision was made and the gastric lumen was then accessed with the Seldinger technique Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire 18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated We confirmed that we were in the gastric lumen and the balloon was pulled up creating apposition of the gastric wall and the anterior abdominal wall The T fasteners were all crimped and secured into position As was in the plan the gastrostomy was secured to the skin and into the tube Sterile dressing was applied Aspiration demonstrated gastric content Gastrostomy tube study with interpretation Radiographic gastrostomy tube study with gastric contrast with Keywords cardiovascular pulmonary esophageal rupture thoracotomy drainage of pleural fluid esophageal perforation esophageal exploration laparoscopy gastrostomy pleural fluid diagnostic laparoscopy radiographic gastrostomy gastric lumen gastrostomy tube gastric contrast gastric interpretation abdominal pleural lumen esophageal tube MEDICAL_TRANSCRIPTION,Description Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung Medical Specialty Cardiovascular Pulmonary Sample Name Thoracoscopy Thoracotomy Transcription PREOPERATIVE DIAGNOSES Empyema of the left chest and consolidation of the left lung POSTOPERATIVE DIAGNOSES Empyema of the left chest consolidation of the left lung lung abscesses of the left upper lobe and left lower lobe OPERATIVE PROCEDURE Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses and multiple biopsies of pleura and lung ANESTHESIA General FINDINGS The patient has a complex history which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax There was also noted to be some mild infiltrates of the right lung The patient had a 30 year history of cigarette smoking A chest tube was placed at the other hospital which produced some brownish fluid that had foul odor actually what was thought to be a fecal like odor Then an abdominal CT scan was done which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT The patient was started on antibiotics and was then taken to the operating room where there was to be a thoracoscopy performed The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions but there was bloody mucous in the left main stem bronchus and this was suctioned out This was suctioned out with the addition of the use of saline in the bronchus Following the bronchoscopy a double lumen tube was placed but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day The patient was transferred for continued evaluation and treatment Today the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted These were suctioned but it was enough to produce a temporary obstruction of the left mainstem bronchus Eventually the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that The chest tube tract which was about in the sixth or seventh intercostal space but it was not possible to dissect enough down to get a acceptable visualization through this tract A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout Remarkably the surface of the lower lobe laterally was not completely covered with a fibrotic line but it was more the line anterior and posterior and more of it over the left upper lobe There were many pockets of purulent material which had a gray white appearance to it There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time There seemed to be an abscess that was about 3 cm in dimension all the lateral basilar segment of the lower lobe near the area where the chest tube was placed Many cultures were taken from several areas The most remarkable finding was a large cavity which was probably about 11 cm in dimension containing grayish pus and also caseous like material it was thought to be perhaps necrotic lung tissue perhaps a deposit related to tuberculosis in the cavity The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm PROCEDURE AND TECHNIQUE With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this Therefore the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved but it was clear that we would be unable to complete the procedure by thoracoscopy Therefore posterolateral thoracotomy incision was made entering the pleural space and what is probably the sixth intercostal space Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense Suture ligatures of Prolene were required When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity which appeared to be from pulmonary veins and these were sutured with a tissue pledget of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14 French Foley catheter was passed into the area of the tear and the balloon was inflated which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed The patch was sutured onto the pulmonary artery tear A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity Also on the pulmonary artery repair some material was used and also thrombin Gelfoam and Surgicel After reasonably good hemostasis was established pleural cavity was irrigated with saline As mentioned biopsies were taken from multiple sites on the pleura and on the edge and on the lung Then two 24 Blake chest tubes were placed one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex These were later connected to water seal suction at 40 cm of water with negative pressure Good hemostasis was observed Sponge count was reported as being correct Intercostal nerve blocks at probably the fifth sixth and seventh intercostal nerves was carried out Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib Metallic clip was passed through the rib to facilitate passage of an intracostal suture but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table so that pericostal sutures were used with 1 Vicryl The chest wall was closed with running 1 Vicryl and then 2 0 Vicryl subcutaneous and staples on the skin The chest tubes were connected to water seal drainage with 40 cm of water negative pressure Sterile dressings were applied The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition Keywords cardiovascular pulmonary empyema biopsies bronchus declaudication endothoracic hydropneumothorax left lower lobe left lung left upper lobe mainstem pleura thoracoscopy thoracotomy thoracotomy with declaudication declaudication and drainage double lumen tube sixth intercostal space lung abscesses pleural cavity intercostal space upper lobe double lumen chest tube cavity tube chest lung pulmonary pleural intercostal MEDICAL_TRANSCRIPTION,Description A 26 mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta re implanting the celiac superior mesenteric artery and right renal as an island and the left renal as a 8 mm interposition Dacron graft utilizing left heart bypass and cerebrospinal fluid drainage Medical Specialty Cardiovascular Pulmonary Sample Name Thoracoabdominal Aneurysm Transcription POSTOPERATIVE DIAGNOSIS Type 4 thoracoabdominal aneurysm OPERATION PROCEDURE A 26 mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta re implanting the celiac superior mesenteric artery and right renal as an island and the left renal as a 8 mm interposition Dacron graft utilizing left heart bypass and cerebrospinal fluid drainage DESCRIPTION OF PROCEDURE IN DETAIL Patient was brought to the operating room and put in supine position and general endotracheal anesthesia was induced through a double lumen endotracheal tube Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30 degree angle The left groin abdominal and chest were prepped and draped in a sterile fashion A thoracoabdominal incision was made The 8th interspace was entered The costal margin was divided The retroperitoneal space was entered and bluntly dissected free to the psoas bringing all the peritoneal contents to the midline exposing the aorta The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm It was dissected free circumferentially The aortic bifurcation was dissected free dissecting free both iliac arteries The left inferior pulmonary vein was then dissected free and a pursestring of 4 0 Prolene was placed on this The patient was heparinized Through a stab wound in the center of this a right angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet This was hooked to a venous inflow of left heart bypass machine A pursestring of 4 0 Prolene was placed on the aneurysm and through a stab wound in the center of this an arterial cannula was placed and hooked to outflow Bypass was instituted The aneurysm was cross clamped just above T10 and also cross clamped just below the diaphragm The area was divided at this point A 26 mm graft was then sutured in place with running 3 0 Prolene suture The graft was brought into the diaphragm Clamps were then placed on the iliacs and the pump was shut off The aorta was opened longitudinally going posterior between the left and right renal arteries and it was completely transected at its bifurcation The SMA celiac and right renal artery were then dissected free as a complete island and the left renal was dissected free as a complete Carrell patch The island was laid in the graft for the visceral liner and it was sutured in place with running 4 0 Prolene suture with pledgetted 4 0 Prolene sutures around the circumference The clamp was then moved below the visceral vessels and the clamp on the chest was removed re establishing flow to the visceral vessels The graft was cut to fit the bifurcation and sutured in place with running 3 0 Prolene suture All clamps were removed and flow was re established An 8 mm graft was sutured end to end to the Carrell patch and to the left renal A partial occlusion clamp was placed An area of graft was removed The end of the graft was cut to fit this and sutured in place with running Prolene suture The partial occlusion clamp was removed Protamine was given Good hemostasis was noted The arterial cannula of course had been removed when that part of the aneurysm was removed The venous cannula was removed and oversewn with a 4 0 Prolene suture Good hemostasis was noted A 36 French posterior and a 32 French anterior chest tube were placed The ribs were closed with figure of eight 2 Vicryl The fascial layer was closed with running 1 Prolene subcu with running 2 0 Dexon and the skin with running 4 0 Dexon subcuticular stitch Patient tolerated the procedure well Keywords cardiovascular pulmonary dacron graft thoracoabdominal cerebrospinal thoracoabdominal aneurysm running prolene prolene suture dissected free graft interposition aneurysm dacron cannula bifurcation aorta endotracheal proleneNOTE MEDICAL_TRANSCRIPTION,Description Left mesothelioma focal Left anterior pleural based nodule which was on a thin pleural pedicle with no invasion into the chest wall Medical Specialty Cardiovascular Pulmonary Sample Name Thoracoscopy Thoracotomy Mesothelioma Transcription PREOPERATIVE DIAGNOSIS Left mesothelioma focal POSTOPERATIVE DIAGNOSIS Left pleural based nodule PROCEDURES PERFORMED 1 Left thoracoscopy 2 Left mini thoracotomy with resection of left pleural based mass FINDINGS Left anterior pleural based nodule which was on a thin pleural pedicle with no invasion into the chest wall FLUIDS 800 mL of crystalloid ESTIMATED BLOOD LOSS Minimal DRAINS TUBES CATHETERS 24 French chest tube in the left thorax plus Foley catheter SPECIMENS Left pleural based nodule INDICATION FOR OPERATION The patient is a 59 year old female with previous history of follicular thyroid cancer approximately 40 years ago status post resection with recurrence in the 1980s who had a left pleural based mass identified on chest x ray Preoperative evaluation included a CT scan which showed focal mass CT and PET confirmed anterior lesion Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction In the outpatient setting the patient was willing to proceed PROCEDURE PERFORMED IN DETAIL After informed consent was obtained the patient identified correctly She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty She was sedated and intubated with double lumen endotracheal tube without difficulty She was positioned with left side up Appropriate pressure points were padded The left chest was prepped and draped in the standard surgical fashion The skin incision was made in the posterior axillary line approximately 7th intercostal space with 10 blade taken down through tissues and Bovie electrocautery Pleura was entered There was good deflation of the left lung __________ port was placed followed by the 0 degree 10 mm scope with appropriate patient positioning Posteriorly a pedunculated 2 5 x 3 cm pleural based mass was identified on the anterior chest wall There were thin adhesions to the pleura but no invasion of the chest wall that could be identified The tumor was very mobile and was on a pedunculated stalk approximately 1 5 cm It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion Camera was placed through this port Laparoscopic scissors were placed through the posterior port but it was necessary to have another instrument to provide more tension than just gravity Therefore because of the need to bring the specimen through the chest wall a small 3 cm thoracotomy was made which incorporated the posterior port site This was taken down to the subcutaneous tissue with Bovie electrocautery Periosteal elevator was used to lift the intercostal muscle off The ribs were not spread Through this 3 cm incision both the laparoscopic scissors as well as Prestige graspers could be placed Prestige graspers were used to pull the specimen from the chest wall Care was taken not to injure the capsule The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall Care was taken not to transect the stalk Specimen came off the chest wall very easily There was good hemostasis At this point the EndoCatch bag was placed through the incision Specimen was placed in the bag and then removed from the field There was good hemostasis Camera was removed A 24 French chest tube was placed through the anterior port and secured with 2 0 silk suture The posterior port site was closed 1st with 2 0 Vicryl in a running fashion for the intercostal muscle layer followed by 2 0 closure of the latissimus fascia as well as subdermal suture 4 0 Monocryl was used for the skin followed by Steri Strips and sterile drapes The patient tolerated the procedure well was extubated in the operating room and returned to the recovery room in stable condition Keywords cardiovascular pulmonary mini thoracotomy pleural based mass pleural based nodule chest wall mesothelioma focal pleural chest thoracotomy mesothelioma laparoscopic thoracoscopy MEDICAL_TRANSCRIPTION,Description The patient was originally hospitalized secondary to dizziness and disequilibrium Extensive workup during her first hospitalization was all negative but a prominent feature was her very blunted affect and real anhedonia Medical Specialty Cardiovascular Pulmonary Sample Name Telemetry Monitoring Transcription DIAGNOSES PROBLEMS 1 Orthostatic hypotension 2 Bradycardia 3 Diabetes 4 Status post renal transplant secondary polycystic kidney disease in 1995 5 Hypertension 6 History of basal cell ganglia cerebrovascular event in 2004 with left residual 7 History of renal osteodystrophy 8 Iron deficiency anemia 9 Cataract status post cataract surgery 10 Chronic left lower extremity pain 11 Hyperlipidemia 12 Status post hysterectomy secondary to uterine fibroids PROCEDURES Telemetry monitoring HISTORY FINDINGS HOSPITAL COURSE The patient was originally hospitalized on 04 26 07 secondary to dizziness and disequilibrium Extensive workup during her first hospitalization was all negative but a prominent feature was her very blunted affect and real anhedonia She was transferred briefly to Psychiatry however on the second day in Psychiatry she became very orthostatic and was transferred acutely back to the medicine She briefly was on Cymbalta however this was discontinued when she was transferred back She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued She was able to maintain her pressures then was able to ambulate without difficulty We had wanted to pursue workup for possible causes for autonomic dysfunction however the patient was not interested in remaining in the hospital anymore and left really against our recommendations DISCHARGE MEDICATIONS 1 CellCept 500 mg twice a daily 2 Cyclosporine 25 mg in the morning and 15 mg in the evening 3 Prednisone 5 mg once daily 4 Hydralazine 10 mg four times a day 5 Pantoprazole 40 mg once daily 6 Glipizide 5 mg every morning 7 Aspirin 81 mg once daily FOLLOWUP CARE The patient is to follow up with Dr X in about 1 week s time Keywords cardiovascular pulmonary orthostatic hypotension bradycardia basal cell ganglia cerebrovascular event renal osteodystrophy dizziness disequilibrium telemetry monitoring MEDICAL_TRANSCRIPTION,Description Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula Medical Specialty Cardiovascular Pulmonary Sample Name Tessio Catheter Insertion Transcription OPERATIONS PROCEDURES 1 Insertion of right internal jugular Tessio catheter 2 Placement of left wrist primary submental arteriovenous fistula PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring lines were placed The right neck chest and left arm were prepped and draped in a sterile fashion A small incision was made at the top of the anterior jugular triangle in the right neck Through this small incision the right internal jugular vein was punctured and a guidewire was placed It was punctured a 2nd time and a 2nd guidewire was placed The Tessio catheters were assembled They were measured for length Counter incisions were made on the right chest They were then tunneled through these lateral chest wall incisions to the neck incision burying the Dacron cuffs They were flushed with saline A suture was placed through the guidewire and the guidewire and dilator were removed The arterial catheter was then placed through this and the tear away introducer was removed The catheter aspirated and bled easily It was flushed with saline and capped This was repeated with the venous line It also aspirated easily and was flushed with saline and capped The neck incision was closed with a 4 0 Tycron and the catheters were sutured at the exit sites with 4 0 nylon Dressings were applied An incision was then made at the left wrist The basilic vein was dissected free as was the radial artery Heparin was given 50 mg The radial artery was clamped proximally and distally with a bulldog It was opened with a 11 blade and Potts scissors and stay sutures of 5 0 Prolene were placed The vein was clipped distally divided and spatulated for anastomosis It was sutured to the radial artery with a running 7 0 Prolene suture The clamps were removed Good flow was noted through the artery Protamine was given and the wound was closed with interrupted 3 0 Dexon subcutaneous and a running 4 0 Dexon subcuticular on the skin The patient tolerated the procedure well Keywords cardiovascular pulmonary internal jugular tessio catheter arteriovenous fistula submental tunneled tessio catheter internal jugular radial artery tessio jugular artery catheterNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Thoracentesis Left pleural effusion Left hemothorax Medical Specialty Cardiovascular Pulmonary Sample Name Thoracentesis Transcription PREOPERATIVE DIAGNOSIS Left pleural effusion POSTOPERATIVE DIAGNOSIS Left hemothorax PROCEDURE Thoracentesis PROCEDURE IN DETAIL After obtaining informed consent and having explained the procedure to the patient he was sat at the side of a stretcher in the emergency department His left back was prepped and draped in the usual fashion Xylocaine 1 was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed and then we proceed to draw by hand about 1200 mL blood This blood was nonclotting and it was tested twice Halfway during the procedure the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s Therefore we laid him off his right side while keeping the chest catheter in place At that time I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure Overall besides the described episode the patient tolerated the procedure well and afterwards we took another chest x ray that showed much improvement in the pleural effusion and at that particular time with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not Keywords cardiovascular pulmonary pleural effusion hemothorax thoracentesis chest MEDICAL_TRANSCRIPTION,Description Thoracentesis left Malignant pleural effusion left with dyspnea Medical Specialty Cardiovascular Pulmonary Sample Name Thoracentesis 1 Transcription PREOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea POSTOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea PROCEDURE Thoracentesis left DESCRIPTION OF PROCEDURE The patient was brought to the recovery area of the operating room After obtaining the informed consent the patient s posterior left chest wall was prepped and draped in usual fashion Xylocaine 1 was infiltrated above the seventh intercostal space in the midscapular line Initially I tried to use the thoracentesis set after 1 Xylocaine had been infiltrated but the needle of the system was just too short to reach the pleural cavity due to the patient s very thick chest wall Therefore I had to use a 18 spinal needle which I had to use almost in its entire length to reach the fluid From then on I proceeded manually to withdraw 2000 mL of a light milky fluid The patient tolerated the procedure fairly well but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle At that time it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine At any rate we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation We then thought that if she was doing fine then we will send her home A chest x ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure Keywords cardiovascular pulmonary malignant pleural effusion chest wall pleural effusion dyspnea thoracentesis fluid pleural MEDICAL_TRANSCRIPTION,Description Insertion of a left subclavian Tesio hemodialysis catheter and surgeon interpreted fluoroscopy Medical Specialty Cardiovascular Pulmonary Sample Name Tesio Hemodialysis Catheter Insertion Transcription OPERATION 1 Insertion of a left subclavian Tesio hemodialysis catheter 2 Surgeon interpreted fluoroscopy OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and MAC anesthesia was administered Next the patient s chest and neck were prepped and draped in the standard surgical fashion Lidocaine 1 was used to infiltrate the skin in the region of the procedure Next a 18 gauge finder needle was used to locate the left subclavian vein After aspiration of venous blood Seldinger technique was used to thread a J wire through the needle This process was repeated The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon interpreted fluoroscopy Next the subcutaneous tunnel was created The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff A dilator and sheath were passed over the individual J wires The dilator and wire were removed and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath which was simultaneously withdrawn The process was repeated Both distal tips were noted to be in good position The Tesio hemodialysis catheters were flushed and aspirated without difficulty The catheters were secured at the cuff level with a 2 0 nylon The skin was closed with 4 0 Monocryl Sterile dressing was applied The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords cardiovascular pulmonary needle tesio hemodialysis catheter hemodialysis catheter fluoroscopy catheters catheter tesio hemodialysisNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient is a 4 month old who presented with supraventricular tachycardia and persistent cyanosis Medical Specialty Cardiovascular Pulmonary Sample Name Supraventricular Tachycardia Consult Transcription HISTORY The patient is a 4 month old who presented today with supraventricular tachycardia and persistent cyanosis The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised Parents however did note the patient to be quite dusky since the time of her birth however were reassured by the pediatrician that this was normal The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness some irritability and rapid heart rate Parents do state that she does appear to breathe rapidly tires somewhat with the feeding with increased respiratory effort and diaphoresis The patient is exclusively breast fed and feeding approximately 2 hours Upon arrival at Children s Hospital the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement northwest axis and poor R wave progression possible right ventricular hypertrophy FAMILY HISTORY Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed REVIEW OF SYSTEMS A complete review of systems including neurologic respiratory gastrointestinal genitourinary are otherwise negative PHYSICAL EXAMINATION GENERAL Physical examination that showed a sedated acyanotic infant who is in no acute distress VITAL SIGNS Heart rate of 170 respiratory rate of 65 saturation it is nasal cannula oxygen of 74 with a prostaglandin infusion at 0 5 mcg kg minute HEENT Normocephalic with no bruit detected She had symmetric shallow breath sounds clear to auscultation She had full symmetrical pulses HEART There is normoactive precordium without a thrill There is normal S1 single loud S2 and a 2 6 continuous shunt type of murmur could be appreciated at the left upper sternal border ABDOMEN Soft Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected X RAYS Review of the chest x ray demonstrated a normal situs normal heart size and adequate pulmonary vascular markings There is a prominent thymus An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs a left superior vena cava draining into the left atrium a criss cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left sided morphologic left ventricle The left atrium drained through the tricuspid valve into a right sided morphologic right ventricle There is a large inlet ventricular septal defect as pulmonary atresia The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch There was a small vertical ductus as a sole source of pulmonary artery blood flow The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter Biventricular function is well maintained FINAL IMPRESSION The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function The saturations are now also adequate on prostaglandin E1 RECOMMENDATION My recommendation is that the patient be continued on prostaglandin E1 The patient s case was presented to the cardiothoracic surgical consultant Dr X The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention The patient will require some form of systemic to pulmonary shunt modified pelvic shunt or central shunt as a durable source of pulmonary blood flow Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age These findings and recommendations were reviewed with the parents via a Spanish interpreter Keywords cardiovascular pulmonary congenital heart disease cyanotic ductal dependent pulmonary blood flow ventricular septal defect blood flow supraventricular tachycardia tachycardia ventricular supraventricular shunt heart pulmonary MEDICAL_TRANSCRIPTION,Description Subxiphoid pericardiotomy Symptomatic pericardial effusion The patient had the appropriate inflammatory workup for pericardial effusion however it was nondiagnostic Medical Specialty Cardiovascular Pulmonary Sample Name Subxiphoid Pericardiotomy Transcription PREOPERATIVE DIAGNOSIS Symptomatic pericardial effusion POSTOPERATIVE DIAGNOSIS Symptomatic pericardial effusion PROCEDURE PERFORMED Subxiphoid pericardiotomy ANESTHESIA General via ET tube ESTIMATED BLOOD LOSS 50 cc FINDINGS This is a 70 year old black female who underwent a transhiatal esophagectomy in November of 2003 She subsequently had repeat chest x rays and CT scans and was found to have a moderate pericardial effusion She had the appropriate inflammatory workup for pericardial effusion however it was nondiagnostic Also during that time she had become significantly more short of breath A dobutamine stress echocardiogram was performed which was negative with the exception of the pericardial effusions She had no tamponade physiology INDICATION FOR THE PROCEDURE For therapeutic and diagnostic management of this symptomatic pericardial effusion Risks benefits and alternative measures were discussed with the patient Consent was obtained for the above procedure PROCEDURE The patient was prepped and draped in the usual sterile fashion A 4 cm incision was created in the midline above the xiphoid Dissection was carried down through the fascia and the xiphoid was resected The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium An 0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart This suture was used to retract the pericardium and the pericardium was nicked with 15 blade under direct visualization Serous fluid exited through the pericardium and was sent for culture cytology and cell count etc A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed The heart was visualized and appeared to be contracting well with no evidence of injury to the heart The pericardium was then palpated There was no evidence of studding A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium It was sewn into place with 0 silk suture There was some air leak of the left pleural cavity so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium It was sewn in the similar way to the other chest tube Once again the area was inspected and found to be hemostatic and then closed with 0 Vicryl suture for fascial stitch then 3 0 Vicryl suture in the subcutaneous fat and then 4 0 undyed Vicryl in a running subcuticular fashion The patient tolerated the procedure well Chest tubes were placed on 20 cm of water suction The patient was taken to PACU in stable condition Keywords cardiovascular pulmonary subxiphoid pericardiotomy symptomatic pericardial effusion chest x rays echocardiogram dobutamine pleural cavity chest tube pericardial effusion pericardium inflammatory subxiphoid pericardiotomy heart chest effusion pericardial MEDICAL_TRANSCRIPTION,Description Emergent subxiphoid pericardial window transesophageal echocardiogram Medical Specialty Cardiovascular Pulmonary Sample Name Subxiphoid Pericardial Window Transcription PREOPERATIVE DIAGNOSIS ES 1 Endocarditis 2 Status post aortic valve replacement with St Jude mechanical valve 3 Pericardial tamponade POSTOPERATIVE DIAGNOSIS ES 1 Endocarditis 2 Status post aortic valve replacement with St Jude mechanical valve 3 Pericardial tamponade PROCEDURE 1 Emergent subxiphoid pericardial window 2 Transesophageal echocardiogram ANESTHESIA General endotracheal FINDINGS The patient was noted to have 600 mL of dark bloody fluid around the pericardium We could see the effusion resolve on echocardiogram The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks There was no evidence of endocarditis The mitral valve leaflets moved normally with some mild mitral insufficiency DESCRIPTION OF THE OPERATION The patient was brought to the operating room emergently After adequate general endotracheal anesthesia his chest was prepped and draped in the routine sterile fashion A small incision was made at the bottom of the previous sternotomy incision The subcutaneous sutures were removed The dissection was carried down into the pericardial space Blood was evacuated without any difficulty Pericardial Blake drain was then placed The fascia was then reclosed with interrupted Vicryl sutures The subcutaneous tissues were closed with a running Monocryl suture A subdermal PDS followed by a subcuticular Monocryl suture were all performed The wound was closed with Dermabond dressing The procedure was terminated at this point The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition Keywords cardiovascular pulmonary endocarditis valve replacement st jude echocardiogram transesophageal pericardium blake drain st jude mechanical valve subxiphoid pericardial window pericardial window aortic valve tamponade subxiphoid valve pericardial aortic MEDICAL_TRANSCRIPTION,Description Chest pain Chest wall tenderness occurred with exercise Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Graded Exercise Treadmill Transcription INDICATIONS Chest pain PROCEDURE DONE Graded exercise treadmill stress test STRESS ECG RESULTS The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol The heart rate increased from 68 beats per minute to 178 beats per minute which is 100 of the maximum predicted target heart rate The blood pressure increased from 120 70 to 130 80 The baseline resting electrocardiogram reveals a regular sinus rhythm The tracing is within normal limits Symptoms of chest pain occurred with exercise The pain persisted during the recovery process and was aggravated by deep inspiration Marked chest wall tenderness noted There were no ischemic ST segment changes seen during exercise or during the recovery process CONCLUSIONS 1 Stress test is negative for ischemia 2 Chest wall tenderness occurred with exercise 3 Blood pressure response to exercise is normal Keywords cardiovascular pulmonary stress test blood pressure bruce protocol chest pain graded exercise graded exercise treadmill electrocardiogram ischemia sinus rhythm treadmill chest wall tenderness chest wall stress chest MEDICAL_TRANSCRIPTION,Description Insertion of right subclavian central venous catheter Need for intravenous access status post fall and status post incision and drainage of left lower extremity Medical Specialty Cardiovascular Pulmonary Sample Name Subclavian Central Venous Catheter Insertion Transcription PREOPERATIVE DIAGNOSES 1 Need for intravenous access 2 Status post fall 3 Status post incision and drainage of left lower extremity POSTOPERATIVE DIAGNOSES 1 Need for intravenous access 2 Status post fall 3 Status post incision and drainage of left lower extremity PROCEDURE PERFORMED Insertion of right subclavian central venous catheter SECOND ANESTHESIA Approximately 10 cc of 1 lidocaine ESTIMATED BLOOD LOSS Minimal INDICATIONS FOR PROCEDURE The patient is a 74 year old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries The patient went to OR today for an I D of left lower extremity degloving injury Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested PROCEDURE Informed consent was obtained by the patient and her daughter All risks and benefits of the procedure were explained and all questions were answered The patient was prepped and draped in the normal sterile fashion After landmarks were identified approximately 5 cc of 1 lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid Locator needle was used to correctly cannulate the right internal jugular vein Multiple attempts were made and the right internal jugular vein was unable to be cannulized Therefore we prepared for a right subclavian approach The angle of the clavicle was found and a 22 gauge needle was used to anesthetize approximately 5 cc of 1 lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch The right subclavian vein was then accessed A guidewire was placed with a Cook needle and then the needle was subsequently removed and a 11 blade scalpel was used to nick the skin A dilator sheath was placed over the guidewire and subsequently removed The triple lumen catheter was then placed over the guidewire and advanced to 14 cm All ports aspirated and flushed Good blood return was noted and all ports were flushed well The triple lumen catheter was then secured at 14 cm using 0 silk suture A sterile dressing was then applied A stat portable chest x ray was ordered to check line placement The patient tolerated the procedure well and there were no complications Keywords cardiovascular pulmonary intravenous access incision and drainage subclavian central venous catheter central venous catheter lower extremity venous intravenous lidocaine subclavian needle catheter insertion MEDICAL_TRANSCRIPTION,Description Dobutrex stress test for abnormal EKG Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Dobutrex Transcription INDICATIONS Keywords cardiovascular pulmonary dobutrex stress test abnormal ekg dobutrex inferior abnormality ischemic heart disease ventricle µg kg minute stress test stress MEDICAL_TRANSCRIPTION,Description Thallium stress test for chest pain Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Thallium Transcription INDICATIONS Chest pain STRESS TECHNIQUE Keywords cardiovascular pulmonary chest pain ecg stress thallium stress test aerobic capacity ejection fraction gated tomographic spect system myocardial perfusion thallous chloride ventricle wall motion stress test stress MEDICAL_TRANSCRIPTION,Description Chest pain hypertension Stress test negative for dobutamine induced myocardial ischemia Normal left ventricular size regional wall motion and ejection fraction Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Dobutamine Myoview Transcription INDICATIONS Chest pain hypertension type II diabetes mellitus PROCEDURE DONE Dobutamine Myoview stress test STRESS ECG RESULTS The patient was stressed by dobutamine infusion at a rate of 10 mcg kg minute for three minutes 20 mcg kg minute for three minutes and 30 mcg kg minute for three additional minutes Atropine 0 25 mg was given intravenously eight minutes into the dobutamine infusion The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute QS pattern in leads V1 and V2 and diffuse nonspecific T wave abnormality The heart rate increased from 86 beats per minute to 155 beats per minute which is about 90 of the maximum predicted target heart rate The blood pressure increased from 130 80 to 160 70 A maximum of 1 mm J junctional depression was seen with fast up sloping ST segments during dobutamine infusion No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process MYOCARDIAL PERFUSION IMAGING Resting myocardial perfusion SPECT imaging was carried out with 10 9 mCi of Tc 99m Myoview Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29 2 mCi of Tc 99m Myoview The lung heart ratio is 0 36 Myocardial perfusion images were normal both at rest and with stress Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67 CONCLUSIONS 1 Stress test is negative for dobutamine induced myocardial ischemia 2 Normal left ventricular size regional wall motion and ejection fraction Keywords cardiovascular pulmonary chest pain dobutamine myoview dobutamine myoview stress test spect imaging stress test dobutamine infusion ejection fraction hypertension myocardial ischemia myocardial perfusion ventricular size wall motion dobutamine stress myocardial myoview ischemia ventricular perfusion MEDICAL_TRANSCRIPTION,Description Subxiphoid pericardial window A 10 blade scalpel was used to make an incision in the area of the xiphoid process Dissection was carried down to the level of the fascia using Bovie electrocautery Medical Specialty Cardiovascular Pulmonary Sample Name Subxiphoid Pericardial Window 1 Transcription OPERATION Subxiphoid pericardial window ANESTHESIA General endotracheal anesthesia OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient s family including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the neck and chest were prepped and draped in the standard surgical fashion A 10 blade scalpel was used to make an incision in the area of the xiphoid process Dissection was carried down to the level of the fascia using Bovie electrocautery The xiphoid process was elevated and the diaphragmatic attachments to it were dissected free Next the pericardium was identified The pericardium was opened with Bovie electrocautery Upon entering the pericardium serous fluid was expressed In total cc of fluid was drained A pericardial biopsy was obtained The fluid was sent off for cytologic examination as well as for culture A 24 Blake chest drain was brought out through the skin and placed in the posterior pericardium The fascia was closed with 1 Vicryl followed by 2 0 Vicryl followed by 4 0 PDS in a running subcuticular fashion Sterile dressing was applied Keywords cardiovascular pulmonary xiphoid process pericardium subxiphoid pericardial window endotracheal anesthesia bovie electrocautery subxiphoid pericardial bovie electrocautery subxiphoid window pericardial MEDICAL_TRANSCRIPTION,Description Stress test Adenosine Myoview Ischemic cardiomyopathy Inferoseptal and apical transmural scar Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Adenosine Myoview Transcription INDICATIONS Ischemic cardiomyopathy status post inferior wall myocardial infarction status post left anterior descending PTCA and stenting PROCEDURE DONE Adenosine Myoview stress test STRESS ECG RESULTS The patient was stressed by intravenous adenosine 140 mcg kg minute infused over four minutes The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute Underlying atrial fibrillation noted very wide QRS complexes The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140 80 to 110 70 with adenosine infusion Keywords cardiovascular pulmonary stress test adenosine adenosine myoview stress test ischemic cardiomyopathy spect cardiomyopathy electrocardiogram myocardial infarction stress test adenosine myoview adenosine myoview stress myoview stress test ptca and stenting myoview stress transmural scar adenosine infusion septal motion adenosine myoview myocardial perfusion hypokinesis inferoseptal ischemic myocardial myoview perfusion scan MEDICAL_TRANSCRIPTION,Description Dobutamine stress test for atrial fibrillation Medical Specialty Cardiovascular Pulmonary Sample Name Stress Test Dobutamine Transcription INDICATIONS Atrial fibrillation coronary disease STRESS TECHNIQUE The patient was infused with dobutamine to a maximum heart rate of 142 ECG exhibits atrial fibrillation IMAGE TECHNIQUE The patient was injected with 5 2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system IMAGE ANALYSIS It should be noted that the images are limited slightly by the patient s obesity with a weight of 263 pounds There is normal LV myocardial perfusion The LV systolic ejection fraction is normal at 65 There is normal global and regional wall motion CONCLUSIONS 1 Basic rhythm of atrial fibrillation with no change during dobutamine stress maximum heart rate of 142 2 Normal LV myocardial perfusion 3 Normal LV systolic ejection fraction of 65 4 Normal global and regional wall motion Keywords cardiovascular pulmonary dobutamine stress test atrial fibrillation lv myocardial perfusion lv systolic ejection fraction coronary disease dobutamine ejection fraction gated tomographic spect system thallous chloride wall motion stress fibrillation atrial MEDICAL_TRANSCRIPTION,Description The patient is admitted for shortness of breath continues to do fairly well The patient has chronic atrial fibrillation on anticoagulation INR of 1 72 The patient did undergo echocardiogram which shows aortic stenosis severe The patient does have an outside cardiologist Medical Specialty Cardiovascular Pulmonary Sample Name SOAP Shortness of Breath Transcription SUBJECTIVE The patient is admitted for shortness of breath continues to do fairly well The patient has chronic atrial fibrillation on anticoagulation INR of 1 72 The patient did undergo echocardiogram which shows aortic stenosis severe The patient does have an outside cardiologist I understand she was scheduled to undergo workup in this regard PHYSICAL EXAMINATION VITAL SIGNS Pulse of 78 and blood pressure 130 60 LUNGS Clear HEART A soft systolic murmur in the aortic area ABDOMEN Soft and nontender EXTREMITIES No edema IMPRESSION 1 Status shortness of breath responding well to medical management 2 Atrial fibrillation chronic on anticoagulation 3 Aortic stenosis RECOMMENDATIONS 1 Continue medications as above 2 The patient would like to follow with her cardiologist regarding aortic stenosis She may need a surgical intervention in this regard which I explained to her The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days In the interim if she changes her mind or if she has any concerns I have requested to call me back Keywords cardiovascular pulmonary shortness of breath medical management atrial fibrillation aortic stenosis atrial fibrillation breath stenosis cardiologist aortic anticoagulation inr MEDICAL_TRANSCRIPTION,Description Chest Single view post OP for ASD Atrial Septal Defect Medical Specialty Cardiovascular Pulmonary Sample Name Single Frontal View of Chest Transcription EXAM Single frontal view of the chest HISTORY Atelectasis Patient is status post surgical correction for ASD TECHNIQUE A single frontal view of the chest was evaluated and correlated with the prior film dated mm dd yy FINDINGS Current film reveals there is a right sided central venous catheter the distal tip appears to be in the superior vena cava Endotracheal tube with the distal tip appears to be in appropriate position approximately 2 cm superior to the carina Sternotomy wires are noted They appear in appropriate placement There are no focal areas of consolidation to suggest pneumonia Once again seen is minimal amount of bilateral basilar atelectasis The cardiomediastinal silhouette appears to be within normal limits at this time No evidence of any pneumothoraces or pleural effusions IMPRESSION 1 There has been interval placement of a right sided central venous catheter endotracheal tube and sternotomy wires secondary to patient s most recent surgical intervention 2 Minimal bilateral basilar atelectasis with no significant interval changes from the patient s most recent prior 3 Interval decrease in the patient s heart size which may be secondary to the surgery versus positional and technique Keywords cardiovascular pulmonary atrial septal defect central venous catheter bilateral basilar atelectasis single frontal view distal tip endotracheal tube sternotomy wires basilar atelectasis atrial venous catheter endotracheal tube sternotomy atelectasis chest asd MEDICAL_TRANSCRIPTION,Description Pulmonary disorder with lung mass pleural effusion and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder The patient is admitted for lung mass and also pleural effusion The patient had a chest tube placement which has been taken out The patient has chronic atrial fibrillation on anticoagulation Medical Specialty Cardiovascular Pulmonary Sample Name SOAP Lung Mass Transcription SUBJECTIVE The patient is admitted for lung mass and also pleural effusion The patient had a chest tube placement which has been taken out The patient has chronic atrial fibrillation on anticoagulation The patient is doing fairly well This afternoon she called me because heart rate was in the range of 120 to 140 The patient is lying down She does have shortness of breath but denies any other significant symptoms PAST MEDICAL HISTORY History of mastectomy chest tube placement and atrial fibrillation chronic MEDICATIONS 1 Cardizem which is changed to 60 mg p o t i d 2 Digoxin 0 25 mg daily 3 Coumadin adjusted dose 4 Clindamycin PHYSICAL EXAMINATION VITAL SIGNS Pulse 122 and blood pressure 102 68 LUNGS Air entry decreased HEART PMI is displaced S1 and S2 are irregular ABDOMEN Soft and nontender IMPRESSION 1 Pulmonary disorder with lung mass 2 Pleural effusion 3 Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder RECOMMENDATIONS 1 From cardiac standpoint follow with pulmonary treatment 2 The patient has an INR of 2 09 She is on anticoagulation Atrial fibrillation is chronic with the rate increased Adjust the medications accordingly as above Keywords cardiovascular pulmonary lung mass pleural effusion chest tube placement chest tube pulmonary disorder atrial fibrillation chest anticoagulation effusion lung pulmonary atrial fibrillation MEDICAL_TRANSCRIPTION,Description Insertion of a 8 Shiley tracheostomy tube A 10 blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch Dissection was carried down using Bovie electrocautery to the level of the trachea Medical Specialty Cardiovascular Pulmonary Sample Name Shiley Tracheostomy Tube Insertion Transcription OPERATION Insertion of a 8 Shiley tracheostomy tube ANESTHESIA General endotracheal anesthesia OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient s family including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next a 10 blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch Dissection was carried down using Bovie electrocautery to the level of the trachea The 2nd tracheal ring was identified Next a 11 blade scalpel was used to make a trap door in the trachea The endotracheal tube was backed out A 8 Shiley tracheostomy tube was inserted and tidal CO2 was confirmed when it was connected to the circuit We then secured it in place using 0 silk suture A sterile dressing was applied The patient tolerated the procedure well Keywords cardiovascular pulmonary tracheostomy shiley tracheostomy tube sternal notch bovie electrocautery tracheostomy tube electrocautery endotracheal shiley tube MEDICAL_TRANSCRIPTION,Description Repair of total anomalous pulmonary venous connection ligation of patent ductus arteriosus repair secundum type atrial septal defect autologous pericardial patch subtotal thymectomy and insertion of peritoneal dialysis catheter Medical Specialty Cardiovascular Pulmonary Sample Name Septal Defect Repair Transcription TITLE OF OPERATION 1 Repair of total anomalous pulmonary venous connection 2 Ligation of patent ductus arteriosus 3 Repair secundum type atrial septal defect autologous pericardial patch 4 Subtotal thymectomy 5 Insertion of peritoneal dialysis catheter INDICATION FOR SURGERY This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection Following initial stabilization she was transferred to the Hospital for complete correction PREOP DIAGNOSIS 1 Total anomalous pulmonary venous connection 2 Atrial septal defect 3 Patent ductus arteriosus 4 Operative weight less than 4 kilograms 3 2 kilograms COMPLICATIONS None CROSS CLAMP TIME 63 minutes CARDIOPULMONARY BYPASS TIME MONITOR 35 minutes profound hypothermic circulatory arrest time 4 plus 19 equals 23 minutes Low flow perfusion 32 minutes FINDINGS Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left sided veins Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence Nonobstructed ascending vein ligated Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin At completion of the procedure right ventricular pressure approximating one half of systemic normal sinus rhythm good biventricular function by visual inspection PROCEDURE After the informed consent the patient was brought to the operating room and placed on the operating room table in supine position Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines The patient was prepped and draped in the usual sterile fashion from chin to groins A median sternotomy incision was performed Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw A subtotal thymectomy was performed Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure Pursestrings were deployed on the ascending aorta on the right Atrial appendage The aorta was then cannulated with an 8 French aorta cannula and the right atrium with an 18 French Polystan right angle cannula With an ACT greater than 400 greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2 0 silk tie Systemic cooling was started and the head was packed and iced and systemic steroids were administered During cooling traction suture was placed in the apex of the left ventricle After 25 minutes of cooling the aorta was cross clamped and the heart arrested by administration of 30 cubic centimeter kilogram of cold blood cardioplegia delivered directly within the aortic root following the aorta cross clamping Following successful cardioplegic arrest a period of low flow perfusion was started and a 10 French catheter was inserted into the right atrial appendage substituting the 18 French Polystan venous cannula The heart was then rotated to the right side and the venous confluence was exposed It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed The two openings were then anastomosed in an end to side fashion with several interlocking sutures to avoid pursestring effect with a running 7 0 PDS suture Following completion of the anastomosis the heart was returned into the chest and the patient s blood volume was drained into the reservoir A right atriotomy was then performed during the period of circulatory arrest The atrial septal defect was very difficult to expose but it was sealed with an autologous pericardial patch was secured in place with a running 6 0 Prolene suture The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6 0 Prolene sutures The venous cannula was reinserted Cardiopulmonary bypass restarted and the aorta cross clamp was released The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which following a prolonged period of rewarming allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15 French Blake drains Venous decannulation was followed by aortic decannulation and administration of protamine sulfate All cannulation sites were oversewn with 6 0 Prolene sutures and the anastomotic sites noticed to be hemostatic With good hemodynamics and hemostasis the sternum was then smeared with vancomycin placing closure with stainless steel wires The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred in very stable condition to the pediatric intensive care unit I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Given the magnitude of the operation the unavailability of an appropriate level cardiac surgical resident Mrs X attending pediatric cardiac surgery at the Hospital participated during the cross clamp time of the procedure in quality of first assistant Keywords cardiovascular pulmonary total anomalous pulmonary venous connection patent ductus arteriosus ligation secundum type atrial septal defect atrial septal defect subtotal thymectomy peritoneal dialysis catheter cross clamp cardiopulmonary bypass pulmonary venous atrial septal septal defect anomalous venous atrial arteriosus patent ductus septal aorta pulmonary MEDICAL_TRANSCRIPTION,Description The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission Medical Specialty Cardiovascular Pulmonary Sample Name Shortness Of Breath Progress Note Transcription She was evaluated this a m and was without any significant clinical change Her white count has been improving and down to 12 000 A chest x ray obtained today showed some bilateral infiltrates but no acute cardiopulmonary change There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia She has been on Zosyn for the infection Throughout her hospitalization we have been trying to adjust her pain medications She states that the methadone did not work for her She was immune to oxycodone She had been on tramadol before and was placed back on that There was some question that this may have been causing some dizziness She also was on clonazepam and alprazolam for the underlying bipolar disorder Apparently her husband was in this afternoon He had a box of her pain medications It is unclear whether she took a bunch of these or precisely what happened I was contacted that she was less responsive She periodically has some difficulty to arouse due to pain medications which she has been requesting repeatedly though at times does not appear to have objective signs of ongoing pain The nurse found her and was unable to arouse her at this point There was a concern that she had taken some medications from home She was given Narcan and appeared to come around some Breathing remained somewhat labored and she had some diffuse scattered rhonchi which certainly changed from this a m Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity With O2 via mask oxygenation was stable at 90 to 95 after initial hypoxia was noted A chest x ray was obtained at this time An ECG was obtained which shows a sinus tachycardia noted to have ischemic abnormalities In light of the acute decompensation she was then transferred to the ICU We will continue the IV Zosyn Respiratory protocol with respiratory management Continue alprazolam p r n but avoid if she appears sedated We will attempt to avoid additional pain medications but we will continue with the Dilaudid for time being I suspect she will need something to control her bipolar disorder Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission At this juncture she does not appear to need an intubation Pending chest x ray she may require additional IV furosemide Keywords cardiovascular pulmonary shortness of breath pulmonary medicine bipolar disorder icuNOTE MEDICAL_TRANSCRIPTION,Description Ligation and stripping of left greater saphenous vein to the level of the knee Stripping of multiple left lower extremity varicose veins Varicose veins Medical Specialty Cardiovascular Pulmonary Sample Name Saphenous Vein Ligation Stripping Transcription PREOPERATIVE DIAGNOSIS Varicose veins POSTOPERATIVE DIAGNOSIS Varicose veins PROCEDURE PERFORMED 1 Ligation and stripping of left greater saphenous vein to the level of the knee 2 Stripping of multiple left lower extremity varicose veins ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS Approximately 150 mL SPECIMENS Multiple veins COMPLICATIONS None BRIEF HISTORY This is a 30 year old Caucasian male who presented for elective evaluation from Dr X s office for evaluation of intractable pain from the left lower extremity The patient has had painful varicose veins for number of years He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins It was recommended that the patient undergo a saphenous vein ligation and stripping He was explained the risks benefits and complications of the procedure including intractable pain He gave informed consent to proceed OPERATIVE FINDINGS The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region The vein was stripped from the saphenofemoral junction to the level of the knee Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly Additionally there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult OPERATIVE PROCEDURE The patient was marked preoperatively in the Preanesthesia Care Unit The patient was brought to the operating suite placed in the supine position The patient underwent general endotracheal intubation After adequate anesthesia was obtained the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline A diagonal incision was created in the direction of the inguinal crease on the left A self retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified The vein was isolated with a right angle The vein was followed proximally until a multiple tributary branches were identified These were ligated with 3 0 silk suture The dissection was then carried to the femorosaphenous vein junction This was identified and 0 silk suture was placed proximally and distally and ligated in between The proximal suture was tied down Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein An incision was created at the level of the knee The distal segment of the greater saphenous vein was identified and the left foot was encircled with 0 silk suture and tied proximally and then ligated The distal end of the vein stripping device was then passed through at its most proximal location The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity Next attention was made towards the multiple tributaries of the varicose vein within the left lower leg Multiple incisions were created with a 15 blade scalpel The incisions were carried down with electrocautery Next utilizing sharp dissection with a hemostat the tissue was spread until the vein was identified The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed Additionally some segments were removed The stripping approach would be vein stripping device Multiple branches of the saphenous vein were then ligated and or removed Occasionally dissection was unable to be performed as the vein was too friable and would tear from the hemostat Bleeding was controlled with direct pressure All incisions were then closed with interrupted 3 0 Vicryl sutures and or 4 0 Vicryl sutures The femoral incision was closed with interrupted multiple 3 0 Vicryl sutures and closed with a running 4 0 subcuticular suture The leg was then cleaned dried and then Steri Strips were placed over the incisions The leg was then wrapped with a sterile Kerlix Once the Kerlix was achieved an Ace wrap was placed over the left lower extremity for compression The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit Keywords cardiovascular pulmonary varicose veins saphenous vein stripping ligation vein stripping lower extremity saphenous varicose vein ligated MEDICAL_TRANSCRIPTION,Description Selective coronary angiography coronary angioplasty Acute non ST elevation MI Medical Specialty Cardiovascular Pulmonary Sample Name Selective Coronary Angiography Angioplasty Transcription PREOPERATIVE DIAGNOSIS AND INDICATIONS Acute non ST elevation MI POSTOPERATIVE DIAGNOSIS AND SUMMARY The patient presented with an acute non ST elevation MI Despite medical therapy she continued to have intermittent angina Angiography demonstrated the severe LAD as the culprit lesion This was treated as noted above with angioplasty alone as the stent could not be safely advanced She has residual lesions of 75 in the proximal right coronary and 60 proximal circumflex and the other residual LAD lesions as noted above She will be continued on her medical therapy At age 90 she is not a good candidate for aortic valve replacement and coronary bypass grafting PROCEDURE PERFORMED Selective coronary angiography coronary angioplasty PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the cath lab placed on the table in the supine position The area of the right femoral artery was prepped and draped in a sterile fashion Using the percutaneous technique a 6 French sheath was placed in the right femoral artery under fluoroscopic guidance With the guidewire in place a 5 French JL 4 catheter was used to selectively angiogram the left coronary system The catheter was removed The sheath flushed The 5 French 3DRC catheter was then used to selectively angiogram the right coronary artery The cath removed the sheath flushed It was decided that intervention was needed in the severe lesions in the LAD which appeared to be the culprit lesions for the non ST elevation MI The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained we rebolused and the ACT was slightly lower We repeated the level and it was slightly higher We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV Additionally the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started A 6 French CLS 3 5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal An Apex 2 5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated Angiography was then performed demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium The balloon was inflated and removed repeat angiography performed We attempted to advance a Driver 2 5 x 24 mm bare metal stent but I could not advance it beyond the proximal LAD where there was significant calcification The stent was removed Attempts to advance the same 2 5 x 15 mm Apex balloon that was previously used were unsuccessful It was removed a new Apex 2 5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed Repeat angiography demonstrated no evidence of dissection One more attempt was made to advance the Driver 2 5 x 24 mm bare metal stent but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal I felt that further attempts in this calcified vessel in a 90 year old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection so the stent was removed The guidewires and guide cath were removed The sheath flushed and sutured into position The patient moved to ICU in stable condition with no chest discomfort at all CONTRAST Isovue 370 120 mL FLUORO TIME 9 4 minutes ESTIMATED BLOOD LOSS 30 mL HEMODYNAMICS Aorta 185 54 Left ventriculography was not performed I did not make an attempt to cross this severely stenotic aortic valve The left main is a large vessel giving rise to LAD and circumflex vessels The left main has no significant disease other than calcification in the walls The LAD is a moderate to large vessel giving rise to small diagonals and then a moderate to large third diagonal and then a small fourth diagonal The LAD has significant calcification proximally There is a 50 stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent This resulted in a 30 residual mostly eccentric calcified plaque Following this there was a 50 stenosis in the LAD just after the takeoff of the third diagonal This was not ballooned Beyond this is an 80 stenosis prior to the fourth diagonal and then a 99 stenosis after the fourth diagonal These 2 lesions were dilated with 10 residual prior to the fourth diagonal and 25 residual distal to the fourth diagonal As noted above this area was not stented because I could not safely advance the stent Note there was also a 50 stenosis at the origin of the moderate to large third diagonal that did not change with angioplasty The circumflex is a large nondominant vessel consisting of a large obtuse marginal with multiple branches The proximal circumflex has an eccentric 60 stenosis prior to the takeoff of the obtuse marginal The remainder of the vessel was without significant disease The right coronary was a large dominant vessel giving rise to a large posterior descending artery and small to moderate first posterolateral small second posterolateral and a small to moderate third posterolateral branch The right coronary has an eccentric smooth 75 stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch The remainder of the right coronary and its branches were without significant disease Keywords cardiovascular pulmonary non st elevation mi selective coronary angiography coronary angioplasty calcified plaque coronary angiography st elevation stenosis lad coronary selective angiography angioplasty balloon vessel stent MEDICAL_TRANSCRIPTION,Description Elevated cardiac enzymes fullness in chest abnormal EKG and risk factors No evidence of exercise induced ischemia at a high myocardial workload This essentially excludes obstructive CAD as a cause of her elevated troponin Medical Specialty Cardiovascular Pulmonary Sample Name Radionuclide Stress Test Transcription INDICATION FOR STUDY Elevated cardiac enzymes fullness in chest abnormal EKG and risk factors MEDICATIONS Femara verapamil Dyazide Hyzaar glyburide and metformin BASELINE EKG Sinus rhythm at 84 beats per minute poor anteroseptal R wave progression mild lateral ST abnormalities EXERCISE RESULTS 1 The patient exercised for 3 minutes stopping due to fatigue No chest pain 2 Heart rate increased from 84 to 138 or 93 of maximum predicted heart rate Blood pressure rose from 150 88 to 210 100 There was a slight increase in her repolorization abnormalities in a non specific pattern NUCLEAR PROTOCOL Same day rest stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test NUCLEAR RESULTS 1 Nuclear perfusion imaging review of the raw projection data reveals adequate image acquisition The resting images showed decreased uptake in the anterior wall However the apex is spared of this defect There is no significant change between rest and stress images The sum score is 0 2 The Gated SPECT shows moderate LVH with slightly low EF of 48 IMPRESSION 1 No evidence of exercise induced ischemia at a high myocardial workload This essentially excludes obstructive CAD as a cause of her elevated troponin 2 Mild hypertensive cardiomyopathy with an EF of 48 3 Poor exercise capacity due to cardiovascular deconditioning 4 Suboptimally controlled blood pressure on today s exam Keywords cardiovascular pulmonary sinus rhythm cardiac enzymes abnormal ekg stress test elevated troponin heart rate blood pressure radionuclide chest ekg stress ischemia MEDICAL_TRANSCRIPTION,Description Pulmonary function test Mild restrictive airflow limitation Clinical correlation is recommended Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test 5 Transcription OBSERVATIONS FEV1 is 3 76 103 predicted FVC is 4 98 110 predicted Ratio is 75 FEF 25 75 is 3 053 82 predicted postbronchodilator improves by 35 DLCO is 35 121 predicted Residual volume is 3 04 139 predicted Total lung capacity is 8 34 120 predicted Flow volume loop reviewed INTERPRETATION Mild restrictive airflow limitation Clinical correlation is recommended Keywords cardiovascular pulmonary fev1 fvc fef dlco lung capacity postbronchodilator pulmonary function test restrictive airflowNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 16 year old male with Q fever endocarditis Medical Specialty Cardiovascular Pulmonary Sample Name Q Fever Endocarditis Transcription HISTORY OF PRESENT ILLNESS This is a follow up visit on this 16 year old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q fever endocarditis He is also taking digoxin aspirin warfarin and furosemide Mother reports that he does have problems with 2 3 loose stools per day since September but tolerates this relatively well This has not increased in frequency recently Mark recently underwent surgery at Children s Hospital and had on 10 15 2007 replacement of pulmonary homograft valve resection of a pulmonary artery pseudoaneurysm and insertion of Gore Tex membrane pericardial substitute He tolerated this procedure well He has been doing well at home since that time PHYSICAL EXAMINATION VITAL SIGNS Temperature is 98 5 pulse 84 respirations 19 blood pressure 101 57 weight 77 7 kg and height 159 9 cm GENERAL APPEARANCE Well developed well nourished slightly obese slightly dysmorphic male in no obvious distress HEENT Remarkable for the badly degenerated left lower molar Funduscopic exam is unremarkable NECK Supple without adenopathy CHEST Clear including the sternal wound CARDIOVASCULAR A 3 6 systolic murmur heard best over the upper left sternal border ABDOMEN Soft He does have an enlarged spleen however given his obesity I cannot accurately measure its size GU Deferred EXTREMITIES Examination of extremities reveals no embolic phenomenon SKIN Free of lesions NEUROLOGIC Grossly within normal limits LABORATORY DATA Doxycycline level obtained on 10 05 2007 as an outpatient was less than 0 5 Hydroxychloroquine level obtained at that time was undetectable Of note is that doxycycline level obtained while in the hospital on 10 21 2007 was 6 5 mcg mL Q fever serology obtained on 10 05 2007 was positive for phase I antibodies in 1 2 6 and phase II antibodies at 1 128 which is an improvement over previous elevated titers Studies on the pulmonary valve tissue removed at surgery are pending IMPRESSION Q fever endocarditis PLAN 1 Continue doxycycline and hydroxychloroquine I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications She assures me that he is compliant with his medications We will however repeat his hydroxychloroquine and doxycycline levels 2 Repeat Q fever serology 3 Comprehensive metabolic panel and CBC 4 Return to clinic in 4 weeks 5 Clotting times are being followed by Dr X Keywords cardiovascular pulmonary q fever q fever endocarditis endocarditis doxycycline fever MEDICAL_TRANSCRIPTION,Description Pulmonary valve stenosis supple pulmonic narrowing and static encephalopathy Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Valve Stenosis Transcription HISTORY The patient is a 19 year old boy with a membranous pulmonary atresia underwent initial repair 12 04 1987 consisting of pulmonary valvotomy and placement of 4 mm Gore Tex shunt between the ascending aorta and pulmonary artery with a snare This was complicated by shunt thrombosis __________ utilizing a 10 mm balloon Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy On 04 07 1988 he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10 mm balloon He has been followed conservatively since that time A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg Right coronary artery to pulmonary artery fistula was also appreciated The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair PROCEDURE The patient was placed under general endotracheal anesthesia breathing on 30 oxygen throughout the case Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a 7 French sheath a 6 French wedge catheter was inserted The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries This catheter was then exchanged over wire for a 5 French marker pigtail catheter which was directed into the main pulmonary artery Using a 5 French sheath a 5 French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta ascending aorta and left ventricle This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the recovery room in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was normal with no evidence of intracardiac shunt Left sided heart was fully saturated Phasic right atrial pressures were normal with an A wave similar to the normal right ventricular end diastolic pressure Right ventricular systolic pressure was mildly elevated at 45 systemic level There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries Phasic branch pulmonary artery pressures were normal Right to left pulmonary artery capillary wedge pressures were normal with an A wave similar to the normal left ventricular end diastolic pressure of 12 mmHg Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta Phasic ascending and descending pressures were similar and normal The calculated systemic and pulmonary flows were equal and normal Vascular resistances were normal Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus The pulmonary valve appeared to be thin and moved well The median branch pulmonary arteries were of good size with normal distal arborization Angiogram with contrast injection in the right coronary artery showed a non dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery INITIAL DIAGNOSES 1 Membranous pulmonary atresia 2 Atrial septal defect 3 Right coronary artery to pulmonary artery fistula SURGERIES INTERVENTIONS 1 Pulmonary valvotomy surgical 2 Aortopulmonary artery central shunt 3 Balloon pulmonary valvuloplasty CURRENT DIAGNOSES 1 Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus 2 Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing 3 Small right coronary artery to main pulmonary fistula 4 Static encephalopathy 5 Cerebral palsy MANAGEMENT The case to be discussed with combined Cardiology Cardiothoracic Surgery case conference Given the mild degree of outflow tract obstruction in this sedentary patient aggressive intervention is not indicated Conservative outpatient management is to be recommended Further patient care will be directed by Dr X Keywords cardiovascular pulmonary membranous pulmonary atresia atrial septal defect pulmonary artery fistula pulmonary valvotomy central shunt pulmonary valvuloplasty static encephalopathy cerebral palsy hypoplastic pulmonary annulus pulmonary valve stenosis outflow tract obstruction ventricular systolic pressure branch pulmonary arteries systolic pressure pulmonary arteries pulmonary valve branch pulmonary coronary artery catheterization artery pulmonary pressures coronary MEDICAL_TRANSCRIPTION,Description Increasing oxygen requirement Baby boy has significant pulmonary hypertension Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Hypertension Pediatric Consult Transcription INDICATION FOR CONSULTATION Increasing oxygen requirement HISTORY Baby boy XYZ is a 29 3 7 week gestation infant His mother had premature rupture of membranes on 12 20 08 She then presented to the Labor and Delivery with symptoms of flu The baby was then induced and delivered The mother had a history of premature babies in the past This baby was doing well and then we had a significant increasing oxygen requirement from room air up to 85 He is now on 60 FiO2 PHYSICAL FINDINGS GENERAL He appears to be pink well perfused and slightly jaundiced VITAL SIGNS Pulse 156 56 respiratory rate 92 sat and 59 28 mmHg blood pressure SKIN He was pink He was on the high frequency ventilator with good wiggle His echocardiogram showed normal structural anatomy He has evidence for significant pulmonary hypertension A large ductus arteriosus was seen with bidirectional shunt A foramen ovale shunt was also noted with bidirectional shunt The shunting for both the ductus and the foramen ovale was equal left to right and right to left IMPRESSION My impression is that baby boy XYZ has significant pulmonary hypertension The best therapy for this is to continue oxygen If clinically worsens he may require nitric oxide Certainly Indocin should not be used at this time He needs to have lower pulmonary artery pressures for that to be considered Thank you very much for allowing me to be involved in baby XYZ s care Keywords cardiovascular pulmonary high frequency ventilator structural anatomy foramen ovale oxygen requirement hypertension pulmonary MEDICAL_TRANSCRIPTION,Description Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Medicine Clinic Followup Transcription SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema She was last seen in the clinic in March 2004 Since that time she has been hospitalized for psychiatric problems and now is in a nursing facility She is very frustrated with her living situation and would like to return to her own apartment however some believes she is to ill to care for herself At the present time respiratory status is relatively stable She is still short of breath with activity but all in all her pulmonary disease has not changed significantly since her last visit She does have occasional cough and a small amount of sputum production No fever or chills No chest pains CURRENT MEDICATIONS The patient s current medications are as outlined ALLERGIES TO MEDICATIONS Erythromycin REVIEW OF SYSTEMS Significant for problems with agitated depression Her respiratory status is unchanged as noted above EXAMINATION General The patient is in no acute distress Vital signs Blood pressure is 152 80 pulse 80 and respiratory rate 16 HEENT Nasal mucosa was mild to moderately erythematous and edematous Oropharynx was clear Neck Supple without palpable lymphadenopathy Chest Chest demonstrates decreased breath sounds throughout all lung fields coarse but relatively clear Cardiovascular Distant heart tones Regular rate and rhythm Abdomen Soft and nontender Extremities Without edema Oxygen saturation was checked today on room air at rest it was 90 ASSESSMENT 1 Chronic obstructive pulmonary disease emphysema severe but stable 2 Mild hypoxemia however oxygen saturation at rest is stable without supplemental oxygen 3 History of depression and schizophrenia PLAN At this point I have recommended that she continue current respiratory medicine I did suggest that she would not use her oxygen when she is simply sitting watching television or reading I have recommended that she use it with activity and at night I spoke with her about her living situation Encouraged her to speak with her family as well as primary care physician about making efforts for her to return to her apartment Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be Keywords cardiovascular pulmonary respiratory copd chronic obstructive pulmonary disease pulmonary medicine clinic depression emphysema followup hypoxemia oxygen schizophrenia oxygen saturation pulmonary medicine medicine clinic chest medicine pulmonary MEDICAL_TRANSCRIPTION,Description Sample of Pulmonary Function Test Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test 4 Transcription SPIROMETRY Spirometry reveals the FVC to be adequate FEV1 is also adequate 93 predicted FEV1 FVC ratio is 114 predicted which is normal and FEF25 75 is 126 predicted After the use of bronchodilator there is no significant improvement of the abovementioned parameters MVV is also normal LUNG VOLUMES Reveal a TLC to be 80 predicted FRC is mildly decreased and RV is also mildly decreased RV TLC ratio is also normal 97 predicted DIFFUSION CAPACITY After correction for alveolar ventilation is 112 predicted which is normal OXYGEN SATURATION ON ROOM AIR 98 FINAL INTERPRETATION Pulmonary function test shows mild restrictive pulmonary disease There is no significant obstructive disease present There is no improvement after the use of bronchodilator and diffusion capacity is normal Oxygen saturation on room air is also adequate Clinical correlation will be necessary in this case Keywords cardiovascular pulmonary fev1 fev1 fvc fvc fef25 frc lung volumes saturation on room air pulmonary function test diffusion capacity oxygen saturation pulmonary function function test spirometry fev bronchodilator diffusion capacity oxygen saturation pulmonary MEDICAL_TRANSCRIPTION,Description Pulmonary Function Test in a patient with smoking history Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test 1 Transcription HISTORY Smoking history 50 pack years of smoking INDICATION Dyspnea PROCEDURE FVC was 59 FEV1 was 45 FEV1 FVC ratio was 52 The predicted was 67 FEF 25 75 was 22 improved about 400 cc which represents 89 improvement with bronchodilator SVC was 91 Inspiratory capacity was 70 Residual volume was 225 of its predicted Total lung capacity was 128 IMPRESSION 1 Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element 2 Probably there is some restrictive element because of fibrosis The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume 3 Diffusion capacity was not measured The flow volume loop was consistent with the above Keywords cardiovascular pulmonary pulmonary function test diffusion capacity dyspnea fef fev1 fev1 fvc ratio fvc pft residual volume svc smoking history bronchodilator bronchospastic fibrosis inspiratory capacity lung capacity obstructive lung disease pulmonary function MEDICAL_TRANSCRIPTION,Description Sample of Pulmonary Function Test Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test 3 Transcription SPIROMETRY Spirometry reveals the FVC to be adequate FEV1 is also normal at 98 predicted and FVC is 90 5 predicted FEF25 75 is also within normal limits at 110 predicted FEV1 FVC ratio is within normal limits at 108 predicted After the use of bronchodilator there is some improvement with 10 MVV is within normal limits LUNG VOLUMES Shows total lung capacity to be normal RV as well as RV TLC ratio they are within normal limits DIFFUSION CAPACITY Shows that after correction for alveolar ventilation is also normal Oxygen Saturation on Room Air 98 FINAL INTERPRETATION Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease There is some improvement after the use bronchodilator Diffusion capacity is within normal limits Oxygen saturation on room air is also normal Clinical correlation will be necessary in this case Keywords cardiovascular pulmonary fvc fev1 fev1 fvc ratio fef lung volumes saturation on room air pulmonary function test pulmonary function oxygen saturation spirometry bronchodilator lung diffusion oxygen saturation pulmonary capacity MEDICAL_TRANSCRIPTION,Description Pulmonary function test Mild to moderate obstructive ventilatory impairment Some improvement in the airflows after bronchodilator therapy Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test Transcription OBSERVATIONS The forced vital capacity is 2 84 L and forced expiratory volume in 1 second is 1 93 L The ratio between the two is 68 Small improvement is noted in the airflows after bronchodilator therapy Lung volumes are increased with a residual volume of 196 of predicted and total lung capacity of 142 of predicted Single breath diffusing capacity is slightly reduced IMPRESSION Mild to moderate obstructive ventilatory impairment Some improvement in the airflows after bronchodilator therapy Keywords cardiovascular pulmonary lung volume forced expiratory volume forced vital capacity airflows total lung capacity bronchodilator therapy bronchodilatorNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Patient with complaints of significant coughing and wheezing Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Consultation 2 Transcription PAST MEDICAL HISTORY Unremarkable except for diabetes and atherosclerotic vascular disease ALLERGIES PENICILLIN CURRENT MEDICATIONS Include Glucovance Seroquel Flomax and Nexium PAST SURGICAL HISTORY Appendectomy and exploratory laparotomy FAMILY HISTORY Noncontributory SOCIAL HISTORY The patient is a non smoker No alcohol abuse The patient is married with no children REVIEW OF SYSTEMS Significant for an old CVA PHYSICAL EXAMINATION The patient is an elderly male alert and cooperative Blood pressure 96 60 mmHg Respirations were 20 Pulse 94 Afebrile O2 was 94 on room air HEENT Normocephalic and atraumatic Pupils are reactive Oral mucosa is grossly normal Neck is supple Lungs Decreased breath sounds Disturbed breath sounds with poor exchange Heart Regular rhythm Abdomen Soft and nontender No organomegaly or masses Extremities No cyanosis clubbing or edema LABORATORY DATA Oropharyngeal evaluation done on 11 02 2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses which clear with liquid swallow and double saliva swallow ASSESSMENT 1 Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration 2 Old CVA with left hemiparesis 3 Oropharyngeal dysphagia 4 Diabetes PLAN At the present time the patient is recommended to continue on a regular diet continue speech pathology evaluation as well as perform double swallow during meals with bolus sensation He may use Italian lemon ice during meals to help clear sinuses as well The patient will follow up with you If you need any further assistance do not hesitate to call me Keywords cardiovascular pulmonary pulmonary evaluation cough wheezing congestion coughing and wheezing breath sounds oropharyngeal dysphagia pulmonary breath sounds dysphagia aspiration sinuses oropharyngeal coughing swallowing MEDICAL_TRANSCRIPTION,Description Pulmonary Function Test to evaluate dyspnea Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Function Test 2 Transcription HISTORY Smoking history zero INDICATION Dyspnea with walking less than 100 yards PROCEDURE FVC was 59 FEV1 was 61 FEV1 FVC ratio was 72 The predicted was 70 The FEF 25 75 was 45 improved from 1 41 to 2 04 with bronchodilator which represents a 45 improvement SVC was 69 Inspiratory capacity was 71 Expiratory residual volume was 61 The TGV was 94 Residual volume was 113 of its predicted Total lung capacity was 83 Diffusion capacity was diminished IMPRESSION 1 Moderate restrictive lung disease 2 Some reversible small airway obstruction with improvement with bronchodilator 3 Diffusion capacity is diminished which might indicate extrapulmonary restrictive lung disease 4 Flow volume loop was consistent with the above and no upper airway obstruction Keywords cardiovascular pulmonary pulmonary function test diffusion capacity dyspnea fef fev1 fev1 fvc ratio fvc flow volume loop pft svc smoking history airway obstruction bronchodilator extrapulmonary residual volume restrictive lung disease walking pulmonary function lung disease pulmonary function lung capacity MEDICAL_TRANSCRIPTION,Description Port A Cath insertion template Catheter was inserted after subcutaneous pocket was created the sheath dilators were advanced and the wire and dilator were removed Medical Specialty Cardiovascular Pulmonary Sample Name Port A Cath Insertion Transcription PROCEDURE PERFORMED Port A Cath insertion ANESTHESIA MAC COMPLICATIONS None ESTIMATED BLOOD LOSS Minimal PROCEDURE IN DETAIL Patient was prepped and draped in sterile fashion The left subclavian vein was cannulated with a wire Fluoroscopic confirmation of the wire in appropriate position was performed Then catheter was inserted after subcutaneous pocket was created the sheath dilators were advanced and the wire and dilator were removed Once the catheter was advanced through the sheath the sheath was peeled away Catheter was left in place which was attached to hub placed in the subcutaneous pocket sewn in place with 2 0 silk sutures and then all hemostasis was further reconfirmed No hemorrhage was identified The port was in appropriate position with fluoroscopic confirmation The wound was closed in 2 layers the 1st layer being 3 0 Vicryl the 2nd layer being 4 0 Monocryl subcuticular stitch Dressed with Steri Strips and 4 x 4 s Port was checked Had good blood return flushed readily with heparinized saline Keywords cardiovascular pulmonary hemostasis port a cath insertion fluoroscopic confirmation cath insertion insertion fluoroscopic subcutaneous catheter sheath dilators wire MEDICAL_TRANSCRIPTION,Description Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis Medical Specialty Cardiovascular Pulmonary Sample Name Pulmonary Followup Note Transcription SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis She was last seen in the Pulmonary Medicine Clinic in January 2004 Since that time her respiratory status has been quite good She has had no major respiratory difficulties however starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort She denies any problems with cough or sputum production No fevers or chills Recently she has had a bit more problems with fatigue For the most part she has had no pulmonary limitations to her activity CURRENT MEDICATIONS Synthroid 0 112 mg daily Prilosec 20 mg daily prednisone she was 2 5 mg daily but discontinued this on 06 16 2004 Plaquenil 200 mg b i d Imuran 100 mg daily Advair one puff b i d Premarin 0 3 mg daily Lipitor 10 mg Monday through Friday Actonel 35 mg weekly and aspirin 81 mg daily She is also on calcium vitamin D vitamin E vitamin C and a multivitamin ALLERGIES Penicillin and also intolerance to shellfish REVIEW OF SYSTEMS Noncontributory except as outlined above EXAMINATION General The patient was in no acute distress Vital signs Blood pressure 122 60 pulse 72 and respiratory rate 16 HEENT Nasal mucosa was mild to moderately erythematous and edematous Oropharynx was clear Neck Supple without palpable lymphadenopathy Chest Chest demonstrates decreased breath sounds but clear Cardiovascular Regular rate and rhythm Abdomen Soft and nontender Extremities Without edema No skin lesions O2 saturation was checked at rest On room air it was 96 and on ambulation it varied between 94 and 96 Chest x ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis She has not had the previous chest x ray with which to compare however I did compare the markings was less prominent when compared with previous CT scan ASSESSMENT 1 Lupus with mild pneumonitis 2 Respiratory status is stable 3 Increasing back and joint pain possibly related to patient s lupus however in fact may be related to recent discontinuation of prednisone PLAN At this time I have recommended to continue her current medications We would like to see her back in approximately four to five months at which time I would like to recheck her pulmonary function test as well as check CAT scan At that point it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control Keywords cardiovascular pulmonary pulmonary medicine clinic cat scan lupus respiratory status chest x ray interstitial disease lupus pneumonitis pneumonitis pulmonary function test pulmonary status respiratory difficulties chest x ray interstitial respiratory chest pulmonary MEDICAL_TRANSCRIPTION,Description Insertion of subclavian dual port Port A Cath and surgeon interpreted fluoroscopy Medical Specialty Cardiovascular Pulmonary Sample Name Port A Cath Insertion 5 Transcription PROCEDURES PERFORMED 1 Insertion of subclavian dual port Port A Cath 2 Surgeon interpreted fluoroscopy OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating room and general endotracheal anesthesia was administered Next the chest was prepped and draped in a standard surgical fashion A 18 gauge spinal needle was used to aspirate blood from the subclavian vein After aspiration of venous blood Seldinger technique was used to thread a J wire The distal tip of the J wire was confirmed to be in adequate position with surgeon interpreted fluoroscopy Next a 15 blade scalpel was used to make an incision in the skin Dissection was carried down to the level of the pectoralis muscle A pocket was created A dual port Port A Cath was lowered into the pocket and secured with 2 0 Prolene Both ports were flushed The distal tip was pulled through to the wire exit site with a Kelly clamp It was cut to the appropriate length Next a dilator and sheath were threaded over the J wire The J wire and dilator were removed and the distal tip of the dual port Port A Cath was threaded over the sheath which was simultaneously withdrawn Both ports of the dual port Port A Cath were flushed and aspirated without difficulty The distal tip was confirmed to be in adequate position with surgeon interpreted fluoroscopy The wire access site was closed with a 4 0 Monocryl The port pocket was closed in 2 layers with 2 0 Vicryl followed by 4 0 Monocryl in a running subcuticular fashion Sterile dressing was applied The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords cardiovascular pulmonary surgeon interpreted fluoroscopy j wire dual port port a cath port a cath subclavian fluoroscopy cathNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Atypical pneumonia hypoxia rheumatoid arthritis and suspected mild stress induced adrenal insufficiency This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission Medical Specialty Cardiovascular Pulmonary Sample Name Pneumonia Discharge Summary Transcription ADMISSION DIAGNOSES 1 Pneumonia failed outpatient treatment 2 Hypoxia 3 Rheumatoid arthritis DISCHARGE DIAGNOSES 1 Atypical pneumonia suspected viral 2 Hypoxia 3 Rheumatoid arthritis 4 Suspected mild stress induced adrenal insufficiency HOSPITAL COURSE This very independent 79 year old had struggled with cough fevers weakness and chills for the week prior to admission She was seen on multiple occasions at Urgent Care and in her physician s office Initial x ray showed some mild diffuse patchy infiltrates She was first started on Avelox but had a reaction switched to Augmentin which caused loose stools and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin Her O2 saturations drifted downward They were less than 88 when active at rest varied between 88 and 92 Decision was made because of failed outpatient treatment of pneumonia Her medical history is significant for rheumatoid arthritis She is on 20 mg of methotrexate every week as well as Remicade every eight weeks Her last dose of Remicade was in the month of June Hospital course was relatively unremarkable CT scan was performed and no specific focal pathology was seen Dr X pulmonologist was consulted He also was uncertain as to the exact etiology but viral etiology was most highly suspected Because of her loose stools C difficile toxin was ordered although that is pending at the time of discharge She was continued on Rocephin IV and azithromycin Her fever broke 18 hours prior to discharge and O2 saturations improved as did her overall strength and clinical status She was instructed to finish azithromycin She has two pills left at home She is to follow up with Dr X in two to three days Because she is on chronic prednisone therapy it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia She is to continue the increased dose of prednisone at 20 mg up from 5 mg per day We will consult her rheumatologist as to whether to continue her methotrexate which we held this past Friday Methotrexate is known on some occasions to cause pneumonitis Keywords cardiovascular pulmonary adrenal insufficiency hypoxia cough fevers weakness chills atypical pneumonia loose stools rheumatoid arthritis azithromycin arthritis pneumonia MEDICAL_TRANSCRIPTION,Description Consult for subcutaneous emphysema and a small right sided pneumothorax secondary to trauma Medical Specialty Cardiovascular Pulmonary Sample Name Pneumothorax Subcutaneous Emphysema Transcription REASON FOR CONSULTATION Pneumothorax and subcutaneous emphysema HISTORY OF PRESENT ILLNESS The patient is a 48 year old male who was initially seen in the emergency room on Monday with complaints of scapular pain The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema a small right sided pneumothorax but no other findings The patient was admitted for observation PAST SURGICAL HISTORY Hernia repair and tonsillectomy ALLERGIES Penicillin MEDICATIONS Please see chart REVIEW OF SYSTEMS Not contributory PHYSICAL EXAMINATION GENERAL Well developed well nourished lying on hospital bed in minimal distress HEENT Normocephalic and atraumatic Pupils are equal round and reactive to light Extraocular muscles are intact NECK Supple Trachea is midline CHEST Clear to auscultation bilaterally CARDIOVASCULAR Regular rate and rhythm ABDOMEN Soft nontender and nondistended Normoactive bowel sounds EXTREMITIES No clubbing edema or cyanosis SKIN The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday DIAGNOSTIC STUDIES As above IMPRESSION The patient is a 48 year old male with subcutaneous emphysema and a small right sided pneumothorax secondary to trauma These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend RECOMMENDATIONS At this time the CT Surgery service has been consulted and has left recommendations The patient also is awaiting bronchoscopy per the Pulmonary Service At this time there are no General Surgery issues Keywords cardiovascular pulmonary trauma tracheobronchial bronchoscopy scapular pain subcutaneous emphysema pneumothorax subcutaneous emphysema MEDICAL_TRANSCRIPTION,Description Left hemothorax rule out empyema Insertion of a 12 French pigtail catheter in the left pleural space Medical Specialty Cardiovascular Pulmonary Sample Name Pigtail Catheter Insertion Transcription PREOPERATIVE DIAGNOSIS Left hemothorax rule out empyema POSTOPERATIVE DIAGNOSIS Left hemothorax rule out empyema PROCEDURE Insertion of a 12 French pigtail catheter in the left pleural space PROCEDURE DETAIL After obtaining informed consent the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion Xylocaine 1 was injected and then a 12 French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space It was difficult to draw fluid by syringe but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR Samples were sent for culture and sensitivity aerobic and anaerobic The patient and I decided to admit him for a period of observation at least overnight He tolerated the procedure well and the postprocedure chest x ray showed no complications Keywords cardiovascular pulmonary chest pleural space pigtail catheter insertion empyema hemothorax MEDICAL_TRANSCRIPTION,Description Chest tube talc pleurodesis of the right chest Medical Specialty Cardiovascular Pulmonary Sample Name Pleurodesis Transcription PREOPERATIVE DIAGNOSIS Large recurrent right pleural effusion POSTOPERATIVE DIAGNOSIS Large recurrent right pleural effusion PROCEDURE 1 Conscious sedation 2 Chest tube talc pleurodesis of the right chest INDICATIONS The patient is a 65 year old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion Chest catheter had been placed previously and she had been draining up to 1 5 liters of serous fluid a day Eventually this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur SPECIMENS None ESTIMATED BLOOD LOSS Zero NARRATIVE After obtaining informed consent from the patient and her daughter the patient was assessed and found to be in good condition and a good candidate for conscious sedation Vital signs were taken These were stable so the patient was then given initially 0 5 mg of Versed and 2 mg of morphine IV After a couple of minutes she was assessed and found to be awake but calm so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped The patient was given additional 0 5 mg of Versed and 0 5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive The patient tolerated the procedure well She did complain of up to a 7 10 pain but quickly this was brought under control The chest tube was unclamped Now the patient will be left to rest and she will get a chest x ray in the morning Keywords cardiovascular pulmonary chest tube talc pleurodesis lateral decubitus position decubitus position talc pleurodesis pleural effusion chest tube chest pleurodesis talc recurrent pleural effusion tube MEDICAL_TRANSCRIPTION,Description Ultrasound guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea Medical Specialty Cardiovascular Pulmonary Sample Name Pleurocentesis Transcription PREOPERATIVE DIAGNOSIS Right pleural effusion with respiratory failure and dyspnea POSTOPERATIVE DIAGNOSIS Right pleural effusion with respiratory failure and dyspnea PROCEDURE Ultrasound guided right pleurocentesis ANESTHESIA Local with lidocaine TECHNIQUE IN DETAIL After informed consent was obtained from the patient and his mother the chest was scanned with portable ultrasound Findings revealed a normal right hemidiaphragm a moderate right pleural effusion without septation or debris and no gliding sign of the lung on the right Using sterile technique and with ultrasound as a guide a pleural catheter was inserted and serosanguinous fluid was withdrawn a total of 1 L The patient tolerated the procedure well Portable x ray is pending Keywords cardiovascular pulmonary pleural effusion dyspnea gliding sign hemidiaphragm pleural catheter pleurocentesis respiratory serosanguinous fluid ultrasound pleural MEDICAL_TRANSCRIPTION,Description Coil embolization of patent ductus arteriosus Medical Specialty Cardiovascular Pulmonary Sample Name Patent Ductus Arteriosus Transcription HISTORY The patient is a 5 1 2 year old who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus An echocardiogram from 09 13 2007 demonstrated a 3 8 mm patent ductus arteriosus with restrictive left to right shunt There is mild left atrial chamber enlargement with an LA AO ratio of 1 821 An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy The patient underwent cardiac catheterization for device closure of a ductus arteriosus PROCEDURE After sedation and local Xylocaine anesthesia the patient was prepped and draped Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a 5 French sheath a 5 French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries The atrial septum was not probe patent Using a 4 French sheath a 4 French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta ascending aorta and left ventricle A descending aortogram demonstrated a small type A patent ductus arteriosus with a small left to right angiographic shunt Minimal diameter was approximately 1 6 mm with ampulla diameter of 5 8 mm and length of 6 2 mm The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta This catheter exchanged over wire for a 5 French nit occlude delivery catheter through which a nit occlude 6 5 flex coil that was advanced and allowed to reconfigure the descending aorta Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery Once the stable device configuration was confirmed by fluoroscopy device was released from the delivery catheter Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity Cineangiograms were obtained with injection in the descending aorta After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the recovery room in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left to right shunt through the ductus arteriosus The left sided heart was fully saturated The phasic right sided and left sided pressures were normal The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP QS ratio of 1 1 Vascular resistances were normal A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left to right angiographic shunt The branch pulmonary arteries appeared normal There is otherwise a normal left aortic arch Following coil embolization of the ductus arteriosus there is no change in mixed venous saturation No evidence of residual left to right shunt There is no change in right sided pressures There is a slight increase in the left sided phasic pressures Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP QS ratio of 1 1 Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery There is a trace residual shunt through the center of coil mass INITIAL DIAGNOSES Patent ductus arteriosus SURGERIES INTERVENTIONS Coil embolization of patent ductus arteriosus MANAGEMENT The case to be discussed at Combined Cardiology Cardiothoracic Surgery case conference The patient will require a cardiologic followup in 6 months and 1 year s time including clinical evaluation and echocardiogram Further patient care be directed by Dr X Keywords cardiovascular pulmonary cardiac murmur coil embolization cineangiograms patent ductus arteriosus pulmonary artery patent ductus descending aorta ductus arteriosus catheterization MEDICAL_TRANSCRIPTION,Description Six month follow up visit for paroxysmal atrial fibrillation PAF She reports that she is getting occasional chest pains with activity Sometimes she feels that at night when she is lying in bed and it concerns her Medical Specialty Cardiovascular Pulmonary Sample Name PAF 6 Month Followup Transcription REASON FOR VISIT Six month follow up visit for paroxysmal atrial fibrillation PAF She reports that she is getting occasional chest pains with activity Sometimes she feels that at night when she is lying in bed and it concerns her She is frustrated by her inability to lose weight even though she is hyperthyroid MEDICATIONS Tapazole 10 mg b i d atenolol chlorthalidone 50 25 mg b i d Micro K 10 mEq q d Lanoxin 0 125 mg q d spironolactone 25 mg q d Crestor 10 mg q h s famotidine 20 mg Bayer Aspirin 81 mg q d Vicodin p r n and Nexium 40 mg given samples of this today REVIEW OF SYSTEMS No palpitations No lightheadedness or presyncope She is having mild pedal edema but she drinks a lot of fluid PEX BP 112 74 PR 70 WT 223 pounds up three pounds Cardiac Regular rate and rhythm with a 1 6 murmur at the upper sternal border Chest Nontender Lungs Clear Abdomen Moderately overweight Extremities Trace edema EKG Sinus bradycardia at 58 beats per minute mild inferolateral ST abnormalities IMPRESSION 1 Chest pain Mild Her EKG is mildly abnormal Her last stress echo was in 2001 I am going to have her return for one just to make sure it is nothing serious I suspect however that is more likely due to her weight and acid reflux I gave her samples of Nexium 2 Mild pedal edema Has to cut down on fluid intake weight loss will help as well continue with the chlorthalidone 3 PAF Due to hypertension hyperthyroidism and hypokalemia Staying in sinus rhythm 4 Hyperthyroidism Last TSH was mildly suppressed she had been out of her Tapazole for a while now back on it 5 Dyslipidemia Samples of Crestor given 6 LVH 7 Menometrorrhagia PLAN 1 Return for stress echo 2 Reduce the fluid intake to help with pedal edema 3 Nexium trial Keywords cardiovascular pulmonary atrial fibrillation ekg paroxysmal atrial fibrillation chest pains pedal edema hyperthyroidism paf atrial MEDICAL_TRANSCRIPTION,Description Ligation clip interruption of patent ductus arteriosus This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch Medical Specialty Cardiovascular Pulmonary Sample Name Patent Ductus Arteriosus Ligation Transcription TITLE OF OPERATION Ligation clip interruption of patent ductus arteriosus INDICATION FOR SURGERY This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left sided aortic arch She has now been put forward for operative intervention PREOP DIAGNOSIS 1 Patent ductus arteriosus 2 Severe prematurity 3 Operative weight less than 4 kg 600 grams COMPLICATIONS None FINDINGS Large patent ductus arteriosus with evidence of pulmonary over circulation After completion of the procedure left recurrent laryngeal nerve visualized and preserved Substantial rise in diastolic blood pressure DETAILS OF THE PROCEDURE After obtaining information consent the patient was positioned in the neonatal intensive care unit cribbed in the right lateral decubitus and general endotracheal anesthesia was induced The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion It was then test occluded and then interrupted with a medium titanium clip There was preserved pulsatile flow in the descending aorta The left recurrent laryngeal nerve was identified and preserved With excellent hemostasis the intercostal space was closed with 4 0 Vicryl sutures and the muscular planes were reapproximated with 5 0 Caprosyn running suture in two layers The skin was closed with a running 6 0 Caprosyn suture A sterile dressing was placed Sponge and needle counts were correct times 2 at the end of the procedure The patient was returned to the supine position in which palpable bilateral femoral pulses were noted I was the surgical attending present in the neonatal intensive care unit and in charge of the surgical procedure throughout the entire length of the case Keywords cardiovascular pulmonary clip interruption ligation patent ductus arteriosus premature baby intercostal space arteriosus interruption pulmonary circulation MEDICAL_TRANSCRIPTION,Description PICC line insertion Medical Specialty Cardiovascular Pulmonary Sample Name PICC line insertion Transcription PROCEDURE PERFORMED PICC line insertion DESCRIPTION OF PROCEDURE The patient was identified by myself on presentation to the angiography suite His right arm was prepped and draped in sterile fashion from the antecubital fossa up Under ultrasound guidance a 21 gauge needle was placed into his right cephalic vein A guidewire was then threaded through the vein and advanced without difficulty An introducer was then placed over the guidewire We attempted to manipulate the guidewire to the superior vena cava however we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein It was very tortuous area We made several more attempts using the mapping system to pass the glide over that area but we were unable to do that Decision was made at that point then to just do a midline catheter The catheter was cut to 20 cm then we inserted back to the introducer The introducer was removed The catheter was secured by two 3 0 silk sutures Appropriate imaging was then taken Sterile dressing was applied The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor We may make another attempt in the near future using a different approach Keywords cardiovascular pulmonary picc picc line angiography guidewire superior vena cava subclavian vein venogramNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Sinus bradycardia sick sinus syndrome poor threshold on the ventricular lead and chronic lead Right ventricular pacemaker lead placement and lead revision Medical Specialty Cardiovascular Pulmonary Sample Name Pacemaker Lead Placement Rrevision Transcription PROCEDURE Right ventricular pacemaker lead placement and lead revision INDICATIONS Sinus bradycardia sick sinus syndrome poor threshold on the ventricular lead and chronic lead EQUIPMENT A new lead is a Medtronic model 12345 threshold sensing at 5 7 impedance of 1032 threshold of 0 3 atrial threshold is 0 3 531 and sensing at 4 1 The original chronic ventricular lead had a threshold of 3 5 and 6 on the can ESTIMATED BLOOD LOSS 5 mL PROCEDURE DESCRIPTION Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine The patient received a venogram documenting patency of the subclavian vein Skin incision with blunt and sharp dissection Electrocautery for hemostasis The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads The leads were sequentially checked Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava Ultimately a ventricular lead was placed in apex of the right ventricle secured to base pocket with 2 0 silk suture Pocket was irrigated with antibiotic solution The pocket was packed with bacitracin soaked gauze This was removed during the case and then irrigated once again The generator was attached to the leads placed in the pocket secured with 2 0 silk suture and the pocket was closed with a three layer of 4 0 Monocryl CONCLUSION Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model 12345 Keywords cardiovascular pulmonary medtronic atrial subclavian sick sinus syndrome pacemaker lead placement ventricular pacemaker ventricular lead lead bradycardia pacemaker threshold ventricular MEDICAL_TRANSCRIPTION,Description Nuclear cardiac stress report Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy Medical Specialty Cardiovascular Pulmonary Sample Name Nuclear Cardiac Stress Report Transcription NUCLEAR CARDIOLOGY CARDIAC STRESS REPORT INDICATION FOR STUDY Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy PROCEDURE The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg kg min delivered over a total of 4 minutes At completion of the second minute of infusion the patient received technetium Cardiolite per protocol During this interval the blood pressure 150 86 dropped to near 136 80 and returned to near 166 84 at completion No diagnostic electrocardiographic abnormalities were elaborated during this study REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease yet no active ischemia at this time A fixed defect is seen in the high anterolateral segment A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum There is no evidence for active ischemia in either distribution Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity When viewed from the vertical projection the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall A limited segment of apical myocardium is still viable No gated wall motion study was obtained CONCLUSIONS Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above There is no indication for active ischemia at this time Keywords cardiovascular pulmonary angina pectoris ischemic cardiomyopathy myocardial perfusion adenosine provocation cardiolite perfusion nuclear cardiac stress report coronary artery disease active ischemia ischemic angina MEDICAL_TRANSCRIPTION,Description Insertion of transvenous pacemaker for tachybrady syndrome Medical Specialty Cardiovascular Pulmonary Sample Name Pacemaker Insertion Transcription PREOPERATIVE DIAGNOSIS Tachybrady syndrome POSTOPERATIVE DIAGNOSIS Tachybrady syndrome OPERATIVE PROCEDURE Insertion of transvenous pacemaker ANESTHESIA Local PROCEDURE AND GROSS FINDINGS The patient s chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated In the left subclavian region a subclavian stick was performed without difficulty and a wire was inserted Fluoroscopy confirmed the presence of the wire in the superior vena cava An introducer was then placed over the wire The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy Following calibration the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area The subcutaneous tissues were irrigated and closed with Interrupted 4 O Vicryl and the skin was closed with staples Sterile dressings were placed and the patient was returned to the ICU in good condition Keywords cardiovascular pulmonary insertion of transvenous pacemaker fluoroscopy tachybrady tachybrady syndrome chest pacemaker subclavian subcutaneous superior vena cava syndrome transvenous pacemaker wire insertion MEDICAL_TRANSCRIPTION,Description Pacemaker ICD interrogation Severe nonischemic cardiomyopathy with prior ventricular tachycardia Medical Specialty Cardiovascular Pulmonary Sample Name Pacemaker Interrogation Transcription PROCEDURE NOTE Pacemaker ICD interrogation HISTORY OF PRESENT ILLNESS The patient is a 67 year old gentleman who was admitted to the hospital He has had ICD pacemaker implantation This is a St Jude Medical model current DRRS 12345 pacemaker DIAGNOSIS Severe nonischemic cardiomyopathy with prior ventricular tachycardia FINDINGS The patient is a DDD mode base rate of 60 max tracking rate of 110 beats per minute atrial lead is set at 2 5 volts with a pulse width of 0 5 msec ventricular lead set at 2 5 volts with a pulse width of 0 5 msec Interrogation of the pacemaker shows that atrial capture is at 0 75 volts at 0 5 msec ventricular capture 0 5 volts at 0 5 msec sensing in the atrium is 5 34 to 5 8 millivolts R sensing is 12 12 0 millivolts atrial lead impendence 590 ohms ventricular lead impendence 750 ohms The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules followed by 36 joules followed by 36 joules times 2 VF detection criteria set at 187 beats per minute with therapy of 25 joules followed by 36 joules times 5 The patient is in normal sinus rhythm IMPRESSION Normally functioning pacemaker ICD post implant day number 1 Keywords cardiovascular pulmonary cardiomyopathy ventricular tachycardia pacemaker icd interrogation millivolts impendence interrogation pacemaker MEDICAL_TRANSCRIPTION,Description Single chamber pacemaker implantation Successful single chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure Medical Specialty Cardiovascular Pulmonary Sample Name Pacemaker Single Chamber Transcription SINGLE CHAMBER PACEMAKER IMPLANTATION PREOPERATIVE DIAGNOSIS Mobitz type II block with AV dissociation and syncope POSTOPERATIVE DIAGNOSIS Mobitz type II block status post single chamber pacemaker implantation Boston Scientific Altrua 60 serial number 123456 PROCEDURES 1 Left subclavian access under fluoroscopic guidance 2 Left subclavian venogram under fluoroscopic evaluation 3 Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345 serial number 123456 4 Insertion of single chamber pacemaker implantation Altrua serial number 123456 5 Closure of the pocket after formation of pocket for pacemaker PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient was brought to the cath lab draped and prepped in the usual sterile fashion received 1 5 mg of versed and 25 mg of Benadryl for conscious sedation Access to the right subclavian was successful after the second attempt The first attempt accessed the left subclavian artery The needle was removed and manual compression applied for five minutes followed by re accessing the subclavian vein successfully The J wire was introduced into the left subclavian vein The anterior wall chest was anesthetized with lidocaine 2 2 inch incision using a 10 blade was used The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis The patient went asystole during the procedure The transcutaneous pacer was used The patient was oxygenating well The patient had several compression applied by the nurse However her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby After that the J wire was tunneled into the pocket and then used to put the 7 French sheath into the left subclavian vein The lead from the Boston Scientific Dextrose model 12345 serial number 12345 was inserted through the left subclavian to the right atrium however it was difficult to really enter the right ventricle and while the lead was in place the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium The findings were showing different anatomy may be consistent with persistent left superior vena cava and the angle to the right ventricle was different At that point the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place At that point the lead was actively fixated The stylet was removed The R wave measured at 40 millivolts The impedance was 580 and the threshold was 1 3 volt The numbers were accepted and because of the patient s fragility and the different anatomy noticed in the right atrium concern about putting a second lead with re access of the subclavian was high I decided to proceed with a single chamber pacemaker as a backup system After that the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion The lead was attached to the pacemaker in the header The pacemaker was single chamber pacemaker Altura 60 serial number 123456 After that the pacemaker was put in the pocket Pocket was irrigated with normal saline and was closed into two layers deep interrupted 3 0 Vicryl and surface as continuous 4 0 Vicryl continuous The pacemaker was programmed as VVI 60 and with history is 10 to 50 beats per minute The lead position will be evaluated with chest x ray No significant bleeding noticed CONCLUSION Successful single chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure No significant bleed Keywords cardiovascular pulmonary mobitz av dissociation syncope mobitz type ii block boston scientific altrua subclavian venogram ventricular single chamber pacemaker implantation single chamber pacemaker pacemaker implantation pacemaker vein chest atrium ventricle atrial implantation chamber MEDICAL_TRANSCRIPTION,Description Implantation of a dual chamber permanent pacemaker Medical Specialty Cardiovascular Pulmonary Sample Name Pacemaker Dual Chamber Transcription CLINICAL HISTORY This 78 year old black woman has a history of hypertension but no other cardiac problems She noted complaints of fatigue lightheadedness and severe dyspnea on exertion She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm consistent with sinoatrial exit block and she is on no medications known to cause bradycardia An echocardiogram showed an ejection fraction of 70 without significant valvular heart disease PROCEDURE Implantation of a dual chamber permanent pacemaker APPROACH Left cephalic vein LEADS IMPLANTED Medtronic model 12345 in the right atrium serial number 12345 Medtronic 12345 in the right ventricle serial number 12345 DEVICE IMPLANTED Medtronic EnRhythm model 12345 serial number 12345 LEAD PERFORMANCE Atrial threshold less than 1 3 volts at 0 5 milliseconds P wave 3 3 millivolts Impedance 572 ohms Right ventricle threshold 0 9 volts at 0 5 milliseconds R wave 10 3 Impedance 855 ESTIMATED BLOOD LOSS 20 mL COMPLICATIONS None DESCRIPTION OF PROCEDURE The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1 lidocaine for local anesthesia A 2 1 2 inch incision was made below the left clavicle and electrocautery was used for hemostasis Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator The deltopectoral groove was explored and a medium sized cephalic vein was identified The distal end of the vein was ligated and a venotomy was performed Two guide wires were advanced to the superior vena cava and peel away introducer sheaths were used to insert the two pacing leads The venous pressures were elevated and there was a fair amount of back bleeding from the vein so a 3 0 Monocryl figure of eight stitch was placed around the tissue surrounding the vein for hemostasis The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage The leads were tested with a pacing systems analyzer and the results are noted above The leads were then anchored in place with 0 silk around their suture sleeve and connected to the pulse generator The pacemaker was noted to function appropriately The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket The incision was closed with two layers of 3 0 Monocryl and a subcuticular closure of 4 0 Monocryl The incision was dressed with Steri Strips and a sterile bandage and the patient was returned to her room in good condition IMPRESSION Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein The patient will be observed overnight and will go home in the morning Keywords cardiovascular pulmonary medtronic enrhythm cephalic vein dual chamber dual chamber permanent pacemaker dyspnea on exertion echocardiogram fatigue hypertension lightheadedness normal sinus rhythm pacemaker permanent pacemaker sinoatrial exit block sinus bradycardia valvular heart disease bradycardia medtronic atrial MEDICAL_TRANSCRIPTION,Description Myocardial perfusion imaging patient with history of MI stents placement and chest pain Medical Specialty Cardiovascular Pulmonary Sample Name Myocardial Perfusion Imaging 1 Transcription MEDICATIONS Plavix atenolol Lipitor and folic acid CLINICAL HISTORY This is a 41 year old male patient who comes in with chest pain had had a previous MI in 07 2003 and stents placement in 2003 who comes in for a stress myocardial perfusion scan With the patient at rest 10 3 mCi of Cardiolite technetium 99 m sestamibi was injected and myocardial perfusion imaging was obtained PROCEDURE AND INTERPRETATION The patient exercised for a total of 12 minutes on the standard Bruce protocol The peak workload was 12 8 METS The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute which was 69 of the age predicted maximum heart rate response The blood pressure response was normal with a resting blood pressure of 130 100 and a peak blood pressure of 158 90 The test was stopped due to fatigue and leg pain EKG at rest showed normal sinus rhythm The peak stress EKG did not reveal any ischemic ST T wave abnormalities There was ventricular bigeminy seen during exercise but no sustained tachycardia was seen At peak there was no chest pain noted The test was stopped due to fatigue and left pain At peak stress the patient was injected with 30 3 mCi of Cardiolite technetium 99 m sestamibi and myocardial perfusion imaging was obtained and was compared to resting myocardial perfusion imaging MYOCARDIAL PERFUSION IMAGING 1 The overall quality of the scan was good 2 There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging 3 The left ventricular cavity appeared normal in size 4 Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis Overall left ventricular systolic function was low normal with calculated ejection fraction of 46 at rest CONCLUSIONS 1 Good exercise tolerance 2 Less than adequate cardiac stress The patient was on beta blocker therapy 3 No EKG evidence of stress induced ischemia 4 No chest pain with stress 5 Mild ventricular bigeminy with exercise 6 No diagnostic abnormality on the rest and stress myocardial perfusion imaging 7 Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46 at rest Keywords cardiovascular pulmonary myocardial perfusion imaging bruce protocol cardiolite ekg mets mi spect st t bigeminy blood pressure chest pain exercise tolerance myocardial perfusion normal sinus rhythm peak workload sestamibi stents stress tachycardia ventricular ventricular cavity stress myocardial perfusion perfusion imaging myocardial perfusion mci hypokinesis imaging MEDICAL_TRANSCRIPTION,Description Myocardial perfusion imaging patient had previous abnormal stress test Stress test with imaging for further classification of CAD and ischemia Medical Specialty Cardiovascular Pulmonary Sample Name Myocardial Perfusion Imaging 2 Transcription CLINICAL HISTORY This is a 64 year old male patient who had a previous stress test which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia PERTINENT MEDICATIONS Include Tylenol Robitussin Colace Fosamax multivitamins hydrochlorothiazide Protonix and flaxseed oil With the patient at rest 10 5 mCi of Cardiolite technetium 99 m sestamibi was injected and myocardial perfusion imaging was obtained PROCEDURE AND INTERPRETATION The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol The peak workload was 7 METs The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute which was 85 of the age predicted maximum heart rate response The blood pressure response was normal with the resting blood pressure 126 86 and the peak blood pressure of 134 90 EKG at rest showed normal sinus rhythm with a right bundle branch block The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6 which remained abnormal till about 6 to 8 minutes into recovery There were occasional PVCs but no sustained arrhythmia The patient had an episode of supraventricular tachycardia at peak stress The ischemic threshold was at a heart rate of 118 beats per minute and at 4 6 METs At peak stress the patient was injected with 30 3 mCi of Cardiolite technetium 99 m sestamibi and myocardial perfusion imaging was obtained and was compared to resting images MYOCARDIAL PERFUSION IMAGING 1 The overall quality of the scan was fair in view of increased abdominal uptake increased bowel uptake seen 2 There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex This appeared to be partially reversible in the resting images 3 The left ventricle appeared normal in size 4 Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening The calculated ejection fraction was 70 at rest CONCLUSIONS 1 Average exercise tolerance 2 Adequate cardiac stress 3 Abnormal EKG response to stress consistent with ischemia No symptoms of chest pain at rest 4 Myocardial perfusion imaging was abnormal with a large sized moderate intensity partially reversible inferior wall and inferior apical defect consistent with inferior wall ischemia and inferior apical ischemia 5 The patient had run of SVT at peak stress 6 Gated SPECT images revealed normal wall motion and normal left ventricular systolic function Keywords cardiovascular pulmonary stress test arrhythmia baseline heart rate bruce chest pain mets protocol peak heart rate spect st segment response svt aerobic capacity blood pressure exercise heart rate ischemia ventricular systolic function myocardial perfusion imaging cardiolite technetium inferior apical myocardial perfusion perfusion imaging stress myocardial imaging perfusion MEDICAL_TRANSCRIPTION,Description Myocardial perfusion study at rest and stress gated SPECT wall motion study at stress and calculation of ejection fraction Medical Specialty Cardiovascular Pulmonary Sample Name Myocardial Perfusion Imaging 3 Transcription DIAGNOSIS Shortness of breath Fatigue and weakness Hypertension Hyperlipidemia INDICATION To evaluate for coronary artery disease Keywords cardiovascular pulmonary myocardial perfusion imaging spect wall motion study at stress rest and stress perfusion study at rest calculation of ejection fraction normal left ventricular wall spect wall motion study ventricular wall motion myocardial perfusion study perfusion imaging blood pressure nonspecific st ventricular wall gated spect spect wall motion study stress test heart rate ejection fraction myocardial perfusion technetium tetrofosmin ischemia ekg imaging spect heart ventricular mci resting perfusion stress myocardial MEDICAL_TRANSCRIPTION,Description Multiple stent placements with Impella circulatory assist device Medical Specialty Cardiovascular Pulmonary Sample Name Multiple Stent Placements Transcription PROCEDURE PERFORMED 1 Left heart catheterization left ventriculogram aortogram coronary angiogram 2 PCI of the LAD and left main coronary artery with Impella assist device INDICATIONS FOR PROCEDURE Unstable angina and congestive heart failure with impaired LV function TECHNIQUE OF PROCEDURE After obtaining informed consent the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state The right groin was prepped and draped in the usual sterile manner Lidocaine 2 was used for infiltration anesthesia Using modified Seldinger technique a 7 French sheath was introduced into the right common femoral artery and a 6 French sheath was introduced into the right common femoral vein Through the arterial sheath angiography of the right common femoral artery was obtained Thereafter 6 French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained Thereafter a 4 French sheath was introduced into the left common femoral artery using modified Seldinger technique Thereafter the pigtail catheter was advanced over an 0 035 inch J wire into the left ventricle and LV gram was performed in RAO view and after pullback an aortogram was performed in the LAO view Therefore a 6 French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained ANGIOGRAPHIC FINDINGS 1 LV gram LVEDP was 15 mmHg LV ejection fraction 10 to 15 with global hypokinesis Only anterior wall is contracting There was no mitral regurgitation There was no gradient across the aortic valve upon pullback and on aortography there was no evidence of aortic dissection or aortic regurgitation 2 The right coronary artery is a dominant vessels with a mid 50 to 70 stenosis which was not treated The left main coronary artery calcified vessel with disease 2 The left anterior descending artery had an 80 to 90 mid stenosis First diagonal branch had a more than 90 stenosis 3 The circumflex coronary artery had a patent stent INTERVENTION After reviewing the angiographic images we elected to proceed with intervention of the left anterior descending artery The 4 French sheath in the left common femoral artery was upsized to a 12 French Impella sheath through which an Amplatz wire and a 6 French multipurpose catheter were advanced into the left ventricle The Amplatz wire was exchanged for an Impella 0 018 inch stiff wire The multipurpose catheter was removed and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2 5 l min Thereafter a 7 French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0 014 inch wire was advanced into the left anterior descending artery and a second 0 014 inch Asahi soft wire was advanced into the diagonal branch The diagonal branch was predilated with a 2 5 x 30 mm Sprinter balloon at nominal atmospheres and thereafter a 2 5 x 24 Endeavor stent was successfully deployed in the mid LAD and a 3 0 x 15 mm Endeavor stent was deployed in the proximal LAD The stent delivery balloon was used to post dilate the overlapping segment The LAD the diagonal was rewires with an 0 014 inch Asahi soft wire and a 3 0 x 20 mm Maverick balloon was advanced into the LAD for post dilatation and a 2 0 x 30 mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres At this point it was noted that the left main had a retrograde dissection A 3 5 x 18 mm Endeavor stent was successfully deployed in the left main coronary artery The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery Kissing inflations of the LAD and the circumflex coronary artery were performed using 3 0 x 20 Maverick balloons x2 balloons inflated at high atmospheres of 14 RESULTS Lesion reduction in the LAD FROM 90 to 0 and TIMI 3 flow obtained Lesion reduction in the diagonal from 90 to less than 60 and TIMI 3 flow obtained Lesion reduction in the left maintained coronary artery from 50 to 0 and TIMI 3 flow obtained The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened From the right common femoral artery a 6 French IMA catheter was advanced and an 0 035 inch wire down into the left common femoral and superficial femoral artery over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes The right common femoral artery and vein sheaths were both sutured in place for further observation Of note the patient received Angiomax during the procedure and an ACT above 300 was maintained IMPRESSION 1 Left ventricular dysfunction with ejection fraction of 10 to 15 2 High complex percutaneous coronary intervention of the left main coronary artery left anterior descending artery and diagonal with Impella circulatory support COMPLICATIONS None The patient tolerated the procedure well with no complications The estimated blood loss was 200 ml Estimated dye used was 200 ml of Visipaque The patient remained hemodynamically stable with no hypotension and no hematomas in the groins PLAN 1 Aspirin Plavix statins beta blockers ACE inhibitors as tolerated 2 Hydration 3 The patient will be observed over night for any hemodynamic instability or ischemia If she remains stable the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis Keywords cardiovascular pulmonary impella circulatory assist device impella assist device unstable angina congestive heart failure heart catheterization ventriculogram aortogram angiogram ventricular dysfunction pigtail catheter was advanced femoral artery and vein artery and vein asahi soft wire circumflex coronary artery common femoral artery modified seldinger technique multiple stent placements timi flow multiple stent impella circulatory french sheath femoral artery endeavor stent descending artery coronary artery common femoral asahi soft anterior descending femoral coronary artery impella catheterization MEDICAL_TRANSCRIPTION,Description Resting Myoview perfusion scan and gated myocardial scan Findings consistent with an inferior non transmural scar Medical Specialty Cardiovascular Pulmonary Sample Name Myoview Perfusion Scan Transcription INDICATIONS Previously markedly abnormal dobutamine Myoview stress test and gated scan PROCEDURE DONE Resting Myoview perfusion scan and gated myocardial scan MYOCARDIAL PERFUSION IMAGING Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32 6 mCi of Tc 99m Myoview Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD YYYY The lung heart ratio is 0 34 There appears to be a moderate size inferoapical perfusion defect of moderate degree The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55 CONCLUSIONS Study done at rest only revealed findings consistent with an inferior non transmural scar of moderate size and moderate degree The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD YYYY We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed Keywords cardiovascular pulmonary myoview perfusion scan rest study spect imaging dobutamine myoview stress test ejection fraction gated myocardial scan hypokinesis ventricular systolic function resting myoview perfusion scan myoview stress test resting myoview myocardial perfusion myoview perfusion perfusion scan myocardial scan myocardial myoview perfusion MEDICAL_TRANSCRIPTION,Description MRI Right parietal metastatic adenocarcinoma LUNG metastasis Medical Specialty Cardiovascular Pulmonary Sample Name MRI of Lung Adenocarcinoma Transcription CC Found unresponsive HX 39 y o RHF complained of a severe HA at 2AM 11 4 92 It was unclear whether she had been having HA prior to this She took an unknown analgesic then vomited then lay down in bed with her husband When her husband awoke at 8AM he found her unresponsive with stiff straight arms and a strange breathing pattern A Brain CT scan revealed a large intracranial mass She was intubated and hyperventilated to ABG 7 43 36 398 Other local lab values included WBC 9 8 RBC 3 74 Hgb 13 8 Hct 40 7 Cr 0 5 BUN 8 5 Glucose 187 Na 140 K 4 0 Cl 107 She was given Mannitol 1gm kg IV load DPH 20mg kg IV load and transferred by helicopter to UIHC PMH 1 Myasthenia Gravis for 15 years s p Thymectomy MEDS Imuran Prednisone Mestinon Mannitol DPH IV NS FHX SHX Married Tobacco 10 pack year quit nearly 10 years ago ETOH Substance Abuse unknown EXAM 35 8F 99BPM BP117 72 Mechanically ventilated at a rate of 22RPM on 00 FiO2 Unresponsive to verbal stimulation CN Pupils 7mm 5mm and unresponsive to light fixed No spontaneous eye movement or blink to threat No papilledema or intraocular hemorrhage noted Trace corneal reflexes bilaterally No gag reflex No oculocephalic reflex MOTOR SENSORY No spontaneous movement On noxious stimulation Deep nail bed pressure she either extended both upper extremities RUE LUE or withdrew the stimulated extremity right left Gait Station Coordination no tested Reflexes 1 on right and 2 on left with bilateral Babinski signs HCT 11 4 92 Large heterogeneous mass in the right temporal parietal region causing significant parenchymal distortion and leftward subfalcine effect There is low parenchymal density within the white matter A hyperdense ring lies peripherally and may represent hemorrhage or calcification The mass demonstrates inhomogeneous enhancement with contrast COURSE Head of bed elevated to 30 degrees Mannitol and DPH were continued MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures She underwent surgical resection of the tumor Pathological analysis was consistent with adenocarcinoma GYN exam CT Abdomen and Pelvis Bone scan were unremarkable CXR revealed an right upper lobe lung nodule She did not undergo thoracic biopsy due to poor condition She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center In March 1993 the patient exhibited right ptosis poor adduction and abduction OD 4 4 strength in the upper extremities and 5 5 strength in the lower extremities She was ambulatory with an ataxic gait She was admitted on 7 12 93 for lower cervical and upper thoracic pain paraparesis and T8 sensory level MRI brainstem spine on that day revealed decreased T1 signal in the C2 C3 C6 vertebral bodies increased T2 signal in the anterior medulla and tectum and spinal cord C7 T3 Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7 T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and or metastasis The patient was treated with Decadron and analgesics and discharged to a hospice center her choice She died a few months later Keywords cardiovascular pulmonary mri lung metastatic adenocarcinoma parietal breathing pattern cranial xrt t1 signal sensory level iv load adenocarcinoma metastatic leptomeningeal MEDICAL_TRANSCRIPTION,Description Loculated left effusion multilobar pneumonia Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency Medical Specialty Cardiovascular Pulmonary Sample Name Multilobar Pneumonia Transcription REASON FOR CONSULTATION Loculated left effusion multilobar pneumonia Keywords cardiovascular pulmonary neck bruits nasal cannula rhythm pneumonia chest tube fluid collection pleural effusion multilobar pneumonia pleural loculations multilobar MEDICAL_TRANSCRIPTION,Description Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band Posterior leaflet abscess resection Medical Specialty Cardiovascular Pulmonary Sample Name Mitral Valve Repair Annuloplasty Transcription OPERATIONS 1 Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet 2 Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band 3 Posterior leaflet abscess resection ANESTHESIA General endotracheal anesthesia TIMES Aortic cross clamp time was minutes Cardiopulmonary bypass time total was minutes PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next the patient s chest and legs were prepped and draped in standard surgical fashion A 10 blade scalpel was used to make a midline median sternotomy incision Dissection was carried down to the level of the sternum using Bovie electrocautery The sternum was opened with a sternal saw and full dose heparinization was given Next the chest retractor was positioned The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned We then prepared to place the patient on cardiopulmonary bypass A 2 0 Ethibond double pursestring was placed in the ascending aorta Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine Next double cannulation with venous cannulas was instituted A 3 0 Prolene pursestring was placed in the right atrial appendage Through this was passed our SEC cannula This was connected to the venous portion of the cardiopulmonary bypass machine in a Y shaped circuit Next a 3 0 Prolene pursestring was placed in the lower border of the right atrium Through this was passed our inferior vena cava cannula This was likewise connected to the Y connection of our venous cannula portion We then used a 4 0 U stitch in the right atrium for our retrograde cardioplegia catheter which was inserted Cardiopulmonary bypass was instituted Metzenbaum scissors were used to dissect out the SVC and IVC which were subsequently encircled with umbilical tape Sondergaard s groove was taken down Next an antegrade cardioplegia needle and associated sump were placed in the ascending aorta This was connected appropriately as was the retrograde cardioplegia catheter Next the aorta was cross clamped and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole Next a 15 blade scalpel was used to open the left atrium The left atrium was decompressed with pump sucker Next our self retaining retractor was positioned so as to bring the mitral valve up into view Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4 0 silk After doing so the P2 segment of the posterior leaflet was excised with a 11 blade scalpel Given the laxity of the posterior leaflet it was decided to reconstruct it with a 2 0 Ethibond pledgeted suture This was done so as to reconstruct the posterior annular portion Prior to doing so care was taken to remove any debris and abscess type material The pledgeted stitch was lowered into place and tied Next the more anterior portion of the P2 segment was reconstructed by running a 4 0 Prolene stitch so as to reconstruct it This was done without difficulty The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle There was noted to be a small amount of central regurgitation It was felt that this would be corrected with our annuloplasty portion of the procedure Next 2 0 non pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion Care was taken to go from trigone to trigone Prior to placing these sutures the annulus was sized and noted to be a size for the Cosgrove Galloway suture band ring from Medtronic After as mentioned we placed our interrupted sutures in the annulus and they were passed through the CG suture band The suture band was lowered into position and tied in place We then tested our repair and noted that there was very mild regurgitation We subsequently removed our self retaining retractor We closed our left atriotomy using 4 0 Prolene in a running fashion This was done without difficulty We de aired the heart We then gave another round of antegrade and retrograde cardioplegia in warm fashion The aortic cross clamp was removed and the heart gradually resumed electromechanical activity We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5 0 Prolene We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed We then gave full dose protamine and after noting that there was no evidence of a protamine reaction we removed our aortic cannula This site was buttressed with a 4 0 Prolene on an SH needle The patient tolerated the procedure well We placed a mediastinal 32 French chest tube as well as a right chest Blake drain The mediastinum was inspected for any signs of bleeding There were none We closed the sternum with 7 sternal wires in interrupted figure of eight fashion The fascia was closed with a 1 Vicryl followed by a 2 0 Vicryl followed by 3 0 Vicryl in a running subcuticular fashion The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the intensive care unit in good condition Keywords cardiovascular pulmonary mitral valve repair mitral valve abscess resection leaflet abscess cosgrove galloway medtronic bovie electrocautery cannulation bypass annuloplasty cardioplegia mitral MEDICAL_TRANSCRIPTION,Description Suspension microlaryngoscopy rigid bronchoscopy dilation of tracheal stenosis Medical Specialty Cardiovascular Pulmonary Sample Name Microlaryngoscopy Transcription PREOPERATIVE DIAGNOSIS Airway obstruction secondary to laryngeal subglottic stenosis POSTOPERATIVE DIAGNOSIS Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis OPERATION PERFORMED Suspension microlaryngoscopy rigid bronchoscopy dilation of tracheal stenosis INDICATIONS FOR SURGERY The patient is a 56 year old white female with a history of relapsing polychondritis which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway She currently is trach dependent for her airway because of glottic and subglottic stenosis but she is having no significant problems breathing and talking around her trach tube and came for further evaluation Endoscopic reevaluation of her tube and nature of the proposed procedure done Risk and complications of bleeding infection alteration of with speech or swallowing failure to improve her airway and loss of voice Cardiorespiratory anesthetic results were discussed in length The patient states she understood and wished to proceed DESCRIPTION OF OPERATION The patient was taken to the operating room and placed in the supine position Under adequate general endotracheal anesthesia the patient s 5 metal tracheostomy tube was removed and a 5 laser safe endotracheal tube was inserted The patient was then prepared for endoscopy The Kantor laryngoscope was then inserted Oral cavity hypopharynx larynx and nasal cavity showed good dentition with good tongue buccal cavity and mucosa without lesions Larynx was then short epiglottis Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords This appeared to be stable and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild to moderate subglottic stenosis otherwise this appeared to be stable However distally the level of the trach site examined with the microscope and 0 and 30 degree telescopes The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube The laryngoscope was removed and a 5 x 30 pediatric rigid bronchoscope was then passed The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out Mid and distal trachea were widely patent Trachea and mainstem bronchi were patent without obvious disease The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant This was further dilated and following which was removed and a new 5 metal tracheostomy tube inserted The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition Keywords cardiovascular pulmonary airway obstruction oral cavity bronchoscopy buccal cavity hypopharynx laryngeal larynx microlaryngoscopy nasal cavity polychondritis subglottic tracheal stenosis tracheostomy tube scar tissue subglottic stenosis tracheal airway cavity tube scarring stenosis MEDICAL_TRANSCRIPTION,Description Right pleural effusion and suspected malignant mesothelioma Medical Specialty Cardiovascular Pulmonary Sample Name Mesothelioma Pleural Biopsy Transcription PREOPERATIVE DIAGNOSIS Right pleural effusion and suspected malignant mesothelioma POSTOPERATIVE DIAGNOSIS Right pleural effusion suspected malignant mesothelioma PROCEDURE Right VATS pleurodesis and pleural biopsy ANESTHESIA General double lumen endotracheal DESCRIPTION OF FINDINGS Right pleural effusion firm nodules diffuse scattered throughout the right pleura and diaphragmatic surface SPECIMEN Pleural biopsies for pathology and microbiology ESTIMATED BLOOD LOSS Minimal FLUIDS Crystalloid 1 2 L and 1 9 L of pleural effusion drained INDICATIONS Briefly this is a 66 year old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma Upon transfer he had a right pleural effusion demonstrated on x ray as well as some shortness of breath and dyspnea on exertion The risks benefits and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed PROCEDURE IN DETAIL After informed consent was obtained the patient was brought to the operating room and placed in supine position A double lumen endotracheal tube was placed SCDs were also placed and he was given preoperative Kefzol The patient was then brought into the right side up left decubitus position and the area was prepped and draped in the usual fashion A needle was inserted in the axillary line to determine position of the effusion At this time a 10 mm port was placed using the knife and Bovie cautery The effusion was drained by placing a sucker into this port site Upon feeling the surface of the pleura there were multiple firm nodules An additional anterior port was then placed in similar fashion The effusion was then drained with a sucker Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura Of note feeling the diaphragmatic surface it appeared that it was quite nodular but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease This will be worked up with further imaging study later in his hospitalization After the effusion had been drained 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc The lungs were then inflated and noted to inflate well A 32 curved chest tube chest tube was placed and secured with nylon The other port site was closed at the level of the fascia with 2 0 Vicryl and then 4 0 Monocryl for the skin The patient was then brought in the supine position and extubated and brought to recovery room in stable condition Dr X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies The counts were correct x2 at the end of the case Keywords cardiovascular pulmonary double lumen endotracheal pleural surface chest tube pleural biopsy malignant mesothelioma vats pleurodesis pleural biopsies pleural effusion pleural vats pleurodesis mesothelioma MEDICAL_TRANSCRIPTION,Description Posterior mediastinal mass with possible neural foraminal involvement benign nerve sheath tumor by frozen section Left thoracotomy with resection of posterior mediastinal mass Medical Specialty Cardiovascular Pulmonary Sample Name Mediastinal Mass Resection Transcription PREOPERATIVE DIAGNOSIS Posterior mediastinal mass with possible neural foraminal involvement POSTOPERATIVE DIAGNOSIS Posterior mediastinal mass with possible neural foraminal involvement benign nerve sheath tumor by frozen section OPERATION PERFORMED Left thoracotomy with resection of posterior mediastinal mass INDICATIONS FOR PROCEDURE The patient is a 23 year old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina For this reason Dr X and I agreed to operate on this patient together Please note that two surgeons were required for this case due to the complexity of it The indications and risks of the procedure were explained and the patient gave her informed consent DESCRIPTION OF PROCEDURE The patient was brought to the operating suite and placed in the supine position General endotracheal anesthesia was given with a double lumen tube The patient was positioned for a left thoracotomy All pressure points were carefully padded The patient was prepped and draped in usual sterile fashion A muscle sparing incision was created several centimeters anterior to the tip of the scapula The serratus and latissimus muscles were retracted The intercostal space was opened We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization Through our small anterior thoracotomy and with the video assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta The lung was deflated and allowed to retract anteriorly With a combination of blunt and sharp dissection and with attention paid to hemostasis we were able to completely resect the posterior mediastinal mass We began by opening the tumor and taking a very wide large biopsy This was sent for frozen section which revealed a benign nerve sheath tumor Then using the occluder device Dr X was able to _____ the inferior portions of the mass This left the external surface of the mass much more malleable and easier to retract Using a bipolar cautery and endoscopic scissors we were then able to completely resect it Once the tumor was resected it was then sent for permanent sections The entire hemithorax was copiously irrigated and hemostasis was complete In order to prevent any lymph leak we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace The wounds were then closed in multiple layers A 2 Vicryl was used to approximate the ribs The muscles of the chest wall were allowed to return to their normal anatomic position A 19 Blake was placed in the subcutaneous tissues Subcutaneous tissues and skin were closed with running absorbable sutures The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition Keywords cardiovascular pulmonary posterior mediastinal mass neural foraminal nerve sheath tumor frozen section thoracotomy mediastinal mass foraminal neural sheath mediastinal MEDICAL_TRANSCRIPTION,Description Myoview nuclear stress study Angina coronary artery disease Large fixed defect inferior and apical wall related to old myocardial infarction Medical Specialty Cardiovascular Pulmonary Sample Name Mayoview 1 Transcription MYOVIEW NUCLEAR STRESS STUDY REASON FOR THE TEST Angina coronary artery disease FINDINGS The patient exercised according to the Lexiscan nuclear stress study received a total of 0 4 mg of Lexiscan At peak hyperemic effect 25 8 mCi of Myoview injected for the stress imaging and earlier 8 1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest stress sequence The data analyzed using Cedars Sinai software The resting heart rate was 49 with the resting blood pressure of 149 86 Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172 76 EKG at rest showed to be abnormal with sinus rhythm left atrial enlargement and inverted T wave in 1 2 and aVL as well as from V4 to V6 with LVH Maximal stress test EKG showed no change from baseline IMPRESSION Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test please refer to the Myoview interpretation MYOVIEW INTERPRETATIONS FINDINGS The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end diastolic volume of 227 end systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall EF was calculated at 32 estimated 35 to 40 Cardiac perfusion reviewed showed a large area of moderate to severe intensity in the inferior wall and small to medium area of severe intensity at the apex and inferoapical wall Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI No reversible defects indicative of myocardium at risk The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near normal perfusion IMPRESSION 1 Large fixed defect inferior and apical wall related to old myocardial infarction 2 No reversible ischemia identified 3 Moderately reduced left ventricular function with ejection fraction of about 35 consistent with ischemic cardiomyopathy Keywords cardiovascular pulmonary myoview myoview interpretations spect gated spect protocol myoview nuclear stress study nuclear stress study stress study stress test stress lexiscan ekg inferoapical angina wall resting MEDICAL_TRANSCRIPTION,Description Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy Medical Specialty Cardiovascular Pulmonary Sample Name Metastasectomy Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma POSTOPERATIVE DIAGNOSIS Metastatic renal cell carcinoma PROCEDURE PERFORMED Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double lumen endotracheal tube with a tube thoracostomy which was used to drain the left chest after the procedure ANESTHESIA General endotracheal anesthesia with double lumen endotracheal tube FINDINGS Multiple pleural surface seeding many sub millimeter suspicious looking lesions DISPOSITION OF SPECIMENS To Pathology for permanent analysis as well as tissue banking The lesions sent for pathologic analysis were the following 1 Level 8 lymph node 2 Level 9 lymph node 3 Wedge left upper lobe apex which was also sent to the tissue bank and possible multiple lesions within this wedge 4 Wedge left upper lobe posterior 5 Wedge left upper lobe anterior 6 Wedge left lower lobe superior segment 7 Wedge left lower lobe diaphragmatic surface anterolateral 8 Wedge left lower lobe anterolateral 9 Wedge left lower lobe lateral adjacent to fissure 10 Wedge left upper lobe apex anterior 11 Lymph node package additional level 8 lymph node ESTIMATED BLOOD LOSS Less than 100 mL CONDITION OF THE PATIENT AFTER SURGERY Stable HISTORY OF PROCEDURE The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into The patient agreed based on the risks and the benefits of the procedure which were presented to him and was taken to the operating room A correct time out procedure was performed The patient was placed into the supine position He was given general anesthesia was endotracheally intubated without incident with a double lumen endotracheal tube Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double lumen tube Following this the decision was made to proceed with the surgery The patient was rolled into the right lateral decubitus position with the left side up All pressure points were padded The patient had a sterile DuraPrep preparation to the left chest A sterile drape around that was applied Also the patient had Marcaine infused into the incision area Following this the patient had a posterolateral thoracotomy incision which was a muscle sparing incision with a posterior approach just over the ausculatory triangle The incision was approximately 10 cm in size This was created with a 10 blade scalpel Bovie electrocautery was used to dissect the subcutaneous tissues The auscultatory triangle was opened The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly The muscle was not divided After the latissimus muscle was retracted anteriorly the ribs were counted and the sixth rib was identified The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears Following this the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges The patient tolerated the procedure well without any complications The largest lesion was the left upper lobe apex lesion which was possibly multiple lesions which was taken in one large wedge segment and this was also adjacent to another area of the wedges The patient had multiple pleural abnormalities which were identified on the surface of the lung These were small white spotty looking lesions and were not confirmed to be tumor implants but were suspicious to be multiple areas of tumor Based on this the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions Following this the patient had a 32 French chest tube placed in the anteroapical position A 19 French Blake was placed in the posterior apical position The patient had the intercostal space reapproximated with 2 0 Vicryl suture and the lung was allowed to be re expanded under direct visualization Following this the chest tubes were placed to Pleur evac suction and the auscultatory triangle was closed with 2 0 Vicryl sutures The deeper tissue was closed with 3 0 Vicryl suture and the skin was closed with running 4 0 Monocryl suture in a subcuticular fashion The patient tolerated the procedure well and had no complications Keywords MEDICAL_TRANSCRIPTION,Description Resting Myoview and adenosine Myoview SPECT Medical Specialty Cardiovascular Pulmonary Sample Name Mayoview Transcription PROCEDURE DONE Resting Myoview and adenosine Myoview SPECT INDICATIONS Chest pain PROCEDURE 13 3 mCi of Tc 99m tetrofosmin was injected and resting Myoview SPECT was obtained Pharmacologic stress testing was done using adenosine infusion Patient received 38 mg of adenosine infused at 140 mcg kg minute over a period of four minutes Two minutes during adenosine infusion 31 6 mCi of Tc 99m tetrofosmin was injected Resting heart rate was 90 beats per minute Resting blood pressure was 130 70 Peak heart rate obtained during adenosine infusion was 102 beats per minute Blood pressure obtained during adenosine infusion was 112 70 During adenosine infusion patient experienced dizziness and shortness of breath No significant ST segment T wave changes or arrhythmias were seen Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77 Lung heart ratio was 0 40 TID ratio was 0 88 IMPRESSION Normal adenosine Myoview myocardial perfusion SPECT Normal left ventricular regional and global function with left ventricular ejection fraction of 77 Keywords cardiovascular pulmonary myoview gated dynamic imaging myoview spect resting myoview spect tc 99m adenosine myoview adenosine infusion ejection fraction myocardium systolic thickening tetrofosmin adenosine myoview spect adenosine MEDICAL_TRANSCRIPTION,Description Mediastinal exploration and delayed primary chest closure The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification Medical Specialty Cardiovascular Pulmonary Sample Name Mediastinal Exploration Transcription TITLE OF OPERATION Mediastinal exploration and delayed primary chest closure INDICATION FOR SURGERY The patient is a 12 day old infant who has undergone a modified stage I Norwood procedure with a Sano modification The patient experienced an unexplained cardiac arrest at the completion of the procedure which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago She did not meet the criteria for delayed primary chest closure PREOP DIAGNOSIS Open chest status post modified stage I Norwood procedure POSTOP DIAGNOSIS Open chest status post modified stage I Norwood procedure ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma At completion of the procedure no major changes in hemodynamic performance DETAILS OF THE PROCEDURE After obtaining informed consent the patient was brought to the room placed on the operating room table in supine position Following the administration of general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned Through a separate incision and another 15 French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV PA connection as well as inferior most aspect of the ventriculotomy The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires The subcutaneous tissue and skin were closed in layers There was no evidence of significant increase in central venous pressure or desaturation The patient tolerated the procedure well Sponge and needle counts were correct times 2 at the end of the procedure The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case Keywords cardiovascular pulmonary mediastinal exploration delayed primary chest closure extracorporeal membrane oxygenation stage i norwood procedure sano modification chest closure infant mediastinal exploration closure endotracheal chest MEDICAL_TRANSCRIPTION,Description Lexiscan myoview stress study Chest discomfort Normal stress rest cardiac perfusion with no indication of ischemia Normal LV function and low likelihood of significant epicardial coronary narrowing Medical Specialty Cardiovascular Pulmonary Sample Name Mayoview 2 Transcription LEXISCAN MYOVIEW STRESS STUDY REASON FOR THE EXAM Chest discomfort INTERPRETATION The patient exercised according to the Lexiscan study received a total of 0 4 mg of Lexiscan IV injection At peak hyperemic effect 24 9 mCi of Myoview were injected for the stress imaging and earlier 8 2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars Sinai software The patient did not walk because of prior history of inability to exercise long enough on treadmill The resting heart rate was 57 with the resting blood pressure 143 94 Maximum heart rate achieved was 90 with a maximum blood pressure unchanged EKG at rest showed sinus rhythm with no significant ST T wave changes of reversible ischemia or injury Subtle nonspecific in III and aVF were seen Maximum stress test EKG showed inverted T wave from V4 to V6 Normal response to Lexiscan CONCLUSION Maximal Lexiscan perfusion with subtle abnormalities non conclusive Please refer to the Myoview interpretation MYOVIEW INTERPRETATION The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end diastolic volume of 115 and end systolic of 51 EF estimated and calculated at 56 Cardiac perfusion reviewed showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring IMPRESSION 1 Normal stress rest cardiac perfusion with no indication of ischemia 2 Normal LV function and low likelihood of significant epicardial coronary narrowing Keywords cardiovascular pulmonary chest discomfort lexiscan myoview stress study mci spect gated spect myoview lexiscan stress test ekg lexiscan myoview lv function coronary narrowing heart rate blood pressure myoview interpretation cardiac perfusion cardiac ischemia perfusion stress MEDICAL_TRANSCRIPTION,Description The patient had undergone mitral valve repair about seven days ago Medical Specialty Cardiovascular Pulmonary Sample Name Mediastinal Exploration Right Atrium Repair Transcription PREOPERATIVE DIAGNOSES 1 Cardiac tamponade 2 Status post mitral valve repair POSTOPERATIVE DIAGNOSES 1 Cardiac tamponade 2 Status post mitral valve repair PROCEDURE PERFORMED Mediastinal exploration with repair of right atrium ANESTHESIA General endotracheal INDICATIONS The patient had undergone mitral valve repair about seven days ago He had epicardial pacing wires removed at the bedside Shortly afterwards he began to feel lightheaded and became pale and diaphoretic He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s 70s DETAILS OF PROCEDURE The patient was taken emergently to the operating room and placed supine on the operating room table His chest was prepped and draped prior to induction under general anesthesia Incision was made through the previous median sternotomy chest incision Wires were removed in the usual manner and the sternum was retracted There were large amounts of dark blood filling the mediastinal chest cavity Large amounts of clot were also removed from the pericardial well and chest Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation This was repaired with two horizontal mattress pledgeted 5 0 Prolene sutures An additional 0 silk tie was also placed around the base of the atrial appendage for further hemostasis No other sites of bleeding were identified The mediastinum was then irrigated with copious amounts of antibiotic saline solution Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart as well as straight mediastinal chest tube The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures The skin was then closed with a running subcuticular stitch The patient was then taken to the Intensive Care Unit in a critical but stable condition Keywords cardiovascular pulmonary mitral valve repair exploration median sternotomy chest incision pericardial mediastinal exploration pacing wires cardiac tamponade chest tubes mitral valve valve repair mediastinal mitral wires atrium repair MEDICAL_TRANSCRIPTION,Description Lung wedge biopsy right lower lobe and resection right upper lobe Lymph node biopsy level 2 and 4 and biopsy level 7 subcarinal PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe which were also identified by CT scan Medical Specialty Cardiovascular Pulmonary Sample Name Lung Biopsy Pathology Report Transcription CLINICAL HISTORY A 48 year old smoker found to have a right upper lobe mass on chest x ray and is being evaluated for chest pain PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe which were also identified by CT scan The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter The patient was referred for surgical treatment SPECIMEN A Lung wedge biopsy right lower lobe B Lung resection right upper lobe C Lymph node biopsy level 2 and 4 D Lymph node biopsy level 7 subcarinal FINAL DIAGNOSIS A Wedge biopsy of right lower lobe showing Adenocarcinoma Grade 2 Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin B Right upper lobe lung resection showing Adenocarcinoma grade 2 measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin Two 2 hilar lymph nodes with no metastatic tumor C Lymph node biopsy at level 2 and 4 showing seven 7 lymph nodes with anthracosis and no metastatic tumor D Lymph node biopsy level 7 subcarinal showing 5 lymph nodes with anthracosis and no metastatic tumor COMMENT The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor there is isolated nests of tumor cells within the air spaces Furthermore immunoperoxidase stain for Ck 7 CK 20 and TTF are performed on both the right lower and right upper lobe nodule The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe Keywords cardiovascular pulmonary pet scan wedge biopsy morphology lung wedge biopsy lymph node biopsy lymph node lower lobe tumor biopsy lobe lung mass lymph node MEDICAL_TRANSCRIPTION,Description The right upper lobe wedge biopsy shows a poorly differentiated non small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy Medical Specialty Cardiovascular Pulmonary Sample Name Lung Biopsy Pathology Report 1 Transcription GROSS DESCRIPTION A Received fresh labeled with patient s name designated right upper lobe wedge is an 8 0 x 3 5 x 3 0 cm wedge of lung which has an 11 5 cm staple line There is a 0 8 x 0 7 x 0 5 cm sessile tumor with surrounding pleural puckering B Received fresh labeled with patient s name designated lymph node is a 1 7 cm possible lymph node with anthracotic pigment C Received fresh labeled with patient s name designated right upper lobe is a 16 0 x 14 5 x 6 0 cm lobe of lung The lung is inflated with formalin There is a 12 0 cm staple line on the lateral surface inked blue There is a 1 3 x 1 1 x 0 8 cm subpleural firm ill defined mass 2 2 cm from the bronchial margin and 1 5 cm from the previously described staple line The overlying pleura is puckered D Received fresh labeled with patient s name designated 4 lymph nodes is a 2 0 x 2 0 x 2 0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue E Received fresh labeled with patient s name designated subcarinal lymph node is a 2 0 x 1 7 x 0 8 cm aggregate of lymphoid material with anthracotic pigment FINAL DIAGNOSIS A Right upper lobe wedge lung biopsy Poorly differentiated non small cell carcinoma Tumor Size 0 8 cm Arterial large vessel invasion Not seen Small vessel lymphatic invasion Not seen Pleural invasion Not identified Margins of excision Negative for malignancy B Biopsy 10R lymph node Anthracotically pigmented lymphoid tissue negative for malignancy C Right upper lobe lung Moderately differentiated non small cell carcinoma adenocarcinoma Tumor Size 1 3 cm Arterial large vessel invasion Present Small vessel lymphatic invasion Not seen Pleural invasion Not identified Margins of excision Negative for malignancy D Biopsy 4R lymph nodes Lymphoid tissue negative for malignancy E Biopsy subcarinal lymph node Lymphoid tissue negative for malignancy COMMENTS Pathologic examination reveals two separate tumors in the right upper lobe They appear histologically distinct suggesting they are separate primary tumors pT1 The right upper lobe wedge biopsy part A shows a poorly differentiated non small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy The right upper lobe carcinoma identified in the resection part C is a moderately differentiated adenocarcinoma with obvious gland formation Keywords cardiovascular pulmonary lung biopsy wedge lobe pathologic lymph node node lymphoid malignancy lung lymph biopsy MEDICAL_TRANSCRIPTION,Description Right upper lung lobectomy Mediastinal lymph node dissection Medical Specialty Cardiovascular Pulmonary Sample Name Lobectomy Lymph Node Dissection Transcription OPERATION 1 Right upper lung lobectomy 2 Mediastinal lymph node dissection ANESTHESIA 1 General endotracheal anesthesia with dual lumen tube 2 Thoracic epidural OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered with a dual lumen tube Next the patient was placed in the left lateral decubitus position and his right chest was prepped and draped in the standard surgical fashion We used a 10 blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula Dissection was carried down in a muscle sparing fashion using Bovie electrocautery The 5th rib was counted and the 6th interspace was entered The lung was deflated We identified the major fissure We then began by freeing up the inferior pulmonary ligament which was done with Bovie electrocautery Next we used Bovie electrocautery to dissect the pleura off the lung The pulmonary artery branches to the right upper lobe of the lung were identified Of note was the fact that there was a visible approximately 4 x 4 cm mass in the right upper lobe of the lung without any other metastatic disease palpable As mentioned a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung Next we began by ligating the pulmonary artery branches of the right upper lobe of the lung This was done with suture ligature in combination with clips After taking the pulmonary artery branches of the right upper lobe of the lung we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung This likewise was ligated with a 0 silk It was stick tied with a 2 0 silk It was then divided Next we dissected out the bronchial branch to the right upper lobe of the lung A curved Glover was placed around the bronchus Next a TA 30 stapler was fired across the bronchus The bronchus was divided with a 10 blade scalpel The specimen was handed off We next performed a mediastinal lymph node dissection Clips were applied to the base of the feeding vessels to the lymph nodes We inspected for any signs of bleeding There was minimal bleeding We placed a 32 French anterior chest tube and a 32 French posterior chest tube The rib space was closed with 2 Vicryl in an interrupted figure of eight fashion A flat Jackson Pratt drain 10 in size was placed in the subcutaneous flap The muscle layer was closed with a combination of 2 0 Vicryl followed by 2 0 Vicryl followed by 4 0 Monocryl in a running subcuticular fashion Sterile dressing was applied The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the PACU in good condition Keywords cardiovascular pulmonary mediastinal thoracic epidural lymph node dissection lymph node artery branches lobectomy lung anesthesia bovie electrocautery lymph pulmonary branches MEDICAL_TRANSCRIPTION,Description VATS right middle lobectomy fiberoptic bronchoscopy mediastinal lymph node sampling tube thoracostomy x2 multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor Medical Specialty Cardiovascular Pulmonary Sample Name Lobectomy VATS Transcription PREOPERATIVE DIAGNOSIS Right middle lobe lung cancer POSTOPERATIVE DIAGNOSIS Right middle lobe lung cancer PROCEDURES PERFORMED 1 VATS right middle lobectomy 2 Fiberoptic bronchoscopy thus before and after the procedure 3 Mediastinal lymph node sampling including levels 4R and 7 4 Tube thoracostomy x2 including a 19 French Blake and a 32 French chest tube 5 Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor ANESTHESIA General endotracheal anesthesia with double lumen endotracheal tube DISPOSITION OF SPECIMENS To pathology both for frozen and permanent analysis FINDINGS The right middle lobe tumor was adherent to the anterior chest wall The adhesion was taken down and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis The final frozen pathology on this entire area returned as negative for tumor Additional chest wall abnormalities were biopsied and sent for pathologic analysis and these all returned separately as negative for tumor and only fibrotic tissue Several other biopsies were taken and sent for permanent analysis of the chest wall All of the biopsy sites were additionally marked with Hemoclips The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe ESTIMATED BLOOD LOSS Less than 100 mL CONDITION OF THE PATIENT AFTER SURGERY Stable HISTORY OF PROCEDURE This patient is well known to our service He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control The patient was subsequently taken to the operating room on April 4 2007 was given general anesthesia and was endotracheally intubated without incident Although he had markedly difficult airway the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi No abnormalities were noted in the entire tracheobronchial tree and based on this the decision was made to proceed with the surgery The patient was kept in the supine position and the single lumen endotracheal tube was removed and a double lumen tube was placed Following this the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded Sterile DuraPrep preparation on the right chest was placed A sterile drape around that was also placed The table was flexed to open up the intercostal spaces A second bronchoscopy was performed to confirm placement of the double lumen endotracheal tube Marcaine was infused into all incision areas prior to making an incision The incisions for the VATS right middle lobectomy included a small 1 cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula The camera port was in the posterior axillary line in the eighth intercostal space through which a 5 mm 30 degree scope was used Third incision was an anterior port which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space and the third incision was a utility port which was a 4 cm long incision which was approximately one rib space below the superior pulmonary vein All of these incisions were eventually created during the procedure The initial incision was the camera port through which under direct visualization an additional small 5 mm port was created just inferior to the anterior port These two ports were used to identify the chest wall lesions which were initially thought to be metastatic lesions Multiple biopsies of the chest wall lesions were taken and the decision was made to also insert the auscultatory incision port Through these three incisions the initial working of the diagnostic portion of the chest wall lesion was performed Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative The right middle lobe was noted to be adherent to the anterior chest wall This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue but no tumor cells Based on this the decision was made to not proceed with chest wall resection and continue with right middle lobectomy Following this the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45 mm EndoGIA stapler Following division of the right superior pulmonary vein the right middle lobe bronchus was easily identified Initially this was thought to be the main right middle lobe bronchus but in fact it was the medial branch of the right middle lobe bronchus This was encircled and divided with a blue load stapler with a 45 mm EndoGIA Following division of this the pulmonary artery was easily identified Two branches of the pulmonary artery were noted to be going into the right middle lobe These were individually divided with a vascular load after encircling with a right angle clamp The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk and following this an additional branch of the bronchus was noted to be going to the right middle lobe A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus This was divided with a blue load stapler 45 mm EndoGIA Following division of this the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe Following complete division of the fissure the lobe was put into an EndoGIA bag and taken out through the utility port Following removal of the right middle lobe a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package Node station 8 or 9 nodes were easily identified therefore none were taken The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted A 19 French Blake was placed into the posterior apical position and a 32 French chest tube was placed in the anteroapical position Following this the patient s lung was allowed to reexpand fully and the patient was checked for air leaking once again Following this all the ports were closed with 2 0 Vicryl suture used for the deeper tissue and 3 0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4 0 Monocryl suture was used to close the skin in a running subcuticular fashion The patient tolerated the procedure well was extubated in the operating room and taken to the recovery room in stable condition Keywords cardiovascular pulmonary middle lobe endogia fiberoptic mediastinal lymph node vats bronchoscopy chest tube chest wall endotracheal tube endotracheally lobectomy lung cancer pneumonitis sampling thoracostomy utility port lumen endotracheal tube superior pulmonary vein chest wall lesions anterior chest wall middle lobectomy fiberoptic bronchoscopy anterior chest lymph node node port chest bronchus tumor pulmonary incision MEDICAL_TRANSCRIPTION,Description Probable right upper lobe lung adenocarcinoma Specimen is received fresh for frozen section labeled with the patient s identification and Right upper lobe lung Medical Specialty Cardiovascular Pulmonary Sample Name Lung adenocarcinoma Path Report Transcription CLINICAL HISTORY Probable right upper lobe lung adenocarcinoma SPECIMEN Lung right upper lobe resection GROSS DESCRIPTION Specimen is received fresh for frozen section labeled with the patient s identification and Right upper lobe lung It consists of one lobectomy specimen measuring 16 1 x 10 6 x 4 5 cm The specimen is covered by a smooth pink tan and gray pleural surface which is largely unremarkable Sectioning reveals a round ill defined firm tan gray mucoid mass This mass measures 3 6 x 3 3 x 2 7 cm and is located 3 7 cm from the closest surgical margin and 3 9 cm from the hilum There is no necrosis or hemorrhage evident The tumor grossly appears to abut but not invade through the visceral pleura and the overlying pleura is puckered FINAL DIAGNOSIS Right lung upper lobe lobectomy Bronchioloalveolar carcinoma mucinous type COMMENT Right upper lobe lobectomy Tumor type Bronchioloalveolar carcinoma mucinous type Histologic grade Well differentiated Tumor size greatest diameter 3 6 cm Blood lymphatic vessel invasion Absent Perineural invasion Absent Bronchial margin Negative Vascular margin Negative Inked surgical margin Negative Visceral pleura Not involved In situ carcinoma Absent Non neoplastic lung Emphysema Hilar lymph nodes Number of positive lymph nodes 0 Total number of lymph nodes 1 P53 immunohistochemical stain is negative in the tumor Keywords cardiovascular pulmonary bronchioloalveolar carcinoma mucinous mucoid mass lymph nodes upper lobe visceral bronchioloalveolar carcinoma lymph pleural margin tumor adenocarcinoma specimen lobe lung MEDICAL_TRANSCRIPTION,Description Right lower lobectomy right thoracotomy extensive lysis of adhesions mediastinal lymphadenectomy Medical Specialty Cardiovascular Pulmonary Sample Name Lobectomy Lymphadenectomy Transcription PREOPERATIVE DIAGNOSIS Right lower lobe mass possible cancer POSTOPERATIVE DIAGNOSIS Non small cell carcinoma of the right lower lobe PROCEDURES 1 Right thoracotomy 2 Extensive lysis of adhesions 3 Right lower lobectomy 4 Mediastinal lymphadenectomy ANESTHESIA General DESCRIPTION OF THE PROCEDURE The patient was taken to the operating room and placed on the operating table in the supine position After an adequate general anesthesia was given she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion Lateral thoracotomy was performed on the right side anterior to the tip of the scapula and this was carried down through the subcutaneous tissue The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly The chest was entered through the fifth intercostal space A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection The right lower lobe was identified There was a large mass in the superior segment of the lobe which was very close to the right upper lobe and because of the adhesions it could not be told if the tumor was extending into the right upper lobe but it appeared that it did not Dissection was then performed at the lower lobe of the fissure and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe Then dissection of the hilum was performed and the branches of the pulmonary artery to the lower lobe were ligated with 2 0 silk freehand ties proximally and distally and 3 0 silk transfixion stitches and then transected The inferior pulmonary vein was dissected after dividing the ligament and it was stapled proximally and distally with a TA30 stapler and then transected Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected The bronchus was stapled with a TA30 bronchial stapler and then transected and the specimen was removed and sent to the Pathology Department for frozen section diagnosis The frozen section diagnosis was that of non small cell carcinoma bronchial margins free and pleural margins free The mediastinum was then explored No nodes were identified around the pulmonary ligament or around the esophagus Subcarinal nodes were dissected and hemostasis was obtained with clips The space below and above the osseous was opened and the station R4 nodes were dissected Hemostasis was obtained with clips and with electrocautery All nodal tissue were sent to Pathology as permanent specimen Following this the chest was thoroughly irrigated and aspirated Careful hemostasis was obtained and a couple of air leaks were controlled with 6 0 Prolene sutures Then two 28 French chest tubes were placed in the chest one posteriorly and one anteriorly and secured to the skin with 2 0 nylon stitches The incision was then closed with interrupted 2 0 Vicryl pericostal stitches A running 1 PDS on the muscle layer a running 2 0 PDS in the subcutaneous tissue and staples on the skin A sterile dressing was applied and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition ESTIMATED BLOOD LOSS 100 mL TRANSFUSIONS None COMPLICATIONS None CONDITION Condition of the patient on arrival to the intensive care unit was satisfactory Keywords cardiovascular pulmonary right lower lobe gia stapler mediastinal non small cell carcinoma cancer frozen section hilum lobectomy lymphadenectomy lysis of adhesions pleura thoracotomy upper lobe lower lobectomy adhesions chest MEDICAL_TRANSCRIPTION,Description Left lower extremity venous Doppler ultrasound Medical Specialty Cardiovascular Pulmonary Sample Name Lower Extremity Venous Doppler Transcription LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND REASON FOR EXAM Status post delivery five weeks ago presenting with left calf pain INTERPRETATIONS There was normal flow compression and augmentation within the right common femoral superficial femoral and popliteal veins Lymph nodes within the left inguinal region measure up to 1 cm in short axis IMPRESSION Lymph nodes within the left inguinal region measure up to 1 cm in short axis otherwise no evidence for left lower extremity venous thrombosis Keywords cardiovascular pulmonary popliteal veins superficial femoral common femoral inguinal region lymph nodes venous doppler lower extremity lymph inguinal axis doppler extremity venous MEDICAL_TRANSCRIPTION,Description Lower Extremity Arterial Doppler Medical Specialty Cardiovascular Pulmonary Sample Name Lower Extremity Arterial Doppler Transcription RIGHT LOWER EXTREMITY The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0 8 LEFT LOWER EXTREMITY The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery with biphasic waveform at the posterior tibial artery Ankle brachial index of 0 9 IMPRESSION Mild bilateral lower extremity arterial obstructive disease Keywords cardiovascular pulmonary lower extremity arterial doppler posterior tibial artery ankle brachial index arterial doppler triphasic waveform common femoral biphasic waveform tibial artery ankle brachial brachial index lower extremity doppler triphasic femoral popliteal brachial waveform extremity arterial MEDICAL_TRANSCRIPTION,Description Left lower lobectomy Medical Specialty Cardiovascular Pulmonary Sample Name Lobectomy Left Lower Transcription OPERATION Left lower lobectomy OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position After general endotracheal anesthesia was induced the appropriate monitoring devices were placed The patient was placed in the right lateral decubitus position The left chest and back were prepped and draped in a sterile fashion A right lateral thoracotomy incision was made Subcutaneous flaps were raised The anterior border of the latissimus dorsi was freed up and the muscle was retracted posteriorly The posterior border of the pectoralis was freed up and it was retracted anteriorly The 5th intercostal space was entered The inferior pulmonary ligament was then taken down with electrocautery The major fissure was then taken down and arteries identified The artery was dissected free and it was divided with an Endo GIA stapler The vein was then dissected free and divided with an Endo GIA stapler The bronchus was then cleaned of all nodal tissue A TA 30 green loaded stapler was then placed across this fired and main bronchus divided distal to the stapler Then the lobe was removed and sent to pathology where margins were found to be free of tumor Level 9 level 13 level 11 and level 6 nodes were taken for permanent cell specimen Hemostasis noted Posterior 28 French and anterior 24 French chest tubes were placed The wounds were closed with 2 Vicryl A subcutaneous drain was placed Subcutaneous tissue was closed with running 3 0 Dexon skin with running 4 0 Dexon subcuticular stitch Keywords cardiovascular pulmonary lower lobectomy electrocautery endo gia stapler subcutaneous drain endotracheal subcutaneous lobectomy MEDICAL_TRANSCRIPTION,Description Patient is here to discuss possible open lung biopsy Medical Specialty Cardiovascular Pulmonary Sample Name Lung Biopsy Discussion Transcription CHART NOTE She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow Dr XYZ had seen her because of her complaints of shortness of breath Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis but wanted her to have an open lung biopsy so he had her see Dr XYZ Estep He had concurred with Dr XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy She was ready to go ahead with this and felt that it was important she find out why she is short of breath She is very concerned about the findings on her CAT scan and pulmonary function test She seemed alarmed to report that Dr XYZ had found that her lung capacity was reduced to 60 of what should be normal However I told her that two years ago Dr XYZ did pulmonary function studies which showed the same change in function And that really her pulmonary function test at least compared from two years ago had not really changed over this period of time After discussing the serious nature of an open lung biopsy the fact that her pulmonary function studies have not changed in two years the fact that she likely has a number of other things that are contributing to her being out of breath which is deconditioning and obesity she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy In fact when I called Dr XYZ to talk to him about cancelling the procedure he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed I also explained to patient that I did not think Dr XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those And also I spoke with Dr XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities I had a 30 minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan x ray and pulmonary function tests And if there was some sign that this was a progressive problem she could still go ahead with the lung biopsy But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful We are going to see her back in a month to see how her breathing is doing We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time I told her I would try to talk to her sister sometime in the next day or two Keywords cardiovascular pulmonary discuss interstitial pneumonitis lung biopsy lung capacity pulmonary function test shortness of breath pulmonary function studies pulmonary function function biopsy lung interstitial pulmonaryNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description The patient is a 65 year old female who underwent left upper lobectomy for stage IA non small cell lung cancer She returns for a routine surveillance visit The patient has no evidence of disease now status post left upper lobectomy for stage IA non small cell lung cancer 13 months ago Medical Specialty Cardiovascular Pulmonary Sample Name Lobectomy Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 65 year old female who underwent left upper lobectomy for stage IA non small cell lung cancer She returns for a routine surveillance visit She has undergone since her last visit an abdominopelvic CT which shows an enlarging simple cyst of the left kidney She underwent barium swallow which demonstrates a small sliding hiatal hernia with minimal reflux She has a minimal delayed emptying secondary tertiary contractions PA and lateral chest x ray from the 11 23 09 was also reviewed which demonstrates no lesions or infiltrates Review of systems the patient continues to have periodic odynophagia and mid thoracic dysphagia This most likely is secondary to tertiary contractions with some delayed emptying She has also had increased size of the left calf without tenderness which has not resolved over the past several months She has had a previous DVT in 1975 and 1985 She denies weight loss anorexia fevers chills headaches new aches or pains cough hemoptysis shortness of breath at rest or dyspnea on exertion MEDICATIONS Aspirin 81 mg p o q d Spiriva 10 mcg q d and albuterol p r n PHYSICAL EXAMINATION BP 117 78 RR 18 P 93 WT 186 lbs RAS 100 HEENT Mucous membranes are moist No cervical or supraclavicular lymphadenopathy LUNGS Clear to auscultation bilaterally CARDIAC Regular rate and rhythm without murmurs EXTREMITIES No cyanosis clubbing or edema NEURO Alert and oriented x3 Cranial nerves II through XII intact ASSESSMENT The patient has no evidence of disease now status post left upper lobectomy for stage IA non small cell lung cancer 13 months ago PLAN She is to return to clinic in six months with a chest CT She was given a prescription for an ultrasound of the left lower extremity to rule out DVT She will be called with the results She was given a prescription for nifedipine 10 mg p o t i d p r n esophageal spasm Keywords cardiovascular pulmonary non small cell lung cancer lobectomy lung cancer non small cell lung cancer MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis Medical Specialty Cardiovascular Pulmonary Sample Name Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis POSTOPERATIVE DIAGNOSIS Subglottic upper tracheal stenosis OPERATION PREFORMED Direct laryngoscopy rigid bronchoscopy and dilation of subglottic upper tracheal stenosis INDICATIONS FOR THE SURGERY The patient is a 76 year old white female with a history of subglottic upper tracheal stenosis She has had undergone multiple previous endoscopic procedures in the past last procedure was in January 2007 She returns with some increasing shortness of breath and dyspnea on exertion Endoscopic reevaluation is offered to her The patient has been considering laryngotracheal reconstruction however due to a recent death in the family she has postponed this but she has been having increasing symptoms An endoscopic treatment was offered to her Nature of the proposed procedure including risks and complications involving bleeding infection alteration of voice speech or swallowing hoarseness changing permanently recurrence of stenosis despite a surgical intervention airway obstruction necessitating a tracheostomy now or in the future cardiorespiratory and anesthetic risks were all discussed in length The patient states she understood and wished to proceed DESCRIPTION OF THE OPERATION The patient was taken to the operating room placed on table in supine position Following adequate general anesthesia the patient was prepared for endoscopy The top sliding laryngoscope was then inserted in the oral cavity pharynx and larynx examined In the oral cavity she had good dentition Tongue and buccal cavity mucosa were without ulcers masses or lesions The oropharynx was clear The larynx was then manually suspended Epiglottis area epiglottic folds false cords true vocal folds with some mild edema but otherwise without ulcers masses or lesions and the supraglottic and glottic airway were widely patent The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds At the base of the subglottis there was a narrowing and in the upper trachea restenosis had occurred Moderate amount of mucoid secretions these were suctioned following which the area of stenosis was dilated Remainder of the bronchi was then examined The mid and distal trachea were widely patent Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers lesions or evidence of scarring The scope was pulled back and removed and following this a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out Once this had been completed dramatic improvement in the subglottic upper tracheal airway accomplished Instrumentation was removed and a 6 endotracheal tube uncuffed was placed to allow smooth emerge from anesthesia The patient tolerated the procedure well without complication Keywords cardiovascular pulmonary stenosis epiglottis subglottic bronchoscope bronchoscopy endoscopic laryngoscopy laryngotracheal reconstruction larynx oral cavity pharynx tracheal true vocal folds vocal upper tracheal stenosis subglottic upper tracheal subglottic upper upper tracheal airway cavity patent MEDICAL_TRANSCRIPTION,Description Specimen Lung left lower lobe resection Sarcomatoid carcinoma with areas of pleomorphic giant cell carcinoma and spindle cell carcinoma The tumor closely approaches the pleural surface but does not invade the pleura Medical Specialty Cardiovascular Pulmonary Sample Name Immunohistochemical Study Transcription CLINICAL HISTORY Patient is a 37 year old female with a history of colectomy for adenoma During her preop evaluation it was noted that she had a lesion on her chest x ray CT scan of the chest confirmed a left lower mass SPECIMEN Lung left lower lobe resection IMMUNOHISTOCHEMICAL STUDIES Tumor cells show no reactivity with cytokeratin AE1 AE3 No significant reactivity with CAM5 2 and no reactivity with cytokeratin 20 are seen Tumor cells show partial reactivity with cytokeratin 7 PAS with diastase demonstrates no convincing intracytoplasmic mucin No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody No significant reactivity is demonstrated with melanoma marker HMB 45 or Melan A Tumor cell nuclei spindle cell and pleomorphic giant cell carcinoma components show nuclear reactivity with thyroid transcription factor marker TTF 1 The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic giant cell carcinoma and spindle cell carcinoma components FINAL DIAGNOSIS Histologic Tumor Type Sarcomatoid carcinoma with areas of pleomorphic giant cell carcinoma and spindle cell carcinoma Tumor Size 2 7 x 2 0 x 1 4 cm Visceral Pleura Involvement The tumor closely approaches the pleural surface but does not invade the pleura Vascular Invasion Present Margins Bronchial resection margins and vascular margins are free of tumor Lymph Nodes Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes Pathologic Stage pT1N1MX Keywords cardiovascular pulmonary cytokeratin 20 hmb 45 melanoma spindle cell carcinoma tumor cells carcinoma immunohistochemical lung cytokeratin sarcomatoid spindle pleural cell tumor MEDICAL_TRANSCRIPTION,Description Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome Medical Specialty Cardiovascular Pulmonary Sample Name IV Procainamide Infusion Transcription PREOPERATIVE DIAGNOSIS Syncopal episodes with injury See electrophysiology consultation POSTOPERATIVE DIAGNOSES 1 Normal electrophysiologic studies 2 No inducible arrhythmia 3 Procainamide infusion negative for Brugada syndrome PROCEDURES 1 Comprehensive electrophysiology studies with attempted arrhythmia induction 2 IV Procainamide infusion for Brugada syndrome DESCRIPTION OF PROCEDURE The patient gave informed consent for comprehensive electrophysiologic studies She received small amounts of intravenous fentanyl and Versed for conscious sedation Then 1 lidocaine local anesthesia was used Three catheters were placed via the right femoral vein 5 French catheters to the right ventricular apex and right atrial appendage and a 6 French catheter to the His bundle Later in the procedure the RV apical catheter was moved to RV outflow tract ELECTROPHYSIOLOGICAL FINDINGS Conduction intervals in sinus rhythm were normal Sinus cycle length 768 ms PA interval 24 ms AH interval 150 ms HV interval 46 ms Sinus node recovery times were also normal at 1114 ms Corrected sinus node recovery time was normal at 330 ms One to one AV conduction was present to cycle length 480 ms AH interval 240 ms HV interval 54 ms AV nodal effective refractory period was normal 440 ms at drive cycle length 600 ms RA ERP was 250 ms With ventricular pacing there was VA disassociation present Since there was no evidence for dual AV nodal pathways and poor retrograde conduction isoproterenol infusion was not performed to look for SVT Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts Drive cycle length 600 500 and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms or refractoriness There was no inducible VT Longest run was 5 beats of polymorphic VT which is a nonspecific finding From the apex 400 600 with 2 extrastimuli were delivered again with no inducible VT Procainamide was then infused 20 mg kg over 10 minutes There were no ST segment changes HV interval after IV Procainamide remained normal at 50 ms ASSESSMENT Normal electrophysiologic studies No evidence for sinus node dysfunction or atrioventricular block No inducible supraventricular tachycardia or ventricular tachycardia and no evidence for Brugada syndrome PLAN The patient will follow up with Dr X She recently had an ambulatory EEG I will plan to see her again on a p r n basis should she develop a recurrent syncopal episodes Reveal event monitor was considered but not placed since she has only had one single episode Keywords cardiovascular pulmonary arrhythmia attempted arrhythmia induction conduction sinus rhythm electrophysiologic studies sinus node iv procainamide brugada syndrome electrophysiology sinus ventricular MEDICAL_TRANSCRIPTION,Description Lexiscan Nuclear Myocardial Perfusion Scan Chest pain Patient unable to walk on a treadmill Nondiagnostic Lexiscan Normal nuclear myocardial perfusion scan Medical Specialty Cardiovascular Pulmonary Sample Name Lexiscan Nuclear Scan Transcription EXAM Lexiscan Nuclear Myocardial Perfusion Scan INDICATION Chest pain TYPE OF TEST Lexiscan unable to walk on a treadmill INTERPRETATION Resting heart rate of 96 blood pressure of 141 76 EKG normal sinus rhythm nonspecific ST T changes left bundle branch block Post Lexiscan 0 4 mg injected intravenously by standard protocol Peak heart rate was 105 blood pressure of 135 72 EKG remains the same No symptoms are noted SUMMARY 1 Nondiagnostic Lexiscan 2 Nuclear interpretation as below NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL Resting and stress images were obtained with 10 4 32 5 mCi of tetrofosmin injected intravenously by standard protocol Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake There is no evidence of reversible or fixed defect Gated SPECT revealed mild global hypokinesis more pronounced in the septal wall possibly secondary to prior surgery Ejection fraction calculated at 41 End diastolic volume of 115 end systolic volume of 68 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction 41 by gated SPECT Keywords cardiovascular pulmonary lexiscan nuclear myocardial perfusion scan treadmill bundle branch block mci tetrofosmin nuclear myocardial perfusion scan blood pressure gated spect ejection fraction myocardial perfusion ejection fraction myocardial lexiscan nuclear MEDICAL_TRANSCRIPTION,Description Nonischemic cardiomyopathy branch vessel coronary artery disease congestive heart failure NYHA Class III history of nonsustained ventricular tachycardia hypertension and hepatitis C Medical Specialty Cardiovascular Pulmonary Sample Name Hypertension Cardiomyopathy Transcription PROBLEMS LIST 1 Nonischemic cardiomyopathy 2 Branch vessel coronary artery disease 3 Congestive heart failure NYHA Class III 4 History of nonsustained ventricular tachycardia 5 Hypertension 6 Hepatitis C INTERVAL HISTORY The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications However he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest He has history of orthopnea and PND He has gained a few pounds of weight but denied to have any palpitation presyncope or syncope REVIEW OF SYSTEMS Positive for right upper quadrant pain He has occasional nausea but no vomiting His appetite has decreased No joint pain TIA seizure or syncope Other review of systems is unremarkable I reviewed his past medical history past surgical history and family history SOCIAL HISTORY He has quit smoking but unfortunately was positive for cocaine during last hospital stay in 01 08 ALLERGIES He has no known drug allergies MEDICATIONS I reviewed his medication list in the chart He states he is compliant but he was not taking the revised dose of medications as per discharge orders and prescription PHYSICAL EXAMINATION VITAL SIGNS Pulse 91 per minute and regular blood pressure 151 102 in the right arm and 152 104 in the left arm weight 172 pounds which is about 6 pounds more than last visit in 11 07 HEENT Atraumatic and normocephalic No pallor icterus or cyanosis NECK Supple Jugular venous distention 5 cm above the clavicle present No thyromegaly LUNGS Clear to auscultation No rales or rhonchi Pulse ox was 98 on room air CVS S1 and S2 present S3 and S4 present ABDOMEN Soft and nontender Liver is palpable 5 cm below the right subcostal margin EXTREMITIES No clubbing or cyanosis A 1 edema present ASSESSMENT AND PLAN The patient has hypertension nonischemic cardiomyopathy and branch vessel coronary artery disease Clinically he is in NYHA Class III He has some volume overload and was not unfortunately taking Lasix as prescribed I have advised him to take Lasix 40 mg p o b i d I also increased the dose of hydralazine from 75 mg t i d to 100 mg t i d I advised him to continue to take Toprol and lisinopril I have also added Aldactone 25 mg p o daily for survival advantage I reinforced the idea of not using cocaine He states that it was a mistake may be somebody mixed in his drink but he has not intentionally taken any cocaine I encouraged him to find a primary care provider He will come for a BMP check in one week I asked him to check his blood pressure and weight I discussed medication changes and gave him an updated list I have asked him to see a gastroenterologist for hepatitis C At this point his Medicaid is pending He has no insurance and finds hard to find a primary care provider I will see him in one month He will have his fasting lipid profile AST and ALT checked in one week Keywords cardiovascular pulmonary congestive heart failure hypertension cardiomyopathy coronary artery disease ventricular tachycardia nonischemic cardiomyopathy branch vessel nyha class nonischemic tachycardia orthopnea MEDICAL_TRANSCRIPTION,Description An 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation Medical Specialty Cardiovascular Pulmonary Sample Name Hypertension Consult Transcription HISTORY OF PRESENT ILLNESS The patient is an 84 year old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall Basically the patient states that yesterday she fell and she is not certain about the circumstances on her driveway and on her left side hit a rock When she came to the emergency room she was found to have a rapid atrial tachyarrhythmia and was put on Cardizem with reportedly heart rate in the 50s so that was stopped Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker An ECG this morning showing normal sinus rhythm with frequent APCs Her potassium at that time was 3 1 She does recall having palpitations because of the pain after the fall but she states she is not having them since and has not had them prior She denies any chest pain nor shortness of breath prior to or since the fall She states clearly she can walk and she would be able to climb 2 flights of stairs without problems PAST CARDIAC HISTORY She is followed by Dr X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure On 05 12 08 preserved left and right ventricular systolic function aortic sclerosis with apparent mild aortic stenosis and bi atrial enlargement She has previously had a Persantine Myoview nuclear rest stress test scan completed at ABCD Medical Center in 07 06 that was negative She has had significant mitral valve regurgitation in the past being moderate but on the most recent echocardiogram on 05 12 08 that was not felt to be significant She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker She does have a history of significant hypertension in the past She has had dizzy spells and denies clearly any true syncope She has had bradycardia in the past from beta blocker therapy MEDICATIONS ON ADMISSION 1 Multivitamin p o daily 2 Aspirin 325 mg once a day 3 Lisinopril 40 mg once a day 4 Felodipine 10 mg once a day 5 Klor Con 20 mEq p o b i d 6 Omeprazole 20 mg p o daily presumably for GERD 7 MiraLax 17 g p o daily 8 Lasix 20 mg p o daily ALLERGIES PENICILLIN IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST FAMILY HISTORY She states her brother died of an MI suddenly in his 50s SOCIAL HISTORY She does not smoke cigarettes abuse alcohol nor use any illicit drugs She is retired from Morse Chain and delivering newspapers She is widowed She lives alone but has family members who live either on her property or adjacent to it REVIEW OF SYSTEMS She denies a history of stroke cancer vomiting of blood coughing up blood bright red blood per rectum bleeding stomach ulcers She does not recall renal calculi nor cholelithiasis denies asthma emphysema pneumonia tuberculosis sleep apnea home oxygen use She does note occasional peripheral edema She is not aware of prior history of MI She denies diabetes She does have a history of GERD She notes feeling depressed at times because of living alone She denies rheumatologic conditions including psoriasis or lupus Remainder of review of systems is negative times 15 except as described above PHYSICAL EXAM Height 5 feet 0 inches weight 123 pounds temperature 99 2 degrees Fahrenheit blood pressure has ranged from 160 87 with pulses recorded at being 144 and currently ranges 101 53 to 147 71 pulse 64 respiratory rate 20 O2 saturation 97 On general exam she is a pleasant elderly woman who is hard of hearing but is alert and interactive HEENT Shows cranium is normocephalic and atraumatic She has moist mucosal membranes Neck veins were not distended There are no carotid bruits Lungs Clear to auscultation anteriorly without wheezes She is relatively immobile because of her left hip fracture Cardiac Exam S1 S2 regular rate frequent ectopic beats 2 6 systolic ejection murmur preserved aortic component of the second heart sound There is also a soft holosystolic murmur heard There is no rub or gallop PMI is nondisplaced Abdomen is soft and nondistended Bowel sounds present Extremities without significant clubbing cyanosis and there is trivial to 1 peripheral edema Pulses appear grossly intact Affect is appropriate Visible skin warm and perfused She is not able to move because of left hip fracture easily in bed DIAGNOSTIC STUDIES LAB DATA Pertinent labs include chest x ray with radiology report pending but shows only a calcified aortic knob No clear pulmonary vascular congestion Sodium 140 potassium 3 7 it was 3 1 on admission chloride 106 bicarbonate 27 BUN 17 creatinine 0 9 glucose 150 magnesium was 2 on 07 13 06 Troponin was 0 03 followed by 0 18 INR is 0 93 white blood cell count 10 2 hematocrit 36 platelet count 115 000 EKGs are reviewed Initial EKG done on 08 19 08 at 1832 shows MAT heart rate of 104 beats per minute no ischemic changes She had a followup EKG done at 20 37 on 08 19 08 which shows wandering atrial pacemaker and some lateral T wave changes not significantly changed from prior Followup EKG done this morning shows normal sinus rhythm with frequent APCs IMPRESSION She is an 84 year old female with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery Telemetry now reviewed shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia which has been corrected There has been no atrial fibrillation documented I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath She actually describes feeling good exercise capacity prior to this fall Given favorable risk to benefit ratio for needed left hip surgery I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil which has been started which should help control the multifocal atrial tachycardia which she had and would watch for heart rate with that Continued optimization of electrolytes The patient cannot take beta blockers as previously Toprol reportedly caused shortness of breath although there was some report that it caused bradycardia so we would watch her heart rate on the verapamil The patient is aware of the cardiac risks certainly it is moderate and wishes to proceed with needed surgery I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr X after discharge Regarding her mild thrombocytopenia I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease management of left hip fracture as per orthopedist Keywords cardiovascular pulmonary hypokalemia shortness of breath atrial tachycardia sinus rhythm hip fracture atrial tachycardia rhythm apcs cardiac regurgitation aortic hypertension pulmonary MEDICAL_TRANSCRIPTION,Description Patient with hypertension syncope and spinal stenosis for recheck Medical Specialty Cardiovascular Pulmonary Sample Name Hypertension Progress Note Transcription SUBJECTIVE The patient is a 78 year old female who returns for recheck She has hypertension She denies difficulty with chest pain palpations orthopnea nocturnal dyspnea or edema PAST MEDICAL HISTORY SURGERY HOSPITALIZATIONS Reviewed and unchanged from the dictation on 12 03 2003 MEDICATIONS Atenolol 50 mg daily Premarin 0 625 mg daily calcium with vitamin D two to three pills daily multivitamin daily aspirin as needed and TriViFlor 25 mg two pills daily She also has Elocon cream 0 1 and Synalar cream 0 01 that she uses as needed for rash ALLERGIES Benadryl phenobarbitone morphine Lasix and latex FAMILY HISTORY PERSONAL HISTORY Reviewed Mother died from congestive heart failure Father died from myocardial infarction at the age of 56 Family history is positive for ischemic cardiac disease Brother died from lymphoma She has one brother living who has had angioplasties x 2 She has one brother with asthma PERSONAL HISTORY Negative for use of alcohol or tobacco REVIEW OF SYSTEMS Bones and Joints She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg She had been followed by Dr Mills but decided to see Dr XYZ who referred to her Dr Isaac She underwent several tests She did have magnetic resonance angiography of the lower extremities and the aorta which were normal She had nerve conduction study that showed several peripheral polyneuropathy She reports that she has myelogram last week but has not got results of this She reports that the rest of her tests have been normal but it seems that vertebrae shift when she stands and then pinches the nerve She is now seeing Dr XYZ who comes to Hutchison from KU Medical Center and she thinks that she probably will have surgery in the near future Genitourinary She has occasional nocturia PHYSICAL EXAMINATION Vital Signs Weight 227 2 pounds Blood pressure 144 72 Pulse 80 Temperature 97 5 degrees General Appearance She is an elderly female patient who is not in acute distress Mouth Posterior pharynx is clear Neck Without adenopathy or thyromegaly Chest Lungs are resonant to percussion Auscultation reveals normal breath sounds Heart Normal S1 and S2 without gallops or rubs Abdomen Without masses or tenderness to palpation Extremities Without edema IMPRESSION PLAN 1 Hypertension She is advised to continue with the same medication 2 Syncope She previously had an episode of syncope around Thanksgiving She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias 3 Spinal stenosis She still is being evaluated for this and possibly will have surgery in the near future Keywords cardiovascular pulmonary progress note hypertension spinal stenosis syncope spinal stenosis infarction orthopnea MEDICAL_TRANSCRIPTION,Description Holter monitor report Predominant rhythm is sinus Triplet maximum rate of 178 beats per minute noted Medical Specialty Cardiovascular Pulmonary Sample Name Holter Monitor Report 1 Transcription INDICATIONS Predominant rhythm is sinus Heart rate varied between 56 128 beats per minute average heart rate of 75 beats per minute Minimum heart rate of 50 beats per minute 640 ventricular ectopic isolated beats noted Rare isolated APCs and supraventricular couplets One supraventricular triplet reported Triplet maximum rate of 178 beats per minute noted Keywords cardiovascular pulmonary holter monitor heart rate supraventricular triplet heart beatsNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Holter monitoring for syncope Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds Medical Specialty Cardiovascular Pulmonary Sample Name Holter Monitor Report 2 Transcription INDICATION Syncope HOLTER MONITOR SUMMARY ANALYSIS Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds Total beats of 108 489 heart rate minimum of approximately 54 beats per minutes at 7 a m and maximum of 106 beats per minute at approximately 4 p m Average heart rate is approximately 75 beats per minute total of 31 to bradycardia longest being 225 beats at approximately 7 in the morning minimum rate of 43 beats per minute at approximately 01 40 a m Total ventricular events of 64 primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2 7 mm IMPRESSION OF THE FINDINGS Predominant sinus rhythm with occasional premature ventricular contraction occasional atrial premature contractions and Mobitz type 1 Wenckebach several episodes Mobitz type II 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted No significant pauses noted Keywords cardiovascular pulmonary artefact ventricular contraction holter monitor premature contractions mobitz type holter beatsNOTE MEDICAL_TRANSCRIPTION,Description Placement of a subclavian single lumen tunneled Hickman central venous catheter Surgeon interpreted fluoroscopy Medical Specialty Cardiovascular Pulmonary Sample Name Hickman Central Venous Catheter Placement Transcription PROCEDURE PERFORMED 1 Placement of a subclavian single lumen tunneled Hickman central venous catheter 2 Surgeon interpreted fluoroscopy OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and anesthesia was administered Next a 18 gauge needle was used to locate the subclavian vein After aspiration of venous blood a J wire was inserted through the needle using Seldinger technique The needle was withdrawn The distal tip location of the J wire was confirmed to be in adequate position with surgeon interpreted fluoroscopy Next a separate stab incision was made approximately 3 fingerbreadths below the wire exit site A subcutaneous tunnel was created and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff The catheter was cut to the appropriate length A dilator and sheath were passed over the J wire The dilator and J wire were removed and the distal tip of the Hickman catheter was threaded through the sheath which was simultaneously withdrawn The catheter was flushed and aspirated without difficulty The distal tip was confirmed to be in good location with surgeon interpreted fluoroscopy A 2 0 nylon was used to secure the cuff down to the catheter at the skin level The skin stab site was closed with a 4 0 Monocryl The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition Keywords cardiovascular pulmonary j wire distal tip stab incision tunneled hickman central venous catheter subclavian venous fluoroscopy hickman catheterNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Holter monitoring For bradycardia and dizziness Medical Specialty Cardiovascular Pulmonary Sample Name Holter Monitoring Transcription INDICATION Bradycardia and dizziness COMMENTS 1 The patient was monitored for 24 hours 2 The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute 3 There were occasional premature atrial contractions seen no supraventricular tachycardia was seen 4 There was a frequent premature ventricular contraction seen Between 11 00 a m and 11 15 a m the patient was in ventricular bigemini and trigemini most of the time During rest of the monitoring period there were just occasional premature ventricular contractions seen No ventricular tachycardia was seen 5 There were no pathological pauses noted 6 The longest RR interval was 1 1 second 7 There were no symptoms reported Keywords cardiovascular pulmonary holter monitoring bradycardia bigemini dizziness heart rate interval predominant premature premature ventricular contraction rhythm sinus trigemini ventricular bradycardia and dizziness premature ventricular monitoring MEDICAL_TRANSCRIPTION,Description Holter Monitor Report Medical Specialty Cardiovascular Pulmonary Sample Name Holter Monitor Report Transcription INTERPRETATION 1 Predominant rhythm is normal sinus rhythm 2 No supraventricular arrhythmia 3 Frequent premature ventricular contractions 4 Trigemini and couplets 5 No high grade atrial ventricular block was noted 6 Diary was not kept IMPRESSION Frequent premature atrial contractions couplets and trigemini Keywords cardiovascular pulmonary atrial ventricular block holter monitor report holter monitor frequent premature holter monitor rhythm ventricular contractions trigemini atrial MEDICAL_TRANSCRIPTION,Description Left heart catheterization coronary angiography left ventriculography Severe complex left anterior descending and distal circumflex disease with borderline probably moderate narrowing of a large obtuse marginal branch Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 7 Transcription PROCEDURE Left heart catheterization coronary angiography left ventriculography COMPLICATIONS None PROCEDURE DETAIL The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration A 6 French arterial sheath was placed in the usual fashion Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic The right coronary artery was difficult to cannulate because of its high anterior takeoff This was nondominant Several catheters were used Ultimately an AL1 diagnostic catheter was used A pigtail catheter was advanced across the aortic valve Left ventriculogram was then done in the RAO view using 30 mL of contrast Pullback gradient was obtained across the aortic valve Femoral angiogram was performed through the sheath which was above the bifurcation was removed with a Perclose device with good results There were no complications He tolerated this procedure well and returned to his room in good condition FINDINGS 1 Right coronary artery This has an unusual high anterior takeoff The vessel is nondominant has diffuse mild to moderate disease 2 Left main trunk A 30 to 40 distal narrowing is present 3 Left anterior descending Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch there is 80 to 90 narrowing The diagonal is a large vessel about 3 mm in size 4 Circumflex Dominant vessel 50 narrowing at the origin of the obtuse marginal After this there is 40 narrowing in the AV trunk The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch which has 70 ostial narrowing and then after this the posterior descending has 80 narrowing at its origin 5 Left ventriculogram Normal volume in diastole and systole Normal systolic function is present There is no mitral insufficiency or left ventricular outflow obstruction DIAGNOSES 1 Severe complex left anterior descending and distal circumflex disease with borderline probably moderate narrowing of a large obtuse marginal branch Dominant circumflex system Severe disease of the posterior descending Mild left main trunk disease 2 Normal left ventricular systolic function Given the complex anatomy of the predominant problem which is the left anterior descending given its ostial stenosis and involvement of the bifurcation of the diagonal would recommend coronary bypass surgery The patient also has severe disease of the circumflex which is dominant This anatomy is not appropriate for percutaneous intervention The case will be reviewed with a cardiac surgeon Keywords cardiovascular pulmonary heart catheterization coronary angiography left ventriculography arterial sheath coronary artery obtuse marginal branch angiography catheterization MEDICAL_TRANSCRIPTION,Description Left heart catheterization with left ventriculography and selective coronary angiography A 50 distal left main and two vessel coronary artery disease with normal left ventricular systolic function Frequent PVCs Metabolic syndrome Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 6 Transcription PREOPERATIVE DIAGNOSES 1 Dyspnea on exertion with abnormal stress echocardiography 2 Frequent PVCs 3 Metabolic syndrome POSTOPERATIVE DIAGNOSES 1 A 50 distal left main and two vessel coronary artery disease with normal left ventricular systolic function 2 Frequent PVCs 3 Metabolic syndrome PROCEDURES 1 Left heart catheterization with left ventriculography 2 Selective coronary angiography COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the Cardiac Catheterization Laboratory in fasting state Both groins were prepped and draped in the usual sterile fashion Xylocaine 1 was used as local anesthetic Versed and fentanyl were used for conscious sedation Next a 6 French sheath was placed in the right femoral artery using modified Seldinger technique Next selective angiography of the left coronary artery was performed in multiple views using 6 French JL4 catheter Next selective angiography of the right coronary artery was performed in multiple views using 6 French 3DRC catheter Next a 6 French angle pigtail catheter was advanced into the left ventricle The left ventricular pressure was then recorded Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds The left heart pull back was then performed The catheter was then removed Angiography of the right femoral artery was performed Hemostasis was obtained by Angio Seal closure device The patient left the Cardiac Catheterization Laboratory in stable condition HEMODYNAMICS 1 LV pressure was 163 0 with end diastolic pressure of 17 There was no significant gradient across the aortic valve 2 Left ventriculography showed old inferior wall hypokinesis Global left ventricular systolic function is normal Estimated ejection fraction was 58 There is no significant mitral regurgitation 3 Significant coronary artery disease 4 The left main is approximately 7 or 8 mm proximally It trifurcates into left anterior descending artery ramus intermedius artery and left circumflex artery The distal portion of the left main has an ulcerated excentric plaque up to about 50 in severity 5 The left anterior descending artery is around 4 mm proximally It extends slightly beyond the apex into the inferior wall It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators At the ostium of the left anterior descending artery there was an eccentric plaque up to 70 to 80 best seen in the shallow LAO with caudal angulation There was no other flow limiting disease noted in the rest of the left anterior descending artery or its major branches The ramus intermedius artery is around 3 mm proximally but shortly after its origin it bifurcates into two medium size branches There was no significant disease noted in the ramus intermedius artery however The left circumflex artery is around 2 5 mm proximally It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch The mid to distal circumflex has a moderate disease which is relatively diffuse up to about 40 to 50 The right coronary artery is around 4 mm in diameter It gives off conus branch two medium size acute marginal branches relatively large posterior descending artery and a posterior lateral branch In the mid portion of the right coronary artery at the origin of the first acute marginal branch there is a relatively discrete stenosis of about 80 to 90 Proximally there is an area of eccentric plaque but seem to be non flow limiting at best around 20 to 30 Additionally there is what appears to be like a shell like lesion in the proximal segment of the right coronary artery as well The posterior descending artery has an eccentric plaque of about 40 to 50 in its mid segment PLAN Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery Continue risk factor modification aspirin and beta blocker Keywords cardiovascular pulmonary heart catheterization ventriculography coronary angiography dyspnea metabolic syndrome two vessel coronary artery disease echocardiography selective coronary angiography anterior descending artery branches coronary angiography artery catheterization MEDICAL_TRANSCRIPTION,Description Left heart catheterization selective bilateral coronary angiography and left ventriculography Revascularization of the left anterior descending with angioplasty and implantation of a drug eluting stent Right heart catheterization and Swan Ganz catheter placement for monitoring Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 5 Transcription PREOPERATIVE DIAGNOSES 1 Acute coronary artery syndrome with ST segment elevation in anterior wall distribution 2 Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery last procedure in 2005 3 Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation He is intubated and ventilated POSTOPERATIVE DIAGNOSES Acute coronary artery syndrome with ST segment elevation in anterior wall distribution Primary ventricular arrhythmia Occluded left anterior descending artery successfully re canalized with angioplasty and implantation of the drug eluting stent Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery well collateralized PROCEDURES Left heart catheterization selective bilateral coronary angiography and left ventriculography Revascularization of the left anterior descending with angioplasty and implantation of a drug eluting stent Right heart catheterization and Swan Ganz catheter placement for monitoring DESCRIPTION OF PROCEDURE The patient arrived from the emergency room intubated and ventilated He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated The right femoral area was prepped and draped in usual sterile fashion Lidocaine 2 mL was then filled locally The right femoral artery was cannulated with an 18 guage needle followed by a 6 French vascular sheath A guiding catheter XB 3 5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery which is well collateralized An angioplasty wire with present wire was advanced into the left anterior descending artery and could cross the area of occlusion within the stent An angioplasty balloon measuring 2 0 x 15 was advanced and three inflations were obtained It successfully re canalized the artery There is evidence of residual stenosis within the distal aspect of the previous stents A drug eluting stent Xience 2 75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres The intermittent result was improved An additional inflation was obtained more proximally His blood pressure fluctuated and dropped in the 70s correlating with additional sedation There is patency of the left anterior descending artery and good antegrade flow The guiding catheter was replaced with a 5 French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve The right femoral vein was cannulated with an 18 guage needle followed by an 8 French vascular sheath A 8 French Swan Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle pulmonary artery and pulmonary capillary wedge position Cardiac catheter was determined by thermal dilution The procedure was then concluded well tolerated and without complications The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring Fluoroscopy time was 8 2 minutes Total amount of contrast was 113 mL HEMODYNAMICS The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization His initial blood pressure was 96 70 with a mean of 83 and the left ventricular pressure was 17 mmHg There was no gradient across the aortic valve Closing pressure was 97 68 with a mean of 82 Right heart catheterization with right atrial pressure at 13 right ventricle 31 9 pulmonary artery 33 19 with a mean of 25 and capillary wedge pressure of 19 Cardiac output was 5 87 by thermal dilution CORONARIES On fluoroscopy there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution A Left main coronary The left main coronary artery is of good caliber and has no evidence of obstructive lesions B Left anterior descending artery The left anterior descending artery was initially occluded within the previously stented proximal to mid segment There is minimal collateral flow C Circumflex Circumflex is a nondominant circulation It supplies a first obtuse marginal branch on good caliber There is an outline of the stent in the midportion which has mild 30 stenosis The rest of the vessel has no significant obstructive lesions It also supplies significant collaterals supplying the occluded right coronary artery D Right coronary artery The right coronary artery is a weekly dominant circulation The vessel is occluded in intermittent portion and has a minimal collateral flow distally ANGIOPLASTY The left anterior descending artery was the site of re canalization by angioplasty and implantation of a drug eluting stent Xience 15 mm length deployed at 2 9 mm final result is good with patency of the left anterior descending artery good antegrade flow and no evidence of dissection The stent was deployed proximal to the bifurcation with a second diagonal branch which has remained patent There is a septal branch overlapped by the stent which is also patent although presenting a proximal stenosis The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery There is good antegrade flow and no evidence of distal embolization CONCLUSION Acute coronary artery syndrome with ST segment elevation in anterior wall distribution complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery Acute coronary artery syndrome with ST segment elevation in anterior wall distribution related to in stent thrombosis of the left anterior descending artery successfully re canalized with angioplasty and a drug eluting stent There is mild to moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery well collateralized Right femoral arterial and venous vascular access RECOMMENDATION Integrilin infusion is maintained until tomorrow He received aspirin and Plavix per nasogastric tube Titrated doses of beta blockers and ACE inhibitors are initiated Additional revascularization therapy will be adjusted according to the clinical evaluation Keywords cardiovascular pulmonary ventricular arrhythmia coronary artery syndrome st segment elevation heart catheterization selective bilateral coronary angiography ventriculography catheterization swan ganz catheter anterior descending artery drug eluting stent coronary artery angioplasty stent coronary anterior angiography artery heart MEDICAL_TRANSCRIPTION,Description Left heart catheterization with ventriculography selective coronary angiography Standard Judkins right groin Catheters used were a 6 French pigtail 6 French JL4 6 French JR4 Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 3 Transcription NAME OF PROCEDURE Left heart catheterization with ventriculography selective coronary angiography INDICATIONS Acute coronary syndrome TECHNIQUE OF PROCEDURE Standard Judkins right groin Catheters used were a 6 French pigtail 6 French JL4 6 French JR4 ANTICOAGULATION The patient was on heparin at the time COMPLICATIONS None I reviewed with the patient the pros cons alternatives risks of catheterization and sedation including myocardial infarction stroke death damage to nerve artery or vein in the leg perforation of a cardiac chamber dissection of an artery requiring countershock infection bleeding ATN allergy need for cardiac surgery All questions were answered and the patient desired to proceed HEMODYNAMIC DATA Aortic pressure was in the physiologic range No significant gradient across the aortic valve ANGIOGRAPHIC DATA 1 Ventriculogram The left ventricle is of normal size and shape normal wall motion normal ejection fraction 2 Right coronary artery Dominant There was insignificant disease in the system 3 Left coronary Left main left anterior descending and circumflex systems showed no significant disease CONCLUSIONS 1 Normal left ventricular systolic function 2 Insignificant coronary disease PLAN Based upon this study medical therapy is warranted Six French Angio Seal was used in the groin Keywords cardiovascular pulmonary standard judkins french pigtail selective coronary angiography heart catheterization ventriculography catheterization angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization with left ventriculography and selective coronary angiography Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 4 Transcription NAME OF PROCEDURE 1 Left heart catheterization with left ventriculography and selective coronary angiography 2 Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery HISTORY This is a 58 year old male who presented with atypical chest discomfort The patient had elevated troponins which were suggestive of a myocardial infarction The patient is suspected of having significant obstructive coronary artery disease therefore he is undergoing cardiac catheterization PROCEDURE DETAILS Informed consent was given prior to the patient was brought to the catheterization laboratory The patient was brought to the catheterization laboratory in postabsorptive state The patient was prepped and draped in the usual sterile fashion 2 Xylocaine solution was used to anesthetize the right femoral region Using modified Seldinger technique a 6 French arterial sheath was placed Then the patient had already been on heparin Then a Judkins left 4 catheter was intubated into the left main coronary artery Several projections were obtained and the catheter was removed A 3DRC catheter was intubated into the right coronary artery Several projections were obtained and the catheter was removed Then a 3DRC guiding catheter was intubated into the right coronary artery Then a universal wire was advanced across the lesion into the distal right coronary artery Integrilin was given Then a 3 0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds Then a projection was obtained Then a 3 0 x 15 Vision stent was placed into the distal right coronary artery The stent was deployed at 15 atmospheres for 25 seconds Post stent the patient was given intracoronary nitroglycerin after one projection Then there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful Then a pilot 150 wire was advanced across the lesion Then attempt to place the 2 0 x 8 power saver across the lesion was performed However it was felt that there was adequate flow and no further intervention needed to be performed Then the stent delivery system was removed A pigtail catheter was placed into the left ventricle Hemodynamics followed by left ventriculography was performed Then a pullback gradient was performed and the catheter was removed Then the right femoral artery was visualized and using angiography and then an Angio Seal was applied The patient was transferred back to his room in good condition FINDINGS 1 Hemodynamics The opening aortic pressure was 116 61 with a mean of 64 The opening left ventricular pressure was 112 with end diastolic pressure of 23 LV pressure on pullback was 106 with end diastolic pressure of 21 Aortic pressure was 111 67 with a mean of 87 The closing pressure was 110 67 2 Left ventriculography The left ventricle was of normal cavity size and wall thickness There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis The overall systolic function appeared to be mildly reduced with ejection fraction between 40 and 45 The mitral valve had no significant prolapse or regurgitation The aortic valve appeared to be trileaflet and moved normally 3 Coronary angiography The left main is a normal caliber vessel This bifurcates into the left anterior descending and circumflex arteries The left main is free of any significant obstructive coronary artery disease The left anterior descending is a large vessel that extends to the apex It gives off approximately 10 septal perforators and 5 diagonal branches The first diagonal branch was large The left anterior descending had mild irregularities but no high grade disease The left circumflex is a nondominant vessel which gives rise to two obtuse marginal branches The two obtuse marginal branches are large There is a relatively small left atrial branch The left circumflex had a 50 stenosis after the first obtuse marginal branch The rest of the vessel is moderately irregular but no high grade disease The right coronary artery appears to be a dominant vessel which gives rise to three right ventricular branches four posterior lateral branches two right atrial branches and two small conus branches The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high grade disease However distal between the second and third posterolateral branch there is a 90 stenosis The rest of the vessels had mild irregularities but no high grade disease Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20 residual stenosis Then after stent placement there was 0 residual stenosis however there was partial occlusion of the third posterolateral branch Then a wire was advanced through this and there was improvement of flow There is improvement from TIMI grade 2 to TIMI grade 3 flow CLINICAL IMPRESSION 1 Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery 2 Two vessel coronary artery disease 3 Elevated left ventricular end diastolic pressure 4 Mild anterolateral and moderate inferoapical hypokinesis RECOMMENDATIONS 1 Integrilin 2 Bed rest 3 Risk factor modification 4 Thallium scintigraphy in approximately six weeks Keywords cardiovascular pulmonary heart catheterization ventriculography selective coronary angiography angioplasty stent placement transluminal percutaneous coronary artery coronary angiography coronary angioplasty diastolic pressure obtuse marginal percutaneous transluminal catheterization artery coronary angiography MEDICAL_TRANSCRIPTION,Description Selective coronary angiography left heart catheterization and left ventriculography Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 11 Transcription NAME OF PROCEDURES 1 Selective coronary angiography 2 Left heart catheterization 3 Left ventriculography PROCEDURE IN DETAIL The right groin was sterilely prepped and draped in the usual fashion The area of the right coronary artery was anesthetized with 2 lidocaine and a 4 French sheath was placed Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg A left 4 4 French Judkins catheter was placed and advanced through the ostium of the left main coronary artery Because of difficulty positioning the catheter the catheter was removed and a 6 French sheath was placed and a 6 French 4 left Judkins catheter was placed This was advanced through the ostium of the left main coronary artery where selective angiograms were performed Following this the 4 French right Judkins catheter was placed and angiograms of the right coronary were performed A pigtail catheter was placed and a left heart catheterization was performed followed by a left ventriculogram The left heart pullback was performed The catheter was removed and a small injection of contrast was given to the sheath The sheath was removed over a wire and an Angio Seal was placed There were no complications Total contrast media was 200 mL of Optiray 350 Fluoroscopy time 5 3 minutes Total x ray dose is 1783 mGy HEMODYNAMICS Rhythm is sinus throughout the procedure LV pressure of 155 22 mmHg aortic pressure of 160 80 mmHg LV pullback demonstrates no gradient The right coronary artery is a nondominant vessel and free of disease This also gives rise to the conus branch and two RV free wall branches The left main has minor plaquing in the inferior aspect measuring no more than 10 to 15 This vessel then bifurcates into the LAD and circumflex The circumflex is a large caliber vessel and is dominant This vessel gives rise to a large first marginal artery a moderate sized second marginal branch and additionally gives rise to a large third marginal artery and the PDA There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90 in severity The origin of the first marginal artery has a severe stenosis measuring approximately 90 in severity The distal circumflex has a 60 lesion just prior to the origin of the third marginal branch and PDA The proximal LAD is ectatic The LAD gives rise to a large first diagonal artery that has a 90 lesion in its origin and a subtotal occlusion midway down the diagonal Distal to the origin of this diagonal branch there is another area of ectasia in the LAD followed by an area of stenosis that in some views is approximately 50 in severity The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall The overall ejection fraction is preserved There is moderate dilatation of the aortic root The calculated ejection fraction is 63 IMPRESSION 1 Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall 2 Coronary artery disease with high grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery There is subtotal stenosis at the origin of the first obtuse marginal artery 3 A 60 stenosis in the distal circumflex 4 Ectasia of the proximal left anterior descending with 50 stenosis in the mid left anterior descending 5 Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch Keywords cardiovascular pulmonary coronary angiography catheterization ventriculography heart catheterization coronary artery stenosis artery angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization left and right coronary angiography left ventricular angiography and intercoronary stenting of the right coronary artery Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 10 Transcription PROCEDURE Left heart catheterization left and right coronary angiography left ventricular angiography and intercoronary stenting of the right coronary artery PROCEDURE IN DETAIL The patient was brought to the Catheterization Laboratory After informed consent he was medicated with Versed and fentanyl The right groin was prepped and draped and infiltrated with 2 Xylocaine Percutaneously 6 French arterial sheath was placed Selective native left and right coronary angiography was performed followed by left ventricular angiography The patient had a totally occluded right coronary We initially started with a JR4 guide We were able to a sport wire through the total occlusion and saw a very tight stenosis We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated We then attempted to put a 30 x 12 mm stent across the stenosis but we had very little guide support the guide kept coming out We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion We finally had to go an AL2 guide we were concerned that this could cause some proximal dissection That guided seated we did have initial difficulty getting the wire back across the stenosis and we did see a little staining suggesting we did have some tearing from the guide tip The surgeons were put on notice in case we could not get this vessel open but we were able to re cross with a sport wire We then re dilated the area of stenosis and with good guide support we were able to get a 30 x 23 mm Vision stent where the lesion was and post dilated it to 18 atmospheres Routine angiography did show that the distal posterolateral branch seems to be occluded whether this was from distal wire dissection or distal thrombosis was unclear but we were able to re wire that area and get a 25 x12 Vision balloon and dilate the area and re establish flow to the small segment We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres Final angiography showed resolution of the dissection We could see a little staining extrinsic to the stent No perforation and excellent flow During the intervention we did give a bolus and drip of Angiomax At the end of the procedure we stopped the Angiomax and gave 600 mg of Plavix We did a right femoral angiogram however the Angio Seal plug could not take so we used manual pressure and a Femostop We transported the patient to his room in stable condition ANGIOGRAPHIC DATA Left main coronary is normal Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60 stenosis of the LAD before it bifurcates into diagonal The diagonal does appear to have about 50 osteal stenosis There is a lot of plaquing further down the diagonal but good flow The rest of the LAD looked good pass the proximal 60 stenosis and after the diagonal branch Circumflex artery was nondominant vessel consisting of an obtuse marginal vessel The first obtuse marginal had a long 50 narrowing and then the AV groove branch was free of any disease Some mild collaterals to the right were seen Right coronary angiography revealed a total occlusion of the right coronary just about 0 5 cm after its origin After we got a wire across the area of occlusion we could see some thrombosis and a 99 stenosis just at the curve Following the balloon angioplasty we established good flow down the distal vessel We still had about residual 70 stenosis When we had to go back with the AL2 guide we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection We re dilated and then deployed Repeat angiography now did show some hang up off dye distally We never did have the wire that far down so this was probably felt to be due to distal embolization of some thrombus After deploying the stent we had total resolution of the original lesion We then directed our attention to the posterolateral branch which the remainder of the vessel was patent giving off a large PDA The posterolateral branch appeared to be occluded in its mid portion We got a wire through and dilated this We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent Repeat angiography now showed no significant dissection a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch but this was excluded by the stent There were no filling defects in the stent and excellent flow The distal posterolateral branch did open up although it was little under filled and there may have been some mild residual disease there IMPRESSION Atherosclerotic heart disease with total occlusion of right coronary successfully stented to zero residual with repair of a small proximal dissection Minor distal disease of the posterolateral branch and 60 proximal left anterior descending coronary artery stenosis and 50 diagonal stenosis along with 50 stenosis of the first obtuse marginal branch Keywords cardiovascular pulmonary heart catheterization coronary angiography ventricular angiography intercoronary stenting intercoronary coronary stenting stenosis angiography MEDICAL_TRANSCRIPTION,Description Left heart cath selective coronary angiography LV gram right femoral arteriogram and Mynx closure device Normal stress test Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Angiography 1 Transcription CLINICAL INDICATION Normal stress test PROCEDURES PERFORMED 1 Left heart cath 2 Selective coronary angiography 3 LV gram 4 Right femoral arteriogram 5 Mynx closure device PROCEDURE IN DETAIL The patient was explained about all the risks benefits and alternatives of this procedure The patient agreed to proceed and informed consent was signed Both groins were prepped and draped in the usual sterile fashion After local anesthesia with 2 lidocaine a 6 French sheath was inserted in the right femoral artery Left and right coronary angiography was performed using 6 French JL4 and 6 French 3DRC catheters Then LV gram was performed using 6 French pigtail catheter Post LV gram LV to aortic gradient was obtained Then the right femoral arteriogram was performed Then the Mynx closure device was used for hemostasis There were no complications HEMODYNAMICS LVEDP was 9 There was no LV to aortic gradient CORONARY ANGIOGRAPHY 1 Left main is normal It bifurcates into LAD and left circumflex 2 Proximal LAD at the origin of big diagonal there is 50 to 60 calcified lesion present Rest of the LAD free of disease 3 Left circumflex is a large vessel and with minor plaque 4 Right coronary is dominant and also has proximal 40 stenosis SUMMARY 1 Nonobstructive coronary artery disease LAD proximal at the origin of big diagonal has 50 to 60 stenosis which is calcified 2 RCA has 40 proximal stenosis 3 Normal LV systolic function with LV ejection fraction of 60 PLAN We will treat with medical therapy If the patient becomes symptomatic we will repeat stress test If there is ischemic event the patient will need surgery for the LAD lesion For the time being we will continue with the medical therapy Keywords cardiovascular pulmonary selective coronary angiography lv gram femoral mynx heart cath mynx closure device heart catheterization femoral arteriogram stress test coronary angiography heart arteriogram catheterization lad coronary angiography MEDICAL_TRANSCRIPTION,Description Left heart catheterization and bilateral selective coronary angiography Left ventriculogram was not performed Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Angiography 2 Transcription PROCEDURES PERFORMED 1 Left heart catheterization 2 Bilateral selective coronary angiography 3 Left ventriculogram was not performed INDICATION Non ST elevation MI PROCEDURE After risks benefits and alternatives of the above mentioned procedure were explained in detail to the patient informed consent was obtained both verbally and in writing The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion 1 lidocaine solution was used to infiltrate the skin overlying the right femoral artery Once adequate anesthesia had been obtained a thin walled 18 gauge Argon needle was used to cannulate the right femoral artery A steel guidewire was inserted through the needle into the vascular lumen without resistance A small nick was then made in the skin The pressure was held The needle was removed over the guidewire Next a Judkins left 4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire The guidewire was removed The catheter was connected to the manifold and flushed The ostium of the left main coronary artery was engaged Using hand injections of nonionic contrast material the left coronary system was evaluated in several different views Once an adequate study had been performed the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter The catheter was then removed over the guidewire Next a Judkins right 4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire The guidewire was removed The catheter was connected to manifold and flushed The catheter did slip into the left ventricle During the rotation the LVEDP was then measured The ostium of the right coronary artery was then engaged Using hand injections of nonionic contrast material the right coronary system was evaluated in several different views Once adequate study has been performed the catheter was then removed The sheath was lastly flushed for the final time FINDINGS LEFT MAIN CORONARY ARTERY The left main coronary artery is a moderate caliber vessel which bifurcates into the left anterior descending and circumflex arteries There is no evidence of any hemodynamically significant stenosis LEFT ANTERIOR DESCENDING ARTERY The LAD is a moderate caliber vessel which is subtotaled in its mid portion for approximately 1 5 cm to 1 cm with subsequent TIMI I flow distally The distal portion was diffusely diseased The proximal portion otherwise shows minor luminal irregularities The first diagonal branch demonstrated minor luminal irregularities throughout CIRCUMFLEX ARTERY The circumflex is a moderate caliber vessel which traverses through the atrioventricular groove There is a 60 proximal lesion and a 90 mid lesion prior to the takeoff of the first obtuse marginal branch The first obtuse marginal branch demonstrates minor luminal irregularities throughout RIGHT CORONARY ARTERY The RCA is a moderate caliber vessel which demonstrates a 90 mid stenotic lesion The dominant coronary artery gives off the posterior descending artery and posterolateral artery The left ventricular end diastolic pressure was approximately 22 mmHg It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads which resolved after the injection was complete IMPRESSION 1 Three vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI I flow distally and 90 circumflex lesion and 90 right coronary artery lesion 2 Mildly elevated left sided filling pressures PLAN 1 The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting These findings and plan were discussed in detail with the patient and the patient s family The patient is agreeable 2 The patient will be continued on aggressive medical therapy including beta blocker aspirin ACE inhibitor and statin therapy The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting In light of the patient s history of cranial aneurysmal bleed the patient will be held off of Lovenox and Integrilin Keywords cardiovascular pulmonary non st elevation coronary angiography ventriculogram heart catheterization bypass grafting catheterization coronary artery angiography luminal branch descending circumflex vessel guidewire MEDICAL_TRANSCRIPTION,Description Left heart catheterization left ventriculography coronary angiography and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Ventriculography Angiography 1 Transcription PROCEDURE Left heart catheterization left ventriculography coronary angiography and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery This gentleman has had a non Q wave troponin positive myocardial infarction complicated by ventricular fibrillation PROCEDURE DETAILS The patient was brought to the catheterization lab the chart was reviewed and informed consent was obtained Right groin was prepped and draped sterilely and infiltrated 2 Xylocaine Using the Seldinger technique a 6 French sheath was placed in the right femoral artery ACT was checked and was low Additional heparin was given A 6 French pigtail catheter was passed Left ventriculography was performed The catheter was exchanged for a 6 French JL4 catheter Nitroglycerin was given in the left main Left coronary angiography was performed The catheter was exchanged for a 6 French __________ coronary catheter Nitroglycerin was given in the right main and right coronary angiography was performed Films were closely reviewed and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM Considering his age and his course it was elected to stent both these lesions ReoPro was started and the catheter was exchanged for a 6 French JR4 guide ReoPro was given in the RCA to prevent no reflow A 0 014 Universal wire was passed The lesion was measured A 4 5 x 18 mm stent was passed and deployed to moderate pressures with an excellent result The catheter was removed and exchanged for a 6 French JL4 guide The same wire was passed down the circumflex and the lesion measured A 2 75 x 15 mm stent was deployed to a moderate pressure with an excellent result Plavix was given The catheter was removed and sheath was in place The results were explained to the patient and his wife FINDINGS 1 Hemodynamics Please see attached sheet for details ED was 20 There is no gradient across the aortic valve 2 Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion in which there is a question of diffuse very minimal global hypokinesis There is mild MR noted 3 Coronary angiography a Left main normal b LAD Some very minimal luminal irregularities There is a 1st diagonal which has a branch that is 1 5 mm with a proximal 50 narrowing c Left circumflex is basically a marginal branch in which distally there was a long 98 lesion d The RCA is large dominant and has a mid somewhat long 70 lesion 4 Stenting a The RCA revealed a lesion that went from 70 to a 5 B The circumflex went from 95 to 5 CONCLUSION 1 Decreased left ventricular compliance 2 Borderline normal overall ejection fraction with mild mitral regurgitation 3 Triple vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex which is basically old 4 Successful stenting of the right coronary artery and the circumflex RECOMMENDATION ReoPro stent protocol Plavix for at least 9 months aggressive control of risk factors I have ordered Zocor and a fasting lipid panel AICD will be considered realizing when this gentleman becomes ischemic he is at high risk for fibrillating Keywords cardiovascular pulmonary heart catheterization ventriculography coronary angiography stenting distal circumflex coronary artery coronary lesion catheterization cardiac angiography heart rca artery circumflex MEDICAL_TRANSCRIPTION,Description Right heart catheterization Refractory CHF to maximum medical therapy Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization 2 Transcription PROCEDURE PERFORMED Right heart catheterization INDICATION Refractory CHF to maximum medical therapy PROCEDURE After risks benefits and alternatives of the above mentioned procedure were explained to the patient and the patient s family in detail informed consent was obtained both verbally and in writing The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion 1 lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein Once adequate anesthesia has been obtained a thin walled 18 gauge Argon needle was used to cannulate the right internal jugular vein A steel guidewire was then inserted through the needle into the vessel without resistance Small nick was then made in the skin and the needle was removed An 8 5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance The guidewire and dilator were then removed The sheath was then flushed A Swan Ganz catheter was inserted to 20 cm and the balloon was inflated Under fluoroscopic guidance the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position Hemodynamics were measured along the way Pulmonary artery saturation was obtained The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration The patient tolerated the procedure well The patient returned to the cardiac catheterization holding area in stable and satisfactory condition FINDINGS Body surface area equals 2 04 hemoglobin equals 9 3 O2 is at 2 liters nasal cannula Pulmonary artery saturation equals 37 8 Pulse oximetry on 2 liters nasal cannula equals 93 Right atrial pressure is 8 right ventricular pressure equals 59 9 pulmonary artery pressure equals 61 31 with mean of 43 pulmonary artery wedge pressure equals 21 cardiac output equals 3 3 by the Fick method cardiac index is 1 6 by the Fick method systemic vascular resistance equals 1821 and transpulmonic gradient equals 22 IMPRESSION Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38 on current medical therapy as well as elevated right sided filling pressures and a high systemic vascular resistance PLAN Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve the patient will need to be discharged home on Primacor The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia At this time we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy We will also increase his Lasix to 80 mg IV q d We will increase his amiodarone to 400 mg daily We will also continue with his Coumadin therapy As stated previously we will discontinue vasodilator therapy starting with the Isordil Keywords cardiovascular pulmonary chf cardiac catheterization swan ganz heart catheterization internal jugular pulmonary artery heart jugular cannulate vascular needle pulmonary therapy MEDICAL_TRANSCRIPTION,Description Left heart catheterization and bilateral selective coronary angiography The patient is a 65 year old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest Medical Specialty Cardiovascular Pulmonary Sample Name Heart Cath Coronary Angiography Transcription PROCEDURE PERFORMED 1 Left heart catheterization 2 Bilateral selective coronary angiography ANESTHESIA 1 lidocaine and IV sedation including fentanyl 25 mcg INDICATION The patient is a 65 year old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest It was accompanied by diaphoresis and shortness of breath The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain He underwent adenosine Cardiolite which revealed 2 mm ST segment depression in leads II III aVF and V3 V4 and V5 Stress images revealed left ventricular dilatations suggestive of multivessel disease He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test PROCEDURE After risks benefits alternatives of the above mentioned procedure were explained to the patient in detail informed consent was obtained both verbally and writing The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner 1 lidocaine solution was used to anesthetize the right inguinal area Once adequate anesthesia had been obtained a thin walled Argon needle was used to cannulate the right femoral artery The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin The needle was removed and a pressure was held A 6 French arterial sheath was advanced over the guidewire without resistance The dilator and guidewire were removed and the sheath was flushed A Judkins left 4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire The guidewire was removed and the catheter was connected to the manifold and flushed The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter The catheter was removed over guidewire and a Judkins right 4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire The guidewire was removed and the catheter was connected to the manifold and flushed The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material the right coronary artery was evaluated in both diagonal views This catheter was removed The sheath was flushed the final time The patient was taken to the postcatheterization holding area in stable condition FINDINGS LEFT MAIN CORONARY ARTERY This vessel is seen to be heavily calcified throughout its course Begins as a moderate caliber vessel There is a 60 stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery LEFT ANTERIOR DESCENDING CORONARY ARTERY This vessel is heavily calcified in its proximal portion It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex There is a 90 stenosis in the proximal portion and 90 ostial stenosis in the first and second anterolateral branches There is sequential 80 and 90 stenosis in the mid portion of the vessel Otherwise the LAD is seen to be diffusely diseased LEFT CIRCUMFLEX CORONARY ARTERY This vessel is also calcified in its proximal portion There is a greater than 90 ostial stenosis which appears to be an extension of the lesion in the left main coronary artery There is a greater than 70 stenosis in the proximal portion of the first large obtuse marginal branch otherwise the circumflex system is seen to be diffusely diseased RIGHT CORONARY ARTERY This is a large caliber vessel and is the dominant system There is diffuse luminal irregularities throughout the vessel and a 80 to 90 stenosis at the bifurcation above the posterior descending artery and posterolateral branch IMPRESSION 1 Three vessel coronary artery disease as described above 2 Moderate mitral regurgitation per TEE 3 Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities 4 Long standing history of phlebitis PLAN Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement Keywords cardiovascular pulmonary left heart catheterization bilateral selective coronary angiography regurgitation gallops diaphoresis shortness of breath coronary angiography proximal portions catheterization artery coronary bilateral selective angiography mitral stenosis vessel guidewire MEDICAL_TRANSCRIPTION,Description Left and right heart catheterization and selective coronary angiography Coronary artery disease severe aortic stenosis by echo Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Angiography Transcription INDICATION Coronary artery disease severe aortic stenosis by echo PROCEDURE PERFORMED 1 Left heart catheterization 2 Right heart catheterization 3 Selective coronary angiography PROCEDURE The patient was explained about all the risks benefits and alternatives to the procedure The patient agreed to proceed and informed consent was signed Both groins were prepped and draped in usual sterile fashion After local anesthesia with 2 lidocaine 6 French sheath was inserted in the right femoral artery and 7 French sheath was inserted in the right femoral vein Then right heart cath was performed using 7 French Swan Ganz catheter Catheter was placed in the pulmonary capillary wedge position Pulmonary capillary wedge pressure PA pressure was obtained cardiac output was obtained then RV RA pressures were obtained The right heart catheter _______ pulled out Then selective coronary angiography was performed using 6 French JL4 and 6 French 3DRC catheter Then attempt was made to cross the aortic valve with 6 French pigtail catheter but it was unsuccessful After the procedure catheters were pulled out sheath was pulled out and hemostasis was obtained by manual pressure The patient tolerated the procedure well There were no complications HEMODYNAMICS 1 Cardiac output was 4 9 per liter per minute Pulmonary capillary wedge pressure mean was 7 PA pressure was 20 14 RV 26 5 RA mean pressure was 5 2 Coronary angiography left main is calcified _______ dense complex 3 LAD proximal 70 calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate size vessel has 70 stenosis Left circumflex has diffuse luminal irregularities OM1 has 70 stenosis is a moderate size vessel Right coronary is dominant and has minimal luminal irregularities SUMMARY Three vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure RECOMMENDATION Aortic valve replacement with coronary artery bypass surgery Keywords cardiovascular pulmonary lad proximal femoral artery sheath catheter selective coronary angiography coronary artery disease pulmonary capillary wedge capillary wedge coronary angiography coronary artery heart catheterization catheterization heart artery stenosis angiography pressure coronary MEDICAL_TRANSCRIPTION,Description Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore Tex graft Chronic renal failure and thrombosed left forearm arteriovenous Gore Tex bridge fistula Medical Specialty Cardiovascular Pulmonary Sample Name Fogarty Thrombectomy Transcription PREOPERATIVE DIAGNOSES 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula POSTOPERATIVE DIAGNOSIS 1 Chronic renal failure 2 Thrombosed left forearm arteriovenous Gore Tex bridge fistula PROCEDURE PERFORMED 1 Fogarty thrombectomy left forearm arteriovenous Gore Tex bridge fistula 2 Revision of distal anastomosis with 7 mm interposition Gore Tex graft ANESTHESIA General with controlled ventillation GROSS FINDINGS The patient is a 58 year old black male with chronic renal failure He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality OPERATIVE PROCEDURE The patient was taken to the OR suite placed in supine position General anesthetic was administered Left arm was prepped and draped in appropriate manner A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop Transverse graftotomy was created A 4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow A fistulogram was performed and the above findings were noted In a retrograde fashion the proximal anastomosis was patent There was no narrowing within the forearm graft Both veins were flushed with heparinized saline and controlled with a vascular clamp A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia Utilizing both blunt and sharp dissection the brachial vein as well as distal anastomosis was isolated The distal anastomosis amputated off the fistula and oversewn with continuous running 6 0 Prolene suture tied upon itself The vein was controlled with vascular clamps Longitudinal venotomy created along the anteromedial wall A 7 mm graft was brought on to the field and this was cut to shape and size This was sewed to the graft in an end to side fashion with U clips anchoring the graft at the heel and toe with interrupted 6 0 Prolene sutures Good backflow bleeding was confirmed The vein flushed with heparinized saline and graft was controlled with vascular clamp The end of the insertion graft was cut to shape in length and sutured to the graft in an end to end fashion with continuous running 6 0 Prolene suture Good backflow bleeding was confirmed The graftotomy was then closed with interrupted 6 0 Prolene suture Flow through the fistula was permitted a good flow passed The wound was copiously irrigated with antibiotic solution Sponge needles instrument counts were correct All surgical sites were inspected Good hemostasis was noted The incision was closed in layers with absorbable sutures Sterile dressing was applied The patient tolerated the procedure well and returned to the recovery room in apparent stable condition Keywords cardiovascular pulmonary chronic renal failure thrombosed gore tex bridge fistula arteriovenous fogarty thrombectomy anastomosis gore tex bridge fogarty thrombectomy prolene suture renal failure distal anastomosis bridge fistula interposition renal prolene MEDICAL_TRANSCRIPTION,Description Chest pain and non Q wave MI with elevation of troponin I only Left heart catheterization left ventriculography and left and right coronary arteriography Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization 1 Transcription PROCEDURES Left heart catheterization left ventriculography and left and right coronary arteriography INDICATIONS Chest pain and non Q wave MI with elevation of troponin I only TECHNIQUE The patient was brought to the procedure room in satisfactory condition The right groin was prepped and draped in routine fashion An arterial sheath was inserted into the right femoral artery Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively Cine coronary angiograms were done in multiple views Left heart catheterization was done using the 6 French pigtail catheter Appropriate pressures were obtained before and after the left ventriculogram which was done in the RAO view At the end of the procedure the femoral catheter was removed and Angio Seal was applied without any complications FINDINGS 1 LV is normal in size and shape with good contractility EF of 60 2 LMCA normal 3 LAD has 20 to 30 stenosis at the origin 4 LCX is normal 5 RCA is dominant and normal RECOMMENDATIONS Medical management diet and exercise Aspirin 81 mg p o daily p r n nitroglycerin for chest pain Follow up in the clinic Keywords cardiovascular pulmonary arteriography coronary arteriography heart catheterization ventriculography angiograms MEDICAL_TRANSCRIPTION,Description Flexible bronchoscopy to evaluate the airway chronic wheezing Medical Specialty Cardiovascular Pulmonary Sample Name Flexible Bronchoscopy Transcription PROCEDURE Flexible bronchoscopy PREOPERATIVE DIAGNOSIS ES Chronic wheezing INDICATIONS FOR PROCEDURE Evaluate the airway DESCRIPTION OF PROCEDURE This was done in the pediatric endoscopy suite with the aid of Anesthesia The patient was sedated with sevoflurane and propofol One mL of 1 lidocaine was used for airway anesthesia The 2 8 mm flexible pediatric bronchoscope was passed through the left naris The upper airway was visualized The epiglottis arytenoids and vocal cords were all normal The scope was passed below the cords The subglottic space was normal The patient had normal tracheal rings and a normal membranous portion of the trachea There was noted to be slight deviation of the trachea to the right At the carina the right and left mainstem were evaluated The right upper lobe right middle lobe and right lower lobe were all anatomically normal The scope was wedged in the right middle lobe 10 mL of saline was infused 10 was returned This was sent for cell count cytology lipid index and quantitative bacterial cultures The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle The left upper lobe and left lower lobe were normal The scope was withdrawn The patient tolerated the procedure well ENDOSCOPIC DIAGNOSIS Left mainstem bronchomalacia Keywords cardiovascular pulmonary flexible bronchoscopy airway arytenoids bronchomalacia bronchoscopy endoscopy suite epiglottis mainstem subglottic vocal cords wheezing chronic wheezing tracheal lobe MEDICAL_TRANSCRIPTION,Description Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy Severe tracheobronchitis mild venous engorgement with question varicosities associated pulmonary hypertension right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy Medical Specialty Cardiovascular Pulmonary Sample Name Flexible Fiberoptic Bronchoscopy Transcription PREOPERATIVE POSTOPERATIVE DIAGNOSES 1 Severe tracheobronchitis 2 Mild venous engorgement with question varicosities associated pulmonary hypertension 3 Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy PROCEDURE PERFORMED Flexible fiberoptic bronchoscopy with a Right lower lobe bronchoalveolar lavage b Right upper lobe endobronchial biopsy SAMPLES Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe INDICATIONS The patient with persistent hemoptysis of unclear etiology PROCEDURE After obtaining informed consent the patient was brought to Bronchoscopy Suite The patient had previously been on Coumadin and then heparin Heparin was discontinued approximately one and a half hours prior to the procedure The patient underwent topical anesthesia with 10 cc of 4 Xylocaine spray to the left nares and nasopharynx Blood pressure EKG and oximetry monitoring were applied and monitored continuously throughout the procedure Oxygen at two liters via nasal cannula was delivered with saturations in the 90 to 100 throughout the procedure The patient was premedicated with 50 mg of Demerol and 2 mg of Versed After conscious sedation was achieved the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx There was minimal redundant oral soft tissue in the oropharynx There was mild erythema Clear secretions were suctioned Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure a total of 16 cc of 2 Xylocaine was applied Vocal cord motion was normal The bronchoscope was then advanced through the larynx into the trachea There was evidence of moderate inflammation with prominent vascular markings and edema No frank blood was visualized The area was suction clear of copious amounts of clear white secretions Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem The bronchoscope was then sequentially advanced into each segment and sub segment of the left upper lobe and left lower lobe There was significant amount of inflammation induration and vascular tortuosity in these regions No frank blood was identified No masses or lesions were identified There was senile bronchiectasis with slight narrowing and collapse during the exhalation The air was suctioned clear The bronchoscope was withdrawn and advanced into the right main stem Bronchoscope was introduced into the right upper lobe and each sub segment was visualized Again significant amounts of tracheobronchitis was noted with vascular infiltration In the sub carina of the anterior segment of the right upper lobe there was evidence of a submucosal hematoma without frank mass underneath this The bronchoscope was removed and advanced into the right middle and right lower lobe There was marked injection and inflammation in these regions In addition there was marked vascular engorgement with near frank varicosities identified throughout the region Again white clear secretions were identified No masses or other processes were noted The area was suctioned clear A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe The bronchoscope was then withdrawn and readvanced into the right upper lobe Endobronchial biopsies of the carina of the sub segment and anterior segment of the right upper lobe were obtained Minimal hemorrhage occurred after the biopsy which stopped after 1 cc of 1 1000 epinephrine The area remained clear No further hemorrhage was identified The bronchoscope was subsequently withdrawn The patient tolerated the procedure well and was stable throughout the procedure No further hemoptysis was identified The patient was sent to Recovery in good condition Keywords cardiovascular pulmonary bronchoalveolar lavage endobronchial biopsy cytology microbiology tracheobronchitis venous engorgement varicosities pulmonary hypertension flexible fiberoptic bronchoscopy fiberoptic bronchoscopy lobe bronchoalveolar lavage endobronchial hemorrhage oropharynx vascular bronchoscopy biopsy submucosal bronchoscope MEDICAL_TRANSCRIPTION,Description Right and left heart catheterization coronary angiography left ventriculography Medical Specialty Cardiovascular Pulmonary Sample Name Heart Catheterization Transcription PROCEDURES 1 Right and left heart catheterization 2 Coronary angiography 3 Left ventriculography PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the cardiac catheterization laboratory Patient was prepped and draped in sterile fashion Via modified Seldinger technique the right femoral vein was punctured and a 6 French sheath was placed over a guide wire Via modified Seldinger technique right femoral artery was punctured and a 6 French sheath was placed over a guide wire The diagnostic procedure was performed using the JL 4 JR 4 and a 6 French pigtail catheter along with a Swan Ganz catheter The patient tolerated the procedure well and there were immediate complications were noted Angio Seal was used at the end of the procedure to obtain hemostasis CORONARY ARTERIES LEFT MAIN CORONARY ARTERY The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery No significant stenotic lesions were identified in the left main coronary artery LEFT ANTERIOR DESCENDING CORONARY ARTERY The left descending artery is a moderate sized vessel which gives rise to multiple diagonals and perforating branches No significant stenotic lesions were identified in the left anterior descending coronary artery system CIRCUMFLEX ARTERY The circumflex artery is a moderate sized vessel The vessel is a stenotic lesion After the right coronary artery the RCA is a moderate size vessel with no focal stenotic lesions HEMODYNAMIC DATA Capital wedge pressure was 22 The aortic pressure was 52 24 Right ventricular pressure was 58 14 RA pressure was 14 The aortic pressure was 127 73 Left ventricular pressure was 127 15 Cardiac output of 9 2 LEFT VENTRICULOGRAM The left ventriculogram was performed in the RAO projection only In the RAO projection the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50 Severe mitral regurgitation was also noted IMPRESSION 1 Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50 2 Severe mitral regurgitation 3 No significant coronary artery disease identified in the left main coronary artery left anterior descending coronary artery circumflex coronary artery or the right coronary artery Keywords cardiovascular pulmonary ventriculography catheterization seldinger hypokinesis estimated ejection fraction severe mitral regurgitation descending coronary artery coronary artery aortic pressure heart catheterization stenotic lesions coronary artery heart angiography anterior ventricular ventriculogram lesions MEDICAL_TRANSCRIPTION,Description Fiberoptic flexible bronchoscopy with lavage brushings and endobronchial mucosal biopsies of the right bronchus intermedius right lower lobe Right hyoid mass rule out carcinomatosis Chronic obstructive pulmonary disease Changes consistent with acute and chronic bronchitis Medical Specialty Cardiovascular Pulmonary Sample Name Fiberoptic Flexible Bronchoscopy Transcription PREOPERATIVE DIAGNOSES 1 Right hyoid mass rule out carcinomatosis 2 Weight loss 3 Chronic obstructive pulmonary disease POSTOPERATIVE DIAGNOSES 1 Right hyoid mass rule out carcinomatosis 2 Weight loss 3 Chronic obstructive pulmonary disease 4 Changes consistent with acute and chronic bronchitis 5 Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes 6 Left vocal cord irregularity PROCEDURE PERFORMED Fiberoptic flexible bronchoscopy with lavage brushings and endobronchial mucosal biopsies of the right bronchus intermedius right lower lobe ANESTHESIA Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution LOCATION OF PROCEDURE Endoscopy suite 4 After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry noninvasive blood pressure and EKG monitoring Prior to starting the procedure the patient was noted to have a baseline oxygen saturation of 86 on room air Subsequently she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90 to 91 on room air The patient was placed on a supplemental oxygen as the patient was sedated with above stated medication As this occurred the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx The cords were noted to oppose bilaterally on phonation There was some slight mucosal irregularity noted on the vocal cord on the left side Additional topical lidocaine was instilled on the vocal cords at which point the bronchoscope was introduced into the trachea which was midline in nature The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled At this time the bronchoscope was further advanced through the main stem and additional lidocaine was instilled Bronchoscope was then further advanced into the right upper lobe which revealed no evidence of any endobronchial lesion The mucosa was diffusely friable throughout Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled At this point the bronchoscope was then advanced to the right bronchus intermedius At this time it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening The mucosal area throughout this region was severely friable Additional lidocaine was instilled as well as topical epinephrine At this time bronchoscope was maintained in this region and endobronchial biopsies were performed At the initial attempt of inserting biopsy forceps some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized At this time bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty At this time the biopsy forceps were easily passed and visualized in the right bronchus intermedius At this time multiple mucosal biopsies were performed with some mild oozing noted Several aliquots of normal saline lavage followed After completion of multiple biopsies there was good hemostasis Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments The bronchoscope was then withdrawn to the distal trachea At this time bronchoscope was then advanced to the left main stem Additional lidocaine was instilled The bronchoscope was advanced to the left upper and lower lobe subsegments There was no endobronchial lesion visualized There is mild diffuse erythema and fibromucosa was noted throughout No endobronchial lesion was visualized in the left bronchial system The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system At this time bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout The bronchoscope was subsequently withdrawn and the patient was sent to recovery room During the bronchoscopy the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93 to 94 The patient remained at this level of saturation or greater throughout the remaining of the procedure The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea This was confirmed by her daughter and mother who were also present at the bedside postprocedure The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well The patient also admitted to continued smoking in spite of all of the above The patient was extensively counseled regarding the continued smoking especially with her present symptoms She was advised regarding smoking cessation The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off The patient was also administered Solu Medrol 60 mg IV x1 in recovery room There was no significant bronchospastic component noted although because of the severity of the mucosal edema erythema and her complaints short course of steroids will be instituted The patient was also advised to refrain from using any aspirin or other nonsteroidal anti inflammatory medication because of her hemoptysis At this time the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea to either contact myself or return to ABCD Emergency Room for evaluation of possible admission However the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well Keywords cardiovascular pulmonary carcinomatosis chronic obstructive pulmonary disease fiberoptic flexible bronchoscopy lavage brushings endobronchial mucosal biopsies mucosal bronchoscope atrovent topical fiberoptic hemoptysis bronchoscopy endobronchial oropharynx MEDICAL_TRANSCRIPTION,Description Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies Mild tracheobronchitis with history of granulomatous disease and TB rule out active TB miliary TB Medical Specialty Cardiovascular Pulmonary Sample Name Flexible Fiberoptic Bronchoscopy 1 Transcription POSTOPERATIVE DIAGNOSIS Mild tracheobronchitis with history of granulomatous disease and TB rule out active TB miliary TB PROCEDURE PERFORMED Flexible fiberoptic bronchoscopy diagnostic with a Right middle lobe bronchoalveolar lavage b Right upper lobe bronchoalveolar lavage c Right lower lobe transbronchial biopsies COMPLICATIONS None Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe INDICATION The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis PROCEDURE After obtaining an informed consent the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions The patient had appropriate oxygen blood pressure heart rate and respiratory rate monitoring applied and monitored continuously throughout the procedure 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100 saturations achieved Topical anesthesia with 10 cc of 4 Xylocaine was applied to the right nares and oropharynx Subsequent to this the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg With this adequate consciousness sedation was achieved 3 cc of 4 viscous Xylocaine was applied to the right nares The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx The oropharynx and larynx were well visualized and showed mild erythema mild edema otherwise negative There was normal vocal cord motion without masses or lesions Additional topical anesthesia with 2 Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc The bronchoscope was then advanced through the larynx into the trachea The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions These were suctioned clear The bronchoscope was then advanced through the carina which was sharp Then advanced into the left main stem and each segment subsegement in the left upper lingula and lower lobe was visualized There was mild tracheobronchitis with mild friability throughout There was modest amounts of white secretion There were no other findings including evidence of mass anatomic distortions or hemorrhage The bronchoscope was subsequently withdrawn and advanced into the right mainstem Again each segment and subsegment was well visualized The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments No specific masses or other lesions were identified throughout the tracheobronchial tree on the right There was mild tracheal bronchitis with friability Upon coughing there was punctate hemorrhage The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe These again had no other anatomic lesions identified The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained The bronchoscope was withdrawn and the area was suctioned clear The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed Samples were taken and the bronchoscope was removed suctioned the area clear The bronchoscope was then re advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe Minimal hemorrhage was identified and suctioned clear without difficulty The bronchoscope was then withdrawn to the mainstem The area was suctioned clear Fluoroscopy revealed no evidence of pneumothorax The bronchoscope was then withdrawn The patient tolerated the procedure well without evidence of desaturation or complications Keywords cardiovascular pulmonary bronchoalveolar lavage lobe tracheobronchitis granulomatous miliary tb tb flexible fiberoptic bronchoscopy bronchoscope flexible fiberoptic transbronchial biopsies bronchoscopy oropharynx MEDICAL_TRANSCRIPTION,Description Emergent fiberoptic bronchoscopy with lavage Status post multiple trauma motor vehicle accident Acute respiratory failure Acute respiratory distress ventilator asynchrony Hypoxemia Complete atelectasis of left lung Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system Medical Specialty Cardiovascular Pulmonary Sample Name Fiberoptic Bronchoscopy with Lavage Transcription PREOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung POSTOPERATIVE DIAGNOSES 1 Status post multiple trauma motor vehicle accident 2 Acute respiratory failure 3 Acute respiratory distress ventilator asynchrony 4 Hypoxemia 5 Complete atelectasis of left lung 6 Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system PROCEDURE PERFORMED Emergent fiberoptic plus bronchoscopy with lavage LOCATION OF PROCEDURE ICU Room 164 ANESTHESIA SEDATION Propofol drip Brevital 75 mg morphine 5 mg and Versed 8 mg HISTORY The patient is a 44 year old male who was admitted to ABCD Hospital on 09 04 03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions requiring ventilatory assistance The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation Chest x ray as noted above revealed complete atelectasis of the left lung The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy PROCEDURE DETAIL A bronchoscope was inserted through the oroendotracheal tube which was partially obstructed with blood clots These were lavaged with several aliquots of normal saline until cleared The bronchoscope required removal because the tissue clots were obstructing the bronchoscope The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina The endotracheal tube was noted to be in good position The bronchoscope was advanced through the distal trachea There was a white tissue completely obstructing the left main stem at the carina The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes There was diffuse mucus impactions tissue as well as intermittent clots There was no evidence of any active bleeding noted Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system There is no plugging or obstruction of the right bronchial system The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified approximately 4 cm above the main carina The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure Throughout the procedure pulse oximetry was greater than 95 throughout There is no hemodynamic instability or variability noted during the procedure Postprocedure chest x ray is pending at this time Keywords cardiovascular pulmonary multiple trauma motor vehicle accident acute respiratory failure acute respiratory distress ventilator asynchrony hypoxemia atelectasis bronchoscopy lavage fiberoptic bronchoscopy endotracheal tube acute respiratory asynchrony bronchoscope fiberoptic endotracheal bronchial ventilatory tube respiratory MEDICAL_TRANSCRIPTION,Description Reduced exercise capacity for age no chest pain with exercise no significant ST segment changes with exercise symptoms of left anterior chest pain were not provoked with exercise and hypertensive response noted with exercise Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Stress Test 2 Transcription INDICATION This 69 year old man is undergoing a preoperative evaluation for anticipated prostate surgery He is having a transurethral prostate resection performed by Dr X for treatment of severely symptomatic prostatic hypertrophy He has recently completed radiation therapy to T11 for a plasmacytoma He has recently complained of left anterior chest pain which radiates down the left upper arm towards the elbow This occurs during quiet periods such as in bed at night It may last all night and still be present in the morning It usually dissipates as the day progresses There are no obvious triggers and there are no obvious alleviating factors The patient has no known cardiac risk factors He is currently taking Avodart 0 5 mg daily Wellbutrin 300 mg daily Xanax 0 25 mg p r n Uroxatral 10 mg daily and omeprazole 20 mg daily PHYSICAL EXAMINATION On physical examination the patient appears pale and fatigued He is 66 inches tall 205 pounds for a body mass index of 32 His resting heart rate is 80 His resting blood pressure is 120 84 His lungs are clear His heart exam reveals a regular rhythm and normal S1 and S2 without murmur gallop or rub appreciated The carotid upstroke is normal with no bruit identified The peripheral pulses are intact The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal DESCRIPTION The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue He did not experience his left anterior chest pain with exercise He did achieve a maximal heart rate of 129 beats per minute which is 85 of his maximal predicted heart rate His maximal blood pressure was 200 84 double product of 24 000 and achieving 7 METs As noted the resting electrocardiogram was normal With exercise there were no significant deviations from baseline and no arrhythmias CONCLUSION 1 Reduced exercise capacity for age 2 No chest pain with exercise 3 No significant ST segment changes with exercise 4 Symptoms of left anterior chest pain were not provoked with exercise 5 Hypertensive response noted with exercise Keywords cardiovascular pulmonary regular rhythm s1 s2 chest pain hypertensive bruce protocol exercise stress test blood pressure resting electrocardiogram anterior chest heart rate rhythm electrocardiogram stress chest heart MEDICAL_TRANSCRIPTION,Description Chest pain Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Stress Test 4 Transcription INDICATION Chest pain DESCRIPTION OF PROCEDURE After informed consent was obtained from the patient the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring The patient s baseline heart rate was 85 beats per minute and blood pressure was 124 90 The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12 8 METs The patient s maximum blood pressure during this stress part was 148 80 and the patient achieved heart rate of 152 with no EKG changes no chest pain FINDINGS 1 Normal hemodynamic response to exercise 2 No EKG changes suggestive of ischemia 3 No chest pain during the stress test 4 Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test Keywords cardiovascular pulmonary treadmill stress test heart rate blood pressure stress test treadmill hemodynamic ekg chest MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy diagnostic Hemoptysis and history of lung cancer Tumor occluding right middle lobe with friability Medical Specialty Cardiovascular Pulmonary Sample Name Fiberoptic Bronchoscopy 1 Transcription PREOPERATIVE DIAGNOSIS 1 Hemoptysis 2 History of lung cancer POSTOPERATIVE DIAGNOSIS Tumor occluding right middle lobe with friability PROCEDURE PERFORMED Fiberoptic bronchoscopy diagnostic LOCATION Endoscopy suite 4 ANESTHESIA General per Anesthesia Service ESTIMATED BLOOD LOSS Minimal COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain Due to her prior history it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis She was brought to endoscopy suite 4 and informed consent was obtained PROCEDURE DETAILS The patient was placed in the supine position and intubated by the Anesthesia Service Intravenous sedation was given as per Anesthesia The fiberoptic scope was passed through the 8 endotracheal tube into the main trachea The right mainstem bronchus was examined The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted Upon examining the right middle lobe there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe The clot was lavaged with normal saline and there was noted to be tumor behind this clot Tumor completely occluded both segments of the right middle lobe Scope was then passed to the subsegments of the right lower lobe which were individually examined and noted to be grossly free of endobronchial lesions Scope was pulled back to the level of the midtrachea passed into the left mainstem bronchus Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions There were some secretions noted throughout the left lung The scope was retracted and passed again to the right mainstem bronchus The area of the right middle lobe was reexamined The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation It did not appear as if a scope or cannula could be passed distal to the tumor Due to continued oozing 1 cc of epinephrine was applied topically with adequate hemostasis obtained The area was examined for approximately one minute for assurance of adequate hemostasis The scope was then retracted and the patient was sent to the recovery room in stable condition She will be extubated as per the Anesthesia Service Cytology and cultures were not sent due to the patient s known diagnosis Further recommendations are pending at this time Keywords cardiovascular pulmonary hemoptysis lung cancer tumor fiberoptic bronchoscopy endoscopy suite adequate hemostasis fiberoptic bronchoscopy endobronchial lesions middle lobe lobe MEDICAL_TRANSCRIPTION,Description No chest pain with exercise and no significant ECG changes with exercise Poor exercise capacity 6 weeks following an aortic valve replacement and single vessel bypass procedure Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Stress Test 3 Transcription INDICATIONS An 82 year old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single vessel coronary bypass graft procedure The patient has had a complicated postoperative course with rapid atrial fibrillation pleural effusions anemia and thrombocytopenia He is currently stabilized and improving in strength He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program He has a few other significant medical problems MEDICATIONS 1 Toprol XL 25 mg daily 2 Simvastatin 80 mg daily 3 Aspirin 81 mg daily 4 Synthroid 0 5 mg daily 5 Warfarin 1 5 mg daily PHYSICAL EXAMINATION The patient appears pale and fragile He is comfortable at rest His resting heart rate is 80 His resting blood pressure is 112 70 His conjunctivae are pale His lungs have decreased breath sounds throughout and dullness at the bases bilaterally Heart exam reveals a distant S1 and S2 There is a short 2 6 systolic ejection murmur The extremities are normal without clubbing cyanosis or edema The resting echocardiogram showed a sinus rhythm at 70 beats per minute There is poor R wave progression across the pericardium and Q waves inferiorly DESCRIPTION The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath He did not experience chest pain with exercise He did achieve a maximal heart rate of 100 which is 72 of his maximal predicted heart rate His maximal blood pressure was 190 70 resulting in a double product of 19 000 and achieving 2 3 METS As noted the resting electrocardiogram had inferior Q waves and poor R wave progression There were no significant ST segment changes with exercise There were only rare ventricular premature beats with exercise CONCLUSION 1 Poor exercise capacity 6 weeks following an aortic valve replacement and single vessel bypass procedure 2 No chest pain with exercise 3 No significant ECG changes with exercise 4 The patient is considered stable to enter our cardiac rehabilitation program I recommend the patient have a complete blood count basic metabolic profile and TSH obtained prior to entering the rehab program Keywords cardiovascular pulmonary bruce protocol exercise stress test cardiac rehabilitation program blood pressure cardiac rehabilitation heart rate stress rehabilitation heart atrial MEDICAL_TRANSCRIPTION,Description Exercise stress test with nuclear scan for chest pain Chest pain resolved after termination of exercise Good exercise duration tolerance and double product Normal nuclear myocardial perfusion scan Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Stress Test Transcription INDICATION Chest pain INTERPRETATION Resting heart rate of 71 blood pressure 100 60 EKG normal sinus rhythm The patient exercised on Bruce for 8 minutes on stage III Peak heart rate was 151 which is 87 of the target heart rate blood pressure of 132 54 Total METs was 10 1 EKG revealed nonspecific ST depression in inferior and lateral leads The test was terminated because of fatigue The patient did have chest pain during exercise that resolved after termination of the exercise IN SUMMARY 1 Positive exercise ischemia with ST depression 0 5 mm 2 Chest pain resolved after termination of exercise 3 Good exercise duration tolerance and double product NUCLEAR INTERPRETATION Resting and stress images were obtained with 10 1 mCi and 34 1 mCi of tetraphosphate injected intravenously by standard protocol Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect Gated SPECT revealed normal wall motion ejection fraction of 68 End diastolic volume of 77 end systolic volume of 24 IN SUMMARY 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction of 68 by gated SPECT Keywords cardiovascular pulmonary chest pain ekg sinus st depression mci gated spect nuclear myocardial perfusion scan ejection fraction myocardial perfusion perfusion scan heart rate spect stress nuclear chest MEDICAL_TRANSCRIPTION,Description Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage Bilateral upper lobe cavitary lung masses Airway changes including narrowing of upper lobe segmental bronchi apical and posterior on the right and anterior on the left There are also changes of inflammation throughout Medical Specialty Cardiovascular Pulmonary Sample Name Fiberoptic Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Bilateral upper lobe cavitary lung masses POSTOPERATIVE DIAGNOSES 1 Bilateral upper lobe cavitary lung masses 2 Final pending pathology 3 Airway changes including narrowing of upper lobe segmental bronchi apical and posterior on the right and anterior on the left There are also changes of inflammation throughout PROCEDURE PERFORMED Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage ANESTHESIA Conscious sedation was with Demerol 150 mg and Versed 4 mg IV OPERATIVE REPORT The patient is residing in the endoscopy suite After appropriate anesthesia and sedation the bronchoscope was advanced transorally due to the patient s recent history of epistaxis Topical lidocaine was utilized for anesthesia Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent This may be normal anatomic variant The scope was advanced into the trachea The main carina was sharp in appearance Right upper middle and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left No specific intrinsic masses were noted Under direct visualization the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe Also cytologic brushings and protected bacteriologic brushing specimens were obtained Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe During lavage some caseous appearing debris appeared intermittently The specimens were collected and sent to the lab Procedure was terminated with hemostasis having been verified The patient tolerated the procedure well Throughout the procedure the patient s vital signs and oximetry were monitored and remained within satisfactory limits The patient will be returned to her room with orders as per usual Keywords cardiovascular pulmonary inflammation lung masses lobe cavitary bronchoalveolar biopsies segmental bronchi fiberoptic bronchoscopy lavage cavitary segmental lobe MEDICAL_TRANSCRIPTION,Description A 44 year old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain MI has been ruled out She has been referred for an exercise echocardiogram Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Stress Test 1 Transcription Informed written consent has been obtained from the patient I explained the procedure to her prior to initiation of such The appropriate time out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient procedure physician documentation position There were no safety concerns noted by staff nor myself REST ECHO EF 60 No wall motion abnormalities EKG shows normal sinus rhythm with mild ST depressions The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol exceeding target heart rate no angina nor significant ECG changes seen Peak stress echo imaging shows EF of 75 no regional wall motion abnormalities There was resting hypertension noted systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise No dysrhythmias noted IMPRESSION 1 Negative exercise ECG echocardiogram stress evaluation for inducible ischemia in excess of target heart rate 2 Resting hypertension with appropriate response of blood pressure to exercise These results have been discussed with the patient Other management as per the hospital based internal medicine service To be clear there were no complications of this procedure Keywords cardiovascular pulmonary ecg echocardiogram exercise stress test ecg wall motion abnormalities target heart rate hypertension echocardiogram MEDICAL_TRANSCRIPTION,Description Ivor Lewis esophagogastrectomy feeding jejunostomy placement of two right sided 28 French chest tubes and right thoracotomy Medical Specialty Cardiovascular Pulmonary Sample Name Esophagogastrectomy Jejunostomy Chest Tubes Transcription OPERATION 1 Ivor Lewis esophagogastrectomy 2 Feeding jejunostomy 3 Placement of two right sided 28 French chest tubes 4 Right thoracotomy ANESTHESIA General endotracheal anesthesia with a dual lumen tube OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Prior to administration of general anesthesia the patient had an epidural anesthesia placed In addition he had a dual lumen endotracheal tube placed The patient was placed in the supine position to begin the procedure His abdomen and chest were prepped and draped in the standard surgical fashion After applying sterile dressings a 10 blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus Dissection was carried down through the linea using Bovie electrocautery The abdomen was opened Next a Balfour retractor was positioned as well as a mechanical retractor Next our attention was turned to freeing up the stomach In an attempt to do so we identified the right gastroepiploic artery and arcade We incised the omentum and retracted it off the stomach and gastroepiploic arcade The omentum was divided using suture ligature with 2 0 silk We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2 0 silk Next we turned our attention to performing a Kocher maneuver This was done and the stomach was freed up We took down the falciform ligament as well as the caudate attachment to the diaphragm We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest We also did a portion of the esophageal dissection from the abdomen into the chest area The esophagus and the esophageal hiatus were identified in the abdomen We next turned our attention to the left gastric artery The left gastric artery was identified at the base of the stomach We first took the left gastric vein by ligating and dividing it using 0 silk ties The left gastric artery was next taken using suture ligature with silk ties followed by 2 0 stick tie reinforcement At this point the stomach was freely mobile We then turned our attention to performing our jejunostomy feeding tube A 2 0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz We then used Bovie electrocautery to open the jejunum at this site We placed a 16 French red rubber catheter through this site We tied down in place We then used 3 0 silk sutures to perform a Witzel Next the loop of jejunum was tacked up to the abdominal wall using 2 0 silk ties After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately we turned our attention to closing the abdomen This was done with 1 Prolene We put in a 2nd layer of 2 0 Vicryl The skin was closed with 4 0 Monocryl Next we turned our attention to performing the thoracic portion of the procedure The patient was placed in the left lateral decubitus position The right chest was prepped and draped appropriately We then used a 10 blade scalpel to make an incision in a posterolateral non muscle sparing fashion Dissection was carried down to the level of the ribs with Bovie electrocautery Next the ribs were counted and the 5th interspace was entered The lung was deflated We placed standard chest retractors Next we incised the peritoneum over the esophagus We dissected the esophagus to just above the azygos vein The azygos vein in fact was taken with 0 silk ligatures and reinforced with 2 0 stick ties As mentioned we dissected the esophagus both proximally and distally down to the level of the hiatus After doing this we backed our NG tube out to above the level where we planned to perform our pursestring We used an automatic pursestring and applied We then transected the proximal portion of the stomach with Metzenbaum scissors We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus The pursestring was then tied down without difficulty Next we tabularized our stomach using a 80 GIA stapler After doing so we chose a portion of the stomach more distally and opened it using Bovie electrocautery We placed our EEA stapler through it and then punched out through the gastric wall We connected our anvil to the EEA stapler This was then secured appropriately We checked to make sure that there was appropriate muscle apposition We then fired the stapler We obtained 2 complete rings 1 of the esophagus and 1 of the stomach which were sent for pathology We also sent the gastroesophageal specimen for pathology Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins We then turned our attention to closing the gastrostomy opening This was closed with 2 0 Vicryl in a running fashion We then buttressed this with serosal 3 0 Vicryl interrupted sutures We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it Next we placed two 28 French chest tubes 1 anteriorly and 1 posteriorly taking care not to place it near the anastomosis We then closed the chest with 2 Vicryl in an interrupted figure of eight fashion The lung was brought up We closed the muscle layers with 0 Vicryl followed by 0 Vicryl then we closed the subcutaneous layer with 2 0 Vicryl and the skin with 4 0 Monocryl Sterile dressing was applied The instrument and sponge count was correct at the end of the case The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition Keywords cardiovascular pulmonary ivor lewis esophagogastrectomy jejunostomy thoracotomy dual lumen tube chest tubes bovie electrocautery chest endotracheal electrocautery abdomen gastric esophagus tubes vicryl stomach MEDICAL_TRANSCRIPTION,Description Endotracheal intubation The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather PCO2 was 29 and pO2 was 66 on the 15 liters Medical Specialty Cardiovascular Pulmonary Sample Name Endotracheal Intubation 1 Transcription PROCEDURE PERFORMED Endotracheal intubation INDICATION FOR PROCEDURE The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather PCO2 was 29 and pO2 was 66 on the 15 liters NARRATIVE OF PROCEDURE The patient was given a total of 5 mg of Versed 20 mg of etomidate and 10 mg of vecuronium He was intubated in a single attempt Cords were well visualized and a 8 endotracheal tube was passed using a curved blade Fiberoptically a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology AFB and fungal smear and culture A separate trap B was then lavaged for bacterial C S and Gram stain and was sent for those purposes The patient tolerated the procedure well Keywords cardiovascular pulmonary nonrebreather respiratory distress falling saturation endotracheal intubation lavage breathingNOTE MEDICAL_TRANSCRIPTION,Description Exercise myocardial perfusion study The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59 Medical Specialty Cardiovascular Pulmonary Sample Name Exercise Myocardial Perfusion Study Transcription CLINICAL INDICATION Chest pain INTERPRETATION The patient received 14 9 mCi of Cardiolite for the rest portion of the study and 11 5 mCi of Cardiolite for the stress portion of the study The patient s baseline EKG was normal sinus rhythm The patient was stressed according to Bruce protocol by Dr X Exercise test was supervised and interpreted by Dr X Please see the separate report for stress portion of the study The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen which is most likely secondary to soft tissue attenuation artifact There is however mild partially reversible perfusion defect seen which is more pronounced in the stress images and short axis view suggestive of minimal ischemia in the inferolateral wall The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59 CONCLUSION 1 The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall 2 Normal LV systolic function with LV ejection fraction of 59 Keywords cardiovascular pulmonary chest pain cardiolite ekg spect lv systolic function lv ejection fraction myocardial perfusion study spect study ejection fraction myocardial perfusion ischemia MEDICAL_TRANSCRIPTION,Description Echocardiographic examination Borderline left ventricular hypertrophy with normal ejection fraction at 60 mitral annular calcification with structurally normal mitral valve no intracavitary thrombi is seen interatrial septum was somewhat difficult to assess but appeared to be intact on the views obtained Medical Specialty Cardiovascular Pulmonary Sample Name Echocardiography Transcription REASON FOR EXAM CVA INDICATIONS CVA This is technically acceptable There is some limitation related to body habitus DIMENSIONS The interventricular septum 1 2 posterior wall 10 9 left ventricular end diastolic 5 5 and end systolic 4 5 the left atrium 3 9 FINDINGS The left atrium was mildly dilated No masses or thrombi were seen The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening EF of 60 The right atrium and right ventricle are normal in size Mitral valve showed mitral annular calcification in the posterior aspect of the valve The valve itself was structurally normal No vegetations seen No significant MR Mitral inflow pattern was consistent with diastolic dysfunction grade 1 The aortic valve showed minimal thickening with good exposure and coaptation Peak velocity is normal No AI Pulmonic and tricuspid valves were both structurally normal Interatrial septum was appeared to be intact in the views obtained A bubble study was not performed No pericardial effusion was seen Aortic arch was not assessed CONCLUSIONS 1 Borderline left ventricular hypertrophy with normal ejection fraction at 60 2 Mitral annular calcification with structurally normal mitral valve 3 No intracavitary thrombi is seen 4 Interatrial septum was somewhat difficult to assess but appeared to be intact on the views obtained Keywords cardiovascular pulmonary ventricular hypertrophy normal wall motion ventricle atrium annular calcification mitral valve interatrial septum hypertrophy annular thrombi ventricular structurally septum valve mitral MEDICAL_TRANSCRIPTION,Description Endovascular Brachytherapy EBT Medical Specialty Cardiovascular Pulmonary Sample Name Endovascular Brachytherapy Transcription ENDOVASCULAR BRACHYTHERAPY EBT The patient is to undergo a course of angioplasty for in stent restenosis The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site After this a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function Keywords cardiovascular pulmonary endovascular brachytherapy ebt angioplasty stent vessel atherectomy endovascular brachytherapyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Endotracheal intubation Respiratory failure The patient is a 52 year old male with metastatic osteogenic sarcoma He was admitted two days ago with small bowel obstruction Medical Specialty Cardiovascular Pulmonary Sample Name Endotracheal Intubation Transcription PROCEDURE Endotracheal intubation INDICATION Respiratory failure BRIEF HISTORY The patient is a 52 year old male with metastatic osteogenic sarcoma He was admitted two days ago with small bowel obstruction He has been on Coumadin for previous PE and currently on heparin drip He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness A code blue was called On my arrival the patient s vital signs are stable His blood pressure is systolically in 140s and heart rate 80s He however has 0 respiratory effort and is unresponsive to even painful stimuli The patient was given etomidate 20 mg DESCRIPTION OF PROCEDURE The patient positioned appropriate equipment at the bedside given 20 mg of etomidate and 100 mg of succinylcholine Mac 4 blade was used A 7 5 ET tube placed to 24th teeth There is good color change on the capnographer with bilateral breath sounds Following intubation the patient s blood pressure began to drop He was given 2 L of bolus I started him on dopamine drip at 10 mcg Dr X was at the bedside who is the primary caregiver he assumed the care of the patient will be transferred to the ICU Chest x ray will be reviewed and Pulmonary will be consulted Keywords cardiovascular pulmonary metastatic osteogenic sarcoma respiratory failure bowel obstruction blood pressure endotracheal intubation endotracheal sarcoma MEDICAL_TRANSCRIPTION,Description Echocardiogram was performed including 2 D and M mode imaging Medical Specialty Cardiovascular Pulmonary Sample Name Echocardiogram 1 Transcription EXAM Echocardiogram INTERPRETATION Echocardiogram was performed including 2 D and M mode imaging Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M mode Cardiac chamber dimensions left atrial enlargement 4 4 cm Left ventricle right ventricle and right atrium are grossly normal LV wall thickness and wall motion appeared normal LV ejection fraction is estimated at 65 Aortic root and cardiac valves appeared normal No evidence of pericardial effusion No evidence of intracardiac mass or thrombus Doppler analysis outflow velocity through the aortic valve normal inflow velocities through the mitral valve are normal There is mild tricuspid regurgitation Calculated pulmonary systolic pressure 42 mmHg ECHOCARDIOGRAPHIC DIAGNOSES 1 LV Ejection fraction estimated at 65 2 Mild left atrial enlargement 3 Mild tricuspid regurgitation 4 Mildly elevated pulmonary systolic pressure Keywords cardiovascular pulmonary lv ejection fraction ejection fraction tricuspid regurgitation systolic pressure valves atrial echocardiogram MEDICAL_TRANSCRIPTION,Description Echocardiographic Examination Report Angina and coronary artery disease Mild biatrial enlargement normal thickening of the left ventricle with mildly dilated ventricle and EF of 40 mild mitral regurgitation diastolic dysfunction grade 2 mild pulmonary hypertension Medical Specialty Cardiovascular Pulmonary Sample Name Echocardiogram 3 Transcription REASON FOR EXAM 1 Angina 2 Coronary artery disease INTERPRETATION This is a technically acceptable study DIMENSIONS Anterior septal wall 1 2 posterior wall 1 2 left ventricular end diastolic 6 0 end systolic 4 7 The left atrium is 3 9 FINDINGS Left atrium was mildly to moderately dilated No masses or thrombi were seen The left ventricle was mildly dilated with mainly global hypokinesis more prominent in the inferior septum and inferoposterior wall The EF was moderately reduced with estimated EF of 40 with near normal thickening The right atrium was mildly dilated The right ventricle was normal in size Mitral valve showed to be structurally normal with no prolapse or vegetation There was mild mitral regurgitation on color flow interrogation The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction The aortic valve appeared to be structurally normal Normal peak velocity No significant AI Pulmonic valve showed mild PI Tricuspid valve showed mild tricuspid regurgitation Based on which the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg Anterior septum appeared to be intact No pericardial effusion was seen CONCLUSION 1 Mild biatrial enlargement 2 Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40 3 Mild mitral regurgitation 4 Diastolic dysfunction grade 2 5 Mild pulmonary hypertension Keywords cardiovascular pulmonary angina coronary artery disease septal ventricular diastolic systolic pulmonary hypertension mitral regurgitation septum tricuspid thickening dysfunction wall ef regurgitation atrium valve dilated mitral ventricle mildly MEDICAL_TRANSCRIPTION,Description Echocardiogram for aortic stenosis Transthoracic echocardiogram was performed of adequate technical quality Concentric hypertrophy of the left ventricle with normal function Doppler study as above most pronounced being moderate aortic stenosis valve area of 1 1 sq cm Medical Specialty Cardiovascular Pulmonary Sample Name Echocardiogram 2 Transcription EXAM Echocardiogram INDICATION Aortic stenosis INTERPRETATION Transthoracic echocardiogram was performed of adequate technical quality Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function Ejection fraction is 60 without any obvious wall motion abnormality Left atrium and right side chambers are of normal size and dimensions Aortic root has normal diameter Mitral and tricuspid valves are structurally normal except for minimal annular calcification Valvular leaflet excursion is adequate Aortic valve reveals annular calcification Fibrocalcific valve leaflets with decreased excursion Atrial and ventricular septum are intact Pericardium is intact without any effusion No obvious intracardiac mass or thrombi noted Doppler reveals mild mitral regurgitation mild to moderate tricuspid regurgitation Estimated pulmonary pressure of 48 Systolic consistent with mild to moderate pulmonary hypertension Peak velocity across the aortic valve is 3 0 with a peak gradient of 37 mean gradient of 19 valve area calculated at 1 1 sq cm consistent with moderate aortic stenosis IN SUMMARY 1 Concentric hypertrophy of the left ventricle with normal function 2 Doppler study as above most pronounced being moderate aortic stenosis valve area of 1 1 sq cm Keywords cardiovascular pulmonary moderate aortic stenosis annular calcification concentric hypertrophy aortic stenosis echocardiogram stenosis valve aortic MEDICAL_TRANSCRIPTION,Description Duplex ultrasound of legs Medical Specialty Cardiovascular Pulmonary Sample Name Duplex Ultrasound Legs Transcription DUPLEX ULTRASOUND OF LEGS RIGHT LEG Duplex imaging was carried out according to normal protocol with a 7 5 Mhz imaging probe using B mode ultrasound Deep veins were imaged at the level of the common femoral and popliteal veins All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity The long saphenous system displayed compressibility without evidence of thrombosis The long saphenous vein measured cm at the proximal thigh with reflux of seconds after release of distal compression and cm at the knee with reflux of seconds after release of distal compression The small saphenous system measured cm at the proximal calf with reflux of seconds after release of distal compression LEFT LEG Duplex imaging was carried out according to normal protocol with a 7 5 Mhz imaging probe using B mode ultrasound Deep veins were imaged at the level of the common femoral and popliteal veins All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity The long saphenous system displayed compressibility without evidence of thrombosis The long saphenous vein measured cm at the proximal thigh with reflux of seconds after release of distal compression and cm at the knee with reflux of seconds after release of distal compression The small saphenous system measured cm at the proximal calf with reflux of seconds after release of distal compression Keywords cardiovascular pulmonary duplex ultrasound b mode ultrasound duplex imaging compression echogenicity femoral intraluminal thrombus popliteal saphenous vein thrombosis release of distal compression calf with reflux distal compression duplex ultrasound legs saphenous release distal veins MEDICAL_TRANSCRIPTION,Description Dobutamine Stress Echocardiogram Chest discomfort evaluation for coronary artery disease Maximal dobutamine stress echocardiogram test achieving more than 85 of age predicted heart rate Negative EKG criteria for ischemia Medical Specialty Cardiovascular Pulmonary Sample Name Dobutamine Stress Test 1 Transcription DOBUTAMINE STRESS ECHOCARDIOGRAM REASON FOR EXAM Chest discomfort evaluation for coronary artery disease PROCEDURE IN DETAIL The patient was brought to the cardiac center Cardiac images at rest were obtained in the parasternal long and short axis apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg kg per minute for low dose increased every 2 to 3 minutes by 10 mcg kg per minute The patient maximized at 30 mcg kg per minute Images were obtained at that level after adding 0 7 mg of atropine to reach maximal heart rate of 145 Maximal images were obtained in the same windows of parasternal long and short axis apical four and apical two windows Wall motion assessed at all levels as well as at recovery The patient got nauseated had some mild shortness of breath No angina during the procedure and the maximal amount of dobutamine was 30 mcg kg per minute The resting heart rate was 78 with the resting blood pressure 186 98 Heart rate reduced by the vasodilator effects of dobutamine to 130 80 Maximal heart rate achieved was 145 which is 85 of age predicted heart rate The EKG at rest showed sinus rhythm with no ST T wave depression suggestive of ischemia or injury Incomplete right bundle branch block was seen The maximal stress test EKG showed sinus tachycardia There was subtle upsloping ST depression in III and aVF which is a normal response to the tachycardia with dobutamine but no significant depression suggestive of ischemia and no ST elevation seen No ventricular tachycardia or ventricular ectopy seen during the test The heart rate recovered in a normal fashion after using metoprolol 5 mg The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior anteroseptal inferior lateral and septal walls at low dose All walls mentioned were augmented in a normal fashion At maximum dose all walls were augmented on all views except for the short axis was foreshortened was uncertain about the anterolateral wall at peak exercise however of the other views the lateral wall was showing normal thickening and normal augmentation EF improved to about 70 The wall motion score was unchanged IMPRESSION 1 Maximal dobutamine stress echocardiogram test achieving more than 85 of age predicted heart rate 2 Negative EKG criteria for ischemia 3 Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view This is considered the negative dobutamine stress echocardiogram test medical management Keywords cardiovascular pulmonary chest discomfort coronary artery disease predicted heart rate dobutamine stress echocardiogram anterolateral wall echocardiogram test wall motion stress echocardiogram short axis dobutamine stress heart rate dobutamine stress ekg echocardiogram artery ischemia heart MEDICAL_TRANSCRIPTION,Description Echocardiogram with color flow and conventional Doppler interrogation Medical Specialty Cardiovascular Pulmonary Sample Name Echocardiogram Transcription REASON FOR EXAMINATION Cardiac arrhythmia INTERPRETATION No significant pericardial effusion was identified The aortic root dimensions are within normal limits The four cardiac chambers dimensions are within normal limits No discrete regional wall motion abnormalities are identified The left ventricular systolic function is preserved with an estimated ejection fraction of 60 The left ventricular wall thickness is within normal limits The aortic valve is trileaflet with adequate excursion of the leaflets The mitral valve and tricuspid valve motion is unremarkable The pulmonic valve is not well visualized Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg Doppler interrogation of the mitral in flow pattern is within normal limits for age IMPRESSION 1 Preserved left ventricular systolic function 2 Mild mitral regurgitation 3 Mild tricuspid regurgitation Keywords cardiovascular pulmonary arrhythmia wall motion ventricular systolic function color flow conventional doppler systolic function mitral regurgitation mild tricuspid tricuspid regurgitation echocardiogram doppler cardiac ventricular systolic tricuspid valve mitral regurgitation MEDICAL_TRANSCRIPTION,Description Dual Chamber ICD Implantation fluoroscopy defibrillation threshold testing venography Medical Specialty Cardiovascular Pulmonary Sample Name Dual Chamber ICD Implantation Transcription PROCEDURE 1 Implantation dual chamber ICD 2 Fluoroscopy 3 Defibrillation threshold testing 4 Venography PROCEDURE NOTE After informed consent was obtained the patient was taken to the operating room The patient was prepped and draped in a sterile fashion Using modified Seldinger technique the left subclavian vein was attempted to be punctured but unsuccessfully Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein Venogram was then performed Under fluoroscopy via modified Seldinger technique the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava then the right atrium and then into the inferior vena cava A second guidewire was placed in a similar fashion Approximately a 5 cm incision was made in the left upper anterior chest The skin and subcutaneous tissue was dissected out of the prepectoral fascia Both guide wires were brought into the pocket area A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava The dilator and guidewire were removed A Fixation ventricular lead under fluoroscopic guidance was placed through the sheath into the superior vena cava right atrium and then right ventricle Using straight and curved stylettes it was placed in position and screwed into the right ventricular apex After pacing and sensing parameters were established in the lead the collar on the lead was sutured to the pectoral muscle with Ethibond suture A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava The dilator and guidewire were removed An Active Fixation atrial lead was fluoroscopically passed through the sheath into the superior vena cava and then the right atrium Using straight and J shaped stylettes it was placed in the appropriate position and screwed in the right atrial appendage area After significant pacing parameters were established in the lead the collar on the lead was sutured to the pectoral muscles with Ethibond suture The tract was flushed with saline solution A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture Deep and superficial layers were closed with 3 0 Vicryl in a running fashion Steri strips were placed over the incision Tegaderm was placed over the Steri strips Pressure dressing was applied to the pocket area Keywords cardiovascular pulmonary venography defibrillation threshold testing venogram dual chamber icd implantation dual chamber icd superior vena cava seldinger technique pectoral muscle steri strips dual chamber ethibond suture superior vena vena cava dual chamber icd implantation fluoroscopy atrium pectoral vein fluoroscopically vena cava lead guidewire MEDICAL_TRANSCRIPTION,Description Insertion of a double lumen port through the left femoral vein radiological guidance Open exploration of the left subclavian and axillary vein Metastatic glossal carcinoma needing chemotherapy and a port Medical Specialty Cardiovascular Pulmonary Sample Name Double Lumen Port Inserstion Transcription PREOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port POSTOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port PROCEDURES 1 Open exploration of the left subclavian axillary vein 2 Insertion of a double lumen port through the left femoral vein radiological guidance DESCRIPTION OF PROCEDURE After obtaining the informed consent the patient was electively taken to the operating room where he underwent a general anesthetic through his tracheostomy The left deltopectoral and cervical areas were prepped and draped in the usual fashion Local anesthetic was infiltrated in the area There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin which made us suspicious that may be __________ but at any rate I tried to cannulate it subcutaneously and I was unsuccessful Therefore I proceeded to make an incision and was able to isolate the vein which would look very sclerotic I tried to cannulate it but I could not advance the wire At that moment I decided that there was no way we are going to put a port though that area I packed the incision and we prepped and redraped the patient including both groins Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty The introducer was placed and then a wire and then the catheter of the double lumen port which had been trimmed to position it near the heart It was done with radiological guidance Again I was able to position the catheter in the junction of inferior vena cava and right atrium The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area The port had been aspirated satisfactorily and irrigated with heparin solution The drain incision was closed in layers including subcuticular suture with Monocryl Then we went up to the left shoulder and closed that incision in layers Dressings were applied The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition Keywords cardiovascular pulmonary axillary vein subclavian double lumen port femoral vein radiological guidance glossal carcinoma port inserstion femoral radiological metastatic carcinoma chemotherapy anesthetic catheter MEDICAL_TRANSCRIPTION,Description The patient was admitted after undergoing a drawn out process with a small bowel obstruction Medical Specialty Cardiovascular Pulmonary Sample Name Discharge Summary Respiratory Failure Transcription DISCHARGE DIAGNOSIS 1 Respiratory failure improved 2 Hypotension resolved 3 Anemia of chronic disease stable 4 Anasarca improving 5 Protein malnourishment improving 6 End stage liver disease HISTORY AND HOSPITAL COURSE The patient was admitted after undergoing a drawn out process with a small bowel obstruction His bowel function started to improve He was on TPN prior to coming to Hospital He has remained on TPN throughout his time here but his appetite and his p o intake have improved some The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine At one point we were unsuccessful at weaning him off the dopamine but after approximately 11 days he finally started to tolerate weaning parameters was successfully removed from dopamine and has maintained his blood pressure without difficulty The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left sided pneumonia This has been treated successfully with Zyvox and Levaquin and Diflucan He seems to be currently doing much better He is only using BiPAP in the evening As stated above he is eating better He had some evidence of redness and exquisite swelling around his genital and lower abdominal region This may be mainly dependent edema versus anasarca The patient has been diuresed aggressively over the last 4 to 5 days and this seems to have made some improvement in his swelling This morning the patient denies any acute distress He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation He will be discharged to Garden Court skilled nursing facility DISCHARGE MEDICATIONS INSTRUCTIONS He is going to be going with Protonix 40 mg daily metoclopramide 10 mg every 6 hours Zyvox 600 mg daily for 5 days Diflucan 150 mg p o daily for 3 days Bumex 2 mg p o daily Megace 400 mg p o b i d Ensure 1 can t i d with meals and MiraLax 17 gm p o daily The patient is going to require physical therapy to help with assistance in strength training He is also going to need respiratory care to work with his BiPAP His initial settings are at a rate of 20 pressure support of 12 PEEP of 6 FIO2 of 40 The patient will need a sleep study which the nursing home will be able to set up PHYSICAL EXAMINATION VITAL SIGNS On the day of discharge heart rate 99 respiratory rate 20 blood pressure 102 59 temperature 98 2 O2 sat 97 GENERAL A well developed white male who appears in no apparent distress HEENT Unremarkable CARDIOVASCULAR Positive S1 S2 without murmur rubs or gallops LUNGS Clear to auscultation bilaterally without wheezes or crackles ABDOMEN Positive for bowel sounds Soft nondistended He does have some generalized redness around his abdominal region and groin This does appear improved compared to presentation last week The swelling in this area also appears improved EXTREMITIES Show no clubbing or cyanosis He does have some lower extremity edema 2 distal pedal pulses are present NEUROLOGIC The patient is alert and oriented to person and place He is alert and aware of surroundings We have not had any difficulties with confusion here lately MUSCULOSKELETAL The patient moves all extremities without difficulty He is just weak in general LABORATORY DATA Lab work done today shows the following White count 4 2 hemoglobin 10 2 hematocrit 30 6 and platelet count 184 000 Electrolytes show sodium 139 potassium 4 1 chloride 98 CO2 26 glucose 79 BUN 56 and creatinine 1 4 Calcium 8 8 phosphorus is a little high at 5 5 magnesium 2 2 albumin 3 9 PLAN Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning Hopefully long term planning will be discharge home He has a history of end stage liver disease with cirrhosis which may make him a candidate for hospice upon discharge The family initially wanted to bring the patient home but he is too weak and requires too much assistance to adequately consider this option at this time Keywords cardiovascular pulmonary respiratory failure hypotension anemia anasarca end stage liver disease drawn out process bowel obstruction blood pressure dopamine discharge MEDICAL_TRANSCRIPTION,Description Dobutamine stress test for chest pain as the patient was unable to walk on a treadmill and allergic to adenosine Nondiagnostic dobutamine stress test Normal nuclear myocardial perfusion scan Medical Specialty Cardiovascular Pulmonary Sample Name Dobutamine Stress Test Transcription EXAM Dobutamine Stress Test INDICATION Chest pain TYPE OF TEST Dobutamine stress test as the patient was unable to walk on a treadmill and allergic to adenosine INTERPRETATION Resting heart rate of 66 and blood pressure of 88 45 EKG normal sinus rhythm Post dobutamine increment dose his peak heart rate achieved was 125 which is 87 of the target heart rate Blood pressure 120 42 EKG remained the same No symptoms were noted IMPRESSION 1 Nondiagnostic dobutamine stress test 2 Nuclear interpretation as below NUCLEAR INTERPRETATION Resting and stress images were obtained with 10 8 30 2 mCi of tetrofosmin injected intravenously by standard protocol Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect Gated and SPECT revealed normal wall motion and ejection fraction of 75 End diastolic volume was 57 and end systolic volume of 12 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction of 75 by gated SPECT Keywords cardiovascular pulmonary nuclear myocardial perfusion scan dobutamine stress test ejection fraction myocardial perfusion perfusion scan dobutamine stress stress test myocardial perfusion nuclear dobutamine stress MEDICAL_TRANSCRIPTION,Description Patient had some cold symptoms was treated as bronchitis with antibiotics Medical Specialty Cardiovascular Pulmonary Sample Name Discharge Summary Transcription DISCHARGE DIAGNOSES 1 Acute respiratory failure resolved 2 Severe bronchitis leading to acute respiratory failure improving 3 Acute on chronic renal failure improved 4 Severe hypertension improved 5 Diastolic dysfunction X ray on discharge did not show any congestion and pro BNP is normal SECONDARY DIAGNOSES 1 Hyperlipidemia 2 Recent evaluation and treatment including cardiac catheterization which did not show any coronary artery disease 3 Remote history of carcinoma of the breast 4 Remote history of right nephrectomy 5 Allergic rhinitis HOSPITAL COURSE This 83 year old patient had some cold symptoms was treated as bronchitis with antibiotics Not long after the patient returned from Mexico the patient started having progressive shortness of breath came to the emergency room with severe bilateral wheezing and crepitations X rays however did not show any congestion or infiltrates and pro BNP was within normal limits The patient however was hypoxic and required 4L nasal cannula She was admitted to the Intensive Care Unit The patient improved remarkably over the night on IV steroids and empirical IV Lasix Initial swab was positive for MRSA colonization Discussed with infectious disease Dr X and it was decided no treatment was required for de colonization The patient s breathing has improved There is no wheezing or crepitations and O2 saturation is 91 on room air The patient is yet to go for exercise oximetry Her main complaint is nasal congestion and she is now on steroid nasal spray The patient was seen by Cardiology Dr Z who advised continuation of beta blockers for diastolic dysfunction The patient has been weaned off IV steroids and is currently on oral steroids which she will be on for seven days DISPOSITION The patient has been discharged home DISCHARGE MEDICATIONS 1 Metoprolol 25 mg p o b i d 2 Simvastatin 20 mg p o daily NEW MEDICATIONS 1 Prednisone 20 mg p o daily for seven days 2 Flonase nasal spray daily for 30 days Results for oximetry pending to evaluate the patient for need for home oxygen FOLLOW UP The patient will follow up with Pulmonology Dr Y in one week s time and with cardiologist Dr X in two to three weeks time Keywords cardiovascular pulmonary acute respiratory failure bronchitis acute on chronic renal failure severe hypertension diastolic dysfunction cold symptoms iv steroids nasal spray nasal steroids MEDICAL_TRANSCRIPTION,Description Direct laryngoscopy and bronchoscopy Medical Specialty Cardiovascular Pulmonary Sample Name Direct Laryngoscopy Transcription PREOPERATIVE DIAGNOSIS Subglottic stenosis POSTOPERATIVE DIAGNOSIS Subglottic stenosis OPERATIVE PROCEDURES Direct laryngoscopy and bronchoscopy ANESTHESIA General inhalation DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operative table General inhalational anesthesia was administered through the patient s tracheotomy tube The small Parsons laryngoscope was inserted and the 2 9 mm telescope was used to inspect the airway There was an estimated 60 70 circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds The stoma showed some suprastomal fibroma The remaining tracheobronchial passages were clear The patient s 3 5 neonatal tracheostomy tube was repositioned and secured with Velcro ties Bleeding was negligible There were no untoward complications The patient tolerated the procedure well and was transferred to recovery room in stable condition Keywords cardiovascular pulmonary laryngoscopy and bronchoscopy direct laryngoscopy subglottic stenosis bronchoscopy laryngoscopy subglottic stenosis MEDICAL_TRANSCRIPTION,Description The patient is a 61 year old female who was treated with CyberKnife therapy to a right upper lobe stage IA non small cell lung cancer CyberKnife treatment was completed one month ago She is now being seen for her first post CyberKnife treatment visit Medical Specialty Cardiovascular Pulmonary Sample Name CyberKnife Treatment Followup Transcription HISTORY OF PRESENT ILLNESS The patient is a 61 year old female who was treated with CyberKnife therapy to a right upper lobe stage IA non small cell lung cancer CyberKnife treatment was completed one month ago She is now being seen for her first post CyberKnife treatment visit Since undergoing CyberKnife treatment she has had low level nausea without vomiting She continues to have pain with deep inspiration and resolving dysphagia She has no heartburn cough hemoptysis rash or palpable rib pain MEDICATIONS Dilantin 100 mg four times a day phenobarbital 30 mg three times per day levothyroxine 0 025 mg p o q day Tylenol with Codeine b i d prednisone 5 mg p r n citalopram 10 mg p o q day Spiriva q day Combivent inhaler p r n omeprazole 20 mg p o q day Lidoderm patch every 12 hours Naprosyn 375 mg p o b i d oxaprozin 600 mg p o b i d Megace 40 mg p o b i d and Asacol p r n PHYSICAL EXAMINATION BP 122 86 Temp 96 8 HR 79 RR 26 RAS 100 HEENT Normocephalic Pupils are equal and reactive to light and accommodation EOMs intact NECK Supple without masses or lymphadenopathy LUNGS Clear to auscultation bilaterally CARDIAC Regular rate and rhythm without rubs murmurs or gallops EXTREMITIES No cyanosis clubbing or edema ASSESSMENT The patient has done well with CyberKnife treatment of a stage IA non small cell lung cancer right upper lobe one month ago PLAN She is to return to clinic in three months with a PET CT Keywords cardiovascular pulmonary non small cell lung cancer cyberknife therapy lung cancer cell lung cancer cyberknife MEDICAL_TRANSCRIPTION,Description CT of chest with contrast Abnormal chest x ray demonstrating a region of consolidation versus mass in the right upper lobe Medical Specialty Cardiovascular Pulmonary Sample Name CT of Chest with Contrast Transcription EXAM CT chest with contrast HISTORY Abnormal chest x ray which demonstrated a region of consolidation versus mass in the right upper lobe TECHNIQUE Post contrast enhanced spiral images were obtained through the chest FINDINGS There are several discrete patchy air space opacities in the right upper lobe which have the appearance most compatible with infiltrates The remainder of the lung parenchyma is clear There is no pneumothorax or effusion The heart size and pulmonary vessels appear unremarkable There was no axillary hilar or mediastinal lymphadenopathy Images of the upper abdomen are unremarkable Osseous windows are without acute pathology IMPRESSION Several discrete patchy air space opacities in the right upper lobe compatible with pneumonia Keywords cardiovascular pulmonary ct chest air space axillary chest x ray consolidation contrast contrast enhanced effusion hilar infiltrates lung lymphadenopathy mass mediastinal parenchyma patchy air space pneumonia pneumothorax right upper lobe spiral images with contrast air space opacities upper lobe opacities ct lobe chest MEDICAL_TRANSCRIPTION,Description Cerebrovascular accident CVA with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule Acute bronchitis with reactive airway disease Medical Specialty Cardiovascular Pulmonary Sample Name CVA Discharge Summary Transcription DIAGNOSES ON ADMISSION 1 Cerebrovascular accident CVA with right arm weakness 2 Bronchitis 3 Atherosclerotic cardiovascular disease 4 Hyperlipidemia 5 Thrombocytopenia DIAGNOSES ON DISCHARGE 1 Cerebrovascular accident with right arm weakness and MRI indicating acute subacute infarct involving the left posterior parietal lobe without mass effect 2 Old coronary infarct anterior aspect of the right external capsule 3 Acute bronchitis with reactive airway disease 4 Thrombocytopenia most likely due to old coronary infarct anterior aspect of the right external capsule 5 Atherosclerotic cardiovascular disease 6 Hyperlipidemia HOSPITAL COURSE The patient was admitted to the emergency room Plavix was started in addition to baby aspirin He was kept on oral Zithromax for his cough He was given Xopenex treatment because of his respiratory distress Carotid ultrasound was reviewed and revealed a 50 to 69 obstruction of left internal carotid Dr X saw him in consultation and recommended CT angiogram This showed no significant obstructive lesion other than what was known on the ultrasound Head MRI was done and revealed the above findings The patient was begun on PT and improved By discharge he had much improved strength in his right arm He had no further progressions His cough improved with oral Zithromax and nebulizer treatments His platelets also improved as well By discharge his platelets was up to 107 000 His H H was stable at 41 7 and 14 6 and his white count was 4300 with a normal differential Chest x ray revealed a mild elevated right hemidiaphragm but no infiltrate Last chemistry panel on December 5 2003 sodium 137 potassium 4 0 chloride 106 CO2 23 glucose 88 BUN 17 creatinine 0 7 calcium was 9 1 PT INR on admission was 1 03 PTT 34 7 At the time of discharge the patient s cough was much improved His right arm weakness has much improved His lung examination has just occasional rhonchi He was changed to a metered dose inhaler with albuterol He is being discharged home An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57 moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation He will follow up in my office in 1 week He is to start PT and OT as an outpatient He is to avoid driving his car He is to notify if further symptoms He has 2 more doses of Zithromax at home he will complete His prognosis is good Keywords cardiovascular pulmonary subacute infarct atherosclerotic cardiovascular disease cerebrovascular accident coronary infarct external capsule cva cerebrovascular mri bronchitis cardiovascular xopenex atherosclerotic accident MEDICAL_TRANSCRIPTION,Description Chest pain shortness of breath and cough evaluate for pulmonary arterial embolism CT angiography chest with contrast Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 Medical Specialty Cardiovascular Pulmonary Sample Name CT Angiography Transcription CT ANGIOGRAPHY CHEST WITH CONTRAST REASON FOR EXAM Chest pain shortness of breath and cough evaluate for pulmonary arterial embolism TECHNIQUE Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 FINDINGS There is no evidence for pulmonary arterial embolism The lungs are clear of any abnormal airspace consolidation pleural effusion or pneumothorax No abnormal mediastinal or hilar lymphadenopathy is seen Limited images of the upper abdomen are unremarkable No destructive osseous lesion is detected IMPRESSION Negative for pulmonary arterial embolism Keywords cardiovascular pulmonary airspace consolidation pleural effusion pneumothorax lymphadenopathy hilar ct angiography pulmonary arterial arterial embolism angiography ct chest arterial pulmonary embolism isovue MEDICAL_TRANSCRIPTION,Description Shortness of breath for two weeks and a history of pneumonia CT angiography chest with contrast Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 Medical Specialty Cardiovascular Pulmonary Sample Name CT Angiography 1 Transcription CT ANGIOGRAPHY CHEST WITH CONTRAST REASON FOR EXAM Shortness of breath for two weeks and a history of pneumonia The patient also has a history of left lobectomy TECHNIQUE Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue 300 FINDINGS There is no evidence of any acute pulmonary arterial embolism The main pulmonary artery is enlarged showing a diameter of 4 7 cm Cardiomegaly is seen with mitral valvular calcifications Postsurgical changes of a left upper lobectomy are seen Left lower lobe atelectasis is noted A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe image 12 A small left pleural effusion is noted Right lower lobe atelectasis is present There is a right pleural effusion greater than as seen on the left side A right lower lobe pulmonary nodule measures 1 5 cm There is a calcified granuloma within the right lower lobe IMPRESSION 1 Negative for pulmonary arterial embolism 2 Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension 3 Cardiomegaly with mitral valvular calcifications 4 Postsurgical changes of a left upper lobectomy 5 Bilateral pleural effusions right greater than left with bilateral lower lobe atelectasis 6 Bilateral lower lobe nodules pulmonary nodules and interval followup in three months to confirm stability versus further characterization with prior studies is advised Keywords cardiovascular pulmonary shortness of breath pneumonia pulmonary embolism isovue 300 axial ct images ct angiography lower lobe pulmonary lobectomy isovue angiography arterial atelectasis pleural ct embolism MEDICAL_TRANSCRIPTION,Description A 68 year old white male with recently diagnosed adenocarcinoma by sputum cytology An abnormal chest radiograph shows right middle lobe infiltrate and collapse Patient needs staging CT of chest with contrast Medical Specialty Cardiovascular Pulmonary Sample Name CT Chest 2 Transcription CLINICAL HISTORY A 68 year old white male with recently diagnosed adenocarcinoma by sputum cytology An abnormal chest radiograph shows right middle lobe infiltrate and collapse Patient needs staging CT of chest with contrast Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam TECHNIQUE Multiple transaxial images utilized in 10 mm sections were obtained through the chest Intravenous contrast was administered FINDINGS There is a large 3 x 4 cm lymph node seen in the right supraclavicular region There is a large right paratracheal lymph node best appreciated on image 16 which measures 3 x 2 cm A subcarinal lymph node is enlarged also It measures 6 x 2 cm Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm There is also a soft tissue density best appreciated on image 36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit The liver parenchyma is normal without evidence of any dominant masses The right kidney demonstrates a solitary cyst in the mid pole of the right kidney IMPRESSION 1 Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm 2 Extensive mediastinal adenopathy as described above 3 No lesion seen within the left lung at this time 4 Supraclavicular adenopathy Keywords cardiovascular pulmonary supraclavicular cervical adenopathy pulmonary nodules lymph node adenopathy pulmonary chest MEDICAL_TRANSCRIPTION,Description Coronary Artery CTA with Calcium Scoring and Cardiac Function Medical Specialty Cardiovascular Pulmonary Sample Name Coronary CT Angiography CCTA 3 Transcription EXAM Coronary artery CTA with calcium scoring and cardiac function HISTORY Chest pain TECHNIQUE AND FINDINGS Coronary artery CTA was performed on a Siemens dual source CT scanner Post processing on a Vitrea workstation 150 mL Ultravist 370 was utilized as the intravenous contrast agent Patient did receive nitroglycerin sublingually prior to the contrast HISTORY Significant for high cholesterol overweight chest pain family history Patient s total calcium score Agatston is 10 his places the patient just below the 75th percentile for age The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque The distal LAD was unreadable while the proximal was normal The mid and distal right coronary artery are not well delineated due to beam hardening artifact The circumflex is diminutive in size along its proximal portion Distal is not readable Cardiac wall motion within normal limits No gross pulmonary artery abnormality however they are not well delineated A full report was placed on the patient s chart Report was saved to PACS Keywords cardiovascular pulmonary coronary artery cta calcium scoring cardiac function coronary artery ct scoring lad midportion cta calcium cardiac coronary artery angiography MEDICAL_TRANSCRIPTION,Description CCTA with Cardiac Function Calcium Scoring Medical Specialty Cardiovascular Pulmonary Sample Name Coronary CT Angiography CCTA 2 Transcription CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY PROCEDURE Breath hold cardiac CT was performed using a 64 channel CT scanner with a 0 5 second rotation time Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL sec Retrospective ECG gating was performed The patient received 0 4 milligrams of sublingual nitroglycerin prior to the to the scan The average heart rate was 62 beats min The patient had no adverse reaction to the contrast Multiphase retrospective reconstructions were performed Small field of view cardiac and coronary images were analyzed on a 3D work station Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease CORONARY CTA 1 The technical quality of the scan is adequate 2 The coronary ostia are in their normal position The coronary anatomy is right dominant 3 LEFT MAIN The left main coronary artery is patent without angiographic stenosis 4 LEFT ANTERIOR DESCENDING ARTERY The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30 in stenosis severity Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities 5 The ramus intermedius is a small vessel with minor irregularities 6 LEFT CIRCUMFLEX The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis 7 RIGHT CORONARY ARTERY The right coronary artery is a large and dominant vessel It demonstrates within its mid segment calcified atherosclerosis less than 50 stenosis severity Left ventricular ejection fraction is calculated to be 69 There are no wall motion abnormalities 8 Coronary calcium score was calculated to be 79 indicating at least mild atherosclerosis within the coronary vessels ANCILLARY FINDINGS None FINAL IMPRESSION 1 Mild coronary artery disease with a preserved left ventricular ejection fraction of 69 2 Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy Thank you for referring this patient to us Keywords cardiovascular pulmonary coronary ct angiography ventricular ejection fraction anterior descending artery coronary artery disease coronary ct ct angiography cardiac ct obtuse marginal ventricular ejection ejection fraction coronary artery artery angiography coronary ccta atherosclerosis ventricular beats min anterior vessel stenosis ct cardiac disease MEDICAL_TRANSCRIPTION,Description CT chest with contrast Medical Specialty Cardiovascular Pulmonary Sample Name CT Chest 1 Transcription EXAM CT chest with contrast REASON FOR EXAM Pneumonia chest pain short of breath and coughing up blood TECHNIQUE Postcontrast CT chest 100 mL of Isovue 300 contrast FINDINGS This study demonstrates a small region of coalescent infiltrates consolidation in the anterior right upper lobe There are linear fibrotic or atelectatic changes associated with this Recommend followup to ensure resolution There is left apical scarring There is no pleural effusion or pneumothorax There is lingular and right middle lobe mild atelectasis or fibrosis Examination of the mediastinal windows disclosed normal inferior thyroid Cardiac and aortic contours are unremarkable aside from mild atherosclerosis The heart is not enlarged There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions Very limited assessment of the upper abdomen demonstrates no definite abnormalities There are mild degenerative changes in the thoracic spine IMPRESSION 1 Anterior small right upper lobe infiltrate consolidation Recommend followup to ensure resolution given its consolidated appearance 2 Bilateral atelectasis versus fibrosis Keywords cardiovascular pulmonary pneumonia chest pain short of breath coughing up blood upper lobe infiltrate ct chest ct chest isovue MEDICAL_TRANSCRIPTION,Description Selective coronary angiography left heart catheterization with hemodynamics LV gram with power injection right femoral artery angiogram closure of the right femoral artery using 6 French AngioSeal Medical Specialty Cardiovascular Pulmonary Sample Name Coronary Angiography Transcription REASON FOR EXAM Dynamic ST T changes with angina PROCEDURE 1 Selective coronary angiography 2 Left heart catheterization with hemodynamics 3 LV gram with power injection 4 Right femoral artery angiogram 5 Closure of the right femoral artery using 6 French AngioSeal Procedure explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation The patient was draped and dressed in the usual sterile fashion The right groin area infiltrated with lidocaine solution Access to the right femoral artery was successful okayed with one attempt with anterior wall stick Over a J wire 6 French sheath was introduced using modified Seldinger technique Over the J wire a JL4 catheter was passed over the aortic arch The wire was removed Catheter was engaged into the left main Multiple pictures with RAO caudal AP cranial LAO cranial shallow RAO and LAO caudal views were all obtained Catheter disengaged and exchanged over J wire into a JR4 catheter the wire was removed Catheter with counter clock was rotating to the RCA one shot with LAO position was obtained The cath disengaged and exchanged over J wire into a pigtail catheter Pigtail catheter across the aortic valve Hemodynamics obtained LV gram with power injection of 36 mL of contrast was obtained The LV gram assessed followed by pullback hemodynamics The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6 French AngioSeal with no hematoma The patient tolerated the procedure well with no immediate postprocedure complication HEMODYNAMICS The aortic pressure was 117 61 with a mean pressure of 83 The left ventricular pressure was 119 9 to 19 with left ventricular end diastolic pressure of 17 to 19 mmHg The pullback across the aortic valve reveals zero gradient ANATOMY The left main showed minimal calcification as well as the proximal LAD No stenosis in the left main seen the left main bifurcates in to the LAD and left circumflex The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD The LAD gave off two early diagonal branches The second was the largest of the two and showed minimal lumen irregularities but no focal stenosis Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA The left circumflex was large and patent 6 0 mm in diameter All three obtuse marginal branches appeared to be with no significant stenosis The obtuse marginal branch the third OM3 showed at the origin about 30 to 40 minimal narrowing but no significant stenosis The PDA was wide patent with no focal stenosis The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal LV gram showed that the LV EF is preserved with EF of 60 No mitral regurgitation identified IMPRESSION 1 Patent coronary arteries with normal left anterior descending left circumflex and dominant left circumflex system 2 Nondominant right which is free of atheromatous plaque 3 Minimal plaque in the diagonal branch II and the obtuse marginal branch III with no focal stenosis 4 Normal left ventricular function 5 Evaluation for noncardiac chest pain would be recommended Keywords MEDICAL_TRANSCRIPTION,Description Acute on chronic COPD exacerbation and community acquired pneumonia both resolving However she may need home O2 for a short period of time Medical Specialty Cardiovascular Pulmonary Sample Name COPD Pneumonia SOAP Transcription SUBJECTIVE Review of the medical record shows that the patient is a 97 year old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation The patient does have a longstanding history of COPD However she does not use oxygen at her independent assisted living home Yesterday she had made improvement since being here at the hospital She needed oxygen She was tested for home O2 and qualified for it yesterday also Her lungs were very tight She did have wheezes bilaterally and rhonchi on the right side mostly She appeared to be a bit weak and although she was requesting to be discharged home she did not appear to be fit for it Overnight the patient needed to use the rest room She stated that she needed to urinate She awoke decided not to call for assistance She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker She attempted to walk to the rest room on her own She sustained a fall She stated that she just felt weak She bumped her knee and her elbow She had femur x rays knee x rays also There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side This morning she denied any headache back pain or neck pain She complained mostly of right anterior knee pain for which she had some bruising and swelling OBJECTIVE VITAL SIGNS The patient s max temperature over the past 24 hours was 36 5 her blood pressure is 148 77 her pulse is 87 to 106 She is 95 on 2 L via nasal cannula HEART Regular rate and rhythm without murmur gallop or rub LUNGS Reveal no expiratory wheezing throughout She does have some rhonchi on the right mid base She did have a productive cough this morning and she is coughing green purulent sputum finally ABDOMEN Soft and nontender Her bowel sounds x4 are normoactive NEUROLOGIC She is alert and oriented x3 Her pupils are equal and reactive She has got a good head and facial muscle strength Her tongue is midline She has got clear speech Her extraocular motions are intact Her spine is nontender on palpation from neck to lumbar spine She has good range of motion with regard to her shoulders elbows wrists and fingers Her grip strengths are equal bilaterally Both elbows are strong from extension to flexion Her hip flexors and extenders are also strong and equal bilaterally Extension and flexion of the knee bilaterally and ankles also are strong Palpation of her right knee reveals no crepitus She does have suprapatellar inflammation with some ecchymosis and swelling She has got good joint range of motion however SKIN She did have a skin tear involving her right forearm lateral which is approximately 2 to 2 5 inches in length and is at this time currently Steri Stripped and wrapped with Coban and is not actively bleeding ASSESSMENT 1 Acute on chronic COPD exacerbation 2 Community acquired pneumonia both resolving However she may need home O2 for a short period of time 3 Generalized weakness and deconditioning secondary to the above Also sustained a fall secondary to instability and not using her walker or calling for assistance The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed PLAN 1 I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i e walker Myself and one of her daughter s spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living 2 We will obtain an orthopedic consult secondary to her fall to evaluate her x rays and function Keywords cardiovascular pulmonary community acquired pneumonia copd exacerbation home o2 acute on chronic pneumonia exacerbation copd MEDICAL_TRANSCRIPTION,Description Common CT Chest template Medical Specialty Cardiovascular Pulmonary Sample Name CT Chest Transcription TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast FINDINGS The heart size is normal and there is no pericardial effusion The aorta and great vessels are normal in caliber The central pulmonary arteries are patent with no evidence of embolus There is no significant mediastinal hilar or axillary lymphadenopathy The trachea and mainstem bronchi are patent The esophagus is normal in course and caliber The lungs are clear with no infiltrates effusions or masses There is no pneumothorax Scans through the upper abdomen are unremarkable The osseous structures in the chest are intact IMPRESSION No acute abnormalities Keywords cardiovascular pulmonary sequential axial ct images optiray pericardial effusion mediastinal hilar axillary lymphadenopathy ct chest upper abdomenNOTE MEDICAL_TRANSCRIPTION,Description Chronic obstructive pulmonary disease COPD exacerbation and acute bronchitis Medical Specialty Cardiovascular Pulmonary Sample Name COPD Bronchitis Discharge Summary Transcription DIAGNOSIS AT ADMISSION Chronic obstructive pulmonary disease COPD exacerbation and acute bronchitis DIAGNOSES AT DISCHARGE 1 Chronic obstructive pulmonary disease exacerbation and acute bronchitis 2 Congestive heart failure 3 Atherosclerotic cardiovascular disease 4 Mild senile type dementia 5 Hypothyroidism 6 Chronic oxygen dependent 7 Do not resuscitate do not intubate HOSPITAL COURSE The patient was admitted from the office by Dr X She was placed on the usual medications that included Synthroid 0 05 mg a day enalapril 5 mg a day Imdur 30 mg a day Lanoxin 0 125 mg a day aspirin 81 mg a day albuterol and Atrovent nebulizers q 4 h potassium chloride 10 mEq 2 tablets per day Lasix 40 mg a day Humibid L A 600 mg b i d She was placed on oral Levaquin after a load of 500 mg and 250 mg a day She was given oxygen encouraged to eat and suctioned as needed Laboratory data included a urinalysis that had 0 2 WBCs per high power field and urine culture was negative blood cultures x2 were negative TSH was 1 7 and chem 7 sodium 134 potassium 4 4 chloride 93 CO2 34 glucose 105 BUN 17 creatinine 0 9 and calcium 9 1 Digoxin was 1 3 White blood cell count was 6100 with a normal differential H H 37 4 12 1 platelets 335 000 Chest x ray was thought to have prominent interstitial lung changes without acute infiltrate There is a question if there is mild fluid overload The patient improved with the above regimen By discharge her lungs fell back to her baseline She had no significant shortness of breath Her O2 saturations were stable Her vital signs were stable She is discharged home to follow up with me in a week and a half Her daughter has been spoken to by phone and she will notify me if she worsens or has problems PROGNOSIS Guarded Keywords cardiovascular pulmonary chronic obstructive pulmonary disease exacerbation chronic obstructive pulmonary disease pulmonary copd discharge bronchitis MEDICAL_TRANSCRIPTION,Description Selective coronary angiography Placement of overlapping 3 0 x 18 and 3 0 x 8 mm Xience stents in the proximal right coronary artery Abdominal aortography Medical Specialty Cardiovascular Pulmonary Sample Name Coronary Angiography Abdominal Aortography Transcription NAME OF PROCEDURE 1 Selective coronary angiography 2 Placement of overlapping 3 0 x 18 and 3 0 x 8 mm Xience stents in the proximal right coronary artery 3 Abdominal aortography INDICATIONS The patient is a 65 year old gentleman with a history of exertional dyspnea and a cramping like chest pain Thallium scan has been negative He is undergoing angiography to determine if his symptoms are due to coronary artery disease NARRATIVE The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2 lidocaine Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg Received additional Versed and fentanyl during the procedure Please refer to the nurses notes for dosages and timing The right femoral artery was entered and a 4 French sheath was placed Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta Via the right Judkins catheter the guidewire was easily infiltrated to the thoracic aorta and over aortic arch The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed This revealed a very high grade lesion at the proximal right coronary artery This catheter was exchanged for a left 4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed The patient was found to have the above mentioned high grade lesion in the right coronary artery and a coronary intervention was performed A 6 French sheath and a right Judkins guide was placed The patient was started on bivalarudin A BMW wire was easily placed across the lesion and into the distal right coronary artery A 3 0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres The intermediate result was improved with TIMI 3 flow to the terminus of the vessel Following this a 3 0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection This was stented with a 3 0 x 8 mm Xience stent deployed again at 17 atmospheres Final angiograms revealed excellent result with TIMI 3 flow at the terminus of the right coronary artery and approximately 10 residual stenosis at the worst point of the narrowing The guiding catheter was withdrawn over wire and a pigtail was placed This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection The catheter was removed The bivalarudin was stopped at the termination of procedure A small injection of contrast given through arterial sheath and Angio Seal was placed without incident It should also be noted that an 8 French sheath was placed in the right femoral vein This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea Total contrast media 205 mL total fluoroscopy time was 7 5 minutes X ray dose 2666 milligray HEMODYNAMICS Rhythm was sinus throughout the procedure Aortic pressure was 170 81 mmHg The right coronary artery is a dominant vessel This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals In the proximal right coronary artery there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity After intervention there is TIMI 3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow There was approximately 10 residual stenosis at the worst part of the previous stenosis The left main is without disease and trifurcates into a moderate sized ramus intermedius the LAD and the circumflex The ramus intermedius is free of disease The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment This measures 25 to 30 at its worst point The circumflex is a large caliber vessel There is a proximal 15 to 20 stenosis and an area of ectasia in the proximal circumflex Distally this circumflex gives rise to a large bifurcating marginal artery and beyond that point the circumflex is a small vessel within the AV groove The aortogram demonstrates eccentric aneurysm formation This may represent a small retrograde dissection as well There was some dye hang up in the wall IMPRESSION 1 Successful stenting of subtotal stenosis of the proximal coronary artery 2 Non obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery 3 Left to right collateral filling noted prior to coronary intervention 4 Small area of eccentric aneurysm formation in the abdominal aorta Keywords cardiovascular pulmonary xience stents thallium scan coronary artery coronary angiography abdominal aortography artery coronary angiography stents flow vessel abdominal catheter circumflex stenosis proximal MEDICAL_TRANSCRIPTION,Description A 67 year old male with COPD and history of bronchospasm who presents with a 3 day history of increased cough respiratory secretions wheezings and shortness of breath Medical Specialty Cardiovascular Pulmonary Sample Name COPD Discharge Summary Transcription HISTORY OF PRESENT ILLNESS A 67 year old male with COPD and history of bronchospasm who presents with a 3 day history of increased cough respiratory secretions wheezings and shortness of breath He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis superimposed upon longstanding COPD Unfortunately over the past few months he has returned to pipe smoking At the time of admission he denied fever diaphoresis nausea chest pain or other systemic symptoms PAST MEDICAL HISTORY Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy COPD as described above history of hypertension and history of elevated cholesterol PHYSICAL EXAMINATION Heart tones regular with an easily audible mechanical click Breath sounds are greatly diminished with rales and rhonchi over all lung fields LABORATORY STUDIES Sodium 139 potassium 4 5 BUN 42 and creatinine 1 7 Hemoglobin 10 7 and hematocrit 31 7 HOSPITAL COURSE He was started on intravenous antibiotics vigorous respiratory therapy intravenous Solu Medrol The patient improved on this regimen Chest x ray did not show any CHF The cortisone was tapered The patient s oxygenation improved and he was able to be discharged home DISCHARGE DIAGNOSES Chronic obstructive pulmonary disease and acute asthmatic bronchitis COMPLICATIONS None DISCHARGE CONDITION Guarded DISCHARGE PLAN Prednisone 20 mg 3 times a day for 2 days 2 times a day for 5 days and then one daily Keflex 500 mg 3 times a day and to resume his other preadmission medication can be given a pneumococcal vaccination before discharge To follow up with me in the office in 4 5 days Keywords cardiovascular pulmonary increased cough respiratory secretions wheezings shortness of breath acute asthmatic bronchitis asthmatic bronchitis respiratory breath asthmatic copd MEDICAL_TRANSCRIPTION,Description CCTA with cardiac function and calcium scoring Medical Specialty Cardiovascular Pulmonary Sample Name Coronary CT Angiography CCTA 1 Transcription HISTORY Coronary artery disease TECHNIQUE AND FINDINGS Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual source CT scanner with postprocessing on Vitrea workstation Patient received oral Metoprolol 100 milligrams 100 ml Ultravist 370 was utilized as the contrast agent 0 4 milligrams of nitroglycerin was given Patient s calcium score 164 volume 205 this places the patient between the 75th and 90th percentile for age There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible Cardiac wall motion was within normal limits Left ventricular ejection fraction calculated to be 82 End diastolic volume 98 mL end systolic volume calculated to be 18 mL There is normal coronary artery origins There is codominance between the right coronary artery and the circumflex artery There is mild to moderate stenosis of the proximal LAD with mixed plaque Mild stenosis mid LAD with mixed plaque No stenosis Distal LAD with the distal vessel becoming diminutive in size Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque Once again the distal vessel becomes diminutive in size Circumflex shows mild stenosis due to focal calcified plaque proximally No stenosis is seen involving the mid or distal circumflex The distal circumflex also becomes diminutive in size The left main shows small amount of focal calcified plaque without stenosis Myocardium pericardium and wall motion was unremarkable as seen IMPRESSION 1 Atherosclerotic coronary artery disease with values as above There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery 2 Consider cardiology consult and further evaluation if clinically indicated 3 Full report was sent to the PACS Report will be mailed to Dr ABC Keywords cardiovascular pulmonary coronary ct angiography vitrea workstation cardiac wall motion proximal lad distal lad focal calcified plaque coronary artery disease cardiac function calcium scoring wall motion distal vessel calcified plaque distal circumflex artery disease mild stenosis coronary artery ccta scoring atherosclerotic vessel calcium calcified lad circumflex distal plaque coronary artery stenosis MEDICAL_TRANSCRIPTION,Description The patient admitted with palpitations and presyncope Medical Specialty Cardiovascular Pulmonary Sample Name Consult Palpitations Presyncope Transcription HISTORY OF PRESENT ILLNESS The patient is a charming and delightful 46 year old woman admitted with palpitations and presyncope The patient is active and a previously healthy young woman who has had nine years of occasional palpitations Symptoms occur three to four times per year and follow no identifiable pattern She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate The last two episodes the most recent of which was yesterday were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision On neither occasion did she lose consciousness Yesterday she had a modestly active morning taking a walk with her dogs and performing her normal routines While working on a computer she had a spell Palpitations persisted for a short time thereafter as outlined in the hospital s admission note prompting her to seek evaluation at the hospital She was in sinus rhythm on arrival and has been asymptomatic since No history of exogenous substance abuse alcohol abuse or caffeine abuse She does have a couple of sodas and at least one to two coffees daily She is a nonsmoker She is a mother of two There is no family history of congenital heart disease She has had no history of thoracic trauma No symptoms to suggest thyroid disease No known history of diabetes hypertension or dyslipidemia Family history is negative for ischemic heart disease Remote history is significant for an ACL repair complicated by contact urticaria from a neoprene cast No regular medications prior to admission The only allergy is the neoprene reaction outlined above PHYSICAL EXAMINATION Vital signs as charted Pupils are reactive Sclerae nonicteric Mucous membranes are moist Neck veins not distended No bruits Lungs are clear Cardiac exam is regular without murmurs gallops or rubs Abdomen is soft without guarding rebound masses or bruits Extremities well perfused No edema Strong and symmetrical distal pulses A 12 lead EKG shows sinus rhythm with normal axis and intervals No evidence of preexcitation LABORATORY STUDIES Unremarkable No evidence of myocardial injury Thyroid function is pending Two dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease IMPRESSION PLAN Episodic palpitations over a nine year period Outpatient workup would be appropriate Event recorder should be obtained and the patient can be seen again in the office upon completion of that study Suppressive medication beta blocker or Cardizem was discussed with the patient for symptomatic improvement though this would be unlikely to be a curative therapy The patient expresses a preference to avoid medical therapy if possible Thank you for this consultation We will be happy to follow her both during this hospitalization and following discharge Caffeine avoidance was discussed as well ADDENDUM During her initial evaluation a D dimer was mildly elevated to 5 CT scan showed no evidence of pulmonary embolus Lower extremity venous ultrasound is pending however in the absence of embolization to the pulmonary vasculature this would be an unlikely cause of palpitations In addition no progression over the nine year period that she has been symptomatic suggests that this is an unlikely cause Keywords cardiovascular pulmonary presyncope palpitations episodic palpitations beta blocker ultrasound palpitations and presyncope sinus rhythm heart disease heart MEDICAL_TRANSCRIPTION,Description Left and right coronary system cineangiography Left ventriculogram PCI to the left circumflex with a 3 5 x 12 and a 3 5 x 8 mm Vision bare metal stents postdilated with a 3 75 mm noncompliant balloon x2 MEDICAL_TRANSCRIPTION,Description Juxtaductal coarctation of the aorta dilated cardiomyopathy bicuspid aortic valve patent foramen ovale Medical Specialty Cardiovascular Pulmonary Sample Name Coarctation of Aorta Transcription HISTORY The patient is a 4 month old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16 A bicuspid aortic valve was also seen without insufficiency or stenosis The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta PROCEDURE After sedation and general endotracheal anesthesia the patient was prepped and draped Cardiac catheterization was performed as outlined in the attached continuation sheets Vascular entry was by percutaneous technique and the patient was heparinized Monitoring during the procedure included continuous surface ECG continuous pulse oximetry and cycled cuff blood pressures in addition to intravascular pressures Using a percutaneous technique a 4 French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place There was good blood return from both the ports Using a 4 French sheath a 4 French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries The atrial septum was not probe patent Using a 4 French sheath a 4 French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ascending aorta and left ventricle A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery The transverse arch measured 5 mm Isthmus measured 4 7 mm and coarctation measured 2 9 x 1 8 mm at the descending aorta level The diaphragm measured 5 6 mm The pigtail catheter was exchanged for a wedge catheter which was then directed into the right innominate artery This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist Pressure pull back following angioplasty however demonstrated a residual of 15 20 mmHg gradient Repeat angiogram showed mild improvement in degree of aortic narrowing The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist The pigtail catheter was then reintroduced for a pressure pull back measurement and final angiogram Flows were calculated by the Fick technique using an assumed oxygen consumption Cineangiograms were obtained with injection in the descending aorta After angiography two normal appearing renal collecting systems were visualized The catheters and sheaths were removed and topical pressure applied for hemostasis The patient was returned to the pediatric intensive care unit in satisfactory condition There were no complications DISCUSSION Oxygen consumption was assumed to be normal Mixed venous saturation was low due to mild systemic arterial desaturation and anemia There is no evidence of significant intracardiac shunt Further the heart was desaturated due to VQ mismatch Phasic right sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A wave similar to the normal left ventricular end diastolic pressure of 12 mmHg Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull back to the descending aorta The calculated flows were mildly increased Vascular resistances were normal A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels There is discrete juxtaductal coarctation of the aorta Flow within the intercostal arteries was retrograde Following balloon angioplasty of coarctation of the aorta there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull back to the descending aorta The calculated systemic flow fell to normal values Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries The narrowest diameter of the aorta measured 4 9 x 4 2 mm DIAGNOSES 1 Juxtaductal coarctation of the aorta 2 Dilated cardiomyopathy 3 Bicuspid aortic valve 4 Patent foramen ovale INTERVENTION Balloon dilation of coarctation of the aorta MANAGEMENT The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4 6 months The further cardiologic care will be directed by Dr X Keywords cardiovascular pulmonary coarctation juxtaductal dilated cardiomyopathy bicuspid aortic valve patent foramen ovale catheter was inserted mmhg systolic gradient mmhg systolic systolic gradient descending aorta catheterization mmhg ventricular aorta aortic foramen MEDICAL_TRANSCRIPTION,Description Left and right coronary system cineangiography cineangiography of SVG to OM and LIMA to LAD Left ventriculogram and aortogram Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent Medical Specialty Cardiovascular Pulmonary Sample Name Cineangiography Transcription PROCEDURES UNDERTAKEN 1 Left coronary system cineangiography 2 Right coronary system cineangiography 3 Cineangiography of SVG to OM 4 Cineangiography of LIMA to LAD 5 Left ventriculogram 6 Aortogram 7 Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent NARRATIVE After all risks and benefits were explained to the patient informed consent was obtained The patient was brought to the cardiac catheterization suite The right groin was prepped in the usual sterile fashion Right common femoral artery was cannulated using a modified Seldinger technique and a long 6 French AO sheath was introduced secondary to tortuous aorta Next Judkins left catheter was used to engage the left coronary system Cineangiography was recorded in multiple views Next Judkins right catheter was used to engage the right coronary system Cineangiography was recorded in multiple views Next the Judkins right catheter was used to engage the SVG to OM Cineangiography was recorded Next the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J wire for a 4 French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views Next an angled pigtail catheter was advanced into the left ventricular cavity LV pressures were measured LV gram was done and a pullback gradient across the aortic valve was done and recorded Next an aortogram was done and recorded At this point I decided to proceed with percutaneous intervention of the left circumflex Therefore AVA 3 5 guide was used to engage the left coronary artery Angiomax bolus and drip was started Universal wire was advanced past the lesion and a 2 5 balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres Next we attempted to advance a 3 0 x 12 stent to the distal lesion however we were unable to pass the stent Next second dilatations were done again with the 2 5 balloon at 18 atmospheres however we are unable to break the lesion We next attempted a cutting balloon Again we are unable to cross the lesion therefore a buddy wire technique was used with a PT choice support wire Again we were unable to cross the lesion with the stent We then try to cross with a noncompliant balloon which we were unsuccessful We also try to cutting balloon again we were unsuccessful Despite multiple dilatations we were unable to cross anything beyond the noncompliant balloon across the lesion therefore finally the procedure was aborted Final images showed no evidence of dissection perforation or further complication The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results The patient tolerated the procedure very well without complications was taken off the operating table and transferred back to cardiac telemetry floor DIAGNOSTIC FINDINGS 1 The LV LVEDP was 4 LVES is approximately 50 55 with inferobasal hypokinesis No significant MR No gradient across the aortic valve 2 Aortogram The ascending aorta shows no significant dilatation or evidence of dissection The valve shows no significant aortic insufficiencies The abdominal aorta and distal aorta shows significant tortuosities 3 The left main The left main coronary artery is a large caliber vessel bifurcating the LAD and left circumflex with some mild distal disease of about 10 20 4 Left circumflex The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70 80 stenosis The mid left circumflex is a high grade 80 diffuse tortuous stenosis 5 LAD The LAD is a totally 100 occluded vessel The LIMA to LAD is patent with only a small to moderate caliber LAD There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60 70 The diagonal shows proximal 80 stenosis 6 The right coronary artery The right coronary artery is 100 occluded There are retrograde collaterals from left to right to the distal PDA and PLV branches The SVG to OM is 100 occluded at its take off The SVG to PDA is not found however presumed 100 occluded given that there is collateral flow to the distal right 7 LIMA to LAD is widely patent ASSESSMENT AND PLAN Attempted intervention to the left circumflex system only able to perform plano balloon angioplasty unable to pass stents noncompliant balloons or cutting balloon Final images showed some improvement however continued residual stenosis At this point the patient will be transferred back to telemetry floor and monitored We can attempt future intervention or continue aggressive medical management The patient continues to have residual stenosis in the diagonal however due to the length of this procedure I did not attempt intervention to that diagonal branch Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia focus on treatment to that lesion Keywords cardiovascular pulmonary coronary system cineangiography svg to om lima to lad ventriculogram aortogram percutaneous intervention circumflex obtuse marginal branch balloon angioplasty coronary artery balloon cineangiography lad MEDICAL_TRANSCRIPTION,Description Left pleural effusion parapneumonic loculated Left chest tube placement Medical Specialty Cardiovascular Pulmonary Sample Name Chest Tube Placement Transcription PREOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated POSTOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated OPERATION Left chest tube placement IV SEDATION 5 mg of Versed total given under pulse ox monitoring 1 lidocaine local infiltration PROCEDURE With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion A 1 lidocaine was liberally infiltrated into the skin subcutaneous tissue deep fascia and the anterior axillary line just below the level of the nipple The incision was made and deepened through the different layers to reach the intercostal space The pleura was entered on top of the underlying rib and finger digital palpation was performed Multiple loculations were encountered Break up of loculations was performed posteriorly and a chest tube was directed posteriorly Only a small amount of fluid was noted to come out initially This was sent for various studies Soft adhesions were encountered The plan was to obtain a chest x ray and start Activase installation Keywords cardiovascular pulmonary activase chest tube placement pleural effusion chest tube lidocaine infiltration parapneumonic loculated pleural chest MEDICAL_TRANSCRIPTION,Description Resection of left chest wall tumor partial resection of left diaphragm left lower lobe lung wedge resection left chest wall reconstruction with Gore Tex mesh Medical Specialty Cardiovascular Pulmonary Sample Name Chest Wall Tumor Resection Transcription PREOPERATIVE DIAGNOSIS Left chest wall tumor spindle cell histology POSTOPERATIVE DIAGNOSIS Left chest wall tumor spindle cell histology with pathology pending PROCEDURE Resection of left chest wall tumor partial resection of left diaphragm left lower lobe lung wedge resection left chest wall reconstruction with Gore Tex mesh ANESTHESIA General endotracheal SPECIMEN Left chest wall with tumor and left lower lobe lung wedge resection to pathology INDICATIONS FOR PROCEDURE The patient is a 79 year old male who began to experience back pain approximately 2 years ago which increased Chest x ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening A biopsy was performed at an outside hospital Kaiser and pathology was consistent with mesothelioma The patient had a metastatic workup which was negative including a brain MRI and bone scan The bone scan showed only signal positivity in the left 9th rib near the tumor The patient has a significant past medical history consisting of coronary artery disease hypertension non insulin dependent diabetes longstanding atrial fibrillation anemia and hypercholesterolemia He and his family were apprised of the high risk nature of this surgery preoperatively and informed consent was obtained PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position The patient was intubated with a double lumen endotracheal tube Intravenous antibiotics were given A Foley catheter was placed The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass The skin and subcutaneous tissues were dissected sharply with the electrocautery Good hemostasis was obtained The tumor was easily palpable and clearly involving the 8th to 9th rib A thoracotomy was initially made above the mass in approximately the 7th intercostal space Inspection of the pleural cavity revealed multiple adhesions which were taken down with a combination of blunt and sharp dissection The thoracotomy was extended anteriorly and posteriorly It was clear that in order to obtain an adequate resection of the tumor approximately 4 rib segment of the chest wall would need to be resected The ribs of the chest wall were first cut at their anterior aspect The ribs 7 8 9 and 10 were serially transected after the interspaces were dissected with electrocautery Hemostasis was obtained with both electrocautery and clips The chest wall segment to be resected was retracted laterally and posteriorly It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement Inferiorly the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor The spleen and the stomach were identified and were protected Inferiorly the resection of the chest wall was continued in the 10th interspace The dissection was then carried posteriorly to the level of the spine The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe which provided a complete resection of all palpable and visible tumor in the lung A 2 0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection Posteriorly the chest wall segment was noted to have an area at the level of approximately T8 and T9 where the tumor involved the vertebral bodies The ribs were disarticulated closed to or at their articulations with the spine Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery There was no disease grossly involving or encasing the aorta The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section The specimen was oriented for the pathologist who came to the room Hemostasis was obtained The vent in the diaphragm was then closed primarily with a series of figure of 8 1 Ethibond sutures This produced a satisfactory diaphragmatic repair without undue tension A single 32 French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly This was secured with a 1 silk suture The Gore Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect A series of 1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually The resulting mesh closure was snug and deemed adequate The serratus muscle was reapproximated with figure of 8 0 Vicryl The latissimus was reapproximated with a two 1 Vicryl placed in running fashion Of note two 10 JP drains were placed over the mesh repair of the chest wall The subcutaneous tissues were closed with a running 3 0 Vicryl suture and the skin was closed with a 4 0 Monocryl The wounds were dressed The patient was brought from the operating room directly to the North ICU intubated in stable condition All counts were correct Keywords cardiovascular pulmonary chest wall tumor resection diaphragm left lower lobe lung wedge resection chest wall reconstruction chest wall segment gore tex mesh chest wall tumor chest wall pleural cavity lower lobe wedge resection resection tumor wall chest anesthesia electrocautery wedge mesh lung MEDICAL_TRANSCRIPTION,Description Bilateral pleural effusion Removal of bilateral 32 French chest tubes with closure of wound Medical Specialty Cardiovascular Pulmonary Sample Name Chest Tube Removal Transcription PREOPERATIVE DIAGNOSIS Bilateral pleural effusion POSTOPERATIVE DIAGNOSIS Bilateral pleural effusion PROCEDURE PERFORMED Removal of bilateral 32 French chest tubes with closure of wound COMPLICATIONS None INDICATIONS FOR PROCEDURE The patient is a 66 year old African American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts this necessitated to close the wounds with sutures The patient was agreeable to proceed OPERATIVE PROCEDURE The patient was prepped and draped at the bedside over both chest tube sites The pressures applied over the sites and the skin was closed with interrupted 3 0 Ethilon sutures The skin was then cleansed and Vaseline occlusive dressing was applied over the sites The same procedure was performed on the other side The chest tubes were removed on full inspiration Vital signs remained stable throughout the procedure The patient will remain in the intensive care unit for continued monitoring Keywords cardiovascular pulmonary serous drainage bilateral pleural effusion pleural effusion chest tubes effusion pleural chest MEDICAL_TRANSCRIPTION,Description Postcontrast CT chest pulmonary embolism protocol 100 mL of Isovue 300 contrast is utilized Medical Specialty Cardiovascular Pulmonary Sample Name Chest Pulmonary Angio Transcription EXAM CTA chest pulmonary angio REASON FOR EXAM Evaluate for pulmonary embolism TECHNIQUE Postcontrast CT chest pulmonary embolism protocol 100 mL of Isovue 300 contrast is utilized FINDINGS There are no filling defects in the main or main right or left pulmonary arteries No central embolism The proximal subsegmental pulmonary arteries are free of embolus but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal findings would be discussed in more detail below There is no evidence of a central embolism As seen on the prior examination there is a very large heterogeneous right chest wall mass which measures at least 10 x 12 cm based on axial image 35 Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3 3 cm Given the short interval time course from the prior exam dated 01 23 09 this finding has not significantly changed However there is considerable change in the appearance of the lung fields There are now bilateral pleural effusions small on the right and moderate on the left with associated atelectasis There are also extensive right lung consolidations all new or increased significantly from the prior examination Again identified is a somewhat spiculated region of increased density at the right lung apex which may indicate fibrosis or scarring but the possibility of primary or metastatic disease cannot be excluded There is no pneumothorax in the interval On the mediastinal windows there is presumed subcarinal adenopathy with one lymph node measuring roughly 12 mm suggestive of metastatic disease here There is aortic root and arch and descending thoracic aortic calcification There are scattered regions of soft plaque intermixed with this The heart is not enlarged The left axilla is intact in regards to adenopathy The inferior thyroid appears unremarkable Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe this finding is indeterminate and if there is need for additional imaging in regards to hepatic metastatic disease follow up ultrasound Spleen adrenal glands and upper kidneys appear unremarkable Visualized portions of the pancreas are unremarkable There is extensive rib destruction in the region of the chest wall mass There are changes suggesting prior trauma to the right clavicle IMPRESSION 1 Again demonstrated is a large right chest wall mass 2 No central embolus distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings are not well assessed 3 New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung 4 See above regarding other findings Keywords cardiovascular pulmonary chest pulmonary embolism chest pulmonary embolism protocol bilateral pleural effusions chest wall mass metastatic disease pulmonary isovue subsegmental metastatic disease mass lung embolism chest angio MEDICAL_TRANSCRIPTION,Description A lady was admitted to the hospital with chest pain and respiratory insufficiency She has chronic lung disease with bronchospastic angina Medical Specialty Cardiovascular Pulmonary Sample Name Chest Pain Respiratory Insufficiency Transcription We discovered new T wave abnormalities on her EKG There was of course a four vessel bypass surgery in 2001 We did a coronary angiogram This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease She may continue in the future to have angina and she will have nitroglycerin available for that if needed Her blood pressure has been elevated and so instead of metoprolol we have started her on Coreg 6 25 mg b i d This should be increased up to 25 mg b i d as preferred antihypertensive in this lady s case She also is on an ACE inhibitor So her discharge meds are as follows 1 Coreg 6 25 mg b i d 2 Simvastatin 40 mg nightly 3 Lisinopril 5 mg b i d 4 Protonix 40 mg a m 5 Aspirin 160 mg a day 6 Lasix 20 mg b i d 7 Spiriva puff daily 8 Albuterol p r n q i d 9 Advair 500 50 puff b i d 10 Xopenex q i d and p r n I will see her in a month to six weeks She is to follow up with Dr X before that Keywords cardiovascular pulmonary chest pain respiratory insufficiency chronic lung disease bronchospastic angina insufficiency chest angina respiratory bronchospastic MEDICAL_TRANSCRIPTION,Description Chest tube insertion done by two physicians in ER spontaneous pneumothorax secondary to barometric trauma Medical Specialty Cardiovascular Pulmonary Sample Name Chest Tube Insertion in ER Transcription PREOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis POSTOPERATIVE DIAGNOSES 1 Right spontaneous pneumothorax secondary to barometric trauma 2 Respiratory failure 3 Pneumonia with sepsis INFORMED CONSENT Not obtained This patient is obtunded intubated and septic This is an emergent procedure with 2 physician emergency consent signed and on the chart PROCEDURE The patient s right chest was prepped and draped in sterile fashion The site of insertion was anesthetized with 1 Xylocaine and an incision was made Blunt dissection was carried out 2 intercostal spaces above the initial incision site The chest wall was opened and a 32 French chest tube was placed into the thoracic cavity after examination with the finger making sure that the thoracic cavity had been entered correctly The chest tube was placed A postoperative chest x ray is pending at this time The patient tolerated the procedure well and was taken to the recovery room in stable condition ESTIMATED BLOOD LOSS 10 mL COMPLICATIONS None SPONGE COUNT Correct x2 Keywords cardiovascular pulmonary spontaneous pneumothorax barometric trauma respiratory failure sepsis pneumonia blunt dissection chest wall thoracic cavity chest x ray chest tube insertion chest tube pneumothorax tube chest insertion MEDICAL_TRANSCRIPTION,Description Chest PA Lateral to evaluate shortness of breath and pneumothorax versus left sided effusion Medical Specialty Cardiovascular Pulmonary Sample Name Chest PA Lateral Transcription EXAM Chest PA Lateral REASON FOR EXAM Shortness of breath evaluate for pneumothorax versus left sided effusion INTERPRETATION There has been interval development of a moderate left sided pneumothorax with near complete collapse of the left upper lobe The lower lobe appears aerated There is stable diffuse bilateral interstitial thickening with no definite acute air space consolidation The heart and pulmonary vascularity are within normal limits Left sided port is seen with Groshong tip at the SVC RA junction No evidence for acute fracture malalignment or dislocation IMPRESSION 1 Interval development of moderate left sided pneumothorax with corresponding left lung atelectasis 2 Rest of visualized exam nonacute stable 3 Left central line appropriately situated and stable 4 Preliminary report was issued at time of dictation Dr X was called for results Keywords cardiovascular pulmonary effusion interstitial thickening chest pa lateral shortness of breath chest pneumothorax MEDICAL_TRANSCRIPTION,Description Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain Medical Specialty Cardiovascular Pulmonary Sample Name Chest Pain Office Note Transcription DISCHARGE DIAGNOSES 1 Chest pain The patient ruled out for myocardial infarction on serial troponins Result of nuclear stress test is pending 2 Elevated liver enzymes etiology uncertain for an outpatient followup 3 Acid reflux disease TEST DONE Nuclear stress test results of which are pending HOSPITAL COURSE This 32 year old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain O2 saturation at 94 with both atypical and typical features of ischemia The patient ruled out for myocardial infarction with serial troponins Nuclear stress test has been done results of which are pending The patient is stable to be discharged pending the results of nuclear stress test and cardiologist s recommendations He will follow up with cardiologist Dr X in two weeks and with his primary physician in two to four weeks Discharge medications will depend on results of nuclear stress test Keywords cardiovascular pulmonary chest pain serial troponins premature coronary artery disease coronary artery disease nuclear stress test stress test MEDICAL_TRANSCRIPTION,Description Delayed primary chest closure Open chest status post modified stage 1 Norwood operation The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Medical Specialty Cardiovascular Pulmonary Sample Name Chest Closure Transcription PROCEDURE Delayed primary chest closure INDICATIONS The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation Given the magnitude of the operation and the size of the patient 2 5 kg we have elected to leave the chest open to facilitate postoperative management He is now taken back to the operative room for delayed primary chest closure PREOP DX Open chest status post modified stage 1 Norwood operation POSTOP DX Open chest status post modified stage 1 Norwood operation ANESTHESIA General endotracheal COMPLICATIONS None FINDINGS No evidence of intramediastinal purulence or hematoma He tolerated the procedure well DETAILS OF PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position Following general endotracheal anesthesia the chest was prepped and draped in the usual sterile fashion The previously placed AlloDerm membrane was removed Mediastinal cultures were obtained and the mediastinum was then profusely irrigated and suctioned Both cavities were also irrigated and suctioned The drains were flushed and repositioned Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line The sternum was then smeared with a vancomycin paste The proximal aspect of the 5 mm RV PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches The skin was closed with interrupted nylon sutures and a sterile dressing was placed The peritoneal dialysis catheter atrial and ventricular pacing wires were removed The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case Keywords cardiovascular pulmonary open chest stage 1 norwood operation hypoplastic left heart syndrome delayed primary chest closure chest closure norwood operation MEDICAL_TRANSCRIPTION,Description Right hemothorax Insertion of a 32 French chest tube on the right hemithorax This is a 54 year old female with a newly diagnosed carcinoma of the cervix The patient is to have an Infuse A Port insertion Medical Specialty Cardiovascular Pulmonary Sample Name Chest Tube Insertion Transcription PREOPERATIVE DIAGNOSIS Right hemothorax POSTOPERATIVE DIAGNOSIS Right hemothorax PROCEDURE PERFORMED Insertion of a 32 French chest tube on the right hemithorax ANESTHESIA 1 Lidocaine and sedation INDICATIONS FOR PROCEDURE This is a 54 year old female with a newly diagnosed carcinoma of the cervix The patient is to have an Infuse A Port insertion today Postoperatively from that she started having a blood tinged pink frothy sputum Chest x ray was obtained and showed evidence of a hemothorax on the right hand side opposite side of the Infuse A Port and a wider mediastinum The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room DESCRIPTION OF PROCEDURE The area was prepped and draped in the sterile fashion The area was anesthetized with 1 Lidocaine solution The patient was given sedation A 10 blade scalpel was used to make an incision approximately 1 5 cm long Then a curved scissor was used to dissect down to the level of the rib A blunt peon was then used to again enter into the right hemithorax Immediately a blood tinged effusion was released The chest tube was placed and directed in a posterior and superior direction The chest tube was hooked up to the Pleur evac device which was ________ tip suction The chest tube was tied in with a 0 silk suture in a U stitch fashion It was sutured in place with sterile dressing and silk tape The patient tolerated this procedure well We will obtain a chest x ray in postop to ensure proper placement and continue to follow the patient very closely Keywords cardiovascular pulmonary hemothorax hemithorax pleur evac device infuse a port insertion chest tube carcinoma MEDICAL_TRANSCRIPTION,Description Chest pain possible syncopal spells She has been having multiple cardiovascular complaints including chest pains which feel like cramps and sometimes like a dull ache which will last all day long Medical Specialty Cardiovascular Pulmonary Sample Name Chest Pain Cardiac Consult Transcription REASON FOR REFERRAL Chest pain possible syncopal spells She is a very pleasant 31 year old mother of two children with ADD She was doing okay until January of 2009 when she had a partial hysterectomy Since then she just says things have changed She just does not want to go out anymore and just does not feel the same Also at the same time she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband Her 11 year old is having a lot of trouble at school and she often has to go there to take care of problems In this setting she has been having multiple cardiovascular complaints including chest pains which feel like cramps and sometimes like a dull ache which will last all day long She is also tender in the left breast area and gets numbness in her left hand She has also had three spells of falling she is not really clear on whether these are syncopal but they sound like they could be as she sees spots before her eyes Twice it happened when getting up quickly at night and another time in the grocery store She suffered no trauma She has no remote history of syncope Her weight has not changed in the past year MEDICATIONS Naprosyn which she takes up to six a day ALLERGIES Sulfa SOCIAL HISTORY She does not smoke or drink She is married with two children REVIEW OF SYSTEMS Otherwise unremarkable PEX BP 130 70 without orthostatic changes PR 72 WT 206 pounds She is a healthy young woman No JVD No carotid bruit No thyromegaly Cardiac Regular rate and rhythm There is no significant murmur gallop or rub Chest Mildly tender in the upper pectoral areas bilaterally breast exam was not performed Lungs Clear Abdomen Soft Moderately overweight Extremities No edema and good distal pulses EKG Normal sinus rhythm normal EKG ECHOCARDIOGRAM FOR SYNCOPE Essentially normal study IMPRESSION 1 Syncopal spells These do sound in fact to be syncopal I suspect it is simple orthostasis vasovagal as her EKG and echocardiogram looks good I have asked her to drink plenty of fluids and to not to get up suddenly at night I think this should take care of the problem I would not recommend further workup unless these spells continue at which time I would recommend a tilt table study 2 Chest pains Atypical for cardiac etiology undoubtedly due to musculoskeletal factors from her emotional stressors The Naprosyn is not helping that much I gave her a prescription for Flexeril and instructed her in its use not to drive after taking it RECOMMENDATIONS 1 Reassurance that her cardiac checkup looks excellent which it does 2 Drink plenty of fluids and arise slowly from bed 3 Flexeril 10 mg q 6 p r n 4 I have asked her to return should the syncopal spells continue Keywords cardiovascular pulmonary chest pain syncopal echocardiogram ekg cardiac etiology syncopal spells rhythm flexeril cardiac chest MEDICAL_TRANSCRIPTION,Description Carotid Ultrasonic Color Flow Imaging Medical Specialty Cardiovascular Pulmonary Sample Name Carotid Doppler Report Transcription Grade II Atherosclerotic plaques are seen which appear to be causing 40 60 obstruction Grade III Atherosclerotic plaques are seen which appear to be causing greater than 60 obstruction Grade IV The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it RIGHT CAROTID SYSTEM The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease The internal carotid artery shows intimal thickening with some mixed plaques but no increase in velocity and no evidence for any significant obstructive disease The external carotid artery shows no disease The vertebral was present and was antegrade LEFT CAROTID SYSTEM The common carotid artery and bulb area shows mild intimal thickening but no increase in velocity and no evidence for any significant obstructive disease the internal carotid artery shows some intimal thickening with mixed plaques but no increase in velocity and no evidence for any significant obstructive disease The external carotid artery shows no disease The vertebral was present and was antegrade IMPRESSION Bilateral atherosclerotic changes with no evidence for any significant obstructive disease Keywords cardiovascular pulmonary atherosclerotic atherosclerotic plaques obstructive disease carotid artery carotid artery and bulb common carotid artery mild intimal thickening external carotid artery common carotid internal carotid external carotid intimal thickening carotid intimal plaques artery MEDICAL_TRANSCRIPTION,Description Left carotid endarterectomy with endovascular patch angioplasty Critical left carotid stenosis The external carotid artery was occluded at its origin When the endarterectomy was performed the external carotid artery back bled nicely The internal carotid artery had good backflow bleeding noted Medical Specialty Cardiovascular Pulmonary Sample Name Carotid Endarterectomy Angioplasty Transcription PREOPERATIVE DIAGNOSIS Critical left carotid stenosis POSTOPERATIVE DIAGNOSIS Critical left carotid stenosis PROCEDURE PERFORMED Left carotid endarterectomy with endovascular patch angioplasty ANESTHESIA Cervical block GROSS FINDINGS The patient is a 57 year old black female with chronic renal failure She does have known critical carotid artery stenosis She wishes to undergo bilateral carotid endarterectomy however it was felt necessary by Dr X to perform cardiac catheterization She was admitted to the hospital yesterday with chest pain She has been considered for coronary artery bypass grafting I have been asked to address the carotid stenosis left being more severe this was addressed first Intraoperatively an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery The internal carotid artery is quite torturous The external carotid artery was occluded at its origin When the endarterectomy was performed the external carotid artery back bled nicely The internal carotid artery had good backflow bleeding noted OPERATIVE PROCEDURE The patient was taken to the OR suite and placed in the supine position Then neck shoulder and chest wall were prepped and draped in appropriate manner Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery Utilizing both blunt and sharp dissections the common carotid artery the internal carotid artery beyond the atherosclerotic back the external carotid artery and the superior thyroid artery were isolated and encircled with a umbilical tape During the dissection facial veins were ligated with 4 0 silk ligature prior to dividing them Also during the dissection ansa cervicalis hypoglossal and vagus nerve identified and preserved There was some inflammation above the carotid bulb but this was not problematic The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips The common carotid artery was controlled with profunda clamp The patient remained neurologically intact A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery This was extended across the lobe on to the internal carotid artery An endarterectomy was then performed The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline As mentioned before the internal carotid artery is quite torturous This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of 7 0 Prolene suture The wound was copiously irrigated rather an endovascular patch was then brought on to the field This was cut to shape and length This was sutured in place with continuous running 6 0 Prolene suture The suture line began at both sites The suture was tied in the center along the anterior and posterior walls Prior to completing the closure the common carotid artery was flushed The internal carotid artery permitted to back bleed The clamp was placed after completing the closure The clamp was placed at the origin of the internal carotid artery Flow was first directed into the external carotid artery then into the internal carotid artery The patient remained neurologically intact Topical ________ Gelfoam was utilized Of note during the endarterectomy the patient did receive an additional 7000 units of aqueous heparin The wound was copiously irrigated with antibiotic solution Sponge needle and all counts were correct All surgical sites were inspected Good hemostasis noted The incision was closed in layers with absorbable suture Stainless steel staples approximated skin Sterile dressings were applied The patient tolerated the procedure well grossly neurologically intact Keywords cardiovascular pulmonary carotid stenosis carotid endarterectomy endovascular patch angioplasty cervical block carotid artery common carotid artery external carotid artery endovascular patch common carotid external carotid angioplasty artery endovascular neurologically carotid stenosis endarterectomy MEDICAL_TRANSCRIPTION,Description Right subclavian triple lumen central line placement Medical Specialty Cardiovascular Pulmonary Sample Name Central Line Placement Transcription PREOPERATIVE DIAGNOSIS 1 Severe chronic obstructive coronary disease 2 Respiratory failure POSTOPERATIVE DIAGNOSIS 1 Severe chronic obstructive coronary disease 2 Respiratory failure OPERATION Right subclavian triple lumen central line placement ANESTHESIA Local Xylocaine INDICATIONS FOR OPERATION This 50 year old gentleman with severe respiratory failure is mechanically ventilated He is currently requiring multiple intravenous drips and Dr X has kindly requested central line placement INFORMED CONSENT The patient was unable to provide his own consent secondary to mechanical ventilation and sedation No available family to provide conservator ship was located either PROCEDURE With the patient in his Intensive Care Unit bed mechanically ventilated in the Trendelenburg position The right neck was prepped and draped with Betadine in a sterile fashion Single needle stick aspiration of the right subclavian vein was accomplished without difficulty and the guide wire was advanced The dilator was advanced over the wire The triple lumen catheter was cannulated over the wire and the wire then removed No PVCs were encountered during the procedure All three ports to the catheter aspirated and flushed blood easily and they were all flushed with normal saline The catheter was anchored to the chest wall with butterfly phalange using 3 0 silk suture Betadine ointment and a sterile Op Site dressing were applied Stat upright chest x ray was obtained at the completion of the procedure and final results are pending FINDINGS SPECIMENS REMOVED None COMPLICATIONS None ESTIMATED BLOOD LOSS Nil Keywords cardiovascular pulmonary respiratory failure central line placement chronic obstructive coronary disease normal saline subclavian subclavian triple lumen central line placement subclavian vein triple lumen triple lumen central line lumen central line placement central line line placement respiratory xylocaine MEDICAL_TRANSCRIPTION,Description Carotid and cerebral arteriogram abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery Medical Specialty Cardiovascular Pulmonary Sample Name Carotid Cerebral Arteriograms Transcription EXAM Carotid and cerebral arteriograms INDICATION Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery IMPRESSION 1 Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin 2 Mild stenosis of the right internal carotid artery measured at 20 3 Patent bilateral vertebral arteries 4 No significant disease was identified of the anterior cerebral vessels DISCUSSION Carotid and cerebral arteriograms were performed on Month DD YYYY previous studies are not available for comparison The right groin was sterilely cleansed and draped Lidocaine 1 buffered with sodium bicarbonate was used as local anesthetic A 19 French needle was then advanced into the common femoral artery and a wire was advanced Over the wire a sheath was placed A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire Flushed arteriogram was performed Arteriogram demonstrated no significant disease of the great vessels at their origins There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin The vertebral arteries were widely patent Following this the flushed catheter was exchanged for catheter and selective catheterization of the common carotid artery on the right was performed Carotid and cerebral arteriograms were performed The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable The external carotid artery on the right is quite tortuous in its appearance The internal carotid artery demonstrates a mild plaque creating stenosis which is measured approximately 20 Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal No significant stenosis identified There is complete cross filling into the left brain via the right No significant stenosis was appreciated Following this the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion The patient tolerated the procedure well No complications occurred during or immediately after the procedure Stasis was achieved of the puncture site using a VasoSeal The patient will be observed for at least 2 1 2 hours prior to being discharged to home Keywords cardiovascular pulmonary carotid arteriogram bulb carotid duplex catheter cerebral distal femoral artery internal carotid artery needle occlusion sheath stenosis vertebral arteries vessels cerebral arteriograms carotid artery artery arteriograms wire MEDICAL_TRANSCRIPTION,Description Insertion of central venous line and arterial line and transesophageal echocardiography probe Medical Specialty Cardiovascular Pulmonary Sample Name Central Venous Arterial Line Transcription INDICATIONS FOR PROCEDURES Impending open heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure The patient was already under general anesthesia in the operating room Antibiotic prophylaxis with cephazolin and gentamicin were already given A strict aseptic technique was used including use of gowns mask and gloves etc The skin was cleansed with alcohol and then prepped with ChloraPrep solution PROCEDURE 1 Insertion of central venous line DESCRIPTION OF PROCEDURE 1 Attention was directed to the right groin A Cook 4 French double lumen 12 cm long central venous heparin coated catheter kit was opened Using the 21 gauge needle that comes with this kit the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery There was good venous blood return on the first try Using the Seldinger technique the soft J end of the wire was inserted through the needle without resistance approximately 15 cm It was then exchanged for a 5 French dilator followed by the 4 French double lumen catheter and the wire was removed intact There was good blood return from both lumens which were flushed with heparinized saline The catheter was sutured to the skin at three points with 4 0 silk for stabilization PROCEDURE 2 Insertion of arterial line DESCRIPTION OF PROCEDURE 2 Attention was directed to the left wrist which was placed on wrist rest The Allen test was normal A Cook 2 5 French 5 cm long arterial catheter kit was opened A 22 gauge IV cannula was used to enter the artery which was done on the first try with good pulsatile blood return Using the Seldinger technique the catheter was exchanged for a 2 5 French catheter and the wire was removed intact There was pulsatile blood return and the catheter was flushed with heparinized saline solution It was sutured to the skin with 4 0 silk at three points for stabilization Both catheters functioned well throughout the procedure The distal circulation of the leg and the hand was intact immediately after insertion approximately 20 minutes later and at the end of the procedure There were no complications PROCEDURE 3 Insertion of transesophageal echocardiography probe DESCRIPTION OF PROCEDURE 3 The probe was inserted under direct vision because initially there was some resistance to insertion Under direct vision using the 2 Miller blade the upper esophageal opening was visualized and the probe was passed easily without resistance There was good visualization of the heart The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography The probe was removed at the end There was no trauma and there was no blood tingeing Keywords cardiovascular pulmonary open heart surgery central venous line arterial line transesophageal echocardiography probe glenn procedure atrial septectomy aseptic technique pulsatile blood central venous blood return arterial central probe insertion catheter MEDICAL_TRANSCRIPTION,Description Central line insertion Empyema thoracis and need for intravenous antibiotics Medical Specialty Cardiovascular Pulmonary Sample Name Central Line Insertion Transcription PREOPERATIVE DIAGNOSES 1 Empyema thoracis 2 Need for intravenous antibiotics POSTOPERATIVE DIAGNOSES 1 Empyema thoracis 2 Need for intravenous antibiotics PROCEDURE Central line insertion DESCRIPTION OF PROCEDURE With the patient in his room after obtaining the informed consent his left deltopectoral area was prepped and draped in the usual fashion Xylocaine 1 was infiltrated and with the patient in the Trendelenburg position the left subclavian vein was subcutaneously cannulated without any difficulty The triple lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline The catheter was fixed to the skin with sutures The dressing was applied and then the chest x ray was obtained which showed no complications of the procedure and good position of the catheter Keywords cardiovascular pulmonary thoracis intravenous central line insertion empyema catheter MEDICAL_TRANSCRIPTION,Description Right common carotid endarterectomy internal carotid endarterectomy external carotid endarterectomy and Hemashield patch angioplasty of the right common internal and external carotid arteries Medical Specialty Cardiovascular Pulmonary Sample Name Carotid Endarterectomy 1 Transcription PREOPERATIVE DIAGNOSIS Right common internal and external carotid artery stenosis POSTOPERATIVE DIAGNOSIS Right common internal and external carotid artery stenosis OPERATIONS 1 Right common carotid endarterectomy 2 Right internal carotid endarterectomy 3 Right external carotid endarterectomy 4 Hemashield patch angioplasty of the right common internal and external carotid arteries ANESTHESIA General endotracheal anesthesia URINE OUTPUT Not recorded OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Next the right neck was prepped and draped in the standard surgical fashion A 10 blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors The common internal and external carotid arteries were identified The facial vein was ligated with 3 0 silk The hypoglossal nerve was identified and preserved as it coursed across the carotid artery After dissecting out an adequate length of common internal and external carotid artery heparin was given Next an umbilical tape was passed around the common carotid artery A 0 silk suture was passed around the internal and external carotid arteries The hypoglossal nerve was identified and preserved An appropriate sized Argyle shunt was chosen A Hemashield patch was cut to the appropriate size Next vascular clamps were placed on the external carotid artery DeBakey pickups were used to control the internal carotid artery and common carotid artery A 11 blade scalpel was used to make an incision on the common carotid artery The arteriotomy was lengthened onto the internal carotid artery Next the Argyle shunt was placed It was secured in place Next an endarterectomy was performed and this was done on the common internal carotid and external carotid arteries An inversion technique was used on the external carotid artery The artery was irrigated and free debris was removed Next we sewed the Hemashield patch onto the artery using 6 0 Prolene in a running fashion Prior to completion of our anastomosis we removed our shunt We completed the anastomosis Next we removed our clamp from the external carotid artery followed by the common carotid artery and lastly by the internal carotid artery There was no evidence of bleeding Full dose protamine was given The incision was closed with 0 Vicryl followed by 2 0 Vicryl followed by 4 0 PDS in a running subcuticular fashion A sterile dressing was applied Keywords cardiovascular pulmonary angioplasty common carotid artery external carotid artery hemashield patch common carotid carotid endarterectomy external artery carotid hemashield endarterectomy MEDICAL_TRANSCRIPTION,Description Right carotid stenosis and prior cerebrovascular accident Right carotid endarterectomy with patch angioplasty Medical Specialty Cardiovascular Pulmonary Sample Name Carotid Endarterectomy Transcription PREOPERATIVE DIAGNOSES 1 Right carotid stenosis 2 Prior cerebrovascular accident POSTOPERATIVE DIAGNOSES 1 Right carotid stenosis 2 Prior cerebrovascular accident PROCEDURE PERFORMED Right carotid endarterectomy with patch angioplasty ESTIMATED BLOOD LOSS 250 cc OPERATIVE FINDINGS The common and internal carotid arteries were opened A high grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting PROCEDURE The patient was taken to the operating room placed in supine position prepped and draped in the usual sterile manner with Betadine solution Longitudinal incisions were made along the anterior border of the sternocleidomastoid carried down through subcutaneous fat and fascia Hemostasis was obtained with electrocautery The platysmal muscle was divided The carotid sheath was identified and opened The vagus nerve ansa cervicalis and hypoglossal nerves were identified and avoided The common internal and external carotids were then freed from the surrounding tissue At this point 10 000 units of aqueous heparin were administered and allowed to take effect The external and common carotids were then clamped The patient s neurological status was evaluated and found to be unchanged from preoperative levels Once sufficient time had lapsed we proceeded with the procedure The carotid bulb was opened with a 11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external The plaque tapered nicely on the internal and no tacking sutures were necessary Heparinized saline was injected and no evidence of flapping or other debris was noted The remaining carotid was examined under magnification which showed no debris of flaps present At this point a Dacron patch was brought on to the field cut to appropriate length and size and anastomosed to the artery using 6 0 Prolene in a running fashion Prior to the time of last stitch the internal carotid was back bled through this The last stitch was tied Hemostasis was excellent The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system At this point a total of 50 mg of Protamine was administered and allowed to take effect Hemostasis was excellent The wound was irrigated with antibiotic solution and closed in layers using 3 0 Vicryl and 4 0 undyed Vicryl The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well Sponge needles and instrument count were correct Estimated blood loss was 250 cc Keywords cardiovascular pulmonary carotid stenosis cerebrovascular platysmal dacron patch carotid endarterectomy cerebrovascular accident internal carotid carotid stenosis carotids endarterectomy MEDICAL_TRANSCRIPTION,Description Direct current cardioversion This is a 53 year old gentleman with history of paroxysmal atrial fibrillation for 3 years Successful DC cardioversion of atrial fibrillation Medical Specialty Cardiovascular Pulmonary Sample Name Cardioversion Direct Current 1 Transcription PROCEDURE Direct current cardioversion BRIEF HISTORY This is a 53 year old gentleman with history of paroxysmal atrial fibrillation for 3 years He had a wide area of circumferential ablation done on November 9th for atrial fibrillation He did develop recurrent atrial fibrillation the day before yesterday and this is persistent Therefore he came in for cardioversion today He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion The patient was in the SDI unit attached to noninvasive monitoring devices After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s He tolerated it well He will be observed for couple hours and discharged home later today He will continue on his current medications He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself CONCLUSIONS FINAL DIAGNOSES Successful DC cardioversion of atrial fibrillation Keywords cardiovascular pulmonary direct current cardioversion circumferential ablation paroxysmal atrial dc cardioversion direct current atrial fibrillation ablation cardioversion MEDICAL_TRANSCRIPTION,Description Direct current cardioversion Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication Medical Specialty Cardiovascular Pulmonary Sample Name Cardioversion Direct Current Transcription PROCEDURE Direct current cardioversion REASON FOR PROCEDURE Atrial fibrillation PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits including risk of stroke The patient understands as well as her husband The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium There was spontaneous echocardiogram contrast noticed The patient was on anticoagulation with Lovenox received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed The pads applied in the anterior and posterior approach With synchronized biphasic waveform at 150 J one shock was successful in restoring sinus rhythm The patient had some occasional PACs noticed with occasional sinus tachycardia The patient had no immediate post procedure complications The rhythm was maintained and 12 lead EKG was requested IMPRESSION Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication Keywords cardiovascular pulmonary thrombus atrium echocardiogram transesophageal direct current cardioversion atrial fibrillation sinus rhythm sinus rhythm cardioversion MEDICAL_TRANSCRIPTION,Description Problem of essential hypertension Symptoms that suggested intracranial pathology Medical Specialty Cardiovascular Pulmonary Sample Name Cardiology Progress Note Transcription SUBJECTIVE The patient is a 78 year old female with the problem of essential hypertension She has symptoms that suggested intracranial pathology but so far work up has been negative She is taking hydrochlorothiazide 25 mg once a day and K Dur 10 mEq once a day with adequate control of her blood pressure She denies any chest pain shortness of breath PND ankle swelling or dizziness OBJECTIVE Heart rate is 80 and blood pressure is 130 70 Head and neck are unremarkable Heart sounds are normal Abdomen is benign Extremities are without edema ASSESSMENT AND PLAN The patient reports that she had an echocardiogram done in the office of Dr Sample Doctor4 and was told that she had a massive heart attack in the past I have not had the opportunity to review any investigative data like chest x ray echocardiogram EKG etc So I advised her to have a chest x ray and an EKG done before her next appointment and we will try to get hold of the echocardiogram on her from the office of Dr Sample Doctor4 In the meantime she is doing quite well and she was advised to continue her current medication and return to the office in three months for followup Keywords cardiovascular pulmonary cardiology ekg k dur progerss note soap ankle swelling blood pressure chest x ray echocardiogram essential hypertension heart attack hydrochlorothiazide hypertension pathology chest heart intracranial MEDICAL_TRANSCRIPTION,Description Cardioversion Unsuccessful direct current cardioversion with permanent atrial fibrillation Medical Specialty Cardiovascular Pulmonary Sample Name Cardioversion Unsuccessful Transcription REASON FOR EXAM Atrial flutter cardioversion PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits The patient agreed and signed the consent form The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed The pads were applied in the anterior posterior approach The synchronized cardioversion with biphasic energy delivered at 150 J First attempt was unsuccessful Second attempt at 200 J with anterior posterior approach With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function the success of the rate without antiarrhythmic may be low IMPRESSION Unsuccessful direct current cardioversion with permanent atrial fibrillation Keywords cardiovascular pulmonary atrial flutter cardioversion anterior posterior transesophageal atrial fibrillation flutter cardioversion fibrillation atrial MEDICAL_TRANSCRIPTION,Description Male with a history of therapy controlled hypertension borderline diabetes and obesity Risk factors for coronary heart disease Medical Specialty Cardiovascular Pulmonary Sample Name Cardiovascular Letter Transcription Dear Sample Doctor Thank you for referring Mr Sample Patient for cardiac evaluation This is a 67 year old obese male who has a history of therapy controlled hypertension borderline diabetes and obesity He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance Specifically no chest discomfort of any kind no dyspnea on exertion unless extreme exertion is performed no orthopnea or PND He is known to have a mother with coronary heart disease He has never been a smoker He has never had a syncopal episode MI or CVA He had his gallbladder removed No bleeding tendencies No history of DVT or pulmonary embolism The patient is retired rarely consumes alcohol and consumes coffee moderately He apparently has a sleep disorder according to his wife not in the office the patient snores and stops breathing during sleep He is allergic to codeine and aspirin angioedema Physical exam revealed a middle aged man weighing 283 pounds for a height of 5 feet 11 inches His heart rate was 98 beats per minute and regular His blood pressure was 140 80 mmHg in the right arm in a sitting position and 150 80 mmHg in a standing position He is in no distress Venous pressure is normal Carotid pulsations are normal without bruits The lungs are clear Cardiac exam was normal The abdomen was obese and organomegaly was not palpated There were no pulsatile masses or bruits The femoral pulses were 3 in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3 in character There was no peripheral edema He had a chemistry profile which suggests diabetes mellitus with a fasting blood sugar of 136 mg dl Renal function was normal His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL His sodium was a little bit increased His A1c hemoglobin was increased He had a spirometry which was reported as normal He had a resting electrocardiogram on December 20 2002 which was also normal He had a treadmill Cardiolite which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90 of the predicted maximum heart rate There were no symptoms or ischemia by EKG There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging In summary we have a 67 year old gentleman with risk factors for coronary heart disease I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity hypertension possible insulin resistance and some degree of fasting hyperglycemia as well as slight triglyceride elevation He denies any symptoms of coronary heart disease but he probably has some degree of coronary atherosclerosis possibly affecting the inferior wall by functional testings In view of the absence of symptoms medical therapy is indicated at the present time with very aggressive risk factor modification I explained and discussed extensively with the patient the benefits of regular exercise and a walking program was given to the patient He also should start aggressively losing weight I have requested additional testing today which will include an apolipoprotein B LPa lipoprotein as well as homocystine and cardio CRP to further assess his risk of atherosclerosis In terms of medication I have changed his verapamil for a long acting beta blocker he should continue on an ACE inhibitor and his Plavix The patient is allergic to aspirin I also will probably start him on a statin if any of the studies that I have recommended come back abnormal and furthermore if he is confirmed to have diabetes Along this line perhaps we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes which I believe he should This however I will leave entirely up to you to decide If indeed he is considered to be a diabetic a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general and coronary artery disease in particular I do not find an indication at this point in time to proceed with any further testing such as coronary angiography in the absence of symptoms If you have any further questions please do not hesitate to let me know Thank you once again for this kind referral Sincerely Sample Doctor M D Keywords cardiovascular pulmonary cardiovascular letter angioedema beta blocker cardiac evaluation chest discomfort coronary heart disease hypertension metabolic syndrome therapy controlled hypertension truncal obesity controlled hypertension borderline diabetes risk factors heart disease intolerance therapy heart atherosclerosis diabetes coronary aspirin MEDICAL_TRANSCRIPTION,Description Cardiology office visit sample note Medical Specialty Cardiovascular Pulmonary Sample Name Cardiology Office Visit 2 Transcription HISTORY OF PRESENT ILLNESS This 57 year old black female was seen in my office on Month DD YYYY for further evaluation and management of hypertension Patient has severe backache secondary to disc herniation Patient has seen an orthopedic doctor and is scheduled for surgery Patient also came to my office for surgical clearance Patient had cardiac cath approximately four years ago which was essentially normal Patient is documented to have morbid obesity and obstructive sleep apnea syndrome Patient does not use a CPAP mask Her exercise tolerance is eight to ten feet for shortness of breath Patient also has two pillow orthopnea She has intermittent pedal edema PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 135 70 Respirations 18 per minute Heart rate 70 beats per minute Weight 258 pounds HEENT Head normocephalic Eyes no evidence of anemia or jaundice Oral hygiene is good NECK Supple JVP is flat Carotid upstroke is good LUNGS Clear CARDIOVASCULAR There is no murmur or gallop heard over the precordium ABDOMEN Soft There is no hepatosplenomegaly EXTREMITIES The patient has no pedal edema MEDICATIONS 1 BuSpar 50 mg daily 2 Diovan 320 12 5 daily 3 Lotrel 10 20 daily 4 Zetia 10 mg daily 5 Ambien 10 mg at bedtime 6 Fosamax 70 mg weekly DIAGNOSES 1 Controlled hypertension 2 Morbid obesity 3 Osteoarthritis 4 Obstructive sleep apnea syndrome 5 Normal coronary arteriogram 6 Severe backache PLAN 1 Echocardiogram stress test 2 Routine blood tests 3 Sleep apnea study 4 Patient will be seen again in my office in two weeks Keywords MEDICAL_TRANSCRIPTION,Description Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction Medical Specialty Cardiovascular Pulmonary Sample Name Cardiology Progress Note 1 Transcription SUBJECTIVE The patient is not in acute distress PHYSICAL EXAMINATION VITAL SIGNS Blood pressure of 121 63 pulse is 75 and O2 saturation is 94 on room air HEAD AND NECK Face is symmetrical Cranial nerves are intact CHEST There is prolonged expiration CARDIOVASCULAR First and second heart sounds are heard No murmur was appreciated ABDOMEN Soft and nontender Bowel sounds are positive EXTREMITIES He has 2 pedal swelling NEUROLOGIC The patient is asleep but easily arousable LABORATORY DATA PTT is 49 INR is pending BUN is improved to 20 6 creatinine is 0 7 sodium is 123 and potassium is 3 8 AST is down to 45 and ALT to 99 DIAGNOSTIC STUDIES Nuclear stress test showed moderate size mostly fixed defect involving the inferior wall with a small area of peri infarct ischemia Ejection fraction is 25 ASSESSMENT AND PLAN 1 Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction Continue current treatment as per Cardiology We will consider adding ACE inhibitors as renal function improves 2 Acute pulmonary edema resolved 3 Rapid atrial fibrillation rate controlled The patient is on beta blockers and digoxin Continue Coumadin Monitor INR 4 Coronary artery disease with ischemic cardiomyopathy Continue beta blockers 5 Urinary tract infection Continue Rocephin 6 Bilateral perfusion secondary to congestive heart failure We will monitor 7 Chronic obstructive pulmonary disease stable 8 Abnormal liver function due to congestive heart failure with liver congestion improving 9 Rule out hypercholesterolemia We will check lipid profile 10 Tobacco smoking disorder The patient has been counseled 11 Hyponatremia stable This is due to fluid overload Continue diuresis as per Nephrology 12 Deep venous thrombosis prophylaxis The patient is on heparin drip Keywords cardiovascular pulmonary atrial fibrillation systolic dysfunction ace inhibitors coronary artery disease rapid atrial fibrillation congestive heart failure beta blockers heart failure congestive heart asleep MEDICAL_TRANSCRIPTION,Description Cardioversion An 86 year old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation Medical Specialty Cardiovascular Pulmonary Sample Name Cardioversion Transcription HISTORY The patient is an 86 year old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia incomplete compliance with obstructive sleep apnea therapy with CPAP chocolate caffeine ingestion and significant mental stress Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation I have discussed in detail with the patient regarding risks benefits and alternatives of the procedure After an in depth discussion of the procedure please see my initial consultation for further details I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday The patient declined I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate PROCEDURE NOTE The appropriate time out procedure was performed as per Medical Center protocol including proper identification of the patient physician procedure documentation and there were no safety issues identified by myself nor the staff The patient participated actively in this She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm This was confirmed on 12 lead EKG IMPRESSION PLAN Successful resumption of normal sinus rhythm from recurrent atrial fibrillation The patient s electrolytes are now normal and that will need close watching to avoid hypokalemia in the future as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p o b i d metoprolol 50 mg p o b i d Diltiazem CD 240 mg p o daily and digoxin 0 125 mg p o daily and to be clear she does have a permanent pacemaker implanted She will follow up with her regular cardiologist Dr X for whom I am covering this weekend This was all discussed in detail with the patient as well as her granddaughter with the patient s verbal consent at the bedside Keywords cardiovascular pulmonary atrial fibrillation aortic valve paroxysmal normal sinus rhythm sinus rhythm cpap cardioversion fibrillation atrial MEDICAL_TRANSCRIPTION,Description Patient with chest pains CAD and cardiomyopathy Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Radionuclide Stress Test Transcription INDICATION FOR STUDY Chest pains CAD and cardiomyopathy MEDICATIONS Humulin lisinopril furosemide spironolactone omeprazole carvedilol pravastatin aspirin hydrocodone and diazepam BASELINE EKG Sinus rhythm at 71 beats per minute left anterior fascicular block LVBB PERSANTINE RESULTS Heart rate increased from 70 to 72 Blood pressure decreased from 160 84 to 130 78 The patient felt slightly dizziness but there was no chest pain or EKG changes NUCLEAR PROTOCOL Same day rest stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test 53 mg of Persantine were used reversed with 125 mg of aminophylline NUCLEAR RESULTS 1 Nuclear perfusion imaging review of the raw projection data reveals adequate image acquisition The resting images are normal The post Persantine images show mildly decreased uptake in the septum The sum score is 0 2 The Gated SPECT shows enlarged heart with a preserved EF of 52 IMPRESSION 1 Mild septal ischemia Likely due to the left bundle branch block 2 Mild cardiomyopathy EF of 52 3 Mild hypertension at 160 84 4 Left bundle branch block Keywords cardiovascular pulmonary cardiac radionuclide spect sinus rhythm cardiac radionuclide stress test bundle branch block stress test bundle branch chest pains stress test cardiomyopathy nuclear MEDICAL_TRANSCRIPTION,Description Follow up update on patient with left carotid angioplasty and stent placement Medical Specialty Cardiovascular Pulmonary Sample Name Cardiology Letter Transcription Please accept this letter of follow up on patient xxx xxx He is now three months out from a left carotid angioplasty and stent placement He was a part of a CapSure trial He has done quite well with no neurologic or cardiac event in the three months of follow up He had a follow up ultrasound performed today that shows the stent to be patent with no evidence of significant recurrence Sincerely XYZ MD Keywords cardiovascular pulmonary capsure cardiac event ultrasound carotid angioplasty stent placement letter angioplastyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A 49 year old man with respiratory distress history of coronary artery disease with prior myocardial infarctions and recently admitted with pneumonia and respiratory failure Medical Specialty Cardiovascular Pulmonary Sample Name Cardio Pulmo Discharge Summary Transcription ADMISSION DIAGNOSIS 1 Respiratory arrest 2 End stage chronic obstructive pulmonary disease 3 Coronary artery disease 4 History of hypertension DISCHARGE DIAGNOSIS 1 Status post respiratory arrest 2 Chronic obstructive pulmonary disease 3 Congestive heart failure 4 History of coronary artery disease 5 History of hypertension SUMMARY The patient is a 49 year old man who was admitted to the hospital in respiratory distress and had to be intubated shortly after admission to the emergency room The patient s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999 The patient has recently been admitted to the hospital with pneumonia and respiratory failure The patient has been smoking up until three to four months previously On the day of admission the patient had the sudden onset of severe dyspnea and called an ambulance The patient denied any gradual increase in wheezing any increase in cough any increase in chest pain any increase in sputum prior to the onset of his sudden dyspnea ADMISSION PHYSICAL EXAMINATION GENERAL Showed a well developed slightly obese man who was in extremis NECK Supple with no jugular venous distension HEART Showed tachycardia without murmurs or gallops PULMONARY Status showed decreased breath sounds but no clear cut rales or wheezes EXTREMITIES Free of edema HOSPITAL COURSE The patient was admitted to the Special Care Unit and intubated He received intravenous antibiotic therapy with Levaquin He received intravenous diuretic therapy He received hand held bronchodilator therapy The patient also was given intravenous steroid therapy with Solu Medrol The patient s course was one of gradual improvement and after approximately three days the patient was extubated He continued to be quite dyspneic with wheezes as well as basilar rales After pulmonary consultation was obtained the pulmonary consultant felt that the patient s overall clinical picture suggested that he had a significant element of congestive heart failure With this the patient was placed on increased doses of Lisinopril and Digoxin with improvement of his respiratory status On the day of discharge the patient had minimal basilar rales his chest also showed minimal expiratory wheezes he had no edema his heart rate was regular his abdomen was soft and his neck veins were not distended It was therefore felt that the patient was stable for further management on an outpatient basis DIAGNOSTIC DATA The patient s admission laboratory data was notable for his initial blood gas which showed a pH of 7 02 with a pCO2 of 118 and a pO2 of 103 The patient s electrocardiogram showed nonspecific ST T wave changes The patent s CBC showed a white count of 24 000 with 56 neutrophils and 3 bands DISPOSITION The patient was discharged home DISCHARGE INSTRUCTIONS His diet was to be a 2 grams sodium 1800 calorie ADA diet His medications were to be Prednisone 20 mg twice per day Theo 24 400 mg per day Furosemide 40 mg 1 1 2 tabs p o per day Acetazolamide 250 mg one p o per day Lisinopril 20 mg one p o twice per day Digoxin 0 125 mg one p o q d nitroglycerin paste 1 inch h s K Dur 60 mEq p o b i d He was also to use a Ventolin inhaler every four hours as needed and Azmacort four puffs twice per day He was asked to return for follow up with Dr X in one to two weeks Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge Keywords cardiovascular pulmonary discharge summary ada diet congestive heart failure coronary artery disease respiratory arrest chest pain chronic obstructive pulmonary disease emergency room hypertension sputum wheezing respiratory distress myocardial infarctions respiratory failure pulmonary disease basilar rales heart failure infarctions heart wheezes coronary pulmonary discharge respiratory MEDICAL_TRANSCRIPTION,Description Cardiolite treadmill exercise stress test The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2 3 METS Medical Specialty Cardiovascular Pulmonary Sample Name Cardiolite Treadmill Stress Test Transcription CARDIOLITE TREADMILL EXERCISE STRESS TEST CLINICAL DATA This is a 72 year old female with history of diabetes mellitus hypertension and right bundle branch block PROCEDURE The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2 3 METS There was a normal blood pressure response The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest no other significant electrographic abnormalities were observed Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc 99 Cardiolite At peak pharmacological effect the patient was injected with 30 mCi Tc 99 Cardiolite Gating poststress tomographic imaging was performed 30 minutes after the stress FINDINGS 1 The overall quality of the study is fair 2 The left ventricular cavity appears to be normal on the rest and stress studies 3 SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and or reperfusion defect 4 The left ventricular ejection fraction was normal and estimated to be 78 IMPRESSION Myocardial perfusion imaging is normal Result of this test suggests low probability for significant coronary artery disease Keywords cardiovascular pulmonary peak heart rate bundle branch block perfusion imaging stress test mci ventricular cardiolite treadmill MEDICAL_TRANSCRIPTION,Description Left heart cardiac catheterization Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 8 Transcription PROCEDURE PERFORMED 1 Right femoral artery access 2 Selective right and left coronary angiogram 3 Left heart catheterization 4 Left ventriculogram INDICATIONS FOR PROCEDURE A 50 year old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20 to 25 This was a sharp decline from a previous LVEF of 50 to 55 We therefore decided to proceed with coronary angiography TECHNIQUE After obtaining informed consent the patient was brought to the cardiac catheterization suite in post absorptive and non sedated state The right groin was prepped and draped in the usual sterile manner 2 Lidocaine was used for infiltration anesthesia Using modified Seldinger technique a 6 French sheath was introduced into the right femoral artery 6 French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram A 6 French pigtail catheter was used to perform the LV gram in the RAO projection HEMODYNAMIC DATA LVEDP of 11 There was no gradient across the aortic valve upon pullback ANGIOGRAPHIC FINDINGS 1 The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery 2 The left main coronary artery is free of any disease 3 The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease 4 The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches One of its secondary branches which is a small caliber has an ostial 70 stenosis 5 The left anterior descending artery has a patent stent in the proximal LAD The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss There appears to be 30 narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery The diagonal branches are free of any disease 6 The right coronary artery is a dominant vessel and has mild luminal irregularities Its midsegment has a focal area of 30 narrowing as well The rest of the right coronary artery is free of any disease 7 The LV gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55 RECOMMENDATION Continue with optimum medical therapy Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment I have discussed this matter with Dr XYZ and we have decided to proceed with a repeat 2D echocardiogram The mild disease in the distal left anterior descending artery with mild in stent re stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia Keywords cardiovascular pulmonary heart catheterization ventriculogram femoral artery access coronary angiogram lvef distal left anterior descending circumflex coronary artery anterior descending artery femoral artery systolic function cardiac catheterization circumflex coronary anterior descending coronary artery coronary artery catheterization descending MEDICAL_TRANSCRIPTION,Description Percutaneous intervention with drug eluting stent placement to the ostium of the PDA Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 4 Transcription PROCEDURES PERFORMED 1 Left heart catheterization with coronary angiography and left ventricular pressure measurement 2 Left ventricular angiography was not performed 3 Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting 4 Right femoral artery angiography 5 Perclose to seal the right femoral arteriotomy INDICATIONS FOR PROCEDURE Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non ST elevation myocardial infarction He was subsequently dispositioned to the cardiac catheterization lab for further evaluation DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the cardiac catheterization lab where his procedure was performed The patient was appropriately prepped and prepared on the table after which his right groin was locally anesthetized with 1 lidocaine Then a 6 French sheath was inserted into the right femoral artery Over a standard 0 035 guidewire coronary angiography and left ventricular pressure measurements were performed using a 6 French JL4 diagnostic catheter to image the left coronary artery a 6 French JR4 diagnostic catheter to image the right coronary artery a 6 French angled pigtail catheter to measure left ventricular pressure At the conclusion of the diagnostic study the case was progressed to percutaneous coronary intervention which will be described below Subsequently right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque and an arteriotomy that was suitable for a closure device Then a Perclose was used to seal the right femoral arteriotomy HEMODYNAMIC DATA The opening aortic pressure was 91 63 The left ventricular pressure was 94 13 with an end diastolic pressure of 24 Left ventricular ejection fraction was not assessed as ventriculogram was not performed The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible CORONARY ANGIOGRAM The left main coronary artery was angiographically okay The LAD had mild diffuse disease There appeared to be distal tapering of the LAD The left circumflex had mild diffuse disease In the very distal aspect of the circumflex after OM 3 and OM 4 type branch there was a long severely diseased segment that appeared to be chronic and subtotal in one area The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory and there was not much to salvage by approaching this lesion The right coronary artery had mild diffuse disease The PLV branch was 100 occluded at its ostium at the crux The PDA at the ostium had an 80 stenosis The PDA was a fairly sizeable vessel with a long course The right coronary is dominant CONCLUSION Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion This circumflex appears to be chronically diseased and has areas that appear to be subtotal There is a 100 PLV branch which is also chronic and reported in his angiogram in the 1990s There is an ostial 80 right PDA lesion The plan is to proceed with percutaneous intervention to the right PDA The case was then progressed to percutaneous intervention of the right PDA A 6 French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium The lesion was crossed with a long BMW 0 014 guidewire Then we ballooned the lesion with a 2 5 x 9 mm Maverick balloon Subsequently we stented the lesion with a 2 5 x 16 mm Taxus drug eluting stent with a nice angiographic result The patient tolerated the procedure very well without complications ANGIOPLASTY CONCLUSION Successful percutaneous intervention with drug eluting stent placement to the ostium of the PDA RECOMMENDATIONS Aspirin indefinitely and Plavix 75 mg p o daily for no less than six months The patient will be dispositioned back to telemetry for further monitoring TOTAL MEDICATIONS DURING PROCEDURE Versed 1 mg and fentanyl 25 mcg for conscious sedation Heparin 8400 units IV was given for anticoagulation Ancef 1 g IV was given for closure device prophylaxis CONTRAST ADMINISTERED 200 mL FLUOROSCOPY TIME 12 4 minutes Keywords cardiovascular pulmonary coronary angiography ventricular pressure coronary angioplasty french pda drug eluting stent coronary artery disease cardiac catheterization lab plv branch cardiac catheterization femoral artery coronary artery artery coronary angioplasty angiogram angiographically arteriotomy angiography cardiac circumflex ostium ventricular femoral percutaneous catheterization MEDICAL_TRANSCRIPTION,Description Left heart catheterization with coronary angiography vein graft angiography and left ventricular pressure measurement and angiography Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 5 Transcription PROCEDURE PERFORMED 1 Left heart catheterization with coronary angiography vein graft angiography and left ventricular pressure measurement and angiography 2 Right femoral selective angiogram 3 Closure device the seal the femoral arteriotomy using an Angio Seal INDICATIONS FOR PROCEDURE The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease who had her last coronary arteriogram performed in 2004 She has had complaints of progressive chest discomfort and has ongoing risks including current smoking diabetes hypertension hyperlipidemia to name a few The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression DESCRIPTION OF PROCEDURE After informed consent was obtained The patient was taken to cardiac catheterization lab where her procedure was performed She was prepped and prepared on the table after which her right groin was locally anesthetized with 1 lidocaine Then a 6 French sheath was inserted into the right femoral artery over a standard 0 035 guide wire Coronary angiography and left ventricular measurement and angiography were performed using a 6 French JL4 diagnostic catheter to image the left coronary artery A 6 French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit Subsequently a 6 French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection a left ventriculogram at 8 mL per second for a total of 30 mL At the conclusion of the diagnostic evaluation the patient had selective arteriography of her right femoral artery which showed the right femoral artery to be free of significant atherosclerotic plaque Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation As such an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery As such the Perclose was never deployed and was removed intact over the wire from the system We then replaced this with a 6 French Angio Seal which was used to seal the femoral arteriotomy with achievement of hemostasis The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home HEMODYNAMIC DATA Opening aortic pressure 125 60 left ventricular pressure 108 4 with an end diastolic pressure of 16 There was no significant gradient across the aortic valve on pullback from the left ventricle Left ventricular ejection fraction was 55 Mitral regurgitation was less than or equal to 1 There was normal wall motion in the RAO projection CORONARY ANGIOGRAM The left main coronary artery had mild atherosclerotic plaque The proximal LAD was 100 occluded The left circumflex had mild diffuse atherosclerotic plaque The obtuse marginal branch which operates as an OM 2 had a mid approximately 80 stenosis at a kink in the artery This appears to be the area of a prior anastomosis the saphenous vein graft to the OM This is a very small caliber vessel and is 1 5 mm in diameter at best The right coronary artery is dominant The native right coronary artery had mild proximal and mid atherosclerotic plaque The distal right coronary artery has an approximate 40 stenosis The posterior left ventricular branch has a proximal 50 to 60 stenosis The proximal PDA has a 40 to 50 stenosis The saphenous vein graft to the right PDA is widely patent There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above There is also some retrograde filling of the right coronary artery from the runoff of this graft The saphenous vein graft to the left anterior descending is widely patent The LAD beyond the distal anastomosis is a relatively small caliber vessel There is some retrograde filling that allows some filling into a more proximal diagonal branch The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004 Overall this study does not look markedly different than the procedure performed in 2004 CONCLUSION 100 proximal LAD mild left circumflex disease with an OM that is a small caliber vessel with an 80 lesion at a kink that is no amenable to percutaneous intervention The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease The saphenous vein graft to the OM is known to be 100 occluded The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open Normal left ventricular systolic function PLAN The plan will be for continued medical therapy and risk factor modification Aggressive antihyperlipidemic and antihypertensive control The patient s goal LDL will be at or below 70 with triglyceride level at or below 150 and it is very imperative that the patient stop smoking After her bedrest is complete she will be dispositioned to home after which she will be following up with me in the office within 1 month We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits Keywords cardiovascular pulmonary catheterization vein graft angiography angiogram angio seal closure device coronary atherosclerotic heart disease saphenous vein graft ventricular pressure coronary artery saphenous vein atherosclerotic coronary artery bifurcation pda ventricular saphenous MEDICAL_TRANSCRIPTION,Description Cardiac catheterization Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 12 Transcription PREOPERATIVE DIAGNOSIS Coronary artery disease POSTOPERATIVE DIAGNOSIS Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis DESCRIPTION OF PROCEDURE LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY Under local anesthesia with 2 lidocaine with premedication a right groin preparation was done Using the percutaneous Seldinger technique via the right femoral artery a left heart catheterization was performed Coronary arteriography was performed with 6 French performed coronary catheters We used a 6 French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries After using the JR4 6 French catheter nitroglycerin was administered because of the possibility of ostial spasm and following that we used a 5 French JR4 catheter for additional cineangiograms of the right coronary artery A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm as there was dense calcification in the mid abdominal aorta ANALYSIS OF PRESSURE DATA Left ventricular end diastolic pressure was 5 mmHg On continuous tracing from the left ventricle to the ascending aorta there is no gradient across the aortic valve The aortic pressures were normal Contours of intracardiac pressure were normal ANALYSIS OF ANGIOGRAMS Selective cineangiograms were obtained with injection of contrast to the left ventricle coronary arteries and mid abdominal aorta A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position The mitral valve is competent and demonstrates normal mobility The left ventricular cavity is normal in size with excellent contractility Aneurysmal dilatation and or dyskinesia absent The aortic valve is tricuspid and normal mobility The ascending aorta appeared normal Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries An abdominal aortic injection was performed Under fluoroscopy we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis The abdominal aortogram reveals wide patency of that area with mild intimal irregularity There is a normal left renal artery normal right renal artery The celiac seems to be normal but what I believe is the splenic artery seen initially at its origin is normal The common left iliac and common right iliac arteries are essentially normal in this area CORONARY ANATOMY One notes ostial coronary calcification of the right coronary artery Cineangiogram obtained with 6 French JR4 and 5 French JR4 catheters Prior to the introduction of the 5 French JR4 nitroglycerin was administered sublingually The 6 French JR4 catheters appeared to a show an ostial lesion of over 50 There was backwash of dye into the aorta although there is a fine funneling of the ostium towards the proximal right coronary artery In the proximal portion of the right coronary artery just into the Shepherd turn there is a 50 smooth tapering of the right coronary artery in the proximal third Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel The distal portion of the vessel is free of disease The conus branch is seen arising right at the beginning part of the right coronary artery We then removed the 6 French catheter and following nitroglycerin and sublingually we placed a 5 French catheter and again finding a stenosis may be less than 50 At the ostium of the right coronary artery calcification again is identified Backwash of dye noted at the proximal lesion looked about the same 50 along the proximal turn of the Shepherd turn area The left coronary artery is normal although there is a rim of ostial calcification but there is no tapering or stenosis It forms the left anterior descending artery the ramus branch and the circumflex artery The left anterior descending artery is a very large vessel very tortuous in its proximal segment very tortuous in its mid and distal segment There appears to be some mild stenosis of 10 in the proximal segment It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease The remaining portion of the left anterior descending artery is free of disease Upon injection of the left coronary artery we see what I believe is the dye enters probably directly into the left ventricle but via fistula excluding the coronary sinus and we get a ventriculogram performed I could not identify an isolated area but it seems to be from the interventricular septal collaterals that this is taking place The ramus branch is normal and free of disease The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease The patient has a predominantly right coronary system There is no _______ circulation connecting the right and left coronary systems The patient tolerated the procedure well The catheter was removed Hemostasis was achieved The patient was transferred to the recovery room in a stable condition IMPRESSION 1 Excellent left ventricular contractility with normal left ventricular cavity size 2 Calcification of the mid abdominal aorta with wide patency of all vessels The left and right renal arteries are normal The external iliac arteries are normal 3 Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula 4 Ostial stenosis of the right coronary artery that appears to be about 50 or greater The proximal right coronary artery has 50 stenosis as well 5 Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries RECOMMENDATIONS The patient has heavy calcification of the coronary arteries and continued risk factor management is needed The ostial lesion of the right coronary artery may be severe It is at least 50 but it could be worse Therefore she will be evaluated for the possibility of an IVUS and or _______ analysis of the proximal right coronary artery We will reevaluate her stress nuclear study as well Continue aggressive medical therapy Keywords cardiovascular pulmonary intimal calcification stenosis coronary artery disease mid abdominal aorta coronary artery cardiac catheterization coronary arteries descending artery calcification mid proximal aorta catheterization abdominal cardiac intimal coronary artery MEDICAL_TRANSCRIPTION,Description Left Heart Catheterization Chest pain coronary artery disease prior bypass surgery Left coronary artery disease native Patent vein graft with obtuse marginal vessel and also LIMA to LAD Native right coronary artery is patent mild disease Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 10 Transcription EXAM Left Heart Catheterization REASON FOR EXAM Chest pain coronary artery disease prior bypass surgery INTERPRETATION The procedure and complications were explained to the patient in detail and formal consent was obtained The patient was brought to the cath lab The right groin was draped in the usual sterile manner Using modified Seldinger technique a 6 French arterial sheath was introduced in the right common femoral artery A JL4 catheter was used to cannulate the left coronary arteries A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts The same catheter was used to cannulate the vein graft and also LIMA I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful A 6 French pigtail catheter was used to perform left ventriculography and pullback was done No gradient was noted Arterial sheath was removed Hemostasis was obtained with manual compression The patient tolerated the procedure very well without any complications FINDINGS 1 Native coronary arteries The left main is patent The left anterior descending artery is not clearly visualized The circumflex artery appears to be patent The proximal segment gives rise to small caliber obtuse marginal vessel 2 Right coronary artery is patent with mild distal and mid segment No evidence of focal stenosis or dominant system 3 Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site There appears to be possible _______ graft to the diagonal 1 vessel The distal LAD wraps around the apex No stenosis following the anastomotic site noted 4 Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel 5 No other bypass grafts are noted by left ventriculography and also aortic root shot 6 Left ventriculography with an ejection fraction of 60 IMPRESSION 1 Left coronary artery disease native 2 Patent vein graft with obtuse marginal vessel and also LIMA to LAD _______ graft to the diagonal 1 vessel 3 Native right coronary artery is patent mild disease RECOMMENDATIONS Medical treatment Keywords cardiovascular pulmonary chest pain coronary artery disease bypass surgery heart catheterization lima lad obtuse marginal vessel vein graft obtuse marginal marginal vessel coronary artery catheterization coronary artery obtuse marginal bypass vessel graft MEDICAL_TRANSCRIPTION,Description Left heart catheterization LV cineangiography selective coronary angiography and right heart catheterization with cardiac output by thermodilution technique with dual transducer Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization Transcription EXAMINATION Cardiac catheterization PROCEDURE PERFORMED Left heart catheterization LV cineangiography selective coronary angiography and right heart catheterization with cardiac output by thermodilution technique with dual transducer INDICATION Syncope with severe aortic stenosis COMPLICATIONS None DESCRIPTION OF PROCEDURE After informed consent was obtained from the patient the patient was brought to the cardiac catheterization laboratory in a post observed state The right groin was prepped and draped in the usual sterile fashion After adequate conscious sedation and local anesthesia was obtained a 6 French sheath was placed in the right common femoral artery and a 8 French sheath was placed in the right common femoral vein Following this a 7 5 French Swan Ganz catheter was advanced into the right atrium where the right atrial pressure was 10 7 mmHg The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37 10 4 mmHg The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg The pulmonary arterial pressures were noted to be 31 14 21 mmHg Following this the catheter was removed the sheath was flushed and a 6 French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views Following this the catheter was exchanged over the guidewire for 6 French JR4 diagnostic catheter We were unable to cannulate the right coronary artery Therefore we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views Following this this catheter was exchanged over a guidewire for a 6 French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed Following this the catheters were removed Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6 French Angio Seal device The patient tolerated the procedure well There were no complications DESCRIPTION OF FINDINGS The left main coronary artery is a large vessel which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions The left circumflex artery is a short vessel which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches There is a 70 ostial lesion in the first diagonal branch and the second diagonal branch has mild to moderate luminal irregularities The right coronary artery is a very large dominant vessel with a 60 to 70 lesion in its descending mid portion The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions The left ventricle appears to be normal sized The aortic valve is heavily calcified The estimated ejection fraction is approximately 60 There was 4 mitral regurgitation noted The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0 89 cm2 CONCLUSION 1 Moderate to severe coronary artery disease with a high grade lesion seen at the ostium of the first diagonal artery as well as a 60 to 70 lesion seen at the mid portion of the right coronary artery 2 Moderate to severe aortic stenosis with an aortic valve area of 0 89 cm2 3 4 mitral regurgitation PLAN The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair replacement and possible surgical revascularization Keywords cardiovascular pulmonary heart catheterization cineangiography selective coronary angiography thermodilution technique transducer diffuse luminal irregularities cardiac catheterization luminal irregularities aortic valve coronary artery artery catheterization regurgitation angiography thermodilution coronary MEDICAL_TRANSCRIPTION,Description Left cardiac catheterization with selective right and left coronary angiography Post infarct angina Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Cath Selective Coronary Angiography Transcription PREOPERATIVE DIAGNOSIS Post infarct angina TYPE OF PROCEDURE Left cardiac catheterization with selective right and left coronary angiography PROCEDURE After informed consent was obtained the patient was brought to the Cardiac Catheterization Laboratory and the groin was prepped in the usual fashion Using 1 lidocaine the right groin was infiltrated and using the Seldinger technique the right femoral artery was cannulated Through this a moveable guidewire was then advance to the level of the diaphragm and through it a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained Catheter was then withdrawn and a 6 French non bleed back sidearm sheath was then introduced and through this a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium engaged Cineangiograms were obtained of the left coronary system This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium engaged Cineangiograms were obtained and the catheter and sheath were then withdrawn The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition No evidence of hematoma formation or active bleeding COMPLICATIONS None TOTAL CONTRAST 110 cc of Hexabrix TOTAL FLUOROSCOPY TIME 1 8 minutes MEDICATIONS Reglan 10 mg p o 5 mg p o Valium Benadryl 50 mg p o and heparin 3 000 units IV push Keywords cardiovascular pulmonary selective angiography post infarct angina engaged cineangiograms coronary angiography hemodynamic monitoring cardiac catheterization catheterization cineangiograms cardiac coronary MEDICAL_TRANSCRIPTION,Description Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass open sternotomy covered with Ioban insertion of Mahurkar catheter for hemofiltration via the left common femoral vein Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Allograft Transplant Transcription PREOPERATIVE DIAGNOSES 1 Ischemic cardiomyopathy 2 Status post redo coronary artery bypass 3 Status post insertion of intraaortic balloon POSTOPERATIVE DIAGNOSES 1 Ischemic cardiomyopathy 2 Status post redo coronary artery bypass 3 Status post insertion of intraaortic balloon 4 Postoperative coagulopathy OPERATIVE PROCEDURE 1 Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass 2 Open sternotomy covered with Ioban 3 Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein ANESTHESIA General endotracheal OPERATIVE PROCEDURE With the patient in the supine position he was prepped from shin to knees and draped in a sterile field A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm freeing up the right atrium and the ascending aorta and anterior right ventricle The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3 mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava After satisfactory heparinization has been obtained the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium After the heart was brought to the operating room and triggered the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place A cardiectomy was then performed by starting in the right atrium The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan Ganz catheter was brought out into the operative field Cardiectomy was then performed first resecting the anterior portion of the right atrium and then transecting the aorta the pulmonary artery the septum between the right and left atriums and then the heart was removed The right and left atrium aorta and pulmonary artery were prepared for the transplant First we did a side to side anastomosis continued to the left atrium and this was performed using 3 0 Prolene suture and a right atrial anastomosis side to side was performed using 3 0 Prolene suture The pulmonary artery was then anastomosed using 5 0 Prolene and the aorta was anastomosed with 4 0 Prolene The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood Air was evacuated and the sutures were tied down The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass Blood factors and factor VII were given to try and correct the coagulopathy Because of excessive transfusions that were required a Mahurkar catheter was inserted through the left common femoral vein first placing a needle into the vein and then guidewire removed and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2 0 nylon suture Hemofiltration was started in the operating room at this time After he had satisfactory hemostasis we decided to do the chest open and cover it with Ioban which we did and one chest tube was inserted into the mediastinum through a separate stab wound The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively This was left in place and the pulse generation the pacemaker was in a right infraclavicular position which was left in place because of the coagulopathy The patient received 11 units of packed red blood cells 7 platelets 23 fresh frozen plasma 20 cryoprecipitates and factor VII Urine output for the procedure was 520 mL The preservation time of the heart is in the anesthesia sheet The estimated blood loss was at least 6 L The patient was taken to the intensive care unit in guarded condition Keywords cardiovascular pulmonary cardiomyopathy ioban ischemic ischemic cardiomyopathy mahurkar catheter orthostatic seldinger swan ganz allograft aorta balloon cardiac cardiopulmonary bypass catheter coagulopathy coronary artery bypass femoral vein hemofiltration intraaortic intraaortic balloon sternotomy transplantation ventricle inferior vena cava cardiac allograft common femoral vena cava pulmonary artery atrium insertion cardiopulmonary artery MEDICAL_TRANSCRIPTION,Description Cardiac Catheterization An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease presents with an acute myocardial infarction with elevated enzymes Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 1 Transcription INDICATIONS FOR PROCEDURE A 51 year old obese white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes The chest pain occurred early Tuesday morning She was treated with Plavix Lovenox etc and transferred for coronary angiography and possible PCI The plan was discussed with the patient and all questions answered PROCEDURE NOTE Following sterile prep and drape the right groin and instillation of 1 Xylocaine anesthesia the right femoral artery was percutaneously entered with a single wall puncture A 6 French sheath inserted Selective left and right coronary injections performed using Judkins coronary catheters with a 6 French pigtail catheter used to obtain left ventricle pressures and a left ventriculography The left pullback pressure The catheters withdrawn Sheath injection Hemostasis obtained with a 6 French Angio Seal device She tolerated the procedure well Left ventricular end diastolic pressure equals 25 mmHg post A wave No aortic valve or systolic gradient on pullback ANGIOGRAPHIC FINDINGS I Left coronary artery The left main coronary artery is normal The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel Normal diagonal branches Normal septal perforator branches The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches II Right coronary artery The proximal right coronary artery has a focal calcification There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20 at most The right coronary artery is a dominant system which gives off normal posterior descending and posterior lateral branches TIMI 3 flow is present III Left ventriculogram The left ventricle is slightly enlarged with normal contraction of the base but with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion Ejection fraction estimated 40 1 mitral regurgitation echocardiogram ordered DISCUSSION Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end diastolic pressure post A wave but only minor residual coronary artery plaque with calcification proximal right coronary artery PLAN Medical treatment is contemplated including ACE inhibitor a beta blocker aspirin Plavix nitrates An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction Keywords cardiovascular pulmonary cardiac catheterization hodgkin disease beta blocker coronary angiography coronary artery coronary disease elevated enzymes inferoapical myocardial infarction ventriculogram ventriculography acute myocardial infarction proximal right coronary diastolic pressure ejection fraction coronary echocardiogram cardiac catheterization myocardial enzymes infarction artery MEDICAL_TRANSCRIPTION,Description The patient with atypical type right arm discomfort and neck discomfort Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 2 Transcription INDICATIONS FOR PROCEDURE The patient has presented with atypical type right arm discomfort and neck discomfort She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis Of note there was bidirectional flow in the right vertebral artery as well as 250 cm per second velocities in the right subclavian Duplex ultrasound showed at least a 50 stenosis APPROACH Right common femoral artery ANESTHESIA IV sedation with cardiac catheterization protocol Local infiltration with 1 Xylocaine COMPLICATIONS None ESTIMATED BLOOD LOSS Less than 10 ml ESTIMATED CONTRAST Less than 250 ml PROCEDURE PERFORMED Right brachiocephalic angiography right subclavian angiography selective catheterization of the right subclavian selective aortic arch angiogram right iliofemoral angiogram 6 French Angio Seal placement DESCRIPTION OF PROCEDURE The patient was brought to the cardiac catheterization lab in the usual fasting state She was laid supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion 1 Xylocaine was infiltrated into the right femoral vessels Next a 6 French sheath was introduced into the right femoral artery via the modified Seldinger technique AORTIC ARCH ANGIOGRAM Next a pigtail catheter was advanced to the aortic arch Aortic arch angiogram was then performed with injection of 45 ml of contrast rate of 20 ml per second maximum pressure 750 PSI in the 4 degree LAO view SELECTIVE SUBCLAVIAN ANGIOGRAPHY Next the right subclavian was selectively cannulated It was injected in the standard AP as well as the RAO view Next pull back pressures were measured across the right subclavian stenosis No significant gradient was measured ANGIOGRAPHIC DETAILS The right brachiocephalic artery was patent The proximal portion of the right carotid was patent The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50 stenosis IMPRESSION 1 Moderate grade stenosis in the right subclavian artery 2 Patent proximal edge of the right carotid Keywords cardiovascular pulmonary discomfort subclavian stenosis artery french angio seal lao view rao view aortic arch angiogram arch angiogram cardiac catheterization aortic arch brachiocephalic cardiac angiography aortic angiogram stenosis catheterization atypical subclavian MEDICAL_TRANSCRIPTION,Description White male with onset of chest pain with history of on and off chest discomfort over the past several days Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 3 Transcription INDICATIONS FOR PROCEDURE This is a 61 year old white male with onset of chest pain at 04 30 this morning with history of on and off chest discomfort over the past several days CPK is already over 1000 There is ST elevation in leads II and aVF as well as a Q wave The chest pain is now gone mild residual shortness of breath no orthopnea Cardiac monitor shows resolution of ST elevation lead III DESCRIPTION OF PROCEDURE Following sterile prep and drape of the right groin installation of 1 Xylocaine anesthesia the right common femoral artery was percutaneously entered and 6 French sheath inserted ACT approximately 165 seconds on heparin Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed Selective left and right coronary injections performed using Judkins coronary catheters with a 6 French pigtail catheter used to obtain left ventricular pressures and left ventriculography Left pullback pressure Sheath injection Hemostasis obtained with a 6 French Angio Seal device He tolerated the procedure well and was transported to the Cardiac Step Down Unit in stable condition HEMODYNAMIC DATA Left ventricular end diastolic pressure elevated post A wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback ANGIOGRAPHIC FINDINGS I Left coronary artery The left main coronary artery is unremarkable The left anterior descending has 30 to 40 narrowing with tortuosity in its proximal portion patent first septal perforator branch The first diagonal branch is a 2 mm vessel with a 90 ostial stenosis The second diagonal branch is unremarkable as are the tiny distal diagonal branches The intermediate branch is a small normal vessel The ostial non dominant circumflex has some contrast thinning but no stenosis normal obtuse marginal branch and small AV sulcus circumflex branch II Right coronary artery The right coronary artery is a large dominant vessel which gives off large posterior descending and posterolateral left ventricular branches There are luminal irregularities less than 25 within the proximal to mid vessel Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches A 25 smooth narrowing at the origin of the posterior descending branch Posterolateral branch is unremarkable and quite large with secondary and tertiary branches III Left ventriculogram The left ventricle is normal in size Ejection fraction estimated at 40 to 45 No mitral regurgitation Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion DISCUSSION Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation Left coronary system has one hemodynamically significant stenosis a 90 ostial stenosis at the first diagonal branch which is a 2 mm vessel Left ventricular function is reduced with ejection fraction 40 to 45 with inferior wall motion abnormality PLAN Medical treatment including Plavix and nitrates in addition to beta blocker aspirin and aggressive lipid reduction Keywords cardiovascular pulmonary cpk q wave st elevation french angio seal pigtail catheter st segment ejection fraction wall motion diagonal branch posterior descending coronary artery catheterization circumflex rca cardiac st elevation ventricular stenosis artery coronary branch MEDICAL_TRANSCRIPTION,Description Redo coronary bypass grafting x3 right and left internal mammary left anterior descending reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection Placement of a right femoral intraaortic balloon pump Medical Specialty Cardiovascular Pulmonary Sample Name CABG Redo Transcription OPERATIVE PROCEDURE 1 Redo coronary bypass grafting x3 right and left internal mammary left anterior descending reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection 2 Placement of a right femoral intraaortic balloon pump DESCRIPTION The patient was brought to the operating room and placed in the supine position After adequate endotracheal anesthesia was induced appropriate monitoring lines were placed Chest abdomen an legs were prepped and draped in sterile fashion The femoral artery on the right was punctured and a guidewire was placed The track was dilated and intraaortic balloon pump was placed in the appropriate position sewn in place and ballooning started The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4 0 silk and flushed with vein solution The leg was closed with running 3 0 Dexon subcu and running 4 0 Dexon on the skin The old mediastinal incision was opened The wires were cut and removed The sternum was divided in the midline Retrosternal attachments were taken down The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine soaked gauze The heart was dissected free of its adhesions The patient was fully heparinized and cannulated with a single aorta and single venous cannula Retrograde cardioplegia cannula was attempted to be placed but could not be fitted into the coronary sinus safely therefore it was banded and oversewn with 5 0 Prolene An antegrade cardioplegia needle sump was placed and secured to the ascending aorta Cardiopulmonary bypass ensued The ascending aorta was cross clamped Cold blood potassium cardioplegia was given antegrade a total of 10 cc kg It was followed by sumping the ascending aorta The obtuse marginal was identified and opened and an end to side anastomosis was performed with a running 7 0 Prolene suture The vein was cut to length Antegrade cardioplegia was given a total of 200 cc The posterior descending branch of the right coronary artery was identified opened and end to side anastomosis then performed with a running 7 0 Prolene suture The vein was cut to length Antegrade cardioplegia was given The mammary was clipped distally divided and spatulated for anastomosis The anterior descending was identified opened and end to side anastomosis then performed with running 8 0 Prolene suture and warm blood potassium cardioplegia was given The cross clamp was removed A partial occlusion clamp was placed Aortotomies were made The vein was cut to fit these and sutured in place with running 5 0 Prolene suture The partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Atrial and ventricular pacing wires were placed The patient was fully warmed and ventilation was commenced The patient was weaned from cardiopulmonary bypass ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass The patient was decannulated in routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire The linea alba was closed with figure of eight of 1 Vicryl the sternal fascia closed with running 1 Vicryl the subcu closed with running 2 0 Dexon skin with running 4 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords cardiovascular pulmonary coronary bypass grafting internal mammary cardiopulmonary intraaortic femoral artery cabg running prolene suture intraaortic balloon balloon pump ascending aorta prolene suture cardiopulmonary bypass potassium aorta anastomosis prolene coronary cardioplegia bypass MEDICAL_TRANSCRIPTION,Description He is a 67 year old man who suffers from chronic anxiety and coronary artery disease and DJD He has been having some chest pains but overall he does not sound too concerning He does note some more shortness of breath than usual He has had no palpitations or lightheadedness No problems with edema Medical Specialty Cardiovascular Pulmonary Sample Name CAD 6 Month Followup Transcription REASON FOR VISIT Six month follow up visit for CAD He is a 67 year old man who suffers from chronic anxiety and coronary artery disease and DJD He has been having a lot of pain in his back and pain in his left knee He is also having trouble getting his nerves under control He is having stomach pains and occasional nausea His teeth are bad and need to be pulled He has been having some chest pains but overall he does not sound too concerning He does note some more shortness of breath than usual He has had no palpitations or lightheadedness No problems with edema MEDICATIONS Lipitor 40 mg q d metoprolol 25 mg b i d Plavix 75 mg q d discontinued enalapril 10 mg b i d aspirin 325 mg reduced to 81 mg Lorcet 10 650 given a 60 pill prescription and Xanax 0 5 mg b i d given a 60 pill prescription REVIEW OF SYSTEMS Otherwise unremarkable PEX BP 140 78 HR 65 WT 260 pounds which is up one pound There is no JVD No carotid bruit Cardiac Regular rate and rhythm and distant heart sounds with a 1 6 murmur at the upper sternal border Lungs Clear Abdomen Mildly tender throughout the epigastrium Extremities No edema EKG Sinus rhythm left axis deviation otherwise unremarkable Echocardiogram for dyspnea and CAD Normal systolic and diastolic function Moderate LVH Possible gallstones seen IMPRESSION 1 CAD Status post anterior wall MI 07 07 and was found to a have multivessel CAD He has a stent in his LAD and his obtuse marginal Fairly stable 2 Dyspnea Seems to be due to his weight and the disability from his knee His echocardiogram shows no systolic or diastolic function 3 Knee pain We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills 4 Dyslipidemia Excellent numbers today with cholesterol of 115 HDL 45 triglycerides 187 and LDL 33 samples of Lipitor given 5 Panic attacks and anxiety Xanax 0 5 mg b i d 60 pills with no refills given 6 Abdominal pain Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q d 7 Prevention I do not think he needs to be on the Plavix any more as he has been relatively stable for two years PLAN 1 Discontinue Plavix 2 Aspirin reduced to 81 mg a day 3 Lorcet and Xanax prescriptions given 4 Refer over to Scotland Orthopedics 5 Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted Keywords MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting CABG x4 Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function Medical Specialty Cardiovascular Pulmonary Sample Name CABG x4 Transcription PREOPERATIVE DIAGNOSES Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function POSTOPERATIVE DIAGNOSES Progressive exertional angina three vessel coronary artery disease left main disease preserved left ventricular function OPERATIVE PROCEDURE Coronary artery bypass grafting CABG x4 GRAFTS PERFORMED LIMA to LAD left radial artery from the aorta to the PDA left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal INDICATIONS FOR PROCEDURE The patient is a 74 year old gentleman who presented with six month history of progressively worsening exertional angina He had a positive stress test and cardiac cath showed severe triple vessel coronary artery disease including left main disease with preserved LV function He was advised surgical revascularization of his coronaries FINDINGS DURING THE PROCEDURE The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp Left internal mammary artery and saphenous vein grafts were good quality conduits Radial artery graft was a smaller sized conduit otherwise good quality All distal targets showed heavy plaque involvement with calcification present The smallest target was the PDA which was about 1 5 mm in size All the other targets were about 2 mm in size or greater The patient came off cardiopulmonary bypass without any problems He was transferred on Neo Synephrine nitroglycerin Precedex drips Cross clamp time was 102 minutes bypass time was 120 minutes DETAILS OF THE PROCEDURE The patient was brought into the operating room and laid supine on the table After he had been interfaced with the appropriate monitors general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple lumen catheter and Cordis catheter right radial A line Foley catheter TEE probes were placed and interfaced appropriately The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion proper time out was conducted and site identification was performed and subsequently incision was made overlying the sternum and median sternotomy was performed Left internal mammary artery was taken down Simultaneously left forearm radial artery was harvested using endoscopic harvesting techniques Simultaneously endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques Subsequent to harvest the incisions were closed in layers during the course of the procedure Heparin was given Pericardium was opened and suspended During the takedown of the left internal mammary artery it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery Pericardium was opened and suspended Pursestring sutures were placed Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass With satisfactory flow the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart PDA was exposed first The right coronary artery was calcified along its course all the way to its terminal bifurcation Even in the PDA calcification was noted in a spotty fashion Arteriotomy on the PDA was performed in a soft area and 1 5 probe was noted to be accommodated in both directions End radial to side PDA anastomosis was constructed using running 7 0 Prolene Next the posterolateral obtuse marginal was exposed Arteriotomy was performed An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7 0 Prolene This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side to side anastomosis was constructed using running 7 0 Prolene Next a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD LAD was exposed Arteriotomy was performed An end LIMA to side LAD anastomosis was constructed using running 7 0 Prolene LIMA was tacked down to the epicardium securely utilizing its fascial pedicle Two stab incisions were made in the ascending aorta and enlarged using 4 mm punch Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta and the proximal end of the radial artery graft and the side of the aorta separately using running 6 0 Prolene The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de airing maneuvers were performed Following this the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity Temporary V pacing wires were placed Blake drains were placed in the left chest the right chest as well as in the mediastinum Left chest Blake drain was placed just in the medial section where dissection had been performed After an adequate period of rewarming during which time temporary V pacing wires were also placed the patient was successfully weaned off cardiopulmonary bypass without any problems With satisfactory hemodynamics good LV function on TEE and baseline EKG heparin was reversed using protamine Decannulation was performed after volume resuscitation Hemostasis was assured Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves heavy Vicryl for musculofascial closure and Monocryl for subcuticular skin closure Dressings were applied The patient was transferred to the ICU in stable condition He tolerated the procedure well All counts were correct at the termination of the procedure Cross clamp time was 102 minutes Bypass time was 120 minutes The patient was transferred on Neo Synephrine nitroglycerin and Precedex drips Keywords cardiovascular pulmonary radial artery lima pda obtuse marginal exertional angina coronary artery disease triple vessel graft conduit ij triple lumen catheter cordis catheter a line foley catheter tee probes coronary artery bypass grafting cross clamp mammary artery saphenous vein coronary artery artery cabg coronary grafting aorta angina bypass MEDICAL_TRANSCRIPTION,Description Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only He has been referred for cardiac catheterization Medical Specialty Cardiovascular Pulmonary Sample Name Cardiac Catheterization 11 Transcription The patient and his wife had the opportunity to ask questions all of which were answered for them and the patient stated in a clear competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate PROCEDURE NOTE The patient was brought to the Cardiac Catheterization Lab in a fasting state All appropriate labs had been reviewed Bilateral groins were prepped and draped in the usual fashion for sterile conditions The appropriate time out procedure was performed with appropriate identification of the patient procedure physician position and documentation all done under my direct supervision and there were no safety issues raised by the staff He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect Bilateral groins had been prepped and draped in the usual fashion Right femoral inguinal fossa was anesthetized with 1 topical lidocaine and a 6 French vascular sheath was put into place percutaneously via guide wire exchanger with a finder needle All catheters were passed using a J tipped guide wire Left heart catheterization and left ventriculography performed using a 6 French pigtail catheter Left system coronary angiography performed using a 6 French JL4 catheter Right system coronary angiography performed using a 6 French CDRC catheter Following the procedure all catheters were removed Manual pressure was held with the Neptune pad and the patient was discharged back to his room I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses There were no apparent complications A total of 77 cc of Isovue dye and 1 4 minutes of fluoroscopy time were utilized during the case FINDINGS HEMODYNAMICS LV pressure is 120 EDP is 20 aortic pressure 120 62 mean of 82 LV function is normal EF 60 no wall motion abnormalities CORONARY ANATOMY 1 Left main demonstrates 30 40 distal left main lesion which is tapering not felt significantly obstructive 2 The LAD demonstrates proximal moderate 50 lesion and a severe mid LAD lesion immediately after the take off of this large diagonal of 99 which is quite severe with TIMI 3 flow throughout the LAD and the left main 3 The left circumflex demonstrates mid 90 severe lesion with TIMI 3 flow 4 The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity There is a moderate distal PDA lesion of 60 seen IMPRESSION 1 Mild to moderate left main stenosis 2 Very severe mid LAD stenosis with severe mid left circumflex stenosis and moderate prox LAD CAD We are going to continue the patient s aspirin beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg deciliter or less but in the past the patient s LDL had been higher or high Keywords cardiovascular pulmonary wall motion abnormalities cardiac catheterization mid lad timi flow femoral arteriotomy catheterization ischemia angina distal stenosis stress artery coronary lad cardiac MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting CABG x2 left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex St Jude proximal anastomosis used for vein graft Off pump Medtronic technique for left internal mammary artery and a BIVAD technique for the circumflex Medical Specialty Cardiovascular Pulmonary Sample Name CABG 2 Transcription PREOPERATIVE DIAGNOSIS Angina and coronary artery disease POSTOPERATIVE DIAGNOSIS Angina and coronary artery disease NAME OF OPERATION Coronary artery bypass grafting CABG x2 left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex St Jude proximal anastomosis used for vein graft Off pump Medtronic technique for left internal mammary artery and a BIVAD technique for the circumflex ANESTHESIA General PROCEDURE DETAILS The patient was brought to the operating room and placed in the supine position upon the table After adequate general anesthesia the patient was prepped with Betadine soap and solution in the usual sterile manner Elbows were protected to avoid ulnar neuropathy chest wall expansion avoided to avoid ulnar neuropathy phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case A midline sternal skin incision was made and carried down through the sternum which was divided with the saw Pericardial and thymus fat pad was divided The left internal mammary artery was harvested and spatulated for anastomosis Heparin was given Vein resected from the thigh side branches secured using 4 0 silk and Hemoclips The thigh was closed multilayer Vicryl and Dexon technique A Pulsavac wash was done drain was placed The left internal mammary artery is sewn to the left anterior descending using 7 0 running Prolene technique with the Medtronic off pump retractors After this was done the patient was fully heparinized cannulated with a 6 5 atrial cannula and a 2 stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia Medtronic retractors used to expose the circumflex Prior to going on pump we stapled the vein graft in place to the aorta Then on pump we did the distal anastomosis with a 7 0 running Prolene technique The right side graft was brought to the posterior descending artery using running 7 0 Prolene technique Deairing procedure was carried out The bulldogs were removed The patient maintained good normal sinus rhythm with good mean perfusion The patient was weaned from cardiopulmonary bypass The arterial and venous lines were removed and doubly secured Protamine was delivered Meticulous hemostasis was present Platelets were given for coagulopathy Chest tube was placed and meticulous hemostasis was present The anatomy and the flow in the grafts was excellent Closure was begun The sternum was closed with wire followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double layer technique The skin was closed with subcuticular 4 0 Dexon suture technique The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3 0 Keywords cardiovascular pulmonary coronary artery disease angina coronary artery bypass grafting internal mammary artery coronary artery vein graft artery bivad cabg medtronic anastomosis mammary vein circumflex MEDICAL_TRANSCRIPTION,Description Coronary artery bypass grafting times three utilizing the left internal mammary artery left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection Medical Specialty Cardiovascular Pulmonary Sample Name CABG Transcription TITLE OF PROCEDURE Coronary artery bypass grafting times three utilizing the left internal mammary artery left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery total cardiopulmonary bypass cold blood potassium cardioplegia antegrade and retrograde for myocardial protection DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring devices were placed The chest abdomen and legs were prepped and draped in the sterile fashion The right greater saphenous vein was harvested and prepared by ligating all branches with 4 0 Surgilon and flushed with heparinized blood Hemostasis was achieved in the legs and closed with running 2 0 Dexon in the subcutaneous tissue and running 3 0 Dexon subcuticular in the skin Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The pericardium was opened The pericardial cradle was created The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted A retrograde cardioplegic cannula was placed with a pursestring suture of 4 0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4 0 Prolene The ascending aorta was crossclamped Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia The obtuse marginal coronary artery was identified and opened and end to side anastomosis was performed to the reversed autogenous saphenous vein with running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened End to side anastomosis was performed with a running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde potassium cardioplegia were given The mammary artery was clipped distally divided and spatulated for anastomosis The anterior descending was identified and opened End to side anastomosis was performed through the left internal mammary artery with running 8 0 Prolene suture The mammary pedicle was sutured to the heart with interrupted 5 0 Prolene suture A warm antegrade and retrograde cardioplegia were given The aortic crossclamp was removed The partial occlusion clamp was placed Aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture A partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Ventricular and atrial pacing wires were placed The patient was fully warmed and weaned from cardiopulmonary bypass The patient was decannulated in the routine fashion and Protamine was given Good hemostasis was noted A single mediastinal and left pleural chest tube were placed The sternum was closed with interrupted wire linea alba with running 0 Prolene the sternal fascia was closed with running 0 Prolene the subcutaneous tissue with running 2 0 Dexon and the skin with running 3 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords cardiovascular pulmonary cabg cardioplegia potassium cardiopulmonary coronary artery marginal obtuse myocardial autogenous coronary artery bypass grafting running prolene suture saphenous vein ascending aorta prolene suture artery coronary bypassNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Coronary bypass graft x2 utilizing left internal mammary artery the left anterior descending reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection Medical Specialty Cardiovascular Pulmonary Sample Name CABG 1 Transcription PREOPERATIVE DIAGNOSIS Coronary occlusive disease POSTOPERATIVE DIAGNOSIS Coronary occlusive disease OPERATION PROCEDURE Coronary bypass graft x2 utilizing left internal mammary artery the left anterior descending reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal Total cardiopulmonary bypass cold blood potassium cardioplegia antegrade for myocardial protection INDICATION FOR THE PROCEDURE The patient was a 71 year old female transferred from an outside facility with the left main proximal left anterior descending and proximal circumflex severe coronary occlusive disease ejection fraction about 40 FINDINGS The LAD was 2 mm vessel and good mammary was good and obtuse marginal was 2 mm vessel and good and the main was good DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in the supine position Adequate general endotracheal anesthesia was induced Appropriate monitoring devices were placed The chest abdomen and legs were prepped and draped in the sterile fashion The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4 0 Surgilon and flushed with heparinized blood Hemostasis was achieved in the legs and closed with running 2 0 Dexon in the subcutaneous tissue and running 3 0 Dexon subcuticular in the skin Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine soaked gauze The pericardium was opened The pericardial cradle was created The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted A retrograde cardioplegic cannula was placed with a pursestring suture of 4 0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4 0 Prolene Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg The obtuse marginal coronary was identified and opened End to side anastomosis was performed with a running 7 0 Prolene suture and the vein was cut to length Cold antegrade and retrograde potassium cardioplegia were given The mammary artery was clipped distally divided and spatulated for anastomosis The anterior descending was identified and opened End to side anastomosis was performed with running 8 0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross clamp was removed The partial occlusion clamp was placed Aortotomies were made The veins were cut to fit these and sutured in place with running 5 0 Prolene suture A partial occlusion clamp was removed All anastomoses were inspected and noted to be patent and dry Ventilation was commenced The patient was fully warm and the patient was then wean from cardiopulmonary bypass The patient was decannulated in routine fashion Protamine was given Good hemostasis was noted A single mediastinal chest tube and bilateral pleural Blake drains were placed The sternum was closed with figure of eight stainless steel wire plus two 5 mm Mersiline tapes The linea alba was closed with figure of eight of 1 Vicryl the sternal fascia closed with running 1 Vicryl the subcu closed with running 2 0 Dexon skin with running 4 0 Dexon subcuticular stitch The patient tolerated the procedure well Keywords cardiovascular pulmonary coronary occlusive disease coronary bypass graft cabg myocardial mammary artery obtuse marginal cardiopulmonary bypass potassium cardioplegia prolene suture bypass artery anastomosis autogenous obtuse marginal cardiopulmonary potassium retrograde cardioplegia antegrade coronary MEDICAL_TRANSCRIPTION,Description Lumbar osteomyelitis and need for durable central intravenous access Placement of left subclavian 4 French Broviac catheter Medical Specialty Cardiovascular Pulmonary Sample Name Broviac Catheter Placement Transcription PREOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access POSTOPERATIVE DIAGNOSES 1 Lumbar osteomyelitis 2 Need for durable central intravenous access ANESTHESIA General PROCEDURE Placement of left subclavian 4 French Broviac catheter INDICATIONS The patient is a toddler admitted with a limp and back pain who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas The patient needs prolonged IV antibiotic therapy but attempt at a PICC line failed She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement I met with the patient s mom With the help of a Spanish interpreter I explained the technique for Broviac placement We discussed the surgical risks and alternatives most of which have been exhausted All their questions have been answered and the patient is fit for operation today DESCRIPTION OF OPERATION The patient came to the operating room and had an uneventful induction of general anesthesia We conducted a surgical time out to reiterate all of the patient s important identifying information and to confirm that we were here to place the Broviac catheter Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed A flexible guidewire was inserted into the central location and then a 4 French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines The peel away sheath was passed over the guidewire and then the 4 French catheter was deployed through the peel away sheath There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein then it was withdrawn and easily replaced in the superior vena cava The catheter insertion site was closed with one buried 5 0 Monocryl stitch and the same 5 0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred Heparinized saline solution was used to flush the line A sterile occlusive dressing was applied and the line was prepared for immediate use The patient was transported to the recovery room in good condition There were no intraoperative complications and her blood loss was between 5 and 10 mL during the line placement portion of the procedure Keywords cardiovascular pulmonary lumbar osteomyelitis central intravenous access subclavian osteomyelitis broviac catheter catheter toddler intravenous MEDICAL_TRANSCRIPTION,Description Flexible Bronchoscopy pediatric Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Pediatric Transcription FLEXIBLE BRONCHOSCOPY The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit I explained to the parents that the possible risks include irritation of the nasal mucosa which can be associated with some bleeding risk of contamination of the lower airways by passage of the scope in the nasopharynx respiratory depression from sedation and a very small risk of pneumothorax A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back The sample will then be sent for testing The flexible bronchoscopy is mainly diagnostic any therapeutic intervention if deemed necessary will be planned and will require a separate procedure The parents seem to understand had the opportunity to ask questions and were satisfied with the information A booklet containing the description of the procedure and other information was provided Keywords cardiovascular pulmonary flexible bronchoscopy pediatric intensive care unit bleeding bronchi bronchoalveolar lavage bronchoscopy conscious sedation nasal mucosa nasopharynx pneumothorax respiratory pediatric flexible bronchoscopyNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bronchoscopy brushings washings and biopsies Patient with a bilateral infiltrates immunocompromised host and pneumonia Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Brushings Transcription OPERATIVE PROCEDURE Bronchoscopy brushings washings and biopsies HISTORY This is a 41 year old woman admitted to Medical Center with a bilateral pulmonary infiltrate immunocompromise INDICATIONS FOR THE PROCEDURE Bilateral infiltrates immunocompromised host and pneumonia Prior to procedure the patient was intubated with 8 French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress DESCRIPTION OF PROCEDURE Under MAC and fluoroscopy fiberoptic bronchoscope was passed through the ET tube ET tube was visualized approximately 2 cm above the carina Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings The patient tolerated the procedure well Postprocedure the patient is to be placed on a ventilator as well as postprocedure chest x ray pending Specimens are sent for immunocompromise panel including PCP stains POSTPROCEDURE DIAGNOSIS Pneumonia infiltrates Keywords cardiovascular pulmonary mac fluoroscopy fiberoptic bronchoscope bronchoscopy brushings fiberoptic bronchoscope bronchoscopy biopsies pneumonia immunocompromised MEDICAL_TRANSCRIPTION,Description Bronchoscopy with bronchoalveolar lavage Refractory pneumonitis A 69 year old man status post trauma slightly prolonged respiratory failure status post tracheostomy requires another bronchoscopy for further evaluation of refractory pneumonitis Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Bronchoalveolar Lavage Transcription PREOPERATIVE DIAGNOSIS Refractory pneumonitis POSTOPERATIVE DIAGNOSIS Refractory pneumonitis PROCEDURE PERFORMED Bronchoscopy with bronchoalveolar lavage ANESTHESIA 5 mg of Versed INDICATIONS A 69 year old man status post trauma slightly prolonged respiratory failure status post tracheostomy requires another bronchoscopy for further evaluation of refractory pneumonitis PROCEDURE The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube Bronchoscope was advanced Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially lavaged out Relatively few tenacious secretions were noted These were lavaged out Specimen collected for culture No obvious other abnormalities were noted The patient tolerated the procedure well without complication Keywords cardiovascular pulmonary respiratory failure bronchoalveolar lavage refractory pneumonitis tracheostomy bronchoalveolar bronchoscopy pneumonitis MEDICAL_TRANSCRIPTION,Description Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2 Bilateral bronchopneumonia and empyema of the chest left Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Thoracotomy Transcription PREOPERATIVE DIAGNOSES 1 Bilateral bronchopneumonia 2 Empyema of the chest left POSTOPERATIVE DIAGNOSES 1 Bilateral bronchopneumonia 2 Empyema of the chest left PROCEDURES 1 Diagnostic bronchoscopy 2 Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2 DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was taken to the operating room where a time out process was followed Initially the patient was intubated with a 6 French tube because of the presence of previous laryngectomy Because of this I proceeded to use a pediatric bronchoscope which provided limited visualization but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology although there was some mucus secretion that was aspirated Then with the patient properly anesthetized and looking very stable we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope Therefore we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems Some brownish secretions were obtained particularly from the right side and were sent for culture and sensitivity both aerobic and anaerobic fungi and acid fast Then the patient was turned with left side up and prepped for a left thoracotomy He was properly draped I had recently re inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space Immediately it was evident that there was a large amount of pus in the left chest We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus Then we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung We spent several minutes trying to clean up this area Initially I had planned only to drain the empyema because the patient was in a very poor condition but at this particular moment he was more stable and well oxygenated and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure On the upper part of the chest we had limited access but overall we obtained a large amount of solid exudate and we were able to break out loculations We followed by irrigation with 2000 cc of warm normal saline and then insertion of two 32 chest tubes which are the largest one available in this institution one we put over the diaphragm and the other one going up and down towards the apex The limited thoracotomy was closed with heavy intercostal sutures of Vicryl then interrupted sutures of 0 Vicryl to the muscle layers and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus The chest tubes were secured with sutures and then connected to Pleur evac Then the patient was transported Estimated blood loss was minimal and the patient tolerated the procedure well He was extubated in the operating room and he was transferred to the ICU to be admitted A chest x ray was ordered stat Keywords cardiovascular pulmonary chest tubes insertion partial pulmonary decortication thoracotomy bronchoscopy empyema bronchopneumonia diagnostic bronchoscopy pulmonary decortication bilateral bronchopneumonia decortication intercostal pulmonary tubes MEDICAL_TRANSCRIPTION,Description Plastic piece foreign body in the right main stem bronchus Rigid bronchoscopy with foreign body removal Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Foreign Body Removal Transcription PREOPERATIVE DIAGNOSIS Foreign body in airway POSTOPERATIVE DIAGNOSIS Plastic piece foreign body in the right main stem bronchus PROCEDURE Rigid bronchoscopy with foreign body removal INDICATIONS FOR PROCEDURE This patient is 7 month old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom The patient had a chest x ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed supine put under general mask anesthesia Using a 3 5 rigid bronchoscope we visualized between the cords into the trachea There were some secretions but that looked okay Got down at the level of the carina to see a foreign body flapping in the right main stem I then used graspers to grasp to try to pull into the scope itself I could not do that I thus had to pull the scope out along with the foreign body that was held on to with a grasper It appeared to be consisting of some type of plastic piece that had broke off some different object I took the scope and put it back down into the airway again Again there was secretion in the trachea that we suctioned out We looked down into the right bronchus intermedius There was no other pathology noted just some irritation in the right main stem area I looked down the left main stem as well and that looked okay as well I then withdrew the scope Trachea looked fine as well as the cords I put the patient back on mask oxygen to wake the patient up The patient tolerated the procedure well Keywords cardiovascular pulmonary main stem bronchus bronchoscopy airway foreign body removal rigid bronchoscopy MEDICAL_TRANSCRIPTION,Description Bronchoscopy for hypoxia and increasing pulmonary secretions Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 6 Transcription PREOPERATIVE DIAGNOSIS Hypoxia and increasing pulmonary secretions POSTOPERATIVE DIAGNOSIS Hypoxia and increasing pulmonary secretions OPERATION Bronchoscopy ANESTHESIA Moderate bedside sedation COMPLICATIONS None FINDINGS Abundant amount of clear thick secretions throughout the main airways INDICATIONS The patient is a 43 year old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion This morning the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube The patient also had new appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x ray Given these findings it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be OPERATION The patient was given additional fentanyl Versed as well as paralytics for the procedure Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus Extensive secretions extended down into the secondary airways This was lavaged with saline and suctioned dry There is no overt specific occlusion of airways nor was there any purulent appearing sputum The bronchoscope was then advanced into the left mainstem bronchus and there was noted to be a small amount of similar appearing secretions which was likewise suctioned and cleaned The bronchoscope was removed and the patient was increased to PEEP of 10 on the ventilator Please note that prior to starting bronchoscopy he was pre oxygenated with 100 O2 The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture Keywords cardiovascular pulmonary pulmonary secretions bronchoscopy hypoxia peep smv occlusion atelectasis bedside sedation bronchoscope chest x ray mainstem right lower lobe mainstem bronchus MEDICAL_TRANSCRIPTION,Description Diagnostic fiberoptic bronchoscopy Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 7 Transcription PROCEDURE Diagnostic fiberoptic bronchoscopy ANESTHESIA Plain lidocaine 2 was given intrabronchially for local anesthesia PREOPERATIVE MEDICATIONS 1 Lortab 10 mg plus Phenergan 25 mg p o 1 hour before the procedure 2 Versed a total of 5 mg given IV push during the procedure INDICATIONS Keywords cardiovascular pulmonary fiberoptic intrabronchially larynx distal trachea diagnostic fiberoptic bronchoscopy bronchoscopy bronchoscope MEDICAL_TRANSCRIPTION,Description Rigid bronchoscopy removal of foreign body excision of granulation tissue tumor bronchial dilation Argon plasma coagulation placement of a tracheal and bilateral bronchial stents Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 5 Transcription PREOPERATIVE DIAGNOSIS Airway stenosis with self expanding metallic stent complication POSTOPERATIVE DIAGNOSIS Airway stenosis with self expanding metallic stent complication PROCEDURES 1 Rigid bronchoscopy with removal of foreign body prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation 2 Excision of granulation tissue tumor 3 Bronchial dilation with a balloon bronchoplasty right main bronchus 4 Argon plasma coagulation to control bleeding in the trachea 5 Placement of a tracheal and bilateral bronchial stents with a silicon wire stent ENDOSCOPIC FINDINGS 1 Normal true vocal cords 2 Proximal trachea with high grade occlusion blocking approximately 90 of the trachea due to granulation tissue tumor and break down of metallic stent 3 Multiple stent fractures in the mid portion of the trachea with granulation tissue 4 High grade obstruction of the right main bronchus by stent and granulation tissue 5 Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent 6 All in all a high grade terrible airway obstruction with involvement of the carina left and right main stem bronchus mid distal and proximal trachea TECHNIQUE IN DETAIL After informed consent was obtained from the patient he was brought into the operating field A rapid sequence induction was done He was intubated with a rigid scope Jet ventilation technique was carried out using a rigid and flexible scope A thorough airway inspection was carried out with findings as described above Dr D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway It should be noted that Dr Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments Nevertheless all the visible stent was removed and the airway was much better after with the dilation of balloon and the rigid scope We took measurements and decided to place stents in the trachea left and right main bronchus using a Dumon Y stent It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter The right main stem stent was 2 25 cm in length the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length After it was placed excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords The patient tolerated the procedure well and was brought to the recovery room extubated Keywords cardiovascular pulmonary airway argon plasma coagulation bronchial dilation balloon bronchoplasty bronchoscopy bronchus foreign body granulation metallic stent stenosis vocal cords granulation tissue tumor plasma coagulation granulation tissue tracheal argon stents bronchial metallic MEDICAL_TRANSCRIPTION,Description Bronchoscopy with aspiration and left upper lobectomy Carcinoma of the left upper lobe Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Lobectomy Transcription PREOPERATIVE DIAGNOSIS Carcinoma of the left upper lobe PROCEDURES PERFORMED 1 Bronchoscopy with aspiration 2 Left upper lobectomy PROCEDURE DETAILS With patient in supine position under general anesthesia with endotracheal tube in place the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina The carina was in the midline and sharp Moving directly to the right side the right upper and middle lower lobes were examined and found to be free of obstructions Aspiration was carried out for backlog ________ examination We then moved to left side left upper lobe There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction No anatomic lesions were demonstrated The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter After proper position utilizing Betadine solution they were draped A posterolateral left thoracotomy incision was performed Hemostasis was secured with electrocoagulation The chest wall muscle was then divided over the sixth rib The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully At this time the mass was felt in the left upper lobe which measures greater than 3 cm by palpation We examined the superior mediastinum No lymph nodes were demonstrated as well as in the anterior mediastinum Direction was then moved to the fascia where by utilizing sharp and blunt dissection lingual artery was separated into the left upper lobe Casual dissection was carried out with superior segmental arteries and left lower lobe was examined Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue From the top side the bronchus was then separated away from the pulmonary artery anteriorly thus exposing the apical posterior artery which was short Tumor mass was close to the artery at this time We then directed ourselves once again to the lingual artery which was doubly ligated and cut free The posterior artery of the superior branch was doubly ligated and cut free also At this time the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished We then moved anteriorly to doubly ligate the pulmonary vein using 00 silk sutures for ligation and a transection 00 silk suture was used to fixate the vein Using sharp and blunt dissection the bronchus through the left upper lobe was freed proximal Using the TA 50 the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished The anterior artery was seen in the clamp also and was separated and ligated and separated At this time the entire tumor in the left upper lobe was then removed Direction was carried to the suture where 000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place The clamp was then removed No bleeding was seen at this time Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position At this time two chest tubes 28 and 32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture The chest cavity was then closed After reexamination no bleeding was seen with three pericostal sutures of 1 chromic double strength A 2 0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi 000 chromic subcutaneous tissue skin clips to the skin The chest tubes were attached to the Pleur Evac drainage and placed on suction at this time The patient was extubated in the room without difficulty and sent to Recovery in satisfactory Keywords cardiovascular pulmonary ng tube chest tubes endotracheal tube pulmonary vein artery aspiration lobectomy bronchoscopy tumor vein bronchus pulmonary MEDICAL_TRANSCRIPTION,Description Bronchoscopy with brush biopsies Persistent pneumonia right upper lobe of the lung possible mass Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 8 Transcription PREOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass POSTOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass PROCEDURE Bronchoscopy with brush biopsies DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was taken to the operating room where he underwent a general endotracheal anesthesia A time out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4 lidocaine had been infused into the endotracheal tube First the trachea and the carina had normal appearance The scope was passed into the left side and the bronchial system was found to be normal There were scars and mucoid secretions Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB First the basal lobes were explored and found to be normal Then the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated Then the bronchi going to the three segments were visualized and no abnormalities or mass were found Brush biopsy was obtained from one of the segments and sent to Pathology The procedure had to be interrupted several times because of the patient s desaturation but after a few minutes of Ambu bagging he recovered satisfactorily At the end the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition Keywords cardiovascular pulmonary persistent pneumonia bronchoscopy brush biopsies endotracheal tube biopsies bronchial abnormalities pneumonia secretions endotracheal MEDICAL_TRANSCRIPTION,Description Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end stage chemotherapy and radiation induced pulmonary fibrosis Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 2 Transcription INDICATIONS FOR PROCEDURE Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end stage chemotherapy and radiation induced pulmonary fibrosis PREMEDICATION 1 Demerol 50 mg 2 Phenergan 25 mg 3 Atropine 0 6 mg IM 4 Nebulized 4 lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4 lidocaine gel through the right naris 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords PROCEDURE DETAILS With the patient breathing oxygen by nasal cannula being monitored by noninvasive blood pressure cuff and continuous pulse oximetry the Olympus bronchoscope was introduced through the right naris to the level of the cords The cords move normally with phonation and ventilation Two times 2 mL of 1 lidocaine were instilled on the cords and the cords were traversed Further 2 mL of 1 lidocaine was instilled in the trachea just distal to the cords at mid trachea above the carina and on the right and on the left mainstem bronchus Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted Upper lobe and lingula were unremarkable There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment one almost had to pop the bronchoscope around to go down the left mainstem This had been a change from the prior bronchoscopy of unclear significance Distal to this there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns which were faintly hemorrhagic The scope was then removed re introduced up to the right upper lobe middle lobe superior segment right lower anterior lateral and posterior basal subsegments were all evaluated and unremarkable The scope was withdrawn The patient s saturation remained 93 95 throughout the procedure Blood pressure was 103 62 Heart rate at the end of the procedure was about 100 The patient tolerated the procedure well Samples were sent as follows Washings for AFB Gram stain Nocardia Aspergillus and routine culture Lavage for AFB Gram stain Nocardia Aspergillus cell count with differential cytology viral mycoplasma and Chlamydia culture GMS staining RSV by antigen and Legionella and Chlamydia culture Keywords cardiovascular pulmonary cough bronchoscopy olympus bronchoscope nasal insufflation oral antibiotics pulse oximetry sputum ventilation antibiotics nocardia aspergillus chlamydia atropine lidocaine cords topical MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy with endobronchial biopsies A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6 cm right hilar mass consistent with a primary lung carcinoma Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Fiberoptic Transcription HISTORY OF PRESENT ILLNESS A 67 year old gentleman who presented to the emergency room with chest pain cough hemoptysis shortness of breath and recent 30 pound weight loss He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6 cm right hilar mass consistent with a primary lung carcinoma There was also a question of liver metastases at that time OPERATION PERFORMED Fiberoptic bronchoscopy with endobronchial biopsies The bronchoscope was passed into the airway and it was noted that there was a large friable tumor blocking the bronchus intermedius on the right The tumor extended into the carina involving the lingula and the left upper lobe appearing malignant Approximately 15 biopsies were taken of the tumor Attention was then directed at the left upper lobe and lingula Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review Approximately eight biopsies were taken of the left upper lobe Keywords cardiovascular pulmonary endobronchial intermedius fiberoptic bronchoscopy lung carcinoma bronchoscopy fiberoptic chest tumor lobeNOTE MEDICAL_TRANSCRIPTION,Description Bronchoscopy Atelectasis and mucous plugging Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy Transcription PREOPERATIVE DIAGNOSIS Atelectasis POSTOPERATIVE DIAGNOSIS Mucous plugging PROCEDURE PERFORMED Bronchoscopy ANESTHESIA Lidocaine topical 2 Versed 3 mg IV Conscious sedation PROCEDURE At bedside a bronchoscope was passed down the tracheostomy tube under monitoring The main carina was visualized The trachea was free of any secretions The right upper lobe middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema Left mainstem appeared patent Left lower lobe had slight plugging in the left base but much better that previous bronchoscopy findings The area was lavaged with some saline and cleared The patient tolerated the procedure well Keywords cardiovascular pulmonary MEDICAL_TRANSCRIPTION,Description Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoalveolar lavage Transcription POSTOPERATIVE DIAGNOSIS Fever PROCEDURES Bronchoalveolar lavage INDICATIONS FOR PROCEDURE The patient is a 28 year old male status post abdominal trauma splenic laceration and splenectomy performed at the outside hospital who was admitted to the Trauma Intensive Care Unit on the evening of August 4 2008 Greater than 24 hours postoperative the patient began to run a fever in excess of 102 Therefore evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage DESCRIPTION OF PROCEDURE The patient was preoxygenated with 100 FIO2 for approximately 5 to 10 minutes prior to the procedure The correct patient and procedure was identified by time out by all members of the team The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter each time suctioning out the sample into the Lukens trap A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology The patient tolerated the procedure well and had no episodes of desaturation apnea or cardiac arrhythmia A postoperative chest x ray was obtained Keywords cardiovascular pulmonary abdominal trauma bal lavage lukens trap suction splenectomy splenic laceration bronchoalveolar lavage fever catheter bronchoalveolar lavage airwayNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description Bronchiolitis respiratory syncytial virus positive improved and stable Innocent heart murmur stable Medical Specialty Cardiovascular Pulmonary Sample Name Bronchiolitis Discharge Summary Transcription DIAGNOSES 1 Bronchiolitis respiratory syncytial virus positive improved and stable 2 Innocent heart murmur stable HOSPITAL COURSE The patient was admitted for an acute onset of congestion She was checked for RSV which was positive and admitted to the hospital for acute bronchiolitis She has always been stable on room air however because of her age and her early diagnosis she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness She was treated per pathway orders However on the second day of admission the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission There was a heart murmur that was heard that sounded innocent but yet there was no chest x ray that was obtained We did obtain a chest x ray which did show a slight perihilar infiltrate in the right upper lobe However the rest of the lungs were normal and the heart was also normal There were no complications during her hospitalization and she continued to be stable and eating better On day 2 of the admission it was decided she was okay to go home Mother was advised regarding signs and symptoms of increased respiratory distress which includes tachypnea increased retractions grunting nasal flaring etc and she was very comfortable looking for this During her hospitalization albuterol MDI was given to the patient and more for mom to learn outpatient care The patient did receive a couple of doses but she did not have any significant respiratory distress and she was discharged in improved condition DISCHARGE PHYSICAL EXAMINATION VITAL SIGNS She is afebrile Vital signs were stable within normal limits on room air GENERAL She is sleeping and in no acute distress HEENT Her anterior fontanelle was soft and flat She does have some upper airway congestion CARDIOVASCULAR Regular rate and rhythm with a 2 3 6 systolic murmur that radiates to bilateral axilla and the back EXTREMITIES Her femoral pulses were 2 and her extremities were warm and well perfused with good capillary refill LUNGS Her lungs did show some slight coarseness but good air movement with equal breath sounds She does not have any wheezes at this time but she does have a few scattered crackles at bilateral bases She did not have any respiratory distress while she was asleep ABDOMEN Normal bowel sounds Soft and nondistended GENITOURINARY She is Tanner I female DISCHARGE WEIGHT Her weight at discharge 3 346 kg which is up 6 grams from admission DISCHARGE INSTRUCTIONS ACTIVITY No one should smoke near The patient She should also avoid all other exposures to smoke such as from fireplaces and barbecues She is to avoid contact with other infants since she is sick and they are to limit travel There should be frequent hand washings DIET Regular diet Continue breast feeding as much as possible and encourage oral intake MEDICATIONS She will be sent home on albuterol MDI to be used as needed for cough wheezes or dyspnea ADDITIONAL INSTRUCTIONS Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing if she stops breathing or she decides that she does not want to eat Keywords cardiovascular pulmonary bronchiolitis respiratory syncytial virus bulb suctioning innocent heart murmur chest x ray syncytial virus heart murmur respiratory distress lungs MEDICAL_TRANSCRIPTION,Description Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 3 Transcription PROCEDURE Fiberoptic bronchoscopy PREOPERATIVE DIAGNOSIS Right lung atelectasis POSTOPERATIVE DIAGNOSIS Extensive mucus plugging in right main stem bronchus PROCEDURE IN DETAIL Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0 5 mg intravenously given in 2 aliquots The patient was breathing supplemental nasal and mask oxygen throughout the procedure Saturations and vital signs remained stable throughout A flexible fiberoptic bronchoscope was passed through the right naris The vocal cords were visualized Secretions in the larynx were as aspirated As before he had a mucocele at the right anterior commissure that did not obstruct the glottic opening The ports were anesthetized and the trachea entered There was no cough reflex helping explain the propensity to aspiration and mucus plugging Tracheal secretions were aspirated The main carinae were sharp However there were thick sticky grey secretions filling the right mainstem bronchus up to the level of the carina This was gradually lavaged clear Saline and Mucomyst solution were used to help dislodge remaining plugs The airways appeared slightly friable but were patent after the airways were suctioned O2 saturations remained in the mid to high 90s The patient tolerated the procedure well Specimens were submitted for microbiologic examination Despite his frail status he tolerated bronchoscopy quite well Keywords cardiovascular pulmonary bronchoscopy fiberoptic mucomyst atelectasis bronchoscope bronchus carinae larynx main stem mucus nasal plugging trachea fiberoptic bronchoscopy mucus plugging secretionsNOTE MEDICAL_TRANSCRIPTION,Description Rigid bronchoscopy with dilation excision of granulation tissue tumor application of mitomycin C endobronchial ultrasound Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 4 Transcription PREOPERATIVE DIAGNOSIS Tracheal stenosis and metal stent complications POSTOPERATIVE DIAGNOSIS Tracheal stenosis and metal stent complications ANESTHESIA General endotracheal ENDOSCOPIC FINDINGS 1 Normal true vocal cords 2 Subglottic stenosis down to 5 mm with mature cicatrix 3 Tracheal granulation tissue growing through the stents at the midway point of the stents 5 Three metallic stents in place in the proximal trachea 6 Distance from the true vocal cords to the proximal stent 2 cm 7 Distance from the proximal stent to the distal stent 3 5 cm 8 Distance from the distal stent to the carina 8 cm 9 Distal airway is clear PROCEDURES 1 Rigid bronchoscopy with dilation 2 Excision of granulation tissue tumor 3 Application of mitomycin C 4 Endobronchial ultrasound TECHNIQUE IN DETAIL After informed consent was obtained from the patient and her husband she was brought to the operating theater after sequence induction was done She had a Dedo laryngoscope placed Her airways were inspected thoroughly with findings as described above She was intermittently ventilated with an endotracheal tube placed through the Dedo scope Her granulation tissue was biopsied and then removed with a microdebrider Her proximal trachea was dilated with a combination of balloon Bougie and rigid scopes She tolerated the procedure well was extubated and brought to the PACU Keywords cardiovascular pulmonary tracheal stenosis dedo scope bronchoscopy cicatrix dilation endotracheal granulation metal stent mitomycin c proximal trachea vocal cords endobronchial ultrasound granulation tissue proximal tracheal stent MEDICAL_TRANSCRIPTION,Description Bilateral carotid cerebral angiogram and right femoral popliteal angiogram Medical Specialty Cardiovascular Pulmonary Sample Name Bilateral Carotid Cerebral Angiogram Transcription PREOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease POSTOPERATIVE DIAGNOSES 1 Carotid artery occlusive disease 2 Peripheral vascular disease OPERATIONS PERFORMED 1 Bilateral carotid cerebral angiogram 2 Right femoral popliteal angiogram FINDINGS The right carotid cerebral system was selectively catheterized and visualized The right internal carotid artery was found to be very tortuous with kinking in its cervical portions but no focal stenosis was noted Likewise the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery The left carotid cerebral system was selectively catheterized and visualized The cervical portion of the left internal carotid artery showed a 30 to 40 stenosis with small ulcer crater present The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery Visualization of the right lower extremity showed no significant disease PROCEDURE With the patient in supine position under local anesthesia plus intravenous sedation the groin areas were prepped and draped in a sterile fashion The common femoral artery was punctured in a routine retrograde fashion and a 5 French introducer sheath was advanced under fluoroscopic guidance A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above Following completion of the above the catheter and introducer sheath were removed Heparin had been initially given which was reversed with protamine Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and sandbag compression The patient tolerated the procedure well throughout Keywords cardiovascular pulmonary femoral popliteal angiogram carotid cerebral angiogram internal carotid artery carotid artery angiogram carotid cerebral artery MEDICAL_TRANSCRIPTION,Description Bronchoscopy right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration Medical Specialty Cardiovascular Pulmonary Sample Name Bronchoscopy 1 Transcription PROCEDURE Bronchoscopy right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration DETAILS OF THE PROCEDURE The risks alternatives and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed The patient received topical lidocaine by nebulization The flexible fiberoptic bronchoscope was introduced orally The patient had normal teeth normal tongue normal jaw and her vocal cords moved symmetrically and were without lesions I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies Followup fluoroscopy was negative for pneumothorax I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes I then proceeded to inspect the rest of the tracheobronchial tree which was without lesions I performed a bronchial washing after the biopsies in the right upper lobe I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area All of these samples were sent for histology and cytology respectively Estimated blood loss was approximately 5 cc Good hemostasis was achieved The patient received a total of 12 5 mg of Demerol and 3 mg of Versed and tolerated the procedure well Her ASA score was 2 Keywords cardiovascular pulmonary bronchoscopy wang needle biopsy bronchial washing bronchoscope bronchus fiberoptic hemostasis lidocaine nebulization right upper lobe transbronchial transbronchial needle aspiration needle aspiration transbronchial needle upper lobe bronchial precarinal biopsies needle lobeNOTE Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only MTHelpLine does not certify accuracy and quality of sample reports These transcribed medical transcription sample reports may include some uncommon or unusual formats this would be due to the preference of the dictating physician All names and dates have beenchanged or removed to keep confidentiality Any resemblance of any type of name or date orplace or anything else to real world is purely incidental MEDICAL_TRANSCRIPTION,Description A critically ill 67 year old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate Medical Specialty Cardiovascular Pulmonary Sample Name Atrial Flutter Progress Note Transcription HISTORY OF PRESENT ILLNESS Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response which was resistant to treatment with diltiazem and amiodarone being followed by Dr X of cardiology through most of the day This afternoon when I am seeing the patient nursing informs me that rate has finally been controlled with esmolol but systolic blood pressures have dropped to the 70s with a MAP of 52 Dr X was again consulted from the bedside We agreed to try fluid boluses and then to consider Neo Synephrine pressure support if this is not successful In addition over the last 24 hours extensive discussions have been held with the family and questions answered by nursing staff concerning the patient s possible move to Tahoe Pacific or a long term acute care Other issues requiring following up today are elevated transaminases continuing fever pneumonia resolving adult respiratory distress syndrome ventilatory dependent respiratory failure hypokalemia non ST elevation MI hypernatremia chronic obstructive pulmonary disease BPH atrial flutter inferior vena cava filter and diabetes PHYSICAL EXAMINATION VITAL SIGNS T max 103 2 blood pressure at this point is running in the 70s mid 40s with a MAP of 52 heart rate is 100 GENERAL The patient is much more alert appearing than my last examination of approximately 3 weeks ago He denies any pain appears to have intact mentation and is in no apparent distress EYES Pupils round reactive to light anicteric with external ocular motions intact CARDIOVASCULAR Reveals an irregularly irregular rhythm LUNGS Have diminished breath sounds but are clear anteriorly ABDOMEN Somewhat distended but with no guarding rebound or obvious tenderness to palpation EXTREMITIES Show trace edema with no clubbing or cyanosis NEUROLOGICAL The patient is moving all extremities without focal neurological deficits LABORATORY DATA Sodium 149 this is down from 151 yesterday Potassium 3 9 chloride 114 bicarb 25 BUN 35 creatinine 1 5 up from 1 2 yesterday hemoglobin 12 4 hematocrit 36 3 WBC 16 5 platelets 231 000 INR 1 4 Transaminases are continuing to trend upwards of SGOT 546 SGPT 256 Also noted is a scant amount of very concentrated appearing urine in the bag IMPRESSION Overall impressions continues to be critically ill 67 year old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate PLAN 1 Hypotension I would aggressively try and fluid replete the patient giving him another liter of fluids If this does not work as discussed with Dr X we will start some Neo Synephrine but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started 2 Increased transaminases Presumably this is from increased congestion This is certainly concerning We will continue to follow this Ultrasound of the liver was apparently negative 3 Fever and elevated white count The patient does have a history of pneumonia and empyema We will continue current antibiotics per infectious disease and continue to follow the patient s white count He is not exceptionally toxic appearing at this time Indeed he does look improved from my last examination 4 Ventilatory dependent respiratory failure The patient has received a tracheostomy since my last examination Vent management per PMA 5 Hypokalemia This has resolved Continue supplementation 6 Hypernatremia This is improving somewhat I am hoping that with increased fluids this will continue to do so 7 Diabetes mellitus Fingerstick blood glucoses are reviewed and are at target We will continue current management This is a critically ill patient with multiorgan dysfunction and signs of worsening renal hepatic and cardiovascular function with extremely guarded prognosis Total critical care time spent today 37 minutes Keywords cardiovascular pulmonary rapid ventricular response volume depletion atrial flutter atrial hypotension flutter MEDICAL_TRANSCRIPTION,Description Ash split venous port insertion The right anterior chest and supraclavicular fossa area neck and left side of chest were prepped with Betadine and draped in a sterile fashion Medical Specialty Cardiovascular Pulmonary Sample Name Ash Split Venous Port Transcription ASH SPLIT VENOUS PORT PROCEDURE DETAILS The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist The right anterior chest and supraclavicular fossa area neck and left side of chest were prepped with Betadine and draped in a sterile fashion Xylocaine 1 was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter The patient was placed into Trendelenburg position The right internal jugular vein was accessed by a supraclavicular 19 gauge thin walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle Under fluoroscopic control a J wire was advanced into the right atrium The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel A second incision was made 5 cm inferior to the right midclavicular line through which an Ash split catheter was advanced using the tunneling rod in a gently curving pass to exit the skin of the neck incision The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter Sequential dilators were advanced over the J wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control The dilator and wire were removed leaving the sheath in position through which a double lumen catheter was advanced into the central venous system The sheath was peeled away leaving the catheter into position Each port of the catheter was flushed with dilute heparinized saline The patient was returned to the flat position The catheter was secured to the skin of the anterior chest using 2 0 Ethilon suture placed through the suture wings The neck incision was closed with 3 0 Vicryl subcuticular closure and pressure dressing applied Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position The patient was returned to the recovery room for postoperative care Keywords cardiovascular pulmonary ash split venous port venous port anterior chest incision dilators sheath port supraclavicular needle fluoroscopic venous insertion catheter MEDICAL_TRANSCRIPTION,Description Carotid artery angiograms Medical Specialty Cardiovascular Pulmonary Sample Name Bilateral Carotid Angiography Transcription PROCEDURE PERFORMED 1 Selective ascending aortic arch angiogram 2 Selective left common carotid artery angiogram 3 Selective right common carotid artery angiogram 4 Selective left subclavian artery angiogram 5 Right iliac angio with runoff 6 Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections INDICATIONS FOR PROCEDURE TIA aortic stenosis postoperative procedure Moderate carotid artery stenosis ESTIMATED BLOOD LOSS 400 ml SPECIMENS REMOVED Not applicable TECHNIQUE OF PROCEDURE After obtaining informed consent the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state The right groin was prepped and draped in the usual sterile fashion Lidocaine 2 was used for infiltration anesthesia Using modified Seldinger technique a 6 French sheath was placed into the right common femoral artery and vein without complication Using injection through the side port of the sheath a right iliac angiogram with runoff was performed Following this straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed Following this selective engagement in left common carotid artery right common carotid artery and left subclavian artery angiograms were performed with a V Tech catheter over an 0 035 inch wire ANGIOGRAPHIC FINDINGS 1 Type 2 aortic arch 2 Left subclavian artery was patent 3 Left vertebral artery was patent 4 Left internal carotid artery had a 40 to 50 lesion with ulceration not treated and there was no cerebral cross over 5 Right common carotid artery had a 60 to 70 lesion which was heavily calcified and was not treated with the summed left to right cross over flow 6 Closure was with a 6 French Angio Seal of the artery and the venous sheath was sutured in PLAN Continue aspirin Plavix and Coumadin to an INR of 2 with a carotid duplex followup Keywords cardiovascular pulmonary aortic arch angiogram carotid artery angiogram artery was patent common carotid artery arch angiogram subclavian artery aortic arch carotid artery carotid angiography artery angiograms subclavian catheterization aortic angiogram MEDICAL_TRANSCRIPTION,Description Atrial fibrillation with rapid ventricular response Wolff Parkinson White Syndrome recent aortic valve replacement with bioprosthetic Medtronic valve and hyperlipidemia Medical Specialty Cardiovascular Pulmonary Sample Name Atrial Fibrillation SOAP Transcription SUBJECTIVE The patient states that she feels better She is on IV amiodarone the dosage pattern is appropriate for ventricular tachycardia Researching the available records I find only an EMS verbal statement that tachycardia of wide complex was seen There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm The patient states that for a week she has been home postoperative from aortic valve replacement on 12 01 08 at ABC Medical Center The aortic stenosis was secondary to a congenital bicuspid valve by her description She states that her shortness of breath with exertion has been stable but has yet to improve from its preoperative condition She has not had any decline in her postoperative period of her tolerance to exertion The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days Last night she had a prolonged episode for which she contacted EMS Her medications at home had been uninterrupted and without change from those listed being Toprol XL 100 mg q a m Dyazide 25 37 5 mg Nexium 40 mg all taken once a day She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively She states that she has been taking her aspirin at 325 mg q a m She remains on Zyrtec 10 mg q a m Her only allergy is listed to latex OBJECTIVE VITAL SIGNS Temperature 36 1 heart rate 60 respirations 14 room air saturation 98 and blood pressure 108 60 The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC GENERAL She is alert and in no apparent distress HEENT Eyes EOMI PERRLA Sclerae nonicteric No lesions of lids lashes brows or conjunctivae noted Funduscopic examination unremarkable Ears Normal set shape TMs canals and hearing Nose and Sinuses Negative Mouth Tongue Teeth and Throat Negative except for dental work NECK Supple and pain free without bruit JVD adenopathy or thyroid abnormality CHEST Lungs are clear bilaterally to auscultation The incision is well healed and without evidence of significant cellulitis HEART Shows a regular rate and rhythm without murmur gallop heave click thrill or rub There is an occasional extra beat noted which corresponds to a premature atrial contraction on the monitor ABDOMEN Soft and benign without hepatosplenomegaly rebound rigidity or guarding EXTREMITIES Show no evidence of DVT acute arthritis cellulitis or pedal edema NEUROLOGIC Nonfocal without lateralizing findings for cranial or peripheral nervous systems strength sensation and cerebellar function Gait and station were not tested MENTAL STATUS Shows the patient to be alert coherent with full capacity for decision making BACK Negative to inspection or percussion LABORATORY DATA Shows from 12 15 08 2100 hemoglobin 11 6 white count 12 9 and platelets 126 000 INR 1 0 Electrolytes are normal with exception potassium 3 3 GFR is decreased at 50 with creatinine of 1 1 Glucose was 119 Magnesium was 2 3 Phosphorus 3 8 Calcium was slightly low at 7 8 The patient has had ionized calcium checked at Munson that was normal at 4 5 prior to her discharge Troponin is negative x2 from 2100 and repeat at 07 32 This morning her BNP was 163 at admission Her admission chest x ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion Her current EKG tracing from 05 42 shows a sinus bradycardia with Wolff Parkinson White Pattern a rate of 58 beats per minute and a corrected QT interval of 557 milliseconds Her PR interval was 0 12 We received a call from Munson Medical Center that a bed had been arranged for the patient I contacted Dr Varner and we reviewed the patient s managed to this point All combined impression is that the patient was likely to not have had actual ventricular tachycardia This is based on her EP study from October showing her to be non inducible In addition she had a cardiac catheterization that showed no evidence of coronary artery disease What is most likely that the patient has postoperative atrial fibrillation Her WPW may have degenerated into a ventricular tachycardia but this is unlikely At this point we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period I will recheck her potassium magnesium calcium and phosphorus at this point and make adjustments if indicated Dr Varner will be making arrangements for an outpatient Holter monitor and further followup post discharge IMPRESSION 1 Atrial fibrillation with rapid ventricular response 2 Wolff Parkinson White Syndrome 3 Recent aortic valve replacement with bioprosthetic Medtronic valve 4 Hyperlipidemia Keywords cardiovascular pulmonary ventricular tachycardia wolff parkinson white syndrome ventricular response medtronic valve wolff parkinson white syndrome aortic valve replacement atrial fibrillation atrial aortic tachycardia fibrillation ventricular valve medtronic MEDICAL_TRANSCRIPTION,Description Aortogram with bilateral segmental lower extremity run off Left leg claudication The patient presents with lower extremity claudication Medical Specialty Cardiovascular Pulmonary Sample Name Aortogram Leg claudication Transcription PREPROCEDURE DIAGNOSIS Left leg claudication POSTPROCEDURE DIAGNOSIS Left leg claudication OPERATION PERFORMED Aortogram with bilateral segmental lower extremity run off ANESTHESIA Conscious sedation INDICATION FOR PROCEDURE The patient presents with lower extremity claudication She is a 68 year old woman who is very fearful of the aforementioned procedures Risks and benefits of the procedure were explained to her to include bleeding infection arterial trauma requiring surgery access issues and recurrence She appears to understand and agrees to proceed DESCRIPTION OF PROCEDURE The patient was taken to the Angio Suite placed in a supine position After adequate conscious sedation both groins were prepped with Chloraseptic prep Cloth towels and paper drapes were placed Local anesthesia was administered in the common femoral artery and using ultrasound guidance the common femoral artery was accessed Guidewire was threaded followed by a 4 French sheath Through the 4 French sheath a 4 French Omni flush catheter was placed The glidewire was removed and contrast administered to identify the level of the renal artery Using power injector an aortogram proceeded The catheter was then pulled down to the aortic bifurcation A timed run off view of both legs was performed and due to a very abnormal and delayed run off in the left I opted to perform an angiogram of the left lower extremity with an isolated approach The catheter was pulled down to the aortic bifurcation and using a glidewire I obtained access to the contralateral left external iliac artery The Omni flush catheter was advanced to the left distal external iliac artery The glidewire rather exchanged for an Amplatz stiff wire This was left in place and the 4 French sheath removed and replaced with a 6 French destination 45 cm sheath This was advanced into the proximal superficial femoral artery and an angiogram performed I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty The patient was given 5000 units of heparin and this was allowed to circulate A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels A 4 mm x 4 cm angioplasty balloon was used to dilate the area in question Final views after dilatation revealed a dissection A search for a 5 mm stent was performed but none of this was available For this reason I used a 6 mm x 80 mm marked stent and placed this at the distal superficial femoral artery Post dilatation was performed with a 4 mm angioplasty balloon Further views of the left lower extremity showed irregular change in the popliteal artery No significant stenosis could be identified in the left popliteal artery and noninvasive scan For this reason I chose not to treat any further areas in the left leg I then performed closure of the right femoral artery with a 6 French Angio Seal device Attention was turned to the left femoral artery and local anesthesia administered Access was obtained with the ultrasound and the femoral artery identified Guidewire was threaded followed by a 4 French sheath This was immediately exchanged for the 6 French destination sheath after the glidewire was used to access the distal external iliac artery The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath The destination was placed in the proximal superficial femoral artery and angiogram obtained Initial views had been obtained from the right femoral sheath before removal Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery For this reason I performed the angioplasty of the superficial femoral artery using the 4 mm balloon A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation No further significant abnormality was identified To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery A 3 mm balloon was chosen to dilate a 50 to 79 popliteal artery stenosis Reasonable use were obtained and possibly a 4 mm balloon could have been used However due to her propensity for dissection I opted not to I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length This was placed into the left posterior tibial artery A 2 mm balloon was used to dilate the orifice of the posterior tibial artery I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel Final images showed improved run off to the right calf The destination sheath was pulled back into the left external iliac artery and an Angio Seal deployed FINDINGS Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma No evidence of renal artery stenosis is noted bilaterally There is a single left renal artery The infrarenal aorta both common iliac and the external iliac arteries are normal On the right a superficial femoral artery is widely patent and normal proximally At the distal third of the thigh there is diffuse disease with moderate stenosis noted Moderate stenosis is also noted in the popliteal artery and single vessel run off through the posterior tibial artery is noted The perineal artery is functionally occluded at the midcalf The dorsal pedal artery filled by collateral at the high ankle level On the left the proximal superficial femoral artery is patent Again at the distal third of the thigh there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery This was successfully treated with angioplasty and a stent placement The popliteal artery is diffusely diseased without focal stenosis The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice IMPRESSION 1 Normal bilateral renal arteries with a small accessory right renal artery 2 Normal infrarenal aorta as well as normal bilateral common and external iliac arteries 3 The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries Successful angioplasty with reasonable results in the distal superficial femoral popliteal and proximal posterior tibial artery as described 4 Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement Run off to the left lower extremity is via a patent perineal and posterior tibial artery Keywords cardiovascular pulmonary claudication extremity run off angio suite superficial femoral artery popliteal superficial femoral aortogram artery balloon glidewire angioplasty stenosis renal MEDICAL_TRANSCRIPTION,Description Aortic valve replacement using a mechanical valve and two vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery Medical Specialty Cardiovascular Pulmonary Sample Name Aortic Valve Replacement Transcription DIAGNOSIS Aortic valve stenosis with coronary artery disease associated with congestive heart failure The patient has diabetes and is morbidly obese PROCEDURES Aortic valve replacement using a mechanical valve and two vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery ANESTHESIA General endotracheal INCISION Median sternotomy INDICATIONS The patient presented with severe congestive heart failure associated with the patient s severe diabetes The patient was found to have moderately stenotic aortic valve In addition The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient s right system It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure FINDINGS The left ventricle is certainly hypertrophied The aortic valve leaflet is calcified and a severe restrictive leaflet motion It is a tricuspid type of valve The coronary artery consists of a large left anterior descending artery which is associated with 60 stenosis but a large obtuse marginal artery which has a tight proximal stenosis The radial artery was used for the left anterior descending artery Flow was excellent Looking at the targets in the posterior descending artery territory there did not appear to be any large branches On the angiogram these vessels appeared to be quite small Because this is a chronically occluded vessel and the patient has limited conduit due to the patient s massive obesity attempt to bypass to this area was not undertaken The patient was brought to the operating room PROCEDURE The patient was brought to the operating room and placed in supine position A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh The patient weighs nearly three hundred pounds There was concern as to taking down the left internal mammary artery Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory The patient was cannulated after the aorta and atrium were exposed and full heparinization The patient went on cardiopulmonary bypass and the aortic cross clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner The patient was cooled to 32 degrees Iced slush was applied to the heart The aortic valve was then exposed through the aortic root by transverse incision The valve leaflets were removed and the 23 St Jude mechanical valve was secured into position by circumferential pledgeted sutures At this point aortotomy was closed The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow Proximal anastomosis was then carried out to the foot of the aorta The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end to side manner The two proximal anastomoses were then carried out to the root of the aorta The patient came off cardiopulmonary bypass after aortic cross clamp was released The patient was adequately warmed Protamine was given without adverse effect Sternal closure was then done using wires The subcutaneous layers were closed using Vicryl suture The skin was approximated using staples Keywords cardiovascular pulmonary coronary artery bypass grafting saphenous vein graft radial artery graft coronary artery disease congestive heart failure descending artery territory aortic cross clamp aortic valve replacement coronary artery bypass obtuse marginal artery anterior descending artery mechanical valve artery bypass bypass grafting marginal artery radial artery aortic valve coronary artery anterior descending descending artery valve artery aortic grafting MEDICAL_TRANSCRIPTION,Description Aortoiliac occlusive disease Aortobifemoral bypass The aorta was of normal size and consistency consistent with arteriosclerosis A 16x8 mm Gore Tex graft was placed without difficulty The femoral vessels were small somewhat thin and there was posterior packing but satisfactory bypass was performed Medical Specialty Cardiovascular Pulmonary Sample Name Aortobifemoral Bypass Transcription PREOPERATIVE DIAGNOSIS Aortoiliac occlusive disease POSTOPERATIVE DIAGNOSIS Aortoiliac occlusive disease PROCEDURE PERFORMED Aortobifemoral bypass OPERATIVE FINDINGS The patient was taken to the operating room The abdominal contents were within normal limits The aorta was of normal size and consistency consistent with arteriosclerosis A 16x8 mm Gore Tex graft was placed without difficulty The femoral vessels were small somewhat thin and there was posterior packing but satisfactory bypass was performed PROCEDURE The patient was taken to the operating room placed in a supine position and prepped and draped in the usual sterile manner with Betadine solution A longitudinal incision was made after a Betadine coated drape was placed over the incisional area Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia Hemostasis was obtained with electrocautery The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges Attention was then turned to the abdomen where a longitudinal incision was made from the pubis xiphoid carried down subcutaneous fat and fascia Hemostasis was obtained with electrocautery The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery Mild adhesions were lysed The omentum was freed The small and large intestine were run with no evidence of abnormalities The liver and gallbladder were within normal limits No abnormalities were noted At this point the Bookwalter retractor was placed NG tube was placed in the stomach and placed on suction The intestines were gently packed intraabdominally and laterally The rest of the peritoneum was then opened The aorta was cleared both proximally and distally The left iliac was completely occluded The right iliac was to be cleansed At this point 5000 units of aqueous heparin was administered to allow take effect The aorta was then clamped below the renal arteries and opened in a longitudinal fashion A single lumbar was ligated with 3 0 Prolene The inferior mesenteric artery was occluded intraluminally and required no suture closure Care was taken to preserve collaterals The aorta was measured and a 16 mm Gore Tex graft was brought on the field and anastomosed to the proximal aorta using 3 0 Prolene in a running fashion Last stitch was tied Hemostasis was excellent The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis At this point strong pulses were present within the graft The limbs were vented and irrigated Using bimanual technique the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin The grafts were then brought through these care being taken to avoid twisting of the graft At this point the right iliac was then ligated using 0 Vicryl and the clamp was removed Hemostasis was excellent The right common femoral artery was then clamped proximally and distally opened with 11 blade extended with Potts scissors The graft was _____ and anastomosed to the artery using 5 0 Prolene in a continuous fashion with a stitch _______ running fashion Prior to tying the last stitch the graft and artery were vented and the last stitch was tied Flow was initially restored proximally then distally with good results Attention was then turned to the left groin and the artery grafts were likewise exposed cleared proximally and distally The artery was opened extended with a Potts scissors and anastomosis was performed with 5 0 Prolene again with satisfactory hemostasis The last stitch was tied Strong pulses were present within the artery and graft itself At this point 25 mg of protamine was administered The wounds were irrigated with antibiotic solution The groins were repacked Attention was then returned to the abdomen The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft The intraabdominal contents were then allowed to resume their normal position There was no evidence of ischemia to the large or small bowel At this point the omentum and stomach were repositioned The abdominal wall was closed in a running single layer fashion using 1 PDS The skin was closed with skin staples The groins were again irrigated closed with 3 0 Vicryl and 4 0 undyed Vicryl and Steri Strips The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well Sponges and instrument counts were correct Estimated blood loss 900 cc Keywords cardiovascular pulmonary aorta bypass arteriosclerosis abdominal contents aortoiliac occlusive disease gore tex graft aortobifemoral bypass longitudinal incision aortobifemoral hemostasis artery graft MEDICAL_TRANSCRIPTION,Description Dementia and aortoiliac occlusive disease bilaterally Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft Medical Specialty Cardiovascular Pulmonary Sample Name Aortobifemoral Bypass 1 Transcription PREOPERATIVE DIAGNOSIS 1 Aortoiliac occlusive disease bilaterally 2 Dementia POSTOPERATIVE DIAGNOSIS 1 Aortoiliac occlusive disease bilaterally 2 Dementia OPERATION Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 300 cc INTRAVENOUS FLUIDS 1200 cc of crystalloid URINE OUTPUT 250 cc OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the operating room and general endotracheal anesthesia was administered Note that previously the patient was found to have some baseline dementia although slight The patient was seen and evaluated by the neurology team who cleared the patient for surgery The patient was taken to the operating room and general endotracheal anesthesia was administered The abdomen was prepped and draped in the standard surgical fashion We first began our dissection by using a 10 blade scalpel to incise the skin over the femoral artery in the groin bilaterally Dissection was carried down to the level of the femoral vessels using Bovie electrocautery The common femoral superficial femoral and profunda femoris arteries were encircled and dissected out peripherally Vessel loops were placed around the aforementioned arteries After doing so we turned our attention to beginning our abdominal dissection We used a 10 blade scalpel to make a midline laparotomy incision Dissection was carried down to the level of the fascia using Bovie electrocautery The abdomen was opened and an Omni retractor was positioned The aorta was dissected out in the abdomen The left femoral vein was identified There was a nicely clampable portion of aorta visible We as mentioned placed our Omni retractor and then turned our attention to performing our anastomosis Full dose heparin was given Next vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels A 11 blade scalpel was used to make an arteriotomy in the aorta which was lengthened both proximally and distally using Potts scissors We then beveled our proximal graft and constructed an end graft to side artery anastomosis using 3 0 Prolene in a running fashion Upon completion of our anastomosis we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis We then created our tunnels over the iliac vessels We pulled the distal limbs over our ABF graft into the groin We then proceeded to perform our right anastomosis first We applied vascular clamps on the proximal common femoral profunda and superficial femoral arteries We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6 0 Prolene in a running fashion Upon completion of our anastomosis we flushed the common femoral SFA and profunda femoris arteries We then removed our clamp We opened the limb more proximally in the abdomen on the right side We then turned our attention to the left side and similarly placed our vascular clamps We used a 11 blade scalpel to make an arteriotomy in the vessel We then lengthened our arteriotomy both proximally and distally again onto the SFA We constructed a footed end graft to side artery anastomosis using 6 0 Prolene in a running fashion Upon completion of our anastomosis we opened our clamps There was no noticeable leak from the newly constructed anastomosis We checked our proximal graft to aortic anastomosis which was noted to be in good condition We then gave full dose protamine We closed the peritoneum over the graft with 4 0 Vicryl in a running fashion The abdomen was closed with 1 nylon in a running fashion The skin was closed with subcuticular 4 0 Monocryl in a running subcuticular fashion The instrument and sponge count was correct at end of case Patient tolerated the procedure well and was transferred to the intensive care unit in good condition Keywords cardiovascular pulmonary bifurcated hemashield graft aortoiliac occlusive disease aortobifemoral bypass vascular clamps common femoral graft femoral anastomosis aortobifemoral aortoiliac proximal arteriotomy bypass artery endotracheal vessels MEDICAL_TRANSCRIPTION,Description Arterial imaging of bilateral lower extremities Medical Specialty Cardiovascular Pulmonary Sample Name Arterial Imaging Transcription INDICATIONS Peripheral vascular disease with claudication RIGHT 1 Normal arterial imaging of right lower extremity 2 Peak systolic velocity is normal 3 Arterial waveform is triphasic 4 Ankle brachial index is 0 96 LEFT 1 Normal arterial imaging of left lower extremity 2 Peak systolic velocity is normal 3 Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic 4 Ankle brachial index is 1 06 IMPRESSION Normal arterial imaging of both lower extremities Keywords cardiovascular pulmonary peripheral vascular disease ankle brachial index arterial waveform peak systolic velocity arterial imaging biphasic claudication lower extremities lower extremity posterior tibial artery triphasic systolic velocity is normal arterial waveform is triphasic waveform is triphasic normal arterial imaging systolic velocity brachial index velocity brachial imaging arterial MEDICAL_TRANSCRIPTION,Description Left heart cath selective coronary angiogram right common femoral angiogram and StarClose closure of right common femoral artery Medical Specialty Cardiovascular Pulmonary Sample Name Angiogram StarClose Closure Transcription EXAM Left heart cath selective coronary angiogram right common femoral angiogram and StarClose closure of right common femoral artery REASON FOR EXAM Abnormal stress test and episode of shortness of breath PROCEDURE Right common femoral artery 6 French sheath JL4 JR4 and pigtail catheters were used FINDINGS 1 Left main is a large caliber vessel It is angiographically free of disease 2 LAD is a large caliber vessel It gives rise to two diagonals and septal perforator It erupts around the apex LAD shows an area of 60 to 70 stenosis probably in its mid portion The lesion is a type A finishing before the takeoff of diagonal 1 The rest of the vessel is angiographically free of disease 3 Diagonal 1 and diagonal 2 are angiographically free of disease 4 Left circumflex is a small to moderate caliber vessel gives rise to 1 OM It is angiographically free of disease 5 OM 1 is angiographically free of disease 6 RCA is a large dominant vessel gives rise to conus RV marginal PDA and one PL RCA has a tortuous course and it has a 30 to 40 stenosis in its proximal portion 7 LVEDP is measured 40 mmHg 8 No gradient between LV and aorta is noted Due to contrast concern due to renal function no LV gram was performed Following this right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery IMPRESSION 1 60 to 70 mid left anterior descending stenosis 2 Mild 30 to 40 stenosis of the proximal right coronary artery 3 Status post StarClose closure of the right common femoral artery PLAN Plan will be to perform elective PCI of the mid LAD Keywords cardiovascular pulmonary heart cath selective coronary angiogram common femoral angiogram abnormal stress test common femoral artery starclose closure femoral artery angiogram angiographically artery femoral MEDICAL_TRANSCRIPTION,Description Selective coronary angiography of the right coronary artery left main LAD left circumflex artery left ventricular catheterization left ventricular angiography angioplasty of totally occluded mid RCA arthrectomy using 6 French catheter stenting of the mid RCA stenting of the proximal RCA femoral angiography and Perclose hemostasis Medical Specialty Cardiovascular Pulmonary Sample Name Angiography Catheterization 1 Transcription INDICATION Acute coronary syndrome CONSENT FORM The procedure of cardiac catheterization PCI risks included but not restricted to death myocardial infarction cerebrovascular accident emergent open heart surgery bleeding hematoma limb loss renal failure requiring dialysis blood loss infection had been explained to him He understands All questions answered and is willing to sign consent PROCEDURE PERFORMED Selective coronary angiography of the right coronary artery left main LAD left circumflex artery left ventricular catheterization left ventricular angiography angioplasty of totally occluded mid RCA arthrectomy using 6 French catheter stenting of the mid RCA stenting of the proximal RCA femoral angiography and Perclose hemostasis NARRATIVE The patient was brought to the cardiac catheterization laboratory in a fasting state Both groins were draped and sterilized in the usual fashion Local anesthesia was achieved with 2 lidocaine to the right groin area and a 6 French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery Selective coronary angiography was performed with 6 French JL4 catheter for the left coronary system and a 6 French JR4 catheter of the right coronary artery Left ventricular catheterization and angiography was performed at the end of the procedure with a 6 French angle pigtail catheter FINDINGS 1 Hemodynamics systemic blood pressure 140 70 mmHg LVEDP at the end of the procedure was 13 mmHg 2 The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20 angiographic stenosis at the take off of the left circumflex artery The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30 angiographic stenosis The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate to severe ostium The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk The LAD is calcified and diffusely disease in the proximal and mid portion There is mild nonobstructive disease in the proximal LAD resulting in less than 20 angiographic stenosis 3 The right coronary artery is dominant It is septal to be occluded in the mid portion The findings were discussed with the patient and she opted for PCI Angiomax bolus was started The ACT was checked It was higher in 300 I have given the patient 600 mg of oral Plavix The right coronary artery was engaged using a 6 French JR4 guide catheter I was unable to cross through this lesion using a BMW wire and a 3 0x8 mm balloon support I was unable to cross with this lesion using a whisper wire I was unable to cross with this lesion using Cross IT 100 wire I have also used second 6 French Amplatz right I guide catheter At one time I have lost flow in the distal vessel The patient experienced severe chest pain ST segment elevation bradycardia and hypotension which responded to intravenous fluids and atropine along with intravenous dopamine Dr X was notified Eventually an Asahi grand slam wire using the same 3 0 x 8 mm Voyager balloon support I was able to cross into the distal vessel I have performed careful balloon angioplasty of the mid RCA I have given nitroglycerin under the nursing several times during the procedure I then performed arthrectomy using 5 French export catheter I performed more balloon predilation using a 3 0 x16 mm Voyager balloon I then deployed 4 0 x15 mm excised and across the mid RCA at 18 atmospheres with good angiographic result Proximal to the proximal edge of the stent there was still some persistent haziness most likely just diseased artery diffuse plaquing I decided to cover this segment using a second 4 0 x 15 mm excised and two stents were overlapped the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result Left ventricular catheterization was performed with 6 French angle pigtail catheter The left ventricle is rather smaller in size The mid inferior wall is minimally hypokinetic ejection fraction is 70 There is no evidence of aortic wall stenosis or mitral regurgitation Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis CONCLUSIONS 1 Normal left ventricular size and function Ejection fraction is 65 to 70 No MR 2 Successful angioplasty and stenting of the subtotally closed mid RCA This was hard organized thrombus very difficult to penetrate I have deployed two overlapping 4 0 x15 mm excised and with excellent angiographic result The RCA is dominant 3 No moderate disease in the distal left main Moderate disease in the ostium of the left circumflex artery Mild disease in the proximal LAD PLAN Recommend smoking cessation Continue aspirin lifelong and continue Plavix for at least 12 months Keywords cardiovascular pulmonary acute coronary syndrome circumflex artery ventricular catheterization ventricular angiography angioplasty coronary artery coronary angiography arthrectomy femoral angiography perclose hemostasis selective coronary angiography angiographic stenosis rca coronary catheterization artery angiography hemostasis wire lad femoral angiographic stenting proximal MEDICAL_TRANSCRIPTION,Description A sample note on Angina Medical Specialty Cardiovascular Pulmonary Sample Name Angina Transcription ANGINA is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women It is usually located right under the breast bone Physical and emotional stress as well as eating heavy meals can bring it on In a healthy person these stresses are easily handled In a person with an underlying heart condition like coronary artery disease heart valve problem arrhythmias or high blood pressure the heart doesn t get enough blood i e not enough oxygen to the heart muscles Other causes could be due to a hyperactive thyroid disorder or anemia People more likely to have angina may also have diabetes mellitus be overweight smoke have a poor diet with lots of salt and fat fail to exercise have a stressful workload or have a family history of coronary artery disease SIGNS AND SYMPTOMS Pain in chest described as tightness heavy pressure aching or squeezing The pain sometimes radiates to the jaw left arm teeth and or outer ear Possibly a left sided numbness tingling or pain in the arm shoulder elbow or chest Occasionally a sudden difficulty in breathing occurs Pain may be located between the shoulder blades TREATMENT Nitroglycerin relieves the immediate symptoms of angina in seconds Carry it with you at all times Other medications may be prescribed for the underlying heart problems It is important to take them as prescribed by your doctor Surgery may be necessary to open the blocked coronary arteries balloon angioplasty or to bypass them Correct the contributing factors you have control over Lose weight don t smoke eat a low salt low fat diet and avoid physical and emotional stresses that cause angina Such stressors include anger overworking going between extremes in hot and cold sudden physical exertion and high altitudes pressurized airplanes aren t a risk Practice relaxation techniques Exercise Discuss first what you are able to do with your doctor and then go do it Even with treatment angina may result in a heart attack congestive heart failure or a fatal abnormal heartbeat Treatment decreases the odds that these will occur Let your doctor know if your angina doesn t go away after 10 minutes even when you have taken a nitroglycerin tablet Call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps If your pain changes or feels different call your doctor or call 911 if the pain is severe Keywords cardiovascular pulmonary lack of oxygen heart valve arrhythmias blood pressure heart tightness nitroglycerin coronary artery disease oxygen angina coronary chest MEDICAL_TRANSCRIPTION,Description Adenosine with nuclear scan as the patient unable to walk on a treadmill Nondiagnostic adenosine stress test Normal nuclear myocardial perfusion scan Medical Specialty Cardiovascular Pulmonary Sample Name Adenosine Nuclear Scan Transcription INDICATION Chest pain TYPE OF TEST Adenosine with nuclear scan as the patient unable to walk on a treadmill INTERPRETATION Resting heart rate of 67 blood pressure of 129 86 EKG normal sinus rhythm Post Lexiscan 0 4 mg heart rate was 83 blood pressure 142 74 EKG remained the same No symptoms were noted SUMMARY 1 Nondiagnostic adenosine stress test 2 Nuclear interpretation as below NUCLEAR INTERPRETATION Resting and stress images were obtained with 10 4 33 1 mCi of tetrofosmin injected intravenously by standard protocol Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect Gated SPECT revealed normal wall motion ejection fraction of 58 End diastolic volume of 74 end systolic volume of 31 IMPRESSION 1 Normal nuclear myocardial perfusion scan 2 Ejection fraction 58 by gated SPECT Keywords cardiovascular pulmonary adenosine nuclear myocardial perfusion scan chest pain adenosine stress test nuclear myocardial perfusion scan gated spect spect mci myocardial perfusion scan myocardial perfusion adenosine nuclear MEDICAL_TRANSCRIPTION,Description Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only Medical Specialty Cardiovascular Pulmonary Sample Name Abnormal Stress Test Transcription HISTORY OF PRESENT ILLNESS Mr ABC is a 60 year old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only He required 3 sublingual nitroglycerin in total please see also admission history and physical for full details The patient underwent cardiac catheterization with myself today which showed mild to moderate left main distal disease of 30 moderate proximal LAD with a severe mid LAD lesion of 99 and a mid left circumflex lesion of 80 with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA I discussed these results with the patient and he had been relating to me that he was having rest anginal symptoms as well as nocturnal anginal symptoms and especially given the severity of the mid left anterior descending lesion with a markedly abnormal stress test I felt he was best suited for transfer for PCI I discussed the case with Dr X at Medical Center who has kindly accepted the patient in transfer CONDITION ON TRANSFER Stable but guarded The patient is pain free at this time MEDICATIONS ON TRANSFER 1 Aspirin 325 mg once a day 2 Metoprolol 50 mg once a day but we have had to hold it because of relative bradycardia which he apparently has a history of 3 Nexium 40 mg once a day 4 Zocor 40 mg once a day and there is a fasting lipid profile pending at the time of this dictation I see that his LDL was 136 on May 3 2002 5 Plavix 600 mg p o x1 which I am giving him tonight Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation GERD arthritis DISPOSITION The patient and his wife have requested and are agreeable with transfer to Medical Center and we are enclosing the CD ROM of his images Keywords cardiovascular pulmonary standard bruce nitroglycerin abnormal stress test st depressions anginal symptoms stress test lad anginal stress MEDICAL_TRANSCRIPTION,Description Gentleman with long standing morbid obesity resistant to nonsurgical methods of weight loss with BMI of 69 7 Medical Specialty Bariatrics Sample Name Gastric Bypass Discussion 1 Transcription HISTORY OF PRESENT ILLNESS In short the patient is a 55 year old gentleman with long standing morbid obesity resistant to nonsurgical methods of weight loss with BMI of 69 7 with comorbidities of hypertension atrial fibrillation hyperlipidemia possible sleep apnea and also osteoarthritis of the lower extremities He is also an ex smoker He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT PE rates and marginal ulcer problems after surgery which will be discussed later on PHYSICAL EXAMINATION On physical examination today he weighs 514 8 pounds he has gained 21 pounds since the last visit with us His pulse is 78 temperature is 97 5 blood pressure is 132 74 Lungs are clear He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size Abdomen is soft nontender No incisions No umbilical hernia no groin hernia has a large abdominal pannus No hepatosplenomegaly Lower extremities no pedal edema No calf tenderness Deep tendon reflexes are normal Lungs are clear S1 S2 is heard Regular rate and rhythm DISCUSSION I had a long talk with the patient about laparoscopic gastric bypass possible open including risks benefits alternatives need for long term followup need to adhere to dietary and exercise guidelines I also explained to him complications including rare cases of death secondary to DVT PE leak peritonitis sepsis shock multisystem organ failure need for reoperations need for endoscopy for bleeding or leak operations which could be diagnostic laparoscopy exploratory laparotomy drainage procedure gastrostomy jejunostomy for feeding bleeding requiring blood transfusion myocardial infarction pneumonia atelectasis respiratory failure requiring mechanical ventilation rarely tracheostomy rare cases of renal failure requiring dialysis etc were all discussed All these are going to be at high risk for this patient secondary to his supermorbid obese condition I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation marginal ulcer secondary to smoking or antiinflammatory drug intake which can progress on to perforation or bleeding small bowel obstruction secondary to internal hernia or adhesions signs and symptoms of which are described so the patient could alert us for earlier intervention symptomatic gallstone formation during rapid weight loss how to avoid it by taking ursodiol which will be prescribed in the postoperative period Long term complication of gastric bypass including hair loss excess skin multivitamin and mineral deficiencies protein calorie malnutrition weight regain weight plateauing psychosocial and marital issues addiction transfer etc were all discussed with the patient The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk He will be seen by cardiologist pulmonologist He will also undergo long Medifast dieting under our guidance which is a very low calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities He will also see a psychologist nutritionist and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long term success Especially for him in view of his restricted mobility supermorbid obesity status and possibility of a pulmonary hypertension secondary to sleep apnea he has been advised to have retrievable IVC filter and also will go home on Lovenox He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so All these were discussed with the patient The patient understands He wants to go to surgery All questions were answered I will see him in few weeks before the planned date of surgery Keywords bariatrics medifast medifast dieting hypertension atrial fibrillation hyperlipidemia sleep apnea morbid obesity metabolic comorbidities weight loss supermorbid obesity gastric bypass bypass MEDICAL_TRANSCRIPTION,Description Preop evaluation regarding gastric bypass surgery Medical Specialty Bariatrics Sample Name Gastric Bypass Preop Eval Transcription REASON FOR VISIT Preop evaluation regarding gastric bypass surgery The patient has gone through the evaluation process and has been cleared from psychological nutritional and cardiac standpoint also had great success on the preop Medifast diet PHYSICAL EXAMINATION The patient is alert and oriented x3 Temperature of 97 9 pulse of 76 blood pressure of 114 74 weight of 247 4 pounds Abdomen Soft nontender and nondistended ASSESSMENT AND PLAN The patient is currently in stable condition with morbid obesity scheduled for gastric bypass surgery in less than two weeks Risks and benefits of the procedure were reiterated with the patient and significant other and mother which included but not limited to death pulmonary embolism anastomotic leak reoperation prolonged hospitalization stricture small bowel obstruction bleeding and infection Questions regarding hospital course and recovery were addressed We will continue on the Medifast diet until the time of surgery and cleared for surgery Keywords bariatrics medifast medifast diet preop evaluation gastric bypass surgery bypass surgery gastric bypass MEDICAL_TRANSCRIPTION,Description Patient scheduled for laparoscopic gastric bypass Medical Specialty Bariatrics Sample Name Gastric Bypass Discussion 2 Transcription HISTORY The patient is scheduled for laparoscopic gastric bypass The patient has been earlier seen by Dr X her physician She has been referred to us from Family Practice In short she is a 33 year old lady with a BMI of 43 otherwise healthy with unsuccessful nonsurgical methods of weight loss She was on laparoscopic gastric bypass for weight loss She meets the National Institute of Health Criteria She is very well educated and motivated and has no major medical contraindications for the procedure PHYSICAL EXAMINATION On physical examination today she weighs 216 pounds with a BMI of 43 5 pulse is 96 temperature is 97 6 blood pressure is 122 80 Lungs are clear Abdomen is soft nontender There is stigmata for morbid obesity She has cesarean section scars in the lower abdomen with no herniation DISCUSSION I had a long talk with the patient about laparoscopic gastric bypass possible open including risks benefits alternatives need for long term followup need to adhere to dietary and exercise guidelines I also explained to her complications including rare cases of death secondary to DVT PE leak peritonitis sepsis shock multisystem organ failure need for re operation including for leak or bleeding gastrostomy or jejunostomy for feeding rare case of respiratory failure requiring mechanical ventilation etc with myocardial infarction pneumonia atelectasis in the postoperative period were also discussed Short term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation marginal ulcer secondary to smoking or anti inflammatory drug intake which can progress on to perforation or bleeding small bowel obstruction secondary to internal hernia or adhesions signs and symptoms of which were discussed The patient would alert us for earlier intervention Symptomatic gallstone formation secondary to rapid weight loss were also discussed How to avoid it by taking ursodiol were also discussed Long term complications of gastric bypass including hair loss excess skin multivitamin and mineral deficiencies protein calorie malnutrition weight regain weight plateauing need for major lifestyle and exercise and habit changes avoiding pregnancy in the first two years etc were all stressed The patient understands She wants to go to surgery In preparation of surgery she will undergo very low calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities She will also see a psychologist nutritionist and exercise physiologist for a multidisciplinary effort for short and long term success for weight loss surgery I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time Keywords bariatrics medifast laparoscopic gastric bypass short term complications long term complications gastric bypass complications of gastric bypass weight loss MEDICAL_TRANSCRIPTION,Description Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap Band Medical Specialty Bariatrics Sample Name Bariatric Consult Surgical Weight Loss 1 Transcription PAST MEDICAL HISTORY She has a history of hypertension and shortness of breath PAST SURGICAL HISTORY Pertinent for cholecystectomy PSYCHOLOGICAL HISTORY Negative SOCIAL HISTORY She is single She drinks alcohol once a week She does not smoke FAMILY HISTORY Pertinent for obesity and hypertension MEDICATIONS Include Topamax 100 mg twice daily Zoloft 100 mg twice daily Abilify 5 mg daily Motrin 800 mg daily and a multivitamin ALLERGIES She has no known drug allergies REVIEW OF SYSTEMS Negative PHYSICAL EXAM This is a pleasant female in no acute distress Alert and oriented x 3 HEENT Normocephalic atraumatic Extraocular muscles intact nonicteric sclerae Chest is clear to auscultation bilaterally Cardiovascular is normal sinus rhythm Abdomen is obese soft nontender and nondistended Extremities show no edema clubbing or cyanosis ASSESSMENT PLAN This is a 34 year old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap Band ABC will be asking for a letter of medical necessity from Dr XYZ She will also see my nutritionist and social worker and have an upper endoscopy Once this is completed we will submit her to her insurance company for approval Keywords bariatrics elective surgical weight loss surgical weight loss weight loss loss weight bmi surgical pounds MEDICAL_TRANSCRIPTION,Description Evaluation for bariatric surgery Medical Specialty Bariatrics Sample Name Bariatric Consult Surgical Weight Loss 3 Transcription PAST MEDICAL HISTORY Her medical conditions driving her toward surgery include hypercholesterolemia hypertension varicose veins prior history of stroke She denies any history of cancer She does have a history of hepatitis which I will need to further investigate She complains of multiple joint pains and heavy snoring PAST SURGICAL HISTORY Includes hysterectomy in 1995 for fibroids and varicose vein removal She had one ovary removed at the time of the hysterectomy as well SOCIAL HISTORY She is a single mother of one adopted child FAMILY HISTORY There is a strong family history of heart disease and hypertension as well as diabetes on both sides of her family Her mother is alive Her father is deceased from alcohol She has five siblings MEDICATIONS As you know she takes the following medications for her diabetes insulin 70 units 6 units times four years aspirin 81 mg a day Actos 15 mg Crestor 10 mg and CellCept 500 mg two times a day ALLERGIES She has no known drug allergies PHYSICAL EXAM She is a 54 year old obese female She does not appear to have any significant residual deficits from her stroke There may be slight left arm weakness ASSESSMENT PLAN We will have her undergo routine nutritional and psychosocial assessment I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia as well as hypertension with significant weight loss She is otherwise at increased risk for future complications given her history and weight loss will be a good option We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company Keywords bariatrics evaluation for bariatric surgery bariatric surgery varicose veins weight loss varicose veins diabetes bariatric surgical loss surgery hypertension weight MEDICAL_TRANSCRIPTION,Description Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success Medical Specialty Bariatrics Sample Name Discharge Summary Gastric Bypass Transcription ADMISSION DIAGNOSIS Morbid obesity BMI is 51 DISCHARGE DIAGNOSIS Morbid obesity BMI is 51 PROCEDURE Laparoscopic gastric bypass SERVICE Surgery CONSULT Anesthesia and pain HISTORY OF PRESENT ILLNESS Ms A is a 27 year old woman who suffered from morbid obesity for many years She has made multiple attempts at nonsurgical weight loss without success She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate She underwent her procedure HOSPITAL COURSE Ms A underwent her procedure She tolerated without difficulty She was admitted to the floor post procedure Her postoperative course has been unremarkable On postoperative day 1 she was hemodynamically stable afebrile normal labs and she was started on a clear liquid diet which she has tolerated without difficulty She has ambulated and had no complaints Today on postoperative day 2 the patient continues to do well Pain controlled with p o pain medicine ambulating without difficulty tolerating a liquid diet At this point it is felt that she is stable for discharge Her drain was discontinued DISCHARGE INSTRUCTIONS Liquid diet x1 week then advance to pureed and soft as tolerated No heavy lifting greater than 10 pounds x4 weeks The patient is instructed to not engage in any strenuous activity but maintain mobility No driving for 1 to 2 weeks She must be able to stop in an emergency and be off narcotic pain medicine She may shower She needs to keep her wounds clean and dry She needs to follow up in my office in 1 week for postoperative evaluation She is instructed to call for any problems of shortness of breath chest pain calf pain temperature greater than 101 5 any redness swelling or foul smelling drainage from her wounds intractable nausea vomiting and abdominal pain She is instructed just to resume her discharge medications DISCHARGE MEDICATIONS She was given a scripts for Lortab Elixir Flexeril ursodiol and Colace Keywords bariatrics laparoscopic gastric bypass gastric bypass morbid obesity liquid diet bmi discharge MEDICAL_TRANSCRIPTION,Description Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux en Y gastric bypass Medical Specialty Bariatrics Sample Name Bariatric Consult Surgical Weight Loss 4 Transcription HISTORY OF PRESENT ILLNESS Ms A is a 55 year old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux en Y gastric bypass The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers NutriSystem Jenny Craig TOPS cabbage diet grape fruit diet Slim Fast Richard Simmons as well as over the counter measures without any long term sustainable weight loss At the time of presentation to the practice she is 5 feet 6 inches tall with a weight of 285 4 pounds and a body mass index of 46 She has obesity related comorbidities which includes hypertension and hypercholesterolemia PAST MEDICAL HISTORY Significant for hypertension for which the patient takes Norvasc and Lopressor for She also suffers from high cholesterol and is on lovastatin for this She has depression for which she takes citalopram She also stated that she had a DVT in the past prior to her hysterectomy She also suffers from thyroid disease in the past though this is unclear the nature of this PAST SURGICAL HISTORY Significant for cholecystectomy in 2008 for gallstones She also had a hysterectomy in 1994 secondary to hemorrhage The patient denies any other abdominal surgeries MEDICATIONS Norvasc 10 mg p o daily Lopressor tartrate 50 mg p o b i d lovastatin 10 mg p o at bedtime citalopram 10 mg p o daily aspirin 500 mg three times a day which is currently stopped vitamin D Premarin 0 3 mg one tablet p o daily currently stopped omega 3 fatty acids and vitamin D 50 000 units q weekly ALLERGIES The patient denies allergies to medications and to latex SOCIAL HISTORY The patient is a homemaker She is married with 2 children aged 22 and 28 She is a lifelong nonsmoker and nondrinker FAMILY HISTORY Significant for high blood pressure and diabetes as well as cancer on her father side He did pass away from congestive heart failure Mother suffers from high blood pressure cancer and diabetes Her mother has passed away secondary to cancer She has two brothers one passed away from brain cancer REVIEW OF SYSTEMS Significant for ankle swelling The patient also wears glasses for vision and has dentures She does complain of shortness of breath with exertion She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain The patient denies ulcerative colitis Crohn disease bleeding diathesis liver disease or kidney disease She denies chest pain cardiac disease cancer and stroke PHYSICAL EXAMINATION The patient is a well nourished well developed female in no distress Eye Exam Pupils equal and reactive to light Extraocular motions are intact Neck Exam No cervical lymphadenopathy Midline trachea No carotid bruits Nonpalpable thyroid Neuro Exam Gross motor strength in the upper and lower extremities equal bilaterally with no focal neuro deficits noted Lung Exam Clear breath sounds without rhonchi or wheezes Cardiac Exam Regular rate and rhythm without murmur or bruits Abdominal Exam Positive bowel sounds Soft nontender obese and nondistended abdomen Lap cholecystectomy scars noted No obvious hernias No organomegaly appreciated Lower extremity Exam Edema 1 Dorsalis pedis pulses 2 ASSESSMENT The patient is a 55 year old female with a body mass index of 46 suffering from obesity related comorbidities including hypertension and hypercholesterolemia who presents to the practice for consideration of gastric bypass surgery The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity related comorbidities PLAN In preparation for surgery we will obtain the usual baseline laboratory values including baseline vitamin levels I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy Also the patient will meet with the dietitian and psychologist as per her usual routine I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10 preoperative weight loss in preparation for surgery Keywords bariatrics jenny craig medifast nutrisystem richard simmons slim fast tops weight watchers cabbage diet grape fruit diet roux en y laparoscopic roux en y gastric bypass weight loss modalities surgical weight loss body mass index weight loss MEDICAL_TRANSCRIPTION,Description Evaluation for elective surgical weight loss via the Lap Band as opposed to gastric bypass Medical Specialty Bariatrics Sample Name Bariatric Consult Surgical Weight Loss 2 Transcription PAST MEDICAL HISTORY She had a negative stress test four to five years ago She gets short of breath in walking about 30 steps She has had non insulin dependent diabetes for about eight years now She has a left knee arthritis and history of hemorrhoids PAST SURGICAL HISTORY Pertinent for laparoscopic cholecystectomy tonsillectomy left knee surgery and right breast lumpectomy PSYCHOLOGICAL HISTORY Negative except that she was rehabilitated for alcohol addiction in 1990 SOCIAL HISTORY The patient is married She is an office manager for a gravel company Her spouse is also overweight She drinks on a weekly basis and she smokes about two packs of cigarettes over a week s period of time She is doing this for about 35 years FAMILY HISTORY Diabetes and hypertension MEDICATIONS Include Colestid 1 g daily Actos 30 mg daily Amaryl 2 mg daily Soma and meloxicam for her back pain ALLERGIES She has no allergies however she does get tachycardic with caffeine Sudafed or phenylpropanolamine REVIEW OF SYSTEMS Otherwise negative PHYSICAL EXAM This is a pleasant female in no acute distress Alert and oriented x 3 HEENT Normocephalic atraumatic Extraocular muscles intact nonicteric sclerae Chest is clear Abdomen is obese soft nontender and nondistended Extremities show no edema clubbing or cyanosis ASSESSMENT PLAN This is a 51 year old female with a BMI of 43 who is interested in the Lap Band as opposed to gastric bypass ABC will be asking for a letter of medical necessity from XYZ She will also need an EKG and clearance for surgery She will also see my nutritionist and social worker and once this is completed we will submit her to her insurance company for approval Keywords bariatrics elective surgical weight loss surgical weight loss weight loss lap band gastric bypass loss weight lap band lost gained diabetes gastric bypass overweight surgical MEDICAL_TRANSCRIPTION,Description Chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies and history of asthma Medical Specialty Allergy Immunology Sample Name Evaluation of Allergies Transcription HISTORY A 55 year old female presents self referred for the possibility of evaluation and treatment of allergies diminished taste xerostomia gastroesophageal reflux disease possible food allergies chronic GI irritability asthma and environmental inhalant allergies Please refer to chart for history and physical and review of systems and detailed medical history IMPRESSION 1 Chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies history of asthma 2 History of fibromyalgia 3 History of peptic ulcer disease history of gastritis history of gastroesophageal disease 4 History of chronic fatigue 5 History of hypothyroidism 6 History of depression 7 History of dysphagia RECOMMENDATIONS RAST allergy testing was ordered for food allergy evaluation The patient had previous allergy testing done less than one year ago iby Dr X which was requested The patient will follow up after RAST allergy testing for further treatment recommendations At this point no changes in her medication were prescribed until her followup visit Keywords allergy immunology chronic glossitis xerostomia probable environmental inhalant allergies probable food allergies environmental inhalant allergies rast allergy testing rast inhalant food allergy MEDICAL_TRANSCRIPTION,Description This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR Medical Specialty Allergy Immunology Sample Name Kawasaki Disease Discharge Summary Transcription ADMITTING DIAGNOSIS Kawasaki disease DISCHARGE DIAGNOSIS Kawasaki disease resolving HOSPITAL COURSE This is a 14 month old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated neutrophils and thrombocytosis elevated CRP and ESR When he was sent to the hospital he had a fever of 102 Subsequently the patient was evaluated and based on the criteria he was started on high dose of aspirin and IVIG Echocardiogram was also done which was negative IVIG was done x1 and between 12 hours of IVIG he spiked fever again it was repeated twice and then after second IVIG he did not spike any more fever Today his fever and his rash have completely resolved He does not have any conjunctivitis and no redness of mucous membranes He is more calm and quite and taking good p o so with a very close followup and a cardiac followup he will be sent home DISCHARGE ACTIVITIES Ad lib DISCHARGE DIET PO ad lib DISCHARGE MEDICATIONS Aspirin high dose 340 mg q 6h for 1 day and then aspirin low dose 40 mg q d for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p o once a day He will be followed by his primary doctor in 2 to 3 days Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG all the live virus vaccine and if he gets any rashes any fevers should go to primary care doctor as soon as possible Keywords allergy immunology mucous membranes conjunctivitis ad lib kawasaki disease vaccine fever aspirin DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009842974 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient No 42974 Patient is a female who presents with nervousness of present illness Notes anxiety started a few weeks ago with start of new position of job professor Describes nervousness as anxiety Stress about work makes it worse sundays mondays and says it is constant Endorses loss of appetite difficulty falling a sleep decrease in interest No other aggravating or alleviating factors Denies sad feelings fatigue concentration feelings of guilt Denies fevers chills palpitations diarrhia constipation weight loss gain PMH Denies FHx Father Heart attack SHx married professor no smoke drink socially no drug use allergies none meds tylenol Discharge Discharge Studies Summary discharged to home nursing facility follow up with physician in one week prescription medication course recommended suggested dietary restrictions S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009821961 Gender Female Attachment Control Number XA 7B 002 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient No 21961 Patient is a yo female who presents with 3 years of of present illness irregular menstrual bleeding Before she experienced 28 day cycles of 5 days of moderate bleeding and precede by PMS symptoms of breast tenderness cramps However now thep atient experiences no pattern and 2 6 days of bleeding that can vary from light to very heavy using more than 3 4 menstrual napkins per day PMH HTN Medications HCTZ 12 5g Hospitalizations Twice for childbirth FH Older brother HTN Mother osteoarthritis Social history Employed as an office manager Never smoker rare alcohol use denies use of illicit drugs ROS Positive for hot flashes and sweating denies fever chills change in weight lightneadedness dry skin tremors Discharge Discharge Studies Summary discharged to home nursing facility prescription medication course recommended suggested dietary restrictions follow up with physician in one week S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 30607 Gender Male Visit Attending Physician Dr Ankunding Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis CC 3 yo M complaining of stomach pain HPC Epigastric pain that started 2 months ago Intermittent pain rated 10 that has been happening more frequently 3 times day Described as burning sensation No radiation Appetite is OK but eating less because feels bloated and full afterwards Pain waking him up at night 3 times week Started taking tums 1 month ago initially helped with pain but not Pre existing Developed Conditions anymore occasionally feels nauseous no vomiting No Impacting Hospital Stay changes to bowel habits Has noticed that stools are darker but no blood in stools No floating stools in toilet No greasy stools No change to urination PMHX nil Medicatons Motrin for muscle soreness from working in construction 1 week Tums for this pain NKDA Nil surg hx social hx smoking 1 pack day since 1 yo usually drinks 3 week stopped a few weeks ago because of pain ROS negative except as above Discharge follow up with physician in one week prescription Summary medication course recommended suggested dietary restrictions discharged to home nursing facility VS 3S Q990 70 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009883849 Gender Female Attachment Control Number XA 7B 008 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient ID 83849 Patient is a woman with 3 weeks of trouble sleeping of present illness She recently lost her son on The trouble sleeping is new She has trouble falling asleep and staying asleep She as tried ambien which did not help She admits to decrease energy decreased interest in doing things she enjoys increase fatigue increase in lethargy increased eating appetite audio and visual hallucination of her son as well as of her neighbor She denies decrease in concentration agitation or suicidal homicidal ideation She has a good support system and is not interested in meeting a therapist but is interested in taking medication to help her sleep ROS neg for fevers chills nausea vomiting diarrhea constipation PMH HTN Meds include HCTZ and lisinopril Diet non restrictive No allergies FH Mom with several episodes of depression SH supportive husband at home Denies recreational drugs or tobaccor 1 2 wine a week Discharge Discharge Studies Summary follow up with physician in one week prescription medication course recommended suggested dietary restrictions discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 20078 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis yo female with PMH HTN presents with 3 years of irregular periods Periods occur 3wk 4months apart and are 2 6 days with heavy and light bleeding LMP 2 months ago Also experiencing hotflashes x1yr and vaginal dryness Previously regular pregnancies 28 day Pre existing Developed Conditions cycle and lasting 5 days G2P2000 14 years ago and 10 years ago Both full term vaginal births and patient Impacting Hospital Stay was able to breastfeed Denies weight changes fatigue mood bloating changes eg swelling skin hair breast nipple changesm abdominal discharge pain dysuria Menarche at 14 Unsure of mother s menstrual hx No pertinent mfamily hx Patient is sexually active with husband and has never had STI Discharge regular diet no activity restrictions no discharge Summary meds follow up in two to three weeks with regular physician VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 45563 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 45 yo f prsented with episodesnof nervousesnss since a fwe weeks Episodes statret suddenly Increases when she has to give lecture to the students and no alleviating factors Pt was initially working as a reseracher however now as to kecture the class No h o palapitations or tremors H o insomnia difficulty in falling a sleep sleeps for 7 hrs a day No daytime sleepiness Takes 5 6 cupd om coffee day h o lass of humger not no lass of wt Pre existing Developed Conditions Unremarkable PMH None Impacting Hospital Stay PSH none Medication None Allegies None SH Acohols Social 1 2 drinks weekend on coccasions CAGE 0 4 No tobacco no drugs Sexually active with husband Contaception Vasectomy by mences normal 28 days cycle 5 6 pads Pap 10 months back normal Travel Nil occupation English lecturer FA Father died of heart attack mother noral Discharge discharged to home nursing facility suggested dietary Summary restrictions follow up with physician in one week prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 55152 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 26 y o female comes in complaining of heart palpitations Patient has had these sensation of fast heart beat for 5 years but in the past three weeks they have become more frequent 3 weeks ago they started happening 1 2 times per day though in the past week they happen once every few days Patient describes that during these episodes she has SOB sensation that her throat is closing diaphoresis and clammy feeling Patient describes that during the most recent episode Pre existing Developed Conditions she lost sensation in her fingers Patient denies known Impacting Hospital Stay emotional triggers to epi PMHX Episodes started five years ago but happened very rarely Medications None Allergies NKDA Social history Patient is sexually active with her boyfriend They use condoms consistently for contraception Denies smoking and recreatino drug use Patient bought a condo three months ago and lost her job two months ago and describes that she has had feelings of S FMHx non contributory Discharge some activity restrictions suggested strict diet Summary check back with physican in case of relapse full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 44902 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis y female comes with complains of increased nervousness for the last few weeks Noted to have an recent change in role in scool and is more nervous on weekends sicne she has an english class to deliver on mondays her symptoms have remained constant no releieving factors Has occasional headache relived with tylenol She also has stress at home in taking care of family members He consumes caffiene frequently She denies fever sad modd decreased Pre existing Developed Conditions concentration no chest pian palpitations SOB no diarrhea increased sweating or similar episodes of Impacting Hospital Stay nervousness in past No weight loss appetite good Has diffiulty falling asleep ROS Negative except above Medications Tylenol Allergy NKDA PMH No HTn DM hypercholestrolemia No other mental illness PSH None FAmily H Nothing contributory Social and sexual H Sexually active with husband occasional EtOH No Illicit drugs No Tob smoking Gynec Reglular periods Discharge some activity restrictions suggested full course of Summary antibiotics check back with physican in case of relapse strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 45127 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 45 YO F C O NERVOUSNESS FOR FEW WEEKS CONSTANT WORSENING ON SUNDAY AND MONDAY BEOFRE HER LECTURE AND WORRIES ABOUT HER LECTURE H o DIFFICULTY IN FALLING SLEEP H o RECENT INCREASE STRESS IN LIFE AND TAKING RESPONSIBILTY OF SON MOTHER AND IN LAWS H o TAKING 5 6 GLASS OF COFFEE EVERYDAY NO H o PALPITAION SHORTNESS OF BREATH CHEST PAIN SWEATING Pre existing Developed Conditions NUMBNESS CHOKING DIFFICULTY CONCENTRATION GULIT Impacting Hospital Stay FEELING ROS NEGATIVE EXCEPT ABOVE PMH PSH NONE MEDS TYLENOL OCCASIONAL FOR PAIN FH FATHER DIED OF HEART ATTACK GYN OBS LMP 1 WEEK BACK AND CYCLE REGUALR SSH 1 2 GLASS OF DRINK ON WEEKEND NO SMOKING AND ILLICIT DRUG USE UPTODATE WITH PAP SMEAR Discharge follow up in two to three weeks with regular physician Summary regular diet no activity restrictions no discharge meds VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009894064 Gender Female Attachment Control Number XA 7B 009 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient ID 94064 HPI 20 yo F c o bilateral headche X 1 day pain is dull of present illness constant and progressively worsening no radiations pain is worsened by light and walking and bending mildly relieved by ibuprofen No speech problems weakness or visual loss She reports N V and mild URI symptoms Had mild fever this morning no neck pain Mother had migraine and she has used OCP for 2 years now ROS negative except as above PMH None PSH none ALL NKDA MEDS OCP and ibuprofen FH as per HPI SH Marijuana and alcohol use 2 3 times weekly Eats balance diet and exercises She has not been under any stress lately Discharge Discharge Studies Summary regular diet no discharge meds follow up in two to three weeks with regular physician no activity restrictions VS 3S Q990 7550 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843643 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 43643 Patient is a yo woman presenting to clinic to nervousness of present illness She reports feeling nervous all of the time with it being worse Sunday and Monday This began a few weeks ago when at the time she started lecturing as a college professor on Mondays Reports not having an appetite on Sundays and Mondays and back to baseline on Tuesday Has trouble falling asleep for past few weeks Admits to life stressors with teaching and mom living with her and taking care of in laws who have medical issues This has worsened over past weeks Has never had this before and no family history of this Denies change in vision or hearing weakness in extremities change in weight temperature intolerance and change in bowel habits PMHx none PMSx none Meds tylenol for headache with reading Allergies none FHx father died at 65 of MI SHx 1 2 glasses of wine occassionally denies tobacco use denies drug use ROS as per HPI otherwise negative Discharge Discharge Studies Summary suggested dietary restrictions discharged to home nursing facility prescription medication course recommended follow up with physician in one week VS 3S Q990 7550 1090001004290 123691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 56830 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis Pt is a 26 yo F who presents with palpitations Onset 3 weeks ago Described as heart pounding No triggers Episodes last 15 30 min and first occurred 1 2x day but have increased in frequency Had newly assocaited finger numbness 2 weeks ago prompting her to go to ED CBC metabolic panel EKG and cardiac enzymes were negative Has associated nausea SOB throat tightening and clamminess Confirms h o similar symptoms occurring 5 years ago with episodes occurring 1 2x month Recently stressed due to purchasing a condo Pre existing Developed Conditions and losing her job Denies associated diaphoresis Impacting Hospital Stay chest pain or rash ROS fever chills heat intolerance weight change change in appetite headache vision change vomiting change in bowel movements abdominal pain change in urination rash weakness PMH none Meds none Surgeries none Allergies NKDA SHX Denies illicit drug use EtOH use or tobacco use Good diet and exercise FHx none Discharge no discharge meds regular diet follow up in two to Summary three weeks with regular physician no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843118 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient No 43118 CC 45 yo F with nervousness of present illness HPI Patient comes in for 2 3 weeks of nervousness Symptoms have been constant and associated with diminished appetite and difficulty falling asleep They intensify on Sunday nights and Monday before she gives lectures Patient is a college English literature professor Of note patient mentions many stressors and responsiblities and feels as if she is overwhelmed and losing her mind at times ROS weight loss palpitations diaphoresis headache heat intolerance suicidal ideation PMH none only hospitalized twice for the birth of her two kids NKDA meds tylenol as needed for headaches FH father had MI at 65 SH drinks socially no smoking or drug use college English literature teacher 2 kids Discharge Discharge Studies Summary discharged to home nursing facility prescription medication course recommended follow up with physician in one week suggested dietary restrictions S 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 30271 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 35 YO M W stomach pain Pain comes and goes No specific onset doesn t radiate relieved initially with Tums no precipitationg factors Duration is 2 months Associated with eating describes bloating sensation No previous episodes Pain is 5 10 in midepigastric region Describes as burning pain Patient going through divorce but negative for decreased interest guilt energy has changes in sleep but associated with pain and no thoughts of harming Pre existing Developed Conditions self ROS negative for weight diet fever urinary GI or Impacting Hospital Stay thyroid changes Positive for decreased appetite Patient also endorses dark stools Not related to food No reflux Endorses nausea PMH none PSH none Medications Tums not currently taking motrin FH both parents in good health uncle with bleeding ulcer Social 5 1PPD couple beers week but not currently taking no travel no drugs works as construction worker not currently sexually active Discharge check back with physican in case of relapse full Summary course of antibiotics strict diet some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009833364 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient No 33364 HPI 3 yo m c o stomach pain of present illness gradually started 2 months ago comes and goes like burning middle upper part of his abdomen 10 in intensity lasts 1 2 hours for each pain he has had that pain 2 3 times a day recently tums relieves his pain at first but now it doesn t relieve his pain reports nausea ROS denies vomiting fever diarrhea weight loss loss of appetite PMH no major illnesses no past surgical histories no history of hospitalization Allegy NKDA Meds motrin for pain FH Noncontributory SH 0 1PPD for the past 20 years EtOH a few beers a week no illicit drugs he is not sexually active no hisotry of sexually transmitted infections he is construction worker Discharge Discharge Studies Summary some activity restrictions suggested check back with physican in case of relapse full course of antibiotics strict diet VS 3S Q990 70 1090001004290 1234691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 888 999 0000 Fax 888 999 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 56992 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis Patient is a yo F who comes to clinic for a F U for palpitations Patient was sent to the ER 2 weeks prior for finger numbness with worsening palpitations workup came up negative for any pathology She claims palpitations started 5 years ago and has been intermittent since and worsening 3 weeks ago She notes the intensity to be the same and notes finger numbness started 2 weeks prior Numbness does not radiate and no color changes observed Patient denies Pre existing Developed Conditions caffeine use or recent anxiety Patient notes SOB and throat tightness which started 5 years ago as well Impacting Hospital Stay Endorces nausea and Hot and cold temperature changes Denies N V D or constipation or urinary changes PMH None PSH None Allergies none Meds None FH None OBGYN Regular 30 day menstrual cycles lasting 4 days LMP month ago Pap smear 6 months ago WNL GOPO SH Unemployed Denies tobacco Alcohol or drug use Sexually active with boyfriend uses condoms Discharge strict diet check back with physican in case of Summary relapse some activity restrictions suggested full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009890835 Gender Male Attachment Control Number XA 7B 009 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 90835 CC I have a headache of present illness HPI woman complaining of headache since she woke up yesterday morning Dull constant pain all over her head Associated with nausea and vomiting neck pain stiffness achy feeling all over her body Subjective fever Associated photophobia runny nose and scratchy throat Tried taking ibuprofen and tylenol with no relief Denies aura symptoms sensitivity to sounds chest pain abdominal pain ROS Negative except mentioned in HPI PMH meds allergies None OCPs ibuprofen and tylenol NKDA PSH None Fam Hx Mom with migraines dad with hyperlipidemia OBGYN GOPO menses regular 28 day intervals with moderate flow 3 4 tampons day Denies pain spotting OCPs Social hx Sales associated at a sports store lives with roommate and is safe sexually active with 1 partner using condoms 2 3 drinks on weekends CAGE 0 4 denies tobacco mariguana use several times wk counseled on dangers Discharge Discharge Studies Summary follow up in two to three weeks with regular physician regular diet no discharge meds no activity restrictions S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 337 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo male presenting with stomach pain HPI Pt reports burning gnawing sensation to epigasric area x 2 months with 5 10 intensit and waxing and waning course The pain does not radiate to the back or Pre existing Developed Conditions anywhere Initially Tums alleviated pain but no longer Impacting Hospital Stay helping wakes up in the middle of the night with epigastric pain abdoinal bloating PMH None Allergies None Meds Tums No surgeries none oher than abofe FAm Hx uncle with bleeding ulcer works in high elevation construction Smokes 1 2 to 1 ppd X 30 yrs social Etoh no rec drugs Discharge check back with physican in case of relapse some Summary activity restrictions suggested full course of antibiotics strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843566 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient No 43566 Patient is a yo F with nervousness These symptoms of present illness began a few weeks ago Patient describes feeling overwhelmed with taking care of her mother her tasks for her job as an English professor and her two kids Patient has had decreased appetite and trouble falling asleep Patient has regular menses every 28 30 days She denies changes in weight changes in skin pigmentation hair loss changes in bowel Patient denies headaches palpitations diaphoresis Patient denies chest pain tremor PMH none PSH none Meds Tylenol for rare headaches SH no tobacco use social EtOH use no illicit drugs FH father myocardial infarction no hx of malignancy hypercortisolism Discharge Discharge Studies Summary no activity restrictions follow up in two to three weeks with regular physician no discharge meds regular diet VS 3S Q990 7550 1090001004290 123691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 31237 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis 35 yo presenting with 2 months of epigastric pain nausea Pt reports nausea and epigastric pain for 2 months has not had any emesis Pain is described a burning and gnawing intermittent with no relation to eating Pt reported some improvement with Tums at first but has not helped more recently The pain does not radiate anywhere Denies HA light headedness SOB cough wheezing palpitations Pre existing Developed Conditions jarrhea constipation No recent travel Uses Motrin Impacting Hospital Stay frequently for back pain Smoker endoreses back pain PMH back pain Meds Motrin PSH none FH non contributory SH construction worker stressful job wife left him recently lives alone now no kids smoker 10 20 pk yrs 3 4 beers wk no recreational drugs ALL none Discharge no discharge meds follow up in two to three weeks with Summary regular physician regular diet no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009850829 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 50829 yo female presents with heart racing her heart racing of present illness started 2 weeks ago and occurs 1 to 2 times day or once every a few days associated with numbness in all her fingers shortness of breath nausea with no vomiting and hot and cold feeling when she has palpation She also notices fatigue after heart racing with difficulty concentration She feels stressed recntly but denies the palpation is related to her period She denies any specific things to induced the heart racing She denies any change in body weight sleep problems diarrhea or constipation OBGYN regular period with no complications LMP was 1 5 week ago ROS negative except as above allergy NKDA medications noen PMH PSh none SH no smoking EtOH or illicit drugs Sexually active with a sex partner and use condem FH noncontributory Discharge Discharge Studies Summary full course of antibiotics strict diet some activity restrictions suggested check back with physican in case of relapse S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 10542 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis This patient is a female presenting to the getting awoken with from progressively complaints sleep with of RLQ RLQ pain pain that Pt reports rating she 5 10 be ED was seems to worse constant in severity and described as a dull aching pain She notes associated diarrhea that has occured the last 2 3 days 4 5 times per day with loose watery stool Denies any Pre existing Developed Conditions blood in her stool No other ill symptoms or urinary symptoms preceding this illness LMP was 2 weeks ago Impacting Hospital Stay and was normal She was last sexually active 9 months ago with her partner She had no history of pregnancy or previous STI PMH None NKDA Surgical Hx None Social Student studying pre med biology does not smoke drinks alcohol about 2 times per month denies recreational drug use Discharge no activity restrictions regular diet follow up in Summary two to three weeks with regular physician no discharge meds VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 54922 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis y o female to clinic after visiting ER 2 weeks ago for palpitations workup in ed was wn for Metabolic panel Cardiac enzymes ECG and CBC Patient has been having episodes of SOB hot flashes nausea throat tightness cold and clammy hands 1 2x daily since ER visit Also has paresthesia in fingertips No signifance with temperature changes Unable to pinpoint Pre existing Developed Conditions a specific time for events No skin Changes No Hair Impacting Hospital Stay or exertional She repoits being tired and changes concentration No changes She in is sleep not depressed appetite SOB lack energy non of levels concentration after an episode of palpitations Pt reports recent stress of losing job 2 months ago LMP 1 week ago regular suxually active with boyfriend uses condoms No PMH meds NKDA no sx or hx no relevant fam hx Discharge suggested dietary restrictions prescription medication Summary course recommended discharged to home nursing facility follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 93158 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis HPI 20 yo F presents with headache starting yesterday morning Pt says it is like a bad hangover but no drinking hx Headache is all over the head dull constant nonradiating and slightly alleviated by ibuprofen and sleeping Aggravated by walking and bending over to tie shoes Associated with photophobia feeling warm nausea and vomiting Pt vomited up food first and then green sputum Pt also has achy pain all over muscles No dizziness no Pre existing Developed Conditions chills no trauma eye pain changes in vision chest pain SOB abdominal pain constipation or diarrhea Pt Impacting Hospital Stay had runny nose with scratchy throat before headache No ill contacts ROS negative except as noted above NKDA Meds BC pills PMH none PSH none Fhx dad has HTN mother has migraine headache Shx Pt does not smoke Drinks 2 3 drinks a week Smokes 3 4 joints a week works at sporting goods store Discharge strict diet check back with physican in case of Summary relapse some activity restrictions suggested full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009852368 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 52368 HPI 26 yo f presents with palpitations that started first 5 of present illness years ago She feels like her heart is pacing faster and pounding when she has these episodes In last 2 weeks her palpitations have gotten worse Shortness of breath nausea felling hot accompanies her episodes She has not had loss of consciousness before She denies any triggering events Episodes generally last up to 30 minutes She denies change in appetite change in bowel movenents change in urinary habits change in hair and skin change in voice chest pain She denies mood changes and anxiety No consumption of coffe or energy drinks Menstraul periods are regular Allergies NKA PMH PSH Noncontributary sh Non smoker no alcohol no illigal drugs sexually active only with her boyfriend Discharge Discharge Studies Summary check back with physican in case of relapse some activity restrictions suggested full course of antibiotics strict diet VS 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 33393 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo M presents to the office complaining of stomach pain for the past 2mo Describes the pain as intermittent burning and has progressively been getting worse Rates his pain as 5 10 in intensity but does not radiate He has been taking tums to alleviate his symptoms States that sometimes his stool is of darker color but no blood Has been experiencing some Pre existing Developed Conditions nausea but no vomiting and decreased appetite Denies Impacting Hospital Stay fever HA lightheadedness lumps in his throuat diarrhea constipation changes in bladder habits weight changes ROS Negative except as above NKDA Medications Tylenol PMH Back pain muscle spasm PSH None SH Smokes 1 2 to 1PPD day for 15 years drinks occasionaly recently stopped due to his painm not sexual active works as a high elevation construction FH Uncle had a bleeding ulcer Discharge regular diet no activity restrictions follow up in Summary two to three weeks with regular physician no discharge meds VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY, Real Hospital Of Ph Excellence in Healthcare since Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 53937 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis HPI pt is a 26 yo F who presents for f u for palpitations noticed palpitations 5yrs ago occured sporadically became more frequent until 3wks ago when she experienced them 1 2x per day since her ED visit she has still experienced these palpiations occuring once every few days the palpitations are accompanied by SOB feelings of tighness in her throat nausea feeling cold clammy and a feeling of impending doom also had cold feeling in hands at her recent ED visit with these palpiations Pre existing Developed Conditions denies avoiding places because of the palpitations Impacting Hospital Stay has difficulty concentrating and feels fatigued after episodes ROS negative for fever chest pain feelings of depression Meds non All NKDA PMH none PSH none FH noncontributory SH Lives alone recently lost job and has been looking for new job Sexually active with boyfriend uses condoms consistently no hx of STDS no alcohol smoking drug use Discharge full course of antibiotics check back with physican in Summary case of relapse some activity restrictions suggested strict diet S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 2442 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 17 yo M with h o feeling like heart is beating out of his chest for 2 3 months Has had 5 6 episodes each occuring randomly lasting 3 4 minutes each Nothing alleviates or aggravates Last episode was 2 days ago while playing basketball Felt chest pressure light headededness and shortness of breathe Episode lasted 10 minutes and went away on its own He has been taking friends for 2 weeks for college performance Pre existing Developed Conditions and feels like this was associated with one episode Impacting Hospital Stay Review of systems denies fever chills fatigue weight loss anxiety nausea vomiting abdominal symptoms urinary symptoms dizziness weakness cough chest pain PMH surgery none medication friends NKDA FH father MI at mom with thyroid problem SH college student lives with roommate in on weekends no tobacco marijuana x1 at a party Exercises 2 3 miles per week eats balanced diet stressed about college Discharge strict diet some activity restrictions suggested full Summary course of antibiotics check back with physican in case of relapse VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009872047 Gender Female Attachment Control Number XA 7B 007 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient No 72047 pt is a 35 y o f who presents with 6 months of irregualr of present illness menses Her normal menses occur every 4 5 wks with 3 4 days of bleeding with 4 5 tampons needed on the first day over the last 6 months she has had only 2 periods during which she has had heaveir bleeding requiring 7 tampons on the ifrst day She has not noticed any clotting in her menses and denies any discharge No pain burning or discomfort noticed not recetn illness or sick contacts The pt has not noticed any triggering events nothing makes it better or worse she has not noticed anyother symptoms She is currently sexually active with her boyfirend and does not use contraceptives because she does not think she can become pregnant She is monogamous No pst STDs No PMH no surgical hisotry FH notable of cervical cancer in granmother breast cancer in mother She drinks vwery seldom no tobacco no drugs No meds or allergies pap smears up to date No past pregancies Discharge Discharge Studies Summary discharged to home nursing facility follow up with physician in one week suggested dietary restrictions prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 50934 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis 26yo F presents for a follow up appointment after having palpitations and numbness of her fingers in both hands 2 weeks ago The patient refers palpitations lasting for 15 30 minutes for the past 5 years with unknown cause during the episodes she has nause and an important dyspnea but no cough or chest pain She denies dizziness and any other focal neurologic signs The last palpitation was yesterday nothing seems to Pre existing Developed Conditions elicit such episodes She has not lost her Impacting Hospital Stay consciousness Healthy diet practices exercise No fatigue sadness psychologic trauma The exam results were informed to the patient ROS normal urine and bowel movements no headache dizziness no abdominal pain PMH none PSH none Meds none Allergies none FH none SH looking for a job monogamous with boyfriend regularly condoms no EtOH no smoking no illicit drugs Discharge no activity restrictions follow up in two to three Summary weeks with regular physician no discharge meds regular diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009870171 Gender Female Attachment Control Number XA 7B 007 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 70171 Patient is a female with PMH significant for of present illness inability to conceive who presents with 6 months of heavy menstrual bleeding She reports that previously her menstrual cycles lasted approximately 3 days and now last 7 days cycles occur every other month She also reports needing to change her tampon pac every 1 2 hours Denies light headedness SOB abdominal pain vaginal discharge hx of STI s gential lesions or sores Pt reports that she was on OCP s when she started menses at age which regulated her periods Not currently using contraception Last Pap smear 6 months ago was normal Sexually active with one male partner Pt reports hx of not being able to conceive with her ex husband despite trying for 9 years Meds None Allergies NKDA PMH None PSH None FH Aunt breast cancer grandmother cervical cancer SH Lives W 2 adopted kids No hx of tobacco use or illicit drug use Less than 1 beer month Discharge Discharge Studies Summary no activity restrictions follow up in two to three weeks with regular physician regular diet no discharge meds VS 3S Q990 7550 1090001004290 345691823728 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009855937 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient 55937 HPI Pt is a 26 yo F here for followup at outpatient clinic for of present illness heart palpitations Palpitations began 5 years ago but episodes have increased in frequency X 3 weeks Went to 2 weeks ago and workup was completed Persistent episodes of heart palpitations throat tightness nausea shortness of breath quick bodily temperature changes and occassional numbness in distal upper extremities lasting 15 30 min resolving on own Feels as if something bad is going to happen Denies headaches dizziness changes in vision perioral numbness dry skin changes in menstrual period changes in bowel movements Recent stressors include buying new condo and losing job patient lives alone Boyfriend as main support Of note CBC Metabolic panel cardiac enzymes and ECG all WNL from visit as above PMH none no surgeries FamHx noncontributory Social denies etoh drugs cigarrettes recent job loss lives alone Meds none NKA Discharge Discharge Studies Summary follow up with physician in one week suggested dietary restrictions prescription medication course recommended discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 61114 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis 17 YO M WITH RECENT H o FLU C O CHEST PAIN X 1 DAY IT STARTED YESTERDAY SUDDENLY CONSTANT NON PROGRESSIVE ON LEFT SIDE OF THE CHEST SHARP KNIFE QUALITY AGGRAVTES WITH DEEP BREATHING RELIEVED WITH NORMAL BREATHING ALSO PARTIALLY RELIEVED WITH SITTING PATIENT HAD FLU LAST WEEK WEEK WHICH RESOLVED WITHOUT Pre existing Developed Conditions ANY MEDICATION Impacting Hospital Stay DENIED SOB PALPIATAIONS COUGH HEADACHE WEIGHT APPETITE SKIN URINARY CHANGES SLEEP MOOD JOINT PAIN PMH LAST WEEK FLU ASTHMA MEDS ALBUTEROL INHALOR BUT USING LESS FREQUENTLY TYLENOL FOR CHEST PAIN NKA FH FATHER ASTHMA AND HTN MOM FINE SH BEER DENIED SMOKING ILLICT DRUGS Discharge discharged to home nursing facility follow up with Summary physician in one week suggested dietary restrictions prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 54854 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis Patient is old complaining of worsening paroxysmal heart palpitations for past 3 weeks 2 weeks ago patient went to the ED because of palpitation and numbness in all her fingers ED tests were negative CBC EKG metabolic panel and cardiac enzymes The patient is coming to clinic today for followup visit She continues to complain of heart palpitations No associated numbness of fingers at this time States Pre existing Developed Conditions palpitations initially started 5 years ago Associated symptom of nausea suddenly turning cold after being Impacting Hospital Stay hot tightness of throat Denies being anxious or having panic attacks Denies tremors skin changes ROS No fevers chills vomiting chest pain sob abdominal pain edema in legs urinary bowel changes PMH None PSH None Medications None Allergies None Social Does not drink use tobacco or use drugs In between jobs Discharge suggested dietary restrictions discharged to Summary home nursing facility follow up with physician in one week prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 36640 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 35 yo M c o stomach problems since 2 montsh ago Patient radiating reports Pain epigastric is described abdominal as gnawing pain and non burning intermitent lasting 1 2 hours and gotten progressively worse Antacids used to alleviate pain but not anymore nothing exhacerbates pain Pain unrelated to daytime or to meals Patient denies constipation or diarrhea Patient denies blood in stool but have noticed them Pre existing Developed Conditions darker Patient also reports nausea Denies recent illness or fever He also reports fatigue since 2 weeks Impacting Hospital Stay ago and bloating after eating ROS Negative except for above findings Meds Motrin once week Tums previously PMHX Back pain and muscle spasms No Hx of surgery NKDA FHx Uncle has a bleeding ulcer Social Hx Smokes since 15 yo PPD No recent EtOH use Denies illicit drug use works on high elevation construction Fast food diet Exercises 3 4 times week but stopped 2 weeks ago Discharge some activity restrictions suggested full course of Summary antibiotics check back with physican in case of relapse strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009833366 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient No 33366 3 YO M CONSTRUCTION WORKER USING MOTRIN C O of present illness PAIN IN EPIGASTRIUM FOR 2 MONTHS IT IS GRADUAL IN ONSET EPISODIC BURNING IN QUALITY NON RADIATING W O AGGRAVATED AND RELIEVED FIRST BY TUMS BUT FROM LAST 2 WKS NOT RELIEVED BY ANYTHING IT IS ASSOCIATED WITH BLOATING BELCHING AND WAKE UP AT NIGHT DUE TO PAIN FOR 2 WKS HIS STOOL COLOR CHANGE TO DARKER BROWN FOR 2 MONTHS HE REPORTS HIS PAIN WORSEND BY LAST 2 WKS NOW TUMS NOT WORKING HIS APPETITE ALSO DECREASED HE DENIES YELLOWNESS OF SKIN DISTENSION OF BELLY DIFFICULTY IN FLUSHING STOOLS WEIGHT MOOD CHNAGES AND BURNING SENSATION IN CHEST AND CHANGE IN TASTE OF MOUTH EXCEPT AS ABOVE PMH NONE MEDS AS HPI PSH HOSP NONE FH N C ALL NKA SSH SMOKES 0 1 PPD FOR 1 YRS AND OCCASIONALLY DRINKS ETOH Discharge Discharge Studies Summary no activity restrictions regular diet no discharge meds follow up in two to three weeks with regular physician S 3S Q990 70 900004290 1234691823728 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient DVM Provider s Pt ID 00981941 Gender Male Attachment Control Number XA 7B 000 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 1941 male presents with 5 6 heart punding episodes over of present illness the last 2 3 months Patient states the ocurr randomly no inciting factors and self resolve on their own On one occassion patient had an episode while he was playing basketball in which he became light headed sob and experienced a pressure like sensation in his chest no pain no radiation did not lose consciousness or fall Every episode last a couple minutes Denies any fevers chills weight loss HA seixures chest pain cough nause vomiting difficulty urinating or stooling He is a college student plays basketball club team is sexually active with gf and wears condoms consistently He does not have any and prescribed meds but he takes his friends aderrall prescriptions a couple times a week to study Couple cups of coffee per week No smoking or illicit drug use Ocasioanl etoh on weekends No pmhx surg hx Famhx mom thyroid problem dad MI at 52 Discharge Discharge Studies Summary no activity restrictions regular diet no discharge meds follow up in two to three weeks with regular physician VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009850354 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient No 50354 yo female presents for a follow for palpitations She was of present illness seen in the emergency department 2 weeks ago for palpitations At that time Complete blood count Metabolic panel Cardiac enzymes ECG were all within normal limits Today she continues to experience episodes and are progressively getting worse Have been occuring for 5 yrs Now has new onset of nubness in fingers Episodes last 15 20 mins and are accompanied by SOB Nausea Hot cold clammy and has fatigue after episode for the rest of the episodes are random no triggers Neg for syncope constipation diarrhea skin changes depression anxiety mania psychosis suicide PMH none Allegies none Meds none Hos surge none Family hx none Sexual currently sexually active one partner BF uses condoms every time neg for hx of STD last pap was 6 months ago Social Stressed lost job bought new appartment Discharge Discharge Studies Summary no activity restrictions no discharge meds follow up in two to three weeks with regular physician regular diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 579 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis Patient is a male with no pmh who presents today for chest palpitations Patient reports that for the past 2 3 months he has had the spontaneous onset of these chest palpitations that last 3 4 minutes They do not appear to be associated with anything and they tend to abate on its own He reports that sometimes during these episodes he will also experience chest pressure fatigue and SOB and even occured during his basketball Pre existing Developed Conditions game of note he reports use of 2x week to study He is worried that he will have more episodes in Impacting Hospital Stay the future He reports that his mood is good and currenlty denies anxiety weakness fatigue SOB Chest pain bowel changes diarrhea constipation tremors recent illnesses or trauma pmh none psh noen allergies none meds sporadic FH mother with thyroid disease father with MI Tobacco none Drugs and marijuana use 1x Discharge suggested dietary restrictions follow up with Summary physician in one week prescription medication course recommended discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 34103 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis This is a male with 2 months of burning pain in the epigastric region that is worsening The pain is nonradiating and is rated No aggravating factors Pain was relieved with TUMS previously but no relief anymore The pain has no relation to meals but wakes the patient up at night 3 nights a week The pain is associated with nausea for 2 months and darker stool for 2 weeks as well as decreased appetite and abdominal bloating No vomiting diarrhea Pre existing Developed Conditions constipation change in urinary symptoms fevers Impacting Hospital Stay chills backaches from construction work Meds motrin for backaches TUMS No Allergies No significant past medical or surgical history Social Family starting History history smoking of an beers uncle PPD per with x20 week years peptic prior ulcers no to illicit this pain drug use going through a divorce works in construction not currently sexually active regular diet and exercise Discharge full course of antibiotics check back with physican in Summary case of relapse some activity restrictions suggested strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009833640 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient No 33640 Patient is a yo male who presents with a 2month history of present illness of worsening stomach pain He describes the pain as a burning gnawing pain in the mid epigastric region and experiences it about 2x day within the last week he also notes that it has twice woken him up from sleep Tums helped only at first and he denies any other alleviating aggravating factors He has also had nausea bloating after he eats and dark stools during this time period but denies any vomiting constipation diarrhea foul smelling stools hematochezia or pain on defecation He denies any reflux dysphagia joint pain vision changes rashes yellowing of his skin or nighttime coughing PMHx Frequent backaches and spasms Denies any history of GERD PSHx None Fam Hx Uncle with a bleeding stomach ulcer SOcial Hx Works in construction Previously drank 2 3 beers per week but stopped due to bloating Current smoker with 5 packyear smoking history No illic Discharge Discharge Studies Summary strict diet full course of antibiotics some activity restrictions suggested check back with physican in case of relapse S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 276 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo M complains of burning stomach pqin that has been going for 2 months The pain is located in epigastric area does not radiate and is itermittent It has not been worsening At its worse it is Patient reports that the pain has woken him up from his sleep Anti acids used to help the pain but not anymore Patient reports associated nasuea but has not vomitted Patient denies any changes to his bowel or urinary habits but reports that his stools have been recently darker No weight loss or changes in appetite No Pre existing Developed Conditions fevers no night sweats No blurry vision SOB Impacting Hospital Stay headaches or rashes ROS occasional joins and back pain associated with working in construction allergies NKDA meds motrin 2 pills per week PMH none PSH none FH uncle with bleeding ulcer SH PPD for the last 20 years occasional EtOH Not sexually active no illicit drugs no exercise High fat diet Discharge suggested dietary restrictions follow up with Summary physician in one week discharged to nome nursing facility prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 83836 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis hpi 67 yo f c o sleeping distutrbance since 3 weeks factors progressive recent and h o no son associated death 3 weeks and relieving back and of non S c o visual and auditory hallucinations h o loss intrest and lack of energy and assoc with increased early morning awakenings and increase in appetite She denies guilt loss of concentration and psychomotor Pre existing Developed Conditions retardation and suicidal ideation no fever headaches Impacting Hospital Stay snoring at nights weight changes sob palpitations ros negative except above allergies nka nkda pmh and psh htn X 15 yrs and no dm neds HCTZ Lisinopril Ambient obgyn 1mp 15 y ago sh active with husband no smoking occasinal 1 glass wine on weekends no rec drugs and coffee Discharge regular diet follow up in two to three weeks with Summary regular physician no discharge meds no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 36860 Gender Male Visit Attending Physician Dr 11 Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 35 y o m with stomach ache HPI started 2 months ago intermittent occurs twice per day it mediam annoying pain not worsen by any thing associated with nausia no vomiting there is a Pre existing Developed Conditions bloating senation no fever Impacting Hospital Stay PMH back pain for 10 y on moltren PSH neg FH uncle with bleeding peptic ulcer SH smoker 1 ppd since 15 y o not sexually active beer per week ALLergies nkd Discharge some activity restrictions suggested check back with Summary physican in case of relapse strict diet full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009855854 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 55854 Patient is a female who presented with heart palpitations of present illness The symptoms began 5 years ago but have increased in frequency in the past few weeks and now she has episodes 1 2 times a day at most 2 weeks ago she went to the ED after an episode because she also experiences b l numbness in her hands She denies any weakness or sensory changes When the episodes occur she has periods of SOB and nausea but no chest pain LOC dizziness lightheadedness or vomitting She experiences tightness in her throat and feels hot then cold and clammy She denies any changes in sleep interest energy levels appetite Allergies NKDA Meds none PMHx none PSx none Fx noncontributory Social lost her job 2 months ago does not smoke drink do recreational drugs Discharge Discharge Studies Summary discharged to home nursing facility prescription medication course recommended suggested dietary restrictions follow up with physician in one week S 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 54086 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis Patient is a yo F that presents for f u of palpitations after being seen in the ED The palpitations began 5 years ago increased in frequency 3 weeks ago About 2 weeks ago durng her fingers went numb so she went to the ED workup was WNL Since then she has plapitations every couple of days Her fingers have not gone numb again She described the palpitations as heart racing She has associated SOB Pre existing Developed Conditions nausea tight throat and feels cold and clammy These Impacting Hospital Stay symptoms resolve in 15 30 minutes Nothing exacerbates or alleviates her symptoms She denies chest pain loss of consciousness abdominal pain changes in bowel or bladder habbits fevers Denies mood changes sleep difficulty LMP was 2 weeks ago No past medical history past surgeries medications or known allergies No pertinent family history Patient reports she bought a condo 3 months ago but lost her job 2 months ago No alcohol tobacco drugs Sexually active Discharge discharged to home nursing facility prescription Summary medication course recommended follow up with physician in one week suggested dietary restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Mrs Provider s Pt ID 009890737 Gender Female Attachment Control Number XA 7B 009 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient No 90737 yo f COMplains of severe headache since yesterday of present illness started after she woke up in the morning it is the worse headache of her life no radiation aggravated by walking and bending over she also feels warm and had nausea and vomited 3 times food material and greenish in the last vomiting with no blood she has photophobia and pain in her neck with stiffness she denies dizziness LOC weakness numbness rash seizures vision or speech problem she uses marjiwana 3 4 wk and uses OCP PMH ALL PSH NONE MEDS OCP FH HEADACHE HER MOTHER SH NO CIGARETTE ALCOHOL OCCASIONALLY SEXUALLY ACTIVE WITH BOYFRIEND Discharge Discharge Studies Summary full course of antibiotics some activity restrictions suggested check back with physican in case of relapse strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 81657 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis Patient a female has come to the physician s office because of trouble sleeping She said it has been going on for 3 weeks It had stayed the same She took Ambine and it didnt help Nothing makes it worse She has 1 cup of coffee every morning She leaves 4 5 hours a night She tried taking naps but isnt able too She doesnt like excerising anymore She has no Interest in her activity She has been eating Pre existing Developed Conditions more she states She lost her son She Impacting Hospital Stay denies any sucide thoughts as per above PMHX High Blood Pressure HTZC Lisnopril Remission from Breast Cancer Allergies NKAD PSHX Lumpectomy Appendix removal Normal childbirth FHX Father stroke and High Blood pressure Mother Depression SHX None Discharge discharged to home nursing facility prescription Summary medication course recommended suggested dietary restrictions follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009838307 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 38307 Th epatient is male who came in due to stomach of present illness problems since 2 months ago which lasts for 2 to 3 hours with accompanying nausea located at the epigastrio area graded 5 out of 10 The pain is progressing and is intermittent with no radiation Pain was described as a burning sensation Tums was initially used to alleviate the pain but in the long run it does not work for the patient anymore Stools were also noted to be darker in color darker brown no presence of blood no changes in odor and consistency He also has been eating less because of the pain No changes in weight ROS occasional back pains PMH none PSH none FH healthy SH works at a construction site quit smoking previously half to 1 ppd day since he was yo drinks occasionally 1 to 2 beers no illicit drug use currently not sexually active Discharge Discharge Studies Summary some activity restrictions suggested strict diet check back with physican in case of relapse full course of antibiotics S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009860077 Gender Male Attachment Control Number XA 7B 006 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 60077 Patient is a male with sharp chest pain when of present illness breathing started yesterday morning and has been the same since is not positional left upper chest reports stuffy nose and muscle aches of 3 4 days denies sick contacts or traveling was rock climbing the other day in an indoor gym pain does not radiate took albuterol and tylenol with minimal relief denies any trauma or illiciting factors HPI exercise induced asthma in the past using albuterol less frequently meds denies allergies denies hospitalizations denies surgeries denies family dad has asthma and high cholesterol grampa had an MI at 68 social denies smoking drinking or drugs ROS denies headaches or weight loss has been feeling warm denies nausea vomiting problems breathing heart burn problems lieing down constipation or diahrea denies focal weakness denies any worsening of asthma denies traveling or sick contacts Discharge Discharge Studies Summary strict diet check back with physican in case of relapse full course of antibiotics some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009841741 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient 41741 Pt is a 45 yo F with a 3 week hx of nervousness She describes it of present illness as being worried by many aspects of her life including work and taking care of her children She also has had difficulty sleeping decreased appetite and libido Around the same time the nervousness began she started a new position at work as a lecturer She denies feeling depressed a loss of interest feelings of guilt decreased energy or concentration psychomotor changes or suicidal homicidal ideation She denies distractibility and muscle tension She denies fever chills No palpitations or sweating No chest pain or shortness of breath No cold heat intolerance or hair skin changes ROS negative except per HPI PMH none no psychiatric history PSH None FH father died of myocardial infarction Medications occasional tylenol Allergies NKDA SH english literature professor no smoking or illicit drugs occasional EtOH sexually active with husband only Discharge Discharge Studies Summary discharged to home nursing facility suggested dietary restrictions prescription medication course recommended follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 70499 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 35F GO presenting to clinic with heavy periods Pt states that she had normal monthly periods up until 6 months ago when she began having heavier pedios having to change her tampon every few hours Denies any significant menstrual pain Previously tried to get pregnant for 9 years unsuccessfully with past partner unknown why No hx of STDS Last pap smear 6 mo ago all normal pap smears in past First period was at old Also endorses increased pigmentation on Pre existing Developed Conditions hands and around her neck flexion areas that is new within the past year Sexually active with her Impacting Hospital Stay boyfriend of vaginal pain discharge pruritis PMHX PSHx Meds allg none Soc hx lives with 2 daughters in house works in call center Health related behaviors tobacco use drugs rare social alc fam hx aunt with breast cancer grandmother with cervical cancer ROS any F C NS skin changes HA blurry vision CX pn SOB dysuria Discharge follow up with physician in one week discharged to Summary home nursing facility suggested dietary restrictions prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009872720 Gender Female Attachment Control Number XA 7B 007 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient No 72720 35 y o f presents with c o problems with menstruation for 6 of present illness months periods used to be regular prior to 6 months but started to have amenorrhea for motns then heavy menses LMP was 2 months which very heavy uses 7 tampons ore than when periods were regular also has some rahses on hands and necks but denies joints paints and stiiffness gain weight 10 lbs in 6 months no change in appetite but fatigue regular ROS denies dizziness chest pain SOB abd pain N V allergy NKDA medications none PMH insignificant PSH insignificant SH single has a boyfriend denies Tobacco occasional ETOH denies recreational drugs sexual h as above sexually active with boyfriend not use condom Discharge Discharge Studies Summary follow up in two to three weeks with regular physician regular diet no discharge meds no activity restrictions S 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009894823 Gender Female Attachment Control Number XA 7B 009 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient No 94823 20 yo f GOPOAO presents to the clinic for headache of present illness Headache is located all throughout her head The pain is dull and achey in nature constant in duration and when asked to rate from 0 10 she states its really bad The headache has not progressively worsened This is the first time she has expierienced these symptoms She reports having nausea and vomiting yesterday Vomiting 3x over the course of 1 day Quantity is 1 2 cups Denies blood or odor Light hurts her eyes but does not affect her headache She also reports feeling achey all throughout her body She further states that she feels warm LMP 2 weeks ago Regular 28 day cycles Periods last 4 5 days Uses 5 6 pads a day Denies spotting between periods Medications Birth Control for 2 years Allergies Hospitalizations SexualHx Noncontributory Discharge Discharge Studies Summary follow up in two to three weeks with regular physician no discharge meds regular diet no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009882513 Gender Female Attachment Control Number XA 7B 008 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient No 82513 HPI 67 yo F c o sleeping problems since It has of present illness been constant and patient denies any previous episodes Patient feels tired everyday and nothing alleviates or aggraveates Patient feels sad decreased interest in life loss energy but denies any suicidal ideation Patient states that weight has been the same Patient is concern about her sleeping condition ROS negative except for above Allergies NKDA Med HCTZ Lisonopril PMH breast cancer PSH breast surgery SH no tobacco patient used to drink wine but last time was 3 weeks ago no illicit drugs sexually active with husband FH father died of stroke at age mother died at age and suffered from depression Discharge Discharge Studies Summary strict diet check back with physican in case of relapse some activity restrictions suggested full course of antibiotics VS 3S Q9 50 100010042 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 53698 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis yo female presents to the office for evaluation Palpitations of have heart been palpitation occuring more since recently 5 years ago she refers an episode of hand numbness BL after the palpitation occured She also refered feeling hot cold and clammy in the extremity SOB and nausea Denies any chest pain during the eipisoed She worries that somwthing terrible is about to happend Lab work done last visit was for any abnormalities Pre existing Developed Conditions Denies headache fever chills abdominal pain Impacting Hospital Stay chest pain weakeness or loss of sensation in any part of her body with exception of her hands PMH None PSH None Social Unemployed at the moment Denies alcohol smoking and drug use She walks 3 4 times a week for 30 60 min Denies any consumption of Cofee or energy drinks She is in a lot of stress atthe moment she bought a condo and lost her job Sexually active with Boyfriend use condoms and for STD FH Unremarkable Discharge suggested dietary restrictions follow up with Summary physician in one week discharged to home nursing facility prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009810891 Gender Female Attachment Control Number XA 7B 001 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient 10891 Patient a female has come to the emergency of present illness department today because of abdominal pain It started 8 hours ago RLQ pain Getting worse Constant nature Started suddenly in severity Cramping pain No radiation Tried Ibuprofen and it helped a little bit Worsened by walking Had diarrhea a few days ago day of bowel movements Brown color No nausea or vomiting Couldn t eat anything since last dinner OB GYN GOPO Menses regular 4 30 Occasional had cramps with menses ROS negative except as above Allergies NKDA Medications Ibuprofen PMH PSH None FHx None Social history occasional drinking once a month no smoking no IDU Had sexual intercourse 9 months ago with condom Discharge Discharge Studies Summary check back with physican in case of relapse full course of antibiotics some activity restrictions suggested strict diet VS 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY, Real Hospital Of Ph Excellence in Healthcare since Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 45232 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis HPI female c o nervousness for 2 3 weeks sudden after changing of work content continous getting worse no previous episodes no alleviating or exacerbating factors worse on monday morning has initial insomnia reading before bed 5 6cups coffee a day anorexia decreased libido stress at Pre existing Developed Conditions work Impacting Hospital Stay denies heat intolerance diaphoresis chest pain sob headache diarrhea constipation alopecia dizziness nausea vomiting muslce tension ROS no change in urinary habits PMH no hospitalization surgery NKDA med tylenol no Rx FH Father died of MI at SH no smoking rec drugs occ EtOH exercise regularly regular diet not sexual active due to poor libido Discharge full course of antibiotics check back with physican in Summary case of relapse strict diet some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 41190 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis Pt is a 45 y o F presenting for nervousness Pt has been noticing that she has been consistently nervous for the past 2 weeks 2 weeks ago she began doing lectures at work instead of research as a english lit professor she notices her nervousness is worse on sunday night monday mornings when preparing lectures She is nervous at work and home but there have been no changes and she feels safe at home has noticed a Pre existing Developed Conditions and decreased hight monday decreased interest morning appetites in sex Pt especially denies difficulty weight sunday falling changes asleep Impacting Hospital Stay on skin hair changes abd pain n v diarrhea constipation urinary changes Surgical hx none PMH none allergies none Social no drugs tobacco 2 drinks of alcohol 2x month walks 3x week for exercise balanced diet drinks 5 6 coffees day regularly hospitalization 2 normal vaginal deliveries FH father death due to MI at 65 y o Medications tylenol for rare headache Discharge no discharge meds follow up in two to three weeks with Summary regular physician regular diet no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 31353 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 35 yo M with no PMH p w epigastric pain x2 months Pain further described as a burning gnawing intermittent pain rated 5 10 in severity without radiation Tums initially provided some relief but no longer helps Denies any other exacerbating or alleviating factors Pain not worse with PO intake not worse at night Pre existing Developed Conditions Patient also reports feeling bloated after meals Reports nausea No vomiting diarrhea constipation Impacting Hospital Stay fevers or chills Denies similar pain in the past PMH Back pain muscle spasms PSH None Meds Motrin Allergies None SH works in construction smokes 0 5 1 pack per day x20 years drinks a few beers per week no drug use Discharge check back with physican in case of relapse full Summary course of antibiotics some activity restrictions suggested strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 35617 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 35 yo m c o stomach problems X 2 months worsening nonradiating midepigastric burning pain previously episodes were once a week now occurring 2x day accompanied with nausea previously alleviated with TUMS no vomit changes in bowel movements but has noctied stools are darker over the past 2 weeks no weight loss Pre existing Developed Conditions no fever chest pain shortness of breath nightsweats no fatigue Impacting Hospital Stay no association with meals medications motrin for muslce pain TUMS allergies nkda pmh lower back pain psh none social works in construction drinks a couple of beers per week but recently has stoppped due to the pain no illict drug use 1 2 1 ppd for 20 years Discharge regular diet no activity restrictions follow up in Summary two to three weeks with regular physician no discharge meds VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 00981869 Gender Male Attachment Control Number XA 7B 000 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 1869 M presents with history of intermittent chest palpitations of present illness for the past 3 months Reports 5 6 episodes in this time frame lasting 3 4 minutes not associated with exertion and self resolves Most recent episode was while he was playing basketball felt heart pounding light headed but did not lose consciousness Patient reports chest pressure and dyspnea something not previously associated with palpitations Patient reports using adderall recently to study for college along with excessive energy drink intake Patient denies headaches vision changes nervousness abdominal pain sweating or diarrhea ROS negative except as above PMH none NKDA Medications Adderall from friend Family Dad had heart attack at alive Mom has some thyroid issues PSH none Social denies tobacco use EtOH use on weekends denies illicit drugs sexually active with gf uses condoms Exercises frequently on Intramural basketball team Discharge Discharge Studies Summary check back with physican in case of relapse full course of antibiotics strict diet some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 54829 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis CC female with palpitations for 5 years HPI female with no significant PMH who has had episodes of palpitations for 5 years with increasing frequency for the past 3 weeks These episodes Tast 15 30 minutes and she experiences shortness of breath throat tightness nausea and feels cold and clammy during these episodes During 1 episode 2 weeks ago she also felt numbness in her fingers She denies chest pain fever or weight changes Her periods occur regularly every 30 days She Pre existing Developed Conditions denies skin or hair changes or sensitivity to heat or Impacting Hospital Stay cold The patient has been under stress lately and feels like she is going to die when these episodes occur Previously seen in ED 2 weeks ago labs and EKG normal but EKG performed after episode over PMH none PSH none Meds none allergies none FH none social history Currently unemployed lives alone sexually active with boyfriend no alcohol tobacco or drug use Discharge regular diet no discharge meds no activity Summary restrictions follow up in two to three weeks with regular physician VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009844854 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 44854 Patient yo c o refers feel nervousness for last weeks no of present illness pain O other symptoms no changes in urinary habits no changes bowel movemnts she felt worried about a lot strest in the job and take care of the mom ros no problems with sleep no palpitations no changes in her skin and hair pmh none aller none medications tylenol occupation english teacher fh father died heart attack gyn obs g2p2ao last pap smear normal LMA ONE WEEK ago sh no tobaco products no drink alcohol Discharge Discharge Studies Summary check back with physican in case of relapse full course of antibiotics strict diet some activity restrictions suggested VS 3S Q990 7550 1090001004290 123691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 52172 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis Pt is a26 yo F with no PMH complaining of heart palpitations she says the heart palpitations started 5 years ago but have become more frequent over the past 3 weeks They last for a about 15 30 min and and occur about 1 2 times per day The patient is not abl to identify any triggers or causes for her palpitations She says that she is under a lot of stress in general due to losing her job and just having bought a new home but has never suffere from panic attacks or generalized Pre existing Developed Conditions anzxiety disorder There is nothing she can do to Impacting Hospital Stay alleviate or aggravate her symptoms She says the symptoms are associated with SOB nause throat tightness and a hot and cold clammy feeling ROS pt deneis fever chills weakness fatigue chest pain lightheadedness gain or loss of weight change in apetite she also says that she has had no changes in her sleep PMH none Allergies none SOCHX lives alone sales consultant no smoking alcoholmor drugs Discharge full course of antibiotics check back with physican in Summary case of relapse strict diet some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 999 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 84116 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis Patient is a female c o trouble sleeping States she has trouble falling asleep not mainitng sleep Started about weeks ago Goes to bed around and doesn t fall asleep till tosses and turns during that time as well as thinks about recently deceased son Son died weeks ago in car acident was old wakes up at which is earlier then her norm was previously getting 8 hours of sleep Has been devastated over loss of son states she does have Pre existing Developed Conditions some sadness Has loss of interest in scapbooking and Impacting Hospital Stay reading Feels drained fatigued has no energy Eating more no recent weight changes No suicidal or homicidal ideation Has good support system No previous psychiatric hospitalizations or treatments Had episode 4 days ago of seeing son negative exceot as above Allergies NKDA Meds HCTZ lisinopril PMH htn breast cancer PSH lumpectomy drinks 4 6 glasses wine week nothing since week Discharge suggested dietary restrictions prescription medication Summary course recommended discharged to home nursing facility follow up with physician in one week VS S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843157 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 43157 HPI 45 YO F C O NERVOUSNESS STARTED FEW WEEKS AGO of present illness GETTING WORSE SHE HAS DIFFUCULT IN FALLING A SLEEP SONSUMES MUCH COFFEE SHE SWITHCH HER WORK RECENTLY AND SHE FEELS OVERWELMED SHE DENIES ANY WEIGHT CHANGES DIARRHEA OR CONSTIPATIONS TREMORS HAIR OR SKIN CHANGES SADNESS GUILTY SENSATION RASH FATIGUE PALPITATIONS ROS NEGATIVE EXCEPT AS ABOVE ALLERGIES NKDA MED TYLENOL PMH NONE PSH ONLY FOR HER DELIVERY 2 TIMES SH ETOH OCCASIONALLY NONE SMOKER NO ILLICIT DEUGS SEXUALLY ACTIVE WITH HER HUSBAND WORK AS A ENGLISH PROFESSOR OB GYN LMP 1 WEEKS AGO REGULAR NO VAGINAL DISCHARGE DRYNESS LAST PAP SMEAR AND MAMOGRAM WERE 10 M AGO AND WERE NORMAL FH FATHER WITH HEART DISEASE Discharge Discharge Studies Summary discharged to home nursing facility follow up with physician in one week suggested dietary restrictions prescription medication course recommended S 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 30208 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis HPI 35 yo m comes for stomach problems that started 2 months ago It is in the middle and upper portion of the stomach 5 10 intensity burning or gnawing in nature comes and goes and progressively worsen and happens everyday Tums helps at first but not anymore no aggrav factors Pre existing Developed Conditions He also feel like nauseated 2 months ago and loss of Impacting Hospital Stay appetite stool seems darker 2 weeks ago also bloating sensation for 2 months and pain causes difficulty sleeping PMH back pain and is taking motrin 200mg for that PSH hosp none FH uncle from father side has bleeding disorder SH construction worker cig half ppd since yo stopped Etoh drinking no illicit drugs Discharge no discharge meds regular diet follow up in two to Summary three weeks with regular physician no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 38273 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 35 yo M with burning and gnawing pain in the epigastric burping region 2 Eating months less due Nausea to pain bloating but denies fullness loss x of appetite and weight loss Denies vomiting and diarrhea Pain alleviated temporarily with Tums but has progressed and now Tums is ineffective Pani wakes him Pre existing Developed Conditions up in middle of night Also reports darkening of stools X 2 weeks Denies Tight headness dizziness fatigue Impacting Hospital Stay Denies history of anemia PMH Muscle spasms in back Meds Motrin 2x200 mg once per week Tums Allergies none PSH none Fhx uncle hx of bleeding ulcer Social denies EtOH use drug use tobacco works as construction worker Discharge check back with physican in case of relapse strict Summary diet full course of antibiotics some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax 999 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Miss Patient ID NARH 45052 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis HPI 45 y o female english literature professor c o feeling anxiet at work home and generally anytime for past 2 3 weeks She reports decreases appetite and sexual drive around the same time of onset reports that anxiety is worse the day before her having to give lectures at work and feels overwhelmed She denies any weight changes bower or abdominal complains No urinary complaints No SOB chest pain or cough She does experience headaches occasionally relieved by tyelnol Pre existing Developed Conditions ROS noncontributary except as above Impacting Hospital Stay PMH occasional headaches PSH nil Meds tylenol Allergies NKDA SH occasionally consumes a glass of wine does not smoke or use illicit drugs drinks 5 6 coffee throughout the day for as long as she can remember sexually active with husband but reports decreased sexual desure since onset of anxiety walks 3 times a week for approx 1 mile and eats diet of protein fruits and vegetables FH fateher died of MI Discharge no activity restrictions follow up in two to three Summary weeks with regular physician regular diet no discharge meds VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 54775 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis 26 y o female with c o palpitations since last 2 wks Pt started experiencing palpitations 5 yrs ago but it has worsened over the last 2 wks pt also experienced an episode of numbness of hands and fingers 2 weeks ago and it has subsided now SOB during palpitation episodes PT also experiences nausea during palpitations episodes PT does not take caffeine No Pre existing Developed Conditions chest pain Heat intolereance No LOC no headches Impacting Hospital Stay ROS as above ALLEGIES NKDA MEDS none PMH none except for palpitations PSH none no hospitalizations FMH no similar complains in family members OBGYN LMP 1 wk ago regular 5pads day flow moderate pap smear 6 months ago normal no previous pregnancies Discharge no discharge meds follow up in two to three weeks with Summary regular physician regular diet no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009881403 Gender Female Attachment Control Number XA 7B 008 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient 81403 Patient is a yo F c o difficulty falling asleep staying asleep of present illness and waking up early She also reports feeling drained and fatigued when she wake up in the morning She reports no changes to her sleep hygeine and that she drinks 1 cup of coffee every day No snoring at night Reports loss of her son 3 weeks ago and reports the new onset of seeing her son and hearing music a few times She has never experienced auditory or visual hallucinations in the past She denies any suicidal ideations trouble concentrating or memory loss She does report having an increased appetite for the past 2 weeks and she has been eating more PMH HTN breast cancer remission PSH bilateral mastectomy Meds HCTZ lisinopril ambien Allergies none SH non smoker drinks wine 2 3x week no illicit drugs she is a retired receptionist LMP at age Denies weight changes ROS none see HPI FH dad HTN cholesterol MI Depression in mom Discharge Discharge Studies Summary prescription medication course recommended follow up with physician in one week suggested dietary restrictions discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009834044 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient ID 34044 Patient is a male who complains of burning of present illness epigastrics pain X 2 months Gradual onset and increase in frequency used to be 1 X per week now 3 nights per week 2x per day Previously relieved by tums Resolves spontaneously Not associated with meals or activity Endorses bloating nausea and decreased appetite Denies fever chest pain SOB hematemesis hematochezia melena weight changes fatigue Past illness include back spasms Taking Motrin PRN for spasms No past hospitalizations surgeries or allergies Social Construction worker Endorses poor diet eats whatever is available Not exercising well recently due to poor appetite and pain 20 pack year history of smoking No currently alcohol consumption quit 2 weeks ago No other durg intake Not sexually active Family history peptic ulcer disease uncle Discharge Discharge Studies Summary no discharge meds follow up in two to three weeks with regular physician no activity restrictions regular diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 21293 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo with irregular periods no pattern to her periods when they occur they range from 2 6 days in length began 3 years ago previous periods were regular endorses hot flashes sweating vaginal dryness lubricant helps night sweats denies headaches breast changes hair changes skin changes vision changes Pre existing Developed Conditions as above PMHX HTN diagnosed 6 years ago Impacting Hospital Stay NKDA Medications HCTZ ospitalizations 2 vaginal deliveries Family hx mom overweight and has osteoarthritis older brother with HTN Social lcohol occasional glass of wine no smoking and illicit drugs sexually active with husband IUD in place obgyn Hx last PAP a year ago and normal no hx of abdomal PAP exams menarche at age last period 2 months ago Discharge suggested dietary restrictions prescription medication Summary course recommended discharged to home nursing facility follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009883139 Gender Female Attachment Control Number XA 7B 008 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 83139 HPI 67 yo F c o trouble with her sleep Patient has noticed that of present illness since he son died in a car accident 3 weeks ago she has been feeling sad w o energy tired and she has been crying easyly Additionally she has some difficult falling sleep and also waking up in the middle of the night Patient used to sleep around 8 hours and now she is sleepin about 4 hours Patient also has seen her dead son at her house and has hearing him singing Patient also has loss interest of doing things that she used to like such as drink a glass of wine during the week Patient denies thoughts about hurting herself fever GI symptoms changes in skin ROS negative except as above PMH HTN CA cancer 20 years ago PSH bilateral mastectomy 20 years ago last check up everything was normal SH patient is retired secretary of hospital use to drink 2 3 glasses of wine in the past but no anymore since her son died Discharge Discharge Studies Summary no activity restrictions no discharge meds follow up in two to three weeks with regular physician regular diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 92079 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home with Support Services Diagnosis 20 Y female came with complaint of progressively increasing headache for the past 1 day It was sudden in onset constant in nature and started when the patient woke up from bed It was severe in intensity and located all over the head It is aggrevated by light It is also aggrevated by bending forwards Patient also complains of mild fever and runny nose Pre existing Developed Conditions associated with vomiting and neck stiffness There is no loss of consciousness weakness dizziness tearing Impacting Hospital Stay of the eyes rash or previous respiratory tract infection No previous similar complaints as above No past medical history NKA NKDA She is on OCP No urinary or bowel changes She is sleeping well Fhx Mother also has migraines occupation Patient works in sales Social history Patient consuems marijuana 3 4 times a week Drinks 1 glass wine on weekends No tobacco consumption Sexually active with 1 partner on contraception Discharge prescription medication course recommended discharged Summary to home nursing facility suggested dietary restrictions follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 84163 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 67 yo F c 0 insomnia Patient has insomnia for the last 3 weeks It takes her longer to fall asleep and to remain asleep Her insomnia was precipitated by the loss of her son that past away in an MVA She experiences insomnia every night since that has not been improving Patient tried Ambien to help her insomnia but it didn t work Patient has loss of inerest No Guilt feelings has less energy because she can not sleep No suicide thoughts or ideation No cold intolerance Pre existing Developed Conditions no hair loss Impacting Hospital Stay PMH HTN 15 yrs Breastcancer for which she has been in remission for the last 15 years Allergies NKA Medication Ambien HCTZ Lisinopril Hosp lumpectomie chemo radiation for breastcancer burst appendix FMH father died of stroke age Mother has bouts of depression OBGYN LMP 15 yrs ago Social Tobacco Ilicit drug use EtOH 2 3 glasses of wine per week Discharge follow up with physician in one week prescription Summary medication course recommended suggested dietary restrictions discharged to home nursing facility VS 3S Q990 50 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 90893 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis pt is a 20 y o F presenting with dull constant headache since yesterday morning She states it is a diffuse headache progressive in naure It doesn ot radiated anywhere worsedned with bending over and walking mildly better with OTC pain medication Pt aslo has 2 episodes of greenish vomit last night Secondly she endorses a runny nose recenly and Feeling warm and Pre existing Developed Conditions having body aches Pt denies changes in vision hearing CP SOB chills or abdominla pain Impacting Hospital Stay ROS normal exceopt mentioned above All none Meds OCP OTC pain meds PNHX none PSHX none FHx migraines in mother HLD in father Shx denies tobacco use ocaaional alcohol use smokes 4 5 joints of marijuana week deniesrecent travel or sick contacts Discharge check back with physican in case of relapse some Summary activity restrictions suggested strict diet full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 73769 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Home Diagnosis 35 y o F presents to the office c o problems with menstruation Started 6 months ago for the first time w o precipiating event Nothing alleviates or aggravates it LMP was 2 months ago Menses are regular but have changed in duration from 3 4 days to 7 days now in flow from 4 tampons on first day to 7 now Refers unintentional 10 pound weight gain in 6 months and fatigue Last Pap smear 6 month ago and was negative Denies pain with menstruation fever nausea vomiting SOB urinary or bowel changes appetite Pre existing Developed Conditions changes sleep problems vaginal discgarge or Impacting Hospital Stay itchyness vaginal dryness abdominal pain or chest pain ROS Neg except as above PMH None All NKDA Med None PSH None FH Non contributory SH Administrator Denies smoking or drug use drinks alcohol occasionally Sexually active with 1 partner no protection no STDS prefers men Has 2 adopted kids as she could not get pregnant Discharge follow up with physician in one week suggested dietary Summary restrictions discharged to home nursing facility prescription medication course recommended VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 21280 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo F complains of irregular menstural period for the last 3 years The period does no follow any specific pattern The periods last for 2 6 days and can be heavy 5 6 pads das or light 2pads day The patient also describes hot flashes sewating for a year and recent night sweats x1 She denies itching vaginal dicharge or pain she further denies any palpitatopn weight loss fever or change in bowel movement or urination She further denies any breast swelling or nippel discharge Pre existing Developed Conditions ob gyn G2P2 menarche at age period has been regualr before last pap smear 1 year ago Impacting Hospital Stay normal uses IUD for contraception for last 20 years last change 4 years ago ROS negativ as per HPI Allergies NKDA Medication HCTZ PMH high blood pressure PSH none SH no smoking occasional EtOH no illicit drugs works as office amanger Sexual inercourse with husband only FH mother ostheroarthritis Discharge full course of antibiotics check back with physican in Summary case of relapse some activity restrictions suggested strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 00983882 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 3882 male has come to the physician s office today of present illness because of epigastric pain burning intermittent 10 intensity start 2 mons ago no radiation aggrav by nothing allev by antacid no related to food assoc w melena bloating no fever weight loss anorexia no change of urinary no fatique no dyspnea no cough and chest pain PMH no similar CC back pain 1y Med motrin NKAD FH mother and uncle have PUD no sex no h oSTD 1 2 PPD 20y occasional EtOH no recreational drug use Discharge Discharge Studies Summary full course of antibiotics check back with physican in case of relapse some activity restrictions suggested strict diet VS 3S Q990 70 1090001004290 1234691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 83401 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis yo retired Female receptionist comes in for 3 weeks of decreased sleeping She goes to bed at and falls asleep at midnight She tosses and turns all night and wakes up at She can t nap at night and feels tired all day She saw her dead son in the kitchen once and hear her neighbor throwing a party once while falling asleep Her only son died 3 weeks ago in a MVA and the patient is very sad She has had Pre existing Developed Conditions increased appetitie and stopped walking in the Impacting Hospital Stay evenings patient denies suicidal thoughts or thoughs of ha SH no toxic habits sexually acctive with husband PMH Lap Appendectomy right lumpectomy 10 years ago for breast cancer htn Meds Thiazide lisinopril ambien for 5 days NKDA OBGYN 1 vaginal uncomplicated delivery menopause at yo FH father had stroke htn and high cholesterol mother had depression Discharge check back with physican in case of relapse strict Summary diet some activity restrictions suggested full course of antibiotics VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009860605 Gender Male Attachment Control Number XA 7B 006 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient ID 60605 17 M comes to the office with complaint of L sided chest of present illness pain Started yesterday morning Sharp in nature Denies any radiation Not worse at any time of the day Worse with deep breath and movement Unclear if worse with exertion or just movement Has had no relief with tylenol or albuterol inhaler In addition reports that over the last few days has had a stuffy nose and muscle aches Has also felt warm ROS No palpiations SOB peeing and pooping normally Denies feeling light headed or dizzy PMH Exercise induced asthma well controlled with albuterol PSH none FH Asthma and high cholesterol father Grandpa MI at 72 No FHx of other cardiac conditions or sickle cell Allergies NKDA SH Drinks alcohol occasionally Denies smoking or any illicit drugs including cocaine Discharge Discharge Studies Summary full course of antibiotics check back with physican in case of relapse some activity restrictions suggested strict diet VS 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843158 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 43158 45yo F C O NERVOUSNESS of present illness WORSE ON SUNDAY MONDAY RECENT SWITCH INTO A STRESSFUL JOB FEELS ANXIOUS OVERWHELMED CAFFEINE 5 6CUPS DAY NOT DISTRACTED DIFFICULTY IN FALLING ASLEEP HEADACHE NO HYPERTHYROID MENSTRUAL SYMPTOMS APPETITE POOR Discharge Discharge Studies Summary some activity restrictions suggested full course of antibiotics check back with physican in case of relapse strict diet VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax 1111 Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 92745 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis Patient is a female has come to the doctor s Severe bilateral office complaining headache Rated of headache 8 10 in fro severity 1 a day Non radiating Constant and progressive worsened by neck movements and walking Tried ibuprofen and tylenol and sleep but didnt help Associated with nausea bilius emesis fever No head trauma No skin rashes nor urine or bowel problems decreased appetitie No Pre existing Developed Conditions she Impacting Hospital Stay ROS negative except as above PMH none PSH none All none Famhx no family history of migraines Sexual active with biyfriend Use condoms consistently for protection On OCPS oral and vaginal sex only Social hx No tobacco or recreational drug use 2 3 glasses of wine on the weekends Lives in an apartment with roommate Discharge no discharge meds regular diet follow up in two to Summary three weeks with regular physician no activity restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 81417 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis hpi 67 yo F C O sleepleness x 4 wks It satrted following the death of her son in MVA she was alright pruior to that She only sleeps for about 4 hrs depite susing ambien which is no longer helping her sleep She Pre existing Developed Conditions denies wt loss fever sucidal ideation but she reports Impacting Hospital Stay to be hearing voices and seeing things she denies any flashbacks or nighmares Ros As per HPI pmh breat ca remission LUMPECTOMY 10 yrs ago Laparotomy 20 yrs ago HTN X uses LISINOPRIL hctz Fh mom is alive but has depression Dad is dead passed away from HTN Discharge prescription medication course recommended follow up Summary with physician in one week suggested dietary restrictions discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 317 Gender Male Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis 17 yo M presents with 2 3 month history of intermittent episodic heart pounding with tachycardia The episodes have occurred 5 6 times during this period and most recently were associated with chest pressure and dyspnea The episodes occur during activity or at rest Patient reports a previous physical exam to play sports was normal Patient uses Adderall recreationally Pre existing Developed Conditions ROS Negative except as above Allergies None Impacting Hospital Stay Medications Adderall recreational usage not patient s prescription PMHX None Past Surgical Hx None Social History Recretional Adderall usage multiple times per week unknown dosage Drinks 3 4 beers both days on weekends Remote single episode of marijuana use tobacco use works as student FHx Father a smoker had myocardial infarction at age Mother has unknown thyroid disease Discharge prescription medication course recommended follow up Summary with physician in one week suggested dietary restrictions discharged to home nursing facility VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 0098339 Gender Male Attachment Control Number XA 7B 003 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient 339 Patient is a yo M who presents for burning gnawing of present illness epigastric pain that began 2 months ago and has been getting worse Pt states he used to get symptoms once weekly but now happen 2 3 X per day Pt endorses nausea feeling full after eating and dark stools Episodes are intermittent and are 5 10 in severity with no pain at this time Denies vomiting chest pain SOB diaphoresis fevers diarrhea hematochezia weight loss testicular pain or dysuria Symptoms are not worsened by anything or by eating Pt symptoms used to be improved by tums but arent anymore PMHx back pain muscle spasm motrin once weekly No allergies no surgeries no hospitalizations Family history of bleeding ulcer in uncle Works as a high elevation construction worker Smoker 1 2 ppd 1ppd since ag 15 years Pt used to drink a few beers occasionally but none recently No drug use Eats fast food Not sexually active Discharge Discharge Studies Summary strict diet check back with physican in case of relapse full course of antibiotics some activity restrictions suggested VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009860827 Gender Male Attachment Control Number XA 7B 006 Visit Encounter Admitted Discharged Discharged to Home with Support Services Assessment Reported Symptoms History Patient No 60827 Patient is a male with a PMHx of asthma of present illness complaining of chest pain onset yesterday morning He describes the chest pain as sharp non radiating and exacerbated by deep inspiration and movement He notes that the pain has worsened since the onset He denies SOB palpitations nausea and vomiting Pt confirms a recent illness with myalgias and nasal congestion for three days ROS negative except stated as above PMHx exercise induced asthma Medication albuterol as needed Allergies none PSHx none FHx asthma father HLD father CAD grandfather Social non smoker occasional alcohol no illicit drug use Discharge Discharge Studies Summary suggested dietary restrictions discharged to home nursing facility follow up with physician in one week prescription medication course recommended VS 3S Q990 7550 1090001004290 12345691823728 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009852969 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient 52969 Pt is a female that presents with worsening heart of present illness palpitations Pt describes heart palpitations over the past 5 years which recently increased in frequency to 1 2x day Episodes last about 10 15 minutes and are associated with shortness of breath throat tightness nausea and cold clamy feeling after the event These episodes ate out of the blue and not associated with any activity or stress Patient is recently under a lot of stress after losing buying a condo and losing her job shortly after However she reports good social support Pt reported to ED two weeks ago for similar episodes associated with numbness of both fingers CBC electolytes ECG and cardiac enzymes were normal PMH none Sx none Meds None NKA Family Hx none Social No smoking no drinking no illicit drugs sex with boyfriend with condom use Discharge Discharge Studies Summary prescription medication course recommended discharged to home nursing facility suggested dietary restrictions follow up with physician in one week VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009843853 Gender Female Attachment Control Number XA 7B 004 Visit Encounter Admitted Discharged Discharged to Transfer to Other Institution Assessment Reported Symptoms History Patient ID 43853 yo F with no significant PMH presents with nervousness X of present illness 3 weeks Constant No aggravating or alleviating factors Drinks coffee for many years no recent increases in caffeine intake No other stimulants This has never happened before No pain Has trouble falling asleep No hair loss No weight changes Has started giving lectures in front of students Feels overwhelmed Denies hx of bipolar anxiety depression Normal menstrual periods No fevers chills nausea vomiting chest pain palpitations SOB diarrhea constipation or urinary changes PSH none Alleriges none Meds none Fam hx noncontributory Denies hx of bipolar disease anxiety or mental illness Social Denies tobacco or illicit drug use Minimal occasional social alcohol use Discharge Discharge Studies Summary suggested dietary restrictions follow up with physician in one week prescription medication course recommended discharged to home nursing facility VS 3S Q990 7550 1090001004290 123691823728 DISCHARGE_SUMMARY,Not A Real Hospital Of Excellence in Healthcare since Ph 0000 Fax Patient Discharge Summary Not A Real Hospital Department of Family Medicine Patient Patient Name Patient ID NARH 93749 Gender Female Visit Attending Physician Dr Admit Date Discharge Date Discharge Disposition Transfer to other Institution Diagnosis HPI 20 yo F complains of headache since yesterday The headache is 8 10 in intensity not localized dull and constant The pain is worsening She tried ibuprophen and tylenol but no relief walking and bending over makes the pain worse She has vomited 3 times with vomitus mixed with food She denies any aura She has been having runny nose sorer throat and cough She feels warm No recent weight changes No weakness Pre existing Developed Conditions tingling sensations or sleeping problems No bowel Impacting Hospital Stay habit changes She had previously had some episodes of headaches which were mild and went away after a few minutes ROS negative except as above Allergies NKA Meds Ibuprophen OCPs for 2 years FH Mother had migraine headache Father had HTN SH smokes marijuana occasionally EtOH 2 3 wines on weekends no tobacco Sexually active with a boyfriend of uses condoms Discharge discharged to home nursing facility prescription Summary medication course recommended follow up with physician in one week suggested dietary restrictions VS 3S Q990 7550 1090001004290 DISCHARGE_SUMMARY,Not a Memorial Hospital Of Non Profit Contact Physician Hospital Discharge Summary Provider Dr Patient Provider s Pt ID 009851151 Gender Female Attachment Control Number XA 7B 005 Visit Encounter Admitted Discharged Discharged to Home Assessment Reported Symptoms History Patient 51151 HIP A yo F came to the clinic for a F U of palpitations of present illness Started 5 years ago for the first time and resolved spontaneously Reports a new episode of palpitation since 3 weeks ago and since it started it is getting worse It is associated with SOB diaphoresis numbness in her finger and cold and heat intolerance Refers been under stress lately because of the loss of her work Denies headaches weakness sleeping problems fatigue or any pain ROS Negative except as above PMH none ALL NKDA Med None PSH None FH Noncontributory SH Loss her job recently no EtOH no smoking no drugs Discharge Discharge Studies Summary some activity restrictions suggested strict diet check back with physican in case of relapse full course of antibiotics VS 3S Q990 7550 1090001004290 INVOICE_RECEIPT, W 81100 Document No TD01167104 Date Member CASH BILL CODE DESC PRICE Disc AMOUNT QTY RM RM 9556939040118 KF MODELLING CLAY KIDDY FISH 1 PC 9 000 0 00 9 00 Total 9 00 Rour ding Adjustment 0 00 Round d Total RM 9 00 Cash 10 00 CHANGE 9 00 1 00 GOODS SOLD ARE NOT RE TURNABLE OR EXCHANGEABLE 9 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,tan woon yann INDAH GIFT HOME DECO Tel Fax RECEIPT 01 Cashier CN Location SP 05 0531 MB M026588 Room No 01 050100035279 Desc Item Qty Price Amt RM ST PRIVILEGE CARD GD INDAH 88888 1 10 00 10 00 GF TABLE LAMP STITCH i 62483 1 55 90 55 90 DISC 10 00 5 59 Total Qty 2 TOTAL AMT RM 60 31 ROUNDING ADJ 0 01 RM 60 30 CASH RM 70 30 CHANGE RM 10 00 Thank You Please Come Again Goods Sold Are Not Returnable Dealing In Wholesale And Retail INVOICE_RECEIPT, MR CO REG 933109 X KAWASAN PERINDUSTRIAN BALAKONG MR TESCO TERBAU INVOICE CHOPPING BOARD 35 5x25 5CM 803M EZ10HD05 24 8970669 1 X 19 00 19 00 AIR PRESSURE SPRAYER SX 575 1 1 5L HC03 7 15 9066468 1 X 8 02 8 02 WAXCO WINDSHILED CLEANER 120ML WA14 3A 48 9557031100236 1 X 3 02 3 02 BOPP TAPE 48MM 100M CLEAR FZ 04 36 6935818350846 1 X 3 88 3 88 Item s 4 Qty s 4 TOTAL RM 33 92 ROUNDING ADJUSTMENT RM 0 02 TOTAL ROUNDED 33 90 RM 33 90 CASH RM 50 00 CHANGE RM 16 10 SH01 ZK09 T4 R000027830 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,tan woon yann YONGFATT ENTERPRISE JM0517726 NO 122 124 TEL GST ID 000849813504 SIMPLIFIED TAX INVOICE CASH Doc No CS00031663 Date Cashier USER Time Sakesperson Ref ftum Qty S Price Amount Tax E8318 1 80 91 80 91 SR ELEGANT SCH TR BAG 15 Total Qty 1 80 91 Total Sales Excluding GST 80 91 Discount 0 00 Total GST 0 00 Rounding 0 01 Total Sales Inclusive of GST 80 90 CASH 100 00 80 90 Change 19 10 GST SUMMARY Tax Code Amt RM Tax RM SR 0 80 91 0 00 Total 80 91 0 00 GOODS SOLDARE NOT REFUNDABLE ONLY INVOICE_RECEIPT, MR M SDN BHD CO REG 8Q71 D 10T 1851 A 1851 B JALAN KPB KAWASAN PERINDUSTRIAN BALAKONG INVOICE KILAT AUTO FCO WASH SHINE ES1000 1L WA45 22A 12 955591500133 1 X 3 11 3 11 KILAT ECO AUTO WASH WAX W 1000 1L WA44 A 12 95559150012 1 X 4 2 4 2 WD40 277al MOQ 2572 WA43 A 24 0795700084 1 X 11 23 11 23 99 SERAI WANYI 900G WD00 15 955551400385 1 X 7 45 7 45 HANDKERCHIEF 7138 2PCS PI12PJ11 4 9090822 i X 4 50 4 50 Item s 5 Qty s 5 Total RM 30 91 ROUNDING ADJUSTMENT RM 0 01 TOTAL ROUNDED RM 30 90 CASH 30 99 RM 51 00 CHANGE RM SH01 Z153 T2 R000002902 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, 2616 Cash Bill 01 143008 Date Cashier 01 Description Qty Price Amount RM RM Plastic 2 15 50 31 00 Total 31 00 Total Amount 31 00 Cash Received 101 00 Change 70 00 Goods Sold are non refundable Thank You Please Come Again 31 00 INVOICE_RECEIPT,tan chay yee SOON HUAT MACHINERY ENTERPRISE JM0352019 K TEL FAX GST ID 002116837376 CASH SALES Doc No CS00004040 Date Cashier USER Time Salesperson Ref Item Qty S Price S Price Amount Tax 1072 1 80 00 80 00 80 00 REPAIR ENGINE POWER SPRAYER 1UNIT workmanship service 70549 1 160 00 160 00 160 00 GIANT 606 OVERFLOW ASSY 1071 1 17 00 17 00 17 00 ENGINE OIL 70791 1 10 00 10 00 10 00 GREASE FOR TOOLS 40ML AKODA 70637 1 6 00 6 00 6 00 EY20 PLUG CHAMPION 1643 1 8 00 8 00 8 00 STARTER TALI 70197 1 10 00 10 00 10 00 EY20 STARTER HANDLE 70561 2 18 00 18 00 36 00 HD40 1L COTIN Total Qty 9 327 00 Total Sales 327 00 Discount 0 00 327 00 Total 0 00 Rounding 0 00 Total Sales 327 00 CASH 327 00 Change 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,tan chay yee S H H MOTOR 801580 T No Tel Fax INVOICE ITEM DESC QTY U PRICE RM TOTAL 4132 1 20 00 20 00 CROCS 300X17 TUBES SUB TOTAL 20 00 ROUNDING ADJUSTMENT 0 00 GRAND TOTAL 20 00 CASH 20 00 CHANGE 0 00 PRINT BY root TOKEN NO 0 STATION ID A1 PID POS INVOICE NO 22497 Thanks Your Support 3 20 00 INVOICE_RECEIPT,A02045 PERNIAGAAN V TEL FAX GST NO SIMPLIFIED TAX INVOICE GOGIANT ENGINEERING M SDN BHD Recelpt CS00082552 Salesporson Date Cashier USER Time RM RM Item Qity RSP Amount 8239 GB 1 15 00 15 00 SR 11 PROWESS H DUTY SILICONE GUN G D2 9555075109147 7 00 21 00 SR X TRASEAL RTV ACETIC SILICONE SA 107 9744 GB 1 18 00 18 00 SR CENTRAL PUNCH SET 3PCS 1 4 5 32 1 4 12525 GB 1 50 00 50 00 SR 24 WRENCH 2016 0 70 2 10 SR PVC WIRE TAPE 1PC X 7YD TOT QTY 9 106 10 Excluded GST Sub Total RM 106 10 Discount RM 0 00 Total GST RM 6 37 Rounding RM 0 02 Total RM 112 46 CASH 112 45 Change RM 0 00 GST SUMMARY Tax Code Amount GST SR 6 106 10 6 37 Total 106 10 6 37 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,KC peare 0598 Gerbang Alaf Restaurants 65351 M formerly known as Golden Arches Restaurants Licensee of McDonald s Level 6 Bangunan TH Damansara Uptown3 No 3 Jalan SS21 39 47400 Petaling Jaya GST ID No 000504664064 McDonald s BHP Taman 328 Tel No TAX INVOICE MFY Side 1 INV 003281900229170 ORD 50 REG 19 QTY ITEM TOTAL 2 ChicMcMuffin 11 00 1 M Porridge 5 60 1 BM 2HotCakes 10 00 1 L Coke TakeOut Total incl GST 26 60 Total Rounded 26 60 Cash Tendered 100 00 Change 73 40 TOTAL INCLUDES 6 GST 1 51 We d love to hear your feedback sit OR Download My McD Feedback from Google Play App Store to share your experience Thank You and Please Come Again Customer Service Hotline INVOICE_RECEIPT, TRADING CO 742016 W 67 JLN TEL FAX GST NO 001006288896 TAX INVOICE HE EDG UNICORN TWIN SUPER GLUE USG 99 9557368063013 1 X 5 20 5 20 S SS EZL A4 CYBER MIX COLOR PAPER 100 S8 1 X 8 90 8 90 S No Qtys 2 No Items 2 TAX AMT S 6 RM 13 30 GST 6 RM 0 80 TAX AMT Z 0 RM 0 00 GST 0 RM 0 00 TAX AMT E 6 RM 0 00 EXC GST 6 RM 0 00 TOTAL RM 14 10 CASH RM 20 00 CHANGE RM 5 90 THANK YOU FOR SHOPPING GOODS SOLD ARE NOT RETURNABLE Frid v Time Cas r Wc5 SWH 01 Inv R000721136 INVOICE_RECEIPT, U13 SETIA TEL FA SHAH 03 GST NO SIMPLIFIED TA INVOICE CASH RECEIPT CSP0393921 DATE SALESPERSON TIME 15 28 00 ITEM QTY U P AMOUNT RM 2000160000024 1 15 00 S 20 1 6KG 500MM BIG STRETCH FILM TAL QUANTITY 1 SUB TOTAL GST 15 00 DISC 0 00 ROUNDING 0 00 TOTAL 15 00 CASH 15 00 CHANGE 0 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TA AMT SR 14 15 6 0 85 l A TUTAL 0 85 GOODS SOLD ARE NOT REFUNDABLE THANE YOU FOR CHOOSING US PROVIDE ORIGINAL BILL FOR GOODS ECHANGE WITHIN 1 WEEK FROM GOODS HUST BE IN ORIGINAL STATE TO BE ENTITLED FOR ECHANGS INVOICE_RECEIPT,HOME MASTER HARDWARE ELECTRICAL NO 113G BANDAR SETIA ALAM SELANGOR Company Reg No SA03711551 P GST Reg No 001637511168 TAX INVOICE Involce No CS 67832 Date Cashier CASHIER RM Code 24MMx7Y MONE TAPE 1 00 x 15 90 15 90 SR Subtotal 15 90 Total Excl of GST 15 00 Total Incl of GST 15 90 Total Amt Rounded 15 90 Payment 50 00 Change Due 34 10 Total Item s 1 G ummary Amount RM Tax RM SR 6 15 00 0 90 THANK YOU ANY GOODS RETURN PLEASE DO WITHIN WITH ORIGINAL RECEIPT TQM INVOICE_RECEIPT,RESTORAN HASSANBISTRO SELANGOR TAX INVOICE TERMINAL DATE TOKEN CT1 TABLE CT1 Pru ct Qty U Price GST Total MAKANAN 1 15 00 0 15 00 ZR Total Items 1 00 Total Qty 1 00 Sub Total RM Discount 15 00 RM 0 00 Total Excl 6 GST RM GST 6 RM 15 00 Total Incl 6x GST 0 00 RM Rounding RM 15 00 0 00 CASH RM CHANGE RM 15 00 0 00 Thank You Come Again INVOICE_RECEIPT,ASIA MART SA0264195 T NO 23 BATU 10 001609584640 TAX INVOICE Doc No CS02070163 Date Cashier EIRA Time Salesperson EIRA Ref GST GST Item S Price S Price Amount Tax Qty 9556641320027 17 0 85 15 25 SR 0 90 DELICIA CHOCOLATE 50G 9556231110045 1 3 55 3 55 3 55 ZRL GARDENIA ORIGINAL CLASSIC JUMBO 600G 9556127101331 1 1 41 1 50 1 50 SR HU NS LIME 50G 8850199320722 1 1 42 1 51 1 51 SR DOREMON CATCAT JOY 15G 8850199320722 1 1 42 1 51 1 51 SR DOREMON CATCAT JOY 15G 8888002188511 1 2 30 2 44 2 44 SR MINUTE MAID PULPY OREN 350ML 9898002188511 1 2 30 2 44 2 44 SR MINUTE MAID PULEY OREN 1350ML i 1 60 1 60 SR TINGE DRINK 500ML 955657031213 2 74 2 90 2 90 SR 100 Pros 150 Total Cit 25 32 69 Total Sales Excluding GST 31 03 Discount 0 00 Total GST 1 65 Rounding 0 02 Tatal Sales Inclusive of GST 32 70 CASH 40 00 Change 7 30 GST SUMMARY Tax Code Amt RM SR 6 Tax RM 27 48 1 65 ZRL 0 3 55 0 00 Total 31 03 1 65 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,LIGHTROOM GALLERY SDN BHD No ROC No A GST No Tel Fax TAX INVOICE Station CASHIER Bill No LCS03908 Cas r ANGELA Cover 1 Bill Date Bill Start Code 300 C0001 Name CASH Address GST No CH50514 SR T5 JOINT 2PIN 2PCS 1 RM 2 83 UNI 2 83 YT51874 SR YE30 BK 7W WW LED TRACK LIGHT 2 RM 33 02 UNI 96 RM 66 04 Sub Total RM 68 87 Service Charge RM 0 00 GST TAX 6 RM 4 13 TO RM 73 00 CA RM 73 00 CHANGE RM 0 00 It em Count 2 Qty Count 3 0 Closed Bill Thank You Please come again Goods Sold are not refundable returnable BANK ACC MBB BANK ACC MBB BANK ACC AMBANK GST Summary Amount RM Tax RM SR 6 68 87 4 13 ZR OS EZ 0 00 0 00 INVOICE_RECEIPT,LIGHTROOM GALLERY SDN BHD No ROC No A GST No Tel Fax CREDIT NOTE Station CASHIER C N No LCN00211 Cashier ANGELA Cover 1 Bill Date Bill Start Code 300 E0009 Name Address GST No SR REFER LCS03158 0 SR 1059 18W SQ WW BK SUR LED LIGHT 1059 SQUARE BLACK FRAME 2 RM 18 77 UNI 2 25 RM 37 55 Sub 1 al RM 37 55 Service Charge RM 0 00 GST TAX 6 RM 2 25 TOTAL RM 39 80 CASH RM 39 80 CHANGE RM 0 00 Item Count 2 Qty int 2 0 Closed Bill Thank You Please come again Goods Sold are not refundable returnable BANK ACC MBB BANK ACC MBB BANK ACC AMBANK GST Summary Amount RM Tax RM SR 6 37 55 2 25 ZR OS EZ 0 00 0 00 INVOICE_RECEIPT,3 180048 Shell ISNI PETRO TRADING Company No A Site 1066 Telephone GST No Receipi Invoice number 60000053668 35 10 litre Pump 02 V Power 97 RM 86 00 A 450 RM litre Total RM 86 00 Visa RM 86 00 00 GST A RM 4 87 Total Gross A RM 86 00 Shell Loyalty Card Points Awarded 35 Date Time Num OPT 06051 02 Diesel 8 Petrol RON 95 given Relief under Section 56 3 b GST Act Thank You Pleasae Come Again INVOICE_RECEIPT,Rsk SYL ROASTED DELIGHTS 75 PJ TEL GSI ID 002046390272 Doc No SO00022185 TABLE A10 Cashier USER Date Salesperson Time Description Qty Price Amount T02 BRAISED PORK 20 7 00 14 00 RICE WITH PEANUT IT PORK 1 0 12 00 12 00 SMALL V02 SOUR SPICY 1 0 12 00 12 00 MUSTARD B03 JASMINE GREEN 2 0 2 30 4 60 TEA HOT R05 ROAST PORK 1 0 11 90 11 90 ROAST CHICKEN RICE Total Qty 7 51 42 Total Sales Excluding GST 51 42 Discount 0 00 Total GST 3 08 Rounding 0 00 XW Total Sales Inclusive of GST 54 50 INVOICE_RECEIPT,TEO HENG STATIONERY PBOEKS 001451637 M NO TEL FAX GST No 000689913856 SIMPLIFIED TAX INVOICE CASH Receipt No CS1801 26874 Date ITEM QTY U P DISC AMOUNT RM 9557068000035 1 3 50 5 69 3 30 JIANYU STELL RULER 30CM THICK 1 1 1 30 0 00 1 30 LAMINATE FILM Total Qty 2 4 60 SUB TOTAL EX 4 60 TOTAL TAX 0 28 ROUNDING 0 02 TOTAL 4 90 CASH 4 90 CHANGE 0 00 GST SUMMARY TAX CODE AMOUNT TAX RM RM SR 6 00 4 60 0 28 TOTAL 4 60 0 28 Note Indicated The Item Sold Has Been Related To GST Goods Services Tax GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, X NO 43 45 47G IJOK 1851 GST No TAX INVOICE TRN 1CR0576494 COUNTER 1 CASHIER HOCK Qty UOM U Price Amt Amt Inc Tax Code 48X230ML 1 KOTAL 8 49 8 49 9 00 SR GST 6 0 51 Total Qty 1 00 9 00 Total Includes GST 6 9 00 Customer s Payment Cash 50 00 Change 41 00 GST Summary Amount Tax SR 8 49 0 51 Goods sold are not returnable Thank you for shopping at FUYI MINI MARKET INVOICE_RECEIPT,TEO HENG STATIONERY BOOKS 001451637 M NO TEL FAX GST No SIMPLIFIED TAX INVOICE CASH Receipt No CS1801 26821 Date ITEM DISC AMOUNT QTY U P RM 9555017370017 1 28 00 7 14 26 00 LION FILE 220 307 LAMINATING FILM Total Qty 1 26 00 SUB TOTAL EX 26 00 TOTAL TAX 1 56 ROUNDING 0 01 TOTAL 27 55 CASH PAI 27 55 CHANGE 17 0 00 for GST SUMMARY AMOUNT TAX TAX CODE RM RM SR 6 00 26 00 1 56 TOTAL 26 00 1 56 Note Indicated The Item Sold Has Been Related To GST Goods Services Tax GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,TED HENG STATIONERY BOOKS M TEL FAX GST No SIMPLIFIED TAX INVOICE CASH Receipt No CS1801 26717 Date ITEM QTY U P DISC AMOUNT RM 9556655864036 1 26 42 9 14 24 00 CBE BADGE CLIP 100PCS 9555535000663 1 28 00 0 00 28 00 NISO A4 LAMINATING FILM Total Qty 2 52 00 SUB TOTAL EX 52 00 TOTAL TAX 3 12 ROUNDING 0 02 TOTAL 55 10 CASH 55 10 CHANGE 0 00 GST SUMMARY TAX CODE AMOUNT TAX RM RM SR 6 00 52 00 3 12 TOTAL 52 00 3 12 Note Indicated The Item Sold Has Been Related To GST Goods Services Tax GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,TEO HENG STATIONERY BOOKS M TEL FAX GST No SIMPLIFIED TAX INVOICE CASH Receipt No CS1801 27037 Date ITEM QTY U P DISC AMOUNT RM TP 24 5 1 32 0 00 6 60 DOUBLE SIDED TISSUE TAPE 18MM 9557546631393 5 2 08 0 00 10 38 G SOFT 6ML QUICK DRY CORRECTION PEN Total Qty 11 10 16 98 SUB TOTAL EX 16 98 TOTAL TAX 1 02 ROUNDING JAN 0 00 TOTAL 18 00 CASH 18 00 CHANGE 0 00 GST SUMMARY TAX CODE AMOUNT TAX RM RM SR 6 00 16 98 1 02 TOTAL 16 98 1 02 Note Indicated The Item Sold Has Been Related To GST Goods Services Tax GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,TED HENG STATIONERY a BOOKS 001451637 M NO TEL FAX GST No SIMPLIFIED FAX INVOICE CASH Receipt No CS1802 27714 Date ITEM QTY U P DISC AMOUNT RM 9555067700208 10 10 57 0 00 105 66 IK YELLOW 70GRAMS 9557583450025 1 17 45 0 00 17 45 PAPYRUS DARK COLOUR PAPER 4974052801334 1 2 70 0 00 2 70 ARTLINE 70 9557546953990 1 0 85 0 00 0 85 FASTER CX5N BALL PEN 6924238702311 2 0 85 0 00 1 70 CBE HANDYCUTTER 9556655112694 1 8 40 0 00 8 40 CBE A4 SIZE 20 POCKETS REFILLABLE NEW CLEAR HOLDER 9557369305006 2 3 96 0 00 7 92 EAGLE F4 120 NUMBERING FOOLSCAP BOOK Total Qty 18 144 68 SUB TOTAL BXV 144 68 TOTAL TAI 8 68 ROUNDING 0 01 TOTAL 153 35 CASH 153 35 CHANGE 0 00 GST SUMMARY AMOUNT TAX CODE TAX RM RM SR 6 00 144 68 8 68 TOTAL 144 68 8 68 Note Indicated The Item Sold Has Been Related To GST Goods Services Tax GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,1 MR D I Y M SDN BHD CO Reg 860671 D GST ID No 000306020352 TAX INVOICE SOURING PAD 1018 4 48 S WA03 24240 955522130108 4 X 2 80 11 20 SCISSOR GFISH S AD51 24360 9064422 2 X 1 50 3 00 TRAILING SKT 5GN SP 3X1 25MM CABLE 2 S WA27 20 9553114461966 1 X 22 90 22 90 Item s 3 Qty s 7 Total Incl GST 6 RM 37 10 CASH RM 50 00 CHANGE RM 12 90 GST Summary Amt RM Tax RM GST S 6 35 00 2 10 14 03 18 SH03 ZJ20 T1 R000418193 OPERATOR TMDC EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, LOT P J IJOK GST ID NO INVOICE NO T0049 24 01 18 1973 GARBAGE BAG BLUE 74C RM1 25 s 1974 GARBAGE BAG GREEN 74 RM1 25 s Total Sales Inclusive GST RM 2 50 CASH RM 5 00 CHANGE RM 2 50 GST Summary Amount RM Tax RM s 6 2 36 14 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, 481500 M C W KHOO HARDWARE SDN BHD NO 50 JALAN PBS KAWASAN PERINDUSTRIAN Tel Fax GST Reg No 000549584896 Tax Invoice Invoice No CR 1803 0064 Date Cashier No khoo Counter No c1 Printed Date Item Name Qty Unit Price Amount AIR ADAPTOR 1 5 4 00 20 00 SR 5 Item s Total 20 00 GST 6 1 20 Net Total 21 20 Rounding Adj 0 00 Net Total Rounded 21 20 Cash 21 20 Change 0 00 GST Summary Item Amount GST SR 6 1 20 00 1 20 Thank You Please Come Again INVOICE_RECEIPT, U TAX INVOICE Invoice OR18030502160349 Item Qty Total SR 100100000060 4 Vege 5 50 1 5 50 SR 100100000006 Pork 2 70 1 2 70 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 774 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive OI GST Thank You Come Again Like and Follow Us on Facebookl INVOICE_RECEIPT, BHD H 3RD FLR AEON SC JEJAKA SHOPPING HOURS SUN THU 1000 HRS 2230 HRS FRI SAT 1000 HRS 2300 HRS 1x 00000799651 75 00SR AMBROSIAL GREEK Sub total 75 00 Total Sales Incl GST 75 00 Total After Adj Incl GST 75 00 CASH 100 00 Item Count 1 Change Amt 25 00 Invoice No 2018030610100080498 GST Summary Amount Tax GR 6 70 75 4 25 Total 70 75 4 25 1010 008 0080498 0305582 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, U TAX INVOICE Invoice OR18030302170430 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 72 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U INVOICE Invoice OR18D31002160274 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 3 7 74 6 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A03041 PERNIAGAAN V TEL FAX GST NO SIMPLIFIED TAX INVOICE GOGIANT ENGINEERING M SDN BHD Receipt CS00084670 Salesperson Date Cashier USER Time RM RM Item Qty RSP Amount 10273 170 00 170 00 SR 14 TRU CUT CUTTING DISC PC 2547 GA1801 1 35 00 35 00 SR KOBELCO G 12 2 6MM WELDING 12133 GA 1801 2 7 50 15 00 SR CS 3 750 PAINT BRUSH 10157 GA1801 2 5 50 11 00 SR CS 2 750 PAINT BRUSH 12131 GA 1801 1 3 60 3 50 SR CS 1 1 2 750 PAINT BRUSH 9555752615725 GA 1801 1 25 00 26 00 SR 2 LAMBWOOL YANDA ROLLER REFIL 20 PCS 2226 GA1801 1 6 00 6 00 SR DIAMOND COTTON GLOVE 8104 3679 GA1801 5 1 00 5 00 SR 10 WELDING GLASS BLACK 1PCS 3680 GA180 10 0 30 3 00 SR WELDING GLASS CLEAR 1 PC 9655058800696 GA1801 2 8 00 16 00 SR AEC BROOM NO 5110 C W IRON HANDLE 6891 GB1801 2 12 00 24 00 SR S STEEL DUST PAN L CAN HANDLE 23 X 28 X TOT QTY 28 313 50 Excluded GST Sub Total RM 313 50 Discount RM 0 00 Total GST RM 18 81 Rounding RM 0 01 Total RM 332 30 CASH 332 30 Change RM 0 00 GST SUMMARY Tax Code Amount GST SR 6 313 50 18 81 Total 313 50 18 81 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, U INVOICE Invoice OR18031202170432 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 06 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18031402160311 Item Qty Total SR 100100000060 4 Vege 5 50 1 5 50 SR 100100000006 Pork 2 70 1 2 70 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR 357 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, Tel GST ID 0016 6993 5104 TAX INVOICE NO 42 58244 Date PAX NO 4 Cashier cashier3 Waiter HANYIN Qty Code Desc Total RM 3 SABA SHIO YAKI SET 53 70 1 SALMON SHIO SET 21 90 4 ICED GREEN TEA 4 00 SUBTOTAL 79 60 DISCOUNT 30 00 Total Amount 49 60 Serv Charge 10 4 96 GST 6 3 27 Rounding Adj 0 03 Total Amount 57 80 TOTAL RM 57 80 Type 3 GST Summary Amount Rill TAX RM SR U 54 56 3 37 Thank You Ploase Come Again INVOICE_RECEIPT, YHM S117 Second Floor 1 Jalan Desa Tebrau TAX INVOICE Order No 1000219 Receipt No Pax 1 Cashier Cashier Eat In Item Qty U Price Amount Tax FG A00019 1 1 50 1 50 SR Green Tea FG H00001 1 8 80 8 80 SR Kake Udon R FG H00100 1 2 80 2 80 SR Enoki Tempura SubTotal 13 10 Total 13 10 TOTAL MYR 13 10 Total Excluded Tax 12 36 0 74 Payment Detail Is Cash 20 10 Cash Change 7 00 Tax Summary Tax Code Amount MYR Tax MYR SR 6 1 36 0 74 Thank You Please Come Again INVOICE_RECEIPT,BREWERY TAP Owner by Castle Blue S B 1035693 T GST No Plaza Lot TEL GUEST CHECK Table No DOG Order No 11649 Date Cashier ORDER LOGIN PRN ON QTY ITEM RM Dine In 1 Tiger 2 Bucket HH 95 00 SR 2 Tiger Bucket HH 1 Chicken wings 22 00 SR 1 French Fries 12 00 SR 1 Tiger Bucket HH 50 00 SR 4 SubTotal 179 00 GST 6 10 74 Rounding Adj 0 01 Net Total 189 75 Tax Summary Amount Tax SR GST 06 179 00 10 74 THANK YOU PLEASE COME AGAIN Goods Sold Are Non Refundable K INVOICE_RECEIPT,THREE STOOGES BISTRO CAFE TABLE BAR 7 ORDER 00012916 BIZDATE CASHIER CASHIER BILL DT RM QTY ITEM AMOUNT 1 HH GUINESS 12 GLASSES 150 00 1 HH TIGER 12 GLASSES 145 00 2 SUB TOTAL 295 00 SERVICE CHARGE 10 29 50 GST 6 19 47 ROUNDING ADJ 0 02 NL TOTAL 343 95 Tax Commar Amount Tax SVC ERVICL 10 295 00 50 SR GS 6 324 50 Thank me INVOICE_RECEIPT,THREE STOOGES BISTRO CAFE 001661886464 TAX INVOICE TABLE G7 INV NO POSO1 000123719 INV DATE INV DT RM QTY ITEM AMOUNT 1 HH GUINESS 12 GLASSES 150 0 SVC 1 SUB TOTAL 150 00 SERVICE CHARGE 10 15 00 GST 6 NET TOTAL 174 90 CASH 200 00 CHANGE 25 10 Tax Summary Amount Tax SVC SERVICE CHARGE 10 150 00 15 00 SR GST 6 165 00 9 90 Thank You Plz Come Again INVOICE_RECEIPT,Geoventure Taste Of The Wor Id 965857 A Lot 38 39 TEL GST REG NO RESERVATION NO SIMPLIFIED TAX INVOICE Invoice 581355 Cashier POS No 1 Pax 0 Date Table No C38 ITEM QTY U P RM DISC S Amt GST RM S Tiger Bucket GTG02 1 55 00 0 0 58 30 S Service Chrg Incl GST 6 RM 5 83 Total Sales Incl GST 6 RM 64 13 Rounding Adjustment RM 0 02 TOTAL RM 64 15 CASH RM 100 00 CHANGE RM 35 85 Main Item Count 1 Total Discount RM 0 00 GST Summary Amount RM Tax RM S 6 60 50 3 63 Z 0 0 00 0 00 K INVOICE_RECEIPT,32 PUB BISTRO own by CNU TRADING PETALING JAYA GST Reg No 000416321536 Tax Invoice Table 5 INV No 504233 Pax s 0 Date Cashier CHEN Description Qty U price Total TAX 5 BTL 2 X 95 00 190 00 SR Total Excluding GST 179 25 GST Payable 10 75 Total Inclusive of GST 190 00 TOTAL 190 00 Closed 32 Server CHEN CASH 200 00 CHANGE 10 00 GST Summary Amount RM Tax RM SR 6 I 79 25 10 75 K Thank You INVOICE_RECEIPT, U Parindustrian TAXINVOICE Invoice OR18031802170384 Itern Qty Total SR 1001D0000031 3 Vege 4 40 1 4 40 SR 100100000064 Add Vegetable 0 50 1 0 50 SR I00100000114 Add Chicken 3 70 1 3 70 Total Amount 8 60 GST 6 0 49 Nett Total 8 60 Payment Mode Amount CASH 8 60 Change 0 00 GST Summary Amount Tax SR GST 6 811 0 49 GST REG 000656195584 BAR WANG RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U Perindustrian TAXINVOICE Invoice OR18032702170334 Item Qty Total SR 00100000056 Fried Noodle S 2 00 1 2 00 SR 100100000006 1 Pork 2 70 1 2 70 SR 100100000015 Vegetable 1 10 2 2 20 Total Amount 6 90 GST 6 0 39 Nett Total 6 90 Payment Mode Amount CASH 6 90 Change 0 00 GST Summary Amount Tax SR GST 6 6 51 039 GST REG 000656195584 BAR PERMAS JAYA Price Inclusive OI GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, TEL CO NO JM0195368 D GST NO 000150511616 TAXINV 002 1550040 Cashier CASHIER2 1 VEGETABLES 2 20 ZRL 1 LTK OMEGA PLUS IDS 5 70 ZRL 1 VEGETABLES 1 00 ZRL 1 VEGETABLES 2 00 ZRL 1 VEGETABLES 8 00 ZRL 1 SEAFOOD 8 50 ZRi 1 FISH BALI CAKE 1 20 SR Item Count 7 SUBTOTAL 28 60 TL RM 28 60 6 GST 0 07 Payment Details CASH 100 00 CASH CHANGE 71 40 002 1550040 CASHIER2 GST Summary Amount RM Tax RM SR 6 1 20 0 07 ZRI 0 27 40 0 00 Thank you Please come again Y GOCIDS SOLD ARE NOT REFUNDABLE INVOICE_RECEIPT,RESTAURANT 000000 7259 CASHIER01 DPT 05 RM 149 00 DPI 04 RN 21 00 CASH RM 170 00 INVOICE_RECEIPT,1000078 HARDWARE TRADING JM0292487 D NO 4 JALAN PERJIRANAN 10 TEL FAX GSTID 00157049056 TAX INVOICE Doc No CS000586 Date Cashier USER Time Salesperson Ref GST GST Itern Qty S Price S Price Amount Tax 2587 1 00 PCS 48 00 50 88 50 88 SR 10 WING COMPASS GBB1801 576 1 00 SET 47 17 50 00 50 00 SR 1 8 4 12PCS HOLLOW PUNCH SET Total Qty 2 100 88 Total Sales Excluding GST 95 17 Discount 0 00 Total GST 5 71 Rounding 0 02 Total Sales Inclusive of GST 100 90 CASH 101 00 Change 0 10 GST SUMMARY Tax Coda Amt RM Tax RM SR 6 95 17 5 71 Total 95 17 5 71 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,PERNIAGAAN ZHENG HUI V TEL FAX GST NO SIMPLIFIED TAX INVOICE CASH Receipt CS00085298 Sajesperson Date Cashier USER Time RM RM Item Qty RSP Amount 3934 1 7 56 7 56 SR CAR PARKING COUPON TOT QTY 1 7 65 Excluded GST Sub Total RM 7 55 Discount RM 0 00 Total GST RM 0 45 Rounding RM 0 00 Total RM 8 00 CASH 8 00 Change RM 0 00 GST SUMMARY Tax Code Amount GST SR 6 7 55 0 45 Total 7 55 0 45 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,A03096 Home of Timeless Kitchenette Sdn Bhd Company no 1174703 K GST Reg no 0000 6771 Guest Check Invoice no 000039121 Date Cashier Mizan Genting Server Open Table 25 Pax 6 1 Ribs Platter SR 259 90 1 Naughty Spare Rib Full SR 106 90 Slab 1 Apple 350ml SR 13 90 1 Sour Apple Mojito SR 18 90 1 Berry Easy SR 18 90 1 Aust Rib eye Steak SR 74 90 1 Fruity Garden Salad SR 21 90 2 HR Asahi 1 1 2 SR 77 80 Sub total 593 10 Inclusive GST 6 33 57 Total Total 593 10 GST Summ Amt RM Tax RM SR 6 559 53 33 57 OS 0 0 00 0 INVOICE_RECEIPT, U Perindustrian TAX INVOICE Invoice OR18032202170428 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000064 Add Vegetable 0 50 1 0 50 Total Amount 7 60 GST 6 0 43 Nett Total 7 60 Payment Mode Amount CASH 7 60 Change 0 00 GST Summary Amount Tax SR 7 17 0 43 GST REG 000656195584 PERMAS JAYA Price Inclusive OI GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A03115 TO FOR SHOPPING WITH PAGOH REST AND SERVICE AREA REHAT RAWAT myNEWScarellne MYNEWS RETAIL SB 306295 X FKA BISON STORES SB TAX REG ID CBP 000709361664 QTY PRICE DISC 10 00 0 00 10 00 ZRL SUB TOTAL 10 00 GRAND TOTAL 10 00 CASH 20 00 MYR 20 00 CHANGE DUE 10 00 TOTAL QTY 1 ZRL 0 GOODS 10 00 TAX 0 00 BILL 18550 389 4768 2303180113 PRICE IS GST INCLUSIVE x INVOICE_RECEIPT, U 7 Kawasan Perindustrian TAXINVOICE Invoice OR18032402170368 Item Qty Total SR 100100000027 2Meat 2 Vege 8 70 1 8 70 SR 100100000064 Add Vegetable 0 50 1 0 50 Total Amount 9 20 GST 6 0 52 Nett Total 9 20 Payment Mode Amount CASH 9 20 Change 0 00 GST Summary Amount Tax SR GST 6 8 68 0 52 GST REG 000656195584 RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Againl Like and Follow Us on Facebook Y INVOICE_RECEIPT,A03120 CARREFOUR RESTAURANT JM0725755 U 18 JALAN PERMAS PERMAS ID TEL TABLE 3 CASH MEMBER POINTS 0 00 RECEIPT DATE SALESPERSON TIME CASHIER BAI HE ITEM QTY U P DISC AMOUNT 238 1 10 00 10 00 1033 1 3 00 3 00 TOTAL QTY 2 TOTAL POINTS 0 00 SUB TOTAL 13 00 DISC 0 00 SERVICE CHARGE 0 00 GOV TAX 0 78 ROUNDING 0 02 TOTAL 13 80 CASH 13 80 CHANGE 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, U TAX INVOICE Invoice OR18031902160324 Item Qty Total SR 100100000001 Chicken 2 70 1 2 70 SR 100100000060 4 Vege 5 50 1 5 50 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebookl INVOICE_RECEIPT, UNIHAKKA 867388 U Perindustrian TAX INVOICE Invoice OR18032102170360 Item Qty Total SR 100100000121 Yong Tau Foo S 1 60 1 1 60 SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 Total Amount 8 70 GST 6 0 49 Nett Total 8 70 Payment Mode Amount CASH 8 70 Change 0 00 GST Summary Amount Tax SR GST 6 82 0 49 GST REG 000656195584 PERMAS JAYA Price inclusive OI GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAXINVOICE Invoice OR18032902170347 item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 Total Amount 7 10 GST 0 40 Nett Total 7 10 Payment Mode Amount CASH 7 10 Change 0 00 GST Summary Amount Tax 3R GST 656 6 70 0 40 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U Kawasan Perindustrian TAXINVOICE Invoice OR18033002170384 Item Qit Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount s Tax SF 7 74 0 48 GST REG 000656195584 PERMAS JAYA Price Inclusive Oi GST Thank You Come Againl Like and Follow Us on Facebook INVOICE_RECEIPT, Triple Six Point Enterprise 666 No Tel Receipt no REC 0015016 Date Payment Type Cash Receipt Receipt No REC 0015016 QTY ITEM PRICE TOTAL RM RM 2x Hey Song 4 30 7 60 Camellia green tea 580ml Disc 1 0000 Discount 1 00 Total Amount 7 60 Tendered 10 00 Change 2 40 V INVOICE_RECEIPT,B I G Din s Indepenstaut Graws BENS INDEPENDENT GROCER SDN BHD Heights 758 I F 0 209 759 GST REG NO 0002494176 Tax Invoice BATO220180120255 Sy 880905900708 7 90 2 70 Z Evian Mineral Water 6x1 25L 0682011784 5 50 1 5 50 S Item 2 Total with GST 6 77 20 Qty 4 Rounding 0 00 Total Saving 0 00 Total 77 20 Tender Cash 100 00 Change 22 80 GST Analysis Goods Tax Amount S 6 50 47 0 Z 0 2 70 0 00 EXCHANGE REFUND MAY BE ALLOWED WITHIN DAYS WITH ORIGINAL TAX INVOICE THANK YOU PLEASE COME AGAIN BAT0220180120255 INVOICE_RECEIPT, s PERI PERI CHICKEN s Chickenland Malaysia Sdn Bhd s Tel Fax Tax Invoice GST ID 000097492992 4 76 SYAFIQ 2 Chk 8660 Guest0 DELIVERY CHG 4 00 S 4 1 4 Chic 1sd T 17 90 71 60 S 4 1 4 H S 4 CharGrill Veg R TC S GrillVeg H GrillVeg H GrillVeg H GrillVeg H 3 1 4 Chic 1sd T 17 90 53 70 S 3 1 4 M S 3 Coleslaw R T S Sub Total 129 30 Amt Due 129 30 GST 6 7 30 How was it for you Your feedback is important SO please complete our A meal for you 10 friends is up for grabs Survey Code MAL025 T C apply For Take Away and Delivery food is best consumed within 2 hours GSTSummary Amount RM GST RM S GST 6 122 00 7 30 Z GST O 0 00 0 00 INVOICE_RECEIPT, B 519537 X LOT GST ID NO INVOICE NO 18341 T0138 19 03 18 840ML RM11 40 Total Sales Inclusive GST RM 11 40 CASH RM 11 40 CHANGE RM 00 GST Summary Amount RM Tax RM S 6 10 75 65 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,PETRODELI ENTERPRISE Company No SA0127959 D Site Telephone GST No Invoice number 39 42 litre Punp 09 FuelSave 95 RM 85 54 C 2 170 RM litre Total RM 85 54 Visa RM 85 54 Relief GST C RM 0 00 Total Gross C RM 85 54 Shell Loyalty Card Points Awarded 39 Date Time Num OPT 09 Diesel Petrol RON95 given Relief under Section 56 3 b GST Act Thank you Please come again INVOICE_RECEIPT,SUN WONG KUT SDN BHD Company No 20965 W Site Telephone GST No Invoice number 39 54 litre Pump 07 FuelSave 95 RM 88 17 C 2 230 RM litre Total RM 88 17 Visa RM 88 17 Relief GST C RM 0 00 Total Gross C RM 88 17 Shell Loyalty Card Points Awarded 39 Date Time Num OPT 40278 07 Diesel Petrol RON95 given Relief under Section 56 3 b GST Act Thank you Please come again INVOICE_RECEIPT,RESTAURANT JTAWE JIAWE HOUSE 13 JLN TASI UTAMA 8 L INVOICE Invoice 9820 Cashier admin POS No 1 Date Table 16 ITEM QTY U P RM DISC 4 Aint RM B Bean Bitterground Fish Head S 1 35 00 0 00 F Hong ong Sauteed s 1 16 00 0 00 Steamed Egg S 1 10 00 0 00 Chinese Tea 2 0 60 0 00 1 20 COLD Rice B 2 1 50 0 00 3 Sub Total Before Discount RM 65 20 Service Charge RM 0 00 Total Sales RM 65 20 Rounding Adjustment RM 0 00 TOTAL RM 65 20 INVOICE_RECEIPT, H NO 19 G819 1819 2 GST No TAX INVOICE TRN CR0008964 COUNTER 3 CASHIER 1 UOM GST Price Tax Tax Code WALL S TOPTEN CHOCOLATE 73ML 1 WALK 1 60 1 60 1 60 ZRL WALL S TOPTEN CHOCOLATE 73ML 1 WALK 1 60 1 60 1 60 ZRL MAGNUM ALMOND 90ML 1 WALK 4 50 4 50 4 50 ZRL Cloud 9 plus 22g 1 WALK 0 50 0 50 0 50 ZRL Total Qty 4 00 8 20 Total Includes GST 0 8 20 Customer s Payment Cash 20 20 Change 12 00 GST Summary Amount RM Tax RM ZRL 0 8 20 0 00 Goods sold are not returnable Thank you for shopping at INVOICE_RECEIPT,LIAN CHI PU TIAN VEGETARIAN RESTAURANT X GST ID No 001147416576 Tel 669 Table 8 Cashier Date item Qty Price Amount S 15 90 CURRY MIXED VEGE 515 1 16 85 16 85 SR S CD 13 90 517 1 14 73 14 73 SR 12 PCS 12 00 410 1 12 72 12 72 SR POT 3 00 TI GUAN YIN TEA 822 1 3 18 3 18 SR B 1 50 PLAIN RICE 922 2 1 59 3 18 SR Gross Amt 47 80 Svr Tax 2 87 GST 6 2 86 Net Amt 53 55 GST Summary Amount RM Tax RM a 0 2 87 0 00 SR il 6 47 80 2 86 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, 124525 H NO 19 G 19 1 GST No TAX INVOICE TRN CR0007636 COUNTER 4 CASHIER 11 GST Price Tax Tax Code POKKA COFFEE VANILLA MILK COFFEE 1 WALK 3 20 3 20 3 20 ZRL Total Qty 1 00 3 20 Total Includes GST 0 3 20 Customer s Payment Cash 5 20 Change 2 00 GST Summary Amount RM Tax RM ZRL 0 3 20 0 00 Goods sold are not returnable Thank you for shopping at INVOICE_RECEIPT, S B 519537 X LOT P T GST ID NO INVOICE NO 18314 102 8991 NUTRI PLUS TELUR RM9 90 Z Total Sales Inclusive GST RM 9 90 CASH RM 10 00 CHANGE RM 10 GST Summary Amount RM Tax RM Z 0 9 90 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, 0 519537 X BESI GST ID NO INVDICE NO 18299 102 5J8017 RM62 50 Z 5 X RM 12 50 RM79 00 Z X RM 15 80 Total Sales Inclusive GST RM 141 50 CASH RM 150 00 CHANGE RM 3 50 GST Summary Amount RM Tax RM Z 0 141 50 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, BHD H FLR AEON JLN JEJAKA CHERAS GST ID 002017394688 SHOPPING HOURS MON SUN 1000 HRS 2200 HRS 1x 000004089728 5 90SR SAKUMASHIKIOROP 1x 000007572029 5 90SR BINDER CLIP BL 1x 000006731878 5 90SR 150YEN CAR NECK Sub total 17 70 Total Sales Incl GST 17 70 Total After Adj Incl GST 17 70 CASH 50 70 Item Count 3 Change Amt 33 00 Invoice No 2018021951320026157 GST Summary Amount Tax SR 6 16 71 0 99 Total 16 71 0 99 002 0026157 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No 113825 W GST Reg No 001492992000 No 8 Jalan SUNWAY VELOCITY Tel Slip No 0010104733 PEI YI Trans 114793 Member Card No Card Expiry Description Amount TOMBOW C Tape CX5N 2pc 9 89 19 78 T Spring Issue 20 Reba L11 X VENTURE UNEXPLA BK 12 00 Z Member Discount 1 20 PU EXPANDING FILE TS 20 90 T Member Discount 2 09 Total RM Incl of GST 49 39 Rounding Adj 0 01 Total RM 49 40 Cash 50 00 CHANGE 0 60 Item Count 5 GST Summary Amount RM Tax RM T 6 36 41 2 18 Z 0 10 80 0 00 Total Savings 3 29 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT, NO SR 1 GST ID 002139201536 Tax Invoice No CS 20242 Qty Tax RM Durafile H399 110 X 95mm 100 SR 58 30 Name Badge H 0 5500 809 Metal Name Badge Clip 1 SR 21 20 100 s 200000 Total Amt Incl GST 6 79 50 Rounding Adjustment Total Arnt Payable 79 50 Paid Amount 100 00 Change 20 50 Total Qty Tender 101 GST Summary Amount Tax RM RM SR A 75 00 4 50 Total 75 00 4 50 THANK YOU For ano enquirv please contact us INVOICE_RECEIPT,3180303 GL HANDICRAFT TAILORING Company Reg No 75495 W GST Reg No 001948532736 TAX INVOICE Involce No CS 10012 Date Cashier 01 RM Code SAFETY PINS BUTTERFLY S 6 00 BOXS y 17 00 102 00 SR Subtotal 102 00 Total Excl of GST 96 23 Total incl of GST 102 00 Total Amt Rounded 102 00 Payment 102 00 Change Due 0 00 Total Item 5 6 GST Summary Amount RM Tax RM SR 6 96 23 5 77 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, 162761 M NO 32 33 JALAN SR 1 9 ID 002139201536 Tax Invoice No CS 20322 Qty Tax RM Durafile H399 110 x 95mm 200 SR 116 60 Name Badge H 0 5500 809 Metal Name Badge Clip 2 SR 42 40 Total Amt Incl GST 6 159 00 Rounding Adjustment Total Amt Payable 159 00 Paid Amount 200 00 Change 41 00 Total Qty Tender 202 GST Summary Amount Tax RM RM SR A 150 00 9 00 Total 150 00 9 00 THANK YOU For ano enauiv please contact us INVOICE_RECEIPT, NO 32 33 JALAN SR SEKSYEN GST ID 00213201536 Tax Invoice No CS 20243 Qty Tax RM F Castell 187057 75 Tack it 2 SR 12 00 75g White new 5 6600 Total Amt Incl GST 6 12 00 Rounding Adjustment Total Amt Payable 12 00 Paid Amount 20 00 Change 8 00 Total Qty Tender 2 GST Summary Amount Tax RM RM SR A 11 32 0 68 Total 11 32 0 68 THANK YOU For anv enauirv please contact us INVOICE_RECEIPT, Mi CafE Dimiliki W No GST Reg No 000306700288 GUEST CHECK Table A INV No 153887 Pax s 2 Date Cashier Cashier A Qty Description Total TAX 1 205 SUONG NON RAM CHUA 9 90 SR 205 Sweet Sour Pork Ribs 1 217 Tau Hu Don Thit Chi 9 90 SR 217 Stuff Meat Tau Fu 1 605 TRA DA 1 50 SR 605 Vietnamese Iced Tea Total Excluding GST 21 30 Serv Charge 3 0 65 GST payable 6 1 31 Total Inclusive of GST 23 26 Rounding Adj 0 01 TOTAL 23 25 Closed Server Cashier A GST Summary Amount RM Tax RM Inquries Like us Facebook Email INVOICE_RECEIPT,THAI DELICIOUS RESTAURANT Bill No Table Date A3 Cashier 123 Pax 4 Description Qty Price Amount 1 06S BRAISED 1 20 00 20 00 PORK LEG SMALL 2 32 PHRANAKON 1 28 00 28 00 SALTEDEGG SQUID 3 51 GARLIC FRIED 1 13 00 13 00 KAILAN viring 4 84 THAI STYLE 1 15 00 15 00 KERABU TOFU in Nill 5 130 PLAINRICE 4 1 80 7 20 6 113 COCONUT 1 6 50 6 50 THAI 7 116 DISTILLED 1 0 60 0 60 WATER 8 106B COLD 1 2 50 2 50 PANDAN GINGER TEA Total 92 80 Grand Total 92 80 Cash Received 100 00 Change 7 20 AVERAGE PAX S 23 20 Thank You Please Come Again INVOICE_RECEIPT,MR D I Y M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 ENDAH PARADE TAX INVOICE TOILET BRUSH 47 2311 S HD03 04 06 9067860 1 X 2 70 2 70 CEMENT KN BLK 2 S KF12 9071872 1 X 1 60 1 60 HSS TWIST DRILL 5 5 S KH22 500 6909906163102 1 X 3 30 3 30 HSS TWIST DRILL 6 1 S KH12 500 6909906163103 1 X 3 30 3 30 CURTAIN STRAPS S CK11 22 31 400 8720019 2 X 2 50 5 00 Item s 5 Qty s 6 TOTAL INCL GST 6 RM 15 90 CASH RM 50 00 CHANGE RM 34 10 GST Summary Amt RM Tax RM GST S 6 15 00 0 90 SH01 ZJ03 T3 R000100808 OPERATOR TSGC EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,HON HWA HARDWARE TRADING Company Reg No 001055194X NO 37 JALAN MANIS 7 GST Reg 001125220352 TAX INVOICE CB 87870 M C2 0 Cashier cash1 Qty Description Price Total RM 0 9 3 4 ALUMINIUM ROD 6 00 5 40 SR 5 PVC WALLPLUG 1 00 5 00 SR 50PCS 5 9 Type 2 Total 10 40 Discount 0 00 Rounding Adj 0 00 Total Inclusive GST 10 40 CASH 10 40 GST Summary Code Net Amt GST Total RM SR SR 9 81 0 59 10 40 Total 9 81 0 59 10 40 Thank you Please come again I Goods soid are not returnable for refund or exchange Il INVOICE_RECEIPT,MR D I Y SDN BHD CO REG 704427 T PERINDUSTRIAN GST ID No 001092886528 CHERAS LEISURE MALL TAX INVOICE BATTERY LR03 4B AAA 4 PCS S XC12 1 X 3 90 3 90 Item s 1 Qty s 1 Total Incl GST 6 RM 3 90 CASH RM 4 00 CHANGE RM 0 10 GST Summary Amt RM Tax RM GST S 6 3 68 0 22 24 11 17 SH01 ZT09 T2 R000011248 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,HON HWA HARDWARE TRADING Company Reg No 001055194X NO 37 JALAN 7 GST Reg 001125220352 TAX INVOICE CB 69158 M C1 0 Cashier cash3 Qty Description Price Total RM 2 1 TOWEL ROD 6 00 12 00 SR BRACKET END 2 3 4 TOWEL ROD 4 00 8 00 SR BRACKET 5 3 4 TOWEL ROD 4 00 20 00 SR BRACKET END 4 3 4 TOWEL ROD 5 50 22 00 SR BRACKET ROUND 1 25MM X 10 WALL PLUG 3 50 3 50 SR 1 SANDFLEX SAW 4 50 4 50 SR BLADE 18T 1 SCREW 7 00 7 00 SR 5 3 4 BRACKET 1 50 7 50 SR 6 1 S STEEL ROD 15 80 94 80 SR Item Discount 0 00 17 3 4 ALUMINIUM ROD 5 80 98 60 SR 44 Type 10 Total 277 90 Discount 0 90 Rounding Adj 0 00 Total Inclusive GST 277 00 CASH 277 00 GST Summary Code Net Amt GST Total RM SR SR 261 32 15 68 277 00 Total 261 32 15 68 277 00 Thank you Please come again Goods sold are not returnable for relund or exchange Il INVOICE_RECEIPT,VIVOPAC MARKETING SDN BHD M TEL FAX GST REG 000565805056 TAX INVOICE Doc CS21539777 Date Promoter Terminal T02 Cashier ME DESCRIPTION PRICE Disc AMOUNT TAX QTY RM RM CODE 9 x 13 10A 1 00 PKT 0 7500 0 75 SR 26 x 33 85HT Red 1 00 PKT 8 0000 8 00 SR 24 x 28 75HT Red 1 00 PKT 6 0000 6 00 SR Price Label PLAIN 2 00 ROLL 1 5000 3 00 SR Item Count 4 Item Qty 5 00 Sub Total Exclusive GST 17 75 GST 6 1 07 Rounding Adj 0 02 Rounded Total RM 18 80 Cash 20 00 Cash Change 1 20 GST Summary Amount RM Tax RM SR 6 17 75 1 07 Terms Conditions Goods sold are not refundable with cash For exchange of goods sold the following apply 1 The original receipt must be presented 2 Exchange is done within 7 days from date of receipt 2 In good condition and in it s original pakcing INVOICE_RECEIPT,MR D I Y SDN BHD CO REG 704427 T GST ID No 001092886528 CHERAS LEISURE MALL TAX INVOICE CLOTH PEG E 140 S WA36 9555112901406 1 X 5 90 5 90 Item s 1 Qty s 1 Total Incl GST 6 RM 5 90 CASH RM 5 90 GST Summary Amt RM Tax RM GST S 6 5 57 0 33 18 10 17 SH01 ZT09 T3 R000000163 OPERATOR GCHT NOR MASLIZA EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR D I Y SDN BHD CO REG 704427 T KAWASAN PERINDUSTRIAN BALAKONG GST ID No 001092886528 CHERAS LEISURE MALL TAX INVOICE PADLOCK ST P6150 50MM S 0202 6942131561507 1 X 9 90 9 90 Item s 1 Qty s 1 Total Incl GST 6 RM 9 90 CASH RM 10 00 CHANGE RM 0 10 GST Summary Amt RM Tax RM GST S 6 9 34 0 56 28 12 17 SH01 ZT09 T1 R000020832 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR KUCHAI W PERINDUSTRIAN BALAKONG GST ID No 000473792512 TESCO EXTRA KAJANG TAX INVOICE BOOSTER CABLE XH 500A S CE72 10 9001620 1 X 29 90 29 90 MOTH BALLS 150G S EC21 41 71 1 X 2 10 2 10 DIY GOLD TWIST DRILL 3MM S LB22 20 9071246 1 X 2 50 2 50 HSS TWIST DRILL 160MM S LG32 42 6909906163107 1 X 3 30 3 30 Item s 4 Qty s 4 TOTAL INCL GST 6 RM 37 80 CASH RM 40 00 CHANGE RM 2 20 GST Summary Amt RM Tax RM GST S 6 35 66 2 14 08 03 17 42 SH01 B028 T2 R000017473 OPERATOR TRAINEE EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, No TAX INVOICE Slip 0000000011000136498 Date Time 1 12 Trans 311136194 Staff 95837 Description Amount TX 50346155 80X50X18 2 pc 269 00 538 00 SRS Total RM Including GST 6 538 00 Rounding Adj 0 00 Total Rounded 538 00 Visa 538 00 GST SR 6 538 00 30 45 Amt Excl GST 507 55 No of Items 2 Thank you Please come again T3620000011000136498 INVOICE_RECEIPT, TAX INVOICE Slip 0000000011000140428 Date Time 1 06 Trans 311140123 Staff 96728 Description Amount TX 30169728 CH 2 pc 4 90 9 80 SRM 70350938 CH 90 00 SR S Total RM Including GST 6 99 80 Rounding Adj 0 00 Total Rounded 99 80 Mastercard 99 80 GST SR 6 99 80 5 64 Amt Excl GST 94 16 of Items 3 Thank you Please come again T3620000011000140428 INVOICE_RECEIPT,FY EAGLE ENTERPRISE 002065464 NO PBS TEL FAX GST NO TAX INVOICE RECEIPT CS00031180 DATE SALESPERSON TIME CASHIER USER ITEM QTY U P AMOUNT RM RM 12089 2 3 50 7 00 SR TAPE OPP 48MMX80Y CLEAR B PY ECS TOTAL QUANTITY 2 SUB TOTAL 6 60 DISC 0 00 GST 0 40 ROUNDING 0 00 TOTAL 7 00 CASH 7 00 CHANGE 0 00 GST SUMMARY CODE AMOUNT TAX AMT SR 6 60 6 0 40 TAX TOTAL 0 40 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, Tel Fax GST ID 000429166592 RECEIPT Terminal 188 5505P0S004 Trans 255018 Date Cashier CH110137 MSM 8999002310564 2 2 50 5 00 Item Count 2 Total 5 00 Rounding Adjustment 0 00 Total After Rounding 5 00 Cash 10 00 CHANGE 5 00 GST Rate Amt Excl GST RM Tax RI4 S 6 4 72 0 28 Z 0 0 00 0 00 Points THE Join ty Programme today 6605505001880000255018 Print Date Note Any request for production of full tax invoice must be made within 3 months from the date of purchase If the request is not made within the prescribed time frame NYDIN may based on its absolute discretion reject the request Thank You and Please Come Again INVOICE_RECEIPT, Tel Fax GST ID RECEIPT Terminal 195 5505P0S011 Trans 261172 Date Cashier CH107691 MSM MYCLIP BINDER CLIP 12S 25MM 12S EA S 2901060611145 1 2 00 2 00 MYCLIP BINDER CLIP 15MM 12S CS S 2901060611213 2 12 00 24 00 HYCLIP BINDER CLIP 15MM 12S EA S 2901060611206 10 1 00 10 00 PARTNER E LOPE 4 51NX9 5IN W4292 EA S 9555023304655 2 2 20 4 40 QUALITY LFTTER TRAY T 1196 MIX EA S 9555052401196 3 14 90 44 70 Item Count 18 Total Rounding Adjustment E M M MAR PT 3 ricin IN 85 10 0 00 Total After Rounding N IND 85 10 Cash 100 10 CHANGE 15 00 GST Rate Amt Excì GST RM Tax RM S 6 80 27 4 83 I 0 0 00 0 00 Your Total Savings 8 00 Points Missed 85 Join cur Meriah Loyalty Programme today 6605505001950000261172 Print Date Note Any request for production of full tax invoice must be made within 3 months from the date of purchase If the request is not made within the prescri ibed time frame MYDIN may based on its absolute discretion reject the request Thank You and Please Come Again INVOICE_RECEIPT,ADVANCO COMPANY Company Reg No V NO 1 3 Jalan 12 Link Maju GST Reg 001658445824 TAX INVOICE CB 398313 M M2 0 Cashier c2000 Qty Description Price Total FUJI XEROX EVERYDAY A4 70GSM E SR 5 27499 11 00 55 00 Item Discount 0 20 1 00 CANON PG 47BK E400 BLACK FINE SR 1 27736 29 00 29 00 6 Type 2 Total 84 00 Disc 20 X 5 1 00 Rounding Adj 0 00 Total Inclusive GST 83 00 CASH 85 00 Change 2 00 GST Summary Code Net Amt GST Total SR 6 78 30 4 70 83 00 Total 78 30 4 70 83 00 Thank you Please come again Goods sold are not returnable for refund or exchange INVOICE_RECEIPT, CHERAS 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS 1x 000004497295 5 90SR WET TISSUE 150S Sub total 5 90 Total Sales Incl GST 5 90 Total After Adj Incl GST 5 90 CASH 50 00 Item Count 1 Change Amt 44 10 Invoice No 2018032251310415556 GST Summary Amount Tax SR 6 5 57 0 33 Total 5 57 0 33 5131 041 0415556 0305215 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, BHD 3RD FLR AEON JLN JEJAKA GST ID 002017394688 SHOPPING HOURS MON SUN 1000 HRS 2200 HRS 000008190901 5 90SR STERILE FILTRAT Sub total 5 90 Total Sales Incl GST 5 90 Total After Adj Incl GST 5 90 CASH 10 00 Item Count 1 Change Amt 4 10 Invoice No 201802095132 GST Summary Amount Tax SR 6 5 57 0 33 Total 5 57 0 33 5132 002 0301371 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN Booh pay Already INVOICE_RECEIPT,POPULAR BOOK M SDN BHD Company No 113825 W GST Reg No 001492992000 No 8 FESTIVAL CITY MALL Tel 20 Slip No Description Amount 70g P Copy 450 S 3pc 13 69 41 07 T Stat Great Saving 9 60 Total RM Incl of GST 31 47 Rounding Adj 0 02 Total RM 31 45 Cash 50 00 CHANGE 18 55 Item Count 3 GST mary Amount RM Tax RM T 6 29 69 1 78 Total Savings 9 60 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No W GST Reg No 001492992000 No 8 SUNWAY VELOCITY Tel 03 9201 Slip No 0010111111 Trans 121722 Description Amount PB SHT P 11H A4 10 S C O 2pc 3 50 7 00 T R RING 500 s 2 65 T Total RM Incl of GST 9 65 Cash 50 00 CHANGE 40 35 Item Count 3 GST Summary Amount RM Tax RM T 6 9 10 0 55 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online m INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No 113825 W GST Rex No 001492992000 No 8 Jalan SUNWAY VELOCITY Tel 6920 Slip No 0020070154 PEI YI Trans 77499 Description Amount 70g P Copy 450 S 2pc 13 69 27 38 T Stat Great Saving 6 40 Total RM Incl of GST 20 98 Rounding Adj 0 02 Total RM 21 00 Cash 50 00 CHANGE 29 00 Item Count 2 GST Summary Amount RM Tax RM T 6 19 79 1 19 Total Savings 6 40 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT,3 1810012 WAHIN HARDWARE U TEL STORE FAX GST Number 000048898048 TAX INVOICE Invoice No CS0013132 Date ItemDescription Quantity Price GST Inc Amount 14 MINI ROLLER REFILL 2 2 6500 5 30 SR 24 X18 ROLLERPAINT HANDLE 2 3 1800 6 36 SR 33 5LRT BLACK OXIDE PAINT 1 30 7400 30 74 SR Gross Amount 40 00 Total GST Amt 2 40 Sub Total 42 40 Rounding Adj 0 00 Total RM 42 40 Amount Paid 42 40 Amount Change 0 00 Quantity Count 5 Total Item Sold 3 GST SummaryAmount RM GST Amount RM SR 6 40 00 2 40 THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00011983 Date Cashier USER Time 16 15 00 Salesperson Ref II Qty S Price Amount Tax 1476 3 15 90 47 70 SR 25KG SIKA CREAM 88 Total Qty 3 47 70 Total Sales Excluding GST 45 00 Discount 0 00 Total GST 2 70 Rounding 0 00 Total Sales Inclusive of GST 47 70 CASH 47 70 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 45 00 2 70 Total 45 00 2 70 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 2 M SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00011955 Date Cashier USER Time 1721 00 Salesperson Ref Item Qty S Price Amount Tax 1587 1 7 42 7 42 SR SPRAY PAINT Total Qty 1 7 42 Total Sales Excluding GST 7 00 Discount 0 00 Total GST 0 42 Rounding 0 00 Total Sales Inclusive of GST 7 42 CASH 7 42 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 7 00 0 42 Total 7 00 0 42 TURNABLE THANK YOU INVOICE_RECEIPT,31812012 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00011926 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 3122 1 29 68 29 68 SR W33 105MM 4 CUTTING DISC Total Qty 1 29 68 Total Sales Excluding GST 28 00 Discount 0 00 Total GST 1 68 Rounding 0 00 Total Sales Inclusive of GST 29 68 CASH 29 68 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 28 00 1 68 Total 28 00 1 68 THANK YOU INVOICE_RECEIPT, 000115154944 TAX INVOICE Slip 0000000111000395667 Date Time 7 13 Trans 411395668 Staff 95651 Description Amount TX 910347623 Cak 22 50 SR 999900245 Retai 36 00 SR 599937000 Drink 1 00 SR 999900701 Dark Chocolate 70 U 2 po i 6 90 13 80 SR Total RM Including GST 6 73 30 Rounding Adj 0 00 Total Rounded 73 30 Cash 73 30 GST SR 6 73 30 4 15 Amt Excl GST 69 15 of Items 5 73 30 Thank you Please come again INVOICE_RECEIPT,3181201 2 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012441 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1971 1 148 40 148 40 SR PASIR HALUS 1 LOAD SMALL Total Qty 1 148 40 Total Sales Excluding GST 140 00 Discount 0 00 Total GST 8 40 Rounding 0 00 Total Sales Inclusive of GST 148 40 CASH 148 40 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 140 00 8 40 Total 140 00 8 40 8 40 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, Chili Chili s Grill Bar P Tel GST ID 001042104320 Tax Receipt GST 0 001042104320 4 CHILIS3 23 Anis Chk 1080323 Gst4 TBL64 1 EAT IN 1 PINEAPPLE JUICE 12 95 S 1 TOSTADA CHIPS 16 95 S 1 CHP BWL CK 29 95 S 1 MARG CK 27 95 S Subtotal 87 80 10 Srv Chg 8 78 GST 6 5 81 Total 102 39 0 01 Total 102 40 YOUR OPINION MATTERS 102 40 We invite you to complete our GUEST EXPERIENCE SURVEY YOU COULD WIN RM500 CASH OR CHILI S VOUCHER FOR RM1 000 A WINNER EVERY MONTH Visit YOUR SURVEY CODE 501 Pls enter within the next 4 days Must be or above Void where prohibited See web for complete rules and sweepstakes details Amount RM GST RM S GST 6 96 58 5 81 Z GST 0 0 00 0 00 INVOICE_RECEIPT, GST Reg No 000465809408 Tax Invoice Table 15 INV No 593101 Pax s 2 Date Cashier SIM Description Qty U price Total TAX Smoked Duck Spaghetti 1 X 12 50 12 50 SR Hot Green Tea 1 X 3 00 3 00 SR Coffee H 1 X 4 90 4 90 SR Rendang Chicken Rice 1 X 9 90 9 90 SR Total QTY 4 Total Excluding GST 28 58 GST payable 6 1 72 Total Inclusive of GST 30 30 TOTAL 30 30 Closed 001 Server SIM CASH 50 00 CHANGE 19 70 30 30 GST Summary Amount RM Tax RM SR 6 28 58 1 72 INVOICE_RECEIPT,31803014 BEYOND BROTHERS HARDWARE 872981 V JLN TEL FAX GST ID 001921974272 TAX INVOICE Bill To PDP UTEK M SDN BHD NEAR TO KPJ HOSPITAL 019 2616 281 MR NEO Doc No CS00067741 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 11028 1 150 00 159 00 159 00 SR BATU CEMENT A 600PCS 11046 2 80 00 84 80 169 60 SR PASIR HALUS 11000 6 16 00 16 96 101 76 SR YTL CEMENT 50KG NEW PRICE 11036 1 3 00 3 18 3 18 SR KAPUR A1 10012 2 3 00 3 18 6 36 SR SALUNG TANGAN GETAH 1PAIR 1682 1 00 2 12 2 12 SR BENANG NYLON 18 2567 1 16 00 16 96 16 96 SR GERMANY SUDU PLASTER 2564 1 6 90 7 31 7 31 SR SUDU PLASTER KAYU NORMAL 0 2686 1 4 50 4 77 4 77 SR PAPAN SIMEN HITAM 1521 1 19 90 21 09 21 09 SR e MMAN RULE TIMBANG 18 3879 1 100 00 106 00 106 00 SR 0 KERETA TOLAK H D OREN 3416 1 1 20 1 27 1 27 SR 0 PAKU KAYU 1 KECIL 3432 1 0 00 0 00 0 00 SR 0 MAYBANK 5122 0481 6723 Total Qty 20 599 43 Total Sales Excluding GST 565 50 Discount 0 00 past Total GST 33 93 Rounding 0 02 Malsales Inclusive of GST 599 45 CASH 599 45 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 565 50 33 93 Total ERE SO 27 93 INVOICE_RECEIPT, AL MENDIS THE MINES ZAWIAJAYA FOOD N BEVERAGE SDN BHD 1168272 U 106 107 LEVEL 1 THE MINES MALL SERDANG SRI KEMBANGAN GST Reg No 001685499904 Tax Invoice Table 23 Order 116455 Bjll V001 515592 Pax s 2 Date Cashier TAMEEM EMS Ref 180321142900_515592_bjc5691918 365 Description Qty U price Total TAX Maghgout Lamb W 1SI M X 22 50 22 50 SR Garden Salad S 1 X 5 90 5 90 SR TEA POT BIG 1 X 12 90 12 90 SR Total Excluding GST 41 30 Serv Charge 10 4 13 GST Payable 2 73 Total Inclusive of GST 48 16 Rounding Adj 0 01 TOTAL 48 15 Closed 011 Server TEMP STAFF CASH 50 00 CHANGE 1 85 GST Summary Amount RM Tax RM SR 6 45 43 2 73 Thank You Please Come Again POWERED BY SISPOS COM MY INVOICE_RECEIPT, HARDWARE TRADING No 7 Simpáng Off Tel Fax No Company Reg No 002231061 T GST Reg No 001269075968 TAX INVOICE Invoice No CS 24198 Date LST RM Code BEG GUNI 10 00 NOS X 0 70 7 00 SR Subtotal 7 00 Total Incl of GST 7 00 Payment 7 00 Change Due 0 00 Total Item s 10 GST Summary Amount RM Tax RM SR 00 6 6 60 0401 THANK YOU A PLEASE COME AGAIN GOODS SOLD ARE NOT RETURNABLE INVOICE_RECEIPT, Tel Fax No Company Reg No 002231061 T GST Reg No 001269075968 TAX INVOICE Invoice No CS 24399 Date Cashier LST RM Code BEG GUNI 10 00 NOS X 0 70 7 00 SR Subtotal 7 00 Total Incl of GST 7 00 Payment 7 00 Change Due 0 00 Total Item s 10 GST Summary Amount RM Tax RM SR 0 6 6 60 0 40 THANK YOU PLEASE COME AGAIN GOODS SOLD ARE NOT RETURNABI INVOICE_RECEIPT, Tel Fax No Company Reg No 002231061 T GST Reg No 001269075968 TAX INVOICE Invoice No CS 23304 Date Cashier LST RM Code SIMEN S 3 00 x 2 00 6 00 SR Subtotal 6 00 Total In of GST 6 00 Payment 6 00 Change Due 0 00 Total Item s 3 GST Summary Amount RM Tax RM SR a 6 5 66 0 34 0 34 THANK YOU PLEASE COME AGAIN GOODS SOLD ARE NOT RETURNABLE INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012440 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 2623 2 2 12 4 24 SR NAIL PER PACK RM2 3483 1 7 95 7 95 SR 1 1 2 SANCORA PAINT BRUSH 1452 1 10 07 10 07 SR 7 PAINT ROLLER SET 1664 2 26 50 53 00 SR 1LT BIG TREE HIGH GLOSS PAINT 1665 450 0 30 133 56 SR CEMENT BRICK 1041 3 15 90 47 70 SR 6 X 35 CORRUGATED ROOFING SHEET 2430 4 18 02 72 08 SR CEMENT 50KG 1812 2 16 96 33 92 SR 10 2X 3 1792 3 7 42 22 26 SR 10 1 X 2 1840 2 40 28 80 56 SR K10 1X8 Total Qty 470 465 34 Total Sales Excluding GST 439 00 Discount 0 00 Total GST 26 34 Rounding 0 00 Total Sales Inclusive of GST 465 34 CASH 465 34 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 439 00 26 34 Total 439 00 26 34 26 34 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, No 193573 M Level G2 Block D1 GST ID No 000377700352 TEL Tax Invoice P S 07 A INV No 0207140118000488 T D 44 Ticket No 028165 Entry Time Sun Paid Time Sun Parking Time 1 45 Parking Fee Rate A RM4 00 Amount 14 1 18 RM3 77 GST 6 00 RM0 23 Total 4 00 RM4 00 Paid RM4 00 Change RMO 00 Inclusive 6 GST Thank You INVOICE_RECEIPT,3 18 01 017 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012507 Date Cashier USER Time 16 Salesperson Ref Item Qty S Price Amount Tax 1811 1 13 57 13 57 SR 8 2X3 1042 4 18 55 74 20 SR 7 X 35 CORRUGATED ROOFING SHEET 1921 1 5 30 5 30 SR NAIL PER PACK RM5 Total Qty 6 93 07 Total Sales Excluding GST 87 80 Discount 0 00 Total GST 5 27 Rounding 0 00 Total Sales Inclusive of GST 93 07 CASH 93 07 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 87 80 5 27 Total 87 80 5 27 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 0750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS012543 Date Cashier USER Time 15 39 Salesperson Ref Item Qty S Price Amount Tax 2402 1 3 71 3 71 SR 25MM GI NIPPLE 1462 2 0 64 1 27 SR SEAL TAPE 1748 1 5 83 5 83 SR 32MM POLY SOCKET 2247 1 33 92 33 92 SR 1 BALL VALVE Total Qty 5 44 73 Total Sales Excluding GST 42 20 Discount 0 Total GST 2 53 Rounding 0 Total Sales Inclusive of GST 44 73 CASH 44 73 Change 0 GST SUMMARY Tax Code Amt RM Tax RM SR 6 42 20 2 53 Total 42 20 2 53 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012626 Date USER Time Salesperson Ref Item Qty S Price Amount Tax 1943 1 23 32 23 32 SR HOES SET Total Qty 1 23 32 Total Sales Excluding GST 22 00 Discount 0 00 Total GST 1 32 Rounding 0 00 Total Sales Inclusive of GST 23 32 CASH 23 32 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 22 00 1 32 Total 22 00 1 32 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012664 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1627 1 4 45 4 45 SR WALL SCRAPER 3 2167 2 50 88 101 76 SR 4 5KG RENDEROC PLUG 1735 1 10 07 10 07 SR 5 SCRAPER ADAMARK Total Qty 4 116 28 Total Sales Excluding GST 109 70 Discount 0 00 Total GST 6 58 Rounding 0 00 Total Sales Inclusive of GST 116 28 CASH 116 28 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 109 70 6 58 Total 109 70 6 58 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 18 01017 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012514 Date Cashier USER Time 10 Salesperson Ref Item Qty S Price Amount Tax 1938 2 6 89 13 78 SR 4 ROLLER SET 1618 1 40 28 40 28 SR 7LT TOPLUS EMULSION PAINT 2430 2 18 02 36 04 SR CEMENT 50KG 2225 1 4 77 4 77 SR PLASTIC TRAP L Total Qty 6 94 87 Total Sales Excluding GST 89 50 Discount 0 00 Total GST 5 37 Rounding 0 00 Total Sales Inclusive of GST 94 87 CASH 94 87 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 89 50 5 37 Total 89 50 5 37 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012493 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1720 1 3 18 3 18 SR SPONGE SCRUB W PLASTIC HANDLE 1604 1 10 07 10 07 SR 4 1 2 PLASTERING TROWEL Total Qty 2 13 25 Total Sales Excluding GST 12 50 Discount 0 00 Total GST 0 75 Rounding 0 00 Total Sales Inclusive of GST 13 25 CASH 13 25 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 12 50 0 75 Total 12 50 0 75 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 18 01 017 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012494 Date USER Time Salesperson Ref Item Qty S Price Amount Tax 1432 1 2 12 2 12 SR GLOVE 1200 PER PAIR Total Qty 1 2 12 Total Sales Excluding GST 2 00 Discount 0 00 Total GST 0 12 Rounding 0 00 Total Sales Inclusive of GST 2 12 CASH 2 12 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 2 00 0 12 Total 2 00 0 12 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012727 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1432 3 2 12 6 36 SR GLOVE 1200 PER PAIR Total Qty 3 6 36 Total Sales Excluding GST 6 00 Discount 0 00 Total GST 0 36 Rounding 0 00 Total Sales Inclusive of GST 6 36 CASH 6 36 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 6 00 0 36 Total 6 00 0 36 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012659 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1512 2 10 60 21 20 SR 104 COTTON GLOVE DOZEN Total Qty 2 21 20 Total Sales Excluding GST 20 00 Discount 0 00 Total GST 1 20 Rounding 0 00 Total Sales Inclusive of GST 21 20 CASH 21 20 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 20 00 1 20 Total 20 00 1 20 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 18 010 17 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012726 Date Cashier USER Time 15 Salesperson Ref Item Qty S Price Amount Tax 1432 6 2 12 12 72 SR GLOVE 1200 PER PAIR Total Qty 6 12 72 Total Sales Excluding GST 12 00 Discount 0 00 Total GST 0 72 Rounding 0 00 Total Sales Inclusive of GST 12 72 CASH 12 72 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 12 00 0 72 Total 12 00 0 72 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 18 010 17 5 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012504 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1762 1 7 95 7 95 SR 17MM COMB SPANNER 1041 2 15 90 31 80 SR 6 X 35 CORRUGATED ROOFING SHEET Total Qty 3 39 75 Total Sales Excluding GST 37 50 Discount 0 00 Total GST 2 25 Rounding 0 00 Total Sales Inclusive of GST 39 75 CASH 39 75 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 37 50 2 25 Total 37 50 2 25 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 802016 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00013254 Date Cashier USER Time 15 Salesperson Ref Item Qty S Price Amount Tax 1921 1 5 30 5 30 SR NAIL PER PACK RM5 Total Qty 1 5 30 Total Sales Excluding GST 5 00 Discount 0 00 Total GST 0 30 Rounding 0 00 Total Sales Inclusive of GST 5 30 CASH 5 30 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 5 00 0 30 Total 5 00 0 30 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 180201 6 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00013251 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1099 3 90 10 270 30 SR 110MM X 5 8M UNDERGROUND PIPE Total Qty 3 270 30 Total Sales Excluding GST 255 00 Discount 0 00 Total GST 15 30 Rounding 0 00 Total Sales Inclusive of GST 270 30 CASH 270 30 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 255 00 15 30 Total 255 00 15 30 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,31802016 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00013118 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 2786 2 4 77 9 54 SR 12M WIRE ROPE CLIP 1471 1 4 77 4 77 SR 4 X KINKI BRD 2 WAY SCREWDRIVER 1943 2 23 32 46 64 SR HOES SET Total Qty 5 60 95 Total Sales Excluding GST 57 50 Discount 0 00 Total GST 3 45 Rounding 0 00 Total Sales Inclusive of GST 60 95 CASH 60 95 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 57 50 3 45 Total 57 50 3 45 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3180201 6 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012693 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 3483 1 7 95 7 95 SR 1 1 2 SANCORA PAINT BRUSH Total Qty 1 7 95 Total Sales Excluding GST 7 50 Discount 0 00 Total GST 0 45 Rounding 0 00 Total Sales Inclusive of GST 7 95 CASH 7 95 UU G I i Amt RM Tax RM S 6 7 50 0 45 Total 7 50 0 45 GOUDSSOLD APE JOT RETURNABLE THANK YOU INVOICE_RECEIPT,31800 01 6 SYARIKAT PERNIAGAAN GIN KEE 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00013066 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 1701 5 6 36 31 80 SR 6 8 BATU BAG 2167 1 50 88 50 88 SR 4 5KG RENDEROC PLUG Total Qty 6 82 68 Total Sales Excluding GST 78 00 Discount 0 00 Total GST 4 68 Rounding 0 00 Total Sales Inclusive of GST 82 68 CASH 82 68 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 78 00 4 68 Total 78 00 4 68 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,180201 6 SYARIKAT PERNIAGAAN GIN 81109 A NO TEL GST ID 000750673920 SIMPLIFIED TAX INVOICE CASH Doc No CS00012922 Date Cashier USER Time 10 Salesperson Ref Item Qty S Price Amount Tax 1700 6 6 36 38 16 SR PASIR HALUS BAG 2430 2 18 02 36 04 SR CEMENT 50KG Total Qty 8 74 20 Total Sales Excluding GST 70 00 Discount 0 00 Total GST 4 20 Rounding 0 00 Total Sales Inclusive of GST 74 20 CASH 74 20 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 70 00 4 20 Total 70 00 4 20 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3 1802 01 6 BEYOND BROTHERS HARDWARE 872981 V TEL FAX GST ID 001921974272 TAX INVOICE Doc No CS00065374 Date Cashier USER Time Salesperson Ref GST GST item Qity S Price S Price Amount Tax 4432 2 30 63 50 S9 6 GAL WHITE CONTAINER Total Qty 2 63 60 Total Sales Exc ig GST 60 00 Discount 0 00 Total GST 3 60 Rounding 0 00 Total Sales Inclusive of GST 63 60 CASH 63 60 Change 0 00 GST SUMMARY Tax Code Amt RM TaxiRM SR 6 60 00 3 60 Total 60 00 3 60 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,3180301 RESTORAN TEL GST ID NO 000696532992 TAX INVOICE INVOICE 1 161696 TIME CASHIER JAHABA R ALI SELF SERVICE 1000 QTY DESCRIPTION PRICE AMOUNT 1 MAKANAN 2 30 2 30 S 1 MAKANAN 1 40 1 40 S 1 MAKANAN 1 60 1 60 S Sub Total Incl GST RM 5 30 Round Adjustmt RM 0 00 Total RM 5 30 Payment CASH RM 10 00 Change RM 4 70 GST 6 Paid RM 0 30 GST ANALYSIS AMT RM TAX RM S 6 5 00 0 30 Z 0 0 00 0 00 THANK YOU PLEASE COME AGAIN Teguh Mr INVOICE_RECEIPT,3180301 For staff S B 587969 U GST NO 000342237184 ID 5033 23 Jln Burung Tmn KL TAX INVOICE pos1N M c ID POS7 Receipt Description Disc Subtotal 061558 BMS MILK THISTLE 1 X 111 30 36 75 72 35 S 910845 TRILON E CRM 1 X 7 00 7 00 TOTAL Including GST 79 35 ROUNDING 0 00 NET 79 35 TENDER 100 00 CHANGE BALANCE 20 65 GST Summary Amt Excl Gst Tax RM ZRL 0 00 7 00 0 00 SR 6 00 68 25 4 10 GOODS SOLD ARE NON REFUNDABLE BUT EXCHANGEABLE WITHIN 7 DAYS WITH RECEIPT PLUS GOODS ARE IN RESALEABLE CONDITION All face mask injectable are non returnable non exchangeable special promotion INVOICE_RECEIPT, NO TEL FAX GST NO 06839928 TAX INVOICE Bill To Receipt CS0874 Date Salesperson Time 10 51 Cashier USER GST GST Item Qty RSP RSP Amount 107636 3 78 82 68 248 04 SR HAGER TIMER 24HRS POWER RESERVE TOT QTY 3 248 04 Excluded GST Sub Total 234 Discount 0 Total GST 14 04 Rounding 0 01 Total 248 05 CASH 248 05 Change 0 GST SUMMARY Tax Code Amount GST SR 6 234 14 04 Total 234 14 04 GOODS SOLD ARE NOT RETURNABLE THAN YOU INVOICE_RECEIPT, 728515 M Tel Fax GST ID RECEIPT Terminal 195 5505P0S011 Trans 322563 Date Cashier CH107004 MSM PARTNER E LOPE 4 5INX9 5IN W4292 EA S 3555023304662 2 2 60 5 20 PLASTIC BAG RM0 20 EA S 2300000017984 1 0 20 0 20 TEN Q E LOPE 15INX1OIN TQ S1015 EA S 9555023307724 2 2 50 5 00 UMOE S NT 100MX75M N GRN EA S 9555495401722 1 3 00 3 00 UMOE S NT 100MX75M N YLW EA S 5555495400985 1 3 00 3 00 UMOE S NT 50MX38M N YLW EA S 9555495400961 1 2 50 2 50 UMOE S NE 75NX5OM N PINK EA S 9555495401814 1 2 50 2 50 Item Count S 9 Total 21 40 Rounding Adjustment 0 00 Total Atter CRounding 21 40 Cash 50 00 CHANGE 28 60 GST Rate Amt Excl GST RM Tax RM S 6 20 19 1 21 Z 0 0 00 0 00 Points Missed 20 Join our Meriah Loyalty Programme today 6605505001950000322563 Print Date Any request for production of full tax invoice or related payment information shall be made within 3 months from the date of purchase failing which MYDIN at its absolute discretion as deem fit may reject or refuse to entertain such request Thank You and Please Come Again INVOICE_RECEIPT, ELECTRICAL TRADING NO TEL FAX GST NO 000683900928 TAX INVOICE Bill To Receipt CS00093091 Date Salesperson Time 11 Cashier USER GST GST Item Qty RSP RSP Amount 102749 1 44 40 47 06 47 06 SR FUJI CONTACTOR SC 03 240VAC 106766 1 49 00 51 94 51 94 SR ANLY FLOATLESS RELAY 240V AFS 1 TOT QTY 2 99 00 Excluded GST Sub Total 93 40 Discount 0 00 Total GST 5 60 Rounding 0 00 Total 99 00 CASH 100 00 Change 1 00 GST SUMMARY Tax Code Amount GST SR 6 93 40 5 60 Total 93 40 5 60 GOODS SOLD ARE NOT RETURNABLE THAN YOU INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No Mahkota Selangor GST REG NO Tax Invoice INV No 1053110 Cashier Thandar Date Description Qty U price Total TAX Milo B 2 X 2 80 5 60 SR Take Away 2 X 0 20 0 40 SR Total QTY 4 Total Excluding GST 5 66 GST payable 6 0 34 Total Inclusive of GST 6 00 TOTAL 6 00 CASH 6 00 GST Summary Amount RM Tax RM SR 6 5 66 0 34 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No Mahkota Selangor GST REG NO Tax Invoice INV No 1052580 Cashier Thandar Date Description Qty U price Total TAX Teh B 2x 2 20 4 40 SR Cham B 1 X 2 20 2 20 SR Herbal Tea 1 X 1 70 1 70 SR Take Away 4 x 0 20 0 80 SR Total QTY 8 Total Excluding GST 8 59 GST payable 6 0 51 Total Inclusive of GST 9 10 TOTAL 9 10 CASH 9 10 GST Summary Amount RM Tax RM SR 6 8 59 0 51 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1044120 Cashier Thandar Date Description Qty U price Total TAX Kopi B 1 X 2 20 2 20 SR Cham B 1 X 2 20 2 20 SR Take Away 2 x 0 20 0 40 SR Total QTY 4 Total Excluding GST 4 54 GST payable 6 0 26 Total Inclusive of GST 4 80 TOTAL 4 80 CASH 4 80 GST Summary Amount RM Tax RM SR 6 4 54 0 26 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1054650 Cashier Date Description Qty U price Total TAX Teh B 2 X 2 20 4 40 SR Bunga 1 X 1 70 1 70 SR Take Away 3 x 0 20 0 60 SR Total QTY 6 Total Excluding GST 6 33 GST payable 6 0 37 Total Inclusive of GST 6 70 TOTAL 6 70 CASH 6 70 GST Summary Amount RM Tax RM SR 6 6 33 0 37 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No Mahkota Selangor GST REG NO Tax Invoice INV No 1047523 Cashier Thandar Date Description Qty U price Total TAX Kopi B 1 X 2 20 2 20 SR Teh B 1 X 2 20 2 20 SR Cham B 2 X 2 20 4 40 SR Take Away 4 X 0 20 0 80 SR Total QTY 8 Total Excluding GST 9 07 GST payable 6 0 53 Total Inclusive of GST 9 60 TOTAL 9 60 CASH 9 60 GST Summary Amount RM Tax RM SR 6 9 07 0 53 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1040841 Cashier Thandar Date Description Qty U price Total TAX Cham B 2 X 2 20 4 40 SR Roti Steam 2 X 1 10 2 20 SR Take Away 2 x 0 20 0 40 SR Total QTY 6 Total Excluding GST 6 62 GST payable 6 0 38 Total Inclusive of GST 7 00 TOTAL 7 00 CASH 7 00 GST Summary Amount RM Tax RM SR 6 6 62 0 38 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1044151 Cashier Thandar Date Description Qty U price Total TAX Kopi 0 B 1 X 2 10 2 10 SR Take Away 1 x 0 20 0 20 SR Total QTY 2 Total Excluding GST 2 17 GST payable 6 0 13 Total Inclusive of GST 2 30 TOTAL 2 30 CASH 2 30 GST Summary Amount RM Tax RM SR 6 2 17 0 13 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No 2 Tax Invoice INV No 1030720 Cashier Date Description Qty U price Total TAX Milo B 2 X 2 80 5 60 SR Take Away 2 X 0 20 0 40 SR Total QTY 4 Total Excluding GST 5 66 GST payable 6 0 34 Total Inclusive of GST 6 00 TOTAL 6 00 CASH 6 00 GST Summary Amount RM Tax RM SR 6 5 66 0 34 INVOICE_RECEIPT, M Licensee of McDonald s Level 6 Bangunan TH Uptown3 SS21 Petaling Jaya GST ID No 000504664064 McDonald s Shell 36 Tel No TAX INVOICE MFY Side 1 INV 003621900066840 ORD 18 REG 19 QTY ITEM TOTAL 1 M McChicken 9 50 1 M Coke 1 M Fries 1 McChicken 5 00 1 9Nuggets 10 90 1 Sweet and Sour Sauce 1 Barbecue Sauce TakeOut Total incl GST 25 40 Total Rounded 25 40 Cash Tendered 26 00 Change 0 60 TOTAL INCLUDES 6 GST 1 44 Thank You and Please Come Again Guest Relations Center INVOICE_RECEIPT,107 Gerbang Alaf Restaurants 65351 M formerly known as Golden Arches Restaurants Licensee of McDonald s Level 6 Bangunan TH Uptown3 SS21 39 47400 Petaling Jaya GST ID No 000504664064 McDonald s Shell Cheras 36 Tel No TAX INVOICE MFY Side 1 INV 003621900059183 ORD 07 REG 19 QTY ITEM TOTAL 1 M Coke 3 50 1 McChicken 5 00 TakeOut Total incl GST 8 50 Total Rounded 8 50 Cash Tendered 50 00 Change 41 50 TOTAL INCLUDES 6 GST 0 48 Thank You and Please Come Again INVOICE_RECEIPT, TAX INVOICE GST ID 000164270080 2 COUNTER1 2003 saiful Chk 263370 Guestl TBL35 1 1 028 DINO I E 7 45 S 2 R03 N LEMAK fc E 17 83 35 66 S 1 N22 SPRG NDL su cr E 9 34 S 1 B02 HALF BL EGG E 4 53 S 1 D19 CHAM I E 5 57 S CASH 73 00 62 55 Subtotal 62 55 10 Srv Chg 6 25 6 GST 4 13 Total 72 93 RND ADJ 0 02 TTL ATF RND 72 95 Payment 73 00 Change Due 0 05 2003 CLOSED THANK YOU PLEASE COME AGAIN PRICE IS GST INCLUSIVE GSTSummary Amount RM GST RM S GST 6 68 82 4 13 Z GST O 0 00 0 00 INVOICE_RECEIPT, 1248446 V NO JLN TEMENGGUNG SELANGOR GST Reg No 001375580160 Tax Invoice Table 9 Order 114105 Bill V042 513777 Pax s 0 Date Cashier SOFYA Description Qty U price Total TAX B1 Green Tea 2 X 1 00 2 00 SR N8 Shiro Ramen 1 X 12 80 12 80 SR R9 1 X 19 80 19 80 SR F8 1 X 8 80 8 80 SR SB01 Sushi Yellow 4 X 1 80 7 20 SR SB02 Sushi Red 2 X 2 80 5 60 SR Total Excluding GST 56 20 Serv Charge 10 5 62 GST Payable 3 71 Total Inclusive of GST 65 53 Rounding Adj 0 02 TOTAL 65 55 Closed Server SOFYA VISA 65 55 GST Summary Amount RM Tax RM SR 6 61 82 3 71 Thank you Please Come Again Powered By INVOICE_RECEIPT,Gerbang Alaf Restaurants 65351 M Licensee of McDonald s Level 6 Bangunan TH Damansara Uptown3 SS21 Petaling GST ID No 000504664064 McDonald s 188 Tel No TAX INVOICE MFY Side 1 INV 001881904580783 ORD 70 REG 19 QTY ITEM TOTAL 1 L McChicken 11 10 1 L Coke 1 L Fries 2 Small Cone 2 00 TakeOut Total incl GST 13 10 Total Rounded 13 10 Cash Tendered 20 00 Change 6 90 TOTAL INCLUDES 6 GST 0 74 ink You and Please Come Again Guest Relations Center INVOICE_RECEIPT,HAPPY SNACKS ENTERPRISE U A JALAN MERANTI 2A SEKSYEI BANDAR BARU BATANG KALI 44300 03 60570314 ST Reg No 000129863680 Bill No HP01 188357 Date Cashier 123 Tax Invoice Description Qty Price Amount 1 SR 9556173380636 1 14 31 14 31 350PCS FRUIT PLUS APPLE 2 SR 9556296307411 1 12 51 12 51 300PCS LOT100 CANDY ASSORTED Total 26 82 0 00 Total Sales Inclusive GST 26 82 Rounding Adjustment 0 02 Amount To Be Paid 26 80 Cash Received 50 00 Change 23 20 GST Summary Tax Code Taxable Amount GST SR 6 00 25 30 1 52 GST 1 52 GST Include Item Thank You Please Come Again INVOICE_RECEIPT,SWC ENTERPRISE SDN BHD V GST 002017808384 Tax Invoice No 00518087100028 005002 BATANGKALI 2 8 002 OPEN CODE SR ITEM 0025679 U 3x8 00 24 00 S 0025679 U 1x7 00 7 00 S PD 3 20 3 80 Authorize BATANGKALI S STAR 12X13 1X180 0020323 PKT 1x1 00 1 00 S STAR 15X16 AA 1X120 0020324 PKT 1x1 80 1 80 S Item 4 SubTotal Incl GST 30 00 Qty 6 Spec Disc 0 00 Saving 3 80 Rounding 0 00 Total 30 00 Cash 50 00 Change 20 00 GST Summary Amount RM Tax RMJ S 6 28 30 1 70 GOODS SOLD ONLY EXCHANGEABLE WITHIN 3 DAYS GOODS SOLD ARE NOT REFUNDABLE THANK YOU FOR YOUR KIND SUPPORT PLEASE COME AGAIN INVOICE_RECEIPT,L TWO FLORIST HANDICRAFT 002062543 P NO BANDAR UTAMA TEL CASH RECEIPT CS00007203 DATE SALESPERSON 001 TIME 11 CASHIER USER ITEM QTY U P AMOUNT NE3555 2 1 00 2 00 1 1 2 SAFETY PIN SB 01 3 1 7 00 7 00 SATIN BIAS TAPE 12MMX3Y TOTAL QTY 3 R IDOZ SUB TOTAL 9 00 DISC 0 00 TAX 0 00 ROUNDING 0 00 TOTAL 9 00 CASH 20 00 CHANGE 11 00 BARANG YANG DIJUAL TIDAK BOLEH DITUKAR INVOICE_RECEIPT, watsons Watson s Personal Care Stores Company Reg No 289892V GST Reg No 000947339264 USJ Summit Subang SS 22241 WS CUT SCISSORS 18 00 S 64542 QVS TEMPO TWEEZER 17 90 S 21434 WS BABY WIPES FRAG 7 90 S PWP LESS 30 2 37 95448 WATSONS BASKET 0 00 Z SUBTOTAL QTY 4 RM41 43 ROUNDING RMO 02 SUBTOTAL QTY 4 RM41 45 CASH RM51 50 CHANGE CASH RM10 05 GST SUMMARY Rate Net RM GST RM Total RM S 6 00 39 09 2 34 41 43 STATEMENT Loyalty acc number 9926016 Description Total Points Opening Balance 2264 Earned Points 43 Closing Balance 2307 00440010036 0003 ika INVOICE_RECEIPT, POPULAR BOOK CO M SDN BHD Co No I 13826 W GST Ree No to 8 Jalan KSL CITY Tel Slip No Ni Trans 246761 Description Amount N 7 65 T PB F RING FILE W CLI 6 99 T Total RM Incl of GST 14 64 Rounding Ad 0 01 Total RM 14 65 Cash 50 00 CHANGE 35 35 item Count 2 GST Summary Amount RM Tax RM T 6 13 81 0 83 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Bus Chinese books onlino my INVOICE_RECEIPT, KHE ELECTRICAL TRADING 001465242 V 33 G TEL FAX GST ID 000143474688 TAX INVOICE Bill To CASH Doc No CS00058953 Date Cashier USER Time Salesperson 002 Ref GST GST Item Qty S Price S Price Amount Tax 1113 2 48 00 50 88 101 76 SR 105W E27 PLCE TUBE Total Qty 2 101 76 Total Sales Excluding GST 96 00 Discount 0 00 Total GST 5 76 Rounding 0 01 Total Sales Inclusive of GST 101 75 CASH 101 75 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 96 00 5 76 Total 96 00 5 76 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,Perbang Alaf Restaurants formerly known as Golden Arches Restaurants Licensee of McDonald s Level 6 Bangunan TH Uptown3 Jaya GST ID No 000504664064 IcDonald s Tel No TAX INVOICE MFY Side 1 INV 00 ORD 15 REG 19 QTY ITEM TOTAL 1 L McChicken 11 10 1 L Coke 1 L Fries 1 6Nuggets 7 50 1 Barbecue Sauce ì AyamGoreng TA 9 90 TakeOut Total incl GST 28 50 Total Rounded 28 50 Cash Tendered 50 00 Ch 21 50 TOTAL INCLUDES 6 GST 1 61 Thank You and Please Come Again INVOICE_RECEIPT,KIKU JAPANESE RESTAURANT TK DIVISION KITCHEN SDN P TEL INVOICE Invoice 9722 Cashier admin POS No 1 Table D3 Date Pax 0 ITEM QTY U P RM DISC Amt RM Chicken Katsu Bento BEN02 1 12 90 0 00 12 90 Omu Curry Fried Rice Set Set10 1 6 90 0 00 6 90 Katsu Don Fish Set TS02 Kat 1 9 90 0 00 9 90 Sub Total Before Discount RM 29 70 Service Charge RM 0 00 Total Sales RM 29 70 Rounding Adjustment RM 0 00 TOTAL RM 29 70 CASH RM 30 00 CHANGE RM 0 30 INVOICE_RECEIPT, Desa City A Northpoint Office Mid Valley City GST ID Outlet Tel Tax Invoice Invoice No DPC11 53409 001 0006 POS No DPC11 Cashier DPC1PT1 Date time Description Qty U Price Total RM Double Rg Cup 1 20 00 20 00 SR Colour Rice 1 1 50 1 50 SR Sub Total 21 50 Roun adj 0 Total Incl GST 21 50 Cash MYR 22 00 Cash Change 0 50 GST Tax Rate Sale RM Tax RM Summary SR 6 0 20 28 1 22 Thank you Please come again www baskin com my INVOICE_RECEIPT, X INVOICE NO 03 02 18 RM 50 S 7094 NEOBUN PLASTER 10PCS RM3 20 s Total Sales Inclusive GST RM 3 70 CASH RM 10 00 CHANGE RM 6 30 GST Summary Amount RM Tax RM 6 3 49 a 21 INVOICE_RECEIPT,FUN N CHEER LOT 37636 JALAN 6 37A TAMAN BUKIT 52100 Tel TAX INVOICE GST ID No 001439154176 Cashier CS01 S P MAL No 0200419363 Item Desc Qty Price Amt KAIN BEBOLA S SHA BU SR 0412638 2 14 90 29 80 Total Qty 2 TOTAL EXCL GST 28 11 ADD GST 6 1 69 29 80 CASH 50 00 CHANGE 20 20 GST summary Amount RM Tax RM SR 6 28 11 1 69 0 00 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,Your order number is tealive CT281 Tealive Shell Ottogo Enterprise 002570632 X GSTID 001018802176 SHELL STATION PT15944 TAX INVOICE Take Away Bill No 394024495 COMPLETED Date Sales Remarks Item Name Qty Price RM Hazelnut Coco L 1 7 50 SR Pearl 1 1 10 Sub Total RM8 60 Rounding RM0 00 Total Sales Incl GST 6 RM8 60 Cash 8 60 Tendered 9 00 Change 0 40 Code Amount Tax SR 6 8 12 0 48 You have just missed out 8 points Sign up for a Tealive UniTea Card today to enjoy exclusive member promotions and collect BPoints to redeem on future purchases Thank You Please Come Again Printed at INVOICE_RECEIPT, X GST ID 000182431744 TAX INVOICE Invoice 000 074020 Take Out Date Original Slice 2 RM26 00 DoubleChoc Slice 1 RM13 00 Grand Total RM 39 00 Bill Inclusive of 6 GST RM2 21 Cash RM50 00 Change RM11 00 001 Myo 1 000 074020 1 INVOICE_RECEIPT, S B S19537 X GST ID NO INVOICE NO 18311 103 17 02 18 CAN 4 6 320ML RM106 50 S 2101 SMOOTH RM106 50 s Total Sales Inclusive GST RM 213 00 CASH RM 213 00 CHANGE RM 00 GST Summary Amount RM Tax RM S 6 200 94 12 06 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, 519537 JLN DEVELOPMENT GST ID NO INVOICE NO 18311102T0395 566890 17 02 18 489 TIGER BEER CAN 4 6 320M RM108 50 S Total Sales Inclusive GST RM 108 50 CASH RM 150 00 CHANGE RM 41 50 GST Summary Amount RM Tax RM S 6 102 36 6 14 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,SUNFISH 484297 M 22 LRG PERUSAHAAN TEL NO 10256 TABLE 12 SALTED F RICE 8 50 êFRIED EGG 1 80 NASI LEMAK DRUMSTICK 9 80 SOYA CINCAU 4 30 LARGE ICE TEA 4 30 SUBTOTAL 28 70 RM CASH 100 00Ç CHANGE 71 30 INC 6 GST 1 62 TAX INVOICE 001 001 0934 0001 R GST 002008047616 THANK YOU INVOICE_RECEIPT,Mr Dakgalbi Solaris GST No President 02 Solaris 50 KL GST No TEL Sales PosNo 86 Description qty Price Fried Rice 3 Pax 1 71 00 S 1 Item Inclusive of GST 71 00 Round Amt 0 00 TOTAL 71 00 Cash 71 00 Cash Received 101 00 Change 30 00 GST 6 4 02 GSTSummary Amount RM GST RM S GST 6 66 98 4 02 Z GST 0 0 00 0 00 Receipt No 18010500047 Person S Admin Table No Hall 9 INVOICE_RECEIPT,THE STORE MALAYSIA SDN BHD 8199K NO Sun RN CASHIER 0009998 UNI WORKER S CARD 1 31 100 S 20000004300 4 3 10 12 40 S UNI A6 NOTE BOOK 120 S 2000001592021 18 1 30 23 40 S TOTAL ITEM 22 TOTAL SALES INCLUSIVE GST 35 80 TOTAL PAYABLE AMOUNT 35 80 CASH 50 00 CHANGE 14 20 GST SUMMARY AMOUNT RM TAX RM 9 GST 6 33 82 1 98 Z GST 0 0 00 0 00 33 82 1 98 MOHON KAD THE STORE DAN KUMPULKAN MATA GANJARAN HARI INI TERIMA KASIH KERANA MEMBELI BELAH DI THE STORE MARBLE COATING COOKWARE 2018 STICKER s 1 INVOICE_RECEIPT,NYONYA COLORS 1 UTAMA LITTLE CRAVINGS SDN BHD D HQ 7 Jln SS21 34 47400 PJ TEL GST ID 001382293504 MC 01 REG CASHIER TaxInvNo 1 000001 KUIH RM2 70 S ONDEH ONDEH RM2 95 S YELLOW LAKSA RM11 6 60 S YELLOW LAKSA RM11 60 S YELLOW LAKSA RM11 60 S AIR SEJUK RMJ 65 S CENDOL RM5 30 S SOS RM7 20 S 8 No SUBTOTAL RM53 60 CASH RM100 00 CHANGE RM46 40 TAXABLE AMOUNT RM50 57 6 GST RM3 03 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,KING S CONFECTIONERY S B 273500 U KSB TEL NO GST ID 000294060032 Tax Invoice Inv No KSB80051978 Date Cashier FT8303 Ctr 02 Code Desc Qty RM D Amt 201019 KAYA PUFF 4 1 60 0 6 40 S 231027 Slice Cak 1 8 70 0 8 70 S 101110 Cheese Le 1 3 50 30 2 45 S 251030 Cheese Ta 1 3 40 0 3 40 S 171153 D R BUTTE 1 4 20 0 4 20 S Qty 8 25 15 Rounding Adj 0 00 Due 25 15 Pay 25 15 Change 0 00 Total Included GST 6 1 42 GOODS SOLD NOT RETURNABLE EXCHANGEABLE THANK YOU PLEASE COME AGAIN TASTY BAKING HEALTHY NATION Visit us online at INVOICE_RECEIPT,Yam Fresh No Keporing Tel GST ID 001817907200 Bill No 001 3246 Dine In Date R05 Oyster Mee 1 RM9 90 Take Away A07 BlackSugar Ice 1 RM7 50 Fresh Milk Pearl Herb J RM3 00 Take Away S02 Pudding Soybean 1 RM8 90 Take Away Grand Total RM 29 30 Bill Inclusive of 6 GST RM1 66 Cash RM30 30 Change RM1 00 Thank You Please visit us at Facebook Yam Fresh S Wifi SSID yamfresh Wifi Pasword buyadrinkfirst 001 001 3246 11 INVOICE_RECEIPT,Zen and coffee 28 GST Number 001363259392 Date Receipt No 57269 Served By Cashier Pax 2 Table L2 1 Saba shioyaki 20mins 26 00 S 1 28 00 S 1 Spicy ASARI Pasta 19 00 S 1 Ebi Mentai Pasta 22 00 S 1 Green Tea 10 00 S Extra 1 Tea Cup Subtotal 105 00 Total 105 00 Cash 105 00 Change 0 00 GST Summary Tax Code Amount Tax S 6 99 05 5 95 Business Hour MON FRI SAT SUN Tel Email Facebook Instagram Wifi Password Thank You Please come again Pawered by ARMS F B INVOICE_RECEIPT,Guardian Health And Beauty Sdn Bhd Tel Company Reg 1101083 T GST Reg 000899874816 RM 121095079 GDN MC H W ENC ROM 5 90 S 121095079 GDN MC H W ENC ROM 5 90 S 121095081 GDN MC H W N DREAM 5 90 S 121095081 GDN MC H W N DREAM 5 90 8 P3 KDP G HW 4012 11 60 SUBTOTAL 12 00 TOTAL GST INCL 12 00 CASH 12 00 YOUR SAVINGS FOR TODAY 11 60 GST Rate GST Excl GST Amt S 6 11 32 0 68 Thank You For Shopping At Guardian All Amounts Are in RM Goods sold are non refundable Dispensed medicines sold are not returnable All exchanges and returns including Guardian brand products must be made within 7days with original receipts and product in original condition St TaxInv 41336 INVOICE_RECEIPT,a MR D I Y KUCHAI BHD CO W JALAN 6 KAWASAN PERINDUSTRIAN BALAKONG GST ID No 0004737925 MENJALARA KEPONG HQ TAX INVOICE EPOXY PUTTY 2 X 50GM S WA17 9555075106825 1 X 8 50 8 50 CORD TIE 3PCS S AF 10 1000 9067170 1 X 2 70 2 70 PAPER CLIP 8PCS NO4 S MI11 3 21 9082115 1 X 2 50 2 50 HOOK HY 0021 S DC11 2 69467599002 1 X 2 50 2 50 DOOR GUARD EC008 S TJ 10 100 9002148 3 X 4 50 13 50 MULTI FAN BLADE 16 FB1688 S WA50 30 9750009 1 X 6 30 6 30 KEY HOLDER GRID VS S 0100 9045734 1 X 7 50 7 50 DOOR GUARD FOOT AW D48 S TD33 5 200 2 X 4 90 9 80 Item s 8 Qty s 11 Total Incl GST 6 RM 53 30 EDC RM 53 30 7186 MASTER GST Summary Amt RM Tax RM GST S 6 50 28 3 02 16 03 18 SH01 B026 T2 R000178141 OPERATOR THQT EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,TAX INVOICE DOMINO S PIZZA GST REF NO 0069426248 DOMINO S PIZZA SEGAMBUT D CARRY OUT NOW Pay By CASH Order 955 By 5224 Order Time 2 54 37 Date Name MS YING Pickup Time Qty Menu Desc Coupon Disc Price 9 HT BQ 2 2P2C R 2 30 30 9 NYC CP 2 2P2C R 2 30 30 27 60 60 60 Total Items Sub Total 60 60 Coupon Discount 27 60 Grand Total 33 00 Payment 50 00 Change Due 7 00 6 GST Included 87 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code CBC2694095554 Thank you for visiting Domino s Please Come Again 3 0 0 8 8 8 3 3 3 We are compliant to the PDPA 200 Visit terms to view our Personal Data Protection Policy owned by Dommal Food Services A INVOICE_RECEIPT,MY HAPPY PHARMACY PLT LLP0007299 LGN NO 12 SELANGOR TEL GST ID 000241512448 SIMPLIFIED TAX INVOICE CASH Doc No CS00038813 Date A Time Salesperson S005 Ref Item Qty S Price Amount Tax OTC 000127 1 20 50 20 50 SR FLANIL ANAL GESIC CR 60G Total Qty 1 20 50 1 otal Sales Excluding GST 19 34 Discount 0 00 Total GST 1 16 Rounding 0 00 Total Sales inclusiva of GST 20 50 CASH 21 00 Change 0 50 GST SUMMARY Tax Code Amt RM Tax RM SR 6 19 34 1 16 Total 19 34 1 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No 113825 W GST Reg No 001492992000 No Tel 66 Slip No Description Amount PB D S Tape 12mm 1 90 T H C A4 400 S 9 90 T Total RM Incl of GST 11 80 Cash 11 80 Item Count 2 GST Summary Amount RM Tax RM T 6 11 13 0 67 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT,R KEDAI 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT 1 Doc No CS00010344 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 100140 4 24 00 25 44 101 76 SR BESI Y 12 CQ Total Qty 4 101 76 Total Sales Excluding GST 96 00 Discount 0 00 Total GST 5 76 Rounding 0 00 Total Sales Inclusive of GST 101 76 CASH 150 00 Change 48 24 GST SUMMARY Tax Code Amt RM Tax RM SR 6 96 00 5 76 Total 96 00 5 76 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,R KEDAI YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT NO Doc No CS00010527 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101869 2 60 00 63 60 127 20 SR PASIR KASAR D Total Qty 2 127 20 Total Sales Excluding GST 120 00 Discount 0 00 Total GST 7 20 Rounding 0 00 Total Sales Inclusive of GST 127 20 CASH 150 00 Change 22 80 GST SUMMARY Tax Code Amt RM Tax RM SR 6 120 00 7 20 Total 120 00 7 20 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,R KEDAI YEW 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00011351 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101756 10 16 50 17 49 174 90 SR SIMEN Total Qty 10 174 90 t Total Sales Excluding GST 165 00 Discount 0 00 Total GST 9 90 Rounding 0 00 Total Sales Inclusive of GST 174 90 CASH 174 90 his Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 165 00 9 90 Total 165 00 9 90 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,Cele R MBB K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00010930 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 100088 3 55 00 58 30 174 90 SR B R C A10 1 7X4M Total Qty 3 174 90 Total Sales Excluding GST 165 00 Discount 0 00 Total GST 9 90 Rounding 0 00 Total Sales Inclusive of GST 174 90 CASH 200 00 Change 25 10 GST SUMMARY Tax Code Amt RM Tax RM SR 6 165 00 9 90 Total 165 00 9 90 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,TAX INVOICE BHPetrol Subang NO V GST REG NO 000768122880 Cashier 888 Invoice No 1 916166 Item U Price Qnty Amount infiniti 97 E4MP3 2 570 16 32 41 95 S TOTAL SALES RM 41 95 TOTAL AMOUNT PAYABLE RM 41 95 EDC MASTER RM 41 95 CST SUMMARY Amount RM Tax RM S Standard 6 39 58 2 37 ECARD WONG TAI CHIN Card Number Merchant Number Reference Number 199258579655 AWARD Balance 412 Earned 41 New Balance 453 EPOINTS Expiry 24 Thank You For Shopping At SHPetromart Customer Service INVOICE_RECEIPT, PREPAY CHIT NUMBER 29721 THIS IS NOT A RECEIPT A Tax Invoice will be issued upon the completion of the sale transaction Cashier 465 Transaction No 1 8046 Item U Price Qnty Amount PPF P1 1 000 6 6 00 TOTAL AMOUNT CASH RM 6 00 Thank You Please Come Again Customer Service INVOICE_RECEIPT,P BILLION SIX ENTERPRISE Tel GST Reg No 000944312320 Tax Invoice Invoice No C 170891 Date Cashier 123 Description Qty Price Amount 1 SR 9556405112205 11 5 80 63 80 TG7 7 HIPS PLATE 50PCS JP Total 63 80 Disposal Discount 0 00 Total Sales Inclusive GST 06 00 63 80 Master Card IST Summary Amount RM Tax RM SR 6 00 63 fo 60 19 3 61 Barang yang sudah di beli wang tidak dapat di kembalikan Pertukaran barang hanya boleh dibual dalam 3 hari sahaja dengan resit INVOICE_RECEIPT,GOODS SOLD ARE NOT RETURNABLE Halti YOU SLF CASH CARRY V NO 15 JLN TSJ2 TMN SUBANG JASA pt OFF JIN BT 3 SUBANG TEL FAX TAX INVOICE GST ID 001169362944 SIMPLIFIED TAX INVOICE CASH Doc No CS00241999 Date Cashier WOON Time Salesperson Ref Item Qly S Price Amount Tax 9557366100208 21 20 21 20 SR CRISPO MINYAK SAPI 800G Total Qty 21 20 Total Sales Excluding GST 20 00 Discount 0 00 Total GST 1 20 21 20 Rounding 0 00 Total Sales 21 20 Inclusive of GST CASH 100 00 Change 78 80 GST SUMMARY Tax Corte Amt RM Tax RM SR 6 20 00 1 20 Total 20 00 1 20 INVOICE_RECEIPT,of SLF CASH CARRY NO 15 TSJ2 TMN JASA OFF 40000 TEL FAX TAX INVOICE CASH RECEIPT CS00241867 DATE SALESPERSON TIME CASHIER ITEM QTY U P AMOUNT 6194020100124 4 11 32 45 28 S UNIT ROYAL BAKING POWDER 450G TOTAL QUANTITY 4 SUB TOTAL 45 28 DISC 0 00 TAX 0 00 ROUNDING 0 00 TOTAL 48 00 CASH CHANGE 48 2 48 00 0 00 GOODS SOLD ARE NOT RETURNABLE THANK You GST SUMMARY CODE AMOUNT TAX AMT SR 45 28 6 2 72 TAX TOTAL 2 72 INVOICE_RECEIPT,SUPER SEVEN CASH CARRY SDN BHD 590150 A SUPER SEVEN NO 1 Jalan Euro 1 Off Jalan TEL FAX if GST 11 000639090688 TAX INVOICE Customer Mrs ONG GUAT CHYE TAX INVOICE NO 195147 COUNTER 002 OPLRATOR SYUNADAH BT FAIZAL A CASHIER RM 300UP 3 6KG 63 00 FM411000055 4 252 00 ZR BERAS BIRI BIRI 10KG 5 ISTIMEWA 53 50 9556606389892 1 53 50 ZR BAWANG BESAR INDIA CINA GUNI 8 50 FM429000000 2 17 00 ZR BABAS CILI 1KG 19 50 955606500035 19 50 ZR BABAS KARI DAGING 1KG 17 20 95c6065000345 1 17 20 ZR LILI 3KG kCK 7 90 9554100157801 1 7 90 SR QUANTITY 10 Units 367 10 Total Sales Incl GST 6 RM367 10 Rounding Adjustment RMO 00 Nel lotal RM367 10 Payment Method VISA CARD GST Summary Sales Amt Tax Amt RM RM ZR 0 359 20 0 00 SR 6 7 45 0 45 FLEASE VERIFY YOUR RECEIPT LEAVING THE COUNTER GOMDS SOLD ARE NOT RETURNABLE MANK YOU INVOICE_RECEIPT, PJ SS6 GST ID NO 000181747712 INVOICE NO 18301 102 07 02 18 2471 888 LYCHEES IN SYRUP 5 RM10 14 s 83 X RM 3 38 270 CSR GULA 12 1KG RM35 20 Z Total Sales Inclusive GST RM 45 34 Rounding Adjustment RM 01 Rounding RM 45 35 CREDIT RM 45 35 CHANGE RM 00 GST Summary Amount RM Tax RK S 6 9 57 57 Z 0 35 20 00 45 35 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,is Phone URBAN M A G Served by rojan Tax Invoice 1 A 42210 140220 GST ID 000220499968 Qty Size Item Price 1 Bag Fee RM0 20 1 MY EDV Meal RM11 90 6 Meatball Sub 1602 Fountain Drink 1 Cookies 1 MY EDV Meal RM11 90 6 BBQ Chicken Strips Sub 16oz Fountair Drink 1 Cookies Cash Rounding RM0 01 Total Eat In RM24 00 R Cash RM30 00 Change RM6 00 Tax Info GST 6 6 24h RM1 36 Total Excl GST RM22 65 Take our 1 Minute Survey at and get a FREE COOKIE with next purchase Redemption of 1 cookie per transaction INVOICE_RECEIPT, FOODICIOUS H NO 9 Tel ST Reg No 000897208320 Tax Invoice Table T13 Order 275705 Bill V015 673381 Pax s 0 Date Cashier Cashier Description Qty U price Total TAX Tori Teriyaki Don 1 X 12 80 12 80 SR Tako Ball 1 X 0 00 0 00 Sushi 1 80 4 X 1 80 7 20 SR Sushi 2 80 2 X 2 80 5 60 SR reen Tea 1 X 1 00 1 00 SR Total Excluding ST 26 60 Serv Charge 10 2 66 ST Payable 1 76 Total Inclusive of ST 31 02 Rounding Adj 0 02 TOTAL 31 00 Closed 0 Server Cashier CASH 31 00 ST Summary Amount RM Tax RM SR 6 29 26 1 76 Thank You Please Come Again INVOICE_RECEIPT,P YONG CEN ENTERPRISE GST NO CASH RECEIPT DATE SALESPERSON TIME COUNTER ITEM QTY U P AMOUNT 9555223500307 24 2 33 55 99 SR FEI YAN BRAND YOUNG CORN 425G 2 333X 9557166110018 2 2 00 4 00 ZRL ASAM BOI 65G TOTAL QUANTITY 26 SUB TOTAL 59 99 DISC 0 00 GST 3 36 TAX 0 00 ROUNDING 0 00 63 35 TOTAL 63 35 CASH 63 35 CHANGE 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,MR D I M KAWASAN SERI GST ID No 000306020352 TESCO EXTRA ARA DAMANSARA TAX INVOICE PILLAR SINK TAP S FZ02 6 54 9072351 2 X 23 90 47 80 SHIELDTOX FIK 600 IL MP S WA01 24 9556111988559 1 X 2S S AR62 9064017 4 X 3 00 12 00 PLASTIC BAGS S 99999 1 X 0 20 0 20 VANCE LIGHTER 1s VT02 S WB22 50 1000 9555258606166 5 X 0 60 3 00 Item s 5 Qty s 13 TOTAL INCL GST 6 D RM 71 90 CASH RM 72 00 CHANGE RM 0 10 GST Summary Amt RM Tax RM GST S 6 67 83 4 07 buy wale tap 02 03 18 17 23 SH01 ZJ42 T1 R000227410 OPERATOR TADC A IM ABDUL EXCHANGE AR ALLOWED WITHIN 7 DAY W TH RECEIPT STRICTL Y NO CASH REFUND INVOICE_RECEIPT,ENW Hardware Centre M A GST Reg No 000155453440 No G3 Blk G JIn PJU 1A 3 TEL 9829 Tax Invoice No CS00230322 Cash Sale Ara D sara Tel H P 012 659 9829 Item Qty U Price RM 001533 1 00 19 00 19 00 SR 2kgs Wood Lacquer Thinner 000920 1 00 10 00 10 00 SR 1 5kg Ufixx Putty Filler 006828 2 00 2 50 5 00 SR 100 x 8 x 45m Sand Paper Roll Total Amt Incl GST 6 34 00 Rounding Adjusment 0 00 Total Amt Payable 34 00 Total Qty Tender 4 GST Summary Amount RM GST RM SR 6 32 07 1 93 POINT 0 00 Goods sold are not returnable b Thank you for shopping at ENW Hardware Centre M buy paint INVOICE_RECEIPT,MR D I Y M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 TESCO EXTRA ARA DAMANSARA TAX INVOICE COPPER BASIN PILLAR TAP B S JA01 04 1 X 29 90 40MM S LE51 2 6942131561408 1 X 8 90 8 90 Item s 2 Qty s 2 TOTAL INCL GST 6 RM 38 80 CASH RM 50 00 CHANGE RM 11 20 GST Summary GST S 6 x Amt RM Tax RM 36 60 2 20 28 03 18 SH01 ZJ42 T2 R000246362 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, POPULAR BOOK CO M SDN BHD Co No 113825 W GST Reg No 001492992000 No 8 Jalan Tel Slip No 9070058756 SITI Trans 21396 Description Amount R ENV4 5 9 5 1 90 T Uni P S Env 4 5x9 75 2 10 T Total RM Incl of GST 4 00 Cash 10 00 CHANGE 6 00 Item Count 2 GST Summary Amount RM Tax RM T 6 3 77 0 23 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT, BHD 126926 H 3RD FLR AEON JLN JEJAKA CHERAS 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS VALUED CUSTOMER 1370001392 1x 000000118927 16 90SR V CHOR FRA 1x 000005270385 10 45SR CE 13312 LONG H 1x 000007940774 7 90SR BL 1x 000007940781 7 90SR BL 1x 000007940781 7 90SR BL 1x 000001397686 4 10SR LIDI BROOM W P 1x 000006697655 4 90SR E 71 MP WATER D 1x 000002926759 8 90SR UNICORN 24MMX DISC 10 8 01 0 89 1x 000003767016 7 30SR SW CE3914B NYL 1x 000001501083 2 50SR 18MMX1 WHITE D DISC 10 2 25 0 25 1x 000004146858 18 90SR CABLE BOX DISC 41 11 16 7 74 1x 000001888854 0 20SR PLASTICS BAG Sub total 88 97 Total Sales Incl GST 88 97 Rounding Adj 0 02 Total After Adj Incl GST 88 95 CASH 100 00 Item Count 12 Change Amt 11 05 Invoice No 201 GST Summary Amount Tax SR 6 83 93 5 04 Total 83 93 5 04 1008 210 2100090 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, BHD H 3RD FLR AEON JLN JEJAKA CHERAS GST ID 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS VALUED CUSTOMER 1370001392 1x 000002781709 15 50SR BIO ZIP POWDER 1x 000002781709 15 50SR BIO ZIP POWDER Sub total 31 00 Total Sales Incl GST 31 00 Total After Adj Incl GST 31 00 CASH 50 00 Item Count 2 Change Amt 19 00 Invoice No 2018030910080010555 GST Summary Amount Tax SR 6 29 24 1 76 Total 29 24 1 76 1008 001 0010555 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, POPULAR BOOK CO M SDN BHD Co No 113825 W GST Reg No 001492992000 No 8 7118B Tel 110318 Slip No WANI Trans 250504 Description Amount DOCUMENT HOI A4 9101A Tra 5pc 1 15 5 75 Total RM Incl of GST 5 75 Cash 50 00 CHANGE 44 25 I tem Count 5 GST Summary Amount RM Tax RM T 6 5 42 0 33 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT, BHD JEJAKA CHERAS GST ID SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS 1x 000001888854 0 20SR PLASTICS BAG 1x 000000616775 13 94ZR WC W O HAF 1x 000000616775 14 817R WC W O H F ix 000000616775 13 53ZR WC W I H F Sub total 42 48 Total Sales inci GST 42 48 Rounding Adj 0 02 Total After Adj Inci GST 42 50 CASH 50 00 Item Count 4 Change Amt 7 50 Invoice No 2018031210060010139 GST Summary Amount Tax SR 6 0 19 0 01 ZR 0 42 28 0 00 Total 42 47 0 01 1008 001 0010139 0304662 TEL THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, MR W KAWASAN PERINDUSTRIAN BALAKONG GST ID No 0004737925 STRAND MALL KOTA DAMANSARA TAX INVOICE PYEDRAIN CLOG FREE CLDR02 1000ML S WA05 9556268000210 3 X 15 00 45 00 Item s 1 Qty s 3 TOTAL INCL GST 6 RM 45 00 CARD RM 45 00 GST Summary Amt RM Tax RM GST S 6 42 45 2 55 03 18 SHO2 8011 T1 R000183898 OPERATOR STMT AZMIZAN EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, TSH POWER HARDWARE TRADING 002458685 T Tel 2096 TAX INVOICE GST Reg No 000460664832 Invoice No 01 145995 Date Description Qty Price Amount 1 MAJESTA HSS 2 4 00 8 00 SR JOBBER DRILLS 3 5MM Sub Total 8 00 Round Amt 0 00 NET TOTAL 8 00 Cash Received 8 00 GST Summary Amount RM Tax RM SR 6 00 7 55 0 45 Thank You Please Come Again INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE STUDENT SOCKS 3PCS BK S JH61 4 200 9034915 1 X 9 50 9 50 BELT 5202 3 VS S QI31 9034870 1 X 22 90 22 90 PVC MAN PPER 969 BK S WA36 9555590500184 1 X 10 50 10 50 Item s 3 Qty s 3 Total Incl GST 6 RM 42 90 CASH RM 50 00 CHANGE RM 7 10 GST 6 included in total RM 2 43 17 03 18 SH01 ZJ86 T1 R000110133 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D l Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE CARBON FIBER CARTRIDGE CTO 98 10 S CC22 52 62 25 9063785 2 X 5 30 10 60 Item s 1 Qty s 2 Total Incl GST 6 RM 10 60 CASH RM 20 00 CHANGE RM 9 40 GST 6 included in total RM 0 60 SH01 ZJ86 T3 R000060727 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, 000002 BAIFU M Sdn Bhd COMPANY NO 814198 X DAISO JAPAN PHONE GST ID 001389649920 WELCOME TAX INVOICE RCPT NO 18252 REG 01 CSH 00000008 4997642045475 Plastic spoons 8pcs 5 90 X 3 17 70 SR 4997642045482 Plastic forks 8pcs 5 90 X 3 17 70 SR SUB TOTAL INCL GST 35 40 TOTAL RM 35 40 CASH 50 00 CHANGE 14 60 ITEMS SOLD 6 Tax Code Amt RM GST RM GST 6 000 33 40 2 00 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG S 0205 5 60 9074624 1 X 19 90 19 90 NST S WA33 100 1000 9180501 1 X 0 80 0 80 S S RH 008 24 5CM S AD41 2 5 100 9067474 1 X 7 30 7 30 Item s 3 Qty s 3 Total Incl GST 6 RM 28 00 CASH RM 40 00 CHANGE RM 12 00 GST 6 included in total RM 1 58 26 03 18 25 SH01 ZJ86 T1 R000112587 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE TRAC DRY IRON TR 231IR 1200W SR N S WA10 12 9555493002853 1 26 90 26 90 SINGLE BEDSHEET SET 90 188 20CM S JD52 63 20 9034713 1 X 23 90 23 90 Item s 2 Qty s 2 Total Incl GST 6 RM 50 80 CASH RM 51 00 CHANGE RM 0 20 GST 6 included in total RM 2 88 25 03 18 SH01 ZJ86 T1 R000112415 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 0003060352 IOI PUCHONG CBD4110 S WA21 1 X 25 90 25 90 PLASTIC BAGS S 99999 1 X 0 0 Item s 2 Qty s 2 Total Incl GST 6 RM 26 10 CASH RM 50 00 CHANGE RM 23 90 GST 6 included in total RM 1 48 23 03 18 SH01 ZJ86 T1 R000111754 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, GOLDEN KEY 000760274 K TEL FAX E Mail Website S P INVOICE No Desc Code Qty Price Disc Amount 1 NORMAL KEY 33100 4 4 00 0 00 16 00 2 NORMAL KEY LONG 33101 1 5 00 0 00 5 00 Total Qty 5 Sub Total 21 00 Discount 0 00 Net Total 21 00 Cash Received 50 00 Change 29 00 GOODS SOLD ARE NOT RETURNABLE REFUNDABLE INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE MULTIPURPOSE BROOM 737P W 4FT S WA16 24 2 X 6 50 13 00 HOSE PUMP C88351 S KE23 33 53 1 X 1 90 1 90 Item s 2 Qty s 3 Total Incl GST 6 RM 14 90 CASH RM 20 00 CHANGE RM 5 10 GST 6 included in total RM 0 84 24 03 18 18 02 SH01 ZJ86 T1 R000112043 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE WHITE CABLE TIE 4 200MM 8 S UB52 1 X 3 90 3 90 WHITE CABLE TIE 5 250 S UH32 1 X 6 50 6 50 HOSE PUMP C88351 S KE23 33 53 1 X 1 90 1 90 Item s 3 Qty s 3 Total Incl GST 6 RM 12 30 CASH RM 50 00 CHANGE RM 37 70 GST 6 included in total RM 0 70 24 03 18 SH01 ZJ86 T1 R000112046 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, Elitetrax Marketing No 1 TEL HN Customer Service GST REG NO 000551006208 Original You were served by Salesman 6005283 CANON CART PG 2 30 00 60 00 S6 Total Incl Of GST 60 00 UOB Terminal RM 60 00 Card No 9014 Auth Code R13299 GST Inclusive Amount RM Tax RM S6 6 00 of 60 00 3 40 Date Time Branch POS Transac 11 02 18 2 24403 SalesmanID Cashier ID CashierName 803216 801817 I Use This Code WELCOME20 To Enjoy I RM 20 Discount Online Now I Shop With Confidence at Keep Receipt as proof of Purchase Visit for more promotions and offers 660002007000020024409120180211140759 INVOICE_RECEIPT,KAISON FURNISHING SDN BHD L4 17 B Level 4 No 761834 D GST Reg No Tel Slip 0000MLW P3000024348 Staff Date Description Amount RM Barcode 10182079 FLOWER BUNCH ROSE 122 pcs 18 90 2 305 80 SR Item No 30001640 FLOWER BUNCH CRYST 240 pcs 13 90 3 336 00 SR Item No 30001635 FLOWER BUNCH 7HD P 130 pcs 16 90 2 197 00 SR Total RM 7 838 80 CASH MYR 7 840 00 Change 1 20 GST Amt RM GST RM Total RM SR 6 7 395 09 443 71 7 838 80 GOODS SOLD ARE NON CASH REFUNDABLE EXCHANGE OF GOODS WITHIN 14 DAYS ACCOMPANIED BY ORIGINAL RECEIPT INVOICE_RECEIPT, W TEL FAX 03 GST ID 001011499008 TAX INVOICE Doc No CS00183946 Date Cashier ÚSER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 1015 2 12 00 1272 1524 SR PEACOCK YELLOW 1012 4 34 00 38 04 144 16 SR STATICE FULL IMP 1145 1 58 00 61 48 61 48 SR CONCORDO 2H 1037 2 6 00 6 36 12 72 SR SNOW 1050 1 3 50 3 71 3 71 SR FLORIDA BEAUTY 1097 4 9 00 9 54 38 16 SR L 1098 3 4 50 4 77 14 31 SR M 1006 1 22 00 23 32 23 32 SR ROSE INDIA SUPERIOR 2748 4 12 00 12 72 50 88 SR SUCCULENT L Total Qty 22 374 18 Total Sales Excluding GST 353 00 Discount 0 00 Total GST 21 18 Rounding 0 02 Total Sales Inclusive of GST 374 20 CASH 400 00 Change 25 80 GST SUMMARY Tax Code Amt RM Tax RM SR 6 353 00 21 18 Total 353 00 21 18 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,ADVANCO COMPANY Company Reg No 725186 V NO 1 3 Jalan 12 Link Maju GST Reg 001658445824 TAX INVOICE CB 389772 8 08 53 M M1 0 Cashier c1000 Qty Description Price Total CANON PG 47BK E400 BLACK FINE SR 1 27736 29 00 29 00 Type 1 Total 29 00 Rounding Adj 0 08 Total Inclusive GST 29 00 CASH 50 00 Change 21 00 GST Summary Code Net Amt GST Total SR 6 27 36 1 64 29 00 Total 27 36 1 64 29 00 Thank you Please come again Goods soid are not returnable for refund or exchange INVOICE_RECEIPT,ADVANCO COMPANY Company Reg No 725186 V NO 1 3 Jalan 12 Link Maju GST Reg 001658445824 TAX INVOICE CB 395164 M M1 0 Cashier c1000 Qty Description Price Total UNICORN GLUE STICK USG 21G 2 SR 2 27755 5 80 11 60 Item Discount 10 1 16 2 Type 1 Total 11 60 Rounding Adj 0 01 Total Inclusive GST CLOSS CASH 20 00 Change 9 55 GST Summary Code Net Amt GST Total SR 6 9 85 0 59 10 44 Total 9 85 0 59 10 44 NAS GREAT IDEA Thank you Please come again Goods sold are not returnable for refund or exchange INVOICE_RECEIPT,Cash Sale SINNATHAMBY HOLDINGS T NO 17 18 41 Document No T03 18 199913 Date DESC PRICE Disc AMOUNT TAX QTY RM RM CODE ROYAL GOLD LUXURIOUS KITCHEN TOWEL 6R 60 1UNIT 13 50 0 00 13 50 SR Total Qty 1 Total Inclusive GST 6 13 50 Rounding Adjustment 0 00 Rounded Total RM 13 50 Cash 13 50 GST Summary Amount RM Tax RM SR 6 12 74 0 76 NNN Thanks You INVOICE_RECEIPT,Cash Sale T Document No T04 18 084227 Date DESC PRICE Disc AMOUNT TAX QTY RM RM ODE POLY CHOPPING BOARD 013 3 UNIT 4 80 0 00 14 40 SR PLASTIC BOWL 2 80 JNIT 2 80 0 00 22 40 SR PLASTIC CONTAINER W COVER MS SQ 1 6 UNIT 1 hi 0 00 9 00 SR BENXON PPHYGIENIC CUP A0 70022 OZ 50PCS 1 UNIT 10 00 0 00 10 00 SR STAEDTLER LUNA COLOUR PENCIL 11 UNIT 4 90 0 00 53 90 SR Total Qty 29 Total Inclusive GST 6 109 70 Rounding Adjustment 0 00 Rounded Total RM 109 70 Cash 109 70 GST Summary Amount RM Tax RM SR 6 103 49 6 21 NNN Thanks You INVOICE_RECEIPT,ADVANCO COMPANY Company Reg No 725186 V NO 1 3 Jalan 12 Link Maju GST Reg 001658445824 TAX INVOICE CB 389720 4 2153 M M2 0 Cashier c2000 Qty Description Frice Total UNICORN 20CM HALF WHITE RULEF SR 1 A15961 0 80 0 80 CBE S217 CBE 7 SCISSORS 2 0MM SR 1 A27269 e 20 6 20 2 Type 2 Total 7 00 Rounding Adj 0 00 Total Inclusive GST 7 00 CASH 50 00 Change 43 00 GST Summary Code Net Amt GST Total SR 6 6 60 0 40 7 00 Total 6 60 0 40 7 00 Thank you Please come again Goods sold are not returnable for refund or exchange INVOICE_RECEIPT,Smartrich Eperson 000115154944 TAX INVOICE Slip 0000000109000712950 Date Time Trans 409712949 Staff 95897 Description Amount TX 598336001 6 Chicken Curry Puff 4 bag 5 50 22 00 SR Total RM Including GST 6 22 00 Rounding Adj 0 00 Total Rounded 22 00 Cash 22 00 GST SR 6 22 00 1 25 Amt Excl GST 20 75 of Items 4 Thank you Please come again APPROVED Ian BY In DATE INVOICE_RECEIPT, Yo TRENDYMAX M SDN BHD Company Reg No 583246 A P6 Block c GM Klang Wholesale City Whatsapp GST Reg 000384098304 TAX INVOICE CB GM3 46792 Cashier W001 erah C6 Remarks Qty Description Price Disc Total 1 MS 15 00 0 00 15 00 SR LOYALTY PACKAGE 10 IB RDM 28 90 28 90 260 10 SR IRON BASKET ROUND 27 25 12 AOR5058 5 00 6 00 54 00 SR 50MM PULL FLOWER RIBBON 1 QC 0 00 0 00 0 00 SR HORSE CALENDAR 24 Type 4 Total 329 10 0 00 Rounding Adj Total Inclusive GST 329 10 329 10 VISA GST Summary Code Net Amt GST Total SR 6 310 47 18 63 329 10 Total 310 47 18 63 329 10 Points 310 Thank you Please come again I Goods sold are not returnable for refund or exchange INVOICE_RECEIPT, PRINT EXPERT SDN BHD 1 98965 A NO 18 0 16 TEL 03 5550588 FAX GST ID 000886677504 Doc No SO0004684 DEPT Cashier USER Date 1 01 018 Salesperson Time 16 3 00 Description Qty Price Amount DESIGN 1 31 80 31 80 FOAMBOARD 91X46CM 3 63 60 190 80 DESIGN 31 80 63 60 ROLLUP BUNTING 178 08 356 16 DESIGN 1 31 80 31 80 FLYERS 100 0 73 73 14 DEPOSIT CS00489793 1 647 30 647 30 Total Qty 110 in Total Sales Excluding GST 94 34 Discount 0 00 Total GST 5 66 Rounding 0 00 Total Sales of GST 100 00 1 YOU HAVE A NICE DAY INVOICE_RECEIPT,PRINT EXPERT SDN BHD 989625 A NO TEL GST ID 000886677504 TAX INVOICE Receipt CS00489817 Table 13 Staff Date Cashier USER Time Description Qty Price Amt Tax A4 CLR COPY 8 0 53 4 24 SR Total 8 4 24 T otal Sales Excluding GST 4 00 Discount 0 00 Service Charge 0 00 Total GST 0 24 Rounding 0 01 Total Sales Inclusive of GST 4 25 CASH 4 30 CHANGE 0 05 GST SUMMARY Tax Code Amt RM SR 6 4 00 0 24 Total 4 00 0 24 indicated this tax code beiong to service charges GOODS SOLD ARE NOT RETURNABLE ITEM NOT nrom nr INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No W GST Reg No 001492992000 No 8 Jalan Tel Slip No 8020178503 192915 Description Amcunt PB SHT P 11H A4 50 S 16 90 T No Plastic Bag Campai 0 20 T Issue Spring Ingot RM PB 2D R FILE A4 40MM 2pc 7 99 15 98 T Stat Buy 2eRM 13 2 98 Total RM Incl of GST 30 10 Cash 40 10 CHANGE 10 00 Item Count 5 GST Summary Amount RII Tax RM T 6 28 39 1 71 Z 0 0 00 0 00 Total Savings 2 98 BE A POPULAR CARI MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD W GST Reg No 001492992000 No 8 Jalan Tel Slip No 8020188757 Member Card No Card Expiry Description Amount DOCUMENT HOL A4 1486A Tra 2pc a 1 15 2 30 T Member Discount 0 24 PB PVC A4 L FLD PBA41 25 2pc o 3 90 7 80 T Member Discount 0 78 Canon Cal AS120V Grey 29 90 T Member Discount 2 99 Nasi APRi6 Seashore BK 5 00 Z Total RM Incl of GST 40 99 Rounding Ad 0 01 Total RM 41 00 Cash 51 00 CHANGE 10 00 Item Count 6 GST Summary Amount RM Tax RM T 6 33 95 2 04 Z 0 5 00 0 00 Total Savings 4 01 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD W GST Reg No 001492992000 No EMPIRE SHOPPING GALLERY Tel Slip No 1010104759 Member Card No Card Expiry Description Amount SC Acr Frame S103M 2pc e 5 50 11 00 T Member Discount 1 10 Total RM Incl of GST 9 90 Cash 20 00 CHANGE 10 10 Item Count 2 GST Summary Amount RM Tax RM T 6 9 34 0 56 Total Savings 1 10 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online INVOICE_RECEIPT, W Tel 03 5519 083 Fax 03 5519 083 GST ID 00100595710 Tax Invoice No CS180319 0015 Qty RM Tax TAPE 50 1 30 00 SR Total Amt Incl GST 6 31 80 Rounding Adjustment 0 00 Total Amt Payable 31 80 Paid Amount 31 80 Change 0 00 Total Qty Tender 1 Deposit GST Summary Amount Tax RM RM SR 6 30 00 1 80 Total 30 00 1 80 THANK YOU Goods Sold are not returnable 19 03 018 INVOICE_RECEIPT,RELAIS TOTAL Tel Le a 12 36 V201855892CAISSIER 1 C DESIGNATION P U QTE TOTAL CAFE CREME 12 00 2 24 00 CAFE EXPRESSO 10 00 2 20 00 CHOCOLAT CHAUD 12 00 1 12 00 Total Facture 56 00 DH REGLE PAR ESPECE 56 00 DH Merci de votre visite ICE 000081241000051 INVOICE_RECEIPT,TONYMOLY VIVA CITY TONYMOLY SHOP GSI ID Tay Invoice TERMINAL 880 SALES NO 7807949 SALES DATE CASH Then Fiona GL I CASH POIN 0 EGG PORE blackHEAD STEAM BALM2EAC SR SS04018600 1 55 90 55 90 Disc 10 00 5 59 LGG PORE TIGHTENING COOLING PA30g SR SS04017600 1 55 90 55 90 Disc 10 00 5 59 DISCOUNT 10 EAC ZR DIS10 1 0 00 0 00 Item Count 3 Total Sales Incl GST 100 62 Rounding Adjustment 0 02 Total After Rounding VISA Card No App Code a0000000031010 GST summary Amount RM Tax RM SR 6 94 92 5 70 ZR 0 0 00 0 00 Total promotional saving 11 18 P inted on Thank You Pleace Come Again INVOICE_RECEIPT,TONYMOLY VIVA CITY TONYMOLY SHOP GST Tax Invoice TERMINAL 880 SALES NO 8807947 SALES DATE Then Fiona CLIENT CASH POINT EARNED 0 PURE ECO SNAIL MOISTURE GEL 300 SR BD06000800 1 39 90 39 90 Item Count 1 Total Sales Incl GST 39 90 Rounding Adjustment 0 00 Total After Rounding 39 90 VISA 39 90 Card No App Code a0000000031010 Gi Summary Amount RM Tax RM SR 6 37 64 2 26 Pr inted on Thank you INVOICE_RECEIPT,TONYMOLY VIVA CITY TONYMOLY SHOP Tax Invoice TERMINAL 880 SALES NO 8807946 SALES DATE CASHIER Then Fiona CLIENT CASH POINT EARNED 0 HONDER CHEESE FIRMING CREAM EAC SR FE02001600 1 69 90 69 90 Disc 30 00 20 97 DISCOUNT 30 EAC ZR DIS30 1 0 00 0 00 Item Count 2 Total Sales Incl GST 48 93 Rounding Adjustment 0 02 Total After Rounding 48 95 VISA 48 95 Card No App Code a0000000031010 GUI summary Amount RM Tax RM SR 6 46 16 2 77 ZR 0 0 00 0 00 Total promotional saving 20 97 i inted on Thank You Please Come Again INVOICE_RECEIPT,EXPrint Anzel Advertising M bhd H Tel GST No 002121732090 Tax Cash Sales No UDA C818 01575 Qty RM Tex A4 BW Simili 80gsm 7 00 7 42 SP 1 00 Total Amt Incl GST 6 7 42 Rounding Adjustment 0 01 Total Amt Payable 7 40 Paid Amount 10 00 Change 2 60 Total Qty Tender 7 THANK YOU For any anquiry please e mail us E GST Summary Amount RM RM ens 7 00 Total 7 00 0 42 THANK YOU For any enquiry please e mail us INVOICE_RECEIPT,EXPrint Anzel Advertising M H Unif G Tel 6706 GST No 002121732090 Tax Cash Sales No UDA 0818 01713 Qty RM Tex Plastic Lamination At 2 00 4 24 81 2 00 A4 COL Simili SOgsm 2 00 4 24 81 2 00 Total Amt Ind GST 6 8 48 Rounding Adjustment 0 02 Totel Amt Peyable 8 50 Paid Amount 100 00 Change 91 50 Total Qty Tender 4 THANK YOU For any enquiry please e mail us E GST Summary Amount Tab RM SR A 8 00 Total 8 00 0 48 THANIC YOU For any enquiry pleuse E mail us INVOICE_RECEIPT, REF MR D I Y KUCHAI SDN BHD Co Reg 750441 W A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 0004737925 SG WANG TAX INVOICE MAGNETIC WHITEBOARD LD001 90 60CM S E208 9087396 1 X 35 00 35 00 JAPE DISPENSER SETJE600 CITRUS S WA36 9556481779603 2 X 19 90 39 80 CANDLE E8001050 S 0C32 4172 40 9044364 1 X 9 50 9 50 BALL PEN 6BK 0 5MM KC1069 S RC11 23 42 6953070994578 1 X 2 90 2 90 WHITE BOARD MARKER SET 8858 S SB17 240 9082825 1 X 3 30 3 30 FIRST AID KIT S CG61 2 48 9061496 I X 26 90 26 90 PLANNING MAGNET 30MM S RC22 24 288 9088524 1 X 2 30 2 30 Item s 7 Qty s 8 Total Incl GST 6 RM 119 70 CASH RM 0 00 CHANGE RM 0 30 GST Summary Amt RM Tax RM GST S 6 1 92 6 78 15 03 18 15 41 SH01 B019 T2 R000243654 OPERATOR TRAINEE CASHIER ARE ALLOWED WITHIN 7 AY WITH RECEIPT GTRICTLY NO CASH REFUND INVOICE_RECEIPT,PREMIO PREMIO W GST Reg No 001032994816 F G 01 JALAN SS 5750 TAX I NVOICE Invoice No KJ1 248350 Date Cashier su MAY Description Qty Price Amount 1 SR SQUARE THUMB 30 0 85 25 44 TACKS Total 25 44 Discount 0 00 Total Sales Inclusive GST 6 00 25 44 Rounding Adjustment 0 01 Amount To Be Paid 25 45 Cash Received 25 50 Change 0 05 Starting We will no longer be issuing handwritten invoices Your service jobs such as photocopy and printing are replaced by the order form along with a copy of this receipt All goods and service are subjected to the 6 GST during checkout All goods sold are not returnablelrefundable Exchanges are only acceptable within 3 days with a proof of receipt All cartridge toner sales are final and non refundable No cash refunds for credit card purchases No refunds or exchanges will be entertained without proof of receipt Terms and conditions appplied GST Summary Amount RM Tax RM SR 6 00 24 00 1 44 Thank you for Shopping at PREMIO Have a Nice Day For the latest news and updates like us on INVOICE_RECEIPT,SOON FATT S B 81497 P LUT GST REG NO 000788250624 TAX INVOICE DESC QTY PRICE AMOUNT TAXCODE RM RM 51190030 A1 BIHUN ISTIMEWA 3KG 10 10 00 100 00 ZRL 060400063 YSF BUAH KERAS 3KG 1 36 80 36 80 SR 012700054 HOBE RED KIDNEY BEAN 425GM 1 58 00 58 00 SR 51580020 CAP LANG JAGUNG MANIS 425GM 1 53 80 53 80 SR 50460020 DAIRY CHAMP EVAP 390GM 1 113 90 113 90 SR Total Inc GST 6 362 50 Rounding Adjustment 0 00 Final Total 362 50 Cash 400 00 Change 37 50 GST Summary Amount RM Tax RM ZRL 0 100 00 0 00 SR 6 247 64 14 86 C02102772 362 50 INVOICE_RECEIPT,BEMED SP SDN BHD 8155 GST Reg CASH RECEIPT CB Cashier be Qty Code Desc Price Total ALPHA LIPIO LIFE LINE 450MG 450G 1 184810 165 00 165 3R 1 Type 1 SubTotal 105 00 Rounding Adj 0 00 Total Inclusive GST 165 00 MASTER 105 00 GST Summary Amount Tax MYR MYR SR 155 00 9 34 ONG GUAT CHYE Points 3 052 Thank you Please come again 165 00 INVOICE_RECEIPT,B BEST RESTAURANT 001610235 P GST NO TEL ITTAX INVOICE BILL NO 00118887 POS01 BIZDATE CASHIER Manager PRINTED RM 1 FISHBALL NOODLE 7 00 1 SUB TOT 7 00 GST 6 0 42 ROUNDING ADJ 0 02 NET TOTAL 7 40 Cash 7 40 CHANGE 0 00 Thank You Please Come Again All Item Will Be Charges GST INVOICE_RECEIPT,staff 13 BEST RESTAURANT 001610235 P GST NO 001800839168 NO AN SS4C 5 I 778 TAX INVOICE BILL NO 00127408 POS01 BIZDATE CASHIER Manager PRINTED RM 2 FISHBALL NOODLE 7 00 14 00 2 SUB TOTAL 14 00 GST 6 0 84 ROUNDING ADJ 0 01 NET TOTAL 14 85 Cash 14 85 CHANGE 0 00 Thank You Please Come Again All Item Will Be Charges GST INVOICE_RECEIPT, GST TAX NO 000900000096 TEL FAX GST NO 000988880896 TAX INVOICE B L FOINTS o RECBIFT CS00168420 DATE ITEM QTT U P DISC AMOUNT 3555060603117 1 4 90 0 00 4 90 S 3R S HURIXS 9555060603162 1 5 60 0 00 60 s SR HU HURIES TOTAL QUANTITI 2 SUB TOTAL GST 12 19 DISC 0 00 GST 0 69 SVC CHG 0 00 ROUNDING 0 04 TOTAL 12 15 CASH 50 15 CHANGE 38 00 GST SUHMARY CODE AMOUNT TAX AMT SR 11 50 6 0 69 TAX TOTAL 0 69 3 STANDARD 6 2 ZERO RATED THANE YOU GST NO 000988880896 SALES FOINTS 0 B L POINTS 0 INVOICE_RECEIPT,Ref No 0 00696305041961 Goods Sold Are Not Returnable TO P walk they Gegi Cash Carry Sdn Bhd Sek 09 GST Reg No 001951645696 05 se200209 42193 MIGHTY 11L 2 X 11 50 23 00 S MIGHTY BLEACH 10L 2 X 11 50 23 00 S GARDENIA SOMMERSET COTTAGE 300G 1 X 4 45 4 45 S No of items 5 Total Incl GST RM 50 45 Master 9113 50 45 Change RM 0 00 Missed Point Today 47 Served by GST Suamary GST Code Amount RM Tax RM S 06 0 47 60 2 85 Ref No 0 Goods Sold Are Not Returnable TQ INVOICE_RECEIPT,TANJONGMAS BOOKCENTRE PJ A LOT 4233 NO ID GST 002147033088 TAX INVOICE BILL 28544 CASH1 10 02 B CODE DESC QTY U PRICE AMT 4971850134824 1 53 00 53 00s CALCULATOR SCIENTIFIC 27932 1 5 40 5 40s M G R3 GEL PEN 0 5MM 3 S 9555684639363 1 3 60 3 60s FABER CASTEL SUPER TRUE SUB TOTAL Total GST I 3 51 TOTAL ITEM S 3 TOTAL QUANTITY S 3 TOTAL INCL GST RM CARD TYPE VISA CARD NO THANK YOU PLEASE COME AGAIN GOODS SOLD ARE NOT RETURNABLE GST Taxable Amt GST Amt s SR I 6 58 49 3 51 INVOICE_RECEIPT,BEMED SP SON BHD GST Reg CASH RECEIPT CB Gashier be Qiy Code Desc Price Total NH DELICADERMA PROTECTIVE CR 50M 1 348000 76 00 76 BR 11 BEPROGENT OR LS 30G 1 173032 10 00 10 ZRL ALPHA LIPID LIFE LINE 450MG 450G 1 184310 165 00 185 3R 3 Type 3 SubTotal 251 00 Cash Promotion 34 00 Rounding Adj 0 00 Total inclusive GST 217 00 MA ER 217 00 GST Summary Amount Tax MYR MYR SR 185 28 11 72 ZRL 10 00 0 00 ONG GUAT CHYE Points nt 215 Thank yow Please come again INVOICE_RECEIPT,Thank You Please come again Goods Sold Are Note Returnable For feedback or croplaint please call REDEEM VOUCHER BEFORE POINTS EXPIRY L Cash Carry Sdn Bhd 317041 W PT17920 SEKSYEN U9 Reg No 001951645696 Invoice No 45691 Date Counter 07 RUDGET TOILET ROLL 20 S 1 X 12 61 12 61 S No of items 1 Subtotal Incl GST RM 12 61 Rounding RM 0 01 Total Incl GST RM 12 60 Cash RM 50 00 Change RM 37 40 Missed Point Today 11 Served by GST Summary GST Code Amount RM Tax RM S 06 0 11 90 0 71 00600716214045691 Thank You Please come again Goods Sold Are Not Returnable For feedback or complaint please call REDEEM VOUCHER BEFORE POINTS EXPIRY L INVOICE_RECEIPT,Thank You Please come again Goods Sold Are Not Returnable For feedback or complaint please call REDEEM VOUCHER BEFORE POINTS EXPIRY Segi Cash Carry Sdn Bhd 317041 W PT17920 SEKSYEN U9 GST Reg No 001951645696 Invoice No 47735 Date Counter 03 UNICA PAIL 6GL 600 1 X 17 41 17 41 S MASSIMO FINE WHOLEMEAL 420G 1 X 2 64 2 64 Z No of items 2 Total Incl GST RM 20 05 Cash RM 50 00 Change RM 29 95 Missed Point Today 19 Served by BT OTHMAN GST Summary GST Code Amount RM Tax RM S 6 0 16 42 0 99 Z 0 0 2 64 0 00 Ref No 00600676213047735 Thank You Please come again Goods Sold Are Not Returnable For feedback or complaint please call INVOICE_RECEIPT,Your order number is Petaling Jaya GST ID No 000504664064 T 178 Tel No TAX INVOICE MFY Side 1 INV 001780200112117 ORD 64 REG 2 QTY ITEM TOTAL 2 L FiletOFish 21 18 2 L Coke NO Ice e ZL Fries 1 6Nuggets 7 10 1 Barbecue Sauce 1 Small Cone 1 00 Eat In Total incl GST 29 28 Rounding Adjust 0 02 Total Rounded 29 30 Cash Tendered 50 00 Change 29 30 20 70 TOTAL INCLUDES 6 GST 1 66 Thank You and Please Come Again Customer Service Hotline INVOICE_RECEIPT,MEI LET RESTAURANT NO 2 JALAN TEL 9863 NO GST 0010 9273 4976 TAX INVOICE TABLE 08 BILL NO 00015047 10P01 CASHIFR ADMINISTRATOR BILL DT RM 1 TALAPIA DEEP FRIED WITH SWEET 40 00 SR C14 M 1 BRAISED PORK BELLY WITH BITTER GO 18 00 SR K17 S 3 WATER TEA 40 50 1 50 SR 3 RICE 1 50 4 50 SR i 8 SUB TOTAL 64 00 GST 6 3 84 ROUNDING ADJ 0 01 NET TOTAL 67 85 Cash 100 00 CHANGE 32 15 Tax Summary Amount Tax SR GST 6 64 00 3 84 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,KING S CONFECTIONERY S B U GKJ SS6 4 PUSAT BANDAR PETALING TEL NO GST ID 000294060032 Tax Invoice Inv No GKJ30785499 Date Cashier FT10060 Ctr 01 Code Desc Qty RM D Amt 201026 SCONE M 1 7 50 0 7 50 S Qty 1 7 50 Rounding Adj 0 00 Due 7 50 Pay 20 00 Change 12 50 Total Included GST 6 0 42 GOODS SOLD NOT RETURNABLE EXCHANGEABLE THANK YOU PLEASE COME AGAIN TASTY BAKING HEALTHY NATION Visit us online at INVOICE_RECEIPT,YONG SOON FATT S B P TEL GST REG NO 000788250624 TAX INVOICE P Plea DESC QTY PRICE AMOUNT TAXCODE RM RM 011100029 KCL SOH HOON 5KG 1 CTN 31 50 31 50 SR 070100004 BAWANG PUTIH 1 KG 37 50 37 50 ZRL 51190030 A1 BIHUN ISTIMEWA 3KG 5 PKT 10 00 50 00 ZRL 010400058 ABC TEPUNG URI KAYU 1KG 1 CTN 27 00 27 00 ZRL 50100010 LIMA SAJAH TEPUNG BERAS 500 1 CTN 26 80 26 80 ZRL 012700007 ALISHAN YOUNG CORN 425GM 1 CIN 52 00 52 00 SR 01270100 NEW SUN BUTTON MUSHROOM 425 1 CTN 58 00 58 00 SR 0010 RAMBUTAN BERAS SST 5 10KG PKT 36 00 156 00 ZRL 50460020 DAIRY CHAMP EVAP 390GM 1 CTN 113 90 113 90 SR 010700098 LIFE sos CILI 340GM 1 CTN 63 60 63 60 SR 010700060 MAGGI SOS TOMATO 325GM 1 CIN 62 20 62 20 SR 010700031 LIFE SOS CILI 500GM 1 CTN 41 20 41 20 SR 010700057 MAGGI SOS TOMATO 475GM 1 CIN 39 00 39 00 SR Total Inc GST 6 758 70 Rounding Adjustment 0 00 Final Total 758 70 Cash 760 00 Change 1 30 GST Summary Amounts RM Tax RM SR 6 435 28 26 12 ZRL 0 297 30 0 00 001099379 758 70 INVOICE_RECEIPT, X A GST ID No 001656262656 Tel Tax Invoice S 03 A INV No r D 22 Ticket No 07111 Entry Time Mon 21 Paid Time Mon Parking Time 1 2 Parking Fee Rate A RM7 00 Amount RM6 60 GST Included 6 00 RMO 40 Total RM7 00 Paid RM7 00 Change RMO 00 Inclusive 6 GST Thank You INVOICE_RECEIPT,GL HANDICRAFI do TAIN Company Reg No 75495 W GST Reg No 001948532736 TAX INVOICE Involce No es 10090 Date Cashier 01 RM Code NONA M ACRYIC YARN 10 00 PKTS x 13 00 130 00 SR Subtotal 130 00 Total Excl of GST 122 64 Total Incl of GST 130 00 Total Amt Rounded 130 00 Payment 130 00 Change Due 0 00 Total item s 10 GST Summary Amount RM Tax RM SR 2 6 122 64 7 36 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,GL HANDICRAFT TAll ORING Company Reg No 75495 W GST Reg No 001943532736 TAX INVOICE Involce No CS 10217 Date Cashier 01 RM Code NONA M ACRYIG YARN 8 00 PKTS 24 13 00 104 00 SR Subtotal 104 00 Total Excl of GST 98 11 Total Incl of GST 104 00 Total Amt Rounded 104 00 Payment 104 00 Change Due 0 00 Total Item a 8 GST Summary Amount RM Tax RM SR 6 98 11 5 89 THANK YOU 14241 PLEASE COME INVOICE_RECEIPT,ARTRANGE STATIONERS PRINT U TEL FAX GST ID 0017252 TAX INVOICE CASH Receipt CS00058574 Date Cashier USER Time Salesperson Ref Item Qty S Price Amount Tax 3474370026019 2 7 70 15 40 SR PENTEL CORRECTION PEN 18ML ZLC1 W TOT QTY 2 15 40 Total Sales Excluding GST 14 53 Discoun 0 00 Total GST 0 87 Rounding 0 00 Total Sales Inclusive of GST 15 40 CASH 50 00 Change 34 60 GST SUMMARY Tax Code Amt RM Tax RM SR 6 14 53 0 87 Total 14 53 0 87 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,TIMES BOOKSTORES GST Reg No Goods sold are not refundable Exchandeable within 14 daus of purchase Cash Sales No 199176 POSTED Brh Ter Shits 49 T01 1 Oper MAY80302 Product Descrittion Unit Price 9tu Disc BST Amount 4902505482038 PILOT BP 1RT BALLPOINT PE 5 1 41 1 0 00 0 08 1 49 4902505463303 PILOT FUDE MAKASE BRUSH P 5 5 56 1 0 00 0 33 5 89 4902505911026 PILOT M PENCIL S GRIP 05 5 4 71 1 0 00 0 28 4 99 Total Qtu 3 Total RH 12 37 Roundino Adjustments RM 0 02 Tendered CASM RH 58 00 Chande RM 37 65 Nest Price Item to GST summeru Amount RM Tax RM 5 6 11 68 0 69 Z10 0 00 0 00 Date Time For feedback email to mu or call INVOICE_RECEIPT, KITCHEN CITTA MALL KITCHEN SDN BHD 26 RD FLOOR CITTA MALL NO 1 JALAN PJU 1A 4B JLN PETALIN JAYA SELANOR ST 002007515136 Tax Invoice Table D2 POSTED Order 149308 Bill V007 147795 Pax s 4 Date Description Qty U price Total TAX Salmon Teriyaki Wazen 1 X 25 90 25 90 SR Chicken Salad Sashimi ozen 1 X 25 90 25 90 SR Chicken Katsu Curry Wazen 1 X 19 90 19 90 SR Saba Teriyak Wazen 1 X 25 90 25 90 SR Total Excluding ST 97 60 Serv Charge 10 9 76 ST Payable 6 44 Total Inclusive of ST 113 80 TOTAL 113 80 Closed 1528 Server PETER VISA WON TAI CHIN b42 ST Summary Amount RM Tax RM SR 6 107 36 6 44 uest Signature Thank You Please Come Again POWERED BY ww MYSIS COM MY 113 80 INVOICE_RECEIPT,OSTED BEMED SP SDN BHD P 8155 GST Reg CASH RECEIPT CB Cashier be Qty Code Desc Price Total PRISTIN OMEGA 3 FISH OIL 2X150 S VIP 1 269250 300 00 300 8R ALPHA LIPID LIFE LINE 450MG 450G 2 184810 165 00 330 8R 80 DERMAPRO OINT 15G 1 178104 5 00 OK 5 ZRL 4 Type 3 SubTotal 635 00 Rounding Adj 0 00 tal Inclusive GST 635 00 MASTER 635 00 GST Summary Amount Tax MYR MYR SR 594 34 35 66 ZRL 5 00 0 00 ONG GUAT CHYE Points 1 124 Thank you Please come again the INVOICE_RECEIPT,CP POSTED YONG CEN ENTERPRISE NO 001147981824 CASH RECEIPT CS00633900 DATE SALESPERSON TIME COUNTER ITEM QTY U P AMOUNT 2411662040 100 0 25 25 00 ZRL IKAM BILIS KOPEK Att 10G 24118023030 1 25 00 25 00 SR TEPUNG JAGUNG CAP BINTANG 20 40 2411862303 1 42 50 42 50 ZRL VITAMAS CARTON TOTAL QUANTITY 102 SUB TOTAL 92 50 DISC 0 00 GST 1 50 TAX 0 00 ROL WDING 0 00 94 T L 94 00 CASH 94 00 CHANGE 0 00 GOODS SOLD ARE NOT RETURMABLE THANK YOU INVOICE_RECEIPT, P BILLION SIX ENTERPRISE Tel GST Reg No 000944312329 FOSTED Tax Invoice Invoice No 1 148409 Date 12 Cashier 123 Description QTY Price Amount 1 SR 9555255201883 1 12 00 12 00 5001 BAKERY DEEP TRAY 18 14 BCM K T Total 12 00 Discount ass Total Sales inclusive GST 6 00 12 00 Cash Received 5008 Change 38 00 GSI Summary Amount RM Ta RM SR 6 00 11 32 0 68 Darang yang sudah di beli wang tidak dapat di kernbalikan Pertukaran barang hanya boleh dibual dalam 3 han haja dengan resit INVOICE_RECEIPT,AMANO MALAYSIA SON BHD 682288 V TEL 5003 GST ID 001137704960 EVOIDED TAX INVOICE P S 02 A INV NO 0002300417000138 1 D 11 Ticket No 029190 Entry Time Sun Paid Time Sun Parking Time 3 30 Type A RM3 00 Parking Fee RM2 83 GST Included 6 00 RMO 17 Total 3 1 RM3 00 Paid RM3 00 Change PMO 00 Thark You Inclusive 6 GST INVOICE_RECEIPT, V 5003 r ID 001137704960 TAX INVOTOSTED P S 02 A INV No T D 11 Tidket NO 029332 Entry Time sun 20 Paid Time an 21 51 Parking Time 1 29 Type Rate A RM1 00 Parking F Fee RMO 94 GST Included 6 00 RM0 06 Total RM1 00 Paid RM1 00 Change RM0 00 Thank You Inclusive 6 GST INVOICE_RECEIPT, GST ID NO 000181747712 INVOICE NO 18023 103 05 05 17 2832 AH HUAT WHT COFFEE GO RM12 65 5 9500 MASSIMO WHEAT GERK 400 RM2 39 s 2022 CADBURY CHOCOLATE DAIL RM9 65 s 066 MILD FUZE 3IN1 ORIGINAL RM13 65 s 384 MISTER POTATO TOMATO 16 RM3 99 s Total Sales Inclusive GST RM 42 33 Rourding Adjustment RH 02 Rounding RM 42 35 CREDIT RM 42 35 CHANGE RN 00 GST Summary Amount RM Tax RM 6 39 92 2 41 FOSTER 42 35 Thank come again Keep the invoice for applicable returns INVOICE_RECEIPT,PERNIAGAAN RIANG RIÁ gst 001662431232 1210644T TAX INVOICE N07 JLN UERO ALAM 27 T S BASIN BESAR 400002 1 00 X 21 32 21 32 S No Qtys 1 00 No Items 1 TOTAL 22 60 CASH 30 00 CHANGE 7 40 TAXABLE AMT S 21 32 GST 6 1 28 TAXABLE AMT Z 0 00 GST 0 0 00 THANK YOU FOR SHOPPING 6000 SOLD ARE NOT REFUNDABLE Rabu Time 21 51 Cashier NSK WT1 SFULL OB Inv R000039737 22 60 INVOICE_RECEIPT,BEMED SP SDN BHD P 8155 GST Reg CASH CB 59581331715 Cashier 0 Qty Code Desc Price Total PIL CHI KIT TECK AUN 12 S SR 1 160160 1 58 15 80 14 22 PANADOL ACTIFAST 20 S ZRL 1 458140 12 00 12 00 ALPHA LIPID LIFE LINE SR 1 184810 165 00 165 00 3 Type 3 SubTotal 191 22 Rounding Adj 0 02 Total Inclusive GST 191 20 VISA 191 20 OK GST Summary Amount Tax MYR MYR SR 169 08 10 14 ZRL 12 00 0 00 ONG GUAT CHYE Points 1 305 191 20 Thank you Please come again INVOICE_RECEIPT, P 99 SPEED 519537 X NO INVOICE NO 154 1K8 RM20 80 s 02 X RM 10 40 Total Sales Inclusive GST RM 20 90 CASH RH 21 00 CHANGE RM 20 GST Summary Asount RM Tax RM s 6 19 62 1 18 20 fo Thank You Please come again INVOICE_RECEIPT, P HERO DISTRIBUTION SDN BHD Subang Jasa 666770 U GST Reg 001627654144 4243 Compleks Perniagaan Sr Gaya OIn Tmn Subang Jasa 3 FOSTED 40150 Selangor Tax Invoice S1P03201705170016 Cashier CAP MAKMUR MINYAK PACKET 1KG 9555845400009 2 50 3 7 50 Z H GRASS K DELLY F POW S BERRY 250G i 9555124301089 6 00 3 18 00 S SA 10 s PKT 515474 7 99 2 15 98 Z Ibem 3 Total with GST 6 41 48 Qty e Rounding 0 02 Total Saving 0 00 Total 41 50 Tender Master 5148 App 83650 41 50 Change 0 00 GST Analysis Goods Tax Amount S 6 16 98 1 02 41 50 2 0 23 48 0 00 Member Num 80148970 Thank you for shopping with us Please come again INVOICE_RECEIPT, P 2 Ségi Cash Camy Bhd Sek 09 Shah Alam GST Reg No 001951645696 POSTED OK Invoice No 34867 Date Counter 09 MFM ROSES ALL PURPOSE FLOUR 12X8506 1 X 18 60 18 60 Z TLC SOTONG SAUCE 725G 1 X 2 69 2 69 S TLC FISH SAUCE 725G 1 X 2 70 2 70 S ROYAL BAKING POWDER 450G 2 X 11 69 23 38 S KUAT HARIMAU BLEACH LEMON TP 2X900ML 2 X 5 51 Disc 1 53 7 96 S INDOCAFE COFFEEMIX 3IN1 100X20G 1 X 33 90 33 90 S UDANG XL 0 434 X 39 90 17 32 Z BURUNG PUYUH PC 4 X 2 95 11 80 S No of items 10 Total Incl GST RM 118 35 Master XXXXXXXXXXXX0000 118 35 Change RM 0 00 Savings RM 3 06 Missed Point Today 113 Served by 118 35 GST Summary GST Code Amount RM Tax RM Z 00 0 35 92 0 00 S 06 0 77 76 4 67 Ref No 00600736354034867 Goods Sold Are Not Returnable TQ INVOICE_RECEIPT, P Broadview Marketing 728384 M No 9 G U3 D Sek U3 GST Reg No 000203587584 Tax Invoica FOSTED Bill No BM 159572 Date Cashier Description Qty Price Amount 1 SR HM BAG 10 X 1 4 70 4 70 16 500gm Total 4 70 Total Item Discount 0 00 Total Sales Inclucive GST 4 70 Cash Received 4 70 OK GST Summery Tax Code Taxable Amount GST SR 6 00 4 43 0 77 GST 0 27 GST Include Item 4 7 Thank You Please Came Again INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No Mahkota Tax Invoice INV No 854150 Cashier Date Description Qty U price Total TAX Guiness Stout B Promotion 4 X 15 40 61 60 SR Bottle B 4 X 0 30 1 20 ZRL Total QTY 8 Total Excluding GST 59 31 GST payable 6 3 49 Total Inclusive of GST 62 80 TOTAL 62 80 CASH 62 80 GST Summary Amount RM Tax RM SR 6 58 11 3 49 ZRL 0 1 20 0 00 INVOICE_RECEIPT, GST ID NO INVOICE NO T0496 22 11 17 261 HELANG MINYAK MASAK SKG RM48 70 Z 2 X RM 24 35 8038 JASMINE SUPER 5 SPECIA RM29 90 Z 086 GREENLINK BIOTECH BRIKE RM8 40 S 2829 LIFEBUOY COOL FRESH SO RM13 98 S 2 X RM 6 99 820 PIPIT BLEACH 2 1KG TP RM4 20 861 FAB PERFECT BAR B 130 RM9 00 10 X RM 90 S51 NESCAFE CLASSIC ARABICA RM67 80 Z 3 X RM 22 60 4 Total Sales Inclusive GST RM 181 98 Rounding Adjustment RM 02 Rounding RM 182 00 CREDIT RM 182 00 CHANGE RM 00 GST Summary Amount RM Tax RM 6 33 56 2 02 Z 07 146 40 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, NO INVOICE NO T0466 01 11 17 0515 SNEK KU TAM TAM CRAB F RM3 65 s 0649 TIC TAC CANDY MINT WH RM2 10 5178 MENTOS SOUR MIX CHEWY RM2 45 s 2651 MUNCHYS CRACKER SANDWI RM8 38 s 2 X RM 4 19 0249 JULIES PEANUT BUTTER S RM7 55 s 820 PIPIT BLEACH 2 1KG TP RM4 20 s 480 TOP SUPER WHITE RED 2 RM12 65 s 9170 CA3210 CAMEL SHORTHAND RM1 90 s 9413 CS 1002 AS H COVER NOT RM4 80 S 8445 7CC UHU GLUE RM4 40 2 X RM 2 20 Total Sales Inclusive GST RM 52 08 Rounding Adjustment RM 02 Rounding RM 52 10 CASH RM 60 00 CHANGE RM 7 90 GST Summary Amount RM Tax RM 6 49 12 2 96 Thank You Please come again the invoice for applicable returns INVOICE_RECEIPT,ING4006 IN SPARKLE Co nov639240 H No Lot Tel GST ID 001429012480 Date Tax Invoice No 10100023492 531600309035 1 250 00 250 00 S ALARM G COB 333 L A66 L A71 LC 1 Promoter SK05 CHAN ZHI BEW Total Sales Incl GST 6 RM 250 00 Total Sales RM 250 00 Cash RM 300 00 Changes RM 50 00 GST Summary Amount RM Tax RM S 6 235 85 14 15 Z 0 0 00 0 00 Cashier 0005 CASHIER 1 000 Have a nice day Thank you POS 6 63 Customer Name Customer Signature INVOICE_RECEIPT,TELKEN SERVICE ELKEN SERVICE SON BHD 310184 X No Tel Fax no GST Reg No 000154042368 TAX INVOICE DATE TUE S 0 NO SS3511032318 JOB TYPE MAINTENANCE INVOICE NO ESS447 004439 BILL TO ADDRESS TEL TYPE OF UNIT DESCRIPTION SUPPLY PRICE QTY TOTAL RM RM VALUE PACK A BP SER SR 235 85 1 235 85 CARBON FILTER BP SERIES 1 SEDIMENT FILTER BP SERIES 1 SUBTOTAL 235 85 DISCOUNT SUBTOTAL FXCLUDING GST 235 85 GST 6 14 15 TOTAL AMOUNT DUE 250 00 PAYMENT MODE CASH 250 00 GST SUMMARY AMOUNT GST AMOUNT EXCLUSIVE INCLUSIVE RM RM RM 0 ZRL Zero rate 0 00 0 00 0 00 6 SR Standard rate 235 85 14 15 250 00 0 RS Relief Supply 0 00 0 00 0 00 TOTAL AMOUNT 235 85 14 15 250 00 CHECKLIST Feedwater pressure psi 20 Feed water TDS 006 Before service RO TDS 000 After service RO TDS 000 REMARK BP37613 chg 1 2 Customer Acceptance of Attended By Product Service in good order Tech ID ESS447 mer Signature Thank You INVOICE_RECEIPT,I 0 4 00 0 00 THANK YOU AND DO VISIT US AGAIN n P NISANTHI Machine 003 11 POSIED FIVE STAR CASH CARRY 1365663 P G 23 G 22 Tel Fax POS 3 GST No 000610435072 TAX INVOICE RECEIPT NO 00550388 9555339300051 X 1 45 00 S AKS APPALAM 3KG of Quantity Out 1 NET TOTAL 45 00 CASH 45 00 GST Summary Amount RM Tax RM S 6 42 45 2 55 Z 0 0 00 0 00 THANK YOU AND DO VISIT US AGAIN P NISANTHI Machine 003 INVOICE_RECEIPT,CP Broadview Marketing Bhd 728384 M No 9 G U3 D Sek U3 GST Reg No 000203587584 Tax Invoice Bill No BM 161113 Date Cashier Merlin escription Qty Price Amount 1 SR4 HMBAS oto 1 18 00 18 00 24 X36 2kg Total 18 00 Total Itern Discount 0 00 Total Salez Inclucive GST 18 00 Cash Received 18 00 ok GST Summery Tax Cade Texable Amount GST SR 6 00 16 98 1 02 GST 1 02 GST Include Itern FOSTERY Thank You Please Come Again INVOICE_RECEIPT, P BEMED SP SDN BHZ No G U3 G 8155 GST Reg 001734164480 CASH RECEIPT CB Cashier puteri Qty Code Desc Price Total ALPHA LIPID LIFE LINE SR 1 184810 165 00 165 00 1 Type 1 SubTotal 165 00 Rounding Adj 0 00 Total Inclusive GST 165 00 VISA 165 00 OK GST Summary Amount Tax MYR MYR SR 155 66 9 34 ONG GUAT CHYE Points 1 460 165 Thank you Please come again INVOICE_RECEIPT,cp SUPER SEVEN CASH CARRY SBN BHD 28 05 590150 A TEL FAX GST ID 000639090688 TAX INVOICE TAX INVOICE NO 138652 COUNTER 002 OPERATOR RM KK KACANG GORENG 400G 07 20 9556624004265 3 21 60 SR TERUNG 3 15 42066 1 3 15 ZR 2 30 42006 1 2 30 ZR BAWANG BESAR INDIA 00 98 42901 x 0 98 ZR QUANTITY 6 Units Total Sales Incl GST 6 RM28 03 Rounding Adjustment RM0 02 Net Total RM28 05 Fayment Method CASH Received Cash RM28 05 Change RM0 00 GST Summary Sales Amt Tax Amt RM RM SR 6 ZR 0 28 05 20 38 1 22 6 43 0 00 LEASE VERIFY YOUR RECEIPT BEFORE LEAVING THE COUNTER OSTED GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, 99 SPEED MART S B S19537 X GST 10 NO INVOICE NO 18028 103 T0269 10 05 17 RM6 85 5 9413 CS 1002 A5 H COVER NOT RM4 65 S Total Sales Inclusive GST RM 11 50 CASH RM 52 00 CHANGE RM 40 50 GST Summary AmountiRM Tax RM S 6 10 85 65 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, 99 SPEED 519537 X LOT P T TMN NO INVOICE NO 18028 T0369 563498 10 05 17 2174 A W SARSAPARILLA 1 5L RM2 85 2502 COKE ZERO 1 25L STOP RM2 50 s 261 HELANG MINYAK MASAK SKG RM24 40 Z 325 CINTAN MI PERISA ASLI 5 RM3 65 S 311 MAMEE EXPRESS MI CAWAN RM1 29 5425 MACOI HOT CUP MEE TOM RM3 50 02 X RM 1 75 066 MILO FUZE 3IN1 ORIGINAL RM13 65 s 1821 JULIES SUGAR CRACKERS RM6 70 22 X RM 3 35 6059 588 TWISTIES COOKIES 1 RM2 30 S 371 BIN BIN RICE CRACKER 15 RM11 90 s 2 X RM 5 95 Total Sales Inclusive GST RM 72 74 Rounding Adjustment RM 01 Rounding RM 72 75 CASH RM 100 00 CHANGE RM 27 25 GST Summary Amount RM Tax RM s 6 45 60 2 74 Z 0 24 40 00 Thank You Please again Keep the invoice for applicable returns INVOICE_RECEIPT,S Y STATIONERY 002050590 H NO TEL FAX EMAIL TEL FAX E Mail GST Reg No 000906854400 S P SALES Inv No CS 0004323 INVOICE No Description UOM Code Qty U Price Total MYR 1 LION FILE 6 S SPRING FILE PCS MFF350 50 1 60 80 00 SR Discount 10 00 8 00 Item Count 50 Total Sales Incl GST 6 72 00 Total Amount Payable 72 00 Cash Received 100 00 Change 28 00 GST Summary Amount MYR Tax MYR SR 6 67 92 4 08 GOODS SOLD ARE NOT RETURNABLE REFUNDABLE INVOICE_RECEIPT,Worf Catary FIVE STAR CASH is CARRY 1365663 P Tel Fax POS 3 GST No 000610435072 TAX INVOICE RECEIPT NO 00522899 X 2 19 80 S MAP 500GM 9 90 19 80 Quantity Out 2 NET TOTAL 19 80 CASH 50 00 30 20 GST Summary Amount RM Tax RM S 6 18 68 1 12 Z 0 0 00 0 00 THANK YOU AND DO VISIT US AGAIN P NISANTHI Machine 003 10 49 INVOICE_RECEIPT, KING S CONFECTIONERY S B U KJ1 NO 20 A1 JALAN SS6 3 EL GST ID 000294060032 Tax Invoice Inv No KJ130659712 Date Cashier FW1254 Ctr 01 Code Desc Qty RM D Amt 181010 French Lo 8 2 40 0 19 20 S Qty 8 19 20 Rounding Adj 0 00 Due 19 20 Pay 20 00 Change 0 80 Total Included GST 6 1 09 600 SOLD NOT RETURNABLE EXCHANGEABLE KASIH SILA DATANG LAGI TO TASTY BAKING HEALTY NATION Visit us online at INVOICE_RECEIPT,of B BEST RESTAURANT 001610235 P GST NO TEL 778 T TAX INVOICE BILL NO 00134609 POS01 BIZDATE CASHIER Manager PRINTED RM 3 FISHBALL NOODLE 7 00 21 00 3 SUB TOTAL 21 00 GST 6 1 26 ROUNDING ADJ 0 01 NET TOTAL 22 25 Cash 22 25 CHANGE 0 00 22 25 Thank You Please Come All Item Will Be Charges GST POSTED INVOICE_RECEIPT,A04053 DI HUAN YA RESTAURANT Company Reg No JM0681589 W 5 JALAN PERMAS TEL FAX GST ID Table TAX INVOICE TA3 Inv No 199977 Cashier c001 Date Qty Description Total RM Tax 1 106 33 00 SR TAKE AWAY ROASTED DUCK WITH CHINESE HERB HALF Total Sales Amount 33 00 GST 6 1 98 Rounding Adjustment 0 02 TOTAL 35 00 CASH 55 00 Change Returned 20 00 Item Count 1 GST Summary Amount RM Tax RM SR 6 33 00 1 98 Thank You Please Come Again Goods Sold Are Not Returnable Closed by c001 18 11 05 POSWAY MYTH POS SOLUTION INVOICE_RECEIPT, Jaya Tel Cash Receipt HQ Table Bill No 1863 Sevr By manager 5 Create Time Qty Description Total RM 1 BC001 CLAYPOT F TOFU 18 90 2 C004 STIR RED CURRY 37 80 RM18 90 2 DR001C THAI ICE TEA 13 80 RM6 90 2 DR002C THAI ICE GREEN 13 80 RM6 90 1 SD002 THAI STYLE 16 00 ACACIA LEAF 1 SQ003L STEAMED SQUIDS 32 00 I 2 T002S SPICY THAI TOM 50 00 AFOOD S RM25 00 1 V001 FRIED KANGKUNG 16 90 1 V002 S FRIED KAILAN 18 90 DFISH 2 W003 THAI STYLE 31 80 PRAWN RM15 90 13 W006 WHITE RICE PER 26 00 FILL RM2 00 28 SUBTOTAL 275 90 Type 11 Qty 28 Bill Total 275 90 Rounding Adj 0 00 NET TOTAL 275 90 CASH 275 90 Thank You Please Come Again manager INVOICE_RECEIPT, 867388 U Perindustrian TAX INVOICE Invoice OR18040202170496 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, 867388 U Perindustrian TAX INVOICE Invoice OR18040302160397 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 Total Amount 7 10 GST 6 0 40 Nett Total 7 10 Payment Mode Amount CASH 7 10 Change 0 00 GST Summary Amount Tax SR GST 6 6 70 0 40 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, 867388 U TAX INVOICE Invoice OR18040902160299 Total Item Qty SR 100100000060 4 Vege 1 5 50 5 50 SR 100100000006 Pork 2 70 1 2 70 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Amount Payment Mode 8 20 CASH 0 00 Change GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U Perindustrian TAX INVOICE Invoice OR18041002160370 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000064 Add Vegetable 0 50 1 0 50 Total Amount 7 60 GST 6 0 43 Nett Total 7 60 Payment Mode Amount CASH 7 60 Change 0 00 ST Summary Amount Tax SR GST 6 7 17 0 43 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U 7 Kawasan Perindustrian TAX INVOICE Invoice OR18041102170437 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A04034 Company No JM0632980 Site 2591 Telephone GST No 77 Receipt Invoice number 60000437782 22 73 litre Pump 02 FuelSave 95 RM 50 00 C 2 200 RM litre Total RM 50 00 Cash RM 50 00 Relief GST C RM 0 00 Total Gross C RM 50 00 Customer Copy Terminal ID 84259112 ID STAN 274961 000000 Entry Mode MSR 1 Card Attendant Tag Card XXXXXXXXX0053 Response 000 APPROVED Attendant MRifan Date Time Num OPT 02 Diesel Petrol RON95 given Relief under Section 56 3 b GST Act Thank you Please come again INVOICE_RECEIPT, PREPAY CHIT NUMBER 57381 THIS IS NOT A RECEIPT A Tax Invoice will be issued upon the completion of the sale transaction Cashier 465 Transaction No 1 494268 Item U Price Qnty Amount PPF P7 1 000 50 50 00 TOTAL AMOUNT CASH RM 50 00 Thank You For Shopping At BHPetromart Customer Service INVOICE_RECEIPT,A04059 cvender LAVENDER CONFECTIONERY BAKERY S B COMPANY NO V TEL GST ID NO 001872379904 TAX INVOICE Qty Descriptions Amount 1 EUROPEAN WALNUT 6 50 T 1 ORANGE PEEL CHOCOLATE 5 80 T 2 TOTAL 12 30 CASH 20 00 CHANGE 7 70 Incl 6 GST 0 70 PRICES INCLUSIVE 6 GST GST Summary Amount Tax T GST 11 60 0 70 Z Zero Rated 0 00 0 00 Sign THANK YOU 1 All sales are final Goods sold are not refundable nor exchangeable 2 Our products contain no added preservatives please consume within a day or keep according to recommendations on packaging 3 For feedback please retain this Tax Invoice Seek store manager assistance OR drop us an email 4 Tax Invoice can only be issued on the purchase date Amendment is not allowed once issued Csh INVOICE_RECEIPT, U Perindustrian TAX INVOICE Invoice OR18041802170465 Item Qty Total SR 100100000031 3 Vege 4 40 1 4 40 SR 00100000064 Add Vegetable 0 60 1 0 60 SR 100100000065 Add Meats 0 90 1 0 90 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 7 00 GST 6 0 40 Nett Total 7 00 Payment Mode Amount CASH 7 00 Change 0 00 GST Summary Amount Tax SR GST 6 6 60 0 40 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A04063 UNIHAKKA INTERNATIONAL SDN BHD U 7 Kawasan Perindustrian TAX INVOICE Invoice OR18041602170486 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000015 Vegetable 1 10 1 1 10 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, Duty Free Zone JB Tel Faxa GST ID 000752517120 TAX INVOICE Invil J100086182 0000000J10000087385 Staff SJ10263 Trans 89282 Date Description Amount X000001720 L01 MINSTON ROUND 3 slo 90 00 270 00 SR Total RM 270 00 Cash 300 00 Change in RM 30 00 No of Qty 3 GST Net Amt GST Amount SR 6 254 72 15 28 270 00 Eligible PVP Ampunt is 270 00005 5OLD ARE NOT REFUNDABLE THANK YOU INVOICE_RECEIPT, TEL CO NO JM0195368 D GST NO 000150511616 TAXINV 003 1565495 Cashier CASHIER3 1 SEAFOOD 23 40 ZRL 1 KENKO BEBOLA IKAN 200G 2 40 SR 1 SILKEN TOFU 300G 1 10 SR 1 VEGETABLES 1 80 ZRL 1 VEGETABLES 5 50 ZRL 1 VEGETABLES 1 30 ZRL 1 VEGETABLES 2 20 ZRL 1 MAS GOOD MELAKA NOODLES 3 20 SR 1 VEGETABLES 4 00 ZRL Item Count 9 SUBTOTAL 44 90 TL RM 44 90 8 GST 0 38 Payment Details CASH 100 00 CASH CHANGE 55 10 003 1565495 CASHIER3 GST Summary Amount RM Tax RM SR 6 6 70 0 38 ZRL O 38 20 0 00 Thank you Please come again butting GOODS SOLD ARE NOT REFUNDABLE INVOICE_RECEIPT, UNIHAKKA INTERNATIONAL U 7 Kawasan Perindustrian TAXINVOICE Invoice OR18041902170358 Item Qty Total SR 100100000030 2 Vege 3 30 1 3 30 SR 100100000169 Veggies 1 30 1 1 30 SR 100100000170 Imported Veggies 1 60 1 1 60 SR 100100000008 Seafood S 3 70 1 3 70 Total Amount 9 90 GST 6 0 56 Nett Total 9 90 Payment Mode Amount CASH 9 90 Change 0 00 GST Summary Amount Tax SR GST 6 934 056 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,TAX INVOICE 194079 DOMINO S PIZZA GST REF NO 001694261248 DOMINO S PIZZA PERMAS JAYA No 12 Jalan Permas Jaya 10 Bandar Baru Permas Jaya 81750 Masai Johor CARRY OUT TIMED Pay By CASH Order 6224 By WEB 30263 Order Time 10 15 18 Date Name MS Pickup Time Qty Menu Desa Coupon Disc Price 1 6 HT TE FPP FREE 12 80 1 6 HT BP WTUE1A E 12 80 21 70 25 60 Total Items Sub Total 25 60 Coupon Discount 21 70 Grand Total 3 90 Payment 5 00 Change Due 01 10 6 GST Included 0 22 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code WBD171560041515 Thank you for visiting Domino s Please Come Again 1 3 0 0 8 8 3 3 3 3 We are compliant to the PDPA Visit terms to view our Personal Data Protection Policy Owned by Dommal Food Services A 1 INVOICE_RECEIPT,A04080 TAX INVOICE DOMINO S PIZZA GST REF NO 001694261248 DOMINO S PIZZA PERMAS JAYA No 12 Jalan Permas Jaya 10 Bandar Baru Permas Jaya 81750 CARRY OUT NOW Pay By CASH Order 5633 By 1036 Order Time 18 Date Name MRS Pickup Time Qty Menu Desa Coupon Disa Price 1 MCWBQ LVD1P PS 3 80 1 REV CAN LVD1P PS 3 50 1 6 HT KC LVD1P PS 14 30 9 20 21 60 Total Items Sub Total 21 60 Coupon Discount 9 20 Grand Total 12 40 Payment 12 50 Change Due 00 10 6 GST Included 0 70 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code CBD111560563307 Thank you for visiting Domino s Please Come Again 1 3 0 0 8 8 8 3 3 3 We are compliant to the PDPA Visit terms to view our Personal Data Protection Policy owned by Dommal Food Services INVOICE_RECEIPT,A04082 TE COFFEE BEAN TEA LEAF M SDN BD Company No No 000384106496 Tax Invoice Qty Descriptions Amount 1 CAFE LATTE S 11 32 T STTL 11 32 6 GST 0 68 1 TOTAL 12 00 CAS 12 00 CANGE 0 00 GST Summary Amount Tax T 6 GST 11 32 0 68 Z Zero Rated 0 00 0 00 PASSION FOR COFFEE TEA SINCE All Bean Points earned from Jan Dec will expire by the following year Scan and provide us your feedback WIFI Password AZMEER SA POS INVOICE_RECEIPT,A04085 De Maximum Thai Express Sdn Bhd 1241045 D PTD 81300 TAX INVOICE NO 8 5664 Date Cashier Unit Price Total RM 1 D15 8 90 8 90 THAI ICE TEA 1 FR01 12 90 12 90 BEL ACAN FRIED RICE Total Amount 21 80 Rounding Adj 0 00 Total Amount 21 80 TOTAL RM 21 80 Type 2 Qty 2 Xposmart WiFiPOS Since INVOICE_RECEIPT, BHD H JLN JEJAKA GST ID 002017394688 SHOPPING HOURS SUN THU HRS 2200 HRS FRI SAT HRS 2300 HRS VALUED CUSTOMER 1170086176 1x 000000811101 2 50SR TAMAGO S DISC 30 1 75 0 75 Sub total 1 75 Total Sales Incl GST 1 75 Total After Adj Incl GST 1 75 CASH 1 80 Item Count 1 Change Amt 0 05 Invoice No 2018041810090010447 GST Summary Amount Tax SR 6 1 65 0 10 Total 1 65 0 10 1009 001 0010447 0306654 PAVITHRA AEON UNIVERSITI TEL THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, BHD H 3RD FLR AEON SC JLN JEJAKA CHERAS GST ID 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2230 HRS FRI SAT 1000 HRS 2300 HRS 1x 000000417969 4 00SR GREEN PEA CHEES 1x 000000418294 3 90SR BIG NUT BREAD 1x 000000418218 2 30SR ONION CHEESE Sub total 10 20 Total Sales Incl GST 10 20 Total After Adj Incl GST 10 20 CASH 10 20 Item Count 3 Change Amt 0 00 Invoice No 201 GST Summary Amount Tax SR 6 9 62 0 58 Total 9 62 0 58 1010 026 0260452 0304271 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, BHD H 3RD FLR JLN GST ID 002017394688 SHOPPING HOURS SUN THU HRS 2230 HRS FRI SAT HRS 2300 HRS 1x 000008204363 14 99SR KIT KAT SHARE B Item promo 9 99 5 00 1x 000001018506 21 10SR BERYLS TTOW 1x 000001057437 18 29SR VH BOX 180G SE Item promo 12 89 5 40 1x 000001057436 18 29SR VH BOX 180G RA Item promo 12 89 5 40 1x 000001011536 31 60SR LINDT DT125 1x 000005914876 9 90SR MILO NUGGETS FU Sub total 98 37 Total Sales Incl GST 98 37 Rounding Adj 0 02 Total After Adj Incl GST 98 35 CASH 100 00 Item Count 6 Change Amt 1 65 Invoice No 201804221080567 GST Summary Amount Tax SR 6 92 80 5 57 Total 92 80 5 57 008 0080567 0307614 TEL THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT,A040 TAX INVOICE DOMINO S PIZZA GST REF NO 0069426248 DOMINO S PIZZA TAMAN UNIVERSITI 30 Jln Kebudayaan 7 Tmn Universiti 8300 Skudai CARRY OUT NOW Pay By CASH Order 8554 By 5586 Order Time 3 Date Name MRS Pickup Time Qty Menu Desa Coupon Diso Price 6 HT KB LSF PSJ 5 60 6 HT KB LSF PSI 5 60 CWAH AOA ADI 4 50 4 80 45 70 Total Items Sub Total 45 70 Coupon Discount 4 80 Grand Total 30 90 Payment 0 00 Change Due 70 0 6 GST Included 75 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code CBD28074085544 Thank you for visiting Domino s Please Come Again 3 0 0 8 8 8 3 3 3 We are compliant to the PDPA Visit terms to view our Personal Data Protection Policy Owned by Dommal Food Services A o INVOICE_RECEIPT,A04111 TAX INVOICE DOMINO S PIZZA GST REF NO 001694261248 DOMINO S PIZZA TAMAN UNIVERSITI 30 Jln Kebudayaan 7 Tmn Universiti 81300 Skudai CARRY OUT NOW Pay By CASH Order 8557 By 5586 Order Time 13 Date Name MS Pickup Time Qty Menu Deso Coupon Disc Price 0 20 1 PLSB R 1 RCD AOA4 ADI 14 50 1 PEP CAN LVDR RGH 3 50 1 PEP CAN LVDR RGH 3 50 1 T B LVDR RGH 7 50 1 9 HT AC LVDR RGH 27 80 17 40 57 00 Total Items Sub Total 57 00 Coupon Discount 17 40 Grand Total 39 60 Payment 40 00 Change Due 00 40 6 GST Included 2 24 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code CBD280740855719 Thank you for visiting Domino s Please Come Again 1 3 0 0 8 8 8 3 3 3 We are compliant to the PDPA Visit terms to view our Personal Data Protection Policy owned by Dommal Food Services sdn Bhd Co No 1 INVOICE_RECEIPT, YHM S117 Second Floor 1 Jalan Desa Tebrau Taman Desa Tebrau 81100 002105827328 TAX INVOICE Order No 1000070 Receipt No 003 1227834 Pax 1 Cashier Cashier Eat In Item Qty U Price Amount Tax FG A00019 2 1 50 3 00 SR Green Tea FG H00027 1 3 80 3 80 SR Chikuwa Tempura FG H00030 1 3 80 3 80 SR Karaage FG Y00133 1 16 80 16 80 SR Otm Spicy Yakiniku Bowl R FG Y00226 1 16 80 16 80 SR Otm Spicy Teri Chicken Bowl R FG Y00229 1 18 80 18 80 SR Otm Tori Katsu Set FG Y00268 1 0 00 0 00 SR Katsu Sauce FG Y00264 1 0 00 0 00 SR Miso Soup FG Y00229 1 18 80 18 80 SR Otm Tori Katsu Set FG Y00267 1 0 00 0 00 SR Taru Taru Sauce FG Y00265 1 0 00 0 00 SR Wakame Soup SubTotal 81 80 Total 81 80 TOTAL MYR 81 80 Total Excluded Tax 77 18 4 62 Payment Details Cash 85 00 Cash Change 3 20 Tax Summary Tax Code Amount MYR Tax MYR SR 6 77 18 4 62 Thank You Please Come Again INVOICE_RECEIPT, T Tel GST ID No 002069884928 TAX INVOICE PS8418042783 S P POS1 Loc PMS Walk In Table 39 Item Qty U Price Disc Amount 404 TEH ICE 1 3 50 0 00 3 50 S 220 KAMPUNG 1 10 00 0 00 10 00 S 101 BUTTER KAYA 1 2 50 0 00 2 50 S 440 SUGARCA ICE 1 2 90 0 00 2 90 S Total Items 4 Sub Total 18 90 Less Discount 0 00 Round 0 00 Total Due GST inc 18 90 Paid Cash 50 00 Change 31 10 S GST 6 17 83 1 07 Please Come Again INVOICE_RECEIPT, BHD H 3RD FLR AEON JLN GST ID 002017394688 SHOPPING HOURS SUN THU HRS 2200 HRS FRI SAT URS 3300 HRS 1x 000001010646 7 74SR 1x 000002336695 38 80SR NIVEA SUN LOTI Sub total 46 54 Total Sales Incl GST 46 54 Rounding Adj 6 01 Total After Adj Incl GST 46 55 CASH 100 00 Item Count i Change Amt 53 45 Invoice No 2018042010090010411 GST Summary Amount To SR 6 43 90 2 64 Total 43 90 2 64 1009 001 0010411 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, BHD H FLR JLN GST ID 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS 1x 000000517515 2 00SR ASSORTED PREMIU 1x 000000810692 2 40SR INDIVIDUAL SUS Sub total 4 40 Total Sales Incl GST 4 40 Total After Adj Incl GST 4 40 CASH 50 50 Item Count 2 Change Amt 46 10 Invoice No 2018041210090260073 GST Summary Amount Tax SR 6 4 15 0 25 Total 4 15 0 25 1009 026 0260073 0900724 AZIZAH UNIVERSITI TEL 1 300 80 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, H Tel Fax Email GST ID No 000902660096 TAX INVOICE Invoice No 01 428985 Date Cashier PJSTAFF5 Sales Persor NOT APPLICABLE Description Qty Price Amount 02353830 2 3 20 6 40 SR Water Oil Tumbler or Jug Bottle 5L Qty 2 Discount 0 00 Total Inclusive GST 6 40 Round Amt 0 00 TOTAL 6 40 Cash Received 100 00 Change 93 60 GST Summary Amount RM Tax RM SR 6 00 6 04 0 36 Goods Sold Are Not Returnable Refundable Thank You Please Come Again INVOICE_RECEIPT,A044 TAX INVOICE DOMINO S PIZZA GST REF NO 0069426248 DOMINO S PIZZA PERMAS JAYA No 2 Jalan Permas Jaya 0 Bandar Baru Permas Jaya 8750 CARRY OUT NOW Pay By CASH Order 763 By 5533 Order Time 7 57 Date Name MS Pickup Time 8 2 Qty Menu Desa Coupon Diso Price 6 HT KB p50C PSI 5 60 8 40 5 60 Total Items Sub Total 5 60 Coupon Discount 8 40 Grand Total 7 20 Payment 0 00 Change Due 02 80 6 GST Included 0 4 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code CBD2756076357 Thank you for visiting Domino s Please Come Again 3 0 0 8 8 8 3 3 3 my We are compliant to the PDPA Visit to view our Personal Data Protection Policy owned by Dommal Food Services A INVOICE_RECEIPT, BHD H 3RD FLR SC JLN JEJAKA CHERAS SHOPPING HOURS SUN THU 1000 HRS 2230 HRS FRI SAT 1000 HRS 2300 HRS VALUED CUSTOMER 1190052101 1x 000008541987 7 00ZR SA MIX PLUM 1x 000002009131 7 50ZR R GALA APPLE 1x 000001058621 9 85SR FOUR SEAS SEAW 1x 000001038556 16 50SR CHEK HUP 2IN1 Item promo 12 99 3 51 1x 000007634147 7 50ZR TOMATO AMOROS 1x 000007570247 12 50ZR FRANCE GREEN KI 1x 000004291008 4 80ZR T CHERRY HONEY 1x 000000135412 15 90SR SUSHI SET PTC 1x 000000381093 4 33ZR JAMBU AIR MADU 1x 000000388658 2 50ZR CUT FRUITS 1 99 1x 000000820868 8 00ZR ZA M N BEAUTY 1x 000000381000 4 61ZR CAVANDISH BANAN 1x 000002003191 10 90ZR BLUEBERRY 1x 000000532075 3 90SR EGG KANI MAYO S 1x 000000512077 3 00SR COLESLAW SANDWI 1x 000008202802 7 50SR WANFA DRIED FIS Sub total 122 78 Total Sales Incl GST 122 78 Rounding Adj 0 02 Total After Adj Incl GST 122 80 CASH 200 00 Item Count 16 Change Amt 77 20 Invoice No 201 GST Summary Amount Tax SR 6 50 13 3 01 ZR 0 69 64 0 00 Total 119 77 3 01 1010 005 0050063 0306651 PJ NUR AYU PERMAS JAYA TEL 1 300 80 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT,Tissue 2 Hand wash Guardian Health And Beauty Sdn Bhd 6498 Company Reg 1101083 T GST Reg 000899874816 RM 121093307 G BX TISSU 4X150 a 6 88 S 2X 6 88 121087265 HK BX TISS P04 A 13 76 S 121095623 GDN CMINT H 12 90 S 121096057 GDN KTCH LILY500ML 6 90 S PWP121096057 2 07 SUBTOTAL 38 37 TOTAL GST INCL 38 37 CASH 40 35 ROUNDING ADJUSTMENTS 0 02 CHANGE DUE 2 00 YOUR SAVINGS FOR TODAY 7 53 GST Rate GST Excl GST Amt S 6 36 20 2 17 a Promo price items Thank You For Shopping At Guardian All Amounts Are in RM Goods sold are non refundable Dispensed medicines sold are not returnable All exchanges and returns including Guardian brand products must be made within 7days with original receipts and product in original condition TaxInv 14072 INVOICE_RECEIPT,Toilet Roll r coffee TF Value U GST Reg No Tel 09 220388 Tax Invoice BTB092080590274 9 05 8 Cashier bt2_nina 2 7 4 KCA TOILET ROLL 3PLY 0R 955522780068 2 50 2 25 00 S SUPER CRWC 36G 5 HAZELNUT 9555037203555 3 90 3 90 S SUPER CRWC 40G 5 CLASSIC 8888240000897 3 90 3 90 S ITEM 3 Total with GST 6 52 80 QTY 4 ROUNDING 0 00 TOTAL 52 80 TENDER Visa App 5836 52 80 CHANGE 0 00 GST Analysis Goods Tax Amount S 6 49 80 3 00 Z 0 0 00 0 00 Thank You See You Again Please Retain Receipt In Case Of Goods Exchange Within 7 Days Of Purchase Except PERISHABLE FROZEN CHILLED ITEMS No Refund Is Allowed INVOICE_RECEIPT,1 1 0 00 3180404 THANK PLEASE VISIT US AGAIN Goods Sold Are Not Refundable Returnable Or Exchangeable ed CHECKERS HYPERMARKET SDN BHD 2945 COMPANY NO 564429 W GST NO TEL Date Time Cashier AZIZAH Cntr Mch No CHJKL 222 Shift No 3 Invoice No 222221980 OFFICIAL RECEIPT 1 SAJI MINYAK MASAK 5KG Z BTL 1 22 90 13 2 91 19 99 TOTAL 19 99 Rounding Adj 0 01 Rounding 20 00 GST INCLUDED 0 00 CASH 20 00 CHANGE 0 00 TOTAL LOADING CHARGES 0 00 No Of Item s 1 GST Summary Amount RM Tax RM ZRL 0 Z 19 99 0 00 INVOICE_RECEIPT,3180404 daff ref BERRY S CAKE HOUSE T GST No 001287233536 No 1 Jln Puteri Careline P Session 11444 User 1 TAX Invoice No 14551 POS 2 Desc Code Qty Price Amount 00014960 RAISIN ALMOND BREAD 1 00 4 55 4 55 00002493 CHEESE ROLL 4 1 00 3 90 3 90 00002479 BUTTER ROLL 4 1 00 2 80 2 80 Total Inclusive of Tax 11 25 Rounding Adjustment 0 00 SubTotal 11 25 RINGGIT M SIA 20 00 Payment 20 00 Change 8 75 Item Count 3 Item Total 3 GST Summary Amount GST GST 0 0 00 0 00 GST 6 10 61 0 64 Receipt Trx No 14551 1582555 All Berry s products are available at Berry s Outlet Only INVOICE_RECEIPT, K GST ld IND JLN TEL TAX INVICE REG C01 KL 001 038354 B W P S A4 A3 S RM1 38 1 No GST TA AMT RM1 30 GST 6 RMO 08 TOTAL RM1 38 ROUNDING RMO 02 CASH RM1 40 TAX INVOICE OF GST GOODS SOLD ARE NOT RETURNABLE INVOICE_RECEIPT, K GST ID 000517095424 42 46 JLN TEL TAX INVOICE REG C01 KL 001 037846 CLR P S A4 A3 S RM5 00 1 No GST TA AMT RM4 72 GST 6 RMO 28 TOTAL RM5 00 CASH RM5 00 TAX INVOICE OF GST GOODS SOLD ARE NOT RETURNABLE INVOICE_RECEIPT,3180404 staff ref GH DISTRIBUTOR MARKETING SDN BHD 1097826 H Tel GST Reg No TAX INVOICE Invoice No 095_01 03124 Date 1 Cashier SOON WAH PRN ON QTY ITEM RM Retail Takeaway 2 TAU SAR PNEAH S 24PCS 12 50 25 00 SR 2 SubTotal 25 00 Net Total 25 0 C 50 00 C GE 25 00 Tax Summary Amc nt Tax SR Inclusive of GST 6 23 58 1 42 THANK YOU PLEASE COME AGAIN Goods Cold Are Non Refundable INVOICE_RECEIPT,customer Jasm 3180404 MENTAL INITIAL SDN BHD 1206674 T GST Reg No 000435761152 Tax Invoice Table 12 Order 152842 Bill V031 551345 Pax s 0 Date Cashier Khong Description Qty J price Total TAX Green Tea 2 x 1 00 2 00 SR Shiro Ramen 1 X 12 80 12 80 SR Sushi 1 80 10 X 1 80 18 00 SR Sushi 2 80 1 X 2 80 2 80 SR Total Excluding GST 35 60 Serv Charge 10 3 56 GST Payable 2 36 Total Inclusive of GST 41 52 Rounding Adj 0 02 TOTAL 41 50 Closed Server Khong VISA 41 50 GST Summary Amount RM Tax RM SR 6 39 16 2 36 Guest Signature Thank you Please Come Again Powered By INVOICE_RECEIPT,3180502 the Roti man bakery 000965911 p Tel GST MC 01 REG C01 Bacon RM4 90 S Walnut Raisin RM8 60 S Dark Rye Bun RM6 90 S 3 No SUBTOTAL RM20 40 CASH RM20 40 TAX INVOICE NO 223894 THANK YOU PLEASE COME AGAIN PRICE INCLSIVE 6 GST INVOICE_RECEIPT,Welcome to the Family FamilyMart Maxincone Resources Sdn Bhd GST ID 000468594688 0020 The Sunnit USJ Tax Invoice 1000000163 POS 02 Staff Desc Amt RM Spritzer M Water 1 51 ea 3 70 S TOTAL 3 70 Cash 10 00 CHANGE 6 30 ITEMS SOLD 1 Tax Code Ant RM GST RM S 6 3 49 0 21 THANK YOU PLEASE COHE AGAIN BE A PART OF OUR FAHILY TODAY FACEBOOK 1 0 0 0 0 0 0 1 6 INVOICE_RECEIPT,Welcome to the Family FamilyMart Maxincome Resources Sdn 8hd D No ID 0023 KLIA2 ARRIVAL Tel No TAX INVOICE POS 04 CSH Staff REKHA Desc Amt RM MarlboroMegaIceBlstBox Logo 2 58 SUB TOTAL Inc GST 18 80 TOTAL 18 80 CASH 50 00 CHANGE 31 20 ITEMS SOLD 2 Tax Code Amt RM Tax RM 6 17 74 1 06 NK YOU PLEASE COME AGAIN PART OF OUR FAMILY TODAY CEBOOK FamilyMartMY INVOICE_RECEIPT,CITY MILK R C VENTURE SDN BHD W GST NO 001557721088 Tax Invoice Order 139358 INV No 539319 Date Cashier City Milk Cashier Description Qty U price Total TAX Banana Milkshake R 1 X 9 50 9 50 SR Total QTY 1 Total Excluding GST 8 96 GST payable 6 0 54 Total Inclusive of GST 9 50 TOTAL 9 50 CASH 10 50 CHANGE 1 00 GST Summary Amount RM Tax RM SR 6 8 96 0 54 Thank You Please Come Again INVOICE_RECEIPT,SIMPLIFIED TAX INVOICE AA PHARMACY SUBANG HEALTHCARE K GST NO 001536708608 B 8 JALAN SS15 4D TEL CASH RECEIPT CS00251915 DATE SALESPERSON C3 TIME CASHIER C3 ITEM QTY U P AMOUNT GST GST 030249 1 14 90 14 90 S BOX 100S SUPER SAFE POWDER FREE NITRIL 03022 1 14 00 14 00 S S SIZE SUPER SAFE LATEX GLOVE POWDER F TOTAL QUANTITY 2 SUB TOTAL 27 27 DISC 0 00 GST 1 64 ROUNDING 0 01 TOTAL 28 90 CASH 28 90 CHANGE 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU S STANDARD RATED Z ZERO RATED GST SUMMARY CODE AMOUNT TAX AMT SR 27 27 6 1 64 TAX TOTAL 1 64 INVOICE_RECEIPT,DIGI TELECOMMUNICATIONS SDN BHD M TAX INVOICE GST Reg Number 001211957248 POS Login ID Store Name DS001 BP009 OSCAR COLOUR LAB TELECOMMUNICATION SDN BHD 523847 W BILL PAYMENT Paid Amount 234 40 Sub Total Amount 234 40 Total Amount 234 40 Credit Card 234 40 Credit Card No XXXX XXXX XXXX 6974 Total Amount Collected 234 40 Customer Name Mobile No Account No 180 7 Customer Copy Thank You Have a nice day 34013001929120171013 INVOICE_RECEIPT,TAX INVOICE H No Reg 000555819008 Cash Sales No CS 19204 Date 1 Max 10 1M staples 2X 14 20 28 40 Total Salec Inclucive GST 6 28 40 CASH 50 00 CHANGE 21 60 GST Summary Amaunt RM Tax RM SR 6 26 79 1 61 Goads sold are not retumable Thank you Please again INVOICE_RECEIPT,SIMPLIFIED TAX INVOICE AA PIARMACY SUBANG HEALTHCARE K GST NO 001536708608 B 8 JALAN SS15 4D TEL CASH RECEIPT CS00224314 DATE SALESPERSON TIME CASHIER C1 ITEM QTY U P AMOUNT GST GST 1394 1 57 00 57 00 S UNIT WAYCARE WOUND DRESSING WATERPROOF 2045179052517 1 5 30 5 30 S BOX 1008 AROS NON WOWEN SWAB ALCOHOL P 9557037001047 1 3 90 3 90 S EACH PAN MATE COTTON BUDS 400TIPS 8896 3 1 70 5 10 S UNIT UNIGLOVES STERILE GAUZE SWAB 10CM 9556250921884 1 6 80 6 80 Z 1 BOX GENTAMICIN CREAM TOTAL QUANTITY 7 SUB TOTAL 74 06 DISC 0 00 GST 4 04 ROUNDING 0 00 TOTAL DEBIT CARD CHANGE 0 00 GOODS SOLD ARE NOT RETURNADLE THANK YOU S STANDARD RATED Z ZERO RATED GST SUMMARY CODE AMOUNT TAX AMT SR 67 26 6 4 04 ZRL 6 80 0 0 00 TAX TOTAL 4 04 INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7721F711 VE0514 Date MAKASSAR FRESH MARKET Azlan 3737 DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 10 8 2 4 26 WHOLEMEAL 2 78 2 4 0 2 5 56 O C UUMBO 2 97 10 7 0 3 8 91 Total 0 supplies 7 61 CR CHOOL 1 0 72 20 0 0 20 14 40 2 40 4 0 0 4 9 60 Total 6 supplies excl GST 24 00 GST 1 44 Total 6 supplies Inc GST 25 44 Total 0 supplies 7 61 Total Payable 33 05 Received above goods in good order condition The recipient of Gardemia s products LS required to make necessary adjustments to its input tax claims on the bosic of the adjustments shown in chis Tax Invorce Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, Tel Fax GSTID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7830F715 VE0514 Date DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 5 0 0 5 10 65 WHOLEMEAL 2 78 5 0 0 5 13 90 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 39 40 CR CHOCLT 0 72 20 2 0 L8 12 96 Total 6 supplies excl GST 12 96 GST 0 78 Total 6 upplies Inc GST 13 74 Total 0 supplies 39 40 Total Payable 53 14 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7730F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Anrt RM O C WHITE 2 13 10 1 0 9 19 17 WHOLEMEAL 2 78 5 0 0 5 13 90 0 C JUMBO 2 97 5 3 0 2 5 94 Total 0 supplies 39 01 CR CHOCL 0 72 0 8 0 8 5 76 TWIG CHOC 1 33 0 9 0 9 11 97 Total 6 supplies excl GST 17 73 GST 1 07 Total 6 supplies Inc GST 18 80 Total 0 supplies 39 01 Total Payable 20 21 E O E Received above goods in good order condition The recipient Gardenia s products is required to moke necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, GARDENL BAKERIES KISSON Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7727F713 VE0514 Date Ridzuan DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 6 3 0 3 6 39 WHOLEMEAL 2 78 6 3 0 3 8 34 0 C JUMBO 2 97 5 3 0 2 5 94 Total 0 supplies 20 67 DELICIA B SCOTCH 3 72 3 0 a 3 11 16 BUN SBILIS 0 84 20 0 0 20 16 80 HAZEL CHOC 6 90 6 0 0 6 41 40 Total 6 supplies excl GST 69 36 GST 4 16 Total 6 supplies Inc GST 73 52 Total 0 supplies 20 67 Total Payable 194 19 E 0 E A Received above goods in good condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7725F714 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM D C WHITE 2 13 5 10 0 5 10 65 WHOLEMEAL 2 78 5 2 0 3 8 34 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 9 57 CR VANILLA 0 72 10 0 0 10 7 20 CR CORN 0 72 10 0 0 10 7 20 Total 6 supplies excl GST 14 40 GST 0 86 Total 6 supplies Inc GST 15 26 Total 0 supplies 9 57 Total Payable 24 83 E 0 E Received above goods un good order condition The recipient of Gardenia s products LS required to make necessary adjustments to its input tax claims on the basto of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7724F717 VI Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 5 3 2 4 26 WHOLEMEAL 2 78 5 2 0 3 8 34 O C JUMBO 2 97 3 3 0 0 0 00 Total 0 supplies 12 60 DELICIA B SCOTCH 3 72 3 1 0 2 7 44 CR CHOCLT 0 72 10 0 0 10 7 20 CR B SCOTCH 0 72 10 9 0 I 0 72 SQ S BERRY 0 84 8 0 0 8 6 72 BUN SBILI 0 84 0 10 0 10 8 40 Total 6 supplies excl GST 13 68 GST 0 82 Total 6 supplies Inc GST 14 50 Total 0 supplies 12 60 Total Payable 27 10 E E O E Received above goods in good oder condition The recipient of Gardenia s products is required to make necessary ady astments to its input tax clauns in the basic or the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER SCOPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7825F713 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Jss Exc D Sale Amt RM O C WHITE 2 13 5 2 0 3 6 39 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 5 2 0 3 8 91 Total 0 supplies 23 64 KAYA ORI 2 40 5 0 0 5 12 00 Total 6 supplies excl GST 12 00 GST 0 72 Total 6 supplies Inc GST 12 72 Total 0 supplies 23 64 Total Payable 36 36 E S O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL SDNI Tel Fax GST ID 00381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7828F715 VE0514 Dote 11909 DD Description U P Iss Exc D Sale Anrt RM O C WHITE 2 13 5 2 0 3 6 39 2 78 5 0 0 5 13 90 0 0 JUMBO 2 97 2 4 U 2 5 94 Total 0 supplies 14 35 DELICIA B SCOTCH 3 72 3 0 0 3 11 16 CR CHOCLT 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 25 56 GST 1 53 Total 6 supplies Inc GST 27 09 Total 0 supplies 14 35 Total Payable 41 44 E O E Received above goods in good order condution The recuptent of Gardenta s products 15 required to make necessary adjustments to its input tox loins on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER SCOPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7824F715 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Anrt RM O C WHITE 2 13 5 x 0 4 8 52 WHOLEMEAL 2 78 5 3 0 2 5 56 0 C JUMBO 2 97 5 L 0 3 8 91 Total 0 supplies 22 99 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 BUN SBILIS 0 84 10 0 0 10 8 40 Total 6 supplies excl GST 15 84 GST 0 95 Total 6 supplies Inc GST 16 79 Total 0 supplies 22 99 Total Payable 39 78 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOME R SCOP INVOICE_RECEIPT,unature TS notrequred ACCOUNT S COPY GARDENIA BAKERIES KL X Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7821F714 14 Date DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 5 2 3 6 39 WHOLEMEAL 2 78 5 o 5 13 90 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 35 14 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 CR CHOCLT 0 72 20 0 0 20 14 40 CR B SCOTCH 0 72 20 a 0 20 14 40 Total 6 supplies excl GST 36 24 GST 2 17 Total 6 supplies Inc GST 38 41 Total 0 supplies 35 14 Total Paydble 73 55 E 0 E Received above goods un good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7819F712 VE0514 Date MAKASSAR FRESH MARKET Ridzuan DD Description U P Iss Exc D Sale Amt RM o c WHITE 2 13 5 3 0 2 4 26 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 27 45 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 CR B SCOTCH 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 21 84 GST 1 31 Total 6 supplies Inc GST 23 15 Total 0 supplies 27 45 Total Payable 50 60 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment_Note CUSTOMER SCOPY INVOICE_RECEIPT, ES KL BHD Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7817F712 VE0514 Date MAKASSAR FRESH MARKET BHD 3737 DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 5 2 0 3 6 39 WHOLEMEAL 2 78 x 1 0 0 0 00 0 0 JUMBO 2 97 4 3 0 1 2 97 Total 0 supplies 9 36 DELICIA B SCOTCH 3 72 0 1 0 1 3 72 CR CORN 0 72 15 7 0 8 5 76 BUN SBILIS 0 84 0 4 0 4 3 36 Total 6 supplies excl GST 1 32 GST 0 07 Total 6 supplies Inc GST 1 39 Total 0 supplies 9 36 Total Payable 7 97 E O E Received above goods in good order condition The recipient of Gandenia s products is required to make necessary adjustments to its input tax clains on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY team INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7806F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM o c WHITE 2 13 12 0 0 12 25 56 WHOLEMEAL 2 78 5 0 0 5 13 90 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 54 31 TWIG CHOC 1 33 10 0 0 10 13 30 Total 6 supplies excl GST 13 30 GST 0 80 Total 6 supplies Inc GST 14 10 Total 0 supplies 54 31 Total Payable 68 41 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claums on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, FRESH TEL TERMINAL 002 CASHIER SV2 FRUITS 24 00 40158 1 24 00 FRUITS 16 00 40158 1 16 00 VOLUME 2 Items Sub Total RM40 00 Rounding Adj RM0 00 Total RM40 00 Payment Type CASH Received Cash RM50 00 Change RM10 00 Thank You Pls Come Again Goods Sold Are Not Returnable PLS VERIFY YOUR BILL BEFORE LEAVING THE godents INVOICE_RECEIPT,GARDENIA BAKERIES X Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7805F712 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM o c WHITE 2 13 5 1 0 4 8 52 WHOLEMEAL 2 78 1 2 a 1 2 78 0 C JUMBO 2 97 3 1 0 2 5 94 Total 0 supplies 11 68 CR B SCOTCH 0 72 10 0 0 10 7 20 Total 6 supplies excl GST 7 20 GST 0 43 Total 6 supplies Inc GST 7 63 Total 0 supplies 11 68 Total Payable 19 31 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7803F712 VE0514 Date MAKASSAR FRESH MARKET Ridzuan DD Description U P Iss Exc D Sale Amt RM o c WHITE 2 13 5 1 0 4 8 52 WHOLEMEAL 2 78 5 2 0 3 8 34 0 C JUMBO 2 97 3 2 0 1 2 97 Total 0 supplies 19 83 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 CR B SCOTCH 0 72 10 0 0 10 7 20 BUN SBILIS 0 84 10 0 0 10 8 40 2 40 3 0 0 3 7 20 Total 6 supplies excl GST 30 24 GST 1 81 Total 6 supplies Inc GST 32 05 Total 0 supplies 19 83 114 Total Payable 51788 E 0 E 5 09 Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, BAKERIES Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7905F713 VE0514 Date DD Description U P Iss Exc D Sale Anrt RM O C WHITE 2 13 7 0 0 7 14 91 WHOLEMEAL 2 78 4 3 0 1 2 78 0 C JUMBO 2 97 2 0 0 2 5 94 Total 0 supplies 23 63 CR VANILLA 0 20 0 0 20 14 40 CR CORN 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 28 80 GST 1 72 Total 6 supplies Inc GST 30 52 Total 0 supplies 23 63 Total Payable 54 15 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER SCO INVOICE_RECEIPT, BAKERIES Tel Fax GST DD TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7903F711 VE0514 Date Azlan 3737 DD Description U P Iss Exc D Sale AmT RM O C WHITE 2 13 0 1 0 1 2 13 WHOLEMEAL 2 78 5 0 0 5 13 90 0 0 JUMBO 2 97 3 o 0 3 8 91 BONZ SAVER 2 97 3 0 0 3 8 91 Total 0 supplies 29 59 CR CHOCLT 0 72 6 6 0 0 0 00 Total 6 supplies excl GST 0 00 GST 0 00 Total 6 supplies Inc GST 0 00 Total 0 supplies 29 59 Total Payable 29 59 E 0 E Received above goods in good order condition The recipient of Gardenia s products 15 required to make necessary adjustments to its input tax clains on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOME R SCOP INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GSTID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7930F713 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Aut RM O C WHITE 2 13 10 0 0 10 21 30 0 C JUMBO 2 97 0 2 0 2 5 94 Total 0 supplies 15 36 CR VANILLA 0 72 0 5 0 5 3 60 CR B SCOTCH 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 10 80 GST 0 64 Total 6 supplies Inc GST 11 44 Total 0 supplies 15 36 Total Payable 26 80 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES X Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7929F714 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Exc D Sale Amt RM O C WHITE 2 13 3 1 0 2 4 26 WHOLEMEAL 2 78 3 2 0 1 2 78 0 C JUMBO 2 97 3 1 0 2 5 94 Total 0 supplies 12 98 DELICIA B SCOTCH 3 72 0 1 0 1 3 72 CR CHOCLT 0 72 20 0 0 20 14 40 MUFFIN C W 1 25 0 9 0 9 11 25 TWG T MISU 1 33 0 10 0 10 13 30 Total 6 supplies excl GST 13 87 GST 0 84 Tntnl 6 supplies Inc GST 14 71 Total 0 supplies 12 98 Total Payable 1 73 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GSTID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7928F713 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM o c WHITE 2 13 4 2 0 2 4 26 WHOLEMEAL 2 78 4 0 0 4 11 12 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 30 23 BUN SBILIS 0 84 20 0 0 20 16 80 Total 6 supplies excl GST 16 80 GST 1 01 Total 6 supplies Inc GST 17 81 Total 0 supplies 30 23 Total Payable 48 04 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7925F716 VE Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 2 0 0 2 5 56 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 23 83 DELICIA B SCOTCH 3 72 3 0 0 3 11 16 CR CHOCLI 0 72 20 0 0 20 14 40 CR B SCOTCH 0 72 0 13 0 13 9 36 SQ S BERRY 0 84 0 5 0 5 4 20 Total 6 supplies excl GST 12 00 GST 0 72 Total 6 supplies Inc GST 12 72 Total 0 supplies 23 83 Total Payable 36 55 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note RE PRINT INVOICE_RECEIPT, W NO TEL FAX GST ID 001371123712 TAX INVOICE Doc No CS00020001 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 17007 65 00 15 50 15 50 1 007 50 ZRL UDANG KERING Total Qty 65 00 1 007 50 Total Sales Excluding GST 1 007 50 Discount 0 00 Total GST 0 00 Rounding 0 00 Total Sales Inclusive of GST 1 007 50 CASH 1 100 00 Change 92 50 GST SUMMARY Tax Code Amt RM Tax RM ZRL 0 1 007 50 0 00 Total 1 007 50 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, W TEL FAX GST ID 001371123712 TAX INVOICE Doc No CS00020648 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 17007 39 00 15 81 15 81 616 59 ZRL UDANG KERING Total Qty 39 00 616 59 Total Sales Excluding GST 616 59 Discount 0 00 Total GST 0 00 Rounding 0 01 Total Sales Inclusive of GST 616 60 1 VISA 616 60 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM ZRL 0 616 59 0 00 Total 616 59 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7919F712 VI Date DD Description U P Iss Exc D Sale Amt RM C WHITE 2 13 6 4 0 2 4 26 WHOLEMEAL 2 78 2 3 0 1 2 78 0 C JUMBO 2 97 0 3 0 3 8 91 Total 0 supplies 7 43 CR VANILLA 0 72 10 0 0 10 7 20 CR CORN 0 72 20 0 0 20 14 40 Q CHOCML 0 84 8 0 0 8 6 72 Total 6 supplies excl GST 28 32 GST 1 69 Total 6 supplies Inc GST 30 01 Total 0 supplies 7 43 Total Payable 22 58 E O E Received above goods in good order lition The recipient of Gardenia s products LS required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7918F715 Date MAKASSAR FRESH MARKET zlan 3737 DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 2 8 6 12 78 WHOLEMEAL 2 78 0 1 0 1 2 78 0 C JUMRO 2 97 2 0 0 2 5 94 Total 0 supplies 9 62 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 CR CHOCLT 0 72 10 0 0 10 7 20 Total 6 supplies excl GST 14 64 GST 0 88 Total 6 supplies Inc GST 15 52 Total 0 supplit 9 62 Total Payable 5 90 E G E Received above goods in good order condition The reciptent of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,signata GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7917F711 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM 0 0 WHITE 2 13 9 2 0 7 14 91 WHOLEMEAL 2 78 6 1 0 5 13 90 0 c JUMBO 2 97 4 3 0 1 2 97 Total 0 supplies 31 78 CR CHOCLT 0 72 20 9 0 11 7 92 Total 6 supplies excl GST 7 92 GST 0 48 Total 6 supplies Inc GST 8 40 Total 0 supplies 31 78 Total Payable 40 18 E D E Received above goods in good order condition The recupient of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7916F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 10 2 0 8 17 04 WHOLEMEAL 2 78 2 2 0 0 0 00 0 C JUMBO 2 97 0 2 0 2 5 94 Total 0 supplies 11 10 DELICIA R BERRY 3 72 0 2 0 2 7 44 Total 6 supplies excl GST 7 44 GST 0 45 Total 6 supplies Inc GST 7 89 Total 0 supplies 11 10 Total Payable 3 21 E D E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax clauns on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7911F714 VI Date MAKASSAN FRESH MARKET DD Description U P Iss Exc 0 Sale Amt O C WHITE 2 13 3 0 1 2 13 WHOLEMEAL 2 78 3 3 0 3 8 34 0 0 JUMBO 2 97 5 0 5 14 85 Total 0 sumplies 25 32 DELICIA B SCOTCH 3 72 2 0 0 2 7 44 CR CHOCLT 0 72 20 0 0 20 14 40 CR B SCOTCH 0 72 20 3 e 17 12 24 SQ S BERRY 0 84 14 0 0 14 11 76 BUN SBILIS 0 84 0 2 0 2 1 68 MUFFIN B W 1 25 0 5 0 5 6 25 Total 6 supplies excl GST 37 91 GST 2 27 Tntnl 6 supplies Inc GST 40 18 Total 0 supplies 25 32 Total Payable 65 50 E O E Received above goods in good order condition The reciptent of Gardenia s products is required to make necessary adjustments to its cinput tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7908F714 V E0514 Date MAKASSAR FRESH MARKET DD Description U P lss Exc D Sale Amt RM O C WHITE 2 13 3 1 0 4 26 WHOLEMEAL 2 78 3 o o 3 8 34 0 C JUMBO 2 97 2 1 0 1 2 97 Total 0 supplies 15 57 CR CHOCLT 0 72 20 10 0 10 7 20 Total 6 supplies excl GST 7 20 GST 0 43 Total 6 supplies Inc GST 7 63 Total 0 supplies 15 57 Total Payable 23 20 E 0 E Received above goods in good order condition The recipient of Gardenta s products 15 required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER SCO INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7030F715 VI Date MAKASSAR FRESH MARKET DD Descr on U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 26 61 DELICIA B SCOTCH 3 72 3 0 0 3 11 16 CR CHOCLT 0 72 20 0 0 20 14 40 BUN SBILIS 0 84 10 0 0 10 8 40 Total 6 supplies excl GST 33 96 GST 2 03 Total 6 supplies Inc GST 35 99 Total 0 supplies 26 61 Total Payable 62 60 E O E Received above goods in good order condition The reciptent of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7020F710 VE0514 Date Azlan 3737 DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 2 2 0 0 0 00 Total 0 supplies 6 39 CR CHOCLT 0 72 15 4 0 11 7 92 Total 6 supplies excl GST 7 92 GST 0 48 Total 6 supplies Inc GST 8 40 Total 0 supplies 6 39 Total Payable 14 79 O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7024F713 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 26 61 CR VANILLA 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 14 40 GST 0 86 Total 6 supplies Inc GST 15 26 Total 0 supplies 26 61 Total Payable 41 87 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7018F712 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 2 0 1 2 78 0 C JUMBO 2 97 4 1 0 3 8 91 Total 0 supplies 18 08 CR CHOCLT 0 72 20 0 0 20 14 40 CR CORN 0 72 0 3 0 3 2 16 Total 6 supplies excl GST 12 24 GST 0 73 Total 6 supplies Inc GST 12 97 Total 0 supplies 18 08 Total Payable 31 05 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, BAKERIES X Tel Fax GST ID 00038 1399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7023F713 VE0514 Date MAKASSAR FRESH MARKET DALAN SS 154B DD Description U P Iss Exc D Sale Amt RM 0 C WHITE 2 13 2 1 0 1 2 13 WHOLENEAL 2 78 2 0 0 2 5 56 BONZ SAVER 2 97 3 0 o 3 8 91 Total 0 supplies 16 60 CR CHOCLT 0 72 20 0 0 20 14 40 BUN SBILIS 0 84 10 1 0 9 7 56 Total 6 supplies excl GST 21 96 GST 1 31 Total 6 supplies Inc GST 23 27 Total 0 supplies 16 60 Total Payable 39 87 E D E Received above goods in good order condition The recipient of Gardemia s products is required to make necessary adjustments to its input tax claums on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7029F711 VI Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 9 0 9 19 17 WHOLEMEAL 2 78 8 2 0 6 16 68 0 C JUMBO 2 97 3 0 0 3 8 91 Total 0 supplies 44 76 TWIG CHOC 1 33 10 0 0 10 13 30 Total 6 supplies excl GST 13 30 GST 0 80 Total 6 supplies Inc GST 14 10 Total 0 supplies 44 76 Total Payable 58 86 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7025F713 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 26 61 CR CHOCLT 0 72 20 9 0 11 7 92 Total 6 supplies excl GST 7 92 GST 0 48 Total 6 supplies Inc GST 8 40 Total 0 supplies 26 61 Total Payable 35 01 Received above goods in good order condition The recipient of Gardenia s products LS required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7022F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 1 0 2 5 56 0 0 JUMBO 2 97 3 5 0 2 5 94 Total 0 supplies 6 01 TWIG CHOC 1 33 20 0 0 20 26 60 Total 6 supplies excl GST 26 60 GST 1 60 Total 6 supplies Inc GST 28 20 Total 0 supplies 6 01 Total Payable 34 21 E O E Received above goods un good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7019F712 VF0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 6 0 0 6 12 78 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 10 0 0 10 29 70 Total 0 supplies 50 82 BUN SBILIS 0 84 20 0 0 20 16 80 Total 6 supplies excl GST 16 80 GST 1 01 Total 6 supplies Inc GST 17 81 Total 0 supplies 50 82 Total Payable 68 63 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, GARDENIA BAKERIES KL Fax03 GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7017F714 VE0514 Date MAKASSAR FRESH MARKET Ridzuan DD Description U P Iss Exc D Sale Amt RH O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 31 4 0 1 2 78 0 C JUMBO 2 97 6 0 0 6 17 82 Total 0 supplies 21 43 CR VANILLA 0 72 20 0 0 20 14 40 CR CORN 0 72 20 0 0 20 14 40 HAZEL CHOC 6 90 8 0 0 8 55 20 Total 6 supplies excl GST 84 00 GST 5 03 Total 6 supplies Inc GST 89 03 Total 0 supplies 21 43 Total Payable 110 46 E O E Received above goods in good order condition The reciptent of Gardenia s products LS required to make necessary adjustments to Lts input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7015F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 4 1 0 3 6 39 WHOLEMEAL 2 78 4 1 0 3 8 34 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 26 61 CR CHOCLT 0 72 0 3 0 3 2 16 CR CORN 0 72 0 1 0 1 0 72 Total 6 supplies excl GST 2 88 GST 0 17 Total 6 supplies Inc GST 3 05 Total 0 supplies 26 61 Total Payable 23 56 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tox claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7014F714 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 1 0 2 4 26 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 3 1 0 2 5 94 Total 0 supplies 18 54 CR B SCOTCH 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 14 40 GST 0 86 Total 6 supplies Inc GST 15 26 Total 0 supplies 18 54 Total Payable 33 80 E D E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER SCOPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7012F715 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 6 0 0 6 12 78 WHOLEMEAL 2 78 2 1 0 1 2 78 0 C JUMBO 2 97 4 0 0 4 11 88 Total 0 supplies 27 44 CR CORN 0 72 20 9 0 20 14 40 CR B SCOTCH 0 72 0 1 0 1 0 72 SQ CHOCMLT 0 84 0 9 0 9 7 56 BUN SBILIS 0 84 20 0 0 20 16 80 SC CLASSIC 1 84 4 0 0 4 7 36 Total 6 supplies excl GST 30 28 GST 1 82 l 6 supplies Inc GST 32 10 Total 0 supplies 27 44 Total Payable 59 54 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7010F714 4 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Ant RM 0 C WHITE 2 13 3 4 0 1 2 13 WHOLEMEAL 2 78 3 3 0 0 0 00 0 C JUMBO 2 97 3 3 0 0 0 00 Total 0 supplies 2 13 DELICIA B SCOTCH 3 72 0 2 0 2 7 44 CR CORN 0 72 20 0 0 20 14 40 SQ CHOCMLT 0 84 12 0 0 12 10 08 TWIG C DRM 1 33 8 0 0 8 10 64 Total 6 supplies excl GST 27 68 GST 1 65 Total 6 supplies Inc GST 29 33 Total 0 supplies 2 13 Total Payable 27 20 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7009F714 VI 1 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 3 0 0 3 6 39 WHOLEMEAL 2 78 3 1 0 2 5 56 0 C JUMBO 2 97 2 0 0 2 5 94 Total 0 supplies 17 89 DELICIA B SCOTCH 3 72 3 0 0 3 11 16 CR CHOCLT 0 72 20 0 0 20 14 40 CR B SCOTCH 0 72 20 0 0 20 14 40 Total 6 supplies excl GST 39 96 GST 2 39 Total 6 supplies Inc GST 42 35 Total 0 supplies 17 89 Total Payable 60 24 E 0 E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7008F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 9 2 0 7 14 91 WHOLEMEAL 2 78 6 2 0 4 11 12 0 C JUMBO 2 97 8 1 0 7 20 79 Total 0 supplies 46 82 CR B SCOTCH 0 72 0 1 6 1 0 72 Total 6 supplies excl GST 0 72 GST 0 04 Total 6 supplies Inc GST 0 76 Total 0 supplies 46 82 Total Payable 46 06 E Received above goods in good order condition ne recipient of Gardenia s products 1S Sequired to make necessary adjustments to its tax claims on the ba ic of the ents shown in this Tax Invoice Note RE PRINT INVOICE_RECEIPT,GARDENIA BAKERIES KI Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7005F711 Date MAKASSAR FRESH MARKET Azlan 3737 DD Description U P Iss Exc D Sale Amt RM 0 C WHITE 2 13 7 0 0 7 14 91 WHOLEMEAL 2 78 2 0 0 2 5 56 0 C JUMBO 2 97 1 0 0 1 2 97 Total 0 supplies 23 44 CR VANILLA 0 72 25 0 0 25 18 00 BUN SBILIS 0 84 10 0 0 10 8 40 Total 6 supplies excl GST 26 40 GST 1 58 Total 6 supplies Inc GST 27 98 Total 0 supplies 23 44 Total Payable 51 42 E 0 E Received alove goods in good order condition The recinient of Gardenia s products is required to make necessary adjustments to its input tox claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT, GARDENIA BAKERIES KL Tel Fax GST ID TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7001F710 VE0514 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 4 1 0 3 6 39 WHOLEMEAL 2 78 5 0 0 5 13 90 0 C JUMBO 2 97 5 0 0 5 14 85 Total 0 supplies 35 14 CR CHOCLT 0 72 0 5 0 5 3 60 Total 6 supplies excl GST 3 60 GST 0 22 Total 6 supplies Inc GST 3 82 Total 0 supplies 35 14 Total Payable 31 32 E O E Received above goods in good order condition The recuptent of Gardenia s products is required to make necessary adjustments to its input tax cloims on the basic of the adjustments showr in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,GARDENIA BAKERIES KL Tel Fax GST ID 000381399040 TAX INVOICE ADJUSTMENT NOTE Cash Inv No 7026F713 Date MAKASSAR FRESH MARKET DD Description U P Iss Exc D Sale Amt RM O C WHITE 2 13 6 0 0 6 12 78 WHOLEMEAL 2 78 3 0 0 3 8 34 0 C JUMBO 2 97 4 1 0 3 8 91 Total 0 supplies 30 03 CR VANILLA 0 72 20 6 0 14 10 08 BUN SBILIS 0 84 0 2 0 2 1 68 KAYA PANDN 2 40 6 0 0 6 14 40 Total 6 supplies excl GST 22 80 GST 1 36 Total 6 supplies Inc GST 24 16 Total 0 supplies 30 03 Total Payable 54 19 E O E Received above goods in good order condition The recipient of Gardenia s products is required to make necessary adjustments to its input tax claims on the basic of the adjustments shown in this Tax Invoice Adjustment Note CUSTOMER S COPY INVOICE_RECEIPT,MR M D LOr 1851 A 18S1 B GST ID No 000306020352 SELAYANG MALL TAX INVOICE MULTI PURPOSE TRAYW HANDLE E 1311 EC S 9555112911610 1 X 5 90 5 90 TRANSPARENT PROTECTOR PY11 S MC22 1 X 2 70 2 70 Item s 2 Qty s 2 TOTAL INCL GST 6 RM 8 60 CASH RM 20 00 CHANGE RM 11 40 GST 6 included in total RM 0 49 06 04 16 SH01 ZJO8 T2 R000593260 OPERATOR SLC EALIL ARASI EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR GST ID No 000473792512 SG WANG SPONGE DISHES 6103 S UH14 21 32 9068739 1 X 3 30 3 30 Item s 1 Qty s 1 Total Incl GST 6 RM 3 30 CASH RM 3 30 GST 6 included in total RM 0 19 17 04 16 14 02 SH01 B019 T3 R000034325 OPERATOR CHC JIVAN EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR KUCHAI GST ID No 000473792512 SG WANG PARTITION 1072 10CM S IC12 4947989310729 1 X 7 30 7 30 TELESCOPIC ROD 2PCS 4065 VS S MD22 1 X 4 80 4 80 CURTAIN BAR 70CM S JD32 100 9063983 3 X 3 10 9 30 D S TAPE 1 8 15M S RH42 88 9080456 1 X 1 50 1 50 Item s 4 Qty s 6 Total Incl GST 6 RM 22 90 CASH RM 23 00 CHANGE RM 0 10 GST 6 included in total RM 1 30 17 04 16 14 01 SH01 B019 T3 R000034324 OPERATOR CHC JIVAN EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,99 S B 519537 X TMN ID NO INVOICE NO 17881 102 T0298 S63094 14 12 16 5422 MI SEDAAP MI GORENG AS RM3 79 s 0155 TWISTIES CHIPSTER ORIG RM2 B5 0954 MISTER POTATO BBQ B RM4 90 S 2 X RM 2 45 5588 EAGLE FRIED DACE WT SA RM13 98 S 2 X RM 6 99 183 PLANTA 2406 RM5 20 507 COKE 1 SL RM5 98 S 2 X RM 2 99 5725 CAP TAKRAW BERAS SUPER RM24 95 Z Total Sales Inclusive GST RM 61 65 CREDIT RM 61 65 CHANGE RM 00 GST Summary Amount RM Tax RM 67 34 62 2 08 Z 07 24 95 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,COSWAY M SDN BHD 50118 A Tel 1000 Fax Email GST REGISTRATION NO 000743903232 TAX INVOICE COSWAY CENTER K074 USER ID K074 ID LEE YEIN INV NO DATE KO74 001096 MTD RC AT K074 111 90 MTD SV GV AT K074 10 56 10 55 MTD QV AT K074 10 56 PRODUCT QTY ICU eV U PRICE TOTAL RM RM 8 089884 2 0 00 26 70 53 40BR B3F1 PMBATHROOM CLEANER 80 8 8R PM BATHROOM CLEANER 8 081118 1 0 00 32 70 32 708R A3F1 PMFLR CLEANER 80 08112 4 0 00 0 00 0 008R PM CONFLOOR CLEANER PINE 8 741698 1 0 00 25 80 25 809R A2F F1 BG MASK 74169 157 7 2 0 00 0 00 0 008R BG HYDRATING SPA MASK 80 74160 1 0 00 0 00 0 008R BG VISIBLY SOFT MIK MASK AMT PAID incl GST RMIT1 90 Aml Paid excl GST RM 105 57 GST AMT RM6 33 PAID BY CC 7186 RMI11 90 TOTAL QTY 15 RC EARNED 3 RP USED 0 RC USED 0 Total SV 10 56 Total GV 10 56 BJF from Inv No RC Balance 0 00 Member Signature V2 82 GST Summary AMT RM TAX RM excl GST SR 6 105 57 6 33 ZR 0 0 00 0 00 EX OS 0 0 00 0 00 TOTAL 105 57 6 33 BUC DE Dr same store within fourteen i4 days from the purchased deste subject to Company s approval IOU Items ITRICT be redeemed within Three 3 monthe from the deste ci Involce Terms E Conditions applied INVOICE_RECEIPT, TEL FAX GST ID NO 001600892928 HQ ADD DATE INVOICE NO 11508705 HERBY PIPA GAO CONCENTRATE TCM 47 70 SR 005820091 2x 26 5000 VIP Disc 10 00 5 30 SUBTOTAL INCL GST 6 00 RM 47 70 ROUNDING ADJ RM 0 00 TOTAL INCL GST 6 00 RM 47 70 TERMINAL PBB VISA 47 70 CHANGE RM 0 00 GST Summary Amount RM Tax RM SR 6 00 45 00 2 70 QTY 2 01 107 MAH THIAM BRANCH M003 PRINT DATE VIP LEE MEI YEIN TOTAL SAVING RM 5 30 THANK YOU PLEASE COME AGAIN GOODS SOLD ARE NOT REFUNDABLE BUT EXCHANGEABLE AT STORE OF PURCHASE WITHIN 7 DAYS WITH ORIGINAL RECEIPT AND PRODUCT IN ORIGINAL CONDITION BUSINESS HOURS VISIT US AT INVOICE_RECEIPT, TEL FAX U GST No 001888309248 TAX INVOICE Inv No 16 073042 DATE 1 9557892102639 IBUPROFEN 400MG 10 3 00 X 3 00 9 00 Z 2 0253K AMOXICAP 500MG CAPSU 2 00 X 6 00 12 00 Z 3 9557892201011 NOFLUX TAB 90MG 10 5 00 X 4 00 19 98 4 9556492002837K FEBRICOL RX 10 2 00 X 2 70 5 40 2 5 9316254866387 VITAMORE EPO 1000MG 2 00 X 68 00 DISC 28 00 108 00 6 9555197602366 NOVA ROSELLE F VIT 1 00 X 28 60 DISC 2 90 25 70 Rounding 0 02 TOTAL 180 10 GST 8 70 PAYMENT TOTAL PAYMENT 180 10 CHANGE 0 00 VISA 180 10 Rate TOTAL GST 6 144 98 8 70 Z 0 26 40 0 00 LEE MEI YEIN Prev Balance 2651 Points Earn 171 Complete FARMASI ALPHA COM GOODS SOLD ARE NOT RETURNABLE Total Sales Inclusive GST 6 INVOICE_RECEIPT, S B 519537 X PUSAT ID NO INVOICE NO 17858 102 21 11 16 5386 STAR BRAND GARBAGE BAG RM31 80 6 X RM 5 30 Total Sales Inclusive GST RM 31 80 CASH RM 50 00 CHANGE RM 18 20 GST Summary Amount RM Tax RM s 6 30 00 1 80 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, S B 519537 PUSAT NO INVOICE NO 17872 102 T0476 05 12 16 GARBAGE BAG RM15 90 3 RM 5 30 Total Sales Inclusive GST RM 15 90 CASH RM 51 00 CHANGE RM 35 10 GST Summary Amount RM Tax RM 6 15 00 90 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,Guardian Health And Beauty Sdn Bhd Tel Company Reg 01101083 T GST Reg 000899874816 RM 2X 2 20 0092000 GDN WATER 500ML 4 40 S PRICE OVERIDE GDN WATER 500ML 1 84 Reason Code 3 SUBTOTAL 2 56 TOTAL GST INCL 2 56 CASH 50 55 ROUNDING ADJUSTMENTS 0 01 CHANGE DUE 48 00 YOUR SAVINGS FOR TODAY 1 84 GST Rate GST Excl GST Amt S 6 2 42 0 14 Thank You For Shopping At Guardian All Amounts Are in RM Goods sold are non refundable All exchanges and returns including Guardian brand products must be made within 7days with original receipts and product in original condition INVOICE_RECEIPT, GST ID NO INVOICE NO 17566 102 T0280 03 02 16 RM82 80 2 06 X RM 13 80 Total Sales Inclusive GST RM 82 80 CREDIT RM 82 80 CHANGE RM 00 GST Summary Amount RM Tax RM Z 82 80 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,OLD ASIA OWN BY CHEF T LG226 LGF 00406865408 TEL 03 7700299 DUPLICATE RECEIPT MC 0 REG YENG LIN 3 02 206 08834 TABLE NO 0 4CT SEAFOOD FRIED PRICE RM3 50 SR FISH HEAD RM 50 SR FISH CAKE RM7 90 SR G CRISPY CHIC RICE RM5 90 SR V GRILL CHIC RICE RM6 50 SR W MELON JUICE RM7 5 50 SR RIBENA RM5 90 SR 2X 90 ICED CHINESE TEA RM3 80 SR 9 No SERV CHG 0 RM8 25 GST TA AMT RM90 75 GST 6 RM5 45 SUBTOTAL RM96 20 CASH RM00 00 YOUR CHANGE RM3 80 TAX INVOICE NO 03970 TAX INVOICE THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,MR M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 SELAYANG MALL TAX INVOICE BASKET W HOOK 9314 S UF31 3 41 6934091453268 1 X 3 50 3 50 TOILET PAPER HOLDER BWJ 2503 S W 18 24 6946208425037 1 X 17 50 17 50 Item s 2 Qty s 2 TOTAL INCL GST 6 RM 21 00 CASH RM 21 00 GST 6 included in total RM 1 19 25 01 16 SH01 ZJ08 T3 R000276342 OPERATOR SLC NOR RUZITA EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000473792512 KEPONG TAX INVOICE TISSUE HOLDER Z 66 VS S MC22 32 9068477 2 X 5 30 10 60 HOOK 1526 S MG12 3 32 36 9068722 2 X 2 30 4 60 PLACEMAT 145 S IF31 9062301 2 X 1 90 3 80 FURNITURE S MAT 2PCS 3243 S MF13 22 3 24 9067630 2 X 2 50 5 00 PARTITION 1072 10CM S IA12 4947989310729 2 X 7 30 14 60 CNY DECO A002 26CM S XE11 22 30 1 X 10 90 10 90 CNY DECO A003 21CM S IE21 60 8711468 1 X 7 90 7 90 FREE CNY RED PACKET S 99292 1 X 0 00 0 00 Item s 8 Qty s 13 TOTAL INCL GST 6 RM 57 40 CASH 100 00 CHANGE RM 42 60 GST 6 included in total RM 3 25 24 01 16 11 SHO1 B003 T1 R000379771 OPERATOR KPC BASHUDEV NEUPANE EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, GST ID NO INVOICE NO 17556 103 24 01 16 RM13 58 5 2 X RM 6 79 Total Sales Inclusive GST RM 13 58 Rounding Adjustment RM 02 Rounding RM 13 60 CASH RM 14 00 CHANGE RM 40 GST Summary Amount RM Tax RM s 6 12 82 76 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,MR M JALAN KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 SELAYANG MALL TAX INVOICE CUSHION 43 43CM S NZ 1 X 14 90 14 90 12610 VS S 1A00 6 96 6934091490607 1 X 5 90 5 90 S S SQUARE STAND SSB0775 A S UK11 5 80 6942008427899 1 X 6 50 6 50 POT HOLDER SQUARE S MC52 10 300 9067846 5 X 2 50 12 50 MOSQUITO RACKET 108 S NA41 2 51 1 X 13 50 13 50 STEMGLASS ST01 9AW 6WGB CG 8ST 9oz S A31 42 8 8992787966728 1 X 24 90 24 90 MOSQUITO RACKET 108 S NA41 2 51 1 X 13 50 13 50 Item s 7 Qty s 9 TOTAL INCL GST 6 RM 64 70 CASH RM 100 00 CHANGE RM 35 30 GST 6 included in total RM 3 66 SH01 ZJ08 T3 R000270508 OPERATOR SLC EALIL ARASI EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND DUPLICATE COPY INVOICE_RECEIPT,Golden Arches Restaurants Sdn 65351 M Level 6 Bangunan TH Damansara Uptown3 No 3 Jalan SS21 Petaling Jaya Selangor GST ID No 000504664064 s 251 Tel No TAX INVOICE MFY Side 1 INV ORD 95 REG 19 QTY ITEM TOTAL 2 VM 15 90 2 M Coke 2 M Fries 1 4 00 2 SundaeChoc 6 40 1 ChocTop 1 90 TakeOut Total incl GST 28 20 Total Rounded 28 20 Cash Tendered 100 00 Change 71 80 TOTAL INCLUDES 6 GST 1 60 Thank You and Please Come Again Customer Service Hotline INVOICE_RECEIPT, GST ID NO INVOICE NO 17714 102 T0382 560197 30 06 16 8019 MARIGOLD HL MILK 1L RM13 58 S 2 X RM 6 79 559 TIGER BEER BOTTLE 660ML RM13 70 S Total Sales Inclusive GST RM 27 28 Rounding Adjustment RM 02 Rounding RM 27 30 CASH RM 27 30 CHANGE RM 00 GST Summary Amount RM Tax RM 6 25 74 1 54 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, Fresh No Tel GST ID 001817907200 Invoice 001 9822 Dine In Date Fresh Signature C 1 RM7 90 1 Milk Sub Total RM7 90 6 GST RM0 47 Rounding RM0 02 Grand Total 18 35 Cash RM10 50 Change RM2 15 Thank You Please visit us at Facebook Fresh 001 001 9822 1 INVOICE_RECEIPT,A PIE THING FOUR QUARTERS SDN BHD 1079369 P No 128G JLN SS21 35 NO 001716617216 TAX INVOICE OrderNo 1106368 Cashier 1 Smores Pie 10 50 SR 1 Chocolate Mint Pie 12 50 SR 1 The Mashacre Soda 20 90 SR SET Chicken Mushroom P SR SET Lemon Lime Soda SR SUBTOTAL 43 90 TOTAL 43 90 Total Excluding GST 41 42 6 GST 2 48 Payment Details CASH 100 00 CASH CHANGE 56 10 001 1105624 GST Summary Amount RM Tax RM SR 6 41 42 2 48 Follow us on Facebook Instagram Twitter apiething INVOICE_RECEIPT, SDN BHD 509213A Tel 1000 Fax STREGISTRATION NO 000212623360 TAX INVOICE eCOSWAY CENTER G091 USERI ID G091 ID VPM185710 INV NO DATE MTD RC AT G091 230 60 MTD eV AT G091 2 10 PRODUCT QTY eV LIPRICE TOTAL RM RM 8 089884 1 0 70 26 70 26 70BR B3F1 PM BATHROÓN 80 0888 4 ER PM BATHROOM CLEANER 8 741698 2 1 40 25 80 51 608R A2F1 BG MASK 80 74147 3 0 00 0 00 0 00ER BG HYDRATING SPA MASK 80 74169 0 00 0 00 0 008R BG VISIBLY SOFT MILK AMT PAID Incl GST RM70 30 Amt Pald excl GST RM 73 87 GST AMT FM4 43 PAID BY CC 7186 RM78 30 TOTAL QTY 10 RC EARMED RP USED 0 RC UGED 0 Total eV 2 10 Total 00 0 BIF from Inv No A W134 by 1 00 QU Balance 0 00 Member Bigneture V2 60 GST Summary AMT RM 5 TAX FR excl GST SR 6 73 87 4 43 ZR 0 0 00 0 00 EX OS 0 0 00 0 00 TOTAL 73 87 4 43 score cen DE or reumed er the tame store within fourteen 14 days from the purchased deste subject to Company s approvel IOU Iteme must be edeemed within Three 3 months from the deste di Invoice Terms Ex Conditions applied INVOICE_RECEIPT, X GST ID NO INVOICE NO RM 1 05 Total Sales Inclusive GST RM 2 10 CASH RM 5 10 CHANGE RM 3 00 GST Summary Amount RM Tax RM 6 1 98 12 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,MR KUCHAI GST ID No SG WANG HANDPHONE STICKER WNY 037 S RC21 1000 4 X 2 80 11 20 DECO STICKER 128 S QF12 1 X 2 10 2 10 Item s 2 Qty s 5 Total Incl GST 6 RM 13 30 CASH RM 13 30 GST 06 included in total RM 0 75 07 06 16 26 SH08 B019 T3 R0000442 OPERATOR SGWT SITI AMINAH EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,SIMPLIFIED TAX INVOICE SIN THYE COMPANY REG NO 00168397 H GST NO 001329332224 TEL FAX MON SAT SUN CASH RECEIPT CS00052997 DATE SALESPERSON 6 TIME USER ITEM QTY U P AMOUNT 813086000911 1 103 77 103 77 KR600 KING S SAFETY SHOES TOTAL QUANTITY 1 SUB TOTAL 103 77 DISC 0 00 TAX 0 00 ROUNDING 0 00 TOTAL 110 00 CASH 110 00 CHANGE 0 00 GST SUMMARY CODE AMOUNT TAX AMT SR 103 77 6 6 23 TAX TOTAL 6 23 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,MR KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000473792512 KEPONG TAX INVOICE STORAGE BOX 70581 S UE21 31 6936136217897 1 X 12 50 12 50 Item s 1 Qty s 1 TOTAL INCL GST 6 RM 12 50 CASH RM 15 00 CHANGE RM 2 50 GST 6 included in total RM 0 71 22 04 16 13 13 SH01 B003 T1 R000406157 OPERATOR KPOC BUDHA PRATAP SING EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, PLATINUM SDN BHD GND FLR Tel GST ID 001151160320 Bill No Take Out Date DoubleCoco Slice 1 RM12 60 Mother s Slices 1 RM13 50 Tiramisu Slice 1 RM12 60 Cheese Slice 1 RM12 60 Grand Total RM 51 30 Bill Inclusive of 6 GST RM2 90 Cash RM51 30 002 1 1 INVOICE_RECEIPT,MR M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 SELAYANG MALL TAX INVOICE BISCUIT CONTAINER 1087S S IE51 3 61 24 8800170 4 X 8 90 35 60 12 COLORS GOLD DUST S 0A13 9044944 1 X 5 90 5 90 HANGER CL45 Y5S S BE32 51 71 9064123 2 X 7 50 15 00 DENTAL FLOSS 2PCS FH01 2Y VS S MG22 9068764 1 X 2 50 2 50 SEAL PLASTIC 18PCS B7 13 8CM 9 8CM V S MH11 2 9068369 1 X 2 90 2 90 CURTAIN BAR 70CM S JD32 100 9063983 2 X 3 10 6 20 Item s 6 Qty s 11 TOTAL INCL GST 6 RM 68 10 CASH RM 100 10 CHANGE RM 32 00 GST 6 included in total RM 3 85 22 04 16 SH01 ZJ08 T3 R000302998 OPERATOR SLC EALIL ARASI EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,Aneka Intertrade Marketing X Wellmart KP2 GST Reg No 001532760064 Tel Fax KPB02201605190117 180g Blueberry 9555039900643 3 05 1 3 05 S SIEW PAK CHOY ikat 7070184 0 94 2 000 3 78 2 ITEM 2 Total with GST 6 6 83 QTY 3 ROUNDING 0 02 TOTAL SAVING 0 00 TOTAL 6 85 TENDER Cash 20 00 CHANGE 13 15 GST Analysis Goods Tax Amount S 6 2 88 0 17 Z 0 3 78 0 00 Consider PTS 6 Please CHECK your BALANCE due and all goods purchased are IN ORDER THANK YOU SEE YOU AGAIN NO REFUND OR EXCHANGE IS ALLOWED INVOICE_RECEIPT,B 519537 NO INVOICE NO 17664 103 T0027 560272 11 05 16 967 ANCHOR SERBUK CUCI 4KG RM18 80 S 2 RM 9 40 886 DOVE CREAM BAR SOAP 100 RM26 50 10 RM 2 65 5551 FERNLEAF FULL CRM MILK RM40 95 S 2267 COLGATE GREAT REGULAR RM15 98 2 RM 7 99 265 LEE KUM KEE SOS TIRAM C RM22 80 3 RM 7 60 193 CHEONG CHAN SOS KARAMEL RM5 09 S 2394 MISTER POTATO CHIPS BB RM7 90 2 RM 3 95 8019 MARIGOLD HL MILK 1L RM12 70 S 2 RM 6 35 706 BINTANG TEPUNG JAGUNG 4 RM1 35 5 2216 NUTELLA FERRERO 9547 NUTRIPLUS CHEESE CHICK RM10 50 S 2 RM 5 25 Total Sales Inclusive GST RM 177 22 Rounding Adjustment RM 02 Rounding RM 177 20 CREDIT RM 177 20 CHANGE RM 00 GST Summary Amount RM Tax RM 6 167 19 10 03 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,MR M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 MUTIARA KOMPLEKS TAX INVOICE TISSUE BOX ZXD 19 S JD22 64 6943612200243 1 X 12 50 12 50 FRUIT PLATE 9 VS S LA31 2 41 2 X 4 50 9 00 Item s 2 Qty s 3 TOTAL INCL GST 6 RM 21 50 CASH RM 51 50 CHANGE RM 30 00 GST 6 included in total RM 1 22 22 05 16 SH01 ZJ19 T2 R000170536 OPERATOR MTRC THARU VIJAY EXCHANGE ARE ALLOWED WITHIN 3 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,Best Denki Malaysia A Lot LG No Best Denki 1 Utama Tel No Opening Hrs Date 2 51 Slip 0020018018 Staff KC Trans 20980 Sold by BD1187 SIMPLIFIED INVOICE Model Price Qty Amount 240201 COMPUTER ACCESSORIES 89 00 1 89 00 S Total RM 89 00 Cash 100 00 Cash 11 00 GST S 6 89 00 5 04 Goods sold are not returnable exchangable Thank you Please come again INVOICE_RECEIPT, Tel GST ID 000926818304 Tax Invoice Date Time INV No 388171 Table Take Away Counter C1 Pax 1 Staff NG XIN YEE Description Tax Unit Price Unit Discount Amount Cod ALACARTE SUSHI 2 80 RM 2 80 2 0 00 RM5 60 SR ALACARTE SUSHI 1 80 RM 1 80 2 0 00 RM3 60 SR Qty 4 Total Excl GST RM9 20 Discount RM0 00 After Discount RM9 20 Service Charge Excl GST RM0 00 GST RMO 55 Item Value Adj RMO 00 Total Sales RM9 75 Tendered RM10 00 Change RM0 25 GST Summary Excl Amount RM Tax RM SR 6 9 20 0 55 Settled at THANK YOU AND PLEASE COME AGAIN INVOICE_RECEIPT,3 Vital fact 3 lark UROKO JAPANESE CUISINE SDN 1023 0191 GST Reg No 001126838272 Bill No 01H 26411 Date Cashier FLOR Table No T03 Qty Description Amount 1 28 00 28 00 SR 1 SET 38 68 SR 38 68 1 6 00 SR 2 GREEN TEA 1 00 2 00 SR 5 Total 74 68 Discount 00 Service Chg 10 00 7 47 GST 4 93 Grand Total 87 08 Rounding Adjustment 202 Net Total 87 10 M GST Summary Amount RM Tax RM SR 6 00 82 15 4 93 INVOICE_RECEIPT,FACE TO FACE NOODLE HOUSE FTOF NOODLE HOUSE U Tel GST ID 001927782400 Date INV No 443181 Table 12 Dine In Counter C1 Staff T Y Description Tax Unit Price Unit Discount Amount Code 711 Omega Half Boiled Egg RM 3 20 1 0 00 RM3 20SR 706 Toasted Bread Homemade Kaya RM 4 30 1 0 00 RM4 30SR 837 Honey Lemon Hot RM 3 90 1 0 00 RM3 90SR 838 Honey Lemon Cold RM 4 20 1 0 00 RM4 20 SR 2022 House Specialty Hot Spicy Pan Mee Dry b RM 8 00 1 0 00 RM8 00SR 2021 House Specialty Hot Spicy Pan Mee Dry a RM 8 00 1 0 00 RM8 00SR Qty 6 Total Amount RM31 60 Discount RM0 00 After Discount RM31 60 Cent Rounding RM0 00 Total Sales RM31 60 Loo GST Summary Excl Amount RM Tax RM SR 6 29 81 1 79 INVOICE_RECEIPT,p 8 02 EIGHT OUNCE COFFEE a EIGHT OUNCE COFFEE CO THE GARDENS MALL The Gardens Mall Mid Valley City No 002063339520 Tax Invoice Invoice No POS022881 Date Transaction by No Description Amt RM Code 1 Hot Chocolate 13 00 SR 1 Cappucino 13 00 SR 1 Caramel Almond Crepe 13 90 SR Total Sales Inclusive 6 GST 3 39 90 Total 39 90 Cash 50 00 Change 10 10 GST Summary Amount Tax SR GST 6 37 64 2 26 Thank You Please Come Again Powered by m INVOICE_RECEIPT,SKCA HARDWARE TIMBER SDN BHD HIT CO REG NO 946207 D Hardward KG DUSUN NANDING TEL FAX e mail website GST ID 001828540416 TAX INVOICE Item s Amt RM Tax 07 ZZ 207 COLEX BLACK BASIC 6724MIX 43 00 ST 06 ZZ 206 COLEX BLACK BASIC 6723MIX 2 X 43 00 86 00 ST BLACK RAIN SHOE 41 08 RAIN S 2928MIX 13 00 ST Total Incl GST 6 142 00 Total 142 00 CASH 152 00 Change 10 00 Total Qty 4 Summary Amt RM Tax RM Si 6 133 96 8 04 THANK YOU PLEASE COME AGAIN GOODS SOLD ARE NOT REFUNDABLE R05934 Cashier CASHIER 01 M001 Shift 01 Version 91 1 15_C INVOICE_RECEIPT,CLTIP H G ANN GIAP TRADING SDN BHD SE NO L TEL FAX Company Reg No 557752 H GST Reg No 000436633600 TAX INVOICE Name CASH IA 1 3 5 LITRE MAX COATING 1 0000 48 00 SR 2 THINNER 1 GALLON 1 0000 18 00 SR Total Sales Inclusive GST 6 66 00 Round Adj 0 00 Final Total 66 00 CASH 66 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 62 26 3 74 INV NO CS 020819 Date AGENT THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, HWA Telephone No GST No Receipt 33037 Date Terminal CW01 Served by Employee Item Price Qty Value Liquid Medicine RM33 90 x1 RM33 90 Items count 1 Total Sales Incl GST 6 RM33 90 Cash Tendered RM100 00 Change RM66 10 Nett of Tax RM31 98 GST 6 RM1 92 SR RM31 98 RM1 92 Standard Rated Tax RM0 00 RM0 00 ZR RM0 00 RM0 00 Zero Rated Tax ZR RM0 00 RM0 00 Thank You INVOICE_RECEIPT, INVOICE NO 18124 S66449 14 08 17 RMB 99 S 2190 SPRING FRESH MINERAL W RM1 40 S 5353 SUMMER GOAT MILK BODY RM3 99 S Total Sales Inclusive GST RM 14 38 Rounding Adjustment RM 02 Rounding RM 14 40 CASH RM 20 00 CHANGE RM 5 60 GSv summary Amount RM Tax RM S 6 13 56 82 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,Guardian Health And Beauty Sdn Bhd 5789 Company Reg 1101083 T GST Reg 000899874816 RM 121066051 500X3 A 13 78 S SUBTOTAL 13 78 TOTAL GST INCL 13 78 CASH 20 00 ROUNDING ADJUSTMENTS 0 02 CHANGE DUE 6 20 YOUR SAVINGS FOR TODAY 3 49 GST Rate GST Excl GST Amt 8 6 13 00 0 78 A Promo price items Thank You For Shopping At Guardian All Amounts Are in RM Goods sold are non refundable All exchanges and returns including Guardian brand products must be made within 7days with original receipts and product in original condition INVOICE_RECEIPT,K STATIONERY OFFICE SUPPLIES TEL I FAX Emall Company Reg No 001260452 W GST Reg No 001506648064 TAX INVOICE Invoice No CSA34539 Date Cashier 1 RM Code NAME CARD 1 x 148 00 148 00 SR Subtotal 148 00 Total Excl of GST 139 62 Total Incl of GST 148 00 Payment 148 00 Change Due 0 00 Total Item a 1 GST Summary Amount RM Tax RM SR 6 139 62 8 38 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,MPH BOOKSTORES SDN BHD GST No 00054252544 MPH Utama Shopping Centre Tel Fax STICKERS OTHER GIFT 3x10 49 31 4 S Total Amount incl GST 31 4 Rounding 0 02 TOTAL 31 45 CASH 50 00 CHANGE 18 55 Z 0 GST 0 00 0 00 S 6 GST 29 69 1 8 ITEMS 3 CASHIER TRAIN2 TRAINEE STAFF INVOICE NO 008558 TRANS 009628 SHF 1 POS 12 O4BFRTL Goods sold are non returnable Exchanges may be made for books only within days from the date of purchase with this receipt Conditions apply Thank You for Shopping at MPH AT ONE UTAMA INVOICE_RECEIPT,BECON STATIONER Becon Enterprise Sdn V Tel GST No 000670859264 Tax Invoice 0017756 Cashier Date Time 1648 Pos No 181 Shift 1 MEMBER PRICE Name YI Point 496 Product Name Code Qty U RM GST Total RM Payment Voucher UEW 6 x72 5 s pack 1011801 5 18 7 30 SR 131 40 CD R MAXELL MX CDR 100 s 1120221 1 92 80 SR 92 80 CD SLEEVE REFILL DATBAO 0B103 VR100 KAYE 1120472 1 8 50 SR 8 50 PUNCHER MAX DP F2BN 1240302 02 1 14 85 SR 14 85 Sub Total 247 55 GST 14 01 Rounding 0 00 Total Include GST 247 55 Cash 300 00 Change 52 45 Customer Saving from RRP 27 30 Price Inclusive of GST6 GST Summary Amount RM Tax RM SR 6 00 233 54 14 01 Thank You for shopping at BECON Goods sold are not exchangabl le refundable INVOICE_RECEIPT,buardian Health And Beauty Sdn Company Reg 1101085 1 651 Reg 000899874816 RM 121062680 100 PLUS 500ML 2 28 S SUBTOTAL 2 28 TUTAL 651 INUL 2 28 CASH 5 00 RUUNDING ABJUSTMENTS 0 02 CHANDE DUE 0 70 651 Rate 651 EXCI 651 Amt S 6 2 15 0 15 Thank You For Shopping At buardian All Amounts Are in RM boods sold are non retundable Dispensed medicines sold are not returnable All exchanges and returns including buardian brand products must be made within days with original receipts and product in original condition INVOICE_RECEIPT,buardian Health And Beauty Sdn 03 60952052 Company Reg 1101085 I 651 Reg 000899874816 RM 121056217 SUUK CR 4 80 S SUBTUTAL 4 80 DISCUUNIABLE 4 80 6 IRX DISC 0 24 Reason 8 SUBTUTAL 4 51 KUUNDING ADJUSTMENTS 0 01 TUTAL 651 INCL 4 50 CASH 4 50 YUUR SAVINGS FUR TUDAY 0 29 651 Rate 651 EXCL 651 Amt CE 6 4 25 0 26 Thank You For Shopping At buardian All Amounts Are in KM boods soid are non retundable Dispensed medicines sold are not returnable All exchanges and returns including Guardian brand products must be made within days with original receipts and Product in original condition 18 INVOICE_RECEIPT,TAX INVOICE Eco Shop Marketing Sdn Bhd GST Reg No 000313901056 Company No 734055 M Lot Wilayah Malaysia INV No BWMC02000047293 CS I BWM0034 STK QTY RM JT5501 CHOPSTICK HOLDER 72 1 65045039 2 33 1 2 33 PLIERS 6 110G 120PCS PELAYAR 74020030 2 33 1 2 33 771 2 MULTI PURPOSE FOOD TONGS 63065005 2 33 3 6 99 LS301 SCALESCRAPER LARGE 360 63165004 2 33 1 2 33 PVC WALL PLUG 4 S 40 10 PLUG 74065001 2 33 1 2 33 Total 7 16 31 Rounding Adj 0 01 Balance Due 16 30 Payment Cash 17 00 Change Cash 0 70 GST Summary SR 6 15 40 0 91 ZR 0 0 00 0 00 Produce Bill for Exchange Within 3 Days No Cash Refund Thank you Please Come Again INVOICE_RECEIPT,AUSOSI De Maximum Thai Express Sdn Bhd D PTD 81300 TAX INVOICE NO 6485 Date Cashier Unit Price Total RM 2 D15 8 90 17 80 THAI ICE TEA 1 FR01 12 90 12 90 BELACAN FRIED RICE Total Amount 30 70 Rounding Adj 0 00 Total Amount 30 70 TOTAL RM 30 70 Type 2 Qty 3 Xposmart WiFiPOS Since 1985 INVOICE_RECEIPT, 867388 U TAX INVOICE Invoice OR18051502160344 Item Qty Total SR 100100000006 Pork 2 70 1 2 70 SR 100100000060 4 Vege 5 50 1 5 50 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 774 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18053002160412 Item Qty Total SR i00100000170 Imported Veggies 1 60 1 1 60 SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 Total Amount 8 70 GST 6 0 49 Nett Total 8 70 Payment Mode Amount CASH 8 70 Change 0 00 GST Summary Amount Tax SR GST 6 8 21 0 49 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, BHD H 3RD FLR JLN CHERAS GST ID 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2230 HRS FRI SAT 1000 HRS 2300 HRS VALUED CUSTOMER 1170008317 1x 000001048211 11 25SR NATUREL PREMIU 1x 000005043675 10 50SR JOY DISHWASHIN 1x 000001427416 45 90SR 303027 COOK KN 6 Off 43 15 2 75 1x 000006783617 4 59ZR CED NATURAL HIM 1x 000007787980 4 90SR BL 5004C 4 GALL 6 Off 4 61 0 29 1x 000004820628 12 15SR KLEENEX FT SOF 1x 000003596418 13 65SR ONWARDS TOM Sub total 99 90 Total Sales Incl GST 99 90 Total After Adj Incl GST 99 90 CASH 100 00 Item Count 7 Change Amt 0 10 Invoice No 2018052710100070177 GST Summary Amount Tax SR 6 89 92 5 39 ZR 0 4 59 0 00 Total 94 51 5 39 007 0070177 0300892 PJ HANIF REGULAR STAMP S 3 BONUS STAMP S 0 TOTAL STAMP S 3 INVOICE_RECEIPT,A05023 BHD 126926 H 3RD FLR SC JLN JEJAKA CHERAS GST ID SHOPPING HOURS SUN THU HRS 2200 HRS FRI SAT HRS 2300 HRS VALUED CUSTOMER 1250016708 1x 000004921851 93 90SR Z TP GIKEN I3 Aeon card DISC 4 69 89 21 1x 000006227678 169 00SR TEFAL COMFORT M Titability Item promo 149 00 20 00 Aeon card DISC 7 45 141 55 1x 000008612854 V 558 00SR A161S545 TEFAL Item promo 259 00 299 00 Aeon card DISC 12 95 246 05 Sub total 476 81 Total Sales Incl GST 476 81 Rounding Adj 0 01 Total After Adj Incl GST 476 80 CASH 500 00 Item Count 3 Change Amt 23 20 Invoice No 201 GST Summary Amount Tax SR 6 449 82 26 99 Total 449 82 26 99 1013 313 3130177 0304023 CST REGULAR STAMP S 14 BONUS STAMP S 0 TOTAL STAMP S 14 Stamps Loyalty Program Product s sold are neither exchangeable nor refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN EXCLUSIVE FOR MEMBERS We Love To Hear Your Feedback Visit www surveymonkey com r CSIS store www surveymonkey com r CSIM mall Share Your Experience Get RM5 Aeon Gift Voucher INVOICE_RECEIPT, U TAX INVOICE Invoice OR18051602160350 Item Qty Total SR 100100000060 4 Vege 5 50 1 5 50 SR 100100000001 Chicken 2 70 1 2 70 Total Amount 8 20 GST 6 0 46 Nett Total 8 20 Payment Mode Amount CASH 8 20 Change 0 00 GST Summary Amount Tax SR GST 6 7 74 0 46 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18051402170467 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000065 Add Meats 0 90 2 1 80 Total Amount 8 90 GST 6 0 50 Nett Total 8 90 Payment Mode Amount CASH 8 90 Change 0 00 GST Summary Amount Tax SR GST 6 8 40 0 50 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, 867388 U TAX INVOICE Invoice OR18050702170462 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000170 Imported Veggies 1 60 1 1 60 Total Amount 8 70 GST 6 0 49 Nett Total 8 70 Payment Mode Amount CASH 8 70 Change 0 00 GST Summary Amount Tax SR GST 6 8 21 0 49 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, 867388 U TAX INVOICE Invoice OR18051002160062 Item Qty Total SR 100100000060 4 Vege 5 50 1 5 50 SR 100100000009 Seafood M 4 80 1 4 80 Total Amount 10 30 GST 6 0 58 Nett Total 10 30 Payment Mode Amount CASH 10 30 Change 0 00 GST Summary Amount Tax SR GST 6 9 72 0 58 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18050902160378 Item Qty Total SR 100100000061 5 Vege 6 60 1 6 60 Total Amount 6 60 GST 6 0 37 Nett Total 6 60 Payment Mode Amount CASH 6 60 Change 0 00 GST Summary Amount Tax SR GST 6 6 23 0 37 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, 81750 JOHOR Tel GST ID No 002069884928 TAX INVOICE PS8418053885 S P POS Loc PMS Walk In Table 27 Item Qty U Price Disc Amount 711 WM TUNA 1 5 00 0 00 5 00 S 224 CANTONESE 1 10 00 0 00 10 00 S 2202 T A KAMPUNG 1 10 40 0 00 10 40 S 301 KOPI HOT 2 2 80 0 00 5 60 S Total Items 4 Sub Total 31 00 Less Discount 0 00 Round 0 00 Total Due GST Inc 31 00 Paid Cash 51 00 Change 20 00 S GST 6 29 24 1 76 Please Come Again INVOICE_RECEIPT, W GST No 001507647488 No Tel Heaven Earth Ayataka Green Tea 1 5L 8888002119454 5 00 1 5 00 S Konnyaku 10g 8888338001119 3 50 2 7 00 S ITEM 2 Total with GST 6 12 00 QTY 3 ROUNDING 0 00 TOTAL SAVING 0 00 TOTAL 12 00 TENDER Cash 50 00 CHANGE 38 00 GST Analysis Goods Tax Amount S 6 11 32 0 68 2 0 0 00 0 00 MEMBER 0000036581 Points Earned 11 Member YUEN Thank You See You Again Customer Care Line 012 70928 INVOICE_RECEIPT, Tmn Tel GST NO Qty Descriptions Amount 1 8 PANDAN KAYA CAKE 55 00 T 2 HOTDOG BUN 5 60 T 1 OTA BOAT 3 50 T 2 SPICY CHICKEN FLOSS 5 80 T 1 DIRTY BREAD 5 80 T 7 TOTAL 75 70 CASH 100 00 CHANGE 24 30 PRICES INCLUSIVE 6 GST Thank you Please come again GST Summary Amount Tax T 6 GST 71 42 4 28 Z Zero Rated 0 00 0 00 1 Goods sold are not refundable or exchangeable 2 Our products contain no added preservatives please keep in fridg Time Csh 109 POS Shf INVOICE_RECEIPT, U TAX INVOICE Invoice OR18052202160306 Total Item Qty SR 100100000035 1 Meat 3 Vege 1 7 10 7 10 SR I00100000171 Meat Dish 3 00 1 3 00 SR 100100000169 Veggies 1 30 1 1 30 Total Amount 1 40 GST 6 0 65 Nett Total 11 40 Payment Mode Amount CASH 11 40 0 00 Change GST Summary Amount Tax SR GST 6 10 75 0 65 GST REG 000656195584 BAR WANG RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,AOS 65351 M Licensee of McDonald s Level 6 Bangunan TH Damansara Uptown3 SS21 GST ID No 000504664064 McDonald s Permas Ja a 096 Tel No TAX INVOICE MFY Side 1 INV 000960100030435 ORD 69 REG 1 QTY ITEM TOTAL 1 L FiletOFish 11 10 I L Coke 1 L Fries Eat In Total incl GST 11 10 Total Rounded 11 10 Cash Tendered 21 10 Change 10 00 TOTAL INCLUDES 6 GST 0 63 Thank You and Please Come Again Guest Relations Center INVOICE_RECEIPT, U TAX INVOICE Invoice OR18052402170329 Item Qty Total SR 100100000025 1 Meat 2 Vege 6 00 1 6 00 SR 00100000170 Imported Veggies 1 60 1 1 60 SR 100100000149 Add Vegetable X 0 80 1 0 80 Total Amount 8 40 GST 6 0 48 Nett Total 8 40 Payment Mode Amount CASH 8 40 Change 0 00 GST Summary Amount Tax SR GST 6 7 92 0 48 GST REG 000656195584 PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18052702160246 Item Qty Total SR 100100000053 Herbal Tea Iced 2 00 1 2 00 SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000170 Imported Veggies 1 60 1 1 60 Total Amount 10 70 GST 6 0 61 Nett Total 10 70 Payment Mode Amount CASH 10 70 Change 0 00 GST Summary Amount Tax SR GST 6 10 09 0 61 GST REG 000656195584 BAR WANG RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A05143 TAX INVOICE DOMINO S PIZZA GST REF NO 001694261248 DOMINO S PIZZA TAMAN UNIVERSITI 30 Jln Kebudayaan 7 Tmn Universiti 81300 Skudai CARRY OUT NOW Pay By CASH Order 1131 By WEB 30503 Order Time Date Name MS Pickup Time Qty Menu Deso Coupon Disa Price 1 6 HT KB WTUE1A I 15 60 8 90 15 60 Total Items Sub Total 15 60 Coupon Discount 8 90 Grand Total 6 70 Payment 50 00 Change Due 43 30 6 GST Included 0 38 SUPPORT OUR SMILE CAMPAIGN Did we smile at you Let us know at and receive a 30 off side item e coupon upon survey submission Survey Code WBE080740082052 Thank you for visiting Domino s Please Come Again 1 3 0 o 8 8 8 3 3 3 We are compliant to the PDPA Visit to view our Personal Data Protectio t Over by 1 INVOICE_RECEIPT,3 1804009 MR D I Y M SON BHD CO REG 860671 D KAWASAN PERINDUSTRIAN GST ID No 000306020352 101 PUCHONG TAX INVOICE ACRYLIC TAPE 18MM 1 5M S UA12 4 X 2 90 11 60 DBL SIDE CLEAR ACRYLIC TAPE VST106C S WA10 8 64 9554100363103 1 X 11 90 11 90 TEST PEN 886A S XG02XA21 9020529 1 X 1 90 1 90 S DRIVER 860 4 6730003 TR S LF31 2 9071681 1 X 3 30 3 30 COL SCREWDRIVER 4 TR S LB31 1 X 2 50 2 50 Item s 5 Qty s 8 Total Incl GST6 RM 31 20 EDC RM 31 20 1116 VISA GST 6 included in total RM 1 77 SH01 ZJ86 T1 OPERATOR TRAINEE EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR M SDN BHD CO REG 860671 D PERINDUSTRIAN GST ID No 000306020352 IOI PUCHONG TAX INVOICE OPENER SS MT 005 S AI31 9064430 1 X 8 80 8 80 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s 2 Qty s 2 Total Incl GST 6 RM 9 00 CASH RM 10 00 CHANGE RM 1 00 GST 6 included in total RM 0 51 11 04 18 SH01 ZJ86 T2 R000116475 OPERATOR IOIT FATIHAH EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, isn Name plh MR M BHD CO REG 860671 D GST ID No 000306020352 IOI PUCHONG TAX INVOICE CAULKING GUN S KE41 51 2 50 1 X 6 30 6 30 S B HEAVY DUTY SCOURPAD 5S B315 S WA10 9555559040027 2 X 2 50 5 00 VIP HANDLE DUSTPAN 370 2 5 S WA12 9555221303467 1 X 3 90 3 90 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s 4 Qty s 5 Total Incl GST 6 RM 15 40 CASH RM 15 40 GST 6 included in total RM 0 87 SH01 ZJ86 T1 R000118079 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND 7 DAV NTTU DICLIDIT INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A B KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX 10Y CBD4110 S WA29 20 9553114461423 1 X 25 90 25 90 SPONGE S MAGIC 4S S GB06 24 288 9064350 1 X 0 90 0 90 SPONGE MESH F004 4S S BD52 10 100 6928794601200 1 X 2 30 2 30 COLANDER RM20202 S BQ21 31 2 144 6926292505723 1 X 5 50 5 50 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s 5 Qty s 5 Total Incl GST 6 RM 34 80 CASH RM 100 00 CHANGE RM 65 20 GST 6 included in total RM 1 97 04 18 SH01 ZJ86 T1 R000118085 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX CBD4110 S WA29 20 9553114461423 1 X 25 90 25 90 SPONGE S MAGIC 4S S GB06 24 288 9064350 1 X 0 90 0 90 SPONGE MESH F004 4S S BD52 10 100 6928794601200 1 X 2 30 2 30 COLANDER RM20202 S BQ21 31 2 12 144 6926292505723 1 X 5 50 5 50 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s 5 Qty s 5 Total Incl GST 6 RM 34 80 CASH RM 100 00 CHANGE RM 65 20 GST 6 included in total RM 1 97 19 04 18 SH01 ZJ86 T1 R000118085 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE RUBBER BOOTS P 968BK SIZE8 BLACK S WA60 9555590501204 1 X 9 90 9 90 SEKOPLAS H D GARBAGE 89c m 117cm 10s S WA57 16 9557002081113 4 X 9 50 38 00 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s 3 Qty s 6 Total Incl GST 6 RM 48 10 CASH RM 50 20 CHANGE RM 2 10 GST 6 included in total RM 2 72 25 04 18 SH01 ZJ86 T1 R000119242 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, MR M SDN BHD CO REG 860671 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE BRUSH 1 5 628 S KE51 9071503 1 X 2 10 2 10 Item s 1 Qty s 1 Total Incl GST 6 RM 2 10 CASH RM 2 10 GST 6 included in total RM 0 12 26 04 18 SH01 ZJ86 T2 R000120516 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND SULU ARE NUT INVOICE_RECEIPT, MR M SDN BHD CO REG 860671 D LOT A B KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 IOI PUCHONG TAX INVOICE SEKOPLAS H D GARBAGE 89cm 117cm 10s S WA57 16 9557002081113 4 X 9 50 38 00 Item s 1 Qty s 4 Total Incl GST 6 RM 38 00 CASH RM 50 00 CHANGE RM 12 00 GST 6 included in total RM 2 15 27 04 18 SH01 ZJ86 T2 R000120718 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, M BHD 126926 H FLR JLN JEJAKA CHERAS GST ID 002017394688 SHOPPING HOURS SUN THU 1000 HRS 2200 HRS FRI SAT 1000 HRS 2300 HRS 7 rand 1x 000006142384 viun MUNCHY S CREAM 3x 000005709410 18 60SR TOPVALU BESTPRI 6 20 Sub total Total Sales Incl GST 26 11 Rounding Adj 0 01 Total After Adj Incl GST 26 10 CASH 50 00 Item Count 4 Change Amt 23 90 Invoice No 2018042810080010325 GST Summary Amount Tax SR 6 24 63 1 48 Total 24 63 1 48 1008 001 0010325 0 BALOO 1 300 80 2366 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, 3 1804058 MR D I Y M SDN BHD CO REG 860671 D A KAWASAN PERINDUSTRIAN GST ID No 000306020352 IOI PUCHONG TAX INVOICE ALUMINIUM FOIL 25SQ 30CM 7 62M S BJ41 2 52 24 9069295 1 X 5 50 5 50 SEKOPLAS H D GARBAGE 89c 117cm 10s WA58 16 9557002081113 5 X 9 50 47 50 PLASTIC BAGS S 99999 1 X 0 20 0 20 Item s s Total Incl GST 6 RM 53 20 CASH RM 100 20 CHANGE RM 47 00 GST 6 included in total RM 3 01 28 04 18 40 SH01 ZJ86 T3 R000064333 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,x 31 804005 muns indumy 06 ejeny MR D I Y M SDN BHD CO REG 860671 D A GST ID No 000306020352 IOI PUCHONG TAX INVOICE LAVA FOOD CONTAINER FC202 500ml S WA26 9555047302026 1 X 1 80 1 80 LAVA CANISTER CST7700 530ml S WA33 9555047301890 2 X 1 60 3 20 Item s 2 Qty s 3 Total Incl GST 6 RM 5 00 CASH RM 50 00 CHANGE RM 45 00 GST 6 included in total RM 0 28 30 04 18 SH01 ZJ86 T2 R000121653 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, GST NO INVOICE NO 0857 INDOCAFE COFFEEMIX 31N RM29 95 5 407 CADBURY CHOCOLATE HAZEL RM7 49 s Total Sales Inclusive GST RM 37 44 Rounding Adjustment RM 01 Rounding RM 37 45 CREDIT RH 37 45 CHANGE RM 00 GST Summary Amount RM Tax RM s 6 35 32 2 12 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,ENW Hardware Centre M Sdn A GST Reg No 000155453440 No G3 Blk G JIn PJU 1A 3 TEL Tax Invoice No CS00233394 Cash Sale Ara D sara Tel 6929 H P 012 659 9829 Item Qty U Price RM 001697 5 00 1 00 5 00 SR S10 Starter 766271 1 00 22 00 22 00 SR 1L 6627 Seamaster Super Glo Total Amt Incl GST 6 27 00 Rounding Adjusment 0 00 Total Amt Payable 27 00 Total Qty Tender 6 GST Summary Amount RM GST RM SR 6 25 47 1 53 POINT 0 00 Goods sold are not returnable Thank you for shopping at ENW Hardware Centre M Sdn shd buy partin INVOICE_RECEIPT,ENW Hardware Centre M A GST Reg No 000155453440 No G3 Blk G JIn PJU 1A 3 TEL 9829 Tax Invoice No CS00233521 Cash Sale Ara D sara Tel 6929 H P 012 659 9829 Item Qty U Price RM VEWT5 1 00 99 00 99 00 SR 5L T Nippon Vinilex EasyWash NP N 1882T 000605 100 30 00 30 00 SR Cristin 4 Blue Stripe Roller Refill 002882 1 00 3 50 3 50 SR 1 Nylon Paint Brush 001065 1 00 2 50 2 50 SR 4 X 24 Roller Handle 001741 1 00 21 00 21 00 SR Clipsal 4g 1w Switch Total Amt Incl GST 6 156 00 Rounding Adjusment 0 00 Total Amt Payable 156 00 Total Qty Tender 5 GST Summary Amount RM GST RM SR 6 147 17 8 83 POIN 0 00 Goods sold are not returnable Thank you for shopping at ENW Hardware Centre M Sdn Bhd buy paird INVOICE_RECEIPT,ENW Hardwal e Centre M A GST Reg No 000155453440 No G3 Blk G JIn PJU 1A 3 TEL 9829 Tax Invoice I No CS00232967 Cash Sale Ara D sara Tel H P 9829 Item Qty U Price 001781 i 00 16 00 16 00 SR Big Cotton Mop 500g 002115 1 00 1 00 1 00 SR Cement WS150 1 00 25 00 25 00 SR 320ml WoodSheer Mahagany 150 102193 1 00 9 00 9 00 SR Broom 908 Total Amt incl GST 6 51 00 Rounding Adjusment 0 00 Total Amt Payable 51 00 Total Qty Tender 4 GST Summary Amount RM GST RM SR 6 48 10 2 90 POINT 0 00 Goods sold are not returnable Thank you for shopping at ENW Hardware Centre M buy First aid INVOICE_RECEIPT,MR M KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 TESCO EXTRA ARA DAMANSARA TAX INVOICE SUS304 HOOK 48804 S TZ11 9073805 1 X 9 90 9 90 WOODEN SHEET 60 20CM S AR11 9064189 4 X 1 90 LAVA PAIL PL623 3 GALLON S WA53 9555047308370 1 X 5 50 5 50 Item s 3 Qty s 6 TOTAL INCL GST 6 RM 23 00 CASH RM 50 00 CHANGE RM 27 00 GST Summary Amt RM Tax RM GST S 6 21 70 1 30 27 04 18 40 SH01 ZJ42 T1 R000235438 OPERATOR EXCHANGE ARE ALLOWED WITHIN 7 DAY WITH RECEIPT buy Wooden sheet STRIQTLY NO CASH REFUND INVOICE_RECEIPT,KFA SUPPLY ROC SA0416111 K GST No 002126950400 TAX INVOICE Bill No CS0032277 Date Cashier CT001 0001 Item Qty Price Amount STAR 74CM x79CM 10KEPING 9555794100234 1 11 60 11 60 SR Qty 1 Total RM 11 60 CASH 12 00 Change 0 40 GST Summary Amount Tax SR 6 10 94 0 66 Total 10 94 0 66 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, U TAX INVOICE Invoice OR18051302170332 Item Qty Total SR 100100000037 1 Fish 3 Vege 8 10 1 8 10 SR I00100000064 Add Vegetable 0 60 1 0 60 Total Amount 8 70 GST 6 0 49 Nett Total 8 70 Payment Mode Amount CASH 8 70 Change 0 00 GST Summary Amount Tax SR GST 6 8 21 0 49 GST REG 000656195584 BAR RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,Aastry AMPHAWA THAI TEA CO Dimiliki oleh T PLUS F B TEL TELEPHONE FAX FAX GST ID TAX INVOICE Order No 197 UFO 0 Receipt CSPD029197 Staff TAKE AWAY Date Cashier Time Description Qty Price Amt Tax M03 THAI MILK TEA CHA 1 8 90 8 90 SR YEN Total 1 Total Sales Excluding GST 8 90 Discount 0 00 Service Charge 0 00 Total GST 0 53 Rounding 0 02 Total Sales Inclusive of GST 9 45 CASH 10 00 CHANGE 0 55 GST SUMMARY Tax Code Amt RM Tax RM SR 6 8 90 0 53 Total 8 90 0 53 indicated this tax code belong to service charges GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, U TAX INVOICE Invoice OR18050502160248 Item Qty Total SR 100100000035 1 Meat 3 Vege 7 10 1 7 10 SR 100100000170 Imported Veggies 1 60 1 1 60 SR 100100000099 Coke 2 50 1 2 50 Total Amount 11 20 GST 6 0 63 Nett Total 11 20 Payment Mode Amount CASH 11 20 Change 0 00 GST Summary Amount Tax SR GST 6 10 57 0 63 GST REG 000656195584 BAR WANG RICE PERMAS JAYA Price Inclusive Of GST Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A05111 SIZZLING STONEGRILL Dimiliki Oleh Dove Holdings GST ID 0013 7941 8112 TAX INVOICE NO 15 80292 Date Cashier c001 Tax Qty Code Desc Unit Price Total RM SR 2 6 10 12 20 07 CREAM OF MUSHROOM SOUP SR 1 12 90 12 90 101 NOODLE SOUP O T ROCK SR 1 14 90 14 90 107 SPICY T S SPAGHETTI SR 2 34 90 69 80 40 SIRLOIN STEAK SR 1 19 90 19 90 51 GRILLED MARINATED SR 1 18 90 18 90 54 GRILLED CHICKEN CHOP SR 1 6 90 6 90 99 ICED LEMON TEA Total Amount 155 50 GST 6 9 31 Rounding Adj 0 01 Total Amount 164 80 TOTAL RM 164 80 Type 7 Qty 9 GST Summary Amount RM TAX RM SR 6 155 50 9 31 ZR 0 0 00 0 00 Xposmart WiFiPOS Since INVOICE_RECEIPT, No 35 Kebudayaan 8 Taman University Tel OUTLET J18 TAMAN UNIVERSITY TAX INVOICE GST ID 000801587200 2 COUNTER1 2003 RAJAN Check 24382 Cover 2 Table 20 1 Dine In 1 ST15 10 28 S 1 DN3 Dry Curry EN S 1 TF16 H Soya Milk S 1 LB2 Spring Roll Bkt 5 19 S 1 FS2 Org Yog Smot 8 96 S Sub Total 24 43 10 Srv Chg 2 45 GST 6 1 61 Total 28 49 Rounding 0 01 Total 28 50 Paid 50 00 CASH 50 00 Change Due 21 50 INCLUSIVE 0 00 4004 CLOSED THANK YOU PLEASE COME AGAIN GST 6 included in total GSTSummary Amount RM GST RM S GST 6 26 88 1 61 Z GST O 0 00 0 00 INVOICE_RECEIPT, Tax Invoice TABLE T10 Pax 1 OP RAO RUBY POS Title POS001 POS POS001 Rcpt A18000010451 1 ICE MOCHA RM 12 99 SUBTOTAL RM 12 99 Svr Chrg 10 RM 1 30 GST 6 RM 0 86 TOTAL RM 15 15 Total item 1 Total Qty 1 CASH RM 100 15 Change RM 85 00 Closed Bill TEL INVOICE_RECEIPT, Tel GST ID 0016 6993 5104 TAX INVOICE NO 47 66346 Date PAX NO 1 Cashier c002 Qty Code Desc Total RM 1 BUTA SHOGA YAKI SET 19 90 1 ICED GREEN TEA 1 00 Serv Charge 10 2 09 GST 6 138 Rounding Adj 0 03 Total Amount 24 40 TOTAL RM 24 40 Type 2 Qty 2 CASH 30 40 Change RM 6 00 GST Summary Amount RM TAX RM SR 6 22 99 1 38 Thank You Please Come INVOICE_RECEIPT, PROMO 1994 Gerbang Alaf Restaurants Bhd 65351 M Licensee of McDonald s Level 6 Bangunan TH Damansara Uptown3 No 3 SS21 39 47400 GST ID No 000504664064 McDonald s BHP 328 Tel No TAX INVOICE MFY Side 1 INV 003281900047036 ORD 94 REG 19 QTY ITEM TOTAL 1 Nasi McD AGSpi Telur Set 14 95 1 Nasi McD AGSpi Telur XTRA Sambal 1 00 1 M IceLemonTea 1 L Nasi Lemak Burger 18 55 1 L Fries 1 L 100Plus 2 Nasi McD AGSpi Set 25 90 2 M IceLemonTea 1 AyamGrgSpicy TA 9 90 1 4Nuggets 1P 0 00 1 French Cheese Sauce Takanut Total incl GST 70 30 Cas indered 70 30 Change 0 00 TOTAL INCLUDES 6 GST 3 98 Thank You and Please Come Again Guest Relations Center INVOICE_RECEIPT, W TEL GST ID 1805213696 SIMPLIFIED TAX INVOICE CASH Doc No CS172418 Date Cashier USER Time 12 40 Salesperson Ref Item Qty S Price Amount Tax 1264 1 25 25 SR NON WOWEN 3 PLY FACE MASK EAR LOOP 50 S Total Qty 1 25 Total Sales Excluding GST 23 58 Discount 0 Total GST 1 42 Rounding 0 Total Sales Inclusive of GST 25 CASH 50 Change 25 GST SUMMARY Tax Code Amt RM Tax RM SR 6 23 58 1 42 Total 23 58 1 42 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,SWC ENTERPRISE SDN BHD U GST ID 002017808384 Tax Invoice No 0051808219001118 005001 BATANGKALI 1 118 001 OPEN CODE S ITEM 0025679 U 2x11 80 23 60 S 0025679 U 2x8 80 17 60 S Item 2 SubTotal Incl GST 41 20 Qty 4 Spec Disc 0 00 Saving 0 00 Rounding 0 00 Total 41 20 Cash 512 00 Change 470 80 GST Summary Amount RM Tax RM S 6 38 86 2 34 OODS SOLD ONLY EXCHANGEABLE WITHIN 3 DAYS GOODS SOLD ARE NOT REFUNDABLE THANK YOU FOR YOUR KIND SUPPORT PLEASE COME AGAIN INVOICE_RECEIPT,ANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 THERMAL ROLL BLUE 57MMx6OMM12MM 10ROLL PKT 1 X 35 0000 35 00 SR Total Sales Inclusive 051 6 35 00 Discount 0 00 Total 35 00 Round Adj 0 00 Final Total 35 00 CASH 40 00 CHANGE 5 00 GST Summary Amount RM Tax RM SR 6 33 02 1 98 INV NO CS SA 0086229 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 PUNCH CARD WITH HOLE 1 X 11 9000 11 90 SR 2 WORKER S CARD 1 15 100 S WOC 115 1 X 3 0000 3 00 SR Total Sales Inclusive GST 6 14 90 Discount 0 00 Total 14 90 Round Adj 0 00 Final Total 14 90 CASH 20 00 CHANGE 5 10 GST Summary Amount RM Tax RM SR 6 14 06 0 84 INV NO CS SA 0108558 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SON BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Ad 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM x RM SR 6 8 21 0 49 INV NO CS SA 0077188 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0079030 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYU ISTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2002 0001 LAMINATING FILM A4 SIZE 220MMx310MM 1 X 3 0000 3 00 SR Total Sales Inclusive GST 6 3 00 Discount 0 00 Total 3 00 Round Ack 0 00 Final Total 3 00 CASH 20 00 CHANGE 17 00 GST Summary Amount RM Tax RM SR 6 2 83 0 17 INV NO CS SA 0078908 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,STATIONERYSHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SUPPLY SON BHD 1135772 K CASH SALES COUNTER THERMAL ROLL BLUE 57MMx60MMx12MM 10ROLL PKT 1 X 35 0000 35 00 SR 2 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 43 70 Discount 0 00 Total 43 70 Round Adj 0 00 Final Total 43 70 CASH 50 00 CHANGE 6 30 GST Summary Amount RM Tax RM SR 6 41 23 2 47 INV NO CS SA 0082716 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 4X 2 9000 11 60 SR 2 CASH BOOK 80PGS A4 70GSM CARD COVER SCB 4012 1 X 3 3000 3 30 SR Total Sales Inclusive GST 6 14 90 Discount 0 00 Total 14 90 Round Adj 0 00 Final Total 14 90 CASH 20 00 CHANGE 5 10 GST Summary Amount RM Tax RM SR 6 14 06 0 84 INV NO CS SA 0075638 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,STATIONERYSHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 MAX STAPLE 10 1M 2 X 1 0000 2 00 SR Total Sales Inclusive GST 6 2 00 Discount 0 00 Total 2 00 Round Adj 0 00 Final Total 2 00 CASH 2 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 6 1 89 0 11 INV NO CS SA 0093978 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 MAX STAPLE 10 1M 3X 1 0000 3 00 SR Total Sales Inclusive GST 6 3 00 Discount 0 00 Total 3 00 Round Adj 0 00 Final Total 3 00 CASH 3 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 6 2 83 0 17 INV NO CS SA 0103617 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGi PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,CANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 2X 2 9000 5 80 SR Total Sales Inclusive GST 6 5 80 Discount 0 00 Total 5 80 Round Adj 0 00 Final Total 5 80 CASH 6 00 CHANGE 0 20 GST Summary Amount RM Tax RM SR 6 5 47 0 33 INV NO CS SA 0086778 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 2X 2 9000 5 80 SR Total Sales Inclusive GST 6 5 80 Discount 0 00 Total 5 80 Round Adj 0 00 Final Total 5 80 CASH 6 00 CHANGE 0 20 GST Suary Aount RM Tax RM SR 6 5 47 0 33 INV NO CS SA 0098805 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,AANYUSTATIONERY Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 THERMAL ROLL BLUE 57MMx60MMx12MM 10ROLL PKT 1 X 36 0000 36 00 SR Total Sales Inclusive GST 6 36 00 Discount 0 00 Total 36 00 Round Adj 0 00 Final Total 36 00 CASH 50 00 CHANGE 14 00 GST Summary Amount RM Tax RM SR 6 33 96 2 04 INV NO CS SA 0130363 Date Total Qty 1 Print Time F Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 JOURNAL BOOK 80PGS A4 70G CARD COVER SJB 4013 1 X 3 9000 3 90 SR Total Sales Inclusive GST 6 3 90 Discount 0 00 Total 3 90 Round Adj 0 00 Final Total 3 90 CASH 10 00 CHANGE 6 10 GST Summary Amount RM Tax RM SR 6 3 68 0 22 INV NO CS SA 0121215 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,ANYUSTATIONERY SHOP NO Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2022 0124 DEFLECT O 120 X 55MM L SHAPE TAG HOLDER LANDSCAPE DDKRL 120X55 5 X 2 2000 11 00 SR 2 2020 0231 7 POP MOBILE STAND M 1755 5 X 4 5000 22 50 SR Total Sales Inclusive GST 6 33 50 Discount 0 00 Total 33 50 Round Adj 0 00 Final Total 33 50 CASH 50 00 CHANGE 16 50 GST Summary Amount RM Tax RM SR 6 31 60 1 90 INV NO CS SA 0121370 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 MAX STAPLE 10 1M 2X 1 0000 2 00 SR Total Sales Inclusive GST 6 2 00 Discount 0 00 Total 2 00 Round Adj 0 00 Final Total 2 00 CASH 2 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 6 1 89 0 11 INV NO CS SA 0122858 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 BILL BOOK 5 x8 BB 5882 1 X 3 5000 3 50 SR 2 RESTAURANT ORDER CHIT NCR 3 5 x6 2 X 2 9000 5 80 SR Total Sales Inclusive GST 6 9 30 Discount 0 00 Total 9 30 Round Adj 0 00 Final Total 9 30 CASH 50 00 CHANGE 40 70 GST Summary Amount RM Tax RM SR 6 8 77 0 53 INV NO CS SA 0125293 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,STATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SUPPLY SON BHD 1135772 K CASH SALES COUNTER 1 5000 0001 PHOTOCOPY SERVICES A 4 SIZE 100 X 0 1000 10 00 SR 2 9100 0007 CUTTING CHARGES 1 X 2 0000 2 00 SR Total Sales Inclusive GST 6 12 00 Discount 0 00 Total 12 00 Round Adj 0 00 Final Total 12 00 CASH 15 00 CHANGE 3 00 GST Summary Amount RM Tax RM SR 6 11 32 0 68 INV NO CS SA 0112280 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3X2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0118810 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook 1 INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 ARTLINE 500A W BOARD MARKER BLACK 1 X 3 7000 3 70 SR 2 RESTAURANT ORDER CHIT NOR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 12 40 Discount 0 00 Total 12 40 Round Adj 0 00 Final Total 12 40 CASH 15 00 CHANGE 2 60 GST Summary Amount RM Tax RM SR 6 11 70 0 70 INV NO CS SA 0111837 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3X2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0108918 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVEOR INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0120436 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0122588 Date Kamter Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AC IN TERIMA KASIH SILA DA NG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 PRO ADHESIVE LABEL WHITE 2585 1 X 2 2000 2 20 SR 2 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR 3 7002 0014 SONOFAX EC THERMAL ROLL BLUE 57MMx60MMx12MM 10ROLL PKT 1 X 36 0000 36 00 SR Total Sales Inclusive GST 6 46 90 Discount 0 00 Total 46 90 Round Adj 0 00 Final Total 46 90 CASH 100 00 CHANGE 53 10 GST Summary Amount RM Tax RM SR 6 44 25 2 65 INV NO CS SA 0133215 Date Total Qty 5 Print Time Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT, Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2046 0021 POM POM M 2314 2X5 0000 10 00 SR Total Sales Inclusive GST 6 10 00 Discount 0 00 Total 10 00 Round Adj 0 00 Final Total 10 00 CASH 20 00 CHANGE 10 00 GST Summary Amount RM Tax RM SR 6 9 43 0 57 INV NO CS SA 0073011 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,ANYUSTATIONERY SHOP NO X Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2044 0137 ARTLINE EG 40 GLUE STICK 40G 1 X 5 6000 5 60 SR 2 2000 0002 IK YELLOW SIMILI PAPER A4 70GSM 450 s REAM 1 X 10 9000 10 90 SR Total Sales Inclusive GST 6 16 50 Discount 0 00 Total 16 50 Round Adj 0 00 Final Total 16 50 CASH 50 00 CHANGE 33 50 GST Summary Amount RM Tax RM SR 6 15 57 0 93 INV NO CS SA 0074397 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERYSHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 7002 0014 THERMAL ROLL BLUE 57MMx6OMM12MM 10ROLL PKT 1 X 35 0000 35 00 SR Total Sales Inclusive GST 6 35 00 Discount 0 00 Total 35 00 Round Adj 0 00 Final Total 35 00 CASH 50 00 CHANGE 15 00 GST Summary Amount RM Tax RM SR 6 33 02 1 98 INV NO CS SA 0097366 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,ANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0096677 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERYSHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2000 0063 S 69 MULTI PURPOSE PAPER 40 S A4 120GSM 1 X 4 5000 4 50 SR Total Sales Inclusive GST 6 4 50 Discount 0 00 Total 4 50 Round Adj 0 00 Final Total 4 50 CASH 50 00 CHANGE 45 50 GST Summary Amount RM Tax RM SR 6 4 25 0 25 INV NO CS SA 0094236 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERYSHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 F CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3X2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0094876 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATEFOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 5000 0001 PHOTOCOPY SERVICES A4 SIZE 50 X 0 1000 5 00 SR Total Sales Inclusive GST 6 5 00 Discount 0 00 Total 5 00 Round Adj 0 00 Final Total 5 00 CASH 5 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 6 4 72 0 28 INV NO CS SA 0097493 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook Sanyu Stationery INVOICE_RECEIPT,SANYUSTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 5000 0001 PHOTOCOPY SERVICES A4 SIZE 50 X 0 1000 5 00 SR Total Sales Inclusive GST 6 5 00 Discount 0 00 Total 5 00 Round Adj 0 00 Final Total 5 00 CASH 100 00 CHANGE 95 00 GST Summary Amount RM Tax RM SR 6 4 72 0 28 INV NO CS SA 0097491 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERYSHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 RESTAURANT ORDER CHIT NCR 3 5 x6 3 X 2 9000 8 70 SR Total Sales Inclusive GST 6 8 70 Discount 0 00 Total 8 70 Round Adj 0 00 Final Total 8 70 CASH 10 00 CHANGE 1 30 GST Summary Amount RM Tax RM SR 6 8 21 0 49 INV NO CS SA 0128032 Date Total Qty 3 Print Time Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYU ISTATIONERY SHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 CAMIS NCR BILL BOOK 5 x8 BB 5882 1 X 3 5000 3 50 SR 2 RESTAURANT ORDER CHIT NCR 3 5 x6 2X 2 9000 5 80 SR Total Sales Inclusive GST 6 9 30 Discount 0 00 Total 9 30 Round Adj 0 00 Final Total 9 30 CASH 10 00 CHANGE 0 70 GST Summary Amount RM Tax RM SR 6 8 77 0 53 INV NO CS SA 0126902 Date Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,counter SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 5002 0080 WIRE o 3 1 DOUBLE WIRE A4 34 LOOPS 6 4MM WHITE 6 X 4 0000 24 00 SR 2 5002 0004 PVC RIGID SHEET BINDING CC A4 12 X 0 8000 9 60 SR Total Sales Inclusive GST 6 33 60 Discount 0 00 Total 33 60 Round Adj 0 00 Final Total 33 60 CASH 50 00 CHANGE 16 40 GST Summary Amount RM Tax RM SR 6 31 70 1 90 INV NO CS SA 0127449 Date Total Qty 18 Print Time 4 18 55 Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERYSHOP Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 2000 0240 CAMPAP CR 36364 A4 10S BRIEF CARD CAMPAP ARTO 1 X 3 9000 3 90 SR Total Sales Inclusive GST 6 3 90 Discount 0 00 Total 3 90 Round Adj 0 00 Final Total 3 90 CASH 10 00 CHANGE 6 10 GST Summary Amount RM Tax RM SR 6 3 68 0 22 INV NO CS SA 0128324 Date Total Qty 1 Print Time Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,SANYUSTATIONERY SHOP SETIA Mobile Whatsapps Tel GST ID No 001531760640 TAX INVOICE Owned By SANYU SUPPLY SDN BHD 1135772 K CASH SALES COUNTER 1 BILL BOOK 5 x8 BB 5882 2X 3 5000 7 00 SR Total Sales Inclusive GST 6 7 00 Discount 0 00 Total 7 00 Round Adj 0 00 Final Total 7 00 CASH 7 00 CHANGE 0 00 GST Summary Amount RM Tax RM SR 6 6 60 0 40 INV NO CS SA 0129861 Date Total Qty 2 Print Time Goods sold are not Returnable Refundable THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN TERIMA KASIH SILA DATANG LAGI PLEASE KEEP THIS RECEIPT FOR PROVE OF PURCHASE DATE FOR I T PRODUCT WARRANTY PURPOSE Follow us in Facebook INVOICE_RECEIPT,AIK HUAT HARUWARE ENTERPRISE NO 013 TEL FA GST NO SIMPLIFIED TA INVOICE CASH RECEIPT CSP0397224 DATE SALESPERSON TIME ITEM QTY U P AMOUNT RM RM 4060150000005 1 4 00 4 00 S 15AMP UMS PLUG TOP SIRIM TOTAL QUANTITY 1 SUB TOTAL GST 4 00 DISC 0 00 ROUNDING 0 00 TOTAL 4 00 CASH 20 00 DHANGE 16 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TA AMT SR 3 77 6 0 23 TA TOTAL 0 23 COODS SOLD ARB NOT refundable THANK YOU POR CHOOSING US PLS PROVIDE ORIOINAL BILL FOR coods EZCHANGE WITHIN 1 WEEK PROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO BE ENTITLED ROR ECHANCE INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERPRISE SETIA ALAM 17 0 SETIA INDAH X 013 X SETIA ALAM TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CBP0408083 DATE ALESPERSON AH002 TIME ITEM BIY U P AMOUNT RM RM 0079567600084 1 14 00 14 00 S 277ML WD 40 ANTI RUST LUBRICANT ATOTAL QUANTITY 1 SUB TOTAL GST 14 00 DISC 0 00 ROUNDING 0 00 TOTAL 14 00 CASH 14 00 CHANGE 0 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT 13 21 6 0 79 TAX TOTAL 0 79 COODS SOLD ARB NOT THANK YOU FOR CHOOSING US PLS PROVIDE ORIGINAL EILL FOR UCUS EXCHANGE WITHIN 1 WEEK FROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO BB ENTITLED FOR EXCHANGE INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERPRISE X NO 17 0 JALAN SETIA INDAH X 013 X TEL FAX GST NO SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0382398 DATE SALESPERSON TIME ITEM QTY U P AMOUNT RM RM 6521000000008 1 6 00 6 00 S 8 X 3 6MM 100PCS BLACK CABLE TIES TOTAL QUANTITY 1 SUB TOTAL GST 6 00 DISC 0 00 ROUNDING 0 00 TOTAL 6 00 CASH 20 00 CHANGE 14 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 5 66 6 0 34 TAX TOTAL 0 34 GOODS SOLD ARE NOT REFUNDABLE THANK YOU FOR CHOOSING US PLS PROVIDE ORIGINAL BILL FOR coods EXCHANGE WITHIN 1 WEEK FROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO BE ENIITLED FOR EXCHANGE if INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERPRISE SETIA ALAM X NO 17 0 JALAN SETIA INDAH X U13 X SETIA ALAM SEKSYEN TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0415633 DATE SALESPERSON AH019 TIME ITEM QTY U P AMOUNT RM RM 120000143 1 16 00 16 00 S SCHNEIDER VIVACE 15A S SOCKET TOTAL QUANTITY 1 SUB TOTAL GST 16 00 DISC 0 00 ROUNDING 0 00 TOTAL 16 00 CASH 1 5 00 CHANGE 0 00 GST 0 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 15 09 6 0 91 TAX TOTAL 0 91 COODS SOLD ARE NOT REFUNDABLE THANK YOU FOR CHOOSING US PLS PROVIDE ORIGINAL BILL FOR GOODS EXCHANGS WITHIN 1 W3BK FROM GOODS MUST BE IN ORIGINAL SIATE TO BE ENTITLED FOR EXCHANG3 INVOICE_RECEIPT,canter AIK HUAT HARDWARE ENTERPRISE SETIA ALAM G JALAN SETIA INDAH X U13 X TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0405591 DATE SALESPERSON AH019 TIME ITEM QTY U P AMOUNT RM RM 9555783202031 1 30 00 30 00 S 7001 CZ LEVER SINK TYPE SINK TAP TOTAL QUANTITY 1 SUB TOTAL GST 30 00 DISC 0 00 ROUNDING 0 00 TOTAL 30 00 CASH 30 00 CHANGE 0 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 28 30 6 1 70 TAX TOTAL 1 70 GOODS SOLD ARE NOT REFUNDABLE THANK YOU FOR CHOOSING US PLS PROVIDE ORIGINAL BILL FOR GOODS EXCHANGE WITHIN 1 WEEK FROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO BE ENTITLED FOR EXCHANGE INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERPRISE SETIA ALAM X NO 17 G JALAN SETIA INDAH X U13 X SETIA ALAM TEL FAX GST NO 000394528763 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0420207 DATE SALESPERSON AH019 TIME ITEM QTY U P AMOUNT RM RM 8710163220987 2 12 00 24 00 S PHILIPS 18W E27 827 ESSENTIAL BULB W WHI TOTAL QUANTITY 2 SUB TOTAL GST 24 00 DISC 0 00 ROUNDING 0 00 TOTAL 24 00 CASH 100 00 CHANGE 76 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 22 64 6 1 36 TAX TOTAL 1 36 GOODS SOLD ARE NOT REFUNDABLE THANK YOU FOR CHOOSING US PLS PROVIDE ORIGINAL BILL FOK GOOUS EXCHANGE WITHIN 1 WSEK FROM TRANSACION GOODS MUST BE IN ORIGINAL STATE TO BE ENTITLED FOR EXCHANGE INVOICE_RECEIPT,AIK HUAT HARUWARE ENTERPRISE SETIA ALAM JALAN SETIA INDAH X 013 X SETIA ALAM TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0422870 DATE SALESPERSON AH019 TIME ITEM QTY U P AMOUNT RM RM 4060010002913 2 3 50 7 00 S UMS 13A SWITCH SOCKET PC 2913A TOTAL QUANTITY 2 SUB TOTAL GST 7 00 DISC 0 00 ROUNDING 0 00 TOTAL 7 00 CASH 50 00 CHANGE 43 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 6 60 6 0 40 TAX TOTAL 0 40 GOODS SOLD ARB NOT REFUNDABLE THANK YOU FOR CHOOSING US FLS PROVIDE ORIGINAL EILL FOR GOODS EXCHANGE WITHIN 1 WEBK FROM 1RANSACTION GOODS MUST BE IN ORIGINAL STATE TO BE ENTITLED FOR EXCHANGE INVOICE_RECEIPT,AIK HUAT HARDWAKE ENTERPRISE SETIA ALAM JALAN SETIA INDAH X U13 X SETIA ALAM TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE Quit Counter CASH RECEIPT CSP0406159 DATE SALESPERSON TIME ITEM QTY U P AMOUNT RM RM 9200310000040 3 8 00 24 00 S 40MM 2K BELLE PADLOCK TOTAL QUANTITY 3 SUB TOTAL GST 24 00 DISC 0 00 ROUNDING 0 00 TOTAL 24 00 CASH 50 00 CHANGE 26 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 22 64 6 1 36 TAX TOTAL 1 36 GOODS SOLD ARE NOT THANK YOU FOR PLS PROVIDE ORIC EXCHANGE MUST x INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERFRISE SETIA JALAN SETIA SEKSYEN U13 40170 SNAH TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0388298 DATE SALESPERSON AH002 TIME ITEM QTY U P AMOUNT RM RM 120000143 1 16 00 16 00 S SCHNEIDER VIVACE 15A S SOCKET TOTAL QUANTITY 1 SUB TOTAL GST 16 00 DISC 0 00 ROUNDING 0 00 TOTAL 16 00 CASH 16 00 CHANGE 0 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 15 09 6 0 91 TAX TOTAL 0 91 GOODS SOLD ARB NOT REFUNDABLE THANK YOU FOR CHOOSING US FLS PROVIDE ORIGINAL BILL FOR GOODS EXCHANGE WITHIN 1 WEEK FROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO BE ENTITLED FOR EXCHANGE INVOICE_RECEIPT,AIK HUAT HARDWARE ENTERPRISE SETIA ALAM SDN BHU 822737 X NO 17 G JALAN SETIA INDAH X U13 X SETIA ALAM SEKSYEN 013 TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0422102 DATE SALESPERSON AH019 TIME ITEM QTY U P ANDUNT RM RM 4536000000012 1 2 00 2 00 S 1 2 PVC BIB TAP 2000070000010 1 0 50 0 50 S 9001 BM SEALING TAPE YELLOW TOTAL QUANTITY 2 SUB TOTAL UST 2 50 DISC 0 00 ROUNDING 0 00 TOTAL 2 50 CASH 10 00 CHANGE 7 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 2 36 6 0 14 TAX TOTAL 0 14 GOODS SOLD ARE NOT refundable THANK YOU FOR CHOOSLONG US PLS PROVIDE ORIGINAL BILL FOR EXCHANGE WITHIN 1 WEEK FROM TRANSACTION GOODS MUST BE IN ORIGINAL STATE TO 68 ENTITLED FOR EXCHANGE INVOICE_RECEIPT,TUKAR KEPALA GAS DAPUR AIK HUAT HARDWARE ENTERPRISE SETIA SDN BHU 822737 X NO 17 G JALAN SETIA INDAH X U13 X SETIA SEKSYEN TEL FAX GST NO 000394528768 SIMPLIFIED TAX INVOICE CASH RECEIPT CSP0404314 DATE SALESPERSON AH019 TIME ITEM QTY U P AMOUNT RM RM 9555019100268 1 28 00 28 00 S MILUX M268 GAS REGULATOR H D TOTAL QUANTITY 1 SUB TOTAL GST 28 00 DISC 0 00 ROUNDING 0 00 TOTAL 28 00 CASH 40 00 CHANGE 12 00 GST 6 INCLUDED IN TOTAL GST SUMMARY CODE AMOUNT TAX AMT SR 26 42 6 1 58 TAX TOTAL 1 58 GOODS SOLD ARB NOT REFUNDABLE THANE YOU FOR CHOOSING US PLS PROVIDE ORIGINAL BILL FOR COODS EXCHANGE WITHIN 1 WEEK FROM GOODE MUST BB TN OREGINAJ ENTITLED FOR EXCHANCE INVOICE_RECEIPT,FY EAGLE ENTERPRISE 002065464 X NO 42 JALAN PBS TEL FAX GST NO TAX INVOICE RECEIPT CS00040529 DATE SAL ESPERSON TIME USER ITEM QTY U P AMOUNT RM RM 15894 1 22 00 22 00 SR 8PCS AA ENERGIZER BP ME WF 15895 1 22 00 22 00 SR 8PCS AAA ENERGIZER BP SC WF 12139 1 8 00 8 00 SR EVEREADY SHD AA 4PC 1215BP4 YD PM WF TOTAL QUANTITY 3 SUB TOTAL 49 06 DISC 0 00 GST 2 94 ROUNDING 0 00 TOTAL 52 00 CASH 52 00 CHANGE 0 00 GST SUMMARY CODE AMOUNT TAX AMT SR 49 06 6 2 94 TAX TOTAL 2 94 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,TQ FOR SHOPPING WITH PUSAT DAGANGAN PHILEO DAMANSARA PUSAT DAGANGAN PHILEO DAMANSARA NO 9 JALAN mynews com MYNEWS RETAIL SB 306295 X FKA BISON STORES SB TAX REG ID CBP 000709361664 QTY PRICE DISC AMT GP GREENCELL EXTRA HEAVY DUTY AAA 4 2 1 6 00 0 00 6 00 SR SUB TOTAL 6 00 GRAND TOTAL 6 00 CASH 50 00 MYR 50 00 CHANGE DUE 44 00 TOTAL QTY 1 SR 0 GOODS 6 00 TAX 0 00 BILL 1856 608 9161 2806180322 PRICE is GST INCLUSIVE INVOICE_RECEIPT,MRT aperatad by rapidKL TAX INVOICE RAPID RAIL sou GST Reg No OTP Sale receipt TSC 22MGOOSUBS 11002 Agent ID 114500 SHIFT ID 38599 Transaction 89 Date Description Quantity Amount ax RM code Media nb 3097352783 Balance before RM 1 90 Balance after RM 31 40 TNG Reload RM 30 1 RM 29 50 ES Reload Fee 1 RM 0 50 SR Total RM 30 00 Rounding RM 0 00 Including GST RM 0 00 GST Summary Amount GST SR GST 0 00 RM 0 50 RM 0 00 ES GST 0 00 RM 29 50 RM 0 00 Payment mode Amount Cash RM 30 00 Please retain receipt for reference JK Date printed INVOICE_RECEIPT,AD6140 TAX INVOICE BHPetrol Permas Esjay Fuel Enterprise CO REG NO T GST REG NO 000153358336 Cashier 465 Invoice No 1 642195 Prepay Chit Number 12091 Item U Price Qnty Amount Inf RON95 P3 2 200 22 73 50 00 R TOTAL SALES RM 50 00 ROUNDING ADJ RM 0 00 TOTAL AMOUNT PAYABLE RM 50 00 CASH RM 50 00 Prepay Deposit RM 50 00 Prepay Refund RM 0 00 GST SUMMARY Amount RM Tax RM R Relief 50 00 0 00 Relief under Section 56 3 b GST Act Thank You For Shopping At BHPetromart Customer Service INVOICE_RECEIPT, U TAX INVOICE Invoice OR18060402170527 Item Qty Total SR 100100000006 Pork RM2 54 1 RM2 54 SR 100100000060 4 Vege RM5 13 1 RM5 18 Total Amount RM7 72 GST 0 RM0 00 Rounding RM0 02 Nett Total RM7 70 Payment Mode Amount CASH RM7 70 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 7 72 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U GST Reg No 001559298048 Tel Table Counter Invoice No SP null Date Payment Type Cash Member Number 3000000100068587 TAKE AWAY Butter slice Cheese 1 RM4 15 ST Discount RM 0 20 Europe Bun 1 RM3 70 ST Discount RM 0 18 Green Tea Mochi 1 RM3 30 ST Discount RM 0 16 Toast B Coffee Cream Ch 1 RM7 85 ST Discount RM 0 39 Walnut Multigrain 1 RM3 95 ST Discount RM 0 19 Total Incl GST RM21 83 Rounding RM0 02 Grand Total RM21 a 85 Total Paid RM50 00 Change RM28 15 Discount Summary Discount RM1 12 GST Summary GST Summary Item Amount RM GST RM ST 0 5 21 83 0 00 NS 0 0 0 00 0 00 INVOICE_RECEIPT,PCL XL error Warning IllegalMediaSource A06015 UNIHAKKA INTERNATIONAL SDN BHD 867388 U TAX INVOICE Invoice OR18060902170388 Item Qty Total SR 100100000035 1 Meat 3 Vege RM6 69 1 RM6 69 SR 100100000015 Vegetable RM1 03 1 RM1 03 Total Amount RM7 72 GST 0 RM0 00 Rounding RM0 02 Nett Total RM7 70 Payment Mode Amount CASH RM7 70 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 7 72 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAXINVOICE Invoice OR18061002160368 Item Qty Total SR 100100000171 Meat Dish RM2 83 1 RM2 83 SR 100100000031 3 Vege RM4 15 1 RM4 15 SR 100100000170 Imported Veggies RM1 50 1 RM1 50 Total Amount RM8 48 GST 0 RM0 00 Rounding RM0 02 Nett Total RM8 50 Payment Mode Amount CASH RM8 50 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 8 48 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, GST Reg No 001559298048 Baru Permas Jaya Tel No Table Counter Invoice No SP null Date Payment Type Cash Member Number 3000000100068587 TAKE AWAY T Butter Sugar Bun 1 RM2 25 ST Discount RM 0 45 T Cookie Cream Bun 1 RM3 20 ST Discount RM 0 16 T Green Tea Mochi 1 RM3 30 ST Discount RM 0 16 T Pastry Chicken Floss 1 RM3 20 ST Discount RM 0 16 T Saha Bread 1 RM4 60 ST Discount RM 0 23 Total Incl GST 0 RM15 39 Rounding RM0 01 Grand Total RM15 40 Total Paid RM50 00 Change RM34 60 Discount Summary Discount RM1 16 GST Summary GST Summary Item Amount RM GST RM ST 0 5 15 39 0 00 NS 0 0 0 00 0 00 INVOICE_RECEIPT, BHD H FLR JLN JEJAKA SHOPPING HOURS SUN THU 1000 HRS 2230 HRS FRI SAT 1000 HRS 2300 HRS 1x 000001038556 15 56SR CHEK HUP 2IN1 Item promo 12 99 2 57 1x 000006429720 10 28SR MS SWM ENZO RT 1x 000005457342 18 50SR ORANGE 1x 000000812627 10 00SR US RED GLOBE 1x 000006454333 10 50SR CN PEAR 1x 000004023432 14 00SR AP 4S 1x 000008626349 10 90SR AUS SEEKA KIWI Item promo 9 00 1 90 1x 000007773877 7 90SR CHILE ANGELENO 1x 000000388658 2 50SR CUT FRUITS 1 99 1x 000004291022 4 80SR CHERRY SUNGOLD 1x 000007802317 18 90SR TURKEY CHERRY 2 Item promo 11 90 7 00 1x 000000135412 15 00SR SUSHI SET PTC Sub total 127 37 Total Sales Incl GST 127 37 Rounding Adj 0 02 Total After Adj Incl GST 127 35 CASH 150 00 Item Count 12 Change Amt 22 65 Invoice No 2018061010100170023 GST Summary Amount Tax SR 0 127 37 0 00 Total 127 37 0 00 017 0170023 0252828 PJ CST ZAHIR REGULAR STAMP S 4 BONUS STAMP S 0 TOTAL STAMP S 4 AEON Stamps Loyalty Program Product s sold are neither exchangeable nor refundable TEL AEON THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT, U TAX INVOICE Invoice OR18061202170371 Item Qty Total SR 100100000006 Pork RM2 54 1 RM2 54 SR 100100000060 4 Vege RM5 18 1 RM5 18 Total Amount RM7 72 GST 0 RM0 00 Rounding RM0 02 Nett Total RM7 70 Payment Mode Amount CASH RM7 70 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 7 72 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18061102170340 Item Qty Total SR 100100000015 Vegetable RM1 03 4 RM4 12 SR 100100000056 Fried Noodle S RM1 88 1 RM1 88 Total Amount RM6 00 GST 0 RM0 00 Nett Total RM6 00 Payment Mode Amount CASH RM6 00 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 6 00 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, W GST No 001507647488 No 89 91 Tel MT161201806020100 Coca Cola 320ml 9555589200385 1 40 1 1 40 Z F N Gotcha Buggy 75ml 8853815002880 0 95 1 0 95 Z King Oyster Mushroom Unit Unit 6936489102000 3 50 1 3 50 Z LKK Kum Chun Oyster Sauce 770g 078895129052 5 65 1 5 65 Z Whole Chicken 17803 2006031014359 10 99 1 306 14 35 N ITEM 5 Total 25 85 QTY 5 ROUNDING 0 00 TOTAL SAVING 0 00 TOTAL 25 85 TENDER Cash 50 00 CHANGE 24 15 GST Analysis Goods Tax Amount S 6 0 00 0 00 Z 0 25 85 0 00 MEMBER 0000036581 Points Earned 25 Member SHOO YUEN Thank You See You Again Il Customer Care Line INVOICE_RECEIPT,A06035 LEMON TREE RESTAURANT JTJFOODS GST 001085747200 No 3 Jalan Permas Bandar Baru Permas Jaya 81750 07 3823455 SIMPLIFIED TAX INVOICE INVOICE NO CS00014769 INVOICEDATE WAITER Vanessa Pax Table 01 1 5 CUST C0001 NAME CASH QTY DESCRIPTION AMT 1 X 205 9 80 9 80 SR 1 x X1 SKY JUICE 0 50 0 50 SR Ice SUB TOTAL 10 30 GST 0 0 00 ROUNDING ADJ 0 00 TOTAL AMOUNT 10 30 CASH 11 00 CHANGE AMT 0 70 ITEM COUNT 2 GST Summary Amount Tax SR 10 30 0 00 Total 10 30 0 00 THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN LIKE US ON FACEBOOK INVOICE_RECEIPT, TEL FAX GST ID 000931172352 TAX INVOICE Doc No CS01076695 Date Cashier Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 9557821042500 1 2 50 2 50 2 50 SRO YELLOW ROCK SUGAR 250G 2200056 1 2 80 2 80 2 80 SRO GREEN BEAN 280G 9556894200006 1 8 90 8 90 8 90 SRO ROYAL UMBRELLA BERAS WANGI 1KG Total Qty 3 14 20 Total Sales Excluding GST 14 20 Discount 0 00 Total GST 0 00 Rounding 0 00 Total Sales Inclusive of GST 14 20 CASH 20 20 Change 6 00 GST SUMMARY Tax Code Amt RM Tax RM SRO 0 14 20 0 00 Total 14 20 0 00 GOODS SOLD ARE NOT RETURNABLE THANK YOU RE PRINT INVOICE_RECEIPT, 81750 JOHOR Tel GST ID No 002069884928 TAX INVOICE PS8418065765 S P POS1 Loc PMS Walk In Table 24 Item Qty U Price Disc Amount RM 230 MONGOLIA CHICKEN 1 9 40 0 00 9 40 S 101 BUTTER KAYA 1 2 35 0 00 2 35 S 205 MEE HUN KUEY 1 8 00 0 00 8 00 S 412 NESLO ICE 1 4 25 0 00 4 25 S 432 HONEY RED TEA ICE 1 4 15 0 00 4 15 S Total Items 5 Sub Total RM 28 15 Less Discount 0 00 Round 0 00 Total Due GST Inc 28 15 Paid Cash 50 00 Change 21 85 S GST 0 28 15 0 00 Please Come Again INVOICE_RECEIPT,A06057 KEDAI RUNCIT ZBH MASAI GST TAX INVOICE 195360 CLERK01 000000 INVOICE NO 052949 BILL 2x 1 00 RM2 00 Z RUNCIT 1x 7 80 RM7 80 7 RUNCIT 4x 2 20 RM8 80 Z RUNCIT 1x 1 80 RM1 80 Z RUNCIT 2x 4 50 RM9 00 Z RUNCIT 1x 14 00 RM14 00 Z RUNCIT SUBTOTAL RM43 40 ZERO TAX AMT RM43 40 0 Z RMO 2 ITEM ANT RM43 40 TTL CASH RM43 40 INVOICE_RECEIPT, GST SHOPPING HOURS SUN THU HRS 2230 HRS FRI SAT HRS 2300 HRS 1x 000001082678 14 85SR PREMIER 4X200S Item promo 10 99 3 86 1x 000003384541 13 86SR APACHE BLACK 1x 000006420611 15 00SR SUPER ESSENSO M Item promo 13 75 1 25 Sub total 38 60 Total Sales Incl GST 38 60 Total After Adj Incl GST 38 60 CASH 50 00 Item Count 3 Change Amt 11 40 Invoice No 201806121070265 GST Summary Amount Tax SR 0 38 60 0 00 Total 38 60 0 00 1010 007 0070265 0306651 PJ NUR AYU REGULAR STAMP S 1 BONUS STAMP S 0 TOTAL STAMP S 1 AEON Stamps Loyalty Program Product s sold are neither exchangeable nor refundable TEL THANK YOU FOR YOUR PATRONAGE PLEASE COME AGAIN INVOICE_RECEIPT,A06069 GRANDMA HOMES RESTAURANT JM0840871 W NO 3 5 JALAN PERMAS 11 BANDAR BARU PERMAS JAYA 81750 GST ID TAX INVOICE Receipt CS00001615 Table 12 Staff Date Cashier USER Time Dencription Qty Price Amt Tax 4 3 50 14 00 SR 1 3 00 3 00 SR 1 3 00 3 00 SR 1 8 00 8 00 SR 1 2 50 2 50 SR 1 34 00 34 00 SR 1 35 00 35 00 SR 1 28 00 28 00 SR OFFER 1 12 90 12 90 SR i 108 00 108 00 SR 1 85 00 85 00 SR 1 52 00 52 00 SR 1 24 00 24 00 SR 1 2 50 2 50 SR OFFER 1 12 90 12 90 SR 1 4 50 4 50 SR T02 2 17 50 35 00 SR 1 3 00 3 00 SR 1 3 00 3 00 SR 1 3 00 3 00 SR Total 24 473 30 Total Sales Excluding GST 473 30 Discount 0 00 Service Charge 0 00 Total GST 0 00 Rounding 0 00 Total Sales Inclusive of GST 473 30 CASH 500 00 CHANGE 26 70 GST SUMMARY Tax Code Amt RM Tax RM SR 0 0 473 30 0 00 Total 473 30 0 00 indicated this tax code belong to service charges GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT, U TAX INVOICE Invoice OR18061602170510 Item Qty Total SR 100100000035 1 Meat 3 Vege RM6 69 1 RM6 69 SR 100100000015 Vegetable RM1 03 1 RM1 03 Total Amount RM7 72 GST 0 RM0 00 Rounding RM0 02 Nett Total RM7 70 Payment Mode Amount CASH RM7 70 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 7 72 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, UNIHAKKA U TAX INVOICE Invoice OR18061802170501 Item Qty Total SR 100100000035 1 Meat 3 Vege RM6 69 1 RM6 69 SR 100100000170 Imported Veggies RM1 50 1 RM1 50 Total Amount RM8 19 GST 0 RM0 00 Rounding RM0 01 Nett Total RM8 20 Payment Mode Amount CASH RM8 20 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 8 19 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U TAX INVOICE Invoice OR18062002170346 Item Qty Total SR 100100000035 1 Meat 3 Vege RM6 69 1 RM6 69 SR 100100000170 Imported Veggies RM1 50 1 RM1 50 Total Amount RM8 19 GST 0 RM0 00 Rounding RM0 01 Nett Total RM8 20 Payment Mode Amount CASH RM8 20 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 8 19 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT, U GST Reg No 001559298048 Table Counter Invoice No SP null Date Payment Type Cash Member Number 3000000100068587 TAKE AWAY T Butter slice Cheese 1 RM4 15 ST Discount RM 0 41 T Green Tea Mochi 1 RM3 30 ST Discount RM 0 33 T Honey Walnut 1 RM3 70 ST Discount RM 0 37 T Saha Bread 1 RM4 60 ST Discount RM 0 46 Total Incl GST 0 RM14 18 Rounding RM0 02 Grand TotarRM14 20 Total Paid RM20 20 Change RM6 00 Discount Summary Birthday Discount RM1 57 GST Summary GST Summary Item Amount RM GST RM ST 0 4 14 18 0 00 NS 0 0 0 00 0 00 INVOICE_RECEIPT, Alaf Restaurants 65351 M Licensee of McDonald s Level 6 Bangunan TH Uptown3 Petaling GST ID No 000504664064 McDonaid s 309 Tel No TAX INVOICE MFY Side 1 INV 003090200024723 ORD 60 REG 2 QTY ITEM TOTAL 1 L 9Nuggets 12 80 1 9Nuggets 1 Barbecue Sauce 1 Sweet and Sour Sauce 1 L Sprite Less Ice 1 L Fries Eat In Total inci GST 12 80 Total Rounded 12 80 Cash Tendered 13 00 Change 0 20 TOTAL INCLUDES 0 GST 0 00 Thank You and Please Come Again INVOICE_RECEIPT, 867388 U TAX INVOICE Invoice OR18062202170372 Item Qty Total SR 100100000170 Imported Veggies RM1 50 1 RM1 50 SR 100100000031 3 Vege RM4 15 1 RM4 15 SR 100100000171 Meat Dish RM2 83 1 RM2 83 Total Amount RM8 48 GST 0 RM0 00 Rounding RM0 02 Nett Total RM8 50 Payment Mode Amount CASH RM8 50 Change RM0 00 GST Summary Amount RM Tax RM SR GST 0 8 48 0 00 GST REG 000656195584 PERMAS Thank You Come Again Like and Follow Us on Facebook INVOICE_RECEIPT,A06117 IDEAL MENU GROUP SDN BHD 1143655 H TAX INVOICE Receipt CS10031697 Table 10 Staff Date Cashier SM CASHIER Time Description Qty Price Amt Tax A1 LO BAK RICE SET 1 12 00 12 00 SR BUBBLE GREEN TEA 1 0 00 0 00 SR Total 2 12 00 Total Sales Excluding GST 12 00 Discount 0 00 Service Charge 0 00 Total GST 0 00 Rounding 0 00 Total Sales Inclusive of GST 12 00 CASH 20 00 CHANGE 8 00 GST SUMMARY Tax Code Amt RM Tax RM SRO 0 12 00 0 00 Total 12 00 0 00 indicated this tax code belong to service charges THANK YOU PLEASE COME AGAIN Il INVOICE_RECEIPT, Wender LAVENDER CONFECTIONERY BAKERY S B COMPANY NO TEL GST ID NO 001872379904 TAK INVOICE Qty Descriptions Amount 1 HONEV SOFT TOAST 3 30 T 2 XIAO GE GE 5 40 T 1 PARMESAN CHEDDAR CHEES 4 15 T 1 TOFFEE DANISH 5 45 T 2 EGG TART 5 10 T 1 OTAK CHEESE BUN 3 10 T 8 TOTAL 26 50 CASH 50 00 CHANGE 23 50 GST Summary Amount Tax T GST 26 50 0 00 Z Zero Rated 0 00 0 00 Sign THANK YOU 1 All sales are final Goods sold are not rafundable nor exchangeable 2 Our products contain no added preservatives please consume within a day or keep according to recommendations on packaging 3 For feedback please retain this Tax Invoice Seak store manager assistance OR drop us an email 4 Tax Invoice can only be issued on the purchase date Amendment is not allowed once issued Shr INVOICE_RECEIPT,AD61311 PASIR HARDWARE SDN BHD 801222 M GST ID No 000144596992 NO TAMAN PASIR KG PASIR 81700 Tel Fax Tax Invoice Bill No POS 53796 Date Cashier ash Payment Cash Item Qty Price Amount PLUG TOP 13A BIASA MK 08 00 WAAN34 3 8 00 24 00 SRO UMS 13A LUG SINGLE 4 00 ST00014 3 4 00 12 00 SRO Gross Amt 36 00 GST 6 0 00 Net Amt 36 00 Received 36 00 Change 0 00 Round Adj 0 00 GST Summary Amount RM Tax RM SRO 0 36 00 0 00 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,RESTORAN DE COFFEE O NO NO TAX INVOICE Receipt CS00119810 Date Time GST GST Item Qty Price AMOUNT SR COFFEE O T AWAY 1 2 30 2 30 SR TEA T AWAY 1 2 40 2 40 SR COFFEE T AWAY 2 2 40 4 80 SR SOYA BEAN T AWAY 1 2 10 2 10 TOTAL 5 11 60 Excluded GST Sub Total 10 94 Total GST 0 66 TOTAL 11 60 GST SUMMARY Tax Code Amount GST SR 6 10 94 0 66 Total 10 94 0 66 GOODS SOLD ARE NOT RETURNABLE THANK YOU INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Chéras NO Tax Invoice INV No 1076565 Cashier Thandar Date Description Qty U price Total TAX Teh B 1 1 X 2 20 2 20 SR Cham B 1 X 2 20 2 20 SR Milo B 1 X 2 80 2 80 SR Take Away 3 x 0 20 0 60 SR Total QTY 6 Total Excluding GST 7 37 GST payable 6 0 43 Total Inclusive of GST 7 80 TOTAL 7 80 CASH 7 80 GST Summary Amount RM Tax RM SR 6 7 37 0 43 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1085405 Cashier Thandar Date Description Qty U price Total TAX Teh B 1 x 2 20 2 20 SR Cham B 1 X 2 20 2 20 SR Herbal Tea 2 X 1 70 3 40 SR Take Away 4 x 0 20 0 80 SR Total QTY 8 Total Excluding GST 8 11 GST payable 6 0 49 Total Inclusive of GST 8 60 TOTAL 8 60 CASH 8 60 GST Summary Amount RM Tax RM SR 6 8 11 0 49 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1159923 Cashier Thandar Date Description Qty U price Total TAX Teh B 2 X 2 20 4 40 SR Take Away 2 X 0 20 0 40 SR Total QTY 4 Total Excluding GST 4 54 GST payable 6 0 26 Total Inclusive of GST 4 80 TOTAL 4 80 CASH 4 80 GST Summary Amount RM Tax RM SR 6 4 54 0 26 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Tax Invoice INV No 1126479 Cashier Thandar Date Description Qty U price Total TAX Cham B 1 X 2 20 2 20 SR Dunhill 1 X 17 00 17 00 SR Take Away 1 X 0 20 0 20 SR Total QTY 3 Total Excluding GST 18 31 GST payable 6 1 09 Total Inclusive of GST 19 40 TOTAL 19 40 CASH 19 40 GST Summary Amount RM Tax RM SR 6 18 31 1 09 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1074908 Cashier Thandar Date Description Qty U price Total TAX Teh B 2 X 2 20 4 40 SR Herbal Tea 1 X 1 70 1 70 SR Take Away 3 X 0 20 0 60 SR Total QTY 6 Total Excluding GST 6 33 GST payable 6 0 37 Total Inclusive of GST 6 70 TOTAL 6 70 CASH 6 70 GST Summary Amount RM Tax RM SR 6 6 33 0 37 INVOICE_RECEIPT, 65351 M Licensee of McDonald s Level 6 Bangunan TH Uptown3 SS21 Petaling Jaya GST ID No 000504664064 McDonald s Shell 36 Tel No TAX INVOICE MFY Side 1 INV 003621900031356 ORD 58 REG 19 QTY ITEM TOTAL 1 L McChicken 11 10 1 L Coke 1 L Fries 1 6Nuggets 7 80 1 French Cheese Sauce TakeOut Total incl GST 18 90 Total Rounded 18 90 Cash Tendered 50 00 Change 31 10 TOTAL INCLUDES 6 GST 1 07 Thank You and Please Come Again Guest Relations Center INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1128507 Date Description Qty U price Total TAX Kopi B 1 X 2 20 2 20 SR Take Away 1 X 0 20 0 20 SR Total QTY 2 Total Excluding GST 2 27 GST payable 6 0 13 Total Inclusive of GST 2 40 TOTAL 2 40 2 40 GST Summary Amount RM Tax RM SR 6 2 27 0 13 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1128461 Cashier Thandar Date Description Qty U price Total TAX Teh B 1 X 2 20 2 20 SR Milo B 1 X 2 80 2 80 SR Total QTY 2 Total Excluding GST 4 72 GST payable 6 0 28 Total Inclusive of GST 5 00 TOTAL 5 00 CASH 5 00 GST Summary Amount RM Tax RM SR 6 4 72 0 28 INVOICE_RECEIPT,SANG KEE CHERAS RESTAURANT 0910559 U NO ID GST 02268816 TAX INVOICE NO 74285 999 03 05 28 EMS Ref 18050320240 74285 dhh2476558 4 B CODE QTY U PRICE AMT 95565705139 1 2 50 2 50s ALL SOFT DRINK CAN SUB TOTAL 2 50 Total GST I 0 14 Total Itemos 1 Total Quanuty 1 RM Total Incl GST 2 50 Pay Cash 2 50 Change 0 00 THANK YOU PLEASE COME AGAIN GST Taxable Amt GST Amt s SR I 6 2 36 0 14 INVOICE_RECEIPT,MR D I Y M SDN BHD CO D GST ID No 000306020352 MELAWATI MALL TAX INVOICE UNI CLASSIC QUALITY BOND UC 1701B 17 S WA20 1 X 2 70 2 70 Item s 1 Qty s 1 Total Incl GST 6 RM 2 70 CASH RM 10 00 CHANGE RM 7 30 GST Summary Amt RM Tax RM GST S 6 2 55 0 15 28 05 18 SH01 ZJ94 T3 R000059251 OPERATOR MLWC NORAZLINA EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR D I Y M SDN BHD CO REG 860871 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 MELAWATI MALL TAX INVOICE ARTLINE WHITEBOARD MAKER PEN 500A R S 4974052854583 1 X 3 10 3 10 ARTLINE WHITEBOARD MAKER PEN 500A B S 4974052854569 1 X 3 10 3 10 MAGNETIC WHITEBOARD LD001 120 90CM S HC07 08 6 9087397 1 X 63 00 63 00 Item s 3 Qty s 3 Total Incl GST 6 RM 69 20 CASH RM 69 20 GST Summary Amt RM Tax RM GST S 6 65 28 3 92 03 05 18 SH02 ZJ94 T1 R000090406 OPERATOR MLWC SITI AISHAH EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1219461 Cashier Thandar Date Description Qty U price Total TAX Coke 1 X 2 10 2 10 ZRL Soya Bean 1 X 2 10 2 10 ZRL Total QTY 2 Total Excluding GST 4 20 Total Inclusive of GST 4 20 TOTAL 4 20 CASH 4 20 GST Summary Amount RM Tax RM ZRL 0 4 20 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1207108 Cashier Date Description Qty U price Total TAX Teh B 1 X 2 10 2 10 ZRL Cham B 1 X 2 10 2 10 ZRL Take Away 2x 0 20 0 40 ZRL Total QTY 4 Total Excluding GST 4 60 Total Inclusive of GST 4 60 TOTAL 4 60 CASH 4 60 GST Summary Amount RM Tax RM ZRL 0 4 60 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1199976 Cashier Date Description Qty U price Total TAX Teh B 1 X 2 10 2 10 ZRL Cham B 1 X 2 10 2 10 ZRL Soya Bean 1 X 1 70 1 70 ZRL Take Away 3 x 0 20 0 60 ZRL Total QTY 6 Total Excluding GST 6 50 Total Inclusive of GST 6 50 TOTAL 6 50 CASH 6 50 GST Summary Amount RM Tax RM ZRL 0 6 50 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1188875 Cashier Date Description Qty U price Total TAX Teh B 1 X 2 10 2 10 ZRL Cham B 1 X 2 10 2 10 ZRL Take Away 2 x 0 20 0 40 ZRL Total QTY 4 Total Excluding GST 4 60 Total Inclusive of GST 4 60 TOTAL 4 60 CASH 4 60 GST Summary Amount RM Tax RM ZRL 0 4 60 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV 1183154 Cashier Thandar Date Description Qty U price Total TAX Teh B 1 X 2 20 2 20 ZRL Cham B 1 X 2 20 2 20 ZRL Take Away 2x 0 20 0 40 ZRL Total QTY 4 Total Excluding GST 4 80 Total Inclusive of GST 4 80 TOTAL 4 80 CASH 4 80 GST Summary Amount RM Tax RM ZRL 0 4 80 0 00 INVOICE_RECEIPT, TAX INVOICE GST IID 000164270080 2 COUNTER1 2003 saifui Chk 274898 Guestl TBL35 1 1 B02 HALF BL EGG E 4 53 S 1 B03 HNN TST b k E 5 57 S 1 D19 CHAM I E 5 57 S CASH 20 00 15 67 Subtotal 15 67 10 Srv Chg 1 55 Total 17 22 RND ADJ 0 02 TTL ATF RND 17 20 Payment 20 00 Change Due 2 80 2003 CLOSED THANK YOU PLEASE COME AGAIN GST AT 0 GSTSummary Amount RM GST RM S GST O 17 20 0 00 Z GST 0 0 00 0 00 INVOICE_RECEIPT,10 GRAM Gourmet Sbn Bhd 1152264 K No GST Reg No 002055098368 Tax Invoice Table Check 514658 Pax s 0 Date Cashier Cashier Morning Description Qty U price Total TAX P02 Spaghetti Aglio Olio Chicken Breast 1 X 15 00 15 00 SR Total Excluding GST 15 00 Total GST 0 0 00 Total Inclusive of GST 15 00 TOTAL 15 00 Closed 8888 Server Cashier Morning CASH 15 00 GST Summary Amount RM Tax RM SR 0 15 00 0 00 Thank You Please Come Again INVOICE_RECEIPT,LEONG HENG SHELL SERVICE STATION Company W 1 4 MILES CHERAS 43000 Site 2188 Telephone GST No Invoice number Pre auth code A01A1529424173 22 73 litre Pump 06 FuelSave 95 RM 50 00 C 2 200 RM litre Total RM 50 00 Cash RM 50 00 Relief GST C RM 0 00 Total Gross C RM 50 00 Date Time Num POS CNo Shift 331 Diesel Petrol RON95 given relief under Section 56 3 b GST Act Thank You and Please Come Again INVOICE_RECEIPT,PROSPER NIAGA Company No Tel No GST No Pre Authorisation Pre auth code A02A1530024046 38 61 litre Pump 07 V Power 97 RM 100 00 K 2 590 RM litre Total RM 100 00 Cash RM 100 00 0 00 SR GST K RM 0 00 Total Gross K RM 100 00 Cashier MFikri2 This is not the final fiscal receipt Date Time Num POS CNo Shift 659 Diesel Petrol RON95 given relief under Section 56 3 b GST Act Thank You and Please Come Again INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1170190 Cashier Date Description Qty U price Total TAX Cham B 2 x 2 20 4 40 ZRL Take Away 2x 0 20 0 40 ZRI Total QTY 4 Total Excluding GST 4 80 Total Inclusive of GST 4 80 TOTAL 4 80 CASH 4 80 GST Summary Amount RM Tax RM ZRL 0 4 80 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Mahkota Selangor GST REG NO Tax Invoice INV No 1175805 Cashier Thandar Date 52 Description Qty price Total TAX Teh B 1 X 2 20 2 20 ZRL Cham B 1 X 2 20 2 20 ZRL Bunga Kekwa 1 X 1 70 1 70 ZRL Take Away 3 X 0 20 0 60 ZRL Total QTY 6 Total Excluding GST 6 70 Total Inclusive of GST 6 70 TOTAL 6 70 CASH 6 70 GST Summary Amount RM Tax RM ZRL 0 6 70 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1212276 Cashier Date Description Qty U price Total TAX Teh B 1 X 2 10 2 10 ZRL Cham B 1 X 2 10 2 10 ZRL Take Away 2x 0 20 0 40 ZRL Total QTY 4 Total Excluding GST 4 60 Total Inclusive of GST 4 60 TOTAL 4 60 CASH 4 60 GST Summary Amount RM Tax RM ZRL 0 4 60 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1212055 Cashier Thandar Date Description Qty U price Total TAX Cham B 1 X 2 10 2 10 ZRL Bunga 1 X 1 60 1 60 ZRL Take Away 2 X 0 20 0 40 ZRL Total QTY 4 Total Excluding GST 4 10 Total Inclusive of GST 4 10 TOTAL 4 10 CASH 4 10 GST Summary Amount RM Tax RM ZRL 0 4 10 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W No Mahkota Selangor GST REG NO Tax Invoice INV No 1187070 Cashier Thandar Date Description Qty U price Total TAX Teh B 2 X 2 20 4 40 ZRL Milo B 1 X 2 80 2 80 ZRL Take Away 3 X 0 20 0 60 ZRL Total QTY 6 Total Excluding GST 7 80 Total Inclusive of GST 7 80 TOTAL 7 80 CASH 7 80 GST Summary Amount RM Tax RM ZRL 0 7 80 0 00 INVOICE_RECEIPT,RESTORAN WAN SHENG 002043319 W Selangor GST REG NO Tax Invoice INV No 1201504 Cashier Thandar Date Description Qty U price Total TAX Teh B 1 X 2 10 2 10 ZRL Cham B 2 X 2 10 4 20 ZRL Nescafe B 1 X 2 50 2 50 ZRL Take Away 4 x 0 20 0 80 ZRL Total QTY 8 Total Excluding GST 9 60 Total Inclusive of GST 9 60 TOTAL 9 60 CASH 9 60 GST Summary Amount RM Tax RM ZRL 0 9 60 0 00 INVOICE_RECEIPT, 1248446 V NO JLN TEMENGGUNG SELANGOR GST Reg No 001375580160 Tax Invoice Table 9 Order 120820 Bill V042 520388 Pax s 0 Date Cashier SOFYA Description Qty U price Total TAX B1 Green Tea 3 X 1 00 3 00 SR T2 Unagi Temaki 1 X 5 80 5 80 SR R5 Tori Don I X 12 80 12 80 SR N8 Shiro Ramen 2 X 12 80 25 60 SR SB01 Sushi Yellow 5 X 1 80 9 00 SR SB02 Sushi Red 2 X 2 80 5 60 SR Total Excluding GST 61 80 Serv Charge 10 6 18 Total Inclusive of GST 67 98 Rounding Adj 0 02 TOTAL 68 00 Closed Server SOFYA VISA 68 00 GST Summary Amount RM Tax RM SR 0 67 98 0 00 Thank you Please Come Again Powered By INVOICE_RECEIPT,MR W KAWASAN PERINDUSTRIAN GST ID No 000473792512 KEPONG TAX INVOICE STEEL WOOL SH 2 S EZ03 5 X 1 79 8 95 Item s 1 Qty s 5 Total Incl GST RM 8 95 CASH RM 50 00 CHANGE RM 41 05 GST Summary Amt RM Tax RM GST SR 0 8 95 0 00 15 06 18 SH02 B003 T2 R000551481 OPERATOR KPOT EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR KUCHAI W KAWASAN PERINDUSTRIAN GST ID No 000473792512 KEPONG TAX INVOICE KNIFE 7240 S BB21 41 61 6926292571513 1 X 15 57 15 57 M FUNCTION SCISSORS K56 S GA07 6926292592327 1 X 7 45 7 45 KIWI S S KNIFE NO 475 5 S WA37 1 X 4 25 4 25 Item s 3 Qty s 3 Total Incl GST RM 27 27 ROUNDING ADJUSTMENT RM 0 02 TOTAL ROUNDED RM 27 25 CASH RM 30 00 CHANGE RM 2 75 GST Summary Amt RM Tax RM GST SR 0 27 27 0 00 30 06 18 13 27 SH01 B003 T1 R000639004 OPERATOR KPOT ASYRAF ALI EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,99 SPEED MART S 8 519537 X TMM GST ID NO INVOICE NO 18385 103 T0148 8402 MSM PRAI 1K RM23 60 z 8 X RM 2 95 Total Sales Inclusive GST RM 23 60 CASH RM 24 00 CHANGE RM 40 GST Summary Amount RM Tax RM z 0 23 60 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT, 519537 X LOT P T TMN INDAH PERDANA GST ID NO INVOICE NO 18388 103 T0126 05 05 18 0715 KNORR CHICKEN STOCK 1K RM134 80 08 X RM 16 85 8048 GARDENIA ENRICHED WHIT RM2 35 Z Total Sales Inclusive GST RM 137 15 CASH RM 150 15 CHANGE RM 13 00 GST Summary Amount RM Tax RM S 6 127 20 7 60 2 07 2 35 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,99 SPEED MART S B 519537 X LOT P T TMN INDAH PERDANA GST ID NO INVOICE NO 18396 102 T0362 13 05 18 0715 KNORR CHICKEN STOCK 1K RM16 85 S 5596 HYGIENIC 7 5 INCH COLO RM6 06 s 6 X RM 1 01 Total Sales Inclusive GST RM 22 91 Rounding Adjustment RM 01 RM 22 90 RM 50 00 CHANGE RM 27 10 GST Summary Amount RM Tax RM 6 21 60 1 31 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,99 SPEED MART S B S19537 X LOT P T TMN INDAH PERDANA GST ID NO INVOICE NO 18418 102 T0260 04 06 18 620 CARNATION SUSU KRIMER S RM7 50 Z 3 X RM 2 50 0715 KNORR CHICKEN STOCK 1K RM15 90 Z Total Sales RM 23 40 CASH RM 25 00 CHANGE RM 1 60 GST Summary Amount RM Tax RM Z 0 23 40 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,99 SPEED MART S B 519537 X TMN INDAH PERDANA GST ID NO INVOICE NO 18418 102 T0262 04 06 18 620 CARNATION SUSU KRIMER S RM5 00 Z 2 X RM 2 50 0715 KNORR CHICKEN STOCK 1K RM15 90 Z Total Sales RM 20 90 CASH RM 21 00 CHANGE RM 10 GST Summary Amount RM Tax RM Z 0 20 90 00 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,MR W PERINDUSTRIAN GST ID No 000473792512 KEPONG TAX INVOICE EVA MEN SANDAL M1044 1 SIZE 6 10 S WA26 12 9555825905982 1 X 11 23 11 23 Item s 1 Qty s 1 Total Incl GST RM 11 23 ROUNDING ADJUSTMENT RM 0 02 TOTAL ROUNDED RM 11 25 CASH RM 50 00 CHANGE RM 38 75 GST Summary Amt RM Tax RM GST SR 0 11 23 0 00 11 06 18 SH02 B003 T2 R000550476 OPERATOR KPOT EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,MR W GST ID No 000473792512 KEPONG TAX INVOICE 1 21 CYLINDRICAL LOCK 3871SS S GA06 07 1 X 17 45 17 45 Item s 1 Qty s 1 Total Incl GST RM 17 45 CASH RM 50 00 CHANGE RM 32 55 GST Summary Amt RM Tax RM GST SR 0 17 45 0 00 SH01 B003 T1 R000637565 OPERATOR KPOT EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,FILL IN ENTERPRISE Company No MA0057302 Telephone GST No Pre Authorisation Pre auth code A01A1527956635 45 45 litre Pump 12 FuelSave 95 RM 100 00 C 2 200 RM litre Total RM 100 00 Cash RM 100 00 Relief GST C RM 0 00 Total Gross C RM 100 00 Cashier BHasan This is not the final fiscal receipt Date Time Num POS CNo Shift 868 Diesel Petrol RON95 given Relief under Section 56 3 b GST Act Thank You and Please Come Again INVOICE_RECEIPT, 481500 M C W KHOO HARDWARE SDN BHD PBS Tel Fax GST Reg No 000549584896 Tax Invoice Invoice No CR 1805 0201 Date Cashier No khoo Counter No c1 Printed Date Item Name Qty Unit Price Amount 2032 ENERGIZER BATTERY PC PKT 1 6 40 6 40 SR 9V ENERGIZER BATTERY 522BP1G PKT 1 11 53 11 53 SR 2 Item s Total 17 93 GST 6 1 08 Net Total 19 01 Rounding Adj 0 01 Net Total Rounded 19 00 Cash 19 00 Change 0 00 GST Summary Item Amount GST SR 6 2 17 93 1 08 Thank You Please Come Again INVOICE_RECEIPT,Dian Realties Sdn Bhd Co No 20154 T GST Registration No 000650247680 02 03 Level 2 27 Jalan Ismail Tel Fax TAX INVOICE Tax Invoice no 3521 0602 00602 010100 Pay parking ticket 5 00 RM Length of stay 0 Dy 0 Hr 16 Min 029928870020018150387040 Amount Incl GST 5 00 RM Acceptad total 5 00 RM GST 6 0 28 RM Thank you INVOICE_RECEIPT,Dion Realties Sdn Bhd Co No 20154 T GST Registration No 000850247680 02 03 Level 2 Tel Fax TAX INVOICE Tax Invoice no 7698 0601 00601 010100 Pay parking ticket 5 00 RM 11 40 Length of stay 0 Dy 0 Hr 17 Min 02992887002011018148410260 Amount Incl GST 5 00 RM Accapted total 10 00 RM Change 5 00 RM GST 6 0 28 RM Thank you INVOICE_RECEIPT, GST Registration No 001751072768 Car Park Office Tel Fax TAX INVOICE Tax Invoice No 0714 0601 00601 010100 Pay parking ticket 1 50 RM Length of stay 0 Dy 0 Hr 19 Min 0247295105 Total amount 1 50 RM Accepted total 2 00 RM Change 0 50 RM GST 0 0 00 RM Thank you INVOICE_RECEIPT, 481500 M C W KHOO HARDWARE SDN BHD Tel Fax GST Reg No 000549584896 Tax Invoice Invoice No CR 1806 0729 Date Cashier No tee Counter No c2 Printed Date Item Name Qty Unit Price Amount 100 X 4L COMPRESSOR OIL TIN 1 48 00 48 00 SR 1 Item s Net Total MYR 48 00 Rounding Adj 0 00 Net Total Rounded MYR 48 00 Cash 48 00 Change 0 00 GST Summary Item Amount MYR GST MYR SR a 0 1 48 00 0 00 Thank You Please Come Again INVOICE_RECEIPT,Dion Realties Sdn Bhd Ca No 20154 T GST Registration No 000850247680 02 03 Level 2 27 Jalan Ismail Tel Fax TAX INVOICE Tax Invoice no 4953 0602 00602 010100 Pay parking ticket 5 00 RM Length of stay 0 Dy 0 Hr 15 Min 029928870020018176397900 Amount Incl GST 5 00 1 RM Accepted total 10 00 RM Change 5 00 RM G S T 0 00 0 00 RM Thank you INVOICE_RECEIPT,MR M SDN BHD to REG 6 PERINDUSTRIAN GST ID No 000306020352 TESCO EXTRA ARA DAMANSARA TAX INVOICE WACH BALL 1S S GA01 2 X 1 13 2S S GB12 2 X 2 83 5 66 PLASTIC BAGS S 99999 1 X 0 19 0 19 Item s 3 Qty s 5 TOTAL INCL GST RM 8 11 ROUNDING ADJUSTMENT RM 0 01 TOTAL ROUNDED RM 8 10 CASH RM 50 00 CHANGE RM 41 90 GST Summary Amt RM Tax RM GST SR 0 8 11 0 00 17 06 18 SH01 ZJ42 T1 R000242600 OPEFATOR TADC ALIM ABDUL EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT,TQ FOR SHOPPING WITH OASIS OASIS OASIS OASIS myNEWScareline MYNEWS RETAIL SB 306295 X FKA BISON STORES SB TAX REG ID CBP 000709361664 QTY PRICE DISC AMT HE 333 3S UNICORN BALL PEN BLUE 1 1 90 0 00 1 90 SR HE 3S 70 UNICORN MARKER BK 1 4 50 0 00 4 50 SR MR BANANA 140G 1 1 30 0 00 1 30 SR SUB TOTAL 7 70 GRAND TOTAL 7 70 CASH 8 00 MYR 8 00 CHANGE DUE 0 30 TOTAL QTY 3 SR 0 GOODS 7 70 TAX 0 00 a BILL 4449 517 12949 2906180053 PRICE is GST INCLUSIVE INVOICE_RECEIPT, SP3 OGN GROUP SDN BHD Roc 1026984 X No 29M G U3 G Seksyen U3 Subang Perdana 40150 3999 GST Reg No 002077622272 TAXINVOICE Invoice No SP3 01 147902 Date Cashier Jimart Description Qty Price Amount 1 SR 6001188379050 5 3 68 18 40 Kitchen Lighter 2015 2 SR 9555586101265 1 9 91 9 91 Cotton White Mop 450 I HDL Total Item Discount 0 00 Total Sales Inclusive GST 0 00 28 31 Rounding Adjustment 0 01 TOTAL 28 30 CASH 50 00 Change 21 70 GST Summary Amount RM Tax RM SR 0 00 28 31 0 00 i love jimart GOODS SOLD ARE NOT RETURNABLE Thank You Please Come Again INVOICE_RECEIPT,buy Class SP3 OGN GROUP SDN BHD Roc 1026984 X No 29M G U3 G Seksyen U3 Subang 40150 3999 GST Reg No TAXINVOICE Invoice No SP3 01 148852 Date Cashier Jimart Descriptior Qty Price Amount 1 SR 0809152 1 7 45 7 45 Rhomb Scissors 4 2040 2 SR 1050901900021 1 7 45 7 45 Sharpening Stone 108 8 3 SR 9555047307540 1 4 62 4 62 LAVA Water Jug 2 25L 4 SR 24900007 12 2 74 32 88 Glass W Flower LG10001 Total Item Discount 0 00 Total Sales Inclusive GST 0 00 52 40 Rounding Adjustment 0 00 TOTAL 52 40 CASH 53 00 Change 0 60 GST Summary Amount RM Tax RM SR 0 00 52 40 0 00 i love jimart GOODS SOLD ARE NOT RETURNABLE Thank You Please Come Again INVOICE_RECEIPT,PANDAH INDAH PULAU KETAM RESTAURANT TEL GUEST CHECK Table 6 Check 113355 Pax s 0 Date Server CASHIER 1 KUO POH C 2 PAX 6 00 2 TEA EXTRA PERSON 1 PAX 2 00 1 TONG HOU 10 00 1 MUTTAN SLICE 15 00 1 SOUP 0 00 1 TOM YUM 0 00 3 NO OF HEAD 2 SET ABOVE 60 00 Subtotal 93 00 TOTAL 93 00 INVOICE_RECEIPT,RESTAURANT JIAWE JIAWE I HOUSE 13 JLN TASI UTAMA 8 L INVOICE Invoice 13834 Cashier admin POS No 1 Date Table T AWAY 1 ITEM QTY U P RM DISC Ant RM Butter Cream Chicken Rice 3 9 00 0 00 2 Sub Total Before Discount RM 27 00 Service Charge RM 0 00 Total Sales RM 27 00 Rounding Adjustment RM 0 00 TOTAL RM 27 00 CASH RM 50 00 CHANGE RM 23 00 INVOICE_RECEIPT, S B 519537 X LOT GST ID NO INVOICE NO 18386 103 S68008 03 05 18 s 483 CAN 320ML IC RMS 60 Total Sales Inclusive GST RM 19 90 CASH RM 19 90 CHANGE RM 00 GST Summary Amount RM Tax RM 6 18 77 1 13 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT GST Reg No 000670224384 Tax Invoice Table 40 Bill V001 536988 Order 137088 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX 1 D 20 00 SR Chicken Item 1 D 15 00 SR Vege item 1 D 22 00 SR Sausage Fried Rice L 1 D 5 00 SR Beverage Total Excluding GST 62 00 GST Payable 3 72 Total Inclusive of GST 65 72 Rounding Adj 0 02 TOTAL 65 70 Closed 1 Server 113 CASHIER CASH 65 70 GST Summary Amount RM Tax RM SR 6 62 00 3 72 Thank You Please Come Again INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M GST Reg No 000670224384 Tax Invoice Table 37 Bill V001 539829 Order 139931 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX 1 D 15 00 SR Omellete Item 1 D 10 00 SR Vege Item S 1 D 22 00 SR Rice W Seafood Meat Item Single 1 D 5 00 SR Beverage Total Excluding GST 52 00 Total Inclusive of GST 52 00 TOTAL 52 00 Closed 1 Server 113 CASHIER CASH 52 00 GST Summary Amount RM Tax RM SR 0 52 00 0 00 Thank You Please Come Again INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M GST Reg No 000670224384 Tax Invoice Table 38 Bill V001 538701 Order 138803 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX 1 D 32 00 SR Chicken Item 1 D 4 00 SR White Rice 1 D 18 00 SR Vege Item M 1 D 8 00 SR Rice W Seafood Meat Item Single 1 D 5 00 SR Beverage Total Excluding GST 67 00 GST Payable 4 02 Total Inclusive of GST 71 02 Rounding Adj 0 02 TOTAL 71 00 Closed 1 Server 113 CASHIER CASH 71 00 GST Summary Amount RM Tax RM SR i 67 00 4 02 Thank You Please Come Again INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M NO 1 GST Reg No 000670224384 Tax Invoice Table 03 Bill V001 539233 Order 139336 Date Cashier 113 CASHIER Pax s 0 Qty Descrint ion Total TAX 1 D 70 00 SR Grouper 1 D 15 00 SR Vege item 1 D 8 00 SR Ümellete Item 1 D 8 00 SR White Rice 1 D 5 00 SR Beverage Total Excluding GST 106 00 GST Payable 6 36 Total Inclusive of GST 112 36 Rounding Adj 0 01 TOTAL 112 35 Closed 1 Server 113 CASHIER CASH 112 35 GST Summary Amount RM Tax RM SR 6 106 00 6 36 Thank You Please Come Agai in INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M GST Reg No 000670224384 Tax Invoice Table 37 Bill V001 538524 Order 138624 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX 1 D 15 00 SR Rice W Seafood Meat Item Single 1 D 5 00 SR Beverage 1 D 20 00 SR Noodle Item Single Total Excluding GST 40 00 GST Payable 2 40 Total Inclusive of GST 42 40 TOTAL 42 40 Closed 1 Server 113 CASHIER CASH 42 40 GST Summary Amount RM Tax RM SR 6 40 00 2 40 Thank You Please Come Again INVOICE_RECEIPT,MEGAH RETAIL No 000936312932 TAX INVOICE 03 290900 Inv No Promoter 00 Item Code Qty U Price Amt 350ML CALPIS ORIGINAL SR 9556404118038 1 2 49 2 49 500ML COKE SR 9555589200392 1 2 20 2 20 Sub Total RM 4 69 Rounding Adj RM 0 01 Total Sales Inclusive GOT RM 4 70 Cash RM 5 00 Change RM 0 30 GST Summary Amount GST Amt SR 6 00 4 43 0 26 ZR00 00 0 00 0 00 No of Item 2 Total Qty 2 PrintedBy 290900 GOODS SOLD ARE NOT RETURNABLE THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT, S B S19537 X GST ID NO INVOICE NO 18291 102 T0163 28 01 18 973 COKE LIGHT 500ML RM4 40 S 2 X RM 2 20 5581 SPRITZER MINERAL WATER RM23 50 Total Sales Inclusive GST RM 27 90 CASH RM 28 00 CHANGE RM 10 GST Summary Amount RM Tax RM 6 26 33 1 57 Thank You Please come again Keep the invoice for applicable returns INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCIALAM TRANSPORT Doc No CS00012013 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101756 5 16 50 17 49 87 45 SR SIMEN Total Qty 5 87 45 Total Sales Excluding GST 82 50 Discount 0 00 Total GST 4 95 Rounding 0 00 Total Sales Inclusive of GST 87 45 CASH 87 45 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 82 50 4 95 Total 82 50 4 95 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00011904 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101756 10 16 50 17 49 174 90 SR 100160 5 3 00 3 18 15 90 SR KAPUR AIR A1 Total Qty 15 190 80 Total Sales Excluding GST 180 00 Discount 0 00 Total GST 10 80 Rounding 0 00 Total Sales Inclusive of GST 190 80 CASH 190 80 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 180 00 10 80 Total 180 00 10 80 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00013125 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 100588 5 23 00 24 38 121 90 SR SILING PRIMP 1X9 B Total Qty 5 121 90 Total Sales Excluding GST 115 00 Discount 0 00 Total GST 6 90 Rounding 0 00 Total Sales Inclusive of GST 121 90 CASH 121 90 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 115 00 6 90 Total 115 00 6 90 GOODS SOLD ARE T RETURNABLE THANK YOU RE PRINT INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Brii To SUCIALAM JAYA TRANSPORT Doc No CS00012431 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 100135 4 8 00 8 48 33 92 SR BESI R 5 5 CQ 100139 8 17 00 18 02 144 16 SR BESI Y 10 CQ Total Qty 12 178 08 Total Sales Excluding GST 168 00 Discount 0 00 Total GST 10 08 Rounding 0 00 Total Sales Inclusive of GST 178 08 CASH 178 08 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 168 00 Total 168 00 10 08 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00012389 Date Cashier USER Time 14 17 00 Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 100211 1 200 0 23 0 24 292 56 SR BATU 101870 1 68 90 SR PASIR HALUS D Total Qty 1 201 361 46 Total Sales Excluding GST 341 00 Discount 0 00 Total GST 20 46 Rounding 0 00 Total Sales Inclusive of GST 361 46 CASH 361 46 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 341 00 20 46 Total 341 00 20 46 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCIALAM TRANSPORT Doc No CS00012330 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 00139 6 17 108 12 SR BESI Y 10 CQ 100135 4 8 00 8 48 33 92 SR BESI R 5 5 CQ 101756 15 16 50 17 49 262 35 SR SIMEN Total Qty 25 404 39 Total Sales Excluding GST 381 50 Discount 0 00 Total GST 22 89 Rounding 0 00 Total Sales Inclusive of GST 404 39 CASH 404 39 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 381 50 22 89 Total 381 50 22 89 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT NO 1 Doc No CS00013033 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101870 1 65 00 68 90 68 90 SR PASIR HALUS D 101756 5 16 50 17 49 87 45 SR SIMEN 100160 2 3 00 3 18 6 36 SR KAPUR AIR A1 Total Qty 8 162 71 Total Sales Excluding GST 153 50 Discount 0 00 Total GST 9 21 Rounding 0 00 Total Sales Inclusive of GST 162 71 CASH 162 71 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 153 50 9 21 Total 153 50 9 21 GOODS SOLD ARE NOT RETURNABLE THANK YOU RE PRINT INVOICE_RECEIPT,KEDAI PAPAN YEW CHUAN 0005583085 K TEL FAX GST ID 000781500416 TAX INVOICE Bill To SUCI ALAM JAYA TRANSPORT Doc No CS00012658 Date Cashier USER Time Salesperson Ref GST GST Item Qty S Price S Price Amount Tax 101870 1 65 00 68 90 68 90 SR PASIR HALUS D Total Qty 1 68 90 Total Sales Excluding GST 65 00 Discount 0 00 Total GST 3 90 Rounding 0 00 Total Sales Inclusive of GST 68 90 CASH 68 90 Change 0 00 GST SUMMARY Tax Code Amt RM Tax RM SR 6 65 00 3 90 Total 65 00 3 90 GOODS SOLD ARE T RETURNABLE THANK YOU INVOICE_RECEIPT, GH DISTRIBUTOR MARKETING SDN BHD H Tel GST Reg I No 001315377152 TAX INVOICE Invoice No 216_01 21047 Date 1 Cashier PART TIMERS 05 PRN ON QTY ITEM RM Retail Takeaway 4 TAU SAR PNEAH S 16PCS 9 00 36 00 SR 2 DB TAU SAR PNEAH S 12PCS 7 60 15 20 SR 2 BEH TEH SAW 8PCS 8 00 16 00 SR 2 PHONG PNEAH 6PCS 9 00 18 00 SR 10 SubTotal 85 20 Net Total 35 20 Cash 100 20 CHANGE 15 00 ax Summary Amount Tax SR GST O 85 20 0 00 THANK you PLEASE COME AGAIN Goods Sold Are Non Refindable INVOICE_RECEIPT,AMTECH ELECTRICAL SUPPLIES 001963477 M GST ID No 001285423104 PUSAT email Tel F ax Tax Invoice Bill No POS 27408 Date Cashier amt Payment Cash Item Qty Price Amount 30W SUPER T8 LED TUBE D L FNM 16 00 00004285 5 16 00 80 00 SR 2x40W LED F FITTING EMPTY ITK 14 00 00002348 4 14 00 56 00 SR Gross Amt 136 00 GST 6 0 00 Net Amt 136 00 Received 150 00 Change 14 00 Round Adj 0 00 GST Summary Amount RM Tax RM SR 0 136 00 0 00 THANK YOU PLEASE COME AGAIN INVOICE_RECEIPT,Cash Sale KT WONG TRADING H Phone GST Registration No 000613294080 Doc ument No KTW031475 Date DESC PRICE Disc AMOUNT TAX QTY CODE BERAS ASAS 10KG 15 BAG 24 90 X 373 50 SR SUN sos TIRAM 6KG 4BOTOL 15 95 63 80 SR COKE 24 X 325ML 2PETI 26 00 X 52 00 SR Sub Total Inclusive GST 489 30 Rounding Adj 0 00 Rounded Total RM 489 30 GST Summary Amount Tax SR 0 0 489 30 0 00 Payment Detail Cash 489 30 INVOICE_RECEIPT,POPULAR BOOK CO M SDN BHD No 113825 W GST Reg No 001492992000 No 8 Tel 66 Slip No Description Amount Max HD 10K Stapler 7 30 T WBD Issues 20 Rebate Total RM Incl of GST 7 30 Cash 10 00 CHANGE 2 70 Item Count 2 GST Summary Amount RM Tax RM T 6 6 89 0 41 Z 0 0 00 0 00 Total Savings 0 00 BE A POPULAR CARD MEMBER AND ENJOY SPECIAL DISCOUNTS THANK YOU PLEASE COME AGAIN Buy Chinese books online my INVOICE_RECEIPT,OCEAN LC PACKAGING ENTERPRISE GST NO FAX TAX INVOICE Lai 000000 4x 38 00 RM152 00 Others SUBTOTAL RM152 00 GST TAXABLE RM152 00 GST 0 RM0 00 ITEMS 4Q CASH RM152 00 INVOICE_RECEIPT,MR M SDN BHD CO REG 860671 D KAWASAN PERINDUSTRIAN BALAKONG GST ID No 000306020352 PUSAT PERNIAGAAN BUNGA RAYA MANTIN TAX INVOICE SPRAYER SX 260 550ML S HA06HD01 3 70 9065940 4 X 1 79 7 16 Item s 1 Qty s 4 Total Incl GST RM 7 16 ROUNDING ADJUSTMENT RM 0 01 TOTAL ROUNDED RM 7 15 CASH RM 20 20 CHANGE RM 13 05 GST Summary Amt RM Tax RM GST SR 0 7 16 0 00 15 07 18 10 35 SH01 ZI33 T2 R000010082 OPERATOR TRAINEE CASHIER EXCHANGE ARE ALLOWED WITHIN 7 DAYS WITH RECEIPT STRICTLY NO CASH REFUND INVOICE_RECEIPT, W NO JALAN PUSAT PERNIAGAAN BUNGA RAYA 4 PUSAT PERNIAGAAN BUNGA RAYA TEL FAX GST Reg No Invoice No Date Cashier TAX INVOICE Description Qty Price Amount 1 SRO 9555544201075 4 4 35 17 40 PRO BALANCE 400GM BEFF 2 SRO 9555544201198 3 4 35 13 05 PRO BALANCE LAMB 400GM Total 30 45 Discount 0 00 Total Sales Inclusive GST 0 00 30 45 Cash Received 30 50 Change 0 05 GST Summary Amount RM Tax RM SRO 0 00 30 45 0 00 Thank You Please Come Again Terima Sila Datang Lagi Good Sold Are Not Refunable And Returnable INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M GST Reg No 000670224384 Tax Invoice Table 24 Bill V001 540401 Order 140508 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX 1 D 28 00 SR Tilapia 1 D 16 00 SR Vege item 1 D 7 00 SR White Rice 1 D 5 00 SR Beverage 1 D 3 00 SR Herbal Tea Item Total Excluding GST 59 00 Total Inclusive of GST 59 00 TOTAL 59 00 Closed 1 Server 113 CASHIER CASH 59 00 GST Sumnary Amount RM Tax RM SR 0 59 00 0 00 Thank You Please Come INVOICE_RECEIPT,ONE ONE THREE SEAFOOD RESTAURANT M NO 1 GST Reg No 000670224384 Tax Invoice Table 37 Bill V001 540338 Order 140447 Date Cashier 113 CASHIER Pax s 0 Qty Description Total TAX D 15 00 SR Rice W Seafood Meat Item Single 1 D 5 00 SR Beverage 1 D 15 00 SR Noodle Item Single Total Excluding GST 35 00 Total Inclusive of GST 35 00 TOTAL 35 00 Closed 1 Server 113 CASHIER CASH 35 00 GST Summary Amount RM Tax RM SR 0 35 00 0 00 Thank You Please Come Again